pdf file about the author(s) charl verwey organisational unit of paediatrics & child health, university of the witwatersrand, south africa cornelis van der merwe department of radiology, university of the witwatersrand, south africa tanyia pillay department of radiology, university of the witwatersrand, south africa citation verwey c, van der merwe c, pillay t. pulmonary agenesis, pulmonary aplasia and pulmonary hypoplasia: can you differentiate them? s afr j rad. 2017;21(1), a1163. https://doi.org/10.4102/sajr.v21i1.1163 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract pulmonary agenesis, pulmonary aplasia and pulmonary hypoplasia: can you differentiate them? charl verwey, cornelis van der merwe, tanyia pillay copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: pulmonary underdevelopment is categorised into three groups: pulmonary agenesis, pulmonary aplasia and pulmonary hypoplasia. pulmonary agenesis is the complete absence of the lung parenchyma, bronchus and lung vasculature. pulmonary aplasia is characterised by the absence of the lung parenchyma and pulmonary vasculature; however, there is a rudimentary blind-ending bronchus present. pulmonary hypoplasia is defined by the presence of a bronchus and rudimentary lung parenchyma with a reduction in number and size of airways, alveoli and pulmonary vasculature. objective: this is an educational poster in the form of a quiz to identify and differentiate the type of pulmonary underdevelopment according to imaging features, associations and aetiology. method: radiological images of patients with pulmonary underdevelopment, who presented to the paediatric department of chris hani baragwanath academic hospital, were selected. conclusion: it is reported that up to 50% of patients with pulmonary agenesis and pulmonary aplasia have at least one other systemic congenital abnormality. secondary pulmonary hypoplasia is more common than primary pulmonary hypoplasia and the aetiology is often evident on the imaging series. radiological imaging is essential in differentiating the type of pulmonary underdevelopment. about the author(s) cornelis van der merwe department of radiology, chris hani baragwanath academic hospital, university of the witwatersrand, south africa kelly h. hoffmann department of pediatric surgery, chris hani baragwanath academic hospital, university of the witwatersrand, south africa tanyia pillay department of radiology, chris hani baragwanath academic hospital, university of the witwatersrand, south africa citation van der merwe c, hoffmann kh, pillay t. a presentation of a recent case series on vacterl associations. s afr j rad. 2017;21(1), a1140. https://doi.org/10.4102/sajr.v21i1.1140 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract a presentation of a recent case series on vacterl associations cornelis van der merwe, kelly h. hoffmann, tanyia pillay copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (vacterl) association is described as the non-random co-occurrence of congenital malformations. the diagnosis of vacterl association requires 3 component features of the following: vertebral, anorectal, cardiac, tracheoesophageal, renal or limb abnormalities, in the absence for evidence of another condition. the incidence of vacterl association is reported as between 1 in 10 000 to 1 in 40 000. the aetiology of vacterl is still unclear, although the genetic spectrum is becoming somewhat better understood. object: this poster is an educational presentation on a case series of vacterl association patients and the role radiology has in the identification of the associations. method: images presented represents a case series of vacterl association patients who presented to the paediatric surgery department at the chris hani baragwanath academic hospital in april and may 2016. conclusion: vacterl association is reported to be an uncommon disorder. this case series highlights various imaging features of vacterl association and proves the importance of screening for associated abnormalities in any patient presenting with one of the vacterl associations. about the author(s) gopolang magano department of diagnostic radiology, university of the witwatersrand, south africa tanyia pillay department of diagnostic radiology, university of the witwatersrand, south africa susan lucus department of diagnostic radiology, university of the witwatersrand, south africa citation magano g. pillay t. lucus s. paediatric doctors’ error rate in detection of paediatric elbow injuries in rahima moosa mother and child hospital. s afr j rad. 2017;21(1), a1124. https://doi.org/10.4102/sajr.v21i1.1124 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract paediatric doctors’ error rate in detection of paediatric elbow injuries in rahima moosa mother and child hospital gopolang magano, tanyia pillay, susan lucus copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction: elbow fractures are common paediatric injuries that are often misdiagnosed. quality imaging and accurate interpretation are essential to avoid complications which can result in growth disturbance. aim: this study aimed to determine error rates of elbow injuries by medical doctors in the paediatric department in rahima moosa mother and child hospital. method: a total of 28 doctors participated in the study. twenty preselected radiographs (10 normal and 10 abnormal) were projected in a powerpoint slide show, and the doctors completed a tick sheet to assess whether the x-ray was normal or not. this was followed by a 20-minute tutorial on the approach to paediatric elbow x-rays. then the same images were projected in a different sequence and with a more detailed tick sheet for the readers to evaluate. results: the detection rate of elbow fractures by paediatric doctors is poor. although there was an improvement in the detection of fractures before (50.7%) and after (53.9%) the tutorial, the difference was not statistically significant (paired t-test; p = 0.16). conclusion: the paediatric elbow is a common site where pathology is missed on x-rays. the study showed that the detection rate of elbow fractures by the paediatric doctors is poor, even after a tutorial on the radiological features. we recommend ongoing in-service training of clinicians to maximise the detection of fractures. about the author(s) zakariya vawda department of medical imaging and clinical oncology, stellenbosch university, south africa citation vawda z. diagnostic reference levels for paediatric computed tomography. s afr j rad. 2017;21(1), a1152. https://doi.org/10.4102/sajr.v21i1.1152 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: vawda z, pitcher r, akudugu j, groenewald w. diagnostic reference levels for paediatric computed tomography. s afr j rad. 2015;19(2); a846. https://doi.org/10.4102/sajr.v19i2.846. ethical consideration has been approved by the department of ethics, stellenbosch university, south africa. conference abstract diagnostic reference levels for paediatric computed tomography zakariya vawda copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. objectives: to establish local diagnostic reference levels (ldrls) for emergency paediatric head computed tomography (ct) scans performed at a south african tertiary-level hospital and to compare these with published data. materials and methods: a retrospective analysis was conducted of volume-based ct dose index (ctdivol) and dose length product (dlp) data from uncontrasted paediatric head ct scans performed in the trauma and emergency unit of a tertiary-level south african hospital from january 2013 to june 2013. a random sample of 30 patients in each of three age groups (0 years – 2 years, > 2 years – 5 years and > 5 years – 10 years) was used. ldrl values were compared with several national drls from europe and australia. results: mean ctdivol and dlp values were 30 mgy and 488 mgy.cm for the 0 years – 2 years age group, 31 mgy and 508 mgy.cm for the > 2 years – 5 years group and 32 mgy and 563 mgy.cm for the > 5 years – 10 years group, respectively. the mean dlp for 0-year olds – 2-year olds was the only parameter outside the range of corresponding published reference data. stratification into narrower age groupings showed an increase in dlp values with age. conclusion: an institutional review of the head ct scanning technique for emergency studies performed on children less than 2 years of age is recommended. this study highlights the role of ldrls in establishing institutional dosimetry baselines, in refining local imaging practice and in enhancing patient safety. standard age stratification for drl and ldrl reporting is recommended. 39 sa journal of radiology • september 2006 hydatid disease is an important public health problem in many parts of the world, especially in sheep and cattle farming areas.1 most human cases occur where dogs and livestock are raised together. echinococcosis or hydatid disease is common in south africa. it is usually hepatic or pulmonary and usually occurs in children. this particular case focuses on an adolescent with primary hydatid infection of the liver and spillage into the peritoneum. this resulted in encysted peritoneal hydatidosis. a 14-year-old girl was referred from a secondary level rural hospital with a vague history of lethargy and abdominal distention over a period of many months. investigations showed her to have a haemoglobin level of 10 g/dl and positive echinococcosis serology with a titre of 1:80. her remaining biochemistry test results, including her liver functions, were normal. in addition, abdominal ultrasonography was performed. this showed a massive cystic collection in the right hypochondrium with numerous daughter cysts and associated ascites (fig. 1). the ct scan revealed a hepatic hydatid cyst with primary spillage into the parahepatic and paracolic spaces (figs 2 a-c). encysted peritoneal hydatidosis with a hepatic hydatid cyst d l kathan, mb chb, msc, mba s c griffith-richards, mb chb, bsc (physiotherapy) s j przybojewski, mb chb, mmed (rad d), fcr diag (sa), dip pec (sa) m strachan, mb chb y vadachia, mb chb h von bezing, mb chb department of radiology, tygerberg hospital and stellenbosch university fig. 1. longitudinal ultrasound of right upper quadrant showing the hydatid cyst with multiple small daughter cysts. fig. 2. a. axial contrasted ct scan demonstrates the hepatic hydatid cyst with internal daughter cysts/brood capsules. fig.2b. the hydatid cyst projects beyond the liver margin inferiorly and has ruptured at its anterior margin. case report pg 39-40.indd 39 9/6/06 2:58:30 pm case report 40 sa journal of radiology • september 2006 the patient was initially treated with albendazole, but her response was poor. after 2 weeks, the patient underwent surgery to remove the cyst. after surgery, her management once again included albendazole, after which she recovered well. rupture and spillage of hepatic hydatid cyst can lead to dissemination and anaphylaxis. this could prove to be fatal.2 the presenting condition of our patient may be termed encysted hydatidosis.3 early surgical intervention is of paramount importance.4 percutanous removal of cysts or injection by way of hypertonic saline solution, is successful in the management of encysted hydatidosis.5 1. chrieki m. echinococcosis – an emerging parasite in the immigrant population. am fam physician 2002; 5: 817-820. 2. lahiri k. parasitic infections of the respiratory tract. j postgrad med 1993; 39: 144-148. 3. paksoy odev k. percutanous treatment of liver hydatid cysts. ajr 2005; 185: 727-734. 4. wong ls. hydatid liver disease as a cause of recurrent pancreatitis. j r coll surg edinb 1999; 44: 407-409. 5. bhat s. transdiaphragmatic extension of hepatic hydatid cyst. indian j chest dis allied sci 2002; 44: 1-4. fig.2c. axial contrasted ct scan of the abdomen shows intraperitoneal spillage with multiple small cysts compressing the liver and resulting in a scalloped contour. case report price: r380.00sa medical association, health & medical publishing group private bag x1, pinelands, 7430 tel: 021-6578200 • fax: 021-6834509 e-mail: carmena@hmpg.co.za or brents@hmpg.co.za order n ow! price: r500.00 sama price: r450.00 clinical med ad.indd 1 8/8/06 12:17:24 pm r520.00 r470.00 pg 39-40.indd 40 9/6/06 2:58:33 pm case report navicular stress fracture r v p de villiers mmed (radd) sa department of radiology, tygerberg academic hospital and university of stellenbosch, tygerberg, w cape abstract the diagnosis of a navicular fracture is difficult and often delayed due to a nonspecific clinical presentation and subtle imaging findings. initial radiographs are often negative. historically isotope bone scans were recommended, but now ct and mr imaging are suggested due to the higher specificity.imaging of both feet allows internal comparison and may also detect an asymptomatic or unsuspected contralateral fracture. ct is a reliable indicator of fracture healing. the imaging evidence of fracture healing usually lags behind the clinical picture. introduction navicular fractures commonly occur in elite athletes, including runners, gymnasts and football players. clinical the diagnosis is often delayed for months. clinically the onset is insidious with nonspecific signs and symptoms. the interval between symptoms and the diagnosis may be from 7 weeks to 4 months or longer,' clinically the patient complains of pain along the dorsomedial aspect of the midfoot. on examination there may be pain to palpation along the medial longitudinal arch or dorsum of the foot. foot anomalies that may be associated with navicular stress fractures are a short first metatarsal and a relatively long second ray,' pathology most navicular stress fractures involve the middle third of the navicular. this is due to a relative avascularity of the middle third of the navicular. fractures may be complete or incomplete. incomplete fractures involve the dorsal 5 mm of the navicular adjacent to the talonavicular joint.' fig. 1. plain x-ray of subtle fracture of navicular bone. 34 sa journal of radiology • august 2003 imaging imaging of a suspected stress fractures starts with radiographs of the foot. the initial radiographs are often negative (fig. 1). historically isotope bone scans were recommended, but now ct and mr imaging are suggested due to the higher specificity (fig. 2). should an early fracture be suspected, fat-saturated mrl techniques (stir or fatsat t2/proton density) are used to assess for bone marrow oedema of the stress response (fig. 3). as the fracture is linear and located in the middle third of the bone, ct imaging must be performed perpendicular and parallel to the mid/ fig. 2. isotope bone scan of foot showing increased tracer uptake in navicular suggestive of a stress fracture. fig. 3. mri of the foot. sagittal stir image. note increased signal intensity in the navicular with associated fracture line compatible with occult fracture. no fracture was present on the plain x-ray. case report fig. 4. coronal ct of navicular. note fracture line surrounded by sclerosis fig. 5. coronal ct of both navicula. stress fracture of right navicular with complete fracture and displacement. fig. 6. axial ct mult/planar image chip fracture of navicular. foot (fig. 4). imaging of both feet allows internal comparison and may also detect an asymptomatic or unsuspected contralateral fracture (fig 5). multislice ct with multiplanar reformatting is the method of choice (fig. 6). ct is a reliable indicator of fracture healing. the imaging evidence of fracture healing usually lags behind the clinical picture.' treatment navicular stress fractures are treated with cast immobilisation. this treatment results in a successful outcome in 80% of patients and most athletes return to sport in 5 6 months.' references j. georgen t. venn-watson e. rossman d. et al. tarsal navicular stress fractures in runners. afr 1981; 136: 339-346. 2. pavlov h. torg j. freiberger r. tarsal navicular stress fractures: radiographic evaluation. radiology 1983; 148: 641-645. 3. spitz dj. newberg ah. imaging of stress fractures in the athlete. radiol clin north am 2002; 40: 324-326. 4. khan k. fuller p. bruckner p. outcome of conservative and surgical management of navicular stress fractures in athletes. am f sports med 1992; 20: 657-666. 35 sa journal of radiology • august 2003 case reports a grossly distended gallbladder masquerading as an infected hydatid cyst of the liver a n 87 year old woman was referred with symptoms of loss of weight, loss of appetite and nausea. physical examination revealed a large, non-tender mass in the right side of the abdomen thought to represent a possible cystic kidney. previous chest radiographs had demonstrated a large calcified hydatid cyst in the right lobe of the liver, as also shown by computed tomography (ct) (figure 1). previous barium enema had also demonstrated the large calcified echinococcus cyst and the colon had been markedly displaced to the left due to an infrahepatic mass. further ct sections demonstrated an apparently septated, low attenuation mass 10 cm below the calcified hydatid cyst, in the inferior aspect of the liver. the mass revealed a fairly thick enhancing wall, did not contain any calcification, but demonstrated a wfc van gelderen department of radiology, wanganui base hospital, wanganui, newlealand figure 1: ct demonstrates il heavily ca/c/fled hydatid cyst superiorly in the right lobe of the liver. 29 sa journal of radiology. may 1996 small pocket of air in its anterior aspect (figure 2). the remainder of the liver was normal, but the gallbladder could not be identified. subsequent ultrasound (us) examination (figure 3) confirmed the calcified hydatid cyst. it also demonstrated the hypoechoic mass related to the inferior aspect of the liver, containing multiple small hyperechoic areas, thought to confirm pockets of air as they were almost offluorescent" echogenicity and the acoustic shadows cast were not remarkable. as the gallbladder was not separately identified, a huge distended infected gallbladder was considered in the differential diagnosis, but in view of the other definite echinococcus cyst, a second infected hydatid cyst was advanced as a more likely diagnosis. militating against either diagnosis was the absence of significant pain or tenderness. figure 2: ct section 10 em below image in figure 1, reveals a large septated mass of low attenuation situated at the inferior aspect of tile liver containing a pocket of air anteriorly. this was thought to represent an infected hydatid cyst. the gal/bladder was not visualised. a cholecystotomy was performed revealing a grossly distended thick walled gallbladder containing an enormous number and variety of gallstones. finger palpation of the interior of the gallbladder revealed a probable gallbladder carcinoma and histology after punch biopsy confirmed this diagnosis. to page 3d office: european congress or raoiology ecr'97 neutorgasse 9/2a a-lolo vienna 1austria pilone: (+431 i) 533 40 64, 533 40 65, 533 40 66 fax: (+43/1) 533 40 649 email: orfice@ecr.telbcom.at www: www.rcr.telecom.at\ecr a grossly distended gallbladder masquerad ing as an infected hydatid cyst of the liver deadlines: figure 3: a transverse us section of the mass demonstrates a thick walled structure containing multiple small bright hyperechoic areas casting unremarkable shadows. this was erroneously thought to confirm the ct findings of an infected hydatid cyst. the surgeon's comment was as follows: "none of the many thousands of stones of all varieties and sizes were reported on us or cr scanning, nor was the carcinoma of the gallbladder". the ct and us images have subsequently been shown to radiological colleagues at other hospitals, and there was some reassurance in that they did not make a correct diagnosis more readily. the above case report demonstrates just how difficult it can be to establish a correct diagnosis, even ifthe disease process is of enormous proportions. in retrospect the non-visualisation of the gallbladder on both ct and us should have alerted one, but even then this is a well-known occurrence ifthe patient had had a meal before the examination. submission of abstracts: sept. 20, 1996 reduced registration fee: dec. 2, 1996 advance registration: jan. 31,1997 30 sajournal of radiology· may 1996 sajr cpd .indd cpd questionnaire 159 sajr november 2013 vol. 17 no. 4 concerning endovascular therapy for acute tumour-related obstruction of the superior vena cava using a self-expanding nitinol stent: 1. superior vena cava syndrome is characterised by venous congestion and increased pressure resulting from a displacement or compression of the superior vena cava (svc), which takes a fast and acute course in most circumstances. 2. the stanford classification divides stenoses into four types, with type iii being complete obstruction with reverse circulation in the azygos vein. 3. general and pharmacotherapeutic treatments can alleviate and cure symptoms with great clinical success. 4. in the event of severe symptoms, endovascular stent implantation represents the method of choice for acute treatment and is capable of providing rapid relief in up to 90% of cases. 5. failures after stent implantation may be linked to tumour invasion into the svc through the stent mesh and thrombus formation, with relevant stenosis defined as a constriction of the lumen by more than 50%. concerning cerebral schistosomiasis: 6. schistosomiasis is one of the most common parasitic infections among humans, and infection of the nervous system is rare. 7. on mri, cerebral schistosomiasis has a pseudo-tumour-like appearance that is hyperintense on t1w images and hyperintense on t2w images. concerning adrenal lesions encountered in current medical practice – a review of their radiological imaging: 8. most incidental adrenal lesions in patients without a background history of malignancy are benign, with the incidence almost zero. 9. ct is the cornerstone of adrenal imaging with morphology, ct densitometry, washout percentage and distant spread being crucial determinants that help to characterise an adrenal mass and guide diagnosis. 10. chemical shift imaging is the principal technique employed in the mr evaluation of adrenal lesions using inand out-of-phase techniques, and exploits the presence of abundant intracellular lipid in adenomas that helps to distinguish them from non-adenomatous lesions. 11. when classifying an adrenal neoplasm, it is not imperative to broadly establish if the lesion is hyper-functioning or non-hyper-functioning. 12. metastases are the most common malignant lesion affecting the adrenal gland, found in approximately 37% of cancer patients at autopsy. 13. myelolipoma is a benign, non-functioning adrenal neoplasm composed of an admixture of mature adipose tissue and haemopoietic elements, with macroscopic fat being the hallmark feature. 14. most adrenal lesions are successfully detected and accurately characterised on a single patient visit, using ct methods only with very few lesions requiring further evaluation by specialised techniques or expertise. concerning ct-guided biopsy of suspected malignancy: a potential pitfall: 15. any manipulation of paragangliomas, without appropriate medical therapy, can result in excess catecholamine release leading to a catecholamine crisis. 16. thirteen per cent of patients with a catecholamine-secreting tumour will not be hypertensive, and 8% will be asymptomatic altogether. concerning dual (type iv) left anterior descending artery: 17. this is seen relatively often with congenital malformations such as complete transposition of the great arteries and tetralogy of fallot. 18. dual left anterior descending coronary artery is defined as the presence of two lads within the anterior inter-ventricular sulcus: a short lad that courses and terminates low in the aivs, and a long lad that originates from either the lad proper or the right coronary artery, then enters the distal aivs and courses to the apex. concerning cribriform pattern in brain mri: a diagnostic clue for mucopolysaccharidosis: 19. the earliest and most common abnormality found in patients with mps is cystic lesions that correspond to enlargement of the virchow-robin perivascular spaces (pvs), which are arachnoidlined spaces that accompany penetrating arteries and arterioles into the brain parenchyma. 20. pituitary sellar abnormalities include a j-shaped, elongated sella with a shallow anterior convexity owing to an exaggerated normal shallow impression of the sulcus chiasmaticus. mark each numbered statement as true (a) or false (b). a maximum of 5 ceus will be awarded per correctly completed test. instructions: 1. cpd questionnaires must be completed online by registering with www.cpdjournals.co.za. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your cpd certificate(s). 4. please contact the online manager (021 681 7200 or publishing@hmpg.co.za) in the event of queries. accreditation number: mdb001/012/01/2013 (clinical) earn 54 cme credits, explore hundreds of educational and scientific electronic exhibits, and select from 80 sessions. learn more and register at www.arrs.org/meeting. advance your skills and connect with t o p r a d i o l o g i s t sm a n c h e s t e r g r a n d h y a t t early-bird deadline: february 21, 2014 pre-registration deadline: april 4, 2014 original article diagnosis of paget's disease from chest radiographs: the~~dense coracoid sign" abstract incidental paget's disease of the shoulder as detected on chest radiographs is considered. five patients demonstrated typical proximal humeral pagetoid involvement, but involvement of the acromiocoracoid or glenocoracoid parts of the scapula was twice as frequent. the dense coracoid was a constant feature and this sign should be sought on chest radiographs especially in the older patient. introduction the radiological features of paget's disease of the shoulder were noted on chest radiographs in 16 patients. the parts of the shoulder girdle involved were analysed and the prevalence of humeral and scapular involvement determined. wfc van gelderen . mbchb. ffrad (d) (sa) tygerberg hospital and the university of stellenbosch, cape town methods and results the chest radiographs of 16 patients with shoulder girdle involvement due to paget's disease were retrospectively is sa journal of radiology. november 1996 reviewed. infive patients (30%) the diagnosis of paget' s disease was made meidentally from chest x -rayswith a localized view of the shoulder. a frontal radiograph of the pelvis and a lateral film of the skull con£rmed the diagnosis. in a further ilpatients, radiographs of the pelvis and! or skull were available in conjunction with chest x-rays, and shoulder girdle involvement was seen as part of widespread paget's disease. the patients ranged in age from 44-79 years (average 65 years), 12 males and 4 females. one patient was black, 4 were caucasian and 11 of mixed descent. chest radiographs were requested for further evaluation of pulmonary or cardiac disease and no shoulder complaints were mentioned on the request forms. the shoulder girdle involvement was carefully analysed in each patient. in one patient both proximal humeri and clavicles were involved symmetrically and extensively by coarse sclerotic paget's disease. in five patients only the proximal humerus was involved, unilateral in two patients and bilateral in three patients. in ten patients the scapula only was affected, bilateral acromiocoracoid involvement in one patient, and unilateral involvement in the remainder. (five left side,four right side). the unilateral disease included: acromiocoracoid only (five patients), glenocoracoid only (three patients) and acromioglenocoracoid disease (one patient). sclerosisof the coracoid, whether accompanied by acromial or glenoid involvement, was detected in all cases of scapular involvement radiographs of the pelvis demonstrated paget's diseasein 13,were normal in one and not available in two patients. the lateral skull x-rays showed involvement by paget's disease in eight, were normal in three and not available in five patients. the above features are illustrated (figures 1-3).achestx-rayina62yearoldman demonstrated incidental sclerosis of the topage19 diagnosis of paget's disease frorn chest radiographs: the "dense coracoid sign" from page 18 coracoid and acromial processes of the left scapula (figure 1). pelvis and skull x-rays demonstrated extensive paget's disease. eight years later features on chest figure 1: chest demonstrates density and expansion of the acromiocoracoid aspect of the left scapula (arrow) without the humeral head being affected. features are consistent with pagel's dise . radiographs remained unchanged but the pagetoid involvement of the pelvis and skull had become far more advanced. a 52 year old man presented with a spontaneous left pneumothorax and increased density of the right acromiocoracoid scapula was noted on a chest radiograph (figure 2). a frontal figure 2: predominant involvement of acromiocoracoid part of right scapula due to paget's disease. glenoid affected to a lesser degree and humerus normal. note expansion and sclerosis of coracoid process discovered incidentally on chest xray. pelvic radiograph demonstrated involvement by paget's disease but the lateral skull x -ray was normal. a 65 year old man was referred for a chest x -ray because of respiratory symptoms. infective changes were noted in the left lower lobe but incidental increased density and expansion of the left glenocoracoid scapula was also noted (figure 3).a radiograph of the pelvis con:6rmed figure 3: marked pagetoid involvement of glenocoracoid aspect of left scapula with acromion less affected and proximal humerus unaffected. incidental finding on chest radiograph and x-ray pelvis confirmed diagnosis of paget's disease but radiographs of the skuif demonstrated unsuspected multiple myeloma. signs of paget's disease. a lateral skull x-ray showed no pagetoid features but instead demonstrated signs of co-existing multiple myeloma. the latter diagnosis was subsequently confirmed clinically. discussion paget's disease may affect one bone or many and its distribution tends to be widespread and haphazard. the bones most often affected are the pelvis,femur, tibia,lower part of the spine and the skull, whereas the clavicle, ribs, sternum and the bones of the arm are lessoften aflected.' the scapula and thehumerushavebeenidentifiedasunusual sitesofinvolvement-" our experience has been different, with shoulder involvement being more common, however only a small number of patients has been 19. sa journal of radiology· november 1996 considered. the prevalence of paget' s disease in south africa has previously been assessed" itis considered to be rare amongst the black races of theafrican continent. ofspeci:6.cinterest isthat paget's disease of the shoulder can be diagnosed from chest radiographs, and the disgnosis can then be confirmed by taking x-rays of the pelvis and skull. in dveoutofl6 patients involementwas limited to the proximal humerus, but in 120 patients the scapula was involved, and in particular the coracoid part. the latter part would always be included on a chest x-ray; and a sclerotic, expanded coracoid process with coarse trabecu lation should alert one to the possible diagnosis of paget' s disease. acrorniocoracoid involement was found to be more common than glenocoracoid disease but both types were associated with pagetoid features of the pelvis and! or skull. as chest radiographs form the largest part of the workload of radiology departments' specific attention should be given to the shoulder girdle, especially in the older patient. therapeutic implications of estabhshing a diagnosis of paget's disease are of definite importance. references 1. renton p. pag t's disease. in: sulton d.a textbook of radiology and imaging, vol i. edinburgh: chur hill livingstone, 1993 : 79 82. 2. yochum tr & rowe lj. essentials of skeletal radiology, vow. baltimore :williams& wilk ns, 1987 :865 866. 3. ilamdy re. paget's disease of bone : assessmem and management, eastbome, england: armour pharmaceutical company limited, 1981 :44-49. 4. barry he. paget's disease of bone. edinburgh and london: e&s livingstone ltd, 1969: 42 43. 5. guyer pb & chamberlain at paget's disease of bone in south africa. clinical radiology 1988: 39: 51 52. abstract introduction case report discussion conclusion ethical considerations acknowledgements references about the author(s) charlotte de wilde department of radiology, ghent university, belgium alain bols department of oncology, az st.-jan brugge-oostende, belgium ivo van den berghe department of pathology, az st.-jan brugge-oostende, belgium kenneth coenegrachts department of radiology, az st.-jan brugge-oostende, belgium citation de wilde c. bols a. van den berghe i. coenegrachts k. extraosseous ewing’s sarcoma, a case report on a rare diagnosis in an 80-year-old woman with a large abdominal mass. s afr j rad. 2017; 21(1), a1183. https://doi.org/10.4102/sajr.v21i1.1183 case report extraosseous ewing’s sarcoma, a case report on a rare diagnosis in an 80-year-old woman with a large abdominal mass charlotte de wilde, alain bols, ivo van den berghe, kenneth coenegrachts received: 26 jan. 2017; accepted: 14 mar. 2017; published: 29 may 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract extraosseous or extraskeletal ewing’s sarcoma is a very rare mesenchymal soft tissue malignancy. we report on a case of abdominal swelling in an 80-year-old woman caused by a large intra-abdominal ees. this case report illustrates that ewing’s sarcoma can occur in adults and elderly, and highlights the importance of early diagnosis because of poor prognosis. introduction this case report demonstrates the rare diagnosis of an extraskeletal ewing sarcoma (ees) in an elderly woman with a large abdominal mass. ees is commonly diagnosed in a younger population, which makes our case very unusual. this article discusses the presentation and typical radiological appearance of extraskeletal ewing sarcoma and the differential diagnoses with their radiological appearances. case report an 80-year-old female patient was referred by her general practitioner and presented at the radiology department for an abdominal ultrasound. she complained about painless abdominal swelling for several weeks. a firm intra-abdominal mass was palpable during clinical examination. the abdominal ultrasound showed a large, heterogeneous and minimally vascularised intra-abdominal midline mass, measuring about 25 cm × 20 cm (figure 1). figure 1: ultrasound image of the mass with doppler technique, showing a large, heterogeneous and minimally vascularised intra-abdomina mass, situated on the midline and measuring about 25 cm × 20 cm (asterisk). the ultrasound was followed by a computed tomography (ct) scan of the abdomen with oral and intravenous contrast agent. ct showed a large (20 cm × 27 cm ×16 cm) (figure 2), lobulated mass with heterogeneous contrast uptake, lack of calcifications and central necrosis, probably originating from the mesentery. there was no evidence of invasion of the adjacent small bowel. no metastatic lesions were seen. an ultrasound-guided core biopsy was performed (figure 3). figure 2: axial computed tomography images of the mass, showing a large (20 cm × 27 cm ×16 cm), lobulated mass with heterogeneous contrast uptake, lack of calcifications and central necrosis, originating from the mesentery (asterisk). evident mass effect but no invasion of the adjacent small bowel. figure 3: sagittal computed tomography images of the mass (asterisk). microscopic examination of the biopsy sample revealed a high-grade small blue round cell tumour, immunohistochemically compatible with an extraskeletal ewing’s sarcoma (figure 4). the diagnosis was confirmed with fluorescence in situ hybridisation (fish) cytogenetic evaluation and immunohistochemistry staining, the latter showing positive cd 99 and synaptofysine staining (figure 5). figure 4: histological image (hematoxylin and eosin staining, enlargement 200x) showing compact growth of the high-grade small blue round cell tumour with focal desmoplasia (arrow). figure 5: immunohistochemical images (enlargement 10 × 5) showing positive cd99 and (a) synaptophysin (b) immunohistochemistry staining. discussion ewing’s sarcoma is a high-grade rounded cell sarcoma, which arises from both skeletal and extraskeletal mesenchymal cells with a t(11;22) chromosomal translocation. however, there are important differences between the extraosseous and the osseous type of ewing’s sarcoma. these differences mainly comprise age distribution, clinical presentation, prognosis, treatment and survival. ees is more common in adults, although usually in young adults in contrast to our case. adults tend to have a worse prognosis than children with this presentation of ewing’s sarcoma. a possible explanation for the worse outcome in adults is the inability to tolerate the aggressive chemotherapy.1,2 it is important to recognise that approximately 20% of all cases of ewing’s sarcomas occur in patients older than 18 years and at least 50% of these patients have an extraskeletal presentation. the most prevalent extraskeletal sites are the chest (most common), the abdomen (both intraand retroperitoneal), the soft tissues of the extremities (the gluteal region and the lower extremities are relatively common sites) and the head and neck region (most rare location).2,3,4 on ct, abdominal eess show heterogeneous contrast enhancement with hypoattenuating areas corresponding to necrosis and high-density foci in cases of haemorrhage. calcification is atypical, occurring in approximately 10% of tumours at presentation. when present, it appears faint and amorphous.2,4 most abdominal eess are unilateral and do not cross the midline, in contrast to our case.3 the radiological differential diagnosis for abdominal ees includes: other peritoneal tumours such as lymphoma, peritoneal metastasis and lymph node metastases (often with associated retroperitoneal lymph node enlargement) gastrointestinal stromal tumours (gist) (gastric or small bowel gist, extends exophytically from the gastrointestinal tract) desmoid tumour (arising at the site of scarring from prior surgery) other soft tissue sarcomas (like synovial sarcoma and rhabdomyosarcoma).4,5 extraskeletal ewing’s sarcomas in adults are large tumours that metastasise to the lung and can invade adjacent organs, although they tend to displace adjacent structures rather than invade them. they are aggressive tumours, often with distant metastases and local recurrence and a 5-year survival rate of less than 50%.3 patients with localised ees are treated aggressively with neoadjuvant chemotherapy, followed by surgery and in the event of inadequate surgical margins, post-operative radiotherapy. molecular-targeted treatments are in development.2,3 the case discussed above was treated with neoadjuvant carboplatin-etoposide, followed by excision of the tumour and radiotherapy. conclusion extraskeletal ewing’s sarcomas are rare tumours and even more rare in the abdomen. they occur in an older age group compared to osseous ewing’s sarcoma, but are rare in the elderly. they should, however, be considered in the differential as this will help guide pathologists and clinicians in making the final diagnosis. ethical considerations there were no ethical conflicts. this article does not contain any studies with human or animal subjects. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.d.w. and k.c. performed the ultrasound and computed tomography scan on the patient. they followed up the histology results and the oncological treatment with i.v.d.b. and the oncological treatment with a.b., respectively. references applebaum ma, worch j, matthay kk, et al. clinical features and outcomes in patients with extraskeletal ewing sarcoma. cancer. 2011;117(13):3027–3032. https://doi.org/10.1002/cncr.25840 javery o, krajewski k, o’regan k, et al. a to z of extraskeletal ewing sarcoma family of tumors in adults: imaging features of primary disease, metastatic patterns, and treatment responses. ajr am j roentgenol. 2011;197:w1015–w1022. https://doi.org/10.2214/ajr.11.6667 somarouthu bs, shinagare ab, rosenthal mh, et al. multimodality imaging features, metastatic pattern and clinical outcome in adult extraskeletal ewing sarcoma: experience in 26 patients. br j radiol. 2014;87:20140123. https://doi.org/10.1259/bjr.20140123 huh j, kim kw, park sj, et al. imaging features of primary tumors and metastatic patterns of the extraskeletal ewing sarcoma family of tumors in adults: a 17-year experience at a single institution. korean j radiol. 2015;16(4):783–790. https://doi.org/10.3348/kjr.2015.16.4.783 ulusan s, koc z, kayaselcuk f. gastrointestinal stromal tumours: ct findings. br j radiol. 2008;81(968):618–623. https://doi.org/10.1259/bjr/90134736 abstract introduction case discussion conclusion acknowledgements references about the author(s) bogna targonska department of radiology, renown regional medical center, reno, nv, united states jamie frost helen devos childrens hospital, advanced radiology services, grand rapids, mi, united states sanjay prabhu department of radiology, boston children’s hospital, boston, ma, united states citation targonska b, frost j, prabhu s. anti-ma2-antibody-associated encephalitis: an atypical paraneoplastic neurologic syndrome. s afr j rad. 2018;22(1), a1310. https://doi.org/10.4102/sajr.v22i1.1310 case report anti-ma2-antibody-associated encephalitis: an atypical paraneoplastic neurologic syndrome bogna targonska, jamie frost, sanjay prabhu received: 11 jan. 2018; accepted: 03 mar. 2018; published: 17 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract paraneoplastic syndromes are a heterogeneous group of conditions affecting cancer patients, where the signs and symptoms are not owing to the local effects of the tumour but instead owing to humoral or immunologic effects. we describe an unusual presentation of a paraneoplastic neurologic syndrome presenting with predominant involvement of the hypothalamus and deep grey nuclei secondary to an anterior mediastinal germinoma and associated with anti-ma2 antibody. introduction paraneoplastic syndromes may affect multiple organ systems and may cause metabolic, endocrine, dermatologic, haematologic and neurologic derangements. paraneoplastic neurologic syndrome (pns) is a rare entity and can affect various areas of the central or peripheral nervous system. onset of symptoms may in some instances precede the diagnosis of the underlying malignancy. furthermore, findings on imaging of the brain may be the first step in the patient’s workup and consideration of this entity is important in further management. case an adolescent male presented to the emergency department with prolonged fatigue progressing over 5 months. this was followed by subjective fevers, decreased memory and increased confusion in the few days prior to presentation and finally an episode of hallucinations the evening prior to presentation. the patient had no prior medical or surgical history and no known allergies. vaccinations were up to date. he denied smoking, drinking or illicit drug use. on examination in the emergency department, the patient was somnolent, but rousable, and answered questions appropriately. there was no focal neurological deficit. cell count and chemistry panel were unremarkable. lumbar puncture revealed normal opening pressures, lymphocytic pleocytosis and an elevated protein level. cerebrospinal fluid was negative for ebstein–barr virus (ebv), cytomegalovirus (cmv), herpes simplex virus (hsv), tumour markers and anti-ace (sarcoid). oliogoclonal bands were positive, and an expanded work up for autoimmune causes and paraneoplastic processes was initiated. magnetic resonance imaging (mri) demonstrated abnormal t2 signal in the basal ganglia, thalami, hypothalamus and anterior midbrain. increased signal was also noted involving both medial temporal lobes, left greater than right (figure 1). these regions showed avid enhancement (figure 2). figure 1: (a) axial fluid attenuation inversion recovery (flair) imaging demonstrating symmetric increased signal involving the basal ganglia and thalami bilaterally, (b) increased signal intensity is also noted in the hypothalamus, anterior midbrain and to varying degrees in both medial temporal lobes. figure 2: axial t1-weighted post-contrast imaging (a and b) demonstrating avid enhancement corresponding to the regions of t2/flair signal abnormality. given the high clinical suspicion for a paraneoplastic process, further imaging was obtained including a scrotal ultrasound and computed tomography (ct) chest. the ultrasound was negative, but the ct demonstrated an anterior mediastinal mass (figure 3). figure 3: axial (a) and sagittal (b) contrast enhanced computed tomography imaging of the chest demonstrates a well-defined cystic and solid mass containing punctate calcifications in the anterior mediastinum, without mass effect on the adjacent vascular structures. the patient underwent resection of the anterior mediastinal mass. analysis of the pathology specimen revealed a 4-cm germinoma associated with a thymic epithelial cyst. the paraneoplastic panel results became available at that time and demonstrated positive anti-ma2 antibodies. follow-up imaging on day 7 after surgery demonstrated persistence of t2/flair abnormality, but a significant reduction in the degree of enhancement compared to pre-operative imaging (figure 4). figure 4: t1-weighted post-contrast imaging (a and b) following surgery demonstrates near-complete resolution of the previously noted enhancement. discussion paraneoplastic neurological syndromes occur in patients with cancer and cause a wide range of clinical symptoms. damage to the nervous system is thought to result from immunologic cross-reactivity between neoplastic antigens and normal neuronal tissues. the most common pns is the lambert-eaton myasthenic syndrome (lems), which occurs in 2% – 3% of patients with small-cell lung cancer.1 overall, pns affect less than 1% of cancer patients and are rare compared to the direct effects of the tumour, its metastases or the effects of cancer treatment.1,2 therefore, a diagnosis of a paraneoplastic syndrome should be made after the exclusion of other causes for the patient’s symptoms. fifty per cent of primary tumours associated with paraneoplastic limbic encephalitis are small-cell lung carcinomas.3 other tumours associated with pns include testicular germ cell tumours, breast cancer, thymoma, lymphoma and teratoma.4 anti-ma2-associated encephalitis is a pns characterised by isolated or combined limbic, diencephalic or brainstem dysfunction.5,6 these antibodies can be detected in serum and cerebrospinal fluid and are highly specific for this disease entity. clinicopathologic features of paraneoplastic limbic encephalitis are well-defined, with patients usually presenting with short-term memory loss, seizures, irritability, depression and cognitive decline. however, less than 30% of patients with anti-ma2 encephalitis exhibit the typical clinical presentation of limbic encephalitis, and therefore this entity may go unrecognised for a prolonged period of time before the diagnosis is made.1,2 patients may present with a wide array of symptoms, including excessive sleepiness, ocular movement abnormalities, hypokinesis or pure psychiatric disturbance.5,6 a series published by dalmau et al. included 38 patients with anti-ma2-associated encephalitis, where neurological symptoms preceded tumour diagnosis in 62% of patients. areas of the brain involved on mri may include a combination of the medial temporal lobes, hypothalamus, basal ganglia, thalami or the upper brainstem. the regions of abnormality demonstrate increased signal on t2wi/flair sequences and may occasionally enhance. early identification and treatment of the underlying malignancy is the most important component of treatment of the paraneoplastic syndrome. unlike many of the other paraneoplastic syndromes, anti-ma2-associated encephalitis has a relatively high response rate to treatment, with approximately 30% demonstrating neurological improvement and another 20% – 40% stabilising in response to therapy.5,6 in our case, the diagnosis of paraneoplastic encephalitis was made based on imaging findings, presence of anti-ma2 antibodies and exclusion of other causes. conclusion we have presented an unusual case of a paraneoplastic neurological syndrome presenting with primarily hypothalamic and basal nuclei involvement and associated with anti-ma2 antibodies where the tumour was found secondarily. this emphasises the need to consider rare diagnoses such as pns when faced with unusual neurologic findings. acknowledgements the authors would like to thank dr michael rivkin, department of neurology at boston children’s hospital. competing interests the authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article. authors’ contributions b.t. wrote the article with the help of j.f. ds.p. was the supervising mentor. references rees jh. paraneoplastic syndromes: when to suspect, how to confirm, and how to manage. j neurol neurosurg psychiatry. 2004;75(suppl 2):ii43–ii50. https://doi.org/10.1136/jnnp.2004.040378 pelosof lc, gerber de. paraneoplastic syndrome: an approach to diagnosis and treatment. mayo clinic proceed. 2010;85(9):838–854. https://doi.org/10.4065/mcp.2010.0099 sahashi k, sakai k, mano k, hirose g. anti-ma2 antibody related paraneoplastic limbic/brain stem encephalitis associated with breast cancer expressing ma1, ma2, and ma2 mrnas. j neurol neurosurg psychiatry. 2003;74(9):1332–1335. https://doi.org/10.1136/jnnp.74.9.1332 zhang h, zhou c, wu l, ni f, zhu j, jin t. are onconeural antibodies a clinical phenomenology in paraneoplastic limbic encephalitis? mediators inflamm. 2013;2013:1–9. yamamoto t, tsuji s. anti-ma2-associated encephalitis and paraneoplastic limbic encephalitis. brain nerve. 2010;62(8):838–851. dalmau j, graus f, villarejo a, et al. clinical analysis of anti-ma2-associated encephalitis. brain. 2004;127(8):1831–1844. https://doi.org/10.1093/brain/awh203 abstract references about the author(s) leonie scholtz department of radiology, university of pretoria, south africa citation scholtz l. cardiovascular imaging in south africa: is the heartache easing? s afr j rad. 2016;20(2), a1045. http://dx.doi.org/10.4102/sajr.v20i2.1045 editorial cardiovascular imaging in south africa: is the heartache easing? leonie scholtz copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract there is an escalation in the prevalence of cardiovascular disease in sub-saharan africa. the radiology community of south africa plays an important role in curbing this epidemic. cardiovascular magnetic resonance is now regarded as a very important tool in our diagnostic armamentarium, and in this issue some of the established applications, as well as exciting new developments, are discussed. according to albert einstein, the world is a dangerous place to live; not because of the people who are evil, but because of the people who don’t do anything about it. the world is experiencing a steady rise in deaths due to cardiovascular disease (cvd). in a recent paper published by roth et al., in the new england journal of medicine, data from the global burden of disease study 2013 were analysed, and it was concluded there was a rise of 41% in the incidence of cvd between 1990 and 2013.1 the factors underlying the global epidemic are population growth, an aging society and particularly in the developing world an explosion of risk factors: a striking example of the epidemiologic transition.1,2 eighty percent of deaths due to cvd occur in developing countries.3 although the epidemic is already rampant in many parts of the world, for example south east asia, eastern europe and the gulf states, sub-saharan africa is particularly vulnerable due to the multitude of challenges. hypertension, urbanisation, a rise in diabetes mellitus, obesity, smoking, physical inactivity and the growing number of long-term survivors with hiv and/or aids contribute heavily to an epidemic that is imminent and may have already become established in some population groups in africa.4 despite a steady decline in the rate of infection worldwide, the hiv and/or aids infection rate in sub-saharan africa remains high. there is a substantially increased risk of cvd in hiv-infected patients (both in treated and untreated patients).5,6 in the diagnosis and management of cvd, sophisticated imaging is playing an increasing and, in some situations, indispensable role. with the advance of technology has come an increased use of imaging procedures to screen for covert but potentially life-threatening cvd. the value of imaging is, for the first time, now the focus of randomised trials.7 cardiac imaging, historically, has always been the underdog amongst our imaging armamentarium in south africa, but during the past few years we have seen a welcome change. a concerted effort from the radiological society of south africa (rssa) has resulted in workshops and meetings conducted by world experts on computerized coronary arteriography (ccta), as well as the recent first cardiovascular magnetic resonance conference (cmr) locally. industry also participated in an effort to decrease the amount of negative conventional angiograms and to streamline and direct the correct referrals to non-invasive alternative imaging. this resulted in productive discussions between the cardiology and radiology communities and laid a foundation for better communication in the future. the south african cardiac imaging society (sasoci), a sub-committee of rssa, was founded in 2015 and the first webinar series on cmr was recently held under their supervision. this special south african journal of radiology cardiac magnetic resonance issue underscores the welcome interest that now exists amongst radiologists and academic institutions to actively promote cardiac imaging in south africa. post-processing forms an important part of cmr and is aptly addressed here and so are pericardial and valvular diseases, which remain the most common cardiovascular afflictions locally. tissue characterisation is probably the most exciting and unique aspect of cmr. mapping techniques will enable us in future not only to differentiate between different forms of pathology, but also to quantify the degree of myocardial involvement. hypertrophic and infiltrative cardiomyopathies are good examples where cmr is playing an increasing role. unfortunately, in spite of our substantial efforts we still face huge challenges in south africa: the general population does not have access to sophisticated high-end imaging, especially in rural areas. south africa has a serious shortage of health-care workers and a lack of sufficient cmr and ccta experience amongst local radiologists. infectious diseases, which include hiv, tuberculosis and malaria, receive priority amongst policymakers. the lack of cause-specific mortality data probably adds to the perceived inertia amongst the policymakers to address the threat more proactively. radiology can play an important role in the diagnosis of cvd. we need to train more radiologists and we need to keep them here. we also need to continue with our efforts to expand local expertise, especially regarding ct and cmr, and we need to participate with the clinicians in the documentation of cardiac abnormalities. more diagnostic facilities need to be installed in the rural areas (e.g. mobile chest x-ray and echocardiography equipment), which will go a long way to screen patients with cardiac abnormalities. they can then be referred to specialised centres for more sophisticated clinical and diagnostic imaging assessment. the egyptian writer maquib mahfouz who won the nobel prize for literature in 1988 said, ‘you can tell whether a man is clever by his answers. you can tell whether a man is wise by his questions.’ policymakers often demand answers and surround themselves with experts who supply them with the requested solutions. more than often these solutions fail to address the root of the matter. opposed to the uncritical consumption of the information market, we are challenged to question the comfortable and the traditional. paraphrasing einstein and mahfouz: we need wise men, not clever men, to care for mankind and to guide world events. references roth ga, forouzanfar mh, moran ae, et al. demographic and epidemiologic drivers of global cardiovascular mortality. n engl j med. 2015;372(14):1333–1341. http://dx.doi.org/10.1056/nejmoa1406656 omran ar. the epidemiologic transition. a theory of the epidemiology of population change. milbank mem fund q. 1971;49(4):509–538. http://dx.doi.org/10.2307/3349375 lopez ad, mathers cd, ezzati m, jamison dt, murray cjl. measuring the global burden of disease and risk factors, 1990–2001. in: lopez ad, mathers cd, ezzati m, jamison dt, murray cjl, editors. global burden of disease and risk factors. washington, dc: the international bank for reconstruction and development/the world bank; 2006; n.p. onen cl. epidemiology of ischaemic heart disease in sub-saharan africa. cardiovasc j afr. 2013;24(2):34–42. http://dx.doi.org/10.5830/cvja-2012-071 islam fm, wu j, jansson j, wilson dp. relative risk of cardiovascular disease among people living with hiv: a systematic review and meta-analysis. hiv med. 2012;13(8):453–468. http://dx.doi.org/10.1111/j.1468-1293.2012.00996.x data collection on adverse events of anti hivdsg, smith c, sabin ca, et al. factors associated with specific causes of death amongst hiv-positive individuals in the d:a:d study. aids. 2010;24(10):1537–1548. douglas ps, hoffmann u, lee kl, et al. prospective multicenter imaging study for evaluation of chest pain: rationale and design of the promise trial. am heart j. 2014;167(6):796–803.e1. http://dx.doi.org/10.1016/j.ahj.2014.03.003 abstract introduction case presentation discussion conclusion acknowledgements reference about the author(s) prema mohandas department of general surgery, southland hospital, new zealand ahmed o.a. krim department of radiology, southland hospital, new zealand paul samson department of general surgery, southland hospital, new zealand citation mohandas p, krim aoa, samson p. unexpected finding of splenic peliosis in a traumatic spleen in a patient with cleidocranial dysplasia. s afr j rad. 2018;22(1), a1371. https://doi.org/10.4102/sajr.v22i1.1371 case report unexpected finding of splenic peliosis in a traumatic spleen in a patient with cleidocranial dysplasia prema mohandas, ahmed o.a. krim, paul samson received: 04 june 2018; accepted: 22 july 2018; published: 27 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract we present a case of traumatic rupture of the spleen in a man with cleidocranial dysplasia. the computed tomography imaging showed multiple low-grade lacerations of the spleen which initially led to conservative patient management. however, with clinical deterioration, the patient underwent an emergent splenectomy. post-operative histology revealed splenic peliosis with multiple lacerations. the radiological and surgical management of post-traumatic splenic peliosis may differ from those with an otherwise normal spleen. introduction splenic peliosis is an extremely rare benign condition characterised by the presence of blood-filled cysts varying in size from one millimetre to several centimeters1. while peliosis may occur in any organ belonging to the mononuclear phagocytic system (which includes the liver, spleen, bone marrow and lymph nodes), isolated splenic peliosis remains rare1. there have been no published cases of patients with splenic peliosis associated with cleidocranial dysplasia. to our knowledge, only 21 cases of isolated splenic peliosis have been reported in the literature2. radiological imaging can be non-specific in splenic peliosis, and the most common differential diagnoses include lymphoma, vascular tumours or infective pathology3. cleidocranial dysplasia, also known as cleidocranial dysostosis, is a congenital disorder caused by a genetic mutation. it is a rare generalized skeletal dysplasia with a bone developmental abnormality. the condition is characterised by widened sutures, multiple wormian bones, hypoplasia or aplasia of the clavicles, abnormal teeth, vertebral and pubic symphysis abnormalities4. case presentation a 35-year-old gentleman presented to the emergency department (ed) following a motor-bicycle accident (mba). he was known to have congenital cleidocranial dysplasia, but an otherwise unremarkable history. on clinical assessment, the patient was haemodynamically stable with significant tenderness over the left lateral chest wall and left hip. trauma computed tomography (ct) revealed multiple posterior rib fractures on the left side with a small haemopneumothorax, multiple splenic lacerations with a subcapsular haematoma (figure 1) and a comminuted fracture of the left femoral head with posterior dislocation. the splenic laceration was managed conservatively with serial clinical assessment, and the left femoral head fracture was repaired operatively by total hip joint replacement on day two post admission. later during admission, serial blood tests revealed a drop in haemoglobin concentration and the patient cardiovascularly deteriorated (day 10 post admission). an urgent ct scan revealed that the spleen had increased in size with an associated subcapsular and intraparenchymal haematoma and a moderate amount of free fluid in the pelvis (figure 2). in view of his clinical and radiological deterioration, the patient was expedited to the operating theatre and underwent an emergency laparotomy. intra-operative findings were of 3000 ml of frank intraperitoneal blood with clots and multiple lacerations of the spleen. splenectomy was performed and the patient went on to make an unremarkable recovery and was discharged home a week later. figure 1: (a) axial and (b) coronal images on the day of admission, showing multiple lacerations of the spleen with a subcapsular haematoma. figure 2: (a) axial and (b) coronal images on day 10 post admission showing an enlarged spleen with an increased size of the subcapsular and intraparenchymal haematomas and free fluid surrounding the spleen and liver. histopathology noted subcapsular haemorrhage and, on sectioning, the specimen showed multiple haemorrhagic cyst-like lesions of up to 35 mm in diameter and traumatic haemorrhage (figure 3). these cystic blood-filled lesions within the splenic parenchyma were consistent with splenic peliosis. figure 3: pathology, cut specimen of the splenic parenchyma characterised by multiple blood-filled cyst-like lesions of varying sizes within the splenic parenchyma. discussion splenic peliosis is a rare condition and often clinically silent, until found incidentally on routine scans. splenic rupture, either spontaneous or traumatic, may result in acute presentation5. the etiology of splenic peliosis is often unclear, however, causal links between chronic alcoholism, corticosteroids, aids and the oral contraceptive pill are thought to be linked 2. in some cases, no predisposing link can be found1,3. there is a view in the literature that these represent congenital or acquired vascular malformations which manifests into cystic dilation under raised local intravascular pressure6. interestingly, our case had congenital cleidocranial dysplasia. although there has been no reported associative link in the literature between peliosis and cleidocranial dysplasia, it is plausible that these patients may be predisposed to congenital vascular malformations and hence possibly a higher incidence of peliosis. the diagnosis of splenic peliosis relies on the radiological findings of multiple small hypo-attenuating cyst-like lesions with fluid levels mostly located around the para-follicular region of the spleen1. if the cysts rupture, either spontaneously or secondary to trauma, subcapsular haematoma, splenic laceration, and intra-abdominal haemorrhage will be evident. the radiological diagnosis of peliosis, or any other incidental pathology, can be very challenging in the setting of abdominal trauma, as the findings might be obscured by co-existent splenic lacerations. ct imaging interpretation may upgrade the splenic injury due to the presence of congenital haemorrhagic cysts mimicking the appearance of multiple splenic lacerations. the main ct imaging findings of peliosis are multiple well-defined or ill-defined low-density lesions, high density in presence of haemorrhage, with a variable pattern of enhancement post contrast7. magnetic resonance imaging can also aid in the diagnosis of peliosis, although ct imaging is routine in trauma1. the surgical management in splenic laceration with peliosis may differ from those with a normal spleen with a lower threshold for splenectomy. this is to prevent organ rupture and reduce the risk of life-threatening morbidity and mortality. prophylactic splenectomy has been recommended in those individuals with an incidental diagnosis of splenic peliosis6. in the presence of trauma, surgical intervention and splenectomy is effective management, although where patients are haemodynamically stable, and resources permit, interventional radiology to perform splenic artery embolization can also be effective8. conclusion isolated splenic peliosis is a rare entity, which could predispose patients to life-threatening bleeding with or without significant trauma. ct imaging plays an important role in the diagnosis and patient management, and surgical intervention is the definitive management to prevent life-threatening morbidity and mortality. acknowledgements this case report was conducted in the department of surgery and department of radiology, southland hospital, new zealand. dr beom jun lee, radiology trainee, who assisted with the initial manuscript editing and structure. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions p.m. (surgical registrar) was the project leader who wrote the manuscript. a.o.a.k. (consultant radiologist) was responsible for the main supervision, manuscript editing, radiological input and legends. p.s. (consultant surgeon) provided surgical reviewing. reference j davidson, k tung, splenic peliosis: an unusual entity: br j radiology. 2010 jun; 83; e126–e128. begum s, khan mr. splenic peliosis and rupture – a surgical emergency: case report and review of the available literature. j appl hematol 2016;7:143–147. https://doi.org/10.4103/1658-5127.198508 daniel j ashbrook, roger w james, andrea j philips, anthony g holbrook, andrew c agombar – splenic peliosis with spontaneous rupture: report of two cases. bmc surgery. 2006;6:9 https://doi.org/10.1186/1471-2482-6-9 ankur singh et al, cleidocranial dysplasia with normal clavicles: a report of a novel genotype and a review of seven previous cases: molecular syndromology. 2015;6:83–86. https://doi.org/10.1159/000375354; pmid:26279653 pmcid:pmc4521062 g singh-ranger, n rajarajan, s aftab, splenic peliosis – a potentially fatal condition which can mimic malignancy, international seminar in surgical oncology. 2007;4:27. https://doi.org/10.1186/1477-7800-4-27; pmid:18067667 pmcid:pmc2222050 tsokos m1, erbersdobler, pathology of peliosis, a forensic sci int. 2005 apr 20;149(1):25–33. https://doi.org/10.1016/j.forsciint.2004.05.010 pmid:15734106 christop a. karlo, paul stolzmann, richard k, katem alkadhi, computer tomography of the spleen: how to interpret the hypodense lesion. insight imaging 2013; 4;65–75. https://doi.org/10.1007/s13244-012-0202-z; pmid:23208585 pmcid:pmc3579987 oriordan k, blei a, vogelzang r, nemcek a, abecassis m. peliosis hepatis with intrahepatic hemorrhage: successful embolization of the hepatic artery. hpb surg 2000;11(5):353–8. https://doi.org/10.1155/2000/94813; pmid:10674752 pmcid:pmc2423992 sajr 982 cribriform pattern in brain mri: a diagnostic clue for mucopolysaccharidoses s biswas, mb bs; s chakraborty, mb bs, md (radiodiagnosis) department of radiodiagnosis, institute of post-graduate medical education and research, and seth sukhlal karnani memorial (ipgme&r and sskm) hospital, kolkata, west bengal, india corresponding author: s biswas (b iswasshamick1@gmail.com) mucopolysaccharidoses (mps) represents a heterogeneous group of inherited lysosomal storage disorders characterised by defective degradation of long-chain complex carbohydrates called glycosoaminoglycans (gags). to date, 11 distinct types of mps have been described, each as a result of deficient enzymatic activity of specific lysosomal hydrolase. the most common types are hurler and hunter syndromes. we report a case of a child presenting with macrocephaly, clinically suspected to be due to hydrocephalus. an mri (3 tesla) brain study demonstrated the cribriform pattern in the brain caused by dilated perivascular spaces, which is a diagnostic clue for the presence of mps. s afr j rad 2013;17(4):147-148. doi:10.7196/sajr.982 a 2-year-old boy presented with macrocephaly, initially suspected to be due to hydrocephalus. there were no focal neurological deficits. a 3t mri of the brain, however, revealed macrocephaly, thickened diploeic spaces (most prominent in the occipital region) and the presence of a j-shaped sella (fig. 1). a cribriform pattern (otherwise known as ‘honeycombing’ or ‘sieve-like’ appearance) (figs 2 and 3) was present, caused by dilated perivascular spaces, diffusely involving the bilateral subcortical white matter (wm), centrum semiovale, periventricular deep white matter and corpus callosum. other findings included supratentorial ventriculomegaly, diffuse cerebral cortical atrophy with prominent cortical sulci and extra-axial csf (cerebrospinal fluid) spaces (figs 4 and 5). a hypoplastic odontoid process and thickened ligaments posterior to the odontoid, causing craniovertebral (cv) junction stenosis, were also observed (fig. 1). skeletal survey of the child revealed features suggestive of mucopolysaccharidosis 1h (hurler syndrome), which was further confirmed by quantitative and qualitative urinary glycosoaminoglycan (gag) analysis1 revealing elevated levels of dermatan and heparan sulphate. fig. 1. sagittal t2 (tr/te, 3880/109 ms) image shows macrocephaly (small solid arrow) with j-shaped sella (large solid arrow), and dilated perivascular spaces in the corpus callosum (arrowhead). hypoplastic odontoid process (thin arrow) with thickened ligaments posterior to the odontoid (curved arrow) causing c-v junction stenosis (open arrow) is also noted. fig. 2. axial t2 flair (tr/te/ti, 9502/125/2250 ms) image at the level of the fronto-parietal lobes shows the cribriform pattern (arrows) of enlarged perivascular spaces in the subcortical and deep white matter and centrum semiovale. fig. 3. axial t2 flair (tr/te/ti, 9502/125/2250 ms) image at the level of the temporal lobes shows the cribriform pattern (arrows) of enlarged perivascular spaces in the deep white matter. fig. 4. sagittal t2 (tr/te, 3880/109 ms) -weighted image shows the diffusely enlarged perivascular spaces (long arrow). fig. 5. coronal t2 (tr/te, 3260/101 ms) -weighted image shows the hydrocephalus with dilated lateral ventricles (black arrow) and 3rd ventricle (small arrow) with diffuse cerebral cortical atrophy and prominent cortical sulci (long arrow). also seen is atrophied corpus callosum containing prominent perivascular space (arrowhead). discussion the earliest and most common abnormality found in patients with mps is cystic lesions that correspond to enlargement of the virchow-robin perivascular spaces (pvs), which are pia-lined spaces that accompany penetrating arteries and arterioles into the brain parenchyma.2 the pvs dilatation reflects impairment of csf re-absorption owing to accumulation of gags in the vacuolated gargoyle cells3 of the leptomeninges. with disease progression, the lesions become widespread and extensive, reflecting the development of infarcts in demyelination.4 the pvs are hypo-intense on t1-weighted images, iso-intense to csf on t2-weighted images, are suppressed completely on flair images, and do not show any diffusion restriction or contrast enhancement. in mps, these diffusely enlarged pvs affect the periventricular wm, corpus callosum, basal ganglia, subcortical wm, centrum semiovale, thalami and brain stem, resulting in the cribriform or spindle-like pattern. such enlargement of the pvs can also be seen in lowe syndrome5 and hypomelanosis of ito.6 lacunar infarcts, cystic periventricular leukomalacia, multiple sclerosis, cryptococcosis and neuro-epithelial cysts may also mimic enlarged pvs.7 communicating hydrocephalus occurs along with the enlargement of extra-axial subarachnoid spaces. the deposition of gags in the meninges impairs the function of arachnoid granulations, leading to abnormal csf reabsorption. macrocephaly is a common finding in mps, often associated with metopic beaking and a scaphocephalic configuration.2 diffuse cerebral cortical atrophy may be symmetric or asymmetric, resulting from neuronal death and gliosis, induced by the accumulation of gags. apart from cerebral atrophy, corpus callosum thinning occurs owing to ventricular dilatation and the effect of enlarged pvs within it. the common posterior fossa abnormalities are mega cisterna magna and arachnoid cysts. pituitary sella abnormalities include a j-shaped sella – an elongated sella with a shallow anterior convexity owing to an exaggerated normal shallow impression of the sulcus chiasmaticus. thickening of the diploe also occurs in mps. signal intensity abnormalities in the brain parenchyma are commonly seen in the periventricular wm and the basal ganglia. the meninges, most commonly around the craniovertebral (cv) junction, are often thickened and, in severe cases, can compress the medulla or upper cervical cord. associated atlanto-axial subluxation, odontoid dysplasia and a short posterior arch of atlas can exacerbate the cv junction stenosis.2 conclusion mucopolysaccharidoses (mps) represent a rare lysosomal storage disorder that can be detected early in the paediatric age group by mri of the brain. although the musculoskeletal features are far more characteristic than the neuroradiological abnormalitites, the importance of this cribriform pattern in a paediatric brain lies in the fact that it points to the diagnosis of a very few, rare inherited diseases. consequently, recognition of this pattern can act as an imaging pointer for mps. 1. lehman tja, miller n, norquist b, underhill l, keutzer j. diagnosis of the mucopolysaccharidoses. rheumatology 2011;50:v41-v48. [http://dx.doi.org/10.1093/rheumatology/ker390] 1. lehman tja, miller n, norquist b, underhill l, keutzer j. diagnosis of the mucopolysaccharidoses. rheumatology 2011;50:v41-v48. [http://dx.doi.org/10.1093/rheumatology/ker390] 2. osborn ag. osborn’s brain − imaging, pathology and anatomy. 1st ed. salt lake city, usa: amirsys, 2013:887-888. 2. osborn ag. osborn’s brain − imaging, pathology and anatomy. 1st ed. salt lake city, usa: amirsys, 2013:887-888. 3. sequeira ff, gandhi s, kini u, bhat i. named cells in dermatology. indian j dermatol venereol leprol 2012;78(2):207-216. [http://dx.doi.org/10.4103/0378-6323.93650] 3. sequeira ff, gandhi s, kini u, bhat i. named cells in dermatology. indian j dermatol venereol leprol 2012;78(2):207-216. [http://dx.doi.org/10.4103/0378-6323.93650] 4. atlas sw. magnetic resonance imaging of the brain and spine. 4th ed. philadelphia: lippincott williams & wilkins, 2009:419-420. 4. atlas sw. magnetic resonance imaging of the brain and spine. 4th ed. philadelphia: lippincott williams & wilkins, 2009:419-420. 5. de carvalho-neto a. oculocerebrorenal syndrome of lowe − magnetic resonance imaging findings in the first six years of life. arq neuropsiquiatr 2009;67(2-a):305-307. 5. de carvalho-neto a. oculocerebrorenal syndrome of lowe − magnetic resonance imaging findings in the first six years of life. arq neuropsiquiatr 2009;67(2-a):305-307. 6. almeida as, cechin we, ferraz j, et al. hypomelanosis of ito: report of a case. j pediatr (rio j) 2001;77(1):59-62. 6. almeida as, cechin we, ferraz j, et al. hypomelanosis of ito: report of a case. j pediatr (rio j) 2001;77(1):59-62. 7. kwee rm, kwee tc. virchow-robin spaces at mr imaging. radiographics 2007;27:1071-1086. [http://dx.doi.org/10.1148/rg.274065722] 7. kwee rm, kwee tc. virchow-robin spaces at mr imaging. radiographics 2007;27:1071-1086. [http://dx.doi.org/10.1148/rg.274065722] radiology_oct04 introduction meningio-angiomatosis (ma) is a rare congenital hamartomatous malformation of the leptomeninges often also involving the adjacent cerebral cortex. some cases are associated with neurofibromatosis (nf) whereas others develop in isolation. case report a 6-year-old girl presented after a prolonged grand mal seizure. she had suffered from recurrent focal seizures affecting her right side since 1 year of age and also suffered from a mild right-sided hemiplegia. there were no clinical or radiological stigmata of nf. an electro-encephalogram (eeg) demonstrated abnormal electrical activity over both temporoparietal regions. an unenhanced computed tomography (ct) scan of the brain showed multiple areas of hyperintensity in the left parietal lobe extending in a linear radial fashion along a number of gyni and sulci over the surface of the brain (fig. 1a). moderate contrast enhancement was seen adjacent to some of these hyperintensities (fig. 1b). the hyperintense areas appeared denser than blood. as there was no suspicion of any acute subarachnoid haemorrhage this was assumed to be calcification. on unenhanced t1-weighted magnetic resonance (mr) images no direct evidence of any meningeal thickening could be seen, although slight thickening and a mild increase in signal intensity was seen within the cortex over the convexity of the parietal lobe (fig. 2a). no abnormal signal intensity was noted in this area on t2-weighted or proton-density images, although some prominent vessels were seen over the brain surface (fig. 2b). bright signal was, howcase report 27 sa journal of radiology • october 2004 meningioangiomatosis — case report and subject review i c duncan ffrad (d) f i spiro frcr sunninghill hospital sandton johannesburg fig 1a. unenhanced axial ct scan showing linear hyperintense material over the surface of the left parietal lobe with extension into the sulci in keeping with calcified proliferative leptomeningeal tissue. fig 2a. unenhanced coronal t1-weighted mr scan showing no meningeal thickening over the left parietal lobe but slight increase in the signal intensity of areas of the surface cortex itself. fig 2b. no significant signal abnormality is noted on either standard t2-weighted or proton-density images (illustrated here). some prominent surface vessels are seen. fig 2c. coronal flair image showing bright signal arising from the thickened leptomeninges. fig 1b. contrast-enhanced ct scan at the same level showing some areas of contrast enhancement within the abnormal tissue. 28 sa journal of radiology • october 2004 ever, noted on the post-gadolinium flair (fig. 2c) and post-gadolinium t1-weighted images (figs 2d f). digital subtraction arteriography was then performed. selective left external carotid arteriograms showed no abnormal dural supply, whereas selective left internal carotid arteriograms showed enlargement of the posterior parietal branch of the left middle cerebral artery with some smaller slightly dysplastic looking branches seen in the same area as the abnormalities shown on the scan (figs 3a d). the diagnosis of meningiomatosis was made on the basis of the clinical and radiological findings, but the child has since been lost to follow-up with the result that no histological confirmation could be obtained. discussion ma is a rare benign hamartomatous lesion of the cerebral cortex and adjacent leptomeninges, first described by bassoe and nuzum1 in 1915 in a patient with nf. the term ‘meningio-angiomatosis’ was first used in 1937 by worcester-drought et al.,2 who also first suggested that ma may represent a forme fruste of nf. many cases have been reported in nf patients, but not all are associated with nf.3-5 in sporadic cases the male/female ratio is more equal and the mean patient age tends to be somewhat younger, children and young adults being affected. patients typically present clinically with headaches and seizures but some cases are also found incidentally at autopsy6,7 or during cranial imaging.8 in most cases the ma affects the cerebral cortex, usually in the frontal or temporal regions. some cases may show case report fig 2d. contrast-enhanced coronal t1-weighted image showing the enhancing thickened leptomeninges over the brain surface. fig 2e. contrast-enhanced axial t1-weighted image at the same level as fig 2b showing the densely-enhancing surface tissue and sulcal extension. fig 2f. contrast-enhanced sagittal t1-weighted image showing the anteroposterior extent of the lesion. note the radial extension within the sulci and possibly through the perivascular spaces as well. fig 3a. selective left internal carotid digital subtraction arteriogram, lateral projection, showing enlargement of the posterior parietal branch of the left middle cerebral artery corresponding to the prominent surface vessel seen in fig. 2b. fig 3b. same run, later image showing a local collection of slightly dysplastic looking branches over the affected cortex. no abnormalities were noted during the venous phase. fig 3c. same vessel, right anterior oblique view, again showing the relatively prominent parietal branch. fig 3d. same run, later image again showing the slightly dysplastic-looking vessels over the cortex. no abnormalities of the external carotid dural supply were noted. case report 29 sa journal of radiology • october 2004 involvement of the third ventricle, thalamus or brainstem.6,9 the characteristic pathological findings include leptomeningeal meningovascular fibroblastic proliferation and a variable degree of leptomeningeal calcification.3,10 there is angiomatous proliferation within the meninges, sometimes with associated arteriovenous shunting. the fibroblastic and angiomatous proliferation can extend in a linear fashion along the virchow-robin perivascular spaces, thereby appearing to ‘penetrate’ the cortical grey matter.3 the degree of calcification can vary from numerous psammona bodies histologically to dense calcification and even ossification.8 changes may also be seen in the adjacent brain cortex (mengiocephalo-angioneuromatosis). the cortical changes include the presence of neurofibrillary tangles, thought to represent degenerative changes in entrapped neurons.6 on unenhanced ct scans the calcifications may be seen as either linear or granular in nature,3 whereas noncalcified areas or lesions may range from isodense to moderately hypodense with the low-density appearance probably representing a loosely packed cellular matrix consisting of prominent perivascular spaces and scattered meningeal spindle (fibrous) cells.7 the degree of contrast enhancement is variable. on mr scans the lesions tend to be isoto hypointense to grey matter on t1-weighted images. non-calcified areas or lesions are typically hyperintense on t2weighted images with areas of dense calcification producing marked t2 shortening and thus appearing as hypo-intense areas often within the center of the lesion.3,8,10 again contrast enhancement is variable. angiographic findings also vary from normal through the presence of an avascular ‘mass’ to the finding of abnormal vessels.4,8,10 the differential diagnosis of ma includes the sturge-weber syndrome, meningioma, granulomatous meningitis (sarcoid or tuberculosis) and calcified infiltrating glioma. ma can be readily differentiated from sturgeweber syndrome in that the calcification in the latter is parenchymal (gyral) and is associated with brain tissue atrophy on sectional imaging and a venous collateral (‘pseudophlebitic’) pattern in the affected regions at arteriography.3 total surgical resection is the treatment of choice for ma, with the prognosis being very good with complete cure from seizures in most cases.4-6 references 1. bassoe p, nuzum f. report of a case of central and peripheral neurofibromatosis. j nerv ment dis 1915; 42: 785-796. 2. worcester-drought c, dickson wec, mcmenemey wh. multiple meningeal and perineural tumours with analogous changes in the glia and ependyma (neurofibroblastomatosis). brain 1937; 60: 85-117. 3. aizpuru rn, quencer rm, norenberg m, altman n, smirniotopoulos j. meningioangiomatosis: clinical, radiologic and histopathologic correlation. radiology 1991; 179: 819-821. 4. ogilvy cs, chapman ph, gray m, de la monte sm. meningioangiomatosis in a patient without von recklinghausens’s disease j neurosurg 1989; 70: 483-485. 5. harada k, inagawa t, nagasako r. a case of meningioangiomatosis without von recklinghausen’s disease. report of a case and a review of 13 cases. childs nerv syst 1994; 10: 126-130. 6. halper j, scheithauer bw, okazaki h, laws ej. meningio-angiomatosis: a report of six cases with special reference to the occurrence of neurofibrillary tangles. j neuropathol exp neurol 1986; 45: 426-446. 7. rubenstein lj. the malformative central nervous system lesions in the central and peripheral forms of neurofibromatosis. a neuropathological study of 22 cases. ann ny acad sci 1986; 486: 14-29. 8. partington cr, graves vg, hegstrand lr. meningioangiomatosis. am j neuroradiol 1991; 12: 549-552 9. kollias ss, crone kr, ball wj, prenger ec, ballard et. meningioangiomatosis of the brain stem. case report. j neurosurg 1994; 80: 732735. 10. tien rd, osumi a, oakes jw, madden jf, burger pc. meningioangiomatosis: ct and mr findings. j comput assist tomogr 1992; 16: 361-365. case report multiple phaeochromocytoma (adrenal and extra-adrenal) l d r tsatsi ms chs, fcrad(d}sa m a mabiletsa sse, mschs department of diagnostic radiology medical university of southern africa case presentation a 17-year-old-girl was referred from a rural hospital with problems of hypertension secondary to suspected coarctation of the aorta, and aortic incompetence. her main complaints were headaches and palpitations. clinicallyshe had mild to moderate hypertension, tachycardia, left ventricular enlargement and a systolic murmur. there were no abdominal masses. investigations performed excluded coarctation of the aorta and aortic incompetence. ecg confirmed sinus tachycardia with left ventricular hypertrophy. renal artery stenosis was also excluded by a normal renogram. she was then investigated for other causes of hypertension including phaeochromocytoma. serum urea and electrolytes were normal. urine vanillylmandelic acid (vma) and metanephrines were also normal. imaging cxr there were no positive findings despite clinical early cardiomegaly. mibgscan this showed no features of phaeochromocytoma. ultrasound a homogeneous soft-tissue mass measuring 4.5 x 4.2 em, slightly lobulated and well defined was visualised on the left side of the aorta just above its bifurcation. no calcifications were noted. the aorta was not compressed. another similar mass measuring 2.9 x 2.9 em, triangular, and more regular in outline, was visualised at the upper pole of the left kidney. there were no other positive findings (fig. i). ct scan of the abdomen the patient was allergic to iodine and had to be premedicated with prednisone, and alpha-blockers were also given to avert a hypertension crisis (fig. 2). a homogeneous retroperitoneal tumour, isodense to skeletal muscle, was found to the left of the aorta just above its bifurcation. it was lateral to the aorta, and anterolateral to the spinal column and left psoas muscle. it measured 6.0 x 4.2 x 5.8 em. the 22 sa journal of radiology. september 2002 fig. 1. transverse sonar mid-abdomen showing left para-aortic mass organ of zuckerkandl. fig. 2. pre-contrast ct sca~ of the abdomen axial showing a left para-aortic tumour isoaense to skeletal muscle. margins were lobulated and clear. there was a marked homogeneous enhancement post contrast except for a small hypodense area at the inferior pole thought to be cystic necrosis. there was no infiltration or compression of surrounding structures (fig. 3.) a second tumour was found in the left adrenal gland measured 3.8 x 2.3 x fig. 3. reconstructed ct image corona! showing left para-aortic mass just above the aortic bifurcation organ of zuckerkandl. case report fig. 4. contrast-enhanced ct axial showing markedly enhancing extra-adrenal phaeochromocytoma, left para-aortic region. fig. 5. contrast-enhanced ct of the abdomen. coronal reconstruction shows left suprarenal tumour (adrenal phaeochromocytoma). 36.6 em. it was smooth and enhanced homogeneously and markedly post contrast (fig. 4). the right adrenal gland was normal. both renal arteries were normal. no lymph node enlargement was noted. there were no liver or bone metastases. coronal and sagittal multiplanar reconstruction (mpr) aided in localisation and visualisation of tumours (fig.5). biopsy an excision biopsy was performed and two phaeochromocytomas removed. no postoperative complications were reported. . histology confirmed the diagnosis of phaeochromocytoma. discussion phaeochromocytoma is a subtype of the paragangliomas, a neuroendocrine tumour that arises from paraganglionic tissue. i it is responsible for 0.1% of hypertension cases. location it occurs anywhere in the sympathetic nervous system from the neck to the sacrum: (l; adrenal medulla (85 90%); (iz) extra-adrenal (10 15%), with the majority adjacent to the kidneys; and (iii) other sites including the organ of zuckerkandl, the gonads, bladder and thoracic para-vertebral region. our patient's tumour was in the left adrenal gland and the organ of zuckerkandl (extra-adrenal site adjacent to aortic bifurcation). clinical findings symptoms are secondary to excess catecholamine production. classical presentation is: (1; paroxysmal (50%) or sustained (50%) hypertension accompanied by headaches, tachycardia, diaphoresis, palpitations and anxiety, with 9% of patients asymptomatic;' (ii) elevated vanillylmandelic acid in 24-hour urine and metanephrines (these were normal in our patient); and (iit) elevated serum catecholamines. 1-4 ruleoflo this postulates that 10% of cases are;'? (i) familial; (ii) children; (iil; bilateral adrenal; (iv) extra-adrenal ; (v) multiple; and (vi) malignant. associations 1. multiple endocrine neoplasia (phaeochromocytoma, usually bilateral and almost always intra-adrenal).' 23 sa journal of radiology • september 2002 • sipple syndrome: phaeochromocytoma, medullary carcinoma of the thyroid (mct) and parathyroid adenoma (multiple endocrine neoplasia (men) type ii). • mucosal neuroma syndrome (men type iii) mct plus intestinal ganglioneuromatosis plus phaeochromocytoma. 2. neuroectodermal disorders: tuberous sclerosis, neurofibromatosis,von hippel lindau syndrome. 2 3. familial phaeochromocytosis. 4. carney's syndrome: paraganglioma plus gastric epitheloid leiomyosarcoma plus pulmonary chondioma.' imaging plain x-rays or ivu with tomograms may reveal a mass above the kidney with renal involvement but in our case it did not help. both are low in sensitivity and specificity,' ultrasound is helpful in children where it has proved to be highly suecessful.' a well-marginated solidi complex cystic tumour, homo or heterogeneous is found in the adrenal or • 1·3para-aortic areas. ct scan. localisation is accurate in 91% of cases with tumours> 2 ern.' sensitivity is 93 100%. it is the method of choice. detection rates are high. the small number of failures tend to occur in children with poorly developed fat planes and in cases of extra-adrenal phaeochromocytoma. ct shows adrenal/extra-adrenal mass with strong contrast enhancement. low density areas are due to necrosis or haemorrhage.' calcifications are rare. nb: n contrast injection may precipitate hypertensive crisis in patients not on alpha-adrenergic blockers.' in case report our case the patient was already on treatment. mr. the detection rate is also high with mri and it may eventually replace ct as the investigation of choice since it involves no radiation.' its use is limited by cost and availability. 2 phaechromocytomas are extremely hyperintense on t2wl and show marked enhancement post contrast. intensity is considerably higher when compared with adenoma and metastases.' nuclear medicine studies scintigraphy with mibg is 80 90% sensitive, and 98% specific,' it is useful in detection of extraadrenal tumours or when adrenals are normal on ct and mri. false-positive and false-negative results have both been recorded.' in our patient mibg showed no evidence of phaeochromocytoma; false-negative result. arteriography and venous sampling these are occasionally used in the search for ectopic tumours.' arteriography: localisation is useful in more than 90%. usually hypervascular lesion with intense tumour blush enlarged feeding arteries and neovascularisation.' complications malignancy in 10% of lymph nodes, liver, lungs, and bone. metastases may be hormonally active.' references 1. weissleder r, rieumont mj, wittenberg j. primer of diagnostic imaging. 2nd ed. st louis: mosby,1997: 293 294. 2. dahnert w radiology review manual. 4th ed. baltimore: lippincott,1999: 781-782. 3. sutton d. textbook of radiology and imaging. 6th ed. vol 2. london: churchill livingstone, 1997: 1077-1082. 4. grainger rg, allison d. diagnostic radiology. 2nd ed. london: churchhill livingstone, 1997: 1170-1171. r nhs ~~ lanarkshire locum consultant radiologists (these posts may lead to permanent positions) with clinical services expanding as a result of the installation of a new 1.5t mri scanner, lanarkshire acute hospitals nhs trust has opportunities for consultant radiologists to work at either our brand new wishaw general hospital or our recently rejuvenated hospital at monklands. a new pacs system covering all sites within the trust combined with our doppler ultrasound scanners, a multislice ct scanner and mammography will all bring lanarkshire to the leading edge of imaging technology and patient management. at lanarkshire acute trust, we know that not everyone can commit themselves to a 'normal' working week. there are those who can make a valuable contribution, but only on a part-time or jobshare basis. that's why we go out of our way to provide the flexibility that's increasingly demanded in the modern workplace, so you can take advantage of our brand new hospitals and radiology facilities, and at the same time develop your career at your own time and pace. preferably holding or working towards the frcr or equivalent, you will also have completed higher specialist training in radiology as well as possess a ccst in radiology or equivalent. centrally located for glasgow and edinburgh, lanarkshire boasts affordable housing and excellent educational facilities. informal enquiries will be welcomed by dr t j nunn, associate medical director on 01698 366549 or dr j roberts, clinical director for radiology for wishaw general hospital on 01698 366514 and dr a j naismith, associate medical director on 01236 712308 or dr j guse, clinical director, imaging services on 01236 712175 for monklands hospital. an information pack is available from the senior personnel manager, medicalpersonnel department, wishaw general hospital, 50 netherton street, wishaw ml2 oop. telephone +44 (0) 1698 366551. fax +44 (0) 1698 366554. please quote ref mw276. closing date 27 september 2002. 24 sajournal of radiology. september2002 references about the author(s) peter k. schoub department of radiology, parklane radiology, johannesburg, south africa citation schoub p. breast cancer imaging in south africa in 2018. s afr j rad. 2018;22(2), a1666. https://doi.org/10.4102/sajr.v22i2.1666 editorial breast cancer imaging in south africa in 2018 peter k. schoub copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. it is with great pride that i present the south african journal of radiology (sajr) breast issue. breast cancer is the most common cancer diagnosed in women in south africa, and together with cervical cancer, constitutes the leading cause of cancer death.1 early diagnosis of breast cancer is key to reduce mortality.2 breast imaging is an ever-growing sub-specialty of radiology, both in south africa and worldwide. the goal is to detect cancer changes as early as possible and to be able to accurately differentiate cancer from non-malignant breast pathology. the ability to rule out cancer, either by confirming the benignity of a lesion or by excluding the presence of any abnormality at all, is as important as showing features of malignancy.3 the intention with this sajr issue is to provide a platform for local radiologists to publish breast imaging articles, and, in particular, to identify various aspects of breast radiology that are of importance in the south african context. one of these is the high human immunodeficiency virus (hiv) prevalence in the population. so far, it has not been shown that women with hiv are at a higher risk of developing breast cancer or that they necessarily present at a later stage than non-hiv patients.4 there is, however, strong evidence that women with hiv develop breast cancer at a younger age. this is corroborated by dr minnie et al. in their retrospective study. the implication is that breast cancer screening, or at the very least, education about breast cancer, needs to be directed at younger women. hiv should possibly be considered an independent risk factor for earlier breast cancer development, and consequently, screening from a younger age. unfortunately, there is a desperate shortage of radiology services in the public sector in south africa, and as a result, most women do not have access to screening mammography.5 at present, the guidelines from the national department of health regarding screening for breast cancer do not cover mammography at all, and instead, promote clinical breast examination as the primary screening test.5,6 therefore, we must acknowledge that mammography screening in this country is available only to a small percentage of the population, those with private medical aids and possibly those in large city centres where tertiary-level public hospitals do offer mammograms. the topic of screening mammography remains contentious after nearly 50 years of mammography. nonetheless, screening has been definitively shown to reduce mortality from breast cancer and the optimal starting age and intervals for mammography are becoming clearer. dr lipschitz has examined the literature, and composed a lucid, thoughtful breast cancer screening guideline. one of the most frequent diagnoses for palpable breast lumps, especially in the younger age group, is that of fibroadenomas. despite the likely benignity of breast lumps in younger women, we are seeing a growing number of high-grade cancers in young women, some of which mimic fibroadenomas.7 taking into account the paucity of mammography equipment in most public health systems across the african continent, the reluctance to use mammography in younger women and the unfeasibility of performing biopsies on all masses, dr olarinoye-akorede et al. have submitted a very useful study undertaken in zaria, nigeria, on the utility of breast ultrasound in younger patients with palpable breast lumps. in experienced hands, and abiding by certain proven descriptors, ultrasound is both highly sensitive and specific in determining malignancy in solid breast masses.8 breast density as a risk factor for breast cancer is a topic that is often under-appreciated by radiologists and referring clinicians. current data suggest that density alone is a risk factor for cancer development, while also causing a masking effect of underlying malignancy.9 in the united states of america (usa), it has become law in most states that women are informed of the density of their breasts on mammogram so that they can elect for additional imaging.10 in south africa, most practices that offer mammography also offer breast ultrasound. similarly, tomosynthesis mammography, which also reduces the masking effect of dense tissue, has been widely adopted. two articles in this issue address breast density. dr jackie smilg’s article reviews categorisation and implications of density on mammogram examinations. the article is an excellent summary of the supplemental imaging that should be performed in all women with dense breast tissue. dr minnie et al. performed a cross-sectional study comparing radiologist-determined breast density with that of automated breast density software. they were able to clearly demonstrate the unreliability of radiologist density appreciation. taking into account the subjective appreciation of density and the implications of assigning breast density, an objective and reproducible method of density determination may well prove to be a standard of practice.11,12 this is an area where artificial intelligence promises to assist in disease identification. breast magnetic resonance imaging (mri) has become an invaluable tool in breast cancer imaging. although the cost of the equipment and studies themselves has limited accessibility in south africa, most privately funded patients, and a significant number of patients in public hospitals, have access to breast mri. the national guidelines include breast mri in screening guidelines for high-risk women.5 following a review of the latest literature, i have attempted to simplify guidelines for the utilisation of breast mri. indications such as high-risk screening are universally accepted. other indications such as preoperative staging, problem solving and monitoring of neoadjuvant therapy applicable in many but not all situations.13,14 understanding mri’s advantages and limitations and the situations whereby mri will benefit patient outcomes is imperative to making correct imaging decisions. a prospective study by dr cloete et al. examines the use of breast mri in evaluating potentially benign masses in the breast. although ultrasound remains the mainstay of investigating these lesions, the study is particularly relevant in investigating two additional factors relating to breast mri. the first one is the application of the kaiser score, otherwise known as the tree flowchart. this decision-making tool, which allows a stepwise evaluation of a breast lesion based on multiple imaging features, should not replace the breast imaging reporting and data system (birads) system, but rather complement it.15,16 it is particularly useful for radiologists who are still learning how to interpret breast mri scans. the second topic discussed in this article is the usage of apparent diffusion coefficient (adc) maps. there is increasing evidence that quantitative assessment of adc values can reliably confirm benignity, and possibly malignancy in breast lesions.17 dr. pam smilg has contributed a clinical perspective on pseudo-angiomatous stromal hyperplasia (pash). this condition is seen not infrequently, and can mimic carcinoma both clinically and radiologically.18 this article shows us examples and reminds all breast imagers to consider pash in a differential diagnosis and realise that the diagnosis of pash may be concordant with relatively suspicious imaging findings. finally, we have a fascinating article from ramaema and hift that looks at the utility of multiparametric breast mri (contrast enhancement, t2 weighted and dwi/adc sequences) in differentiating breast cancer from tuberculosis of the breast. there is growing emphasis on qualitative and quantitative multiparametric imaging in breast mri19. the qualities of various different sequences can be combined to provide highly specific diagnostic information. i hope you will find this issue of interest. i also hope that it will inspire some of you who have an interest in breast imaging to submit your own breast-related content for publishing. up until now, we have based most of our guidelines and protocols on data from the usa and europe. it will be far more beneficial to have data from within southern africa upon which to base our breast imaging decisions, improve our diagnostic skills and help optimise breast cancer outcomes throughout our region. references prevalence cancer. cansa – the cancer association of south africa [homepage on the internet]. 2018 [cited 2018 sept 16]. available from: https://www.cansa.org.za/south-african-cancer-statistics/ ahn s, wooster m, valente c, pisapati k. impact of screening mammography interval on stage and treatment in women diagnosed with breast cancer. the american society of breast surgeons 19th meeting. 2018;403820:51–52. soo m, rosen e, baker j, vo t, boyd b. negative predictive value of sonography with mammography in patients with palpable breast lesions. am j roentgenol. 2001;177(5):1167–1170. https://doi.org/10.2214/ajr.177.5.1771167 grover s, martei y, puri p, et al. breast cancer and hiv in sub-saharan africa: a complex relationship. j global oncol. 2018;(4):1–11. https://doi.org/10.1200/jgo.2016.006585 lince-deroche n. breast cancer [homepage on the internet]. hst.org.za. 2017 [cited 2018 sept 16]. available from: http://www.hst.org.za/publications/south%20african%20health%20reviews/17_breast%20cancer%20in% keeping abreast of breast and cervical cancer | health resources [homepage on the internet]. healthresources.org.za. 2018 [cited 2018 sept 16]. available from: https://www.healthresources.org.za/keeping-abreast-breast-and-cervical-cancer.html song s, cho n, chu a, et al. undiagnosed breast cancer: features at supplemental screening us. radiology. 2015;277(2):372–380. https://doi.org/10.1148/radiol.2015142960 stavros t. sonographic evaluation of solid breast nodules. breast canc res. 2004;6(s1). https://doi.org/10.1186/bcr822 boyd n, rommens j, vogt k, et al. mammographic breast density as an intermediate phenotype for breast cancer. lancet oncol. 2005;6(10):798–808. https://doi.org/10.1016/s1470-2045(05)70390-9 trubo r. recent findings may inform breast density notification laws. jama. 2015;313(5):452. https://doi.org/10.1001/jama.2014.17914 gweon h, youk j, kim j, son e. radiologist assessment of breast density by bi-rads categories versus fully automated volumetric assessment. am j roentgenol. 2013;201(3):692–697. https://doi.org/10.2214/ajr.12.10197 youk j, gweon h, son e, kim j. automated volumetric breast density measurements in the era of the bi-rads fifth edition: a comparison with visual assessment. am j roentgenol. 2016;206(5):1056–1062. https://doi.org/10.2214/ajr.15.15472 morris e. diagnostic breast mr imaging: current status and future directions. magn reson imag clin n am. 2010;18(1):57–74. https://doi.org/10.1016/j.mric.2009.09.005 wang l. mr imaging: future imaging techniques. radiol clin n am. 2017;55(3):553–577. https://doi.org/10.1016/j.rcl.2016.12.009 woitek r, spick c, schernthaner m, et al. a simple classification system (the tree flowchart) for breast mri can reduce the number of unnecessary biopsies in mri-only lesions. eur radiol. 2017;27(9):3799–3809. https://doi.org/10.1007/s00330-017-4755-6 dietzel m, baltzer p. how to use the kaiser score as a clinical decision rule for diagnosis in multiparametric breast mri: a pictorial essay. insights imag. 2018;9(3):325–335. https://doi.org/10.1007/s13244-018-0611-8 partridge s, demartini w, kurland b, eby p, white s, lehman c. quantitative diffusion-weighted imaging as an adjunct to conventional breast mri for improved positive predictive value. am j roentgenol. 2009;193(6):1716–1722. https://doi.org/10.2214/ajr.08.2139 birdwell r. analysis of the mammographic and sonographic features of pseudoangiomatous stromal hyperplasia. year bk diagn radiol. 2009;2009:53–54. https://doi.org/10.1016/s0098-1672(08)79213-0 marino m, helbich t, baltzer p, pinker-domenig k. multiparametric mri of the breast: a review. journal of magnetic resonance imaging. 2017;47(2):301–315. original article lumbar spine x-rays for back pain still justified as a • •screening examination in south africa a t scher fcrad(d) sa department of radiology, tygerberg academic hospital and university of stellenbosch, tygerberg, w cape abstract standard teaching in the imaging approach to patients with back pain is that plain x-ray should only be obtained after 3 months of conservative treatment and thorough clinical examination and appropriate laboratory investigations. this approach, while appropriate in first-world countries, may lead to conditions such as tuberculosis of the spine being overlooked. an analysis was therefore made of 1 383 patients with complaints of lower back pain who were referred for x-ray of the lumbar spine. in 28 patients active spinal tuberculosis was diagnosed; in 8 of these patients the diagnosis had not been suspected clinically. it is concluded that in south africa with its unsophisticated patient population and poor facilities,limited x-ray (lateral and ap view) of the lumbar spine is justified in patients presenting with back pain for the first time . introduction it is now accepted and well-documented in both the european and american literature that radiological investigation in patients presenting with backache should be reserved for those patients who fail to respond after a 2 3-month period of conservative treatment. in a frequently cited investigation, nachemson 1 reported that in the absence of clinically suspicious features, routine radiographs in patients with backache have a 1 in 2 500 chance of detecting serious disease. it is questionable, however, whether this well-reasoned approach can be adopted as the level of sophistication of the patient population differs markedly between first-world and third-world countries, certainly in south africa, where diseases such as spinal tuberculosis are not only common, but are increasing in frequency, there is perhaps justification for utilising routine radiographs of the lumbar spine as a primary investigation in patients presenting with backache. methods a retrospective review was undertaken of patients presenting either to the general outpatient or orthopaedic outpatient departments at tygerberg 9 sa journal of radiology • august 2003 hospital during a 9-month period. patients with complaints of low back pain (n = 1 383) were referred for radiography of the lumbar spine. antero-posterior (ap) and lateral views of the lumbar spine were obtained and reviewed by a single radiologist. in cases where spinal tuberculosis was detected, the clinical records were analysed in order to ascertain whether a diagnosis of spinal tuberculosis was suspected prior to the patient being xrayed. results table i shows the radiological findings in the group of patients examined, in 805 patients no abnormalitywas detected. in 515 there was evidence of either degenerative disk disease or facet joint disease. fourteen patients had changes of paget's disease, while 6 patients showed changes of neoplastic disease and 20 patients had evidence of spondylolisthesis. in the group of 28 patients with active spinal tuberculosis, review of their clinical records revealed that in 8 patients the diagnosis had not been suspected clinically (fig. ia, b). table i. observation on x-ray examination of the lwnbar spine in 1 383 consecutive patients presenting with backache (n) normal 805 facet joint artluosis } 515spondylosis paget's disease 14 neoplastic disease 6 spondylolisthesis 20 tuberculosis 28 total 1383 original article b fig. 1a, b. ap and lateral views of the lumbar spine showing destruction of the vertebral body of l3 with narrowing of the l3-4 disk space due to spinal tuberculosis. discussion lumbar spine radiography is an examination associated with a high radiation dose. for an individual patient, the standard three film examination involves an average absorbed radiation dose of 2.2 msv; this is about 40 times the dose received during chest radiography;' halpin et al: suggested that as every radiation exposure carries a 1/80 000 risk per msv of inducing a fatal cancer, this would mean statistically that of the 700000 people who underwent lumbar spine radiography in the uk in 1973, 19 people would die each year as a consequence of these x-rays. nachemson 1 and waddell,' in separate reports, suggest that careful clinical evaluation together with appropriate blood tests, including erythrocyte sedimentation rate (esr), are more appropriate initial investigations than x-ray. these authors reserve radiographic investigation for those patients whose symptoms have not settled after 3 months of conservative treatment. the above approach makes several assumptions which are not necessarily correct with regard to third-world patient populations. language problems are a major barrier to obtaining an accurate clinical history. further, in south africa many patients do not return for their follow-up appointments. patients from poor socio-economic circumstances who have abnormal laboratory tests and fail to return for follow-up are extremely difficult to contact. as such it is difficult to request them to present for treatment. in light of all the above it is very difficult to ensure that patients with back pain who are not improving on treatment, or who have abnormal laboratory investigations, will return to hospital before their disease has advanced significantly. the primary purpose of plain film radiography of the lumbar spine is to exclude the presence of serious disease. these are conditions which produce symptomatology very similar to that experienced due to mechanical or discogenic back pain. in his compre10 sa journal of radiology • august 2003 hensive review of the value of radiology for back pain, butt' mentions conditions such as spondylosis, ankylosing spondylitis, and in the older patient, metastasis to the base of the pedicle. significantly, he does not mention infective conditions of the vertebral bodies and disc spaces. our radiographic protocol for screening patients with back pain utilises only two radiographs, the lateral and ap views. special attention is paid to ensuring that the thoracolumbar junction is demonstrated on the radiographs. we find that the ap view is of considerable value in the diagnosis of spinal tuberculosis. paravertebral abscesses, early disk space narrowing and posterior spinal involvement are shown to advantage. spinal tuberculosis is endemic in south africa and tuberculosis is particularly prevalent in the western cape. amongst the coloured population, there has been an untoward, sustained rise in the incidence of tuberculosis. this upward trend commenced in 1971, and the predicated pulmonary tuberculosis incidence rate for the coloured group for the year2001 was 672/100 000 of the population," many patients with spinal tuberculosis present with grumbling back pain. the degree of pain experienced is unreliable in predicting abnormal radiological findings as reported by halpin et al.? and in a separate investigation by kelen et al? conclusion in this series, utilisation of lumbar spine radiography as an initial investigation in patients presenting with backache, was responsible for the detection of spinal tuberculosis in 8 patients. crosier has reported a time original article lag of at least 4 months between the onset of backache and the first proper clinical examination in a series of patients with spinal tuberculosis in south africa. the extra cost involved in routine radiography of the lumbar spine as an initial investigation as well as the irradiation dose to the patient, must be weighed against the dangers of overlooking early spinal tuberculosis. progression of untreated spinal tuberculosis to spinal cord compression and paraplegia is a catastrophe for the patient, often resulting in life-long disability. in our view, the use of a limited two-film radiographic examination of the lumbar spine as an initial investigation in patients presenting with backache is justified and should be performed in those countries where tuberculosis is endemic. references 1. nachemson a. a critical look at conservative treatment for low back pain. in: jayson m, ed. the lumbar spine and back pain. london: sector, 1976: 355-366. 2. national radiological protection board. living witll radiation. london: hmso, 1989. 3. halpin sfs, yeoman l, dundas dd. radiographic examination of the lumbar spine in a community hospital: an audit of current practice. bm1l992; 1: 87-89. 4. waddell g. an approach 10 backache. british jol/mal of hospital medicine 1982; 28: 187-219. 5. butt wp. radiology for back pain. clin radial 1989; 40: 6-10. 6. grzybowski s. exploring some hypotheses on tuberculosis with a distinguished visitor from abroad. epidemiological comments 1993; 20(6): 90-99. 7. kelen gd, noji ek, doris pe. guidelines for the use of lumbar spine radiography. ailii emerg med 1986; 15: 245-251. 8. crosier jh. spinal tuberculosis and paraplegia a personal viewpoint. south african [ournal of balle joint surgery 1993: forum. for our client, a peripheral hospital in the south-east of the netherlands, we are currently seeking a hospital characteristics: • 373 beds and 2 outpatient clinics • 900 employees in total • pleasant and informal working climate • high quality of patient care diagnostic radiographer m/f job requirements: • registered to practice radio-diagnostics • self-sufficient and accurate • a flexible & patient oriented attitude is relevant to this job • willingness to also work evening-, nightand on-call shifts job specifications: • patient examinations through amongst others ct nd mri • heart catheterisations • individual research as well as research with colleagues and medical specialists • excellent remuneration and additional benefits care force takes care of your transferring process to the netherlands. we arrange all the necessary documents and your registration. also, we facilitate housing and we provide intensive support with regard to your and your family's integration in the netherlands. interested? please send your resume and motivation to the (email) address below or contact us first on telephone number +31 263554110. besides the abovementioned post, care force can offer numerous other interesting vacancies. all medical doctors of all specialities are invited to respond: open applications are very welcome. ( reree jansbuitensingel7 • 6811 aa arnhem' the netherlands phone +31 (0)26-35541 10 • fax +31 (0)26-3554628 e-mail info@care-force.com • www.care-force.com 11 sa journal of radiology • august 2003 mailto:info@care-force.com http://www.care-force.com original paper original paper � sa journal of radiology • september 2006 original paper abstract aim. the aim was to evaluate the safety and efficacy of percutaneous nephrolithotomy (pcnl) at our academic hospital. the primary objective was to determine the percentage successful pcnl procedures performed. methods. the study included 169 patients (116 males, 53 females; mean age 45 years, range 6 75 years) treated with pcnl in our department of radiology between 1997 and 2004. the data of all the pcnls done at the vascular suite from 1997 to 2004 were retrieved from the department of radiology records and a retrospective data analysis was performed. results. a total of 169 patients underwent pcnl treatment from 1997 until 2004. of these, 121 (72%) had one procedure and 38 (21%) had a second pcnl procedure, while 9 (6%) of the patients had three or more attempts. the average number of pcnls performed was 21 (5 – 35) per year. the average theatre time was 121 minutes (30 250). the two complications documented were blood loss in 13 (7%) and postoperative fever in 3 (1.75%) patients. most of the stones were located in the lower pole of the kidney (43%) with 36% located in the renal pelvis, 14% in the midpole and 6% in the upper pole. one hundred and twenty (71%) patients were stone-free after pcnl treatment. incomplete removal of stones was noted in 30 (18%) patients and the procedure was a complete failure in 19 (11%) of the patients. conclusion. pcnl has proved to be a safe and effective method of stone treatment in our academic setting. our complication rate was within acceptable limits. we may improve our success rate if we make the nephrostomy tract above the 12th rib in the treatment of midpole stones. introduction percutaneous nephrolithotomy (pcnl) is an effective procedure to treat patients with complex renal stones, e.g. staghorn calculi and stones greater than 20 mm in diameter. the treatment of choice for small, less complex renal stones is extracorporeal shock-wave lithotripsy (eswl).1 we have treated renal stones mainly with pcnl at our academic hospital, as eswl was not available until 2004. a retrospective data analysis was performed to evaluate the percentage of successful pcnls and to see whether success rates and operating times improved as experience was gained at our centre. aim the aim was to evaluate the safety and efficacy of percutaneous nephrolithotomy at the department of diagnostic radiology, universitas hospital, bloemfontein, an academic institution. the primary objective was to determine the percentage of successful percutaneous nephrolithotomies performed. the second objective was to compare the theatre time on a yearly basis to see if a reduction in duration of procedures occurred with time as experience was gained. the third objective was to determine the success in treatment of stones located in the upper calyx through a lower calyx nephrostomy tract. patients and methods the study included 169 patients (116 males, 53 females; mean age 45 years, range 6 75 years) treated with pcnl in the radiology department between 1997 and 2004 (an average of 21 patients per year). routine preoperative evaluation showed renal and/or impacted proximal ureteric stones in all of these patients. the data were collected retrospectively and evaluated. all procedures are carried out under general anaesthesia with the patient prone. the percutaneous tract was made by the interventional radiologist under ultrasound combined with percutaneous stone removal m n van der ness, mb chb, da (sa), drcog (uk) c s de vries, mb chb, mmed (rad) department of diagnostic radiology, universitas hospital, university of the free state, bloemfontein f m claassen, mb chb, fcurol (sa) s w wentzel, mb chb, mmed (urol) department of urology, universitas hospital, university of the free state, bloemfontein j joubert, phd department of biostatistics, universitas hospital, university of the free state, bloemfomtein pg 6-8.indd 6 9/6/06 2:56:21 pm original paperoriginal paper � sa journal of radiology • september 2006 fluoroscopy guidance. two guide wires were placed down the ureter. one of these wires was used as a safety wire. a balloon dilator was placed over the guide wire and a sheath was placed in the tract. renal stones were removed through the tract and sheath with a nephroscope by the urologist. after the procedure a double-j stent was placed down the ureter and a 24 fr catheter was placed in the nephrostomy tract to control bleeding. to minimise the risk of hyponatraemia we limited the irrigation time and we used mannitol or saline as irrigation fluid. the procedure was considered a success if all the stone/s were removed. when the stone/s were only partially removed, the procedure was considered incomplete. these patients received a second procedure. the procedure was considered a failure when no stone/s could be removed after multiple attempts. operation time was recorded from time of induction of general anaesthesia to termination of the procedure. results renal stones were located as follows: 43% located in the lower pole, 36% in the renal pelvis, 14% in the middle pole and 6% located in upper pole. some of the patients had multiple stones. the treatment was successful in 120 (71%) of the patients who were stone-free. incomplete removal of stones occurred in 30 (18%) patients and the procedure was a complete failure in 19 (11%) of the patients, as no stones could be removed (fig. 1). of the 169 patients, 121 (72%) had only 1 procedure, 38 (22%) had 2 procedures, 6 (4%) had 3 procedures and 3 (2%) had more than 3 procedures (fig. 2). the two main complications were blood loss and fever (fig. 3). blood loss occurred in 13 patients (7%) which was considered a major complication when it was severe enough to require termination of the procedure and/or blood transfusion. transient fever was documented in 3 patients (1.75%). no mortalities occurred as a result of pcnl. the total complication rate during this period is estimated at 8.75% no significant reduction in operation time occurred during the 8-year period. the mean (range) operative duration was 121 (30 250) minutes which equals an average cost of r 4 235 per session (fig. 4). discussion pcnl is an effective method of treatment of urolithiasis with the overall stone-free rate ranging from 66% to 93.7%,1,2 which correlates with our current results of 71%. note that results in the literature refer to treatment of large or multiple stones, and stones in the inferior calyx which are better suited for pcnl treatment. eswl is the treatment of choice for small renal stones.1 we did not have the option to use eswl so treated all renal stones with pcnl. pcnl is safe to perform for all age groups, including children and the elderly.3,4 the published complication rates range from 21% to 44%.5,6 our complication rate of 8.7 % is within acceptable limits. most of the complications encountered at our department were clinically insignificant and could be managed conservatively. no blood transfusions or open surgery were required. no reports of sepsis were documented. the low rate of transient fever (1.75%) may however be attributed to suboptimal documentation. pcnl has no long-term adverse effects on kidney fig 1. outcome/year as a percentage of total pcnl performed. 0 10 20 30 40 50 60 70 80 90 100 1997 1999 2001 2003 one procedure repeat procedures fig 1. outcome/year as a percentage of total pcnl performed. 0 10 20 30 40 50 60 70 80 90 1997 1999 2001 2003 succesful incomplete failure fig. 2. number of repeat procedures as a percentage of totals. fig. 2. number of repeat procedures as a percentage of totals. 0 10 20 30 40 50 60 70 80 90 100 1997 1999 2001 2003 one procedure repeat procedures fig 1. outcome/year as a percentage of total pcnl performed. 0 10 20 30 40 50 60 70 80 90 1997 1999 2001 2003 succesful incomplete failure fig. 2. number of repeat procedures as a percentage of totals. pg 6-8.indd 7 9/6/06 2:56:23 pm original paper � sa journal of radiology • september 2006 function.7 severe complications such as acute hyponatraemia and renal failure are very rare and we had no cases reported.8 no intrathoracic complications, e.g hydrothorax or pneumothorax, were encountered as all the procedures used a subcostal approach. no injuries to surrounding organs occurred. this can be attributed to the appropriate choice and positioning of the puncture into the desired calyx under ultrasound and fluoroscopic guidance.9 the operative theatre time usually varies between 60 and 210 minutes according to the literature, which correlates with our theatre time of an average of 121 (30 – 250) minutes.10 the operative theatre time was recorded from induction of general anaesthesia until conclusion of the procedure. no decrease in theatre time was observed during the time span of the study. the rotation of registrars with different levels of experience may have contributed to this. conclusion pcnl, used as the principal method in treating renal stones at our institution, has proved itself to be a safe and effective method when compared with reports in the literature. our complication rate is within acceptable limits. we may improve our success rate in treating midpole stones by making the nephrostomy tract above the 12th rib, should this be indicated. 1. martin tv, sosa re. shock-wave lithotripsy. in: walsh pc, retik ab, vaughan ed, wein aj, eds. campbell’s urology, 7th ed, vol 3. philadelphia, pennsylvania: wb saunders, 1998: 2740. 2. badaway h, salama a, eissa m, et al. percutaneous management of renal calculi: experience with percutaneous nephrolithotomy in 60 children. j urol 1999; 162: 1710-1713. 3. desai m, redhorkar v, patel s, bapat s, desai m. pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. j endourol 1999: 13: 359-364. 4. stoller ml, bolton d, st lezin m, lawrence m. percutaneous nephrolithotomy in the elderly. urology 1994; 44: 651-654. 5. gupta r, kumar a, kapoor r, et al. prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy. bju int 2002; 90: 809-813. 6. troxel sa, low rk. renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever. j urol 2002; 168: 1348-1351. 7. liou ls, streem sb. long-term renal functional effects of shock wave lithotripsy, percutaneous nephrolithotomy and combination therapy: a comparative study with solitary kidney. j urol 2001; 166: 36-37. 8. chou ch, chau t, yang ss, lin sh. acute hyponatremia and renal failure following percutaneous nephrolithotomy. clin nephrol 2003; 59(3): 237-238 9. osman m, wendt-nordahl g, heger k, et al. percutaneous nephrolithotomy with ultrasonographyguided renal access: experience from over 300 cases. bju int 2005; 96: 875-878. 10. sahin a, tekgul s, erdem e, et al. percutaneous nephrolithotomy in older children. j ped surg 2000; 35: 1336-1338. fig 3. morbidity as a result of pcnl in comparison with the number of patients. 0 50 100 150 200 250 1997 1999 2001 2003 max time min time 0 20 40 60 80 100 120 140 160 180 patients blood loss fever the two main complications were blood loss and fever (fig. 3). blood loss occurred in 13 patients (7%) which was considered a major complication when it was severe enough to require termination of the procedure and/or blood transfusion. transient fever was documented in 3 patients (1.75%). no mortalities occurred as a result of pcnl. the total complication rate during this period is estimated at 8.75% fig 3. morbidity as a result of pcnl. fig 4. average theatre time in minutes during period 1997 to 2004. fig 4. average theatre time in minutes during period 1997 to 2004. 0 50 100 150 200 250 1997 1999 2001 2003 max time min time 0 20 40 60 80 100 120 140 160 180 patients blood loss fever the two main complications were blood loss and fever (fig. 3). blood loss occurred in 13 patients (7%) which was considered a major complication when it was severe enough to require termination of the procedure and/or blood transfusion. transient fever was documented in 3 patients (1.75%). no mortalities occurred as a result of pcnl. the total complication rate during this period is estimated at 8.75% fig 3. morbidity as a result of pcnl. fig 4. average theatre time in minutes during period 1997 to 2004. pg 6-8.indd 8 9/6/06 2:56:24 pm star abstract imaging the liver selected topics lawrence h schwartz md introduction many imaging modalities are used to evaluate the liver. in the united states, unlike many other parts of the world, computed tomography is the most commonly performed examination for evaluation of hepatic lesions. mr! is used with increasing frequency in select clinical situations especially as mr! techniques are refined, and mr! examinations are easier to perform. there are relative advantages and disadvantages of both hepatic mr and ct. in general, ct is less costly than mr, more readily available, and most radiologists and many referring physicians have a relatively high degree of confidence in looking at ct images. some studies, however, have found that ct is less sensitive and specific than mr for detection and characterization of focal hepatic disease. hepatic mr has several distinct advantages over computed tomography. mr provides outstanding intrinsic soft contrast that can enhance subtle differences between normal and pathologic tissues and tissues of different histologic subtypes. non-ionizing radiation is used and mr! contrast agents are not nephrotoxic. mr! images may be acquired with multiplanar capabilities which are especially useful in depicting various anatomic relationships. mr studies of the liver take considerably longer than do ct studies and are more difficult to obtain uniform image quality. there is still controversy about the precise method of performing both these studies. the issues of the type, dose and delivery of iv contrast media as well as equipment utilized are under intense investigation. in mr!, the pulse sequence used, pulse sequence parameters and use of contrast is also under investigation. the remainder of this talk will. focus on selected issues in hepatic imaging with ct and mr! as they relate to oncology imaging. comparative imaging studies initial studies many of the initial ct and mr! comparative imaging studies performed in the 1980s and 1990s used dated technology that would not be considered current now. therefore, the results of these studies are not applicable with to day's imaging equipment. many of these studies used axial ct instead of spiral or multidetector technology, therefore, thick rather than thin slices were used, which also limits comparison with newer technologies. mr technology was also relatively slower in the past. this, again, resulted in studies that used thicker slices and frequently used non-breath-hold pulse sequences. in addition, none of the currently used contrast agents were available in these initial comparative imaging trials, limiting both the 35 sa journal of radiology • december 2002 sensitrvity and specificity for the detection of focal hepatic lesions. liver metastases metastases are the most common liver malignancy and occur at least 20 times more frequently than primary hepatocellular cancer. the evaluation of metastatic disease to the liver is one of the most common indications for liver imaging. in general, liver mr is more sensitive for the detection of liver metastases than contrastenhanced ct. liver metastases have a wide variety of appearances on mr images. most are oflow signal intensity on t 1weighted images and bright on t2weighted images. imaging features that are suggestive of malignancy include a target -sign or a halo of high signal intensity peripherally, or a heterogeneous signal intensity, with illdefined borders. it is critical to differentiate between benign hepatic lesions including cysts and hemangiomas and metastases. this distinction is relatively easy with mr! and may be performed with t2-weighted images and contrast enhanced images. morphologically, on both t2 and post contrast images metastases are generally complex and heterogeneous, and frequently ill-defined, while cysts and hemangiomas are homogeneous and sharply defined. contrast-enhanced mri, especially with gadolinium based agents, increases both detection of liver metastases and aids in liver lesion characterization. metastases have a variable appearance after gadolinium administration. they may be either hypervascular and enhance on the early arterial phase or hypovascular and enhance later. they often enhance with a complete peripheral ring. the star abstract use of mr contrast agents, other than gadolinium dtpa, has been investigated for a number of years and an additional contrast agent has gained fda approval. superparamagnetic iron oxide (spio-ferumoxides) is a reticuloendothelial specific, particulate mr contrast agent. spio's change hepatic parenchymal contrast by shortening the spin-spin relaxation, resulting in a reduction in signal intensity in tissue containing the contrast agent. most hepatic tumors do not contain reticuloendothelial cells. therefore, the contrast between the tumor and normal hepatic parenchyma will be increased. ferumoxides are principally a t2-contrast agent. if it is necessary to do a tl-weighted sequence, then a preeontrast study must also be performed. the current formulation of this agent is administered over 30 minutes by lv.infusion. as this contrast agent and others enter the market, a cost-benefit analysis will need to be performed to assess the added benefit, considering not only the costs of contrast agent, but also additional time required for imaging, patient preparation and scan interpretation. hepatocellular •carcinoma ct large hepatocellular carcinomas tend to be heterogeneous, and may demonstrate a typical mosaic appearance on ct. smaller hccs are often isodense and difficult to detect on conventional ct, which is performed during the portal venous phase of enhancement. conventional ct has a sensitivity of 48% and a specificity of 70% in the detection of hcc. noncontrast and delayed images slightly increase lesion detection by conventional ct. the development of spiral ct, which allows scanning during the arterial phase of enhancement, has been a major advance. tumors can be imaged during the period when many hccs are hyperdense relative to the unenhanced parenchyma. arterial phase imaging detects 30 to 40% more tumor nodules than conventional ct, and will be the only phase to show tumor in 7 to 10% of patients. direct ct arteriography and ct arterioportography direct ct arteriography refers to ct done during catheter injection of contrast into the hepatic artery. hccs are detected as hypervascular lesions, with a sensitivity of approximately 91%. this technique is invasive and requires identification of accessory arteries to the liver.it is also subject to a variety of false positive results. ct arterioportography (ctap) refers to ct scanning done during catheter injection of contrast into the superior mesenteric artery. contrast flows to the bowel and returns to the liver via the portal vein, opacifying the normal hepatic parenchyma. liver tumors, which are supplied by the hepatic artery, appear as hypodense lesions relative to the normal enhanced parenchyma. ctap is considered the most sensitive preoperative method of detecting liver tumors, but has several limitations in cirrhosis. for example, dysplastic nodules may be hypodense and mistaken for hcc and perfusional defects are common. mr! the morphology of hcc is well demonstrated by mri. tumor capsules and central scars are more frequently seen than on ct. hcc 36 sa journal of radiology • december 2002 demonstrates variable signal intensity on tl-weighted images. relative to normal hepatic parenchyma, approximately 1/3 of hccs are hypointense, 1/3 of hccs are hyperintense, and 1/3 are isointense. high signal intensity on tl-weighted images is sometimes due to the presence of intracellular lipid, but in other cases the cause is not known. numerous studies have investigated the characterization of regenerative, dysplastic, and malignant nodules by mri. contrastenhancement is important because tl and t2 signal intensity alone is insufficient for reliable distinction of these entities. three different mri contrast agents have been studied; gadolinium, ferumoxides, and manganese. gadolinium-dtpa is an extracellular paramagnetic contrast agent that produces enhancement in vascular tissues on tl weighted images. dynamic gadoliniumenhanced mri is the preferred sequence for visualization of hcc, because of the typical hypervascular pattern of enhancement in the arterial phase and because some well differentiated hccs may only be seen during the delayed phase. hccs do not contain a significant number of reticuloendothelial cells, and so are more easily visualized against the darkened background on t2-weighted images. while ferumoxides may help lesion detection on t2-weighted images, ferumoxides do not appear to increase lesion detection when compared with gadolinium-enhanced mri. mangafodipir trisodium is a manganese based hepatobiliary contrast agent taken up by hepatocytes and secreted in the bile. manganese causes tl shortening. as a result, normal parenchyma is bright on tl w images, and lesions are relatively dark. star abstract three-dimensional imaging with the rapid scanning ability of multidetector ct and volumetrie mri, it is feasible to obtain a threedimensional data set of the entire liver during a single breath hold. with reconstruction of this data, high-quality three-dimensional images may be obtained. they are useful in presurgical planning and mapping of lesions. these images may be combined with other imaging of the liver to produce a comprehensive, non-invasive method for evaluating the hepatic parenchyma, hepatic vasculature and biliary tree. selected reading comput assist tol11ogr1996; 20: 337-342. 7. mitsuzaki k, yamashita y, ogata i, et al. 1. semelka rc, worawattanakul s, kelekis nl, et multiple-phase helical ct of the liver for detectal. liver lesion detection, characterization, and ing small hepatomas in patients with liver cireffect on patient management: comparison of rhosis: contrast-injection protocol and optimal single-phase spiral ct and current mr techtiming. afr 1996; 167: 753-757. niques. j magn reson imaging 1997; 7: 10408. oliver jh 3rd, baron rl, federle mp, et al.1047. detecting hepatocellular carcinoma: value of 2. hagspiel kd, neidl kfw, eichenberger ac, et unenhanced or arterial phase cr imaging or al. detection ofliver metastases: comparison of both used in conjunction with conventional superpararnagnetic iron oxide-enhanced and portal venous phase contrast-enhanced ct unenhanced mrl at 1.5 t with dynamic ct, imaging. air 1996; 167: 71-77, intraoperative us, and percutaneous us. 9. earls jp, theise nd, weinreb jc, et al. dysplasticradiology 1995; 196(2): 471-478. nodules and hepatocellular carcinoma: thin3. schultz jf,bell jd, goldstein rm, et al, hepatic section mr imaging of explanted cirrhotic uvtumor imaging using iron oxide mrl: ers with pathologic correlation. radiology1996; comparison with computed tomography, din201: 207-214, ical impact, and cost analysis. ann surg oneol 10, semelka rc, lee jk, worawattanakul s. et al.1999; 6: 691-698. sequential use of ferumoxide particles and 4, semelka rc, cance wgomarcos hb, et ai, liver gadolinium chelate for the evaluation of focal metastases: comparison of current mr techliver lesions on mrl, ] magn reson imaging niques and spiral ct during arterial portograj 998; 8: 670-674, phy for detection in 20 surgically staged 11. winston cb, schwartz lh. fong y. et al.cases, radiology 1999; 213: 86-91. hepatocellular carcinoma: mr imaging finds. yamagami t. arai y. matsueda k, et al. the ings in cirrhotic livers and noncirrhotic livers, cause of nonturnorous defects of portal perfuradiology. 1999; 210: 75-79. sian in the hepatic hilum revealed by cr during 12. lopez hanninen e, vagi tl, bechstein wo, et al.arterial portography. am j roentgenol 1999; biphasic spiral computed tomography for172: 397-402. detection of hepatocellular carcinoma before 6. stevens wr, gulino sp, batts kp, et al. mosaic resection or orthotopic liver transplantation. pattern of hepatocellular carcinoma: histologic invest radio11998; 33: 2j6-221. basis for a characteristic ct appearance, j ~rimary careradiology--------i fa mettlet; jt; milton j guiberteau/ carolyn m voss & c e urbina here's a practical resource designed to help practitioners select appropriate radiologic tests for a full range of common disorders. from simple x-rays to sophisticated imaging studies, this clinical reference examines virtually every procedure in use today. it's organized by anatomic system, with a focus on symptoms and suspected clinical problems, to make reference simple. this valuable tool helps readers order even the most expensive and complex radiologic studies with confidence. features e:> examines the pros and cons of a broad spectrum of imaging studies, including their diagnostic value and their cost effectiveness. e:> addresses when a study should or should not be ordered, and the proper sequence in which radiologic tests should be performed for specific symptoms or suspected disorders. e:> offers full coverage of common inpatient and outpatient conditions, such as chest pain, asthma, diabetes, and back pain. e:> describes both adult and pediatric conditions. e:> illustrates normal anatomy, normal variants, and common diseases and disorders with more than 300 clearly reproduced illustrations. e:> includes step-by-step guidance on the interpretation of x-ray images. e:> considers common pitfalls and how to avoid them. e:> highlights vital information with quick reference tables. e:> integrates the perspectives and experience of two radiologists, a general medical internist, and a family practice physician. may 2000, paperback, 285 pp, 340 illustrations, wbs, r799 orders: sa medical association, private bag xl, pinelands 7430. tel (021) 530-6527. fax (021) 531-4126. e-mail: fpalm@samedical.org limited local stock. 37 sa journal of radiology. december 2002 mailto:fpalm@samedical.org radiology_aug04 review article 19 sa journal of radiology • august 2004 abstract the progress made in diagnostic and therapeutic medicine has resulted in an increase in the number of malpractice suits brought against medical practitioners. to constitute negligence it must be shown that the conduct of the accused did not measure up to the standard of care the law required of him in the particular circumstances and that he acted with guilt and therefore can be blamed for the deed. this paper describes medical practitioner negligence and reviews relevant cases. introduction the enormous progress made in diagnostic and therapeutic medicine in the past decades has resulted in an increase in the number of malpractice suits brought against medical practitioners. this has been due to various factors which include: the physician’s changing role in the community; legal aid becoming available to even the poor; the country becoming a democracy, with people aware of their rights; the recognition of self determination; the res ipsa loquitur principle, which moved the burden of proof to the practitioner; strict consent procedures; and the creation of higher patient expectations. negligence to constitute negligence it must be shown that the conduct of the accused did not measure up to the standard of care the law required of him in the particular circumstances and that he acted with guilt and therefore can be blamed for the deed. south african courts regard negligence merely as a fault and use an objective test in the ascertainment thereof (s v ngubani). in the case of kruger v coetzee, the appeal court expressed the test for negligence as follows. ‘for the purpose of liability, culpa (guilt) arises if: 1. a diligens pater familias (responsible head of the family) in the position of the defendant would (i) foresee the reasonable possibility of his conduct injuring another in his person or property and causing him patrimonial loss; and (ii) would take reasonable steps to guard against such an occurrence; and 2. the defendant failed to take such steps.’ in s v burger it was stipulated by judge a j holmes that extreme care is not expected from the diligens pater familias, but that ‘he treads life’s pathway with moderation and prudent common sense’. the objective reasonable man test takes the circumstances as well as the specific expertise of the accused into account. in s v mahlalela, a herbalist was charged with murder. he gave a child herbs and beer to drink and the child died due to the poisonous content of the mixture. it was concluded that the defendant should have foreseen the death of the child, all the more as he was an expert on herbs. he was therefore found guilty of culpable homicide. in van wyk v lewis reasonable conduct was described as follows: ‘a medical practitioner is not to bring to bear upon the case entrusted to him the highest possible degree of professional skill, but he is bound to employ reasonable skill and care. and in deciding what is reasonable the court will have regard to the general level of skill and diligence possessed and exercised at the time by the members of the branch of the profession to which the practitioner belongs.’ the requirements for negligence are: (i) the possibility of the occurrence of the consequence should reasonably have been foreseen in the circumstances; (ii) reasonable guarding against the possibility should have been taken; and (iii) there is failure to take steps that should reasonably have been taken. negligence and medical practitioners where a person enters a profession he becomes an expert and the standard of care expected is raised to the level of a practitioner of such vocation. the circumstances in which medical negligence occurr are taken into account (van wyk v lewis). the same standard of care is not expected from a doctor called out at night in a rural setting as from a doctor working in a fully equipped and staffed hospital. on a number of occasions the courts have accepted different standards of care for specialists and general practitioners. performance should comply with the standard of conduct medical negligence s f otto mb chb, llb, lld department of diagnostic radiology university of the free state and universitas hospital bloemfontein for a reasonable specialist of the same specialty. existing knowledge and methods of treatment at the time are taken into account (van wyk v lewis). knowledge of new developments in medicine will be taken into account. the practitioner must ensure that he acquaints himself with new developments and that his patient is not prejudiced by use of outdated methods. where different schools of opinion exist on a method of treatment, a practitioner does not act improperly where he makes use of a method favoured by a respectable minority.1 in kovalsky v krige, a doctor used ferric chloride to stop bleeding. although other doctors testified that they would have used different methods, the practitioner was not held liable. imperitia culpae adnumeratur — lack of skill is reckoned as a fault! a practitioner is always negligent if he performs a procedure knowing that he does not have the necessary skill, knowledge or experience. in dale v hamilton a physician used an x-ray appliance to diagnose a condition and the plaintiff sustained serious burns. it transpired that the coolidge tube had been placed too near to the patient, causing the burns. a trained radiologist would have noted the defect. the court found that the radiologist was obliged to ascertain the appliance’s operational safety and that he was not entitled to rely on the expert’s installation thereof.1 in s v mkwetshana the accused, a young intern, saw a patient, a woman suffering form asthma. the latter became restless and had difficulty breathing. she was agitated, restless, appeared cyanotic and foamed at the mouth. the intern diagnosed asthma and administered 20 ml of aminophyllin ivi. with no improvement after 5 minutes, he decided that it was epilepsy and administered 20 ml paraldehyde. the patient improved but died 15 minutes later due to the lethal doses of paraldehyde. on appeal it was submitted that the accused was inexperienced, still an intern and the only doctor on duty and that he had acted in an emergency. the appeal court upheld the decision of culpable homicide due to the above rule. the locality rule was set in van wyk v lewis, viz. that the same degree of care and skill practised in a large city hospital could not be expected from a practitioner working in a rural area. van der merwe and olivier2 and strauss3 state that in view of modern developments no justification exists for retention of the locality rule. neethling et al.4 submit that the nature of the community where the practitioner works should be considered as should opportunities to keep abreast with new developments. an error of clinical judgment: the law does not require the doctor to be infallible in his conduct, and an error of clinical judgment will not constitute negligence where the proper standard of care has been followed. in pringle v administrator of transvaal it was shown that when applying a test for medical negligence, an inordinately inflexible standard of care should not be applied which blurs the distinction between surgical mishap and medical malpractice. where a practitioner acts according to customary practice, generally approved and accepted by the profession, he will normally have a good defence against allegations of negligent conduct. claassen and verschoor1 hold that innovation and experimentation bring about two conflicting interests: the patient who is not to be exposed to abuse and the interests of the practitioner and society by furthering knowledge. neethling et al.4 argue that the standard of care required is not of the ‘average’ medical practitioner, but that of the ‘reasonable’ medical practitioner. proof of negligence proof of negligence in civil cases is on a balance of probabilities. in civil cases the onus rests on the plaintiff, and negligence as well as damage due to the negligence must be proven. proof in criminal cases must be beyond reasonable doubt and the onus of proof rests on the state. expert evidence is usually needed to assist the court in determining the reasonable man standard. examples of negligent malpractice incorrect diagnosis wrong diagnosis can lead to liability of the physician. it usually includes the wrong treatment of the patient. incorrect diagnosis in an ill patient is a problem, but even more so where an illness is diagnosed from which the patient does not suffer. in ex parte v rautenbach a married woman was diagnosed with a venereal disease. her husband left her and she claimed that she suffered damage from the misdiagnosis. a practitioner is only held liable if the diagnosis implies the lack of reasonable care and skill with regard to the ordinary care and skill of the profession. in dube v the administrator of transvaal judge a j review article 20 sa journal of radiology • august 2004 corbett stated that the case should be divided in to three questions: • what was the factual cause of the eventual condition (volkmann’s contracture)? • did the respondent’s negligence cause or contribute to the condition due to his not exercising reasonable care and skill? • if liability is proved, what amount must be awarded for damages? on the first question the appeal court found that the volkmann’s contracture was due to the ischaemic condition. on the second question the following aspects were considered: • would the reasonable, skilled and careful physician have realised that a serious ischaemic condition was developing? the answer was yes. • was there a remedial action that could reasonably have been taken? the answer was yes, by removing or splitting the cast. • would the reasonable practitioner have been aware of the remedial actions? the answer was yes. • would the remedial action have prevented the damage suffered? the answer was yes. • did the respondent fail to take the steps? the answer was yes. this meant that the practitioner neglected his duty and was negligent. treatment a physician must treat a patient after diagnosing a condition as a reasonable, skilled and careful physician should do. a physician is not asked to guarantee cure. the treatment must be completed before a physician’s duties end. withdrawal from the relationship with a patient at a critical stage and/or without consent of the patient constitutes negligence. procedures • the wrong procedure. • the wrong patient. • the wrong part. foreign bodies • the object most frequently left in the body is the surgical swab (van wyk v lewis). • x-rays. where a patient is submitted to x-ray treatment, diagnostic or therapeutic, the risk of being burned or injured always exists. the lack of specialist knowledge required for the utilisation of this type of treatment will be conclusive proof of negligence. a radiologist must measure up to the standard established for specialists in his particular specialty. he will not be held liable where he executed proper care. he will, however, be liable if he deviates from the customary and recognised standards. in dale v hamilton supra the radiologist was liable for burns due to the wrong installation of a tube. drugs liability can result from administering the wrong drug, administering the correct drug in a negligent manner, inappropriate dosage, where the patient becomes addicted to the drug, where the patient is seriously injured or killed by the adverse effects of the drug (allergic reaction, where an overdose is given, where the wrong medication was chosen for the illness). the oral administration of external medication or the intravenous injection of oral medication is negligent per se. in s v van schoor a young physician administered a drug with arsenic acid in a lethal dosage to two patients who died, after consulting with the senior doctor. the senior doctor was not aware of the different dosage (10 times stronger) of the new batch of the drug that arrived and gave instructions appropriate to the previous batch. dr van schoor was found not to have exercised the degree of care necessary as he was dealing with a dangerous drug that required a higher standard of care, and the fact that the drug was to be administered intravenously necessitated a higher standard of care. see also s v mkwetshana supra. it must be kept in mind that some patients might be allergic or over-sensitive to drugs. a practitioner should know the side-effects of any drug he prescribes or administers. in the case of possible allergic reactions, the necessary precautions must be taken to ensure immediate remedial action. the possibility of side-effects should be made known to patients and they should be instructed to report any adverse effect immediately. defective instruments or equipment vicarious liability vicarious liability deviates from the principle of delictual liability in the sense that the employer is not at fault. the requirements for vicarious liability are: • master-servant relationship. this must exist at the time the delict is committed by the employee. the relationship starts when someone places his manpower at the disposal of another for remuneration. there must be control exercised by the employer. there must a contract of employment (location conduction operarum). • the delict must have been committed in the execution of duties. this applies to duties of employreview article 21 sa journal of radiology • august 2004 review article 22 sa journal of radiology • august 2004 ment as direct obligation as well as actions incidental thereto or in the general course thereof. • the act of the employee must meet the requirements for an actionable wrong. it follows that hospital authorities will be held liable for the actions of staff, including professional staff. the question on the position of the paying patient receiving treatment in a state hospital as well as the non-paying patient arises. in dube v the administrator of transvaal it was held that hospital authorities are liable for the negligent conduct of employees at all times. • a physician can be held liable for the negligence of his employees if a master-servant relationship exists. references 1. claassen njb, verschoor t. medical negligence. pretoria: digma, 1992. 2. van der merwe nj, olivier pjj. die onregmatige daad in die suid afrikaanse reg. 5th ed. pretoria: jp van der walt, 1985. 3. strauss sa. doctor, patient and the law. 2nd ed. pretoria: jl van schaik, 1963. 4. neethling j, potgieter jm, visser pj. deliktereg. durban: butterworths, 1989. cases cited dale v hamilton 1924 wld 184 dube v administrator, transvaal 1963 (4) sa 260 (w) ex parte v rautenbach 1938 sr 150 kovalsky v krige 1910 20 ctr 822 kruger v coetzee 1966 (2) sa 428 (a) pringle v administrator, transvaal 1990 (2) sa 379 (w) s v van schoor 1948 (40) sa 349 (c) s v burger 1975 (4) sa 877 (a) s v mahlalela 1966 (1) sa 226 (a) s v makwetshana 1965 (2) sa 493 (n) s v ngubani 1985 (3) sa 677 (a) van wyk v lewis 1924 ad 438 clinical guideline practical radiology of plasmacytoma and multiple myeloma andrew du toit mb chb, ffrad lucille wood ba (nurs sci), msc (medicine) (haematol), rn, rm, dip. intensive nursing care, ward admin and clinical teaching peter jacobs mbbch, md, phd (medicine), fcp (sa), facp, frcp, mcap, frc path, frs department of haematology and bone marrow transplant unit incorporating the searl/ research laboratory for cel/ular and molecular biology, constantiaberg medi·c/inic, cape town abstract the traditional approach to diagnosis and staging in myeloma, based on haematologie and biochemical criteria, can be improved by inclusion of new forms of imaging. standard radiographs have limited value but are still required because the majority of patients present with disease readily detected by this means. also rapid extensive skeletal coverage is possible. scintigraphy is limited by its poor sensitivity. ct is restricted to a region of interest but is however more accurate than dxa for demonstrating trabecular bone loss and density so that it emerges as valuable in the evaluation of therapy. mr! is currently the best choice for revealing marrow infiltration and, in ideal circumstances, the most sensible combination includes spine, pelvis and proximal femur mr! with skull, chest and rib x-rays. furthermore mr! is finding a place in documenting prognosis when these individuals are treated. introduction localised or disseminated monoclonal proliferation of plasma cells produces a wide range of symptoms and signs primarily in the skeleton. prominent among the latter is discomfort due to generalised osteoporosis, solitary or multiple lytic lesions i in addition to pathological fracture.' associated is synthesis of a paraprotein which can typically be detected in serum and as bence-lones proteins in urine although the more primitive variants may not secrete and occasionally not even produce the aberrant immunoglobulin molecule.' metabolic consequences are increases in blood calcium and urate that are risk factors for kidney failure.' invasion of the bone marrow impairs haematopoiesis' with both humoral and cell-mediated immunity being compromised," the cause is unknown although the natural history is well described with median survival of only 7 months.' in contrast modern 22 sa journal of radiology • february 2003 management improves quality of life by optimum support and combinations of alkylating agents with corticosteroids while investigational approaches centre on haematopoietic stem cell transplantation and thalidoruide." clinical features presentation may be protean and with the increasing use of routine biochemical screening, as part of health care management, diagnosis can be made when only biochemical changes are reported incidentally from the laboratory. prominently pain is axial reflecting demineralisation that may be severe, is often aggravated at night and is characteristically responsive to biphosphonates." areas of destruction vary in number and size. strong correlations exist with cytokines that alter both osteoclastic and osteoblastic activity.ii myelomatous masses may erode the cortex and give rise to large subcutaneous swellings, underlie breaks, predispose to vertebral compression and occasionally present as tumours in breast, stomach or adjoining the spinal column. haematologically there are varying degrees of normochromic and normocytic anaemia pathophysiologically attributed to the chronic inflammatory state and associated with a marked increase in erythrocyte sedimentation rate. until late in the course leucocyte and platelet counts are preserved." bone marrow aspiration reveals increased numbers of plasmacytes many of which may be pleomorphic and, together with their extent and distribution seen in the trephine, are included in some staging procedures." biochemical consequences are clinical guideline increases in calcium and urate with a distinctive spike in the gamma region on serum protein electrophoresis. free light chains, filtered at the glomerulus, are then deposited in the tubules so contributing to renal dysfunction with polyuria and dehydration culminating in a self-perpetuating cyde that is, however, initially reversible. sometimes profound degrees of immune compromise reduce polydonal antibodies and predispose to sinopulmonary infection. approximately 10% of patients develop amyloidosis that has widespread effects typically producing nephrotic syndrome but perhaps more ominously restrictive cardiomyopathy. a wide range of other features exist to trap the unwary diagnostician and a high degree of awareness will often lead to an early diagnosis." laboratory evaluation there is no substitute for a carefully taken history followed by meticulous examination, maintaining a high degree of awareness and simple bedside tests of which urinalysis remains invaluable." the next stage is confirmation and since a number of the findings are mimicked by other disorders it is wise to combine as many abnormal findings as possible to secure the diagnosis but primarily rely on the presence of the serum paraprotein designated an m-peak and intramedullary plasmacytosis. staging defines anticipated outcome and provides a practical means for monitoring management. the most widely used of these is that described by durie and salmon (table i)." recent studies support the use of b2 microglobulin and c-reactive protein." an approach to imaging plain film radiography approximately 80% of individuals have abnormalities at presentation and this remains a logical first step in studying the skeleton." however no systematic approach appears to have been described for the integration of these changes into established staging systems":" although there is, not surprisingly, a loose correlation implicit between advancing tumour and skeletal damage. to provide a more structured approach to this risk factor a new grading is proposed (table ii). bone mineral density as part of an ongoing evaluation, (jacobs, wood, hitchcock and du toit unpublished data) this is quantitated initially and followed serially seeking to define the influence of different interventions, particularly the use of biphosphonates." we have found that the much favoured dxa often underestimates trabecular thinning which is readily evident on computerised axial tomography." scintigraphy radionuclide scanning using technetium-99m labelled diphosphonate is typically normal or shows areas of decreased uptake. the explanation for this relative insensitivity is that the osteoblastic activity in these tumours is outweighed by the aggressive stage criteria tablei.classificationof myeloma (modified from durie and salmon's). the best predictors are degree of anaemia, quantitation of paraprotein and serum calcium level i: all must be present ii iii: one or more only needed subclassification a:= serum creatinine < 120 ljmol/l il= serurn creatinine> 120 ij.mol/l. 23 sa journal of radiology • february2003 • haemoglobin value> 100 gil • serum calcium < 2.2 mmol/l • radiographically normal bone structure solitary bone plasmacytoma •m-component igg < 50 gil 19a< 3 gil urine light chain < 4 gl24 hours fitting neither stage i nor stage iii • haemoglobin value < 85 gil • serum calcium value >2.2 mrnol/l • advanced osseous destruction • m-component igg > 70 gil 19a> 50 gil urine light chain> 12 gl24 hours clinical guideline table ii. constantiaberg grading of skeletal changes (jacobs, wood and du toitunpublished data). uncertainty exists as to whether the total amount of cortical damage reflected in multiple small defects has different value to a smaller number of much larger areas of destruction grade criteria o i ii a. b. c. iii n normal diffuse demineraiisation less than 10 lytic lesions maximum 1 cm 2-4cm greater than 5 cm more than 10 bony defects associated pathological fracture destruction of the hypertrophic osteoclasts." computerised tomography (ct) although not routinely used it may nevertheless demonstrate early trabecular bone destruction within a vertebral body where other imaging modalities are negative. magnetic resonance imaging(mri) support derives from a greater sensitivity in revealing otherwise occult invasion which is seen in about 50% of asymptomatic patients with normal xvrays." representative areas are full spine, pelvis and proximal femora because these contain the normal haematopoietic tissue that harbours the neoplasm. three patterns are discern able (table iii).21 focal accumulations exhibit lowtl and low or high t2 signal in approximately equal numbers of untreated cases. the variegated or salt and pepper appearance has small nodules on tl and is sometimes best appreciated in the pelvis. a diffuse involvement has similar intensity to the isolated deposits with homogenous replacement resembling other intramedullary proliferative disorders. mixed pictures occur depending on the status of the immunoproliferative neoplasm. this variable appearance results from relatively even neoplastic distribution throughout the haematopoietic tissue in widespread disease contrasting with the small or large nodules composed entirely of tumour in localised patterns. compounding factors are increasing age with conversion of red to yellow marrow that influences both detection and character of the image produced by the myeloma. thus, although nortable m. magnetic resonance imaging in myeloma (modified from kaplan et al.21) signal pattern tl t2 focal low high or low variegated or salt & pepper low mild high diffuse low high or low 24 sajournal of radiology. february2003 mal haematopoiesis is impaired with replacement of the former, the relative increase in the adipocytes gives an enhanced signal, which offsets reduction from areas of infiltration, and so the scan may look normal. contrast enhancement with gadolinium is often marked but neither specific nor essential if any abnormality has already been demonstrated. similarly medullary invasion may be patchy although widespread overall so that an adequate trephine biopsy will invariably demonstrate the aetiology. hence mri is not usually required to direct the aspiration site. vertebral fractures are seen with significant osteoporosis, which is frequent, and approximately 60% of compression fractures look benign. thus in 37 patients with 224 fractures, 67% had this appearance, 33% appeared malignant and, interestingly, 14 of these or 38% had no sinister features." the distribution of such radiological changes was similar to that observed in non-myelomatous demineralisation predominantly in the lower dorsal and upper lumbar regions. in contrast ominous features are low tl signal extending from the vertebral body into the pedicles and posterior elements, diffuse body involvement, multiple level involvement and extension outside of bone to form a soft tissue mass." the anatomical site may be helpful in detecting malignancy since those above t4 are usually pathological. a prognosis on therapeutic outcome can be correlated with durie and salmon stage iii where four groups are defined; normal, fewer or more than 10 focal sites and widespread infiltration." it is notable that with apparently solitary lesions mri will typically reveal other deposits. clinical guideline following therapy those with lower grades based on both biopsy and radiological criteria experienced significantly longer fracture-free survival than where more extensive changes were present. it is also useful to forecast response. in durie and salmon stage i invasion is associated with subsequent progression." stage iii patients with normal images (24%) achieve better results with therapy and survive longer than those where this is abnormal." when coupled with crp this pair were the best independent prognostic indicators for survival. this method can be refined using contrast when complete response is defined as resolution of the baseline abnormality and is superior to persistence of any change even if this is only peripheral rim enhancement." references 1. ravaud p, thepot c, auleley gr, amor b. imaging of multiple myeloma. ann med interne 1996; 147: 370-375. 2. scutellari pn, orzincolo c. bone disease in multiple myeloma: analysis of 253 controlled cases, with reappraisal of diagnostic criteria and current imaging techniques. radiol med 1993; 85: 235-246. 3. bartoloni c, flamini g, logroscino c, et al. igd (kappa) 'nonsecretory' multiple myeloma: report of a case. blood 1980; 56: 898-901. 4. clark ad, shetty a, soutar r. renal failure and multiple myeloma: pathogenesis and treatment of renal failure and management of underlying myeloma. blood rev 1999; 13: 79-90. 5. rajkumar sv; fonseca r, dewald gw, et al. cytogenetic abnormalities correlate with the plasma cell labeling index and extent of bone marrow involvement in myeloma. cancer genet cytogenet 1999; 113: 73-77. 6. paglieroni t, mackenzie mr. studies on the pathogenesis of an immune defect in multiple myeloma. j clin invest 1977; 59: 1120-1133. 7. bataille r. multiple myeloma. n engl j med 1997; 336: 1657-1664. 8. huff ca, jones rj. bone marrow transplantation for multiple myeloma: where we are today. curr opin oneo12002; 14: 147-151. 9. tosi p, cavo m. thalidomide in multiple myeloma: state of art. haematologica 2002; 87: 233234. 10. berenson jr. bone disease in myeloma. current treatment options in oncology 200 i; 2: 271-283. 11. ely sa,knowles om. expression of cd56/neural cell adhesion molecule correlates with the presence of lytic bone lesions in multiple myeloma and distinguishes myeloma from monoclonal gammopathy of undetermined significance and lymphomas with plasmacytoid differentiation. am j patho12002; 160: 1293-1299. 12. jacobs p, wood l. myeloma and other immunoproliferative disorders. cme 1999; 17: 253-257. 13. bartl r, frisch b. bone marrow histology in multiple myeloma: prognostic relevance of histologic characteristics. hematol rev 1989; 3: 87108. 14. jacobs p. myeloma. disease-a-month 1990; 36: 317-371. 15. durie bg, salmon se. a clinical staging system for multiple myeloma: correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. cancer 1975; 36: 842-854. 16. the myeloma trialists' collaborative group. combination chemotherapy versus melphalan plus prednisone as treatment for multiple myeloma: an overview of 6,633 patients from 27 randomised trials. j clin oneo11998; 16: 38323842. 17. collins c. multiple myeloma. tn:husband jes, reznek rh, eds. imaging in oncology. new york: isis medical media, 1998: 625-634. 18. berenson jr, lichtenstein a, porter l, et al. long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. the myeloma aredia study group. j clin oneal 1998; 16: 593-602. 19. solomon 0, jacobs p.bone densitometryrole of quantitative computed tomography. s afr med j2oo2; 92: 486. 20. abildgaard n, glerup h, rungby j, et al. biochemical markers of bone metabolism reflect osteoclastic and osteoblastic activity in multiple myeloma. eur j haematol2oo0; 64: 121-129. 21. kaplan pa, helms ca, dussault r, anderson mw, major nm. musculoskeletal mrt. philadelphia: saunders, 2001: 23-53. 22. lecouvet fe, van de berg bc, maldague be, et al. vertebral compression fractures in multiple myeloma. part 1. distribution and appearance at mr imaging. radiology 1997; 204: 195-199. 23. lecouvet fe, malghem j, michaux l, et al. vertebral compression fractures in multiple myeloma. part u. assessment of fracture risk with mr imaging of spinal bone marrow. radiology 1997; 204: 201-205. 24. lecouvet fe, van de berg bc, michaux l, et al. stage tij multiple myeloma. clinical and prognostic value of spinal bone marrow mr imaging. radiology 1998; 209: 653-660. 25. van de berg bc, lecouvet fe, michaux l, et al. stage i multiple myeloma: value of mr imaging of the bone marrow in the determination of prognosis. radiology 1996; 201: 243-246. 26. moulopoulos la, dimopoulos ma, alexanian r, leeds ne, libshitz hi. multiple myeloma: mr patterns of response to treatment. radiology 1994; 193: 441-446. 25 sa journal of radiology • february 2003 abstract introduction method results discussion conclusion acknowledgements references about the author(s) daniël luyt department of clinical imaging sciences, university of the free state, south africa delmé hurter department of radiology, kimberley hospital complex, south africa gina joubert department of biostatistics, university of the free state, south africa citation luyt d, hurter d, joubert g. the relationship between computed tomography measurement of the optic nerve sheath diameter and elevated intracranial pressure in non-trauma patients. s afr j rad. 2016;20(1), a1060. http://dx.doi.org/10.4102/sajr.v20i1.1060 original research the relationship between computed tomography measurement of the optic nerve sheath diameter and elevated intracranial pressure in non-trauma patients daniël luyt, delmé hurter, gina joubert received: 13 july 2016; accepted: 05 sept. 2016; published: 23 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the early detection and treatment of raised intracranial pressure (icp) is critical in the prevention of mortality and morbidity as a result of secondary ischemic brain injury. measuring the optic nerve sheath diameter (onsd) on computed tomography (ct) to predict raised icp may be useful in cases where routine ct investigations of the brain are indicated and invasive icp monitoring is not available, or a lumbar puncture (lp) is contraindicated. objective: the purpose of this study was to determine if the onsd can be measured on digital images obtained by routine ct investigations of the brain, to identify patients with non-traumatic causes of elevated icp, and to provide the observer with a non-invasive, objective measurement to predict elevated icp. method: we conducted a cross-sectional, retrospective analysis of anonymised patient data, comparing the onsd on ct imaging with the opening pressure manometry during lp on patients who presented with focal neurology or with a glasgow coma scale score of less than 15. the study sample consisted of 67 patients, ≥18 years of age, treated at the emergency department of the kimberly hospital complex from 01 march 2013 to 31 december 2014. results: an onsd measurement of ≥4.8 mm identified patients with an elevated icp with a sensitivity of 92.9% and a specificity of 97.6%, using a 95% confidence interval. raising the onsd cut-off value to ≥5.0 mm decreased the sensitivity to 85.7% but increased the specificity to 100%, eliminating all patients with a normal icp. conclusion: the onsd can be measured on digital images obtained by routine ct investigations of the brain to predict elevated icp in non-trauma patients, ≥18 years of age, with acceptable sensitivity and specificity. introduction raised intracranial pressure (icp) is frequently associated with conditions such as meningitis, stroke and post resuscitation syndrome. the early detection and treatment of raised icp is critical in the prevention of increased mortality and morbidity as a result of secondary ischemic brain injury. although invasive icp monitoring is not routinely undertaken or available at peripheral referral hospitals, computed tomography (ct) imaging is often performed in these settings. demonstrating a relationship between non-invasive ct measurement of the optic nerve sheath diameter (onsd) and elevated icp may be particularly useful in cases where routine ct investigations of the brain are indicated and invasive icp monitoring is not available, or a lumbar puncture (lp) is contraindicated. other non-invasive methods, such as magnetic resonance imaging (mri) and ultrasound (us) measurement of the onsd, have already shown acceptable results as screening tools to estimate the probability of elevated icp.1 however, the routine use of mri to measure the onsd is limited by availability and time constraints in critically ill patients. other limitations include expertise in obtaining images, especially after hours, as well as the use of non-routine sequences to make accurate measurements, precluding its widespread clinical utility.1 on the contrary, although us is readily available, the onsd measurement is operator dependent and only useful in predicting elevated icp in the hands of experienced operators.2 the mechanism responsible for the distention of the optic nerve sheath complex can be explained by the communication between the subarachnoid space surrounding the optic nerve and the intracranial subarachnoid space. the distended dural sheath can be measured on imaging as an increase in size of the optic nerve sheath complex when the icp is elevated.3,4 noticeable differences in the onsd occur within seconds after a change in icp, making it possible to detect immediate changes in icp by measuring the onsd.5 the use of clinical fundoscopy to exclude elevated icp may provide false negative results, as papilledema may only develop several days after the icp has increased.6 bäuerle and nedelmann7 reported no correlation between the onsd, gender and body mass index in patients ≥18 years of age, which enabled us to use a single age cut-off value to indicate elevated icp in our study population. additionally, the radiology department of the kimberly hospital complex routinely performs ct investigations of the brain to assess for the safety of an lp prior to the procedure, in patients who present with either focal neurological signs or a decreased level of consciousness.8 we, therefore, hypothesised that patients ≥18 years of age with non-traumatic causes of elevated icp could be identified by measuring the onsd on digital images obtained by routine ct investigations of the brain, which would provide the observer with a non-invasive, objective measurement to predict elevated icp. method study sample and design we conducted a cross-sectional, retrospective analysis of anonymised patient data after ethics committee approval had been obtained, comparing onsd on ct, with icp measured by opening pressure manometry during lp. the study sample incorporated patients, ≥18 years of age, who presented with either focal neurological signs or a decreased level of consciousness to the emergency department at the kimberley hospital complex, during the period from 01 march 2013 to 31 december 2014. all patients who received both a ct scan of the brain and an lp where opening pressure manometry was determined were included in the study. patients with a failed lp procedure, or for whom the time and technique of the lp were not recorded, were excluded from the study. optic nerve sheath diameter measurement the digital ct images were obtained from the picture archiving and communications system. all of the images were acquired with a siemens somatom sensation 16-slice ct scanner, using the non-enhanced ct brain protocol with 1.0-mm slice thickness, kernel h60 sharp, field of view 200 mm and adjusted window width (50) and level (250),9 on a matrix size of 512 × 512. the onsd measurements were performed by radiology registrars experienced in digital ct image reconstruction and measurement. all of the measurements were confirmed by a qualified radiologist. in order to avoid any bias, the onsd measurements were determined without any prior knowledge of the lp opening pressure measurements. the transverse diameter of the optic nerve sheath complex was measured perpendicular to its course in the orbit on double oblique axial images, 10 mm behind the globe, as described by vaiman et al.,10 and the average of the measured values for left and right oncds was used to represent the onsd of the patients, consistent with the method used by caffery et al.11 figure 1 demonstrates a double oblique axial ct image of the optic nerve sheath complex, where measurements were taken, 10 mm behind the globe.10 figure 1: optic nerve sheath diameter measurement on an axial computed tomography image. lumbar puncture opening pressure measurement the lp opening pressure values were obtained from patient data collected during the study period. the lp procedures were performed by medical officers working in the emergency department, according to the standardised protocol used at the kimberley hospital complex. all lp opening pressure values were recorded with a manometer in centimetres of water (cmh2o), with the patient lying in the left lateral decubitus position, legs straight, and the patient relaxed at the time of measurement to avoid any false elevation of opening pressure because of the valsalva effect.8 the zero level of the manometer was adjusted to approximate the level of the left atrium, which corresponds to the position of the spinal canal in the left decubitus position.8 all measurements were documented with the time and technique of the procedure. the medical officers performing the lp and recording the opening pressure had no prior knowledge of the onsd measurement. elevated opening pressure at lp was defined as a pressure >20 cmh2o.12 statistical analysis numerical data were summarised by means and standard deviations. sensitivity, specificity and predictive values (with 95% confidence intervals) were calculated for all possible cut-off values of onsd, ranging from 3.1 mm to 5.9 mm, to find the onsd cut-off value with the highest sensitivity and specificity for high lp opening pressure values measuring >20 cmh2o. results a total of 67 patients were referred for ct investigation of the brain to assess for safety of lp prior to the procedure. from this study population, two patients were excluded because of unsuccessful lp procedures and nine patients were excluded because the opening pressure or the time of the procedure was not recorded. of the 56 patients included in the study, 14 patients had elevated icps >20 cmh2o and 42 patients presented with normal opening pressures ≤20 cmh2o. an onsd measurement of ≥4.8 mm yielded the highest combined accuracy for indicating elevated lp opening pressures >20 cmh2o, with a statistically significant correlation of 0.88 (p < 0.01) between onsd and lp opening pressure as demonstrated in figure 2. figure 2: correlation between lumbar puncture opening pressure (cmh2o) and optic nerve sheath diameter (mm). the sensitivity for the onsd cut-off value ≥4.8 mm was 92.9% (95% ci 68.5% – 98.7%) and the specificity was 97.6% (95% ci 87.7% – 99.6%); the positive predictive value was 92.9% (95% ci 68.5% – 98.7%) and the negative predictive value was 97.6% (95% ci 87.7% – 99.6%) for identifying elevated lp opening pressure. ct measurements <4.8 mm were recorded in 42 (75.0%) patients and ≥4.8 mm in 14 (25.0%) patients. the correlations with the lp opening pressures are summarised in table 1. table 1: computed tomography optic nerve sheath diameter measurements compared to lumbar puncture opening pressure. lowering the onsd cut-off to ≥4.4 mm yielded 100% sensitivity but decreased specificity to 64.3%. raising the onsd cut-off to ≥5.0 mm decreased sensitivity to 85.7% but increased specificity to 100% for raised lp opening pressure. discussion invasive icp monitoring is not routinely performed or available at most peripheral referral hospitals in south africa. however, the availability of ct imaging at these sites provides us with an opportunity to predict elevated icp by measuring the onsd. this method is particularly useful in cases where routine ct investigations of the brain are indicated and invasive icp monitoring is not available, or an lp is contraindicated. it may also be used to identify patients who require referral for invasive icp monitoring. kalantari et al.13 demonstrated a strong correlation between non-invasive mri and ct measurements of the onsd with raised icp. similarly, geeraerts et al. reported that an enlarged onsd at mri was a robust predictor of raised icp with a sensitivity of 90% and a specificity of 92% in a retrospective study of 38 patients who required both invasive icp monitoring and mri, with a best single retro-orbital onsd cut-off value of 5.82 mm. they increased their sensitivity for detecting raised icp to 100% by lowering the cut-off to 5.3 mm.1 although mri measurement of the onsd yielded excellent results, it is not usually indicated in these settings. geeraerts et al.1 also made use of a special non-routine proton density or t2-weighted turbo spin echo fat-suppressed sequence to measure the onsd. the generalised use of mri measurement of the onsd is limited by availability, time constraints in critically ill patients, metal implants and operator expertise, especially after hours. using retro-orbital ultrasound to measure the onsd, as performed by rajajee et al.2 demonstrated similar results with a best single onsd cut-off measuring ≥4.8 mm, a sensitivity of 96% and a specificity of 94% for indicating elevated icp. the use of us to measure the onsd is operator dependent, and these results were obtained by neuro-intensivists experienced in us measurement of the onsd.2 du toit et al.8 correlated us measurement of the onsd with lp opening pressure with acceptable negative predictive values, but failed to demonstrate acceptable results to predict elevated icp, highlighting the need for technical expertise when using this method to measure the onsd and likely limiting its generalised clinical utility to predict elevated icp. our results demonstrated a strong correlation between onsd and lp opening pressure using a best single onsd cut-off measuring ≥4.8 mm, with an acceptable sensitivity of 92.9% and specificity of 97.6% for predicting elevated icp. lowering the onsd cut-off to ≥4.4 mm yielded 100% sensitivity but decreased specificity to 64.3%, and raising the onsd cut-off to ≥5.0 mm decreased sensitivity to 85.7% but increased specificity to 100%, effectively eliminating all cases with normal icp. sekhon et al.14 reported a strong correlation between icp and onsd measured on ct using a retro-orbital cut-off value of 6.0 mm; they also found that onsd measurement was a much better predictor of icp than traditional ct findings such as sulcal and basal cisternal effacement, ventricular compression and cerebral herniation. possible reasons for the difference in the published onsd cut-off values for predicting elevated icp include the different imaging modalities used for onsd measurement, inter-observer variability and the distance behind the globe where the measurements were taken. however, various authors1,2 consistently found a positive correlation between the onsd measurement and elevated icp. we used the same technique as vaiman et al.,10 who obtained the most reliable results for icp monitoring, measuring the transverse onsd 10 mm behind the globe. to ensure accuracy and reproducibility, we used a constant window width (50) and level (250) for ct measurement of the onsd, in keeping with published results from fidor-mikita and krupski.9 although invasive icp monitoring remains the gold standard for diagnosing elevated icp, it is not routinely performed in these settings and it is not readily available.1 the advantages of measuring the onsd on ct include the use of images obtained from routine ct brain investigations, as well as the availability of the necessary equipment and expertise to obtain the images and perform the onsd measurements at most referral centres. our study is limited by its retrospective nature and relatively small sample size, but compares well with that of geeraerts et al.1 who performed a retrospective study on 38 patients. the novelty of measuring the onsd on ct images requires further investigation with larger prospective studies investigating the relationship between ct and mri measurement of the onsd, the specific ct window width and level settings required for accurate measurement of the onsd and correlation with invasive icp. this should address some additional limitations we encountered during this study. conclusion the onsd can be measured on digital images obtained by routine ct investigations of the brain to predict elevated icp in non-trauma patients ≥18 years of age, providing the observer with a non-invasive objective measurement to predict elevated icp. measuring the onsd can help identify patients who need early referral and treatment to prevent secondary brain injury. the onsd cut-off with the highest combined sensitivity and specificity for elevated icp measured ≥4.8 mm. raising the onsd cut-off to ≥5.0 mm decreased sensitivity, but excluded all patients with a normal icp in our study population. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions d.l. planned the study, wrote the protocol, performed the data collection and data interpretation and wrote the draft manuscript. d.h. was the supervisor in this study, assisted with the planning, interpretation of results and write up. g.j. assisted with the planning, performed the data analysis, assisted with the data interpretation and write up. all authors approved the final paper. references geeraerts t, newcombe v, coles j, et al. use of t2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. crit care. 2008;12:r114. http://dx.doi.org/10.1186/cc7006 rajajee v, vanaman m, fletcher jj, jacobs tl. optic nerve ultrasound for the detection of raised intracranial pressure. neurocrit care. 2011;15:506–515. http://dx.doi.org/10.1007/s12028-011-9606-8 zaidi sjh, yamamoto lg. optic nerve sheath diameter measurement by ct scan in vp shunt obstruction. hawaii j med public health. 2014;73:251–255. geeraerts t, launey y, martin l, et al. ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. intensive care med. 2007;33:1704–1711. http://dx.doi.org/10.1007/s00134-007-0797-6 hansen hc, lagrèze w, krueger o, helmke k. dependence of the optic nerve sheath diameter on acutely applied subarachnoidal pressure: an experimental ultrasound study. acta ophthalmol. 2011;89:e528–e532. http://dx.doi.org/10.1111/j.1755-3768.2011.02159.x hansen hc, helmke k. validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. j neurosurg. 1997;87:34–40. http://dx.doi.org/10.3171/jns.1997.87.1.0034 bäuerle j, nedelmann m. sonographic assessment of the optic nerve sheath in idiopathic intracranial hypertension. j neurol. 2011;258:2014–2019. http://dx.doi.org/10.1007/s00415-011-6059-0 du toit g, hurter d, nel m. how accurate is ultrasound of the optic nerve sheath diameter performed by inexperienced operators to exclude raised intracranial pressure? s afr j radiol. 2015;19(1); art. #745, 1–5. http://dx.doi.org/10.4102/sajr.v19i1.745 fidor-mikita e, krupski w. computed tomography imaging of orbits in thyroid orbitopathy. j pre-clin clin res. 2008;2:059–063. vaiman m, gottlieb p, bekerman i. quantitative relations between the eyeball, the optic nerve, and the optic canal important for intracranial pressure monitoring. head face med. 2014;10:32. http://dx.doi.org/10.1186/1746-160x-10-32 caffery ts, perret jn, musso mw, jones gn. optic nerve sheath diameter and lumbar puncture opening pressure in nontrauma patients suspected of elevated intracranial pressure. am j emerg med. 2014;32:1513–1515. http://dx.doi.org/10.1016/j.ajem.2014.09.014 weatherall dj, ledingham jgg, warrell da. oxford textbook of medicine. 3rd ed. south africa: oxford university press; 1996. volume 3 section 18–33/24.2.6:3843. kalantari h, jaiswal r, bruck i, et al. correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. am j emerg med. 2013;31:1595–1597. http://dx.doi.org/10.1016/j.ajem.2013.07.028 sekhon ms, griesdale de, robba c, et al. optic nerve sheath diameter on ct is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury. intensive care med. 2014;40:1267–1274. http://dx.doi.org/10.1007/s00134-014-3392s7 abstract introduction research methods and design ethical consideration results discussion conclusion acknowledgements references about the author(s) mark a. nicolaou department of diagnostic radiology, university of the witwatersrand, johannesburg, south africa kathleen jacobs department of diagnostic radiology, chris hani baragwanath hospital, johannesburg, south africa sindeep bhana department of endocrinology, chris hani baragwanath hospital, johannesburg, south africa kershlin naidu endocrinologist, netcare waterfall city hospital, johannesburg, south africa veronique nicolaou department of endocrinology, chris hani baragwanath hospital, johannesburg, south africa citation nicolaou ma, jacobs k, bhana s, naidu k, nicolaou v. a retrospective study correlating sonographic features of thyroid nodules with fine-needle aspiration cytology in a south african setting. s afr j rad. 2019;23(1), a1749. https://doi.org/10.4102/sajr.v23i1.1749 original research a retrospective study correlating sonographic features of thyroid nodules with fine-needle aspiration cytology in a south african setting mark a. nicolaou, kathleen jacobs, sindeep bhana, kershlin naidu, veronique nicolaou received: 09 apr. 2019; accepted: 05 may 2019; published: 26 june 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: thyroid nodules are prevalent worldwide. detection rates are increasing because of the use of ultrasonography. ultrasound has become the first-choice imaging modality in evaluating nodules. the decision to perform an us-guided fine-needle aspiration (fna) is based on a nodule’s sonographic features. thus, it is essential to accurately risk stratify thyroid nodules so that they are appropriately referred for fna. objectives: the aim of this study was to correlate the ultrasound imaging features of thyroid nodules with fna cytology and surgical histopathology results, and to risk stratify patients using the american thyroid association (ata) classification for each imaging characteristic with the likelihood of the nodule being malignant. method: retrospective analysis of a thyroid ultrasound database at chris hani baragwanath academic hospital, over the period 2015–2017. frequencies and percentages were used to summarise the data. univariate logistic regression analyses were used to assess the accuracy of sonographic features in predicting the histologically determined diagnosis for thyroid tumours. results: a total of 113 nodules underwent fna, of which 104 were diagnostic. the best three ultrasound features that pose a higher risk for malignancy are absent halo, presence of microcalcifications and hypoechoic appearance. no single nodule feature is an absolute indicator for malignancy. there is a high agreement between ata classification and cytopathology or histology when nodule features are grouped into clusters. agreement between the ata classification and cytopathology/histology was 86.7% with a kappa of 0.714. the agreement between the cytopathology fna results and lobectomy histopathology was 98.8% with a kappa of 0.973. conclusion: this study contributes to the paucity of data available for sub-saharan africa and provides reassurance that our results are consistent with international studies. the study confirms that the usage of a thyroid nodule classification system improves characterisation and increases accuracy in detecting thyroid malignancies, thus sparing many patients the morbidity of unnecessary thyroid surgery. keywords: thyroid; nodule; fine-needle aspiration; fna; american thyroid association; ata; thyroid cancer. introduction background thyroid nodules are prevalent worldwide and seen in patients of all age groups. detection rates are higher than previously reported with the ever-increasing use of thyroid ultrasonography. several large international studies report that up to 76% of women have at least one thyroid nodule and as many as 57% of routine autopsies discover incidental nodules.1 the majority of nodules are asymptomatic and are benign in 80%–92% of cases.2 when a thyroid nodule is discovered incidentally or clinically, there is a necessity for workup and further investigation. thyroid nodules and ultrasound a thyroid nodule is defined as a distinct focal lesion within the thyroid parenchyma.3 ultrasound has become the first-choice imaging modality in screening and detection of thyroid nodules. this is not only because of its excellent spatial resolution compared to computed tomography (ct) and magnetic resonance imaging (mri), but also because the thyroid gland is easily visualised sonographically because of its superficial location anatomically.2 the next step in the evaluation of a thyroid nodule is to perform an ultrasound-guided fine-needle aspiration (fna) if the nodule/s meet certain sonographic criteria. thyroid scintigraphy is performed in the evaluation of thyroid nodules in patients with biochemical hyperthyroidism. there is a relatively low risk of nodules being malignant with only 4%–8% of thyroid nodules diagnosed as malignant on cytology.2,4 despite this low risk, the discovery of a nodule on ultrasound can lead to anxiety for the patient and may lead to unnecessary fna and/or surgery being performed. clear sonographic guidelines are essential in determining whether a fna is indicated because sonography alone cannot definitively diagnose a malignancy but may obviate the need for fna.5 since the introduction of ultrasound-guided fna, there has been a significant increase in the likelihood of malignancy at surgical resection.6 thyroid nodule classification systems there are numerous thyroid nodule risk stratification systems that have been developed. the two most commonly used systems are the american thyroid association (ata) management guidelines and the american college of radiology thyroid imaging reporting and data system (acr tirads.).7 both systems combine thyroid nodule ultrasound findings and give an estimated risk of malignancy.8,9 they both utilise ultrasound features of the thyroid nodule that include echogenicity of the nodule sharpness of the border/margin of the nodule shape of the nodule (taller-than-wide configuration in transverse plane) presence/absence of a halo around the nodule microcalcifications internal architecture or composition of the nodule (spongiform, cystic or solid) nodule vascularity (peripheral vs. central vascularity). the difference between the two aforementioned systems is that the ata guidelines use a pattern-based approach rather than a scoring system utilised in the acr tirads.6,9,10 cytopathological evaluation once an fna is performed, the sample is evaluated and reported on by a cytologist. in order for the cytopathological report to be universal and unambiguous, a standardised format of reporting was developed in the form of the bethesda system for reporting thyroid cytopathology.11 this system classifies results into six diagnostic categories: non-diagnostic or unsatisfactory benign atypia of undetermined significance (aus) or follicular lesion of undetermined significance (flus) follicular neoplasm or suspicious for a follicular neoplasm suspicious for malignancy malignant the six categories stratify the risk associated with malignancy (table 1)11. table 1: risk stratification for categories of the bethesda system for reporting thyroid cytopathology.6 the aim of this study was to evaluate the predictive value of ultrasonographic findings in the diagnosis of benign and malignant thyroid nodules in our setting and, furthermore, to confirm the accuracy of the cytopathological diagnosis where histopathological results were available. research methods and design this retrospective cross-sectional study was performed at the chris hani baragwanath academic hospital (chbah) in soweto, johannesburg. patients seen at various outlying clinics and outpatient departments in chbah were referred for ultrasound-guided thyroid fnas at the chbah endocrine clinic. adult patients with normal thyroid function tests were included in the study if the fnas were performed at the chbah endocrinology clinic. those with deranged thyroid functions were only included if they were biochemically hypothyroid. patients were excluded from the study if the fna cytology results were non-diagnostic/unsatisfactory according to bethesda classification or if they initially had aus/flus cytology and they did not return for a repeat fna – that is, lost to follow-up. ultrasound examination and fine-needle aspiration technique two dedicated endocrinologists trained in thyroid sonography performed the ultrasound-guided fnas, thus reducing inter-user variability. because only two endocrinologists were trained in thyroid ultrasonography and thyroid fna, all results from the clinic were derived from their findings. the thyroid ultrasound was performed and if indicated, based on imaging features, an fna was performed at the same time. in cases of multiple thyroid nodules, the most suspicious nodule, based on imaging features, was sampled. the endocrine unit uses a siemens acuson x300 machine with a linear probe frequency range of 5 mhz–14 mhz and a ge logiq p5 with a linear probe frequency range of 5 mhz–13 mhz. fine-needle aspirations were performed by the two endocrinologists using a standardised international thyroid fna technique, namely, the patient in supine position with the neck hyper-extended. a bd precisionglide 27g (1¼ inch) needle attached to a plastic 10 ml syringe was used to aspirate the nodule under direct ultrasound guidance. the needle was passed into the nodule for a duration of 10–30 s with no negative pressure applied to the syringe. two to three needle passes were obtained from a nodule. no local anaesthesia was used. each needle specimen was smeared on four to eight glass slides. half the slides were left to air dry and the remainder of the slides were prepared with 95% ethyl alcohol cytological fixative spray. the glass slides were then submitted to the national health laboratory services (nhls) for cytological evaluation by a single cytopathologist, which reduced inter-observer variability. data collection a database of 113 thyroid fnas was constructed using records from the endocrine clinic dating from may 2015 until september 2017. data were recorded in a spreadsheet using microsoft excel. data were excluded where cytopathological results were reported as non-diagnostic/unsatisfactory for evaluation and those patients who were lost to follow-up after their initial fna cytopathology demonstrated aus/flus. the demographic data of the patients were anonymised and included the age and gender. the following thyroid nodule characteristics on ultrasound were recorded: transverse nodule size, presence of microcalcifications, internal nodule vascularity on colour doppler, echogenicity relative to neck strap muscle echogenicity, solid nodule architecture, taller-than-wide configuration (transverse orientation) and presence or absence of a halo. the ata classification system was used to categorise the nodules. the cytopathology result of all the fnas was followed up and recorded according to the bethesda classification system. patients were referred for surgery if their fna results were bethesda iii/iv (two abnormal fna results), bethesda v (suspicious for malignancy) or bethesda vi (malignant). histological results of these patients were also included in the database. data analysis frequencies and percentages were used to summarise the data. univariate logistic regression analyses were used to assess the accuracy of the sonographic features in predicting the histologically determined diagnosis for thyroid tumours. positive predictive values, negative predictive values, sensitivity and specificity were determined from the model and plotted as a bar graph for each sonographic feature. agreement between ata classification, cytopathology and histology results, as well as cytopathology and histology results, was determined using cohen’s kappa. all analyses were performed at the 95% confidence interval. the data were analysed using stata version 13.1 (statcorp, usa). ethical consideration the human research ethics committee at the university of the witwatersrand granted ethics clearance on 04 october 2017. clearance certificate number is m170970. consent obtained from chbah medical advisory committee. results a final total of 100 thyroid nodule fnas were included in the study of 113 patients. only 13 thyroid nodule fnas were excluded from the study, 9 of which for being non-diagnostic/unsatisfactory and a further 4 patients who were lost to follow-up after initially having aus/flus on their first fna cytopathology. there were 84 females and 16 males in the study. the age range was 16–82 years. the nodule size range was 10 mm–60 mm with a mean nodule size of 30.5 mm. forty-two of the 100 patients were referred for surgical intervention; this was according to the patients’ bethesda classification or if they had repeat aus/flus on cytology results. of all the patients referred for surgery, 79% were confirmed malignant on histopathology. of the 100 thyroid nodules, 67% were benign and 33% were malignant on histopathology. half of the patients referred for surgery because of follicular neoplasm on cytopathology had follicular carcinoma on histopathology. patients who had repeat aus/flus were also referred for surgery – 25% of these patients had malignant histology. there was only one patient who had cytopathology suspicious for a hurthlë cell neoplasm who had benign histopathology. the number of fnas and outcomes of the cytopathology and histology results are graphically presented in figure 1. figure 1: summary of results of thyroid nodules sampled. the histology results determined the following: 17 papillary thyroid carcinoma (ptc) and five follicular variant of ptc (67%), four follicular carcinomas (13%), three hurthlë cell carcinomas (follicular cell variant) (9%), three medullary carcinomas (3%) and one anaplastic carcinoma (2%). nine of the surgical specimen histology results were benign. these results are presented in figure 2. figure 2: breakdown of malignant nodules with histology. the diagnostic performance of each thyroid nodule feature on sonar is outlined in table 2 demonstrating the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv). table 2: diagnostic performance of each thyroid nodule characteristics in detecting malignancy. agreement between the ata classification and cytopathology/histology was 86.7% with a kappa of 0.714 (see table 3). the agreement between the cytopathology fna results and surgical histopathology was 98.8% with a kappa of 0.973. table 3: agreement table between american thyroid association classification and cytology/histological outcomes. discussion in this retrospective study, we found that the best three ultrasound features that pose a higher risk of malignancy, using a positive likelihood ratio, are nodules with an absent halo, the presence of microcalcifications and those with a hypoechoic appearance. however, no single feature is an absolute indicator for malignancy as none had a clinically relevant positive likelihood ratio of greater than 10. these results reflect findings similar to that of the international literature. a systematic review and meta-analysis of thyroid ultrasound features by remonti et al.5 showed comparable outcomes regarding prediction of malignancy by specific nodule features. in our study group, both microcalcifications (91.1%) and taller-than-wide configuration (95.5%) were found to be highly specific in malignant nodules. this was also noted by remonti et al.5 with microcalcifications and taller-than-wide configuration having a specificity of 87.8% and 96.6%, respectively. the aforementioned meta-analysis also found that single ultrasound features had a generally low sensitivity, thus being poor at excluding malignancy. we found that hypoechogenicity was the most sensitive feature with 54.5% sensitivity compared with 62.7% in the meta-analysis by remonti et al.5 however, incorporating nodule features into clusters and using a recognised system, such as the ata guidelines, increased the accuracy and probability of a nodule being correctly identified as malignant. this is verified by the high agreement percentage between the assigned ata classification and cytopathology/histopathology results. this is not only re-assuring for operators performing thyroid sonography, but also for patients, eliminating the need for further invasive testing or surgery. in a resource-constrained setting, such as ours, this alleviates surgical burden, thus freeing up more operating time for cases where surgery is truly indicated. we found a high agreement between the cytopathology results and the histopathology for patients referred for lobectomies. this highlights the benefit of using a standardised reporting structure such as the bethesda classification. this also demonstrates a major advantage of performing us-guided fna; with an increased ability to predict malignancy at surgical resection, many patients are spared the morbidity of unnecessary thyroid surgery. conclusion this study is the first comprehensive report for southern africa correlating sonographic features of thyroid nodules with fna cytology and histopathology. it confirms that a certain cluster of sonographic features for thyroid nodules aids in predicting thyroid malignancy. furthermore, the sensitivity and specificity in detecting malignancy, utilising ultrasonography, were consistent with studies performed elsewhere, thus providing reassurance in the usefulness of such a tool, particularly in a resource poor country such as south africa. limitations of the study despite the small sample size, this study significantly contributes to the paucity of data available for sub-saharan africa and provides reassurance that our results are consistent with numerous international studies. collecting data from a single hospital population limits the applicability of such a study to the racial and socio-economic demographics of chris hani baragwanath academic hospital situated in the urban township of soweto. non-diagnostic fna samples were excluded, thus creating a bias against nodules that were difficult to sample adequately. in addition, analysing combinations of ultrasound features may provide more insight into risk and probability of malignancy rather than individual features alone. recommendations the findings of this study confirm that the usage of a thyroid nodule classification system improves characterisation and increases accuracy in detecting thyroid nodule malignancies on ultrasound. thus, it would be prudent for any department performing thyroid sonography to incorporate a classification system into their practice. furthermore, it would also be useful to compare the two most used thyroid classification systems, ata and acr tirads, to determine how the two reporting systems compare in terms of their accuracy in detecting malignancy in a thyroid nodule. acknowledgements the authors would like to thank drs sindeep bhana, kershlin naidu and veronique nicolaou for access to records and performance of us-guided fnas at the chbah endocrine clinic; dr luvo fatman who reported on the fna cytopathology specimens; and lukhanyo nyathi for assistance with the statistical analysis. competing interests the authors have declared that no competing interest exist. author’s contributions m.a.n. was the main author and was responsible for the protocol, data collection, database construction and compilation of the article. k.j. made conceptual and editorial contributions and was the internal supervisor of m.n.’s master’s degree. s.b. made editorial contributions. v.n. was the principal supervisor and assisted with project design, review and analysis. k.n. was one of the endocrinologists who performed the sonars and thyroid fnas, was involved in data collection and conceptualisation of the study and made editorial contributions. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ezzat s, sarti d. thyroid incidentalomas: prevalence by palpation and ultrasonography. arch intern med. 1994;154(16):1838–1840. https://doi.org/10.1001/archinte.1994.00420160075010 dhanadia a, shah h, dave a. ultrasonographic and fnac correlation of thyroid lesions. gujarat medical journal 2014;69(1):75–81. xie c, cox p, taylor n, laporte s. ultrasonography of thyroid nodules: a pictorial review. insights imaging. 2016;7(1):77–86. https://doi.org/10.1007/s13244-015-0446-5 lin j-d, chao t-c, huang b-y, chen s-t, chang h-y, hsueh c. thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology. thyroid. 2005;15(7):708–717. https://doi.org/10.1089/thy.2005.15.708 remonti lr, kramer ck, leitão cb, pinto lcf, gross jl. thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. thyroid. 2015;25(5):538–550. https://doi.org/10.1089/thy.2014.0353 heller mt, gilbert c, ohori np, tublin me. correlation of ultrasound findings with the bethesda cytopathology classification for thyroid nodule fine-needle aspiration: a primer for radiologists. am j roentgenol. 2013;201(3):487–494. https://doi.org/10.2214/ajr.12.9071 yoon jh, lee hs, kim e-k, moon hj, kwak jy. malignancy risk stratification of thyroid nodules: comparison between the thyroid imaging reporting and data system and the 2014 american thyroid association management guidelines. radiology. 2016;278(3):917–924. https://doi.org/10.1148/radiol.2015150056 horvath e, majlis s, rossi r, et al. an ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. j clin endocrinol metab. 2009;94(5):1748–1751. https://doi.org/10.1210/jc.2008-1724 russ g. risk stratification of thyroid nodules on ultrasonography with the french ti-rads: description and reflections. ultrasonography. 2016;35(1):25–38. https://doi.org/10.14366/usg.15027 moon w-j, jung sl, lee jh, et al. benign and malignant thyroid nodules: us differentiation – multicenter retrospective study. radiology. 2008;247(3):762–770. https://doi.org/10.1148/radiol.2473070944 cibas es, ali sz. the 2017 bethesda system for reporting thyroid cytopathology. j am soc cytopathol. 2017;6(6):217–222. https://doi.org/10.1016/j.jasc.2017.09.002 abstract introduction research methods results ethical considerations discussion conclusion acknowledgements references about the author(s) erica prinsloo dr george mukhari academic hospital, pretoria, south africa cornelia minné dr george mukhari academic hospital, pretoria, south africa wim greeff dr george mukhari academic hospital, pretoria, south africa citation prinsloo e, minné c, greeff w. measuring breast density: comparing computer-automated breast density quantification with an observer-based method in a south african academic context. s afr j rad. 2018;22(2), a1358. https://doi.org/10.4102/sajr.v22i2.1358 original research measuring breast density: comparing computer-automated breast density quantification with an observer-based method in a south african academic context erica prinsloo, cornelia minné, wim greeff received: 26 apr. 2018; accepted: 06 june 2018; published: 21 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: dense breast tissue may not only ‘mask’ small, non-calcified cancers but also represents an independent risk factor for the development of breast cancer. computer-automated breast density quantification (cabd) software tools have been developed for the calculation of volumetric breast density. objectives: this study sought: (1) to compare observer-based breast density scores, using the fifth edition of the breast imaging reporting and data system (bi-rads), with the breast density scores calculated using cabd quantification software tools, (2) to determine inter-reader variability in breast density scoring between qualified radiologists, between radiologists in training (registrars) and between these two groups and (3) to determine intra-reader reliability in breast density scoring. methods: a cross-sectional study was performed using the data of 100 patients (200 breasts). three qualified radiologists and three registrars were asked to review the mammograms in question and to assign a breast density score according to the fifth edition of the breast imaging reporting and data system (bi-rads) reporting system. two readings took place at a minimum of 30 days apart. the percentage agreement between the automated and observer-based scores was calculated and intra-reader and inter-reader reliability values were determined. results: the study found that there was poor agreement between the breast densities calculated by cabd and the more subjective observer-based bi-rads density scores. these results further reflect a statistically significant degree of inter-reader and intra-reader variability in the evaluation of breast density. conclusion: we conclude that the use of automated breast density quantification (i.e. cabd) is a valuable tool for the reduction of variability in breast density ratings. introduction mammographic breast density has been the subject of scholarly scrutiny and legal debate for more than 40 years.1 landmark studies by authors, such as wolf and tabár, paved the way for subsequent research regarding the relationship between mammographic density, parenchymal patterns and breast cancer risk.1 published data suggest that dense breast tissue may not only ‘mask’ small, non-calcified cancers but also represents an independent risk factor for the development of breast cancer. a meta-analysis published in 20062 showed that women with ≥ 75% dense breasts have a four to six times greater risk for developing breast cancer than do women with < 5% dense breasts. it is information like the above that has led to the introduction of wide-ranging legislation surrounding breast cancer screening in countries like the united states.3 traditionally, breast density is assessed by using observer-based scores and qualitative area-based measurements. these methods, however, are limited in terms of subjectivity, reliability and reproducibility.4 more recently, computer-automated breast density quantification (cabd) software tools have been introduced for the calculation of volumetric breast density in an attempt to overcome these limitations. using these methods, women identified as having denser breasts would typically proceed to undergo additional screening with modalities such as automated breast ultrasound, handheld breast ultrasound or magnetic resonance imaging (mri) to further evaluate for pathological lesions that may not be apparent on mammography. breast cancer burden in south africa and the role of mammography screening breast cancer is a leading cause of cancer-related deaths among females in the developing world.5 the south african incidence of breast cancer is 22.2% of all cancers with 29.99 adjusted cases per 10 000 per year.6 the five-year breast cancer survival rate in sub-saharan africa is estimated to be less than 40%, which compares unfavourably with the 86% rate of a country like the united states. some authors ascribe the poor survival rates in sub-saharan african patients to a lack of awareness, cultural beliefs and the existence of advanced disease stage at the time of presentation.7 as part of a standardised mammography report, the fifth edition of the american college of radiology’s breast imaging reporting and data system (bi-rads) initiative advises that breast density should be recorded and, where needed, described. patients have to be informed regarding the diminished accuracy of mammography in dense breasts.8 the common aim of all mammography screening programmes is to reduce the rate of advanced breast cancer and to identify as many invasive lesions as early as possible. mammography, as a screening tool, is limited in terms of detecting small pathological lesions in dense breasts. in spite of this limitation, however, mammography has been identified to date as the only modality capable of reducing breast cancer mortality.9 thus, mammography remains the primary screening modality in patients with dense breasts, and supplemental screening efforts should be regarded as adjuncts to mammography.10 supplemental screening options include automated breast ultrasound, handheld ultrasound, mri and digital breast tomosynthesis. assessment of mammographic density mammographic density refers to the ratio of radiopaque epithelial and stromal tissue elements in the background of radiolucent fatty tissue. the skin is also radiopaque and contributes to some of the mammographic density. mammographic density does not correlate with breast firmness at physical examination.4 observer-based assessment methods the evaluation of breast density is usually performed by an experienced observer performing a visual assessment of a two-view mammogram (i.e. craniocaudal and mediolateral oblique views). factors taken into account include the relative proportion of glandular tissue to fatty tissue in the breast, the shape and size of the breast, the fibroglandular pattern of the breast and the radiographic protocols that were used.11 the most widely used scoring system is the four-point, fifth edition of bi-rads, with the following categories, depicted in table 1.8 table 1: breast imaging reporting and data system 5th edition breast density. density may also be scored on a continuous scale and expressed as a percentage.11 there remains; however, large inter-reader and intra-reader variability in the observer-based evaluation of breast density. some authors have suggested an inter-reader agreement of only 49%.4 observer-based scoring is still the most widely used method because of the additional costs involved with computer-based assessments.12 computer-based qualitative methods vendor-specific digital software algorithms can calculate reproducible breast densities and express them in terms of either area density or volume density. area density percentage algorithms interactive thresholding is a semi-automated method of area density calculation.12 this method relies on the user to select the grey level threshold value for a digital mammogram and retains a measure of subjectivity.12 volume density percentage algorithms volume density percentages can be calculated from the three-dimensional data sets acquired by digital breast tomosynthesis, ultrasound, computed tomography (ct) or mri. volume density percentage is defined as: where vf is the fibroglandular tissue volume and vt is the total breast volume.12 alternatively, two-dimensional digital mammograms can be used to calculate the three-dimensional properties of the breast. this is computed by factoring in the image pixel data, as well as radiographic protocol elements such as x-ray tube potential, target material, filter material, paddle height and breast compression.11 these algorithms may help to reduce observer errors; however, considerable miscalculations are still possible because of the fact that the three-dimensional properties of the breast are evaluated using two-dimensional images. currently, there are two united states food and drug administration-approved software programs available that provide fully automated volume density percentages, each with their own proprietary algorithms: quantra (hologic inc., bedford, ma, usa) and volpara (mātikana international, wellington, new zealand).12 research methods study design this study employed a cross-sectional design and evaluated cabd against an observer-based bi-rads fifth edition breast density scoring system. patients who underwent full-field digital mammography between 01 october 2015 and 31 july 2016 at the dr george mukhari academic hospital (dgmah) in ga-rankuwa, south africa, for both screening and diagnostic purposes, were included in this study. the majority of patients presenting to the mammography unit were symptomatic patients referred on the grounds of their clinical findings. the patients, selected for participation in this study included all asymptomatic female patients who presented for screening mammograms at the dgmah; those symptomatic patients aged 18 years or older who were referred to the dgmah with the clinical suspicion of breast cancer; and patients who had undergone the standard craniocaudal and mediolateral oblique views. conversely, those excluded from this study were patients who had undergone a previous mastectomy, patients with ulcerating breast cancer and patients with incomplete data. data collection three qualified radiologists and three registrars (radiology residents) were asked to review the mammograms in question and assign a breast density score to each patient according to the bi-rads fifth edition reporting system. the specialists were all general radiologists with an interest in mammography whose experience ranged from four years to newly qualified. the registrars’ experience ranged from two to six months of full-time rotation in mammography. the readers were specifically asked not to interpret pathology and were blinded to the automated breast density score. the readers were asked not to change the window level of the images. to determine intra-reader variability, each mammogram was scored twice by each reader. readings took place at a minimum of 30 days apart. readers were blinded to their previous scores, as well as to the scores of other readers. the computer-generated breast density results were recorded by a research assistant. the typical information values calculated by the cabd are presented in table 2. table 2: the typical information values calculated by the computer-aided diagnosis. a dimensions 8000 with svdx 400 workstation and quantra version 2.1.1 software package (both hologic inc., bedford, ma, usa) were used. statistical analysis comparisons of the automated breast density and volume with the observer-based scoring were assessed by calculation of a percentage agreement. interand intra-reader reliabilities were assessed by calculation of kappa statistics and correlations. categorical scores were compared using fisher’s exact test. all statistical procedures were performed via statistical analysis system (sas institute inc., cary, nc, usa), release 9.4, running on microsoft windows® (microsoft corp., redmond, wa, usa) for a personal computer. all statistical tests were two-sided, and p-values smaller than or equal to 0.05 were considered to be significant. various arbitrary guidelines exist to characterise kappa values. fleiss characterises kappa values of more than 0.75 to be excellent, those from 0.4 to 0.75 as fair to good and those below 0.4 as poor. a sample size of 100 patients (200 breasts) was used. results the mean age of the screened population group was 51.7 years (with a ± standard deviation of 13.89 years). the median age was 51 years (interquartile range: 41–63 years). the youngest patient was 18 years of age and the oldest patient was 84 years of age. it is important to note that symptomatic patients under the age of 35 years only underwent mammography after ultrasound was performed, when calcifications were suspected. limited views are usually done, as per institutional protocols. standard craniocaudal and mediolateral views in patients under the age of 35 years are only employed for specific indications and where deemed necessary by the reporting radiologist. on comparing the bi-rads density category scores (a–d) by the readers with those of the cabd, the study found that there was a 36.7% agreement (95% confidence interval [ci]: 34.0%–39.5%) for the registrar group and only a 33.2% (95% ci: 30.5% – 35.9%) for the specialist group. when using a dichotomous score of dense (bi-rads scores c and d) versus non-dense (bi-rads scores a and b), these scores improved slightly to 57.8% (95% ci: 55.0% – 60.6%) for the registrar group and 51.2% (95% ci: 48.3% – 54.0%) for the specialist group, respectively. the intra-reader reliability (comparing first and second readings) using the bi-rads density category scores (a–d) for the registrar group was 57% (kappa value = 0.4012 and p < 0.0001). the intra-reader reliability for the specialist group was 74.1% (kappa value = 0.6012 and p < 0.001). when using the dichotomous score of dense (bi-rads scores c and d) versus non-dense (bi-rads scores a and b), the intra-reader reliability improved to 70.9% (kappa value = 0.3940%) for the registrars and 88.0% (kappa value = 0.6799) for the specialists. the inter-reader reliability for both groups was found to be mostly poor. these findings are presented in tables 3 and 4.13 the readers were anonymised and assigned a reader code. table 3: inter-reader reliability for density by registrars. table 4: inter-reader reliability for density by specialists. ethical considerations informed consent was not needed for this type of retrospective study because data were anonymised and the study did not present an extra burden to the patients and their families. written consent was obtained from hospital management and a clearance certificate was secured from the relevant medical school and university ethics committees prior to the commencement of the study (smurec/m/240/2016: pg). discussion our study found that there was poor agreement between the breast densities calculated by cabd and the more subjective observer-based bi-rads density scores. in comparison, a recent large european study14 demonstrated moderate agreement between radiologists using the bi-rads fourth edition and cabd measurements using volpara software. the agreement between categorical volumetric density and bi-rads scores in the above-mentioned study was 57.1% (kappa 0.55 [0.53–0.56]). our findings of poor agreement between the cabd and observers in terms of breast density could be attributed to various factors such as a bias towards defensive practice, a tendency to over or underestimate, work pressure and fatigue, viewing conditions and contextual influences.12 it is also important to remember that the specialist group consisted of radiologists with less than five years of experience. furthermore, these radiologists were all generalists and not dedicated breast imagers. it could be argued that this is representative of the actual situation in many south african academic institutions. on the contrary, the available software for fully automated breast density measurements has been shown to be robust and be able to provide reproducible quantitative measures.15,16 our results further reflect the presence of a statistically significant degree of interand intra-reader variability in the evaluation of breast density. these findings are consistent with those of other large studies.17,18 in a recent multicentre observational study19 that included data from 200 000 screening mammograms, the rate of individual radiologists assigned to a dichotomous ‘dense category’ ranged widely from 6.3% to 84.5%. when consecutive mammograms were interpreted by different radiologists, over an average span of 1.2 years, there was 17.2% discordance in the ‘dense’ versus ‘non-dense’ assignments. it is furthermore important to note that breast density was characterised in the bi-rads fourth edition on the basis of the percentage of glandular tissue within each breast (i.e. into the categories of < 25%, 25% – 50%, 51% – 75% or > 75%, respectively). in the new fifth edition, these percentiles are eliminated and replaced by the four category descriptors. the advent of the fifth edition of bi-rads also appears to have had an additional deleterious impact on the inter-reader agreement of breast density scoring, in comparison with the bi-rads fourth edition.20 it is argued that, because of the subjective nature of the bi-rads breast density assessment, the decision for supplemental screening may be more dependent on who the reporting radiologist is than on the actual amount of fibroglandular tissue in the imaged breast.21 the call is being made for automated breast density measures to be adopted as part of the standard mammographic evaluation protocol in order to reduce variability in breast density ratings and to produce standardised thresholds for supplementary screening. currently, there is no formal mammography screening programme in south africa. mammography screening currently takes place on an individual case-by-case basis. limitations of the study notably, the available specialists who took part in this study all had less than five years of experience. this is; however, a realistic reflection of the situation in many south african academic hospitals. of the mammograms that were used, 66% were normal, 26% had masses and 8% had other findings such as architectural distortion, calcifications and oedema. it is unclear if visible lesions on these images may have produced a bias towards denser scoring by the readers. a future study using normal mammograms may be of benefit. conclusion the authors are of the opinion that the use of automated breast density quantification is a valuable tool to reduce variability among breast density ratings. this may be especially true in the south african academic context wherein preliminary mammography reports are generated by trainees and approved by general radiologists, who often have less than five years of experience. the potential benefits and costs of cabd use in south african academic hospitals should be carefully considered. there is a need for the development of national protocols regarding the use of software tools in the evaluation of breast density to occur. such protocols should also direct decision-making efforts towards adding supplementary screening for women with dense breasts. this; however, should ultimately form part of a larger drive towards the implementation of a south african national breast screening programme. acknowledgements our sincere thanks go to professors h.p. schoeman (statistician) and m.e. kisansa (head of the department, diagnostic radiology and imaging, dgmah) for their support in the research. we would also like to acknowledge doctors h. mohoroe, m. joubert, d.j. cloete and h. kamombe-zingware who kindly participated as readers. competing interests the authors declare that they have no financial or personal relationship which may have inappropriately influenced them in writing this paper. authors’ contributions e.p. was the project leader and primary researcher. c.m. was responsible for the project design. c.m. and w.g. made conceptual contributions. references wolf jn. risk for breast cancer development determined by mammographic parenchymal pattern. cancer. 1976;37:2486–2492. https://doi.org/10.1002/1097-0142(197605)37:5%3c2486::aid-cncr2820370542%3e3.0.co;2-8 pettersson a, graff re, ursin g, et al. mammographic density phenotypes and risk of breast cancer: a meta-analysis. j natl cancer inst. 2014;106(5):dju078. https://doi.org/10.1093/jnci/dju078 jennifer s, haas cpc. the divide between breast density notification laws and evidence-based guidelines for breast cancer screening. jama intern med. 2015;175(9):1439–1440. https://doi.org/10.1001/jamainternmed.2015.3040 freer pe. mammographic breast density: impact on breast cancer risk and implications for screening. radiographics. 2015;35:302–315. https://doi.org/10.1148/rg.352140106 torre la, bray f, siegel rl, ferlay j, lortet-tieulent j, jemal a. global cancer statistics, 2012. ca cancer j clin. 2015;65(2):87–108. 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2];165(7):457. available from: http://annals.org/article.aspx?doi=10.7326/m15-2934 irshad a, leddy r, ackerman s, et al. effects of changes in bi-rads density assessment guidelines (fourth versus fifth edition) on breast density assessment: intraand interreader agreements and density distribution. am j roentgenol [serial online]. 2016 dec [cited 2018 apr 13];207(6):1366–1371. available from: http://www.ajronline.org/doi/10.2214/ajr.16.16561 gastounioti a, conant ef, kontos d. beyond breast density: a review on the advancing role of parenchymal texture analysis in breast cancer risk assessment. breast cancer res. 2016;18(1):1–13. https://doi.org/10.1186/s13058-016-0755-8 sajr cme aug integrated imaging – the complementary roles of radiology and nuclear medicine j warwick,1 bsc, mb chb, fcnp (sa), mmed, phd; j lotz,2 ma, msc, mmed, fcrad (sa), frcr 1 division of nuclear medicine, tygerberg academic hospital and stellenbosch university, cape town, south africa 2 division of radiodiagnosis, tygerberg academic hospital and stellenbosch university, cape town, south africa corresponding author: j warwick (jw@sun.ac.za) this article was first published in the august 2013 issue of continuing medical education (vol. 31, issue 8), and is reproduced here because of its topicality and desirability of reaching a broader audience. diagnostic imaging is a dynamic field, which has evolved rapidly during the past few decades. new modalities have developed and research techniques have migrated into clinical practice. imaging has seen a greater integration of various modalities, defining the entity of diagnostic clinical imaging sciences. nuclear medicine has undergone a metamorphosis over the past 30 years. established scintigraphic techniques for detecting breaches in the blood-brain barrier and liver masses has been replaced by ultrasound, computerised tomography (ct) and magnetic resonance imaging (mri). simultaneously, there has been significant growth in the use of positron emission tomography (pet), sentinel node imaging, targeted radiotherapy and several molecular imaging techniques. radiology has experienced exponential growth with regard to helical multi-slice ct scanning using multiple-row detector arrays for the simultaneous collection of data at different slice locations, allowing rapid acquisition of large datasets of longitudinal volumes. the optimal mri field strength in general clinical practice is 1.5 tesla (t), while 3 t allows mapping of cerebral cortical function by utilising blood oxygen level-dependent (bold) imaging. in vivo spectroscopy monitors neuronal viability, cell membrane proliferation and energy metabolism. current clinical 3 t products have been developed to fit within the physical constraints of 1.5 t platforms by using compact magnets with small fringe fields. magnets with field strengths of 7 t and even higher are in experimental use.1 an important influence on medical imaging since the beginning of the 21st century has been the increasing availability of hybrid imaging systems. these systems enable a more integrated approach, and define the unitary entity of diagnostic clinical imaging sciences. the concept of hybrid imaging is simple – pet or a single photon emission computed tomography (spect) scanner is integrated with a ct scanner on a single platform. the patient is examined using both techniques in immediate succession without any positional changes. images are fused and displayed by dedicated software. detailed anatomical imaging combined with the high sensitivity of functional information provides much more information than would be provided by the two individual techniques. the composite images are also generally better appreciated by clinicians. ct scanners on integrated platforms are mostly high-quality multi-slice diagnostic units. adding contrast enhancement affords the potential for performing a single comprehensive diagnostic study. pet/mri, a recent development, is currently being clinically evaluated. this article highlights clinical scenarios where radiology and nuclear medicine are combined to address specific clinical problems. an exhaustive list of these problems is inapplicable, as unique diagnostic dilemmas continually occur. in our experience, these are best addressed by continuous interaction and regular interdisciplinary meetings between the two disciplines. oncology due to its high sensitivity, pet– using the glucose analogue [f-18] flourodeoxyglucose (fdg) – is transforming the diagnosis and management of many malignancies. integrated pet/ct studies enhance both accuracy and logistic efficiency. abnormal fdg uptake helps the radiologist to scrutinise areas of subtle anatomical changes, often increasing specificity (fig. 1). ct also enhances specificity by localising fdg uptake to physiological sites, such as brown fat, which on pet alone can mimic nodal disease. similarly, the limitations inherent in the ability of fdg-pet to distinguish a neoplasm from inflammation are sometimes improved by ct patterns that are more suggestive of either inflammation or a neoplasm. pet generally has excellent sensitivity, while ct detects small lung nodules more accurately. fig. 1. two cases of the complementary roles of pet and ct, showing (a) an enlarged lymph node identified on ct in a patient with lung cancer negative on pet/ct, and (b) hodgkin’s disease in a patient with involvement of multiple lymph nodes above the diaphragm in which pet identified involvement of a single node in the splenic hilum. size-based lymph node evaluation for metastatic involvement (short axis >10 mm) and morphology has a low sensitivity and specificity. fdg-pet frequently demonstrates small nodes that are not benign and large nodes that are not metastatic (fig. 1). fdg uptake has the ability to distinguish residual tumour activity from scar tissue in residual masses after chemotherapy.2 neuro-endocrine tumours an integrated approach is essential in the assessment of neuro-endocrine tumours (nets). the final diagnostic analysis combines functional, morphological and positional information. a detailed radiological work-up is only possible once a functional lesion has been localised. localisation of well-differentiated nets is performed by using labelled analogues of somatostatin, or molecules concentrated by nets.3 staging and planning of targeted radiotherapy require functional techniques, while anatomical imaging is important for monitoring disease and planning of surgery (fig. 2). fig. 2. patient with a mass on the greater curve of the stomach on gastroscopy. histology showed a net. whole body somatostatin-receptor imaging with [tc-99m] tekrotyd shows disease restricted to the stomach lesion and a lymph node. these are shown on ct with calcification in the stomach lesion, as well as incidental liver and left kidney cysts. musculoskeletal imaging bone scintigraphy is a first-line technique for surveying the entire skeleton for metastases in patients with cancer of the breast and prostate, as well as small-cell lung carcinoma. while highly sensitive, the specificity is reduced by numerous benign processes (e.g. degenerative changes, old trauma). here, radiology has a long-established complementary role, as local radiographs of these sites identify most benign causes of increased activity, whereas normal radiographs are suggestive of metastatic disease. the sensitivity of mri depends on focal loss of the t1 signal due to metastatic replacement/destruction of marrow fat cells in trabecular bone. t1 changes appear up to three months before other modalities are positive;4 however, mri studies are limited by cost and a small field of view, disqualifying it as a viable screening alternative to bone scintigraphy. t1-weighted mri sequences should be reserved for specific clinical problems, e.g. breast carcinoma with persistent lower back pain, and equivocal focal activity on a bone scan not resolved with plain radiographs. diffusion-weighted whole-body mri is an exciting new development with promising results for cancer detection, widely reported in the recent literature.5 bone scintigraphy plays a complementary role in benign bone disease, adding sensitivity and enabling an entire skeletal survey. most fractures are diagnosed using conventional radiographs, but bone scanning is a cost-effective and sensitive means of detecting fractures, which have a normal appearance on plain films (e.g. undisplaced, difficult sites) and insufficiency/stress fractures. scintigraphy also allows localisation of sites causing back, ankle or foot pain. when there are subtle or multiple anatomical abnormalities, active osteoblastic activity can direct therapeutic interventions to sites requiring relief of pain (fig. 3). fig. 3. (a) a patient with left foot pain, identified as having accessory navicular bones in both feet on x-ray. (b) a bone scan localised the pain source to the accessory navicular bone, (c) which is again demonstrated on subsequent a 3d ct reconstruction. acute osteitis in children can present challenging diagnostic dilemmas. these children often present as emergency cases, acutely ill and with raised inflammatory markers. the presenting complaint may, however, be limited to diffuse bone pain with normal erythrocyte sedimentation rate (esr) and white blood cell (wbc) counts. plain film examination of the affected limb should precede special investigations. ultrasound is an excellent first-line investigation and is often diagnostic (fig. 4). ct is an acceptable alternative, but an mri study, when available, is definitive, showing the extent of trabecular oedema and soft-tissue involvement. skeletal scintigraphy remains particularly valuable when mri availability is limited, symptoms are poorly localised, or multifocal disease is suspected.6 fig. 4. a longitudinal ultrasound section demonstrating a periosteum of a tibial shaft displaced by inflammatory collection in a young patient with clinical signs of infection. soft-tissue infection ultrasound is normally the first line of investigation, but mri, with its superior soft-tissue discrimination, is the investigation of choice. inflammatory processes are identified by a hyperintense signal on t2 stir or post-contrast t1 fat saturation sequences. however, an altered anatomy because of previous trauma or surgery may render findings equivocal. in these situations the introduction of infection markers such as labelled wbcs, fdg, and [ga-67] citrate assist in the evaluation of disease (fig. 5). these tracers are specific and sensitive, demonstrating inflammatory processes before anatomical changes occur. the choice of technique depends on the suspected site and chronicity of the infection. the role of fdg-pet/ct is still being defined, but it is likely to become important in many of these clinical scenarios.7 fig. 5. a patient who required open reduction and internal fixation of a fractured left femur following a gunshot injury. the subsequent development of secondary infection is confirmed on [tc-99m] white cell scanning. the presence of a fixation device would affect mri and ct in this case. pulmonary embolism the imaging of acute pulmonary embolism has advanced with the widespread implementation of ct pulmonary angiography (ctpa) and the emerging role of ventilation perfusion (vq) spect (vqs). ctpa is based on the direct detection of emboli presenting as filling defects in affected vessels, while vqs images the functional consequences of the emboli, i.e. underperfused lung segments (fig. 6). vqs, using new interpretation criteria, achieves excellent sensitivity and specificity with few equivocal studies, and today should be utilised by all nuclear medicine units.8 comparative literature is limited and complicated by the lack of a gold standard, and confused by comparisons of ctpa with older planar vq studies. fig. 6. different cases showing pulmonary emboli as (a) a perfusion-ventilation mismatch using vqs, and (b) as an arterial filling defect on ctpa. both ctpa and vqs are excellent first-line investigations and their availability often determines the first choice. specific considerations such as compromised cardiorespiratory function or structural lung disease favour the use of ctpa when both modalities are available. similarly, a mosaic perfusion pattern in the appropriate clinical setting on high-resolution ct scans is diagnostic for chronic pulmonary embolism as a cause of unexplained pulmonary hypertension. conversely, vqs has a significantly lower radiation dose, making its use preferable in pregnancy, in patients with impaired renal function, and in patients in whom prior reactions to contrast media are suspected. perhaps, most importantly, performing the other examination is useful in those cases where one modality is initially equivocal or discordant with the clinical setting. acute cholecystitis ultrasound is the initial imaging technique of choice in patients with suspected acute cholecystitis. this is justified in light of its widespread availability and efficacy in the majority of patients. in cases where ultrasound is difficult to interpret (e.g. technically difficult examinations, acalculous disease), hepatobiliary scintigraphy has a high sensitivity and specificity,9 making it an appropriate second-line investigation when clinical suspicion is high. liver lesions functional imaging with characteristic scintigraphic patterns can assist with the identification of liver lesions detected on anatomical imaging (fig. 7). in liver lesions equivocal for metastatic disease, increased uptake of fdg on pet/ct distinguishes metastatic disease from benign lesions. increased tc-99m colloid uptake in a liver lesion is specific for focal nodular hyperplasia. haemangiomas show enhancement of tc-99m-labelled red blood cells. developments in mri liver contrast media have resulted in substances that mirror the biodistribution patterns of radionuclide tracers. gadolinium chelates are distributed to the interstitial space, ferumoxides are taken up by kupffer cells, and the new mangafodiper agents create t1 shortening after hepatocyte uptake via the b6 receptor. exquisite anatomical detail is an added advantage, but this has significant financial implications. fig. 7. different cases showing liver lesions on ct with characterisation being confirmed as (a) focal nodular hyperplasia with increased [tc-99m] colloid uptake, (b) and as haemangioma with intense [tc-99m]-labelled red blood cell uptake. residual splenic tissue patients with resistant idiopathic thrombocytopenic purpura, despite splenectomy, often have continued destruction of platelets by small amounts of residual splenic tissue. this tissue is frequently difficult to detect using anatomical imaging alone. spect/ct using [tc-99m]-labelled damaged red blood cells is sensitive and specific for splenic tissue (fig. 8), allowing lesions to be located and guiding their surgical removal. fig. 8. residual splenic tissue identified by [tc-99m] white blood cells in a patient with treatment-resistant idiopathic thrombocytopenic purpura, despite a previous splenectomy. renal imaging ultrasound plays an essential role in many types of renal disease. the combination of ultrasound and other anatomical modalities with functional imaging is particularly rewarding in the renal system. diuresis renography using tc-99m mag-3 clarifies the significance of hydronephrosis and/or hydro-ureter. obstructive nephropathy can be ruled out in patients with a normal diuretic response, while reduced differential renal function, especially on serial studies, points to the need for intervention (fig. 9). fig. 9. bilateral hydronephnosis on ct. the renogram shows no obstruction of the left kidney, with normal function and a good response to furosemide at 20 min. the right kidney has a differential function of only 14% due to obstructive nephropathy. the distinction between renal artery stenosis and renal vascular hypertension explains the different roles of angiography and captopril renography in the management of these patients. while anatomical imaging is essential for the detection and sometimes for the treatment of stenotic arterial lesions, captopril renography determines the functional significance of lesions, predicts the outcome of interventions, and detects renovascular hypertension related to microvascular disease. radiology and nuclear medicine have overlapping roles in the imaging of renal scarring and vesico-ureteric reflux (vur) in children. a first-time urinary tract infection (uti) requires ultrasound, which, if normal, obviates the need for further imaging. children with recurrent utis or abnormalities on ultrasound normally require a variety of possible investigations.10 dimercaptosuccinic acid (dmsa) renal scintigraphy is the most sensitive widely available technique to detect renal scarring. for vur, a micturating cysto-urethrogram (mcug) provides important anatomical information, while indirect cystography is a well-tolerated procedure which has a low radiation dose. incidental renal masses are being increasingly identified on advanced imaging modalities, more so with present-generation multi-slice ct scanners. a renal pseudotumour due to a prominent column of bertin shows uptake of tc-99m dmsa, while renal tumours show no uptake.11 interventional radiology the interventional radiologist may be assisted by functional imaging. the choice of an optimal site for taking a biopsy is often facilitated by pet/ct, revealing active disease processes in more accessible sites. similarly, the use of metabolic information can reduce sampling errors. managing gastrointestinal bleeding is challenging when endoscopy is negative, or difficult to interpret owing to large amounts of intraluminal blood. angiography and embolisation of bleeding sites can be assisted by localisation of gastrointestinal bleeding sites using [tc-99m]-labelled red blood cells (fig. 10). even localisation limited to the major artery involved prior to angiography can assist with catheter placement. the growing utilisation of targeted radiotherapy for palliation of inoperable liver lesions requires close collaboration between the interventional radiologist, who places the catheter in the hepatic artery, and the nuclear medicine physician, who administers the therapy, after scintigraphically confirming correct positioning. fig.10. dynamic images on [tc-99m] scintigraphy using labelled red blood cells, showing the appearance of activity in the right iliac fossa, localised to the bowel in the ileo-caecal region on spect/ct. conclusions taking a complementary rather than an exclusive approach allows for the optimal utilisisation of the diverse spectrum of imaging technologies available. this philosophy is being practised increasingly with the advent of hybrid imaging, and the resulting interdependence of these disciplines. a good understanding of the strengths and weaknesses of the different modalities available is needed to achieve this goal. it is the duty of imaging specialists to develop approaches to clinical problems that are better integrated, provide improved care, diagnostic accuracy, and cost-effectiveness. the optimal utilisation of all imaging modalities, including their complementary strengths, differing availability, and cost considerations, is arguably the single most important challenge to all diagnostic imaging clinicians. summary • a more integrated approach to medical imaging using radiology and nuclear medicine techniques can frequently better address specific clinical problems. • pet/ct is generally more sensitive and specific for the detection of malignancies than either modality in isolation. • mri and bone scan modalities have complementary roles in musculoskeletal imaging. • labelled white blood cells, fdg, and [ga-67] citrate are particularly useful for imaging soft-tissue infections when the anatomical location is altered by previous trauma or surgery. • ctpa and vq spect are both excellent first-line investigations for detecting pulmonary embolism. • hepatobiliary scintigraphy is a useful second-line investigation for detecting acute cholecystitis if ultrasound is equivocal. • characteristic scintigraphic patterns can assist with the characterisation of liver lesions detected on anatomical imaging. • renography clarifies the functional significance of hydronephrosis and/or hydro-ureter on anatomical imaging. • renal scintigraphy using tc-99m dmsa can assist in the characterisation of incidental renal masses identified on anatomical imaging. • pet/ct and labelled red cell studies can assist the radiologist in better directing interventional procedures. 1. blamire am. the technology of mri – the next 10 years? br j radiol 2008;81(968):601-617. 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[http://dx.doi.org/10.1111/j.1365-2796.2008.01980.x] 9. alobaidi m, gupta r, jafri sz, et al. current trends in imaging evaluation of acute cholecystitis. emerg radiol 2004;10(5):256-258. 9. alobaidi m, gupta r, jafri sz, et al. current trends in imaging evaluation of acute cholecystitis. emerg radiol 2004;10(5):256-258. 10. coulthard mg. nice on childhood uti: nasty processes produce nasty guidelines. bmj 2007;335:463-464. 10. coulthard mg. nice on childhood uti: nasty processes produce nasty guidelines. bmj 2007;335:463-464. 11. vitti ra, maurer ah. single photon emission computed tomography and renal pseudotumor. clin nucl med 1985;10(7):501-503. 11. vitti ra, maurer ah. single photon emission computed tomography and renal pseudotumor. clin nucl med 1985;10(7):501-503. abstract introduction methods results ethical consideration discussion limitations of the study conclusion acknowledgements references about the author(s) abubakar farate department of nuclear medicine, sefako makgatho health sciences university, south africa dr george mukhari academic hospital, south africa aadil a. gutta department of nuclear medicine, sefako makgatho health sciences university, south africa dr george mukhari academic hospital, south africa karien de graaf department of radiology, femina women’s hospital, south africa trevor mdaka department of nuclear medicine, sefako makgatho health sciences university, south africa dr george mukhari academic hospital, south africa citation farate a, gutta aa, de graaf k, mdaka t. evaluation of hypofunctioning thyroid nodules with technetium-99m mibi and ultrasonography. s afr j rad. 2017;21(1), a1099. https://doi.org/10.4102/sajr.v21i1.1099 original research evaluation of hypofunctioning thyroid nodules with technetium-99m mibi and ultrasonography abubakar farate, aadil a. gutta, karien de graaf, trevor mdaka received: 26 sept. 2016; accepted: 05 dec. 2016; published: 27 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: fine needle aspiration cytology (fnac) cannot reliably differentiate follicular adenoma from follicular carcinoma (fc), which requires histological evidence of capsular or vascular invasion. fc is the most predominant thyroid cancer in our loco-regional environment, indicating the need for improvement in preoperative diagnostic accuracy of thyroid nodules to ensure appropriate and timely interventions. objective: the purpose of this study was to assess the role of technetium-99m methoxyisobutylisonitrile (99mtc-mibi) scintigraphy and ultrasonography (usg) in the differential diagnosis of thyroid nodules. methods: forty-two patients with hypofunctioning thyroid nodules were prospectively studied with 99mtc-mibi scintigraphy and usg to differentiate benign from malignant nodules. an injection of 740 mbq of 99mtc-mibi was intravenously administered, followed by semiquantitative analysis of dual-phase scans using a 4-point (0 to 3) scoring system. usg was subsequently performed and interpretation was based on some sonographic criteria for malignancy. in the following days and weeks, patients underwent fnac followed by surgery and histopathologic examination. results: all malignant nodules were positive on 99mtc-mibi and all but two malignant nodules were positive on usg. the sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and accuracy are, respectively, 100%, 70%, 65%, 100%, and 81% for 99mtc-mibi scintigraphy; 87%, 78%, 68%, 91% and 81% for usg; and 83%, 100%, 100%, 96% and 64% for fnac. there was no statistically significant difference between 99mtc-mibi scintigraphy and usg performance for both benign (p = 0.317) and malignant (p = 0.573) nodules. conclusion: 99mtc-mibi scintigraphy and usg are important imaging modalities in the evaluation of thyroid nodules, particularly follicular neoplasms which are frequently associated with non-diagnostic cytology. introduction thyroid nodules are common clinical problems in the adult population with estimated prevalence of 2% to 6% by palpation and 19% to 35% by ultrasonographic technique.1 the majority of these nodules are benign with malignancy accounting for 5% or less.2 early detection of differentiated thyroid carcinoma results in improved survival rate if completely excised and followed with radioiodine ablation. despite the generally good accuracy of fine needle aspiration cytology (fnac), differentiating between benign and malignant follicular neoplasms remains challenging. this is particularly problematic in our loco-regional setting where follicular carcinoma (fc) is the most common form of primary thyroid cancer.3 a reliable diagnosis of fc can only be made when capsular or vascular invasion is seen on histologic examination.4 deciding between total thyroidectomy and risky two-stage surgery for malignancy found at postoperative histology is almost always a problem especially when the facility for frozen section is not available. functional thyroid imaging has been used for the evaluation of thyroid nodules, and a number of single photon emission computed tomography radiopharmaceuticals have been investigated. technetium-99m methoxyisobutylisonitrile (99mtc-mibi) has frequently been the tumour-seeking agent of choice because of its availability, favourable radiation dosimetry and higher tumour-to-background ratios.5 reports of other studies have shown that 99mtc-mibi scintigraphy is highly sensitive for thyroid neoplasia6,7,8 and has a high negative predictive value (npv) for excluding malignant thyroid nodules.6,7,8,9,10 the studies of mezosi et al.,6 hurtado-lópez et al.,7 wale et al.8 and demirel et al.9 recorded sensitivity and npv of 100% but they had very low specificity and positive predictive value (ppv). although a negative 99mtc-mibi scan virtually excludes malignancy in a hypofunctional thyroid nodule, the low specificity and ppv are problematic, thus necessitating the need for complementary diagnostic modalities such as ultrasonography (usg). ultrasonography is frequently the first-line imaging modality of choice for the evaluation of thyroid nodules because of its availability, non-invasiveness and lack of radiation exposure to the patient. it helps reveal clinically impalpable nodule(s) and can determine whether a nodule is solid or cystic, precisely define its size, site and number. usg has certain features that are suggestive of thyroid malignancy, including microcalcifications, marked hypoechogenicity, irregular or microlobulated margins, lesions assuming a taller than wider shape configuration, incomplete halo, marked intranodular vascularity pattern on colour or power doppler, invasion of adjacent structures and presence of abnormal cervical lymphadenopathy.11 smith-bindman et al.12 identified intranodular microcalcifications as the strongest predictor of thyroid cancer. studies have also shown that the likelihood of cancer in thyroid nodules increases with increasing number of sonographic characteristics of malignancy but at the expense of sensitivity.12,13 cappelli et al.13 observed that ultrasound elastography is a very useful tool in the detection of malignancy in thyroid nodules when cytology results are inconclusive. 99mtc-mibi scintigraphy and usg have been used independently in the evaluation of thyroid nodules. to the best of the authors’ knowledge, literature reviews suggest that studies that assessed or compared usg (utilising both grey scale and doppler sonographic criteria) and 99mtc-mibi scan in the evaluation of hypofunctional thyroid nodules are limited. erdem et al.14 evaluated thyroid nodules using 99mtc-tetrafosmin (a radiopharmaceutical similar to 99mtc-mibi) scintigraphy and colour doppler ultrasound. in their study, 99mtc-tetrafosmin was more sensitive compared with doppler usg (sensitivity of 100% vs. 80%). demirel et al.9 compared the radionuclide thyroid angiography, 99mtc-mibi and power doppler ultrasound. they found power doppler usg to be more sensitive than 99mtc-mibi scan (sensitivity of 100% vs. 67%). the two studies, however, considered only the doppler sonographic criteria. the purpose of this study was to assess the diagnostic performances of 99mtc-mibi scintigraphy and usg in the preoperative evaluation of hypofunctional thyroid nodules, most importantly follicular thyroid neoplasms, and in addition, to compare the two imaging techniques. methods subjects the study cohorts consisted of all eligible patients with thyroid nodule(s) who were referred for thyroid scintigraphy at the nuclear medicine department, dr george mukhari academic hospital, garankuwa between march 2013 and april 2014. a nodule was defined as a palpable mass in the thyroid gland detected either by the patient or identified by a physician during neck examination. all patients had hypofunctional thyroid nodules as determined by 99mtc-pertechnetate thyroid scintigraphy and all were euthyroid as confirmed by serum thyroid hormone measurements. imaging protocol radionuclide imaging 99mtc-pertechnetate scintigraphy: twenty minutes after injection of 185 mbq of 99mtc-pertechnetate, anterior neck image was acquired with a large field-of-view gamma camera (e.cam, siemens medical solution usa, inc., pa, usa) equipped with a low-energy, parallel-hole, high-resolution collimator. acquisition was preset to 10 minutes (or 250 000 counts) using a 256 x 256 matrix with a digital zoom of 2.0. the energy window was set at 20% and centred at the 140 kev photopeak of 99mtc. 99mtc-pertechnetate scan was performed to objectively determine the functionality of the nodule. patients with hypofunctioning or cold nodule(s) were included in this study. 99mtc-mibi scintigraphy: 99mtc-mibi scan was performed within 3 to 7 days after the 99mtc-pertecnnetate scan. intravenous injection of 740 mbq of 99mtc-mibi was followed by early (20 minutes) and delayed (2 hours) imaging of the thyroid under the same acquisition conditions as employed for the 99mtc-pertechnetate scan. each scan was evaluated by a fellowship-trained nuclear medicine physician with more than 5 years of experience who was blinded to the clinical data and ultrasound results. the 99mtc-mibi images were semiquantitatively analysed by a four-point scoring system10: score-0: no significant uptake, score-1: uptake increased compared with the background activity but less than normal thyroid tissue, score-2: uptake equal to normal thyroid tissue and score-3: uptake greater than normal thyroid tissue with retention on the delayed image. we considered score-3 to be positive for malignancy. ultrasonography a board-certified radiologist performed usg with a siemens acuson x 300 scanner (siemens medical solutions, ca, usa) using electronically focused near-field linear transducer with a bandwidth of 5–10 mhz. the radiologist had no prior knowledge of clinical data or scintigraphy. malignant sonographic characteristics were defined as microcalcifications, type-3 intranodular vascularity (defined as intranodular flow with multiple vascular poles chaotically arranged, with or without significant perinodular vessels), a shape that was taller than it was wide, an irregular or microlobulated margin, marked hypoechogenicity and presence of an abnormal regional lymph node. we classified nodules as positive or negative. if a single feature suggestive of malignancy was present, the nodule was classified as positive. if a nodule had none of these features, it was classified as negative (benign). the results of 99mtc-mibi scintigraphy and usg were compared with fnac and histopathological findings. ultrasound-guided fnac the same radiologist who performed the ultrasound examinations carried out the ultrasound-guided fnacs. the procedure was performed on all thyroid nodules with or without sonographic features suspicious of malignancy. ultrasound-guided fnac was performed with a 22-gauge needle attached to a 5-ml disposable plastic syringe. each lesion was aspirated at least twice. the aspirated specimen was smeared on a glass slide and fixed in 95% alcohol for papanicolaou. additional special staining was performed according to the requirements of the cytopathologists. cytologic diagnoses were rendered by an experienced pathologist as benign, follicular neoplasm, indeterminate, inconclusive or malignant. statistical analysis statistical analysis was performed using statistical analysis system, release 9.2, running under microsoft windows. descriptive statistics such as mean, standard deviation, frequency and percentage were obtained. the sensitivity, specificity, ppv, npv and accuracy of each diagnostic method were calculated using two-by-two contingency tables based on the definitive histopathologic diagnosis. the differences between the two modalities were assessed applying the exact mcnemar test. a p < 0.05 was considered statistically significant. results a total of 42 patients (39 women and 3 men) with hypofunctional thyroid nodule(s) were prospectively evaluated with 99mtc-mibi and usg. they were aged between 19 and 73 (mean age: 44.8 ±13.49). the nodules were classified according to histologic findings (table 1). of the 42 cases studied, 15 (35.7%) were malignant and 27 (64.3%) were benign at histology. the data confirmed the presence of fc in 8 of 15 nodules (53.3%) and papillary carcinoma (pc) in 7 of 15 nodules (46.7%). the benign cases comprised 17 colloid goitres, 6 nodular goitres, 2 follicular adenomas and 2 hürthle cell adenomas. table 1: summary of 99mtc-mibi, ultrasonography and fine needle aspiration cytology findings in the assessment of thyroid nodules. 99mtc-mibi was positive in all the 15 (100%) patients with carcinomas, whereas usg was positive in 13 of 15 (86.7%) cases. false-positive findings were seen in 8 of 27 (29.6%) patients on 99mtc-mibi scintigraphy and in 6 of 27 (22.2%) patients on usg. there was no statistically significant difference between 99mtc-mibi scintigraphy and usg performance for both benign (p = 0.317) and malignant (p = 0.573) nodules. when the two modalities were compared, 99mtc-mibi scintigraphy was more sensitive and had higher npv than usg. however, usg was slightly more specific with marginally higher ppv than 99mtc-mibi. review of fnac results showed that only 5 of 15 (33%) histologically proven cancers had positive cytology preoperatively. of these, pcs were positive for malignancy in 4 of 7 nodules (57%) and only 1 of 8 nodules (12.5%) of fcs. in addition, the accuracy of fnac was lower when compared with the two modalities (64% for usg vs. 81% each for 99mtc-mibi and usg). the diagnostic performance of 99mtc-mibi scintigraphy, usg and fnac in assessment of thyroid nodules are presented in table 2. table 2: comparison of the diagnostic performances of 99mtc-mibi, ultrasonography and fine needle aspiration cytology in the evaluation of thyroid nodules. ethical consideration the research ethics committees of the university of limpopo and dr george mukhari academic hospital approved the study, with ethical clearance number: mrec/m/20/2013: pg. informed consent was obtained from all of the participants, and confidentiality was observed throughout the study by the use of a number coding system. discussion a thyroid nodule is one of the frequently encountered problems in endocrinology. the main aim of management is to identify the small proportion of patients with malignant lesions who require prompt intervention and also to avoid unnecessary investigation or treatment for otherwise benign disease. the surgical procedure varies depending on the clinical suspicion for malignancy. most thyroid nodules can be diagnosed on fnac, and only follicular neoplasms cannot be reliably identified.5 fnac was diagnostic in only 1 of 8 (12.5%) patients with fc. this is of a particular concern in the semi-urban and rural population (like our region) where fc is reported as the predominant primary thyroid cancer. our data revealed an insignificant difference in frequency of the two main types of differentiated thyroid cancers (fc: 53.3% vs. pc: 46.7%). this trend may be a reflection of changing iodine status as a result of widespread iodisation programme. further, epidemiologic studies are essential to validate this finding. when results are inconclusive or clinical and fnac findings are discordant, additional diagnostic steps are often crucial to decide on the appropriate surgical actions; such measures include usg, radionuclide imaging and clinical risk stratification using age, gender, size of the nodule, growth rate and prior neck irradiation. 99mtc-mibi scintigraphy and usg have been investigated independently. to the best of our knowledge, there is no published literature that evaluated hypofunctioning thyroid nodule with 99mtc-mibi scintigraphy and usg (utilising both grey scale and doppler features) at the same time. 99mtc-mibi was introduced in 1989 as a myocardial perfusion imaging agent,6 but it was subsequently shown to accumulate in a variety of tumours, including thyroid neoplasms.6,10 99mtc-mibi is a lipophilic cationic complex with high affinity for mitochondria, and its accumulation in mitochondria-rich neoplastic cells such as malignant neoplasm is driven by mitochondrial negative transmembrane potential.6 accordingly, 99mtc-mibi uptake and retention is more common in neoplastic nodules (carcinomas and adenomas) than it is in other benign conditions. retention of 99mtc-mibi in thyroid adenomas particularly hürthle cell is related to high level of mitochondria-rich eosinophilic cells.15 which is why unlike other adenomas, hürthle cell adenoma shows persistent tracer retention, making it a close rival of malignancy (figure 1). nevertheless, despite accumulation in adenomas, intense 99mtc-mibi uptake and retention considerably increases the probability of carcinoma, whereas low or no uptake almost reliably excludes malignancy.6,10 for instance, in our study, we found hypofunctioning thyroid nodules that showed malignant characteristics on both 99mtc-mibi scan and usg; the diagnoses of carcinomas were subsequently confirmed at histology (figures 2 and 3). surgical removal of nodules with high 99mtc-mibi uptake and non-surgical treatment for mibi-negative nodules had been suggested.16 figure 1: 99mtc-mibi scintigraphy and ultrasonography of the thyroid of a 36-year-old woman with isthmic thyroid nodule. there is increased activity on early (a) and delayed (b) 99mtc-mibi scan. ultrasonography showed a well-defined nodule (c) with marked intranodular vascularity pattern on power doppler (d). histology confirmed an hürthle cell adenoma. figure 2: 99mtc-mibi scintigraphy and ultrasonography of the thyroid of a 65-year-old woman with left thyroid nodule. there is intense 99mtc-mibi uptake on both early (a) and delayed (b) images in the left lobe of the thyroid. ultrasonography (c) showed multiple microcalcifications (arrows). the features on the two studies are suggestive of malignancy. histology confirmed a papillary carcinoma. figure 3: 99mtc-mibi scintigraphy and ultrasonography of the thyroid of a 42-year-old woman with right thyroid nodule. intense 99mtc-mibi uptake on early (a) and delayed (b) images is noted in the right lobe of the thyroid. ultrasonography (c) showed a well-defined mass that is taller than wider shape (arrowed). the features on the two studies are suggestive of malignancy. histology confirmed a follicular carcinoma. our study revealed that all the 99mtc-mibi-positive nodules were confirmed to be malignant and 99mtc-mibi-negative nodules were proven to be benign at histology. thus, we obtained sensitivity and npv of 100% with 99mtc-mibi. these findings are consistent with other studies in which they found both the sensitivity and npv of 100%.6,7,8,9 the high npv of 99mtc-mibi entails that a negative scan virtually excludes malignancy in a thyroid nodule and this could obviate the need for unnecessary surgical procedures. the major limitation of 99mtc-mibi is the reported wide range of specificity and ppv.6,7,8,9,10 we obtained a specificity of 70% and a ppv of 65% in our study. these findings correlate closely with studies of sathekge et al.10 (specificity of 66% and ppv of 77%) and hurtado-lópez et al.7 (specificity of 61% and ppv of 62%). the reported wide range of specificity and ppv may be explained by the uptake of 99mtc-mibi in some benign conditions. in our study, all the four thyroid adenomas showed persistent uptake and retention of 99mtc-mibi. these findings are similar to the reports of other studies.6,9 for the purpose of this study, we focused on evaluating patients with palpable single thyroid nodule regardless of whether or not an additional nodule was present at usg. if we had excluded patients with additional nodule(s), a significant number of patients with thyroid cancers would have been missed. usg revealed additional nodules in 38% of our cohorts and 25% of these had malignant nodules. the presence of additional nodule(s) at ultrasound is frequently reported at 20% to 48%.2 kaur et al.17 found additional nodules in 32% of their subjects who had single thyroid nodule by palpation. discrepancy between the true prevalence of thyroid nodules and that obtained by palpation has been reported.2 the sensitivity, specificity and npv of usg in the differential diagnosis of nodular thyroid disease in our study were 86.7%, 77.8%, and 91.3%, respectively. these are in keeping with the studies of kaur et al.17 and koike et al.18 furthermore, 99mtc-mibi was more sensitive (100% vs. 87%) and had higher npv (100% vs. 91%) compared to usg. both modalities maintained the same accuracy of 91%. however, they did not differ significantly in terms of their overall performance for both benign (p = 0.317) and malignant (p = 0.573) nodules. erdem et al.14 compared 99mtc-tetrofosmin scintigraphy with colour doppler usg. they found 99mtc-tetrafosmin to be more sensitive than doppler usg (sensitivity of 100% vs. 80%). however, their study used another ligand (i.e. tetrofosmin) tagged to 99mtc whose physical properties and mechanism of tumour localisation are similar to mibi. demirel et al.9 also compared radionuclide thyroid angiography, 99mtc-mibi with power doppler usg and found that power doppler usg was more sensitive than 99mtc-mibi scan (sensitivity of 100% vs. 67%). however, these studies assessed only the doppler ultrasound features of the nodules and compared them with scintigraphic findings using histology as gold standard (i.e. they did not include other grey scale sonographic characteristics that are suggestive of either benign or malignant nodule as variables). limitations of the study the relatively small patient cohort is a limitation of our study. secondly, surgeons might have used all the available information (including results of 99mtc-mibi scintigraphy and ultrasound scan) for surgical decision-making such that only nodules with high suspicion for malignancy were given preference. consequently, the vast majority of patients with benign nodules would have been left out, potentially introducing a performance bias. conclusion 99mtc-mibi and usg detected almost all malignant nodules including those nodules that were inconclusive on fnac. thus, the two modalities can complement fnac to improve diagnostic accuracy. this is especially important in follicular neoplasms, which are frequently associated with non-diagnostic cytology (cytology detected merely 12.5% of fc in our review). 99mtc-mibi and usg can also be used to pre-select patients for fnac on the basis of suspicious malignant features and the two modalities can help guide biopsy to the most abnormal area. acknowledgements the authors wish to acknowledge the support of prof. m.e. kisansa, the head of radiology, sefako makgatho health sciences university and dr george mukhari academic hospital. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this manuscript. authors’ contributions a.f. was the principal investigator and was responsible for study conception, design, data analysis and manuscript writing. a.a.g. made conceptual contribution, design and manuscript editing. k.d. helped with data collection and performed ultrasound scan. t.m. helped with manuscript editing. references dean ds, gharib h. epidemiology of thyroid nodules. best pract res clin endocrinol metab. 2008;22(6):901–911. http://dx.doi.org/10.1016/j.beem.2008.09.019 polyzos sa, kita m, avramidis a. thyroid nodules–stepwise diagnosis and management. hormones (athens). 2007;6(2):101–119. http://dx.doi.org/10.14310/horm.2002.111107 kalk wj, sitas f, patterson 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http://dx.doi.org/10.1001/archsurg.136.3.334 about the author(s) nantes combrinck department of clinical imaging sciences, university of the free state, south africa stefan jansen van vuuren department of forensic pathology, university of the free state, south africa citation combrinck n. the role of post-mortem computed tomography in assault victims with head trauma in central south africa. s afr j rad. 2017;21(1), a1164. https://doi.org/10.4102/sajr.v21i1.1164 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia,usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract the role of post-mortem computed tomography in assault victims with head trauma in central south africa nantes combrinck, stefan jansen van vuuren copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: the role of post-mortem computed tomography (pmct) has been studied extensively, though not in south africa. in many countries, it has become an important adjunct to the routine forensic examination. objectives: the study compared the findings of pmct and conventional autopsy in victims of assault who presented with head injuries. the outcomes were compared to similar studies published internationally. method: a non-randomised prospective analytical study method was utilised. victims of assault who presented with head injuries underwent pmct, followed by a conventional autopsy. the findings were compared. results: pmct proved superior for detecting bony injuries. autopsy was more effective in detecting subdural haemorrhages. no major statistical difference was found in detecting intra-axial injuries. more injuries were detected in total by combining the findings of pmct and autopsy. several ethical and logistical problems were identified, mainly resulting from the computed tomography (ct) scanner not being in the same facility as the forensic laboratory. our findings were similar to those of other published studies. conclusion: pmct is an important augmentation to conventional autopsy of trauma victims and could add valuable diagnostic information to the forensic examination. a ct scanner on site would eliminate the logistical and ethical problems identified during the study. abstract introduction research method and design results discussion conclusion acknowledgments references about the author(s) nasr timol department of radiology, university of kwazulu-natal, south africa department of health, university of kwazulu-natal, south africa khatija amod department of radiology, inkosi albert luthuli central hospital, south africa rohen harrichandparsad department of neurosurgery, university of kwazulu-natal and inkosi albert luthuli central hospital, south africa royston duncan department of radiology, lake smith & partners and university of kwazulu-natal, south africa tarylee reddy biostatistics unit, medical research council, south africa citation timol n, amod k, harrichandparsad r, duncan r, reddy t. imaging findings and outcomes in patients with carotid cavernous fistula at inkosi albert luthuli central hospital in durban. s afr j rad. 2018;22(1), a1264. https://doi.org/10.4102/sajr.v22i1.1264 original research imaging findings and outcomes in patients with carotid cavernous fistula at inkosi albert luthuli central hospital in durban nasr timol, khatija amod, rohen harrichandparsad, royston duncan, tarylee reddy received: 09 aug. 2017; accepted: 18 oct. 2017; published: 25 jan. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: carotid cavernous fistulas (ccfs) are relatively uncommon and are difficult to diagnose clinically. radiological imaging plays a significant role in making the diagnosis with recent advances improving the ability of radiologists to diagnose the condition. despite these developments, digital subtracted angiography (dsa) remains the gold standard in diagnosing ccfs and simultaneously provides the opportunity for intervention. objectives: to determine the imaging findings of patients presenting to inkosi albert luthuli central hospital (ialch) with a ccf and to assess the outcome of endovascular intervention. method: we reviewed the electronic records and archived imaging data of consecutive patients diagnosed with ccf between january 2003 and may 2016 at ialch, in particular, the imaging findings, intervention and subsequent outcomes. results: computed tomography (ct) was the most utilised imaging modality prior to patients undergoing dsa. a dilated superior ophthalmic vein (96%) was the most prevalent imaging finding on axial imaging. at dsa, all except two patients had high-flow fistulas. the fistulas predominantly drained anteriorly (69.44%) and a cavernous internal carotid artery aneurysm was identified in eight patients. occlusion of the fistula was attained in all patients that were compliant with follow-up and underwent intervention (n = 36, 100%), but parent artery sacrifice was required in 10 cases (27.78%). conclusion: a wide range of imaging modalities can be used in the workup of a ccf. ct is currently the most accessible modality in our setting, with limited access to magnetic resonance imaging. on axial imaging, a dilated superior ophthalmic vein is the commonest finding. classification of a fistula according to flow dynamics and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional barrow’s classification. management outcomes at our institution compare well with available local and international data. introduction the cavernous sinuses (cs) are paired dural venous sinuses that form part of a complex network of venous channels into which the superficial venous system of the head drains. it receives venous blood from the superior and inferior ophthalmic veins, sylvian veins and pterygoid venous plexus and in turn empties into the superior and inferior petrosal sinuses which ultimately drain via the internal jugular vein. because of its location in the parasellar region, many neurovascular structures (including the internal carotid artery [ica]) traverse the sinus providing an opportunity for complex interactions to occur between the structures (see figures 1 and 2). figure 1: schematic diagram depicting anatomical relationship between structures within the cavernous sinus. figure 2: tributaries and drainage of cavernous sinus. the ica has a tortuous path and is divided into segments. after passing through the superior part of the foramen lacerum to enter the cranial cavity, the ica reaches the petroclinoid ligament where it passes anteriorly between the layers of the dura that form the cs taking up a medial position within the sinus. the ica then exits the cs in the region of the anterior clinoid process. branches of the ica arising within the cs are the meningohypophyseal artery (mha), inferolateral trunk (ilt) and capsular artery which in turn give off sub-branches supplying the dural covering of the cs. the medial wall of the cs is supplied by branches of the mha and capsular arteries whilst the inferior and lateral walls are supplied by the ilt. the ica’s companion branch, the external carotid artery (eca), whilst supplying the major structures of the head and neck, also supplies parts of the meningeal layers in the cavernous region of the brain via distal sub-branches such as the middle meningeal artery which anastomose with distal branches of the ilt. carotid cavernous fistulas (ccfs) are abnormal arteriovenous communications between the carotid circulation and the cs, resulting in increased cs pressure and siphoning of the cerebral arterial supply. the ccf may be spontaneous or traumatic and have a variable flow dynamic (high vs. low flow).1 the barrow classification is the most popular system used to classify ccfs. the classification categorises fistulas according to their arterial supply. type a fistulas are direct communications between the cavernous segment of the ica and the cs. types b, c and d are indirect communications between the cs and dural meningeal branches of the ica or eca. direct fistulas (type a) are usually accompanied with high flow rates and are mostly a consequence of craniofacial fractures, aneurysmal rupture or surgical intervention. rarely, diseases causing weakness of the arterial walls may predispose to the development of a spontaneous direct fistula. indirect fistulas (types b, c and d) have an unclear aetiology and appear to be more prevalent in post-menopausal, diabetic and hypertensive women. other risk factors include collagenopathies, cs thrombosis, sinusitis and pregnancy. indirect fistulas have low flow rates and are usually spontaneous.2,3 carotid cavernous fistulas are infrequent. direct fistulas are more common than the indirect types but just 0.2% of patients with traumatic brain injuries go on to develop direct fistulas.4,5 carotid cavernous fistulas have a varied clinical presentation (ocular symptoms, cranial nerve neuropathies, headache or pulsatile tinnitus) which is dependent on the type, flow dynamics, size, location, route of venous drainage and duration of the fistula. fistulas may complicate and result in intracranial haemorrhage and ischaemia. smaller fistulas may remain asymptomatic.1,2 multiple imaging modalities are used to make the diagnosis of a ccf. digital subtraction angiography (dsa) is considered the gold standard to diagnose and plan therapy and intervene when necessary. computed tomography (ct) and magnetic resonance imaging (mri) are valuable and are quite often the initial imaging modalities used. ultrasonography (us) is a more recent addition to the initial diagnostic workup.4 digital subtraction angiography whilst being invasive is necessary for making an accurate anatomical diagnosis and for the planning of further management by identifying the exact location of the breach in the affected artery, the drainage pattern and the possible contributing factors such as thrombosis and aneurysms. at angiography, distal flow and cerebral collateral circulation is also assessed in the event that the ica needs to be sacrificed in the course of management.4,6 treatment options in ccfs are based on the type of fistula, degree of clinical symptoms and risk of complications. treatment options in indirect fistulas with low risk of complications include conservative treatment and radiosurgery. high-flow, direct fistulas or failed conservative treatment of low flow fistulas requires endovascular or surgical intervention.6 at intervention, the aim of repair is to occlude the site of communication whilst ensuring the ica remains patent. if the defect is too large or if embolisation fails, the parent artery (ica) is sacrificed after assessing the adequacy of collateral cerebral blood flow. research method and design formal ethics approval was obtained from the biomedical research ethics committee (brec), college of health sciences, university of kwazulu-natal (brec ref no.: be475/16). data were collected retrospectively from all patients presenting with ccf that were managed by the department of neurosurgery at inkosi albert luthuli central hospital (ialch) in durban, south africa, from january 2003 to may 2016. the imaging modalities used in the workup and management of these patients included ct and mri. most of the preliminary imaging was carried out at various base hospitals and referring centres prior to the patients’ arrival at ialch. the available reports and images of these studies were reviewed and analysed. all patients subsequently underwent dsa and intervention, if necessary, at ialch. interventional procedures were performed in the angiography suite in the radiology department by an experienced neurosurgeon and/or interventional radiologist. angiography was initially performed using a siemens axiom artis fa floor mounted machine. subsequently, from 2011 onwards, angiography was performed using a siemens artis q zee biplane machine. all patients underwent local or general anaesthesia where appropriate. vascular access was obtained via the femoral artery and intravenous heparin was administered to prevent thrombosis. a balloon occlusion test was performed on all patients to assess collateral blood flow should parent artery sacrifice need to be considered. dsa images were reviewed and data collected. all data with categorical variables were presented as frequencies and proportions, and continuous variables were summarised by means or medians, where appropriate. the shapiro–wilk test was used to test for normality. fisher’s exact test was used to test whether there were significant associations between categorical variables of interest. results initially, 38 patients were included in the study over the 13-year period. the mean age of the patients was 37.6 with a range of 9–94. the majority of patients were older than 30 years (60.52%). there were 24 male patients (63.16%) and 14 female patients (36.84%). in approximately two-thirds of the cases, the fistula was post-traumatic. a statistically significant difference was observed in the proportion of fistulas caused by trauma between men and women (91.67% vs. 21.4%, p < 0.001). this is presented in figure 3. figure 3: relationship between gender and cause. most patients presented with orbital and/or ocular signs (92.11%). neurological signs and symptoms were noted in more than half of the patients (60.53%). the specific symptoms and signs are presented in figure 4. the most prevalent sign was proptosis and the least prevalent was a depressed level of consciousness. alteration of mental state in these patients was most likely as a consequence of other injuries sustained. figure 4: clinical presentation observed in patients presenting with a carotid cavernous fistula. patients were most frequently imaged with ct prior to angiography (81.58%, n = 31). there were five patients who underwent mri only (13.16%) and three patients who had both a ct and an mri (7.89%) prior to an angiogram. no prior imaging was performed in two patients who went straight to angiography. no documented usage of ultrasound in the initial workup was recorded. not all prior imaging reports or images were available for review as some patients had imaging at their referring hospital and either did not bring their imaging with them or the findings were not documented. a total of 13 patients had no available data prior to dsa regarding the findings on previous imaging or had no scan at all. the imaging findings for the 25 patients with imaging data are presented in figure 5. the most common finding was dilatation of the superior ophthalmic vein (96%) followed by proptosis (60%) and cavernous sinus distension (40%). figure 5: imaging findings in patients presenting with a carotid cavernous fistula. a total of four patients who did not undergo intervention or did not comply with follow-up were excluded from the subsequent analysis (n = 4). the reasons for exclusion are documented in table 1. although most patients presented with a single fistula, a few exceptions (n = 3) were noted with two simultaneous fistulas. for ease of statistical analysis, each fistula was analysed independently. a total of 36 fistulas in 34 patients were considered for analysis. dsa findings are presented in table 2. the fistulas were classified according to their flow dynamic, cause and the presence of aneurysm or pseudoaneurysm. high-flow fistulas were present in all but two patients (n = 34, 94.44%). there was early filling of the affected cs in all patients. the fistulas did not favour a particular side and had predominantly anterior drainage only (n = 25, 69.44%). aneurysms were identified in eight patients (22.22%) and psuedoaneurysms in two cases (5.56%). all patients passed the trial balloon occlusion test, suggesting adequate collateral blood flow. table 1: patients excluded from digital subtraction angiography and outcome analysis. table 2: digital subtraction angiography findings. fistula occlusion was attained via embolisation or trapping in all cases that were compliant with management and in whom intervention was attempted (n = 36, 100%). sacrifice of the affected ica was required in 10 patients (27.78%). reasons for sacrifice are demonstrated in figure 6. no documented post-procedural complications were noted. figure 6: reasons for internal carotid artery sacrifice in patients with carotid cavernous fistulas undergoing endovascular intervention (n = 10). one of the patients presented post-trauma, with bilateral high-flow fistulas. multiple balloons were deployed bilaterally, which resulted in reduced filling but persistence of the fistula. a repeat angiogram was then performed at a later date. the right fistula, which was smaller, was treated successfully using a covered stent (jo stent). the left fistula, however, was larger and required sacrifice of the left ica to occlude the fistula. in table 3, the relationship between outcome and demographic data, the side of fistula and presence of an aneurysm, respectively, is presented. sacrifice of the ica was slightly higher in those who had an intracavernous ica aneurysm compared to those who did not (37.5% vs. 25%); however, this finding was not statistically significant (p = 0.658). a higher rate of ica sacrifice was also observed in fistulas on the right side (35.3% vs. 21.1%); this result was also not statistically significant (p = 0.463). table 3: relationship between outcome and various factors. discussion with the advent of ct and mri, diagnosis of ccfs via non-invasive means has become easier. most patients at our centre underwent ct prior to angiography. however, access to mr imaging in a limited resource setting still remains a challenge as only eight patients in total had mri as part of their diagnostic workup. a dilated superior ophthalmic vein is often the initial finding on imaging and was found in 96% of the reviewed image data in our study, which compared favourably to other reports of 86% – 100% on enhanced ct and 75% – 100% on t1w or post-contrast mri.4 other findings on axial imaging include proptosis, retrobulbar fat stranding, sinus distension and early/avid enhancement of the affected cs (see figures 7 and 9). in addition, ct allows easier identification of fractures and complications such as haemorrhage, whereas mri allows the detection of abnormal flow voids within the cs. magnetic resonance is understood to be superior to ct in detection of subtle signs.4 figure 7: a 33-year-old male presented with a post-traumatic carotid cavernous fistula. axial post-contrast computed tomography brain image demonstrates an enlarged tortuous left superior ophthalmic vein (arrow). figure 8: a 24-year-old female presented with a spontaneous history of proptosis, visual disturbance and pulsatile tinnitus: (a) axial source image from a computed tomography angiography demonstrates early enhancement of a distended right cavernous sinus (arrowhead) and a dilated ipsilateral superior ophthalmic vein (arrow). (b) lateral left vertebral artery angiogram with carotid compression (heuber manoeuvre) in the same patient displays early filling of the distended cavernous sinus via the fistula (arrow) with drainage via anterior and inferior venous pathways (arrowheads). figure 9: a 39-year-old male presented with proptosis and chemosis 6 months after being involved in a motor vehicle accident: (a) axial t2w magnetic resonance imaging shows abnormal flow voids within the right cavernous sinus (arrow) as well as proptosis of the right globe. (b) additional t2w slices in the same patient demonstrate a dilated ipsilateral superior ophthalmic vein (arrowhead). (c) flow-related hyperintensity is noted on the mr time-of-flight (tof) source images. (d) the corresponding mr tof 3d mip images display a dilated right superior ophthalmic vein (asterisk) with enhancement in the region of the right cavernous sinus (arrow). detection of flow-related hyperintensity within the affected cs on mr sequences such as three-dimensional fast imaging with steady state precession (fisp) and three-dimensional time-of-flight source images add value, especially in the event of subtle or absent findings on standard spin echo mr sequences.7 non-invasive angiography techniques such as computed tomography angiography (cta) and mr angiography (mra) sometimes allow determination of the size and exact location of the fistula (see figure 8). the administration of gadolinium does not provide any additional benefit.7 transcranial us is well known to be cost-effective and non-invasive. ccf evaluation includes views through the temporal, orbital and carotid windows. the cs are identified as a symmetric cluster of flow on either side of the anterior clinoid process. asymmetry of these structures suggests a possible fistula. on doppler us, the superior orbital vein may show arterialisation, increased velocity and dilatation secondary to reversal of flow.4 although most fistulas drain anteriorly to the ophthalmic veins, these orbital features may be absent in other patterns of drainage and may result in missed diagnosis. carotid evaluation shows a reduced resistive index on the affected side. a decrease in velocity within the cerebral arteries on the ipsilateral side because of steal phenomenon may be present8. despite its ability to strongly suggest a fistula, ultrasound falls short in determining the precise size and location of the fistula and does not add much value in clinical practice. notwithstanding the advances of the other imaging modalities in their ability to diagnose a ccf, dsa remains the gold standard.4 this is mainly because normal non-invasive imaging does not exclude the diagnosis of a ccf and also because of the ability of angiography to identify fistula angioarchitecture whilst allowing simultaneous planning and intervention. at dsa, the supplying arterial structures in low flow fistulas, the breech in the vessel wall in high-flow fistulas and venous drainage pattern can be easily assessed.4 early contrast enhancement of the affected cs usually indicates the presence of a fistula (see figure 10). anterior venous drainage patterns are the commonest drainage pathway1 which is further supported by our study and accounts for the predominance of orbital/ocular signs. specific assessment for cortical venous drainage at angiography is advised as urgent treatment is indicated, if present, because of its association with potentially life-threatening sub-arachnoid/intracerebral haemorrhage.9 figure 10: a 42-year-old female presented with proptosis, chemosis and an audible orbital bruit after sustaining a fall: (a) selected digital subtraction angiography of the left internal carotid artery demonstrates early filling of the left cavernous sinus (arrow) with drainage via the anterior and inferior pathways (arrowhead). (b) post-embolisation angiogram demonstrates successful occlusion of the fistula with preservation of the parent artery. a six-vessel angiogram is recommended over a four-vessel study as a small low flow fistula may be missed. if the fistula is not identified because of high flow, manoeuvres such as the mehringer-hieshima and heuber manoeuvres can be utilised to slow down the flow and allow identification of the fistula.6 assessing the arterial supply allows classification of the ccf by means of the barrow’s classification. this classification was found to be confusing and did not add further value in terms of further management. in our experience, classifying the fistula according to its flow dynamic and documenting the presence of an intracavernous aneurysm or pseudoaneurysm was found to be more practical (see figure 11). figure 11: classification system used during study. ideal management involves occlusion of the fistula whilst ensuring the affected ica remains patent. conservative treatment is reserved for patients with indirect ccfs and who have tolerable and few symptoms. for all other fistulas requiring intervention, occlusion via endovascular means is the preferred method.3 to accomplish this, agents such as detachable balloons, coils, embolic materials and stents can be utilised via a transarterial or transvenous route.10 if the fistula cannot be occluded, sacrifice of the affected ica may be required. surgical treatment is reserved when the endovascular approach is unsuccessful. emergent intervention is sometimes required if angiographic or clinically poor prognostic features are present (see table 4).9 table 4: poor prognostic features necessitating emergent treatment. it is preferable to preserve the parent artery, as patients may develop immediate or delayed neurological deficits as a result of ischaemia,11 although this was not our experience. furthermore, the development of a new cerebral aneurysm or evolution of existing aneurysms and subsequent aneurysmal rupture as a result of altered cerebral haemodynamics in patients with parent artery sacrifice has not been convincingly disproved.12 over the years, worldwide studies have showed varying degrees of success at achieving the ideal outcome. internal carotid artery preservation rate in reviewed studies ranged between 40% and 84%13,14 and ccf occlusion between 86% and 100%.13,15 to date, scant local data exist to our knowledge. in a single local study, szkup and beningfield,16 in their series of 34 cases, documented a preserved parent artery in approximately 53% of their cases and attained occlusion in 91%. most of the cases requiring sacrifice were because of large tears in the affected vessel generally secondary to trauma. the results at our centre, of occlusion in all (100%) of the cases and a 72.22% ica preservation, is similar in comparison to the reviewed local and international data. spontaneous direct ccfs are commonly secondary to rupture of an intracavernous ica aneurysm. in our study, 37.5% (n = 3) of patients with such an aneurysm ultimately required sacrifice of their ica. although this relationship was not statistically significant, studies suggest that parent artery occlusion is sometimes a necessary choice if first-line methods using detachable balloons or coils fail.17 limitations of the study not all prior imaging data were available for review, particularly imaging that was performed at referring institutions and hospitals. with recent and continued improvement being made in the way data are stored at our local facilities, perhaps a more comprehensive follow-up study can be performed at a later date. conclusion initial imaging in our locale was dominated by ct whilst mr imaging was reserved for a few cases because of accessibility. us, which is thought to have little clinical value, was not utilised. a dilated superior ophthalmic vein is usually present on imaging, especially if the fistula is accompanied by anterior venous drainage. caution should be taken in the absence of this sign to not miss a fistula with an alternate drainage pathway. digital subtraction angiography remains the gold standard allowing diagnostic confirmation, management planning and therapeutic intervention. classification of the fistulas according to flow dynamic and noting the presence of aneurysms or pseudoaneurysms was found to be more practical in comparison to the traditional barrow’s classification. the outcomes of 100% fistula occlusion and 72.22% ica preservation compares well with available local and international data. acknowledgments competing interests the authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article. authors’ contributions n.t. was the principal investigator and wrote the manuscript. k.a. and r.h. were the supervisors of the study and made conceptual contributions towards the study and participated in manuscript editing. r.d. assisted with critical review of the manuscript and was directly involved in patient management. t.r. assisted with statistical analysis and contributed to the results section of the study. references aralasmak a, karaali k, cevikol c, et al. venous drainage patterns in carotid cavernous fistulas. isrn radiol. 2014;2014:1–7. https://doi.org/10.1155/2014/760267 ringer aj, salud l, tomsick ta. carotid cavernous fistulas: anatomy, classification, and treatment. neurosurg clin north am. 2005;16(2):279–295. https://doi.org/10.1016/j.nec.2004.08.004 zanaty m, chalouhi n, tjoumakaris si, hasan d, rosenwasser rh, jabbour p. endovascular treatment of carotid-cavernous fistulas. neurosurg clin north am. 2014;25(3):551–563. https://doi.org/10.1016/j.nec.2014.04.011 dos santos d, monsignore lm, nakiri gs, cruz aa, colli bo, abud dg. imaging diagnosis of dural and direct cavernous carotid fistulae. radiol bras. 2014;47(4):251–255. schiavi p, picetti e, donelli v, servadei f. diagnosis and 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https://doi.org/10.2214/ajr.149.3.587 gemmete jj, ansari sa, gandhi dm. endovascular techniques for treatment of carotid-cavernous fistula. j neuro-ophthalmol. 2009;29(1):62–71. https://doi.org/10.1097/wno.0b013e3181989fc0 linskey me, jungreis ca, yonas h, et al. stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced ct. am j neuroradiol. 1994;15(5):829–843. lesley ws, rangaswamy r. balloon test occlusion and endosurgical parent artery sacrifice for the evaluation and management of complex intracranial aneurysmal disease. j neurointerv surg. 2009;1(2):112–120. https://doi.org/10.1136/jnis.2009.000539 wu z, zhang y, wang c, yang x, li y. treatment of traumatic carotid-cavernous fistula. int neuroradiol. 2000;6(4):277–289. https://doi.org/10.1177/159101990000600402 norman d, newton t, edwards m, decaprio v. carotid-cavernous fistula: closure with detachable silicone balloons. radiology. 1983;149(1):149–157. https://doi.org/10.1148/radiology.149.1.6611922 lewis ai, tomsick ta, tew jm. management of 100 consecutive direct carotid-cavernous fistulas results of treatment with detachable balloons. neurosurgery. 1995;36(2):239–245. https://doi.org/10.1227/00006123-199502000-00001 szkup p, beningfield s. endovascular treatment of post-traumatic carotid-cavernous fistulae using latex detachable balloons. s afr j radiol. 2005; 9(1): 4–14. kobayashi n, miyachi s, negoro m, et al. endovascular treatment strategy for direct carotid-cavernous fistulas resulting from rupture of intracavernous carotid aneurysms. am j neuroradiol. 2003;24(9):1789–1796. abstract introduction methods ethical considerations results discussion conclusion acknowledgements references about the author(s) nompumelelo e. mlambo department of radiology, college of health sciences, university of kwazulu-natal, south africa nondumiso n.m. dlamini department of radiology, college of health sciences, university of kwazulu-natal, south africa ronald j. urry department of urology, college of health sciences, university of kwazulu-natal, south africa citation mlambo ne, dlamini nnm, urry rj. correlation between radiological and histopathological findings in patients undergoing nephrectomy for presumed renal cell carcinoma on computed tomography scan at grey’s hospital. s afr j rad. 2017; 22(1), a1339. https://doi.org/10.4102/sajr.v22i1.1339 original research correlation between radiological and histopathological findings in patients undergoing nephrectomy for presumed renal cell carcinoma on computed tomography scan at grey’s hospital nompumelelo e. mlambo, nondumiso n.m. dlamini, ronald j. urry received: 06 mar. 2018; accepted: 11 july 2018; published: 10 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the incidence of renal cell carcinoma (rcc) is increasing globally owing to the increased use of cross-sectional imaging. computed tomography (ct) scan is the modality of choice in the diagnosis and pre-operative assessment of rcc. nephrectomy is the standard treatment for rcc and pre-surgery biopsy is not routinely practised. the accuracy of ct diagnosis and staging in a south african population has not been established. objectives: to determine the accuracy of ct scan in the diagnosis and pre-operative staging of rcc at grey’s hospital. methods: a retrospective chart review was performed; ct scan reports and histopathological results of adult patients who underwent nephrectomy for presumed rcc on ct scan between january 2010 and december 2016 were compared. results: fifty patients met the inclusion criteria for the study. ct significantly overestimated the size of renal masses by 0.7 cm (p = 0.045) on average. the positive predictive value of ct for rcc was 81%. cystic tumours and those 4 cm and smaller were more likely to be benign. ct demonstrated good specificity for extra-renal extension, vascular invasion and lymph node involvement, but poor sensitivity. conclusion: in our south african study population, ct is accurate at diagnosing rcc, but false-positives do occur. non-enhancing or poorly enhancing, cystic, fat-containing and small lesions (4 cm or smaller) are more likely to be benign and ultrasound-guided biopsy should be considered to avoid unnecessary surgery. ct assessment of extra-renal extension and vascular invasion is challenging and additional imaging modalities such as magnetic resonance imaging (mri) venogram, duplex doppler ultrasound or positron emission tomography–computed tomography (pet/ct) may be beneficial. introduction the prevalence of renal cell carcinoma (rcc) is increasing globally.1 this is partly owing to the increasing use of cross-sectional imaging in the clinical assessment of patients, leading to more tumours being discovered incidentally.2,3 imaging plays a key role in the diagnosis of rcc and computed tomography (ct) scan is the modality of choice.3,4 surgery is the standard treatment for non-metastatic rcc.4,5 currently, in south africa, pre-surgery biopsy of renal masses in adults is not routinely practised, and nephron sparing surgery is not routinely offered, particularly in the resource-constrained state sector.5 accurate imaging is therefore essential, not only for establishing the likely diagnosis but also for staging, surgical planning, determining the extent of nephrectomy to be performed (radical or partial) and choosing the surgical approach.1,2,3,4 there are no data to determine the accuracy of ct imaging in the diagnosis and staging of rcc in south african patients. a better understanding of benign conditions presumed to be rcc on ct imaging and the accuracy of staging of renal tumours has the potential to reduce unnecessary nephrectomies and direct the use of pre-operative biopsy of renal masses. methods setting grey’s hospital is a tertiary 530-bed academic hospital in pietermaritzburg, south africa. it has a wide catchment area covering a population of approximately 3 million people. it is the tertiary referral centre for urology and radiology for the entire referral area which includes primary health care clinics, district and regional hospitals. data collection all adult patients who underwent nephrectomy at grey’s hospital for presumed rcc on ct imaging from 01 january 2010 to 31 december 2016 were included in the study. a retrospective chart review was performed, and patient records were traced using theatre registers. computed tomography reports and images were retrieved from the radiology information system (ris) and picture and archiving system (pacs). histopathological results were obtained from the national health laboratory service (nhls). data collected included patient demographics, imaging findings and histopathological findings. specifically, final histology diagnosis, tumour size, local invasion, vascular invasion and lymph node spread were assessed. computed tomography scan and histopathology reports produced during patient investigation and management were used, and images and specimens were not reviewed or re-reported for this study. all ct scan reports were overseen by a specialist radiologist during routine clinical reporting but not all by the same radiologist. tumours were staged according to the american joint committee on cancer tumour, nodes and metastases (tnm) classification.6 cystic lesions were classified according to the bosniak classification.7 computed tomography scanning methodology all ct scans were performed using a siemens somatom sensation cardiac 64 slice scanner (siemens medical solutions sw, erlangen) with 0.5 s gantry rotation speed and a tube voltage of 120 kv. the tube current was determined using an automated current modulator. scans were performed using collimation with slice thickness of 5 mm, pitch of 1.15 and image reconstruction of 1 mm. for contrast-enhanced scans, 100 ml of omnipaque 300 contrast was injected intravenously at a flow rate of 3 ml/s. scans were performed in four phases. an unenhanced phase was used to provide a baseline to determine enhancement, and for assessment of the presence of intralesional calcifications and fat. an arterial phase (corticomedullary phase) at 10 s delay was used to enable the differentiation of an enhanced cortex and medulla and allow for the identification of renal vein tumour invasion. a parenchymal phase (porto-venous/nephrographic phase) at 70 s delay was used to identify and characterise small renal masses and assess for inferior vena cava (ivc) tumour invasion. an excretory phase at 10 min delay was used to delineate the relationship of the tumour to the collecting system. patients were scanned from the lower thorax to the pubic symphysis in all phases except for the arterial phase where they were scanned from the diaphragm to the iliac crests. table 1 highlights the main ct features that were used to differentiate benign from malignant renal tumours. table 1: criteria for differentiating benign and malignant renal tumours on computed tomography scan. statistical analysis data were collected and analysed using the ibm statistical package for social sciences (spss) version 24 (ibm corp, armonk, new york, the united states of america). the pearson chi-squared test (χ2) was used to compare categorical variables. if the projected frequency in a cell of a two-by-two table, assuming a null hypothesis, was less than five observations, the fischer’s exact test was used. the student’s t-test was used to compare quantitative variables. a p-value of less than 0.05 (5%) was considered statistically significant. the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of ct scan for variables studied were determined using the histopathological results as the gold standard. ethical considerations this study was a retrospective chart review study. ethics approval for this study was granted by the biomedical research ethics committee (brec) of the university of kwazulu-natal (be004/17). results of the 119 adult patients who underwent nephrectomy during the study period, 35 were excluded because their ct scan images were not available, 26 because the indication for nephrectomy was not suspected to be rcc, 7 because the histopathological results could not be traced and 1 for being under the age of 18 years. fifty patients fulfilled the inclusion criteria. the mean age was 54 years (range 23–74 years) with a male to female ratio of 1:1. thirteen patients (26%) had incidentally discovered renal lesions picked up on other imaging modalities or on ct performed for non-related pathology, 34 patients (68%) were symptomatic with an abdominal mass, flank pain or haematuria and four patients (8%) had imaging to identify a primary lesion after discovery of metastatic disease. the mean tumour size was 9 cm (range 1 cm–28 cm). histopathology findings are illustrated in figure 1. the non-rcc malignant tumours found at histopathology were adenocarcinoma, transitional cell carcinoma and squamous cell carcinoma. the benign lesions found were solid benign tumours (angiomyolipoma, oncocytoma and leiomyoma) and benign cysts. in two patients, inflammatory changes in the kidney were mistaken for rcc on imaging. figure 1: distribution of histopathological findings: histology final diagnosis (n; %) table 2 demonstrates a comparison of patient and tumour characteristics on imaging in patients with confirmed rcc (n = 38) and those with benign findings on histology (n = 9). table 2: comparison of patient and tumour characteristics on imaging in patients with confirmed renal cell carcinoma and those with benign findings on histology (excluding the three patients with non-renal cell carcinoma malignancy). the single benign tumour greater than 10 cm was a fat-poor angiomyolipoma which was reported on ct as being a possible rcc, illustrated in figure 7. of the cystic lesions, 66% were benign. figure 2 illustrates the ct size of rccs compared to benign tumours. the majority of benign lesions (67%) were less than 4 cm on imaging, and ct imaging size > 4 cm was significantly associated with rcc (p = 0.002). patients younger than 40 years were not significantly more likely to have benign lesions than older patients. figure 2: comparison of computed tomography tumour size between renal cell carcinomas and benign lesions. computed tomography significantly overestimated rcc tumour size compared to measured size at histopathology, with a mean overestimation of 0.7 cm (p = 0.046). as a result, there was post-operative reduction in the t-stage in six patients (16%). computed tomography demonstrated a ppv of 81% for the diagnosis of rcc. the sensitivity, specificity, ppv and npv of ct for tumour staging are tabulated in table 3. very few patients had positive findings for local invasion, vascular invasion and lymph node involvement, resulting in high levels of agreement between ct and histopathology findings. table 3: sensitivity, specificity, positive predictive value and negative predictive value of computed tomography scan for tumour staging. figures 3–5 demonstrate true-positive findings in three patients with confirmed rcc on histopathology, and figures 6–8 demonstrate false-positive findings in three patients with suspected rcc on imaging but in whom leiomyoma, angiomyolipoma and a benign cyst were diagnosed at histopathology. figure 3: incidental finding of renal cell carcinoma (rcc) on a post-caesarean section ultrasound. contrast-enhanced portovenous phase computed tomography images show: (a) an ill-defined hypoenhancing mass lesion in the left renal cortex (arrow) with a poor plane of separation between the mass and the psoas muscle, concerning for extra-renal extension. (b) coronal image demonstrates that the mass arises in the lower pole of the left kidney. (c) sagittal image demonstrates post-partum changes with an enlarged uterus as well as a thickened uterine wall and air within the uterine cavity (arrow). a diagnosis of clear cell rcc was confirmed at histology. figure 4: coronal (a, b) and axial (c) contrast-enhanced portovenous phase computed tomography scan images demonstrate a large right renal mass with capsular rupture and tumour extension into the perinephric space (white arrow). extensive metastatic retroperitoneal lymphadenopathy (black arrow) with encasement and subsequent narrowing of the right renal artery (open white arrow). there is also compression and anterior displacement of the inferior vena cava (ivc) (dashed black arrow). there was no tumour thrombus in the renal vein (not shown) and ivc. the findings of local tumour invasion involving the perinephric space and lymph node spread were confirmed at histology. figure 5: renal cell carcinoma (rcc) in a patient who presented with a pathological right femoral neck fracture. portovenous phase computed tomography scan coronal images demonstrate (a) a large exophytic heterogeneously enhancing right renal lower pole mass (black arrow) with perinephric fat stranding and thickening of gerota’s fascia. (a and b) multiple lytic skeletal metastases in the spine, pelvis and right femur with associated neck of femur fracture (white arrows). (c) an enhancing tumour thrombus in the right renal vein (arrow). there is no extension of the tumour thrombus to the inferior vena cava. (d) bilateral adrenal gland metastases (arrows) were present. these findings are consistent with stage 4 disease. figure 6: non-renal cell carcinoma (rcc) benign renal tumour. portovenous phase-enhanced computed tomography (ct) scan (a) axial, (b) sagittal and (c) coronal demonstrates a small exophytic rounded cystic lesion with a large uniformly enhancing solid component in the right renal mid pole (white arrow). no associated fat stranding. this lesion was assessed as rcc at ct scan. post-nephrectomy histology results showed a benign leiomyoma. figure 7: (a, b) non-enhanced axial computed tomography (ct) images show a large exophytic high-density soft tissue mass arising from the left kidney mid pole anteriorly (arrow in image a), perinephric haemorrhage and fat stranding (white arrow in image b). sagittal (c) – there is also thickening of the gerota’s fascia (black arrow). portovenous phase axial images (d) and (e) demonstrate mild enhancement of the renal mass and the perinephric collections. a small focus of intralesional fat (arrowhead) is demonstrated by an arrowhead in the image (a, d). this was diagnosed as haemorrhagic renal cell carcinoma on ct scan, and histology results showed angiomyolipoma (lipid-poor). figure 8: nephrographic phase computed tomography images (a) axial and (b) sagittal demonstrate a multiloculated exophytic complex cystic mass with rim enhancement and enhancing thick septae in the right renal upper pole (black arrow). no associated perirenal fat stranding. computed tomography diagnosis of cystic renal cell carcinoma was made; histological diagnosis was that of a simple cyst. a further large simple renal cyst is noted in the lower pole of the right kidney (white arrow). most patients underwent radical nephrectomy. of the 44 (88%) patients who underwent radical nephrectomy, 89% had rcc and 11% had benign pathology. the mean tumour size on imaging in these patients was 9.5 cm. six patients (12%) underwent partial nephrectomy for lesions on ct scan of less than 4 cm. of these, 33% had rcc and 67% had benign pathology. the mean tumour size on imaging in these patients was 3.3 cm. discussion computed tomography is widely accepted as the diagnostic modality of choice in the diagnosis and staging of rcc. it has a diagnostic accuracy of up to 93% and sensitivity and specificity for staging of up to 90%.1,2,8 our study demonstrated a ppv of 81% and a false-positive rate of 19% for ct diagnosis of rcc. in two studies of patients who underwent surgery for presumed rcc on ct, kutikov et al. found a benign rate of 16.1%9 and silver et al. of 16.9%.10 in a similar study, fuji et al. found a benign histopathological diagnosis in 11% of the partial nephrectomy specimens and 3.5% of radical nephrectomy specimens.11 compared to these studies, our study demonstrates a slightly higher rate of false-positive results. in contrast, alkaabnah et al. reported a higher benign rate of 30% in patients undergoing partial nephrectomy.12 nakashima et al. attributed a low benign incidence rate of 6.63% in their study to the use of magnetic resonance imaging (mri) in conjunction with ct scan in their patients, as mri is known to be more sensitive in detecting small amounts of intralesional fat.8 computed tomography scanning is known to overestimate the tumour size compared to pathological size which may lead to tumours being down-staged post-surgery.2,3 tumour size plays an important role in surgical planning because tumours smaller than 4 cm are likely to be amenable to partial nephrectomy, whereas larger tumours will likely require radical nephrectomy.3,13 partial nephrectomy is further favoured in tumours with a peripheral location in the kidney and is specifically indicated in patients with an absent contralateral kidney, bilateral kidney tumours, renal insufficiency and risk factors for future renal impairment.4,10,11,13 we found that ct significantly overestimated tumour size by 0.7 cm on average and that this resulted in down-staging in some patients. chen et al. also demonstrated tumour size overestimation by ct. this was seen particularly in tumours less than 7 cm.2 early arterial clamping during nephrectomy may result in a decrease in tumour blood volume. this is thought to be the main reason for the smaller pathological tumour size compared to radiological size, as most rccs are hypervascular.1,3 another reason suggested is that tumour fixation with formalin may cause shrinkage of the tumour.1,2 extra-renal tumour extension is assessed on ct by evaluation of the integrity of the renal capsule, the presence of perinephric fat stranding and the presence of enhancing nodules.3 bradley et al. demonstrated that the presence of perinephric collateral vessels and thickening of gerota’s fascia are more reliable indicators of perinephric tumour extension than the presence of fat stranding alone.14 there are other causes of perinephric fat stranding which include oedema, fibrosis, vascular engorgement and inflammation secondary to renal calculi or infection.4 computed tomography tends to overdiagnose lymph node spread, which is defined as a lymph node with short axis diameter of greater than 1 cm.3 this is a poor indicator, however, because nodal enlargement can result from reactive hyperplasia owing to current or previous inflammation. also, small lymph nodes can harbour micro-metastases, resulting in false-negative findings.3,13 lymph nodal invasion can be differentiated from reactive hyperplasia by assessing the enhancement pattern as metastatic lymph nodes tend to have similar enhancement pattern to the primary tumour.4 assessment of the renal veins and ivc for vascular invasion is performed on images obtained during corticomedullary and nephrographic phases, respectively.4,13 maximal opacification of the renal vessels to allow for confident diagnosis of tumour extension into the renal vein is achieved in the late corticomedullary phase (25–70 s post-intravenous contrast administration). vascular invasion is indicated by the presence of an intra-vascular enhancing filling defect, focal venous wall enhancement and infiltration of adjacent soft tissues. on rare occasions, tumour thrombus extends into the right atrium and pulmonary arteries.3,4 adequate assessment of tumour thrombus extent is crucial for patient counselling and surgical planning. a thoracoabdominal surgical approach is required for tumour thrombus extending into the supra-hepatic ivc.1,3 in our study, ct showed high specificity but unexpectedly poor sensitivity for extra-renal extension and venous invasion, suggesting that ct is not effective at identifying these findings. this is contradicted by what is described in the literature where ct has been well documented to have high sensitivity and specificity.1,2,8 we believe that this is partly explained by the low number of patients with extra-renal extension and venous invasion in the study. further scrutiny, however, may support the concept that ct diagnosis of extra-renal and vascular invasion in rcc is difficult. sokhi et al. reported ct sensitivity for renal vein invasion in t3a rcc to be 59% – 69%.15 computed tomography is unlikely to perform well in cases of microscopic or small volume extension into the perinephric tissue and renal vein. this highlights the importance of using indirect signs such as perinephric fat stranding, thickening of gerota’s fascia and collateral vessels. if there is doubt about vascular invasion, an mri venogram or a duplex doppler ultrasound may be beneficial.16 fluorodeoxyglucose (fdg) pet/ct imaging has a limited role in imaging of primary renal tumours owing to physiological activity in the urinary system. however, pet and/or ct has a role in detecting tumour spread and is more sensitive for skeletal metastases than bone scintigraphy. pet and/or ct can be used to differentiate between tumour thrombus and bland thrombus. assessing lymph node spread remains challenging as pet and/or ct has reduced sensitivity in identifying tumour spread in lymph nodes less than 7 mm owing to reduced spatial resolution. furthermore, pet and/or ct demonstrates increased radiotracer uptake in both reactive lymphadenopathy and metastatic lymph nodes, resulting in a potential for false-positive results.17 the most common benign tumour presumed to be rcc on ct in our study was a complex cystic mass which was classified as either bosniak 3 or bosniak 4. figure 8 demonstrates a cystic lesion graded as a bosniak 3 cyst on ct scan, which was found not to be a malignancy on histopathology. magnetic resonance imaging has been suggested to better evaluate bosniak 3 lesions. however, it tends to exaggerate septal thickness and demonstrates variable enhancement owing to variation in image quality, risking an overestimation of the allocated bosniak grade.18 despite any additional diagnostic value it may add, mri may not be feasible as it is expensive and not readily available. other benign lesions discovered in our study were oncocytoma, benign leiomyoma, angiomyolipoma and pyelonephritis with or without nephrolithiasis. some studies have reported lipid-poor angiomyolipoma to be the most common benign tumour presumed to be rcc on ct scan, followed by oncocytoma.8,9,10,11,16 ethnicity may predict the type of benign tumours found at nephrectomy performed for presumed rcc, with most asian studies reporting angiomyolipoma as the most common benign tumour and studies from the us reporting oncocytoma.2,8,10,11,12 oncocytoma cannot be confidently distinguished from rcc on imaging.11,16 we expected that given the high burden of infectious diseases in south africa, we would see more inflammatory lesions such as xanthogranulomatous pyelonephritis, tuberculosis and aspergillosis being mistaken for rcc. our study focused on patients with an imaging diagnosis of rcc, implying that as these conditions were not found in our study, they are not being mistaken for rcc. it is well established that small renal tumours are more likely to be benign, with a 1.33 times increased risk of malignancy per centimetre increase in the size of a tumour.19 this is in line with our finding that the majority of benign lesions were less than 4 cm and that there was a significant association between larger tumours and rcc. until recently, pre-surgery biopsy of renal masses has not been widely practised because of concerns of tumour seeding and lack of therapeutic benefit. this mindset is changing, however, with recent evidence coming out in favour of pre-surgery biopsy of small renal masses to reduce overall morbidity and avoid over-treatment of benign lesions.20 we found, further, that smaller lesions were more likely to be treated by partial nephrectomy. this study was performed in a single centre and is limited by the small sample size, which impacted the assessment of the sensitivity and specificity of ct scan for staging of rcc. a multicentre study performed in a larger cohort may yield more accurate results. furthermore, false-negative results could not be assessed in our study because we only included patients with the pre-operative radiological diagnosis of rcc. conclusion computed tomography scan is the modality of choice for diagnosis and staging of rcc. in our population, ct is accurate at diagnosing rcc. false-positives occur in the cases of benign cystic lesions, benign solid tumours and inflammatory lesions. the high burden of infectious disease in south africa does not appear to increase the false-positive rate. computed tomography overestimates the size of renal lesions, which may result in down-staging at histopathology. non-enhancing or poorly homogeneously enhancing masses, cystic lesions, especially those with simple features, fat-containing lesions and lesions 4 cm or smaller are more likely to be benign. in these cases, ct, mri or ultrasound-guided biopsy should be considered to avoid unnecessary surgery. computed tomography assessment of extra-renal extension and vascular invasion is challenging and additional imaging modalities such as mri venogram, duplex doppler ultrasound or pet and/or ct may be beneficial. acknowledgements the authors would like to thank catherine connolly for her assistance with data analysis. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.e.m., primary investigator, performed literature review, prepared research proposal protocol for ethics board approval, gathered data for analysis and prepared the primary write-up of the research manuscript. n.n.m.d. supervised the research project and helped with data analysis and manuscript write-up. r.j.u. was the co-supervisor of the research project, assisted with data collection and analysis, and helped with manuscript write-up. references nazim sm, ather mh, hafeez k, salam b. accuracy of multidetector ct scans in staging of renal carcinoma. int j surg. 2011;9(1):86–90. https://doi.org/10.1016/j.ijsu.2010.07.304 chen w, wang l, yang q, liu b, sun y. comparison of radiographic and pathologic sizes of renal tumors. int braz j urol. 2013;39(2):189–194. https://doi.org/10.1590/s1677-5538.ibju.2013.02.06 liu y, song t, huang z, zhang s, li y. the accuracy of multidetector computed tomography for preoperative staging of renal cell carcinoma. int braz j urol. 2012;38(5):627–636. https://doi.org/10.1590/s1677-55382012000500007 sheth s, scatarige jc, horton km, corl fm, fishman ek. current concepts in the diagnosis and management of renal cell carcinoma: role of multidetector ct and three-dimensional ct. radiographics. 2001;21 spec no:s237–s254. https://doi.org/10.1148/radiographics.21.suppl_1.g01oc18s237 singh a, urry rj, hardcastle tc. five year review of open radical nephrectomies at a regional hospital in south africa: room for improvement. s afr j surg. 2018;56(1):35–39. edge s, byrd d, compton c, et al. ajcc cancer staging manual. 7th ed. new york: springer-verlag; 2010. bosniak ma. the current radiological approach to renal cysts. radiology. 1986;158:1–10. https://doi.org/10.1148/radiology.158.1.3510019 nakashima k, kitagawa y, izumi k, mizokami a, gabata t, namiki m. diagnostic accuracy of pre-operative imaging findings in presumed clinical t1a renal cell carcinomas. oncol lett. 2016;11(5):3189–3193. https://doi.org/10.3892/ol.2016.4330 kutikov a, fossett lk, ramchandani p, et al. incidence of benign pathologic findings at partial nephrectomy for solitary renal mass presumed to be renal cell carcinoma on preoperative imaging. urology. 2006;68(4):737–740. https://doi.org/10.1016/j.urology.2006.04.011 silver da, morash c, brenner p, campbell s, russo p. pathologic findings at the time of nephrectomy for renal mass. ann surg oncol. 1997;4(7):570–574. https://doi.org/10.1007/bf02305538 fujii y, komai y, saito k, et al. incidence of benign pathologic lesions at partial nephrectomy for presumed rcc renal masses: japanese dual-center experience with 176 consecutive patients. urology. 2008;72(3):598–602. https://doi.org/10.1016/j.urology.2008.04.054 alkaabnah a, alasmar a, alsaidah n, et al. radiological and pathological findings in partial nephrectomy for renal masses; experience at king hussein medical center. j roy med serv. 2015;22(2):41–44. https://doi.org/10.12816/0011365 ng cs, wood cg, silverman pm, tannir nm, tamboli p, sandler cm. renal cell carcinoma: diagnosis, staging, and surveillance. ajr am j roentgenol. 2008;191(4):1220–1232. https://doi.org/10.2214/ajr.07.3568 bradley aj, macdonald l, whiteside s, johnson rj, ramani va. accuracy of preoperative ct t staging of renal cell carcinoma: which features predict advanced stage? clin radiol. 2015;70(8):822–829. https://doi.org/10.1016/j.crad.2015.03.013 sokhi hk, mok wy, patel u. stage t3a renal cell carcinoma: staging accuracy of ct for sinus fat, perinephric fat or renal vein invasion. br j radiol. 2015;88(1045):20140504. https://doi.org/10.1259/bjr.20140504 woo s, cho jy. imaging findings of common benign renal tumors in the era of small renal masses: differential diagnosis from small renal cell carcinoma: current status and future perspectives. korean j radiol. 2015;16(1):99–113. https://doi.org/10.3348/kjr.2015.16.1.99 liu y, et al. the place of fdg pet/ct in renal cell carcinoma: value and limitations. front oncol. 2016;6(201). https://doi.org/10.3389/fonc.2016.002101 bosniak ma. the bosniak renal cyst classification: 25 years later. radiology. 2012;262(3):781–785. https://doi.org/10.1148/radiol.11111595 pierorazio pm, patel hd, johnson mh, et al. distinguishing malignant and benign renal masses with composite models and nomograms: a systematic review and meta-analysis of clinically localized renal masses suspicious for malignancy. cancer. 2016;122(21):3267–3276. https://doi.org/10.1002/cncr.30268 richard po, lavallée lt, pouliot f, et al. is routine use of renal tumor biopsy associated with lower rates of benign histology following nephrectomy for small renal masses? j urol. 2018;200:1–6. https://doi.org/10.1016/j.juro.2018.04.015 74 sa journal of radiology • december 2007 it seems our journal is moving on so well that there are other parties who would like to join us. i have had requests motivating to have a section of the journal dedicated to a specific discipline. the first of these is medical oncology, who have funding, a high-profile experienced scientific editorial team and who are extremely interested. other parties to consider within radiation science are nuclear medicine physicians, radiographers, radiation physicists and radiation biologists. the benefits would be a stronger, richer and more diverse journal with a wider readership. the longevity and interest in the journal would be extended and we would bring our colleagues closer to us. this is a natural grouping of specialties associated with radiation and imaging under the banner of radiology (as this is the name of the existing journal). this is a proposal which we must consider. added to this is the possibility of representing africa. movements are under way under the auspices of the isr (international society of radiology) to form an african society of radiology. we want to play a large leadership role here and offering our journal to represent the whole of africa is a vision that should be high on the agenda. i am in favour of change towards a stronger, wider group representing all of africa; within this i will endeavour to retain our identity and influence by striving for excellence and productivity in research. medline/pubmed (nlm) accreditation is the holy grail of a journal. i have applied on our behalf and i am awaiting a response. please contact me via email at docsav@mweb.co.za for comments good or bad, as i may have overlooked something in my overeager response. bigger, better, stronger, faster: should we join them or go it alone? savvas andronikou chief editor editorial pg74.indd 74 12/11/07 2:23:20 pm about the author(s) mauritz venter department of diagnostic radiology, university of the witwatersrand, south africa citation venter m. a radiation dose review for paediatric fluoroscopy in an academic south african referral hospital. s afr j rad. 2017;21(1), a1141. https://doi.org/10.4102/sajr.v21i1.1141 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract a radiation dose review for paediatric fluoroscopy in an academic south african referral hospital mauritz venter copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: it is important to reduce radiation exposure in children. there are no published south african paediatric fluoroscopic dosage references. aim: this study aims to determine the dose area product (dap) values in children undergoing common fluoroscopic examinations and comparing the values to international standards. commonly used examinations are contrasted swallows, contrasted enemas and vesico-urethrograms (vcus). the primary endpoint of this study will be the comparison of the median and third quartile dap values for the four specified age groups to the values of the national uk radiological protection board. method: we adhere to the radiological society of south africa (rssa)/south african society of paediatric imaging’s (saspi) guidelines. the third quartile and mean dap values were collected between march 2013 and march 2016 for each study performed, categorised into four age groups (0 year – 1 year, 2 years – 5 years, 6 years – 10 years and 11 years – 16 years) and stratified by our three major examinations. the data were compared to literature from the national uk radiological protection board. results: dap values for contrasted swallows were significantly lower in the three youngest age groups. there was no significant difference in the oldest age group. dap values for vcus were significantly lower in the youngest age group. there was no significant difference in the other three age groups. for our contrasted enemas, there were no data to compare with. conclusion: by following the saspi guidelines, our overall dap values compared better than the uk national patient dose database values in the younger age groups and no worse in the older age groups. about the author(s) sunette claassens diagnostic radiology, university of the witwatersrand, south africa claire mitchell general surgery, university of the witwatersrand, south africa tebogo hlabangana diagnostic radiology, university of the witwatersrand, chris hani baragwanath hospital, south africa citation claassens s, mitchell c, hlabangana t. quality assessment of thyroid ultrasound and implementation of a standard reporting template to be used in training hospitals. s afr j rad. 2017;21(1), a1125. https://doi.org/10.4102/sajr.v21i1.1125 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract quality assessment of thyroid ultrasound and implementation of a standard reporting template to be used in training hospitals sunette claassens, claire mitchell, tebogo hlabangana copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: ultrasound is the conventional and best imaging modality used to visualise the thyroid and thyroid-related diseases. an adequate ultrasound report can significantly influence clinicians in making management decisions in patients with such diseases. aim: the aim of this study was to critically assess the quality of thyroid ultrasound reports generated at charlotte maxeke johannesburg academic hospital (cmjah), a training hospital in johannesburg, south africa. methods: a retrospective cross-sectional study was performed. the quality of thyroid ultrasound reports was determined by using a tick sheet – a sheet having items that should be included in a thyroid ultrasound report. the contents of the tick sheet were guided by the current literature (including thyroid imaging reporting and data system [tirads] and thyroid, head and neck cancer foundation [thanc]). the tick sheet was designed by the principal investigator and supervisors. the quality of reports of training radiologists, sonographers as well as qualified radiologists were documented. comparisons of the quality of reports were made between the above groups of reporters. results: a retrospective analysis of thyroid ultrasound reports conducted at cmjah revealed that the reports are of poor quality and little value to the referring clinician. the quality of the reports was poor regardless of the training level or experience of the reporter. conclusion: because of the poor quality of the reports, a standard thyroid ultrasound reporting template has since been introduced at cmjah. about the author(s) sarah arthur department of paediatrics, severn deanery, united kingdom savvas andronikou bristol royal hospital for children, university of bristol, united kingdom citation arthur s, andronikou s. technical report: ‘flat earth lung’ a curved multiplanar reconstruction for demonstration and follow-up of scattered metastatic lung nodules in children. s afr j rad. 2017;21(1), a1153. https://doi.org/10.4102/sajr.v21i1.1153 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract technical report: ‘flat earth lung’ a curved multiplanar reconstruction for demonstration and follow-up of scattered metastatic lung nodules in children sarah arthur, savvas andronikou copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: lung metastases from paediatric wilms tumour and osteosarcoma are currently diagnosed and presented to multidisciplinary medical teams using cross-sectional computer tomography (ct) slices. clear demonstration of the extent, distribution and progression of lesions can direct medical and surgical interventions. for non-radiologists, viewing and appreciating the state of the multifocal metastatic disease in a plethora of on-screen images and from text reports can be very difficult. innovative thinking to condense multiple cross-sectional slices into visually comprehensible images is crucial to ensure important information is accurately communicated and further aid clinical decision-making. aim: to describe a novel ct curved reformatting technique to generate a standardised single image of the lungs that demonstrates pulmonary metastases. methods: we describe a simple reconstruction technique using the curved reformatting function on osirix freeware, to flatten out the peripheral lung parenchyma into a single image much like a map of the world represents the outer surface of the earth. we provide examples that demonstrate multifocal peripheral lesions and the normal anatomy simultaneously in one image. in addition, we demonstrate the use of minimum intensity projection (minip) views for higher accuracy, pitfalls and future applications. conclusion: generating curved multiplanar reconstructions of the lung can aid clinical decision-making and disease progression by accurately representing pulmonary metastases in children via a single image. this quick, easy and systematic technique, aptly named ‘flat earth lung’, negates the need to scroll through cross-sectional ct scans and can be utilised in multidisciplinary team meetings and multimedia reports. further uses extend to case note illustration for communication between colleagues. abstract introduction materials and methods statistical analysis ethical consideration results discussion conclusion acknowledgements references about the author(s) dar m. saleem department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india wani a. haseeb department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india arshed h. parry department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india robbani irfan department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india najar m. muzaffar department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india gojwari tariq department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india shah o. javed department of surgical gastroenterology, sher-i-kashmir institute of medical sciences, srinagar, india imza feroz department of radiodiagnosis, sher-i-kashmir institute of medical sciences, srinagar, india citation saleem dm, haseeb wa, parry ah, irfan r, muzaffar nm, tariq g, et al. preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: a prospective study. s afr j rad. 2019;23(1), a1727. https://doi.org/10.4102/sajr.v23i1.1727 original research preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: a prospective study dar m. saleem, wani a. haseeb, arshed h. parry, robbani irfan, najar m. muzaffar, gojwari tariq, shah o. javed, imza feroz received: 23 feb. 2019; accepted: 31 mar. 2019; published: 10 june 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: characterisation of pancreatic cystic lesions has a direct role in their management and computed tomography is the mainstay of investigation for diagnosing and characterising them. objectives: the aim of this study was to prospectively assess the diagnostic accuracy of contrast-enhanced computed tomography (cect) in preoperative characterisation of pancreatic cystic lesions with histopathology as the reference standard. method: a total of 38 patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were preoperatively evaluated with cect. images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images and overall diagnostic accuracy calculated. imaging findings were compared with histopathology, or cytology and/or intra-operative findings. results: serous cystadenoma (sca) was the most common cystic pancreatic lesion found in 31.6% of patients followed by mucinous cystadenoma (mca) (26.3%), solid pseudo-papillary tumour (spt) (21.1%) and intra-ductal papillary mucinous neoplasm (ipmn) (10.5%). three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. the diagnostic accuracy of cect for pancreatic cystic lesions was found to be 72.5% conclusion: the diagnostic accuracy of computed tomography (ct) was high for sca, ipmn and pancreatic cysts, and low for mca and spt. combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for sca. unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards mca. solid cystic pancreatic head lesions in young females may be suggestive of spt. a dilated main pancreatic duct in a cystic lesion with internal septations may point towards ipmn. fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. lastly, pseudocysts and neuroendocrine tumours with cystic components are great mimickers of pancreatic cystic lesions, and a history of pancreatitis and hormonal profile of patients should always be sought. keywords: serous cystadenoma; mucinous cystadenoma; solid pseudo-papillary tumour; intra-ductal papillary mucinous neoplasm; simple pancreatic cyst; pancreatic lymphangioma. introduction pancreatic lesions can be either solid, cystic or solid–cystic in nature, either of which can be benign, borderline or malignant. most cystic lesions of the pancreas are benign.1,2,3 characterisation becomes the sine qua non in distinguishing pancreatic cystic lesions as it has a direct bearing on their management, for example, to differentiate true cystic neoplasms from pancreatic pseudocysts. serous cystadenomas (scas), mucinous cystic neoplasms and intra-ductal papillary mucinous neoplasms constitute more than 90% of primary cystic pancreatic neoplasms.2 simple cysts and scas are benign and, if asymptomatic, can be safely followed. on the contrary, mucinous neoplasms are potentially malignant, justifying their surgical resection.1,2,3 cystic pancreatic lesions are usually found incidentally on imaging studies performed for other reasons, and as many as 35% of patients are totally asymptomatic at the time of diagnosis.1,2,3 similar to bosniak’s classification for renal cysts, a radiological classification based on imaging features of pancreatic cystic lesions has been suggested.4 pancreatic cystic lesions include unilocular cysts, micro-cystic lesions, macro-cystic lesions and mixed cystic lesions with a solid component. fine needle aspiration provides a tissue diagnosis, but is often non-diagnostic because of sampling error5 and various limitations.6 its sensitivity for diagnosis of cystic lesions is much lower than for solid lesions.7,8 imaging modalities such as ultrasonography (us), computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography and endoscopic us play a key role in characterisation, staging, surgical planning and assessment for treatment.9,10,11 the best approach to obtain an exact preoperative diagnosis is the combined evaluation of all available clinical, serological, radiological and biopsy findings. ultrasonography is not an ideal screening tool for the detection of pancreatic masses because of its relatively low sensitivity.12,13 the major limitation of endoscopic us is its inability to stage disease beyond the pancreas, thus it is generally used as an adjunct to or after multidetector computed tomography (mdct). magnetic resonance imaging is useful for iso-enhancing pancreatic masses that are not directly seen on ct.14 susceptibility of mri to significant image degradation by respiratory motion artefact is even more so in contrast studies, which is often critical for characterising pancreatic lesions, limits its diagnostic capability.15,16 in spite of advances in mri in abdominal imaging, ct is still the preferred imaging modality for both initial detection and characterisation of cystic pancreatic lesions, especially the macro-cystic ones.17 computed tomography is an excellent imaging modality for pancreatic cystic lesions because of its widespread availability and ability to detect cysts.18 this study was undertaken to evaluate the possible role of ct in the preoperative characterisation of pancreatic lesions, on the basis of various morphological characteristics, because preoperative fine needle aspiration cytology may lack the desired diagnostic accuracy, more so in cases of cystic lesions. materials and methods prior to imaging, the risks and benefits were discussed with each patient and informed consent taken. patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were included in this study. patients with inflammatory, parasitic or purely solid pancreatic lesions based on imaging, clinical and laboratory profiles and patients with deranged renal function tests, contrast allergy and pregnancy were excluded from the study. to characterise the pancreatic cystic lesions, a real-time ultrasound examination of the abdomen was done, followed by contrast-enhanced ct (cect). ultrasound was done using a 3.5 mhz curvilinear and 7.5 mhz linear array probe on an aloka prosound ssd-3500sx machine. all ct examinations were performed on a siemens somatom sensation 64. contrast-enhanced ct of the abdomen was performed on all patients. the anterior cubital vein of the patients was cannulated using an 18g intravenous cannula. a pressure injector was used to inject 120 ml–150 ml of contrast (omnipaque) as per body weight. after obtaining the topogram and non-contrast images of the abdomen, a portal venous phase ct was performed 40–60 s after the start of contrast injection. on a workstation, multi-planar coronal, sagittal and axial reconstructions were performed. analysis of ct images was performed on a picture archiving and communication system (pacs) workstation monitor by an experienced radiologist with more than 15 years of abdominal imaging experience. the radiologist was blinded to the histopathological and surgical findings, but not to the clinical history of the patients. images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images. imaging findings were compared with histopathology/cytology and/or intra-operative findings. the final diagnosis was confirmed by histopathology/cytology in all cases. statistical analysis the data were analysed using statistical software spss v20 and stata v11. categorical variables were described in terms of frequency and percentage and the continuous variables in terms of descriptive statistics like mean, standard deviation (sd), minimum, maximum and range. also, the sensitivity, specificity and accuracy were calculated. all the results were determined at the 5% significance level. ethical consideration this was a prospective observational study conducted between october 2015 and december 2018, with approval from the institutional ethical committee (iec) (no. sims 1 31/iec-skims/2015–75) and a final sample size of 38. results of the 38 patients diagnosed with cystic pancreatic lesions on imaging, 12 patients (31.6%) had sca, 10 patients (26.3%) had mucinous cystadenomas (mca), 8 (21.1%) had solid pseudo-papillary tumours (spt), 4 (10.5%) patients had intra-ductal papillary mucinous neoplasms (ipmn), 3 patients (7.9%) had simple cysts and 1 patient (2.6%) had a lymphangioma. the age group and mean age (in years) at the time of diagnosis and gender distribution of various pancreatic cystic lesions are shown in table 1. distribution with respect to anatomic location in the pancreas is shown in table 2. the mean size of a sca on ct was 3.5 cm and that of mca was 7.3 cm; mean size of spt was 5.3 cm. table 1: age, mean age (in years) and gender distribution of various pancreatic cystic lesions at the time of diagnosis. table 2: distribution of pancreatic cystic lesions as per the anatomic site. the enhancement pattern on cect was defined as either absent or enhancement of the wall, septae, both septae and wall and solid–cystic with enhancement of solid component, as shown in table 3. excluding spt that has a solid component, table 4 shows the loculation pattern and the size of the locules (in multilocular cystic lesions) in the truly cystic pancreatic lesions. intra-hepatic biliary radicles and common bile duct (cbd) were not dilated in any of the cystic lesions. main pancreatic duct (mpd) dilatation was seen in the four patients (100%) with ipmn and in two patients (20%) with mca; normal mpd seen in the rest of the cystic lesions. table 3: enhancement pattern on computed tomography of various pancreatic cystic lesions. table 4: loculation pattern and size of pancreatic cystic lesions. ten of the 12 cystic lesions diagnosed as sca on ct proved to be sca on histopathology examination (hpe) as well; one was diagnosed as a pseudocyst of pancreas and the other as mca on hpe. six of the 10 patients were correctly diagnosed as mca on ct; three were found to be pseudocysts and one was a sca on hpe or surgery. five of the eight patients were correctly diagnosed as spt on ct, while the other three proved to be neuroendocrine tumours with cystic components on hpe. all of the four cases of ipmn, three cases of simple cysts and one case of lymphangioma were correctly identified on ct. the diagnostic accuracy of cect for pancreatic cystic lesions was found to be 72.5%, with 57.16% and 83.89% as the lower and upper 95% confidence interval limits. discussion serous cystadenoma was the most common cystic pancreatic lesion found in 31.6% of patients in our study followed by mca (26.3%), spt (21.1%) and ipmn (10.5%). three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. serous cystadenoma was found predominantly in females in our study (male:female ratio of 1:5) with mean age of 44.5 years, similar to the studies of atalay et al.19 and parra-herran et al.20 serous cystadenomas were predominantly located in the head or uncinate process (66.7%) (figure 1) and the body of pancreas (33.3%). none were located in the pancreatic tail. megibow et al.21 reported that serous cystic neoplasm is most often found in the pancreatic head. atalay et al.19 reported 23 cases of scas of pancreas, all of which were present in the head and body of the pancreas. of the 12 scas, 2 (16.7%) were unilocular and 10 (83.3%) were multiloculated, consistent with the study of atalay et al.19 all the multiloculated scas had the size of the largest locule, less than 20 mm. johnson et al.22 reported that on ultrasound, scas usually have more than six loculi that are less than 2 cm in diameter. bhatt and vaishnav23 found that scas were approximately 5 cm–6 cm in size with small internal cysts < 2cm, with septations. however, curry et al.24 reported that the largest cyst in each tumour was smaller than 2 cm in only 14 (64%) out of the 22 patients. four (33.3%) scas had a lobulated outline that is characteristic of sca,18,25 while others had a regular outline. central scar, a characteristic of sca,18,25 was noted only in two (16.7%) of the scas (figure 1b). torresan et al.26 reported that although seen in less than 20% of scas, demonstration of a central scar by ct or mri is a highly diagnostic feature of a sca. calcification was seen in none of the 12 scas in our study. however, central calcification can be seen in scas within the fibrous stroma.25 curry24 reported central calcification in 10% of all cystic pancreatic lesions in their study (5/50), of which 80% were scas. the majority of scas in our study (10/12) showed septal enhancement (figure 1b) on cect, as also reported by balthazar et al.27 biliary radicles, cbd and mpd were not dilated in any scas in our study, which is consistent with the literature. rarely, giant lesions can cause compression of the mpd or bile ducts.28 histopathology examination revealed the two pancreatic cystic lesions presumptively diagnosed as scas on ct in our study to be pseudocyst of pancreas and mca. both these lesions were unilocular or oligocystic, and hence mca and pseudocysts are close differentials. figure 1: axial non-contrast-enhanced computed tomography image (a) in a 37-year-old female patient showing fluid density lobulated lesion in the head of pancreas. axial contrast-enhanced computed tomography image (b) in the same patient showing a multiloculated cystic mass in the head of pancreas with enhancing septations, a central stellate scar and no definite wall enhancement, suggestive of serous cystadenoma. high power magnification (40x) photomicrograph (c) of the same patient confirmed the diagnosis of micro-cystic serous cystadenoma. mucinous cystadenoma was the second most common pancreatic cystic lesion (26.3%) with a mean age of 47 years at the time of diagnosis and seen exclusively in females in our study. they were predominantly located in tail (80%) (figure 2) and pancreatic body (20%), with no lesions seen in head or uncinate process. mean size of mca (7.3 cm) was larger than sca and spt in our study. the findings are consistent with the majority of other studies19,20,29 the majority of mcas were unilocular (60%) with 40% appearing multilocular in our study. the size of the largest locule was >20 mm in multiloculated lesions. unilocular or macro-cystic pattern,30 with wall enhancement, is very helpful in diagnosing mca on ct. curry24 reported that the largest locule in each tumour was larger than 2 cm in 24 patients (86%) with mca. mucinous cystadenomas showed a smooth external contour (figure 2) in our study consistent with the world literature.31 calcifications were present in none of these lesions, although mcas may have a peripheral eggshell calcification.25 wall enhancement was seen in all cases of mcas in our study on cect (figure 2b), with only 40% cases showing variable enhancement of septations. cohen-scali et al.32 reported that the lack of wall enhancement was specific for macro-cystic sca in comparison with mca. biliary radicles, cbd and mpd were not dilated in any mca; however, warshaw et al.31 reported that very rarely they can cause ductal obstruction, but do not communicate with the mpd. three cases were misdiagnosed as mca on ct, which turned out to be pseudocysts. pseudocyst with wall enhancement is a close differential for mca on ct, especially if the past history of pancreatitis is not forthcoming. because of significant wall enhancement, one unilocular sca was wrongly labelled as mca on ct. figure 2: axial non-contrast-enhanced computed tomography image (a) in a 49-year-old female patient showing large fluid attenuation cystic lesion in the tail of pancreas with a smooth external contour. axial contrast-enhanced computed tomography image (b) in the same patient showing a non-enhancing cystic lesion in the tail of pancreas with subtle wall enhancement, suggestive of mucinous cystadenoma. low power magnification (scanner 4x) photomicrograph (c) of the same patient confirmed the diagnosis of mucinous cystadenoma. solid pseudo-papillary tumour constituted 21.1% of pancreatic lesions in our study with 75% of patients under the age of 30 years, with a mean age of 26.5 years and was seen exclusively in females. it was predominantly located in head of pancreas (75%) (figure 3) in our study, with only 25% cases in the tail region (figure 4). these findings were in resonance with other studies.33-37 all the cases of spt in our study had a solid cystic appearance on ct with an enhancing large solid component (figures 3b and 4b). none had a pure cystic appearance. casedei et al.35 reported four cases of solid pseudo-papillary neoplasms and all four were solid well-defined masses. alves et al.37 conducted a study on 10 pancreatic solid pseudo-papillary neoplasms, and found that on radiology the tumour was solid cystic or solid with almost equal frequency. this disparity of results in the spt appearance in our study could be accounted for because of exclusion of purely solid lesions. kehagias et al.38 reported that enhancing solid areas in spt are typically peripheral in location, whereas cystic spaces are usually more centrally located. calcification was an inconsistent finding with variable pattern seen in only 2 two (50%) lesions in a peripheral location. megibow et al.21 reported calcifications in 29% of spts. common bile duct, mpd and the biliary tree were normal in all spt cases consistent with the literature.39 no metastatic liver lesions were present in our study, although metastases can occur.40 three of these lesions presumptively diagnosed as spt on ct in our study turned out to be neuroendocrine tumours on hpe. we determined that non-functioning neuroendocrine tumours become large and undergo cystic change, thus closely resembling spts on cross-sectional imaging. choi et al41 reported that spts with a minimal cystic component or no intra-tumoural haemorrhage are difficult to differentiate from islet cell tumours. figure 3: axial non-contrast-enhanced computed tomography image (a) in a 26-year-old female patient showing a well-defined lesion in the pancreatic head or uncinate process with axial contrast-enhanced (b) and magnified post-contrast computed tomography image (c) showing an enhancing solid lesion with a non-enhancing component suggestive of solid pseudo-papillary tumour. histopathology examination confirmed the same. figure 4: axial non-contrast-enhanced computed tomography image (a) in a 31-year-old female patient showing a large lesion in relation to the tail of pancreas with a central hypodense area. axial contrast-enhanced computed tomography image (b) in the same patient showing enhancement of the solid component of the lesion with non-enhancing areas suggestive of a solid pseudo-papillary tumour. high power magnification (40x) photomicrograph (c) of the same patient showing hyaline globules, pseudo-papillae and nuclear grooves confirming the diagnosis of solid pseudo-papillary tumour. intra-ductal papillary mucinous neoplasm was seen in 10.5% of our patients with a mean age of 56 years at the time of diagnosis and exclusively with a male distribution, consistent with the international literature reflecting a predominance in middle to elderly men.42 an equal number of lesions were seen in the head and the body region (figure 5). paal et al.42 reported that 18 of 22 ipmns were present in the head. the mean size of the lesions at sonography was 2.65 cm, and at ct and pathology it was 2.5 cm, which is consistent with the literature.43 all the ipmns appeared as cysts with internal septa (figure 5). the main pancreatic duct was dilated in all the four cases (figure 5); however, communication of the cyst with the mpd was difficult to identify in three patients and was identified only in one patient with certainty. procacci44 found that at us and ct, branch duct tumours, which were mainly located at the uncinate process, were seen as fluid-filled masses with central septa and the pancreatic duct was dilated. paal et al.42 conducted a study on 22 pancreatic ipmns. radiologically, the cases presented with inhomogeneous solid or cystic masses. however, a dilated pancreatic duct was present in all cases. we found that cystic pancreatic lesions with enhancing septa and dilated mpd in an elderly male are helpful pointers towards ipmn. figure 5: axial contrast-enhanced computed tomography image in a 52-year-old male patient revealing a cystic lesion with septations in the body of pancreas with a dilated main pancreatic duct. a presumptive diagnosis of intra-ductal papillary mucinous neoplasm was made and histopathology examination confirmed the computed tomography diagnosis. simple pancreatic cysts constituted 7.9% of the pancreatic cystic lesions with fluid attenuation on ct, and no septations, solid component or calcifications were seen within them. the outline was smooth. no enhancement was seen on post-contrast ct (figure 6). the main pancreatic duct and biliary tree were not dilated. these features are consistent with the world literature.45,46 the least common cystic pancreatic lesion was pancreatic lymphangioma, with only one case seen in our study. the 55-year-old woman showed a multi-cystic peripancreatic lesion closely abutting the pancreas and insinuating in between the surrounding structures with no mass effect. few tiny calcific foci were also seen; however, no definite fat attenuation was noted. a presumptive diagnosis of pancreatic lymphangioma was made on ct and subsequently proved on hpe. figure 6: axial contrast-enhanced computed tomography image in a 25-year-old male patient showing a simple pancreatic cyst. no septation or wall enhancement seen. main pancreatic duct is not dilated. summarising, the overall diagnostic accuracy of cect in diagnosing pancreatic cystic lesions was 72.5% in our study. johnson et al.22 were able to definitively diagnose 93% of serous tumours (14/15 tumours), and procacci et al.47 reported that ct findings allowed correct characterisation of only 60% of cystic pancreatic masses. conclusion the diagnostic accuracy of ct was high in case of sca, ipmn and pancreatic cysts, and low in case of mca and spt. combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for sca. unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards mca. solid cystic pancreatic head lesions in young females may be suggestive of spt. dilated mpd in a cystic lesion with internal septations may point towards ipmn. fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. lastly, pseudocysts and neuroendocrine tumours with a cystic component are great mimickers of pancreatic cystic lesions, and history of pancreatitis and hormonal profile of patients should always be sought. acknowledgements competing interests the authors have declared that no competing interests exist. the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. author’s contributions all the authors were involved in data collection, case visits and inference of 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oligocystic adenoma from mucinous cystadenoma and intraductal papillary mucinous tumor. am j roentgenol. 2006;187(5):1192–1198. https://doi.org/10.2214/ajr.05.0337 torresan f, casadei r, solmi l, et al. the role of ultrasound in the differential diagnosis of serous and mucinous cystic tumours of the pancreas. eur j gastroenterol hepatol. 1997;9(2):169–172. balthazar ej, chako ac. computed tomography of pancreatic masses. am j gastroenterol. 1990;85(4):343–349. https://doi.org/10.1007/s00117-008-1755-1 schulz hu, kellner u, kahl s. a giant pancreatic serous microcystic adenoma with 20 years followup. langenbecks arch surg. 2007;392(2):209–213. https://doi.org/10.1007/s00423-006-0146-1 atef e, nakeeb ae, hanafy ee, et al. pancreatic cystic neoplasms: predictors of malignant behaviour and management. saudi j gastroenterol. 2013;19(1):45–53. https://doi.org/10.4103/1319-3767.105927 sahani d, prasad s, saini s, et al. cystic pancreatic neoplasms evaluation by ct and magnetic resonance cholangiopancreatography. gastrointest endosc clin n am. 2002;12(4):657–672. warshaw al, compton cc, lewandrowski k, et al. cystic tumors of the pancreas. new clinical, radiologic, and pathologic observations in 67 patients. ann surg. 1990;212(4):432–443. cohen-scali f, vilgrain v, brancatelli g, et al. discrimination of unilocular macrocystic serous cystadenoma from pancreatic pseudocyst and mucinous cystadenoma with ct: initial observations. radiology. 2003;228(3):727–733. https://doi.org/10.1148/radiol.2283020973 vassos n, agaimy a, klein p, et al. solid-pseudopapillary neoplasm (spn) of the pancreas: case series and literature review on an enigmatic entity. int j clin exp pathol. 2013;6(6):1051–1059. yoon dy, hines oj, bilchik aj, et al. solid and papillary epithelial neoplasms of the pancreas: aggressive resection for cure. am surg. 2001;67(12):1195–1199. casedei r, santini d, calculli l, et al. pancreatic solid-cystic papillary tumor: clinical features, imaging findings and operative management. j pancreas. 2006;7(1):137–144. adkisson d, harris as, bridges md, et al. solid pseudopapillary tumor of pancreas: report of five cases. int j hepatob pancreat dis. 2012;2:9–14. https://doi.org/10.5348/ijhpd-2012-5-cs-3 alves jr, amico ec. solid-pseudopapillary neoplasm of the pancreas: case series and literature review. j pancreas. 2015;16(3):218–226. kehagias d, smyrniotis v, gouliamos a, et al. cystic pancreatic neoplasms: computed tomography and magnetic resonance imaging findings. int j pancreatol. 2000;28(3):223–230. https://doi.org/10.1385/ijgc:28:3:223 ye j, ma m, cheng d, et al. solid-pseudopapillary tumor of the pancreas: clinical features, pathological characteristics, and origin. j surg oncol. 2012;106(6):728–735. https://doi.org/10.1002/jso.23195 coleman km, doherty mc, bigler sa. solid-pseudopapillary tumor of the pancreas. radiographics. 2003;23(6):1644–1648. https://doi.org/10.1148/rg.236035006 choi jy, kim mj, kim jh, et al. solid pseudopapillary tumor of the pancreas: typical and atypical manifestations. am j roentgenol. 2006;187:178–186. https://doi.org/10.2214/ajr.05.0569 paal e, thompson ldr, przygodzki rm, et al. clinicopathologic and immunohistochemical study of 22 intraductal papillary mucinous neoplasms of the pancreas, with a review of the literature. mod path. 1949;12(5):518–528. adsay nv, adair cf, heffess cs, et al. intraductal oncocytic papillary neoplasms of the pancreas. am j surg pathol. 1996;20(8):980–994. procacci c, graziani r, bicego e, et al. intraductal mucin-producing tumors of the pancreas: imaging findings. radiology. 1996;198(1):249–257. https://doi.org/10.1148/radiology.198.1.8539388 haaga jr, lanzieri cf, gilkeson rc. the pancreas. in: haaga jr, editor. computed tomography and magnetic resonance imaging of the whole body. 4th ed. philadelphia, pa: elsevier, 2003; p. 1395–1485. shirkhoda a, mittelstaedt ca. demonstration of pancreatic cysts in adult polycystic disease by computed tomography and ultrasound. am j roentgenol. 1978;131:1074–1106. https://doi.org/10.4103/2303-9027.163001 procacci c, biasiutti c, carbognin g, et al. characterization of cystic tumors of the pancreas: ct accuracy. j comput assist tomogr. 1999;23(6):906–912. sajr 20(1).indb reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of sa journal of radiology: we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for sa journal of radiology, we ask that you take a moment to update your electronic portfolio on http://www. sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajr.org.za 2. in your ‘user home’ [http://www.sajr.org. za/index.php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 sa journal of radiology aadil ahmed akhilanand chaurasia alex doruyter anne m. cahill anne marie du plessis aruna patil ayesha mitha bijan bijan chantal stewart chirag k. ahuja christelle ackermann christopher szabo cornelia (ria) minne dan zaharie domagoj javor finn srinivasan franck girard frank a. imarhiagbe gareth bydawell hein els imitiaz nagdee jackie smilg jan lotz jim spies juanita bezuidenhout khaled a. matrawy leon janse van rensburg mala modi mariam q. said-hartley matthew goodier mayuri govind miranda durand nasreen mahomed nathalie duchesne nausheen khan richard pitcher sally e. candy sandeep jakhere shalendra misser steve j. beningfield sulaiman moosa suresh k. chamarthi werner s. harmse zarina lockhat sajr 20(1)_greyscale.pdf blank_1.pdf ole_link1 ole_link2 _enref_1 _enref_2 _enref_3 _enref_4 _enref_5 _enref_6 _enref_7 _enref_8 _enref_9 _enref_10 _enref_11 _enref_12 _enref_13 _enref_14 _enref_15 _enref_16 _enref_17 ole_link1 ole_link1 ole_link2 ole_link3 tips for the radiologist academic writing in resultsradiology of a local ian c duncan ffrad(d) sa unitas interventional unit, centurion sunninghili hospital, sandton towards the end of last year a survey was conducted of contributions by local authors in the peer-reviewed literature. a big thanks goes to all of you who answered this call. there are undoubtedly a number of other authors in south africa who have not listed their publications here but this survey was never intended to present an exhaustive list of all known writings by south african radiologists. it was thought that the survey would not amount to much but we were somewhat surprised by the response we had. printed here is a list of contributions by those local authors who replied to the survey. we have limited the list to those publications in the local and international peer-reviewed journals during the last 5 years. mainly to preserve the sanity of the editor we have not included the many contributions to textbooks or articles printed in the sajr. we have also not included abstracts from international congress or poster presentations. but from this list one can take heart that south african radiologists are continuing to make their mark throughout the world. this survey was intended to be a 'one-off' but the sajr could survey continue to publish abstracts of future articles by local authors as a regular feature so that readers can remain aware of these ongoing contributions. your opinions on this could be addressed to the editor of the sajr or placed on the rssa website discussionforum. recent publications by south african radiologists erasmus jh, thompson ioc, van rensburg lj, van der westhuizen ai. central calcifying odontogenic cyst. a review of literature and the role of advanced imaging techniques. dento maxillo-facial radiology 1998; 27: 3035. langlais rp,van rensburg lj, guidry j, et al. magnetic resonance imaging in dentistry. applications of digital imaging modalities for dentistry. dent clin north am 2000; 44: 411-426. janse van rensburg l, thompson ioc, kruger hec, norval ejg. the hemangiomatous ameloblastoma: clinical, radiological and pathological features. oral surg oral med oral pathol oral radiol endod 2001; 91: 315-321. janse van rensburg l. imaging odontogenic cysts and tumours. oral and maxillofacial surgery clinics of north america 2001; 13: 657-696. hewitt pm, beningfield sj, bornman pc, krige jej, van wyk mec, 60 sa journal of radiology • june 2003 terblanche j. pancreatic carcinoma. diagnostic and prognostic implications of a normal pancreatogram. surg endosc 1988; 12: 867-869. sperryn cw, beningfield sj, immelman ej. functional entrapment of the popliteal artery. australas radio12000; 44(1):121-124. williams-jones s,beningfield s, brink j. mistaken angiographic diagnosis of traumatic aorto-atrial fistula. australas radio11998; 42: 264-266. beningfield s. boerhaave's syndrome ruptured oesophagus, with mediastinal abscess. s afr med j 1999; 89: 42-43. beningfield sj, bowie g, marshall m, et al. evaluation of a new type of direct digital radiography machine. s afr med j 1999; 89: 1182-1188. carr p, couper i, beningfield sj,mars sm. a simple telemedicine system using a digital camera. j telemed telecare2000; 6: 233-236. krige jej,beningfield sj,beckingham ij. technical factors in the construction and use of a biliary access loop. radiology 1998; 209: 883. krige jej,beckingham i, terblanche j, beningfield sj. ductal dilatation and stenting for residual hepatolithiasis. gut 1999; 44: 581-582. andronikou s, kader e. bronchial mucoepidermoid tumour in a child presenting with organomegaly due to secondary amyloidosis: case report and review of the literature. pediatr radio12001; 31: 348-350. millar ajw, hartley p, khan d, spearman w, andronikou s, rode h. extended hepatic resection with transplantation back-up for an 'unresectable' tumour. pediatr surg int 2001; 17: 378-381. tips for the radiologist andronikou s, fieggeru ag. klippelfeil syndrome with cervical diastematomyelia in an 8-year-old boy. pediatr radio12001; 31: 636. millar aj, rode h, andronikou s. an unusual complication of retrosternal colon interposition successfully managed by median sternotomy and revision retrosternal pull-through. paediatr surg int 2001; 17: 563-565. andronikou s, kader e, weiman cj. the ct features of abdominal tuberculosis in children. pediatr radiol 2002; 32: 75-81. andronikou s, dix-peeks s, meerkotter d. five cases of paediatric cervical spine distraction injury. radiology now2001; 18 (3):13-16. andronikou s, smith b. 'spina ventosa' tuberculous dactylitis. arch dis child 2002; 86: 206. andronikou s, sinclair-smith c, millar aj. an enteric duplication cyst if the pancreas causing abdominal pain and pancreatitis in a child. pediatr surg int 2002; 18(2): 190-192. nel l, hatherhill m, davies j, et al. organophosphate poisoning complicated by a tachyarrhythmia and acute respiratory distress syndrome in a child. j paediatric child health 2002; 38: 530-532. andronikou s, iadwat s, douis h. patterns of disease in 53 children with tuberculous spondylitis on mri and the role of gadolinium. pediatr radiol 2002; 32: 799-805. andronikou s, millar a]w; kader e, weiman cj. anatomic considerations in the imaging of 'reduced-size'liver transplantation in children. pediatr radio12002; 32: 793-797. andronikou s, weiman cj, kader e. classical and unusual appearances of hydatid disease in children. pediatr radio12002; 32: 817-828. andronikou s. pathological correlation of ct-detected mediastinallymphadenopathy in children: the lack of size threshold criteria for abnormality. pediatr radio12002; 32: 912. andronikou s, mchugh k, iadwat s, linward j. bilateral parotid hemangiomas in infancy: mri features and special considerations. eur radial (in press). mcculloch m, andronikou s, goddard e, et al. the angiographic features of 21 south african children with takayasu'saortitis. pediatr radiol (in press). harrison dc, richards jc, andronikou s, weiman c. bilateral retinoblastoma presenting with simultaneous phthisis bulbi and buphthalmos. j pediatr ophthalmol strabismus (in press). andronikou s, usher r, moon a. a unique cases of peritoneal metastatic disease in a child, after excision of a franz tumour (solid pseudopapillary tumour). pediatr radial (in press). andronikou s, fasulakis s, usher r. indications for ct and mri in paediatric tuberculosis and the features that give specificity. pediatr radial (in press). fieggen ag, millar a, rode h, ngiloi p, andronikou s, peter j. spinal cord involvement in pygopagus conjoined twins: case report and review of the literature. childs nerv syst 2003; 19: 183-187. andronikou s, joubert r, weiman c, kader e. computed tomography features of basal ganglia and periventricular calcification in childhood. s afr medj2001; 91: 659-660. andronikou s, cooke ml, donen a, et al. violence against children in the 61 sajournal of radiology. june2003 western cape a study by children for the benefit of children. s afr med j 2001;91: 1033-1035. andronikou s, bertelsman je. ctscanning: essential for conservative management of paediatric blunt abdominal trauma. s afr med j 2002; 92(1): 35-38. andronikou s, fink am. radiation risk in paediatric ct. s afr med j2002; 92: 516. clarke dl, thomson sr, madiba te, sanyika c. preoperative imaging of pancreatic cancer: a management-oriented approach. j am call surg 2003; 196(1):119-129. corr p,blyth d, sanyika c, royston d. efficacy and cost-effectiveness of bronchial arterial embolisation in the treatment of major haemoptysis. s afr medj2001; 91: 861-864. solway, sanyika c, hadley gp, corr p. colour doppler ultrasound assessment of the inferior vena cava in patients with wilms' tumour. clin radial 1999; 54: 811-814. sanyika c, corr p, royston d, blyth de pulmonary angiography and embolization for severe hemoptysis due to cavitary pulmonary tuberculosis. cardiovasc intervent radio11999; 22: 457-460. sanyika c, corr p, haffejee a. palliative treatment of oesophageal carcinoma efficacy of plastic versus self-expandable stents. s afr med j 1999;89:640-643. bhigjee ai, sanyika c. disseminated cysticercosis. j neural neurosurg psychiatry 1999; 66: 545. koen af, blumberg lh. north american blastomycosis in south africa simulating tuberculosis. clin radio11999; 54: 260-262. tips for the radiologist scher at. rugby injuries to the cervical spine and spinal cord: a lo-year review. clin sports med 1998; 17(1): 195-206. emby dj. keeping our reports unambiguous and user-friendly. am j roentgenol2002; 179: 1644-1645. emby dj, hunter m. the value of ultrasound in the hl'v-infected patient with a fever of undetermined origin. s afr med j 2002; 92: 566. emby dj. palliative treatment of malignant ascites. am j roentgenol 2002; 179: 532. emby dj. foot ischaemia due to tootightlaces. safr med]l997; 87: 1560. blaylock rsm, emby d, hopley m, toogood jw. the peritoneo-saphenous shunt for palliation of refractory ascites. safr j surg2001; 39: 83. de villiers r, kuyler j. superior sagittal thrombosis. 5 afr med j 2000; 90: 481. du toit df, stauss dc, blaszczyck m, de villiers r, warren bl. endovascular treatment of penetrating thoracic outlet arterial injuries. eur j vasc endovasc surg 2000; 19: 489-495. john kd, segal j, hassan h, levy rd , amin m. acute pancreatitis in sowetan africans. a disease with high mortality and morbidity. int j pancreatol1997; 21: 149-155. modi g, modi m, martinus j , rodda j, saffer d. spinocerebellar ataxia type 7 ( sca7 ) in three black south african families. acta neurol scand 2000; 101: 177-182. modi g, modi m. cryoglobulins and cold agglutinins in acute aortoarteritis (takayasu's disease) with associated tuberculous lymphadenitis. br j rheumatol2000; 39: 337-338. modi m, modi g. postpartum cerebral angiopathy in a patient with chronic migraine. headache 2000; 40: 677-681. modi g, modi m, martinus j, saffer d. new onset seizures associated with hn infection an analysis of 60 hospital based patients. neurology 2000; 55: 1558-1561. modi g, meehan a, modi m, saffer d. a demyelinating disorder of the central nervous system occurring in black south africans. j neurol neurosurg psychiatry 2001; 70: 500505. modi m, modi g. new onset seizures in hn infected patients a review and guide to management. s afr med j2001; 91: 1025-1026. modi g, modi m , martinus j,vangu m. new onset seizure in hn infected patients without intracranial mass lesions or meningitis a clinical, radiological and spect scan study. j neurol sci 2002; 15: 202-229. connor m, modi m, mochan a , modi g. neurological manifestations of hn infection in adults an overview. southern africa journal of hw medicine 2001; 6: 42-48. mochan a , modi m, modi g. stroke in south african black hn positive patients: a prospective analysis. stroke 2003; 34:10-15. benitha r, modi m, tikly m. osteolysis of the cervical spine and mandible in systemic sclerosis: a case report with ct and mr! findings. rheumatology2002; 41: 1-3. duncan ic. the 'aura' sign: an unusual cultural variant affecting mr imaging. amj roentgenol 2001; 177: 1487. duncan ic, fourie pa. embolization of a bullet in the internal carotid artery. am j roentgenol 2002; 179: 1572-1573. duncan ic, fourie pa. catheterdirected intra-arterial abciximab administration for the acute thrombotic occlusions during neurointerventional procedures. interventional neuroradiology 2002; 8: 159-168. duncan ic, sher bj, pencharz m. kinking of bilateral internal carotid arteries that mimics posttraumatic radiographic prevertebral soft-tissue widening. am j roentgenol2002; 179: 1352. fourie pa, duncan ic. microsnareassisted mechanical removal of intraprocedureal distal middle cerebral arterial thromboembolism. am j neuroradiol2003; 24: 630-632. duncan ic, fourie pa. a novel method of circumferential flow reduction during percutaneous embolotherapy of extracranial vascular malformations: the 'cookiecutter' technique. am j neuroradiol (in press). duncan ic, fourie pa. endovascular management of concomitant posttraumatic high vertebrovertebral and caroticojugular fistulas in a single patient using balloons, coils and a covered stent. j endovasc ther (in press). 62 sa journal of radiology • june 2003 abstract introduction cardiovascular magnetic resonance techniques left ventricular dysfunction myocarditis cardiomyopathy pericardial disease coronary artery disease peripheral vascular disease human immunodeficiency virus-associated pulmonary arterial hypertension myocardial steatosis cardiac tumours and tumour mimics conclusion acknowledgements references about the author(s) vishesh sood division of radiology, department of radiation medicine, university of cape town groote schuur hospital, cape town, south africa stephen jermy cape universities body imaging centre, university of cape town, south africa department of medicine, university of cape town, south africa hadil saad cape universities body imaging centre, university of cape town, south africa department of medicine, university of cape town, south africa petronella samuels cape universities body imaging centre, university of cape town, south africa department of medicine, university of cape town, south africa sulaiman moosa division of radiology, department of radiation medicine, university of cape town ntobeko ntusi cape universities body imaging centre, university of cape town, south africa department of medicine, university of cape town, south africa hatter institute of cardiovascular research in africa, department of medicine, university of cape town, south africa citation sood v, jermy s, saad h, samuels p, moosa s, ntusi n. review of cardiovascular magnetic resonance in human immunodeficiency virus-associated cardiovascular disease. s afr j rad. 2017;21(2), a1248. https://doi.org/10.4102/sajr.v21i2.1248 review article review of cardiovascular magnetic resonance in human immunodeficiency virus-associated cardiovascular disease vishesh sood, stephen jermy, hadil saad, petronella samuels, sulaiman moosa, ntobeko ntusi received: 28 june 2017; accepted: 28 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract despite ongoing advances in the treatment of patients with human immunodeficiency virus (hiv) or acquired immunodeficiency syndrome (aids), they remain a major global public health concern conferring an increased risk of morbidity and mortality in affected individuals. this is, in part, because of the widespread dysfunction imposed by hiv and its treatment on the cardiovascular system, including the myocardium, valvular apparatus, pericardium and coronary, pulmonary and peripheral vasculature. in recent times, cardiovascular magnetic resonance (cmr) imaging has emerged as the gold standard tool for assessment of a variety of indications, allowing comprehensive characterisation of functional, morphological, metabolic and haemodynamic sequelae of several cardiovascular pathologies. furthermore, continued advancement in imaging techniques has yielded novel insights into the underlying pathophysiology and guides future therapeutic strategies. in this article, we review the various clinical phenotypes of hiv-associated cardiovascular disease and highlight the utility of cmr in their assessment. introduction as of late 2015, there were approximately 36.7 million people worldwide living with human immunodeficiency virus (hiv) or acquired immunodeficiency syndrome (aids), with an estimated 2.1 million people becoming newly infected in that same year.1 despite the decreasing incidence of de novo infections seen over the past decade, hiv infection remains a major global public health concern, with most infected individuals living in lowto middle-income countries, particularly in sub-saharan africa.1 as a consequence of the introduction of combination antiretroviral therapy (art), the survival of people living with hiv infection has improved substantially.2 south africa has the largest number of people living with hiv infection and also the largest art roll-out programme globally.3 however, despite our improved understanding of the disease and early initiation of art, hiv infection is associated with significant complications, including cardiovascular disease (cvd). hiv-associated cvd results from a complex interplay of factors, including, but not limited to, chronic inflammatory processes resulting from hiv infection itself, opportunistic infections, concurrent metabolic changes resulting from the use of art and conventional risk factors for atherosclerotic cvd.4 consequently, hiv-associated cvd involves all segments of the cardiovascular tree, commonly affecting the left ventricular (lv) myocardium, valvular apparatus, pericardium and coronary, pulmonary and peripheral vasculature.4 various modalities of cardiovascular imaging are integral to the assessment of cvd, and many are ingrained into the modern practice of cardiovascular medicine. cardiovascular magnetic resonance (cmr) has emerged as the gold standard technique for many indications, allowing comprehensive characterisation of functional, morphological, metabolic and hemodynamic sequelae of various cardiovascular manifestations. in this article, we review phenotypes of hiv-associated cvd along a clinical continuum and highlight the utility of cmr in their assessment. cardiovascular magnetic resonance techniques several unique properties of cmr contribute to its widespread utility in the assessment of the cardiovascular system. the relatively high spatial and temporal resolution coupled with excellent tissue contrast enables comprehensive assessment of multiple parameters pertaining to cardiovascular morphology and function, without exposure to ionising radiation.5 furthermore, the ability to obtain images in any tomographic plane regardless of body habitus confers significant advantage in patients with limited sonographic acoustic windows.5 characterisation of myocardial tissue is a unique feature of cmr, traditionally achieved through late gadolinium-enhanced imaging and based on the relative difference in volume of distribution of intravenously administered contrast [and subsequent alteration of longitudinal relaxation (t1) times] between normal and abnormal myocardium.5 more recently, native (precontrast) t1 and t2 mapping techniques have allowed direct measurement of myocardial relaxation times on a pixel-wise basis, parameters which have been extensively validated offering similar diagnostic performance and superior sensitivity for inflammation, infiltration, acute injury and fibrosis as compared with delayed enhancement imaging in detecting myocardial pathology.5,6,7 t1 maps are most commonly acquired using modified look-locker inversion recovery (molli)-based or saturation recovery single-shot acquisition (sasha)-based sequences in the short-axis plane at the basal, mid and apical lv levels. the underlying principle involves the application of an inversion or saturation pulse followed by successive sampling of the relaxation curve as myocardial longitudinal magnetisation returns to its original level. the entire relaxation curve is then extrapolated from the acquired data and the native t1 values extracted. for ease of interpretation, these values are displayed as a colour map superimposed on anatomic images, allowing global and segmental quantification of t1 values using targeted regions-of-interest (rois). the further acquisition of t1 maps following contrast administration allows for the estimation of myocardial extracellular volume (ecv), a marker of myocardial tissue remodelling which has been shown to be a robust measure of the degree of myocardial fibrosis.7 in addition to the assessment of biventricular function using ejection fraction (ef), several cmr techniques have been developed to quantify myocardial deformation (i.e. strain) throughout the cardiac cycle. in essence, this is achieved using multiple magnetic labels (in the form of black lines or tags) which are superimposed on and embedded into the myocardium at the start of a cine sequence (see figure 1). the subsequent deformation of these tags is assessed throughout the cardiac cycle and allows for inferences to be made about myocardial strain in various (circumferential, radial and longitudinal) planes. figure 1: short-axis images through the mid-left ventricle with application of myocardial tagging at end-diastole (a). tag lines follow myocardial deformation (b) during the cardiac cycle and allow quantification of myocardial strain parameters in the circumferential, longitudinal and radial directions. left ventricular dysfunction left ventricular systolic and diastolic dysfunction are well documented in hiv-infected persons, with most data emerging from echocardiography-based studies.8,9 conventional indices available for the assessment of lv function include the ef, volumes, wall motion, thickness and mass.5 the measurement of systolic and diastolic strain and strain rate parameters provides more sensitive information about global and regional cardiac function and cardiac deformation properties, and changes in strain parameters often predate the development of overt lv systolic dysfunction.10 several studies using cmr have consistently demonstrated the presence of regional lv systolic and diastolic dysfunction in asymptomatic individuals.10,11,12 in the setting of preserved ef, impairment was detected on cmr as reduced circumferential,10 longitudinal11 and radial12 strain and strain rate measurements. a cross-sectional study of 698 hiv-infected persons showed that 48% had diastolic dysfunction, which was associated with the co-existence of conventional cardiovascular risk factors (including age, elevated body mass index, elevated total cholesterol and presence of hypertension and diabetes mellitus).13 another study of 129 hiv-infected patients showed a 47% higher median myocardial lipid content and 76% prevalence of myocardial fibrosis, using mr spectroscopic and parametric mapping techniques, respectively, raising suspicion that these morphologic abnormalities may underlie cardiac dysfunction in this subset of patients.11 myocarditis inflammatory changes within the myocardium have been extensively studied in the context of hiv infection and contribute significantly to the eventual decline in cardiovascular function and the development of cardiomyopathy in affected individuals.4,14 direct invasion of cardiomyocytes by hiv has been described, though this occurs in a haphazard fashion with no clear association between viral load and extent of myocardial involvement.15 worsening immunosuppression predisposes to cardiotropic viral infection (herpes simplex virus, cytomegalovirus, parvovirus and coxsackie b3 most commonly implicated) and infection by opportunistic pathogens including mycobacterium tuberculosis, toxoplasma gondii, cryptococcus neoformans and histoplasma capsulatum.4 it is worth noting, however, that no specific pathogen is identified in up to 80% of affected patients, and clinical presentation is heterogeneous with a large proportion of patients remaining asymptomatic despite ongoing subclinical myocardial oedema and inflammation.16 cardiovascular magnetic resonance is a powerful tool for diagnosing myocarditis because of its ability to accurately delineate areas of myocardial oedema, necrosis, infiltration and fibrosis. standard cine balanced steady-state free precession (bssfp) sequences may show regional wall motion abnormalities, areas of increased wall thickness associated with acute inflammation and the presence of co-existent pathologies, which includes characterisation of the extent, location and haemodynamic significance of any pericardial effusions. myocardial oedema appears as high signal on t2-weighted short tau inversion recovery sequences (stir) (see figure 2), and more recently, prolongation of native t1 and t2 values as detected through mapping techniques has been shown to be a sensitive imaging biomarker of active myocardial inflammation.6 the acquisition of post-contrast images yields further insight as regional vasodilation and acute myocardial necrosis result in altered gadolinium kinetics, with an increased uptake and rapid distribution of gadolinium chelates into the expanded interstitial space. the acquisition of t1-weighted images acquired approximately 2–5 min following contrast administration allows for the quantitative assessment of the myocardial early gadolinium enhancement ratio (eger), a ratio between myocardial and musculoskeletal enhancement, which highlights the variation in gadolinium distribution resulting from tissue damage (typically eger > 4.0 considered abnormal). late gadolinium-enhanced mr images use inversion recovery sequences to null normal myocardium, highlighting areas of retained contrast as high signal areas representative of focal myocardial fibrosis. findings classically include linear, patchy or nodular areas of enhancement in a non-coronary distribution (most commonly the basal inferolateral walls) with a mid-wall or sub-epicardial pattern17 (see figure 3). lastly, while more commonly a marker of diffuse myocardial fibrosis, the ecv fraction (calculated from native and post-contrast t1 maps) may also be elevated in myocarditis.18 figure 2: t2-weighted stir image at the level of the mid-left ventricle shows an elevated myocardial skeletal muscle signal intensity ratio (sir) of 2.5 (normal < 1.9) in keeping with diffuse myocardial oedema. figure 3: short-axis (a), 2-chamber (b) and 4-chamber (c) late gadolinium phase-sensitive inversion recovery images show linear mid-wall enhancement in the lateral wall of the lv (white arrows). luetkens et al. studied 28 hiv-infected patients, on haart with hiv rna < 200 copies/ml, using cmr and found elevated parameters indicating myocardial inflammation (native t1 time, relative t2 signal intensity ratios and eger) as compared with healthy controls.19 ntusi et al. looking at 103 hiv-infected individuals, without known cvd, found evidence of subclinical myocardial oedema and an increased incidence of pericardial effusions, providing additional evidence for chronic myocardial inflammation.20 cardiomyopathy acquired cardiomyopathy in the context of hiv infection represents the final common pathway of a complex and multifactorial process resulting in systolic and diastolic dysfunction and, most often, progression to a dilated cardiomyopathy (see figure 4). in ‘the heart of soweto study’ the prevalence of hiv-associated cardiomyopathy was reported as 38%, comprising both patients with clinical features of heart failure and those noted to have subclinical lv dysfunction on echocardiography.21 figure 4: four-chamber (a) and 2-chamber (b) ssfp images showing a markedly dilated left ventricle in a patient with known hiv-associated cardiomyopathy. although echocardiography remains the first-line imaging modality for the diagnosis of hiv-associated cardiomyopathy, cmr allows comprehensive, easily reproducible assessment of cardiac morphology and function, with added tissue characterisation techniques allowing the detection and quantification of underlying myocardial fibrosis through late gadolinium enhancement (lge) and parametric mapping techniques (see figure 5). this proves useful in both prognostication and longitudinal follow-up in this subset of patients as higher levels of myocardial fibrosis have been correlated with an increase in all-cause mortality. figure 5: t1 map at the level of the mid-lv (a) shows a markedly elevated myocardial t1 time of 1414 m/s (normal 1052 m/s ± 23 m/s at 3 t) (b) in keeping with diffuse myocardial fibrosis. pericardial disease the spectrum of pericardial disease associated with hiv is broad with isolated pericardial effusions reported as the commonest manifestation. although non-specific, their presence supports active inflammation and may add weight to the diagnosis of subclinical myocarditis or point to primary pericardial disease, with mycobacterium tuberculosis being the most likely pathogen implicated. historic studies demonstrated that tuberculous pericarditis accounted for over 80% of causes of pericardial effusion in hiv-infected individuals occurring in sub-saharan africa.22,23 the underlying pathophysiology implicates retrograde lymphatic spread from peribronchial and mediastinal lymph nodes or haematogenous dissemination from primary tuberculous infection. the manifestations of tuberculous involvement of the pericardium may include pericarditis, pericardial effusions with or without associated effusive-constrictive syndromes and progression to calcified pericardial constriction.24,25,26 cardiovascular magnetic resonance is useful in both characterisation of morphology and assessment of haemodynamic sequelae associated with tuberculous pericardial disease. cine ssfp images demonstrate the size and location of effusions, and although not specifically t2 weighted, they frequently allow visualisation of organised fibrin strands within the pericardial sac (see figure 6). furthermore, as progressive inflammation results in decreasing pericardial compliance and the development of constriction, right ventricular filling pressures rise with subsequent flattening of the interventricular septum producing a characteristic ‘d’ shaped lv or even transient septal inversion to the left side (diastolic septal bounce) in early diastole5,27 (see figure 7). figure 6: cmr ssfp images (a and b) show marked pericardial thickening (white arrows) and a large pericardial effusion containing organised fibrin strands (white asterisk). a large left-sided pleural effusion is also evident (black asterisk). figure 7: short-axis ssfp sequences at end-diastole (left) and end-systole (right) show systolic flattening of the interventricular septum (white arrow) indicative of right ventricular pressure overload. preand post-contrast t1-weighted anatomic images allow accurate measurement of pericardial thickness and may show high signal areas of enhancement in keeping with active inflammation or fibrosis (see figure 8). the detection of morphological abnormalities of the pericardium coupled with evidence of constrictive physiology is helpful in identifying patients who would benefit from surgical pericardiectomy and in guiding subsequent stripping procedures. figure 8: short-axis ssfp (a) and t1-weighted (b) images demonstrate the presence of a large pericardial effusion (white arrow) and marked thickening of the visceral and parietal pericardium. four-chamber (c) and short-axis (d) late gadolinium images show intense enhancement of the thickened visceral and parietal pericardium (white arrows) and the large hypointense pericardial effusion (white asterisk). coronary artery disease the association between hiv and accelerated coronary artery disease (cad) is well described and has been the focus of extensive study in recent years.28 despite overall decline in all-cause mortality related to the introduction of art, patients with hiv have an increased risk of acute myocardial infarction as compared with the general population.29 the reason for this is both complex and multifactorial, with hiv-mediated endothelin dysfunction and art-related dyslipidaemia (particularly associated with protease inhibitor use) playing a role.29 endothelial cells are thought to alter procoagulant, anticoagulant and fibrinolytic pathways in vivo, while underlying hiv-associated platelet dysfunction and background vasculitis likely contributes to the development of cad.30,31 furthermore, the chronic inflammatory state imposed by hiv infection is associated with an increased risk of spontaneous coronary artery dissection (see figure 9). in addition to traditional framingham risk factors, duration of hiv infection and lower cd4–cd8 ratios correlate with increased coronary arterial plaque burden.32 figure 9: four-chamber (a), short-axis (b) and 2-chamber (c) late gadolinium-enhanced images show a high signal transmural infarction of the lv apex (arrow heads) in an hiv-positive patient with spontaneous coronary artery dissection. the presence of a low signal intensity apical thrombus is also noted (white arrow). despite the known relationship between hiv infection and accelerated atherosclerosis, the anticipated pandemic of cvd related to cad has not materialised in sub-saharan africa. ‘the heart of soweto study’ showed that, of the de novo manifestations of heart disease within the hiv-positive subset of the cohort (518 of 5328 cases), cad was the primary diagnosis in only 14 patients (2.7%).21 in a cohort of 12 800 hiv-infected patients, zhang et al. concluded that increasing age was associated with non-aids defining illnesses, including cvd.33 the widespread accessibility to art may, in part, be responsible for the changing spectrum of diseases related to hiv, with an overall shift from aids-related illnesses to long-term age-related complications.28 coronary angiography has been the gold standard for the assessment of the coronary arteries for several decades, offering high spatial and temporal resolution of coronary flow. a significant limitation has been its inability to provide information about the affected vessel walls themselves, preventing further study of plaque characteristics and vascular remodelling associated with ongoing or subclinical disease. computed tomography is more recently recognised as a robust tool for the assessment of coronary anatomy and quantification of overall calcified and non-calcified plaque burden, but has limitations in its ability to offer further insights into the underlying properties of tissues being imaged. ongoing advancements in high field strength coronary mr have shown great promise in accurately gauging the degree of coronary stenosis, allowing coronary vessel wall imaging, measurement of coronary blood flow velocities and further characterisation of non-calcified plaques using delayed enhancement imaging techniques.32 in a study of 35 hiv-positive patients, a significant increase in right coronary artery vessel wall thickness was found as compared with healthy controls.34 another publication showed that the extent of local coronary epicardial adipose tissue was significantly related to coronary endothelial dysfunction as measured on coronary cmr.35 with the ongoing advances in the treatment for hiv and a steadily increasing life expectancy in infected individuals, accelerated cad is likely to play a more significant role in hiv-related cvd over time, and novel cmr techniques offer insights that may broaden our understanding of this condition and inform future treatment strategies. peripheral vascular disease human immunodeficiency virus-associated vasculopathy encompasses a wide spectrum of conditions including cerebrovascular disease, peripheral arterial thrombosis, arterial aneurysms and deep venous thrombosis. its epidemiology remains incompletely characterised, with several described histological subtypes and a multifactorial aetiology.36 cmr techniques used to study this entity include measurement of reduced aortic distensibility, as demonstrated by cine acquisitions through various aortic planes and increased pulse wave velocity as calculated from phase contrast velocity encoded sequences. both measures have been shown to be sensitive markers of reduced aortic elastic function, predictive of both future adverse cardiovascular events and mortality in several population-based studies. a study by rider et al. found that treated hiv infection in patients without concurrent metabolic syndrome was associated with an 11% increase in pulse wave velocity and 14% regional reduction in aortic distensibility as compared with healthy controls.37 this effect was similar in hiv-negative patients with metabolic syndrome and additive in the subset of patients with both illnesses occurring concurrently.37 the effects of chronic inflammation and art-associated lipodystrophy exert similar effects on the entire vascular system, with increased carotid artery intima-media thickness (c-imt) on b-mode ultrasound shown to be predictive of future stroke and myocardial infarction. c-imt, as measured by carotid cmr, has been shown to correlate well with sonographic measurements, with the added advantage of preserved resolution along the entire length of the examined arteries and ability to derive novel whole vessel parameters including plaque volume quantification, which may be useful as surrogate markers for longitudinal follow-up of cardiovascular risk in this subset of patients.38 human immunodeficiency virus-associated pulmonary arterial hypertension the estimated prevalence of pulmonary arterial hypertension (pah) in the hiv population is 0.5%, up to 2500-fold greater than that of the general population.39 the precise mechanism is uncertain, with both host and viral factors thought to contribute to the underlying pathogenesis. furthermore, an increased propensity for thromboembolic disease or recurrent pulmonary infections with resulting pulmonary fibrosis likely contributes to the development of pah and the high mortality associated with this condition. the imaging findings of hiv-associated pah are indistinguishable from those of primary pah, with morphologic abnormalities observed including, dilatation of the pulmonary trunk, main pulmonary arteries and eventually the right ventricle (rv) and right atrium. cine imaging is used for the quantification of rv indices (end systolic and diastolic volumes, ef and myocardial mass) and assessment of tricuspid regurgitation, following annular distortion related to rv dilatation.40 lge has been noted at the superior and inferior lv or rv hinge-points in patients with pah.40 the degree of enhancement has been shown to relate to rv volume and mass, raising suspicion that increased mechanical strain exacerbates structural deformation at the insertion points of the interventricular septum, resulting in architectural distortion and fibrosis of the myocardium in this region.41 myocardial steatosis 1h-mr spectroscopy (1h-mrs) is broadly accepted as a fast, accurate and reproducible means for the quantification of intra-cellular triglyceride content in the cytosol of non-adipose cells.42 most commonly, a single volume of interest (voxel) is positioned over the interventricular septum, and myocardial spectra (with and without water suppression) are acquired at end-systole in several cardiac planes using either point-resolved spectroscopy (press) or stimulated echo acquisition mode (steam) sequences. subsequent analysis allows the expression of several myocardial lipid constituents (including triglycerides, saturated and unsaturated fatty acids) as a percentage of the overall tissue water content. two recent studies using 1h-mrs have demonstrated increased myocardial lipid content in patients with hiv, adding weight to the hypothesis that morphologic alterations in myocardial tissue and possible lipotoxicity may underlie subclinical lv dysfunction.11,43 cardiac tumours and tumour mimics thrombi represent the most common cardiac mass, with stagnant blood flow in the setting of lv systolic dysfunction, myocardial infarction or aneurysms, and dilated cardiomyopathy coupled with a chronic inflammatory state predisposing to their formation. when large, these may be readily apparent on transthoracic echocardiography; however, suboptimal visualisation of the left atrial appendage and lv apex may compromise their detection with potentially disastrous clinical consequences. additionally, despite good sonographic visualisation of the lv apex, layered mural thrombi may be difficult to differentiate from underlying myocardium. in contrast, thrombi are readily detected on cmr, largely appearing as low intensity mass lesions that are incompatible with the normal myocardial contour or commonly noted intra-cardiac anatomical structures (e.g. crista terminalis, papillary muscles, moderator band and eustachian valve) on standard cine ssfp sequences. the acquisition of early post-gadolinium inversion recovery sequences, typically 1–2 min following intravenous contrast administration, facilitates detection as the avascular thrombi appear hypointense in contrast to the enhancing blood pool and perfused myocardium. there is a substantial increase in the risk of developing non-hodgkin’s lymphoma in hiv-infected patients, with secondary involvement of the heart found frequently at post-mortem, thought to result from lymphatic, haematogenous or direct extension. clinical presentation is often heterogeneous with patients remaining asymptomatic until the tumour produces significant mass effect or obstruction of cardiac chambers or great vessels,44 resulting in pulmonary or systemic embolisation45 or conduction abnormalities.46 most cases are of the diffuse large b-cell subtype, presenting as a solid, ill-defined mass typically centred in the right atrium with infiltration along the epicardium and tricuspid annulus, with associated encasement, rather than invasion, of the coronary arteries.47 the relatively low likelihood of concurrent intratumoural haemorrhage or necrosis results in a homogenously hypoor isointense mass on t1-weighted images, with variable lge (see figure 10). figure 10: four-chamber (a) and 3-chamber (b) ssfp sequences in a patient with known lymphoma show an isointense left atrial mass (arrows) arising from the inter-atrial septum. corresponding late gadolinium-enhanced images (c and d) show heterogeneous enhancement of the mass. cardiovascular magnetic resonance thus enables comprehensive characterisation of cardiac masses, with cine imaging allowing characterisation of the size, shape and location of these lesions while allowing review of potential complications, including mass effect on adjacent coronary arteries and infiltration of surrounding structures, that may explain co-existing conduction defects and haemodynamic sequelae related to valvular dysfunction. conclusion human immunodeficiency virus infection affects the entire cardiovascular axis through a complex interplay of multiple host, viral and treatment related factors. the availability of and access to art have had a significant impact on improving the survival in patients with hiv or aids, and it is likely that over time, adverse cardiovascular events are likely to play an increased role in contributing to causes of morbidity and mortality in this subset of patients. cmr offers an opportunity to comprehensively assess the cardiovascular system, allowing detection of subclinical disease or detailed characterisation of known pathologies and informing subsequent clinical practice with the hopes of improving outcomes in affected individuals. furthermore, the non-invasive and non-ionising nature of cmr make it a robust, flexible research tool well suited to longitudinal follow-up of patients and the development of novel imaging biomarkers that will serve to improve our understanding of disease processes, treatment effects and overall cardiovascular outcomes in hiv-infected individuals over time. acknowledgements this manuscript is not funded. prof. n. ntusi gratefully acknowledges support from the national research foundation and the medical research council of south africa, as well as the harry crossley foundation. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.s. was responsible for the initial draft of the publication, and selection and processing of figures. p.s. was responsible for acquisition of cmr cases. s.j., h.s., s.m. and n.n. were responsible for the critical review and final approval of the manuscript, and selection and processing of figures. references unaids fact sheet 2016 [homepage on the internet]. unaids [cited 2017 may]. available from: http://www.unaids.org hogg rs, heath kv, yip b, et al. improved survival among hiv-infected individuals following initiation of antiretroviral therapy. jama. 1998;279(6):450–454. https://doi.org/10.1001/jama.279.6.450 evans d. ten years on 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women. am j physiol heart circ physiol. 2016;310:h14–h19. https://doi.org/10.1152/ajpheart.00612.2015 nelson md, victor rg, szczepaniak ew, simha v, garg a, szczepaniak ls. cardiac steatosis and left ventricular hypertrophy in patients with generalized lipodystrophy as determined by magnetic resonance spectroscopy and imaging. am j cardiol. 2013;112(7):1019–1024. https://doi.org/10.1016/j.amjcard.2013.05.036 matsuo s, sato y, miyamoto a, et al. primary malignant lymphoma of the right atrium resulting in superior vena caval syndrome in an hiv-positive patient: depiction at multislice computed tomography and magnetic resonance imaging. cardiovasc revasc med. 2006;7(4):255–257. https://doi.org/10.1016/j.carrev.2006.03.108 skalidis ei, parthenakis fi, zacharis ea, datseris ge, vardas pe. pulmonary tumor embolism from primary cardiac b-cell lymphoma. chest. 1999;116(5):1489–1490. https://doi.org/10.1378/chest.116.5.1489 llitjos jf, redheuil a, puymirat e, vedrenne g, danchin n. aids-related primary cardiac lymphoma with right-sided heart failure and high-grade av block: insights from magnetic resonance imaging. ann cardiol angeiol (paris). 2014;63(2):99–101. https://doi.org/10.1016/j.ancard.2013.03.004 jeudy j, kirsch j, tavora f, et al. from the radiologic pathology archives: cardiac lymphoma: radiologic-pathologic correlation. radiographics. 2012;32(5):1369–1380. https://doi.org/10.1148/rg.325115126 opinion capitation of radiology practice in a managed care environment in the usa and south africa: johannesburg seminar 2-3 march 1996 i n the managed care environment entrenched or emerging, respectively, in the united states and south africa, the use of capitation payments to larger networks of radiology practices seems likely to accelerate with increases in teleradiology,horizontal and vertical integration of health services, and the demand for utilisation management and outcomes measurement. the common views of leaders in radiology in two nations as diverse as the united states and south africa are instructive. both can see that the major payers (the large hmo in the united states and either the new national government or the large medical schemes organisations now offering indemnity insurance in south africa) have a common problem: the total costs of radiology services are rising far faster than the payer's ability to meet these costs. it was noted in the january 1996 issue of the radiological society of south africa's new publication, update, that some us radiological groups have seen their incomes drop 50% in recent years, due to an estimated 28% oversupply of board-certified radiologists, and also to the creation of large networks or radiology practices. paul f gross director hea/th group strategies ply ltd (australia) 32 sa journal of radiology. may 1996 the net result is the consolidation of radiology practices to reduce costs, achieve economies of scale" and retain income for radiologists. if a radiology practice loses a contract because it bid too high a capitation rate to payers in a large geographical area or population, that practice could go under. one us radiology practice was approached by a large (over 70 000 members) managed care organisation (mco) to capitate diagnostic radiology and magnetic resonance imaging (mri). it got proactive, collected data on the use rates of radiology services, designed its own utilisation management software based on windows 3.1 (now used in over 40 us radiology practices) and negotiated five contracts in its region of california. it also subcontracted with another radiology practice, offering a discounted fee for service so it could cover a wider geographical area than was possible from its practice. in south africa and the united states, developments in teleradiology could accelerate the use of capita ted contracts between payers and larger radiology practice networks. faced with annual increases of over 20% in radiology costs, us employers such as the 23 000 employee harris corporation in florida contracted with one of the new us radiology entrepreneurs (medical technology transfer corp mit) which has linked to the university of california los angeles medical center. harris has a 7-year contract with mtt based on a flat capitation fee related to 1993 prices, effectively holding harris' radiology costs constant until 2002, saving harris about us$10 million over 7 years. four facets of this contract may be relevant to radiologists outside the usa. first, radiology costs become more predictable for the payer. second, ucla provides its expertise in remote areas in ct, mri, ultrasound or x-ray via electronic links, providing an opinion immediately for critical to page 33 radiology practice in a managed care environment cases or by express mail for less critical cases. third, while such telemedicine is experimental in many nations, the radiologist's opinion is attracting a teleradiology reimbursement. aetna and metlife, two large commercial insurance companies, are also customers ofmtt and they reimburse for such a service. so does the us medicare system, which has a 3-year project under way in four us states. fourth, teleradiology may enable radiologists to reduce the costs of any unnecessary surgery and inappropriate hospital admissions, particularly in remote areas which may lack specialist expertise in diagnostic imaging. one region of kaiser permanente now sends digital ct and mri images to the homes of the radiologists so they don't need to come to the hospital to given an expert opinion. another large hmo in new mexico allows primary care practitioners to send electrocardiograms and x-rays to specialists and then use video-confereneing for further consultations. in nations with large, inhabited rural areas lacking health facilities (such as the united states and south africa), developments in teleradiology will encourage the larger urban hospitals to employ fewer inhouse radiologists because a wide range of radiology sub-specialists will now be available on-line. professional fees will decline in hospitals and the quality of and access to radiological services will increase in previously deprived areas. hospital radiology services may again become revenue centres rather than high cost centres. in this environment, government and large payers are likely to push for capita ted contracts for radiology and also for pathology, cardiology and other procedural specialties. in such an environment, solo practitioners will be at a signifkant disadvantage if they have only one or two diagnostic imaging modalities, or their equipment is outdated, or they lack access to subspecialist radiologist expertise such as neuroradiology. at a 2-day training program on capitation contracting that our company implemented for 120 radiologistsin johannesburg from 2-3 march 1996, the message from the radiological society was clear: rationalise on a regional basis as managed care emerges in south africa, as funders introduce managed fee-for-service or capitation methods of payment. teleradiology system supports extensive multi-tasking t ecmed imaging (pty) limited recently launched their teleradiology system incorporating telema)(l'm software from cemax-icon. the cemax-icon™ product has been chosen by over 5000 users worldwide, as well as supporting over 1500 network users due to its superb image acquisition, transfer, display and image quality. this fda approved and dicom 3 compatible teleradiology system supports extensive multi-tasking by allowing acquisition and display; simultaneous with image transfer between two stations. performance is further enhanced by using state of the art macintosh power pc systems, supporting hi-resolution 1200 x 1600 portrait or 1600 x 1200 landscape displays in a single or dual monitor configuration. higher resolutions display systems are also available. the acquisition software supports film digitization via a high resolution 2000 x 2500 x 12 bit laser scanner, for all film sizes up to 14 x 17 inch (35 x 43cm). the laser film digitizer may be complemented by an interface supporting up to four video modalities like ct, mri, ultrasound, nuclear medicine as well as dsa units. image transmission via local or wide area networks is available. display software functionality includes optimising brightness and contrast settings, magnifying glass, roam, paging, multiframe display, video invert, reporting and many more, giving the radiologist extensive functionality to aid the diagnosis. 33 sa journal of radiology. may 1996 the fail-safe telecommunications software package provides automatic re-dial, if line is lost, user selectable compression ratios for either lossless or lossy image compression, as well as a telecommunications log file used as a permanent record of all transmission activities. send, receive and retrieve communications are available for receiving or retrieving images from other display stations. support for standard telephone lines, isdn or diginet connections, allows customised medical network solutions for all sites. the system also forms the basis for an extensive departmental network, allowing connection into computer radiography (cr) systems, as well as allowing upgrades for a complete pacs system. installed base equipment can be connected to a dicom 3 network via customised dicom 3 gateways. for further details, please contact teaned (pty)ltdon(oll)3154874. short report placement of tunnelled silicone haemodialysis catheters in a radiology • • •intervention unit j h bartlett mbchb e loggenberg mmedrad(d) c s de vries mmedrad(d) department of diagnostic radiology university of the free state bloemfontein as an alternative to surgical placement, tunnelled haernodialysis catheters can be placed in the sterile environment of an interventional unit. the same dress code and access to the unit is used as in a sterile operating theatre. this was a retrospective study conducted over a 3-year period. placement was done under real-time ultrasound guidance under sterile conditions. suitable venous puncture was done and the guide wire manipulated under fluoroscopy. if necessary, a venogram may be used to determine the patency of the vein (figs 1 4) as well as any anatomical variants or displacement by tumours or masses (fig. .5). the catheter is then tunnelled from a distant position on the anterior abdominal wall and placed in a central vein via a peel-away sheath and the catheters are always manipulated under fluoroscopy to determine the optimal position (figs 6 8). fig. 1. internal jugular vein. fig. 2. doppler flow in internal jugular vein. after placement in the superior vena cava, free back-flow of blood 29 sa journal of radiology • june 2002 fig. 3. determine patency of vein. fig. 4. needle in internal jugular vein under ultrasound guidance. fig. 5. venogram to determine patency of internal jugular and superior vena cava. should be present and a post placement venogram must always be done short report fig. 6. guidewire through di/ator and peel-away catheter. to prove the patency as well as the exact position of the line (fig. 9). eight children and 52 adults underwent the procedure. the puncture areas included the right jugular (n = 35), left jugular (n = 14), right subclavian (n = 2), left subclavian (n = i), left femoral (n = 4) and right femoral (n = 4). two patients received multiple punctures, 2 lines were used for 1 patient, and 6 venograms were done. no sepsis was reported after the follow-ups of 1 week and 1 month. as can be seen, the right internal jugular vein is the preferred site of puncture because of the easier placement of the guide wires and catheters from this position. placement of silicone catheters in an interventional unit is a good alternative to provide easily accessible ports for haemodialysis. there is a low complication rate, e.g. accidental fig. 7. tunnelled catheter with dilator and peelaway sheath in place. fig. 8. determine the length of the catheter. 30 sa journal of radiology • june 2002 fig. 9. haemodialysis catheter in correct position. puncture of the carotid artery or pneumothorax, because the whole procedure is done under direct fluoroscopyand ultrasound guidance. no sepsis within 1 month of the procedure was reported. case report jejuno-ileal diverticulitis and renal failure m s moodley fcs (sa) b singh fcs(sa), md department of surgery, university of nata/, durban fvawda ffrad(sa) j maharaj ffrad (sa) department of radi%gy, king edward vii/ hospital, durban introduction there is increasing awareness that jejune-ileal diverticulae are more than an interesting incidental finding on radiological contrast studies. a survey of the literature reveals numerous case reports and small series of this pathologic entity presenting in exotic guise. this report adds to these findings; there is no report in the english literature of jejuno-ileal diverticulitis manifesting with profound acute diarrhoea and consequent renal failure. case report a 69-year-old woman presented with a 2-week history of progressive, severe diarrhoea; she admitted to about eight watery, non-offensive episodes per day. a further complaint was of generalised dull abdominal pain, not coliey in nature. attempts at outpatient management by her general practitioner were not helpful, hence her presentation to king edward viii hospital, durban. her co-morbid risks included type 2 diabetes and hypertension, both of which were well controlled. on examination she was noted to be chronically ill-looking and clinically dehydrated. her general examination was normal, as were her vital signs and temperature. positive findings were confined to her abdominal assessment, with notable lower abdominal tenderness and watery brown stool on rectal examination. admission chest and plain abdominal radiographs were normal. serum urea and electrolytes were markedly deranged; the serum potassium was 7.1 mmolil (normal3.5 5.3 mmol!l), urea 55 mmol!l (normal 3.3 6.6 mmol!l) and creatinine 476 mmolil (normal 15 115 mmol/l). hyperuricaemia resulted in a marked metabolic acidosis with a serum bicarbonate level of 8.5 mmol/l (normal22 28 mmol!l). fluid resuscitation was commenced with normal saline while monitoring central venous pressure and urine output measurements. response to treatment was prompt and satisfactory and confirmed by improvement in her biochemical profiles as tabulated (table i). investigation of the diarrhoea was simultaneous with her fluid management. the microbiological assessment of the stool did not reveal any pus cells or parasites and culture was negative for pathogenic bacteria. a barium enema was requested in view of the patient's clinical profile, to exclude a non-benign colonic lesion. for technical reasons related to the diarrhoea, this was not possible. enteroelysis was undertaken as an imaging alternative; this revealed multiple jejuno-ileal diverticulae, with a predominance in thejejunum (fig. i). the patient was commenced on oral antibiotic therapy (oral neomycin and metronidazole) on day 4, with satisfactory clinical outcome. the diarrhoea decreased in frequency; and had abated by discharge on day 10. abdominal pain also diminished markedly in response to this therapy. a barium enema done subsequently was normal. at 3-month and 6table i.serum urea and electrolyte response to fluid and antibiotic therapy day na k cl rco) urea creatinine 0 127 7.1 98 8.5 55.0 476 129 4.5 109 13.8 32.4 126 3 129 3.0 103 17 17.0 130 5 l34 3.2 los 15.6 15.4 158 7 136 3.9 u2 16.7 13.7 87 8 128 3.6 106 14 14.7 113 10 134 3.7 113 14.3 4.8 89 subclassification na sodium; k potassium; cl chloride; heo, bicarbonnte, 37 sa journal of radiology • august 2003 case report fig. 1 a. barium study of the small bowel showing multiple diverticulae predominantly in the jejunum; arrows point to two of the larger ones. fig. 1 b. delayed film from small bowel study show· ing retention of contrast in multiple dlverticulae. month reviews following discharge the patient was noted to be well. discussion primary jejuno-ileal diverticulae are pulsion pseudo-diverticulae that arise on the mesenteric aspect of the bowel at the point of mesenteric vascular penetration of the muscularis propria. aetiologically, like their colonic counterparts, chronic raised intraluminal pressure is implicated on the basis of small bowel dyskinesia and dis-coordinate peristalsis.' some authors suggest that there may be an associated smooth muscle myopathy.' jejuno-ileal diverticulae are usually paired and enclosed within mesenteric fat, so masking their presence in the asymptomatic case at laparotomy for some other reason. true incidence is therefore difficult to assess, with reports ranging from 0.25% to 4.6% based on radiologic enteroelysis and postmortem pressure distension results." usually, small bowel diverticulae (sbd) are more common and larger in the proximal jejunum, and decrease in size and number as one progresses down the small bowel; they are found two times more often in males than in females, usually in the sixth and seventh decades of life. reports of concomitant colonic diverticulae vary from 20% to 75% of cases." most cases of jejuno-ileal diverticulae are asymptomatic. acutely, patients may present with diverticular abscess, massive haemorrhage, perforation (usually with localised peritonitis), functional or mechanical obstruction, or small bowel volvulus." severe diarrhoea, as in the patient discussed, is not a described form of acute manifestation. in those patients with less dramatic forms of the disease, symptoms include chronic low-grade gastrointestinal haemorrhage, self-limiting partial obstruction, vague chronic abdominal pain and malabsorption. steatorrhoea is the result of bile salt deconjugation in an environment of 38 sa journal of radiology • august 2003 altered bacterial flora. this overgrowth also results in bacterial consumption of vitamin b'2 with consequent megaloblastic anaemia." iejuno-ileal diverticulosis has been implicated in the occasional 'benign pneumoperitoneum' in patients without peritonitis; this is explained by the passage of air through the permeable mucosa of the thin-walled pouch.' diagnosing sbd depends largely on the awareness of the pathology by the attending surgeon and radiologist. from a surgical perspective, rarity results in diagnostic delay while more likely differentials are excluded appendicitis, acute cholecystitis, peptic ulcers and colonic diverticulitis. radiologically, they may be missed if present in small numbers or if large mouthed, resulting in rapid emptying of the contrast medium. in addition, small diverticulae may be missed if inadequate filling pressure is generat ed at the time of enteroclysis. management is supportive in the vast majority of cases, as with colonic diverticulitis. this entails bowel rest, broad-spectrum antibiotics to suppress the bacterial overgrowth, and analgesia. there are reports of prokinetic agent use with good effect in the management of cases of functional obstruction. usual indications for surgery are perforation and small bowel obstruction. local resection and anastomosis of the affected segment is entirely satisfactory. lesser procedures such as excision and simple closure are frowned upon as they are associated with a higher rate of breakdown and fistula formation.s the enigma that is sbd need not be so; a heightened awareness of its existence will result in earlier small bowel imaging, with the obvious benefits of an early diagnosis. our case case report reveals prompt response to a pathology that would have been difficult to manage had the diagnosis not been made as early as it was, albeit by default. references 1. kongara kr, soffer ee. intestinal motility in small bowel diverticulosis: a case report and review of the literature. j clin gastroenterol2000; 30: 84-86. 2. krisnamurthy s, kelly mm, rohrman ca. jejunal diverticulosis. gastroenterology 1983; 85: 538-547. 3. maglinte ddt, chern ish sm, deweese r, kelvin fm, brunelle rl. acquired jejunoileal diverticular disease: subject review. radiology 1986; 158: 577-580. 4. alvarez oa, mejia a, ostrower vs, lee m. jejunal diverticulitis manifesting with abdominal wa.ll abscess. am j gastroenterol1995; li: 2060-2062. 5. de bree e, grammatikakis j, christodoulakis m, tsiftsis d. the clinical significance of acquired jejunoileal diverticula. am j gastroenterol 1998; 93: 2523-2528. 6. rodriguez he, ziauddin mf, quiros ed, brown am, podbielski fj. jejunal diverticulosis and gastrointestinal bleeding. j clin gastroenterol 2001; 33: 412-414. 7. zager js, garbus je, shaw jp, cohen mg, garber sm. jejunal diverticulosis: a rare entity with multiple presentations, a series of cases. digestive surgery 2000; 17: 643-645. 8. schwesinger wh, sirinek kr, gaskijl h\1, velez jp' corea jj, strodel we. iejunoileal causes of overt gastrointestinal bleeding: diagnosis, management and outcome. am surg2001; 67: 383-387. 39 sa journal of radiology • august 2003 with corinth, you can see things from a different angle while working and living in the uk? are you interested? consult with corinth today. 35 years of global recruitment experience makes corinth healthcare the expert in medical recruitment. recruiting for the uk now work with us and we'll work for you corinth@icon.co.za www.corinthhealthcare.com more choice more money more benefits more opportunities more experience australia ..__.."" (0v0) . / connthy healthcare new zealand canada south africa united kingdom '24.* mailto:corinth@icon.co.za http://www.corinthhealthcare.com abstract introduction case report discussion conclusion acknowledgements references about the author(s) henrietta w.h. mcgrath department of radiology, chelsea and westminster hospital, united kingdom alexander fitzhugh department of radiology, chelsea and westminster hospital, united kingdom maria javed department of radiology, chelsea and westminster hospital, united kingdom neesha rockwood department of infectious diseases and hiv, chelsea and westminster hospital, united kingdom farhat kazmi department of radiology, chelsea and westminster hospital, united kingdom citation mcgrath hwh, fitzhugh a, javed m, rockwood n, kazmi f. unusual complication and successful high-dose chemotherapy treatment of advanced burkitt’s lymphoma in an adult hiv-positive patient. s afr j rad. 2017;21(2), a1230. https://doi.org/10.4102/sajr.v21i2.1230 case report unusual complication and successful high-dose chemotherapy treatment of advanced burkitt’s lymphoma in an adult hiv-positive patient henrietta w.h. mcgrath, alexander fitzhugh, maria javed, neesha rockwood, farhat kazmi received: 03 june 2017; accepted: 17 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract adult burkitt’s lymphoma emerged as an aids-defining condition in the 1980s. we describe a case of hiv-associated adult burkitt’s lymphoma diagnosed and treated with high-dose chemotherapy in our institution, complicated by unusual bilateral renal vein tumour thrombi and tumour lysis syndrome. we believe this unique case highlights the need for early recognition of current and potential complications on staging computed tomography imaging, as well as successful use of a high-dose chemotherapy regimen. introduction burkitt’s lymphoma is a highly proliferative b-cell neoplasia first described as a childhood illness endemic to malaria areas of africa. following the emergence of hiv in the 1980s, its significance as an aids-defining condition was soon recognised with a far more aggressive natural history, and its significance as an aids-defining condition was demonstrated. hiv-associated lymphomas remain a significant cause of morbidity and mortality, especially within sub-saharan africa, and familiarity with imaging findings is essential in suggesting the initial diagnosis, identifying complications and assessing response to treatment. we present a case of adult burkitt’s lymphoma with advanced disease. case report a 49-year-old man presented near cardiac-arrest with a 4-week history of weight loss, night sweats, back pain and difficulty walking. he was cachectic (42 kg), with massive hepatomegaly and a large sternal soft tissue mass (figure 1). blood tests demonstrated acute renal failure (creatinine 168 µmol/l, lactate 22 mmol/l, calcium 2.84 and phosphate 3.1 mmol/l). figure 1: (a) axial post-contrast ct imaging of the thorax on soft tissue windows demonstrates destruction of the sternum with surrounding soft tissue mass lesion (arrow); (b) post-contrast imaging 1 month later demonstrates a good response to treatment, with marked reduction in soft tissue volume and bony infiltration. a new hiv-1 diagnosis was made (cd4 lymphocyte count 3 cells/µl, viral load 912 376 copies/ml). epstein-barr viral titres were 21 620 500 copies/ml. computed tomography (ct) suggested burkitt’s lymphoma with disease affecting the lungs, heart (figure 2), sternum, liver, vertebrae and kidneys with bilateral renal vein tumour thrombi. biopsy of the sternal mass demonstrated diffuse lymphoid infiltrates of skeletal muscle in a starry sky pattern, in keeping with burkitt’s lymphoma. figure 2: (a) axial post-contrast thoracic ct imaging demonstrates pericardial tumour infiltration (arrow) with full resolution on (b) post-contrast imaging obtained 1 month later. the patient was commenced on antiretroviral therapy including descovy and dolutegravir, with a rituximab-codox-m/ivac chemotherapy regimen.1 his initial management was complicated by tumour lysis syndrome,2 pseudomonas bacteraemia and cytomegalovirus infection of the gastrointestinal tract, all successfully treated. subsequent ct imaging revealed an excellent treatment response, regression of extensive hepatic and renal infiltration and resolution of bilateral renal vein tumour thrombi, allowing anticoagulation to be discontinued. discussion first reported in 1958, burkitt’s lymphoma can be usefully subdivided into endemic, sporadic (without geographical limitation) and immunodeficiency-associated. predominantly a disease of childhood (representing 40% of paediatric non-hodgkin’s lymphomas3), burkitt’s lymphoma represents fewer than 5% of lymphoma affecting adults and carries a worse prognosis with advancing age (5-year survival between 50% and 65% without central nervous system [cns] involvement at presentation3). our patient presented at the age of 49 with ct-stage iv hiv-associated immunodeficient burkitt’s lymphoma, with a high lactate on admission, an additional poor prognostic marker (2-year survival of 63% vs. 86% of patients with a normal serum lactate level).3 while tissue diagnosis remains essential, ct staging (using both st jude/murphy’s and ann arbor scoring systems4) guides treatment. early recognition of extensive intra-abdominal involvement [renal and hepatic (figure 3)] helped the clinicians anticipate and promptly treat tumour lysis syndrome. most centres commence treatment within 24 h – 48 h, and ct should not delay pursuit of a tissue diagnosis or treatment. figure 3: (a) axial post-contrast abdominal ct demonstrates extensive liver tumour infiltration (arrows) with compression of the left portal vein. right renal tumour infiltration is illustrated (circle). (b) post-contrast imaging obtained after 1 month demonstrates marked improvement, with resolution of the left portal vein compression. bilateral renal vein tumour thrombosis is an uncommon complication, not typically seen in lymphoma, necessitating anticoagulation (figure 4).5,6 ct confirmed resolution, allowing a return to thromboprophylaxis alone. figure 4: (a) axial post-contrast abdominal ct demonstrates bilateral renal vein tumour thrombi (arrows) with extensive renal tumour infiltration, most marked on the right. the tumour thrombi have resolved on (b) post-contrast imaging obtained 1 month later, and there has been a marked reduction in renal tumour volume. disease confined to the abdomen is described in 50%,7 usually hepatosplenomegaly which may be observed on ultrasound. abdominal and pelvic ct is beneficial for further characterisation and better demonstrates potential involvement of the distal small bowel, caecum and appendix.8 involvement of the central nervous system heralds a poor prognosis (5-year survival drops to < 30%); our patient underwent ct and magnetic resonance imaging (mri) brain which did not demonstrate cns disease. bilateral cavernous sinus involvement has been described in an immunocompetent individual with confirmed burkett’s lymphoma,9 diagnosed using ct and multi-parametric mri; although the patient responded to first line cyclophosphamide-vincristine chemotherapy, cns disease recurred and the patient died after 11 months. involvement of the distal urinary tract, testicular involvement, pancreatic disease and jaw involvement has been described in adults. positron emission tomography–computed tomography (pet-ct) has been utilised to identify additional sites of disease, with a low false negative rate. however, a high false positive rate has been noticed within the immunosuppressed population attributed to concurrent opportunistic infections. conclusion we have described the imaging findings of burkitt’s lymphoma affecting an immunodeficient adult, emphasising the need for prompt diagnosis. ct delineated our patient’s disease, subsequently confirming an excellent response to high-dose chemotherapy, and identified current (renal vein tumour thrombus) and potential complications (tumour lysis syndrome). radiologists should employ alternative modalities (ultrasound and mri) to investigate extra-abdominal disease foci where clinically appropriate. acknowledgements competing interests the authors declare they have no personal or financial relationship which may have influenced them in writing this article. authors’ contributions h.w.h.m., a.f. and n.r. wrote the case report. m.j. assisted with radiological images and editing. f.k. supervised the case report. references alwan f, he a, montoto s, et al. adding rituximab to codox-m/ivac chemotherapy in the treatment of hiv-associated burkitt lymphoma is safe when used with concurrent combination antiretroviral therapy. aids. 2015;29(8):903–910. https://doi.org/10.1097/qad.0000000000000623 wilson fp, berns js. tumor lysis syndrome: new challenges and recent advances. adv chronic kidney dis. 2014;21(1):18–26. https://doi.org/10.1053/j.ackd.2013.07.001 divine ́m, casassus p, koscielny s, et al. burkitt lymphoma in adults: a prospective study of 72 patients treated with an adapted pediatric lmb protocol. ann oncol. 2005;16:1928–1935. https://doi.org/10.1093/annonc/mdi403 perkins as, friedberg jw. burkitt lymphoma in adults. am soc haematol. 2008; 341–348. https://doi.org/10.1182/asheducation-2008.1.341 wagner jr, honig sc, siroky mb. non-hodgkin’s lymphoma can mimic renal adenocarcinoma with inferior vena caval involvement. urology. 1993;42(6):720–723; discussion 723–724. https://doi.org/10.1016/0090-4295(93)90543-j samlowski ee, dechet c, weissman a, samlowski we. large cell non-hodgkin’s lymphoma masquerading as renal carcinoma with inferior vena cava thrombosis: a case report. https://doi.org/ molyneux em, rochford r, griffin b, et al. burkitt’s lymphoma. lancet. 2012;379:1234–1244. https://doi.org/10.1016/s0140-6736(11)61177-x satishchandra h, sridhar as, pooja bp. imaging of burkitt’s lymphoma-abdominal manifestations. j cancer res ther. 2013;9(1):128–130. https://doi.org/10.4103/0973-1482.110383 boukobza m, brouland j-p. burkitt’s lymphoma with bilateral cavernous sinus involvement: a case report. 2016;2016(2016), article id 253994. https://doi.org/10.5171/2016.253994 reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of sa journal of radiology: in an effort to facilitate the selection of appropriate peer reviewers for sa journal of radiology, we ask that you take a moment to update your electronic portfolio on http://www. sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajr.org.za 2. in your ‘user home’ [http://www.sajr.org. za/index.php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 aadil a. ahmed akhilanand chaurasia alex doruyter anil bhaya anith chacko aruna patil ashesh ranchod catherine mccarthy chirag k. ahuja chris trauernicht christelle ackermann christopher westgarth-taylor colin n. menezes cornelia (ria) minne elaine joseph farhana e. suleman farhat kazmi franck girard frank a. imarhiagbe gaurav sundar glenda jonathan graeme meintjes halvani moodley heleen hanekom imitiaz a. nagdee jacqueline s. smilg james nuttall john r. ouma kapila hari lee fairlie leon janse van rensburg leonie scholtz lynne williams mala modi mariam q. said-hartley mary hammes matthew d.m. goodier maya patel mayuri govind mike sathekge miranda durand moaaz omar nasreen mahomed nausheen khan nondumiso n. dlamini perry j. pickhardt philippe lefere pieter meyer pru ive ramy mansour razaan davis reza sirous richard d. pitcher sabatta tsotetsi sally e. candy sandeep jakhere scott heinlein shalendra k. misser stanley makgere stefan przybojewski steve j. beningfield suresh k. chamarthi susan lucas thomas g. walker thulani nyathi walter kucharczyk werner s. harmse willem a. groenewald zarina lockhat we appreciate the time taken to perform your review successfully. acknowledgement to reviewers http://www.sajr.org.za http://www.sajr.org.za http://www.sajr.org.za http://www.sajr.org.za http://www.sajr.org.za http://www.sajr.org.za/index.php/sajr/user http://www.sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za � sa journal of radiology • june 2006 a few ideas on training in radiology c de vries, mmed (rad d) department of radiology, university of the free state there has been a lot of discussion around the problems facing radiology registrars in south africa. some of these problems include the lack of consultant coverage in the academic setting, old equipment in training hospitals and not enough time spent on official teaching and tutoring as a result of the heavy work load faced by the radiology departments in the public sector. this prompts the questions – is our radiology training on a par with the rest of the world and does the training reflect these problems faced by academic radiology departments and the registrars they train? the answer is a very definite ‘no’. by working around our problems we train world-class radiologists. new equipment has made an impact and registrars in radiology now have access to mri on a daily basis, whereas before the installation of the equipment, registrars were only occasionally exposed to mri from the private sector. new solutions the theoretical part of the registrar training could be addressed by a modular 4-year curriculum. this modular curriculum would be based on a sound knowledge of radiological anatomy, radiation physics, mri physics and applied physiology which would then be assessed by the college of radiology, or the university, during the primary exam. this 4-year approach divides the essential knowledge into modules, spread over a 5-year period in such a way that it can be entered into at any stage. at the end of 4 years the registrar will have been exposed to all the essential theory of radiology, irrespective of where or when he/she entered into the programme. uniformity and co-operation the idea is to get all the training institutions on board and have a unified theoretical curriculum. training and lectures can then be shared by all the participating universities. this can quite easily be achieved by making use of teleconferencing to facilitate a combined meeting, during which presented lectures can be interactively viewed and heard by the participating universities. this has recently been put into practice and a very successful teleconference meeting was held involving the universities of bloemfontein, pretoria and stellenbosch (see 'specialty corner' in this issue for current events). glass half-full the problem regarding the high case loads can actually be viewed as an advantage to the training registrar. to become a radiologist you have to do radiology and the more you do, the more experience you will gain and the better you will become at your chosen specialty. the test: the ‘real world’ my question to south african-trained radiologists working in the uk, australia and elsewhere in the world is this — was your training really that bad? coert de vries guest editor � sa journal of radiology • june 2006 editorial pg2.indd 2 7/11/06 12:44:39 pm sajr 1021 body imaging s k misser,1 mb chb, fcrad (d) sa; d b steer,2 fcs (sa), frcs (c); s purcell,3 fcpath (sa) 1 lake smit and partners, durban, south africa 2 alberlito hospital, ballito kwazulu-natal, south africa 3 hainsworth, purcell and associates, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) a 38-year-old woman presented with a painful left paramedian infra-umbilical abdominal wall mass. she was a keen athlete and otherwise well. the following ultrasound images and mri sequences (after gadolinium administration) were obtained. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 15 january 2014. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. s afr j rad 2013;17(4):156-157. doi:10.7196/sajr.1021 fig. 1. sagittal b-mode sonar image. fig. 2. sagittal colour duplex sonar image. fig. 3. axial post-gd t1-weighted image through lesion. fig. 4. coronal post-gd t1-weighted image. about the author(s) sucari s.c. vlok department of radiodiagnosis, tygerberg hospital, university of stellenbosch, south africa sam w. moore department of paediatric surgery, tygerberg hospital, university of stellenbosch south africa pawel t. schubert department anatomical pathology, university of stellenbosch, tygerberg hospital south africa richard d. pitcher department of radiodiagnosis, tygerberg hospital, university of stellenbosch, south africa citation vlok ssc, moore sw, schubert pt, pitcher rd. the sensitivity and specificity of radiological features of hirschsprung’s disease in a cohort of south african children. s afr j rad. 2017;21(1), a1165. https://doi.org/10.4102/sajr.v21i1.1165 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract the sensitivity and specificity of radiological features of hirschsprung’s disease in a cohort of south african children sucari s.c. vlok, sam w. moore, pawel t. schubert, richard d. pitcher copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: hirschsprung’s disease (hd) is classically defined as the absence of ganglion cells of the myenteric plexus of the bowel. patients typically present with delayed passage of meconium and specific features on plain radiograph and contrasted enema supporting the diagnosis. rectal biopsy remains the gold standard. hypothesis: the radiological features of hd in south african children are distinct from those described in other parts of the world and may be influenced by a number of factors, including delayed diagnosis in a resource-limited setting, higher proportion of cases with total colonic aganglionosis and higher prevalence of allied disorders. aims and objectives: to assess the diagnostic accuracy of the radiological features of hd in a cohort of south african (sa) children and to compare and contrast these findings with published international works in order to facilitate the early diagnosis of hd disease in our setting. methods: a retrospective audit of the radiological features on abdominal radiograph and contrasted enema of all the patients who received suction rectal biopsies after presenting with clinical features of hd at tygerberg children’s hospital, cape town, south africa, from january 2007 through march 2015 was performed, with prospective component leading up to may 2016. conclusion: pathology results have been revealed, and the sensitivity and specificity of the radiological findings was calculated, compared with those in the literature and presented at the saspi paediatric imaging congress in november 2016. case report pelvic abscess formation in perforated carcinoma of the jejunum abstract a 76 year old chinese woman presented with a pelvic abscess, secondary to perlorated carcinoma of the jejunum. plain abdominal radiograph showed a mottled lesion which corresponded to the site of the perlorated tumour seen on ct and confirmed during laparotomy. the clinical and imaging features of carcinoma of the jejunum are briefly reviewed. wilfred cg peh dmrd, frcr, fams associate professor "judywc ho mbss, frcs senior medical officer departments of diagnostic radiology and 'surgery, the university of hong kong, queen mary hospital, hong kong introduction carcinoma of the jejunum is a rarely encountered lesion which usually manifests clinically with non-specific signs and symptorns.abscess formation from its perforation as a presenting feature has, to our knowledge, not been described previously. we report the clinical and radiological findings in such a case. this article. is a reprint ol a case report from the diagnostic clinics senes of the singapore medical journal. case report a 76 year old chinese woman first presented to our hospital with a one day history of abdominal pain, most severe over the left lower quadrant. there was no significant past history except for a rather vague history of constipation for one year. examination revealed an obese and febrile woman. vital signs were stable. there was generalised abdominal tenderness, mostsevere over the left lower quadrant, but no 21 sa journal of radiologynovember 1996 palpable mass. rectal examination was negative. her temperature spiked soon after admission. the white cell count was raised at 20.2 g/dl with predominant neutrophilia (18.5 g/dl). liver and renal function tests were normal, as were serum amylase levels. she was started on intravenous antibiotics with a presumptive diagnosis of diverticulitis. plain abdominal radiograph on admission (figure 1) showed a large rounded figure 1: plain radiograph shows a rounded mottled area (arrows) in the left abdomen. mottled area in the left upper quadrant, with no evidence ofbowel obstruction. ct done three days later confirmed the presence of a large mass of soft tissue density at this site (figure 2a). this mass contained oral contrast indicating communication with the bowel lumen. air and debris-like material within the mass correlated with topage22 pelvic abscess in jejunal carcinoma ultrasound also confinned the presence of a large pelvic fluid collection. at laparotomy, a polypoidal tumour, measuring 8 cm in diameter; was present in the proximal jejunum. its base was perforated and sealed with omentum. loculated abscesses were present at the left iliacfossaand the pelvis,each containing about 50 ml of pus. there was extensive lymphadenopathy along the course of the superior mesenteric artery small bowel resection with end-to-end anastomosis and abscess drainage was done. on histopathologicalexamination, the tumour had infiltrated through the full thickness of the bowel wall into the surrounding subserosal adipose tissue. the lesion was extensively ulcerated, and the serosa showed changes of peritonitis. the diagnosis was undifferentiated carcinoma of the figure 3: contrast instilled via a ry/e's tube shows extrinsic compression and obstruction of the duodena/loop. figure 2(a): ct of upper abdomen shows a large soft tissue mass with irregular borders (arrowheads). it contains barium, debris and air (arrows). the mottled appearance on plain radiographs. the outer margins of this mass were irregular with ill-definition of the adjacent intra-, peritoneal fat and muscle layers of the left abdominal flank (figure 2b). this was continuous with a large fluid collection in the left lower abdomen and pelvis (figure 2c). figure 4: ct of the upper abdomen shows massive lymph nodes (arrows) compressing the distal duodenum (arrowheads). discussion primary tumours of the small bowel constitute a mere 1-2% of allgastrointestinal malignancies. carcinoma of the jejunum is rarer still, comprising 0.22% ofli 438 cases of gastrointestinal tumours in one series', the rarity of jejunal carcinoma issupported in other large studies of small bowel tumours+" signs and symptoms of small bowel malignancy are vague and non-specific, often being present for months or years before the diagnosis is made. 1,5,7,8 the more frequent presentations of this tumour are pain, anorexia, weight loss,bleeding or small bowel obstruction.v" perforation is a rare presenting feature of adenocarcinoma of the jejunum, occurring in only one patient in a series obi cases'there were no instances of perforation in two other large series, jenunum. her postoperative recoverywas complicated initially by wound infection. she then developed bilestained vomiting about four weeks later. water soluble contrast meal showed complete obstruction at the third part of the duodenum (figure 3), which was shown to be due to massive lymphadenopathy on ct (figure 4).the rapid progression of lymphadenopathy subsequently produced bilateral ureteric obstruction. she finally died seven weeks afterthe operation. figure 2(c): ct at level of the pelvic brim shows large fluid col/ections (arrows). to page 23 22 sajournal of radiologynovember 1996 pelvic abscess in jejunal carcinoma from page 22 comprising 16 and 32 patients, respeetively.3,4it was interesting to note that in a pathological study of iocases of jejunal adenocarcinoma, all i 0 cases showed transgression through the bowel wall, with direct extension of tumour into the mesenteryin 4 cases? it is thereforesurprising that perforation and its sequelae are not manifested more frequently, as in our patient where perforation was followed by infection and abscess formation. the plain abdominal radiograph is usually unhelpful for the diagnosis of jejunal carcinoma unless a complication such as obstruction or perforation had occurred. the unusual plain film appearance of a large mottled area was probably produced by debris and air within an abscess cavity adjacent to the site of perforation. this feature was not recognised at the time the radiograph was taken as it was thought to be due to faecal material. in retrospect however, this was unlikely as its shape was too circular and no other adjacent faecal-filled bowel loops were evident radiologically. the large soft tissue mass seen on cr was produced by a combination of the tumour mass, abscess cavity and surrounding adherent omentum. the cr appearance of jejunal carcinoma has previously been recognised as a polypoidal or annular mass causing luminal narrowing. 10, ii although extra-luminal growth andinfiltration of the surrounding fat have been described in tumours, the irregularity of the mass outline and streaky ill-definition of the adjacent fat in our case was due to an infective process.the path of spread of infection was clearly demonstrated on ct by fuzziness of both the inner and outer walls of the left abdominal wallmuscuiature, leading to fluid couections in the left iliac fossa and pelvis.these findings oflocalised peritonitis and pus were subsequently confirmed at surgery. initial cr failed to detect mesenteric lymph node invasion in our patient, reflecting the experience of other investigators. i i moreover, lymph node enlargement in jejunal carcinoma is unusually not as bulky asthat characteristicallyseen in lymphoma." a remarkable feature of our case was the rapid onset and progression of massive lymphadenopathy; which eventually lead to her unexpectedly quick demise. we are unable to explain the aggressive behaviour of this tumour. ct in combination with small bowel enema has been advocated for the detection and preoperative staging of thistumour'!" small bowel enema is more sensitive than conventional small bowel follow-through examination in detecting jejunal carcinomas, manifest as polypoidal intra-luminal masses, annular strictures or ulcerated masses. indirect evidence of tumour includes dilated bowel loops and fistulas," in our case, cr also illustrated the unusual presentation of pelvic abscess formation in jejunal carcinoma. 23 sajournal of radiology. november 1996 references 1. martin rg. malignant tumours of the small intestine. surgical clinics ofn071hamerica 1986;66:779-85. 2. ebert pa, zuidema gd. primary tumours of the small intestinc.an:hivesofsutgery 1965;91 :452-5. 3. wilson jm, melvin db, gray gf, thorbjamarson b. primary malignancies of the small bowel: a report of 96 cases and review of the literature. annals of surgery 1974;100:175-9. 4. bridge mf, perzin kh. primary adenocarcinoma of the jejunum and ileum. a clinicopathologic study,. ctmmr 1975;36:187&s7. 5. sager gf. primary malignant tumours of the small intestine. a twenty-two year experience with thirty patients. americanjournal ofsutgery 1978; 135:601-3. 6. freund h, lavi a, pfelfennann r, durstal. primary neoplasms of the small bowel. american joumal of sur· g:ry 1978;135:757-9. 7. gupta s, gupta s. primary tumours of the small bowel: a clinicopathological study of 58 cases. journal of surgical onm/ogy 1982;20: 161-7. 8. barclaythc, schaptra dv. malignant tumors of the small intestine. cancer 1985;51 :878-8 1. 9. williamson rcn, welch ce, malt ra. adenocarcinoma and lymphoma of the small intestine. distribution and etiologic associations. annals of sur· g:ry 1983;197:172-8. 10. dudiak km, johnson cd, stephens dh. primary tumors of the small intestine: cr evaluation. ameli· canjoumalofroentgeno/ogy 1989;152:995-8. 11. laurent f, raynaud m, bisetjm, beisserie-lacroix m, grelet p,drouillardj. diagnosis and categorization of small neoplasms: role of computed tomography. gastrointestinalradi%joll991; 16:115-9. 12. bessettejr, maglinte ddt, kelvin fm, chemish sm. primary malignant tumours in the small bowel: a comparison of small-bowel enema and conventional followthrough examination. american journal of rnentgm%gy 1989;153:741-4. about the author(s) lisel v. richter-joubert department of radiology, groote schuur hospital, university of cape town, south africa donovan jacobs department of radiology, groote schuur hospital, university of cape town, south africa tracy kilborn department of radiology, red cross children’s war memorial hospital, university of cape town, south africa citation richter-joubert lv. jacobs d. kilborn t. surge of subacute sclerosing panencephalitis. s afr j rad. 2017;21(1), a1126. https://doi.org/10.4102/sajr.v21i1.1126 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract surge of subacute sclerosing panencephalitis lisel v. richter-joubert, donovan jacobs, tracy kilborn copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. subacute sclerosing panencephalitis (sspe) is a poorly understood complication of measles infection, presenting in up to 1 in 2500 infected children, resulting in devastating neurocognitive outcomes and a high mortality rate. the onset is insidious, with patients presenting with seizures and progressive cognitive decline around 6–10 years after measles infection. the diagnosis is frequently delayed due to lack of clinical suspicion, but can be confirmed by typical electroencephalogram (eeg) findings and positive cerebrospinal fluid (csf) serology. although imaging is not diagnostic, the vigilant radiologist has a unique opportunity to direct decision-making by identifying the correct clinical context and supportive mri findings. five years after the measles outbreak of 2009–2011, a rise in the incidence of sspe can be expected in south africa, as has been experienced at our institution. we present a series of seven confirmed sspe patients that presented to red cross war memorial children’s hospital between 2014 and 2016 and describe the clinical and radiological features to raise awareness of the condition amongst radiologist and clinicians. about the author(s) schadie vedajallam clinical neurosciences, university of bristol, united kingdom anith chacko clinical neurosciences, university of bristol, united kingdom ewan simpson clinical neurosciences, university of bristol, united kingdom savvas andronikou clinical neurosciences, university of bristol, united kingdom ngoc j. thai clinical neurosciences, university of bristol, united kingdom citation vedajallam s. chacko a. simpson e. andronikou s. thai nj. accuracy of non-radiologists and laypeople for identifying children with cerebral cortical atrophy from ‘mercator map’ curved reconstructions of the brain. s afr j rad. 2017;21(1), a1142. https://doi.org/10.4102/sajr.v21i1.1142 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: accuracy of non-radiologists and laypeople for identifying children with cerebral cortical atrophy from ‘mercator map’ curved reconstructions of the brain. 7th annual international conjoint meeting and exhibition of the society of pediatric radiology (spr) and the european society; 2016 may 15-20; chicago, illinois, us. springer berlin heidelberg; 2016. https://doi.org/10.1007/s00247-016-3579-x conference abstract accuracy of non-radiologists and laypeople for identifying children with cerebral cortical atrophy from ‘mercator map’ curved reconstructions of the brain schadie vedajallam, anith chacko, ewan simpson, savvas andronikou, ngoc j. thai copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: communication of cortical brain atrophy in children with term hypoxic-ischaemic injury (hii) to parents and the legal fraternity contesting compensation rights can be very difficult using text and standard cross-sectional images. when demonstrating the cortex in hii, a single image of the brain surface, much like the way a map of the earth is derived from a globe, can be generated from curved reconstruction of coronal magnetic resonance imaging (mri) scans, that is, a mercator map. laypeople’s ability to identify abnormal scans from such maps without prior training requires evaluation before routine use. aim: to determine the sensitivity and specificity of laypeople in detecting abnormal brain scans through review of mercator flat-earth maps of the brain, without prior training. methods and materials: ten mercator map images were provided to 100 participants with a distribution of 5 hii, 1 cortical dysplasia and 4 reported normal. participants were required to identify abnormal scans. sensitivity and specificity overall and for sub-groups were derived by averaging true positives and true negatives and false positives and false negatives. results and conclusion: the results show a strong ability for laypeople to identify normal versus abnormal mri brain studies using mercator maps. the sensitivity and specificity in this group is 67% and 73%, respectively. non-radiologist physicians and radiographers performed slightly better than laypeople as expected. radiologists of course, had very high sensitivity and specificity of 86% and 100%. the mercator map is therefore a viable tool in the communication of complex mr imaging to the layperson. abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) mark nicolaou grey’s hospital, university of kwazulu-natal, south africa matthew goodier grey’s hospital, university of kwazulu-natal, south africa citation nicolaou m, goodier m. adult intussusception: an unlikely diagnosis. s afr j rad. 2017; 21(1), a1063. https://doi.org/10.4102/sajr.v21i1.1063 case report adult intussusception: an unlikely diagnosis mark nicolaou, matthew goodier received: 25 july 2016; accepted: 10 oct. 2016; published: 20 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract intussusception happens when a portion of bowel telescopes into the adjacent bowel segment. it is a rare condition in the adult population, particularly in the young adult, and poses a diagnostic dilemma to the attending clinician because of its variable clinical presentation. radiological imaging is important in the early diagnosis, and it allows prompt surgical management to avoid severe complications, particularly bowel ischaemia and necrosis. this case report describes the clinical and multimodality radiological findings of an ileocolic intussusception secondary to a mucosa-associated lymphoid tissue (malt) lymphoma in a young adult patient. introduction intussusception happens when a portion of the digestive tract becomes telescoped (intussusceptum) into the adjacent bowel segment (intussuscipiens) as a result of peristalsis.1,2 primary or idiopathic causes are unknown and occur in the small intestine. secondary cause is thought to initiate from a mural bowel lesion or irritant that serves as a lead point and causes altered peristalsis. intussusception is uncommon in adults. it is estimated that only 5% of all intussusceptions occur in adults, and only 1% – 5% of bowel obstructions in adults are the result of an intussusception.3 the majority of cases in adults are because of the secondary causes with an identifiable lead point discovered intra-operatively.1,3 conversely, paediatric causes are usually primary and can be managed non-operatively with pneumatic enema in 80% of patients.1 case presentation a 24-year-old male patient known with retroviral disease and previously treated pulmonary tuberculosis (tb) presented with a 1-day history of sudden right iliac fossa pain associated with emesis and obstipation. on arrival, an ultrasound of the abdomen was performed, which showed several loops of dilated, fluid-filled bowel in the right side of the abdomen as well as a bowel-within-bowel appearance with a concentric wall thickening (‘doughnut sign’) which was concerning for an ileocolic intussusception as shown in figure 1. figure 1: axial ultrasound of the abdomen depicting a bowel-within-bowel appearance with concentric thickening of the bowel (arrowhead), with the mesentery of the intussusceptum (arrow) dragged into the intussuscipiens (asterisk). a computed tomography (ct) of the abdomen (figure 2) was performed which confirmed invagination of the terminal ileum into the ascending colon. a rounded enhancing mass adjacent to the medial aspect of the intussusceptum was thought to be the lead point of the intussusception. there was evidence of high-grade small bowel obstruction and possible ischaemic necrosis of the involved bowel. figure 2: contrast-enhanced coronal computed tomography of the abdomen demonstrating invagination of the terminal ileum along with its mesentery (arrow) into the ascending colon (arrowhead). histopathological examination of the resection specimen found the lead point to be a submucosal tumour with features of a low-grade b-cell malt lymphoma. the patient proceeded to an emergency laparotomy, and a bowel resection involving the terminal ileum, caecum and proximal ascending colon was performed. histopathological examination of the resected specimen demonstrated a mucosal and submucosal tumour, as the lead point, which had typical features of a low-grade b-cell mucosa-associated lymphoid tissue (malt) lymphoma. the patient had an uneventful recovery period post-operatively. discussion the clinical presentation of adult intussusception is variable and symptoms are often non-specific. the majority of cases in adults present with features of a partial bowel obstruction such as nausea, vomiting and constipation. melena and an abdominal mass may also be present.3 classification of intussusception is either anatomical (e.g. ileocolic or enteroenteric) or may be pathological, based on the underlying pathology.2 in the adult population, common underlying lead points in the small intestine can be due to the presence of intraor extraluminal lesions such as a meckel’s diverticulum, inflammatory bowel lesions, postoperative adhesions, lipoma, adenomatous polyps, lymphoma and metastases. iatrogenic causes have been described whereby indwelling intestinal tubes can act as a lead point. adenocarcinoma is seen in approximately one-third of cases involving the small intestine. malignant adenocarcinoma forms the majority of causes of intussusception in the large bowel.1,3 typically, a mucosal lesion serves as a lead point, whereby peristalsis at this point causes invagination of the proximal bowel segment into the distal bowel segment.3 this leads to further obstruction of intestinal contents causing more vigorous peristalsis in the affected segment, which causes further telescoping of the intussuscepted segment. eventually, blood flow within the mesentery of the intussusceptum is compromised, with oedema leading to further obstruction and ultimately bowel ischaemia.3,4 although a lead point is usually present in adult intussusception, 20% of cases are idiopathic. in our particular case, it is peculiar that a non-benign lesion was the lead point, given his relatively young age. however, it has become apparent in recent literature that an increased incidence of intussusception has been reported in patients with aids. this is understood to be due to the high incidence of infectious and neoplastic conditions of the bowel in patients with aids, such as lymphoid hyperplasia, kaposi’s sarcoma and non-hodgkin’s lymphoma.5 of particular interest is that the average age for intussusception in an hiv-positive adult was lower (41 years) compared with 63 years in a non-hiv-infected patient in a study performed by wood et al.6 this is important for clinicians to be aware of in regions where hiv is prevalent. abdominal radiographs are typically non-specific but may demonstrate the presence and level of bowel obstruction. ultrasound is the most useful initial imaging modality. classical imaging findings include the ‘target’ or ‘doughnut’ signs in the transverse view and the ‘pseudokidney’ sign or ‘hayfork’ sign in the longitudinal view.1,7 an abdominal ct is currently considered as the most sensitive radiological method to confirm intussusception.3 the characteristic features of ct scan include an inhomogeneous target sign consisting of the layers of bowel or a sausage-shaped soft tissue mass with a layered effect; in addition, mesenteric fat and vessels within the bowel lumen may also be seen on contrast-enhanced scans. in the setting of a suspected intussusception, ct can provide valuable additional information, including not only confirming the diagnosis but also delineating the location, the nature of any associated masses and its relationship of the affected bowel to surrounding tissues. it can also aid in staging a patient with a suspected non-benign cause for intussusception. abdominal ct may be able to differentiate between intussusception without a lead point from those with a lead point, which is key in planning subsequent management.2,3,4 management in the adult population is surgical with primary resection of the involved bowel with either end-to-end anastomosis of the resected ends in a non-emergent setting or a defunctioning colostomy with repair at a later stage.2,4 conclusion intussusception in the adult population poses a diagnostic dilemma for the attending clinician due to its rarity and vague clinical presentation. ultrasound is often the most useful initial investigation with ct providing useful adjunctive information in many cases allowing the management team to establish not only the cause of the bowel obstruction but also its location and the presence and nature of the lead point. acknowledgements the author thanks dr matthew goodier, the head clinical unit consultant radiologist, grey’s hospital, pietermaritzburg, south africa. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.n. followed up the patient and wrote the case report. m.g. proof read the case report and assisted with image capture and editing. references marinis a, yiallourou a, samanides l, et al. intussusception of the bowel in adults: a review. world j gastroenterol. 2009;15(4):407–411. http://dx.doi.org/10.3748/wjg.15.407 kim yh, blake ma, harisinghani mg, et al. adult intestinal intussusception: ct appearances and identification of a causative lead point. radiographics 2006;26:733–744. http://dx.doi.org/10.1148/rg.263055100 azar t, berger dl. adult intussusception. ann surg. 1997;226:134–138. http://dx.doi.org/10.1097/00000658-199708000-00003 begos dg, sandor a, modlin im. the diagnosis and management of adult intussusception. am j surg 1997;173:88–94. http://dx.doi.org/10.1016/s0002-9610(96)00419-9 gayer g, zissin r, apter s, papa m, hertz m. pictorial review: adult intussusception – a ct diagnosis. br j radiol. 2002;75(890):185. http://dx.doi.org/10.1259/bjr.75.890.750185 wood bj, kumar pn, cooper c, silverman pm, zeman rk. aids-associated intussusception in young adults. j clin gastroenterol. 1995;21(2):158–162. http://dx.doi.org/10.1097/00004836-199509000-00019 weissberg dl, scheible w, leopold gr. ultrasonographic appearance of adult intussusception. radiology. 1977;124:791–792. http://dx.doi.org/10.1148/124.3.791 abstract introduction discussion conclusion acknowledgements references about the author(s) pankaj nepal st. vincent’s medical center, connecticut, united states devendra kumar hamad medical corporation, doha, qatar vijayanadh ojili department of radiology, university of texas health, san antonio, united states citation nepal p, kumar d, ojili v. abnormal descent of the testis and its complications: a multimodality imaging review. s afr j rad. 2018; 22(1), a1374. https://doi.org/10.4102/sajr.v22i1.1374 pictorial essay abnormal descent of the testis and its complications: a multimodality imaging review pankaj nepal, devendra kumar, vijayanadh ojili received: 10 june 2018; accepted: 31 july 2018; published: 27 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract cryptorchidism refers to an absence of the testis in the scrotal sac. testicular descent occurs in two stages: transabdominal and gubernacular. the descent of the testis can be arrested in its usual path of descent (true undescended testis) or can migrate from the usual path of descent (ectopic testis). localising the missing testis is important for surgical planning, as well as for identification of complications that are more common with cryptorchidism. ultrasound is the initial imaging modality to visualise, as well as localise the testis in cryptorchidism. however, ultrasound imaging is limited in visualising testes that are not superficial in location. this article highlights various examples of abnormal descent of the testis in usual as well as unusual locations and complications of undescended testes. further evaluation with computed tomography scan or magnetic resonance imaging is needed in indeterminate cases and for identification of complications. we have highlighted the role of specific modalities with imaging findings in this pictorial review for the appropriate selection of each modality in clinical practice. introduction an absence of the testis in the scrotal sac is defined as cryptorchidism. the true undescended testis has arrested migration along its usual path of descent, or it is termed ectopic testis when it migrates from its usual path of descent to lie in an unusual location. an atrophic or congenital absence of the testis may simulate a similar situation. in infants, correct localisation of the testis is essential for surgical management, because the approach may vary with the location. in adults, however, it is still important to localise the testes and identify the complications. undescended testes are seen in approximately 1% – 6% of newborn males. the incidence is even higher in preterm infants, reported at 30%.1 most undescended testes migrate into the lower scrotum within the first 3 months of life, probably as a consequence of a postnatal surge of testosterone. only in less than 1% of the cases does the testis remain persistently undescended by the age of 1 year.1 cryptorchidism occurs four times more commonly unilaterally than bilaterally. around 70% of undescended testes are palpable on clinical examination. clinically, it can sometimes be difficult to distinguish an undescended testis from a retractile testis, which is excessively mobile.2 discussion in 80% of patients with cryptorchidism, the testis is manually palpable in the inguinal canal.3 the normal course of testicular descent is retroperitoneally from the inferior pole of the kidney to the scrotum.4 the testis shares its embryological development with the kidney, and thus, it initially develops in the upper abdomen and migrates towards the inguinal canal through the deep inguinal ring after 21 weeks of gestation. the migration is almost complete at 30 weeks of gestation. various factors influence the descent: hormones, including gonadotropins and testosterone, as well as active migration of the gubernaculum, determine its final position. the gubernaculum is the ligament that connects the developing testis to the scrotum and is responsible for inguinoscrotal descent. under the influence of hormones (e.g. testosterone), the gubernaculum contracts and the testis descends into the scrotum. the gubernacular phase is more prone to error, whereas the transabdominal phase of arrest accounts for 5% – 10% of cases. on imaging, cryptorchidism can be broadly divided into two groups: arrested descent or ectopic testes. arrested descent descent of the testes is along the normal path, but incomplete. the testis may be located in the inguinal canal (80%), near the pubic tubercle or, uncommonly, in the abdomen. the testis is often small and abnormal with a short spermatic cord. ectopic descent descent of the testes is away from the normal path. the testis is most often found in the superficial inguinal pouch. other uncommon locations are perineal, abdominal wall, pelvic, crural, penile and femoral. the testis and spermatic cord are usually normal. most frequent locations to aid a directed search for the testicles are shown in figure 1.6 figure 1: the most frequent locations of true and ectopic undescended testis. imaging modalities the purposes of imaging are to correctly localise the testis and assess viability and size (assess for atrophy). the aim is also to detect cases of vanished testis or agenesis. ultrasound is an initial imaging modality to localise the testes, as well as to assess vascularity on colour doppler imaging. if the testis is not identified in the scrotum on ultrasound, then the ‘tracking the cord’ technique is useful.5 starting below the inguinal crease, the common femoral artery and vein can be traced with the ultrasound probe in the transverse axis (figure 2). the spermatic cord is identified in the inguinal canal, seen as an oval echogenic structure, anteromedial to the common femoral vessels. the common iliac and internal iliac vessels can then be traced cranially up to the bifurcation of the aorta to look for an abdominal testis. a superficial scan of the iliac fossa and pelvis is also performed to search for the testes. figure 2: greyscale ultrasound in a 6-month-old infant showing an undescended testis in the right inguinal canal (star). ultrasound is particularly useful in visualising superficially localised testes in the inguinal canal, inguinal pouch and subcutaneous location. ultrasound has approximately 40%–50% sensitivity, 70%–80% specificity and around 88% accuracy for localisation of an undescended testis.7 it has superior resolution in demonstrating the superficial location of testes, such as along the rectus sheath, inguinal canal or perineum. colour doppler imaging is excellent in demonstrating vascularity within the testes (figure 3). the limited accuracy of ultrasound is because of difficulty in visualising intra-abdominal, pelvic, retroperitoneal or ectopic testes (20%).8 another limitation of ultrasound is failure to differentiate an atrophic testis from a lymph node or the gubernaculum. figure 3: sagittal ultrasound image of the left upper abdomen with a linear probe in a 2-year-old male child with left cryptorchidism. cross-sectional imaging modalities like computed tomography (ct) scans and magnetic resonance imaging (mri) are used in indeterminate cases on ultrasonography, as well as in the assessment of complications. the testes appear hypodense on ct, and it may be difficult to differentiate them from lymph nodes or small cystic structures. ct scan involves significant radiation and raises concerns regarding the radiation dose as the majority of imaging for cryptorchidism occurs in the paediatric age group. ct scan is, however, superior in evaluating and staging known cases of testicular malignancy. magnetic resonance imaging has a higher sensitivity of approximately 90% and specificity of almost 100% in localising the testes compared to ultrasound.9 plain and contrast-enhanced coronal t1-weighted (t1w) mri can differentiate the gubernaculum, testes and spermatic cord. the spermatic cord can be followed to locate the undescended testes. the ectopic, pelvic or retroperitoneal location of the testes can be easily identified (figure 4). the testis normally appears hyperintense on t2-weighted (t2w) mri. recently, diffusion-weighted mri has been used to show a markedly hyperintense signal within testes, which helps to differentiate it from lymph nodes and surrounding structures.10 contrast-enhanced mri is also better for visualisation, demonstrating testicular enhancement, which is also indicative of viability (figures 4, 5, and 6). figure 4: (a) coronal t2-weighted (t2w), (b) t2w axial and (c) t1-weighted (t1w) axial magnetic resonance images in a 12-month-old male with bilateral undescended testes, demonstrating ectopic testes at the superficial inguinal ring (white arrows). figure 5: (a) coronal and (b) axial t2-weighted (t2w) magnetic resonance images in 9-month-old male child showing true undescended right testis (star) at the level of the root of penis, near the pubic tubercle (black arrow). the crura of the penis are seen at this level (circles). the inguinal canal (white arrow) is well visualised on coronal section. figure 6: use of contrast-enhanced imaging in a 7-month-old male with an undescended left testis: (a) coronal t2w image shows a true undescended testis in the left iliac fossa (bold white arrow). (b) axial post-contrast subtraction image confirms a homogenously enhancing undescended left testis (bold arrow). if until the age of 6 months (corrected for gestational age) a testis has not descended, surgery should be performed within the subsequent year, preferably by the age of 18 months. histological examination proves that undescended testes suffer a progressive loss of germ cells as well as leydig cells.11 prepubertal orchidopexy addresses the issue of infertility, and there has been worldwide evidence that it may decrease the risk of testicular cancer in children with cryptorchidism.12 imaging algorithm seventy per cent of undescended testes are palpable manually, and in the remaining 30% of non-palpable undescended testis, the current algorithm is to perform abdominal-scrotal ultrasound first. ultrasound is sensitive in visualising testes in the inguinoscrotal region or localised to the superficial abdomen wall and perineum. if the ultrasound findings are non-diagnostic, the next imaging modality is mri. ct is non-invasive but is unreliable in identifying the testes and carries the risk of radiation. as per international guidelines from the american association of urology (2014), imaging in cryptorchidism is currently advocated as an adjunct. according to their guidelines, diagnostic laparoscopy or open exploration must be performed on all non-palpable cryptorchid patients.13 this should, however, take into account the local expertise and practice available. viable and normal size undescended testes are treated with orchidopexy, depending upon expertise, with laparoscopy or an open surgical approach. a small and atrophic intra-abdominal testis can be treated with orchiectomy. preoperative localisation of the testis definitely aids in surgical planning and approach.14 it may reduce the extent of exploration and time for anaesthesia. accurate pre-surgical localisation of the testis can provide the surgeon with the anatomic knowledge to tailor the operative approach. mri has almost 100% specificity in identifying and localising the testes. laparoscopy and surgery are difficult in children who have had previous inguinal or scrotal surgery because of scarring, increased risk of injury and reduced mobility of the spermatic cord. cryptorchidism associated with ambiguous genitalia or hypospadias also need mandatory imaging to evaluate for the presence of mullerian structures. the authors feel that this topic has not received much attention in the literature recently. this then begs the question that in the absence of visualisation of testes with mri, is it logical to undergo surgery? further research into the role of imaging in undescended testis is necessary before concluding imaging just as an adjunct. a simple imaging algorithm for cryptorchidism has been designed by the authors and illustrated in figure 7. figure 7: imaging algorithm in undescended testis. complications complications of undescended testes include an increased incidence of infertility, trauma, malignancy, torsion, other associated anomalies, as well as inguinal hernia. although there has been dispute regarding orchiopexy reducing the risk of testicular cancer, it certainly increases the detection of malignancy through testicular self-examination.15 the incidence of testicular malignancy among men with an undescended testicle is approximately 1 in 1000–2500, which is certainly higher than the normal population. testicular malignancy has been reported in 10% – 15% of patients with undescended testes16 (figures 8 and 9). figure 8: coronal non-contrast computed tomography abdomen of a 35-year-old male who presented to the emergency department with right flank pain. figure 9: a 30-year-old male patient with a left-sided undescended testis: (a) ultrasound imaging in the left inguinal location showed an atrophic and echogenic testis (bold white arrowhead). postoperative findings were consistent with testicular non-seminomatous germ cell tumour and epididymis disjunction. (b) contrast computed tomography for systemic work-up revealed necrotic heterogeneous lymph nodal metastasis (bold white arrow) in the left para-aortic location, which regressed after chemotherapy. if a testicle is located in the inguinal location, it might be prone to trauma or pressure against the pubic bone because of its superficial location (figure 10). the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes.11 torsion of an undescended testis can be attributed to the development of a testicular tumour, increasing the weight and distorting the normal anatomy of the organ. torsion of an intra-abdominal testicle may present as an acute abdomen. inguinal hernias may be associated with the cryptorchidism17 (figure 11). figure 10: a 15-year-old boy with trauma to the inguinal region presented to the emergency department. figure 11: a 30-year-old male presented to the emergency department with pain in the right inguinal region with a large inguinoscrotal hernia on clinical examination: (a) coronal and (b) sagittal images of a computed tomography abdomen demonstrated an undescended testis (arrow on image a) along its path in the right lower abdomen, located lateral to the surface of urinary bladder (u). there was an associated large right omental hernia (arrow on image b). (c) the undescended testis is hyperintense (arrow on image c) on axial t2-weighted magnetic resonance images. conclusion clinicians and radiologists should be aware of the chronology of normal testicular descent, the common and uncommon locations of cryptorchidism, the specific imaging approach, as well as the complications associated with undescended testes. acknowledgements the authors would like to thank dr devendra kumar, consultant, hamad medical corporation, for his contribution of images. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions p.n. was responsible for cases collection and writing of the manuscript. v.o. was responsible for editing of the manuscript and study design and d.k. contributed towards the images and case collection. references nah sa, yeo cs, how gy, et al. undescended testis: 513 patients’ characteristics, age at orchidopexy and patterns of referral. arch dis child. 2014;99(5):401–406. https://doi.org/10.1136/archdischild-2013-305225 snodgrass w, bush n, holzer m, zhang s. current referral patterns and means to improve accuracy in diagnosis of undescended testis. pediatrics. 2011;127(2):382–388. https://doi.org/10.1542/peds.2010-1719 mackinnon ae. the undescended testis. indian j pediatr. 2005;72(5):429–432. https://doi.org/10.1007/bf02731742 tasian ge, copp hl, baskin ls. diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. j pediatr surg. 2011;46(12):2406–2413. https://doi.org/10.1016/j.jpedsurg.2011.08.008 vijayaraghavan sb. sonographic localization of nonpalpable testis: tracking the cord technique. indian j radiol imaging. 2011;21(2):134–141. https://doi.org/10.4103/0971-3026.82298 cryptorchidism. the origin, the cure [image on the internet]. [cited 2017 feb 2017]. available from: http://tophealthnews.net/cryptorchidism/# adesanya oa, ademuyiwa ao, evbuomwan o, adeyomoye aa, bode co. preoperative localization of undescended testes in children: comparison of clinical examination and ultrasonography. j pediatr urol. 2014;10(2):237–240. https://doi.org/10.1016/j.jpurol.2013.09.023 frush dp, sheldon ca. diagnostic imaging for pediatric scrotal disorders. radiographics. 1998;18(4):969–985. https://doi.org/10.1148/radiographics.18.4.9672981 yeung ck, tam yh, chan yl, lee kh, metreweli c. a new management algorithm for impalpable undescended testis with gadolinium enhanced magnetic resonance angiography. j urol. 1999;162(3):998–1002. https://doi.org/10.1016/s0022-5347(01)68046-7 kantarci m, doganay s, yalcin a, aksoy y, yilmaz-cankaya b, salman b. diagnostic performance of diffusion-weighted mri in the detection of nonpalpable undescended testes: comparison with conventional mri and surgical findings. ajr am j roentgenol. 2010;195(4):268–273. https://doi.org/10.2214/ajr.10.4221 park kh, lee jh, han jj, lee sd, song sy. histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. int j urol. 2007;14(7):616–621. https://doi.org/10.1111/j.1442-2042.2007.01788.x pettersson a, richiardi l, nordenskjold a, kaijser m, akre o. age at surgery for undescended testis and risk of testicular cancer. n engl j med. 2007;356(18):1835–1841. https://doi.org/10.1056/nejmoa067588 tasian ge, yiee jh, copp hl. imaging use and cryptorchidism: determinants of practice patterns. j urol. 2011;185:1882. https://doi.org/10.1016/j.juro.2010.12.065 smolko mj, kaplan gw, brock wa. location and fate of the nonpalpable testis in children. j urol. 1983;129(6):1204–1206. https://doi.org/10.1016/s0022-5347(17)52643-9 pinczowski d, mclaughlin jk, läckgren g, adami ho, persson i. occurrence of testicular cancer in patients operated on for cryptorchidism and inguinal hernia. j urol. 1991;146(5):1291–1294. https://doi.org/10.1016/s0022-5347(17)38071-0 benson rc jr, beard cm, kelalis pp, kurland lt. malignant potential of the cryptorchid testis. mayo clin proc. 1991;66(4):372–378. https://doi.org/10.1016/s0025-6196(12)60660-0 radwan k, joelle d, sid-ali b, sylviane b, alexia b, olivier t. a rare variant of inguinal hernia: cryptorchid testis at the age of 50 years. etiopathogenicity, prognosis and management. int j surg case rep. 2014;5(7):416–418. https://doi.org/10.1016/j.ijscr.2014.03.015 original article the patient with head injury and a glasgow coma score of 15 is a brain ct examination indicated? s l benade mmed(rad d) (sa), a t scher fcrad(d)sa department of radiology, tygerberg academic hospital and university of stellenbosch. tygerberg, w cape abstract the decision as to whether to perform a ct examination of the brain in patients with a glasgow coma score of 15 after injury is often difficult, given the limited ct scanning facilities available in state hospitals. a retrospective evaluation of 100 consecutive head-injury patients presenting with a glasgow coma score of 15 at tygerberg hospital was therefore carried out. in a surprisingly high number of patients (50%) abnormal findings due to the injury were detected. analysis of the clinical history parameters did not demonstrate a significant association with abnormal ct findings. it is therefore concluded that brain ct examination in patients with a glasgow coma score of 15 is justified, and that the glasgow coma scale is a poor predictor of intracranial injury. introduction there is intense debate in the medical literature over whether headinjury patients with a glasgow coma score of 15 need to be examined by ct. this debate is driven by the need to identify all patients with potentially serious injuries against the limited ct scanning facilities available at many institutions. the glasgow coma scale was developed in 1974 as an evaluation instrument to monitor patients with altered consciousness. it is a simple and reproducible examination, utilising three categories of patient response, i.e. the ability to open the eyes,the best verbal response, and the best motor response. patients and methodology this study is based on the retrospective database evaluation of 100 consecutive head-injury patients (injuries < 36 hours before admission) referred for a brain ct investi14 sa journal of radiology. august 2003 gation. all patients were 13 years of age or older, and on admission had a glasgow coma score of 15. the fulltime trauma doctors at the trauma unit at tygerberg hospital assessed the glasgow coma score of patients on admission. results in this study of 100 head-injury patients, the ct examination was abnormal in 56 patients (56%). in 6 patients the pathology was unrelated to the head injury (fig 1). abnormal (traumarelated) 50% normal 44% fig. 1. ctfindings for 100 head-injured patients with a glasgow coma score of 15. the spectrum of unrelated pathology in the 6 patients was as follows: • cysticercosis • posterior cerebral artery infarct • posterior cerebral artery aneurysm • calcified granuloma • posterior inferior cerebral artery infarct with subarachnoidal bleedmg • lacuna infarct of the basal ganglia mechanisms of injury (fig. 2): • 19 motor vehicle accidents (mvas) · 6 pedestrians · 12 passengers · 1 motorcycle/motorbike cyclist • 68 assaults 7 physical · 60 object original article unknown 1% ---, other 12% assaults 68% fig.2. mechanism of injury in 100 patients with glasgow coma score of 15. . 1 unknown • 12 other • 1 unknown skull x-ray findings • 42 (84%) of the 50 patients had single or multiple injuries • the findings in the 42 patients with fractures were: • 15 (36%) extra-axial bleeding 22 (52%) intra-axial bleeding or contusions 22 (52%) diffuse brain swelling and/or pneumocranium • 9 (16%) of the 50 patients did not have a fracture, but showed: 2 patients had a small subdural bleed 1 patient had subarachnoid bleeding 5 patients had a contusion .discussion fifty patients had abnormal ct findings related to their trauma (figs 3 and 4). this is a very high incidence and there are several reasons for this. one of these is in the design of this study. most studies in the literature are based on consecutive head-injury patients with a glasgow coma score of 90 80 70 e 60 q.l ~ 50 cl. 0 40lo '0 30 54;,g 0 20 10 28 26 0 cl) $ol "0 c: eq.l c '§ ol,_ ~.5 :::::sc3 ,"0 co (ii ol .oc: '2co q.l ci).c: q.l= ~~ ,_ q.l §~'ë cl)q.l ou, ')('u; ~ ~ :@~ 0w.o e :::::s __ ci-c:.o :::::sc:,_ q.l0 o c:a. fig. 3. findings in 50 patients with an abnormal trauma related ct. fig. 4. ct scan of a patient with a glasgow coma score of 15 who was assaulted. there are right parietal and !eft fronta! cerebra! contusions. 15, all of whom had routine brain ct, while in this study only patients with clinical indications were examined. in comparison, ieret et al.' found abnormal findings in 9.4% of 712 consecutive patients with a glasgow coma score of 15 who were evaluated with brain ct over a i-year period. age the average patient age was 31 years (median 28 years). this compared with larger studies in the literature, with a average age of 33 years.' 15 sa journal of radiology • august 2003 gender seventy-two percent of patients were male and 28% were female. this is comparable with other studies which showed that more males than females presented with head injuries in trauma units." mechanisms of injury sixty-eight patients were assaulted, 19 were mva patients, 12 had fallen and 1 history was unknown. in a study of 2 766 patients, shackford et au identified assault as the mechanism of injury in only 8% of patients. livingston et al.6 showed that as a mechanism of injury assault was associated with a higher incidence of intracranial pathology. the very high percentage of assaults in this study in comparison with the literature is probably the reason for the high number of abnormal cts. clinical history in the patient group with abnormal ct findings, 96% had headache, original article 34% nausea and vomiting, 22% loss of consciousness, 10% had memory loss and 10% convulsions. no clear distinction was observed in comparison with the normal ct group. conclusion this analysis revealed that 56% of patients with a glasgow coma score of 15 had abnormal ct findings, many of which were significant. assault as a mechanism of injury occurred far more frequently in this series than in large series analysed in other countries. analysis of the clinical history parameters did not demonstrate any significant association with abnormal ct findings. an abnormal neurological examination and suspicion of a skull fracture did have a strong association with abnormal ct findings. in 84% of patients with one or more fractures, the ct examination was abnormal. in light of the above findings it can be concluded that brain ct examination in patients with a glasgow coma score of 15 is justified, and that the glasgow coma scale is a poor predictor for normal brain ct examination. references 1. ieret js,mandell m,anziska b, et al. clinical predictors of abnormality disclosed by computed tomography after mild head trauma. neurosurgery 1993; 32( 1): 9-16. 2. nagy kk, joseph kt, krosner sm, et al. the utility of head computed tomography after minimal head injury. j trauma 1999; 46: 268 -270. 3. miller ec, holmes jf, derlet rw utilizing clinical factors to reduce head ct scan ordering for minor head trauma patients. j emerg med 1997; 15: 453-457. 4. stiell lg, wells ga, vandemheen k, et al. variation in ed use of computed tomography for patients with minor head injury. ann emerg med 1997; 30(1): 14-22. 5. shackford sr, wald sl, ross se, et al. the clinical utility of computed tomography scanning and neurologic examination in the management of patients with minor head injuries. j trauma 1992; 33: 385-393. 6. livingston dh, lader pa, koziol j, hunt cd. the use of ct scanning to triage patients requiring admission following minimal head injury. j trauma 1991; 31: 483-489. 16 sa journal of radiology. august 2003 department of health government of western australia royal perth hospital advanced trainee (fellow) in breast imaging applications are invited from medical practitioners who are fully registrable in western australia to fill the above position from 19 january 2004 to 16 january 2005. applicants should possess the part" dracr or equivalent and wish to gain further experience in breast imaging. five (5) sessions will be spent in breast imaging and the remaining 5 sessions in general cross sectional imaging. royal perth multi-disciplinary breast service provides screening and diagnostic clinics, as well as a pre-operative hookwire localisation service. royal perth hospital is a 955 bed major teaching hospital. the radiology department provides a full range of diagnostic and interventional radiological services to the hospital and to royal perth rehabilitation hospital and the spinal unit. the department has two dsa units, a superconductive 1.0 tesla magnetic resonance scanner, two siemens ct scanners, and modern ultrasound equipment (including colour doppler). the appointee will be expected to assist with undergraduate and postgraduate teaching programs, applicants are encouraged to participate in research projects and also participate in the departmental on-call roster. royal perth multi-disciplinary breast service runs a busy screening and diagnostic breast imaging service. extensive experience in image-guided biopsy including mammotome vacuum assisted biopsy will be available as well as experience gained in pre-operative hookwire localisation. terms and conditions of employment are in accordance with the medical practitioners (metropolitan health services) ama industrial agreement 2002. the salary range currently for this position is a$64,975 a$98,940 per annum together with a professional expenses allowance of a$1 ,949 per annum. point of commencement in the salary range is dependent upon qualifications and experience. further details regarding this position may be obtained from professor mark khangure, head of department, diagnostic and interventional radiology, royal perth hospital on (+61 8) 9224 2126, facsimile (+61 8) 9224 2912, e-mail: mark.khangure@health.wa.gov.au or dr elizabeth wylie, department of diagnostic and interventional radiology, royal perth hospital on (+61 8) 9224 2125, facsimile (+61 8) 9224 2912 or e-mail: liz.wylie@health.wa.gov.au applications stating qualifications, previous experience and the names and addresses of two professional referees should be forwarded to joyce o'hara, senior administrative assistant, clinical services, royal perth hospital, gpo box x 2213, western australia 6847. closing date: friday 29 august 2003. mailto:mark.khangure@health.wa.gov.au mailto:liz.wylie@health.wa.gov.au about the author(s) raksha ramlakhan department of radiology groote schuur hospital, red cross war memorial children’s hospital, university of cape town, south africa nicky wieselthaler department of radiology groote schuur hospital, red cross war memorial children’s hospital, university of cape town, south africa vishesh sood department of radiology groote schuur hospital, red cross war memorial children’s hospital, university of cape town, south africa komala pillay national health laboratory service (nhls), university of cape town, south africa citation ramlakhan r, wieselthaler n, sood v, pillay k. juvenile xanthogranuloma: awakening of the other histiocytosis? s afr j rad. 2017;21(1), a1154. https://doi.org/10.4102/sajr.v21i1.1154 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract juvenile xanthogranuloma: awakening of the other histiocytosis? raksha ramlakhan, nicky wieselthaler, vishesh sood, komala pillay copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. juvenile xanthogranuloma is the lesser known and less innocuous of the histiocytic disorders. this non-langerhans cell histiocytic disorder, as we know it, is a benign proliferative disorder manifesting as cutaneous lesions in young children. extracutaneous lesions are less common with most systemic lesions reported in the liver, spleen, lung, eye, central nervous system and bones. these lesions usually spontaneously regress, or if not, treatment is based on severity and includes resection, chemotherapy and radiation. mortality is rare. we present a case series of three patients presenting to red cross children’s hospital over a 2-year period. we discuss the variable clinical presentation, the diverse imaging findings and the confirmatory histopathological diagnoses and treatment. we describe a cutaneous thigh lesion with visceral involvement. this poster highlights the first reported solitary bone lesion in the ulna. it also emphasises the aggressive and lethal nature of a cervical spine lesion. we demonstrate the difficulty in radiologically distinguishing these lesions from other tumours. abstract introduction materials and methods results discussion conclusion limitations acknowledgements references about the author(s) sefiya a. olarinoye-akorede department of radiology, ahmadu bello university teaching hospital, nigeria garba h. yunusa department of radiology, unman dan-fodiyo university, nigeria halima aliyu department of radiology, ahmadu bello university teaching hospital, nigeria ahmed u. hamidu department of radiology, ahmadu bello university teaching hospital, nigeria citation olarinoye-akorede sa, yunusa gh, aliyu h, hamidu au. breast imaging reporting and data systems category 3 (probably benign) breast lesions detected on diagnostic breast ultrasound: the prevalence, outcome and malignancy detection rate in zaria, nigeria. s afr j rad. 2018; 22(2), a1315. https://doi.org/10.4102/sajr.v22i2.1315 original research breast imaging reporting and data systems category 3 (probably benign) breast lesions detected on diagnostic breast ultrasound: the prevalence, outcome and malignancy detection rate in zaria, nigeria sefiya a. olarinoye-akorede, garba h. yunusa, halima aliyu, ahmed u. hamidu received: 05 feb. 2018; accepted: 03 sept. 2018; published: 01 nov. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: probably benign breast lesions in the breast imaging reporting and data systems (bi-rads 3) constitute a crucial category and a considerable number of all palpable breast masses. local data concerning the outcome of such lesions in the nigerian environment is almost non-existent. objectives: the goal of this article is to report the frequency, outcome and malignancy detection rate among palpable breast masses that were categorised on ultrasound as bi-rads category 3 (probably benign) according to the american college of radiology (acr). methods: between january 2015 and july 2017, 603 patients had diagnostic whole-breast ultrasound scans. there were 277 women who complained of palpable breast masses, of whom 151 women were diagnosed as having bi-rads 3 lesions. the final lesion outcome was determined by either biopsy or ultrasound follow-up examination for a total of 2 years. all data were recorded and analysed with statistical package for the social sciences (spss) version 20 (chicago, usa). results: the frequency of bi-rads category 3 lesions among all the women who underwent breast ultrasound was 25% (151/603); and 54% (151/277) in patients with palpable breast masses. there were 25 patients who were excluded because of incomplete data or who were lost to follow-up. a total of 122 patients had both ultrasound examination and histopathologic diagnosis, while only 4 were followed up for 2 years on ultrasound alone. of the 122 women biopsied, 117 (95.9%) had benign histologic outcomes, and of the remaining 5, cancer was confirmed in 2 (1.6%), while the remaining 3 patients (2.5%) had lesions considered intermediate at histology (juvenile papillomatosis, borderline phylloides and atypical ductal hyperplasia). three out of four patients who had ultrasound follow-up alone had stable lesions after 2 years, while one patient had complete resolution. conclusion: this study found a significantly high biopsy rate of 80% (122/151) for probably benign lesions but a low detection rate for malignancy (1.6%). follow-up with imaging rather than biopsy for lesions sonographically described as probably benign, will reduce medical costs and unwarranted invasive procedures. introduction the ‘probably benign’ assessment (category 3) in the breast imaging reporting and data systems (bi-rads) is assigned to lesions with specific imaging findings. these include a solid mass with an oval shape, circumscribed margin, parallel orientation, homogenous echo texture and no suspicious malignant characteristics.1,2 while these masses have benign imaging features, there is still a low (< 2%) risk for malignancy.3 radiologists have a key role to play in deciding on the definitive management as to whether the mass should be biopsied or not. the american college of radiology (acr) management recommendation is a short-interval imaging follow-up usually at 6, 12 and 24 months, which is considered a reasonable alternative to biopsy.1,4,5,6 for the purposes of auditing, a bi-rads 3 assessment has been reclassified recently by the 5th edition of bi-rads as audit positive (previously audit negative) for all screening modalities – mammography, ultrasound and mri.7 in contrast, for diagnostic imaging, bi-rads 3 assessment is considered as audit negative.7 nonetheless, there is a general low threshold for biopsy even when the imaging features are benign.8 this situation is also observed in nigeria. in this study, we report on the frequency of probably benign breast lesions, the outcome and the detection rate for malignancy in zaria, with the purpose of reviewing the biopsy-driven practice for masses with benign features. materials and methods the ethics committee of ahmadu bello university teaching hospital approved this retrospective review of 603 patients who had whole-breast diagnostic ultrasound examinations between january 2015 and july 2017 (abuth/hrec/d38/2018). of these, 151 women had palpable breast masses that were classified as probably benign (bi-rads 3). we excluded 25 patients with incomplete data or loss to follow-up and finally recruited 126 patients for this study (122 had both ultrasound and biopsy; 4 had ultrasound follow-up alone at 6, 12 and finally 24 months). high-resolution ultrasound scans of the breasts were performed by the breast radiologists using a mindray ultrasound machine (dc-8, china), equipped with a 7 mhz–12 mhz linear transducer. physical examination of the breast and axilla was performed in the seated position, noting relevant findings before commencing the scan. with the arms raised, each breast was firstly scanned in the supine position for the medial portions of the breast, then in the contralateral posterior oblique position for the lateral breast portion. overlapping transverse and longitudinal ultrasound scanning technique, as well as radial and anti-radial scanning was done in real time until the entire breast was scanned. the nipple–areolar complex and lastly the axilla were also examined with ultrasound. the images were evaluated in a team context by the performing breast radiologists (with 4 and 9 years of experience) using the acr bi-rads 4th edition (ultrasound 1st edition),2 the stavros criteria,3 as well as personal experiences in our institution. the cases selected were those that satisfied the criteria for bi-rads category 3, namely a solid mass with an oval or gently lobulated shape, circumscribed margin, uniform echotexture and a parallel orientation. complicated cysts were also classified as probably benign. lesions that were definitely benign like simple cysts and normal lymph nodes were excluded, as were lesions with any suspicious features like irregular margins, antiparallel orientation or posterior shadowing. the standard of reference for lesion outcome was histopathology or 2 year follow-up (at 6 months, 1 year and 2 years). all data were recorded and analysed using spss version 20 (spss inc., chicago, il, usa). figures and tables were used to show descriptive frequency distributions. results the mean age of the patients was 29.7 ± 11.3 years (range 13–68 years). the modal age of the patients was 20–29 years, accounting for 47% (table 1). table 1: age distribution of patients with breast masses diagnosed as probably benign. the frequency of probably benign lesions from this study was 151/603 (25.0%). it also constituted 54%, or 151 of the 277 women with palpable lesions. outcome data were available for 126 patients, which was either histology (n = 122) or ultrasound follow-up after initial ultrasound examination at 6, 12 and 24 months (n = 4) (table 2). table 2: outcome of breast imaging reporting and data systems 3 lesions. of the 122 patients with histologic confirmation, 117 (95.9%) had a benign outcome; out of these, 74 (63.24%) were fibroadenomas (figure 1). others, shown in table 3, included fibrocystic disease, lactating adenoma, benign ductal papilloma, duct ectasia, chronic inflammatory mass, oil cyst (figures 2a & 2b) and galactocoele. figure 1: palpable right breast lump in an 18-year-old woman noticed 6 months previously. ultrasound showed an oval-shaped homogenous hypoechoic mass with well-defined margins. posterior acoustic enhancement and edge shadowing are seen. histology confirmed the diagnosis of a fibroadenoma. figure 2: a palpable left breast lump in a 48-year-old woman. she had a breast trauma 3 years prior to presentation: (a) ultrasound of the left breast showed a well-defined hyperechoic mass and (b) left medio-lateral oblique mammogram showing a mass with a calcified (egg shell) rim. at the patient’s request, she had a biopsy, which confirmed an oil cyst (from post-traumatic fat necrosis). table 3: types of benign breast lesions. of the remaining five women, three had intermediate (borderline) lesions, which included juvenile papillomatosis, borderline phylloides and atypical ductal hyperplasia. invasive ductal carcinoma (figure 3) was detected in the other two women. overall, the malignancy detection rate from this study was therefore 1.3% (2/151). figure 3: left breast lump in a 44-year-old woman 3 years prior to presentation. ultrasound examination showed a round hypoechoic mass with circumscribed margins and posterior acoustic enhancement. ultrasound assessment was breast imaging reporting and data systems 3 (probably benign). histologic diagnosis was invasive ductal carcinoma. the patients who were followed up with ultrasound alone had stable lesions after 2 years (n = 3) with no symptoms and were downgraded to bi-rads 2 (benign). these were fibroadenomas (n = 2) and ductal ectasia (n = 1). complete resolution occurred in a patient with mondor’s disease, which was downgraded to bi-rads 1 (negative). discussion probably benign masses are a frequent finding in ultrasound examinations of the breast. it constitutes a problematic category because its definitive management is dependent on whether it is upgraded to malignancy or downgraded to benign. in this study, it accounted for 25% of all breast ultrasound examinations. this is similar to the reports of 25% by barr et al.9 in the usa and 24.9% by moon et al.10 in korea. this study constituted mostly younger women between 20 and 29 years old (mean age 29.7 ± 11.3; range of 13–68 years). in other studies, the women were older as reported by moon et al. (mean 44.5; range 15–78 years);10 park et al. (mean 34, range 12–64 years)8 and harvey et al. (mean 44.4; range 12.2–87.8 years).11 the acr recommendation for management of bi-rads 3 lesion is short-term ultrasound follow-up at 6, 12 and 24 months.2,7 although very few (four) of our patients were compliant with this recommendation, which spanned 2 years, the lesions that we evaluated with only ultrasound follow-up had benign outcomes as with previous findings of alimoglu et al. moon et al. and raza et al.1,10,12 the authors believe that one of the reasons for poor compliance could be the lack of evidence in the community to support low prevalence of malignancy for probably benign breast lesions; hence the high biopsy rate. this study aimed to address this. also, anxiety from fear of cancer could make patients opt for biopsy, which is quicker, as observed by harvey et al.11 three of our patients had stable lesions after 2 years, while in one patient the mass completely resolved. in the study by alimoglu et al.1 70% of the lesions remained stable during follow-up, 13.1% showed interval regression while 14.0% showed interval progression. they noted that the majority of the interval changes occurred within the first 2 years. in contrast, in the study by moon et al. 906 out of 920 (98.5%) turned out benign.10 the rest of our patients (122 of 126) had tissue sampling. of these masses, 95% were histologically benign. the commonest histologic finding was fibroadenoma. this was not surprising given that fibroadenoma is the commonest mass in young african women. fibrocystic disease is mostly seen in the fourth decade and malignancy in the fifth decade.13 the malignancy rate of 1.3% found in this study correlates with the cancer detection rate of less than 2% that is associated with breast masses that are categorised as probably benign.6,12,14,15 lower cancer detection rates than ours (0.2%, 0.7%, 0.8%) among bi-rads 3 lesions have been previously reported by graf et al. chae et al. and baum et al.6,16,17 however, in these studies, ultrasound was combined with mammography, which improved diagnostic accuracy. mri bi-rads category 3 is not frequently used. it is associated with higher malignancy detection rates when compared with ultrasound or mammography.18 this is likely because the criteria for mri bi-rads category 3 are not well established as it is a relatively new modality. our study replicated the fact that the risk for breast cancer is less than 2% for bi-rads 3 lesions. when this is considered against the background of significantly higher cost of biopsy in our centre, imaging short-term follow-up would be ideal. also, unnecessary high tissue sampling of benign masses would be avoided. initial 6 month ultrasound follow-up will be critical to detect rapidly growing masses because we noticed that our patients’ compliance declined with long follow-up intervals. however, where the patient is not able to return for a follow-up examination or if imaging is not available to the patient, they should be offered an immediate biopsy.19 conclusion ultrasound is a cost-effective alternative to biopsy for benign breast lesions. however, patients should be carefully assessed before their lesions are assigned to the bi-rads 3 category. physicians and radiologists need to explain the goals of follow-up with their patients effectively to ensure better compliance and reduce anxiety. limitations there were 25 patients who were excluded for loss to follow-up and incomplete data, thus creating an unavoidable bias. the small sample size limits interpretation. nonetheless, our results are in accordance with previous studies that involved larger sample sizes. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution s.a.o-a. and g.h.y. were responsible for conception and design of the study. s.a.o-a., g.h.y. and a.u.h. were responsible for critical analysis for intellectual content. h.a. and a.u.h. were responsible for the collection, analysis and interpretation of data. preparation of the manuscript was done by s.a.o-a. and h.a. all the authors read and approved the final manuscript. references alimoglu e(1), alimoglu mk, ceken k, et al. bi-rads category 3 nonpalpable breast masses on sonography: long-term results of a prospective cohort study. j clin ultrasound. 2012;40(3):125–134. https://doi.org/10.1002/jcu.21894 american college of radiology. bi-rads – ultrasound. 1st ed. in: d’orsi cj, mendelson eb, ikeda dm, et al. editors. breast imaging and data systems (bi rads) atlas. 4th ed. reston, va: american college of radiology, 2003; n.p. stavros at, thickman d, rapp cl, dennis ma, parker sh, sisney ga. solid breast nodules: use of sonography to distinguish between benign and malignant lesions. radiology. 1995;196 (1):123–34. https://doi.org/10.1148/radiology.196.1.7784555 giess cs, smeglin lz, meyer je, ritner ja, birdwell rl. risk of malignancy in palpable solid breast masses considered probably benign or low suspicion: implications for management. j ultrasound med. 2012;31(12):1943–1949. https://doi.org/10.7863/jum.2012.31.12.1943 graf o, helbich th, fuchsjaeger mh, et al. follow-up of palpable circumscribed non-calcified solid breast masses at mammography and us: can biopsy be averted? radiology. 2004;233(3):850–856. https://doi.org/10.1148/radiol.2333031845 graf o, helbich th, hopf g, graf c, sickles ea. probably benign breast masses at us: is follow-up an acceptable alternative to biopsy? radiology. 2007;244(1):87–93. https://doi.org/10.1148/radiol.2333031845 d’orsi c, sickles ea, mendelson eb, morris ea. breast imaging reporting and data system: acr bi-rads breast imaging atlas. 5th ed. reston, va: american college of radiology; 2013. park ym, kim ek, lee jh, et al. palpable breast masses with probably benign morphology at sonography: can biopsy be deferred? acta radiol. 2008;49(10):1104–1111. https://doi.org/10.1080/02841850802438504 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https://doi.org/10.1148/radiol.2483071786 santen rj, cerilli la, harvey ja. the breast: gynecomastia and benign breast disease in women. in: besser gm, thorner mo, editors. comprehensive clinical endocrinology. london: elsevier science, 2002; p. 585–612. heinig j, witteler r, schmitz r, kiesel l, steinhard j. accuracy of classification of breast ultrasound findings based on criteria used for bi-rads ultrasound. ultrasound obstet gynecol. 2008;32(4):573–578. https://doi.org/10.1002/uog.5191 kim ek, ko kh, oh kk, et al. clinical application of bi-rads final assessment to breast sonography in conjunction with mammography. am j roentegenol. 2008;190(5):1209–1215. https://doi.org/10.2214/ajr.07.3259 chae ey, cha jh, shin hj, choi wj, kim hh. reassessment and follow-up results of bi-rads category 3 lesions detected on screening breast ultrasound. am j roentgenol. 2016;206(3):666–672. https://doi.org/10.2214/ajr.15.14785 baum jk, hanna lg, acharyya s, et al. use of bi-rads 3 probably benign category in the american college of radiology imaging network digital mammographic imaging screening trial. radiology. 2011;260(1):61–67. grimm lj, anderson al, baker ja, et al. frequency of malignancy and imaging characteristics of probably benign lesions seen at mri. ajr am j roentgenol. 2015;205(2):442–447. https://doi.org/10.2214/ajr.14.13530 american college of radiology. breast imaging reporting and data system-magnetic resonance imaging (bi-rads-mri). 1st ed. reston, va: american college of radiology; 2003. revie\n cerebrovascular • •neurolmaglng: ""hich tests and ""hen? michael hoffmann durban cerebrovascular group, department of surgery, university of natal, durban cerebrovascular neuroimaging requires careful clinical and rad iological correlation for interpretation. with a profusion of tests avai lable, what is the best investigation and when? determination of brain pathology and pathophysiology was for a long term largely deductive with no objective evidence. early neurologists had to wait for autopsy information for a definitive diagnosis. both the impervious, intact skull and the dearth of clinically useful brain treatment strategies contributed to the "dark ages of the brain". the situation today is vastly differentin that we are overwhelmed with an ever increasing array of new investigative tools. these include colour duplex doppler flow imaging (cdfi), transcranial doppler (tcd), magnetic resonance imaging (mri), magnetic resonance angiographic imaging (mra), single photon emission computed tomographic imaging (specf), spiral computerised tomography (helical or spiral cf) and positron emission tomography (pet). coincidentwith such a wide choice ofbrain imaging methods, are the imminent acute stroke therapies (antithrombotics, thrombolytics, neuroprotective and gene based therapies) that are antidpated within the next few months to years. despite the complexity of the brain, outward manifestations of impairment remain limited to long tract signs,visual deficits and cognitive deficits, underscoring the need for paraclinical evidence of malfunction. colourduplexflowimaging (cdf!) has become a routine test for extra cranial arterial assessment with excellent sensitivity and specificity as compared to angiography.' plaque characteristics are most accurately 6 sa journal of radiology. september 1996 assessed with cd fi and area stenosis as measured by doppler as opposed to diameter stenosis as measured by angiography is a more accurate correlate of the true anatomical degree of stenosis.2 a recent and at present still clinical investigation extension of cdf! is power doppler imaging (pod. this new modality generates intravascular colour signals from the amplitude of the echo signal, which in tum depends on the intensity of the sampled red blood cells.it overcomes the two major limitations of cdfi which are the assessment of high grade stenosis and the intrastenotic diameter and area reduction in heavily calcified plaques, which are commonly encountered. in addition the method is angle independent and free from aliasing artifacts which is a limitation of cd pi. the poi contrasts the lumen with colour similar to angiography. in this respect it essentially bridges the gap between angiography and cdf! whose major limitations were inability to image the outer vessel boundary and residual vessellumen." transcranial doppler (tcd) has established applications for the reliable diagnosisof intracranial vessel stenosis,vasospasm, willisian collateralisation and arteriovenous malformations. inaddition, it is useful for the detection of vasomotor testing and monitoring and brain death.' a more recent and highly clinically relevant application is in the detection of intracranial emboli, whether of cardiac, large artery or exogenous source. the diagnosis of patent foramen ovale, an important predisposing factor in a significant proportion of young stroke patients of "un determined aetiology", is most easily and cheaply done by contrast ("bubble'] tcd.6 the differentiation of symptomatic from asymptomatic carotid stenoses can also be fadlitated by determining the degree of artery to artery embolisation bytcd by performing hits (high intensity transient signals) counts. 7 both duplex and powertcd t:-:o~pa':"':'g-e7:---...... revie\i\i frompage6 are currently in the clinical investigational stage with promise for considerable widening of their applications magnetic resonance imaging has afforded the excellent anatomical detail of the brain especially in areas which do not show up weil on computerised tomographic (ct) scanning such as the brainstem, cerebellum and spinal cord. routine mr imaging by spin echo sequences, the best known beingt1, t2 and proton density weighted images.tl images enable high tissue to tissue differentiation (anatomy), t2 images are most useful for intratissue characteristics (pathology) and proton density weighted images aid differentiation of focal tissue changes adjacent to free fluid such as the subarachnoid space and ventricles. this has resulted in unheralded accuracy of diagnoses of posterior circulation infarction especially of the brainstem, cerebellum and diencephalon. thrombolysis with tissue plasminogen activator is now indicated for a subset of acute stroke patients'the accurate, early detection of this treatable subgroup of patients is dependent on the appropriate investigative technique.as a consequence, the requirement for ultra early detection of infarctive and haemorrhagic components is of vital importance. two new investigative techniques, mr diffusion (mrd) and mr perfusion (mrp) allow tissue changes of cytotoxic oedema to be seen within 1 hour of onset. 9 ultrafast echoplanar imaging may reduce this to about 30 minutes and allowsimaging of ischaemie tissue that has been experimentally reversed in the animal model by drugs such as nmda antagonists.p!' although not routine in clinicalpractice, these methods hold promise, mr angiography (mra) has already reached routine clinical practice with the two principle techniques; namely, time of flight (tof) and phase contrast (pc) each having their partienlar attributes" most usefully combined with transcranial doppler and duplex doppler to grade stenoses, a two and three dimensional cerebrovascular tree can be imaged entirely noninvasively. mra adds only about 10 minutes to the conventional mrl scan of the brain and it is easy to see that this may rapidly become a routine part of cerebrovascular imaging. finally, magnetic resonance spectroscopy (mrs) although not yet in clinical use, may detect the earliest possible changes of ischaemia at cellular level by measuring increases of lactate and a fallin high energy phosphates. 13 computerised tomographic brain scanning has improved with respect to definition and speed of examination with each new generation of scanners. because of its inherent drawbacks itis relegated to the task of characterisation of sudden brain syndromes into either mass lesions or stroke, and in the case of stroke, to differentiate haemorrhage from bland infarction, ho~ever due to its popularity and relatively lower cost it will probably retain its position as the most widely used brain scanning method. the novel application ofhelical ct scanning of blood vessels has become so useful clinically that even dissection of carotid arteries, until recently the domain of conventional angiography,can be reliably diagnosed by this method." spect has been shown to be a sensitive indicator of cerebral perfusion and the most sensitive brain scan for the demonstration of ischaemia and infarction in the acute phase. three different tracers are available for clinical use; hmpao, iodine 123 and tc ethyl cysteinate dimer. the radionucleotide is injected intravenously and accumulates in different areas of the brain proportionate to the rate of delivery of nutrientslblood flow to that volume of brain tissue. technology has allowed the combination of gamma cameras and computerised tomography to create three dimensional construction of images. the major advantage ofspect is its functional imaging capadtywhich complements the 7 sa journal 'of radiology. september 1996 standard anatomical imaging using magnetic resonance and the older computerised tomography scans. spect is also affordable and considerably cheaper than positron emission tomography (pet). the latter is globally limited by cost and the necessity for proximity to radionucleotide processing (a cyclotron). in fact, the cost of spect is similar to the conventional ct scan without contrast. the major advantage of pet over spect isimproved resolution and its capability for the measurement ofregional cerebral metabohsm. biochemical information from receptor activity measurement such as muscarinic, benzodiazepine, serotonergic and dopaminergic receptor systems are possible but are not in routine clinical use and remain experimental atthe time ofwriting is the quest for pathophysiological subtyping in acute stroke has never been more urgent. the long hst of animal-effective, human-failure stroke drugs has been blamed squarely on the unreahstically long time window of24 48 hours or more for patient recruitment. now that we appreciate that "time is brain" and strive for sub 6 hour recruitment period for acute stroke intervention, this may nevertheless be unnecessarily rigid and exclude potentially salvageable patients with slightly longer time frames, 16 such subtyping can only be done with the strategic choice of a combination of functional and structural neuroimaging. by means oitcd andmra the site of arterial occlusion can be defined in order to determine the desirability of thrombolytic therapy and to exclude patients with distal arterial or branch occlusion or those without occlusion. tissue viability can be determined to some degree by early speer, diffusion weighted mrl and extent of hypo perfusion can be deduced by cl.the exact choice, timing and interpretation of these modalities remains within the domain of the art and science ofmedidne. lopage8 revievv !rampage 7 all the tests have the capability of me asuring either anatomical or functional derangement of the brain or indeed both and many have the added capability of depicting pathophysiological events in three axes (x, y and z axes) and four (time) dimensional domains. in combination with the specialities of cardiovascular medicine and vascular surgery it can readily be appreciated that the heart and the entire cerebrovascular tree can be evaluated noninvasively.this constitutes not only the heart, but also the aortic arch and its major .branches, the cervicocephalic vessels (vertebral arteries vlv3, common, extemal and internal carotid), the intracranial carotid (siphon region and v 4 vertebral sections) and the circle of willis and its major branches. conventional angiography today seems destined largely for the exclusion of infrequent vasculitic disorders and clarification of discrete anatomical features of aneurysms and arteriovenous malformations. the current approach to cerebrovascular diagnostics demands an immediate appraisal of the stroke mechanisms as all early and secondary preventative treatment is entirely dependent on determination of the pathophysiology. in the acute stroke situation, the initial three questions the clinician has to answer before initiating treatment are is it a stroke (and not a neoplasm, seizure or migraine), if it is a stroke, is it bland infarction or haemorrhage; and ifblandinfarction what subtype (because these have different treatments). broad categories include 1) small vessel atherosclerotic disease (lacunarj.z) large vessel atherosclerotic disease (carotid, vertebral or intracranial stenoses), 3) cardioembolism (disrhythmias, valvular, dyskinetic segments, paradoxical embohsm),4) other (dissection, prothrombotic, vascuhtic) and 5) undetermined groups. briefly, treatment options include: antiaggregant therapy and risk factor control for small vessel disease, carotid endarterectomy and at times aortic branch vessel bypass for large vessel disease. most cardiac diseases are eminently treatable: antithrombotics for dissection, anticoagulants for many prothrombotic disorders and immunosuppressive agents for many of the vasculitides constitute effective albeit not always curative treatment today. using combinations of the neurodiagnostic armamentarium to advantage is the key to accurate diagnosis and hence cost efficacy.the latter isparticularly relevant given current (and very likely future) financial restraints and managed health care. in the clinical context it may be readily appreciated how mra may clearly depict a stenosis in a large brain supplying vessel which may be graded by transcranial doppler. likewise, spiral ct may complement duplex doppler of a brain supplying cervicocephalic vessel. in both instances invasive intra-arterial angiography is obviated. transcranial doppler and duplex doppler not only rapidly and cost effectively diagnose large artery disease but may also diagnose high intensity transient signals (hits), diagnostic of emboli in most instances and whether the embologenic site is cardiac,major vessel (carotid bifurcation) or intracranial stenosis. spect andtcd have been usefully combined for prognostication and stroke subtype classification,to guide therapy and to deduce a cerebral perfusionindex." both tcd and spect may be used to estimate cerebrovascular reserve using co2, acetazolamide or paper bag rebreathing as vasodilatory agents.' such subtyping of cerebral ischaemie symptomatology allows refinement of treatment options such as earlier and more appropriate carotid endarterectomy (cea). spect iscurrently the best early stroke imaging test and provides objective evidence for diaschisis type neurological deficits, seen with a variety of stroke patients both cortical and subcortical.' 5 s sa journal of radiologyseptember 1996 as one of many possible illustrative examples, it is easy enough to appreciate that a clinical diagnosis of posterior circulation ischaemia or minor infarction (so called vertebrobasilar insufficiency) is rarely made with confidence. such patients are notoriously difficult to diagnose and usually have had numerous speciality consultations and a long hst of costly nondiagnostic investigations, mainly because they present with a plethora of symptoms that may fluctuate with time. even isolated tinnitus and vertigo may be presenting features and masquerade as otologic problems, but more commonly a nondescript "wooziness" is reported, much to the despair of the clinician. with a clinical suspicion though, in the absence of other disease, mra of the vertebral and basilar arteries, usefully combined with transcranial doppler might detect the responsible vertebral artery origin disease or basilar stenosis. antiaggregant treatment may be then prescribed with conviction or changed to tielepidine or warfarin as required. both doctor and patient will benefit from more precise diagnosis of the neurological symptomatology. biotechnology has rewarded us with remarkably clear pictures of the brain structure and function that impact on management. the most challenging issue facing the clinician and radiologist today isthe knowledge of discriminatory use of these modalities. clearly, no exact step by step flow diagram for stroke investigation can be presented as every stroke patient is different. investigation must be tailored and individualised. stroke should be recognised as a multidisciplinary syndrome and so too isthe investigation. the way forward seems certain to be a close multidisciplinary haison for each individual patient. the effective, orderly use of tests can save time, speed up diagnosis and save the patient from undergoing unnecessary, expensive and at times potentially harmful tests. despite the ever increasing fractionation of medical sub to page 15 abstract introduction clinical history magnetic resonance imaging findings pathologic findings discussion conclusion acknowledgements references about the author(s) margaret e. kisansa department of radiology, school of medicine, sefako makgatho health sciences university, dr george mukhari hospital, south africa nndweleni m. bida department of pathology, school of medicine, sefako makgatho health sciences university, dr george mukhari hospital, south africa pule mutati department of medicine, school of medicine, sefako makgatho health sciences university, dr george mukhari hospital, south africa peter s. ramoroko department of cardiothoracics, school of medicine, sefako makgatho health sciences university, dr george mukhari hospital, south africa citation kisansa me, bida nm, mutati p, ramoroko ps. case of tuberculous pericarditis presenting as a giant pericardial adhesion and masquerading as a pericardial tumour. s afr j rad. 2018;22(1), a1359. https://doi.org/10.4102/sajr.v22i1.1359 case report case of tuberculous pericarditis presenting as a giant pericardial adhesion and masquerading as a pericardial tumour margaret e. kisansa, nndweleni m. bida, pule mutati, peter s. ramoroko received: 02 may 2018; accepted: 22 july 2018; published: 27 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract chronic pericarditis characterised by adhesions between the parietal and visceral pericardium is called adhesive pericarditis. in south africa, tuberculosis is the most common cause of chronic pericarditis. we report a case of adhesive pericarditis that mimicked a tumour. introduction tuberculous pericarditis is a common disease among the african and asian populations because of the high prevalence of tuberculous infections.1 chronic pericarditis characterised by adhesion between the parietal and visceral pericardium is called adhesive pericarditis. we report a case of a young female patient who presented with adhesive pericarditis that mimicked a pericardial tumour. clinical history a 27-year-old female patient presented with swelling of the abdomen and difficulty in breathing. she had a history of a tuberculous pericardial effusion one year prior to admission and had completed a regimen consisting of six months of anti-tuberculous therapy and steroids. clinical examination revealed a patient in respiratory distress, with congested neck veins and massive ascites. she had mild pallor, tachycardia and pedal oedema. the lungs were clear. the full blood count showed a low haemoglobin 9.7 g/dl, a low red cell count 3.30 × 1012/l and a normal white cell count. the renal function tests were grossly normal, and this patient did not have the human immunodeficiency virus (hiv). electrocardiogram (ecg) showed right axis deviation with inverted t waves in leads ii, iii, avf, v1–v6. the patient had features of constrictive pericarditis. the echocardiography report was unresolved and confusing with a conclusion of a suspected tumour or thrombus in the right ventricle. cardiac catheterisation study showed that the right ventricular (rv) and left ventricular (lv) pressures were consistent with constrictive pericarditis. the patient was then referred for magnetic resonance imaging (mri) to further evaluate for the suspected tumour and ventricular function. magnetic resonance imaging findings magnetic resonance imaging was performed on a philips multiva 1.5 tesla scanner. images were acquired in the para septal long axis, short axis and four-chamber views. intravenous contrast was administered to further evaluate the mass lesion. the findings confirmed a large 6 cm × 4 cm × 8 cm mass compressing the right ventricle. the short axis post contrast t1 spectral presaturation inversion recovery black blood (t1_spir_bb) sequence image in figure 1 showed a high signal intensity mass lesion compressing the right ventricle; this was associated with a nodular pericardium and massive ascites. the lesion was closely adherent to the pericardium but separable from the rv wall. the mass remained hyperintense on t2 short tau inversion recovery black blood (t2_stir_bb) sequences (figure 2). proton density short tau inversion recovery black blood (pd stir bb) series in figure 3 also demonstrated a predominantly high signal intensity mass with hypointense streaks. the persistent high signal on both t1 and t2 sequences indicated the absence of fluid. failure to suppress on all the fat suppression sequences, confirmed the absence of fat. there was marked mass effect, which impeded ventricular filling in diastole. a pronounced septal bounce was evident on the functional imaging series (not shown). the cardiac function was severely depressed with an ejection fraction (ef) of < 40%. figure 1: short axis post contrast t1 spectral presaturation inversion recovery black blood sequence showing a high signal mass lesion (black arrow) with an associated nodular pericardium (black arrowhead) and massive ascites (white arrow). figure 2: the lesion (black arrow) remains hyperintense on the t2 weighted short axis series. figure 3: proton density (4-chamber view) shows a predominantly hyperintense lesion with mass effect, as indicated by the white arrow. pathologic findings the patient subsequently underwent total pericardial stripping with excision of the mass. histology showed fibrous pericardium with chronic inflammatory aggregates, including predominant lymphocytes with granulation tissue formation as seen in figures 4 and 5. there was fibrinous exudate characterised by an eosinophilic meshwork of threads and amorphous coagulum, without a granulomatous response. figure 4: haematoxylin and eosin (h&e) photomicrograph at 20× magnification of the fibrous pericardium showing organising fibrin deposition. figure 5: haematoxylin and eosin (h&e) photomicrograph at higher magnification (40×) of the organising fibrin deposition showing an amorphous coagulum of acellular fibrin. discussion pericarditis is defined as inflammation of the pericardium, and this has a number of causative agents like infection, neoplastic conditions, systemic conditions including collagen vascular diseases, trauma and others.1 morphologically, the manifestations of pericardial disease include fibrin, fluid (serous, blood and lymph), purulent matter, fibrous tissue, neoplasm, granuloma, calcium and cholesterol.2 these conditions present with different clinical and radiological manifestations, as well as a diversity of causal agents as indicated above. cherian (2004) reported that it was common to find pericardial effusions of unknown aetiology with an incidence of approximately 11% – 32% in countries like france, the united kingdom (uk) and the united states (us).1 in south africa, however, tuberculous pericarditis is the commonest cause of pericardial inflammation and effusions, with an incidence of 69.5%.3 tuberculosis is a multisystem disease, which is uncommon in developed countries, with an incidence reported at 4%.3 on the contrary, its prevalence in developing countries is very high, and hiv has led to a further increase in the numbers of affected individuals.1,4 tuberculosis pericarditis, caused by mycobacterium tuberculosis, results from infection of the pericardium, most commonly by haematogenous or retrograde lymphatic spread.1 there are three clinico-pathological forms of chronic pericardial disease, viz. adhesive pericarditis, adhesive mediastino-pericarditis and constrictive pericarditis.5 adhesive pericarditis is characterised by adhesion between the parietal and visceral pericardium.5,6 the disease is seen commonly in low socio-economic settings as a result of rheumatic heart disease, tuberculosis or, less commonly, pyogenic infections.7 in a small proportion of cases, the cause is unknown.7 the second form of chronic pericardial disease may occur together with mediastinal involvement, referred to as adhesive mediastino-pericarditis.5 in this instance, the pericardial sac is obliterated because of adhesion between the two layers of the pericardium, as well as between the parietal pericardium and surrounding mediastinal structures, chest wall and diaphragm. the third form of chronic pericardial disease takes the form of constrictive pericarditis, characterised by marked thickening of the parietal pericardium, with less involvement of visceral pericardium causing constriction of the great vessels entering and leaving the heart.5 the pericardial space is obliterated by dense fibrous tissue, which is often calcified.2,5 in many instances, tuberculosis is the most common cause. occasionally, pericardial heart disease may be because of pyogenic infection,8 and in some, the cause is unknown.7 in tuberculous pericarditis, granulomas may not be histologically apparent if the patient is treated. in this case, polymerase chain reaction (pcr) may be useful to establish the diagnosis.1 tissue cultures, however, have been found to be the most reliable.1,9 cardiac mri demonstrates the morphologically thickened pericardium10 and demonstrates functional changes that occur secondary to constriction (constrictive pericarditis). these changes are because of systolic and diastolic dysfunction, which is a result of impaired ventricular filling.7 this patient presented with an unusual form of constrictive tuberculous pericarditis, which was due to a pericardial adhesion that presented as a compressive mass. this resulted in a focal mass-like adhesion causing compression of the right ventricle and rv dysfunction. surgical treatment in the form of pericardiectomy was performed, and the postoperative period was uneventful. the diagnosis of pericarditis was confirmed at histology. the patient was clinically well at follow-up, 12 months after surgery. conclusion the diagnosis of pericardial adhesions should be included in the differential diagnosis of patients with pericardial effusions who suddenly present with a pericardial mass. acknowledgements the authors would like to thank dr m.j. chokoe-maluleke who worked closely with prof. bida on the histology slides. she could not be contacted at the time of this publication. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors contributions m.e.k. was responsible for the conception, design and drafting of the article, acquiring and reporting the mri images, revising critically for intellectual content and approval of the final version to be published. n.m.b. was responsible for acquiring and reporting the pathology slides, design and revising critically for intellectual content and approval of the final version to be published. p.m. was responsible for the clinical notes and approval of final version for publication. p.s.r. was responsible for the surgical notes and approval of the final version to be published. references cherian g. diagnosis of tuberculous aetiology in pericardial effusions. postgrad med j. 2004;80(943):262–266. https://doi.org/10.1136/pgmj.2003.013664 roberts wc. pericardial heart disease: its morphologic features and its causes. proc (bayl univ med cent). 2005;18(1):38–55. pmcid: pmc1200698; pmid: 16200146. mayosi bm, burgess lj, path mc, doubell af. tuberculous pericarditis. circulation. 2005;112:3608–3616. https://doi.org/10.1161/circulationaha.105.543066 ntsekhe m, wiysonge c, volmink ja, commerford pj, mayosi bm. adjuvant corticosteroids for tuberculous pericarditis: promising, but not proven. qjm – mon j assoc physicians. 2003. https://doi.org/10.1093/qjmed/hcg100 schoen fj, mitchell rn. the heart. in: kumar v, abbas ak, fausto n, aster jc. editors. robbins and cotran pathologic basis of disease. philadelphia: elsevier health sciences (saunders), 2009; p. 523–578. peebles cr, shambrook js, harden sp. pericardial disease-anatomy and function. br j radiol. 2011;84(spec. issue 3). https://doi.org/10.1259/bjr/16168253 khandaker mh, espinosa re, nishimura ra, et al. pericardial disease: diagnosis and management. mayo clin proc. 2010;85(6):572–593. https://doi.org/10.4065/mcp.2010.0046 bhatarai m, yost g, good cw, white cf, nepal h. primary purulent pericarditis with cardiac tamponade due to oropharyngeal polymicrobial infection: a case report and literature review. korean j thorac cardiovasc surg. 2014;47(2):155–159. https://doi.org/10.5090/kjtcs.2014.47.2.155 trautner bw, darouiche ro. tuberculous pericarditis: optimal diagnosis and management. clin infect dis. 2001;33(7):954–961. https://doi.org/10.1086/322621 hayashi h, kawamata h, machida m, kumazaki t. tuberculous pericarditis: mri features with contrast enhancement. br j radiol. 1998;71(846):680–682. https://doi.org/10.1259/bjr.71.846.9849395 http://www.sajr.org.za open access sa journal of radiology issn: (online) 2078-6778, (print) 1027-202x page 1 of 1 corrigendum authors: paul rischbieter1 christine sinclair1 andrew lawson1 samia ahmad1 affiliations: 1department of radiology, university of pretoria, south africa corresponding author: paul rischbieter, rischbieter.p@gmail.com dates: published: 31 aug. 2017 how to cite this article: rischbieter p, sinclair c, lawson a. & ahmad s. corrigendum: uterine artery embolisation as an effective choice for symptomatic fibroids: five-year outcome. s afr j rad. 2017;21(1):a1265. https://doi.org/10.4102/sajr. v21i1.1265 copyright: © 2017. the authors. licensee: aosis. this work is licensed under the creative commons attribution license. in the initially published version of this article, the ethical considerations statement was omitted. ethical considerations approval for this study was obtained from the steve biko academic hospital, the mmed protocol committee and the university of pretoria faculty of health sciences research ethics committee (protocol number 443/2015). the omission has not altered the study’s findings of significance or overall interpretation of the study results. the authors apologise for any inconvenience caused. corrigendum: uterine artery embolisation as an effective choice for symptomatic fibroids: five-year outcome note: doi of original article: http://dx.doi.org/10.4102/sajr.v20i1.959 read online: scan this qr code with your smart phone or mobile device to read online. http://www.sajr.org.za mailto:rischbieter.p@gmail.com https://doi.org/10.4102/sajr.v21i1.1265 https://doi.org/10.4102/sajr.v21i1.1265 http://crossmark.crossref.org/dialog/?doi=10.4102/sajr.v21i1.1265=pdf&date_stamp=2017-08-31 http://dx.doi.org/10.4102/sajr.v20i1.959 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) ilonka warnich department of diagnostic radiology, university of the witwatersrand, johannesburg, south africa mark nicolaou department of diagnostic radiology, university of the witwatersrand, johannesburg, south africa zelia sofianos department of diagnostic radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa jacobus a. pienaar department of diagnostic radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa jacob varghese department of diagnostic radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa citation warnich i, nicolaou m, sofianos z, joubert g, pienaar ja, varghese j. page kidney: a rare cause of secondary hypertension. s afr j rad. 2019;23(1), a1762. https://doi.org/10.4102/sajr.v23i1.1762 case report page kidney: a rare cause of secondary hypertension ilonka warnich, mark nicolaou, zelia sofianos, jacobus a. pienaar, jacob varghese received: 31 may 2019; accepted: 16 july 2019; published: 23 sept. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract page kidney is a rare phenomenon that can present with hypertension. the presence of a subcapsular perirenal collection causes parenchymal compression leading to renal hypoperfusion. subsequent activation of the renin–angiotensin–aldosterone system results in an increase in systemic blood pressure. the causes of renal subcapsular collections are varied, with most cases being secondary to post-traumatic haematomas. we present the case of a young hypertensive patient, treated as primary hypertension with persistently uncontrolled blood pressures. this was despite good treatment adherence. on further investigation, imaging identified the presence of bilateral subcapsular collections. this case illustrates the importance of a thorough workup in a young hypertensive patient with refractory hypertension. given that page kidney is curable, timeous intervention can save the patient from unnecessary medications and the morbidity of uncontrolled blood pressures. keywords: page kidney; young; hypertension; secondary hypertension; subcapsular collection. introduction page kidney is an entity that few doctors have come across and is rarely considered as part of the differential diagnosis in a young hypertensive patient. however, it is a crucial diagnosis to make, as it is a potentially curable cause of secondary hypertension. case presentation a 23-year-old female presented to the emergency department (ed) with an acute history of neck stiffness and headache, not responding to analgesia. she had been diagnosed with hypertension at a local clinic and was referred to the ed for further workup and management. on initial clinical examination, blood pressure was noted to be 187/117 mmhg. the patient was found to have photophobia, neck stiffness and disorientation. she was worked up for possible meningitis or a subarachnoid haemorrhage. both conditions were subsequently excluded after cerebrospinal fluid (csf) biochemistry and computed tomography (ct) brain imaging, respectively. the patient’s renal function was noted to be normal at this stage. during her initial admission, her blood pressure remained elevated despite appropriate therapy and she was later discharged on anti-hypertensive treatment. the patient then re-presented 4 months later and was admitted as a hypertensive urgency with a blood pressure of 178/118 mmhg. on physical examination, bilateral flank masses were palpated. further systematic examination revealed no other abnormalities. the patient’s blood results showed deterioration in renal function. the patient’s blood pressure was eventually controlled with a combination of three anti-hypertensive agents. an erect abdominal radiograph demonstrated fullness in bilateral renal fossae with obscuration of the psoas outlines, as shown in figure 1. a bedside ultrasound performed by the attending clinicians revealed bilateral encapsulated renal cysts. a working diagnosis of polycystic kidney disease was made. a subsequent ultrasound was then repeated in the radiology department, showing bilateral subcapsular renal collections with low-level internal echoes (figure 2). a contrast ct study of the abdomen was performed and demonstrated large bilateral subcapsular perirenal collections with the fluid measuring 24 hounsfield units (figure 3a and 3b). additional findings included compression and anatomical distortion of the kidneys. figure 1: erect abdominal radiograph demonstrating fullness of bilateral renal fossae with obscuration of the psoas outline suggestive of renal masses. associated mass effect evidenced by inferior displacement of adjacent bowel loops. figure 2: sagittal ultrasound image of the right kidney depicting a large perirenal hypoechoic fluid collection with hyperechoic internal echoes compatible with complex fluid. associated medial displacement and compression of the right kidney. similar findings were seen on the contralateral side (not shown) figure 3: (a, b) contrast-enhanced axial and coronal computed tomography of the abdomen demonstrating large bilateral subcapsular collections (stars) causing compression of the renal parenchyma (arrowheads). the aforementioned imaging features were in keeping with bilateral perirenal haematomas. a differential diagnosis of bilateral renal lymphangiomatosis was entertained. however, given the complex nature of the fluid on ultrasound and elevated hounsfield units on ct, this diagnosis was less likely. on further clinical evaluation, the patient denied any history of prior trauma. an underlying coagulopathy was excluded. the patient was subsequently referred to a tertiary institution for further management. ethical consideration informed consent from the patient was obtained; permission from the ceo of the hospital was also obtained. discussion the workup of a young hypertensive patient, defined as hypertension below the age of 30, has traditionally consisted of extensive investigations to exclude a secondary cause. however, the prevalence of hypertension among the young has rapidly increased, doubling over the past decade, and in most cases a diagnosis of primary hypertension is made.1 because of the high demand on healthcare costs, it has been recommended that the routine workup of these patients is limited to baseline investigations. special tests, such as renal imaging, should be directed and reserved for patients with a clinical suspicion of an underlying cause.1 in most institutions, renal ultrasound is still considered a baseline investigation; however, it is not always readily available. therefore, as in our case, young patients are frequently managed as primary hypertension with a resultant delay in the diagnosis of a secondary cause. irvine page first described the phenomenon of page kidney in 1939 after wrapping canine kidneys in cellophane and observing a consequent rise in blood pressure.2 engle and page documented the first clinical case of page kidney in 1955, when a young american football player was diagnosed with a subcapsular renal haematoma and concomitant hypertension. following a nephrectomy, the patient’s blood pressure normalised.3 the presumed pathogenesis of hypertension is by sustained renal parenchymal compression with altered small vessel haemodynamics. the resultant hypoperfusion and microangiopathic ischaemia then trigger the renin–angiotensin–aldosterone system (raas), leading to salt and water retention with a rise in systemic blood pressure.3 this mechanism of hyper-reninaemic hypertension has been likened to goldblatt’s model of renovascular hypertension, which is caused by compression or stenosis of the major renal vasculature.4 many causes for page kidney exist. the external renal compression is most often in the form of a subcapsular collection. the subcapsular space is a potential perinephric space where fluids, such as blood, pus, urine, lymph, exudates or transudates, can collect.5 these occur secondary to various underlying conditions, which will guide the workup of the patient. the traumatic or iatrogenic subcapsular haematoma has been shown to be the most common cause of page kidney.6 previously, most cases were attributed to football or non-sports-related blunt abdominal trauma, referred to as a classical page kidney.7 analysis of cases reported after 1991 revealed an etiological shift towards the iatrogenic subcapsular haematoma.8 these most often occurred as complications of renal allograft biopsies but also after extracorporeal shock wave lithotripsy or ureteronephroscopic procedures.3 non-traumatic causes of page kidney are uncommon with isolated cases reported in the literature. these include spontaneous renal haemorrhage secondary to underlying tumours, arteriovenous malformations, cyst rupture, glomerulonephritis or vasculitis. subcapsular urinomas and lymphatic collections have also been described. in some cases, page kidney may be idiopathic.6,7 it is important to keep in mind that there may be a significant time lapse between the traumatic insult and the diagnosis of hypertension, with intervals from days to decades having been reported. the traumatic event could even occur unnoticed. the presentation can range from non-specific signs and symptoms with an insidious onset, to an acute episode of hypertensive urgency or emergency.4 page kidney should always be a consideration in the young hypertensive patient presenting with a renal mass or previous abdominal trauma.9 renal ultrasound and contrast-enhanced ct are generally sufficient in the diagnosis of page kidney.6 in cases of spontaneous renal haemorrhage, an important underlying cause to consider as part of the workup will include neoplastic lesions. of these, angiomyolipomas and renal cell carcinomas are the most common.10 a renal mass may not always be evident on the initial imaging and in some cases is only diagnosed on follow-up imaging after resolution of the haematoma.5 if no tumour is evident on ct, selective renal angiography can be valuable to assess for vascular diseases, such as polyarteritis nodosa, arteriovenous malformations or renal artery aneurysms.5 therapeutic embolisation can then be considered as part of the management. angiographic evaluation should especially be considered in cases of recurrent non-traumatic page kidney.4 spontaneous renal haemorrhage can also be caused by coagulation disorders, which should form part of the diagnostic workup.10 bilateral renal lymphangiomatosis, also referred to as lymphangiectasia, is an uncommon cause of page kidney. the typical imaging findings are bilateral subcapsular low-density fluid collections, with hounsfield units ranging from 0 to 10. renal ultrasound findings can include multiseptated perirenal fluid collections with or without peripelvic cysts.11 as an ancillary investigation, lymphoscintigraphy will reveal perirenal lymphatic leakage. aspiration and biochemistry of the perirenal fluid can assist in the diagnostic workup.11 previously, the management of classical page kidney involved radical nephrectomy or open surgery. with medical advances and improvements in anti-hypertensive drugs, especially those directed against the raas, management has shifted to a more conservative approach.8 there is still no standardisation in the definitive treatment of page kidney, which will depend on various patient factors, as well as the underlying cause.3 conservative management of subcapsular haematomas, with follow-up imaging to ensure resolution, can be successful in some cases.3 surgical intervention, however, is often necessary. the two main goals are to decompress the kidney by evacuating the haematoma and to remove the fibrocollagenous pseudocapsule, which can form in chronic cases.12 recent case reports have shown minimally invasive procedures such as laparoscopicor radiologic-assisted percutaneous drainage to be viable therapeutic alternatives.3 percutaneous drainage is thought to have higher success rates in subcapsular haematomas of less than 3 weeks duration. more chronic organised haematomas often require invasive procedures for adequate evacuation.3 in cases of lymphangiomatosis, the preferred management includes percutaneous drainage with injection of sclerosing agents.11 in some cases of page kidney, patients may require chronic anti-hypertensive treatment, regardless of the underlying cause and resolution thereof. this is partly because of the fact that there is often a delay in diagnosis with subsequent perinephric scarring.7,12 conclusion this case illustrates the need for a comprehensive workup of the young hypertensive patient and the importance of page kidney as a secondary, potentially reversible cause. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions i.w. made a substantial contribution to the conception and design, literature review and drafting of the article; m.n. made a substantial contribution to the conception and design, drafting and revision of the article; z.s. made a substantial contribution to the acquisition of data and drafting of the case report; j.a.p. made a substantial contribution to the acquisition of data and drafting of the case report; j.v. made a substantial contribution to the conception and design, revision and approval of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in the study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references mangena p, chb mb, sa fcp, saban s, chb mb, sa f. an approach to the young hypertensive patient. samj. 2016;106(1):36–38. https://doi.org/10.7196/samj.2016.v106i1.10329 page ih. the production of persistent arterial hypertension by cellophane perinephritis. jama. 1939;113(23):2046–2048. https://doi.org/10.1001/jama.1939.02800480032008 kobel mc, nielsen tk, graumann o. acute renal failure and arterial hypertension due to subcapsular haematoma: is percutaneous drainage a feasible treatment? bmj case rep [serial online]. 2016[cited 2019 may 18]. available from: https://doi.org/10.1136/bcr-2015-212769 kenis i, werner m, nacasch n, mbbs k. recurrent non-traumatic page kidney. imaj. 2012;14(7):452–453. haddad mc, hawary mm, khoury nj, abi-fakher fs, ammouri nf, al-kutoubi ao. radiology of perinephric fluid collections. clin radiol. 2002;57(5):339–346. https://doi.org/10.1053/crad.2001.0854 arslan s. sciencedirect bilateral nontraumatic recurrent page kidney. radiol case rep [serial online]. elsevier inc; 2017[cited 2019 may 18];12(3):511–513. available from: https://doi.org/10.1016/j.radcr.2017.05.003 smyth a, collins cs, thorsteinsdottir b. page kidney: etiology, renal function outcomes and risk for future hypertension. j clin hypertens. 2012;14(4):216–221. https://doi.org/10.1111/j.1751-7176.2012.00601.x dopson sj, jayakumar s, velez jcq. page kidney as a rare cause of hypertension: case report and review. yajkd [serial online]. national kidney foundation, inc.; 2009[cited 2019 may 18];54(2):334–339. available from: https://doi.org/10.1053/j.ajkd.2008.11.014 sokhal ak, prakash g, saini dk, singh k. page kidney: a rare but surgically treatable cause of hypertension. saudi j kidney dis transpl. 2018;29(1):193–197. https://doi.org/10.4103/1319-2442.225183 ahn t, roberts mj, navaratnam a, hirst j, wood s. recurrent spontaneous renal haemorrhage due to polyarteritis nodosa: a medical cause for a surgical problem. anz j surg[serial online]. 2017[cited 2019 may 18]. https://doi.org/10.1111/ans.13914 choudhury s, sridhar k, pal d. renal lymphangiectasia treated with percutaneous drainage and sclerotherapy. int j adolesc med health[serial online]. 2017[cited 2019 may 18]. available from: https://doi.org/10.1515/ijamh-2017-0024 davies mc, perry mj, georges s. urological management of ‘page kidney’. bju int. 2006;98(5):943–944. https://doi.org/10.1111/j.1464-410x.2006.06432.x letters letters to the editor no scientific or medical journal would be complete without a section for the publication of letters from its readership. the importance of a 'letters, section is that it promotes academic interaction, allowing readers to voice an opinion, whether positive or negative, to anything printed within the journal or other issues of relevance to south african radiology. this issue therefore introduces a letters forum into the sajr and includes the first of hopefully many more letters to come. hepatic 'pseudo lesions' still an unrecognised pitfall the interesting short report entitled 'hepatic "pseudo lesions" still an unrecognised pitfall', i in the september 2002 edition of the sajr by drs ian duncan and pieter fourie, also illustrates a second helical ct scan pitfall. on their image taken during the early (arterial) phase of the contrast-enhanced ct scan, demonstrating unenhanced hepatic veins (fig. i), marked inhomogeneity of splenic enhancement is also shown. while most radiologists recognise this as a normal phenomenon, many of our non-radiological colleagues do not. clinical colleagues suspecting malignant or inflammatory splenic pathology have asked me on numerous occasions about this appearance. the authors of the article sum up these pitfalls very aptly when they state: 'although helical scanning has led to increased lesion detectability, it has also produced some artifacts unique to this technique: as the custodians of imaging, our role in defining what is normal must always remain as important as detecting what is abnormal. donemby western deep levels hospital western levels 1. duncan ic, fourie pa. hepatic 'pseudo lesions' still an unrecognised pitfall. south african journal of radiology 2002; 6(3): 36. in the article entitled 'bronchiolitis obliterans an illustrative case following toxic fume exposure' by sher and duncan (sa]r2002; 6(4): 43-45), the legend for figs 3a and 3b should read as follows: 'the darker areas are the abnormal ones indicating areas of air trapping.' erratum figs 3a and b. the same scan slices 8s in fig. 2 taken at different wind'!w.settings that further accentuate the mosaic attenuation pattern. the darker areas are the abnormal ones mdlcatmg areas of alf trappmg and hypoperfusion. 63 sa journal of radiology. june 2003 abstract introduction rectum anatomy technical-related pitfalls pathology-related pitfalls conclusion acknowledgements references about the author(s) joel bortz lsg imaging, los angeles, united states citation bortz j. potential pitfalls in the anorectal region during ct colonography: a discussion and pictorial overview of common pitfalls. s afr j rad. 2017;21(1), a1108. https://doi.org/10.4102/sajr.v21i1.1108 pictorial essay potential pitfalls in the anorectal region during ct colonography: a discussion and pictorial overview of common pitfalls joel bortz received: 05 oct. 2016; accepted: 09 nov. 2016; published: 28 feb. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract common potential anorectal pitfalls are presented with accompanying ct colonography images. although most lesions are benign, care must be taken in not missing an underlying cancer. introduction it is highly likely that requests for computer tomographic colonography (ctc) will increase because it was very recently added to the colorectal cancer screening tests in the united states.1 a steep learning curve exists for ctc.2 there are many entities in the anorectal region, which may cause interpretation problems for those with limited ctc experience.3,4 most findings do not require further investigation and may require just a digital rectal examination or anoscopy without the need for an optical colonoscopy (oc).3 ctc is a minimally invasive, fast, safe, low-dose and accurate study.5 an adequately prepared bowel with good distension of the colon is essential to achieve a successful study.3 based on the author’s experience, having performed > 6000 ctc examinations, the most common technical-related potential pitfalls (placement of the rectal catheter, stool and artefacts) and pathology-related pitfalls (internal haemorrhoids, polyps, cancer, hypertrophied anal papilla, perforation because of oc complications, and extrinsic impressions) are described with ctc images.2,4,6,7,8 in female patients, it is essential to always check that the catheter is in the rectum and not in the vagina before commencing insufflation.9 rectum anatomy the rectum is mostly a retroperitoneal organ commencing at the mid-sacral level and ending in the anal canal; its average length is 15 cm. it does not have haustral markings. the longitudinal taenia coli end at the rectosigmoid junction and continue only as a smooth muscle layer in the rectum.10 the three valves of houston (superior, middle and inferior) encircle about a third to a half of the rectal circumference.11 in a ctc study, the middle valve may serve as a landmark for the location of lesions in the rectum (figure 1). it indicates the level of the abdomino-peritoneal reflection anteriorly; it is typically 8 cm from the anal verge and demarcates the lower and middle third of the rectum.11 the dentate line (figure 2) represents the anatomic anorectal line, which is identified by an undulating demarcation in the rectal mucosa about 3 cm above the anal verge.10 figure 1: (a) 2d coronal view showing inferior, middle and superior valves of houston. (b) 2d sagittal view showing the three valves of houston in the rectum: superior (black arrow), middle (red arrow), inferior (white arrow). figure 2: anatomy of rectum: middle rectal fold of valve of houston and inferior rectal fold of valve of houston: 1, submucosal space and internal haemorrhoidal plexus; 2, external haemorrhoidal plexus in peri-anal space. technical-related pitfalls a rectal catheter can cause interpretation problems.12 it is preferable to use a small gauge (25 fr or smaller) disposable flexible latex-free catheter, with an inflatable balloon,13 which can be distended up to 50 cc without the risk of the balloon rupturing (figure 3). the catheter may obscure pathology in some patients.6 to minimise this potential pitfall, it is important to deflate the balloon in the prone view: (1) to obtain a full scan series without an inflated balloon, to ensure good visualisation of the distal rectum, and (2) to better visualise internal haemorrhoids, if present.6,9 figure 3: (a) hard catheter is unsuitable as it may cause perforation; (b) green arrow indicates trifurcation of tube and attached syringe for balloon distension; yellow arrow indicates rectal drainage bag. white arrow indicates connection to co2 insufflator. white circle shows black indicator line. the catheter must not be inserted into the rectum beyond the black line (white circle). inflated balloon (white arrows). blue arrows indicate two green filters to trap any faecal fluid from entering and contaminating the co2 insufflator. figures 4 to 6 illustrate several catheter-related pitfalls. the catheter may impinge on the valve of houston causing an extrinsic impression. if co2 flow is obstructed by any cause, deflate the balloon, pull back on the catheter until flow resumes and then re-inflate the balloon. an inflated balloon may cause a defect called the meniscus sign;14 this is a normal artefact which is depicted in figure 7. 2d and 3d views are complementary, and if available translucent display (td) shows what lies beneath the surface. this software displays different colour attenuation values: red indicates soft tissue; white indicates high attenuation values, such as barium; green indicates negative values in the fat attenuation range; and blue indicates negative values, such as air.14 figure 4: (a) 3d image shows the tip of catheter (white arrow) extending beyond the superior valve of houston; (b) 3d image shows tip of catheter projecting beyond the superior valve of houston causing simulation of polyp appearance (white arrows). figure 5: (a) 3d endoluminal view showing tube in direct contact with valve of houston (black circle). (b) 3d endoluminal view showing tube causing a bulge on rectal mucosa (black arrows). (c) 2d sagittal view shows tube impinging on fold (white circle). figure 6: (a) 3d view shows kinking of tube (black arrows); (b) 2d view shows tip of rectal tube bent to 90° (white circle). this obstructs flow of co2. figure 7: (a) 3d view showing meniscal defect (black arrows) due to balloon; (b) 3d view showing meniscal defect (black arrows) from inflated balloon; (c) 3d view showing polypoidal lesion (black arrows). white arrows show margin of meniscal sign; (d) td shows mainly barium (black arrows) indicating stool. occasionally, the rectal tube itself may obscure a sessile polyp in the rectum. the author’s standard technique is to perform a 360° fly around the rectal catheter to ensure adequate visualisation of all surrounding features. incomplete collapse of the balloon may cause artefacts that appear as polypoidal lesions. artefacts are an unwanted feature on a ctc image that may obscure or simulate pathology.15 the presence of residual stool remaining after a laxative preparation may present interpretation challenges. fluid and stool tagging reduces such challenges.6,16 untagged luminal fluid will not appear white on the 2d views, which means that if a lesion is present it will not be apparent. tagging with iodinated contrast (e.g. gastrografin or iohexol) enables lesions in fluid to be easily identified using windowing (w:2000 hu, l: 0 hu). a two-view series allows evaluation of the anterior and posterior walls because of shifting of fluid in these positions. figure 8 illustrates some stool-related pitfalls. stool may present as a polypoidal lesion on 3d endoluminal flythrough. it may move to the dependant bowel surface between the two-view study (supine and prone), which differentiates it from a sessile polyp.16 on 2d views, foci of air may be present in the polypoidal lesion.16 figure 8: (a) 2d supine axial view showing density on posterior wall with lucency within it (black arrow). white circle = rectal catheter; (b) prone axial study shows the density has shifted to anterior wall indicating stool (black arrow). white circle = rectal catheter; (c) 3d endoluminal view showing polypoidal lesion (black circle); (d) 2d coronal view shows air (red arrow) which indicates the lesion is stool. it is important to be familiar with the appearance of artefacts; they can obscure lesions or be mistaken for pathology. hip prosthesis-related artefacts are because of beam hardening and scatter, which cause dark streak artefacts. software is available to reduce beam hardening effects.17these streaks are between two high attenuation objects, for example, metal or bone, with surrounding bright streaks.15 poor patient positioning could also produce artefacts. figure 9 shows these types of artefacts. artefact-related pitfalls are fairly common. figure 10 illustrates that an air bubble artefact may appear to be a lesion. the ‘dense waterfall’ sign (figure 11) is an artefact that is related to actively flowing opacified luminal fluid.18 although this appearance is rarely seen in the rectum, it is fairly commonly seen in the other five colon segments. figure 9: (a) 3d endoluminal view showing artefacts (black arrows) obscuring visualisation of the rectum; (b) 2d axial of the same patient shows streak artefacts limiting visualisation of colon (red arrow). this is a typical example of artefacts caused by hip prostheses; (c) 3d view shows ‘black hole’ artefact. it represents an absence of data due to poor patient positioning, which caused cut-off related to incomplete scanning; (d) coronal view shows incorrect positioning of the patient as the symphysis pubis is not included. correct patient positioning must include 3 cm below symphysis pubis and 3 cm above the diaphragm. figure 10: (a) 3d view shows curvilinear density indicating an artefact (black arrows); (b) td shows thin blue line (black arrows) with a small blob of barium (white arrow) inferiorly indicating barium and air artefact. figure 11: (a) dense ‘waterfall sign’ in the rectosigmoid region, caused by flowing fluid (red arrow) during the scan process; (b) 3d endoluminal view showing artefact from fluid movement; (c) dense waterfall sign in descending colon showing classical streak artefact because of fluid movement. pathology-related pitfalls internal haemorrhoids are the most frequently seen and diagnosed condition affecting the anorectal region.14 they may appear polypoid or mass-like when thrombosed or advanced.4 haemorrhoids are the result of dilated vascular channels above the dentate line (figure 12). rectal varices, in contrast to haemorrhoids, have a tubular, serpiginous appearance.2,4 haemorrhoids may be identified on both the prone and supine studies, but in the supine study the inflated rectal balloon may compress internal haemorrhoids, which may make them difficult to diagnose. when the patient is in the prone position, the catheter’s balloon should routinely be deflated to decompress internal haemorrhoids, if present, in order to visualise them.3,6,16 some radiologists do not deflate the balloon for fear that the rectal tube may not remain in situ. the author has hardly ever experienced this happening. the balloon can be re-inflated should there be a need for further views (e.g. lateral decubitus) which require a patient to turn from the prone position.16 figure 13 presents examples of the importance of deflating the balloon in the prone study for visualisation of internal haemorrhoids. figure 12: (a) internal haemorrhoid above the dentate line and (b) external haemorrhoids. figure 13: (a) supine 3d view with inflated balloon showing internal haemorrhoid (black arrow); (b) prone 3d view with deflated balloon showing polypoidal haemorrhoids (black arrows); (c) prone 2d axial view with deflated balloon showing large haemorrhoids (*); (d) 3d supine view of inflated balloon. internal haemorrhoid (white arrow); (e) 3d prone view with deflated balloon shows internal haemorrhoids more prominently (black arrows); (f) 2d axial view with deflated balloon (white arrow) showing internal haemorrhoids (*). white arrow indicates the placement of the catheter. internal haemorrhoids may be confused with a hypertrophied anal papilla, a benign condition occurring in response to chronic irritation or anal fissuring.3 it is essentially an internal skin tag, which represents focal fibrous prominence of tissue at the dentate line.3 anal papillae are small, usually < 6 mm in size. they are usually single, but multiple papillae have been reported; occasionally, they may be polypoidal in appearance.3 the diagnosis of an anal papilla is made by its consistent anatomic position at the anorectal junction. in the vast majority of cases, the papilla is in contact with the rectal tube at its lowest visualised point. when considering whether a polypoidal mass is an anal papilla or a rectal polyp, the clue is their respective location in relation to the catheter (figure 14). a polyp would be a short distance from the catheter. figure 14: (a) 3d image showing linear internal haemorrhoids (black arrows) and anal papilla (circle) in close proximity to the catheter; (b) 3d image of a polyp (circle) away from the catheter. polyps may be sessile or pedunculated. on 3d, they present as polypoid lesions, and they are homogeneous on 2d. sessile polyps do not move and usually have a thin covering of barium on their surface. the shape and form of flat lesions and carpet lesions are potential pitfalls.19 a study is considered positive when a lesion ≥ 6 mm is detected. polyps ≥ 10 mm are routinely removed. the chance of malignancy is < 1% in an asymptomatic low-risk individual (figure 15).3 large advanced adenomas (> 10 mm, large polyp) represent the key target sign for crc screening and prevention; they are at higher risk for cancer progression.3,20 between 90% and 95% of advanced adenomas are 10 mm or larger in size, but only adenomas and serrated polyps have the possibility of future transformation into cancers.21 figure 15: (a) 3d view showing 7 mm sessile polyp (black arrow); (b) td showing predominantly red = soft tissue (black arrow) indicating polyp; (c) 2d axial supine view shows homogenous polypoidal density in keeping with a polyp (white arrow); (d) 3d endoluminal view showing an 11 mm polypoid lesion (black arrow); (e) 2d axial view showing homogenous lesion (black arrow); (f) td showing predominantly red = soft tissue (black arrow) compatible with an advanced adenoma. flat lesions are usually < 30 mm in size and are elevated approximately 3 mm above the colonic mucosa. they are a subset of sessile polyps that do not have a polypoidal appearance22 and occur most commonly in the rectum and caecum. if they are ≥ 30 mm in size, they are termed carpet lesions (figure 16) or laterally spreading tumours.23 despite their large size, carpet lesion histology is usually a villous adenoma or tubulovillous adenoma. high-grade dysplasia may also be present. malignancy is not a common finding in carpet lesions.19,23 figure 16: (a) 3d endoluminal view of rectum showing rectal catheter and carpet lesion extending for 40 mm (white arrows). histology confirmed tubulovillous adenoma; (b) td view showing rectal catheter and lobulated high intensity regions (black arrows) covered with a thin layer of barium (white); (c) 2d axial view of rectum with rectal catheter (white circle). polyp view showing flat soft tissue lesion (white arrows). note the etching of positive contrast material on the surface of the lesion; (d) optical colonoscopy view confirms ctc finding of a minimally raised somewhat lobulated carpet lesion in the rectum (black arrows). when evaluating anorectal ctc images, we need to consider the possibility of a malignant lesion. a cancer has an irregular polypoid appearance with thickening of the bowel wall. figure 17 shows rectal cancer. rectal tumours may be aggressive in immunocompromised patients, particularly those who have the acquired immunodeficiency syndrome.3 figure 17: (a) prone colon-map showing left rectal wall lesion (black arrow). rectal catheter (red arrow); (b) 3d view of an irregular polypoidal lesion in rectum in keeping with cancer (black arrows); (c) 2d axial image shows catheter (white circle) and soft tissue mass with thickening of the left rectal wall in keeping with cancer (white arrow). we need to be mindful of possible perforations caused by diagnostic and therapeutic procedures at oc.7,24,25 direct mechanical trauma may be caused by injury to the colon by the end of the endoscope, or from the abrasive effect of the side of the scope as it is advanced or withdrawn.24 in the rectum, the colonoscope may be retroflexed; this may result in a single ‘contained perforation’, which may be complicated by faecolith formation (figure 18). before commencing a ctc following an incomplete or failed oc, it is essential to exclude perforation. a pre-procedure low-dose ct scan is performed to assess whether free air is present, and if visualised, the ctc study is not performed.16 risk of colonic perforation during ctc is rare because of the use of automatic insufflation and a small gauge soft rectal catheter. 16,25,26 figure 18: (a) 3d view of a ‘contained’ perforation of rectum (black arrows). calcified enterolith (white arrow); (b) 2d axial view shows a ‘contained’ perforation and calcified faecalith (white arrow) and rectal catheter (white circle). any structure that lies adjacent to the colon may cause an extrinsic impression on the colon lumen. 14 these impressions are easily identifiable when 2d multiplanar reformation is performed. the most common sources of these impressions include the uterus and adnexa (figure 19). figure 19: (a) 3d view showing an extrinsic impression from a pedunculated uterine fibroid (arrows); (b) 2d axial showing pedunculated uterine fibroid (f) causing narrowing of rectum (white arrow). conclusion potential anorectal region pitfalls may be related to technique, interpretation or specific anatomical features.2,3,4 knowledge of these potential pitfalls should prevent ctc readers from missing cancers and avoid misdiagnosis of benign lesions. acknowledgements clinton bopp is thanked for drawing the line diagrams of the anatomy of the rectum and internal haemorrhoids. professor d kim, wisconsin university, is thanked for the carpet lesion images. mrs. leonie munro for assisting with the editing and proofreading of this article. competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references bibbins-domingo k, grossman dc, curry sj, et al. screening for colorectal cancer: us preventive services task force recommendation statement. jama. 2016;315:2564–2575. https://doi.org/10.1001/jama.2016.5989 lefere p, gryspeerdt s. ct colonography: avoiding traps and pitfalls. insights imaging. 2011;2:57–68. https://doi.org/10.1007/s13244-010-0054-3 pickhardt pj. 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and implication for screening of asymptomatic adults. radiology. 2006;239(2):313–316. https://doi.org/10.1148/radiol.2392052002 neri e, halligan s, hellström m, et al. the second esgar consensus statement of ct colonography. eur radiol. 2013;23:720–729. https://doi.org/10.1007/s00330-012-2632-x abstract introduction case report discussion conclusion acknowledgements references about the author(s) sanjay m. khaladkar department of radiology, dr. d.y. patil medical college, hospital & research centre, dr. d.y. patil vidyapeeth, india shishir chauhan department of radiology, dr. d.y. patil medical college, hospital & research centre, dr. d.y. patil vidyapeeth, india abhijit m. patil department of radiology, dr. d.y. patil medical college, hospital & research centre, dr. d.y. patil vidyapeeth, india siddappa g. gandage department of radiology, dr. d.y. patil medical college, hospital & research centre, dr. d.y. patil vidyapeeth, india surbhi chauhan kalra department of radiology, dr. d.y. patil medical college, hospital & research centre, dr. d.y. patil vidyapeeth, india citation khaladkar sm, chauhan s, patil am, gandage sg, kalra sc. dyke–davidoff–masson syndrome with crossed cerebellar atrophy. s afr j rad. 2017;21(1), a1207. https://doi.org/10.4102/sajr.v21i1.1207 case report dyke–davidoff–masson syndrome with crossed cerebellar atrophy sanjay m. khaladkar, shishir chauhan, abhijit m. patil, siddappa g. gandage, surbhi chauhan kalra received: 27 apr. 2017; accepted: 27 june 2017; published: 26 sept. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract dyke–davidoff–masson syndrome is a rare condition with classical, clinical and radiological changes – mental retardation, hemiparesis, facial asymmetry, seizures and cerebral hemiatrophy with calvarial changes. contralateral cerebellar atrophy is rare and occurs if insult occurs after 1 month of age. we report a case of a 6-year-old female child presenting with right-sided hemiparesis, convulsions and left cerebral hemiatrophy with an old infarct in left middle cerebral artery (mca) territory, ipsilateral calvarial thickening and right (crossed) cerebellar atrophy. introduction dyke–davidoff–masson syndrome (ddms) is a rare disease characterised by cerebral atrophy in one cerebral hemisphere because of an insult in utero or in early childhood (acquired cases) characterised by hemiparesis, seizures, mental retardation and facial asymmetry. it is associated with calvarial thickening and hyperpneumatisation of the frontal sinuses. ipsilateral cerebellar atrophy occurs if the insult occurs before the age of 1 month while contralateral cerebellar atrophy is seen when the insult occurs after the age of 1 month.1,2 case report a 6-year-old female child presented with giddiness for 4 days. she had a history of right-sided hemiparesis and right sided focal convulsions for 3½ years. birth history was normal with full term normal vaginal delivery; baby cried immediately after birth with no neonatal intensive care unit (icu) stay. magnetic resonance imaging (mri) of the brain showed atrophy of the right cerebellar hemisphere with prominence of the cerebellar folia (figure 1). left cerebral peduncle was small in size suggestive of wallerian degeneration (figure 2). left cerebral hemisphere was atrophic as evident from the prominence of sulcal spaces, sylvian fissure and ex-vacuo dilatation of the left lateral ventricle with the shift of midline structures towards left. an old infarct with gliosis was noted in left fronto-temporo-parietal region appearing hypointense on t1wi and hyperintense on t2wi and fluid attenuation inversion recovery with no restriction on diffusion weighted imaging. associated uniform thickening of the calvarium was noted on the left side (figures 3 and 4). magnetic resonance angiography showed attenuation and reduced signal intensity of the m2 and m3 segments of the left middle cerebral artery (mca) (figure 5). a diagnosis of davidoff–dyke–masson syndrome type iii was made. figure 1: axial t1 sequence showing right cerebellar atrophy with prominence of cerebellar folia (arrow). figure 2: axial fluid attenuation inversion recovery sequence showing small sized left cerebral peduncle because of wallerian degeneration (arrow) with left cerebral hemiatrophy. figure 3: (a) axial fluid attenuation inversion recovery sequence; (b) coronal t2 sequence showing gliosis in left parieto-occipital region (arrow) with left cerebral hemiatrophy and ex-vacuo dilatation of the left lateral ventricle (arrow). figure 4: coronal t2 sequence showing gliosis in the left parietal region with left cerebral hemiatrophy, ex-vacuo dilatation of the left lateral ventricle and right cerebellar atrophy (arrow). figure 5: magnetic resonance angiography of the brain showing attenuation and reduced signal intensity of m2 and m3 segments of left mca (arrow). discussion dyke–davidoff–masson syndrome is a rare condition derived from its researchers dyke, davidoff and masson who first reported the condition in 1933. changes of facial asymmetry, hemiparesis, seizures and mental retardation were seen in nine patients. diffuse or subtotal cerebral hemiatrophy is the classical imaging finding. however, occasionally unilateral focal atrophy may be seen in the cerebral peduncle, thalami, parahippocampal region, pons and crossed cerebellar hemisphere. the clinical features of ddms are mental retardation, focal or generalised seizures, learning disabilities and contralateral hemiparesis with an upper motor neuron type of facial palsy. although there is no sex predilection and any side of the brain can be involved, male gender and involvement of left cerebral hemisphere are commonly found.2 there are two types, the infantile or congenital variety, and the acquired type. the infantile variety occurs because of gestational or neonatal vascular occlusion of the mca, unilateral cerebral arterial circulation anomalies, coarctation of the mid-aortic arch or infections. patients become symptomatic in the perinatal period or infancy. the acquired type results from prolonged febrile seizures, birth asphyxia, infection, ischemia, tumour and haemorrhage. the classical computed tomography (ct) and mri findings of ddms are seen only if the brain insult occurs before 3 years of age. the formation of brain sulci begin in the 4th month of gestation and usually complete by the end of the 8th month. the maximum growth of a child’s head occurs in the early years because of outward pressure of the enlarging brain on the cranial vault and reaches half of its adult size by the end of 1 year and 75% of the adult size by the end of 3 years. hence only if brain damage occurs before 3 years of age, there is increased growth of the other structures overlying the brain, resulting in thickening of the cranial vault with increased width of diploic spaces, enlarged paranasal sinuses and an elevated orbital roof. several ischemic episodes due to different causes lead to a reduction in the production of brain-derived neurotrophic factors with resultant cerebral atrophy.2 dyke–davidoff–masson syndrome or cerebral hemiatrophy, is a congenital neonatal or early infantile condition. mental retardation may not be always present. seizures often occur months or years after the onset of hemiparesis. speech or language disorder may be present. ct and mri findings characteristically demonstrate parenchymal abnormality because of unilateral loss of cerebral volume with compensatory bone alterations in the adjacent calvarium.3 no prominent sulci are observed if the vascular insult occurs during embryogenesis (when the formation of gyri and sulci is incomplete). if the vascular insult occurs after sulcation is complete or after birth, then prominent sulci are seen. ct and mri show gliosis, encephalomalacia, porencephaly, loss of gyri and white matter in the involved cerebral hemisphere with the prominence of the adjoining sulcal spaces and sylvian fissure. ipsilateral enlargement of the lateral ventricle with midline shift towards the atrophic side is seen in the hemiatrophic brain. ipsilateral internal capsule, thalamus and cerebral peduncle are small or hypoplastic secondary to wallerian degeneration. skull vault shows compensatory changes reflecting adaptations to the cerebral hemiatrophy. thickening of the ipsilateral calvarium (diploic spaces and inner table), loss of convolutional markings in the inner table of the skull, elevation of the petrous ridge, orbital roof and sphenoid wing, overdevelopment of the frontal sinus, displacement of the falx attachment and diminished size of middle or anterior cranial fossa are usually seen.3 three patterns of ddms are seen on mri. pattern 1 shows diffuse cortical and subcortical atrophy. pattern 2 shows diffuse cortical atrophy with porencephalic cysts, and pattern 3 shows previous infarction with gliosis in the middle cerebral artery (mca) territory. the differential diagnosis for the triad of epilepsy, hemiplegia and hemiatrophy includes sturge–weber syndrome, rasmussen’s encephalitis and hemimegalencephaly.4 ipsilateral or crossed cerebellar atrophy (cca) is rarely reported in ddms. ipsilateral cerebellar atrophy occurs if the insult occurs before the age of 1 month while contralateral cerebellar atrophy is seen when the insult occurs after the age of 1 month.1 crossed cerebellar diaschisis is due to contralateral cerebellar dysfunction because of a lesion in the ipsilateral cerebral hemisphere. it can be transient or permanent. crossed cerebellar diaschisis or cerebellar atrophy occurs because of contralateral cerebellar hypometabolism secondary to a supratentorial insult. it is usually diagnosed by positron emission tomography (pet) imaging. however, it can also be diagnosed by perfusion-weighted mri before structural changes appear on conventional mri. there is a functional disconnection of the cerebellar hemisphere from the cerebral cortex. interruption of the cerebro-ponto-cerebellar pathway causes transneuronal metabolic depression.5 diaschisis is because of transient impairment of functional activity in an area remote from the site of the primary brain lesion. there is a reduction in blood flow and oxygen uptake in the cerebellar hemisphere contralateral to the side of supratentorial ischemic insult.1 cerebro-cerebellar diaschisis (ccd) can also be observed in the supratentorial infarcts, haemorrhage, arteriovenous malformation and tumour. ccd is initially a reversible functional process without structural change seen on pet scan and perfusion mri. with the continuation of the insult, irreversible cca occurs which can be detected on ct and mri. cca is rare and irreversible and is the continuum of the biological process seen in crossed cerebellar diaschisis.1 reversible ccd and irreversible cca belong to the same spectrum. ccd and cca were mistakenly used interchangeably in the literature.6 rarely diffuse cerebellar atrophy may occur in ddms probably due to insufficiency in the posterior circulation.7 conclusion dyke–davidoff–masson syndrome with ipsilateral or cca is a rare entity, which can be diagnosed on ct and mri. the timing of the insult can be predicted from the presence of ipsilateral or cca. acknowledgements competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions s.c and s.m.k. were responsible for the diagnosis of case, review of literature and preparation of case report. s.m.k. was responsible for the preparation of case report as per journal’s requirement. a.m.p. and s.g.g. provided guidance for making the case report. references gupta r, joshi s, mittal a, luthra i, mittal p, verma v. magnetic resonance imaging depiction of acquired dyke–davidoff–masson syndrome with crossed cerebro-cerebellar diaschisis: report of two cases. j pediatr neurosci. 2015;10(3):294–296. https://doi.org/10.4103/1817-1745.165730 roy u, panwar a, mukherjee a, biswas d. adult presentation of dyke–davidoff–masson syndrome: a case report. case rep neurol. 2016;8(1):20–26. aguiar ph, liu cw, leitão h, et al. mr and ct imaging in the dyke–davidoff–masson syndrome. report of three cases and contribution to pathogenesis and differential diagnosis. arq neuropsiquiatr. 1998;56(4):803–807. sharma s, singh s, bhagat s, garcha h. dyke–davidoff–masson syndrome/cerebral hemiatrophy in an adult male: a rare imaging case. indian j appl radiol. 2016;2(1):1–3. narra r, kamaraju sk, pasupaleti b, jukuri nr. dyke–davidoff–masson syndrome: a case report of cerebral hemiatrophy with crossed cerebellar diaschisis. afr j med health sci. 2015;14(2):150–152. https://doi.org/10.4103/2384-5589.170195 algahtani ha, aldarmahi aa, al-rabia mw, young gb. crossed cerebro-cerebellar atrophy with dyke–davidoff–masson syndrome. neurosciences (riyadh). 2014;19(1):52–55. gökçe e, beyhan m, sade r. radiological imaging findings of dyke–davidoff–masson syndrome. acta neurol belg. 2017:1–9. sajr 22-1 & 2_2018_contents.indd http://www.sajr.org.za open access table of contents i original research interventionalists’ perceptions on a culture of radiation protection andré rose, kerry e. uebel, william i. rae south african journal of radiology | vol 22, no 1 | a1285 | 19 march 2018 original research reliability assessment of a mechanism-based approach to post-injury knee magnetic resonance imaging interpretation by general radiologists james stutterheim, matthew d. goodier south african journal of radiology | vol 22, no 1 | a1253 | 04 june 2018 original research fatty meal sonography comparing coconut oil and chocolate bar with full-fat yoghurt as cholecystagogues for gallbladder ejection fractions benjamin spangenberg, jacques janse van rensburg south african journal of radiology | vol 22, no 1 | a1312 | 18 june 2018 original research a retrospective analysis of time delays in patients presenting with stroke to an academic emergency department diteboho khalema, lara n. goldstein, susan lucas south african journal of radiology | vol 22, no 1 | a1319 | 21 june 2018 original research inter-observer variability influences the lugano classification when restaging lymphoma jacobus möller, tiaan steyn, nantes combrinck, gina joubert, alicia sherriff, jacques janse van rensburg south african journal of radiology | vol 22, no 1 | a1357 | 31 july 2018 original research bone of contention: the applicability of the greulich–pyle method for skeletal age assessment in south africa dashnee govender, matthew goodier south african journal of radiology | vol 22, no 1 | a1348 | 08 august 2018 original research is computed tomography of the head justified in patients with minor head trauma presenting with glasgow coma scale 15/15? chuma singata, sally candy south african journal of radiology | vol 22, no 1 | a1329 | 27 september 2018 original research correlation between radiological and histopathological findings in patients undergoing nephrectomy for presumed renal cell carcinoma on computed tomography scan at grey’s hospital nompumelelo e. mlambo, nondumiso n.m. dlamini, ronald j. urry south african journal of radiology | vol 22, no 1 | a1339 | 10 october 2018 case report anti-ma2-antibody-associated encephalitis: an atypical paraneoplastic neurologic syndrome bogna targonska, jamie frost, sanjay prabhu south african journal of radiology | vol 22, no 1 | a1310 | 17 may 2018 67 77 84 88 94 102 108 113 121 page i of ii table of contents i editorial re-inventing the future of the radiological research footprint in south africa maya patel south african journal of radiology | vol 22, no 1 | a1665 | 18 october 2018 opinion paper postgraduate radiology education in nigeria: looking backward and forward bukunmi m. idowu south african journal of radiology | vol 22, no 1 | a1362 | 29 august 2018 review article magnetic resonance imaging in exertional compartment syndrome of the forearm: case-based pictorial review and approach to management bishum rattan, shalendra k. misser south african journal of radiology | vol 22, no 1 | a1284 | 18 april 2018 review article magnetic resonance imaging of classified and unclassified müllerian duct anomalies: comparison of the american society for reproductive medicine and the european society of human reproduction and embryology classifications devimeenal jegannathan, venkatraman indiran south african journal of radiology | vol 22, no 1 | a1259 | 23 april 2018 review article the role of imaging in rheumatoid arthritis kgomotso kgoebane, mahmood m.t.m. ally, martha c. duim-beytell, farhana e. suleman south african journal of radiology | vol 22, no 1 | a1316 | 11 july 2018 pictorial essay pictorial essay: computed tomography findings in acute aortic syndromes navdeep singh, pankaj goel, yadwinder singh south african journal of radiology | vol 22, no 1 | a1309 | 23 may 2018 pictorial essay abnormal descent of the testis and its complications: a multimodality imaging review pankaj nepal, devendra kumar, vijayanadh ojili south african journal of radiology | vol 22, no 1 | a1374 | 27 september 2018 original research imaging findings and outcomes in patients with carotid cavernous fistula at inkosi albert luthuli central hospital in durban nasr timol, khatija amod, rohen harrichandparsad, royston duncan, tarylee reddy south african journal of radiology | vol 22, no 1 | a1264 | 25 january 2018 original research multidetector computed tomography has replaced conventional intravenous excretory urography in imaging of the kidneys: a scoping review of multidetector computed tomography findings in renal tuberculosis ntombizakhona b.a. mthalane, nondumiso n.m. dlamini south african journal of radiology | vol 22, no 1 | a1283 | 16 february 2018 1 3 10 16 29 35 40 46 55 vol 22, no 1 (2018) issn: 1027-202x (print) | issn: 2078-6778 (online)south african journal of radiology http://www.sajr.org.za open access table of contents ii case report cleidocranial dysplasia: radiological mimic of pyknodysostosis – a case report harmeet kaur, kamini gupta, punit tiwari south african journal of radiology | vol 22, no 1 | a1326 | 14 june 2018 case report fulminant amoebic colitis in the era of computed tomography scan: a case report and review of the literature suman mewa kinoo, vikesh v. ramkelawon, jaynund maharajh, bugwan singh south african journal of radiology | vol 22, no 1 | a1354 | 15 august 2018 case report magnetic resonance imaging findings in a patient with seropositive neuromyelitis optica siviwe s. mpateni, naye c. sihlali, emma c. gardiner, nkululo gigi south african journal of radiology | vol 22, no 1 | a1306 | 30 august 2018 129 133 case report computed tomographic diagnosis of aortocaval fistula navdeep singh, aneesh mangalasseril kuriakose, regi an george, shirish vaidya south african journal of radiology | vol 22, no 1 | a1363 | 12 september 2018 case report case of tuberculous pericarditis presenting as a giant pericardial adhesion and masquerading as a pericardial tumour margaret e. kisansa, nndweleni m. bida, pule mutati, peter s. ramoroko south african journal of radiology | vol 22, no 1 | a1359 | 27 september 2018 case report unexpected finding of splenic peliosis in a traumatic spleen in a patient with cleidocranial dysplasia prema mohandas, ahmed o.a krim, paul samson south african journal of radiology | vol 22, no 1 | a1371 | 27 september 2018 137 140 143 page ii of ii 125 137 editorial breast cancer imaging in south africa in 2018 peter k. schoub south african journal of radiology | vol 22, no 2 | a1666 | 07 november 2018 review article are you dense? the implications and imaging of the dense breast jacqueline s. smilg south african journal of radiology | vol 22, no 2 | a1356 | 23 august 2018 review article understanding indications and defining guidelines for breast magnetic resonance imaging peter k. schoub south african journal of radiology | vol 22, no 2 | a1353 | 30 october 2018 review article screening mammography with special reference to guidelines in south africa shirley lipschitz south african journal of radiology | vol 22, no 2 | a1370 | 31 october 2018 original research measuring breast density: comparing computer-automated breast density quantification with an observer-based method in a south african academic context erica prinsloo, cornelia minné, wim greeff south african journal of radiology | vol 22, no 2 | a1358 | 21 august 2018 original research human immunodeficiency virus infection in breast cancer patients: the prevalence thereof and its effect on breast cancer characteristics at dr. george mukhari academic hospital breast clinic, ga-rankuwa, south africa nikoli van zyl, cornelia minné, dikeledi h. mokone south african journal of radiology | vol 22, no 2 | a1361 | 30 august 2018 146 148 152 164 171 176 original research differentiation of breast tuberculosis and breast cancer using diffusion-weighted, t2-weighted and dynamic contrast-enhanced magnetic resonance imaging dibuseng p. ramaema, richard j. hift south african journal of radiology | vol 22, no 2 | a1377 | 25 october 2018 original research breast imaging reporting and data systems category 3 (probably benign) breast lesions detected on diagnostic breast ultrasound: the prevalence, outcome and malignancy detection rate in zaria, nigeria sefiya a. olarinoye-akorede, garba h. yunusa, halima aliyu, ahmed u. hamidu south african journal of radiology | vol 22, no 2 | a1315 | 01 november 2018 original research magnetic resonance imaging of fibroadenoma-like lesions and correlation with breast imaging-reporting and data system and kaiser scoring system daniel j. cloete, cornelia minne, peter k. schoub, jan h.r. becker south african journal of radiology | vol 22, no 2 | a1532 | 07 november 2018 clinical perspective pseudoangiomatous stromal hyperplasia: presentation and management – a clinical perspective pamela smilg south african journal of radiology | vol 22, no 2 | a1366 | 29 october 2018 reviewer acknowledgement south african journal of radiology | vol 22, no 1 | a1680 | 26 november 2018 183 190 195 204 209 vol 22, no 2 (2018): breast radiology, sub-edited by peter k. schoub, parklane radiology, south africa radiology_aug04 abstract complex regional pain syndrome (cprs), type 1 is a pain disorder that develops unpredictably and can follow a minor injury. a 12-year-old boy presented with severe pain in the feet and could not walk or stand weight bearing. normal x-rays showed osteopenic changes and radiolucent lines, which appeared to be stress fractures. three-phase bone scintigraphy showed no uptake in the left lower leg on the blood pool phase or on the immediate or delayed images. this indicated typical cprs type 1 in children. the uptake in the right foot was increased and the stress fracture and other illness could not be differentiated. computed tomography was done to exclude stress fractures. only osteopenic changes in both calcaneus bones were found and there was no evidence of cortical stress fractures. magnetic resonance images revealed oedema in the calcaneus and talus bones of both feet. the patient received epidural narcotic infusion with sympathetic blockage for 1 week combined with extensive physiotherapy. the blood pool phase of the bone scan became normal within 2 weeks, and increased uptake in both feet was noticed. the patient was followed up with mri every 3 months and the bone marrow oedema disappeared after 6 months. introduction reflex sympathetic dystrophy (rsd) or the newer synonym, complex regional pain syndrome (cprs), type 1 is a pain disorder that develops unpredictably and can follow a minor injury.1,2 crps type 1 is not limited to a single peripheral nerve distribution, and is associated with oedema, changes in skin blood flow, abnormal sudomotor activity in the region of the pain, and allodynia or hyperalgesia. in crps type 2 or causalgia there is history of a peripheral nerve injury, thus the pain and autonomic disturbance can be identical to crps type 1 but has a nerve-specific distribution.2 case report a 12-year-old boy presented with severe pain in the feet, worse in the left foot, which increased over a period of 2 weeks to such an extent that he could not walk or stand weight bearing. although he was active in a number of sports no incident of injury was reported. on examination both feet were cold, pale and mildly swollen and he experienced paraesthesiae (pins and needles), hyperalgesia (extreme pain response to a minimally painful stimulus) and allodynia (unpleasant painful sensation induced by nonpainful stimulus such as light touch on the affected area). normal x-rays were taken of both feet. these showed marked osteopenic changes and radiolucent lines which appeared to be stress fractures, especially in the left calcaneus (figs 1a and 1b and figs 2a and 2b). three-phase bone scintigraphy was done, which showed no uptake in the left lower leg on the blood pool case reports 38 sa journal of radiology • august 2004 reflex sympathetic dystrophy/complex regional pain syndrome, type 1 s h botha mb chb, mfammed department of diagnostic radiology university of the free state bloemfontein fig. 1a. lateral x-ray of right foot showing radiolucent lines and osteopenia. fig.1b. lateral x-ray of left foot showing radiolucent lines and osteopenia. fig. 2a. oblique x-rays of right foot showing possible stress fractures of calcaneus bones. phase or on the immediate or delayed images (fig. 3). this indicated typical rsd in children. in contrast, adult uptake is usually increased. when the intensity was increased, the delayed images in the left calcaneus showed a slight increase in uptake. the uptake in the right foot was increased and the stress fracture and other illness could not be differentiated (fig. 4). computed tomography (ct) was done to exclude stress fractures. only osteopenic changes in both calcaneus bones were found and there was no evidence of cortical stress fractures (fig. 5). magnetic resonance images (mris) were taken of both feet and revealed marked oedema in the calcaneus and talus bones of both feet. some soft-tissue oedema especially over the left ankle was also present (fig. 6 and figs 7a and 7b). there was contradiction between the two diagnoses of stress fractures and cprs type 1. as cprs type 1 is a clinical diagnosis the boy was treated as such. he was admitted into hospital and received epidural narcotic infusion with sympathetic blockage for a period of 1 week combined with extensive physiotherapy (3 times a day). fortunately he recovered remarkably. if he had had stress fractures his condition would have worsened. the blood pool phase of the bone scan became normal within 2 weeks, and increased uptake in both feet was noticed. he was followed up with mri every 3 months and the bone marrow oedema disappeared after 6 months. discussion the physiology, diagnosis and management of cprs type 1 is discussed below. 39 sa journal of radiology • august 2004 case reports fig. 2b. oblique x-rays of left foot showing possible stress fractures of calcaneus bones. fig. 3. blood flow phase showing cut-off sign in the left lower leg. fig. 4. blood pool phase showing still no uptake in the left leg with increased uptake in the right foot. fig. 5. axial ct image of both feet showing osteopenic changes. fig. 6. sagittal stir image of the left foot showing soft-tissue oedema and bone marrow oedema in calcaneus and talus bones. fig. 7a. axial stir mr images of both feet showing oedema of soft tissue and bone marrow. fig. 7b. coronal stir mr images of both feet showing oedema of soft tissue and bone marrow. pathophysiology in patients with sympathetically maintained pain it is likely that the major site of abnormality is in the wide-dynamic-range neurons in the spinal cord. the hypothesis is that an initiating trauma event sensitises these neurons with associated proliferation of alpha-receptors on low threshold mechanoreceptors and in the surrounding tissues. a normal mechanical stimulus results then in excessive firing of wide-dynamic-range neurons, causing abnormal pain sensation. the proliferation of alpha-receptors in the surrounding tissues, including the blood vessels and other end organs explains the clinical features of autonomic activation seen in the disorder.3 clinical features pain is the main clinical manifestation of crps type 1 and is disproportionate to that expected of the severity of the underlying injury. the pain combines with autonomic disturbance such as skin colour, skin temperature, sudomotor activity and swelling changes.1,3 precipitating factors the initiating cause in crps type 1 may be either trauma of external origin or iatrogenic, post surgery. in some patients particularly children, no definite injury can be identified.1,4 diagnosis the diagnosis of crps type 1 is essentially clinical and is made on the basis of the combination of excessive pain together with autonomic disturbance in the area of the pain. specific investigations plain x-ray: routine radiography was first used to confirm the presence of crps type 1. however, the soft tissue swelling and demineralisation are nonspecific and a late manifestation of the illness.5 bone scan: bone scintigraphy provides a non-invasive method of diagnosis. in adults it demonstrates increased uptake on both blood pool and delayed images, and in children a decreased uptake in all the phases. this is, however, only 60% sensitive.5,6 magnetic resonance imaging: mri can provide supportive evidence for crps type 1. soft-tissue changes and bone marrow oedema are early changes and muscle atrophy is present in the disorder’s later stages. mri may also be helpful in patient follow-up.5 management the treatment of crps type 1 includes physiotherapy, drugs (analgesia, antidepressants, anticonvulsants) and sympathetic blockade.1,3 conclusion although cprs type 1 is a clinical diagnosis, imaging methods such as bone scintigraphy and mri are helpful in the differential diagnosis and in follow-up of these patients. references 1. blombery pa. a review of reflex sympathetic dystrophy. aust fam physician 1995; 24: 16511655. 2. walker sm, cousins mj. complex regional pain syndromes: including ‘reflex sympathetic dystrophy’ and ‘causalgia’. anaesth intensive care 1997; 25: 113-125. 3. phelps gr, wilentz s. reflex sympathetic dystrophy. int j dermatol 2000; 39: 481-486. 4. murray cs, cohen a, perkins t, davidson je, sills ja. morbidity in reflex sympathetic dystrophy. arch dis child 2000; 82: 231-233. 5. schweitzer me, mandel s, schwartzman rj, knobler rl, tahmoush aj. reflex sympathetic dystrophy revisited: mr imaging findings before and after infusion of contrast material. radiology 1995; 195(1):211-214. 6. zyluk a, birkenfeld b. quantitative evaluation of three-phase bone scintigraphy before and after the treatment of post-traumatic reflex sympathetic dystrophy. nucl med commun 1999; 20: 327-333. case reports 40 sa journal of radiology • august 2004 editorial 01behalf of cannon communications i would like to express our thanks at being appointed publisher for the radiologicalsociety's officialjournal. publishing often appears, on the surface,to be a simple field in which to do business. indeed there are numerous examples of publications starting ug blossoming for a year or two then vanishing.in the arena of professional and trade publications a lot of effort has to be expended to maintain one is titles. it is not possible to display on the front coverthe photo of some celebrity or alluringmodel in order to boost sales' in the cannon communications stable we are fortunate to have titles that have been around for up to 26 years. 2 sajournal of radiology. march 1996 on a personal note i am delighted to be involvedwith this publication as, for 18 years,i was involved with the imaging industry a "first love" you might say.on the practical side the intention is to use this experience to provide an on-going update on the technology involvedin imaging in an easilyreadable form.the variouscompanies have expressed a willingness to support this concept. feedback from you the readers as to what topics should be covered would be most welcome asit is you we are serving. on the subject of company support, it is only through the financialsupport of the advertisers that we are ableto bring you this journal. to receive this journal on a subscription-only basis would mean a significant increase in your costs, be it either for subscription or membership fees. we are convinced that professor corr's enthusiasm will allow us to achieve the goal of accreditation for the journal. accreditation we believe is a significant challenge but one that we have to address in the light of global acceptance. for those unfamiliar with the term, accreditation means that articles accepted for publication can form part of your c.v in addition there are subsidies for academic departments. this latter benefit certainly needs no elaboration. again this is a reward you can derive from participation. as publishers we look forward to contributing to radiology in south africa. roger short star abstract oncologic imaging in 2002 and beyond hedvig hricak md the thrust of cancer care in the new millennium is implementing "risk adjusted, patient specific therapy': cancer is not one disease, it is many, it presents a remarkably different clinical behavior and treatment response even in the same host. modern cancer treatment planning is guided by two key principles: 1) the choice of therapy must be based on evidence rather than opinion or habit, and 2) the volume and extent of disease should be optimally assessed prior to treatment, in order to allow for the most effective patient-specific therapy. imaging is emerging as an important adjunct to the clinical assessment of cancer, contributing to tumor detection, characterization, staging, treatment planning and follow-up. diagnostic imaging is widening its scope from anatomy to adding information about metabolism and function. the general forward direction of medical imaging aims toward increasing sensitivity and specificity, while decreasing invasiveness and minimizing cost. continuing increases in computer power have fueled the progress, followed by the rapid expansion of communication technology and by the advances in molecular biology. the revolutionary advances in molecular biology and genetics are being introduced into cross-sectional imaging offering great gains to oncology. novel imaging paradigms are being developed to provide non-invasive assessment of tissues at the cellular and molecular levels. imaging modalities of the future will be increasingly biology-centered. at least three modalities are poised to participate in this revolution: magnetic resonance (mr), positron-emission tomography (pet) and optical imaging. imaging algorithms are already evolving in response to the changes in clinical treatment approaches, scientific discoveries and technological innovations. the technologic advances that are also impacting the daily practice of oncology are pacs , teleradiology and computer-aided diagnosis (cad). pacs has empowered many leading medical centers in the united states, western europe and japan (with many other countries being in transition) to become "film-less': the daily routine of "reading", flexibility in workflow, the ability to retrieve information in seconds and communicate the findings with referring physicians has dramatically changed the way we practice modern medicine. teleradiology can provide access to sophisticated subspecialty-imaging interpretation worldwide and may help in overcoming the presently occurring shortage of radiologists in the industrialized world. computeraided diagnosis will, in the future, be an important component of modern imaging and will be essential in screening. cad when fully developed 8 sa journal of radiology • december 2002 and implemented will be able to identify normal appearing structures (as well as normal variants) making the reading by the radiologist unnecessary for a large portion of screened images. this may alleviate the staffing shortages and reduce the cost of screening. computer-aided diagnosis will be used in reading images obtained with most techniques. while already in clinical use for mammography, it will expand to the reading of screening procedures such as virtual ct colonoscopy and lung ct. advances in cross-sectional imaging the increasing computer power in cross-sectional imaging has facilitated the acquisition of 3 dimensional data, permitting high-resolution volumetric acquisition of images, thus facilitating diagnosis. multi-row detector ct and 3d mr have also made virtual endoscopy possible and it is evolving into an increasingly accepted clinical imaging technique. this technique is presently being applied to practically every anatomic channel: colon, esophagus, stomach, small bowel, bronchial tree, blood vessels, urinary tract (including the bladder), etc. virtual endoscopy promises to reduce the number of invasive procedures and limit conventional, invasive endoscopic procedures to targeted biopsy if the virtual studies disclose abnormalities. fusion of images generated from different imaging modalities, such as mr, ct and pet, is showing that the advantages of two techniques can be maximized. the advantages of pet's ability to detect metabolic abnormality are thus combined with the spatial star abstract resolution afforded by ct. pet-ct scanners are already in clinical use in multiple medical centers advancing oncologic diagnosis. instruments providing fusion of mr and ct are currently being designed and will be of great value in diagnostic and radiation therapy planning. scanners offering fusion of pet and mr will undoubtedly follow. mr technology is versatile, and therefore very much in demand for functional and metabolic imaging. functional mr has become extremely valuable in the preoperative evaluation of brain cancer guiding the surgeon away from the motor and sensory centers. mapping of foci of specific brain activity with functional mr! by displaying images of metabolic activity data, as for instance for heat/pain sensation, motor, memory centers, etc., is becoming the basis of functionally based medicine and will have an important future role in the study of mental diseases. proton spectroscopic mr imaging is already used clinically in the study of brain and prostate carcinoma. extension of mr spectroscopic techniques to breast cancer is underway in multiple centers. with this technique the spectroscopic information is superimposed as a grid on the mr image and the spectroscopy voxel can display the increased presence of choline and naa, supplying metabolic data from the brain tumors. this approach is particularly valuable in the differentiation of tumor recurrence from necrosis following radiation therapy. for prostate cancer, the use of different three-dimensional spectroscopic imaging data on the ratio of choline and normally occurring citrate, has resulted in improved detection, diagnosis of extra-capsular spread, assessment of tumor aggressiveness and surveillance of treatment. pet/ct • •imaging most pet/ct studies performed today are diagnostic fdg scans. the basis of cancer detection by fdg is the increase in glucose metabolism by cancer cells. the magnitude of elevated fdg uptake and accumulation within tumors is most commonly expressed by the standardized uptake value (svv), defined by the ratio of the activity per unit mass in the lesion, to the administered activity per unit patient mass. svv values for fdg of >2.5 fdg have been successfullyused to differentiate between benign and malignant lesions. tumor aggressiveness may be correlated with a higher magnitude suv. the greatest advantage of pet/ct over other imaging modalities is its' thousand to millionfold higher sensitivity over other techniques. this permits glucose metabolism and countless other biochemical reaction rates to be measured by strict application of the tracer principle. radiotracer quantities in the nannomolar concentrations, which do not perturb the body's metabolism, may be used to perform the measurements. since the nannomolar range is the concentration range of most receptor proteins and tumor target antigens in the body, positron-emission tomography is ideal for this type of imaging. tumor uptake by fdg, and the resultant value of the test, is cancer site specific. the fdg radiotracer is not well suited for the detection of all cancers; e.g. prostate cancer, especially when the cancer is low-grade. several alternative tracers are currently under 9 sa journal of radiology • december 2002 clinical investigation and new ones, with a promising potential for tumor biology, are under development. iic_ methionine, a tracer, which has been used to differentiate tumor from normal tissue on account of elevated protein synthesis is a candidate for this application. the rapid (10 minute) uptake and plateau of iic-methionine within prostate cancers, allows whole body pet/ct imaging (with decay correction), in spite of the short 20minute half-life of iic methionine, with minimal interference from the bladder. the use of 18f-fluorodihydrotestosterone has recently been studied in patients with metastatic prostate cancer in search for a noninvasive method to quantify androgen receptors (ar) by pet. the mismatch in positive findings between fdg and 18f-fdht suggests the presence of variations in androgen dependence of the different sites, but histologic confirmation of this finding has not yet been obtained. pet/ct can also be used as an adjunct to ct and mr! in measuring treatment response. the ability to discern viable from necrotic tissue has been an important application of pet. however, the difficulty of separating viable tumor post therapy from inflammation has reduced the reliability of fdg as a quantitative index of response. most analyses consist of an assessment of the change in suv. as suv is a concentration measure, a reduction in tumor volume can result in improved tumor perfusion, which would be manifested in an increase in the suv. to circumvent this paradox where an increase in fdg could be a consequence of either tumor progression or response, we have introduced the concept of total lesion glycolysis, which combines suv with the volstar abstract ume of fdg elevation. this semiquantitative value is a practical and empirical method with which to test the hypothesis of the utility of fdg in the assessment of treatment response. the optimal choice of radiotracers for tumor diagnosis and follow-up depends on the organ site. the concept of using pet with multiple radiotracers, which answer different questions, is likely to become an important thrust in the future of nuclear medicine. molecular • •imaging molecular imaging can be defined as the in vivo depiction and measurement of metabolic processes at the cellular and molecular level. this differs from classical diagnostic imaging that focuses on anatomical abnormalities. the development of basic molecular biological assay techniques is providing more tools for the better understanding and treatment of disease processes at a basic level. the development of transgenic and knockout animal models of human diseases, allows the systematic approach to the study of the genetic and molecular basis of cancer in a reproducible animal model system. associated with these developments, the newly introduced reporter gene systems, have allowed the non-invasive imaging of fundamental biological processes, such as gene transcription. utilizing the experience gained from the application of cellular and sequence specific dna probes for florescent microscopy of tissue sections, new approaches have been developed for the in vivo study of these processes. this has resulted in new techniques, using reporter constructs and molecular probes, which allow the measurement and monitoring of transcriptional activity (both activation and suppression) of endogenous genes in host tissue. these developments are providing exciting opportunities to assess specific signal transduction pathways targeted by specific anti-tumor drugs. this should lead to individual patientspecific drug therapy. imaging would be the guide for the optimal drug regimen and dose. it would be monitoring the therapeutic impact of the selected drug regimen by measuring the drug's effect on specific proteinprotein interactions. from this research, new "end points" for monitoring drug response may emerge. clinicians would benefit from new quantitative methods for the identification of "partial response" and "complete response" reflecting changes in the metabolism and biology of the tumor. purely anatomical descriptors, such as caliper diameter measuring tumor size will become obsolete. imaging reporter constructs to monitor gene therapy is another approach of molecular imaging. it is now possible to monitor the distribution, concentration and persistence of viral vectors and the level of therapeutic transgene expression by this noninvasive imaging technique. further developments of imaging probes include radiolabeled substrates, targeted contrast agents and ligands, which allow the non-invasive elucidation of specific cell cycle systems and signal transduction pathways,which are altered in cancer. with the further development of molecular imaging techniques, it is anticipated that we will be able to visualize the actual molecular signatures of cancer 10 sa journal of radiology • december 2002 in patients. it should be possible within the next decade to visualize and determine which genes are being expressed in specific cancers and translate this information directly into better clinical management of an individual patient. at present, all the in vivo research in molecular imaging is being conducted on animals, mostly on mice and rats. new animal imaging instruments: micropet, micro-ct and small animal mr have facilitated this research. these noninvasive approaches of obtaining measurable information in a sequential mode have produced significant advances, as has the development of suitable receptors integrating and following reporter gene manifestations. genetic imaging genetic imaging is assuming increased importance. to be able to participate in genetic medicine, the information must be imaged at the molecular level. the directions of genetic imaging are: a) gene expression using intracellular or extracellular reporter genes. an accepted technique in animal genetic imaging employs reporter genes such as lucifer's (the firefly gene responsible for making it glow in the dark). b) screening of populations at known risk ( either specific gene identification or family disease history) in order to discover the earliest phase of disease. c) providing guidance for and follow-up of gene therapy. image-guided gene therapy, whether introducing good genes carried by adeno or retroviruses or with stem cells carrying the good gene, is making slow advances. all present imaging techniques will be star abstract used to guide the micro-catheters or needles to the desired target. i although progress is painfully slow there have been successes. suggested reading 1. blasberg g, gelovani (tjuvajev) j. moleculargenetic imaging: a nuclear-based perspective. molecular imaging2002; 1(3):160-180. 2. collins fs, patrinos a, jordan e, et al. new goals for the u.s. human genome project: 1998-2003. science, 1998; 282: 682-689. 3. dachman, ah; kuniyoshi, jk; boyle, cm; samara, y; hoffmann, kr; rubin, dt; hanan, 1. ct colonography with three-dimensional problem solving for detection of colonic polyps. ajr. american journal of roentgenology, 1998; 171(4):989-995. 4. feig sa,yafeemj. digital mammography, computer-aided diagnosis and tele-mammography. radiol clin north am, 1995; 3: 1205-1230. 5. johnson cd, dachman ah. ct colonography: the next colon screening examination? radiology 2000; 216: 331-341. 6. kurhanewicz j, vigncron db, hricak h, narayan p, carroll p, nelson sj. three-dimensional h-1 mr spectroscopic imaging of the in situ human prostate with high (0.24-0.7-cm3) spatial resolution. radiology, 1996; 198(3):795805. 7. lander es, et al. initial sequencing and analysis of the human genome. nature 2001 409: 814823. 8. lee cc, jack cr jr, riederer sj. use of functional magnetic resonance imaging. neurosurg clin nam, 1996; 7(4):665-683. 9. luboldt w, bauerfeind p, wildermuth s, marincek b, fried m, debatin, je colonic masses; detection with mr colonography. radiology 2000: 216 383-388. 10. moshage we, achenbach s, seese b, bachmann k, kirchgeorg m. coronary arterystenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam ct. radiology, 1995, 196(3): 707-714. il. nelson sj, huhn s, vigneron db, et al. volume mrt and mrsi techniques for the quantitation of treatment response in brain tumors: presentation of a detailed case study. j magn reson imaging, 1997; 7(6):1146-1152. 12. sidransky d. emerging molecular markers of cancer. cancer2002;2(3):210-2j9. 13. tang y, yamashita y, arakawa a, namimotot, mitsuzaki k, abe y, katahira k, takahashi m. pancreaticobiliary ductal system: value of half-fourier rapid acquisition with relaxation enhancement mr cholangiopancreatography for postoperative evaluation radiology 2000; 215: 81-88. 14. tearney g), brezinski me, southern jf, bouma be, boppart sa, fujimoto jg. optimal biopsy in human gastrointestinal tissue using optical coherence tomography. t1jeamerican journal of gastroenterology j 997, 92: 18001804. 15. varmus h, weinberg ra. genes and the biology of cancer, 1993. scientific american library, new york. 16. venter jc, et al. the sequence of the human genome. science 2001 291: 1304-1351. 17. weissleder r, mahmood u. molecular imaging. radiology2001, 219: 316-333. nuclear medicine physician i radiologist australia partnership opportunity • lifestyle our client is a well-respected and rapidly expanding diagnostic imaging group comprising 16 partners, radiologists and nuclear medicine physicians.they service a network of private practices, public hospitals and private hospitals covering speciality, general imaging and intervention procedures. three of the sites include nuclear medicine performing both adult and paediatric studies. the group is competitively placed with all modalities including mr!,an excellent skill base, state-of-the-art equipment, accreditation, a sound administrative structure and a considerable itcommitment. thisposition offers clinical variety including the opportunity for city based private and hospital work as well as rural work. australia's capital city, canberra, combines the advantages of a smaller city lifestyle with all the facilities one expects of a major capital city. it is close to the snow, coast and sydney. travel time to work, excellent schools, shops, recreation facilities and restaurants is minutes from home. thispractice is unique in the australian imaging industry as a totally medically owned and run comprehensive imaging partnership that wishes to remain so. appropriate applicants can look forward to being offered the opportunity to join this team. if you would like to remain in control of your professional career with the option of partnership, then consider the added benefits of a comprehensive progressive practice and life style in canberra. ideally we are seeking a nuclear medicine physician with expertise in ultrasound or a radiologist with a sub-specialty interest. for more information please call kerry mcgill for a confidential discussion or forward your resume to: recruitment professionals pty ltd po, box 481 balgowlah nsw 2093 australia • ph 09 61 2 9907 8633 fax 09 61 2 9907 8644 email: kmcgill@recruitprof.com.au 11 sa journal of radiology • december 2002 mailto:kmcgill@recruitprof.com.au editorial academic writing ian c duncan ffrad (d) sa spiro, wilson, duncan and fourie, inc. sunninghl/l hospital, sandton unitas interventional unit, centurion •in radiology for many south african radiologists the production of a scientific article within our field may seem like an insurmountable task, or worse still one not even worth contemplating at all. this became readily apparent to me when compiling this particular edition of the sajr in that the only articles available for review and publication, barring two-and-a-half, were my own. in the struggle to man the academic departments and state hospitals or cope with the frantic daily hyperactivity of private practice, the writing of articles has largely fallen by the wayside. with the exception of the thesis requirements for certain of the university mmed degrees there is little or no teaching of or encouragement for academic writing in radiology in current-day south africa. and yet as my research for this issue has shown all is not lost as a number of local radiologists continue to make highly significant written contributions to the body of radiological knowledge, both locally and overseas. academic writing is not some mysterious skill enjoyed by only a select few. like any other it is one developed through trial and error and ongoing experience. the necessary material is available to us all. every day at work we see those fascinating or unusual conditions or excellent examples of more common conditions. these cases may be shared among colleagues in the same reporting room, or later at a departmental or interdisciplinary meeting, tutorial or even at a local or international conference. some may find their way into departmental or practice film libraries, and are often forgotten about; many end up in individual 'collections'; a few end up as examination cases. the tragedy is that these highly instructive cases are usually only ever shared among a few. publishing them in a journal allows a much wider exposure to a far greater audience. this is certainly not the insurmountable task that it seems. in this issue, which is dedicated to this subject of academic writing in radiology, we take a look at some of the motivations behind this activity with some tips on how to get started in article writing and publication. we also pay tribute to some of the contributions made in recent years by local radiologists to the international radiological literature. may these enthuse you with the desire to start writing if you have never done so, to try again if you have tried and failed, or to aspire to greater academic contributions if you are already a seasoned writer. give it a try. you will be amazed at what you can achieve. some changes to the format of the sajr will be noted, including the introduction of a letters section and more formal instructions for authors. the journal is itself in a transition process, with the intention that if so desired by the local radiological community it could eventually become a properly peer-reviewed and accredited journal. professor coert de vries, head of the department of radiology at the uovs, has been appointed managing editor of the sajr and will oversee its running in the future. ian duncan editor 3 sa journal of radiology • june 2003 abstract introduction case study discussion conclusion acknowledgements references about the author(s) ju-mei chang department of radiology, edendale hospital, south africa hassan lameen department of radiology, edendale hospital, south africa department of radiology, nelson r. mandela school of medicine, university of kwazulu-natal, south africa garth c. skinner department of ent surgery, edendale hospital, south africa citation chang j-m, lameen h, skinner gc. multiple large vessel aneurysmal formation in hiv-infected patients. s afr j rad. 2017;21(2), a1186. https://doi.org/10.4102/sajr.v21i2.1186 case report multiple large vessel aneurysmal formation in hiv-infected patients ju-mei chang, hassan lameen, garth c. skinner received: 30 jan. 2017; accepted: 13 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a new form of aneurysmal dilatation of large vessels is becoming known in patients with human immunodeficiency virus (hiv) infection. we present a case report of a patient with this anomaly and discuss the radiological dilemmas involved in the diagnosis of the disease. this case highlights the need for computed tomography (ct) angiography as the imaging medium of choice. introduction multiple mycotic aneurysm formation is an unusual disease usually associated with elderly atherosclerotic patients, posttraumatic victims, immunosuppressed patients or intravenous drug abusers. with the emergence of the hiv and/or aids pandemic, another bizarre form of vascular pathology is emerging. multiple aneurysmal deformation of large vessels without an infective aetiology is being documented in hiv and/or aids patients with very low cd4 counts.1 there is an intracranial and extracranial presentation. hiv-associated vasculopathy was first described in 1987, commonly presenting as arterial occlusive disease, aneurysmal disease or spontaneous arteriovenous fistula.1 the incidence of symptomatic vasculitis in hiv-infected patients is 1%.1 imaging is necessary to establish the diagnosis, assess the number of aneurysms and characterise the aetiology of infective versus non-infective disease as well as mapping the anatomy for the surgeon to repair the defect. computed tomography (ct) angiography is the current imaging modality of choice for any suspected arterial aneurysm, owing to its high resolution with 3d reconstruction, precise vascular anatomy and demonstration of possible associated complications which may influence the management planning. mr angiography is reserved for the patient who has limitations or contraindications for ct angiogram; with newer mri techniques, there is improvement of the spatial and temporal resolution which allows us to competently evaluate the aorta, cerebral arteries and peripheral arteries. sonography can be of use if one suspects a peripheral arterial aneurysm in a patient, but generally it is unreliable in the diagnosis of aortic aneurysms. case study a 38-year-old man presented to a regional hospital with a 2-week history of right thigh pain radiating to his knee and lower back. he had recently been diagnosed with hiv with a cd4 count of 257 cells/µl. he had not started antiretroviral therapy. he had no previous history of trauma to the groin area. he was a smoker for the past 7 years. he was not diabetic or suffering from any concomitant cardiovascular disease. on clinical examination, a palpable painful right inguinal mass was found. it was immobile and pulsatile, measuring 4 cm × 5 cm in size. there were no signs of overlying inflammation. his peripheral pulses were all present and equal in both legs. he walked with a limping gait. his specialised investigations included a routine full blood count, urea and electrolytes. his white cell count of 8.6 × 103 µl was normal. there were no other serum abnormalities detected. initially, an ultrasound of his groin and abdomen was performed. the abdominal aorta was normal up to the level of the bifurcation. a right common femoral artery aneurysm was noted, measuring 4.26 cm in diameter. a second left sided common femoral artery aneurysm measuring 2 cm in diameter, with septation, was found. there was normal blood flow noted in the femoral arteries. subsequently, a ct angiogram was performed. bilateral common femoral artery aneurysms were present (figure 1a and 1b). the larger right femoral aneurysm was associated with perivascular soft tissue oedema. there was dilatation of the coeliac trunk and a left sided abdominal aortic aneurysm (figure 2a and 2b). as the patient lacked any clinical signs of being acutely ill, the diagnosis of multiple aneurysm formation in hiv infection was favoured rather than that of a multiple mycotic aneurysms. the patient was referred to a vascular unit at a tertiary hospital for surgical intervention. figure 1: contrasted axial and coronal images (a and b) demonstrate aneurysms seen at both inguinal regions (arrows), which are consistent with common femoral artery aneurysms. the right aneurysm measures approximately 5 cm in diameter, with significant surrounding perivascular oedema and enlarged inguinal lymph nodes. the left femoral aneurysm measures approximately 2 cm in diameter. figure 2: axial contrast images (a and b) demonstrate dilatation of coeliac trunk with an outpouching representing another similar aneurysm. perivascular soft tissue thickening may suggest an enlarged coeliac lymph node. discussion vascular complications, unique to hiv-infected patients, are now being seen due to the increasing incidence of hiv infection worldwide. they include multiple aneurysm formation, vasculitis and large vessel occlusive disease.1 it is believed that hiv-related multiple large vessel aneurysmal formation constitutes a distinct clinical and pathological entity.2 the aneurysms are usually multiple and saccular in nature, favouring the carotid and superficial femoral arteries. other large vessel sites, for example, thoracic aorta, abdominal aorta, common iliac and popliteal, have also been regularly documented as being involved with aneurysmal formations. a multi-loculated appearance can be seen on imaging because of multiple false aneurysm formation along the vessel wall at the site of transmural necrosis. the median age of presentation is between 30 and 40 years. this is much younger than patients presenting with atherosclerotic disease. patients usually present with a subacute history of an expanding mass. pain is the next most common symptom.1 this is very different to that of a patient presenting with a mycotic aneurysm. these patients are usually acutely ill, with multiple organ failure. however, a patient with hiv-related large vessel aneurysmal formation can present acutely because of haemodynamic instability from aneurysmal rupture or with respiratory distress because of airway compression. these patients usually present at an advanced stage of immunosuppression. in nair et al.’s series, 90% of their patients presented with a median cd4 count of < 400 cells/µl. low serum albumin and elevated globulin levels were also consistent findings.2 they established that the inflammation affected the vasa vasora of the major vessels. an influx of neutrophils, plasma cells and lymphocytes causes an intense endothelial swelling which leads to a thrombotic occlusion of the vasa vasora. hiv proteins are noted within these lymphocytes, but the exact significance of this abnormality is yet to be defined. transmural necrosis of the vessel wall occurs because of the probable ischemia and results in weakness and aneurysmal formation. the exact pathogenesis is still unknown. theories such as direct virally mediated destruction or immune complex formation are favoured. there is slim supporting evidence that favours damage by another opportunistic pathogen such as mycobacterial, bacterial or syphilitic infections. their series of 92 aneurysms in 28 patients yielded positive cultures in only 3 patients.2,3 the colour doppler ultrasound features are typical of pseudo aneurysms with a defect or blow out of the vessel wall and turbulent pulsatile blood flow. there is also marked thickening of the vessel adjacent to the aneurysm and hyperechoic spotting of the arterial wall.4 the intracranial aneurysms described by blignaut are usually single and at the anterior communicating artery. most of the aneurysms have a neck width larger than 50% of the transverse width of the sac. multiple aneurysms were more commonly found in the internal carotid artery.5 du pont et al, described the first case in zimbabwe in 1989 that reported a salmonella-related mycotic aneurysmal disease.6 since then, increasingly more cases have been reported independent of bacterial infection. these cases show a predilection for young men who are in the advanced stages of hiv and/or aids as demonstrated by low cd4 levels. treatment of these aneurysms involves open exposure and repair, or endovascular therapy. the combination of a low cd4 count and low albumin levels (< 35 g/l) is a poor prognostic sign. patients should be optimised prior to surgical repair.7 bellows et al. have reported spontaneous regression of an abdominal aortic aneurysm in a hiv patient over a 6-month period. there are also other reports of mycotic aneurysms, although extremely rare, regressing on antibiotic therapy alone.8,9 conclusion relatively healthy hiv-infected patients presenting with a single, large vessel, arterial aneurysm must always be screened for other large aneurysms from the neck to the popliteal regions. the interesting finding in our case is the location of the aneurysms close to the main vessel bifurcations, a feature that demands further research. ct angiograms are the imaging modality of choice. in cases where ct imaging is contraindicated, doppler ultrasound or mr angiography can be utilised. these cases should be prioritised because of the high nature of spontaneous rupture with immediate haemodynamic compromise. acknowledgements competing interests the authors declare that they have no financial or personal relationships, which may have inappropriately influenced them in writing this article. authors’ contributions h.l. was responsible for selecting the case for publication during a routine ct reporting duty at ladysmith hospital (outreach service), the images and the clinical information were collected. he was also responsible for reviewing the first written draft of the paper from the aspect of clinical context and journal requirements for case report. jm.c. was responsible for the literature review and written the first draft of the article. g.c.s. was responsible for reviewing the paper draft from the aspect of clinical context and english grammar. references mulaudzi tv. hiv – associated vasculopathy. cme. 2009;27:320–322. nair r, abdool-carrim ato, chetty r, robbs jv. arterial aneurysms in patients infected with human immunodeficiency virus: a distinct clinicopathological entity? j vasc surg. 1999;29:600–607. https://doi.org/10.1016/s0741-5214(99)70304-6 robbs jv. pathogenesis and pathology of hiv-related large vessel disease. s afr j surg. 2009;47(2):44–45. woolgar jd, ray r, maharaj k, robbs jv. colour doppler and grey scale ultrasound features of hiv-related vascular aneurysms. br j radiol. 2002;75(899):884–888. https://doi.org/10.1259/bjr.75.899.750884 blignaut g, loggenberg e, de vries c. the radiological appearance of intracranial aneurysms in adults infected with the human immunodeficiency virus (hiv). s afr j rad. 2014;18(1):art 586. du pont jr, bonavita ja, digiovanni rj, spector hb, nelson sc. acquired immunodeficiency syndrome and mycotic abdominal aneurysms. a new challenge? report of a case. j vasc surg. 1989;10(3):254–257. https://doi.org/10.1016/0741-5214(89)90438-2 heikkinen ma, dake md, alsac ja, zarins ck. multiple hiv-related aneurysms: open and endovascular treatment. j endovasc. 2005;12:405–410. https://doi.org/10.1583/04-1425.1 bellows ph, anaya-ayala je, younes hk, et al. spontaneous regression of an abdominal aneurysm in an immunocompromised patient. vasc med. 2010; 15(4):315–319. https://doi.org/10.1177/1358863x10375331 wilson tn, kew k, taranth a. multiple mycotic aneurysms of the pulmonary arteries resolving with conservative management. multislice ct examination findings. j thorac imaging. 2008;23:197–201. https://doi.org/10.1097/rti.0b013e318176b917 abstract introduction cardiac mri in patients with arrhythmia and cardiac devices how we scan patients with implanted devices safety protocol and preand post-mri icd interrogation cardiac magnetic resonance protocol modified inversion pulse sequence conclusion references about the author(s) nam ju lee department of radiology and radiological science, johns hopkins university, united states harold i. litt department of radiology, university of pennsylvania, united states citation lee nj, litt h. imaging of patients with implanted devices and arrhythmia. s afr j rad. 2016;20(2), a1046. http://dx.doi.org/10.4102/sajr.v20i2.1046 review article imaging of patients with implanted devices and arrhythmia nam ju lee, harold i. litt received: 06 june 2016; accepted: 28 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract expanding implantable cardioverter-defibrillator (icd) indications and significant morbidity and mortality reduction benefits have resulted in a large number of routine icd implants with appropriate icd shocks for ventricular arrhythmias. the side-effects and lack of long-term efficacy of antiarrhythmics have made ventricular tachycardia (vt) ablation an increasingly attractive treatment option. although cardiac magnetic resonance imaging (cmr) is considered the gold standard technique for imaging of myocardial fibrosis to diagnose and guide vt ablation targets in patients with cardiac arrhythmia, safety concerns and significant artifacts from the devices significantly limit the application of cmr. we discuss how to decrease artifact from cardiac devices and the role of a modified inversion pulse late gadolinium enhancement (lge) cmr sequence as a useful tool in this setting, and we review techniques, safety protocols and limitations from the perspective of our institution’s experience. introduction in the united states, approximately 116 000 implantable cardioverter-defibrillators (icds) and 397 000 cardiac pacemakers were implanted in 2009.1,2 expanding icd indications and significant morbidity and mortality reduction benefits have resulted in a large number of routine icd implants with appropriate icd shocks for ventricular arrhythmias.3 the side-effects and lack of long-term efficacy of antiarrhythmics have made ventricular tachycardia (vt) ablation an increasingly attractive treatment option.4 in 70% to 90% of patients with a secondary prevention icd, a substrate-guided vt ablation must be pursued because of haemodynamic instability or multiple vt morphologies.4 late gadolinium enhancement (lge) magnetic resonance imaging (mri) is an important technique for assessing myocardial viability and fibrosis. for patients undergoing catheter ablation of vt, the assessment of scar transmurality, size and location provided by lge mri enables accurate identification of the arrhythmogenic substrate, leading to more effective selection of sites for ablation.1,5 this approach has the potential to decrease procedure times and increase success rates for ablation procedures.1 up to 75% of patients who could benefit from lge mri have implanted cardiac devices6 and will have an indication for one or more cardiac mri examinations during their lifetime. the presence of these devices presents two issues for cardiac mri: safety and image artifacts.1 traditionally, cardiac devices have been a contraindication to mri owing to safety concerns with a potential risk to pacemaker-dependent and icd patients, of temporary or permanent device malfunction, mechanical forces causing dislocation and movement of the device or leads, and induction of arrhythmia.6 radiofrequency (rf) energy absorbed by leads may lead to heating, which could result in oedema or scarring at the lead tip-myocardial interface or an increase in pacing thresholds that may need to be addressed by increasing device output. an icd may interpret gradients as vt or ventricular fibrillation2,3,4,7 and pacemakers may induce arrhythmia by interpreting rf pulses or gradients as beats and provide a paced beat at the same time as a natural beat. pacemakers have many additional features, most of which should be turned off for mri. there is also a manufacturer-dependent ‘magnet rate’, which may be controlled by a reed switch. the reed switch is activated by a magnet, which brings two metal strips together to complete an electrical circuit. in a mri system, the reed switch will flip about 50% of the time and generally will change pacing to an asynchronous mode at the magnet rate, which varies from 60 to 100 bpm depending upon the manufacturer.3,4,7 the safety aspects of mri in device patients has been studied extensively in the past decade, demonstrating that cardiac mri can be performed safely at 1.5 tesla (t) in patients with implanted cardiac devices, provided that their rhythm is not device dependent and appropriate guidelines are followed.1 at the hospital of the university of pennsylvania, we perform mri on patients with non-mri-conditional pacemakers and icds routinely using the protocol described below. more recently, an mr-conditional icd/cardiac resynchronisation therapy system has been approved3,6 and shown to be safe and effective when scanned at 1.5t.8 the soft-tissue contrast available with mr techniques is advantageous in diagnosing complications near an increasing variety of mr-safe metallic hardware, although the spatial encoding mechanisms utilised in conventional mri methods are often severely compromised. mitigating these encoding difficulties has been the focus of numerous research investigations over the past two decades. such approaches include view-angle tilting, short echo time projection reconstruction acquisitions, single-point imaging, prepolarised mri, and postprocessing image correction.9 multispectral mri techniques, such as multi-acquisition variable-resonance image combination (mavric), where the off-resonance induced by metallic implants is countered by imaging at multiple resonance frequencies9,10 and combining the resultant images to produce a composite artifact-free image, is a promising method for 3d imaging. another technique, that of slice encoding for metal artifact correction (semac),11,12 where the metal-induced off-resonance is countered by a combination of view-angle tilting (vat)13,14 and phase encoding in the z-direction, together with an appropriate reconstruction scheme, has been successfully applied in musculoskeletal imaging applications. a hybrid approach that combines mavric and semac has also been proposed.15 cardiac mri in patients with arrhythmia and cardiac devices all cardiac magnetic resonance imaging (cmr) sequences are affected by the metallic device generator, which induces strong off-resonance field perturbations within the myocardium. a right-sided generator, or generator away from the heart, may reduce inhomogeneity in the region of the heart. in comparison with pacemakers, the larger size of the icd pulse generator and large coil affect image quality substantially. sequences less affected by field inhomogeneity may be used, for example, spin echo instead of gradient echo for localisers, non-balanced gradient echo cine images instead of balanced gradient echo (figure 1), or by reducing echo time (te) and increasing bandwidth (figure 2) as much as possible.16 steady-state free-precession (ssfp) gradient echo (figure 2c) and inversion recovery (ir) sequences with longer tes are associated with increased magnetic susceptibility artifacts compared with non-balanced gradient echo and spin echo sequences. artifacts resulting from pacemaker/icd generators can be reduced by use of lower magnetic field strength and shorter tes; however, such adjustments may compromise the image signal intensity and contrast. the use of spin echo techniques produces black blood contrast, which is not always desirable and is typically associated with a high specific absorption rate (sar), which may reduce safety.17,18 recently, schwitter et al. reported that fast gradient echo (fge) produces better quality and smaller icd-related artifacts for cmr than ssfp in patients with an mri-conditional icd system. fge yielded good to moderate image quality in this multicentre study in 74% of left ventricle (lv) and 84% of right ventricle (rv) acquisitions. in these patients implanted with icd systems designed for the mr environment, cmr can offer diagnostic information in most cases.16 the ssfp sequence is the most commonly used sequence for cardiac functional analysis, but is more susceptible to field inhomogeneities than fge. importantly, many pulse sequences used in clinical mri practice for viability/scar imaging, myocardial perfusion imaging, tagging and flow measurements, use fge-type readouts. also, highly accelerated cardiac acquisitions based on novel compressed sensing strategies can use an fge read-out, and are therefore expected to work reliably in patients with this implanted icd system and avoid ssfp-related artifacts.16 figure 1: gradient echo cine images. non-balanced gradient echo cine images (a–j) instead of balanced ssfp reduces artifact from generator. figure 2: effect of bandwidth on artifact: (a) non-balanced gradient echo cine with low bandwidth (250 hz/pixel); (b) increasing bandwidth to 600 hz/pixel allows visualisation of more of the heart. (c) real-time ssfp cine sequence has more severe artifact. the use of an inversion pulse to properly null the myocardium on lge sequences requires field homogeneity, making artifacts from implanted devices particularly problematic for these sequences (figure 3).18 spurious myocardial hyperintensity results from insufficient spin inversion, which in turn results from inadequate spectral bandwidth of the nonselective adiabatic ir pulses.1 on lge sequences with a standard inversion pulse, cardiac devices generate central dark signal in the direct vicinity of the icd generator (frequently 3 cm – 5 cm surrounding the icd), where the metal components result in a frequency shift that is sufficiently strong to introduce an intravoxel dephasing in the mri signal, and a surrounding ring-like hyperintensity artifact that is created by a metal-induced frequency shift not strong enough to cause a signal void but sufficiently strong to cause an improper inversion of the signal, which appears similar to the hyperenhancement of myocardial fibrosis.2 the artifact affects > 50% of the lv, predominantly the anterior and apical segments owing to the proximity of these areas of the myocardium to the icd generator.3 these hyperintensity artifacts can mask regions of scar tissue or other late enhancement, severely compromising the diagnostic value of lge mri, leading to false negative or false positive diagnoses.1 given the increasing importance of fibrosis imaging in the diagnosis, follow-up and treatment of vt patients and other cardiac diseases (e.g. arrhythmogenic right ventricular cardiomyopathy or sarcoidosis), there is a need for strategies to address the challenge posed by icd artifacts in lge cmr. figure 3: standard lge sequence (a, b and c). there is central dark signal artifact from the generator with peripheral high signal intensity artifact affecting the heart. whilst improved designs of icd and leads will minimise artifacts and improve safety in the longer term, short-term solutions for artifact reduction are most likely to result from new cmr protocols using techniques such as bandwidth modulation.2 these multi-khz off-resonance effects resulting in hyperintensity artifacts can be considerably reduced by using a wideband ir pulse in the lge sequence without requiring additional hardware, time or reconstruction.2,7 this technique has recently been extended to a modified wideband 3-d lge sequence,1 and to allow cardiac t1 mapping without significant icd-induced artifacts.19 mri is emerging as a reliable noninvasive test for myocardial tissue characterisation using cardiac t1 mapping and extracellular volume (ecv) fraction determination. unlike myocardial biopsy, these mri methods provide a means to sample the whole heart noninvasively.19,20 in the context of heart failure (hf) induced by nonischaemic cardiomyopathy, cardiac t1 and ecv fraction mapping may be better than lge mri for quantification of myocardial fibrosis burden. an arrhythmia-insensitive-rapid (air) cardiac t1 mapping pulse sequence21 with a short scan time (i.e. 2–3 heart beats) is well suited for imaging patients with advanced hf, because they often have rapid heart rates and/or irregular heart rhythm and/or limited breath-hold capacity. hong et al. incorporated a saturation rf pulse with wide frequency bandwidth to achieve uniform t1 weighting in the heart in the presence of an icd. in their study, t1 measured in the presence of an icd using the original air sequence was significantly lower (absolute percentage error > 10.1%) than the control t1 values measured with original air without icd, whereas t1 measured with wideband air with icd was similar (absolute percentage error < 2.0%).19 how we scan patients with implanted devices patient screening when a physician requests cmr in a patient with a device, the case is evaluated by an attending radiologist, who determines both whether another acceptable diagnostic modality is available, and also if the information gained from the mri will have considerable impact on patient treatment or prognosis. after this screening, we gather information regarding the device, including year of manufacture and model, date of placement, presence of epicardial leads/coil system or abandoned/capped endovascular leads, pacemaker dependence and renal function. the presence of an older device (entered the market before 2000), leads or generator in place for less than 6 weeks, presence of epicardial, abandoned or capped leads, pacemaker dependence in the presence of an icd, and glomerular filtration rate (gfr) < 30 ml/min. are considered factors that engender additional risk and may prompt additional safety review or a modified consent process. safety protocol and preand post-mri icd interrogation multidisciplinary collaboration and strategic planning are important for establishing a successful program for mri in device patients. in our institution, a group including cardiovascular radiologists and electrophysiology (ep) physicians developed a comprehensive clinical protocol addressing patient care and flow during and after the cmr. informed consent is obtained from all patients after a discussion of the risks and benefits of the procedure. the devices are interrogated and reprogrammed by an electophysiologist (or ep physician’s assistant) as appropriate before and after mri according to the guidelines of the european society of cardiology22 and the literature.4,23 tachyarrhythmia detection and therapy is disabled in patients with an icd. in patients dependent on pacemakers, bradycardia parameters are programmed to an asynchronous mode at an appropriate support rate. in non-dependent patients, the rate-responsiveness feature is temporarily disabled, and demand pacing modes left in place. additional pacemaker features are generally turned off to limit interference. ecg, blood pressure and pulse oximetry is continuously monitored during mri by an advanced cardiovascular life support (acls)-certified provider and clinical symptoms are recorded. a device programmer is kept on hand and an ep provider is either present throughout the exam or readily available. after completion of the scan, the device is re-interrogated to assess any parameter changes, and programming is restored to the initial pre-procedure mode. cardiac magnetic resonance protocol cmr is performed using a 1.5t scanner (siemens avanto, espree, or aera, malvern, pa, usa). whilst cmr in device patients has been reported at 3t,24 we have chosen to restrict studies to 1.5t. all imaging sequences are adjusted to obtain sar < 2.0 w/kg. our cmr protocol in patients with cardiac devices includes: localisers performed using spin echo technique, axial single-shot dark blood half fourier turbo spin echo, multiplanar long-axis non-balanced gradient echo cine, an optional perfusion sequence, post-contrast short-axis non-balanced gradient echo cine, a ti scout, and both standard and wideband inversion pulse lge sequences using a phase-sensitive ir technique. gradient echo cine sequences are obtained with minimum te and a 6 mm slice thickness. the optimal inversion time to achieve ‘nulling’ of the normally enhancing myocardium is estimated using a cine inversion scout sequence before obtaining delayed enhancement sequence; this is the only balanced gradient echo (ssfp) sequence in the acquisition, and is usually subject to considerable artifact. we obtain short-axis cine images after contrast both for time efficiency and as an additional method to evaluate myocardial enhancement if lge sequences are severely affected by artifact. as the wideband lge sequence is not currently available for clinical use by the manufacturer of our scanner, its use at our institution is under a research protocol, and therefore both conventional and wideband lge sequences are acquired. modified inversion pulse sequence the rf inversion pulse in the conventional lge sequence on our 1.5t units is a hyperbolic secant adiabatic inversion pulse. although the inversion pulse is spatially nonselective, it has a spectral bandwidth of 1.1 khz. for a cardiac device generator that is typically 5 cm – 10 cm away from the patient’s heart, the expected resonance offset of the myocardium is in the 2 khz – 6 khz range, well outside the bandwidth of the inversion pulse currently used. consequently, the signal from the affected myocardium is not properly inverted and is typically hyperintense, undermining appropriate diagnostic interpretation (figure 3). a wideband adiabatic inversion pulse (bandwidth 3.8 khz) properly inverts the signal from the myocardium affected by the device generator (figures 4 and 5). this inversion pulse was implemented into the existing two-dimensional ir lge sequence, replacing the conventional inversion pulse. figure 4: three-chamber (a and c) and two-chamber (b and d) lge images. a modified wideband lge sequence (c and d) reduces artifact from the generator compared with standard lge sequence (a and b). figure 5: lge acquisitions in a 52-year-old patient with cardiac sarcoid and an icd. there is significant high signal intensity artifact overlying the heart from the icd generator on the short-axis: (a) and 4-chamber view; (c) typical lge sequence, which mimics transmural lge. high signal intensity artifact is eliminated using the modified wideband lge technique on short-axis; (b) and 4-chamber views; (d) lge sequence and demonstrate true areas of lge in the septum. as the modified sequence requires higher b1 amplitude resulting in high sar, we performed all studies on a 1.5t magnet.2 in an analysis of 264 cmr studies performed using the modified inversion pulse sequence, 20 out of 264 cases (7.5%) were deemed suboptimal, with icd artifact limiting diagnosis. sixteen out of the 264 cases were severely limited and two cases were felt to be mildly limited. no complications have been seen specifically related to the use of the wideband sequence. several factors influence the size of the metallic artifact including metallic composition such as stainless steel and larger size of the device (icds are generally larger than pacemakers), the orientation of the icd with respect to the direction of the magnetic field, the type of pulse sequence applied such as ssfp gradient echo, ir sequences with longer tes, and sequence parameters (such as magnetic field strength, voxel size, and echo train length).17,18 non-ferromagnetic components such as titanium and pulse sequences such as spin echo sequences result in less susceptibility artifact. icd leads contain little ferromagnetic components compared to the generator, resulting in minimal artifact. lower magnetic field strength, shorter tes, and a smaller field of view (fov) can decrease artifact size although image quality may be compromised.17,18 bmi and device-heart distance correlate with the size of icd artifacts.3 the most direct effect of scanning larger patients is the need for a larger fov, which involves lower gradient strengths compared with imaging at a smaller fov. this results in decreased rf depth penetration, decreased spatial resolution, and decreased signal-to-noise ratio, all of which lead to decreased image resolution and potentially a larger artifact size,25 although this effect may be offset by a greater distance from the generator to the heart border. additional chemical shift artifact may play a role in the setting of increased fat-water interfaces within the subcutaneous fat. conclusion artifacts related to implanted devices are mostly related to field inhomogeneity and can be reduced by increasing the distance from the heart, decreasing dependence on field homogeneity using short te non-balanced gradient echo (gre) cine and wideband lge sequences. our experience with performing cardiac mri in patients with implanted devices over 10 years has shown that the modified lge sequence removes most device artifact and is useful to evaluate myocardial fibrosis and scar for both diagnostic purposes and to identify arrhythmogenic substrate prior to planned ablation. however, acquisition of pre-icd implantation cmr will provide detailed scar characterisation not affected by metal artifact and should be considered in patients thought to be likely to require future vt ablation. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.j.l. collected and analysed all data at the perelman school of medicine of the university of pennsylvania, prepared the initial manuscript draft whilst working at staten island university hospital, and edited the manuscript whilst working at johns hopkins university. h.l. was the project leader, was responsible for the project design, supervised all data acquisition and analysis, and edited and finalised the manuscript at the perelman school of medicine of the university of pennsylvania. references rashid s, rapacchi s, shivkumar k, plotnik a, finn jp, hu p. modified wideband three-dimensional late gadolinium enhancement mri for patients with implantable cardiac devices. magn reson med. 2016;75(2):572–584. http://dx.doi.org/10.1002/mrm.25601 rashid s, rapacchi s, vaseghi m, tung r, shivkumar k, finn jp, et al. improved late gadolinium enhancement mr imaging for patients with implanted cardiac devices. radiology. 2014;270(1):269–74. http://dx.doi.org/10.1148/radiol.13130942 mesubi o, ahmad g, jeudy j, et al. impact of icd artifact burden on late gadolinium enhancement cardiac mr imaging in patients undergoing ventricular tachycardia ablation. pacing clin electrophysiol. 2014;37(10):1274–1283. http://dx.doi.org/10.1111/pace.12405 dickfeld t, tian j, ahmad g, et al. mri-guided ventricular tachycardia ablation: integration of late gadolinium-enhanced 3d scar in patients with implantable cardioverter-defibrillators. circ arrhythm electrophysiol. 2011;4(2):172–184. http://dx.doi.org/10.1161/circep.110.958744 tian j, ahmad g, mesubi o, jeudy j, dickfeld t. three-dimensional delayed-enhanced cardiac mri reconstructions to guide ventricular tachycardia ablations and assess ablation lesions. circ arrhythm electrophysiol. 2012;5(2):e31–e35. http://dx.doi.org/10.1161/circep.111.968636 nazarian s, beinart r, halperin hr. magnetic resonance imaging and implantable devices. circ arrhythm electrophysiol. 2013;6(2):419–428. http://dx.doi.org/10.1161/circep.113.000116 stevens sm, tung r, rashid s, et al. device artifact reduction for magnetic resonance imaging of patients with implantable cardioverter-defibrillators and ventricular tachycardia: late gadolinium enhancement correlation with electroanatomic mapping. heart rhythm. 2014;11(2):289–298. http://dx.doi.org/10.1016/j.hrthm.2013.10.032 gold mr, sommer t, schwitter j, et al. full-body mri in patients with an implantable cardioverter-defibrillator: primary results of a randomized study. j am coll cardiol. 2015;65(24):2581–2588. http://dx.doi.org/10.1016/j.jacc.2015.04.047 koch km, hargreaves ba, pauly kb, chen w, gold ge, king kf. magnetic resonance imaging near metal implants. j magn reson imaging. 2010;32(4):773–787. http://dx.doi.org/10.1002/jmri.22313 koch km, lorbiecki je, hinks rs, king kf. a multispectral three-dimensional acquisition technique for imaging near metal implants. magn reson med. 2009;61(2):381–390. http://dx.doi.org/10.1002/mrm.21856 lu w, pauly kb, gold ge, pauly jm, hargreaves ba. semac: slice encoding for metal artifact correction in mri. magn reson med. 2009;62(1):66–76. http://dx.doi.org/10.1002/mrm.21967 hargreaves ba, chen w, lu w, et al. accelerated slice encoding for metal artifact correction. j magn reson imaging. 2010;31(4):987–996. http://dx.doi.org/10.1002/jmri.22112 butts k, pauly jm, gold ge. reduction of blurring in view angle tilting mri. magn reson med. 2005;53(2):418–424. http://dx.doi.org/10.1002/mrm.20375 cho zh, kim dj, kim yk. total inhomogeneity correction including chemical shifts and susceptibility by view angle tilting. med phys. 1988;15(1):7–11. http://dx.doi.org/10.1118/1.596162 koch km, brau ac, chen w, et al. imaging near metal with a mavric-semac hybrid. magn reson med. 2011;65(1):71–82. http://dx.doi.org/10.1002/mrm.22523 schwitter j, gold mr, al fagih a, et al. image quality of cardiac magnetic resonance imaging in patients with an implantable cardioverter defibrillator system designed for the magnetic resonance imaging environment. circ cardiovasc imaging. 2016;9(5):e004025. stradiotti p, curti a, castellazzi g, zerbi a. metal-related artifacts in instrumented spine. techniques for reducing artifacts in ct and mri: state of the art. eur spine j. 2009;18(suppl. 1):102–8. http://dx.doi.org/10.1007/s00586-009-0998-5 sasaki t, hansford r, zviman mm, et al. quantitative assessment of artifacts on cardiac magnetic resonance imaging of patients with pacemakers and implantable cardioverter-defibrillators. circ cardiovasc imaging. 2011;4(6):662–670. http://dx.doi.org/10.1161/circimaging.111.965764 hong k, jeong ek, wall ts, drakos sg, kim d. wideband arrhythmia-insensitive-rapid (air) pulse sequence for cardiac t1 mapping without image artifacts induced by an implantable-cardioverter-defibrillator. magn reson med. 2015;74(2):336–345. http://dx.doi.org/10.1002/mrm.25712 miller ca, naish jh, bishop p, et al. comprehensive validation of cardiovascular magnetic resonance techniques for the assessment of myocardial extracellular volume. circ cardiovasc imaging. 2013;6(3):373–383. http://dx.doi.org/10.1161/circimaging.112.000192 fitts m, breton e, kholmovski eg, et al. arrhythmia insensitive rapid cardiac t1 mapping pulse sequence. magn reson med. 2013;70(5):1274–1282. http://dx.doi.org/10.1002/mrm.24586 roguin a, schwitter j, vahlhaus c, et al. magnetic resonance imaging in individuals with cardiovascular implantable electronic devices. europace. 2008;10(3):336–346. http://dx.doi.org/10.1093/europace/eun021 nazarian s, halperin hr. how to perform magnetic resonance imaging on patients with implantable cardiac arrhythmia devices. heart rhythm. 2009;6(1):138–143. http://dx.doi.org/10.1016/j.hrthm.2008.10.021 ranjan r, mcgann cj, jeong ek, et al. wideband late gadolinium enhanced magnetic resonance imaging for imaging myocardial scar without image artefacts induced by implantable cardioverter-defibrillator: a feasibility study at 3 t. europace. 2015;17(3):483–488. http://dx.doi.org/10.1093/europace/euu263 uppot rn, sahani dv, hahn pf, gervais d, mueller pr. impact of obesity on medical imaging and image-guided intervention. ajr am j roentgenol. 2007;188(2):433–440. http://dx.doi.org/10.2214/ajr.06.0409 case report malignant gastrointestinal stromal cell tumour (gist) of the stomach w spies mschs c s de vries mmedrad(d) department of diagnostic radiology university of the free state bloemfontein case presentation a 55-year-old female patient presented with a painful mass in the left hypochondrium. sonar revealed a well-demarcated round thin-walled lesion with internal echoes with a homogeneous pattern (fig. i). the mass measured approximately 15 x 13 cm. duplex doppler revealed a low venous flow pattern, and a sonar-guided fine needle aspiration (fna), revealed a bloody aspirate (fig. 2). computerised tomography (ct) was done immediately after ultrasound investigation. no oral contrast was given. the cystic lesion (hounsfield unit (hu) = 18 on precontrast study) was situated adjacent to the stomach in the lesser omental sac. it was difficult to differentiate the cystic lesion from either the stomach or the pancreas on ct. the splenic artery could also not be differentiated from the cystic lesion. the post-con.trast ct showed rim enhancement, fig. 1. sonar of a thin-walled lesion with internal echoes. fig. 2. duplex doppler revealing low venous flow penem. fig. 3, pre-contrast ct. but no enhancement of the contents was apparent (figs 3 and 4). 31 sa journal of radiology • june 2002 fig. 4, post-contrast ct. the preliminary differential diagnosis included a haemorrhagic pseudocyst, thrombosed splenic artery aneurysm, subacute haematoma, or abscess. a splenic, hepatic and superior mesenteric artery (sma) angiogram revealed no significant pathology, splenic artery aneurysm, or neovascularity. a surgical exploration and resection was then done. stomach wall slices showed the presence of a cellular tumour with small areas of necrosis. evidence of spindle-shaped and epithelioid cells was found. a slight pleomorphism was present with an average of 2 mitosis per 10 high-field magnification. the final diagnosis was a malignant gastrointestinal stromal cell tumour (gist). discussion gists are uncommon mesenchymal tumours of the gastrointestinal (gi) tract. gists include tumours previously designated as leiomyoma, cellular leiomyoma, leiomyoblastoma and leiomyosarcoma. the oesophagus is the exception, with leiomyoma the most common mesenchymal tumour. studies show that phenotypically undifferentiated gists are also genetically different from leiomyomas and schwannomas and support their dascase report sification apart from leiomyornas.' gists are composed of spindle (70%) or epithelioid (30%) cells. 10 30% are malignant, showing intra-abdominal spread and/or liver metastasis. gists are both malignant and benign. they may be submucosal, subserosal or intraluminal. the ct appearance of a gist may include a sharply defined mass with homogeneous attenuation, sometimes with clarification. a study by kim et al? analysed the clinical presentation, pathology and long-term follow-up of 19 patients with gist tumours (12 gastric, 2 duodenal, 3 jejunal and 2 rectal). the most common clinical presentation was gi bleeding. ct, contrast studies, and endoscopy were used to identify tumour mass. in only two instances could the diagnosis of gist be made preoperatively. histology was variable and the size of the tumours ranged from 0.8 to 23 em. the clinical course is favourable with complete resection. needle biopsy can be used for the diagnosis of gist tumours preoperatively. gist can be classified as benign, borderline, or malignant using immunochemistry, size, mitotic activity and clinical outcome. spindle cell and epithelioid types can be distinguished. cytomorphology alone cannot be used to assess malignancy and predictions of aggressiveness but must be interpreted with a gross and histological examination of the resected specimen. immunocytochemical staining for cd is helpful in confirming the diagnosis. care must be taken to differentiate epithelioid-type gists from adenocarcinoma. gists are also immunohistochernically positive for c-kit (cdl17), cd34 and sometimes for actin, but are mostly negative for desmin and s-l 00 protein. the malignant gist especially,shows activating mutations in the c-kit gene. gist and gi autonomic nerve tumours (gants) can overlap. the cell of origin is not well understood, but resemblance to the interstitial cells of gajal, expression of the smooth muscle markers and occurrence outside of the gi tract suggest an origin from multipotential cells that can differentiate into cajal and smooth muscle cells. references 1. dodd lg, nelson rc, mooney ee, gottfried m. fine-needle aspiration of gastrointestinal stromal tumours. am] clin patho/199b; 109: 439-443. 2. kim cj, day s,yehka.gastrointestinal stromal tumours: analysis of clinical and pathologic factors. am surg2001; 67: 135-137. 32 sa journal of radiology'. june 2002 abstract introduction methods ethical consideration results discussion conclusion acknowledgements references about the author(s) sheila t. ominde department of diagnostic imaging and radiation medicine, university of nairobi, nairobi, kenya timothy m. mutala department of diagnostic imaging and radiation medicine, university of nairobi, nairobi, kenya citation ominde st, mutala, tm. multicentre study on dynamic contrast computed tomography findings of focal liver lesions with clinical and histological correlation. s afr j rad. 2019;23(1), a1667. https://doi.org/10.4102/sajr.v23i1.1667 original research multicentre study on dynamic contrast computed tomography findings of focal liver lesions with clinical and histological correlation sheila t. ominde, timothy m. mutala received: 18 sept. 2018; accepted: 02 feb. 2019; published: 21 may 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: current advancements in dynamic contrast imaging of the liver have enabled increased sensitivity in the diagnosis of liver lesions. evaluation and characterisation of the enhancement pattern of liver lesions in respect to the liver parenchyma aids in making a specific diagnosis. objectives: the aim of this study was to determine the liver findings on dynamic contrast computed tomography (ct) scanning and correlate them with clinicopathologic findings. methods: this prospective cross-sectional study included 61 patients and took place between august 2017 and february 2018. dynamic contrast ct was performed and the images were evaluated by two experienced radiologists. correlation of the ct findings with histology results from an ultrasound-guided biopsy was done. data analysis was performed using spss version 20.0. results: hepatocellular carcinoma (hcc) was the most common malignant lesion seen and showed three patterns of enhancement: homogenous, abnormal internal vessels and heterogeneous enhancement. abnormal internal vessel pattern was most specific (90.6%) and showed a high positive predictive value (ppv) of 78.6%. rapid washout showed a specificity of 87.5% and a ppv of 72.2% in the diagnosis of hcc. dynamic contrast ct scan had a sensitivity of 93%, specificity of 50%, ppv of 91% and diagnostic accuracy of 95.5% in differentiation of benign and malignant liver lesions. considering only liver imaging reporting and data system (li-rads) category 5 as conclusive for hcc diagnosis, our study did not miss a significant number of hccs. liver imaging reporting and data system category 5 showed specificity of 81.3% and ppv of 75%. conclusion: enhancement patterns on a dynamic contrast ct scan of the liver are useful in the interpretation of ct images for specific diagnoses. keywords: dynamic contrast ct; focal liver lesion; enhancement pattern; arterial phase; porto-venous phase; delayed phase. introduction because of the current increase in incidence of primary liver cancers, it is important to apply a systematic approach in the diagnosis and management of focal liver lesions.1 key in the evaluation of focal liver lesions is a thorough clinical history and physical examination, relevant laboratory and radiological investigations, and histopathology. histopathology is the gold standard in making the final diagnosis; however, it is not always possible, as it is invasive.2 computed tomography (ct) is currently routinely used in the evaluation of the liver.3 dynamic ct has been found to have high sensitivity and specificity in the diagnosis of focal liver lesions. an earlier prospective multi-institutional study performed by vassiliades et al.4 compared the sensitivity of ct and high-field mri (1.5t) in the detection of hepatic metastases. the study included 69 cancer patients. non-contrast ct showed an overall sensitivity of 57%, dynamic ct 71% and delayed ct 72%. various subsequent studies showed improved performance of dynamic ct in focal liver lesions. triphasic ct of focal liver tumours performed in pakistan to differentiate benign from malignant lesions was found to have sensitivity and specificity of 100% and 80%, respectively. the positive predictive value (ppv) was 94.5%, negative predictive value (npv) was 100% and diagnostic accuracy 95.5%.5 a systematic review by colli et al. in patients with chronic liver disease showed the sensitivity and specificity of helical ct in the diagnosis of hepatocellular carcinoma (hcc) to be 68% and 93%, respectively.6 another systematic review and meta-analysis showed 74.8% sensitivity and 95.6% specificity in the diagnosis of hepatic metastases.7 sensitivity estimates for helical ct in colorectal liver metastases in another meta-analysis was 64.7%.8 the liver imaging reporting and data system (li-rads), launched in 2011, is used to standardise the reporting of dynamic imaging of the liver in patients at risk of hcc. nodules are categorised as definitively benign (li-rads 1), probably benign (li-rads 2), indeterminate probability of being hcc (li-rads 3), probably hcc (li-rads 4) and definitively hcc (li-rads 5). liver imaging in various imaging centres in our country has no standard ct protocol. most patients are scanned in the portovenous phase only, and this poses a challenge in the characterisation of lesions. the main reason for this is not documented; however, it is important to bring to the fore the diagnostic value of dynamic contrast ct and to avoid unnecessary extra radiation to patients who receive incomplete or inadequate studies. multiple studies have been conducted around the world on the role of dynamic contrast ct in characterising and distinguishing focal liver lesions. however, to the best of our knowledge, no data have been published locally, thus the purpose of this study was to compare local findings and diagnostic accuracy to studies in other parts of the world. this will help to evaluate our standard of diagnostic performance and hence initiate strategies for improvement where need be. this study aims at creating a local database on the spectrum of findings and the diagnostic performance of dynamic contrast ct imaging of the liver. the study findings will be useful to both radiologists and hepatobiliary surgeons. methods this prospective, cross-sectional study was performed at the radiology departments of the kenyatta national hospital and plaza imaging solutions. the aims of the study were firstly to determine the liver findings on dynamic contrast ct scanning and correlate these findings with clinicopathologic findings and secondly to evaluate the diagnostic performance of dynamic contrast ct of the liver. the sample size was determined using fisher’s formula. patient consent was obtained. the study included patients who were at least 18 years of age who presented to the radiology department for abdominal ct scan and who were suspected to have liver pathology (based on clinical examination and/or previous ultrasound findings) with no known primary malignancy. patients who declined to give consent, had any contraindication to contrast media use, had a known extra-hepatic malignancy, had a known histologic diagnosis of the hepatic lesion or had inconclusive biopsy results were excluded. sixty-one patients were recruited for the study. a questionnaire was used to collect both qualitative and quantitative data. it recorded the patients’ demographic information, clinical history, family history and socio-economic history. the ct scanner somatom definition as 128 slice by siemens (2014) was used at kentatta national hospital (knh) and the aquilion one 640 slice by toshiba (2013) was used at plaza imaging solutions. precontrast scans were done followed by contrast-enhanced triple-phase scans. arterial phase scanning was acquired at 30–40 s following dynamic injection of the contrast agent, portovenous phase at 70 s and equilibrium/delayed phase at 180 s. enhancement characteristics of each lesion in each phase were evaluated by two consultant radiologists and the principal investigator. the findings were then recorded in tabulated forms. the patients had a follow-up ultrasound-guided liver biopsy. the histological specimens were sent to pharmcet healthcare laboratory and analysed by an experienced consultant pathologist. histology results were recorded alongside the radiological findings. data were analysed using the spss program (version 20.0). the quantitative data were analysed by using descriptive statistics and presented through percentages, means, standard deviations and frequencies. the information was displayed by the use of bar charts, pie charts, tables and in prose form. ethical consideration permission to conduct this research was obtained from kenyatta national hospital, university of nairobi ethics and research committee (reference number p931/12/2016). results sixty-one patients with focal liver lesions were analysed with dynamic contrast ct scanning. ten presented with characteristically benign lesions and were thus not biopsied. these included eight simple hepatic cysts and two haemangiomas. fifty-one patients with a total of 62 focal liver lesions underwent biopsy. seven patients had more than one focal lesion; however, only the most suspicious lesion was biopsied. the assumption was that all lesions were part of the same disease process. out of the 51 focal liver lesions, seven (13.7%) were benign and 44 (86.3%) were malignant, based on characteristic enhancement patterns. final histopathological results showed eight (15.7%) benign and 43 (84.3%) malignant lesions. out of the eight benign lesions, two (25%) were adenomas, two (25%) liver abscesses, one (12.5%) haemorrhagic cyst, one (12.5%) fibrosis and two (25%) focal nodular hyperplasia (fnh). malignant lesions were hcc (44.2%), metastatic adenocarcinoma (30.2%), cholangiocarcinoma (18.6%), metastatic squamous cell carcinoma (2.3%), gallbladder adenocarcinoma (2.3%) and non-hodgkin’s lymphoma (2.3%). mean lesion size was 5.8 cm with a range of 1.4 cm–17.6 cm. benign lesions had a mean diameter of 4.7 cm while malignant lesions had a mean diameter of 6.3 cm. metastatic lesions had a mean diameter of 4.5 cm. different enhancement patterns were seen in the 51 biopsied lesions. the sensitivity, specificity and ppv for different enhancement patterns associated with each diagnosis are summarised in table 1. table 1: diagnoses and corresponding enhancement. hepatocellular carcinoma lesions showed three patterns of enhancement: homogenous, abnormal internal vessels and heterogeneous enhancement. abnormal internal vessel pattern (figure 1) was most sensitive (57.9%) and specific (90.6%) with a high ppv (78.6%). figure 1: a 73-year-old man who presented with abdominal pain. axial computed tomography scan images: (a) precontrast; (b) arterial phase shows abnormal internal vessels (black arrows). heterogeneous enhancement of fnh had 100% sensitivity and 95.9% specificity but had a low ppv (15.4%). the non-enhancing pattern of metastasis (figure 2) exhibited sensitivity of 50% and specificity of 89.2% with a ppv of 63.6%. an abscess showed incomplete ring enhancement as seen in figure 3. figure 2: a 70-year-old man who presented with abdominal pain with no known primary malignancy. axial computed tomography scan images of biopsy proven metastatic adenocarcinoma showing: (a) hypo-attenuation in the precontrast phase and no enhancement in (b) arterial, (c) portovenous and (d) delayed phase. figure 3: a 36-year-old female who presented with a long history of intermittent fever. coronal computed tomography scan images of an abscess in segment v of the liver (a) precontrast, (b) arterial phase and (c) portovenous phase showing incomplete ring enhancement (arrow). delayed enhancement of cholangiocarcinoma (figure 4) showed 25% sensitivity and 95.3% specificity with a ppv of 50%. thirteen of the hcc lesions demonstrated rapid arterial washout with a sensitivity of 68.4%, specificity of 87.5% and a ppv of 72.2%. figure 4: a 54-year-old male with hepatocellular carcinoma in segment vii of the liver who presented with right upper-quadrant pain. axial computed tomography scans showing: (a) arterial phase enhancement and (b) rapid washout in the portovenous phase. of the histologically proven lesions, 35 (57.4%) were in males and 26 (42.6%) in females. malignancies were seen in 65% of males and benign lesions in 75% of females. chronic liver disease resulting from hepatitis b virus (hbv) was seen in one (5%) of the hcc patients (p = 0.373). chronic alcohol use was noted in 65% of patients with hcc (p = 0.046). no patient with hcc confirmed hiv infection. seven (36.8%) of the 19 patients with hcc reported a history of smoking (p = 0.247). further, 75% of patients with cholangiocarcinoma had a history of chronic alcohol use (p = 0.119) and 50% history of smoking (p = 0.192). both patients with adenoma had a history of oral contraceptive use (7 and 10 years’ duration). dynamic ct diagnosed 44 (86.3%) malignant and seven (13.7%) benign lesions based on characteristic enhancement patterns. on later histological evaluation, 43 (84.3%) were malignant and eight (15.7%) were benign. thus, there were 40 true positive, four false positive, four true negative and three false negative results reported on ct-based assessment of liver lesions. dynamic ct was found to have a sensitivity of 93%, specificity of 50%, ppv of 91%, npv of 57% and diagnostic accuracy of 95.5% in differentiating benign from malignant liver lesions. the li-rads categories of the lesions are summarised in table 2. table 2: liver imaging reporting and data system categories of the 61 liver lesions. lesions classified as li-rads 1 had characteristic benign findings, as either simple cysts or haemangiomas and were thus not biopsied. one (25%) of the li-rads 2 lesions was a metastatic lesion, while the remaining lesions (75%) were two adenomas and a haemorrhagic cyst. three (75%) of the li-rads 3 lesions were metastases, and one (25%) was an abscess. four (75%) of the lesions classified as category 4 were malignant (three cholangiocarcinoma and one non-hodgkin’s lymphoma). two (25%) of the lesions classified as category 4 were fnh. eighteen (75%) of the li-rads 5 lesions were hcc and six (25%) were other malignancies (one cholangiocarcinoma and five metastases). one (7.7%) of the lesions classified as category other malignancy (om) was hcc, 10 (76.9%) were other malignancies (four cholangiocarcinoma, five metastases, one gallbladder adenocarcinoma) and two (15.4%) were benign (tuberculous abscess, fibrosis). the diagnostic accuracies for hcc diagnosis of the li-rads criteria are summarised in table 3. table 3: diagnostic performance of hepatocellular carcinoma diagnosis using liver imaging reporting and data system 4 and 5 categories. discussion our study documented 84.3% malignant lesions, which is comparable to a retrospective study by matilde et al.9 that excluded simple cysts and showed 87% of the lesions to be malignant. metastases were the most common malignant finding at 53%, followed by hcc at 31%. this was unlike our study, which showed hcc to be the most common malignant lesion at 44.2%. the mean lesion size of 5.8 cm was higher than in the study by matilde et al.,9 which found 4.9 cm, and a similar study in pakistan by hafeez et al.,5 which found 3.4 cm. metastatic lesions in this study were larger in size (mean 4.5 cm) compared to those in a study by soyer et al., which had a mean lesion size of 2.2 cm.10 these larger sizes could be explained by the health-seeking behaviour in our population, where patients present at a late stage of disease. no differences were noted between the patients at kenyatta national hospital and those at plaza imaging solutions. hepatocellular carcinoma showed three patterns of enhancement: homogenous, abnormal internal vessels and heterogeneous enhancement. the abnormal internal vessel pattern was most specific (90.6%) and showed a high ppv (78.6%). heterogeneous enhancement of fnh had 95.9% specificity but had a low ppv (15.4). matilde et al. showed the abnormal vessels of hcc to have a specificity of 98% and a ppv of 90%.9 rapid washout showed a specificity of 87.5% and ppv of 72.2% in the diagnosis of hcc. this study showed 68.4% of hcc had rapid washout. lee et al. found arterial hyperenhancement in 86% and 78% of hcc lesions by the two observers, respectively, and 76% showed rapid washout.11 studies by ferdey et al.12 and lancomis et al.13 showed 75% and 74%, respectively, of hyperattenuation of cholangiocarcinoma on delayed images. the hyperattenuating areas in cholangiocarcinoma on delayed phase images seem to be related to the large amount of interstitial space in the fibrous stroma of the tumour.14 delayed enhancement of cholangiocarcinoma showed a specificity of 95.3% and ppv of 50% in our study. various studies have shown most metastatic liver lesions to be hypovascular. the non-enhancing pattern of metastasis exhibited a specificity of 89.2% and ppv of 63.6% in this study. the non-enhancing pattern of metastasis demonstrated a specificity of 96% and a ppv of 75% in the study by matilde et al.9 in a retrospective study by leslie and colleagues, 90% of metastases showed hypodense enhancement on arterial phase.15 precontrast imaging allowed depiction of all hepatic metastases (sensitivity, 100%), compared to 66% in the study by soyer et al.10 malignant lesions were more frequent in men (65%), while benign lesions were mostly in women (75%). kerlin et al. also demonstrated malignant lesions to be more common in males.16 hepatic adenomas and fnh were exclusively found in females. baum et al. were the first to demonstrate the relationship of hepatic adenomas and oral contraceptive use.17 in a study by kerlin et al. it was observed that patients with hepatic adenoma were young and 91% were female. they observed that 89% of them had used oral contraceptives.16 in this study both of the patients with adenoma reported oral contraceptive use. hepatocellular carcinoma and cholangiocarcinoma occurred predominantly in males (m:f 16:3 and 3:1, respectively). there was a significant correlation between the history of alcohol intake and hcc in this study (p = 0.046). heavy alcohol consumption has been shown to increase the risk of hcc.18 globally, 78% of hcc is attributable to hbv (53%) or hepatitis c virus (hcv) (25%), according to a study by perz et al.19 sampling errors resulting from liver biopsy technique were beyond the scope of this study. only patients with conclusive histology findings were included. although high diagnostic accuracy (86%) was noted in our results, we had four false positive results. three of these lesions were labelled as malignant because of hypervascularity and proved to be fnh. one lesion was hypovascular and proved to be a tuberculous abscess. higher diagnostic accuracy of 95% was recorded in a similar study by hafeez et al.5 this study demonstrated dynamic ct scan to have a sensitivity of 93%, specificity of 50% and ppv of 91% in differentiation of benign and malignant liver lesions. possible causes of false negative cases could be inaccurate timing of the different phases of enhancement. considering only li-rads 5 as conclusive for hcc diagnosis, our study missed one out of the 19 hcc lesions (specificity = 81.3%). however, if both li-rads 4 and 5 are combined as definitely indicating the diagnosis of hcc, the specificity decreased to 62.5% but the sensitivity remained the same at 94.5%. a study by trillaud et al.20 on characterisation of liver nodules using mri showed improved sensitivity and reduced specificity when combining li-rads 4 and 5. we confirmed that lesions classified as li-rad 5 that show arterial phase hyperenhancement and washout at ct should be considered as hcc, as documented in the latest li-rads version.21 there is benefit in differentiating li-rad category 4 and 5 lesions to improve diagnostic accuracy. conclusion dynamic contrast ct scan has high diagnostic accuracy in focal liver lesions. various lesions show characteristic enhancement patterns that are useful in the interpretation of ct images for specific diagnoses, emphasising the need for national standardisation of protocols for liver evaluation. limitations of the study only one lesion per patient was biopsied, with the assumption that all lesions were the same disease process. a larger sample size and additional local studies are necessary to strengthen our findings. some of the patients who were candidates for this study were lost to follow-up, either because of death or because of financial constraints. sampling errors resulting from liver biopsy technique were beyond the scope of this study. acknowledgements the authors extend their sincere thanks to mr r. gichuki (statistician) and the radiographers at the kenyatta national hospital and plaza imaging solutions. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions s.t.o. and t.m.m. designed the study and conducted the literature review. s.t.o. recruited the study participants. s.t.o. and t.m.m. evaluated the results and prepared the article for publication. t.m.m. critically reviewed the manuscript. s.t.o. and t.m.m. read and agreed on the final manuscript. references marrero ja, ahn j, rajender reddy k. acg clinical guideline: the diagnosis and management of focal liver lesions. am j gastroenterol. 2014;109(9):1328–1347. https://doi.org/10.1038/ajg.2014.213 rockey dc, caldwell sh, goodman zd, nelson rc, smith ad. liver biopsy. hepatology. 2009;49(3):1017–1044. https://doi.org/10.1002/hep.22742 luersen gf, bhosale p, szklaruk j. state-of-the-art cross-sectional liver imaging: beyond lesion detection and characterization. j hepatocell carcinoma. 2015;2:101–117. vassiliades vg, foley wd, alarcon j, et al. hepatic metastases: ct versus mr imaging at 1.5t. gastrointest radiol. 1991;16(1):159–163. https://doi.org/10.1007/bf01887334 hafeez s, alam ms, sajjad z, khan za, akhter w, mubarak f. triphasic computed tomography (ct) scan in focal tumoral liver lesions. j pak med assoc. 2011;61(6):571–575. colli a, fraquelli m, casazza g, et al. accuracy of ultrasonography, spiral ct, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. am j gastroenterol. 2006;101(3):513–523. https://doi.org/10.1111/j.1572-0241.2006.00467.x floriani i, torri v, rulli e, et al. performance of imaging modalities in diagnosis of liver metastases from colorectal cancer: a systematic review and meta-analysis. j magn reson imaging. 2010;31(1):19–31. https://doi.org/10.1002/jmri.22010 bipat s, van leeuwen ms, comans efi, et al. colorectal liver metastases: ct, mr imaging, and pet for diagnosis – meta-analysis. radiology. 2005;237(1):123–131. https://doi.org/10.1148/radiol.2371042060 nino-murcia m, olcott ew, jeffrey rb, lamm rl, beaulieu cf, jain ka. focal liver lesions: pattern-based classification scheme for enhancement at arterial phase ct. radiology. 2000;215(3):746–751. https://doi.org/10.1148/radiology.215.3.r00jn03746 soyer p, poccard m, boudiaf m, et al. detection of hypovascular hepatic metastases at triple-phase helical ct: sensitivity of phases and comparison with surgical and histopathologic findings. radiology. 2004;231(2):413–420. https://doi.org/10.1148/radiol.2312021639 lee khy, o’malley me, haider ma, hanbidge a. triple-phase mdct of hepatocellular carcinoma. am j roentgenol. 2004;182(3):643–649. https://doi.org/10.2214/ajr.182.3.1820643 feydy a, vilgrain v, denys a, et al. helical ct assessment in hilar cholangiocarcinoma: correlation with surgical and pathologic findings. am j roentgenol. 1999;172(1):73–77. https://doi.org/10.2214/ajr.172.1.9888743 lacomis jm, baron rl, oliver jh, nalesnik ma, federle mp. cholangiocarcinoma: delayed ct contrast enhancement patterns. radiology. 1997;203(1):98–104. https://doi.org/10.1148/radiology.203.1.9122423 asayama y, yoshimitsu k, irie h, et al. delayed-phase dynamic ct enhancement as a prognostic factor for mass-forming intrahepatic cholangiocarcinoma. radiology. 2006;238(1):150–155. https://doi.org/10.1148/radiol.2381041765 leslie df, johnson cd, johnson cm, ilstrup dm, harmsen ws. distinction between cavernous hemangiomas of the liver and hepatic metastases on ct: value of contrast enhancement patterns. am j roentgenol. 1995;164(3):625–629. https://doi.org/10.2214/ajr.164.3.7863883 kerlin p, davis gl, mcgill db, weiland lh, adson ma, sheedy pf. hepatic adenoma and focal nodular hyperplasia: clinical, pathologic, and radiologic features. gastroenterology. 1983;84(5 pt 1):994–1002. baum j, bookstein j, holtz f, klein e. possible association between benign hepatomas and oral contraceptives. lancet. 1973;302(7835):926–929. https://doi.org/10.1016/s0140-6736(73)92594-4 kuper h, tzonou a, kaklamani e, et al. tobacco smoking, alcohol consumption and their interaction in the causation of hepatocellular carcinoma. int j cancer. 2000;85(4):498–502. https://doi.org/10.1002/(sici)1097-0215(20000215)85:4<498::aid-ijc9>3.0.co;2-f perz jf, armstrong gl, farrington la, hutin yjf, bell bp. the contributions of hepatitis b virus and hepatitis c virus infections to cirrhosis and primary liver cancer worldwide. j hepatol. 2006;45(4):529–538. https://doi.org/10.1016/j.jhep.2006.05.013 trillaud h, bruel j-m, valette p-j, et al. characterization of focal liver lesions with sonovue®-enhanced sonography: international multicenter-study in comparison to ct and mri. world j gastroenterol. 2009;15(30):3748–3756. https://doi.org/10.3748/wjg.15.3748 mitchell dg, bruix j, sherman m, sirlin cb. li-rads (liver imaging reporting and data system): summary, discussion, and consensus of the li-rads management working group and future directions. hepatology. 2015;61(3):1056–1065. https://doi.org/10.1002/hep.27304 abstract introduction patients and methods ethical consideration results discussion conclusion acknowledgements references about the author(s) dibuseng p. ramaema division of radiation medicine, nelson r mandela school of medicine, university of kwazulu-natal, south africa richard j. hift division of medicine, nelson r mandela school of medicine, university of kwazulu-natal, south africa citation ramaema dp, hift rj. differentiation of breast tuberculosis and breast cancer using diffusion-weighted, t2-weighted and dynamic contrast-enhanced magnetic resonance imaging. s afr j rad. 2018; 22(2), a1377. https://doi.org/10.4102/sajr.v22i2.1377 original research differentiation of breast tuberculosis and breast cancer using diffusion-weighted, t2-weighted and dynamic contrast-enhanced magnetic resonance imaging dibuseng p. ramaema, richard j. hift received: 16 june 2018; accepted: 06 sept. 2018; published: 25 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the use of multi-parametric magnetic resonance imaging (mri) in the evaluation of breast tuberculosis (btb). objectives: to evaluate the value of diffusion-weighted imaging (dwi), t2-weighted (t2w) and dynamic contrast-enhanced magnetic resonance imaging (dce-mri) in differentiating breast cancer (bca) from btb. method: we retrospectively studied images of 17 patients with bca who had undergone pre-operative mri and 6 patients with pathologically proven btb who underwent dce-mri during january 2014 to january 2015. results: all patients were female, with the age range of btb patients being 23–43 years and the bca patients being 31–74 years. breast cancer patients had a statistically significant lower mean apparent diffusion coefficient (adc) value (1072.10 ± 365.14), compared to the btb group (1690.77 ± 624.05, p = 0.006). the mean t2-weighted signal intensity (t2si) was lower for the bca group (521.56 ± 233.73) than the btb group (787.74 ± 196.04, p = 0.020). an adc mean cut-off value of 1558.79 yielded 66% sensitivity and 94% specificity, whilst the t2si cut-off value of 790.20 yielded 83% sensitivity and 83% specificity for differentiating between btb and bca. the homogeneous internal enhancement for focal mass was seen in bca patients only. conclusion: multi-parametric mri incorporating the dwi, t2w and dce-mri may be a useful tool to differentiate bca from btb. introduction although breast cancer (bca) is the most prevalent malignancy amongst south african women, accounting for 20.62%,1 the prevalence of breast tuberculosis (btb) is by contrast much lower, with reported ranges between 0.3% and 0.4%.2,3 breast tuberculosis is a manifestation of extra-pulmonary tuberculosis (eptb), a condition which has become considerably more commonly encountered as a consequence of the human immunodeficiency virus (hiv) pandemic;4,5 yet, studies and guidelines on the management of eptb frequently do not mention the breast as a potential site for tuberculosis.6,7,8 given the infrequency with which btb is diagnosed, little research has been performed on the disease. breast tuberculosis and bca may present clinically in a very similar fashion leading to potential misdiagnosis9,10; given that an accurate diagnosis is essential if the patient is to receive correct and timely treatment, this may be problematic.8 conventional imaging with mammography and ultrasound has limited ability to differentiate between btb and bca.11 it is therefore appropriate to investigate the use of newer and more complex imaging modalities in the differentiation of bca and btb. studies that have used magnetic resonance imaging (mri) to differentiate eptb from malignant lesions are those which focused on other body parts such as the central nervous system (cns)12,13,14 and the musculoskeletal system.15,16 peng et al. used the diffusion-weighted imaging (dwi) and magnetic resonance spectroscopy (mrs) to differentiate intracranial tuberculomas from high-grade gliomas and found significant differences. the diagnostic accuracy was higher when using the minimum apparent diffusion coefficient (adc) value from the dwi than the maximum mrs ratios of cho/cr, cho/naa and cho/cho.13 magnetic resonance imaging has also been utilised in pulmonary tuberculosis (ptb) to differentiate between tuberculous and malignant nodules.17,18,19,20 only one study was found in the literature which aimed to differentiate btb from bca with the use of mrs in four btb patients with no comparison group.21 the authors suggested that the absence of choline peak and the presence of a strong lipid peak favoured btb rather than bca.21 there are multiple studies that utilise dwi and adc to distinguish malignant from benign breast disease.22,23,24,25,26,27 diffusion-weighted imaging measures the microscopic movement of water molecules in biological tissues, with the pathologic processes altering their mobility; the detection of these changes aids in lesion characterisation.28 the adc is derived from dwi sequences. apparent diffusion coefficient values, measured in mm2/s, are calculated within a given area. this reflects water restriction. tissues with high adc values, because of increased diffusion, display a brighter signal, whereas those with lower adc values appear darker, because of restricted diffusion.29 most malignant lesions display lower adc values when compared to benign or inflammatory lesions.26 rong-feng qu et al. recently conducted a meta-analysis of the differential diagnosis of benign and malignant breast tumours. the authors found that the adc values of normal breast tissues were higher than those of benign tissues, and that the values of benign lesions were higher than those of malignant tumours.23 breast dynamic contrast-enhanced magnetic resonance imaging (dce-mri) involves administration of a magnetic compatible intravenous (iv) contrast agent in order to detect and characterise lesions.30 further advantage is the ability to evaluate the breast lesion enhancement parameters and kinetic curves. it has been demonstrated that during the wash-in rate, malignant lesions demonstrated higher maximum enhancement when compared to benign lesions.31 dynamic contrast-enhanced mri kinetic characteristics have been shown to correlate with tumour neovascularity in which more vascular tumours demonstrate strong enhancement.32 the t2-weighted (t2w) mri uses the tissue transverse relaxation times to generate the signal.33 the displayed t2 signal intensity (t2si) is used in the characterisation of tissues and lesions.33 studies that used the t2si in the discrimination of benign and malignant breast lesions mainly analysed the morphologic t2si appearance rather than the quantitative values.34,35 the majority of bcas appear hypointense on t2w, compared to most benign lesions that appear hyperintense.36 the purpose of our study was to evaluate the use of the dwi parameter of adc, the dce-mri enhancement morphologic characteristics and the t2w parameter of t2si value to differentiate bca from btb. patients and methods we retrospectively identified 24 patients with histologically proven bca (including ductal carcinoma in situ [dcis]) who underwent dwi, t2w and dce-mri during january 2014 to december 2014. seven patients did not have a full set of images on the picture archiving and communication system (pacs) and were excluded from the study, which resulted in the final total of 17 patients. for the btb group, we included six prospectively and consecutively identified patients with proven btb who also underwent the dwi, t2w and dce-mri. although five patients had conclusive histology from either the breast or the axillary lymph nodes, one patient had inconclusive histology from breast and axilla, but had proven concurrent ptb, for which she was receiving anti-tuberculous therapy (att). her clinical and radiological features were compatible with btb, and both the breast and the axillary nodes responded satisfactorily to att. all btb patients had undergone screening investigations at the referring breast clinic, including ultrasonography, with or without mammograms, depending on their age. following the histological confirmation of btb, the patients were invited for a baseline mri scan within 2 weeks of confirmation of the diagnosis. scans were not performed within 2 weeks of a biopsy in order to avoid the presence of haematoma and/or inflammation confounding our results. magnetic resonance imaging image acquisition magnetic resonance imaging images were retrospectively analysed following retrieval from the hospital’s pacs. magnetic resonance imaging was performed on a 1.5 telsa machine (siemens, erlangen, germany) using a dedicated breast coil. the patients were scanned in the prone position. a power injection of 20 ml intravenous (iv) magnevist® (gadopentetate dimeglumine, bayer) standard 469 mg/ml (0.5 mmol/ml) at a dosage of 0.1 mmol/kg was administered to all the patients. the iv contrast rate was 3 ml/s followed by a 20 ml saline flush administered as a bolus. the t1 dynamic phase scan time was 6 min 41 s, during which five dynamic sequences were obtained in the axial position at various time points. the dwi images with the adc map were also acquired during the same scan. the technical parameters are reported in table 1. table 1: local dynamic contrast-enhanced breast magnetic resonance imaging protocol technical parameters. magnetic resonance imaging image analysis all the images were read by one of the authors who is a radiologist with more than 10 years’ experience in breast radiology. the following qualitative parameters were recorded: the bca pathological subtype from the pathology records. the dce-mri parameters were classified using the breast imaging reporting and data system (bi-rads) descriptors37 and included the following: the enhancement pattern: either mass-like enhancement (mass) or non-mass enhancement (nme). non-mass enhancement distribution pattern: focal, linear, segmental, regional, multiple regions or diffuse. non-mass enhancement internal enhancement: homogeneous, heterogeneous, clumped and clustered ring. mass internal enhancement: homogeneous, heterogeneous, rim enhancement and dark internal septations. the presence or absence of axillary nodes was added to the above descriptors. we further recorded the adc values (×10−6 mm2/s) derived from the dwi images, and t2si value derived from the t2w. for the quantitative parameters, the region of interest (roi) was drawn on three contiguous axial images around the lesion circumference and the average recorded. all images were analysed on the dedicated syngo-via (siemens, erlangen, germany) reading platform. statistical analysis data were entered into an excel spreadsheet (microsoft excel 2013. redmond, wa) and analysed using the stata software package (statacorp. 2015: stata statistical software, release 14. college station, tx). differences in adc value and t2si between the two groups were assessed with a two-tailed unpaired t-test. differences in adc value and t2si with enhancement pattern matching were assessed using analysis of variance (anova). the results were considered significant where p < 0.05. ethical consideration ethical clearance was obtained from the institution’s biomedical research ethics committee (brec) (reference number bf213/13). results patient characteristics all the patients were female. the ages of the btb patients ranged from 23 to 43 years, and for those with bca, 31–74 years. three btb patients were hiv positive, one hiv negative and two not tested. the bca subtypes included 13 cases of invasive ductal cancer (idc) (76.5%); 3 cases of dcis (17.6%), of whom one had high-grade dcis; and 1 case (5.9%) of invasive lobular cancer (ilc). radiologic findings the mri morphological enhancement characteristics of the bca patients are shown in figure 1 and those of btb in figure 2. figure 1: dynamic contrast-enhanced magnetic resonance imaging enhancement characteristic of various patients with breast cancer: (a) clustered ring, (b) clumped, (c) linear distribution, (d) homogeneous (e) larger homogeneous pattern and (f) multicentric heterogeneous enhancement. figure 2: dynamic contrast-enhanced magnetic resonance imaging enhancement patterns of various patients with breast tuberculosis: (a) focal rim, (b) multiple regions rim, (c) same patient as (b) to better demonstrate multiple rim enhancement on the non-subtracted t1-weighted image, (d) clumped diffuse and (e) clumped diffuse associated with rim-enhancing left axillary nodes. mass versus non-mass enhancement pattern in the patients with btb, 3/6 (50%) had mass-like enhancement, and 3/6 (50%) had nme patterns. in the patients with bca, 11/17 (65%) had mass-like enhancement, and 6/17 (35%) had nme patterns. enhancement patterns amongst the btb patients, 3 (50%) had clumped diffuse nme, 2 (33%) showed focal mass rim and 1 (17%) demonstrated multiple regions mass rim. axillary nodes in btb patients demonstrated rim enhancement (figure 2). of the bca patients, 5 (29%) had heterogeneous enhancement, 7 (41%) had homogeneous enhancement, 4 (24%) had clumped enhancement and 1 (6%) had clustered ring enhancement (figure 1). apparent diffusion coefficient and t2-weighted signal intensity values the representative images demonstrating data extraction for adc values and t2si measurements of the bca and btb patients are depicted in figure 3. figure 3: apparent diffusion coefficient value and the t2 signal intensity measurements. (a–c) axial dynamic contrast-enhanced magnetic resonance imaging (dce-mri), diffusion-weighted imaging (dwi) and t2-weighted (t2w)-mri images of a 61-year-old female patient with left breast cancer: (a) axial t1 post-contrast subtracted image demonstrates strongly homogeneous enhancing mass with neovascularity in the left breast. (b) corresponding axial dwi-mri apparent diffusion coefficient (adc) map image shows dark signal. (c) axial t2-weighted image shows the tumour hypointensity. (d–f) axial dce-mri, dwi and t2w-mri images of a 41-year-old female patient with left breast tuberculosis: (d) axial t1 post-contrast subtracted image demonstrates a hypointense rim-enhancing mass in left breast; (e) corresponding axial dwi-mri adc map image demonstrates a bright signal; and (f) axial t2-weighted image shows a uniformly hyperintense signal. we found significant differences in both adc and mean t2si values between the two groups. the mean adc for btb was 1690.8 ± 624.1, and for bca, it was 1072.1 ± 365.1 (p = 0.006). the mean t2si for btb was 787.7 ± 196.0, and for bca, it was 521.6 ± 233.7 (p = 0.020) (table 2). table 2: comparison of the diffusion-weighted imaging and t2-weighted magnetic resonance imaging quantitative parameters for the breast tuberculosis and breast cancer patients. with regard to the adc values, receiver operating characteristic (roc) curve analysis showed a sensitivity of 66.7% (ci 22.3% – 95.7%) and specificity of 94.1% (ci 71.3% – 99.9%) for a diagnosis of btb at a cut-off value of 152.2 × 106 mm2/s, with an area under the curve (auc) of 0.81 (ci 0.60% – 0.94%) (figure 4). figure 4: preliminary receiver operating characteristic curve analysis of the apparent diffusion coefficient value of the breast lesions for differentiating cancer from tuberculosis. the corresponding values for t2si were 83.3% specificity (ci 35.9% – 99.6%) and 82.4% sensitivity (ci 56.6% – 96.2%) at a cut-off value of 670.6, with an auc of 0.77 (ci 0.54% – 0.91%) (figure 5). figure 5: preliminary receiver operating characteristic curve analysis of the t2 signal intensity of the breast lesions for differentiating cancer from tuberculosis. breast cancer versus breast tuberculosis with matched patterns these differences persisted when the two groups were matched for the patterns of mass-like enhancement (mass) and non-mass enhancement (nme) and compared with anova. significance was shown for both mean adc value (p = 0.040) and t2si (p = 0.015). discussion this study evaluated the ability of the two quantitative mri markers, the adc value and the t2si, and the qualitative dynamic post-contrast enhancement patterns to discriminate between bca and btb. utility we have shown that bca patients have significantly lower mean adc and t2si values compared to btb patients. roc curve analysis suggests that the adc value is a better discriminator between bca and btb; however, the confidence intervals are unacceptably wide and further validation, using a larger sample, is required before these can be accepted as having real diagnostic value. explanation this outcome is explicable in that malignant lesions have high cellularity with resulting restricted diffusion, yielding lower adc values, a parameter derived from the dwi. this finding has been shown to be consistent across many studies,23,24,25,26,27,38,39 with few exceptions.12 woodhams et al.24 found malignant breast tumours to have lower adc values than benign lesions; furthermore, the idc displayed lower values when compared to the non-invasive ductal cancer (nidc). in contrast, chatterjee et al.12 found similar adc values for brain tuberculomas and brain metastases. the studies that utilised t2si to discriminate the benign from the malignant breast lesions predominantly focused on the qualitative t2 signal morphologic appearance rather than the quantitative value as in our study.34,35 the data on the use of quantitative t2si as a discriminator between benign and malignant breast lesions are scanty.40 other studies in which t2si quantitative values were used in differentiating benign from malignant lesions involve other parts of the body and not the breast.41,42 henz et al.41 investigated pulmonary nodules with mri using the quantitative parameters adc and t2si in a granulomatous endemic area. they found both the mean t2si ratio and the adc to be significant in differentiating the benign from the malignant pulmonary nodules. post-contrast morphological analysis revealed that the homogeneous internal enhancement pattern was exclusively observed in bca patients. this qualitative feature can be used as a further descriptor for separating the two conditions when other imaging or pathology results are equivocal. the diffuse distribution of btb was visually associated with enlargement of the breast; although this appearance can be confused with inflammatory bca, the presence of rim-enhancing axillary nodes is more supportive of btb than bca.43 conclusion based on our findings, we conclude that the combination of dce-mri morphologic enhancement pattern, the t2si and the quantitative dwi adc values may provide some useful non-invasive information in distinguishing malignant from non-malignant illness (in this case, btb) in patients with suspicious breast lesions. development of accurate diagnostic algorithms will require accumulation of a larger patient database for btb in particular; more broadly, however, continued investigation is appropriate in terms of the development of tests to distinguish malignant from benign disease more generally. as with mammographic and ultrasonic findings, the mri findings alone are not sufficient to distinguish btb and bca with acceptable accuracy, and histology remains essential for this purpose. acknowledgements this publication was made possible by grant number: r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the government. further funding for operational costs was obtained from the university of kwazulu-natal (ukzn) strategic funds. the authors also wish to acknowledge the medical education partnership initiative (mepi) for providing seed funding. competing interests the author declares that they have no financial or personal relationships that may have inappropriately 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concatto n, watte g, marchiori e, et al. magnetic resonance imaging of pulmonary nodules: accuracy in a granulomatous disease-endemic region. eur radiol. 2016;26(9):2915-20. https://doi.org/10.1007/s00330-015-4125-1 peng y, jiang y, antic t, giger ml, eggener se, oto a. validation of quantitative analysis of multiparametric prostate mr images for prostate cancer detection and aggressiveness assessment: a cross-imager study. radiology. 2014;271(2):461–471. https://doi.org/10.1148/radiol.14131320 sathekge amm, d’asseler y, vorster m, gongxeka h, van de wiele c. tuberculous lymphadenitis: fdg pet and ct findings in responsive and nonresponsive disease. eur j nucl med mol imaging 2012;39(7):7. reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and 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http://www.sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za letter condensing osteitis of the clavicle right shoulder two and a half years after the chest pain incident, chest radiographs taken atthis time revealed no change in appearance or size of the dense clavicular lesion. ofl6 histologicallyproven cases, all occurring in women mostly presenting in the fourth or fifth decades (age range 26-63), only two were asymptomatic with the lesiondiscovered serendipitously' as was the situation in the abovecase condensing osteitis of the clavicle is an important condition to recognise as the plain films should be diagnostic and no further investigation should generally be required. the important condition to consider in the differential diagnosis is a solitary sclerotic metastatic deposit which would require further investigation. although the above patient was asymptomatic, some patients do have severe pain andnon-steroidalanti-inflammatorymedication may be required. in some patients where the pain is refractory, excision of the medial third of the clavicle may be necessary as a last resort.' to the editor: the article on the very rare condition of condensing osteitis of the inferomedial aspect of the clavicle' was most interesting and prompts the following short case notes. a43 year old woman with a history of left chest pain was referred for radiographs of the chest and thoracic spine which demonstrated a "coin lesion" overlying the inferomedial aspect of the right clavicle. on the frontal chest radiograph the lesion appeared to be within the medial clavicle, but on the antero-posterior thoracic spine film the nodule appeared to be intrapulmonary in location due to a superimposed vessel which seemed to be part of the "coin lesion". the dilemma was expeditiously resolved by taking radiographs specifically angled to show the medial clavicle which confirmed that the rounded sclerotic lesion was intraclavicular in location. no associated inferomedial bony spur or osteophyte was demonstrated, there was no soft tissue swelling and the sternoclavicular joint was normal. ofparticularinterestwas that the patient had had no pain or soft tissue swelling related to the medial aspect of the right clavicle.no history of previous trauma was elidted.two years before the presentation of chest pain she had experienced right sided shoulder pain,andshe again presented with pain in the wfc van gelderen ffrad(d) (sa) consultant radiologist departmentofradiology vtánganui base hospital wang;mui new zealand references 1. ooi gc, pch wcg. condensing osteitis of the clavicle. southafrican journal of radiology. i 996; 1 [21:25-27. 2. greenspan a, gerscovich e, szabo rm, mathews if jg. condensing osteitis of the clavicle: a rare but frequently misdiagnosed condition. american loumal of rxn~1991;156:10l1-1015. figure 1: close up view of right clavicle on frontal chest radiograph demonstrates rounded sclerotic area involving inferomedial aspect of right clavicle consistent with sclerosing osteitis (arrows) maurice vveinbren award in radiology 1996 the award isoffered annually (in respect of a calendar year) by the council ofthe college ofmedidne of south africa for a paper ofsuffident merit dealing either with radiodiagnosis radiotherapy, nuclearmedidoe or diagnostic ultrasound. tile award consists of a certificate and a mooal. the closing date is 15 february 1997. tile guidelines pertaining to the award can be obtained from the executive secretary, mrs bemise bothma at 17 milner road, rondebosch, 7700ortci: (021) 689-3161,fax: (021) 68s-3766,e-mail:cmsa·adm@iafrica.com 25 sa journal of radiology. november 1996 about the author(s) sunette claassens department of paediatric radiology, university of the witwatersrand, south africa charl verwey organisational unit of paediatric pulmonology, university of the witwatersrand, south africa tanyia pillay department of paediatric radiology, university of the witwatersrand, south africa citation claassens s, verwey c, pillay t. an approach to non-radiodense aspirated foreign bodies in the paediatric patient. s afr j rad. 2017;21(1), a1143. https://doi.org/10.4102/sajr.v21i1.1143 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia,usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract an approach to non-radiodense aspirated foreign bodies in the paediatric patient sunette claassens, charl verwey, tanyia pillay copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction: foreign body aspiration is a common and often serious problem in paediatric patients. approximately 80% of paediatric foreign body aspiration episodes occur in children younger than 3 years. almost 90% of aspirated foreign bodies are non-radiodense and therefore not seen on radiographs. clinical presentation may be subtle and can become a diagnostic dilemma, particularly if there is no witnessed aspiration. aim: an educational poster on a radiological approach to aspirated non-radiodense foreign bodies. methods: we present serial chest radiographs of bronchoscopically confirmed non-radiodense foreign bodies. conclusion: knowledge about the different radiological features suspicious for foreign body aspiration is essential and can guide appropriate intervention including bronchoscopic retrieval, which may prevent permanent pulmonary sequelae. abstract introduction tracheal and oesophageal tubes and lines conclusion acknowledgements references about the author(s) rishi p. mathew department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada timothy alexander department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada citation mathew rp, alexander t, patel v, low g. chest radiographs of cardiac devices (part 1): lines, tubes, non-cardiac medical devices and materials. s afr j rad. 2019;23(1), a1729. https://doi.org/10.4102/sajr.v23i1.1729 review article chest radiographs of cardiac devices (part 1): lines, tubes, non-cardiac medical devices and materials rishi p. mathew, timothy alexander, vimal patel, gavin low received: 04 mar. 2019; accepted: 05 may 2019; published: 29 july 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract chest radiographs (cxrs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. they play a vital role in intensive care units for evaluating the critically ill. it is therefore very common for the radiologist to encounter tubes, lines, medical devices and materials on a daily basis. it is important for the interpreting radiologist not only to identify these iatrogenic objects, but also to look for their accurate placement as well as for any complications related to their placement, which may be seen either on the immediate post-procedural cxr or on a follow-up cxr. in this article, we discussed and illustrated the routinely encountered tubes and lines that one may see on a cxr as well as some of their complications. in addition, we also provide a brief overview of other important non-cardiac medical devices and materials that may be seen on cxrs. keywords: chest radiographs; endotracheal tube; tracheostomy tube; nasogastric tube; central venous catheter; swan ganz catheter; intercostal drainage tube. introduction among the various imaging modalities available for assessing the cardiothoracic system, the chest radiograph (cxr) is the most commonly used. in addition, the cxr is very useful in assessing the numerous tubes, lines, medical devices and materials, as well as for identifying any equipment-related complications. the american college of radiology (acr) recommends a cxr immediately after the placement of a medical tube, catheter or device, to check for malposition or for intraor post-procedural-related complications. as any medical device has the potential for coiling, mispositioning, kinking or fracturing and malfunctioning, the complications that may ensue are often not immediately apparent clinically. hence, it is of utmost importance to identify these on the immediate post-procedural cxr or follow-up cxrs for the physician or surgeon to replace or reposition these devices.1 the objective of this article is to provide a comprehensive review of the numerous tubes, lines and non-cardiac medical devices or materials that may be seen on cxrs, their appearance on cxrs and how to evaluate for their accurate placement, as well as to be aware of associated complications that need to be considered. tracheal and oesophageal tubes and lines endotracheal tube the endotracheal (et) tube is inserted for maintaining the patency of the airways or to provide airway support. the accurate positioning of the et tube is assessed by calculating the distance of the tip of the et tube from the carina. an ideal position would be 5 cm above the carina (figure 1a) with the patient’s head in a neutral position, taking into consideration that neck extension or flexion would lead to 2 cm of movement upwards or downwards. in cases where the carina is not visible on the cxr, the aortic ‘knob’ can be used as a useful landmark. the carina is just distal to the aortic arch, and if the et tube is just above the aortic arch, it can be considered to be in a safe position midway between the vocal cords and the carina.2 if the carina is not visible an additional landmark that could be utilised is by confirming that the et tip lies between the t2 and t4 vertebrae.3 figure 1: (a) magnified chest radiograph showing an accurately placed endotracheal tube with its distal end (arrow) located above the carina. other lines and tubes visualised are the right internal jugular vein central venous catheter (star) and the nasogastric tube (arrow head); (b) chest radiograph showing a malpositioned endotracheal tube with its tip in the right main bronchus (arrow). a central venous catheter is noted in the right atrium (star). a malpositioned et tube (figure 1b) is the most common complication associated with et tube insertion. complications associated with a wrongly placed cephalad et tube include inefficient ventilation and distension of the stomach and vocal cord injury caused by the inflated cuff. hence, the et tube tip should be at least 3 cm caudal to the vocal cords. if the et tube is advanced too caudally, the tube can selectively intubate one of the main bronchi, usually the right, leading to segmental or complete collapse of the lung. accidental intubation of the oesophagus is a potentially fatal complication. in such cases, a frontal cxr may show the et tube lateral to the tracheal air column and the identification of a column of air lateral to the trachea along with an overdistended stomach.4 tracheostomy tube tracheostomy tubes (figure 2) are inserted for long-term ventilation. its distal end should be midway between the stoma and the carina at the level of third thoracic vertebra. when compared with the et tube, the position of the tracheostomy tube is maintained with neck flexion and extension. figure 2: chest radiograph showing an accurately positioned tracheostomy tube (arrow). the width of the tube should not exceed two-thirds of the tracheal width, and the cuff should not distend the tracheal wall. complications associated with tracheostomy tubes include subcutaneous emphysema, haematoma and pneumomediastinum. granulation tissue formation and fibrosis at the site of the stoma can lead to tracheal stenosis.1,4 nasogastric tube nasogastric (ng) tubes are frequently used for suction of stomach contents, administration of medication and for feeding. the ng tube has multiple side holes and a thin radiopaque marker line along one side, enabling it to be identified on a radiographic study (figure 3a). the proximal side hole is indicated by a short break in this line. both the upper side hole and tip should be located clearly below the gastroesophageal (ge) junction. an ideal position of the ng tube would be with its tip in the stomach caudal to gastric cardia or at least 10 cm distal to the ge junction.1,4 a malpositioned ng tube is the commonest complication and can lead to lung perforation, oesophageal perforation, pneumonia and pneumothorax.5,6 figure 3: (a) chest radiograph showing an accurately positioned nasogastric tube with its proximal side hole (arrowhead) and tip located beyond the gastroesophageal junction. in addition, an endotracheal tube (black arrow) and a right internal jugular vein central venous catheter (star) are noted on this chest radiograph; (b) a malpositioned dobhoff tube (white arrow) in the right main bronchus. additionally, a left central venous catheter (star) is noted with its tip in the superior vena cava. dobhoff tubes are flexible tubes with a narrow bore measuring 4 mm in diameter for delivering enteral nutrition. unlike ng tubes, suction cannot be applied to these tubes, making it useful only for feeding and delivery of drugs. these tubes provide two advantages over the ng tube1 because of their narrow bore; they are better tolerated by patients2, and the tubes enable post-pyloric feeding. these tubes are inserted into the stomach or duodenum with the aid of a guidewire through the nasal passage, which is then removed once the distal end of the tube is in an acceptable position. the distal end of the tube has a metallic end visible on a cxr. the gold standard for confirming an accurately inserted dobhoff tube is by radiographic examination. complications associated with these tubes include accidental insertion into the airway (figure 3b), and if advanced further into the lungs may lead to trachea-pulmonary complications such as pneumothorax.7 figure 4: (a) chest radiograph showing an intercostal drainage (icd) tube introduced for pneumothorax; (b) a pigtail catheter (arrow) in the right thorax inserted for pleural effusion. additionally, a malpositioned right peripherally inserted central venous catheter (picc) [star] is noted with its tip in the left brachiocephalic vein. figure 5: (a) chest radiograph showing a right central venous catheter (arrow) with its end located in the svc. in addition, bilateral intercostal drainage tubes (stars) and mediastinal drainage tube (arrow head) are noted; (b) chest radiograph showing a left-sided, peripherally inserted central catheter with its tip (arrow) in the right atrium; (c) a tunnelled right central venous catheter. figure 6: magnified chest radiograph showing a malpositioned right central venous catheter in the left brachiocephalic vein. figure 7: magnified chest radiograph showing a widened superior mediastinum secondary to central venous catheter induced haematoma. figure 8: chest radiograph showing a swan ganz or pulmonary artery catheter (white arrow), with its tip in the right pulmonary artery. the other devices on this chest radiograph are an endotracheal tube (black arrow), a mediastinal drainage tube (arrow head) and a prosthetic aortic valve (star). chest drainage or inter costal drainage tubes an intercostal drainage tube, also called tube thoracostomy, is commonly inserted for pneumothorax, haemothorax, pleural effusion, and empyema. it also enables instilling antibiotics (after port pneumonectomy for empyema), fibrinolytics, saline and sclerosing agents (pleurodesis). figure 9: haemostatic packing in the right thorax in a 67-year-old male who underwent pneumonectomy. in addition, visualised are a tracheostomy tube (arrow head), a malpositioned dobhoff tube (black arrow) in the mid-oesophagus, a right central venous catheter with its tip in the mid-svc (star) and an intercostal drainage tube (white arrow). both anteroposterior (ap) and lateral cxrs are required for optimal assessment of an intercostal drain (icd) tube. like the ng tube, an icd tube also contains side holes that can be identified by the interruption of its radiopaque outline on a cxr. the side holes of the icd tubes should be in the thoracic cavity and not in the chest wall or outside the chest. some of the complications associated with icd tubes that may be seen on cxrs include: malpositioning (commonest complication), tube kinking, subcutaneous emphysema, pneumothorax and retained catheter fragment.8 a properly placed tube for pneumothorax (figure 4a) should orient antero-superiorly, and an adequately positioned tube for pleural fluid evacuation should be directed posterior-inferiorly. the numerous locations where the tube may be malpositioned include the interlobar fissure, lung parenchyma and subcutaneous soft tissues.9 there are several tubes available for thoracostomy and these include the traditional wide bore (>28 f) catheters and the newer popular pigtail catheters (10–14f) (figure 4b) inserted by guide wires.10 figure 10: chest radiograph showing heavily calcified breast implants obscuring the lung bases. figure 11: (a) frontal radiograph of the head and neck of a typical shunt series showing the proximal catheter (arrow) in the right lateral ventricle; (b) lateral radiograph of the head and neck of a typical shunt series showing the proximal catheter (arrow) in the lateral ventricle; (c) chest radiograph of a typical (ventriculoatrial) shunt series showing the distal catheter (arrow) terminating at the cavoatrial junction (star) and (d) magnified image of an abdominal radiograph showing an abandoned ventriculoperitoneal shunt catheter in the pelvis (arrow). cardio-vascular lines on chest radiograph central venous catheter a central venous catheter (cvc), also known as a central venous pressure (cvp) catheter or a central catheter or line, is a catheter (figure 5a) that provides access for administering drugs or fluids, monitoring central venous or pulmonary artery pressure, monitoring central venous blood oxygen saturation, transvenous cardiac pacing, access for extracorporeal blood products and interventions. these catheters are usually inserted via the subclavian or internal jugular vein and less frequently via the femoral vein. a peripherally inserted central catheter (picc) is a cvc of smaller calibre (figure 5b) that is usually inserted via the antecubital vein and remains in place for months.2,11,12 tunnelled cvcs (figure 5c) are cuffed catheters that provide long-term intravenous access for a variety of purposes, which include parenteral nutrition, chemotherapy and haemodialysis. the commonest application for this cvc is for haemodialysis in patients with renal failure.13 most clinicians prefer the cvc tip to be positioned at or just above the cavoatrial junction. as the cavoatrial junction may be difficult to identify on a cxr, the most commonly used and reproducible landmark is two vertebral body levels below the carina. an alternative landmark would be the reflection of the svc contour with the right heart border and the point where the bronchus intermedius intersects the right heartborder.14 a lower placement is preferred for cannulations introduced from the left side. the various types of cvcs, potential contraindications and complications are shown in table 112 and figures 6 and 7. table 1: a summary of the various central venous catheters, potential contraindications and complications.12 pulmonary artery catheter or swan ganz catheter pulmonary artery catheterisation involves inserting a catheter (swan ganz) through a central vein (mostly the subclavian or jugular vein and rarely through a femoral vein) into the right heart and finally into the pulmonary artery (figure 8). its function is to measure cardiac output, stroke volume, mixed venous oxygen saturation, intracardiac pressure and pulmonary wedge capillary pressure. an ideal location of the pulmonary artery catheter (pac) tip would be in either the right or left pulmonary artery, not extending beyond the proximal interlobar artery, i.e. within 2 cm of the hilum. if the pac tip extends beyond the large pulmonary arteries complications such pulmonary infarction or injury to small vessels, that is, pseudoaneurysm, can occur. a malpositioned pac tip within the right ventricle increases the risk for ventricular arrhythmias and cardiac perforation.11,15,16 other complications related to pac insertion that may be seen on chest radiographs include pneumothorax, haematoma and catheter migration.16 figure 12: a vagal nerve stimulator, its electrode (arrow) and pulse generator (star) in a 10-year-old male patient diagnosed with lennox-gastaut syndrome and suffering from refractory seizures. non-cardiac iatrogenic medical devices and materials medical devices and materials such as electrocardiogram (ecg) leads, ventilator tubing, syringes, clamps, temperature sensors, post-coronary artery bypass grafting (cabg) sternotomy wires, surgical clips, orthopaedic implants, gown snaps, etc. are commonly seen on cxrs. because of its limited scope, we have not included cardiac devices in this article. however, there are other non-cardiac iatrogenic objects that can be seen on cxrs and these have been summarised in table 2. radiologists need to recognise them, be aware of their function and look for any related complications. table 2: a list of some of the other non-cardiac iatrogenic materials and medical devices that may be seen on chest radiographs. figure 13: endovascular stent graft in the thoracic aorta of a 75-year-old man, placed after aneurysm repair. figure 14: oesophageal stent inserted in a 68-year-old female with dysphagia secondary to oesophageal carcinoma. figure 15: transjugular intrahepatic portosystemic shunt stent in a 62-year-old female patient with portal hypertension. conclusion a variety of tubes, lines and medical devices may be seen on cxrs of patients admitted in a hospital. a thorough evaluation of these cxrs is important. radiologists need to recognise these medical materials, assess them for accurate placement and look for abnormal radiographic presentations, which will enable them to inform the relevant physician or surgeon in a timely manner and help avoid potential consequences. acknowledgements competing interests the authors have declared that no competing interests exist. author’s contributions r.p.m. was the project leader and wrote the manuscript. t.a. was the lead subject authority, supervised manuscript writing and helped acquire the images. v.p. did supervision of manuscript and helped acquire the images. g.l. did supervision of manuscript and helped acquire the images. ethical consideration all ethical considerations have been taken into account. no patient identity or patient information has been revealed. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references jain sn. a pictorial essay: radiology of lines and tubes in the intensive care unit. indian j radiol imaging. 2011;21(3):182–190. https://doi.org/0.4103/0971-3026.85365 hunter tb, taljanovic ms, tsau ph, et al. medical devices of the chest. radiographics. 2004;24(6):1725–1746. https://doi.org/10.1148/rg.246045031 goodman lr, conrardy pa, laing f, et al. radiographic evaluation of endotracheal tube position. ajr am j roentgenol. 1976;127(3):433–434. 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indian j radiol imaging. 2010;20(4):304–306. https://doi.org/10.4103/0971-3026.73535 radiology_oct04 editorial 2 sa journal of radiology • october 2004 the south african journal of radiology is now coming of age.with the appointment of an editor-in-chief, the creation of a new academic editorial board and the use of a more formalised peer-review system for all submissions, the journal is set to raise its profile among other radiological publications. with the implementation of the above changes we will eventually attempt to have the journal indexed internationally, thereby transforming it into the more substantial publication that south african radiology deserves. our standards of training and practice are high and there is good demand for our expertise — let our journal in turn reflect this. many thanks go to professor j p van niekerk for his encouragement and support in making this transition and for facilitating our growth. coming of age ian c duncan ffrad (d) sa unitas interventional unit centurion, and sunninghill hospital sandton johannesburg message from the new editorial committee the south african journal of radiology has followed a sometimes roller-coaster course in recent times, with issue quality varying widely. this spectrum of quality has largely resulted from lack of a central and consistent editorial voice. in a recent attempt to improve the control and quality of the journal, a number of important changes have been made, starting with the introduction of a full-time editor-inchief. the first appointed editor-in-chief is ian duncan. this post will be held for a period of 4 years, and is aimed at ensuring continuity in the running of the journal. the editorial committee has also been changed with immediate effect, and now consists of professor coert de vries (deputy editor) (university of the free state), professor leonie scholtz (university of pretoria), professor darius tsatsi (medunsa), dr savvas andronikou (university of cape town), professor peter corr (university of kwazulu-natal), professor alan scher (university of stellenbosch), professor steve beningfield (university of cape town), and dr malan van rensburg (private practice, pretoria). the rotating guest editorship will continue. each academic department will be responsible for one of seven issues, with an eighth ‘open’ issue completing the 2year cycle. the head of department (guest editor) or nominee will canvass articles from staff members, including registrars and radiographers, but should also try and elicit articles from private practices in his or her area. any article received from any author may be considered for publication by the rotating guest editor in an upcoming issue, regardless of the geographical location of the author(s). it is hoped that each and every senior registrar will produce at least one article (at least a case report) before he or she qualifies. this could include publication of mmed theses. to further encourage the submission of articles an annual prize will be awarded for the best articles from a registrar and a qualified radiologist, as judged by the editorial committee. once the journal is fully accredited with the department of education, academic departments will be able to apply for subsidies for each article produced. another incentive is that cpd points can be awarded for all articles published, with 15 points for the first author and 5 points per co-author. a total of 3 published case reports would thus earn the (first) author nearly all of the required cpd points for a year. finally there is the maurice weinbren award, given each year for the best research paper published by a south african radiologist in the preceding year. this is awarded through the colleges of medicine of south africa. the sajr is currently listed with the department of education as a locally approved journal (see http://www.education.gov.za/content/documents/ 307.pdf, item no 118). three basic requirements must be met for a journal to be thus listed: there must be a minimum of 3 issues per year, there must be a suitable editorial committee at the helm, and all articles must be peer-reviewed. all future articles will now undergo blinded peer-review. reviewers will be invited and may or may not include members of the editorial committee. the journal could eventually be submitted for international indexing, which if successful would lead to all published articles being listed on pubmed. the peer-review process will improve the quality of our publication. one or two senior reviewers will review each article, and the editorial office will inform authors about the progress of the review process. note that electronic submission of articles will greatly expedite the review process, and that authors will be expected to adhere to the standard publication format (see instructions for authors). non-reviewed features that will appear will include news items, event and conference listings, pictorial interludes, book reviews, and the cpd questionnaire. a reciprocal arrangement with the south african medical journal allows selected articles published in the samj to be republished later in the sajr. anyone wishing to publish formal research under this arrangement is advised to approach the samj initially. all qualified radiologists and radiographers, or radiologistsand radiographers-in-training are invited to submit articles for publication in the sajr. articles will also be accepted from other sources, provided they are of radiological relevance. invited and guest editorials will be featured. all queries concerning the journal can be addressed to: the editor-in-chief, sajr, po box 14031, lyttelton, 0140, e-mail: docdunc2@mweb.co.za telephonic enquiries can be made c/o lizl geldenhuys at (012) 664-8844. editorial 3 sa journal of radiology • october 2004 the editors about the author(s) gerhard van der westhuizen department of clinical imaging sciences, university of the free state, south africa mianda naude department of radiology, 3 military hospital, south africa mariette nel department of biostatistics, university of the free state, south africa citation van der westhuizen g, naude m, nel m. the yield of pathological findings from routine screening chest x-rays in a military population. s afr j rad. 2017;21(1), a1127. https://doi.org/10.4102/sajr.v21i1.1127 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract the yield of pathological findings from routine screening chest x-rays in a military population gerhard van der westhuizen, mianda naude, mariette nel copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: the south african military health services (samhs) includes a screening chest x-ray (s-cxr) as part of a yearly medical examination for members over the age of 40. the yield from s-cxr programmes in resource-limited countries, such as south africa, is mostly unknown. this data is relevant where a high burden of hiv and tuberculosis (tb) leads to significant morbidity and mortality. objectives: to evaluate the efficacy of an s-cxr programme for the detection of pulmonary tuberculosis (ptb) and other significant pathology in asymptomatic military patients. method: this retrospective descriptive study analysed s-cxrs reported between may 2011 and october 2015 at 3 military hospital, bloemfontein, south africa. the findings were categorised as either significant findings that changed patient management or insignificant findings that identified previous or possible underlying pathology. results: a total of 4137 s-cxr reports done on 2371 patients were included. of these, 3696 (89.3%) were male and 441 (10.7%) were female reports, and the sample had a median age of 44.7 years. in total, 304 (7.4%) s-cxrs had significant findings (95% ci; 6.6%–8.2%), 464 (11.2%) had insignificant findings and 76 (1.8%) had both. furthermore, 38 s-cxrs (0.92%) showed active ptb, 75 (1.8%) showed possible ptb and 241 (5.8%) showed previous ptb. additional significant findings included solitary pulmonary nodules, pleural effusions, lymphadenopathy, pneumonia, interstitial lung disease, bronchiectasis, chronic obstructive pulmonary disease, pulmonary hypertension and cardiac pathology. conclusion: an s-cxr programme is a feasible method of screening asymptomatic patients for ptb and other significant pathology in resource-limited environments with a high burden of disease. radiology_oct04 32 sa journal of radiology • october 2004 introduction neurofibromatosis is a hereditary congenital disorder consisting of dysplasias and tumours of tissues arising from the ectodermal and mesodermal layers of the embryo. the most commonly encountered subtype is neurofibromatosis type 1 (nf-1). shown in this report are several manifestations of nf-1 demonstrated on magnetic resonance imaging (mri) in 2 individual cases. case reports case 1 an 8-year-old boy with a cervical spine deformity was referred to an orthopaedic surgeon. axillary freckling and other prominent cutaneous manifestations of nf-i were present. plain film studies of the cervical spine showed a marked cervical kyphosis with subluxation of c2 on c3. mri of the cervical spine was requested to rule out a neoplasm prior to cervical fusion. this scan showed a marked gibbus deformity at c2-c3 due to the subluxation of c2 on c3 with narrowing of the subarachnoid space surrounding the cervical spinal cord (fig. 1a). the cord itself appeared normal. below the level of the kyphosis mild dural ectasia and posterior vertebral body scalloping were noted (fig. 1b). mri of the brain showed numerous hyperintense foci in the basal ganglia and deep white matter, right caudate head, right lentiform nucleus and cerebellum consistent with non-neoplastic hamartomatous lesions (figs 1c, 1d and 1e). the appearance of these lesions was unchanged when compared with a scan obtained 2 years before. case 2 a 4-year-old boy with external stigmata of neurofibromatosis presented with a mild right-sided proptosis and suspected orbital tumour. cranial mri showed dysplasia of the right sphenoid wing, with an osseous defect and herniation of the temporal lobe into the posterior aspect of the orbit (fig. 2a). the subarachnoid space around the temporal lobe itself appeared widened, with associated dilatation of the temporal horn of the right lateral ventricle. there was an enhancing mass within the superolateral aspect of the right orbit, in keeping with a plexiform neurofibroma (figs 2b and 2c). this extended posteriorly along the ophthalmic division of the trigeminal nerve. the optic nerve itself appeared displaced and stretched but otherwise normal. the ocular globe was normal. the brain scan showed further dysplasia of the right half of the calvarium with hemcase report neurofibromatosis type i — some cranial and spinal manifestations b j sher f c rad (d) sa i c duncan f f rad (d) sa sunninghill hospital sandton johannesburg fig 1a. sagittal t2-weighted mr images showing the focal gibbus at the c2, c3 and c4 levels. the canal is narrowed at this level but no cord hyperintensity is seen. fig 1b. sagittal t1-weighted image showing slight posterior vertebral body scalloping and dural ectasia at the c5 and c6 levels. icranial enlargement, and enlarged surface sulci and gyri of the right cerebal hemisphere together with unilateral enlargement of the right lateral ventricle secondary to the increase in volume of the right hemicranial cavity (figs 2d and 2e). discussion the phakomatoses (phakos (greek) = birthmark, spot or freckle) are a group of congenital disorders characterised by the development of dysplasias and neoplasias of organs arising from the embryonic ectodermal plate (involving the skin, central and peripheral nervous systems and eyes), and to a lesser degree structures derived form the mesodermal layer (including bone, cartilage and blood vessels) and the endodermal layer case report 33 sa journal of radiology • october 2004 fig 1c. coronal flair image showing focal hyperintensities in the head of the right caudate nucleus and subcortical white matter of the temporal lobes. fig 1d. coronal flair image at a more posterior level showing a focal hyperintensity in the right lentiform nucleus and subinsular white matter. fig 1e. coronal flair image showing hyperintensities within the cerebellar white matter. all lesions had remained radiologically stable for 2 years. fig 2a. axial t2-weighted image shows dysplasia of the right sphenoid wing with herniation of the peritemporal subarachnoid space into the posterior right orbit. fig 2b. axial gadolinium-enhancement t1-weighted image at the same level showing an enhancing plexiform neurofibroma within the lateral aspect of the orbit (arrow). fig 2c. coronal gadolinium-enhanced t1-weighted image at the same level showing the enhancing plexiform neurofibroma in the lateral aspect of the orbit (arrow). fig 2d. axial gadolinium-enhanced t1-weighted image showing dilation of the peritemporal subarachnoid space and temporal horn of the right lateral ventricle. fig 2e. axial gadolinium enhanced t1-weighted image at a higher level showing dysplasia of the right hemicalvarium with associated enlargement of the surface sulci and right lateral ventricle secondary to the increased hemicalvarial volume. (including the gastro-intestinal tract). owing to the predominantly ectodermal involvement these syndromes are also termed the ‘neurocutaneous syndromes’ or ‘congenital neuroectodermal dysplasias’.1 the commonest of the neuroectodermal syndromes is nf-i, also known as von recklinghausen's neurofibromatosis. with a prevalence of 1:3 000 1:5 000 individuals, nf-1 is over 10 times commoner than neurofibromatosis type ii (nf-2). nf-1 is genetically distinct from the less common nf-2 in that nf-1 is related to an abnormal gene occurring on the long arm of chromosome 17 whereas nf-2 results from an abnormal gene on chromosome 22. both types are inherited as autosomal dominant disorders, with nf-1 having a penetrance of almost 100% and spontaneous mutation rate of about 50%.2 the nf-1 gene is a tumour suppressor gene that becomes inactivated as a result of the mutation.3 a similar mechanism affecting tumour suppression genes on chromosome 22 results in the clinical manifestations of nf-2. for further discussion about the genetics and manifestations of nf-2 readers are referred to an earlier article in this journal by kritzinger.4 the diagnostic criteria for nf-1 are listed in table i. central nervous system lesions occur in about 15 20% of patients with nf-1.1,3 these include optic gliomas, occuring in 5 15% of patients,1 of which half become symptomatic and which can involve the optic nerves and/or pathways. brain lesions include gliomas, particularly the juvenile pilocytic astrocytoma and brainstem gliomas. gliomas in nf-1 can also occur in the optic pathways, hypothalamus, third ventricle, basal ganglia, tectum, cerebral peduncles, cerebellum and cerebral hemispheres.1,3,5 these gliomas are generally low-grade tumours. non-neoplastic hamartomatous lesions, also termed ‘unidentified nf-1 objects’ or ‘unos’ can be found in up to 80% of patients with nf-1.1,5 these lesions are found anywhere within the brain parenchyma but particularly in the basal ganglia, thalamus, internal capsule, brainstem, cerebellum and supratentorial white matter.1, 3 these lesions are iso-intense on t1-weighted and hyperintense on t2-weighted and flair mr images and show no mass effect, vasogenic oedema or contrast enhancement. they are seen in about 75% of children with nf-1, first appearing at around 3 years of age and resolving by the age of 20 years.6 progression or change in any of these lesions in a child older than 10 12 years of age is suspicious of a neoplasm and therefore demands closer follow-up. it is currently thought that these lesions represent regions of myelin vacuolisation, with areas of separation of myelin as it spirals around the nerve axons.7 it is also thought that the myelin eventually repairs itself, causing the lesions to show spontaneous regression.3 intracranial dural lesions include dural ectasia, meningoceles and meningioangiomatosis.3 in addition to the intracranial neuro-ectodermal dysplasias and tumours found in nf-1, various dysplasias of mesodermally derived cranial structures can be found, including vascular and osseous orbital dysplasias. associated vascular lesions include stenoses of the extracranial and intracranial arteries and the development of cerebral aneurysms or arteriovenous malformations. of the osseous dysplasias, only sphenoid wing dysplasia is of any critical clinical importance.3 a defect in the sphenoid wing allows the temporal lobe to herniate into the posterior aspect of the orbit. arterial pulsations within the temporal lobe are transmitted into the orbit causing pulsatile exophthalmos, sometimes with secondary dysplasia or atrophy of the globe and other orbital contents.1,3 sphenoid wing dysplasia is often associated with plexiform neurofibromas in the orbit or peri-orbital regions.3 the characteristic peripheral and craniofacial nerve lesions of nf-1 are the neurofibromas and plexiform neurofibromas, the latter often occuring within the orbit and extending backwards into the cavernous sinus through the superior orbital fissure, but generally not beyond meckel's 34 sa journal of radiology • october 2004 case report table i. diagnosis for neurofibromatosis 1 criteria for nf-1 (two or more of the following) • six or more café au lait macules (diameter > 5 mm in prepubertal patients and > 15 mm in postpubertal patients) • two or more neurofibromas or one plexiform neurofibroma • axillary or inguinal freckling • optic glioma • two or more lisch nodules (iris hamartomas) • a characteristic osseous lesion (sphenoid) dysplasia or cortical thinning of long bone, with or without pseudarthrosis • first-degree relative (parent, sibling, or child) with nf-1 case report 35 sa journal of radiology • october 2004 cave.5 these generally follow the course of the ophthalmic division of the trigeminal nerve.3 on mr imaging plexiform neurofibromas tend to be slightly hyperintense relative to muscle and hypo-intense to brain on t1-weighted images and of high signal intensity relative to brain and muscle on t2-weighted images, sometimes demonstrating a central hypointense region in t2-weighted images due to a central core of fibrous tissue. contrast enhancement is variable.1,3 spinal manifestations are common in nf-1. scoliosis and kyphosis are the most commonly encountered skeletal abnormalities that result from dysplasia of the vertebral bodies.1,3 other bony vertebral abnormalities include increased interpedicular distances, hypoplasia of the pedicles and other posterior elements, posterior scalloping of the vertebral bodies and enlargement of neural outlet foramens. these changes can either be due to primary bone dysplasia with dural ectasia or secondary to the effects of neurofibromas. the neurofibromas generally affect the dorsal nerve roots and are intradural extramedullary tumours which can extend extradurally thorugh the neural foramens, then being known as ‘dumb-bell’ or ‘hourglass’ tumours. malignant neurofibromas are uncommon, with an estimated frequency of malignancy of up to 10%.3 meningeal dysplasia is probably responsible for the development of lateral arachnoid cysts or meningoceles that can herniate through the neural outlet foramens, often widening the foramens in a manner similar to emerging neurofibromas. meningoceles can also result in posterior vertebral scalloping. the csf-filled meningocele can be differentiated from neurofibromas as the latter show some central hypointensity on t2-weighted images and are of higher signal intensity than csf on t1-weighted images.1,3 references 1. braffman b, naidich tp. the phakomatoses: part 1. neurofibromatosis and tuberous sclerosis. neuroimaging clin north am 1994; 4: 299324. 2. aoki s, barkovich aj, nishimura k, et al. neurofibromatosis types 1 and 2: cranial mr findings. radiology 1989; 172: 527534. 3. barkovich aj. the phakomatoses. in: barkovich aj, ed. pediatric neuroimaging. 3rd ed. philadelphia, lippincott williams & wilkins, 2000: 383-441. 4. kritzinger hg. neurofibromatosis type 2 — a case study sa journal of radiology 2002; 6: 3740. 5. osborn ag. disorders of histiogenesis: neurocutaneous syndromes. in: osborn ag, ed. diagnostic neuroradiology. st louis: mosby, 1994: 72-113. 6. sevick r, barkovich a, edwards m, koch t, berg b, lempert t. evolution of white matter lesions in neurofibromatosis type 1: mr findings. am j roentgenol 1992; 159: 171-175. 7. dipaolo dp, zimmerman ra, rorke lb, zackai eh, bilaniuk lt, yachnis at. neurofibromatosis type 1: pathological substrate of high-signal intensity foci in the brain. radiology 1995; 195: 721-724. case report multiple renal arteries a pitfall in renovascular • •intervention basil j sher fcrad(d)sa ian c duncan ffrad(d)sa sunninghili medicallnslitule sandton abstract we describe how the presence of multiple renal arteries complicated the diagnosis of a major renal arterial injury following a lower thoracic penetrating injury. incomplete assessment of the arteriographic evidence obtained during any invasive renal vascular investigation could result in a missed diagnosis. introduction the identification of multiple renal arteries has traditionally been of major importance to the renal surgeon, particularly for the pre-planning of renal transplantation. i as we show here this can also present a pitfall for the interventional radiologist when trying to isolate a vascular abnormality such as a focal renal arterial injury. case report a 51-year-old man presented 7 days after a stab wound of the lower left chest posteriorly with continuous macroscopic haematuria. he was referred to our unit for arteriographic assessment of the kidneys and immediate endovascular management of any appropriate vascular injury thus discovered. an abdominal ct scan allegedly showed a major renal injury with a perinephric haematoma. this scan was unfortunately not available to us for personal review at the time of the angiogram. upon admission to the angiography suite the patient was stable haemodynarnically. obvious macroscopic haematuria was seen in the urinary catheter drainage bag. an initial abdominal aortic flush run was performed. this showed a normal intact right kidney and no obvious abnormality of the left kidney but did indicate the presence of multiple left renal arteries (fig. 1). the exact number of these could not be assessed and the left renal nephrogram was poorly visualised mainly due to image degradation due to cardiac, respiratory and bowel motion artefact. selective catheterisation of the left renal arteries was then undertaken using a 4f c2 catheter over a hydrophilic guidewire. the first renal artery catheterised sup40 sa journal of radiology • june 2003 fig. 1. digital subtraction flush abdominal aortogram suggesting the presence of two left sided renal arteries. the quality of the image is somewhat degraded by bowel gas and bowel and respiratory motion. plied the lower pole and other than mild catheter-induced spasm appeared normal (fig. 2a). the second artery catheterised supplied areas of the middle and upper pole regions of the kidney (fig. 2b). an irregularly contoured parenchymal outline was seen which was initially considered to be due to the perinephric haematoma. the angiogram had not revealed any visible intrarenal vascular injury at this stage, and it was decided at this point to stop the procedure. however, after further analysis of the available images it was decided that the summated nephrographic pattern was incomplete and that further attempts be made to try and identify other left renal branches that might reveal a significant vascular injury. a third renal artery was thus eventually found. selective angiography of this vessel showed filling of a pseudoaneurysm arising from this branch intrarenally (fig. 3a) this vessel was then embolised using two 3 x 2 mm fibered gianturco coils (fig. 3b). the patient made an uneventful recovery thereafter with no further haematuria. case report fig. 2. selective lower (2a) and upper (28) muitipie renal arteriograms. visual summation of the associated nephrograms led initially to an erroneous interpretation of a kidney possibly distorted by the perinephric haematoma or renal lacerations. discussion embryologically the definitive renal artery is not recognisable until the third month of fetal life. it arises from the most caudal of the three suprarenal arteries, all of which represent persistent mesonephric or lateral splanchnic arteries. additional aberrant renal arteries thus represent persistent mesonephric arteries." aberrant renal arteries can arise from the aorta anywhere between tll and l4 and occur in approximately 25% of all individuals.' they are commoner on the left than on the right.' there are two main types of multiple renal arteries. fig. 3. a more careful search yielded a third renal artery harbouring a pseudoaneurysm and calyceal fistula related to one of its parenchymal branches (3a). the offending branch was then successfully occluded using two gianturco coils (38). 1. polar arteries: usually to the upper pole. these may arise from the main renal artery, from a hilar artery or directly from the aorta. they pass directly into the renal parenchyma without passing through the renal hilum. 2. supplementary arteries: usually to me lower pole and arising from me aorta near the origin of the main renal artery (77%). these pass through the renal hilum into the parenchyma. they may occasionally also arise from other aortic branches including me iliac, superior and inferior mesenteric, coeliac, middle colic, lumbar or medial sacral arteries. further supply to small areas of 41 sa journal of radiology • june 2003 i the parenchyma can come from the capsular arteries as well. each aberrant artery will supply its own area of the renal parenchyma, with little or no cross-supply between these separate compartments. traditionally this anatomical information has been of great importance to the renal surgeon, particularly when planning renal transplant surgery,' here we have shown that the presence of these same anatomical variants can also provide a significant pitfall for the interventional radiologist in attempting to identify and eventually treat by endovascular means a lesion affecting me intrarenal arteries. several important technical issues have been raised by this case : 1. the quality of the images obtained during a digital subtraction arteriogram of the abdomen should always be optimised as much as possible, including sedation or full anaesthesia for restless patients, smooth muscle relaxants to paralyse the bowel and use of apnoea during me image acquisitions where possible. 2. an initial flush aortogram is essential and where possible should use a large enough field of view to include both nephrograms. the completeness of these nephrograms should be assessed at this point. if these are complete, then me nephrograms of selective renal arterial catheterisation of multiple renal arteries should, upon visually summating all their component parts, show a similar complete nephrogram. 3. in me face of overwhelming clinical evidence of a significant renal injury me study is not considered complete until the pathology is found or fully excluded, which may require a prolonged search for all accessory renal arteries present. case report in conclusion, our case demonstrates an important diagnostic pitfall associated with multiple renal arteries supplying a kidney. in the face of overwhelming clinical evidence of a major renal injury and two negative selective renal branch arteriograms of the same kidney, proper angiographic interpretation and persistence led to the discovery of a third vessel harbouring a significant arterial injury. it is vital that in all similar circumstances the nephrograms are visually summated, and that all accessory renal arteries be thus identified and examined accordingly until a complete renal vascular anatomical study is achieved. references i. pozniak ma, balison dj, lee it, tambeaux rh, vehling dt, moon td. cr angiography of potential renal transplant donors. radiographies 1998; 18: 567-587. 2. williams pl, warwick r, eds. gray's anatomy. 36th ed. london: churchill livingstone, 1980: 212-213. 3. carlson bm, ed. pattens' foundations of embryology. 4th ed. new york: mcgraw-hili, 1981: 495-497. 4. davidson ai, hartman ds, eds. radiology of the . kidney and urinary tract. 2nd ed. philadelphia: we saunders, 1994: 94. 42 sa journal of radiology. june 2003 about the author(s) maria kaloianova department of radiology, university of the witwatersrand, south africa jaishree naidoo department of radiology, university of the witwatersrand, south africa heather thomson department of paediatrics, charlotte maxeke johannesburg academic hospital, university of the witwatersrand, south africa louisa bhengu department of human genetics, national health laboratory services, school of pathology, university of witwatersrand, south africa citation kaloianova m, naidoo j, thomson h, bhengu l. krabbe disease: an unusual presentation of optic nerve enlargement. s afr j rad. 2017;21(1), a1159. https://doi.org/10.4102/sajr.v21i1.1159 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: kaloianova m, naidoo j, thomson h, bhengu l. krabbe disease – an unusual presentation of optic nerve enlargement. s afr j rad. 2015;19(2); a887. https://doi.org/10.4102/sajr.v19i2.887 conference abstract krabbe disease: an unusual presentation of optic nerve enlargement maria kaloianova, jaishree naidoo, heather thomson, louisa bhengu copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. krabbe disease is an autosomal recessive leukodystrophy that presents clinically with regression of milestones, excessive irritability and inconsolable crying. the pathologic basis of the disease is abnormal myelin metabolism resulting from a deficiency in the galactocerebrosidase enzyme with subsequent white matter destruction. although optic atrophy is a classic presentation of krabbe disease, we report on two patients who are biological brothers presenting with optic nerve enlargement in addition to other typical magnetic resonance imaging features of krabbe disease, thereby confounding the initial diagnosis. abstract introduction clinical findings conclusion acknowledgements references about the author(s) alexandra renn chelsea and westminster hospital, london, united kingdom farhat kazmi chelsea and westminster hospital, london, united kingdom nasir khan chelsea and westminster hospital, london, united kingdom bhavin rawal chelsea and westminster hospital, london, united kingdom elaine o’boyle chelsea and westminster hospital, london, united kingdom citation renn a, kazmi f, khan n, rawal b, o’boyle e. the hiv manifestations within the gastrointestinal tract: a pictorial review. s afr j rad. 2017;21(2), a1233. https://doi.org/10.4102/sajr.v21i2.1233 pictorial review the hiv manifestations within the gastrointestinal tract: a pictorial review alexandra renn, farhat kazmi, nasir khan, bhavin rawal, elaine o’boyle received: 04 june 2017; accepted: 27 july 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the aim of the pictorial review are to review the hiv manifestations within the gastrointestinal tract. we have detailed five conditions, with reference to the patients’ cd4 count – gastrointestinal tuberculosis, kaposi’s sarcoma, small bowel lymphoma, cytomegalovirus colitis and anal carcinoma. introduction hiv, aids and cd4 count the acquired immunodeficiency syndrome (aids) was first described as a clinical entity in 1981, and hiv (human immunodeficiency virus) was identified as the causative organism in 1983.1 the hiv virus is recognised by host cells that exhibit the cd4 surface glycoprotein. in a healthy person, their cd4 count ranges from 500 cells/mm3 to 1200 cells/mm3.2 the hiv virus replicates within these cells, resulting in their destruction and defective t cell homeostasis and subsequent immunodeficiency. hence, aids is a disorder of cell-mediated immunity, clinically defined by the presence of multiple opportunistic infections and certain characteristic malignancies.1,2 hiv within the gastrointestinal tract gastrointestinal pathology in hiv includes a number of rare infections and tumours related to immunosuppression. the gastrointestinal disease manifestations of hiv can be subdivided into two categories: infections and hiv acquired neoplasm. infections: cytomegalovirus tuberculosis hiv acquired neoplasm: kaposi sarcoma non-hodgkin’s lymphoma squamous cell carcinoma the presentation of each disease is variable, the incidence increasing should the patients’ cd4 count fall below certain thresholds, as detailed below3,4,5,6,7: kaposi sarcoma: < 350 cells/μl3 anal carcinoma: < 350 cells/μl4 non-hodgkin’s lymphoma: < 200 cells/μl5 tuberculosis: < 200 cells/μl6 cytomegalovirus colitis: < 100 cells/μl7 clinical findings we have pictorially reviewed the various gastrointestinal manifestations in hiv, with reference to patients cd4 count. small bowel lymphoma we have focused specifically on small bowel lymphoma. the incidence of primary small bowel lymphoma is rare and is estimated to attribute to just 0.9% of all gastrointestinal tract tumours.8 there is a slight male predominance, with a male: female ratio of 3:2.6.8 however, the incidence is increasing, primarily because of the increased rate of hiv. one study9 has stated that over half of the patients diagnosed with small bowel lymphoma (specifically, non-hodgkin’s lymphoma) also have aids. small bowel lymphoma typically involves the terminal ileum, and becomes less frequent proximally.10 the radiological features of small bowel lymphoma include: focal thickening of the bowel wall, measuring between 1 and 7 cm9 fungating masses tumour infiltration of the myenteric nerve plexus, resulting in aneurysmal bowel dilatation8 solid mass lesion (rare).8 as demonstrated in figures 1 and 2, there is lymphomatous infiltration of the ileocaecal valve, with circumferential thickening of the terminal ileum and caecum, lymphadenopathy and upstream small bowel dilatation. the patient was a 50-year-old male, with a cd4 count of 190 (cells/μl). subsequent histological analysis following endoscopic biopsy confirmed the diagnosis of non-hodgkin’s lymphoma. figure 1: coronal reconstruction of the portovenous phase of a ct abdomen of a 50-year-old male patient demonstrating lymphomatous circumferential thickening of terminal ileum and caecum (arrowed). figure 2: coronal reconstruction of portovenous phase enhancement of a 50-year-old male (as figure 1), demonstrating enlarged lymph nodes along the ileocaecal vessels (solid arrow) and upstream fluid-filled loops of small bowel (dashed arrow). cytomegalovirus colitis cytomegalovirus (cmv) is a prevalent type of herpes simplex virus. cmv colitis is common, with an incidence of 5% – 10%, typically affecting the severely immunocompromised hiv patient.7 the radiological features of cmv colitis are non-specific, and include bowel wall thickening, mucosal ulceration and luminal narrowing. it can be either diffuse or segmental, and typically involves the ascending colon and caecum, but can also extend to the terminal ileum. unsurprisingly, cmv colitis is often misdiagnosed as inflammatory bowel disease.7,11 however, murray et al.11 identified there to be relative sparing of the transverse colon, helping distinguish the two. also, unlike inflammatory bowel disease, 42% of those infected also have ascites.11 although the features are non-specific, diagnosis should be considered in hiv patients with a cd4 count of less than 100 cells/μl.7,11 figures 3 and 4 demonstrate mural thickening and mucosal enhancement of the sigmoid, in a male patient with an undetectable cd4 count. this was the only segment of bowel affected. a diagnosis of cmv colitis was made upon serology. figure 3: axial reconstruction of portovenous phase–enhanced ct, demonstrating circumferential mural thickening of the sigmoid colon (arrowed). figure 4: coronal reconstruction of portovenous phase–enhanced ct, of the above patient, again demonstrating circumferential mural thickening of the sigmoid colon. anal squamous cell carcinoma the main causative agent of anal squamous cell carcinoma is infection with the human papilloma virus (hpv). although hiv is not a direct cause, it is an indicator of further co-infection of sexual transmitted diseases, particularly in patients engaging in anoreceptive intercourse.12 furthermore, patients with hiv are seven times more likely to have persistent hpv.4 mri is the preferred imaging modality for the assessment of anal tumours, providing detailed information regarding size, location and local invasion. the malignant tissue within the anal canal demonstrates low signal intensity on t1-weighted imaging. on t2-weighted imaging and short tau inversion recovery (stir) sequences, it appears as intermediate signal intensity, lower than ischioanal fat.13 on ct, anal squamous cell carcinoma appears as a solid, enhancing mass, becoming more heterogeneous as its size increases12,13 figures 5 and 6 demonstrate a 42-year-old hiv-positive male patient, with a cd4 count of 16 cells/μl. t2-weighted imaging indicates a large, soft tissue mass, resulting in extensive soft tissue invasion. the mass demonstrates intermediate signal intensity, lower than the surrounding adipose tissue. figure 5: t2-weighted mr imaging, axial slice of a 42-year-old male patient, demonstrating a large anal soft tissue mass (arrowed) of intermediate signal intensity, with local soft tissue invasion. histology confirmed the diagnosis of squamous cell carcinoma. figure 6: sagittal t2-weighted mr imaging of a 42-year-old male patient (as shown in figure 5), demonstrating a large anal soft tissue mass (arrowed) of intermediate signal intensity, with local soft tissue invasion. gastrointestinal tuberculosis worldwide, tuberculosis (tb) is prevalent, particularly amongst patients with hiv, and it has been estimated that up to 70% of patients will develop tb in their lifetime.6 as detailed above, the chance of developing tb greatly increases with a fall in cd4 count, with the threshold being approximately 200 cells/μl.6 gastrointestinal manifestations are typically secondary to pulmonary tb.14 abdominal tuberculosis can affect any segment of the gastrointestinal tract but most commonly the terminal ileum8 because of the large volume of lymphoid tissue in this area.14 on ct/mri, this will appear as circumferential thickening of the affected segment of the bowel, with surrounding lymphadenopathy.14 however, ct/mri features are often non-specific, and can be confused with inflammatory bowel disease or malignancy.14 characteristic appearances include: asymmetric thickening of the terminal ileum and medial wall of the caecum14 significant lymphadenopathy, with central areas of reduced attenuation.14 figures 7 and 8 demonstrate the imaging findings of two different patients with abdominal tb. both patients’ cd4 count at presentation was < 100 cells/μl. figure 7: axial reconstruction of portovenous phase–enhanced ct in a 23-year-old male patient with a cd4 count of 70 cells/μl. the image demonstrates diffuse serosal thickening of the jejunum (dashed arrow), ascites and peritoneal nodularity (solid arrow). histological diagnosis of tb was made following ascitic tap. figure 8: coronal t2-weighted mri. this image is of a 30-year-old male with a cd4 count of < 100 cells/μl, demonstrating a 4 cm segment of thickened distal and terminal ileum, with localised perforation. confirmation of tb was made upon endoscopic biopsy and histology. kaposi sarcoma kaposi sarcoma (ks) is considered to be an aids defining illness. gastrointestinal ks is the most common involvement in disseminated disease, being identified in around half of the patients.1,15 involvement includes any part of the gastrointestinal tract, including the gallbladder. the most commonly affected site is the duodenum.15 portovenous-enhanced ct is the preferred imaging modality, with 80% of patients with disseminated disease demonstrating enhancing lymph nodes.15 the masses most commonly appear polypoid (< 3 cm), although larger masses are possible. figures 9 and 10 demonstrate a 50-year-old male patient, with cd4 count of 320 cells/μl at initial presentation, with rectal thickening and an enhancing mesorectal node. the diagnosis of rectal ks was made upon transrectal biopsy. figure 9: axial reconstruction, portovenous-enhanced ct imaging of a 50-year-old male patient. the image demonstrates rectal thickening (dashed arrow) and an enhancing mesorectal node (solid arrow). figure 10: axial t2-weighted mri imaging. the patient is a 50-year-old male with thickening of the posterior wall of the rectum. mri was performed to aid surgical management. conclusion the gastrointestinal tract is a common location for many aids defining and non-defining illnesses. as detailed above, depletion of the patients cd4 count increases their likelihood of developing certain pathologies. in conditions such as cmv colitis and abdominal tb, the imaging features can be non-specific, with few subtle defining characteristics. an understanding of the disease processes associated with hiv, together with correlation with the patients cd4 count, aids diagnosis and management. acknowledgements competing interests the authors declare they have no personal or financial relationship which may have influenced them in writing this article. authors’ contributions a.r. was the lead author and editor. f.k. was the lead consultant involved in the project, and contributed cases. n.k. contributed cases. b.r. was a contributing author. e.o. assisted in editing. references kumar p, clark m. clinical medicine. 6th ed. edinburgh: w.b. saunders company; 2005. p. 129–134. u. s. department of health & human services. lab tests and why they are important [homepage on the internet]. london [updated 2017 apr 2; cited 2017 apr 10]. available from: https://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/understand-your-test-results/cd4-count/ center em, garg s. significance of hiv viral load and cd4 count on kaposi sarcoma in the era of highly-active-antiretroviral therapy [homepage on the internet]. poster presented at id week 2014, october 2015 [cited 2016 apr 10]. available from: https://idsa.confex.com/idsa/2014/webprogram/paper46986.html dandapani s, eaton m, thomas c, pagnini p. hivpositive anal cancer: an update for the clinician. j gastrointest oncol [serial online]. 2010 [cited 2016 apr 10];1(1):34–44. available from: https://www.ncbi.nlm.nih.gov/pubmed/22811803 kirk o, pedersen d, cozzi-lepri a, et al. non-hodgkin lymphoma in hiv-infected patients in the era of highly active antiretroviral therapy. blood [serial online]. 2001 [cited 2017 jul 16];98(12):3411. available from: http://www.bloodjournal.org/content/bloodjournal/98/12/3406.full.pdf?sso-checked=true jaryal a, raina r, sarkar m, sharma a. manifestations of tuberculosis in hiv/aids patients and its relationship with cd4 count. lung india. 2011;28(4):263–266. https://doi.org/10.4103/0970-2113.85687 hongjun l, ning l, dongwu b, et al. radiology of hiv/aids: a practical approach. 1st ed. new york: springer; 2001. p. 587–588. ghai s, pattison j, ghai s, o’malley m, khalili k, stephens m. primary gastrointestinal lymphoma: spectrum of imaging findings with pathologic correlation. rsna radiographics. 2007;27(5):1371–1388. https://doi.org/10.1148/rg.275065151 balthazar ej, noordhoorn m, megibow aj, gordon rb. ct of small-bowel lymphoma in immunocompetent patients and patients with aids: comparison of findings. am j roentgenol. 1997;168(3):675–680. https://doi.org/10.2214/ajr.168.3.9057513 lee a, grant b, griffin n. grainger and allison’s diagnostic radiology. 1st ed. london: elsevier; 2013. p. 882. murray j, evans s, jeffrey p, halvorsen r. cytomegalovirus colitis in aids: ct features. am j roentgenol. 1995;165(1):67–71. https://doi.org/10.2214/ajr.165.1.7785636 ryan dp, compton cc, mayer rj. carcinoma of the anal canal. n engl j med. 2000;342(11):792–800. https://doi.org/10.1056/nejm200003163421107 koh dm, dzik-jurasz a, o’neill b, tait d, husband je, brown g. pelvic phased-array mr imaging of anal carcinoma before and after chemoradiation. br j radiol. 2008;81(962):91–98. https://doi.org/10.1259/bjr/96187638 harisinghani mg, mcloud tc, shepard j-ao. tuberculosis from head to toe. rsna radiogr. 2000;20(2):449–469. https://doi.org/10.1148/radiographics.20.2.g00mc12449 restrepo cs, martínez s, lemos ja, et al. imaging manifestations of kaposi sarcoma. rsna radiogr. 2006;26(4):169–1185. https://doi.org/10.1148/rg.264055129 editorial petercorr mbchb, ffrao(o}ba, frcr, m mtjii(uct) . dlflll'tmtmt of rlhll%fy, iln/vbi"1ty of nbtiii k~eping up to date with advances in radiology is difficult for the practising radiologist. the aim of our journal is to provide useful reviews on important issues which you can use in day to day practice. a further aim is to offer radiologists an opportunity to have their work published in a peer reviewjournal.we would like to encourage registrars in particular to send us their work we will invite specialists outside radiology to write for us. radiologists need to 3 sajournal of radiology· march 1996 understand the perspectives of our clinical colleagueswho, after all, are our customers] we hope to focus on broader local and global issues in technology,health economics, and education. in any profession, knowledge is the greatest asset.it is built up by years of training, time and expense. yourknowledge databasewill depreciate in valueunlessyou add to it by reading and learning. like in business, knowledge can be considered asyour capital. maintenance of capital value requires continual investment. in medicine asin business living offcapitalleadsto bankrupcyl a commitment to life long learningisboth wise medicine and goodbusiness!'. i hope you find this fust editionusefulandinforrnative the editor i. naidich tp, osronlag leamingstategies. lntlcfneuromdidogy 1995;1 (2):125-126. radiology_oct04 abstract the majority of patients with gynaecological cancers present with advanced stages in which external beam radiation forms a major component of the treatment. these patients undergo simulation for treatment planning prior to radiation. currently the lower extent of the disease is evaluated by vaginal examination and marked using a lead wire on the anterior abdominal wall in the pelvic region. a 2 cm margin inferior to this level is used as the lower border of the treatment field. the suggested modified technique includes the placement of an indigenously designed perspex vaginal obturator with graduations at 1 cm distance from its tip. following vaginal examination the obturator can be inserted into the vagina and fixed at the predefined length using a fixation device. the radio-opaque markers can be seen even in the lateral films. twentyfive consecutive patients underwent the procedure and the differences between the two methods of marking the lower border were calculated. the external lead wire was inferior to the internal obturator in 19 patients (76%) ranging from 0.5 cm to 3 cm (median 1.5 cm, mean 1.37 cm). it was at the same level in 4 patients (16%) and 1 cm superior to the internal obturator in 2 (8%). with the modified technique using the internal obturator application for delineating the lower border of vaginal disease or vault, it was possible to decrease the length of field thereby reducing the chances of treatment-related toxicity, especially groin and vulval reactions, as well as avoiding treatment interruptions. introduction the majority of patients with gynaecological cancer require external beam radiation to the pelvis as a major component of their treatment.1,2 the lower border of the treatment field is determined following vaginal examination and assessment of the extension of the disease into the vagina. the purpose of the modified technique is: (i) to accurately assess the lower extent of the disease and define the lower border of the external radiation field in both the anteroposterior/ posteroanterior (ap/pa) and lateral fields; and (ii) to decrease the field size and reduce treatment-related side-effects. methods and materials twenty-five consecutive patients scheduled to undergo external beam radiation therapy for postoperative treatment of gynaecological cancers (carcinoma of the cervix and body of the uterus) underwent the modified technique of insertion of a vaginal obturator. the patients underwent vaginal examination at the simulator. the lower border of the disease was noted and the distance from the introitus was measured. the obturator was then adjusted to that distance using the graduated markings and was fixed with a fixation device to prevent it being pushed in by changes in the position of the legs. using the present technique, after the lower extent of disease has been noted, an external leadwire marker is placed over the original article 23 sa journal of radiology • october 2004 treatment optimisation using external beam radiation in gynaecological cancers v sharma md phd u majeed fcrad (onc) d joseph dip (rt) s lindikile dip (rlt) n madhoo nat dip (d) nat dip (t) h copelyn fcrad (onc) j kotzen mmed rad (t) m mohiuddin mmedrad (onc) b donde mmedrad (t) d van der merwe phd departments of radiation oncology and medical physics johannesburg hospital and university of the witwatersrand 24 sa journal of radiology • october 2004 anterior abdominal wall in the pelvic region. the lower border of the external field is 2 cm below the leadwire marker as seen on the simulator. all 25 patients had placement of the external lead wire as well as the internal vaginal obturator. (figs 1, 2a and 2b). the obturator and the external wire markers were placed by different clinicians to eliminate bias. fig. 3 shows the estimated difference (inferior, at the same level and superior) of the external wire marker from the internal vaginal obturator which was taken as level ‘0’. results the external wire marker was 0.5 3 cm inferior to the internal obturator in 19 patients (76%) (median 1.5 cm and mean 1.37 cm), at the same level in 4 (16%) and superior by 1 cm in 2 (8%) as seen on the ap/pa simulator films (figs 1 and 2a). the external wire was not visible in the lateral films (fig. 2b). discussion most patients with gynaecological cancers present with advanced stages in which external beam radiation is the main component of treatment.1,2 the treatment field size used should be optimised to control the disease with minimum side-effects. an external marker is not as accurate as an internal marker for two reasons: (i) there will be additional divergence of the beam from an external marker in comparison with an internal marker which is dependent on the anterior posterior separation of the patient; and (ii) the placement of the external marker is less accurate and more dependent on the experience of the treating physician. the modified procedure of using an internal obturator will optimise the field size and also help in localisation of the centre of the field as recommended3 for postoperative treatments. the advantages of the modified technique are: (i) accurate assessment of the vaginal extent of the lesion; (ii) reduction of treatment-related sideeffects in the groin and perineum enabling completion of the treatment in the prescribed time; and (iii) it is simple to perform and is easily reproducible. conclusion the accurate assessment of the lesion on simulator x-rays (ap/pa and lateral film) will provide adequate coverage of the disease as well as help in reducing the toxicity of the treatment. the change in clinical practice at our centre should also be evaluated by others. references 1. dinshaw ka, rao dn, shroff pd. hospital based cancer registry, mumbai, india. tata memorial hospital, 1998: 52. 2. dinshaw ka, shrivastava sk, muckaden ma, sharma v, deore sm, viswanathan ps. factors influencing treatment strategies using mdr brachytherapy for cervical cancer. in: mould rf, battermann jj, martinez aa, speiser bl, eds. brachytherapy from radium to optimization. veenandaal, netherlands: nucletron international, 1994: 67-78. 3. glassburn jr, brady lw, grisby pw. endometrium. in: perez ca, brady lw, halperin ec, schmidt-ullrich rk, eds. principles and practice of radiation oncology. philadelphia: lippincott williams & wilkins, 2004: 1916-1933. original article fig. 1. the vaginal obturator (indigenously designed). fig. 2. simulator films: ap view/lateral view showing both the external wire and the internal obturator. fig. 3. differences in obturator and external marker position. by prof steve beningfield from friday 13th to sunday 15th october this year, the inaugural meeting of the hepato-pancreatico-biliary association of south african (hpbasa) was held in the sandton convention centre. organised by professor martin smith and dr jose ramos on behalf of the founding committee, this meeting was decidedly not dominated by any group, but was rather specifically meant as a multidisciplinary gathering of those interested in liver and pancreatic disease. radiology was represented by a number of our group, as were radiation oncologists, nuclear medicine physicians, surgeons, physicians, anaesthetists, the medical funders and the ultimate arbiters, the pathologists. regrettably, one of the liver pathology pioneers, professor pauline hall, was unable to be present. a number of interesting sessions included discussions on non-alcoholic fatty liver disease (nafld) and non-alcoholic steatohepatitis (nash), and the importance in suspecting this condition, particularly before liver resection. overt steatosis can compromise the residual liver postoperatively, leading to potentially fatal acute liver failure. liver biopsy and the current role of cytology were also discussed, with some of the controversy around tumour seeding of the biopsy track debated. recurrent acute idiopathic pancreatitis and its investigation came under scrutiny, with the role of endoscopic ultrasound (eus) and microlithiasis highlighted. pancreatic cancer was also examined, including the various chemotherapy and radiotherapy options, but there remains little positive in this condition. liver tumours were broadly discussed, and in particular the role that gadobenate in mri has in resolving focal nodular hyperplasia (fnh) versus adenoma was presented by martin haagensen. the thorny issue of an fnh without a scar versus well-differentiated hepatocellular carcinoma (hcc) could possibly be resolved by this agent, using the delayed scans to prove biliary excretion and therefore presumably a functional drainage system. the potential for delayed excretion by the nodular-type cholangiocarcinoma (and possibly hcc) would need to be considered, however. therapeutic intervention for hpb malignancy, including cholangiocarcinoma and metastases, was presented by charles sanyika. a clear overview of the radiological options in tumor oncology was given, with the relative values of radiofrequency ablation, percutaneous ethanol injection and chemoembolisation debated. the role of radioactive yttrium also has some supporters. the differences in behaviour of the ‘african’ versus ‘asian’ types of hcc still has no clear resolution, but may account for the variation in reported efficacy of chemoembolisation. eus is very much the up-and-coming modality, with a number of pivotal roles supported for this technology, but the difficulty in learning the ultrasound component was emphasised. a thought-provoking presentation on conscious sedation focussed on the dangers of over-sedation for procedures. pancreatic and liver cysts were covered, including management of the increasingly diagnosed intraductal papillary mucinous neoplasm (ipmn previously also called ductectatic mucinous adenocarcinoma). mucinous cystic neoplasms generally were also addressed by professor christos dervenis from greece. ipmn, in particular, has experienced a similar rise from obscurity that has been seen with gastrointestinal stromal tumours (gists) the recent upsurge of ipmn has reportedly been labelled ‘a plague’. fibro-polycystic liver disease (liver or ductal plate malformations) was very well packaged by prof alan paterson from wits, who drew the audience’s attention to a seminal article by desmet1 attempting to link together the confusing and apparently discrete entities of the polycystic liver diseases, caroli’s (both the disease and the syndrome did you know they were different?), plus those little nuisances better known to pathologists, the von meyenburg complexes. in essence the proposal is that there is either an ectatic or an involutional (or necroinflammatory) process that affects the development of the ductal plate system at various levels of branching. (the ductal plate is an embryological sleeve of periportal tissue that goes on to become the biliary tree). varying degrees of associated fibrosis occur in either process. it is broken down thus: a useful pictorial review covering the same theme has recently appeared in radiographics.2 the johannesburg transplantation group’s activities were thoroughly covered, emphasising some of the particular local financial, political, and ethical issues around liver transplants. the present status of their pancreatic transplantation programme was also covered, detailing the move away from the use of the pancreatic duct-to-bladder implant to gut implantation. intrahepatic islet cell transplants (injected into the portal vein), the delegates were told, had not shown good long-term results so far. also, a number of donor pancreases are required to harvest cells for a single patient. thrombosis and portal hypertension were also covered from medical, radiological and surgical perspectives. the transjugular intraheptic stent (tips) technique has largely moved shunting activity away from surgery, but there was a strong view expressed that surgical shunting may need to be dusted off and re-introduced. covered tips stents appear to offer the promise of longer patency, but there is also work at reducing flow in patients with tips who develop problematic hepatic encephalopathy (which can be devastating to personal function). all in all, this was a very useful forum to gain in-depth insights into the way the other members of a team address the diseases affecting a particular group of organs. there was strong support for making this an annual gathering, and again, with the specific intent of making it as inclusive as possible. 1. desmet vj. congenital diseases of intrahepatic bile ducts: variations on the theme ‘ductal plate malformation’. hepatology 1992; 16:1069-1083 2. brancatelli g, federle mp, vilgrain v, vullierme mp, marin d, lagalla r. fibropolycystic liver disease: ct and mr imaging findings. radiographics 2005; 25: 659-670. the hpbasa inaugural meeting hepato pancreatico biliary imaging contributor: steve beningfield 39 sa journal of radiology • december 2006 b table i biliary branches ectasia necroinflammatory small autosomal von meyenburg dominant complexes/ polycystic kidney ‘microhamarto disease (adpkd) mas’ (the old adult type) medium size autosomal congenital hepatic recessive polycystic fibrosis (chf) kidney disease (arpkd) (the old infantile type) central/large caroli's disease caroli's syndrome ducts (= caroli's disease plus chf) extrahepatic choledochal cyst extrahepatic biliary atresia pg39.indd 39 12/11/06 11:04:05 am original article intraoperative digital subtraction angiography in neurovascular disorders r boer" fcs(sa) and do royston'" ffrad(d)sa # department of neurosurgery, wentworth hospital, durban • department of radiology, wentworth hospital. durban the importance of intraoperative dsa in the management of complex neurovascular disorders is explained. both neu rosurgeon and radiologist work in theatre as a team. abstract intraoperative digital subtraction angiography is useful for assessing the results of complex neurovascular procedures. fiftyfive patients with a vms, aneurysms (berry and bacterial), carotid-cavernous fistulae, spontaneous intracranial haemorrhages and penetrating head injuries had intraoperative angiograms. sixteen of these patients had findings on the angiogram which altered the surgical procedure. there were no angiographic complications. we found intraoperative digital subtraction angiography a valuable adjunct to several neurovascular procedures. 24 sajournal of radiology. september 1996 introduction in the past neurosurgeons have relied mainly on direct visualisation or postoperative angiography to assess the results of complex neurovascular procedures. advances in equipment have made it easier and faster to perform intraoperative angiography. intraoperative angiography facilitates the immediate assessment of neurovascular procedures and allows the surgeon to correct any technical defects.we report our experience with intraoperative angiography at wentworth hospital. patients and methods from april 1990 to december 1994 fiftyfive intraoperative angiograms were performed at wentworth hospital. angiograms were done via a transfemoral approach. a sheath was introduced preoperatively and flushed with heparinised saline (2000u/1 000ml of normal saline at30ml!hr). the patient was then anaesthetised and placed in the required position for surgery. the theatre table had a radiolucent extension to facilitate screening of the aortic arch and neck vessels. the standard three-pin mayfield-kees head-holder was used as required. (radiolucent carbon fibre headholders are available). angiography was performed with a mobile digital subtraction imaging system (ziehm exposeop cb7 -d). this consisted of a c-arm, digital processing unit, dual video monitors and an image storage unit. the appropriate carotid or vertebral artery was catheterised during or at the end of the procedure asrequired by the surgeon. contrast iohexol (6-1 oml) (omnipaque, nycomed) was injected by hand to delineate the relevant vascular anatomy. the images were reviewed immediately. if it was felt that the surgical procedure was in any way unsatisfactory or incomplete further surgery was performed under the same topage25 i ntraoperative cj igital subtraction angiography in neurovascular disorders frompage24 anaesthetic. the sheath was removed at the end of the procedure. postoperatively the groin was monitored for the development of haem atom a and peripheral pulses checked. routine postoperative angiography was not performed. results fifty-five intraoperative angiograms have been performed at wentworth hospital. the surgical procedures performed are detailed in table 1. there were no angiographic complications table i: intraoperative angiograms performed at wentworth hospital (1990-1994) aneurysms (berry) 17 arteriovenous malformations 17 carotid-cavernous fistulas 5 spontaneous haemorrhages 4 traumatic haemorrhages 5 bacterial aneurysms 3 other 4 total 55 although not strictly monitored the intraoperative angiogram added an additional forty-fiveto sixty minutes to the procedure (including the time required to place the femoral sheath preoperatively). the four patients with spontaneous intracranial haemorrhage had intraoperative angiography,as their clinicalcondition necessitated immediate transfer to theatre for evacuation of the haematoma, precluding preoperative angiography. intraoperative angiograms were used to 10calise pseudoaneurysms or arteriovenous fistulae in patients with traumatic haemorrhages following penetrating head injury. patients with mycotic aneurysms had intraoperative angiograms to help localise the aneurysms. intraoperative angiograms were used to monitor the successful surgical closure of carotid cavernous fistulae. table ii: cases with angiographic findings which altered the surgical procedure pcoaa posterior communicating artery aneurysm avm arteriovenous malformation asdh acute subdural haematoma mcaa middle cerebral artery aneurysm ccf carotid-cavernous fistula ica internal carotid artery patient pathology anglographic findings and surgical action 4 r pcoaa residual neck-clip repositioned 8 l parietal avm residual feeder-removed 11 r occipital avm residual feeder 12 spontaneous asdh intraop angio demonstrated the cause of asdhmcaaclipped 15 r occipitoparietal avm residual feeder-removed 16 lccf residual ccf after packingrepacked three times 17 rccf residual ccf after packing-repacked 25 transected vessel angio showed transected following stab vessel which was then localised and clipped 27 l occipital avm three intraap angiograms done until complete excision 34 bacterial aneurysms(3} 4th aneurysm identified with intraap angio 35 r occipital avm residual feeder-removed 39 inflammatory mcaa spontaneous thrombosis of aneurysm shown on intraop angio 40 spontaneous ich intraop angio demonstrated the cause of ichmcaaclipped 50 rica aneurysm non-filling of ica following clipping clip repositioned 53 r paraclinoid aneurysm non filling of pcoa following clipping· clip repositioned 55 l frontal avm residual avmremoved sixteen of these angiograms revealed findings which altered the surgical procedure (tableii) . six of the patients with avms required further surgery to completely excise thea vm. three of the aneurysms had to have clipsrepositioned, due to a residual neck in one case and occluded vesselsin two cases.one mycotic aneurysm had thrombosed at the time of surgery.in a second patient with multiple mycotic aneurysms an additional aneurysm was detected on the intraoperative angiogram. two patients with spontaneous intracerebral haemorrhages were found to have middle cerebral artery aneurysms. this finding enabled immediate clipping. in one of our patients a clip which was 25 sajournal of radiology. september1996 compromising the lca was repositioned immediately due to the intraoperative angiogram finding. discussion in the past, most intraoperative angiography was performed by using fluoroscopy or rapid serial-ftlm angiography, following either direct puncture of the internal carotid or by retrograde catheterisation of the superiidal temporal artery. i severalauthors have reported the use of a mobile digital subtraction imaging system. i ,2,3 the advantages of this system are immediate review of subtracted images, high contrast resolution and superior spatial resolution (although not as good as conventional film lo page 28 radiology_may04 case report 34 sa journal of radiology • may 2004 introduction anomalous origin of the right vertebral artery from the distal part of the aortic arch is very rare and is discovered as an incidental finding during an angiographic study or in laboratory specimens. it has been suggested that these anomalies are of diagnostic importance and may be associated with arteriovenous malformations or cerebral aneurysms. although no conclusive evidence exists that vertebral artery anomalies are associated with a higher incidence of cerebrovascular disorders, some authors hypothesise that the anomalous origin and distribution of the large aortic arch vessels can cause changes in cerebral haemodynamics that may lead to cerebrovascular anomalies. case report a 40-year-old man was referred to the emergency unit with a clinical picture and signs suggestive of a cerebrovascular accident. no medical history was available and all attempts to contact the family failed. a pre-contrast ct examination showed a 3 x 3 cm haemorrhage that extended from the left temporal lobe superiorly to the level of the third ventricle with surrounding oedema (fig. 1). there was no evidence of intraventricular breakthrough or subarachnoid haemorrhage. the midline was displaced 3 mm to the right. a large low-density lesion situated in the territory of the right middle cerebral artery was also present with ex vacuo enlargement of the ipsilateral ventricle in keeping with an old infarct. for further evaluation of the cause of the intracerebral haemorrhage, four-vessel digital subtraction angiography was embarked on 10 days after presentation. during the procedure some difficulty was experienced with the selective catheterisation of the supra aortic vessels with a headhunter, largely because of the repeated catheterisation of a vessel that originated from the arch but seemed to cross the midline from left to right. it was then decided to perform an aortic arch flush to try and establish the anatomy of the arch and its branches, using a pigtail catheter. the right vertebral artery was found not to arise from the right subclavian artery, but instead its origin was distal to the left subclavian artery as the last of the supra-aortic vessels (figs 2a and b). no arteriovascular malformation or aneurysm could be demonstrated. discussion many variations occur in the number and position of the vessels that arise from the aortic arch. a common form with three branches arising from rare variation in the origin of the right vertebral artery p ligege mb chb l scholtz mb chb, mmedrad (d) department of radiology university of pretoria fig. 1. ct scan of the patient depicting a large intra-cerebral haematoma in the left temporal region with area of gliosis in the right frontal and temporal area. figs 2 a and b. ap and left anterior oblique projections during angiography showing the origin of the right vertebral artery distal to the left subclavian artery. a b case report 35 sa journal of radiology • may 2004 the aortic arch is found in approximately 80% of persons. the branching order is right brachiocephalic artery, left common carotid artery and left subclavian artery. when more than three branches arise from the aortic arch, the vertebral arteries are usually added. a common form, with four vessels, is one in which the left vertebral artery arises between the left common carotid artery and the left subclavian artery. the frequency of this variant ranges from about 2.4% to 5.8%. a very rare variation is the origin of the right vertebral artery distal to the left subclavian artery, with only eight cases previously published in the literature. the reported order of branching has then been as follows: right brachiocephalic artery, left common carotid artery, left subclavian artery and finally the right vertebral artery. the right vertebral artery usually arises: (i) from the upper, posterior surface of the subclavian artery (80%); (ii) directly from the aortic arch (5%); (iii) from the right common carotid artery (0.28%); or (iv) from the site of bifurcation of the brachiocephalic trunk into the right subclavian artery and right common carotid artery (1.11%). a detailed knowledge of the anomalous origins of supraaortic vessels is of importance in patients who have to undergo four-vessel angiography. if a vertebral artery cannot be found in the usual position, the possibility of such a variant must be considered. the exsistence of these anomalies also accounts for the policy in many practises, of routinely performing an angiogram of the aortic arch before attempting selective catherisation of the carotid and vertebral arteries. further reading 1. bergman ra, thompson sa, adel k afifi, et al. compendium of human anatomic variation. text, atlas, and world literature 1989; 60-63, 359. 2. lemke a-j, benndorf g, liebig t, et al. anomalous origin of the right vertebral artery: review of the literature and case report of right vertebral artery origin distal to the left subclavian artery. american journal of neuroradiology 1999; 20: 13181321. 3. bergman ra, adel k afifi, miyauchi r, et al. vertebral arteries. in: university of iowa health care, virtual hospital, ed. illustrated encyclopedia of human anatomic variation: opus ii: cardiovascular system: arteries: head, neck and thorax. pdf file star abstract lung cancer • •screening using low-dose ct philippe grenier md lung cancer is the leading cause of death from cancer among men and women in the united states. despite new diagnostic techniques, the overall five-year survival rate remains about 14% and most patients still present with advanced disease. there has long been interest in screening to detect lung cancers when they are smaller and presumably at earlier and more curable stages, as witnessed by the support for previous screening trials using chest radiography and cytologic examination of sputum. unfortunately, these trials failed to reach the ultimate goal of a diagnostic screening test, le. a decrease in disease-specific mortality. the screened groups had the same number of deaths from lung cancer as the control groups, and screening was effectively abandoned. with the development of helical ct and at present time multislice ct scanner, there has been a resurgent interest in screening for lung cancer. data obtained from subjects at the time of study entry (prevalencescreening data) from recent trials using low-dose ct suggest that this technique could save lives in persons at high risk non randomised trials two non-randomized studies from japan used chest radiography; low dose ct, and examination of a 3day pooled sputum sample for screening. these trials enrolled 9544 people more than 40 years of age (1, 2). the early lung cancer action project (elcap), performed in new york, enrolled 1000 high-risk smokers over the age of 60 years. this trial has a nonrandomized design and uses chest radiography and low dose ct (3). in 1999, the mayo clinic enrolled 1520 current or formers smokers (~ 50 years old who had smoked 20 pack/years or more) in a nonrandomtable 1. results of nonrandomized trials in lung cancer screening using low dose ct usa (mayo germany usa (new york) japan clinic) (muenster) no of subjects 1000 9544 1500 919 age >60 >40 ~50 >40 cancer detected 27 53 21 13 detection rate 2.7% 0.56% 1.4% 1.4% stage 1 85% 80% 50% 62% 38 sajournal of radiology • december 2002 ized trial. all the patients underwent base-line low dose ct and sputum cytologic examination and they will have an annual follow-up for 3 consecutive years. a trial at the university of munster in germany enrolled 919 participants all smokers over the age offorty (4). the results of these trials have confirmed that ct is more sensitive than conventional chest radiography for the detection of lung nodules and that some of these nodules prove to be lung cancer (table 1). for instance in the elcap study, ct detected more cases of lung cancer (27%vs 9.1%) than chest radiography and more patients screened by ct have resectable early stage disease (3). in the mayo clinic study, 24 cases of lung cancer have been diagnosed with 21 (14%) prevalence and 3 incidence • cases (1.3%). in the munster study; 13 lung cancers were depicted (14%), 8 (62%) of whom had a stage i disease (4). limitation of nonradomised trials cancer screening programs should do more good than harm, at a financial cost acceptable to society. to be good means to extend quality of life (qaly) and reduce mortality from the tumor. to do harm means to induce complications of the screening test, anxiety due to lead-time and consequences of false positive diagnoses. the true clinical significance of the small tumors found by screening is unknown and their effects on mortality waits for future investigation (4). given the data from simple arm stud. ies performed in japan, the united states and germany, it is plausible (but unproved) that earlier detection star abstract of lung cancer will likely result in decreased mortality. it is not clear at what price this will occur. the biases induced by the screening program are important to consider. the lead-time bias expresses that a reduction in survival from a cancer is not the same as mortality. a cancer detected earlier by a screening test may lead to the death of the patient at the same time it would occur if the tumor was not detected. because of the lead-time bias, a screening test that increases the survival time does not imply a reduced mortality. the length-time bias is defined by the tendency of a screening test to detect slow-growing or less invasive lesions than those detected in non screening populations. such tumors often have a better, sometimes excellent, prognosis. the selection bias is due to the tendency of health conscious people to volunteer for (or to maneuver themselves into) a screening program. such people adhere to treatment advice and are generally healthier. the over-diagnosis bias is related to the diagnosis by histopathologists of benign lesions or in situ cancers as invasive carcinomas. pathologists find multiple "lung tumors" in 5 20% of lobectomy specimens from patients with stage i lung cancers, which they classify as adenomatous hyperplasia or bronchioloalveolar adenomas. these two processes are believed to be precursors of invasive lung cancers. volume doubling times of lung cancer is longer (1 40 months, mean 15 months) in ct program than chest radiography (1 18 months, mean 5 months). the size of the nodule at diagnosis does not necessarily correlate with the clinical outcome. in a recent study of 510 patients with tlnomo disease (tumors less than 3 cm in diameter), there was no statistical correlation between small size at diagnosis and survival (5). patients with 3-cm masses had the same outcomes as those with nodules less than 1 cm in diameter. tumors may already have demonstrated their potential to remain localized or to metastasize by the time they are visible on ct imaging. in some studies, about 60% of patients with clinical stage i disease (radiographically detected; tumors less than 3 cm in diameter) died from lung cancer within five years despite appropriate therapy. this suggests that a high percentage of patients have disseminated, occult disease at the time of presentation. it is important to recognize that even a lo-mm lung cancer is not an earlier lung cancer; 10-mm lung cancer has approximately doubled thirty times and is in the last third of the expected time life of lung cancer. finally, a recent experimental study showed that a i-cm tumor can shed approximately 3 million to 6 million cells into the blood every 24 hours. false positives in addition to detecting an increased number oflung cancers, low dose ct found at least one undetermined nodule in 39-50% of all screened patients. the majority of these nodules should be benign, but evaluation of all these nodules is not a trivial problem. this could create a very expensive diagnostic strategy. consequences (costs) of false positive diagnoses have also to be taken into consideration (anxiety, unnecessary further imaging, biopsy or even surgery, complications of investigation and financial outcomes). morbidity and mortality considera39 sa journal of radiology • december 2002 tions are particularly disconcerting in cases of benign lesions and overdiagnosed cancers. in the mayo clinic trial, 2244 uncalcified lung nodules were identified in 60% of 1520 participants. the authors estimate that approximately 98% of these are falsely positive findings. assuming that their 13% incidence rate of undetermined lung nodules continues, almost all patients will have at least one false positive examination after only a few years of screening. randomized controlled trials they eliminate lead-time, length and selection biases, but they are very difficult to set up. contamination is a major problem. they take a very long time to produce definite results and in the interval technology changes and their results may not be relevant when trial finally reports. several groups are now proposing prospective randomized controlled trials using low dose ct. in the us, one cooperative group organized by the american college of radiological . imaging network (acrin), sponsored by the national cancer institute (nci) has designed a multicenter randomized controlled trial involving 80 000 participants over five years which should have the power to detect a 20% reduction in mortality. tills project is based on 2 arms: the screening group would be examined by annual low dose ct, the control group will be examined by annual chest radiograph. it is now funded and should start next year. other projects of randomized trials have been designed in europe. although there are some differences in inclusion criteria and arms, there is a potential star abstract opportunity to pool the data and reinforce the power of the results. a european coordination has been established on this matter under the umbrella of the european society of thoracic imaging and the european association of radiology. for the moment, only pilot studies (1000 patients for 2 years) have been funded in two countries (france and denmark). the recommended lung nodule management algorithm is designed to expedite surgery for lung cancer and table 2. definition and classification of nodules in lung cancer screening program a pulmonary nodule is defined as soft tissue or ground glass opacity of rounded shape. category 1. benign nodules: lesions showing central, rim, uniform or other benign distribution of calcification; fat attenuation within the nodule, clear linear or linear branching densities, or known to be stable size for a least 12 months (for ct, defined as within measurement error of up to -20%). category 2. micronodules ie: (4 mm diameter. the characteristics and locations of all nodules will be documented for purposes of future comparison at annual screening ct). category 3. indeterminate nodules of 5-10 mm diameter whose growth rate is, as yet, undetermined which do not fall into category 1. category 4. nodules> 10 mm diameter which do not fall into the description for benign nodules, or those <10 mm if known to be enlarging on serial ct studies. nodule characteristics may include round or spiculated margins, and cavitation. focal areas of ground glass are also included in this category. all category 3 nodules will be measured and observed for tumor growth at 3, 6, 9, 12 and 24 months. table 3. nodule measurement recommendation in lung cancer screening trials program 1. soft tissue nodules are be measured (in mm) on standard lung and soft tissue windows, using the maximum short axis (x) and long axis (y) diameters taken at the widest point of the nodule. tumor volume can be calculated from the 2 dimensional measurements using the prolate eclipse formula (dimension x x dimension y x 0.52). 2. recent research using specially designed computer softwares have shown that tumors are frequently irregular in shape and may also grow asymmetrically. these new softwares, which are currently still under development, and not completely validated promise to be considerably more accurate for assessing tumor growth. minimize intervention for benign nodules (tables 2 and 3). concluding remarks and learning objectives low dose ct is an effective technique for diagnosing asymptomatic stage la non small cell lung cancer. effect on mortality from lung cancer is not known. cost per year of life saved has yet be determined. calculating cost and effectiveness will require a randomized trial or same equivalent. suggested reading 1. kaneko m, eguchi k, ohmatsu h, et al. peripheral lung cancer screening and detection with low-dose spiral cr versus radiograph. radiology 1996; 201: 798·802. 2. sane s, takashima s, li r, et al. mass screening for lung caneer with mobile spiral computed tomography scanner. lancet 1998; 351: 1242· 1245. 3. henschke cl, mccauley di, yanke1evitzof, et al. early lung cancer action project: overall design and findings from baseline screening. lancet 1999; 354: 99· 105. 4. patz ef, goodman pc, bepler g. screening for lung cancer. the new england journal of medicine 2000; 343: 1627·1633. 5. patz ef jr, rossi s, harpole dh jr, herndon je, goodman pc. correlation of tumor size and survival in patients with stage la non-small eell lung cancer. chest2000; 117: 1568·1571. 6. yanke1evitzof, reeves ap, kostis wi, zhao b, henschke cl small pulmonary nodules: volumetrically determined growth rates based on cr evaluation. radiology2000; 217: 251·256. 7. ko jp, betke m. chest ct: automated nodule detection and assessment of change over timepreliminary experience. radiology 2001; 218: 7· 27. 40 sa journal of radiology. december 2002 abstract introduction methods sampling method data analysis ethical consideration results discussion of results conclusion acknowledgements references about the author(s) nashil singh department of radiology, university of pretoria, steve biko academic hospital, pretoria, south africa heleen hanekom department of radiology, university of pretoria, steve biko academic hospital, pretoria, south africa farhana e. suleman department of radiology, university of pretoria, steve biko academic hospital, pretoria, south africa citation singh n, hanekom h, suleman fe. the accuracy of magnetic resonance imaging diagnosis of non-osseous knee injury at steve biko academic hospital. s afr j rad. 2019;23(1), a1754. https://doi.org/10.4102/sajr.v23i1.1754 original research the accuracy of magnetic resonance imaging diagnosis of non-osseous knee injury at steve biko academic hospital nashil singh, heleen hanekom, farhana e. suleman received: 01 may 2019; accepted: 25 july 2019; published: 25 sept. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: preoperative magnetic resonance imaging (mri) has internationally been proven to reduce unnecessary knee arthroscopies and assist with surgical planning. this has the advantage of avoiding unnecessary surgery and the associated anaesthetic risk, as well as reducing costs. no data were found in the recently published literature assessing the accuracy of mri interpretation of knee ligament injury in the public sector locally. objectives: this pilot study aimed to determine the accuracy of mri in detecting non-osseous knee injury in a resource-limited tertiary-level academic hospital in pretoria, south africa, compared to the gold standard arthroscopy findings. method: this was an exploratory retrospective analysis of 39 patients who had mri and arthroscopy at steve biko academic hospital (sbah). true positive, true negative, false positive and false negative results were extrapolated from findings in both modalities and translated into sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for each structure. results: negative predictive values were recorded as 97%, 81%, 90% and 100% (anterior cruciate ligament [acl], medial meniscus [mm], lateral meniscus [lm] and posterior cruciate ligament [pcl], respectively), which were comparative to recently published international literature. the ppv results were lower than those previously evaluated at 55%, 58%, 55% and not applicable. the sensitivities and specificities of the ligaments were 83%, 58%, 83% and not applicable; and 87%, 81%, 70% and not applicable, respectively. conclusion: magnetic resonance imaging was found to be sensitive and specific, with a high npv noted in all structures evaluated. negative results can therefore be used to avoid unnecessary surgery to the benefit of the patient and state. the study reiterates that high accuracy can be obtained from mri on a 1.5-tesla non-dedicated scanner, with interpretation by generalist radiologists. keywords: musculoskeletal; magnetic resonance imaging; mri; anterior cruciate ligament; acl; posterior cruciate ligament; pcl; medial meniscus; lateral meniscus. introduction the knee joint is primarily a hinge joint; however, its flexibility allows for a wide range of further movements, but at the expense of stability.1 this accounts for a large presenting patient population with traumatic and non-traumatic ligament injuries, including sports injuries.2 internationally, the high prevalence of knee ligament derangement is widely accepted, with significant associated costs for diagnosis and treatment.3,4 the american college of radiology appropriateness criteria suggest magnetic resonance imaging (mri) as the primary radiological investigation for suspected non-osseous knee injury, furthermore suggesting that primary clinical examination after injury has shown a low diagnostic yield.5,6 the yield from the first clinical assessment alone, direct to arthroscopy, is low (between 35% and 70%)7 higher accuracy from clinical assessment has been described (75%–96%) by rayan et al., reaffirming referral to mri following a specialist review.8 magnetic resonance imaging is the gold standard imaging investigation. the modality is unparalleled in the evaluation of non-osseous knee structure derangement, being well suited for high-resolution assessment of the musculoskeletal (msk) system, including muscle, tendon, ligament and occult bone injuries.9,10,11 arthroscopy is considered the gold standard in terms of definitive diagnosis of internal derangements of the knee. it is both sensitive and specific, furthermore being both diagnostic and therapeutic.12 if one considers that arthroscopy is an invasive procedure that may have a negative result (4.7% reported complication rate), a major disadvantage in addition to possible patient surgical and anaesthetic complications is the expense of theatre cost and inpatient stay.13 a 1997 study had suggested a $680 (usd) saving of mri before arthroscopy, and 42% of patients could have potentially avoided surgery altogether based on the mri results.4 arthroscopy is also user dependant and subject to its unique set of errors, limiting its accuracy.14 the effective use of preoperative mri has been proven to reduce unnecessary surgical arthroscopies and assist with preoperative planning.4,5,6 this includes preoperative planning in situations including arthrofibrosis, or specific pathologies including ramp lesions or meniscal root attachment tears. these are important review areas for the radiologist and may prove to be ‘blind spots’ for the orthopaedic surgeon, depending on the arthroscopic approach used. recent studies comparing mri and clinical examination to arthroscopy have shown up to 100% negative predictive value (npv) for an anterior cruciate ligament (acl) injury and 96% npv for meniscal injury.12 a negative mri would reduce unnecessary arthroscopies and has the added benefit of avoiding the associated costs, including theatre use, hospital stay and post-operative management. to the benefit of the patient, both surgical and anaesthetic complications may altogether be avoided.4 international articles have previously examined the accuracy of mri by using arthroscopy as the gold standard. crawford et al., in a review, examined previous literature on mri against arthroscopy by making use of a ‘modified coleman’ methodology to identify scientifically credible and reproducible articles on the topic. sixty-three articles were divided into two groups; their extrapolated findings demonstrated the mri accuracy in detecting medial meniscus (mm), acl and posterior cruciate ligament (pcl) injuries. sensitivities were 91%, 76% and 86%, respectively; specificities were 81%, 93% and 95%, respectively; positive predictive value (ppv) was 83%, 80% and 82%, respectively; and npv was 90%, 91% and 96%, respectively.7 a study by singla and kansal compared acl, pcl, mm and lateral meniscus (lm) mri findings with those of arthroscopy. the ranges for results for the respective structures were: sensitivities of 76%–89.1%, specificities of 71.4%–94.3%, ppv of 66.7%–85.2% and npv of 76.9%–97.1%.15 a prospective study by madhusudhan et al. compared clinical examination, mri and arthroscopy. when compared to arthroscopy, acl imaging was 91.8% specific with a 94% npv, whilst the corresponding results for meniscal imaging were 50% and 31%.16 meniscus tears, however, showed a higher ppv of 75%.16 these results are however conflicting with other literature in which it was found that a definitive mri diagnosis of a meniscal tear was made 95% of the time.17 the south african healthcare system is vastly different in the private and public sectors, with limitations of resources and large patient loads in the latter sector. in the public sector, this may translate into long time delays between clinical diagnosis and elective special investigations given the large population it serves. in steve biko academic hospital (sbah), msk imaging is performed amongst other examinations, on a non-dedicated low field 1.5-tesla (t) mri scanner, and findings are reported by general radiologists with interest and experience; however, there is no accredited subspeciality training in msk imaging. much international literature exists outlining the accuracy of mri in diagnosis in non-osseous knee structure disruption, and the benefits to patients and hospitals alike. no local data are present, given the resource limitations at most south african tertiary state hospitals. the aim of this pilot study was to determine the accuracy (sensitivity, specificity, ppv and npv) of mri in detecting non-osseous knee structure injury (acl, pcl, mm and lm) in a resource-limited tertiary-level academic hospital in pretoria, south africa, as compared to the arthroscopy findings. methods this was a retrospective analysis, comparing the mri knee reports documenting non-osseous internal derangements of the knee with the corresponding knee arthroscopy report findings at sbah, a tertiary care hospital. adult patients (18 years and older) who had received a knee arthroscopy (left or right knee) preceded by an mri of the corresponding knee for the period of 01 january 2013 to 01 march 2018 were included in the study. sampling method all patients at sbah had an mri preceding the arthroscopy as outlined by the arthroplasty department, eliminating bias of severity of injury. a total of 39 patients were utilised, dictated by the patient records found, meeting both inclusion and exclusion criteria in the given 5-year period. four structures were assessed, namely acl, pcl, mm and lm. thereafter, the results were classified into true positive (tp), true negative (tn), false positive (fp) and false negative (fn) results. the total findings were extrapolated into sensitivity, specificity, ppv and npv. data analysis the descriptive statistics mean, median, standard deviation and inter-quartile range were used to describe any continuous variables. frequencies and proportions were used to describe the categorical variables, such as the presence of a tear on mri or arthroscopy. sensitivity and specificity, along with positive and negative predicative values, were calculated by using arthroscopy as the gold standard. cohen’s kappa statistics were calculated to test the agreement between mri and arthroscopy. tests were evaluated at the 5% level of significance. four parameters, namely sensitivity, specificity, ppv and npv, were calculated to assess the reliability of the mri results. ethical consideration ethics approval was granted by the university of pretoria faculty of health sciences research ethics committee. the ethics committee was asked for waiver of patient consent as this was a retrospective study. consent was obtained from the chief executive officer of sbah to use the reports from the hospital picture archiving and communication system (pacs) (mri findings), as well as from the patient records (arthroscopy findings). ethics protocol number is 442/2018. results a total of 39 patients who had arthroscopy at sbah were evaluated. twenty-six of the total patients were female patients and 13 patients were male patients (f:m = 2:1). the ages of the patients ranged from 18 to 69 years with a mean age of 36. sixty-nine per cent of the patients were 40 years old or younger. considering arthroscopy as the gold standard, mri findings for derangements of four structures (acl, pcl, mm and lm) were compared to their corresponding arthroscopic theatre reports. a total of 76.9% (30 of 39) of the patients had a positive result (some structural tear) noted between the two examinations, with nine of the 39 patients having all four intact structures between both studies. true positive, tn, fp and fn results were recorded for each ligament per patient, and respective sensitivity, specificity, ppv and npv were calculated (see table 1). table 1: results of each structure evaluated. with regard to the anterior cruciate ligament, medial meniscus, lateral meniscus and posterior cruciate ligament, the findings at mri and arthroscopy are presented in figure 1. the resulting true positive, true negative, false positive and false negative results are presented in figure 2. this equated to an 83%, 58%, 83%, not applicable sensitivity and 87%, 81%, 70%, not applicable specificity, respectively. a ppv of 0.55, 0.58, 0.55, not applicable and npv of 0.97, 0.81, 0.90, 1.0 were extrapolated. figure 1: comparison between magnetic resonance imaging and arthroscopic findings–tear versus intact ligament. figure 2: comparison of results by ligament. kappa testing, which accounts for the possibility of chance agreement as a more robust means to measure inter-observer agreement, was calculated for each of the ligaments. a kappa value of 0.59, 0.39 and 0.47 was found for the acl, mm and lm, respectively. landis and koch regard values fair in the range of 0.21–0.40, and in moderate agreement in the range of 0.41–0.60.18 the pcl, however, which had two tears noted on mri and none on arthroscopy, had a 0.00 cohen kappa value (figure 3). figure 3: kappa values for each structure. discussion of results in our study, 39 patients were managed at sbah; the results for npv were recorded as 97%, 81%, 90% and 100% for acl, mm, lm and pcl, respectively. the npv demonstrates the proportion of negative mris, which were tn. in our study, we found that if a patient had no tear noted on mri, they were highly unlikely to have a tear seen on arthroscopy. this was in keeping with previous studies that demonstrated high npv of mri in knee ligament derangement.7,12,15 in one study, npvs were recorded as 90% (mm), 91% (acl) and 96% (pcl)7 (figure 4). figure 4: negative predictive values. the ppv is the proportion of patients with tears on mri being true tears confirmed on arthroscopy. the ppv results were 55%, 58%, 55% and not applicable (acl, mm, lm and pcl, respectively), which were lower than comparative previous literature. in a comparative study, the ppv for the four structures was between 66% and 85%.15 the sensitivities and specificities of the ligaments were 83%, 58%, 83% and not applicable and 87%, 81%, 70% and not applicable (acl, mm, lm and pcl, respectively) sensitivity (tp rate) is the measure of how mri correctly identifies a tear as such. specificity (tn rate) is the ability to exclude injury, by using the arthroscopy results as the gold standard. the sensitivities and specificities of the ligaments were comparable to previous evidence. one study, which extrapolated the results for 63 former similar credible international studies looked at mri against arthroscopy, by using a ‘modified coleman method’ found the sensitivities to be 76%, 91% and 86% and the specificities to be 93%, 81% and 95% for mm, acl and pcl, respectively.7 figure 5 demonstrates the sensitivity and specificity of the acl and mm against figures from a comparative study. our results were corresponding to previous evidence, with the largest discordancy our low sensitivity in the mm (58%). figure 5: anterior cruciate ligament and medial meniscus sensitivity and specificity compared to comparative study. the largest discrepancy was noted to be the low sensitivity of the mm (58%). this stems from a high fn rate. in our study, there were three fn results (7.69%). on retrospective review of these three mri studies, none of the classic radiological findings (high signal in contact with the superior or inferior aspect of the meniscus, nor distortion of the normal meniscus shape) were present to suggest a radiologically missed tear17,19 (see figures 6 and 7). given that the image acquisition quality was acceptable for the other structures, as supported by their higher yield correlation (figure 8), a postulation may be that there were errors in diagnosis at arthroscopy itself, as suggested by a previous article.20 figure 6: true positive medial meniscus tear: (a) coronal view and (b) sagittal view. figure 7: false negative medial meniscus tear: (a) coronal view and (b) sagittal view. figure 8: images from a true positive anterior cruciate ligament tear: (a) sagittal view and (b) coronal view. unlike the mr images and reports that are stored on picture archiving and communication system (pacs) and can be retrospectively interrogated, a reviewer is purely reliant on a single hard copy of the surgical report with intraoperative pictures, which is kept in the patient’s file. the report is influenced by the skills of the performing surgeon and cannot thereafter be assessed. another notable difference in our study, compared to previous literature, was the time interval between mri and arthroscopy. as the interval lengthens, there is an increased chance for discrepancy between the examination, including healing, worsening of injury or even an interim new injury occurring. a similar situation has been previously described, where healing was postulated during the long interval between the two investigations, leading to likely inconsistency in results between the examinations.20 in our study, the difference in time between the two investigations ranged from 2 to 1527 days (mean of 237 days) (figure 9), which reflects the high patient load and burden on resources in our setting. this was a much larger interval than in a previously described study (5.8 weeks or approximately 41 days).16 in two of our patients with the longest interval between mri and arthroscopy (1523 days and 853 days), one study was completely congruent; however, the other had an fp lm tear (seen on mri and not on arthroscopy). healing may well have taken place between examinations resulting in inaccuracy of comparison. figure 9: time difference between magnetic resonance imaging and arthroscopy. the fn totals were low in comparison to the fps (1, 0, 3, 2 for acl, pcl, mm and lm, respectively). this demonstrates a tendency of the reporting radiologists to ‘overcall’ abnormalities, rather than tears being erroneously missed completely. in two instances, fp was secondary to ungraded degenerative tears (pcl and mm). the use of the word tear, rather than degeneration, reflects misinterpretation of normal aging as pathology. the lack of uniform nomenclature used within the reporting of both modalities means that inter-observer interpretation of the report is discrepant, and readers may be unsure of the tear severity grade, for example, a degenerative tear is a normal aging finding or pathological and requires further management. grading of the tear (grade 1, 2 or 3) is a well-known classifying system, may be a more informative solution to express the degree of injury.21 the mris had all been performed on a single 1.5-t philips achieve mri scanner, which was installed at the institution on 27 february 2006. this negated any variability of hardware and acquisition quality. previous evidence suggests no advantage in using a 3-t rather than a 1.5-t mri scanner, nor with dedicated high field extremity mri.22,23,10,24 all mri studies were reported by generalist radiologists, with no sub-specialisation in msk, although a previous article had suggested high accuracy in similar circumstances.25 conclusion the pilot study performed at sbah found the mri accuracy in determining non-osseous knee structural derangements to be comparable to previous international literature, by using arthroscopy as the gold standard. the study reiterates that high accuracy can be obtained from mri on a 1.5-t non-dedicated scanner, with interpretation by generalist radiologists particularly for identifying cruciate ligament injuries. magnetic resonance imaging was found to be sensitive and specific, particularly for the acl. a high npv was also noted in all four structures evaluated, in keeping with previous literature. this means negative results may be used to avoid an unnecessary surgical procedure to the benefit of the patient and state, and reinforces the role of mri in excluding injury in the setting of equivocal clinical findings. acknowledgements the authors acknowledge prof. z. lockhat, sbah department of radiology and theatre staff, as well as management for assistance with this study and access to patient records. the authors also acknowledge mr charl janse van rensburg of the biostatistics unit from the south african medical research council for aiding in the statistics aspect of this study. competing interests the authors have declared that no competing interests exist. authors’ contributions n.s. was the lead author. f.e.s. and h.h. were the supervisors. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily 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affecting the gi tube. it was only in the late nineties with the advent of the spiral (helical) and then multi row detector ct that cross-sectional imaging became a serious competitor to barium studies. virtual endoscopy is about to become clinical and optical approaches will be upon us before we know it. barium imaging has undergone great changes during the last 20 years. its use after a glorious era of superb double contrast artistry has gradually decreased. endoscopy has advanced, become more patient friendly and as it has the advantages of biopsy and self-referral it has practically eliminated the barium studies of the upper and lower alimentary tube in the industrialized world. lately cross-sectional imaging, particularly multi row detector ct has taken away many of its applications. as barium examinations are used less frequently in most radiology training programs, the number of examinations is insufficient for adequate training. the quality of barium examinations and their accuracy is therefore generally decreasing for most old favorites, such as the double contrast barium enema and the upper gastrointestinal examination. present uses of barium sulfate is barium dead? it is not. it has just lost its preeminence and has metamorphosed. some applications have survived. barium is still supreme for some examinations where fluoroscopy and an intraluminal contrast medium give immediate and accurate answers in many clinical situations. to name the most important: 1. to study motility. 2. pre surgery for reflux remedy. 3. to evaluate the size of hiatus herma. 4. to find the site of suspected perforation. (after iodine contrast medium fails to show site, barium is used as it has better signal to noise.) 5. same applies for localizing gastrostomy or jejunostomy tubes, (if the iodine study fails to give acceptable answers). 6. same applies to find or exclude the 12 sa journal of radiology • december 2002 presence of anastomotic leaks. 7. for small bowel studies, including double contrast enteroelysis. 8. as an additive to avoid using the rigorous cleansing maneuvers inherited from barium enema and conventional colonoscopy, before performing ct or mr virtual colonoscopy. 9. when conventional endoscopy cannot be performed or has failed for whatever reason. some contrast media that are inexpensive, safe and have been around for many years just refuse to die. present role of cross-sectional imaging the increasing computer power in cross-sectional imaging and particularly the advent of multi row detector ct has for the first time facilitated the acquisition of 3 dimensional data, permitting high resolution volumetric acquisition of images, thus facilitating diagnosis. multi row detector ct making 3d acquisition possible, and 3d mr have made virtual endoscopy an increasingly accepted clinical imaging technique. this technique is presently being routinely used in the colon and is increasingly replacing barium enemas as well as diagnostic conventional colonoscopy. virtual ct endoscopy is starting to be applied to practically every part of the gi tube: esophagus, stomach, small bowel, mesenteric blood vessels, although these procedures are still in the research stage. mr imaging of the alimentary tube is very promising. it has with fast sequences been able to suppress artifacts produced by peristalsis and with star abstract its wide range of soft tissue contrast resolution has been very informative particularly in the evaluation of crohn's disease, pelvic lipomatosis and mesenteritis. it also shows promise in the assessment of cancer of the entire alimentary tube. mr virtual colonoscopy has not as yet achieved the general acceptance of its ct equivalent, but it is gaining acceptance in several european centers. it is even being used as part of mr total body screening programs. different approaches are also being tested to eliminate the need for bowel cleansing before the performance of mr colonoscopy, one using gadolinium enema the other adding barium to a low residue diet for several days before the examination. petct fusion of images generated from different imaging modalities, such as mr, ct and pet is showing that advantages of two techniques can be maximized. this approach has great potential in oncologic imaging of the alimentary tube. the advantages of pet's ability to detect malignant nodes are combined with the superior spatial resolution of ct. this is of particular value in the staging of carcinoma of the esophagus where the evaluation of mediastinal nodes is essential. computer-aided detection (cad) the reduction and eventually the elimination of perception errors in cross-sectional studies of the alimentary tube will be of particular importance in screening with ct virtual colonoscopy. the present approaches use neural-network computers that are taught what is normal with all its variations. the computer is the able to distinguish polyps and cancer from folds, although different techniques will be necessary for the distinction from fecal residue. cad should also help in providing screening at an affordable price. computer aided diagnosis will be particularly important in the studies of populations at risk as identified in the future with genetic screening. virtual colonoscopy screening of such populations will improve the odds of survival. optical coherence tomography the development of new imaging modalities like optical coherence tomography, adds new dimensions to medical imaging of the alimentary tube. it is expected that it will be possible in the future to identify early precancerous, dysplastic, changes in many parts of the gi tube. examples are changes in barrett's esophagus as well as in the colon mucosa in chronic ulcerative colitis. molecular imaging of the alimentary tube at present this approach is still only experimental. at this time the most successful approach consists of introducing exogenous reporter genes into cancer cells. these are then implanted into the peritoneal cavity of nude mice with either fluorescent, (optical) or radioactive probes. it is probable that such approaches will be soon introduced into ctinical practice. suggested reading 1. horton km, fishman ek. volume-rendered 3d cr of the mesenteric vasculature: normal anatomy, anatomic variants, and pathologic conditions. radiographies 2002; 22: 161-172. 2. johnson cd, dachman ah. cr colonography: the next colon screening examination? radiology2000; 216: 331-341. 3. ferrucci, jt. colon cancer screening with virtual colonoscopy. air 200 i; 177: 975-988. 4. luboldt w, bauerfeind p, wildermuth s, marincek b, fried m, debatin tf. colonic masses: detection with mr colonography, radiology2000; 216. 5. luboldt w, morrin mm. mr colonography: status and perspective. abdoml imaging 2002; 27: 400-409. 6. tearney gj, brezinski me, southern jf. bouma be, boppart sa, fujimoto jg. optimal biopsy in human gastrointestinal tissue using optical coherence tomography. the american journal of gastroenterology 1997;92: 1800-1804. 7. lander es, et al. initial sequencing and analysis of the human genome. nature 2001; 409: 814823. 8. venter jc, et al. the sequence of the human genome. science2001;291: 1304-1351. 9. hulman bj,neiman hl. translating molecular imaging research into practice: summary of the proceedings of the american college of radiology colloquium, april 22-24, 2001 radiology2002; 222: 19-24. 13 sa jou rnal of radiology • december 2002 abstract the majority of patients with carcinoma of the oesophagus present with advanced disease and difficulty in swallowing as their main symptom. these patients receive intraluminal radiation therapy for quick relief of dysphagia as one of the main palliative options. presently lesion length is estimated depending on the filling defect seen on hexabrix swallow, which is measured against the number of vertebrae the lesion spans (each vertebra is taken to measure 2.5 cm). we have devised a modification of the technique for the intraluminal procedure, with patients having a localisation film with hexabrix at the simulator using a magnification graticule, with the grid projecting at 1 cm intervals at the isocentre. ten consecutive patients underwent the procedure and the lesion length was calculated using the modified as well as the earlier technique. the mean and median differences in lengths calculated were 1.72 cm and 1.5 cm respectively (range 1.25 2.50 cm). the length of the lesion was longer when the number of vertebrae was used for an estimation of the length. with the modified technique it was possible to decrease treatment length and the number of normal oesophageal mucosa in the treatment volume, thereby reducing the chance of treatment-related complications such as strictures and ulceration. introduction the majority of patients with carcinoma of the oesophagus present with advanced stage disease and poor prognosis, with difficulty in swallowing as the major presenting symptom.1 intraluminal radiation therapy is useful for controlling the endoluminal disease and this treatment modality leads to rapid improvement in swallowing. various authors have published on the use of low and high dose rate intraluminal brachytherapy alone or in combination with external beam radiation therapy for the palliation of advanced oesophageal cancer.2-5 ideally, the palliative treatment should not aggravate the patient’s symptoms by causing treatmentrelated toxicity or complications. the purpose of the modified technique is: (i) accurate assessment of the length of the lesion on hexabrix swallow; and (ii) to decrease the fluoroscopy time during the procedure, thereby reducing staff exposure to radiation. methods and materials ten consecutive patients due for intraluminal radiation therapy for carcinoma of the oesophagus underwent the modified technique of simulation with hexabrix using the magnification graticule with the grid projecting at 1 cm interval at the isocentre prior to the procedure (fig. 1). the length of the lesion and the centre of original article 31 sa journal of radiology • may 2004 vertebral height as the measure of lesion length in carcinoma of the oesophagus — is it accurate? v sharma md, phd b donde mb bch, mmed rad (t) m mohiuddin mb bs, mmed rad (onc) b s rabin mb bch, mmed rad (t) u majeed mb bs, ffrad (onc) d chetty mb chb c nyongensa mb bs a msemo mb bs department of radiation oncology, johannesburg hospital and university of the witwatersrand d van der merwe phd department of medical physics, johannesburg hospital and university of the witwatersrand r glynn-thomas mb bch, dmrd (rcp, rcs) department of radiology, johannesburg hospital and university of the witwatersrand original article 32 sa journal of radiology • may 2004 field for treatment were localised and marked. the localised centre was tattooed and a lead wire placed at the centre. this procedure facilitated the positioning of the high dose rate (hdr) treatment catheter and assessment of the treatment length. patients received premedication with pethidine and buscopan 30 minutes before the procedure. the pharynx was anaesthetised with a topical spray using xylocaine 4%. the brachytherapy tube was inserted under fluoroscopic guidance6 and fixed in position using a face mask. in the present procedure, insertion of the catheter is done under fluoroscopic guidance after giving hexabrix to demarcate the proximal end of the lesion. most of the time, the distal end of the lesion cannot be delineated without giving hexabrix 3 4 times with repeated fluoroscopy. the length of the lesion is therefore estimated by correlating with the number of vertebrae from the hexabrix swallow performed in the radiology department (each vertebra is taken to measure 2.5 cm). 7,8 table i shows the estimated length of the lesion using the number of vertebrae, the length as measured using a simulation film with grid and the diffig. 1. simulator film with grid (vertebral length = 2.5 vertebrae = 6.25 cm, grid length = 5 cm). table 1. lesion length on hexabrix swallow patient number vertebral height simulator magnification difference (cm) grid length (cm ) (cm) 1. 12.00 10.00 2.00 2. 8.00 6.00 2.00 3. 8.50 6.00 2.50 4. 7.50 6.00 1.50 5. 9.50 8.00 1.50 6. 7.50 6.00 1.50 7. 6.50 5.00 1.50 8. 6.25 5.00 1.25 9. 6.50 5.00 1.50 10. 8.00 6.00 2.00 mean (cm) 8.02 6.30 1.72 median (cm) 7.75 6.00 1.50 minimum (cm) 6.25 5.00 1.25 maximum (cm) 12.00 10.00 2.50 fig. 2. basic anatomy of the oesophagus showing four vertebrae = 10 cm. original article 33 sa journal of radiology • may 2004 ference between these two lengths. the lengths according to vertebrae height were 6.25 12.0 cm (i.e. 2.5 vertebrae to 5 vertebrae), whereas the lengths according to the magnification graticule with grid were 5 10 cm, the difference being 1.25 2.50 cm (mean 1.72 cm, median 1.5 cm). discussion most patients with carcinoma of the oesophagus present with difficulty in swallowing as their main symptom. the role of intraluminal brachytherapy is to relieve the dysphagia without increasing the side-effects by treating minimal normal oesophageal mucosa. the present procedure of estimation of the length of the lesion by estimating the vertebral length is recommended by potter and limbergen7 and is depicted by denittis8 (fig. 2). the modified technique of doing prior simulation has already been published by us.6 the advantages of the modified technique are: (i) accurate assessment of the length of the lesion; (ii) reduction in treatment length as well as normal mucosa treated, thereby decreasing the morbidity of treatment -related strictures and ulceration; (iii) reduced staff exposure as repeated fluoroscopy is eliminated; and (iv) reduced chance of hexabrix aspiration in patients as the modified technique is performed before sedation and topical anaesthesia. conclusion accurate assessment of the lesion length on hexabrix will reduce normal mucosa irradiation and decrease the toxicity of the treatment. it is recommended that the change in clinical practice done at our centre be evaluated by other groups. references 1. sur rk, donde b, levin cv, mannell a. fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer. int j radiat oncol biol phys 1998; 40: 447-453. 2. rider wd, mendoza rd. some opinions on the treatment of cancer of esophagus. am j roentgenol radium ther nucl med 1969; 105: 514-517. 3. mannell a, murray w. oesophageal cancer in south africa. a review of 1926 cases. cancer 1989; 64: 2604-2608. 4. sharma v, dinshaw ka, agarwal jp, et al. intraluminal brachytherapy for palliation of advanced / recurrent carcinoma of the esophagus. j brachytherapy international 1999; 15: 85-92. 5. sharma v, mahantshetty u, dinshaw ka, deshpande r, sharma s. palliation of advanced /recurrent esophageal cancer with high dose rate brachytherapy. int j radiat oncol biol phys 2002; 52: 310-315. 6. dinshaw ka, sharma v, pendse am, et al. the role of intraluminal radiotherapy and concurrent 5 fluorouracil infusion in management of carcinoma esophagus.: a pilot study. j surg oncol 1991; 47: 155-160. 7. potter r, limbergen ev. oesophageal cancer. in: gerbaulet a, potter r, mazeron jj, meertens h, limbergen ev, eds. the gec estro handbook of brachytherapy. leuven, belgium: estro, 2002: 515-537. 8. denittis as. esophagus. in: perez ca, brady lw, halperin ec, schmidt-ullrich rk, eds. principles and practice of radiation oncology. philadelphia: lippincott, williams and wilkins, 2004: 1282-1304. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) dolongo c. onyangunga department of radiology, school of clinical medicine, university of kwazulu-natal, durban, south africa jagidesa moodley women’s health and hiv research unit, department of obstetrics and gynaecology, school of clinical medicine, university of kwazulu-natal, durban, south africa citation onyangunga dc, moodley j. hysterosalpingographic evaluation of human immunodeficiency virus-infected and uninfected infertile women. s afr j rad. 2020;24(1), a1767. https://doi.org/10.4102/sajr.v24i1.1767 original research hysterosalpingographic evaluation of human immunodeficiency virus-infected and uninfected infertile women dolongo c. onyangunga, jagidesa moodley received: 03 july 2019; accepted: 14 jan. 2020; published: 24 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: hysterosalpingography (hsg) is an outpatient fluoroscopy-guided procedure that evaluates the uterine cavity and fallopian tube patency in infertile women. its cost-effective use is being challenged with the human immunodeficiency virus (hiv) burden in kwazulu-natal, which characteristically affects multiple organs. objectives: the aim of this study was to describe the hsg findings in a group of hiv-infected and uninfected infertile women. method: this was a retrospective study conducted over a 4-year period (2012–2016) in which the hsg images and reports of 178 infertile patients from records of the radiology department were re-reviewed for abnormalities of the cervix, uterus and fallopian tubes. their clinical data and radiological findings were entered into a pre-coded data sheet and analysed. results: the frequency of hiv infection amongst patients with infertility was found to be 32.6%. forty-four patients were on antiretroviral therapy at the time of the hsg examination, whereas three had not yet started treatment. from the 178 hsg reports, 109 (61.2%) were abnormal. tubal pathologies were the most common abnormalities, accounting for 79 of the 109 cases and was higher in hiv-infected women than in hiv-uninfected women (p = 0.001). uterine filling defects were demonstrated in 13 of the 109 cases. there were two cases of cervical abnormalities. conclusion: the study demonstrated that tubal abnormalities were the most common findings amongst infertile women undergoing hsg and occurred predominantly in hiv-infected patients. keywords: hysterosalpingography; infertility; hiv; sexually transmitted diseases; fallopian tubes; radiology. introduction infertility is defined as the incapacity of a couple at reproductive age to conceive after regular and unprotected sexual intercourse within 2 years.1 it may be classified as primary infertility for a couple who never conceived or secondary infertility when occurring after a previous pregnancy. infertility remains a serious health concern with sociocultural implications, particularly in women of african ancestry.2 in africa, 30% – 40% of couples present with infertility.3 the major cause of infertility in south africa (sa) is sexually transmitted disease, which leads to genital tract pathology including endometritis and salpingitis, complicated by tubal mucosal damage and blockage. the human immunodeficiency virus (hiv) epidemic in sa over the last three to four decades has compounded the impact of sexually transmitted infections on infertility.4,5,6 however, treatment of hiv infection has been reported to reduce infertility rates.7,8 a variety of imaging techniques including hysteroscopy, ultrasonography (us), hysterosalpingography (hsg) and pelvic magnetic resonance imaging (mri) are available to evaluate the patency of the female genital tract for the investigation of infertility. the unavailability of expertise and the costs of imaging techniques, such as mri and diagnostic laparoscopy, make hsg the most commonly used first-line imaging technique for evaluating female infertility in district and most regional hospitals in sa. to the best of our knowledge, there are no local reports on hsg findings in hiv-infected women with infertility. this is of importance for the kwazulu-natal province, which carries the highest burden of the hiv pandemic, with rates of approximately 37% in antenatal attendees.9 therefore, the aim of this study was to report on hsg findings in a setting of high hiv infection rates. methods study design this was a descriptive, retrospective study covering a 4-year period, from 01 january 2012 to 31 december 2016, in the radiology department of a central hospital in durban, kwazulu-natal. the radiological information system of the hospital was used to obtain the relevant clinical records and imaging findings of patients referred for hsg as part of an infertility work-up during the study period. each included patient had prior us of the pelvis and laboratory tests for ovulation. hysterosalpingography was performed according to standard protocols, with the images reviewed by both a gynaecologist and a radiologist.10 the final reports were documented by the radiologist. the report and final images were archived in a radiology information database. for the purpose of this study, both the reports and the images were re-reviewed by the author, a registrar in radiology, and by a specialist radiologist with 4 years of experience. the socio-demographic and clinical information was recorded on a structured data sheet. the documentation of the hiv status was considered absolute criteria for inclusion. we considered the risk factor profile of women with secondary infertility as well.11 women with incomplete clinical information, other proven causes of infertility and a history of tuberculosis or records of anti-tuberculosis treatment were excluded from the study. all statistical analysis was performed using statistical package for the social sciences (spss version 25, ibm corp, 2017). the results were expressed as mean and standard deviation. the z-test was used for the difference between means. a p-value of < 0.05 was considered statistically significant. results the records of 178 infertile women with complete information who underwent hsgs were retrieved. the mean (standard deviation [s.d.]) age and duration of infertility of the patients were 33.3 ± 4.7 years and 5.64 ± 4.1 years, respectively. amongst them, 64.6% had primary infertility and 35.4% had secondary infertility. hysterosalpingography reports were normal in 38.8% (69/178) of patients, whilst the remaining 61.2% patients (109/178) had at least one abnormal hsg finding. subgroup analysis showed that 120 (67.4%) women were hiv-uninfected and 58 (32.6%) were hiv-infected. forty-four patients were on antiretroviral therapy at the time of hsg examination, whereas three had not yet started treatment. the demographic and clinical profiles of the infertile women are presented in tables 1 and 2. table 1: demographic and clinical profile of infertile women. table 2: demographic and clinical profile of infertile women based on human immunodeficiency virus status. of the 41 women who had previous pelvic surgery, 27 were hiv-uninfected and 14 were hiv-infected. the association with hiv infection was significant (p = 0.047). forty-three (24.2%) women provided a history of pelvic inflammatory disease (pid) and 24 (55.81%) of those were hiv-infected. pelvic inflammatory disease and hiv were also significantly associated (p = 0.001). sixty-three patients presented with secondary infertility before undergoing hsg. previous caesarean delivery was performed in 29 of these patients presenting with uterine and/or tubal abnormalities at hsg. human immunodeficiency virus infection was more frequent in the caesarean delivery group than in the vaginal delivery group (p = 0.000). tubal pathologies were the most common abnormalities and accounted for 79/109 (72.5%) of the abnormal findings. they presented as bilateral occlusions or unilateral tubal occlusions with hydrosalpinx. the next most common abnormality was seen in the uterine cavity, with 13 filling defects. the majority (14) of filling defects were confirmed on pelvic us as air bubbles and not considered as a pathology; 10 were submucosal fibroids and three were congenital uterine malformations. there was one uterine synechia. cervical pathologies included elongated cervix and stenosed cervix, where the procedure was then abandoned. ten hiv-infected patients (17.2%) had more than one documented cause of infertility. tubal pathologies were the only cause of infertility that was significantly associated with hiv infection (p = 0.001). the hsg findings are presented in table 3. table 3: hysterosalpingography findings. discussion the main findings of this study showed that a substantial proportion of patients who had hsgs were hiv-infected (32.6%). the study confirmed a smaller number of hiv-infected infertile women <25 years old and a larger proportion between 25 and 40 years of age. although infertility affects all reproductive ages, it was also not documented in any hiv-uninfected patients less than 25 years of age. in a similar study conducted by heis et al.,12 the overall mean age was 31.5 years (s.d. 5.9 years), with maximum occurrence at 18–46 years and a mean (s.d.) infertility duration of 4 ± 3.4 years. panti13 reported a mean age of 28.9 ± 6.5 years and a mean duration of infertility of 7.47 ± 1.6 years. chen and walker14 reported that the age-specific fertility rates of hiv-infected women are reduced as compared to uninfected women, except for those in the 15–19 years age range where fertility is said to be higher based on reports from many countries. in this study, the incidence of primary infertility was higher than that of secondary infertility, which is in accordance with other studies.13,14,15 however, contradictory findings where secondary infertility was more common than primary infertility have also been documented.6,16 we did not find any significant statistical association between the duration of infertility and hiv. the frequency of hiv infection in the study was 32.6%. this prevalence rate is much higher than previous reported values from gabon (9.3%),17 tanzania (18.2%)17 and sa (20%).18 the high rates of hiv are probably because kwazulu-natal has the highest hiv burden in sa; the rate amongst antenatal attendees is 37%.8 it should be noted that 25% of the hiv-infected infertile women in this study had not initiated anti-retroviral (arv) treatment. although no side effects or adverse events of hsg were noted in the study for both infected and uninfected women, the study was not designed to evaluate the complications in hiv-infected women following hsg. this might be regarded as a limitation of the study. it is plausible that any invasive procedure of the female genital tract in hiv-infected women may cause infective complications. this needs further investigation and it seems intuitive that gynaecologists initiate arvs prior to any investigations for infertility. we only found one study in the current literature that has evaluated hsg procedures in hivpatients.19 the results of this study revealed that 38.8% of the patients had normal hsgs; however, our finding is lower than the 49.2% reported previously in a similar study in nigeria.8 this may be related to the hiv burden in the study sample. other studies have recorded 16.6% and 29.1% of normal findings.13,20,21 tubal factor infertility was seen in 79.3% of our hiv-infected patients. some hiv-infected patients (6.2%) had more than one documented cause of infertility. tubal factor was the only cause of infertility that was significantly associated with hiv infection (p = 0.001). yahya et al.7 reported tubo-peritoneal factor as the most common cause of infertility (seen in 81% of hiv-infected patients) and the association as statistically significant, with a p-value of 0.048. similarly, adegoke et al.8 reported that tubo-peritoneal abnormalities were more common amongst infertile women infected with hiv as compared to those without hiv infection. adesiyun et al.4 also reported a study on hsg and found that distal tubal occlusion with hydrosalpinx was mainly associated with hiv infection. limitations of the study there was no follow-up of the patients to monitor any long-term complications related to the procedure. furthermore, there was no record of the duration or initiation of arv regimen. many patients were excluded from the study because of a history of tuberculosis or anti-tuberculosis treatment, even though there was a concurrent positive medical history of hiv. it is important to note that the infertile women were investigated without examining their spouses; thus, it could be that their infertility is related to their partners. this is a major limitation of this study. conclusion this study has shown that hsg remains an important diagnostic tool in the evaluation of the infertile women, particularly in public-sector health facilities in sa, where there is a lack of equipment, technology and expertise. hysterosalpingograms are cheap, quick and easily accessible. we demonstrated that tubal abnormalities were the most common findings amongst infertile women undergoing hsg, occurring predominantly in hiv-infected patients. acknowledgements the authors would like to thank prof. d.p. ramaema, head of radiology department at inkosi albert luthuli central hospital, who gave access to their data base system. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. ethical consideration approval for the study was granted by the bioethics research committee (be: 406/17), university of kwazulu-natal, the postgraduate education committee, hospital management and the kwazulu-natal department of health. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references who. reproductive health indicators for global monitoring. report of the second interagency meeting. who/rhr/01.19. geneva: world health organization, department of reproductive health and research; 2001 mascarenhas mn, flaxman sr, boerma t, vanderpoel s, stevens ga. national, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. plos med. 2012;9(12):1001356. https://doi.org/10.1371/journal.pmed.1001356 leke rj, oduma ja, bassol-mayagoitia s, bacha am, grigor km. regional and geographical variations in infertility: effects of environmental, cultural, and socioeconomic factors. environ health perspect. 1993;101(2):73–80. https://doi.org/10.1289/ehp.93101s273 adesiyun ag, ameh c, eka a. hysterosalpingographic tubal abnormalities and hiv infection among black women with tubal infertility in sub-saharan africa. gynecol obstet investig. 2008;66(2):119–122. https://doi.org/10.1159/000128600 lash mm, yaghamee a, strohsnitter w, lalwani s. association between secondary infertility and fallopian tube obstruction on hysterosalpingography. j reprod med. 2008;53(9):677–680. mazzuca p, caruso a, caccuri f. hiv-1 infection, microenvironment and endothelial cell dysfunction. new microbiol, 2016;39(3):163–173. yahya a, adesiyun a, olorukooba aa. seroprevalence and clinical correlates of human immunodeficiency virus infection among women with infertility in north-western nigeria. trop j obstet gynaecol. 2018;35(2):177–183. https://doi.org/10.4103/tjog.tjog_17_18 adegoke aa, anthony e, olumide ab, folake o, idowu aa. hysterosalpingographic tubal abnormalities in retroviral (hiv) positive and negative infertile females. j clin diagn res. 2013;7(1):35–38. https://doi.org/10.7860/jcdr/2012/4938.2664 national department of health. saving mothers 2011–2013: sixth report on confidential enquiries into maternal deaths in south africa. fact sheet. pretoria: national committee for confidential enquiry into maternal deaths, department of health republic of south africa; 2015. chapman s, nakielny r. chapter 6: aids to radiological procedures. in: watson n, jones h, editors. chapman & nakielny’s guide to radiology procedures. 4th ed. london: elsevier, 2001; p. 175–180. dhont n, luchters s, muvunyi c, et al. the risk factor profile of women with secondary infertility: an unmatched case-control study in kigali, rwanda. bmc womens health. 2011;11:32. https://doi.org/10.1186/1472-6874-11-32 heis m, 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2010;13(3):264–267. favot i, ngalula j, mgalla z, klokke ah, gumodaka b, boerma jt. hiv infection and sexual behavior among women with infertility in tanziania: a hospital-based study. int j epidemiol. 1997;26(2):414–419. https://doi.org/10.1093/ije/26.2.414 statistics south africa. midyear population estimates 2017 [homepage on the internet]. department: statistics south africa republic of south africa. [cited 2017 dec. 12] available from: https://www.stassa.gov.za nwankwo nc, akani ci. pattern of hysterosalpingography in patients with infertility in port harcourt. west afr j radiol. 2005;12(1);15–19. https://doi.org/10.4314/wajr.v12i1.34200 elsie km, rosemary kb, structural finding at hysterosalpingography in patients with infertility at private clinics in kampala, uganda. afr health sci. 2004;4(3):178–181. onwuchekwa cr, oriji vk. hysterosalpingography pattern of infertility in women of reproductive age. j hum reprod sci. 2017;10(3):178–184. https://doi.org/10.4103/jhrs.jhrs_121_16 pictorial interlude 44 sa journal of radiology • september 2006 cutaneous metastases localised to the umbilicus are named ‘sister mary joseph’s nodules’. sister mary joseph, who was the superintendent nurse and surgical assistant of dr william mayo at st. mayo hospital from 1856 to 1939, was the first to note the link between umbilical nodules and intra-abdominal malignancies. metastases to the umbilicus are uncommon and represent only 10% of all secondary tumours which have spread to the skin. this umbilical nodule usually represents a poor prognosis.1 umbilical neoplastic nodules may be due to a primary tumour in 38% of cases, to endometriosis in 32% of individuals and in 30% may actually be secondary tumour deposits from a primary tumour elsewhere.2 in the case of metastases the source of the primary tumour is usually the gastro-intestinal (35-65%) or genito-urinary (12-35%) tract.3 this case demonstrates the presence of a large sister mary joseph’s nodule in a 16-year-old female patient who presented with a recurrence of a yolk sac tumour locally, and peritoneal, subserosal and liver metastases. clinically an umbilical node was palpable. 1. hill m, o’leary jp. sister mary joseph and her node. am surg 1996; 62: 328-329. 2. gabriele r, conte m, egidi f, borghese m. umbilical metastases: current viewpoint. world j surg oncol 2005; 3: 13. 3. galvan vg. sister mary joseph’s nodule. ann intern med 1998; 128: 410. sister mary joseph’s nodule a erlank, mb chb c ackermann, mb chb, mmed rad (diag), mrcs (uk) p j greyling, mb chb department of radiology, stellenbosch university and tygerberg academic hospital fig. 1. axial postcontrast ct of the abdomen – sister mary joseph nodule. also note the presence of subserosal and peritoneal metastases. chris hani baragwanath hospital hosted a neuroradiology workshop from 24 to 27 july organised by general electric. this was facilitated by the visit of dr shawn halpin, a neuroradiologist from cardiff university; and dr azim celik, a physicist and ge advanced application specialist. the workshop was attended by the radiology and radiography staff of chbh. lectures and case quizzes were held in the morning, and hands-on advanced mr training was given in the afternoons. this was well facilitated by dr celik. mr spectroscopy, tensor imaging, and special mra techniques were practised. dr shawn halpin is an experienced neuroradiologist who trained in london. he has published numerous articles in renowned international radiology and neurology journals, has contributed many chapters to books, and most of all is friendly and down-to-earth. dr. azim celik is a phd in physics. he trained in the us, and is now based in turkey. he has a deep understanding of mr physics – quite mind-boggling. he has also published in international radiology journals, where his main interest is working on new sequences. the format worked very successfully as the knowledge was garnered first hand, in our environment, and with our patients and machine. this was an excellent learning and sharing opportunity for all. our thanks go to ge, with our hope that this was just an appetiser, with lots more to look forward to. the neurological association of south africa (nasa) will be holding its annual 2007 congress at the sandton convention centre from wednesday 28 march to saturday 31 march. this congress is being hosted by the neurology department of the university of the witwatersrand under prof. girish modi, and promises to be one of the better local congresses with at least eight international speakers; of special added interest to neuroradiology enthusiasts will be a series of neuroradiology lectures by prof. jonathan kleefield. prof. kleefield is an associate professor affiliated to harvard medical school. he has been a neuroradiologist since 1978, is the author or coauthor of numerous scientific publications and book chapters, and is a highly regarded teacher nationally and internationally. this is not a congress any radiologist with an interest in neuroradiology will want to miss. a special rate will be negotiated for registrars, consultants in public service, and for sessional attendance. please liase with your local nasa member for schedule details, etc., closer to the time. conference news neuroradiology workshop pg 44.indd 44 9/6/06 2:59:14 pm abstract introduction case report ethical consideration discussion conclusion acknowledgements references about the author(s) alain m. mukendi department of urology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa amer rauf department of radiology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa sean doherty department of urology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa florence mahlobo department of radiology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa peter afolayan department of urology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa shabina dawadi department of radiology, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa citation mukendi am, rauf a, doherty s, mahlobo f, afolayan p, dawadi s. renal arteriovenous malformation: an unusual pathology. s afr j rad. 2019;23(1), a1704. https://doi.org/10.4102/sajr.v23i1.1704 case report renal arteriovenous malformation: an unusual pathology alain m. mukendi, amer rauf, sean doherty, florence mahlobo, peter afolayan, shabina dawadi received: 16 dec. 2018; accepted: 10 apr. 2019; published: 30 may 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract renal arteriovenous malformations are rare renal vascular abnormalities. more commonly, the term refers to the congenital type of malformation. only a few cases have ever been presented and reported in the literature, mostly with a nidus. we present the clinical, ultrasound and computed tomography findings and discuss the management related to a 63-year-old male with a right congenital renal arteriovenous malformation without a nidus that was successfully managed with coil embolisation. relevant literature is hereby reviewed to highlight characteristic imaging and appropriate treatment. keywords: renal vascular malformations; congenital renal arteriovenous fistula; vascular nidus; coil embolisation; endovascular management. introduction renal vascular malformations are abnormal communications between the renal arterial and venous systems. the most common type is acquired (arteriovenous fistula [avf]), the congenital type occurring in less than 1% of the general population.1 congenital renal arteriovenous malformations (avms) are rare renal vascular abnormalities and are a rare cause of haematuria which can be fatal.2 based on the vessel architecture, congenital renal avms can be distinguished into three forms: the cirsoid type is the most common, with multiple arteriovenous interconnecting varix-like vascular communications; the angiomatous type, characterised by a single large artery feeding multiple interconnecting distal branches and draining veins; and the aneurysmal or cavernosal type, occurring in elderly patients, typically from a pre-existing arterial aneurysm which has eroded into an adjacent vein.3 in general, the congenital renal arteriovenous communication is made through a network of abnormal vessels (nidus) without interlaying capillaries.4 there are a limited number of reports in the literature regarding the topic of renal avms. we present the clinical, ultrasound and computed tomography (ct) findings and the management related to a 63-year-old male with a congenital right renal avm, without a nidus, that was successfully managed with coil embolisation. relevant literature is hereby reviewed to highlight characteristic imaging and appropriate treatment. case report a 63-year-old male patient was referred with lower urinary tract symptoms, who never had haematuria but suffered from episodic right flank pains that he described as pressure like pains. there was no previous history of renal trauma, renal biopsy or renal surgery. physical examination was unremarkable. ultrasound study outlined a large, high-output avm at the upper pole of right kidney (figure 1). computed tomography angiography demonstrated enlargement of the right main renal artery, its anterior branch and the upper pole segmental artery of the anterior branch. an arteriovenous fistula was noted between a branch of upper pole segmental artery and a single draining vein. no nidus was seen. ectasia of the feeding arterial segment and aneurysmal dilatation of the draining vein was seen at the site of the avm (figure 2). figure 1: ultrasound and doppler study outlining a large, high-output arteriovenous communication in the upper pole of the right kidney. figure 2: computed tomography demonstrating the right upper pole arteriovenous malformation: (a–e) axial plane images during arterial phase outline a single dilated upper pole segmental branch of the renal artery and immediate filling of the dilated draining vein; (f) coronal plane images during arterial phase show a single dilated upper pole segmental artery and rapid filling of a single aneurysmal draining vein without any nidus; (g) multi planar reconstruction in the coronal plane outlining the dilated right main renal artery and its upper pole segmental branch, a single dilated, tortuous draining vein and aneurysmal dilatation at the site of arterial communication. endovascular management was the best option after weighing the risk versus benefit of a more invasive surgical option. renal angiography was performed with a 5f c2 (cobra) catheter and angle tip 0.035” hydrophilic guide wire (merit). a high-output avm was outlined (figure 3). a 0.018” guide wire and 2.8f micro-catheter were passed through a c2 catheter and positioned in the ectatic feeding artery of the avm. the first micro coil slipped to the venous side because of high flow, but it did not migrate proximally and stayed close to the arterial feeder. two micro coils were placed in the arterial feeder. the ectatic segment of the feeding artery was packed with two coils. however, the fistula was still filling due to high flow (figure 4) and the procedure was abandoned because of incomplete embolisation with plans made for a second intervention. figure 3: angiogram demonstrating the arteriovenous malformation: the arterial feeder (black arrows) is shown communicating with the venous aneurysm (white arrow). figure 4: angiogram after the first-coil embolisation demonstrating the first micro coil that migrated to the venous side because of high flow. the ectatic segment of the feeding artery was packed with coils but despite that there was still filling of the arteriovenous malformation because of high flow. at the second intervention, the empty spaces between the previously deployed coils in the feeding artery were packed with seven coils of different sizes. one small coil slipped into one of the branches of the upper pole segmental artery. complete occlusion of the feeding artery was noted on the final angiograms. no filling of the venous channel was seen (figure 5). figure 5: angiogram after the second-coil embolisation demonstrating complete occlusion of the communication with coils. following coil embolisation, no obvious post-embolisation syndrome (fever, nausea, vomiting and pains) was noted 48 h after the procedure. at the 2-week follow-up, renal doppler demonstrated satisfactory occlusion of the avm. the findings remained unchanged 4 weeks later (figure 6). figure 6: post-embolisation ultrasound and doppler demonstrating a thrombus in the feeding artery and absence of venous flow 4 weeks after the procedure: (a) post-embolisation ultrasound of the right kidney showing a thrombus in the feeding artery at the right upper pole. (b) post-embolisation colour doppler demonstrating absence of venous flow. ethical consideration human research ethics committee (medical) clearance certificate no. m180894. discussion renal avms can be congenital or acquired. as stated by nassiri et al, renal avms are divided into two categories: acquired renal avms and congenital renal avms. the acquired types, commonly called avfs, are the most common ones and are frequently caused by iatrogenic injuries such as renal biopsy or surgery, penetrating or blunt renal trauma and malignant renal tumours. the congenital renal avms are subdivided into two groups: (1) avms comprising multiple arterial feeders, a vascular nidus and multiple draining veins and (2) congenital renal avfs (cravfs) which are rare (<3%), involving a single tortuous feeding artery and a dilated aneurysmal draining vein without a nidus.5 the patient presented in this report had a cravf. the congenital type occurs as a result of focal spontaneous vascular development failures between the 4th and 10th week of life. they remain asymptomatic until the third or fourth decade of life.6 patients most commonly present with haematuria resulting from rupture of small venules into the renal collecting system from raised intravascular pressure.2 about 30% of patients may present with signs of congestive heart failure from high-output fistulas, and up to 50% with cardiomegaly and hypertension.7 other common clinical presentations include colicky pain, tenderness or fullness in the flank region and a continuous bruit over the flank.8 the two-dimensional mode ultrasound typically reveals a focal area of irregular connecting cystic lesions. colour doppler will demonstrate the presence of flow in these tortuous cystic areas, with a mosaic of colours indicating turbulent flow in these vascular malformations. pulsed wave doppler will reveal the presence of venous and arterial flow with high-flow velocity and turbulent diastolic flow. there is also spectral broadening present and pulsatile flow in the draining vein.9 computed tomography plays an important role in the diagnosis of a possible underlying renal avm. the correct scanning protocol, timed correctly, is essential to make an accurate diagnosis.10 a small renal avm can be missed because of thickly sectioned images or inappropriate timing; therefore, thin-section ct using a collimation of at least 1 mm and a reconstruction interval of 0.5 mm–1 mm should be used. multidetector ct with its high spatial resolution allows for evaluation of the shunt itself with ct angiography.11 computed tomography findings include the following: pre-contrast – renal haemorrhage, renal parenchymal and vascular wall calcifications, round or oval masses in the collecting system which reveal themselves as aneurysms or varices on angiographic phase images; post contrast – early enhancement of the ipsilateral renal vein and ivc; ct angiography – dilated and tortuous arterial branches with aneurysmal dilatation of the feeding artery or draining vein, renal aneurysms or varices.11 management of renal avms is either surgical or endovascular. surgical management consists of partial or total nephrectomy. it is invasive, reserved for unstable patients or in patients with vascular anatomical difficulties. it requires several days of hospitalisation and is associated with high morbidity.12 endovascular management for stable patients consists mainly of transarterial renal embolisation.13 arteriovenous malformations without a nidus (as in this case) are mainly managed by blocking the feeding artery with coils or amplatzer vascular plugs (avps). metallic coils or micro coils of stainless steel or platinum are the main treatment option.12,14 selection of the appropriate coil size and adequate packing of the arterial feeder are crucial for a successful procedure. coil migration is a known complication. migrated coils in the venous system, such as the inferior vena cava, can be snared by retrieval sets. in high-flow fistulas, the risk of coil migration can be minimised by using detachable coils, inflating a balloon in the venous segment or putting an inferior vena cava filter (caging technique).12 amplatzer vascular plugs are cylindrical self-expanding nitinol wire mesh.15 these are used in high-flow avms with aneurysmal dilatation of the feeding artery and high risk of coil migration.5 arteriovenous malformation with nidus is treated with ablation of the nidus with gelfoam, alcohol and viscous liquid embolics. coils cannot penetrate the complex network of a nidus, but liquid embolic ablation of the nidus can be combined with coil embolisation of arterial feeders in complex high-flow avms. because of high flow, viscous sclerosing liquid embolic agents (nbca [n-butyl cyanoacrylate], onyx and squid) are preferred over gelfoam and alcohol. conclusion congenital renal avfs are rare entities associated with a myriad of clinical presentations. only a limited number of cases have been reported in the literature. endovascular management is the treatment of choice for stable patients. coils or amplatzer plugs are the main treatment option. selecting the appropriate coil size for adequate packing of the arterial feeder or complete occlusion of the fistula is crucial for a successful procedure and avoidance of coil migration in high-output flow settings. in this case, complete occlusion was achieved and a follow-up doppler test showed no flow. acknowledgements competing interests the authors have declared that no competing interests exist. the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. author’s contributions a.m.m. made a substantial contribution to conception and design, acquisition of data, drafted the manuscript and critically revised it for important intellectual content and approved the final version to be published. a.r. made a substantial contribution to design, acquisition of data, drafted the manuscript and critically revised it for important intellectual content and approved the final version to be published. s.d. critically revised it for important intellectual content and approved the final version to be published. f.m. made acquisition of data and drafted the manuscript. p.a. made acquisition of data and drafted the manuscript. s.d. made acquisition of data and drafted the manuscript. references cura m, elmerhi f, suri r, et al. vascular malformations and arteriovenous fistulas of the kidney. acta radiol. 2010;51:144. https://doi.org/10.3109/02841850903463646 chimpiri ar, natarajan b. renal vascular lesions: diagnosis and endovascular management. semin intervent radiol. 2009;26(3):253–261. https://doi.org/10.1055/s-0029-1225665 pegado p, dias jl, costa nv, bilhim t. renal arteriovenous malformation managed with embolization – case report and review of literature. acta radiol. 2015; xxvii(105):79–82. guneyli s, cinar c, bozkaya h, et al. congenital and acquired renal arteriovenous malformations: curative embolization with onyx. iran j radiol. 2017;14(2):e25672. https://doi.org/10.5812/iranjradiol.25672 nassiri n, dudiy y, carroccio a, et al. transarterial treatment of congenital renal arteriovenous fistulas. j vasc surg. 2013;58:1310–1315. https://doi.org/10.1016/j.jvs.2013.05.010 neeraj v, cinosh m, kim jm, et al. massive hematuria due to congenital renal arteriovenous malformation successfully treated by renal artery embolization. j assoc phys india. 2018;66:78–80. iwazu y, muto s, miyata y, et al. the origin of idiopathic renal arteriovenous malformation with giant twin aneurysms. clin nephrol. 2013;79:81. https://doi.org/10.5414/cn107228 dames el, ng lg, tay kh. congenital renal arteriovenous malformation presenting with gross hematuria after a routine jog: a case report. j med case rep. 2014;8:65. https://doi.org/10.1186/1752-1947-8-65 takebayashi s, aida n, matsui k. arteriovenous malformations of the kidneys: diagnosis and follow-up with color doppler sonography in six patients. ajr am j roentgenol. 1991;157:991–995. https://doi.org/10.2214/ajr.157.5.1927824 gandhi s, patel k, pandya v, raval m. renal arteriovenous malformation presenting with massive hematuria. radiol case rep. 2015;10(1):1068. https://doi.org/10.2484/rcr.v10i1.1068 maruno m, kiyosue h, tanoue s, et al. renal arteriovenous shunts: clinical features, imaging appearance, and transcatheter embolization based on angioarchitecture. radiographics. 2016;36(2):580–595. https://doi.org/10.1148/rg.2016150124 hatzidakis a, rossi m, mamoulakis c, et al. management of renal arteriovenous malformations: a pictorial view. insights imag. 2014;5:523–530. https://doi.org/10.1007/s13244-014-0342-4 mavili e, donmez h, ozcan n, et al. transarterial embolization for renal arterial bleeding. diagn interv radiol. 2009;15:143–147. sauk s, zuckerman da. renal artery embolization. semin intervent radiol. 2011;28:396–406. https://doi.org/10.1055/s-0031-1296082 tresley j, bhatia s, kably i, et al. amplatzer vascular plug as an embolic agent in different vascular pathologies: a pictorial essay. indian j radiol imaging. 2016;26:254–261. https://doi.org/10.4103/0971-3026.184422 abstract introduction case report ethical considerations discussion conclusion acknowledgements references about the author(s) demaré potgieter department of medical physics (g68), university of the free state, south africa william i.d. rae department of medical physics (g68), university of the free state, south africa coert s. de vries department of clinical imaging sciences (g61), university of the free state, south africa citation potgieter d, rae wid, de vries cs. limiting foetal doses during a four-vessel angiogram and endovascular stent-assisted berry aneurysm repair: a case report. s afr j rad. 2017; 21(1), a1188. https://doi.org/10.4102/sajr.v21i1.1188 case report limiting foetal doses during a four-vessel angiogram and endovascular stent-assisted berry aneurysm repair: a case report demaré potgieter, william i.d. rae, coert s. de vries received: 13 feb. 2017; accepted: 30 apr. 2017; published: 30 june 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a 36-year-old female patient, 20 weeks pregnant, was diagnosed with a left internal carotid artery aneurysm. fluoroscopically guided repair was justified. a four-vessel cerebral angiogram was performed, and a left paraclinoid aneurysm was demonstrated. the patient subsequently underwent endovascular stent-assisted berry aneurysm repair. as the patient was pregnant, the procedure was preceded by consideration of the required radiation protection. the foetal dose was estimated as negligible. active management of foetal exposures may improve radiation protection during pregnancy. introduction endovascular treatment of a pregnant patient constitutes additional radiation risk to the foetus, owing to the increased radiobiological sensitivity of foetal cells.1 risk reduction is important to minimise stochastic effects. case report a 36-year-old female patient, who was 20 weeks pregnant, was referred to the universitas academic hospital in bloemfontein, with a suspected left internal carotid artery (ica) aneurysm. she presented with a chronic headache and dysphasia. magnetic resonance imaging (mri) was performed, showing a left ica aneurysm and infarction, which was possibly related to emboli from the aneurysm. the patient was counselled regarding treatment options. the possible adverse effects of the radiation on her baby, and their mitigation, were explained. a four-vessel cerebral angiogram was performed on the patient, and a left paraclinoid aneurysm, which appeared to be superiorly projecting, was demonstrated (figure 1). figure 1: (a) fluoroscopic image of the complex aneurysm protruding superiorly from the left carotid artery and (b) three-dimensional rendering of the aneurysm. it was recommended that the patient undergo an endovascular stent-assisted repair, as open surgery would pose a high risk to the unborn. the multi-lobulated dome made rupture likely and allowing the pregnancy to continue without the treatment of the aneurysm could have serious consequences. before the procedure, a medical physicist was consulted to determine the radiation protection measures required to protect the foetus. accordingly, a rados rad-60 personal alarm dosimeter with a measurement range of 1 µsv to 9.99 sv was placed on the patient’s abdomen with the limit set to 1 msv (annual dose limit for a member of the public). a lead apron, with 0.25 mm lead thickness equivalence, was placed under the patient’s abdomen, and an additional lead apron, with 0.35 mm lead thickness equivalence, was placed over her abdomen and over the alarm dosimeter, thus shielding the foetus. this was used as a precautionary measure to ensure that the dose, from sources external to the patient, to the foetus, is negligible. internal scatter cannot be modified, and as the radiation is to the head in this case, internal scatter is assumed to be minimal at the fluoroscopic energies used. ultrasound-guided puncture was made in the right femoral artery, and a 6f sheath set was placed. via exchange, a 6-f-guiding catheter was placed in the left ica after which a micro-catheter was placed passing the aneurysm to the middle of the cerebral artery. a second micro-catheter was then placed in the aneurysm. via the first micro-catheter, an endovascular remodelling device of size 4 mm × 20 mm was placed covering the aneurysm neck. via the second micro-catheter, the aneurysm was then successfully embolised with seven detachable coils. the control angiogram demonstrated no aneurysmal flow, and all vessels were patent (figure 2). the stent was detached, and the catheters and guide catheter were removed. the sheath was left in place and removed when clotting was normalised. figure 2: the repaired aneurysm showing no aneurysmal flow and all the adjoining vessels patent. foetal radiation exposure was limited by using fluoro roadmaps, minimal angiogram exposures, pulsed fluoroscopy and shielding the abdomen. the alarm dosimeter reading after the completion of the procedure was 1 μsv. the exposure parameters and dose area product (dap) values were recorded (table 1). table 1: parameters used during procedures and recorded dap meter readings. dap meters are widely used in interventional x-ray units, however, the radiation hazard cannot readily be obtained from the dap value. kisielewicz et al. formulated a relationship to estimate the patient entrance surface dose (esd) from the dap values.2 this relationship, however, can only be used as a guideline because the parameters used in this case and that used by kisielewicz et al. differ to some extent. using this relationship, the patient esd, after the four-vessel angiogram, was 100.82 mgy and for the endovascular stent-assisted aneurysm repair was 826.45 mgy, which was found to be 23.67% of the diagnostic reference level (drl) used in our department. the esd values calculated the approximate entrance dose. this was predominantly to the patient’s head. to calculate the foetal dose, the uterine dose was calculated using pcxmc® software for calculating organ and effective doses in radiography and fluoroscopy examinations. this monte carlo-based method was developed by stuk (the radiation and nuclear safety authority in finland).3 the software assumes a patient height of 178.6 cm, weight of 73.20 kg and age of 30 years. the software calculated the total uterine dose, which was used as a surrogate for dose to the foetus as being at the background level. ethical considerations the study protocol was approved by the health sciences research ethics committee, university of the free state [hsrec 200/2016]. discussion the international commission on radiological protection (icrp) report 84 defines several situations in which radiation use is appropriate.4 any examination or therapy involving radiation exposure of a pregnant patient should be justified and optimised, however negligible the radiation exposure might be.5 in this case, the aneurysm appeared to be un-ruptured, but because of the multi-lobulated dome, rupture was considered likely. allowing the pregnancy to continue without aneurysm repair could have had serious short-term consequences – thus, the procedure was justified. for optimisation, clinical purpose should be achieved with a minimal radiation dose delivered to the foetus.4 here, the dose was reduced by using appropriate radiation protection, including fluoro roadmaps, minimal angiogram exposures, pulsed fluoroscopy and shielding. the dosimeter confirmed that the doses measured were indeed minimal. according to the icrp, prenatal doses from most diagnostic procedures conducted properly will not cause any adverse effects to the foetus. dose-dependent exposure risk depends on gestational age, being maximal during organogenesis and the early foetal period.1 the current acceptable cumulative dose of ionising radiation to the foetus is 50 mgy,4 but current data suggest that there is no increase in the incidence of gross congenital malformation in humans during pregnancy at doses less than 200 mgy.6 in this case, the foetus received doses well below these threshold values. conclusion this case report demonstrates that radiation protection measures can be successfully employed for pregnant patients requiring head and neck interventional procedures, and it was used to educate and reassure the interventional team. adequate shielding of the abdomen and good technique gave the team confidence that there would be a negligible dose to the foetus, well below the threshold values for increased risk. acknowledgements the authors thank the staff of the clinical imaging sciences department, school of medicine, university of the free state, for assistance in obtaining information regarding the procedure. they also thank ms. t. mulder, medical editor, school of medicine, university of the free state, for technical and editorial preparation of the manuscript. competing interests the authors declare that they have no conflict of interest. authors’ contributions d.p. was the main researcher. she collected, processed and analysed the data and was the primary author of this document. w.i.d.r was the main supervisor and was involved in the writing of the manuscript as well interpreting the results. c.s.d.v. was involved in the conception as well as in the writing of the manuscript. references hojreh a, prosch h, karanikas g, homolka p, trattnig s. protection of the unborn child in diagnostic and interventional radiological procedures. radiologe. 2015;55(8):663–672. (article in german). https://doi.org/10.1007/s00117-015-2816-x kisielewicz k, truszkiewicz a, wach s, wasilewska-radwańska m. evaluation of dose area product vs. patient dose in diagnostic x-ray units. phys med. 2011;27(2):117–120. https://doi.org/10.1016/j.ejmp.2010.07.001 tapiovaara m, siiskonen t. pcxmc 2.0. user’s guide. stuk-tr 7. c2008 [cited 2017 feb 8]. available from: https://www.stuk.fi/documents/12547/474783/stuk-tr7.pdf/6f42383b-be6d-468a-9a00-a49ca8c9ef31 international commission on radiological protection (icrp). pregnancy and medical radiation. icrp publication 84. ann icrp. 30(1). c2000 [cited 2017 feb 8]. available from: http://www.icrp.org/publication.asp?id=icrp%20publication%2084 gomes m, matias a, macedo f. risks to the fetus from diagnostic imaging during pregnancy: review and proposal of a clinical protocol. pediatr radiol. 2015;45(13):1916–1929. https://doi.org/10.1007/s00247-015-3403-z austin lm, frush dp. compendium of national guidelines for imaging the pregnant patient. ajr am j roentgenol. 2011;197(4):w737–w746. https://doi.org/10.2214/ajr.10.6351 about the author(s) wim greeff faculty of health sciences, sefako makgatho health sciences university, south africa jacobus van marle faculty of health sciences, sefako makgatho health sciences university, south africa ali dehghan-dehnavi faculty of health sciences, sefako makgatho health sciences university, south africa citation greeff w, van marle j, dehghan-dehnavi a. venous function after pharmaco-mechanical thrombolysis for extensive ileofemoral deep vein thrombosis: six-year outcome. s afr j rad. 2017;21(1), a1129. https://doi.org/10.4102/sajr.v21i1.1129 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract venous function after pharmaco-mechanical thrombolysis for extensive ileofemoral deep vein thrombosis: six-year outcome wim greeff, jacobus van marle, ali dehghan-dehnavi copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: chronic venous insufficiency is an important complication following ileofemoral deep venous thrombosis. early thrombus removal may preserve venous function and prevent this complication. objective: to evaluate the long-term outcome following pharmaco-mechanical thrombolysis (pmt) for proximal deep venous thrombosis in a private, specialist vascular unit. methods: all patients who had undergone pmt for ileofemoral deep venous thrombosis (ifdvt) between august 2009 and january 2016 were invited to return for clinical assessment and venous ultrasound study. clinical findings were recorded according to the villalta score and clinical, etiological, anatomical and pathological (ceap) classification. quality of life (qol) was assessed according to the venous insufficiency epidemiologic and economic study (veines) qol/sym questionnaire. results: a total of 32 patients (35 legs) were evaluated. there were 25 females and 7 males with a mean age of 33.5 years. the mean follow-up period was 31 months. results: twenty-four patients (75%) were c0, c1 (1), c2 (2), c3 (2) and c4 (3). with the villalta score, 28 patients had mild or no evidence of venous disease (scores 0, 1 or 2). four patients had moderate symptoms (scores 3–6). with the veines questionnaire, the results were good with the scores for qol ranging between 0.30 and 0.60 and the sym range being 0.32–0.61. the venous ultrasound only found four patients to have mild fibrosis with reflux. conclusion: patients who had undergone pmt for extensive ifdvt showed no significant clinical signs of chronic venous insufficiency, had excellent function on venous ultrasound and reported excellent qol. about the author(s) anith chacko clinical neurosciences, university of bristol, united kingdom ewan simpson clinical neurosciences, university of bristol, united kingdom schadie vedajallam clinical neurosciences, university of bristol, united kingdom savvas andronikou clinical neurosciences, university of bristol, united kingdom ngoc j. thai clinical neurosciences, university of bristol, united kingdom citation chacko a, simpson e, vedajallam s, andronikou s, thai nj. assessing the viability of 3d printed brain models derived from mri scan data in the communication of complex patterns of hypoxic ischaemic injury to lay-people. s afr j rad. 2017;21(1), a1146. https://doi.org/10.4102/sajr.v21i1.1146 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract assessing the viability of 3d printed brain models derived from mri scan data in the communication of complex patterns of hypoxic ischaemic injury to lay-people anith chacko, ewan simpson, schadie vedajallam, savvas andronikou, ngoc j. thai copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: communication of bilateral, symmetric, zonal cortical brain atrophy in children with term hypoxic ischaemic injury (hii) to parents and the legal fraternity contesting compensation rights, using text reports, can be very difficult. 3d printed models, which may be viewed through grasping and rotating, may be useful for conveying such changes to non-radiologists and lay-people. in this report we describe the technical aspects of generating a 3d printed model from a paediatric brain mri and provide completed examples in children with partial prolonged hii and controls. aim: to describe the technical aspects of producing 3d printed models of the brain in children using examples of children with term partial prolonged hii as well as age matched controls and to provide completed models for public consideration. methods and materials: the technical method for utilising 3dt1/3d flair images, stripping the skull and converting to stereolithography (stl) format is described as well as the 3d printing consideration for creating 3d models of the brain. mri scans of 4 children, who demonstrated atrophy after having sustained partial prolonged hii at term and age matched controls were 3d printed using the described technique. these scans are used for demonstration of the advantages. results and conclusion: 3d printing, using the described technique, was successful and generated 3d models in patients which could be compared with controls in contour and size for the purposes of diagnosing cortical atrophy in children who sustained peri-natal partial prolonged hii at term. case report 30 sa journal of radiology • september 2006 case report abstract a case report demonstrating the plain film and ct findings of emphysematous pyelonephritis in a patient with polycystic kidney disease, an extremely rare occurrence. introduction emphysematous pyelonephritis is a rare, complicated pyelonephritis that is considered life-threatening.1,2 it is extremely rare in the literature in combination with autosomal dominant polycystic kidney disease. we present such a case with pertinent diagnostic imaging. case report clinical details a 36-year-old female patient, known with type 1 diabetes mellitus was referred to our hospital with a 2-day history of frank haematuria, severe lower back ache, diarrhoea and vomiting. the patient had been feeling unwell for a few days prior to the haematuria episode. she was known to have autosomal dominant polycystic kidney disease with mild chronic renal impairment and hypertension. on physical examination, the patient was pyrexial with a temperature of 38 degrees celsius. she was tachycardic, with a pulse of 110 bpm, and hypotensive with a blood pressure of 96/54 mmhg. the patient had severe left-sided renal angle tenderness. the rest of the abdomen was soft, with no signs of peritonism. the patient’s urine showed macroscopic haematuria and leucocytes were present on dipstick testing. the blood urea at the time was 22.4 mmol/l; the serum creatinine was 284 μmol/l. imaging findings plain radiographs of the chest and abdomen showed an elevated left hemidiaphragm, a medially displaced stomach bubble and a large, ovoid gas shadow in the left flank region (figs 1 and 2). an ultrasound of the kidneys was requested which showed the typical appearance of polycystic kidney disease on the right side. the left kidney was obscured by gas artefact and visualisation of the spleen, the left renal bed and the psoas region was very poor. in the light of the patient’s severe illness, pyrexia and renal impairment, a ct scan of the abdomen was performed. the patient took oral contrast material prior to the scan. no intravenous contrast was used. the ct scan showed multiple cysts in both kidneys with the left kidney more severely involved than the right. there were small gas locules outlining the margin of the left kidney. a large, laterally positioned cyst contained mainly gas with a prominent gas/fluid level. a second large, medially positioned cyst contained fluid emphysematous pyelonephritis in a patient with polycystic kidney disease yousuf vadachia, mb chb melanie strachan, mb chb, lmcc stephanie b griffith-richards, mb chb, bsc (physio) stefan jerzy przybojewski, mb chb, mmed (rad d), fcrad (diag), dip pec (sa) david louis kathan, mb chb department of radiology, tygerberg hospital and stellenbosch university fig 1. chest x-ray showing raised left hemidiaphragm and air-fluid level in left upper quadrant. pg 30-32.indd 30 9/6/06 2:57:47 pm case report 31 sa journal of radiology • september 2006 that appeared denser than the remaining cysts, as well as small locules of gas (fig. 3). there was marked fat stranding around the left kidney. the contrast-filled stomach was medially displaced (fig. 4). there was no evidence of free air within the peritoneal cavity. clinical outcome the patient was taken to emergency surgery. the left renal bed was explored and 2 large gas-containing cysts were found. there was a large amount of necrotic slough within the cysts, as well as in the adjacent renal tissue. the cysts were drained, some debridement of the surrounding tissue was done and surgical drains were left in situ. the patient recovered slowly with drainage and antibiotic cover. her renal function slowly improved to her baseline level of functioning, with a blood urea of 13.3 mmol/l and serum creatinine of 160 μmol/l. microscopy of tissue removed at the time of the surgery showed necrotic material with numerous gram-negative bacilli. culture yielded escherichia coli. discussion emphysematous pyelonephritis is a rare and life-threatening condition. prompt diagnosis allows for appropriate management to be initiated speedily. clinical findings are often non-specific and radiographic confirmation of gas within the kidney is diagnostic.3 our fig. 2. abdominal x-ray, showing the displaced stomach bubble (black arrow). laterally, a large ovoid gas shadow is seen (white arrow). fig. 3. ct scan at the level of porta hepatis. multiple renal cysts are seen (black arrow). a large air-fluid level is seen in a laterally positioned left renal cyst as well as gas outlining the wall of the cyst (white arrow). fig. 4. ct scan at the level of the lower pole of both kidneys. the contrastfilled stomach is displaced medially (star). a thin membrane is seen (white arrow) separating two large cysts in the left kidney. the lateral cyst is filled with necrotic slough, pus and gas, the medial cyst is filled with denser material with small locules of gas. these were the 2 cysts confirmed to be infected at the time of surgery. pg 30-32.indd 31 9/6/06 2:57:50 pm case report 32 sa journal of radiology • september 2006 case demonstrates some of the radiological signs in the extremely rare occurrence of emphysematous pyelonephritis in a polycystic kidney. plain film. the gas filling the renal cyst and renal parenchyma appears as a lucent cavity in the region of the left renal bed. gas collection in the renal parenchyma may appear as mottled radiolucent shadows on the plain film.1 the raised left hemidiaphragm in our patient may represent a large subphrenic inflammatory mass, or may be due to the enlarged polycystic left kidney. ultrasound. chou et al.1 highlight a few ultrasound findings which may be helpful in diagnosing emphysematous pyelonephritis, such as echogenic gas locules within the renal parenchyma, and ‘dirty shadows’1 cast by gas locules. owing to the gas outlining the left kidney in our patient, visualising the renal parenchyma was extremely difficult. furthermore, the normal renal architecture was distorted by the polycystic disease. thus ultrasound was not helpful in the diagnosis of this case. ct scanning. ct scan is considered to be the best modality for confirmation of the diagnosis.2 this was borne out in our case. the gas within the involved renal cysts was clearly visualised, as well as gas outlining the kidney within gerota’s fascia. the inflammatory changes and fat stranding around the left kidney was visualised. the denser fluid within the medial large cyst is most likely purulent fluid and/or blood. the aetiology of emphysematous pyelonephritis has been postulated to be due to fermentation of glucose by gas-producing organisms, especially e. coli, in diabetics to form carbon dioxide and hydrogen.2 anaerobic organisms are rare pathogens.2 in non-diabetics the presence of impaired host immunity, focal renal infarctions, or obstruction are considered to be predisposing factors.4 our patient appears to be at higher than normal risk due to the combination of diabetes and adult polycystic kidney disease. haemorrhage into the cysts is a known complication of polycystic kidney disease. this could conceivably have been the precipitating factor causing obstruction of the involved cysts, colonisation by gas-forming bacteria and a rich substrate for bacterial growth leading to the emphysematous pyelonephritis. 1. chou yh, tiu cm, chen tw, chen kk, chang t. emphysematous pyelonephritis in a polycystic kidney. demonstration by ultrasound and computed tomography. j ultrasound med 1990; 9: 355-357. 2. shokeir aa, el-azab m, mohsen t, el-diasty t. emphysematous pyelonephritis: a 15 year experience with 20 cases. urology 1997; 49: 343-346. 3. evanoff gv, thompson cs, foley r, weinman ej. spectrum of gas within the kidney. emphysematous pyelonephritis and emphysematous pyelitis. am j med 1987; 83: 149-154. 4. levinson ed, weidner fa. emphysematous pyelonephritis in a polycystic kidney. urol radiol 1981; 3: 39-41. pg 30-32.indd 32 9/6/06 2:57:51 pm abstract introduction research methods and design ethical considerations results discussion conclusion acknowledgements references about the author(s) dashnee govender department of radiology, grey’s hospital, university of kwazulu-natal, south africa matthew goodier department of radiology, grey’s hospital, university of kwazulu-natal, south africa citation govender d, goodier m. bone of contention: the applicability of the greulich–pyle method for skeletal age assessment in south africa. s afr j rad. 2018; 22(1), a1348. https://doi.org/10.4102/sajr.v22i1.1348 original research bone of contention: the applicability of the greulich–pyle method for skeletal age assessment in south africa dashnee govender, matthew goodier received: 16 mar. 2018; accepted: 15 may 2018; published: 08 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the greulich–pyle (gp) method is one of the most commonly used radiographic techniques for skeletal age (sa) determination. the applicability of this method for populations outside of the united states has been questioned and this has been investigated in several recent studies around the world. only limited data are available on the accuracy of the gp method for a south african population. objective: to determine the accuracy and reliability of the gp method in a population from kwazulu-natal, south africa. method: a retrospective study was performed using a digital database consisting of 102 hand-wrist radiographs. the sa was estimated by two readers with different levels of experience, using the gp method. differences between estimated sa and chronological age (ca) were analysed. results: skeletal age determined with the gp method was found to significantly differ from ca. for the population as a whole, the gp method underestimated age. the greatest mean underestimation between sa and ca was 11.5 ± 17 months and 7.4 ± 13.2 months for the 10.1 to 15 year age groups in male and female patients, respectively. the method was found to have excellent interand intra-observer reliability. conclusion: the gp method generally significantly underestimates age for both genders. overestimation is also possible with individuals as young as 16 years old found by the method to be skeletally mature. until new sa assessment tools are developed for south africa, use of supplementary means of determination of sa should be considered, especially in medico-legal cases. introduction skeletal maturity assessment is used in a variety of settings, including medical, forensic, medico-legal and for sporting reasons.1,2,3 there are various radiographic methods of skeletal age (sa) assessment; however, a commonly used technique is to compare a single hand-wrist radiograph with a standard reference.4 the greulich–pyle (gp) method, because of its simplicity, is one of the most frequently utilised methods worldwide.5,6 the major alternative technique utilising a hand-wrist radiograph is the tanner–whitehouse 2 (tw2) method.7 assessment of the degree of ossification of the medial clavicular epiphysis8 or evaluation of the ossification and fusion of the iliac crest apophyses (risser staging system) are useful in certain specific situations. methods that utilise magnetic resonance imaging or ultrasound have also been described but are not widely used.9,10 odontological evaluation is a non-radiological technique for estimating sa.11 greulich and pyle published their ‘radiographic atlas of skeletal development of the hand and the wrist’ in 1959. this atlas contains reference images of male and female standards of the left wrist and hand from birth until 19 years for male and 18 years for female patients. the standards are based on a population of ‘caucasian’ children, ‘above average in economic and educational status’, residing in the united states, using measurements compiled in the 1930s.12 sa is determined by a comparison between the left hand-wrist radiograph of the subject to the nearest matching reference radiograph. the radiographic standards used in the gp method were based on a narrowly defined population, which was both genetically and socio-economically homogeneous. it is far from clear if these standards of skeletal maturation using data from the first half of the twentieth century can be applied to current populations that differ geographically, genetically and socio-economically from the gp reference population. indeed, studies performed in numerous countries have sought to assess the accuracy of the gp atlas in various populations.13,14,15,16,17,18,19,20,21 some studies have concluded that the gp atlas is applicable to the studied populations.19,20 however, most have questioned the accuracy of the gp method, particularly in less developed countries such as turkey, malawi and south africa.13,14,15,16,18 a further factor that may affect the utility of a given method in a less developed setting is the performance of the test in the hands of inexperienced readers. groell et al. found a trend that suggests that the reliability of the bone age estimations was higher in experienced readers compared to radiology residents; however, the differences did not reach statistical significance.19 chiang et al. failed to show a statistically significant difference between readers of different levels of experience.21 despite the widespread use of this method, there is a scarcity of local research on the accuracy and reliability of the gp method. to date only one published study of the method, limited to a male population, has been performed in south africa.18 our study is the first to assess the accuracy and reliability of the gp method of skeletal assessment for both sexes in a south african population. research methods and design a quantitative, observational analytical, comparative cross-sectional study was conducted during may–june 2017, on 102 patients of both sexes, aged between 0 and 21 years, who had hand-wrist radiographs at grey’s hospital, pietermaritzburg, south africa, between january 2012 and august 2016. digital hand-wrist images obtained by computed radiography were accessed from the picture archiving and communication system (see figures 1 and 2). antero-posterior (ap) or postero-anterior (pa) views including the phalanges, metacarpals, carpals, distal ulna and radius were used. the gp atlas uses the left hand-wrist radiograph by convention as a standard for sa assessment. when images of both hands for the same patient were available, the left-sided radiograph was used. if only the right-sided radiograph was available, then this was used. all the radiographs included in the study were of outpatients who had been imaged in the emergency department for suspected trauma as identified by the history provided on the imaging request form. radiographs performed as part of the work up of significant medical or systemic disorders were specifically excluded. figure 1: digital hand-wrist radiograph (right) of a female subject with a chronological age of 20 years 8 months was matched to the gp standard image of a 17-year-old by both readers. figure 2: digital hand-wrist radiograph (left) of a male subject with a chronological age of 15 years 10 months was matched to the gp standard image of a 14-year-old subject by both readers. poor quality radiographs (poor clarity, poor positioning and incomplete views) were excluded. patients with fractures, congenital abnormalities, arthritis or any other obvious disease of the hands and wrist that could affect skeletal maturation or hinder determination of age were excluded. two readers of different levels of experience, a specialist radiologist with five years of experience and a radiology registrar in the first year of training, independently assessed the sa according to the gp method. the readers were blinded to the chronological age (ca) of each subject. in order to assess intra-observer reliability, following an interval of approximately five weeks after the initial assessment, a subset of 10 randomly selected radiographs from the sample were again reviewed independently by the same two readers, again blinded to the ca. ethical considerations this was a retrospective study of radiological records and images. patient confidentiality was ensured by anonymisation of all patient data. ethical approval was obtained from university of kwazulu-natal biomedical research ethics committee (be006/17). consent was obtained from grey’s hospital management. results figure 3 shows the age and sex distribution of the study population. of note is the larger number of individuals from the older age groups and the male predominance of the study population. figure 3: age and sex distribution of the study population. figures 4 and 5 illustrate the linear correlation between sa as estimated by the gp method and ca for the reader. in the figures, reader 1 refers to the radiology consultant and reader 2 refers to the radiology registrar. figure 4: scatterplot of the skeletal age estimated by reader 1 (y-axis) and the chronological age (x-axis) in months (pearson’s correlation coefficient = 0.973). figure 5: scatterplot of the skeletal age estimated by reader 2 (y-axis) and the chronological age (x-axis) in months (pearson’s correlation coefficient = 0.966). the intraclass correlation coefficient (icc) was used to measure the consistency of measurements between the observers. an f test was used to test if the icc was significantly different from 0. the icc between the two reader’s estimates was 0.99 (p < 0.001). therefore, correlation was excellent between the two readers (an icc of > 0.75 is considered excellent). table 1 shows the difference between sa and ca estimations by reader 1 for the population as a whole. a one-sample t-test was performed showing the difference was statistically significant (p < 0.001). mean difference = mean ca mean sa. the positive mean difference (7.4 ± 15.7) indicated an underestimate. therefore, application of the gp method resulted in a statistically significant underestimation of age (p < 0.001). table 1: whole population difference between the skeletal age and chronological age for reader 1. following a similar methodological approach to that of dembetembe et al.18 tables 2 and 3 were divided into two sections of analysis. the first section deals with patients prior to age of expected skeletal maturity and the second section for patients at or after the age of expected skeletal maturity (18 and older in female patients and 19 years and older in male patients). this is because the estimated sa is no longer able to be correlated with ca after full skeletal maturity is reached and thus an increasing discrepancy between estimated sa and ca is expected to occur with increasing ca. individuals after the expected age of skeletal maturity were thus presented separately. table 2: group analysis of difference between the skeletal age and chronological age for reader 1 for various ages in male patients only (n = 61). table 3: group analysis of difference between the skeletal age and chronological age for reader 1 for various ages in female patients only (n = 24). amongst male patients, the mean differences (ca − sa) ranged from an overestimation of 3 ± 5 months to an underestimation of 11.5 ± 17 months for the age categories ≤ 19 years. overall, a mean underestimation of 4.4 ± 14.5 months was recorded for age categories ≤ 19 years. amongst female patients, the mean differences (ca minus sa) ranged from an overestimation of 1.8 ± 20.2 months to an underestimation of 7.4 ± 13.2 months for the age groups ≤ 18 years. overall, a mean underestimation of 2.4 ± 12.8 months was noted for the age categories ≤ 18 years. according to the gp atlas, skeletal maturity is reached at 18 years for women and at 19 years for men. table 4 shows the number of female patients who had achieved full skeletal maturity in different age groups. there were two female patients in the study population with a ca of 18. only one of these female patients was found to be both chronologically and skeletally 18 years old. the other chronologically 18-year-old was estimated to have a sa of 15. interestingly, there were two female patients with a ca of 20, who were found to have sas of 18 and 17. one female patient with a ca of 16 had a sa of 18 (i.e. had attained skeletal maturity). similarly, one female patient with a ca of 17 had a sa of 18. table 4: the number and percentage of skeletally mature female patients per chronological age group. table 5 shows the number of male patients who had achieved full skeletal maturity in different age groups. male patients who were both chronologically and skeletally 19 years old represent only 40% of the 19-year age group. therefore, 60% of the 19-year-old male patients had not reached skeletal maturation. the remaining three male patients who had cas of 19 years all had sas of 18. there was one male patient with a ca of 16 who had a sa of 19 (i.e. attained skeletal maturity). one male patient with a ca of 17 had a sa of 19. table 5: the number and percentage of skeletally mature male patients per chronological age group. pearson’s correlation coefficient (r) was calculated and a paired t-test was performed to assess intra-observer reliability showing a strong correlation (pearson r = 0.99) between the two readings performed five weeks apart with no statistical significant difference noted in the readings (p > 0.05). discussion in light of the uncertainty related to the applicability of the gp method in south africa, we set out to investigate the accuracy and reliability of the method in a local population. there was a distinct male predominance in the sample population. this was also a feature of similar previous studies.16,17 this is likely accounted for by an anticipated higher number of male patients in a population selected from referrals for suspected trauma. a similar reason explains the relative lack of very young patients < 5 years of age. the reliability of the gp method in our study was acceptable with excellent interand intra-observer agreement. similar findings occurred in previous studies.19,21 this is thought to be because of the simplicity of the gp method6 and is one of the reasons why the gp method is such a popular method of sa estimation method worldwide.5 our study also found no significant difference between the two readers of differing levels of experience with good agreement between the consultant radiologist and the registrar. this suggests that the concept of sa estimation by means of comparison with radiographic standards is not only reliable but also intuitive and can be readily utilised even with little prior experience. the most important findings of the study were the poor accuracy of the gp method. overall, there was a statistically significant underestimation of age for both genders. the results were more variable in specific age groups, with age being on average overestimated in some age groups and underestimated in others. interestingly, the results of other studies performed in africa have also suggested that the atlas underestimates age.16,18 the study performed in malawi by lewis et al. demonstrated a significant underestimation of sa in malawian children when compared to the gp atlas reference radiographic standards.16 the study by dembetembe et al. performed on an exclusive male population from the western cape province of south africa also showed a consistent underestimation of age. in that study, epiphyseal fusion of the hand and the wrist was not often complete by 19 years, leading the authors to suggest that the onset of epiphyseal fusion occurs approximately two years later in male africans. internationally, studies performed in brazil and turkey showed that the gp method consistently overestimated age for both sexes.13,22,23 of particular medico-legal and forensic interest, is the possibility of drawing erroneous conclusions of adulthood based on the finding of full skeletal maturity by radiographic methods. such errors could result in children being considered by the legal system as adults and vice versa. this study found several instances of children under 18 years of age having attained full skeletal maturity as well as individuals 18 years and older with immature skeletons. these findings suggest that reliance on the gp method as evidence for age determination in defendants of uncertain age lacks a basis in the scientific literature. the normal progress of skeletal maturation in children is a complex and multifactorial process. our study population is different from the reference population originally studied by greulich and pyle in numerous ways. we studied a genetically heterogeneous population likely to be from diverse socio-economic circumstances. acquired systemic disorders (e.g. human immunodeficiency virus [hiv] and tuberculosis [tb]) may play a role. suboptimal nutritional status and specific nutritional disorders (often subclinical) are particularly prevalent in the community. for these reasons, the major limitation of this study was a lack of detailed information regarding patients’ medical history, including nutritional status. it is possible that some patients may have been suboptimally nourished or may have had systemic diseases not specifically mentioned on the referral form. on the other hand, in this respect the study population is likely to truly reflect what is present in the community. conclusion although no method of sa estimation can be completely accurate, the findings of this study support the conclusion that the gp method should be used with caution in the south african population. even given the relatively small sample size, the method was found to significantly underestimate age for both genders. on the other hand, in a few cases, overestimation is possible with individuals as young as 16 years old found by the method to have reached skeletal maturity. the findings of this study have significant clinical, forensic and medico-legal implications. supplementary means of determination of sa should be considered, especially in medico-legal cases. ultimately, accurate standards for sa estimation based on data from the south african population will need to be developed. acknowledgements the authors thank catherine connoly and preshnee govender for assistance with the statistical analysis of the data. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions d.g. was the primary author and was responsible for the research proposal protocol, data collection and compilation of the research manuscript. m.g. was the supervisor and assisted with the project design, review, study analysis and manuscript editing. references black sm, aggrawal a, payne-james j. age estimation in the living: the practitioner’s guide. hoboken: john wiley and sons: 2011. engebretsen l, steffen k, bahr r, et al. the international olympic committee consensus statement on age determination in high-level young athletes. br j sports med. 2010;44(7):476–84. https://doi.org/10.1136/bjsm.2010.073122 schmidt s, nitz i, schulz r, schmeling a. applicability of the skeletal age determination method of tanner and whitehouse for forensic age diagnostics. int j legal med. 2008;122(4):309–14. https://doi.org/10.1007/s00414-008-0237-3 cole al, webb l, cole t. bone age estimation: a comparison of methods. br j radiol. 1988;61(728):683–6. https://doi.org/10.1259/0007-1285-61-728-683 gilli g. the assessment of skeletal maturation. horm res paediatr. 1996;45(suppl. 2):49–52. https://doi.org/10.1159/000184847 buckler j. how to make the most of bone ages. archiv dis childh. 1983;58(10):761. https://doi.org/10.1136/adc.58.10.761 tanner jm. assessment of skeletal maturity and prediction of adult height (tw2 method). london: academic press; 1983. schmeling a, schulz r, reisinger w, mühler m, wernecke k-d, geserick g. studies on the time frame for ossification of the medial clavicular epiphyseal cartilage in conventional radiography. int j legal med. 2004;118(1):5–8. http://doi.10.1007/s00414-003-0404-5 terada y, kono s, tamada d, et al. skeletal age assessment in children using an open compact mri system. magn reson med. 2013;69(6):1697–702. https://doi.org/10.1002/mrm.24439 mentzel h-j, vilser c, eulenstein m, et al. assessment of skeletal age at the wrist in children with a new ultrasound device. pediatr radiol. 2005;35(4):429–33. http://doi.10.1007/s00247-004-1385-3 cameriere r, ferrante l, cingolani m. age estimation in children by measurement of open apices in teeth. int j legal medi. 2006;120(1):49–52. http://doi.10.1007/s00414-005-0047-9 greulich ww, pyle si. radiographic atlas of skeletal development of the hand and wrist. am j med sci. 1959;238(3):393. https://doi.org/10.1097/00000441-195909000-00030 büken b, şafak aa, yazıcı b, büken e, mayda as. is the assessment of bone age by the greulich–pyle method reliable at forensic age estimation for turkish children? forensic sci int. 2007;173(2):146–53. https://doi.org/10.1016/j.forsciint.2007.02.023 koç a, karaoglanoglu m, erdogan m, kosecik m, cesur y. assessment of bone ages: is the greulich pyle method sufficient for turkish boys? pediatr int. 2001;43(6):662–5. https://doi:10.1046/j.1442-200x.2001.01470.x mora s, boechat mi, pietka e, huang h, gilsanz v. skeletal age determinations in children of european and african descent: applicability of the greulich and pyle standards. pediatr res. 2001;50(5):624–8. https://doi:10.1203/00006450-200111000-00015 lewis c, lavy c, harrison w. delay in skeletal maturity in malawian children. bone joint j. 2002;84(5):732–4. https://doi.org/10.1302/0301-620x.84b5.0840732 moradi m, sirous m, morovatti p. the reliability of skeletal age determination in an iranian sample using greulich and pyle method. forensic sci int. 2012;223(1):372.e1–4. https://doi.org/10.1016/j.forsciint.2012.08.030 dembetembe ka, morris ag. is greulich-pyle age estimation applicable for determining maturation in male africans? s afr j sci. 2012;108(9/10), art. #1036, 6 pages. http://dx.doi.org/10.4102/sajs.v108i9/10.1036 groell r, lindbichler f, riepl t, gherra l, roposch a, fotter r. the reliability of bone age determination in central european children using the greulich and pyle method. br j radiol. 1999;72(857):461–4. https://doi.org/10.1259/bjr.72.857.10505010 van rijn rr, lequin mh, robben sg, hop wc, van kuijk c. is the greulich and pyle atlas still valid for dutch caucasian children today? pediatr radiol. 2001;31(10):748–52. https://doi.org/10.1007/s002470100531 chiang k-h, chou as-b, yen p-s, et al. the reliability of using greulich-pyle method to determine children’s bone age in taiwan. tzu chi med j. 2005;17(6):417–20. available from: https://app.tzuchi.com.tw/file/tcmjd/94-6/1-4.pdf de sousa dantas i, dos anjos pontual a, almeida msc, et al. evaluation of the greulich and pyle method in the determination of bone age and chronological age in a brazilian population. derecho y cambio social. 2015;12:1–14. moraes m, moraes l, medici-filho e, graziosi m. reliability of greulich & pyle and eklöf ringertz methods for skeletal age evaluation in brazilian children. rev odontol unesp. 2003;32(1):9–17. abstract answer discussion acknowledgements references about the author(s) shalendra misser lake smit and partners inc, durban, south africa citation misser s. answer and discussion: cardiovascular imaging quiz case. s afr j rad. 2016;20(1), a1112. http://dx.doi.org/10.4102/sajr.v20i1.1112 quiz case answer and discussion: cardiovascular imaging quiz case shalendra misser received: 14 oct. 2016; accepted: 15 oct. 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a 32-year-old woman presented with shortness of breath, nyha grade 2–3, becoming progressively worse and affecting her activities of daily living. she underwent extensive investigations shown in the series of images including chest radiograph, abdominal sonar, computed tomography of chest and abdomen as well as a cardiac magnetic resonance imaging study. there were several submissions received with satisfactory approaches to the clinico-radiological question posed. a noteworthy response was submitted by dr amjed kadhim from iraq. the most comprehensive answer and approach to the diagnosis was, however, received from dr fourie bezuidenhout who is the winner of this quiz case. congratulations to dr bezuidenhout on winning the prize of r2000 sponsored by the rssa. answer a 32-year-old woman presented with shortness of breath, nyha grade 2–3, becoming progressively worse and affecting her activities of daily living. she underwent extensive investigations shown in the series of images including chest radiograph, abdominal sonar, computed tomography of chest and abdomen as well as a cardiac magnetic resonance imaging (mri) study. the chest x-ray (figure 1) performed on admission demonstrated a reticulonodular pattern of lung field opacification with areas of coalescent consolidation. right paratracheal and hilar lymphadenopathy was noted as well as a shallow left lower mid-zone surface convexity pleural reaction. wasting of the soft tissues was indicative of chronicity or systemic disease. figure 1: chest radiograph performed on admission. ultrasound of the liver (figure 2) revealed hepatomegaly with multiple rounded and ovoid foci of reduced echogenicity surrounded by echogenic halos in both lobes of the liver. no increased vascularity, calcification or central necrosis was shown in any of the lesions. the portal venous system and the biliary tree were otherwise normal. there was no significant enlargement of the spleen or focal splenic lesion identified; however, a coarse echo texture of the spleen was noted. a few sub-centimetre para-aortic nodes were also documented. there was no ascites and the rest of the abdominopelvic sonar was unremarkable (figure 3). figure 2: (a) colour duplex sonar image of the liver and (b) b-mode higher frequency sonar image of the liver. figure 3: coronal reformatted ct images of the liver: (a) precontrast study, (b) arterial phase and (c) portal venous phase. computerised tomography (ct) scan of the abdomen demonstrated the multiple hepatic lesions with isodense to slightly hyperdense central lesion density and surrounding low attenuation margin on the precontrast acquisition. the lesions did not demonstrate significant post-contrast enhancement, and they appeared hypodense to surrounding hepatic parenchyma on the portal venous phase study. fleshy para-aortic nodes were noted in figure 4 with no significant central necrosis. figure 4: axial ct images of the upper abdomen: (a) precontrast study, (b) arterial phase and (c) portal venous phase. ct of the lung bases (figures 5a and figure 6) identified extensive peribronchovascular nodules in the parahilar and centrilobular interstitial compartments. there was subsegmental ground glass opacity, and areas of consolidation noted in the lower zones of both lungs. the left pleural effusion and minimal pleural thickening was also noted. figure 5b shows a clear demarcation of abnormal myocardial thickening and reduced enhancement of the interventricular septum and adjacent left ventricle (annotated by the arrows). the appearance suggests myocarditis or oedema of the ventricular and septal wall. figure 5: axial ct images of (a) the lower lung fields and (b) at level of left ventricle. figure 6: coronal reformatted ct images of the lower lung fields. ecg-gated cardiac mri was arranged in the light of suspected cardiomyopathy to account for the progressive dyspnoea. axial dual-chamber t2-weighted mri of the heart demonstrated corresponding hyperintensity in the left ventricular wall and the midand basal interventricular septum in keeping with myocardial oedema (annotated by the arrows) (figure 7). a heterogenous pattern of enhancement is shown on the post-gadolinium (trufi) study with areas of non-perfusion in the early phase of the dynamically enhanced sequence (annotated by the arrows) and equivalent areas of delayed gadolinium-induced enhancement on the subsequent images up to 12 minutes post-injection (annotated by the arrows) (figure 8). this was shown to involve epicardial and mid-myocardial portions of the ventricular and septal wall crossing multiple vascular territories. a sliver of pericardial fluid was noted at the apical region. the right ventricle appeared to be spared and the cardiac valves visualised were normal. the lung field changes were again noted. figure 7: axial dual-chamber cardiac t2-weighted mri image. figure 8: axial post-contrast trufi mr images performed at time intervals after intravenous gadolinium injection: (a) dynamic, (b) 2 minutes, (c) 5 minutes and (d) 12 minutes delay. haematological and biochemical tests revealed mild anaemia, infiltrative pattern on the liver function test with elevation of the alkaline phosphatase and gamma-glutamyl transferase as well as raised serum angiotensin converting enzyme level at 117.9u/l (normal 8–52). echocardiogram confirmed reduced myocardial contractility with an ejection fraction of 40%. a final diagnosis was made of multisystem disease with pleuro-pulmonary, hepatic and cardiac abnormalities compatible with granulomatous infiltration because of disseminated sarcoidosis. discussion the concept of sarcoidosis was first introduced in 1877 by jonathan hutchinson, in a patient with cutaneous manifestations of a granulomatous disease.1 carl boeck demonstrated the cutaneous lesions described by hutchinson in a number of illustrations but these were never published. it was only in 1899 when the nature of the disorder was really appreciated after his grandson, caesar boeck, published a case study of a patient with what he termed sarkoid, meaning resembling a sarcoma but with benign features.2 the term sarcoidosis arose from this report and it has remained to this day. sarcoidosis is a multisystem granulomatous disease characterised by the presence of non-caseating granulomas in the affected organs. although sarcoidosis typically presents with paratracheal and bilateral hilar lymphadenopathy as well as pulmonary infiltration, it has been shown to affect any organ system. table 1 lists the spectrum of disorders associated with sarcoidosis referable to each organ system. pulmonary and lymphatic involvement are most common, documented in 90% and 30% of cases, respectively.3 extrapulmonary manifestations in the central nervous system, abdominal viscera and cardiovascular system are variably expressed in different population groups under the influence of demographic, environmental and genetic factors. the disease, however, does occur in all races, both sexes and all ages. there is a distinct predilection for young adults under 40 years of age, peaking in women in the late third decade. a second peak is noted in the sixth decade. death because of sarcoidosis is estimated at 1%–5% in different population groups. apart from japan, where cardiac sarcoidosis (cs) is the principle extrapulmonary manifestation and commonest cause of death, in the rest of the world respiratory failure is the leading cause of death.4 table 1: spectrum of disorders associated with sarcoidosis referable to each organ system.3,4,5,6,7,8,9 sarcoidosis occurs in genetically susceptible individuals who are exposed to certain suspected environmental agents. these include infectious microbes (such as mycobacteria), organic agents (e.g. pine tree pollen) and inorganic substrates (e.g. zirconium) which are proposed to incite a t-cell-mediated response triggered by underlying genetic predisposition particularly referable to the (human leukocyte antigen) hla phenotypes. these sequentially result in a cascade of cytokine and other inflammatory cell-mediated processes that cause accumulation of t-lymphocytes and macrophages at the sites of inflammation in the affected organ.5 the typical sarcoid lesion comprises non-caseating epithelioid cell granulomata. these can occur in any organ and the course of the granuloma is variable. in the lungs, these granulomas are located along the connective tissue sheaths around arteries, venules and bronchoalveolar airways and manifest as parahilar peribronchovascular interstitial thickening.6 this thickening may be smooth or nodular. subpleural pulmonary parenchymal and pleural granulomas appear as subpleural nodules along the surface convexities of the lungs. conglomeration of several granulomas in the presence or absence of fibrosis appears as ground glass opacity which is localised to the alveolar septa and perivascular interstitium. nodules exceeding 1 cm in size are because of coalescent granulomas and may appear as focal areas of consolidation. these can progress to form masses and may mimic infection, cryptogenic organising pneumonia or bronchiolo-alveolar carcinoma.7 siltzbach classification of sarcoidosis, albeit nearly five decades old, is still in worldwide clinico-radiological use daily.8 table 2 shows the value of this system as a useful prognostic tool. table 2: stage of sarcoidosis and features on chest radiography including percentage of patients seen with the particular stage at initial presentation and the corresponding prognosis for each stage.8 high-resolution ct is superior to chest radiography and conventional ct in the discrimination of active inflammation from fibrotic lung disease. this is a critical aspect of diagnosis as the presence of fibrosis (which demonstrates septal lines, architectural distortion, honeycombing, bulla and traction bronchiolectasis) indicates an irreversible process, whereas inflammation (manifested by ground glass opacity, nodules and alveolar opacities) will be responsive to therapy.7 in addition, these several features of sarcoidosis that can be categorised as either typical or atypical features is summarised in table 3. table 3: typical and atypical features of thoracic sarcoidosis.7 the liver is the third visceral site of sarcoidosis infiltration after pulmonary and lymphatic involvement. it is estimated that 10% – 25% of patients can have hepatic sarcoidosis.9 the commonest imaging abnormality is hepatomegaly with diffuse isoechogenicity of the liver. increased hepatic echogenicity, indistinguishable from hepatic steatosis, is also possible. a coarsened echo texture may be attributed to coalescence of multiple granulomas and surrounding fibrosis. although at biopsy hepatic granulomas are demonstrable in up to 60% – 80% of specimens, only 5% of cases have lesions that can be shown using radiological imaging by sonar or ct.10 it is quite unusual to see these granulomas at ultrasound. they typically have a low central echogenicity and occasionally a surrounding echogenic halo. they are usually not associated with much architectural distortion, and the rest of the hepatic parenchyma may appear otherwise normal. hepatic granulomas, which range from 1 mm to 2 mm up to a few centimetres in size, may also be isoechoic to liver and could potentially be sonographically occult in a number of patients, only to be discovered on cross-sectional imaging studies subsequently performed. generally, hepatic granulomas show reduced vascularity. they could be difficult to sonographically distinguish from other causes of granulomas (including tuberculosis and systemic lupus), regenerating nodules in cirrhosis, hepatic adenomas or metastases. primovist mri studies and multiphasic ct examinations are able to further characterise the lesions. liver disease in sarcoidosis is reportedly a quiescent disease but can result in a cholestatic syndrome (with pruritus and jaundice), portal hypertension and hepatic failure. the latter is seen in only 1% of patients with sarcoidosis.9 cardiac involvement in sarcoidosis is principally because of infiltration of the myocardium by sarcoid granulomas. although only 7% of patients with sarcoidosis present with cardiac symptoms, autopsy studies variably indicate 20% – 50% may have cardiac disease.12,13 cs was first described in 1929 at a post-mortem examination that revealed epicardial granulomas in a patient that had similar skin lesions.14 the diagnosis of cs can only be proven on histology by subendocardial biopsy, but expertise to perform this biopsy is not always available and the diagnostic yield thereof is suboptimal. currently, the diagnosis may be inferred through the abnormalities induced on electrocardiogram, echocardiogram or mri in the presence of extracardiac sarcoidosis.15,16 the diagnostic criteria most widely accepted are listed in table 4. table 4: japanese ministry of health and welfare (jmhw) 2007 revised guidelines for the diagnosis of cardiac sarcoidosis.15 the classic clinical presentation is that of heart block; however; other conduction abnormalities including ventricular tachycardia (sustained or non-sustained most commonly because of re-entry circuit abnormality), supraventricular arrhythmia or ventricular fibrillation are described.17 some patients develop cardiomyopathy that may progress to cardiac failure. sudden cardiac death is a feared complication in cs. pathologically, the classic cs lesion is a non-caseating epithelioid cell granuloma containing t-lymphocytes and macrophages. the lesions may be identified in one of three phases of the inflammatory process. early inflammatory changes show lymphocytes and a few giant macrophages with small granulomas. in the intermediate phase, well-formed granulomas are demonstrated, and in the late stage, fibrosis with few granulomas and chronic inflammatory cells predominate. echocardiography is useful in the detection of regional wall motion abnormalities or other morphologic abnormalities including ventricular aneurysms, basal septal thinning and ventricular wall thickening. dilatation of the left ventricle and reduced ejection fraction are poor prognostic factors. ct is not routinely performed for cardiac assessment; however, at the time of high-resolution computed tomography (hrct) performed for assessment of pulmonary disease, one may demonstrate cardiomegaly, variable myocardial thickness, pericardial disease and presence of aneurysms. these changes are better appreciated on ecg-gated cardiac multidetecor ct studies.18 cardiac mri has become a critical aid to the diagnosis of cs as it is an excellent modality to demonstrate morphologic and functional characteristics of cardiomyopathies. dedicated cardiac phased array-coils utilised with ecg-triggering improve spatial and contrast resolution for better lesion detection. there remains a challenge in the imaging of patients with intracardiac defibrillators or pacemakers in situ, but these are no longer an absolute contraindication with mri-compatible units now widely available. t2-weighted fast spin echo images usually in short axis depict the inflammatory changes of acute phase of cs as focal areas of increased signal intensity. these may be associated with variable wall thickness showing areas of t2-weighted hyperintensity or early phase enhancement after gadolinium. this is compatible with inflammatory change and related oedema.18 granulomas may also be seen as focal nodular areas of similar signal change. cine cardiac mri sequences can demonstrate areas of regional wall motion abnormality or ventricular hypokinesia associated with severe myocardial infiltration. the latter progresses to congestive cardiomyopathy with heart failure. late gadolinium-induced enhancement, most commonly affecting the lateral walls and basal septum, may show the true extent of myocardial infiltration beyond vascular territories indicative of a non-ischaemic aetiology. typically transmural, mid-myocardial or subepicardial patterns of enhancement are demonstrated. this is in contradistinction to the subendocardial pattern seen in ischaemia-related delayed post-gadolinium enhancement encountered in coronary artery disease. there is a strong correlation between the extent of late gadolinium enhancement of the myocardium and disease severity as well as prognostic outcome.19 improvement in the extent of myocardial signal abnormality and reduction in post-gadolinium enhancement are seen after therapy.18 radionuclide imaging techniques are also used to assess myocardial perfusion and infiltration. thallium 201 and technetium 99 m cardiac-scintigraphy scans performed at rest show areas of reduced isotope uptake in the myocardium of patients with cs. these perfusion defects are largely because of fibrogranulomatous change in the myocardium or may be related to localised small vessel vasoconstriction or other metabolic processes.20 upon exercising, these perfusion defects may resolve or become less appreciable indicating a reverse-distribution pattern in cs when compared with ischaemic cardiomyopathy. more recently, 18f-fluorodeoxyglucose positron emission tomography (pet) has gained much recognition as the superior radionuclide imaging modality for cs assessment. it can be used to show disease activity by highlighting the areas of active inflammatory change as well as identifying perfusion defects because of fibrogranulomatous destruction of the myocardium in scarring. the sensitivity of pet for diagnosis of cs has been estimated at 82% – 100% in recent studies.18,20 the prognosis in cs is variable and depends on the stage at which the patient presents, the extent of extrapulmonary dissemination, nyha functional class, left ventricular dysfunction and the presence of sustained arrhythmia. cs therefore, despite being a relatively rare condition, is a potentially fatal manifestation of sarcoidosis and a leading cause of death in this multisystem disease. clinical, radiological and pathological correlation and consultation is crucial to the successful early diagnosis and effective treatment of cs. acknowledgements competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references hutchinson j. case of livid papillary psoriasis. in: illustrations of clinical surgery. volume 1. london: j&a churchill, 1877; p. 42–43. boeck c. multiple benign hud-sarkoid. norsck laegevidensk. 1899;60:1321. statement on sarcoidosis. joint statement of the american thoracic society (ats), the european respiratory society (ers) and the world association of sarcoidosis and other granulomatous disorders (wasog) adopted by the ats board of directors and by the ers executive committee, february 1999. am j respir crit care med. 1999;160(2):736–755. gideon nm, mannino dm. sarcoidosis mortality in the united states 1979–1991: an analysis of multiple-cause mortality data. am j med. 1996;100:423–427. http://dx.doi.org/10.1016/s0002-9343(97)89518-6 miller bh, rosado-de-christenson ml, mcadams hp, fishback nf. thoracic sarcoidosis: radiologicpathologic correlation. radiographics. 1995;15(2):421–437. http://dx.doi.org/10.1148/radiographics.15.2.7761646 nishimura k, itoh h, kitaichi m, nagai s, izumi t. pulmonary sarcoidosis: correlation of ct and histopathologic findings. radiology. 1993;189(1):105–109. http://dx.doi.org/10.1148/radiology.189.1.8372178 criado e, sánchez m, ramírez j, et al. pulmonary sarcoidosis: typical and atypical manifestations at high-resolution ct with pathologic correlation. radiographics. 2010;30(6):1567–1586. http://dx.doi.org/10.1148/rg.306105512 siltzbach le. sarcoidosis: clinical features and management. med clin north am. 1967;51(2):483–502. http://dx.doi.org/10.1016/s0025-7125(16)33069-3 iannuzzi mc, rybicki ba, teirstein as. sarcoidosis. n engl j med. 2007;357(21):2153–2165. http://dx.doi.org/10.1056/nejmra071714 warshauer dm, lee jkt. imaging manifestations of abdominal sarcoidosis. am j roentgenol. 2004;182(1):15–28. http://dx.doi.org/10.2214/ajr.182.1.1820015 kessler a, mitchell dg, israel hl, goldberg bb. hepatic and splenic sarcoidosis: ultrasound and mr imaging. abdom imaging. 1993;18(2):159–163. http://dx.doi.org/10.1007/bf00198055 matsui y, iwai k, tachibana t, et al. clinicopathological study of fatal myocardial sarcoidosis. ann n y acad sci. 1976;278:455–469. http://dx.doi.org/10.1111/j.1749-6632.1976.tb47058.x silverman kj, hutchins gm, bulkley bh. cardiac sarcoid: a clinicopathologic study of 84 unselected patients with systemic sarcoidosis. circulation. 1978;58:1204–1211. http://dx.doi.org/10.1161/01.cir.58.6.1204 bernstein m, konzlemann fw, sidlick dm. boeck’s sarcoid: report of a case with visceral involvement. arch intern med. 1929;44(5):721–734. http://dx.doi.org/10.1001/archinte.1929.00140050098009 sarcoidosis diagnostic criteria revising committee. diagnostic standard and guidelines for sarcoidosis. jpn j sarcoidosis granulomatous dis. 2007;27:89–102. yoshida y, morimoto s, hiramitsu s, et al. incidence of cardiac sarcoidosis in japanese patients with high-degree atrioventricular block. am heart j. 1997;134:382–386. http://dx.doi.org/10.1016/s0002-8703(97)70070-x birnie dh, sauer wh, bogun f. hrs expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. heart rhythm. 2014;11(7):1305–1323. http://dx.doi.org/10.1016/j.hrthm.2014.03.043 jeudy j, burke ap, white cs, kramer gbg, frazier aa. cardiac sarcoidosis: the challenge of radiologic-pathologic correlation. radiographics. 2015;35:657–679. http://dx.doi.org/10.1148/rg.2015140247 shafee ma, fukuda k, wakayama y, et al. delayed enhancement on cardiac magnetic resonance imaging is a poor prognostic factor in patients with cardiac sarcoidosis. j cardiol. 2012;60(6):448–453. http://dx.doi.org/10.1016/j.jjcc.2012.08.002 kim js, judson ma, donnino r, et al. cardiac sarcoidosis. am heart j. 2009;157(1):9–21. http://dx.doi.org/10.1016/j.ahj.2008.09.009 radiology_oct04 editorial 2 sa journal of radiology • october 2004 the south african journal of radiology is now coming of age.with the appointment of an editor-in-chief, the creation of a new academic editorial board and the use of a more formalised peer-review system for all submissions, the journal is set to raise its profile among other radiological publications. with the implementation of the above changes we will eventually attempt to have the journal indexed internationally, thereby transforming it into the more substantial publication that south african radiology deserves. our standards of training and practice are high and there is good demand for our expertise — let our journal in turn reflect this. many thanks go to professor j p van niekerk for his encouragement and support in making this transition and for facilitating our growth. coming of age ian c duncan ffrad (d) sa unitas interventional unit centurion, and sunninghill hospital sandton johannesburg message from the new editorial committee the south african journal of radiology has followed a sometimes roller-coaster course in recent times, with issue quality varying widely. this spectrum of quality has largely resulted from lack of a central and consistent editorial voice. in a recent attempt to improve the control and quality of the journal, a number of important changes have been made, starting with the introduction of a full-time editor-inchief. the first appointed editor-in-chief is ian duncan. this post will be held for a period of 4 years, and is aimed at ensuring continuity in the running of the journal. the editorial committee has also been changed with immediate effect, and now consists of professor coert de vries (deputy editor) (university of the free state), professor leonie scholtz (university of pretoria), professor darius tsatsi (medunsa), dr savvas andronikou (university of cape town), professor peter corr (university of kwazulu-natal), professor alan scher (university of stellenbosch), professor steve beningfield (university of cape town), and dr malan van rensburg (private practice, pretoria). the rotating guest editorship will continue. each academic department will be responsible for one of seven issues, with an eighth ‘open’ issue completing the 2year cycle. the head of department (guest editor) or nominee will canvass articles from staff members, including registrars and radiographers, but should also try and elicit articles from private practices in his or her area. any article received from any author may be considered for publication by the rotating guest editor in an upcoming issue, regardless of the geographical location of the author(s). it is hoped that each and every senior registrar will produce at least one abstract introduction conventional imaging ultrasound magnetic resonance imaging discussion conclusion acknowledgements references about the author(s) kgomotso kgoebane department of radiology, university of pretoria, south africa mahmood m.t.m. ally department of internal medicine, university of pretoria, south africa martha c. duim-beytell department of internal medicine, university of pretoria, south africa farhana e. suleman department of radiology, university of pretoria, south africa citation kgoebane k, ally mmtm, duim-beytell mc, suleman fe. the role of imaging in rheumatoid arthritis. s afr j rad. 2018; 22(1), a1316. https://doi.org/10.4102/sajr.v22i1.1316 review article the role of imaging in rheumatoid arthritis kgomotso kgoebane, mahmood m.t.m. ally, martha c. duim-beytell, farhana e. suleman received: 07 feb. 2018; accepted: 29 apr. 2018; published: 11 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract conventional radiographs of the hands and feet have traditionally been used in the diagnosis, management and monitoring of patients with rheumatoid arthritis (ra). however, they are not sensitive enough to detect changes early in the disease process. erosions may only be visible up to two years after the onset of disease, and soft tissue involvement may not be detected at all. early diagnosis can also be made challenging as markers such as erythrocyte sedimentation rate and c-reactive protein may be normal in up to 20% – 25% of cases. the latest classification criteria (american college of rheumatology/european league against rheumatism [acr/eular] rheumatoid arthritis classification criteria 2010), often used to diagnose ra, incorporate the role of ultrasound and magnetic resonance imaging detection of synovitis, enabling earlier diagnosis and correct classification of patients. this article looks at the role of the various imaging modalities used in the diagnosis and management of ra. introduction rheumatoid arthritis (ra) is a chronic auto-immune disease which is characterised by persistent inflammation and joint damage. early diagnosis provides a window of opportunity for cost-effective therapeutic intervention. the earlier patients are diagnosed and treated, the better the outcome. clinical and laboratory assessment of ra remains the cornerstone of diagnosis and monitoring of response to treatment. early diagnosis can be challenging as the serological and conventional radiological characteristics are often absent. in patients with active disease, acute-phase response laboratory tests such as erythrocyte sedimentation rate (esr) or c-reactive protein (crp) may be normal in up to 20% – 25% of cases.1 conventional radiographs of the hand and feet tend to show presence of erosions as late as one to two years after onset of the disease.2 the latest classification criteria (american college of rheumatology/european league against rheumatism [acr/eular] rheumatoid arthritis classification criteria 2010) (see box 1),3 often used to diagnose ra, incorporate the role of ultrasound (us) and magnetic resonance imaging (mri) detection of synovitis in the criteria, enabling earlier diagnosis and correct classification of patients. studies have outlined patients clinically being assessed as having undifferentiated arthritis, but following us or mri, classified as ra, impacting on their management.4 with the ground-breaking advances made in the management of ra, optimal treatment mandates treating to a target of at least low disease activity. ongoing disease activity is associated with increased morbidity and premature mortality. newer imaging applications have an important role to play in early diagnosis, monitoring response and identifying poor prognostic factors.5 box 1: diagnostic criteria for rheumatoid arthritis: 2010 american college of rheumatology/european league against rheumatism rheumatoid arthritis classification criteria. rheumatoid arthritis is associated with both articular and extra-articular manifestations. articular involvement is classically a symmetrical inflammatory polyarthritis affecting both small and large joints. joint disease is characterised by synovial thickening, bone oedema, bone erosions, joint space narrowing, joint subluxations and specific deformities. the small joints of the hand and feet are commonly affected in early disease. the presence of peripheral joint erosions is associated with cervical spine involvement.6 changes in the cervical spine include erosion of the odontoid process, cranial settling, atlanto-axial subluxation, erosions of vertebral body margins and spinous processes, and disc space narrowing with resultant apophyseal joint ankylosis. cranial settling and atlanto-axial subluxations pose high risk for cervical cord compression.7 progression of cervical spine damage in ra creates an increased risk for myelopathy and sudden death because of spinal cord and brainstem compression.6 conventional imaging conventional radiography is still used in the assessment of patients with ra. it is; however, not sensitive enough to detect changes such as bone erosions in early disease.8,9 it is important to remember that most of what we know today about the pathology of ra originates from plain conventional radiography. radiography emphasises the importance of cortical bone, which is very clear on normal x-rays because of its calcium content. erosion of cortical bone is known to be the main characteristic of erosive ra5 (figure 1). radiographs still represent a useful technique despite its limitations, because of easy availability, reliability, experience and relative low cost.10 many clinical trials still use radiographic progression as an outcome measure, with radiographic scoring methods well established and sensitive to change.11 disadvantages of radiographs include the following: low sensitivity to detect early joint damage, assessment of inflammatory joint involvement is indirect and insufficient because only peri-articular soft tissue swelling is detected, three-dimensional structures are shown in two dimensions and ionising radiation is used. figure 1: fontal radiograph of both hands demonstrating bilateral symmetrical disease. ultrasound ultrasonography allows valuable assessment of soft tissues and can distinguish synovial thickening, presence of fluid in joints, bursae and tendon sheaths, basic abnormalities of tendons, ligaments, entheses and small erosions8 (figure 2). high-resolution us equipment using high frequency transducers makes it possible to assess in detail the smallest anatomical alterations, which is of great value for early diagnosis and monitoring of chronic arthritis. synovial hypertrophy is a characteristic of chronic synovitis and is regarded as a very reliable biomarker of aggressive ra. synovial hypertrophy can be seen as circumscribed polypoid structures or have a bushy appearance on us images. various features and the distribution of cartilage damage can be analysed in great detail with us, while bone erosions as small as one-tenth of a millimetre can be detected (figure 3). more precise diagnosis based on the identification of specific anatomical targets can be made when us findings are combined with clinical data in patients with early disease, especially when they have seronegative ra. up to 50% of patients with early ra do not test positive for ra-associated antibodies (rf or anti-ccp ab).2 the combination of higher spatial resolution and multi-planar exploration makes us superior when compared to conventional radiography. the higher spatial resolution of us makes it possible to examine tendons in great detail, and the following can be detected: tendon sheath widening, inhomogeneity of tendon structure, localised reduction of tendon diameter, contour defects, synovial cysts, interruption, fragmentation, disappearance of echotexture and tears in the tendon.12 ultrasound-guided joint and soft tissue aspirations or infiltrations allow for increased accuracy. ultrasound has the following disadvantages: it requires additional training, is not always reproducible (examiner dependent) and is not suited for the assessment of deep joints.10 figure 2: transverse ultrasound image at the level of the second metacarpal demonstrating tenosynovitis of the extensor tendons of the hand. figure 3: longitudinal ultrasound at the level of the second metacarpophalangeal joint shows synovial hypertrophy with an early erosion. doppler us is used to evaluate soft tissue hyperaemia,12 and it can be used to distinguish between active and inactive inflammatory tissue8 (figure 4). ongoing angiogenesis in areas of synovial hypertrophy is responsible for the intra-articular doppler signal in patients with chronic arthritis. the continued presence of intensely perfused areas of synovial hypertrophy inside the joint is a reliable indicator of insufficient response to therapy and is predictive of the development of erosions.12 figure 4: transverse doppler ultrasound demonstrating positive doppler activity in the tendon sheath in keeping with active disease. magnetic resonance imaging magnetic resonance imaging can assess all the structures affected by ra. these include soft tissue, cartilage and bones. this imaging method is highly sensitive and can detect early erosions up to three years before they may be seen with conventional radiography (figure 5 a and b). a small dedicated extremity coil with thin slices, not > 3 mm, is advised. magnetic resonance imaging sequences, used accordingly, are hand protocols, commonly utilised worldwide. the t1-weighted (t1w) sequence is used to detect anatomy of the imaged hand. t2-weighted (t2w), proton density-weighted fat-saturated (pdw-fs) and short-tau inversion recovery (stir) sequences are ideal modalities to detect free fluid and regions of inflammation. in ra, this would then assist in easy diagnosis of synovitis, tenosynovitis (figure 6), synovial effusions and bone oedema (figure 7)6. diffusion-weighted imaging (dwi) sequences, together with t2w and stir sequences, offer feasibility in identifying synovitis in the wrist and hand, without the use of intravenous gadolinium in patients in whom contrast is contra-indicated.13 active disease is demonstrated by high signal on dwi at high b values as opposed to low signal of normal bone marrow. the disadvantage of dwi is the low signal-to-noise ratio and artefacts from the inhomogeneities in the magnetic fields when used in the hands and feet.14 figure 5: (a) frontal radiograph of the both hands shows no evidence of erosive disease. (b) post-contrast fat-suppressed coronal t1-weighted magnetic resonance imaging of the same hand demonstrating an erosion (white arrow) and active synovitis (grey arrow). figure 6: axial proton density-weighted fat-saturated post-contrast magnetic resonance imaging at the level of the metacarpal bones demonstrating enhancement of the flexor tendons within the flexor compartment in keeping with tenosynovitis. figure 7: proton density-weighted fat-saturated coronal magnetic resonance imaging. gadolinium-contrasted t1w sequences allow further detection of active inflammation in areas of enhanced vascularity. fat suppression in the post-contrast sequences allows contrast-enhanced tissues to be demonstrated more easily (figure 8).15 dynamic contrast imaging (dce) using time-intensity curves may be employed and/or applied objectively to quantify synovial inflammation and is useful for early diagnosis and monitoring of therapy.13 figure 8: post-contrast fat-suppressed t1-weighted coronal magnetic resonance imaging. delayed gadolinium-enhanced mri of cartilage is a technique developed to assess early loss of collagen and proteoglycans in cartilage before it is visible macroscopically.16 the functional sequence used more commonly for the assessment of cartilage however, is t2 mapping, which acquires multiple te’s in a single sequence. high t2 correlates with increased water content and decreased collagen and proteoglycan content in cartilage, in keeping with regions of cartilage injury.14 bone marrow oedema (bme) actually refers to tissue water. the high t2w signal of mri comes from the protons in free water molecules which are found inside cells (not lipocytes) and blood vessels and are concentrated in areas where inflammation is present. inflammatory lesions are detected by using the sensitive t2w and/or pdw sequences where inflammation is seen as a bright signal. calcified cortical bone and trabecular bone are seen as black voids on t2w images, while the adjacent tissue, which is usually marrow fat in the normal subchondral bone, generates a signal that silhouettes the actual bone. bone trabeculae are very small and difficult to see. magnetic resonance imaging bme is present in many different conditions and is not disease specific, but it has a special significance in ra because it is not only an indicator of inflammation but a marker of bone pathology and future bone damage as well. evidence from clinical studies showed that synovitis (increased synovial thickness) is greater in joints where bme is present. it also showed that treatment with the anti-tnf agent, golimumab, decreased the crp (which is normally associated with therapeutic response); this decrease in crp runs parallel with reductions in synovitis and bme. these measures correlate strongly with each other and are often all found in the same joint; but evidence from further studies showed that the absence of bme made the formation of mri erosions highly unlikely over a period of 12 months. in the presence of bme; however, the likelihood that erosions would form was drastically increased. various groups in different studies have shown that bme is the strongest of conventional and imaging biomarkers for the prediction of erosive progression of ra.5 discussion modern treatment of the disease requires very early detection and rigid control of inflammatory arthritis. magnetic resonance imaging has increased sensitivity for detecting ra pathology over clinical examination and radiographs, and it can be used for the benefit of patients suffering from this disease. the exact role of mri in managing ra patients in clinical practice requires further research, especially regarding the determination of clinical algorithms for the use of mri, the role of mri imaging in monitoring existing ra and the understanding of how imaging can help to improve the cost-effectiveness of current biologic treatment regimens used in the management of ra.17 evidence from different clinical studies has shown that conventional radiography, us or mri can be used to confirm the diagnosis when clinical and laboratory data on their own are not enough. mri bme is a strong predictor of bone damage and can be used as a prognostic indicator in ra. inflammation detected by imaging may be a more accurate reflection of therapeutic response than the clinical measures used to monitor disease activity. mri and us can be used to monitor disease progression in patients with ra.8,9 clinical trials evaluating expensive therapies could use mri as an outcome measure allowing for shorter trials as mri changes are apparently much faster.4 in 2003, the outcome measures in rheumatoid arthritis clinical trials (omeract) group with the rheumatoid arthritis magnetic resonance imaging score (ramris) system established a highly reliable sum-score based on semi-quantitative rating of severity of synovitis, bone oedema, joint inflammation and erosions in the hands and wrist joints.6,15 according to the omeract group, synovitis is an area in the synovial compartment that shows above-normal enhancement after gadolinium contrast administration of a thickness greater than the width of the normal synovium. erosions are sharply delineated bone lesions that are located at the joint margins.3 the ramris system has been shown to be a useful, sensitive tool for the evaluation of therapy response in ra. rheumatoid arthritis magnetic resonance imaging score criteria use a sum-score of 23 joint sites of the hand, comprising metacarpophalangeal (mcp) joints two–five, carpo-metacarpophalangeal (cmc) joints one–five, intercarpal joints, radiocarpal joints and radioulnar joints; yielding the sum of individual joints subscore for synovitis, bme and erosions.18 schleich et al.18 conducted a study in january 2015 to evaluate inflammation and joint destruction of the dominant hand in patients with ra, using the modified ramris 5. this study was performed in germany. patients had mri scans at baseline and also had follow-up scans performed accordingly. on both occasions, 23 joints of the hands and five joints of the hand, respectively, were scored, and a comparison study was performed. assessment of the hands was performed using the ramris and ramris 5 simultaneously and graded according to bone oedema, erosions and synovitis. joints used in ramris 5 include mcp 2 and 3, capitate bone, triquetral bone and distal ulna for analysis of erosions and bone oedema. these are joints and bones that are commonly affected in ra. schleich et al. found that ramris 5 can be used in assessing inflammatory joint changes and therapy monitoring in patients affected with ra. rheumatoid arthritis magnetic resonance imaging score 5 has been found to be a time-and resource-saving technique and may have a role in routine clinical practice.18 studies have shown both mri and us to be highly sensitive in assessing the inflammation of joints.19,20 us; however, cannot image for bme, a strong indicator of future bone damage and disease progression.5 it may also fail to adequately assess some joint regions11 and is extremely operator dependent but has the advantage of being cheaper and more readily available and easily allows for intervention such as us-guided intra-articular injections. magnetic resonance imaging has the advantage of greater joint coverage and the detection of bme but is more expensive and less accessible in the resource-constrained environment. magnetic resonance imaging, therefore, has an important role to play in early diagnosis of ra, and patients may then be followed up by us for monitoring and treatment response, provided an experienced operator is available. this would prove cheaper, safer and more accessible. however, if us is equivocal or cannot reach the region of interest, then mri is advised.21 further research is needed to optimise the roles of these advanced imaging modalities in ra to provide cost-effective management of patients.16 conclusion conventional radiography has been the gold standard for imaging in ra for a long time, but the sensitivity for structural damage in the diagnosis of ra is low and disease activity cannot be assessed. despite these limitations, it remains a useful modality in routine clinical management of patients with ra. us and mri (especially contrast-enhanced mri) are rapidly becoming the imaging examinations of choice for the detection of early disease in patients because of increased sensitivity. newer imaging applications are useful to diagnose and monitor disease progression in ra in routine clinical practice. in resource-poor countries, these applications could potentially assist earlier diagnosis, when patients are more likely to respond to conventional therapies and could also help stratify subgroups of patients most likely to respond to expensive biologic therapies. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions k.k. was responsible for drafting of the article, made contribution to design and approved the final version to be published. m.m.t.m.a. was responsible for conception of the article, revising critically for intellectual content and approval of the final version to be published. m.c.d.b. was responsible for acquisition of images and revising critically for intellectual content and approval of the final version to be published. f.e.s. was responsible for drafting of the article, made contribution to design, acquisition of images and revising critically for intellectual content, and approved the final version to be published. references keenan rt, swearingen cj, yazici y, et al. erythrocyte sedimentation rate and c-reactive protein levels are poorly correlated with clinical measures of disease activity in rheumatoid arthritis, systemic lupus erythematosus and osteoarthritis patients. clin exp rheumatol. 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diagnostics of rheumatoid arthritis. bmc med [serial online]. 2014 [cited 2014 sept 12]. available from http://biomedcentral.com/1741-7015/12/49 xubin l, xia l, xiangke d, zhaoxiang y: diffusion-weighted mr imaging for assessing synovitis of wrist and hand in patients with rheumatoid arthritis: a feasibility study. j mri. 2014(32):350–353. noguerol tm, luna a, cabrera mg, riofrio ad. clinical applications of advanced magnetic resonance imaging for arthritis evaluation. world j orthop. 2017;8(9):660–673. https://doi.org/10.5312/wjo.v8.i9.660 mcqueen f, lassere m, edmonds j, et al. omeract rheumatoid arthritis magnetic resonance imaging studies. summary of omeract 6 mr imaging module. j rheumatol. 2003;30(6):1387–1392. mathew aj, danda d, conaghan pg. mri and ultrasound in rheumatoid arthritis. curr opin rheumatol. 2016; 28:323–329. https://doi.org/10.1097/bor.0000000000000282 cohen sb, potter h, deodhar a, emery p, conaghan p, østergaard m. extremity magnetic resonance imaging in rheumatoid arthritis: updated literature review. arthritis care res. 2014;63(5):660–665. https://doi.org/10.1002/acr.20413 schleich c, buchbender c, sewerin p, miese f, aissa j, brinks r. evaluation of a simplified version of the rheumatoid arthritis magnetic resonance imaging score (ramris) comprising 5 joints (ramris). clin exp rheumatol. 2015;33(2):209–215. brown ak, conaghan pg, karim z, et al. an explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. arthritis rheum. 2008;58(10):2958–2967. https://doi.org/10.1002/art.23945 gandjbakhch f, conaghan pg, ejbjerg b, et al. synovitis and osteitis are very frequent in rheumatoid arthritis clinical remission: results from an mri study of 294 patients in clinical remission or low disease activity state. j rheumatol. 2011;38(9):2039–2044. https://doi.org/10.3899/jrheum.110421 vyas s, bhalla as, ranjan p, kumar s, kumar u, gupta ak. rheumatoid arthritis revisited – advanced imaging review. pol j radiol. 2016;81:629–635. https://doi.org/10.12659/pjr.899317 abstract introduction research method and design ethical considerations results discussion limitations of the study conclusion acknowledgements references about the author(s) arno celliers department of diagnostic radiology, university of the free state, south africa fekade gebremariam department of pelonomi radiology, university of the free state, south africa gina joubert departement of biostatistics, university of the free state, south africa thami mweli dr sulman and partners, netcare rosebank hospital, south africa husain sayanvala locum radiologist, cape town, south africa louis holtzhausen department of sport and exercise medicine, university of the free state, south africa citation celliers a., gebremariam f., joubert g. et al. clinically relevant magnetic resonance imaging (mri) findings in elite swimmers’ shoulders. s afr j rad. 2017;21(1), a1080. https://doi.org/10.4102/sajr.v21i1.1080 original research clinically relevant magnetic resonance imaging (mri) findings in elite swimmers’ shoulders arno celliers, fekade gebremariam, gina joubert, thami mweli, husain sayanvala, louis holtzhausen received: 17 aug. 2016; accepted: 09 nov. 2016; published: 20 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: shoulder pain is the most common and well-documented site of musculoskeletal pain in elite swimmers. structural abnormalities on magnetic resonance imaging (mri) of elite swimmers’ symptomatic shoulders are common. little has been documented about the association between mri findings in the asymptomatic shoulder versus the symptomatic shoulder. objective: to assess clinically relevant mri findings in the shoulders of symptomatic and asymptomatic elite swimmers. method: twenty (aged 16–23 years) elite swimmers completed questionnaires on their swimming training, pain and shoulder function. mri of both shoulders (n = 40) were performed and all swimmers were given a standardised clinical shoulder examination. results: both shoulders of 11 male and 9 female elite swimmers (n = 40) were examined. eleven of the 40 shoulders were clinically symptomatic and 29 were asymptomatic. the most common clinical finding in both the symptomatic and asymptomatic shoulders was impingement during internal rotation, with impingement in 54.5% of the symptomatic shoulders and in 31.0% of the asymptomatic shoulders. the most common mri findings in the symptomatic and asymptomatic shoulders were supraspinatus tendinosis (45.5% vs. 20.7%), subacromial subdeltoid fluid (45.5% vs. 34.5%), increased signal in the ac joint (45.5% vs. 37.9%) and ac joint arthrosis (36.4% vs. 34.5%). thirty-nine (97.5%) of the shoulders showed abnormal mri features. conclusion: mri findings in the symptomatic and asymptomatic shoulders of young elite swimmers are similar and care should be taken when reporting shoulder mris in these athletes. asymptomatic shoulders demonstrate manifold mri abnormalities that may be radiologically significant but appear not to be clinically significant. introduction shoulder pain is the most common musculoskeletal complaint in competitive swimmers.1,2 competitive swimmers registered with the usa swimming national governing body average a distance of 60–80 km per week and 1.56 million overhead rotations per year.3 both the stroke volume and multiple overhead rotations place tremendous stresses on the rotator cuff and glenohumeral joint, eventually resulting in the ‘swimmer’s shoulder’.3,4 arthroscopic findings suggest that the term swimmer’s shoulder covers a variety of pathologies, including labral wearing and subacromial impingement.5 connor et al. hypothesised that asymptomatic dominant shoulders of elite overhead athletes may have a higher incidence of magnetic resonance imaging (mri) abnormalities than either their non-dominant shoulders or shoulders of asymptomatic volunteers.6 elite swimmers demonstrate mri changes of the shoulder similar to the imaging changes found on mris of persons with painful clinical syndromes.2 there seems to be limited information regarding mri findings in overhead athletes who are asymptomatic. it has been suggested that these findings may be unique to overhead athletes, and care must be taken to correlate clinical history and physical examination with mri findings in these patients with symptoms, as these changes might have been present premorbidly.2 therefore, symptoms should not necessarily be attributed to the mri changes. in a study by sein et al., 84% of the swimmers studied had a positive impingement sign and 69% of those demonstrated supraspinatus tendinopathy on mri. they concluded that supraspinatus tendinopathy was the major cause of shoulder pain in elite swimmers and this was induced by intensive swimming training.4 however, it was not possible to draw conclusions in the asymptomatic shoulders, as this portion of the studied group only constituted 9% of the total sample. fredericson et al. evaluated asymptomatic overhead athletes and all of the athletes studied had mri findings that could be considered abnormal, despite the fact that they were clinically asymptomatic.2 they concluded that mri changes could be interpreted as evidence of a previous subclinical injury unknown to the athlete and that perhaps accumulation of multiple micro traumas has an additive effect in the absence of a significant single injury.2 our study serves to underline the important message that findings on imaging always need to be correlated with symptoms, as radiological abnormalities often do not correspond with clinical problems. screening or pre-injury mri is rarely available for comparison when an athlete develops clinical symptoms. an improved understanding of the baseline signal changes in a pre-injury setting may lead to targeted injury-prevention training strategies.7 miniaci et al. advocated baseline shoulder mri for all baseball pitchers owing to the difficulty in interpreting signal changes in these athletes.7 improved understanding of subclinical or clinically irrelevant findings in the overhead athlete may decrease the number of unnecessary medical or surgical interventions. according to the researcher’s literature search, this study is one of the largest studies investigating both shoulders in the symptomatic as well as the asymptomatic elite swimming population (table 1). table 1: comparison with similar studies. research method and design for this cross-sectional study, the study population was voluntarily selected from the university of the free state’s swimming team located in bloemfontein, south africa. the clinical examinations were conducted at the department of sport and exercise medicine at the university of the free state and the imaging (mri) was done at the pelonomi regional hospital in bloemfontein. the sample included 20 volunteers, both male and female elite swimmers between the ages of 16 and 25 years, with symptomatic and asymptomatic shoulders. an elite swimmer was defined as a swimmer with the ability to perform a 100 m freestyle race at or faster than 75% of a national record swimming time.8 exclusion criteria were: previous shoulder surgery, previous fracture of the shoulder, inability or unwillingness to participate in the mri and clinical shoulder examination. none of the swimmers were excluded from the study. a standardised, self-administered swimming training questionnaire was completed by each study participant on the day of the mri study. descriptive characteristics were obtained for each swimmer using a standardised shoulder service questionnaire.4 items pertaining to the subject included age, gender, birth date, occupation, arm dominance (right, left or ambidextrous) and an overview of general health. clinical parameters of the shoulder condition included the affected shoulder (right, left or both), date of injury onset, mechanism of onset (whether traumatic or insidious). frequency and severity of the shoulder pain, stiffness of the shoulder, difficulty in reaching behind the back, difficulty with activities above the head, overall shoulder status, current level of activity and highest level of sport at the time of examination were obtained by the sports physician in the clinical shoulder questionnaire. all of the 20 participants (n = 40 shoulders) were examined clinically by a sports physician (m phil (sports medicine), university of cape town), with a special interest in the swimmer’s shoulder. the clinical examination included examination of shoulders (symptomatic and asymptomatic), rotator cuff tests, impingement tests, instability tests as well as evaluation for local tenderness (sternoclavicular joint, acromioclavicular joint, biceps, subacromial). the findings of these tests were recorded on a standardised clinical form. materials the mris were performed, using a magnetom aera 1.5-tesla mri scanner (siemens), utilising high-resolution technique with a dedicated shoulder coil in a standardised protocol with fixed sequence parameters (time of repetition, time of echo, slice thickness, matrix, field of view). procedure mri without arthrography was performed on both shoulders of all 20 participants (n = 40) with the arm placed in adduction and neutral rotation. the following sequences were performed: (1) coronal plane: t2-weighted fse and a pd fse sequence with fat saturation; (2) sagittal oblique plane: t2-weighted fse and a pd fse sequence with fat saturation; (3) axial plane: t2* gre and a pd fse sequence with fat saturation. the images were reviewed by three consultant radiologists, one with a musculoskeletal radiology subspecialty and two with experience in musculoskeletal radiology. the radiologists were blinded to grouping, dexterity, as well as clinical history and examination. their findings were documented on a standardised self-administered assessment form that was compiled from stoller’s textbook of mri in orthopaedics and sports medicine.9 the checklist consisted of 135 variables that had to be evaluated in the three different planes. there was some overlap in the different planes between the anatomical structures that had to be evaluated, and the findings of the same anatomical structures were collated in the statistical analysis of the data. the following anatomical structures had to be evaluated and commented on: coronal plane (1) rotator cuff, (2) ac joint, (3) biceps tendon (longhead), (4) labrum, (5) ighl, (6) glenohumeral joint cartilage, (7) osseous structures (humeral head, glenoid, scapula, suprascapular notch), (8) deltoid, (9) subacromial subdeltoid bursa; axial plane: (1) ac joint, (2) subscapularis and biceps tendon, (3) labrum, (4) joint capsule structures, (5) glenohumeral joint cartilage, (6) osseous structures (hill-sachs deformities, posterolateral humeral head, glenoid, coracoid process, spinoglenoid notch), (7) supraspinatus and infraspinatus tendons, (8) pectoralis major muscle and deltoid; sagittal oblique plane: (1) rotator cuff, (2) acromion, (3) ac joint, (4) rotator interval, biceps tendon, coracohumeral ligament and sghl, (5) glenoid fossa, (6) mghl,ighl, (7) subacromial subdeltoid bursa.9 for each item, a yes or no had to be indicated by the radiologists. for analysis, consensus between the radiologists was used (i.e. the answer given by two or more of the radiologists). analyses results were summarised by frequencies and percentages (categorical variables) and means, standard deviations or percentiles (numerical variables). statistical comparison of subgroups was done using fisher’s exact test owing to sparse cells. p-values of less than 0.05 were considered statistically significant. ethical considerations the study was conducted in accordance with the principles of the declaration of helsinki and good clinical practice guidelines.10 all participants signed an informed consent form and consent was obtained from legal guardians for participants younger than 18 years. the ethics committee of the faculty of health sciences, university of the free state approved the study, with ethical clearence number: ecufs nr 117/2014. results the demographics, symptoms and clinical examination were compared with the methods and questions as performed in a previous study evaluating elite swimmers.4 demographics of the swimmers eleven (55%) of the elite swimmers were male and 9 (45%) were female. the mean age was 18.9 years and all swimmers had been coached for at least 5 years, with a median time of 11.5 years. nineteen swimmers (95%) represented their country at an international level and one swimmer (5%) was competing at the national level. median training time spent on a specific stroke was 60% freestyle, 14% butterfly stroke, 12.5% backstroke and 20% breaststroke. the median time the swimmers practised in the water was 13.5 h/week (range: 3 h/week – 18 h/week) and the median distance swum was 40 km/week (range: 9 h/week – 60 km/week). clinical symptoms of the 40 shoulders studied, 11 (27.5%) were symptomatic. two swimmers (n = 4 shoulders) reported bilateral shoulder pain and 7 (n = 7 shoulders) reported unilateral shoulder pain. all 11 symptomatic shoulders were painful during activity (27.3% always, 18.2% daily, 27.3% weekly and 27.3% monthly). in 2 of the 11 symptomatic shoulders (18.8%), severe pain with activities above their head was stated. in 6 (54.6 %) of the 11 symptomatic shoulders, the complaint was that of a stiff shoulder (severe: 36.4%, moderate: 9.1%, mild: 9.1%). the participants with symptomatic shoulders (n = 11 shoulders) were asked to grade their shoulder pain into none, mild, moderate, severe or very severe. in five shoulders (45.5%), the self-assessed shoulder pain was found to be mild. all symptomatic shoulders (n = 11) received physiotherapy, 9 (81.8%) previously received corticosteroid injections and 8 (72.7%) previously received acupuncture. clinical examination of the shoulder of the 40 shoulders examined, the most common positive findings were: a positive impingement sign in internal rotation elicited with the hawkins-kennedy test (n = 15; 37.5%), positive o’ brien’s sign (n = 12; 30.0%), biceps tenderness (n = 11; 27.5%), as well as ac joint tenderness (n = 9; 22.5%). sternoclavicular tenderness (18.2% vs. 17.2%) was slightly more common in the symptomatic group. none of the shoulders demonstrated muscle wasting of the rotator cuff or supporting muscles. of the 11 symptomatic shoulders, one (9.1%) had reduced power of four out of five for rotator cuff strength testing, as well as mild anterior instability. none of the asymptomatic shoulders demonstrated loss of power or instability. details regarding the clinical examination findings in swimmers are shown in table 2. table 2: clinical examination findings. magnetic resonance imaging findings of the 29 asymptomatic shoulders studied, 25 (86.2%) had mri changes which could be viewed as abnormal. ten (91%) of the 11 symptomatic shoulders had abnormal mri findings. the most common mri findings (figures 1–3) in the symptomatic shoulders were supraspinatus partial tear (45.5% in symptomatic shoulders vs. 20.7% in asymptomatic shoulders), subacromial subdeltoid fluid (45.5% vs. 34.5%), increased signal in the ac joint (45.5% vs. 37.9%), supraspinatus tendinosis (36.4% vs. 10.3%) and ac joint arthrosis (36.4% vs. 34.5%). supraspinatus tendinosis (36.4% vs. 10.3%) and partial tear of the supraspinatus (45.5% vs. 20.7%) were much more common in the symptomatic shoulders compared with the asymptomatic shoulders. biceps tendinosis was common in both symptomatic and asymptomatic shoulders (18.2% vs. 6.9%). degeneration in the proximal bicipital groove (18.2% vs. 0%) was more common in the symptomatic population. thickening of the inferior glenohumeral ligament was more common in the asymptomatic shoulders (13.8% vs. 0.0%). increased signal of the labrum and labral tears were comparable in the two groups (10.0% vs. 10.3%). figure 1: magnetic resonance imaging findings in the rotator cuff. figure 2: magnetic resonance imaging findings in and around the ac joint. figure 3: magnetic resonance imaging findings in the joint capsule. twenty (50%) of the shoulders in this study (n = 40) had a positive impingement sign with the hawkins-kennedy impingement test. of these, 8 (72.7%) were clinically symptomatic shoulders (n = 11) and 12 (41.4%) were clinically asymptomatic shoulders (n = 29). in both groups, 25% of the shoulders had positive clinical signs of impingement that were correlated with mri features of supraspinatus tendinosis (2 of 8 asymptomatic, 3 of 12 symptomatic). in the clinically symptomatic group (n = 11), three (27.3%) shoulders tested negative for impingement but still demonstrated mri features consistent with supraspinatus tendinosis. in the clinically asymptomatic group (n = 29), 17 (58.6%) tested negative for impingement clinically, but only four of these (23.5%) demonstrated mri features consistent with supraspinatus tendinopathy. discussion shoulder pain in overhead athletes is a common problem owing to tremendous repetitive stresses.6 we examined elite swimmers clinically and with bilateral shoulder mri. most of these young elite swimmers aspire to compete at the senior international level. they spend on average 13.5 hours a week in the pool and swim an average of 40 km/week. the emphasis of the study was on differentiating clinically insignificant mri findings in elite athletes from those that are clinically and radiologically significant (figure 4). it is paramount to provide a baseline of what might be considered clinically irrelevant signal changes and findings in this population, in order to reduce further morbidity by limiting over-diagnosis and preventing unnecessary surgical interventions. miniaci et al. advocated baseline shoulder mri for all baseball pitchers owing to the difficulty in interpreting signal changes in these athletes.7 figure 4: summary of the most common magnetic resonance imaging findings. we aimed to evaluate the overlap of mri findings in the symptomatic and asymptomatic shoulders in order to elucidate the fact that asymptomatic shoulders may demonstrate manifold mri abnormalities that may be radiologically significant but appear not to be clinically significant. of the asymptomatic shoulders studied, 86.2% had mri changes which could be viewed as abnormal. this corresponds to previous studies that showed that mri abnormalities in asymptomatic overhead athletes are common.2,4,11 the most common findings in both the symptomatic and asymptomatic shoulders were subacromial subdeltoid fluid (figure 5), increased signal at the ac joint (figure 6), ac joint arthrosis, supraspinatus tendinosis (figure 7) and biceps tendinosis (figure 8). there were 11 symptomatic shoulders in our sample group with the most common clinical findings being impingement, ac joint tenderness, positive o’ brien’s sign and biceps tenderness. the asymptomatic group also demonstrated positive clinical findings, with subacromial impingement, biceps tenderness and sternoclavicular tenderness being the most common findings. ac joint tenderness was less common in the asymptomatic group. the studied group consisted of a slightly smaller symptomatic group than sein et al., but our athletes more frequently demonstrated local ac joint tenderness and positive o’brien’s sign. increased signal at the ac joint is a common finding in both the symptomatic and asymptomatic shoulders of overhead athletes and does not correlate with patient symptomatology as also noted in agreement with reuter et al.12 in this study, type 1 acromion shape was most common followed by type 2 and type 3. there was no direct correlation between shoulder pain and acromion shape. figure 5: subacromial subdeltoid fluid in the asymptomatic dominant shoulder of a 16-year-old swimmer. figure 6: increased signal in the ac joint in the asymptomatic non-dominant shoulder of a 17-year-old swimmer. figure 7: supraspinatus tendinosis in the asymptomatic non-dominant shoulder of a 19-year-old swimmer. figure 8: fluid in the bicipital groove in the asymptomatic dominant shoulder of a 17-year-old swimmer. supraspinatus tendinopathy was a common finding in both the symptomatic and asymptomatic shoulders, with it being nearly twice as common in the symptomatic shoulders. previous studies also found supraspinatus tendinopathy to be a dominant finding.4 biceps tendinosis was approximately twice as common in the symptomatic shoulder. connor et al. showed that subacromial subdeltoid fluid was a common finding in the asymptomatic shoulder.6 this study demonstrated similar results with subacromial and/or subdeltoid fluid found in 34.5% of the asymptomatic shoulders. in a study where reuter et al. evaluated shoulder mri changes in 23 triathletes, 57% of the asymptomatic group and 31% of the symptomatic group demonstrated ac joint arthrosis.12 the current study demonstrated nearly equal percentages of ac joint arthrosis (36.4% symptomatic vs. 34.5% asymptomatic). most of our findings correlate with previous studies done, demonstrating multiple abnormal mri signal changes in the asymptomatic shoulder.4,11 limitations of the study the majority of the studied population was from the same training facility with the same coaching staff. therefore, the analysis may suffer from sampling errors related to local factors and/or the fact that clinical symptoms were based on subjective self-reporting. the study sample consists of volunteers; therefore, there is a lack of randomisation. another limitation is that previous studies7 referred to the possibility that owing to the young age of the athletes, some of the observed mri findings might become symptomatic later in their professional career. further studies with long-term follow-up are required. mri was done without arthrography as complications could not be justified. therefore, there is no arthroscopic correlation with mri findings. another possible limitation is that the study did not make use of t1w mr sequences. sequences used were derived from stoller textbook of muskulosceletal mri, which did not include t1w sequences. although it is not essential for this study, t1w sequences may be utilised in future studies. conclusion the importance of this study lies in the fact that supraspinatus abnormalities on mri are common in asymptomatic shoulders. asymptomatic shoulders demonstrate manifold mri abnormalities that may be radiologically significant but appear not to be clinically significant. the researcher suggests a pre-season baseline mri for all elite swimmers with follow-up imaging if supraspinatus pathology was identified on the baseline mri. an improved understanding of the baseline signal changes in a pre-injury setting may lead to targeted injury-prevention training strategies. improved understanding of subclinical or clinically irrelevant findings in this population may lead to avoidance of unnecessary medical or surgical intervention. acknowledgements the authors would like to thank melvin, sam and joshua for performing the imaging. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions f.g. was the project leader and a.c. was the lead author. g.j. made conceptual contributions and did the biostatistical analysis. l.h. performed the clinical examinations and also made conceptual contributions. h.s. and t.m. identified the necessity for this research analysis and assisted in the finalisation of this article. references bak k. the practical management of swimmer’s painful shoulder: etiology, diagnosis, and treatment. clin j sport med. 2010;20(5):386–390. http://doi.org/10.1097/jsm.0b013e3181f205fa fredericson m, ho c, waite b, jennings f, peterson j, williams c, et al. magnetic resonance imaging abnormalities in the shoulder and wrist joints of asymptomatic elite athletes. pm r. 2009;1(2):107–116. available from: http://www.sciencedirect.com/science/article/pii/s193414820800018x heinlein sa, cosgarea aj. biomechanical considerations in the competitive swimmer’s shoulder. sports health. 2010 ;2(6):519–525. available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3438875&tool=pmcentrez&rendertype=abstract sein ml, walton j, linklater j, et al. shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. br j sports med. 2010;44(2):105–113. http://dx.doi.org/10.1136/bjsm.2008.047282 brushøj c, bak k, johannsen hv, faunø p. swimmers’ painful shoulder arthroscopic findings and return rate to sports. scand j med sci sports. 2007;17(4):373–377. available from: http://www.ncbi.nlm.nih.gov/pubmed/16805785 connor pm, banks dm, tyson ab, coumas js, d’alessandro df. magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. am j sports med. 2003;31(5):724–727. miniaci a, mascia at, salonen dc, becker ej. magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. am j sports med. 2002;30(1):66–73. aujouannet ya, bonifazi m, hintzy f, vuillerme n, rouard ah. effects of a high-intensity swim test on kinematic parameters in high-level athletes. appl physiol nutr metab. 2006;31(1975):150–158. http://dx.doi.org/10.1139/h05-012 stoller dw. magnetic resonance imaging in orthopaedics and sports medicine. philadelphia, pa: lippincott williams & wilkins; 2007. world medical association. declaration of helsinki – ethical principles for medical research involving human subjects [homepage on the internet]. 2013 [cited 2015 dec 7]. available from: http://www.wma.net/en/30publications/10policies/b3/ klein m, tarantino i, warschkow r, et al. specific shoulder pathoanatomy in semiprofessional water polo players: a magnetic resonance imaging study. orthop j sport med. 2014;2:1–6. http://dx.doi.org/10.1177/2325967114531213 reuter rm, hiller wd, ainge gr, et al. ironman triathletes: mri assessment of the shoulder. skeletal radiol. 2008;37(8):737–741. http://dx.doi.org/10.1007/s00256-008-0516-6 editorial quality assurance in radiology q uality assurance can be defined as providing a service to the patient that meets certain acceptable professional standards. the concept of quality assurance (qa) is not new. it was introduced into japan after the second world war and the culture of qa has spread globally into most service industries including medicine. radiology is well suited to the concept of qa. we provide the patient and referring doctor with a service. the quality of the service can be measured objectively and can be compared with set standards that have been established by professional bodies. such standards have been developed by the royal college of radiologists of the uk, the australasian college of radiologists and the american college of radiologists. in south africa, alan scher and stuart whittaker of the council for health services accreditation of southern africa (cohsasa) have developed local standards for radiology departments. these standards encompass radiation protection, patient data and image storage, resuscitation equipment, radiological equipment and staff training. cohsasa identifies departments which meet these set standards and provides certificates of quality service. petercorr mbchb, ffrad(d)sa, frcr, mmed(uc7) department of radiology, university of natal 3 sajournal of radiology. may 1996 why is qa important to the practising radiologist? certification of a department will probably be a future requirement in all hmo contracts. certification will also provide patients with information concerning the standard of radiological practice for a particular department. presently cohsasa is assessing a number of private and public hospitals in south africa. if a department does not meet minimum standards cohsasa will provide advice on how to improve the quality of service. the concept is good with benefits for both the radiologist and patient. i would encourage you to take up this opportunity to apply for cohsasa certification. the radiological society and co hsasa will gladly provide you with further details on how to apply. the editor case report ectopic lingual thyroid the role of imaging abstract ectopic thyroid tissue may be found throughout the migration course of the thyroid gland. thyroid ectopy may be partial or total. the most common location of ectopic thyroid tissue is in the tongue base ( lingual thyroid). we discuss the computed tomography (ct) and radioisotope findings of a patient with ectopic lingual thyroid. case report a jl-year-old female presented with a history of feeling of a lump in the throat, but no dysphagia. clinically a reddish lobulated soft tissue mass was seen at the base of the tongue. the patient was euthyroid. a clinical diagnosis of lingual thyroid was made. five x smm axial unenhanced and enhanced ct scans, of the neck and upper mediastinum, and coronals x srnrn enhanced ct scansof the nasopharynx and tongue base were performed on a general electric hi-speed advantage ct scanner. ninety mliohexol 240 was administered intravenously as a bolus using a power injector at 2 rnljsec . technetium radioisotope (2.5 m citc04) scan using a pieker prism 2000 hp gamma j kew ffrad (d)sa. a ahuja frcr, p scott frcs (otol)* departments of diagnostic radiology and organ imaging and *otorhlnolaryngology, prince of wales hospital, sneun, hong kong 26 sajournal of radiology. november 1996 camera was also performed. a homogenous hyperdense enhancing lobular mass, measuring 2.5 x 2 x 2cm, was noted at the base of the tongue and another lesion,measuring2x 1,sx 1,scmwas also noted anterior to the hyoid bone (figures 1-3). bilobular thyroid tissue was confirmed in the figure 2: axial enhanced ct scan demonstrating the intense enhancement of the lingual thyroid (arrow). topage 27 ectopic lingual thyroidthe role of imaging from page 26 thyroglossal duct. it is believed that this migration is achieved through the development of the body of the embryo caudad, and the cephalic progression of the tongue and pharynx. early in the fifth week, the thyroglossal duct loses its lumen, while the foramen caecum remains at the tongue base the descent of the thyroid gland along the thyroglossal tract follows a vertical line in close contact but anterior to the hyoid bone and ends at the level of the upper trachea,leaving in 50% of cases, a midline pyrarnidallobe. it is easy to understand thyroid ectopy as a defective descent of the gland. total thyroid ectopy may be observed at various levels,suprahyoid location -lingual or sublingual, andinfrahyoid location, prelaryngeal.' lingual thyroid isthe most frequently encountered anomaly; accounting for approximately 90% of cases of total thyroidectopy/ in 70-80% oflingual thyroid cases, the ectopic tissue is the only existing thyroid tissue. the presence of a hypertrophied ectopic thyroid gland may be asymptomatic or cause dysphonia and relative obstruction of the upper respiratory and rr======='t7l0;'pr======ïl gastrointestinal tracts. 3 the frequency is estimatedtobe 1/4cxx)4 -l/loocxx).5thepathologicalcondition develops most often between the third and fifth decade and there is a female predominance (7: 1) .4,6 partial thyroid ectopy; that is,ectopic tissue in the presence of a thyroid gland in its normal position may appear at various levels namely; suprahyoid location lingual or sublingual, andinfrahyroid location -prelaryngeal, intra-tracheal, intra-oesophageal or intrathoradc. complications include cardnoma (3% papillary), but there isno increased incidence compared to normally positioned thyroid tissue. 6 1.....--' the differential diagnosis ofa mass located in the foramen caecum area at the tongue base would include adenoma, thyroglossal cyst, angiomas, fibromas, chondromas, lymphangiomas, epithelioma, squamous cell carcinoma, adenoid cystic carcinoma, lymphoma and lymphosarcoma. 6 irregular or inhomogenous contrast enhancement on cr figure 3: axial enhanced ct scan showing ectopic thyroid tissue (arrow) anterior to the hyoid bone (arrowhead). sublingual area on scintigraphy (figure 4). no thyroid tissue was noted at the level of the thyroid cartilage or in the superior mediastinum on cr scan or sdntigraphy. diagnosis: ectopic lingual thyroid. an figure 4: right lateral view of the thyroid tc 04 scintigram demonstrating the ectopic thyroid tissue in the sublingual region (arrows). the asterix denotes the symphysis menti. discussion the thyroid primordium appears at the end of the third gestational week as a midline endodermic swelling in the ventral wall of the pharynx. itpenetrates the underlying mescxlerm and starts its descent, connected to the tongue by a narrow epithelial channel, the sa journal of radiology· november 1996 would be expected in some of these lesions, and confusion with lingual thyroid could occur. the diagnosis of a lingual thyroid however can be confumedbythyroidisotopescanning (technetium oriodine-l23). scintigraphy is useful to confirm the presence of thyroid tissue, to assess other sites of ectopic thyroid tissue, and whether the ectopic tissue is the only thyroid tissue present. it does not however have the spatial resolution of cr or mri scanning, which can delineate the anatomical relations more predsely. ultrasound may be used to evaluate the neck for ectopic thyroid tissue .a suspected lingualthyroid maybe seen as a softtissue mass at the base of the tongue with parenchymal characteristics similar to that of thyroid seen on ultrasound. 7 however, further confirmatory tests, e.g. scintigraphy may need to be done. summary ectopic lingual thyroid is a congenital anomaly caused by failure of migration of the thyroid gland from the embryological pharyngeal position to its usual location in the lower neck. the commonest location of ectopic thyroid is in the tongue base the diagnosis is usually made clinically;with radiology;usually thyroid radioisotope scan, as a confirmatory test. crscanandmriareusefulin delineatingthe anatomical relations. references 1 werz ml. management of the undescended lingual and subhyoidglands laryn~srope 1974;84:507-521 2 weider oj, parker w. lingual thyroid. all! orol 1977;86:84 1848 3 montgomery ml. lingual thyroid: a comprehensive review. west f suig i936;44:442-446. 4. larochelle d, arcand p,belzile m, gagnon nb. e topic thyroid ti ue 3 review of the literature. f otola1)n11979;8[6]:523530 5 haddad a, freinkel s, costom b, shapiro r, tewftkt. management of the undescended thyroid. j otolaryngol 1006;15[6]373-376 6. elprana d, manni jj, smalsagh. lingual thyroid: case report and review of the literature. ort otorhinolaryngol relat sju; 1984;46: 147-152 7 gaines pa, ahuja a, metreweli c. radiological case of the season. congenital conditions of the thyroid. loumol of the hong klmgmedicalassociation 1990;42,[3]: 152-153. radiology_aug04 original article 24 sa journal of radiology • august 2004 abstract this study determined the correlation between radiation doses absorbed by health care workers and dose area product meter (dap) measurements at universitas hospital, bloemfontein. the dap is an instrument which accurately measures the radiation emitted from the source. the study included the interventional radiologists, radiographers and nurses associated with radiological intervention procedures during the period 1 august 2003 31 august 2003. the amount of radiation produced during every procedure was measured by a dose area product meter (dap) and routinely recorded. the absorbed doses received by health care workers were measured using a thermoluminescent dose meter (tld). the tlds were analysed and recorded at the end of each week. health care workers wore tlds on the following areas: forehead, thyroid (attached under thyroid guard), and abdomen (worn under lead jacket). a strong positive correlation (r = 0.9, p = 0.0374) was found between the radiographers’ head tld and dap meter readings. all other correlations between tld and dap readings were not statistically significant. strong positive correlations were found between the tld readings of the radiologists’ and nurses’ bodies, the nurses’ and radiographers’ bodies and the radiologists’ and the radiographers’ bodies, all of which were statistically significant. introduction interventional radiology is often the preferred treatment procedure, but is associated with a certain amount of radiation to the health care workers performing the procedure.1 the resulting health care worker concern for the risk of ionising radiation has prompted research into radiological procedures2 and is of importance to the hospital radiation protection sections.3 fluoroscopic procedures are the main source of radiation because high scatter levels are emitted and the body does not uniformly absorb the doses. the head and limbs receive higher doses because a lead jacket protects the body. the yearly effective dose received by interventional radiologists is approximately equal to the natural background effective dose (average 3m sv), but may be higher.4 except for the thyroid, the lead jacket protects all or a portion of the 12 organs and tissue the international commission on radiological protection determined as most sensitive to radiation. the use of a thyroid guard also decreases the effective dose by approximately a factor of 2.5 health care workers may receive primary and secondary radiation. primary radiation refers to when any body part is placed directly in front of the x-ray and secondary radiation refers to radiation received from ray scatter from the patient or x-ray tube leakage.6 adequate training, procedure optimisation and use and availability of protective measures all contribute to decreasing radiation doses received by health care workers.3 do dose area product meter measurements reflect radiation doses absorbed by health care workers? r raubenheimer b spangenberg g van jaarsveld a koller c de vries mmedrad (d) department of diagnostic radiology university of the free state bloemfontein c p herbst phd c a willemse phd department of medical physics university of the free state bloemfontein g joubert ba, msc department of biostatistics university of the free state bloemfontein regular monitoring of professional radiation is necessary. thermoluminescent dosimetry is used to measure radiation and the apparatus is placed on various parts of the body, namely under the lead jacket to determine radiation on the entire body, on the shoulder or thyroid guard, and on the hand.7 radiologists receive larger radiation doses during abdominal studies than during cerebral studies, even though the average fluoroscopic time is longer for cerebral angiography. this may be because of the increased diffraction from the patient tissue and the shorter distance between the radiologist and the x-ray tube during abdominal studies. the radiologist’s hands receive the highest absorbed dose with an average of 7.1 mrad for cerebral angiography and 39.9 mrad for abdominal and peripheral vascular angiography. the thyroid absorbs the second highest dose.5 during cerebral arteriography, health care workers wear lead jackets and the radiation monitor is often placed beneath the jacket. radiosensitive areas such as the eyes, thyroid and hands are not protected against radiation and are seldom monitored. tryhus et al.8 found that during cerebral angiograms the radiographer and technician received respectively 3 mrem and 2 mrem radiation doses on areas not covered by the lead jacket. the dosage received is much lower than the maximum radiation dose of 5.0 rem. the patient, however, received much higher doses, with radiation near the eyes measuring 20 rem with the maximum recommended dose being 0.5 rem.8 the dose area product (dap) meter is an instrument mounted on the x-ray tube, which accurately measures the radiation emitted from the source after calibration. this study determined the correlation between radiation doses absorbed by health care workers and dap measurements at universitas hospital, bloemfontein. if strong correlations exist, health care workers’ radiation exposure could be derived from the dap readings. methods the study included the interventional radiologists, radiographers and nurses associated with radiological intervention procedures that took place from 1 august 2003 to 31 august 2003 at universitas hospital, bloemfontein. the amount of radiation produced during every procedure was measured by a dap (ptv dianometer m2 model) and routinely recorded. the absorbed doses received by health care workers were measured using a thermoluminescent dose (tld) meter. health care workers wore tlds on the following areas: forehead (worn around head with specially designed headband), thyroid (attached under thyroid guard), and abdomen (worn under lead jacket). the respective health care workers’ tlds were colour coded to enable identification. the tlds were analysed and recorded at the end of every week. per week, three tlds were used for calibration and three tlds measured background radiation in the storage place. radiation was measured in cgy and cgycm2 for the tld and dap meters, respectively. the tld and dap readings that were recorded per week represent all the procedures that took place at the interventional unit during the week. the following spearman’s rank correlations were calculated: dap meter readings and tld meter reading for each health care worker’s body area (head, thyroid and body); and tld head, thyroid and body readings compared between radiologist, nurse and radiographer. results the correlation between the dap and radiologists’ tld readings are given in table i and fig. 1. there was a positive correlation between the dap and tld head reading, a negative correlation with tld thyroid reading, and no correlation with the tld body reading. no correlation was statistically significant. the correlation between the dap and radiographers’ tld readings are given in table i and fig. 2. there was a original article 25 sa journal of radiology • august 2004 table i. correlation between tld and dap readings health care worker area correlation coefficient p-value radiologist head 0.7 0.1881 thyroid -0.7 0.1881 body -0.2 0.7471 radiographer head 0.9 0.0374 thyroid 0.4 0.5046 body -0.2 0.7471 nurse head 0.3 0.6238 thyroid 0.2 0.7471 body -0.4 0.5046 statistically significant positive correlation between the dap and tld head reading, no correlation with tld body reading, and a positive correlation with the tld thyroid reading. the correlation between the dap and nurses’ tld readings are given in table i and fig. 3. there was a positive correlation between the dap and tld head reading, a negative correlation with tld body reading, and no correlation with the tld thyroid reading. no correlation was statistically significant. the correlations between the doses absorbed by the radiologists, radiographers and nurses are given in table ii. although not statistically significant, a positive correlation was found between the tld readings of the radiologists’ and nurses’ heads, as well as between the radiologists’ and radiographers’ heads. no correlation was found between the tld readings of the radiographers’ and nurses’ heads. a negative correlation coefficient was found between the radiologists’ and nurses’ tld thyroid readings, but there was a positive correlation between those of the radiographers and nurses, and no correlation between those of the radiologists and radiographers. a strong positive correlation was found between the tld readings of the radiologists’ and nurses’ bodies, the nurses’ and radiographers’ bodies, as well as the radiologists’ and the radiographers’ bodies, all of which were statistically significant. discussion a positive correlation indicates that an increase in the dap reading is reflected by an increase in the tld reading. the radiologist stands nearest to the dap meter during each procedure and receives a large amount of scattered radiation. the correlation is not statistically significant, possibly because the radiologist’s head is moving constantly and each radiologist has a different physical build, which will result in a variable radiation reading. a negative correlation indicates an increased dap reading, but a decreased tld reading. the radiologist’s body is covered with a lead jacket and by the table, both of which will absorb radiation. the height of the table and the radiologist’s physical build also determine whether the tld is situated under the table. the radiologist may move around during the procedure. these factors would influence the amount of radiation that reaches the tld. the significant correlation between the dap and radiographer’s tld head reading may be because the radiographer’s head is not protected and he/she is more static than the nurse or the radiologist. the radiographer sits or stands at the bottom end of the patient, wears lead jackets and is shielded by the table, which may explain the poor correlation between the dap and radiographer’s tld original article 26 sa journal of radiology • august 2004 fig. 1. correlation between the dap meter and radiologists’ tld meter readings. fig. 2. correlation between the dap meter and radiographers’ tld meter readings. fig. 3. correlation between the dap meter and nurses’ tld meter readings. body reading. the sitting position and the radiographer’s physical build would also influence the reading. an ineffective thyroid guard, openings on the side of incorrectly fastened guards, and the radiographer’s physical build all contribute to variable tld thyroid readings. the nurse moves around or sits during procedures. as a result the radiation may have moved through the patient, bed and lead jacket before a reading is registered. the tld meter receives scattered radiation whereas the dap meter receives direct radiation escaping from the apparatus. the tld body readings of the radiologists, radiographers and nurses showed a strong correlation. the radiation only reaches the tld meter after passing through other members, the patient, bed, equipment and lead jacket. conclusion the only statistically significant correlation between the dap and tld readings was that of the positive correlation between the radiographer’s head tld and dap meter reading. it is not possible to determine health care worker radiation from the dap reading because of the general lack of correlation between the dap and tld readings. references 1. thomson kr. interventional radiology. lancet 1997; 350: 354-358. 2. janssen rjjn, hadders rh, henkelman ms, bos ajj. exposure to operating staff during cardiac catheterisation measured by thermoluminescence. radiation protection dosimetry 1992; 43: 175-177. 3. vano e, gonzalez l, guibelalde e, fernandez jm, ten ji. radiation exposure to medical staff in interventional and cardiac radiology. br j radiol 1998; 71: 954-960. 4. mcewan ac. the unscear 2000 report cited 15 april 2003. available from: http://www.arps.org.au/unscear2000.htm 5. niklason lt, marx mv, chan hp. interventional radiologists: occupational radiation doses and risks. radiology 1993; 187: 729-733. 6. mcparland bj, nosil j, burry b. a survey of the radiation exposures received by the staff at two cardiac catheterization laboratories. br j radiol 1990; 63: 885-888. 7. marshall nw, noble j, faulkner k. patient and staff dosimetry in neuroradiological procedures. br j radiol 1995; 68: 495-501. 8. tryhus m, mettler fa jr, kelsey c. the radiologist and angiographic procedures. absorbed radiation dose. invest radiol 1987; 22: 747-750. original article 27 sa journal of radiology • august 2004 table ii. correlations between the doses absorbed by the radiologists, radiographers and nurses area comparison correlation coefficient p-value head radiologist with nurse 0.3 0.6238 radiologist with radiographer 0.4 0.5046 nurse with radiographer 0 1.000 thyroid radiologist with nurse -0.3 0.6238 radiologist with radiographer 0.1 0.8729 nurse with radiographer 0.6 0.2848 body radiologist with nurse 0.9 0.0374 radiologist with radiographer 1.0 < 0.0001 nurse with radiographer 0.9 0.0374 case report the subvesical duct of luschka a source of bile leakage following gallbladder removal ian c duncan ffrad(d)sa basil j sher fcrad(d)sa sunninghili medical institute sandton abstract we describe a case of bile leakage following laparoscopic cholecystectomy further complicated by iatrogenic central bile duct obstruction. the site ofleakage was identified not from the site of the inadvertent proper hepatic duct ligation but from a damaged aberrant subvesical duct communicating with the gallbladder fossa. the anatomy of these subvesical ducts is explained as is their surgical importance with relation to the aetiology of bil~ leaks after cholecystectomy. introduction bileleaks are recognised complications following cholecystectomy or other hepatobiliary surgery. they can result from direct trauma to a duct or from an anastomotic or cystic duct remnant leakage. the presence of an aberrant bile duct leak may make the radiological detection of the presence and site of the leakage more difficult.i one such example involves the subvesical duct of luschka. case report a 3d-year-old woman presented 1 week after laparoscopic cholecystectomy with jaundice, upper abdominal pain and abdominal distension. a provisional diagnosis of bile duct injury was made. abdominal ultrasonography showed fluid in the gallbladder fossa and subhepatic space (fig. 1) and a large volume of free intraperitoneal fluid. the intrahepatic bile ducts were not dilated. an abdominal mr scan was performed which again showed the fluid fig. 1. axial upper abdominal ultrasound scan showing fluid in the gal/bladder fossa and no dilation of the intrahepatic bile ducts. 44 sa journal of radiology • june 2003 fig. 2. axial t2 mr scan through the lower liver again shows fluid in the gal/bladder fossa as wei/ as the large volume of free intraperitoneal fluid particularly around the right hepatic lobe. in the gallbladder fossa and peritoneal cavity (fig. 2). a mr cholangiogram was attempted to try and show continuity between the right and left main hepatic bile ducts and although the proper hepatic duct was shown to be occluded, no definite answer could be given concerning the existence of free communication between the right and left hepatic ducts or about the site of the bile leakage (fig. 3). fig. 3. mr cholangiogram showing the gal/bladder fossa and free fluid in the subhepatic space. although the intrahepatic ducts are seen, continuity between the hepatic ducts across the confluence cannot be confirmed. the proper hepatic duct is not visualised. these studies were followed by percutaneous transhepatic cholangiography (ptc). this was performed from a left sided approach due to the large volume of perihepatic free fluid around the right lobe, also preempting possible conversion of the case report procedure into a percutaneous drain insertion. during the contrast injection leakage of contrast from a ductlike structure communicating with the anterio-inferior segmental duct (segment 5) and running inferiorly towards the gallbladder fossa was noted (fig. 4). the contrast accumulated progressively in the gallbladder fossa and subhepatic space (fig. 5). this aberrant duct was identified as the subvesical duct of luschka. also fig. 4. percutaneous transhepatle cholangiogram showing leakage of contrast via the damaged subvesical duct of luschka communicating between the anterioinferior segmental duct and the gallbladder fossa. fig. 5. further contrast injection confirms communication between the right and left hepatic ducts with obstruction at the duct confluence. the presence of a clip at this point indicates inadvertent surgical ligation. there is further accumulation of contrast in the subhepatic space. identified was total occlusion of the proper hepatic duct at the confluence of the right and left hepatic ducts but with free communication between the two ducts. a surgical clip was seen at the level of the obstruction confirming an iatrogenic injury. no contrast leak was seen from the site of this obstruction. an external drain was placed into the hepatic duct system via a second more peripheral left-sided access. two days later a choledochojejunostomy was performed by anastomosing a raux: loop to the bile duct confluence. the opening at the subvesical duct was also oversewn at the same time so as to avoid further bile leakage. discussion there are a large number of congenital variants of the intrahepatic and extrahepatic bile ducts" all of which are related to the complex embryological development of the biliary tree. they are seen in up to 42 47% of cases. anomalous or aberrant bile ducts are seen in around 28% of cases.' these ducts are often erroneously referred to as 'accessory' ducts. however they provide the sole path of bile drainage from normal areas of the liver with which they are associated and are more correctly termed 'anomalous' or 'aberrant' ducts. the cholecystohepatic or subvesical duct is a small aberrant intrallepat ic duct that runs close to the wall of the gallbladder just below the surface of the liver in the gallbladder fossa. the original description of this duct was by luschka and it is thus often referred to as 'luschka's duct'. occasionally the subvesical duct may extend into the wall of the gallbladder, but almost never communicates with 45 sa journal of radiology • june 2003 the gallbladder lumen (although it probably did during embryological development). it is present in between 15% and 35% of cases." these ducts drain an area of the inferior right lobe in the vicinity of the gallbladder fossa usually into a segmental tributary of the right hepatic duct, less commonly into the right hepatic duct itself or more rarely into the cystic or common hepatic ducts. these ducts are small, being 1 2 mm in diameter and are typically not accompanied by a portal venous branch. they are usually not seen at cholangiography, particularly mr cholangiography. the greatest clinical significance attached to the presence of these ducts is that they may be damaged during cholecystectomy, whether open or laparoscopic, as the gallbladder is dissected away from its bed." this can then result in a bile leak into the gallbladder bed and subhepatic space. this leak is often limited in extent but many result in the leakage of a considerable volume of bile, as in our case. postoperative bile leaks can occur due to direct duct trauma at a number of sites other than the subvesical duct often related to the presence of other aberrant bile duct variations. i leaks can also occur from a hepaticojejunal anastomosis, common bile duct-tocommon bile duct anastomosis, hepatic resection site or leakage from a ligated cystic duct remnant. postoperative bile leaks, regardless of their site, usually respond well to bile drainage. this can be done internally by placement of a bile duct stent or externally by percutaneous transhepatic biliary drainage.' , radiologists involved in the inves.tigation of bile leakage following cholecystectomy should therefore be aware of the presence of the subvesical case report duct as potential source of bile leakage into the gallbladder fossa. the preferred method of investigation is percutaneous transhepatic cholangiography, particularly as this can then be followed immediately by percutaneous biliary drain insertion to allow external bile diversion thereby facilitating closure of the leak. references 1. suhocki pv;meyers wc. injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. afr 1999; 172: 955-959. 2. healey je, schroy pc. anatomy of the biliary ducts within the human liver: analysis of the prevailing patterns ofbranchings and the major variations of the biliary ducts. arch surg 1953; 66: 599-616. 3. hayes ma, goldenberg is, bishop cc. the development basis for bile duct anomalies. surg gynaecol obstet 1958; 107: 447-456. 4. goor da, ebert pa. anomalies of the biliary tree. arch surg 1972; 104: 302-309. 5. ernest 0, sergent g, mizrahi d, delernazure 0, [hermine c. biliary leaks: treatment by means of percutaneous transhepatic biliary drainage. radiology 1999; 211: 345-348. 46 sa journal of radiology • june 2003 letter letter to the editor chest radiograph: 'let the reader beware' to the editor: enclosed is a photograph of a plain film chest radiograph showing a small metallic skull and crossbones projected over the left clavicle and into the left upper upper lung field (fig. 1). the skull and crossbones are due to a small metal charm worn around the neck of the patient, with the clasp of the necklace also visible. i have entitled the photograph: 'let the reader beware: as a general reminder of the need for eternal vigilance in our profession. i enjoyed ian duncan's 'the ghost in the machine' in the june 2003 issue of the sa]r. i feel that such 'pictorial interludes' or photo pages add interest to journals. i am not sure why the necklace was not removed prior to the x-ray being taken. our radiographers are well aware of the need to remove radioopaque items, but do not press patients to remove items from their persons where patients are reluctant to do so (unless it is found that the item specifically obscures an area of interest). the chest radiograph shows an old fracture of the right clavicle and streaky opacification adjacent to the right hilum. sputum culture from the patient was positive for tuberculosis. donemby anglogold health services western deep levels hospital western levels 31 sa journal of radiology • november 2003 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) beom jun lee department of surgery, southland hospital, new zealand ahmed o. a. krim department of radiology, southland hospital, new zealand paul samson department of surgery, southland hospital, new zealand citation lee bj, krim aoa, samson p. first presentation of crohn’s disease complicated with hepatic portal venous gas and pylephlebitis. s afr j rad. 2017;21(1), a1212. https://doi.org/10.4102/sajr.v21i1.1212 case report first presentation of crohn’s disease complicated with hepatic portal venous gas and pylephlebitis beom jun lee, ahmed o. a. krim, paul samson received: 10 may 2017; accepted: 28 july 2017; published: 02 oct. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the authors present a rare case where radiological findings provided an important diagnostic and prognostic role in a surgical patient with abdominal sepsis. the case in interest describes an extremely rare surgical complication of intestinal crohn’s disease (cd), namely, pylephlebitis and hepatic portal venous gas (hpvg). key radiological findings and their clinical significance are described to further add to the limited published data available on cd with pylephlebitis and hpvg. introduction pylephlebitis, a condition characterised by suppurative thrombosis of the portal vein or its branches, is an extremely rare and often fatal complication of infections in gastrointestinal structures drained by the portal venous system.1,2 micro-perforation and ulceration of intestinal mucosa, or disease invasion deeper into the submucosal layer, can lead to the development of small vessel thrombophlebitis which can extend to the portal venous system. furthermore, similar pathogenesis can lead to the escape of bowel gas into the portal system forming hepatic portal venous gas (hpvg), a rare radiological sign that is often associated with a severe clinical course.3 new-onset intestinal crohn’s disease (cd) with concurrent development of pylephlebitis with or without hpvg is extremely rare, with only seven cases previously described in the literature.4 case presentation a 39-year-old woman presented to the emergency department with acute right-sided abdominal pain in association with fever. she had no previous surgical or medical history and her family history was unremarkable. on examination, she was septic with a non-distended abdomen and right-sided abdominal tenderness. an abdominal ultrasound scan to investigate for cholecystitis showed gas bubbles in the portal vein branches (figure 1). contrast-enhanced abdominal computed tomography (ct) showed circumferential mural thickening and enhancement of the terminal ileum with prominent perienteric vasculature, resulting in a comb sign. the ct scan confirmed the presence of portal venous gas with diffuse portal venous wall thickening and multiple filling defects in distal branches consistent with pylephlebitis (figure 2). figure 1: ultrasound showing portal venous gas as diffuse echogenic foci and reflector shadows in the liver. figure 2: coronal images from a ct abdomen demonstrating (a) circumferential mural thickening and enhancement of the terminal ileum with prominent vasculature resulting in a comb sign (b) portal venous gas with associated portal venous wall thickening and multiple filling defects in distal portal vein branches (arrows) consistent with pylephlebitis. despite initial conservative management with broad spectrum antibiotics, the patient deteriorated with clinical signs of peritonism, and blood tests reported markedly elevated white cell count plus inflammatory markers. the patient, therefore, proceeded to emergency laparotomy. intra-operatively a grossly thickened terminal ileum with mesenteric wrapping was found (figure 3). an ileocolic resection with stapled side-to-side primary anastomosis was performed. pathological examination showed transmural inflammation of the terminal ileum consistent with cd (figure 4). follow-up ct scan of the abdomen performed on day seven post-operatively showed complete resolution of the hpvg and pylephlebitis. the patient was discharged with no surgical complications. figure 3: intra-operative view demonstrating a grossly thickened, oedematous terminal ileum with serosal inflammation and omental wrapping. figure 4: histology of the terminal ileum, demonstrating inflammatory cell invasion through all layers of the intestine and crypt distortion, which is consistent with crohn’s disease (hematoxylin-eosin x 10). discussion both pylephlebitis and hpvg are rare complications of intra-abdominal inflammation. inflammatory bowel disease (ibd), such as cd, has been reported to be a rare but important aetiology of these complications.4 the difficulty in diagnosing ibd can be compounded by such complications, specifically pylephlebitis, as this may present with vague symptoms of visceral abdominal pain, chronic fever and, in advanced cases, jaundice and hepatosplenomegaly.2 both pylephlebitis and hpvg are considered life-threatening radiological signs that correlate with the severity of the underlying abdominal disease and ultimately are associated with a high mortality rate (up to 39%).2 delay in treatment of pylephlebitis can lead to hepatic abscess, mesenteric infarction and bowel necrosis. pylephlebitis diagnosis relies on the demonstration of thrombus in the portal mesenteric system in the setting of suppurative bacteraemia. as clinical presentation is relatively non-specific, radiological studies play an essential role in diagnosis. portal venous phase ct scan is the diagnostic modality of choice. imaging findings are influenced by the site of portal venous involvement, the primary source of infection and intra-abdominal complications. liver imaging findings include unopacified branches of the portal vein, transient hepatic attenuation differences (thad) and intrahepatic abscesses.5 hepatic portal venous gas is readily characterised by linear or dendritic radiolucencies along the periphery of the liver on ct scan or echogenic foci on ultrasound. this is in contrast to air in the biliary tree (pneumobilia) that has a central distribution and remains an important differential diagnosis. while hpvg is a critical radiological sign with associated high mortality, recent reports have suggested that hpvg in patients with cd does not necessarily indicate necrotic bowel.6 our case supports this statement. in addition, we have demonstrated that after the successful surgical treatment of cd, both hpvg and pylephlebitis can be resolved as early as within a week. the role of anticoagulation in the treatment of pylephlebitis remains controversial.2,4 in our case a successful clinical and radiological resolution of pylephlebitis was achieved shortly after the surgical management of the primary bowel disease and antibiotic therapy without the use of anticoagulation. crohn’s disease is often initially managed medically unless there is fulminant sepsis, mechanical complications such as bowel obstruction or perforation. our case demonstrates that the presence of either pylephlebitis or hpvg should warrant early surgical consultation and consideration of operative intervention. we thus propose that in patients with severe operable cd, complicated by hpvg and pylephlebitis, early resection of the affected intestinal segment is a valid, definitive treatment option. conclusion radiological investigations play an essential role in the diagnosis of first presentation of cd with its rare complications of hpvg and pylephlebitis. early surgical intervention may be necessary in some patients for better outcomes to be achieved. acknowledgements this research was performed in the department of surgery and department of radiology, southland hospital, new zealand. the patient’s consent and confidentiality was respected at all times. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions b.j.l. (surgica registrar) was the project leader who wrote the majority of the article. a.o.a.k. (consultant radiologist) was responsible for providing radiological figures and legends. p.s. (consultant general surgeon) was responsible for overseeing the manuscript and providing surgical perspective of the case. references wong k, weisman ds, patrice ka. pylephlebitis: a rare complication of an intra-abdominal infection. j community hosp intern med perspect. 2013;3(2). https://doi.org/10.3402/jchimp.v3i2.20732 choudhry aj, baghdadi ym, amr ma, alzghari mj, jenkins dh, zielinski md. pylephlebitis: a review of 95 cases. j gastrointest surg. 2016;20(3):656–661. https://doi.org/10.1007/s11605-015-2875-3 liebman pr, patten mt, manny j, benfield jr, hechtman hb. hepatic – portal venous gas in adults: etiology, pathophysiology and clinical significance. ann surg. 1978;187(3):281–287. https://doi.org/10.1097/00000658-197803000-00012 shin ar, lee ck, kim hj, et al. septic pylephlebitis as a rare complication of crohn’s disease. korean j gastroenterol. 2013;61(4):219–224. https://doi.org/10.4166/kjg.2013.61.4.219 balthazar ej, gollapudi p. septic thrombophlebitis of the mesenteric and portal veins: ct imaging. j comput assist tomogr. 2000;24:755. https://doi.org/10.1097/00004728-200009000-00017 abboud b, el hachem j, yazbeck t, doumit c. hepatic portal venous gas: physiopathology, etiology, prognosis and treatment. world j gastroenterol. 2009;15(29):3585–3590. https://doi.org/10.3748/wjg.15.3585 abstract introduction imaging tools atrial fibrillation ventricular tachycardia conclusion acknowledgements references about the author(s) benoit desjardins department of radiology, university of pennsylvania, unites states citation desjardins b. imaging for cardiac electrophysiology. s afr j rad. 2016;20(2), a1048. http://dx.doi.org/10.4102/sajr.v20i2.1048 review article imaging for cardiac electrophysiology benoit desjardins received: 13 june 2016; accepted: 05 aug. 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract clinical cardiac electrophysiology is the study of the origin and treatment of arrhythmia. there has been considerable recent development in this field, where imaging has had a transformational impact. in this invited review, we offer a global overview of the most important developments in the use of imaging in cardiac electrophysiology. we first describe the radiological imaging modalities involved in cardiac electrophysiology, to assess cardiac anatomy, function and scar. we then introduce an imaging modality with which readers are probably unfamiliar (electroanatomical mapping [eam]), but which is routinely used by electrophysiologists to plan and guide cardiac mapping and cardiac ablation therapy by catheter, a therapy which can reduce or even cure arrhythmia. we identify the limitations of eam and describe how radiological imaging modalities can complement this technique. we then describe and illustrate how imaging has helped the diagnosis of arrhythmogenic conditions, and how imaging is used to plan and guide clinical cardiac electrophysiologic procedures and assess their results and complications. we focus on the two most common arrhythmias for which imaging has the greatest impact: atrial fibrillation and ventricular tachycardia. introduction clinical cardiac electrophysiology is the study of the origin and treatment of arrhythmia, which is an abnormality in the rate, regularity or sequence of cardiac activation. over 2 million people are affected by arrhythmia in south africa. some of these arrhythmias (post-infarct arrhythmia) are immediately life threatening. other arrhythmias (atrial fibrillation [af]) are not immediately life threatening, but lead to important complications such as strokes. imaging has become an integral part of clinical cardiac electrophysiology. it helps to diagnose arrhythmogenic conditions, to plan and guide palliative or potentially curative procedures, and to assess the results and complications of these procedures. an increasingly popular procedure that can improve or cure arrhythmia is cardiac ablation therapy, which uses catheters to create thermal burns on the surface of the myocardium, to destroy arrhythmogenic foci or pathways. in this invited review, we provide examples of the modern uses of imaging in cardiac electrophysiology. we first introduce the different imaging modalities used in cardiac electrophysiology, focusing on their integration, and discuss how they are used in the context of af and ventricular tachycardia (table 1). table 1: role of imaging modalities. imaging tools several radiological imaging modalities are used in cardiac electrophysiology, including plain film, computed tomography (ct), magnetic resonance imaging (mri), single-photon emission computed tomography (spect), positron emission tomography (pet), angiography and ultrasound. of these, ct, mri and ultrasound are most closely integrated into clinical systems used in cardiac electrophysiology. these imaging modalities are not only able to assess anatomy and function, but can also assess myocardial scar, which is of crucial importance in cardiac electrophysiology. imaging of anatomy and function although ct and mri can assess both anatomy and function, functional imaging from these modalities has not yet been integrated into cardiac electrophysiology systems, so we will focus on the acquisition of high-quality static imaging by ct or mri. imaging of patients with arrhythmia is not easy, and incorrect techniques lead to blurry images. af and premature ventricular contractions (pvcs) are the two most common arrhythmias affecting image acquisition. cardiac computed tomography angiography (cta) can be performed with or without ecg gating. imaging with cardiac gating is preferred, as it produces images that are not corrupted by cardiac motion. however, if a patient has an arrhythmia during the acquisition of gated images, this will create imaging artifacts. this problem can be addressed by using retrospective gating followed by ecg-editing of the cta dataset, which can correct corrupted imaging data from a few pvcs, or by using high pitch techniques, which can acquire images in patients with af (figure 1a). cardiac magnetic resonance angiography (mra) can be performed using a first-pass intravenous (iv) contrast mra technique, using arrhythmia rejection algorithms on the scanner. a free-breathing whole heart mri technique is more robust, as it acquires mri data over a longer period of time (10 min – 15 min), and can reject all bad data acquired during arrhythmia (figure 1b). figure 1: 3d reconstructed data from: (a) cta and (b) mra both show exquisite detail in the structure of the left atrium and pulmonary veins. imaging of scar myocardial scar is intimately related to the generation of arrhythmia, and therefore visualisation of scar is one of the main foci in imaging for cardiac electrophysiology. scar imaging by late gadolinium enhancement (lge) mri has become the gold standard. after an iv bolus of gadolinium-based contrast agent, myocardial imaging is performed after a delay of 10 min – 15 min. after such a delay, the contrast agent has mostly cleared from normal myocardium, but areas of scar have increased extra-cellular spaces and retain the contrast agent longer, creating a difference in signal intensity. this difference is further amplified by the use of nulling pulses. figure 2a shows areas of subendocardial and transmural scar in ischaemic cardiomyopathy, and figure 2b shows patchy scar in cardiac sarcoid. figure 2: late gadolinium enhancement showing scar patterns in different cardiomyopathies: (a) ischaemic cardiomyopathy, with subendocardial and transmural components; (b) cardiac sarcoid, with a patchy multifocal pattern; and (c) myocarditis, with a primarily subepicardial pattern. another approach to image myocardial scar, which is less known to radiologists, is electroanatomical mapping (eam) by catheter. this technique has been used to measure electrical activity in the heart, as well as to guide cardiac ablation therapy. a specialised catheter is advanced into the heart, and its manually guided tip electrode is apposed against the myocardial surface to measure electrical activity. areas of normal myocardium produce high electrical activity, and areas of scar produce low electrical activity. systems have been developed to precisely track the position of the catheter tip in 3d space. a set of coils on the table or patches on the patient generate either a magnetic field or an electrical field, which is detected by special sensors at the tip of the intracardiac catheter, enabling determination of its location in 3d space. by localising in 3d space each measurement of cardiac electrical activity, 3d surface endocardial or epicardial maps of cardiac electrical activity are generated. an endocardial map of the left ventricle (lv) (figure 3a) and of the left atrium (la) (figure 3b) are illustrated. endocardial eams are generated by intracardiac catheters, whereas epicardial eams are generated by intrapericardial catheters or by catheters into epicardial coronary veins. figure 3: electroanatomical maps (eams) of cardiac chambers: (a) eam of the left ventricle. red areas represent low voltage (scar) and purple areas represent normal voltage; (b) eam of the left atrium, with tubular structures representing the pulmonary veins. area of ablation shows low voltage (red) and non-ablated areas show normal voltage (purple). although eams provide anatomic maps of cardiac electrical activity, they are quite crude, as they are generated typically from 100 to 300 catheter measurements (although mapping systems allow 1000 measurements or more). they offer a distorted image of cardiac chamber anatomy and are electrically undersampled. there has been a considerable effort to integrate the better anatomic and scar information provided by ct and mri datasets into the 3d eams, in order to enhance procedural outcomes. there is generally good correspondence between spatial distribution of scar on eams and scar on mri, with some mismatches owing to eam undersampling or poor catheter contact (figure 4). mri offers precise assessment of transmural distribution of scar, and can easily distinguish between subendocardial scar and subepicardial scar. eams are less precise than mri to determine transmural extent of scar. eams are very difficult to interpret when scar distribution is complex or patchy, which is often seen in non-ischaemic cardiomyopathy, whereas complex scar can be better assessed by mri. figure 4: registration of eam and late gadolinium mri. there is a slight mismatch on the left side of the image, where an area of normal voltage on eam (purple) is superimposed on an area of scar on mri (gray). this resulted from a gap in sampling on the eam. image integration to integrate 3d data from ct or mri with eams is a two-step process. the ct or mri data must first be imported into the eam system, and must then be registered to the patient’s anatomy. for left atrial anatomy, a lasso catheter is systematically moved into the la and pulmonary veins, rapidly creating a 3d point cloud map representing the patient’s anatomy, which is then registered to the imported 3d ct or mri surface anatomy. for lv anatomy, fiducials (mitral valve, aortic valve, lv apex) are identified by catheter and on the 3d ct or mri data, and both are registered via these fiducials. registration is then refined using surface-based algorithms, producing a registration error less than 3 mm in accuracy. atrial fibrillation af involves the chaotic electrical activity in the atria (350 bpm – 600 bpm) causing quiver instead of an organised contraction. it is caused by abnormal depolarisation of excitable myocardial tissue extending into the pulmonary veins. it is the most common arrhythmic cause for hospitalisation, causing a twofold increase in mortality and fivefold increase in strokes. two common forms of therapy are medication, which has frequent toxicity and a high rate of failure, and ablation therapy by catheter, which involves the creation of linear thermal lesions to electrically isolate the different parts of the la. planning imaging can help to plan left atrial ablation therapy. it is used (1) in defining the anatomy for proper ablation therapy, (2) to identify potential contraindications to ablation, (3) to identify the relationship between the la and surrounding structures that can be injured by ablation, and (4) to identify which subjects are more at risk of developing af. electrical isolation of the pulmonary veins from the la requires proper planning. the size of the ostia of the pulmonary veins will guide proper catheter selection. the pattern of the pulmonary veins and variant anatomy will affect catheter manipulation and delivery of ablation lesions. the presence of a thrombus in the left atrial appendage can be readily identified by imaging and is a contraindication to ablation. structures surrounding the la can suffer thermal injury from the ablation lesions. the oesophagus courses along the posterior wall of the la and comes into close contact with the wall, separated only by a thin layer of fat. identifying by imaging the path of the oesophagus with respect to the la will determine which ablation lesions are at greater risk of causing potentially lethal thermal injury to the oesophagus, and requires ablation with reduced energy in these areas. the right phrenic nerve travels close to the ostia of the pulmonary veins. identifying by imaging the precise path of the right phrenic nerve helps to prevent thermal injury to the nerve and permanent phrenic palsy. subjects with dilated la are associated with an increased risk of recurrence of af after ablation. imaging allows precise measurement of la volume. more recently (and more controversially), the degree and extent of scarring of the la owing to chronic af might be able to predict the risk of recurrence of af following ablation.1 assessment of la volume and la scar by imaging could help to select the appropriate candidates for ablation. guidance imaging can guide left atrial ablation therapy. the la and pulmonary veins have a complex and variable anatomical pattern, and the ablation procedure involves the creation of linear lesions to electrically isolate the different parts of the la. however, ablation catheters can only perform punctiform lesions, and linear lesions are actually the result of several collinear punctiform lesions without gaps between them (figure 5). imaging guidance enables precise location of the ablation lesions, improving proper electrical isolation without gaps at optimal locations within the la. this leads to improvement in clinical outcome2, decrease in procedure duration, and decrease in fluoroscopy time. modern la ablation techniques involve guidance under virtual reality. the 3d anatomical information from ct or mri is imported into the eam software and registered to the patient. the procedure is then entirely virtually guided by the imported la anatomy (figure 6a). in addition, anatomy of the oesophagus and the phrenic nerves is also used to guide the ablation (figure 6b), and minimise the risk of thermal injury to these structures. figure 5: illustration of ablation lines electrically isolating the different parts of the left atrium. each line is made up of collinear punctiform ablation lesions without gaps. figure 6: an ablation procedure guided by ct data: (a) the ablation catheter is visualised in real-time and ablation lesions are represented by red dots; (b) besides the structure of the left atrium and pulmonary veins, surrounding structures such as the oesophagus (green) and phrenic nerve (yellow) can be used to guide ablation therapy. intraprocedural imaging by intracardiac echocardiography (ice) is becoming integrated into eam systems. ice involves a steerable intravascular catheter using a 64-element vector phased array, with tissue penetration of 16 cm. this technique improves real-time catheter navigation, real-time 3d reconstruction of la anatomy, helps to guide transseptal puncture to access the la from the right atrium (ra), visualise the pulmonary vein ostia, visualise the oesophagus to avoid collateral damage, and helps to recognise complications such as perforations. ice with acoustic radiation force imaging3 can assess tissue elasticity and directly visualise ablation lesions, which are stiffer than normal portions of the la, and can potentially identify gaps. post procedure imaging can identify complications of ablation therapy, such as pulmonary vein stenosis (figure 7), which used to happen in up to 42% of procedures (although this has decreased to 1% with techniques ablating further away from the pulmonary veins ostia4), as well as identify other complications, such as thrombosis, dissection, pulmonary infarction or atrio-oesophageal fistula. more recently, mri has been used to assess results of la ablation therapy.5 the ablation lesions behave similarly to myocardial scar on mri, but with much longer wash-in and wash-out kinetics.6 they show as bright signal on mri days to months after the procedure (figure 8a, b). in about 35% of cases, af recurs weeks or months after the ablation procedure, owing to development of gaps in the linear ablation lesions.7 it is now possible to identify by imaging these developing gaps in the ablation lines causing failure of therapy, and perform a very targeted redo procedure to eliminate those gaps. figure 7: cta shows significant narrowing of the ostium of the left inferior pulmonary vein, a complication of ostial ablation therapy. figure 8: late gadolinium enhancement (a) of the left atrium post ablation. ablation lesions present as bright signal on an otherwise dark myocardium; (b) 3d map representation of the scar (red) distribution. ventricular tachycardia cardiomyopathies, which are diseases involving a deterioration of the function of the myocardium, increase the risk of arrhythmia and sudden cardiac death. cardiomyopathies often present with myocardial scar, which acts as an arrhythmogenic substrate, and surviving muscle bundles within scar are probably responsible for arrhythmia, as they create alternate slow pathways for cardiac conduction.8 imaging can readily identify several of these pathologies. ischaemic cardiomyopathy involves subendocardial scar of variable transmurality, along a vascular territory, accompanied by regional wall motion abnormalities and anatomical remodeling (figure 2a). hypertrophic cardiomyopathy involves wall thickening, with areas of thickening showing diffuse patchy scar. other non-ischaemic cardiomyopathy can reveal multifocal scar (e.g. cardiac sarcoid, figure 2b) or subepicardial scar (e.g. myocarditis, figure 2c). therapy for cardiomyopathy includes the use of medication, the implantation of intracardiac defibrillators, or ablation therapy. cardiac ablation therapy via catheter can be used to destroy the abnormal conduction pathways. unlike left atrial ablation therapy, where ablation lines are created to electrically isolate different parts of the la, ablation lesions in the lv are more clustered, and their purpose is to homogenise the ventricular substrate, to transform mixed scar into pure scar. risk stratification for ischaemic cardiomyopathy to determine which patients require an implantable cardiac defibrillator (icd) currently involves assessment of cardiac function. patients with depressed cardiac functions and left ventricular ejection fraction (lvef) < 35%, will typically require an icd. but a large proportion of patients with icds never experience an icd discharge (and therefore do not really need one), and some patients who are not expected to need an icd present with arrhythmia or sudden cardiac death. mri can assess scar distribution and heterogeneity and can offer better risk stratification. scar involving 25% – 75% of the wall thickness is predictive of inducible ventricular tachycardia. heterogeneous scar showing areas of intermediate signal (gray zone, indicating scar mixed with normal myocardium) is also predictive of ventricular arrhythmia. planning imaging can help to plan for therapy in cardiomyopathy. visualising the anatomy of the coronary sinus and coronary veins is useful prior to implantation of a biventricular pacemaker or icd. in these devices, a third lead is inserted via the coronary sinus and follows an epicardial vein along the surface of the lv. precise knowledge of the course and size of the epicardial veins helps optimal placement of this third lead (figure 9). scar imaging helps to avoid placement of leads in areas of non-viable myocardium which would not be responsive to pacing, and functional imaging can identify areas of latest activation which are optimal for lead placement. figure 9: surface-rendered cta demonstrates the path of the coronary sinus and coronary veins, for planning of implantation of a biventricular pacemaker or icd. the same anatomy is also useful to guide epicardial ablation therapy via the coronary veins, and helps to achieve a higher success rate of ablation of some patterns of epicardial scar. visualising the anatomy of the coronary arteries is useful in epicardial ablation, as coronary arteries are prone to damage by thermal energy from the ablation. one should avoid ablating within 5 mm – 10 mm from a coronary artery to prevent vascular damage. determining the thickness of epicardial fat by imaging is also useful for planning epicardial ablation. unlike endocardial ablation, where the catheter is in close contact with the myocardium (the endocardium is a very thin layer), in epicardial ablation a layer of epicardial fat of variable thickness separates the myocardium from the catheter. epicardial fat > 3 mm thick attenuates amplitudes of epicardial electrograms9, and thick fat can mimic scar. in those cases, fragmented electrograms can help to distinguish scar from thick epicardial fat. furthermore, the ablation procedure can be completely ineffective in areas of very thick epicardial fat (>10 mm). imaging scar location and distribution is important to plan ventricular ablation therapy. critical sites for arrhythmia (target sites for ablation) are typically located in areas of scar demonstrated by mri.10 ablation can target the precise chambers and wall containing scar on mri, saving procedure time and improving outcomes. the distribution of scar across the lv wall can determine the approach for successful ablation. an endocardial approach will be successful for subendocardial scar, and an epicardial approach will be successful for subepicardial scar. if the scar is predominantly intramural, such as in non-ischaemic cardiomyopathy, both approaches might fail. viable but denervated myocardium around scar is prone to arrhythmias, although the underlying mechanism for arrhythmias is not clear.11 after a myocardial infarct, the sympathetic denervation defect is usually larger than the area of scar, and ablation of this viable but denervated myocardium can successfully eliminate critical foci for arrhythmia. areas of denervation can be demonstrated by spect imaging using meta-iodobenzylguanidine (mibg), a norepinephrine analogue, or by pet imaging using hydroxyephedrine (hed), an epinephrine analogue. correlation of extent of denervation with extent of scar on mri can identify additional target sites for ablation. guidance eams have been used to guide ventricular ablation therapy with 50% – 80% success and 40% recurrence post ablation.12 imaging could improve these outcomes. intracardiac echography (ice) can guide ablation during the procedure. the ice catheter is inserted in the right heart and produces ecg-gated 90-degree sector images to generate 3d volumes of the heart. this can improve registration with ct and mri images,13 identify complications such as thrombus, and identify scar tissue by wall thinning or increased echo density. this can also improve control of the tip of the ablation catheter, to target arrhythmias in difficult locations such as papillary muscles.14 real-time mri is also used to guide ablation therapy.15 advantages are absence of ionising radiation, real-time creation of lesions, real-time assessment of scar and monitoring of lesion temperature. disadvantages are lack of food and drug administration (fda) approval, and a significant change in workflow and financial investment. the main technical problems have, however, been solved. specialised ablation catheters have been developed which are actively trackable under mri. thermographic pulse sequences have been developed that can assess the extent of thermal injury from each ablation lesion. techniques have been developed to correct ecg signal distortion inside the scanner. mri-guided ablation could have a great future, but currently remains a purely experimental technique. post procedure mri can be used to assess the location of the ventricular ablation lesions. the enhancement kinetics of these ablation lesions in the lv require a very long delay for lge imaging (90 min6), which is not practical. more recent techniques such as t1 mapping, which do not depend on iv contrast kinetics, have been developed to acutely visualise core ablation lesions and surrounding oedema in the lv.16 although clinical outcome determines the success of the ablation procedure, imaging of ventricular ablation lesions can help to identify location of suboptimal ablation lesions if arrhythmia recurs after ablation. conclusion imaging has numerous uses in clinical cardiac electrophysiology. it helps to diagnose cardiomyopathy; it can assess cardiac anatomy, function and scar; it helps to plan and guide interventions such as device placement or ablation therapy; and it can be used to assess the result and complications of these procedures. although much progress has been made to image arrhythmogenic substrate and integrate the imaging data into mapping and ablation systems, there is plenty of scope for improvement. the spatial resolution of images of scar needs improvement, registration of imported 3d structures with the patient is far from perfect, and in vivo imaging with ice or mri needs further development.17 cost effectiveness still limits availability, and superior outcomes have yet to be demonstrated. acknowledgements competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references oakes rs, badger tj, kholmovski eg, et al. detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. circulation. 2009;119:1758–1767. http://dx.doi.org/10.1161/circulationaha.108.811877 bertaglia e, bella pd, tondo c, et al. image integration increases efficacy of paroxysmal atrial fibrillation catheter ablation: results from the cartomerge italian registry. europace. 2009;11:1004–1010. http://dx.doi.org/10.1093/europace/eup152 eyerly sa, hsu sj, agashe sh, et al. intracardiac acoustic radiation force impulse imaging: a novel imaging method for intraprocedural evaluation of radiofrequency ablation lesions. heart rhythm. 2012;9:1855–1862. http://dx.doi.org/10.1016/j.hrthm.2012.07.003 holmes dr, monahan kh, packer d. pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. j am coll cardiol interv. 2009;2(4):267–276. http://dx.doi.org/10.1016/j.jcin.2008.12.014 peters dc, wylie jv, hauser th, et al. detection of pulmonary vein and left atrial scar after catheter ablation with three-dimensional navigator-gated delayed enhancement mr imaging: initial experience. radiology. 2007;243:690–695. http://dx.doi.org/10.1148/radiol.2433060417 dickfeld t, kato r, zviman m, et al. characterization of radiofrequency ablation lesions with gadolinium-enhanced cardiovascular magnetic resonance imaging. j am coll cardiol. 2006;47:370–378. http://dx.doi.org/10.1016/j.jacc.2005.07.070 badger tj, daccarett m, akoum nw, et al. evaluation of left atrial lesions after initial and repeat atrial fibrillation ablation: lessons learned from delayed-enhancement mri in repeat ablation procedures. circ arrhythm electrophysiol. 2010;3:249–259. http://dx.doi.org/10.1161/circep.109.868356 bolick dr, hackel db, reimer ka, et al. quantitative analysis of myocardial infarct structure in patients with ventricular tachycardia. circulation. 1986;74: 1266–1279. http://dx.doi.org/10.1161/01.cir.74.6.1266 desjardins b, morady f, bogun f. effect of epicardial fat on electroanatomical mapping and epicardial catheter ablation. j am coll cardiol. 2010;56:1320–1327. http://dx.doi.org/10.1016/j.jacc.2010.04.054 bogun fm, desjardins b, good e, et al. delayed-enhanced magnetic resonance imaging in nonischemic cardiomyopathy: utility for identifying the ventricular arrhythmia substrate. j am coll cardiol. 2009;53:1138–1145. http://dx.doi.org/10.1016/j.jacc.2008.11.052 simoes mv, barthel p, matsunari i, et al. presence of sympathetically denervated but viable myocardium and its electrophysiologic correlates after early revascularised, acute myocardial infarction. eur heart j. 2004;25:551–557. http://dx.doi.org/10.1016/j.ehj.2004.02.016 tanner h, hindricks g, volkmer m, et al. catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter euro-vt-study. j cardiovasc electrophysiol. 2010;21:47–53. http://dx.doi.org/10.1111/j.1540-8167.2009.01563.x bunch tj, weiss jp, crandall bg, et al. image integration using intracardiac ultrasound and 3d reconstruction for scar mapping and ablation of ventricular tachycardia. j cardiovasc electrophysiol. 2010;21:678–684. http://dx.doi.org/10.1111/j.1540-8167.2009.01680.x good e, desjardins b, jongnarangsin k, et al. ventricular arrhythmias originating from a papillary muscle in patients without prior infarction: a comparison with fascicular arrhythmias. heart rhythm. 2008;5:1530–1537. http://dx.doi.org/10.1016/j.hrthm.2008.08.032 nazarian s, bluemke da, lardo ac, et al. magnetic resonance assessment of the substrate for inducible ventricular tachycardia in nonischemic cardiomyopathy. circulation. 2005;112:2821–2825. http://dx.doi.org/10.1161/circulationaha.105.549659 ranjan r, kholmovski e, silvernagel j, et al. acute assessment of radiofrequency ablation lesions in mri without the use of gadolinium based contrast. j am coll cardiol. 2014;63(12 suppl.):a389. http://dx.doi.org/10.1016/s0735-1097(14)60389-2 njeim m, desjardins b, bogun f. multimodality imaging for guiding electrophysiology ablation procedures. jacc imaging. 2016;9(7):873–886. abstract introduction case report discussion conclusion acknowledgements references about the author(s) sara zafar radiology department, chelsea and westminster hospital, united kingdom maria javed radiology department, chelsea and westminster hospital, united kingdom neesha rockwood department of hiv, chelsea and westminster hospital, united kingdom farhat kazmi radiology department, chelsea and westminster hospital, united kingdom citation zafar s, javed m, rockwood n, kazmi f. primary central nervous system lymphoma presenting as multiple space-occupying lesions in advanced human immunodeficiency virus infection. s afr j rad. 2017;21(2), a1234. https://doi.org/10.4102/sajr.v21i2.1234 case report primary central nervous system lymphoma presenting as multiple space-occupying lesions in advanced human immunodeficiency virus infection sara zafar, maria javed, neesha rockwood, farhat kazmi received: 04 june 2017; accepted: 01 sept. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a 31-year-old man presented with seizures and cerebellar symptoms on a background of weight loss and lethargy. he was found to be infected with human immunodeficiency virus (hiv) and following radiological imaging, was commenced on treatment for presumed cerebral toxoplasmosis. due to a lack of response, both clinically and on interval imaging, a positron-emission tomography-computed tomography and brain biopsy were undertaken, which demonstrated high-grade primary central nervous system lymphoma (pcnsl). awareness amongst both clinicians and radiologists of the multifarious patterns of intra-cranial involvement in patients with hiv is, therefore, of utmost importance, as the treatment and prognosis of these entities are entirely different. introduction progressive immunosuppression secondary to human immunodeficiency virus (hiv) infection may predispose to opportunistic infections affecting the central nervous system (cns). patients may present with space-occupying lesions, such as toxoplasmosis, cryptococcal disease and tuberculosis, in addition to being associated with an increased incidence of epstein–barr virus (ebv) associated systemic or primary cerebral nervous system lymphoma (pcnsl). distinguishing between these entities by an accurate interpretation of imaging along with the clinical presentation is therefore essential, as the course of treatment in these cases is entirely different.1 case report a 31-year-old man presented to the emergency department in december 2016 with new-onset tonic–clonic seizures, on a background of 19 kg weight loss, progressive lethargy and cognitive decline over the preceding 18 months. he had travelled extensively across the african subcontinent whilst working aboard a ship and during this time had engaged in unprotected intercourse with female sex workers. salient examination findings included nystagmus on right-lateral gaze, past-pointing in the left upper limb, brisk reflexes and an unsteady gait, suggestive of underlying cerebellar pathology. following biochemical and serological investigations, the patient was diagnosed with hiv-1, with a viral load of 1 243 938 copies/ml and a cd4 lymphocyte count of 12 cells/µl. initial computed tomography (ct) imaging revealed multiple lesions in the brainstem, cerebellum, basal ganglia and both cerebral hemispheres, with significant local mass effect and effacement of the left lateral ventricle. magnetic resonance imaging (mri) of the brain was also undertaken at this time, which demonstrated multiple ring-enhancing lesions (figure 1). mediastinal and hilar lymph node enlargement identified on ct imaging of the chest, abdomen and pelvis was felt to be in keeping with persistent generalised lymphadenopathy (pgl) because of advanced hiv as there was no palpable cervical, axillary or inguinal lymphadenopathy (figure 2). figure 1: post-gadolinium t1 contrast enhanced axial slices from mri brain performed 2 days following the initial clinical presentation. multiple ring-enhancing lesions are seen within the right frontal (a), left basal ganglia and corticomedullary junction within the right parietal lobe (b). effacement of anterior horn of the left lateral ventricle is noted (a). figure 2: axial slices from portal venous phase contrast enhanced ct thorax, abdomen and pelvis performed at initial presentation, which demonstrates mediastinal (a) and hilar (b) lymph node enlargement. these nodes were later not found to be fdg-avid on fdg-pet-ct. the patient was commenced on treatment for presumptive toxoplasmosis, with sulfadiazine/pyramethamine/folinic acid and adjunctive high-dose dexamethasone, levetiracetam. he also simultaneously commenced antiretroviral therapy (art) comprising of tenofovir/emtricitabine and dolutegravir, along with prophylactic antibiotics and antifungals against opportunistic infections. blood cultures were negative as was toxoplasma serum immunoglobulin g (igg). tuberculosis with cns involvement and cryptococcoma were considered as differential diagnoses; however, cryptococcal antigen was negative as subsequently were mycobacterial blood and induced sputum cultures. cerebrospinal fluid examination was not attempted in light of the cerebellar lesions. following 2 weeks of toxoplasmosis treatment, there was no improvement in the appearances of the intra-cranial lesions on repeat mr brain imaging, with two new lesions being identified (figure 3). at this point, alternative diagnoses such as systemic lymphoma with intra-cranial metastases and pcnsl were pursued over toxoplasmosis. a fluodeoxyglucose positron-emission tomography (fdg-pet-ct) and brain biopsy were, thus, arranged with the aim of obtaining a more definitive diagnosis. figure 3: axial (a, b) and coronal (c, d) slices from t1 post-contrast enhanced mr brain 2 weeks following the initial imaging. no significant treatment response following 2 weeks of toxoplasmosis treatment with sulfadiazine/pyramethamine/folinic acid and adjunctive high-dose dexamethasone with persistent ring-enhancing lesions identified. there was marked peri-lesional vasogenic oedema and two new lesions were seen. a few of these lesions, for example, the lesion within the head of the left caudate nucleus demonstrated restricted diffusion on diffusion weighted imaging (not demonstrated), in keeping with increased cellularity. this finding is atypical of toxoplasmosis and thus raised the suspicion for alternative diagnoses over toxoplasma. fdg-pet-ct was undertaken 3 weeks following initial presentation and demonstrated high avidity activity only in the brain including the right parietal, right parieto-occipital and left frontal regions as well as the cerebellum and basal ganglia (standardised uptake value [suv] max 7.3 compared with normal brain cortex). no fdg-avid mediastinal lymph nodes were identified and these appearances pointed towards the diagnosis of pcnsl, rather than systemic lymphoma with cerebral metastases. the right parietal lobe brain biopsy demonstrated a suspicious lymphoid infiltrate. mycobacterial and fungal stains were negative as was immunostaining for herpes simplex virus (hsv1), hsv2, cytomegalovirus (cmv) and john cunningham virus (jcv). epstein–barr encoding region (eber) in situ hybridisation staining was also negative; however, this was a likely false negative result, in the context of necrosis and ribonucleic acid (rna) degradation. within the necrotic areas, the cellular outlines and remains were strongly positive for cd20, cd79a and bcl2. they were negative for cd19, cd3, cd5, cd10, bcl6 and pax5. final histopathology results were in keeping with a high-grade b-cell lymphoma that was necrotic. the patient was commenced on matrix chemotherapy (rituximab, methotrexate, cytarabine, with omission of thiotepa for the first two cycles) for hiv-associated primary cerebral lymphoma.2 within 8 weeks of commencement of highly active antiretroviral therapy (haart), there was a 3log10 fold decrease in hiv-1 viral load. there has also been a marked improvement in cognitive function and gait following four cycles of matrix chemotherapy (figure 4). figure 4: post-gadolinium contrast enhanced t1 axial slices from mr brain performed 2 months following the initial clinical presentation. the patient had been commenced on matrix chemotherapy. multiple peripherally enhancing parenchymal (b) and sub-ependymal lesions (a) are demonstrated with a significant improvement in the size of all lesions since the last examination. new high signal on t1 imaging (not demonstrated) may represent post-treatment interval haemorrhage. repeat mri imaging 6 months following initial presentation also demonstrates a reduction in volume of the supra and infra-tentorial parenchymal and sub-ependymal lesions, with improvement in the degree of peri-lesional vasogenic oedema, in keeping with a positive disease response (figure 5). the patient continues to make good progress and is currently being worked up for consolidative therapy with an autologous stem cell transplantation. figure 5: post-gadolinium contrast enhanced t1 axial slices from mr brain following four cycles of matrix chemotherapy, which shows marked interval improvement in both the size of the ring-enhancing lesions (a) and the degree of peri-lesional oedema (b), in keeping with positive disease response. discussion toxoplasmosis and pcnsl are amongst the most common causes of intra-cranial space-occupying lesions in patients with hiv infection.1 distinguishing between these two aetiologies may sometimes be challenging because of a degree of overlap in the spectra of imaging findings. a constellation of imaging modalities including ct, mri, perfusion mr, fdg-pet and thallium-201 single photon emission computed tomography (spect), along with brain biopsy, can therefore be utilised collectively to afford the clinical team the best chance at making the correct diagnosis and initiate appropriate treatment in a timely manner. there is a broad list of differential diagnoses for a ring-enhancing lesion in a patient with hiv including infection (toxoplasma, tuberculous abscesses, tuberculoma and cystercercosis), neoplasia (pcnsl, metastases), demyelination (ms) and vascular disease (haematoma). whilst the presence of multiple ring-enhancing lesions are characteristically associated with toxoplasmosis, a solitary, homogenously-enhancing lesion more frequently typifies primary cerebral lymphoma. occasionally, lymphomatous lesions may demonstrate areas of central necrosis with thicker peripherally enhancing portions, thereby masquerading as ring-enhancing lesions, giving rise to the difficulty distinguishing these two causes, as was the case with our patient.3 the distribution of lesions may be another helpful factor in aiding discrimination, with a preponderance of toxoplasma to the basal ganglia, thalami and cortico-medullary-junction. lymphoma favours a peri-ventricular location with a classic sub-ependymal route of spread. haemorrhage may occasionally be seen in necrotic toxoplasmosis lesions, however, this may also be identified as t1 hyperintensity in patients with lymphoma following the initiation of treatment, as was the case in our patient. (figure 4) diffusion weighted imaging (dwi) also highlights specific differences between these two aetiologies: lymphomatous lesions demonstrate marked restricted diffusion because of the hypercellularity of these lesions, whilst the converse is true of toxoplasma.4 the intra-cranial lesions in our case demonstrated hyperintensity on the dwi, with corresponding central hypointensity on the apparent diffusion coefficient (adc) map, in keeping with a diagnosis of lymphoma rather than toxoplasma. nuclear medicine imaging offers further clues in differentiation, as toxoplasma demonstrates decreased uptake on thallium-201 spect imaging, whereas uptake is increased in lymphoma.5 fdg-pet can also be of value, with lymphomatous lesions demonstrating high metabolic activity and toxoplasmosis and other infections demonstrating hypometabolic features. this was particularly useful in our case.6 conclusion a wide differential diagnosis exists for intra-cranial mass lesions in hiv patients. it can be challenging to distinguish toxoplasmosis from pcnsl, which are two common cns lesions. whilst mri and nuclear medicine provide us with clues to facilitate identifying the underlying aetiology of an intra-cranial mass lesion, invasive brain biopsy may still be required because of the significant overlap in the spectra of imaging findings. utilising nuclear medicine to aid diagnosis may also prevent delays in initiating focused treatment. acknowledgements competing interests the authors declare they have no personal or financial relationship which may have influenced them in writing this article. authors’ contributions s.z. wrote the manuscript along with m.j. n.r. provided the clinical details and authored the case report section whilst f.k. was responsible for providing guidance with regard to selecting appropriate images for the case report, steering the direction of the case report and reviewing the manuscript. references bhigjee al, naidoo k, patel vb, govender d. intracranial mass lesions in hiv-positive patients – the kwazulu/natal experience. s afr med j. 1999;89(12):1284–1288. ferreri aj, cwynarski k, pulczynski e, et al. chemoimmunotherapy with methotrexate, cytarabine, thiotepa, and rituximab (matrix regimen) in patients with primary cns lymphoma: results of the first randomisation of the international extranodal lymphoma study group-32 (ielsg32) phase 2 trial. lancet haematol. 2016;3(5):e217–e227. https://doi.org/10.1016/s2352-3026(16)00036-3 smith ab, smirniotopoulous jg, rushing ej. central nervous system infections associated with human immunodeficiency virus infection: radiologic-pathologic correlation. radiographics. 2008;28(7):2033–2058. https://doi.org/10.1148/rg.287085135 camacho dla, smith jk, castillo m. differentiation of toxoplasmosis and lymphoma in aids patients by using apparent diffusion coefficients. am j neuroradiol. 2003;24(4):633–637. ruiz a, ganz wi, post mj, et al. use of thallium-201 brain spect to differentiate cerebral lymphoma from toxoplasma encephalitis in aids patients. anjr am j neuroradiol. 1994;15(10):1885–1894. love c, tomas mb, tronco gg, palestro cj. fdg pet of infection and inflammation. radiographics. 2005;25(5):1357–1367. https://doi.org/10.1148/rg.255045122 radiology_may04 the swiss artist, paul klee, painted an obscure, but beautiful picture titled ‘angelus novus’. in the painting he depicts the angel of history as though the angel is about to move away from something he is contemplating intently. his eyes are staring, his mouth is open, and his wings are spread. the eminent german philosopher and art critic walter benjamin referred to this painting in one of his theses on the philosophy of history: ‘like the angel, with our faces fixed to the past, we are propelled forward to the future by the force of history. we are driven by a storm which is called progress.’ i intend to paint a picture of how i see the future of radiology, not only at this academic hospital, but also as a science and profession in this country. and with reference to benjamin i want to title my painting ‘the storm of progress’. the history as an introduction i will dwell briefly on the history of this relatively young discipline in medical science. radiology is very much part of the event of modernisation which announced itself just before the beginning of the previous century. the famous eiffel tower was erected for the 1889 world fair in paris. the theme was manufacturing and transformation. this construction still symbolises the romance of technology and progress. i do not intend to recall the chain of events released by modernisation as if counting the beads of a rosary, but rather want to link the past with the present and the future by focusing on a few individuals without whose contributions modern radiology would not have been possible. the scientific achievements of these pioneers opened up new possibilities in medicine. wilhelm conrad röntgen discovered the x-ray on 8 november 1895 in his institute for physics at the julius maximilian university in würtzburg. this achievement of röntgen gave medicine a diagnostic tool. the medical practitioner, specifically the radiologist, was now able to diagnose the abnormal. it signalled the genesis of the art of looking, the art of visual discernment and diagnosis by means of electromagnetic waves of short wavelength. this was nothing less than a revolution in medicine. marie curie and her husband pierre were fascinated by the french physicist henri-antoine becquerel's discovery in 1896 of the natural radiation of uranium salt. their extensive research led to the discovery of radium and radioactivity. at the time the discovery rocked the world of science because it seemed to contradict the principle of the conservation of energy. it forced scientists to reconsider the nature of matter and inaugurated the era of particle physics. marie curie's systematic research introduced radioactive materials in medical diagnostics and therapy. her daughter irene and son-in-law frederic joliot continued her work and discovered artificial radioactivity, which formed the basis of nuclear medicine. marie curie was the first woman to be buried in the pantheon and possibly the greatest female scientist of all time. the development of contrast media and its implementation in angiography soon followed röntgen's discovery. egas moniz, a man of many talents (doctor, politician, senator), was the first scientist who conceived visualisation of cerebral blood vessels using contrast injection. in 1927 at an international meeting of neurologists he presented an account of a successful cerebral angiogram. with cerebral angiography one could now visualise intracranial tumours, vascular abnormalities and aneurisms. in 1929 werner forssmann became the first to develop a technique for the catheterisation of the heart. this he did by inserting a cannula into his own antecubital vein, through which he passed a catheter for 65 cm. he then walked to the xray department where a photograph was taken of the catheter lying in his right auricle. despite the significance of his discovery, forssmann was scorned by his peers. his self-experimentation led to his dismissal. it was only many years later that his pioneering efforts found recognition. the development of the seldingerneedle by sven-ivar seldinger in 1953 was the genesis of modern angiography. with the seldinger technique a percutaneous insertion is made preferably in the femoral artery. a inaugural lecture 4 sa journal of radiology • may 2004 the storm of progress leonie scholtz mb chb, mmedrad (d) department of radiology university of pretoria guide wire is inserted through a thin walled needle and then a plastic preformed catheter. access can be gained to any part of the body via the cardiovascular system. today this technique is applied in virtually every angiogram. charles t dotter introduced a paradigm shift in radiology on 10 june 1963 at the czech radiological congress. his presentation ‘vascular catheterization and angiographic techniques of the future’ gave a complete overview of catheter angiography, and subsequently discussed new and future techniques including his most adventurous technique, catheter endarterectomy. he finished with an historic conclusion, which laid a foundation for interventional radiology: ‘the angiographic catheter can be more than a tool for passive means for diagnostic observation; used with imagination it can become an important surgical instrument.’ a few months later, on 16 january 1964, dotter performed the first percutaneous transluminal angioplasty of a stenotic femoral artery. the first neuro-interventional case in south africa was performed by our own prof. marthinus janse van rensburg of the department of neurosurgery together with dr bloch from johannesburg on 19 march 1976, when they injected silicone particles into a large posterior fossa avm. it can be said that the x-ray has proven to be the greatest technological medical miracle of the 20th century. but it was not until the development of the computer and the genius of godfrey hounsfield who realised that x-ray images could be stored and manipulated by computers, that xrays were used in an amazingly accurate diagnostic device known as computerised axial tomography, or the cat scanner. the announcement by hounsfield, at the 1972 british institute of radiology annual conference, of this machine was the greatest technological step forward in radiology since röntgen's discovery. another milestone was the discovery of the magnetic resonance phenomenon by felix bloch and edward purcell in 1946. in the period between 1950 and 1970 nuclear magnetic resonance (nmr) was developed and used for chemical and physical molecular analysis. in 1971 raymond damadian created one of the most useful diagnostic techniques of our time, magnetic resonance imaging (mri) scans. this procedure allows radiologists to non-invasively image the human body in meticulous detail. die hede ek het die verlede met enkele breë kwasstrepe geskilder en ek glo dat hierdie beeld van die ontwikkeling wat ons soos 'n storm voortgedryf het vanaf die begin van die vorige eeu tot en met die 21e eeu, dit duidelik maak dat die rol en implementering van die sogenaamde röntgenstrale asook ander beeldingsmodaliteite enorme dimensies aangeneem het. waar staan ons vandag en watter rol speel die radioloog in suid-afrika, beide in die diagnostiese en terapeutiese arena? wat die diagnostiese ontwikkeling betref kan ons die volgende konstateer: 1. konvensionele x-strale het ontwikkel om maklik beskikbaar te wees vir almal. maar met nuwe en kragtiger rekenaars en digitalisering ontwikkel ons vinnig na sogenaamde filmlose departemente waar opnames nie net onmiddellik beskikbaar is vir die radioloog op sy skerm voor hom nie, maar waar dit letterlik binne sekondes via telefoon of satelliet dwarsoor die wêreld versend kan word. 2. rekenaartomografie beweeg na al hoe vinniger opnames met sogenaamde ‘multislice’ tegnologie, met beter resolusie en laer stralingsdosisse. drie-dimensionele rekonstruksies vergemaklik diagnose en chirurgiese beplanning. vate en hol organe kan endoluminaal herkonstrueer word. 3. mr-beelding het sekerlik die grootste impak gemaak op diagnose sedert die ontdekking van x-strale. dit kan op elke moontlike dissipline toegepas word. weereens neem die spoed van prosedures toe en die resolusie verbeter. waar mr aanvanklik primêr gefokus het op beelding van neurologiese en muskuloskeletale toestande is daar die afgelope paar jaar enorme ontwikkeling ook op die veld van die kardiovaskulêre stelsel. die longvelde sowel as die buik en bekken word ook nou verbeeld. in baie eerste wêreldlande het sg. magnetiese resonansie cholangio-pankreatografie (mrcp) die meer indringende endoluminale retrograde cholangiopankreatografie (ercp) ondersoek vervang. 4. wat ultraklank betref het die resolusie geweldig verbeter met die koms van sg. ‘powerdoppler’ en ‘tissue harmonics’. 5. die ontwikkeling van die foton emissie tomografie (pet) skandeerders het kerngeneeskunde se rol in diagnostiese radiologie gevestig. röntgen se ontdekking het dus uitgebrei na elke dissipline in die medisyne waar diagnose ter sprake is. ek het ook in die historiese oorsig van die ontwikkeling in radiologie spesifiek melding gemaak van die paradigma verskuiwing wat plaasgevind inaugural lecture 6 sa journal of radiology • may 2004 inaugural lecture 8 sa journal of radiology • may 2004 het. die rol van die radioloog het die afgelope 40 jaar uitgebrei deur die radioloog se toetrede tot die terapeutiese behandeling van die pasiënt. 1. wat die kardiovaskulêre stelsel betref, vorm die intervensionele radioloog deel van ’n span met die implementering van ballonangioplastie prosedures, stent of stentgraft inplantasie asook arterektomie en trombolise. aneurismes of disseksie van die aorta kan sedert 1994 endoluminaal hanteer word en sodoende kan die mortaliteit en morbiditeit van ingrepe dramaties verlaag. deur ’n klein insisie in die lies kan ons perkutaan ’n sg. stent graft prostese inplaas en ’n aneurisme herstel waarna die pasiënt binne ’n uur ’n koppie tee kan geniet en die volgende dag huis toe gaan. torakale aneurismes, disseksie of ruptuur kan ook so hanteer word. uitstekende opvolg rekenaartomografie (rk) beelde kan na so ’n prosedure die resultaat evalueer. 2. in die gastro-intestinale stelsel is ons betrokke by die inplasing van biliêre stents en sogenaamde transjugulere portosistemiese omleidings (tips) prosedures, asook embolisasie van gastro-intestinale bloeipunte. 3. die intervensionele neuroradioloog kan nou intrakraniale aneurismes emboliseer of arteriële malformasies emboliseer. 4. so is daar ook ’n rol in uroradiologie met die inplasing van nefrostomie dreinasiebuise en die perkutane verwydering van stene. 5. ’n relatief nuwe rol is die embolisasie van uteriene miome wat wêreldwyd sterk gevestig word. 6. die intervensionele radioloog kan boonop biopsies neem van letterlik enige tumor. chirurgie kan vergemaklik word deur voorafgaande embolisasies. selfs terapeutiese embolisasies kan chemoterapie komplementeer. 7. tans kan ons enige vernouing in enige arterie of vena dilateer en ook, tydens beskerming distaal, vernouings in die karotisvate dilateer. sodoende voorkom ons distale embolieë en die gevolglike katastrofe van 'n beroerte. 8. die nuutste ontwikkeling van die sogenaamde ‘drug eluting stents’ is sondermeer die mees dramatiese ontwikkeling wat die eliminasie van herstenose betref. die wall street journal het in ’n voorbladartikel hierdie ontwikkeling as die geboorte van ’n biljoen dollar industrie aangekondig. 9. nog ’n interessante ontwikkeling is die sg. magneetgedrewe kateterisasie en stereotakse waar beide x-strale en mr aangewend word vir kateterisasieprosedures sowel as vir kardiale ablasie. 10. nie alle intervensionele prosedures was egter suksesvol nie. laser tegnologie het ’n opwindende veld geopen om plaak en herstenose te behandel, maar dit was ’n mislukking en menige laser apparaat staan tans ongebruik in die kelderverdiepings van baie hospitale. progress surpassing the art of looking have we reached a point where progress has actually surpassed the art of looking or the art of visual discernment? let me explain my question. a colleague and friend recently made the remark in a discussion that nowadays we see too much. in other words, advanced radiological technology has eliminated the art and skills required in the past. the art of looking, of thinking with our eyes, has become redundant. for example, before our magnificent ct and mr images, we used simple measurements on angiograms to establish the presence of an intracranial tumour. distortion of the so-called sylvian triangle could give an indication of a possible intracranial lesion skillfully observed by a radiologist or neurosurgeon. today we simply do a 2-minute mri to locate the tumour. we can even get close to a histological diagnosis if we inject contrast or do spectroscopy. has progress alienated us from the art of healing? the germanic languages have traditionally spoken of medicine as both ‘geneeskunde’ and ‘geneeskuns’. has the latter, ‘geneeskuns’, become a victim of progress? i would certainly answer in the negative under the following conditions: • not if the radiologist applies his/her extensive knowledge of physics to offer the clinician the best imaging modality of choice to identify a certain condition. • not if the radiologist applies this knowledge to obtain the best diagnostic images with the least risk or harm to the patient. • and certainly not if the radiologist continues to apply all the conventional rules of radiology: to recognise what is normal and abnormal; to have a profound knowledge of anatomy; and to use his/her expertly trained eyes on what still remains variations of black and white. the art of healing has always included the craftsmanship of the practitioner as well as the application of the scientific advancements in medicine, the progress made in both knowledge and in technology. the storm of progress has taken medicine by force, but it is a challenge that we may not evade or neglect at any cost. in his inaugural address the principal of the university of pretoria underscored that in order to survive and develop as an academic institution, it is essential to be internationally competitive. he forwarded convincing statistics and figures to back his arguments and he highlighted the present shortcomings in our international ranking. should the criteria be applied to the radiology department of this university, the following must be said. we need state-of-the-art equipment and we need expertise to work in the department and train the students. the equipment of the department is insufficient and outdated. the average age of the equipment exceeds 15 years. we still do not own an mr, which nowadays plays a major role in diagnostic radiology and training of registrars. we are not equipped with a mammography unit for diagnosis or for screening. our nuclear department is the worst off, with extremely outdated equipment. it is unfortunate, but true, that at this stage we cannot compete with any of the private practices in gauteng, not to mention our position in the international arena. fortunately the present circumstances should change with the opening of the new pretoria academic hospital. it is expected that the department will be equipped with the latest developments in x-ray facilities. what about the expertise in our department? like many other departments, the department is currently understaffed, with a massive workload and not enough consultants. this obviously reflects on the quality of reporting and leaves little time for research possibilities and publications. it is essential that we consider the function of this university, and specifically the medical faculty, in the socio-political context of this country. in terms of the bill of rights every south african should have access to good health care. good health care not only entails adequate sanitation, immunisation and tb screening, it also entails good tertiary referral facilities. the patient diagnosed with tb in the primary facility is surely not only entitled to tb medication. when the patient develops a life-threatening episode of haemoptysis, should the patient not be entitled to embolisation of his bronchial arteries by a welltrained interventional radiologist? i believe the patient living in the rural area who develops claudication should, instead of undergoing an amputation, have access to a tertiary medical facility where a well-trained expert can do an interventional procedure. the increasing aids epidemic has also become a threat to the vascular system where we now see advanced aneurismal and occlusive disease in very young patients. surely we cannot simply ignore the pathology. the interventional radiologist has an obligation to salvage their limbs and treat their aneurysms. in radiological terms this treatment includes performing endoluminal procedures, the early diagnosis and treatment of cancers or infections, the embolisation of life-threatening haemorrhage, and the treatment of aneurysms with stent grafts. the new development of teleradiological services could give patients in rural areas easy access to diagnostic consultation. this service should be expanded to each and every clinic in the rural areas and linked up with an institute such as ours. academia, private sector and government one of the major challenges facing us in the establishment of a centre of excellence is the question of financing the costs. i have entered into the academic field after 16 years’ experience in the private sector. i intend to form an alliance with my colleagues in the private sector by which they will become part of this department to share their knowledge and experience with the prospective radiologists. i also see the formation of partnerships with the major enterprises in the medical field as one of our biggest challenges and goals to achieve. the government has budget restraints. although the budget for health increases every year, the percentage of the gdp is on the decline. furthermore, medical inflation is believed to be higher than in other sectors of society. we can no longer live with the expectation that government will finance our future developments. what we can do however is to think innovatively, coming up with ideas how government can make it attractive for the private sector to invest in the tertiary health care sector, specifically in the financing of hi-tech apparatus, without which we cannot hope to achieve our mission goals. lowering the tax burden for private donors or investors could be an option. the downside of the technological advancement is the excessive costs, the upside, however, is that the centres of inaugural lecture 10 sa journal of radiology • may 2004 excellence could attract private patients and therefore to a large extent begin to pay for themselves. the radiology department would be able to offer private patients interventional procedures as well as sophisticated mr imaging. the generated revenue can be utilised for the upgrading of equipment, research, educational material and bonus payments. this may also attract experts to return to the academic environment or to consider partnerships. whist on this subject, allow me to look briefly at the cost implications of interventional procedures. reduction in the overall treatment cost for the government health service by means of intervention is not always appreciated. although the average endoluminal devices are rather costly, the cost of hospital stay including icu, especially for a thoracotomy or abdominal aortic aneurysm (aaa) repair, surpasses that of an endoluminal procedure. interventional procedures can ultimately reduce cost. in addition to the cost saving factor, the mortality and morbidity is also substantially lower. to give an example: the mortality rate for an open surgical repair for a ruptured thoracic aorta approaches 35% whilst for endoluminal repair it is less than 16%. with regard to medical training and the lack of funds, we cannot venture into the future without partnerships with the private sector. most medical faculties lack the equipment needed for postgraduate training. government has however committed itself to private public partnerships. should we negotiate an agreement with the private sector on training, i want to propose the following: 1. in the event of expertise or technology not being available at an academic institution, the secondment of a registrar to the private sector for short periods, in the rule not longer than 3 months, must be considered. 2. the academic department can give accreditation to the private institution or practice for the training to be recognised. this will also entail that the private sector doctors receive a fellowship, or honorary lectureship, that they become part of the departmental academic team, and that they form part of the examination board of the department. medicine in a postmodern world the contemporary german philosopher, peter sloterdijk, in a paper on medicine’s search for excellence, made the observation that all cultures have in common the drive for immunity. man thus longs for an existence free of physical taxation and spiritual taxation, free of abnormalities and foreign agents that threaten his equilibrium. immunity is understood as the experience of well-being (‘in ordnung sein’) of living systems. he argues that historically speaking pre-modern man distinguishes himself from modern man only in this respect, that the pre-modern man relies or insures himself with experiences (in many cases superstitions) that offer vague immunity, whilst modern man in a progressive fashion has come to rely on techniques that offer him exact immunity. the paradigm of the latter can be found in the emergence of the insurance industry, the technological development since the 18th century, and specifically in the development of modern medical science. it is not by chance that the socalled health industries find themselves in the forefront of fortune's top 100 companies. he makes the proposition that we must not forget that medicine is one of the few remaining utopian enclaves in a demystified (read: post-modern) world. every healing that is enacted bears in it the original promise of a modern world, that we are progressively moving to a better world — socio-politically as well as bio-politically. the mentioned triad (insurance, technology and medicine) has established a new type of social contract, a contract that improves the chances between people, or, in his jargon, that optimises immunity. i find sloterdijk a very convincing cultural analyst, and i therefore propose that it is in the interests of the triad to invest in medical care and technology. i am also firmly convinced that the government as facilitator of social contracts can assist enormously in this respect. toekomsperspektiewe waarheen dryf die storm van vooruitgang ons heen? wat is die toekoms van radiologie as beroep? watter uitdagings staan ons te wagte in die toekoms? ons kry al hoe meer te make met ’n interne konflik van belange. in teenstelling met die chirurg, internis, pediater, uroloog of neuroloog, is die radioloog ’n diensverskaffer. die klinikus kan funksioneer sonder die radioloog, maar die radioloog kan nie funksioneer sonder die verwysing van die klinikus nie. feit van die saak is dat die radioloog nie 'n monopolie of alleenreg op sy kundigheid het nie. die oorname van beelding deur ander mediese dissiinaugural lecture 11 sa journal of radiology • may 2004 inaugural lecture 12 sa journal of radiology • may 2004 plines met die gevolglike uitsluiting van die radioloog, het ‘turf battles’ in die lewe geroep. daar is twee moontlike metodes om hierdie sogenaamde ‘turf battles’ te oorkom. in die eerste plek moet superspesialisasie plaasvind wat elke radioloog in ’n posisie van uitnemendheid plaas. die intervensionele radioloog sal in die toekoms toegerus moet word met die volgende vaardighede: beeld vaardigheid (imaging skills), kliniese kundigheid, intervensie vaardigheid, en kennis van genetiese ingeneurswese (genetic engineering). in die tweede plek moet samewerkingsooreenkomste binne ’n etiese raamwerk tussen die rolspelers daargestel word, dit is tussen die radioloog en die kardioloog, die vaskulêre chirug of die neurochirurg. ’n verdere moontlikheid wat al hoe meer aan die orde van die dag is, is die totale omkering van die tradisionle rolverdelings. die vinnige en maklike verkryging van heelliggaambeelding, met die voordeel dat dit binne sekondes verkrygbaar is, en totaal nieindringend is, open die moontlikheid dat die pasiënt direk van die algemene praktisyn na die radioloog verwys word wat op sy of haar beurt die pasiënt met ’n diagnose verwys na ’n klinikus in ’n ander dissipline vir verdere hantering. moderne tegnologiese ontwikkeling het radioloë met finansiële probleme belas wat buite hulle normale kundigheid lê. radiologie as beroep het al hoe meer ontaard in ’n reuse industrie. naas die finansiële bestuursvereistes, het die negatiewe wisselkoers van die rand 'n groot las op privaatpraktyke sowel as op die publieke gesondheidsdienste geplaas. is daar enige oplossings? ek antisipeer dat in die toekoms die sogenaamde professionele praktykbestuurder ’n onmisbare lid sal wees van elke radiologiepraktyk. met betrekking tot die groeiende kapitaaluigawes antisipeer ek dat groot finansiële instansies die aankoop van apparaat sal probeer oorneem. dit sal egter groot kontroversie uitlok. die ontwikkelende teleradiologiese dienste kan die sentralisasie van apparaat uitvoerbaar en prakties maak. die moontlikheid van samesmeltings van praktyke — soos wat in ander professionele beroepe plaasgevind het — tot dié mate dat ons in die toekoms die verskynsel van internasionale praktyke mag sien, sluit ek glad nie uit as die oplossing vir hierdie probleem nie. medical science has not escaped the storm of progress, au contraire; the fact that we have a higher life expectancy today than at any other time in the past is due to the advances made in the field of medicine. but in spite of the breathtaking developments that have taken place, especially in the last century, some of which i had the opportunity to show to you tonight, i am reminded of what marie curie once said: ‘one never notices what has been done, one only sees what remains to be done’. i concur with sloterdijk, that the science of modern medicine is one of the few remaining utopian enclaves promising us a better world — bio-political as well as socio-political. our quest for excellence is fuelled by that promise. radiology_may04 introduction the existence of all multicellular organisms on our planet is in part attributable to the development of a circulatory system. in vertebrates this has evolved to a highly complex structure whose function is to supply oxygen and nutrients to every living cell within the body, making it the largest single ‘organ’ within our bodies. its development and growth are stimulated by a combination of genetic and environmentally controlled factors. the vasculature also undergoes a constant process of maintenance and repair throughout life, with the entire vascular tree being replenished on average every 3 years. this article reviews some of the basic biology of normal and abnormal vascular development and how this relates to the development of vascular anomalies. vasculogenesis and angiogenesis vasculogenesis is the first stage of development of the vascular tree. this involves the differentiation of one or more mesodermally-derived vascular precursor cell types into angioblasts, the migratory precursors of endothelial and vascular smooth muscle cells.1-3 differentiation of angioblasts is followed by the association and assembly of endothelial cells to form the primitive vascular plexus. angiogenesis is the formation of new vessels by sprouting or splitting of pre-existing vessels. sprouting (or budding) angiogenesis occurs in various phases. during the activation phase there is disassembly of the vessel wall followed by proliferation and migration of endothelial cells into the surrounding extracellular matrix. during the resolution, or stabilisation, phase, the proliferation and migration of endothelial cells is halted and the vessel walls, both new and old, are then re-assembled and stabilised. failure to stabilise the new immature vessel leads to it undergoing apoptosis (cell death). non-sprouting angiogenesis (also termed splitting angiogenesis or intussusception) is characterised by the growth of interstitial cellular columns into the lumen of an already existing vessel so as to partition or split the vessel and thus remodel the local vascular network. angiogenesis is dependent upon the complex interaction between endothelial and smooth muscle cells and various growth (angiogenic) factors (table 1) and the extracellular matrix (ecm). the ecm consists of a complex three-dimensional network of (structural) proteins, polysaccharides and signal molecules surrounding the endothelial cell layer and contained by the basal lamina. during the activation stage of angiogenesis the ecm ‘softens’ and ruptures allowing endothelial cells to migrate and proliferate. during and after the resolution stage the ecm helps to reconstitute the vessel wall and thereafter to maintain its stability. ecm factors are listed in table ii. angiogenesis during the embryonic period is driven by the growing metabolic demand within the embryo due to the increase in organ size as well as the increase in distance between capillaries and cells resulting in reduced oxygen diffusion in the developing tissues. after birth angiogenesis is driven by normal physiological events such as growth, exercise, the menstrual cycle or pregnancy, or by pathological conditions such as tumour, ischaemia, inflammation, metabolic derangements, trauma, etc. arteriogenesis is the remodelling of pre-existing arteriolar collateral networks with coalescence of these to form larger conductance arteries which serve to redirect blood flow toward areas of higher metabolic demand. vasculogenesis, angiogenesis and arteriogenesis thus form a continuum involved not only in the primary development but also the maintenance and repair of blood vessels throughout life. the regulation of these processes is brought about by a genetic and environmentally determined balance between a multitude of proangiogenic and antiangiogenic factors and the extracellular matrix review article 18 sa journal of radiology • may 2004 vascular malformations part 1 — normal and abnormal vascular development ian c duncan ffrad (d) unitas interventional unit po box 14031 lytlelton 0410 (ecm). a full description of these growth factors and the ecm (structural proteins) and their role in vasculogenesis/angiogenesis is beyond the scope of this review, but for further information the reader is referred to the excellent reviews on this subject by kubis and levy1,2 and harrigan.3 the differentiation of primitive vessels into arteries, veins or capillaries is determined by flow patterns and is regulated by a class of molecules known as the ephrins. the development of congenital arteriovenous malformations may thus be related to defects in the ephrin signalling system. local environmental stimuli including shear stress or ischaemia in arterio-venous malformations (avms) may stimulate angiogenic factors and produce abnormal vascular remodelling. differences in the expression of various structural proteins and angiogenic factors are seen in different cerebral vascular malformations.3,4 for instance the endothelial and subendothelial layers of avms express more laminin and collagen iv than those in low-flow cavernous malformations, whereas cavernous malformations express more fibronectin than avms. fibronectin and laminin are structural proteins found in the basement membranes of normal vessels, and are thought to maintain the structural integrity of vessel walls by anchoring endothelial cells to the underlying internal elastic membrane and smooth muscle layers. fibronectin tends to predominate in the initial stages of angiogenesis (activation stage) where immature vessels with non-adherent proliferating endothelial cells exist in a fibronectin -rich extracellular matrix. laminin is found mainly during the maturation phase of angiogenesis where more mature vessels with adherent nonproliferating endothelium are found. therefore it can be concluded that cavernous malformations are angiogenically more immature than avms. this relative immaturity of the walls of a cavernous malformation results in a high degree of fragility and thus a tendency to bleed in the absence of increased haemodynamic forces.4 in addition to the differences in the levels of various structural proteins between the two malformation types there is also a difference in the expression of angiogenic factors. although vascular endothelial growth factor (vegf), b fibroblastic growth factor (bfgf) and transforming growth factor α (tgfα) are expressed in both avms and cavernous malformations in keeping with the active angiogenic processes associated with their development, review article 19 sa journal of radiology • may 2004 table i. angiogenetic growth factors1 1. vascular endothelial growth factor (vegfa-e and pigf) • stimulates angiogenesis • stimulates endothelial protease production • causes controlled microvascular permeability to plasma proteins • stimulates the formation of angioblasts from precursor cells • vegf-c and-d are associated with lymphangiogenesis 2. angiopoietins: (ang 1 to 4) • are ligands for the endothelium-specific receptors tie2 • stimulate vascular remodelling (ang1 + tie2) • stimulate endothelial maturation and stabilisation (ang1 + tie2 with vegf) • ang2 with vegf produces loss of adhesion of endothelial cells allowing their migration to occur 3. fibroblast growth factor : (afgf, bfgf) • are potent stimulators of endothelial cell migration, proliferation, sprouting and tube formation • are mainly involved with vascular maintenance and repair 4. platelet derived factor (pdgf) • promotes proliferation and migration of endothelial cells, vascular smooth muscle cells and pericytes 5. transforming growth factor: (tgfα and β) • tgfβ is a potent inhibitor of endothelial cell migration and proliferation 6. others, including egf, tnfα, ephrins, etc. table ii. extracellular matrix factors2 1. coagulation and fibrinolytic factors: • regulation of coagulation is required to avoid thrombosis or haemorrhage during neoangiogenesis 2. metalloproteinosis (mmp) • are proteolytic enzymes that cause degredation of the basal lamina and extracellular matrix before endothelial cell migration 3. integrins: • promote cell-cell and cell-matrix adhesion bfgf is expressed in the endothelia of cms but not in the endothelia of avms. glial cells adjacent to avms express vegf whereas those adjacent to cms express bfgf and tgfα but do not express vegf. venous angiomas, by comparison, do not express growth factors but do express structural proteins of the mature phase of angiogenesis.4 the above examples show distinct biological differences between the different malformation types related to the variable expression of structural matrix proteins and angiogenic factors within each. it would be an oversimplification to claim that a deficiency or functional abnormality of one or more specific structural proteins or angiogenic factors will lead to the development of a specific malformation type as the aetiological development of vascular malformations is undoubtedly multifactorial, depending upon a number of factors including genetic defects, environmental effects (biological and mechanical) and trigger agents or events.5 genetic factors in vascular malformations there is primarily a basic underlying genetic control of vasculogenic and angiogenic processes, modified by metabolic demand and other physiological influences. a clear link between the development of vascular malformations and an identifiable genetic defect has been shown to date in several distinct conditions.6,7 1. hereditary haemorrhagic telangiectasia (hht) (osler-weberrendu): this is a multisystemic angiodysplasia which is inherited as an autosomal dominant trait with varying degrees of penetrance and expressivity. defects in two genes have thus far been identified as being responsible for the induction of the vascular malformations seen in hht.8 these genes are endoglin (chromosome 9, hht 1) and alk-1 (chromosome 12, hht 2), both of which encode for vascular endothelial transmembrane receptors of transforming growth factor -β (tgf-β).1 tgf-β, in turn, plays a role in endothelial cell resolution via activation of the alk-1 pathway, and endothelial cell activation via activation of the alk-5 pathway. a reduction of the levels of endoglin in hht-1 may lead to a decrease in tgf-β levels, affecting both the alk-1 and alk-5 pathways. the alk-5 pathway, however, has a higher sensitivity to the remaining tgf-β than the alk-1 pathway thereby preferentially stimulating endothelial cell activation. in hht-2 reduced alk-1 proteins lead to preferential relative overactivity of the alk-5 pathway again stimulating endothelial cell activation. this activation then stimulates the production of the angiogenic inducer vascular endothelial growth factor (vegf). levels of vegf have been shown to be significantly elevated in patients with hht.9 either interruption of tgf-β function or increased levels of vegf or other related angiogenic factors may thus play a role in the development and growth of the various vascular malformation types seen in hht. 2. venous malformations: venous malformations result from mutations in at least 2 genes on chromosomes 1(1p21-22) and 9 (9p21-22/tie2). the latter gene, tie2, encodes an endothelial cell surface receptor for a group of extracellular signalling molecules called the angiopoeitins which regulate the maturation of primitive vessels. in a number of patients with venous malformations the disease is inherited as an autosomal dominant trait. the blue rubber bleb nevus syndrome (bean syndrome) is an inherited disorder where patients develop venous malformations in the skin, gastrointestinal tract, brain and other organs. 3. arterial malformations in neurofibromatosis type i: nf i results from mutations on chromosome 17. the affected gene, neurofibromin, encodes an intracellular signalling protein that has a role in embryonic vascular development. 4. familial cavernous malformation: cavernous malformations (cms) can be classified as either sporadic or familial. some 20-30% of patients with cms in north america may have the familial form in which an autosomal dominant pattern of inheritance is seen. the genetic mutation responsible for the development of these cms has been identified on the long arm of the 7q chromosome.10 further point mutations have been identified including two on the short arm of chromasome 7(7p15-13) and the long arm of chromosome 3(3q 25.2.27)(ccm52 +3).11,12 the first of these genes, ccm1, has been identified more recently as encoding the krit1 protein which plays a role in intercellular signalling particularly to endothelial cells.13 thus the importance of the above diseases lies in the fact that distinct genetic mutations have now been identified that have led directly to the phenotypic expression of vascular malformation development. all of the above are inherited as autosomal dominant traits, rendering them easy review article 20 sa journal of radiology • may 2004 to identify as genetic abnormalities. others having an autosomal recessive or polygenic pattern of inheritance will undoubtedly be more difficult to identify, but it is probable that as time progresses further specific genetic defects related to the development of vascular malformations will be discovered.6,7 lymphangiogenesis lymphatic vessels develop parallel to blood vessels and drain tissue fluid that results from normal leakage from blood vessels. they arise by both sprouting from existing embryonic veins as well as by the in situ differentiation of lymphatic endothelial cells from lymphangioblasts.14 certain specific proteins have been shown to mediate the development and growth of lymphatic endothelium. these include vascular endothelial growth factors c and d (vegf-c and vegfd) and the receptor vegfr-3(or flt-4).15 it is thought that vegf-c induces lymphatic growth mediated by vegfr-3. other genes that have been shown to be relatively specifically expressed in lymphatic endothelial cells include prox 1, podoplanin and lyve-1. approximately 35% of patients with primary lymphoedema have a positive family history for the disease. primary congenital lymphoedema (milroy's disease) results from mutations on the vegfr-3 (or flt-4) gene found on chromosome 5(5q35.3). abnormal vegfr-3 activity leads to reduced binding of ligands such as angiopoeitin-1(ang-1). the angiopoeitins are ligands for tie-2, an endothelial cell receptor important in the stabilisation and maturation of the vascular network in embryos. ang-1 also seems to inhibit vegfinduced vessel permeability. this would thus lead to increased lymphatic permeability and the development of lymphoedema. late onset lymphoedema (lymphoedema praecox, meige's disease) develops at the onset of puberty. this syndrome together with others including lymphoedema distichiasis (lymphoedema with abnormal hairs from eyelid meibomian glands), lymphoedema and ptosis, and yellow nail syndrome are all linked to inactivation mutations of the foxc2 (mfh-1) gene on chromosome 16 (16q24). lymphatic malformations, in contrast to lymphoedemas, are true malformations composed of dilated lymphatic channels or vesicles filled with fluid but which do not connect with lymphatic vessels. they are present at birth and typically enlarge in the presence of infection.14 they demonstrate a normal endothelial cell replication cycle unlike lymphangiomas which are hypercellular tumours of lymphatic origin.16 because of the developmental association between veins and lymphatics, mixed venolymphatic malformations may occur. endothelial proliferation endothelial cell proliferation occurs as part of the normal angiogenic or lymphangiogenic process. the proliferation of endothelial cells is induced during the activation phase of angiogenesis by factors such as platelet derived growth factor (pdgf) and is inhibited during the resolution phase by factors such as transforming growth factor β1 (tgfβ1).1 mulliken and glowacki16 classified paediatric vascular malformations based on endothelial cell characteristics, specifically the rate of endothelial cell turnover. they differentiated between haemangiomas that are characterised by endothelial cell hyperactivity during the proliferative phase (rapid neonatal growth) followed by diminishing cellularity during the involuting phase later in life, and vascular malformations that are characterised by a normal rate of endothelial cell turnover (compared with normal blood vessel endothelial cell turnover). thus the malformations remain true malformations lined with mature endothelial cells, whereas the haemangiomas are essentially endothelial cell tumours. the lymphatic equivalents are lymphangioma and lymphatic malformations, again differentiated according to lymphatic endothelial cell growth characteristics. the growth and development of an infantile haemangioma mimics the growth of the normal vascular tree in that early lesions are highly cellular with plump endothelial cells lining vascular spaces with very small lumina, and that as they mature the endothelium becomes flattened and the vascular spaces enlarge.17 thus haemangiomas represent a form of ‘runaway’ neoplastic endothelial cell proliferation. increased endothelial proliferation is, however, also seen to occur to a much lesser degree in vascular malformations as well. the rate of endothelial cell turnover is seven times greater in cerebral avms than in normal cerebral blood vessels.18 increased endothelial cell turnover has also been demonstrated in cerebral cavernous malformations.19 thus although increased, endothelial cell growth rates are nowhere near the scale of those seen in haemangiomas, remaining the key differentiating feature between the two vascular abnormalities (table iii). review article 21 sa journal of radiology • may 2004 review article 22 sa journal of radiology • may 2004 the future there is currently a tremendous amount of research being conducted into the role of angiogenesis and genetic mutations in the development of vascular malformations, tumours, inflammatory diseases and other pathological processes. presently under investigation are a number of anti-angiogenic agents being tried for the treatment of various tumours.3 additionally pro-angiogenic agents may someday play an important role in combating the effects of tissue or organ ischaemia. future treatments for vascular and lymphatic malformations will undoubtedly also involve gene-based therapies.7 references 1. kubis n, levy bi. vasculogenesis and angiogenesis: molecular and cellular controls. part 1: growth factors. interventional neuroradiology 2003; 9: 227-237. 2. kubis n, levy bi. vasculogenesis and angiogenesis: molecular and cellular controls. part 2: interactions between cell and extracellular environment. interventional neuroradiology 2003; 9: 239-248. 3. harrigan mr. angiogenic factors in the central nervous system. neurosurgery 2003; 53: 639-661. 4. kilic t, pamir mn, kullu s, eren f, ozek mm, black pm. expression of structural proteins and angiogenic factors in cerebrovascular anomalies. neurosurgery 2000; 46: 1179-1191. 5. lasjaunias pl. segmental identity and vulnerability in cerebral arteries. interventional neuroradiology 2000; 6: 113-124. 6. shovlin cl. genetic aspects of cerebrovascular diseases. interventional neuroradiology 2000; 6: 107-111. 7. vikkula m, boon lm, mulliken jb. molecular genetics of vascular malformations. matrix biol 2001; 20: 327-335. 8. begbie me, wallace gmf, shovlin cl. hereditary haemorrhagic telangiectasia (oslerweber-rendu syndrome): a view from the 21st century. postgrad med j 2003; 79: 18-24. 9. cirulli a, liso a, d'ovido f, et al. vascular endothelial growth factor serum levels are elevated in patients with hereditary haemorrhagic telangiectasia. acta haematol 2003; 110: 29-32. 10. dubovsky j, zabramski jm, kurth j, et al. a gene responsible for cavernous malformations of the brain maps to chromosome 7q. hum mol genet 1995; 4: 453-458. 11. craig hd, günel m, cepeda o, et al. multilocus linkage identifies two new loci for a mendelian form of a stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27. hum mol genet 1998; 12: 1851-1858. 12. günel m, awad ia, finberg k, et al. genetic heterogeneity of inherited cerebral cavernous malformation. neurosurgery 1996; 38: 1265-1271. 13. couteulx sl, jung h, labauge p, et al. truncating mutations in ccm 1, encoding krit 1, cause hereditary cavernous angiomas. nat genet 1999; 23: 189-193. 14. brouillard p, vikkula m. vascular malformations: localized defects in vascular morphogenesis. clin genet 2003; 63: 340-351. 15. karkkainen mj, jussila l, ferrell re, finegold dn, alitalo k. molecular regulation of lymphangiogenesis and targets for tissue oedema. trends in molecular medicine 2001; 7: 18-22. 16. mulliken jb, glowacki j. hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. plast reconstr surg 1982; 69: 412-419. 17. requena l, sangueza op. cutaneous vascular proliferations. part ii. hyperplasia and benign neoplasms. j am acad dermatol 1997; 37: 887919. 18. hashimoto t, mesa-tejada r, quick cm, et al. evidence of increased endothelial cell turnover in brain arteriovenous malformations. neurosurgery 2001; 49: 124-132. 19. sure u, butz n, schlegel j, et al. endothelial proliferation, neoangiogenesis and potential de novo generation of cerebrovascular malformations. j neurosurg 2001; 94: 972-977. table iii. characteristics of haemangiomas and vascular malformations angiogenesis endothelial cell proliferation haemangiomas + ++++ vascular malformations + + radiology_aug04 6 sa journal of radiology • august 2004 abstract an increasing number of patients with metal implants are being referred for magnetic resonance imaging (mri) investigations. implants and devices may be divided into two groups, namely active and passive. this article will focus on passive devices. a device is mr-safe when it is used in the mr environment, but presents no additional risk to the patient or other individuals, although the quality of diagnostic information may be affected. mr procedures may be contraindicated due to various interactions between the mr environment and medical devices, which include torque, translational force, heating, induced electrical currents, magnetic field interactions, artefacts, and misrepresentation. therefore, before deciding whether any object is mrsafe/compatible, the intended use and the possible retaining mechanisms must be considered. introduction an ever-increasing number of patients are being referred for magnetic resonance imaging (mri) investigations, with a subsequent increase in the number of patients presenting with old and new metal implants. the question arises whether it is safe for these patients to enter a magnetic resonance (mr) environment. after review of the literature we compiled this quick guide to safety and compatibility of implants and devices in an mr environment. general considerations implants and devices may be divided into two groups, namely active (especially electronically activated devices, e.g. cochlear implants, implantable cardiac defibrillators, or any other activated device including ventilator and monitoring devices) and passive (clips, sutures, prostheses and any other device that serves its function without power supply). in this article the focus will be on passive devices. when a device is mr-safe it means that when used in the mr environment the device presents no additional risk to the patient or other individuals, although the quality of diagnostic information may be affected. mrcompatible equipment is mr-safe and can be used in the mr environment with no significant effect on its operation or on the quality of diagnostic information. no metal is totally nonmagnetic or non-ferromagnetic, as all metals possess some degree of magnetism. mr procedures may be contraindicated due to various interactions between the mr environment and medical devices, which include torque (product of axial force and the distance of the line of action from the axis) and translational force, both of which could cause possible movement or dislodgement of a ferromagnetic biomedical implant, material, device, or object. other possible hazards and problems include heating, induced electrical currents (in materials that are conductors), magnetic field interactions (functional disruption of device), artefacts, and misrepresentation. translational attraction is assessed by using the deflection angle test, measured at the point of the ‘highest spatial gradient’ for the specific mr system. the deflection angle test central to mr safety testing for metallic implants and devices is as follows: for deflections less than 45° in the deflection angle test, the magnetically induced deflection force is less than the force of gravity on the implant. it review article a quick guide to safety and compatibility of passive implants and devices in an mr environment d j kotzé mb chb c de vries mmed rad (d) department of diagnostic radiology university of the free state bloemfontein implies that any risk imposed by the application of the magnetically induced force is no greater than any risk imposed by normal daily activity in the earth’s gravitational field. there are no concerns about movement or dislodgement in people with implants and devices made from non-ferromagnetic or weakly ferromagnetic materials with a deflection angle between 0° and 44°. a torque value in any implant/ device that is less than that produced by normal daily activities (which include rapidly accelerating vehicles or amusement park rides) is assumed to be safe. translational attraction/deflection and torque could lead to movement or dislodging of ferromagnetic implants. this may cause discomfort or even serious injury to a patient.1 translational attraction effects on external and implanted ferromagnetic objects in the immediate area around the mr system are usually responsible for possible dangers. translational attraction is proportional to the static magnetic field strength, spatial gradient strength, and mass, shape and magnetic susceptibility of the object. deflection angles and magnetic field interactions of an implant can differ significantly between longand short-bore mr. they are usually much higher in a short-bore. higher magnetic field strength mr systems are rapidly increasing worldwide. previously investigations were performed with magnetic fields only up to 1.5t. weakly ferromagnetic objects in lower field strengths may experience much more interaction in higher field strengths. according to faraday’s law any change in a magnet field could induce a current in a conductor. this conductor in the mr environment could be cable, jewellery, metal external fixation devices or even a patient’s arms if he holds his hands together above his head. the current induces heat in the conductor and that could present as burns on the patient. in order to evaluate whether a device is now safe or compatible in the mr environment we need to keep in mind the things that could happen to this device. in summary the relative risk of injury depends on: • ferromagnetic properties of the foreign body • geometry and dimensions of the object • strength of the static magnetic field • strength of the spatial gradient of the mr system • amount of force with which the object is fixed within the tissue (i.e. counter-force or retention force) • whether it is positioned in or adjacent to a particularly sensitive site (vital neural, vascular, or soft tissue including eyes). specific passive devices heart valve prostheses and annuloplasty rings2-4 most exhibited no magnetic field interactions but at 3.0 tesla the carpentier-edwards physio annuloplasty ring, mitral model 4450, edwards lifesciences, irvine, usa showed relatively minor magnetic field interactions. the actual magnetic field interactions exerted on this implant are minor compared with the force exerted by the beating heart (i.e. approximately 7.2 n), therefore mr procedures at 3.0 tesla are not considered to be hazardous. penile implants2,3 weakly ferromagnetic penile implants may cause discomfort. several different penile implants have been tested for mr safety in association with 3.0 tesla mr systems but only duraphase and omniphase demonstrated relatively minor or ‘weak’ magnetic field interactions. most of the other penile implants are considered safe for patients. sutures2,3 two types (flexon suture and steel suture, united states surgical, north haven, ct) showed minor deflection angles and torque at 3.0 tesla. the use of these materials will, however, provide sufficient counter-force to prevent movement or dislodgment. none of the other evaluated sutures (without their needles) displayed magnetic field interactions and appear to be safe at 3.0 tesla. aneurysm clips1-3,5-9 certain types of intracranial aneurysm clips (e.g. those made from martensitic stainless steels such as 177ph or 405 stainless steel) are absolutely contraindicated in mr procedures because magnetically induced forces may be excessive and these clips may displace or dislodge resulting in serious injury or death. non-ferromagnetic, non-magnetic or weakly ferromagnetic aneurysm clips (e.g. those made from phynox, elgiloy, austentitic stainless steels, titanium alloy, or commercially pure titanium) are safe for mr use. only one known ferromagnetic aneurysm clip-related fatality has been reported in the peerreviewed literature. injury due to the presence of an aneurysm clip made from a non-ferromagnetic or weakly review article 7 sa journal of radiology • august 2004 ferromagnetic material has never been reported. there have been cases where patients with ferromagnetic aneurysm clips (deduced from the extent of the artefact seen during mr imaging) have undergone mr procedures without any injuries. the deflection angle test and some form of evaluation of torque are probably the most appropriate means of determining whether a specific aneurysm clip may present a hazard to a patient or individual in the mr environment. aneurysm clips that are considered safe for patients or individuals exposed up to an 8.0 tesla mr system, with deflection angles less than 45° (astm guideline) and relatively minor qualitative torque values were manufactured from: commercially pure titanium (spetzler), elgiloy (sugita), titanium alloy (yasargil, model fe 750t), and mp35n (sundt). shellock’s investigations were highly specific to the types of intracranial aneurysm clips that underwent testing (model, shape, size, blade length, material, etc.). studies indicated that in spite of long-term and/or multiple exposures to 1.5 tesla mr systems there were no clinically significant changes in their magnetic properties. jewellery3 mild-to-moderate movement and/or displacement depending on the body piercing site and the ferromagnetic qualities (e.g. mass, degree of magnetic susceptibility, etc.) of the jewellery may cause uncomfortable sensations. there is also a theoretical possibility of mri-related heating that could cause burns. metallic bodypiercing jewellery should be removed prior to entering the mr environment. if metallic jewellery or piercing cannot be removed the patient should be informed about the potential risks and preferably cancel the procedure. if it is not possible to cancel, then some means of stabilisation (e.g. application of adhesive tape or bandage) should be used to prevent movement or displacement in the mr. to prevent contact with the underlying skin and prevent excessive heating, wrap gauze or tape to at least 1 cm thick around piercing jewellery made from conductive materials. breast devices3 breast tissue expanders constructed with magnetic ports allow for a more accurate detection of the injection site. therefore, these devices are attracted to the static magnetic field of mr systems and may be uncomfortable or become dislodged, causing injury to a patient undergoing an mr procedure. cardiovascular guidewire and catheters3 patients with cardiovascular catheters and accessories with internally or externally positioned conductive metallic components should not undergo mr procedures. interventional mri devices and catheters without metallic components were deemed safe and were not included in the overall ex vivo tests for mr safety. it should be noted that these catheters and accessories were evaluated for mr safety without being connected to monitoring equipment. there is at least one report of a cardiovascular catheter that melted in a patient undergoing mr imaging. there has never been a report of an incident or injury related to retained cardiac pacing wires in association with an mr procedure. coils, filters and stents3,10-13 several of these displayed magnetic field interactions during exposure to an mr environment, although most are incorporated securely into the vessel wall due to tissue ingrowth at about 6 8 weeks after placement. similar devices made from non-ferromagnetic materials, such as the lgm ivc filter (vena tech) used for caval interruption or the wallstent biliary endoprosthesis (schneider (usa), inc.) used for treatment of biliary obstruction, are considered safe for patients undergoing mr procedures. however, not all stents are safe: gianturco stent (cook), and the modified gianturco stent (song), made of stainless steel, displayed magnetic field interactions where the deflection angles were greater than 45° exceeding the astm guideline. retention by tissue ingrowth and stents with hooks or barbs (to prevent migration after placement) may prevent them from posing a substantial risk to an individual. cranial fixation devices3,14 the clamps used for the cranial bone flap fixation system showed no magnetic field interaction and little heating; therefore they seem to pose no risk to the patient in a < 1.5 tesla mr environment. cranial and burr hole fixation implants and devices made from titanium have been tested safe at 3.0 tesla. dental devices3,15 many of the dental implants, devices, materials, and objects evaluated for ferromagnetic qualities exhibited measurable deflection forces, but review article 8 sa journal of radiology • august 2004 only the ones that have magnetically activated components present a potential problem for patients during mr procedures. the other dental implants, devices and materials are held in place with sufficient counterforces to prevent them from causing problems by being moved or dislodged by exposure to mr systems operating at 1.5 telsa or less. contraceptive devices3,16 various devices are listed: • diaphragms contain metallic rings, but they are not a contraindication at 1.5 tesla. • essure is a novel metallic implant for permanent female contraception (in the usa). this is a dynamically expanding micro-coil that is placed in the proximal section of the fallopian tube via a non-incisional technique. an intended benign tissue response that is local, fibrotic and occlusive results in tissue in-growth into the device. it is thus anchored into the fallopian tube. there are no magnetic field interactions, the highest temperature changes were < +0.6°c, and the induced electrical currents are minimal. • the lea shield is a silicon rubber intravaginal barrier. • intrauterine contraceptive devices (iucds) are usually made from non-metallic materials (e.g. plastic) or a combination of non-metallic and metallic materials. copper is the metal most used in an iucd without side-effect. • the mirena device is safe at all static magnetic field strengths. ecg electrodes3 some patients need monitoring during the mr procedure, especially if there is a deterioration of vital signs during the investigation. as mr-guided surgery and therapy are also growing, there is an increased need to monitor patients. investigations that use the electrocardiogram (ecg) for the purpose of gating also require the proper acquisition of the appropriate physiological signal for accurate representation of the mr images. patient safety and proper recording of the ecg in the mri environment require specially developed ecg electrodes. using them during mri procedures protects the patient from potentially hazardous conditions and produces minimal mri-related artifacts. special fibre-optic ecg recording techniques may be used to prevent burns during mr procedures. foley catheters2,3 there are foley catheters available with a temperature sensor. these should never be connected to the temperature monitor during the mr procedure because the equipment is not mr-compatible or safe. cervical fixation devices2,3,17,18 mr procedures should only be performed on patients with halo vests or cervical fixation devices made from non-ferromagnetic and non-conductive materials, that have little or no interaction with the electromagnetic fields generated by mr systems. halo vests or cervical fixation devices may be constructed from either ferromagnetic, non-ferromagnetic, or a combination of metallic components and other materials. although some commercially available halo vests or cervical fixation devices are composed entirely of non-ferromagnetic materials, there is always a theoretical hazard of inducing electrical current in the ring portion of any halo device made from conductive materials (faraday’s law of electromagnetic induction). the patient is also susceptible to possible burn or electrical injuries. noteworthy vibration of metallic components of devices like the halo ring, vertical supports, vest bolts, etc. were observed during mr imaging. haemostatic clips2,3 in several studies at 1.5t no static magnetic field attraction to the clips was observed. at 3.0t the surgiclip spring made from carbon steel (united states surgical, north haven, usa) showed a deflection angle of 90˚ and a qualitative torque of +4. this implant is currently categorised as ‘unsafe’ at 3.0t even though the closing force may provide substantial counterforce to prevent it from being moved or dislodged. most of these implants were manufactured from non-ferromagnetic materials such as tantalum, commercially pure titanium, and non-ferromagnetic forms of stainless steel. some ligating, haemostatic, or other types of clips are made from biodegradable materials. patients who have haemostatic vascular clips, other clips, fasteners, and staples as mentioned in shellock’s booklet should not be at risk for injury during mr procedures. there has never been a report of an injury to a patient associated with a haemostatic vascular clip, other type of clip, fastener, or staple in the mr environment. patients with non-ferromagnetic versions of these implants may undergo mr procedures immediately after they are placed surgically. patients with metallic carotid artery vascular clamps have been imaged using static magnetic fields ranging up to 1.5t without experiencing any discomfort review article 9 sa journal of radiology • august 2004 or neurological consequence, with the exception of the poppen-blaylock clamp. a metallic marking clip, the micromark, made from 316l stainless steel by biopsys medical (irvine, ca), has been developed for percutaneous placement after stereotactic breast biopsy. micromark ii clip (316lvm stainless steel, ethicon endosurgery, cincinnati, ohio) has been tested for mr safety in 1.5 tesla and 3.0 tesla mr systems. the findings indicated that there were no magnetic field interactions associated with exposure to 1.5 tesla and 3.0 tesla mr systems or mri-related heating. owing to excessive ferromagnetism and the associated imaging artefacts that may limit or obscure the area of interest, most biopsy needles, markers and devices are not useful for mr-guided biopsy procedures. otological implants3,19 the ferromagnetic mcgee stapedectomy piston prosthesis is made from platinum and chromium-nickel alloy stainless steel. the manufacturer has recalled this particular otological implant and patients who received these devices should avoid mr procedures. ocular implants3,20 beware of intra-ocular foreign bodies. a patient with a fatio eyelid spring or round wire eyelid spring may experience discomfort but would probably not be injured as a result of exposure to the magnetic fields of an mr system. patients have undergone mr procedures with eyelid wires after having a protective plastic covering placed around the globe along with a firmly applied eye patch. although no such case has ever been reported, the troutman magnetic ocular implant and retinal tacks (made from martensitic stainless steel) may cause injuries to a patient during an mr procedure. orthopaedic implants3,21 most orthopaedic implants, materials, and devices evaluated for ferromagnetism are made from non-ferromagnetic materials and therefore should be safe for patients undergoing mr procedures. only the perfix interference screw used for reconstruction of the anterior cruciate ligament has been found to be highly ferromagnetic. because this interference screw is firmly imbedded in bone, it is held in place with sufficient force to counterbalance it and to prevent movement or dislodgement and should not be considered a contraindication to mr. however, it is preferable to use interference screws made from nonor weakly ferromagnetic materials. pellets and bullets3,22 the risk against benefit and the anatomical location must be considered when deciding to perform an mr procedure in a patient with pellets, bullets, shrapnel or any other ballistic object because it may be contaminated with ferromagnetic materials. surgical instruments3,23,24 interventional mri procedures include a wide spectrum of minimally invasive surgical and therapeutic techniques that include percutaneous biopsy (e.g. breast, bone, brain, abdominal), endoscopic surgery of the abdomen, spine, and sinuses, open-brain surgery, and mr-guided monitoring of thermal therapies (i.e. laser-induced, rf-induced, and cryomediated procedures). for interventional mri procedures surgical instruments and devices must be mrcompatible or at least mr-safe. the key problem of the conventional instruments and devices made from metallic materials in association with interventional mri procedures is primarily image related. other concerns are: unwanted movement due to magnetic field interactions, the missile effect, translational attraction, torque and heating generated by rf power deposition. the lack of commercially available, mr-compatible medical devices and instruments has hampered the widespread implementation of mrguided procedures, mainly those involving the use of complicated instruments such as the endoscope. endoscopy in combination with mr guidance may offer several advantages including a dramatic improvement in the visualisation and orientation of the endoscope, an ability to appreciate complex three-dimensional anatomy in immediate and remote anatomical areas, and a reduction in procedurerelated morbidity. the use of commercially available endoscopes constructed from ferromagnetic materials is restricted in the mr environment owing to the associated substantial magnetic field attraction and production of large imaging artefacts. mr systems like conventional, open-architecture, or the doubledonut mr systems (specially designed) for mr-guided biopsy, therapeutic, and minimally invasive surgical procedures are important clinical applications. to support these interventions and procedures innovative design and construction of instruments and devices are needed. weakly ferromagnetic, non-ferromagnetic or non-metallic materials are used to make special instruments for interreview article 10 sa journal of radiology • august 2004 ventional mr procedures. metallic surgical instruments and other devices potentially pose hazards (e.g. missile effects) or cause other problems such as image distortion, obscuring the region of interest, affecting adequate visualisation of the abnormality, and preventing execution of the procedure. ceramic instruments have exceptionally good qualities for the mr environment because there is no magnetic field attraction, negligible heating, and no substantial image distortion, as determined by the ex vivo testing. tattoos and permanent cosmetics3,25,26 permanent cosmetics like tattooed eyeliner and decorative tattoos may cause mr imaging artefacts and relatively minor, short-term cutaneous reactions. the presence of a permanent cosmetic or decorative tattoo should not prevent the mr examination, since diagnostic information of vital significance may affect management of the patient. prostate seed implant3 prostate cancer is sometimes treated by low-level radiation via a titanium tube implant with graphite, lead and palladium, the theraseed. tests demonstrated safety in an mr environment of 1.5t. transdermal patches3 transdermal delivery system with a metallic component must be removed prior to an mr procedure, as the possibility of burn injury exists. apply a new patch on completion of the examination. vascular access ports3 various implantable vascular access ports and catheters evaluated for compatibility with mr procedures showed no measurable attraction to the static magnetic fields of the mr systems used for testing. the forces were considered to be minor relative to the in vivo application of these implants. accessories, like the infusion set and needles, showed measurable ferromagnetism, with the port-acath needle (deltec, inc., st paul, mn) exceeding the recommended astm deflection angle safety guideline (i.e. greater than 45°). a small strip of adhesive tape is an effective counterbalance to the ferromagnetism. verify that the specific device is in shellock’s list and is safe to enter an mr environment. postoperative patients and mr procedures2,3,12,13 a patient with a metallic object ‘passive implant’ (no electronically or magnetically activated component associated with the operation of the device) that is made from non-ferromagnetic material (e.g. titanium, titanium alloy, nitinol, etc.), may undergo an mr procedure immediately after implantation in an mr system operating at 1.5 tesla or less. a waiting period of 6 8 weeks after placement of other implants or devices that exhibit ‘weakly magnetic’ qualities (e.g. certain stents, atrial septal defect occluders, ventricular septal defect occluders, patent ductus arteriosus occluders) is recommended before performing an mr procedure or allowing the individual or patient to enter the mr environment at < 1.5 tesla.‘weakly’ ferromagnetic intravascular and intracavitary coils, stents, filters, and cardiac occluders become firmly incorporated into tissue 6 8 weeks following placement. retentive or counter-forces provided by tissue ingrowth, scarring, or granulation essentially serve to prevent these objects from presenting risks or hazards to patients or individuals in the mr environment. rigidly fixed implants or devices that may be ‘weakly magnetic’, such as a bone screw, may be studied immediately after implantation. unconscious and unresponsive patients protect the hearing of all unconscious and unresponsive patients prior to being scanned. halfway through the procedure all monitoring lead locations should be repositioned as patients may be unable to report an increase in tissue warmth or pending thermal injury. conclusion before deciding whether any object is mr-safe/compatible carefully consider the intended use and the possible retaining mechanisms like sutures, granulation or tissue ingrowth, thus preventing movement and the possible effect of heating of sensitive tissue. this is a quick guide for passive devices. active devices will be discussed in a later article. all mr rooms should have an up-to-date list of devices and a copy of f g shellock’s pocket guide to mr procedures and metallic objects, which is about as complete as it gets.27 another useful site is shellock’s mri safety.com.28 acknowledgement f g shellock’s information has been reproduced with permission. references 1. shellock fg, crues jv. aneurysm clips: assessment of magnetic field interaction associated review article 11 sa journal of radiology • august 2004 review article 12 sa journal of radiology • august 2004 with a 0.2-t extremity mr system. radiology 1998; 208: 407-409. 2. shellock fg, curtis js. mr imaging and biomedical implants, materials, and devices: an updated review. radiology 1991; 180: 541-550. 3. shellock fg, morisoli s, kanal e. mr procedures and biomedical implants, materials, and devices: 1993 update. radiology 1993; 189: 587599. 4. shellock fg, slimp g. halo vest for cervical spine fixation during mr imaging. am j roentgenol 1990; 154: 631-632. 5. becker rl, norfray jf, teitelbaum gp, et al. mr imaging in patients with intracranial aneurysm clips. am j neuroradiol 1988; 9: 885-889. 6. shellock fg, kanal e. aneurysm clips: evaluation of mr imaging artifacts at 1.5 t. radiology 1998; 209: 563-566. 7. klucznik rp, carrier da, pyka r, haid rw. placement of a ferromagnetic intracerebral aneurysm clip in a magnetic field with a fatal outcome. radiology 1993; 187: 855-856. 8. kanal e, borgstede jp, barkovich aj, et al. american college of radiology white paper on mr safety. am j roentgenol 2002; 178: 13351347. 9. shellock fg, kanal e. yasargil aneurysm clips: evaluation of interactions with a 1.5-t mr system. radiology 1998; 207: 587-591. 10. hennemeyer ct, wicklow k, feinberg da, derdeyn cp. in vitro evaluation of platinum guglielmi detachable coils at 3 t with a porcine model: safety issues and artifacts. radiology 2001; 219: 732-737. 11. hug j, nagel e, bornstedt a, schnackenburg b, oswald h, fleck e. coronary arterial stents: safety and artifacts during mr imaging. radiology 2000; 216: 781-787. 12. liebman ce, messersmith rn, levin dn, lu ct. mr imaging of inferior vena caval filters: safety and artifacts. am j roentgenol 1988; 150: 1174-1176. 13. manke c, nitz wr, djavidani b, et al. mr imaging-guided stent placement in iliac arterial stenoses: a feasibility study. radiology 2001; 219: 527-534. 14. shellock fg, shellock vj. cranial bone flap fixation clamps: compatibility at mr imaging. radiology 1998; 207: 822-825. 15. teitelbaum gp, bradley wg jr, klein bd. mr imaging artifacts, ferromagnetism, and magnetic torque of intravascular filters, stents, and coils. radiology 1988; 166: 657-664. 16. shellock fg, shellock vj. mri safety of cardiovascular implants: evaluation of ferromagnetism, heating, and artifacts. radiology 2000; 214: p19h. 17. duru f, luechinger r, candinas r. mr imaging in patients with cardiac pacemakers. radiology 2001; 219: 856-858. 18. malko ja, hoffman jc jr, jarrett pj. eddy-current-induced artifacts caused by an ‘mr-compatible’ halo device. radiology 1989; 173: 563564. 19. nogueira m, shellock f. otologic bioimplants: ex vivo assessment of ferromagnetism and artefacts at 1.5 t. am j roentgenol 1994; 163: 14721473. 20. albert dw, olson kr, parel jm, hernandez e, lee w, quencer r. magnetic resonance imaging and retinal tacks. arch ophthalmol 1990; 108: 320-321. 21. shellock fg, crues jv. high-field-strength mr imaging and metallic bioimplants: an in vitro evaluation of deflection forces and temperature changes induced in large prostheses (abstract). radiology 1987; 165: 150. 22. teitelbaum gp. metallic ballistic fragments: mr imaging safety and artifacts. radiology 1990; 177: 883. 23. jolesz fa. 1996 rsna eugene p pendergrass new horizons lecture. image-guided procedures and the operating room of the future. radiology 1997; 204: 601-612. 24. shellock fg. compatibility of an endoscope designed for use in interventional mr imaging procedures. am j roentgenol 1998; 171: 12971300. 25. wagle wa, smith m. tattoo-induced skin burn during mr imaging. am j roentgenol 2000; 174: 1795. 26. carr jj. danger in performing mr imaging on women who have tattooed eyeliner or similar types of permanent cosmetic injections. am j roentgenol 1995; 165: 1546-1547. 27. shellock fg. pocket guide to mr procedures and metallic objects. update 1996. philadelphia: lippincott, 2001. 28. shellock fg. mri safety.com. 2001 (accessed february – april 2004). available at: http//www.mrisafety.com/1 opinion don't start the revolution without us ! russell whitehorn mbbch, ffrad(d)(sa) bortz, lake and partners, durban m any who are shopping for a new computer face a dilemma they would like one that does less than those offered, the prospective buyer may simply want to write letters. he finds computers and software that enable him to author books and multimedia publications. of course, you don't have to use all the features and power of your computer and software, but nobody likes to buy a loaf of bread and eat only a slice. the computer industry recognises this problem. huge software "suites" that can do more than the average user can imagine let alone want have been dubbed "bloatware". there has been intense recent interest in socalled "internet machines". these are low-price, stripped down computers that have one main purpose to connect to the internet. they will, by today's elevated standards, have slow processors and little memory. the user who wants to use this computer for a particular task will pull the relevant program off the internet, use it for that specific task and discard it. instead of storing large volumes of data on your own computer it is proposed that servers, accessed over the internet, be used. some problems contain the seeds of their own solution. this is a solution that contains the seeds of its own problem. anyone that has used the internet knows that "netsurfing" is a misnomer "webcrawling" is a far more appropriate metaphor. this modern version of the server/dumb terminal concept may work in a fast local network situation but the current speed of internet traffic makes it a dubious starter in this context. the modern standalone desktop computer is immensely powerful, and is becoming increasingly affordable and easy to use. communication between computers on opposite sides of a city, country or the world is also improving in many ways. modern software facilitates the connecting of computers and the exchange of information. finland has the most advanced telecommunications infrastructure in the world, having had a high speed atm (asynchronous transfer mode) backbone in place for two years while most other countries are still talking about the technology. the finns were also the first to have a gsm network in 1991. it is of interest to note that finland has always had an unregulated telecommunications market. as vincent schmidt of adc telecommunications has said regarding the shortage of bandwidth for the information highway, u ... these problems will be solved. if there is a path to money, people will find it.". however more immediate, urgent and relevant other demands on the south african public purse appear, neglecting our onramp to the information superhighway will so weaken our competitiveness as a nation that the mouths we so justifiably want to feed now will simply be replaced by a greater number in the future and a spiralling descent into thirdworldness will become unstoppable. you may well ask, "what has all of this to do with radiology?" i believe that medicine in general and radiology in particular are excellent examples of the need for affordable fast data communication. as we stare, like startled rabbits, into the oncoming headlights of %7 sa journal of radiology· september 1996 managed health care those of us in private practice realise that increased efficiency and the pursuit of new markets is essential. i'm sure we all hate the cold business-like ring of that, but it appears that we are no longer going to be able to avoid being businessmen. high quality teleradiology is one of the tools we can use in this regard. i stress high quality. if images are to be reported on via teleradiology, without subsequent review of the films, meticulous attention to quality and adherence to the emerging standards is required. unless the source venue is of low volume or there is acceptance of long turnaround times maintenance of quality will generally require greater bandwidth than telephone lines and modems can provide. for moderate volumes bri isdn may be the answer, if you can get it. over short distances the cost of a dedicated, leased diginet line may be justifiable. however there is no currently acceptable solution for reporting films taken in remote areas. reducing bandwidth requirements by decreasing the resolution or colour depth (bits per pixel) is fraught with danger. compression up to some as yet undetermined point is probably ok but remember there is no such thing as a free lunch or even an inexpensive byte. for those with internet access and who would like to see what the world wide web has to offer radiologists a good starting point would be the rsna's web site at: http://www.rsna .org/rsnahome.html you'll find information about courses and congresses as well as the rsna's teaching resources. there are also many links to other useful web sites. another excellent site to find good radiology links is at emory's weblink: http://www.gen .emory.edu/medweb/ medweb.radiology.html one of the best destinations i have come across is the university of iowa's virtual hospital. the radiology page is at: http://indy. radiology. uiowa .edu/providers/ providerdept/lnfobydept.rad.html topage28 http://www.gen don't start the revolution vvithout us ! (rom page 27 don't let these daunting addresses fool you into thinking you can cancel your journal subscriptions and sell your radiology textbooks yet. only the foundations of the information highway are currently under construction, information is still very patchy and varies from excellent to non-existent. the 'net gives you a peep into the future rather than a currently dependable source of information, relevant usenet newsgroups are: alt.image.medical sci.med.radiology sci.med.telernedicine comp, protocols, dicom the computer revolution that has swept the world over the last two decades has been manic in its pace, even in this high speed context the current construction of the "infobahn" is frenetic, the world wide web is said to grow at 50 per cent per month, microsoft reportedly has more people working on internet products than on any other single project. the huge profits realised by internet entrepreneurs has lead to the claim that it is the last gold rush of the millennium, in the words of bill gates, ceo of microsoft, "we are watching something historic happen, and it will affect the world seismically, rocking us the same way the discovery of the scientific method, the invention of printing, and the arrival of the industrial age did.. the highway is going to happen," it's up to us to make sure we're not stranded on a sideroad. intraoperative digital subtraction angiography in neurovascular disorders (rompage 25 angiography), martin et al reported close correlation between intraoperative and postoperative angiograms in their series.' there were three false negative intraoperative angiograms in 66 patients (2 residual aneurysm necks and a small residual thalamicavm) ,we did not perform postoperative angiography to correlate with the intraoperative angiographic findings, it is well recognised amongst neurosurgeons that the successful treatment of intracranial aneurysms andavms is dependent on complete obliteration, postoperative angiograms are performed routinely in some units following aneurysm clipping, in a series of7ls cases fuerberg et al found a residual aneurysm neck in 3,8% of cases,4 lin et al documented regrowth of aneurysms from residual necks in 19 cases' fourteen of these cases presented with a rebleed at an average interval of nine years from clipping, intraoperative angiography enables the surgeon to identify and correct any incompletely treated lesions under the same anaesthetic. it has also been suggested that the immediate availability of intraoperative angiography allows the surgeon to access the extent of resection of an avm at any stage and therefore avoid excessive resection that may include normal brain and nutrient arteries." it is well documented that normal arteries can also be inadvertently occluded by aneurysm clips,3,6,7 immediate recognition of this may prevent infarction, we have found intraoperative angiograms useful in patients presenting with nontraumatic subdural haemorrhage and nonhypertensive intracerebral haemorrhage who are acutely deteriorating secondary to mass effect, an angiogram in theatre allows the surgeon to identify and treat any underlying aneurysm or avm, intraoperative angiography is particularly useful in the management of mycotic aneurysms for several reasons, surgicallocalisation may be extremely difficult as they are commonly situated on a peripheral vessel and are hidden away in a sulcus, these aneurysms can spontaneously thrombose or appear at new sites on the cerebral vasculature. 8,9theintraoperative angiogram allows the confirmation of aneurysms about to be clipped, identifies new ones that may have formed since the last angiogram and helps localise them by using radio-opaque markers. we have also found intraoperative angiography valuable in localising and managing traumatic false aneurysms and fistulae 28 sajournal of radiology· september 1996 if attempted endovascular occlusion of a carotid cavernous fistula is unsuccessful, an intraoperative angiogram is invaluable in ensuring that surgical packing of the cavemous sinus has successfullyoccluded the fistula, conclusion in our series 29% of the angiograms performed revealed findings which altered the surgical procedure in some way,we recommend the use of intraoperative digital subtraction angiography in any neurovascular procedure where the technical result is going to be difficult to assessintraoperatively, references 1. hieshima cb, reicher ma, higashida rt, et al.lntraoperative digital subtraction neuroangiography: a diagnostic and therapeutic tool. alnr 1987;8:759-767. 2. foley kt, cahan ld and hieshima cb. intraoperative angiography using a portable digital subtraction unit.] neurosurg 1986;64:81&818. 3. martin na, bentson j,vinuela f,er al.lntraoperative digital subtraction angiography and the surgical treatment of intracranial aneurysms and vascular malfonnations.] neurosurg. 1990; 73:526533. 4. fuerberg i, lindqvist c, lindqvist m and steiner l. natural history of postoperative aneurysm rests.] neurosurg 1987;66:30-34. 5. lin 1; foxaj and drake cg. regrowth of aneurysm sacs from residual neck following aneurysm clipping. ] neurosurg 1989;70:556-560. 6. barrow dl, boyer kl and joseph cj. intraoperative angiography in the management of neurovascular disorders. neu7tl<u'!1"y 1992;30:153-159. 7.weir b.value of immediate postoperative angiography following aneurysm surgery.] neurosurg 1981 ;54:396-398. 8. bohmfalk cl, story jl, wissinger jp and brown we. bacterial intracranial aneurysm. ] neurosurg 1978;48:369-382. 9. frazeejc, cahan lo and winter j. bacterial intracranial aneurysms.]neulfjsurg1980;53:633-641. � sa journal of radiology • september 2006 training in diagnostic radiology jan lotz, ma, msc, mmed, fcrad, frcr department of radiology, stellenbosch university training in diagnostic radiology has been debated extensively in this country. when i started as a registrar in 1975, diagnostic radiology was limited to ‘black and white’ and fluoroscopy. the academic curriculum was covered in a 4-year course, the first 12 18 months being devoted to acquiring the primary qualifications in anatomy, physics and physiology in most of the mmed courses. since the mid-70s we have seen a digital imaging explosion. first ‘realtime’ ultrasound took centre stage, followed by computed tomography (ct), digital subtraction angiography, magnetic resonance imaging (mri), interventional radiology and pacs. in the early nineties it seemed as if we had exhausted all technical development with real-time three-dimensional imaging, then the second tsunami hit. this time we saw multidetector ct with coronary imaging, real-time mr imaging of the heart, mr spectroscopy, diffusion and perfusion imaging, functional mri and whole-body ct data collection. at the time of writing in 2006 and despite the earth-shattering developments listed above, it is with deep regret that i have to report that diagnostic radiology remains a 4-year course, of which the first 12 18 months are still devoted to passing the primary examinations. inertia to change over the past two and a half decades has been caused by many factors. in a recent editorial in the sajr prof coert de vries alluded to chronic problems in our academic hospitals that prevented necessary adaptations to our concepts of training and research. this is water under the bridge. in a recent report on the current status of radiologist training in south africa, conducted at the 1st and 2nd preexamination courses of the college of radiology of south africa, the majority (82.3% and 91.5%, respectively) of the attendees said that they received ‘formal’ lectures and tutorials. the majority (72.3%) of the respondents on course 2 felt that both their training and the structuring of training were adequate. likewise, they felt that their hospital equipment was adequate (57.4% ). in contrast, fewer of the respondents on course 1 felt the same way – only 47% of the respondents felt that their training and structuring of their training were adequate and only 36.7% felt that their hospital equipment was adequate. less than half of the respondents on both courses said that they received formal assessments . of the candidates, 75% and 85.1% on course 1 and course 2, respectively, intended to remain in a registrar post for a 5th year in departments where this was possible. professor savvas andronikou will present this report and some of our suggestions at a special session on education and training at the isr congress in september. we believe that an integrated national curriculum should be tabled. tuition should be structured accordingly and study material shared. table i represents an abstract of a 4-year modular course that was introduced at the university of the free state in 2004. registrars are editorial pg 2-4.indd 2 9/6/06 2:56:09 pm � sa journal of radiology • september 2006 ta bl e i. p or ti on o f t he m od ul ar c ou rs e de m on st ra ti ng a w ei gh ti ng fo r ea ch s ec ti on w hi ch th en c or re sp on ds to th e nu m be r of w ee ks d ev ot ed to th e se ct io n ov er 4 y ea rs sy st em w ei gh t m od ul es a nn ua l a ca de m ic p ro gr am m e ja nu ar y 20 04 to d ec em be r 20 07 d is tr ib ut io n ye ar 1 ye ar 2 ye ar 3 ye ar 4 r es pi ra to ry sy st em 4 3 w ee ks 3w 3w /3 w /3 w ( 12 w ) m od ul e 1 m od ul e 4 m od ul e 7 m od ul e 10 in te rp re ta tio n of th e d ip hr ag m / d iff us e in te rs tit ia l tr au m a/ po st op er at iv e ch es t x -r ay w al l/p le ur a di se as e m od ul e 2 m od ul e 5 m od ul e 8 m od ul e 11 t he m ed ia st in um a st hm a an d in du st ri al d is ea se pa ed ia tr ic c he st em ph ys em a m od ul e 3 m od ul e 6 m od ul e 9 m od ul e 12 pu lm on ar y in fe ct io n pu lm on ar y pu lm on ar y c on ge ni ta l tu m ou rs th ro m bo -e m bo lis m ab no rm al iti es c ar di o va sc ul ar sy st em 3 2 w ee ks 2w /2 w /2 w /2 w ( 8w ) m od ul e 1 m od ul e 3 m od ul e 5 m od ul e 7 c on ge ni ta l h ea rt c ar di om eg al y a cq ui re d va lv ul ar c ar di om yo pa th y/ di se as e 1 di se as e tu m ou rs m od ul e 2 m od ul e 4 m od ul e 6 m od ul e 8 c on ge ni ta l h ea rt pu lm on ar y is ch ae m ic h ea rt pe ri ca rd iu m di se as e 2 ci rc ul at io n di se as e g as tr o in te st in al sy st em 4 3 w ee ks 3w /3 w /3 w /3 w ( 12 w ) m od ul e 1 m od ul e 4 m od ul e 7 m od ul e 10 a bd om in al s ur ve y d uo de nu m c ol on pa ed ia tr ic g it im ag in g 2 st ud y m od ul e 2 m od ul e 5 m od ul e 8 m od ul e 11 o es op ha gu s sm al l b ow el m es en te ri um a nd en do sc op y an d m om en tu m ra di ol og y m od ul e 3 m od ul e 6 m od ul e 9 m od ul e 12 st om ac h in fla m m at or y pa ed ia tr ic g it c t /m r /i nt er ve nt io n an d di se as e im ag in g 1 th e g it li ve r, p an cr ea s an d bi lia ry sy st em 3 2 w ee ks 2w /2 w /2 w /2 w ( 8w ) m od ul e 1 m od ul e 3 m od ul e 5 m od ul e 7 li ve r 1 bi lia ry s ys te m 1 p an cr ea s 2 in te rv en tio na l p ro ce du re s m od ul e 2 m od ul e 4 m od ul e 6 m od ul e 8 pa nc re as 1 li ve r 2 bi lia ry s ys te m 2 tr an sp la nt at io n/ tr au m a pg 2-4.indd 3 9/6/06 2:56:09 pm editorial � sa journal of radiology • september 2006 currently in the 3rd year of the first cycle. lectures of outstanding quality have been captured on digital disk as an integral component of the course. table ii is an example of individual lectures comprising modules 1, 2 and 3 of the musculo-skeletal system for year one. note that the number of modules is decided by weighting each section on a scale of 1 to 4. the course then extends over 25 weeks each year or 100 weeks over the 4-year period. this allows enough time for flexibility regarding holidays, revision and examination. a national videoconference would conclude a set of modules and we hope to have recognised experts in a specific field to present these lectures to all participants: academic, private, south african and african. we would then extend an open invitation to our registrars to jump onto the ‘merry-go-round’ at any point and to jump off 4 years later to write an examination of international standard. there is one condition: the entire 4 years must be devoted to learning radiology. the ticket to the 4-year ‘merry-go-round’ is a valid primary examination from the college of radiology or a recognised university. jan w lotz table ii. example of detailed content of one module composed of between four and five 20-minute lectures for each module (on 1 day per week). year 1: 2004 module 1 metabolic bone disease 1 consultant lecture (optional) physiology of bone lecture 1 hyper/hypoparathyroidism lecture 2 osteoporosis/osteomalacia lecture 3 rickets lecture 4 conditions associated with increase in bone density module 2 metabolic bone disease consultant lecture (optional) diagnostic approach to the skeleton lecture 1 conditions associated with increase in bone density lecture 2 renal osteodystrophy/hyperphosphatasia lecture 3 scurvy/cushings/juvenile osteoporosis lecture 4 conditions associated with decreased bone density module 3 bone tumours 1 national videoconference diagnostic approach to bone tumours lecture 1 benign tumours lecture 2 cartilaginous tumours lecture 3 cystic mass lesions lecture 4 fibrous tumours pg 2-4.indd 4 9/6/06 2:56:09 pm radiology_oct04 management of acute variceal bleeding patients with portal hypertension may either be asymptomatic or present with symptoms due to variceal bleeding, ascites, encephalopathy or hypersplenism. variceal haemorrhage occurs in up to 85% of cases at the gastro-oesophageal junction. the management of variceal bleeding, and in particular of an acute life-threatening haemorrhage, is both complex and difficult. direct active interventions aimed at controlling variceal bleeding include sclerotherapy, band ligation, vaso-active drug administration, balloon tamponade and surgery. mechanical balloon tamponade and systemic pharmacological therapy may be used either alone or in combination. the use of balloon tamponade is associated with 10 20% morbidity, including aspiration, oesophageal perforation and ulceration. there is also a 30% rebleed rate within 72 hours with a 30% early and late associated mortality.1 endoscopic sclerotherapy is more effective than balloon tamponade in controlling acute variceal haemorrhage.2 emergency endoscopic sclerotherapy is the currently preferred method of treatment for acute variceal haemorrhage and is effective in up to 90% of cases, although multiple endoscopic treatments are often required.3 variceal band ligation is effective, particularly with large varices, and has a lower rebleeding rate than sclerotherapy.4 however, neither endoscopic sclerotherapy nor band ligation addresses the underlying portal hypertension, and rebleeding occurs in up to 50% of patients thus treated. surgery can be considered for patients with recurrent variceal bleeding despite use of the abovementioned treatments. non-shunt operations include urgent liver transplantation, devascularisation procedures and splenectomy. portosystemic shunt procedures are aimed at either diverting portal blood flow, e.g. portocaval or mesocaval shunts, or decompressing the portal system but preserving portal blood flow, e.g. the distal splenorenal (warren) or sarfeh shunts. however, the operative mortality associated with surgical portocaval shunt creation in child’s class c patients is as high as 50%.5 the overall surgical mortality rate regardless of expected clinical outcome and type of shunt created, is around 10 20%.6 the tipss (transjugular intrahepatic portosystemic shunt) procedure developed from a search for a less invasive non-surgical technique aimed at reducing portal pressure. the tipss procedure historical overview rösch and co-workers created the first percutaneous intrahepatic portosystemic shunts in 1969 in experimental animals.7 in 1982, colapinto and co-workers described the creation of percutaneous intrahepatic shunts in 6 human subjects.8 a tract was dilated through the liver parenchyma between a hepatic vein and an intrahepatic portal vein using a balloon catheter inflated across the tract for 12 hours. despite a reduction in portal venous pressure, 4 of the 6 patients developed recurrent bleeding. both colapinto and rösch had experienced major problems in maintaining longterm patency of their shunts. it was only later with the advent of metallic stents that a renewed interest in the tipss procedure came about as these stents could now keep the parenchymal tract open, improving long-term shunt patency.9-12 technique a tipss can be created under either local or general anaesthesia, although anaesthetic support throughreview article 4 sa journal of radiology • october 2004 the transjugular intrahepatic portosystemic shunt (tipss) procedure — a review i c duncan ffrad (d) unitas interventional unit centurion gauteng out the procedure is mandatory. a sheath is placed via an internal jugular vein into a hepatic vein (initially usually the right one). a long curved needle is then placed through the sheath and under fluoroscopic guidance is thrust through the wall of the hepatic vein and adjacent parenchyma into a major branch of the portal vein. a rigid guidewire is then passed through the needle into the portal system and the needle is removed and replaced by a diagnostic catheter. contrast injected through this catheter allows visualisation of the portal system as well as the presence of any visible portosystemic collaterals and varices. the catheter is then exchanged for a balloon catheter and the tract is dilated between the hepatic and portal veins. this parenchymal tract is then stented to ensure shunt patency (figs 1a c). generally selfexpanding stents of 10 12 mm diameter are used. pressure measurements are obtained after stent placement. the goal of treatment is to reduce the portosystemic pressure gradient to less than 10 15 mmhg.13 in most cases the stent is initially dilated to a diameter of 8 mm, but if the portosystemic pressure gradient exceeds 15 mmhg then the stent can be further expanded to 10 or 12 mm diameter to ensure further reduction of any residual pressure gradient. if this pressure gradient reduction is still insufficient a second shunt can be placed through the left hepatic lobe. if varices are visualised the left gastric and/or short gastric veins can be catheterised through the shunt and embolised using occlusion coils, gelfoam, cyanoacrylate or sclerosing agents (figs 2a and 2b). indications, contraindications and patient selection the indications for and contraindications to tipss remain controversial. the national digestive diseases advisory board summarised them in 1994 as follows.14 1. the two accepted indications are: • acute variceal bleeding that cannot be successfully controlled with medical treatment or sclerotherapy • recurrent variceal bleeding unresponsive to medical therapy or repeated sclerotherapy. 2. additional indications include: • intractable ascites • portal hypertension due to hepatic venous outflow obstruction (budd-chiari syndrome). tipss is not recommended for the initial therapy of acute variceal haemorrhage. review article 5 sa journal of radiology • october 2004 fig. 1a. diagramatic representation of the tips shunt with stenting of the tract created between the portal and hepatic veins. fig. 1b. following tipss creation, a self-expanding wallstent has been used to maintain patency of the parenchymal tract between the right hepatic vein and the right portal vein. fig. 1c. a final check portogram shows flow of contrast through the shunt into the hepatic vein thereby decompressing the portal system. it is important that there still be some visible flow of contrast beyond the stent into the intrahepatic portal branches otherwise encephalopathy and liver failure may result. absolute contraindications to tipss include: • severe right-sided heart failure with markedly elevated central venous pressure • polycystic liver disease • severe hepatocellular failure. relative contraindications to tipps include: • active intrahepatic or systemic infection • hypervascular hepatic tumours • severe hepatic encephalopathy refractory to medical therapy • portal vein thrombosis. adequate pre-procedural imaging of the liver is essential for several reasons including review of the hepatic and portal venous anatomy, exclusion of any hypervascular tumour along the intended tract, and confirmation of a patent portal vein. this may be accomplished by colour-flow doppler ultrasound, computed tomography (ct), magnetic resonance imaging (mri) or indirect arterial portography (fig. 3). portal vein occlusion is a relative contraindication as portal vein recannalisation may be possible before placement of the tipss if the occlusion is due to soft thrombus.15 this is usually not possible in cases of chronic portal occlusion. the only definitive treatment for the underlying advanced hepatic pathology that has caused the secondary portal hypertension is liver transplantation. the use of tipss as a bridging procedure prior to transplantation is controversial. however, pre-transplantation tipss has been shown to improve the medical condition and nutritional status of patients, reduce operative blood loss and procedure time, and decrease hospital stay.16 tipss has been used in patients with variceal bleeding at atypical sites such as colonic, stomal and anorectal varices, portal hypertensive gastropathy and patients with hepatorenal syndrome.17,18 it is vital to assess the anatomy of the hepatic and portal veins before a tipss procedure. apart from portal patency, the position of the portal vein bifurcation is the most critical anatomical feature to be identified. schultz et al.19 showed in a study of 31 cadavers that the portal bifurcation was found to be extrahepatic in 48.4%, intrahepatic in 25.8% and ‘junctional’ (i.e. within 1 cm of the capsule) in 25.8%. results and complications the technical success rates for tipss reported in the literature are over 95%. however, in general poor long-term durability appears to be the rule, with an average 25% rate of rebleeding at 1 year. this is usually due to shunt stenosis or occlusion. shunt stenosis is very common, occurring in between 31% and 80% of cases within 1 year.20,21 shunt stenosis occurs in one of two locations, either being within the parenchymal portion, accounting for 30% of stenoses (but 70% of symptomatic stenoses), or at the outflow hepatic vein.22,23 histologically the stenosis within the outflow vein is due to intimal hyperplasia whereas that seen in the stent lumen is a thickened neo-intima consisting of myofibroblasts and collagen, termed ‘pseudo-intimal hyperplasia’. there is mounting evidence that the development of this pseudointimal hyperplasia may be related to associated bile duct injury and bile leakage.24,25 this huge rate of review article 6 sa journal of radiology • october 2004 fig. 2a. after placement of the stent the check portogram demonstrates persistent filling of collateral veins and varices via the coronary vein. fig. 2b. these can then be embolised before the catheters are withdrawn from the portal system. fig. 3. a main prerequisite for a successful tipss procedure is initial confirmation of a patent portal vein, as in this indirect mesentericoportogram. restenosis means that close radiological follow-up of the shunts is mandatory. repeat percutaneous hepatic venography is more efficacious but also more invasive and expensive than doppler ultrasonography. in an attempt to reduce this huge restenosis rate, covered stents are now being used and have improved shortto mid-term shunt patency.26-28 with repeated interventional procedures, the assisted patency rates increase to 80 90% at 1 year and 87% at 3 years.21,23,29 other complications related to the tipss procedure can be divided into short-term and long-term ones. procedural morbidity occurs in up to 10% of cases,30 intraperitoneal haemorrhage in 3 13% and haemobilia in 1 4 %. transient increases in serum bilirubin, transaminases, prothrombin time and ammonia are seen in 10 20% of cases during the first postprocedural week. about 25% of patients develop new or worsened encephalopathy, but only 5% are unresponsive to medical treatment. death from fulminant hepatic failure occurs in 3 7 % of patients within 30 days. acute shunt thrombosis is reported in 3 4 % of cases. acutely thrombosed shunts can by reopened by mechanical clot disruption or thrombolysis or placement of additional stents. other peri-procedural complications include fever and sepsis (3 10%), stent malposition or migration (1 5%), acute renal failure and cardiac arrhythmias. the procedurerelated mortality rate is 0 2 %, death mainly being due to extracapsular perforation with intraperitoneal haemorrhage, hepatic arterial injury or acute right heart failure. overall 30-day mortality rates are variable (3 45%) and are probably related more to the underlying pathology than the procedure itself. roessle et al.31 reported an overall 1-year survival rate of 87% with rates of 100%, 86% and 73% for patients in childs-pugh classes a, b and c respectively. occasionally worsening of the encephalopathy or liver failure after tipss can necessitate stent reduction or even shunt occlusion. when tipss is performed for intractable ascites about 50 75 % of patients will have partial or complete resolution within 1 month.32,33 conclusions tipss is a seldom-performed procedure in south africa. we have performed only 13 cases in our combined practice (johannesburg and pretoria) since 1994. among the reasons for this small number may be the greater availability and efficacy of endoscopic variceal treatment and medical therapies for portal hypertension, lack of knowledge about the availability and usage of the tipss procedure, lack of suitable interventional expertise in many state hospitals and outside the main centres, and lack of a full-time liver transplant programme in south africa. locally tipss has essentially been employed as a palliative procedure. throughout the world the tipss procedure has lost much of its initial popularity owing to poor longterm primary shunt patency rates, although as mentioned these can be improved significantly by performing secondary and further interventions. it is hoped that newer technologies, including the use of covered stents or drug-eluting stents, will reduce the high stenosis rate, leading to better long-term primary patencies and durability of the tipss. references 1. teres j, planas r, panes j, et al. vasospressin /nitroglycerin infusion vs oesophageal tamponade in the treatment of acute variceal bleeding hepatology 1990; 11: 964-968. 2. moreto m, zaballa m, bernal a, et al. a randomized trial of tamponade or sclerotherapy as immediate treatment for bleeding oesophageal varices. surg gynecol obstet 1988; 167: 331-334. 3. grace nd. diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension: american college of gastroenterology practice parameters committee. am j gastroenterol 1997; 92: 10811091 4. gimson ae, ramage jk, panos mz, et al. randomized trial of variceal banding ligation versus portocaval shunting in patients with severe cirrhosis and variceal haemorrhage lancet 1993: 342: 391394. 5. cello jp, grendell jn, crass ra, et al. endoscopic sclerotherapy versus portacaval shunting in patients with severe cirrhosis and variceal hemorrhage. n engl j med 1984; 31: 1589-1594 6. orloff mj, orloff ms, orloff sl, et al. three decades of experience with emergency portocaval shunt for actively bleeding oesophageal varices in 400 unselected patients with cirrhosis of the liver. j am coll surg 1995; 180: 257-272. 7. rösch j, hanafee wn, snow h. transjugular portal venography and radiological portocaval shunt : an experimental study. radiology 1969; 92: 1112-1114. 8. colapinto rf, stronell rd, birch sj, et al. creation of an intrahepatic portosystemic shunt with a gruntzig balloon catheter. can med assoc j 1982; 26: 267-268. 9. palmaz jc, sibbit rr, reuter sr, et al. expandable intrahepatic portocaval shunt stents: early experience in the dog. am j roentgenol 1985; 145: 821-825. 10. rösch j, uchida bt, putnam js, et al. experimental intrahepatic portocaval anastomosis: use of expandable gianturco stents. radiology 1987: 162: 481-485. 11. rössle m, richter gm, noldge g, et al. performance of an intrahepatic portocaval shunt (pcs) using a catheter technique: a case report. hepatology 1988; 8: 1348. 12. richter gm, noeldge g, palmaz jc, et al. the transjugular intrahepatic portosystemic stentshunt (tipss): results of a pilot study. cardiovasc interv radiol 1990; 13: 200-207. 13. laberge jm, ring ej, gordon rl, et al. creation of transjugular portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. radiology 1993; 187: 413-421. 14. shiffman ml, jeffers l, hoofnagle jh, et al. the role of transjugular intrahepatic portosystemic shunts for treatment of portal hypertension and its complications: a conference sponsored by the national digestive diseases advisory board. hepatology 1995; 22: 1591-1597. 15. radosovich pm, ring ej, laberge jm, et al. transjugular intrahepatic portosystemic shunts in patients with portal vein occlusion. radiology 1993; 186: 523-527. 16. menegaux f, keeffe eb, baker e, et al. comparison of transjugular and surgical porreview article 7 sa journal of radiology • october 2004 tosystemic shunts on the outcome of liver transplantation. arch surg 1994; 129: 10181023. 17. haskal zj, scott m, rubin ra, et al. intestinal varices: treatment with transjugular intrahepatic portosystemic shunt. radiology 1994; 91: 183-187. 18. sturgis tm. hepatorenal syndrome: resolution after transjugular intrahepatic portosystemic shunt. j clin gastroenterol 1995; 20: 241. 19. schultz sr, laberge jm, gordon rl, et al. anatomy of the portal vein bifurcation: extraversus intrahepatic locations — implications for transjugular intrahepatic portosystemic shunt. j vasc intervent radiol 1994; 10: 457-459. 20. rossle m, siegerstetter v, huber m, et al. the first decade of the transjugular intrahepatic portosystemic shunt (tips): state of the art liver 1998; 18: 73-89. 21. la berge jm, somberg ka, lake jr, et al. twoyear outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. gastroenterology 1995; 108: 1143-1151. 22. saxon rs, ross pl, mendel-hartvig j, et al. tranjugular intrahepatic portosystemic shunt patency and the importance of stenosis location in the development of recurrent symptoms. radiology 1995; 197: 801-804. 23. haskal zj, pentecost mj, soulen mc, et al. transjugular intrahepatic portosystemic shunts stenosis and revision: early and midterm results. am j roentegenol 1994; 163: 439-444. 24. laberge jm, ferrell ld, ring ej, et al. histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. j vasc interv radiol 1993; 4: 779-786. 25. saxon rr, mendel-hartvig j, corless cl, et al. bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts: comparative histopathologic analysis in humans and swine. j vasc interv radiol 1996; 7: 487-497. 26. saxon rr, timmersmans ha,uchida bt, et al. stent-grafts for revision of tips stenoses and occlusions: a clinical pilot study. j vasc interv radiol 1997; 8: 539-548. 27. haskal zj. improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with ptfe stent-grafts. radiology 1999; 213: 759-766. 28. sze dy, vestring t, liddell rp. recurrent tips failure associated with biliary fistulae: treatment with ptfe-covered stents. cardiovasc intervent radiol 1999: 22: 298-304. 29. sterling km, darcy md. stenosis of transjugular intrahepatic portosystemic shunts: presentations and management. am j roentgenol 1997; 168: 239-244. 30. freedman am, sanyal aj, tisando j, et al. complications of transjugular intrahepatic portosystemic shunts: a comprehensive review. radiographics 1993; 13: 1185-1210. 31. roessle m, haag k, ochs a, et al. the transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. n engl j med 1994; 330: 165-171. 32. crenshsaw wb, gardon fd, mceniff nj, et al. severe ascites: efficacy of the transjugular intrahepatic portosystemic shunt in treatment. radiology 1996; 200: 185-192. 33. ochs a, roessle m, haag, k, et al. the transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. n engl j med 1995; 332: 1192. review article 8 sa journal of radiology • october 2004 case report is the skull x-ray a useful tool in paediatric blunt head injury and are we familiar with an abnormal finding? s andronikou mbchb, fcraddiag (sa), frcr (london) ewelman mbchb e kader mbchb j venter mbchb t kilborn mbchb department of paedlatrfc radiology, university of gape town and institute of child health, red cross war memorial children's hospital, rondebosch, cape town corresponding aut liar sandronlkou department of paediatric radiology, red cross war memorial children's hospital, gape town, 7700 tel: (021) 658-5422. fax: (021) 658-5101. e-mail: docsav@mweb.co.za abstract skull x-ray (sxr) has been, and sti ii is, used in some institutions to detect skull fractures in paediatric head injuries. when no clinical/neurological indication for computed tomography (ct) scanning exists, the presence of a sku ii fracture may be used as an indication for this. this case report demonstrates an unusual sxr finding of oval lucencies in a neurologically normal child who had sustai ned a head injury. the subsequent ct scan demonstrated a subacute subdural haemorrhage with ai r pockets, highlighting the need to recognise 45 sajournal of radiology· february2001 intracranial air. the iiterature is reviewed regarding the usefulness of sxr in childhood head injury. keywords computerised tomography/ skull fracture/ subdural haem orrh age/ pneumocranium introduction some institutions have previously used and continue to use a skull xray (sxr) in the protocol for investigation of blunt head injury.' computerised tomography (ct) is recommended as the imaging modality of choice for investigating blunt head trauma and, when normal in a patient with an isolated head injury, allows the clinician to discharge the patient.': 4 it is in mildly injured patients where there are no positive neurological findings or a glasgow coma scale (gcs) between 13 and 15 that controversy exists on whether a ct scan is routinely indicated.1,2,4,s in an environment where costs and the availability of ct scanning are primary considerations, there is a difficult choice between 1. discharging patients based on negative clinical/neurological findings and running the potential risks of missing an intracranial abnormality; 2. admitting patients for observation without ct scanning, which has been shown by certain authors to be more expensive than the following option 3; 3. subjecting all patients to routine ct scanning. the place of skull radiography is considered controversial,' but detecting a skull fracture is considered an indication for ct scanning in institutions----topage46 mailto:docsav@mweb.co.za is the skull x-ray a useful tool in paediatric blunt head injury and are we farriil iar with an abnornlal finding? from page 45 where sxr is still performed. recognising the skull fracture per se has little clinical benefit, as it has little to do with management or outcome.' it is also well known that in children severe intracranial injury can occur in the absence of skull fractures.' a study from alder hey in liverpool states that sxr is not a reliable predictor of intracranial injury and is indicated only• in penetrating head injury; • when non-accidental injury (nai) is suspected, especially in children less than two years of age; • to confirm/ excl ude suspected depressed skull fracture.' the sensitivity for predicting intracranial injury based on neurological abnormalities was 91 %, while the sensitivity of sxr for predicting intracranial injury was 65%.] other authors have calculated that in a fully conscious child with a skull fracture, the risk of intracranial haematoma was 80 times higher than in a child without a fracture."these are two typical conflicting views on the value of sxr. lloyd et al noted that significant injury was not seen in the absence of neurological signs and symptoms, but brain injury is commonly seen in the absence of a skull fracture.' the number of skull fractures detected was also very low at 2,7%. another feature to note is that intracranial haem atom as sustained from mild head injuries are associated with neither an abnormal skull x -ray nor abnormal neurological findings in up to 16-20% of cases.' as yet unpublished data from our institution showed that no drainable collection found on ct over a five-year period in patients with mild head injury was present without an associated skull fracture. case report we present a case of a four-yearold boy who presented five days after having sustained a blunt head injury from falling off a bed. there was no history of loss of consciousness, but the patient had complained of headaches for the past week and had vomited twice. the glasgow coma scale was 15/15 and no neurological abnormalities were detected on clinical examination. a ct scan was not indicated according to the existing protocol, but a skull x -ray was performed and called normal, resulting in the patient being discharged. when the radiologist reviewed the films the following day, he noted numerous lucencies on the lateral skull film (figure 1), which were puzzling, figure 1: numerous ovallucencies are seen over the temporal and parietal bones on lateral sxr (open arrow) and a faint linear fracture that was missed initially is visible on careful inspection (closed arrow) 46 sa journal of radiology. february 2001 and recalled the patient for a ct scan. the ct scan demonstrated a large right subdural haemorrhage containing air pockets and low densities in keeping with clot evolution (figures 2 and 3). review of the skull x-ray showed a fine vertical fracture line traversing the lucencies. figure 2: axial ct of the brain on bone window setting clearly demonstrates the air pockets (open arrow), explaining the ovallucencies seen on plain film underlying the right parietal bone figure 3: axial ct of the brain on soft tissue/ "brain" window setting demonstrates a significant right-sided subacute subdural haemorrhage (open arrow) that has undergone evolution and the air pockets at the non-dependent portion of the surface col/eclion topage47 is the skull x-ray a useful tool in paediatric blunt head injury and are vye familiar vvith an abnormal finding? frompage46 i head injury i -------------------no neurological findings positive neurological findings skull x-ray skull fracture or other abnormality computed tomography of the head if normal and no other injury, then discharge home conclusion current imaging protocol for paediatric blunt head injury used at the red cross children's hospital this case highlights numerous issues: 1. a child may present with a normal glasgow coma scale and no neurological findings, but still have a significant intracranial bleed that needs surgical intervention. 2. if skull x -rays are to be performed, then we should be aware of features other than skull fractures, such as pockets of air, that are also an indication for ct scanning. 3. assessment of an sxr by nonradiological staff is a drawback of performing routine sxr, as fractures and more confusing findings may be missed. 4. institutions without direct ct access may need to evaluate patients clinically and possibly using skull xrays alone as predictors of intracranial haemorrhage. in such institutions it should be remembered that the neurological findings have a better predictive value than skull x -rays, but if skull x -rays are to be used, then any 47 sa journal of radiology· february 2001 abnormality should urge the clinician to request a ct scan from a tertiary institution. acknowledgements we would like to thank the red cross children's hospital radiographers dawn skippers, jessica bertelsman, sylvia paverd and nasrin lahri for their contribution toward this paper. references 1. lloyd da, carty h, patterson m, butcher ck, roe d. predictive value of skull radiography for intracranial injury in children with blunt head injury. lancet 1997; 349: 821-824. 2. davis rl, mullen n, makela m, taylor ja, cohen w, rivara fp. cranial computed tomography scans in children after minimal head injury with loss of consciousness. ann emerg med 1994; 24: 640-645. 3. davis rl, hughes m, gubler ko, waller pl, rivara fp. the use of cranial ct scans in triage of paediatric patients with mild head injury. paediatrics 1995; 95 (3): 345-349. 4. baker sr, gaylord gm, lantos g, tabadder k, gallagher ej. emergen y skull radiography: the effect of restrictive crit ria on skull radiography and ct use. radiology 1985; 156: 409-413. 5. stein sc, o'malley kf, ross se. is routine computer tomography scanning too expensive for mild head injury? ann emerg med 1991; 20: 1286-1289. 6. teasdale g m, murray g, anderson e et al. risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. bmi 1990; 300: 363-67 about the author(s) heleen hanekom department of radiology, university of the witwatersrand, south africa tanyia pillay department of radiology, university of the witwatersrand, south africa derek harrison department of paediatric surgery, university of the witwatersrand, south africa talietha minnis department of radiology, university of the witwatersrand, south africa citation hanekom h, pillay t, harrison d, minnis t. paediatric gastrointestinal volvulus: twisting our heads around unusual diagnoses. s afr j rad. 2017;21(1), a1160. https://doi.org/10.4102/sajr.v21i1.1160 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract paediatric gastrointestinal volvulus: twisting our heads around unusual diagnoses heleen hanekom, tanyia pillay, derek harrison, talietha minnis copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction: volvulus of the gastrointestinal tract is a rare entity. clinical symptoms are often non-specific, and imaging plays a vital role in the identification and diagnosis. aim: an educational poster highlighting the specific radiological features of gastric, midgut, caecal and sigmoid volvulus. conclusion: recognition of the radiological appearance of volvulus of the gastrointestinal tract is essential to make a prompt diagnosis and thus avoid life-threatening complications. radiology_may04 editorial 2 sa journal of radiology • may 2004 the exciting developments in magnetic resonance imaging are leading ustowards the fetus, the female breast and the prostate gland, resulting in a smiling contented look on the face of radiology, not to mention the prospect of regaining imaging of the coronary arteries (that has been the sole and dearly cherished possession of the cardiologists for decades), with multi-slice computed tomography approaching resolution comparable to digital angiography. despite all the commotion surrounding the mr and ct consoles we can always rely on the interventional magicians to invent new fascinating, sometimes frightening and occasionally totally impractical procedures to stimulate the everlasting repressed surgical pulses in our blood. we have dilated, embolised, occluded, excluded, infiltrated and biopsied almost everything. with radiofrequency ablation (rfa),‘cooking’ is definitely the new kid on the block. rfa has been employed for some time for the treatment of primary and metastatic liver tumours. pancreatic tumours, bone metastases and intra-pulmonary tumours are being treated similarly and rfa has recently entered phase 2 clinical trials for the treatment of small renal tumours. rfa involves the use of high-frequency electrical current to cause heat-based tissue destruction through needle electrodes of varying diameters depending on the size of the tumour treated. limitations include tumours larger than 5 cm in diameter as well as proximity to vascular structures and other visceral organs. treatment of liver tumours can be done percutaneously or as an open procedure during which the tumour can be visualised with an ultrasound probe placed directly on the surface of the liver. rfa is still in its infancy. the initial results are promising and have certainly caught the imagination of interventional radiologists, surgeons and oncologists. the length of treatment varies considerably, depending on the size and number of lesions treated. it would seem that we are facing long sessions of coagulating various lesions, hopefully with excellent results, whilst in the process broadening our musical repertoire, listening to bach, the beatles or britney, depending on the age of the interventional radiologist hanging on to the end of the electrode. radiofrequency ablation leonie scholtz mb chb, mmedrad (d) department of radiology university of pretoria leonie scholtz editor about the author(s) heleen hanekom department of radiology, university of the witwatersrand, south africa susan lucas department of radiology, university of the witwatersrand, south africa savvas andronikou department of paediatric radiology, bristol royal hospital for children, university of bristol, united kingdom pierre goussard department of paediatrics and child health, stellenbosch university, south africa robert p. gie department of paediatrics and child health, stellenbosch university, south africa citation hanekom h, lucas s, andronikou s, goussard p, gie rp. computerised tomography findings in lymphobronchial tuberculosis: a comparison between infants and older children. s afr j rad. 2017;21(1), a1149. https://doi.org/10.4102/sajr.v21i1.1149 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: hanekom h, lucas s, andronikou s, gie r, goussard p. computerised tomography findings in lymphobronchial tuberculosis: a comparison between infants and older children. south afr j infect dis 2015;30(1), 63–64, available here: http://www.sajei.co.za/index.php/saje/article/download/704/862 conference abstract computerised tomography findings in lymphobronchial tuberculosis: a comparison between infants and older children heleen hanekom, susan lucas, savvas andronikou, pierre goussard, robert p. gie copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: pulmonary tuberculosis (tb) in children is characterised by mediastinal and hilar lymphadenopathy. lymphobronchial tb (lbtb) describes the situation where tuberculous lymph nodes affect the airways by compression or erosion. infants may be more susceptible to severe complications because of their specific airway anatomy and immature immune systems. objective: the purpose of this study was to compare the computerised tomography (ct) findings of infants and children older than 12 months with lbtb to determine whether infants are more severely affected. materials and methods: the ct scan reports of 98 children (< 13 years) with lbtb were reviewed retrospectively by a paediatric radiologist for a previous study. the relevant data were extracted from the existing database and the two age groups were compared with regard to lymphadenopathy, airway narrowing and parenchymal complications. results: of the 98 patients, 51% were infants. there was no statistically significant difference between infants and children (> 12 months) with reference to the frequency and distribution of airway compressions, lymphadenopathy and parenchymal findings. however, there was a statistically significant difference (p < 0.05) in the number of infants with complete compressions when compared to the older children. conclusion: as opposed to older children, infants’ airways are more susceptible to complete airway compression as a result of lbtb. this is probably because of the airway size and anatomic development. we therefore recommend that infants presenting with symptoms of airway compression secondary to lbtb should be imaged urgently using ct scanning to ensure correct management. editorial ultrasound training and accreditation petercorr mbchb, ffrad(d)sa. frcr, mmed(uct) department of radiology, university of natal u ltrasound has become the fastest growing modality in radiology internationally over the last few years. it is no wonder considering the rapid advances in transducer and computer technology. with these improvements new applications are being found on a monthly basis. colour and power doppler are now standard on most units. endovascular and endoscopic transducers are still very expensive but the price will drop as technology improves. three dimensional scanning will be available in a few years. the big question is who should perform ultrasound examinations? the answer is clear the sonologist who can perform an accurate diagnostic study after adequate training. ultrasound has never been the sole domain of the radiologist. to believe otherwise is wishful thinking. the largest user group in this country is the general practitioner. there is an urgent need to provide adequate training and accreditation for ultrasound practitioners. a national ultrasound society to enhance standards and provide skills training is required. such societies exist 'throughout the western world. why not south africa? a national ultrasound diploma for medical practitioners and specialists recognised by the medical council would be a big step forward. the editor 3 sajournal of radiology. september 1996 � sa journal of radiology • june 2006� sa journal of radiology • june 2006 abstract fine-needle aspiration biopsy (fnab) is done regularly at our mammography unit on lesions that are non-palpable and difficult to access. studies done at other hospitals on palpable and non-palpable lesions show a wide variety of results. therefore we wanted to develop a database of information regarding fnab results at our own unit. a retrospective descriptive study was done from the reports of all patients who had fnabs at our unit over a 1-year period (15 december 2004 – 1 december 2005). a convenient sampling of 48 women of all ages was used. four patients did not fit the study criteria and were excluded. cytological data were retrieved from the original reports and no standardised criteria were used to determine adequacy. of the available cytology results 23.9% (11 of 46) were positive for malignancy, 17.4% (8 of 46) were negative for malignancy, 4.4% (2 of 46) showed atypical cells and 54.3% (25 of 46) of reported results were inconclusive. in the group of fine-needle aspirations that showed atypical cells (2 patients), neither had a follow-up ultrasound after 3 or 6 months, but both patients were followed up with a mammogram after 6 months. in patients with fine-needle aspiration results that were inconclusive, 20% were followed up with ultrasound after 3 months. after 6 months 8% had a follow-up ultrasound and 36% had a follow-up mammogram. four per cent of the patients had a routine mammogram at 1 year and 56% were referred to the surgery department. (some patients had more than one follow-up examination.) the aim of our audit was to develop baseline statistics regarding fnab results for our unit. the high number of inconclusive results in our study (56.82%) could be due to the fact that fnabs of non-palpable lesions are more difficult to perform. the level of experience of each radiologist performing the aspiration as well as the skill of the cytologist should also be considered. fnabs will be continued at our unit and a follow-up study for comparison of statistics is planned. such a comparison between studies will assist us in setting a standard for future fnab results at our unit. introduction fine-needle aspiration biopsy (fnab) is done regularly at our mammography unit. aspiration is only done on lesions that are non-palpable and difficult to access. fnab of palpable lesions is done at the surgery clinic as preferred by the dedicated breast surgeons. the reason for the execution of our study was to develop a database of information regarding the results of fnabs done on breast lesions that were not palpable and difficult to access. the patients were all seen at our mammography unit. based on our own audited results, continuation of only fnab (sometimes complemented by core biopsy) on these breast lesions will be considered. methods a retrospective descriptive study was done from the reports of all patients who had fnabs performed between 15 december 2004 and 15 december 2005 at our mammography unit, universitas hospital, bloemfontein. this was a convenient sampling of 48 women of all ages. the information was taken from computerised files. approval for the study was obtained from the ethics committee, faculty of health, university of the free state. cytological data were retrieved from the original reports and no original slides were re-evaluated. no standardised criteria were used to determine adequacy. according to internal protocol ultrasound-guided fnabs were only done on lesions that were non-palpable or difficult to biopsy without ultrasound guidance (hereafter referred to as difficult-to-access lesions). the physical examination was not recorded in the patient files. radiological studies (mammogram or ultrasound) were considered non-suspicious if no abnormality was detected or where a benign finding such as a well-circumscribed mass was visible. only lesions that appeared suspicious on ultrasound were sampled. lesions with the typical appearance of a fibro-adenoma, cyst or intraparenchymal lymph node were therefore excluded. fine-needle aspirations were done by a radiologist with a 20 ml syringe and a 22 gauge needle. each patient’s skin was surgically cleaned and anaesthetised with lidocaine. the lesion was then aspirated while negative pressure was applied to the syringe. suspicious cystic lesions were aspirated and fluid was sent for cytological examination. solid lesions were aspirated with the needle being repeatedly advanced and withdrawn in various directions within the lesion. the aspirated content was smeared on glass slides and was immediately evaluated by the cytologist for an adequate amount of cells. results during the period 15 december 2004 to 15 december 2005, 48 patients underwent invasive biopsy procedures at our mammography unit. these procedures were performed in response to suspicious lesions having been found during imaging of the breasts. from the original group of 48 patients, 4 patients did not meet the study criteria and were excluded. fine-needle aspirations were done on the remaining 44 patients of the 44 patients included in this study, 22 patients underwent more than one fnab. despite this, more than one cytology result was available for only 2 of the patients, resulting in a total of 46 available cytology results. audit on breast biopsies of non-palpable and difficult-to-access lesions m naudé, mb chb c s de vries, mmed (rad d) e f nel, dipl rad diagn department of diagnostic radiology, university of the free state, bloemfontein original article original article pg4-5.indd 4 7/11/06 12:45:00 pm of the available cytology results 23.9% (11 of 46) were positive for malignancy, 17.4% (8 of 46) were negative for malignancy, 4.4% (2 of 46) showed atypical cells and 54.3% (25 of 46) of reported results were inconclusive. in the group of fine-needle aspirations that showed atypical cells (2 patients), neither had a follow-up ultrasound after 3 or 6 months, but both patients were followed up with a mammogram after 6 months. in patients with fine-needle aspiration results that were inconclusive, 20% were followed up with ultrasound after 3 months. after 6 months 8% had a follow-up ultrasound and 36% had a follow-up mammogram. four per cent of patients had a routine mammogram at 1 year and 56% were referred to the surgery department. (some patients had more than one follow-up examination.) discussion in a study done in june 2001 at the department of radiology, university of north carolina,1 to determine the diagnostic accuracy of ultrasonographically and stereotactically guided fnab in the diagnosis of nonpalpable breast lesions, fnab proved to have limited value because of the high insufficient sample rate and greater diagnostic accuracy of other interventions, e.g. core-needle biopsy and needle-localised open surgical biopsy. at 18 institutions, 442 women who underwent 22-25 gauge imaging/guided fnab were enrolled. definitive surgical, core-needle biopsy and/or follow-up information was available for 423 (95.7%) of these women. when insufficient samples were included in the analysis and classified as positive, the sensitivity and specificity of fnab were 8588% and 55.6-90.5% respectively. the diagnostic accuracy of fnab was significantly better for detection of masses than for detection of calcifications and with ultrasound guidance than with stereotactic guidance. according to another study done in december 20032 on breastscreening patients, the use of fine-needle aspiration cytology in the assessment of highly suspicious mammographic microcalcifications proved to be a highly accurate, rapid and cost-effective means of triage of patients who would benefit most from the more expensive core biopsy. between january 1996 and june 2000, the dominant radiological abnormality was classified prospectively as high-grade microcalcifications in 182 lesions. data were recorded on patient demographics, radiological features and the findings of fnab and core biopsy, if performed. the results of the screening assessment were then compared with the final histological findings. fnab had a sensitivity of 77.22% and a positive predictive value of 100%. fnab is used as a diagnostic tool and done regularly at our mammography unit on lesions that are non-palpable and difficult to access. this procedure is relatively easy, simple to perform and has a low cost which makes it suitable for developing countries where other complicated diagnostic instruments may not be readily available.3 the aim of this audit was to develop baseline statistics regarding fnab results for our mammography unit. positive cytological results confirm the diagnosis of breast carcinoma and ensure prompt referral to the surgery department. in our audit 23.9% of fnab results showed malignant results, 17.4% no malignancy, 4.4% atypical cells and 54.3% were inconclusive. in a retrospective study done in massachusetts general hospital,4 1 062 breast fnabs were performed on palpable as well as non-palpable breast lesions: 10% were reported unsatisfactory, 42% negative, 20% atypical, 3% suspicious and 25% positive for malignancy. the fact that palpable as well as non-palpable breast lesions were sampled in the abovementioned study, made comparison with our audit very difficult. fnabs of non-palpable lesions are more difficult to perform. the high number of inconclusive results in our study (54.3%), could be attributed to this fact. the level of experience of each radiologist performing the examination as well as the skill of the cytologist, should also be considered. fnabs will be continued at our unit. a follow-up study for comparison of statistics, that will include information regarding clinical examination, radiological reports and fnab results, is planned and this will assist us in setting a standard for future fnab results at our unit. 1. pisano ed, fajardo ll, caudry dj, et al. fine-needle aspiration biopsy of nonpalpable breast lesions in a multicenter clinical trial: results from the radiologic diagnostic oncology group v. radiology 2001; 219(3):785-792. 2. farshid g, rush g. the use of fine-needle aspiration cytology and core biopsy in the assessment of highly suspicious mammographic microcalcifications: analysis of outcome for 182 lesions detected in the setting of a population-based breast cancer screening program. cancer 2003; 99(6):357-364. 3. kanchanabat b, kanchanapitak p, thanapongsathorn w, manomaiphiboon a. fine-needle aspiration cytology for diagnosis and management of palpable breast mass. aust n z j surg 2000; 70(11):791-794. 4. lau sk, mckee gt, weir mm, tambouret rh, eichhorn jh, pitman mb. the negative predictive value of breast fine-needle aspiration biopsy: the massachusetts general hospital experience. breast journal 2004; 10(6):487-491 original article � sa journal of radiology • june 2006 pg4-5.indd 5 7/11/06 12:45:00 pm abstract background methodology results discussion conclusion acknowledgements references about the author(s) james stutterheim department of radiology, university of kwa-zulu natal, south africa matthew d. goodier department of radiology, grey’s hospital, south africa citation stutterheim j, goodier md. reliability assessment of a mechanism-based approach to post-injury knee magnetic resonance imaging interpretation by general radiologists. s afr j rad. 2018; 22(1), a1253. https://doi.org/10.4102/sajr.v22i1.1253 note: additional supporting information may be found in the online version of this article as an online appendix: https://doi.org/10.4102/sajr.v22i1.1253-1 original research reliability assessment of a mechanism-based approach to post-injury knee magnetic resonance imaging interpretation by general radiologists james stutterheim, matthew d. goodier received: 10 july 2017; accepted: 26 mar. 2018; published: 04 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: a mechanism-based approach to post-injury knee magnetic resonance imaging (mri) interpretation, following acute complex knee injury, is cited by several authors to provide increased reporting accuracy and efficiency, by allowing accurate prediction of injury to at-risk structures. this remains to our knowledge untested in a developing world setting and is of interest to us as south african general radiologists. objective: to assess the reliability of a mechanism-based approach to complex post-trauma knee mri interpretation when implemented by general radiologists in a south african setting, and compare our results with the findings of north american authors who compiled and assessed the same classification. to measure the agreement between the observers. methods: a quantitative, observational, investigative, retrospective study was performed using a sample of 50 post-trauma knee mri studies conducted at grey’s hospital, pietermaritzburg. two investigators independently applied the consolidated mechanism-based approach compiled by hayes et al. as a research tool to interpret the knee mri studies, blinded to each other’s findings. results: injury mechanism was assigned in 32% of cases by the principle investigator and in 20% of cases by the supervisor, with fair agreement between the observers (k = 0.39). the investigators agreed that 62% of cases were not classifiable by mechanism, 26% because of highly complex injury and 26% because of non-specific findings. conclusion: our findings indicate that the hayes et al. classification is a non-ideal tool when used by general radiologists in our setting, as the pure injury mechanisms described in the classification were rare in our study group. patient epidemiology and investigator experience are highlighted as potential limiting factors in this study. despite this, we advocate that the concept of a mechanism-based approach for the interpretation of acute post-trauma knee mri holds value for general radiologists, particularly in patients imaged before resolution of bone bruising (within 12–16 weeks of injury), and those injured in sporting and similar athletic activities. background a mechanism-based approach to radiological imaging interpretation, following complex musculoskeletal injury, has logical and useful clinical application because of the predictable synergisms that may occur within a number of complex joints. several classifications have been developed on this basis, such as the young–burgess classification for pelvic fractures and lauge–hansen classification for ankle fractures.1,2 the knee lends itself favourably to this concept, firstly because of the complex interrelation of its primary and secondary stabilising structures, and secondly because of the high positive and negative predictive values of magnetic resonance imaging (mri) for the diagnosis of injury to a wide range of soft tissue structures in the knee.3,4,5 it is well established that knee injuries occur commonly in the athletically active population, with the incidence of significant knee injury estimated to lie in the region of 500 cases per year per 400 000 population in a united kingdom study.6 in a 10-year-long swiss-based study of the epidemiology of knee injuries in over 17 000 athletically active patients, 50% of knee injuries were found to occur in patients between the ages of 20 and 29 years.7 clinical examination is highly sensitive for diagnosing soft tissue injury in patients presenting, following knee injury such as occurring by falling, twisting injury or direct impact, with accuracy ranging between 75% and 96% for the diagnosis of significant ligament or meniscal injury demonstrated by rayan et al.8 magnetic resonance imaging is commonly used by the orthopaedic surgeon as an adjunct to clinical examination and is most useful in the setting of equivocal clinical examination or acute complex knee injury, when the presence of swelling and pain may limit the accuracy of clinical examination.4,8,9 magnetic resonance imaging is highly accurate in the diagnosis of internal derangements of the knee.10 a systematic review comparing mri and arthroscopy findings found high sensitivity and specificity for mri detection of meniscal and cruciate ligament injury with figures between 88% and 99% for all structures except for a relatively lower sensitivity of 79% for the detection of lateral collateral ligament injury.10 a mechanism-based approach to complex post-trauma knee mri interpretation is cited by several authors in the recent literature to provide increased reporting accuracy and efficiency, by allowing accurate prediction of injury to at-risk structures.3,4,11,12 an understanding of the biomechanics of the knee can heighten awareness of injury to key stabilising structures such as the posterolateral or posteromedial corner, as well as subtle but important injuries to key structures such as the anterior cruciate ligament (acl) or posterior cruciate ligament (pcl). undiagnosed injuries left untreated could lead to chronic instability and eventual failure of surgical repair of structures such as the acl.3 such an approach is complementary to an initial thorough screening of individual structures, using an anatomical approach, as detailed in comprehensive musculoskeletal imaging texts such as stoller’s ‘magnetic resonance imaging in orthopaedics and sports medicine’.13 the radiologist requires a clear appreciation of the spectrum of injury types and grades for each structure of the knee, including partial and full thickness ligament tears, the wide variety of meniscal tears, and the complex anatomy of and appearance of injury at the posterolateral corner.14 we, as general radiologists seeking to raise reporting standards by following emerging international trends, took interest in the clinical benefits accredited to a mechanism-based approach in post-trauma mri knee interpretation, notably because of its proposed increased accuracy and efficiency.4 to our knowledge, such an approach has not been tested in a developing world setting where epidemiology of knee injury differs, and patient presentation and referral may be delayed. the consolidated mechanism-based pattern approach for the interpretation of acute post-trauma knee mri compiled by hayes et al.3 is the most comprehensive approach of its kind in the recently published literature, with similar articles on this topic taking a more descriptive approach. the utility of a mechanism-based imaging approach is directly proportional to the percentage of cases that can be thereby classified – the hayes et al. classification stands out in this regard, with 85% of cases classifiable by the approach in their setting. this classification comprises 10 common injury mechanisms and emphasises the initial identification of the pattern of bone bruising, which in combination with the identification of ligamentous and capsular injury allows one to identify the pattern of the injury mechanism. a key component of the classification is the differentiation of impaction and avulsion bone bruising: both are maximal in the subcortical region of the trauma force; however, impaction bruising tends to be larger, has variable location and, when due to impaction across the joint, is seen at contiguous sites on either side of the joint; avulsion oedema, however, is typically more confined and localised at the precise attachment site of the ligament or tendon injured by traction force.14 although some studies suggest onset of resolution of bone bruising from as early as 7–12 weeks,4 and persistence as long as 42 weeks,15 a detailed study by frobell has estimated mean resolution time for femoral bone bruising at 12 weeks and for tibial bone bruising at 24 weeks.16 the primary objective of this study is to quantitatively evaluate the reliability of a mechanism-based approach to post-trauma knee mri interpretation when implemented by general radiologists in a south african setting, using the hayes et al. classification. methodology a quantitative, observational, investigative, retrospective study was performed, using a sample of 50 post-trauma knee mri studies conducted at grey’s hospital, pietermaritzburg, a state-funded tertiary referral centre and teaching hospital in pietermaritzburg, kwazulu-natal, south africa, between 03 january 2012 and 24 june 2014. criteria for inclusion were adult patients (>12 years of age) who had undergone knee mri investigation within 16 weeks of traumatic injury. sixteen weeks was chosen as the most reasonable cut-off. this was firstly to ensure that the majority of cases would lie within the window of detection of bone bruising. secondly, this was in light of the frequently delayed timing between injury and mri in our setting (average time from injury to mri for a chronological sample of 30 patients imaged at grey’s hospital was 9.5 months). normal studies and studies performed for non-traumatic knee pathology were excluded. three of the initial 50 selected cases were eliminated (one normal study, one patient with imaging findings of septic arthritis and one with a bone tumour). the next three sequential cases with imaging findings of traumatic injury were added to restore a number of 50 cases. the study series consisted of a total of 50 knees imaged from 47 patients, as 3 patients had injuries to both knees. all examinations were performed using the same 1.5 tesla magnet mri scanner (phillips medical systems, south africa). patients were scanned using a dedicated knee coil and standard local protocol (sagittal t1w, sagittal stir t2w, axial and coronal proton density with fat saturation, sagittal 3d spir sequences). research tool the mechanism-based classification system for complex knee injuries compiled by hayes et al. was used as the research tool.3 the classification comprises 10 common injury mechanisms and their key individual injury components. the authors devised an image-based quick reference summary of common knee injury mechanisms aimed to improve efficiency when using the hayes et al. classification. the summary is based on the 10 common injury patterns described by hayes et al. and includes for each mechanism a schematic diagram of the position of the knee at the time of injury (sketches were produced by the principal investigator to aid conceptualisation of the position of the knee at the time of injury for each mechanism), corresponding bone bruise and soft tissue injuries outlined on a normal mri scan, and a brief description of the imaging findings. we found it a challenging task to continually cross-reference imaging findings with typed descriptions. the summary yields the classification more user-friendly, especially for those new to or not frequently reporting post-trauma knee mri cases (refer to online appendix 1). the most commonly encountered mechanism in the hayes et al. study, nicknamed the ‘o’donoghue’s unhappy triad’, may occur with either contact or non-contact force and occurs with valgus and internal rotation injury of the flexed knee. this injury results in a typical bone bruise pattern with associated acl and medial collateral ligament (mcl) injury. for the sake of comparison, the digital tool made the classification more practical, as seen in figure 1 extracted from quick reference guide classification3 (also see online appendix 1: figure 6). figure 1: flexion, valgus and external rotation: (a) schematic depicts excessive sudden internal rotation of femur on ‘fixed’ tibia (effective external tibial pivot) with knee in flexed valgus position, (b) anterior cruciate ligament (acl) tear that results from excessive rotation, (c) non-contiguous impactions at the lateral femoral condyle and posterolateral tibia that occur once the acl has given way and (d) right knee medial collateral ligament (mcl) tear that is often incomplete; look for avulsion bone bruise at deep (purple) and superficial (green) mcl portion attachments. a retrospective review was performed on a sample of 50 digital mri knee studies from a picture archive and communication system (pacs), by both the principal investigator (senior registrar at outset of study, now a radiologist in general private practice) and supervisor (radiologist now with 4 years experience in general state practice). the investigators descriptively recorded relevant imaging findings (i.e. bone bruising, acl, pcl, mcl, lateral collateral ligament [lcl] and capsular injuries) relevant to the hayes et al. mechanism-based classification, and remained blinded to each other’s findings, and to the injury circumstances during the imaging interpretation phase. impaction and avulsion bone bruising were differentiated where applicable. the investigators independently correlated the mri findings of each case with the 10 mechanisms of the hayes et al. classification. where there was a clear match between the imaging findings and a particular mechanism in the classification, an injury mechanism was assigned. the investigators remained blinded to one another’s findings and to the injury circumstances so that a reflection of the performance of the classification could be established for each interpreter. the completed investigator findings were then compared to assess the number of cases that were classifiable or non-classifiable by mechanism according the hayes et al. classification. where provided, knee injury circumstances were recorded from the mri request form history, and injuries were classified into the categories motor vehicle and pedestrian vehicle accidents (mva/pva), falls, sporting injury and injury not specified. this was performed following completion of the imaging interpretation phase, to avoid biasing the assignability of a classification, as the focus of the study was assessment of the reliability of an injury mechanism classification based on imaging findings alone. full ethics approval was granted by the biomedical research ethics committee: university of kwazulu-natal biomedical research ethics committee with reference number be518/14. statistical analysis descriptive statistics were employed to determine the percentage of cases classifiable and non-classifiable by the investigators, as well as to determine the potential reasons for non-classifiability to quantitatively assess the reliability of the research tool. the chi-squared test and p-value were used to determine whether there was a significant difference between the percentage of cases classifiable by the investigators and hayes et al. the fleiss’ kappa measure of agreement was used to calculate the interrater reliability. use of statistica was employed for statistical analysis. results frequency distribution tables for gender, age, timing between injury and mri, and knee injured are specified in tables 1, 2, 3 and 4, respectively. table 1: frequency distribution: gender. table 2: frequency distribution: age. table 3: frequencies: injury to magnetic resonance imaging (months). table 4: frequency distribution: side injured. assignability of mechanism there was an agreement between both investigators on the assignable injury mechanism in 14% of cases. this was significantly less than the 85% classifiable cases achieved by hayes et al. using the same classification (p < 0.0005; c2: v = 1.48; table 5). individually, injury mechanism was assigned in 32% by the principal investigator and in 20% by the supervisor. the investigators both agreed that a mechanism could not be assigned in 62% of cases. this was because of high injury complexity in 26%, non-specific findings in 26% and insufficient findings in 10% of the total cases. for the total 76% of assignability and non-assignability of a mechanism, there was fair agreement between the observers (fleiss’ kappa coefficient k = 0.39), as shown in table 6. there was disagreement on the presence of a classifiable injury mechanism in 24% of cases. table 5: injury mechanism assignment. table 6: analysis of agreement for classifiable and non-classifiable mechanisms. in the cases where there was disagreement on a classifiable injury mechanism, the two readers agreed that bone bruising was present in 7 of these 12 cases. bone bruising bone bruising was present in 84% of cases overall. there was complete and near-complete agreement on the presence of bone bruising in 96% of cases (exact agreement on findings in 66% of total cases and near-complete agreement in 30% of total cases, with the latter arbitrarily defined by the authors as a minor variation in interpretation at a single site of bone bruising). of these cases, 54% were agreed to be non-classifiable by mechanism; 13 of 27 cases (48%) were agreed to be non-classifiable because of non-specific findings and 12 of 27 cases (44%) were agreed to be non-classifiable because of high injury complexity. two cases were not classifiable because of insufficient findings. there was disagreement on bone bruising in two cases (4%), meaning that the investigator interpretation of bone bruising sites differed significantly. there was no bone bruising present in 14% of cases, and there was agreement on non-assignability in all of these cases. injury circumstances thirty-four per cent of injuries were sustained during mva/pva, 24% in sporting and similar athletic activities and 20% in falls. in 22% of cases, injury circumstances were not provided. of pva/mva injuries, 2 of 17 knees had classifiable mechanisms, and seven could not be classified because of high injury complexity. of sports and related injuries, 2 of 12 knees had classifiable injuries, four could not be classified because of indeterminate findings, 3 could not be classified because of insufficient findings and there was disagreement on mechanism in 3 knees. there were insufficient imaging findings in 10% of cases, with absent bone bruising in four out of these five cases (note: above findings according to both observers). discussion the major finding of this study is the low rate of cases (14%) agreed classifiable by mechanism, compared to 85% in the original hayes et al. study. pure injury mechanisms outlined in the hayes et al. classification were rare in our study group, and reasons for this are explored below. there was disagreement on injury mechanism in 12 cases (24% of the study sample). of these, in seven cases there was agreement between the observers on the sites of bone bruising. most of these cases had extensive bruising at multiple sites, indicating complex mechanism not fitting with a typical bone bruising pattern from the hayes et al. classification. there was disagreement on the significance of soft tissue injury between the investigators in these cases. in several cases, one investigator assigned a mechanism within a more complex injury, while the other did not. in no single case was a different mechanism assigned by both investigators. hayes et al. do not specify their exact methodology in the application of their classification. it may be that each individual case requires careful scrutiny to identify synergistic injury components possibly within a more complex injury, as well as an awareness of variances that may occur with each mechanism. experience may strongly affect the ability to accurately achieve this. clearer guidelines on the implementation of a mechanism-based classification are anticipated to reduce subjective variability between observers. examples might include minimum criteria, exclusion criteria and a points system for identifying mechanisms. bone bruising is the fundamental starting point in the identification of knee injury mechanism on mri. the finding of high combined complete and near-complete agreement regarding the presence or absence of, as well as the sites of, bone bruising in 96% of cases, with bone bruising agreed present in 84% of cases overall, reinforces that bone bruising is a reliable radiological finding. despite this, there was a low incidence of the typical bone bruise patterns presented in the hayes et al. classification, which are fundamental to a mechanism-based classification. a corresponding high percentage of cases with agreement on bone bruising, namely 54% could not be classified by mechanism, predominantly because of indeterminate findings and high injury complexity. macmahon and palmer4 discuss countless circumstances that lead to traumatic knee injury, involving numerous combinations of the 12 possible movements at the knee and occurring by contact and non-contact forces. questions are thus posed as to whether the hayes et al. classification (or any similar classification) can adequately encompass the full range of common knee injuries, and whether pure mechanisms occur less commonly than they are postulated to. additional injury components such as medial or lateral tibial translation, discussed by macmahon and palmer in one of their published cases, add another dimension to the topic and are not included in the hayes et al. classification. soft tissue injury is complimentary to the detection of fundamental injury mechanism. typical soft tissue injuries were identified jointly by both investigators in only the 14% of cases classified by both investigators. by definition injury mechanism cannot be assigned in the absence of a typical bone bruise pattern. the high incidence and agreement on the presence and site of bone bruising suggests that the inclusion criterion of cases imaged within 4 months of injury was adequate. however, despite this, macmahon and palmer4 indicate that bone bruising is postulated by some authors to resolve by 6–12 weeks. in light of this, a further study could look at applying a mechanism-based image interpretation approach within this window to ensure that subtle bone contusions will not be missed. there was a high combined percentage of mva/pva injuries (34%) and falls (24%) of over 50% in our study sample. the 31% mva/pva statistic correlates with the generally high south african road accident morbidity and mortality reflected by the average 35.8 deaths per 100 000 population, which is almost double world averages of 19 deaths per 100 000 in 1999.17,18 patients injured by mva/pva or falls from a height are more likely to have had complex soft tissue injuries because of high velocity, often with accompanying fractures, and it may be expected that in such cases a single injury mechanism will generally not apply. in this study, of the 31 cases agreed non-categorisable, 17 were because of mva/pva and falls combined. this suggests that the classification was less reliable in this subset of patients. a high percentage of classifiable cases in the hayes et al. study sample (46%) were because of rotational ‘pivot-shift’ injury (classical non-contact rotational injury seen commonly in sports such as soccer and skiing),4 whereas only one case of a pivot-shift mechanism was agreed present by the observers in our study sample. the relatively low 24% of sport-related injuries in our setting and high number of combined mva/pva and falls, suggests considerably different injury epidemiology between our study group and the initial hayes et al. study population. it may be suggested that the hayes et al. classification is best applied in the setting of sporting and recreational athletic activities, when lower velocity trauma and pure injury mechanisms will be more likely. it was surprising to note that only 2 of 12 sports injuries were classifiable. although this is lower than anticipated, it may be argued that there are too few sports-related injuries in our study sample to draw conclusion from. a further study focusing on a south african study sample with sports injuries would be beneficial in confirming this. the south african radiology environment is, following global trends, in evolution from generalist to sub-specialist structure; however, the predominant need within the system remains general radiologists, in light of the high burden of disease and its resource-constrained health services. the authors, both general radiologists, recognise the skills gap that will exist between general radiologists, especially those less experienced, and sub-specialist trained musculoskeletal radiologists dedicated to this field in their every-day practice. this lack of subspecialty training and experience could have been at least partly responsible for the fewer cases classifiable by mechanism in the study group, as well as there being only fair agreement between the observers. accurate and consistent differentiation between impaction and avulsion bone marrow patterns at varying sites, fundamental to the hayes et al. classification, is a skill that will develop with experience and practice. limitations the sample size of 50 cases may be considered a limitation compared with the 100 cases in the hayes et al. study. this study assessed the reliability of a mechanism-based classification when applied by general radiologists who were both relatively inexperienced. further studies assessing the performance of the classification system amongst experienced general radiologists and/or subspecialty musculoskeletal radiologists would be of interest. conclusion is the application of a mechanism-based approach for the interpretation of acute post-trauma knee mri appropriate for general radiologists? we believe yes, as such an approach proposes significant clinical benefits and aims to raise reporting standards and quality. is the hayes et al. classification in particular, a useful tool to achieve this? we have shown that this is a non-ideal tool when used by general radiologists in our setting, in essence because pure injury mechanisms were rare. despite this, we propose that following a thorough initial assessment of individual structures within the knee, a global search for common injury patterns is still warranted, based primarily on bone bruising. this is likely particularly beneficial in patients injured during sporting and similar athletic activities, and within the period of maximal visibility of bone bruising, ideally within 12 weeks of injury. perhaps the identification of synergistic components of complex knee injuries is more clinically relevant than limiting this concept to pure injury mechanisms only. further research is anticipated to identify the effect of investigator experience on the reliability of mri interpretation with a mechanism-based approach. a higher skill and experience level may be required to accurately identify synergistic injury components in the setting of highly complex injuries. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.s. is currently a radiologist in private practice and has enrolled for master’s in medicine at the university of kwazulu-natal. he was the principal investigator and contributed to the writing of this manuscript. m.d.g. is currently a senior radiology consultant at grey’s hospital, pietermaritzburg, a teaching hospital under the university of kwazulu-natal. m.d.g. was the supervisor of this study. both j.s. and m.d.g. performed an independent interpretation of the mri cases in the study sample using the biomechanical approach of hayes et al. references okanobo h, khurana b, sheehan s, duran-mendicuti a, arianjam a, ledbetter s. simplified diagnostic algorithm for lauge-hansen classification of ankle injuries. radiographics. 2012;32:e71–e84. https://doi.org/10.1148/rg.322115017 alton tb, gee ao. classifications in brief: young and burgess classification of pelvic ring injuries. clin orthop relat res. 2014;472:2338–2342. https://doi.org/10.1007/s11999-014-3693-8 hayes cw, brigido mk, jamadar da, propeck t. mechanism-based pattern approach to classification of complex injuries of the knee depicted at mr imaging. radiographics. 2000;20:s121–s134. https://doi.org/10.1148/radiographics.20.suppl_1.g00oc21s121 macmahon p, palmer w. a biomechanical approach to mri of acute knee injuries. ajr am j roentgenol. 2011;197:568–577. https://doi.org/10.2214/ajr.11.7026 manaster bj. knee mr atlas [homepage on the internet]. statdx. amirsys, inc.; 2016 [cited 2016 jul 20]. available from: amirsyssupport@elsevier.com bollen s. epidemiology of knee injuries: diagnosis and triage. br j sports med. 2000;34:227–228. https://doi.org/10.1136/bjsm.34.3.227-a majewski m, susanne h, klaus s. epidemiology of athletic knee injuries: a 10-year study. knee. 2006;13(3):184–188. https://doi.org/10.1016/j.knee.2006.01.005 rayan f, bhonsle s, shukla dd. clinical, mri, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries. int orthop. 2009;33(1):129–132. https://doi.org/10.1007/s00264-008-0520-4 mohan br, gosal hs. validity of clinical diagnosis in meniscal tears. int orthop. 2007;31(1):57–60. https://doi.org/10.1007/s00264-006-0131-x oei eh, nikken jj, verstijnen ac, ginai az, myriam hunink mg. mr imaging of the menisci and cruciate ligaments: a systematic review. radiology. 2003;226(3):837–848. https://doi.org/10.1148/radiol.2263011892 lim sy, peh wcg. magnetic resonance imaging of sports injuries of the knee. ann acad med. 2008;37(4):354–361. sanders tg, medynski ma, feller jf, lawhorn kw. bone contusion patterns of the knee at mr imaging: footprint of the mechanism of injury. radiographics. 2000;20:s135–s151. https://doi.org/10.1148/radiographics.20.suppl_1.g00oc19s135 stoller d. magnetic resonance imaging in orthopaedics and sports medicine. philadelphia, pa: lippincott williams & wilkins. 2007; pp. 305–731. hayes cw, coggins ca. sports-related injuries of the knee: an approach to mri interpretation. clin sports med. 2006;25(4):659–679. https://doi.org/10.1016/j.csm.2006.06.008 boks ss, vroegindeweij d, koes bw, bernsen rm, hunink mg, bierma-zeinstra sm. mri follow-up of posttraumatic bone bruises of the knee in general practice. ajr am j roentgenol. 2007;189(3):556–562. https://doi.org/10.2214/ajr.07.2276 frobell rb. change in cartilage thickness, posttraumatic bone marrow lesions, and joint fluid volumes after acute acl disruption: a two-year prospective mri study of sixty-one subjects. j bone joint surg am. 2011;93(12):1096–1103. https://doi.org/10.2106/jbjs.j.00929 sukhai a, jones a, haynes r. epidemiology and risk of road traffic mortality in south africa. sagj. 2009;91(1):4–15. https://doi.org/10.1080/03736245.2009.9725325 motor vehicle deaths: countries compared [homepage on the internet]. 1999. [cited 2017 april 19]. available from from: http://www.nationmaster.com/country-info/stats/health/motor-vehicle-deaths abstract introduction case report ethical consideration discussion conclusion acknowledgements references about the author(s) monica s. msomi department of radiology, pietermaritzburg metropolitan complex, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa nondumiso n. dlamini department of radiology, pietermaritzburg metropolitan complex, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa citation msomi ms. dlamini nn. cherubism: a case report. s afr j rad. 2017;21(1), a1118. https://doi.org/10.4102/sajr.v21i1.1118 case report cherubism: a case report monica s. msomi, nondumiso n. dlamini received: 02 nov. 2016; accepted: 30 jan. 2017; published: 21 apr. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract cherubism is rarely described in the african paediatric population. orphanet currently lists cherubism as a rare disease; its prevalence is unknown and difficult to determine because of the wide clinical spectrum. approximately 300 cases have been reported in various ethnic groups worldwide. this report analyses a child referred to our hospital for bilateral jaw swelling, diagnosed with cherubism based on clinical and radiological findings, and confirmed on histology. introduction cherubism is currently listed in orphanet as a rare disease of unknown prevalence due to its wide clinical spectrum, with approximately 300 cases reported in various ethnic groups worldwide.1 it is an uncommon, benign, self-limiting fibro-osseous disorder characterised by painless progressive bilateral enlargement of the mandible and maxilla, first described by william jones in 1933.2,3,4,5 both hereditary and sporadic cases have been described.2,4,5 it is inherited as an autosomal-dominant disorder with variable penetrance, and a mutation in chromosome 4p16.3 has been demonstrated.2,4,6 recent studies have shown it to be a genetically separate entity from fibrous dysplasia,2,4,5,6 of which it was initially thought to be a subset. it presents typically in childhood, as early as age 2,3,4,5 with painless symmetric enlargement of the jaw associated with slight upward turning of the eyes. ancillary findings include dental arch and dental eruption abnormalities,2,3,5,6 and submandibular and cervical lymph node enlargement.3,6 minor signs such as gum epulis and gum overgrowth are useful to diagnose relatives of affected children, in order to define a comprehensive family history. extragnathic skeletal involvement is rare.2 case report a 7-year-old girl presented with swollen gums and painless mandibular swelling for 2 years. the radiological findings demonstrated on a radiograph (figure 1) and a computed tomography (ct) scan (figures 2 and 3) of the mandible were in keeping with a diagnosis of cherubism. this was confirmed on histology. a definite family history was obtained, which ascertained a sporadic form of the disease. genetic tests were not performed. management was initially conservative, but the patient later had surgery for dental complications. a subsequent ct scan demonstrated static disease. the patient is currently undergoing periodical clinical follow-up. figure 1: radiograph of the mandible demonstrating diffuse bone expansion with extensive, bilateral, cystic multilocular lucencies with a soap-bubble appearance and associated endosteal scalloping, cortical thinning and malpositioning of teeth. figure 2: axial computed tomography scan at the level of the mandible and inferior alveolar process, demonstrating diffuse, bilateral, expansile, multilocular lucencies in the mandible, with a soap-bubble appearance. endosteal scalloping, cortical thinning and areas of cortical absence are also observed. mild sclerosis and deformity of the inferior alveolar process are also demonstrated, and small submandibular and submental lymph nodes (not shown) are also present. figure 3: frontal (a) and lateral (b) three-dimensional reconstructed computed tomography scans demonstrating diffuse, bilateral, expansile, multilocular lucencies in the mandible, with a soap-bubble appearance. dental malposition is also demonstrated. the condylar heads of the mandible, temporomandibular joints and maxilla are not involved. ethical consideration the patient’s identity was protected. this case report is purely for educational and academic purposes. discussion the radiographic hallmark of cherubism is bilateral, symmetrical, multiloculated radiolucent lesions in the mandible extending from the region of the molar teeth towards the midline,5 resulting in a soap-bubble appearance of the jaw.3 maxillary involvement is less frequent, characterised by a soft tissue density in the maxillary antrum resulting in the ‘hard palate sign’ on lateral skull radiographs.5 absence of periosteal reaction is another important feature.2 sparing of the mandibular condyles has traditionally been considered a hallmark of this condition, but there have been reports of involvement of the condyles.2,4,5 unilateral cases of cherubism have been reported.3,5 panoramic radiographs are acceptable for the initial diagnosis, but multi-planar and three-dimensional ct reconstructions are mandatory for optimal visualisation of the extent of disease.2 histology has limited value for the diagnosis2 and demonstrates fibrous stroma containing abundant multinucleated giant cells,2,3,4,6 a finding which is not pathognomonic. the diagnosis, therefore, depends on clinico-radiological findings.2,3 radiographic differential diagnoses for cherubism include cranio-facial fibrous dysplasia, brown tumour of hyperparathyroidism, familial gigantiform cementoma,2,4 and central giant cell granuloma.3,5,6 cherubism and fibrous dysplasia can be distinguished clinically and histologically. features that favour the diagnosis of cherubism include bilateral mandibular involvement and limitation to the mandible. furthermore, patients with fibrous dysplasia do not present with swollen cheeks or dental derangement4 and tend to present at a later age.5 brown tumour is excluded on clinical and biochemical grounds. lesions in central giant cell granuloma have a predilection to involve the anterior mandible, are rarely bilateral or symmetrical and tend to present later.5 familial gigantiform cementomas consist predominantly of focal maxillary lesions often with extension into the orbits and nasal septum.2,4,5 cherubism may be associated with other genetic diseases such as ramon’s syndrome, noonan’s syndrome, jaffe–campanacci syndrome and neurofibromatosis type 1.2,6 our patient did not have any family history or express any clinical features of these conditions. there is a tendency towards spontaneous remission,2,5 with partial or full regression and sclerotic involution by adulthood,2,4 mostly without the need for treatment.2,5,6 medical agents may be used to reduce the size of lesions,2 and limited surgical resection may be performed for cosmetic or functionality purposes.2,3,5,6 radiotherapy is contraindicated due to risks such as malignancy and osteonecrosis.2,3 complications of cherubism include ocular disturbances such as proptosis and diplopia, which may rarely prolong beyond regression of the lesions of the jaw,2 and problems with speech, mastication and swallowing,2,3 which were reported by our patient. conclusion cherubism is rarely described in the african paediatric population. histology has limited value for the diagnosis, which is primarily clinico-radiological. acknowledgements the authors thank dr vicci du plessis for her suggested revisions for this case report. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.s.m. performed literature review and did the primary write up of the manuscript. n.n.d. assisted with the literature review and manuscript editing. references cherubism: best clinical practice. orphanet j rare dis 2012:7(suppl 1)s6. https://doi.org/10.1186/1750-1172-7-s1-s6 wagel j, luczak k, hendrich b, guziński m, sąsiadek m. clinical and radiological features of nonfamilial cherubism: a case report. pol j radiol. 2012;77(3):53–57. https://doi.org/10.12659/pjr.883375 hille jj, buch b, evans wg, shakenovesky b, butz s. cherubism: two case reports and a review of the literature. j dent assoc s afr. 1986;41(7):461–466. beaman fd, bancroft lw, peterson jj, kransdorf mj, murphey md, menke dm. imaging characteristics of cherubism. ajr am j roentgenol. 2004;182:1051–1054. https://doi.org/10.2214/ajr.182.4.1821051 jain v, sharma r. radiographic, ct and mri features of cherubism. pediatr radiol. 2006;36:1099–1104. https://doi.org/10.1007/s00247-006-0261-8 koch bl. cherubism. [homepage on the internet]. last updated 10.08.2016. [cited 2017 mar 28]. available from: https://my.statdx.com/document/cherubism 34 sa journal of radiology • september 2006 abstract we present a case of an adult male who sustained severe spinal injury following relatively minor injury. plain film, computed tomography (ct) scans and magnetic resonance (mr) images aided the diagnosis of os odontoideum with c1-2 subluxation and high cervical spinal cord compression. incidental detection of an os odontoideum should not be considered as a variant anomaly but should be referred for appropriate spinal evaluation and surveillance. introduction os odontoideum is an ossicle with smooth circumferential margins representing the odontoid process or dens. it lacks continuity with the body of c2 and its importance lies in the fact that trauma may compromise a previously asymptomatic atlanto-axial joint. we present a case of an adult male who sustained severe spinal injury following relatively minor injury. we believe that an os odontoideum should not be considered as a variant anomaly, and because such patients are vulnerable to severe spinal cord injury, they should be referred for spinal evaluation and surveillance. case report a 22-year-old man sustained an injury to his neck when he was pushed into the back of a pick-up truck. he reports that when his head hit a metal plate in the truck, he felt dizzy followed by a sensation of pins and needles in his arms and legs. he was subsequently unable to move his arms and legs at all. his childhood had been uneventful, and he had worked as a bricklayer’s assistant. he was admitted with a diagnosis of spastic quadraparesis. he has recovered to some degree, being able to spastic quadraparesis following a relatively minor injury the ‘os odontoideum’ s moosa, mb chb, bsc hons (pharm), mphil, fc rad (diag) department of radiology, groote schuur hospital and university of cape town s andronikou, mb bch, fc rad (diag), frcr (lond), phd department of radiology, tygerberg hospital and stellenbosch university case report case report fig. 1. lateral neck view demonstrating an atlantodental interval (adi) of 11 mm compared to the normal for adult males of up to 3 mm. well-corticated bony ossicles are visualised superior and inferior to the anterior arch. the dens is small and the posterior arch of c1 is displaced anteriorly. the spinal canal is reduced in diameter. fig. 2. open mouth view demonstrating a small cupola-shaped dens. pg 34-36.indd 34 9/6/06 2:58:02 pm 35 sa journal of radiology • september 2006 walk unaided for short distances and has regained some power in both hands. plain film, computed tomography (ct) scan and magnetic resonance (mr) images are presented in figs 1 5. a diagnosis of os odontoideum with c1-2 subluxation and high cervical spinal cord compression was made. discussion os odontoideum (greek ‘tooth like’) is a rare anomaly of the second cervical vertebra which was first described from postmortem studies by giacomini in 1886.1 by definition, an os odontoideum is a small accessory ossicle with smooth, well-corticated borders that is separated from the base of a shortened odontoid process. the size and shape of the ossicle can vary. the atlanto-axial joint exhibits the greatest mobility in the vertebral column and is also the least stable.1 os odontoideum frequently leads to atlanto-axial instability with spinal-cord compression.2 atlanto-axial instability can arise from multiple causes including inflammatory arthritides, trauma, infection, laxity of the transverse ligament, e.g. trisomy 21 and other congenital abnormalities. plain cervical spinal radiographs are usually sufficient to obtain a diagnosis. os odontoideum has been classified into two anatomic types, orthotopic and dystopic. orthotopic describes an ossicle that moves with the anterior arch of c1, whereas dystopic defines an ossicle that is functionally fused to the basion. minor trauma can produce symptoms when the dystopic os is freed and subluxes anterior to the arch of c1.3 the gap between the os odontoideum and the odontoid process extends to above the superior articular facet of the atlanto-axial joint. this is in contrast to an acute fracture or non-union of the odontoid in which the gap is narrow and irregular and extends into the body of the axis below the level of the superior facet.1 case report fig. 3. flexion view demonstrating a decrease in spinal canal diameter with flexion while the adi increases in dimensions. fig. 4. axial ct demonstrating the increased adi. fig. 5. sagittal t2-weighted mr image demonstrating abnormal high signal in the cord which is kinked at the upper cervical level. the markedly narrowed spinal canal and anterior csf effacement is well visualised. pg 34-36.indd 35 9/6/06 2:58:03 pm case report 36 sa journal of radiology • september 2006 os odontoideum is associated with hypoplasia of the posterior arch as well as anterior arch hypertrophy, compensating for the increased stress placed on the latter. it occurs commonly in trisomy 21, klippel-feil and other craniocervical malformations. the aetiology of os odontoideum remains unsettled but this does not play a major role in its diagnosis or management.3 the proponents who feel that it is a congenital abnormality suggest that the mechanism involves the failure of the os terminale to fuse, or failure of the main part of the odontoid process to fuse with the body of the axis.1 (sa: ok?) fielding et al.4 attributed os odontoideum to a disunited fracture by presenting cases with a history of trauma and previously normal radiographs. they propose that subsequent to an odontoid fracture, the proximal portion is pulled by the contraction of the alar ligament and non-union is facilitated by vascular interruption. in our case, a second ossicle inferior to the anterior arch is uncommon and probably points to a traumatic origin. the literature supports the ability of cervical plain films to establish the diagnosis of os odontoideum but their sensitivity and specificity as well as the need for additional confirmatory studies is still unreported.3 flexion and extension plain films have been used to depict the degree of c1 and c2 instability. anterior subluxation of the os in relation to the body of c2, as was the case in this patient, predominates over posterior subluxation.3 ct scans have been used to better define the bony anatomy of the os odontoideum and the odontoid process. the role of mri has been to evaluate the spinal cord and to provide additional anatomical information. both ct and mri assist in operative planning of unstable os odontoideum. the degree of c1-2 instability does not seem to correlate with the neurological status in patients with os odontoideum and a sagittal spinal canal diameter on plain films of 13 mm or less is strongly associated with myelopathy.3 asymptomatic patients with os odontoideum, with or without c1-2 instability may be managed with clinical and radiological surveillance. those with symptoms and/or neurological signs and c1-2 instability may be managed with posterior c1-2 internal fixation and fusion.3 conclusion os odontoideum is a potentially mechanically unstable condition which is associated with trisomy 21 and other congenital conditions. minor trauma may result in severe spinal cord injury. cervical plain films are usually diagnostic. both ct and mri assist in operative planning. the incidental detection of an os odontoideum should not be considered as a variant anomaly but should be referred for appropriate spinal evaluation and surveillance. this may have special relevance in children whose sporting activities may have to be restricted. 1. forlin e, herscovici d, bowden jr. understanding the os odontoideum. orthopaedic review 1992; 21: 1441-1446. 2. dai l, wen y, bin n, jia i. os odontoideum: etiology, diagnosis and management. surg neurol 2000; 53: 106-109. 3. os odontoideum. neurosurgery 2002; 50: s148-s155. 4. fielding jw, hensinger rn, hawkins rj. os odontoideum. j bone joint surg am 1980; 62: 376-383. pg 34-36.indd 36 9/6/06 2:58:03 pm abstract introduction case report discussion conclusion acknowledgements references about the author(s) swati singh department of radiodiagnosis, vivekananda polyclinic and institute of medical sciences, india vaishali upadhyaya department of radiodiagnosis, vivekananda polyclinic and institute of medical sciences, india rajat agarwal department of radiodiagnosis, vivekananda polyclinic and institute of medical sciences, india ratni b. gujral department of radiodiagnosis, vivekananda polyclinic and institute of medical sciences, india citation singh s, upadhyaya v, agarwal r, gujral rb. rare case of solitary plasmacytoma of the skull in a young male patient. s afr j rad. 2017;21(1), a1133. https://doi.org/10.4102/sajr.v21i1.1133 case report rare case of solitary plasmacytoma of the skull in a young male patient swati singh, vaishali upadhyaya, rajat agarwal, ratni b. gujral received: 24 nov. 2016; accepted: 22 feb. 2017; published: 21 apr. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract solitary plasmacytoma of bone without signs of multiple myeloma is a rare entity. it usually presents as an osteolytic lesion in the axial skeleton of an elderly patient. here, we report a case of solitary plasmacytoma in the skull of a young male patient which emphasises the need to consider it in the differential diagnosis of a destructive calvarial mass lesion even in this age group. introduction plasma cell neoplasms are a group of disorders characterised by the neoplastic proliferation of a single clone of plasma cells. solitary plasmacytoma of bone (spb) also known as osseous plasmacytoma is a rare form constituting less than 5% of all cases of plasma cell disorders. it presents at the median age of 55 years.1 being the disease of older adults, the occurrence of spb in a young individual is extremely rare, with only about 1.1% of cases occurring in individuals younger than 30 years of age.2 we would like to report such a case of spb in the skull of a young male patient. case report a 25-year-old male patient presented with a 6-month history of a gradually progressive, painless swelling at the back of the head associated with headache. on examination, there was a firm, non-tender, subcutaneous swelling in the left parieto-occipital region with normal overlying skin. no neurological abnormality was evident. haemoglobin, blood counts, blood urea, serum creatinine and electrolytes including serum calcium were done and found to be normal. immunoelectrophoresis for serum proteins revealed normal levels of immunoglobulins. urinalysis for bence-jones proteins showed no abnormal findings. bone marrow examination was done which did not reveal any signs of systemic myelomatosis. x-rays of the skull showed a well-defined lytic lesion in the left parietal bone with an associated large soft tissue component. no marginal sclerosis or periosteal reaction was noted (figure 1a and 1b). non-contrast computed tomography (ncct) revealed a well-defined heterogeneous hyperdense mass lesion centred on the left parietal bone causing bone destruction, compressing the adjacent brain parenchyma and bulging into the scalp. a few small bony fragments were seen at the periphery of the lesion (figure 2). magnetic resonance imaging (mri) of the brain with contrast demonstrated a well-defined heterogeneously enhancing soft tissue mass lesion measuring 8.0 cm × 7.9 cm × 6.8 cm causing destruction of the left parietal bone and bulging into the scalp. some flow voids were seen with the mass. no restricted diffusion or surrounding oedema was noted. there was mass effect with compression of adjacent brain parenchyma and mild midline shift to the right side. the mass was compressing adjacent superior sagittal sinus but not invading it (figures 3, 4, 5 and 6). skeletal survey of the body revealed no other lytic lesions anywhere in the body. figure 1: (a) x-ray of the skull pa view shows a well-defined lytic lesion with irregular margins in the left parietal bone and (b) x-ray of the skull lateral view shows the associated soft tissue component. no sclerosis or periosteal reaction is seen. figure 2: non-enhanced ct scan in axial plane shows a heterogeneous mass lesion in the left parietal bone causing bone destruction with compression of adjacent brain parenchyma and extension into the scalp. figure 3: axial t1-weighted mr image shows a heterogeneous mass lesion in left parietal bone causing bone destruction. figure 4: axial t2-weighted mr image showing the mass with lack of edema in adjacent brain parenchyma. figure 5: contrast enhanced t1-weighted axial mr image showing intense heterogenous enhancement of the mass lesion. figure 6: contrast enhanced sagittal t1-weighted mr image also shows the mass lesion with lack of infiltration of adjacent brain parenchyma. the patient underwent left parieto-occipital craniotomy with gross total excision of the mass. histopathological examination revealed a plasmacytoma with massive amyloid deposition. discussion solitary plasmacytoma of bone without signs of multiple myeloma is a rare entity. the diagnosis is based on the presence of radiologically solitary bone lesion; histological evidence of tumour consisting of monoclonal plasma cells; fewer than 5% plasma cells in bone marrow; less than 2.0 g/dl monoclonal protein (m protein) in the serum when it is present; negative urine test for bence-jones protein with no evidence of hyperglobulinemia, hypercalcaemia or anaemia.3 solitary plasmacytoma of bone mostly occurs in axial skeleton, such as skull and vertebra. it shows male preponderance and is extremely rare in patients less than 30 years of age.4 on radiography, spb presents as a well-defined osteolytic lesion with clear margins and narrow zone of transition. there is no bony sclerosis or periosteal reaction. the lesion is hyperdense on ncct and shows marked homogenous enhancement with contrast. small bony fragments may be seen at the periphery. on mri, spb appears isointense on t1-weighted images and hyperintense on t2-weighted images. intratumoural flow voids have been described. the lesion shows dense but heterogeneous enhancement with contrast.3,5,6 although plasmacytoma was part of the radiological differential in our case, it was considered unlikely taking into account its extreme rarity in young patients. the other radiological differentials that were considered included osteosarcoma, metastasis, eosinophilic granuloma and bone lymphoma. osteosarcoma is the most common primary bone malignancy and frequently occurs in adolescence. osteosarcoma usually involves long bones with primary calvarial involvement being rare. in our case, the lesion could have been an osteosarcoma but lack of matrix mineralisation and periosteal reaction were points against this diagnosis. calvarial metastases are usually blood-borne metastases arising secondarily to lung, kidney, thyroid and gastro-intestinal carcinomas; sarcomas; and malignant melanomas. these are often small and multiple but can be single and large with regular or irregular margins. in our case, no primary tumour was detected elsewhere making metastasis an unlikely possibility. eosinophilic granuloma is usually seen in children and young adults with skull as a predilection site. in our patient, the tumour was a large, well-demarcated lytic mass lesion, and typical radiological findings such as bevelled edges and button sequestrum were absent. primary lymphoma of the skull is extremely rare. it shows permeative or moth eaten type of bone destruction associated with soft tissue component. however, this was not consistent with the pattern of bone destruction seen in our case where a large well-defined lytic lesion was found in the left parietal bone. conclusion although typically a disease of older adults, this case report emphasises the need to consider the possibility of spb in the differential diagnosis of a large calvarial mass lesion causing bone destruction even in younger patients. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.s. was responsible for literature compilation. v.u. was responsible for image acquisition, guiding and editing the manuscript. r.a. was responsible for image editing and typesetting. the idea and guidance regarding this article was given by r.b.g. references dimopoulas ma, moulopoulos la, maniatis a, alexanian r. solitary plasmacytoma of bone and asymptomatic multiple myeloma. blood. 2000;96:2037–2044. jawad mu, scully sp. skeletal plasmaytoma: progression of disease and impact of local treatment; an analysis of seer database. j hematol oncol. 2009;2:41. https://doi.org/10.1186/1756-8722-2-41 tanaka m, shibui s, nomura k, nakanishi y. solitary plasmacytoma of the skull: a case report. jpn j clin oncol. 1998;28(10):626–630. https://doi.org/10.1093/jjco/28.10.626 kilciksiz s, celik ok, agaoglu fy, haydaroglu a. a review for solitary plasmacytoma of bone and extramedullary plasmacytoma. scientific world j. 2012;2012:895765. https://doi.org/10.1100/2012/895765 okamoto k, ito j, funusawa t, et al. solitary plasmacytoma of the occipital bone: a report of two cases. eur radiol. 1997;7:503–506. https://doi.org/10.1007/s003300050192 mahale a, ullal s, thiagarajan d, das s. plasmacytoma of the base of skull – a case report. indian j med paediatr oncol. 2007;28(3):34–37. editorial andrew du toit mb chb, ff rad (d) sa levin and partners constantiaberg mediclinic cape town relevant radiological •reporting dactors and patients are aware of advances in imaging trends. radiologists like to show beautiful images at clinical meetings, and patients research via the internet or hear about new modalities through friends who have experienced modern imaging. these new machines sometimes make pathology startlingly obvious, but does the interpretation that we convey in the report really help the clinician? radiologists endeavour to keep pace with imaging advances, and invest in expensive hardware that requires ongoing investment in expensive software upgrades. they modernise the waiting room and the dictation system, and design new packets for the new mr! machine. yet the most important part of our final product, the report, never really receives any attention. many radiologists adopt and keep a style of reporting from mentors who impressed them during registrar training. in private practice radiologists are pressurised to issue reports within minutes of the examination being completed. in many cases this is possible, but how many times have you signed off a report that you wish could have received more attention or been worded differently? it's out there on paper now, and you probably would have preferred to consult the referring clinician, think about the problem and give a more satisfactory report the next day. our final product on paper needs the same attention that we give to the image. essentially this means better knowledge of pathology, an understanding of what the clinician needs to know and a few lessons in sentence construction so that the report does not read like a grade 3 essay.this applies to the bread and butter stuff as well, such as the routine daily mobile chest x-ray done in the icu. meaningful liaison with the critical care staff, preferably by joining ward rounds, will ensure a report that has much more relevance rather than once again describing a shadow without knowing about the patient's fluid status. for this edition of the journall decided that the theme should be relevant radiological reporting and asked my colleagues to come up with something in their field of interest. we have such varied demands that it is difficult to keep pace with the advances in every field of medicine. some studies we feel uncomfortable with, but one can go a long wayan basic radiology skills if one is aware of what is important in the conclusion. andrew du toit editor 3 sajournalof radiology. february2003 star abstract staging lung cancer philippe grenier md in non-small cell lung cancer (nsclc), radical surgical resection is considered to represent therapy most likely to offer cure. this is usually only possible if there is no involvement of unresectable structures and no distant metastases. in advanced disease, particularly in the presence of distant metastases, cure is usually not possible and palliative chemotherapy and radiotherapy is considered the most appropriate therapeutic strategy. in small cell lung cancer (sclc) treatment consists of chemotherapy with or without additional radiotherapy. in selected cases of disease limited to one hemithorax: radical surgery in combination with chemoand/or radiotherapy may provide curative treatment. the aim of staging procedures is to determine the extent of the disease and, thus, select the most appropriate treatment. for this purpose it is important to reliably detect local tumor extent (t stage: tl-t4) as well as the presence or absence of lymphatic (n stage: no-n3) and hematogeneous (m stage: mo, ml) metastases (table 1). staging system revisions in stage grouping of the tnm subsets in the international system for staging lung cancer were made 1997, to provide greater specificity for identifying patient groups with similar prognoses and treatment options. patients who are likely to benefit from surgical resection are those with localized disease. only stages i, ii and ilia can be considered as technically resectable (table 2). patients considered as definitely unresectable are those having distant metastases (ml), controlateral or subclavian lymph node metastases (n3) or tumor classified t4. the local extent of tumor affects the extent of surgery required for radical resection. generally, a tumor surtable i. tnm description for staging lung cancer (1) tx primary tumor cannot be assessed or cannot be visualized despite presence of malignant cells in sputum or bronchial washings to no evidence of primary tumor tis carcinoma in situ tl 'iumor s 3 cm surrounded by lung or visceral pleura; without bronchoscopic evidence of infiltration of main bronchus t2 tumor> 3 cm / infiltration of main bronchus> 2 cm to carina / infiltration of visceral pleura / obstructive pneumonitis or atelectasis extending to the hilum but not involving entire lung t3 infiltration of main bronchus < 2 cm to carina / infiltration of parietal or mediastinal pleura, chest wall, pericardium, diaphragm / obstructive pneumonitis or atelectasis of entire lung t4 infiltration of heart, great vessels,trachea, esophagus, vertebral body / malignant pleural or pericardial effusion / satellite tumor nodules within the same lobe nx regional lymph nodes cannot be assessed no no regional lymph node metastases nl metastasis to ipsilateral intrapulmonary, peribronchial or hilar lymph nodes n2 metastasis to ipsilateral mediastinal and/or subcarinallymph nodes n3 metastasis to contralateral hilar, contralateral mediastinal, ipsior contralateral scalene or supraclavicular lymph node metastases (note: cervical or abdominal lymph node metastases are considered ml) mx presence of distant metastases can not be assessed mo no distant metastases ml distant metastases (brain, adrenal, skeleton etc.), lymphatic distant metastases (cervical and abdominal lymph nodes), satellite tumor nodules in other lobes 14 sa journal of radiology • december 2002 star abstract tableii. stagegrouping tnm subsets (1) stagela tl no mo stagei b t2 no mo stageiia tl nl mo stageii b t2 nl mo t3 no mo stageiii a t3 nl mo tl-3 n2 mo stageiii b t4 no-2 mo tl-4 n3 mo stageiv tl-4 no-3 ml rounded by aerated lung with no invasion of the main bronchus (tl) can be resected by lobectomy, whereas infiltration of the main bronchus, chest wall, diaphragm or mediastinum requires more aggressive surgery (pneumonectomy or sleeve resection, resection of chest wall, diaphragm etc.) which is associated with higher morbidity and mortality. infiltration of structures that are either unresectable (heart) or in which resection is usually associated with higher morbidity or mortality (esophagus, brachial plexus, spine, aorta, superior vena cava etc.) are usually considered inoperable, particularly in view of the usually poor survival associated with these degrees of tumor extent. other features do not affect resectability but reflect a more extensive tumor spread such as the presence of satellite tumor nodules in the same lobe. as treatment options in small cell lung cancer are more limited a simplified staging system is often used in clinical practice (table 3). tumour extent ct continues to playa major role in preoperative staging of non-small cell lung cancer for selecting those tableiii. staging of small celllung cancer (veteransadministration lung cancer study group) (2) verylimited disease (vld) stagei and ii limited disease (ld) primary tumor limited to one hemithorax ipsilateralhilar,mediastinalor supraclavicularlymph node metastases contralateralmediastinallymph node metastases atelectasis paralysisof recurrent or phrenic nerve smallpleural effusionwith no malignant cells extensivedisease i (edi) contralateralhilar or supraclavicularlymph node metastases infiltrationof chestwall pleuraleffusion(exceptfor smalleffusionwith non malignant cells) superiorvena cavasyndrome metastasesto controlaterallung extensivedisease ii (edii) pleuriticcarcinomatosis lymphangiticcarcinomatosis distant metastases patients with localized disease who are likely to benefit from surgical resection. certain ct findings have been demonstrated as being diagnostic of unresectable disease. in many of these situations, biopsy proof of diagnosis is necessary but thoracotomy is not indicated. although gross mediastinal invasion can be confidently diagnosed with ct, the contiguity of tumor with adjacent mediastinal structures is not equivalent to definite invasion. mr has the same limitations as ct in distinguishing tumor contiguity from tumor extension into mediastinal structures. owing to its superior contrast resolution, mr may demonstrate subtle chest wall invasion and be superior to ct in this regard. mr is also thought to be more accurate that ct in depicting chest wall invasion from superior sulcus tumor that commonly involves the vertebra posteriorly, and the subclavian vessels and brachial plexus 15 sa journal of radiology • december 2002 anteriorly. on the other hand, using helical scanning with thin collimation, bolus injection of contrast medium, and sagittal and coronal reconstructions, the anatomical environment of the plexus may also be accurately assessed with ct. mr remains an alternative only in cases in which the ct findings are inconclusive and in those in which extension into the neural foramina and epidural space is suspected. both ct and mr! cannot reliably differentiate between benign and malignant pleural and pericardial effusions. presence of malignant pleural or pericardial effusion is best diagnosed by demonstration of malignant cells at aspiration. nodal extent ct is very valuable in detecting mediastinal lymph node enlargement. low sensitivity of ct is due to its inability to detect microscopic metasstar abstract tases within normal-sized lymph nodes. low specificity arises from the frequent occurrence of enlarged hyperplastic nodes. consequently, all patients with abnormal mediastinal lymph nodes on ct scans need lymph node resection or biopsy. mr has no superiority over ct and is not indicated in this regard. positron emission tomography (pet) with f18 2 fluoro-2-deoxy-d-glucose (fdg) is more sensitive and specific than ct for nodal staging in lung cancer. mediastinoscopy has proven to be unnecessary in patients with ct evidence for stage i disease and a negative pet of the regional nodes. increased fdg uptake in hilar and mediastinal lymph nodes can be used to direct surgical nodal sampling. the combined use of ct and pet to stage intrathoracic nodal metastases is not only clinically useful but also costeffective. pet reduces the probability that a patient with unresectable mediastinal nodal metastases will undergo an attempt at curative resection. distant metastases in most institutions lung cancer patients undergo routine staging procedures including chest radiographs, ct of the chest, abdomen and brain, bone scintigraphy and ultrasound examination of the abdomen. because the adrenal glands are the most common site for extrathoraeie metastases, ct examination should include the upper abdomen. an adrenal mass however may represent an incidental adenoma. most incidental nonhyperfunctioning adrenal adenomas are less than 3 cm in diameter and of uniform low attenuation « 10 hu), because of their fat content. routine unenhanced ct of the adrenal glands allows accurate prospective characterization of many adrenal masses in patients with lung carcinoma. in institutions in which pet is readily available, this may be performed as the only additional examination after ct, as it is the most accurate non-invasive imaging technique to confirm or exclude both lymph node and distant metastases (except for brain metastases) in a single examination. whole-body fdg-pet improves the detection of extrathoracic disease and alters management in up to 40% of cases. conclusion ct remains the imaging technique of choice in staging lung cancer. despite its limitation, ct is indicated in order to determine the extent of the primary tumor, to evaluate the mediastinal space for the presence of nodal enlargement, and to screen metastatic disease in the adrenal glands. mr is only indicated as an additional examination in patients with superior sulcus tumor. whole body pet is the best technique for screening both lymph node and distant metastases. suggested reading 1. mountain cf. revisions in the international system for staging lung cancer. chest 1997; ill: 1710-1717. 2. stahel ra, ginsberg r, haveman k. staging and prognostic factors in small cell lung cancer: a consensus report. lung cancer 1989; 5: 119124. 3. parek bj, louie 0, altorki n. staging and the surgical management of lung cancer. in: "the radiologic clinics of north america. lung cancer': henschke cl, w.b. saunders company, philadelphia, 2000, vol38, p 545-562. 4. macari m, rofsky nm, naidich dp, megibow aj. non-small cell lung carcinoma: usefulness of unenhanced helical cr of the adrenal glands in an un monitored environment. radiology 1998; 209: 807-812. 5. webb wr, gatsonis c, zerhouni ea, heelan rt, glazer gm, francis ir, mcneil bj.cr and mr imaging in staging non-small cell bronchogenic carcinoma: report of the radiologic diagnostic oncology group. radiology 1991; 178: 705-713. 6. peterman rm, van putten jwg, meuge1sarjj, et al. preoperative staging of non-small cell lung cancer with positron emission tomography. n engl j med 2000; 343: 2547. earnest f, ryu jh, miller gm, luetrner ph, forstrom la, burnett ol, rowland cm, swensen sj,midthun de. suspected non-small cell lung cancer: incidence of occult brain and skeletal metastases and effectiveness of imaging for detection pilot study. radiology 1999; 211: 137-145. 16 sa journal of radiology • december 2002 abstract introduction case report magnetic resonance imaging (findings over 3 years) discussion conclusion acknowledgements references about the author(s) denny mathew department of radiology, university of the witwatersrand, south africa nasreen mahomed department of radiology, university of the witwatersrand, south africa department of radiology, rahima moosa mother and child hospital, south africa south african society of paediatric imaging (saspi), cresta, south africa citation mathew d, mahomed n. vanishing white matter disease imaged over 3 years. s afr j rad. 2019;23(1), a1661. https://doi.org/10.4102/sajr.v23i1.1661 case report vanishing white matter disease imaged over 3 years denny mathew, nasreen mahomed received: 03 sept. 2018; accepted: 04 dec. 2018; published: 27 feb. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract childhood ataxia and central nervous system hypomyelination (cach), also known as ‘vanishing white matter disease’ (vwm), is a leukoencephalopathy with autosomal recessive inheritance. it is characterised by normal psychomotor development initially, with an onset of neurological deterioration that follows a chronic and progressive course. stress conditions such as febrile infections, minor head trauma or even acute fright provoke major episodes of neurological deterioration. we present a case of a 2-year-old child who presented with spasticity and cerebellar ataxia. after magnetic resonance imaging (mri) of the brain, cach/vwm was diagnosed on the basis of the typical clinical and mri findings. as there is no known cure for cach/vwm, our patient was followed up over 3 years with mris of the brain to assess the progressive involvement of the cerebral white matter. in those patients with suggestive or inconclusive mri findings for cach/vwm, particularly in the presymptomatic stage and adult onset variants, involvement of the inner rim of the corpus callosum should prompt the inclusion of cach/vwm in the differential diagnosis. biochemical markers such as the asialotransferrin:transferrin ratio in the cerebrospinal fluid can also potentially be used as a screening tool in this subset of patients prior to gene mutation analysis. introduction childhood ataxia and central nervous system hypomyelination (cach), also known as ‘vanishing white matter disease’ (vwm) and ‘myelinopathia centralis diffusa’, is a leukoencephalopathy with autosomal recessive inheritance.1,2,3 a study in canada in 1988 described severe infantile leukodystrophy amongst the native cree indian villages, termed ‘cree leukoencephelophathy’,4 a condition that is now recognised as a phenotypic variant of cach/vwm.5 although vwm was initially described in young children, it is now well known that it has a wide phenotypic spectrum, affecting people of all ages, with the age of onset inversely proportional to the clinical severity.1,2 childhood ataxia and central nervous system hypomyelination (vanishing white matter disease) is characterised by normal psychomotor development initially, with an onset of neurological deterioration that follows a chronic and progressive course.1,2,3 stress conditions such as febrile infections, minor head trauma or even acute fright provoke major episodes of neurological deterioration in this condition.12,3 the exact prevalence of vwm is unknown; however, it may be one of the more common leukodystrophies.3 in a study of unclassified leukodystrophies in childhood by van der knaap et al., cach was the most common, with 21 of a total of 92 patients found to have magnetic resonance imaging (mri) features of cach/vwm.6 this article aims to provide more insight into cach/vwm, with a focus on the progression of the mri brain imaging findings in our patient, who was imaged over 3 years. our understanding of cach/vwm continues to evolve, with increasing literature over the last two decades providing a better understanding of the imaging findings and genetic mutations. case report we present a case of a 2-year-old child who initially presented with cerebellar ataxia and spasticity and was subsequently booked for mri of the brain. the provisional diagnosis was that of cach/vwm based on the clinical presentation and classical mri findings. magnetic resonance imaging (findings over 3 years) the initial mri (figure 1a–c) demonstrated diffuse, symmetrical, white matter signal abnormalities with mild cystic degeneration and involved the corpus callosum, basal ganglia and cerebellar white matter. these regions corresponded with high signal intensity on the t2 weighted image (t2wi), proton density (pd) and fluid attenuation inversion recovery (flair) sequences and showed no enhancement post-gadolinium. there was sparing of the subcortical white matter. figure 1: initial magnetic resonance imaging (mri) (after clinical presentation): (a) axial fluid attenuation inversion recovery (flair) image with high signal in the cerebellar white matter tracts with associated mild cystic degeneration. (b and c) axial flair images show a classical mri picture of cach/vwm – diffuse symmetric signal abnormality with mild cystic degeneration in the cerebral white matter, sparing the u fibres. cach/vwm, childhood ataxia and central nervous system hypomyelination (vanishing white matter disease). a radiating linear pattern within the abnormal white matter was suggestive of the remaining normal white matter tracts (figure 2a). the corpus callosum involvement was limited to the inner rim and spared the outer rim (figure 3a). diffusion-weighted images showed an increase in diffusivity of the abnormal white matter, which was likely secondary to the rarefaction and cystic degeneration. figure 2: magnetic resonance imaging after 1 year: (a) parasagittal t1 weighted imaging (t1wi) demonstrates radiating stripes stretching across the rarefied white matter, which is suggestive of the remaining normal white matter tracts. (b and c) axial fluid attenuation inversion recovery (flair) images with significant progression in the white matter signal abnormality and cystic degeneration. figure 3: magnetic resonance imaging after 2 years: (a) sagittal t1 weighted imaging (t1wi) demonstrates involvement of the inner rim of the corpus callosum. (b and c) axial fluid attenuation inversion recovery (flair) images with further progressive signal abnormalities and cystic degeneration of the white matter. follow-up mri of the brain after 1 and 2 years (figure 2a–c and figure 3a–c) demonstrated progressive cystic degeneration in a radial pattern of the affected deep white matter over time, with signal intensity changing to that of cerebrospinal fluid (csf) on t2wi, flair and pd sequences. discussion childhood ataxia and central nervous system hypomyelination (vanishing white matter disease) is caused by mutations in any of the five genes encoding the five subunits of the eukaryotic translational initiation factor 2b (eif2b).2 although eif2b mutations have previously been described with an affinity for cerebral white matter only, it is now known that there is an association with ovarian failure.7 gynaecological studies have demonstrated that the gene for vwm is located on chromosome 3q27.8 prior to the availability of genetic testing for cach/vwm, the diagnosis of this entity was based on typical clinical and mri findings.2 the proposed diagnostic criteria for vwm include the following:9 initial motor and mental development is normal or near normal. neurological deterioration has an early-childhood onset with an episodic and chronic progressive course. neurological signs of spasticity and cerebellar ataxia (epilepsy and optic atrophy may also occur, but are not mandatory). magnetic resonance imaging findings of symmetrical and bilateral involvement of the cerebral white matter, with parts or all of the white matter demonstrating signal intensities similar to that of csf over time. childhood ataxia and central nervous system hypomyelination (vanishing white matter disease) can be diagnosed on the account of all four obligatory criteria being met.9 van der knaap et al. have described obligatory and suggestive mri criteria for the diagnosis of vwm in those patients with classical mri findings (table 1); however, the use of these criteria is not applicable to identify the rare and atypical mri variants.10 table 1: magnetic resonance imaging criteria for the diagnosis of vanishing white matter. all patients with cach/vwm demonstrate mri abnormalities, even the symptomless at-risk siblings of a proband.3 magnetic resonance imaging typically shows diffuse and symmetrical involvement of the cerebral white matter with sparing of the u fibres, internal capsules and outer part of the corpus callosum.1 the cortical grey matter is always spared.1 over time there is progressive rarefaction and cystic degeneration of the white matter that is eventually totally replaced by csf-like signal intensity on t1wi, t2wi and flair images (figure 1a–c, figure 2a–c, figure 3a–c).11 on t1wi and flair images, radiating stripes may be seen stretching across the rarefied white matter, which are suggestive of the remaining normal white matter tracts (figure 2a).3 the cerebellar white matter may be affected, as evidenced in our case (figure 1a), and the brainstem may also demonstrate abnormal signal intensity, particularly in the pontine central tegmental tracts.1 cerebellar atrophy may occur in late stages and ranges from mild to severe, primarily involving the vermis.3 contrast enhancement does not occur in cach/vwm and diffusion-weighted imaging shows increased diffusion in areas of rarefaction and cystic degeneration.1,12 in a study conducted by van der lei et al. that looked at the characteristics of the early mri findings in vwm, the mri abnormalities were not always widespread and diffuse in the presymptomatic or early stages of vwm, in contrast to what was previously thought.2 the initial changes were noted in the periventricular and bordering deep white matter. the inner rim of the corpus callosum was involved in all patients in this study and was also evidenced in our case (figure 3a).2 the follow-up of mri imaging of these patients demonstrated the more classical diffuse, symmetrical mri picture of vwm.2 magnetic resonance spectroscopy (mrs) of the affected cerebral white matter demonstrates a stage-dependant reduction of the normal metabolite peaks with the accumulation of glucose and lactate at csf-like concentrations.1,10 loss of the normal n-acetyl aspartate, choline and creatine peaks are a result of the rarefaction and cystic degeneration.13 the mrs findings at the end stage of this spectrum are not diagnostic for cach/vwm, as they may be evident in any cystic white matter disease.10 cerebrospinal fluid analysis may demonstrate a decreased asialotransferrin:transferrin ratio, which has a high sensitivity and specificity for patients with eifb2-related mutations.14 this biochemical marker offers the potential to be used as a screening tool in selected cases prior to expensive dna sequencing tests in patients with suggestive or inconclusive mri findings.14 in individuals with a rapid neurological decline following a febrile infection, the differential for cach/vwm includes acute disseminated encephalomyelitis (adem) and encephalitis.2 unlike cach/vwm, children with adem may have evidence of inflammation in the csf with mri of the brain typically showing asymmetric, multifocal, white matter abnormalities. encephalitis demonstrates variable lesions in the white, as well as grey matter, where cach/vwm only involves the white matter.2 in both adem and encephalitis, contrast enhancement may be apparent, which is not evident in cach/vwm.2 the differential diagnosis for cach/vwm also includes other inherited disorders presenting in infancy and childhood with progressive neurological deterioration and diffuse white matter abnormalities. alexander disease demonstrates increasing frontoparietal white matter atrophy with cystic degeneration and, unlike cach/vwm, contrast enhancement of selected grey and white matter structures are characteristic of this disease.3 macrocephaly is present in patients with alexander disease but may also occur in selected cases of cach/vwm.15 in x-linked adrenoleukodystrophy, metachromatic leukodystrophy, krabbe disease and canavan disease, diffuse cerebral white matter changes occur but in the absence of cystic degeneration.3 in megalencephalic leukoencephalopathy with subcortical cysts, mri shows diffuse supratentorial white matter abnormalities, subcortical cysts mostly in the frontoparietal border zone region and anterior-temporal subcortical white matter and, unlike cach/vwm, the cerebral white matter does not undergo diffuse rarefaction and cystic degeneration.3 the imaging appearance of mitochondrial disorders may appear similar to that of cach/vwm with diffuse white matter rarefaction and cystic degeneration.3 conclusion childhood ataxia and central nervous system hypomyelination (vanishing white matter disease) is a chronic and progressive white matter disorder, often exacerbated by infection or minor head trauma. the proposed diagnostic and mri criteria assist in making the diagnosis of cach/vwm with a high degree of certainty in those patients with typical clinical and mri findings. however, in those patients with suggestive or inconclusive mri findings, involvement of the inner rim of the corpus callosum should prompt the inclusion of vwm in the differential diagnosis. cerebrospinal fluid analysis of asialotransferrin:transferrin ratio can also be used in this subset of patients as a screening tool prior to gene testing. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution d.m. was responsible for the review of literature, review of the imaging studies and preparation of the case report as per the journal requirements. n.m. was responsible for the diagnosis of the case, interpretation of the imaging studies, initial write-up of the case report and editing of the final article. references bugiani m, boor i, powers jm, scheper gc, van der knaap ms. leukoencephalopathy with vanishing white matter: a review. j neuropathol exp neurol. 2010;69(10):987–996. https://doi.org/10.1097/nen.0b013e3181f2eafa van der lei h, steenweg m, barkhof f, et al. characteristics of early mri in children and adolescents with vanishing white matter. neuropediatrics. 2012;43(1):22–26. https://doi.org/10.1055/s-0032-1307456 schiffmann r, fogli a, van der knaap ms, boespflug-tanguy o. childhood ataxia with central nervous system hypomyelination/vanishing white matter. genereviews®. washington, dc: university of washington, seattle; 1993–2018. black dn, booth f, watters gv, et al. leukoencephalopathy among native indian infants in northern quebec and manitoba. ann neurol. 1988 oct;24(4):490–496. https://doi.org/10.1002/ana.410240403 fogli a, wong k, eymard-pierre e, et al. cree leukoencephalopathy and cach/vwm disease are allelic at the eif2b5 locus. ann neurol. 2002 oct;52(4):506–510. https://doi.org/10.1002/ana.10339 van der knaap ms, breiter sn, naidu s, hart aam, valk j. defining and categorizing leukoencephalopathies of unknown origin: mr imaging approach. radiology. 1999 oct;213(1):121–133. https://doi.org/10.1148/radiology.213.1.r99se01121 fogli a, rodriguez d, eymard-pierre e, et al. ovarian failure related to eukaryotic initiation factor 2b mutations. am j hum genet. 2003;72:1544–1550. https://doi.org/10.1086/375404 leegwater paj, könst aam, kuyt b, et al. the gene for leukoencephalopathy with vanishing white matter is located on chromosome 3q27. am j hum genet. 1999;65:728–734. https://doi.org/10.1086/302548 van der knaap ms, barth pg, gabreëls fj, et al. a new leukoencephalopathy with vanishing white matter. neurology. 1997 apr;48(4):845–855. https://doi.org/10.1212/wnl.48.4.845 van der knaap ms, pronk jc, scheper gc. vanishing white matter disease. lancet neurol. 2006;55:413–423. https://doi.org/10.1016/s1474-4422(06)70440-9 scali o, di perri c, federico a. the spectrum of mutations for the diagnosis of vanishing white matter disease. neurol sci. 2006 sep;27(4):271–277. https://doi.org/10.1007/s10072-006-0683-y patay z. diffusion-weighted mr imaging in leukodystrophies. eur radiol. 2005 nov 15;15(11):2284–2303. https://doi.org/10.1007/s00330-005-2846-2 bizzi a, castelli g, bugiani m, et al. classification of childhood white matter disorders using proton mr spectroscopic imaging. am j neuroradiol. 2008;29:1270–1275. https://doi.org/10.3174/ajnr.a1106 vanderver a, hathout y, maletkovic j, et al. sensitivity and specificity of decreased csf asialotransferrin for eif2b-related disorder. neurology. 2008;70(23):2226–2232. https://doi.org/10.1212/01.wnl.0000313857.54398.0e lauder jr, dallara am. vanishing white matter disease with macrocephaly. amsrj. 2015;1(2):138–143. https://doi.org/10.15422/amsrj.2015.03.005 case report dystrophic calcification in an old cerebral infarction ian c duncan ffrad(d) sa basil j sher fc rad(d) sa sunninghi/l hospita/ sandton case report a 61-year-old female patient presented with severe mitral regurgitation and left ventricular outflow obstruction, treated by mitral valve replacement and cardiac myomectomy respectively. the immediate postoperative period was complicated by multiorgan failure and a right -sided frontal lobe cerebral infarct probably on a cardia embolic basis (fig. i). she made a good recovery from all of these post operative complications. eighteen months later she presented again with transient bilateral recurrent visual field defects, headache and vertigo with nausea and vomiting. as part of the neurological imaging work-up an unenhanced computed tomographic (ct) scan of the brain was performed which showed no evidence of any recent haemorrhage or recurrent infarction, but which show~d the uncommon finding of dystrophic calcification within the old right frontal infarct (fig. 2). fig. 1. unenhanced axial ct scan showing a nonhaemormagic infarct in the right fronta//obe. fig. 2. unenhanced axial ct scan done 18 months later showing areas of dystrophic calcification foj/owing a gyriform pattern. 48 sa journal of radiology • june 2003 discussion dystrophic calcification within cerebral infarcts is an uncommon phenomenon. the first reported cases in the radiological literature date back to 19841 and 19852 where a total of six cases were identified by means of ct scanning. calcification within the infarcted territories was found on ct scans performed between 9 months and 5 years after the initial ictus. in none of these six cases was the serum calcium level elevated although in two cases a low serum calcium had been recorded on several occasions. in 1988, parisi et al:' described a 60-year-old man who presented with a large left frontoparietal infarction. a follow-up ct scan done 18 days after the initial presentation showed areas of hyperintensity within the infarct thought initially to represent haemorrhagic transformation. as a result the anticoagulation therapy was stopped whereafter the patient continued to deteriorate and eventually died 4 days later. autopsy of the brain showed no evidence of recent haemorrhage but did demonstrate the presence of calcium salts throughout the infarcted area, particularly within the grey matter at the margins of the infarct. again no significantly elevated serum calcium levels were ever found during the period of hospitalisation. the importance of this particular case was the rapidity of onset of the ct hypertensity and the initial mistaken diagnosis of haemorrhagic transformation of the infarct although such haemorrhagic transformation must still represent the commonest cause of a change within any recently infarcted area to a hyperintense appearance on ct scans, particularly in a patient on anticoagulacase report table i. causes of intracranial calcification physiological pineal gland habenular commissure choroid plexus dural, cerebral falx idiopathic basal ganglia calcification ligamentous calcification pathological • arteriosclerosis • cerebral aneurysm • intracranial vascular malformation • previous haematoma including subdural haematoma • tumour: craniopharyngioma, oligodendroglioma, chordoma, meningioma, choroid plexus papilloma, dermoid, ependymoma, astrocytoma, lipoma of the corpus callosum, pituitary adenoma, medulloblastoma, metastases • infections: tuberculoma, cysticercosis, toxoplasmosis, cytomegalovirus, rubella, herpes, hiv, healed abcess • fahr syndrome • sturgeweber syndrome • tuberous sclerosis, down's syndrome, melas, cockayne syndrome, neurofibromatosis • hypercalcaemia: parathyroid disease, renal failiure • hypoparathyroidism, pseudohypoparathyroidism • carbon monoxide, lead poisoning • systemic lupus erythematosus • post cerebral irradiation or methotrexate therapy tion therapy. the exact pathophysiologic mechanism by which this dystrophic calcification occurs remains unknown. hypercalcaemia does not appear to play any role in its development. ct is far more sensitive than plain film imaging in detecting calcification and many more calcified areas or lesions can thus be identified with ct imaging. other known causes of cerebral calcification are listed in table i. to date no reports concerning the magnetic resonance imaging (mr!) appearance of dystrophic calcification in cerebral infarcts have appeared. again given the tl hyperintense signal of so-called 'wet calcium' within a tissue or the t2 hypointense signal sometimes seen in areas of calcification, the mr appearance could also be confused with subacute or chronic haemorrhage within an infarct. in conclusion, this case represents an example of rare dystrophic calcification within a cerebral infarct. as shown in the literature the onset of such calcification can occur within days of presentation and must be differentiated from haemorrhagic transformation in this setting. references i. kapila a. calcification of cerebral infarction. radiology 1984; 153: 685-687. 2. kuzuhara s, naito y, namura y, takahashi r, chiba k. ct demonstration of calcification within old cerebral infarcts. j comput assist tomagr 1985; 9: 268-271. 3. parisi j, place j, nag s. calcification in a recent cerebral infarct radiologic and pathologic correlation. call j neurol sci j 988; 15: 152-1ss. 49 sa journal of radiology. june 2003 about the author(s) shalendra misser lake smit and partners inc, durban, south africa citation misser, s. cardiovascular imaging: quiz case. s afr j rad. 2016;20(1), a1053. http://dx.doi.org/10.4102/sajr.v20i1.1053 quiz case cardiovascular imaging: quiz case shalendra misser received: 29 june 2016; accepted: 08 july 2016; published: 31 aug. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a 32-year-old lady presented with shortness of breath, (new york heart association [nyha] grade 2–3), becoming progressively worse, associated with cough, chest pain and constitutional symptoms. she underwent extensive investigations shown in the series of images including chest radiograph, abdominal sonar, computed tomography of chest and abdomen as well as a cardiac magnetic resonance imaging study. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to shalendra.misser@lakesmit.co.za no later than 30 september 2016. the winning respondent will receive a r2000 award from the rssa. a detailed diagnosis and discussion will be presented within sajr, volume 18, 2016. figure 1: chest radiograph performed on admission. figure 2: sonar image of the liver: (a) in colour duplex; (b) in b-mode higher frequency. figure 3: axial ct images of the upper abdomen: (a) pre-contrast study; (b) arterial phase; (c) portal venous phase. figure 4: axial ct images of the lower lung fields (a) and at the level of the left ventricle (b). figure 5: coronal reformatted ct images of the lower lung fields. figure 6: axial dual chamber cardiac t2-weighted mri image. figure 7: axial post-contrast trufi mr images performed at time intervals after intravenous gadolinium injection: (a) dynamic; (b) 2 minutes; (c) 5 minutes; (d) 12 minutes delay. abstract answer discussion acknowledgements references about the author(s) shalendra misser lake smit and partners inc, durban, south africa citation misser, s. answer and discussion: abdominal and neuroimaging quiz case. s afr j rad. 2016;20(1), a1088. http://dx.doi.org/10.4102/sajr.v20i1.1088 quiz case answer and discussion: abdominal and neuroimaging quiz case shalendra misser received: 04 sept. 2016; accepted: 08 sept. 2016; published: 28 sept. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a 40 year old lady had a ct and an mri scan of her brain for investigation of severe headache following recent recurrent bowel surgery. the post-operative course was complicated by abdominal wall haematoma and she required multiple blood transfusions. background history of multiple previous bowel resections and chronic anti-inflammatory therapy for inflammatory bowel disease was noted. it is heartening to note that several good submissions were received for the abdominal and neuroimaging quiz case. noteworthy responses were received from drs melanie strachan, francois roux, and mohammed azfar siddiqui, however no completely correct diagnosis was received. answer five years prior to the current presentation, this 40 year old lady was diagnosed with crohn’s disease. she underwent multiple laporotomies for resection of strictured segments of small bowel and was placed on intensive disease modifying therapy including corticosteroids and immunosuppressive agents. computerised tomography image in figure 1 demonstrates inflammatory change of the ascending and descending colon with associated ‘comb sign’ of the respective right and left colic branches. segmental small bowel and transverse colon wall thickening is noted. in figure 2 there is marked mural thickening in the descending colon with a long segment stricture, ‘comb sign’ with hypertrophy of the paracolic vessels and associated fat stranding. similar inflammatory changes are seen involving a distal small bowel loop in figure 3. the computerised tomography study therefore demonstrated acute exacerbation with flare up of the bowel-related inflammation due to acute on chronic crohn’s enterocolitis. figure 1: coronal reformat images (a, b and c) of the abdomen in venous phase after intravenous (iv) contrast administration. figure 2: sagittal. figure 3: axial images of the abdomen in venous phase after iv contrast administration. the patient was subsequently taken to theatre for laporotomy. the surgery was difficult due to extensive adhesions. post-operative complication of abdominal wall haematoma and falling haemoglobin level was noted, for which multiple blood transfusions were administered. a week after surgery, the patient developed severe thunderclap type headaches associated with blurring of vision and variable right lower limb paresis. figure 4, axial noncontrasted ct scan of the brain revealed subtle effacement of the sulcal spaces over the right cerebral hemisphere especially at the frontal and perisylvian region. note was also made of isodensity over the right frontal surface convexity. this however did not explain the ipsilateral right monoparesis. figure 4: axial noncontrasted ct image. mri study of the brain was arranged to further elucidate the cause of this unusual presentation. t2-weighted (figure 5) and t1-weighted (figure 6) mri sequences confirmed the right frontal gyral swelling with effaced right middle and superior frontal sulci. subtle gyral swelling was also observed in the parasagittal left frontal precentral region. figure 7, a coronal flair image showed, in addition to the frontal gyral swelling, an extra-axial fluid collection over the right frontal lobe convexity and in the sulci due to a sliver of subdural and subarachnoid blood respectively. a right sublenticular cyst was also incidentally noted. figure 5: axial t2 image. figure 6: axial t1-weighted mri image. figure 7: coronal flair mri image. restricted diffusion signal was demonstrated on the b1000 diffusion imaging sequence (figure 8) as well as corresponding adc shortening (figure 9) in the right frontal surface collection, in the left paramedian pre-rolandic frontal lobe and a small focus at the right peritrigonal region. the former represented the reduced diffusivity within the extra-axial blood in the right frontal haemorrhage while the latter two areas of restricted diffusion correspond to acute ischaemic change. figure 8: axial dwi b1000 mr images (a–d). figure 9: corresponding axial adc map mr images (a–d). the susceptibility weighted imaging (swi) minimum intensity projection (mip) sequence images in figure 10 clearly delineate the presence of subarachnoid blood located within the right superior frontal sulci, right perisylvian sulci, left central sulcus and bilateral parieto-occipital areas. the swi phase images (figure 11) confirm that the swi signal abnormalities are due to blood products with corresponding hypointensity. figure 10: axial swi mr images (a and b). figure 11: corresponding axial phase mr images (a and b). a final diagnosis was made of reversible cerebral vasoconstriction syndrome associated with vasospastic ischaemic change in both hemispheres (especially left frontal lobe) secondary to post-operative state, severe blood loss and haemotransfusion. sadly, the patient succumbed to multi-organ failure and demised before follow-up imaging was possible. discussion reversible cerebral vasoconstriction syndrome (rcvs) has recently gained much recognition particularly in the neuroradiological literature. call-fleming syndrome is one of the names attached to this syndrome after description by these authors in 1988 of an entity called reversible cerebral segmental vasoconstriction.1 calabrese et al. coined the name of rcvs in 2007.2 it is characterised by sudden onset of severe, unremitting headaches (classically described as thunderclap) associated with nausea, vomiting and seizures. in some cases long tract signs attributable to ischaemic injury, may be detected clinically. most reports3,4 describe a higher preponderance in female patients, particularly in the fourth and fifth decades as well as in the post-partum period. the pathophysiology includes a transient dysregulation in cerebrovascular tone with segmental or focal arterial branch stenoses and areas of post-stenotic ectasia.4 several precipitating causes and triggers have been identified (table 1). table 1: precipitating factors and conditions associated with rcvs. neuroimaging features range from a normal mri study to convexal subarachnoid haemorrhage, cerebral ischaemic changes, intracerebral haemorrhage to pres-like lesions. singhal et al.5 showed a normal initial ct or mri study in 55% of patients with rcvs and 81% with positive neuroimaging finding on subsequent studies. most authors concur that a high index of clinical suspicion is warranted and treatment should be instituted earlier. some have documented starting treatment despite the absence of any significant neuroimaging abnormality on initial studies. for those patients demonstrating convexity subarachnoid haemorrhage (sah) in the presence of thunderclap headache, rcvs has been shown to be the lead cause of this combination in the last 10 years.6 other causes of non-aneurysmal convexal sah are listed in table 2. convexal sah may be quite subtle on baseline ct scan and is best assessed on swi mip sequences that demonstrate blood in the sulci over the cerebral surface convexities. swi phase images are useful in confirming that the paramagnetic swi sulcal abnormality is due to haemorrhage, rather than calcification or gyral surface metal deposition. table 2: causes of nonaneurysmal convexal sah.3,4,5 table 3: useful list of features distinguishing rcvs from pancs. the diagnostic criteria for rcvs are shown in box 1. a principal feature is the absence of any aneurysm of the intracranial vessels to account for the sah. digital subtraction angiography (dsa) is the gold standard of intracranial cerebral arteriography with the best spatial and temporal resolution for the demonstration of peripheral smaller calibre vessels. disadvantages of dsa include the invasiveness, potential for vascular injury, use of radiation and intravenous contrast. currently, non-invasive indirect methods of angiography are primarily used to assess the intracranial vessels in the setting of sah. box 1: summary of the critical elements for diagnosis of rcvs. computerised tomography angiography (cta) has several advantages including excellent spatial resolution, reproducibility for follow-up imaging, short imaging time as well as possibility to be performed at the time of the initial ct scan. branch vessel depiction on volume rendered reformat cta images shows the smaller calibre vessels well up to the third order divisions. a ‘string of beads’ sign may be seen with sequential areas of vascular narrowing in rcvs (figure 12). multidetector ct scanners of today have significantly improved resolution, comparable to dsa. disadvantages of cta include lack of scope for intervention, use of radiation and intravenous contrast. figure 12: (a) curved yellow arrows showing segmental areas of subtle vascular narrowing at the a3 branches of the anterior cerebral arteries; (b) curved blue arrow demonstrating focal reduction in calibre of the right middle cerebral artery m1 segment. straight yellow arrows showing sequential stenoses in the right middle cerebral arterial branches due to severe vasoconstriction. magnetic resonance angiography (mra) can be performed immediately at the time of mri and if available is a useful tool for assessment of the intracranial vasculature. the relatively poorer spatial resolution makes assessment of the peripheral or smaller calibre branches difficult on mra when compared to dsa or cta. the non-invasive nature, absence of ionising radiation and time of flight acquisition which can be performed without gadolinium are attractive advantages of mra. lack of availability in the acute setting, long sequence acquisition time and sedation or anaesthesia requirement are some disadvantages of mra. cerebrospinal fluid (csf) analysis for protein, glucose and cell content is an important diagnostic criterion for rcvs. in the principal differential diagnosis of primary angiitis of the central nervous system, the csf may show mild pleocytosis and elevated protein level. these are not features of rcvs. dependant on the amount of sah, the value of csf assessment may be variable as the parameters are influenced by the presence of blood. reversibility of angiographic abnormalities within twelve weeks of the initial presentation requires demonstration of partial or usually complete resolution of the vasospasm shown on initial vascular imaging. in cases of death occurring before repeat imaging could be performed, post-mortem confirmation of absence of vasculitis, intracranial atherosclerosis and aneurysm would be contributory to the diagnosis of rcvs. the primary diagnostic dilemma is differentiating rcvs from primary angiitis of the central nervous system (pancs). rcvs is commonly seen in women between 20 and 40 years of age whereas pacns is more often encountered in middle-aged men. a precipitating factor is frequently identifiable in rcvs but not so in pacns where the headache is of insidious onset. generally, in most patients with rcvs, the angiographic changes resolve completely or substantially within 12 weeks. it is crucial to confirm absence of an intracranial aneurysm, as aneurysmal sah is also an important differential diagnosis. further differential considerations are venous sinus thrombosis and arterial dissection of the carotid and/or vertebral arteries which may also present with acute thunderclap headaches. these conditions may not be diagnosable on plain ct scans or by csf analysis. mri to assess the parenchyma as well as complete arterial and venous phase angiography of the intracranial and extracranial vessels is therefore indicated to exclude these differential diagnoses. treatment is empirical and includes calcium-channel blockers and high dose corticosteroids.6 removal or reduction of an offending precipitant is vital. the prognosis is uncertain and influenced by several factors, but most patients recover completely. in cases with established infarction demonstrated on diffusion weighted mri, the prognosis tends to be worse and death may unfortunately ensue as in the patient presented. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. references call gk, fleming mc, sealfon s, levine h, kistler jp, fisher cm. reversible cerebral segmental vasoconstriction. stroke. 1988;19:1159–1170. http://dx.doi.org/10.1161/01.str.19.9.1159 calabrese lh, dodick dw, schwedt tj, singhal ab. narrative review: reversible cerebral vasoconstriction syndromes. annals of internal medicine. 2007; 146(1):34–44. http://dx.doi.org/10.7326/0003-4819-146-1-200701020-00007 ducros a. reversible cerebral vasoconstriction syndrome. the lancet neurology. 2012;11(10):906–917. http://dx.doi.org/10.1016/s1474-4422(12)70135-7 ducros a, boukobza m, porcher r, sarov m, valade d, bousser mg. the clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome: a prospective series of 67 patients. brain. 2007;130:3091–3101. http://dx.doi.org/10.1093/brain/awm256 singhal ab. diagnostic challenges in rcvs, pacns, and other cerebral arteriopathies. cephalalgia. 2011;31(10):1067–1070. http://dx.doi.org/10.1177/0333102411410084 ducros a, wolff v. the typical thunderclap headache of reversible cerebral vasoconstriction syndrome and its various triggers. headache. 2016;56:657–673. http://dx.doi.org/10.1111/head.12797 sajr 1020 neonatal imaging: diagnosis s k misser,1 mb chb, fc rad (d) sa; t a mitha,2 bsc, mb chb, fcp (sa) paed; a s shaik,2 mb chb, fcs (sa), cert (paed surg) sa 1 lake smit and partners, durban, south africa 2 parklands hospital, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) we congratulate dr saifullah khalid, department of radiodiagnosis, jawaharlal nehru medical college, aligarh muslim university, aligarh, uttar pradesh, india, for her excellent diagnosis, for which she receives the award of r1 000 from the rssa. notable second-place entries were made by drs aadil ahmed, samuel manikkam, jacqueline du toit,  phil harries-jones and shaun scheepers. drs misser et al. elaborate below on the images and findings. please refer to page 116 of the august 2013 issue of the sajr (http://dx.doi.org/10.7196/sajr.934) for the presenting details and the investigative images. s afr j rad 2013;17(4):154-156. doi:10.7196/sajr.1020 diagnosis imaging and findings this first set of radiographs was taken of a neonate born at 33 weeks’ gestation. birth weight was 1.5 kg and the initial apgar scores were satisfactory. respiratory distress and bile-stained nasogastric returns were noted post-delivery. fig. 1 is a plain abdominal radiograph showing the umbilical venous line, right femoral peripheral line to the ivc and a nasogastric tube with tip in the distended pyloric antrum. ‘double bubble’ configuration of the stomach and first segment of the duodenum is noted. the rest of the abdomen is gasless. incidental note is made of the hemivertebra of the tenth dorsal level with missing ipsilateral left tenth rib. slight angulation of the sacral tip to the right is also identified. the lateral shoot-through (fig. 2) confirms the bowel abnormality and the apparent anomaly of the forearm bones with club hand configuration. this is confirmed on the babygram image (fig. 3) where the left radius and thumb is noted to be absent (type iv radial club hand deformity). in addition, the moderate cardiomegaly and plethoric appearance of the lung fields raise suspicion for an intracardiac left-to-right shunt (e.g. atrioventricular septal defect/avsd) or patent ductus arteriosus (pda). the gastroduodenal distension, d10 hemivertebra, gentle rightward scoliosis, absent left tenth rib and sacral angulation are all again noted. fig. 4 reveals a harlequin deformity of the orbits, which is associated with craniosynostosis of the coronal suture or plagiocephaly. clinical examination of the child noted the abnormality of the left forearm and wrist with club hand deformity, a sacral pit and a systolic cardiac murmur. there was no marked brachicephaly or other cranial deformity. the respiratory distress was managed as for surfactant deficiency disease, a surgical opinion was sought regarding the bowel abnormality, and a full cardiac assessment was arranged. the echocardiogram revealed three left-to-right shunts including an asd, ventricular sepal defects (vsd) and a large pda. the duodenal atresia was successfully corrected and the post-operative period was uneventful. further investigation included chromosomal studies, which were negative for major chromosomal abnormalities. the combination of all the clinico-radiographic findings made vacterl association (va) (vertebral anomalies, anal atresia, cardiac defects, tracheoesophageal fistula and/or esophageal atresia, renal anomalies and limb defects) the most likely diagnosis. fanconi anaemia is an important diagnosis to exclude by relevant testing. the apparent harlequin deformity was probably incidental, but may be a feature of baller-gerold syndrome, which has a few overlapping features with va. in the last month, the baby had successful cardiothoracic surgery for correction of the septal defects and is currently recovering well. further management includes future orthopaedic mangement of the left upper limb deformity. discussion va is the expanded acronym for the nonrandom association of multiple birth defects originally described as the vater syndrome.1 the term ‘association’ is thought to be more appropriate than a syndrome as the features are not pathogenetically linked but rather tend to occur more frequently in such a group than in the general population. the abnormalities are predominantly of structures derived from the embryonic mesoderm. table 1 outlines the various systemic abnormalities that are associated with the vacterl constellation. a diagnosis of va is made if at least three of the clinical associations are present. genetics most cases of va are sporadic. the condition rarely occurs twice in a family. the incidence is estimated at 1.6 in 10 000 live births. no specific gene locus has been identified, but there are several genes implicated in this condition. sonic hedgehog gene (shh), for instance, is regarded as a keystone sequence, especially in those patients with oesophageal atresia and anorectal malformations.2 shh encodes for an intracellular signaling protein vital for embryogenesis. early disruption of the mesodermal differentiation in utero at the first 5 weeks has been suggested as the basis for the nonrandom association of va.3 in addition, va is known to occur more frequently in infants born to diabetic mothers.4 microdeletions of the fox gene cluster at chromosome 16, long arm deletions of chromosome 13 and 12 as well as trisomy of chomosome 18 have been implicated among other gene defects. vertebral defects these are probably the most common association in va. the spectrum includes segmentation anomalies such as hemivertebrae, fused vertebrae or hypersegmentation. any combination of vertebral and other skeletal anomalies is seen, especially rib and sternal abnormality. cord tethering and sacral abnormalities also occur more frequently. the vertebral defects rarely account for mortality in these patients. recently, sonar has been introduced as a useful modality in the assessment of vertebral defects. anorectal malformations the presence of an anorectal abnormality is clinically apparent in the first few days of life and usually requires early surgical correction. some children will require repeat corrective or reconstructive surgical procedures. cardiac defects and vascular anomalies in many series of va, congenital cardiac abnormalities prove to be the most common associated defect. intracardiac shunts, particularly vsd, are seen frequently. in most patients, the vsd is generally one of several cardiac defects present, rarely found in isolation. the single umbilical artery was noted to be present more commonly in va, and it was suggested by temtamy et al.4 shortly after the initial description that v in vater should include vascular, in addition to vertebral abnormalities. tracheo-oesophageal fistula and atresia these foregut abnormalities occur variably in 50 80% of patients with va.5 antenatal sonar diagnosis of polyhydramnios or absence of the stomach fluid echo should alert the obstetrician to look for other possible congenital abnormalities. early post-partum surgery is indicated after the subtype of foregut anomaly is determined. early and late neonatal complications including chest infections are an important cause of co-morbidity. renal abnormalities these may be less apparent than other components of va, and dedicated imaging of the renal tract may be required to elucidate such anomalies. structural renal malformations may be a significant cause of morbidity, particularly recurrent infections and premature renal failure. limb defects several limb malformations have been added to the list of possible appendage defects. the classic description included radial ray anomalies also known as radial club hand. classifications of this deformity originally described with gradation of mild to severe radial aplasia have been revised with several additions, including recent inclusion of a fifth sub-type of absent radius with associated deficiency of the humerus and variable involvement of carpal bones. differential diagnosis there is considerable overlap between the various syndromes; subtle findings on clinical examination, imaging and laboratory testing will enable a final diagnosis. proper diagnosis aids further adequate genetic counseling of families. table 2 delineates the main distinguishing features in the major differential diagnoses, which include fanconi anaemia, feingold syndrome, charge syndrome, digeorge syndrome (or 22q11.2 deletion syndrome), oculo-auriculo-vertebral syndrome, currarino syndrome and vacterl h. in south africa, the relative increased incidence of fanconi anaemia in our population of afrikaner descent must alert the clinician to the relevant testing in any patient with features of va owing to the considerable overlap of features, especially the radial ray abnormality. the recessive inheritance pattern, propensity for malignancies in early adulthood and shortened lifespan of patients with fanconi anaemia warrants early diagnosis of this entity, as genetic counselling is increasingly being offered to affected families. management and prognosis the management of patients with va depends on the attendant components of the spectrum present at birth. major life-threatening malformations require urgent neonatal surgical attention. orthopaedic treatment of limb abnormalities and corrective surgeries for cardiac malformations and scoliosis may be planned/staged in several surgical procedures. the vast development in specialised neonatal and post-surgical icu facilities has resulted in a better overall prognosis in the managed va child. the subsequent long-term prognosis is variable and highly dependent on the severity of the individual components in the patient. in addition, each patient will have to endure a further list of complications, related to the component encountered, throughout life. particular note must be made of the normal neurocognitive functioning in patients with va. this is a significant positive feature. some patients may have a normal lifespan without life-threatening issues, but the vast majority will require close surveillance for complications owing to significant associated morbidity. 1. quan l, smith dw. the vater association: vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, radial dysplasia. in: the clinical delineation of birth defects. volume xii. g.i. tract including liver and pancreas. bergsma d, ed. baltimore: williams and wilkins, 1972:75-78. 1. quan l, smith dw. the vater association: vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, radial dysplasia. in: the clinical delineation of birth defects. volume xii. g.i. tract including liver and pancreas. bergsma d, ed. baltimore: williams and wilkins, 1972:75-78. 2. martinez-frias m l, bermejo e, frias jl. the vacterl association: lessons from the sonic hedgehog pathway. clin genet 2001;60:397-398. 2. martinez-frias m l, bermejo e, frias jl. the vacterl association: lessons from the sonic hedgehog pathway. clin genet 2001;60:397-398. 3. khoury mj, cordero jf, greenberg f, james lm, erickson jd. a population study of the vacterl association: evidence for its etiologic heterogeneity. pediatrics 1983;71:815-820. 3. khoury mj, cordero jf, greenberg f, james lm, erickson jd. a population study of the vacterl association: evidence for its etiologic heterogeneity. pediatrics 1983;71:815-820. 4. temtamy sa, miller jd. extending the scope of the vater association: definition of the vater syndrome. j pediatr 1974;85:345-349. 4. temtamy sa, miller jd. extending the scope of the vater association: definition of the vater syndrome. j pediatr 1974;85:345-349. 5. solomon bd. vacterl/vater association. orphanet journal of rare diseases 2011;6:56 5. solomon bd. vacterl/vater association. orphanet journal of rare diseases 2011;6:56 editorial non-invasive coronary artery • •imaging peter corr mb chb, ffrad(d)sa, frcr, mmed department of radiology. nelson r mandela school of medicine, university of natal, durban ischaemicheart disease (ihd) was the ninth commonest cause of prematuredeath in south africa during 2000.1 the world health report for 20022 cites the increasing prevalence of obesity, hypertension, high cholesterol and tobacco consumption as major risk factors for ihd in both the developed and developing world. a recent who report warns of a marked increase in the prevalence of ihd in young women. non-invasive imaging of the coronary arteries as a screening procedure to detect and score coronary artery calcification as a marker of disease has been used for a number of years with electron beam ct. recent developments in multislice ct technology allow excellent spatial resolution of the coronary arteries as thin section maximum intensity projections (mips) and multiplanar reconstructions (mprs). mips provide a better overview of the coronary artery and give an accurate impression of the arterial lumen, while mprs are better suited to assess stented segments, plaque composition and calcified arteries. volume and surface-shaded displays are useful to display the coronary arteries to referrring clinicians. vessel tracking software allows accurate measurement of the degree of artery stenosis. comparison of 16 multislice ct with the gold standard of conventional coronary arteriography has demonstrated a 95% specificity and 86% sensitivity of multislice coronary ct angiography for the detection of coronary artery disease." potential applications of this technology are the early detection of coronary atherosclerotic disease, the exclusion of coronary artery occlusion prior to patients undergoing major surgery, the exclusion of artery occlusion in patients with chest pain, and the follow-up of patients following coronary stenting or bypass grafting.' magnetic resonance (mr) of the heart has been demonstrated to be an accurate investigation of cardiac morphology and perfusion,' however, accurate mr coronary angiography remains elusive. advances in navigator pulse sequences may improve this technology to the level of multislice ct angiography. how do all these exciting technological developments impact on you the practising radiologist? it means that unless the radiologist takes an active interest in non-invasive cardiac imaging, it will go the same way as angiography and echocardiography went in the 1970s and 80s, into the domain of cardiology and with it vascular imaging. only by becoming familiar with cardiac anatomy and pathophysiology will the radiologist be able to retain and grow this exciting technology and so provide a valuable service to his or her patients in the future. 1. bradshaw d, groenewald p, laubscher r, et al. initial burden of disease estimates for south africa 2000. s afr med j2003; 93: 682-688. 2. world health organisation. world health report 2002. geneva: who, 2002. 3. nieman k, cademartiri f,lemos pa, raaijmakers r, pattynama pmt, de feyter pj. reliable non invasive coronary angiography with fust submijlimeter multislice spiral cr. circulation 2002; 106: 2051-2054. 4. becker cr, knez a, leber a, et ol. detection of coronary artery stenoses with multislice cr angiography. j comput assist tomogr 2002; 26: 750-755. 5. ropers d, ulzheimer s,wenke! e, baum u, giesler t, derlien h. investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with ecg gated image reconstruction. am j cardioi200l; 88: 792-795. 6. nguyen td, nuval a, mulukutla s,wang y.direct monitoring of coronary artery motion with cardiac fat navigator echoes. magn reson med 2003; 50: 235-241. peter corr editor 3 sajournal of radiology • november 2003 pdf file abstract introduction objectives methods results discussion conclusion acknowledgements references appendix 1 about the author(s) nondumiso dlamini department of radiology, university of kwazulu-natal, south africa matthew goodier department of radiology, university of kwazulu-natal, south africa citation dlamini n, goodier m. adequacy of ultrasound reports in patients presenting with obstructive jaundice at a tertiary hospital radiology department. s afr j rad. 2016;20(1), a1034. http://dx.doi.org/10.4102/sajr.v20i1.1034 original research adequacy of ultrasound reports in patients presenting with obstructive jaundice at a tertiary hospital radiology department nondumiso dlamini, matthew goodier received: 12 may 2016; accepted: 28 july 2016; published: 22 sept. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: patients with obstructive jaundice require a stepwise approach to investigation and management. ultrasound (us) is the initial screening modality of choice and has been shown to be accurate in demonstrating the presence of dilated bile ducts, as well as the level and cause of obstruction. for adequate radiological communication to the clinician, degree of bile duct dilatation, level of obstruction, appearance of the transition zone and cause of obstruction must be reported. however, without a structured reporting method, much of this information may be omitted. objectives: the aim of the study was to investigate the adequacy of us findings in patients with obstructive jaundice, as documented, without standardised reporting. methods: a retrospective chart review of 130 us reports of adult patients presenting at grey’s hospital us department with a clinical assessment of obstructive jaundice was conducted. data for the period january to december 2013, were analysed. us reports of patients with dilated bile ducts were assessed for report adequacy by looking at four important clinical factors, that is, the degree of bile duct dilatation, the level of obstruction, the appearance of the transition zone and the cause of the obstruction. results: a report adequacy score was assessed in 79 patients with dilated bile ducts; however, two reports were excluded because of obscuration by gas. there was a high level of report inadequacy (38%) without the use of a structured reporting template. the level of obstruction was the most common component missing from the reports (25%), followed by the appearance of the transition zone (18%) and cause of obstruction (12%). conclusion: we propose the use of an us report template for obstructive jaundice patients in order to ensure comprehensive reporting. structured radiological reporting will improve the method of communication between clinicians and radiologists, thus improving the quality of patient care. introduction jaundice is a commonly encountered condition in clinical practice.1,2 differentiating between obstructive (surgical) and non-obstructive (medical) jaundice can be achieved clinically by using a combination of clinical signs, symptoms and biochemical markers.2,3,4,5,6,7 it is important to differentiate between the two conditions because patients with obstructive jaundice usually require surgical or radiological intervention.3,8 ultrasound (us) is the initial screening modality of choice for patients with obstructive jaundice as it assists in the cost-effective management of these patients by determining the need for further imaging.2,3,4,5,8,9 in order to achieve these goals, us reports of these patients should include the presence and degree of bile duct dilatation and the level and cause of obstruction.3,8 radiology reports are an important method of communication between the radiologist and the referring clinician.10 structured radiological reporting has been shown to improve the quality of radiological reports. these reports can be integrated with the picture archiving and communication system (pacs), thus improving the service provided by the radiology department and also improving the efficiency of communication between the radiologist and the referring clinician.10,11,12,13 several studies have been performed to demonstrate the accuracy of us in the assessment of bile duct dilatation and level and cause of obstruction.4,8,14 however, no previous studies have specifically investigated us report adequacy in patients with biliary obstruction. we investigated the quality of information documented in the us reports of patients with obstructive jaundice in our institution without any standardised form of reporting, to assess their communication value to the referring clinician. objectives the objectives of the study were: to determine the diagnostic adequacy of us reports by application of a novel scoring system and to compare us report adequacy among practitioners of varying levels of experience (sonographers, junior doctors, senior doctors and consultants). methods our study is a retrospective chart review of us reports of adult (≥ 18 years) patients who presented at grey’s hospital us department with a clinical assessment of obstructive jaundice specified on the request form. this included documentation of the presence of clinical jaundice with other additional symptoms such as dark urine, pale stool, right upper quadrant pain and pruritus or documentation of biochemical markers suggestive of obstructive jaundice on liver function tests (lfts), that is, elevated alkaline phosphatase, gamma-glutamyl transpeptidase and bilirubin. request forms of patients who fulfilled our inclusion criteria were obtained from the us department filing system. us reports of the selected patients were retrieved from the radiology information system and pacs. the us examinations were performed on the toshiba aplio xg and philips hd7 xe machines, using a wide-range, low-frequency curved-probe of 3–5 mhz and the c5-2 probe, respectively. the biliary tree was assessed trans-abdominally, using longitudinal and transverse views with the patient in the supine or right anterior oblique position. the bile ducts were considered dilated if the internal diameter of the common bile duct (cbd) was > 7 mm or if the intrahepatic bile ducts were > 2 mm in diameter. all us examinations were performed during working hours. in order to maintain confidentiality, each patient was allocated a study number. data for a period of 12 months (january to december 2013) were collected. a total number of 130 us reports were analysed. ethical clearance was obtained from the university of kwazulu-natal biomedical research ethics committee. data were collected from the us request forms and us reports using designed data collection sheets, with key parameters pertaining to the aim of the study. reports of patients with the presence of dilated bile ducts on us were scored by their level of completeness. a report was considered adequate if it mentioned all four of the following: the degree of bile duct dilatation; the level of obstruction; the appearance of the transition zone; and the cause of obstruction. a report missing any of the above items was considered inadequate. data were analysed using stata v13 software. us examinations were performed by radiology consultants, registrars, medical officers (mos) and sonographers. report adequacy scores among the different ranks (sonographers, junior doctors [both mos and registrars with less than 2 years of experience working in a radiology department], senior doctors [both mos and registrars with more than 2 years of experience working in a radiology department] and consultants) were compared. us reports were also assessed for recommendation of further imaging by the personnel performing the us. results we reviewed 130 us reports of adult patients (age range of 20–89 years; mean 51.3). ninety were female and 40 were male patients. of these patients, 51 (39.2%) did not have dilated bile ducts on us, and 79 (60.8%) had dilated bile ducts. of the 79 reports, 2 (2.5%) were excluded from the report adequacy score assessment because they mentioned the limitation of us examination because of obscuration by gas resulting in difficulty to assess the site of obstruction. sixty-two percent (48/77) of reports were found to be adequate and 38% (29/77) were inadequate (table 1). the level of obstruction was the most common component missing from the reports (25%), followed by appearance of the transition zone (18%) and the cause of obstruction (12%) (table 2). the degree of bile duct dilatation was the most often reported component with 96% of reports commenting on this finding. table 1: score of adequacy of diagnostic ultrasound reports. table 2: report adequacy score components. us findings were completely normal in 37% (19/51) of the patients without dilated bile ducts. cholelithiasis was found in 59% (30/51) of these patients. of the 79 patients with dilated ducts, 33% (26/79) of the reports suggested a benign cause of obstruction and 53.2% (42/79) reports suggested a malignant cause. of the 42 patients with a malignant cause of obstruction, 57.1% (24/42) were female patients and 42.9% (18/42) were male patients (age range was 32–89; mean of 60.3). of the 26 patients with a benign cause of obstruction, 92.3% (24/26) were female patients and 7.7% (2/26) were male patients (age range, 20–79; mean of 43.4). the spectrum of findings is displayed on figure 1. figure 1: the spectrum of suggested causes of biliary obstruction in both benign and malignant groups: (a) cause of obstruction; (b) benign and (c) malignant. in the total 130 patients who we assessed, 26.9% (35/130) cases were reported by sonographers, 29.2% (38/130) cases were reported by junior doctors, 36.2% (47/130) cases were reported by senior doctors and 7.7% (10/130) cases were reported by consultants (table 3). table 3 demonstrates the difference in the report adequacy score of us reports in patients with dilated bile ducts, which demonstrates a significant difference in the level of adequacy of us reports among different ranks, with p = 0.04. table 3: adequacy of diagnostic reports by different ranks. recommendation for further investigation by the person performing the us examination was uncommon among all the ranks. junior doctors recommended additional investigation most often (25%) and senior doctors least often (11%). sonographers and consultants both recommended additional investigations in 14% of reports. none of these group differences were statistically significant. discussion the aim of radiological investigation in patients with obstructive jaundice is to confirm the presence of dilated bile ducts, demonstrate the level and cause of obstruction and assist in assessing tumour resectability in malignant cases.2,3,4,5,6,7,8,9 us has been shown to be accurate in demonstrating the presence of dilated bile ducts with a sensitivity of 55–95% and specificity of 71–96%.1,5 the sensitivity of us continues to increase in determining the cause and level of obstruction with improved image resolution, imaging technique and use of tissue harmonics, all contributing to enhanced image quality.2,4,5,6,7,8 us is reported to have a lower sensitivity in demonstrating the cause of obstruction with accuracy of 23–88%, particularly in the distal cbd.1,2,5,6,7,8,9 false-negative results are seen in patients with obstructive jaundice without dilated bile ducts on us and when there is obscuration of the extrahepatic bile ducts by gas.2,5,6,7 us is used as the initial screening modality in patients with obstructive jaundice because it does not make use of ionising radiation, is easily available, is non-invasive and is inexpensive.1,2,3,4,5,7,8,9,14 because of the risk of mortality and morbidity and high cost, invasive procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography are usually reserved for therapeutic intervention and tissue diagnosis.2,3,4,5,7,9 several studies have demonstrated the accuracy of us in the assessment of bile ducts dilatation and level and cause of obstruction.4,8,14 however, no previous studies have specifically investigated the adequacy of us reports in patients with biliary obstruction. we investigated the quality of information documented in us reports at our institution in order to assess their communication value to the referring clinician. an adequate report would mention all four clinical factors mentioned above. our study demonstrates a high inadequacy rate of 38% of us reports in patients with obstructive jaundice who had dilated bile ducts on us (table 1). radiology reports are the main means of communication between the radiologist and the referring clinician, and they should be clear and precise and address the question raised by the referring clinician.10,11,12,15 the components of a comprehensive radiological report should include patient demographics, imaging procedure descriptions, relevant clinical information, findings, pertinent negative findings, study limitations, comparison studies and reports, impression, differential diagnosis and follow-up or additional diagnostic studies to clarify or confirm the impression.11,12,15 structured radiology reporting has been shown to enhance the standard of reporting by improving the quality and consistency of radiology reports that are reproducible. this also results in better patient care and decreases cost by eliminating transcription and thus reducing report turnaround time, resulting in a shorter hospital stay.10,11,12,13 additionally, there is complete documentation of information because the request form, images and the report findings are archived and retrieved electronically.10,11,12 structured reports can be used by radiologists for teaching, research, clinical quality improvement and for billing.12 the radiological society of north america established a radiology report committee that creates a library of report templates for different modalities and procedures, which is aimed at standardising radiological reports using structured reporting.11,12 us has been shown to have low sensitivity in determining the cause of biliary obstruction especially in the distal cbd, mainly because us is dependent on several factors such as operator experience, technical factors and patient body habitus.2,3,14 in our study, only 2.5% (2/79) of reports of patients with dilated bile ducts documented the limitation of the examination because of obscuration by gas. this percentage is significantly lower than the results of the study by tsang et al., which demonstrated that up to 49% of their patients with obstructive jaundice had limited us examination because of obscuration by gas and an us diagnosis could not be made.1 turning the patient to an oblique, lateral or upright position or giving water orally and allowing at least 4 hours of fasting before us examination could improve visualisation of the biliary system.3,6,7,14 in our study, lack of documentation of the limitations of us examination, for example, obscuration by gas or patient body habitus, could be one of the reasons for the low number of adequate reports. the level of obstruction was the most common component missing from the reports at 25%; followed by transition zone at 18% and cause of obstruction at 12% (table 2). lack of documentation of limitations of the us study could also be related to the relatively low adequacy in documentation of the level of obstruction, the appearance of the transition zone and cause of obstruction at 75%, 82% and 88%, respectively (table 2). the importance of documenting the level of obstruction is that it determines the approach of the therapeutic or diagnostic intervention, as more proximal obstruction is better approached percutaneously and distal obstruction endoscopically.2,3,6 carefully assessing the transition zone gives an indication of the most likely diagnosis, for example, benign strictures usually taper gradually and malignant strictures usually demonstrate an abrupt cut-off (figure 2).6,9 this information is vital to ensuring the most efficient and thus cost-effective pathway for further investigation and management of the patient. figure 2: examples illustrating the differences in the appearance of the transition zone in some study patients: (a) smooth tapering of a benign stricture in the distal common bile duct (white arrow) in a patient with chronic pancreatitis; (b) coarse calcifications in the head of pancreas (yellow arrow) in the same patient; (c) and (d) abrupt cut-off of the common bile duct (white arrow) in two different patients with pancreatic head masses. there were a higher number of inadequate reports among junior doctors and sonographers at 55% and 45%, respectively (table 3). one of the reasons implicated for poor quality of radiology reports is the lack of supervision and insufficient training in reporting skills for junior staff.11 this poses a challenge in a resource-limited environment like ours, with limited staff. according to hall et al., lack of formal instruction for residents in reporting skills is because of a lack of consensus about what constitutes a good radiology report.15 in a study by tsang et al., it was demonstrated that us report auditing with implementation of us skills training improves the accuracy rate of us reports of patients with obstructive jaundice.1 recommendation of further imaging or other diagnostic tests and intervention is part of an efficient radiological report and helps facilitate further imaging and management of patients, especially when the us report is inconclusive.8,9 our study demonstrates an overall low-frequency of recommendation for further investigation by the person performing the us examination, ranging from 11% to 25%. malignancy was the most common suggested cause of obstruction in our patients, at 53.2% (42/79), which is compatible with other studies4,8,14 (figure 1). the most common malignant cause of obstruction was a pancreatic head mass at 48%, which correlates with findings from other studies.1,5,14 interestingly, we found a female predominance of 57.1% (24/42) in the malignant cases. malignant causes of biliary obstruction including head of pancreas carcinoma are documented to be more common in male patients.8,14 the older age group, age range 32–89 and a mean of 60.3 in our patients, correlates with findings from other studies that the incidence of malignant cause of obstruction increases with advancing age.5,8 figure 3 illustrates a malignant cause of obstruction secondary to invasion of the cbd by gallbladder carcinoma. figure 3: example of a malignant cause of biliary obstruction: (a) gallbladder mass (white arrow) which has invaded segments 4a and b of the liver (yellow arrow in image a and b) and the porta hepatis (red arrow in image c), causing obstruction of the common bile duct. the most common benign cause of obstruction was an obstructing calculus (61.5%), with a female predominance of 92.3% (24/26). there was no us diagnosis in 27% (7/26) of patients with benign cause of obstruction (figure 1). these findings also correlate with other studies, which indicate that choledocholithiasis is the most common benign cause of biliary obstruction.1,4,9,14 the younger age group with a mean age of 43.4 in our patients also correlates with findings in other studies.8 figure 4 illustrates a benign cause of obstruction because of choledocholithiasis. figure 4: example of a benign cause for biliary obstruction: (a) obstructing calculus (white arrow) in the distal common bile duct as a rounded echogenic structure with posterior acoustic shadowing, causing proximal dilatation of the common bile duct; (b) multiple gallbladder calculi (white arrow) in the same patient. concluding recommendations effective investigation and management of patients with biliary obstruction usually requires multimodality imaging with a stepwise approach of several imaging and therapeutic techniques.3,4,7,8,9 poor planning and strategising when imaging and managing patients with biliary obstruction may lead to redundant investigations or unnecessary imaging, which will result in increased cost, delayed diagnosis and increased hospital stay and can result in unnecessary morbidity and possibly mortality.3 several algorithmic approaches have been described, including guidelines from the american college of radiology (acr) appropriateness criteria, and they all use us as an initial imaging modality.3,5,9 figure 5 illustrates our proposed referral approach for further investigation in patients with biliary obstruction confirmed on us in our department. this approach is modified from o’connor et al., krige et al. and the acr appropriateness criteria.3,5,9 we also propose a standard reporting template for us reporting in patients with biliary obstruction in our department (appendix 1). the impact of this standardised reporting guide on us report adequacy in our institution will be a topic for further research in our department. figure 5: referral approach for patients with obstructive jaundice. limitations of the study this study was performed in a single tertiary institution with limited radiology staff. this could result in bias; therefore, our results cannot be generalised. inherent limitations include potential biases resulting from exclusion of request forms that were illegible, patients with mixed picture on lft results and patients who had inadequate information provided on the request forms. conclusion our study demonstrates that at our institution there is a low rate of us report adequacy for patients with obstructive jaundice and a very low rate of recommendation of appropriate further imaging. in an attempt to improve this, we encourage the use of a standard template for us reporting for patients with biliary obstruction as well as a protocol directing further investigation. the impact of this standardised reporting guide on us report adequacy in our institution will be a topic for further research in our department. acknowledgements the authors thank catherine connoly for her assistance with data analysis. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.d. was the primary investigator and prepared the manuscript, m.g. was the supervisor for the project, made conceptual contribution and was involved with manuscript editing. references tsang yha, lau kch, tee lmf, kan e. performance of ultrasound in evaluating patients with obstructive jaundice. poster session presented at: european congress of radiology 2013. http://dx.doi.org/10.1594/ecr2013/c-1730 karki s, joshi ks, regmi s, gurung rb, malla b. role of ultrasound as compared with ercp in patient with obstructive jaundice. kathmadu univ med j. 2013;11(43):237–240. krige jej, beningfield sj, shaw jm. modern imaging in patients with obstructive jaundice. cme [serial online]. 2007 [cited 2016 mar 21]; 25(7):328–331. available from: http://www.ajol.info/index.php/cme/article/download/43782/27303 ghimire r, lohani b, pradhan s. accuracy of ultrasonography in evaluation of level and cause of biliary obstruction: a prospective study. kathmandu univ med j. 2005;3(1):17–21. lalami t, couto ca, rosen mp, et al. acr appropriateness criteria jaundice. j am coll radiol. 2013;10(6):402–409. http://dx.doi.org/10.1016/j.jacr.2013.02.020 baron rl, tublin me, peterson ms. imaging the spectrum of biliary tract disease. radiol clin north am. 2002;40(6):1325–1354. http://dx.doi.org/10.1016/s0033-8389(02)00045-3 rudralingam p, sukumar sa. imaging of jaundiced adult. imaging. 2013;22:1–16. http://dx.doi.org/10.1259/imaging/51415473 pandit sp, panthi m. ultra-sonographic prediction of the causes & level of obstruction in the diagnosis of obstructive jaundice. postgrad med j nams [serial online]. 2011 [cited 2016 mar 21]; 11(2):8–10. available from: http://www.pmjn.org.np/index.php/pmjn/article/viewfile/53/52 o’connor oj, o’neill s, maher mm. imaging of biliary tract disease. ajr. 2011;197(4):w551–w558. http://dx.doi.org/10.2214/ajr.10.4341 naik ss, hanbidge a, wilson sr. radiology reports: examining radiologist and clinician preferences regarding style and content. ajr. 2001;176(3):591–598. http://dx.doi.org/10.2214/ajr.176.3.1760591 govender n, andronikou s, goodier mdm. adequacy of paediatric renal tract ultrasound requests and reports in a general radiology department. pediatr radiol. 2012;42(2):188–195. http://dx.doi.org/10.1007/s00247-011-2259-0 kahn ce jr, langlotz cp, burnside es, et al. toward best practices in radiology reporting. radiology. 2009;252(3):852–856. http://dx.doi.org/10.1148/radiol.2523081992 berman gd, gray rn, lui d, tyhurst jj. structured radiology reporting: a 4 – year case study of 160,000 reports. paper presented at: integrating the healthcare enterprise (ihe) symposium of the rsna 2001 annual meeting; nov 25–30 [homepage on the internet]. [cited 2016 mar 21]. available from: http://www.structuredreporting.com/structurad-rsna-01.pdf al-obaid s, alhilli mra, fadhel aa. the role of ultrasound and magnetic resonance imaging in the diagnosis of obstructive jaundice. iraqi postgrad med j. 2007;6(1):7–17. hall fm. language of the radiology report: primer for residents and wayward radiologists. ajr. 2000;175(5):1239–1242. http://dx.doi.org/10.2214/ajr.175.5.1751239 appendix 1 original articles the pathogenesis and radiological features of hut lung authors eric d bateman mbchb, md, frcp, och associate professor and head respiratory clinic groote schuur hospital and university of cape town david stickells mbchb, op abst (sa), fcp(sa) registrar hillel goodman frcr, ffrad(o){sa) principal specialist radiologist i n 1967 the term "transkeisilicosis"was proposed by palmer and daynes for a form of domestically-acquired pneumoconiosis found in women from the rural transkei and ciskei which radiologically was indistinguishable from silicosis seen in south african gold miners.i the source of silica was thought to be from quartz-containing grinding rocks used for preparing the daily standard meal of ground maize. post-mortem histology on two cases confirmed the appearance of silicosis, and a small epidemiologic study of healthy young nurses in the transkei confirmed early changes of pneumoconiosis in approximately 7%.1 subsequently, on the basis of findings in a larger and more detailed case collection conducted in our clinic involving the study of clinical presentation, lung physiology, bronchoalveolar lavage cell counts and histological appearance of lung biopsies, we concluded that although silicosis may account for some of the changes in some patients with this clinical entity, it appears that inhalation of non-quartz containing dust and smoke from bio-mass fuelled fires might be of greater significance in the aetiology/ the more general term "hut lung" was therefore suggested. recognition of this condition is clearly impor4 sajournal of radiology· may 1996 tant in distinguishing it from other forms of interstitial lung disease,most notably disseminated or miliary tuberculosis, and sarcoidosis,and from a public health standpoint, it is a preventable disease leading to significant complications and mortality. this paper will highlight aspects of the pathogenesis and radiologicalfeatures of this condition. pathogenesis the concept of dust diseases (pneumoconiosis) occurring in settings other than the confines of the workplace is being increasingly recognised. silicaparticles may be found'in the lungs of persons living in deserts,' and have even been found in egyptian mummies" although silicosis is rare in this setting, cases of severe silicosis and even progressive massive fibrosis have been found in inhabitants of himalayan villages exposed to dust storms.' outdoor exposure to dusty environments such as tractor ploughing in the free state" and farming activities in rural canada have also been shown to cause disease.' silica is the best .recognised fibrogenic dust in these studies, but several lines of evidence suggest that silica alone may not be responsible for the nodules seen in hut lung. 1. although respirable free silica can be identified in the ground maize, estimates of silica particles in the lung are low, even within nodules? 2. a small field study in which atmospheric silica was sampled by means of personal samplers on subjects grinding with sandstone (100% quartz), confirmed that the concentration of respirable quartz in surrounding air was low, and that the cumulative time-weighted exposure was well below that recommended for industry and mines. such levels would not be expected to cause pneumoconiosis, and certainly not life-threatening disease.' 3. similar radiological and pathological appearances have been found in the lungs of to page 5 the pathogenesis and radiological features of hut lung women who have not ground maize and from others living elsewhere in southafrica.' it should be noted however that unlike exposure in industry, domestic exposure begins at a very young age. ltis possible that previously considered safe doses of silica delivered to infants or adolescent children might be pathogenic. infants of mothers who grind are frequently bound on the mother's back or lie at her side,and girls take part in the family chores from their early teens. smoke from bio-mass fuelled fires (coal, wood, dung or plant material) contains carbon black and a range of other particulate material which is retained in the lungs and is visible bronchoscopically both free within the airways and submucosa. pathology specimens confirmed the blackening of lung tissue with focal aggregates of carbonaceous material, and even anthracotic nodules. a common practice in rural traditional dwellings is to cook inside a hut (rondavel) which has no central chimney, and in cold weather farnilymembers sleep around the fire for warmth. a field study has confirmed exceedingly high smoke concentrations under these conditions. the role of tuberculosis in patients with . hut lung is difficult to define. a large proportion of patients show features compat ible with healed tuberculosis raising the question of which came first, and whether calcified hilar glands represent silica exposure or are the result of tuberculosis infection. it is also possible that, as in gold miners pneumoconiosis, patients with hut lung have increased susceptibility to tuberculosis. no satisfactory epidemiologic data is available to provide answers to these questions. pipe-smoking by rural transkei women is not uncommon and tobacco smoke particles may also playa role in the pathogenesis/ it is therefore likely that hut lung is the result of a mixture of dusts, delivered to the lung in women in pursuing a traditional rural lifestyle. the prevalence of hut lung has not been established, but as lifestyle changes occur (including the design of huts, the provision of chimneys in dwellings, changing patterns of cooking and use of fuels, and increased reliance on commercially ground maize), the incidence of this disease can be expected to diminish or disappear. if employed alone, the previously suggested provision of maize grinders at local stores to replace grinding between rocks in the home is unlikely to eliminate this condition. i clinical presentation patients are frequently asymptomatic or are x-rayed because of upper respiratory tract symptoms relating to acute infections. many are picked up during contact tradng for tuberculosis. a minority have symptoms compatible with chronic bronchitis with variable degrees of dyspnoea. severe caseshave features of cor pulmonale. one-third of patients in our series were smokers and a similar proportion had historical or x -ray evidence of previous tuberculosis, several without microbiological confirmation. 2 chest radiology chest radiographic changes range from diffuse fine rounded regular nodules resembling miliary tuberculosis to extensive fibrosis resernblingprogressive massive fibrosis (figures 1a and 2a). the majority have nodules of varying size and density. the profusion scores (ilo-uicc scoring system for pneumoconiosis) range from 1/13/3 changes. all zones of the lung are usually involved although not uniformly, but progressive massive fibrosis usually affects upper lobes and is surrounded by characteristic traction bullae. 5 sa journal of radiology. may 1996 figure la: chest radiograph of il 59-year old woman with hut lung showing the diffuse fine nodular interstitial patlem with loss of vascular clarity. figure tb: hrct lung views of the patient shown in la confirming the presence of evenly distributed centri/obular nodules in profusion. fissures are nol thickened and bronchovascular markings are normal. h~ resol~tion scanning we have recently investigated the appearance of hut lung on high resolution ct scan and have confirmed a high incidence of areas oflocalised scarring compatible with tuberculosis, particularly in the lung apices and frequently associated with calcified hilar adenopathy egg-shell calcification as found in silicosis has not been observed. localised areas of bronchiectasis suggest previous tuberculous or non-tuberculous pneumonia complicated by to page 6 the pathogenesis and radiological features of hut lung scarring. the varying density and size of the nodules is uniform and indistinguishable from the appearances of miliary tuberculosisor of nodular sarcoidosis(figures 1b and 2b). however, the beaded pattern along bronchovascular markings which is characteristic of sarcoidosis has not been observed. we have concluded however that the ct appearances of hut lung are indistinguishable from these other two conditions,and for this reason hrct isnot viewed as an essential investigation in such cases. figure 28: chest radiograph of a b3-year old woman with hut lung. nodules are of variable size and less profuse in the apices. vascular clarity is lost. figure 2b: hrct views of the lungs of the patient in 2a. a diffuse eentrilobular distribution is seen with slight bronchial wall thickening. irregular spiculated nodules of varying size are evident, some possibly representing bronchovascular markings. interlobular fines are thickened. diagnosis fibreoptic bronchoscopy with transbronchial biopsies is of greater value for confirming the diagnosis. segmental large volume (200ml) bronchoalveolar lavage (bal) is of some value in distinguishing hut lung from tuberculosis and sarcoidosis. in sarcoidosis lymphocyte percentages in the bal fluid are generally elevated (>il %). similar elevations in lymphocyte numbers are present in a large proportion of patients with miliary tuberculosis, but also in a minority of patients with hut lung. a common feature in hut lung is the large proportion of macro phages that contain inorganic inclusions and appear black under light microscopy. total cellnumbers are not elevated and the proportions of other inflammatory cells are not increased.' conclusions the concept of domestically acquired pneumoconiosis is not unique to south africa,but severalpractices of rural lifestyle commonly practiced in south africa contribute to the epidemic here. these include cooking with bio-mass fuels on open fires in poorly ventilated huts, grinding maize between quartz-containing rocks, pipe smoking and possibly tuberculosis. the incidence of the disease should decline over coming decades, but it remains an important diagnosis to consider in patients with interstitial lung disease,and requires chlferentiation from sarcoidosis, miliary tuberculosis and other diseases. although most cases are mild, it might predispose to tuberculosis, and is often associated with areas ofbronchiectasis which giverise to chronic or intermittent symptoms. respiratory failure and death are probably rare but recognised complications. although the hrct has been used to define the 6 sajournal of radiology· may 1996 spectrum of changes in patients with hut lung, it does not provide an alternative to fibreoptic bronchoscopy for confirming the diagnosis. references 1. palmer pes, daynes wg.transkei silicosis.safrmed ]]967;41:1182-8. 2. grobbelaar jp, bateman ed. hut lung: a domestically acquired pneumoconiosis of mixed aetiology in rural women. thorax 1991;46:334-340. 3. hirsch m, bar-ziv j, lehmann e, goldberg gm. simple siliceous pneumoconiosis of bedouin females in the negev desert. clin radio1l974;25:507-1 o. 4. tapp e, curry a,anneld c. sand pneumoconiosis in an egyptian mummy. bmii975;ii:276. 5. norboot,angchuk pt, yahya m et al. silicosis in a himalayan village population: role of environmental dust. thorax 1991;46:341-3. 6. dubovsky h. pneumoconiosis and tractor ploughing. medical proceedings 1968; 14:56-59. 7. green fhy, yoshida k, fick g, paulj, hugh a, green wf. characterization of airborne mineral dusts associated with farming in rural alberta, canada. intarch occup environ health 1990;62:423-30. abstract introduction methods ethical consideration results discussion limitations of the study conclusion acknowledgements references about the author(s) diteboho khalema department of radiology, university of the witwatersrand, south africa lara n. goldstein department of emergency medicine, faculty of health sciences, university of the witwatersrand, south africa susan lucas department of radiology, university of the witwatersrand, south africa citation khalema d, goldstein ln, lucas s. a retrospective analysis of time delays in patients presenting with stroke to an academic emergency department. s afr j rad. 2018;22(1), a1319. https://doi.org/10.4102/sajr.v22i1.1319 original research a retrospective analysis of time delays in patients presenting with stroke to an academic emergency department diteboho khalema, lara n. goldstein, susan lucas received: 12 feb. 2018; accepted: 25 apr. 2018; published: 21 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: stroke presents commonly to the emergency department (ed), and is a common cause of morbidity and mortality in south africa. early ed presentation and early neuroimaging are required in order for thrombolysis to be a potential therapeutic modality. objectives: to determine the time to ed presentation, time to computed tomography (ct) scan and the potential influencing factors for patients with stroke. methods: a retrospective record review of all patients who presented with clinical features of stroke to a tertiary academic ed in johannesburg, south africa, from 01 january to 31 december 2014. results: data from 232 eligible stroke patients were analysed. the median time to presentation to the ed was 33 h with the majority of patients (81.3%) presenting after the 4.5 h window for thrombolysis. the median time to ct was 8 h. only 3.9% of patients had a ct scan within one hour of arrival. patients with loss of consciousness were associated with earlier hospital presentation (p = 0.001). none of the patients were thrombolysed. conclusion: patients with stroke commonly present late to hospital. if we are to make a difference in this group of vulnerable patients, further education and training needs to be emphasised regarding ‘time is brain’. communication and commitment is also required by the emergency medical services, ed and radiology staff in order to prioritise stroke patients and to reduce delays. introduction ischaemic stroke is ranked as the third leading cause of death in south africa.1 guidelines for ischaemic stroke thrombolysis, though controversial, advocate its administration within 3 h of stroke onset (which can be extended up to 4.5 h for certain patient groups).2,3,4,5 there are various provisos, however, before this can occur – computed tomography (ct) scan exclusion of an intra-cranial haemorrhage, large ischaemic stroke or other non-stroke diagnoses as well as the exclusion of contraindications to the drug itself.5 despite its availability, there are still low rates of stroke thrombolysis. this is mainly because of time delays in patient presentation to hospital, as well as in-hospital delays such as protracted times in obtaining a ct scan.6,7,8 more than 60% of stroke patients present after the recommended 3 h window period in both developing and developed countries.6,7,8,9,10 given the growing burden of stroke worldwide and the paucity of data from the developing world, the aim of this study was to investigate the time from stroke symptom onset to presentation to the emergency department (ed), the time from arrival to ct scan acquisition and the potential influencing factors. methods this study was a retrospective record review of all patients who presented with clinical features of stroke to a tertiary academic ed in johannesburg, south africa, from 01 january to 31 december 2014. the ed has approximately 60 000 patient visits per annum. data collection patients presenting with stroke were identified through the ed triage and patient registers, as well as the radiology department ct reports. the files of these patients were then retrieved from the records department and the data captured by a single researcher (d.k.). trauma patients, patients with a diagnosis other than stroke and patients with incomplete data were excluded (figure 1). figure 1: identification of patients with potential stroke. statistical analysis categorical variables were presented in percentage format. continuous variables such as time were presented as medians with interquartile ranges (iqr) (as the time data were positively skewed). the differences in time to ed presentation were evaluated in a number of different subgroups and assessed using the mann–whitney test (for two level co-variates) or kruskal–wallis test (for more than two levels) for the continuous variables. the subgroups evaluated were sex, smoking, alcohol, medical history and clinical signs. data analysis was carried out using sas (version 9.4 for windows). the 5% significance level was used throughout. ethical consideration ethical approval for the study was obtained from the human research ethics committee (medical) of the university of the witwatersrand (m150123). results figure 1 shows the inclusion and exclusion of patients available for analysis. the patient demographic data are summarised in table 1. table 1: demographics of patients presenting with stroke (n = 193). time to emergency department the median time to presentation to the ed was 33 h (interquartile range 8 h – 111 h). categorisation of patient presenting times based on the thrombolytic window period is shown in figure 2. the actual distribution of patient presentation times in hours is shown in figure 3. figure 2: categorisation of presenting times to emergency department by thrombolytic window periods. figure 3: distribution of presenting times for stroke patients to the emergency department. time to computed tomography the median time from presentation to the ed to ct was 8 h (interquartile range 4–21 h). there were only nine patients (3.9%) who received a ct scan within one hour of arrival in the ed. figure 4 demonstrates the distribution of time delays in the patients obtaining their ct. figure 4: distribution of presenting times to arrival at computed tomography for stroke patients. tables 2 and 3 show the time delays to ed presentation based on patient demographic characteristics, previous medical history and clinical signs. table 2: comparison of times to emergency department presentation by subgroup. table 3: comparison of times to emergency department presentation by medical history and clinical signs. discussion the burden of stroke is profound.11 although controversial, the only available potential option for treatment is thrombolysis; however, time constraints and usage precautions make its administration challenging.2,3,4,5 both patient and hospital factors play a role in delays to stroke treatment. demographics endogenous oestrogen is commonly deemed to be neuroprotective. the incidence of stroke amongst women appears to increase after menopause as this hormone wanes.12 this is reflected in the female preponderance of stroke in our study as well as in other south african stroke studies.13,14 in contrast, this is contrary to studies from england, nigeria, india, china and australia.6,7,8,10,15 there is no clear explanation for this phenomenon. the median stroke age was similar to the other south african stroke studies.13,14 this is younger than in developed countries. this may be related to the increased resources and other fiscal differences associated with developed countries or perhaps because of the higher rate of hypertension in south africa.16 south africa’s high rate of hypertension may also be a major influencing factor in the higher relative rate of haemorrhagic strokes compared to developed countries.16 in the united states, the proportion of all strokes because of ischaemia and haemorrhage are 87% and 13%, respectively.17,18 time to emergency department presentation despite efforts to increase public awareness of stroke, significant delays in seeking care after stroke still occur.10 perhaps there is greater stroke awareness in gauteng than in the free state, as daffue et al. found that only 7.5% of patients presented within the 4.5 h therapeutic window compared to 18.7% of our population. similar to our findings, the majority of their patients (82%) presented 8 h after symptom onset.13 our presentation time to ed findings almost parallels other lowand middle-income countries like nigeria7 (21%) and china6 (25%) but are lower than in developed countries like england10 (<3 h presentation rate of 39.5%) and australia8 (31.3% presenting within 4.5 h). lack of knowledge has been postulated to be a causative factor that has led to various community educational programmes in order to overcome it.15 this absence of stroke awareness amongst the population is not the only contributor to this deficit. anosognosia is the ‘lack of awareness or the underestimation of a specific deficit in sensory, perceptual, motor, affective or cognitive functioning due to a brain lesion’. prevalence of anosognosia in stroke varies between 10% and 58% depending on the time since the brain insult.19 this cannot account for the vast majority of patients delaying their presentation to hospital, however. it is, perhaps, the psychological defence mechanism of ‘denial’ rather than the pathology-related denial that may lead to these patients avoiding admitting that their symptoms may indeed be a stroke and therefore could be a contributing factor to their delayed presentation. logistical difficulties in accessing hospital care could also have led to late patient presentation. although this is not considered to be a significant contributing factor in developed countries, the difference in access to pre-hospital care in our population is different.8 according to nielsen et al.’s study on the status of pre-hospital care in 13 lowand middle-income countries, including south africa, large proportions of severely ill and injured people are still not able to receive formal pre-hospital emergency medical care.20 in a prospective stroke study in nigeria that enrolled 81 patients, no patients were brought to hospital by ambulance.7 inability to access an ambulance to transport the patient to the hospital could have caused delays in their presentation. the retrospective nature of our study meant that information regarding this piece of the puzzle was unfortunately not available. time to computed tomography early ct is necessary to exclude a haemorrhagic stroke, a large ischaemic stroke or other non-stroke diagnoses, which are all contraindications to thrombolysis.5 the amount of time patients spend between the ed and ct can cause significant in-hospital delays, thereby making them ineligible for thrombolysis.21 the majority of our patient population had a ct scan performed after 1 h from ed arrival – this is longer than the 25 min recommended by the american heart association.5 these guidelines have since been amended with a new recommendation which states that ‘brain imaging studies should be performed within 20 min of ed arrival in at least 50% of patients who may be candidates for’ time-sensitive stroke therapies.22 in a study conducted by ogbole et al. in nigeria, time delays to ct were found to be more significant in patients with an ischaemic stroke than in patients with a haemorrhagic stroke. this was attributed to the more exaggerated symptoms that patients with haemorrhagic strokes display, making them more likely to get their ct sooner.23 maestroni et al. found that patients presenting within 3 h were more likely to have a ct earlier than patients arriving after 3 h.24 this was echoed in canada where patients who presented soon after stroke onset were male, had no history of stroke and arrived at hospital from a setting other than home, had an increased likelihood of timely neuroimaging.21 a good working relationship between radiology and the ed, as well as ancillary staff, such as porters and clerks, would be integral to decreasing delays to ct acquisition. patient factors influencing presentation times although female patients presented earlier than their male counterparts, this was not statistically significant because of the wide range of presentation times smoking and alcohol usage also did not influence presenting times. in contrast to this, medical history did play a role. time to presentation: medical history and clinical signs loss of consciousness was associated with earlier presentation to hospital. a stroke registry review by jiang et al. in china also found loss of consciousness associated with earlier presentation to hospital – no other associated co-morbidities were found.25 besides the finding of delayed presentation associated with diabetes by jin6, most other analyses of co-morbidities found no association.7,8,9,10 decreased level of consciousness was associated with earlier patient presentation to ed. this is similar to other studies.6,24 unconscious patients may be perceived as having a more serious condition than a patient with unilateral symptoms, rendering the family more likely to bring them in earlier, hence the earlier presenting time. jin et al. found a higher percentage of patients with haemorrhagic stroke presented with decreased level of consciousness compared to patients with an ischaemic stroke.6 being diabetic excludes patients from the later thrombolysis window.22 therefore, early presentation to hospital and education of stroke symptoms should be particularly emphasised in education to this patient group. that being said, patients known with diabetes have also been shown to have poorer outcomes when thrombolysed for stroke.26 the most common presenting symptoms were hemiplegia and facial paresis. these are the most common and easily identifiable stroke symptoms and strong independent predictors of a stroke.27 in this study, these factors were not necessarily associated with early presentation in contrast to a study conducted by gargano et al.28 education may help to address this shortfall. barriers to early stroke presentation and thrombolysis none of the patients in the study received thrombolysis. a rwandan study had the same findings.29 the biggest challenge was that patients arrived at hospital after the thrombolysis window period and were therefore not eligible. twenty-five (13.7%) of our patients could have potentially received thrombolysis having presented within 3 h and a further nine patients in the 4.5 h time window – if they had met the inclusion criteria. as this was a retrospective study, patient knowledge was not assessed. williams et al. found that 75% of stroke patients could not accurately identify their symptoms as a stroke. patients who had a stroke previously were more likely to identify their symptoms as a stroke but did not necessarily present early to hospital. even patients with risk factors for stroke were not aware of symptoms and the available treatment of stroke.30 at-risk patients and their families should be educated about compliance to medication, changing of lifestyle and early presentation, should they develop a stroke. anosognosia, denial and logistical issues are patient-based factors that could have contributed to delayed presentation. in-hospital delays can potentially be decreased with good communication and a team approach to management. limitations of the study patient files and ct reports that could not be recovered limited the sample size for time to ed presentation and patient demographics. patient times (time of stroke onset, time of ed arrival and time to ct) were not always documented. these limitations were mainly as a result of the retrospective nature of the study. conclusion in a south african academic hospital setting, the vast majority of stroke patients had a delayed presentation to hospital outside the window for thrombolysis. public education to improve awareness of early symptoms of stroke and the available treatment including the time limitations could improve the management of stroke. communication and commitment is also required by the emergency medical services, ed and radiology staff in order to prioritise stroke patients to reduce delays. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions d.k. and l.n.g. conceptualised the study and were involved in statistical analysis and interpretation of the data. d.k. collected the data and drafted the initial version of the manuscript. d.k., l.n.g. and s.l. revised, edited and contributed substantially to the critical revision of the manuscript. final approval of the version to be published was made by all authors who agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. d.k. takes responsibility for the paper as a whole. references mortality and causes of death in south africa. 2015: findings from death notification [homepage on the internet]. released nov 2017. 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acknowledgements references about the author(s) rachel hubbard radiology department, chelsea and westminster hospital, united kingdom jalpa kotecha hiv department, chelsea and westminster hospital, united kingdom thomas nash acute assessment unit, chelsea and westminster hospital, united kingdom yu jin lee radiology department, chelsea and westminster hospital, united kingdom nasir khan radiology department, chelsea and westminster hospital, united kingdom farhat kazmi radiology department, chelsea and westminster hospital, united kingdom citation hubbard r, kotecha j, nash t, lee yj, khan n, kazmi f. radiology examination as a diagnostic aid in presentations with wide differential diagnoses: case report of new hodgkin’s lymphoma on a background of poorly controlled hiv. s afr j rad. 2017;21(2), a1239. https://doi.org/10.4102/sajr.v21i2.1239 case report radiology examination as a diagnostic aid in presentations with wide differential diagnoses: case report of new hodgkin’s lymphoma on a background of poorly controlled hiv rachel hubbard, jalpa kotecha, thomas nash, yu jin lee, nasir khan, farhat kazmi received: 07 june 2017; accepted: 08 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract hodgkin’s lymphoma and disseminated mycobacterium avium complex (mac) infection share similar clinical features; both may affect human immunodeficiency virus (hiv)-positive individuals. we discuss a patient with poorly controlled hiv-infection presenting with chest sepsis, dyspnoea and weight loss. whilst the initial working diagnosis was that of mac infection, pathology results had not met diagnostic criteria. lymph node biopsy instead revealed classical hodgkin’s lymphoma. we discuss the role of radiological examination in cases of diagnostic uncertainty. introduction hodgkin’s lymphoma (hl) and disseminated mycobacterium avium complex (mac) infection are seen in patients who are human immunodeficiency virus (hiv)-positive. they often share similar clinical features such as fever, night sweats, lymphadenopathy, anaemia and weight loss. it may be difficult to distinguish these conditions clinically; mycobacterial cultures may only aid diagnosis after several weeks of incubation. radiological imaging is therefore important to aid accurate, timely diagnosis and guide biopsy. we present a case illustrating a diagnostic dilemma in a patient presenting with poorly controlled hiv. case report a 55-year-old man presented to the accident and emergency department with a 2-month history of dyspnoea (acutely worsening over 2 days preceding admission), cough productive of purulent sputum, fever and weight loss. he was known to be hiv-positive (genotype-2, diagnosed 1991) but had been non-compliant with antiretroviral medication (truvada, darunavir and ritonavir) for 2 years. additional background included a history of depression, subdural haematoma, recurrent bacterial chest infections and drug abuse (daily heroin smoker). on examination, he was unkempt, cachectic and dehydrated. he was septic but maintaining normal oxygen saturations on room air. cardiovascular and neurological examinations were unremarkable. he was tachypnoeic and crepitations were auscultated at the right lung base. his abdomen was non-tender with palpable hepatosplenomegaly. right-sided anterior cervical and right-sided inguinal lymphadenopathy was palpated. blood tests revealed microcytic iron-deficient anaemia, lymphopaenia with white cell count 2.6 × 109/l, c-reactive protein 198 mg/l, normal electrolytes and renal function, raised alkaline phosphatase level (1664 iu/l), hypoalbuminaemia (22 g/l) and deranged clotting. lactate dehydrogenase was raised at 515 iu/l. serology demonstrated serum epstein–barr virus (ebv) dna pcr of 26 900 and positive hepatitis b core-antigen (e-antigen negative). hiv-2 viral load was 720 and cd4 count was 28 cells/μl (3%). a chest radiograph demonstrated right basal opacification. computerised tomography of the chest abdomen and pelvis (ct-cap) revealed patchy air space opacification at the left oblique fissure, left lower and right lower lobes, paraseptal and central lobular emphysema and bibasal atelectasis (figures 1 and 2). hepatosplenomegaly was confirmed and free fluid was evident throughout the abdomen and pelvis (figure 3). multiple enlarged lymph nodes (up to 1.8 cm diameter) were visualised throughout the thorax, abdomen and pelvis (figures 4 and 5). figure 1: coronal computerised tomography of the chest demonstrating bibasal lower lobe tree in bud appearance suspicious for tb. figure 2: axial computerised tomography of the chest demonstrating tree in bud appearances within the lung. figure 3: coronal computerised tomography of the abdomen demonstrating hepatosplenomegaly. figure 4: axial computerised tomography of the chest demonstrating extensive mediastinal lymph nodes, the blue arrow points to the pre-vascular nodes, the white arrow points to the right hilar node and the red arrow points to the pre-carinal and subcarinal nodes. figure 5: anterior mediastinal lymph nodes. sputum cultures identified pseudomonas aeruginosa; acid alcohol fast bacilli (aafb) smears were negative. tests for respiratory viruses, atypical organisms and pneumocystis jirovecii were negative. urine and blood cultures were negative, with no growth on mycobacterial blood cultures up to that point. optimised antiretroviral therapy was restarted alongside intravenous piperacillin and tazobactam. on multi-disciplinary team meeting, the clinical case was deemed to be in keeping with a diagnosis of respiratory tuberculosis. alternative differentials included atypical lower respiratory tract infection (including mac infection) or lymphoma. the patient subsequently underwent supraclavicular lymph node biopsy, which revealed classical hl. a positron emission tomography ct (pet-ct) scan diagnosed ‘stage 3b’ but suggested that some lymphadenopathy may have been secondary to concurrent hiv-related lymphadenopathy or infection. a staging ct head excluded cerebral metastases. he was consequently initiated on a regimen of adriamycin, bleomycin, vinblastine and dacarbazine (abvd) chemotherapy. notably, one sputum culture subsequently grew mycobacterium intracellulare; following this, another sputum culture grew mycobacterium mucogenicum. neither organism was grown on subsequent sputum samples. neither of two mycobacterial blood cultures nor a lymph node mycobacterial culture showed any growth on final reporting. at least two sputum cultures positive for the same organism or one positive culture from a ‘sterile’ site (such as blood, lymph nodes or bone marrow) are required to diagnose atypical mycobacterial infection.1,2 the positive sputum cultures were therefore not considered significant. discussion the patient presented our multi-disciplinary team with a diagnostic challenge. given his clinical presentation including low cd4 count, mycobacterial infection was felt to be the most likely diagnosis. however, radiological imaging highlighted significant, widespread lymphadenopathy throughout the thorax, abdomen and pelvis, which was later confirmed by tissue diagnosis to be hl. hodgkin’s lymphoma is more prevalent in hiv-positive individuals, and is often aggressive with b symptoms at presentation; it is associated with ebv-positivity.3 interestingly, unlike other malignancies, its incidence has not decreased with the introduction of highly active antiretroviral therapy, although overall and progression-free survival has improved. ct-pet is superior to conventional ct for staging. however, biopsy is essential to confirm diagnosis.4 mac (m. avium and m. intracellulare) accounts for up to 85% of infectious causes of abdominal lymphadenopathy in acquired immunodeficiency syndrome (aids).5 whilst m. avium is common in disseminated mac, m. intracellulare is a more important respiratory pathogen. mac lung disease may present as either apical fibrocavitary disease or nodular and bronchiectatic changes (right middle lobe or lingula). the disease course is often indolent and it may be difficult to distinguish environmental contamination from clinically relevant infection. consequently, bronchial lavage or biopsy is often required to aid diagnosis.6 mycobacterium mucogenicum is typically seen in catheter-related and post-traumatic skin infections. it rarely causes respiratory tract infection, and positive sputum cultures are often because of environmental contamination.7 widespread homogenous lymphadenopathy may be a feature of both mac and hl; however, lymphadenopathy is often massive in hl (> 3 cm diameter).5 hepatosplenomegaly is commoner in mac than in hl.5 hl tends to be seen with a cd4 count around 240 cells/μl4; in contrast, disseminated mac is typically found with cd4 < 50 cells/μl.1 hiv-2 tends to be less virulent with lower rates of progression to aids than in hiv-1; there are many differences in the behaviour of the virus and the consequent effects on the immune system that may explain this. the hiv-2 virus has a lower replication efficiency than hiv-1 and varies in its use of co-receptors. there are also differences in the levels and activity of the viral proteins tat and nef, which are thought to lead to a reduced rate of de novo t-cell infection and less immune activation (immune activation is strongly predictive of disease progression) in hiv-2 compared with hiv-1 infection.8 in hiv-2 infection, there are increased levels of cd4+cd25+ regulatory t-cells, an increased ability to replace infected cd4+ t-cells, and less t-cell apoptosis than in hiv-1 infection.8 our patient, however, had poorly controlled, progressive hiv-2. this was likely because of his poor compliance with medication: he had stopped taking antiretrovirals on multiple occasions in the past and developed multiple resistances; his cd4 count had varied from 81 cells/μl – 370 cells/μl over the previous 12 years. conclusion hl and mac present similarly in hiv-positive patients. although the level of immunocompromise at which they present can differ, both represented feasible differential diagnoses in this case. in these situations, radiological assessment is essential in interpreting the clinical picture, guiding biopsy and, ultimately, achieving a confirmed diagnosis. ethical consideration no patient identifiable information has been presented. written consent has been obtained from the patient prior to publication; a copy of the consent form has been provided. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions r.h. co-wrote the manuscript alongside j.k. and t.n. guidance with regard to selecting the appropriate imaging for the case report and helping steer the direction of the case report was provided by y.j.l., n.k. and f.k. references nelson m, dockrell dh es on behalf of the bgs. british hiv association and british infection association guidelines for the treatment of opportunistic infection in hiv-seropositive individuals 2011. hiv med. 2011;12(2):75–82. https://doi.org/10.1111/j.1468-1293.2011.00944_1.x management of opportunist mycobacterial infections: joint tuberculosis committee guidelines 1999 [homepage on the internet]. [cited 2017 may 21]. available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/non-tuberculous-mycobacteria/opportunist-mycobacteria-guideline/opportunist-mycobacteria-guideline/ carbone a, gloghini a, serraino d, spina m. hiv-associated hodgkin lymphoma. curr opin hiv aids [serial online]. 2009 [cited 2017 may 21];4(1):3–10. available from: http://content.wkhealth.com/linkback/openurl?sid=wkptlp:landingpage&an=01222929-200901000-00003 jacobson ca, abramson js. hiv-associated hodgkin’s lymphoma: prognosis and therapy in the era of cart. adv hematol. 2012;2012:507257. https://doi.org/10.1155/2012/507257 carucci lr, halvorsen ra. abdominal and pelvic ct in the hiv-positive population. abdom imaging. 2004;29(6):631–642. https://doi.org/10.1007/s00261-004-0180-9 griffith de, aksamit t, brown-elliott ba, et al. an official ats/idsa statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. am j respir crit care med. 2007;175(4):367–416. https://doi.org/10.1164/rccm.200604-571st adékambi t, ids of america, as of blood, transplantation m, long s, msg of mycobacteria. mycobacterium mucogenicum group infections: a review. clin microbiol infect [serial online]. 2009 [cited 2017 aug 1];15(10):911–918. available from: http://www.ncbi.nlm.nih.gov/pubmed/19845703 vidya vijayan kk, karthigeyan kp, tripathi sp, hanna le. pathophysiology of cd4+ t-cell depletion in hiv-1 and hiv-2 infections. front immunol [serial online]. 2017 [cited 2017 jul 16];8:580. available from: http://www.ncbi.nlm.nih.gov/pubmed/28588579 abstract introduction materials and methods ethical considerations results discussion implications, limitations and future applications conclusion acknowledgements references about the author(s) erhardt gerber department of radiology, faculty of health sciences, university of cape town, cape town, south africa qonita said-hartley department of radiology, faculty of health sciences, university of cape town, cape town, south africa rufkah gamieldien department of radiology, faculty of health sciences, university of cape town, cape town, south africa tharbit hartley cape radiology, cape town, south africa sally candy division of diagnostic radiology, university of cape town, groote schuur hospital, cape town, south africa citation gerber e, said-hartley o, gamieldien r, hartley t, candy s. accuracy of plain radiographs in diagnosing biopsy-proven malignant bone lesions. s afr j rad. 2019;23(1), a1768. https://doi.org/10.4102/sajr.v23i1.1768 original research accuracy of plain radiographs in diagnosing biopsy-proven malignant bone lesions erhardt gerber, qonita said-hartley, rufkah gamieldien, tharbit hartley, sally candy received: 04 july 2019; accepted: 15 sept. 2019; published: 06 dec. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the diagnosis of primary bone tumours is a three-fold approach based on a combination of clinical, radiological and histopathological findings. radiographs form an integral part in the initial diagnosis, staging and treatment planning for the management of aggressive/malignant bone lesions. few studies have been performed where the radiologist’s interpretation of radiographs is compared with the histopathological diagnosis. objectives: the study aimed to determine the frequency of bone tumours at a tertiary hospital in south africa, and, using a systematic approach, to determine the sensitivity and specificity of radiograph interpretation in the diagnosis of aggressive bone lesions, correlating with histopathology. we also determined the inter-observer agreement in radiograph interpretation, calculated the positive and negative predictive values for aggressive/malignant bone tumours and computed the cumulative effect of multiple radiological signs to determine the yield for malignant bone tumours. method: a retrospective, descriptive and correlational study was performed, reviewing the histopathological reports of all biopsies performed on suspected aggressive bone lesions during a 3-year period from 2012 to 2014. the radiographs were interpreted by three radiologists using predetermined criteria. the sensitivity and specificity of the readers’ interpretation of the radiograph as ‘benign/non-aggressive’ or ‘aggressive/malignant’ were calculated against the histology, and the inter-rater agreement of the readers was computed using the fleiss kappa values. results: of the 88 suspected ‘aggressive or malignant’ bone tumours that fulfilled the inclusion criteria, 43 were infective or malignant and 45 were benign lesions at histology. reader sensitivity in the diagnosis of malignancy/infective bone lesions ranged from 93% to 98% with a specificity of 53% – 73%. the average kappa value of 0.43 showed moderate agreement between radiological interpretation and final histology results. the four radiological signs with the highest positive predictive values were an ill-defined border, wide zone of transition, cortical destruction and malignant periosteal reaction. the presence of all four signs on radiography had a 100% yield for a malignant bone tumour or infective lesion. conclusion: the use of a systemic approach in the interpretation of bone lesions on radiographs yields high sensitivity but low specificity for malignancy and infection. the presence of benign bone lesions with an aggressive radiographic appearance necessitates continuation of the triple approach for the diagnosis of primary bone tumours. keywords: bone tumours; radiopathological correlation; plain film findings; bone tumour biopsy; histology results. introduction in comparison with benign bone lesions, primary malignant lesions are much less common, found to be roughly a hundred times less frequent.1,2 in fact, the majority of malignant bone lesions are on account of secondary metastatic deposits.3 the diagnosis of primary bone tumours is based on a triple combination of clinical, radiological and histopathological findings.4 relevant clinical factors include age, history of trauma, systemic symptoms, mass, malignancy or infection and correlation with clinical examination and biochemistry.3,4 radiologically, despite advances in cross-sectional computed tomography (ct) and high strength magnetic resonance imaging (mri), standard radiographic imaging remains the mainstay in the initial diagnosis, and correlates best with the final histology.5,6 supplementary ct is useful for evaluating the cortex and matrix, and mri for determining the intramedullary and soft tissue extent, as well as in assessing for skip lesions and involvement of surrounding structures.2,7,8 it is important that the interpreting radiologist is familiar with the features of common benign bone tumours, as appropriate recognition of these lesions avoids unnecessary additional imaging or biopsy.9,10 unfortunately, benign and malignant tumours could appear similar. some of the known mimickers include osteomyelitis, fibrous dysplasia, avulsion injuries, bone infarcts, hyperparathyroidism and osseous sarcoidosis.11 undiagnosed bone lesions are classified as aggressive or benign tumours. interpretation is possible either through a systematic analytical approach based on radiographic features or by recognition of characteristic imaging features, musculoskeletal knowledge and experience.12,13 biopsy is indicated if a bone lesion has an aggressive appearance and includes an ill-defined margin, a wide zone of transition, cortical expansion and destruction, and a malignant periosteal reaction.9 open biopsy is the gold standard in obtaining tissue samples for a histological diagnosis, despite risks of tumour spillage, potential morbidity, time and cost required. specialist care in lesion management is important, particularly to avoid changes in treatment plans and unnecessary amputations related to biopsy complications.14,15,16 cytologically, lesions are classified into benign, malignant and non-neoplastic, including infective and metabolic bone lesions.2 previous studies that have examined pre-biopsy imaging demonstrated a poor positive predictive value for malignancy (50% – 75%).17,18,19,20,21,22,23 on the contrary, other studies have shown higher sensitivities and specificities when including mri and computer-aided detection.24,25,26,27 given the paucity of literature on this topic locally, this study was implemented to test a radiologist’s interpretation of plain radiographs against a histopathological diagnosis. materials and methods this was a retrospective, descriptive and correlational study comparing the assessment of malignancy on radiographic imaging with the histopathological diagnosis on biopsy. the study population comprised all those patients (aged 13 years and older) who had undergone bone biopsy performed at groote schuur hospital between 01 january 2012 and 31 december 2014. only patients with available histology were included. patients without radiographic imaging, inadequate histology or biopsies that yielded soft tissue (non-osseous) tumours were excluded from the study. three general radiologists with approximately the same seniority/expertise (5-year post-graduate experience) independently reviewed the anonymised digital plain film images stored on a removable usb device; they were blinded to each other’s findings. each radiologist categorised bone lesions as either ‘benign’, ‘aggressive/malignant’ or ‘inconclusive’ on a data collection sheet based on the following eight radiological signs: lytic lesion, ill-defined margin, wide zone of transition, malignant periosteal reaction, cortical destruction, eccentric location, multiple lesions, and absent or chondroid matrix. these signs were selected based on imaging literature.12,13,28 the readers were not instructed as to the number of positive/negative radiological signs that would constitute an aggressive, benign or inconclusive lesion. for each case, a final radiological diagnostic decision was generated using a majority rule from three of the principal readers: a decision of two out of three or three out of three was taken as a majority decision. the majority vote was classified as aggressive or benign. to avoid the possible devastating consequences of missing a malignant bone tumour, equivocal or inconclusive final decisions were grouped together with ‘malignant’ as positive findings in calculating sensitivity and specificity to avoid any delay in the diagnosis of a possible malignant bone tumour. ‘non-aggressive’ final decisions were categorised as negative findings. we calculated positive predictive value (ppv) and negative predictive value (npv) for aggressive/malignant bone tumours, based on the eight radiological signs mentioned above. we also calculated the cumulative effect of multiple radiological signs in determining the ppv for these tumours. sensitivity and specificity were calculated for the readers independently and for the ‘majority vote’. histological results were separated into benign lesions, malignant lesions and infection, and the frequencies were recorded for each category. results were expressed as frequencies and percentages for categorical variables. radiopathological correlation was determined between the majority vote’s final decisions and the final histology using the kappa (κ) statistics. inter-observer agreement was also determined for the readers’ final decisions using the kappa statistics (fleiss kappa value). a weighted kappa value was determined for inter-rater concordance when the ‘inconclusive’ final decisions were grouped together with the ‘aggressive’ final decisions as positive and benign final decisions grouped together as negative. ethical considerations all cases were anonymised. ethics approval was obtained from the human ethics research committee of the faculty of health sciences, university of cape town (hrec ref: 892/2014). results the original data set comprised 138 patients who had bone biopsies performed during the study period, from 01 january 2012 to 31 december 2014. ten patients were excluded on the basis of inadequate histological samples, 23 patients had hystologically-proven soft-tissue (non-osseous) lesions and 17 patients had no available imaging. the final sample size included 88 patients; 52% were males and 48% were females (age range 13–81 years), and 45% (40/88) were under the age of 30 years. in the study sample, 43/88 (49%) bone lesions were found to be malignant or infective on biopsy. of these, 31 were primary malignant bone tumours, seven were infective and five metastatic. forty-five (51%) lesions were histologically benign. the findings are summarised in tables 1 and 2. table 1: summary of histologically malignant/aggressive of infective lesions (n = 43). table 2: summary of histologically benign lesions (n = 45). radiopathological correlation was confirmed in 70/88 (79.5%) cases with an overall sensitivity of 80% and a kappa value of 0.61, demonstrating substantial agreement between radiographic interpretation and final histology. a summary of the readers’ radiological interpretations of the 88 cases is presented in figure 1. reader 1 categorised 36/88 lesions (41%) as aggressive/malignant, 26/88 (30%) as benign and thought that the findings were inconclusive in 26/88 (30%) cases. combining the aggressive and inconclusive findings resulted in a sensitivity of 98% and specificity of 56%. figure 1: comparison between the readers’ radiographic interpretations. similarly, combining the aggressive and inconclusive findings resulted in a sensitivity of 93% and specificity of 60% for reader 2, and a sensitivity of 95% and specificity of 73% for reader 3 (table 3). table 3: sensitivity and specificity for the interpretation of readers 1, 2 and 3. when the radiographic interpretations were combined through majority vote method, 45/88 (51%) of lesions were assessed as aggressive/malignant, 31/88 (35%) as benign and 12/88 (14%) were assessed as inconclusive. this resulted in an overall sensitivity of 95% and specificity of 64%. there was an overall moderate agreement between the readers as calculated by the kappa value. using a weighted kappa value when combining the inconclusive final decisions and aggressive/malignant decisions as positive interpretations and benign interpretations as negative interpretations, there was a higher inter-observer agreement as there were only two variables with values bordering between moderate and substantial agreement (table 4). table 4: inter-observer reliability. the ppv and npv are presented in figure 2. the four signs with the highest ppv and npv were the same for all three readers and the majority vote. the order of decreasing ppv was malignant periosteal reaction (90%), cortical destruction (81%), wide zone of transition (81%) and ill-defined margin (77%). the signs with the highest npv were ill-defined margin (80%), wide zone of transition (75%), cortical destruction (73%) and malignant periosteal reaction (64%). (these are referred to as ‘major signs’ from this point.) figure 2: positive and negative predictive values of individual signs used. calculating pooled results did not lead to higher values because of inter-rater variability. the presence of all four major signs was associated with 100% ppv in predicting malignancy or infection. discussion in our study the percentages of aggressive lesions (including both malignant tumour and osteomyelitis) and benign bone tumours was similar ( 49% vs. 51%). of the aggressive lesions, 16% were attributable to infection. osteosarcoma was the most common malignant lesion (25.6%), and non-aggressive giant cell tumour (15%) and osteochondroma (13%) were the two most common benign bone tumours. these findings are consistent with other studies performed on the african continent. in a large nigerian study, obalum et al. found that of the reviewed biopsies, 54% were benign and 46% malignant.23 the most common benign lesion in their series was osteochondroma (15%), with the most common malignant lesion being osteosarcoma (27%). the mean age of patients in their study was 25 years and the peak incidence of biopsied bone lesions occurred in the third decade. another nigerian study found 30% of biopsies to be benign, 49% histologically malignant (including 28% metastatic deposits and 17% osteosarcomas). nine percent of biopsies in this series had an inconclusive histology.22 the higher incidence of infective lesions and relatively higher rate of osteogenic sarcoma compared with our study are explained by the fact that the mean age of their sample was 32 years and included a higher proportion of children. our study did not include patients younger than 13 years as they are treated at an affiliated dedicated paediatric institution. the higher prevalence of metastases could be because of the inclusion of rib, vertebra and pelvic lesions. in a recent series in india, laishram et al. also found that the most common malignant tumour was osteosarcoma (11%), with osteochondroma (22%) being the commonest benign bone lesion. their study revealed a surprisingly high prevalence of chronic osteomyelitis comprising 37% of their aggressive appearing lesions, resulting in a disproportionately high rate of malignant and infective lesions (58%).21 our study had a significantly lower prevalence of osteomyelitis (16%), again probably because of the fact that osteomyelitis is more common in children.29 another explanation could be that the diagnosis of chronic osteomyelitis at our institution is based largely on clinical, biochemical and microbiological evaluation rather than on imaging and biopsy. similar results have been reported in the developed world. in a study of more than 100 biopsy specimens, jelinek et al. had a significant higher percentage yield for malignant histology (70% vs. 49%). the proportion of the most common malignant and benign tumours was similar to our study, with osteosarcoma being 18% and non-aggressive giant cell tumour 15%. the mean age in their study population was 38 years.17 the differences could be explained by the fact that their study exclusively analysed the histology of primary bone tumours and excluded metastases, infections, and inflammatory and metabolic diseases. in our series, we described 5/88 (6%) cases with pathologically confirmed osseous tuberculosis (tb). extra-pulmonary tb is seen in 1% – 3% of patients with tb in the developed world and approximately 10% in endemic countries such as south africa. moreover, the risk of tb is 20% – 37% higher in patients with human immunodeficiency virus (hiv). the relatively low rate of skeletal tb in our series could be because skeletal tb is rare when compared with pulmonary tb and tb lymphadenitis. most osseous tb (50%) affects the spine whilst 15% of cases present as septic arthritis of the hip. spinal biopsies and joint aspirates were not included in our series. finally, tb of the spine and large joints is more common in children and young adults, and patients aged less than 13 years were excluded from our series.29,30,31 the kappa value of 0.61 for radiographic interpretation and final histology indicates substantial agreement, with an overall sensitivity of 80%. this finding is low when compared with similar studies. vijayaraghavan et al. also correlated histological diagnosis with radiological interpretation based on lodwick et al.’s method of classification and calculated an 80% case correlation.13,25 the high correlation between imaging and final diagnosis in their study could be attributed to a larger sample size and the fact that they reviewed clinical data, radiographs, ct and mri and had discussions on the cases. negash et al. reported a case correlation of 84% with a kappa agreement of 0.82 which could be because of the inclusion of mri findings and consensus decision-making at combined clinical and radiological incorporation meetings.26 there was a high rate of ‘inconclusive’ interpretations by the readers, where radiographs were not convincing for aggressive or non-aggressive findings. possible reasons for this include unwillingness to commit without cross-sectional imaging, absence of clinical history for patients aged more than 40 years and lack of awareness that the lesions were biopsied. this could be explained by the moderate inter-reader agreement. when the malignant/aggressive interpretations and inconclusive interpretations were combined as positive findings versus the benign radiographic findings as negative findings, the inter-observer agreement improved to 0.48–0.63, indicating moderate to substantial agreement between the readers. using set criteria, sensitivity was high (ranging between 93% and 98%) in correctly diagnosed malignant/infective lesions on radiographs. when using the ‘majority vote’, the sensitivity was 95%, with only two infective lesions that would have been missed/misinterpreted. there was no statistically significant difference between the sensitivity of individual readers and the pooled sensitivity using the majority vote method. this suggests an understandable reluctance to categorically call a lesion benign, given the serious implications of missing a malignancy or infection. reader specificity in the current study ranged from 53% to 73%, averaging to 64% with the ‘majority vote’. the true specificity could not be calculated because the majority of bone lesions with benign features are not biopsied. another explanation for low specificity was the frequent (up to one-third of cases) selection of ‘inconclusive’ option. assessing a single radiological sign has some value in calculating ppv and npv, with high ppv for malignant tumours and infection in the presence of an ill-defined margin, a wide zone of transition, malignant periosteal reaction and cortical destruction. however, 20% of these lesions yielded benign histology. the overall low ppv and npv in the other four radiological signs (‘lytic lesion’, ‘eccentric location’, ‘multiple lesions’ and ‘absent or chondroid matrix’) could be explained by the fact that not all of these eight radiographic signs are necessarily present in an aggressive bone lesion, benign lesions could mimic aggressive lesions, malignant lesions could have varying appearances, and lesion matrix is more useful for guiding differential diagnosis than lesion aggressiveness.7,12 more importantly, the ppv for malignancy or infection increased proportionally with an increase in the number of positive radiological signs. if three signs were present, then ppv was 97%. where there were four major signs, the ppv was 100%. unfortunately, the absence of any of the major signs did not exclude malignancy or infection but had a combined yield of 10% for malignant bone tumour and infection. implications, limitations and future applications in this study where data were obtained from a tertiary hospital having a specialised oncology clinic, with experienced orthopaedic surgeons and musculoskeletal radiologists, half of the biopsied lesions were benign. delay in diagnosis and treatment must be balanced against the financial implications of time-off work, loss of income and surgically related morbidity and mortality that may result from unnecessary surgical treatment. the study is limited by its small sample number. although the national health laboratory stores the histological results of previous 5 years, the hospital’s picture archiving and communication system (pacs) was introduced only in 2012, allowing review of digital radiographs of only 3 years. printed radiographs were not accessible and were excluded from this study. additionally, malignant bone lesions are relatively uncommon and copies of radiographs of patients referred for biopsy from outside institutions were not universally available for review. the study group is heavily skewed to include only those patients whose radiographs demonstrated lesions with aggressive imaging features, and also excluded children aged less than 13 years, thus underestimating true incidences in the referral region. the current study only evaluated radiographic interpretation and further research could have included the contribution of mri in improving the sensitivity and specificity of identifying malignant bone lesions. additionally, a combined weekly meeting at our institution would have helped aiding in bone tumour characterisation, improving registrar training and ultimately leading to better management of patients with bone tumours. similar studies may also include the classic benign ‘leave-alone’ or ‘do not touch’ bone lesions for assessment of readers’ knowledge in identifying benign bone lesions. a larger review study is recommended to assess radiographic features and incorporate a scoring system. this could lead to further categorisation of bone tumours and ultimately to improved confidence of clinicians and radiologists in their assessment and recommendations on follow-up and need for further imaging investigations or biopsy. conclusion the study findings concur with other reported studies from developed and developing countries. the demonstration of high sensitivity in diagnosing primary malignant bone tumours using an established systematic review schema when interpretating radiographs confirms their usefulness as a screening tool. contrasting this, the low specificity may be attributed to the fact that benign bone lesions often have imaging findings that mimic aggressive lesions. we found that the absence of any of the four ‘major radiological signs’ had a low yield (10%) for malignancy and the presence of all 4 major signs had a 100% yield for malignancy or osteomyelitis. even with experienced readers, the diagnosis of primary malignant tumours could be difficult and the fear of missing a malignancy often results in a large number of unnecessary biopsies. a combined clinico-radiological and histopathological approach with regular follow-up and mri in selected cases 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benign bone tumours. radiol oncol. 2004;38(3):165–169. enneking wf, spanier ss, goodman m. a system for the surgical staging of musculoskeletal sarcoma. clin orthop relat res [serial online]. 1980;153(6):106–120. available from: http://www.ncbi.nlm.nih.gov/pubmed/7449206 castellazzi l, mantero m, esposito s. update on the management of pediatric acute osteomyelitis and septic arthritis. int j mol sci. 2016;17(6):855. https://doi.org/10.3390/ijms17060855 tseng c-c, huang r-m, chen k-t. tuberculosis arthritis: epidemiology, diagnosis, treatment. clin res foot ankle. 2014;2(2):131–137. garg rk, somvanshi ds. spinal tuberculosis: a review. j spinal cord med. 2011;34(5):440–454. https://doi.org/10.1179/2045772311y.0000000023 editorial status of mr in south africa magnetic resonance imaging (mri) has developed from an experimental imaging modality in the late seventies to an essential imaging investigation in radiology at the beginning of the millennium. the first mr scanner was installed by the medical research council in cape town in 1986. as part of the winter school of the south african association of physicists in medicin and biology, we sent out questionnaires to the main mr vendors in south africa to determine the current status of mr in this country. in the questionnaire we asked questions about the number, type, field strength of scanners and their geographic distribution. we recorded the number of patients scanned per week, the breakdown per anatomical region, and the mbchb, ffrad(d)sa, frcr, m med(ucn manpower of radiologists, radiographers and physicists involved in mr. we received replies from all five mr vendors. in june 2000 there were 56 mr scanners, although this is likely to be increased to 60 by the end of 2000. fifty-four are in the private sector (96%) and two are in the public sector (universitas and wentworth hospitals). the number of mr scanners in public hospitals is likely to be increased by two to a total of four by year-end. most scanners are relatively new, with an average age of around three years. the oldest, which is now 10 years old, is being replaced. there have been two trends in the mr market in recent years: a trend towards open systems and a recent trend towards high field, high gradient mr systems. there are 17 1.st strength scanners (30%), many with strong gradients with fast slew rates. there are ii open 0.2t systems (20%), many in smaller cities and towns. currently 24 scanners (43%) are in gauteng, nine in the cape town area and four in durban. the remaining 29 (52%) are evenly distributed in the smaller cities and towns throughout the country. the patient workload varied from 15 to 60 patients per five-day week for each scanner. anatomical regions scanned in an average week were: spine 50%, brain 20%, musculoskeletal 20%, cardiac and peripheral vessels 10%. it was difficult to assess how many radiologists and radiographers were actively performing mr imaging as this information was not forthcoming. there are about 10-12 medical physicists interested in and involved with mr. there are a number of encouraging features from this small survey. south africa is well placed internationally with almost 60 scanners working, many of which are relatively new technology. many practices have formed alliances with public/academic departments to provide public patient imaging services and training of registrars and radiographers. the installed base is relatively new and many of the high field systems are capable of performing advanced cardiac and neurovascular sequences like cerebral diffusion and perfusion imaging for stroke investigations. the future growth in mr will be in cardiac and peripheral vascular applications. coronary mr imaging is becoming a reality and the role of cardiology in mr imaging will have to be addressed by the radiology society and speciality. will mr go the same way as echocardiography? for radiologists to protect their referral base, they will have to keep up-to-date with the recent advances in mr technology and ultra fast imaging. this is no easy task considering the rapid advance of technology with new developments in hardware and software sequences arriving on the market almost monthly. peter corr head: department of radi%gy, university of nata/ peter corr editor 3 sajournal of radiology. augus12000 -~---______!...:..__-------- abstract introduction cardiovascular implantable electronic devices cardiac valves and valve replacements or repair amplatzer septal occluder and amplatzer ductal occluder ethical consideration conclusion acknowledgements references about the author(s) rishi p. mathew department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada timothy alexander department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada citation mathew rp, alexander t, patel v, low g. chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices. s afr j rad. 2019;23(1), a1730. https://doi.org/10.4102/sajr.v23i1.1730 original research chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices rishi p. mathew, timothy alexander, vimal patel, gavin low received: 04 mar. 2019; accepted: 05 may 2019; published: 31 july 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract several new innovative cardiac devices have been created over the last few decades. chest radiographs (cxrs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. it is important for the interpreting radiologist to not only identify these iatrogenic objects but also to assess for their accurate placement, as well as for any complications related to their placement, which may be seen either on the immediate post-procedural cxr or on a follow-up cxr. keywords: chest radiographs; pacemaker; implanted cardioverter defibrillators; cardiac resynchronisation therapy; implantable loop recorder; valve replacement; transcatheter valve replacement; amplatzer septal occluder; amplatzer ductal occluder. introduction over the last few decades, several new innovative cardiac medical devices have been created. almost all of the patients with implanted cardiac devices such as pacemakers, implantable cardioverter defibrillators (icds), cardiac resynchronisation therapy (crt) devices, implantable loop recorders (ilr) and cardiac prosthetic valves undergo chest radiographs (cxrs) on a regular basis. therefore, it is not uncommon for the resident, radiologist, intensivist or physician to be presented with a conundrum of cxrs having a variety of these devices on a day-to-day basis. chest radiographs are the initial modality for evaluating the device location and its integrity after implantation and for diagnosis of complications and malfunction.1 the intention of this article is to inform the readers about these cardiac devices, their indications, their proper position on cxrs and commonly associated complications. cardiovascular implantable electronic devices cardiovascular implantable electronic devices (cieds) include implantable cardiac pacemakers, icds, crt devices (also known as biventricular devices) and implantable cardiac monitors. in 2012 alone, at least 3 million patients were implanted with cieds.2 in the united states, approximately 100 000 icds and 300 000 pacemakers are implanted annually,3 while in the uk, the 10-year average growth rate for pacemakers and icds is 4.7% and 15%, respectively.4 it is important to understand the basic functions and differences between various cieds, as well as to recognise them on a radiograph. the cied is composed of two main components: the pulse generator encased in titanium and the pacemaker or icd lead(s). the pulse generator (figure 1) comprises the circuitry, a lithium battery and the connector port. the cied lead has five major parts: a conductor, insulation (silicone rubber or polyurethane), electrode(s), a fixing mechanism and a terminal connector pin. proximally the leads are connected to the generator by the terminal connector by means of a connector block.5 lead tips can be fixed actively or passively. leads placed passively have radiolucent ‘tines’ at their end that anchor the lead tips in position. with time, the myocardium surrounding the lead tip undergoes fibrosis, further securing the lead tip in place. active fixation leads have a retractable screw at its end which is deployed when the lead is placed in position. specific situations where active fixation is used include right ventricular (rv) leads in the outflow tract and in situations where the right atrial (ra) leads must be secured to the tissue for stability. active fixation leads are more commonly used in younger patients as it can be extracted much easier than passive fixation leads.6 figure 1: basic components of a cardiovascular implantable electronic device (cied) generator include the battery (black star), the circuitry (white star) and the terminal connector ports (arrow heads). the pacemaker generator contains the manufacturer logo (white arrow). this pacemaker is mri conditional as indicated by the curvilinear line (black arrow) near the manufacturer logo. pacemakers a pacemaker is a medical device that regulates the heart rate by electrical impulses delivered through electrodes to the heart muscles. the primary aim of this device is to maintain an adequate heart rate so as to not fall below a certain limit (mostly 60 beats/min), either because of a dysfunction of the heart’s natural pacemaker or because of a block in the electrical conduction system of the heart.4,5 pacemakers can be temporary or permanent. temporary pacemakers these pacemakers are meant for short-term use during hospitalisation such as for bradydysrhythmia following a heart attack, cardiac surgery or drug overdose. the main equipment of the temporary pacemaker (the external pacemaker generator) is located outside the body and may be attached to the patient’s skin by a tape or body by a belt.6 the method of choice for temporary pacing in the intensive care unit (icu) is transvenous pacing. temporary epicardial pacing is the most common choice following cardiac surgery and for permanent pacing in children. other alternatives include transthoracic, transesophageal or transcutaneous pacing routes.7,8 permanent transvenous pacemakers these pacemakers are meant for chronic cardiac rhythm dysfunction with abnormally low heart rate and, in general, have a sensing (and/or pacing) lead in the right atrium and a pacing (and/or sensing) lead in the right ventricle. permanent pacemakers can be single-chamber pacemakers (usually with a single lead in the apex of the right ventricle especially for patients with atrial fibrillation; however, a single lead may be seen in the atrium for patients with sick sinus syndrome), dual-chamber pacemakers (with two leads, one in the ra appendage and the second in the rv apex) (figure 2a and b) or biventricular pacemakers also known as crt devices that have been developed for treating severe congestive heart failure. the crt device will be discussed later separately.1,8,9 the leads of the permanent pacemakers are inserted using a transvenous route usually through the left or right subclavian vein or rarely through the internal jugular, axillary or femoral vein. the pulse generator is implanted into the subcutaneous layer of chest below the clavicle and above the pectoral muscle (prepectoral fascia). rarely, the pulse generator may be placed under the skin of the abdomen, inframammary site in women for cosmetic reasons and right infraclavicular site for the left handed.4,10 during the insertion of a pacemaker, the standard procedure is a fluoroscopic evaluation of the positioning of the pacemaker electrodes, followed up by a cxr post insertion. chest radiographs are also useful for identifying abandoned pacemaker leads (figure 3) and complications (figure 4a and b) which have been elaborated on in detail in table 1.4,10 figure 2: frontal (a) and lateral (b) view chest radiographs showing a dual-chamber pacemaker with the right atrial lead (arrow) in the right atrial appendage forming a ‘j’ on the lateral view and the right ventricular lead (arrow head) pointing towards the cardiac apex. figure 3: a chest radiograph (cxr) showing abandoned pacemaker leads in the right atrium and the right ventricle. figure 4: frontal (a) and lateral (b) view chest radiographs (cxrs) showing a dual-lead pacemaker with the right atrial lead (arrow) abnormally positioned in the inferior vena cava. table 1: how to assess cardiac implantable electronic devices on chest radiographs. recently, leadless pacemaker systems have been developed as a minimally invasive option for patients requiring single-chamber pacemaker placement. the two rv leadless pacemaker systems currently available for clinical use are the nanostim™ leadless pacemaker system (lps) (st. jude medical) and the micra™ transcatheter pacing system (tps) (medtronic), both of which are inserted via femoral venous access and implanted directly into the rv wall. on cxrs, these devices appear as a linear radiopaque material implanted into the rv wall. potential complications that can be identified on cxrs include device dislodgment and cardiac perforation.11 implanted cardioverter defibrillators an icd is a medical device capable of producing a large amount of electrical energy in a single output, used to defibrillate the heart. it is mainly used in patients with tachydysrhythmias (e.g. ventricular tachycardia or ventricular fibrillation) and for preventing cardiac arrest. an icd usually comprises of a single lead with one or two shock coils. a shock coil has a relatively thick electrode to reduce the risk of damage to the myocardium from the defibrillating shock. when a two-shock-coil device is placed accurately, one shock coil will be terminating at the brachiocephalic vein–svc junction and the second coil in the rv (figure 5a and b). as these shock coils are radiopaque, they can be readily identified on a cxr, enabling icds to be differentiated from a pacemaker.5,10,12 a newer approach is to place a subcutaneous icd lead to the left of the sternum (figure 6). figure 5: chest radiographs posterior–anterior (a) and lateral views (b) showing a dual-lead implantable cardioverter defibrillator with its characteristic shock coils implanted in a 62-year-old female patient with non-ischaemic cardiomyopathy. figure 6: a subcutaneous implantable cardioverter defibrillator implanted in a 27-year-old male patient with hypertrophic cardiomyopathy. during surgery in the operating room, a cied can sense an external magnetic interference (emi) that can affect its pacing function. the source of the emi may include electrocautery, external defibrillation, radio frequency ablation (rfa) and dental instruments. a cardiac device magnet (figure 7) may be used temporarily by placing it securely and directly over the cied generator to switch the cied to asynchronous pacing mode and hence prevent the emi from interfering with the device pacing. once the magnet has been removed, the cied will revert to its original programmed settings.9 figure 7: a chest radiograph showing a doughnut magnet placed over a pacemaker. a detailed stepwise approach to the assessment of an icd including its associated complications (figures 8a and b, 9 and 10) on a cxr is like a pacemaker and is elaborated on in table 1. figure 8: posterior–anterior (a) and lateral (b) chest radiograph views showing a dual-lead implantable cardioverter defibrillator with a single right ventricular shock coil. note its right atrial lead (arrow) malpositioned in the superior vena cava. figure 9: a dual-lead implantable cardioverter defibrillator with a subtle fracture (arrow) in the proximal portion of the right atrial lead, close to the generator. figure 10: a dual-lead implantable cardioverter defibrillator showing externalised conductors (arrows) of its right ventricular lead, leading to its failure. cardiac resynchronisation therapy devices (implantable cardioverter defibrillator and pacemaker combinations) icd and pacemaker leads can be used in various combinations to produce a crt device. the most common combination is a biventricular pacemaker with an icd (figure 11a and b), where the two pacemaker leads are noted in the right atrium and lv, while the shock lead of the icd is in the rv. cardiac resynchronisation therapy devices are mainly used for treating congestive heart failure (chf). the crt device can be more commonly an icd (crt-d) or a standalone pacemaker (crt-p). the main aim of this device, in addition to a being pacemaker or icd, is to synchronise the left ventricular contraction to improve the symptoms of chf.5,10,12 the assessment of a crt device on a cxr is no different from the other cieds. figure 11: frontal (a) and lateral (b) chest radiographs showing a cardiac resynchronisation therapy device with its pacemaker leads (arrow heads) in the right atrial appendage and the left ventricle, and its implantable cardioverter defibrillator shock coils (arrows) in the superior vena cava and right ventricular apex. by closely evaluating the cied generator, a radiologist can determine if the device is mr conditional, as there are several ‘absolute’ contraindications to performing magnetic resonance imaging (mri) in patients implanted with non-mr conditional cieds (elaborately detailed in table 1),13 although some of these contraindications remain slightly disputed.14 insertable cardiac monitor or implantable loop recorder an insertable cardiac monitor (icm) or ilr (figure 12) is a miniaturised subcutaneous electrocardiographic monitoring device that has been extensively used for evaluating patients with unexplained syncope, symptomatic palpitations in adults, transient or occult atrial fibrillation (af) and in the evaluation of a stroke.12 when compared to pacemakers and icds, icms do not require central venous access or direct contact with the endocardium, thereby negating the risk for endocardial infection. the device is generally implanted in the subcutaneous tissue overlying the left pectoralis muscle with a 1 cm – 2 cm incision that does not require conscious sedation. on a cxr, the icm appears like a usb drive with no wires or leads attached to it. insertable cardiac monitor mimics on a pa cxr include a usb flash drive, an e-vape device and a leadless cardiac pacemaker in the rv, which can be differentiated from them on a lateral cxr.1,15 figure 12: chest radiograph of a 67-year-old female patient with an implantable loop recorder. cardiac valves and valve replacements or repair landmarks of the cardiac silhouette and of the thorax can enable the identification of heart valves on a cxr. by drawing an imaginary line extending from the left atrial appendage to the right cardiophrenic angle (figure 13)16 on a pa cxr and a line extending from the carina to the apex on the lateral view, positions of the valves can be roughly estimated. the pulmonic valve is the most superiorly positioned valve in both views, appearing in partial profile on both projections. on both views, the aortic valve is located superior to the axis line, appearing in profile and in front on the frontal and lateral views, respectively. in contrast, the mitral valve is located inferior to the axis lines on both views, appearing en face on the frontal projection and in profile on the lateral view. the tricuspid valve is located the most inferiorly on both projections, appearing anteriorly and en face on the lateral view. nevertheless, because of anatomical and physiological variations and differences in radiographic projections, valve identification based solely on cxr can be unreliable, necessitating the need for additional details such as clinical history.16 figure 13: by drawing an imaginary line extending from the left atrial appendage to the right cardiophrenic angle on a posterior–anterior (a) chest radiograph and an imaginary line from the carina to the cardiac apex on the lateral view (b), the cardiac valves can be identified.16 valvular heart disease is associated with significant morbidity and mortality and affects roughly more than 100 million people worldwide, and the current standard of management is surgical valve replacement (figures 14–20). alternatively, transcatheter valve replacement without surgery has been gaining popularity over the last decade, especially in patients not suitable for surgery. based on the leaflet material, the two types of prosthetic heart valves available are the mechanical and biological or bioprosthetic heart valves (bhvs).17 the various types of biological and mechanical prosthetic valves have been highlighted in table 2, and they all look slightly different on imaging. the choice between mechanical valve and bioprosthetic valve remains controversial and is based on multiple parameters (tables 2 and 3).18,19 figure 14: chest radiograph showing a mitral annuloplasty c ring (arrow). note the dual-lead pacemaker with accurately placed right atrial and right ventricular leads. figure 15: frontal (a) and lateral (b) chest radiographs showing mitral (perimount tissue) valve replacement (arrow) in a patient with severe mitral stenosis. figure 16: frontal (a) and lateral (b) chest radiographs showing an aortic valve (perimount magna ease tissue valve) replacement (arrow) in a 76-year-old male patient with severe aortic stenosis. figure 17: frontal (a) and lateral (b) chest radiographs showing transcatheter aortic valve replacement (arrow) in an 81-year-old female patient with severe aortic stenosis. figure 18: frontal (a) and lateral (b) chest radiographs showing an isolated prosthetic tricuspid valve replacement (starr edwards valve) (arrow) in a 51-year-old male patient with a history of ebstein’s anomaly. note the implanted pacemaker with its epicardial leads. figure 19: frontal (a) and lateral (b) chest radiographs showing prosthetic aortic (black arrow), mitral (white arrow) and tricuspid (arrow head) valves in a 72-year-old female patient with a history of aortic and mitral stenosis, tricuspid regurgitation and complete heart block. figure 20: frontal (a) and lateral (b) chest radiographs (cxrs) showing prosthetic pulmonary valve replacement (arrows). table 2: types of prosthetic heart valves. table 3: bioprosthetic and mechanical heart valves: advantages and disadvantages. identification of the prosthetic heart valve on a cxr is made possible by detecting any or all its radiopaque parts which may include the base ring, stent, struts, cage, ball or disc. in some cases, a prosthesis may have no radiopaque component and hence cannot be identified radiographically. in most cases, the base ring is radiopaque. several prosthetic valves have radiopaque struts or stents above or below the base ring. if the projections are long, the prosthetic heart valve is either a ball-in-cage or bioprosthesis. literature sources are available,20 providing detailed algorithms guiding in the identification of prosthetic heart valves on cxrs which is beyond the scope of this article. a stepwise approach to the evaluation of cxrs following cardiac valve replacement is elaborated in table 4.21 table 4: a stepwise approach for the evaluation of chest radiographs following cardiac valve replacement. amplatzer septal occluder and amplatzer ductal occluder the amplatzer septal occluder (aso) (avp, aga medical corp., golden valley, mn, usa) is the most commonly used device for transcatheter closure of secundum atrial septal defects. the location of the aso on a cxr is based on the position of the secundum atrial septal defect (asd). on frontal cxrs (figure 21a), the aso is projected to the right or over the spinous processes between the t7 and t9 vertebral bodies, and on lateral cxrs (figure 21b), the aso is projected anterior to or over the hilar-caval line.22 aso migration or embolisation is a recognised complication with an incidence of 0.4% – 1.1%, which can be identified on a cxr. common sites of migration are the right cardiac chambers and pulmonary artery, while left-sided migration is rare.23 figure 21: chest radiographs showing a normally positioned amplatzer septal occluder (arrow) in a 4-year-old girl with a history of a secundum atrial septal defect. note that the aso is projecting over the right lateral margins of the t8 vertebral body on the frontal view (a) and located anterior to the hilar-caval line on the lateral view (b).16 the amplatzer ductal occluder (ado) is a mushroom-shaped self-expandable nitinol wire mesh used for occluding large patent ductus arteriosus (pda), while smaller pdas are occluded by the transcatheter method using gianturco coils. a recognised complication with the ado, like the aso, is device embolisation or migration (figure 22a and b).24 figure 22: a migrated amplatzer duct occluder placed for patent ductus arteriosus. aortogram in the oblique anterior–posterior view (a) shows transcatheter deployment of the amplatzer duct occluder in the lumen of the aorta. post-procedural chest radiograph (b) shows migration of the device (arrow). ethical consideration all ethical considerations have been taken into account. no patient identity or patient information has been revealed. conclusion as more and more patients are living with cieds and prosthetic valves, it is important that residents, radiologists and physicians are aware of these devices and recognise them on a cxr. radiologists in particular have a specific and important role in the evaluation of these devices. an early and accurate identification of device malfunction, fracture or migration can help prompt the physician or surgeon to intervene in a timely manner and help avoid preventable life-threatening catastrophes. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions r.p.m. was the project leader and wrote the manuscript. t.a. was the lead subject authority, contributed to the supervision of the manuscript and helped acquire the images. v.p. contributed to the supervision of the manuscript and helped acquire the images. g.l. contributed to the supervision of the manuscript and helped acquire the images. funding this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references brixey ag, fuss c. innovative cardiac devices on chest imaging: an update. j thorac imaging. 2017 nov;32(6):343–357. https://doi.org/10.1097/rti.0000000000000304 tom j. management of patients with cardiovascular implantable electronic devices in dental, oral, and maxillofacial surgery. anesth prog. 2016 summer;63(2):95–104. https://doi.org/10.2344/0003-3006-63.2.95 buch e, 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better? int cardiovasc res j. 2013;7(2):71–74. tillquist mn, maddox tm. cardiac crossroads: deciding between mechanical or bioprosthetic heart valve replacement. patient prefer adherence. 2011;5:91–99. https://doi.org/10.2147/ppa.s16420 mehlman dj. a pictorial and radiographic guide for identification of prosthetic heart valve devices. prog cardiovasc dis. 1988 may–jun;30(6):441–464. https://doi.org/10.1016/0033-0620(88)90006-0 steiner rm, mintz g, morse d, kotler m, flicker s, raichlen js. the radiology of cardiac valve prostheses. radiographics. 1988 mar;8(2):277–298. https://doi.org/10.1148/radiographics.8.2.3283868 lee ey, siegel mj, chu cm, gutierrrez fr, kort hw. amplatzer atrial septal defect occlude for pediatric patients: radiographic appearance. radiology. 2004;233(2):471–476. https://doi.org/10.1148/radiol.2332031707 martinez-quintana e, rodriguez-gonzalez f. risks factors for atrial septal defect occlusion device migration. int j angiol. 2016;25(5):e63–e65. https://doi.org/10.1055/s-0034-1395976 haponiuk i, chojnicki m, jaworski r, et al. miniinvasive hybrid procedure for device migration after percutaneous closure of persistent arterial duct: a case report. wideochir inne tech maloinwazyjne. 2012;7(3):202–205. https://doi.org/10.5114/wiitm.2011.27367 about the author(s) eben a. strasheim department of diagnostic radiology, university of the witwatersrand, south africa citation strasheim ea. patient related factors influencing the quality of paediatric chest radiographs. s afr j rad. 2017;21(1), a1161. https://doi.org/10.4102/sajr.v21i1.1161 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia,usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract patient related factors influencing the quality of paediatric chest radiographs eben a. strasheim copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: the chest x-ray is the most common radiographic examination performed worldwide due to its versatility. by improving the quality of chest radiographs and avoiding repeat x-rays, the collective radiation dose to children can be decreased. aim: to identify patient related factors that influence the quality of paediatric chest radiographs by assessing the quality of chest radiographs and to compare the quality of chest radiographs in ‘radiologically’ sick patients to those of ‘radiologically’ normal patients. method: a retrospective study was performed to determine the quality of paediatric chest radiographs forming part of an existing database. the sample size of 280 radiographs, included radiographs of children aged 3 days to 13 years. radiographic errors were captured on an electronic tick-sheet, consisting of 12 specific radiographic errors commonly made in practice and included the presence or absence of respiratory pathology. data was extracted with regards to each of the 12 errors, patient demographics and presence of respiratory pathology to identify associations. results: there was a statistically significant, low correlation present between the radiographic error count and the presence of respiratory pathology (p < 0.001). there was a statistically significant difference in the quality of chest radiographs of children aged 0 months – 18 months and those aged 37 months – 156 months (p < 0.05). conclusions: the results of this study have demonstrated that there is a correlation between the presence of respiratory disease on a paediatric chest radiograph and the quality of the chest radiograph. the number of errors detected were higher in patients with respiratory pathology on the chest radiograph. sajr 19_1&2 book file.indb reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of sa journal of radiology: we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for sa journal of radiology, we ask that you take a moment to update your electronic portfolio on http://www. sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajr.org.za 2. in your ‘user home’ [http://www.sajr.org. za/index.php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 sa journal of radiology aadil ahmed ahmed ahidjo ajmal ikram anne-marie du plessis aruna patil benjamin taragin bev newman christelle ackermann clive daniell darshan reddy dilesh chhiba dirk van der merwe dorothy bulas frank a. imarhiagbe gloria soto hansraj mangray hein els himal gajjar jacqueline du toit jaishree naidoo jan lotz jeanne lubbe johan g. blickman kassa darge kieran mchugh kimberly applegate liesel davel mala modi maria i. boechat marilyn j. goske matthew goodier miranda durand nausheen khan nicky wieselthaler ntobeko a.b. ntusi otto schulze peter mercouris r. minne r. a.j. nievelstein richard de villiers richard pitcher sally e. candy sam moore sandeep jakhere shalendra k. misser shaun scheepers sherwin chan sinclair wynchank steve j. beningfield suresh k. chamarthi tanyia pillay thomas g. walker tim cain tracy kilborn victor mngomezulu werner harmse zarina lockhat abstract introduction methods results discussion conclusion acknowledgements references about the author(s) wim greeff dr. george mukhari academic hospital, sefako makgatho health sciences university, south africa ali reza dehghan-dehnavi dr. george mukhari academic hospital, sefako makgatho health sciences university, south africa jacobus van marle unitas hospital, department of surgery, sefako makgatho health sciences university, south africa citation greeff w, dehghan-dehnavi ar, van marle j. venous function after pharmacomechanical thrombolysis for extensive iliofemoral deep vein thrombosis. s afr j rad. 2017; 21(1), a1214. https://doi.org/10.4102/sajr.v21i1.1214 original research venous function after pharmacomechanical thrombolysis for extensive iliofemoral deep vein thrombosis wim greeff, ali reza dehghan-dehnavi, jacobus van marle received: 19 may 2017; accepted: 27 june 2017; published: 29 aug. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: chronic venous insufficiency is an important complication following iliofemoral deep venous thrombosis. early thrombus removal may preserve venous function and prevent this complication. this study represents the largest reported south african series of pharmacomechanical thrombolysis for iliofemoral deep venous thrombosis to date. objective: to evaluate the long-term outcome following pharmacomechanical thrombolysis for proximal and extensive deep venous thrombosis in a private, specialist vascular unit. methods: all patients who underwent pharmacomechanical thrombolysis for iliofemoral deep venous thrombosis between august 2009 and january 2016 were invited to return for clinical assessment and venous ultrasound. clinical findings were recorded according to the villalta score and clinical, etiology, anatomic and pathology (ceap) classification. the quality of life (qol) was assessed utilising the veines-qol/sym questionnaire, providing two scores per patient, one describing the qol and the other symptom severity (sym). results: thirty two patients (35 legs) were evaluated. there were 25 females and 7 males, with a mean age of 33.5 years (±14 years). the mean follow-up period was 31 months (range 3 months – 80 months). results of the ceap classification were c0 = 24 (75%), c1 = 1 (4%), c2 = 2 (6%), c3 = 2 (6%) and c4 = 3 (9%). thirty-one (97%) patients had villalta scores from 0 to 4, indicating no or mild evidence of venous disease. one patient (3%) had a villalta score of 6, indicating post-thrombotic syndrome. the mean qol score was 87% (±12) and the mean sym score was 86% (±14). twenty-four (75%) patients had no abnormality on ultrasound, with fibrosis the most observed abnormality. conclusion: most patients who had undergone pharmacomechanical thrombolysis for extensive iliofemoral deep venous thrombosis showed few significant clinical signs of chronic venous insufficiency, had excellent function on venous ultrasound and reported excellent qol. introduction venous thromboembolism (vte) is a multifactorial disease that may manifest as deep venous thrombosis (dvt), pulmonary embolism (pe) or both. dvt is a common problem encountered in clinical practice, with the complications ranging from minor to the severe, and even life-threatening. subsequent chronic venous insufficiency (cvi) because of post-thrombotic syndrome (pts) is associated with increased morbidity and poses a significant health care burden.1 pts significantly impacts health-related quality of life (qol) after dvt. it is characterised by a chronic feeling of limb heaviness, swelling, pain, paraesthesia and/or leg ulcers. the incidence of pts is 30% – 50% with iliofemoral dvt, with leg ulcers developing in 5% – 10% of patients.1,2 the use of anticoagulation therapy alone in the treatment of vte is well established. however, there is increasing evidence favouring active intervention with thrombolysis and/or mechanical thrombus removal in iliofemoral dvt.3,4,5 catheter-directed thrombolysis (cdt) significantly improves venous disease-specific qol and furthermore decreases the economic burden of this disease entity.1,6,7 recently presented results from the attract trial suggests that removing the thrombus reduces early dvt symptoms and reduces the severity of pts in the subgroup of patients with iliofemoral dvt. an expert panel ascribed this to the different prognosis and natural history of iliofemoral dvt compared with femoropopliteal dvt.8 there are multiple clinical scoring systems available to aid in the evaluation of venous diseases. the ‘ceap’ classification describes clinical signs (c), etiology (e), anatomic distribution (a) and the underlying venous pathology based on ultrasound (p).9 another scoring system, the villalta score, specifically assesses the development of pts.10 many scales exist to evaluate the health-related qol of patients. the most extensively validated is the veines-qol/sym questionnaire. this is best utilised to assess the effect of dvt on the qol, as well as the outcome of treatment.11 methods this is a cross-sectional study with ethical clearance from the sefako makgatho university research ethics committee (smurec/m/272/2015:pg). patients who underwent pharmacomechanical thrombolysis (pmt) for iliofemoral deep venous thrombosis (ifdvt) between august 2009 and january 2016 were invited for a clinical assessment and venous ultrasound study. the clinical examinations were focussed on venous disease-specific findings, utilising the c-class of the ceap classification (table 1) and the villalta score (table 2). table 1: clinical parameters of the clinical, etiology, anatomic and pathology classification. table 2: villalta scale. the venous ultrasound examinations were performed by an independent dedicated vascular technologist, who was blinded to the results of the clinical scoring systems. normal venous flow was considered as spontaneous, phasic and augmentable without reflux on augmentation manoeuvres. the veins were considered normal if they were compressible without narrowing or fibrosis. when seen, abnormalities were localised to specific venous segments from the popliteal vein distally to the inferior vena cava proximally.12 each participant completed the self-administered veines-qol/sym questionnaire.11 this is a 26-item tool used to evaluate a patient’s venous disease-specific qol and symptom severity (sym). ten items are symptom related, nine assess limitations to daily activities, one assesses the time of day the symptoms are most intense (used as a descriptor only), one assesses changes over the past year and five cover the psychological impact of venous disease.13 the results from each participant were converted to ‘t-scores’, utilising the veines-qol/veines-sym scoring manual provided by the original authors who had designed and validated the questionnaire.13 two summary scores are generated for each patient, one relating to qol, the other describing sym. for reporting and interpretation purposes, these t-scores were converted to percentages, based on hypothetical best-case and worst-case scenarios. results all statistical analyses were undertaken using the sas programme (sas institute inc., carey, nc, usa, release 9.4), running on microsoft windows. a total of 46 patients underwent pmt for ifdvt during the period of august 2009 to january 2016. thirty-two patients were available for follow-up: 25 females and 7 males. the left leg was involved in 24 patients, the right leg in 5 patients while 3 patients had bilateral involvement. in 26 patients, full thrombus clearance was achieved, while 6 patients had partial clearance as shown by post-therapy venography. in 18 patients, there was a residual stenosis in the common iliac vein following thrombolysis; 12 required venous stent placement and 6 patients underwent percutaneous balloon angioplasty (pta). two patients had an abnormal inferior vena cava, one being hypoplastic and the other absent. the distribution of villalta scores are shown in figure 1. the distribution of patients according to the c-classes from the ceap classification is shown in figure 2. the mean qol score was 87% (range 75% – 99%) and the mean sym score was 86% (range 72% – 100%) is shown in table 3. the mean qol and sym percentages are recorded for each villalta score. the inverse relationship between the qol/sym and villalta scores are illustrated in figure 3. figure 1: results of the villalta scores (n). figure 2: distribution of patients according to clinical findings utilising the clinical, etiology, anatomic and pathology classification (n). figure 3: relationship between the villalta score and the veines-qol/sym score. table 3: mean quality of life and sym scores. twenty-four patients (75%) had normal venous function and anatomy on follow-up ultrasound examination. in 8 patients, abnormal findings were recorded: these included stenosis, fibrosis and/or reflux. there was a statistically significant correlation between the presence of abnormal sonar findings and a higher ceap classification. the lower c-scores had normal sonars, while the higher c-scores were more abnormal (p = 0.070) in table 4. the same was found with the villalta scores. lower villalta scores were often normal on ultrasound, and the higher villalta scores were often abnormal (p = 0.007) as shown in table 5. table 4: clinical, etiology, anatomic and pathology compared with ultrasound. table 5: villalta compared with ultrasound. discussion venous thromboembolism is commonly encountered in clinical practice with an incidence of 1.0–1.5 per 1000 persons per year and is responsible for more than 100 000 deaths per year in the united states.1 pts develops in 20% – 50% of patients with proximal leg dvt, even when optimal anticoagulation therapy is used.2 pts is characterised by symptoms of leg heaviness, pain, swelling, itching and paraesthesia. open-leg ulcers occur in 5% – 10% of cases with pts.2,14 the estimated costs of managing pts in the us are estimated to be in the order of $1100 in the first year of treatment for mild to moderate pts, and $5000 for severe pts with open ulcers. the mean annualised medical cost for patients with pts is $14 800 higher than for patients that do not have pts,1 emphasising the economic burden of the disease. persisting thrombus has been linked to venous valve dysfunction and pts.2 standard anticoagulation therapy has been proven efficient in preventing thrombus extension and pe, but does not remove the thrombus from the vein.15,16 active interventions focus on thrombus removal, with concurrent anticoagulant use. recently presented data have shown that early thrombus removal preserves venous function and limits the severity of pts in patients with iliofemoral dvt, but has not shown added benefit in femoropopliteal dvt.8 all our patients had iliac vein involvement with thrombus extending into the inferior vena cava in 12 patients (38%). surgical venous thrombectomy with anticoagulation proved effective in preventing venous reflux and pts, but is invasive and requires a temporary arterio-venous fistula to enhance venous outflow.17 systemic thrombolysis is effective in lysing the thrombus and maintaining venous patency with 43% of patients progressing to pts, versus 64% for standard anticoagulation. the limitation is more bleeding complications, at 10% versus 8% compared to standard anticoagulation.18 catheter-directed thrombolysis allows localised administration of thrombolytics directly into the thrombus. it is effective in restoring venous patency and comparable to systemic thrombolysis in preventing pts, with a lower rate of bleeding complications. the relative-risk reduction in pts with cdt is 26%.6,19 pharmacomechanical thrombolysis utilises catheter-directed administration of a fibrinolytic agent directly into the thrombus, concomitant with a catheter-based device to macerate the thrombus. this speeds up thrombus clearance and decreases the amount of fibrinolytic required. the safety, efficacy and cost-effectiveness are currently being evaluated.20 in our study, patients received pmt with actilyse® (alteplase, recombinant tissue plasminogen activator; boehringer ingelheim pty) infused via an angiojet™ (peripheral thrombectomy system; boston scientific) catheter. thrombus clearance was reported according to the grading system reported by mewissen et al.21 twenty-six patients had complete lysis (100%) and six patients had partial lysis (50% – 99%). there was no statistically significant difference in outcomes between patients that had partial clearance versus full clearance. underlying structural abnormalities have been reported in a significant number of patients with extensive iliofemoral dvt.19 in this series, there were 18 patients with residual stenosis after successful thrombolysis and was managed by stent placement in 12 patients and percutaneous angioplasty (pta) in 6 patients. clinical findings defined according to the c-class of the ceap classification and the villalta scores showed that the majority of patients had no signs of chronic venous disease. the villalta score is a disease score specific for pts. points are given for five symptoms (pain, cramps, heaviness, paraesthesia and pruritus) and six clinical signs (pretibial oedema, skin induration, hyperpigmentation, redness, venous ectasia and pain on calf compression). points are given for each of these 11 descriptors according to severity, ranging from 0 for not present to 3 for severe. furthermore, if a venous ulcer was present, the severity of the condition was classified as severe, regardless of the presence or absence of other signs or symptoms. the patient was diagnosed as having pts if the villalta score was ≥ 5 or if a venous ulcer was present. a score of 5–9 signifies mild disease, 10–14 moderate disease and ≥ 15 severe disease.22 only four patients had objective findings of chronic venous disease with skin pigmentation, venous eczema or lipodermatosclerosis, placing them in the c4 category. we, however, did not differentiate between c4a and c4b. only one patient had pts with a villalta score of 6. the veines-qol/sym questionnaire addresses venous disease-specific qol. the questionnaire was well received by the patients and easily completed. the processed data produce two t-scores per patient, which by themselves do not contribute to understanding the patient’s qol as there are no reference scales that define a good versus a bad outcome. this is a limitation of the veines-qol/sym questionnaire. for the interpretive purposes of this study, the t-scores were converted to percentages, based on hypothetical worst-case and best-case scenarios. this generated two percentages, qol% and sym% which were easier to use. our patients reported a good qol with minimal symptoms because of cvi (table 3). higher qol scores reflect better qol and higher sym scores represent fewer symptoms. there was no statistically significant correlation between the veines, c-classification and villalta scores, although the trend was that low villalta scores (absence of pts) had better qol and fewer symptoms. most patients with normal venous function and anatomy on venous ultrasound also had low cand villalta scores. the limitations of this study are the small sample size with no control arm receiving systemic anticoagulation alone. this limits the ability to generalise the findings. conclusion patients with ifdvt who had successful thrombus removal with pmt showed few significant residual signs of chronic venous disease, had excellent venous function on venous ultrasound and had excellent qol. pmt is not indicated for all patients with above the knee dvt given the added invasiveness, cost and potential for complications. pmt must however, be considered when thrombus extends into the iliac veins because of the increased severity of pts symptoms in these patients. acknowledgements competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions w.g. was responsible for patient scheduling and clinical evaluation, collecting and processing of data, preparing and editing the manuscript, and online submission for publication. a.r.d.d. was the co-supervisor. j.v.m. was the treating clinician and main supervisor who provided the topic and was involved in clinical evaluation, processing of data and review and editing of the manuscript. references grosse sd, nelson re, nyarko ka, richardson lc, raskob ge. the economic burden of incident venous thromboembolism in the united states: a review of estimated attributable healthcare costs. thromb res. 2016;137:3–10. https://doi.org/10.1016/j.thromres.2015.11.033 kahn sr. the post thrombotic syndrome. thromb res. 2011;127:s89–s92. https://doi.org/10.1016/s0049-3848(11)70024-x comerota aj, throm rc, mathias sd, haughton s, mewissen m. catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. j vasc surg. 2000;32(1):130–137. https://doi.org/10.1067/mva.2000.105664 elsharawy m, elzayat e. early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis: a randomised clinical trial. eur j vasc endovasc surg. 2002;24(3):209–214. https://doi.org/10.1053/ejvs.2002.1665 comerota aj. thrombolysis for deep venous thrombosis. j vasc surg. 2012;55(2):607–611. https://doi.org/10.1016/j.jvs.2011.06.005 haig y, enden t, grøtta o, et al. post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (cavent): 5-year follow-up results of an open-label, randomised controlled trial. lancet haematol. 2016;3(2):e64–e71. https://doi.org/10.1016/s2352-3026(15)00248-3 liew a, douketis j. catheter-directed thrombolysis for extensive iliofemoral deep vein thrombosis: review of literature and ongoing trials. expert rev cardiovasc ther. 2016;14(2):189–200. https://doi.org/10.1586/14779072.2016.1121096 attract fails to meet primary endpoint, but experts agree results are ‘hypothesis-generating’. vascular news. 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https://doi.org/10.1016/j.ejvs.2005.07.020 lamping dl, schroter s, kurz x, kahn sr, abenhaim l. evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. j vasc surg. 2003;37(2):410–419. https://doi.org/10.1067/mva.2003.152 kahn sr, ginsberg js. relationship between deep venous thrombosis and the postthrombotic syndrome. arch intern med. 2004;164(1):17–26. https://doi.org/10.1001/archinte.164.1.17 hence pk, wakefield t. thrombus resolution and vein wall injury: dependence on chemokines and leukocytes. thromb res. 2009;123 suppl 4:s72–8. https://doi.org/10.1016/s0049-3848(09)70148-3 henke pk, comerota aj. an update on etiology, prevention, and therapy of postthrombotic syndrome. j vasc surg. 2011;53(2):500–9. https://doi.org/10.1016.j.jvs.2010.08.050 plate g, ekl b, norgren l, ohlin p. venous thrombectomy for iliofemoral vein thrombosis – 10-year results of a prospective randomised study. eur j vasc surg. 1997;374:367–374. https://doi.org/10.1016/s1078-5884(97)80286-9 watson l, broderick c, mp a. thrombolysis for acute deep vein thrombosis. cochrane database syst rev. 2014;(1):cd002783. https://doi.org/10.1002/14651858 enden t, haig y, kløw ne, et al. long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the cavent study): a randomised controlled trial. lancet. 2012;379(9810):31–38. https://doi.org/10.1016/s0140-6736(11)61753-4 vedantham s, goldhaber sz, kahn sr, et al. rationale and design of the attract study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis. am heart j. 2013;165(4):523–530.e3. https://doi.org/10.1016/j.ahj.2013.01.024 mewissen mw, seabrook gr, meissner mh, cynamon j, labropoulos n, haughton sh. catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. radiology. 1999;211(1):39–49. https://doi.org/10.1148/radiology.211.1.r99ap4739 soosainathan a, moore hm, gohel ms, davies ah. scoring systems for the post-thrombotic syndrome. j vasc surg. 2013;57(1):254–261. https://doi.org/10.1016/j.jvs.2012.09.011 abstract introduction research method and design results discussion study limitations and pitfalls conclusion acknowledgements references about the author(s) sithembiso m. langa department of radiology, college of health sciences, university of kwazulu-natal, durban, south africa nondumiso n.m. dlamini department of radiology, college of health sciences, university of kwazulu-natal, durban, south africa balasoobramanien pillay department of vascular /endovascular surgery, college of health sciences, university of kwazulu-natal, durban, south africa citation langa sm, dlamini nnm, pillay b. spectrum of multi-detector computed tomography imaging findings of thoracic vascular injuries secondary to blunt chest trauma: correlation with vascular intervention and patient outcomes. s afr j rad. 2019;23(1), a1709. https://doi.org/10.4102/sajr.v23i1.1709 original research spectrum of multi-detector computed tomography imaging findings of thoracic vascular injuries secondary to blunt chest trauma: correlation with vascular intervention and patient outcomes sithembiso m. langa, nondumiso n.m. dlamini, balasoobramanien pillay received: 27 dec. 2018; accepted: 06 may 2019; published: 23 july 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: thoracic vascular injuries following blunt chest trauma are the second leading cause of trauma-related deaths. multi-detector computed tomography (mdct) is the imaging modality of choice in detecting these injuries. objectives: to determine the spectrum of vascular injuries detected on mdct imaging in patients who sustained blunt chest trauma, and to assess the various types of management options and patient outcomes. method: we retrospectively reviewed archived medical records of polytrauma patients who presented with blunt chest trauma and confirmed vascular injury on mdct and vascular intervention images between may 2015 and august 2018 at inkosi albert luthuli central hospital. results: thirty-nine patients with vascular injury findings were analysed. the injury spectrum comprised: 15 aortic injuries (ai), 19 non-aortic injuries (nai), 4 combined (ai and nai) and 1 aorto-venous injury. a majority of males (69%) with an overall mean age of 39 years constituted the study cohort. the commonest injury mechanisms included motor vehicle collisions (61%) and pedestrian accidents (28%); the remaining 11% were shared amongst motorbike accidents or falling from a moving train or a height. the subclavian artery (36%) was the most common anatomical location in the nai and the frequent imaging finding was vessel occlusion (55%). the most common imaging findings in ai were the indirect signs (20.5%) followed by a grade iii injury (15.4%). six patients with a grade iii ai were successfully managed with endovascular repair. conclusion: a thorough knowledge of blunt vascular injury spectrums and imaging manifestations is critical when interpreting mdct scans. awareness of the mechanism of injury will trigger a high index of suspicion and probe a search for a vascular injury. keywords: blunt chest trauma; mdct findings; vascular injuries; vascular intervention; durban. introduction trauma-related morbidity-mortality is a worldwide burden. blunt chest trauma accounts for approximately 20% of the injury mechanisms.1,2,3,4,5 in our setting, the prevalence of aetiologic blunt trauma mechanisms of motor vehicle collisions, pedestrian accidents and falling from a height has a shared similarity to published data in first-world countries; however, variation is noted in respect of other compounding injury mechanisms in our setting such as assaults, interpersonal violence and train accidents.3,6,7 imaging plays a pivotal role in patient management, as clinical signs and symptoms in trauma patients may be unreliable because a majority of the patients present with impaired consciousness.8,9 although chest radiographs are usually the first-line screening modality in most trauma centres, they offer limited potential in determining the presence of a vascular injury.4,9,10 the current use of focused assessment with sonography for trauma (fast) may confirm few additional thoracic trauma findings.1 however, contrast-enhanced multi-detector computed tomography (mdct) triumphs as the imaging modality of choice owing to quick acquisition as well as the ability to diagnose life-threatening and occult injuries that are undetectable on radiographs and ultrasound.2,10 with improved image quality and spatial resolution on mdct, it has curtailed the use of the invasive conventional digital subtraction angiography (dsa) as a diagnostic tool to definitively exclude a vascular injury. angiography is currently reserved for equivocal mdct findings or endovascular intervention.11 the use of full-body computed tomography (ct), also known as pan ct, has been advocated in the initial assessment of polytrauma patients and has proved to reduce the mortality rate.12 there are no south african data that describe mdct findings of vascular injuries secondary to blunt thoracic trauma in our patient population. the international literature documents a broad and variable spectrum of vascular injuries resulting from blunt chest trauma. aortic injuries supersede injuries of other major vessels (i.e. aortic arch branches) according to published data. in this study, we describe the vascular injury spectrum (aortic and non-aortic) together with other associated thoracic injuries. the aim of this retrospective study is to describe the mdct findings of blunt vascular injuries as well as to assess the types of management plan, vascular interventions and relevant patient outcomes. research method and design the study was performed at inkosi albert luthuli central hospital (ialch) which has a tertiary level 1 trauma unit that serves the durban metropolitan area and the rest of kwazulu-natal. all state patients in the province with thoracic vascular injuries requiring surgical intervention, specialised care and trauma intensive care unit (ticu) management are referred to the centre. data of all polytrauma patients with blunt chest trauma referred to the radiology department for mdct scan who fulfilled our inclusion criteria were obtained from the radiology information system (ris) and picture archiving and communication system (pacs). clinical data for these patients were obtained from the hospital information system (meditec). data were collected for the period of may 2015 to august 2018. we included patients who were aged 18 years and older with reported vascular injuries. exclusion criteria applied to patients younger than 18 years, patients with no reported vascular injuries, patients with only unenhanced mdct scan performed, patients with no records of a documented radiology report on the system, scans with false positive findings and patients imaged at their base hospital. data were collected relating to patient demographics (age and gender), mechanism of injury, scan times, scan protocols, reported vascular injuries/ findings, associated thoracic non-vascular injuries, vascular interventions and patient outcomes in terms of their survival, discharge or demise. the aortic injuries were assigned different categories to aid analysis. perivascular haematoma and vessel wall irregularity were considered as indirect aortic injury signs, whereas direct signs were assigned grade i (intimal flap finding), grade ii (dissection, an intramural haematoma or intimal flap of greater than 1 cm length), grade iii (pseudoaneurysm) and grade iv (rupture with contrast extravasation). the non-aortic vascular injury signs were classified in terms of intimal flap, vessel calibre reduction, vessel wall irregularity, occlusion, pseudoaneurysm, perivascular haematoma, contrast extravasation, transection and arteriovenous fistula formation. the scans were reported by medical officers, registrars and consultant radiologists. selected scans with positive reported vascular injuries were reviewed by a consultant radiologist with a five years’ experience and false positive vascular injury findings were excluded. scans were performed using a siemens somatom definition as and siemens somatom definition flash. the decision of the imaging protocol was based upon the trauma surgeon’s discretion following clinical assessment. full-body ct angiograms and chest ct angiograms were performed according to the prescribed department imaging protocol. one millimetre reformats were done and images were analysed in 3-dimension (3d) and multiplanar reformats (mpr). data analysis was performed using the ibm spss statistics version 25 software. descriptive analysis, frequencies of demographic data, mechanism of injury, scan protocols, scan time, vascular injury spectrums and thoracic non-vascular injury spectrums were performed. data were further analysed to depict correlation between injury types and patient outcomes; correlation between vascular injuries and associated thoracic non-vascular injuries; as well as correlation between the types of patient management and patient outcomes. ethical consideration ethics approval was obtained from the biomedical research ethics committee (brec:be 343/18), college of health sciences, university of kwazulu-natal. results a total of 420 mdct whole-body and chest scans were performed for blunt chest trauma in polytrauma patients during the study period (may 2015 to august 2018). there was a male predominance of 316 (74.9%). a majority of scans (257 [61%]) were performed outside working hours. full-body ct angiogram scan was the most frequent imaging protocol request with a 93% frequency. thirty-nine patients with positive vascular findings that satisfied our inclusion criteria were selected. a total of 381 patients were excluded on the basis of these criteria: 72 were under 18 years of age; 284 had no reported vascular injuries and 3 had false positive vascular injury findings on review of the scans; 10 had no formal radiology report; 12 only had unenhanced ct scans. the false positive findings included an aortic intercostal branch, aortic wall calcification and brachiocephalic artery wall calcification, which were all misdiagnosed as tiny outpouchings or pseudoaneurysm. in the 39 patients with positive vascular findings, males constituted 69% (27/39); with an age range of 20–80 years and a mean of 39.15. twenty scans were performed outside working hours, and a full-body ct angiogram (see table 1) was the most requested imaging protocol (31 requests). figure 1 demonstrates the frequency of recorded injury mechanisms. a total of 15/39 patients had isolated aortic injuries, 19/39 had isolated non-aortic injuries, 4/39 had a combination of aortic plus non-aortic injuries and 1/39 had a combined aortic and azygous vein injury (table 1). multiplicity of pathological findings were documented in patients with aortic and non-aortic injury as demonstrated in tables 2 and 3. in 12.8% of cases, the injuries involved more than one vessel. the most frequent aortic injury imaging findings were indirect signs (20.5%), followed by grade iii (15.4%), grade i (10.3%) and grade ii (5.1%) findings. there was no record of aortic injury with active contrast extravasation or aortic rupture (grade iv injury). table 3 depicts a summary of aortic injuries according to the grading system as well as non-aortic injuries. a total of six patients with a grade iii aortic injury received endovascular intervention (tevar) and were all successfully discharged with 0% mortality reported, (table 3). one patient that received tevar also had a concomitant subclavian artery pseudoaneurysm that was endovascularly stented and involvement of the vertebral artery origin that was coiled. one patient with grade ii aortic injury received no intervention because of overall poor prognosis, and another with similar injury was assessed to be stable by the vascular surgery team on discharge and was meant to receive subsequent delayed intervention but was lost to follow up. the remainder of the aortic injury findings of indirect signs and grade i injuries were subjected to conservative management. however, six patients within the aortic injury category inclusive of indirect signs and grade i injury demised as a result of overall poor prognosis related to associated severe extra-thoracic injuries. figure 1: mechanism of injury – n (%). table 1: computed tomography scan protocol and types of vascular injury. table 2: analysis of computed tomography findings in vascular injury. table 3: summary of vascular injuries, injury combinations, frequencies, management and outcomes. the vessels involved in non-aortic injuries are demonstrated in figure 2a, and their respective management is listed in table 3. the most frequent imaging finding in the non-aortic injuries was vessel occlusion 16/23 (70%), followed by intimal flap 4/23 (17%), wall irregularity and reduced vessel calibre (3/23; 13% each), perivascular haematoma 2/23 (9%) and pseudoaneurysm 1/23 (4%) (table 2). figure 2b demonstrates correlation of non-aortic vessels with injury types that were found, and a high incidence of vessel occlusion was seen in carotid and vertebral arteries followed by the subclavian artery. figure 2c correlates the non-aortic vascular injury types or findings with the mortality rate and a high mortality rate is demonstrated amongst patients with vessel occlusion, particularly with involvement of carotid and vertebral arteries; however, there were other associated severe extra-thoracic injuries. associated non-vascular thoracic injury findings are represented in figure 3. figure 2: non-aortic arterial injury (n) shows (a) a spectrum of non-aortic arterial vessels; (b) correlates the arterial vessel to injury type; (c) correlates arterial vessel injury type to mortality rate. figure 3: associated non-vascular thoracic injuries in relation to the vascular injury category. discussion blunt thoracic vascular injuries following trauma are uncommon, and in our study constituted 9.2% of all injuries in patients referred to the ct department for suspected vascular injury after blunt trauma. similar to international published data, motor vehicle collision was the most frequent underlying injury mechanism, accounting for 61% in our cases.5 thoracic clinical signs and symptoms may be unreliable in predicting the presence of a blunt vascular injury.9 the mechanism whereby there is high velocity and rapid impact or deceleration should raise a high index of suspicion of a blunt vascular injury. these patients usually present with multiple injuries.4,8,9,13,14 other indirect indicators of a vascular injury include a rapid decline in blood pressure with no response to fluid resuscitation and drainage of high volumes of bright red blood from the intercostal drain, usually ≥ 2000 mls.15,16 full-body angiogram mdct scan protocol is a well-established imaging protocol particularly in polytrauma patient evaluation and has been proved to reduce mortality.12,17 at ialch, a frequently requested full-body protocol entails unenhanced ct brain plus c-spine; post intravenous contrast angiographic phase from base of skull to pelvis ± extremities as determined by the trauma surgeon’s assessment if complex extremity fractures are present; a portal-venous phase abdomen and pelvis; and a delayed phase if there is an indication or suspicion of a renal tract injury. selective regional chest ct imaging protocol was performed in fewer patients who were fully conscious with pure thoracic blunt trauma or who at least received other extra-thoracic ct scan imaging at the referring base hospital. the proposed pathophysiology in blunt vascular trauma is that of a high velocity rapid deceleration process with shearing forces and that of direct blow to a vessel or direct blow to the chest with a rapid increase in intrathoracic pressure or impingement of the aorta between the spine and sternum.4,12 the most commonly reported injury profile involving the thoracic aorta typically occurs at the aortic isthmus, which is the junction between the mobile arch and fixed descending aorta, followed by ascending aorta and distal descending aorta.5,8,9,18,19 our study demonstrates a slightly higher incidence of non-aortic injury (23/39) in isolation or in combination with other vessel injuries at 58.9% compared with aortic injury incidence (20/39) (table 2). furthermore, multiplicity of vascular injuries in our patients occurred at a rate of 12.8%, which correlates with a report by gotway and dawn.18 the classification or grading of aortic injuries is demonstrated in figure 4.14 our study has demonstrated that all grade iii aortic injuries occurred at the isthmus (figure 6). there is a paucity of literature (data) highlighting the non-aortic great vessel injuries when compared with aortic injuries. this is also due to fewer studies that look at all the great vessels, but rather there are case reports and studies looking at individual vessels. of the non-aortic injuries, the brachiocephalic trunk injuries constitute about 50% of the great vessel injuries, and the other vessels comprise the remainder.17 comparatively we recorded the subclavian artery being the commonest (36%) of non-aortic vessel injuries (figure 7), followed by the vertebral and carotid artery. the brachiocephalic trunk and common carotid artery injuries tend to occur closer to their origins, whereas subclavian artery injuries typically occur more distally.4 the systemic venous and pulmonary circulation injuries are very rare.4,17 in our study there was a solitary azygous arch pseudoaneurysm (figure 8), which occurred concurrently with an aortic indirect injury finding and no intervention was performed owing to other severe extra-thoracic injuries. figure 4: diagram demonstrating aortic injury classification. figure 5: arrow in image (a) and (b) showing aortic intimal injury (grade i), and a star annotation in (a) is lymphadenopathy not to be confused with mediastinal haematoma. arrow heads in (c) and (d) demonstrate the lower thoracic aorta anterior wall irregularity (indirect sign) and an elongated intimal flap indicating a focal dissection (grade ii). arrows in another patient in (e) and (f) indicating a more conspicuous aortic dissection (grade ii) at the level of the diaphragmatic hiatus. figure 6: aortic pseudoaneurysm (grade iii) with respective endovascular intervention images in two different patients. arrow head in (a) shows axial image of a subtle aortic small pseudoaneurysm, which is better demonstrated on mpr formats in (b) and (c). arrow in another patient (f), (g) shows a larger pseudoaneurysm in the proximal descending aorta and mediastinal haematoma (indirect sign). subsequent pre-intervention digital subtracted angiograms in (d) and (h) and respective post tevar images (e) and (i) demonstrating successful treatment of the pseudoaneurysms. figure 7: subclavian artery occlusion and associated haematoma, seen as abrupt cut-off of the right subclavian artery in image (a), better demonstrated in image (c) maximum intensity projection reformat and image (d) 3d volume rendered image, with the arrow. figure 8: thick arrows in (a) and (b) demonstrate an azygous arch pseudoaneurysm and surrounding mediastinal haematoma. arrows in (c) and (d) in the same patient show anterior wall irregularity (indirect sign) in the lower thoracic aorta. in view of the known high mortality and morbidity related to thoracic vascular injuries, particularly with active bleeding (contrast extravasation), time becomes a crucial factor in detection of these vascular injuries and prompt implementation of definitive management, before serious complications unfold.4 mdct angiogram is the gold standard imaging modality and has shown enormous capabilities in injury diagnosis.4,5,11,12 in our setting, the radiology resident trainees, who are almost always the first image interpreters, need to be familiar with the direct and indirect signs of the vascular injury spectrum on mdct. the use of multiplanar display in image interpretation enhanced by maximum intensity projection (mip) has been proved to significantly aid the injury detection (figure 6).5,11,17 blunt aortic injury imaging spectrum is variable and many authors classify the injuries differently.19 however, the consistent characterisation is that of indirect aortic injury signs and direct signs. direct imaging features of aortic vascular injuries include rupture with contrast extravasation (grade iv injury), pseudoaneurysm (grade iii injury) which is an outpouching contained within the adventitia, intramural haematoma or dissection (grade ii injury) and intimal tear/ flap (grade i injury), which appears as a thin filling defect with or without adherent thrombus (figures 4, 5 and 6).14 indirect signs include peri-aortic haematoma and wall irregularity or abrupt calibre change.5,11,12,13,20,21 we noted the most frequent aortic findings or injury combinations of indirect signs commonly manifesting with periaortic haematomas, followed by grade iii injury (pseudoaneurysms), some of which had a co-existing finding of intimal flap in our patients (table 3). generally, the grade i aortic injuries or findings of indirect signs are managed conservatively with anticoagulants where necessary, and adequate follow up is important because it is reported that approximately half of the intimal tears of greater than 1 cm will progress to pseudoaneurysms within 8 weeks.4,9,19 one of our patients with a grade ii injury could not be found for a follow up and another demised. there has been a growing trend with enormous benefits of actively treating the higher aortic injury grades with an endovascular aortic stent graft (also known as thoracic endovascular aneurysm repair [tevar]) rather than open surgery which poses physiological challenges and prohibitive costs.20 figure 2 depicts the frequency of non-aortic great vessel arterial injuries in our study, with the subclavian artery being the commonest. the reported blunt vascular injury imaging spectrum of findings in non-aortic injuries includes intimal flap or non-stenotic luminal filling defect, wall thickening reflecting intramural haematoma or dissection, wall irregularity, reduced calibre, focal outpouching or pseudoaneurysm, complete occlusion, transection, arteriovenous fistula formation and an associated perivascular haematoma.17,22 occlusion has been reported to be the commonest blunt trauma manifestation in the common carotid artery.17 we also observed complete vessel occlusion to be the most frequent injury in the non-aortic great vessel injury in our patients, and it was also the common finding in all cases with common carotid artery involvement (figure 2b). the second frequent finding was intimal flap, followed by other less frequent signs such as wall irregularity, reduced calibre and perivascular haematoma (figure 2b). there was a single count of a pseudoaneurysm with surrounding haematoma which, however, occurred concurrently with an aortic pseudoaneurysm in the same patient, which were all managed with endovascular stenting as per current standard management (figure 9). figure 9: right subclavian artery pseudoaneurysm. thick arrows in (a), (b) and (c) demonstrate a large lobulated contained contrast extravasation in keeping with subclavian artery pseudoaneurysm, with a surrounding haematoma. the arrow in (c) mip reformatted image shows an additional aortic pseudoaneurysm (grade iii). images (d) and (e) are pre-intervention planning images, and these were successfully treated with stenting of the right subclavian artery pseudoaneurysm, coiling of the vertebral artery and stenting of the aortic pseudoaneurysm (f) and (g). occlusion of the carotid artery system carries a high morbidity and mortality, and little can be done if there is already established significant brain infarction.17 in our study, non-aortic injury, particularly of carotid and vertebral arteries, was observed to carry high mortality (figure 2b and 2c). however, there was no endovascular or surgical intervention performed, owing to other fatal extra-thoracic injuries. international literature documents a variety of associated thoracic injuries in patients who sustained blunt vascular trauma. the commonest injury profiles in some patient series included chest wall fractures and pleural based injuries, followed by lung parenchyma injuries (presented as consolidation or contusions or lacerations) occurring moderately, followed by mediastinal injuries and diaphragmatic injuries occuring in lesser frequency than the aforementioned.1,10 in our study, we also recorded several associated non-vascular chest injuries or findings, depicted in figure 3, the commonest being chest wall fractures in both aortic and non-aortic injuries. at face value, it does appear that there is increased likelihood of a vascular injury if there are multiple rib fractures; however, there was no statistical significance established in our study. study limitations and pitfalls the study was performed in a single centre and the sample size is small. there was poor patient follow up in both conservatively and endovascularly managed patients owing to discharge home or to referral base hospitals, which may possibly be related to socio-economic factors. the inherent known limitation of artefacts in ct angiography in emergency trauma patients such as motion artefact and poor window settings during image display and interpretation of the study may yield false positive results (figure 10). in our study, we tried to overcome this by re-evaluating the selected patient images and excluding the patients with false positive findings as per second opinion from a specialist radiologist. we only selected patients with positive vascular findings on ct imaging and therefore false negative results were not assessed. the use of mpr image display can help solve other areas of subtle uncertainty, such as small aortic branches, to avoid misdiagnosis (figure 10a and 10b). although cardiac electrocardiogram (ecg) gated ct angiography is said to minimise motion artefact, it is, however, not a feasible method of examination in an emergency trauma setting. using appropriate window settings improves the sensitivity of diagnosing subtle findings such as an intimal injury or flap and will eliminate misinterpretation of mural calcifications as vascular injury (figure 10e and 10f). this can be achieved by the use of a smooth soft tissue reconstruction ct kernel and the use of a wide window setting (approximately 200 level and 800 width) to allow better visualisation of filling defects or wall calcifications from intravascular dense contrast.23 figure 10: examples of pitfalls in some of our patients. long arrows in (a) and (b) demonstrate a thoracic aorta vessel branch mistaken for a small pseudoaneurysm. image (c) arrow shows an aortic diverticulum with overlying minimal wall calcification. image (d) arrows show motion artefact, not to be mistaken for dissection. arrows in image (e) show apparent aortic wall abnormalities mistaken for post traumatic injury, but on adequate adjustment of window settings these were wall calcifications (f). conclusion a comprehensive knowledge of the spectrum of mdct findings for vascular injuries is needed to improve their detection, and a high index of suspicion that is usually based on the mechanism of injury directs a thorough search for vascular injuries. vascular injuries involved more than one vessel in 12.8% of our cases, alerting radiologists to always search for more than one vessel injury during interpretation of blunt trauma mdct scans. most of our patients were treated conservatively and all our grade iii aortic injuries were treated with tevar with a zero mortality rate, thus indicating a prospect of a promising management outcome with this method of treatment in a small patient cohort. acknowledgements the authors acknowledge catherine connolly for all the statistics support and ialch radiology department for all the support pertaining to research data collection archives. competing interests the authors have declared that no competing interests exist. author’s contributions s.m.l. was the principal investigator and prepared the manuscript. n.n.m.d. was the primary supervisor and b.p. was the co-supervisor; they made conceptual contributions towards the study and participated in the manuscript editing. funding no funding or grants were acquired for conducting this study. very minor costs relating to document printings and meeting appointments were on principal author’s account. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views expressed in this article are those of the authors and not an official opinion of the affiliated institutions. references magu s, yadav a, agarwal s. computed tomography in blunt chest trauma. indian j chest dis allied sci. 2009;51(2):75–81. palas j, matos ap, mascarenhas v, et al. multidetector computer tomography: evaluation of blunt chest trauma in adults. radiol res pract. 2014;article id 864369:1–12. https://doi.org/10.1155/2014/864369 langdorf mi, medak aj, hendey gw, et al. prevalence and clinical import of thoracic injury identified by 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https://doi.org/10.1177/1538574411431648 ait ali yahia d, bouvier a, nedelcu c, et al. imaging of thoracic aortic injury. diagn interv imaging. 2015;96(1):79–88. https://doi.org/10.1016/j.diii.2014.02.003 mirakhur a, cormack r, eesa m, et al. endovascular therapy for acute trauma: a pictorial review. can assoc radiol j. 2014;65(2):158–167. https://doi.org/10.1016/j.carj.2012.09.005 forman mj, mirvis se, hollander ds. blunt thoracic aortic injuries: ct characterisation and treatment outcomes of minor injury. eur radiol. 2013;23(11):2988–2995. https://doi.org/10.1007/s00330-013-2904-0 holloway bj, rosewarne d, jones rg. imaging of thoracic aortic disease. br j radiol. 2011;84 spec no 3(spec iss 3):s338–s354. https://doi.org/10.1259/bjr/30655825 case report tc99m oiphosphonate • • •imaging .glant cell tumours on mop scanning mm sathekge, mj and rp clauss, mbchb department of nuclear medicine ga-rankuwa medunsa abstract tenpatients with histologically proven giant cell tumour (biopsy) were imaged with 3-phase bone scanning, using 99m tc-mop. the perfusion (phase i) and uptake (phase iii) were compared to the normal contralateral side and the rest of the skeleton was inspected for other abnormalities. ninety per cent of lesions showed a doughnut-type pattern of uptake and presented with moderately increased perfusion (2.9 normal ± o. 7) and markedly increased uptake of tracer (7.5 normal ± 1.4). the patient with diffuse uptake had a pathological fracture. introduction giant cell tumour of bone is a primary skeletal neoplasm of unknown cellular ongm." it is an expansile and highly vascular neoplasm that usually arises in the metaphyseal regions oflong bones such as distal femur, proximal tibia and distal radius. it is now believed that the true giant cell tumour (get) is always malignant although it is late to metastasise, it has a high potential for local recurrence. 3 radionuclide bone scan in ga has been used to determine the anatomic extent of the lesion and to detect other skeletal lesions.4 weclescribefeaturestodifferentiategct onradionuclide bone scan from other lesions. materials and methods ten patients (7 males and3 females,mean age 32,6) with biopsy proven gcrwere evaluated using a 3 phase bone scan. 99m tc oiphosphonate (mop) was used as tracer and imaging was performed using a sophy osx camera with a low energy highreselutioncollimator. 700mbq 99mtc mdpwereinjected into an antecubital vein at 60 frames per second (phasel] followed by a pool imageofl minute (phasell), acquired 3 hours later (phase iii).the maximum activity on the perfusion curve (phase dofthepatho3s sa journal of radiology· september 1996 logical side was compared to that of the normal side.maximum uptake (phase iii) in the giant cell tumour was compared with contralateral normal bone uptake by image profile. results of the lopatients, 9 (90%) showed a doughnutpattem, that is markedly increased activity in the periphery of the lesion with a cold centre (figure 1).thepatient with diffuse uptake had a pathologicalfracture.a1l tumours were at least 6cm in size (mean8,6an±2,7) and occurred figure 1: whole body scanwhich shows the lesion with most commonly a cold centre.l.__ .....j in the proximal tibia in 4 patients and distal radius in 2 patients. mean perfusion of the tumour was 2,9 times normal (so ±o,7) while mean uptake was 7,5 times normal (so ± 1,4) see table 1. normalised perfusion curves are shown in figure 2 and perfusion images in figure 3.an image profile of the uptake in table i: results patient ma nj la mg mm tm mj mf me jm gender m m m f f m f m m m age 31 23 18 35 48 19 20 46 36 50 position dh of dr pt dr ph ot pt pt pt size (cm) 8 10 6 7 7 6 8 10 9 15 doughnut n y y y y y y y y y diffuse y n n n n n n n n n fracture y n n n n n n n n n perfusion 2,5:1 4:1 3:1 2,5:1 3:1 2:1 2:1 3:1 4:1 3:1 uptake 7:1 6:1 7:1 6:1 8:1 10:1 9:1 8:1 8:1 6:1 dh • distal humerus of • distal femur dr • distal radius pt • proximal tibia ph • proximal humerus to page 40 tecmednet for customised medical network solutions fda approved ~--------------------dicom 3 compatibility multi-tasking computer system upgradeability for pacs features: teleradiology applications computer radiography applications isdn diginet network solutions pacs applications lan wan networks dicom 3 network linkages high performance configurations cost-effective solutions archive management installed base connectivity medical gateways laser camera connectivity m teemed (ptv) ltdlu.i head office midrand halfway gardens office park, o0 r:i asparagus rood, vorna volley, midrand1.:11 p.o, box 4229, halfway house 1685tel: (011) 315-4874 i}] durban: (031) 701-0311cape town: (021) 592-2464/5/6/7 bloemfontein: (051) 30-4211 tc99m diphosphonate inlaging giant cell tumours on mdp scanning frompage38 the pathological to the normal region is shown in figure 4. figure 2: normalised perfusion curves from regions of interest phase / (dark curve from the contralateral, norma/ bone), figure 3: perfusion 60 frames of 1 second compressed to 15 frames of 4 second (phase i). figure 4: an image profile of the uptake in the pathological to the normal region (phase 1//). discussion giant cell tumour is common between the ages of20 and 40 as confirmed in our series. often patients present with pain following trauma and sometimes with a mass or swelling. a pathological fracture occurs in loper cent of cases. ithe origin of ger iscontroversial.it is formed by multinucleated giant cells within intervening stromal cells and often there is a striking sinusoidal vascular bed with focal telangiectasia, sometimes with changes such as fibrosis, necrosis and cyst formation. 5 osteoblastic activityis usually confined to the peripheral reactive margtn+we noted that ger rarely involves the joint space, as confirmed by other authors. however; not infrequently ajoint effusion may be present. 7 osteoblastic activity with bone formation in the periphery and little or none centrally has been cited as the major reason for the doughnut-type pattem of uptake in giant cell tumours.' other factors such as secondary telangiectasia,cyst formation and necrosis may also contribute to this patten." imagingtechnique also contributes to the ability to demonstrate a doughnut.' some workers believe that lesions should show a doughnut rather than a diffuse pattern with improved techniques.this isshown in our series (9/10 get) and wascorrfumed with speer imaging (figure 5). the differential diagnosis for this type rono legs tone legs toi1o legs tone legs tono l.egs totto legs tono legs toi'io legs tomo legs toho i..£gs toi'lo legs tomo i..egs figure 5: speet images demonstrating a doughnut-type pattern of uptake, of uptake includes aneurysmal cone cyst and nonosteogenic fibroma, which unlike gct, have an unimpressive degree of tracer uptake. we found that the uptake was markedlyincreased while perfusion was moderately increased. the patient with diffuse uptake of tracer in our serieshad a pathological futcture which could explain the obliteration of a doughnut pattem as suggested by other workers? the 40 sa journal of radiology. september 1996 reason for this could be osteoblastic activity with focal tracer accumulation in the centre ofthefutcture.1ogcfsarerarelymulticentric but may occasionally cause skip metastases. ii these fractures are best evaluated by radionuclidescan, thus being helpful with the entire approach to the diagnosis and managementofgcfs. conclusion a doughnutpattemin a metaphyseal region oflong bone withmarkedlyincreased uptake in the periphery and moderate perfusion makesthedifferential diagnosisofgcflikely. however, diffuse pattern can occur,especially in the presence of a pathological fracture or with poor imaging technique. reasons for the doughnut pattern could be increased peripheral uptake due to reactive secondary bone formation or decreased activity in the centre secondary to cyst, telangiectasis or necrosis. radionuclide bone scan is important in the management of eer,especially in caseswith skip lesions and multicentricity. refurenres 1 .apley ag, solomon l; concise system of orthopaedics and /ractures 1988. butterworths pp67 2, dahlin d: giant celltumour. in bone tumours . general aspectsanddatain6221 ruses; 3rded.springfle1d, charlesc, thomas 1987,pp99-1is 3. du toitjg: osteoclastoma :a review of the condition and areportof5 cases. s.aji:mai.j. 1983;64787-791. 4, levine e, et al: scintigraphic evaluation of giant cell tumourofbone:ajr 1984; 143-348 5. goodgold i-im, chen dcp, majd m,etat scintigraphic featuresofgiantcelltumour.clinnudmai.1983;9:526 6.jaffee hl: histogenesis ofbone tumours, tumours ofbone and soft tissue. 8thannual clinical conferenceatthe universityoftexas.lvidandersonl-iospitali963,pp47 7. van nostrand d, madewell je, mcnisch lm, et al: radionuclide bone scanning in giant cell'iurnour: j nud. md 1s€6;2732s-338 8.jaffeehl:tumoursandtumoruusamditionsofdle&mesand loint>, philadelphia, lea and febiger, 1958,ppl8-43 9. krasnow!\z, zsitman at, collier d, et al: flow study and speer irnagingfor the diagnosis of giant cell tumour of bone: clinnudma:11988; 13:89-92 iq, shifrin l z: giant cell tumourofbone. clin orth relres l~ il .peirner ca, chiller al, mankin hj, smith ri: multicentric giant cell tumour of bone. j bone joint surg (am) lffij;62:652-656 abstract introduction pulmonary vein imaging pulmonary vein embryology pulmonary vein normal anatomy pulmonary vein anomalies conclusion acknowledgements references about the author(s) paul cronin department of radiology, division of cardiothoracic radiology, university of michigan medical center, united states aine m. kelly department of radiology, division of cardiothoracic radiology, university of michigan medical center, united states citation cronin p. kelly am. pulmonary venous abnormalities encountered on pre-radiofrequency ablation mapping multidetector computed tomography. s afr j rad. 2017; 21(1), a1189. https://doi.org/10.4102/sajr.v21i1.1189 review article pulmonary venous abnormalities encountered on pre-radiofrequency ablation mapping multidetector computed tomography paul cronin, aine m. kelly received: 21 feb. 2017; accepted: 05 apr. 2017; published: 03 july 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract multidetector computed tomography (mdct) elegantly renders pulmonary venous anatomy. with increasing numbers of radiofrequency ablation procedures being performed, there is now a greater emphasis on pre-procedure imaging to delineate this anatomy. pulmonary venous mapping studies can be performed with or without ecg-gating. however, ecg-gating improves both the quality of 3d images and the accuracy of pulmonary vein (pv) ostial diameter measurements. including the superior thorax, and not just the left atrium and central pvs, allows visualization of aberrant pulmonary venous drainage to the brachiocephalic veins or superior vena cava. normally, there are two superior pvs, one right and one left, and two inferior pvs, one right and one left. the right superior vein usually drains the right upper and middle lobe. the left superior vein drains the left upper lobe including the lingula. the inferior veins drain their respective lower lobe. pv anatomy is more variable than pulmonary arterial anatomy, and developmental anomalies are common. this article describes, illustrates and reviews the common anomalies of the pvs in our experience performing over 1000-pre-radiofrequency ablation cardiac mdct studies. the commonest anomalies are supernumerary or accessory veins (on the right) and a (left) common trunk. more rarely, partial anomalous pulmonary venous return and cor triatriatum are seen, and rarest of all is total anomalous pulmonary venous return, pv varix and single or multiple vein stenosis or atresia. introduction for over two decades, computed tomography (ct) has provided users with precise images of the pulmonary vascular anatomy. more recently, there has been increased interest in the clinical and radiology literature regarding normal or anomalous pulmonary vascular anatomy. with the wide variety of percutaneous endoluminal diagnostic and therapeutic procedures now available, and innovative new procedures such as pulmonary vein (pv) and left atrial ablation performed more commonly, the need to know the normal pulmonary vascular anatomy and common anomalies has increased. there is now a greater emphasis on pre-procedure imaging to delineate anatomy using thin collimation multidetector computed tomography (mdct), which elegantly depicts the precise anatomy. using mdct scans obtained for pv mapping prior to radiofrequency ablation, the common anomalies of the pvs are reviewed. atrial fibrillation (af) is both the most common cardiac arrhythmia and sustained supraventricular arrhythmia. electrical disconnection with catheter ablation within the pv or in the posterior left atrium (la) around the pv ostium is a recognised therapeutic option. pre-ablation imaging is crucial for the effectiveness of the ablation procedure. whether performing vein ablation or employing newer techniques using circumferential extraostial ablation, it is also important to know the ostial orientation and diameter and presence or absence of venous anomalies. to maximize success rates, all veins require ablation. however, anomalous pv ostia are significantly smaller when accessory or larger when a common trunk than the superior or inferior pv ostia. therefore, these vein ablations may require smaller or larger catheters. pre-ablation imaging can minimise catheter-related complications and improve procedural success rates by documenting pv ostial anatomy, ostial sizes and variants. the purpose of this article is to describe the common anomalies of the pvs illustrated with our experience in performing over 1000 pre-radiofrequency ablation cardiac mdct mapping studies. a selection of ct images to illustrate the common anomalies of the pvs is presented. pulmonary vein imaging left atrium and pv mapping using helical ct scanners has been performed since the invention of the mdct scanner using 4-, 8-, 16-, 64and >64-detector scanners. currently, at our institution, patients are scanned on a 64-detector scanner. some institutions use ecg-gating while others do not. ecg-gating can be performed in patients in sinus rhythm. in general, one-third to one-half of patients undergoing these studies cannot undergo ecg-gated examinations because of arrhythmias. as there is both phasic change in pv ostial diameters and phasic change in ostial positions during the cardiac cycle, ecg-gating allows assessment of the pvs at a single phase of the r-r interval, such as 75% r-r, that is, end diastole when there is least cardiac motion and maximal venous distention.1 another advantage of ecg-gating is it improves both the quality of 3d images and the ability to detect thrombus within the la and/or left atrial appendage. a disadvantage of ecg-gating is increased radiation dose. test bolus timing with a region of interest placed in the la can be employed to determine the peak enhancement within the la. non-ionic intravenous contrast material in total administered with a power-injector at a rate of approximately 4 ml/sec–5 ml/sec through an antecubital vein is generally used. the collimation used is approximately 1 mm, with a sub-millimetre reconstruction interval. the heart or the entire thorax may be scanned during a single breath-hold. including the superior thorax, and not just the la and central pvs, allows visualization of aberrant pulmonary venous drainage to the brachiocephalic veins or superior vena cava (svc).1 for an average-sized adult male patient, the effective radiation dose for a scan performed without ecg-gating is approximately 10 msv.1 studies performed with ecg-gating have a radiation dose of approximately 15 msv for prospective gating and 20 msv for retrospective gating. the acquired images can be reviewed as axial data, multiplanar reformatted images or using advanced processing such as volume rendering or endocardiac views. pulmonary vein embryology veins develop in the mesoderm, which first becomes converted into blood islands and later unite to form vessels. the venous system is made up of two main groups of veins, the cardinal system, which drains the body wall, and the vitelline system. the vitelline veins go on to form the pvs, the inferior vena cava (ivc) and the portal vein. the pvs start as a network of capillaries around the lungs. by the fourth week of embryogenesis, the primitive common pv appears as a solid outgrowth from the sinoatrial region of the heart.2 this outgrowth projects caudally and eventually connects with the foregut venous plexus, above where the lung buds will form. at this stage, the foregut has not split into the ventral respiratory tube and dorsal alimentary tube. when this occurs, they acquire separate communications to the heart,2 the alimentary tube via the cardinal veins, which will become the svc and azygos system, and the respiratory tube via pvs, which drain through the common pv into the la. the common pv divides into a right and left branch, which then further bifurcates. later the growing la absorbs the common pv and first order branches resulting in four pvs, the right and left superior and inferior pv.2,3,4 pulmonary vein normal anatomy there are four pvs, two superior pvs and two inferior pvs, one right and one left respectively. the right superior vein usually drains the right upper and middle lobe. the left superior vein drains the left upper lobe including the lingula. the inferior veins drain their respective lower lobe (figure 1).1 figure 1: normal pulmonary vein anatomy displayed on long axis reformatted computed tomography images in a 73 year-old man prior to radiofrequency ablation therapy for atrial fibrillation: (a) right superior pulmonary vein; (b) left superior pulmonary vein; (c) right inferior pulmonary vein; (d) left inferior pulmonary vein; (e) three-dimensional models of normal left atrium and pulmonary vein anatomy showing the right superior pulmonary vein (rspv), right inferior pulmonary vein (ripv), left superior pulmonary vein (lspv), left inferior pulmonary vein (lipv) and left atrium (la); (f) endocardial views of the left atrium and pulmonary veins showing normal anatomy with the right superior pulmonary vein (r sup), right inferior pulmonary vein (r inf), left superior pulmonary vein (l sup) and left inferior pulmonary vein (l inf), with annotation of each pulmonary vein orifice. the pvs are separate from the bronchoarterial bundles, and take a different course/angle as well, especially the superior veins. the right superior pulmonary vein (rspv) passes inferomedially, posterior to the svc and initially anterior to the right pulmonary artery before passing below it to enter the most superolateral aspect of the la. the left superior pulmonary vein (lspv) also passes inferomedially, anterior and in close relationship to the left pulmonary artery, to enter the most superior and lateral aspect of the la near the left atrial appendage. the inferior pvs take a more direct and horizontal course to enter the most inferolateral aspect of the la.1 pulmonary vein anomalies pulmonary vein anatomy is more variable than pulmonary arterial anatomy, and developmental anomalies are common. the developmental anomalies include variations in number, stenosis and dilatations, and abnormal pulmonary-systemic connections as shown in box 1.2,5,6 the commonest anomalies are variations in number, either supernumerary veins or a common trunk. when variations occur, the right side tends to have accessory veins (one or more), and the left side tends to have convergent veins (a short or long common trunk) which drains into the la. marom et al. found that most patients (71%) had two ostia on the right side for upper and lower lobe veins, but 28% had three to five ostia on the right side, which were because of one or two separate middle lobe vein ostia and 2% had a single venous ostium on the right side. most patients (86%) had two ostia on the left side for upper and lower lobe veins, but the remaining 14% had a single left ostium.7 cronin et al. demonstrated that while the majority of patients, 82%, had four pvs, with a superior and inferior ostium on the right and a superior and inferior ostium on the left, 9% had five veins, 4.5% had three veins, 3% had two anomalies and 0.5% had three anomalies.8 the commonest anomalies reported in the literature and in our cohort of patients are outlined in (table 1). box 1: pulmonary venous anomalies. table 1: the commonest pulmonary vein anomalies. pulmonary vein varix pulmonary vein varix is a dilated pv that may be either congenital or acquired.9 its appearance can simulate a lung nodule on chest radiographic images or on contrast material enhanced chest ct.10 pv varix has not been identified in any of our patients imaged with pre-procedure mapping ct examinations. supernumerary veins supernumerary or accessory veins are common. an accessory vein has its own independent atriopulmonary venous junction separate from the superior and inferior pvs. supernumerary veins result from excessive resorption, and most commonly involve a third vein on the right, which usually drains the middle lobe (figure 2). it is reported to be found in, approximately, 1.6% – 26% of individuals.2,7,8,11,12 tsao et al. in a series of 43 cases reported that the right middle lobe vein may drain directly into the la in 23% of patients, share a common ostium to the proximal rspv in 69% of patients and share a common ostium to the proximal right inferior pulmonary vein (ripv) in 8% of patients.12 in another review of 200 consecutive patients referred for ct imaging prior to a radiofrequency ablation procedure for af, the authors found that in 83.5% of patients the middle lobe pulmonary vein (mlpv) drained to the rspv, in 11% of patients it drained into the la (figure 2) and in 5.5% of patients it drained into the ripv (figure 3).8 the ostial diameter of the right middle pv is usually significantly smaller than the four main pvs.8 another common supernumerary variant is an accessory vein draining the superior segment of the right lower lobe directly into the la (figure 4). when present, an accessory pv has a significantly smaller diameter, on average 8 mm compared to the main pvs, 16mm – 17 mm.8 left middle veins are rare occurring in 0.1% – 0.5% of patients in our experience (figure 5). figure 2: supernumerary veins in a 55-year-old man with atrial fibrillation. the middle lobe pulmonary vein has direct drainage into the left atrium: (a) the whole left atrial endocardial view with the right superior pulmonary vein ostium (r sup), right middle pulmonary vein draining directly in to the left atrium (r mid), right inferior pulmonary vein (r inf), left superior pulmonary vein (l sup), left inferior pulmonary vein (l inf) and left atrial appendage (laa); (b) three-dimensional model of the left atrium and pulmonary veins which shows the right superior pulmonary vein ostium (rspv), middle lobe pulmonary vein ostium (rmpv), right inferior pulmonary vein ostium (ripv), left superior pulmonary vein ostium (lspv) and left inferior pulmonary vein ostium (lipv). figure 3: the (a) middle lobe pulmonary vein (arrow) draining directly into the right inferior pulmonary vein; (b) multiplanar reformat. figure 4: supernumerary vein in another patient with atrial fibrillation. a vein draining the superior segment of the right lower lobe pulmonary vein draining directly into the left atrium, 3d view of the left atrium shows the right superior pulmonary vein (rspv), the superior segment of the right lower lobe pulmonary vein (ss ripv), the right inferior pulmonary vein proper (ripv), the left superior pulmonary vein (lspv) and the left inferior pulmonary vein (lipv). figure 5: supernumerary vein in a 52-year-old man with atrial fibrillation, with a left middle pulmonary vein draining the lingula directly into the left atrium: (a) three-dimensional model of the left atrium and pulmonary veins, which shows the left superior pulmonary vein (lspv), left accessory pulmonary vein draining the lingula directly to the left atrium. this is equivalent to an accessory middle lobe vein on the right. this is labelled as the left middle pulmonary vein (lmpv). left inferior pulmonary vein (lipv), right superior pulmonary vein (rspv) and right inferior pulmonary vein (ripv); (b) the left atrial endocardial view which shows the left superior pulmonary vein ostium (lspv), left middle pulmonary vein ostium (lmpv), left inferior pulmonary vein ostium (lipv) and left atrium appendage (laa). multiples of supernumerary veins may also occur including two middle lobe veins (one draining the medial segment and the other draining the lateral segment of the middle lobe) directly into the la (figure 6). combinations of supernumerary veins may also be seen, including two accessory pvs, with one accessory vein draining the middle lobe and another vein draining the superior segment of the right lower lobe directly to the la. combinations and multiples of supernumerary veins may also occur. these include direct drainage of the middle lobe into the la with three ripvs (figure 7). another variation, with two middle lobe veins (one draining the medial segment and the other draining the lateral segment of the middle lobe) draining directly into the la and an accessory vein draining the superior segment of the right lower lobe in addition to the ripv (figure 8). figure 6: multiples of supernumerary veins in another patient with atrial fibrillation, with two middle lobe veins (one draining the medial segment and the other draining the lateral segment of the middle lobe) draining directly into the left atrium. left superior pulmonary vein (lspv), left inferior pulmonary vein ostium (lipv), right superior pulmonary vein ostium (rspv), middle lobe pulmonary vein ostium draining the medial segment of the middle lobe (med mlpv), middle lobe pulmonary vein ostium draining the lateral segment of the middle lobe (lat mlpv) and right inferior pulmonary vein (ripv): (a) three-dimensional model. (b) endocardial view. figure 7: combination of supernumerary veins in a 48-year-old man prior to a radiofrequency ablation procedure for atrial fibrillation: (a) three-dimensional model. there is direct drainage of the middle lobe into the left atrium and three right inferior pulmonary veins. left superior pulmonary vein (lspv), left inferior pulmonary vein (lipv), right superior pulmonary vein (rspv), middle lobe pulmonary vein (mlpv), first right inferior pulmonary vein (1st ripv), second right inferior pulmonary vein (2nd ripv) and third right inferior pulmonary vein (3rd ripv). (b) endocardial view. right superior pulmonary vein (rspv), middle lobe pulmonary vein (mlpv), first right inferior pulmonary vein (1st ripv), second right inferior pulmonary vein (2nd ripv) and third right inferior pulmonary vein (3rd ripv). figure 8: combination of supernumerary veins in another patient with atrial fibrillation, with two middle lobe veins draining directly into the left atrium, and an accessory vein draining the superior segment of the right lower lobe in addition to the right inferior pulmonary vein: (a) three-dimensional model. left superior pulmonary vein (lspv), left inferior pulmonary vein (lipv), right superior pulmonary vein ostium (rspv), first middle lobe pulmonary vein ostium (1st mlpv), second middle lobe pulmonary vein ostium (2nd mlpv), right inferior pulmonary vein (ripv) and accessory right inferior pulmonary vein draining the superior segment of the right lower lobe (ss ripv); (b) endocardial view. right superior pulmonary vein ostium (rspv), first middle lobe pulmonary vein ostium (1st mlpv), second middle lobe pulmonary vein ostium (2nd mlpv), right inferior pulmonary vein (ripv) and accessory right inferior pulmonary vein draining the superior segment of the right lower lobe (ss ripv). common trunk a common trunk occurs when the superior and inferior veins converge to form a single atriopulmonary venous junction. a common ostium for the superior and inferior veins is reported to occur in approximately 2.4% – 25% of individuals.1,7,8,9,11,13,14 most are on the left (figure 9), and a single common left vein is much more common than a common right vein (figure 10). bilateral common trunks have not been described in the literature, and no patient in our experience has had bilateral common trunks. embryologically, this is because of incomplete resorption of the primitive common pv. marom et al. found a left common trunk in 14% of subjects while.7 cronin et al. found a single common left pv trunk in 6.5%, and a single common right pv trunk in two patients (1%).8 when present, a common pv trunk has a significantly larger diameter than normal pvs. cronin et al. also found that a common trunk (mean diameter 24 mm) was statistically larger than the mean diameter of the superior or inferior pvs, and mean right-sided or left-sided pv diameters. a common trunk between the right inferior and left inferior pulmonary veins (lipvs) has been reported. combinations of supernumerary veins with a common trunk are noted (figure 11). figure 9: common left trunk in a 53-year-old woman with atrial fibrillation: (a) three-dimensional image. left superior pulmonary vein (lspv), left inferior pulmonary vein (lipv), left common trunk (lct), right superior pulmonary vein (rspv), right inferior pulmonary vein (ripv), left atrium (la); (b) three-dimensional model. right superior pulmonary vein (rspv), right inferior pulmonary vein (ripv), left common trunk (lct) and left atrial appendage (laa). figure 10: common right trunk in another patient with atrial fibrillation: (a) axial image. right superior pulmonary vein (rspv); (b) three-dimensional model. right superior pulmonary vein (rspv), right inferior pulmonary vein (ripv), right common trunk (rct), left superior pulmonary vein (lspv) and left inferior pulmonary vein (lipv); (c) endocardial view. right common trunk (rct), left superior pulmonary vein (lspv), left inferior pulmonary vein (lipv) and left atrial appendage (laa). figure 11: combination of supernumerary veins with a common trunk. there is a middle lobe vein draining directly into the left atrium and an accessory vein draining the superior segment of the right lower lobe in addition to the right inferior pulmonary vein and common left trunk, endocardial view. right superior pulmonary vein (rspv), middle lobe pulmonary vein (mlpv), right inferior pulmonary vein (ripv), accessory right inferior pulmonary vein draining the superior segment of the right lower lobe (ss ripv) and left common trunk (lct). single or multiple vein stenosis or atresia congenital pv stenosis usually involves multiple veins, is bilateral, is of varying degree of severity and occurs at the ostium, though may extend peripherally.2,12,15,16,17 the exact mechanism is unknown. the stenosis can result in asymmetric vascular distribution and pulmonary edema and kerley b lines. the prognosis is poor and, therefore, congenital stenoses are seen in the paediatric rather than the adult population.2 while non-significant (<50% stenosis) diffuse or focal stenoses can rarely be seen on pre-procedure ct studies, significant single or multiple pv stenosis or atresia has not been identified in any of our patients pre-procedure. pv stenosis is a recognised complication of the pv ablation procedure (figure 12). these stenoses are usually mild; (figure 12a). rarely post procedure stenoses can be severe requiring treatment with angioplasty or stenting, (figure 12b).11 figure 12: (a) a three-dimensional model of a patient: post radiofrequency ablation for atrial fibrillation showing minor stenoses in the left superior and left inferior pulmonary veins (arrow); (b) a three-dimensional model of another patient: post ablation shows stenoses in the right and left superior pulmonary veins severe enough to require stent insertion (arrow). anomalous pulmonary venous return a variety of anomalous pulmonary and systemic connections exists. drainage can be either partial or total. partial anomalous pulmonary venous return (papvr) has an incidence of approximately 0.5%, involves the right lung more frequently than the left lung and is usually hemodynamically insignificant but may be hemodynamically significant when associated with congenital heart disease or scimitar syndrome.18,19,20,21 all papvrs are left-to-right shunts, but the shunt is usually hemodynamically insignificant. anomalous veins of the right lung most often drain the right upper lobe to the svc, and this is the most frequent isolated papvr overall. this is usually associated with a sinus venosus type of atrial septal defect.10 a papvr draining into veins below the diaphragm i.e. the ivc, portal, hepatic, or other, is association with hypoplasia of the right lung and has been called the scimitar, venolobar or hypogenetic lung syndrome. the spectrum of anomalies and prognosis is variable and depends on the size of the left-to-right shunt. anomalous veins of the left lung most often drain the left upper lobe, and this is the most frequent isolated papvr on the left.10 distinction should be made between a left svc and an anomalous vertical pv. an anomalous pulmonary vertical vein drains some or all of the left pulmonary venous drainage, ascends superiorly, and drains into the left brachiocephalic vein. the left svc drains into the heart. in our experience, we have had three patients with right superior papvr, two patients with direct drainage of the rspv to the svc (figure 13), and one with drainage of the rspv and an accessory ripv to the svc via the azygos vein (figure 14). we have had one further patient with a right inferior papvr with drainage of the ripv to the ivc (figure 15). we have also had two patients with a left superior papvr, with the lspv draining to the left brachiocephalic vein via a vertical vein. figure 13: partial anomalous pulmonary venous return in a 49-year-old man. the right superior pulmonary drains directly into the superior vena cava (svc): (a) axial image; (b) oblique coronal image. figure 14: partial anomalous pulmonary venous return in a 51-year-old woman. the right superior pulmonary vein and an accessory right inferior pulmonary vein drain into the superior vena cava (svc) via the azygos vein: (a) axial image; (b) sagittal image; (c) coronal image; (d) oblique axial image. figure 15: partial anomalous pulmonary venous return in a 62-year-old man. one right inferior pulmonary vein drains into the left atrium, and another right inferior pulmonary vein drains into the ivc. right inferior pulmonary vein (ripv), partial anomalous pulmonary venous return (papvr of the ripv) and inferior vena cava (ivc). three-dimensional model. anomalous pulmonary venous return with total anomalous pulmonary venous return (tapvr), there is obligatory interatrial communication through an atrial septal defect or patent foramen ovale. pulmonary vascularity may be increased and there may be cyanosis.10 these abnormal pulmonary-systemic venous connections are best classified based on their embryologic derivation and the anatomy of the anomalous connection. based on this classification, four types are described. (1) supracardiac: (a) into derivatives of the right cardinal system (svc or azygous vein); (b) into derivatives of the left cardinal system (a persistent left svc, vertical vein or left brachiocephalic vein). (2) cardiac: (a) into derivatives of the left cardinal system (the coronary sinus); (b) into the right atrium. (3) infracardiac: (a) into the unbilicovitelline system (the portal vein or ductus venosus); (b) into the ivc. (4) mixed: a combination of two or more of the anomalies described above may occur.4 the supracardiac drainage type of tapvr has drainage to a left vertical vein that extends to the left brachiocephalic vein. the infracardiac drainage type of tapvr, which is the least common type, is associated with severe congestive heart failure. tapvr is associated with asplenia (right isomerism).10 we have not identified any patients with tapvr on pre-ablation mapping ct. cor triatriatum cor triatriatum is a congenital cardiac malformation because of an abnormal connection between the common pv and the atria. it is characterised by the presence of a fibromuscular membrane separating the la into two parts: the upper of the chambers communicates with the pvs and the lower with the mitral valve containing the left atrial appendage.22 with cor triatriatum there appears to be a double atrium, however, the accessory atrium is in fact a dilated primitive common pv which has failed to resorb. the dilatation is because of stenosis of the primitive common pv at the level of the la. it has no clear gender predilection. there is an association with other cardiac defects in up to 50% of cases, the most frequent being atrial septal defects and the second most frequent, anomalous pv return.22,23 severity is variable and clinical manifestations may occur within the first few days of life or be delayed until adulthood depending on severity of pv hemodynamic obstruction.2 the natural history of this defect is dependent on the size of the orifice in the membrane. infants are critically ill and have a poor survival rate without early treatment if ostia are small or not present. if the connection is large or is associated with an atrial septal defect, patients in childhood or young adulthood present with a clinical picture mimicking mitral stenosis with pulmonary hypertension. appearance in adulthood is well-documented22 and usually corresponds to patients with an unrecognised non-obstructive cor triatriatum because of multiple or a large fenestration in the left atrial membrane.22 we have found two patients with incidental unrecognised non-obstructive cor triatriatum (figure 16). figure 16: a fibromuscular membrane (arrow) separating the left atrium into two parts: the upper of the chambers communicates with the pulmonary veins and the lower with the mitral valve containing the left atrial appendage: (a) axial image; (b) endocardial view shows the fibromuscular membrane separating the left atrium into two parts. the lower row of images shows non-obstructive cor triatriatum in another patient, a 28-year-old man with atrial fibrillation, fibromuscular membrane (arrow); (c) axial image; (d) oblique axial image; (e) coronal image. conclusion multidetector ct elegantly renders the pulmonary venous anatomy. with increasing numbers of radiofrequency ablation procedures being performed, there is now a greater emphasis on pre-procedure imaging to delineate this anatomy. using thin collimation mdct, the common anomalies of the pvs can be identified. the commonest anomalies are supernumerary or accessory veins (on the right) and a (left) common trunk. more rarely, papvr and cor triatriatum are seen, and rarest of all are tapvr, pv varix and single or multiple vein stenosis or atresia. acknowledgements competing interests the authors declare that they have no financial or personal relationships, which may have inappropriately influenced them in writing this article. authors’ contributions p.c. and a.m.k. contributed images. the text was written by p.c., with contributions from a.m.k. p.c. and a.m.k. were responsible for drafting the manuscript, which was critically reviewed by p.c. and a.m.k. references cronin p, sneider mb, kazerooni ea, et al. mdct of the left atrium and pulmonary veins in planning radiofrequency ablation for atrial fibrillation: a how-to guide. am j roentgenol. 2004;183(3):767–778. https://doi.org/10.2214/ajr.183.3.1830767 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pulmonary vein drainage patterns on multidetector ct with measurements of pulmonary vein ostial diameter and distance to first bifurcation. acad radiol. 2007;14(2):178–188. https://doi.org/10.1016/j.acra.2006.11.004 vanherreweghe e, rigauts h, bogaerts y, meeus l. pulmonary vein varix: diagnosis with multi-slice helical ct. eur radiol. 2000;10:1315–1317. https://doi.org/10.1007/s003300000381 demos tc, posniak hv, pierce kl, olson mc, muscato m. venous anomalies of the thorax. ajr am j roentgenol. 2004;182(5):1139–1150. https://doi.org/10.2214/ajr.182.5.1821139 scharf c, sneider m, case i, et al. anatomy of the pulmonary veins in patients with atrial fibrillation and effects of segmental ostial ablation analyzed by computed tomography. j cardiovasc electrophysiol. 2003;14:150–155. https://doi.org/10.1046/j.1540-8167.2003.02444.x tsao hm, wu mh, yu wc, et al. role of right middle pulmonary vein in patients with paroxysmal atrial fibrillation. j cardiovasc electrophysiol. 2001;12(12):1353–1357. https://doi.org/10.1046/j.1540-8167.2001.01353.x sato m, tanaka d, nakajo m. meandering pulmonary veins with a common inferior trunk: an anomalous left inferior pulmonary vein entering an anomalous right inferior pulmonary vein. radiat med. 2007;25(8):426–429. https://doi.org/10.1007/s11604-007-0155-1 lickfett l, lewalter t, nickenig g, naehle p. common trunk of the right and left inferior pulmonary veins: previously unreported anatomic variant with implications for catheter ablation. heart rhythm. 2007;4(9):1244–1245. https://doi.org/10.1016/j.hrthm.2007.02.012 adey ck, soto b, shin ms. congenital pulmonary vein stenosis: a radiographic study. radiology. 1986;161(1):113–117. https://doi.org/10.1148/radiology.161.1.3763853 belcourt cl, roy dl, nanton ma, et al. stenosis of individual pulmonary veins: radiologic findings. radiology. 1986;161(1):109–112. https://doi.org/10.1148/radiology.161.1.3763852 saida y, eguchi n, mori k, tanaka yo, ishikawa s, itai y. isolated pulmonary vein stenosis associated with full intrapulmonary compensation. ajr am j roentgenol. 1999;173(4):961–962. https://doi.org/10.2214/ajr.173.4.10511157 gustafson ra, warden he, murray gf, hill rc, rozar ge. partial anomalous pulmonary venous connection to the right side of the heart. j thorac cardiovasc surg. 1980;98:861–868. van meter c jr, leblanc jg, culpepper ws 3rd, et al. partial anomalous pulmonary venous return. circulation. 1990;82(suppl 5):195–198. posniak hv, dudiak cm, olson mc. computed tomography diagnosis of partial anomalous pulmonary venous drainage to the azygos vein. cardiovasc intervent radiol. 1993;16:319–320. https://doi.org/10.1007/bf02629166 dillon eh, camputaro c. partial anomalous pulmonary venous drainage of the left upper lobe vs duplication of the superior vena cava: distinction based on ct findings. ajr am j roentgenol. 1993;160:375–379. https://doi.org/10.2214/ajr.160.2.8424355 almendro-delia m, trujillo-berraquero f, araji o, de vinuesa pg, fernández jm. cor triatriatum sinistrum in an elderly man. int j cardiol. 2008;125(2):e27–e29. erkut b, kocak h, kaygin ma, ceviz n. cor triatriatum associated with severe valvular pulmonary stenosis and patent ductus arteriosus: an unreported constellation. int j cardiol. 2006;113(1):108–110. https://doi.org/10.1016/j.ijcard.2005.08.015 pictorial interlu de 'the ghost in the machine' ian c duncan ffrad (d) sa unitas interventional unit centurion an artefactual image created by superimposition of the temporal bones in a nearlateral projection after mask acquisition and three-dimensional computer-generated reconstruction during a cerebral digital subtraction rotational angiographic study. 36 sa journal of radiology • june 2003 about the author(s) steven meyer department medical imaging and clinical oncology, division of radiodiagnosis, stellenbosch university, south africa richard d. pitcher department medical imaging and clinical oncology, division of radiodiagnosis, stellenbosch university, south africa willem a. groenewald department medical imaging and clinical oncology, division of radiodiagnosis, stellenbosch university, south africa citation meyer s, pitcher rd, groenewald wa. diagnostic reference levels in lowand middle-income countries: early ‘alaram’ bells? s afr j rad. 2017;21(1), a1139. https://doi.org/10.4102/sajr.v21i1.1139 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract diagnostic reference levels in lowand middle-income countries: early ‘alaram’ bells? steven meyer, richard d. pitcher, willem a. groenewald copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: in 1996, the international commission on radiological protection (icrp) introduced diagnostic reference levels (drls) as a quality assurance tool for radiation dose optimisation. although many countries have published drls, available data are largely from high-income countries. there is arguably a greater need for drls in lowand middle-income countries (lmics), where imaging equipment may be older, and trained imaging technicians are scarce. to date, there has been no critical analysis of the published work on drls in lmics. such work is important to evaluate data deficiencies and stimulate future quality assurance initiatives. purpose: to review the published work on drls in lmics and to critically analyse the comprehensiveness of available data. material and methods: medline, scopus and web of science database searches were conducted for english language articles published between 1996 and 2015 documenting drls for diagnostic imaging in lmics. retrieved articles were analysed and classified by geographical region, country of origin, contributing author, year of publication, imaging modality, body part and patient age. results: fifty-three articles reported drls for 28 of 135 lmics (21%), reflecting data from 26 of 104 (25%) middle-income countries and 2 of 31 (6%) low-income countries. general radiography (n = 26, 49%) and computerised tomography (n = 17, 32%) data were most commonly reported. paediatric drls (n = 14, 26%) constituted approximately one-quarter of published work. conclusion: published drl data are deficient in the majority of lmics, with the paucity most striking in low-income countries. drl initiatives are required in lmics to enhance dose optimisation. opinion telemedicine forum being established wê are told that information is the currency of the nineties. information couldsimply be regarded as any data which isuseful.a significant advantage of information in digital format is the ability to utilise that information at two or more differentlocations, markedly increasing its usefulness. intrinsic to the information revolution over the preceding decades have been advancesin computer and telecommunications technology. the single overriding factor in the success of these information technology industries was the use of standardised hardware and software components, ensuring compatibility between a variety of manufacturers, permitting the industry's phenomenal growth. these standards include mechanical and electrical connections, transmission media, electronic signal characteristics and sophisticated software protocols and applications. the ability to capture, process and store information in digital formathas already had a huge impact on radiology. just as in information technology the development cfmedical and radiological standards at various strata has been a critical element in allowing the cohesive and productive evolution oftechnical advances in our profession. the same need for standards must apply to the rapidly germinating field of telemedicine, as a specialized hybrid branch of information technology and medicine. again multiple layers of standards and protocols are required covering physical, electrical and software aspects, but beyond that are the medical and medicolegal considerations. there are atleastthree good practical reasons for developing locally accepted standards firstly, to protect the public and the medical profession; secondly, to allow intercommunication between systems; and thirdly, to avoid obsolescence.already examples of inferior performance ofteleradiology systems have raised the level of anxiety concerning medicolegal action. standards may well differ according to individual circumstances of specific telemedicine systems, with the various permutations of potential links between and within hospitals, practices, clinics and homes. should a set ofbasic southafrican hardware and software standards addressing medical image transmission be pubhshed? should these be verified and certification be implemented? one would envisage that dicom 3 standards would be non-negotiable.digital image andmonitor specifications would probably be the next most important, requiring at least a 2cxxlby 2cxxlmatrix size and 12 bits of contrast resolution for diagnostic chest radiology (and possibly a 4000 by 4000 matrix size for mammography), ideallywith high luminance, flicker-free screens. compression isa more contentious issue, particularly whether it is permissible to aliow'lossy' compression with the attendant irreversible lossof data. intercommunication between various systems andfuture upgrade potential would besharedconcems probably ultimately determined bymarketforces. following a meeting of interested parties in capetown on 20january 1996,proposals 4 sajournal of radiology· september 1996 and discussion on these topics led to the formation of a steering committee on telemedicine which has as its objective the establishment of a national forum on telemedicine. this committee presently consists of dr jan lo12 (chairman), prof steve beningfield (ucf), dr pieter se.rfontein (provincial administration westem cape), dr ashwin hurribunce (sandf), dr stuart rutherfoord (pathologist, university stellenbosch) anddr lennox mathews (advisor, dept ofnational health). private practice, state, provincial, military and academic groups are therefore represented and both radiology and pathology specialties are included.any representatives from other interested groups or specialities would be warmly welcomed the intention of the proposed forum isto represent allinterested parties, acting as a conduit between users of telemedicine and central government. the department of health has already constituted a committee evaluating the appropriateness and application of telemedicine in this country and has been informed of the planned development of the forum.this governmental committee would be the most likely avenue of communication with central structures, and many of these issues are pe.rhapsmore appropriately addressed atthat level. we hope that the proposed national telemedicine forum will serve to help cultivate the discipline required to prevent the devaluation of our own unique currency, medical information. a south african national telemedicine forum homepage can be accessed on internet at the following address: http://www.stm.ac.za! local/academic/ anat path! neuro_path!telemed.html jlotz sjbeningfield http://www.stm.ac.za! about the author(s) kevin daffue department of clinical imaging science, university of the free state, south africa citation daffue k. computed tomography stroke findings and population demographics at pelonomi hospital, bloemfontein. s afr j rad. 2017;21(1), a1122. https://doi.org/10.4102/sajr.v21i1.1122 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: daffue k, joubert g, et al. computed tomography stroke findings and population demographics at pelonomi hospital, bloemfontein. s afr j rad. 2016;20(1), a993. https://doi.org/10.4102/sajr.v20i1.993 conference abstract computed tomography stroke findings and population demographics at pelonomi hospital, bloemfontein kevin daffue copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: stroke remains the highest cause of death in patients more than 50 years old in south africa and the fourth highest cause of death overall. there is a paucity of information regarding this disease in free state province. objectives: to assess the stroke profile of patients referred for computed tomography (ct) imaging to our institution along with evaluating factors that could improve stroke management. method: the demographic information, stroke risk factors, stroke types and time to imaging were evaluated for all patients who presented for ct stroke imaging from july 2014 until july 2015. information was gathered prospectively from the hospital and radiology information systems. results: the study included 174 patients (53.5% women, 46.5% men). their mean age was 59 years (sd 14.6). the most prevalent risk factors were hypertension (83.7%), smoking (20.5%) and diabetes (15.0%). the population group consisted of 67.8% ischaemic (n = 118) and 32.2% (n = 56) haemorrhagic strokes. the majority of patients with a known time of symptom onset (n = 102) presented after 8 h (82.4%). the median order to report time (ort) was 61 min (range 18–1361 min). the median arrival to report time (art) was 32 min (range 4–893 min). conclusion: our stroke population did not differ significantly from others in south africa and africa overall. preand in-hospital delays significantly influenced patient numbers qualifying for thrombolysis. http://www.sajr.org.za open access00 page 1 of 1 reviewer acknowledgement read online: scan this qr code with your smart phone or mobile device to read online. read online: scan this qr code with your smart phone or mobile device to read online. in an effort to facilitate the selection of appropriate peer reviewers for the sa journal of radiology, we ask that you take a moment to update your electronic portfolio on https:// sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajr.org.za 2. in your ‘user home’ [https://sajr.org.za/index. php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this volume of the sa journal of radiology. we appreciate the time taken to perform your review(s) successfully. aadil a. ahmed abdu h. dambatta aine m. kelly ajit k. reddy akhilanand chaurasia alex doruyter amanda louw anil bhaya aruna patil ashesh ranchod ashish verma bukunmi m. idowu chris trauernicht cornelia r. minne dibuseng ramaema eser sanverdi farhana e. suleman franck girard frank a. imarhiagbe gareth bydawell gary reubenson georg wagener halvani moodley hamid o. hamid heleen hanekom jacqueline s. smilg james nuttall jenny edge john r. ouma jurgen h. runge leora sweidan linda t. hlabangana mala modi margaret e. kisansa mariam q. said-hartley matthew d.m. goodier maya patel mike m. sathekge miranda durand muhammad a. makusidi nausheen khan nondumiso n. dlamini pamela smilg paramita hota peter k. schoub rajiv kapur ramy mansour ranjeet jagdale richard d. pitcher sally e. candy sandeep jakhere shalendra k. misser shirley lipschitz sonay aydin sudeep roplekar sughra raza sulaiman moosa sushil g. kachewar thomas adejoh thulani nyathi vijay dahya vishesh sood werner s. harmse willem a. groenewald wim greeff zarina lockhat acknowledgement to reviewers http://www.sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za/index.php/sajr/user https://sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za radiology_aug04 review article 13 sa journal of radiology • august 2004 abstract many different artefacts can occur during magnetic resonance imaging (mri), some affecting the diagnostic quality, while others may be confused with pathology. an artefact is a feature appearing in an image that is not present in the original object. artefacts can be classified as patientrelated, signal processing-dependent and hardware (machine)-related. this article presents an overview of mri artefacts and possible rectifying methods. introduction artefacts remain a problematic in magnetic resonance imaging (mri). some affect the quality of the examination, while others may be confused with pathology. an artefact is a feature appearing in an image that is not present in the original object. depending on their origin, artefacts are typically classified as patient-related, signal processingdependent and hardware (machine)related. it is important to recognise these artefacts and have a basic understanding of their origin, especially those mimicking pathology. in this article emphasis is placed on recognition of artefacts and possible rectifying methods. patient-related mr artefacts motion artefacts motion is one of the most common artefacts in mr imaging, causing either ghost images or diffuse image noise in the phase-encoding direction. the reason for mainly affecting data sampling in the phase-encoding direction is the significant difference in the time of acquisition in the frequencyand phase-encoding directions. frequency-encoding sampling in all the rows of the matrix (128, 256 or 512) takes place during a single echo (milliseconds). phase-encoded sampling takes several seconds, or even minutes, owing to the collection of all the k-space lines to enable fourier analysis. major physiological movements are of millisecond to seconds duration and thus too slow to affect frequency-encoded sampling, but they have a pronounced effect in the phase-encoding direction. periodic movements such as cardiac movement and blood vessel or csf pulsation cause ghost images, while non-periodic movement causes diffuse image noise (fig. 1). ghost image intensity increases with amplitude of movement and the signal intensity from the moving tissue. several methods can be used to reduce motion artefacts, including patient immobilisation,1 cardiac and respiratory gating,2 signal suppression of the tissue causing the artefact,1 choosing the shorter dimension of the matrix as the phase-encoding direction, view-ordering or phase-reordering methods3 and swapping phaseand frequency-encoding directions1 to move the artefact out of the field of interest. flow flow can manifest as either altered intravascular signal (flow enhancement or flow-related signal loss), or flow-related artefacts (ghost images or spatial misregistration). flow enhancement, also known as inflow effect, is caused by fully magnetised protons entering the imaged slice while the stationary protons have not fully regained their magnetisation. a short overview of mri artefacts l j erasmus mb chb d hurter mb chb m naudé mb chb h g kritzinger mb chb department of diagnostic radiology university of the free state bloemfontein s acho mmedsc department of medical physics university of the free state bloemfontein fig. 1. motion artefact (t1 coronal study of lumbar vertebrae). the fully magnetised protons yield a high signal in comparison with the rest of the surroundings. high velocity flow causes the protons entering the image to be removed from it by the time the 180-degree pulse is administered. the effect is that these protons do not contribute to the echo and are registered as a signal void or flow-related signal loss (fig. 2). spatial misregistration manifests as displacement of an intravascular signal owing to position encoding of a voxel in the phase direction preceding frequency encoding by time te/2. the intensity of the artefact is dependent on the signal intensity from the vessel, and is less apparent with increased te. metal artefacts metal artefacts occur at interfaces of tissues with different magnetic susceptibilities, which cause local magnetic fields to distort the external magnetic field. this distortion changes the precession frequency in the tissue leading to spatial mismapping of information. the degree of distortion depends on the type of metal (stainless steel having a greater distorting effect than titanium alloy),4 the type of interface (most striking effect at soft tissue-metal interfaces), pulse sequence and imaging parameters. metal artefacts are caused by external ferromagnetics such as cobalt containing make-up, or internal ferromagnetics such as surgical clips, spinal hardware and other orthopaedic devices. manifestation of these artefacts is variable, including total signal loss, peripheral high signal and image distortion (figs 3 and 4). reduction of these artefacts can be attempted by orientating the long axis of an implant or device parallel to the long axis of the external magnetic field, possible with mobile extremity imaging and an open magnet.5,6 further methods used are choosing the appropriate frequency encoding direction, since metal artefacts are most pronounced in this direction,4 using smaller voxel sizes,5 fast imaging sequences,6 increased readout bandwidth5,6 and avoiding gradient-echo imaging when metal is present.5 a technique called mars (metal artefact reduction sequence) applies an additional gradient, along the slice select gradient at the time the frequency encoding gradient is applied.5 signal processingdependent artefacts the ways in which the data are sampled, processed and mapped out on the image matrix manifest these artefacts. chemical shift artefact chemical shift artefact occurs at the fat/water interface in the phase encoding or section-select directions (fig. 5). these artefacts arise due to the difference in resonance of protons as a result of their micromagnetic environment. the protons of fat resonate at a slightly lower frequency than those of water. high field strength magnets are particularly susceptible to this artefact.7 determination of the artefact can be made by swapping the phaseand frequency-encoding gradients and examining the resultant shift (if any) of the tissues. partial volume partial volume artefacts arise from the size of the voxel over which the signal is averaged. objects smaller than the voxel dimensions lose their identity, and loss of detail and spatial resolution occurs. reduction of these artifacts is accomplished by using a smaller pixel size and/or a smaller slice thickness. review article 14 sa journal of radiology • august 2004 fig. 2. flow-related signal loss in the carotid and basillary arteries (t2 axial study of the brain). figs 3 and 4. metal-related artefacts. fig. 5. chemical shift artefact: bright and dark streaks around the kidneys in an axial gradientecho opposed-phase image (acknowledgement ge health care). wrap around this artefact is a result of mismapping of anatomy that lies outside the field of view but within the slice volume. the selected field of view is smaller than the size of the imaged object. the anatomy is usually displaced to the opposite side of the image (figs 6 and 7). it can be caused by non-linear gradients or by undersampling of the frequencies contained within the return signal. the sampling rate must be twice the maximal frequency that occurs in the object (nyquist sampling limit). if not, the fourier transform will assign very low values to the frequency signals greater than the nyquist limit. these frequencies will then ‘wrap around’ to the opposite side of the image, masquerading as low-frequency signals. in the frequency encode direction a filter can be applied to the acquired signal to eliminate frequencies greater than the nyquist frequency. in the phase encode direction, artefacts can be reduced by an increasing number of phase encode steps (increased image time). for correction, a larger field of view may be chosen. gibbs phenomenon (ringing artefact) this is caused by the under-sampling of high spatial frequencies at sharp boundaries in the image.8,9 lack of appropriate high-frequency components leads to an oscillation at a sharp transition known as a ringing artefact. the artefact occurs near the sharp boundaries, where high contrast transitions in the object occur. it appears as multiple, regularly spaced parallel bands of alternating bright and dark signal that slowly fade with distance (fig. 8). ringing artefacts are more prominent in smaller digital matrix sizes. methods employed to correct gibbs artefact include filtering the kspace data prior to fourier transform, increasing the matrix size for a given field of view, the gegenbauer reconstruction and bayesian approach.10-12 machine/hardware-related artefacts this is a wide, still expanding subject and should be discussed separately. only a few common artefacts that should be recognised are mentioned. when in doubt, however, a technician should be consulted. radiofrequency (rf) quadrature13 rf detection circuit failure arises from improper detector channel operation. fourier-transformed data display a bright spot in the centre of the image. if one channel of the detector has a higher gain than the other it will result in object ghosting in the image. this is the result of a hardware failure and must be addressed by a service representative. external magnetic field (b0) inhomogeneity14 b0 inhomogeneity leads to mismapping of tissues. inhomogeneous external magnetic field causes either spatial, intensity, or both distortions. intensity distortion occurs when the field in a location is greater or less than in the rest of the imaged object (fig. 9). spatial distortion results from long-range field gradients, review article 15 sa journal of radiology • august 2004 figs 6 and 7. wrap around artefacts. fig. 8. gibbs artefact (t1 sagittal study of the brain). fig. 9. b0 inhomogeneity: intensity distortion across a t1 axial study of the lumbar vertebrae. which remain constant in the inhomogeneous field. gradient field artefacts (b1 inhomogeneity)15 magnetic field gradients are used to spatially encode the location of signals from excited protons within the volume being imaged. the slice select gradient defines the volume (slice). phaseand frequency-encoding gradients provide the information in the other two dimensions. any deviation in the gradient would be represented as a distortion. as the distance increases from the centre of the applied gradient, loss of field strength occurs at the periphery. anatomical compression occurs and is especially pronounced on coronal and sagittal imaging. when the phase-encoding gradient is different, the width or height of the voxel are different, resulting in distortion. anatomical proportions are compressed along one or the other axis. square pixels (and voxels) should be obtained. ideally the phase gradient should be assigned to the smaller dimension of the object and the frequency gradient to the larger dimension. in practice this is not always possible because of the necessity of displacing motion artefacts. this may be corrected by reducing the field of view, by lowering the gradient field strength or by decreasing the frequency bandwidth of radio signal. if correction is not achieved, the cause might be either a damaged gradient coil or an abnormal current passing through the gradient coil. rf inhomogeneity15 variation in intensity across the image may be due to the failure of the rf coil, non-uniform b1 field, nonuniform sensitivity of the receive only coil (spaces between wire in the coil, uneven distribution of wire), or presence of non-ferromagnetic material in the imaged object. asymmetrical brightness14 there is a uniform decrease in signal intensity along the frequencyencoding axis. signal drop-off is due to filters that are too tight about the signal band. some of the signal generated by the imaged section is, thereby, inappropriately rejected. a similar artefact may be caused by non-uniformity in slice thickness. rf noise14,15 rf pulses and precessional frequencies of mri instruments occupy the same frequency bandwidth as common sources such as tv, radio, fluorescent lights and computers. stray rf signals can cause various artefacts. narrow-band noise is projected perpendicular to the frequency-encoding direction. broadband noise disrupts the image over a much larger area. appropriate site planning, proper installation and rf shielding (faraday cage) eliminate stray rf interference. zero line and star artefacts. a bright linear signal in a dashed pattern that decreases in intensity across the screen and can occur as a line or star pattern, depending on the position of the patient in the ‘phase-frequency space’. zero line and star artefacts are due to system noise or any cause of rf pollution within the room (faraday cage). if this pattern persists, check for sources of system noise such as bad electronics or alternating current line noise, loose connections to surface coils, or any source of rf pollution. if a star pattern is encountered, the manufacturer should readjust the system software so that the image is moved off the zero point. stars/zippers. although less common, stars/zippers are bands through the image centre due to an imperfect faraday cage, with rf pollution in, but originating from outside, the cage. residual free induction decay stimulated echo also causes stars/zippers. rf tip angle inhomogeneity15 these are patchy areas of increased or decreased signal intensity. this artefact is produced by variations in rf energy required to tip protons 90 or 180 degrees within the selected slice volume. bounce point artefact15 absence of signal from tissues of a particular t1 value is a consequence of magnitude sensitive reconstruction in inversion recovery imaging. when the chosen t1 equals 69% of the t1 value of a particular tissue, a bounce point artefact occurs. use phase-sensitive reconstruction inversion recovery techniques. surface coil artefacts (attenuation of signal)15 close to the surface coil the signals are very strong resulting in a very intense image signal (fig. 10). further from the coil the signal strength drops rapidly due to the attenuation with a loss of image brightness and significant shading review article 16 sa journal of radiology • august 2004 review article to the uniformity. surface coil sensitivity intensifies problems related to rf attenuation and rf mismatching. slice-to-slice interference14 non-uniform rf energy received by adjacent slices during a multi-slice acquisition is due to cross-excitation of adjacent slices with contrast loss in reconstructed images (fig. 11). to overcome these interference artefacts, include the acquisition of two independent sets of gapped multi-slice images, subsequently reordered during display of the full image set. references 1. elster ad, burdette jh. questions & answers in magnetic resonance imaging. 2nd ed. st. louis: mosby, 2001. 2. huda w, slone rm. review of radiologic physics. philadelphia: lippincott, williams & wilkins, 1995. 3. nguyen td, ding g, watts r, wang yi. optimization of view ordering for motion artifact suppression. magn reson imaging 2001; 19: 951-957. 4. suh js, jeong ek, shin kh, et al. minimizing artifacts caused by metallic implants at mr imaging: experimental and clinical studies. am j roentgenol 1998; 171: 1207-1213. 5. chang sd, lee mj, munk pl, janzen dl, mackay a, xiang qs. mri of spinal hardware: comparison of conventional t1-weighted sequence with a new metal artifact reduction sequence. skeletal radiol 2001; 30: 213-218. 6. viano am, gronemeyer sa, haliloglu m, hoffer fa. improved mr imaging for patients with metallic implants. magn reson imaging 2000; 18: 287-295. 7. smith rc, lange rc, mccarthy sm. chemical shift artifact: dependence on shape and orientation of the lipid-water interface. radiology 1991; 181: 225-229. 8. elgavish ra, twieg db. improved depiction of small anatomic structures in mr images using gaussian-weighted spirals and zero-filled interpolation. magn reson imaging 2003; 21: 103112. 9. lee sj. an improved method for reduction of truncation artifact in magnetic resonance imaging. proceedings of spie: applications of digital image processing 1998; 4360: 587-598. 10. archibald r, gelb a. a method to reduce the gibbs ringing artifact in mri scans while keeping tissue boundary integrity. ieee trans med imaging 2002; 21: 305-319. 11. bakir t, reeves sj. a filter design method for minimizing ringing in a region of interest in mr spectroscopic images. ieee trans med imaging 2000; 19: 585-600. 12. schultz rr, stevenson rl. a bayesian approach to image expansion for improved definition. ieee trans med imaging 1994; 3: 233-242. 13. holden m, breeuwer mm, mcleish k, hawkes dj, deevil sf, hill dl. sources and correction of higher-order geometrical distortion for serial mr brain imaging. proceedings of spie 2001; 4322: 69-78. 14. bushberg jt, seibert ja, leidholdt jun. em, boone jm. the essential physics of medical imaging. baltimore: williams and wilkins, 1994. 15. pusey e, lufkin rb, brown rk, et al. magnetic resonance imaging artifacts: mechanism and clinical significance. radiographics 1986; 6: 891911. fig. 10. surface coil artefact: high signal at anterior thoracic wall adjacent to surface coil. fig. 11. slice-to-slice interference (t1 axial study of lumbar vertebrae). original article reporting the small bowel examination dj solomon ffrad (d) sa levin & partners constantiaberg mediclinic cape town introduction relative to the upper gastrointestinal tract and colon, diseases of the small intestine are relatively rare. outside of a dedicated gastrointestinal unit requests for investigation of the small bowel are infrequent, limiting the interest and diligence of the radiologist performing the small bowel examination. ultrasound, ct and more recently mr all contribute to assessment of small bowel pathology but generally the initial request is for a barium small bowel examination. technique many small bowel examinations are performed by conventional follow-through, with or without intermittent fluoroscopy during transit of barium through the small bowel. this procedure is limited by the narrowing of the lumen caused by drug-induced transit acceleration, causing crowding of the mucosal folds and a false appearance of nodularity. it cannot test distensibility of the lumen, and early mural infiltration or subtle stenoses may be missed. the small bowel enema (sbe) should be the investigation of choice. discomfort caused during intubation must be appreciated and the radiologist should be sensitive to the patient's need for reassurance, adequate topical anaesthesia and mild sedation if required. the hypotonia induced by jejunal distention allows for display of all distended loops to the end of the examination and folds are straightened, making it possible to determine morphological normality. the examination is quicker and importantly more frequent fluoroscopy may show intermittent segmental dilatation, indicating subtle stenoses (fig. i). fig. 1. intermittent segmental dilatation in a patient with multiple stenoses due to small bowel lymphoma. the report interpreting and reporting the small bowel investigation depends on a knowledge of normal morphology and understanding the clinical history. morphologic normality is based on observation of the fold pattern (valvulae conniventes), lumen diameter and wall thickness. fold density is higher in the jejunum (4 7 folds per inch) and gradually reduces to the ileum (2 4 4 sa journal of radiology • february 2003 folds per inch). fold thickness is greater in the jejunum (2 mm), being thinner and shallower in the ileum (1 mm). it is important to measure fold thickness during adequate lumen distention. lumen diameter is somewhat technique-dependent but generally considered to be up to 4.5 cm in the jejunum and 3.5 cm in the ileum. wall thickness must be assessed when two adjacent loops are parallel to each other over a length of 5 cm and should be approximately 2 mm for a single wall thickness. transit time through the small bowel is variable and may be influenced by factors such as infusion rate, presence of food content and a loaded caecum. objective criteria have been defined but should only be applied when the infusion rate can be controlled by a mechanical pump. assesment is made after 300 ml have been infused at 75 ml/min, with normal motility regarded as the jejunum having filled with approximately one-third of loops in contraction, hypermotility when greater than two-thirds ofloops are in contraction, and hypomotility when the jejunum has not yet filled and few loops are in contraction. however, few radiologists have the use of a mechanical infusion pump and transit time is generally made subjectively. as with all radiological investigations, reporting a study should depend on the clinical indication for the procedure and the questions asked by the referring doctor. the commonest indications for a small bowel examination are: (i) assessment of crohn's disease; (ii) diarrhoea or malabsorption states; (iii) partial mechanical small bowel obstruction; and (iv) obscure git bleeding. original article crohn's disease to confirm the presence or absence of crohn's disease on the basis of history or prior studies requires a dedicated and detailed examination of the terminal ileum, assessing it in varying degrees of distension and compression. a normal report may state: 'normal small bowel mucosal and fold patterns. the terminal ileum has a normal appearance and no features to suggest crohn's disease have been demonstrated: having decided that the examination is abnormal the following features need to be mentioned in the report. 1. are the abnormal features specific for crohn's disease, and if not a differential diagnosis should be given. if the changes are non-specific it is important not to make a definitive radiological diagnosis of crohn's as the label may remain with the patient for life. (fig. 2). 2. describe the nature and estimated length of involvement. 3. identify and characterise proximal skip lesions. 4. does the appearance of a stenosis .suggest active inflammation which will respond to medical treatment or is it a smooth tapered fibrotic stricture with proximal dilatation that may require surgery. 5. identify complications such as a fistula or features to suggest an adjacent abscess. each of these questions should be answered in the report as they have an important bearing on the clinician's choice of management. fig. 2. non-specific nodular rr:~cosal s"!elling in the terminal ileum due to yersmla enteritis. diarrhoea/malabsorption states most pathological conditions of the small bowel that cause malabsorption are due to some form of mucosal infiltrate although other conditions such as lymphangectasia, jejunal diverticulosis, scleroderma and coeliac disease should be considered. therefore the following points should be reflected in the report of a small bowel examination in this clinical setting: (i) are there diverticulae? (ii) are the folds thickened, and if so is this regular or nodular, segmental or diffuse?; (iii) abnormality of fold density; and (iv) bowel shortening. partial mechanical small bowel obstruction here the aim is to identify stenotic lesions in the small bowel. stenoses usually have a non-specific appearance but the likely cause may be inferred from the characteristics of the stenosis and the patient's history. the following features may help to narrow down the differential diagnosis: (i) the site of the stenosis; (ii) single or multiple stenoses; (iii) degree of proximal dilatation; and (iv) other small bowel abnormalities, in particular an abnormal terminal ileum which may indicate crohn's disease. git bleeding the sensitivity of the small bowel examination in this clinical setting is low but a sbe is usually requested before proceeding to angiography. the report in this situation should reflect the following points: (t) is there a meckel's diverticulum? (ii) mucosal mass and its nature, e.g. a cavitating lesion may represent melanoma, lymphoma or leiomyosarcoma whereas a polypoid lesion may reflect a benign polyp or a melanoma metastasis; and (iii) focal mucosal distortion as seen in the presence of a vascular malformation. conclusion the pathological spectrum of small bowel disease is wide, and other than the pathognomonic features of crohn's disease, all abnormalities have a differential diagnosis that should be interpreted in conjunction with the patient's clinical history and consultation with the referring doctor. the report should be kept as simple as possible with positive and negative findings reflecting the radiologist's understanding of the clinical problem. 5 sa journal of radiology • february2003 pdf file opinion 'the medium is the message. this is mere/y to say that the personal andsocial consequences of any medium that is, of anyextensionof ourselves result from the new scale that is introduced into our affairs by each extension ofourselves, orbyanynew technology. " marshall mcluhan (1911-80), canadianoornmunications theorist. urderstanding media, (1964). '"tis education forms the common mind, just as the twig is bent, the tree's inclined. " ajexanderpope (1688-1744), english satirical poet. epistle to cobham. sj beningfield ljbpanmstjt iii r8d/tjitjgy, flitiiiite 8t:1iujjp 1itjbpjt1ll, cape tllwn syou've just splashed out on a fancy new computer system with all the bells and whistles cd-rom drive, sound card, modem, plenty of ram etc., and have survived the stress of getting windows 95 up and running and talking to most of your hardware. what's in it for your radiology education? is there any software worthwhile parting with your hardearned cash for, and will it really make you a better radiologist?some years ago i remember hearing an educational expert saying that he believed that computers were excellent for testing knowledge but not for teaching it.was he correct when it comes to radiology? to be fair to the new kid on the block, we are only beginning to plumb the depths of the technology. the high technical demands of the visual data in radiology images stresses all but the top of the range computer systems. image quality on standard pc monitors, although reasonable, can 't hope to match that of the standard radiograph. colour, video and animation have yet to be utilised to their full potential in multimedia radiology. sound reproduction is really only of direct 24 sa journal of radiology. march 1996 relevance in doppler topics, although it does also humanise and soften the application's interface with the user. speed of response is a critical factor responses of under a second can totally change the nature of an interaction, transforming it from a sluggish wade through treacle to an exciting and stimulating interchange of inputs and replies. unless one uses a really fast, ram-crammed pentium and a high speed cd-rom drive, the tedium of waiting for images to appear can only be usefully countered by brewing a cup of coffee or reading a page in grainger and al1ison. threedimensional imaging makes especially severe demands on computer hardware, meaning that unless one spends tens of thousands of rands on state-of-the-art workstations, one can't view these images in anything like human-friendly form. on the other hand, peter mayle in his recently re-released "expensive things" illustrates the human tendency to be dissatisfied with whatever one has, where nothing is good or perfect enough, particularly if one already has it all. this human weakness finds fertile ground in the computer world where speed, speed and more speed is the ultimate goal, driving users obsessively from one upgrade to the next. computer phobia is another hurdle which potentially isolates the new media from a sizeable chunk of the population. the reason for this phenomenon must be an area ripe for research itis always intriguing to me how clear the divide between computerphobes and computerphilesis. yetitis odd th at even as a selfconfessed computer fan i arn seldom drawn to spend much time at computer exhibits at congresses. is this because they lack the immediate gratification of conventional media such as books, joumals or video, or is one just as unlikely to sit down and read an article on mr! of the shoulder at a congress as to spend half an hour going through a multimedia exhibit on the sametopic.? oris it because a limited range of predetermined interactions is likely to be available, or that one balks at the effort of mastering the operational basics of a particular exhibit? complete searchable textbooks on cd-rom, such as resnick's multivolume "diagnosis of bone and joint disorders" are being released with increasing frequency. the gamut of list-type books is also eminently suitable for computerisation, with dalmert's "radiology review manual"beingreleased on cd-rom inapril this year. one has to question though, whether the purchase of some of these isn't to fulfil a psychological need to feel omnipotent, to be in control of all the information by dint of possessing it, while suspecting that you will never read or view most of it? i'm sure the same often applies to textbooks. the main advantage of software media must be the ability to structure sophisticated searches to produce customised output, compared to the more limited search permutations with books. the ability to search selectively with elaborate criteria is a major benefit as seen with the resounding success of computerised literature searches. being able to interact meaningfully with information and produce personalised extracts of relevant material, being able to "cut-and-paste' selected text or images is very convenient i have to confess thatthe quotes used here were lifted straight from microsoft's "bookshelf'95" cdrom one of the areas which seems to me to be especially suited to computerisation, particularly animation, is the principles ofmri physics. although some software packages allow the input ofsequence parameters and show the resulting mr! image, they do this without delving into the physics minefield. none to my knowledge have capitalised on the potential of displaying the various spin sequences tllpage80 opinion vvhither breast • • •imaging in south africa? ij movson mbchb, dmrd (london) consultant radi%glst, department of radiology, addmgton hospital, university of nata/ weare living in an age of sophisticated technology in which the explosion of scientific data and research is tending to overwhelm us. itis an age in which it is becoming impossible for one person to have an indepth knowledge of every branch of radiology. we need to keep a sense of pro portion, a sense ofbalance. the philosophy of using a machine gun to shoot a fly instead of a fly swatter is an expensive one. people are not even aware that they are practising this philosophywhich is unrealistic in this age of cost consciousness. this is especially relevant in southafrica where the health budget is limited, and will be so for a longtime. the breast is a skin appendage with straightforwardanatomy with arelatively urnited nurnber of pathologies affecting it. for practical purposes the whole of mammography is dedicated to the early diagnosis ofbreast carcinoma, in an attempt to influence favourably the prognosis andsurvival rate of this common disease which affects approximately 10% of the female population. the fact that there is such a plethora of mammographic publications in every radiological journal, shows how little we understand the disease andhowrelativelyprimitive is our ability to diagnose this condition early. in spite of all the modalities we have, the antidpated reduction of mortality ofbreast carcinomain a screened population is 30%. this is substantial but illustrates once again, how inadequate our current knowledge is, because 70% of the targeted population has not been helped. my remarks are to emphasise the need for a realistic cost effective approach. film screen mammography themainstay of the diagnosis ofbreast disease will for a long time depend on a foundationmade up of three layers: • clinical examinations • ftlmscreenmammography • ultrasound in selling real estate we all know that the three most important factors in selling a home are location, location, location. in marnmographywe also have three important factors for success, namely dedication, dedication, dedication, this dedication must start with the radiolcgstundertakingmammographywho must be familiar with every facet of the subject. he or she must know how to achieve the best possible diagnostic radiograph with the equipment available. the technical side of mammography including quality control, is welldocurnented. the radiologist must work step by step with the radiographer in the production of the mammogram, which means tailoring views required to solve a particular problem. mostofusdoingmammographyin 4 sajournal of radiology. november 1996 south africa are self taught, and this includes our radiographers. specialised courses forradiographe.rs and radiologists are not freely available in south africa. most of us have learned by trial and error. having visited mammographic centres in britain and the usa, i am convinced we can produce excellent work by our dedication to mammography. ifyou cannot send yourradiographers on dedicated courses, try to send her to a local mammography centre where good work is being done. there is an excellentvideo film which was produced by the american college of radiology. it is worth purchasing this video which can be repeatedly reviewed by the mammographers in your department. this video becomes a readily available hands-on teacher for all the staff doing mammography, especially for those in relatively isolated situations (american college ofradiology). radiologists should also try to visit dedicated centres overseas, and ifthis isnotpossible,visitlocal centres dedicated to good work we have to be constantly self critical, and to constantly review the quality of our work it is amazing with intelligent experience, how quality does improve. try to do double readingwherever possible. ifthis is not possible, keep your problem cases aside and discuss them with another colleague involved in mammography. the question of whether a radiologist should be involved in breast examination of the patient remains controversial. i personallystrongly believe that this should be done. in our department, after the mammogram has beenreviewed by the radiologist, the patient is informed that we prefer to examine the patient and that after the examination we again review the mammogram to decide whether we require further views or ultrasonographyforfurther elucidation, weknowthatinasmanyas ls%ofcases, a clinicallypalpable mass maynotbe detected at mammography. by constantly practising clinical examination together with the topage5 whither breast irnaging in south africa? frompage4 mammographic and ultrasonographic findings at hand, the dedicatedmammographer can become skilled in interpretation of breast disease. on occasions a carcinoma missed by the surgeon or by an experienced gynaecologist is found by the radiologist because he or she has the added advantage of seeing the mammogram before examining the patient. this holistic approach to medicine is worth striving for. young people under the age of30years are not infrequently sent to our department. doctors often do not understand the limitations and undesirability of doing mammography at such an early age. under these circumstances, we refer the patient to a breast surgeon for opinion. the examination is initially limited to a medio-lateral oblique view. the cranio-caudal view is only done if it is felt that this view will be contributory. we often complement this investigation with a breast ultrasound examination. if there is a strong family history of breast carcinoma at an early stage, i.e. the patient's mother or sister had a carcinoma at an early age, our criterion for not undertaking the mammogram is not so strict. itisimportantto establish a rapport with one's referring colleagues and to assure them that we are not competing with them we· are after all,on the same side,namely the side of the patient. as a radiologist, i do not think it is our duty to supersede the referring surgeon in giving advice. itis best to leave this to the doctor who is treating the patient. i always explain this to the patient and this can avoid unpleasantness with one's colleagues. itis always important to obtain a followup histological report of all cases which have had a biopsy. this is the best way to learn and to get perspective of which way our assessment of mammograms is going. i would like to comment on a fewpractical points which are of relevance and are contributory towards achieving excellence: 1.a dedicated viewing box is an essential requirement for adequate mammography. if you do work without such a box, the difference with one is unbelievable. most ordinary boxes have a weaker light than the dedicated box. this results in underillumination of the mammogram. i am sure that all radiologists involved in mammography will confirm that underillumination and underpenetration of the breast associated with inadequate compression of the breast are very important reasons for the missed diagnosis of breast carcinoma. adequate processing is of course absolutely essential. 2.with regard to exposure factors, we try and work within the 100-200 mas range. we have found we get our most diagnostic studies in the range. with experience, the radiographer can adjust her initial kv reading and density to obtain the above mas. 3.1t is important to choose a radiographer with empathy for her patients to do mammography. the patients coming for mammography are amongst the most frightened and apprehensive in the world frightened about the procedure and apprehensive, with good reason, about the outcome of the examination. "is this cancer doctor"? is the standard question we are askeel. mammography currently remains an art in spite of all the scientific background for this procedure. ultrasonography ultrasonography' of the breast is an absolute necessity in any mammographic department. for some time the main use of ultrasonography has been in differentiating solid from cystic lesion, but not absolutely for a solid lesion. where possible, one should have available high resolution real-time equipment, preferably linear array transducers of 7-10 mhz frequency. the technique of ultrasound of the breast is well documented, the ideal situation would be for the 5 sajournal of radiology. november 1996 mammographer doing the clinical and mammographic examination to also be able to do the ultrasound examination. for many reasons this is not always possible. ultrasound is a modality useful in solving mammographic and clinical problems. it is universally not accepted as a breast screening modality at this point in time. it is most often used in assessing indeterminate masses with well defined or poorly seen margins. when a mass is palpable and not visible on a mammogram, especially in the dense breast, ultrasound is used to differentiate solid from cystic lesions. if solid, biopsy may have to be considered. with modern equipment one can diagnosecysts 2-3 mmindiarneter. itisimportant to realise that large deeply situated cysts within a large fatty breast may remain undetected. calcified circumscribed masses do not require an ultrasound examination. they are usually due to an involuting fibroadenoma. pleomorphic microcalcification with a mass usually requires a biopsy to exclude malignancy. ultrasound is useful to assess inflammatory disease and to assist in the diagnosis of breast abscessor post surgical fluid collection. more and more radiologists are trying to make a definitive diagnosis ofbreast carcinoma by ultrasound, but according to the literature, ultrasound has too high a false negative rate, to be acceptable as a screening modality. it also cannot detect nne micrccalclfications as well as mammography can. ultrasound also has a distinct false positive rate. ultrasound is now being used for guided aspirations, core biopsy and needle localisation of solid lesions visible at ultrasound. ultrasound guided mammotomy a new technique of ultrasound guided mammotomy is being developed. a new biopsy device, a mammotome, uses a topage6 whither breast imaging in south africa? fram page 5 vacuum within a tissue transport mechanism, enablingmultiple tissue sampling with one insertion of the instrument under ultrasound guidance. this method gives a better and more accurate sampling ofbreast tissue suspicious of malignancy. colour dopp'ler ultrasouncl the principle of this technique' isbased on the fact that tumours larger than a few millimetres stimulate neovascularisation. these give rise to flow signals which can be detected as high velocity signalsof a specific nature. high velocity flow is detected only in malignancies. there is the potential with this technique to differentiate malignant from benign lesions. cancers as small as 10 mm are found to be positive for flow signals. recently there has been the addition of a micro bubble contrast agent for colour doppler ultrasound. anew agent, levovist (shu s08a; scheringag) has been developed, and contains micro bubbles small enough to cross the lung barrier. this technique increased the sensitivity and specificityoffour patients to 100% enabling the accurate differentiation of benign masses from carcinoma.this work in progress is very exciting and hopefully will have a great future. other methods ofbreast imaging are as follows: xeromammography this modality, which was popular for several years, has been phased out by the excellence of modem film screen equipment. xeromarnmography is no longer used in south africa. y technetium 99-m sestarnibi is being used experimentally to try and improve the sensitivity and specificity in the diagnosis of breast carcinoma. this compound is a cardiac perfusion agent which accumulates in myocardial tissue in proportion to the regional coronary blood flow'. the effectiveness is as yet unknown and is not a method for general use at this stage. digital mammography computer ~ided diagnosis this modality is in the developmental stage and may well have a great future. "thus far no artificial intelligence system that derives its input directly from a mammographic image has been shown to improve accuracy of diagnosis beyond that of an unaided radiologist". the role of mri in assessing and managing 6reast disease "the value ofmri for breast cancer is as yet not widely accepted by the medical community, let alone the public. finally,the cost of contrast enhanced magnetic resonance imaging and scarcity of magnetic resonance units capable of performing an adequate breast study prohibits examination of even a fraction of the adult female population" .6 i think this one sentence describes in a succinct way the current status of this modality, very applicable to our situation in south africa. it would appear that there is a consensus of opinion that mr! should be confined to certain difficult cases,and that decisions in clinical management must be made together with mammographic and clinical information. position emission tomography pet pet is a very specialised expensive form of nuclear medicine not readily availablefor general use in this country in the foreseeable future. the current opinion is that pet may have an important role as a 6 sa journal of radiology. november 1996 non-invasive early indicator oftreatrnent efficacy,andmaytherefore have a role in planning chemotherapy. 7 conclusion different methods of breast imaging have been described. some have been discarded and some are in the investigative and developmental stage. some of these are time consuming and expensive. they can only be done in special cases. research must continue, and hopefully our diagnosis of breast carcinoma will be successful at an early stage. for practical purposes however, we have to rely on modalities which are affordable and accessible to most people, in a country such as ours and probably the world at large. these modalities are mammography and ultrasonography. references 1 valerie p, jackson md. the current role of u1trasonographyinbreastlmaging rcnavol33, no 6; novtmi:x:y1955. 2 parkersh, dennis ma, stavrosat,johnson ki<. ultrasound guided mammotomy-a new breast biopsy terlmiqueldmsl2: 113-118;mayt1une 1996. 3 keder rp, cosgrove 0, mcready vr, bamber kc, carter er: micro bubble contrastagent for color doppler us: effect on breastmasses. work in progress: radi· duu.1996; 198:679-686. 4 khalkhali, cutrone ja, mena lg et al. scintimammography:the complementary roleoficppm sestamibi prone breast imaging forthe diagnosis of breastcarcinoma.rat/idogy 1995: 196;421-426. 5 stephenageig&martinjyaffedigitalmammography, computer aided diagnosis, andtelemammography. rcnanovtmi:x:y 1995:p1205. 6 teresa a coons, phd mrl's role in assessing and managingbreastdisease.rmli%gia:dtlólno/nty,march! april1996.vol67:no4;p311-336. 7 dorit 0, adler and l wahl rl: new methods for lmagingthe breast. techniques, findings and potential. air, 1995;164: 19-30 star abstract imaging in oncology from unknown primary to therapy response assessment lawrence h schwartz md imaging the unknown primary the management from both a clinical and radiological perspective of patients who present with metastases of unknown primary origin is a clinical challenge, despite an increasing number of imaging modalities available to image these patients. the importance of correctly identifying the site of primary tumor relates to the therapeutic approach to these patients and the differences in survival based upon finding and treating the primary tumor. unknown primary tumors actually encompass a heterogeneous group of tumors with various clinical presentations, imaging features, treatments and outcomes. one of the most common presentations of unknown primary is in the enlargement of cervical lymph nodes. other common presentations include axillary adenopathy, ascites, bone or marrow metastases. because of the heterogeneous nature of this tumor, some have advocated whole body imaging techniques, while others have advocated focused imaging based upon the site of initial suspicion and any other clinical information which may help the radiologist differentiate sites of tumors. in patients that present with enlargement of cervical lymph nodes, palpation and localization may be helpful in determining the site of the primary tumor. additional sonographic guided needle aspiration may provide additional information. specifically, the type of malignancy; squamous, undifferentiated or adenocarcinoma may be determined which will help define the site of primary tumor. in approximately 12% of patients, the primary tumor site cannot be located in patients who present with cervical lymphadenopathy. ct and mri playa role in evaluation of the neck in all these patients, increasingly, however whole body imaging is being used. initial studies suggest that fdg pet scanning for the detection of unknown primary cancer may be helpful. in one study, pet revealed pathologic accumulations of fdg in 27 of 53 patients. another subset of patients with unknown primary cancers present with axillary lymph node metastases. mri may prove to be the imaging 18 sa journal of radiology • december 2002 modality of choice in patients presenting with axillary adenopathy positive for adenocarcinoma but negative physical examination and negative mammogram. although treatment is controversial, most patients undergo mastectomy. in a study at mskcc 16 patients who presented with biopsy proven adenocarcinoma to the axilla were evaluated with breast mri. the primary breast cancer was identified on mri in 12/15 (80%). there was one false positive and no false negative examinations. with knowledge of the mri results, il patients underwent ultrasound and 9/11 (82%) were identified on ultrasound. whether these lesions would have been found on ultrasound without knowledge of the mri results is uncertain. as ultrasound is more widely available and less costly than mri, a comparison of these two modalities would warrant further study. breast mri performed for breast cancer detection requires the use of a contrast agent and relies on the inherent vascularity of malignant breast lesions. the problem is that benign lesions can also be vascular and demonstrate enhancement. therefore, false positives can pose a significant problem in interpretation of the exam. fibroadenomas, recent scars, proliferative and non-proliferative fibrocystic changes, inflammatory processes, atypia, radial scar, and lcis can all demonstrate enhancement. imaging in therapy response assessment the response of tumors to therapeutic agents such as chemotherapy and radiotherapy is commonly assessed on radiologic images. star abstract radiologic images provide critical information about changes in tumor size on serial examinations performed prior to, during, and after chemotherapy or radiation therapy regimens. such an assessment cannot reliably be obtained from physical examination in most cases,yet is essential for determining whether or not the particular therapy is benefiting the patient, or whether a particular experimental therapeutic agent is effective against a specific tumor. the remainder of this talk will be to review techniques using conventional and novel imaging modalities to assess therapy response, including computed tomography (ct), magnetic resonance imaging (mri) and positron emission tomography (pet). clinical questions such as which modality to use, how many lesions to measure, and what technique to measure will be addressed. comparison will be made between currently used criteria for therapy response and the value of newer techniques including pet and mri perfusian kinetics will be discussed. the world health organization (who) response assessment criteria was set up in 1979 to standardize the recording and reporting of response assessment for solid tumors so that the response outcomes can be compared between various research organizations, trials, and therapies. even though a tumor is three dimensional, the response assessment is performed on the basis of measurements from cross sectional scans in two dimensions. after therapy, the percentage reduction or percentage increase in the corresponding measurements is used for calculating response assessment. who criteria recommended the change in the cross product as the method for evaluating therapy response. several changes in the who criterion have been recognized over time resulting in situations where responses are no longer comparable. the various sources of variabilities have been in the definition of 'measurable' and 'evaluable' lesion, the minimum lesion size and the number of lesions to be recorded for patients with multiple lesions, the definition of progressive disease, and the processing and analysis of imaging data from relatively new technologies such as ct/mr!. disease progression as defined by a 25% increase is used by some groups as the increment in a single lesion and the change in the total tumor burden by others. in 1994, several organizations, such as the european organization for research and treatment of cancer, belgium, national cancer institute, usa, and others started to review these issues with the intent of revising the who criterion based on the experience and knowledge accumulated since its initiation. under these principles, response evaluation criteria in solid tumors (recist) guidelines have been published. three primary changes made were 1) adopting uni-dimensional measurement (in terms of a tumor's maximum diameter) as the underlying metric for response assessment, 2) making the cutoff point for definition of progressive disease higher, and 3) specifying very dear cut guidelines about minimum lesion size and the number of lesions to consider for response assessment of a patient with multiple lesions. the minimum lesion size at which a tumor will be considered measurable is decided as >=20 mm for conventional imaging modalities 19 sa journal of radiology • december 2002 (x-ray, ct, mri) and >=10mm for spiral ct scan. these cutoffs are imposed to avoid measurement error. all measurable lesions up to a maximum of 5 per organ and 10 lesions in total, representative of all involved organs are to be used for response assessment. response data from several trials were re-analyzed by both criteria to assess the extent of agreement between them. james et al analyzed 569 patients accrued on 8 phase ii and phase iii studies of various cancers and reported a kappa coefficient of 0.95 as a demonstration of excellent agreement between the response and non-response categories as assigned by who and recist criteria. only 12% less patients were found to move to the sn category from the progression category (n=128) due to the stricter recist definition of progressive disease. we have seen greater differences between recist and who. in a group of 25 patients on clinical trials, there was a significant difference in percentage change in measurement of tumors using uni-dimensional measurement compared to bi-dimensional cross-products. the therapeutic response assessment in 20% (5/25) of patients would be changed if unidimensional measurements were used and in 8% (2/25) of patients if volumetric measurements were used. there was no statistically significant difference in cross-product or area response assessment, nor would any therapeutic response be reclassified if area calculation was used instead of cross-product. there are also other methods of assessing therapy response, including the use of pet scanning and functional mri. these will be discussed, 1. 2. 3. 4. 5. 6. ..... ~ 7. ~ ~ ~ 8. '-oj '-oj::s ~ ~ ~::. ~ ::sc ~ ~...... -t:.~ ~ i star abstract compared and contrasted with more standard techniques outlined above. suggested reading miller ab,hoogstraten b, staquet m, et al. reporting results of cancer treatment. cancer 1981; 47: 207-214. therasse p, arbuck sg, eisenhauer ea, et al. new guidelines to evaluate the response to treatment in solid tumors. j natl cancer inst2000; 92: 205-216. james k, eisenhauer e, christian m, et al. measuring response in solid tumors: unidimensional versus bidimensional measurement, j natl cancer inst 1999; 91: 523-528. dachman ah, maceneaney pm, adedipe a, et al. tumor size on computed tomography scans: is one measurement enough? cancer 2001; 91: 555-560. schwartz lh, ginsberg ms, decorato d, et al. evaluation of tumor measurements in oncology: use of film-based and electronic techniques. clin onc2000; 18(10): 2179-2184. ea morris, lh schwartz, mb drotman, sj kinl, lk tan, l liberman, af abramson, kj van zee, and dd dershaw. evaluation of pectoralis major muscle in patients with posterior breast tumors on breast mr images: early experience. radiology 2000; 214: 67. ea morris, lh schwartz, dd dershaw, kj van zee, af abramson, and l liberman. mr imaging of the breast in patients with occult primary breast carcinoma. radiology 1997; 205: 437. kb bohuslavizki, s klutmann, and s kroger. fdg pet detection of unknown primary tumors. j nt/cl med 2000; 41: 816. abstract introduction case report discussion conclusion acknowledgements references about the author(s) denny mathew department of radiology, university of the witwatersrand, south africa heliodora de lima helen joseph hospital, johannesburg, south africa rahima moosa mother and child hospital, johannesburg, south africa nasreen mahomed department of radiology, university of the witwatersrand, south africa department of radiology, rahima moosa mother and child hospital, johannesburg, south africa south african society of paediatric imaging, cresta, south africa citation mathew d, de lima h, mahomed n. embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient – a rare cause of obstructive jaundice. s afr j rad. 2019;23(1), a1662. https://doi.org/10.4102/sajr.v23i1.1662 case report embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient – a rare cause of obstructive jaundice denny mathew, heliodora de lima, nasreen mahomed received: 04 sept. 2018; accepted: 28 oct. 2018; published: 10 jan. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract rhabdomyosarcoma (rms) is the most common soft-tissue sarcoma in the paediatric age group, ranking fourth in frequency after central nervous system tumours, neuroblastomas and nephroblastomas. embryonal rms of the biliary tree is considered a rare entity, with the most common clinical presentation being that of obstructive jaundice. we present the case of a 4-year-old boy who presented with hepatomegaly and obstructive jaundice. biochemically, there was evidence of elevated ductal enzymes with conjugated hyperbilirubinaemia. the magnetic resonance imaging (mri) features were consistent with a biliary rms with the differential diagnosis of a choledochal cyst initially included based on the computed tomography images. the diagnosis of embryonal biliary rms was later confirmed on histology. this case illustrates the importance of considering malignant aetiologies in paediatric cases of obstructive jaundice, as this entity is infrequently described in the literature and may mimic the appearance of a choledochal cyst. the demonstration of enhancement of intraductal material within the biliary tree on mri and the presence of arterial waveforms within the intraductal mass on ultrasound assists in the differentiation between biliary rms and a choledochal cyst. introduction rhabdomyosarcoma (rms) is a malignant tumour of skeletal cell morphology, with the most common sites in the paediatric population being the head and neck, genitourinary system and extremities.1,2,3 embryonal biliary rms is considered a rare entity with only about 50 cases being described in the literature, the largest being a series involving 25 patients over a period of 25 years.2 given the low incidence of biliary rms, the diagnosis is challenging, making the imaging evaluation of particular importance in defining the site of origin and tumour extent.3 in addition, as a result of the sheltered location of these masses, they are discovered very late, as in our patient, making it difficult to determine the precise organ of origin, and further complicating the diagnosis and potential management.1 this case report aims to highlight this diagnosis and justify the inclusion of biliary rms in the differential diagnoses of a child presenting with obstructive jaundice.3,4 case report a 4-year-old boy presented with a 3-month history of yellow discolouration of his eyes, dark urine and pale stools as well as a 2-month progressive history of abdominal distension. on physical examination, he was pale, had scleral icterus and the abdomen was distended with a large palpable liver. on the day of his admission, serology revealed elevated liver ductal enzymes with conjugated hyperbilirubinaemia, an elevated international normalised ratio (inr) and iron deficiency anaemia. the abdominal ultrasound (us) demonstrated a heterogeneous periportal mass with internal flow on colour doppler and associated dilatation of the common bile duct (cbd), cystic duct, gall bladder and intrahepatic bile ducts. a computed tomography (ct) scan of the abdomen and pelvis with an intravenous and oral contrast agent showed a large (60 mm × 45 mm × 89 mm), fusiform-shaped mass with heterogeneous contrast uptake, parallel to the expected course of the cbd (figure 1), with the superior aspect not separable from the adjacent porta hepatis or proximal central bile ducts (figure 2). the portal vein was partially attenuated with no evidence of tumour thrombosis. the medial border of this mass was separable from the pancreas, with the lateral border deviating and partially compressing the d1 and proximal d2 segment of the duodenum with no features of bowel obstruction. inferiorly, the mass extended just below the inferior pole of the right kidney. the aorta was slightly displaced to the left but not attenuated and the inferior vena cava (ivc) partially attenuated with no tumour thrombus. there was secondary diffuse intrahepatic bile duct dilatation and marked dilatation of the gallbladder and cystic duct. the pancreatic duct was also dilated throughout its course. ascites was present and there was no evidence of metastases to the liver, lung or visualised bone, but associated enhancing para-aortic and mesenteric nodes were noted. the prostate gland, scrotal sac and contents were normal. figure 1: axial post contrast computed tomography image at the level of the origin of the superior mesenteric artery (white arrow) demonstrating a fusiform-shaped mass (black arrows) with heterogeneous contrast uptake, parallel to the expected course of the common bile duct. associated findings of prominent intrahepatic bile ducts and a dilated pancreatic duct. figure 2: coronal post contrast computed tomography image demonstrating a heterogeneous mass within the common bile duct (black arrows) with the superior aspect not separable from the adjacent porta hepatis or proximal central bile ducts (white arrow). magnetic resonance imaging (mri) of the abdomen and magnetic resonance cholangiopancreatography (mrcp) with contrast were of added value in better delineating the origin and extent of the mass already suspected of being bile duct in origin on ct. the lesion filled the dilated cbd (figure 3) and demonstrated asymmetric mural thickening of the cbd (figure 4). there was associated dilation of the gallbladder and a small calculus was noted within the dilated cystic duct (figure 4). the contrast-enhanced mri demonstrated heterogeneous enhancement within the solid components of this mass. magnetic resonance cholangiopancreatography illustrated a dilated cbd with a large filling defect as well the previously noted findings of dilated intrahepatic bile ducts and pancreatic duct (figure 5). figure 3: coronal t2-weighted magnetic resonance imaging illustrating a fusiform-shaped mass arising within the common bile duct (black arrows) extending superiorly to the level of the porta hepatis. this mass is largely hyperintense on t2-weighted imaging with patchy regions of hypointensity, likely secondary to coagulative necrosis. figure 4: axial t2-weighted magnetic resonance imaging demonstrating asymmetric mural thickening of the common bile duct (black arrows) with dilation of the gallbladder and a small calculus (white arrow) within the dilated cystic duct. figure 5: coronal magnetic resonance cholangiopancreatography shows distension of the gallbladder with dilated intrahepatic bile ducts, cystic duct and pancreatic duct. the common bile duct is dilated with a large filling defect (black arrows) and no normal calibre common bile duct is visualised distally. the mri features were consistent with a biliary rms with the differential diagnosis of a choledochal cyst initially included based on the ct images. the patient was taken to theatre where the ascites was drained and the peritoneal cavity inspected. a solid heterogeneous mass was found within the dilated cbd. in addition, there was a periportal lymph node mass as well as peritoneal wall deposits. multiple tissue biopsies were sent off for histopathological evaluation. microscopy confirmed the presence of a high-grade malignant tumour consisting of primitive mesenchymal cells of varying phases of myogenesis with a variable content of rhabdomyoblasts. the immunohistochemical features were in keeping with embryonal rms with positive stains of periodic acid-schiff (pas), desmin, myogenin and myod1. there were representative sections that showed that the tumour infiltrated into the fibrovascular connective tissue as well as evidence of angiolymphatic infiltration. perinodal soft-tissue extension was noted; however, no biliary mucosa was present for assessment. the immunophenotypic features were in keeping with embroyonal rms with the probability of bile tract origin based on imaging and intraoperative findings. the patient then received post-operative chemotherapy and was initiated on cycle 1 of the vice protocol which included vincristine, isosfamide, carboplatin and etoposide. unfortunately, a few days after initiating treatment, the patient became very ill in the ward. his abdomen became very tense and distended which caused splinting of the diaphragm. he subsequently developed respiratory distress and demised. discussion rhabdomyosarcoma is the most common soft-tissue sarcoma in the paediatric age group and represents 5% – 10% of all malignant solid tumours in childhood.1 rhabdomyosarcoma ranks fourth in frequency among childhood tumours after central nervous system tumours, neuroblastomas and nephroblastomas.1 embryonal rms was first described by wilks and moxon in 1875 on the basis of the typical location and gross description of the tumour.4 in the intergroup rhabdomyosarcoma studies i–iv between 1972 and 1998, of all the cases of rms, only 0.5% of cases involved the biliary tree.3 the international classification of rhabdomyosarcoma (icr) provides a prognostically relevant classification that includes histological subtypes as being of superior prognosis (botyroid and spindle cell rms), intermediate prognosis (typical embryonal rms) and poor prognosis (alveolar rms).5 in the paediatric population, the two main histological subtypes of rms are embryonal and alveolar, with embryonal rms accounting for nearly 70% of all cases and usually affecting children less than 8 years of age.1,6 histopathologically, rms is characterised by myoblastic differentiation and expression of skeletal muscle markers, such as desmin, myogenin and/or myod1.6 the median age of presentation of embryonal rms is 3 years, with a slight male predominance.7 the most common clinical presentation is that of obstructive jaundice, which is seen as a presenting symptom in 60% − 80% cases, and may be accompanied by hepatomegaly, abdominal distension and acholic stools.7,8 this is frequently also accompanied by elevated liver enzymes and conjugated bilirubin.3 less commonly, pain, nausea, vomiting and fever may also be noticed.2 unlike rms at other sites, rms of biliary pathology usually suggests embryonic origin, and in children, there are no neoplasms that arise from the bile duct other than rms.7 obstructive jaundice in the paediatric population beyond the neonatal period may be secondary to choledochal cysts, choledocholithiasis, strictures as a result of chronic cholangitis and rarely neoplasms such as biliary rms.3 abdominal us is typically the initial imaging study performed in any patient presenting with obstructive jaundice. in our patient, this demonstrated a soft-tissue mass in the region of the porta hepatis with adjacent mass effect and intrahepatic bile duct dilatation. computed tomography and mri/mrcp was then used to better delineate the site of origin, assess the tumour extent and evaluate for metastatic lesions. magnetic resonance imaging and mrcp confirmed a mass originating within the biliary system that enhanced heterogeneously, followed the signal characteristics of muscle on t1-weighted imaging and was hyperintense on t2wi. haemorrhage and necrosis may be apparent in larger lesions of biliary rms and the imaging features of central tumour necrosis may mimic the appearance of a choledochal cyst.3 previous case reports have alluded that biliary rms is often misdiagnosed as a choledochal cyst on imaging.3 demonstration of enhancement of intraductal material within the biliary tree on mri and the presence of arterial waveforms within the intraductal mass on us assists in the differentiation between biliary rms and choledochal cyst filled with sludge.3 the presence of regional nodal disease or distant metastases on imaging at the time of diagnosis is of added value in considering a neoplasm as the primary cause of the obstructive jaundice.3 the current treatment modalities include a combination of surgical removal, radiation and chemotherapy.2 although gross total excision is not always possible, the prognosis remains relatively good which is probably owing to the favourable histology.2 neoadjuvant chemotherapy followed by resection of the residual tumour has been associated with good outcomes.3 conclusion biliary rms is a rare entity but should be included in the differential diagnosis of any child presenting with obstructive jaundice.9 imaging plays an important role in the diagnosis and management of this malignancy as well as in differentiating it from a choledochal cyst. the prognosis and long-term survival of biliary rms has improved with advances in surgery, radiotherapy and chemotherapy. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution d.m. was responsible for the review of literature, review of the imaging studies as well as the write-up and preparation of the case report as per journal requirements. h.d.l. (intern) compiled the clinical and surgical notes, imaging reports and histology results. n.m. was responsible for the diagnosis of the case, interpretation of the imaging studies and editing of the final article. d.m. and h.d.l. share joint first co-authorship. references mahomed n, van wyk m, pather s. an unusual presentation of an intraabdominal rhabdomyosarcoma. sajch. 2011;5(2):60–62. kumar v, chaudhary s, kumar m, gangopadhyay an. rhabdomyosarcoma of biliary tract – a diagnostic dilemma. indian j surg oncol. 2012;3(4):314–316. https://doi.org/10.1007/s13193-012-0186-7 kinariwala dj, wang ay, melmer pd, mccullough wp. embyronal rhabdomyosarcoma of the biliary tree: a rare cause of obstructive jaundice which can mimic choledochal cysts. indian j radiol imaging. 2017;27:306–309. https://doi.org/10.4103/ijri.ijri_460_16 nemade b, talapatra k, shet t, banavali s, muckaden ma, laskar s. embryonal rhabdomyosarcoma of the biliary tree mimicking a choledochal cyst. j cancer res ther. 2007;3(1):40–42. https://doi.org/10.4103/0973-1482.31971 rudzinski er, anderson jr, hawkins ds, skapek sx, parham dm, teot la. the world health organization classification of skeletal muscle tumors in pediatric rhabdomyosarcoma: a report from the children’s oncology group. arch pathol lab med. 2015;139(10):1281–1287. https://doi.org/10.5858/arpa.2014-0475-oa cramer sl, miller al, pressey jg, et al. pediatric anaplastic embryonal rhabdomyosarcoma: targeted therapy guided by genetic analysis and a patient-derived xenograft study. front oncol. 2018;7:1–6. https://doi.org/10.3389/fonc.2017.00327 kitagawa n, aida n. biliary rhabdomyosarcoma. pediatr radiol. 2007;37(10):1059. https://doi.org/10.1007/s00247-007-0531-0 shen ch, dong kr, tao yf, et al. liver transplantation for biliary rhabdomyosarcoma with liver metastasis: report of one case. transplant proc. 2017;49(1):185–187. https://doi.org/10.1016/j.transproceed.2016.11.028 ali s, russo ma, margraf l. biliary rhabdomyoscarcoma mimicking choledochal cyst. j gastrointest liver dis. 2009;18(1):95–97. abstract introduction case report discussion conclusion acknowledgements references about the author(s) manoj mathur department of radiodiagnosis, government medical college, india saryu gupta department of radiodiagnosis, government medical college, india citation mathur m, gupta s. looking beyond the sella: suprasellar infundibular prolactinoma. s afr j rad. 2016;20(1), a1036. http://dx.doi.org/10.4102/sajr.v20i1.1036 case report looking beyond the sella: suprasellar infundibular prolactinoma manoj mathur, saryu gupta received: 14 may 2016; accepted: 24 sept. 2016; published: 22 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this is a case report of a 24-year-old female who presented with galactorrhoea and elevated serum prolactin levels of 150 ng/ml. the intrasellar pituitary gland demonstrated normal morphology and characteristic enhancement. the pituitary stalk was thickened and revealed a non-enhancing lesion on dynamic contrast imaging, which was interpreted as a functioning microadenoma. the patient exhibited significant clinical improvement after initiation of therapy with a dopamine agonist, cabergoline. introduction typically, pituitary adenomas are intrasellar in location, but infrequently, pituitary tumours may occur ectopically within pituitary rests. a pituitary tumour is considered ectopic when the adenoma has no communication with intrasellar pituitary gland.1 ectopic pituitary adenoma was first described by erdheim in 1909.2 these tumours may be functioning or non-functioning. functioning tumours tend to be diagnosed earlier because of the hormonal imbalances they induce. the non-functioning tumours present with symptoms related to local mass effect on neighbouring structures and therefore present later. the hypothalamus and pituitary gland act synergistically via the hypothalamic–pituitary axis. the hypothalamus stimulates the release of all other hormones of the anterior pituitary except for prolactin (prl). the secretion of prl is inhibited by the hypothalamus, and this negative regulatory effect on prolactin is mediated via the release of dopamine into the hypothalamic–hypophyseal portal vessels. both intrasellar and ectopic prolactinomas are usually under feedback regulation by dopamine and its analogues. the principal effects of prl are its role in lactation and reproduction. this article documents a report of an ectopic functioning pituitary microadenoma (microprolactinoma), diagnosed at magnetic resonance imaging (mri). case report a 24-year-old female patient presented with headache, galactorrhoea and menstrual irregularity. her prl levels were elevated at 150 ng/ml (normal reference range is 3–24 ng/ml). growth hormone and thyroid-stimulating hormone levels were normal. there were no visual field defects on perimetry measurements and the visual acuity was normal. radiographs of the cranium were normal and a mri was requested. t1-weighted non-contrast mri demonstrated thickening of the pituitary stalk (figure 1). dynamic contrast-enhanced t1 sagittal (figure 2a) and coronal (figure 2b) images of the sellar and parasellar regions revealed a hypoenhancing microadenoma in the anterior aspect of the pituitary stalk. this tumour was not connected to the intrasellar pituitary gland. the intrasellar pituitary gland was normal in height and signal intensity on both preand post-contrast images with a flat superior contour. the parasellar regions were normal bilaterally. the optic chiasm displayed normal morphology with no evidence of compression, and the sphenoid sinus and clivus were normal in appearance. figure 1: unenhanced t1-weighted image reveals thickening of the pituitary stalk. the adeno and neurohypophysis are visualised in their normal intrasellar location. figure 2: (a) sagittal post-contrast t1-weighted image defines the adenoma in the distal part of the thickened pituitary stalk. the adenoma enhances less than the stalk and the gland; (b) coronal dynamic contrast-enhanced image reveals a hypo enhancing mass in the pituitary stalk. there is no significant compression of the optic chiasm. a diagnosis of an ectopic pituitary microadenoma within the pituitary stalk was made. in view of the elevated prl levels, the adenoma was assumed to be a microprolactinoma and medical treatment with cabergoline was initiated. the patient’s prl levels decreased to 20 ng/ml after 4 months of treatment. however, a follow up mri performed at 4 months revealed no regression in the size of the microadenoma (figure 3). as reduction in prl levels often predates tumour regression, the patient continued treatment with a maintenance dose of cabergoline. figure 3: contrast-enhanced mri performed at an interval of 4 months after initiation of medical treatment with cabergoline revealed no significant regression in the size of adenoma, despite the prolactin levels having returned to normal. the decrease in hormone levels usually precedes the reduction in tumour size. discussion ectopic pituitary adenomas can occur in the suprasellar region, sphenoid sinus, cavernous sinus and clivus.3 the most common location for an ectopic adenoma is the sphenoid sinus, followed by the suprasellar region.3,4 the ectopic location of sphenoid sinus adenomas can be explained by the fact that the rathke’s pouch takes its origin from the primitive pharynx and ascends cranially to form the anterior pituitary. the posterior pituitary and median eminence of the hypothalamus are derived from the neuroectoderm at the base of the forebrain, and the infundibulum or pituitary stalk originates from the ventromedial hypothalamus. as the stalk enters the pituitary, it is enveloped by the pars tuberalis, which is a part of the anterior pituitary. stalk adenomas are postulated to arise from pituitary cell rests within the arachnoid layer covering the stalk.5 alternatively, they can arise from pars tuberalis which covers the stalk anteriorly, close to the pituitary insertion. these cell rests have the potential to develop into an adenoma, even though they do retain the negative feedback regulation by dopamine and its analogues.6 on unenhanced scans, stalk adenomas manifest as thickening of the stalk. the normal stalk measures 3.25 ± 0.56 mm at the level of optic chiasma and tapers down to measure 1.91 ± 0.4 mm at its pituitary insertion.7 after the administration of gadolinium, these tumours typically demonstrate hypo or delayed enhancement, relative to the normal pituitary, and dynamic contrast-enhanced mri is the imaging modality of choice for their diagnosis. alternative aetiologies for stalk thickening include tumours (germinoma, lymphoma and leukaemia), granulomatous conditions (langerhans cell histiocytosis, neurosarcoidosis and tuberculosis) and inflammatory conditions (infundibuloneurohypophysitis).7 turcu et al. studied 152 cases of pituitary stalk lesions in a mayo clinic review study and defined the role of clinical history, biochemical tests and mri morphology in characterising these lesions.8 as dopamine inhibits the release of prl by the anterior pituitary, its analogues, bromocriptine and cabergoline form the mainstay in the medical management of prolactinomas. this treatment also reduces the size of the tumour. following treatment, the prl levels decrease in a matter of days to weeks and precede the tumour shrinkage. this was also observed in our case. surgical treatment is reserved for patients who are refractory to cabergoline or in the presence of significant pressure effect on the optic chiasm. conclusion for a holistic evaluation of the pituitary gland, it is imperative that we examine beyond the sella so that adenomas lurking in ectopic locations do not remain undetected. ectopic pituitary adenomas are best diagnosed by dynamic contrast-enhanced mri. awareness of the various ectopic locations assists in making the correct diagnosis. acknowledgements competing interests the authors declare that they have no financial or personal relationships, which may have inappropriately influenced them in writing this article. authors’ contributions m.m. was the principal investigator who diagnosed the case and did subsequent follow up. s.g. assisted in the write up of the case and helped in follow up as well. references matsuno a, katayama h, okazaki r, et al. ectopic pituitary adenoma in the sphenoid sinus causing acromegaly associated with empty sella. anz j surg. 2001;71:495–498. http://dx.doi.org/10.1046/j.1440-1622.2001.02173.x erdheim j. über einen hypophysentumor von ungewöhnlichem sitz. beitr pathol anat. 1909;46:233–240. appel jg, bergsneider m, vinters h, salamon n, wang mb, heaney ap. acromegaly due to an ectopic pituitary adenoma in the clivus: case report and review of literature. pituitary. 2012;15 suppl 1:s53–s56. http://dx.doi.org/10.1007/s11102-011-0345-9 hong jf, ding xh, wang ss. coexistence of ectopic pituitary adenoma and empty sella in a patient with acromegaly: a case report and review of literature. neurol india. 2012;60:304–306. http://dx.doi.org/10.4103/0028-3886.98517 ueda r, katayama m, yoshida k, kawase t. suprasellar peri-infundibular ectopic prolactinoma. neurol med chir (tokyo). 2003;43:51–54. http://dx.doi.org/10.2176/nmc.43.51 yang bt, chong vfh, wang zc, xian jf, chen qh. sphenoid sinus ectopic pituitary adenomas: ct and mri findings. bjr. 2010;83:218–224. http://dx.doi.org/10.1259/bjr/76663418 hamilton be, salzman kl, osborne ag. anatomic and pathologic spectrum of pituitary infundibular lesions. ajr. 2007;188:w223–w232. http://dx.doi.org/10.2214/ajr.05.2027 turcu af, erickson bj, lin e, et al. pituitary stalk lesions: the mayo clinic experience. j clin endocrinol metab. 2013;98(5):1812–1818. http://dx.doi.org/10.1210/jc.2012-4171 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) denny mathew department of diagnostic radiology, university of the witwatersrand, johannesburg, south africa nasreen mahomed department of radiology, rahima moosa mother and child hospital, university of the witwatersrand, johannesburg, south africa south african society of paediatric imaging (saspi), cresta, south africa citation mathew d, mahomed n. pancreatic kaposiform hemangioendothelioma complicated by kasabach–merritt phenomenon: a rare entity. s afr j rad. 2019;23(1), a1760. https://doi.org/10.4102/sajr.v23i1.1760 case report pancreatic kaposiform hemangioendothelioma complicated by kasabach–merritt phenomenon: a rare entity denny mathew, nasreen mahomed received: 20 may 2019; accepted: 25 june 2019; published: 19 aug. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract primary pancreatic tumours are a rare and unusual entity in children. in this article, we present the case of an 8-month-old girl who presented with obstructive jaundice. the differential diagnosis based on imaging studies was that of a pancreatic vascular neoplasm; however, with the laboratory evidence of kasabach–merritt phenomenon (kmp), this prompted the diagnosis of pancreatic kaposiform hemangioendothelioma. a core biopsy of the pancreatic mass was taken at laparotomy and confirmed this diagnosis. the pancreas is an exceedingly rare site of occurrence for this tumour, with only nine cases being published to date. the clinical, biochemical, imaging and pathological findings are discussed to highlight a rare and potentially life-threatening vascular tumour. keywords: radiology; paediatrics; paediatric surgery; paediatric radiology; pancreas vascular tumours. introduction kaposiform hemangioendothelioma (khe) is a rare, high-flow vascular tumour of infancy or early childhood that was first described by zuckerberg et al. in 1993.1,2 kaposiform hemangioendothelioma is a locally aggressive tumour that may infiltrate the surrounding tissues and is usually of cutaneous origin from the extremities, torso body wall and cervico-facial regions.1 retroperitoneal, mediastinal and visceral organ involvement are rare.1 the incidence of khe based on the cases observed at a large referral centre has been estimated to be 0.07/100 000 children per year, while retroperitoneal khe was reported in no more than 30 cases in the english literature.1,3 the pancreas is an exceedingly rare site of occurrence for this tumour, with only nine cases being published to date.4 we present the case of a pancreatic khe involving the head of the pancreas. case presentation an 8-month-old girl presented with signs and symptoms of obstructive jaundice, with an associated history of progressive abdominal distension. serology revealed elevated liver ductal and transaminase enzymes with conjugated hyperbilirubinaemia, normocytic anaemia, thrombocytopenia and coagulation abnormalities. the liver function test results were as follows: total bilirubin 92 µmol/l (normal range 0–21), conjugated bilirubin 86 µmol/l (normal range 0–6), gamma-glutamyltransferase (ggt) 967 u/l (normal range 1–39), alkaline phosphatase (alp) 1117 u/l (normal range 124–341), alanine transaminase (alt) 134 u/l (normal range 3–30) and aspartate transaminase (ast) 99 u/l (normal range 0–79). the haemoglobin level was 9.0 g/dl (normal range 10.5–13.7), mean corpuscular volume (mcv) 84.4 fl (normal range 70.0–86.0) and platelets 21 ×109/l (normal range 180–440). the abdominal ultrasound (us) demonstrated a bulky, homogeneous, soft tissue mass in the head of the pancreas that was isoechoeic to the remainder of the pancreatic gland, with associated findings of dilated intrahepatic bile ducts and ascites. internal flow was demonstrated within this lesion on colour flow doppler assessment. this was followed by a computed tomography (ct) scan of the abdomen and pelvis with an intravenous and oral contrast agent. computed tomography imaging showed an ill-defined, enhancing mass in the head of the pancreas (figures 1–3), with a poor plane of separation from the d2 segment of the duodenum (figures 1 and 3). enhancing soft tissue, which extended beyond the confines of the pancreatic head into the region of the porta hepatis, was also noted and appeared to be contiguous with this mass (figure 1). figure 1: coronal post-contrast computed tomography image demonstrating an ill-defined, enhancing mass in the head of the pancreas (black arrow), with a poor plane of separation from the d2 segment of the duodenum (white arrow) and peripancreatic extension to the porta hepatis (white star). secondary findings of ascites (black star). figure 2: sagittal post-contrast computed tomography image illustrating a bulky, inhomogeneously enhancing mass in the head of the pancreas (black arrow) with ill-defined margins and extension into the porta hepatis (white star). figure 3: axial post-contrast computed tomography image demonstrating the locally invasive pancreatic mass (black arrow) with a poor plane of separation from the d2 segment of the duodenum (white arrow). the parents of the child decided to use a traditional healer, which delayed the magnetic resonance imaging (mri) of the abdomen by 2 months. the mri abdomen demonstrated a pancreatic mass of poorly defined margins that had progressively enlarged and extended across tissue planes (figure 4a and b). there was encasement of the superior mesenteric artery as demonstrated by the sandwich sign (figure 5a and b), peripancreatic extension into the porta hepatis (figure 4a) and also intrahepatic bile duct dilatation (figure 4b). figure 4: coronal t2-weighted (t2w) magnetic resonance images: (a) pancreatic mass (white star) with ill-defined margins and a lobulated contour (broken white arrow). evidence of peripancreatic extension to the porta hepatis. this lesion is locally invasive, as demonstrated by the inseparability from the d2 segment of the duodenum (solid white arrow); (b) associated findings of dilated intrahepatic bile ducts (broken black arrow) and ascites (black star). figure 5: axial t2-weighted (t2w) magnetic resonance images showing the pancreatic head mass with intermediate signal intensity and encasement of the superior mesenteric artery (white arrow) in (a) and (b) – sandwich sign. the differential diagnosis based on the imaging studies was that of a pancreatic vascular neoplasm; however, with the laboratory evidence of kasabach–merritt phenomenon (kmp), this prompted the diagnosis of a pancreatic khe. given the large size and peripancreatic extension of this lesion, a differential diagnosis of pancreaticoblastoma was considered; however, these lesions are typically heterogeneous in appearance with both cystic and solid components and often have calcifications. after correction of the patient’s thrombocytopenia, an open biopsy of the pancreatic mass was taken at laparotomy. macroscopy of the specimen demonstrated a dark brown wedge of tissue measuring 10 mm × 5 mm× 6 mm. microscopy (figure 6a–f) showed representation of pancreatic parenchyma, which contained a lobulated spindle cell neoplasm with slit-like vascular spaces, extravasated red blood cells, haemosiderin and hyaline globules. there was no necrosis and mitotic activity was 0 in 10 consecutive high-power fields (hpfs). no plasma cell infiltrate, no gland or acinus formation and no squamous corpuscles or nests were noted. in the presence of adequate controls, the following immunohistochemical stains were performed: cytokeratin ae1/3 negative, strongly positive cd34 and negative human herpes virus 8 (hh8). based on the above findings, the anatomical pathology report was indicative of a khe. figure 6: photon microscopy of the pancreatic histology specimen with different magnification: (a) this low power image shows residual pancreatic tissue (centre circle) with surrounding lobules of the neoplastic infiltrate (4 × 10 magnification); (b) this higher power view of the same area (a) shows pancreatic acina, with surrounding and intermingled lobules of the neoplastic infiltrate (arrows) (10×10 magnification); (c) the neoplasm comprises spindled cells in swirling nodules. slit-like vascular spaces are present (arrow). extravasated red blood cells (oval) and hyaline globules (triangle) can be seen. haemosiderin pigment is noted (square) (10×10 magnification); (d) this higher power view of the same area (c) better demonstrates the extravasated red blood cells (arrow) and hyaline globules (arrow head). occasional inflammatory cells are visible (circle) (20×10 magnification); (e) this high-power image shows the spindle cell detail (40×10 magnification). the nuclei are elongated and bland with little pleomorphism and pale cytoplasm, with indistinguishable cell borders (arrow head). haemosiderin pigment is evident (circle) and occasional extravasated red blood cells are present (arrow); (f) this image shows pancreatic acina and adjacent tumour. in the centre is a nodule of tumour bulging into a vessel, the so-called ‘promontory sign’ (circle) (20×10 magnification). although the ascites had improved, the jaundice and thrombocytopenia had become progressively worse. the patient was treated with interferon alpha but subsequently demised. discussion in approximately 70% of cases, khe may be complicated by kmp, a life-threatening complication characterised by profound thrombocytopenia and consumptive coagulopathy.1 this is secondary to the activation and aggregation of platelets, which results in thrombocytopenia, consumption of fibrinogen and ongoing fibrinolysis, which ultimately leads to tumour enlargement with intralesional bleeding. kasabach–merritt phenomenon is typically associated with larger, more aggressive lesions and there are currently no specific criteria to risk-stratify patients with regard to the occurrence or recurrence of kmp.3 cutaneous lesions with a maximal diameter greater than 8 cm, or lesions with involvement of the retroperitoneum or visceral organs, have been implicated as risk factors.3 despite kmp traditionally being described as thrombocytopenia or coagulopathy associated with any vascular anomaly, it is not a complication of infantile or congenital haemangioma and is a common occurrence with khe.5 haemangiomas may appear similar to khe on imaging, except for the more aggressive and locally invasive nature of this lesion.6 this together with laboratory evidence of kmp may assist in the differentiation between these two entities. on ultrasound, khe appears as a homogeneous, ill-defined, soft tissue mass, which may be isoechoeic or hyperechoic compared to the pancreas, with associated mild to marked increased vascularity on colour doppler.2,6 all previously reported cases described a mass in the head of the pancreas, as in this case report.6 although the possibility of a vascular tumour could be suggested on us, a more specific diagnosis cannot be made because of the limitations in demonstrating the infiltrative portions and exact extent of khe. computed tomography and mri together with magnetic resonance cholangiopancreatography (mrcp) are of added value in localising the mass, assessing the tumour extent and giving information of any associated findings such as dilation of the pancreatic and biliary ducts, duodenal obstruction and ascites. leung et al. presented a case of a pancreatic khe presenting with neonatal duodenal obstruction.1 the infiltrative nature of these lesions has been reported as a unique characteristic of khe, assisting in differentiating this from other vascular tumours, with the exception of angiosarcomas.2 mri findings typically show a lobulated, invasive mass with increased signal intensity on t2wi and avid enhancement following intravenous gadolinium.6 ryu et al. reported 12 cases of pathologically proven khe across the body, with lesions demonstrating heterogeneous regions of isointensity or mild hyperintensity on t2 weighted imaging (t2wi) and heterogeneous enhancement post-contrast administration.2 regions of low signal on t2wi are likely secondary to hemosiderin deposition and dense hyaline stromal responses.2 the heterogeneous enhancement was likely associated with the pathological nature of vascular channels and thin-walled lymphatic vessels in khe.2 the treatment of pancreatic khe is variable and depends on associated vascular invasion, extent of the mass and the degree of biliary obstruction.6 medical therapies for khe and kmp include systemic steroids, vincristine, inteferon-alpha and aspirin.7 in cases with associated biliary obstruction, complete surgical resection with a whipple operation has been reported and there have also been successful attempts at biliary stenting and external drainage (palliative surgery), pending spontaneous tumour regression.1,6 historically, angiography and embolisation have been used for the diagnosis and treatment of khe.8 these procedures are currently primarily used as an adjunct to planned surgical resection to minimise bleeding intra-operatively.8 mammalian target of rapamycin (mtor) inhibitors such as sirolimus have proven to be effective in the treatment of cutaneous khe.7 triana et al. described a case of pancreatic khe not responding to sirolimus and suggested the possibility of a different molecular profile compared to the cutaneous form as a result of the resistance to mtor inhibitors treatment.7 conclusion pancreatic khe is an exceedingly rare vascular tumour that mostly occurs during infancy and early childhood. khe may be misdiagnosed on imaging as a congenital or infantile haemangioma; however, the infiltrative pattern of khe with its ill-defined margins and extension across tissue planes is a unique feature of khe and may assist in the differentiation. the presence of kmp is useful in supporting the specific diagnosis. despite kmp traditionally being described as thrombocytopenia or coagulopathy associated with any vascular anomaly, it is not a complication of infantile or congenital haemangioma. although imaging modalities such as ct and mri may assist in delineating this lesion, the formation of a clear pre-operative diagnosis remains difficult and early surgical exploration and rapid frozen biopsy are recommended. pancreatic vascular malformations are best managed in a multidisciplinary setting with extensive experience in the treatment of vascular anomalies, as the treatment differs based on the size, location, associations and complications. acknowledgements the authors would like to thank dr g. davies and dr e. van den berg from the division of anatomical pathology, university of the witwatersrand, for their support. dr g. davies provided the photon microscopy images of the pancreatic histology specimen together with the annotations and legends. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions d.m. was responsible for the review of literature, compiling of the radiological and histology images, write-up of the case report and the preparation of this article as per journal requirements. n.m. was responsible for the diagnosis of the case, interpretation of the imaging studies, compiling of the radiology images and editing of the final article. funding no grants or financial aid facilitated the conduct of the work described in this article or the writing of this article. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references leung m, chao nsy, tang pmy, liu k, chung kly. pancreatic kaposiform hemangioendothelioma presenting with duodenal obstruction and kasabach–merritt phenomenon: a neonate cured by whipple operation. eur j pediatr surg rep. 2014;2(1):7–9. https://doi.org/10.1055/s-0033-1361835 ryu yj, choi yh, cheon je, et al. imaging findings of kaposiform hemangioendothelioma in children. eur j radiol. 2017;86:198–205. https://doi.org/10.1016/j.ejrad.2016.11.015 croteau se, liang mg, kozakewich hp, et al. kaposiform hemangioendothelioma: a typical features and risks of kasabach-merritt phenomenon in 107 referrals. j pediatr. 2013;162(1):142–147. https://doi.org/10.1016/j.jpeds.2012.06.044 wang x, xiong q. pancreatic hemangioendothelioma, an extremely rare vascular anomaly in children: a case report and literature review. oncol lett. 2015;10(2):793–797. https://doi.org/10.3892/ol.2015.3270 enjolras o, wassef m, mazoyer e, et al. infants with kasabach-merritt syndrome do not have ‘true’ hemangiomas. j pediatr. 1997;130(4):631–640. https://doi.org/10.1016/s0022-3476(97)70249-x saigal g, hildoer d, parra-herran c, pelaez l. unusual presentation of a pancreatic mass in an infant: pancreatic haemangioendotheliomatosis. br j radiol. 2011;84(1008):232–235. https://doi.org/10.1259/bjr/87625027 triana pj, dore m, nuñez vc, et al. pancreatic kaposiform hemangioendothelioma not responding to sirolimus. eur j pediatr surg rep. 2017;5(1):e32–e35. https://doi.org/10.1055/s-0037-1604358 drolet ba, trenor cc iii, brandao lr, et al. consensus-derived practice standards plan for complicated kaposiform hemangioendothelioma. j pediatr. 2013;163(1):285–291. https://doi.org/10.1016/j.jpeds.2013.03.080 about the author(s) anith chacko clinical neurosciences, university of bristol, united kingdom schadie vedajallam clinical neurosciences, university of bristol, united kingdom savvas andronikou clinical neurosciences, university of bristol, united kingdom ewan simpson clinical neurosciences, university of bristol, united kingdom ngoc j. thai clinical neurosciences, university of bristol, united kingdom citation chacko a, vedajallam s, andronikou s, simpson e, ngoc j, thai nj. patterns of the cortical watershed continuum of term gestation hypoxic ischaemic injury – the ‘wish-bone sign’. s afr j rad. 2017;21(1), a1162. https://doi.org/10.4102/sajr.v21i1.1162 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract patterns of the cortical watershed continuum of term gestation hypoxic ischaemic injury – the ‘wish-bone sign’ anith chacko, schadie vedajallam, savvas andronikou, ewan simpson, ngoc j. thai copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: partial prolonged-term hypoxic ischaemic injury (hii) involves the cortical and subcortical watershed zones of the brain, which are visually difficult to conceive. new innovative methods of demonstrating watershed cortical atrophy using flattened maps of the brain surface give added insight into distribution of the watershed zone by demonstrating the entire brain surface. aim: to determine and validate patterns of hii sustained at birth in term infants using cross-sectional magnetic resonance imaging (mri) and the innovative mercator and scroll map views of cortical surface anatomy, to define the distribution of the watershed zones in children with partial prolonged injury. materials and methods: a total of 100 paediatric mri brain scan reports with an mri and clinical diagnosis of chronic term hypoxic injury were read by three radiologists independently. all sites of abnormality were recorded and patterns were classified. patients with partial prolonged and combined patterns were evaluated using mercator and scroll map reconstructions, generating schematics of the watershed zone. results: predominant patterns of disease were partial prolonged and acute profound types. the watershed zone was demonstrated, on the derived maps, representing a continuum of involvement in the shape of a ‘wish-bone’ extending bilateral from frontal lobes to posterior parietal lobes in band-like fashion along the para-falcine cortex and intersected by another band of atrophy in the peri-rolandic regions extending along peri-sylvian cortices. this is defined in schematics as a visual aid. conclusion: predominant patterns of injury in term hypoxic ischaemic injury are described and quantified, with the ‘wish-bone sign’ introduced to describe the typical distribution pattern of partial prolonged hii in the watershed zone. case report ' recurrent lifethreatening haemoptysis in pulmonary tuberculosis the importance of pulmonary angiography saziso msimang dip int med (inst. vinnista) peter corr mb chb, ffrad (d) sa, frcr, mmed department of radiology. nelson r mandela school of medicine, university of natal, durban introduction life-threatening haemoptysis in patients with pulmonary inflammatory disease is usually due to bleeding from enlarged bronchial arteries. i bronchial arteriography usually identifies the bleeding site which can be embolised at the same time.' recurrence of haemoptysis may be due to incomplete embolisation, the presence of undetected systemic collaterals or the presence of a leaking pulmonary artery (rasmussen) aneurysm.' we present a case of recurrent haemoptysis from a bleeding pulmonary artery aneurysm that was successfully treated by endovascular occlusion. case report a 17-year-old girl from a poor socio-economic background was referred as an emergency to the cardio-thoracic unit with a history of massive haemoptysis of at least 500 ml over 24 hours. a week earlier she had been admitted to a local hospital with a history of cough, night sweats, loss of appetite and loss of weight. she had minor haemoptysis at that time. on admission the patient was noted to be dyspnoeic and pale. the full blood count revealed a haemoglobin level of 6.6 gldl. the chest radiograph demonstrated a miliary pattern almost certainly representing tuberculosis. a high-resolution computed tomography scan (hrct) confirmed the miliary pattern in addition to a right upper lobe cavity and left lower lobe consolidation. her hw test was negative. the patient was treated with oxygen, intravenous antibiotics and antitb drugs. the patient also received a blood transfusion and was booked for bronchial artery embolisation. the bronchial and intercostal arteries were carefully studied. a common bronchial trunk gave rise to a single right bronchial artery and two 23 sa journal of radiology. november 2003 bronchial arteries on the left. the bronchial arteries and right superior intercostal artery were enlarged and demonstrated hypervascularity. transcatheter embolisation of these vessels was performed using embospheres. postembolisation images demonstrated successful occlusion of the distal branches. the patient continued to have minor haemoptyses at a rate of 50 100 ml per 24 hours. a repeat angiogram showed occluded bronchial arterial branches. there was recanalisation of the right superior intercostal artery, which was successfully embolised once again. a left internal mammary artery was also embolised due to its hypervascularity. however the patient's haemoptysis increased to i 000 ml over a 24-hour period. a post-contrast ct of the chest demonstrated an enhancing lesion in the left lower lobe (fig. la). a selective pulmonary angiogram was performed demonstrating that this was a pseudoaneurysm arising from the left lower lobe pulmonary artery branch (fig. lb). the aneurysm was occluded successfully with steel coils (fig. le). the patient's haemoptysis completely resolved soon after, and the patient was discharged on antitb drug therapy. discussion although most patients with pulmonary inflammatory disease and haemoptysis bleed from the bronchial circulation, the pulmonary arterial circulation should be immediately evaluated if the bronchial angiogram is normal or if the patient does not show any improvement following embolisation." a rasmussen aneurysm is a pseudoaneurysm of the case report fig. 1a. contrast-enhanced ct of the lower chest demonstrates an aneurysm in the left lower lobe of the lung. fig. 1b. rasmussen aneurysm of the left lower lobe pulmonary artery (arrow). fig. te. occlusion of the aneurysm with steel coils (arrow). terminal branches of the pulmonary artery within the wall of a tuberculous cavity caused by inflammatory necrosis or erosion of the vessel wall. in one series 4% of patients with cavitatory tuberculosis had pulmonary artery aneurysms detected at postmortem.' haemoptysis results from intimal rupture of the aneurysm. bleeding into the cavity is expectorated or results in auto compression of the ruptured aneurysmal sac. a rasmussen aneurysm has to be systematically searched for in patients with haemoptysis from a destructive lung process. bronchoscopy usually enables location of the haemorrhage to a specific lobe, which may allow directed angiographic evaluation; however fiberoptie bronchoscopy has some disadvantages in the diagnosis of massive, active haemoptysis. it is difficult to localise the bleeding site with fiberoptie bronchoscopy (fob) in patients with massive haemoptysis because of excessive blood in the bronchi. in a recent article, hsaio et al.6 documented that fibreoptic bronchoscopy prior to bronchial artery embolisation is unnecessary in patients with haemoptysis of known cause if the site of bleeding can be determined on conventional imaging. a pseudoaneurysm typically forms months to years after the initial exposure to tuberculosis or reactivation of the disease and the development of cavitatory disease. a chest radiograph can demonstrate a welldefined opacity and a repeat study may show an increase in the size of the opacity. a post-contrast ct demonstrates a well-defined enhancing rounded structure, which often lies within the lung parenchyma adjacent to the vessel, as demonstrated in our patient. a pulmonary angiogram confirms the diagnosis. we recommend that in patients with haemoptysis, if the bronchial arteries are normal or if the embolisation does not stop the haemorrhage, pulmonary and systemic arteries (intercostals, subclavian, internal mammary arteries) should be studied, such an approach is essential to avoid a delay in the diagnosis, as in our case. transcatheter coil embolisation of the rasmussen aneurysm is safe and very effective in stopping the haemoptysis.' detachable balloons and stainless steel platinum coils are generally used. references 1. marshall tt, flower cd, jackson je. the role of radiology in the investigation and management of patients with haemoptysis. gin radio11996; 51:391-400. 2. white ri jun. bronchial artery embolotherapy for control of acute hemoptysis: analysis of outcome. chest 1999; 115:912-915. 3. sanyika c, corr p, royston 0, blyth of. pulmonary angiography and embolization for severe hemoptysis due to cavitary pulmonary tuberculosis. cardiovasc intervent radio11999; 22:457-460. 4. wong ml, szkup p, hopley mj. percutaneous embolotherapy for life-threatening hemoptysis. chest2002; 121:95-102. 5. patankar t, prasad s, deshmukh h, mukherji sk. fatal hemoptysis caused by ruptured giant rasmussen's aneurysm. am j roentgeno12000; 174:262-263. 6. hsiao ei, kirsch cm, kagawa ft, wehner jh, jensen wa, baxter rb. utility of fiberoptie bronchoscopy before bronchial artery embolization for massive hemoptysis. am j roentgenol2001; 177:861-867. 7. santelli ed, katz ds, goldschmidt am, thomas ha. embolization of multiple rasmussen aneurysms as a treatment of hemoptysis. radiology 1994; 193:396-398. 24 sa journal of radiology • november 2003 radiology_aug04 abstract during the past 4 years, 15 patients have undergone intravascular removal of foreign bodies — 9 central venous line fragments, 3 guidewires, 2 pacemaker leads and 1 misplaced embolisation coil. ten foreign bodies (including 2 guidewires, 2 pacemaker leads and 6 central venous catheter fragments) were recovered from the big veins and right heart, 3 (central venous line fragments) from the pulmonary arterial system and 2 (an embolisation coil and a guidewire) from the arterial system. the percutaneous removal of foreign bodies is efficient with few complications. surgery should only be considered for patients in whom removal attempts with endovascular interventional techniques have failed. introduction in the past, intravascular foreign bodies had to be removed surgically, but the percutaneous retrieval of intravascular foreign bodies has become a frequently used technique since it was first described 40 years ago,1 largely replacing open surgical removal. commonly encountered intravascular foreign bodies include fragments of central venous catheters (most common), knotted pulmonary artery (swan ganz) catheters, lost guidewires or guidewire fragments, misplaced embolisation coils and metallic stents. an estimated 0.1% of venous catheters suffer breakage2 but no data are available for other types of intravascular objects. the rate of serious complications caused by foreign body embolism is as high as 71%, with the mortality rate ranging from 24% to 60%.3,4 in the case of intravenous foreign objects, such as a fragment of a central venous catheter, it is important that the procedure be done as soon as possible. attempts at removal from the venous system prior to migration into the pulmonary circulation has the lowest morbidity and the highest chance of success (figs 1a and 1b).5 method a vascular sheath big enough to allow removal of the foreign body in question must be used. sometimes it is helpful to cut the sheath tip obliquely in order to increase the cross-sectional diameter of the opening allowing a bigger object to be pulled into case reports 31 sa journal of radiology • august 2004 endovascular foreign objects retrieved by interventional radiologists at universitas hospital h f potgieter mb chb e loggenberg mmedrad (d) department of diagnostic radiology university of the free state and universitas hospital bloemfontein fig. 1a. infusoport without catheter. fig. 1b. lost central venous line in ivc and right atrium. the sheath (fig. 2).5 the most useful device in foreign body retrieval is the nitinol goose neck snare.6 advantages of this device include the predefined loop diameter, the shape-memory properties of the nitinol, and the ability to develop a variable amount of force in the loop. other devices that may be useful in this procedure include dormia-type baskets, selfmade wire-snares (looped guidewire in a diagnostic catheter), biopsy forceps and purpose-designed fragment graspers. as a standard procedure the microvena goose neck snare (fig. 3) was used with different guiding catheters in a siemens multistar interventional unit. the goose neck snare was manipulated over the free floating end of the lost object, which was snared and then removed through the sheath. results at universitas hospital radiology unit 15 patients have undergone intravascular removal of foreign bodies during the past 4 years. this included 9 central venous line fragments, 3 guidewires (figs 4a and 4b), 2 pacemaker leads and 1 misplaced embolisation coil. ten foreign bodies (including 2 guidewires, 2 pacemaker leads and 6 central venous catheter fragments) were recovered from the big veins and right heart, 3 (central venous line fragments) from the pulmonary arterial system and 2 (an embolisation coil and a guidewire) from the arterial system. all but 1 of the foreign bodies were removed successfully during the first attempt. the recovery of a 3 cm central line fragment from the pulmonary artery of 1 patient failed initially, but the second attempt 1 week later was successful. no serious adverse events were recorded during the procedures or immediately thereafter. discussion results continue to prove that percutaneous removal of foreign bodies is highly efficient (success rates more than 90% in most studies) with few complications. the added attraction of the procedure is that many seriously ill patients with iatrogenic foreign bodies do not have to be exposed to the increased surgical/anaesthetic risk. owing to the associated complication risk, surgery should only be considered when removal attempts with endovascular interventional techniques have failed. references 1. thomas j, sinclair-smith b, bloomfield d, davachi a. non-surgical retrieval of a broken segment of steel spring guide from the right case reports 32 sa journal of radiology • august 2004 fig. 2. snared line fragment being recovered through sheath. fig. 3. microvena goose neck snare. fig. 4a. lost guidewire in ivc. fig. 4b. guidewire in snare. atrium and inferior vena cava. circulation 1964; 30: 106-108. 2. burri c, henkemeyer h, passler hh. catheter embolism. schweiz med wochenschr 1971; 101: 1575-1577. 3. fisher rg, ferreyro r. evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. am j roentgenol 1978; 130: 541-548. 4. richardson jd, grover fl, trinkle jk. intravenous catheter emboli. experience with twenty cases and collective review. am j surg 1974; 128: 722-727. 5. allison dj, jackson je. vascular interventional techniques in the thorax. in: grainger rg, allison dj, eds. grainger and allison's diagnostic radiology: a textbook of medical imaging. 4th ed. london: churchill livingstone, 1997: 607 621. 6. cekirge s, weiss jp, foster rg, neiman hl, mclean gk. percutaneous retrieval of foreign bodies: experience with the nitinol goose neck snare. j vasc interv radiol 1993; 4: 805-810. case reports 33 sa journal of radiology • august 2004 radiology_oct04 introduction pulmonary artery aneurysms are a rare finding in general radiological practice. the possible causes are myriad and diverse in pathophysiology. patients with post-stenotic dilatation of the main pulmonary artery usually present fairly late with insidious cardiorespiratory symptoms. diagnosis requires radiological imaging assistance as the clinical findings are nonspecific. case report a 73-year-old woman presented to our medical outpatient department with gradually progressive dyspnoea over the past 2 years. the breathlessness was initially present on exertion. at the time of assessment, however, she had progressed to grade iii dyspnoea with associated palpitations, especially on exertion. she had no other significant preceding medical history. clinical examination revealed early diastolic and long mid-systolic murmurs along the left heart border. she also had a 3 cm hepatomegaly and mild right heart failure. an electrocardiogram (ecg) revealed slight right axis deviation and ventricular extrasystoles. a chest radiograph done on admission demonstrated massive expansion of the left cardiac border with markedly increased cardiothoracic ratio. there were no radiological features of overt cardiac failure. the aortic outline was clearly delineated with some age-related tortuosity. considerations at this point included giant left atrium, pulmonary artery aneurysm, giant right atrium, massive pericardial cyst or effusion (fig. 1). we then proceeded to perform a computed tomography scan, which revealed a massively dilated main pulmonary artery as well as dilated right and left pulmonary arteries. slight right atrial and right ventricular dilatation was also noted. the rest of the mediastinal structures were within normal limits. a diagnosis of aneurysm of the main pulmonary artery was made (fig. 2). an echocardiogram confirmed pulmonary valvular stenosis with post-stenotic dilatation and pulmonary artery aneurysm formation. the pulmonary valve pressure gradient was > 28 mmhg. the patient settled on low-dose diuretic therapy, and following cardiothoracic surgical consultation it was decided that no surgical intervention was warranted. she was followed up at the clinic. discussion aneurysms of the pulmonary artery (paa) are rare in adults. predisposing conditions include congenital and acquired heart disease, e.g. left-to-right shunting or pulmonary valve stenosis with post-stenotic dilatation. other causes include infection (tuberculosis, syphilis, osteomyelitis, pneumonia), systemic vasculitides (hughes-stovin’s disease, behcet’s disease), collagen vascular diseases, connective tissue disorders, (marfan’s syndrome, ehler’s-danlos 30 sa journal of radiology • october 2004 case report pulmonary artery aneurysm s k misser mb chb j m maharajh mb chb, mmed, ffrad (d) department of radiology university of kwa-zulu-natal nelson r mandela school of health sciences and king edward viii hospital durban fig. 1. postero-anterior chest radiograph performed on admission. fig. 2. axial ct scan of the chest at the level of the main pulmonary artery. case report 31 sa journal of radiology • october 2004 syndrome), trauma (direct or blunt chest injury), mucoid vasculopathic changes and idiopathic paa.1 irrespective of the underlying cause, most paa are associated with pulmonary arterial hypertension. clinically patients usually present with symptoms of mild congestive heart failure of insidious onset, haemoptysis and bronchial compression, or the aneurysm is discovered incidentally on chest radiography for unexplained dyspnoea.2 post-stenotic dilatation of the pulmonary artery is a common feature of pulmonary stenosis, but does not usually reach aneurysmal proportions. in most cases of post-stenotic dilatation the main or left pulmonary artery is involved. one plausible explanation for this is the sharp angle at which the right pulmonary artery emerges, causing the near-vertical, high-velocity jet to bypass its origin.3 in the patient reported here the degree of dilatation was marked and both right and left pulmonary arteries were involved. a possible associated degenerative process (especially since she was in her 8th decade) is thought to be responsible for this appearance. clinical response to routine antifailure/diuretic therapy is usually good, but the response cannot be predicted. long-term outcome of untreated paa is not well documented. one-third of patients with paa, from all causes, will die from aneurysm rupture. aneurysms associated with post-stenotic dilatation persist after treatment but are of no clinical significance. recent reports have described the use of balloon valvuloplasty in correcting the valvular stenosis with resultant reduction in pulmonary arterial pressures and aneurysm stability.4 our patient responded very well to medical therapy and her symptoms have almost completely settled. we shall continue to re-assess her clinical status as well as the trans-pulmonary valve pressure gradient as an index of stability. acknowledgements special thanks to professor p corr for editing the manuscript, mr steve odayan (chief radiographer) for assistance with imaging and ms marianne singh for technical support. references 1. deterling ra, clagett ot. aneurysms of the pulmonary artery. am heart j 1947; 34: 471. 2. lopez-candales a, kleiger re, aleman-gomez j, kouchoukos nt, botney md. pulmonary artery aneurysm: review and case report. clin cardiol 1995; 18: 738-740. 3. tami lf, mcelderry mw. pulmonary artery aneurysm due to severe congenital pulmonic stenosis. case report and literature review. angiology 1994; 45: 383-390. 4. butto f, lucas rv, edwards je. pulmonary artery aneurysm: a pathological study of five cases. chest 1987; 91: 237-240. abstract introduction brief history of radiology in nigeria eligibility for postgraduate radiology education in nigeria current structure of radiology residency in nigeria problems and challenges recommendations conclusion acknowledgements references about the author(s) bukunmi m. idowu union diagnostics and clinical services, lagos, nigeria citation idowu bm. postgraduate radiology education in nigeria: looking backward and forward. s afr j rad. 2018; 22(1), a1362. https://doi.org/10.4102/sajr.v22i1.1362 opinion paper postgraduate radiology education in nigeria: looking backward and forward bukunmi m. idowu received: 06 may 2018; accepted: 18 june 2018; published: 29 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract formal postgraduate radiology education (residency training) in nigeria commenced in 1976 at the university college hospital, ibadan, oyo state. currently, two postgraduate medical colleges (one national and the other international or regional) are saddled with the responsibility of superintending the training programme. this is a chronicle of the evolution of radiology in nigeria with emphasis on the current status of the training programme and areas that require improvement. though the programme has delivered a quality healthcare workforce for the country and the international community since inception, significant but surmountable difficulties still exist. it is hoped that all stakeholders and policy-makers will take note and safeguard the future of the specialty. introduction nigeria is the most populous african nation with an estimated population of 191 million people1 in 2017 and is located in west africa between latitudes 4°n and 14°n, and longitudes 2° e and 15° e. there are 36 states or provinces, a federal capital territory and 774 local council areas in the country. postgraduate medical education has been defined as the ‘constellation of learning activities carried out to enable doctors to develop relevant competencies and deeper knowledge in specific subject areas after completion of basic medical education’. it encompasses ‘pre-registration training, vocational and/or professional training, specialist and subspecialist training, as well as other forms of training obtained after the initial undergraduate medical education’ with the aim of ‘developing new knowledge and innovations for high-level medical practice’.2 the all-encompassing training serves to prepare them for future roles as clinicians, mentors, educators, researchers and administrators.3 until the establishment of postgraduate medical colleges in nigeria, nigerian medical specialists were trained abroad, mainly in england, scotland, ireland and the united states of america (us). establishment of a local training programme has been shown to be more sustainable and cost-effective than reliance on expatriates.3,4 it may also help to stem the emigration of highly-skilled physicians (the brain drain menace).5,6 in addition, training in the local environment would enable trainees to provide much needed clinical service delivery simultaneously.7 as previously observed: … there is a lack of literature about the radiology education infrastructure in africa. this gap in the literature can be challenging for radiologists who would like to collaborate, contribute, and learn from differences, similarities, and challenges in radiology education systems outside their countries.8(p. 1) this article attempts to chronicle the evolution of postgraduate radiology education in nigeria, identify existing impediments to the training of world-class radiologists, proffer solutions and make recommendations to facilitate improvement. brief history of radiology in nigeria the first x-ray machine was installed in the first radiology department in nigeria at the lagos general hospital, lagos state, in 1913.4 angiography and fluoroscopy machines were installed at the university college hospital (uch), ibadan, oyo state, southwest nigeria, in 1961 and 1972, respectively.9 the first ultrasound machine in nigeria was also installed in uch in 1975.4,10 installation of the first computed tomography (ct) scanner, also in uch ibadan, followed much later in 1987 and remained the only ct scanner in the country until 1995.4,11 the first magnetic resonance imaging (mri) machine in nigeria was commissioned at the national hospital, abuja, in 1999.4 since these landmark events, radiography machines and ultrasound scanners have become ubiquitous in the country. multislice ct scanners have also become more available in the urban centres (public and private hospitals and diagnostic centres); in fact, a state-of-the-art toshiba aquilon 640-slice ct scanner was installed at the ibom specialist hospital, akwa-ibom state, in 2015. there are now 1.5 tesla mri machines in an increasing number of private and a few public health facilities across the country. the first generation of nigerian radiologists who trained in the united kingdom obtained their diploma in medical radiodiagnosis (dmrd) from the royal colleges of physicians and surgeons of london, united kingdom, while some obtained additional fellowship subsequently. the first nigerian to qualify as a radiologist was dr michael aneke benedict ogakwu (dmrd 1960).4 he was followed by others in radiodiagnosis in that decade (table 1). the first nigerian professor of radiology was prof s.b. lagundoye who was appointed on 01 october 1976.9 prof b.c. umerah also became a professor in 1977. the first nigerian woman to qualify as a radiologist was dr foluso a. ladapo-elebute (dmrd 1971)4 followed by the other pioneer women mentioned in table 2. dr ladapo-elebute was also the first nigerian female professor of radiology. the first american-trained nigerian radiologist was dr john chukwudi odita who became a diplomate of the american board of radiology in 1975 and a board-certified paediatric radiologist in 1995.4 dr taiyewo moses kolawole was the first nigerian to obtain a fellowship (ffr) in general radiology and was also the first subspecialist, having completed a fellowship in neuroradiology at the university of western ontario in 1977.12 table 1: pioneer radiologists in nigeria. table 2: pioneer women radiologists in nigeria. there are two professional bodies of radiologists in the country: a regional association (association of radiologists of west africa [arawa]) founded in 1962 and a national association (association of radiologists in nigeria [arin]) which was incorporated and registered with the corporate affairs commission in 2010. these two bodies have a healthy working relationship, with arawa being responsible for regional cooperation and integration in the west african sub-region, while arin is responsible for handling national issues within nigeria. nigerian radiologists can belong to both bodies simultaneously. member countries of arawa currently include anglophone west african countries (nigeria, ghana, liberia, sierra-leone and the gambia), after the francophone countries effectively pulled out of arawa in 1989 by forming the societe de radiologie d’afrique noire francophone (radiological society for francophone africa).4 the two postgraduate medical colleges saddled with the responsibility of training radiologists (and other medical specialists) locally, are the west african college of surgeons (wacs) and the national postgraduate medical college of nigeria (npmcn). the wacs was inaugurated in 1960 as the association of surgeons of west africa which morphed into wacs in december 1972.4,13 the national postgraduate medical college of nigeria started as the postgraduate programme of the nigerian medical council or the national medical college in 1970 and segued into the npmcn in 1979.2,7 overseas-trained fellows constituted the founding fellows of the radiology faculty in both colleges, while other foreign trained fellows who qualified subsequently became fellows of the colleges or radiology faculty by election. these colleges function separately though they cooperate with each other. the west african college of surgeons was set up by the heads of government of the aforementioned five anglophone west african countries, while the federal government of nigeria set up the npmcn. both are meant to produce a medical specialist workforce to meet the healthcare needs of the respective localities. the npmcn faculty of radiology had 21 foundation fellows (this includes few radiotherapists).2 formal radiology residency training by npmcn commenced in 1976 with four candidates (dr obadiah folorunsho komolafe, dr ayotunde oluremi ogunseyinde, dr solomon sunday daini and dr adebayo olanrewaju taiwo).4 dr o.f. komolafe was inducted as the first fellow by examination of the npmcn faculty of radiology in may 1980. as of december 2011, the npmcn had produced a total of 145 radiologists by examination.4 the radiology faculty was one of the six founding faculties of wacs. dr henry peter adebayo adedokun was the first to obtain the wacs radiology fellowship by examination in 1983.4 the next set of wacs radiology fellows qualified in october 1984: col (dr) a.i. audu, dr kolawole olufemi iyun and dr johnny uzoma valmon monu.13 as of december 2011, wacs faculty of radiology had produced a total of 210 radiologists by examination.4 it must be noted that a number of these radiologists hold the fellowships of both colleges. it is noteworthy that between 1960 and 1980 when the country produced the first locally trained radiologist, only about 40 radiologists (two per annum) were successfully trained abroad.4 as of 2015, an estimated 250–300 radiologists practise in the country at a ratio of one radiologist to 566 000 people.14 eligibility for postgraduate radiology education in nigeria undergraduate medical education in nigeria lasts a minimum of six years for students who gain admission via the unified tertiary matriculation examination (utme) route or a minimum of five years for those admitted via the direct entry route (undertaken by candidates with advanced-level certificates or those who already have first degrees in medical-related courses). successful medical students are awarded the mbbs or mbchb or mbbch degree on completion of undergraduate studies. there are 32 fully accredited and six partially accredited medical schools in nigeria with a capacity to train a total of 3325 medical doctors annually.15 the new doctors are granted temporary registration with the medical and dental council of nigeria (mdcn), allowing them to practise under the supervision of an attending or consultant. full registration is obtained upon successful completion of a compulsory 1-year housemanship or internship in an accredited training centre. after internship, those still younger than 30 years of age proceed on a compulsory 1-year national youth service corp (nysc) scheme. thereafter, a doctor becomes eligible to attempt the primary (qualifying) examinations of the postgraduate medical colleges. the first (1976) set of npmcn radiology residents sat the primary examination. thereafter, a waiver was granted by both colleges in order to attract young doctors to the ‘unpopular’ specialty. the waiver had to be nullified after more than two decades when the number of doctors applying for radiology residency exceeded the available training slots. consequently, npmcn recommenced primary examinations in september 2001 (three candidates, one passed), while wacs started theirs in october 2004. in essence, there were no radiology primary exams between 1976 and 2001 or 2004. the two postgraduate faculties of radiology organise the primary examination for prospective residents biannually. the result of the primary exams enjoys reciprocal validity between the two colleges after payment of an administrative (exemption) fee. the primary examination (‘primaries’) comprises multiple-choice questions in three subjects: basic physics, anatomy and clinical medicine. it is, in addition to a hospital-based interview, a prerequisite for admission into a formal radiology residency training programme at accredited hospitals across the country. the hospital-based pre-admission written and/or oral interviews are conducted independently by each training centre and are held on average about once in two years. the intake per hospital varies – usually, less than 20% of those who apply are admitted (in some cases, less than 5%). the hospitals train the residents, while the postgraduate colleges conduct the periodic examinations and award the fellowships. current structure of radiology residency in nigeria the radiology faculties of both postgraduate colleges are responsible for supervision of radiology residency, curriculum design and periodic review, accreditation of training centres and conducting three examinations biannually (primary examination, part one [membership] examination and part two [fellowship] examination). the admission requirements for both colleges are similar but there are some (minor) differences in the curricula and structure of their training programmes. categories of residents in training include primary residents (employed and paid by the hospital in which they are undergoing residency training), supernumerary residents (sponsored by another institution to the hospital in which they are doing their residency training) and self-sponsored residents. currently, 13 teaching hospitals have full accreditation, while eight have partial accreditation of the npmcn for radiology residency training. of these 21, only four are owned by state or provincial governments, while the others are owned by the federal government of nigeria.16 fourteen training centres have full accreditation of the wacs radiology faculty, while two have partial accreditation.17 some of the training centres have concurrent accreditation from both colleges. the purpose of the accreditation is to: ‘ensure that minimum standards in faculties and staffing are maintained in training institutions to facilitate training to the level expected’.18 the accreditation process evaluates the prospective training centres based on the following criteria19,20 that are scored quantitatively: qualifications and experience of personnel and faculty (prescribed number, appropriate trainers: trainees ratio, support staff); availability of infrastructure (electricity, water, radiological suites, call rooms); availability of core and support equipment; structure and content of the training programme (didactic lectures, tutorials, read-out sessions, and so on); opportunities for or evidence of skill acquisition (procedure register, log book); access to new information (internet access, departmental library) and regular feedback or evaluation (periodic continuous assessment, annual progress report). the recommended ratio of resident doctors to consultants or attendings is a minimum of 3:1 or maximum 4:1, that is, one senior registrar and two registrars or two senior registrars and two registrars to one consultant or attending. trainers and examiners are required to be at least five years post-fellowship. the colleges determine the number of training slots allotted to each training centre based on the number of trainers (one trainer: four trainees) and availability of the aforementioned training facilities. if a training centre can expand and provide more of these requirements, then the colleges could allow them more training slots. full accreditation (all the requirements for accreditation are satisfied) lasts for 5 years, while partial accreditation (only some of the requirements for accreditation are satisfied) lasts for 2 years before another review or reassessment. a centre may get partial accreditation if one of the core radiological equipment (ct, mri and fluoroscopy) is faulty or unavailable or if the trainees far outnumber the trainers. resident doctors from centres with partial accreditation have to undergo training in the deficient area in one of those with full accreditation (external posting) before becoming eligible for examination. a resident doctor can undergo the radiology training programmes of both colleges simultaneously. failure of a resident to pass the part one or part two examinations after three sittings or failure to complete the entire programme within the stipulated five years (depending on the policy of each training centre) may lead to withdrawal from the radiology residency training programme. such withdrawn (relocated) candidates can attach themselves to another fully accredited training centre to complete their training. however, if a candidate is relocated before passing part one, he or she reverts to medical officer status. both colleges organise separate part one and part two examinations which do not enjoy reciprocity unlike the primary examinations. success in the part one examination is a pre-requisite to membership of either college. in order to be eligible for this exam, residents (registrars) must have undergone at least 24 months of actively supervised radiology rotations evidenced by in-training assessment scores and completed logbooks. the rotations or postings include dark room, plain radiography, fluoroscopy, mammography, ultrasonography, ct and mri. the order of rotation differs amongst the training centres. in addition, candidates must have attended update or revision courses in radiological or medical physics and clinical radiology which are organised by the colleges. the part 1 examination comprises multiple-choice questions (medical physics, radiological anatomy, clinical radiology), essays (clinical radiology), image slideshows (radiological anatomy, clinical radiology) and image reporting sessions or viva voce. successful residents are upgraded and admitted into the senior residency training programmes as senior registrars. a senior resident is required to rotate through the same radiology postings (except dark room and medical physics) for another 24 months, conduct a radiological research and submit a dissertation. in addition to these, the npmcn requires the submission of a book of at least six case reports that the candidate managed during their period of training. success in the part two examination admits the senior resident into the fellowship of the college whose exam they passed.21 the part two comprises clinical multiple-choice questions, essays (wacs only), slideshow, image reporting sessions or viva voce and defence of the candidate’s dissertation. dissertation defence has been a component of npmcn radiology part two examinations, since the first fellow of the faculty by examination sat the examination in 1979. in contrast, dissertation defence for wacs radiology part two examinations commenced in october 2009, having been waived hitherto alongside the primary examination at the inception of the wacs radiology faculty. regarding the part two dissertation, after passing the part one exam, the candidate chooses a topic (guided by their departmental supervisor and policy) and submits a proposal to the college, after obtaining study approval from the ethics committee of the training institution (two different proposals are submitted separately if the candidate wishes to pursue the part two programmes at both colleges). on receiving the proposals (and payment of assessment fees), the faculty secretary and/or chairman selects two external assessors (similar to journal peer reviewers) outside the training centre of the candidate to vet the submitted proposal. the reports of the assessors determine whether the proposal is accepted or rejected by the faculty. if rejected, the candidate restarts the process with a new topic or substantial modification of the proposal. if accepted, the candidate may proceed with the study. both outcomes are often communicated to the candidate in writing. to be eligible for npmcn part 2 exams, the proposal must have been approved at least 12 months prior to the time of screening application forms, log books and completed dissertations for the exams. during the part two exams, the candidate faces the hitherto anonymous external assessors to defend their dissertation. there are three possible outcomes of the dissertation defence: full (straight) pass, provisional pass (need to make minor corrections) and failed defence (major flaws rendering the dissertation unacceptable with a need to rewrite the dissertation or reconduct the study and resit the defence in six months or one year). problems and challenges general problems with residency training in nigeria despite its successes, a myriad of problems confront postgraduate medical education in nigeria. previous authors2,22,23,24,25,26,27 have written extensively about these but key impediments will be highlighted here. residency training in nigeria has no legal imprimatur. indeed, the entire training programme has been whimsically suspended twice in the last five years by the federal government. only recently has a bill been submitted to parliament to secure legal backing and access to annual budgetary provisions. currently, the programme is poorly funded and curriculum review is not regular. there is a shortage of trainers and lack of commitment by trainers. a previous study22 put the contribution of trainers to the training of residents in nigeria at 26% – 50%. trainees often complain of being subjected to various forms of bullying.28,29 furthermore, the trainers do not undergo performance appraisal by their trainees. in addition, an endemic patronage culture means that competent hands are sometimes omitted in the selection of trainers or academics for the training centres. similarly, the system of recruiting examiners for the postgraduate colleges needs to be more transparent. the current over-emphasis on service provision rather than training is not helpful. with resident doctors working between 80 and 168 h per week, the programme appears to be managed as a conduit for cheap assistants and workforce to the training centres or trainers rather than an educational enterprise.2,22 the fellowships versus phd controversy introduced another dimension into postgraduate medical education in nigeria. in 2008, the national universities commission (nuc) decreed that those who do not possess a phd can no longer teach at universities.2,26,30,31,32 the issue has lingered and is yet to be resolved conclusively, leaving much uncertainty in the minds of resident doctors and junior consultants. presently, there are no phd programmes in radiology in nigerian universities though some specialties are already developing the curriculum. research proposals submitted by residents to the colleges for approval suffer needless delays without consequent sanction of the offending examiners. this often increases the duration of training for affected residents, exposing them to the risk of expulsion from the programme before completion. there are other sundry issues, including inadequate training centres and training slots, incessant industrial disharmony in the health sector which often disrupts training,33,34 the penchant of the wacs to charge exorbitant or prohibitive fees for its services and the abysmal pass rate in college exams.35 brain drain is also hitting the programme hard – the few specialists being trained are emigrating in droves to europe, the caribbean, us, canada, australia, the middle east and even other african countries, lured by better remuneration, living and working conditions and a quest to raise their children in an environment with better opportunities. others leave because of the rather paradoxical lack of employment opportunities after completing their training – this may be due partly to the problematic 2010 agreement between the academic staff union of universities (asuu) and the federal government to raise the retirement age of professors from 60 to 70 years. consequently, vacancies for academic positions are not as readily available as before. problems peculiar to radiology residency training some problems are peculiar to radiology residency, partly because of constantly evolving technological advancement.8,14,36,37,38,39 the curriculum for radiology residency is designed to produce general radiologists. there is no formal subspecialty training in nigeria at the moment, although there is a growing interest amongst residents and consultants in the commencement of subspecialty training.36,37 this is as a result of the availability of more sophisticated imaging modalities in private and some public hospitals and a higher demand for more qualitative reports by clinicians. conventional radiography and ultrasound are the only regularly functioning modalities in many training centres often because of frequent breakdown of equipment without prompt repair. computed tomography, mri, fluoroscopy and mammography units are the worst affected. in fact, the fluoroscopy units in the vast majority of training centres are out of service. this sad reality forces many residents to choose ultrasound-based topics for their part two dissertations. the perennial problem of epileptic power supply in the country has had a pernicious effect on radiology training. it is often responsible for equipment breakdown and most of the training centres resort to running their equipment on generators which adds to operative costs and is often difficult to sustain. some modern training equipment or facilities are unavailable in some of the training centres – picture archive computerised system (pacs), electronic reporting systems, planar scintigraphy, positron emission tomography (pet) scanners, elastography, breast tomosynthesis, interventional radiology and transcranial doppler. the lack of pacs means that several interesting teaching cases are lost irretrievably. many of the available ct scanners in the training centres are four slices with only a few centres having 64-slice or 128-slice scanners. similarly, the mri scanners in most of the training centres are low-field strength (0.2–0.3 tesla) units.38 these low-tech machines often produce comparably low-quality images. finally, instruction in medical physics is still suboptimal and this perennial problem has plagued the programme since inception.4,40 there have been improvements of late but they need to be sustained. recommendations from the foregoing, it is clear that radiology residency training in nigeria needs to be strengthened in order to continue delivering on its core mandate areas of training and research. in addition to the general proposals for improving postgraduate medical education in nigeria (comprehensive structural or organisational review, improved funding, curriculum review, retraining of trainers and incorporation of regular appraisal or monitoring or evaluation),2 the following would help to improve radiology training in particular: commencement of subspecialty training in the country is necessary.36 the society for paediatric imaging in nigeria (spin)41 and the nigeria society for interventional radiology (nisir) have already been formed but are still in its infancy. other subspecialties need to take root in the country as quickly as possible to make the programme more robust. bidirectional performance appraisal where trainees also get to evaluate their trainers is overdue.42 the current system suffers from little or no accountability on the part of the trainers.43 furthermore, addition of leadership training and non-interpretive skills (quality improvement, patient safety, professionalism and ethics, compliance or regulatory or legal issues, research and imaging informatics) to the radiology residency curriculum is highly desirable.44,45,46,47 re-instatement of the overseas clinical attachment and/or getting external examiners from the royal college (uk) or american board (usa) to partake in the fellowship examinations could help give the programme a greater international outlook and acceptability. the format of the fellowship exams of both npmcn and wacs could also be aligned to the royal college exam pattern as has been successfully implemented in various forms by malaysia, hong kong, south africa48 and singapore.49 intercalation of phd and fellowship programmes as has been conducted in the usa50 or a modification of the south african master of medicine programme48 would seem a logical way out of the needless controversy over possession of phd by medical doctors at universities.51 institution of departmental equipment budget for the servicing and replacement of old equipment, equipment donation by philanthropists and public–private partnership schemes for the procurement and maintenance of equipment will help in running the training centres sustainably.52 the process of employment into academic or trainer positions in the training centres needs to be more merit-driven. the current system is unduly influenced by politics of various shades, primordial sentiments, patronage and personal idiosyncrasies. in addition to professional qualifications and competencies, there is a need to instruct trainers in modern medical education and pedagogical techniques.29,53 undergoing the fellowship training of the foundation for advancement of international medical education and research (faimer) is recommended.54 finally, the author agrees fully with the submission of rabinowitz et al.39(p. 7) that: radiologists, radiology organizations, and radiology vendors in high-income countries are in a unique position to help african training programs, with donations of money, teaching time, teaching materials, equipment, and equipment service contracts. it is important that such endeavours be undertaken with knowledge of local political and medical systems to avoid wasting scarce, donated resources. fellowship and observership opportunities are also invaluable. conclusion there is no doubt that the radiology residency programme in nigeria has reasonably fulfilled its purpose since inception. training the next generation of radiologist physicians and trainers is an important task that requires meticulous planning, absolute commitment and adequate funding. the programme needs to be streamlined and properly repositioned to keep producing competent radiologists who are capable of fitting into the future roles of radiology in healthcare delivery.55 acknowledgements competing interests the author declares that he has no financial or personal relationships that may have inappropriately influenced him in writing this article. references population reference bureau. world population data sheet 2017 [homepage on the internet]. 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[cited 2018 feb 11]. available from: http://npmcn.edu.ng/accreditation-guidelines/ bode co, olatosi jo, ademuyiwa a. accreditation of training programmes by the west african college of surgeons. j west afr coll surg. 2012;2(2):95–109 olatosi jo. west african college of surgeons fellowship examinations. j west afr coll surg. 2014;4(4):12–14. yusufu l, ahmed a, odigie vi, delia iz, mohammed aa. residency training program: perceptions of residents. ann afr med. 2010;9:91–94. https://doi.org/10.4103/1596-3519.64745 ogundipe oa, olagunju at, lasebikan vo, coker ao. burnout among doctors in residency training in a tertiary hospital. asian j psychiatr. 2014;10:27–32. https://doi.org/10.1016/j.ajp.2014.02.010 aguocha gu, onyeama gm, bakare mo, igwe mn. prevalence of depression among resident doctors in a teaching hospital, south east nigeria. int j clin psychiatry. 2015;3:1–5. esan o, adeoye a, onakoya p, et al. features of residency training and psychological distress among residents in a nigerian teaching hospital. s afr j psychiatr. 2014;20:46–50. https://doi.org/10.7196/sajp.426 uwakwe r. residency training programme in nigeria – problems and prospects. niger j psychiatr. 2015;13(2):13–21. ogbonnaya ce. the strengths and weaknesses of the ophthalmology training programme in nigeria – a participant’s viewpoint. niger j ophthamol. 2005;13(2):42–45. https://doi.org/10.4314/njo.v13i2.11963 ogunsemi oo, alebiosu oc, shorunmu ot. a survey of perceived stress, intimidation, harassment and well-being of resident doctors in a nigerian teaching hospital. niger j clinc pract. 2010;13(2):183–186. abodunrin ol, temitayo-obor aa, arinde jt, et al. intimidation, harassment and discrimination in internship and residency training in a teaching hospital in south-west nigeria. eur j pharm med res. 2017;4(7):856–863. issa ba, adedoyin ot. global trend in the qualifications of medical educators. savannah j med res pract. 2013;2:36–45. onwudiegwu u. medical teachers and teaching qualification: abstracts from nigerian medical association annual scientific meeting, april 21–25, 2010. niger med j. 2010;1:39–51. otegbayo ja. pursuing academic qualification during residency training: justification and feasibility. ann ib postgrad med. 2003;1:37–39. adeloye d, david ra, olaogun aa, et al. health workforce and governance: the crisis in nigeria. hum resour health. 2017;15:32. https://doi.org/10.1186/s12960-017-0205-4 akinyemi o, atilola o. nigerian resident doctors on strike: insights from and policy implications of job satisfaction among resident doctors in a nigerian teaching hospital. int j health plann manage. 2013;28: e46–e61. https://doi.org/10.1002/hpm.2141 ohwovoriole ae, obembe a. a review of the results of the examinations for fellowship of the nigerian postgraduate medical college (1972–84). med educ. 1987;21:250–254. https://doi.org/10.1111/j.1365-2923.1987.tb00698.x atalabi om, adekanmi aj, bamgboye ea. the state of radiology subspecialty training in the west african subregion: the residents’ perspective. west afr j radiol. 2013;1:20(2):69–73. adeyekun aa. residents’ perception of postgraduate radiology training in nigeria. west afr j med. 2010;29:314–317. monu juv, hewlett v, ostlere s. international skeletal society outreach in sub-saharan west africa. skeletal radiol. 2011;40:251–254. https://doi.org/10.1007/s00256-010-1084-0 rabinowitz da, pretorius s. postgraduate radiology training in sub-saharan africa: a review of current educational resources. acad radiol. 2005;12:224–231. https://doi.org/10.1016/j.acra.2004.11.014 obed ri, ekpo me, omojola ad, abdulkadir mk. medical physics professional development and education in nigeria. med phys int. 2016;4(2):96–98. atalabi om, omidiji o. radiologists join to implement pediatric imaging training, education and outreach in nigeria. pediatr radiol. 2014;44:669. https://doi.org/10.1007/s00247-014-2927-y huete á, julio r, rojas v, et al. evaluation of radiology teachers’ performance and identification of the ‘best teachers’ in a residency program. acad radiol. 2016;23(7):779–788. https://doi.org/10.1016/j.acra.2016.02.015 zhivkova h. evaluation of the lecturer: the ideal and reality. ann commun orient educ. 1992;5:215–222. donnelly ef. a leadership development curriculum for radiology residency. j grad med educ. 2015;7:296–297. https://doi.org/10.4300/jgme-d-14-00644.1 heitkamp de, kerridge wd, ballenger ze, tawadros am, gunderman rb. a leadership development program for radiology residents. j am coll radiol. 2017;14:1468–1470. https://doi.org/10.1016/j.jacr.2017.05.005 neiman hl. noninterpretive skills for radiology residents. am j roentgenol. 2000;174:1523–1528. https://doi.org/10.2214/ajr.174.6.1741523 american board of radiology. noninterpretive skills resource guide 2018 [homepage on the internet]. [cited 2018 jun 26]. available from: https://www.theabr.org/wp-content/uploads/2018/02/nis-study-guide-2018.pdf pitcher r, de vries c, lockhat z. the fc rad diag(sa): stretched, but still in step – report on a royal college observership. s afr j radiol. 2017;21(1):a1092. https://doi.org/10.4102/sajr.v21i1.1092 peh wcg. the past decade of diagnostic radiology in singapore: how much progress have we really made? ann acad med. 2003;32(4):427–428. rahal a, head hw, jung aj, et al. combined radiology residency/phd program for education of academic radiologists: a response to revitalizing the radiology research enterprise. radiology. 2007;245:14–20. https://doi.org/10.1148/radiol.2451070168 booth tc, mehrzad h, wardlaw jm, jackson a, gilbert fj. training the next generation of radiology researchers. report on a joint meeting of the royal college of radiologists and the wellcome trust and an overview of college strategies in developing radiology research. clin radiol. 2012;67:411–416. https://doi.org/10.1016/j.crad.2011.09.014 saidu sa, umar fk. the challenges of running magnetic resonance imaging services in the tertiary health centres of nigeria. kanem j med sci. 2016;2(10):83–87. arogundade ra. adult learning principles for effective teaching in radiology programmes: a review of the literature. west afr j med. 2011;30(1):3–10. https://doi.org/10.4314/wajm.v30i1.69876 foundation for advancement of international medical education and research. 10 years of improving world health through education [homepage on the internet]. 2011 [cited 2018 mar 11]. available from: https://www.faimer.org/publications/10anniv.pdf the future role of radiology in healthcare. european society of radiology statement 2009. insights imaging. 2010;1:2–11. https://doi.org/10.1007/s13244-009-0007-x sajr 19_1&2 book file.indb reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers 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bulas frank a. imarhiagbe gloria soto hansraj mangray hein els himal gajjar jacqueline du toit jaishree naidoo jan lotz jeanne lubbe johan g. blickman kassa darge kieran mchugh kimberly applegate liesel davel mala modi maria i. boechat marilyn j. goske matthew goodier miranda durand nausheen khan nicky wieselthaler ntobeko a.b. ntusi otto schulze peter mercouris r. minne r. a.j. nievelstein richard de villiers richard pitcher sally e. candy sam moore sandeep jakhere shalendra k. misser shaun scheepers sherwin chan sinclair wynchank steve j. beningfield suresh k. chamarthi tanyia pillay thomas g. walker tim cain tracy kilborn victor mngomezulu werner harmse zarina lockhat abstract introduction case report discussion conclusion acknowledgements references about the author(s) siviwe s. mpateni department of diagnostic radiology, livingstone tertiary hospital, port elizabeth, south africa naye c. sihlali department of diagnostic radiology, livingstone tertiary hospital, port elizabeth, south africa emma c. gardiner rheumatology department, livingstone tertiary hospital, port elizabeth, south africa nkululo gigi department of internal medicine, livingstone hospital, port elizabeth, south africa citation mpateni ss, sihlali nc, gardiner ec, gigi n. magnetic resonance imaging findings in a patient with seropositive neuromyelitis optica. s afr j rad. 2018;22(1), a1306. https://doi.org/10.4102/sajr.v22i1.1306 case report magnetic resonance imaging findings in a patient with seropositive neuromyelitis optica siviwe s. mpateni, naye c. sihlali, emma c. gardiner, nkululo gigi received: 02 jan. 2018; accepted: 23 june 2018; published: 30 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract we present the case of a 23-year-old female with a subacute history of complex additive neurology which consisted of progressive unilateral visual impairment and subsequent blindness of the right eye, in conjunction with distal lower motor neuron symptoms of weakness and sensory loss from t4 level down. special investigations performed, included serology and an urgent magnetic resonance imaging (mri) of the brain and spinal cord, which exhibited a diffuse demyelinating disease of the brain and spinal cord without the typical features of multiple sclerosis (ms) and laboratory findings, which were positive for the aqp-4 antibody, confirming the diagnosis of neuromyelitis optica (nmo). pulsed methylprednisolone was initiated urgently with good effect and immunosuppression with cyclophosphamide was added after the exclusion of additional pathology. she experienced a complete resolution of her weakness and sensory impairment upon discharge; however, her unilateral visual loss remained. the recent advances in the identification of autoimmune biomarkers and the widening spectrum of imaging findings in nmo necessitate that the clinician and radiologist keep abreast of the current diagnostic tools and criteria that distinguish nmo from other demyelinating conditions. introduction neuromyelitis optica (nmo), also known as devic’s disease, is an idiopathic demyelinating disease of the central nervous system that is typified by severe and intermittent involvement of the optic nerve, spinal cord and brain. this clinical entity was previously considered a variant of multiple sclerosis (ms), but recent developments in clinical, radiological and immunological characteristics of the disease have paved the way for a more detailed definition of this condition as a separate neurological affliction.1,2,3 the aetiology of this condition is driven by the action of the autoantibody, namely, nmo-immunoglobulin g (igg), against aquaporin-4 (aqp4) water channels. aquaporin-4 channels are highly populated in the astrocytes which facilitate the transportation of water through cell membranes.4,5 the spinal cord and optic nerves are occupied by aquaporin channels and appear to be the preferential targets, probably because of the increased permeability of the blood-brain barrier in these regions.4 the previous classification of nmo regarded the condition as a clinical subtype or variant of ms, and this resulted in delayed detection and misrecognition of nmo. the early differentiation between nmo and ms is particularly important because the course of nmo is more severe and the treatment strategies for attack prevention differ. immunotherapies approved for the treatment of ms have proven ineffective and even appear to aggravate nmo relapses.1 the diagnostic limitations of complex neurological findings in patients who present with overlapping upper and lower motor neuron signs remain a challenge for health care practitioners, especially in resource-limited centres. the cohesive application of clinical, radiological and immunological findings to reach a definitive diagnosis is of the utmost importance in such settings. case report we present the case of a 23-year-old female who was referred to livingstone tertiary hospital with a 1-year history of coombs-positive autoimmune haemolytic anaemia secondary to systemic lupus erythematosus (sle). she was previously on corticosteroid therapy which was discontinued and she had no other established organ involvement. she developed progressive loss of vision in the right eye, in association with left hemiparesis and subtle sensory deficit extending inferiorly from the level of t4. on clinical examination, she was fully conscious and oriented; her vision was limited to light perception in the right eye and fundoscopy revealed a clinically pale right optic disc. further neurological assessment revealed that she had motor weakness with 4-/5 power in the left upper and lower limbs and sensory impairment predominantly affecting the left side with a t4 sensory level. in addition, she had bilateral sensorimotor weakness superimposed on her left hemiparesis and features of chronic distal lower motor neuron polyneuropathy. initial investigations included serology and urgent magnetic resonance imaging (mri) of the brain and spinal cord with contrast (figures 1–6). figure 1: sagittal t2-weighted magnetic resonance image depicting a hyperintense longitudinally extensive spinal cord lesion extending from the cervicomedullary junction to the c4 vertebra. figure 2: sagittal short ti inversion recovery magnetic resonance images demonstrating longitudinally extensive spinal cord lesion. figure 3: sagittal t1-weighted image depicting hypointensity in the splenium and cervical spinal cord. figure 4: axial fluid-attenuated inversion recovery magnetic resonance image demonstrating hyperintensity in the splenium of corpus callosum in a ‘bridging arch pattern’. figure 5: axial fluid-attenuated inversion recovery magnetic resonance showing patchy hyperintensity in the midbrain and depicting faint hyperintensity of the right posterior optic nerve. figure 6: axial t2-weighted image with hyperintense subcortical white matter lesions. magnetic resonance imaging of the cervical spine revealed a t2 hyperintense central grey matter lesion extending longitudinally and contiguously across three vertebral body lengths. brain mri demonstrated similar t2 hyperintense lesions involving the splenium of the corpus callosum, the midbrain and centrum semiovale. there were no perivenular radially oriented lesions (dawson fingers) that are typical of ms. cerebrospinal fluid analysis demonstrated no lymphocytes, normal protein and negative oligoclonal bands. serum studies were positive for aqp4-antibodies (nmo-igg), confirming the diagnosis of nmo. treatment with high-dose corticosteroid therapy and cyclophosphamide was initiated and this led to a complete resolution of the patient’s weakness and sensory deficit; however, the visual impairment in the right eye persisted. discussion there are limited studies on the prevalence of nmo in the southern african population, especially in human immunodeficiency virus-(hiv) negative subjects, and this condition is likely underdiagnosed. north american studies depict ranges from 0.5 to 4.4 per 100 000, with a higher incidence in asian populations, indian populations and african populations, with women being more commonly affected with a ratio of 6.5–1.4 acute attacks are characterised by progressive loss of vision in one or both eyes, varying degrees of weakness or paralysis in the legs or arms, sensory deficits as well as bladder and/or bowel dysfunction. the onset of optic neuritis can be unilateral or bilateral and may be confounded by concurrent myelitis; hence, serological findings can serve to be a valuable diagnostic tool. nmo-immunoglobulin g offers a specificity of more than 90% and sensitivity of 70% – 90% for this condition.5 conventional magnetic resonance (mr) imaging changes have traditionally been recognised in the spinal cord and optic nerves. however, recent studies documenting cerebral involvement have mandated the inclusion of cerebral involvement as one of the major supportive criteria. the lesions in nmo are typically hyperintense on t2-weighted images. the distribution is observed in the regions of the central nervous system known to be rich in aqp4, typically in a periependymal distribution in the periventricular white matter, corpus callosum and central grey matter of the spinal cord.5 both ms and nmo present with circumventricular cerebral lesions; however, there are salient defining imaging features that distinguish these conditions on imaging. ms frequently presents with discrete, ovoid lesions which lie perpendicular to the ventricles (radially oriented perivenular lesions commonly referred to as ‘dawson fingers’).5,6 in contradistinction, the lesions in nmo occur along the ependymal lining of the lateral ventricles, the regions around the third ventricle, cerebral aqueduct and fourth ventricle. these are heterogeneous, oedematous and form large confluent lesions creating a ‘marbled pattern’. there may be notable involvement of the splenium presenting as a unique ‘bridging arch pattern’ as was demonstrated in this case (figure 4).2,5,6 similar large, confluent and heterogeneous lesions occur in the cerebral white matter, which may be contiguous with the periependymal lesions. spinal cord imaging features in nmo demonstrate the presence of longitudinally extensive spinal cord lesions (lescls), which extend contiguously across at least three vertebral segments.2,3,4 lescls are, however, not exclusive to nmo and appear to be less disease specific in children than in adults. they are frequently observed in children with acute disseminated encephalomyelitis, as well as in 17% of those with ms and in 67% – 88% of those with monophasic transverse myelitis.5,6 in nmo there is a preferential involvement of the central grey matter which is abundant with aqp4 in the glial cell processes adjacent to the ependymal cells of the central canal with lesions frequently affecting the cervical and thoracic spinal cord.3,5 lesions in nmo exhibit high signal intensity on t2-weighted images and low signal intensity on t1-weighted images. in ms, however, hypointense lesions on t1-weighted images are very rare. the typical spinal cord features of ms are of multiple, short lesions which have a peripheral, asymmetric and often posterior distribution.6 optic nerve changes occur in both nmo and ms. the associated imaging features of both depict acute nerve sheath thickening and enhancement; however, long-segment inflammation that extends posteriorly to the optic chiasm should rouse the suspicion of nmo, especially when findings are simultaneous and bilateral.5,6 the current diagnostic criteria for nmo mandate the occurrence of: (1) optic neuritis, (2) myelitis and (3) at least two of the following three supportive criteria: longitudinally extensive spinal cord lesions seropositivity for igg antibodies that bind aqp4 on astrocytes brain imaging findings non-diagnostic for ms.2,5 the fulfilment of the current diagnostic criteria differentiates nmo from other demyelinating disorders, which is crucial as specific therapeutic interventions are required to reduce the frequency of flare-ups. mr imaging in patients with nmo has revealed an expanding array of lesion subtypes with which the radiologist must be familiar.5 in presenting this case, we would like to draw special attention to the imaging features and the diagnostic biomarkers that assist in defining nmo as a clinical entity. conclusion novel immunological investigations (nmo-igg/aqp4-antibody) have had a tremendous impact in achieving greater diagnostic accuracy. with this case we hope to highlight the diagnostic complexity encountered when analysing the imaging findings in nmo and encourage a high-index of suspicion when met with the above-mentioned imaging features. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions e.c.g. and n.c.s. encouraged case selection and offered guidance for final edit. n.g. compiled the clinical data and s.s.m. compiled the imaging data and wrote the case report. references beiruti k, saleh sa, daitzchman m, shahien r. neuromyelitis optica spectrum disorder: a case report. j mult scler. 2016;3:192. https://doi.org/10.4172/2376-0389.1000192 wingerchuk dm, lennon va, pittock sj, lucchinetti cf, weinshenker bg. revised diagnostic criteria for neuromyelitis optica. neurol. 2006;66:1485–1489. https://doi.org/10.1212/01.wnl.0000216139.44259.74 evangelopoulos me, koutsis g, andreadou e, potagas c, dimirakopoulos a, sfagos c. neuromyelitis optica spectrum disease with positive autoimmune indices: a case report and review of the literature. case rep in med. 2011, article id 393568. https://doi.org/10.1155/2011/393568 sarbu n, shih ry, horkanye-szakaly i, oleaga l, smirniotopoulos jg. white matter diseases and radiologic-pathologic correlation. radiographics. 2016;36:1426–1447. https://doi.org/10.1148/rg.2016160031 barnett y, sutton ij, ghadiri m, masters l, zivadinov r, barnett mh. conventional and advanced imaging in neuromyelitis optica. am j neuroradiol. 2014;35:1458–1466. https://doi.org/10.3174/ajnr.a3592 kim hj, paul f, lana-peixoto ma, et al. mri characteristics of neuromyelitis optica spectrum disorder. am acad neurol. 2015;84(11):1165–1173. pictorial interlude 41 sa journal of radiology • september 2006 a 54-year-old man presented with a longstanding history of peripheral artery disease and right leg pain for 2 weeks. an angiogram demonstrated no filling of the celiac axis or superior mesenteric artery implying stenosis/cut-off of these vessels. a meandering mesenteric artery was visible. the direction of flow in this vessel was shown by retrograde filling of the middle colic branch of the proximal superior mesenteric artery, which in turn provided collateral flow to the superior mesenteric artery, and then subsequently, collateral flow to the celiac artery through an enlarged pancreaticoduodenal artery. (figs 1 a and b). the digital subtraction arteriogram (dsa) imaging findings were incidental and the patient had no symptoms of mesenteric ischaemia or abdominal discomfort. discussion the meandering artery is an existing vessel, which only enlarges with abdominal arterial occlusion. the combination of superior mesenteric artery and celiac axis occlusion in an asymptomatic patient is rare and these vessels usually have retrograde filling via the meandering mesenteric artery.1,2 the meandering mesenteric has great surgical significance. it should therefore be noted on arteriogram and surgically preserved when performing aortic procedures, left colon resections (where the inferior mesenteric artery fills the superior mesenteric artery and/ or celiac truncus) and right and transverse colon resections (where the inferior mesenteric artery has previously been ligated during aortic surgery and is filled by the superior mesenteric artery).3 conclusion the meandering mesenteric artery is a rare finding with the combination of superior mesenteric artery and celiac axis occlusion. its main function is to preserve mesenteric perfusion in patients with severe arterial disease. therefore, it should be noted on arteriograms and surgically preserved when planning bypass surgery for peripheral arterial disease or colon resections. 1. reiner l, rodriques fl, jimenez fa, platt r. injection studies on mesenteric artery circulation. iii. occlusion without intestinal infarction. ama arch pathol 1962; 73: 461-472. 2. kahn p, abrahams hl. inferior mesenteric arterial patterns: angiographic study. radiology 1964; 82: 429-442. 3. gourley ej, gering sa. the meandering mesenteric artery: a historic review and surgical implications. dis colon rectum 2005; 48: 996-1000. the meandering inferior mesenteric artery melanie strachan, mb chb, lmcc ii (can) yousuf vadachia, mb chb stefan przybojewski, mb chb, mmed (rad diag), fcrad diag (sa), dip pec (sa) department of radiology, stellenbosch university and tygerberg hospital fig. 1a. digital subtraction arteriogram shows prograde filling of the abdominal aorta, bilateral renal arteries and inferior mesenteric artery. there is no filling of the celiac axis or superior mesenteric artery, implying stenosis or cut-off of these vessels. a meandering artery is visible. fig. 1b. the direction of flow in the meandering mesenteric artery is shown with retrograde filling of the middle colic branch of the superior mesenteric artery. there is subsequent filling of the superior mesenteric artery by the middle colic branch. pg 41.indd 41 9/6/06 2:58:47 pm revie\n echo enhancing •agents in ultrasound petercorr mbchb, ffrad(d)sa, frcr, mmed(uct) department of radiology, university of natal e cho enhancing micro bubble agents show great promise for blood pool imaging in diagnostic ultrasound. i their applications include vascular enhancement of both large vessels such as the renal and carotid arteries as well as small arteries in the kidneys, brain and liver. they are being used as contrast agents in hysterosalpinography, micturating cystourethrograms and as oral contrast agents. targeted echo enhancers have been used to delineate thrombus and the endocardial lining of the heart. i these micro bubbles are a few microns in diameter and they resonate extremely well with 3-lomhz transducers used in diagnostic ultrasound. this resonance causes extensive cross sectional scattering and excellent reflectivity. the micro bubbles are small enough to pass through the pulmonary capillaries allowing arterial enhancement via intravenous injection. there are three generations of micro bubble agents.' the first generation agent has a very short life of a few seconds. echovist (schering) is such an example. in second generation micro bubbles a stabilizing agent (palmitic acid) is added to increase the intravascular half life and produce ultrasound detected vascular enhancement. levovist (schering) and albunex (nycomed) are examples." the third generation of micro bubbles have greater intravascular stability and life and higher reflectivity. these include echogen (sonus), nus (nycomed) and shu 563a (schering).' practical applications will be initially limited to colour flow ultrasound but the third generation agents have such significant reflectivity that they may be used with grey scale as well. promising applications include: transcranial imaging of cerebrovascular disease and vascular tumours such as meningiomas examination of breast masses by evaluating tumour perfusion diagnosis of coronary artery disease by documenting perfusion defects improved ultrasound diagnosis of liver, spleen, kidney, prostate, testicular and thyroid tumours (figures 1a and 1b) figure ts: ultrasound of the right/obe of the liver of a 60 year old man with ruo pain demonstrates an ill defined echogenic mass (arrow). 5 sa journal of radiology· september 1996 figure 1b: after the injection of levovist there is a marked intratumora/ enhancement of the mass confirming its hypervascu/arity (arrow). this was confirmed to be a hepatoma. improved visualisation of blood flow in carotid, vertebral, renal and peripheral arteries echo enhancing agents will be particularly useful to enhance doppler signals which are very weak or difficult to obtain or in situations of very slow blood flow. in situations of slow flow such as critical carotid stenosis, enhancement of a weak signal will be very helpful to distinguish between critical stenosis and total carotid occlusion. the first micro bubble contrast agent to be approved by the medicines control council will be on the market in south africa later this year. cost may be a critical factor in their initial acceptance. references 1. u1trasonographic echo enhancing agents. editor d. cosgrove. clin rad 1996;51 :1-56( supp). 2. fan p, czuwala pj, nanada nc. comparison of various agents in contrast enhancement of color flow doppler images: an in vitro study. ultrasound med bioi lffi3;19:4547. 3. dejongh n, hoffl. ultrasound scattering properties of albun ex microspheres. ultrasollics1993;31: 175-181. 4. schurmann r, schliefr. saccharide based contrast agents. characteristics and diagnostic potential. radiol med1 994;87: 15-23. 5. unger e, lund p, shen d. nitrogen riled liposomes as a vascular us contrast agent: preliminary evaluation. radio/oy 1992;185:453-456. abstract introduction epidemiology classification risk factors clinical manifestations radiological manifestations non-radiological investigation clinical management prevention conclusion acknowledgements references about the author(s) nasreen mahomed department of radiology, faculty of health sciences, university of the witwatersrand, south africa gary reubenson department of paediatrics & child health, faculty of health sciences, university of the witwatersrand, south africa citation mahomed n, reubenson g. immune reconstitution inflammatory syndrome in children. s afr j rad. 2017;21(2), a1257. https://doi.org/10.4102/sajr.v21i2.1257 review article immune reconstitution inflammatory syndrome in children nasreen mahomed, gary reubenson received: 24 july 2017; accepted: 19 sept. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract immune reconstitution inflammatory syndrome (iris) refers to a collection of inflammatory disorders, predominantly related to infectious processes that manifest after the initiation of antiretroviral therapy (art) and can be classified as unmasking or paradoxical. the prevalence of iris in children in sub-saharan africa is low. approximately half of all cases are associated with mycobacterium tuberculosis. it may be difficult to distinguish iris from tuberculosis and other opportunistic infections radiologically; therefore, radiological findings must be interpreted with clinical and laboratory findings. in this review article, we describe the clinical and radiological manifestations of iris in children and provide illustrative radiological examples. introduction antiretroviral therapy (art) has revolutionised the care of hiv-infected children. compared to untreated children, life expectancy and quality of life are substantially better for children receiving art.1,2 however, like any medication, art has side effects and potential adverse consequences; the immune reconstitution inflammatory syndrome (iris) is one such adverse consequence.3,4,5 iris refers to a collection of inflammatory disorders, predominantly related to infectious processes that manifest after initiation of art. it is usually a self-limiting condition, but on occasion may be severe and rarely can be life-threatening. in most cases, art can be continued and appropriate antimicrobial therapy is provided for the relevant opportunistic infection.6 the immunological changes that occur following initiation of art are complex,7,8 but as the name implies, iris occurs when art-associated improved immune function results in an excessive immune response.9 interestingly, paradoxical worsening of symptoms following initiation of treatment has been described in hiv-uninfected patients and follows a similar improvement in immune function. paradoxical tuberculosis (tb) reactions are the best known examples of this.10,11 epidemiology early, retrospective studies estimated iris incidence as high as 30%; however, more recent evidence suggests a much lower rate of < 10%.5,6,12,13 a recent south african study using the international network for the study of hiv-associated iris criteria reported a paradoxical tb-iris incidence of 4.8% among 104 children under 8 years of age.14 the incidence of iris varies according to the associated micro-organism or underlying condition, the definition of iris used, including whether paradoxical or unmasking forms of iris or both are included, the region of the world and local incidence of particular opportunistic infections and age of the children. epidemiological studies on the overall incidence of iris and on specific forms of iris in children are limited in number and as a result of the factors mentioned above. classification iris is typically classified as either unmasking or paradoxical; however, this distinction may be difficult, as both forms may coexist in the same child and other explanations for the findings should be considered.15 unmasking iris refers to clinical features related to a previously undiagnosed, asymptomatic or subclinical infection, whereas paradoxical iris is worsening of a previously diagnosed or partially treated condition. non-infectious forms of iris include autoimmune processes and malignancies.14,15,16,17 precise diagnostic criteria for iris have been suggested, but consensus on such criteria has not been reached. however, iris should be strongly considered when:9,18 art has been recently initiated, usually within the last 2–6 weeks, but iris has been reported many months after initiation. there has been a substantial decline in hiv viral load, usually with a significant rise in cd4 count – however, iris may occur in the absence of either or both of these. local or systemic inflammatory changes occur related to a previously diagnosed (paradoxical iris) or unrecognised (unmasking iris) infectious condition – however, iris has been reported for non-infectious conditions, including malignancies and autoimmune diseases. an alternative explanation for these changes is not identified. this can be very challenging as progression of hiv, new opportunistic infections, drug-resistant pathogens, and medication side effects may present similarly. risk factors the risk for and severity of iris are largely informed by two factors. firstly, the degree of cd4+ t-cell immune suppression; the lower the pre-treatment cd4 count, the higher the risk of iris.13 secondly, the virological and immunological responses to art; the more rapid the decline in hiv viral load and the faster the rise in cd4 count, the greater the likelihood of developing iris.13,18 this likely explains the declining incidence in paediatric iris as children are being diagnosed earlier and are started on art soon thereafter, usually before progression to profound immune suppression.19 clinical manifestations clinical manifestations of iris are dependent on the implicated pathogen and frequently involve worsening of previously identified manifestations or the onset of new symptoms, similar to those encountered with non-iris–related infections with the same pathogen. mycobacterium tuberculosis (tb) is implicated in approximately half of adults with iris.21 tb is less commonly implicated in paediatric iris, possibly related to the paucibacillary nature of paediatric tb.14 other pathogens commonly implicated are bacille calmette–guérin (bcg) vaccine,22,23 cytomegalovirus (cmv)24 and non-tuberculous mycobacteria (ntm).25 less common causes of paediatric iris include herpes simplex, kaposi sarcoma (caused by human herpesvirus 8),26,27 cryptococcus neoformans,28 pneumocystis jirovecii29 and parvovirus b19.30 this differs from adults, where cryptococcal iris28 is more likely and bcg-iris essentially does not occur. systemic manifestations include fever, weight loss, fatigue and pain.20 common clinical manifestations of iris in children are tabulated in table 1. in children dermatological manifestations such as seborrhoeic dermatitis and herpes zoster are not uncommon, generally mild and not associated with radiological changes. table 1: common clinical manifestations of immune reconstitution inflammatory syndrome. radiological manifestations mycobacterium tuberculosis–associated immune reconstitution inflammatory syndrome radiologically it is important to distinguish iris from tb or other opportunistic infections, including ntm and cmv. drug-resistant tb is a clinical and laboratory diagnosis, not a radiological diagnosis and both drug-sensitive and drug-resistant tb can manifest iris reactions.17,31 the most common radiological manifestations of tb-iris occur within the chest and include new or worsening hilar or mediastinal lymphadenopathy, which may cause tracheo-bronchial compression. other common chest radiological findings include worsening or new air space consolidation, pleural effusions, reticular infiltrates or nodular infiltrates (figures 1–3).14,16,17,31 figure 1: an 11-year-old hiv-infected boy, cd4 count 9 cells/mm3 (4%), was initiated on art. he developed progressive symptoms consistent with disseminated tb and responded well to continuation of art and standard four-drug tb treatment. frontal chest radiograph taken at the time of art initiation (a) demonstrates a normal chest radiograph. frontal chest radiograph (b) taken 3 weeks after art initiation demonstrates a diffuse reticular nodular infiltrate with bilateral hilar lymphadenopathy (open arrows) and small pleural effusions (closed arrows). a diagnosis of unmasking tb-iris was made. figure 2: a 3-year-old hiv-infected girl initiated on art 2 weeks after starting tb treatment. cd4 count was not available. frontal chest radiograph taken at the time of art initiation: (a) demonstrates bilateral hilar lymphadenopathy (open arrows). chest radiograph taken 2 weeks after art initiation; (b) demonstrates right middle lobe consolidation and collapse (closed arrow), with worsening hilar lymphadenopathy (open arrows). in combination with the clinical, radiological and laboratory findings, a diagnosis of paradoxical tb-iris was made. figure 3: a 4-year-old hiv-infected boy living with an adult diagnosed with pulmonary tb was initiated on art. three months later, he developed symptoms of pulmonary tb, which was microbiologically confirmed (unmasking iris). he was initiated on appropriate tb treatment and initially improved; 3 weeks later he presented with fever and worsening respiratory symptoms and signs (paradoxical iris). computed tomography of the chest, axial, soft tissue window (a and b) demonstrates mediastinal and hilar lymph nodes (arrows) encasing the bronchi bilaterally. there is also posterior mediastinal involvement with anterior displacement of the left atrium and a small right pleural effusion; (c) axial lung window demonstrates dense right middle lobe and apical segment of right lower lobe consolidation with lingular consolidation. a diagnosis of paradoxical and unmasking tb-iris was made. art and tb treatment were continued and corticosteroids were administered; he demonstrated a good clinical response and is currently well; (d) axial ct chest axial lung window performed 6 months later demonstrates resolution of the consolidation, with residual lymphadenopathy (open arrows). abdominal manifestations of tb-iris include ascites, abdominal lymphadenopathy, and splenic micro-abscesses.16 central nervous system (cns) manifestations are uncommon and include tb meningitis, which may cause obstructive hydrocephalus, or associated tuberculomas.16 bacille calmette–guérin–associated immune reconstitution inflammatory syndrome bcg-associated iris is well recognised16 and in some settings is the most commonly identified cause.16,22 it usually manifests with inflammatory changes at the injection site and/or within the ipsilateral draining lymph nodes. chest radiographic changes are uncommon and may be indistinguishable from tb.22 unusual manifestations of bcg-iris have been reported (figure 4). figure 4: a 9-month-old hiv-infected girl, with cd4 count 9 cells/mm3 (1.53%), was admitted with severe malnutrition, right axillary and left thigh abscesses, generalised lymphadenopathy, hepatosplenomegaly and clinical evidence of hiv encephalopathy. art was initiated with subsequent worsening of the thigh abscess. an aspiration was performed on the left thigh abscess which cultured mycobacterium bovis bcg, confirmed using molecular testing. appropriate antimycobacterial treatment was provided: (a) (lateral) and (b) (ap), radiograph of the lower limbs demonstrate an air containing abscess in the upper left lateral thigh soft tissues (open arrow) and generalised left lower limb soft tissue swelling. no periosteal reaction was demonstrated in visualised bones. she was readmitted a year later, still on antimycobacterial treatment with soft tissue abscesses in the right thigh, forehead, abdominal wall and left forearm; (c) (left lateral knee) demonstrates osteomyelitis, with lytic lesions within the proximal tibial metaphysis and a cortical break along the anterosuperior tibial margin (open arrow). there is periosteal reaction along the tibia and distal femur (closed arrow) with generalised soft tissue oedema; (d) (left ap forearm) demonstrates another focus of osteomyelitis with lytic lesions in the proximal metadiaphysis of the ulna (open arrows), associated periosteal reaction and osteopenia of the left ulna and radius. bone aspiration again confirmed m. bovis bcg, now resistant to first-line antimycobacterial agents, necessitating surgical drainage; however, the patient did not survive. a diagnosis of bcg-iris was made. mycobacterium avium complex immune reconstitution inflammatory syndrome mycobacterium avium complex (mac)–associated iris manifests radiologically as necrotic lymph nodes identified on ultrasound, computed tomography or magnetic resonance imaging. these may be indistinguishable from other mycobacterial infections. the diagnosis of mac may be made from tissue culture;16 however, cultures are commonly negative. therefore, a high level of clinical suspicion is required. radiologically, it may be difficult to distinguish iris from tb and other opportunistic infections so radiological findings must be interpreted in combination with clinical and laboratory findings.16,17,31 non-radiological investigation investigation is largely informed by the particular infection under consideration. measurement of viral load and cd4 counts are helpful, particularly when poor adherence to therapy is suspected. a significant decline in viral load from baseline, as well as a substantial increase in cd4 count, is suggestive of iris, but not essential for making the diagnosis.9,18 of note, children with suspected local or regional bcg-iris can generally be diagnosed based on clinical manifestations and microbiological confirmation using lymph node biopsy or fine-needle aspiration is seldom warranted unless alternative diagnoses are under consideration. if samples are submitted from patients with suspected bcg-related disease, it is vital to indicate this on the laboratory request form so that appropriate testing to differentiate tb from bcg can be performed. clinical management the most important components of effective management are to treat the iris-related infection using the same modalities as for non-iris–related infections with that pathogen. because iris is frequently mild and self-limiting, in most patients continuation of art is to be encouraged.6 in patients with severe or life-threatening iris, including airway compression by hilar or mediastinal lymph nodes or expansile cns mass lesions, it may rarely be appropriate to interrupt art until their condition stabilises, whereafter art can be safely restarted.6 stopping art is not to be taken lightly and when being considered should involve discussion with a specialist or subspecialist. in children with pain and discomfort from bcg-iris lymphadenitis, consideration should be given to needle aspiration of fluctuant areas to relieve symptoms. such aspiration may need to be repeated.22 in addition to continuation of art and treating the implicated pathogen, patients with iris may benefit from anti-inflammatory medicines. in mild and moderate cases, non-steroidal anti-inflammatory drugs (nsaids) have been used to provide symptomatic relief and may hasten iris resolution. in more severe cases, corticosteroids may be required for a number of weeks, whereafter they can be tapered and stopped.6 the additional immune suppression related to corticosteroid use is a concern in such patients and specialist input is advised before their commencement. prevention if hiv is diagnosed early and art initiated soon thereafter, iris is unlikely.23 recent improvements in early infant diagnosis of hiv followed by almost immediate initiation of art have resulted in iris becoming uncommon.23 furthermore, it is important to consider opportunistic infection prior to art initiation as initiating treatment for them first may reduce the risk of iris developing. this is particularly true for cns tb and cryptococcal meningitis where art initiation should be delayed during the initial weeks of treatment in order to reduce the risk of iris. tuberculous mass lesions (tuberculomas) have been associated with life-threatening cns-iris.13,32 in most patients with tb, art can be safely initiated about 2 weeks after tb treatment has commenced; however, extrapolating from experience in adults with hiv-associated cryptococcal meningitis, art initiation should be delayed by at least 6–8 weeks.33 routine prophylactic use of nsaids or corticosteroids to reduce the risk of iris is not recommended, rather patients at high risk for iris should be closely monitored for new or worsening symptoms so that iris can be timeously identified and treated. conclusion while art has revolutionised the care of hiv-infected children, art has side effects and potential adverse consequences which include iris. iris is typically classified as either unmasking or paradoxical; however, this distinction may be difficult, as both forms may coexist in the same child and other explanations for the clinical findings should be considered. approximately half of all iris (adult and paediatric) cases are associated with m. tuberculosis. the commonest radiological manifestations of tb-iris include new or worsening hilar or mediastinal lymphadenopathy, worsening or new air space consolidation, pleural effusions, reticular infiltrates or nodular infiltrates. it may be difficult radiologically to distinguish iris in children from tb and other opportunistic infections so radiological findings must be interpreted in combination with clinical and laboratory findings. acknowledgements we would like to acknowledge dr gillian sorour for her contribution towards the clinical cases. competing interests the authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article. authors’ contributions both authors contributed equally to writing the article, thus co-first authors. g.r. was predominantly responsible for the clinical component and n.m. for the radiology. references nesheim sr, kapogiannis bg, soe mm, et al. trends in opportunistic 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with aids and cryptococcal meningitis. j acquir immune defic syndr. 2007;45(5):595–596. https://doi.org/10.1097/qai.0b013e318061b5eb barry sm, lipman mc, deery ar, et al. immune reconstitution pneumonitis following pneumocystis carinii pneumonia in hiv-infected subjects. hiv med. 2002;3(3):207–211. https://doi.org/10.1046/j.1468-1293.2002.00115.x watanabe d, taniguchi t, otani n, et al. immune reconstitution to parvovirus b19 and resolution of anemia in a patient treated with highly active antiretroviral therapy. j infect chemother. 2011;17(2):283–287. https://doi.org/10.1007/s10156-010-0111-3 theron s, andronikou s, george r, et al. non-infective pulmonary disease in hiv-positive children. pediatr radiol. 2009;39(6):555–564. https://doi.org/10.1007/s00247-009-1156-2 zolopa a, andersen j, powderly w, et al. early antiretroviral therapy reduces aids progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. plos one. 2009;4(5):e5575. https://doi.org/10.1371/journal.pone.0005575 bisson gp, molefi m, bellamy s, et al. early versus delayed antiretroviral therapy and cerebrospinal fluid fungal clearance in adults with hiv and cryptococcal meningitis. clin infect dis. 2013;56(8):1165–1173. https://doi.org/10.1093/cid/cit019 technology update connectivity . teleradiology and beyond (part one) connectivity, teleradiology and telemedicine, these are some of the "buzz words" describingthe latest technology in our field and, as with any new technology, it has spawned its own jargon and set of acronyms. this article aims to explain some of the jargon and in so doing enhance the levelof discussion of this important topic. why connectivity? throughout the world health care providers are finding that improved productivity and efficiency are critical to long term success.the use of connectivity has the following primary goals: • connect existing digital equipment in order to reduce manual activities and increase departmental efficiency: • move images quickly throughout the fadlity to enhance patient care. • move image data between facilitiesin order to make use of centres of excellence to speed diagnosis. • integrate image data with diagnostic information to improve the diagnostic process. • to allow disadvantaged communities access, via telecommunications, to specialistcare. one of the most common terms that is being bandied about is dicom. what is drcom and why is it so important? drcom is an acronym for digital imaging and communications in medidne.drcom wasdevelopedbytheamerican college of radiology (acr) in conjunction with the national electrical manufacturers' association (nema) in america. the current version of the standard is "version 3,0". we are talking here of connecting two devices together, and as far as dicom is concemed that means we have to describe both ends of the connection. this leads to the concept of service classes. service classes provide very specific information about the kinds of images to be exchanged and the expected operation of the devices on both ends of the connection. an alternative description of a service dass is a sop class (sop stands for service/objectpair). images are called "objects" and the operations the device is to perform on the images are called"services".in addition, devices daim conformance to a service class as either a user or a provider. by way of another example, laser print ers are providers of the basicgreyscale print management service class. drcom requires the manufacturer to publish a conformance statement for all devices that claim conformance to the standard. the conformance statement contains very specific information about the device. to use the laser printer example above, the conformance statement would contain the following information: • the network on which it operates, for example tcpiip over ethernet • the service class (or classes) that the device conforms to, for example basic greyscale print managernent (ibis means it prints black and white images) • the range of values supported for various functions, for example formats of l-up to 35-up and that it can print 4096 x 5120 pixels • optional functions that are supported, such as slides rt will be dear from the above that the simple statement "dicom compatible" doesn't mean very much and that an indepth investigation is needed to establish whether devices will indeed "talk" to each other and perform useful work next we look at modems and isdn modem stands for modulator demodulator. the most common application of a modern is the fax machine where a document is scanned and the information (characters and graphics) is modulated the service class user/provider .a concept 1-------1 ~ ~ 1.=_-' although the ct scanner 'provides" images, it is a uhr of the ilorage eervlee provided by the archive and display system. it thus claims conformance as a user of the ct image storage service class, the image archive and display system claims conformance as a provider of the ct image storage service class, 42 sa journal of radiology. september 1996 to page 43 c()nnectivity . teleradiology and beyond (part 1) frompage42 onto a tone that can be transmitted down a conventional telephone line.at the receiving end the tone is demodulated back into characters and graphics and printed out. standard faxes operate at 9600 bits per second (or 9600 baud). moderns on computers that share data or access the internet can run at up to 28 800 baud, however this is approaching the limit of what a standard telephone line can handle. the next generation of telephone lines will use integrated services digital network (isdn). when you pick up your phone, the dial tone you hear is sent from your telephone exchange which, in modem areas, is a powerful digital switch. the switch, in turn, is linked to hundreds of thousands of high speed digital connections that are capable of carrying thousands of voice and data conversations simultaneously. the problem comes in with the line that connects your phone to this network it is analog! as can be appreciated, this may work well for voice and faxes but when we want to transfer massive amounts of data (such as contained in a radiographic image) we are faced with a very slow system. isdn is a fully digital service which allows simultaneous high-speed transfer of live video, data and fax over a conventional telephone line. isdn comprises two types of communications channels: b channels (bearer channels] b channels are designed to carry virtually any kind of digital information. they are normal telephone lines that are capable of carrying data at 64000 bits per second. d ch31u1els (delta ch3lu1els) d channels carry call signalling and set-up information such as the telephone number of the network. this channel dramatically speeds up connection time. basic rate basic rate isdn provides the user with two 64kbps b channels and one 16kbps d channel. basic access represents lsdnin its simplest form. theauthorwishes tv thank the sa. isdn forum, ge medical, teemed (kodak health systems), sa. philips and siemens forprovidinginformation for this article. company news pi"iilli's medical telemedicine the diagnostic information highway of the future philips medical systemsoffer a range of products, continuing development and support expertise. optimising resource management by providing professional expertise remotely, where previously no service was offered, or to achieve competitive business advantage for the private practitioner, will be increasingly addressed by the use of computer driven communication networks. from the 'total concept' approach of a large investment,single picturearchivingand communication systems (pacs) of the ] 970s, a phased, modular approach is todays formula for implementation. philips medical systems has fully adopted a customer focused, bottom up design approach, allowing customisation to achieve specific requirements. the principle is that transmission, display, manipulation and storage of digital images should offer physicians clinical advantages, improve operation of health care institutions, and ultimately optimise patient service. the modular concept facilitates staged integration of the radiology information system (ris), the digital information of mr, ct, anglographic and rif applications, cassette based computed radiography and remote tele-irnages the evolvement of the dicom standard for transferring images and associated information between digital devices regardless of manufacturer, provides further expansion of the integrated modular approach. 43 sa journal of radiology. september 1996 the philips "iele-imager" teleradiology system offers custom designed software the basic system, which can be fully extended in a modular approach, comprises a capture station, a viewing station and the transmission medium. multiple resolution choic s from lk2 to 4k.2 filmdigitisationwith 12bit grey scale imaging, choice of compression factors and combined with 1600 x 1200 monitor display, provide superior diagnostic capability. image transmission can take p.lace by standard telephone lines, diginet or isdn !.ines,local or wide area networks. the ability to interconnect the system with other modalities ct, mr, angio, rif and cornputed radiography provide for an integrated network development. for more information, contact your local philips medical representative, or tel. (011) 4803035; e-mail mbrandt® iafrica.com. topag844 about the author(s) liam lorentz department of radiology, university of the witwatersrand, south africa jaishree naidoo department of radiology, university of the witwatersrand, south africa citation lorentz l. naidoo j. generalised lymphangiomatosis: a diagnostic challenge. s afr j rad. 2017;21(1), a1123. https://doi.org/10.4102/sajr.v21i1.1123 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract generalised lymphangiomatosis: a diagnostic challenge liam lorentz, jaishree naidoo copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: systemic, generalised lymphangiomatosis is a rare condition usually presenting in childhood or young adulthood. characterised by proliferation of normal, mature lymphatic tissue, this benign disease may involve multiple organ systems. the brain is unaffected as it is devoid of lymphatic channels. the condition may ultimately result in severe, debilitating symptoms, and its aggressive nature may mimic malignancy. because of its variable and unpredictable presentation, the evaluation of generalised lymphangiomatosis is a diagnostic challenge. the role of imaging is paramount in the diagnosis and establishing the extent of the disease. objectives: we present the case of a 3-year-old male with bleeding diatheses and hepatosplenomegaly clinically and large mediastinal mass on plain chest radiography. with a high index of suspicion for lymphoma, the child underwent multiple imaging modalities including chest and long bone radiography, abdominal ultrasound, contrast-enhanced chest and abdominal computed tomography (ct), with positron emission tomography (pet) and chest and abdominal magnetic resonance imaging (mri). method: imaging demonstrated a cystic, mediastinal mass encompassing the major vessels, pericardium and trachea. similar masses were also located within the abdomen encasing the aorta. ct demonstrated splenomegaly with multiple low attenuation foci. there was no focal increase in 19-fdg uptake on pet/ct imaging. mri confirmed multiple areas of bone marrow involvement. results: histological evaluation of the bone marrow trephine was inconclusive. biopsy of the mediastinal mass was histopathologically described as cavernous lymphangioma. conclusion: this case illustrates the obscure presentation and variable course of generalised lymphangiomatosis. whole body short tau inversion recovery (stir) mri provides an indication of the extent of the disease including bone marrow infiltration. the prime clinical dilemma is exclusion of malignancy. multi-disciplinary discussion with multi-modality imaging is required to diagnose and manage the condition. case report � sa journal of radiology • june 2006 abstract the incidence of skeletal tb is increasing. a better understanding of the mri features of proven tb spondylitis in our setting is needed. materials and methods. histologically proven cases of tb spondylitis, with mr imaging performed at universitas hospital on a 1.5t scanner, were reviewed. results. typical findings of vertebral column involvement were seen in all patients, namely multiple levels affected and paravertebral abscesses. the thoracic spine was involved more than the lumbar spine. in nearly all cases intervertebral disc involvement was noted. posterior longitudinal ligaments were intact in all but 1 patient, even though there was some elevation in a number of patients. abscess walls were also found to be thick instead of thin as expected. introduction there is a world-wide increased incidence of tuberculosis (tb), with the hiv pandemic contributing significantly to this trend.1,2 the most common extrapulmonary location of tb is the spine; in over 50% of the cases of bone and joint involvement.3 because mri facilities are more readily available, imaging of suspected spinal tb using this modality has increased. mri is now the preferred imaging modality for patients with suspected spinal tb.4,5 we wanted to evaluate the imaging features of histologically proven cases in our setting. mri features that suggest tb are: • soft-tissue masses/abscesses • involvement of multiple vertebral segments of the spine • absence of reactive sclerosis. materials and methods we identified all patients who had vertebral biopsies for suspected tb spondylitis, from july 2002 until november 2005. of these, we selected all patients who had histology results confirming tb spondylitis, and a recent mri of the affected vertebrae. twenty-three patients conformed to the above-mentioned criteria, (11 male and 12 female). patients’ age ranged from 17 to 75 years, with an average age of 36 years. all mr studies were performed at universitas hospital, on a ge signa 1.5tesla mr, with all patients imaged with t1 and t2 multiplanar spin echo sequences. additional stir images were acquired for 10 of these patients, while gadolinium was administered in 16 cases. images were assessed by an experienced radiologist. pre-prepared recording sheets were used. the histology results were known to the assessor. limitations of the study include examiner subjectivity regarding some findings, especially abscess wall thickness, and the fact that no follow-up imaging was performed after treatment. abnormalities the following abnormalities were assessed: 1. vertebral involvement • level(s) affected • number of vertebrae involved • complete destruction • partial destruction (including anterior, posterior and diffuse vertebral body involvement) • signal intensities in partially affected vertebrae • iso-intense, hyper-intense or hypo-intense compared with normal vertebrae 2. disc involvement • destruction • partial destruction (including height loss and fragmentation) • complete destruction • signal changes in partially destructed discs 3. paravertebral abscess/soft-tissue mass formation • anterior location/ posterior location with intraspinal extension • thin or thick walled • septae present 4. longitudinal ligament involvement • elevation • destruction • anterior/posterior location mri findings in proven mycobacterium tuberculosis (tb) spondylitis original article � sa journal of radiology • june 2006 d j kotzé, mb chb l j erasmus, mb chb department of diagnostic radiology, university of the free state, bloemfontein table i. level of epicentre of vertebral involvement n = 23 % high thoracic (t1-4) 4 17 mid thoracic (t5-8) 6 26 lower thoracic (t9-12) 6 26 l1 0 0 l2 2 9 l3 2 9 l4 3 13 l5 0 0 original article pg6-12.indd 6 7/11/06 12:46:04 pm results vertebral involvement there was complete destruction of at least one vertebral body in 14 patients (69%) (11 of 16 (69%) patients with thoracic and 3 of 7 (43%) with lumbar involvement). tables i-iii show the levels of vertebral involvement, distribution of partial destruction and signal intensities in partially affected vertebrae. disc involvement tables iv and v show the extent of disc involvement and signal intensities in partially affected discs. paravertebral abscess formation paravertebral abscess formation is shown in table vi. longitudinal ligament involvement table vii lists the longitudinal ligament involvement. discussion tuberculous spondylitis/spondylodiscitis is caused by the mycobacterium tuberculosis bacillus. the features of the disease were first described by percival pott. the disease has potentially serious morbidity with severe neurological impairment and disfiguring deformity. also known as pott’s disease, spinal infection follows haematogenous seeding from a distant source, and an extraspinal source of infection should be considered. the basic lesion is a combination of osteomyelitis and arthritis. typically, more than one vertebra is involved. the area usually affected is the anterior aspect of the vertebral body adjacent to the subchondral plate. tb may spread from that area to adjacent intervertebral discs. in adults, disc disease is secondary to the spread of infection from the vertebral body. in children, because the disk is vascularised, it can be a primary site. vertebral collapse and kyphosis follows progressive bone destruction. spinal canal luminal diameter narrowing is due to abscess formation, granulation tissue, or direct dural invasion. consequently there is � sa journal of radiology • june 2006 table ii. distribution of partial destruction part of vertebral body anterior and posterior only anterior only posterior thoracic 13 of 16 (81%) 2 of 16 1 of 16 lumbar 7 of 7 (100%) 0 0 table iii. signal intensities in partially affected vertebrae iso-intense % high signal % low signal % total t1 6 of 23 26 0 of 23 0 17 of 23 74 23 t2 3 of 23 13 17 of 23 74 3 of 23 13 23 post gd 3 of 16 19 13 of 16 81 0 of 23 0 16 stir 1 of 10 10 9 of 10 90 0 0 10 table iv. extent of disc involvement n = 23 % no involvement 1 4 complete destruction 8 30 partial destruction only 7 35 partially and completely destructed discs 7 30 table v. signal intensities in partially affected discs iso-intense % high signal % low signal % total t1 11 of 14 79 0 of 14 0 3 of 14 21 14 t2 0 of 14 0 8 of 14 57 6 of 14 43 14 post gd 0 of 10 0 3 of 10 30 7 of 10 70 10 stir 0 of 5 0 2 of 5 40 3 of 5 60 5 original article pg6-12.indd 7 7/11/06 12:46:04 pm � sa journal of radiology • june 2006 spinal cord compression and thus neurological deficits. kyphotic deformity may follow collapse of the anterior vertebral bodies. paraspinal abscesses in the lumbar region gravitate along the sheath of the psoas to the femoral region and erosion through to the skin may follow. in our study the epicentre of involvement was at the thoracic level in 16 of 23 patients (69%), with the epicentre in the remainder (31%) at the lumbar level. this is contrary to the findings of sinan et al.6 where involvement was greater in the lumbar spine. with thoracic involvement, the distribution at different levels (high, mid and lower) was fairly equal. none of the patients had l1 or l5 as the epicentre of involvement. there was complete destruction of at least one vertebral body in 14 patients (69%). partially affected vertebrae showed destructive changes in both the anterior and posterior parts of the vertebral body in 87% (20 of 23). signal intensities in partially affected vertebrae were predominantly hypo-intense on t1 (74%), hyper-intense on t2 (74%), hyperintense after gadolinium administration (81%), and hyper-intense on stir sequences (figs 1 3). all patients, with the exception of one who had no disc involvement, had varying degrees of complete and partial disc destruction at different levels. all 23 patients showed paravertebral abscess formation, extending between 2 and 6 vertebral levels. in the majority of patients (21 of 23, 91%) there was extension of the abscess adjacent to the anterior and posterior aspects of the vertebral bodies, while 61% (14 of 23) of the abscesses had a thick irregular wall, with a thin smooth wall in the remainder. septae were present in 18 of 23 abscesses (78%). sclerosis was table vi. paravetebral abscess formation n = 23 % only anterior 1 4 only posterior (with spinal extension) 1 4 anterior and posterior (with spinal extension) 21 92 thin wall 9 39 thick, irregular wall 14 61 septae present 18 78 table vii. longitudinal ligament involvement n = 23 % none 0 0 elevation anterior and posterior, without destruction 12 52 elevation and destruction anterior with only elevation posterior 10 43 elevation and destruction posterior, without anterior involvement 1 4 fig 1. t1 sagittal image. partial destruction of the anterior and posterior vertebral bodies of l2 and l3. original article original article pg6-12.indd 8 7/11/06 12:46:05 pm � sa journal of radiology • june 2006 seen in 13%(3 of 23) of affected vertebrae (fig. 4). in all 23 patients there was longitudinal ligament involvement, with: • elevation anterior and elevation posterior in 12 (52%) • elevation and destruction anterior, with only elevation posterior in 10 (44%) • elevation and destruction posterior without anterior involvement in 1 (4%). fig. 5 shows elevation with an intact posterior longitudinal ligament. fig 2. t2 sagittal image. predominantly anterior vertebral body destruction of l2, with gibbus formation. � sa journal of radiology • june 2006 fig 3a. t1 sagittal image. low signal in affected thoracic vertebrae. original article pg6-12.indd 9 7/11/06 12:46:05 pm 10 sa journal of radiology • june 2006 conclusion this study confirmed the findings of previous studies, namely: • paravertebral abscess formation involving multiple levels7-9 • subligamentous spread to multiple levels6 • hyper-intensity of affected vertebrae on t2 images6 • hypo-intensity of affected vertebrae on t1 images6 we found that abscess walls were thickened in about 60% in contrast to previously reported thin, smooth walls.6 in our study all but one patient had at least partial disc destruction. the posterior longitudinal ligaments were elevated in all patients, but only destroyed in one. anterior ligaments were elevated in 22 patients, with associated destruction in 10 (43%). these findings have not previously been specifically reported. further studies that focus on the pattern of ligament involvement and the abscess walls would be of value. objective measurement of the abscess walls would obviate examiner subjectivity. 10 sa journal of radiology • june 2006 fig 3c. sagittal stir image. high signal in affected vertebrae. fig 3b. t2 sagittal image. high signal in affected vertebrae. original article original article pg6-12.indd 10 7/11/06 12:46:05 pm 11 sa journal of radiology • june 2006 fig 3d. t1 postcontrast sagittal image. enhancement of the affected vertebrae. 11 sa journal of radiology • june 2006 fig 4a. t2 axial image. fig 4b. t1 postcontrast axial image. demonstrating thick irregular paravertebral abscess walls. original article pg6-12.indd 11 7/11/06 12:46:05 pm 12 sa journal of radiology • june 2006 references 1. restrepo cs, lemos df, gordillo h, et al. imaging findings in musculoskeletal complications of aids. radiographics 2004; 24:1029-1049. 2. engin g, acuna b, acuna g, tunaci m. imaging of extrapulmonary tuberculosis. radiographics 2000; 20:471-488. 3. tuberculous spodylitis; wheeless textbook of orthopaedics. duke university medical center, http://www. wheelessonline.com online book. 4. kotevoglu n, tasbasi i. diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department. rheumatol int 2004; 24: 9-13. 5. hidalgo ja, alangaden g. http://www.emedicine.com/med/topic 1902.htm emedicine online articlepott disease july 2005. 6. sinan t, al-khawari h, ismail m, ben-nakhi a, sheikh m. spinal tuberculosis: ct and mri features. ann saudi med 2004; 24(6): 437-441. 7. de vuyst d, vanhoenacker f, gielen j, bernaerts a, de schepper am. imaging features of musculoskeletal tuberculosis. eur radiol 2003; 13: 1809-1819. 8. khoo lt, mikawa k, fessler r. a surgical revisitation of pott distemper of the spine. the spine journal 2003; 3: 130-145. 9. nayoung jung, jee wh, ha ky, park ck, byun jy. discrimination of tuberculous spondylitis from pyogenic spondylitis on mri. ajr 2004; 182: 1405-1410. 12 sa journal of radiology • june 2006 fig 5. t2 sagittal image. elevated, but intact posterior longitudinal ligament. original article pg6-12.indd 12 7/11/06 12:46:05 pm abstract introduction report structure the fellowship of the royal college of radiologists royal college of radiologists appeals process conclusion acknowledgements references about the author(s) richard pitcher division of radiodiagnosis, department of medical imaging and clinical oncology, stellenbosch university, south africa coert de vries department of clinical imaging sciences, university of the free state, south africa zarina lockhat department of radiology, steve biko academic hospital, university of pretoria, south africa citation pitcher r, de vries c, lockhat z. the fc rad diag(sa): stretched, but still in step – report on a royal college observership. s afr j rad. 2017;21(1), a1092. https://doi.org/10.4102/sajr.v21i1.1092 review article the fc rad diag(sa): stretched, but still in step – report on a royal college observership richard pitcher, coert de vries, zarina lockhat received: 16 sept. 2016; accepted: 09 oct. 2016; published: 31 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a delegation of the college of radiologists of the overarching colleges of medicine of south africa observed the spring sitting of the part 2b examination of the fellowship of the royal college of radiologists (frcr) in london, in april 2016. although the principal focus of the observership was the part 2b examination, the delegates also assessed broader aspects of the frcr. this report presents an overview of current frcr practices, including the findings of an independent review of the frcr, and reflects on the implications for the south african fellowship examination. the report is based on discussions with key royal college role players, direct observation of the part 2b examination and web-based documentation. it allows appreciation of the continued close alignment of the fc rad diag(sa) (fellowship of the college of radiologists of the colleges of medicine of south africa) with the frcr and highlights expected trends in the fc rad diag(sa). it also documents the increasing human resources required for successful conduct of examinations. it is hoped that the report will be of interest and relevance to the broad south african radiological community and to those contemplating specialist training in the discipline. it is trusted that it will encourage wider involvement of radiological and medical physics colleagues in the various fc rad diag(sa) examination processes. introduction historically the fc rad diag(sa), the fellowship of the college of radiologists (cr) of the colleges of medicine of south africa (cmsa), has been aligned with the fellowship of the royal college of radiologists (frcr). cmsa representatives have periodically observed the frcr examination to ensure cr assessment methods remain abreast of international trends. the authors observed the spring sitting of the part 2b examination of the frcr in london, from saturday, 9 april, to friday, 15 april 2016. report structure although the principal focus of the observership was the part 2b examination, cr delegates assessed broader aspects of the frcr, including the findings of an independent review of their examination by medical education experts, commissioned in 2014.1 this report presents a broad overview of current frcr practices, followed by a detailed analysis of each component of the examination, including review findings, and reflects on the implications for the fc rad diag(sa). the report allows appreciation of the continued close alignment of the fc rad diag(sa) with the frcr and highlights expected trends in the fc rad diag(sa). it also documents the increasing human resources required for successful conduct of examinations. it is thought that the report will be of interest and relevance to the broad south african radiological community and to those contemplating specialist training in the discipline. it is hoped that it will encourage wider involvement of radiological and medical physics colleagues in the various cr examination processes. the fellowship of the royal college of radiologists overview the examination has three components. part 1 radiation physics radiological anatomy completion required by the end of the first year of training. part 2a the written examination, comprising six modules completion required by the end of the third year of training. part 2b the clinical examination, comprising three modules completion required by the end of the fourth year of training. progress through the frcr stages is aligned with progress in uk registrar training. the consequences of failure include extension of training time or even exclusion from training. part 2b admission requires completion of parts 1 and 2a, as well as satisfactory completion of an approved period of speciality training, determined by workplace assessments. six attempts at any frcr examination are permitted. examination committee structure overall frcr integrity is governed by the fellowship examination board (feb), established in 2012. each frcr component has a dedicated examination board that sets examinations, evaluates candidate performance and reports to the feb. part l (physics) fellowship of the royal college of radiologists format candidates must be in a registrar training post. the 2-hour examination comprises 40 multiple choice questions (mcqs). there is no negative marking. the pass mark varies at each sitting, based on question difficulty, determined by a criterion-referenced, standard setting technique. fellowship of the royal college of radiologists review findings the true or false mcq format should be abolished, since this only tests factual recall. single best answer (sba) questions should be introduced, as these evaluate knowledge application and allow more meaningful post hoc analysis. royal college of radiologists response it is difficult to examine the basic sciences in sba format.2 a forum has been established to review the physics syllabus and examination format. comparison with and implications for the fc rad diag(sa) sa candidates may write the examination prior to embarking on registrar training. no more than three attempts are permitted, including university master of medicine (mmed) part l exams. (there is reciprocity between the cr and university part l exams.) the current cr 3-hour physics examination, combining short written answers and true–false responses, will likely be replaced by the sba format following appropriate examiner training. in the interests of continuity, it is proposed that a 3-year, fixed-term fc rad diag(sa) part l physics examination committee be appointed. this should have representation from all training centres and the private sector. part l (anatomy) fellowship of the royal college of radiologists format candidates must be in a registrar training post. the 90-minute examination is a 100-image ‘spot test’, using a ‘name the structure’ approach. candidates work at individual work stations. to accommodate the large number of candidates, four different image sets are used, in four sequential sessions per examination sitting. a broad, two-dimensional ‘blueprint’ based on modality and body system is used. (the blueprint simply refers to the examination weighting that is given to sections in the curriculum.) there is comprehensive post hoc statistical analysis. fellowship of the royal college of radiologists review findings difficulty and passing standards should be comparable between sets within a single examination sitting, and across sittings. the emphasis should be on testing cognitive skills and the application of knowledge, rather than factual recall. there should be more formal blueprinting aligned with core learning outcomes. the coverage of each assessment depends on the expertise and knowledge of the examiners setting the paper at the time. there is no historical record to guide comparisons of paper difficulty over time and no use of anchor or reference questions to assess comparability of candidate performance and standards. royal college of radiologists response an ‘automation project’ has been initiated to manage digital image banks, with a view to an online digital part l anatomy examination. this will address many concerns of the review. comparison with and implications for the fc rad diag(sa) the current examination format mirrors that of the frcr but has 60 images, lasts 3 hours and totals 300 marks. it is suggested that a fixed-term part l anatomy examination committee be appointed, as for physics. written component (part 2a) fellowship of the royal college of radiologists format the core-knowledge modular assessment comprises six papers, written in a staged fashion during the second and third years of training. candidates are examined on clinical radiology and the basic sciences, according to the specialty training curriculum for clinical radiology.3 any number of papers may be written at one sitting. each examination lasts 2 hours and comprises 75 sba items directly linked to one of the six major components of the curriculum: module 1: cardiothoracic and vascular module 2: musculoskeletal module 3: gastro-intestinal module 4: genitourinary, female imaging module 5: paediatric module 6: central nervous system, head and neck. there is a simple blueprint, which defines the proportion of questions by sub-topic. fellowship of the royal college of radiologists review findings a single assessment is recommended. there should be more formal blueprinting, aligned with core learning outcomes. the coverage of each assessment is dependent on the knowledge of the examiners setting papers at the time, as for the part l anatomy. royal college of radiologists response from spring 2018, the structure will revert to a single sba examination covering the core curriculum. a two-dimensional blueprint is being considered. comparison with and implications for the fc rad diag(sa) the fc rad diag(sa) part 2 written component is an exit examination taken in the same semester as the oral examination. it may not be attempted prior to 36 months of registrar training. currently, fc rad diag(sa) part 2 examiners conduct two consecutive sittings of the written and oral components and then step down. all training institutions and some private radiologists are represented on the examiner panel. appointment of a 3-year, dedicated part 2 written examination committee is recommended. the current format includes only short written answers, with no sbas. it is recommended that sbas be included, following formal examiner training. fellowship of the royal college of radiologists part 2b examination fellowship of the royal college of radiologists format the examination represents a three-component assessment, evaluating workplace skills. the authenticity of the assessment is a key characteristic. this is not an exit examination, but a core-knowledge examination and may be attempted from 30 months of training. the examination is convened in spring and autumn each year and comprises the following: rapid reporting (rr) long case reporting (lcr) oral assessment. part 2b examiner board the board comprises 24 examiners, appointed following written application and formal recruitment, and after thorough evaluation of each applicant’s curriculum vitae and teaching experience. appointments are for 6 years and governed by a formal job description and code of conduct. four new examiners are recruited annually, replacing four who have completed their term. examiner profile examiners are fellows with at least 7 years of consultant experience in a uk training program and significant involvement in registrar teaching and assessment. examiner duties prepare images for oral, rr and lcr examinations mark the rr and lcr examinations conduct the oral examination review the performance of individual examinations continually develop the examination, ensuring its ongoing relevance. for the first year, new examiners observe the spring and autumn sittings and prepare at least 100 examination cases. senior examiners select the rr and lcr material. one senior examiner is the lead for each sitting and moderates differences in mark allocation that cannot be resolved by consensus. there is diversity of examiner age, gender, ethnicity and uk geographical distribution. candidates candidates are only identified by number: 290 candidates sat the examination; 150 were from the uk. examiners do not examine their own candidates. digital platform the examination has a digital platform, utilising osirix (vendor) software. this software has a steep learning curve and is subject to the usual software gremlins but facilitates complete simulation of the clinical environment. rapid reporting fellowship of the royal college of radiologists format the exam is convened over the weekend prior to the oral examination. it is also conducted on osirix software, on apple hardware, in a computer laboratory that is leased and set up at the royal college of radiologists (rcr) for each sitting. candidates receive an excellent briefing on osirix, are assigned to individual workstations and work at their own pace, completing 30 cases in 35 minutes. only plain radiographs are included. at least 40% – 50% of cases are normal. abnormal cases have a single abnormality. all abnormalities are strictly emergencyor trauma-related. for each case, candidates are required to state whether the radiograph is normal or abnormal. if abnormal, the pathology must be specified. all images are held in the rcr database. material is subject to post hoc review of suitability. a rr pass is not required to pass the examination as a whole. fellowship of the royal college of radiologists review findings the assessment is authentic, simulating the reporting environment. difficulty should be comparable between sets of cases within a single sitting, and across sittings. a greater number of items should be included to improve reliability. some form of standard setting is required. royal college of radiologists response there is no current consensus on the optimum method of standard setting. comparison with and implications for the fc rad diag(sa) the fc rad diag(sa) rr mirrors that of the frcr, but 60 cases are included, enhancing reliability. the rr is included in the written component. a pass in the rr is required to progress to the oral examination. defined case-selection inclusion criteria must be rigorously defined. abnormal cases should have a single abnormality and be strictly within the realm of emergency/trauma radiology. more detailed post hoc analysis is required. long case reporting current fellowship of the royal college of radiologists format the exam is conducted in the same computer laboratory as the rr and written over the weekend preceding the week of the oral examination. cases are selected from the rcr digital database, which is managed by one of the permanent administrative rcr staff. candidates are shown an introductory video on the osirix software immediately prior to the examination and work on two dummy cases before the start. the examination comprises six clinical cases of varying difficulty, to be completed in 60 minutes. candidates work at their own pace. for each case, candidates are provided with the age, gender, clinical presentation and a list of included images. marking takes place during the week of the orals but is independent of the orals. it is undertaken by a small, separate group of examiners. lcr markers see the cases for the first time when marking begins and before viewing marking memoranda. this provides a reality check in terms of expectations and assigning level of difficulty. examiners mark the first few scripts, assessing candidate performance, and decide whether the marking memorandum requires modification. long cases are double-marked, each marker being blinded to the score of the other marker. memoranda provide detailed guidelines on mark allocation. to pass a case, candidates are required to identify the majority of key radiological signs and to reach a reasonable diagnosis. discrepancies between individual markers are resolved by consensus wherever possible. concise answers are expected. the answer sheet has the following subdivisions: observations, interpretation, principal diagnosis, differential diagnosis and management. candidates are not required to pass a minimum number of cases. the large number of candidates dictates that candidates take one of four possible lcr sets. fellowship of the royal college of radiologists review findings the comparability of set difficulty and passing standards between sets within and across sittings is a concern. although it is difficult to achieve high reliability in clinical assessments, the reliability of part 2b and its individual components is lower than acceptable for high stakes assessments. the marking scheme should make provision for the award of the full range of marks, from very low to very high. standard setting is required. royal college of radiologists response there is no consensus on the optimum method of standard setting. comparison with and implications for the fc rad diag(sa) the fc rad diag(sa) part 2 lcr comprises seven cases, with 20 minutes for each case. marks are allocated according to a rubric that is broadly comparable with that of the frcr. candidates must pass at least four out of seven cases and achieve an overall pass mark for the lcr component. it is proposed that future marking memoranda define criteria for allocation of a wider range of marks. for the past 5 years the cr has employed a part-time it consultant to configure the lcr examination and to manage a central repository of lcr examination cases. since the 2016 rcr observership, a senior academic radiologist has been appointed as convener of the lcr examination, for a fixed term. this is seen as the first step towards creating an lcr examiner panel. from the second semester of 2016, lcr scripts will be double-marked. marking will be conducted by a separate group of examiners, in parallel with the oral examination. there will also be more comprehensive moderation of lcr marking. orals fellowship of the royal college of radiologists format the examination is conducted in soundproof rooms and on a digital platform, utilising osirix software. there are separate monitors for examiner and candidate. examiners provide their own images. prior to each session, examiner pairs show each other their films, explaining what is expected, and how marks will be allocated. this is the only moderation. candidates see two examiner pairs, for 30 minutes apiece. there should be at least 10 scoring opportunities in each 30-minute session. discussion of a single modality is a scoring opportunity. examiner pairs are kept constant throughout the week and combine inexperience with experience. for each image set, examiners prepare a memorandum, listing the cases to be shown, the diagnosis and the salient radiological features, with space for comment on each case. the complete examination blueprint is shown by each examiner pair. the overriding question is whether the candidate is ‘safe’. the emphasis is on protecting the public against unsafe practice. examiners prompt candidates if specific signs have not been identified, but such candidates are marked down. at the end of each oral, examiners independently assign a mark before conferring and reaching a consensus mark. there is no requirement to pass a minimum number of cases. borderline candidates are reviewed at an examiner meeting at the end of each day. there is no formal moderation of mark allocation. fellowship of the royal college of radiologists review there is good training for examiners, briefing of candidates and feedback to failing candidates and their supervisors. the value of clinical oral examinations in specialised fields such as radiology was acknowledged. however, the current format is not considered good practice. there is examiner-related variance in case-selection and behaviour within stations, posing risks to robustness and defensibility. the system is dependent on the skill and conduct of individual examiners. there is reliance on examiners to police their own material and there is thus no means of defending challenges arising from this. there are no anchor or reference cases across examiner pairs. a more structured format was recommended to mitigate risk while preserving important positive features. each case should be started with a clinical request form or scenario, preserving authenticity while ensuring that candidates understand what is being asked. all images should be centrally pooled and held by the college. global reference cases are required. this would improve defensibility of the examination, reduce unnecessary variance between stations, limit examiner-related variance within stations and enhance standard setting. although examiners can distinguish failing, borderline and excellent candidates, significant unintentional and intentional weighting could occur with the current narrow assessment scale, making it challenging to distinguish between candidates. a test-specific blueprint is required to ensure careful coverage in case selection. recognised standard setting should be applied to each component of the part 2b. in addition, success in the part 2b should be subject to achieving a defined minimum mark for each component. examiners should score independently and only use the examiner meeting to discuss significant differences within examiner pairs. royal college of radiologists response there is no consensus on the best method for oral examination standard setting. the scoring system will be reviewed. comparison with and implications for the fc rad diag(sa) in line with rcr review recommendations, the following changes were implemented in the first semester of 2016: a digital examination was delivered on a microsoft powerpoint platform. all cases were moderated at a full-day preparatory examiner meeting, where expectations and pass or fail criteria were defined. all cases had unequivocal radiological signs. material for each session was standardised. a text slide provided the clinical context for each case. candidates were not prompted to help them identify radiological features. only once the main radiological features had been identified did examiners engage in a discussion of the differential diagnosis and management. where candidates failed to identify the main radiological signs, examiners moved to the next case. the full blueprint was covered for each candidate. candidates must achieve an overall (combined) oral mark of at least 50% and may not score less than 40% in a single oral. since the 2016 rcr observership, the cr has employed a part-time it consultant to configure the digital oral examination and to manage a central repository of oral examination cases. a senior academic radiologist has also been appointed as convener of the oral examination, for a fixed term. this is seen as the first step towards creating an oral examiner panel. royal college of radiologists appeals process this provides a formal means of reviewing a candidate’s examination results. while not a complaints procedure, it enables candidates to challenge a fail result on the basis of procedural irregularity in the conduct or the determination of the result of an examination. any appeal that challenges the academic judgement of examiners or that is based on extenuating personal circumstances or lack of awareness of examination regulations is considered invalid. comparison with and implications for the fc rad diag(sa) the cmsa website defines the current unifying appeals process for the constituent colleges.4 conclusion the format of the fc rad diag(sa) remains closely aligned with that of the frcr. the fc rad diag(sa) and the frcr currently face similar challenges. the following are recommended. examiner resources initiate a system to ensure long-term, continuous, active involvement of all south african academic radiologists, as well as representatives of the special interest groups of the radiological society of south africa, in the cr examination processes. constitute formal examination boards, with fixed-term appointments, for each component of the fc rad diag(sa). examination format part i physics: convert to a sba format. part ii written: convert to a hybrid system of short answers and sbas. examination content ensure careful blueprinting of each component of the fc rad diag(sa) and close alignment of examination content with the published curriculum. develop a central repository of examination material for each component of the examination. marking procedures revise mark allocations in the long case and oral components, in line with international best practice. post hoc analysis once appointed, examination boards should be responsible for the conduct of formal, post hoc analysis of each component of the examination process, utilising standard software packages. candidate feedback once appointed, examination boards should introduce a sustainable system for candidate feedback, thereby allowing candidates to address deficiencies. the precise mechanism of candidate feedback will vary across the various components of the examination. in-course assessment strengthen and formalise institution-based workplace assessment, supervisor reports and an annual review of competence progression. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.p., z.l. and c.d.v. conceived the project and collected and collated all data. r.p. drafted the initial manuscript with editorial contributions by z.l. and c.d.v. references royal college of radiologists examinations review [homepage on the internet]. 2014 [cited 2016 apr 9]. available from: https://www.rcr.ac.uk/sites/default/files/frcr_review_report_final.pdf frcr examinations review – comment from the rcr [homepage on the internet]. [cited 2016 apr 9] available from: https://www.rcr.ac.uk/sites/default/files/frcr_review_rcr_commentary.pdf specialty training curriculum for clinical radiology. the royal college of radiologists [homepage on the internet] [cited 2016 apr 9]. available from: https://www.rcr.ac.uk/sites/default/files/docs/radiology/pdf/curriculum_cr_28_october_2014_final.pdf cmsa appeals process [homepage on the internet] [cited 2016 july 14]. available from: file:///c:/users/us/downloads/examination_appeals_mechanism_5_10_2016.pdf review article mediastinal assessment in traumatic rupture of the aorta abstract the precise method for measuring mediastinal widening in thoracic trauma is poorly understood and too much emphasis is placed on it as the sole criterion for performing aortography. this review article describes the established methods of measurement and their limitations, and also discusses the importance of other signs pointing to aortic rupture such as blurring of the aortic knuckle and a subjective impression of mediastinal abnormality which are more helpful in determining the need for angiography. introduction cmyoung m88s(lond) frcs(ed) ffrad(d)(sa) department of radi%gy, groote schuur hospital and university of cape town the commonest site of aortic injury is at the isthmus i.e.between the left subclavian artery origin and the ligamentum arteriosum and is thought to be due to deceleration affecting fixed and relatively mobile segments of the organ. rupture causes immediate death in up to 90% of trauma victims. a small number of severely a sa journal of radiology· may 1996 injured patients however may be in the fortunate position of having an increased chance of survival owing to the development of rapid evacuation transportation and regional trauma centres. those who reach hospital have a contained rupture i.e. a localized false aneurysm. this feature is often not recognized on a chest radiograph as a much wider area of haem atom a obscures it'. mediastinal widening in these cases is caused by bleeding from associated injuries to minor arteries and veins; nevertheless the association has been shown to be useful as originally described by marsh and sturm.' if the mediastinal haematoma had been' caused by blood from the aortic rupture, then the patient would almost certainly have exsanguinated. the natural history of these false aneurysms is poorly understood. clinical management and also the modem radiological literature is still largely based on parmley's 1958 post-mortem study of mortality data' as quoted in pais' excellent seminars review on angiography in the trauma patient," pais states that in parmley's paper there was no angiographic correlation and therefore patients with aortic false aneurysm who had survived were not takén into consideration. a recent review on the subject in clinical radiology by white and mirvis from baltimore' states that 40% of untreated patients die within 24 hours of hospital admission. although the evidence for this is not given, the percentage figure corresponds exactly with parmley's data. several other contemporary authors suggest that the immediate natural history may be more benign than suggestedv" and this has also been our experience" cowley found that there was no statistical assodation between mortality and either transport time to the hospital or time from injury to operation." richardson found that no patient with ruptured aorta or aortic branch injury reaching hospital died from that injury before its operative treatment, bearing in mind that other topage9 mediastinal assessment in traumatic rupture of the aorta life-threatening injuries in these patients required operation first. 7 standard methods of mediastinal measurement it is common practice in our institution (both by radiologistsand trauma surgeons) to assessmediastinal width on chest x-ray post thoracic trauma, using 8 cm as a criterion for aortography. this measurement was described by marsh and sturm, radiologist and surgeon respectively in their landmark article in the annals ofthoradc surgery.2 they compared 47 severely injured patients with 100 controls using a 100 cm antero-posterior (ap) supine chest film. five cases of aortic rupture were found in patients with a widened mediastinum, and they concluded that a mediastinal measurement more than 8 cm was a definite indication for aortography. the slightlymisleading phrase" at the level of the aortic knob" was used in the text, although their diagram clearly shows the measurement was made immediately above the aortic knuckle, the position recommended by milne et al in their description of the "vascular pedicle".9 figure 1.' diagram of mediastinal structures seen on a supine chest radiograph to show method of transverse width measurement (ml+mr) (see text). transverse mediastinal width (the "vascular pedicle") the distance from the midline (spinous process) to the left border of the left subclavian artery take-off (ml) is added to the distance from the midline to the intersection of the right border of the superior vena cava (svc) and right main bronchus (mr) (see figure 1). milne et al give an elegant explanation of the nature of the vascular pedicle in a series of three articles describing the normal subject, the patient with acquired heart disease and also the traumatised patient," 10, ii they point out that when the patient assumes the supine position, the pedicle width increases to a different extent on each side. the subclavian artery, forming the left side of the superior mediastinum, has a low compliance hence will change little in diameter. the venous structures making up the right border; superiorly the right brachiocephalic vein and inferiorly the svc, will change markedly in size between the erect and supine postures. it is important to note that the clarity of the right paratracheal stripe and the azygos vein is preserved. milne et al also observed that increased mediastinal width occurs in fluid overload or cardiac decompensation, and this is also related to venous distension. when the vascular pedicle width is increased because of extravascular fluid (as in aortic rupture), then the enlargement occurs principally on the left as the subclavian artery is posteriorly situated and haematoma related to the rupture surrounds it. the clarity of the right side of the superior mediastinum, formed by the svc, is preserved as it is more anterior and hence remote from the haematoma. note on the diagram how the right paratracheal stripe and azygos may be effaced and the paraspinal lines displaced (see figure 2). 9 sajournal of radiology. may 1996 figure 2: diagram of mediastinal gt scan showing azygos vein entering svg, and effacement of the vein and the right paratracheal stripe by haematoma. note how a haematoma that extends into the superior mediastinum would expand to left around the left subclavian artery, preserving the outline of the right border of svg, a more anterior structure (see text). it is important to bear in mind that a focalmediastinal widening above the point of measurement of the vascularpedicle can be an indication of major vascular injury and is therefore an indication for aortography. technical aspects the focus-film distance (ffd) of the radiograph is of little consequence. a lordotic projection as is often obtained in the semierecticu patientmaymagnifythesuperior mediastinal structures with lossofdefinition of the aortic arch and hence may lead to unnecessary angiography" figure 3: diagram of chest radiograph to show delermination of mediaslinal width lo chest width ratio (mig ratio) (see text). lapags 10 mediastinal assessrnent in traurnatic rupture of the aorta mediastinal width to chest width ratio (mie ratio) seltzer et al described the use of the mlc ratio in the assessment of traumatic aortic rupture in theajrin 1981.13 thegreatest width of the mediastinum is taken at the level of the aortic arch i.e.it includes the aortic knuckle and svc (m) (seefigure3). it is divided by the intemal thoracic diameter from inner rib margin to inner rib margin (c) at the same level. the authors recommended that the maximum mie ratio be taken as 0.25 and this would identify 95% of cases with aortic rupture and give a false positive rate of25%. their study also found little relation between rib fracture and aortic tear. technical aspects seltzer et al found no statistical difference in mie ratios comparing supine or sitting ap radiographs and postero-anterior (pa) erect films, although the overall trend was that supine ap films had the largest ratios. there is no significant change in mie ratio with increase or decrease offfd.! discussion woodring and king discuss the limitations of transverse mediastinal width (tmw) and mie ratio in an important paper' the overall object of their study was to examine the usefulness of precise measurements as against subjective assessment of mediastinal abnormality. they concluded as a result of their own study that excessive mediastinal widening was helpful in determining the need for aortography, but that a normal measurement was not. there was such an extreme overlap of values of mediastinal width and mie ratio between normals and abnormals, that precise measurement could not reliably separate the two groups. they observed that using an mie ratio ofo.25 or greater to define abnormality as recommended by seltzer et al13 would lead to a false positive rate as high as 99%. the main reason for this is that mediastinal width includes the aortic arch (as used in mie ratio) and is related to normal unfolding of the aorta that occurs with age. there is only a modest correlation between increasing patient age and widening of the vascular pedicle.' inwoodring and king's experience there were a number of cases of ruptured aorta or brachiocephalic arteries that had a superior mediastinal width of less than 8 cm, the criterion for aortography quoted by marsh and sturm.' they suggested modifying the values of transverse mediastinal width and mie table i: radiographic associations of aortic rupture mediastinal widening abnormality ol aortic knuckle or descending aorta left apical pleural cap displacement ol trachea to the right displacement of nasa-gastric tube to the right inferior displacement ol left main bronchus filling-in of aortopulmonary window widening ol right paratracheal stripe effacement of vena azygos left haemothorax r or l paraspinalline displacement pulmonary contusions rib iractures (no association found by seltzer et a~ ratio to 7.5 cm and 0.38 respectively to a give a more acceptable false positive rate than marsh and sturm's 8 cm,andseltzeretal's mie ratio ofo.25 would have given.patients with values above these levels would have aortograms, but would also have angiography performed below these levels, in the presence of other signs of mediastinal abnormality (e.g.blurring of aortic arch or aorto-pulmonary window ete). forty-one per cent of patients with proven arterial injury in their series and using their criteria had tmw within normal limits, and 69% had a normal mie ratio. 10 sa journal of radiology· may 1996 it has been suggested that an erect chest film be done ifpossible-" this may provide optimal assessment of the aortomediastinal contour compared with the supine view, but it is important to be aware that the mediastinal measurements as described in the literature are designed for the supine view. angiographyvs cr intra-arterial digital subtraction angiography (la dsa) is recommended as the procedure of choice by mirvis et al.!s it has the same accuracy as conventional arteriography with a considerable saving in time and film cost. at groote schuur hospital we perform two views using la dsa, frontal (postero-anterior) and left anterior oblique, similar to mirvis et ai's technique. we prefer angiography to computed tomography (ct) in our institution for several reasons: cr is prone to misregistration artefacts, and can be difficult to interpret, although these problerns may be overcome with the advent of spiral ct; the patients are often unco-operative leading to major motion image degradation; and our thoracic surgeons request angiography to precisely define the abnormality. if ct was performed first some patients would then require two investigations both with a large contrast load, i.e. a patient whose ct showed a mediastinal haematoma would then go on to angiography. we consider that an arch aortogram is a minimally invasive, quick and relatively easy procedure to perform and to interpret, bearing in mind the usual pitfalls caused by the ductus which are beyond the scope of this article. the necessity for angiography inpatients with a normal chest radiograph savastano et al state that angiography is not necessary in patients with blunt chest trauma whose chest radiographs show no to page 11 mediastinal assessrnent in traumatic rupture of the aorta signs ofleft haemornediastinum." white and mirvis state that a normal radiograph excludes traumatic aortic rupture (tal) unless there is a compelling clinical reason to suspect the diagnosis, and usually obviates further studies." they were unaware of any chest film falsely negative for tal in their institution. woodring and king however did have two cases with small false aneurysms of the isthmic region with normal radiographs, and four cases with no mediastinal haemorrhage but large false aneurysms visible on the film.' they concluded that chest radiography has limitations in detecting vascular injury but table ii: learning points 1. mediastinal measurements are made on a supine film 2. transverse mediastinal width (tmw) is measured above the aortic knuckle 3. maximum tmw can usefully be modified to 7.5 cm 4. mic ratio is of little value 5. mediastinal measurements within normal limits do not exclude major vascular injury 6. pay close attention lo mediastinal abnormalities, ask advice of a senior colleague if unsure 7. it is acceptable to have a low threshold for performing aortography when there are mediastinal abnormalities 8. a large number of false positives suggesting aortic rupture are to be expected on chest radiography 9. angiography is not necessary in patients with a normal chest radiograph 10. if aortic rupture is suspected perform aortography not ct nevertheless have adopted a policy of performing aortography based on specific mediastinal abnormalities and no longer perform precise measurements oftmw andmicratio. it seems reasonable therefore to accept that a normal chest radiograph precludes the need for aortography, but it is important to be aware that mediastinal widening may progress whilst the patient is in hospital. we have observed this phenomenon on occasion at our institution. timing of angiography does the aortograrn have to be performed immediately, or can there be a delay? this is an ethical problem even though current evidence points to a benign immediate course of aortic false aneurysms. these data have been gathered retrospectively,and as stated above more critically ill patients who formerlywould have died may present to trauma units, i.e. the potential for early rupture of a false aneurysm still exists. i consider that urgent angiography should still be done, for although the potential for early rupture is small, the consequences of missing such an injury are catastrophic. the plain radiographic features that suggest or are associated with aortic rupture are well known, and i shall not elaborate on them further. (see table 1). note the learning points as described in table ii. acknowledgement i am most grateful to dr hillel goodman for his helpful comments. references i. woodring jh, and king je. determination of normal transverse mediastinal width and mediastinalwidth to chest-width (m/c) ratio in control subjects: implications for subjects with aortic or brachiocephalicarteriallnjury. the journal of trauma i 989;29:no 9:1268-1272. 2. marsh dg and sturm jr. traumatic aortic rupture: roentgenographic indications of angiography. theannals of thoracic surgery aprii1976;21:no 4:337340. 3. parmley lf, mattingley tw, manion wc et al. nonpenetrating traumatic injury of the aorta. circulation 1958;17:1006-1101. 4. pais so. diagnostic and therapeutic angiography in the trauma patient. seminars in roentgenology july 1992;xxvll:n03:211-232. 5. white cs and mirvis se. pictorial review: imaging of traumatic aortic injury. clinical radiology 1995;50:281-287. 6. cowley ra, turney sz, hankins fr et al. rupture of thoracic aorta caused by blunt trauma: a fifteen year experience. ithorac cardiovascsurg i 990;1 00:652-661. 7. richardson jd, wilson me, miller fb. the widened mediastinum. diagnostic and therapeutic priorities. annsurgl990j211:731-736. 8. von oppel uo, thierfielder cf, beningfield sj et al. traumatic rupture of the descending thoracic aorta. samji8may 1991;79:595-598. 11 sajournal of radiology· may 1996 9. milne enc, pistolesi m, minati m et al. the vascular pedicle of the heart and the vena azygos. part j: the normal subject. radiology 1984;152: 1-8. 10. pistolest m, milne enc, minati m et al. the vascular pedicle of the heart and the vena azygos. part il: acquired heart disease. radiology 1984;152:9-17. ii. milne enc, imraytj, pistolesi m et al. the vascular pedicle and the vena azygos. part ill: in trauma-the "vanishing" azygos. radiology 1984; 153:25-31. 12. hollman as, adams fg. the influence of the lordotic projection on the interpretation of the chest radiograph. clinical radiology 1989;40:360-364. 13. seltzer se, d'orsi c, kirshner r et al. traumatic aortic rupture: plain radiographic findings. air november 1981;137:l0l1-10l4. 14. mirvis se, bidwell jk, buddemeyer eu et al. value of chest radiography in excludingtraumatic aortic rupture. radiology 1987;163:487-493. 15. mirvis se, pais so, gens dr. thoracic aortic rupture: advantages of lntra-arterial digital subtraction angiography. air may 1986; 146:987-991. 16. savastano s,feltin gp, miotto d et al. value of plain chest film in predicting traumatic aortic rupture. ann radioi1989;32: 196-200. pictorial interlude renovascular anatomy as depicted by multislice helical ct jonathan p hack fcrad(d) sa sunninghili hospital, sandton multislice helical computed tomography (msct) represents state-ofthe-art in modern ct imaging at present. the four channel or 'quad' multislice scanner uses between 8 and 32 detector rows for image acquisition instead of the single channel and detector row of older conventional and helical ct scanners. a four channel (quad) multidector row ct is eight times faster than single slice ct. eight slices are obtained per second (four slices per rotation at two rotations per second) as opposed to single slice helical ct (one slice per rotation at one rotation per second.). this provides the following benefits: improved temporal resolution. faster image acquisition results in fewer motion artifacts (voluntary and involuntary). improved spatial resolution. thinner slices, combined with appropriate data overlap, improves resolution along the z-axis, reducing partial volume artifacts and thus increasing diagnostic accuracy. improved vascular opacification. because scanning is completed rapidly, contrast can be administered at a faster rate, improving vascular opacification and conspicuity. reduced image noise. rapid scanning allows for an increase in ma thus reducing image noise and thus improving image quality. efficient x-ray tube utilisation. as imaging is completed more rapidly,' tube heating is reduced, thus eliminating the need to wait for tube cooling between scans. during the lifetime of a tube, eight times more images are produced, reducing cost. as shown in this pictorial essay, msct has an accuracy comparable to conventional angiography in identifying renal arterial anatomy and also has the added ability to simultaneously define renal venous anatomy. scanning technique and image display all images were obtained during the imaging of prospective living renal donors, using an mx8000 quad multislice ct scanner (philips medical systems, cleveland, ohio). postprocessing was performed on an mxview workstation (philips medical systems, cleveland, ohio). phase 1: 6.5 mm effective slice width images are obtained from the diaphragm to the symphasis pubis in order to evaluate for urolithiasis and to provide baseline density measurements of renal masses. 37 sa journal of radiology • june 2003 non-ionic low osmolar contrast medium is then introduced intravenously via an antecubital vein utilising an 18 gauge cannula at a rate of 5 ml per second. phase 2: after a delay determined by a bolus tracking device, 1.3 mm effective slice width images are obtained from above the celiac axis to below the iliac arteries in order to map the renal arteries and veins. phase 3: after a delay of 65 seconds, 3.2 mm effective slice width images are obtained from the diaphragm to symphasis pubis. this allows for further evaluation of the renal venous system, the renal parenchyma and remaining intraabdominal viscera. plain film post ct: this allows us to detect medullary sponge kidney, papillary necrosis, as well as duplication anomalies of the collecting systems. images are displayed as multiplanar reformatted images (mpr), angiographic maximum intensity projection images (mip), 3d surfaceshaded images or as 4d volumerendered images. renovascular anatomy arterial anatomy the renal arteries are two large arteries which arise from the sides of the aorta immediately below the superior mesenteric artery at the upper margin of l2. their relative positions may vary according to the position of the kidneys. although the right renal artery may travel in an oblique plane, they are often both horizontal. in 70% of cases there are single arteries bilaterally (figs 1 and 2). pictorial interlude fig.1. volume rendered (40) image of normal renal arieries. fig. 2. mip image of normal renal eneties. anatomic variants thirty per cent of patients have multiple renal arteries, which may be : (i) supplementary arteries (to the hilum) (figs 3 5); (ii) capsular arteries; (iii) polar arteries, which may arise from the main renal artery or from the aorta (figs 4 6); and (v) extrahilar branching (figs 3 and 4). fig. 3. mip image demonstrafing a supplementary ariery on the left and eariy extra hllar branching on the right. fig. 4. 30 surface shaded image demonstrating bilateral supplementary stteties, early extra hilar branching on the left and a left sided polar ariery. fig. 5. 40 volume rendered image demonstrating a left sided polar and supplementary ariery. fig. 6. curved mpr demonstrating a small left sided polar ariery. 38 sa journal of radiology • june 2003 venous anatomy the right renal vein is short (± 2 2.5 cm) and is single in 85% of cases. it does not usually receive any significant tributaries. the left renal vein is long (± 8.5 cm). it is single and preaortic in position in 85% of cases and it receives the left spermatic, inferior phrenic and, usually, the left adrenal veins (figs 7 and 8). it passes just below the origin of the superior mesenteric artery. fig. 7. curved mpr demonstrating normal renal veins. fig. 8. curved mpr demonstrating large left gonadal veins and the left adrenal vein. anatomic variants right renal vein: (t) multiple veins (fig 9); and (il) gonadal and adrenal veins may occasionally drain into the right renal vein. left renal vein: (i) multiple veins (fig.lo); (it) circumaortic vein (figs 11 and 12); and (iit) retroaortic vein (fig. b). lumbar veins may drain into the renal vein (fig. 14). pictorial interlude fig. 9. volume rendered image demonstrating complete duplication of the right renal vein. fig. 10. volume rendered image demonstrating partial duplication of the left renal vein and a large left gonadal vein. fig. 11. curved mpr demonstrating a clrcumeortic left renal vein. fig. 12. volume rendered image demonstrating a circumaortic left renal vein. fig. 13. curved mpr demonstrating s retro-sortic left renal vein. fig. 14. curved sagittal mpr demonstrating a large lumbar vein draining into the left rensl vein. acknowledgement images 3, 4 and 10 courtesy of j rydberg, et al. further reading i. pozniac ma, balison dj, lee ft jr, tambeaux rh, uehling ot, moon td. ct angiography of potential renal transplant donors. radiographies 1998; 18: 556-587. 2. rydberg j, kopecky kk, tann m, et al. evaluation of prospective living renal donors for iaparoscopic nephrectomy with multislice ct: the marriage of minimally invasive imaging with minimally invasive surgery. radiogmphics2001; 21: 5223-5226. 3. gray g. gray's anatomy. the classic collector's edition. new york: bounty books, 1977: 556557,619. 4. http://www.indyrad.jul?uj.edu/multjslice-ctl (jast accessed 0 i april 2003), 39 sa journal of radiology • june 2003 http://www.indyrad.jul?uj.edu/multjslice-ctl abstract introduction ventricular assist devices ethical consideration conclusion acknowledgements references about the author(s) rishi p. mathew department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada timothy alexander department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada citation mathew rp, alexander t, patel v, low g. chest radiographs of cardiac devices (part 2): ventricular assist devices. s afr j rad. 2019;23(1), a1732. https://doi.org/10.4102/sajr.v23i1.1732 review article chest radiographs of cardiac devices (part 2): ventricular assist devices rishi p. mathew, timothy alexander, vimal patel, gavin low received: 04 mar. 2019; accepted: 05 may 2019; published: 31 july 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract heart failure is considered a worldwide pandemic affecting 26 million people globally. patients who are unfit or waiting for cardiac transplantation may benefit from alternate mechanical support therapies using ventricular assist devices. it is not uncommon for radiologists, especially those working in institutions with a high volume of cardiac transplantations, to be presented with radiographs containing these devices. the role of the radiologist is not only to accurately identify these devices, but also to evaluate for any complications. keywords: left ventricular assist device; right ventricular assist device; intra-aortic balloon pump; extracorporeal membrane oxygenation; berlin heart; heartmate ii; heartware lvad; heartmate iii. introduction heart failure (hf) is considered a worldwide pandemic affecting 26 million people globally. heart failure is characterised by the decreased ability of the heart to pump and/or fill with blood.1 in the united kingdom, approximately 500 000 people are affected,2 while in the united states it is approximately 5.1 million. the gold standard treatment for hf is cardiac transplantation, but only a select few go on to receive this treatment, either because of donor shortage or being unfit for surgery. many patients may benefit from alternate mechanical support therapies using ventricular assist devices (vads). rapid advances in medical technologies over the last few decades have produced a myriad of new devices and improvements in existing ones. chest radiographs (cxrs) are typically obtained in these patients, and it is not uncommon for the radiologist to be presented with a cxr containing a cardiac device. the role of the radiologist involves identifying the device on the cxr, as well as careful assessment for accurate placement and excluding complications. the intention of this article is to provide insight into the various vads found in clinical practice, identifying the most commonly used types, assessing their placement and highlighting complications on cxrs. ventricular assist devices ventricular assist devices are used in patients with ventricular dysfunction – right, left or biventricular – and can be temporary or permanent, based on the clinical indication. temporary vads are used as a bridge to myocardial recovery or during cardiac transplantation. permanent vads may be used for the same reason but are typically selected in patients who require long-term treatment for myocardial dysfunction and who are not fit for cardiac transplantation. temporary ventricular assist devices intra-aortic balloon pump an intra-aortic balloon pump (iabp) is a polyethylene balloon that spans the entire length of the thoracic aorta, placed percutaneously via femoral artery access. the iabp comes in different lengths with iabp selection determined based on the patient’s height. the iabp inflates during diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal arteries. immediately prior to systole, it deflates producing a vacuum effect leading to forward blood flow to the aorta and its branches. although the iabp is predominately radiolucent on a cxr, it has radiopaque tips proximally and distally. on the cxr, the cephalad radiopaque tip should be 2 cm above the carina (figure 1). an alternate landmark would be the aorto-pulmonary window. placing the iabp too caudally may occlude the celiac, superior mesenteric or renal arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries. complications that can occur with iabp include vascular (e.g. limb ischaemia, renal insufficiency, mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation, tear and incorrect positioning] infection and neurological sequelae).3,4,5 figure 1: chest radiograph showing an intra-aortic balloon pump placed in a 53-year-old male with acute post-infarction ventricular septal rupture and cardiogenic shock. note that the radiopaque tip of the intra-aortic balloon pump (arrow) is at or below the level of the carina and needs to be advanced by 2 cm. extracorporeal membrane oxygenation cannula extracorporeal membrane oxygenation (ecmo) is increasingly being employed in adult patients who fail to wean after cardiopulmonary bypass post-cardiac surgery, as well as in patients with severe respiratory failure. the intention of ecmo is to provide oxygenated blood while extracting carbon dioxide. the two main types of ecmo devices are veno-arterial (va) ecmo and veno-venous (vv) ecmo. both allow respiratory support, but only va ecmo allows haemodynamic support, and hence only the latter is used for hf. in va ecmo, deoxygenated blood is siphoned off from a vein and oxygenated blood is returned to an arterial vessel (aorta for central va ecmo and proximal femoral, axillary or subclavian artery for peripheral va ecmo), while in vv ecmo, the oxygenated blood is returned to a systemic vein or the right atrium. following appropriate placement, the cannulas are sutured to the skin to prevent displacement and malposition. radiographs of the chest and abdomen are performed to ensure correct cannula positioning. in vv ecmo, the femoral cannula tip should be at the junction of the inferior vena cava (ivc) and the right atrium (ra), and the internal jugular vein (ijv) cannula tip at the junction of the superior vena cava (svc) and the ra. the vv ecmo dual lumen cannula (e.g. avalon elite) is inserted through the right ijv into the ra, with the tip in the ivc (figures 2 and 3). cannulation sites for va ecmo cannulas depend on the device configuration, with femoral-femoral being the commonest3,6 (figure 4). a change in the position of the cannula with reference to an adjacent bony landmark on subsequent radiographs should prompt the radiologist to check for ecmo malfunction. misplacement of the ecmo cannula can lead to vessel obstruction or occlusion (e.g. svc obstruction). other complications that have been reported include gas emboli, thrombosis of veins or arteries, cerebral ischaemia or stroke and haemorrhage because of anticoagulation.6 a summary of the various ecmo configurations and their indications are elaborated in table 1. figure 2: chest radiograph showing a veno-venous extracorporeal membrane oxygenation with the avalon catheter inserted from the right internal jugular vein directly into the superior vena cava, right atrium and inferior vena cava in a 38-year-old male with idiopathic pulmonary fibrosis. figure 3: chest radiograph showing a veno-venous extracorporeal membrane oxygenation with the cannulae in the superior vena cava (white arrow) and right atrium (black arrow) in a 66-year-old male with congestive heart failure (chf) and pulmonary oedema. figure 4: chest radiograph showing a veno-arterial extracorporeal membrane oxygenation placed in a 1-year-old male child with respiratory failure, with the arterial cannula in the right internal carotid artery (black arrow) and the venous cannula in the right femoral vein (white arrow). table 1: various extracorporeal membrane oxygenation configurations and their indications. long-term ventricular assist devices the main indication for these devices is a bridge to cardiac transplantation. in australia, in 2013, nearly 40% of the patients who underwent heart transplant were bridged to transplantation with a long-term vad. a list of the various indications and contraindications for left ventricular assist devices (lvads) are summarised in table 2.7 table 2: indications and contraindications for left ventricular assist devices. the components of a left ventricular assist device in general include the inflow cannula, the impeller (pump), outflow cannula, the percutaneous driveline connected to a power source and the external system controller. the impeller mechanism enables forward blood flow. first-generation lvads, also known as volume displacement devices, used a volume displacement device with valves to pump out blood. because of their poor long-term durability, thrombus formation and increased risk for infections, they have fallen out of favour clinically. currently, the only adult first-generation vad still available, albeit rarely used, is the thoratec vad. it is a pneumatically driven pump and available as either paracorporeal (thoratec pvad) or intracorporeal (thoratec ventricular assist device [ivad]) models, both capable of providing univentricular (left or right) and biventricular support. the thoratec pvad is implanted on the anterior abdominal wall, while the ivad is implanted in a preor intraperitoneal position.8 the berlin heart excor® ventricular assist device (berlin heart, berlin, germany), a first-generation vad, is the most commonly used lvad worldwide in paediatric patients with end-stage hf as a bridge to heart transplantation.9 it consists of a pneumatically driven paracorporeal translucent pump. the device cannulae are made of silicon rubber and coated externally with dacron velour at the site where it exits the upper abdominal wall to encourage granulation tissue formation and reduce the risk of infection. the device can provide both univentricular and biventricular support (figures 5 and 6).10 figure 5: chest (a) and abdominal (b) radiographs showing a berlin heart left ventricular assist device with its inflow (black arrow) and outflow (white arrow) cannulae implanted in the left ventricle and aorta, respectively, in a 2.5-year-old male child with severe left ventricular dysfunction following an episode of myocarditis. figure 6: chest radiograph showing the biventricular assist device (bivad) berlin heart placed in a 2-week-old infant with severe left ventricular dysfunction and right ventricular hypoplasia. note the inflow (right black arrow) and outflow cannulas of the left ventricular assist device in the left ventricle and aorta, respectively, while the inflow (arrow head) and outflow (angled arrow) cannulas of the right ventricular assist device are in the right atrium and pulmonary artery, respectively. second-generation lvads are currently the most frequently used. worldwide, the heartmate ii® (hmii) is the most commonly used second-generation lvad device. the inflow and outflow cannula placements for this device are like the first-generation lvads. the hmii can be differentiated from other lvads as they are placed within the subdiaphragmatic preperitoneal pocket and are therefore visualised below the left hemidiaphragm on a cxr. in addition, the impeller housing unit has a characteristic ‘bell-shaped’ appearance, with its percutaneous single driveline supplying power to the pump exiting from the right upper quadrant of the abdomen.11 during surgical placement, the inflow cannula is oriented posteriorly towards the centre of the left ventricle (lv) cavity and connected to the pump body at roughly a 30° angle, while the outflow cannula is oriented upward to direct blood flow above the diaphragm. malpositioned hmii pumps contribute to nearly 25% of pump thrombosis. other factors that may contribute to pump thrombosis or failure are inflow cannula malposition and outflow cannula kink or compression.12 an acceptable cxr, to reduce the errors from patient rotation on inflow angle measurements, would be one where the sternotomy sutures are seen overlying the patient’s spine or with rotations < 2 cm. the various hmii measurements that may be assessed on an ap cxr include: (1) the pump pocket depth (ppd), (2) the outflow cannula angle and (3) the inflow cannula angle. the outflow cannula is fixed to the body of the hmii with a known angle (generally >100°), and any deviation from the known angle is indicative of a cxr set-up error and rotation. it has been shown that the inflow cannula angle measurements should remain constant on serial imaging. an ideal inflow cannula angle should be >55°–65° to reduce the risk of pump thrombosis (figure 7). also, the inflow cannula should point to the central aspect of the left ventricle on a cxr. a deeper ppd (12 cm–14 cm) is believed to help protect against pump thrombosis. however, ppd measurements are not always precise, as the diaphragm is not a fixed structure, and the bottom of the pump on the cxr may not be the actual nadir of the pocket. also, with time the ppd decreases by 2 cm–2.5 cm because of cranial migration of the pump, even with fixation (figure 8).12,13 a sudden onset of pulmonary oedema could suggest lvad failure. other complications that may be seen on cxr include pneumothorax, pneumomediastinum, pericardial tamponade and infections. documented sites of infection include the superficial driveline, pump pocket, the mediastinum and the internal parts of the pump for which ct is more superior than cxr for evaluation. occasionally, because of device malfunction, the body of the hmii may be replaced without changing the outflow graft, and as a result of variations between the new and old designs, complications such as outflow bend relief detachments and kinking may be seen.5,14 figure 7: an accurately positioned hmii left ventricular assist device in a 67-year-old male with ischaemic cardiomyopathy. note that the inflow cannula (black arrow) angle is 72° and the left ventricular assist device is placed at pump pocket depth (left brace) of 11 cm. note the other parts of the hmii left ventricular assist device – the bell-shaped impeller unit (star), the outflow cannula (arrow head) and the driveline (white arrow). figure 8: follow-up chest radiograph after 1 year showed that the same hmii device had migrated cranially by 2 cm. third-generation lvads use magnetic levitation technology (maglev) enabling rotation without friction or wear, and the pump mechanism produces centrifugal flow. in addition, because of their smaller size, they are implanted in the pericardial space. on cxrs, the impeller units of the heartware lvad (hvad) and the heartmate iii (hmiii) can be differentiated from hmii, as the former have a circular appearance with a centrally located inflow cannula. the differentiating feature between the hvad and hmiii devices are that the radiopaque portion of the hmiii’s outflow cannula is angled, while in the hvad it has a more linear orientation (figures 9 and 10).3,14,15 currently, the most commonly used third-generation lvads is the hvad.16 although echocardiography and ct are the main modalities for detailed evaluation of lvads, as in the second-generation lvads, cxrs can also be used to assess for complications related to third-generation lvad placement. as none of the lvads from any generation are mr safe, mri is contraindicated and has no role in their evaluation.17 abdominal radiographs are useful for assessing lvad driveline damage in the form of fraying or kinking, as damages occurring to the percutaneous portion of the driveline are not evident on visual inspection.18 figure 9: frontal (a) and lateral (b) chest radiographs showing a heartware left ventricular assist device in a 41-year-old male with familial dilated cardiomyopathy. note that its outflow cannula (arrow) is without angulation and it has a circular impeller unit (star). figure 10: frontal (a) and lateral (b) chest radiographs showing a heartmate iii device implanted in a 58-year-old male with severe left ventricular dysfunction. note that the hmiii device has an angled outflow cannula (arrow) and a circular impeller unit (star). myocardial recovery is a known phenomenon in patients with lvads. although an lvad explant would offer a better quality of life and freedom for these patients, many centres have hesitancy to perform these procedures as it can be aggressive and there are no established criteria for the device explant. in addition, re-inserting an lvad in a patient with a previous explant following a relapse of hf can be a challenging task. a minimally invasive lvad decommission procedure that some follow, includes leaving the device in situ, severing the driveline and ligating the outflow graft through a small thoracotomy. this essentially leaves a natural opening for future lvad reimplantation, should it be needed (figure 11a and b).19 figure 11: frontal (a) and lateral (b) chest radiographs showing a decommissioned heartware left ventricular assist device (thick arrow) with an intentionally severed driveline (arrow) in a 33-year-old lady with a history of left coronary dissection. neurological complications are one of the most devastating and common complications in patients with lvads. in those patients with a risk for cerebrovascular disease, a pre-operative carotid ultrasound is often done as a standard evaluation. in those patients with neurological symptoms, a post-operative carotid ultrasound is performed. left ventricular assist devices can alter the waveforms on carotid doppler and findings include a parvus tardus waveform with a low peak systolic velocity and continuous diastolic flow.20 a summary of the classification of various vads and the characteristics of the various permanent lvads are outlined in box 1. box 1: classification of ventricular assist devices and summary of the permanent ventricular assist devices. ethical consideration all ethical considerations have been taken into account. no patient identity or patient information has been revealed. conclusion ventricular assist devices play a crucial role in the management of patients with hf. with recent advances, newer devices have become smaller and more durable. the role of the radiologist is to identify the salient medical device on the radiograph, to evaluate for appropriate device placement and to exclude device-related complications. acknowledgements competing interests the authors have declared that no competing interests exist. author’s contributions r.p.m. was the project leader and wrote the article. t.a. was the lead subject authority, supervision of manuscript and helped acquire the images. v.p. and g.l. were responsible for the supervision of manuscript and helped acquire the images. funding this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references savarese g, lund lh. global public health burden of heart failure. card fail rev. 2017;3(1):7–11. https://doi.org/10.15420/cfr.2016:25:2 cowie mr. the heart failure epidemic: a uk perspective. echo res pract. 2017;4(1):r15–r20. https://doi.org/10.1530/erp-16-0043 mohamed i, lau ct, bolen ma, et al. building a bridge to save a failing ventricle: radiologic evaluation of shortand long-term cardiac assist devices. radiographics. 2015;35(2):327–356. https://doi.org/10.1148/rg.352140149 brixey ag, fuss c. innovative cardiac devices on chest imaging: an update. j thorac imaging. 2017;32(6):343–357. https://doi.org/10.1097/rti.0000000000000304 dipoce j, bernheim a, spindola-franco h. radiology of cardiac devices and their complications. br j radiol. 2014;88(1046):20140540. https://doi.org/10.1259/bjr.20140540 lee s, chaturvedi a. imaging adults on extracorporeal membrane oxygenation (ecmo). insights imaging. 2014;5(6):731–742. https://doi.org/10.1007/s13244-014-0357-x stokes mb, bergin p, mcgiffin d. role of long-term mechanical circulatory support in patients with advanced heart failure. intern med j. 2016;46(5):530–540. https://doi.org/10.1111/imj.12817 jain vr, white cs, pierson rn 3rd, et al. imaging of left ventricular assist devices. j thorac imaging. 2005;20(1):32–40. di molfetta a, filippelli s, ferrari g, et al. berlin heart excor ventricular assist device: multilayer membrane rupture in a pediatric patient. ann thorac surg. 2016;102(2):e129–e130. https://doi.org/10.1016/j.athoracsur.2016.01.022 gazit az, gandhi sk, canter c. mechanical circulatory support of the critically ill child awaiting heart transplantation. curr cardiol rev. 2010;6(1):46–53. https://doi.org/10.2174/157340310790231617 sigakis cjg, mathai sk, suby-long td, et al. radiographic review of current therapeutic and monitoring devices in the chest. radiographics. 2018;38(4):1027–1045. https://doi.org/10.1148/rg.2018170096 adamson rm, bower bl, sundareswaran ks, et al. radiologic assessment of heartmate ii position: minimal pump migration after long-term support. j heart lung transplant. 2015;34(12):1617–1623. https://doi.org/10.1016/j.healun.2015.07.006 taghavi s, ward c, jayarajan sn, et al. surgical technique influences heartmate ii left ventricular assist device thrombosis. ann thorac surg. 2013;96(4):1259–1265. https://doi.org/10.1016/j.athoracsur.2013.05.081 ota t, takayama h, khalpey z, et al. reinforcement of heartmate ii bend relief connection: champagne bottle technique. ann thorac surg. 2013;95(4):e107–e108. https://doi.org/10.1016/j.athoracsur.2012.12.023 rodriguez le, suarez ee, loebe m, et al. ventricular assist devices (vad) therapy: new technology, new hope? methodist debakey cardiovasc j. 2013;9(1):32–37. englert ja, davis ja, krim sr. mechanical circulatory support for the failing heart: continuous-flow left ventricular assist devices. ochsner j. 2016;16(3):263–269. carr cm, jacob j, park sj, et al. ct of left ventricular assist devices. radiographics. 2010;30(2):429–444. https://doi.org/10.1148/rg.302095734 morris mf, staley ll, arabia fa, et al. abdominal x-ray imaging for detection of left ventricular assist device driveline damage. j heart lung transplant. 2012;31(12):1313–1315. https://doi.org/10.1016/j.healun.2012.09.006 macgowan ga, wrightson n, robinson-smith n, et al. myocardial recovery strategy with decommissioning for the heartware left ventricular assist device. asaio j. 2017;63(3):299–304. https://doi.org/10.1097/mat.0000000000000523 cervini p, park sj, shah dk, et al. carotid doppler ultrasound findings in patients with left ventricular assist devices. ultrasound q. 2010;26(4):255–261. https://doi.org/10.1097/ruq.0b013e3181fe2a97 case report a case of cerebral venous thrombosis following the use of contraceptive medication g bunea* fcrad(sa) ib copley+ frcs (ireland) o ajarrl" frcs (edinburgh) abstract cerebral venous thrombosis is an uncommon and serious complication of contraceptive medication, which often masquerades as a simple headache. the clinical picture is often confusi ng and imaging is critical to the diagnosis of this disorder. this case report iiiustrates a case of dural venous thrombosis and a review of the radiological features of cerebral venous thrombosis. 'department of diagnostic radiology, 1department of neurosurgery, medical university of southern africa (medunsa) 33 sa journal of radiology. january 2000 introduction venous sinus thrombosis is a rare event and may have an insidious onset and late sequelae in contradistinction to cavernous sinus thrombosis associated with infection and florid signs. thrombosis involving the dural sinuses is due to three causes: those from changes in blood flow, changes in the vessel wall, or blood abnormalities. blood flow changes are most commonly seen in dehydration. changes in flow and vessel wall are seen in depressed fractures about the midline of the vault. operative interhemispheric (e.g. transcallosal) procedures near the superior sagittal sinus may produce local trauma and stasis. another entity is the vasculitis of behcet's disease. common, non-infectious causes of cerebral venous thrombosis include oral contraceptives, pregnancy and the puerperium. abnormal changes in blood constituents are seen in malnutrition, and blood deficiencies antithrombin iii, protein s & c, disseminated intravascular coagulation, iron deficiency anaemia.' occlusion of the anterior third of the superior sagittal sinus does not produce symptoms or signs whereas thrombosis of the middle third produces upper motor neurone signs, hemior quadriparesis. visual field disturbances or blindness may occur with occlusion of the posterior third of the sinus rapidly followed by decreasing level of consciousness. thrombosis of a transverse sinus is less significant than if the opposite sinus is also occluded. any involvement of the posterior two-thirds is associated with cerebral oedema indicated by engorgement of retinal veins, topage34 a case of cerebral venous thrombosis follo\ni ng the use of contraceptive medication frompage33 meningism and decreased level of consciousness. in subdural parafalx empyema, venous thrombosis followed by infarction may be seen in neglected cases. as the empyema may be restricted to one side or another of the falx, so the neurological deficit may be unilateral before rapid deterioration as the whole superior sagittal sinus becomes involved. case report the patient p.m., a healthy 23 yearold woman, had no previous medical history. she had a child of 5 years of age. a year after delivery, she began with three-monthly injections of norethisterone enantate 200 mg. soon after starting on this treatment, she developed headaches and amenorrhea. three months prior to admission, owing to the headaches, she was changed to levonorgestreli50 ug, ethinyl oestradiol 30 ug oral contraceptive. the change relieved the headaches and there were scanty periods. approximately two days prior to admission, the patient presented at a peripheral hospital with severe headache, nausea and vomiting, decreased vision and confusion (gcs nils) followed by deepening coma. on recovering consciousness, she had a right hemiparesis. her mental recovery was such as to provide the foregoing history. computerized tomography (ct) done at the peripheral hospital (figure 1 and 2) was reported as "a large subdural haematoma (possible venous sinus) occipitally; blood in the quadrigeminal cisterns, possible subarachnoid haemorrhage (sah), blood in the region of the straight sinus. post contrast filling defect in the sagittal sinus possible dural sinus thrombosis". because of the reported sah, the patient was treated with nimodipine. four-vessel angiography, figure 2: ct scan post-contrast shows the empty delta sign in the superior sagittal sinus figure 1a, band c: ct scan pre-contrast on admission demonstrated high-density thrombus in straight sinus, superior sagittal sinus, and in left transverse sinus. a thrombosed vein (cord sign) is seen on the medial aspect of the left temporal lobe figure 3a and b: digital cerebral angiogram in the venous phase demonstrated poor and irregular fil/ing of the superior sagittal sinus, straight sinus, vein of galen, and transverse sinuses. note prominent cortical tributary veins draining into the rostral aspect of the superior sagittal sinus performed il days later (figure 3), confirmed the diagnosis of venous sinus thrombosis. 34 sa journal of radiology· january 2000 topage35 a case of cerebral venous thrombosis foliovvi ng the use of contraceptive rrieclicatiori frompage34 figure 4a and b: repeat ct scan with contrast injection, 12 days later showed strong enhancement of the straight sinus with a central filling defect, and the empty delta sign in the superior sagittal sinus a second ct with contrast (figure 4) was done 12 days later which showed a clear delta sign and clot within straight sinus. magnetic resonance (mr) imaging was requested at 18 days and showed typical high signal thrombus (figure 5) in the dural sinuses. it also showed a left cortical venous infarct. hypertension, and cerebral venous thrombosis (cvt). the evaluation of a patient on contraceptive medication, who complains of worsening headaches, requires exclusion of cvt2 by computed tomography or magnetic resonance imaging. discussion the cerebral side effects of the contraceptive medication include nonspecific headaches or migraine, withdrawal headaches, benign intracranial 35 sa journal of radiology. january 2000 figure sa, b, c and d: sagittal, coronal, and axial t1 and t2-weighted mr images showed high intensity signal within the superior sagittal sinus the manufacturers state that the occurrence for the first time of a migraine type of headache, the more frequent occurrence of an unusually severe headache, or sudden perception disorders is sufficient reason for immediate discontinuation.! a mere change of the drug is probably hazardous. this case shows that cvt can masquerade for many months as a simple headache or even a benign intracranial hypertension. extensions to the deep cerebral veins are associated with a sudden neurological deterioration and poor outcome. imaging is critical to the diagnosis of this disorder, which can be made by non-invasive modalities such as ct or mr. non-enhanced ct scans may show hyperdense thrombus in the dural sinus (dense sinus sign), deep cerebral veins, or cortical veins (cord sign), cortical and subcortical haemorrhagic infarctions, and diffuse cerebral swelling. after contrast the thrombosed sinus remains unopacified with enhancement of the topage36 a case of cerebral venous thrombosis fof lovvi ng the use of contraceptive medication from page35 collaterals in the dura leaves (empty delta sign), the falx appears thickened, there is tentorial (shaggy tentorium) and gyral enhancement, and the transcortical medullary veins may enhance strongly. deep cerebral vein thrombosis appears as a high density thrombus in the deep veins, vein of galen, or straight sinus, with or without basal ganglia infarctions and petechial haemorrhages. the differential diagnosis of dural sinus thrombosis on ct scans includes normal neonates with unmyelinated brain and dense sinus, high-splitting tentorium and pseudodelta sign seen in subarachnoid haemorrhages. mr findings vary with clot age.an acute thrombus is iso-intense with the cortex on tl -weighted images, older haematomas are hyper-intense on tiweighted scans and hypo-intense on t2-weighted images, while sub-acute thrombi are typically hyper-intense on all pulse sequences. in the chronic phase, prominent collateral venous channels can be seen around and within the thrombosed sinus (i.e. recanalisation), and intense enhancement of the thrombus after gadolinium injection (i.e. conversion to vascularized connective tissue). other causes of increased signal within a sinus on spin-echo images must be excluded, such as: turbulent or slow flow, flow entry phenomenon, even echo rephasing, and flow compensation techniques. flow enhancing gradient-echo sequences along with spinecho sequence should allow the differentiation. in acute thrombosis, high field strengths can give a low signal which can be confused with a patent dural sinus. mr angiography or venography provides conclusive evidence of flow in the sinus rather than relying on flow-related enhancement effects in standard imaging. angiographic signs of a thrombosed sinus include non-filling of the dural sinus, filling defects, enlarged medullary veins and other collaterals. thrombosed cortical veins are seen as contrast collections which appear to hang in space with contrast persisting well into the very late venous phase. deep cerebral vein thrombosis is seen as the non-filling of the vein of galen and internal cerebral veins, with or without collaterals." cerebral ctvenography, possible with spiral ct and three-dimensional reconstructions, allows an accurate evaluation of the flow in the cerebral 36 sa journal of radiology. january 2000 venous system.' venous transcranial doppler ultrasonography can be used as a monitoring tool in the evaluation of the collateral venous flow in superior sagittal sinus thrombosis, however it needs further evaluation." apart from anticoagulation and control of raised intracranial pressure, selective venous administrations of fibrinolytic agents by an interventional neuroradiologist is possible.' it is conjectural as to whether or not the use of nimodipine contributed to the patient's eventual excellent recovery. references 1. hoffman mw, bill pla, bhigjee ai, modi g, haribhai hc, keble c. the clinicoradiological profile of cerebral venous thrombosis. s afr med. j, 1992: 82: 341-348. 2. naim-ur-rahman, abdul tahman ai tahan. computed tomographic evidence of an extensive thrombosis and infarction of the deep venous system. stro/le, 1993: 24,5: 744-746. 3. m/ms medical specialties, 1998: 38,4: 184. 4. osborn ag. diagnostic neuroradiology. st louis: mosby. 1994 : 385-395. 5. casey so, alberico ra, patel m, jiminez jm, et al. cerebral ct venography. nadiology, 1996: 198,1: 163-170. 6. valdueza jm, schultz m, harms l, einhaepel km. venous transeramal doppler, ultrasound monitoring in acute dural sinus thrombosis. stroke, 1995: 26,7: 1196-9. 7. scott ja, pascuzzi rm, hall pv, becker gj. treatment of dural sinus throm bosis with local urokinase infusion. j neurosurg, 1988: 68: 284287. abstract introduction methods ethical consideration radiological findings results discussion conclusion acknowledgements references about the author(s) nausheen khan kalafong hospital, university of pretoria, south africa juliane hiesgen kalafong hospital, university of pretoria, south africa citation khan n, hiesgen j. computerised tomography findings in hiv-associated cryptococcal meningoencephalitis at a tertiary hospital in pretoria. s afr j rad. 2017; 21(2), a1215. https://doi.org/10.4102/sajr.v21i2.1215 original research computerised tomography findings in hiv-associated cryptococcal meningoencephalitis at a tertiary hospital in pretoria nausheen khan, juliane hiesgen received: 19 may 2017; accepted: 24 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objective: computerised tomography (ct) scans of 30 patients, admitted with hiv-associated cryptococcal meningoencephalitis (cm), were retrospectively reviewed and the different neuroradiological findings categorised. in addition to the characterisation of the cohort, we looked at whether positive ct scans can indicate negative outcomes when compared with normal imaging. methods: we identified all patients admitted with cm to kalafong hospital in pretoria, south africa, over a 2-year period and selected those who underwent brain ct. abnormal findings were divided into cryptococcal-related lesions and other pathological findings. clinical data, as well as laboratory data and information about the outcomes were collected. results: thirty-nine (44.8%) out of 87 patients had a ct done during the hospital admission, of which 30 were reviewed and independently reported by the authors. the majority of ct scans were non-contrasted (n = 21). four patients (13.3%) had normal imaging. amongst the 26 patients with abnormal cts, we found 16 brain scans (53.3%) with changes most likely attributed to cm. dilated virchow–robin (vr) spaces, found on eight scans (26.7%), were the most common ct finding related to neurocryptococcosis. global cerebral atrophy, present in 17 patients (56.7%), was the prevailing generalised abnormality. the mortality of all patients who underwent imaging was similar (33.3%) to the mortality in the total cohort of patients with cryptococcal meningitis (31%). in the group with cryptococcal-related changes on imaging, the mortality was higher (53.3%) than in both groups and a subgroup of five patients with hydrocephalus showed 100% mortality. conclusion: computerised tomography brain imaging was performed in 44.8% of all patients admitted with cm into our hospital. more than half of the images showed cryptococcal-related pathological findings, of which dilated vr spaces were the most common. only 13.3% of scans were normal. mortality was higher in the patients with cryptococcal-related pathology (53.3% vs. 31%), with hydrocephalus being associated with a 100% mortality. no scan in our cohort showed any pathology requiring neurosurgical intervention or contraindicating the procedure of a lumbar puncture. introduction cryptococcal meningitis is the most common life threatening fungal infection in people living with hiv/aids1 and the second most common opportunistic infection after tuberculosis (tb) in south africa.2 prevalence and mortality in south africa are high,3 and the long-term prognosis is very poor.4 this is despite the good availability of antiretroviral (arv) therapy and national treatment guidelines for neurocryptococcosis. brain imaging in patients with aids and central nervous system (cns) involvement is important, not only for assessing the severity of the presenting entity [e.g. cryptococcal meningoencephalitis (cm)] but also for looking at the degree of underlying neurodegeneration (hiv-related) and to diagnose concomitant conditions (e.g. additional vascular disease, other infections such as neurocysticercosis or tb, tumours, etc.). most authors, therefore, distinguish between cryptococcosis-related and ‘other’ lesions.5,6 in a previous study from kalafong hospital, pretoria, we looked at the clinical presentation and outcomes of all patients admitted with cryptococcal meningitis over a 2-year period.7 however, because of the high burden of patients and the limited resources, only a relatively small number of admitted patients with cryptococcal meningitis underwent cerebral imaging so that we did not analyse the radiological data. the present study complements our previous findings by reviewing the brain computed tomography (ct) scans available of hiv patients with cryptococcal meningitis seen in our institution from 2012 until 2013. we retrospectively analysed and categorised the neuroradiological findings and compared our results with other studies on imaging in neurocryptococcosis. in addition, we looked at outcomes in relevant subgroups of our cohort. methods all patients admitted with cryptococcal meningitis between january 2012 and december 2013 were retrospectively identified, via screening of the discharge summaries, and their files retrieved. only confirmed cases [positive cerebrospinal fluid (csf) diagnosis by india ink stain, cryptococcal antigen test and/or positive fungal culture] were included. in this spin-off study, we retrieved the ct scans of patients who underwent brain imaging during this period. all scans were acquired on the same phillips brilliance 16 slice ct scanner, and the scans were assessed independently by a radiologist and a neurologist. no patient underwent magnetic resonance imaging (mri). data including hivand treatment history, presenting symptoms, blood and csf findings, complications and clinical outcomes (survival) were collected and analysed. ethical consideration ethical approval was obtained by the research ethics committee of the faculty of health sciences, university of pretoria (430/2013). radiological findings for better comparison with other published data, we attempted to categorise the ct abnormalities. although no reported radiological changes in cryptococcal meningitis seem to be specific or unique for the infection, some findings are common and thought to be cryptococcal related. these are, firstly, dilated virchow–robin spaces (vr), defined as small hypodense or cystic, non-enhancing, lesions with a diameter of 2 mm–3 mm on axial slices. secondly, gelatinous pseudocysts, presenting as low-density and non-enhancing lesions, but because of accumulation of the yeast, bigger than vr spaces (>3 mm) and often located in the basal ganglia and periventricular areas. cryptococcomas are a third specific finding and consist of masses also mostly located in the basal ganglia, with or without enhancement and surrounding oedema.6,8,9,10,11 in the setting of confirmed, active cryptococcal meningitis we would also define meningeal enhancement and hydrocephalus (dilated ventricular system with ballooning of third ventricle recess and temporal horns of the lateral ventricles, not attributed to atrophy) as cryptococcal-related radiological findings. other non-specific findings included global cerebral atrophy and symmetrical confluent white matter changes in keeping with hiv encephalopathy. results thirty-nine (44.8%) out of 87 hiv-infected patients admitted with cryptococcal meningitis between 2012 and 2013 underwent brain imaging in our institution. as we did not have an mri scanner at the time, all imaging was restricted to ct imaging of the brain. we were able to retrieve and analyse 31 of the original scans. one of these scans was excluded because of poor quality (motion artefacts). the radiological findings are summarised in table 1. table 1: computerised tomography findings of 30 patients with confirmed cryptococcal meningitis. sixteen patient scans (53.3%) revealed neurocryptococcosis-related abnormalities. dilated vr spaces (figure 1a) were the most commonly found cryptococcosis-related pathological findings in our cohort, identified on 8 out of 30 scans (26.7%), followed by gelatinous pseudocysts (figure 1b) in seven (23.3%), and hydrocephalus (figure 1a) in five cases (16.7%). cryptococcomas (figure 2) were present in 10% of our patients, and we found one soap bubble lesion. the ct scan shown in figure 1 illustrates some of the common radiological features in cm. figure 1: (a) axial computerised tomography scan brain showing dilated virchow–robin (vr) spaces (arrow) as small hypodense non enhancing lesions in the left basal ganglia. note also a larger hypodense lesion in the left external capsule consistent with a gelatinous pseudocyst, in addition, atrophy and mild hydrocephalus; (b) axial brain scan with a pseudocyst in the right basal ganglia and a dilated vr on the left. figure 2: axial contrasted computerised tomography scan with a non-enhancing cryptococcoma in the right basal ganglia. completely normal ct scans were found in only four patients, another six patients had cerebral atrophy and four patients had miscellaneous findings (cerebral atrophy, white matter changes, calcifications and others), without cryptococcal-related pathology. in table 2, we compare our results with other studies on ct imaging in cm. of note is the small percentage of normal scans seen in our study compared to other reports. the numbers of ct brains without pathology in our cohort seem more comparable with the reports of normal images obtained with mri. table 2: comparison of abnormal findings on computerised tomography brain imaging in hiv-associated neurocryptococcosis with other similar studies (in %). furthermore, five patients had communicating hydrocephalus on ct, representing 16.7% of the cohort. compared with other reports, even with mri, this was high. in table 3, the details of the patients with hydrocephalus are listed. table 3: hiv patients with cryptococcal meningoencephalitis presenting with hydrocephalus on computerised tomography brain. the mean cd4 count of the patients that were scanned was 44 cells/µl; and not greatly differing from the mean cd4 count in the whole cohort of cm patients of 52 cells/µl. the overall mortality in the patients that underwent ct brain imaging was 33.3%, hence, very similar to the in-patient mortality in the total cohort of patients with cryptococcal meningitis (31%).7 in the group with cryptococcal-related changes on imaging, the mortality was higher (50%) and a small subgroup of patients with hydrocephalus showed a 100% mortality (n = 5). the patients with normal cerebral imaging and the group of patients that had cerebral atrophy and no other pathological findings, had lower mortalities at 25% and 16.7%, respectively. table 3 shows the details of the patients with hydrocephalus. the mean cd4 count of this subgroup was 69.8 cells/µl, therefore, slightly higher than the cd4 count in the entire group. however, none of these patients developed immune reconstitution inflammatory syndrome (iris). seventeen patients (56.7%) received concurrent treatment for tb while in hospital and on antifungal medication. this is similar to 56.3% of patients in the whole cohort of patients with cm. only two of those had proven tb (one positive sputum culture and one positive on sputum genxpert). the majority of patients were either already on anti-mycobacterial treatment from other health care providers or restarted after they had defaulted tb treatment. some were empirically started during their hospital stay for different reasons such as severe, non-resolving chest radiographs, pancytopenia or generalised lymphadenopathy. other common co-infections were oral candidiasis (n = 8), onychomycosis and herpes simplex infections. discussion previously published data suggest a higher sensitivity of mri compared with ct in the detection and evaluation of neurocryptococcosis-related radiological abnormalities in hiv patients. charlier et al.6 report 92% abnormal mr scans at baseline contrasting with 53% abnormal ct scans in their retrospective analysis in 2008. in 17 of their patients who had dual imaging (ct and mri), the mri detected significantly more lesions (76% vs. 24%, p = 0.005) than ct. dilated vr spaces were especially more frequently visualised by mri than by ct. these findings support prior results and both modalities might well underestimate the extent of pathology when compared with post-mortem studies.14 the presence of abnormal brain imaging had a negative impact on survival, shown in a cohort study from france in 2007 where mortality at 3 months was significantly higher in patients with abnormal brain imaging.15 we analysed in this retrospective spin-off study, the ct scans of 30 hiv patients with confirmed cm. for better comparability, we divided our positive findings into cryptococcal-related radiological pathology and ‘other’ abnormalities. our study correlates with previous results in terms of qualitative findings. consistent with when et al.,16 tien et al.,12 loyse et al.5 and others, we found dilated vr spaces the most common cryptococcosis-related radiological finding at almost 27%. in view of the assumed pathophysiology with the fungus spreading haematologically from the lungs to the brain, this is reasonable. perivascular spaces are small areas with interstitial fluid created by blood vessels entering the meninges, usually only visualised when dilated, and they are the ‘first station’ for the fungus entering the cns. vr spaces are predominantly found in the basal ganglia. when the fungal burden increases and mucous substances from the capsule of the organism are accumulating, dilated vr spaces expand to gelatinous pseudocysts, which by some authors are considered as specific for the disease.17 if clusters of these cysts develop, so called ‘soap bubble’ (figure 3) lesions are found.18 cryptococcomas (figure 2) are intraparenchymal lesions representing a more chronic granulomatous reaction to the infection and, therefore, often not seen in the advanced stages of aids as there is little immune response.19 radiologically, they are larger than the vr spaces and cysts and might be less hypodense. contrast enhancement and surrounding oedema might be present in cryptococcomas in contrast to the latter. none of our patients had intraventricular cysts and only one had a cluster of cysts (soap bubbles). we also did not have any scan detecting meningeal contrast enhancement, which is also regarded as a feature of active disease. this is consistent with previous reports,8 and we believe it mirrors the fact of severe immunosuppression in our cohort with little inflammatory response and also reflects that there were no cases of iris amongst our patients. figure 3: classical soap bubble lesion in the right basal ganglia seen on this contrast-enhanced axial image. compared with other studies, we found a low number of completely normal scans at 13.3% (see table 1). by adding the cases with ‘just’ atrophy (n = 6) we arrive at a percentage of 33%, which is still low. one possible explanation is the better resolution of our current scanner compared to the scanners used in the cited studies (table 2), our data being from 2012 to 2013 and the studies published between 1997 and 2008. the data from the study by moosa and coovadia,13 showed the highest percentage of normal scans, were collected between 1991 and 1994, placing our scans at an approximately 20 year timeand technical advance. the in-patient mortality in the patient group with cts was not different than the mortality of all patients seen over the 2-year period with approximately one third of the patients dying in both groups. the groups did not differ significantly regarding cd4 counts or disease severity. looking at patients with cryptococcal-related abnormalities on imaging, we found higher in-patient mortality in this group (50%) compared to the whole group, confirming the above mentioned results.15 furthermore, we found a relatively high number of ct scans showing hydrocephalus, with or without other pathology (16.7%) and, additionally, all patients who had hydrocephalus died during their hospital stay, resulting in a 100% mortality rate of this subgroup of five patients. while few authors regard hydrocephalus as a non-specific but common feature of cryptococcal meningitis,10 others report cases with hydrocephalus less often (compared with results in table 2). even in mri studies the prevalence of hydrocephalus was low (e.g. 2% in loyse et al.,5 charlier et al.6). there is sound data that raised intracranial pressure correlates with higher mortality and international and national guidelines support aggressive management if the baseline opening csf pressure is raised.20 our own data showed an increased mortality in those patients that were admitted with features consistent with high csf pressures7 and the five patients with communicating hydrocephalus are probably part of this subgroup with poor prognosis. unfortunately, as this was a retrospective study, opening pressures were mostly not documented and, therefore, we cannot compare and correlate the pressures with the imaging. one patient had a normal opening pressure documented and one an increased pressure, but in the remaining three cases the data were incomplete. of note is that in none of the cases was the degree of the hydrocephalus notably extensive on imaging (figure 1), to suggest the necessity for shunt surgery. neither was there a non-communicating hydrocephalus implicating a contraindication for the procedure of a lumbar puncture. there are obvious limitations to the present study. it is not entirely clear why certain patients underwent imaging and others did not and how this might have influenced our results. although most clinicians decide to have a patient scanned in the presence of a reduced level of consciousness, signs of raised intracranial pressure or focal neurological deficit and seizures, not all patients with these features were scanned. there was also no guideline in our hospital, suggesting that all patients with confirmed neurocryptococcosis should have a ct scan of their brain. often, it depended on the personal judgement by the admitting physician, the current burden of work in the radiology department or even trivial factors like the availability of a porter to get the patient in to the scanner. as the nature of this study is retrospective, the available data are not complete, and because of the small numbers we went, without statistical analysis, for a descriptive study. conclusion the neuroradiological findings in our patients with hiv-associated cm are qualitatively similar to previously reported findings. the most common crypto-related abnormality was the presence of dilated vr spaces. our yield in detecting abnormalities on imaging was higher than in previous studies. this finding suggests that modern ct imaging represents a good alternative to mri in resource-limited settings. the presence of cryptococcal-related abnormalities on ct brain is indicative of a higher mortality. the subgroup of patients with communicating hydrocephalus was associated with 100% mortality in our cohort, emphasising the importance of appropriate management of raised intracranial pressure. acknowledgements competing interests the authors declare that they have no conflict of interest in the article. author(s) contributions j.h. (consultant neurologist) collected the clinical data, and n.k. (consultant radiologist) assembled the radiological data. both j.h. and n.k. helped with the manuscript and reference search. references bicanic t, harrison t. cryptococcal meningitis. br med bull. 2005;72:99–118. https://doi.org/10.1093/bmb/ldh043 jarvis jn, harrison ts, corbett el, wood r, lawn sd. is hiv-associated tuberculosis a risk factor for development of cryptococcal disease? aids. 2010;24(4):612–614. https://doi.org/10.1097/qad.0b013e32833547f7 rajasingham r, smith rm, park bj, et al. global burden of disease of hiv-associated cryptococcal meningitis: an updated analysis. lancet infect dis. 2017;17(8):873–881. https://doi.org/10.1016/s1473-3099(17)30243-8 lessels rj, mutevedzi p, heller t, newell ml. poor long-term outcomes for cryptococcal meningitis in rural south africa. samj. 2011;101:251–252. https://doi.org/10.7196/samj.4378 loyse a, moodley a, rich p, et al. neurological, visual, and mri brain scan findings in 87 south african patients with hiv-associated cryptococcal meningoencephalitis. j infect. 2015;70:668–675. https://doi.org/10.1016/j.jinf.2014.10.007 charlier c, dromer f, lévêque c, et al. cryptococcal neuroradiological lesions correlate with severity during cryptococcal meningoencephalitis in hiv-positive patients in the haart era. plos one. 2008;3(4):e1950. https://doi.org/10.1371/journal.pone.0001950 hiesgen j, schutte c, olorunju s, retief j. cryptococcal meningitis in a tertiary hospital in pretoria, mortality and risk factors – a retrospective cohort study. int j std aids. 2017;28(5):480–485. https://doi.org/10.1177/0956462416653559 misziel ka, hall-craggs ma, miller rf, et al. the spectrum of mri findings in cns cryptococcosis in aids. clin radiol. 1996;51:842–850. https://doi.org/10.1016/s0009-9260(96)80080-8 popovich mj, arthur rh, helmer e. ct of intracranial cryptococcosis. am j neuroradiol. 1990;11:139–142. https://doi.org/10.2214/ajr.154.3.2106227 smith a, smirniotopoulos j, rushing ej. from the archives of the afip: central nervous system infections associated with human immunodeficiency virus infection: radiologica-pathologic correlation. radiographics. 2008;28(7):2033–2058. https://doi.org/10.1148/rg.287085135 xia s, xueqin l, yanbin s, et al. a retrospective cohort study of lesion distribution of hiv-1 infection patients with cryptococcal meningoencephalitis on mri. medicine. 2016;95(6):e2654. https://doi.org/10.1097/md.0000000000002654 tien rd, chu pk, hesselink jr, duberg a, willey c. intracranial cryptococcosis in immunocompromised patients: ct and mri findings in 29 cases. am j neuroradiol. 1991;12:283–289. moosa mys, coovadia ym. cryptococcal meningitis in durban, south africa: a comparison of clinical features, laboratory findings, and outcome for human immunodeficiency virus (hiv)-positive and hiv-negative patients. clin infect dis. 1997;24:131–134. https://doi.org/10.1093/clinids/24.2.131 mathews vp, alo pl, glass jd, kumar aj, mcarthur jc. aids related cns cryptococcosis: radiologic-pathologic correlation. am j neuroradiol. 1992;13(5):1477–1486. dromer f, mathoulin-pelissier s, launay o, lortholary o. determination of disease presentation and outcome during cryptococcosis: the crypto a/d study. plos med. 2007;4(2):e21. https://doi.org/10.1371/journal.pmed.0040021 when sm, heinz er, burger pc, boyko ob. dilated virchow–robin spaces in cryptococcal meningitis associated with aids: ct and mr findings. j comput assist tomogr. 1989;13(5):756–762. https://doi.org/10.1097/00004728-198909000-00002 corti m, villafañe mf, negroni r, arechavala a, maiolo e. magnetic resonance imaging findings in aids patients with central nervous system cryptococcosis. rev iberoam micol. 2008;25(4):211–214. vieira ma, costa ch, ribeiro jc, nunes-filho lp, rabelo mg, almeida-neto ws. soap bubble appearance in brain magnetic resonance imaging: cryptococcal meningoencephalitis. rev soc bras med trop. 2013;46(5):658–9. https://doi.org/10.1590/0037-8682-0142-2013 ogbuagu o, villanueva m. extensive central nervous system cryptococcal disease presenting as immune reconstitution syndrome in a patient with advanced hiv: report of a case and review of management dilemmas and strategies. infect dis rep. 2014;6(4):5576. https://doi.org/10.4081/idr.2014.5576 pappas p. managing cryptococcal meningitis is about handling the pressure. clin infect dis. 2005;40(3):480–482. editorial 1997: global links, world wide web and much more! petercorr mbchb, ffrad(d)sa, frcr, mmed(ucn department of radiology, university of natal b y the time you read this, 1997 will be around the corner' sajr has successfully survived its first year] as south africa is an indian ocean rim country, we have established ties with the singapore radiology society and their journal: diagnostic clinics in the singapore medical journal (smj). we will be publishing in this edition a reprint of a case report from the diagnostic clinics series of the smj. we hope to exchange case reports with the smj on a regular basis. we hope that you are able to visitthe journal on the world wide web athttp://wwwimed.co.za/rssa. the home page ofrssa, where you will find a wealth of useful information with links to radiology societies around the world. the exponential growth of the internet is changing the way we work, find information and communicate. southafiica and sa radiologyis well placed to take advantage of our lead in this phenomenon. software development has allowed the generation of radiologicalreports that can be transmitted bye-mail and the internet. it is only a matter of time before radiologicalimages will follow' i wish you and your family a peaceful and happy new year. the editor 3 sajournal of radiology· november 1996 http://athttp://wwwimed.co.za/rssa. original article helical ct of abdominal aortic aneurysms prior to endovascu lar stent graft repair geb hacking mb chb, fcr (d) (sa), frcr (lond) re steyn dcrr(uk) morton and partners capetown p j matley mb chb, fcs (sa), mmed (surg) jeffery and partners cape town introduction conventional abdominal aortic aneurysm (aaa) repair carries significant mortality and morbidity risk. endovascular repair using a stent graft introduced through small femoral cut-downs is an alternative treatment that is minimally invasive and associated with a greatly reduced hospital stay, no requirement for postoperative intensive care and a rapid return to normal physical activity. it is therefore not surprising that this relatively noninvasive percutaneous technique of placing an endovascular stent graft (esg) for repair of aaas has become the treatment preferred by many vascular surgeons for suitable aaas. endovascular repair is currently limited by its considerable cost, the lack of adequate long-term follow-up information proving its durability and the fact that currently only approximately 50% of aneurysms are anatomically suitable for esg repair. case selection depends on careful evaluation of the position of the renal arteries, the 'neck' of the aneurysm, the presence of patent lumbar or inferior mesenteric arteries and the state of the iliac arteries. vascular surgeons rely on radiologists to provide highquality imaging in order to make this assessment. although some units continue to employ conventional aortography in addition to helical ct imaging, most vascular surgeons are currently planning these procedures using ct alone. aims of ct examination the aim of imaging prior to esg placement is to: (i) determine if the aaa is suitable for repair with esg; (it) measure the dimensions of the abdominal aorta, the aneurysm and the iliac arteries in order to size the esg accurately; and (iii) assess and document the relevant vascular anatomy, including branch vesselvari16 sa journal of radiology • february 2003 ants, degree of tortuosity and extent of mural calcification and thrombus. techruque':" a localising pre-contrast helical ct study is performed from the diaphragm to the symphysis pubis. the protocol is an 8 mm slice with a table feed of 16 mm (pitch of2) and a reconstruction increment of 10 mm. this pre-contrast study facilitates accurate planning of the scan range for the contrast enhanced helical ct angiogram. the range must begin just superior to the origin of the coeliac artery and end when a clear distinction can be made between the external and internal iliac arteries. the scan protocol for the contrast enhanced helical ct angiogram is as follows: 3 mm slice thickness, pitch of 2, reconstruction increment 1.5 mm, craniocaudal scan direction, 150 ml of low osmolar contrast iv at 4.5 ml per second if possible, a bolus-tracking programme should be used and the scan triggered at 90 hounsfield units (hu). if one is not available, then use a pre-programmed delay of approximately 20 25 seconds. the scan can then be loaded into a 3d post processing programme and the aorta (from just proximal to the coeliac axis) and the iliac arteries (down to just distal to the common iliac arteries' bifurcations) can be edited out from the rest of the abdominal and pelvic structures. the following anatomical landmarks should be included in the edited 3d data set: (i) the origin of the coeliac axis; (it) the origin of the sma; (iit) the origins of the renal arteries and accessory renal arteries; and (iv) the thrombus, and any calcification original article figs. 1 and 2. examples of reconstructed mip images showing abdominal aorta with an infrarenal aneurysm, left and right renal arteries and left and right iliac artery bifurcations. note the favourable long infrarenal neck and the moderate to severe mural calcification. around the aorta, must be included as well as the lumen this is to provide a guide to the extent of the aneurysm in post processing. a range of high-resolution mip (maximum intensity projection) images can be taken from these edited images. we usually reconstruct 12 images through 1800 about the z-axis, two of which are demonstrated in figs 1 and 2. report the following questions should be answered by the report: 1. is the aaa supraor infrarenal? suprarenal aaas are not suitable for routine esg placement. 2. what is the length of the proximal neck of the aaa? this is the distance from the origin of the most inferior renal artery to the origin of the aaa' if this is less than 10 mm then the aaa is probably not suitable for esg placement. 3. is the neck diameter uniform rather than 'coned' or 'flared'? 4. is there thrombus present in the neck? 5.are there accessory renal arteries and what are their positions relative to theaaa? 6. is the inferior mesenteric artery patent and are there large patent lumbar arteries arising from the aneurysm? 7. what is the true length of each common iliac artery? 8. are the iliac arteries aneurysmal, stenosed, excessivelytortuous or calcified? the report should obviously include any signs of aaa complications and any relevant incidental abdominal or pelvic abnormalities. if there are no anatomical contraindications to esg placement then the measurement sheet should be completed and included with the report. measurements in order to achieve a successful repair of aaa with esg placement, the correct size esg must be ordered from the manufacturer. a measurement sheet, supplied by the manufacturer, should be completed (fig. 3). not only should the length and diameter of the arteries and aaa be documented, but also an assessment of arterial tortuosity, mural thrombus formation and wall calcification should be recorded. we use routine axial cross-sectiond1a·d6l= .... fig. 3. worksheet demonstrating measurements required. 17 sa journal of radiology • february 2003 original article fig. 4. axial ct image showing the cross-sectional measurements of the maximum diameter of the wall of the aneurysm (02a). fig. 5. axial ct image showing the cross-sectiona/ measurements of the maximum diameter of the lumen of the aneurysm (02b). al ct images (figs 4 and 5) to measure diameters of vessels with long axes perpendicular to the axial plane (the usual orientation of the abdominal aorta and most aam). however, for vessels with an oblique orientation we prefer the mip images to measure diameters (figs. 6 and 7). for similar reasons we prefer to use mip images for vessel length measurements because calculations based on the table positions of axial images do not take vessel obliquity or tortuosity into account, which results in length underestimation due to geometrical foreshortening. when using mip 3d reconstructed images to measure diameters and lengths it is important to view these images on a work fig. 6. mip image showing measurement of length of aneurysm neck (u) and length of aneurysm (l2). fig. 7. mip image showing measurement of length of right common iliac artery (l3r). station in order to rotate the images appropriately so that geometrical foreshortening (which can occur whenever a three-dimensional object is viewed in two dimensions) is minimised. imaging for the hard copy, it is not necessary to give the surgeon every axial image, except through the following structures: (i) the origins of all renal arteries; (ii) the neck of the aneurysm; (iit) the bifurcation of the aorta; and (iv) the bifurcation of the iliac arteries. a selection of the remaining images can be included, along with a film of the measurements and the 3d mip images (figs 8-11). 18 sa journal of radiology • february 2003 fig. 8. mip image showing measurements of diameters of left common iliac and left extemal iliac arteries (04l, 05l, 06l, 07l). fig. 9. mip image showing diameter measurements of proximal (01a) and distal (01b) neck, lumen of aneurysm (02b) and distal aorta (03). fig. 10. mip image showing length measurement of right common iliac artery (l3r). surgical perspective the important criteria that disqualify an individual patient from any consideration for endovascular repair relate to a short or excessivelyangulatoriginal article fig. 11. mip image showing length measurement of left common iliac artery (l3l). ed infra-renal neck, the presence of thrombus in the neck, aneurysms of the common iliac arteries that involve the iliac bifurcation bilaterally and iliac arteries that are narrow in calibre or excessively calcified and tortuous. once the surgeon is satisfied that none of these contraindications exist, precise measurements of diameter and length are essential at every level. modular stent graft systems demand precise sizing so that each component fits the patient's anatomy. some devices such as the talent and lifepath are individually constructed on a per-patient basis according to the basic ct images that are provided to the company in the usa, usually through electronic data transfer. several systems such as the zenith and aneurx involve ordering from a limited range of standard components according to the patient's anatomy. the stent graft is then constructed within the aneurysm by deploying the various components into one another. the endologix device represents a new generation of non-modular endovascular stent grafts with a revolutionary'one size fits all' philosophy. this, however, does not eliminate the need for precise measurement, as these systems are still only able to accommodate a limited range of aortic and iliac sizes. vascular surgeons spend a great deal of time planning each individual procedure and ordering each individual stent graft. errors at this stage can mean the difference between a successful endovascular procedure and a complex emergency conversion to open surgery. although some errors can be compensated for using various steut-graft extensions, these increase the cost of the procedure considerably. conclusion a high quality helical ct angiographic study is usually capable of providing all the imaging information necessary to assess whether the aaa in question is technically suitable for successful esg placement. it also allows for the relevant vascular measurements to be acquired in order to size the esg accurately. in the vast majority of cases no further imaging is necessary. in order to acquire relevant and accurate imaging information, the following requirements are necessary: (i) a high quality helical ct scanner capable of 3 mm slice helical 3d data set acquisition over a length of at least 30 cm; (it) a workstation with software appropriate for 3d mip reconstructions and distance measurements; (iit) a dedicated, specialist ct radiographer with specific training and experience in ct angiography and 3d image data set editing and reconstructions; and (iv) good communication between the vascular surgeon and radiologist to ensure that all the relevant imaging information is accurately acquired and reported. with the right equipment, technique and team approach, this technically demanding and time-consuming investigation can become aroutine' non-invasive radiological investigation, providing all the necessary imaging information necessary prior to esg placement. references 1. maatsch k, knapheide c. scan protocols soma tom plus 4. erlangen: siemens aktiengesellschaff, 1997. 2. thumher mm, winkelbauer fw, kretschmer g, polterauer p, lamer j. evaluation of abdominal aortic aneurysm for stent-grafr placement: comparison of gadolinium-enhanced mr angiography versus helical cr angiography and digital subtraction angiography. radiology 1997; 205: 341. 3. semba cp, razavi mk, kee st, et al. applications of spiral cr in endovascular aortic interventions. seminars in interventional radiology 1998; 15: 179. 4. rydberg j, kopecky kk, johnson ms, dalsing mc, persohn sa. stent grafting of abdominal aortic aneurysms: preand postoperative evaluation with multislice helical cr. j computassist tomogr 200 j ; 25: 580. 19 sa journal of radiology • february 2003 abstract introduction limitations and contraindications a practical approach to an unknown cardiomyopathy indications for cmr dilated cardiomyopathy left ventricular noncompaction arrhythmogenic right ventricular cardiomyopathy hypertrophic cardiomyopathy amyloidosis anderson-fabry disease sarcoidosis iron overload cardiomyopathy chest pain syndrome with unobstructed arteries systemic sclerosis churg-strauss rheumatoid arthritis phaeochromocytoma peripartum cardiomyopathy acknowledgements references about the author(s) sulaiman moosa department of radiology, 2 military hospital, wynberg, cape town, south africa ntobeko a.b. ntusi division of cardiology, department of medicine, university of cape town, south africa department of radiology, groote schuur hospital, cape town, south africa cape universities body imaging centre, university of cape town, south africa citation moosa s, ntusi ab. role of cardiovascular magnetic resonance in the evaluation of cardiomyopathy. s afr j rad. 2016;20(2), a1055. http://dx.doi.org/10.4102/sajr.v20i2.1055 review article role of cardiovascular magnetic resonance in the evaluation of cardiomyopathy sulaiman moosa, ntobeko a.b. ntusi received: 29 june 2016; accepted: 01 aug. 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract cardiovascular magnetic resonance imaging plays a central role in the assessment and monitoring of patients with cardiomyopathy. it offers a comprehensive assessment during a single scan setting, with information on ventricular volumes, function and mass as well as tissue characterisation, fibrosis, flow, viability and perfusion. acute tissue injury (oedema and necrosis) can be distinguished from fibrosis, infiltration and iron overload. it provides information on the cause and prognosis of the cardiomyopathy, and its high measurement accuracy makes it ideal for monitoring disease progression and effects of therapy. the present review highlights the main features of commonly encountered cardiomyopathies in imaging practice. introduction cardiomyopathies comprise a wide range of myocardial disorders that may be primary heart diseases or a feature of a systemic disease, and which may or may not have a genetic and/or familial component.1 cardiomyopathy is defined as a: … myocardial disorder in which the heart muscle is structurally and functionally abnormal, in the absence of coronary artery disease, hypertension, valvular disease and congenital heart disease sufficient to cause the observed myocardial abnormality.2 the key aim in the work-up of suspected cardiomyopathy is to identify a potentially treatable underlying cause, to risk-stratify the patient for prognostication, and to apply an effective therapeutic strategy. besides evidence-based pharmacological therapeutic options, therapy includes consideration for an implantable cardioverter defibrillator (icd), cardiac resynchronisation and orthotopic heart transplant.1 cardiovascular magnetic resonance (cmr) provides the opportunity to obtain key information during a single non-invasive study. data on cardiac anatomy, function, tissue characterisation, coronary and microvascular perfusion and valvular structure and function in any selected orthogonal plane, independent of the patient habitus, can be safely acquired. the absence of ionising radiation adds to its safety. this safety feature includes intravenous contrast which allows repeated follow-up imaging, family screening and serial risk stratification. technical aspects and sequences a typical cardiomyopathy protocol is as follows, but should be adjusted as dictated by the clinical suspicion and continuous assessment of images during the scan. gross anatomical images half-fourier single-shot turbo spin-echo (haste) in two to three orthogonal planes. functional imaging balanced steady state free precession (b-ssfp) in long-axis and short-axis views forms the cornerstone of cmr, for reproducible quantification of lv (left ventricle) and rv (right ventricle) function and lv mass. non-contrast tissue characterisation t2-weighted and stir images – oedema detection t1-weighted images – pericardium and fat infiltration assessment t2* images – direct quantification of myocardial iron in vivo. imaging fibrosis (scar) and infiltration gadolinium-based contrast agents are utilised. gadolinium is an extracellular agent that accumulates in regions of interstitial expansion, such as in oedema, fibrosis or infiltration. after an intravenous gadolinium injection (usual dose 0.1 mmol/kg – 0.2 mmol/kg of body mass), three post-contrast phases can be assessed at the following times: first pass is immediate imaging at rest or during stress perfusion to visualise inducible perfusion defects. early gadolinium enhancement (ege), acquired at 90 s – 120 s, detects thrombi, hyperaemia and microvascular obstruction post myocardial infarction. late gadolinium enhancement (lge) acquired at 5 min – 20 min detects delayed contrast washout in areas of infarction, fibrosis or inflammation. sequences utilised for lge include inversion recovery gradient echo (magnitude images) or phase sensitive inversion recovery (psir) images, the latter being less dependent on accurate inversion time, but which is an absolute prerequisite for the former.1,3 lge demonstrates fibrosis (scar) by revealing the relative difference between the scar (delayed contrast washout) and normal myocardium (rapid washout). the pattern and extent of lge varies according to the pathological process and contributes to the correct diagnosis in cardiomyopathy.1 fibrosis is assessed visually, and the extent can be quantified as a percentage of mass using dedicated software. myocardial mapping more recently, myocardial mapping techniques have expanded our ability to characterise myocardium without contrast administration. t1 mapping measures the absolute myocardial t1 relaxation time on a pixel-by-pixel basis, hence being able to detect subtle changes in t1 relaxation times, the latter being proportional to the local concentration of gadolinium. fibrosis causes expansion of the interstitial space and results in increased native t1 times, and the increased gadolinium concentration results in shortening of t1 values.1 t1 mapping is also useful for detecting small amounts of fibrosis and cardiomyopathies with diffuse fibrosis.4 recently, t2 mapping5 and t2* mapping6 has been validated for imaging of myocardial oedema and/or inflammation and iron content, respectively. flow quantification cmr velocity mapping can provide reproducible assessment of valvular disease, intracardiac shunts and congenital heart disease, and compares well with echocardiography.7 limitations and contraindications metallic implants and intracardiac devices (pacemakers and icds) represent the only absolute contraindications to cmr. however, this is being overcome with the increasing use of mr-compatible devices. metallic objects in delicate positions (e.g. within the eye) continue to pose a problem as ferromagnetic objects may act as projectiles within the powerful magnetic field of the scanner and cause injury. relative contraindications include claustrophobia, florid heart failure and clinical instability. cmr up to 3 telsa is safe during all trimesters of pregnancy.8 severe renal failure (glomerular filtration rate [gfr] < 30 ml/min) precludes the use of gadolinium owing to a small but tangible risk of nephrogenic systemic fibrosis, which is enhanced by concomitant heart failure (hf).1 the limited availability of cmr scanners and cmr expertise are currently the most important limitations. a practical approach to an unknown cardiomyopathy the imaging clinician’s first task is to obtain maximum information about the suspected diagnosis by evaluating clinical notes, operative notes, and previous investigations such as electrocardiograms (ecgs), echocardiography (echo), cardiac tomography and prior cmr studies. after performing the anatomical and functional sequences to assess heart morphology and function, the following features should be identified to assist in optimising scan planning:9 myocardial thinning: global myocardial thinning is often found in dilated cardiomyopathy (dcm), left ventricular noncompaction (lvnc), and arrythmogenic right ventricular cardiomyopathy (arvc). regional thinning suggests chronic myocardial infarction, sarcoidosis and burnt-out hypertrophic cardiomyopathy (hcm). enlarged rv: a dilated rv indicates arvc, dcm, sarcoid, chronic myocarditis, intracardiac shunt (e.g. atrial septal defect) and congenital disease (e.g. tetralogy of fallot, ebstein’s anomaly). myocardial hypertrophy: increased myocardial thickness points to hcm, cardiac amyloidosis, anderson-fabry disease and cardiomyopathy related to mitochondrial disease. however, pressure overload conditions such as hypertension, aortic stenosis and aortic coarctation should always be considered. biatrial enlargement: marked atrial enlargement indicates a restrictive cardiomyopathy, amyloidosis, constrictive pericarditis and dcm. indications for cmr cmr is considered as a class i indication for global and regional lv and rv function, volume and mass quantification.10,11 indications include: systolic function assessment in patients with poor echocardiographic acoustic window and precise ejection fraction (ef) determination that will affect management or device implantation, prognostic information from the lge burden, reproducible lv mass assessment and follow-up, rv evaluation in suspected cardiomyopathies, right ventricular ejection fraction (rvef), wall motion abnormalities, oedema and scarring, assessing the cause of lv dysfunction in newly diagnosed heart failure; it can play a role as an effective gatekeeper to coronary angiograms in such patients, screening family members with cardiomyopathy, screening athletes with syncope or aborted sudden cardiac death (scd), chest pain syndrome (cps) with unobstructed coronaries, suspected myocarditis, congenital heart disease and infiltrating conditions. dilated cardiomyopathy dcm refers to lv systolic dysfunction with concomitant lv dilation; rv dilatation may be present. in 50% of cases, the diagnosis remains unknown; up to 30% have a familial association to known genetic abnormalities.12 chronic myocarditis has been implicated in the aetiology of dcm.12 cmr provides accurate evaluation of biventricular efs, volumes and mass assessment, and the pattern of lge allows the exclusion of an ischaemic cause, typically subendocardial or transmural enhancement. lge provides prognostic information and acts as a gatekeeper role to coronary angiography.13 in a large study with dcm and unobstructed coronary arteries, three lge patterns were reported: no lge in 59%, midwall and mainly septal lge in 28%, and subendocardial ischaemic lge pattern in 13%, probably on the basis of transient occlusion by non-obstructive unstable plaque or vasoconstriction.13 other studies have shown additional lge patterns that include epicardial lge, patchy lge and diffuse lge.14 the finding of lge in dcm is associated with increased risk of scd, presumably arrhythmogenic. figure 1 and figure 2 provide the representative imaging features of dcm. figure 1: dilated cardiomyopathy. cine b-ssfp in end-diastole demonstrates enlarged lv volumes with the end-diastolic diameter 67 mm. the end-systolic diameter was 58 mm. figure 2: dilated cardiomyopathy. late gadolinium-enhanced psir images in four-chamber (left) and basal short-axis (right) demonstrating virtual circumferential midwall enhancement (arrows). left ventricular noncompaction lvnc is a rare congenital cardiac disorder owing to arrested embryogenesis and results in a ‘spongy’ appearance of the lv myocardium and apex, commonly involving the anterior and lateral walls and characterised by increased trabeculation and intratrabecular recesses in the myocardium.16 lvnc is associated with neuromuscular disorders and is complicated by heart failure, arrhythmia and thromboembolic events.1 diagnosis is achieved by measuring at end-diastole, the ratio of the noncompact myocardium over the compact myocardium. a value of 2.3 has a sensitivity of 80% and specificity of 99%.17 the absence of well-formed papillary muscles is a clue to the diagnosis.1 lge patterns include subendocardial, midwall and transmural enhancement.1 lvnc is commonly associated with a dcm phenotype. figure 3 demonstrates the imaging features of lvnc. figure 3: left ventricular noncompaction. four-chamber cine b-ssfp demonstrating increased lv trabeculations (arrow) at the lv free wall and apex compared with the compact lv myocardium. the rv trabeculations are prominent too. arrhythmogenic right ventricular cardiomyopathy arvc is a genetic desmosomal disease characterised pathologically by progressive rv myocyte loss and fibrofatty replacement.1 in 75% of cases, the lv is affected and hence it can be misdiagnosed as dcm, especially in phenotypes with early and predominant lv involvement.1 arvc should be considered in all cases of unexplained rv dilation. aborted scd from arrhythmia is often the initial presentation. arvc task force criteria (tfc) forms the cornerstone of the diagnosis, and the 2010 revision has improved sensitivity for gene carriers with limited disease and patients with left-sided disease.18 the values for rvef and edv have been defined on the basis of comparison with normal patient data and divided into two categories. major criteria rv regional wall motion abnormality (akinesia, dyssynchrony or aneurysm) and one of the following: rvef ≤ 40% rv end-diastolic volume ≥ 110 ml/m2 for male and ≥ 100 ml/m2 for female patients. minor criteria regional wall motion abnormality and one of the following: rvef > 40% and ≤45% rv end-diastolic volume ≥ 100 ml/m2 – < 110 ml/m2 for male and ≥ 90 ml/m2 – < 100 ml/m2 for female patients. taking into account the revised tfc for the diagnosis of arvc, a definite diagnosis of arvc is made when a patient has: two major criteria one major and two minor criteria four minor criteria.9 a borderline diagnosis of arvc is made when a patient has: one major and one minor criterion three minor criteria. a possible diagnosis of arvc is made when a patient has: one major or two minor criteria. major and minor criteria have been defined for histology, ecg and family history, and are applied in the diagnosis.18 cmr transaxial cine stack is included as part of the work-up and detects regional and global rv dysfunction, wall motion abnormalities, aneurysms and wall thinning. t1-weighted fat detection and lge are not part of the revised arvc tfc. fat can appear in the rv in healthy individuals and can be difficult to image in the thin rv wall or discriminate with confidence from epicardial fat. lge is part of the arvc protocol and its absence does not preclude the diagnosis but, when present, it has a high diagnostic sensitivity and specificity.19 however, rv lge presents imaging problems:20 firstly, it is difficult to discriminate from rv fat; and secondly it requires significantly different inversion times compared with the lv. however, lge patterns of the rv can delineate different patterns of arvc: (1) classic form – lge in inferior and inferolateral walls; and (2) left-predominant phenotype – septal midwall enhancement with preserved rv function. this type is often misdiagnosed as dcm. figure 4 demonstrates rv free wall dyskinesia, typical of arvc. figure 4: arrhythmogenic right ventricle cardiomyopathy. rv two-chamber views cine b-ssfp in end-diastole (left) and end-systole (right) demonstrating a dyskinetic rv apex (arrows). hypertrophic cardiomyopathy hcm is the most common genetic cardiomyopathy, with an incidence of 1 in 500. it is also the most common cause of sudden death in the young, including athletes. clinical findings and abnormal ecg findings associated with apical or asymmetrical septal hypertrophy, with or without dynamic lv outflow tract obstruction, is diagnostic. pathologically, hcm demonstrates myocyte hypertrophy, disarray and fibrosis, manifesting in various genetic mutations.1 the majority of individuals carrying an hcm genetic defect do not manifest the clinical expression at all times of their lives. hence an unexplained mildly thickened lv wall may be consistent with a hcm-causing mutation. making a diagnosis of hcm can be complicated in patients with aortic stenosis or hypertension.1 cine images allow the detection of lv wall thickness, especially at the apex, basal anteroseptal wall and posterolateral wall – regions that are difficult to visualise on echocardiography. however, a spectrum of lv wall thickening has been described.21 myocardial crypts are additional typical findings. apical aneurysms are associated with an increased risk for arrhythmia, thromboembolic events and progressive heart failure.22 lge is present in 80% of hcm, both patchy or diffuse scarring, the latter in areas of increased thickness typically and less commonly in regions of normal wall thickness.23 patchy lge is typically midwall in thickened myocardium and commonly the rv-lv insertion points are also involved. in burnt-out hcm, the myocardium is thinned and has transmural lge, mimicking ischaemic disease, but not in a coronary artery territory. hcm without lge has 100% event-free survival at 6-year follow-up; lge > 5% of lv mass, septal wall thickness > 30 mm and af are independent predictors of death and icd discharges.24 left ventricular outflow tract (lvot) obstruction and the presence of systolic anterior motion of the mitral valve can be quantified with velocity flow mapping and has been correlated with increased severity of hypertrophy, heart failure and poor outcome.25 figure 5 and figure 6 demonstrate the imaging features of hcm. figure 5: hypertrophic cardiomyopathy. four-chamber end-diastole cine b-ssfp image demonstrating a thickened septum and lv lateral wall. figure 6: hypertrophic cardiomyopathy. two-chamber (left) and short-axis (right) late gadolinium images demonstrate diffuse enhancement of the thickened myocardium (arrows). amyloidosis myocardial involvement in systemic amyloidosis is an important prognostic marker, often presenting as congestive heart failure in 50% of patients, and death occurring in less than 6 months in untreated patients. early detected cases may respond to therapy, and exclusion of other causes is important for management.26 typical cmr findings include normal or reduced lv function, small lv cavity with homogeneous wall thickening, inconsistent rv involvement, biatrial enlargement, interatrial wall thickening, valve thickening, small pericardial effusions and pleural effusions. about 55% of patients with amyloidosis present with asymmetrical septal hypertrophy mimicking hcm.1 lge reflects the distribution of amyloid on histology with widespread subendocardial enhancement, giving the typical ‘zebra’ pattern and sparing the midwall of the septum. other patterns are midwall (33%), and subepicardial (up to 20%).27 rv free wall and interatrial septum lge has been reported.1 when amyloid fibrils accumulate in the myocardium, the wash-in and washout features of gadolinium are abnormal, with inability to null the myocardial signal. the rapid washout from the blood pool and high myocardial uptake results in a dark blood pool, owing to similar t1 values to the visualised myocardium.1 to optimally visualise myocardial and blood pool kinetics in suspected amyloidosis, an inversion time scout is acquired at 5 min after contrast administration. lge has a sensitivity of 86% for detecting amyloid. identifying early abnormalities in patients with normal lv wall thickness is strongly related to the amyloid burden and predicted mortality risk.28,29 figure 7 demonstrates the representative imaging findings of amyloidosis. figure 7: amyloidosis. four-chamber end-diastole cine b-ssfp image (left) demonstrates a thickened septum and lv lateral wall with small pericardial and pleural effusions. the four-chamber late gadolinium image (right) shows diffuse subendocardial enhancement (arrow) in a non-coronary artery distribution, with enhancement of the rv free wall and interatrial septum. anderson-fabry disease anderson-fabry disease is a treatable x-linked disorder of lysosome storage, caused by partial or complete alpha galactosidase a deficiency which results in glycosphingolipid accumulation within the vessels and heart.30 concentric lv hypertrophy and cardiac fibrosis then leads to heart failure. cmr is used to evaluate lv function, wall thickness and scar detection. the typical lge is inferolateral midwall enhancement which correlates well with histology and may serve as a substrate for electrical re-entry and scd.31 recently, t1 mapping has been shown to have a relative specific signature for conditions with a decreased t1 value, especially in areas of lge.32 six per cent of suspected hcm turns out to be anderson-fabry, with important implications for management. anderson-fabry is treated with enzyme replacement, with resultant improvement in lv function. the enzyme replacement is optimally utilised before fibrosis sets in. an unexplained lv hypertrophy, especially in young patients, should have anderson-fabry excluded. sarcoidosis sarcoidosis is a multisystem granulomatous disease affecting the myocardium in 50% of cases, but only half of them are symptomatic.33 hf and arrhythmia are the important presentations, and early identification allows medical therapy and icd implantation. cmr cine imaging facilitates the detection of wall thinning, regional wall motion abnormalities, ventricular dysfunction and pericardial effusion, whilst lge cmr detects fibrosis. lge is typically patchy, midwall or subepicardial, in an unpredictable manner, in the anteroseptal and anterolateral walls as well as in the rv free wall and rv side of the septum.34 sarcoid may mimic ischaemic disease with subendocardial or transmural patterns.35 lge acts as a guide to endomyocardial biopsy and improves after steroid therapy. t2w imaging may monitor disease activity with inflamed oedematous regions being highlighted.34 recently, t1 and t2 mapping has been shown to have a role in the assessment and monitoring of sarcoidosis.36 figure 8 demonstrates the representative imaging findings of sarcoidosis. figure 8: sarcoidosis. end-diastole four-chamber cine b-ssfp image (left) demonstrates increased rv size. the four-chamber late gadolinium psir image (right) demonstrates prominent rv free wall enhancement (smaller arrow) as well as nodular enhancement of the septum and lv lateral wall (larger arrow). iron overload cardiomyopathy cardiac siderosis is evident in transfusion-dependent anaemia and primary haemachromatosis. if chelation therapy is initiated early, the cardiomyopathy is reversible; but the diagnosis is often delayed owing to the late onset of symptoms. t2* imaging arises from local magnetic inhomogeneities that increase with greater iron deposition.1 as myocardial iron increases, heart failure progresses and t2* times diminish so that all heart failure patients have a t2* value < 20 m/sec. the efficacy of chelation can also be monitored.1 cmr has a significant role to play in the diagnosis and management of this disease. chest pain syndrome with unobstructed arteries cmr has increasing utility in providing diagnostic information in patients presenting with troponin-positive cps with normal coronary arteries. it contributes to a diagnosis in 77% of patients, correcting a wrong diagnosis in 10% and changing therapy in 33%.30 the main causes of cps with normal coronary arteries are myocarditis, takotsubo cardiomyopathy, recanalised infarcts and the inflammatory phases of dcm, hcm and arvc. myocarditis myocarditis refers to inflammation of the myocardium that may be caused by infection, autoimmune diseases or drug toxicity; some cases are idiopathic. it has a wide range of clinical manifestations, ranging from an influenza-like viral illness, troponin-positive cps, new onset hf and even scd. the diagnosis is usually one of exclusion, and endomyocardial biopsy is the gold standard but sampling bias and insensitivity limits its utilisation; however, cmr-guided biopsies result in higher yields.37 cmr is a non-invasive tool to diagnose myocarditis, utilising t2-weighted imaging to detect subendocardial and midwall myocardial oedema.38 ege matching areas of t2-weighted hyperintensity may reflect tissue hyperaemia and increased interstitial space, and lge reflects myocardial necrosis which has a subepicardial distribution, with varying degrees of midmyocardial involvement; the subendocardium is often spared. the lateral and inferolateral walls are frequently involved.39 the presence of a typical lge pattern is a strong indicator for the diagnosis, but the absence of this pattern does not exclude the diagnosis.40 the focal lge pattern evolves and becomes diffuse over a period of weeks, then decreases during healing and may become invisible after recovery.37 midwall myocardial scarring can be evident after myocarditis, in a pattern similar to that seen in dcm subjects and suggests that previous myocarditis is a cause of lv dysfunction in a proportion of dcm patients.41 t1 mapping has been shown to be superior to lge and t2-weighted imaging in the diagnosis of myocarditis, without the need for contrast agent.42 figure 9 demonstrates the representative imaging findings of myocarditis. figure 9: myocarditis. t2w short-axis image (left) demonstrates lv inferolateral wall high signal and oedema (arrow). the equivalent late gadolinium image (right) demonstrates epicardial enhancement in the same region (arrow). takotsubo cardiomyopathy takotsubo (also called stress cardiomyopathy or catecholamine-induced cardiomyopathy) is typically seen in postmenopausal women in whom emotional stress may result in a clinical picture similar to acute myocardial infarction with anterior lead ecg changes. however, many patients do not report a clear stressor and this condition has been diagnosed in men. the rapidly reversible lv systolic dysfunction is caused by a temporary stunning of the apical to mid lv segments with apical ballooning, resulting in a dynamic obstruction.1 myocardial oedema is evident as t2-weighted hyperintensity in a focal pattern, matching the wall motion abnormality and related to the severity of the systolic dysfunction.43 lack of lge is typical, and distinguishes it from myocarditis and infarction, but there may be mild patchy lge composite with the myocardial oedema.44 the rv is involved in 25% of cases and complete resolution is typically at 4 weeks.1 figure 10 demonstrates the representative imaging findings of takotsubo cardiomyopathy. figure 10: takotsubo. two-chamber cine b-ssfp at end-diastole (left) and end-systole (right) demonstrating a hypokinetic apex and mid lv, resulting in a japanese ‘octopus trap’ appearance on the end-systole image. systemic sclerosis systemic sclerosis is a connective tissue disorder affecting mainly the skin but also involving the lungs, kidneys and heart.45 myocardial fibrosis is a common finding at autopsy studies.46 lge manifests in a linear midmyocardial wall distribution at the basal and mid-ventricular levels. the development of clinical features indicates a poor prognosis, with a 5year survival rate of 30%.9 churg-strauss churg-strauss is a rare small vessel syndrome with a poor prognosis. a subendocardial pattern of fibrosis in the absence of coronary artery disease is the typical pattern.47 associated features are normal myocardial function, apical obliteration and thrombus formation. elevated blood eosinophils are commonly found and imaging features overlap with hypereosinophillic cardiomyopathy. rheumatoid arthritis rheumatoid arthritis (ra) is a chronic autoimmune disease primarily involving the synovium, but extra-articular manifestations include cardiac involvement which can lead to a 10-year reduction in life span, especially in young women. cmr has been shown to detect diffuse and focal myocardial fibrosis as well as inflammation in ra patients. in addition, myocardial fibrosis and inflammation correlates with a c-reactive protein (crp) score of disease activity as well as with systolic and diastolic strain patterns.48 myocardial fibrosis is not related with disease duration and t1 mapping can provide a new biomarker of disease activity in the heart, beyond that provided by the standard sequences such as short t1 inversion recovery (stir) and lge.48 phaeochromocytoma cardiac involvement in phaeochromocytoma is frequent and often persistent, manifesting as myocarditis, global lv dysfunction, subclinical systolic and diastolic dysfunction as well as focal and diffuse fibrosis. the myocardial effects of phaeochromocytoma have been shown to be beyond that of hypertension; catecholamine-induced cardiac toxicity is the likely cause, leading to inflammation, myocyte necrosis and fibrosis.49 peripartum cardiomyopathy peripartum cardiomyopathy is characterised by heart failure in the last trimester of pregnancy or first six post-partum months in previously healthy women. the cause is unknown and considered to be multifactorial. lge is evident in the midmyocardium, mainly in the anterior and anterolateral segments. these features tend to regress over time as lv function improves.50 future perspectives and conclusion cmr is a unique non-invasive tool and currently integral part of cardiomyopathy work-up. tissue characterisation remains its major strength, detecting fat, oedema, fibrosis, infiltration and infarction. its excellent spatial resolution allows accurate evaluation of biventricular function and morphology. it is predicted that most patients with hf will eventually undergo cmr as part of diagnostic work-up and risk stratification.35 its utility in the south african context is limited by the cost and 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consideration discussion conclusion acknowledgements references about the author(s) natasha sobey department of radiology, inkosi albert luthuli hospital, durban, kwa-zulu natal, south africa lauren raubenheimer department of radiology, groote schuur hospital, university of cape town medical school, cape town, south africa citation sobey n, raubenheimer l. cystic pelvi-abdominal mass in pregnancy: an uncommon presentation of a subserosal leiomyoma. s afr j rad. 2019;23(1), a1683. https://doi.org/10.4102/sajr.v23i1.1683 case report cystic pelvi-abdominal mass in pregnancy: an uncommon presentation of a subserosal leiomyoma natasha sobey, lauren raubenheimer received: 20 nov. 2018; accepted: 28 jan. 2019; published: 18 apr. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract uterine leiomyomas are common benign neoplasms. while generally easily diagnosed, variations in size and type of degeneration can drastically alter the imaging findings and result in diagnostic uncertainty. we present the case of a 34-year-old female with a large, cystic, pelvi-abdominal mass that was discovered in advanced pregnancy and misdiagnosed as an ovarian tumour. intra-uterine demise of a viable foetus during an induction of labour and clinical deterioration necessitated further imaging and emergent surgical intervention. further imaging, intra-operative findings and histopathological correlation revealed a pedunculated uterine leiomyoma with hyaline degeneration and areas of necrosis, complicated by left ovarian vein thrombosis. in addition to the intra-uterine demise, the unfortunate outcome included a total abdominal hysterectomy and unilateral salpingo-oophorectomy in a young patient. typical leiomyomas are easily detected with imaging, however the varied clinical presentation and imaging findings in degenerating leiomyomas can prove a diagnostic challenge. this case describes a rare manifestation of a common condition and its subsequent diagnostic dilemma resulting in dire foeto-maternal outcomes. keywords: leiomyoma; hypercalcaemia; ovarian vein thrombosis; pregnancy; intra-uterine foetal demise. introduction uterine leiomyomas are a common benign neoplasm of the female pelvis, with a reported prevalence of 20%–40% in women of reproductive age.1,2,3 they are predominantly composed of smooth muscle cells with variable amounts of fibrous connective tissue.2 the current literature suggests that the majority of women with uterine fibroids will have normal pregnancy outcomes.4 no link was established between intra-uterine foetal demise and uterine leiomyomas in a meta-analysis in 2008.5 subserosal leiomyomas in particular were also not found to be a significant cause of poor pregnancy outcome.6 however, the literature involving leiomyomas in pregnancy can be problematic to assess as many different variables have been described, including size, number, location, type and gestational age at detection. simultaneous heterogeneity amongst the patient profile (age, parity, race and obesity) further complicates accurate analysis.3 as a result, the relationship between leiomyomas and adverse obstetric outcomes is incompletely understood. accurate diagnosis of leiomyomas in pregnancy is particularly important in a south african context as an increased prevalence of leiomyomas in the african population was described by stewart et al.3 local advances in reproductive health, as well as the current trend of delaying childbearing, further increase the relevance to the south african population, as treating clinicians can expect to see more women with leiomyomas presenting for antenatal and obstetric care.5 typical leiomyomas are readily diagnosed radiologically; however, the appearance of uterine leiomyomas is commonly altered by degenerative changes including cystic, hyaline, myxoid and red degeneration. this can make differentiation between leiomyomas and other adnexal or other intra-abdominal pathology challenging. ultrasound is used to diagnose and monitor the growth of leiomyomas, and typically shows a well-defined hypoechoic mass. intra-lesional cystic areas or calcification depends on the presence of complication or degeneration. computed tomography (ct) generally depicts a soft tissue mass with variable enhancement, which distorts the uterine contour and may exhibit coarse peripheral or central calcification. typical magnetic resonance imaging (mri) features of non-degenerated leiomyomas include a well-circumscribed mass of homogeneously low to intermediate signal intensity (as compared to myometrium) on t1-weighted images, decreased signal intensity on t2-weighted images with surrounding flow voids and variable contrast enhancement. degenerated leiomyomas have variable but characteristic appearances depending on the type of degeneration. defining features include high t1 signal intensity or an irregular, t1-hyperintense rim around a centrally located leiomyoma in red degeneration; high t2 signal intensity in cystic degeneration; low t2 signal intensity with poor enhancement in hyaline degeneration; and very high t2 signal intensity with gradual enhancement on t1-contrasted sequences in myxoid degeneration.2 in this case, a subserosal leiomyoma was misdiagnosed as an ovarian tumour antenatally. there are multiple reported cases of ovarian tumour-like leiomyomas7 but they are rarely reported in pregnancy. case a 34-year-old gravid female was referred to a tertiary hospital at 38+ weeks with a large cystic pelvi-abdominal (pa) mass detected on ultrasound. she had no known medical co-morbidities and one previous uneventful pregnancy culminating in a normal vaginal delivery (nvd) at full term. on presentation, the patient was asymptomatic and examination revealed only an increased symphysis-pubis fundal height (sfh) for expected gestation. urine analysis showed proteinuria and blood tests revealed a minimally elevated cancer antigen-125 of 48 ku/l (normal range 0–35 ku/l) and a normal carcinoembryonic antigen level of 0.7 ng/ml (normal < 5.0 ng/ml). transabdominal ultrasound showed a thick-walled cystic mass measuring approximately 25 cm × 14 cm × 15 cm with no internal vascularity. the mass was assumed to be ovarian in origin. a singleton intra-uterine pregnancy with foetal heartbeat was confirmed. a transvaginal ultrasound scan was not performed. the decision was made to induce labour based on the unclassified proteinuria and the clinical suspicion of possible underlying pre-eclampsia. during the induction of labour, foetal monitoring showed subtle signs of foetal distress, which warranted continuous monitoring, but despite in-patient care and continuous foetal monitoring, there was subsequent intra-uterine foetal demise and the patient delivered a stillborn baby via nvd. following delivery, the patient’s condition deteriorated in the ward, developing a persistent unexplained tachycardia of approximately 150 bpm, a blood pressure of 156/119 mmhg and a serum calcium level well above normal limits (4.25 mmol/l, normal limit is 2.62 mmol/l). emergent cross-sectional imaging in the form of contrasted ct abdomen showed a large cystic mass with a thick, irregular enhancing wall and septations (figure 1), which was inseparable from the uterine fundus (figure 2). in addition, extensive left ovarian and pelvic vein thrombosis (figure 3) and an enlarged, poorly enhancing left ovary were noted (figure 4). figure 1: axial computed tomography of the abdomen during (a) arterial and (b) portal venous phases showing a large centrally hypodense mid-abdominal mass with a thick enhancing wall and septations. figure 2: sagittal portal venous computed tomography shows that the mass is connected to the uterine fundus (arrows). figure 3: coronal (a) and sagittal (b) portal venous computed tomography demonstrates tubular non-enhancing serpiginous structures corresponding to thrombosed left ovarian and parametrial veins (arrows). figure 4: poorly enhancing enlarged left ovary on axial portal venous computed tomography (arrows). exploratory laparotomy revealed a large, friable, thick-walled, pedunculated fundal mass, left ovarian vein thrombosis, necrosis of the left ovary and broad ligament and offensive intra-uterine contents. the decision to proceed to total abdominal hysterectomy and left salpingo-oophorectomy was taken based on significant intra-operative bleeding, friable necrotic tissue and haemodynamic instability. histopathological evaluation revealed a subserosal uterine leiomyoma with extensive hyaline degeneration and necrosis, left ovarian vein thrombosis, haemorrhagic infarction of the left ovary and endometrial and myometrial necrosis. ethical consideration no patient identifiable information has been presented. informed verbal consent was obtained from the patient prior to publication. discussion leiomyomas are characterised by location, whether submucosal, intramural (within the myometrium) or subserosal. the latter are a subtype that may become pedunculated, projecting out of the uterine contour and mimicking an adnexal mass.2 although usually asymptomatic, some pedunculated subserosal leiomyomas may undergo torsion, resulting in infarction. rare but recognised complications linked to uterine leiomyomas in pregnancy include an increased risk of spontaneous abortion, foetal malpresentation, placenta previa, preterm birth, caesarean section and peripartum haemorrhage.6 placental abruption is a rare but potentially devastating outcome that has been inconsistently associated with uterine leiomyomas.6 the strongest correlation with placental abruption has been documented in patients with submucosal or retroplacental leiomyomas.5 ultrasound is employed as the primary diagnostic imaging modality because of its accessibility, safety and bedside application. ultrasound gives information on leiomyoma size, characteristics and complications. cross-sectional imaging is usually not required for initial diagnosis in typical cases and is reserved for patients with diagnostic uncertainty or suspected complications. coarse intra-lesional calcification, although an uncommon finding, remains the most specific sign for leiomyomas.8 difficulties in detection can occur with smaller tumours, those that extend into the uterine cavity, those that occur only in the lower segment and in the absence of intra-lesional calcification. internal heterogeneity depends on the type and degree of degeneration. a cystic appearance occurs with various forms of degeneration and is generally attributed to tumour growth beyond its vascular supply.9 because of the varied imaging patterns, degenerating leiomyomas often pose a diagnostic challenge, as in the case of our patient. hyaline degeneration is the most common type of degeneration, accounting for 60% of cases. cystic degeneration is observed in 4% of leiomyomas and is the terminal sequelae of oedema.10 confirming the diagnosis of ovarian vein thrombosis with ultrasound is highly operator dependent and may be confounded by patient factors such as overlying bowel gas and poor patient cooperation. contrasted abdominal ct is sensitive and specific for ovarian vein thrombosis and should be considered as the initial investigation of choice in the absence of pregnancy. computed tomography features include visualisation of a tubular retroperitoneal mass with central low attenuation extending cephalic to the inferior vena cava or left renal vein.11 leiomyoma-associated hypercalcaemia is a rarely described entity, with seven reported cases to date.12,13,14 the presumed pathophysiology is leiomyoma-induced elevated serum parathyroid hormone-releasing protein (pthrp), with a likely causal relationship proven in all but one case.13 in our patient’s case, serum pthrp was not tested and the role of hypercalcaemia in the eventual outcome cannot be accurately extrapolated because of many concurrent variables. however, it should certainly encourage further research into pthrp-secreting leiomyomas. this case highlights the importance of employing multiple imaging modalities when confronted with a pa mass of uncertain origin in a pregnant patient. it also underscores the importance of a thorough search for the ovaries when imaging a pa mass, although this search may be hampered by distortion and displacement by large masses. magnetic resonance imaging is the most accurate modality to evaluate tumour characteristics and may be utilised in the pregnant patient when ultrasonography is inconclusive.2 conclusion leiomyomas in pregnancy are common and are usually easily diagnosed, with no expected adverse obstetric complications. however, in rare cases, they may present in unpredictable ways with variable imaging findings that delay diagnosis and result in potentially harmful outcomes. pedunculated uterine leiomyomas should be considered in the differential diagnosis of any pa mass. as degenerating leiomyomas are great mimics of other gynaecological and non-gynaecological medical conditions, familiarity with the different types of degeneration and their sonographic appearance is imperative to aid accurate diagnosis. ultrasound should be employed as the initial imaging modality of choice for pa masses in pregnancy. however, its limitations should be carefully considered and cross-sectional imaging should be used where appropriate. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions n.s. was responsible for literature research. l.r. was responsible for obtaining case information. references khanuja e, tyagi m, gupta s, yadav r. leiomyoma with degeneration mimicking an ovarian neoplasm. 2017;2(3):64–65. murase e, siegelman es, outwater ek, perez-jaffe la, tureck rw. uterine leiomyomas: histopathologic features, mr imaging findings, differential diagnosis, and treatment. radiographics [serial online]. 1999 [cited 2018 sep 29];19(5):1179–1197. available from: http://pubs.rsna.org/doi/10.1148/radiographics.19.5.g99se131179 stewart ea, cookson cl, gandolfo ra, schulze-rath r. epidemiology of uterine fibroids: a systematic review. bjog an int j obstet gynaecol. 2017;124(10):1501–1512. https://doi.org/10.1111/1471-0528.14640 segars jh, parrott ec, nagel jd, et al. proceedings from the third national institutes of health international congress on advances in uterine leiomyoma research: comprehensive review, conference summary and future recommendations. hum reprod update. 2014;20(3):309–333. https://doi.org/10.1093/humupd/dmt058 klatsky pc, tran nd, caughey ab, fujimoto vy. fibroids and reproductive outcomes: a systematic literature review from conception to delivery. am j obstet gynecol. 2008;198(4):357–366. https://doi.org/10.1016/j.ajog.2007.12.039 parazzini f, tozzi l, bianchi s. pregnancy outcome and uterine fibroids. best pract res clin obstet gynaecol. 2016;34(2016):74–84. https://doi.org/10.1016/j.bpobgyn.2015.11.017 yorita k, tanaka y, hirano k, et al. a subserosal, pedunculated, multilocular uterine leiomyoma with ovarian tumor-like morphology and histological architecture of adenomatoid tumors: a case report and review of the literature. j med case rep. 2016;10(1):1–7. https://doi.org/10.1186/s13256-016-1167-1 gajewska m, kosinska-kaczynska k, marczewska j, kaminski p. [huge uterine leiomyoma with degenerative changes mimicking ovarian carcinoma – a case report]. ginekol pol [serial online]. 2013 [cited 2018 sep 20];84(2):147–150. available from: http://www.ncbi.nlm.nih.gov/pubmed/23668063 ahamed ks, raymond gs. answer to case of the month # 103 large subserosal uterine leiomyoma with cystic degeneration presenting as an abdominal mass. can assoc radiol j. 2005;56(4):245–248. geeth m, anuradha g, vamsi p, ramkumar v, resident s. leiomyomas masquerading as ovarian neoplasms. iosr j dent med sci [serial online]. 2015 [cited 2018 sep 20];14(7):2279–2861. available from: www.iosrjournals.org achour jenayah a, saoudi s, boudaya f, bouriel i, sfar e, chelli d. ovarian vein thrombosis. pan afr med j [serial online]. 2015 [cited 2018 sep 29];21:251. available from: http://www.panafrican-med-journal.com/content/article/21/251/full/ tarnawa e, sullivan s, underwood p, richardson m, spruill l. severe hypercalcemia associated with uterine leiomyoma in pregnancy. obstet gynecol. 2011;117(2 part 2):473–476. https://doi.org/10.1097/aog.0b013e3181fd29ae rahil a, khan fy. humoral hypercalcemic crisis in a pregnant woman with uterine leiomyoma. j emerg trauma shock. 2012;5(1):87–89. https://doi.org/10.4103/0974-2700.93093 garcha as, gumaste p, cherian s, khanna a. hypercalcemia: an unusual manifestation of uterine leiomyoma. case rep med. 2013;2013:3–5. https://doi.org/10.1155/2013/815252 abstract introduction high-risk screening occult breast cancers pre-operative staging equivocal findings on mammogram and ultrasound – problem solving post-surgical and post-treatment magnetic resonance imaging implant assessment discussion implications and recommendations acknowledgements references about the author(s) peter k. schoub department of radiology, parklane radiology, johannesburg, south africa citation schoub p. understanding indications and defining guidelines for breast magnetic resonance imaging. s afr j rad. 2018;22(2), a1353. https://doi.org/10.4102/sajr.v22i2.1353 review article understanding indications and defining guidelines for breast magnetic resonance imaging peter k. schoub received: 03 apr. 2018; accepted: 07 aug. 2018; published: 30 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract magnetic resonance imaging (mri) of the breast is the most sensitive imaging modality for detecting cancer. with improved scan resolution and correctly applied clinical indications, the specificity of breast mri has markedly improved in recent years. current literature indicates an overall sensitivity for breast mri of 98% – 100% and specificity of 88%. by comparison, the sensitivity and specificity for mammography is in the region of 71% and 98%, respectively. in particular, the very high negative predictive value (npv) of breast mri, which approaches 100%, is hugely useful in establishing absence of disease. furthermore, the ability to accurately delineate viable cancer by way of combining both morphological and functional (contrast enhancement) capabilities means that mri is the best tool we have in terms of local cancer staging and identifying residual or recurrent disease. the high npv also means that breast mri is uniquely capable of ruling out cancer or high-grade ductal carcinoma in situ in appropriate circumstances. i hope that the following guidelines that are based on those of the american college of radiology and the european society of breast imaging in addition to multiple review articles will provide some assistance to radiologists in terms of the correct indications for breast mri. there are few formal guidelines in south africa for the usage of breast mri. in fact, there is a general paucity of guidelines in the international radiology world. the role of breast mri in high-risk screening and identification of the primary in occult breast cancer is universally accepted. thereafter, there is little consensus. by using some general guidelines, and bringing mri into the discussion of multidisciplinary breast cancer management, good clinical practice and consistent decision-making can be established. introduction breast magnetic resonance imaging (mri) has been part of the breast imaging armamentarium for at least 20 years. it was realised early on that mri with the use of intravenous gadolinium contrast was a highly sensitive tool for differentiating cancer from background tissue. as opposed to relying on morphologic changes as seen with mammography, contrast-enhanced mri is effective because it relies on cancer-associated changes at the functional level, most particularly the neovascularity and abnormal capillary permeability that accompany malignancy.1 with a sensitivity between 98 and 100%, and a specificity of up to 88%, mri is a far more accurate modality in diagnosis and characterization of breast malignancy than either mammography or breast ultrasound1,2,3. the negative predictive value (npv) of mri is close to 100% and probably its most powerful attribute, as it provides the ability to unequivocally exclude malignancy4,5,6. the following review article uses guidelines from the american college of radiology (acr)7 and the european society of breast imaging (eusobi)8,9 as a foundation for setting out breast mri indications. this review includes data and opinion from articles written by the most experienced breast mri experts around the world in order for readers to understand the benefits and limitations of mri scanning of the breast. adherence to formal guidance and rational protocols in addition to collaboration amongst the specialists comprising a breast cancer multi-disciplinary team, will ensure appropriate implementation of a breast mri program10,11. many of the changes associated with cancer on mammography relate to hypoxia and regression – desmoplastic reaction, spiculation and micro-calcifications. this means that many of the most typical breast cancers found on mammogram are the least biologically active.12 the higher grade and more aggressive subtypes, for example, triple negative cancers, may be less conspicuous or at least appear similar to benign entities.13 magnetic resonance imaging, on the other hand, demonstrates best the most biologically active cancers (invasive and intra-ductal) and with addition of kinetic enhancement assessment, the ability to differentiate benign-appearing cancers from true benign lesions is further improved.5,12 kinetic or dynamic enhancement refers to the progressive enhancement of a mass or non-mass lesion. it is plotted as the time: intensity curve on a graph. modern software calculates an average for the entire enhancing area. the intensity (percentage) of initial enhancement in the first minute and the degree of contrast persistence or washout are reflected in the curve. the more intense (rapid) the initial enhancement and the more rapid the washout, the higher the likelihood of malignancy. for ease of use, a colour map overlay representing the type of dynamic enhancement is displayed over the area of interest. it is very important to realise that kinetic enhancement assessment is not always accurate and there is a considerable overlap between benign and malignant entities. it should not be used to downstage lesions but can be helpful in upstaging them. it is a valuable tool when used in conjunction with morphology (shape, outline) to determine the likelihood of malignancy.1,14 although breast mri was recognised early on to be highly sensitive, there was a lack of specificity. a combination of high sensitivity and suboptimal specificity resulted in too many false positives. consequently, mri was largely written off as an accurate and feasible investigation other than in certain specific instances. recent advances include dedicated multi-channel breast coils, better fat suppression, higher resolution scans and computer-aided detection (cad) programmes that allow better use of kinetic assessment.14,15 in addition, evidence-based descriptors in the last two editions of the breast imaging, reporting and data system (bi-rads) manual have standardised breast mri assessment and reporting.16 the bi-rads atlas which is produced by the american college of radiology (acr) describes various imaging features on each modality that indicate higher or lower suspicion of a cancer. breast mri has been included in the last two editions of the bi-rads atlas. these enhancements have meant better specificity and the ability to expand the role of breast mri. furthermore, the ability to accurately biopsy lesions17 and insert localisation wires under mri guidance has dramatically improved the value of pre-treatment staging mri.12 magnetic resonance imaging monitoring of neoadjuvant chemotherapy (nac) in appropriate situations18 is also being increasingly adopted and will be further discussed below. this article focuses on the best evidence we have. breast mri is still evolving and long-term studies of survival outcomes are limited. many large studies are being conducted and much work is being directed at making it even more applicable, not to mention affordable. this includes abbreviated contrast-enhanced sequences and non-contrast scans utilising diffusion-weighted imaging (dwi).15 fully understanding the strengths and limitations of mri, allows us to better define indications for the use of mri to detect, locally stage, and monitor treatment of breast cancer (see table 1). table 1: indications for breast magnetic resonance imaging. high-risk screening all patients at high risk of developing breast cancer during their lifetime should undergo mri imaging in addition to mammogram and ultrasound.19 magnetic resonance imaging has been shown to be far more sensitive than the other breast imaging modalities. the excellent sensitivity and high negative predictive value (npv) makes mri the ideal screening test in this population. high-risk patients also tend to get breast cancer at a younger age, have denser breast tissue and are more likely to get high-grade cancers.20,21,22 mammography is generally not offered to women younger than 35 on account of radiation exposure concerns and the higher density of tissue in younger women. the sensitivity of mammography in dense tissue can be as low as 40%.3 magnetic resonance imaging, on the other hand, involves no radiation and is largely unimpeded by dense tissue (see figure 1). figure 1: (a) the left medio-lateral oblique view mammogram of a 38-year-old woman who is a breast cancer susceptibility gene mutation carrier showing heterogeneously dense tissue but no discernible signs of cancer. (b) magnetic resonance imaging in the same patient shows a 4 cm area of non-mass enhancement in the posterior left breast (arrow). histology: high-grade ductal carcinoma in situ (dcis). the following risk factors are absolute indications screening breast mri23: breast cancer susceptibility gene (brca) mutations (including being a first-degree relative of a person with known brca mutation) other genetic disorders chest radiation for lymphoma >20% lifetime risk. the following factors contribute towards the risk of developing breast cancer24: family: first-degree relatives are most important although some models also look at other relatives. number of relatives and age at diagnosis. ashkenazi or afrikaans heritage.25,26 previous biopsy where a high-risk lesion was found, for example, atypical ductal hyperplasia (adh) and lobular carcinoma in situ (lcis) nulliparity dense breast tissue early menarche or late menopause hormone replacement therapy obesity27 personal history of breast cancer.28 calculators online calculators using a variety of different models allow users to calculate annual and lifetime risk of developing breast cancer. most recommendations for high-risk screening, using mri, suggest a threshold of 20% or more lifetime risk. the different models take into account various risk factors to establish likely risk. the two most frequently used calculators are: the ibis calculator based on the tyrer–cuzick model (http://ibis.ikonopedia.com/) the breast cancer risk assessment tool (brisk) based on the gail model (https://www.cancer.gov/bcrisktool/). occult breast cancers occult breast cancers are those that are not identified clinically, on mammogram or ultrasound even though there is evidence of breast malignancy by way of metastatic lymph node disease.29,30,31 (see figure 2). bloody nipple discharge without clinical or radiological evidence of underlying breast cancer may also be considered as a feature of an occult breast cancer.32,33 magnetic resonance imaging sensitivity for identifying occult breast cancer is in the range of 83% – 86%.31 figure 2: mammogram and breast ultrasound (not shown) did not reveal any pathology in either breast. clinically, there were enlarged lymph nodes in right axilla and lymph node biopsy revealed metastatic adenocarcinoma. (a) axial dynamic post-contrast mri shows multiple enlarged, enhancing lymph nodes (white arrow). (b) a small, irregular enhancing mass is evident in the anterior half of the right breast. dynamic post-contrast scan with kinetic colour overlay demonstrating mostly red (i.e. washout that is highly suspicious for malignancy). on kinetic overlay maps, red reflects washout, yellow plateau and blue persistent features on delayed post-contrast scans. magnetic-resonance-imaging-guided biopsy was performed. high-grade invasive ductal carcinoma confirmed on histology. pre-operative staging magnetic resonance imaging in a pre-operative or pre-treatment role posits the tempting notion of ‘more information translates into better treatment outcomes. mri has been shown to identify additional disease (not evident on mammogram or ultrasound) in the same breast as the primary cancer in 15–27% of cases and additional disease in the contralateral breast in 3–6% of cases4 (see figures 3 and 4). however, the literature so far is ambiguous and the topic remains controversial.34 the two predominant end points considered are reoperation rates and disease-free survival.12 several earlier studies, the comparative effectiveness of mri in breast cancer (comice)35 and the pre-operative mri for early-stage breast cancer (monet)36 trials, showed no improvement in either. more recent literature37,38 confirms better reoperation rates in patients who had pre-operative mri, which is better at tumour demarcation, identification of satellite lesions and intra-ductal extension, resulting in fewer positive margins post primary surgery. figure 3: (a) mammogram of a 56-year-old woman with a large cancer in the posterior outer aspect of the right breast. there is asymmetry and subtle distortion anterior to the mass (white arrow). this is suspicious for intra-ductal extension (associated ductal carcinoma in situ). the extent on mammogram measures 6 cm. (b) post-contrast magnetic resonance imaging axial maximal intensity projection (mip) shows extensive segmental non-mass enhancement extending all the way from the posteriorly situated mass to the retroareolar space. extent is 11 cm. the multicentre international prospective meta-analysis (mipa)39 trial is evaluating the role of pre-operative mri and is showing positive results in terms of surgical benefit with minimal increase in mastectomy rate. it is important to realise that certain cancer subgroups benefit more from pre-treatment mri. the general principle is that higher grade, worse prognosis (histological type and molecular subtype) cancers in younger patients with dense tissue, are most likely to benefit from pre-operative mri (see table 2). table 2: appropriateness for pre-operative magnetic resonance imaging. the breast cancer subgroups in which pre-treatment mri has been shown to be particularly beneficial are: invasive lobular carcinoma40,41 triple negative or basal carcinoma42 luminal b and her-2 carcinomas43 intermediate and high-grade dcis.37,44 magnetic resonance imaging has been shown to be the most sensitive modality for demonstrating the presence and extent of dcis.6,45 this, however, must be qualified. magnetic resonance imaging is not sensitive for low-grade dcis. it is, however, sensitive for mediumto high-grade dcis and must be used appropriately.44 it is particularly useful in younger patients and patients with dense breast tissue. it will often show extent of disease far in excess of that represented on mammogram by micro-calcifications alone46 (see table 3). table 3: sensitivity and specificity of magnetic resonance imaging in diagnosing ductal carcinoma in situ. breast mri as part of a pre-treatment work-up is generally not considered appropriate in patients scheduled for mastectomy. however, an exception may be in the case where a nipple sparing mastectomy is being considered and mri is used to rule out cancer invasion of the nipple–areola complex.47 patients with low grade, hormone-responsive solitary cancers in fatty breasts are less likely to benefit from pre-treatment breast mri (see figure 5). likewise locally advanced cancers with clear involvement of skin and/or nipple areola complex, usually do not warrant mri staging (see figure 6). figure 4: post-contrast magnetic resonance imaging in a 40-year-old brca mutation carrier. (a) large spiculated, enhancing mass in left central breast. (b) irregular, spiculated mass in right outer breast. the mass in the right breast was occult on mammogram. (c), mip with kinetic colour overlay showing both masses with malignant enhancement features (white arrows). both masses were confirmed histologically as high-grade invasive carcinomas. brca, breast cancer susceptibility gene. figure 5: mammogram (rmlo) in a 70-year-old patient shows a solitary spiculated mass in the upper breast (white arrow). there is clearly no invasion of surrounding tissue and absence of dense fibroglandular tissue that may be obscuring multifocal or multicentric disease. biopsy revealed a low-grade luminal a cancer. this patient was not a candidate for pre-operative breast magnetic resonance imaging. rmlo, right medio-lateral oblique view. figure 6: mammogram (left medio-lateral oblique view) in a 39-year-old patient with a mass that fills the entire breast. there are inflammatory changes and extensive lymph node metastases. this patient was not a candidate for pre-treatment breast magnetic resonance imaging. lastly, modern mri staging is intimately tied to mri-guided biopsy and localisation. the original research relied upon mri findings not backed up by tissue diagnosis. consequently, positive mri findings necessitated upstaging and more extensive surgery. hence, the higher mastectomy rate without necessarily improving clinical outcomes. magnetic-resonance-imaging-guided biopsy allows us to confirm the presence of actual malignancy. similarly, mri-guided localisation means accurate resection of affected areas identified on pre-operative mri.12,48,49,50 equivocal findings on mammogram and ultrasound – problem solving magnetic resonance imaging must establish presence or absence of disease, not likelihood of malignancy.51,52 an attempt to standardise the role of mri as a relevant problem solver means having guidelines based on certain mammogram features. the best proposal so far is that any abnormal finding that may represent a subtle cancer, but is not amenable to ultrasound or stereotactic biopsy, should be further evaluated on mri.53,54 a suspicious area on mammogram (bi-rads 4) that is not identifiable on ultrasound and not accessible for stereotactic biopsy (tomosynthesis-guided biopsy may mean that even single-view abnormalities are often amenable to biopsy) should be assessed on mri. an example is a new or larger asymmetry or area of architectural distortion seen only on one mammographic view, which is not ultrasound visible and cannot be accessed with guided biopsy. when such an abnormality is seen at baseline mammogram, it should be considered as bi-rads 3 that can be reviewed on mammogram in 6 months55 (see table 4). table 4: appropriateness of breast magnetic resonance imaging in indeterminate mammogram or ultrasound cases. any bi-rads 4 area that can be biopsied under either ultrasound or mammography guidance (stereotactic or tomosynthesis) must be biopsied. magnetic resonance imaging should not be used in these circumstances. magnetic resonance imaging must never replace biopsy. magnetic resonance imaging for equivocal mammogram or ultrasound findings needs to be used judiciously in order to avoid overuse52 (see figure 7). figure 7: (a) mammogram (lcc) in a 42-year-old patient who had an area of architectural distortion in the upper half of the right breast (white arrow). (b) ultrasound indicated a suspicious mass (white arrow) – irregular, anechoic mass with an echogenic halo. however, histology indicated a complex sclerosing lesion. this was felt to be discordant. (c) post-contrast magnetic resonance imaging shows a spiculated solid mass (white arrow). (d) the colour overlay shows washout and plateau features. repeat biopsy-confirmed invasive carcinoma. post-surgical and post-treatment magnetic resonance imaging post-treatment mri indications fall into the following categories: early post-surgery to identify residual disease or need for re-excision.56,57 differentiating cancer recurrence from scarring or fat necrosis.58,59 we still see patients who have undergone surgical excision as the primary histological diagnostic procedure. much of the time, there remains positive cancer margins.56 there appears to be a correlation between volume of residual disease and mri sensitivity. below 5 mm, a residual focus is difficult to distinguish from benign post-surgical change.57 in order to determine the extent of residual disease and to aid decision-making with regard to re-excision or mastectomy, it is often valuable to perform an mri. a similar situation sometimes occurs with a vacuum-assisted biopsy of a small mass or small cluster of micro-calcifications (dcis). vacuum biopsies often remove the entire cancer but in many cases residual or synchronous disease remains. although post-surgical changes including haematoma and enhancing granulation tissue can make diagnosis of residual cancer tricky, there is still a role for mri in the post-surgical setting. magnetic resonance imaging performed in the early post-surgical period – up to 1 week post-procedure – usually avoids the misleading post-surgical enhancement that develops slightly later.56 in more delayed scans, it is important to differentiate fat necrosis, scarring or seroma (with an enhancing wall) from residual cancer (see figure 8). residual cancer at the edge of collections and cysts has several characteristic features such as thick irregular wall enhancement and nodular enhancement.58,59 figure 8: a 48-year-old woman who recently underwent a vacuum-assisted biopsy of a small mass in the right breast. histology confirmed an invasive ductal carcinoma. residual carcinoma was suspected. (a) pre-contrast t1 fat-saturated mri shows a hyperintense round mass with irregular margins (white arrow). the hyperintense signal is because of haematoma. (b) post-contrast-subtracted image shows rim-enhancing mass (white arrow) in the right breast. the rim is thin and uniform. no thickened areas or mural nodules to suggest residual disease. breast cancer recurrence in an altered (post-surgery and radiation) breast can be difficult to identify clinically, on mammogram and ultrasound because of the overlap between scarring, fat necrosis and radiation related inflammatory change. mri is often more accurate at demonstrating malignant from benign post treatment changes59 (see figure 9). figure 9: a 43-year-old patient treated 2 years earlier for high-grade invasive ductal carcinoma in the right breast now has a palpable lump along the right chest wall. (a) mammogram shows a focal asymmetry which is otherwise difficult to characterise because of the posterior position. (b) ultrasound shows a mixed echogenicity mass which appears to contain fat. this is suggestive of fat necrosis. (c) post-contrast mri shows an irregular, spiculated mass against the pectoral muscle. biopsy was performed. high-grade breast cancer recurrence was confirmed at histology. most post-treatment lesions can be diagnosed on mammogram and/or ultrasound. the decision as to whether mri should be performed to resolve the difference between fat necrosis or scarring and recurrent cancer is based on the same principles used when using mri for equivocal findings.53 if a suspicious area is identified on mammogram or ultrasound and is amenable to biopsy, mri is not indicated. if, however, there is a discordant biopsy result or the area is not amenable to biopsy up front, mri should be considered. implant assessment magnetic resonance imaging is the most accurate test to assess integrity of implants.60 silicone specific,t1 and t2 sequences clearly demonstrate intra and extracapsular rupture (see figure 10). nonetheless, clinical guidance is necessary to determine the benefit of mri. if a patient is symptomatic and/or surgery for a damaged prosthesis is being considered, mri may be useful to assist in treatment planning. figure 10: non-contrast, polarity-altered spectral and spatial selective acquisition (pasta) sequences to highlight silicone prostheses. (a) the linguine sign (white arrows) in both silicone prostheses. this indicates intra-capsular rupture. (b) in addition to the intra-capsular rupture, there are areas of high signal outside the implants (white arrows) in keeping with extra-capsular rupture and silicone extravasation. breast mri is more sensitive for picking up cancers in women with prostheses than mammogram or ultrasound.61 although excellent in demonstrating fluid around prostheses, it cannot reliably identify large cell lymphomas.60 treatment monitoring magnetic resonance imaging should be considered whenever a patient is scheduled for neoadjuvant chemotherapy (nac). although ultrasound is generally accurate for assessing change in size (and derived volume) of a tumour mass, mri is now considered the most accurate imaging method to assess response to nac.62 this was similarly demonstrated in the american college of radiology imaging network (acrin) 6657 i-spy 1 trial,63 a prospective, multi-institutional trial that validated the accuracy of breast mr imaging for assessment of neoadjuvant therapy response. some cancers may be non-viable or replaced by fibrosis post chemotherapy, but a residual mass remains. magnetic resonance imaging, by way of its functional capabilities, can reflect tumour viability. this relates to the neovascularity and vascular permeability of viable cancers – indicated by contrast enhancement reflecting vascular changes in the cancer. in addition, functional mri protocols such as dwi can indicate non-viable tumour because of loss of restriction of molecules within the cancer post-chemotherapy.62 the acrin 6698 i-spy 2 trial is assessing the utility of dwi and chemotherapy response.64 magnetic resonance imaging is particularly accurate at monitoring response of her-2 and triple negative cancers being treated with nac.65 it is recognised that nac that includes a taxane may result in underestimation of residual disease because taxanes reduce perfusion independent of the cytotoxic effect these drugs exert. nonetheless, there is great value in mri assessment of response to nac as early non-responders can be identified at an early stage. at this stage, mri is more useful to assess early response rather than establish complete post-treatment resolution.12,66 the guideline for mri monitoring of chemotherapy is to perform three scans: the first scan is performed prior to chemotherapy initiation, the second halfway through the chemotherapy regimen and the third is performed at the end of treatment. comparison of tumour volume and perfusion and/or diffusion characteristics should be made on each scan.12 magnetic resonance image-guided biopsy it is an accepted principle of image-guided biopsies that a lesion visible only on a particular modality should be amenable to biopsy guided by that modality. in order to truly capitalise on the high sensitivity of mri – which identifies otherwise occult primary cancers and determines true disease extent and multifocal or multicentric cancer – it is imperative that any finding that may affect treatment is confirmed histologically or demarcated by wire localisation.67 second look (targeted) ultrasound following the discovery of additional disease on breast mri is strongly advised and an ultrasound-guided biopsy should be performed if the lesion is visible. however, less than half of mri-detected lesions are visible on targeted ultrasound.68 any centre offering breast mri, whether for high-risk screening, pre-operative staging or any of the other indications, should be able to perform mri-guided biopsy. alternatively, an arrangement with a department that does offer mri-guided biopsies should be in place37,67 (see figure 11). figure 11: magnetic-resonance-imaging-guided biopsy. (a) a 44-year-old patient with segmental non-mass enhancement (white arrow) in the right axillary tail. not adequately seen on mammogram. (b) vacuum-assisted biopsy ready. obturator in place – tip corresponds to centre of needle trough (white arrow). histology confirmed high-grade dcis. magnetic resonance image-guided biopsy wire localisation means that an affected area (identified on mri) can be accurately marked out for the surgeon. magnetic resonance image-guided biopsy biopsies are performed using a specialised grid that is digitally superimposed on the breast of interest. a contrast-enhanced, fat-saturated scan is performed and the location of the suspected cancer or dcis is determined as a grid coordinate. together with calculated depth, this allows for accurate placement of a stylet. vacuum-assisted core biopsies are usually performed and tissue markers always inserted post-procedure. wire localisation is performed in a similar way, substituting a wire for the biopsy device. discussion breast mri used as a screening test in women at high risk of breast cancer has been shown to be significantly superior to mammography and ultrasound. at present, it is underutilised.69,70 this is largely because of clinicians not being aware of the benefits that mri offers to patients in a high-risk category.19 screening for high-risk patients applies in the south african context as much as the rest of the world. most medical aids do pay for screening mri in high-risk patients and discovery medical scheme, in particular, is emphasising breast mri in eligible patients.71 although there is obviously limited access to mri facilities in most of the public hospital sector, the policy document on breast cancer control put out by the department of health also advocates breast mri in high-risk patients.72 as with many complex imaging scenarios, there is much to consider when looking at pre-operative scanning. the ability to detect additional multifocal and/or multicentric disease, as well as intra-ductal components allows for more accurate surgical planning and fewer positive margins post-surgery. this advantage is largely dependent on the ability to biopsy additional disease by way of targeted post-mri ultrasound or under mri guidance. similarly, mri-guided localisation defines information about disease extent that can be transferred from the mri scanner to the theatre.37 some centres have the policy that there is benefit from performing pre-operative mri in all breast cancer patients undergoing conservative surgery.73 there remains debate about the role of pre-operative breast mri, although the tide appears to be shifting in favour of mri, especially in higher risk patients and higher grade cancers.73 strong consideration for pre-treatment mri should be given to certain sub-populations of breast cancer such as invasive lobular, her-2, triple negative, high-grade dcis and cancers in young women or high-risk groups.40,42,43 although mastectomy is generally regarded as a contraindication to pre-operative breast mri, in the setting of a planned skinor nipple-sparing mastectomy, pre-operative mri is useful for excluding any cancer invasion or proximity to skin or nipple–areola complex.47 it has also become clear that women with a personal history of breast cancer, especially those who have undergone breast-conserving therapy or are otherwise considered as high risk (brca, family history, dense breast tissue), should have access to mri breast screening.19,28 as noted above, there is no consensus in south africa about the role in pre-operative mri. what is advisable though is discussion of the pros and cons in each case within the setting of a multidisciplinary meeting.74 with appropriate consultation and motivation from treating clinicians, most medical aids are willing to authorise pre-operative mri staging. breast mri is an excellent problem solver because of its high sensitivity and npv.51 as breast imagers, everyone encounters difficult mammogram and ultrasound patients. with access to an mri facility, it is always tempting to obtain answers with an mri scan. however, it is neither practical nor beneficial to go down this road without due caution. there are most certainly situations where indeterminate cases need the tools that mri can provide but it should only be considered when ultrasound or stereotactic biopsy is not practical. occasionally, high breast density compounded by the presence of scarring, fibrocystic disease, free silicone or other obscuring structures makes mammogram and ultrasound extremely difficult to interpret. magnetic resonance imaging may be the only way to reliably rule out cancer in these situations. in terms of mri for monitoring of neoadjuvant therapy, it is becoming clearer that mri has advantages over ultrasound.65 a significant percentage of cancers are not well visualised on ultrasound. magnetic resonance imaging, as we know, is far more sensitive that mammogram or ultrasound for showing extent and multifocality of breast cancers. magnetic resonance imaging is particularly helpful early on in treatment to show non-responders. however, it can also be used to show the absence of disease at the end of chemotherapy. in this respect, it has a high npv although the positive predictive value is less impressive. (a negative post-treatment mri is highly reliable in demonstrating pathological complete response).65,66 once again, an individualised approach, taking into account specific cancer and patient factors, is advised. in south africa, breast mri is only available to a small portion of the population, those who have access to private health facilities or academic hospitals. within that environment, we must make sure that we use it appropriately and judiciously. breast mri is a costly examination that is one of the main reasons limiting its widespread usage and opposition from some quarters. an abbreviated breast mri protocol has been shown to be almost identical in terms of accuracy to a full length scan.75 there is a possibility in the near future that mris of the breast can even be carried out without contrast, using radiomics and dwi kurtosis techniques.76 already quantitative apparent diffusion coefficient (adc) evaluation is showing great promise in distinguishing benign from malignant tissue.15 these advances will hopefully help reduce costs and make clinical indications the most important determinant of breast mri application, rather than simply cost. implications and recommendations annual breast mri is recommended for high-risk patients, most particularly those who have a higher than 20% lifetime risk of developing breast cancer. it is imperative that this message is distributed not only by radiologists, but also by breast surgeons, gynaecologists and genetic counsellors. breast mri in the setting of problem solving, pre-operative staging and investigating residual disease or recurrence needs to be decided upon in the setting of a multidisciplinary team. evidence-based practice, consistent methodology and patient benefit need to be taken into consideration with each case. breast mri should be performed at units capable of doing mri-guided biopsy and localisation. alternatively, breast mri units should have arrangements with other departments that have the interventional capacity. acknowledgements competing interests the author declares that he has no financial or personal relationships that may have inappropriately influenced him in writing this article. references kuhl c. the current status of breast mr imaging part i. choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice. radiology. 2007;244(2):356–378. https://doi.org/10.1148/radiol.2442051620 spick c, szolar d, preidler k, tillich m, reittner p, baltzer p. breast mri used as a problem-solving tool reliably excludes malignancy. eur j radiol. 2015;84(1):61–64. https://doi.org/10.1016/j.ejrad.2014.10.005 kolb t, lichy j, newhouse j. comparison of the performance of screening mammography, physical examination, and breast us and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. radiology. 2002;225(1):165–175. https://doi.org/10.1148/radiol.2251011667 kuhl c. current status of breast mr imaging part 2. clinical applications. radiology. 2007;244(3):672–691. https://doi.org/10.1148/radiol.2443051661 gupta d, billadello l. breast mr imaging in newly diagnosed breast cancer. radiol clin north am. 2017;55(3):541–552. https://doi.org/10.1016/j.rcl.2016.12.008 raza s, vallejo m, chikarmane s, birdwell r. pure ductal carcinoma in situ: a range of mri features. am j roentgenol. 2008;191(3):689–699. https://doi.org/10.2214/ajr.07.3779 acr practice parameter for the performance of contrast-enhanced magnetic resonance imaging (mri) of the breast [homepage on the internet]. c.2004 [updated 2018; 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diagnostic evaluation. am j roentgenol. 2017;208(6):1378–1385. https://doi.org/10.2214/ajr.16.16751 ozcan u, ocak f, altun e. can breast mri facilitate decision-making in equivocal mammography and ultrasonography findings? eur j radiol. 2012;81:s112–s113. https://doi.org/10.1016/s0720-048x(12)70046-3 moy l, elias k, patel v, et al. is breast mri helpful in the evaluation of inconclusive mammographic findings? am j roentgenol. 2009;193(4):986–993. https://doi.org/10.2214/ajr.08.1229 bennani-baiti b, bennani-baiti n, baltzer p. diagnostic performance of breast magnetic resonance imaging in non-calcified equivocal breast findings: results from a systematic review and meta-analysis. plos one. 2016;11(8):e0160346. https://doi.org/10.1371/journal.pone.0160346 bowles e, miglioretti d, sickles e, et al. accuracy of short-interval follow-up mammograms by patient and radiologist characteristics. am j roentgenol. 2008;190(5):1200–1208. https://doi.org/10.2214/ajr.07.3041 chae e, cha j, kim h, et al. evaluation of residual disease using breast mri after excisional biopsy for breast cancer. am j roentgenol. 2013;200(5):1167–1173. https://doi.org/10.2214/ajr.12.9275 krammer j, price e, jochelson m, et al. breast mr imaging for the assessment of residual disease following initial surgery for breast cancer with positive margins. eur radiol. 2017;27(11):4812–4818. https://doi.org/10.1007/s00330-017-4823-y drukteinis j, gombos e, raza s, chikarmane s, swami a, birdwell r. mr imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. radiographics. 2012;32(1):219–234. https://doi.org/10.1148/rg.321115016 daly c, jaeger b, sill d. variable appearances of fat necrosis on breast mri. am j roentgenol. 2008;191(5):1374–1380. https://doi.org/10.2214/ajr.07.4051 wong t, lo l, fung p, et al. magnetic resonance imaging of breast augmentation: a pictorial review. insights imaging. 2016;7(3):399–410. https://doi.org/10.1007/s13244-016-0482-9 yang n, muradali d. the augmented breast: a pictorial review of the abnormal and unusual. am j roentgenol. 2011;196(4):w451–w460. https://doi.org/10.2214/ajr.10.4864 fowler a, mankoff d, joe b. imaging neoadjuvant therapy response in breast cancer. radiology. 2017;285(2):358–375. https://doi.org/10.1148/radiol.2017170180 hylton n, gatsonis c, rosen m, et al. neoadjuvant chemotherapy for breast cancer: functional tumor volume by mr imaging predicts recurrence-free survival – results from the acrin 6657/calgb 150007 i-spy 1 trial. radiology. 2016;279(1):44–55. https://doi.org/10.1148/radiol.2015150013 american college of radiology imaging network (acrin) acrin.org [homepage on the internet]. 2018 [cited 2018 jun 24]. available from: https://www.acrin.org/6698_protocol.aspx schmitz a, teixeira s, pengel k, et al. monitoring tumor response to neoadjuvant chemotherapy using mri and 18f-fdg pet/ct in breast cancer subtypes. plos one. 2017;12(5):e0176782. https://doi.org/10.1371/journal.pone.0176782 marinovich m, sardanelli f, ciatto s, et al. early prediction of pathologic response to neoadjuvant therapy in breast cancer: systematic review of the accuracy of mri. breast. 2012;21(5):669–677. https://doi.org/10.1016/j.breast.2012.07.006 schrading s, strobel k, keulers a, dirrichs t, kuhl c. safety and efficacy of magnetic resonance-guided vacuum-assisted large-volume breast biopsy (mr-guided valb). invest radiol. 2017;52(3):186–193. https://doi.org/10.1097/rli.0000000000000331 demartini w, eby p, peacock s, lehman c. utility of targeted sonography for breast lesions that were suspicious on mri. am j roentgenol. 2009;192(4):1128–1134. https://doi.org/10.2214/ajr.07.3987 miles r, wan f, onega t, lenderink-carpenter a, o’meara e, zhu w. underutilization of supplemental magnetic resonance imaging screening among patients at high breast cancer risk. j womens health. 2018;27(6):748–754. https://doi.org/10.1089/jwh.2017.6623 clauser p, mann r, athanasiou a, et al. a survey by the european society of breast imaging on the utilisation of breast mri in clinical practice. eur radiol. 2017;28(5):1909–1918. https://doi.org/10.1007/s00330-017-5121-4 screening and prevention on your medical aid | discovery health medical scheme – discovery [homepage on the internet]. discovery.co.za.; 2018 [cited 2018 aug 04]. available from: https://www.discovery.co.za/medical-aid/screening-and-prevention-cover health d. policies and guidelines – policies and guidelines [homepage on the internet]. health.gov.za.; 2018 [cited 2018 jul 23]. available from: http://www.health.gov.za/index.php/2014-03-17-09-09-38/policies-and-guidelines# di leo g. worldwide practice of breast mri: insights from the mipa study applications – the mipa study group. european congress of radiology; 2015 march 4–8; vienna, austria: european society of radiology; 2015. https://dx.doi.org/10.1594/ecr2015/b-0757 leong j, to h, saddik d, stelmach w. p3 breast magnetic resonance imaging outcomes and utility of multidisciplinary discussion. breast. 2018;38:191–192. https://doi.org/10.1016/j.breast.2018.02.007 chhor c, mercado c. abbreviated mri protocols: wave of the future for breast cancer screening. am j roentgenol. 2017;208(2):284–289. https://doi.org/10.2214/ajr.16.17205 bickelhaupt s, jaeger p, laun f, et al. radiomics based on adapted diffusion kurtosis imaging helps to clarify most mammographic findings suspicious for cancer. radiology. 2018;287(3):761–770. https://doi.org/10.1148/radiol.2017170273 editorial questioning standard imaging protocols a t scher mb chb, omro, rcp, rcs, fcrad(o) sa head: department of diagnostic radiology, university of stellenbosch, tygerberg, w cape the lack of a unitary specialist examination in radiology, as well as other disciplines is an ongoing problem. differences in content for the primary examinations, questions about the relative standards of the two final examinations (college and mmed) and problems in acceptance of the mmed degrees by overseas colleges,all illustrate the unsatisfactory situation at present. this problem is being tackled urgently by the colleges of medicine of south africa, and hopefully a suitable agreement between the universities offering the mmed degree and the colleges of medicine will be arrived at. one positive feature of the mmed degree in radiodiagnosis is the requirement that a research dissertation be submitted as part of the conditions for award of the degree. this obligatory requirement has generated considerable interesting material. further, the ongoing budgetary crisis in the large teaching hospitals in south africa, which never seems to improve and in fact in some provinces is deteriorat ing, coupled with an ever increasing patient workload, require these departments to scrutinise protocols rigorously in order to decrease costs and increase the throughput of patients. in this edition of the sajr we highlight some of the dissertations done by registrars in our department to illustrate that sometimes protocols are followed more by rote than with good clinical foundation. a welcome relief from the consequences of brutal violence, which forms such a large part of our work in state hospitals, is an ever increasing interest in the imaging of sports injuries. sports imaging in south africa has become the latest addition to the multifaceted radiology discipline. the recent advances in high-quality radiography, high-resolution ultrasound, helical multi-slice ct and high fieldstrength mr!, have been able to demonstrate the musculoskeletal systems as never before. interventional procedures under ultrasonic and ct guidance can accurately infiltrate areas of interest. sports injuries are often subtle and difficult to pinpoint clinically. radiology has demonstrated the ability to help the multidisciplinary sports medicine fraternity in the quest to establish the correct diagnosis, so as to expedite treatment and return the athlete to competitive level as soon as possible. two of the papers in this edition of the sajr illustrate the value of imaging in diagnosis of subtle sports injuries. a t scher editor 2 sa journal of radiology • august 2003 about the author(s) ilana m. viljoen department diagnostic radiology, university of the witwatersrand, south africa tanyia pillay department of paediatric radiology, university of the witwatersrand, south africa susan lucas department diagnostic radiology, university of the witwatersrand, south africa citation viljoen im, pillay t, lucas s. the value of comparative radiographs in the diagnosis of extremity fractures in children by doctors in the emergency department. s afr j rad. 2017;21(1), a1245. https://doi.org/10.4102/sajr.v21i1.1245 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract the value of comparative radiographs in the diagnosis of extremity fractures in children by doctors in the emergency department ilana m. viljoen, tanyia pillay, susan lucas copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction: the practice of routinely requesting radiographs of both limbs (injured and unaffected side) in a suspected extremity fracture in a child for comparison purposes is widespread and accepted in emergency departments in south africa, despite the fact that it has been discouraged in literature. aim: the aim of this study was to evaluate the ability of junior emergency department doctors to diagnose selected common paediatric extremity fractures without and with comparative radiographs. method: study participants evaluated a set of 30 paediatric extremity radiographs, first without comparison radiographs and then 5 days – 7 days later with comparison radiographs. they indicated the presence or absence of a fracture and their level of confidence in making a diagnosis. the selected radiographs included normal films as well as subtle and obvious fractures at the following sites: hand or wrist or forearm, elbow and foot or ankle or lower leg. results: the overall ability to detect paediatric extremity fractures (sensitivity) was unchanged (80%) with and without comparison radiographs (p = 0.28). there was, however, a significant (7.8%) increase in detection rates of elbow fractures only, when comparison radiographs were added (p = 0.0068). there was a significant improvement in confidence levels (12%) amongst the participants with comparative radiographs compared to without them (p = 0.0001). the ability to detect normal paediatric extremity radiographs (specificity) improved by 15.3% with the addition of comparison radiographs (p ≤ 0.0001). conclusion: there is an overestimation of the value of comparison radiographs in diagnosing paediatric extremity fractures. the findings of this study do not support their routine use in the emergency department. selective use is justified. training of junior emergency medicine doctors to recognise paediatric fractures should be prioritised rather than relying on comparative radiographs. pictorial interlude 42 sa journal of radiology • september 2006 often one is confronted with an extracerebral fluid collection/effusion when interpreting computed tomography (ct) of the brain in children. to determine whether the effusion is subarachnoid or subdural, a few basic principles should be kept in mind. subdural effusions are crescent-shaped,1 especially over the frontal and parietal lobes, with the vessels ‘pasted’ against the cerebral surface (fig. 1).2 the interhemispheric fissure anteriorly can be v-shaped or asymmetrical, as the hemisphere is displaced away from the falx at an angle (figs 2a and b).2 subarachnoid effusions emphasise the gyral outlines as the subarachnoid spaces enlarge, especially over the subarachnoid or subdural effusion? m pienaar, bsc, mb chb a brandt, mb chb g dekker, mb chb, mmed (fam) d van der merwe, mb chb s hlongwane, mb chb s i dajee, mb chb, da (sa), mmed (rad d) department of radiology, tygerberg hospital and stellenbosch university pictorial interlude fig. 1. contrasted ct brain showing enhancing dura and meninges, with the contrast-filled vessels (arrows) compressed against an effaced cerebral surface in the presence of a subdural effusion. figs 2a and b. ct studies illustrating the brain surfaces at the interhemispheric fissure pushed away by subdural fluid from the flax, either bilaterally (a) or unilaterally (b). note marked effacement of the gyri and sulci. a b pg 42-43.indd 42 9/6/06 2:59:01 pm 43 sa journal of radiology • september 2006 frontal lobes and interhemispheric fissure when the patient lies supine (fig. 3). it is important to note symmetry of the subarachnoid effusion.2 clinical relevance of this determination is in the evaluation of collections in non-accidental injury (which are often hypodense – indicating chronic effusions). this is also important in pyogenic meningitides with subdural collections,3 where these must be distinguished from the normal subarachnoid spaces in infants less than 1 year of age.2 1. kirkwood jr. essentials of neuroimaging, 2nd ed. new york: churchill livingstone, 1995: 378. 2. barkovich aj. pediatric neuroimaging, 3rd ed. philadelphia: lippincott williams & wilkins, 2000: 606609. 3. barkovich aj. pediatric neuroimaging, 3rd ed. philadelphia: lippincott williams & wilkins, 2000: 371. pictorial interlude fig. 3. uncontrasted ct study illustrating normal frontal enlarged subarachnoid spaces in an infant. the frontal lobes stay parallel to the interhemispheric fissure with subarachnoid effusions, in contrast to subdural effusions. the surface gyri and sulci are prominent, whereas in a subdural collection these would be effaced. pg 42-43.indd 43 9/6/06 2:59:01 pm about the author(s) ntebogang p. mutshutshu department of radiology, university of the witwatersrand, south africa linda t. hlabangana department of radiology, chris hani baragwanath hospital, university of the witwatersrand, south africa citation mutshutshu np, hlabangana lt. are cranial ultrasound requests and reports adequate at two academic hospitals in johannesburg? s afr j rad. 2017;21(1), a1182. https://doi.org/10.4102/sajr.v21i1.1182 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia,usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. conference abstract are cranial ultrasound requests and reports adequate at two academic hospitals in johannesburg? ntebogang p. mutshutshu, linda t. hlabangana copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. background: cranial ultrasound is a cheap, effective and easy to use modality for the evaluation of cranial pathology in very sick paediatric populations. it can be performed as a portable imaging investigation and repeated as many times as possible. new improvements in sonography equipment and technique make it possible for cranial ultrasound to compete with ct scanners in terms of identifying pathology. aim: to determine the adequacy of cranial ultrasound requests and reports at charlotte maxeke johannesburg academic (cmjah) and rahima moosa mother and child hospitals (rmmch) with regards to their completeness, accuracy and clinical relevance. method: a retrospective review of 191 cranial ultrasound requests and reports was performed at two academic centres. a data collection sheet was developed by the principal investigator and supervisor guided by literature with regards to the information required within the cranial ultrasound report. a scoring method was then developed with a maximum score of 3 given for the request adequacy and of 14 for report adequacy. results: only 49.74% of the requests met the criteria for an adequate request. the mean report adequacy score was 7.03 with a sd of (2.02). fifty (50%) of the reports had a maximum score of 7. overall 50.26% of the requests scored average and below average scores. the most commonly reported variable was the presence or absence of hydrocephalus and the least reported was resistive index. results show that reports and requests are inadequate. abstract introduction case report discussion conclusion acknowledgements references about the author(s) navdeep singh department of radiodiagnosis, jubilee mission medical college and research institute, india aneesh mangalasseril kuriakose department of radiodiagnosis, jubilee mission medical college and research institute, india regi an george department of radiodiagnosis, jubilee mission medical college and research institute, india shirish vaidya department of radiodiagnosis, jubilee mission medical college and research institute, india citation singh n, kuriakose am, george ra, vaidya s. computed tomographic diagnosis of aortocaval fistula. s afr j rad. 2018; 22(1), a1363. https://doi.org/10.4102/sajr.v22i1.1363 case report computed tomographic diagnosis of aortocaval fistula navdeep singh, aneesh mangalasseril kuriakose, regi an george, shirish vaidya received: 18 may 2018; accepted: 21 june 2018; published: 12 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract aortocaval fistula is an abnormal vascular communication between an aortic aneurysm and the inferior vena cava. the condition is very rare and life threatening with high mortality. this article reports a case of aortocaval fistula in a 76-year-old male diagnosed using computed tomography. computed tomography, being a non-invasive investigation, ensures early diagnosis and can help in prompt surgical or interventional radiological management which can be life-saving. introduction aortocaval fistula (acf) is a rare complication of abdominal aortic aneurysm (aaa) and is associated with a high mortality rate. it is seen in about 4% of surgeries for ruptured aneurysms.1 early preoperative diagnosis can aid in dedicated preparation for surgical or interventional radiological treatment. while evaluating an aaa on computed tomography (ct), certain imaging findings can help in diagnosing acf. case report a 76-year-old male patient presented with severe abdominal pain associated with breathing difficulty. on examination, the patient was hypotensive with tachycardia and a pulsatile abdominal mass. emergency ultrasonography (us) revealed an infrarenal aortic aneurysm with peripheral thrombus. for further evaluation of the extent of aneurysm, emergency ct angiography was performed using a dual slice helical ct scan (general electric, milwaukee). a total of 100 ml of non-ionic contrast medium iopamidol (lek-pamidol, india), was injected in the right antecubital vein at a flow rate of 4 ml/s. image acquisition was started after a delay of 22 s. the ct parameters were 120 kv, 120 ma, 2 mm slice thickness and 1.5 pitch. the area of coverage extended from the sternal angle to the inguinal region. the scan showed a large infrarenal fusiform aaa with a partially thrombosed periphery. active extra luminal extravasation of contrast was seen from the right lateral wall, into the peritoneal cavity (figures 1 and 3a). there was a fistulous communication on the right posterolateral wall of aorta with the inferior vena cava (ivc), with a flap displaced into the ivc about 4.5 cm distal to the origin of the renal arteries (figure 1). the lower abdominal ivc and iliac veins were opacified on the arterial phase with contrast medium density similar to that of the aorta (hu 350) (figure 2). the upper abdominal ivc was compressed by the aneurysm and the hepatic portion demonstrated minimal opacification with an attenuation of 150 hu. this helped in excluding reflux of contrast from the right atrium as the cause for opacification in the lower abdominal ivc (figure 3b). figure 1: axial contrast-enhanced computed tomography showing a large infrarenal aneurysm (star) having a fistulous communication (white diagonal arrow) on its right posterolateral wall with inferior vena cava (black arrow). figure 2: axial contrast-enhanced computed tomography scan during the arterial phase showing opacification of the common iliac arteries and veins bilaterally, with similar attenuation (white arrows); layering of contrast was observed in the iliac veins (black arrow). figure 3: (a) axial contrast-enhanced computed tomography scan demonstrating active extravasation of contrast into the peritoneal cavity (arrow). contrast is also seen in the renal veins; (b) contrast seen in the hepatic inferior vena cava (arrow) but with less attenuation (hu – 150) owing to reflux from right atrium. in view of these findings, a diagnosis of a ruptured aaa with an acf was made. the patient was planned for emergency surgery. however, he suffered a cardiac arrest before being shifted to the operating room and could not be revived. discussion abdominal aortic aneurysms mostly rupture into the retro-peritoneum or peritoneal cavity. aortocaval fistula is a rare complication of an aortic aneurysm which can occur spontaneously in 1% of patients or along with rupture in 4% of patients.1 men in the sixth to seventh decade are commonly affected. according to a recently proposed mechanism, development of acf involves pressure necrosis of the aortic wall from the aortic aneurysm. this leads to severe periaortic inflammation causing adherence of an aneurysm to the ivc, subsequently eroding into it. various risk factors include atherosclerosis, mycotic aneurysm, syphilis, polyarteritis nodosa and connective tissue disorders like marfan syndrome and ehlers–danlos syndrome.2 the clinical presentation depends upon the acuteness of the condition and the presence of other associated findings, like rupture and dissection. a palpable pulsatile mass with a continuous bruit in a haemodynamically stable patient suggests an unruptured aaa, whereas a ruptured aneurysm presents with severe abdominal pain, hypotension and shock.3 other symptoms include shortness of breath, cold extremities, cyanosis, haematuria and pulmonary oedema. long-standing fistulas often present with features of high output cardiac failure.1,4 preoperative diagnosis is important in planning the operative management and preventing further complications. according to one study, mortality rate in open surgical repair of acf was around 30%, mainly from excessive blood loss, but it was significantly lower if a preoperative diagnosis was available.5 ultrasound examination can be the initial imaging modality to diagnose aaa but has a very limited role in diagnosing acf. multidetector ct angiography is the preferred investigation. simultaneous presence of contrast in the aorta and ivc during the arterial phase is the most important diagnostic sign and this was demonstrated in our patient. quite often, the aneurysm compresses the ivc, thereby making it difficult to evaluate this sign. the screening of the iliac veins and renal veins is very significant in such situations as they may be opacified synchronously and with similar attenuation to the aorta. the reflux of contrast from the right atrium should not be mistaken as acf, as it is of less attenuation. the presence of a fistulous communication between the aorta and ivc is not seen in all cases but was demonstrated in our patient. additional signs which help in diagnosing an acf are the loss of the fat plane between the aorta and ivc, poor perfusion of kidneys and presence of aneurysmal rupture.6 aortography is confirmative in diagnosing the acf. figure 4: volume-rendered arterial phase image displays the opacified aneurysm, iliac veins and inferior vena cava. successful treatment of acfs depends upon early preoperative diagnosis, proper operative planning, haemodynamic stabilisation and prevention of pulmonary embolism. open surgical repair or endovascular repair forms the mainstay of treatment. endovascular repair has the advantage of less blood loss as compared to the open repair with equal success.5 conclusion in conclusion, acf is a rare complication of aaa, associated with a high mortality rate. timely diagnosis is possible by pursuing certain findings at ct imaging which can aid in proper surgical or endovascular planning. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed equally to the diagnosis, management and preparation of the manuscript. references psathas ed, lioudaki s, doulaptsis m, charalampoudis p, klonaris c, verikokos c. clinical manifestations of aortocaval fistulas in ruptured abdominal aortic aneurysm: report of two cases. case rep surg. 2012;2012:123081. davis pm, gloviczki p, cherry kj jr, et al. aorto-caval and ilio-iliac arteriovenous fistulae. am j surg. 1998;176:115–118. https://doi.org/10.1016/s0002-9610(98)00166-4 kumar y, hooda k, li s, goyal p, gupta n, adeb m. abdominal aortic aneurysm: pictorial review of common appearances and complications. ann transl med. 2017;5(12):256. https://doi.org/10.21037/atm.2017.04.32 ravi r, peter sb, swaminathan ts, chandrasekar v. spontaneous aortocaval fistula due to abdominal aortic aneurysm rupture – a case report. indian j radiol imaging. 2006;16:453–456. https://doi.org/10.4103/0971-3026.32245 brightwell re, pegna v, boyne n. aortocaval fistula: current management strategies. anz j surg. 2012;83:31–35. https://doi.org/10.1111/j.1445-2197.2012.06294.x rosenthal d, atkins cp, jerrius hs, clark md, matsuura jh. diagnosis of aortocaval fistula by computed tomography. ann vasc surg. 1998;12:86–87. https://doi.org/10.1007/s100169900122 abstract introduction clinical details discussion conclusion acknowledgements references about the author(s) harmeet kaur department of radiodiagnosis, dayanand medical college & hospital, india kamini gupta department of radiodiagnosis, dayanand medical college & hospital, india punit tiwari department of orthopedics, government medical college, india citation kaur h, gupta k, tiwari p. cleidocranial dysplasia: radiological mimic of pyknodysostosis – a case report. s afr j rad. 2018; 22(1), a1326. https://doi.org/10.4102/sajr.v22i1.1326 case report cleidocranial dysplasia: radiological mimic of pyknodysostosis – a case report harmeet kaur, kamini gupta, punit tiwari received: 20 feb. 2018; accepted: 18 mar. 2018; published: 14 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract cleidocranial dysplasia (ccd) is a rare autosomal dominant skeletal disorder with predominant membranous bone involvement. it may also occur as a sporadic mutation. the diagnosis of this condition is based on the clinical, radiological and genetic findings. it is characterised by hypoplasia or aplasia of the lateral thirds of the clavicles; craniofacial and dental anomalies; and hypoplastic iliac bones. pyknodysostosis is a close radiological mimic of this entity. definite diagnosis is based on the genetic analysis. a 36-year-old short-statured female was referred for computed tomography of the paranasal regions for complaints of a deviated nasal septum and midline depression in her forehead. skeletal screening demonstrated an open metopic suture, wormian bones, maxillary hypoplasia, maldentition and aplastic lateral thirds of both clavicles. in this article, we report a case of ccd, discuss various overlapping features between ccd and pyknodysostosis and attempt to differentiate them radiologically. introduction cleidocranial dysplasia (ccd) is a rare (incidence of 1:100 000),1 autosomal dominant skeletal disorder; however, 40% of cases occur spontaneously with no apparent genetic cause.2 it primarily affects bones which undergo intramembranous ossification, but enchondral bones are also affected. the pathology relating to this condition is owing to an early developmental disorder of mesenchyme or connective tissue. this causes retarded ossification of bone precursors, especially at junctions, which can lead to defective ossification, or even failure of ossification of portions of the skeletal structure.3 in contrast, pyknodysostosis is an autosomal recessive disorder of osteoclast dysfunction, causing generalised osteosclerosis with associated maxillofacial anomalies. pyknodysostosis shares many features with ccd.4 in this article, we discuss various imaging features that are common to these entities as well as those which help to differentiate them radiologically. a dysplastic flexed clivus with convexity towards the endocranium is characteristic of ccd when present and may be useful in differentiating the two entities.5 clinical details a 36-year-old, short-statured female presented to our department for computed tomography (ct) of the paranasal (pns) region before corrective facial surgery for a deviated nasal septum and midline depression in her forehead. her birth history was normal. her intelligence was normal. on physical examination, her weight was 48 kg and height was 120 cm. she had a midline depression on her forehead which was likely owing to an open metopic suture. additional findings included a high-arched palate, depressed nasal bridge, maldentition and mandibular prognathism. she was wearing a dental prosthesis. her shoulders were hypermobile. her family history was unremarkable, suggesting that her disorder was without any obvious genetic cause. based on these findings, craniofacial dysplasia was considered. in addition to ct imaging, a skeletal survey, including radiographs of the skull, shoulders, hands and pelvis, was done. laboratory investigations for serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, thyroid function and vitamin d levels were obtained. they were all within normal range. a lateral radiograph of the skull (figure 1) showed normal bone density, wormian bones (white arrow), mandibular prognathism and supernumerary teeth. radiographs of the pns sinuses (figure 2) revealed an open metopic suture, aplasia of the frontal sinuses, hypoplasia of the maxillary sinuses and underpneumatised mastoids. radiographs of the shoulders (figure 3) demonstrated aplasia of the lateral two-thirds of both clavicles and a bell-shaped thorax. hand and pelvis radiographs were normal. figure 1: lateral radiograph of the skull shows normal bone density with wormian bones in the lambdoid suture (hollow arrow), prognathism and supernumerary teeth (white arrow). patient is wearing dental prosthesis. figure 2: water’s view for paranasal sinuses shows an open metopic suture (hollow arrow), aplastic frontal sinuses, hypoplastic maxillary sinuses (white arrows) and underpneumatised mastoids. figure 3: postero-anterior radiograph of the upper chest shows aplasia of lateral two-thirds of both clavicles (white arrows) and a bell-shaped thorax. non-contrast ct of the pns revealed normal bone density, multiple supernumerary teeth, a deviated nasal septum and a high-arched palate (figure 4), a dysplastic clivus which was flexed with convexity towards the endocranium (figure 5), an open metopic suture and sclerotic mastoids (figure 6). based on the laboratory and radiological findings, the patient was diagnosed as a case of ccd. figure 4: coronal section of computed tomography-paranasal region shows supernumerary unerupted teeth, a deviated nasal septum, hypoplastic maxillary sinuses and a high-arched palate. figure 5: sagittal-section computed tomography scan shows a dysplastic clivus with its flexion deformity and convexity towards the endocranium (arrow). figure 6: axial-computed tomography section at the level of skull base (a) shows under-pneumatised mastoids, non-pneumatised sphenoid sinuses and superiorly (b) shows an open metopic suture (curved arrow). discussion cleidocranial dysplasia is a skeletal dysplasia with characteristic clinical findings and autosomal dominant inheritance. typical clinical findings are hypoplastic or aplastic clavicles, abnormal craniofacial growth, supernumerary teeth, short stature and a variety of other skeletal changes. according to our observations and those of mundlos,6 a complete absence of the clavicles is rare, whereas hypoplasia of the acromial end is common. head circumference is usually at the upper limit without being macrocephalic. there is a broad forehead with frontal bossing and some degree of hypertelorism. the mid-frontal area is poorly developed and shows a frontal groove owing to incomplete ossification of the metopic suture.6 many patients with facial dysmorphism and hypoplastic or aplastic clavicles have gone through life without any functional disability and are detected incidentally. as in our case, the patient was unaware of her disease and was pursuing corrective surgery for cosmetic reasons. but as these diseases have genetic consequences, their exact diagnosis and patient counselling are important. the inheritance of ccd and pyknodysostosis can be variable in a small percentage of cases; hence, their radiological differentiation is also important. short stature, frontal bossing and excessive mobility of shoulder girdle are the most significant clinical findings of ccd.7 broad sutures, large fontanelles persisting into adulthood, numerous wormian bones, numerous unerupted deciduous and supernumerary teeth, maxillary hypoplasia with relative mandibular prognathism and hypoplastic or aplastic clavicles are the pathognomonic radiological findings of ccd. vertebral defects with scoliosis, kyphosis or lordosis; wide pubic symphysis; and anomalies of phalangeal, tarsal, metatarsal, carpal and metacarpal bones may also be present.8 individuals with ccd may have osteopenia and may develop osteoporosis, a condition that makes bones prone to fracture. pyknodysostosis is a rare defect of osteoclast function, resulting in cranio-facial dysplasia like ccd. it shares many features with ccd such as, short stature, delayed closure of sutures and fontanelles, wormian bones, supernumerary teeth, hypoplastic pns sinuses, mandibular prognathism and hypoplasia or aplasia of the acromial ends of the clavicles. while many of the clinical and radiological findings of both entities resemble each other, the increased radiographic bone density should readily distinguish between the two.6 thus, osteosclerosis (increased bone density resulting in fractures) and acro-osteolytic dysplasia of the distal phalanges are considered essentially pathognomonic of pyknodysostosis. to our best knowledge, skull base changes in pyknodysostosis include thickening and sclerosis of the clivus with platybasia and basilar invagination. however, a dysplastic flexed clivus with convexity towards the endocranium has not been mentioned in pyknodysostosis till date and is classical of ccd, seen in 82% of cases,5 and demonstrated in our case. conclusion cleidocranial dysplasia and pyknodysostosis are rare skeletal dysplastic conditions. although genetic typing is the gold standard, these entities can be diagnosed clinically and radiologically. the pathognomonic feature to distinguish between them is bone density, but we suggest that distortion of the clivus with a flexed deformity in ccd is a useful adjunctive feature to differentiate the two. the importance of recognition of these features in the diagnosis and prevention of future complications is stressed. acknowledgements the authors would like to thank the department of otorhinolaryngology, dayanand medical college & hospital, ludhiana, for referring the patient. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions h.k.’s role was in the acquisition of data, drafting the case report, analysis and interpretation of the imaging findings and arranged figures with their legends. k.g. helped in interpreting the data, summarising and revising the article critically for important intellectual content and final approval of the article. p.t. helped in clinical evaluation of the patient, proof reading, editing the article and reviewed the bibliography. references verma p, verma kg, gupta sd. cleidocranial dysplasia: a dilemma in diagnosis? a case report. arch orofac sci. 2010;5(2):61–64. tanaka jl, ono e, filho em, castilho jc, moraes lc, moraes me. cleidocranial dysplasia: importance of radiographic images in diagnosis of the condition. j oral sci. 2006;48(3):161–166. https://doi.org/10.2334/josnusd.48.161 nagarathna c, shakuntala bs, mathew s, krishnamurthy nh, yumkham r. cleidocranial dysplasia presenting with retained deciduous teeth in a 15-year-old girl: a case report. j med case rep. 2012;6:25. https://doi.org/10.1186/1752-1947-6-25 fleming kw, barest g, sakai o. dental and facial bone abnormalities in pyknodysostosis: ct findings – case report. am j neuroradiol. 2007;28:132–134. kreiborg s, jensen bl, björk a, skieller v. abnormalities of the cranial base in cleidocranial dysostosis. am j orthod. 1981;79(5):549–557. https://doi.org/10.1016/s0002-9416(81)90465-6 mundlos s. cleidocranial dysplasia: clinical and molecular genetics-review article. j med genet. 1999;36:177–182. brueton la, reeve a, ellis r, husband p, thompson em, kingston hm. apparent cleidocranial dysplasia associated with abnormalities of 8q22 in three individuals. am j med genet. 1992;43(3):612–618. https://doi.org/10.1002/ajmg.1320430322 sakhi p, yadav p, susmitha r, chawla a, yadav cj, gupta j. clinical spectrum of cleidocranial dysplasia: a case report. natl j community med. 2010;1:162–165. technology refresher course i the multiformat camera whilst very few multitormat cameras, based on cathode ray tube (cri) technology; are purchased these days, it is important to review that technology in order to assess both the impact and potential oflaser imagers. early imaging cameras bolted directly onto the diagnostic monitor (figure 1) had special lenses to figure 1: the imaging camera is bolted directly on to the diagnostic monitor. compensate for spherical aberration because of the curved screen. the applications of these cameras were in the fields of ultrasound and first generation ctscanners. next came the dedicated multifotmat camera, so called because multiple exposures could be made on the same film. these cameras are video based, that is they require a video signal in order to work such a camera featured a tlatscreen crftube, in-line opties and electronic control. the various challenges faced with this type of camera are as follows: stability the image on the crt is built up from the electronic beam crossing the tube at least 625 times from top to bottom. each sweep constitutes a line (a raster line) with a set of 625lines constituting a frame.a frame is built up 25 times a second. with conventional illm an exposure of about 10 frames will be necessary to form an image. it follows, therefore, that each line on each frame must be in exactly the same position on the screen in order to produce maximum sharpness in the image.any instability will result in the raster lines being blurred with a resultant loss in image quality. exposure as stated above, 25 frames a second are produced on the monitor screen. the minimum exposure time is thus 1i25th ofa second. on latermultiformat cameras a method of determining exposure by number of frames (or fields) was developed. an additional issue in determining exposure is the monitor brightness. a change in exposure time causes a sensitometric change in the film's characteristic curve similar to the effect caused by increasing monitor brightness. additionally, an increase in monitor brightness can cause a deterioration in image sharpness due to phosphor flare. it will be appreciated, 32 sajournal of radiologymarch 1996 r therefore, that the monitor is set for a maximum sharpness / brightness compromise with exposure time determining blackness of the image. optical system there are various problems associated with an optical system: • vignetting a loss of brightness at the edges of the image. this is reduced by using a crf screen that islarger than the image field the laser imager 1987 saw the advent of the laser imager with 3m introdudng an infra red system to the american market.today there are seven major manufacturers of laser imagers,namely agfa, dupont, fuji, kodak, konica,3m and polaroid. the output, that is the illm, of the laser imager may look very much like that of a crt multiformat camera, but that iswhere the similarity ends. input although provision can be made on most systems for a video input.laser imagers almost exclusively use a digital interface to the imaging modality. this has far reaching implications with regard to increased departmental productivity where different modalities can be connected to the same imager. much research and development is underway developing local area networks (lan), image gateways, picture achiving and communications systems (pacs) to fully utilise the potential of laser imagers. • spherical aberration this manifests itself as geometric distortion. this is overcome by the use ofin-line optics and a flat screen monitor • density uniformity a falling off of brightness at the edges of the screen due to variations in electron density on the phosphor. this is compensated for electronically by alterïngthe brightness proffie across the screen basic principles the following is a description of the operation of a helium neon (hene) laser: (figure 2) the data from the imaging modality is inputted via the interface electronics and an image buffer which acts as a storage device.the data are then split into x-axis; y-axis and intensity information. tdpsis 88 the development of the imaging camera crt to laser ,pompaus 82 the intensity of the laser beam is varied by means of an acoustic optical modulator. this is a very stable system which delivers 4096 grey levels (compared to 200 on the crt). the beam is then swept to and fro across the film by a system oflenses and a rotating or galvanometric mirror (x-axis).atthe same time the film is transported in the longitudinal direction by a precise mechanical drive system (y-axis). the image is thus "painted" on the film from top to bottom in sequential lines by a very fine laser beam which achieves a pixel size of 80llm. by this means problems of geometric and density distortion common to crt imagers are avoided. exposure the one main disadvantage of the laser imager against the crt imager is exposure time. on the crt it is approximately 40 ms. the laser imager takesanythingjrom 17to45 seconds per film. because of its digital architecture, however, the data for an image can be stored in a queue to maximise throughput. in addition multiple copies can be made independently of the imaging system (ct scanner, mrl, ete.). resolution the resolution of a laser imager is in the region of63oo x 7650 pixels.this applies to the whol hlm. with a crt camera the resolution of 1250 lines applies to each image with 12expoo.tres on a 35 x 43 cm film the resolution of each system is comparable. with less than 12 exposures on a film, the laser imager is superior. this is thefimin the series 'technolog; refresher course". we would welcome feedbackastowhetherlhesubjectmaterial iscomct, whethertheinfonnationshould be more in-depth, and suggestions about what subjects should be covered in future isi'ues. the author wishes to thankagfa, dupont and konica for the infannatian they provided. towards this article. roger short publisher instructions to authors authors are requested to adhere closely to these instructions. failure to complywilllead to delay in publication. manuscripts original articles, technical reports, book reviews and case reports areinvited and should be sent to the editor, sa journal of radiology c/o cannon communications (pty) ltd, po box 2433,randburg, 2125,republicofsouth afuca both in hardcopy and on diskette, ore-mailedtogll1non@so!o.pipex.co.za manuscripts must be submitted exclusively to the journal on the understanding that they have not and willnot be published elsewhere (referto document: conditions of submission ). each author should have participated sufficiently in any submission to take responsibility for its contentsanda letter to this effect, signed by all the authors should accompany the manuscript. papers based on work submitted for examination purposes to a tertiary institution should be accompanied by written permission authorising publication of the material in its original form or part thereof papers accepted for publication become the copyright of the journal. the editor retains the rightto moclifythe style and length of the submitted manuscript (major changes being agreed with the corresponding author) and to decide the time of publication. the journal publishes all material on the understanding that the design of the work has been approved by a relevant ethics committee and! or it conforms to the professional standards andlegislation currently applied in the country of origin (refer to document: conditions of submission). two copies of each manuscript should be submitted and, if applicable, accompanied by two sets of tables,graphs, and illustrations. authors are advised to retain a copy of all material submitted in case of loss as the editor cannot accept responsibility for loss or damage. it is essential that manuscripts be clearly presented with adequate space for editorial comment. the manuscripts should be typed with double spacing on onesideofa4paper(297x212 mm), with 3cm margins; all pages should be numbered consecutively,indudingthose 33 sa journal of radiologymarch 1996 of acknowledgements, references, tables and figure legends. block paragraphing should not be used. headings should be in lower case and not be underlined. manuscripts that do not conform to these requirements will be returned for retyping. papers must be in english and spelling should conform to the concise oxford dictionary of current english. authors are urged to keep their manuscripts as short as possible and to write them in simple precise english. original papers each typescript component should begin on a new page in the following order: title page, abstract and keywords, main text, acknowledgements, references, tables, figure legends tile title page should include title, authors' names (with initials and departmental addresses), authors' qualifications, a short title of not more than 45 characters for the running headlines, and the name, address, telephone and fax numbers (and if available the e-mail address) of the corresponding author to whom proofs and ofiprint requests should be directed. the abstract, comprising a summary of not more than 250words' should highlight the design and objective of the investigation/research, results and conclusions. the abstract should be followed by a list of not more than five key word~ which should not appear in the main title the introduction should succinctly state the purpose of tile article the main body of the text will usually be divided into sections headed methods, results, and discussion. avoid repeating all tile detail in the tables, and avoid repetition of data in the results and discussion sections. the discussion should ernphasisen wand important aspects of the study and conclusions til at follow jromthem. when quotingspedfic materials or drugs, authors should givetheir approved names, with if necessary, proprietary names in parentheses with the name of the manufacturer. case reports case r ports should consist of title page as above, a short abstract and key words, the case report and a brief discussion of the pertinent literature. they should not exceed 1000 words with not more than ten (10) references. case reports should not have more than three authors. abbreviations abbreviations should be unambiguous and only used where appropriate. their meaning should be clearly explained where they are fust introduced e.g.anterior-posterior (ap); computed tomography (0). units and symbols measurements of height, length, mass (weight) and volume should be to p'fiii 86 abstract introduction case report discussion conclusion acknowledgements references about the author(s) tanusha sewchuran department of radiology, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa citation sewchuran t. solid to cystic: a case report of imaging findings of atypical lung metastases. s afr j rad. 2019;23(1), a1663. https://doi.org/10.4102/sajr.v23i1.1663 case report solid to cystic: a case report of imaging findings of atypical lung metastases tanusha sewchuran received: 14 sept. 2018; accepted: 01 nov. 2018; published: 28 jan. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the imaging spectrum of pulmonary metastases varies greatly, with solid and partly cavitating nodules being the most common. when imaging the oncology patient, specifically follow-up imaging post-treatment, the radiological aim is to assess for disease regression and thus treatment response, usually with resolution of these nodules. we report an interesting case series of a patient with primary endometrial carcinoma presenting with pulmonary metastases. this imaging series eloquently depicts the temporal evolution of the metastatic solid pulmonary nodules to cavitating nodules and finally to thin-walled cysts. baseline imaging in this scenario is vital to exclude pre-existing cystic lung disease. the progression of solid pulmonary metastases to simple cysts is an uncommon therapy-related consequence, but an important entity to recognise, not only as an indicator of good treatment response, but also to evaluate for potential life-threatening complications such as spontaneous pneumothoraces. introduction the radiological imaging spectrum of pulmonary metastases is vast and may range from solid nodules to lesions mimicking pulmonary cysts. the histology of the primary tumour is often helpful, particularly in the setting of squamous cell carcinomas, where primary and secondary pulmonary lesions often appear to be cavitating. case report we report an interesting case series of patient km, a 64-year-old female who had presented with a 4-month history of post-menopausal vaginal bleeding. her co-morbidities included senescent hypertension and cardiac disease, stable on double agent anti-hypertensives. she was also a social smoker. an initial pipelle biopsy sent for microscopy revealed moderately differentiated carcinoma in the endometrial tissue which stained positive for vimentin and oestrogen receptors, but negative for carcinoembryonic antigen (cea). this was consistent with endometrial adenocarcinoma. she subsequently presented to radiology for staging computed tomography (ct) scan post-surgery (bilateral salpingo-oophorectomy and total abdominal hysterectomy). her post-operative recovery was volatile with ureteric reimplantation required after iatrogenic injury, several urinary tract infections and renal complications. patient km’s initial ct abdomen/pelvis, with imaging through the lung bases, revealed multiple bilateral solid pulmonary nodules of moderate size, in keeping with stage 4 disease. the distribution was random with no associated calcifications, septal thickening or pleural effusions. she received single agent palliative chemotherapy with paclitaxel 280 mg, a taxane-based chemotherapy agent targeted for the treatment of endometrial adenocarcinomas. the usually used combination treatment of a cisplatin was not utilised owing to her ongoing renal dysfunction. on dedicated chest imaging, approximately a month after initial staging and initiation of treatment, several of the previously noted solid pulmonary nodules now demonstrated discrete central lucencies, in keeping with cavitation. figure 1 eloquently demonstrates this central cavitation. upon completion of the six cycles of chemotherapy, the final staging scan performed approximately 3 months later exhibited good treatment response with disease regression. all the afore-documented solid and early cavitating pulmonary nodules had now resolved to thin-walled cysts with no associated soft tissue component, calcification or ground glass attenuation. no pneumothorax was present. figure 2 depicts the temporal evolution of several focal right lower lobe solid pulmonary nodules to thin-walled cysts on axial ct images. in figure 3, we can also clearly appreciate this cavitating trend on coronal multiplanar reformatted images. figure 1: computed tomography axial image through the right lung base demonstrates early central cavitation of the pulmonary nodules. figure 2: consecutive computed tomography axial image series through the lung bases eloquently depicts the temporal evolution of: (a) solid pulmonary nodules to (c) thin-walled cysts. the magnified insert clearly demonstrates the central cavitation (b). figure 3: coronal multiplanar reformatted images depicts the progression of solid pulmonary nodules to: (a) thick-walled cavitating nodules to (b) thin-walled pulmonary cysts over time. the uncomplicated thin-walled cysts are better appreciated in the magnified insert (b). discussion prior to a decade ago, primary treatment for patients with uterine cancer was radiotherapy based.1 chemotherapy was reserved for patients with recurrent or disseminated disease, especially in the setting of failed hormone therapy.1 the use of taxane-based chemotherapy agents has been documented as being highly effective in the treatment of adenocarcinomas.2 together with platinum agents, such as cisplatin, it is often the first-line chemotherapy agent used. in the documented literature, a patient known with primary adenocarcinoma of the lung, who was treated with docetaxel, demonstrated secondary cavitatory change of the pulmonary metastases with bilateral spontaneous pneumothoraces.2 docetaxel is also a member of the taxane family of chemotherapy agents. paclitaxel, the drug of choice in patient km’s case, demonstrated good treatment responses in advanced/recurrent disease.1 the lung is the most common location for metastatic lesions from a non-pulmonary primary malignancy.3 pulmonary metastases via haematogenous or lymphatic spread is usual, with cavitating or cystic appearing pulmonary metastases considered a subgroup.4 this makes the distinction from incidental non-malignant lung pathology much harder.5 the clinical circumstances and course of disease, that is, an acute onset versus protracted illness, are important considerations when evaluating cystic and cavitating lung lesions.3 according to the fleischner glossary of terms, a cyst is defined as a ‘round circumscribed space surrounded by an epithelial wall of variable thickness’.6 on imaging, it appears as a rounded lucent lesion and is usually thin-walled.6 in comparison, a cavity is a lucent lesion within an area of consolidation or within a nodule.6 a nodule is classified as a rounded opacity measuring up to 3 cm, and may appear poorly or well-defined.6 cavitation of solid pulmonary nodules may be spontaneous or therapy-induced, from either chemotherapy or radiotherapy.7 upper lobe and centrally located lesions are more likely to cavitate.7 whilst squamous cell carcinomas are renowned for cavitating pulmonary lesions, other possible primaries include sarcomas, and gastrointestinal, bladder or pancreatic malignancies.4,5 it has been well-documented that certain chemotherapy agents are known to induce cavitation.1–3 several postulated mechanisms included tumour necrosis or insinuation of air with a check-valve mechanism into the tumour.1–3 spontaneous pneumothoraces have also been reported in previous literature, citing increased intrathoracic pressures following emetic sequelae of chemotherapy or possible bronchopleural fistulae formation from tumour lysis/necrosis, as aetiologies.2 rupture of sub-pleural bullae or emphysematous bullae have also been postulated.8 such patients were subsequently treated with closed chest tube insertion and chemical pleurodesis.2 conclusion the evolution of solid pulmonary metastases to cavitating and then cystic lesions, as a consequence of therapy, is a fairly rare entity albeit an important one to consider. the possibility of spontaneous pneumothorax is an uncommon but significant complication, which requires interval clinical and imaging evaluation to preclude preventable patient morbidity and mortality. acknowledgements competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article. references moxley mk, mcmeekin sd. endometrial cancer: a review of chemotherapy, drug resistance and the search for new agents. oncologist. 2010;15:1026–1033. https://doi.org/10.1634/theoncologist.2010-0087 kao hl, lin wc, hsu hh, huang gs. docetaxel (taxotere)-induced cavity change of pulmonary metastatic lesions complicated by bilateral spontaneous pneumothoraces in a patient with primary adenocarcinoma of the lung. singapore med j. 2013;54(6):e133–e134. https://doi.org/10.11622/smedj.2013114 barnadt p, du toit j. the radiological appearance of metastatic cystic lesions. sajr. 2011;15(4):131–136. https://doi.org/10.4102/sajr.v15i4.358 gaillard f. pulmonary metastases. radiology reference article. radiopaedia.org; 2018 [cited 2018 sep 01]. available from: https://radiopaedia.org/articles/pulmonary-metastases seo jb, im jg, goo jm, chung mj, kim my. atypical pulmonary metastases: spectrum of radiological findings. radiographics. 2001;21(2):403–417. https://doi.org/10.1148/radiographics.21.2.g01mr17403 hansell dm, bankier aa, macmahon h, mcloud tc, muller nl, remy j. fleischner society: glossary of terms for thoracic imaging. radiology. 2008;246(3):697–722. https://doi.org/10.1148/radiol.2462070712 gerada e, gatt n, mizzi a, montefort s. atypical cavity lung lesions: a case report and review of radiological manifestations. intern med. 2014;4(1):1–3. fiorelli a, vicidomini g, napolitano f, santini m. spontaneous pneumothorax after chemotherapy for sarcoma with lung metastases: case report and consideration of pathogenesis. j thorac dis. 2011;3:138–140. 21 sa journal of radiology • june 2006 abstract multiple meningioma is a condition in which the patient has more than 1 meningioma in several intracranial locations with or without signs of neurofibromatosis. the incidence of multiple intracranial meningiomas varies from 1% to 10% in different series. in this case series we report 3 cases of female patients with multiple meningiomas with distinct radiological features. introduction multiple meningiomas attract a lot of interest because of their relative rarity, unclear aetiology and the problems related to proper management strategy.1 multiple meningiomas are not infrequently found in patients with neurofibromatosis type 2 (nf2); however, they occur much less frequently in cases of sporadic meningioma.2 cases three female patients presented with multiple meningiomas. case 1: a 57-year-old female patient presented with a first episode of localising convulsion, headache and confusion. computed tomography (ct) scan revealed multiple contrast-enhanced hyperdense extra-axial masses in the right parietal and parasagittal region (figs 1a and b). case 2: a 49-year-old female patient presented with difficulty in walking and urinary incontinence. on examination she had a hard, immobile elliptical non-tender midline mass on her forehead. she also had weakness of the lower limbs. the cranial nerves were intact. ct scan showed hyperdense parasagittal and left cerebellopontine angle meningiomas (figs 2a and b). case 3: a 51-year-old female patient presented with convulsion and headache. ct scan showed bilateral hyperdense extra-axial enhancing cavernous masses with suprasellar extension (figs 3a and b). a histological diagnosis of fibroblastic meningioma was made in 2 cases and the third case was inoperable. discussion meningiomas are the most common primary non-glial brain tumours and comprise 13 19% of all primary intracranial neoplasm.3 most meningiomas are benign, but 6% are atypical or aggressive and 1 2% are frankly malignant.2 meningiomas arise from arachnoid cap cells2,4 multiple meningiomas a ojo, mb chb e fynn, mb chb, fcrad (d), mmed (rad diag) department of diagnostic radiology, university of limpopo fig. 1a. pre-contrast image showing hyperdense right temporal and frontal parasagittal meningiomas. fig. 1b. post-contrast image showing contrast enhanced right temporal and frontal parasagittal meningiomas. case series pg21-23.indd 21 7/11/06 12:49:15 pm 22 sa journal of radiology • june 2006 case series that line the inner dura but may arise anywhere these cells are located.4 most meningiomas are sporadic and of unknown aetiology. recognised risk factors include genetic factors and cranial irradiation. the only genes known to be associated with meningiomas are nf2 on chromosome 22 and the related cytoskeleton element dal-1 on chromosome 18. they have a peak incidence in patients aged between 40 and 60 years, and affect women more than men. multiple meningiomas are defined as at least 2 spatially separated meningiomas occurring at the same time, or more than 2 meningiomas arising sequentially from 2 clearly distinct regions.1 the term ‘multiple meningiomas’ was first applied by cushing and eisehardt to denote the occurrence of multiple tumours in the absence of neurofibromatosis or acoustic neuromas.5-7 there are 2 distinct hypotheses as to the pathogenesis of multiple meningiomas. the first hypothesis suggests that tumours arise independently which has been supported by the reported histological and cytogenetic differences between the multiple tumours from the same patient. the other hypothesis suggests that a single transforming event occurs and the original clone of cells spreads throughout the meninges in the formation of multiple, clonally related tumours.2,3,4,8 gruber et al.6 described a case of multiple meningioma arising during long-term therapy with the progesterone agonist megerostol acetate in a patient with a low-grade endometrial stromal sarcoma who had total abdominal hysterectomy and bilateral salpingo-oophrectomy and in whom 11 separate intracranial meningiomas of various sizes were identified. the majority of multiple meningiomas (80 90%) are benign and classified as world health organization (who) grade 1.6,7 tomita et al.8 described multiple meningiomas consisting of fibrous meningioma and anaplastic meningioma. atypical meningiomas correspond to who grade 2 and they have a higher rate of recurrence than grade 1, particularly after subtotal resection.5 anaplastic or malignant meningiomas (who grade 3) are the rarest (1 3%).5,6 multiple meningiomas have previously been described as uncommon, but with the advent of ct scans the frequency of detection has increased. with the advent of ct domenicucci et al.2 detected multiple meningiomas in 4.5% of cases, compared with 0.58% of their series in the pre-ct era. sheehy and crockard4 described a rise in detection from 1.1% of cases to 8% with modern ct scanning. granger et al.5 described 16 meningiomas excised in 7 separate surgical procedures in a 69-yearold woman. on ct imaging meningiomas are well-defined extra-axial masses, which displace adjacent brain. most are isoto slightly hyperdense compared with normal brain, and there is a strong uniform enhancement after intravenous contrast.5,6 there is usually minimal peri lesional oedema.6 calcifications and adjacent hyperostosis may be evident. meningioma en plaque covers the inner table resulting in pronounced hyperostosis of the adjacent bone.5 mri may show hypoto isointense signal lesions on t1-weighted imaging and isoto hyperintense on t2-weighted imaging with a strong homogeneous enhancement post gadolinium.2,5,6 most meningiomas show a characteristic dural thickening that tapers peripherally (dural tail sign), accurately localising the tumour to dural or subdural space.6 angiography has a fig. 2a. pre-contrast image showing hyperdense parasagittal and left cerebellopontine angle meningiomas. fig. 2b. post-contrast image showing contrast-enhanced parasagittal and left cerebellopontine angle meningiomas. case series pg21-23.indd 22 7/11/06 12:49:15 pm 23 sa journal of radiology • june 2006 major role to play in assessing highly vascular tumours preoperatively, or tumours that are adjacent to venous sinuses that may be involving the sinuses. the meningeal supply typically gives rise to a ‘spoke-wheel’ appearance and a characteristic ‘mother-in-law’ phenomenon, i.e. the contrast shows up early and stays late into the venous phase.5 conclusion multiple meningiomas are common brain tumours occurring concurrently in several intracranial locations in the same patient. this condition is commonly associated with neurofibromatosis.2 its aetiology is still not known but radiographic features are distinct. 1. spallone a, neroni m, giuffre r. multiple skull base meningiomas: case report. surg neurol 1999; 51:274-280. 2. domenicucci m, santoro a, d’osaldo dh, delfini r, cantore gp, guidetti b. multiple intracranial meningiomas. j neurosurg 1989; 70:255-260. 3. whittle ir, smith c, navoo p, colile d. meningiomas seminar. lancet 2004;363:1535-1543. 4. sheehy jp, crockard ha. multiple meningiomas: a long-term review. j neurosurg 1983; 59:1-5. 5. granger a, sainsbury r, wilkinson t, macfarlane m. multiple meningiomas: case report and review of the literature. journal of clinical neuroscience 2000; 7: 222-228. 6. gruber t, dare ao, balos ll, lele s, fensttermaker ra. multiple meningiomas arising during long-term therapy with progesterone agonist megerostrol acetate, j neurosurg 2004; 100:328-331. 7. bhatoe hs. simultaneous occurrences of multiple meningiomas in different neuroaxial compartments. neurology india 2003; 51:263-265. 8. tomita t, kurimoto m, yamatani k, y, et al. multiple meningiomas consisting of fibrous meningioma and anaplastic meningioma. journal of clinical neuroscience 2003; 10:622-624. fig. 3a. pre-contrast image showing bilateral hyperdense cavernous meningiomas extending into the suprasellar areas. fig. 3b. post-contrast image showing bilateral contrast-enhanced cavernous meningiomas extending into the suprasellar areas. case series pg21-23.indd 23 7/11/06 12:49:16 pm about the author(s) anith chacko clinical neurosciences, university of bristol, united kingdom ewan simpson clinical neurosciences, university of bristol, united kingdom schadie vedajallam clinical neurosciences, university of bristol, united kingdom savvas andronikou clinical neurosciences, university of bristol, united kingdom ngoc j. thai clinical neurosciences, university of bristol, united kingdom citation chacko a, simpson e, vedajallam s, andronikou s, thai nj. curved reformat of the paediatric brain into a ‘mercator/flat-earth map’ – a standardised method for demonstrating cortical surface atrophy resulting from hypoxic ischaemic injury. s afr j rad. 2017;21(1), a1150. https://doi.org/10.4102/sajr.v21i1.1150 note: a selection of conference abstracts: rssa/saspi paediatric imaging congress, 03–06 november 2016, spier estate, stellenbosch, south africa. faculty collaborators: professor kassa darge (body imaging, university of pennsylvania, philadelphia, usa), professor edward lee (thoracic imaging, harvard university, usa), professor beverley newman (cardiac imaging, stanford university, california, usa), professor kimberly applegate (image gently and body imaging, emory university, atlanta, usa) and professor savvas andronikou (thoracic imaging, university of bristol, uk) supported by south african paediatric radiologists, co-ordinated by dr. jaishree naidoo, president of the african society of paediatric imaging and head of division of paediatric radiology, charlotte maxeke johannesburg academic hospital. this conference abstract is partially based on the following publication: society of pediatric radiology, reston, va (united states) (2016). ipr 2016 abstracts. pediatric radiology, 46(suppl1), 1–372. https://doi.org/10.1007/s00247-016-3579-x conference abstract curved reformat of the paediatric brain into a ‘mercator/flat-earth map’ – a standardised method for demonstrating cortical surface atrophy resulting from hypoxic ischaemic injury anith chacko, ewan simpson, schadie vedajallam, savvas andronikou, ngoc j. thai copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. magnetic resonance imaging (mri) in term hypoxic ischaemic injury (hii) demonstrates cortical atrophy in characteristic locations. communicating bilateral zonal injury to parents and in courtrooms using reports and cross-sectional imaging is challenging. an overview map of the brain surface generated from a curved reconstruction of the mri is ideal for such scenarios. freeware was used to derive standardised methods of curved reconstructions of the paediatric brain from three-dimensional mri in 10 children with cortical atrophy from term hii and 10 age-matched ‘controls’. multiple techniques were tested from various planes, different landmark slices and angles of reconstruction at various depths to the surface. two images (derived from the coronal and sagittal planes) were identified as giving the best overview of the watershed, peri-sylvian and peri-rolandic zones. peri-sylvian, peri-rolandic zones and frontal lobes were better demonstrated on mercator maps. scroll maps demonstrated lateral structures poorly but demonstrated central zones, posterior parietal lobes and occipital lobes better. watershed zones were well demonstrated on both maps. localised ‘bi-convex’ interhemispheric fissure widening was present in all hii atrophy patients on both maps, that is, para-sagittal and/or para-falcine watershed atrophy. an intervascular watershed band of atrophy was seen on both maps. peri-rolandic and peri-sylvian atrophy was better demonstrated on mercator maps. ulegyria was identified in 90%. standardised curved reconstruction of the brain surface from mri allows visualisation of key cortical features of term hii on the two derived images which can replace multi-slice mri for communicating cortical findings to legal professionals and parents, and can be embedded within multimedia reports. star abstract the role of mri in bone marrow imaging maximilian freiser md mri has unique capabilities in the visualization of both the normal and abnormal bone marrow. moreover, mri allows us to monitor physiological conversion from hematopoietic (red) to fatty (yellow) marrow and to assess variants in the distribution of both marrow types. in hematopoietic bone marrow, the content of fat is much higher than in the red marrow, in which the signal characteristics are dominated by the higher proportion of water, which is due to the cellular elements. the content of bony trabeculae within the bone marrow is also important for signal characteristics, especially when pulse sequences are applied which are sensitive to susceptibility effects. in the newborn, all bones contain red marrow. during infancy, childhood and adolescence, conversion of red to yellow marrow takes place. this process of bone marrow co~ver~ion proceeds in centripetal direction, most peripheral bones, such as the phalanges of the hands and feet are involved earlier than the more central elements of the lower leg and forearm, respectively. within the long bones, the conversion of the bone marrow starts in the diaphyses and progresses to the metaphyses. the epiphyses, on the other hand, contain yellow marrow when they ossify. at the age of about 22 to 25 years of age, the adult distribution of red and yellow is found. hematopoietic bone marrow in adults is found within vertebral bodies, pelvis, ribs, scapula, skull as well as in the proximal portions of the humerus and femur. it should be noted that fat content increases with age also in those skeletal elements which contain yellow marrow and that islands of hematopoietic marrow may exist in the long bones, especially in the metaphyses which must not be misinterpreted as an infiltration of neoplastic tissue. moreover, various pathological and physiological conditions which are associated with a need of increased red or white cell production, may result in focal or diffuse reconversion of yellow to red marrow: increased menstrual blood loss, severe infections, extensive athletic activities (e.g. marathon runners), extensive bone marrow infiltration by neoplasms or leukemia, hemoglobinopathies etc. mri is able to depict the distribution of yellow and red marrow and to diagnose pathological conditions within the bone marrow. the selection of adequate pulse sequences is critical. tl-weighted spinecho and stir sequences are most useful for this differentiation. inand out-of-phase gradient echo sequences as well as t2* weighted gradient echo sequences may add valuable information. in t2-weighted (fast) spin echo sequences and con27 sa journal of radiology. december 2002 trast enhanced tl-weighted sequences, on the other hand, the ~o~trast between fatty and hematopoietic marrow is greatly reduced. initial results indicate that diffusion weighted imaging (dwi) may be superior to other techniques for specific questions, e.g. differentiation of neoplastic and osteoporotic fractures of the vertebrae. mri is particularly sensitive for the detection of bone marrow manifestations of lymphoma, multiple myeloma as well as bony metastases. this issue will be addressed in another lecture specifically devoted to this subject. there exist many other disorders of the bone marrow which are readily detected using mri. some of them may play an important role in oncologic imaging. bone infarcts and aseptic necrosis bone infarct and aseptic necroses frequently occur in tumor patients and patients with leukemia treated with cytotoxic drugs and steroids. when pain and restriction of motion is reported by the patients bony metastases are suspected. in the late phase, bone infarcts are displa~ed as polycyclic areas with a dense nm ?f calcification in the periphery on plain radiograms which allow for a straightforward diagnosis. in the early stage, however, when bone infarcts cause severe pain, radiographic signs are very discrete. mri shows high signal intensity on stir and fat sat ce scans in the periphery of the lesion, normal fat signal in the center and edema in the adjacent normal bone marrow thus allowing for a specific diagnosis. aseptic necroses are located in the subchondral region of various joints, such as the femoral and humeral star abstract head, the femoral condyles and the talus. in the early stage, minor degrees of osteopenia or the crescent -sign (semicircular lucency) are the only plain film findings. in mri the necrotic zone is clearly demarcated and depending upon the composition of the necrotic tissue high, intermediate or low signal intensities are found. the 'double line sign' at the periphery of the necrotic zone is regarded as a specific feature of aseptic necrosis. stress and insufficiency fractures following radiation therapy, chemotherapy and immobilization patients treated for malignant tumors, who are frequently at older age, are prone to insufficiency fractures. especially previous radiation therapy results in weakening of the bone. insufficiency fractures are often located in the femoral neck, sacrum, iliac bones and lower lumber vertebrae. bone scanning shows focal tracer accumulation in the areas affected by insufficiency fractures thus mimicking bony metastases. with mri (and ct) these insufficiency fractures are readily diagnosed. longitudinal bands of low signal intensity with adjacent bone marrow edema are indicative of insufficiency fractures. in ct, bondlike or geographic areas of sclerosis are visualized. osteomyelitis and cellulitis plain radiography is insensitive for the detection of osteomyelitis before larger areas of trabecular and cortical bone are destroyed (up to 3 weeks after the onset of symptoms). bone scanning is highly sensitive but nonspecific. mri, especially when using fat sat ce scans allows for early diagnosis and precise assessment of the location and extent of the infectious process. extension within the bone marrow, involvement of the cortex, and paraosseus involvement are visualized. following contrast enhancement, abscess cavities and the hypervascular abscess membrane are depicted. following surgical treatment of bone tumors and skeletal metastases the differentiation of reactive tissue and early infection, however, may be difficult or impossible. sapho syndrome is a specific entity which is associated with palmo-plantar pustulosis, psoriasis or skin infections (acne conglobata). it involves multiple skeletal elements, especially the proximal sternum and the medial portions of the clavicles. however, multiple other bones can also be involved. thickening, irregular structure and multiple small bony destructions are found in the involved bones. these features may be misinterpreted as neoplasms and this diagnosis may be supported by multifocal tracer accumulation in the bone scans. mri and ct findings also have an aggressive appearance and awareness of this entity is important to avoid false diagnoses. chronic recurrent multifocal osteomyelitis (crmo) is found in children and adolescents and multiple bones are affected by a chronic type of osteomyelitis. multifocality may also lead to misdiagnosis of osseous metastases. leukemia in acute and chronic types of leukemia, the normal bone marrow is replaced by neoplastic cells. the extent of bone marrow involvement is 28 sa journal of radiology. december 2002 variable. the radiologist may detect homogeneous marrow abnormalities when mri is performed due to symptoms unrelated to a systemic bone marrow disorder (e.g. joint pain) and has to insist on a thorough examination by the internist. for monitoring patients under treatment for leukemia, mri proved not to be useful, even if some anecdotal reports exist in which relapse of the disease was first diagnosed by mri. due to signal alterations within the bone marrow in patients with leukemia, other pathological conditions such as aseptic necroses, osteomyelitis and spondylitis may be difficult to be detected. suggested reading 1. dooms gc, fisher mr, hricak h, richardson m, crooks le, genant hk. bone marrow imaging: magnetic resonance studies related to age and sex. radiology 1985 may; 155(2): 429432. 2. plecha om. imaging of bone marrow disease in the spine. semin museuloskelet radiol 2000; 4(3): 321-327. 3. richards ma, webb ja, jewell se, gregory wm, reznek rh. in-vivo measurement of spin lattice relaxation time (tl) of bone marrow in healthy volunteers: the effects of age and sex. br j radiol1988 jan; 61(721): 30-33. 4. siegel mj, luker gg. bone marrow imaging in children. magn reson imaging glin nam 1996 nov; 4(4): 771-796. 5. smith sr, williams ce, davies jm, edwards rh. bone marrow disorders: characterization with quantitative mr imaging. radiology 1989 sep; 172(3): 805-810. 6. steiner rm, mitchell dg, rao vm, murphy s, rifkin md, burk dl jr, ballas sk, vinitski s. magnetic resonance imaging of bone marrow: diagnostic value in diffuse hematologic disorders. magn reson q 1990 jan; 6(1): 17-34. 7. takagi s, tanaka o. the role of magnetic resonance imaging in the diagnosis and monitoring of myelodysplastic syndromes or leukemia. leuk lymphoma 1996 nov; 23(5-6): 443-450. 8. takagi s, tsunoda s, tanaka o. bone marrow involvement in lymphoma: the importance of marrow magnetic resonance imaging. leuk lymphoma 1998 may; 29(5-6): 515-22. 9. tardivon aa, vanel d, munck in, bosq j. magnetic resonance imaging of the bone marrow in lymphomas and leukemias. leuk lymphoma 1997 mar; 25(1-2): 55-68. technology update computer technology update computer n. automatic electronic apparatus for making calculations or controlling operations that are expressible in numerical or logical terms; hence -1ze v.t. equip with, perform by, produce by, computer. why digital? imagine, for a moment, that you need to send a message to me; you need to tell me whether to come and rescue you, stay where i am, or send for reinforcements. your life, and those of others, depend on correct transmission of this message which must be sent using a flashlight and one of two codes. the first code associates each option with a particular number of flashes of the torch one for rescue, two for stay and three for reinforcements. the second code depends on the use of a slider at the side of the torch to vary the strength of the beam; the three possible messages are respectively represented by a weak signal, a medium-strength one, and a bright one. which coding system would you choose? i'd go for the number-of-flashes option; there's little chance of misinterpretation (provided both you and i understand the code and can count). the other, intensity-of-beam, method leaves plenty of room for confusion: your "bright" may be my "medium" and our r whitehorn macha, ffrad(d) consultant radio/agist in private practice, durban 25 sa journal of radiology. january 2000 attempts to communicate may end up like those of allan donald and lance klusener. a coding system that, when broken down into its most basic sub-units, depends on a signal that is either on or off and pays no attention to the strength of the signal, is a digital one. it is their digital nature that has made modern computers so reliable and successful.why then, you may well ask, does your computer "freeze" so often? remember, the reliability of the number-of-flashes method of communicating by torch is negated if the sender and receiver are badly trained and don't understand the code properly or can't count. similarly, badly written software can "crash" even a reliable digital computer. what's what let's take a look at the basic components of a computer. the most important part of the computer is the least impressive-looking: the "box", usually an unchallenging beige colour (but this is changing as computers become fashion accessories). it has many wires applied to its back, one or more slits and one or more lights on its front, and makes whirring or clicking noises at times. within this box live several components which, being important, will now be introduced. the cpu (central processing unit) the brain of the computer. takes an incoming stream of o's and 1's (data) and, according to instructions (also encoded as a series of 0' sand ] 's) given to it by a program, manipulates this data and sends out a stream of ... yes: o's and] 'so for example if two "pieces" of data, 001 (the number one) and 010 (two), were to arrive at some fictitious processor with the i.nstruction to page 26 technology update from page 25 to add them, the processor would spit out 011 (three). if the data arriving at the processor were a very, very long string of o's and ] 's representing a digitised picture of your child, and a series of instructions went to the processor telling it to increase the contrast in that picture, the ultimate result would be another very, very long string of o's and l's representing a more contrasty picture of your child. memory (ram random access memory and hard drive) picture a craftsman in his workshop. around his waist is a leather pouch in which he holds those tools that he is currently using. those tools that he is not actively using are stored on shelves that line one of the walls of his workshop. the leather pouch is similar to the ram of a computer, the short-term memory that holds those parts of programs and scraps of data that are currently needed by the processor. this memory communicates with the processor very quickly, but has far less capacity than the hard drive and is "volatile" when power supply to the computer is lost, all data in ram is lost. the hard drive is similar to the shelving in our craftsman's workshop. it has a large capacity (perhaps a hundred times that of ram) but fetching data from the hard drive takes much longer than fetching it from ram, just as getting a screwdriver from the shelf takes longer than simply pulling it out of the pouch. data stored on a hard drive remains there when the computer is switched off motherboard if,feeling bored or adventurous, you decide to open your computer and take a peep inside you will see, among other things, a number of cards or boards. the exact number will depend on what you have added to your system, but one that will definitely be there is the "motherboard". this holds the "guts" of the computer including the cpu and ram and may also hold the video (things that appear on your monitor) and sound controllers, which are then said to be "on-board". video card in the bad old days of dos your computer's screen may, at a particular time, have been completely blank apart from some witty and enticing statement such as: c> taken by the eloquence of this you might have been tempted to type: dir. this would have resulted in a whole lot of print appearing on your screen and that's about as complex as things got, video-wise, in those days. onscreen graphics were confined to thrilling stuff like arranging x's, o's and (for the bold) -'s into patterns to depict mickey mouse. nowadays the screen is decorated, even in its "resting" state with thousands (or millions) of colours, littered with icons which await the click of your mouse to launch programs that allow you to show your holiday photos or videos, or (i suppose it must be said, this being a radiology journal) the chest x-ray of a patient who is a hundred kilometres from your rooms. all this involves a huge amount of processing, a task which is shunted away from the main processor to a separate video module, with its own ram, and often to be found on a separate card plugged into the motherboard. sound card the sound producing capabilities of home computers have increased from cryptic beeping to the ability to play the overture from tannhauser (why do we get such a kick out of listening to music over the tinny little speakers that come with our computers? beats me, but i do 26 sa journal of radiology. january 2000 it too). as with video, this intense task is often handled by a separate card. modem if you want to be able to say "yes" when asked "do you have the internet?" you need a modem, your portal to all the information, sleaze and viruses out there. the modem converts data (including pictures and sound) between the digital type that a computer understands and the analogue type that the phone lines demand. keyboard, monitor, mouse the purpose of these is self-evident and, for the moment, we'll ignore them. what shall i buy? i will not try to give specific advice regarding the features to be desired in a computer. such an attempt would be futile, firstly because needs differ from person to person and secondly because the pace of progress would guarantee the obsolescence of the recommendations by the time of their publication, but, some may find a few general pointers helpful. processor names like "pentium" and "pili"each denote a class of processors whose members have similar characteristics and capabilities but operate at different" clock speeds". the clock speed of the processor is indicated by a number like 400 mhz. the performance advantage of a processor which is faster but is within the same class as another (e.g. a pili 500 mhz versus a pili 450 mhz) is fairly predictable and is roughly proportional to the size of the number. the performance advantage of a more recent class of processor (e.g. a pili versus a pil) is less easy to predict and is more dependent on what you do with your computer but it is usually considerable. my general advice when buying topage27 technology update from page 26 a new desktop computer would be to buy into the latest class of processor but to look for the "sweet spot" (the point at which diminishing returns for your money start to set in) with regard to processor speed. it is really not going to make much difference, except for the most demanding of applications, whether your processor is a 550 mhz or a 500, and there's usually a considerable premium to be paid for being at the cutting-edge. ram let's refer back to our analogy above, which equates ram with a leather tool-pouch and hard drives with shelving. imagine a very slick craftsman he's a very fast worker but has only a small pouch to hold tools. he has to stop what he's doing repeatedly to fetch things from the shelves. he'll probably take longer to get a job done than would a slower worker with a larger tool-pouch. similarly, it's no good having the fastest processor available but being short on ram. in my opinion, if it's worth having a modern processor, like a pili (or its non-inrel equivalents), then it's worth having at least 64 mb of ram. hard drive it used to be as inevitable as death and taxes that you would run out of disk space within a year or two of buying a computer. this remains largely true if you are using your computer company news mediswitch mediswitch announces agreement in radiology arena mediswitch, a division of the usko group, has signed an agreement with radpac, a developer and provider of medical practice software for radiologists. the deal will see the full integration of mediswitch's api switch technology with the radpac system, which treats every patient as a separate account because of the in.herently unique character of radiology visits. "currently," explains peter kennedy, mediswitch's business development director, "all existing users are being upgraded to the new mediswitch-enabled version of the system at no extra cost." according to dave langley, managing director of radpac, the deal is particularly beneficial to radpac clients because of the cost saving implications. "with a mediêwitch-enabled version of the software, medical aids will be able to pay radpac users more promptly, because all invoices will be submitted in real-time, and checked for eligibility and availability of funds. in addition, the medical funds themselves will only receive notification of accounts once, thus decreasing duplication, and these will be delivered in electronic format which is easily and immediately incorporated into their databases." the first phase of the deal was expected to be completed by the end of last year. thereafter, any new users will automatically use the mediswitch-enabled vcrsion of 27 sa journal of radiology· january 2000 to do all the things that a modern computer can do, for example to manipulate and store pictures from a scanner or digital camera. if all you're doing is a little word processing and u ing th occasional spreadsheet you'll have a tough time trying to fill one of the modern multi-gigabyte-siz hard drives. but if this is all you're doing, you don't really need a modern "powerhouse" computer. where then, you may ask, can you buy a little, cheap computer with specifications and software honed down to your limited needs? you can't. the industry says you have to do more with your computer. get cracking. radpac. the move into niche ar as of the market follows mediswitch's recent deals across the spectrum of th health care industry, including medical aids, fund administrators and practice management software (pms) providers. about radpac radpac is a windows-based set of comprehensive software modules managing administration requirements within radiology practices. the modules are broken up for different aspects within a practice, and are made up of 15 processes, including client records and reports, a pricing structure (with reports) and security built around a bug-free set of development tools. for more information, contact peter kennedy at usko mediswitch, tel (011) 807·7714, or take a look at mediswitch's web site on http:// www.mediswitch.co.za http://www.mediswitch.co.za case report 37 sa journal of radiology • december 2006 boerhaave’s syndrome, also known as spontaneous oesophageal rupture or post-emetic oesophageal rupture (peor), is perhaps one of the more challenging clinical syndromes encountered in general surgical practice. co-morbidity, delayed diagnosis and associated delayed institution of therapy have resulted in an almost universally poor prognosis, even in specialist surgical units. surgical intervention is usually the mainstay of therapy. there have been few reported cases of successful non-operative management. here we report one such success story. case history a 57-year-old man presented with severe epigastric pain, excessive vomiting and four episodes of frank haematemesis. prior to the onset of the vomiting, he had experienced dull abdominal pain, which later localised to the left lower quadrant. of note, the patient had a background history of sigmoid diverticulosis. the chest radiograph demonstrated a pneumomediastinum and bilateral pleural effusions, larger on the left. in light of the severe haematemesis, an urgent upper endoscopy was performed. two distinct perforations were identified in the distal oesophagus, approximately 2.5 cm from the oesophago-gastric junction. gastritis was also present, and a solitary ulcer was noted on the lesser curve of the stomach. ct scan of the chest and abdomen (fig. 1) confirmed perforation of the distal oesophagus, with associated pneumomediastinum and bilateral pleural effusions. deep in the left iliac fossa, sigmoid diverticulae were demonstrated, together with a contiguous 3.5 by 4 cm abscess (fig. 2). a water-soluble contrast swallow (fig. 3) revealed oesophageal rupture with focal contrast extravasation. the diagnosis was clear. the patient had developed sigmoid diverticulitis and an associated abscess, which resulted in significant vomiting and spontaneous oesophageal rupture or boerhaave’s syndrome. after discussion with the patient and his family, a conservative approach was chosen. follow-up water-soluble contrast swallows were performed at weekly intervals. by six weeks, the patient was well with no residual leak or clinical complaints. discussion boerhaave’s syndrome, also known as post-emetic oesophageal rupture (peor), is one of the more challenging clinical syndromes encountered in general surgical practice. co-morbidity, delayed diagnosis, and associated delayed institution of therapy have resulted in an almost universally poor prognosis, even in specialist units. of all gastro-intestinal perforations, peor is the most frequently fatal.1 a keen index of clinical suspicion, appropriate immediate investigations and timeous referral to the surgical team improves outcome. untreated, peor has a nearly 100% mortality rate.2,3 post-emetic oesophageal rupture successful conservative management s k misser, mb chb, fcrad (d) j maharajh, mb chb, mmed, ffrad (d) department of radiology, nelson r mandela school of medicine, king edward viii hospital, durban h t campbell, mb chb, ffrad (d) department of radiology, r k khan hospital, durban m naidoo, mb chb, fcs (sa) a a gounden, mb chb, fcs (sa) department of surgery, r k khan hospital, durban pictorial interlude fig. 1. chest ct scan at lower thoracic level reveals bilateral pleural collections (→), pneumomediastinum (*) and peri-oesophageal swelling with air-fluid level (#). fig. 2. ct scan through pelvis demonstrates sigmoid diverticulae (→), mesocolonic stranding (#) and an interloop abscess (*). * # * # pg37-38.indd 37 12/11/06 11:03:37 am case report 38 sa journal of radiology • december 2006 radiology plays a pivotal role in the diagnosis of peor. the chest radiograph may demonstrate a pneumomediastinum, pleural effusions (especially left-sided) or hydropneumothorax in peor. mediastinal widening, air-fluid levels in the mediastinum and subcutaneous emphysema are important ancillary findings. the v-sign of naclerio is occasionally identified as a v-shaped lucency projected through the cardiac shadow, representing air loculated between the left hemi-diaphragm and the left inferior mediastinal border. a negative or normal chest radiograph does not exclude peor. han et al.4 documented normal chest radiography in 12% of patients with peor. water-soluble contrast oesophagography is the next investigation of choice to delineate oesophageal rupture. some authors advise using dilute barium and decubitus or shoot-through positioning if the initial study fails to reveal any perforation.5 contrast swallow studies are a useful tool for follow-up of these patients in the subsequent weeks of convalescence. ct scanning expedites the initial assessment of peor, especially in patients who are too ill to undergo endoscopy or contrast studies. ct is capable of demonstrating minor leaks into the posterior mediastinum. an added advantage ct has over endoscopy or a contrast swallow is its ability to demonstrate extra-luminal detail. generally, most patients with peor are best served by some form of surgical oesophageal repair.2 the place for oesophageal stenting in peor has not been clearly established, despite some reports of success.6,7 the conservative, non-surgical management of proven oesophageal disruption is limited to those patients with a well-contained leak, no pleural soiling and no clinically evident sepsis. these patients are usually stable and present later. very few patients with mediastinitis, pleural contamination and incipient multi-organ dysfunction survive with a non-operative management regimen. those who do (as in the index patient), are usually worth reporting. 1. singh h, warshawsky me, herman s, shanies hm. spontaneous oesophageal rupture: boerhaave’s syndrome. clinical pulmonary medicine 2003; 10: 177-182. 2. vial cm, whyte ri. boerhaave’s syndrome: diagnosis and treatment. surg clin north am 2005; 85: 515-524. 3. pate jw, walker wa, cole fh jr, owen ew, johnson wh. spontaneous rupture of the oesophagus: a 30 year experience. ann thorac surg 1989; 47: 689-692. 4. han sy, mcelvein rb, aldrete js, tishler jm. perforation of the oesophagus: correlation of site and cause with plain film findings. am j roentgenol 1985; 145: 537-540. 5. freeman a. in: grainger rg, allison dj, eds. grainger and allison’s diagnostic radiology – a textbook of medical imaging. 4th ed. london: churchill livingstone, 2001: 1033. 6. adam a, watkinson af, dussek j. boerhaave syndrome: to treat or not to treat by means of insertion of a metallic stent. j vasc interv radiol 1995; 6: 741-743; discussion 744-746. 7. neff c, lawson dw. boerhaave’s syndrome: interventional radiologic management. am j roentgenol 1985; 145: 819-820. pictorial interlude fig. 3. contrast swallow demonstrating free distal dorsal oesophageal perforation (*) along the left lateral wall. * pg37-38.indd 38 12/11/06 11:03:39 am radiology_oct04 abstract a total of 57 endovascular embolisation procedures were performed for intractable epistaxis in 51 patients over a 4-year period at the unitas interventional unit near pretoria. long-term follow-up was possible in 36 patients. three cases were due to trauma and 2 directly related to previous facial surgery, 1 patient had hereditary haemorrhagic telangiectasia (hht), and the remaining 45 cases (88.2%) were classed as idiopathic. eight patients (15.7%) had a rebleed between 1 and 33 days after the initial embolisation. four were re-embolised once, 1 was re-embolised twice (the hht patient), and 2 underwent additional ethmoid artery ligation (with no further bleeding). this gives a primary short-term success rate (in all 51 cases) of 86.3% and a secondary assisted success rate of 94.1% for embolisation alone. long-term follow-up was obtained in 36 patients, with 35 (97.2%) reporting no further bleeding after the initial procedure(s). only the patient with hht developed multiple recurrent bleeds. the mortality rate was 0%, the major morbidity rate 2% (1 stroke), and the minor morbidity rate 25% (n = 36), which included transient facial pain, headaches and femoral problems related to access. our results compare favourably with other published series. in conclusion, endovascular embolisation for intractable epistaxis is available locally as an alternative technique for the treatment of this difficult condition. introduction epistaxis is a common condition, affecting an estimated 60% of the general population of whom an estimated 6% will seek or require medical assistance.1 refractory or intractable epistaxis is defined as recurrent or persistent bleeding after appropriate conservative treatment, or multiple episodes of epistaxis over a short period of time, each requiring medical attention.2 intractable epistaxis usually arises from the posterior or superior parts of the nasal cavity, and is therefore not readily controllable by direct pressure, topical cauterisation or anterior nasal packing. arterial ligation has remained the mainstay of treatment for intractable posterior epistaxis in many centres.3-6 percutaneous embolisation of the internal maxillary artery for nasal haemorrhage was first described by sokoloff et al. in 1974.7 several other reports describing the efficacy of endovascular embolisation followed.8-11 currently, endovascular embolisation is an accepted method of treatment for haemorrhage from the nasal cavity or other craniofacial lesions .12,13 materials and methods a retrospective audit was done of 57 percutaneous endovascular embolisation procedures in 51 patients performed over the 4-year period july 1999 june 2003 at the unitas interventional unit in centurion. all patients were referred by an otorhinolaryngologist after failed conventional treatment, generally involving local cauterisation and/or nasal packing; 12 patients had also received a blood transfusion prior to embolisation. we reviewed our procedural data notes, with further clinical data obtained either from initial referral letters or follow-up notes provided by referring clinicians. long-term telephonic follow-up was obtained from 38 patients (respondents), with 13 patients being untraceable during the period of the audit. of the 38 respondents, 2 had died of unrelated causes since the embolisation, with telephonic interviews obtained with the remaining 36. the collection of data was flawed by incomplete clinical record keeping. the most complete data obtained original article 9 sa journal of radiology • october 2004 endovascular treatment of intractable epistaxis — results of a 4-year local audit i c duncan ffrad (d) p a fourie mmed rad (d) c e le grange nat dipl rad h a van der walt bsc (verpl) unitas interventional unit centurion, gauteng were for the 36 respondents, for whom much of the recorded data could be cross-checked and who could also provide missing information in addition to long-term followup. the long-term follow-up period varied from 1 to 47 months. all embolisation procedures were performed in the unitas interventional unit vascular laboratory using a phillips v5000 integris digital monoplane angiography unit (phillips medical systems, netherlands bv). of the procedures 22 (38.6%) were performed under general anaesthesia and 35 (61.4%) under local anaesthesia and sedation. a co-axial microcatheter technique was utilised in 56 procedures (98.2%), with embolisation being performed through a standard 4f diagnostic catheter in only 1 case (1.8%). the co-axial technique involved initial selective catheterisation of the external carotid artery (eca) with a 4f or 5f 0.038-inch lumen diagnostic catheter, followed by superselective catheterisation of the relevant eca branches by placement of a microcatheter through the diagnostic catheter. the type or make of diagnostic catheter and microcatheter/microguidewire system used varied according to operator preference, vascular anatomy and stock availability. both the guiding catheter and microcatheter were continuously irrigated with heparinised saline (2000 u in 1 litre) using a pressure bag system via y-connectors attached to each catheter. systemic heparin was generally not given in uncomplicated cases. initial diagnostic arteriograms of the internal carotid artery (ica) and eca were obtained on each side. the former were done in order to exclude an intracranial aneurysm, arteriovenous shunt or frontal tumour as a possible cause of the bleeding as well as to identify any arterial supply to the nasal cavity from ethmoidal branches of each ophthalmic artery (fig. 1). the ipsilateral internal maxillary artery (imax), defined as the one supplying the nasal cavity from which the bleeding was visualised or assumed to arise, was then superselectively catheterised and embolised in all cases except 1, in which the ipsilateral eca origin was occluded due to atheromatous disease and a contralateral imax embolisation was performed. other vessels superselectively catheterised and embolised included the ipsilateral facial artery (n = 29 (51%)), the contralateral imax (n = 27 (47.4%)), the contralateral facial artery (n = 8 (14%)), the ascending pharyngeal artery (n = 1 (1.7%)) and the accessory meningeal artery (n = 1 (1.7%)). the decision to embolise arteries other than the ipsilateral imax was based upon the relative contributions of each vessel to the supply of the nasal cavity as well as the potential for collateral supply to the nasal cavity (fig. 2a). during arteriography the actual site of the bleeding can usually not be identified and often no abnormal vessels are seen in the nasal cavities, although in several cases a nonspecific generalised nasal mucosal ‘blush’ due to nasal mucosal congestion or arterial tortuosity may be seen (figs 2b 2d). the embolic agents used were microparticles in 56 procedures (98.2%), with cyanoacrylate (b braun, melsungen, germany) and platinum microcoils (target therapeutics, fremont, calif., usa) used as the sole agents in 1. of the 56 procedures performed using microparticles, 47 (77.2%) were done using polyvinyl alcohol (pva) microparticles (trufill, cordis johnson and johnson, miami, fla., usa) and 9 (15.8%) using trisacryl gelatine microspheres (embospheres, guerbet, paris, france). particle sizes ranged from 150 to 700 µm in diameter and were usually between 250 and 500 µm. other adjunctive embolic materials used included cyanoacrylate (n = 5 (8.8%)), platinum microcoils (n = 4 (7%)) and shredded spongistan (cordis, johnson and johnson, miami, fla., usa) (n = 4 (7%)). in all cases where no macroscopic cause of the bleeding such as a pseudoaneurysm could be identified, and where microparticulate embolisation was performed, the desired end-point of embolisation was a significant visible reduction or cessation of flow in the target vessel(s) (fig. 3). the nasal packing was removed in theatre in 56% of cases in which this was documented and afterwards in 44% (n = 36). results the male/female ratio of our patients was 1.2: 1 (28 men and 23 women), and the mean age was 54.4 years (range 17 83 years). only 15 patients were referred from the pretoria area, 36 being transferred from other centres. thirty two (63%) were referred between the months of may and september. the causes of epistaxis in our cases are summarised in table i. of the trauma-related cases 1 occurred shortly after a direct blow to the nose and 1 following a le fort fracture, whereas the 3rd patient (who suffered the intraprocedural stroke) had been severely assaulted 3 weeks before presentation. of the 2 patients whose epistaxis was related to prior surgery, 1 had recently undergone original article 10 sa journal of radiology • october 2004 removal of an osteoma from the sphenoid sinus (with ipsilateral imax occlusion seen at angiography) and the other presented with severe bleeding from a large pseudo-aneurysm of the distal imax following a recent maxillary osteotomy. identifiable risk factors in the respondent group (n = 36) are listed in table ii. none of the respondents volunteered any history of alcohol or illicit drug abuse. one patient had previously undergone radiation therapy for a maxillary tumour considered inactive at the time of the embolisation. one of the non-respondents developed severe epistaxis during the 25th week of pregnancy. no underlying cause for this was found. a 17-year-old girl with sideroblastic anaemia for which she had received multiple blood transfusions over a period of several years was referred for a semi-elective procedure, the only patient in our series not treated on an emergency basis. eight patients (15.7%) developed a rebleed between 1 and 33 days after the initial embolisation (table iii). of these, 4 patients (7.8%) underwent a second embolisation procedure and 1 12 sa journal of radiology • october 2004 original article fig 1. selective internal carotid digital subtraction arteriogram showing supply to the superior nasal cavity via the ethmoidal branches (black arrows) of the ophthalmic artery (white arrow). fig 2a. selective external carotid digital subtraction arteriogram showing the arterial supply to the nasal cavity via terminal branches of the internal maxillary artery (black arrow) and facial artery (white arrow). fig 2b. selective internal maxillary arteriogram (same case as fig. 2a) showing the typical appearance of the nasal arteries prior to embolisation. no bleeding site is identifiable and the arteries have a normal appearance. fig 2c. in some cases a prominent nasal capillary blush may be seen in keeping with mucosal congestion. fig 2d. in others tortuosity of the intranasal arteries may be seen. fig 3. in the same case as shown in figs 2a and 2b, a selective internal maxillary arteriogram following microparticulate embolisation shows very little contrast opacification of the nasal branches, indicating a satisfactory angiographic end-point for embolisation. table i. causes of epistaxis idiopathic 45 88.2% trauma 3 5.9% post surgery 2 3.9% hht 1 2% table ii. risk factors for epistaxis (36 respondents) hypertension 19 52.8% smoking 9 25% anticoagulation/asa 5 13.9% radiation therapy 1 2.8% one patient had also received multiple blood transfusions for chronic sideroblastic anaemia. patient with hereditary haemorrhagic telangiectasia (hht) underwent two further embolisation procedures in our unit and one at another centre. two patients (3.9%) underwent additional surgical ligation of the ethmoid arteries, after which no further bleeding was encountered. one of these was the patient with the le fort ii fracture and the other had an idiopathic-type bleed. one patient had a single post-procedural rebleed for which angiography was repeated but no further embolization performed. forty-four patients (86.3%) therefore responded well to a single embolisation procedure. no further rebleeds were noted in the 4 patients who underwent a second embolisation procedure, giving a cumulative success rate for embolisation alone of 94.1%. with the exception of the patient with hht, none of the 36 living respondents reported a late rebleed after primary or secondary intervention. the mortality rate in our series was 0%, and we encountered only one major complication (2%), being the development of a right-sided cerebral infarction during attempted guiding catheter replacement in a tortuous carotid artery. minor complications are listed in table iv. those related to the femoral access included transient tenderness in 2 cases, a tender lump (nonaneurysmal) in 1 and prolonged numbness around the puncture site in 1. the total minor complication rate for the respondent group is therefore 25%. discussion most cases of epistaxis occur in the anterior nasal cavity in the region of 13 sa journal of radiology • october 2004 original article table iii. rebleeding after initial embolisation patient age (yrs) risk factors time of rebleed cause of rebleed further treatment outcome 1 34 smoker 2 days unknown repeat angiogram only no rebleed 2 58 smoker, multiple rebleeds hht total of 3 eventually well hht over many years embolisations performed palliated for (+ 1 at another centre) > 1 yr with in 2 years intralesional bleomycin 3 50 warfarin and 1/2 day unknown. repeat embolisation no rebleed disprin (cardiac the pi at time of of ipsilateral imax valve the rebleed was only with replacement) 75% microparticles 4 25 pregnant 33 days unknown repeat embolisation no rebleed (25 weeks) of ipsilateral imax only with microparticles 5 83 warfarin 1 day significant repeat embolisation no rebleed (pulmonary collateral supply of ipsilateral imax embolism), pi via accessory and accessory on admission meningeal artery meningeal artery of 34% 6 36 le fort ii 2 days significant surgical ligation of no rebleed fracture collateral supply ethmoid arteries via ethmoid arteries 7 55 hypertension 1/2 day significant collateral surgical ligation of no rebleed supply via ethmoid ethmoid arteries arteries 8 18 maxillary 10 days coil migration and repeat embolisation no rebleed osteotomy with recannalisation using particles, coils imax through coils and cyanoacrylate pseudo-aneurysm inserted previously in the imax pi = prothrombin index. the antero-inferior septum known as little’s area. underlying this is a confluence of arterial territories comprising those of the sphenopalatine artery, the greater palatine artery, the facial artery and the anterior and posterior ethmoidal arteries. this arterial confluence is known as kisselbach’s plexus.14 anterior epistaxis is usually easily controlled by conservative measures including localised pressure, topical cauterisation and vasocontriction, local infiltration with antifibrinolytic agents and anterior nasal packing.15 posterior (and to a lesser degree superior) epistaxis accounts for about 5% of all cases and can be extremely difficult to manage. posterior nasal packing can be done with gauze or balloon catheters. nasal packing has a reported failure rate of 26 52% and a complication rate of 69%.14,16 complications related to packing include nasal trauma, vasovagal response, aspiration, displacement of the packing, persistent bleeding, infection, toxic shock syndrome and hypoxia.15,17 surgical approaches include transantral ligation of the distal imax and ligation of the ethmoid arteries for superior epistaxis.3 more recently endoscopic cauterisation and arterial ligation techniques have been described, although these are technically more demanding.18-20 since the advent of nasal embolisation in 1974,7 the endovascular management of epistaxis has become an established alternative to surgical ligation. in a comparison of efficacy between transantral ligation and embolisation in intractable epistaxis, strong et al.21 reported success rates from the literature of 85% and 90% and average complication rates of 28% and 27% respectively for ligation and embolisation, with success rates of 89% and 94% respectively from their own series. cullen and tami22 showed a failure rate of 21% for embolisation versus 27% for ligation (with or without ethmoid ligation) and an overall complication rate of 16% for embolisation and 18% for imax ligation.22 in their review of the literature, which expanded on that by strong et al., they reported a slightly higher failure rate for embolisation (20%) than for imax ligation (18%) but a significantly higher complication rate for imax ligation (26%) than for embolisation (14%). no difference in major complications rates (5% v. 4%) was noted between the two methods. the goal of embolisation is simply to reduce the arterial pressure head to the affected region without causing any ischaemic damage to the nasal soft tissues,13 so allowing the body to heal itself. the posterior nasal cavity is supplied mainly via the sphenopalatine artery and greater palatine artery, both of which are terminal branches of the imax. this means that the management of posterior epistaxis largely hinges on control of the sphenopalatine artery,23 and explains the equally high rate of success of ipsilateral imax embolisation alone. however, there is still a failure rate of 10 15% for both embolisation and imax/sphenopalatine ligation. in some cases embolisation may succeed where imax ligation fails.24 furthermore, as shown by vitek11 the technical success rate of embolisation increases significantly when additional embolisation of the ipsilateral facial and contralateral imax arteries is performed as well. this attests to the importance of collateral vessels in the facial region with collateral blood supply to the posterior nasal cavity, which probably accounts for a significant percentage of failed imax ligation or embolisation procedures.25-27 the advantage of arteriography is that it can often identify these collateral sources, allowing them to be treated simultaneously. collateral supply to the nasal cavity was important in 4 of our cases, leading to recurrent haemorrhage. in 1 case this involved a collateral pathway via the accessory meningeal artery, a hitherto undescribed variant of importance in the treatment of epistaxis.28 collateral supply via the ethmoid arteries led to secondary surgical intervention in 2 cases. another potential complication related to collateral circulation is the presence of intracranial-extracranial arterial anastomoses, as inadvertent embolisation through these pathways can lead to ophthalmological or neurological complications.12 it is therefore vital to identify these communications during the initial angiographic investigation. although we routinely check both internal and external carotid arteries during each proce14 sa journal of radiology • october 2004 original article table iv. complications of embolisation major (n = 51) cva 1 2% minor (n = 36) headache 3 8.3% transient facial pain/ paresthesia 2 5.5% local groin complications 4 11% dure, we do not follow a rigid treatment protocol with regard to the number of vessels embolised but rather tailor the approach in each patient on the basis of the vascular anatomy, ease or difficulty of selective and superselective catheterisation, and the presence or absence of other associated extracranial vascular disease. nearly 50% of our cases involved single-vessel (ipsilateral imax) embolisation only. two of our cases with a rebleed following initial embolisation of the ipsilateral imax underwent a second procedure involving a repeat microparticulate embolisation of the same vessel, with good outcome. inadequate embolisation, like incomplete imax ligation, can therefore lead to recurrent bleeding. one patient who had a rebleed 2 days after embolisation underwent a repeat arteriogram that showed adequate occlusion of the ipsilateral distal imax branches. no significant collateral vessels were identified, so no further embolisation was performed. no further bleeding was experienced thereafter. false rebleeds following embolisation may occasionally be encountered and may be due to retained blood in and around the nasal packing or blood draining from the paranasal sinuses. we used microcatheter techniques in all cases but 1. although leading to increased expense, procedural duration and complexity, the use of microcatheters has been reported to reduce the number of local cranial complications although to date this has not been proven in any randomised study.29,30 in table v we review four studies conducted during or after 1995 and reporting the routine use of microcatheter techniques and calculate a cumulative success rate of 90.2% and overall complication rate of 13.4% (11.4% minor and 2% major) with microcatheter use. although the use of microcatheter techniques does not improve the overall success rate, there is a tendency towards a lower complication rate. this factor should be weighed up against the additional procedural costs involved. we have also noted that when microcatheters are used, arterial vasospasm, which can prolong and complicate a procedure, is less frequent. one problem apparent in all of the embolisations reported to date is inconsistency in the reporting of minor and major complications and hence variation in the reported figures. other factors such as improvements in catheter and guidewire design and increased operator experience have also probably contributed to the reduction in complication rates in more recent times. other complications related to embolisation for epistaxis reported in other local institutions include ischaemic necrosis of the upper lip (facial arterial embolisation), unilateral trismus (related to deep temporal arterial occlusion) and ischaemic sialadenitis (facial artery embolisation).31 further complications described in the literature include facial nerve paralysis, tongue necrosis, tonsillar ulceration, facial atrophy and transient submandibular gland swelling.32 other potential complications can be related to the femoral access (pain, bruising, pseudoaneurysm or arteriovenous fistula) or to the use of contrast media (allergic reaction, renal failure).33 our single major complication was a stroke related to attempted replacement of a guiding catheter in a very tortuous carotid artery. despite our recent success in treating hyperacute iatrogenic strokes during neuro-interventional procedures with intra-arterial abciximab, we were unable to prevent major cerebral infarction in this case.34 16 sa journal of radiology • october 2004 original article table v. reported success and complication rates since 1995 study no. of patients success rate minor complications major complications overall complication elahi et al., 57 52 (96%) none reported 3 (6%) 3 (6%) 199532 tseng et al., 114 101 (88%) 17 (15%) 2 (1.8%) 19 (16.8%) 19982 leppanen et al., 37 33 (89%) 4 (8%) 0 (0%) 4 (8%) 199929 oguni et al., 37 35 (94.6%) 7 (45%) 0 (0%) 7 (45%) 200033 total 245 221 (90.2%) 28 (11.4%) 5 (2%) 33 (13.4%) all head and neck embolisation procedures should therefore ideally be performed by a team capable of managing serious cerebrovascular complications. one advantage of endovascular treatment is that it can be performed under local anaesthesia with sedation if required. although only 38.6% of our cases were performed under general anaesthesia, we now routinely utilise general anaesthesia for two reasons arising from our accumulated experience. firstly, patients are generally uncomfortable, with nasal packing in situ and occasionally also active bleeding during the procedure. prolonged immobilisation on the angiography table may be required during difficult cases. this results in further patient discomfort and reduced co-operation with movement (voluntary and involuntary), rendering the use of electronic vascular roadmapping useless, further prolonging the procedure and adding to the risk of complications or an incomplete or inadequate procedure. secondly, we now insist on full airway protection by means of a cuffed endotracheal tube before commencing any embolisation procedure in the head and neck region where active bleeding is an issue.28 regardless of whether or not a general anaesthetic is administered, an anaesthetist is always present for patient monitoring and administration of analgesic or sedative drugs as required. one subgroup of patients who develop recurrent epistaxis are those with hht (osler-weber-rendu disease). hht is a genetic multisystemic angiodysplasia. these patients develop fragile nasal mucosal telangiectasias and more than 90% are are prone to repeated and intractable epistaxis18 (figs 4a and 4b). the ent surgeon can miss the diagnosis of hht during the acute presentation.35 embolisation is not a definitive treatment for epistaxis in these patients, but can control an acute bleeding episode. because of the known propensity for epistaxis to recur in these patients, elden et al.30 found that their long-term success rate for embolisation increased from 82% to 90% once the hht patients in their series were excluded. there is still no definitive treatment available for the nasal manifestations of hht. palliative treatment with intramucosal injections of bleomycin (blenoxane, bristol-myers squibb) has been successful in our patient for more than 18 months.36 although embolisation is a good alternative to surgical imax ligation (or related procedures), interventional expertise is only available in the major centres in south africa. of our patients 70% were referred from outside of the pretoria area, although most were from within a 150 km radius of the unitas interventional unit. in their 1998 study of the attitudes of practising otorhinolaryngologists in ohio, cullen and tami22 found that only 16% had referred patients for embolisation; of these 75% had urban practices and the rest were from rural areas. they also found that more hospitals in urban areas than rural ones had embolisation facilities. this situation is mirrored and undoubtedly amplified in south africa. in their comparison of the respective costs of imax ligation and embolisation, strong et al.21 found the average cost per case in 1994 for antral ligation to be us$5 941 versus us$6 783 for embolisation.21 cullen and tami22 calculated the average costs in their institution in 1998 to be us$ 6 184.55 for imax ligation and us$ 4 544.85 for embolisation. these figures include the combined costs of hospitalisation, treatment and consumable items. we were only able to calculate the radiological costs per case, which included the embolisation procedure and interventional theatre costs, as shown in table vi. not included in these figures are the costs of hospitalisation and private anaesthetist and ent specialist fees. the overall cost of hospitalisation would be extremely difficult to calculate, as many patients had already been treated or hospitalised at other institutions before transfer to our own. in general, 17 sa journal of radiology • october 2004 original article fig 4a. selective left facial arteriogram in our hht patient showing multiple enhancing lesions representing small nasal mucosal telangiectasias. fig 4b. endoscopic nasal view showing multiple small red telangiectasias seen through a perforation of the nasal septum, a complication of repeated surgical attempts at managing the recurrent epistaxis in this patient. uncomplicated cases would be admitted overnight for observation either in a high-care facility or more usually a general ward, with discharge or transfer back to the referring institution during the following day. conclusion intractable epistaxis is a debilitating condition, the treatment of which can be extremely difficult. percutaneous transcatheter embolisation of the nasal arteries is an accepted alternative to surgical intervention, with comparable major and minor complication rates, success rates and overall costs. most cases will respond well to a single embolisation procedure, with approximately 10% failing to respond due to factors such as collateral arterial supply and hht. success and complication rates for procedures performed at the unitas interventional unit compare favourably with those reported in the literature to date. these procedures should be performed by suitably experienced interventional radiologists, either under general anaesthesia or local anaesthesia with sedation, with full monitoring and anaesthetic backing. references 1. small m, murray j, maran ag. a study of patients with epistaxis requiring admission to hospital. health bull (edinb) 1982; 40: 20-29. 2. tseng ey, narducci ca, willing sj, silliers mj. angiographic embolization for epistaxis. laryngoscope 1998; 108: 615-619. 3. chandler jr, serrins aj. transantral ligation of the internal maxillary artery for epistaxis. laryngoscope 1965; 75: 1151-1160. 4. wang l, vogel dh. posterior epistaxis: comparison of treatment. otolaryngol head neck surg 1981; 89: 1001-1006. 5. small m, maran agd. epistaxis and arterial ligations. j laryngol otol 1984; 98: 281-284. 6. hunter k, gibson r. arterial ligation for severe epistaxis. j laryngol otol 1989; 83: 1099-1103. 7. sokoloff j, wickbom i, mcdonald d, brahme f, goergen tg, goldberger le. therapeutic percutaneous embolization in intractable epistaxis. radiology 1974; 111: 285-287. 8. van wyck lg, vinuela f, hoeneman h. therapeutic embolization for severe epistaxis j otolaryngol 1982; 11: 271-274. 9. parnes ls, hoeneman h, vinuela f. percutaneous embolization for control of nasal blood circulation. laryngoscope 1987; 97: 13121315. 10. hicks jn, vitek jj. transarterial embolization to control posterior epistaxis. laryngoscope 1989; 99: 1027-1029. 11. vitek jj. idiopathic intractable epistaxis: endovascular therapy. radiology 1991; 181: 113116. 12. kagetsu nj, berenstein a, choi is. interventional radiology of the extracranial head and neck. cardiovasc intervent radiol 1991; 14: 325-333. 13. connors jj iii, wojak jc. epistaxis. in: connors jj iii, wojak jc, eds. interventional neuroradiology: strategies and practical techniques. philadelphia: wb saunders, 1999: 147-156. 14. koh e, frazzini vi, kagetsu nj. epistaxis: vascular anatomy, origins and endovascular treatment. am j roentgenol 2000; 174: 845-851. 15. tan lks, calhoun kh. epistaxis. med clin north am 1989; 83: 43-56. 16. schaitken b, strauss m, houck jr. epistaxis: medical versus surgical therapya comparison of efficacy, complications and economic considerations. laryngoscope 1987; 97: 1392-1396. 17. fairbanks dnf. complications of nasal packing otolaryngol head neck surg 1986; 94: 412-415. 18. elwany s, abdel-fatah h. endoscopic control of posterior epistaxis. j laryngol otol 1996; 110: 432-434. 19. winstead w. sphenopalatine artery ligation: an alternative to internal maxillary ligation for intractable posterior epistaxis. j laryngol 1996; 106: 667-669. 20. pritikin jb, caldarelli dd, panje wr. endoscopic ligation of the internal maxillary artery for treatment of intractable posterior epistaxis. ann otol rhinol laryngol 1998; 107: 85-91. 21. strong eb, bell da, johnson lp, jacobs jm. intractable epistaxis: transantral ligation versus embolization: efficacy review and cost analysis. otolaryngol head neck surg 1995; 113: 674-678. 22. cullen mm, tami ta. comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. otolaryngol head neck surg 1998; 118: 636-642. 23. simpson gt, janfaza p, becker gd. transantral sphenopalatine artery ligation. lar y ngos cope 1982; 92: 1001-1005. 24. breda sd, choi is, persky ms, weiss m. embolization in the treatment of epistaxis after failure of internal maxillary artery ligation. laryngoscope 1989; 99: 809-813. 25. hacien-bay l, rosenbloom js, pile-spellman j, et al. anastomoses in recurrent epistaxis. j vasc intervent radiol 1997; 8: 535-538. 26. lasjaunias p, marsot-dupuch k, doyon d. the radio-anatomical basis of arterial embolization for epistaxis. j neuroradiol 1979; 6: 45-53. 27. lasjaunias p, berenstein a. surgical neuroangiography: functional anatomy of craniofacial arteries. vol 1. berlin: springer-verlag, 1987. 28. duncan ic, dos santos c. accessory meningeal arterial supply to the posterior nasal cavity: another reason for failed endovascular treatment of epistaxis. cardiovasc intervent radiol 2003; 26: 488-491. 29. leppanen m, seppanen s, loranne j, kuoppala k. microcather embolization of intractable idiopathic epistaxis. cardiovasc intervent radiol 1999; 22: 499-503. 30. elden l, montanera w, terbrugge k, willinsky r, lasjaunias p, charles d. angiographic embolization for the treatment of epistaxis: a review of 108 cases. otolaryngol head neck surg 1994; 111: 44-50. 31. duncan ic, spiro fi, van staden d. acute ischaemic sialadenitis following facial artery embolization. cardiovasc intervent radiol 2004; 27: 300-302. 32. elahi mm, panes ls, fox aj, pelz dm, lee dm. therapeutic embolization in the treatment of epistaxis. arch otolaryngol head neck surg 1995; 121: 65-69. 33. oguni t, korogi y, yasunaga t, et al. superselective embolization for intractable idiopathic epistaxis. br j radiol 2000; 73: 1148-1153. 34. duncan ic, fourie pa. catheter-directed intraarterial abciximab administration for acute thrombotic occlusions during neurointerventional procedures. interventional neuroradiology 2002; 8: 159-168. 35. haitjema t, balder w, disch fj, westermann cj. epistaxis in hereditary haemorrhagic telangiectasia. rhinology 1996; 34: 176-178. 36. duncan ic, van der nest l. intralesional bleomycin injections (ibi) for the palliation of epistaxis in hereditary haemorrhagic telangiectasia. am j neuroradiol 2004; 25: 1144-1146. original article 18 sa journal of radiology • october 2004 table vi. average costs per embolisation procedure year rands us dollars ($1 = r8) 1999 r 16 628 us$2 078 2000 r 15 993 us$1 999 2001 r 18 551 us$2 319 2002 r 22 761 us$2 845 2003 r 22 136 us$2 767 the above excludes all hospitalisation costs and professional private fees for the referring ent specialist and anaesthetist. a shortened version of this article was published in the south african medical journal 2004; 94: 373-378. abstract introduction imaging aortic dissection intramural haematoma penetrating atherosclerotic ulcer conclusion acknowledgements references about the author(s) navdeep singh department of radiology, ivy hospital, amritsar, india pankaj goel department of cardiovascular surgery, ivy hospital, amritsar, india yadwinder singh department of cardiology, ivy hospital, amritsar, india citation singh n, goel p, singh y. pictorial essay: computed tomography findings in acute aortic syndromes. s afr j rad. 2018;22(1), a1309. https://doi.org/10.4102/sajr.v22i1.1309 pictorial essay pictorial essay: computed tomography findings in acute aortic syndromes navdeep singh, pankaj goel, yadwinder singh received: 10 jan. 2018; accepted: 12 mar. 2018; published: 23 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract acute aortic emergencies are life-threatening conditions that may require urgent surgical or interventional management. imaging plays an important role in the diagnosis and planning of the management, and timely intervention helps in reducing mortality and morbidity. introduction acute aortic syndrome (aas) is a spectrum of life-threatening aortic diseases consisting of aortic dissection (ad), intramural haematoma (imh) and penetrating atherosclerotic ulcer (pau).1 acute aortic syndrome is often part of a large clinical group of patients presenting with acute chest pain to the emergency room and often difficult to distinguish initially from other causes such as myocardial infarction, pulmonary embolism, and so on. clinical presentation and histological findings of the three entities are similar, typically presenting with acute onset of chest pain and histologically characterised by disruption of the aortic media.2 diagnosis based upon clinical symptoms and physical examination alone is not possible. a multidisciplinary approach is required to reach an accurate diagnosis and for timely intervention. multidetector computed tomography (mdct), transoesophageal echocardiography and magnetic resonance imaging are the imaging modalities which could diagnose aass. however, computed tomography (ct) is the most important investigation performed in acute emergency situations, owing to its accessibility, rapid acquisition and high sensitivity and specificity. apart from diagnosing, the purpose of imaging is to locate the exact site, extension of disease, complications and associated findings which may affect the therapeutic management. imaging triple-rule-out (tro) ct angiography may be employed for evaluation of acute chest pain, as it examines the thoracic aorta, and pulmonary and coronary arteries in a single study. it is a useful investigation in low and moderate risk acute coronary syndrome patients; however, performing tro is technically challenging. the protocol needs to be customised according to the patient profile to achieve the best results. there are studies which did not show any improved clinical outcome of tro, as compared with dedicated pulmonary and coronary angiographies. also, a higher radiation exposure and large contrast medium doses are two major disadvantages of tro.3 as the risk and clinical profile of patients with ad and imh are similar, unenhanced ct is recommended, prior to a contrast study, in patients suspected with aas and blunt chest trauma. unenhanced ct acquisition plays a pivotal role in the diagnosis of imh, as a contrast study alone is not sufficient to make a confident diagnosis. high attenuation contrast decreases the conspicuity to visualise hyperdense imh. intimal calcifications and acute haemorrhages, such as haemothorax and mediastinal haematomas are also easily interpreted on unenhanced ct scans. the recommended scan protocol includes an unenhanced ct scan, followed by a dual phase contrast study, covering the lung apices to the inguinal regions. a total of 100 ml of non-ionic contrast medium containing a high iodine concentration (350 mg/dl) is injected at a flow rate of 4.5 ml/s using an 18-gauge catheter in the right antecubital vein, to reduce artefact from the left brachiocephalic vein. image acquisition is started using the bolus track technique after placing the region of interest (roi) on the ascending aorta with the trigger at 200 hu. automatic acquisition may fail if the roi is placed over a thrombosed vessel; hence, the technician should be prepared to manually start the study. electrocardiogram(ecg-) gated ct is advised when scanning the ascending aorta and arch to reduce motion-related artefacts to produce superior diagnostic-quality images. ecg-based tube current modulation and adjusting the peak voltage according to the patient’s morphology are two of the most effective methods to reduce radiation exposure. in addition, a slow regular heart rate and prospective ecg-gated acquisition could further bring down the dose. aortic dissection aortic dissection is the longitudinal splitting of the aortic media when circulating blood enters through a tear in the intima under haemodynamic force, resulting in the formation of true and false lumens. the incidence ranges from 2.6 to 3.5 cases per 100,000 persons per year with a male predominance.4 hypertension is the most common trigger. marfan syndrome, ehlers–danlos syndrome, bicuspid aortic valve, aortic coarctation, turner syndrome, and cocaine use are considered as some predisposing factors. the ascending aorta near the aortic root is the most common site for dissection initiation and the flap extends along the right anterolateral aspect.5 clinically, ad is characterised by excruciating chest pain radiating to the back. clinical symptoms also depend upon the extent of the dissection and complications such as ischemia and malperfusion. the debakey and stanford systems used for classification of ad are based on disease location, extension and treatment modalities. dissection involving the ascending aorta or aortic arch is classified as stanford type a (debakey type i and ii) and involvement of the aorta distal to the origin of left subclavian artery is classified as stanford type b (debakey type iii). urgent repair is recommended in type a dissections to avoid lethal complications, whereas type b dissections may be managed conservatively in an uncomplicated patient.6 imaging findings on unenhanced ct, intraluminal displacement of intimal calcifications can occasionally be seen, suggesting ad (figure 1). a linear hypodense internally displaced structure representing the intimo-medial flap, separating the true and false lumens, is the most important ct finding seen in approximately 70% of cases (figures 2, 5 and 8c).7 in the present era of endovascular management, differentiation of the true and false lumen is important in planning the management. the true lumen directly communicates with the aorta, and intimal calcifications, if present, surround it (figure 3a). the calibre of the true lumen is smaller as compared to false lumen, which wedges around it owing to permanent systolic pressure. fine linear scattered hypodense areas within the false lumen are termed the cobweb sign (figure 3a). it is specific for the false lumen and represents collagenous residual media fibres.8 the beak sign is another useful sign for the false lumen which represents a wedge of haematoma at the distal end of the false lumen on cross-sectional imaging (figure 3b). it forms an acute angle between the dissection flap and vessel wall and represents the site of propagation.9 the false lumen shows less contrast enhancement compared to the true lumen in the early arterial phase and may appear hyperdense to the true lumen in the venous phase owing to contrast pooling (figure 4). figure 1: axial unenhanced computed tomography scan of thorax demonstrating displaced intimal calcification (arrow), suggesting aortic dissection. figure 2: contrast-enhanced axial computed tomography scan demonstrating a displaced intimal flap (arrow), separating the true and false lumens in a patient with a stanford type a aortic dissection. figure 3: (a) contrast-enhanced axial computed tomography (ct) scan showing intimal calcifications around the true lumen (thick arrow) and linear scattered hypodense areas within the false lumen termed the cobweb sign (thin arrow), representing the remnants of media. the calibre of the true lumen (t) appears smaller than the false (f). (b) axial contrast-enhanced ct scan showing a beak sign (arrow) which is a wedge of haematoma at the distal end of false lumen forming an acute angle with the vessel wall. figure 4: stanford type b dissection with extension into the superior mesenteric artery. contrast-enhanced computed tomography showing lesser enhancement in the false lumen (*) as compared to true lumen. figure 5: type a chronic dissection. contrast-enhanced axial (a) and coronal (b) computed tomography scan showing an ascending aortic aneurysm with chronic dissection. a thin linear low attenuation discontinuous dissection flap (arrow) is seen within the aneurysm. aortic dissection with a thrombosed false lumen could mimic an aortic aneurysm with intraluminal thrombus. intimal calcifications are useful in differentiating between them, as they are located in the centre in ad and at periphery in aortic aneurysm with thrombus. the dissection flap in ad has a smooth contour, whereas mural thrombus usually has an irregular internal surface. intramural haematoma intramural haematoma is the aortic wall thickening, caused by acute haemorrhage contained within the media. it was widely believed that it occurs owing to spontaneous rupture of the vasa vasorum with an intact intima. however, with recent advances in imaging, intimo-medial tears have been detected, suggesting that imh has one entry tear with no exit, whereas ad has entry and exit intimo-medial tears into the aortic lumen. intramural haematoma constitutes 5% – 15% of all cases of aas.10 acute chest pain is the most common presenting symptom. non-enhanced ct is very important in diagnosing imh. imaging findings crescentic aortic wall thickening of increased attenuation is the most vital finding on unenhanced ct scan images (figures 6 and 8a). the lesion will displace intimal calcifications internally, if present. on contrast-enhanced images, the aortic lumen appears narrow without enhancement of the lesion (figures 7 and 8b). on contrast-enhanced ct, it is difficult to distinguish between a thrombosed false lumen of ad and imh. aortic dissection follows a spiral longitudinal course, whereas imh has a constant circumferential relation to the aortic wall which may aid in differentiation.11 figure 6: stanford type a intramural haematoma (imh): (a) unenhanced axial computed tomography (ct) scan showing hyperdense crescentic aortic wall thickening involving the ascending aorta (arrow); (b) stanford type a imh. unenhanced coronal ct scan showing crescentic hyperdense aortic wall thickening (*) compressing the lumen. figure 7: type a intramural haematoma. contrast-enhanced axial (a) and coronal (b) computed tomography scan showing a non-enhancing hypodense crescent-shaped area (arrow) compressing the normal contrast-enhanced aortic lumen. figure 8: coarctation of the aorta with a type a intramural haematoma (imh) and aortic dissection. (a) unenhanced axial computed tomography (ct) scan showing circumferential hyperdense thickening of the ascending aorta (arrow); (b) contrast-enhanced axial ct showing crescentic non-enhancing hypodense area (thin arrow) representing imh with haemopericardium (*) and concentric left ventricular hypertrophy (thick arrow); (c) contrast-enhanced ct scan showing the displaced intimal flap (arrow) and haemopericardium (*). (d) sudden narrowing of the aorta (arrow) distal to origin of the left subclavian artery on sagittal contrast-enhanced images. multiple collaterals (thick arrow) along the anterior chest wall. management of imh is similar to ad, where surgery is advised for type a lesions and type b imhs are managed conservatively.12 penetrating atherosclerotic ulcer penetrating atherosclerotic ulcer is the ulceration of atheromatous plaque, resulting in disruption of the internal elastic lamina and aortic media with haematoma formation. penetrating atherosclerotic ulcer typically occurs in the elderly with a background of advanced atherosclerosis, in contrast to ad which is seen in younger patients. the incidence of pau in aas ranges between 2.3% and 7.6%.13 the aortic arch and descending aorta are the most common sites. clinically, the symptoms of pau are similar to those seen in aas. imaging findings extensive intimal calcifications are the frequent finding on unenhanced ct. a contrast-filled outpouching extending beyond the aortic wall is diagnostic of pau (figure 9). hyperdense haematoma adjacent to the ulceration may be seen on unenhanced ct.14 the lesions can be single or multiple. adjacent aortic wall thickening with atheromatous plaques are often seen. penetrating atherosclerotic ulcer can progress to form a saccular aneurysm or even rarely, rupture. additional imaging findings like haemothorax, haemopericardium, mediastinal haematoma, ad and ischemic findings owing to vascular obstructions can be seen as complications of pau (figure 10). figure 9: penetrating atherosclerotic ulcer. contrast-filled outpouching seen beyond the aortic wall involving the arch of the aorta (arrow). figure 10: ruptured penetrating atherosclerotic ulcer (pau) with contained haematoma. contrast-enhanced computed tomography scan of thorax showing a ruptured pau along the posterior aortic wall (white arrow) with adjacent intramural haematoma (black arrow) appearing as hyperdense aortic wall thickening and a contained haematoma in left pleural space (*). findings were confirmed at surgery. medical management is the preferred treatment option for type b lesions, as in ad, with follow-up imaging to observe progression. surgery is the treatment of choice for patients with aortic rupture, persistent pain, haemodynamic instability and risk of embolisation. the disease prognosis remains poor as surgical intervention is difficult owing to extensive atherosclerotic changes in the remaining aorta. conclusion a dedicated ct protocol comprising an initial unenhanced study followed by post-contrast imaging should be immediately performed in patients suspected with aas. knowledge about the imaging findings of these interrelated conditions can facilitate prompt diagnosis. acknowledgements dr hasta kushte for her help in preparation of manuscript. competing interests the author declares that he has no financial or personal relationship(s) which may have inappropriately influenced him in 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estimated 5.2 million cancer-related deaths worldwide.' south africa is the only developing country with a cancer death rate approximately the same as that of the developed world." approximately 80% of lung cancers are categorised as non-small cell tumours (nsclca) and the rest (20%) are small cell tumours. nsclca can be cytologically subdivided, with adenocarcinoma being the commonest (40%) followed by squamous cell carcinoma (30%) and large cell undifferentiated carcinomas (10%). there are also tumours with mixed cell types where two different tumour cell types are identified in a single tumour (e.g. adenosquamous carcinoma). primary surgery is universally accepted as the treatment of choice in early stage (cstage i and cstage ii) nsclca in selected patients with the physiological reserves to undergo the operation and maintain a reasonable quality of life thereafter. the purpose of surgery is curative, and this requires careful patient selection if fruitless interventions are to be avoided. the overall cure rate after complete resection is 13%.3 staging staging the tumour is crucial to planning of treatment, prognostication, and the final interpretation of the results of therapy. non-invasive imaging techniques (i.e. spiral ct scanning with contrast enhancement) are used to determine the anatomical extent of the disease and thereby to enable clinical staging according to the tumour node metastasis (tnm) staging system.' clinical staging refers to staging prior to surgery and is prefixed by the letter 'c' (ctnm) whilst pathological staging (ptnm) refers to the pathological staging achieved by systematic surgical exploration. international staging system the tnm system (table i) provides a reproducible description of the anatomical extent of the disease and was most recently updated in 1997.4 the t descriptor refers to tumour size, anatomical extent and relationship to adjacent structures. the n descriptor refers to extent of nodal 30 sa journal of radiology • february 2003 disease. the m descriptor refers to presence or absence of metastases. imaging assessment of stage the chest radiograph (high kvp 120 130, pa and lateral) is the way in which most lung cancers are detected and is useful in preliminary clinical staging. t criteria such as size and location of the tumour, atelectasis, pleural effusion and chest wall invasion with rib destruction can be assessed. however, it is insensitive to small nodules and to small to moderate sized lymph node involvement, and is unreliable in ascertaining extent of mediastinal invasion (fig. i). it is therefore insufficient in determining resectability extent in cases of clearly advanced disease. fig. 1. cxr showing lul mass adjacent to the mediastinum. invasion cannot be assessed. surgically proven resectable adenocarcinoma. ct scanning is the dominant imaging modality and should be routinely performed.' the examination must extend inferiorly to include the adrenal glands and liver, which are common sites of distant metastases. it should be performed with intrareview article table i. tnm staging system thmour status (t descriptor) tx primary tumour cannot be assessed, or tumour proven by malignant cells in sputum but not seen on imaging or bronchoscopy to no evidence of primary tumour tis carinoma in situ tl tumour 3 em or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopie evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus)" t2 tumour with any of the following features of size or extent: more than 3 em in greatest dimension involves the main bronchus, 2 em or more distal to the carina invades the visceral pleura associated with atelectasis or obstructive pneumonitis that extends to the hilar region and does not involve the entire lung t3 tumour of any size that directly invades any of the following: chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, parietal pericardium or tumour in the main bronchus < 2 em distal to the carina, but without involvement of the carina or atelectasis or obstructive pneumonitis of the entire lung tumour of any size that invades any of the following: mediastinum, heart, great vessels, trachea, carina, oesophagus, vertebral body or tumour with a malignant pleural or perieardial effusion' or with satellite nodule(s) within the primary tumour lobe of the lung t4 regional lymph nodes (n descriptor) nodes cannot be assessed no lymph node metastases metastases to ipsilateral peribronchial and or ipsilateral hilar lymphnodes, and intrapulmonary nodes involved by direct extension of the primary tumour metastases to ipsilateral mediastinal and or subcarinal lymph nodes metastases to contralateral mediastinal, hilar or scalene or supraclavicular nodes distant metastasis status (m descriptor) mx cannot be assessed nx no nl n2 n3 mo ml no distant metastases distant metastases present" "the uncommon superficial tumour of nny size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus, is also classified ac;ti. [most pleura] effusions in association with a cancer are malignant and caused by the tumour. however. il few patjent's have multiple cytology examinations of the pleural fluid that are negative for tumour. in these cases the fluid is ncr bloody and is nol an exudate. when these elements and clinical judgement dictate that the effusiou is not related to the turnour.the effusion should be excluded as a staging clement. and the patient staged tl, 2 or 3, pericardlal effusion is classified according to tj1c same rules, tseparnte metastatic turnour nodulels) in the ipsilateral non-primary tumour lobe of the lung are also classified ml. venous contrast to allow accurate differentiation of mediastinal and hilar vascular structures from nodal tissue and tumour. the scan must also be displayed with lung and soft tissue settings. ct assessment of t descriptor staging of the t descriptor has an accuracyof85% (fig. 2).6grossmediastinal invasion can be confidently 31 sa journal of radiology • february2003 fig. 2. ct of tt no adenocarcinoma fig. 3. ct showing obvious mediastinal invasion. diagnosed, but it can be difficult to distinguish between tumour contiguity and extension into mediastinal structures (fig. 3). intact fat plane, contact of 3 cm or less with the mediastinum and less than 90° contact with the aorta suggest no invasion, whereas greater than 180° contact with the mediastinal structures usually indicates invasion.' ct assessment of n descriptor n assessment relies on node size with a short axis diameter of greater than 1 cm being considered positive for nodal metastases (fig. 4). however, small nodes can contain microscopic tumour deposits (producing a false-negative assessment in 20% of cases) and conversely large nodes may be clear of metastases (producing a false-positive assessment in 20% of cases for glands greater than 2 cm)," a revi'ew article fig. 4. t2n2: lymph nodes measure greater than 1 em in short axis. systematic approach using one of the accepted lymph node maps should be utilised to describe disease in hilar (nl), ipsilateral mediastinal (n2) and contralateral mediastinal (n3) stations." the profoundly negative impact on survival of nodal metastases is well documented, but the identification of hilar nodal (nl) disease remains a weakness in the clinical assessment. ct assessment of m descriptor the search for metastases is initially limited to the chest and the upper abdomen unless clinical information indicates the need for brain and or bone scanning which are not routinely performed. low density liver lesions are frequently encountered. these are most often benign cysts. ultrasound can be useful in differentiating cystic from solid lesions. isolated adrenal masses are usually benign adenomas. unenhanced ct attenuation of 10 hu or less, or more than 50% washout on id-minute delayed enhanced ct are highly specific for benign adrenal adenomas. to mr. this is of similar accuracy to ct in assessing the t and m descriptors, but may offer an advantage over ct in assessing mediastinal and chest wall invasion, particularly in superior sulcus tumours.' chemical shift mr! accurately differentiates metastases from benign adrenal adenomas. i i positron emission tomography pet scanning relies on the increased metabolism of glucose in tumour cells to characterise glands and masses. its role in routine preoperative staging is yet to be fully defined, but may prove to be useful in enhancing the ct assessment, in examining the nl hilar nodes, and for evaluation of any contralateral parenchymal nodules." stage grouping stage groups were developed on retrospective survival data.' 5-year lnmsubset survival (%) cain situ tlnomo 60 t2nomo 38 tlnimo 34 t2nimo 24 t3nomo 22 t3nimo 9 tln2mo l3 t2n2mo l3 t3n2mo l3 t4anyn 7 n3anyt 3 ml anyt, anyn stage o ia ib iia lib ilia iiib n 32 sa journal of radiology. february 2003 the major prognostic factor is the ability to achieve a complete resection (ro). limited invasion of the mediastinum or of the chest wall (t3) does not prohibit complete resection, and provided the mediastinal glands are not involved s-year survivals of up to 40% can be achieved. pleural effusions in the presence of a lung tumour are almost always malignant and should be considered to be so unless careful cytological analysis of the fluid as well as thorough thoracoscopic examination reveals no malignancy in the pleural space. this is unlikely in advanced t and n categories. malignant effusions confer a t4 status on the tumour and these patients are not surgical candidates. the purpose of detecting mediastinal nodal disease preoperatively is to avoid unnecessary operations that will not favourably influence survival. where large mediastinal glands are recognised on the ct scan, biopsy by mediastinoscopy and or mediastinotomy is undertaken, where these glands are within reach of the mediastinoscope. mediastinoscopy will produce a false-negative result in 25% of cases." clinical staging under stages the full extent of the disease in at least 25% of cases which explains why the overalls-year survival in tino is only 60% (i.e only 60% were in fact tino and the rest had more advanced disease). additional information chest radiograph and ct scanning will provide other valuable information that may influence surgical planrevie\n article ning. background lung disease such as copd, scarring, likely presence of adhesions from previous pleural disease, and cardiac disease can be assessed and factored into the overall risk assessment for surgery (fig. 5). the site and size of the tumour and some anatomical factors identified on the scan can assist in estimating the likely extent of the resection necessary to achieve a complete resection (i.e. lobectomy or pneumonectomy) (fig.6). fig. 5. ti tumour, but note background of copo which may complicate surgical approach. fig. 6. small tumour lll but close to lul bronchus therefore pneumonectomy rather than lobectomy required. conclusion the radiological assessment of lung cancer requires an understanding of the biological behaviour of the disease, and a knowledge of the methods available to study it. critical information required by the surgeon revolves around staging the primary tumour and assessing its resectability based on the information provided above. accurate interpretation of the information requires practice and team work between the radiologist and the thoracic surgeon. although clinical staging under stages the disease in approximately 25% of cases, it is not an unacceptable situation, as it means that with the current system no patient with resectable disease will be denied a potentially curative resection. standardised reporting of the information needs to include a detailed description of the tumour based on the tnm system, and using an agreed upon nomenclature for the lymph nodes based on one of the available lymph node maps. it should also include any co-existing disease that may be used in the overall risk assessment for any planned therapy. finally,the data should be recorded as accurately as possible for the purpose oflater comparisons, used in assessing the response to therapy or the accuracy of clinical staging. references 1. pisani p, parkin om, bray f, ferlay j. estimates of the worldwide mortality from 25 cancers in 1990. int j cancer 1999; 83: 18-29. 2. travis wd, lubin j, rues l, devesa s. united states lung carcinoma incidence trends: declining for most histologic cell types among males, increasing among females. cancer 1996; 77: 2464-2470. 3. martini n, bains s, burt m, et al. incidence of local recurrence and second primary tumours in resected stage i lung cancer. j thorac cardiovasc surg 1995; 109: 120-128. 4. mountain cf. revisions in the international system for staging lung cancer. chest 1997; ill: 1710-1717. 5. webb wr, gatsonis c, zerhouni ea, et a/. ct and mr! imaging in staging non-small cell bronchogenic carcinomas: report of the radiologic diagnostic oncology group. radiology 1991; 178: 705-713. 6. isbicki jr, thetter 0, karg 0, et al. accuracy of computed tomographic scan and surgical assessment for the staging of bronchial carcinoma. a prospective study. j thoroe cardiovasc surg 1992; 104: 413-420. 7. herman sj, winton tl, weisbrod gl, towers mj, mentzer sj. mediastinal invasion by bronchogenic carcinoma: ct signs. radiology 1994; 190: 841-846. 8. naruke t, suemasu k, ishikawa s. lymph node mapping and curability at various levels of metastasis in resected lung cancer. j thoracic cardiovasc surg 1978; 76: 833-839. 9. mountain cf, oresier cm. regional lymph node classification for lung cancer staging. chestl997; 111: 1718-1723. lo. korobkin m. ct characterisation of adrenal masses: the time has come. radiology2000; 217: 629-632. il. miller dg, crovejlo m, mattteucci t, petersen ro , miettinen mm. benign adrenocortical masses: diagnosis with chemical shift mr! imaging. radiology 1992; 185: 345-351. 12. lowe vr, naunheim ks. positron emission tomography in lung cancer. ann thorac surg 1998; 65: 1821-1829. 13. goldstraw p, mannam g, kaplan 0, michail p. surgical management of non-small cell lung cancer with ipsilateral mediastinal nodal metastasis (n2 disease). j thorac cardiovasc surg 1994; 107: 19-27. 33 sa journal of radiology. february 2003 abstract introduction methods design and procedure analysis ethical considerations results and statistical analysis discussion limitation of the study conclusion acknowledgements references about the author(s) leonie scholtz department of radiology, university of pretoria, south africa andré du plessis scholtz and partners radiologists, pretoria, south africa savvas andronikou department of paediatric radiology, bristol royal hospital for children, united kingdom anelia swart scholtz and partners radiologists, pretoria, south africa anton stoltz department of internal medicine, university of pretoria, south africa aneesah khan department of radiology, university of pretoria, south africa aqeela moosa faculty of health sciences, university of pretoria, south africa citation scholtz l, du plessis a, andronikou s, et al. systolic function evaluated with cardiovascular magnetic resonance imaging in hiv-infected patients. s afr j rad. 2016;20(2), a1044. http://dx.doi.org/10.4102/sajr.v20i2.1044 research project no.: ret_2014_up02/201 original research systolic function evaluated with cardiovascular magnetic resonance imaging in hiv-infected patients leonie scholtz, andré du plessis, savvas andronikou, anelia swart, anton stoltz, aneesah khan, aqeela moosa received: 02 june 2016; accepted: 13 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: of all areas worldwide, sub-saharan africa is worst affected by the hiv and/or aids epidemic. cardiovascular manifestations are very common and are a powerful contributor to mortality, but often go undetected. cardiovascular magnetic resonance (cmr) is the most reliable method of assessing cardiac function and morphology and, with this in mind, we initiated a cross-sectional study comparing cmr-determined morphological and functional parameters in asymptomatic hiv-infected patients who were not yet on treatment and early in the disease, with hiv-uninfected control patients. objectives: to ascertain whether there were any morphological abnormalities or systolic functional impairments on cmr in untreated asymptomatic hiv-infected patients, compared with hiv-uninfected control individuals. methods: the cmr studies were performed using a 1.5-t whole-body clinical magnetic resonance 16-channel scanner (achieva, philips medical systems, best, the netherlands), using a cardiac five-element phased-array receiver coil (sense coil). functional assessment was performed on 36 hiv-infected patients and the findings compared with 35 hiv-uninfected control patients who were matched for age and sex. results: there was no significant difference in systolic function between the hiv-uninfected and the hiv-infected patients. the left ventricular end diastolic mass (lvedm) was slightly higher in the hiv-infected group, but this was statistically insignificant. conclusion: no significant differences were found regarding the cmr systolic functional analysis and morphological parameters between the hiv-infected and the healthy volunteers. introduction sub-saharan africa has the highest worldwide incidence of hiv and/or aids, with approximately 6.5 million south africans infected; 69% of all adults and 90% of all children who are infected live in this region.1,2 cardiovascular manifestations in hiv are very common3,4,5,6,7,8 but often go undetected owing to symptoms being attributed to other causes such as pulmonary tuberculosis and neurological manifestations. in the period prior to antiretroviral therapy (art), the prognosis is poor once the cardiovascular system is affected, which is related in part to the late stage of the disease as well as the fact that certain cardiac complications are in themselves a prominent cause of death.9 in developed countries, coronary artery disease is the most common manifestation, mainly owing to accelerated atherosclerosis in patients on art treatment.10 amongst hiv survivors in botswana, there is a high prevalence of atherosclerotic cardiovascular disease (cvd) in younger patients, which conceivably can lead to an increase in mortality owing to premature cvd in these populations.11 in sub-saharan africa, however, pericardial tuberculosis and its sequelae, myocarditis and cardiomyopathy still comprise the predominant cvd presentations.12 cmr is a highly reliable modality used to assess myocardial morphology and function;13 however, the majority of, if not all, cmr studies in hiv-infected patients have been performed on patients already receiving art therapy.14,15,16 consequently, the objective of the present study was to assess the frequency and type of cardiovascular manifestations on cmr in patients with hiv infection who were not yet on treatment with art, versus a control group who were hiv-uninfected and with no known overt cvd. methods study population suitable patients (n = 36) were selected at the hiv and/or aids clinic at the steve biko academic complex, department of health sciences, university of pretoria. the hiv-infected patients were at least 18 years old, class two and three according to the world health organization (who) criteria for hiv, and were not on art. none of the hiv-infected patients had any symptoms that could have been attributed to hiv-related cardiac failure or cardiac involvement. the control group (n = 35) included healthy volunteers from steve biko hospital (health workers). the healthy volunteers were screened for hiv infection before they were enrolled in the study. the groups were matched for age, sex and ethnicity (table 1). table 1: clinical data. the hiv-infected patients underwent a clinical examination at the clinic, and any clinical cardiac findings were documented. a resting standard 12-lead ecg, echocardiography and chest radiograph were done. nt-probnp levels (as a measure of atrial and ventricular distention), plasma hiv viraemia load (copies/ml) and mean cd4+ cell count (cells/μl) were obtained. body surface area (bsa) was calculated for all patients. glomerular filtration rate was determined according to the cockcroft-gault formula on all patients (including the healthy volunteers), prior to cmr, and those with impaired renal function (glomerular filtration rate <60 ml/min) were withdrawn. other exclusion criteria for the hiv-infected patients included drug abusers, patients suffering from claustrophobia, patients with signs of active pulmonary tuberculosis on chest radiograph, and other identifiable causes of cardiac failure, e.g. valve lesions or congenital heart disease. design and procedure the study was a cross-sectional study. cmr studies were performed using a 1.5-t whole-body clinical magnetic resonance 16-channel scanner (achieva, philips medical systems, best, the netherlands), using a cardiac five-element phased-array receiver coil (sense coil). heart rate, blood pressure and oxygen saturation were monitored noninvasively during the examination. the two groups of patients underwent a cmr scan using the same parameters. functional analysis was performed, and all the functional parameters including ejection fraction (ef), end-systolic and end diastolic volumes (esv, edv), stroke volume (sv) as well as left ventricular (lv) mass were obtained. the cmr procedure included the following sequences: scout images axial, coronal and sagittal scans (20 per plane) were done to localise and plan the rest of the study. balanced turbo field echo sequences (btfes), of 10 mm slice thickness, were used for the scout images. functional analysis sequences functional imaging of the left ventricle was performed in two long-axis (twoand four-chamber view) orientations and in a contiguous short-axis orientation to cover the left ventricle from the base to the apex (8 mm slices with a 2 mm inter-slice gap). the acquisition was performed in end-expiration hold. analysis two experienced operators performed the visual image analysis. the readers were blinded to each other and the interpretation was performed on separate computers, utilising the same software (circle cardiovascular imaging inc.), but in different locations. if there was a discrepancy in the findings between the two interpreters, a third (blinded) opinion was sought and the majority opinion regarded as the final result. the long-axis views were used to visualise and confirm possible areas of hypokinesia assessed via the short-axis views. the short-axis images were evaluated with computer-aided analysis packages for planimetry of endocardial and epicardial borders at end diastole and end systole (figures 1 and 2). papillary muscles were excluded in the lv mass analysis (selectable option). figure 1: short-axis views were utilised to perform the functional analysis with dedicated software. figure 2: three-dimensional image indicating the level of the short-axis image obtained. the presence of incidental pericardial effusions (>4 mm in diameter) or pericardial thickening (>1.7 mm in diameter) was documented if present on the four-chamber or short-axis cine sequences. computer-aided analysis included left ventricular ejection fraction (lvef) as a percentage; left ventricular end-systolic volume (lvesv) in ml; left ventricular end diastolic volume (lvedv) in ml; left ventricular stroke volume (lvsv) in ml; and lv mass in grams/m2. ethical considerations approval was obtained from the ethics committee of the faculty of health sciences, university of pretoria. all participants (hiv-infected and control) gave informed consent for participation in the study, which also included consent for intravenous gadolinium contrast injection. the consent form addressed and explained all the possible discomforts during the scan as well as the risks involved with gadolinium, including the rare possibility of nephrogenic systemic sclerosis. the patients and controls were also asked to complete a screening form to address and confirm the absence of any detrimental metal implants or devices. each patient was given a number; patient clinical information was not provided to the radiographers performing the scans. medical personnel not involved in the study recruited the control patients, and the control patients were slotted in (on an ad hoc basis) in between other groups. the readers were blinded to the clinical data. the readers were not present during the scan. a radiologist not involved in the study administered the contrast. results and statistical analysis the major focus of the present study was the comparison of functional and structural abnormalities on cmr in untreated patients who were hiv-infected with hiv-uninfected patients. the clinical data are listed in table 1 and the cmr functional analysis in table 2. table 2: cardiovascular magnetic resonance functional analysis. statistical considerations mean values were compared by two-sided student t tests, with p values as indicated. normality of the underlying distributions could not be verified for all the variables. in all cases, the non-significance could be confirmed by the nonparametric wilcoxon rank sum test. percentages were compared by fisher’s exact test. p values were all non-significant. according to the statistical analysis tests, a sample size of at least 33 participants per group would have been adequate to detect a significant difference in functional analysis parameters between the groups. clinical results in respect of age, weight, bsa and gender ratio, no significant differences were found between the hiv-infected and hiv-uninfected patients. the mean viraemia load of the hiv-infected patients was 137 465.42 copies/ml, and the mean cd4 count 276.94 cells/µl. the mean probnp count of the hiv-infected patients was 32.41 pg/ml. cardiovascular magnetic resonance results regarding all the variables, no significant differences were found in the cmr systolic functional analysis between the hiv-infected and hiv-uninfected patients. the lv mass (lvedm) was slightly higher in the hiv-infected group, but this was not statistically significant (p = 0.129) (table 2). small pericardial effusions (5 mm – 7 mm in diameter) were present in 6 (16.6%) of the 36 hiv-infected patients. none of the patients had significant pericardial thickening. discussion echocardiography is readily available and has been utilised in several studies to assess lv function in hiv-infected patients.17,18,19 functional abnormalities increase with the level of immunosuppression.12,20 both systolic and diastolic dysfunction have been reported at echocardiography in hiv-infected patients.18,21 most of the studies originate from developed countries and the majority of patients included were on art. systolic dysfunction is usually mild and occurs less frequently than diastolic dysfunction.18,20 a study from nigeria performed on patients yet to receive treatment, also reported on impaired function, of which diastolic dysfunction was more prevalent.22 increase in myocardial mass on echocardiography occurs frequently.18,20,21 the cause is speculative and probably multifactorial, and might represent inflammation. very few cmr studies have been performed on hiv-infected patients, and the study numbers are small. the first study by holloway et al. included 90 patients on art where the presence of mild systolic but marked diastolic dysfunction as seen on echocardiography in previous studies, was reported.14 the subsequent study by thiara et al. confirmed their findings.16 two recent studies reported higher native t1 values (969 v. 956 ms in controls) in hiv-infected patients (probably caused by inflammation), as well as the presence of oedema. this was probably responsible for the increase in myocardial mass seen on cmr.15,23 all the studies included patients already on art treatment, except for the study by ntusi et al. which included a small subgroup of patients not yet on treatment.15 there were no statistical differences in the findings between the patients on art and the untreated group in the latter study.15 the study population in the present study included asymptomatic patients not yet on treatment and not yet severely immune compromised. the ef, edv, esv and sv with cmr analysis did not differ between the two groups. this point has not previously been assessed with cmr in a similar setting. myocardial mass was higher in the hiv-infected group, as seen with echocardiography,20 although this was not statistically significant. increased myocardial mass was also observed on cmr by ntusi et al.,15 where it was also associated with mild impairment of lv systolic function. the majority of the patients in their study were, however, already on art. small asymptomatic pericardial effusions are a common occurrence in hiv-infected patients and have been documented in many previous echocardiography and cmr studies. cardiac function can be assessed with cmr, which is now regarded as the gold standard.13 cmr is not yet readily available in sub-saharan africa. south africa specifically has the largest antiretroviral programme in the world. approximately the equivalent of $us1 billion is spent by the south african government on the prevention and treatment of hiv infection. by making cmr readily available, especially in rural areas, the devastating impact of the disease on its young and active inhabitants will be highly beneficial. limitation of the study the study numbers are small and patients on art were not included. larger studies are needed and more patient groups should be studied, including patients on treatment, and patients with clinical cardiovascular manifestations. it is also necessary to compare patients at different stages in the natural history of the disease. conclusion no significant differences were found regarding the cmr systolic functional analysis between the hiv-infected and the healthy volunteers. the lvedm was slightly higher in the hiv-infected group but this was not statistically significant. cmr is regarded as the gold standard for evaluating cardiac function. up till now, echocardiography has been the main diagnostic tool used to evaluate cardiac function in sub-saharan africa. cmr can potentially play an important role in the future. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions l.s. was the project leader. l.s. and a.d.p. performed the functional analysis. l.s. and s.a. were responsible for experimental and project design. a.sw. performed the scans. a.st., a.k. and a.m. sourced the patients. a.st. and s.a. made conceptual contributions. references joint united nations programme on hiv/aids (unaids). global report: unaids report on the global aids epidemic 2012 [homepage on the internet]. 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http://dx.doi.org/10.1016/j.repc.2013.12.006 sanchez-torres rj, garcia-palmieri mr. cardiovascular disease in hiv infection. p r health sci j. 2006;25(3):249–254. islam fm, wu j, jansson j, wilson dp. relative risk of cardiovascular disease among people living with hiv: a systematic review and meta-analysis. hiv med. 2012;13(8):453–468. http://dx.doi.org/10.1111/j.1468-1293.2012.00996.x currie pf, jacob aj, foreman ar, elton ra, brettle rp, boon na. heart muscle disease related to hiv infection: prognostic implications. bmj. 1994;309(6969):1605–1607. http://dx.doi.org/10.1136/bmj.309.6969.1605 ho je, hsue py. cardiovascular manifestations of hiv infection. heart. 2009;95(14):1193–1202. http://dx.doi.org/10.1136/hrt.2008.161463 onen cl. epidemiology of ischaemic heart disease in sub-saharan africa. cardiovasc j afr. 2013;24(2):34–42. http://dx.doi.org/10.5830/cvja-2012-071 ntsekhe m, mayosi bm. cardiac manifestations of hiv infection: an african perspective. nat clin pract cardiovasc 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steatosis and diffuse myocardial fibrosis in hiv-infected adults. j infect dis. 2015;212(10):1544–1551. http://dx.doi.org/10.1093/infdis/jiv274 wever-pinzon o, bangalore s, romero j, silva enciso j, chaudhry fa. inotropic contractile reserve can risk-stratify patients with hiv cardiomyopathy: a dobutamine stress echocardiography study. jacc cardiovasc imaging. 2011;4(12):1231–1238. http://dx.doi.org/10.1016/j.jcmg.2011.09.012 reinsch n, kahlert p, esser s, et al. echocardiographic findings and abnormalities in hiv-infected patients: results from a large, prospective, multicenter hiv-heart study. am j cardiovasc dis. 2011;1(2):176–184. lai h, redheuil a, tong w, et al. hiv infection and abnormal regional ventricular function. int j cardiovasc imaging. 2009;25(8):809–817. http://dx.doi.org/10.1007/s10554-009-9493-7 hsue py, hunt pw, ho je, et al. impact of hiv infection on diastolic function and left ventricular mass. circ heart fail. 2010;3(1):132–139. http://dx.doi.org/10.1161/circheartfailure.109.854943 mondy ke, gottdiener j, overton et, et al. high prevalence of echocardiographic abnormalities among hiv-infected persons in the era of highly active antiretroviral therapy. clin infect dis. 2011;52(3):378–386. http://dx.doi.org/10.1093/cid/ciq066 olusegun-joseph da, ajuluchukwu jn, okany cc, mbakwem ac, oke da, okubadejo nu. echocardiographic patterns in treatment-naive hiv-positive patients in lagos, south-west nigeria. cardiovasc j afr. 2012;23(8):e1–6. http://dx.doi.org/10.5830/cvja-2012-048 luetkens ja, doerner j, schwarze-zander c, et al. cardiac magnetic resonance reveals signs of subclinical myocardial inflammation in asymptomatic hiv-infected patients. circ cardiovasc imaging. 2016;9(3):e004091. http://dx.doi.org/10.1161/circimaging.115.004091 case report 37 sa journal of radiology • september 2006 abstract spinal chordomas in the lumbar region are rare and can easily be overlooked in the differential diagnosis of vertebral column tumours. introduction spinal chordomas mostly present in association with the clivus or sacrum. we report a case where it was overlooked in the differential diagnosis of vertebral column tumours because it presented in the lumbar spine. case a 66-year-old male patient presented with a longstanding history of backache, weakness of both legs, constipation and urinary incontinence; clinically he was tender over the lower thoracic and lumbar spine. conventional x-rays showed destruction of the pedicles of l4 and l5. on magnetic resonance imaging (mri) a large mass was present, centred around l4. the mass involved most of the anterior elements of l4 veretebra and to a lesser extent l3 and l5. a large soft-tissue component projected anteriorly and paravertebrally, and tumour was also filling the spinal canal from l3 to s2. the tumour was heterogeneously hypointense on t1 (fig. 1), hyperintense with multiple septae on t2 (figs 2a and b) and showed diffuse nodular ring enhancement post gadolinium (fig. 3). biopsy confirmed a chordoma. discussion chordomas are rare tumours originating from remnants of the primitive notochord and may arise anywhere along the spinal vertebral column, being most common in a sacral or clival position (85%). only 6% of spinal chordomas originate in the lumbar region. at present, mri is the method of choice for the diagnosis and pre-operative assessment. chordomas are most commonly isoor hypointense on t1-weighted images, and moderately hyperintense on t2-weighted images.1 conventional x-rays show irregular and expansile vertebrae as a result of the destructive, slow-growing and reactive bone-forming nature of the tumour.2 the anterior soft-tissue mass of the involved vertebrae is the most important radiological finding and shows that prevertebral involvement is greater than osseous involvement.3 lumbar vertebra chordoma a erlank, mb chb j j parsons, mb chb g cilliers, mb chb, mmed rad (diag) o c schulze, mb chb c ackermann, mb chb, mmed rad (diag), mrcs (uk) h lameen, mb chb department of radiology, tygerberg hospital and stellenbosch university fig. 1. t1 sagittal. hypointense lobulated soft-tissue mass located in spinal canal destroying part of l3 and l5 vertebrae with complete destruction of l4 vertebra. there is an additional anterior vertebral component and extension into the sacral part of the spinal canal. pg 37-38.indd 37 9/6/06 2:58:14 pm case report 38 sa journal of radiology • september 2006 conclusion this case demonstrates the typical imaging features of a chordoma occurring in a rare location. 1. bosma jj, pigott tj, pennie bh, jaffray dc. en bloc removal of the lower lumbar vertebrae for chordoma. report of two cases. j neurosurgery 2001; 94(2 suppl): 284-291. 2. mindell er. chordoma. j bone joint surg am 1981; 63: 501-505. 3. sundaresan n. chordomas. clin orthop 1986; 204: 135-142. fig. 3. t1 post gadolinium. moderate inhomogeneous enhancement of the soft tissues. figs 2a and b. t2 axial (a) and coronal (b). lobulated hyperintense mass infiltrating spinal canal as well as paravertebral muscles. a b pg 37-38.indd 38 9/6/06 2:58:16 pm original article jumper's knee r v p de villiers mmed (radd) sa department of radiology, tygerbergacademic hospital and university of stellenbosch, tygerberg, w cape abstract patellar tendinopathy or 'jumper's knee' is a common cause of anterior knee pain in athletes. this condition is often resistant to therapy and can cause a premature end to a professional sporting career. mri and highdefinition ultrasound are the modalities of choice for evaluating the athlete with anterior knee pain. ultrasound with a linear, high-resolution 10 or 12 mhz probe is suggested. comparison is always made with the presumed normal contralateral tendon. mri, although more expensive, is not operator-dependent. it also demonstrates a more global picture. fluid-sensitive studies are used in the axial and sagittal planes. the pathology of patellar tendinopathy represents atendinosis, rather than a tendonitis, due to the absence of inflammatory cells. introduction athletes in jumping sports such as basketball, high jump, pole vault, volleyball and netball often suffer from anterior knee pain caused by patellar tendinopathy or 'jumper's knee'. this condition is often resistant to therapy and can cause a premature end to an elite or professional sporting career.' clinically these athletes present to the physiotherapist or sports physician with pain just below the patella that is aggravated by jumping. pain is aggravated by stressing the extensor mechanism, e.g. with weight training or squatting. on examination the patient is tender at the junction between the patella and the patellar tendon.' imaging approach mri and high-definition ultrasound are the modalities of choice for the jumping athlete with anterior knee pain." plain radiography is almost always negative, unless a stress fracture of the inferior patellar pole is present," ultrasound with a linear, high-resolution 10 or 12 mhz probe shows loss of the normal fibrillar echogenieity of the infrapatellar tendon. comparison is always made with the presumed normal contralateral tendon. technically the probe must always be directed perpendicular to the tendon to avoid artifactual anisotropism. the changes may vary from grade 1 tendinosis with generfig. 1. transverse ultrasound scan of infrapatellar tendon. right tendon shows hypoechoic tendinopathic changes. 22 sa journal of radiology. august 2003 fig. 2. sagittal ultrasound scan shows hypoechoic tendinopathic changes of the posterior superior aspect of the right infrapatellar tendon. the left infrapatellar tendon is normal and shows the normal fibrillar pattern. fig. 3. t1 sagittal mri shows subtle hyperintense changes in the whole infrapatellar tendon. compare the signal in the suprapatellar tendon with the signal in the infrapatellar tendon. note the fusiform swelling in the tendon. alised hypoechoic tendon swelling to focal hypoechoic areas. classically,the posterior tendon fibres are predominantly involved. inflammatory changes in the infrapatellar or hoffa's fat pad may be noted. this is demonstrated as hypoechoic shadowing compared with the contralateral fat pad (figs 1 and 2).',2,4.5 although more expensive, mrl is not operator-dependent. it also demonstrates a more global picture. fluid-sensitive studies are used in the axial and sagittal planes. we use the following protocol at our centre: proton-density axial and sagittal, t2 fatsaturation axial and sagittal and proton-density fat-saturation sequences. original article fig. 4. sagittal t2 images show similar hyperintense changes to the tt study of the infrapatel/ar tendon. three millimetre thick sections with no gap, 12 cm field of view, and 512 x 512 matrix with a standard knee coil completes the protocol. the abnormal areas of tendinosis appear as 'bright' or hyperintense areas in the tendon substance. associated stress response or stress fracture is demonstrated in the patella. oedema in the infrapatellar fat pad is well demonstrated on the fat-saturation, fluid-sensitive studies. fig. 5. transverse t2 fat-saturation study shows marked hyperintense changes in the infrapatel/ar tendon. care must be taken not to confuse the 'magic angle' artefact with tendon pathology. this artefact is seen where the tendon courses at 55 degrees to the coil (figs 3 5).4,6,7 the pathology of patellar tendinopathy is based on examination of surgical specimens. at surgery the normally white, glistening and firm tendon appears dull, brownish and soft. microscopically the involved areas show loss of collagen continuity and an increase in ground substance, vascularity and cellularity. the absence of inflammatory cells is stressed, thus the term tendinosis or tendinopathy and not tendonitis." at surgery, either via arthroscopy or longitudinal skin incision, the abnormal tissue is debrided.' references 1. khan k, bonar f, desmond pm, cook jl. young da, visentini pj. patellar tendinosis. findings at histopathologic examination. us and mrl radiology 1996; 200: 821-827. 2. anderson jf,read j, steinweg j. atlas of imaging in sports medicine. sydney: mcgraw-hill, 1998: 216-217. 3. berquist th. imaging of sports injuries. maryland: aspen publishers, 1992:149. 4. bergman ag, fredericson m. mri of stress reactions, muscle injuries and other overuse injuries in runners. mr! clinics of north america 1999: 7:65. 5. ptasznik r. musculoskelatal ultrasound. radial a« north am 1999; 37: 799-803. 6. stoller d. mr! ill crthopaedics and sports medicine. philadelphia: lippincott-raven, 1997: 375-376. 7. resnick d, kang h. internal derangements of loints. emphassls 011 mr bl1agillg. pennsylvania: wh saunders, 1997: 662-665. 23 sa journal of radiology. august 2003 radiology_may04 case report 39 sa journal of radiology • may 2004 case study 1 cns toxoplasmosis a 34-year-old known immunocompromised female patient presented with fever of unknown origin and expressive apraxia. she was also on anti tb treatment for pulmonary tb. on clinical examination she was found to have a fever of 39°c, lymphadenopathy in the right axilla, increased tone in the upper limbs and generally globally increased reflexes. investigations a ct scan done on admission revealed bilateral low-density areas in the internal capsulae. post-contrast images revealed bilateral ring-enhancing lesions with central enhancing nodules — target lesions (figs 1 and 2). further investigations included: (i) cd4+ cell count 127.5/l; (ii) toxoplasma serology — toxoplasma enzyme-linked immunosorbent assay (elisa) immunoglobulin (ig) 3.84 (normal 0 1.0 units); toxoplasma immunofluoresence assay (ifa) polyvalent positive; and (iii) cerebrospinal fluid test for india ink and antigen studies were negative. the patient responded to tb treatment. she was put on warfarin for deep venous thrombosis (dvt). the patient was allergic to bactrim and was given fluoconozole and discharged. three weeks later she deteriorated and died. discussion toxoplasma gondii is a protozoan organism that is ubiquitous in nature. its definitive hosts and reservoir are felines, but it can cause acute infection and disease in humans. the infection is asymptomatic or minimally symptomatic in older children or adults with normal immune function. cysts of t. gondii persist in the central nervous system (cns) as well as extra neural tissues after infection, which keep quiescent, but with immune dysfunction as in hiv/ aids, these cysts may become reactibilateral low-density lesions in the internal capsule, with confirmed cryptococcus meningitis and cns toxoplasmosis in immunocompromised patients zarina lockhat ffrad (d) sa irma van de werke frcr betsie van der walt fcrad(d)sa department of radiology university of pretoria fig. 1. fig. 2. vated and cause disease, the most common of which is toxoplasmic encephalitis, which occurs late in the course of hiv infection when the cd4 cell count has fallen to less than 100 cells/mm3. onset of symptoms is usually gradual, with headache, confusion, fear, lethargy or seizures. on examination patients can have an abnormal level of consciousness or focal neurological signs, such as hemiparesis, ataxia or cranial nerve palsies. amongst all the cns infections seen in aids patients, toxoplasma encephalitis is the most eminently treatable, because it usually responds to antibiotic therapy. for this reason early identification is important, because treatment leads to rapid clinical improvement. three types of cns infection by t. gondii have been described. the first consists of a necrotising abscess, characterised by a mixture of free-living tachyzoites and encysted organisms, vascular reaction, inflammation and petechial haemorrhage. the second type consists of a lesion containing a necrotic cystic centre surrounded by a fibrous capsule, and is usually seen between 2 and 4 weeks of onset of cns infection. the third type is that of chronic abscess formation, in which necrosis and free organisms constitute most of the lesion. on ct the diagnosis is made when there are typical ringenhancing lesions in the presence of serum antibodies to t. gondii. the most common regions of involvement are the cortico-medullary junctions (possibly representing haematogenous dissemination), basal ganglia and thalamus. lesions are typically supratentorial (possibly reflecting the dominant distribution of blood flow) but cerebellar lesions are also relatively common. on occasion the brain stem, hypothalamus and subthalamic regions are involved. rarely intraventricular lesions can be seen. ventricular enlargement is common, which can be present on the basis of atrophy (often itself secondary to hiv encephalitis) or hydrocephalus due to infective meningitis, or partial obstruction of the ventricular outlet, by a toxoplasma lesion. multiple bilateral lesions are usually seen, but a solitary lesion can occur. pre-contrast ct toxoplasma lesions appear as rounded masses that are relatively isodense compared with grey matter and they can often be detected on pre-contrast ct due to the adjacent oedema and mass effect. lesions that appear hyperdense are thought to be due to haemorrhagic necrosis. post-contrast enhancement is either nodular or ring-like in appearance. enhancement can be mild or absent if severely diminished cellular mediated immunity does not allow much of an inflammatory response. the lesions can be very small or as large as several centimetres in diameter, simulating neoplasms such as lymphoma. following therapy lesions are replaced by areas of encephalomalacia and glial scars that are seen on ct as foci of calcification. mr imaging is more sensitive than ct showing more lesions and sometimes revealing lesions when the ct is normal. on mr imaging lesions are typically hypoor iso-intense to grey matter on non-contrast t1-weighted images, and iso-intense or hyper-intense on t2-weighted images. some lesions remain the same or increase in size, while others decrease in response to treatment, multiple coexistent processes (e.g. toxoplasma infection, and another entity, e.g. lymphoma) may be present. discrimination of toxoplasma encephalitis from cerebral lymphoma is a common diagnostic problem, since both can be solitary or multiple, nodular or ring-enhancing, and associated with oedema, often making the lesion indistinguishable on ct or mr. subependymal spread by a periventricular lesion is seen in lymphoma, but not toxoplasma encephalitis, and is one finding that can be helpful in distinguishing the two entities, but is uncommonly seen. failed response to treatment is another feature suggestive of lymphoma. on mr spectroscopy, toxoplasma lesions have markedly increased lipid and lactate peaks with a decrease in other metabolites, while lymphoma has only a mild or moderate increase on lactate and lipids, but a substantial increase in the choline peak (thought to be due to increased cellularity). the diagnosis is confirmed by response to therapy. toxoplasmosis serology is negative in 5 10% of cases. if the patient fails to respond to therapy within 10 14 days, other diagnoses such as primary cns lymphoma or bacterial abscess should be entertained. a definitive diagnosis should be sought by stereotactic brain biopsy. case study 2 — cryptococcus meningitis a 23-year-old woman was admitted in december 2001 with the diagnosis of an acute salpingo oophoritis grade ii, as well as an ectopic pregnancy on the right side, diagnosed by a pelvic ultrasound examination. a laparotomy confirmed the ectopic pregnancy. she looked chronically ill case report 40 sa journal of radiology • may 2004 case report 41 sa journal of radiology • may 2004 and complained of headache. on examination she had diffuse lymphadenopathy. after the neurological consultation a lumbar puncture was performed which revealed clear cerebrospinal fluid with slightly raised proteins at 524 mg/l (normal range 150 450 mg/l). chloride, glucose and adenosine deaminase (ada) were normal. the tb culture, the gram stain and capsular antigen tests for bacterial meningitis were negative. the india ink and cryptococcus neoformans agglutination tests were positive. the patient’s renal function was normal. the white cell count was 4.1 x 109/l. wasserman reaction (wr) test as well as the toxoplasma ifa polyvalent test were negative. she was then started on cryptococcus meningitis treatment with diflucan from december 2001 to february 2002. the patient was suspected to be immunocompromised but she initially refused testing. the cd4 count at this stage was 85/l (normal range 560 2700 x 106/l). the patient was discharged and then readmitted on 16 march 2002 after complaining of malaise for 2 days as well as neck stiffness, vomiting, headache and flank pain. on examination she was drowsy and had severe fundus abnormalities diagnosed by the neurologist as gross papilloedema or severe papillitis or retinitis. the macula and eye movements were normal. there was no weakness of the limbs and sensation on light touch was intact. she had generalised adenopathy. the chest x-ray was normal. the white cell count at this stage was 6.9 x 109/l with 84% neutrophils (40 75%), and 9.8% lymphocytes (20 45 %). a ct scan was done on an emergency basis and revealed low-density ill-defined lesions in the basal ganglia. the ventricles were slightly prominent. after contrast administration no enhancement of the low-density lesions was detected (figs 1 and 2). a repeat lumbar puncture was performed which again revealed clear cerebrospinal fluid with slightly lower but still elevated protein, namely 472 mg/l (normal 150 450 mg/l). chloride, glucose and ada were normal. gram stain and capsular antigens for bacterial meningitis were again negative. the cell count included 143 erythrocytes/mm3, 44 neutrophils/mm3, and 0 lymphocytes. india ink cryptococcus and c. neoformans agglutination were positive. again she was put on anticryptococcal meningitis treatment and on 08 april 2002 her glasgow coma scale dropped to 12/15. another ct brain scan was requested which showed the low-density lesions in the basal ganglia more pronounced than on the original scan (fig. 3). discussion c. neoformans is the most common fungus involving the brain in immunocompromised patients. the prevalence of the infection has been reported as 6 7%. patients with underlying chronic illness such as diabetes mellitus, collagen vascular disease, chronic renal disease, alcoholism, malignancy and fig. 1. pre-contast brain scan showing oedema involving internal capsule bilaterally with faint hyperdensities. fig. 2. contrast-enhanced image, showing bilateral enhancing lesions in the internal capsule. fig. 3. those on immunosuppressive drugs are also more susceptible to cryptococcosis. after hiv and toxoplasmosis it is the third most common infection involving the cns in aids patients. c. neoformans is an encapsulated yeast-like fungus found in mammal and bird excrement, especially pigeon droppings, and is transmitted to humans through inhalation. the lung is the primary site of involvement and spread is via the haematogenous route to other organs. cryptococcus spreads haematogenously to the cns. the cns manifestations may be meningeal or parenchymal. the organism penetrates the meningeal vessel walls as well as colonising the perivascular virchow-robin spaces and cerebrospinal fluid, producing meningitis. after colonising the cerebrospinal fluid, the organisms may extend along the perforating arteries within the perivascular subarachnoid space. the production of voluminous mucoid material may enlarge the perivascular spaces giving rise to small cysts, termed gelatinous pseudocysts. these lesions are non-enhancing because the blood-brain barrier is not disrupted and the patient's immunosuppression may decrease the ability to mount an inflammatory response. on ct these lesions are of a low density similar to cerebrospinal fluid. they follow the expected location of the virchow-robin spaces, mainly in the basal ganglia, thalami, substantia nigra and periventricular regions. large perivascular spaces are also present in the choroid plexus. these lesions are more easily visualised on magnetic resonance imaging, where they have hypointensive signal on t1weighted images and hyperintense signal on t2-weighted images. the signal intensity is essentially similar to cerebrospinal fluid, although it is often slightly higher than csf on t1. cerebral oedema rarely occurs. in patients with aids dilated perivascular spaces should raise the possibility of cryptococcosis, however diagnosing cryptococcosis on the basis of dilated perivascular spaces should be done with caution because generalised cerebral atrophy, the most common cns imaging finding in aids, can also cause this appearance. in the more fulminant form of cryptococcosis or if the disease is not treated, the blood-brain barrier is disrupted and parenchymal seeding occurs. neorovascularity is recruited by meningeal or parenchymal seeds and these may enlarge to manifest as multiple enhancing nodules or a miliary pattern. these lesions can be scattered throughout the parenchyma, usually predominating in areas near the virchow-robin spaces and the choroid plexus as well as the subarachnoid spaces. these lesions usually have a similar appearance on noncontrast ct and mr imaging. smaller parenchymal lesions may be covert on non-contrast imaging. they become quite apparent, however, following administration of contrast on ct and mr. when the organisms extend from the perivascular space into the parenchyma, a collection of organisms, inflammatory cells and gelatinous mucoid material forms. this is considered a cryptococcoma. this may possibly occur from invasion of other meningeal or ependymal surfaces. the most frequent location is adjacent to the perivascular spaces, including the choroid plexus although they can occur anywhere in the parenchyma. cryptococcomas have a variable degree of surrounding vasogenic oedema on ct or mr. cryptococcomas are usually larger masses, which have a variable but often intense enhancement. obstructive hydrocephalus can occur from the choroid plexal masses. other findings that have been described are gyriform enhancement, and punctate calcifications in the leptomeningeal spaces and brain parenchyma. cns cryptococcosis commonly presents with manifestations of meningitis and encephalitis such as headache, nausea, staggering gait, dementia, irritability, confusion and blurred vision. fever and neck stiffness are mild or absent. the course of the disease may be fulminant or chronic and insidious. lumbar puncture is the single most important investigation. csf pressure may be increased and may show mild to moderate leucocytosis, decreased glucose and elevated protein levels. india ink smears demonstrate the yeast. increased cryptococcal antigen may be found in the csf or serum. the differential diagnosis on imaging includes infectious causes such as toxoplasmosis, cytomegalovirus, tuberculoma, pyogenic abscess as well as lymphoma and metastatic disease. cryptococcosis is usually treated with intravenous amphotericin b. surgical drainage of large pseudocysts has been reported. acknowledgement we would like to thank annelize gates for her assistance in the preparation of this article. references 1. davenport c, dillon wp, sze 6. neuroradiology of the immunosuppressed state. radiol clin north am 1992; 30: 611 635. 2. provenzale jm, jinkins jr. brain and spine imaging findings in aids patients. radiol clin north am 1997; 35: 1127 1165. 3. awasthi m, patankar t, shah p, castillo m. cerebral cryptococcosis: atypical appearances on ct. br j radiol 2001; 74: 83 85. case report 42 sa journal of radiology • may 2004 short report development of a postural support device for crosstable radiography of the extremities n ebrahim nat dip rad (diag), fete (london), msc radiography (diag) (uk) department of radiography medical university of southern africa introduction a postural support device (*rsa registered design application no. f2002/0033) was originally developed to provide irnrnobilisation for patients requiring cross-table radiography of the hip joint. on further investigation it was found that it had additional applications, as discussed later. background the routine projections for fractures or dislocations of the hip joint include the antero-posterior projection of the pelvis and the cross-table fig. te. supine pelvis. fig. 1b. cross-table lateral of the hip joint demonstrating the femoral neck. lateral projection of the neck of the femur (figs la and lb), in order to demonstrate the neck of the femur, the unaffected leg has to be raised and supported. radiographers have traditionally used a chair, stacks of soft pads, an individual, or the x-ray tube to support their patients. in 1998 a national survey, utilising self-completing questionnaires was conducted amongst 54 radiographers working in public and private hospitals. respondents were required inter alia to indicate the type of support that they were using, the categories of patients seen, what the repeat rate was and whether they thought their method of support was safe. this survey contributed to a needs analysis for consideration of marketing the device. results forty-one (79.5%) of the 54 questionnaires were returned. they were statistically analysed and revealed the following information (tables i iv). from the above results it can be seen that a large percentage of adults required radiography of the hip joint. one practice had a specially designed support but it was not height adjustable. whilst 56.1% of respondents did not have to repeat the raditable i. patients most often/ equally seen (rating = 1) category percentage geriatrics 63.4 adults 56.1 juveniles 10.5 infants 15.8 table ii. method of support (combined figures) support number percentage box 14 34.1 chair 9 21.9 x-ray tube 22 53.7 assistant 18 43.9 specially designed support 1" 2.4 ~ not height adjustable. 37 sa journal of radiology • september2002 short report table iii. repeat radiographs due to poor support response percentage yes no 43.9 56,] table iv, is your current support safe? response percentage yes no 28.6 71.4 ographic projection, 71.4% of the respondents did not regard their current support as being safe. current problems' a chair is: (l) cumbersome; (ii) not height adjustable in most cases; and (iit) difficult to place outside the area of interest. the leg on the x-ray tube means that: (t) the patient feels insecure; (it) the leg has to be shifted several times when the height of the x-ray tube is adjusted patients may not be wearing shoes and may sustain a burn to the heel; and (iii) the foot is exposed to radiation due to its close proximity to the exiting beam. an assistant has: (l) unnecessary exposure to radiation; (it) back strain; and (iii) difficulty experienced in immobilisation. repeat radiographs the major contributing factors for repeat radiographs are as follows: (t) superimposition of the soft tissues of the unaffected limb on the structure being demonstrated; and (it) motional unsharpness due to discomfort experienced by the patient. solution during 1996 the idea of a leg support was disclosed to the research and ethics committee of the medical university of southern africa. the prototype was designed in 1997. the device was tested at ga-rankuwa hospital's x-ray department. the management of the university also recommended that an application for a design protection be lodged. the final product was manufactured in 2002 (figs 2a and 2b). fig. 3 illustrates the application of the device during cross-table lateral radiography of the hip joint. the device may also be used during cross-table radiography of the lower limb (fig. 4), and cross-table radiography of the shoulder (fig. 5). versatility orthotists, prosthetists, occupational therapists, orthopaedic surgeons and plastic surgeons can also 38 sa journal of radiology • september 2002 fig. 2b. side view of the postural support device. note: the device is: lightweight (1.5 kg), height adjustable (43 66 em), portable, safe and aesthetically attractive. fig. 3. positioning for cross-table lateral radiography of the hip joint using the postural support device. fig. 4. positioning for cross-table lateral radio ography of the lower leg. short report fig. 5. positioning for cross-table lateral radiography of the humerus (axilla) us/ng the postural support device. use the device when fitting appliances, traction or dressings. outcomes the application for design protection through the medical university of southern africa resulted in: (i) the compilation and institution of an intellectual property policy at the medical university of southern africa; and (ii) the submission of a portfolio of evidence entitled 'intellectual property an inventor's perspective' as partial fulfilment of a msc in diagnostic radiography offered by the anglia polytechnic university, cambridge, united kingdom. i would like to thank the management of the medical university of southern africa for their support, professor h s schoeman for his assistance with the statistical analysis, mr j van loggenberg for the manufacture of the prototype, mr grant pywell of asg medical equipment services for his assistance in developing the device, mr mike von seidelfor his assistancein the application for design protection, the management of the x-ray department ga-rankuwa hospital for allowing the trials to be conducted and the student radiographers who assisted with the photography of the device.my thanks also go to the following departments at the medical university of southern africa: the department of medical illustration and audio-visual services, the department of occupational therapy and the department of orthopaedics for their assistance in the development and application of the product. i · d· iprimary care ra 10 ogy---------i fa mettlet; jt; milton j guiberteau, carolyn m voss & c e urbina here's a practical resource designed to help practitioners select appropriate radiologic tests for a full range of common disorders. from simple x-rays to sophisticated imaging studies, this clinical reference examines virtually every procedure in use today. it's organized by anatomic system, with a focus on symptoms and suspected clinical problems, to make reference simple. this valuable tool helps readers order even the most expensive and complex radiologic studies with confidence. features e::> examines the pros and cons of a broad spectrum of imaging studies, including their diagnostic value and their cost effectiveness. e::> addresses when a study should or should not be ordered, and the proper sequence in which radiologic tests should be performed for specific symptoms or suspected disorders. e::> offers full coverage of common inpatient and outpatient conditions, such as chest pain, asthma, diabetes, and back pain. e::> describes both adult and pediatric conditions. e::> illustrates normal anatomy, normal variants, and common diseases and disorders with more than 300 clearly reproduced illustrations. e::> includes step-by-step guidance on the interpretation of x-ray images. e::> considers common pitfalls and how to avoid them. e::> highlights vital information with quick reference tables. e::> integrates the perspectives and experience of two radiologists, a general medical internist, and a family practice physician. may 2000, paperback, 285 pp, 340 illustrations, was, r799 orders: sa medical association, private bag xl, pinelands 7430. tel (021) 530-6527. fax (021) 531-4126. e-mail: fpalm@samedical.org limited local stock. 39 sa journal of radiology • september 2002 mailto:fpalm@samedical.org case report 16 sa journal of radiology • june 2006 degenerative leiomyopathy (dl) is a distinctive form of acquired degenerative visceral myopathy of uncertain aetiology. it occurs mainly in africa and results in intestinal pseudo-obstruction (ip). thirtynine patients from the western cape region of south africa have been reported.1 characteristic clinical features included a chronic, insidious history of repeated attacks of abdominal distension, pain and vomiting. marked gaseous distension with atony and ip, especially of the colon, was noted on x-ray films. megacolon was the most common radiological feature, but pseudo-obstruction extended proximally into the small intestine in some patients with advanced disease. in the majority of cases the condition was progressive and eventually affected the entire gastrointestinal (gi) tract.1 we present a single case of a 9-year-old girl with this condition. case report a 9-year-old sotho girl was referred to the casualty department of a regional hospital with a longstanding history of abdominal pain, intermittent vomiting and constipation. the mother had consulted a number of doctors for a diagnosis and treatment, without success. there was no history of any other diseases, allergies or previous surgery. she had never been treated by a traditional healer. there was no family history of any diseases. her maternal grandfather is a xhosa. the patient was a thin girl with severe abdominal distension. on examination the abdomen was soft, non-tender, with no masses or organomegaly palpable. the abdomen percussed tympanic and bowel sounds were diminished. rectal examination was normal. her full blood count and biochemistry were normal. abdominal x-rays showed severe gas-trapping in both small bowel and colon (figs 1 and 2). further management entailed open, full-thickness bowel biopsies. at laparotomy malrotation was noted, as well as distended small and large bowel. three full-thickness biopsies were taken. the child had ‘prolonged ileus’ post-operatively and rae’s mixture was initiated (5 ml tds) with good effect. the histopathology showed fibrotic muscularis propria and no visible smooth-muscle fibres. nerves and ganglion cells were normal. these findings fit in with degenerative leiomyopathy. degenerative leiomyopathy case report z henning, mb chb s m le grange, mb chb, mmed (surg), cps (sa) r s du toit, mb chb, mmed (surg), fcs (sa) department of surgery, universitas hospital, and university of the free state, bloemfontein fig. 2. abdominal x-ray of 9-year-old sotho girl. fig. 1. chest x-ray of 9-year-old sotho girl. pg16-17.indd 16 7/11/06 3:17:47 pm discussion degenerative leiomyopathy (dl) is a distinctive non-familial myopathy degeneration without mechanical causes of obstruction. it affects mostly africans of the south, east and central parts, but patients from other ethnic groups have been identified. aetiology is still unknown, but smooth-muscle toxin appears to be the likely pathogenic agent. toxins administered through cultural practices (herbal enemas containing mostly dichromates) may be an important cause. an infective cause remains an intriguing, if less possible cause. trypanosoma cruzi is blamed as a possible cause.1 dl rarely affects other family members. a genetic predisposition is needed.2 dl, versus hollow-visceral myopathy, presents in an older group of children, and only rarely in the first year of life. mean age at presentation is 9½ years.1 clinical presentation is a very long history of increasing abdominal distension. initially the megacolon is confined to the anorectal junction. it then progresses to the rest of the large bowel, as well as small bowel. it eventually affects the entire gi tract and results in poor intestinal motility and malnutrition. progressive abdominal distention, megacolon and marked gaseous distension may result in an acute presentation. the primary target, however, is the large bowel. involvement of the urinary bladder is seen in the later stages of the disease.1 diagnosis is based on a distinctive clinical presentation of typical radiological findings and histology (degeneration of smooth muscle).1 treatment at this stage is palliative. no regimen of lasting value proves to be effective. in the acute pseudo-obstruction phase, decompression of the bowel with nasogastric suctioning and colonic irrigation may be effective. long-term bowel rest and parenteral nutrition have no long-term success. medical treatment involves regular rectal irrigations, occasional laxatives and prokinetic agents (cisapride, neostigmine, prostigmine). a low residue diet and broad-spectrum antibiotics are indicated if bacterial overgrowth is suspected. surgical resection has been discouraged because of the progressive nature of the disease. a gastrostomy and/or caecostomy can be done to deflate the bowel, but a colostomy has no beneficial effect and has a tendency to prolapse.1 we found one case report in the literature of a 9-year-old boy with pseudo-obstruction, who was treated with rectal cisapride (8 mg/ kg/24h) and neostigmine (0.04 mg/kg/24h). he went into remission for 9 months. intravenous cisapride (0.15 mg/kg) returned bowel movement in the acute phase.3 conclusion the prognosis of this condition is poor. these patients are faced with the prospect of continuous obstructive symptoms and severe malnutrition, which eventually lead to their demise, usually in their late teens.4 1. moore sw, schneider jw, kaschula rdc. non-familial visceral myopathy: clinical and pathologic features of degenerative leiomyopathy. pediatr surg 2002; 18: 2-6. 2. o'neill j jr. paediatric surgery, 5th ed. st louis: mosby, 1998: 1416. 3. cohen np, booth iw, parashar k, corkery jj. successful management of idiopathic intestinal pseudoobstruction with cisapride. pediatr surg 1988; 23: 229-230. 4. william j, byrne md, cipel l, et al. chronic idiopathic intestinal pseudo-obstruction syndrome in children – clinical characteristics and prognosis. pediatr surg 1977; 90: 585-589. 17 sa journal of radiology • june 2006 radiologists auckland, new zealand the auckland region is renowned as a natural playground, boasting new zealand’s most cosmopolitan city, auckland. there’s every reason for you and your career to feel at home in the city of sails with counties manukau district health board. radiologists choose to work at cmdhb for many reasons. it might be the completion of our brand new department, providing you with a modern superbly equipped department. or maybe it’s the friendly can-do nature of the counties manukau staff. or may be it’s the training and opportunities for radiologists to further there career’s we are currently seeking motivated radiologists to fi ll diagnostic and interventional radiology positions. so if this sounds like the move you have been waiting for then hesitate no further. we will provide relocation assistance, including airfares and accommodation, and also help with immigration and registration. so what are you waiting for to fi nd out more please contact renee darby candidate care consultant on 00 64 21 531 940 or email renee.darby@healthalliance.co.nz position number: c00231 www.jobpulse.co.nz/cmdhb you know a great opportunity when you see it. you’ve got middlemore written all over you. pg16-17.indd 17 7/11/06 3:17:50 pm radiology_oct04 focal fatty infiltration and focal fatty sparing of the liver may be confused with multiple liver metastases on both ultrasound and computed tomography (ct) imaging. radiologists need to be aware of this benign condition so that unnecessary investigations and liver biopsies can be avoided. introduction focal fatty infiltration of the liver is caused by focal deposition of intracellular fat within hepatocytes. although more commonly detected in adults it has also been described in children.1 the most common cause is alcohol abuse, although diabetes, obesity, certain drugs, toxins, protein energy malnutrition and anoxia are recorded as causing fatty change. at a cellular level there is accumulation of fat in cytoplasmic vacuoles. the significance of fatty change is dependent on the severity and cause. when mild it has no effect on liver function and is usually reversible. severe fatty change, however, impairs liver function and can cause cell death.2 focal fatty infiltration can cause difficulty in the interpretation of ct and ultrasound studies of the liver and can easily be confused with liver metastases.3 this is especially true of regions where there is no fatty infiltration in an otherwise diffusely infiltrated liver, called focal fatty sparing.4 this misdiagnosis may lead to unnecessary invasive procedures such as biopsies, and further anxiety on the part of the patient. this diagnostic problem can be avoided by performing an initial unenhanced computed tomography (ct) scan of the liver in all suspected cases and then measuring the density of the affected region in hounsfield units. two representative cases in which the correct diagnosis of fatty infiltration was not initially considered are reported. case reports case 1 a 60-year-old woman presented with a 3-month history of right upper quadrant pain. liver function test results were within normal limits. ultrasound examination demonstrated an unhomogeneous echogenic liver in which multiple liver metastases were suspected. an unenhanced ct study demonstrated multiple geographical areas of low density in the both the left and right lobes. measurement of the liver density confirmed that the lower density areas had a mean density reading of 20 hounsfield units (hu) while the normal parenchyma had a mean density measurement of 40 hu (fig. 1a). the contrast-enhanced study demonstrated decreased perfusion in those regions of low density (fig. 1b). a diagnosis of focal fatty infiltration of the liver was made. the patient was subsequently found to have type 2 diabetes, and her pain settled on oral hypoglycaemic agents. case 2 a 32-year-old woman known to have type 1 diabetes presented with right upper quadrant pain. gallstones were suspected on the basis of the clinical symptoms, and an ultrasound examination confirmed their presence. in addition multiple echogenic lesions resembling liver metastases were noted in both lobes. an ultracase report 25 sa journal of radiology • october 2004 focal fatty infiltration and focal fatty sparing of the liver p corr ffrad (d), frcr, mmed, md department of radiology nelson mandela school of health sciences durban fig. 1a. unenhanced ct of the liver in case 1 demonstrates multiple focal low density regions in both lobes of the liver. region of interest 1 over the fatty left lobe measured 10 hu while region of interest 2 over the right lobe measure 40 hu in keeping with focal fatty infiltration. fig.1b. contrast-enhanced ct at the same level demonstrates the hepatic and portal vein branches passing normally through the regions of fatty infiltration. 26 sa journal of radiology • october 2004 sound-guided percutaneous biopsy of a left lobar lesion demonstrated focal fatty infiltration of otherwise normal hepatocytes. ct of the liver demonstrated multiple areas of low density in both lobes in keeping with diffuse fatty infiltration, with ‘pseudo-lesions’ of foci of normal enhancing liver parenchyma (figs 2a and 2b). a diagnosis of focal fatty sparing of the liver was made. discussion in both these cases an initial diagnosis of liver metastases was considered on the basis of on the ultrasound findings. this is understandable, as the echogenicity of these pseudolesions differs from that of the surrounding parenchyma.5 in both cases measurement of the parenchymal density of the liver on ct suggested the correct diagnosis. the normal density of the liver on unenhanced ct is between 40 and 50 hu. after contrast injection the density reaches 80 120 hu. a good comparison of normal hepatic enhancement is comparison with the enhanced spleen, which has a similar enhanced density. fatty change or infiltration will measure anywhere from 10 to 20 hu. an important diagnostic pointer to the correct diagnosis is the fact that normal hepatic venules and portal venules run through these pseudolesions and are not displaced as would be expected by a focal mass. the true prevalence of focal fatty change or infiltration is unknown in adults, although a recent study in san francisco demonstrated a prevalence of 25.6% in adolescents aged between 15 and 19 years of age.1 although the causation of fatty change or infiltration is well known, the distribution within the liver of focal fatty infiltration and focal fatty sparing is not clearly understood. it is postulated that the distribution of fat deposition is related to regional differences in liver perfusion. studies using ct portography have demonstrated that regions of fat deposition are associated with decreased perfusion.6 yoshimuitsu et al.7 have demonstrated that these hepatic pseudolesions are due to a ‘third inflow’ of blood to the liver via the cholecystic, parabiliary or epigastric-paraumbilical veins.7 the cholecystic vein drains segments iv and v. the parabiliary veins originate in the hepatoduodenal ligament and pancreas to supply the porta hepatis and segment iv. the epigastric-paraumbilical veins drain the abdominal wall into the liver in the region of the falciform ligament.7 the region around the falciform ligament, the porta hepatis and gallbladder fossa bed are usually affected, while the medial segment of the left lobe, especially segment 4, is often spared.5,6 there appears to be an association between the presence of focal fatty sparing in the medial segment of the left lobe and anomalous gastric venous drainage.8 magnetic resonance imaging (mri) has been reported to be diagnostic in confirming the presence of fatty infiltration using opposed phase gradient echo sequences or fat saturation sequences.9,10 these two cases demonstrate the importance of complementary imaging investigations in assessing focal liver pathology. radiologists should always remember to include an unenhanced ct study in their liver imaging protocols and to measure the ct density of focal liver lesions if they are unsure of the diagnosis. references 1. kammen bf, pacharn p, thoeni rf, et al. focal fatty infiltration of the liver: analysis of prevalence and ct findings in children and young adults. ajr am j roentgenol 2001; 177: 10351039. 2. cotran rc, kumar v, collins t. cellular pathology ii. in: cotran rc, kumar v, collins t, eds. pathologic basis of disease. 6th ed. philadelphia: wb saunders, 1999: 31-49. 3. kemper j. ct and mri findings of multifocal liver steatosis mimicking malignancy. abdom imaging 2002; 27: 708-710. 4. mckenzie a. computed tomographic and ultrasound appearances of focal fatty infiltration. aust radiol 1991; 35: 166-168. 5. chong vf, tan yf. ultrasonic hepatic pseudolesions: normal parenchyma mimicking mass lesions in fatty liver. clin radiol 1994; 49: 326329. 6. paulson ek. focal fatty infiltration: a cause for nontumorous defects in left lobe during during ct portography. j comput assist tomogr 1993; 17: 590-595. 7. yoshimuitsu k, honda h, kuroiwa t, et al. unusual haemodynamics and pseudolesions of the noncirrhotic liver at ct. radiographics 2002; 21: s81-s96. 8. kawamori y. focal hepatic fatty infiltration in the posterior edge of the medial segment of the liver associated with anomalous gastric venous drainage. j comput assist tomogr 1996; 20: 356359. case report fig. 2a and 2b. contrast-enhanced ct in case 2 demonstrates multiple pseudolesions in both lobes from focal fatty sparing. note that the normally enhancing parenchyma measures 80 hu (region of interest 2) while the region of fatty infiltration (region of interest 1) measures 15 hu. case report gradenigo's syndrome p potgieter mbchb e loggenberg mmedrad(d) department of diagnostic radiology university of the free state bloemfontein case report a 3-year-old child with a oneweek history of otitis media was treated with intravenous antibiotics in a peripheral hospital. the child then presented with a painful left eye, mild periorbital oedema, diplopia, and otorrhoea from the left ear. on examination the following were found: suppurative otitis media left ear with perforation of the tympanic membrane, musculus rectus lateralis paralysis left eye, facial pain on the left side with n.vi and n.v2 distribution, and periorbital oedema. computed tomography (ct) revealed left mastoid sinus (with air present), and left middle ear and external ear canal opacification. localised phlebitis was indicated by air in the superior and inferior petrosal venous sinuses, as well as the cavernous sinus on the left side. no bone destruction/osteitis was seen, but there was pneumatisation of petrosal bone (figs 1 3). ten-day treatment was given with resolution of the infection and healing .of the tympanic membrane. the treatment included the intravenous antibiotics augmentin (amoxicillin plus clavulanate), metronidazole and chloramphenicol. fig. 1. coronal of brain with air in petrosal venous sinus. fig. 2. axial of brain with air in petrosal venous sinus. discussion a syndrome characterised by the triad of suppurative otitis media, trigeminal nerve pain in the first divi35 sa journal of radiology • june 2002 fig. 3. coronal of brain with air in cavernous sinus. sion distribution and abducens nerve (n.vi) palsy was first described in 1907 by guisseppe gradenigo.' if not recognised early, the syndrome may have fatal complications. incidence of the syndrome has declined with the early use of antibiotics, but it is still seen in neglected cases of otitis media. the diagnostic criteria include suppurative otitis media, trigeminal nerve pain (n.vi) and occasionally n.v2 distribution, and abducens nerve palsy presenting as rectus lateralis palsy of the eye.i otitis media is a common ear infection. with the early use of antibiotics, complications are relatively mild, with perforation of the tympanic membrane most common. more severe complications may arise if the infection is neglected, or the pathogen is resistant to antibiotics. the complications include meningitis, intracranial abscess, spread to the skull base with involvement of ix, x, xi cranial nerves (vernet's syndrome), cavernous sinus involvement, and prevertebral/parapharyngeal abscess.' these complications are presented as: (lj suppurative otitis media with otorrhoea, usually accompanied by mastoiditis; (ii) trigeminal nerve pain due to irritation of the gasserian case report abducens palsy with petrous apicitis ct of brain and hrct of temporal bones ~~ bone erosion or history of chronic ear disease no bone erosion or history of chronic ear disease 1. culture directed iv antibiotics 2. mastoidectomy with drainage of petrous apices 1. culture directed iv antibiotics 2. myringotomy fig. 4. algorithm of management of patients with nervus abducens palsy. ganglion situated in meckel's cave; (iii) abducens nerve palsy presents as m. rectus lateralis weakness/palsy of the eye due to compression of the nerve in dorello's canal, a dural sheath at the petrosphenoidalligament; (iv) periorbital oedema may also be a presenting symptom; and (v) retrobulbar pain. the infection may spread via pneumatised air cell tracts, through vascular channels, or direct extension through facial planes. the infection may spread to the petrous apex of the temporal bone, giving rise to apical petrositis in patients with suppurative otitis media. petrositis may be acute or chronic, depending on the clinical course and severity of the disease. fig. 4 represents a general regimen for approaching a patient with n.v1 palsy.' pneumatisation plays an important role in the spread of the disease throughout the mastoid and petro us bone, but infection and inflammation may also spread to areas of non-pneumatised petrous bone by way of direct extension or venous channels. in this case study, involvement of the cavernous sinus added a twist as to how the infection could spread and the complications that could follow if the patient was not examined and treated properly. references 1. motamed m, kalan a. gradenigo's syndrome. postgrad med j2000: 76: 559-560. 2. minotti am, kountakes se. management of abducens palsy in patients with petrositis. ann otol rhinal laryngol supp11999; 108: 897-902. 36 sa journal of radiology. june 2002 abstract background review question objectives methods steps of scoping review results discussion conclusion acknowledgements references about the author(s) ntombizakhona b.a. mthalane department of radiology, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa nondumiso n.m. dlamini department of radiology, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa citation mthalane n.b.a. dlamini n.n.m. multidetector computed tomography has replaced conventional intravenous excretory urography in imaging of the kidneys: a scoping review of multidetector computed tomography findings in renal tuberculosis. s afr j rad. 2018; 22(1), a1283. https://doi.org/10.4102/sajr.v22i1.1283 original research multidetector computed tomography has replaced conventional intravenous excretory urography in imaging of the kidneys: a scoping review of multidetector computed tomography findings in renal tuberculosis ntombizakhona b.a. mthalane, nondumiso n.m. dlamini received: 08 oct. 2017; accepted: 19 nov. 2017; published: 16 feb. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: tuberculosis (tb) is a worldwide infectious disease burden, especially in non-developed countries, with increased morbidity and mortality among human immunodeficiency virus (hiv)-infected patients. extrapulmonary tb is rare and renal tb is one of the commonest manifestations. the end result of renal tb is end-stage renal disease; however, this can be avoided if the diagnosis is made early. the diagnosis of renal tb is challenging because of the non-specific presentation and low sensitivity of clinical tests. although the sequel of tb infection in the kidney causes varying manifestations depending on the stage of the disease, multidetector computed tomography (mdct) is capable of demonstrating early findings. we performed a 20-year scoping review of mdct findings in renal tb to promote awareness. aim: to identify specific mdct imaging characteristics of renal tb, promote early diagnosis and increase awareness of the typical imaging features. methods and material: we searched published and unpublished literature from 1997 to 2017 using a combination of search terms on electronic databases. we followed the joanna briggs institute guidelines. results: a total of 150 articles were identified, of which 145 were found through electronic search engines and 5 were obtained from grey literature. seventy-nine articles that fulfilled our inclusion criteria were reviewed. these included original research, case reports, literature review, organisational reports and grey literature. conclusion: multidetector computed tomography can reproduce images comparable with intravenous excretory urography; together with advantages of being able to better assess the renal parenchyma and surrounding spaces, it is important in suggesting the diagnosis of renal tb and clinicians should consider including mdct when investigating patients with recurrent urinary tract infection not responding to usual antimicrobial therapy. background tuberculosis (tb) is the commonest communicable infectious disease worldwide and continues to be a serious burden in non-developed countries, being among the top 10 causes of death worldwide.1,2 south africa is one of the top 6 countries in the world with the highest incidence of tb.1 infection with human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids) increases the risk of contracting tb infection and also increases mortality from the disease.1,3,4 hiv-infected patients contributed to 55% of notified tb cases in 2015.1 the incidence of multidrug-resistant and extremely drug-resistant tb is seen to be on a rise in south africa according to the world health organization (who). the use of a more sensitive diagnostic test, that is, genexpert, allowing early diagnosis and initiation of treatment has been implemented in the call to stop the tb epidemic. one of the main goals of the who is to end the global tb epidemic and one of the implementations includes preventative measures such as the use of prophylactic treatment for children and hiv-infected patients.1 tuberculosis is usually caused by infection with mycobacterium tuberculosis; however, there are other described mycobacteria.4,5,6,7,8,9,10,11 tb can affect any system in the body and pulmonary tb is the most common form.2,5,12,13 extrapulmonary tb is uncommon; however, co-infection with hiv or other immunocompromised states increases susceptibility.5,14 urogenital tb is one of the common forms of extrapulmonary tb, with the kidney being the commonest site of infection, accounting for 15% – 20% of cases of extrapulmonary tb.5,10,13,15,16 renal tb may occur as part of disseminated infection or as localised disease.4,8,21 the spread of infection to the kidney is almost always haematogenous from a pulmonary source with inoculation of mycobacteria in the renal cortex forming granulomas.7,16–21 these are invisible on imaging and, in the immunocompetent state, may remain indolent for 5–25 years; however, reactivation may occur during the immunocompromised state, resulting in enlargement and coalescence of the granulomas which then rupture into the renal tubular system.7,16,22–26 some literature report a latent period of up to 40 years.10,11,16 renal tb is particularly rare in children because of the long latent period and it is even rarer in children below 5 years of age.8,9,11,18,23,27 renal tb has been reported to be common in young adults with a male predominance.5,9,11,17,27 the diagnosis of renal tb is difficult and is often delayed because the presence of constitutional symptoms is uncommon, clinical symptoms are non-specific and clinical tests have a low sensitivity.11,13,15,16 patients may present with haematuria, flank pain and sterile pyuria.5,8,11,16,27 renal tb should be strongly suspected in patients with sterile pyuria and recurrent urinary tract infection not responding to normal regimens of antimicrobial treatment, especially in endemic areas.14,15,21,24,26 delayed diagnosis of renal tb often results in end-stage renal disease (esrd) either because of parenchymal destruction or as a complication of chronic obstruction. this increases morbidity and mortality from the disease.14,15,24,28 although radiological manifestations of renal tb are variable,9,12,15,27 multidetector computed tomography (mdct) may aid in early diagnosis of the disease and early initiation of treatment and thus prevention of irreversible complications.2,11,22,25,29 a spectrum of renal pathology ranging from papillitis which eventually causes papillary necrosis, cavitation and spread of infection into the pelvi-calyceal system may occur. extension of infection into the renal pelvis may result in pyonephrosis. urothelial infection and inflammation subsequently progress to fibrosis and the formation of strictures. the ureter often has multiple strictures, which is pathognomonic and strictures in the distal ureter may result in megaureter.2,6,11,16,29 distal ureteric strictures may be secondary to vesicoureteric reflux. strictures at the infundibulum, renal pelvis and pelvi-ureteric junction are also common. varying patterns of hydronephrosis and hydrocalicosis may occur depending on the site of obstruction.2,7,10,11,12,29 urinary bladder involvement causes interstitial cystitis and granulomas may form in the bladder wall mimicking tumour; the end result is that of fibrosis of the bladder wall and reduced bladder capacity.6,7,13,16,26 the end result of chronic infection of the kidney is renal tissue destruction, which is subsequently replaced by dystrophic calcifications and autonephrectomy, also known as ‘putty kidney’.4,12,16,26,30 calcifications in the wall of the ureter and in the bladder wall may also be seen.6,16,17,30 renal tb infection may also spread beyond the renal capsule and form masses, also known as ‘pseudotumour’, which can be confused with renal malignancy.2,7,12,17,27,29 rarely, renal tb may present with single or multiple parenchymal nodules without involvement of the renal collecting system, known as the pseudotumour type.7,12,29 perinephric abscesses which may further complicate with formation of renal sinuses and fistulae are very rare.6,7,11,26,29 the presence of findings related to disseminated tb may be seen through computed tomography (ct) imaging, which may support the diagnosis of renal tb, that is, necrotic or calcified lymph nodes, hepatic and splenic granulomas, adrenal calcifications as well as spinal abnormalities.2,7,10 patients with pulmonary tb and disseminated tb infection may rarely present with renal failure without any evidence of disease in the kidneys, as a result of interstitial nephritis.4,7,11,20 because of haematogenous seeding of mycobacteria to the kidneys, both kidneys are usually affected although clinical and radiological assessment of the kidneys may show pathology in one kidney. it is therefore important to carefully examine the opposite side for subtle changes.16,21,26 patients with renal tb require close monitoring after initiation and completion of treatment because healing occurs by fibrosis resulting in progression of ureteral and pelvic strictures.2,15,24,26 six-monthly follow-up with renal ultrasound (us) for a period of up to 2 years is recommended.15 disease process and spread is almost always in a descending pattern; however, cases of ascending spread of infection from primary genital tb and also rarely as a complication of bacillus calmette–guérin (bcg) injection into the bladder to treat early stage bladder cancer have been reported.2,8,11,12,16 most patients with renal tb have a normal chest x-ray or may have scarring from previous infection.10,11 the diagnosis of renal tb poses a challenge because of the non-specific presentation as well as the intermittent and low yield of the mycobacteria in the urine resulting in a low sensitivity of urine tests. three early-morning urine specimens for acidfast bacilli (afb) culture and histology is the gold standard for the diagnosis;8,13,16,19 however, urine culture demonstrates a low sensitivity of 30% – 40%.15 some authors suggest more specimen collection, up to 5 and even up to 10 specimens.13,23 polymerase chain reaction (pcr) is reported to be more sensitive.8,11,20,29,31 the diagnosis of renal tb requires a high index of suspicion and radiologists play a critical role.6,7,10 computed tomography is readily available, and in the modern era, computed tomography urography (ctu) surpasses traditional intravenous excretory urography (ivu) in renal imaging because it allows comprehensive assessment of the renal parenchyma and surrounding spaces and structures, and better assessment of the urothelial and urinary bladder wall.3,6,22,32 an additional advantage of ct is the assessment of renal function.29,33 intravenous excretory urography, however, has a higher sensitivity in the assessment of early irregularity of the calices (moth-eaten calices) and early changes in the mucosa of the urothelium (mucosal ulcerations),10,17,24,27 but does not allow accurate assessment of the renal parenchyma and surrounding spaces and structures.6,11 other advantages of mdct include the use of reformatted images such as multiplanar reconstruction (mpr), which includes curved mpr to straighten or visualise the entire length of the ureter on the coronal view; the use of maximum intensity projection (mip) and three-dimensional (3d) reconstruction.6,22,32 in addition, using a bone display window when assessing the urinary tract on excretory phase imaging eliminates glare from high-density structures and thus helps with the assessment of calcifications and small urothelial lesions.6 all these technical advances can help optimise the assessment of the renal tract and its complex anatomy as well as help enhance pathology on mdct.6 high radiation dose to the patient is the major concern in multiphase ct imaging of the urinary tract.22,26,29,32,34 awareness of the mdct features of renal tb is important as these may be subtle and unless one actively searches for these features, they may be easily missed.2,3,7 there are several case reports and literature reviews pertaining to mdct imaging findings in renal tb. some original research has been conducted across the world; however, according to our knowledge, there is no research identified in africa regarding the subject. we performed a scoping review of the mdct findings of renal tb, covering a 20-year period, to map these findings and emphasise the importance of meticulously searching for them as well as to promote awareness, especially in patients with known pulmonary tb or disseminated tb infection. we also reviewed the ct imaging protocols that are most appropriate for the diagnosis while considering the effects of high radiation dose acquired from mdct. use of appropriate mdct renal protocol will help improve the sensitivity of mdct in diagnosing renal tb. review question multidetector ct is the modern imaging modality of choice in the diagnosis of renal tb, but unless one meticulously searches for specific features especially in early disease, these can be easily missed, thus subjecting the patient to the detrimental result of end-stage renal failure. early mdct findings of renal tb would include papillary necrosis, cortical granulomas, renal cavitation and abscesses, thickening and enhancement of the urothelium associated with strictures of the infundibulum, renal pelvis and ureter, irregularity of the urothelium involving the renal calices and ureter, non-uniform hydrocalicosis as well as hydronephrosis. it is unclear if radiologists interpreting mdct images of patients with or suspected with tb infection would actively look for renal involvement. objectives the objectives of the study are as follows: to systematically scope the literature on mdct imaging of renal tb to identify specific mdct imaging characteristics of the disease process, promote early diagnosis and increase awareness of the typical imaging features to generate a comprehensive and well-defined list of the mdct imaging findings using a chart, which will help guide radiologists in making a more accurate diagnosis to review the current mdct imaging protocol for suspected renal tb that will increase the accuracy of ct in making the diagnosis. methods a scoping review is a newer and sound method for mapping areas of research and presenting results in an accessible format for knowledge users. although it does not entail quality assessment, it is a rigorous and systematic approach to knowledge synthesis. it provides an overview of the existing literature and can help in identifying the fields in which more research might be necessary in the future. we conducted a scoping review to examine the literature on mdct findings of renal tb. this synthesis method will allow us to explore the broad topic of knowledge from different studies and literature. this scoping review proposal protocol was approved by the university of kwazulu-natal postgraduate office. the study did not require ethical approval. steps of scoping review two reviewers independently collected literature published from january 1997 to june 2017, pertaining to the aims and objectives of the study. we followed the scoping review methods outlined by the joanna briggs institute, which proposes the following framework for the structure of scoping review: (1) title, (2) background, (3) review question/objective, (4) inclusion criteria, (5) search strategy, (6) results, (7) discussion and (8) conclusion including implication for research practice.35 the steps followed in performing the scoping review include the identification of a research question, searching for relevant literature, categorising the topics of included literature, charting and analysis of the selected literature and consulting experts in the research fields, including librarians. identification of relevant literature a comprehensive search to identify both published and unpublished (grey) literature was performed. identification of studies and literature relevant to this scoping review was achieved by searching electronic databases of the published and unpublished literature, which included medline, pubmed, researchgate, cumulative abstracts and case reports, ebscohost and google scholar. our search strategy involved using a combination of search terms that were determined with input from the two reviewers. these included renal tb imaging, mdct imaging of renal tb, mdct + renal tb, extrapulmonary tb imaging and granulomatous nephritis. input from university of kwazulu-natal research librarians was used. selection of literature the selection of data included literature review articles, original research, case reports and health organisation reviews and reports backdated from january 1997 to june 2017. review articles, case reports and original research pertaining to renal tb and radiological and non-radiological publications were included. current reports on the tb pandemic in the world and in south africa also fulfilled our inclusion criteria. the study population included male and female patients of all age groups and there was no geographic limitation. we only selected articles that were published in english. literature focusing on other forms of tb involving other parts of the body, excluding renal tb in the discussion, did not fulfil our inclusion criteria. literature outside our study period was also excluded. data extraction and charting of data windows excel was used to capture and analyse data as per our inclusion and exclusion criteria. the spread sheet was designed to fulfil the aims and objectives of our study. a flow chart was used to summarise the data analysis. results the systematic process of selection of the articles that we reviewed is demonstrated in figure 1. a total of 150 articles were identified, of which 52 articles were excluded because they did not fulfil the inclusion criteria. reasons for exclusion were the following: articles published before 1997, articles that discussed renal tb outside the mdct context (i.e. ultrasound, plain x-ray, magnetic resonance imaging and nuclear imaging), articles discussing extrapulmonary tb but renal tb was not part of the discussion and articles published in languages other than english. all included studies were reviewed and charted independently by two reviewers. figure 1: flow chart showing the selection of articles reviewed. discussion the early mdct findings of renal tb include papillary necrosis which is seen as small poorly marginated areas of hypoattenuation on the nephrographic phase at the tip of the medullary pyramid which gradually extends to involve the entire renal medulla (figure 2). detachment of the necrotic papilla may produce the appearance of a ‘signet ring sign’, seen on the excretory phase as a filling defect in the renal calyx with contrast seen tracking at the periphery of the pyramid.6 wedge-shaped areas of low attenuation or hypoperfusion involving the renal cortex and medulla which cannot be differentiated from other causes of acute pyelonephritis may be seen. this is because of localised inflammation with vasoconstriction and oedema (figure 2).29,36 cavities may form in the renal parenchyma appearing as low-attenuating fluid-filled non-enhancing structures on all phases that fill with contrast on the excretory phase because of their communication with the renal collecting system (figure 3). these may rupture into the perinephric space, forming perinephric abscesses which are seen as rim enhancing hypodense areas with associated thickening of the gerota’s fascia.6,29 small cortical granulomas may be seen on the corticomedullary and nephrographic phases as small rounded minimally enhancing hypoattenuating lesions in the renal cortex.3,6,33,37 occasionally, parenchymal abscess collections are seen as hypodense collections with mild rim enhancement, which are indistinguishable from non-tuberculous abscesses. these may also rupture into surrounding spaces, causing complications.6,29 enhancing single or multiple renal parenchymal masses that do not communicate with the renal collecting system may be seen in ‘psuedotumour type’ (figures 4 and 5).6,29,36 figure 2: post-contrast scan (venous phase) computed tomography (ct) abdomen: (a–d) several small wedge-shaped areas of hypoattenuation in the right kidney in keeping with pyelonephritis (red arrow). few similar areas are noted in the left kidney (yellow arrow). large fluid-filled cavity in the right renal mid pole (black arrow). moderate ascites with associated thickening and enhancement of the parietal peritoneum (white arrows) in keeping with peritonitis. there is also bilateral pleural effusion with associated relaxation atelectasis in the posterior left lower lobe (blue arrows). figure 3: (a) venous phase computed tomography (ct) abdomen demonstrates severe left hydronephrosis (white arrow) because of stricture in the pelvi-ureteric junction, with complete effacement of the renal parenchyma. a parenchymal cavity (black arrow) is present in the right kidney with surrounding heterogeneous low attenuation (red arrow) suggestive of pyelonephritis. (b) delayed phase ct abdomen demonstrates contrast filling of the right renal cavity suggestive of communication with the calyceal system. the left kidney is non-functional. figure 4: post-contrast computed tomography (ct) abdomen, venous phase (a – axial, b – coronal, c – sagittal) and d – delay renal phase (mpr coronal) – a, b and c demonstrate a large heterogeneously enhancing left renal mass with a small cystic area (white arrow). (b) there is invasion of the gerota’s fascia with associated thickening and enhancement (red arrow). (d) there is stenosis of the infundibula (yellow arrows) with slight focal caliectasis and distortion of the calices (black arrows). figure 5: post-contrast computed tomography (ct) (axial, coronal) shows: (a and b) bilateral hydronephrosis with non-uniform dilatation of the calices with areas of cortical thinning (red arrows). the calices are irregular and there is diffuse urothelial enhancement (white arrow). there are also patchy heterogeneous areas of reduced enhancement of the renal parenchyma with mass like areas of confluence (yellow arrow). the kidneys are enlarged. in the renal collecting system, early disease is demonstrated as irregularity of the renal calyces because of ulceration. infundibular stenosis and amputation of the infundibulum with uneven hydrocalicosis are visualised on the excretory phase (figures 4 and 6). overlying parenchymal thinning and areas of parenchymal scaring may be noted (figures 5 and 6).2,3,6,29,33,36,37 focal or diffuse calicosis may be seen without dilatation of the renal pelvis.29 urothelial inflammation demonstrates urothelial wall thickening and enhancement with surrounding fat stranding (figures 5 and 6). a sawtooth appearance of the ureter may be seen because of ulceration. multiple fibrotic strictures can present with a corkscrew appearance of the ureter. coalescence of ureteric strictures results in straitening and a fixed appearance of the ureter, the ‘pipestem ureter’. associated hydronephrosis and hydroureter are also evident.6,29,33,36,37 bladder involvement causes mural thickening and enhancement because of cystitis. bladder wall granulomas are noted as filling defects extending from bladder wall on the excretory phase.6,33,36,37 figure 6: post-contrast scan (venous phase) computed tomography (ct) abdomen demonstrates (a) multiple scattered calcified splenic granulomas (green arrow) and (b and d) calcified mesenteric and retroperitoneal lymph nodes (white arrows). (c) small fluid-filled cavity in the right renal upper pole with adjacent cortical scarring (red arrow). the left kidney is shrunken with non-uniform calicosis (blue arrow) and adjacent parenchymal thinning. there is also prominence of the renal pelvis and thickening and enhancement of the urothelium (yellow arrow) suggestive of a pyelonephritis. the late mdct findings include severe hydronephrosis with marked thinning of the renal cortex and loss of renal function because of chronic obstruction by pelvic or ureteric strictures (figure 3).3,6,29,36 destruction of the renal parenchyma with a shrunken kidney which is replaced by dystrophic calcifications is referred to as ‘putty kidney’ (figure 7). this is end-stage disease and the kidney is non-functional at this stage with no excretion of contrast from the kidney, autonephrectomy.6,24,36 amorphous, spotted, curvilinear, triangular or ring-like calcifications within the collecting system are characteristics of papillary necrosis. lobar calcifications within the collecting system are in line with ‘putty kidney’.6,24,29,33 chronic bladder involvement results in a shrunken bladder with low capacity, which is known as a thimble bladder in the severe form. ureteral and bladder wall calcifications may be seen.6,33,37 uncommon findings and complications include fistulae and sinus formation, which may appear as soft tissue tracts that may be filled with excreted iodine contrast with extensive perirenal inflammatory changes.6,29 concomitant findings of extrapulmonary tb, such as hepatic and splenic granulomas, mesenteric and retroperitoneal lymph nodes, psoas abscess and spine findings may support the suspicion of renal tb (figures 2 and 6).2,3,29 the mdct findings of renal tb are further simplified in the chart provided in figure 8. figure 7: (a and b) venous phase post-contrast computed tomography (ct) demonstrates a shrunken left kidney replaced by dystrophic calcifications (white arrow), in keeping with a ‘putty’ kidney. (c and d) renal delay ct demonstrates contrast excretion in the right kidney (red arrow) and no contrast excretion in the non-functional left kidney, in keeping with autonephrectomy. figure 8: computed tomography findings in renal tuberculosis. the categories of reviewed articles included original research, case reports, literature review (radiological and non-radiological), organisational reports and grey literature. the original research reviewed pertaining to mdct imaging of renal tb is summarised in table 1. moreover, one south african non-radiological original research article regarding renal tb was identified. in this article, nourse et al. performed a study to assess the role of tb in children co-infected with hiv and concluded that tb contributed to proteinuric renal disease. however, it is not clear if this was because of direct infection of the kidney with mycobacterium tb. table 1: summary of original articles on multidetector computed tomography imaging of renal tuberculosis. the clinical presentation of renal tb is summarised in figure 9. of the reviewed case reports, the common presentation was esrd.15,20,21 some of the patients were misdiagnosed, with the final diagnosis of renal tb being made months after initial presentation.16 other presentations included a renal mass which was misdiagnosed as renal cell carcinoma. rare presentations included a sinus in the back at the renal angle and paraspinal regions.9,12,17,23,27 a rare case of association of renal tb with renal tumour was identified.38 few case reports of renal tb in paediatric patients were identified, including that of a 9-month-old.9,18,23 complications of renal tb include formation of sinuses and fistulae, psoas abscess, stricture formation in the renal collecting system, renal failure as well as arterial hypertension.23 the patients discussed in the identified case reports did not have co-infection with hiv. figure 9: clinical presentation of renal tuberculosis. kulchavenya31,39 has classified renal tb into the following four stages: stage 1 – non-destructive form (disease confined to the renal parenchyma. full recovery of the kidney is possible). stage 2 – small destructive form (tb papillitis involving one or both sides; single or multiple. responds to drug therapy. prognosis is favourable). stage 3 – destructive form with one or two caverns (cavernous kidney tb involving one or both kidneys. it may require surgery). stage 4 – widespread destruction form with more than 2 caverns (polycavernous kidney tb which may lead to decreased renal function. pyonephrosis may develop with formation of fistula. it may be self-limiting; the end result is autonephrectomy. contralateral kidney is almost always involved. it almost always requires surgical treatment.). he has also classified bladder tb as follows: stage 1 – infiltrative form (tubercles) stage 2 – ulcerous form (erosive) stage 3 – spastic cystitis (overactive bladder) stage 4 – true microcystitis (shrunken bladder). although ivu is known to be more accurate in the evaluation of early changes in the renal collecting system, that is, moth-eaten calices, infundibular stenosis, amputation of the infundibulum and mucosal ulceration in the ureter, gaudiano et al. demonstrated that the use of mpr and mip images on excretory phase imaging can reproduce images comparable with ivu with high diagnostic accuracy, which is supported by merchant et al. interestingly, wang et al. demonstrated no significant difference in the depiction of moth-eaten calices, amputated infundibulum, autonephrectomy, urinary tract calcifications, renal parenchymal cavities, hydrocalicosis, hydronephrosis and hydroureter on ivu and mdct. the imaging findings of renal tb are non-specific and have a long list of differential diagnosis; however, demonstration of multiple (≥ 2) findings is suggestive of the diagnosis.2,7,10,21,29,33 wang et al. found the presence of multiple findings in their patients in 94% of ivu and 100% of ct examinations. browne et al. recommend that any male patients presenting with uti should be imaged using us as the initial imaging screening tool and women should be imaged after two to three episodes within a 12-month period. in addition, every male patient that is diagnosed with genital tb should be actively investigated for renal tb because of the strong association.4 they also advise that immunocompromised and diabetic patients should be imaged early. the differential diagnosis for renal tb on mdct includes other causes of chronic pyelonephritis and papillary necrosis, xanthogranulomatous pyelonephritis as well as renal cell carcinoma and transitional cell carcinoma.10,12,15,16,21 schistosomiasis should be considered if there is bladder wall calcification; however, in contrast to urogenital tb, there is predominant involvement of the urinary bladder without destructive involvement of the upper urinary tract.16,33,37 treatment of renal tb includes use of anti-tb therapy for a prolonged period, nephrectomy for non-functioning kidneys and renal masses and nephrostomy or stent placement for ureteric strictures to relieve obstruction.2,9,11,12,16,19,27 fine needle aspiration (fna) should be considered before performing nephrectomy in patients from an endemic area presenting with an atypical renal mass.9,12,18,27,29 this is an important consideration in young patients as renal tissue can be preserved if the diagnosis of tb is made preoperatively.9 a high radiation dose to the patient is the major concern in multiphase ct imaging of the urinary tract.22,26,29,32,34 the main aim of ct is to obtain images with opacification of the entire renal collecting system. however, this may be a challenge because of the presence of peristalsis resulting in non-opacification of some parts of the ureters, especially the mid and distal ureters.32 current imaging protocols utilise threeor four-phase scans, which include an unenhanced scan and corticomedullary, nephrographic and excretory phase scan.3,22,32,34 unenhanced images are used as baseline in the assessment of calcifications, hounsfield unit (hu) of the lesions and degree of enhancement of renal lesions.7,22,32 nephrographic phase is performed after intravenous injection of 100 ml–150 ml of 300 mg iodine contrast, at 100 s when both the cortex and medulla enhance. this phase allows adequate depiction of renal parenchymal lesions.32 the excretory phase is obtained to assess the urothelium. the nephrographic phase is omitted in the three-phase scan. use of 250 ml of iv normal saline in adjunct with 10 mg of furosemide has been proven to improve distension and opacification of the renal collecting system; however, furosemide should not be used in patients with contraindications to the medication.32 several options are available to reduce the radiation dose in ct renal imaging. one of them is by reducing the number of scans and performing only two phases, comprising an unenhanced scan and a split-bolus phase scan. in this method, initially, a small contrast bolus (30 ml) is administered iv followed by a larger bolus (100 ml–120 ml) after a 10–15 min delay. computed tomography scanning is performed after the second contrast bolus (see figure 10). this allows for a combination of excretory and corticomedullary phase in one scan. other options include the use of an automatic tube current modulator, increasing pitch and slice thickness as well as reducing the scan field (i.e. covering the kidneys only for the corticomedullary phase).34 figure 10: recommended split-bolus computed tomography imaging protocol for diagnosis of renal tuberculosis. conclusion renal tb is one of the common manifestations of extrapulmonary tb. diagnosis of the disease is challenging because of the non-specific presentation and a multidisciplinary approach will assist in early diagnosis. radiologists can play a pivotal role in suggesting the diagnosis to the clinicians as early features are readily visualised on mdct. identification of acid-fast bacilli in the urine and histology specimens is however the gold standard for the diagnosis. clinicians should consider including mdct imaging when investigating patients with recurrent urinary tract infection, not responding to usual antimicrobial regimens. we suggest a two-phase mdct imaging protocol which would increase the accuracy of the diagnosis while lowering radiation dose to the patients (figure 10). we have simplified the mdct findings of renal tb in the chart provided in figure 8. we also emphasise the importance of using mpr and mip images to enhance early pathology. research in larger population groups, in endemic areas especially in africa, is recommended to focus on assessing the accuracy of mdct in early diagnosis of renal tb as well as the spectrum of mdct manifestations in our population group, particularly those co-infected with hiv/aids. studies in larger population groups are also recommended in endemic areas to assess the prevalence of renal tb in hiv-infected patients diagnosed with either pulmonary or disseminated tb. acknowledgements the authors would like to thank the university of kwazulu-natal librarians for assisting with literature search. competing interests the authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article. authors’ contributions n.b.a.m. prepared the scoping review proposal protocol which was approved by the university of kwazulu-natal postgraduate office and performed the literature search, data analysis and literature review and final write up of the manuscript. n.n.m.d. was the supervisor and co-writer of the manuscript; assisted with writing and editing the scoping review proposal protocol; and performed the literature search, data analysis and literature review and final write up of the manuscript. references world health organization. global tuberculosis report 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[cited 2017 oct 08]. available from: https://www.iconceptpress.com/book/tuberculosis--a-comprehensive-clinical-reference/11000111/1307001022/download/1307001022.pdf abstract introduction magnetic resonance imaging sequences classifications ethical consideration case reviews conclusion acknowledgements references about the author(s) devimeenal jegannathan department of radiology, government kilpauk medical college, india venkatraman indiran department of radiodiagnosis, sree balaji medical college and hospital, india citation jegannathan d, indiran v. magnetic resonance imaging of classified and unclassified müllerian duct anomalies: comparison of the american society for reproductive medicine and the european society of human reproduction and embryology classifications. s afr j rad. 2018; 22(1), a1259. https://doi.org/10.4102/sajr.v22i1.1259 review article magnetic resonance imaging of classified and unclassified müllerian duct anomalies: comparison of the american society for reproductive medicine and the european society of human reproduction and embryology classifications devimeenal jegannathan, venkatraman indiran received: 01 aug. 2017; accepted: 05 feb. 2018; published: 23 apr. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract magnetic resonance imaging (mri), due to its optimal delineation of anatomy, has become the mainstay in imaging for diagnosing müllerian duct anomalies (mda). pelvic mri is requested for various conditions such as primary amenorrhoea, infertility or poor obstetric history with regard to mda, as identifying the exact aetiology for these conditions is vital. knowledge regarding the classification of mda is important, as the treatment varies with respect to the different classes. as all the lesions do not fit within the classification of the american society for reproductive medicine, a new anatomy-based classification was established by the european society of human reproduction and embryology and the european society for gynecological endoscopy, to fulfil the needs of experts. we aim to discuss various classes of classified and unclassified mda with regard to both the above-mentioned classifications and illustrate some of them using various cases based on pelvic mri studies. introduction embryologically, the two-paired müllerian ducts fuse in the midline in the lower part by the 6th to the 11th week of gestation. lateral fusion forms the uterus and upper two-thirds of the vagina and the cephalad parts of the separated ducts form the fallopian tubes. resorption of the midline septum results in a single uterine cavity. the sinovaginal bulb forms the lower third of the vagina, which fuses with the lower part of the fused müllerian ducts.1 any deviation from the above process leads to müllerian duct anomalies (mda). three-dimensional transvaginal ultrasound is almost as sensitive as magnetic resonance imaging (mri) in diagnosing congenital uterine anomalies.2 however, mri is preferred, as the t2 sequences enable clear delineation of the uterine zonal anatomy, ovaries, follicles, vaginal continuity to the uterus and vaginal septum.3 though mda are classified by the american society for reproductive medicine (asrm) into seven classes, there are some anomalies that are not included in the classification. in order to rectify the deficiencies, a new anatomy-based classification was established by the european society of human reproduction and embryology (eshre) and the european society for gynaecological endoscopy (esge),4 classifying the anomalies according to the morphology of the uterus, cervix and vagina, independently.4 clinical presentation of the mda is variable, where patients with obstructive anomalies present earlier. in these young women, the goals of therapy are to relieve the obstruction immediately, restore normal menstruation and sexual function and preserve reproductive potential.5 proper description and classification of the mda on imaging is vital for planning and instituting appropriate treatment. magnetic resonance imaging sequences t2-weighted sequences in all three planes (axial, coronal and sagittal) are adequate. firstly, a sagittal t2-weighted image is obtained (tr/te-4860/86, slice thickness [st] 5mm and nex-2), following which oblique coronal (figure 1) and oblique axial sections are obtained along and perpendicular to the long axis of the uterus. a true coronal section along the long axis of the uterus allows for proper visualisation of the fundal contour. volume sequences such as t2 cube (tr/te-2000/102, st2.8 mm and gap 1.4 mm) are very useful in this regard. with this sequence (figure 2a), reformats in all the planes, including oblique sections, can be determined after image acquisition (figure 2b). when complex anomalies such as accessory uterus-like structures are seen or in the case of didelphys with a divergent fundus, it is usually necessary to repeat the sequences for each component separately to get the exact coronal and axial sections of uterine cavities. t2 cube (ge medical corporation) is very beneficial in these circumstances (figure 2c and d). figure 1: oblique coronal image (a) obtained by planning along the long axis of uterus (white line) on the sagittal t2 sequence (b). figure 2: (a) sagittal t2 sequence demonstrates a rudimentary uterus (white arrow). (b) planning of the t2 cube curved maximum intensity projection (mip). (c) t2 cube curved mip demonstrates a bicornuate rudimentary uterus with an intercornual distance of more than 4 cm and widely separated (yellow arrows). (d) coronal t2 sequence shows both ovaries (white arrows). t1-weighted sequences are used to define any haemorrhagic component in the obstructed anomaly such as haematometra, adenomyosis, ovarian chocolate cyst and benign teratoma. it is also useful for uterine cysts with mucinous components and paravaginal gartner’s duct cysts (figure 3b). figure 3: (a) coronal t2 sequence demonstrates a complete septate uterus with a myoma (star) in the septum. (b) sagittal t2 sequence shows a gartner’s duct cyst with focal sacculations (double-headed white arrow) from the fornix extending along the anterior vaginal wall, well delineated against the instilled gel in the vagina. (c and d) axial t1 sequence demonstrates a left ureterocoele with a blind-ending atretic ureter (white arrows) in the broad ligament. (e) coronal t2 sequence shows a normal right kidney; left kidney not visualised. (f) incidental left adrenal adenoma (fat component in out-of-phase images) marked by a white arrow. coronal screening of the upper abdomen is mandatory in all cases of mda to evaluate for associated renal abnormalities (figure 3e). instillation of vaginal gel (figure 3b) is useful in cases of a blind vagina or transverse or longitudinal vaginal septum. near-field artefacts can be reduced by placing saturation bands at both the anterior and posterior body walls. classifications american society for reproductive medicine (table 1 and figure 4) and eshre and esge classifications are used to illustrate the cases here. figure 4: the american society for reproductive medicine classification. table 1: american society for reproductive medicine classification. the european society of human reproduction and embryology and the european society for gynecological endoscopy classification uterine anatomical deviations are classified as normal uterus u0, dysmorphic uterus u1, septate uterus u2, bicorporeal uterus u3, hemi-uterus u4, aplastic uterus u5 and still unclassified cases u6.4 each main class is further divided into sub-classes (figure 5 and figure 6).4 figure 5: the european society of human reproduction and embryology and european society for gynecological endoscopy classification. figure 6: the european society of human reproduction and embryology and the european society for gynecological endoscopy classification. the main diagnostic features used in the american society for reproductive medicine classification an external fundal contour with dipping of more than 10% or 1 cm,6 indicates a possible diagnosis of uterine didelphys or a bicornuate uterus. two separate uteri with preserved myo-endometrium zonal widths, two cervices and two vaginas are in keeping with didelphys.7 the uterine horns are widely splayed in uterine didelphys. some degree of fusion in the lower uterine segment points more towards a bicornuate uterus than uterine didelphys. to differentiate bicornuate and septate uterus: an intercornual distance of more than 4 cm, an intercornual angle of more than 105° and external fundal dipping favours a bicornuate uterus.7,8 flat or subtle fundal dipping (less than 1 cm), an intercornual distance of less than 4 cm and an acute intercornual angle of less than 75° suggests a septate uterus.9 the septum can be muscular or fibrous. a muscular septum is thick and appears similar to myometrial intensity. a fibrous component is hypointense, thin and sharp. in an arcuate uterus, myometrial dipping in the inner aspect of less than 10% is seen with a convex or flat outer fundal contour. the inner dipping edge is not sharp and saddle shaped,10 differentiating arcuate from a partial septate uterus. the unicornuate uterus does not have the usual rounded fundal contour and oblong shape. zonal anatomy and endometrial–myometrial differentiation is maintained.10,11 absence of myometrial–endometrial differentiation or fundus, body and cervix differentiation represent a hypoplastic uterus.8 salient points of the european society of human reproduction and embryology and the european society for gynecological endoscopy classification bicornuate and didelphys uterus of the previous asrm classification incorporate under bicorporeal uterus u3, subcategories 3a and 3b, respectively. a dysfused septate uterus is 3c. unicornuate uterus is classified under hemi-uterus u4. a clear description of the septate uterus is provided as a fundal midline indentation of >50% of the uterine wall thickness. anything less is included in the subcategory of u1, a dysmorphic uterus.4 the reference for myometrial thickness is obtained on the sagittal image of the uterus by calculating the mean of the measured anterior and posterior wall thicknesses.12 arcuate uterus (type vi of asrm) is not included in the eshre–esge classification system, avoiding unnecessary apprehension created by this almost normal variant as an anomaly. in the eshre–esge classification, these patients are classified as normal or septate, depending on the degree of midline indentation.13 the eshre and esge classification classifies 38 of the 39 congenital anomalies of the female genital tract, whereas the asrm classification is not as comprehensive.13 independent classification of uterine, cervical and vaginal anomalies is made. it is very useful, especially in cases of obstructive cervical or vaginal malformations with a normal uterus, which constitutes about 22 out of the 39 types of anomalies.13 the asrm classification does not provide specific classes for these anomalies and groups them all under class i. the eshre and esge classification uses common terms for describing anomalies and the exact anatomical status of the female genital tract, rather than the liberal non-specific terminologies used in the asrm classification. the eshre and esge classification includes associated anomalies of non-müllerian origin as part of its system to accommodate the renal tract malformations which are common with mda. the embryological origin of the anomalies can be easily identified on the basis of the eshre and esge classification. the eshre and esge classification places less severe anomalies at the beginning with the more deformed anomalies placed as the later classes and sub-classes.4 the eshre and esge classification defines uterine deformities based on the proportions of uterine anatomical landmarks, such as uterine wall, rather than using definite objective numerical values, keeping in consideration the variability of uterine dimensions in different patients.4 ethical consideration written informed consent was obtained from all the patients for publication of this review article, including all the images. case reviews normal uterus u0 a uterus having an interostial straight or curved line with less than 50% of the uterine wall thickness, internal indentation in the midline fundus and a flat external contour on coronal mri section is considered a normal uterus u0 (figure 7). figure 7: coronal oblique t2 sequence shows a normal uterus. no fundal external dipping, intercornual distance of less than 4 cm and internal fundal muscular indentation of less than 50% of the uterine wall thickness. associated right lateral wall intramural fibroid and left benign teratoma seen. dysmorphic uterus u1 a dysmorphic uterus is sub-classified by the shape of the uterine cavity as t-shaped, infantile and others. the other category is used to differentiate minor deformities. septate uterus u2 this is due to an absorption defect. a uterus having a flat external contour and more than 50% internal fundal midline indentation is classified as a septate uterus. it is divided into subtypes a and b (partial [figures 8 and 9] and complete [figure 10] septate) by the extension of the septum above or below the internal cervical os, respectively. when two cervices are identified at clinical examination, it should not be interpreted as uterine didelphys, where no treatment is required. imaging is mandatory.6 septate uteri with two cervices (figure 10) have been documented in the literature.14,15,16,17 the optimum treatment is resection of the septum.18 figure 8: coronal oblique t2 sequence shows no fundal external dipping, an intercornual distance of less than 4 cm and an internal fundal muscular indentation of more than 50% of the uterine wall thickness. associated left pelvic kidney is seen. figure 9: coronal oblique t2 sequence (a) shows no fundal external dipping. there is a partial septum with a muscular and fibrous component separating the endometrial cavity in the fundal region. a single cervix is seen. t2 cube maximum intensity projection (mip) image (b) demonstrates well the inferior sharp end of the septum. partial septate uterus. associated left ovarian cyst. figure 10: coronal oblique t2 sequence demonstrates a complete septate uterus. the outer fundal contour is flat. the intercornual distance is 3.5 cm. internal indentation of the muscular and fibrous component is seen in fundal region (a) and there is only a fibrous component in the lower part (white arrow) (b), extending down to the cervix and two vaginal cavities (c – yellow double-headed arrows). an arcuate uterus may be classified as a partial septate uterus in the eshre–esge classification (figure 8). somayya et al. state that the diagnosis of septate uterus is made frequently by following the eshre–esge classification, resulting in increased hysteroscopic metroplasty.19 this could be considered as one of the limitations of the study. ludwin et al.20 identified the median length of septum as 10.7 mm by the eshre–esge classification and as 21.1 mm by the asrm criteria. in 36.4% of cases of septate uterus, internal fundal indentation was <1 cm by eshre–esge criteria and is usually considered as a normal uterus by asrm. their study further stated that the septate uterus was overdiagnosed and needed to be redefined for determining the treatment option of hysteroscopic metroplasty.20 ludwin et al. stated that using three-dimensional ultrasonography and the asrm classification with morphometric criteria is preferable and that further study with a larger sample size should be evaluated for reliability.21 patients with a complete septate uterus may have multiple associated findings. myomas were seen in the septum and left broad ligament in one of our patients (not shown). there was an associated gartner’s duct cyst that appeared hyperintense on the t1 sequence, extending from the fornix to the anterior vaginal wall. this patient also had a left ureterocoele with a short ureter ending blindly. she had a normal right kidney and an absent left kidney with an incidental left adrenal adenoma (figures 3a–f). a blind-ending ureteral bud in association with renal agenesis and a ureterocoele are rarely reported.22,23,24 magnetic resonance imaging is the modality of choice for diagnosing an atretic ureterocele; other cross-sectional imaging modalities have limited value.23 bicorporeal uterus u3 a bicorporeal uterus is caused by fusion defects, characterised by external indentation of more than 50% of the uterine wall thickness. this is subdivided into partial and complete (figure 11) by the extension of the division above or up to the level of the cervix. a bicorporeal septate uterus (class u3c) has a coexistent absorption defect in addition to the fusion defect and shows fundal indentation exceeding 150%. figure 11: (a, b) axial t2 sequence demonstrates a fundal external indentation exceeding 50% of the uterine wall thickness, dividing the uterine corpus and cervix completely. (c, d) axial t2 sequence demonstrates two vaginal cavities (white arrows). increased risk of placental abnormalities has been reported with uterine anomalies,25 especially with uterus didelphys (figure 12) and bicornuate, unicornuate and septate uteri. uterine didelphys (bicorporeal u3b) with a vaginal septum and obstructed hemivagina resulting in haematometra along with ipsilateral renal agenesis is known as herlyn–werner–wunderlich syndrome (figure 13). the treatment for class u2 and u3c is metroplasty. it is also recommended in cases of arcuate uterus with repeated pregnancy loss.26,27 figure 12: sagittal t2 sequence (a) demonstrates two fundi and two uterine bodies (white arrows) with two endometrial cavities and two cervices (black arrows). post-partum changes seen in the anterior uterus. (b) axial t2 sequence shows post-partum changes with the placenta in fundal and left lateral wall (white arrow) – placenta increta. figure 13: coronal short tau inversion recovery (stir) sequence (a) demonstrates two uterine bodies with endometrial cavities. coronal stir sequence (b) shows two cervices with a compressed right hemivagina (white arrow) and an obstructed fluid distended left hemi-vagina (yellow arrow). it also shows a transverse partial septum. associated ipsilateral renal agenesis was seen (not shown). herlyn–werner–wunderlich syndrome. hemi-uterus u4 a unilaterally formed uterus, which occurs as a result of a formation defect with an absent or incompletely formed contralateral part, is usually laterally deviated. it is sub-classified into subtypes a and b by the presence or absence (figure 14) of a functional cavity in the contralateral component (rudimentary horn communicating or non-communicating). laparoscopic removal of the rudimentary horn is advised if there is a functional cavity. forty percent of hemi-uteri have associated renal anomalies.28 figure 14: sagittal t2 sequence (a) demonstrates non-extension of the endometrial cavity up to the fundal region. coronal oblique t2 sequence (b) shows a unicornuate uterus. banana-shaped endometrial cavity displaced to left side with right ovarian benign teratoma. aplastic uterus u5 an aplastic uterus is a formation defect with bilateral (figure 15) or unilateral, complete or partially absent uterine cavity or rudimentary horn, with or without a cavity or uterine remnants. presence (figure 15) or absence of a functional cavity sub-classifies an aplastic uterus into subtypes a and b. figure 15: sagittal t2 sequence (a) demonstrating a rudimentary uterus. short tau inversion recovery (stir) coronal (b) shows the rudimentary uterus with a cavity and absent ovaries. fundal, body and cervix differentiation as well as endometrial–myometrial differentiation are not seen (figure 2). failure of the müllerian duct to develop leads to müllerian agenesis. parikh et al. state that the most common cause of primary amenorrhea is müllerian agenesis.5 uterovaginal aplasia or hypoplasia is referred to as mayer–rokitansky–küster–hauser syndrome. in type i or the typical form, there is isolated uterovaginal aplasia. laparoscopy can identify müllerian remnants as symmetric muscular buds and normal fallopian tubes.29 in type ii (figure 16) or the atypical form, other upper urinary tract, vertebral, cardiac and otologic malformations are seen.29 figure 16: axial t2 sequence (a) demonstrates a band of vagina (double-headed white arrow) in between the rectum (asterisk) and urethra (yellow arrow). axial t2 sequence (b) identifies both ovaries (yellow arrows) and a left pelvic kidney. mayer–rokintasky–küster–hauser syndrome. still unclassified cases u6 rare anomalies or combined pathologies that do not comply correctly with one of the above six groups are categorised into unclassified (figure 17). ectopic müllerian tissue anomalies such as an accessory-cavitating uterine mass30 and tricavitated uterus13 belong to this category. figure 17: coronal t2 sequence (a) demonstrates a uterus with endo-myometrial differentiation on the left (white arrow) and an additional uterus-like structure (double-headed arrow) on the right side attached to the left-sided uterus by a fibrous band. (b) coronal t2 thick maximum intensity projection (mip) delineates well both uteri (white arrows) and connecting fibrous band (long white arrow). (c) oblique reformation of the left-sided uterus shows a unicornuate uterus with a rudimentary non-communicating horn (white arrow). (d) sagittal t2 sequence shows cervical aplasia. (e) sagittal t2 sequence demonstrates the blind-ended vagina (white arrow). (f) sagittal t2 sequence with vaginal gel instillation shows a transverse septum superiorly (yellow arrow) and a longitudinal septum (white arrows) in the lower part. figure 18 (a and b): sagittal t2 sequence demonstrates the uterus and cervix distended with haematometra with a thick non-canalised inferior margin of the cervix. conclusion the eshre and esge classification is an anatomical and embryological-based classification and includes cervical and vaginal anomalies. a volumetric t2-weighted mri sequence such as t2 cube is the sequence of choice. although the eshre classification is more accommodative than the asrm classification, there are still a few unclassified anomalies. magnetic resonance imaging acquired after the instillation of vaginal gel helps to clearly delineate the transverse and longitudinal vaginal septum. knowledge of the various classifications, differentiating points, imaging characteristics, associated anomalies, syndromes and various available treatment options is vital for the radiologist to guide the treating experts to achieve the best patient outcome. acknowledgements we thank dr prabu dhanasingh and dr sunil kumar for their contribution in figure and artwork preparation. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions d.j. was the project leader. d.j. and v.i. were responsible for experimental and project design. both authors collected and reported the cases and wrote the manuscript. references duncan slb. embryology of the female genital tract: its genetic defects and congenital anomalies. in: shaw rw, soutter wp, stanton sl, editors. gynecology. edinburgh: churchill livingstone, 1992; p. 3–21. graupera b, pascual ma, hereter l, et al. accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of mullerian duct anomalies using eshre-esge consensus on the classification of congenital anomalies of the female genital tract. ultrasound obstet gynecol. 2015;46(5):616–622. https://doi.org/10.1002/uog.14825 troiano rn, mccarthy sm. mullerian duct anomalies: imaging and clinical issues. radiology. 2004;233(1):19–34. https://doi.org/10.1148/radiol.2331020777 grimbizis gf, gordts s, di spiezio sardo a, et al. the eshre/esge consensus on the classification of female genital tract congenital anomalies. hum reprod. 2013;28(8):2032–2044. https://doi.org/10.1093/humrep/det098 parikh rm, nakum k, kadikar gk, gokhle av. mullerian anomalies: a cause of primary amenorrhea. int j reprod contracept obstet gynecol. 2013;2:393–397. https://doi.org/10.5455/2320-1770.ijrcog20130926 mueller gc, hussain hk, smith yr, et al. mullerian duct anomalies: comparison of mri diagnosis and clinical diagnosis. ajr am j roentgenol. 2007;189:1294–1302. https://doi.org/10.2214/ajr.07.2494 behr sc, courtier jl, qayyum a. congenital pelvic abnormalities; imaging of müllerian 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pe, novy mj, lee dm, hickok lr. the diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum. am j obstet gynecol. 2004;190:1669–1675. https://doi.org/10.1016/j.ajog.2004.02.046 sadek sm, ahmad ra, atia h. performance of the eshre/esge classification in differentiating anomalies of double uterine cavity in comparison with the asrm classification. middle east fertil soc j. 2016;21(2):75–81. https://doi.org/10.1016/j.mefs.2015.09.001 ludwin a, ludwin i. comparison of the eshre–esge and asrm classifications of mullerian duct anomalies in everyday practice. hum reprod. 2015;30(3):569–580. https://doi.org/10.1093/humrep/deu344 ludwin a, ludwin i, kudla m, kottner j. reliability of the european society of human reproduction and embryology/european society for gynaecological endoscopy and american society for reproductive medicine classification systems for congenital uterine anomalies detected using three-dimensional ultrasonography. fertil steril. 2015;104 (3):688–697. https://doi.org/10.1016/j.fertnstert.2015.06.019 mohseni mg, hosseini sr, salavati a, dadgari s. ureterocele associated with renal agenesia presented as a pelvic mass in an adult. iran j radiol. 2013;10(1):45–47. https://doi.org/10.5812/iranjradiol.10262 maas kl, lipson sa, hricak h. ureteric bud remnant in two patients with renal agenesis: diagnosis by mri. j comput assist tomogr. 1997;21(5):745–747. https://doi.org/10.1097/00004728-199709000-00016 calleja escudero j, amo garcia a, garrido redondo m, rodriguez toves a, del rio dominguez f, martinez sagarra jm. renal agenesis, cranial blind ureter and ureterocele. report of a case. arch esp urol. 1995;48(1):89–91. tuştaş haberal e, çekmez y, ulu i̇, divlek r, göçmen a. placenta percreta with concomitant uterine didelphys at 18 weeks of pregnancy: a case report and review of the literature. j matern fetal neonatal med. 2016;29(21):3445–3448. https://doi.org/10.3109/14767058.2015.1130819 grimbizis gf, camus m, tarlatzis bc, bontis jn, devroey p. clinical implications of uterine malformations and hysteroscopic treatment results. hum reprod update. 2001;7(2):161–174. https://doi.org/10.1093/humupd/7.2.161 homer ha, li tc, cooke id. the septate uterus: a review of management and reproductive outcome. fertil steril. 2000;73(1):1–14. https://doi.org/10.1016/s0015-0282(99)00480-x li s, qayyum a, coakley fv, hricak h. association of renal agenesis and mullerian duct anomalies. j comput assist tomogr. 2000;24(6):829–834. https://doi.org/10.1097/00004728-200011000-00001 strübbe eh, willemsen wn, lemmens ja, thijn cj, rolland r. mayer-rokitansky-küster-hauser syndrome: distinction between two forms based onexcretory urographic, sonographic, and laparoscopic findings. ajr am j roentgenol. 1993;160(2):331–334. https://doi.org/10.2214/ajr.160.2.8424345 jain n, verma r. imaging diagnosis of accessory and cavitated uterine mass, a rare mullerian anomaly. indian j radiol imaging. 2014;24(2):178–181. https://doi.org/10.4103/0971-3026.134411 abstract introduction case history discussion conclusion acknowledgements references about the author(s) suman mewa kinoo department of surgery, university of kwazulu-natal, king edward viii hospital, durban, south africa vikesh v. ramkelawon ethekwini hospital and heart centre, durban, south africa jaynund maharajh department of radiology, university of kwazulu-natal, king edward viii hospital, durban, south africa bugwan singh department of surgery, university of kwazulu-natal, king edward viii hospital, durban, south africa citation mewa kinoo s, ramkelawon vv, maharajh j, singh b. fulminant amoebic colitis in the era of computed tomography scan: a case report and review of the literature. s afr j rad. 2018;22(1), a1354. https://doi.org/10.4102/sajr.v22i1.1354 case report fulminant amoebic colitis in the era of computed tomography scan: a case report and review of the literature suman mewa kinoo, vikesh v. ramkelawon, jaynund maharajh, bugwan singh received: 04 apr. 2018; accepted: 04 june 2018; published: 15 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract amoebic colitis, caused by ingestion of water or food contaminated with the protozoan entamoeba histolytica, can progress to a fulminant colitis. computed tomography (ct) findings reported in the literature on this type of colitis are sparse. we present a 59-year-old male patient with a one-week history of progressive abdominal pain, abdominal distension and associated watery and bloody diarrhoea. a ct scan revealed deep ulcerations with submucosal and intramural tracking of contrast. colonoscopy and biopsy confirmed a diagnosis of amoebic colitis. the patient required a laparotomy and demised. deep ulcerations with submucosal and intramural tracking of contrast on ct are diagnostic of fulminant amoebic colitis. although not demonstrated at ct in this case, discontinuous bowel necrosis, omental wrapping (seen at laparotomy in our case) and neovascularisation of the bowel wall may be other features to look out for. introduction fulminant amoebic colitis (fac) is the transmural extension of amoebic colitis, associated with a devastating outcome. until a few decades ago, the diagnosis of fac was made without the recourse to computed tomography (ct) scan; diagnosis was largely clinically supported by stool examination and sigmoidoscopic examination, with plain radiology and sonography having a subsidiary diagnostic role. in current practice, largely because of improvements in sanitation and primary health care access, fac is uncommon; thus, the recognition of this entity may be found to be lacking, but should be suspected in those vulnerable to sexually transmitted disease, human immunodeficiency virus infection and those travelling from endemic areas. the difficulty in diagnosis is offset by improvements in diagnostic modalities and their availability, as prompted by our recent experience in managing a patient with fac. to this end, the role of ct scan in the diagnosis of fac merits review. case history a 59-year-old male patient presented with a one-week history of progressive abdominal pain, abdominal distension and associated watery and bloody diarrhoea. there was no history of inflammatory bowel disease, nor antibiotic or herbal enema usage; the patient reported drinking only tap water. on examination, the patient, who was hiv-negative, was dehydrated, pale, pyrexial and had a tachycardia. the blood pressure was normal. the abdomen was distended with generalised tenderness but no peritonism. rectal examination revealed blood on the glove. the patient was resuscitated and commenced on intravenous antibiotics as an infective cause for his acute abdomen was considered most likely. plain chest radiography revealed no pneumoperitoneum, and abdominal radiography revealed a transverse colon diameter of 7 cm with neither thumb printing nor pneumatosis intestinalis. the white cell count was 34 × 109/l, haemoglobin 9 g/dl, urea 9 mmol/l and creatinine 100 µmol/l. an abdominal triple contrast-enhanced (oral, rectal, intravenous) ct scan revealed segments of grossly dilated large bowel with areas of thickening, deep ulceration, contrast tracking deep within the bowel wall and skip areas with normal bowel wall calibre (figure 1), suggesting colitis. colonoscopy revealed areas of inflamed and necrotic mucosa with intervening areas of normal mucosa (figure 2). following colonoscopy and biopsy, the patient’s condition deteriorated and a post-colonoscopy perforation was suspected. at laparotomy, the entire colon was noted to be wrapped with omentum, with no signs of perforation or peritonitis (figure 3). a diagnosis of amoebic colitis was entertained because of the omental wrapping. a diverting loop ileostomy was fashioned as the patient was haemodynamically unstable. anti-parasitic treatment was commenced immediately post-operatively; however, despite this, the patient deteriorated and demised. histopathological evaluation of the colonoscopically guided biopsy confirmed the diagnosis of amoebic colitis (figure 4). figure 1: computed tomography scan with triple contrast. figure 2: colonoscopy findings: areas of normal mucosa (a and b), necrotic mucosa (c and d) and inflamed mucosa (e and f). figure 3: intra-operative picture of the omental ‘wrap’ involving the caecum and ascending colon. figure 4: multiple round to oval amoebic trophozoites (black arrow) measuring 6 nm – 40 nm, resembling macrophages, are seen lying freely within debris. discussion amoebic colitis is caused by ingestion of water or food contaminated with the protozoan entamoeba histolytica (e. histolytica). once the ingested cysts reach the terminal ileum, they undergo excystation and release the trophozoite.1 the trophozoites may or may not penetrate the colonic mucosal barrier. if no penetration occurs, this is regarded as a non-invasive form and the patient has no luminal pathology and no symptoms; if mucosal penetration occurs, the patient will develop symptoms ranging from mild colitis (superficial ulcers, abdominal pain, secretory diarrhoea) to the devastating fac (associated with deep ulcers, perforation and faeculant peritonitis) which carries a high morbidity and mortality in the range of 55% – 100%.2,3 whereas mild amoebic colitis may be diagnosed and treated effectively utilising conservative measures, the confirmation of fac on the basis of diagnostic modalities may be challenging. historically, amoebiasis was confirmed on stool microscopy identifying trophozoites and cysts or stool antigens and the detection of antibodies specific for e. hystolytica.4 because of the low sensitivity of these non-invasive tests, they have been replaced by molecular detection using polymerase chain reaction that demonstrates excellent sensitivity in identification of symptomatic and asymptomatic stool carriers. in addition to the demonstration of free intraperitoneal air or retroperitoneal mottling in patients with fac, the plain abdominal radiograph may reveal features distinctive to amoebic colitis. classically, the involved segments of the colon are not visualised (similar to toxic megacolon of ulcerative colitis) and gaseous distention occurs in the non-diseased colon. in addition, luvuno described ‘fixed displacement’ of the colon as an indicator of the site of perforation, as the uninvolved colon acts as a patch over the perforated areas, to which it becomes adherent.5 although generally not impacting considerably on the overall diagnosis of amoebic colitis, ultrasound examination of the liver is important as between 20% and 30% of patients with amoebic colitis have an associated amoebic liver abscess; recognition and treatment of the latter enhance the overall clinical outcome. invariably, the diagnosis of amoebic colitis may have to be confirmed by a procto-colonoscopy with biopsy demonstrating e. histolytica and the pathognomonic flask-shaped ulcers. however, this carries the potential risk of perforation, especially in an acutely inflamed and possibly ischaemic colon. furthermore, as in this case report, results of the various diagnostic tests may not be timeously forthcoming for a definitive diagnosis and a recourse to laparotomy may be required. although colitis caused by cytomegalovirus, salmonellosis, ulcerative colitis, pseudomembranous colitis and ischaemic colitis may present with pancolitis, discontinuous bowel necrosis is extremely rare in these types of colitis. furthermore, as a result of the ischaemic phenomenon in amoebic colitis, the omentum forms adhesive ‘wraps’ that afford both mechanical protection from microperforation and neovascularisation of the diseased colon, a phenomenon described by luvuno.6 this phenomenon may be apparent on ct scan imaging. even if a diagnosis of fac is made, the clinical challenge is whether to perform surgery on a severely ill patient, because there may be a role for effective conservative treatment when colonic perforations are contained by the omental ‘wraps’ and, less so, by the unaffected small bowel. the role of ct scan in identifying the latter category of patient would be appropriate. the decline in the incidence of fac affords little opportunity to correlate this diagnostic modality with the features of fac, although there are reports of non-specific ct scan features for fac.7 thus, the literature describing the ct scan features of fac is sparse. in a case report, ying et al. report extended submucosal ulcers with intramural dissection of contrast as the characteristic ct scan finding of fac.8 this feature (noted in our patient) represents the underlying flask-shaped ulcer pathology typical of amoebiasis and excludes other infective, inflammatory or ischaemic bowel diseases (figure 1). other non-specific findings (not noted in our patient) include the target sign indicating pancolitis and discontinuous bowel necrosis depicted by alternating enhancing and non-enhancing bowel wall. the latter confirms the vascular occlusion associated with fac.9 contrary to the role of ct scan in the diagnosis of fac, this modality is increasingly used as the primary imaging modality for ulcerative colitis and crohn’s disease. although there is a considerable overlap between the ct scan findings of ulcerative colitis and crohn’s disease, certain defining features of each disease have characteristics that afford distinction from fac. ulcerative colitis is predominantly a mucosal disease, but with disease progression, there is bowel wall thickening that is less than that seen in crohn’s disease. the ct scan features of ulcerative colitis include circumferential, symmetrical thickening of the bowel wall up to 8 mm with fold enlargement (maximal thickness of normal colonic wall is 3 mm when distended and 5 mm when collapsed). furthermore, there is a target appearance of the rectum with proliferation of the perirectal fat. crohn’s disease has transmural involvement that progresses to replacement of submucosal fat with fibrosis and loss of mural stratification.10 crohn’s colitis is also associated with a greater colon wall thickness (> 10 mm) that is eccentric, preferentially mesenteric, and segmental with skip lesions. in addition, there is an association with several extraluminal features such as fistula and abscess formation and mesenteric abnormalities.10 the role of ct in the evaluation of crohn’s disease is well accepted. the ability of ct to depict bowel involvement and extraluminal pathology (e.g. abscess, obstruction and fistula) makes it an essential imaging tool for patient care. the earliest ct finding of crohn’s disease is bowel wall thickening, which usually involves the distal small bowel and colon, although any segment of the gastrointestinal tract can be affected.10 typically, the mural thickening is 5 mm–15 mm.11 a misdiagnosis of fac as crohn’s disease can be deleterious for the patient if steroid treatment is implemented.3 conclusion the challenges presented by fac are confirming the diagnosis (which may require a colonoscopy and biopsy, with its inherent risks of perforation) and deciding on the appropriate management. management depends on the severity of the colitis; both mild and severe colitis can be successfully treated conservatively; however, operative intervention is required when there is a free or a sealed perforation, contained by an omental wrap, which both progress to transmural disease, manifesting as fac. correlating the ct scan findings with the pathological manifestations of the fac will prompt an appropriate management. although a vast differential diagnosis of colitis should always be kept in mind, the majority of other colitis conditions such as ulcerative colitis, inflammatory colitis and ischaemic colitis can be excluded. crohn’s colitis and cytomegalovirus (cmv) colitis may mimic amoebic colitis because of the skip lesions, but these conditions do not present with deep ulcerations, submucosal and intramural tracking of contrast, discontinuous bowel necrosis or omental wrapping and neovascularisation of the bowel wall. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed equally to the writing of this article. references ng dc, kwok sy, cheng y, chung cc, li mk. colonic amoebic abscess mimicking carcinoma of the colon. hong kong med j. 2006;12(1):71–73. stanley sl. amoebiasis. lancet. 2003;361(9362):1025–1034. https://doi.org/10.1016/s0140-6736(03)12830-9 gupta ss, singh o, shukla s, raj mk. acute fulminant necrotising amoebic colitis: a rare and fatal complication of amoebiasis: a case report. cases j. 2009;2:6557. https://doi.org/10.1186/1757-1626-0002-0000006557 tanyuksel m, petri wa jr. laboratory diagnosis of amebiasis. clin microbiol rev. 2003;16(4):713–729. https://doi.org/10.1128/cmr.16.4.713-729.2003 luvuno fm, mtshali z. amoebic colitis and the surgeon. contin med educ. 1983;1:76–79. luvuno fm. role of adhesive wraps in the pathogenesis of complicated amoebic colitis. br j surg. 1988;75:713–716. https://doi.org/10.1002/bjs.1800750730 kimura k, stoopen m, reeder mm, moncada r. amebiasis: modern diagnostic imaging with pathological and clinical correlation. semin roentgenol. 1997;4:250–275. https://doi.org/10.1016/s0037-198x(97)80021-1 ying ks, chan lp, wu sh, wu mj, chang ty, lee ch. ct findings of fulminant amebic colitis: a case report. chin j radiol. 2008;33:205–210. luvuno fm, mtshali z, baker lw. vascular occlusion in the pathogenesis of complicated amoebic colitis: evidence for an hypothesis. br j surg. 1985;72:123–127. https://doi.org/10.1002/bjs.1800720218 gore rm, balthazar ej, ghahremani gg. ct features of ulcerative colitis and crohn’s disease. ajr am j roentgenol. 1996;167(1):3–15. https://doi.org/10.2214/ajr.167.1.8659415 philpotts le, heiken jp, westcott ma. colitis: use of ct findings in differential diagnosis. radiology. 1994;190(2):445–449. https://doi.org/10.1148/radiology.190.2.8284397 case reports posterior circulation positional transient ischaemie attacks due to persistent primitive hypoglossal artery with redundancy abstract a persistent primitive hypoglossal artery was the sole identifiable stroke risk factor for a patient presenting with positional, posterior circulation ischaemie episodes. diagnosis was made by magnetic resonance arteriography and verified by conventional angiography. tortuosity and coiling of the hypoglossal artery was also present. dynamic transcranial doppler sonography was normal and spect brain scanning revealed an area of posterior hemisphere hypoperfusion. redundancy of the primitive hypoglossal artery is the postulated mechanism of cerebral ischaemia. michael hoffmann* mbbch, fcp(sa)neurol peter corr+ mbchb, ffrad(d)sa, frcr,mmed (uct) • department of vascular surgery, cerebrovascular section, department of medicine; stroke unit, entabeni hospital + department of radiology, university of natal 20 sajournal of radiology. may 1996 introduction four different primitive arteries connect future anterior and posterior circulations in the embryonic state,' the trigeminal, otic, hypoglossal or proatlantal arteries normally regress and are replaced by the posterior communicating arteries but may persist in adult life. these four arteries may persist with differing frequencies and varying complications such as cerebral aneurysms? cranial nerve palsies' and as a route of anterior to posterior circulation embolism.' brain ischaemia and infarction have recently been described with such primitive anastomoses without any other cause of embolism or in association with carotid stenosis at the presumed donor emboligenie site.>? hypoglossal arteries are said to be present in 0.05 % of cerebral angiograms and have been reported to be associated with aneurysms'" arteriovenous malformations, 10-12 moyamoya disease!' and arnold chiari malformation." cerebral ischaemia has been describedinone case." the mere presence of the congenital anomaly alone is insufficient to imply causation. a relatively young patient, free of cerebrovascular risk factors is presented with a hypoglossal artery with the additional abnormality of extensive coiling (redundancy) of the vessel in the neck. case report a 48 year old right handed, white woman reported a sudden onset of bilateral visual impairment lasting several minutes, followed by intermittent shaking on both sides of her body lasting about 2 hours. episodes of the body becoming "spastic" every 4-5 minutes were observed by her husband, lasting about 5 minutes at a time. he described the attacks as the arms and legs extending, and her lifting off the bed. the neck would become very stiff and she would arch her spine consistent with opisthotonic posturing. she was totally topage22 think wide! for over ten years now and for decades to come, ge provides mr users with early access to some of the most significant breakthroughs made in mr!, enabling them to stay at the leading edge of mri from both clinical and economic standpoints. wide application range today's radiology suites need extreme system performance to adapt to health care changes. signa products are designed to deliver imaging capabilities with state-ofthe-art advanced applications and to remain at the forefront of technology with the ge mr continuum. these include digital phased-array imaging, ultrafast sequences, advanced vascular and cardiac imaging, echoplanar imaging, and a wide range of surface and digital phased-array coils to support all applications. that is the key to success in this exciting new era of mr. join us in our quest for the future. for more information, please call on (011) 452 1196 or fax (011) 4522005. • wide product range pioneering in magnet technologies, ge offers an extremely wide product range from permanent 0.2 tesla to high field 1.5 t supraconductive magnets. from maximum image quality on signa horizon with hispeed and echospeed capabilities and wide imaging capabilities to the most innovative and dedicated open-magnet systems, surgeons will be able to operate and image patients in real-time with signa mrt. wide magnets ge magnets are designed with patient comfort in mind. whatever the type of application you are looking for, ge has the patient-friendly answer with signa horizon (1.0 and 1.5 t), signa contour (0.5 t), or signa profile (0.2 t). ge medical systems we bring good things to life ge medical systems· 742· 70th avenue edenvale· 7610 r.s.a posterior circulation positional transient ischaemie attacks conscious during these episodes. pins and needles were perceived on both sides but more on the right. numbness of the tongue, partial deafness of the right ear and dizzy spells were other frequent intermittent symptoms. a second similar attack occurred one week later. of note is that turning her head to the left for more than 1-2 minutes invariably provoked dizziness. looking down, such as when going down stairs and turning her head to either side would provoke dizziness. tinnitus was invariable. no headache, weakness, diplopia or imbalance was associated. her past history was notable in that she was diagnosed to have had a right sided "bell's palsy" (of sudden onset) on the 20 july 1995 which lasted about 2 weeks. she had no cerebrovascular risk factors. general and neurological examination was normal save for mild dysmnesia and visuospatial impairment, the latter tested with the rey complex figure test. the clinical assessment at time of first visit included a differential of posterior circulation ischaemia, partial seizures or cardiac dysrhythmias. the basic cerebrovascular relevant blood screen, chest radiograph, electrocardiogram, electroencephalogram, computerised tomography brain scan and cardiac investigations including cardiac echogram were normal. the magnetic resonance imaging (mri) brain scan showed a very small hyperintense focus in the left frontal region of dubious significance. an abnormal signal void due to a carotid basilar anastomosis was detected (figure 1). this anastomosis was confirmed on time of flight magnetic resonance (mr) angiography as a very dilated tortuous hypoglossal artery with an aplastic right vertebral and hypoplastic left vertebral artery (figure 2). selective angiography confirmed the mr angiogram findings (figure 3). the single photon computed tomography (speet) brain scan showed figure 1: a t2 weighted axial scan demonstrates a signal void from the carotid basilar anastomosis (arrow). left hemisphere hypoperfusion to visual inspection and semiquantitative analysis (figure4). the asymmetry index was calculated as 22%, significantlydifferent to the normal controls (n=5) with a mean value of 4.2% for the pariete-occipital region (standard deviation± 2.7, range 0 9.5). figure 2: mr angiogram demonstrates the tortuous left hypoglossal artery (arrow). note the aplastic right vertebral artery (arrowhead). the cerebral vasomotor response was tested with intravenous diamox without any further abnormalities noted on the spect scan. transcranial doppler sonography including dynamic studies with head rotation and flexion was normal. specifically basilar artery velocity was unchanged with head rotation to the right and left for 2 minutes each. she was treated 22 sajournal of radiology. may 1996 figure 3: selective left vertebral angiogram confirms the tortuous left hypoglossal arterial anastomosis (arrow). withaspirin 150 mg daily and presently remains well at 2 months follow up. figure 4: speet scan showing significant ieft parieto·occipital hypopertusion (arrowheads). discussion a series of case reports has implicated primitive caroticovertebral arteries in stroke and cerebral ischaemia. there is also a known stroke risk associated with cervicocephalic redundancy, with various mechanisms such as thrombosis and embolism postulated and dissection signiflcantlyassociated." thernostlikelymechanisrn of ischaemia in our patient is a transient hypoperfusion or thromboembolism from the redundant coils of the primitive to page 23 posterior circulation positional transient ischaemie attacks hypoglossal arterywhich was the main posterior circulatory supply vessel in this patient. when these primitive arteries persist, aplasia or hypoplasia of the vertebrobasilar system is usual as in the patient under discussion. positionalischaemia in anatomically normal vessels and atherostenosis with neck turning is well described by sturzenegger et al.l? inour patient, head turning to either side but more to the left as well as flexion provoked dizziness. both embolic and haemodynamic mechanisms could be pathomechanisms with the normal dynamic trans cranial doppler study marshalling evidence against the latter. this could be a mechanism of ischaemia especially as the abnormal hypoglossal artery served as the sole posterior circulation supply without the benefit of the normally dual vertebral arterial supply. although no posterior circulation infarct was imaged with the aid of an mri brain scan, functional imaging with speet scanning revealed left posterior hemisphere hypoperfusion, a finding that would correlate well with the symptomatology: the reported bell'spalsy was more likely to have been a minor pontine infarct as the clinical presentation was compatible with brain stem ischaemia. although surgicalreconstruction of carotid redundancy has been reported to abolish symptoms of cerebrovascular insufficiency, such treatment would theoretically be contraindicated in our patient inview of the anatomically abnormal posterior circulation. this case demonstrates the utility of mr angiography in the detection of uncommon vascular abnormalities in patients with unexplained transient ischaemie attacks. the hypoglossal arterywhen present is usually the only functional artery to the brain stem and cerebellum and is associated with aplasia or hypoplasia of the vertebral arteries as demonstrated in our patient," to our knowledge, this is the first reported instance of a primitive, persistent hypoglossal artery associated with redundancy without other identifiable cause of positional cerebral ischaemia/infarction. the causal relationship of these dual stroke riskfactors seems certain. the need to exelude such vasculopathy in patients presenting with posterior circulation insufficiency is emphasised as the mechanism is amenable to treatment. diagnosis by noninvasive magnetic resonance angiography should suffice. references 1. padget dh. the development of the cranial arteries in the embryo. contrib embryo/1948;212:259-261. 2. fortner aa, smoker wrk. persistent primitiv trigeminal artery aneurysm evaluated by mr imaging and angiography. j computassisttoylwgr 1988;2(5):847850. 3. jbezaki k, fuji k, kishikawa t. persistent primitive trigeminal artery: a possible cause of trigeminal and abducens nerve palsy. ] neurol neurosurg psychiatry 1989;52(12):1449-1450 4. leipzigtj, dohrmann gj. the tortuous or kinked carotid artery: pathogenesis and clinical considerations. a historical review. surgneuro/1986;25:478-486. 5. bhasi yz, uysal h, peker s,yurdakul m. persistent primitive proatlantal intersegmental artery (proatlantaj artery i) results in "top of the basilar syndrome". stroke 1993;242114-2ll7. 6. gasecki ap, foxaj, lebrun lh, daneault n;forthe collaborators of the north american carotid endarterectomytrial. bilateral occipital infarctions associated with carotid stenosis in a patient with persistenttrigeminal artery. stro/u?] 994;25: 1520-1523. 7. zeman a, anslow p, greenhall r. persistent trigeminal artery and brain stem stroke. cerebrovasc dis 1993;3:236-240. 8. kanai h, nagai h, wakabayashi s, hashimoto n. a large aneurysm of the persistent primitive hypoglossal artery. neurosurgery 1992;30:794-797. 9. yamamoto s, sun ada i, matsuoka y, hakuba a, nishimura s. persistent primitive hypoglossal artery aneurysms report of two cases. neurol med chir (tokyo) 1991;31:199-202. 10. shibata y,hyodo a, saito a, yoshiiy, noset. large arteriovenous malformation associated with persistent primitive hypoglossal artery case report. neural med chir(tokyo) 1991;31 :804-808. 11. yeh h, heissjd, tew jm jr. persistent hypoglossal artery associated with basilar artery aneurysm. neurochirwgica (stuttg) 1987;30: 158-159. 12. murayama y,fujimoto n, matsumoto k. bilateral persistent primitive hypoglossal arteries associated with a large ruptured aneurysm on one side. surg neura11985; 24: 498 502. 13. kurose k, kishi h, sadatoh t. moyamoya disease with persistent primitive hypoglossal artery. neurol med chir(tokyo) 1989;29:528-532. 23 sajournal of radiology. may 1996 14. matsumura m, norjiri k, yumoto y. persistent primitive hypoglossal artery associated with arnold chiari type 1 rnaformanon. surgneuroi1985;24:24 i-244. is. stern j, correll lw, bryan n. persistent hypoglossal artery and persistent trigeminal artery persisting with posterior fossa transient ischa mie attacks; report of2 cases ineurosurg 1978;49:614-619. 16. barbour pl, castaldo je, rae grant ad, gee w, reed jf 3rd, jenny d, longennecker j. internal carotid artery redundancy is significantly associated with dissection. stroke 1994;25: 1201-1206. 17. sturzenegger m, newell dw, douville c, byrd s, schoonover k. dynamic transcranial doppler assessment of positional vertebrobasilar ischaemia. stroke 1994;25:1776-1783. 18. osboma. in diagl10stic radi%lt;. st louis, mosby, 1994:128-132 abstract introduction case report ethical consideration discussion conclusion acknowledgements references about the author(s) denny mathew diagnostic radiology, university of the witwatersrand, johannesburg, south africa daniel n. prince diagnostic radiology, university of the witwatersrand, johannesburg, south africa nasreen mahomed department of radiology, rahima moosa mother and child hospital, university of the witwatersrand, johannesburg, south africa south african society of paediatric imaging (saspi), cresta, south africa citation mathew d, prince dn, mahomed n. extra-skeletal ewing sarcoma of the chest wall in a child. s afr j rad. 2019;23(1), a1733. https://doi.org/10.4102/sajr.v23i1.1733 case report extra-skeletal ewing sarcoma of the chest wall in a child denny mathew, daniel n. prince, nasreen mahomed received: 05 mar. 2019; accepted: 16 may 2019; published: 27 june 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract chest wall or pleural-based tumours represent a heterogeneous group of lesions that are infrequent in children and infants; however, a large proportion of these lesions are malignant in nature. categorising them on the basis of primary versus secondary, site of origin (osseous and cartilage, or soft tissue) and tissue composition may assist in narrowing the differential diagnosis. we present a case of a 7-year-old boy with a progressive history of dyspnoea. the initial chest radiograph (cxr) demonstrated complete opacification of the left hemithorax with no air bronchograms. this was associated with the cut-off of the left main bronchus and mediastinal shift to the right. the post-contrast computed tomography (ct) of the chest showed multiple left-sided enhancing pleural-based masses with collapse of the left lung. these lesions were locally invasive as demonstrated by the intra and extra-thoracic extension. there were no associated erosions of the adjacent ribs or intra-tumoural calcifications. based on the imaging findings, the diagnosis of extra-skeletal ewing sarcoma (es-ews) of the chest wall was made with a differential diagnosis of rhabdomyosarcoma. a core biopsy was performed of the pleural-based mass, and histology with immunohistochemistry confirmed the diagnosis of a malignant small round blue cell tumour; subtype ewing sarcoma family tumour (esft). the child was subsequently commenced on chemotherapy. the diagnosis of es-ews should be considered when a child or adolescent presents with an ill-defined, eccentric, chest wall mass in the absence of a lesion with a primary osseous origin. imaging plays a key role in tumour staging, therapeutic planning and follow-up of patients. keywords: extra-skeletal; ewing sarcoma; tumour; malignant paediatric chest wall lesion; computed tomography. introduction ewing sarcoma family tumours (esft) are a group of malignant small round blue cell tumours with varying degrees of neuroectodermal differentiation.1 they include ewing sarcoma of the bone (ews), extra-skeletal ewing sarcoma (es-ews), peripheral primitive neuroectodermal tumour (ppnet) and askin tumour.2,3,4 despite the contradictory terminology in the literature, this group of tumours is believed to represent the same entity that is histogenetically related, with minor differences in their differentiation.1,2 they are associated with a non-random, reciprocal translocation between chromosomes 11 and 22, t(11;22) (q24;q12), with the resultant formation of ews e26 transformation specific-fusion gene.2,3,5,6 this report aims to highlight an entity that is uncommonly reported in the literature, with an approach to other differential considerations for a locally invasive pleural-based/chest wall lesion in a child. case report a 7-year-old boy presented with a progressive history of dyspnoea. a chest radiograph (cxr) was performed which demonstrated complete opacification of the left hemithorax with no air bronchograms. this was associated with a cut-off of the left main bronchus and mediastinal shift to the right (figure 1a and b). an ultrasound (us) showed multiple pleural-based masses with heterogeneous echo texture and an associated complex left pleural effusion. a computed tomography (ct) scan of the chest with intravenous contrast agent demonstrated multiple ill-defined enhancing left pleural-based masses, with patchy hypodense areas (figure 2a–c). there were no associated intra-tumoural calcifications. these pleural-based masses were locally invasive, as evident by the poor planes of separation between the pericardium (figure 2a), descending thoracic aorta (which was shifted to the right of the vertebral column), and diaphragm. the findings noted on cxr of the left lung collapse with a cut-off of the left main bronchus and mediastinal shift to the right were also evident. the extra-thoracic extension was also noted anteriorly via the intercostal spaces (figure 2a). there were no associated erosions of the adjacent ribs (figure 3) nor extension of the mass into the vertebral canal. a large complex left pleural effusion (25 hounsfield units [hu]) was also present, as previously noted on the us scan. the right lung and chest wall were normal, with no pulmonary nodules or masses to suggest metastases. figure 1: frontal chest radiograph (cxr): (a) initial cxr on presentation demonstrates complete opacification of the left hemithorax with resultant mediastinal shift to the right and cut-off of the left main bronchus (black arrow); (b) cxr post left chest wall/pleural biopsy. left pneumothorax (white arrow) with the left intercostal drain in-situ (black arrow). associated surgical emphysema of the left chest wall (white stars). figure 2: (a–c) axial, sagittal and coronal contrast-enhanced computed tomography images demonstrate left pleural-based masses which enhance heterogeneously (solid black arrows) with patchy hypodense regions suggestive of necrosis. there is an associated large complex left pleural effusion (white star), atelectasis of the left lung and mediastinal shift to the right. there were no associated intra-tumoural calcifications. figure 2a – note the extra-thoracic extension of the mass anteriorly via the intercostal spaces (white arrow) and another pleural-based mass that is inseparable from the pleural pericardial reflection (broken black arrow). figure 3: axial computed tomography image of the chest on bone window demonstrates the absence of associated bony erosions (white arrow). based on the imaging findings, the differential diagnosis was categorised into three main groups: malignant soft tissue tumour (rhabdomyosarcoma, malignant peripheral nerve sheath tumour [mpnst], type ii/iii pleuropulmonary blastoma) esft metastases (rhabdomyosarcoma, neuroblastoma, lymphoma, leukaemia) another differential consideration includes inflammatory myofibroblastic tumour (imt) of the lung or pleura. biopsy of the anterior pleural-based mass was performed for histopathological confirmation. on microscopy, the specimen was composed of a proliferation of small round blue cells arranged in solid sheets. the background stroma was myxoid to oedematous in areas. large areas of haemorrhage were also noted. the individual neoplastic cells were intermediate in size. the cells demonstrated oval nuclei with irregular contours and finely dispersed chromatin. pinpoint nuclei were also noted in other areas. the cells had moderate amounts of pale eosinophilic cytoplasm. brisk mitotic activity was noted with atypical forms seen. no rosettes were identified and a fibrillary background was not identified. no rhabdoid cells were seen. periodic acid-schiff (pas) and periodic acid-schiff with diastase (pas-d) stains highlighted focal glycogen within the neoplastic cells. these features were consistent with a malignant small round blue cell tumour of the chest wall/pleural biopsy. the immunohistochemistry of the biopsy specimens was then performed to further subtype this neoplasm, which were consistent with esft. ethical consideration no patient identifiable information has been presented. discussion j. ewing first described ews in 1921, and it is now believed to be the second-most common malignant bone tumour in children and adolescents after osteosarcoma.6 the origin of ews from structures other than bone is considered rare and is termed es-ews.1 in 1969, tefft et al. initially described an extra-osseous, paravertebral soft tissue, small round cell tumour with morphological features similar to ews.7 angervall and enzinger in 1975 later established the entity es-ews in their review series of 39 cases of extra-osseous examples of ews.7 the most common sites of occurrence of es-ews are the paravertebral region, lower extremities, chest wall, retroperitoneum, pelvis and hip, upper extremities, and head and neck region.2 the lesion within the paravertebral region may either be intradural extramedullary or evident as an extradural mass.2 although es-ews is primarily a soft tissue tumour, it may invade adjacent osseous structures.6 some authors use the term askin tumour for the specific localisation of es-ews within the chest wall.4,5 extra-skeletal ewing sarcoma typically manifests in children and young adults, with 85% of the reported cases being between 20 months and 30 years of age.2 the radiological evaluation of these patients is multimodal; however, the imaging features may be non-specific.2 the imaging findings described below are specific to es-ews of the chest wall in conjunction with our case presented. it may present as a solitary or multiple extra-pulmonary masses, demonstrating a pattern of eccentric growth along the chest wall.3,5 other reported findings include pleural effusions, lymphadenopathy, lung and bone metastases.3 the expansion of this chest wall lesion may result in the secondary collapse of the lung, or it may directly invade the lung parenchyma.5 a paravertebral origin of this lesion may result in extension through the vertebral foramina and can cause secondary bony changes of the adjacent vertebral body.2,5 ultrasound (us) offers the advantages of absence of ionising radiation, easy accessibility and a dynamic study that can be performed at the patient’s bedside, which can also guide needle-biopsy for the histological diagnosis. the us shows that these chest wall masses are often hypoechoic but can have anechoic regions if they are necrotic or haemorrhagic.2 doppler interrogation of the masses reveals associated vascular flow.2 commonly, an associated pleural effusion may be demonstrated.2 the ct findings depict an ill-defined, large, unilateral, soft-tissue chest wall mass, with heterogeneous enhancement post contrast.2 low-attenuation regions within the lesion may also be apparent and are representative of haemorrhagic or necrotic areas.2 associated calcifications are rare, as evident in our case, and have been reported in 10% of the cases.2 associated rib destruction has been reported in 25% – 63% of the cases.2 the magnetic resonance imaging (mri) findings, although non-specific, offer the added advantage in better delineating the margins of the mass and assessing its relationship with the surrounding structures and tumour staging.2,8 the mr depicts an ill-defined, eccentric soft-tissue mass with intermediate signal on t1 weighted imaging (t1wi) and t2 weighted imaging (t2wi) demonstrating a high signal intensity lesion.2,5 areas of haemorrhage or necrosis may be evident as regions of high signal intensity on t1wi and t2wi compared to the skeletal muscle.2 gadolinium administration results in intense enhancement of the solid components of the tumours and is representative of its hyper vascular nature.2,5 these tumours are often locally invasive with direct invasion of the musculature of the chest wall, mediastinum and lung, with subsequent lung collapse, as evident in our case.2 fluorodeoxyglucose positron emission tomography (fdg pet) demonstrates increased radionuclide uptake and may be used in the detection of the primary lesion, residual or recurrent tumour or metastatic lesions.2 the use of other nuclear studies such as indium 111 (111in) penetetreotide and technetium 99m (99mtc) setamibi (mibi) scans also offer promise in the evaluation of treatment response after surgical resection and chemotherapy.2 histologically, esft are small round blue cell tumours – a malignant group of neoplasms with a wide range of differentials.1 this should be differentiated from other examples of small round blue cell tumours which may also occur in the chest wall such as neuroblastoma, embryonal rhadomysosarcoma and lymphoma.6 the diagnosis is based on the combination of both the clinical and imaging features, as well as the immunohistochemical staining and cytogenetic analysis.6 definitive diagnosis is made with fluorescence in-situ hybridisation (fish) to detect the rearrangement of the 22q12 (ewsr1 gene).1 malignant paediatric chest wall tumours represent a diverse group of lesions; however, categorising them on the basis of primary versus secondary, site of origin (osseous and cartilage, or soft tissue) and tissue composition may assist in formulating the differential diagnosis.8 in the presence of a primary oncological diagnosis, metastatic lesions such as neuroblastoma, rhabdomyosarcoma and lymphoma/leukaemia need to be excluded.9 metastatic lesions to the chest wall typically present on imaging as lytic bone lesions with associated cortical disruption and periostitis.9 neuroblastoma may present as a posterior mediastinal mass with direct invasion of the chest wall and may extend into the adjacent neural formamina.9 lymphoma is often associated in those with a compromised immune system [e.g. human immuno deficiency virus/acquired immunodeficiency syndrome (hiv/aids), or immunosuppressive therapy].5 the patient in this case report was not immune-compromised; so, the diagnosis of lymphoma was considered unlikely. the absence of constitutional symptoms in conjunction with the associated negative biochemical and bone marrow findings excludes leukaemia. the absence of a lesion with primary osseous involvement excludes ews of the bone and osteosarcoma; in addition, osteosarcoma is typically associated with centrally dense calcifications.2,9 rhabdomyosarcoma of the chest wall cannot reliably be differentiated on imaging from es-ews, as both demonstrate non-specific findings of an aggressive chest wall lesion.2 bone involvement typically occurs in the late stage of the disease but is reported in ~20% of patients.9 embryonal rhabdomyosarcoma is a subtype which is unique to the paediatric population.10 malignant peripheral nerve sheath tumours arise within the nerve sheaths and may either occur sporadically or within plexiform neurofibromas in patients known with neurofibromatosis type 1 (nf1).9 the presence of a mass lesion that courses along the expected location of a peripheral nerve favours the diagnosis of a peripheral nerve sheath tumour and may be associated with underlying erosions of the adjacent bone.9 pleuropulmonary blastomas typically affect infants and children (overall median age of 4 years).11 type ii and iii pleuropulmonary blastomas have been reported in older patients, and type i (purely cystic) pleuropulmonary blastomas exclusively occur in those younger than 3 years of age.12 type iii (purely solid) pleuropulmonary blastomas are typically well-circumscribed with heterogeneous enhancement, and although primarily intra-thoracic (arising from the lung or pleura), it may involve the chest wall.9 type ii (mixed cystic and solid) pleuropulmonary blastomas are less aggressive and rarely involve the chest wall.9 inflammatory myofibroblastic tumour of the lung usually appears as a solitary, well-marginated, peripheral mass on cxr with heterogeneous enhancement on ct.13 calcifications occur more commonly in children compared to adults.14 pleural imt is exceedingly rare, with only a few published case reports, and may appear locally invasive with the infiltration of the adjacent chest wall.13 as with all oncology cases, the mainstay of treatment is multidisciplinary. biopsy is necessary to confirm the diagnosis after which neoadjuvent chemotherapy is initially used with the aim of decreasing the size of the primary lesion and eliminating micrometastases.2 the primary method for local control is surgical; however, this is dependent on various factors based on the tumour staging.2 this would include factors such as patients’ age, tumour size, location and extent of involvement of adjacent vital structures; presence of encasement of adjacent neurovascular bundles and whether the primary lesion can be completely excised with acceptable margins.2 the thoraco-pulmonary location of es-ews is associated with a poorer prognosis in comparison to es-ews at other sites with the 2and 6-year survival rates reported as 38% and 6%.2 recurrence has also been reported in more than 50% of the cases and may be evident as local recurrence, mediastinal lymphadenopathy or metastatic lesions.2 conclusion extra-skeletal ewing sarcoma is regarded a rare entity that has not been commonly reported but is an important consideration, given the poor prognosis. this diagnosis should be considered when a child or adolescent presents with an ill-defined, eccentric, chest wall mass, in the absence of a lesion with a primary osseous origin. the differential diagnosis should also include rhabdomyosarcoma of the chest wall, as this cannot reliably be differentiated from es-ews on imaging. imaging plays a key role in tumour staging, therapeutic planning and follow-up of these patients. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions d.m. was responsible for the review of literature, preparation of the case report as per journal’s requirements and compiling of the images. d.n.p. compiled the clinical information, radiological images and histology results and also assisted with the literature review. n.m. was responsible for the diagnosis of the case, interpretation of the imaging studies and editing of the final article. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references javalgi ap, karigoudar mh, palur k. blue cell tumour at unusual site: retroperitoneal ewings sarcoma. j clin diagnostic res. 2016;10(4):19–20. https://doi.org/10.7860/jcdr/2016/18302.7618 murphey md, senchak lt, mambalam pk, logie ci, klassen-fischer mk, kransdorf mj. ewing sarcoma family of tumors: radiologic-pathologic correlation. radiographics. 2013;33(3):803–831. https://doi.org/10.1148/rg.333135005 keehn b, jorgensen sa, towbin aj, towbin r. askin tumor. appl radiol. 2017;46(6):32–33. watt ajb. chest wall lesions. paediatr respir rev. 2002;3(4):328–338. https://doi.org/10.1016/s1526-0542(02)00270-1 tateishi u, gladish gw, kusumoto m, et al. chest wall tumors: radiologic findings and pathologic correlation: part 2. malignant tumors. radiographics. 2003;23(6):1491–1508. https://doi.org/10.1148/rg.236015527 karatziou c, pitta x, stergiouda t, karadimou v, termentzis tg. a case of extraskeletal ewing sarcoma originating from the visceral pleura. hippokratia. 2011;15(4):363–365. scheithauer bw, egbert bm. ewing’s sarcoma of the spinal epidural space: report of two cases. j neurol neurosurg psychiatry. 1978;41(11):1031–1035. https://doi.org/10.1136/jnnp.41.11.1031 carter bw, benveniste mf, betancourt sl, et al. imaging evaluation of malignant. radiographics. 2016;36(5):1285–306. https://doi.org/10.1148/rg.2016150208 baez jc, lee ey, restrepo r, eisenberg rl. chest wall lesions in children. am j roentgenol. 2013;200(5):402–419. https://doi.org/10.2214/ajr.12.8883 mathew d, de lima h, mahomed n. embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient – a rare cause of obstructive jaundice. s afr j radiol. 2019;23(1), a1662. https://doi.org/10.4102/sajr.v23i1.1662 khan aa, el-borai ak, alnoaiji m. pleuropulmonary blastoma: a case report and review of the literature. case rep pathol. 2014;1–6. https://doi.org/10.1155/2014/509086 the international pleuropulmonary blastoma registry [homepage on the internet] [cited 2019 may 10]. available from: https://www.ppbregistry.org/health-professionals/basic-facts-about-ppb/age-at-diagnosisgenderlateralit. young-sub n, sang-gon p. inflammatory myofibroblastic tumor of the pleura with adjacent chest wall invasion and metastases to the kidney: a case report. j med case rep. 2018;12(253):1–5. https://doi.org/10.1186/s13256-018-1796-7 lakshmana n, newman b, spotwood s, shireesha n, kolli r. inflammatory pseudotumor. radiographics. 2003;23:719–729. https://doi.org/10.1148/rg.233025073 pictorial interlude colpocephaly nicky wieselthaler mb chá fcrad (d) fcrc (lond) savvas andronikou mb chb, fcrad(d), frcr (lond) department of paediatric radiology red cross war memorial childrens hospital university of cape town and institute of child health colpocephaly was first described by benda in 1940 and termed vesiculocephaly but was renamed colpocephaly by yakovlev and wadsworth in 1946. colpocephaly is a congenital enlargement of the occipital horns of the lateral ventricles. this is caused by a global impairment in brain development with aberrant migration of neuroblasts resulting in a decreased thickness of cerebral white matter in the posterior part of the sentrum semiovale. hence the secondary dilatation of the occipital horns. this abnormality is thought to occur at 1 4 months' gestation. i associated cns abnormalities include corpus callosum agenesis, neuronal migration disorders (lissencephaly, pachygyria), schizencephaly, microcephaly, meningomyelocoele and hydrocephalus. in corpus callosum agenesis often associated with chiari ii malformation the ventricles are also widely spaced, parallel and pointed anteriorly. the clinical features may include learning disability, seizures, spasticity, hypotonia and visual abnormalities. it has been postulated that certain aetiologies may predispose to colpocephaly. these are intra-uterine infection, iugr, perinatal anoxic ischaemie encephalopathy, maternal drug ingestion and trisomy 8 and 9.2 fig. 1. axial non-contrast ct scan of a chi/d's brain with corpus cal/osum agenesis shows the di/ated occipital horns of colpocephaly. the ventricles are also widely spaced and pointed anteriorly. the diagnosis of colpocephaly is made on cr,mri or ultrasound (fig.l). references l. cerullo a, marini c, ceroli s, carelli v, montagna p, tinuper p. colpocephaly in two siblings: further evidence of a genetic transmission. dev med child neuroi2000; 42: 280-282. 2. noorani p, bodensteiner j, barnes p. colpocephaly: frequency and associated findings. j child ne!lroi1988; 3: 100-104. 49 sa journal of radiology • march 2002 abstract introduction research methods and design results discussion conclusion study limitations recommendations for future research acknowledgements references about the author(s) sanele s. mncube greys hospital, radiology department, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa matthew d. goodier greys hospital, radiology department, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa citation mncube ss, goodier md. normal measurements of the optic nerve, optic nerve sheath and optic chiasm in the adult population. s afr j rad. 2019;23(1), a1772. https://doi.org/10.4102/sajr.v23i1.1772 original research normal measurements of the optic nerve, optic nerve sheath and optic chiasm in the adult population sanele s. mncube, matthew d. goodier received: 11 july 2019; accepted: 29 aug. 2019; published: 05 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: imaging assessment of the anterior visual pathway structures, particularly the optic nerves (on), requires knowledge of normal dimensions. several studies suggesting techniques and normal ranges have been performed, but most suffer from various methodological flaws. this study is the first to be performed in a south african population. objectives: the aim of this study was to establish normal measurements of the on, optic nerve sheath (ons) and optic chiasm (oc) on magnetic resonance imaging (mri). method: eighty normal adults between ages of 12 and 65 years were included in this prospective, quantitative, observational, descriptive study to establish normal measurement of the on, ons and oc using a t2w 3d mri sequence. measurements (width and height) were undertaken by two observers independently. results: a total of 80 participants with a mean age of 35 years were studied: 49 females (61.25%) and 31 males (38.75%). there were no statistical differences in the measurements between gender and age correlation. interobserver agreement was best for larger structures, that is, oc width and intracranial on width, respectively. the overall mean of oc width was 13.63 mm (range: 11.13 mm–16.92 mm, standard deviation [s.d.] 1.21); intraorbital on height at 5 mm behind the globe 2.29 mm (range: 1.63 mm–3.33 mm, s.d. 0.43), and intracranial on width 4.27 mm (range: 2.46 mm–5.19 mm, s.d. 0.53). conclusion: normal measurements of the anterior visual pathway structures on mri are best reflected in the larger structures. interobserver variability was poor for the orbital on, ons, intracranial on height and oc height. we recommend that measurements be obtained for the oc width and intracranial on width. the overall mean for the oc width is 13.63 mm and intracranial on width 4.27 mm. keywords: optic nerve; optic sheath; optic chiasm; magnetic resonance imaging; mri; anterior visual pathway. introduction accurate imaging assessment of the anterior visual pathway structures of a patient with abnormal vision requires knowledge of the normal dimensions of these structures. the anterior visual pathway consists of the retina, optic nerve sheath complex (onsc), optic chiasm (oc), and optic tract. for the purposes of this article, anterior visual pathway refers to only the onsc and oc. the onsc comprises the optic nerve (on) and optic nerve sheath (ons). disease detection affecting the anterior visual pathways may be made subjectively. however, objective measurement of these structures is often a very valuable part of the diagnostic assessment. a spectrum of diseases may affect the size of anterior visual pathway structures.1,2 these comprise congenital and acquired conditions. examples include congenital atrophic hypoplasia, optic atrophy, optic neuritis, perineuritis, glaucoma, on glioma, optic sheath meningioma and intracranial pathology causing raised intracranial pressure (icp) such as cryptococcal meningitis, trauma and neoplasm. patients with abnormal vision and optic disc pallor on fundoscopic examination are often referred for imaging. common clinical requests include evaluation of the ons for conditions like atrophy or neuritis and intracranial pathology causing mass effect on the visual pathway structures. the world health organization (who) estimates that approximately 1.3 billion people live with some form of vision impairment globally, 80% of which is considered avoidable.3 the rationale for investigating patients with visual symptoms is to achieve an early diagnosis, to allow prompt intervention to maintain or restore vision and prevent permanent blindness. various modalities have been utilised in the past to image the on with varying degrees of accuracy. most of those modalities are outdated. to date, published reference values for normal on measurements in prescribed textbooks and journal-based resources have several drawbacks. the older studies were based on computed tomography (ct) scan and low-resolution magnetic resonance imaging (mri) images, which could not distinguish the different structures of the onsc. the measurements therefore represent the entire onsc rather than the actual nerve or sheath.4,5 other studies do not clearly define the exact points of measurement.4,6 several international publications report on various studies employing mri for measurements of the anterior visual pathway structures. studies by parravano et al. and daniels et al. looked at both the on and oc.4,5 parravano et al. concluded that measurements of the oc were more reliable than the on. however, this study was based on low-resolution t1w mri sequence. the remainder of the studies measured either the on, ons or oc.6,7,8,9,10,11,12,13,14,15,16 the anterior visual pathway comprises small structures. obtaining measurements of these structures is often challenging because of inherent technical difficulty in measuring small structures. therefore, state-of-the art imaging is necessary. high-resolution mri based on isometric or 3d acquisition techniques is currently the best imaging modality for many applications in neuroradiological imaging and generally forms part of standard neuroradiological imaging protocols.16,17,18 the spatial and contrast resolution achieved by this technique typically allows for accurate evaluation of the various anterior visual pathway structures. to date, there have been no published studies of normal mri measurements of anterior visual pathway structures taken on a south african population. the aim of this study was to ascertain normal measurements of the anterior visual pathway structures in the normal adult population in south africa. research methods and design this was a prospective, quantitative, observational, descriptive study conducted in the department of radiology at greys hospital, a tertiary referral institution in pietermaritzburg, kwa-zulu natal, south africa, which serves a population of 4.5 million. the study population comprised adult patients between the ages of 12 and 65 years, referred for mri of the head and/or neck region without any visual signs and symptoms or central nervous system (cns) pathology potentially affecting the visual pathway. participants were recruited consecutively amongst adult patients referred for mri of the head and/or neck region. an intended sample size of 73 was required to estimate on measurements to within 0.03 mm with 95% probability, assuming a mean of 2.94 mm and standard deviation (s.d.) 0.09. a total of 100 patients were enrolled. the final sample size was 80. twenty patients had technically inadequate examinations because of motion artefact and were excluded from the study. other reasons for exclusion amongst the 20 were a history of pituitary surgery discovered in retrospect, suspected idiopathic intracranial hypertension and inadequate coverage of the oc. images were acquired with a 1.5t ingenia phillips mr system with the use of a multi-array head coil. patients were positioned supine in the magnet. straight gaze was maintained using a bright focal spot, and participants were counselled prior to the examination to avoid eye movements during image acquisition. t2w 3d tse imaging sequence was employed. images were processed on the workstation and archived to the picture archiving and communication system (pacs). five different mri trained radiographers, all of whom received specific training on scanning technique for this study, performed the scans. two observers carried out the measurements independently. the first observer was a senior radiology trainee and the second observer was a consultant radiologist with certification in neuroradiology. the second observer was blinded to the first observer’s measurements, but not to the patients’ demographics and the inclusion criteria. the images were viewed and analysed on pacs using beacon g22s+ with 2 megapixel (1600 × 1200) resolution monitors. multiplanar reconstruction (mpr) and 3d viewing functions were utilised. a digital line measurement ruler was used to perform measurements. further electronic functions like zoom, pan and windowing were also utilised as necessary to optimise image quality and accuracy of measurements. measurements were conducted on the right side only. width and height of the on and ons were obtained on axial and reformatted sagittal images, respectively, and width and height of the oc were obtained on reformatted coronal images. the on was measured at three points: intraorbital segment (5 mm and 10 mm behind the globe) and the intracranial segment (5 mm from the chiasm) (figures 1 and 2). optic nerve sheath measurements were performed at two segments: 5 mm and 10 mm behind the globe (similar points as for the intraorbital on). finally, measurements of the oc were obtained at a single point on reformatted coronal images (figure 3). figure 1: axial t2w 3d magnetic resonance imaging of the right orbit demonstrating the measurement technique: (a and b) intraorbital optic nerve width 5 mm and 10 mm behind the globe, respectively; (c) intracranial optic nerve width and (d and e) optic nerve sheath width 5 mm and 10 mm behind the globe, respectively. figure 2: reformatted sagittal t2w 3d magnetic resonance imaging of the right orbit demonstrating the measurement technique: (a and b) intraorbital optic nerve height 5 mm and 10 mm behind the globe, respectively; (c) intracranial optic nerve height and (d and e) optic nerve sheath height 5 mm and 10 mm behind the globe, respectively. figure 3: reformatted coronal t2w 3d magnetic resonance imaging demonstrating the measurement technique of the optic chiasm width and height. data were collected and recorded in customised microsoft excel tables. analysis was performed using the stata v13 program. descriptive statistics were used to describe the demographic characteristics of the sample. frequency distributions and percentages were used to summarise categorical data such as age, sex, width, and length. ranges, means (in millimetres) and standard deviations were calculated and used to summarise the data. interobserver reliability was tested with the bland and altman method, and presented graphically. ethical consideration full ethics approval was obtained from the university of kwazulu-natal biomedical research ethics committee (brec). reference number: be442/18. results measurements of the anterior visual pathway structures were performed for 80 patients. the mean age was 35 years (range: 13–65 years), 49 (61.25%) females and 31 (38.75%) males. table 1 demonstrates a summary of the overall measurements. there were no measurements with significant statistical differences between males and females. no correlation between age and on measurements was found; the correlation coefficient was poor, varying from −0.14 to 0.19. a perfect direct correlation would be 1. figure 4 shows the overall age distribution of all on measurements. figure 5 demonstrates the overall measurement distribution at each site. figure 4: overall age distribution of optic nerve measurements. no age correlation was demonstrated. the correlation coefficient varied from −0.14 to 0.19. figure 5: box and whisker plot demonstrates the overall measurement distribution at different sites. table 1: overall measurements of the anterior visual pathway structures. figures 6 and 7 demonstrate the frequency distribution of measurements of the intracranial on and oc. figure 6: frequency distribution of the intracranial optic nerve. figure 7: frequency distribution of the optic chiasm. interobserver agreement was tested by the bland & altman test (b&a). the best agreement was for the oc width (agreement interval 96%, s.d. 0.71, p < 0.001; figure 8); on height 5 mm behind the globe (agreement interval 98.8%, s.d. 0.39, p < 0.001) and intracranial on width (agreement interval 95%, s.d. 0.39, p < 0.0072; figure 9). figure 8: agreement interval of the optic chiasm width. figure 9: agreement interval of the intracranial optic nerve width. discussion this study reports normal measurements of the anterior visual pathway structures in adult patients using high-resolution mri. there were no statistically significant differences between males and females for all the acquired measurements of the anterior visual pathway. this finding is consistent with the previous literature and is expected because there are no known structural or physiological differences of the anterior visual pathway structures between sexes. these observations are consistent with findings by dolman et al. and benevento et al.7,16,17,19,20 maresky et al. found that on measurements increase with age from birth to 12 years of age, followed by a plateau from 12 to 18 years.14 the findings of our study showed no correlation between all measurements and age of the selected adult population, confirming that the on attain their final volume by age 12 years and do not change throughout adult years. this correlates with the findings by maresky et al. for their 12–18 years’ age category results. al-haddad et al. reported an increase in on diameter with age, especially in the first 2 years of life, confirming that age-related on size change is a paediatric phenomenon.21 the on diameter in the orbital segment shows progressive decrease, from the retrobulbar to the most posterior segment. there is a corresponding inverse relationship of the ons diameter. karim et al. supported this theory in a study by demonstrating significant decrease in the normal on diameter along its length.11 our results were consistent with this observation. we demonstrated an area difference decrease of 0.16 mm2 between 5 mm and 10 mm of the intraorbital on. this difference is attributed to reduction in the amount of collagen as opposed to neuronal tissue. karim et al. demonstrated a consistent cross-sectional area of the nervous tissue in the orbital on, but decreasing amounts of collagen posteriorly on colour densitometry. interestingly, our results demonstrated a contrasting increase of the intracranial on area by a factor of 1.56. this may be related to decussation. prechiasmatic axons have been demonstrated to be ordered in distinct fascicular bundles, different from that observed along the rest of the nerve.22 the oc area was substantially larger (up to four times) than the intracranial on because of decussation. the anterior visual pathway comprises small structures, including the on. obtaining measurements of these structures is often challenging and a tedious exercise because of inherent technical difficulty in measuring small structures. therefore, identifying reliable points of measurements was an important objective of this study. parravano et al. suggested that the oc width is the most clinically useful measurement, based on it being the largest and easiest structure to measure. our study supports this recommendation as the best interobserver agreement was demonstrated for the oc width. strong agreement was also demonstrated for the intracranial on width and intraorbital on height at 5 mm. however, the latter was a difficult measurement to obtain as it requires mpr to view sagittal reformatted images and further straightening techniques to achieve optimal alignment. therefore, the oc width and intracranial on width are the most clinically reliable points to obtain measurements along the anterior visual pathway. we recommend that measurements be acquired at these locations. the oc width was the most practical point to perform measurements in our experience. the mean oc width was 13.63 mm (range: 11.13 mm–16.92 mm), intracranial on width 4.27 mm (range: 2.46 mm–5.19 mm) and intraorbital on height at 5 mm behind the globe 2.29 mm (range: 1.63 – 3.33 mm). the mean oc width diameter in our study was consistent with that previously reported by wagner et al. of 14.0 mm, but differed slightly from that reported by parravano et al. of 15 mm.5,15 recently, bilal et al. showed comparable results with an oc width of 13.04 mm ±1.21 mm using standard mri sequences in a coronal plane.23 sonography is regaining popularity in the form of high-resolution transbulbar scanning in the assessment of retrobulbar onsc, especially in patients requiring serial monitoring of icp.24,25,26,27 multiple recent studies have assessed its use for measurements of the ons diameter in the setting of raised icp. more studies are required to evaluate correlation between ultrasound and mri for measurements of the on alone.24 ultrasound offers advantages of ease of availability and repeatability. it also shows good reproducibility, measurement accuracy and observer agreement when measurements are performed 3 mm behind the globe.27 the drawbacks of ultrasound include limited penetration to the posterior aspect of the orbit and intracranially. limited operator skill is also postulated to be a disadvantage as orbital sonography is no longer commonly performed. in view of our study findings showing that the intracranial on and oc widths are the most clinically reliable points of measurements, mri is anticipated to remain the imaging modality of choice for most clinical applications. traditionally, measurements are obtained manually by using electronic calipers. with the advent of artificial intelligence (ai) and its growing clinical applications, newer techniques of obtaining anterior visual pathway structures are being investigated with promising outcomes. robert et al. employed a new multi-atlas segmentation method that automatically sections the on to obtain on and ons radii.28 harrigan et al. also recently evaluated a fully automated 3d consistent technique based on a high-resolution, heavily t2-weighted, isotropic mri technique to obtain on and ons radii.29 this technique is more anatomically representative because of its 3d nature. high field strength magnets in a form of 3t are increasingly being used in routine clinical imaging. the 3t magnet strength has clear advantages over the 1.5t, offering superior spatial resolution in depicting the orbital and intracranial anatomy and pathologic findings.30 the 7t is still limited to clinical research settings. use of 3t scanners in similar future studies may yield more positive results of the small orbital onsc structures as it offers better spatial resolution. in addition, newer mechanical designs may also offer more ai compatibilities, which would support seamless development of newer automated measurement techniques. conclusion normal measurements of the anterior visual pathway structures on mri are best reflected in the larger structures. these are the oc width (mean 13.63 mm, range: 11.13 mm–16.92 mm) and intracranial on width (mean 4.27 mm, range: 2.46 mm–5.19 mm). interobserver variability was poor for the orbital on, ons, intracranial on height and oc height. therefore, we recommend that measurements be obtained for the oc width and intracranial on width. study limitations the study participants were recruited at the radiology department. screening questions were used prior to scanning to exclude abnormal vision and potential central visual pathway pathology. no formal eye examinations were performed. as a result, some participants may have had undetected subclinical visual disturbances. this was a single institution study with a limited number of potential study recruits, which prolonged the duration of the study by several months, more than initially anticipated. no specific parameters were set for the electronic functions like zoom, pan and windowing when obtaining the measurements on pacs. this was left to the discretion of each observer to optimise images as they would during routine reporting. lack of standardisation in this regard may introduce undesirable technical differences between observers, which may create inconsistent viewing conditions affecting the ability to measure small structures with accuracy. recommendations for future research further larger population studies are recommended to reliably determine the normal measurements of the smaller anterior visual pathway structures that showed poor interobserver reliability in our study; including the orbital on, ons, intracranial oc height and oc height. acknowledgements the authors would like to thank the following mri radiography staff for their contributions in mri examinations and data collection: shireen mathews, bongekile onyeabo, tendayi chifetete, patricia pokane and nerusha lutchmana. catherine connelly assisted with the statistical design and the analysis. dr werner harmse assisted with the statistical analysis and editorial review. competing interests the authors have declared that no competing interests exist. authors’ contributions s.s.m., the main author, was responsible for the conceptualisation of the study, protocol design, data collection and analysis, and article compilation. m.d.g. was the supervisor of this mmed project, and assisted with conceptualisation and overall editorial review. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this 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m, sadun aa. age-related decline of human optic nerve axon populations. age. 1987;10(1):5–9. https://doi.org/10.1007/bf02431765 al-haddad ce, sebaaly mg, tutunji rn, et al. optic nerve measurement on mri in the pediatric population: normative values and correlations. am j neuroradiol. 2018;39(2):369–374. https://doi.org/10.3174/ajnr.a5456 neveu mm, holder ge, ragge nk, sloper jj, collin jro, jeffery g. early midline interactions are important in mouse optic chiasm formation but are not critical in man: a significant distinction between man and mouse. eur j neurosci. 2006;23(11):3034–3042. https://doi.org/10.1111/j.1460-9568.2006.04827.x bilal dma. measurements of optic chiasm dimensions using magnetic resonance imaging. sudan university of science and technology; khartoun, 2018. steinborn m, fiegler j, kraus v, et al. high resolution ultrasound and magnetic resonance imaging of the optic nerve and the optic nerve sheath: anatomic correlation and clinical importance. ultraschall med. 2011;32(6):608–613. https://doi.org/10.1055/s-0029-1245822 kalantari h, jaiswal r, bruck i, et al. correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. am j emerg med. 2013;31(11):1595–1597. https://doi.org/10.1016/j.ajem.2013.07.028 shirodkar cg, munta k, rao sm, mahesh mu. correlation of measurement of optic nerve sheath diameter using ultrasound with magnetic resonance imaging. indian j crit care med. 2015;19(8):466–470. https://doi.org/10.4103/0972-5229.162465 bäuerle j, schuchardt f, schroeder l, egger k, weigel m, harloff a. reproducibility and accuracy of optic nerve sheath diameter assessment using ultrasound compared to magnetic resonance imaging. bmc neurol. 2013;13(1):187. https://doi.org/10.1186/1471-2377-13-187 harrigan rl, plassard aj, mawn la, galloway rl, smith sa, landman ba. constructing a statistical atlas of the radii of the optic nerve and cerebrospinal fluid sheath in young healthy adults. spie medical imaging, 2017, orlando, florida. https://doi.org/10.1117/12.2081887 harrigan rl, smith ak, mawn la, smith sa, landman ba, editors. improved automatic optic nerve radius estimation from high resolution mri. spie medical imaging, 2017, orlando, florida. https://doi.org/10.1117/12.2254370 mafee mf, rapoport m, karimi a, ansari sa, shah j. orbital and ocular imaging using 3and 1.5-t mr imaging systems. neuroimaging clin n am. 2005;15(1):1–21. https://doi.org/10.1016/j.nic.2005.02.010 case report focal parenchymal sparing in fatty infiltration of the liver bjsher fcrad(d)sa i c duncan ffrad(d)sa sunninghili medical institute sandton, johannesburg introduction fatty infiltration within the liver usually shows a diffuse pattern throughout the organ. however, focal areas of either normal liver tissue sparing or fatty infiltration can occur and can be confused with metastatic disease on sectional imaging, unless one is aware of the typical sites and imaging appearances of these variants. case report a 40-year-old obese woman presented with intermittent right-sided abdominal pain. ultrasound examination of the liver showed a solitary well-defined focal echolucent lesion in the region of the caudate lobe just anterior to the common hepatic duct and portal vein, measuring 2 cm in diameter. the rest of the hepatic parenchyma showed increased echogenicity throughout suggesting diffuse fatty infiltration (fig. i). a computed tomography (ct) scan showed decreased attenuation fig. 1. axial abdominal ultrasound showing diffuse echogenicity of the liver parenchyna with a hypoechoic 'lesion' near the porta hepatis. throughout most of the parenchyma again suggesting fatty infiltration, but with areas of normal attenuation seen at the liver periphery. furthermore, in the same area of the caudate lobe a discrete rounded area with the same diameter as that measured on the earlier ultrasound examination was noted. this area showed a higher attenuation than the surrounding parenchyma, similar to the areas around the periphery of the liver (fig. 2). this area showed enhancement during the arterial, portal return and delayed phases of a triphasic contrastenhanced liver scan compatible with that of normal liver tissue, whereas the rest of the fat-infiltrated parenchyma showed a lesser degree of enhancement during all three phases (figs 3 and 4). on the basis of the ultrasound and ct findings, together with previous 24 sa jou rnal of radiology • march 2002 fig. 2. non-contrast ct scan of the abdomen showing the typical hypodense appearance of a fat-infiltrated liver, with peripheral sparing and the rounded area near the porta hepatis representing focal sparing. it is important not to confuse this round area of fatty sparing with a neoplasm. fig. 3. post-contrast abdominal ct scan during the portal venous return phase showing that the fatinfiltrated liver enhances less than the area of sparing seen in fig. 2. ultrasound reports which indicated no change in the size or appearance of the focus over a period of several months, it was felt that the focal 'lesion' most probably represented an area of focal fatty sparing. the findings were felt to be pathognomonic enough in this particular case so that the added expense of mri for confirmation was unwarranted. the spleen was also found to be enlarged (fig. 4). discussion the usual causes of fatty infiltration of the liver are alcohol abuse, obesity, malnutrition, chemotherapy, hyperalimentation, diabetes, steroid case report fig. 4. post-contrast ct scan of the abdomen, delayed phase, showing a bulky spleen. this is typically seen in a non-alcoholic fatty liver. administration, cushing's syndrome and radiation hepatitis. despite a more typical pattern of diffuse parenchymal infiltration, residual foci of normal unaffected liver parenchyma can be present, usually at the periphery of the liver or abutting the porta hepatis and gallbladder fossa. these may be mistaken for neoplastic lesions unless one is aware of the patterns of fatty sparing.' magnetic resonance imaging (mri) can reliably differentiate nodular fatty infiltration of the liver from metastatic disease, in equivocal cases. sequences include a combination of in-phase and opposed-phase gradient-echo imaging, fat saturation techniques and ferumoxide-enhanced mriy splenic enlargement is commonly seen in patients with non-alcoholic fatty liver, and the recognition of this association may halt further attempts at evaluating the cause of the splenic enlargement. 4 references 1. haaga jr, lanzieri cf. computed tomography and magnetic resonance imaging of the whole body. st louis, missouri: mosby-year book, 1994: 956-959. 2. kroncke tl.multifocal nodular fatty infiltration of the liver mimicking metastatic disease on ct: imaging findings and diagnosis using mr imaging. eur radiol2000; 10: 1095-1100. 3. hirohashi s. nondiffuse fatty change of the liver: discerning pseudotumour on mr images enhanced with ferumoxide: initial observations. radiology 2000 november 217: 415-420. 4. tsushima y. spleen enlargement in patients with non-alcoholic fatty liver, correlation between degree of fatty infiltration in liver and size of spleen. dig dis sci 2000 45(1): 196-200. the pocket radiologist series each title in the pocket radiologist series provides you with the 100 most important diagnoses in a particular radiological speciality. for each diagnosis, you'll find 2 crisply reproduced images, plus consistent, bulleted summaries of... key facts; imaging findings; differential diagnosis; clinical issues; pathologic features and references. this unique organisation makes it remarkably easy to accurately and rapidly confirm or rule out a diagnosis! and all of the pocket radiologisttitles are available as soft cover, pocket-sized books or as personal digital assistant (pda) software to meet your preferred reference style! features high resolution images: multimodality imaging. vibrant colour graphics. crisp black and white images. facts: bulleted text. most essential information. imaging findings: general findings. imaging details of each relevant modality. standard and advanced imaging. recommendations. differential diagnosis: differential list with briefdescriptions. useful guidance to alternatives. pathology findings: gross, microscopic. etiology, epidemiology. genetics. clinical issues: presentation. natural history. prognosis. treatment options. selected references: radiologists and trainees. tit/es in this exciting series pocket radiologist paediatric: top 100 diagnoses coming may 2002, paperback book rb50. pda cd-rom r1 095 pocket radiologist cardiac top 100 diagnoses coming may 2002, paperback book rb50. pda cd-rom r1 095 pocket radiologist spine top 100 diagnoses coming may 2002. paperback book rb50. pda cd-rom r1 095 pocket radiologist brain top 100 diagnoses february 2002. paperback book rb50. pdalcd-rom r1 095 pocket radiologist: head & neck top 100 diagnoses february 2002. paperback book rb50. pdalcd-rom r1 095 pocket radiologist: musculoskeletal top 100 diagnoses february 2002. paperback book rb50. pdalcd-rom r 1 095 orpers sa medical association, private bag x1, pinelands 7430. tel (021) 530-6527, fax (021) 531-1426. e-mail: fpalm@samedlcal.org please allow 4 weeks for delivery. prices subject to foreign exchange fluctuations. 25 sa journal of radiology • march 2002 mailto:fpalm@samedlcal.org abstract introduction aetiopathogenesis diagnosis treatment differential diagnosis discussion conclusion acknowledgements references about the author(s) kavitaa nedunchezhian private practice, chennai, india citation nedunchezhian k. eagle syndrome – an overview. s afr j rad. 2017;21(1), a1247. https://doi.org/10.4102/sajr.v21i1.1247 review article eagle syndrome – an overview kavitaa nedunchezhian received: 28 june 2017; accepted: 04 aug. 2017; published: 21 sept. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract eagle syndrome represents symptoms brought about by compression of vital neurovascular and muscular elements adjoining the styloid process because of the elongation of styloid process or ossification of the stylohyoid or stylomandibular ligament. it is crucial for dentists, otolaryngologists and neurologists to be aware of the elongation of the styloid process and associated signs and symptoms. this article reviews the aetiopathogenesis, classification, investigative procedures and treatment modalities associated with eagle syndrome. introduction eagle syndrome (es) or stylohyoid syndrome is a rare condition that occurs because of the elongation of the styloid process or calcification of the stylohyoid ligament, characterised by painful sensation in the head and neck region.1 this condition was first elucidated by the american otorhinolaryngologist watt weems eagle in 1937.2 most of the patients with styloid elongation or calcified stylohyoid ligament may be asymptomatic. only 4% of affected individuals are known to experience symptoms.3 symptoms may arise only when these ossified structures exert pressure on the various vital structures in the cervico-facial region. symptomatic patients may experience a wide spectrum of symptoms, including pain in cervico-facial region, pharyngeal discomfort, painful neck movements, change in voice, painful tongue movements, increased secretion of saliva, otalgia and headache. the normal styloid process measures approximately 2.5 cm – 3.0 cm in length.2 aetiopathogenesis the aetiology of es is not clearly known. although few suggest that dystrophic and degenerative changes in the hyoid complex of the styloid process might be the cause for es, others suggest that cervico-facial inflammations, tumours, tonsillectomies and trauma could play a major role in causing es.4 the suggested pathophysiological mechanisms for the pain in eagle syndrome5 the following are the different aspects that could lead to pain because of the eagle syndrome: compression of the neural elements, the glossopharyngeal nerve, lower branch of the trigeminal nerve and/or the chorda tympani by the elongated styloid process; fracture of the ossified stylohyoid ligament, followed by proliferation of granulation tissue that causes pressure on surrounding structures, resulting in pain; impingement on the carotid vessels by the styloid process, producing irritation of the sympathetic nerves in the arterial sheath (figure 1); degenerative and inflammatory changes in the tendinous portion of the stylohyoid insertion, a condition called insertion tendinosis; irritation of the pharyngeal mucosa through direct compression by the styloid process; and stretching and fibrosis involving the fifth, seventh, ninth and tenth cranial nerves in the post-tonsillectomy period. figure 1: schematic representation of (a) elongated styloid process causing impingement on vital structures versus (b) normal styloid process. classification systems eagle hypothesised that the syndrome has two types: the classic type and the carotid artery type. these types were also elucidated in the studies of breault6 and lorman and biggs.7 the classic type is often noticed in patients with a history of tonsillectomy and arises secondary to the stimulation of the trigeminal (fifth), facial (seventh), glossopharyngeal (ninth) and vagus (tenth) cranial nerves or their associated branches. eagle speculated that after tonsillectomy, these individuals develop scarring near the styloid apex which subsequently compresses or stretches nerve structures in the space surrounding the styloid process, causing pain. in the carotid artery type, the styloid process gets associated with the carotid nerve plexus and causes a foreign body sensation in the pharynx and cervical pain on rotation of the head. the radiographic classification system according to langlais et al.8 includes the following three types of appearances (figure 2): type i – represents an uninterrupted, elongated styloid process. type ii – the styloid process apparently being joined to the stylohyoid ligament by a single pseudo-articulation, which gives the appearance of an articulated elongated styloid process. type iii – consists of interrupted segments of the mineralised ligament, creating the appearance of multiple pseudo-articulations within the ligament. figure 2: radiographic classification system of styloid elongation (a) type i (b) type ii (c) type iii, according to langlais et al.8 classification of elongation of styloid process based on type of calcification: type i – elongated type ii – pseudo articulated type iii – segmented classification of elongation of styloid process based on pattern of calcification: a – calcified outline b – partially calcified c – nodular d – completely calcified classification based on angulation: narrow normal wide diagnosis the preliminary diagnosis of es is based on a proper medical history and extraoral cum intraoral examination. the elongated styloid process can be felt intraorally by digital palpation. a gentle pressure is exerted using the index finger over the tonsillar fossa; if pain is reproduced or referred to face, head, neck or ear, the presumptive diagnosis of an elongated styloid process is very likely to be present. a styloid process of normal length is usually not palpable. injection of local anaesthetic into the tonsillar fossa relieves the pain and can be used as a diagnostic tool. plain film radiographs are the commonest modality chosen. radiographic imaging includes a panoramic radiograph (figure 3), lateral-oblique mandible, lateral head and neck radiograph, towne plain film radiograph and other facial projections. a threshold length of greater than 3 cm is accepted as abnormal by current conventions. lateral views are the best to show the length of the styloid process but anteroposterior views are also required to determine bilateral involvement and lateral deviation. figure 3: digital orthopantomogram showing the presence of bilateral elongated styloid processes. ct scans have been used in difficult cases to support the diagnosis. three-dimensional reconstruction has made it possible to envision the exact spatial orientation of the styloid processes (figures 4 and 5). ossification of the stylohyoid ligament can be excluded at radiographic imaging. the added advantage of 3-d over 2-d radiographic imaging (conventional radiography) is the elimination of superimposition of anatomic structures and appreciation of soft-tissue changes, which is seldom visible in 2-d radiographic imaging. barium swallow studies can show the impression of the elongated styloid process as a filling defect.3 figure 4: various three-dimensional ct reconstruction images depicting elongation of the styloid process.9,10 (a) 3dct showing elongated styloid in association with vital structures, (b) 3dct antero-posterior view, showing complete and partial calcification of stylohyoid ligament and (c) 3dct depicting elongated styloid process. figure 5: (a) ct-axial view representing styloid process and associated carotid space, and (b) schematic representation. treatment both medical and surgical management options are available for treating styloid elongation, but medical management is known to provide only short-term relief. conservative treatment modalities included transpharyngeal injection of local anaesthetics (lignocaine) and corticosteroids, non-steroidal anti-inflammatory agents (nsaids), diazepam, and the application of heat therapy and traditional chinese herbs. transpharyngeal manipulation with manual fracturing of the styloid process does not usually relieve symptoms but also poses the risk of damaging the nearby neurovascular structures. the most satisfactory and effective treatment is surgical shortening of the styloid process through either an intraoral or external approach.11 prognosis of es is guarded by surgical failures (up to 20% of patients). this may be attributed to intraoperative injury, consequent fibrous entrapment syndrome or inappropriate shortening of the styloid process, assuming that the diagnosis was correct in the first place.12 differential diagnosis a myriad of differential diagnoses has to be ruled out before arriving at a conclusion. some of the differential diagnoses includes laryngopharyngeal dysesthesia, third molar impaction or dental-related pain, neuralgia of the sphenopalatine ganglia, glossopharyngeal and trigeminal nerve, temporomandibular joint disorders (tmds), chronic tonsillo-pharyngitis, hyoid bursitis, sluder’s syndrome, cluster-type headache, migraine, atypical facial pain, oesophageal diverticula, temporal arteritis, cervical vertebral arthritis and benign or malignant neoplasms.13 discussion styloid elongation was first described in 1652 by an italian surgeon, pietro marchetti, who credited it to an ossifying process. in 1937, watt w. eagle coined the term stylalgia to describe the pain associated with this abnormality. eagle reported over 200 cases in a 20-year study process and explained that the normal styloid process is approximately 2.5 cm – 3.0 cm in length. he observed that a slight medial deviation of the styloid process could result in severe symptoms of atypical facial pain.2,6 the diagnosis of es rests on proper medical history and prompt physical examination. an elongated styloid process can be palpated along the tonsillar fossa with the index finger, eliciting or reproducing pain, and injecting a local anaesthetic solution can relieve pain. radiographic imaging plays a key role in providing a confirmatory diagnosis. among all the radiographic imaging techniques, 3-d ct scans seem to provide the best visualisation of the elongation and associated injuries to the adjoining neurovascular and muscular elements. both surgical and non-surgical means of treating es are available. non-surgical means provide only temporary relief, whereas surgical reduction in styloid elongation appears to have a better outcome. however, the prognosis in surgical failures should also be considered. compression of the internal carotid artery because of styloid elongation can lead to a transient ischaemic attack which is quite intimidating. vagus-mediated cardiac inhibition because of es causing sudden death has been recorded in literature, and it was only at autopsy that it was revealed that the elongated styloid process had been compressing both the carotid sinuses; radiographic films had failed to show the anatomical changes.14,15 there is a plethora of disease imitating the symptoms associated with es. it is easy to misinterpret es. for instance, es can be atypically present as an exertional headache, beginning in the right ear and radiating to the neck and to the vertex.16 another reported case was with diffuse bilateral stylohyoid chain ossification which mimicked symptoms of es but was diagnosed as tmd.17 conclusion es can be confused or mistaken for many other conditions, which can be excluded by proper and detailed history, physical examination and radiological investigations. resection of the elongated styloid process is the treatment of choice for long-term benefit. owing to the simple fact that a styloid process with normal length is not normally palpable, simple digital palpation over the tonsillar fossa can help us arrive at a presumptive diagnosis. a definitive diagnosis can then be arrived at after conducting appropriate radiographic investigations. radiologists and dentists need to be cautious when viewing orthopantomograms to ensure that they assess all the structures that can be seen and not just the teeth, alveolar bone and temporomandibular joints. ethical consideration ethical consideration is not applicable for this publication. acknowledgements competing interests the author declares that she has no financial or personal relationship that may have inappropriately influenced her in writing this article. references winkler s, sammartino fj, sr., sammartino fj, jr., monari jh. stylohyoid syndrome. report of a case. oral. surg oral med oral pathol. 1981;51:215–217. https://doi.org/10.1016/0030-4220(81)90043-8 eagle ww. elongated styloid process: report of two cases. arch otolaryngol. 1937;25:584–546. https://doi.org/10.1001/archotol.1937.00650010656008 murtagh rd, caracciolo jt, fernandez g. ct findings associated with eagle syndrome. ajnr am. j. neuroradiol. 2001;22:1401–1402. baugh rf, stocks rm. eagle’s syndrome: a reappraisal. ear nose throat j. 1993;72:341–344. ceylan a, koybas_iog lu a, celenk f, yilmaz o, uslu s. surgical treatment of elongated styloid process: experience of 61 cases. skull base. 2008;18(5):289–295. https://doi.org/10.1055/s-0028-1086057 breault mr. eagle’s syndrome: review of the literature and implications in craniomandibular disorders. j craniomandibular practice. 1986;4:323–337. https://doi.org/10.1080/08869634.1986.11678161 lorman jg, biggs jr. the eagle syndrome. ajr. 1983;140:881–882. https://doi.org/10.2214/ajr.140.5.881 langlais rp, miles da, van dis ml. elongated and mineralized stylohyoid ligament complex: a proposed classification and report of a case of eagle’s syndrome. oral surg oral med oral pathol. 1986;61:527–532. https://doi.org/10.1016/0030-4220(86)90400-7 dong z, bao h, zhang l, hua z. eagle’s syndrome associated with lingual nerve paresthesia: a case report. j oral maxillofac surg. 2014;72:886.e1–886.e4. https://doi.org/10.1016/j.joms.2014.02.011 raina d, gothi r, rajan s. eagle syndrome. indian j radiol imaging. 2009;19:107–108. https://doi.org/10.4103/0971-3026.50826 beder e, ozgursoy ob, ozgursoy sk. current diagnosis and transoral surgical treatment of eagle’s syndrome. j oral maxillofac surg. 2005;63:1742–1745. https://doi.org/10.1016/j.joms.2005.08.017 ghosh lm, dubey sp. the syndrome of elongated styloid process. auris nasus larynx. 1999;26:169–175. https://doi.org/10.1016/s0385-8146(98)00079-0 harma r. stylalgia – clinical experiences of 52 cases. acta otolaryngol. 1966;22:149. das s, suhaimi fh, othman f, latiff aa. anomalous styloid process and its clinical implications. bratisl lek listy. 2008;109(1):31–33. ruwanpura pr, abeygunasekera am, tikiri gk. sudden unexpected death probably due to eagle’s syndrome: a case report. med sci law. 2008;48(4):350–353. https://doi.org/10.1258/rsmmsl.48.4.350 maggioni f, marchese-ragona r, mampreso e, mainardi f, zanchin g. exertional headache as unusual presentation of the syndrome of an elongated styloid process. headache. 2009;49(5):776–779. https://doi.org/10.1111/j.1526-4610.2008.01267.x ramadan su, go¨kharman d, kacar m, kos_ar u. diffuse stylohyoid chain ossification. diagn interv radiol. 2007;13:176–178. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) monica s. msomi department of radiology, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa hansraj mangray department of paediatric surgery, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, south africa vicci du plessis skg radiology, mandurah, australia citation msomi ms. mangray h. du plessis v. an assessment of the accuracy of contrast enema for the diagnosis of hirschsprung disease at a south african tertiary hospital. s afr j rad. 2017;21(1), a1093. https://doi.org/10.4102/sajr.v21i1.1093 original research an assessment of the accuracy of contrast enema for the diagnosis of hirschsprung disease at a south african tertiary hospital monica s. msomi, hansraj mangray, vicci du plessis received: 16 sept. 2016; accepted: 17 jan. 2017; published: 30 mar. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objectives: to compare radiological findings with the histological diagnosis of hirschsprung disease (hd) to establish the usefulness of contrast enema as an initial screening and diagnostic tool. to correlate accuracy of radiological diagnosis at grey’s hospital with international standards. materials and methods: systematic searches were conducted through the picture archiving and communication system and the national health laboratory service records for patients aged 0–12 years, with clinically suspected hd, for whom both contrast enemas and rectal biopsies were performed between 01 january 2011 and 31 august 2015 in a tertiary-level hospital. a total of 54 such patients were identified. diagnostic accuracy levels were calculated by comparing radiological results with histology results, which is the gold standard. results: diagnostic accuracy of contrast enema was 78%, sensitivity was 94.4% and the negative predictive value was 95.7%. specificity (68.8%) and positive predictive values (63%) were considerably lower. a lower false-negative rate of 5.6% was obtained at grey’s hospital as compared with the international reports of up to 30%. conclusion: contrast enema remains useful as an initial screening and diagnostic test for hd. results of this south african tertiary referral hospital were consistent with the best international results for sensitivity of the contrast enema (approximately 80% – 88% in excluding the disease). introduction hirschsprung disease (hd), also known as colonic aganglionosis, is a rare cause of constipation. it is defined as a functional obstruction of bowel caused by the lack of distal enteric ganglion cells with a reported incidence of 1:5000–7200 in newborns.1 variable lengths and segments of bowel may be involved. it is associated with significant morbidity if not diagnosed and treated early; therefore, clinicians are often cautious to promptly identify or exclude this disease. there has been considerable debate about the most appropriate initial test to diagnose hd because all the diagnostic modalities [contrast enema, anorectal manometry (arm) and rectal suction biopsy] can produce false-negative (fn) and false-positive (fp) results.2 following critical evaluation of the sensitivity, specificity and predictive values of these investigations in the 1980s, it was shown that radiologic studies alone are not a sensitive enough tool to exclude hd and that manometry and rectal mucosal biopsy are also required for an accurate diagnosis.3 full-thickness biopsy confirming the absence of ganglion cells remains the gold standard for diagnosis.4 however, the risks associated with rectal biopsy, including bleeding, sepsis, perforation and anaesthesia-related risks,5 led to the development of the rectal suction biopsy as an alternative diagnostic modality, but as mentioned previously, it can produce fp and fn results. contrast enemas therefore continue to play an invaluable role in many centres, and a radiologist’s opinion forms part of the data used by clinicians to decide whether other investigations are necessary in neonates and children with distal bowel obstruction or abnormal bowel habits.3 the contrast enema is often readily available and is the first imaging procedure performed in many centres, including grey’s hospital, a tertiary referral hospital in pietermaritzburg, south africa. however, much controversy exists in the literature regarding its usefulness in the work up of patients with hd.4,6 the best reported sensitivity of the barium enema in excluding hd is approximately 80% – 88%6 and fn rates of up to 30% have been reported.4 the diagnostic accuracy of the contrast enema is, therefore, of continued interest to both clinicians and radiologists, and it is important to constantly assess how accurately radiologists are able to make the diagnosis of hd, with a view to both encouraging good radiological practice as well as identifying possible factors that may contribute to reduced diagnostic accuracy. methods study sample and design a retrospective audit was undertaken of all contrast enemas and rectal biopsies performed on patients aged 0–12 years between 01 january 2011 and 31 august 2015 inclusive. only children investigated with both contrast enema and full-thickness rectal biopsy for the clinical suspicion of hd were included in the study. study description a systematic search was conducted through the picture archiving and communication system (pacs) for patients aged 0–12 years who had been referred for contrast enemas between 01 january 2011 and 31 august 2015 inclusive. a total of 185 patients were identified. the request forms for these patients were reviewed to identify the patients who were specifically referred for the diagnosis or exclusion of hd (history of constipation or changed bowel habits). the total number of patients identified was 97. a concurrent search for rectal biopsy results was conducted through the national health laboratory service (nhls) website, and ultimately a total of 54 patients were identified who had undergone both contrast enema and biopsy. the remaining 43 patients were excluded from the study because they did not meet the selection criteria and were not investigated further for the purposes of our study. enemas were performed at our tertiary institution mostly by trainee radiologists and occasionally by specialist radiologists, while the images were predominantly examined by the performing trainee radiologist in conjunction with a specialist radiologist; on a few occasions, images were examined by a radiology registrar alone. only water-soluble contrast enemas (wsces) are performed at grey’s hospital using gastrografin, omnipaque or ultravist as contrast agents. for the procedure, a foley’s catheter is inserted into the lower rectum and the catheter bulb is not inflated. contrast is passed as far as possible, in most cases until the terminal ileum is opacified. for our study, positive enema results were based mainly on the presence of a transition zone (tz) or calibre change, reversed recto-sigmoid ratio (rrsr) and other ancillary findings such as delayed post-contrast evacuation of bowel, saw-tooth mucosal pattern or mucosal irregularity. full-thickness rectal biopsies were performed under general anaesthesia by a specialist paediatric surgeon at 15 mm above the dentate line, posteriorly, and sent for haematoxylin and eosin (h&e) staining and, occasionally, for calretinin staining. (suction biopsy equipment was not available during the study period but has since been acquired.) specimens were examined by a specialist histopathologist, who looked for the presence or absence of ganglion cells in meissner’s submucosal plexus and auerbach’s intermyenteric plexus, at times with the additional finding of neuronal hyperplasia. related symptoms such as constipation, abdominal distension, vomiting and delayed passage of meconium (where present) were recorded for each patient to ascertain any statistical significance. a data sheet was used to collect the relevant data. the study was approved by the biomedical research ethics committee (be475/15), the provincial department of health and the management of grey’s hospital. ethical consideration this is a blind, retrospective, descriptive study, focusing on the analysis of radiological and histopathological records. patients’ identities are protected and no consent was necessary. statistical analysis data were collected and entered into a computerised database program (microsoft excel). a codebook which included variable names, descriptions and formats was developed. sensitivity and specificity rates for contrast enemas within 95% cis (confidence intervals) were calculated with the method of wilson. the single inconclusive enema result was excluded from this calculation. risk factors associated with a positive histology result were identified using fisher’s exact test. factors associated with a significant p-value at the univariate level were included in a multivariable logistic model. because of the relatively small number of positive cases, each risk factor was also modelled separately adjusting for age and sex. a two-sided p-value of < 0.05 was considered statistically significant for all analyses. data were analysed using the stata v13.1 statistical software. results of the 54 patients included in the study, 28 had positive contrast enemas, 25 had negative enemas and 1 had an inconclusive enema result (table 1). seventeen patients who had positive enemas also had positive histology [true-positives (tps)], while for the remaining 11 patients with positive enemas, 10 patients turned out to have negative histology (fp) and 1 had an inconclusive histology result. of the 25 negative enemas, most (22) had concurrent negative histology (true-negatives), one had positive histology (fn) and two had inconclusive histology results. the single inconclusive enema result had a negative histology result. the three inconclusive histology results were as a result of inadequate or non-representative samples. the inconclusive enema result was because of marked distension of the rectum with faeces and no other supporting features of hd. table 1: screening test evaluation: single table analysis. table 2 denotes the diagnostic evaluation of the contrast enema compared with rectal biopsy as the gold standard. table 2: diagnostic evaluation of the contrast enema compared to rectal biopsy as the gold standard. in terms of risk factors for the disease, with adjustments for age and sex, children who were less than 1 month had a greater chance of testing positive on histology for the disease than children over 1 month of age (table 3). males also had a significantly greater chance of testing positive than females. in terms of radiological features, the presence of an rrsr and a tz each significantly increased the chances of testing positive for the disease (or 3.4, 95% ci 0.6–18.4, p = 0.2 for rrsr and or 4.5, 95% ci 0.9–22.3, p = 0.07 for tz, respectively) (table 3). of the related symptoms, only vomiting was significantly associated with the disease (or 3.7, 95% ci 1.1–12.9, p = 0.03); however, this was not statistically significant when adjusted for age and sex (or 3.6, 95% ci 0.7–18.7, p = 0.1). table 3: risk factors for the disease adjusted for age and sex. discussion results of the grey’s hospital were comparable with the best international results for sensitivity of the contrast enema (approximately 80% – 88%) for excluding hd.6 there is, however, a wide discrepancy between sensitivity and specificity rates. a systematic review by de lorijn et al. concluded that such a discrepancy may be due to differences in the quality of studies and variation as a result of chance because of the low number of included patients.2 nevertheless, lower specificity rates are desirable for screening tests as the benefits of over-referring patients for biopsies, early diagnosis and management of the disease outweigh the risks and costs of missing patients. the high negative predictive value (npv) of 95.7% was consistent with those reported in literature and suggests that very few positive cases are missed, which supports the usefulness of the contrast enema.6 a lower fn rate of 5.6% was obtained as compared to the international reports of up to 30%. this may be because this condition is seen significantly more frequently at the grey’s hospital as compared to other institutions. seventeen out of the 54 studied patients had biopsy-proven hd; this number is significantly higher than the accepted prevalence of the disease and may be related to the fact that the study was conducted in a tertiary-care hospital. the sole fn result was in a child with cerebral palsy and may be related to regular rectal washouts or digital rectal manipulation, which is often performed on cerebral palsy patients and have been shown to lead to fn results.2,4 the significantly higher fp rate of 31.3%, although concerning for radiological overdiagnosis, which may lead to unnecessary biopsies, is desirable for screening tests such as contrast enemas for the aforementioned reasons. a study by o’donovan et al. assessed the validity of using low osmolality wsce instead of barium enemas in neonates and infants for the investigation of hd.3 it found good agreement in the sensitivities and specificities for both groups, which justifies the use of wsce in neonates and infants. the rrsr and the tz were the only radiological features that were significantly associated with the disease. the rrsr was even more significantly associated with the disease than the tz. an rrsr was present in 72.2% of children with the disease and in only 27.3% of children without the disease. the tz was present in 66.7% of children with the disease and in only 18.2% of children without the disease. this is consistent with most literature reports which state that the presence of a radiographic tz on barium enema remains the most accurate diagnostic sign for hd,2,7,8,9 and with the study by o’donovan et al.,3 which reported the rrsr as the most sensitive radiologic sign of hd (figures 1–3). the radiographic tz is also known to be the most reliable radiological sign to evaluate the level of aganglionosis, a finding that has implications for surgical management.9 notwithstanding these factors, taxman et al. suggested that in young infants, the calibre change or tz is more difficult to demonstrate.4 furthermore, de campo et al. demonstrated a normal calibre colon in 75% of children with total aganglionosis,2 which means that the absence of this feature on contrast enema does not exclude hd. figure 1: lateral (a) and frontal (b) views demonstrating long segment hirschsprung disease involving the rectum and distal sigmoid colon, with a transition zone (white arrows) seen in the sigmoid colon. figure 2: lateral (a), oblique (b) and frontal (c) views demonstrating a zone of transition in the region of the recto-sigmoid junction (white arrows) in a patient with hirschsprung disease. a reversed recto-sigmoid ratio is also seen. figure 3: lateral (a) and frontal (b) views in a patient with hirschsprung disease. the lateral view demonstrates a reversed recto-sigmoid ratio. in this study, we did not assess for any correlation between the tzs at contrast enema and at surgery. the most common presenting symptoms for hd are delayed passage of meconium (60% – 90%), abdominal distension (63% – 91%) and bilious vomiting (19% – 37%).1 in older children, the most frequently reported symptom is constipation.1 our study however showed that for all age groups, vomiting was the only symptom that was significantly associated with the disease, although this was not statistically significant when adjusted for age and sex, as aforementioned. delayed passage of meconium (beyond 24 h) was documented in only one child, and while constipation and abdominal distension were reported in patients with and without the disease, no statistical significance was established with these symptoms. lewis et al. demonstrated that patients with hd were more likely to experience symptoms within the first week of life and have delayed passage of meconium, abdominal distension, vomiting and a tz.10 our study was in concordance with at least three of these findings. most of our patients with hd were identified in the neonatal period, had the symptom of vomiting and had a tz on contrast enema. our findings of neonatal age and male sex as risk factors for the disease were also consistent with literature reports. ninety per cent of patients are diagnosed when they are newborns, and the disease is reported to be four times more common in males than females.1 diamond et al. reported that on a univariate analysis, age below 30 days, female sex, absence of a tz and presence of another finding were all statistically, at the 0.05 level, associated with an increased risk of an fp contrast enema result. the presence of bilious emesis or the passage of meconium beyond the first day of life was associated with a decreased risk of an fp result.10 the same study also found that on multivariate analyses, the absence of a tz, female sex and age below 30 days were all associated with an increased risk of an fp result, whereas a history of bilious emesis decreased the risk. our study showed that females are more than three times as likely to be fp as compared to males; 30% of males are fp versus 60% of females (or 3.4, 95% ci 0.5–25, p = 0.2). this is consistent with the finding of the report by diamond et al., but the figures are not statistically significant. absence of a tz was found more often in fp (40%) than tp (33%) patients, although again no statistical association was found. vomiting was found more often in tp rather than in fp patients (or 2.3, 95% ci 0.5–12, p = 0.4). forty-four per cent of children without vomiting were fp versus 25% of children with vomiting (or 0.4, 95% ci 0.1–2.2, p = 0.3). the low or suggests a lower chance of fp with vomiting and provides some support to the findings of the report. our study showed no significant association between another radiological finding and an fp enema result. according to our study, age above 30 days is an indication of an fp enema result, which contradicts the finding of the report by diamond et al. there was only one reported case of delayed passage of meconium in our study, so no comparison could be made concerning this feature. factors associated with a tp result in our study include age less than 30 days, male sex and children presenting with vomiting (table 4). no statistical significance was demonstrated with any of these factors, but the high or values (or 7.2, 95% ci 0.7–69.4, p = 0.1; or 3.4, 95% ci 0.5–25.3, p = 0.3 and or 2.3, 95% ci 0.5–12, p = 0.4, respectively) suggest an association. table 4: risk factors associated with true-positives. lastly, a note about arm. this is a non-invasive diagnostic test, easy to perform in children older than 1 year and has often been suggested as an ideal screening tool.2 a study by de lorijn et al. concluded that it is slightly more sensitive (83% vs. 76%), although less specific (93% vs. 97%) than contrast enemas.4 unfortunately, the costs involved preclude its implementation in our institution. limitations the study is limited to a certain age group. the correct histopathological diagnosis is dependent on the technique of rectal biopsy. radiological interpretation is dependent on the degree of experience of the interpreting radiologist, as well as the study technique and quality of images, which are in turn influenced by the degree of experience of the performing radiologists who in certain instances were junior trainees. patient factors such as lack of co-operation as can be seen with younger patients may also influence the quality of the study or images. the sample size is reduced. conclusion the contrast enema remains useful as a screening test for hd. results of this south african tertiary referral hospital were consistent with the best international results for sensitivity of the contrast enema (approximately 80% – 88% in excluding the disease). however, full-thickness rectal biopsy remains the gold standard for diagnosis of hd. acknowledgements the authors would like to thank catherine connolly for her assistance with data analysis and dr matthew goodier for his assistance with data analysis and suggested revisions for this article. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.s.m. performed literature review, prepared research proposal protocol for ethics board approval, gathered data for analysis, and prepared the primary write-up of the research manuscript. h.m. was the co-investigator of the research project, assisted with data collection for analysis and helped with manuscript editing. v.d.p. supervised the research project and helped with the manuscript editing. references merrow c. hirschsprung disease [homepage on the internet]. 2011 [cited 2015 sep 29]. available from: http://my.statdx.com/document/hirschsprung-disease/6b6f4318-afc8-4809-aaf7-1c5a001ca889 de lorijn f, kremer lc, reitsma jb, benninga ma. diagnostic tests in hirschsprung disease: a systematic review. j pediatr gastroenterol nutr. 2006;42(5):496–505. https://doi.org/10.1097/01.mpg.0000214164.90939.92 o’donovan an, habra g, somers s, malone de, rees a, winthrop al. diagnosis of hirschsprung’s disease. am j roentgenol. 1996;167(2):517–520. https://doi.org/10.2214/ajr.167.2.8686640 de lorijn f, reitsma jb, voskuijl wp, et al. diagnosis of hirschsprung’s disease: a prospective, comparative accuracy study of common tests. j pediatr. 2005;146(6):787–792. https://doi.org/10.1016/j.jpeds.2005.01.044 alehossein m, roohi a, pourgholami m, mollaeian m, salamati p. diagnostic accuracy of radiologic scoring system for evaluation of suspicious hirschsprung disease in children. iran j radiol. 2015;12(2):e12451. https://doi.org/10.5812/iranjradiol.12451 reid jr, buonomo c, moreira c, kozakevich h, nurko sj. the barium enema in constipation: comparison with rectal manometry and biopsy to exclude hirschsprung’s disease after the neonatal period. pediatr radiol. 2000;30(10):681–684. https://doi.org/10.1007/s002470000298 proctor ml, traubici j, langer jc, et al. correlation between radiographic transition zone and level of aganglionosis in hirschsprung’s disease: implications for surgical approach. j pediatr surg. 2003;38(5):775–778. https://doi.org/10.1016/jpsu.2003.50165 taxman tl, yulish bs, rothstein fc. how useful is the barium enema in the diagnosis of infantile hirschsprung’s disease? am j dis child. 1986;140(9):881–884. rosenfield ns, ablow rc, markowitz ri, et al. hirschsprung disease: accuracy of the barium enema examination. radiology. 1984;150(2):393–400. https://doi.org/10.1148/radiology.150.2.6691093 diamond ir, casadiego g, traubici j, langer jc, wales pw. the contrast enema for hirschsprung disease: predictors of a false-positive result. j pediatr surg. 2007;42(5):792–795. https://doi.org/10.1016/j.jpedsurg.2006.12.031 abstract introduction management and outcome discussion ethical considerations acknowledgements references about the author(s) pamela smilg drs incorporated, johannesburg, south africa citation smilg, p. pseudoangiomatous stromal hyperplasia: presentation and management – a clinical perspective. s afr j rad. 2018;22(2), a1366. https://doi.org/10.4102/sajr.v22i2.1366 clinical perspective pseudoangiomatous stromal hyperplasia: presentation and management – a clinical perspective pamela smilg received: 20 may 2018; accepted: 03 aug. 2018; published: 29 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract pseudoangiomatous stromal hyperplasia (pash) is a benign breast condition of collagen proliferation. in this article, four cases are presented in series to illustrate the varying clinical presentations of pash at mammography and sonography, as well as the vastly differing age groups that can be affected. a literature review of the aetiology, pathology and management of pash is included to provide a comprehensive but succinct overview of the condition, what it is and how to recognise and manage it. introduction pseudoangiomatous stromal hyperplasia (pash) is an uncommon and cryptic breast condition, which was first documented in 1986 when it presented in a patient as a palpable breast mass.1 since then, cases of pash with varying presentations have been described.2 the findings in four different patients imaged at union hospital between april 2016 and march 2018 are presented in this report to demonstrate the differing ages and presentations of biopsy-proven pash. the cases highlight the existence of pash, its varied forms of presentation and the implications for further patient management. although uncommon, it is important to be aware of and recognise this condition in order to avoid submitting the patient to unnecessary surgery or follow-up examinations once it has been diagnosed. case 1 miss j, a 40-year-old asymptomatic woman, presented for routine screening. her mammogram (figure 1) revealed a cluster of indeterminate microcalcifications in the right breast, which was classified as breast imaging reporting and data system (birads) iva, and a stereotactic-guided biopsy was recommended. breast sonar examination was non-contributory. pathology demonstrated fibroadenosis with benign microcalcifications and one of the core biopsies showed features of pash (figure 2). in this case, pash was an incidental and unexpected finding. figure 1: (a) mediolateral and (b) craniocaudal mammography projections demonstrating clustered indeterminate calcifications in the right breast (arrows). figure 2: arrows indicate the pseudovascular spaces. case 2 mrs k, a 50-year-old asymptomatic woman, was found to have probably benign nodules in her right breast at previous sonography 12 months earlier. at her annual follow-up mammogram and breast sonar, one of these lesions, located superiorly in the right breast, appeared to have increased very slightly in size and become less well defined on sonar (figure 3e). her mammogram was non-contributory (figure 3a–d), and a sonar-guided biopsy was recommended (birads iv). pathology indicated benign proliferative breast disease with adenosis and pash (figure 4). figure 3: (a–d) normal appearing craniocaudal and mediolateral mammogram views and (e) right breast sonar image revealing a benign-appearing nodule. figure 4: arrows indicate the pseudovascular spaces. case 3 miss m, a 14-year-old girl, presented for sonar assessment of a large, growing, palpable lump in her left breast. corresponding to the lump, there was a 7 cm × 4 cm × 5.7 cm, slightly mixed, predominantly isoechoic, probably benign mass on sonar (figure 5). because of its size, sonar-guided core biopsy was recommended (birads iv). microscopy showed features of pash. figure 5: longitudinal (a) and transverse (b) sonographic images of the predominantly isoechoic, palpable lump. immunohistochemical stains were as follows: estrogen receptor (er) positive in the duct component and negative in the stromal component. progesterone receptor (pr) positive in the epithelial component and negative in the stromal component. mnr116 positive in the epithelial component and negative in the stromal component. androgen receptor focal positive in the stromal component. cd34 positive in the vascular element only. case 4 mrs z, a 71-year-old diabetic woman, presented complaining of a palpable lump in the right breast. her mammogram showed extremely dense tissue with a grade d pattern and increased density in both upper, outer quadrants (figure 6a). sonar demonstrated large areas of hypoechogenicity with posterior shadowing bilaterally (figure 6b), which was difficult to quantify accurately (birads iv). both diabetic mastopathy and pash were considered and sonar-guided biopsies of the dominant areas of hypoechogenicity were advised to exclude neoplasia. pathology indicated features consistent with pash bilaterally (figure 7). figure 6: (a–d) craniocaudal and mediolateral mammogram with a grade d dense breast pattern and (e) sonar demonstrating an area of hypoechogeneity with posterior acoustic shadowing (arrow). figure 7: arrows indicate the pseudovascular spaces. management and outcome in all cases, there was radiological and pathological concordance. annual surveillance was advised for cases 1, 2 and 4. case 3 required no radiological follow-up but was referred for surgical opinion to discuss the option of surgery in view of possible aesthetic problems because of the size and enlargement of the mass and the patient’s preference. however, the patient did not attend her surgical appointment. discussion aetiology and pathogenesis pseudoangiomatous stromal hyperplasia is a benign breast condition of collagen proliferation. the exact aetiology and pathogenesis are unknown, but hormonal factors are known to play a role in the development of pash; it is more common in preand perimenopausal women.3 pash has been shown to occur across a wide age range and has been documented in women from 14 to 67 years old, the majority occurring between 30 and 50 years.4 it is rare over the age of 50, which further correlates with a hormonal aetiology.5,6 pash can also occur in men, associated with gynaecomastia.6 in known cases of pash, the lesion size was shown to change with menses, consistent with a hormone-related fluctuation.1 in addition, pash cases have shown strong stromal cell pr positivity and faint stromal nuclear reactivity for oestrogen was shown in one case, whereas the stromal cell nuclei of control cases without pash did not stain for either receptor.6 presentation clinically, pash usually presents as a mass, typically enlarging, sometimes rapidly.4 it may also present as an incidental, microscopic finding1,7 and may or may not be palpable.2 radiologically, the classic description of pash is of a single, well-circumscribed, round or oval, mobile mass, resembling a fibroadenoma on mammogram and sonar.5 on mammography, it typically has the appearance of a probably benign mass,1 lacking calcification within it.2,8 it varies in size, with measurements of 1 cm–12 cm reported.8 on sonar, it is usually a hypoechoic, oval or round, benign-appearing mass but may be slightly heterogeneous.2,9 if it occurs within fibroadenosis, the imaging findings reflect this, with mammographically dense tissue and sonographic shadowing, hypoechoic tissue.9 on mri, the findings of pash are non-specific and range from an enhancing mass to clumped, non-mass-like enhancement, usually with benign kinetics.2 however, as illustrated by the above cases, pash may present with various other findings, none specific to the condition, and indeed, it is most commonly found as an incidental finding in a biopsy specimen, the biopsy having been done for another reason.9 it can thus be associated with any other specific pathology or tissue type and the morphology of this may be the dominant finding. pathology breast tissue containing pash exhibits stromal cell proliferation, that is, proliferation of collagen, with slit-like channels lined with myofibroblasts (spindle cells) resembling vascular channels.5,6 this is, however, not true angiomatous proliferation and these channels are not blood vessels. because of this, however, it may be histologically mistaken for a vascular neoplasm.5 the spindle cells are positive for vimentin, cd34, bcl2, cd99 and α-smooth muscle actin but negative for cd31 and factor viii (an endothelium-specific marker). in addition, the cells are hormonally sensitive and frequently express pr and less frequently er.1,5,10 differential diagnosis radiological differential diagnosis depends on mode of presentation. as a benign-appearing mass, the main differentials are fibroadenoma and phyllodes.11 within an area of fibroadenosis, the condition may be diagnosed as fibroadenosis. pash may also be misdiagnosed as a different condition at biopsy when it is present as an incidental finding. in addition, pash may be confused with other diffuse breast diseases such as diabetic mastopathy.12 the main pathological differential diagnoses are low-grade angiosarcoma and spindle cell containing entities such as phyllodes and desmoid tumours. management pseudoangiomatous stromal hyperplasia is a benign condition. it is neither premalignant nor a risk factor for the development of carcinoma.6 it is not associated with synchronous carcinoma6 (however, as it occurs together with anything else, it could theoretically coexist as an incidental finding with a carcinoma). if the imaging findings are equivocal, a histological examination is mandatory for a definitive diagnosis.6 a diagnosis of incidental pash requires no active intervention or radiological follow-up. pseudoangiomatous stromal hyperplasia is a birads ii condition. surgery may be performed for enlarging lesions, diffuse pash with massive breast enlargement which is very rare12 and in patients with discordance following triple assessment.6 after surgery, it has been shown to have a low rate of recurrence (15% – 22%).11 there is no established conservative treatment for pash. it responds to tamoxifen; however, the effects may only be sustained with prolonged therapy. long-term tamoxifen may not be ideal because of its side effects10 and would be inappropriate in young premenopausal women. ethical considerations informed consent was obtained from all the patients for inclusion of their images and information in the study. acknowledgements any views expressed in this article are the author’s own and do not reflect the official position of drs inc. the author thanks dr blackburn for providing the images of the pathology slides. competing interests the author declares that she has no personal or financial relationships that may have inappropriately influenced her in writing this article. references powell cm, cranor ml, rosen pp. pseudoangiomatous stromal hyperplasia (pash). am j surg pathol. 1995;19:270–277. https://doi.org/10.1097/00000478-199503000-00004 celliers l, wong d, bourke a. psuedoangiomatous stromal hyperplasia: a study of the mammographic and sonographic features. clin rad. 2010;65(2):145–149. anderson c, ricci a, pederson c, et al. immunocytochemical analysis of oestrogen and progesterone receptors in benign stromal lesions of the breast: evidence for hormonal aetiology in psuedoangiomatous hyperplasia of mammary stroma. radiographics. 1999;19:1086–1088. castro c, whitman g, sahin a. pseudoangiomatous hyperplasia of the breast. am j clin oncol. 2002;25(2):213–216. https://doi.org/10.1097/00000421-200204000-00024 vuitch m, rosen p, erlandson r. pseudoangiomatous hyperplasia of mammary stroma. hum pathol. 1986;17:185–191. https://doi.org/10.1016/s0046-8177(86)80292-1 jaunoo s, thrush s, dunn p. pseudoangiomatous stromal hyperplasia (pash): a brief review. int j surgery. 2011;9(1):20–22. https://doi.org/10.1016/j.ijsu.2010.09.005 mercado c, naidrich s, hamele-bena d. pseudoangiomatous stromal hyperplasia of the breast: sonographic features with histopathological correlation. breast j. 2004;10:427–432. https://doi.org/10.1111/j.1075-122x.2004.21373.x okoshi k, ogawa h, suwa h. a case of nodular pseudoangiomatous hyperplasia (pash). breast cancer. 2006;13(4):349–353. https://doi.org/10.2325/jbcs.13.349 sng k, tan s, mancer jf, tay kh. the contrasting presentation and management of pseudoangiomatous stromal hyperplasia of the breast. singapore med j. 2008;49:e82–e85. pruthi s, reynolds c, johnson re, gisvold jj. tamoxifen in the management of pseudoangiomatous stromal hyperplasia. breast j. 2001;7:434–436. https://doi.org/10.1046/j.1524-4741.2001.07611.x polger mr, denison cm, lester s, meyer je. pseudoangiomatous stromal hyperplasia: mammographic and sonographic appearances. am j roentgenol. 1996;166:349–352. https://doi.org/10.2214/ajr.166.2.8553945 jones k, glazebrook k, reynolds c. pseudoangiomatous stromal hyperplasia: imaging findings with pathologic and clinical correlation. am j roentgenol. 2010;195:1036–1042. https://doi.org/10.2214/ajr.09.3284 review article percutaneous vertebroplasty ivann f van der merwe mmed (rad d) sa, drs schnetler, corbett and partners panorama mediclinic cape town abstract percutaneous vertebroplasty is a safe and successful method for the treatment of vertebral lesions due to osteoporotic fractures, metastatic lesions or haem angiomas. the procedure involves the percutaneous injection of polymethyl methacrylate (pmma) into a pathological vertebral body. the technique is described in detail together with potential complications. strict adherence to selection criteria, a multidisciplinary approach and the need for excellent imaging equipment are stressed. introduction percutaneous vertebroplasty has been performed in france by interventional radiologists since 1984 and involves the percutaneous injection of polymethyl methacrylate (pmma) into a pathological vertebral body.' currently the same procedure is also being used for the treatment of metastatic lesions in different parts of the skeleton (e.g. the acetabulum), but for the purposes of this article i will confine the discussion to the treatment of vertebral lesions. the first cases in france were specifically for the treatment of aggressive or symptomatic vertebral haemangiomas, but in europe the procedure is currently being used mainly for the treatment of primary and secondary malignancies of the vertebrae. in the usa the procedure is more commonly used in the treatment of osteoporotic vertebral fractures than in malignant lesions. this is in part because in the usa it is largely a patient-driven procedure, with the patients having internet 'savvy' and referring themselves directly. in 1998 there were 10 12 physicians performing the procedure in the usa; by 2001, 500 interventional radiologists had been trained and were performing percutaneous vertebroplasties. the procedure is minimally invasive and leads to marked reduction or cure of pain together with the mechanical strengthening of the bone. it is usually done as an outpatient procedure with a success rate of between 80% and 90%.2 the pmma leads to the stabilisation of the bone fragments. it reaches a temperature of 60 70° c on setting, the same temperature reached during the use of radio frequency ablation in the treatment of metastatic deposits.' the result is that this heat generated also leads to lysis of underlying tumour cells. vertebroplasty requires a multidisciplinary approach and strict selection 5 sa journal of radiology • august 2003 criteria are needed to ensure the safety and success of the procedure. vertebroplasty must not be mistaken for kyphoplastywhere a balloon is first inserted into the collapsed vertebra to try to restore some height before cement is injected. indications osteoporotic vertebral fractures sixty per cent of postmenopausal women have osteopenia, of whom 40% will develop osteoporotic fractures, with between 400 000 and 500 000 such fractures occurring annually in the usa. approximately one-third of these patients develop chronic pain of life-altering severity that is unresponsive to conservative management." vertebral fractures are associated with increased morbidity and mortality and may lead to loss of the patient's independence. they are a leading cause of admissions to nursing homes. conservative management may be complicated by pneumonia, dvt and pulmonary emboli. although pain may last for months a number of patients respond well to conservative management and therefore vertebroplasty should not be attempted before a trial of conservative management has been attempted. the duration obviously ranges with individual patients but a timespan of 2 3 weeks is currently being used. however, current findings are that patients who have had a fracture previously treated by vertebroplasty, frequently refuse even to attempt conservative therapy when they have another fracture. malignancies lymphoma, myeloma and metastatic lesions are the most comreview article monly treated vertebral malignancies. these cause pain by infiltration and due to the collapse of the vertebra. although radiation has been used up to now this does not give the same rapid pain relief or stability as one would get with vertebroplasty. it is currently being used in conjunction with vertebroplasty in some centres. conservative management of malignant lesions has the same possible complications as can be expected during conservative management of osteoporotic fractures, while surgery has a much higher morbidity; mortality and cost in patients who often have limited life expectancy. by comparison vertebroplasty leads to partial or complete pain reduction in 80 90% of patients within the first 72 hours." in addition surgery is contraindicated when multiple levels are affected. the clearest indications for vertebroplasty are in patients complaining of severe, focal and mechanical back pain related to neoplastic vertebral collapse, without epidural involvement.' haemangiomas painful destructive vertebral haemangiomas (vh) are very rare. surgical alternatives to vertebroplasty are invasive and require hardware. in these cases vertebroplasty can be considered as an embolisation with bone cement. radiological signs of aggressiveness include: (i) progressive involvement of the vertebral body; (ii) extension to the neural arch; (iii) collapse of the vertebral body; and (iv) increasing soft tissue mass. pre-procedural work up vertebroplasty needs a multidisciplinary approach involving endocrinologists, oncologists, orthopaedic and neurosurgeons. the patients need a thorough neurological evaluation prior to the procedure. it is critical to ensure that the pain is related to the specific vertebral compression and this must be confirmed by clinical evaluation under screening prior to the procedure. identification of the collapsed vertebra under screening followed by direct pressure should replicate the pain the patient is experiencing. clotting profiles are obtained as a coagulation disorder is seen as an absolute contraindication unless corrected. an mr! is done prior to the procedure to help determine the more acute level causing the symptoms, as this may be problematic in patients with more than one affected vertebra on plain films. it is also important to exclude: (i) epidural or foraminal involvement; (ii) cord compression; (iii) tumour extension into the spinal canal or extensively into the pedicles; and (iv) other causes of pain. informed consent is obviously mandatory and we also like to have a family member present at this stage. the procedure, possible complications and expected outcome are discussed in detail. we tend to stress possible complications and downplay outcome as this helps in patient selection. patients not experiencing severe pain often back down at this stage whereas patients with severe pain are less concerned. contraindications coagulation disorders are an absolute contraindication and need to be corrected prior to the procedure if possible. neurological symptoms related to the compression by the 6 sajournal of radiology. august 2003 abnormal vertebral body or tumour extension are also considered a contraindication to the procedure. extension and involvement of the posterior aspect of the vertebral body is seen as a relative contraindication. the more experienced interventional radiologists are doing these cases more frequently. a neurosurgeon must be available in case emergency decompressive surgery is required. technique the procedure is done on an outpatient basis. prior to the procedure a single n dose of antibiotics is given (e.g. 1 g of cefazolin/ancef). the mixture of tobramycin with the cement has been advocated but is seldom used. conscious sedation is administered to the patient but more importantly good local anaesthetic needs to be given, with special attention being given to the periosteum. this is of more value than the n sedation and we use macaine because of its longer action. the patient is carefully monitored throughout the procedure. we have only done two patients under general anaesthesia, both of whom were experiencing severe pain from their metastatic lesions and could not lie still. with the patient in the prone position access to the vertebral body is obtained via the pedicle under screening and ct guidance is not needed.!" most centres use a bipedicular approach although one can also do a unipedicular puncture at a more acute angle, with the result that the tip of the needle is situated close to the midline of the vertebra. the needle is placed at the junction of the anterior one-quarter and posterior threerevievv article fig. 1a,b,c. a patient with severe pain due to an osteoporotic fracture showing movement on breathing. good fil/ing is obtained with the patient being pain free after management. quarters of the body (fig. la.b,c). as the main venous channels of the vertebral body are located in the equatorial plain these should be avoided by inferior placement. we use a bevelled 11gor 13g needle depending on the size of the vertebra. this has two distinct advantages. firstly one can guide the needle to a certain degree as the sharp end of the needle cuts into the bone and tends to guide the neecuein that direction. for this reason we rotate the bevel to the outside when going through the pedicle so as not to penetrate the medial wall of the pedicle. once one is through the pedicle and into the body it is advisable to rotate the bevel 180 degrees so that the sharp aspect of tlle bevel will guide the needle more to the centre of the body. the second reason for using a bevelled needle is that one can rotate it during injection of pmma and this helps in guiding the flow of the cement. some centres do vertebral phlebography on all patients prior to administration of the pmma. the rationale is that if the tip of the needle is in a big draining vein, one will need to advance the needle further forward to try and reposition outside the draining vein. withdrawing the needle is not of help, as the contrast tends to follow the tract to the vein. if we are positioned in a large vein we do tend to advance the needle, but this is seldom of any help. what is important is to try to get a thicker consistency of pmma to inject as this will not drain away as easily and basically embolises the proximal draining vein. the group at johns hopkins have done 205 consecutive cases without phlebography, and have not reported any serious complications." it is important to flush the contrast out of the needle with saline as it may otherwise be difficult to distinguish between contrast and pmma at initial injection. the contrast sometimes also tends to pool in the vertebral body, making evaluation of cement injection more difficult. this contrast can 7 sa journal of radiology • august 2003 also be washed out with some saline but does take a little longer and as one has limited time before the pmma hardens, it is important not to mix the pmma before one is ready to inject. if no vertebral phlebogram was done one should still fill the needle with saline so as to prevent the possible complication of air embolism when injecting the cement. under optimal fluoroscopy the pmma is injected into the body. the correct composition of the mixture with regard to the concentration of barium sulphate and pmma is important, as this will affect the time the mixture takes to set. previously these had to be mixed before administration, but currently there are products on the market which are ready and easy to use and are no more expensive than the original mixtures. with the current products one has about 10 minutes working time, which is ample. cooling the liquid prior to mixing lengthens the time before setting and this may be useful when more than one level will be done. the consistency is roughly that of melted ice cream prior to the injection. the cement is injected under lateral screening until it can be seen in the posterior part of the body (fig. 2a,b,c). the quality of the fluoroscopy unit is extremely important as visualisation of the cement during injection is one of the most important aspects of the procedure. most of the serious complications documented have been associated with poor visualisation. the patients are followed up for 3 4 hours in the unit before being discharged home. they are phoned on day 1 and day 8 after the procedure. review article fig. 2 a,b,c. a 39-year-old patient with colon carcinoma and a single metastatic deposit in the l2 vertebra. she was not a neurosurgical candidate and had already had radiotherapy. the patient had extreme pain and a unilateral approach was used for needle placement. good vertebral filling was attained and the patient was pain free on day 2. complications the most important part in preventing complications is in realising that pain relief is not related to the amount of cement injected." the complication rate is, however, directly related to the amount of pmma injected. the rate of complications is very low and numerous series have not shown any complications. most serious complications are due to the leakage of contrast into the adjacent structures. because this may lead to compression of nerve roots, etc. it must not be performed in a setting where no neurosurgeon is available for emergency decompressive surgery. clinically significant complications with vertebroplasty occur predominantly in patients with spinal metastases, but in most of these cases they resolve with medical treatment.":" in osteoporotic patients rib fractures have occasionally occurred due to the pressure needed to advance the needle through the pedicle. two deaths have been reported in the usa. in both instances the procedure was done under a c-arm in theatre with the patient under general anaesthesia and seven or more levels were done. it is generally accepted that only under exceptional circumstances should more than two levels be done at a time. one case of significant pulmonary embolism was reported in a 41-yearold female patient. she responded well on anticoagulant therapy." conclusion vertebroplasty is a safe and successful method for the treatment of vertebral lesions due to osteoporotic fractures, metastatic lesions or haemangiomas. numerous studies have been done on the procedure and although relatively new in south africa, it is well documented in europe and the usa. 8 sajournal of radiology. august 2003 strict adherence to the selection criteria and a multidisciplinary approach are needed. the few complications reported have been associated with excessive pmma injection, once again stressing the need for excellent imaging conditions. references 1. galibert p,deramond h, preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. neurochirurgie 1987; 33: 166-168. 2, barr jd, barr ms, lemley tj, mccann rm. percutaneous vertebroplasty for pain relief and spinal stabilization, spine 2000; 25: 923-928. 3. deramond h, wright nt, belkoff sm, temperature elevation caused by bone cement polymerisation during vertebroplasty. bone 1999; 25: 17-21. 4. cooper c, athkinson e, jacobsen s. population-based study of survival after osteoporotic fractures, am j epidemio/1993; 37. 5. riggs bl, melton lj, the worldwide problem of osteoporosis: insights afforded byepidemiology. bone 1995; 17: suppl, 5055-5115. 6. martin jb, sugio k, san millian r, murphy kj, piotin m, rufenacht da. vertebroplasty: clinical experience and follow-up results, bone 1999; 25: suppl, 11$-155. 7. murphy k, deramond h. percutaneous vertebroplasty in benign and malignant disease. neutoirnaging cs« nam 2000; 3: 10. 8. deramond h, depriester c, galibert p, le gars d. percutaneous vertebroplasty with polymethylmethacrylate. technique, indications, and results. radio/ clinic north am 1998; 36: 533-546. 9. cotton a, boutry n, cortet b, et al, percutaneous vertebroplasty: state of the art. radiographies 1998; 18: 311-320: discussion 320-323. 10. vasconceles c, gailloud p, beauchop n, et al. is percutaneous vertebroplasty without pre-treatment venography safe? evaluation of 205 consecutive procedures. am j neuroradiol2002; 23: 913-917. i], cotton a, dewatre f, cortet b, et al. percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and leakage of methyl methacrylate at clinical follow-up. radiology 1996; 200: 525-530. 12. chiras j, depriester c, weill a, et al, percutaneous vertebral surgery. techniques and indications. j neuroradio/1997: 24: 45-49. l3. padovani b, kasriel 0, brunner p, et al. pulmonary embolism caused by acrylic cement: a rare complication of percutaneous vertebroplasty. am j neuroradio/1999; 20: 375377. case report by means of gastrotomy. eighty per cent of foreign bodies in the upper gastro-intestinal tract occur in paediatric patients, followed by edentulous adults, prisoners and psychiatric patients.' most objects (80 90%) pass spontaneously, but 10 20% have to be removed endoscopically, and about 1% require surgery," objects thicker than 2 cm and longer than 5 cm tend to lodge in the stomach.' long foreign bodies (> 10 cm) tend to lodge in the duodenum, where perforations may develop. in addition to causing ulceration, bleeding and perforation, it is conceivable that they predispose to goo, as demonstrated in this patient. the spectrum and size of the foreign body noted on the imaging studies served as the reason for our early recourse to surgery, rather than anticipating the spontaneous passage of these foreign bodies. recurrent episodes of foreign body ingestion may occur, especially in prisoners, psychiatric patients and patients with peptic strictures. references 1. goldstein ss, lewis jh, rothstein r. intestinal obstruction due to bezoars. am j gastroenterol 1984; 79: 313-318. 2. mit am, mir ma. phytobezoar after vagotomy with drainage or resection. br j surg 1973; 60: 846-849. 3. webb wa. management of foreign bodies of the upper gastrointestinal tract. gastroenterology 1988; 94: 204-206. 4. schwartz ge polsky hs. ingested foreign bodies of the oesophagus. ann surg 1985; 51: 173178. 5. perelman h. toothpick perforation of the gastrointestinal tract. j abdom surg 1962; 4: 51-53. 6. kock h. operative endoscopy. gastrointest endosc 1977; 24: 65-68. a midline nasopharyngeal cystic structure thornwaldt's cyst ralph drosten mb bch, fcrad d/ag department of thoracic imaging brigham and women's hospital boston, usa case presentation a 39-year-old woman presented to her doctor complaining of a non-productive cough. on examination, the clinician identified a non-inflamed cystic lesion in the soft tissues of the posterior nasopharynx, slightly to the right of the midline. magnetic resonance imaging (mri) examination of the region of interest confirmed a 12 x 11 mm welldefined cystic lesion in the posterior nasopharynx, slightly to the right of centre. it demonstrated a homogeneously hyperintense signal on t1weighted images, fat suppression and stir sequences (figs 1, 2 and 3). it had a thin wall and did not infiltrate the adjacent soft tissues. 40 sa journal of radiology. october 2001 on the basis of these imaging characteristics, the diagnosis of a thornwaldt's cyst was made. discussion thornwaldt's cyst is a midline congenital pouch or cyst, lined by ectoderm, within the nasopharyngeal mucosal space. it is present in 4% of autopsy specimens and develops from an ectopic portion of notochordal remnants in the nasopharynx. the peak age of presentation is 15 30 years.i clinical symptoms range from it being completely asymptomatic and an incidental finding, to persistent nasopharyngeal drainage, halitosis and a foul taste in the mouth. the presenting cough in our patient's case was presumably secondary to nasopharyngeal drainage and irritation. mri is the imaging modality of choice. cysts measure from 1 to 30 mm in diameter and have a high signal intensity on tl and t2-weighted images, probably case report figs 1 and 2. t1 and fat suppression saggital mri images demonstrating a well-defined hyperintense posterior nasopharyngeal midline cystic lesion (arrow). because of proteinaceous fluid content. thomwaldt's cyst is thought to be a persistent focal adhesion between the notochord and ectoderm extending to the pharyngeal tubercle of the occipital bone. i the notochord remnants occasionally give rise to an epithelial tract which empties into the midline of the nasopharynx} this tract may close over and result in a midline cyst which on occasion may become infected. the cyst is usually located in the midline in the longis capitus muscle. extension off the midline is rarely seen. secondary infection may lead to a syndrome consisting of prevertebral muscular spasm and postnasal discharge. thornwaldt's abscess must be surgically drained to prevent extension and retropharyngeal abscess formarion.' the differential diagnosis includes fig. 3. coronal stir image demonstrating 8 retained high signal intensity in the posterior nasopharyngeal midline cystic lesion (arrow). a rathke's pouch but this lesion occurs in the craniopharyngeal canal, anterior and cephalad to thornwaldt's cyst. references 1. dahnert w. radiology review manual. 3rd ed, williams and wilkins, 1996: 295. 2. higgins cb, hricak h. helms c. mr! of the body. raven press. 1992: 368-369. 3. grainger rg. allison oj. diagnostic radiology. vol. 3. churchill livingstone, 1999: 2284. 41 sa journal of radiology. october 2001 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) sheree c. gray department of diagnostic radiology, tshepong hospital complex, klerksdorp, south africa jacobus a. pienaar department of diagnostic radiology, tshepong hospital complex, klerksdorp, south africa zelia sofianos department of diagnostic radiology, tshepong hospital complex, klerksdorp, south africa jacob varghese department of diagnostic radiology, tshepong hospital complex, klerksdorp, south africa ilonka warnich department of diagnostic radiology, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation gray sc, pienaar ja, sofianos z, varghese j, warnich i. incidental amniocele in a case of antepartum haemorrhage. s afr j rad. 2020;24(1), a1817. https://doi.org/10.4102/sajr.v24i1.1817 case report incidental amniocele in a case of antepartum haemorrhage sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese, ilonka warnich received: 15 oct. 2019; accepted: 05 jan. 2020; published: 06 feb. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract an amniocele, or contained uterine rupture, is a phenomenon in which there is herniation of the amniotic sac through a uterine defect, secondary to various causes. it is associated with severe morbidity and mortality. this case presents the findings in a 36-year-old female at 29 weeks gestation who was initially managed as antepartum haemorrhage secondary to placenta previa, based on ultrasound. upon further imaging, an amniocele was diagnosed. this case report illustrates the importance of early identification of this life-threatening condition. keywords: amniocele; contained uterine rupture; foetal imaging; antepartum haemorrhage; placenta previa. introduction an amniocele, otherwise known as a contained uterine rupture, is a rare phenomenon in which there is herniation of the amniotic sac through a uterine defect. this rare entity can be associated with severe morbidity and mortality for both mother and foetus. the causes for an amniocele include certain invasive obstetric/gynaecological procedures or alternatively it may be an idiopathic occurrence. it is more commonly identified in developing countries where these procedures are frequently performed by inexperienced or inadequately trained healthcare professionals. case presentation a 36-year-old pregnant female patient presented to the antenatal clinic with a history of acute lower abdominal pain and associated vaginal bleeding, reporting passing drops of blood without passage of clots. on clinical examination, the patient was haemodynamically stable with no significant abnormalities identified. background clinical history revealed that she was a booked patient and compliant with antenatal follow-up visits. this was her fourth pregnancy, with two previous normal vaginal deliveries at term. records also revealed a previous termination of pregnancy, carried out 5 years prior at 16 weeks of gestational age. the termination was conducted as an inpatient procedure, likely involving invasive uterine instrumentation; however, further details were not available. biochemistry revealed a normal full blood count. she was known to be human immunodeficieny virus (hiv) positive, with a cd4 count of 98 and a viral load of 212, as well as rapid plasma reagin (rpr) negative, rhesus positive and hepatitis b surface antigen negative. she had no other known co-morbidities. during the current pregnancy, the patient had been repeatedly treated with antibiotics for recurrent urinary tract infections with culture-proven escherichia coli. she also had a prolonged hospital admission for more than 2 weeks after presenting with vaginal bleeding, and was assessed with a threatened miscarriage. at the time, the bleeding resolved spontaneously. an initial abdominal ultrasound at 21 weeks of gestational age had identified a low-lying placenta. a subsequent follow-up obstetric ultrasound documented an intrauterine singleton at approximately 29 weeks of gestational age, with a vertex presentation. placenta previa was noted, with the suspicion of morbid adherence. no evidence of abruptio placentae was found. the patient was subsequently admitted to hospital for monitoring and further workup, with a diagnosis of antepartum haemorrhage as a complication of placenta previa. prior to magnetic resonance imaging (mri), a repeat transabdominal ultrasound was performed by the radiology department. this demonstrated a right-sided parauterine cystic lesion, not previously noted, with apparent communication with the uterine cavity (figure 1). placental tissue was confirmed overlying the internal cervical ostium (os) but appeared separate from the main bulk of the placenta (figure 2). figure 1: transverse abdominal ultrasound demonstrating a well-circumscribed, anechoic structure (asterisk), adjacent to placental tissue, occupying the uterine fundus on the right. communication with the uterine cavity is evident, in keeping with the amniocele demonstrated on magnetic resonance imaging. figure 2: longitudinal abdominal ultrasound demonstrating placental tissue (white arrow) overlying the internal ostium (os) of the cervix (asterisk). magnetic resonance imaging was subsequently performed to assess for abnormal placental invasion. it confirmed the presence of an intrauterine singleton pregnancy and showed the major bulk of the main placenta situated along the right uterine wall, extending anteriorly and posteriorly. the placental thickness and signal intensity was appropriate for the gestation, with a normal central cord insertion. a secondary, separate placental component was also identified more inferiorly in the lower segment, extending from the posterior wall to cover the internal cervical os. these features are in keeping with a succenturiate placental lobe, which, in this case, caused major placenta previa. no features of morbidly adherent placenta (map) were identified. however, mri confirmed the incidental ultrasound finding of a defect in the right superior fundal myometrium, through which a large sac containing amniotic fluid had herniated (figures 3 and 4). there was no herniation of foetal parts or cord elements. additionally, there was focal thinning of the remaining fundal myometrium with loss of the normal trilaminar appearance. it was contained by a thin, regular t2-hypointense rim representing an intact overlying serosal layer, showing no communication with the abdominal cavity. the dimensions of the sac measured 67 mm × 48 mm × 66 mm. these findings are in keeping with amniocele formation, or contained uterine rupture. intrauterine amniotic fluid volume remained normal with no oligohydramnios. figure 3: sagittal t2-weighted magnetic resonance imaging demonstrating a defect in the myometrium of the uterine fundus through which part of the amniotic sac has herniated (arrow). placental tissue could be seen lining the anterior and posterior uterine walls, and extending to the fundus anteriorly (asterisks). figure 4: sagittal t2-weighted magnetic resonance imaging demonstrating low-lying placental tissue (white arrow), separate from the main bulk of the placenta, with complete coverage of the internal ostium (os) of the cervix (asterisks). the subsequent plan of obstetric care was to manage the patient conservatively and to deliver the baby via elective caesarean section at 34 to 36 weeks of gestational age. intra-operatively, myometrial dehiscence with a focal protrusion of the amniotic sac was noted. this defect was closed surgically with no complications. no neonatal complications were documented. during the post-partum period, the patient developed a wound haematoma but was subsequently lost to follow-up. ethical consideration this article followed all ethical standards for a research. discussion an amniocele is defined as the ‘herniation of the amniotic sac through a uterine defect’.1 it is, more simply, a contained uterine rupture with the protrusion of amniotic contents – variably including parts of the foetus – through the uterine wall and into the peritoneal cavity. the presence of a uterine defect or weakness within the uterine wall is most often secondary to uterine scarring. this may result from previous uterine surgery, such as myomectomy or caesarean section, or as a complication of previous instrumentation of the uterus, such as dilatation and curettage. rarely, it may be an idiopathic finding in an unscarred uterus.2,3 amniocele formation is more commonly identified in developing countries where obstetric and gynaecological procedures are performed by healthcare workers who may not be experienced or adequately trained.3 there is a paucity of data documenting this rare entity, which is concerning, given that the consequences hereof could result in disastrous morbidity – and even mortality – for both patient and foetus.4 for this reason, it is imperative that this abnormality be detected as early as possible so as to guide the monitoring of both patient and foetus, as well as informing management decisions with the intention of minimising the risks of intrapartum complications. there are both invasive and non-invasive approaches in the management of the amniocele, which could include the following: termination of the pregnancy, surgical uterine repair or, alternatively, vigilant radiological monitoring up until the time of delivery.4 radiological monitoring could be performed using ultrasound or mri at regular intervals in order to monitor for an increase in the size of the amniocele, detect further uterine wall dehiscence or observe for herniation of foetal parts. magnetic resonance imaging is not performed routinely in obstetric imaging, since it is time-consuming, expensive and not readily available. this is especially true for primary healthcare settings. an obstetric ultrasound performed by a competent user is sufficient in most scenarios and even superior due in part to improved spatial resolution.5 magnetic resonance imaging, however, demonstrates superior soft tissue contrast resolution, which makes it an excellent adjunct investigation when further imaging of the placenta is required,5 a common referral indication as illustrated in this case report. variations in placental location, thickness and morphology can be assessed, as well as increasing the diagnostic sensitivity and specificity of a map. an accessory placental lobe is a variation in placental morphology, termed a succenturiate placenta. the term ‘bilobed placenta’ could be used alternatively when the placental components are equal in size. bridging blood vessels can usually be demonstrated within the membranes connecting the accessory lobe. when the accessory placental tissue and associated hypervascular interconnecting membranes are located within the lower uterine segment, a careful evaluation for placenta previa or vasa previa should be performed. rupture of these vessels could result in the grave consequence of foetal exsanguination.5 a low-lying placenta is defined as a placental location within the lower uterine segment, measuring a distance less than 2 cm from the internal os of the cervix. as soon as the cervical os is covered by the placenta, the term placenta previa is used. although still in common use, the descriptors partial, marginal and complete placenta previa should be avoided. apart from an increased risk of antepartum and intrapartum haemorrhage, placenta previa is considered a significant risk factor for the presence of a map. this potentially life-threatening placental variation represents a group of disorders with varying degrees of myometrial invasion – namely placenta accreta, increta and percreta; these describe direct myometrial contact, myometrial invasion and extension beyond the myometrium respectively.5 in addition, obstetric mri could be used for evaluating foetal anatomy, as well as assist in the work up of other ambiguous ultrasound findings such as demonstrated in our reported case of an incidentally identified amniocele. conclusion amniocele formation is a rare entity but may be encountered in the healthcare settings of a developing country such as south africa, and imaging professionals should be aware of its existence. this case illustrates that the identification of one serious and potentially life-threatening pregnancy-related complication does not exclude the presence of other equally serious coexisting conditions, and that thorough investigation and imaging should be performed in all high-risk pregnancies. it also highlights the importance of a high index of suspicion for complications where risk factors are present such as advanced maternal age and previous uterine instrumentation, even in the absence of definitive clinical features. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions s.c.g. made a substantial contribution to the conception and design, drafting and revision of the article; i.w. made a substantial contribution to the conception and design, literature review and revision of the article; z.s. made a substantial contribution to the acquisition of data, literature review and drafting of the case report; j.a.p. made a substantial contribution to the acquisition of data and drafting of the case report; and j.v. made a substantial contribution to the conception and design, revision and approval of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references jo ys, kim mj, lee gsr, kim sj. a large amniocele with protruded umbilical cord diagnosed by 3d ultra-sound. int j med sci. 2012;9(5):387–390. https://doi.org/10.7150/ijms.3383 vimercati a, del vecchio v, chincoli a, malvasi a, cicinelli e. uterine rupture after laparoscopic myomectomy in two cases: real complication or malpractice? case rep obstet gynecol. 2017;2017:1–5. https://doi.org/10.1155/2017/1404815 aiyekomogbon jo, ojah so, shinkafi sm, agom b. a large amniocele through a fundal uterine defect diagnosed on 2d ultrasound imaging. int j case rep images. 2017;8(12):776–781. https://doi.org/10.5348/ijcri-2017121-cr-10860 report c, azzaoui jel, chmichi n, et al. a large amniocele with protruded right arm and hemithorax: a case report and review of the literature. world j pharm life sci. 2019;5(3):28–36. fadl s, moshiri m, fligner cl, katz ds, dighe m. placental imaging: normal appearance with review of pathologic findings. radiographics. 2017;37(3):979–998. https://doi.org/10.1148/rg.2017160155 pictorial interlude diagnosis of paediatric huntington's disease relies on imaging findings savvas andronikou mb bch, fcrad(d), frcr (lond) conrad nel mbchb department of paediatric radiology red cross war memorial children's hospital university of cape town and institute of child health introduction huntington's disease is an autosomally inherited neurodegenerative disorder clinically characterised by fig. 1. axial cerebral ct scsn of s child presenting with seizures. level of the quadrigeminal plate cistern. disturbances of movement, mentation and behaviour. onset is typically in the 5th and 6th decade and symptoms can sometimes occur in an affected child before appearing in the affected parent, who is most likely to be the father. five per cent of patients present under the age of 14 years. juvenile presentation differs from that of adults, who usually show abnormal movements; in children there may be rigidity, dysarthria, progressive mental deterioration and convulsions. convulsions occur frequently but late in the course of the disease. this should fig. 2. level of the thalami. small atrophied heads of the caudate nuclei with resultant squaring and expansion of the frontal horns giving the 'box-like' appearance. these features are diagnostic of huntington's disease. 50 sa journal of radiology • october 2001 be borne in mind when investigating a child with 'epilepsy'.i pathology and radiorogy both computed tomography (ct) and magnetic resonance imaging (mr!) can show striking basal ganglia atrophy (typically volume loss of the head of the caudate nucleus)." secondary focal enlargement of the frontal horns of the lateral ventricles (the lateral walls are convex towards the shrunken caudate nuclei) results in their progressively squared, 'boxlike' appearance. this is best appreciated on coronal images but these are not performed as a routine on ct scanning and therefore the radiologist must be able to appreciate this sign on axial images (figs 1 and 2). a ratio of maximum width of the frontal horns to intereaudate distance < 1.6 is considered diagnostic. increased and decreased putaminal signal intensities on mr! have been reported. also common are associated atrophy of the cerebellum and brain stern." conclusion because the above imaging findings may be encountered during imaging for 'epilepsy' without clinical suspicion for huntington's disease, and because the parental disease may not have manifested clinically as yet, it is of utmost importance that the radiologist be familiar with the characteristic imaging findings. a rapid accurate imaging diagnosis will allow for genetic counselling prior to the child reaching reproductive maturity. references 1. osborn ag. diagnostic neurotadiology. st louis: mosby, 1994: 743-744. 2. kirkwood rj. essentials of neuroimaging. new york: churchill livingstone, 1990: 316. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) isak d. vorster department of diagnostic radiology, faculty of health sciences, university of cape town, cape town, south africa steve beningfield division of radiology, faculty of health sciences, university of cape town, cape town, south africa citation vorster id, beningfield s. evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region. s afr j rad. 2019;23(1), a1720. https://doi.org/10.4102/sajr.v23i1.1720 original research evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region isak d. vorster, steve beningfield received: 04 feb. 2019; accepted: 05 aug. 2019; published: 20 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the immediate response to cardiac arrest is regarded as the most time-critical intervention. first responders for cardiac arrests in imaging departments are often radiology staff. the study aim was to determine radiology staff members’ confidence in initiating basic life support. objectives: the objectives of this study included determining the general confidence levels regarding identifying cardiac arrest and initiation of basic life support (bls) amongst radiology staff within the studied sites, as well as to identify potential areas of uncertainty. another objective included identifying what would contribute to increasing levels of confidence and competence in identifying cardiac arrest and initiating bls. method: a multi-centre cross-sectional survey was conducted using peer-validated, anonymous questionnaires. questionnaires were distributed to radiology staff working in public sector hospitals within the cape town metropole west. due to the limited subject pool, a convenience sample was collected. data were therefore statistically analysed using only summary statistics (mean, standard deviation, proportions, and so on), and detailed comparisons were not made. results: we disseminated 200 questionnaires, and 74 were completed (37%). there were no incomplete questionnaires or exclusions from the final sample. using a 10-point likert scale, the mean ability to recognise cardiac arrest was 6.45 (sd ± 2.7), securing an airway 4.86 (sd ± 2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (sd ± 2.9). only two (2.7%) of the participants had completed a basic life support course in the past year; 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any life support or critical care course. radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. conclusion: the study demonstrated a substantial lack of confidence in providing basic life support in the participating hospital imaging departments’ staff. the participants indicated that regular training and improved support systems would increase confidence levels and improve skills. keywords: cardiac arrest; basic life support (bls); cardiopulmonary resuscitation (cpr); radiology staff; radiologists; radiology department; confidence levels. introduction cardiac arrest is amongst the most serious and life-threatening emergencies in any hospital setting.1 over 80% of cases of sudden death worldwide are because of cardiovascular causes.2 early detection and implementation of resuscitation have been found to optimise a patient’s chance of survival.3 the chances of survival following cardiac arrest are greatly improved by promptly and effectively administering cardiopulmonary resuscitation (cpr) as the first-line intervention.1 the median survival rate of in-hospital cardiac arrest is higher than out-of-hospital cardiac arrest.4 however, the in-hospital survival varies in different areas, and all areas do not contribute to this better survival rate in equal measure.5 although most cardiac arrests will predictably occur in emergency centres (ecs) and high dependency or intensive care units, some do occur in other parts of the hospital. the imaging or radiology department is such an area of the hospital, as it accommodates patients of all degrees of illness for short periods of time while completing investigations, and with increased degree of illness comes a greater risk of cardiac arrest. while there are no south african studies directly evaluating the performance of basic life support (bls) by radiology staff, one did assess in-hospital overall outcomes of cardiac arrest.6 this study (also conducted in cape town) showed that cardiac arrests in the imaging department had the worst outcomes in the hospital.6 a further cape town study revealed poor knowledge of the use of defibrillators and low confidence in initiating bls by ec staff.7 international studies focusing on nursing staff’s bls knowledge and training over the last two decades concluded that, in general, both knowledge and training were deficient.8,9,10,11,12,13 it is likely that bls knowledge and training in local imaging departments are inadequate as well. the aim of this study was to determine whether radiology staff (radiologists, radiographers and both radiologist and radiography trainees, as well as nursing support staff) from public hospitals in the western metro of cape town, south africa, felt sufficiently confident to manage bls. in other words, would they feel comfortable in recognising cardiac arrest, securing an airway, providing rescue breaths and initiating cardiac compressions should the need arise. methods a survey design was used in this study. data were collected from radiology staff at five sites across cape town over a 3-month period. the sites included two tertiary centres – groote schuur hospital and red cross war memorial children’s hospital – and three secondary centres: mitchells plain hospital, new somerset hospital and victoria hospital. the metropole’s tertiary centres (including tygerberg hospital) combined provide 2631 beds to the public healthcare service in cape town and manage more than 700 000 outpatients and 120 000 ec contacts annually. the secondary centres provide 1393 beds to the public health care service in cape town and manage more than 240 000 outpatients and 165 000 ec contacts annually.14 for the 4.5 million people in the western cape who access public health care, a total of 60 531 computed tomography (ct) scans were performed annually in 2013. just over 29 000 (48%) of these ct scans were performed in the western metropole’s hospitals in the region covered in our study.15 participants included radiologists, radiology trainees, radiographers, radiography trainees and nursing support staff working in the imaging departments of the included centres at the time of the survey. a convenience sample of available prospective subjects was collected as it was appreciated that the pool of potential participants was limited. it was also anticipated that staff may be reluctant to contribute to the survey because of unfamiliarity with the subject matter. the sample was captured over a 3-month period from september to november 2017. the data collection tool was adapted from that used by maharaj7 who tested the same hypothesis in emergency care staff working in a subset of public and private cape town ecs.7 the survey provides a series of multiple-choice questions, as well as questions rating the confidence to provide or initiate care, using a 10-point scale. confidence in recognising cardiac arrest, securing an airway, providing rescue breaths and initiating cardiac compressions were the main variables tested this way. participants were also asked to indicate the areas of bls where they felt the least confident, and to suggest the interventions that would make them feel more confident. the demographic data of participants (position in department, experience), details of study site, details on bls training and previous exposure to cardiac arrest were captured. the survey was anonymised, and personal identifying information was not captured. the survey was disseminated via e-mails using the institutional surveymonkey (san mateo, usa) account of the division of emergency medicine, university of cape town. in addition, hard copy surveys were also distributed. these were manually entered into the surveymonkey database by the study team. after completing the data collection, the surveymonkey database was downloaded for analysis. the data are presented using flow charts, tables and figures. also provided is a breakdown of the various participant staff groups who responded with their experience, as well as the proportions of study sites that contributed to the study. answers to the multiple-choice survey questions are also given and analysed using proportional breakdowns. confidence levels of participants are presented using the mean and standard deviation. the data were not considered sufficiently powered to cater for any inferential statistics. ethical consideration ethical approval for this study was obtained from the human research ethics committee of the university of cape town (668/2017) prior to data collection. hospital permission was also obtained from the various site ceos. results a total of 200 questionnaires were disseminated via the online survey tool and hand-delivered hard copies. a total of 74 participants responded over the study period giving an overall response rate of 37%. all returned surveys were completed in full and there were no invalid forms. figure 1 provides a breakdown of the data collection from the various participants and study sites. of the study participants, 69 (93%) worked exclusively in public sector hospitals and 5 (7%) worked in both public and private sector hospitals. figure 1: breakdown of respondents’ demographics. of the participants, 35 (47%) had 0–5 years’ radiology experience, 19 (26%) had 5–10 years’ experience and 20 (27%) had more than 10 years’ experience in their respective roles. the different groups’ experience is presented in table 1. table 1: level of working experience in the imaging department of various study participant groups. of the 74 study participants, 41 (55%) reported that there was no formal bls training at their place of employment. a total of 63 (85%) participants indicated that they had taken part in a bls course at some time: two (2.7%) had taken part in a bls course within the past year and 61 (82.4%) had taken part in a bls course more than a year ago. the remaining 11 (14.8%) reported never having taken part in a bls or equivalent course. of the total 74 responses gathered, 11 (14.9%) respondents reported having completed a trauma course, six (8.1%) reported a critical care course, 22 (29.7%) reported advanced life support course and 28 (37.8%) study participants reported never having completed a trauma, critical care or similar advanced life support course. a total of 72 (97.0%) reported that they were involved in resuscitating a cardiac arrest between 0 and 5 times per month. no further details were collected on the specifics on these events. no participants reported involvement in more than five cardiac arrests per month other than for two (2.7%) participants, who reported exposure to more than 10 cardiac arrests per month – both reported by radiographers, one based at red cross war memorial and the other based at groote schuur hospital. table 2 describes the average confidence levels of each group in terms of recognising cardiac arrest, managing the airway and initiating cpr or chest compressions. table 2: mean (and standard deviation) self-reported confidence levels of participants out of a score of 10 (where 10 was very confident and 0 was no confidence). of the 74 study participants, 18 (24%) reported that they were confident in performing all three of the core components of bls. however, 31 (42%) of participants reported that basic airway management was the component of bls that they felt least confident with. this was followed by basic circulation support (providing chest compressions) where 26 (35%) of participants reported poor confidence. this was followed by basic breathing assistance and support with 24 (32%) of participants reporting poor confidence. there were 55 (74.32%) participants who stated that they would feel more confident in performing bls if there was an ec doctor or nurse present. figure 2 describes the self-reported factors that would increase their confidence in recognising and managing cardiac arrest. figure 2: factors considered to increase confidence of basic life support initiation discussion there was a clear deficiency overall in participant confidence for recognising cardiac arrest, managing an airway, providing rescue breaths and initiating cardiac compressions during cardiac arrest. although radiologists and radiology trainees reported amongst the greatest confidence in recognising cardiac arrest, the confidence levels of radiographers, their trainees and nurses in recognising cardiac arrest, were low. this was concerning, particularly as the latter group is most likely to be amongst first responders in a cardiac arrest. radiology trainees’ confidence was fairly robust concerning managing an airway, providing rescue breaths and initiating cardiac compressions although nurses reported better confidence in providing rescue breaths and initiating cardiac compressions. the reasons for these discrepancies were not tested, but may stem from less exposure to actual arrests, as well as prior and current medical training and experience. radiology trainees are more likely than any of the groups to have been recently exposed to advanced life support training. low confidence levels in the radiography cohort may result in delays in initiating bls which may lead to poorer patient outcomes.16 of course, this study only reports confidence levels and not actual performance which can both be better or worse than the reported confidence would suggest. numerous international studies have shown lack of confidence in initiating bls when confronted with cardiac arrest, not only amongst general nurses, students or non-surgical disciplines, but also within emergency care staff.16,17,18,19,20 maharaj concluded that emergency care staff working in both public and private settings in south africa were not sufficiently confident to initiate bls. as in our study, they showed that the presence of an appropriately trained clinician leading resuscitation boosted confidence in performing bls.7 the lack of regular exposure to cardiac arrest may result either to a degree of complacency or excessive insecurity, leaving staff unprepared to deal with the situation adequately. however, this could potentially be mitigated by ensuring regular bls refresher courses, together with simulation training.18 only 2.7% of participants in our study had taken part in bls updates and training over the previous year. this is a far lower proportion than reported in the local study by maharaj, where 42% of participants indicated that they had participated in a bls course within the past year and yet they still reported low confidence.7 also locally, mabasa suggested that regular advanced life support skills training and the implementation of better support systems would contribute greatly to the positive outcomes of cardiac arrest patients.6 still local, keegan concluded that even nursing staff who attended single bls training sessions retained limited amounts of knowledge and emphasised that repetitive refresher training is of utmost importance.10 less than half of our study participants were aware of how to obtain bls training within their setting. although not specifically determined, the actual availability of training may conceivably be considered a hindrance by removing staff from busy workplaces as well. maharaj demonstrated the discrepancy between private and public service provision and training, where there was less access to courses in the public sector (which is also where our study took place).7 in addition, it is unlikely, considering limited resources, that imaging staff would be prioritised for training. the option of having the ability to rapidly summon an emergency response team was also popular amongst 34 (45.9%) of our study participants. as has been shown, an emergency response team has a significant positive impact on patient care and in-hospital survival outcomes.21 our study did not collect information regarding the emergency response teams or protocols for any of the sampled institutions. nonetheless, bls still needs to be initiated by the first responder irrespective of the clinical setting while awaiting an experienced team to take over life support interventions. this study provides an interesting perspective on the challenges in achieving a confident team in the radiology department. there were limitations to this study. it included only a proportion of cape town hospitals and excluded the private sector. it was also small and the response rate, despite effort from the study team, was lower than anticipated. data collection was challenging because of the various work patterns and different work areas of staff. it was anticipated that staff may be reluctant to participate, given their expected low confidence levels in managing cardiac arrest. as such, it was not possible to analyse groups in more detail or compare groups statistically. it was therefore difficult to generalise the findings beyond this sample. despite the study being limited by its size, the findings echo what is already known elsewhere about the subject. participant replies were consistent with those from other research. it is believed unlikely that a larger sample would yield a markedly different result. although the survey prompted participants to explain their choice whenever ‘other’ was selected as an answer option, this was not performed by any participant. it is unclear why this was the case but may relate to the survey design. because of these limitations, the findings of this study cannot be generalised or offer definitive direction on the bls confidence of radiology staff in public sector hospitals in cape town. conclusion although small, this study showed that many radiology staff and their medically trained support staff within a subset of public hospitals in cape town, south africa, felt insufficiently confident in recognising cardiac arrest, managing the airway and initiating cardiac compressions. it further highlighted the lack of uptake or awareness of regular and refresher bls training within this cohort. it would seem reasonable that advertising and access to bls training, including use of simulation for imaging staff should be re-evaluated as a patient safety initiative. this would require validation and balancing against the other resources used to manage the burden of acute illness and death within public hospitals. the survey tool used for this study could be used to review the retention of core bls knowledge and skills post-training interventions. similarly, opportunities to improve emergency response teams, as well as exposure to cardiac arrest scenarios could be explored in partnership with local ecs, training departments or medical emergency teams. future exploration by means of a larger study cohort to allow subgroup analysis, specifically considering how prior experience and current training and exposure affect confidence, is recommended. acknowledgements the authors would like to acknowledge the divisions of radiology and emergency medicine of the university of cape town for the support provided. they would also like to acknowledge all the participants of this study. competing interests the authors report no conflicts of interest. authors’ contributions all authors contributed equally to the study research and write up. funding information no formal funding was required or accepted in completing this study. data availability statement data sharing is allowed with permission from the authors, as there were new data created and analysed. disclaimer the views expressed in this article are that of the authors and not the official position of the university of cape town or any of the participating study centres. references sasson c, rogers ma, dahl j, et al. predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. circ cardiovasc qual outcomes. 2010 jan;3(1):63–81. https://doi.org/10.1161/circoutcomes.109.889576 gräsner jt, herlitz j, koster rw, et al. quality management in resuscitation – towards a european cardiac arrest registry (eureca). resuscitation. 2011 aug 1;82(8):989–994. https://doi.org/10.1016/j.resuscitation.2011.02.047 hazinski mf, nolan jp, billi je, et al. 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. circulation aha. 2010 oct;122(suppl 2):s250–s275. https://doi.org/10.1161/cir.0b013e3181fe3e4c perkins gd, cooke mw. variability in cardiac arrest survival: the nhs ambulance service quality indicators. emerg med j. 2012;29(1):3–5. https://doi.org/10.1136/emermed-2011-200758 peberdy ma, kaye w, ornato jp, et al. cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the national registry of cardiopulmonary resuscitation. resuscitation. 2003 sep 1;58(3):297–308. https://doi.org/10.1016/s0300-9572(03)00215-6 mabasa te. a prospective study on the outcomes on adult cardiopulmonary resuscitation in cape town. mmed thesis. university of cape town; 2012. maharaj s. a survey to determine whether emergency centre nurses are confident in initiating bls across emergency centres in the western cape metropole. mmed thesis. stellenbosch university; 2013. nyman j, sihovonen m. cardiopulmonary resuscitation skills in nurses and nursing students. resuscitation. 2000 may;47(2):179–184. https://doi.org/10.1016/s0300-9572(00)00226-4 mäkinen m, niemi-murola l, kaila m, et al. nurses’ attitudes towards resuscitation and national resuscitation guidelines: nurses hesitate to start cpr-d. resuscitation 2009;80(12):1399–1404. https://doi.org/10.1016/j.resuscitation.2009.08.025 keenan m, lamacraft g, joubert g. a survey of nurses’ basic life support knowledge and training at a tertiary hospital. ajhpe. 2009 dec;1(1):3–7. dwyer t, mosel williams l. nurses’ behaviour regarding cpr and the theories of reasoned action and planned behaviour. resuscitation. 2002;52(1):85–90. https://doi.org/10.1016/s0300-9572(01)00445-2 whelan y. cardiac arrest: the skills of the emergency nurse practitioner. accid emerg nurs. 1997;5(2):107–110. https://doi.org/10.1016/s0965-2302(97)90092-8 terzi a. nurses’ role in the modern resuscitation era. hosp chron. 2012;7(1):25–31. https://doi.org/10.2015/hc.v7i1.389 tygerberg. annual report 2016 [homepage at internet]. c2016 [cited 2017 dec 11]. available from: https://www.westerncape.gov.za/dept/health/documents/annual_reports/2016. jacobs dg, pretorius ej, barnard mm. ct use. how does the western cape compare? ct utilisation in the western cape versus other international locations. poster presented at: rssa/bissa breast imaging congress 2014. cummins ro, ornato jp, thies wh, et al. improving survival from sudden cardiac arrest: the ‘chain of survival’ concept. circulation. 1991 may 1;83(5):1832–1847. https://doi.org/10.1161/01.cir.83.5.1832 filgueiras filho nm, bandeira ac, delmondes t, et al. assessment of the general knowledge of emergency physicians from the hospitals of the city of salvador (brazil) on the care of cardiac arrest patients. arq bras cardiol. 2006 nov;87(5):634–640. kimaz s, soysal s, cimrin ah, et al. assessment of physicians employed in emergency medical services about their level of knowledge on basic life support, advanced cardiac life support and medicolegal responsibilities. ulus travma acil cerrahi derg. 2006;12(1):59–67. howell p, tennant i, augier r, et al. physicians’ knowledge of cardiopulmonary resuscitation guidelines and current certification status at the university hospital of the west indies, jamaica. the west indian med j. 2014;63(7):739–743. https://doi.org/10.7727/wimj.2013.267 chandrasekaran s, kumar s, bhat sa. awareness of basic life support among medical, dental, nursing students and doctors. indian j anaesth. 2010 mar;54(2):121. https://doi.org/10.4103/0019-5049.63650 chan ps, jain r, nallmothu bk, et al. rapid response teams: a systematic review and meta-analysis. arch intern med. 2010 jan 1;170(1):18–26. https://doi.org/10.1001/archinternmed.2009.424 abstract introduction research methods and design ethical considerations results discussion conclusion acknowledgements references about the author(s) clare a. surridge department of radiology, grey’s hospital, university of kwazulu-natal south africa matthew d.m. goodier department of radiology, grey’s hospital, university of kwazulu-natal south africa citation surridge ca, goodier mdm. an analysis of diagnostic practices in a mammography unit in a tertiary hospital in south africa. s afr j rad. 2017;21(1), a1059. https://doi.org/10.4102/sajr.v21i1.1059 original research an analysis of diagnostic practices in a mammography unit in a tertiary hospital in south africa clare a. surridge, matthew d.m. goodier received: 07 july 2016; accepted: 19 dec. 2016; published: 30 mar. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: breast cancer is the most common cancer in females in south africa. the reporting of breast imaging has been standardised internationally using the breast imaging and reporting data system (bi-rads), which includes guidelines for reporting of breast lesions and further management. ultrasound-guided core-needle breast (ugcnb) biopsy is a widely used method of obtaining histological diagnoses of breast lesions to assist with planning definitive management. objectives: to perform an audit of the ugcnb biopsies performed at the grey’s hospital mammography department and assess the accuracy of the radiologists’ use of the bi-rads scoring system. methods: records of all patients who underwent ugcnb biopsy between 01 january 2014 and 31 october 2015 were reviewed. a retrospective study was performed. results: a total of 304 ugcnb biopsies were performed on 291 patients. the mean age was 49.2 (s.d. = 15.9) years. tissue samples from 303 lesions were adequate for histological assessment, and of these, 51% of the lesions were malignant whilst 49% were benign. the most common malignant and benign diagnoses were invasive ductal carcinoma and fibroadenoma respectively. the bi-rads scoring of the radiologists demonstrated a positive predictive value of 61.6% for the identification of possible malignant lesions. conclusion: this study describes the patient and lesion profile and unit practices in a tertiary hospital setting in south africa. the radiologists’ application of the bi-rads scoring largely conforms to the bi-rads guidelines. the study highlights several challenges encountered by a breast imaging programme in an under-resourced setting as well as making recommendations in overcoming these challenges. introduction breast cancer is the most common cancer found in women in south africa and causes significant mortality and morbidity.1 early diagnosis, allowing the initiation of correct management, is vital for combatting the disease and reducing mortality. it is established practice that patients presenting with breast masses are assessed with a triple approach comprising clinical, radiological and histological evaluations. the radiologist thus plays an important role along with the surgeon and the pathologist in the evaluation and management of such patients. reporting and further management of breast lesions have been standardised by the american college of radiology by means of the breast imaging reporting and data system (bi-rads) guidelines.2 these guidelines have become a widely accepted risk assessment and quality assurance tool in breast imaging. bi-rads guidelines exist for mammography, ultrasound and magnetic resonance imaging of the breasts. the bi-rads assessment categorisation guides patient management and is based on the most abnormal finding of all imaging modalities used to assess the patient.2 the final summary assessment scores the lesion(s) from 0 to 6. category 0 is an incomplete investigation. category 1 is a negative investigation. category 2 describes benign findings. category 3 lesions are probably benign, with a less than 2% chance of malignancy. category 4 lesions are suspicious lesions and are subcategorised into a, b and c, with the chance of malignancy ranging from 2% to 95%. category 5 lesions are highly suspicious and have a greater than 95% chance of malignancy. category 6 lesions are biopsy-proven malignant lesions.2 this allows for a universal and unambiguous description of various factors in the breast imaging assessment, most importantly by quantifying the degree of suspicion of malignancy of a breast lesion by a single number. ultrasound-guided core-needle breast (ugcnb) biopsy is invaluable in the management of patients with breast lesions that require a histological diagnosis to assist with planning further management. ugcnb biopsy has been shown to have many benefits over open surgical biopsy in obtaining a histological diagnosis prior to planning definitive management.3,4,5,6 regular audits should be performed within mammography departments in order to assess the radiologists’ implementation of the bi-rads guidelines. this is important to ensure that the unit is performing satisfactorily and adhering to international guidelines.2 a review of the literature revealed no published results of such an audit performed at a south african hospital. this article describes a retrospective analysis of ugcnb biopsies performed at the grey’s hospital mammography department (ghmd). the data collected included the patient demographics, the bi-rads category, the imaging modalities used to assess the patients and the histological diagnoses obtained from the ugcnb biopsies. the purpose of this study was to perform an audit of the ugcnb biopsies and to analyse the accuracy of the radiologists’ use of the bi-rads scoring system. research methods and design records of all patients who underwent ugcnb biopsies at the ghmd between 1 january 2014 and 31 of october 2015 were reviewed. as this was a retrospective, descriptive study, purposive sampling was used. records of patients of all ages and both sexes were used in this study, including records where patients had single or multiple lesions biopsied. records of patients who underwent a core-needle breast biopsy that was not performed under ultrasound guidance were excluded. further exclusion criteria included fine-needle aspiration, stereotactic core-needle breast biopsy or axillary lymph node biopsy. the biopsies were performed by senior registrars and consultants. the experience of the consultants ranged from 0 to 5 years. no consultants had subspeciality qualifications in breast imaging. all bi-rads classifications were made by consultants. data were collected from the grey’s hospital radiology information system (ghris) and from the national health laboratory services database. data were recorded in the form of a spreadsheet using microsoft excel. the demographic data collected included the patient’s age and sex. the data recorded for each lesion biopsied included the size (maximum dimension on ultrasound), the number of tissue samples obtained from the lesion, the size of the needle used to perform the biopsy, the imaging modality used to assess the lesion (mammography and ultrasound or ultrasound only), the bi-rads category, whether or not the tissue sample was adequate for histological diagnosis and the histological diagnosis. data were analysed using microsoft excel and stata v13. means with standard deviations or medians with interquartile ranges were used to summarise numerical data as appropriate. descriptive statistics was used to present categorical data as frequencies and percentages. ethical considerations ethics approval was obtained from the university of kwazulu-natal biomedical research ethics committee (be 487/15). consent was obtained from the grey’s hospital management. results a total of 304 ugcnb biopsies were performed on 291 patients. there were 289 female and 2 male patients. the mean age was 49.2 years (standard deviation [s.d.] = 15.9) with a range of 12 years – 85 years. the age distribution is shown in figure 1. figure 1: age distribution of the patients in the study (n = 291). the number of lesions biopsied, the number adequate for histological diagnosis and the most common malignant and benign diagnoses are presented in figure 2. the histological diagnoses of all the lesions biopsied are listed in table 1. figure 2: summary of the results of the lesions biopsied in this study. table 1: malignant and benign histological diagnoses of the ultrasound-guided core-needle breast biopsies performed during the study. in the ghmd, it is routine practice that all patients who have a mammogram also have an ultrasound examination as a combined examination during the same appointment. if required, a ugcnb biopsy is also performed on the same day. ultrasound as the only modality of investigation is typically performed on patients younger than 30 years, at the referring clinician’s discretion and for patients who are unable to tolerate a mammogram. of the 291 patients included in the study, 82% (n = 238), with a mean age of 53.1 years (s.d. = 13.65) and a range of 27 85 years, were assessed with ultrasound and mammogram. the remainder of the patients (n = 53, 18%), with a mean age of 31.8 years (s.d. = 13.62) and a range of 12 80 years, were assessed using ultrasound imaging only. of the bi-rads category 4 lesions, not all were allocated a subcategory of a, b or c. the data are represented as category 4 ‘not specified’ (ns) along with the subcategories of a, b or c. for the lesions assessed using both mammography and ultrasound, only one (0.4%) did not have a bi-rads category included in the report. thirty-one lesions (58%) that were assessed with only ultrasound did not have a bi-rads category recorded. this is illustrated in figure 3. figure 3: summary of the number of lesions assigned a bi-rads category. the majority of patients who were evaluated with mammography and ultrasound were assigned bi-rads category 5 (n = 112, 45%), and the majority of the patients assessed with ultrasound were assigned equally to bi-rads category 3 and 4ns (n = 6, 27%). tables 2 and 3 list the histology of the lesions in each bi-rads category according to the imaging modality used. the distribution of the bi-rads categories and the percentage of malignant lesions in each bi-rads category are shown in table 4. table 2: histological diagnoses of the ultrasound-guided core-needle breast biopsy in each bi-rads category for lesions assessed with mammography and ultrasound. table 3: histological diagnoses of the ultrasound-guided core-needle breast biopsy in each bi-rads category for lesions assessed with ultrasound. table 4: distribution of the number of ultrasound-guided core-needle breast biopsy lesions in each bi-rads category with a comparison of the percentage of malignant lesions in category with the bi-rads recommendations. a two-by-two table was used to assess the agreement between the imaging features and the histology (table 5). bi-rads category 2 and 3 lesions were classed as probably benign or benign imaging findings, whilst category 4 and 5 were classed as possibly malignant imaging findings. there were 30 lesions that were congruent with both benign imaging and histological results. conversely, 146 out of 237 lesions (62%) with possibly malignant imaging findings had malignant histology. it is not expected that there would be 100% concordance as the bi-rads categories have varying risks of malignancy. it is expected that there would ideally be 100% concordance only in categories 2 and 6. table 5: two-by-two table comparing the imaging assessment and histology results. in this study, the bi-rads classification system as interpreted by the radiologists using the biopsy results as the gold standard had a sensitivity of 98.6% (95% confidence interval (ci) = 95% – 99%), a specificity of 24.8% (95% ci = 17% – 33%), a positive predictive value (ppv) of 61.6% (95% ci = 52% – 68%) and a negative predictive value (npv) of 93.8% (95% ci = 79% – 99%). the mean size of the breast lesions was 25.8 mm ± 16.8, with a range of 5 mm–100 mm. the size of the lesion was not recorded for 14% (n = 44) of the lesions. the median number of tissue samples obtained from a lesion was three (mean = 3.14 ± 0.8), with a minimum of one tissue sample and a maximum of six tissue samples obtained from a single lesion. in 20% (n = 62) of the lesions, the number of tissue samples obtained was not recorded. the majority of the lesions (53%, n = 147) were biopsied using a 14g needle; an 18g needle was used for 29% (n = 82) of the lesions and a 16g needle was used for 18% (n = 50) of the lesions. in 8% (n = 25) of the lesions, the needle size used was not recorded. of the 29 lesions less than 10 mm in size, 48% (n = 14) were biopsied using a 14g needle. discussion the ghmd serves a large patient drainage area encompassing 3.9 million (38%) of kwazulu-natal’s population.7 as mammography is thus a very limited resource, there is no established screening programme and the services provided at the hospital are only diagnostic. having a standardised guideline such as bi-rads significantly facilitates this process. in this study, we found that when correlating with ugcnb biopsy, radiologists interpreted the bi-rads score with a high sensitivity of 98.6% but with a lower specificity of 24.8%. the overall ppv of 61.6% in this study is much higher than the 35.9% stipulated by the bi-rads guidelines for diagnostic mammography.2 this could be explained by the long waiting times to access specialised breast imaging services, resulting in a higher proportion of malignant lesions being biopsied. another consideration is that the bi-rads guidelines do not have set values for combined mammography and ultrasound evaluation and thus the results may differ from the diagnostic mammography guidelines.2 the ppv of the bi-rads categories was, however, within the limits stipulated by the guidelines for categories 2, 4a, 4b and 4c (table 4). the npv of 93.8% in this study is based on the biopsy results. in a study which analysed the npv of ugcnb biopsies, it was found to be 99.4%.8 the bi-rads guidelines do not stipulate an npv. according to the guidelines, category 2 lesions require routine screening and category 3 lesions should undergo short interval follow-up.2 given the limited access to specialised care, the recommended practice is often altered, whereby lesions with benign features are biopsied upon patient request as opposed to only being followed up by imaging. as a result of this, we biopsied a higher proportion of category 2 bi-rads lesions (4%) in comparison with a previous study by wiratkapun et al.3 (2%). the guidelines also note that the risk of malignancy for category 3 lesions is less than or equal to 2%.2 in this study, 2 out of 25 patients (8%) with lesions categorised as bi-rads 3 had malignant histology. the first was a patient with a 6-month history of a breast lump that had imaging features suggestive of a papilloma with histology demonstrating a papillary carcinoma. the second patient had previously undergone a unilateral mastectomy and whilst on surveillance was found to have an intramammary lymph node that had increased in size. histology demonstrated invasive ductal carcinoma (idc). this lesion was incorrectly categorised as bi-rads 3. high-risk lesions (box 1) are histological diagnoses on core biopsy that imply a high-risk of developing malignancy. in addition, excision biopsies performed on these lesions often result in malignant histological findings.3,9 papillomas are controversial lesions, with some authors classifying these as high-risk lesions; however, in this study, we followed the approach of wiratkapun et al.3 and youk et al.9 who consider these as benign lesions. thus, in this study, there were no high-risk lesions in contrast to other similar studies.3,9 an explanation for this may be that the patients assessed in the unit are all symptomatic as no screening service is offered. the long waiting time may also have resulted in malignancy having already developed by the time the biopsy was performed. box 1: high-risk histological diagnoses. in one interesting case, a patient with a strong family history of breast cancer with a 3-year history of bilateral breast lumps (figure 4) underwent bilateral ugcnb biopsies. the biopsies demonstrated idc in the right breast and invasive lobular carcinoma in the left breast. this histology was confirmed on examination of the mastectomy specimens. the incidence of synchronous bilateral breast carcinoma amongst breast cancer patients was found to be 0.8% in a study by díaz et al.10 furthermore, our case is of particular interest because in a study by gong et al.,11 93% of patients with synchronous breast cancer had the same histological type. figure 4: the right mlo (a), left mlo (b), right cc (c) and left cc (d) mammogram images of a 38-year-old woman who presented with a 3-year history of bilateral breast lumps. the skin markers demonstrate the site of the palpable lesion in each breast. in the central lower quadrant of the right breast, a focal soft tissue density is present with associated pleomorphic calcifications . in the left breast, there is a larger soft tissue density with spiculated margins, architectural distortion and pleomorphic calcifications in the upper outer quadrant. both lesions were hypoechoic on ultrasound, with poorly defined margins and posterior shadowing. ultrasound-guided core-needle biopsy demonstrated idc in the right breast and ilc in the left breast; this histology was confirmed after mastectomy. at ghmd, the routine use of diagnostic mammography is usually limited to patients over the age of 30. there were two patients under the age of 30 on whom mammograms were performed; the decision to perform these mammograms was based on the clinical history and suspicious features of the lesion on ultrasound imaging. the histology for both patients was benign, with one lesion demonstrating inflammatory changes and the other fat necrosis; these lesions were assigned bi-rads category 4b and 4ns, respectively. the patient with inflammatory changes had imaging features thought to represent either atypical fibroadenomas or malignancy. the histology from the ugcnb biopsy was not congruent with the imaging findings and an excision biopsy should have been considered.5,6 there were eight patients with a histological result of ‘benign breast tissue’. of these patients, one had accessory breast tissue and one had oedema underlying a skin lesion which resolved. of the remaining six patients, three were followed up with benign findings confirmed on imaging in two of the patients and repeat biopsy in the third. the remaining three patients were not followed up, despite the discordant imaging and histology results. of these, two patients had imaging features of fibroadenomas and one patient had an intraductal lesion. the preceding cases illustrate a known limitation of ugcnb biopsy, namely false-negative results. the false-negative rate in the literature ranges from 0.1% to 4%.3,5,6,8,9 underestimation of the disease process, another limitation of ugcnb biopsy, has been shown to be most common for ductal carcinoma in situ, lobular carcinoma in situ and atypical ductal hyperplasia.3 the underestimation rate of ugcnb was shown to be 31.4% in a previous study.5 a previous study has advocated that 14g needles should be used in all lesions less than 1 cm in size, with 16g and 18g having comparable results with 14g needles in lesions greater than 1 cm in size,12 whereas a different study has shown that 14g needles are more accurate, and have a decreased underestimation and false-negative rate when compared with 16g needles.13 in the ghmd, this is difficult to adhere to because of stock shortages often resulting in only one size of needle being available. in our study, there was no significant correlation found between lesion size and needle size. other studies have included the number of tissue samples obtained.8,13 the mean number of 3.14 ± 0.8 tissue samples in this study is similar to previous studies that demonstrated means of 3.98 and 3.0, respectively.8,13 a study which investigated the optimal number of core tissue samples needed to obtain a diagnosis demonstrated a 98% diagnostic yield when three core samples were obtained and 100% diagnostic yield when five core samples were obtained.14 in our study, the diagnostic yield was 99.7% (303 out of 304 lesions). tuberculosis (tb) of the breast has a reported prevalence of 3% – 4.5% in all surgical breast lesions in endemic countries.15 a recent study performed in south africa demonstrated a prevalence of 0.3% in all patients who had undergone breast investigation.15 in this study, three (1%) patients had confirmed tb. this may be an underestimation of the true prevalence of the disease in our population as the diagnosis may have been made at a peripheral hospital. this recent study also showed that the yield of acid-fast bacilli on histology specimens which demonstrated necrotising granulomatous inflammation was only 29.6%.15 it is thus possible that some patients in our study could have been misdiagnosed as necrotising granulomatous inflammation if a tb culture was not performed. limitations of the study the sensitivity and specificity in this study should be interpreted with caution as these were derived from the biopsy results and not from a tumour registry or long-term follow-up as per the bi-rads guidelines. likewise, the false-negative rate in this study could not be evaluated as the above data were not available. ghmd only offers a diagnostic service. this limits comparability with other studies in mammography departments which offer a screening programme. recommendations the findings in this study have highlighted some of the shortcomings of the ghmd service. the findings will be used to alter and improve departmental practice. one such shortcoming was that patients who were assessed with only ultrasound did not always have a bi-rads category assigned to them, and the patients assessed as bi-rads category 4 were not further stratified into subgroups a–c. the addition of this information to the generic template on the ghris system will assist with correcting this. radiologists will be encouraged to review the ugcnb results and for patients with discordant lesions to be flagged, so that further management can be instituted. this practice would be beneficial to registrar training and will improve patient care. discussion of these lesions at the regular interdisciplinary meeting will be advised. double reading of studies and ongoing training could be implemented to decrease radiologist error and ensure better compliance with the bi-rads guidelines. conclusion the study describes the patient and lesion profile and unit practices in a tertiary hospital setting in south africa. the radiologists’ application of the bi-rads scoring largely conforms to the bi-rads guidelines. however, the study highlights several challenges encountered by a breast imaging programme in an under-resourced setting, as well as making recommendations for overcoming these challenges. the lack of screening service, large patient load and combined mammography and ultrasound assessments are some of the challenges faced and practices implemented in a developing country setting. acknowledgements the authors thank catherine connolly for assistance with the statistical analysis of the data. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.a.s. was the main author and was responsible for the protocol, data collection and compilation of the manuscript. m.d.m.g. was the supervisor and assisted with project design, review and analysis. c.a.s. was the principal investigator and prepared the manuscript. m.d.m.g. made conceptual contributions and is the supervisor of c.a.s.’s master’s degree. references summary statistics of cancer diagnosed histologically in south africa in 2011 [homepage on the internet]. no date [cited 2016 oct 31]. available from: http://www.cansa.org.za/files/2016/08/ncr-2011-cancer-tables.pdf american college of radiology. acr bi-rads atlas [homepage on the internet]. 5th ed. c2013 [cited 2016 oct 31]. available from: http://www.acr.org/quality-safety/resources/birads wiratkapun c, treesit t, wibulpolprasert b, lertsithichai p. diagnostic accuracy of ultrasonography-guided core needle biopsy for breast lesions. singapore med j. 2012;53(1):40–45. schueller g, schueller-weidekamm c, helbich t. accuracy of ultrasound-guided, large-core needle breast biopsy. eur radiol. 2008;18:1761–1773. https://doi.org/10.1007/s00330-008-0955-4 schueller g, jaromi s, ponhold l, et al. us-guided 14-gauge core-needle breast biopsy: results of a validation study in 1352 cases. radiology. 2008;248:406–413. https://doi.org/10.1148/radiol.2482071994 youk jh, kim e-k, kim mj, lee jy, oh kk. missed breast cancers at us-guided core needle biopsy: how to reduce them. radiographics. 2007;27:79–94. https://doi.org/10.1148/rg.271065029 frith a. census 2011 [homepage on the internet]. no date [cited 2016 oct 30]. available from: https://census2011.adrianfrith.com/place/5 zhang c, lewis dr, nasute p, hayes m, warren lj, gordon pb. the negative predictive value of ultrasound-guided 14-gauge core needle biopsy of breast masses: a validation study of 339 cases. cancer imaging. 2012;12:488–496. https://doi.org/10.1102/1470-7330.2012.0047 youk jh, kim ke, kim mj, oh kk. sonographically guided 14-gauge core needle biopsy of breast masses: a review of 2,420 cases with long-term follow-up. ajr am j roentgenol. 2008;190:202–207. https://doi.org/10.2214/ajr.07.2419 díaz r, munárriz b, santaballa a, et al. synchronous and metachronous bilateral breast cancer: a long-term single-institution experience. med oncol. 2012;29(1):16–24. https://doi.org/10.1007/s12032-010-9785-8 gong sj, rha sy, jeung hc, roh jk, yang wi, chung hc. bilateral breast cancer: differential diagnosis using histological and biological parameters. jpn j clin oncol. 2007;37(7):487–492. https://doi.org/10.1093/jjco/hym056 zhou j-y, tang j, wang z-l, et al. accuracy of 16/18g core needle biopsy for ultrasound-visible breast lesions. world j surg oncol. 2014;12:7. https://doi.org/10.1186/1477-7819-12-7 lai hw, wu hk, kuo sj, et al. differences in accuracy and underestimation rates for 14versus 16-gauge core needle biopsies in ultrasound-detectable breast lesions. asian j surg. 2013;36(2):83–88. https://doi.org/10.1016/j.asjsur.2012.09.003 kirshenbaum k, keppke a, hou k, dickerson m, gajjar m, kirshenbaum g. reassessing specimen number and diagnostic yield of ultrasound guided breast core biopsy. breast j. 2012;18(5):464–469. https://doi.org/10.1111/j.1524-4741.2012.01269.x ramaema dp, buccimazza i, hift rj. prevalence of breast tuberculosis: retrospective analysis of 65 patients attending a tertiary hospital in durban, south africa. s afr med j. 2015;105(10):866–869. https://doi.org/10.7196/samjnew.7704 editorial the radiologist have a place c s de vries mmedrad(d) head: department of diagnostic radiology university of the free state bloemfontein does s/he in modern medicine? why such a question at a time of rapid development in imaging modalities? technically radiology is moving forward rapidly; no other discipline in medicine has advanced to such an extent, but very few people outside our field seem to appreciate this. so what role has the radiologist to play in the field of modern radiology? • is he the money machine for corporate medicine? • is he the technologist producing x-ray images as requested by clinicians, who most of the time don't read the report. is the report worth reading? • is he bent on defrauding the medical aid fund of money? • does he try to do more investigations than appropriate, pushing up the bills? • is he the faceless person who sends out big bills to patients? or is the radiologist, as a trained medical doctor, still a doctor in the true sense, treating his patients with compassion? apart from all the advanced technology used to make correct diagnoses, can he still do a proper supportive clinical examination in the event of equivocal radiological findings; can he advise the patient regarding the best imaging protocol for a satisfactory diagnosis; and finally, do clinicians consult him on imaging issues and value his opinion? the saying goes that a fool can ask more questions than a wise man can answer! while the radiologist answers complicated diagnostic questions every day, s/he often refuses to answer these basic questions. the time has come for us to stand together, to address these issues, and to move forward as diagnostic imaging specialists. we should stand our ground and control our destiny, lest we become only visitors in our own radiology units! cs de vries editor 3 sa journal of radiology • june 2002 radiology_aug04 original article 28 sa journal of radiology • august 2004 abstract we performed an audit to determine the profile of cerebral aneurysms at the universitas hospital bloemfontein, the only government hospital with a vascular suite in the free state and northern cape area. two hundred and twenty-three government patients, diagnosed with cerebral aneurysms during the period 1 january 2000 to 31 december 2003, were included in the study. of the 223 patients, 37.2% were male and 62.8% female. the patients’ average age was 45.5 years (range 11 78 years). most patients (61.4%) were older than 40 years. the average age for males and females was 41.4 and 46.3 years, respectively, with the females being significantly older (95% ci: 1.7 8.2). most patients had single aneurysms (65.5%). more females (42.9%) had multiple aneurysms compared with the males (20.5%) (95% ci females males: 9.9 33.7%). of the patients 40 years and younger, 22.1% had multiple aneurysms compared with 42.3% of the patients older than 40 years (95% ci: 7.8 31.7%). in our audit the females (when compared with the males) had a clear preponderance for cerebral aneurysms, were significantly older, and had a significant increase in multiplicity with an increase in age. introduction the main cause of subarachnoid haemorrhage (sah) is rupture of cerebral aneurysms.1 sah is a very serious disease associated with high mortality and morbidity.1 it is still an open question whether populationwide screening for unruptured cerebral aneurysms is indicated,2 while cerebral angiography remains the diagnostic gold standard.3,4 there have been numerous studies of the incidence of cerebral aneurysms. according to the who monica (multinational monitoring of trends and determinants in cardiovascular disease) stroke study no consistent pattern was observed in sah attack rates in different populations.5 we performed an audit to determine the profile of cerebral aneurysms at universitas hospital, bloemfontein. methods universitas hospital in bloemfontein is the only tertiary hospital in the free state and northern cape and also the only government hospital with a vascular suite in this area. all government patients with a suspected sah are therefore sent to this unit for angiographic assessment. during the period 1 january 2000 to 31 december 2003, 223 patients were diagnosed with cerebral aneurysms. the angiogram reports of these patients were used for data collection. reports of repeat and follow-up aneurysms were excluded. angiography was perfomed using a siemens angioscope unit. four vessel studies were performed in most cases using the following projections: ap, left anterior oblique (lao) 20º, right anterior oblique (rao) 20º and lateral for the carotid arteries, and townes and lateral projections for the vertebral arteries. results of the 223 patients, 83 (37.2%) were male and 140 (62.8%) were female. the patients’ average age was 45.5 years (range 11 78 years), with a peak (48.9%) between the ages of 36 and 50 years (fig. 1). the majority of patients (61.4%) were older than 40 years. the average age for males was 41.4 years and 46.3 years for females, with the females being significantly older (95% ci: 1.7 8.2). the average age for males with single aneurysms was 40.5 years, and for multiple aneurysms, 41.1 years. the average age for females with single aneurysms was 43.1 years, and for multiple aneurysms, 50.5 years. seventy-seven patients (34.5%) had multiple aneurysms while 146 patients (65.5%) had single aneurysms. in the female group, 60 (42.9%) had multiple aneurysms compared with 17 (20.5%) of the males (95% ci: females males 9.9 33.7%). of the patients 40 years and younger, 22.1% had multiple cerebral aneurysms – an audit d j louw mb chb c de vries mmedrad (d) department of diagnostic radiology university of the free state bloemfontein g joubert ba, msc department of biostatistics university of the free state bloemfontein aneurysms compared with 42.3% of the patients older than 40 years (95% ci: 7.8 31.7%). the sites of the aneurysms are given in fig. 2. in the patients with multiple aneurysms, each site was counted separately. the internal carotid artery and posterior communicating artery accounted for the most sites, viz. 76 (22.8%) and 75 (22.5%), respectively. to determine seasonal variation, the year was divided into 3-month periods, starting with 1 september, indicating spring. the number of single aneurysms increased during winter (1 june 31 august), but this was, however, not statistically significant (chi-square p-value 0.5370). discussion previous data suggest that cerebral aneurysms occur more frequently with increasing age,6 peaking in the fourth to fifth decade, and rarely occurring after 75 years.7,8 this is also reflected in our audit, with most patients (61.4%) older than 40 years. according to some authors cerebral aneurysm is a disease with a female preponderance, with the mean age for women older than for men.3,9-11 in the who monica study no consistent pattern was observed in the sex ratio of attack rates in different populations, with men having a higher incidence in finland and russia. women had a higher incidence in poland, northern sweden and denmark. the incidence was the same for east germany, china, yugoslavia and italy.5 in our audit the females had a clear preponderance accounting for 62.8% of the study population, and were significantly older (95% ci: 1.7 8.2). the femaleto-male ratio also increased after the fourth decade, as found by kongable and co-workers.10 the ratio increased to 1:2.1 in the fifth decade compared with 1:1.55 in the third decade. the overall ratio was 1:1.7. the incidence of multiple cerebral aneurysms has been variably assessed at between 5% and 33%.3,6,12-17 in this study, 34.5% of the patients had multiple cerebral aneurysms (ratio 1:2). of the patients older than 40 years, 42.3% had multiple aneurysms. previous data also suggest that multiplicity increases with age.6 females had a significant increased incidence in our study (95% ci: 9.9 33.7%). there is a higher mortality associated in patients with multiple lesions.13,18 an apparent seasonal variation was found in this study, with an increase in single aneurysms during winter. this was, however, not statistically significant and needs to be compared with other south african results. we also wanted to audit the size of the aneurysms, the shape of the neck and aneurysms, as well as treatment. unfortunately these data were not available consistently enough on the reports to audit. this underlines the need to use a standardised format of reporting. references 1. pakarinen s. incidence, aetiology, and prognosis of primary subarachnoid haemorrhage. a study based on 589 cases diagnosed in a defined urban population during a defined period. acta neurol scand 1967; 43: suppl 29, 1-28. 2. wardlaw jm, white pm. the detection and management of unruptured intracranial aneurysms. brain 2000; 123: 205-221. 3. van gijn j, rinkel gj. subarachnoid haemorrhage: diagnosis, causes and management (review) brain 2001; 124: 249-278. 4. mayberg mr, batjer hh, dacey r, et al. guidelines for the management of aneurysmal subarachnoid hemorrhage. a statement for healthcare professionals from a special writing group of the stroke council, american heart association. stroke 1994; 25: 2315-2328. 5. ingall t, asplund k, mahonen m, bonita r. a multinational comparison of subarachnoid hemorrhage epidemiology in the who monica stroke study. stroke 2000; 31: 1054-1061. original article 29 sa journal of radiology • august 2004 fig. 1. age distribution of the patients (n = 223). fig. 2. site of aneurysms (n = 3 34) (ica = internal carotid artery; post com = posterior communicating artery; mca = middle cerebral artery; aca = anterior cerebral artery; vb = vertebrobasilar system). 6. wilson fm, jaspan t, holland im. multiple cerebral aneurysms — a reappraisal. neuroradiology 1989; 31: 232-236. 7. clare ce, barrow dl. infectious intracranial aneurysms. neurosurg clin n am 1992; 3: 551-566. 8. mccormick wf, acosta-rua gj. the size of intracranial saccular aneurysms. an autopsy study. j neurosurg 1970; 33: 422-427. 9. bonita r, thomson s. subarachnoid hemorrhage: epidemiology, diagnosis, management, and outcome. stroke 1985; 16: 591-594. 10. kongable gl, lanzino g, germanson tp, et al. gender-related differences in aneurysmal subarachnoid hemorrhage. j neurosurg 1996; 84: 43-48. 11. ogungbo b, gregson ba, blackburn a, mendelow ad; newcastle subarachnoid study group. trends over time in the management of subarachnoid haemorrhage in newcastle: review of 1 609 patients. br j neurosurg 2001; 15: 388-395. 12. hamby wb. multiple intracranial aneurysms. aspects of treatment. j neurosurg 1959; 16: 558-563. 13. mckissock w, richardson a, walsh l, owen e. multiple intracranial aneurysms. lancet 1964; 15: 623-626. 14. heiskanen o. multiple intracranial arterial aneurysms. acta neurol scand 1966; 41: 356-362. 15. king g, slade hw, campoy f. bilateral intracranial aneurysms. ama arch neurol psychiatry 1954; 71: 326-336. 16. ostergaard jr, hog e. incidence of multiple intracranial aneurysms. influence of arterial hypertension and gender. j neurosurg 1985; 63: 49-55. 17. sengupta rp, mcallister vl. subarachnoid haemorrhage. new york: springer-verlag, 1986. 18. paterson a, bond mr. treatment of multiple intracranial arterial aneurysms. lancet 1973; 1: 1302-1304. original article 30 sa journal of radiology • august 2004 abstract introduction method computed tomography scan classification results discussion limitations of the study future applications conclusion and recommendations acknowledgements references about the author(s) chuma singata department of radiology, faculty of health sciences, university of cape town, south africa sally candy department of radiology, groote schuur hospital, university of cape town, south africa citation singata c, candy s. is computed tomography of the head justified in patients with minor head trauma presenting with glasgow coma scale 15/15? s afr j rad. 2018; 22(1), a1329. https://doi.org/10.4102/sajr.v22i1.1329 original research is computed tomography of the head justified in patients with minor head trauma presenting with glasgow coma scale 15/15? chuma singata, sally candy received: 20 feb. 2018; accepted: 14 june 2018; published: 27 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: in keeping with radiology departments in tertiary referral hospitals in developing countries offering computed tomography (ct) head scan services, the radiology department at groote schuur hospital (gsh) in the western cape of south africa undertakes several such scans annually. of these scans, many are undertaken for post-trauma patients with minor head injury (mhi). while there is agreement that mhi patients with glasgow coma scale (gcs) scores of 13–14/15 may well benefit, there is doubt as to the clinical utility of routine ct head scanning in mhi patients with gcs scores of 15/15. objectives: this retrospective descriptive study of patient records was undertaken to determine the frequency and clinical significance of any abnormalities found on ct head scans of 460 patients with mhi and gcs scores of 15/15, scanned at gsh between 2012 and 2014. method: ethical clearance was obtained and the records of 460 mhi patients with gcs scores of 15/15, loss of consciousness (loc) and amnesia who underwent ct head scanning at gsh between 2012 and 2014 were then retrieved from the philips picture archiving and communication system (pacs). patient records, containing illegible referral forms or technically inadequate ct head scans, were excluded from the study. patients’ biographical, clinical and ct head scan data were entered into sequentially numbered data collection forms. these data were tabulated and summed as percentage distributions. patients’ ct head scan findings were reviewed and classified as either showing normal or abnormal features. abnormalities detected on ct head scans were classified as being either clinically significant or clinically non-significant. results: referral forms and ct scan reports were obtained for 460 mhi patients from a sample of 497 patients, calculated by using the equation for estimating a single proportion from a large sample (precision 1.5%). the sample obtained yielded an acceptable response rate of 460/497 (92.6%). of 460 (100%) scan reports, 320 (69.6%) showed no abnormality, while 140 (30.4%) showed abnormality. of the 140 abnormal scans, 107 (23.3%) showed clinically non-significant abnormality, while 33 (7.2%) revealed clinically significant abnormality. twenty-two (4.8%) of these clinically significant scans showed brain contusion and 11(2.4%) showed skull fracture. no subdural or extradural haematoma, shift or herniation were reported and none of the 33 patients whose ct scans showed clinically significant abnormality underwent urgent neurosurgical intervention. conclusion: of the 460 ct head scans performed at gsh for mhi with loc but normal gcs between 2012 and 2014, none required urgent neurosurgical intervention. this is in accordance with the 2012 kimberley hospital rule (khr), a management protocol which indicates that ct head scanning in patients with mhi and gcs scores of 15/15 can safely be delayed for 8 h. an audit of the records of patients excluded from this study coupled with an analysis of data from other western cape hospital ct head scan databases could help ensure that this scarce resource is used cost-beneficially for all head-injured patients in the western cape catchment area. introduction computed tomography (ct) is an expensive but valuable clinical resource which should be judiciously used to ensure that all patients who might benefit from ct head scanning are scanned timeously. the use of ct scanning in resource-constrained developing countries, such as south africa, should be informed by clear guidelines that ensure that ct is used cost-beneficially. this is especially true where the practice of defensive medicine by referring clinicians drives up the demand for clinically doubtful ct scans. computed tomography scanning for post-trauma patients with head injury constitutes much of the demand for ct scanning in the radiology department at groote schuur hospital (gsh). groote schuur hospital is a level-4 referral hospital with an extensive clinical catchment area. while the injuries patients sustain arise from pedestrian and motor vehicle accidents, falling from heights, gunshot and occupation-related injuries, many of which are associated with alcohol intoxication, the actual scale of such injuries in south africa is inadequately documented and poorly understood.1 a preliminary review of traumatic head injury ct scan request forms received in the gsh radiology department showed that many requests were made for patients with minor head injury (mhi). minor head injury is currently defined as head injury that results in loss of consciousness (loc) for up to 30 min and post-traumatic amnesia (pta) in patients presenting with a glasgow coma scale (gcs) score of 13–15.2,3 the gcs, famously introduced in 1974 by a glasgow working group, is used to objectively record a patient’s level of consciousness and neurological functioning at the bedside in a way that can readily be communicated between clinical staff. there is now a body of published evidence demonstrating the clinical value of the gcs, and it is used in most clinical settings. several authors have argued that because patients with gcs scores of 13 and 14 have more severe injuries than patients with gcs scores of 15, patients with gcs scores of 15 should be regarded as a separate category and be termed ‘minor head injury’.4,5,6,7 at gsh radiology department, it is evident that a high proportion of post-traumatic head injury ct scan requests are made for patients with minor head injuries and gcs scores of 15. this finding raised the question of whether or not the scarce ct resource is being used optimally. this led to the present study being conducted to investigate whether or not the ct head scanning of patients with head injury, a gcs score of 15/15 and no focal neurological deficit would lead to an alteration in the medical or surgical management of the patient. much work has been undertaken to develop decision rules to govern the use of ct scanning in patients with mhi in order to assist clinicians to triage patients after head injury. such work has mainly been carried out in developed world settings where resources are more freely available than they are in the developing world. the computed tomography in head-injured patients (chip) protocol is one such set of guidelines.8 there is a particular need for guidelines in remote settings where the transportation of head-injured patients to centres where ct can be undertaken is notably difficult. in 2012, the kimberley hospital rule (khr) – derived from the national institute for health and clinical excellence (nice) – achieved 95% sensitivity and 45% specificity.9 the khr which allows patients with a gcs score of 15 and a history of loc to be scanned semi-urgently (within 8 h) should be of value in both developed and developing settings. this 8 h rule should assist clinicians to triage patients with head injury, by ensuring that those most in need are scanned soonest, and those patients whose scans are less urgent are scanned later. such triage should adjust the pace at which ct scans are conducted and allow departments to better manage this resource.10 method this retrospective descriptive study of patients’ records and ct brain scan findings was undertaken to determine the frequency and clinical significance of any abnormalities found on the ct head scans of 460 patients with mhi referred to the gsh radiology department between 2012 and 2014. a mhi patient was defined as a patient having a history of loc, pta and a gcs score of 15/15 following an episode of head trauma. after approval had been gained from the human research ethics committee of the university of cape town (hrec ref: 098/2015), the ct request forms and patient reports of 460 patients who underwent ct head scanning over the period 2012–2014 were retrieved from the philips picture archiving and communication system (pacs). the selected patients included in the study all had a gcs score of 15/15, a history of loc and/or pta. patients were included in the study even if they had multisystem trauma, anticoagulant use or evidence of drug or alcohol use, provided they had a gcs score of 15/15. the sample size was calculated at 497 using the equation for estimating a single proportion from a large sample with an acceptable precision of 1.5%. patients whose records revealed any of the following characteristics were excluded from the study: children aged less than 13 years; illegible ct request forms or inadequate reports; inadequate ct scans whether owing to movement, artefact or the incorrect window; reports not reviewed by a senior radiologist; patients with penetrating trauma; clinically palpable or radiographically detected skull fracture; and clinical seizure or focal neurological abnormality. patients were allocated consecutive numbers, and information from their records was then entered into a data recording form. categorical data, including age, sex, loc, pta, indications of trauma, namely, ecchymosis, abrasion, or swelling, were recorded. in addition patients’ symptoms including nausea, vomiting, headache and dizziness were also recorded. computed tomography scan classification computed tomography scans were considered abnormal if they exhibited any of the following characteristics: subdural, epidural or subarachnoid haematoma; parenchymal contusions; cerebral oedema; cerebral herniation (midline shift, uncal or transtentorial); pneumocranium; or skull fracture. patients whose ct scans showed abnormal findings were classed as having non-significant abnormality if their scan revealed ecchymosis, scalp swelling and linear skull fracture. significant ct findings included subdural and extradural haematoma, contusion, cerebral oedema, cerebral herniation, hydrocephalus and depressed or basal skull fracture not detected clinically or on prior skull radiograph. head ct scans were conducted either on a 6-slice siemens or on a 120-slice toshiba helical scanner. bone, brain and epidural window views were obtained for all patients. the data from the data collection sheets were collated, tabulated, summed and presented as percentage distributions as shown in the following section. results the records of 460 patients were extracted from the gsh radiology department’s pacs against the sample of 497 records calculated using the equation for estimating a single proportion from a large sample with a precision of 1.5%. this yielded an acceptable response rate of 460/497(92.6%). an analysis of the ct 460 head scan records is given in figure 1. figure 1: pie chart demonstrating the distribution of normal and abnormal findings on computed tomography in our sample of patients (n = 460). an analysis of the 140 (30%) ct head scans showing abnormality is given in figure 2. figure 2: pie chart differentiation of the abnormal computed tomography brain scans with significant and insignificant findings (n = 460). of the total, 33 clinically significant abnormal ct scans, 22 scans revealed brain contusion, while 11 revealed depressed skull fractures and seven showed base of skull fractures. none of the 33 abnormal ct scans revealed the presence of serious abnormalities such as cerebral herniation, extradural collection, subdural collection or cerebral oedema – abnormalities that would have necessitated urgent neurosurgical intervention. (table 1) table 1: analysis of findings in 33 (7.2%) computed tomography scans showing clinically significant abnormalities. the records of the 33 patients whose ct scans showed significant abnormality were reviewed to determine whether these patients had reported symptoms known to indicate serious head injury: headache, dizziness, vomiting or nausea. these findings are documented in table 2. table 2: number of patients reporting clinically alerting symptoms. of the 19 patients who experienced symptoms, seven had reported dizziness, five had vomited and seven had headache. discussion this study revealed that, of 460 patients who had traumatic head injury with loc and/or amnesia but with a gcs score of 15 at presentation, 33 (7%) had clinically significant ct head scan findings. contusion and depressed skull fracture were the most common significant positive findings in 22 (4.8%) and 11 (2.4%) patients, respectively; 7(1.5%) patients had base of skull fractures. no patient had subdural or epidural haematoma or cerebral herniation requiring urgent neurosurgical intervention. these findings accord with several previous studies. a large prospective study (1382 patients) conducted by miller et al. concluded that procedural ct of the brain in patients with a gcs score of 15 after mhi had minimal significance and was not justifiable.11 stein & ross et al., in a study designed to examine the same question, concluded that only patients with a gcs score of less than 15 warrant immediate and/or urgent ct brain scanning.12 davis et al. after reviewing the ct brains in children with mhi and loc found a number of ct abnormalities similar to those found in this study, though they reported more intracranial haemorrhages (8% vs. 4.7%). their report did not specify the type of haemorrhage found or whether these patients required neurosurgical intervention, but they concluded that ct is a safe and cost-effective means of reducing patient admission for overnight observation and that it significantly reduces the cost incurred by missed or delayed head injury management.13 however, in a prospective study of 712 trauma patients with gcs score of 15, jeret et al. (1993) found that 67 patients had intracranial traumatic lesions, two of whom required neurosurgical intervention and one who died. these authors concluded that there is no risk factor or clinical predictor occurring in isolation or in combination that can provide an accurate prediction of ct abnormality/normality, or that can alter the algorithm of imaging and the management of mhi.5 regarding patients’ symptoms, hsiang et al. (1997) reported a high correlation between headache and mhi.5 nausea and vomiting are however non-specific symptoms that may result from alcohol intoxication and substance abuse, as well as from head injury. in our study, patients with significant findings on ct also reported a higher incidence of vomiting (15%) and headache (21%), than those with insignificant or negative ct findings. this retrospective study of stored patient records did not allow the investigator to determine the clinical history and neurological outcome of patients whose ct scans revealed significant abnormality. computed tomography head decision rules have been mainly formulated in developed countries where the trauma burden, staffing and financial pressures are different from those prevailing in developing countries such as south africa. with this proviso in mind, the khr proposed by bezuidenhout and colleagues in 2013 warrants careful consideration.9 modified from the well-known national institute for health and care excellence (nice) guideline, this offers a single unifying rule that is ideal for a resource-limited environment with high prevalence of trauma. emergency scans are resource-intensive. with 90% sensitivity and 45% specificity in the detection of clinically significant intracranial findings, the khr aims to rationalise the timing of emergency ct brains without reducing the number of scans performed. based on this rule, patients with a normal mental status (gcs 15) but with a history of loc and/or amnesia should undergo ct scanning within 8 h. in the western cape, this would allow the patient to be observed at a primary treatment centre and to be transferred for a ct head scan at a tertiary level referral centre within 8 h. the absence of any patient requiring neurosurgical evacuation of an intracranial haematoma in this study justifies cautious observation in this patient group. the findings in the current study indicate that patients with minor head trauma could be safely managed at primaryor secondary-level units. in busy tertiary trauma units, the reduction in patient numbers could improve the management of those patients with unequivocal head injury. an unpublished study conducted at gsh indicated that the time from a patient being injured to their undergoing an initial ct scan is an astounding 18 h.13 this staggering delay is attributable mainly to the unavoidable constraints which result from the western cape having an overtaxed public-sector ambulance service. a service which cannot cope with the demands placed on it for the safe transport of trauma victims from primaryand secondary-level facilities solely for ct head scans. increasingly, ct scanners are being installed at secondary-level hospitals in south africa but are not staffed outside of normal working hours (08:00 to 16:00). this study suggests that patients who fit the criteria for mhi with a presentation gcs score of 15/15 could safely be managed at the referral hospital awaiting next-day scan. this would have a significant positive impact on heavily burdened ambulance services and on the trauma units at the major tertiary centres. an analysis of the actual cost of the ct head scans conducted at gsh radiology department should be undertaken to allow us to fully understand the work of the department. when a contusion is detected on a patient’s ct head scan, that patient is generally admitted to hospital for neurological observations for a variable period of time. a follow-up ct is often performed to exclude radiological change, even in the absence of neurological deterioration. such patient admissions invariably increase the financial and staffing burden in overstretched neurological units. limitations of the study the data obtained in this retrospective study were limited to the collection of data from patient ct scan request forms submitted by clinicians and stored in gsh, ris and pacs. no files or clinical notes were reviewed; hence, the type of neurosurgical management and the eventual clinical outcome of these mhi patients were not determined. variables such as length of loc may have been inaccurately estimated and the mode of injury was not always documented. the sample size was smaller than many similar studies. we had a shortfall of 35 patients on our recommended calculated sample size. small sample size and different patient demographic and socio-economic factors may play a major role in the different outcomes. this study was confined to the ct scan reports of patients presenting to a single urban tertiary hospital. no further review of the records of patients with illegible records or doubtful ct scan reports was undertaken, and the scale of this aspect of the record review was not estimated. future applications currently, patients presenting post-trauma with normal gcs scores to the radiology department at gsh are imaged urgently in the face of ct resource scarcity. in the light of the findings of this retrospective study, we recommend a large prospective study of patients presenting with head trauma but with a gcs score of 15. this would be designed to include detailed documentation of the mechanism of injury and other associated injuries (including, but not restricted to, suspected cervical spine injuries). a prospective study could be invaluable in helping the radiology service to formulate a safe policy for the management of mhi patients. however, a further review of the records of patients who have undergone ct scans for mhi in other regional referral centres, such as tygerberg hospital (tbh), for example, could yield further insight into this problem at little extra cost. in addition, an audit of the use of ct scan at gsh radiology department for mhi could possibly help the department to use this scarce resource more efficiently as would an audit of the records of patients who underwent ct head scan but whose records were excluded from this study. computed tomography head decision rules have proved effective in other countries with reliable sensitivity and specificity. to curb overutilisation of this scarce resource, a trial of the khr at gsh radiology department is warranted. conclusion and recommendations this study showed that most ct scans performed in patients who had experienced loc after head trauma but who had recovered to normal mental status (gcs score of 15 and no focal neurology) were normal. no scans with herniation and subor epidural haematoma were identified. however, a small number of patients had significant findings, such as intracranial haemorrhage and depressed skull fracture even in the face of a normal level of consciousness and normal neurology. a normal level of consciousness (gcs score of 15) coupled with absence of neurological deficit does not therefore exclude the possibility of the patient having significant traumatic brain injury or eliminate the need for a ct scan imaging in this subgroup of patients. although only 33/460 (7.2%) of patients in this study had a significant ct scan finding warranting referral to a tertiary centre, the clinical needs of this group of patients should be addressed. south africa is a resource-limited country and many health care centres lack trained personnel and may not have ct scanners. this lack of accessibility may delay imaging and essential surgical management. we therefore agree with the khr recommendation that patients with mhi and a gcs score of 15 should undergo ct scanning but that such scanning can safely be delayed by 8 h. a well conducted prospective study with clearly defined clinical parameters may shed light on the subject. it is likely, however, that medical litigation and the potentially catastrophic outcome of a missed intracranial injury will continue to drive the demand for ct in the setting of mhi. acknowledgements the author thanks professors andronikou savvas and rodney ehrlich for their input and advice; brandon vigaro, lyle eyssen and kevin ernstzen, radiology it staff at groote schuur hospital; mr m s gusha who assisted with statistical analysis; dr mankgopo kgatle and baxolele mhlekude for guidance and support during this study. competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this paper author contributions c.s. was the primary author and was responsible for the research proposal protocol, literature review, data collection and compilation of the research manuscript. s.c. was the supervisor and assisted with the project design, review, study analysis and manuscript editing. references nell v, brown d. epidemiology of traumatic brain injury in johannesburg—ii. morbidity, mortality and etiology. socsci med. 1991;33(3):289–296. https://doi.org/10.1016/0277-9536(91)90363-h shoar s, saadat s. ct scanning in minor head injury. ct scanning–techniques and applications. intechopen; 2011,pp. 161–176, cape town. heltemes k, holbrook t, macgregor a, galarneau m. blast-related mild traumatic brain injury is associated with a decline in self-rated health amongst us military personnel. injury. 2012;43(12):1990–1995. https://doi.org/10.1016/j.injury.2011.07.021 teasdale g, jennett b. assessment of coma and impaired consciousness: a practical scale. lancet. 1974;2:81–84. https://doi.org/10.1016/s0140-6736(74)91639-0 hsiang j, yeung t, yu a, poon w. high-risk mild head injury. j neurosurg. 1997;87(2):234–238. https://doi.org/10.3171/jns.1997.87.2.0234 teasdale g. head injury. j neurolneurosurgpsychiatr. 1995;58(5):526–539. https://doi.org/10.1136/jnnp.58.5.526 miller e, derlet r, kinser d. minor head trauma: is computed tomography always necessary? ann emerg med. 1996;27(3):290–294. https://doi.org/10.1016/s0196-0644(96)70261-5 smits m, dippel d, steyerberg e, et al. predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the chip prediction rule. ann intern med. 2007;146(6):397–405. https://doi.org/10.7326/0003-4819-146-6-200703200-00004 bezuidenhout a, hurter d, maydell a, et al. the kimberley hospital rule (khr) for urgent computed tomography of the brain in a resource-limited environment. s afr med j. 2013;103(9):646–651. https://doi.org/10.7196/samj.6876 miller e, holmes j, derlet r. utilizing clinical factors to reduce head ct scan ordering for minor head trauma patients. j emerg med. 1997;15(4):453–457. https://doi.org/10.1016/s0736-4679(97)00071-1 stein s, ross s. the value of computed tomographic scans in patients with low-risk head injuries. neurosurgery. 1990;26(4):638–640. https://doi.org/10.1227/00006123-199004000-00012 jeret j, mandell m, anziska b, et al. clinical predictors of abnormality disclosed by computed tomography after mild head trauma. neurosurgery.1993;32(1):9–15. https://doi.org/10.1227/00006123-199301000-00002 owen j, andronikou s. value of follow-up ct in injury assessment (dissertation).university of cape town; 2015, cape town. star abstract management of a solitary pulmonary nodule philippe grenier md the solitary pulmonary nodule (spn) is a common radiologic abnormality. an estimated 150000 spns are detected annually in the us and are often discovered incidentally at chest radiography or ct. these nodules are caused by a variety of disorders, including neoplasms, infection, granulomas, intrapulmonary lymph node, and vascular and congenital abnormalities. although most spns have benign cause, 35 40% of these nodules are malignant, many of them representing stage i lung cancer that must be distinguished from benign nodules in an expeditious and cost effective manner. small pulmonary nodules (less than one centimeter) of indeterminate etiology are being detected with increasing frequency owing to greater use of computed tomography. since the advance of helical ct scanning, even more pulmonary nodules are being detected. when a spn is depicted, helical thin collimation ct scans through the nodule should be obtained prior to contrast infusion. the use of thin slice thickness is essential for assessing morphology and attenuation. then obtaining a chest study including the upper abdomen is also important for staging purposes and for detecting other additional nodules. in case of multiple nodules present in ct examination, every individual nodule has to be analyzed independently. when the number of nodules present is superior to 6, the probability of granulomatous or metastatic disease is very high and the management is totally different and excluded from this chapter. 1. morphology and density at ct a few types of focal lesions have morphologic characteristics typical enough to allow a specific diagnosis to be made on hrct. examples include arteriovenous pulmonary malformations, fungus ball, rounded atelectasis and mucus plugs. in most of the cases, the morphology of the nodule is not characteristic enough to identify the lesion, but the analysis of the size, margins, content, and density is the first step that can help differentiate benign and malignant lesions. size and margins generally, the smaller the nodule, the more likely it is to be benign. nodules larger than 1 cm are more likely to be malignant, whereas nodules smaller than 0.5 cm are more likely to be benign. however, small size alone does not exclude lung cancer because 15% of malignant nodules are less than 1 cm. margins and contours have been classified as smooth, lobulated, irregular or spiculated. although most nodules with smooth well-defined margins are benign, these features are not 30 sa journal of radiology • december 2002 diagnostic for a benign cause: 21% of malignant nodules have well-defined margins. metastatic carcinomas are often smooth in contour. a lobulated contour implies an even growth which is associated with malignancy. lobulation however also occurs in up to 25% of benign nodules. a nodule with an irregular or spiculated margin is likely to be malignant although occasionally it can be due to focal organizing pneumonia or plasma cell granuloma. content air bronchogram or focal bubblelike lucencies, (pseudocavitation), within a nodule are more common in malignancy (30%) than in benign nodules (5%) and are more suggestive of adenocarcinoma, or bronchioloalveolar cell carcinoma. cavitation is also more common in malignant nodules than benign, but focal benign pulmonary lesions, such as lung abscess can cavitate as well. benign cavitary lesions generally have smooth, thin walls whereas malignant nodules typically have thick, irregular walls. most nodules with a wall thickness greater than 15 mm are malignant, whereas those with a wall thickness less than 4 mm are usually benign. however, there is significant overlap and wall thickness alone cannot be used to confidently differentiate benign from malignant cavitary nodules. calcification: the detection of calcification and assessment of its pattern is an important step to differentiate benign and malignant nodules. there are four benign patterns of calcifications: diffuse, solid and central, laminated, and popcorn like. the first three are typically seen with prior infections, particularly histoplasmosis or tuberculosis. popcorn like calcification is characteristic of chondroid calstar abstract cification in a hamartoma. when present, these patterns of calcification are reliable indicators of a benign cause, although these lesions should be followed radiographically in most cases, unless the calcification is diffuse and dense. eccentric or stippled calcifications are highly suggestive of malignancy. densely calcified spns in patient with a history of primary bone-forming malignancy should not be automatically interpreted as benign lesions. a small central calcification is insufficient for determining the nodule to be benign if the nodule is larger than 2.5 cm with spiculated margins because of the likelihood of cancer in patients with such nodules. density most nodules are of soft tissue density (solid nodules). some others are hazy dense, less dense than vessels, taking a ground glass appearance (non solid nodules). when they are less than 5 mm in diameter, these ground glass areas are most likely benign (atypical adenomatous hyperplasia). beyond 5 mm, they can be malignant (non mucinous bronchioloalveolar cell carcinoma or adenocarcinoma), and they must be regarded with high suspicion of malignancy when larger than 10 mm. presence of soft tissue component within the ground glass opacity (mixed nodule) is also a feature of high suspicion of malignancy (adenocarcinoma). 2. classification of nodules and diagnostic strategies according to its appearance (mortable 1. ct criteria of benign nodules • diffuse and intense calcification • converging vessels (pulmonary arteriovenous malformation, rounded atelectatis) • fat collection (± pop corn calcification) • benign pattern of calcification (central or laminated) table 2. ct criteria of high suspicion of malignancy • size> 20 mm • spiculated contours • air bronchogram or bubble like lucencies • malignant partem of calcification (eccentric, stippled) • non solid nodule (focal ggo) > 10 mm • mixed nodule (ggo+soft tissue) table 3. ct criteria of indeterminate nodule • non solid (focal ggo) < 10 mm • solid < 20 mm • non spiculated contours • without air bronchogram of bubble like lucencies • without malignant calcification • without fat and benign calcification 31 sa journal of radiology • december 2002 phology and density) on ct scans, the lung nodule can be classified as benign, highly suspected of malignancy or indeterminate. nodules considered as benign are those with diffuse calcification or those having a criterion of specificbenign disease (table 1). no additional examination (diffuse calcification) or only radiographic follow up until 2 years stability is requested. nodules showing any of the criteria defining high suspicion of malignancy (table 2) must be biopsied (commonly by videoassisted-thoracoscopic surgery [vats]). the indeterminate nodules (70%) are those presenting with the ct criteria reported in table 3. the differentiation between malignant and benign nodules can be done by different diagnostic approaches including growth rate assessment, contrast enhanced ct, fdg-pet, biopsies, or vats. growth rate assessment doubling time for most malignant nodules is between 30 and 400 days and results in 26% increase in nodule diameter. nodules that double either more rapidly or more slowly typically have a benign cause. stability at chest radiograph or ct over a 2-year period implies a doubling time of at least 730 days and is generally considered to be a reliable indicator of a benign cause. it can be difficult to reliably detect growth in small (10 mm) nodules. for example, a 5 mm nodule can double in volume but its diameter will increase by only 1.25 mm. this 1.25 mm change in diameter cannot be reliably detected with ct. to overcome this limitation, it has been proposed that the growth rate of small nodules be assessed with serial measurements of volume rather than diameter. specific softwares of image analysis allowing the automatic segstar abstract mentation of the contour on ct scans, 3d reconstructions of the nodules, and calculation of nodule volume, have been prepared by industry and are under evaluation. contrast enhanced ct the degree of enhancement has proven to be directly related to the likelihood of malignancy and the vascularity of the nodule. the technique (only for nodules larger than 7 mm) consists of thin section helical ct performed through the nodule before and after (every 30 sec for 5 min), intravenous iodinated contrast material (300 mg/ml at 2 ml/sec, total dose 420 mg/kg). nodular enhancement absent or less than 15 hu after contrast material is strongly predictive of a benign lesion (sensitivity 98%, specificity 73%). the low specificity is due to enhancement observed in some hamartomas and inflammatory lesions. this technique may help select patients for biopsy or surgery (if enhancement is present) or follow-up (if enhancement is absent). fdg-pet increased glucose metabolism in tumors results in increased uptake, trapping and accumulation of fdg, permitting differentiation of benign and malignant nodules. the sensitivity, specificity and accuracy of fdgpet in the diagnosis of benign nodules are 96%, 88% and 94% respectively. lesions with low fdg uptake may be considered benign. the high specificity of fdg-pet for the diagnosis of benign lesions has important clinical utility. however these lesions should be followed radiologically because of false negative results due to small size (lower than 10 mm) and some malignant lesions such as carcinoid and bronchoalveolar cell carcinoma. spn with increased fdg uptake should be considered malignant, although false positive results can be obtained with infections or inflammatory processes such as active tuberculosis, histoplasmosis and rheumatoid nodules. biopsy biopsy of a lung nodule may be necessary in some cases. several options are available. these include bronchoscopy, needle aspiration lung biopsy, video-assisted thoracoscopic surgery (vats) or thoracotomy. to some degree, imaging studies can be valuable in making this choice. if the spn is related to a narrowed or obstructed bronchus or a bronchus is visible within the nodule (a positive bronchus sign) or if an endobronchial lesion is detected with ct, bronchoscopy directed to the proper level is appropriate and often will be diagnostic. in such cases, ct can guide the biopsy attempt. if a positive bronchus sign is not present or the nodule is peripheral, needle aspiration biopsy is more appropriate. ct can be helpful in planning the biopsy. it can indicate the depth of the lesion and the needle can be appropriately marked. in addition, the biopsy approach may be planned to avoid that the path of the needle crosses a bullae or a fissure. the risk of pneumothorax in such cases is increased and a different approach may be used. lesions smaller than 1 cm can be biopsied percutaneously, although the minimum size varies with the skill of the radiologist. needle aspiration yields malignant cells in more than 90% of neoplastic nodules. this percentage can be optimized by having a cytopathologist on site at the time of the biopsy and repeating the biopsy if the specimens are negative. some investigators, because of the lack of availability of a cytopathologist, prefer to use cutting coaxial nee32 sa journal of radiology • december 2002 dles that provide larger samples permitting histological studies. these techniques improve the accuracy of specific diagnosis of benign lesions without any significant increase in the number of complications. a non specific negative biopsy cannot be taken into account to indicate that no cancer is present. ct can also be used in conjunction with vats. localization of the tumor can be done preoperatively using dye or a hooked wire. diagnostic approach of incleterminate nodule the choice between the different diagnostic approaches of an indeterminate nodule depends on the clinical probably of malignancy and the nodule size. • < 5 mm: follow-up ct at 12 and 24 months consider biopsy or removal for nodules that increase in volume (more than 15%) • 5-10 mm: follow-up ct at 3, 6, 12, and 24 months. consider biopsy or removal for nodules that increase in volume (more than 15%) • > 10 mm: consider biopsy. as an alternative, pet or contrastenhanced ct can be done. suggested reading 1. aberle dr, gamsu g, henschke cl, naidich dp, swensen sj. a consensus statement of the society of thoracic radiology. screening for lung cancer with helical computed tomography. j thoraelmaging 2001; 16: 65-68. 2. erasmus jj, connolly je, mcadams hp, roggli vl. solitary pulmonary nodules: part 1. morphologic evaluation for differentiation of benign and malignant lesions. radiographies 2000; 20: 43-58. 3. erasmus jj, mcadams hp, cououyje. solitary pulmonary nodules: part ii. evaluation of the indeterminate nodule. radiographies 2000; 20: 59-66. 4. ginsberg ms, griff sk, go bd, yoo hh, schwartz lh, panicek dm. pulmonary nodules resected at video-asisted thoracoscopic surgery: etiology in 426 patients. radiology 1999; 213: 277-282. abstract introduction research methods and design ethical consideration results discussion conclusion acknowledgements references about the author(s) tiaan p. steyn department of clinical imaging sciences, universitas academic hospital, university of the free state, south africa fekade a. gebremariam department of clinical imaging sciences, universitas academic hospital, university of the free state, south africa citation steyn tp, gebremariam fa. cost analysis of violence-related medical imaging in a free state tertiary trauma unit. s afr j rad. 2019;23(1), a1664. https://doi.org/10.4102/sajr.v23i1.1664 original research cost analysis of violence-related medical imaging in a free state tertiary trauma unit tiaan p. steyn, fekade a. gebremariam received: 15 sept. 2018; accepted: 14 oct. 2018; published: 08 jan. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: violence is a leading public health problem worldwide. beyond the pain and suffering, violence has a significant economic impact on a country’s health, policing and judicial services. because of the lack of current and comprehensive data in south africa, local violence-related economic impact studies are largely estimations. violence-related imaging expenditure, as a component of a public hospital’s expenditure, is yet to be determined. objectives: the goals of this study were to measure the violence-related patient burden on pelonomi tertiary hospital’s (pth) trauma and radiology services, determine the imaging-component cost of violence-related injuries and calculate the financial burden violence has on the hospital’s expenditures. method: from the pth’s trauma unit patient registry, 1380 patients with violence-related injuries were consecutively sampled for 6 months ending 31 december 2017. imaging investigations were documented and categorised according to the south african national department of health’s 2017 uniform patient fee schedule (upfs). descriptive analysis and cost calculations were performed using the 2017 upfs tariff schedule and hospital-specific health efficiency indicators – patient-day equivalent and expenditure per patient-day equivalent. results: violence-related injuries accounted for 50.64% of all trauma department visits and received a total of 5475 imaging investigations. violence-related imaging investigations represented 14.81% of all investigations performed by the radiology department in the study period. overall violence-related admission costs amounted to r35 410 241.85 (8.33% of the hospital’s total expenditure), of which 20.08% (r7 108 845.00) was attributed to imaging investigations. conclusion: violence-related admissions had a high patient and financial burden on pth. the pinnacle of healthcare cost saving is violence prevention; however, the cost-conscious radiologist could assist with cost saving if responsible and ethical imaging practices are followed. introduction in 2008, violence was earmarked as the leading cause of death (31.5%) among 31 177 unnatural deaths recorded in the national injury mortality surveillance system report of south africa. however, violence had already been declared a leading worldwide public health problem in 1996 at the geneva world health assembly.1 locally, the south african police service precincts in and around bloemfontein reported a total of 8101 crimes in the categories of attempted murder, assault with the intent to inflict grievous bodily harm, common assault and robbery with aggravating circumstances. this was for the period 01 april 2017 to 31 march 2018.2 beyond the pain and suffering caused, violence has a significant economic impact on society, both directly and indirectly. some of the direct costs include those borne by the victim and perpetrator as a result of the violence, loss of productivity at work, government expenditure relating to healthcare, policing and judicial services.3,4,5,6,7 because of a lack of comprehensive data in south africa, local cost analysis studies can only estimate the economic impact of violence.8 the provincial departments of health showed the second highest expenditure of all government departments, spending close to r150 billion in the 2015–2016 fiscal year. this translated to an average cost of r3332 per person using public healthcare services in south africa.9,10,11 this is an extremely high burden on both the national and provincial governments’ budgets when taking into consideration that, in 2014, healthcare contributed close to 9% of south africa’s gross domestic product.12 health information (e.g. cost analysis studies) is crucial in the planning, implementation, evaluation and management of healthcare resources, seeing that 82% of the south african population rely on the public healthcare system.10,13,14,15,16 there are limited studies in the south african literature that specifically focus on the cost of medical imaging in violence-related injuries. imaging investigations are expensive and the south african competition commission’s health market inquiry found that medical aid claims relating to imaging investigations increased by an average of 10.98% per year between 2011 and 2014.17 the objective of this study was twofold. firstly, we aimed to determine the violence-related patient burden on trauma and radiology services at pelonomi tertiary hospital (pth), and secondly, to determine the cost of violence-related medical imaging and to contextualise this cost in terms of pth’s total expenditure. research methods and design study design this study was a descriptive cost analysis that aimed to measure the cost of violence-related medical imaging in the setting of a tertiary-level public hospital. because of the complexity of cost analysis studies, the most practical method for estimating this cost was to use the south african national department of health’s 2017 uniform patient fee schedule (upfs). the upfs is a fee schedule used to bill patients using public healthcare facilities, and it is applicable to externally funded patients using public hospitals in all provinces throughout south africa. therefore, the study could more accurately be defined as a descriptive cost analysis using the theoretical maximum cost that can be charged by the hospital for medical imaging. although the data might not reflect the exact cost of performing the imaging investigations, it does provide an estimation thereof. according to the upfs, all imaging investigations are categorised from category a to category e according to the complexity of the investigation. furthermore, each category consists of two fixed prices: a facility fee (depending on the service level of the hospital) and a professional fee (depending on the training level of the healthcare practitioner who interprets the imaging investigation). the 2017 upfs imaging fees are presented in table 1.18 table 1: 2017 uniform patient fee schedule imaging tariffs. research setting and sampling method the pth’s trauma unit served as the study population. this unit provides emergency medical care to the whole of central south africa (free state and parts of the northern and eastern cape) and keeps a detailed electronic patient registry including the diagnosis and mechanisms of injury. because of resource constraints and a high turnover of patients in the trauma unit, violence-related injuries for a 6-month period (01 july 2017 to 31 december 2017) were selectively used to ensure a manageable sample size. consecutive sampling was used to retrospectively select patients from the trauma unit’s patient registry. inclusion criteria consisted of patients of any age who were attended to in the study period and who sustained violence-related injuries in the subgroups of ‘penetrating assaults’, ‘blunt assaults’, ‘combination of blunt and penetrating assaults’ or ‘gunshot injuries’. accidental and self-inflicted injuries were excluded, as well as patients who were dead on arrival. patients who did not receive any imaging were excluded from cost calculations. double registry entries and registry entries with missing data, which could not be recovered from the hospital information system, were also excluded. data collection the trauma unit’s electronic database (microsoft excel format) was filtered according to the inclusion and exclusion criteria. each entry in the filtered database was manually cross referenced with the hospital information system (to eliminate database errors) and to obtain each patient’s discharge date. hereafter, all directly identifiable patient information (name, surname, identity number) were removed from the database to ensure patient confidentiality. patients were only identified with their hospital numbers. hospital numbers and admission dates were cross referenced with the picture archiving and communication system (pacs). each individual examination performed during the patient’s first admission was documented under the relevant modality and upfs category a to e (using the upfs procedure book). the procedure book contains more than 800 individual radiological investigations and procedures, and for this reason, investigations were not further subcategorised. examinations were categorised from a to e and priced according to upfs service level-3 facility fees and upfs specialist professional fees. the final database contained the number of imaging investigations performed for each patient categorised under the different imaging modalities and upfs pricing categories. data analysis descriptive statistics were calculated for continuous data and frequencies and percentages were calculated for categorical data. arithmetic and cost calculations, incorporating the 2017 upfs tariffs, as well as healthcare efficiency indicators and relevant hospital expenses for the study period (obtained from the hospital’s information unit), were used to calculate relevant imaging costs and proportionality between imaging costs and hospital expenditure. limitations imaging investigations performed outside the radiology department such as fluoroscopy in theatre and extended focussed assessment with sonography in trauma, done in the trauma unit, are not uploaded to the pacs and were subsequently not included in the study. this could have led to an underestimation in the total cost of imaging. contrast agents, administered during the imaging investigations were not included in the cost analysis because of varying cost between the different brands, as well as poor documentation of the exact amount and type of contrast that was administered. patients seen at pth’s casualty department (a separately functioning department from the trauma unit) were not included in the study – this was because of the lack of an electronic patient registry. ethical consideration ethical clearances were obtained from the university of the free state’s health sciences research ethics committee (ufs-hsd2018/0052), as well as the free state provincial health research committee (fs_201803_010). all directly identifiable patient information (names, surnames, dates of birth, etc.) were removed to ensure patient confidentiality. results a total of 4966 patients were treated at pth’s trauma unit in 2017, of which 2725 patients were treated during the period 01 july 2017 to 31 december 2017. within this period, 1380 patients matched the inclusion and exclusion criteria. violence-related injuries constituted 50.64% of all trauma department visits during the study period. descriptive statistics are summarised in table 2. table 2: descriptive statistics. the sample of 1380 patients included 1228 males (mean age of 31.22 years) and 152 females (mean age of 32.71 years). the study sample’s injuries consisted of 53.77% penetrating injuries, 37.46% blunt injuries, 2.46% combination injuries and 6.3% gunshot injuries. a combined 5475 individual imaging investigations were performed on 1273 patients in the study sample. a total of 107 patients did not receive any imaging and were excluded from further cost calculations. general x-rays represented the bulk of the imaging investigations, totalling 3834 investigations, and amounted to r843 354.00. computed tomography (ct) scans totalled 1566 investigations; however, they contributed to the highest cost of r5 957 280.00. a detailed breakdown of imaging cost per imaging modality is presented in table 3. a total of 5475 imaging investigations amounted to r7 108 845.00, of which r2 631 939.00 represented level-3 hospital facility fees and r4 476 906.00 the specialist professional fees. table 3: modality-specific facility and professional fees. the average costs of imaging investigations for the different injury types are presented in table 4. table 4: average costs of imaging per injury type. from the patient sample, 978 patients (70.87%) were admitted to hospital with a combined total of 9221 admission days. patients who were not admitted to hospital totalled 295. discussion although the upfs applies to externally funded patients being treated in a public hospital, it should be noted that all state patients are billed according to the upfs tariffs. the upfs tariffs applicable to imaging investigations are used by public hospitals to incorporate the cost of imaging into performance indicators, as well as being used for financial analyses and budgeting. after the invoicing is done, a patient may qualify for a rebate. the percentage rebate is dependent on the income level of the patient and other factors. rebates may be up to 100% in h0 classified patients (pensioners and formally unemployed patients) and 0% in h3 patients (therefore full paying patients). where rebates apply, the rebates are covered by the hospital. aspects such as actual patient invoicing, debt collection and the reconciliation thereof, are beyond the scope of the study. instead, the study used the theoretical maximum that could be charged to patients for medical imaging received in a tertiary government hospital – in other words, no rebates were considered. therefore, if all patients in the study sample were regarded as h0 classified patients, the total invoice for imaging services would have had to be covered by the hospital. the billing total of imaging performed in the study sample was r7 108 845.00. this includes both the professional fees and the facility fees, as set out in the upfs. this billing total is an underestimation of the true amount because of the previously stated limitations. in the study sample, general x-rays were the most frequently performed investigation (n = 3834) and contributed 11.9% to the total imaging bill, whereas ct scans (n = 1566) contributed 83.8% (r5 957 280.00) to the total bill. the modality with the third highest cost was magnetic resonance imaging (mri) (n = 38) totalling r271 510.00, followed by ultrasound (n = 21) and fluoroscopy (n = 16), which totalled r14 109.00 and r22 592.00, respectively. in perspective, for every r1.00 the hospital billed for imaging in violence-related injuries, r0.84 was for ct scans, r0.12 for x-rays and r0.04 for mri. the costs of ultrasound and fluoroscopic investigations were negligible, because records pertaining to ultrasounds performed by trauma personnel and screening procedures performed in theatre were not available for analysis. medical imaging, as a component of in-hospital services and costs, can be put into perspective by determining the patient burden on radiology services, as well as what share it holds in the hospital’s total expenditure. the radiology department performed a total of 36 956 imaging investigations in the study period. violence-related imaging investigations, referred from the trauma unit, constituted 14.81% of all these investigations; however, this is an underestimation because of the study limitations and considering that none of the casualty department’s violence-related imaging referrals were included in the study. to put the imaging costs into perspective, comparison to the hospital’s overall expenditure is needed. this can be done by comparing the data to the hospital’s expenditure per patient-day equivalent (expde). expenditure per patient-day equivalent is widely used as a proxy for a hospital’s cost-effectiveness and is calculated by dividing the hospital’s total expenditure, for a specific period, by the hospital’s patient-day equivalent (pde) for the same period. a single pde is a unit that can represent one or more patients depending on the hospital resources the patient or patients consume in a 24-hour period. this is calculated by using all inpatient days, half of out-patient visits and a third of emergency department visits. the rationale behind the formula is that out-patient visits and emergency department visits are estimated to consume one-half and one-third, respectively, of the resources spent on a single 24-hour patient admission. therefore, expde represents the average cost per patient per 24-hour services rendered by the hospital.19 before comparing the data to the hospital’s expde, an ‘imaging expenditure per patient-day equivalent’ was calculated in accordance with the expde formula. this provided an average imaging cost per pde for the study sample. the study sample included 978 patient hospital admissions with a total of 9221 admission days. this represented 9221 pdes. one-third of the remaining non-admission patients represented 98 pdes, which led to a total of 9319 pdes in the study sample. dividing the total imaging costs with the sample’s pde, amounted to an imaging expde of r762.83. thus, the average cost of imaging per violence-related admission day was r762.83. calculations are summarised in figure 1. figure 1: hospital expenditure per patient day equivalent and imaging expenditure per patient day equivalent. pde, patient-day equivalent; expde, expenditure per patient-day equivalent. calculated from pth’s financials for the study period, irrespective of the admitting department, the average cost per patient per 24-hours (expde) was r3799.79. when the study sample was compared to the hospital’s expde, violence-related imaging was found to constitute 20.08% of the hospital’s average cost per patient per 24-hour admission. consequently, this proved that a considerable portion of money was spent on medical imaging in violence-related hospital admissions. using pth’s expde and the study sample’s pdes, the hospital spent a total of r35 410 241.85 on violence-related trauma admissions for the last 6 months of 2017. this translated to 8.33% of the hospital’s total expenditure of r424 898 583.55 for this period. seeing that violence is unlikely to disappear in the foreseeable future, all role players in the management chain of violence-related hospital admissions should be cost-conscious and avoid unnecessary expenditure. violence and its associated injuries are closely related; therefore, similar studies at set intervals may not only prove useful as cost analysis studies but also prove as useful indicators of the incidence of violence, the financial burden on healthcare services, as well as the effectiveness of existing violence prevention strategies and campaigns. conclusion violence often leads to injury and the need for healthcare. during the last 6 months of 2017, 92.2% (n = 1273) of violence-related trauma department visits to pth received imaging. the radiology department, therefore, plays an important role in the management chain of violence-related injuries. violence-related admissions from the trauma unit cost pth r35 410 241.85 in the last 6 months of 2017. an underestimated 20.08% of this expenditure was attributable to imaging investigations. although we, as radiologists, can’t prevent violence at ground level, the services we provide constitute a significant portion of violence-related healthcare cost. in south africa, with regular budget shortages, a recently announced technical recession and the anticipated implementation of national health insurance, the need for cost-saving strategies is becoming ever more important. acknowledgements the authors would like to thank cornel van rooyen from the department of biostatistics, university of the free state, for his assistance in the statistical analysis of the data, as well as geranda opperman for her assistance in ensuring the data integrity of the initial database. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution f.a.g. and t.p.s. conceptualised and designed the study, conducted the preliminary literature review and obtained ethical clearance from the relevant ethical committees. data capturing and preliminary processing of data was performed by t.p.s. the university of the free state’s department of biostatistics assisted with the statistical analysis of the data. cost calculations were performed by t.p.s. the article was drafted by t.p.s. after which input and final approval was obtained from f.a.g. references donson ha. profile of fatal injuries in south africa: 10th annual report of the national injury mortality surveillance system (nimss) [homepage on the internet]. cape town; 2008[cited 2018 jan 07]. available from: http://www.mrc.ac.za/crime/nimss2008.pdf south african police service. 2017/2018 annual crime statistics [homepage on the internet]. 2018 [cited 2018 sep 12]. available from: https://www.saps.gov.za/services/crimestats.php kruger j, butchart a, seedat m, gilchrist a. a public health approach to violence in south africa. in: bornman e, van eeden r, wentzel m, editors. violence in south africa: a variety of perspectives. pretoria: human sciences research council, 1998; p. 399–404. krug eg, mercy ja, dahlberg ll, zwi ab. the world report on violence and health. lancet [serial online]. 2002[cited 2017 dec 27];360(9339):1083–1088. available from: http://www.ncbi.nlm.nih.gov/pubmed/15298158 repetti rl, taylor se, seeman te. risky families: family social environments and the mental and physical health of offspring. psychol bull [serial online]. 2002;128(2):330–366. available from: http://www.scopus.com.ep.fjernadgang.kb.dk/record/display.uri?eid=2-s2.0-0036517498&origin=resultslist&sort=cp-f&src=s&st1=aggression+and+infants&nlo=&nlr=&nls=&sid=a95495d3c50fb9ffc907b9b9b6c580fb.53bsou7mi7a1nsy7fpjf1g:10&sot=b&sdt=b&sl=37&s=title-abs patel dm, taylor rm, editors. social and economic costs of violence: workshop summary [homepage on the internet]. social and economic costs of violence: workshop summary. national academies press; 2012 [cited 2017 dec 27]; p. 177. available from: http://ovidsp.ovid.com/ovidweb.cgi?t=js&page=reference&d=psyc9&news=n&an=2012-22012-000 foster em, jones d. can a costly intervention be cost-effective?. arch gen psychiatry [serial online]. 2006 [cited 2018 may 28];63(11):1284. available from: http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.63.11.1284 kpmg human and social services. too costly to ignore – the economic impact of gender-based violence in south africa [homepage on the internet]. johannesburg; 2016 [cited 2018 jan 13]. available from: https://assets.kpmg.com/content/dam/kpmg/za/pdf/2017/01/za-too-costly-to-ignore.pdf stats sa. financial statistics of provincial government 2015/2016 [homepage on the internet]. pretoria; 2017 [cited 2018 jan 10]. available from: http://www.statssa.gov.za/publications/p9121/p9121.pdf statistics south africa. general household survey: 2016 [homepage on the internet]. pretoria; 2016 [cited 2018 jun 10]. available from: https://www.statssa.gov.za/publications/p0318/p03182016.pdf statistics south africa. public healthcare: how much per person? [homepage on the internet]. stats sa, 2017 [cited 2018 jun 10]; p. 1. available from: http://www.statssa.gov.za/?p=10548 world health organization. who | south africa [homepage on the internet]. world health organization; 2018 [cited 2018 jun 10]. available from: http://www.who.int/countries/zaf/en/ garrib a, stoops n, mckenzie a, et al. an evaluation of the district health information system in rural south africa. s afr med j. 2008;98(7):549–552. de savigny d, kasale h, mbuya c, munna g, mgalula l. tanzania essential health intervention project interventions – an overview. report no.: 1.3. dar es salaam: tanzania ministry of health; 2002. shaw v. health information system reform in south africa: developing an essential data set. bull world health organ [serial online]. 2005 [cited 2018 may 28];83:632–636. available from: https://www.scielosp.org/pdf/bwho/2005.v83n8/632-636/en rommelmann v, setel pw, hemed y, et al. cost and results of information systems for health and poverty indicators in the united republic of tanzania. bull world health organ [serial online]. 2005 [cited 2018 may 28];83:569–577. available from: https://www.scielosp.org/pdf/bwho/2005.v83n8/569-577/en competition commission south africa. report on analysis of medical schemes claims data – a focus on practitioners [homepage on the internet]. 2017 [cited 2018 jan 10]. available from: http://www.compcom.co.za/wp-content/uploads/2014/09/practitioners_report-on-analysis-of-medical-scheme-claims-data.pdf herbst k, gilbert j. uniform patient fee schedule policy [homepage on the internet]. [cited 2018 jan 6]. available from: http://www.fshealth.gov.za/portal/pls/portal/portal.wwsbr_imt_services.genericview?p_docname=3137182.ppt&p_type=doc&p_viewservice=vah&p_searchstring= chikobvu a, feldman j. an efficiency indicator tool for managing resource expenditure [homepage on the internet]. unisa; 2016[cited 2018 sep 09]. available from: http://uir.unisa.ac.za/bitstream/handle/10500/22950/a_chikobvu_78420784_dbl_thesis.pdf?sequence=1&isallowed=y references about the author(s) colin n. menezes division of infectious diseases, department of internal medicine, chris hani baragwanath academic hospital, south africa department of internal medicine, school of clinical medicine, faculty of health sciences, university of the witwatersrand, south africa citation menezes cn. the need for an active role of the clinical radiologist in the management of the hiv-infected patients. s afr j rad. 2017;21(2), a1226. https://doi.org/10.4102/sajr.v21i2.1226 editorial the need for an active role of the clinical radiologist in the management of the hiv-infected patients colin n. menezes received: 01 june 2017; accepted: 01 june 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. south africa has the highest human immunodeficiency virus (hiv) prevalence rates worldwide. hiv infection rates have risen from 10.3% of the total population in 2002 to rates as high as 12.7% in 2016. the total number of individuals living with hiv infection increased from an estimated 4.72 million in 2002 to 7.03 million in 2016.1 over time, hiv infection has become a chronic manageable disease with improved access to antiretroviral therapy in both public and private sectors, allowing individuals to live longer and lead healthy lives. acquired immunodeficiency syndrome (aids)-related deaths have dropped from 39.6% of the total population in 2006 to 27.9% in 2016.1 understanding the spectrum of complex and protean manifestations of hiv and aids-related diseases are crucial for a clinical radiologist because, despite specific cell tropism, patients may present with pathology in nearly every organ. the cd4+ mononuclear cells and activated cd4+ t lymphocytes are the main targets for this virus. when these cells become depleted, as a result of viral replication and cell death, patients develop aids.2 hiv-infected patients may present with opportunistic infections and malignancies, albeit occasionally, in an atypical or unusual manner, depending on the cd4+ t-lymphocyte count. as a consequence, making a diagnosis is often challenging and clinicians may rely on the assistance of imaging. this may result in a delay in diagnosis and patients receiving inappropriate treatment. the assistance of a clinical radiologist in the management of hiv-infected patients is of great importance. for example, a plain chest x-ray is an easy, first investigation to perform and interpret in an hiv-infected patient presenting with unexplained respiratory or constitutional symptoms. however, when a chest x-ray is normal, a chest ct scan is much better in identifying and characterising conditions such as early interstitial lung disease, lymphadenopathy and pulmonary nodules. this, however, requires the aid of a radiologist.3 a patient may present with neurological symptoms together with ct brain findings that reveal focal brain lesions. these are often difficult to interpret radiologically. in developed countries, toxoplasma encephalitis is the most common cause of focal brain lesions, followed by primary central nervous system lymphoma. in this country, tuberculosis is the most common presumed diagnosis. the microbiological diagnosis of tuberculosis from cerebrospinal fluid is often difficult. cerebral toxoplasmosis is also a common opportunistic infection and the ability to diagnose it is important because it responds well to treatment. the role of the clinical radiologist is to detect and characterise focal lesions and aid the clinician in managing their patients. ct and mri scans may be non-specific. there may be difficulty in differentiating tuberculomas, lymphomas or cerebral abscesses. an experienced radiologist who understands the clinical history can pick up subtle rim-enhancing abscess, particularly in the basal ganglia.4,5,6 radiologists depend on their ability to recognise enhancement of such lesions which usually signifies the presence of inflammation. clinicians, on the contrary, tend to use steroid therapy whilst awaiting the imaging results. clinicians need to be aware that steroids blunt the inflammatory response and may convert enhancing lesions to non-enhancing lesions, affecting the radiological diagnosis.6 with the introduction of antiretroviral therapy, an immune reconstitution inflammatory syndrome (iris) is another important complication that radiologists need to be cognisant of in the management of hiv-infected patients. some patients may develop a paradoxical worsening of their symptoms or an unmasking of symptoms after the initiation of treatment. iris is a diagnosis of exclusion. a rise in cd4 lymphocyte count and a decrease in viral load are common findings associated with iris. therefore, radiological findings need to be understood in the context of the clinical and laboratory findings, emphasising the holistic role of a radiologist in the management of hiv-infected patients.7 there is a growing need for medical practice to become increasingly interdisciplinary. in addition to working with clinicians, radiologists need to understand the clinical features, natural history and treatments of hiv infections that they are required to investigate. a high level of technical training alone is not sufficient enough to adequately contribute to the diagnosis and management of conditions in patients with hiv infection. references statistics south africa. statistical release p0302. mid-year population estimates [homepage on the internet]. 2016 [cited 2017 may 24]. available from: https://www.statssa.gov.za/publications/p0302/p03022016.pdf karris ma, smith dm. tissue-specific hiv-1 infection: why it matters. future virol. 2011;6(7):869–882. https://doi.org/10.2217/fvl.11.48 jasmer rm, gotway mb, creasman jm, webb wr, edinburgh kj, huang l. clinical and radiographic predictors of the etiology of computed tomography-diagnosed intrathoracic lymphadenopathy in hiv-infected patients. j acquir immune defic syndr. 2002;31:291. https://doi.org/10.1097/00126334-200211010-00004 modi m, mochan a, modi g. management of hiv-associated focal brain lesions in developing countries. qjm. 2004;97(7):413–421. https://doi.org/10.1093/qjmed/hch080 garg rk, sinha mk. multiple ring-enhancing lesions of the brain. j postgrad med. 2010;56:307–316. https://doi.org/10.4103/0022-3859.70939 ferracini r. primary malignant non-hodgkin’s lymphomas of the central nervous system in immunocompetent patients: diagnostic, prognostic and therapeutic criteria. pathologica. 1997;89:146. colebunders r, john l, huyst v, kambugu a, scano f, lynen l. tuberculosis immune reconstitution inflammatory syndrome in countries with limited resources. int j tuberc lung dis. 2006;10(9):946–953. case report new ct signs of alveolar cell lor tsatsi mb chb, fc rad (d) sa joozoh bse, mb bs, fmcr (rad) nigeria department of diagnostic radiology medical university of southern africa case presentation an 83-year-old female patient was referred to the medical outpatient department of ga-rankuwa hospital in march 2002 by a general practitioner. her complaint was chest pain and a productive cough with bloodstreaked white sputum of one-month duration. her past medical history appeared uneventful. she was a nonsmoker. her medication history revealed that she has been on antibiotics non-stop for more than one month. on examination her respiration was 34/min, temperature 38°c, pulse 90 beats/min and blood pressure 110/80 mmhg. there was no lymphadenopathy; however, an incidental umbilical hernia was found. an auscultation widespread agitation was found and she coughed out white frothy sputum during the examination. a provisional diagnosis of intractable pneumonia was made. acid-fast bacilli tests were negative on three consecutive occasions. a lung function test revealed a restrictive pattern. •carcinoma radiological investigations chest radiography • left lower lobe opacification (figs 1 and 2) • air bronchiograms in the left lower lobe (figs 3 and 4) • no lymphadenopathy (figs 1 4) • no signs of lobar collapse (figs 1 and2) • cardiomediastinal relationships normal. fig. 1 dense consolidation in the left lower zone with air bronchograms. ctscan one hundred millilitres of intravenous iopromide was used (300 mg, schering, berlin, germany) for contrast studies of the chest. non-contrasted studies were also performed. chest ct photographed on both lung 25 sa journal of radiology • september 2002 fig. 2 consolidation of the left upper and lower lobes. fig. 3. post-contrast axial ct showing an angiogram sign and patchy consolidation. fig. 4 axial ct showing squeezing and bending of air bronchograms. casereport and mediastinal windows demonstrated the ct angiogram sign. i attenuation of the lobe was heterogeneous.' multiple air bronchograms were seen" there was dilatation, stretching, sweeping, widening of the angle and crowding of bronchi .1 a pleural effusion was noted. discussion our patient had specific signs of bronchoalveolar consolidation which include squeezing, stretching and sweeping patent air bronchograms within the consolidated lung.' the 'crazy paving' pattern is due to thickening of the interlobular septae.' all these changes, due to unique lepidic growth of the tumour were also noted.' our patient did not have satellite lesions or bulging tissues, which increase the likelihood of bronchoalveolar carcinoma (bac). other absent signs were pseudocavitation, air fluid level in cavities and marginal enhancement. 4,5 although the ct angiogram sign was present it is also seen in pneumonia, and is therefore nonspecific." references 1. akata s, fukushima a, kakizaki d, ase k, amino s. cr scanning of bronchioalveolar carcinoma: specific appearances. lung cancer 1995; 12: 221-230. 2. irn j, han mc, yu ej, et al. lobar bronchioalveolar carcinoma: 'angiogram sign' on cr scans. radiology 1990; 176: 749-753. 3. zeuthlin n, lasser ec, rigler lg. bronchographic abnormalities in alveolar cell carcinoma of the lung. dis chest 1954; 25: 542549. 4. im j, cho bl, park jh, et al. cr findings oflobar bronchioalveolar carcinoma. j comput assist tomogr 1986; 10: 320-322. 5. manning jt jr, spjut hj, tschen ja. bronchioloalveolar carcinoma: the significance of histopathologic types. cancer 1984; 54: 525534. 6. barsky sh, grossman da, ho j, holmes ec. the multifocality of bronchioloalveolar lung carcinoma: evidence and implications of a multiclonal origin. mod patho11994; 7: 633-640. occult spinal dysraphism l d r tsatsi mb chb, fcrad d)sa department of diagnostic radiology medical university of southern africa b okoli mbbs,mmed department of neurosurgery medical university of southern africa case presentation a 2-month-old male patient presented to our outpatient's department with a diffuse back swelling. the child is the fifth in a family with no history of congenital abnormalities. the pregnancy went full term and was a normal vaginal delivery. a diffuse swelling was noted in the midline in the lumbar region. the mass was covered with normal skin, with no discolouration, hair, sinus or ulceration. it had a soft, fatty feel on palpation. there was no neurological dysfunction. plain film x-rays of the spine demonstrated spina bifida involving the whole spine with sparing of only ti2, ll, l2 and l3 (figs 1 and 2). the defects were more pronounced in the upper cervical and sacral areas. the spinous processes in the thoracic and lumbar areas were visualised though they were not fused. a ct scan reconstruction of the 26 sa journal of radiology • september 2002 fig. 1 ap spinal x-ray of the cervical and thoracic spine showing the extensive spina bifida involving both regions. whole spine demonstrated the spina bifida (figs 3 and 4). mr! findings showed a normal cord from the cervical to the sacral level. by prof z i lockhat the department of radiology at the university of pretoria is now fully equipped with state-of-the-art digital technology, and we are totally immersed in the bits and bytes of the digital world and the pacs system. against this canvas, the videoconference experience linking the university of stellenbosch, university of pretoria and university of the free state was most appropriate and suitably timed. the event was meticulously planned by our resident computer aficionados, dr a du plessis and his counterparts, dr o schulze from the university of stellenbosch and dr f potgieter of the university of the free state. it proved to be a phenomenal success. professor savvas andronikou’s lively and inimitable discussion on paediatric fluoroscopic procedures was highly informative and enlightening. a technical report has also been compiled by dr a du plessis, detailing problems encountered and suggestions put forward. the long-term ambition among the universities involved is to set up a national curriculum, to conduct regular teaching and interactive discussions. the success of this videoconference technically and educationally is a landmark at our institution and should pave the way for future multimedia transmissions and interaction among local and possibly international universities. by prof coert de vries after lots of planning, testing and checking of equipment we arrived expectantly for this occasion at the university of the free state’s teleconference room. this is a dedicated room for teleconferencing with the necessary computers and video screens, as well as 6 isdn lines for telephone link-ups. we received the powerpoint presentation a day before and downloaded it from the internet. the downloading took about 7 hours from a home computer. the powerpoint presentation was then loaded by memory stick onto the videoconference room computer. when the necessary dialogue links were made, we could see the faces of the people in cape town and pretoria, hear their voices and greet a few friends. initially there was microphone feedback, but this was remedied when microphones at the other end were switched off. only the presenter’s microphone should be switched on during the presentation. the powerpoint presentation was advanced manually on our side to correspond with the lecture. it was an excellent lecture, wellreceived and many good comments ensued afterwards. we need to be realistic and acknowledge the problems of the limited band-width of 6 isdn lines. it is difficult to send diagnostic or lecture-quality images from a powerpoint presentation across a telephone network. it requires lengthy download procedures and produces questionable quality. courier transport or even postal cd dispatch may result in quicker and better quality presentations. despite these minor reservations, it is essential that we continue with this novel and highly promising experiment in teaching radiology. by prof alan scher i was pleased to be able to be present at the first interdepartmental videoconference. that this facility is now available and functioning is due to the efforts of dr otto schulze and prof jan lotz. i was surprised at the clarity of the videolink, in that the audiences in bloemfontein and pretoria could clearly be seen and identified. as would be expected, there were the usual technical glitches, but overall the videoconference was a definite success and our two sister departments seemed to enjoy and benefit from prof savvas andronikou’s excellent presentation. i was a little surprised that at the end of the lecture, there was not all that much active questioning and comments from the departments at bloemfontein and pretoria. i think that this is because it is a novel concept for all of us, and as we become more used to videoconferencing, i am sure that the process will become more relaxed and interactive. with the dwindling number of academic radiologists in south africa, i feel that this will go a long way towards maximal utilisation of the areas of expertise present in different departments. by otto schulze, andré du plessis and francois potgieter in our experience the infrastructure to accommodate videoconferencing is established at most universities but it is normally under-utilised. all it took was some technical know-how and the vision to use it. at each of the three sites we had a radiology registrar and a technician orchestrating the test runs leading up to the videoconference. each site had a multimedia terminal which enabled them to manipulate the audiovisual signals generated locally, receive from the remote sites and transmit to the remote sites. problems we encountered during the test runs included poor-quality audiovisual signal when using a 64 kb isdn line compared to a 128 kb isdn line. secondly, there was doubt regarding the quality of x-ray images in powerpoint presentations and delay in transition because of the large size of the images. these problems were solved by moving to another site with a 128 kb isdn line at the university of the free state and by posting the powerpoint presentation on a website to be downloaded by the different universities before the videoconference and displayed independently during the lecture. problems encountered during the videoconference included an audio feedback loop which distorted the presenter’s audio signal. this was solved by asking all the universities to turn off their microphones during the presentation and only to turn them on again when they wanted to ask a question. after the videoconference, suggestions were made that we should re-evaluate the viability of transferring the powerpoint presentations via the videoconference. secondly, that we include the presenter’s face as a ‘picture-within-a-picture’ embedded in the powerpoint presentation. thirdly, that we videoconferencing: university of pretoria, university of stellenbosch and university of the free state contributors: z i lockhat, c de vries, a scher, o schulze, a du plessis, f potgieter, j lotz impression of the first interdepartmental video conference 29 sa journal of radiology • june 2006 the bloemfontein experience of the telelecture on paediatric radiology interuniversity videoconference: the technical solutions and challenge pg29-30.indd 29 7/11/06 12:52:40 pm 30 sa journal of radiology • june 2006 should change the display to voice-activated, so that the video signal reflects the person talking, i.e. the presenter or the person asking a question. despite these minor problems, i believe that we have made the first steps into a new era of education, which appears to be very promising. it is a given that as we do more videoconferencing sessions we will only improve with experience. by jan lotz technically and financially the linking of radiology departments in south africa has proven a viable exercise. a 4-year modular course in theoretical radiology has been developed over a number of years. the course was successfully implemented, with the blessing of prof coert de vries, at the university of the free state. registrars of this university are now in their third year of the mammoth task of recording each module, with illustrations on computer disc. is there a need and will the time come when interested south african universities will join with their fellow registrars in using a modular south africa curriculum for the fcrad and mmed qualifications? technically this has now become possible and academically the modules prove to be of the highest standard. interested parties are welcome to contact us, and if all goes well, we hope to start a synchronised national course in the near future. 1. registrars of the university of the free state. the quality of existing modules is excellent and stands as a tribute to the endeavours of motivated young people. we now need to improve and expand with our colleagues in the rest of the country 2. otto schulze, andré du plessis and francois potgieter for keeping the technical initiative together and afloat. they were assisted by other individuals, too many to thank individually. 3. imaging benefit company the imaging benefit company (sec 21) is a registered non-profit organization established to further the education and training of radiologists in south and southern africa. the company is funded entirely from contributions from private radiology practices and industry: drs schnetler corbett and partners inc, drs scribante and partners inc, drs cronje and partners inc, medical imaging (windhoek). the future acknowledgements new essential reading for all gps systemic disease and the kidney a handbook for clinicians in this book, author professor roal van zyl-smit, shares his vast knowledge of the kidney, and its associated complexities, gained during his many years as a nephrologist and general physician. systemic disease and the kidney offers gps a practical guide to renal problems encountered in general medical practice. the single author text maintains a consistent level of complexity throughout the book and provides a quick and easy to understand reference to renal complications in patients suffering from conditions such as: • diabetes mellitus • hypertension and renovascular disease • collagen vascular diseases • myeloma and amyloidosis • tuberculosis and aids • genetically determined kidney disease in addition it provides an approach to situations such as: • the clinical assessment of the patient with kidney disease • fluid and electrolyte and acid base disorders • acute and chronic renal failure • glomerulonephritis and interstitial nephritis • urinary tract infections and renal stone disease. • lipid disorders encountered in patients with renal disease • an approach to dialysis and transplantation. clinicians will value the book for its practical clinical information as it demystifies the perception that renal disease is ‘difficult’. systemic disease and the kidney – a handbook for clinicians – is available only through the sama – hmpg bookshop, where sama members enjoy special discounts on all purchases. to order: tel: (021) 530 6520 / 6551 • fax: (021) 531 4126 / 3359 • e-mail: books@samedical.org sama member price: r 269,00 non-members: r 289,00 all prices include vat and postage new essential reading for all gps systemic disease and the kidney a handbook for clinicians in this book, author professor roal van zyl-smit, shares his vast knowledge of the kidney, and its associated complexities, gained during his many years as a nephrologist and general physician. systemic disease and the kidney offers gps a practical guide to renal problems encountered in general medical practice. the single author text maintains a consistent level of complexity throughout the book and provides a quick and easy to understand reference to renal complications in patients suffering from conditions such as: • diabetes mellitus • hypertension and renovascular disease • collagen vascular diseases • myeloma and amyloidosis • tuberculosis and aids • genetically determined kidney disease in addition it provides an approach to situations such as: • the clinical assessment of the patient with kidney disease • fluid and electrolyte and acid base disorders • acute and chronic renal failure • glomerulonephritis and interstitial nephritis • urinary tract infections and renal stone disease. • lipid disorders encountered in patients with renal disease • an approach to dialysis and transplantation. clinicians will value the book for its practical clinical information as it demystifies the perception that renal disease is ‘difficult’. systemic disease and the kidney – a handbook for clinicians – is available only through the sama – hmpg bookshop, where sama members enjoy special discounts on all purchases. to order: tel: (021) 530 6520 / 6551 • fax: (021) 531 4126 / 3359 • e-mail: books@samedical.org sama member price: r 269,00 non-members: r 289,00 all prices include vat and postage pg29-30.indd 30 7/11/06 12:54:01 pm original article incidental diagnosis of a gastric mass on chest radiographs w f c van gelderen fcrad(d) sa department of radiology, masterton hospital, masterton, new zealand abstract careful inspection of the infradiaphragmatic area on chest radiographs may lead to diagnosis of different conditions such as gastric fundal masses, sub-diaphragmatic free air, subphrenic abscess, bowel obstruction, etc. case histories are presented for 4 patients in whom the diagnosis of a gastric tumour was made on chest x-ray. the importance of including the infradiaphragmatic area as a review area of the chest x-ray is emphasised. introduction traditional review areas on chest radiographs (important areas that should be reviewed after a systematic examination of the radiographs) include the lung apices, the hilar regions, the retrocardiac area and the costophrenic angles. i the infradiaphragmatic area is not a classical review area, but can easily be added to the last-named review area as many important entities may be identified. conditions include subdiaphragmatic free air, bowel obstruction, hepatic or splenic calcification, signs of previous surgery, subphrenic abscess and abnormality of the gastric air bubble. over a 20-year period 4 cases of a mass in the cardia of the stomach were incidentally detected on chest radiographs by the author. case reports casel a 59-year-old man scheduled for eye surgery was referred for preoperative chest radiographs (fig. la). these revealed signs of chronic obstructive airways disease, a segmental atelectasis in the left lower lobe and an oblong air loculus projecting beyond the left tracheal border. (the latter was due to a localised traction diverticulum, well demonstrated on subsequent barium swallow, and secondary to previous tuberculosis in the left upper lobe). a 5.5 x 4.0 cm rounded mass was identified in the gastric cardia, convex to lateral and extending into the gas shadow of the gastric fundus. the mass was noted to be well-defined, homogeneous, and apparently entirely intragastric on barium examination (fig. lb). the radiological diagnosis of a leiomyoma was confirmed by biopsy. case2 a 61-year-old woman, a known 30 sa journal of radiology. august 2003 fig. 1a. case 1. frontal chest radiograph demonstrates signs of chronic obstructive airways disease, left basal segmental atelectasis (retrocardiac), an air loculus projecting beyond the border of the left side of the trachea due to an oesophageal traction diverticulum (small arrows). and a gastric mass arising from the cardia of the stomach (arrow). fig. 1b. case 1. barium meal confirms mass (leiomyoma) (arrowheads) arising from the cardia of the stomach. asthmatic, presented with acute dyspnoea and cough and a clinical diagnosis of pneumonia was favoured. a frontal chest radiograph revealed a large right-sided pneumothorax, which was treated with an intercostal drainage tube. once the right lung had re-expanded underlying tuberculous infiltration was identified (fig. 2) and active tuberculosis was confirmed clinically. the tuberculosis was treated effectively,and chest films taken 6 original article fig. 2. case 2. frontal chest x-ray shows signs of active tuberculous disease in the right upper lobe and a small rounded mass within the cardia of the stomach (arrow) (unconfirmed leiomyoma). months later only demonstrated some residual fibrotic scarring. a 2.7 x 2.7 cm mass, quite obvious as it was well outlined by air, was noted on all the chest radiographs within the gastric cardia. reviewing the x-rays, a barium study performed 4 years previously was discovered in another x-ray packet and demonstrated the mass to be the same size as the mass on chest radiographs 4 years later. the surgeon opted for a conservative approach, and the radiological diagnosis of a leiomyoma was not confirmed. case3 a 55-year-old woman with known chronic obstructive airways disease was referred for chest radiographs. in addition to the airways disease, a large rounded mass convex to anterior, with a semilunar gas shadow within the stomach in front of it, was demonstrated on the left lateral film (fig. 3a). the frontal film did not reveal the mass and little gas was seen in the stomach. a barium meal was recommended and 4 days later the patient fig. 3a. case 3. lateral chest radiography demonstrates an apparent mass in the stomach protruding convex to anterior (arrows) with a semilunar gastric air shadow anteriorly. fig. 3b. case 3. lateral barium meal film confirms a lobulated mass in the cardia of the stomach (but found to be irregular in outline on other views suggestive of a malignant lesion) and confirmed to be due to a carcinoma. presented with the request form making mention of peptic ulcer syinptoms, profound anaemia and occult blood in the stool. the barium meal (fig. 3b) confirmed the 6.0 x 5.5 cm mass, which was lobulated and thought to be due to a leiomyoma or a carcinoma. gastroscopy demon31 sa journal of radiology. august 2003 strated a polypoid mass with a malignant appearance, confirmed on histology. case4 a 72-year-old woman was referred for a preoperative chest x-ray which demonstrated an apparently incidental3.0 x 2.7 cm mass in the gastric cardia (fig. 4a). previous films were obtained at a later stage and it became evident that a gastric carcinoma had already been diagnosed by endoscopy and abdominal computed tomography (ct) (fig.4b). the patient had presented with loss of weight, fig. 4a. case 4. frontal chest radiography demonstrates a small looulated mass (arrow) situated in the cardia of the stomach protruding into the gastric air bubble convex to lateral. fig. 4b. case 4. axial ct section shows a small mass in the cardia of the stomach (arrows) without extragastric involvement or lymphadenopathy and due to a well-differentiated adenocarcinoma. original article anaemia and a central abdominal mass. ct had demonstrated the mass in the gastric cardia without extragastric extension or lymphadenopathy. a well-differentiated adenocarcinoma was surgically resected. discussion gas was noted to be present in the stomach in 500 of 700 normal chest radiographs.' absence of gas in the stomach may occur associated with oesophageal disease, e.g. carcinoma or achalasia. the gas shadow of the gastric fundus may be indented by a normal left lobe of the liver on its medial aspect or the spleen on its lateral aspect.' an adjacent mass, such as a subphrenic abscess, may also indent the stomach, but other signs such as a left pleural effusion would usually be associated with a subphrenic abscess. apart from an extrinsic impression, an intraluminal mass such as a food bolus or bezoar should be considered. previous surgery for hiatus hernia (fundoplication) can also deform the gastric fundus and simulate a mass: gastric varices and an inverted hiatus hernia can likewise cause a 'mass' in the cardia of the stomach. having excluded an intraluminal mass and an extrinsic impression, the third possibility that should always be excluded relating to any tubular structure, is disease arising from the wall. inthe above case studies, a leiomyoma (often ovoid or rounded with a welldefined outline) or a carcinoma (often less rounded, often lobulated and/or ill-defined polypoid) was responsible in each case. in the cases diagnosed incidentally, the mass within the stomach was rounded, of soft tissue density and clearly outlined by air for at least half of its circumference. in all these instances, however, the mass could have been easily overlooked if the infradiaphragmatic area had not been included as one of the review areas. references 1. pierce]w, graigner rg. the normal chest: techniques. in: sutton d, ed. a textbook of radiology and imaging. 3rd ed. edinburgh: churchill livingstone, 1980: 260. 2. felson b. a review of over 30 000 normal chest roentgenograms. in: felson b, ed. chest roentgenology. philadelphia: wb saunders, 1973: 498-499. 3. chapman ah. the stomach and duodenum. in: sutton d, ed. a textbook of radiology and imaging. 6th ed. edinburgh: churchill livingstone, 1998: 831-832. 4. berk rn. the postoperative stomach. in: tepliek jg, haskin me, eds. surgical radiology. philadelphia: wb saunders, 1981: 490. 32 sa journal of radiology • august 2003 pictorial interlude an unusual renal cyst ralph drosten c f g diedericks* a j van n iekerk* department of thoracic imaging brigham and women's hospital boston, usa 'prinsloo, aitken & partners union hospital alberton case presentation a 35-year-old man presented to hls doctor complaining of nonspecific abdominal pain. his clinical examination and laboratory testing were entirely normal. the supine abdominal x-ray (fig. 1) demonstrated an ill-defined focus of amorphous calcification overlying the left renal lower pole. the erect abdominal film (fig. 2) demonstrated a fluid/calcium level overlying the left renal lower pole. ultrasound examination demonstrated a 22 x 25 mm well-defined cyst, with acoustic shadowing, in the left renal lower pole cortex. fig 1. supine radiograph showing an ill-defined radio-opaque calcific focus overlying the left renal lower po/e. these findings are consistent with the diagnosis of milk of calcium cyst. discussion review of the major radiological textbooks reveals little reference to this entity in relation to the kidney. milk of calcium stones are tiny calculi that are too small to be visualised radiographically as discrete entities, and appear as milky opacities that layer out dependently on upright or decubitis views.' fig. 2. erect radiograph showing dependent layering of calcium in the left renal/ower pote. similar cysts may be found in the breast.' the aetiology of this configuration is unclear and may be secondary to previous infection or haemorrhage/ or stasis. the differential diagnosis includes residual pantopaque used in cyst puncture' rarely performed today. references i. sutton d, young jwr. a concise textbook of clinical imaging. 2nd ed. mosby, 1995: 653. 2. granger rg, allison dj. diagnostic radiology. edinburgh: churchill livingstone, 1997: 1377, 2005,2011. 3. dahnert w. radiology review manual. 3rd ed. baltimore: williams and wilkins, 1996: 644. 50 sa journal of radiology • march 2002 review article • • ••minimising radiation dose using pulsed digital fluoroscopy in the investigation of children savvas andronikou mb bch, fc rad (sa), frcr (lond) marisa mezzabotta mbbch department of paediatric radiology red cross children's hospital school of child and adolescent health university of cape town abstract pulsed fluoroscopy is considered a requisite for paediatric fluoroscopy. the goal of paediatric fluoroscopic studies is to produce interpretable images (to answer a specific question) at the lowest possible radiation exposure. digital pulsed fluoroscopy has the advantage of reducing patient dose while yielding diagnostic images. the radiologist is responsible for choosing the appropriate pulse setting and deciding between storing the image as a 'picture-grab' or a true 'spot-film'. we present a simple description of this technology highlighting the advantages and disadvantages. we also describe in detail our recommended protocol for performing a micturating cystourethrogram and a barium swallow/meal in children. introduction in children, fluoroscopy is most frequently used in the investigation of urinary tract infection! (micturating cystourethrography (meug)) and in screening those children suspected of gastro-oesophageal reflux (barium swallow/meal). paediatric radiology is especially concerned with minimising radiation dose because of the higher risk of radiogenic cancers in children due to medical irradiation." the goal of fluoroscopic studies is to produce interpretable images at the lowest possible radiation exposure and dosage to the patient." aim to describe the advantages of pulsed digital fluoroscopy and to present our recommendations for its use in imaging urinary tract infection and gastro-oesophageal reflux in children with respect to minimising radiation dose. 34 sa journal of radiology. february 2003 discussion most modern fluoroscopic systems use digital technology (as opposed to analogue). these systems digitise the image offering the advantages of image enhancement (post processing) after the image has been stored, and result in a reduction of radiation dose.' images can be stored as 'picture-grabs: 'cine-loops' or 'spot films'. a 'picture-grab' is a stored image of a single fluoroscopic frame at fluoroscopic doses. diagnostic information is, however, not lost in the imaging of uti in children.' a 'cineloop' is a stored series of flouoroscopic frames that can be replayed in rapid sequence, much like a video clip, once again at fluoroscopic doses. a spot film is a radiographic film/screen quality digital image. film quality is significantly improved compared with 'picture-grabs' or 'cine-loops: but there is added radiation exposure," modern fluoroscopy systems also offer two modes of fluoroscopy. either the x-ray beam is continuous or the x-ray beam is emitted for a few strobe-like x-ray pulses each second. pulsing the x-ray beam can reduce radiation exposure to both patients and radiology staff," dose is reduced by simply decreasing the fraction of time that the x-ray beam is emitted. a range of pulsing is offered, from 3 pulses per second (pps) to 30 pps, while the choice of continuous fluoroscopy is also available.when using a 7.5 pps rate, the radiation exposure from fluoroscopy is approximately 75% lower than that from conventional fluoroscopy;' it is therefore up to the operator to choose whether to use pulsed fluoroscopy and what rate of pulsing to use in each individual case. review article other than radiation saving, pulsed fluoroscopy offers the advantage of better temporal resolution of moving objects.' each image of the moving object is sharper than with continuous fluoroscopy because the object is relatively still during each short pulse of xsrays." the disadvantage of pulsed fluoroscopy is that the fewer frames result in the perception of increased noise because the eye averages fewer independent frames,' as well as image animation (jumpiness)." the lower the pulse rate, the higher the perceived image noise.' the percentage of noise at 7.5 pps is twice that at 30 pps. actual image quality is perceived to be noisiest but acceptable at 7.5 pps.' most paediatric fluoroscopic investigations are performed as single contrast techniques with the aim of answering a specific question. in the investigation of uti, the primary objectives are to rule out posterior urethral valves (in males) and to exclude vesico-ureteric reflux. during a barium swallow/meal the radiologist aims to exclude impressions on the oesophagus, malrotation and gastrooesophageal reflux. the radiologist and clinician must then accept that noisier images can yield the same diagnostic information as conventional images even though quality may be decreased.' this is a psychological barrier and radiologist acceptance oflow-radiation images is a vital factor in pulsed fluoroscopy.' the following paragraphs and images describe our recommended method of performing micturating cysto-urethrography and barium swallow/meal at the red cross children's hospital. the protocols include the ideal choice of pulsing, the required views and the recommended method of image storage ('grab' versus 'spot film'). the aim is to store adequate diagnostic information at the lowest radiation dose possible. remember only to screen intermittently and to collimate tightly! collimation can be achieved without radiation by using the positioning light. we begin fluoroscopy using 7.5 pps and this is changed when necessary. meug 1. after catheterising the patient maintain the right side down oblique position throughout the procedure. no preliminary film is necessary;" begin to fill the bladder and 'grab' the bladder-filling image. this is intended to confirm the position of the catheter and assess for early vesico-ureteric reflux (fig. i). the meug: maximum 4lmeges; fwo 'picturegrabs' and fwo 'spot-films' fig. 1. mcug bladder filling: this oblique 'picturegrab' demonstrates the correct placement of the catheter by showing contrast fijiingof the bladder. the position is kept oblique in readiness for the voiding phase. 2. continue intermittent fluoroscopy until the patient begins to void and perform a 'spot-film' while the patient voids with or without the catheter in situ (valves can be diagnosed with the catheter in) (fig. 2).10 ensure that the back of the bladder is visible so that any vesico-ureteric 35 sajournal of radiology. february2003 figs 2a, b and c. voiding image: 2a. 'spot-film' in the oblique position demonstrates a normal urethra in a male. 2b. by including the posterior portion of the bladder, this 'spot-film' in the obi/que position demonstrates grade 1 vesicoureteric reflux during the voiding phase (arrow). performing the contralateral oblique image is not recommended as the voiding phase may be missed, which is impoltant for documenting urethral anatomy and is also the time when reflux is most likely ro occur. minimal contralateral reflux may be missed, however this would not be considered significant. 2c. voidingphase of an mcug recorded using a 'picture-grab'is of lower quality but is adequate for diagnostic information. review article fig. 3. renal area: a 'spot-film' of the renal area is recommended after the voiding film to exclude contrast w/1hin the calyces. a 'picture-grab' may not provide enough detail to distinguish contrast in the calyces from other normal structures. reflux will be recorded and ensure that the tip of the penis is shown to exclude diverticula and anterior urethral valves. optionally this could be a 'picture-grabimage." 3. when voiding is complete, perform a tightly collimated renal 'spotfi.lm'. detail is required for this image to identify contrast in the calyces and therefore a'spot-film' is recommended, but not obligatory (fig. 3).4 4. screen over the bladder, and if residual urine is present in the bladder, record this using a 'picture-grab' in the ap position. avoid unnecessary spot films of the pelvic area for this purpose. barium swallow/meal 1. the child is placed in the left true lateral position and is fed barium via bottle, syringe or straw. the fullcolumn oesophagus is viewed in the true lateral position and a full-length image is stored as a 'picture-grab: which is adequate for evaluating the gastrointestinal tract (fig. 4).8 this allows exclusion of vascular impressions on the oesophagus. 2. the patient is then turned to the right true lateral position with tight collimation of the stomach and duodenal region. an image of early duothe barium swallow/meal: maximum 4 images; al/ 'picture-grabs' figs 4a and b. 'picture-grab' of the lateral oesophagus: 4a. true lateral 'picture-grab' of the oesophagus with a full column of barium demonstrates the normal impressions on the anterior aspect (arrows). 4b. lateral 'picture-grab' demonstrates the aspirated contrast in the trachea adequately in this child with incoordinated swallowing. fig. 5. lateral stomach and duodenum: a 'picturegrab' of the stomach and duodenum in the right side down lateral position demonstrates the normal retroperitoneal course of the duodenum for exclusion of malrotation. denal filling is 'grabbed' (fig. 5). this true lateral image gives information that the duodenum is oriented posteriorly, to exclude malrotation. 3. rapidly turn the patient to the ap position and collimate tightly to the stomach and duodenal c-ioop. include the base of the heart and make sure the spine is truly ap.a 'picture-grab' of a full c-ioop is then 36 sa journal of radiology • february 2003 fig. 6. duodenal c-tooo: a 'picture-grab' of the contrast-filled duodenal c-tooo in the ap position is mandatory for exclusion of malrotation in every patient undergoing a barium swallow/meal, whatever the indication. fig. 7. gastro-oesophageal reflux: if gastrooesophageal reflux is present, a 'picture-grab' is adequate for recording this, as in this patient with contrast refluxing to the level of the hypopharynx. review article stored (fig. 6). try to avoid contrast beyond the 4th part of the duodenum as this compromises your ability to confirm its position and therefore your ability to exclude malrotation. 4. the patient may now be given more oral contrast in the left lateral position to fill the stomach. in the ap position, the patient is screened intermittently for gastro-oesophageal reflux over 3 minutes (not 3 minutes of screening). if reflux is seen, then the image is stored as a 'picture-grab' (fig. 7). reminders remember that fluoroscopic doses (when used intermittently? are far lower than fluoroscopy plus 'spotfilm' doses and that 'picture-grabs' are stored images of fluoroscopy. reserve 'spot-films' for those situations when detail is required. if a pathologic abnormality is identified, further views may be warranted at higher fluoroscopic pulse rates, with the use of continuous fluoroscopy or with the use of 'spot-films: available at the touch of a button. also keep in mind that tight collimation reduces radiation and that a good paediatric radiologist keeps his foot on the fluoroscopy pedal for only a few seconds at a time. conclusion digital systems have allowed us the opportunity to improve an image after it has been stored. the need for repeat images has been reduced using this. with cine loop technology, the radiologist also has the advantage of screening a full swallow or bladder void and then selecting the 'picturegrab' image from the series in retrospect. if we as radiologists get through the psychological barrier of 'ugly' images, we can certainly reduce the dose to our patients. currently, all male children with uti undergo mcug, but the trend with females is to perform lower dose scintigraphic studies. monitoring ph and scintigraphic studies are probably more successful alternatives for investigating gastro-oesophageal reflux in children but offer little anatomic information. fluoroscopy in children is still being performed extensively throughout the world with a relatively low pick-up of pathology. it is our duty to use our equipment and modify our techniques to reduce radiation exposure. pulsed fluoroscopy is considered a requisite for optimal paediatric fluoroscopy,' references i. wilkinson ag, mc cafferty g. pressure-assisted micturating cystourethrography: reduction in duration of procedure and fluoroscopy time. pediatr radio/2002; 32: 783-786. 2. brown ph, thomas rd, silbeberg pj, johnson lm. optimization of a fluoroscope to reduce radiation exposure in pediatric imaging. pediatr radio/2000; 30: 229-235. 3. wessenberg rl, amundson gm. fluoroscopy in children: low exposure technology. radiology 1984; 153: 243-247. 4. bazopoulos ev,prassopoulos pk, damilakis je, raissaki mt, megremis sd, gourtsoyiannis nc. a comparison between digital fluoroscopic hard copies and 105 mm spot films in evaluating vesicoureteric reflux in children. pediatr radio/1998; 28: 162-166. 5. gleijins j, broerse jj, chandie shaw mp, et al. a comparison of patient dose for examinations of the upper gastrointestinal tract at il conventional and digital x-ray units in the netherlands. br j radio/1998; 71: 745-753. 6. brown ph, silbeberg pj, thomas rd, strife jl, towbin rb. a multihospital survey of radiation exposure and image quality in pediatric fluoroscopy. pediair radio/20od; 30: 236-242. 7. mahesh m. fluoroscopy: patient radiation exposure issues. radiographies 2001; 21: 10331045. 8. hernandez rj, goodsitt mm. reduction of radiation dose in pediatric patients using pulsed fluoroscopy. air 1996; 167: 1247-1253. 9. ditchfield mr, de campo je is the preliminary film necessary prior to micturating cystourethrography in children? abdom imaging 1993; 18(2): 191-192. lo. ditchfield mr, grattan-smith jd, de campo jf,hutson jm. vcv in boys: does the presence of the catheter obscure the diagnosis of posterior urethral valves? air 1995; 164: 1233-1235. 37 sa journal of radiology • february 2003 abstract introduction case report discussion conclusion acknowledgements references about the author(s) venkatram krishnan department of radiodiagnosis, safdarjung hospital, delhi, india sunil k. bajaj department of radiodiagnosis, safdarjung hospital, delhi, india abhilash sethy department of radiodiagnosis, safdarjung hospital, delhi, india neetika gupta department of radiodiagnosis, safdarjung hospital, delhi, india citation krishnan v, bajaj sk, sethy a, gupta n. atypical exophytic liver mass: giant pedunculated hepatic haemangioma masquerading as a gastrointestinal stromal tumour of the gastric wall. s afr j rad. 2019;23(1), a1697. https://doi.org/10.4102/sajr.v23i1.1697 case report atypical exophytic liver mass: giant pedunculated hepatic haemangioma masquerading as a gastrointestinal stromal tumour of the gastric wall venkatram krishnan, sunil k. bajaj, abhilash sethy, neetika gupta received: 04 dec. 2018; accepted: 20 jan. 2019; published: 18 mar. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract haemangioma is the most common benign tumour of the liver. however, an exophytic hepatic haemangioma, especially the pedunculated form, is very rare. giant pedunculated haemangiomas are prone to complications because of the narrow size of the pedicle. a large number of lesions can potentially present as exophytic liver masses, and accurate diagnosis can sometimes be challenging. we report a case of an incidentally discovered asymptomatic giant pedunculated liver haemangioma in the region of the lesser sac in a prospective renal donor, which was initially suspected to be a gastrointestinal stromal tumour of the stomach wall. multiphasic computed tomography and confirmatory magnetic resonance imaging scans ultimately revealed the true nature of the lesion, which turned out to be an exophytic pedunculated hepatic haemangioma from the left lobe of the liver. the lesion was then surgically resected and histopathologically confirmed to be a haemangioma. the patient subsequently underwent successful renal donation as planned. being a benign lesion with characteristic imaging features, accurate radiological diagnosis is absolutely essential for the appropriate management of such atypical haemangiomas. introduction haemangioma is the most common benign tumour of the liver. the prevalence is about 0.4% – 20% in necropsies. haemangiomas are usually solitary, occur more commonly in women and are usually found in the posterior segments of the right lobe of the liver. in most cases, they are small and asymptomatic and found incidentally on imaging studies.1 some disagreement exists on the size criteria, but generally haemangiomas >10 cm are considered giant haemangiomas.2,3 giant haemangiomas can be symptomatic secondary to mass effect on the abdominal viscera and surrounding structures. exophytic hepatic haemangiomas, especially the pedunculated forms, are very rare; only a few cases of these have been reported in literature.2,3 in almost half of the reported cases, pedunculated haemangiomas were found to be symptomatic at diagnosis.1 giant pedunculated haemangiomas are even more likely to be symptomatic and are usually diagnosed because of complications secondary to the size of the lesion and its narrow pedicle. asymptomatic cases frequently put forth a challenge in the radiological diagnosis because of difficulty in defining the origin of the mass, as the thin pedicle may sometimes be radiologically undetectable.1 here we present a case of a middle-aged female patient who was being evaluated with multidetector computed tomography (mdct) renal angiography as a prospective renal donor. a giant pedunculated haemangioma from the left liver lobe was incidentally discovered and thought to be a gastrointestinal stromal tumour (gist) from the gastric wall. this lesion presented a diagnostic dilemma. case report a 51-year-old healthy asymptomatic female underwent mdct renal angiography as a prospective renal donor. a large, well-defined, heterogeneously hypoattenuating mass lesion, 11.20 cm in the largest dimension, was incidentally discovered in the region of the lesser sac on the non-contrast computed tomography scan (ncct). the origin of the lesion could not be delineated on a non-contrast scan, as it did not show a definite claw sign with any of the intra-abdominal organs. it was seen to abut and scallop the left lobe of the liver medially and abut the lesser curvature of the stomach posterolaterally; however, there was no obvious infiltration of the lesion into any of the adjacent organs. no significant regional lymphadenopathy or ascites could be identified. with an initial suspicion of a gist arising from the stomach wall, mdct renal angiography was performed in the arterial, portovenous and delayed (5 min) phases, with inclusion of the entire lesion in the scan plane. the lesion in question showed patchy peripheral post-contrast enhancement in the arterial phase matching the aortic attenuation, predominantly in the superomedial juxtahepatic region of the mass. progressive filling in of the mass with contrast was noted in the venous and delayed phases with a few non-enhancing areas within it (figure 1). on multiplanar reconstructions, the relationship of the mass to the adjacent organs was assessed and no definite claw sign was observed with any of them (figure 2). on close inspection, a few definite arterial vascular channels were identified from the left lobe of the liver passing into the mass through a sliver of tissue (pedicle) and supplying the mass in its uppermost part just subjacent to the diaphragm (figure 3). figure 1: non-contrast computed tomography scan (a) showing a mass lesion which appears separated from the liver and is causing scalloping of the left lobe, closely abutting the lesser curvature of the stomach and appearing inseparable from it. post-contrast arterial phase (b) shows patchy peripheral enhancement adjacent to the left lobe of the liver (arrow). portovenous (c) and delayed (d) phases show progressive filling in of the lesion with contrast (arrows). the pattern of enhancement is suggestive of a haemangioma. figure 2: (a) coronal reformat image shows the mass scalloping of the left lobe of the liver. (b) sagittal reformat image shows the mass abutting a wide region of the lesser curvature of the stomach and appearing inseparable from it. however, close inspection shows a sliver of tissue (arrow) extending between the left lobe of the liver and the mass. figure 3: arterial phase thin section reconstructions of the upper part of the mass (a) and (b) show a tortuous vessel with arterial flow within (arrow) passing from the left lobe of the liver into the mass through a thin sliver of tissue (pedicle). the adjoining part of the liver parenchyma also shows abnormal enhancement in the arterial phase. the vessel can be traced back to the left branch of the hepatic artery in successive images (c) and (d) (arrows). on account of the importance of an accurate diagnosis in this patient in view of clearance for a renal transplant, magnetic resonance imaging (mri) was performed in order to confirm the diagnosis. the mass appeared hypointense on t1 with a cleft-like area of lower signal intensity within and diffusely hyperintense on t2/t2 spair (spectral presaturation attenuated inversion recovery sequence: fat saturation sequence) (light bulb sign) with a cleft-like area of markedly higher signal intensity within. further, dynamic contrast-enhanced mri was performed which showed a similar pattern of enhancement in the arterial, portovenous and delayed phases as seen on mdct angiography (figure 4). the central cleft-like region did not show any enhancement. figure 4: t1w image (a) reveals the mass to be hypointense with a cleft-like area of lower signal intensity within. the mass is brightly hyperintense on t2w (b) and spair (c) suggestive of a light bulb sign with a cleft-like area of marked high signal intensity within signifying a hepatic haemangioma. post-contrast scan (d) shows patchy peripheral enhancement. dynamic contrast-enhanced scan (not shown) revealed centripetal enhancement with contrast from the arterial through the delayed phases. ultrasound doppler scan was performed in order to further correlate the findings and confirm the flow pattern within the vessels. the bridging vessels between the liver and the mass were identified, with detectable arterial flow within them (figure 5). a final diagnosis of an incidental asymptomatic giant pedunculated haemangioma of the left lobe of the liver with a thin vascular pedicle was made based on the imaging findings. figure 5: grayscale ultrasound (a) shows the mass lesion scalloping the left lobe of the liver. doppler examination (b) shows increased vascularity in the left lobe of the liver adjacent to the lesion with a tortuous bridging vessel (c) passing through a sliver of tissue from the left lobe to the mass (arrow). doppler waveform (d) from the bridging vessel shows arterial flow. the patient proceeded to surgery for removal of the haemangioma prior to renal donation, and histopathological examination of the mass confirmed the diagnosis of cavernous haemangioma (figure 6). the patient subsequently received clearance for renal donation and underwent successful renal donation as planned. figure 6: post-operative histopathological slides of the mass with haematoxylin and eosin staining (a) and (b) show large, blood-filled cavernous vascular spaces separated by connective tissue stroma typical of cavernous haemangioma. discussion hepatic haemangioma has a female predominance and may occur at any age, but more frequently occurs in the 30–50 years age group, with the mean age being 44 years.4 it is usually solitary and located in a subcapsular location and is more common in the right lobe of the liver, the most frequent location being the posterior segment of the right lobe. hepatic haemangiomas are usually <3 cm in diameter.5 brancatelli et al. have reported that 12% of haemangiomas demonstrate exophytic growth.6 however, pedunculated cases are very rare.2,3 the first case of a giant pedunculated haemangioma was reported by ellis et al. in 1985. in their case, the haemangioma had presented with renal insufficiency and had been found to displace the retroperitoneal fat anteriorly simulating a retroperitoneal mass and was initially diagnosed as an adrenal mass. at surgery, the pathological examination of the mass provided the diagnosis of a giant pedunculated haemangioma.7 subsequently, occasional case reports of giant pedunculated haemangiomas presenting with various symptoms or complications have been published in literature. however, these are few and far between on account of the rarity of the condition. reports have become more commonplace in recent years, probably because of an increase in detection rates because of increasing numbers of patients undergoing mdct scans for various indications and the development of state-of-the-art mdct scanners. most hepatic haemangiomas, being small and intrahepatic, are usually asymptomatic and discovered incidentally.1 giant haemangiomas may result in symptoms because of mass effect secondary to their size and may present with abdominal mass, vague abdominal pain, nausea or vomiting.8 much rarer complications include congestive heart failure secondary to arteriovenous shunting in the haemangioma and thrombocytopenia with consumptive coagulopathy because of the lesion (kasabach meritt syndrome).9 other rare complications include haemorrhage and rupture of the haemangioma.1 a complication specific to pedunculated haemangioma is torsion around its pedicle, subsequent to which the haemangioma undergoes vascular compromise (because of twisting of vessels in the pedicle) followed by infarction, thereby becoming symptomatic. pain is the most frequent symptom in such cases, and it can then present as acute abdomen,10 mimicking a number of other conditions. there have been reports of torsion of a giant pedunculated haemangioma masquerading as acute appendicitis.11 diagnosis in such cases is also challenging as the typical enhancement pattern of haemangioma may not be present because of vascular compromise. even otherwise, pedunculated haemangiomas of the liver are sometimes difficult to diagnose. several conditions can present as exophytic liver masses which can provide a diagnostic challenge. hepatic cysts, haemangiomas, focal nodular hyperplasia, hepatocellular adenomas, hepatocellular carcinoma and metastases can all present as exophytic liver masses to mention a few.12 further, they may have atypical imaging appearances. correct diagnosis of the various conditions is vital, as the management principles are drastically different for the various lesions. moon et al. reported a case of pedunculated hepatic haemangioma mimicking a submucosal tumour of the stomach; the lesion was symptomatic, producing epigastric discomfort with dyspepsia, and was initially suspected to be a submucosal tumour of the gastric wall on the basis of an upper gastrointestinal barium study. computed tomography (ct) subsequently revealed a giant pedunculated haemangioma arising from the left lobe of the liver and compressing the fundus of the stomach.13 giant pedunculated haemangiomas are, unlike in our case, usually symptomatic.1 a notable exception is the case report published by el hajjam et al. where a giant pedunculated hepatic haemangioma was incidentally discovered in an asymptomatic patient being worked up for an anal cancer; the mass was initially suspected to be an infrahepatic peritoneal metastasis, but detailed ct and mri examinations had revealed the characteristic enhancement pattern of a haemangioma and a thin pedicle originating from the segment iv-b of the liver. pathological examination confirmed the diagnosis of a pedunculated hepatic haemangioma.14 the majority of haemangiomas are asymptomatic and do not require treatment in the absence of any definite risk factors for complications. in symptomatic cases, the treatment options include surgery, either laparoscopy or open surgery, or interventional radiology in the form of angioembolisation. the indications for surgical intervention in any haemangioma include a palpable mass, rapid growth, thrombocytopenia, symptomatic patient with abdominal discomfort or pain or complications such as rupture with intraperitoneal bleeding.15 however, pedunculated haemangiomas, particularly larger ones, are usually surgically resected even if asymptomatic because of the high risk of torsion and spontaneous rupture.8 conclusion pedunculated giant haemangioma of the liver is very rare but should always be considered as a possibility in case of an upper abdominal solid lesion in relation to the liver. it is usually symptomatic and presents with complications but may be completely asymptomatic and an incidental finding. it can be confused with a variety of other upper abdominal masses including gastric gist as in our case. pedunculated giant haemangiomas usually require surgical resection even if asymptomatic in view of the high risk for the development of complications. accurate diagnosis can be difficult on the basis of imaging features but is vital in order to avoid unnecessary invasive diagnostic procedures and anxiety for the patient. the importance of the condition lies in the consequences of a misdiagnosis in terms of patient management. the onus of an accurate diagnosis lies on the radiologist. acknowledgements the authors are immensely grateful to the patient for allowing utilisation of her case data in this case report. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution all authors have contributed to the data collection, data analysis, manuscript preparation, literature search and manuscript finalisation processes. references ha cd, kubomoto sm, whetstone bm, parascandola s. pedunculated hepatic hemangiomas often misdiagnosed despite their typical findings. open surg j. 2013;7:1–5. https://doi.org/10.2174/1874300501307010001 vivarelli m, gazzotti f, d’alessandro l, pinna ad. image of the month. emergency presentation of a giant pedunculated liver haemangioma. dig liver dis. 2010;42(6):456. https://doi.org/10.1016/j.dld.2008.12.096 hobbs rd, roses re. giant caudate lobe hemangioma. j gastrointest surg. 2017;21(11):1957–1958. https://doi.org/10.1007/s11605-017-3473-3 bajenaru n, balaban v, săvulescu f, campeanu i, patrascu t. hepatic hemangioma – review. j med life. 2015;8:4–11. nelson rc, chezmar jl. diagnostic approach to hepatic hemangiomas. radiology. 1990;176:11–13. https://doi.org/10.1148/radiology.176.1.2191359 brancatelli g, federle mp, blachar a, grazioli l. hemangioma in the cirrhotic liver: diagnosis and natural history. radiology. 2001;219:69–74. https://doi.org/10.1148/radiology.219.1.r01ap3269 ellis jv, slalzar je, gavant ml. pedunculated hepatic hemangioma: an unusual cause for anteriorly displaced retroperitoneal fat. j ultrasound med. 1985;4:623–624. https://doi.org/10.7863/jum.1985.4.11.623 guenot c, haller c, rosso r. giant pedunculated cavernous hepatic haemangioma: a case report and review of the literature. gastroenterol clin biol. 2004;28:807–810. https://doi.org/10.1016/s0399-8320(04)95133-0 oak cy, jun ch, cho ea, et al. hepatic hemangioma with kasabach-merritt syndrome in an adult patient. korean j gastroenterol. 2016;67:220–223. https://doi.org/10.4166/kjg.2016.67.4.220 darzi a, taheri h, kamali ahangar s, mirzapour shafiei a, asghari y. torsion of a giant pedunculated hemangioma of the liver presenting with acute abdomen: a case report. iranian red crescent med j. 2016;18(8):e38198. https://doi.org/10.5812/ircmj.38198. ersoz f, ozcan o, toros ab, et al. torsion of a giant pedunculated liver hemangioma mimicking acute appendicitis: a case report. world j emerg surg. 2010;5:2. https://doi.org/10.1186/1749-7922-5-2 kim hj, lee dh, lim jw, ko yt, kim kw. exophytic benign and malignant hepatic tumors: ct imaging features. korean j radiol. 2008;9(1):67–75. https://doi.org/10.3348/kjr.2008.9.1.67 moon hk, kim hs, heo gm, et al. a case of pedunculated hepatic hemangioma mimicking submucosal tumor of the stomach. korean j hepatol. 2011;17(1):66–70. https://doi.org/10.3350/kjhep.2011.17.1.66 el hajjam m, lacout a, marzouqi mk-a, lacombe p, marcy py. pedunculated hepatic hemangioma masquerading as a peritoneal tumor. a case report. polish j radiol. 2016;81:51–53. https://doi.org/10.12659/pjr.895327 chang cm, lin sp, lin ch, hsu dw, wei ck, yin wy. early treatment for symptomatic giant hepatic hemangioma: report of three cases and literature review. surg j. 2007;2(4):45–49. radiology_aug04 editorial 2 sa journal of radiology • august 2004 things have changed in this country, and they will keep on changing. my opin-ion from the sideline, however, is that nothing has really changed in the training of our radiologists over the past 30 years despite the introduction of mri, ultrasound, ct and even multi-slice ct. i think the time has come to reflect on the training of our future radiologists. currently there is either a 4or 5-year mmed university course, or the college exam, which candidates write after 4 years in a registrar post. some candidates opt to stay an additional year in an academic department to qualify for uk registration. included in most curricula are anatomy, radiation physics, pathology and radiology. the college or university exam simply evaluates the candidate at one specific point in time. the royal college of radiology has published the third edition of structured training in clinical radiology. this has been done to formalise a curriculum for higher specialist training in radiology. in summary, the uk training consists of a 5-year training programme with relevant basic sciences addressed in the first year. the trainee sits the first frcr examination, which used to include physics, radiological anatomy and radiological techniques but has been reduced to basic physics and radiation safety. candidates use only the first 2 months of training to focus on the syllabus of the first frcr examination. the total training takes a minimum of 5 years and is divided into two components: 48 months of general radiology or core training to cover the interpretive and procedural skills, as well as the relevant anatomy techniques and applied physics of all required subspecialties. in the last 12 months there is subspecialty training allowing the trainee to choose one specialty or opt for training in a mixture of two or more subspecialties. this can be done during the 5th year or in modular parts in the 4th and 5th years. this subspecialty training, however, does not allow the person to register formally for such a subspecialty (for example, neuroradiology or interventional radiology) because additional training is needed in these scopes. as previously mentioned, the first examination (covering physics and radiation) written in the first few months is then followed by the final frcr part a, thus covering all sub-specialties including anatomy, techniques and physics. this can be done after 21/2 years of clinical radiology training and is just a written part whereas the final examination, part b, again covers all the subspecialties and the candidate is examined with reporting sessions as well as oral examinations. (one could sit for this examination after completion of 31/2 years of training.) candidates are also evaluated after each year at the training institution. if rotation systems are used there need to be appraisals of the trainee at the beginning and end of a rotation. now let us rethink the whole story, starting with the exam. an examination at one point in time does not seem very fair to the candidate who has done 4 5 years of training. continuous evaluation is inadequately covered in a logbook. being a postgraduate qualification, certain emphasis needs to be placed on research or at the very least the interpreting of research results. we examine only somebody’s training for radiologists coert de vries mmedrad (d) department of diagnostic radiology university of the free state bloemfontein 4 sa journal of radiology • august 2004 knowledge on reporting x-rays, but doing radiology, especially ultrasound, vascular interventional and mri, involves a certain level of skill that we do not necessarily address in our training. there are lots of problems. let’s try some suggestions. what about a uniform 4-year radiology curriculum where candidates enter the programme after completing a written exam on anatomy and radiation physics? that means 4 years of intensive training in radiology, which definitely includes mri and mri physics. to address the uk registration problem among others, what about a 1-year fellowship programme with the different fellowship programmes distributed across all the training facilities? say for instance, there could be at least two institutions offering a neuroradiology fellowship. in this way we could pool our resources and create quality fellowship programmes. i don’t know whether the idea of dedicated training in certain fields will appeal to private practice, and would appreciate the initiation of a discussion on this topic. editorial coert de vries editor abstract introduction methods results discussion study limitations conclusion acknowledgements references about the author(s) susan w. karanja department of neurosurgery, university of kwazulu-natal, south africa rohen harrichandparsad department of neurosurgery, university of kwazulu-natal, south africa duncan royston department of radiology, entabeni hospital, south africa samson m. motebejane department of neurosurgery, university of kwazulu-natal, south africa ayesha mitha department of radiology, inkosi albert luthuli hospital, south africa citation karanja sw, harrichandparsad r, royston d, motebejane sm, mitha a. comparing computed tomography (ct) angiography versus digital subtraction angiography for the screening of traumatic pseudoaneurysms in transcranial stab injuries. s afr j rad. 2017;21(1), a1197. https://doi.org/10.4102/sajr.v21i1.1197 original research comparing computed tomography (ct) angiography versus digital subtraction angiography for the screening of traumatic pseudoaneurysms in transcranial stab injuries susan w. karanja, rohen harrichandparsad, duncan royston, samson m. motebejane, ayesha mitha received: 23 mar. 2017; accepted: 26 june 2017; published: 31 aug. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract introduction: transcranial stab injuries among the civilian population in south africa are more common than in the west. in a study conducted in durban, south africa, in 1992, transcranial stab injuries accounted for 6% of all head injuries admitted to the neurosurgical unit. digital subtraction angiography (dsa) has been the gold standard for diagnosing traumatic pseudoaneurysms. its use as a screening tool is, however, limited and carries risks of neurological deficits. we postulate that the newer generation computed tomography (ct) scanner would serve as a better screening tool for traumatic pseudoaneurysms following transcranial stab injuries with the blade removed, provided the image quality is good. methods: all patients admitted with a stab to the head with total calvarial penetration from september 2014 to january 2016 were included in the study. those with a retained metallic fragment, incomplete imaging protocols, no penetration of the blade into the brain parenchyma or other causes of penetrating head injury were not included in the study. a retrospective chart review was then done on a prospectively recruited patient cohort. all ct angiograms were performed using a dual source ct scanner. results: a total of 26 patients met the inclusion criteria. there were seven vascular injuries identified on dsa: three traumatic pseudoaneurysms and four vessel cut-offs. one traumatic pseudoaneurysm was missed on computed tomography angiography (cta) because of a poor quality scan. the average sensitivity and specificity of cta compared with dsa was 67% and 95.5%, respectively. negative predictive value for cta was 99.5%. conclusion: a good quality cta carried out on the newer generation ct scanners allows for use of cta as a screening tool for patients with a transcranial stab injury and no retained blade or metallic foreign bodies. introduction transcranial stab injuries among the civilian population in south africa are more common than in the west. penetrating head injury (phi), which includes both missile injuries and transcranial stab injuries, has been reported as representing about 0.4% – 5% of all head injuries in the west.1,2 in a study conducted in durban, south africa, in 1992, transcranial stab injuries alone represented about 6% of all head injuries admitted to the neurosurgical unit. most patients present with the weapon already removed by the assailant.3 non-contrast computed tomography (ct) brains typically show a slot fracture with an underlying tract haematoma (figure 1). vascular complications of phi are reported in about 5% – 40% of these cases.1 du trevou et al. reported vascular injuries in 12% of patients with transcranial stab injuries and this study served to highlight the importance of early digital subtraction angiography (dsa) in patients with phi for detection of vascular injuries. dsa following phi is the gold standard for diagnosis of vascular injury.3 figure 1: (a) computed tomography (ct) scan (bone window) showing a slot fracture with complete calvarial penetration, (b) ct scan of the brain showing a tract haematoma, (c) three-dimensional reconstruction from the digital subtraction angiography (dsa) showing a traumatic pseudoaneurysm, (d) dsa showing a traumatic pseudoaneurysm before endovascular intervention and (e) dsa done following parent vessel occlusion showing complete exclusion of the aneurysm. the role of computed tomography angiography (cta) in the setting of phi is currently undefined because of a paucity of literature. the sensitivity of older generation cta was deemed inadequate for screening of traumatic pseudoaneurysms as these are typically peripherally located lesions affecting smaller sized vessels as compared to the circle of willis (cow). however, with the newer generation ct scanners, we postulated that this would serve as a better screening tool than dsa. factors that limit the use of dsa as a screening tool in the acute setting include that it is labour intensive, requires skilled personnel, is expensive and is not readily available 24 h a day. furthermore, dsa is invasive and carries a 0.4% – 12.2% risk of neurological deficit which is permanent in up to 5.4% of cases.4 cta would act as a suitable screening tool because of its widespread availability, rapid acquisition times, non-invasive nature and 24-h availability of personnel. it would thus form part of the initial trauma imaging and would allow triage decisions to be made rapidly and facilitate early intervention. early diagnosis of vascular injuries in phi would aid in preventing secondary brain injury through haemorrhage or infarction. cta as a screening tool has been shown to have a reduced sensitivity and specificity in the presence of metallic artefacts, which would be the case with a retained knife blade. in this setting, dsa is still the preferred modality for detecting associated vascular injuries. this sensitivity was noted to be lower for non-traumatic intracerebral aneurysms (ntica) injuries of the second and third order branches of the intracranial vessels.5 the objective of this study was to determine the sensitivity of 128-slice dual source ct angiography as compared with dsa as a screening tool for intracranial vascular injuries in patients presenting with transcranial stab injuries and no retained blade. the study received ethics approval from the university of kwazulu-natal biomedical ethics committee (reference number be038/16). methods the study was carried out at a university teaching hospital in durban, south africa. a prospectively collected cohort of consecutive patients admitted with a stab to the head with total calvarial penetration and no retained blade from september 2014 to january 2016 was retrospectively reviewed in this study. both cta and dsa were performed during admission. patients who had incomplete imaging protocols or other causes of phi like missile or machete injuries were excluded. those found with a retained knife blade or no penetration of the brain parenchyma were also excluded from the study. imaging protocol all patients in the study were required to have informed consent for both cta and dsa. this was obtained from the patient or next of kin. all patients had an initial non-contrast ct brain scan performed followed by ct angiography which was done according to the protocol set by the institution’s radiology department (table 1). ct angiography at the institution was done on the siemens definition flash dual source scanner (siemens ag, wittelsbacherplatz, germany). table 1: protocol used for conducting computed tomography angiography and image reconstruction a team comprising fellowship trained neurosurgeons performed the dsa studies on the next available elective day after the cta. dsa was performed using the siemens artis zee biplane machine (siemens ag, wittelsbacherplatz, germany). a standard seldinger technique was used. a carotid run on the side of injury was done. a vertebral run was also performed if the injury was more posteriorly located. image interpretation two independent neuroradiologists reviewed both the ct angiography and dsa images (d.r. and a.m.). the source images were not available for review but the 3d reconstructions were available for review. findings by the two radiologists were correlated with the initial reports which had been done using source images. the radiologists were blinded to the findings on unenhanced ct brain and the reports of the ct angiography. the reviewers graded the quality of ct angiography using the criteria in table 2. they assessed for vasospasm and also identified any vascular injuries on cta and dsa. we were particularly interested in identifying traumatic pseudoaneurysms which are lesions requiring treatment. table 2: computed tomography angiography quality grading criteria used by both radiologists. statistical analysis analysis techniques included descriptive statistics. means and frequencies were utilised to explore the data. contingency tables were utilised to calculate the sensitivity, specificity, negative predictive value (npv) and positive predictive values (ppv) for each observer. the means of these values were then obtained. results a total of 26 patients met the inclusion criteria for the study. of the 26 patients, 25 were males and 1 was female. the mean age of patients in the study was 26.23 years ± 7.32. the mean glasgow coma scale (gcs) on presentation was 13 ± 2 with 20 patients presenting with left-sided stabs and 6 with right-sided stabs; the findings are summarised in table 3. figure 2 shows the common regions of the stab wounds in the patient population. the average duration of time between cta and dsa was 6.38 days ±5.85. figure 2: number of patients and region of stab wounds. table 3: summary of data from patient cohort. the first analysis consisted of comparing the radiologist cta report to the neurosurgical dsa findings. vascular injuries were found in 10 patients on cta and in 7 patients on dsa. four patients had a false-positive cta report and a vascular injury was missed in one patient who had a traumatic pseudoaneurysm on dsa. this gave a sensitivity of 67% and specificity of 91% for cta (ppv 50% and npv 95%) when compared with dsa. of the seven vascular injuries reported, three were traumatic pseudoaneurysms which warranted endovascular treatment. the remaining four patients had vessel cut-off on dsa. figure 3 summarises the distribution of patients with vascular injuries and shows those missed on cta. figure 3: flow-chart summarising patient distribution with regards to diagnosis of vascular injury by digital subtraction angiography. the second analysis was then performed by two radiology consultants (d.r. and a.m.) who compared cta and dsa for detection of traumatic pseudoaneurysms. on cta review, each of the radiologists missed one traumatic pseudoaneurysm but they identified all three on dsa. the cta of the missed injury was noted as being of poor quality. from the data, a.m. had a cta sensitivity of 67% and specificity of 100% (ppv = 100%, npv = 96%). d.r. had a cta sensitivity of 67% and specificity of 91% (ppv = 50%, npv = 95%). this gave anaverage sensitivity of 67% and specificity of 95.5% (ppv = 75%, npv = 99.5%) for cta when compared with dsa. discussion complications of transcranial stab injuries can be vascular or infective with vascular injury being either acute or delayed.6 we focused on acute vascular injury following transcranial stab injury with the blade removed and evidence of intracranial penetration. from the results obtained, the focus was on traumatic pseudoaneurysms which though accounting for approximately 1% of intracranial aneurysms have morbidity and mortality rates as high as 50% if left untreated because of the high risk of rupture.7,8 early detection and treatment of traumatic pseudoaneurysms would thus prevent secondary injury through haemorrhage.9 a 12% incidence of traumatic pseudoaneurysms following stab head has previously been reported in our department. the same study also showed a mortality rate of 26% for patients who presented with the blade removed compared with 11% for those with the blade in place.3 bodanapaly et al. sought to determine the feasibility of cta for detecting vascular injury following phi. they assessed both missile and non-missile injuries and had a cta sensitivity rate of 72.7% for all vascular injuries, which was lower than the 98% reported for intracranial saccular aneurysms.10 in our study, the sensitivity was 67% for traumatic pseudoaneurysms on review of imaging by senior radiologists. in this study, three pseudoaneurysms were identified on dsa and subsequently underwent endovascular parent vessel occlusion. on cta, both radiologists missed one of these injuries. this could be accounted for by the following factors: (1) no source images were available for review by radiologists, (2) lack of admission non-contrast ct scan to allow identification of site of injury and (3) cta was noted to be of poor quality. the average npv for the two senior radiologists even without the source images was 99.5%. excluding the missed pseudoaneurysm because of poor quality cta, the sensitivity of cta for detecting traumatic pseudoaneurysms would be 100%. this shows that ct angiography would be appropriate for screening patients with transcranial stab injuries and no retained metallic foreign bodies. cta is non-invasive, relatively inexpensive, readily available and can be performed immediately after routine unenhanced ct scanning. in view of the advantages offered by a good quality cta, it is our recommendation that cta be used as a screening tool for the detection of traumatic pseudoaneurysms following phi. a senior radiologist or neuroradiologist should review the images, in conjunction with the non-contrast ct brain to focus on the area of potential injury. should they find the image quality to be poor, a repeat cta or dsa would be the next step. dsa is indicated in patients with retained metallic foreign body, poor quality cta or a cta where a vascular injury cannot be confidently excluded. should vasospasm be found on cta our recommendation is to repeat the cta after 1 week, so as not to miss any injuries. following identification of a traumatic pseudoaneurysm in our centre, all patients were treated by endovascular parent vessel occlusion, but surgical parent vessel occlusion is an alternative in centres with no endovascular option. dsa remains the gold standard for diagnosis of vascular injuries following phi. in our centre, it remains the main mode of investigating patients with transcranial stab injuries for vascular lesions. the current role of cta following phi is as one of the main screening tools for vascular injuries. both cta and dsa are used interchangeably following phi.11 dsa is reserved for select cases or where intervention is likely to be needed. like with dsa, it is recommended to repeat the cta to avoid missing delayed vascular injuries. the disadvantages of cta in the setting of transcranial stab injuries are potential artefacts affecting image quality and the inability to have therapeutic intervention in the same setting.12 study limitations this study is limited by the small sample size, the subjective grading of cta by the radiologists and a lack of source imaging for review by the radiology consultants. however, despite not having source images available, all traumatic pseudoaneurysms were identified by both radiologists on good quality cta. the delay of up to 23 days between dsa and cta is also a limitation as during this time any vasospasm that may have been present would have resolved, unmasking any injuries that would have been missed by cta. this would introduce a bias, making dsa seem more sensitive than cta. conclusion a good quality cta on the newer generation ct scanners is an effective screening tool for patients presenting with a transcranial stab injury and no retained blade or metallic foreign objects. it provides a rapid and more cost-effective means of triaging these patients. this allows for earlier intervention in patients with traumatic pseudoaneurysms, thus reducing the morbidity and mortality associated with these rare but dangerous lesions. dsa is indicated if the cta is of poor quality and a traumatic pseudoaneurysm cannot be confidently excluded, or if there is a retained metallic foreign body. acknowledgements we would like to acknowledge yusentha balakrishna, south african research council, for her role in the statistical planning and analysis of this article. competing interests there are no competing interests to declare. authors’ contributions s.w.k. was involved in conceptualisation of the article, collection of data, preparation of the manuscript and preparation of the data collection questionnaires. r.h. was involved in approving the concept of the article, review of the manuscript and approval of the final draft. d.r. was involved in data collection and interpretation and approval of the final copy of the manuscript. a.m. was involved in data collection and interpretation. s.m.m. was involved in conceptualisation of the article and approval of the final copy. references bieler d, franke af, hentsch s, et al. gunshot and stab wounds in germany-epidemiology and outcome: analysis from the traumaregister dgu®. unfallchirurg. 2014;117:995–1004. https://doi.org/10.1007/s00113-014-2647-7 bodanapally uk, saksobhavivat n, shanmuganathan k, aarabi b, roy ak. arterial injuries after penetrating brain injury in civilians: risk factors on admission head computed tomography. j neurosurg. 2015;122:219–226. https://doi.org/10.3171/2014.9.jns14679 du trevou md, van dellen jr. penetrating stab wounds to the brain: the timing of angiography in patients presenting with the weapon already removed. neurosurgery. 1992;31:905–911;discussion 11–12. https://doi.org/10.1227/00006123-199211000-00012 stallmeyer mj, morales re, flanders ae. imaging of traumatic neurovascular injury. radiolo clin north am. 2006;44:13–39. nathoo n, boodhoo h, nadvi ss, naidoo s, gouws e. transcranial brainstem stab injuries: a retrospective analysis of 17 patients. neurosurgery. 2000;47:1117–1122. https://doi.org/10.1097/00006123-200011000-00018 taylor aj, peter jc. patients with retained transcranial knife blades: a high risk group. j neurosurg. 1997;87:512–515. https://doi.org/10.3171/jns.1997.87.4.0512 larson ps, reisner a, morassutti dj, abdulhadi b, harping je. traumatic aneurysms. neurosurg focus. 2000;8:article 4. neuroimaging in the management of penetrating brain injury. j trauma. 2001;51(2 suppl):s7–s11. bodanapally uk, krejza j, saksobhavivat n, et al. predicting arterial injuries after penetrating brain trauma based on scoring signs from emergency ct studies. neuroradiol j. 2014;27:138–145. bodanapally uk, shanmuganathan k, boscak ar, et al. vascular complications of penetrating brain injury: comparison of helical ct angiography and conventional angiography. j neurosurg. 2014;121:1275–1283. syed fk, muhammad ss, muhammad zt, syed ae, shahan w. management of penetrating head injury. j emerg trauma shock. 2011:395–402. nikki t, cortny d, amanda s, warren r. neuroimaging in adult penetrating brain injury: a guide for radiographers. j med radiat sci. 2015;62:122–131. pdf file case report when the normal developmental process of the corpus callosum is disturbed, it may be completely absent or partially formed (hypogenetic) (fig. 1). when it is hypogenetic, the anterior portion (posterior genu and anterior body) will be formed, but the posterior portion (posterior body and splenium) will not. one exception to this largely anterior-to-posterior formation sequence is holoprosencephaly. the callosal anomalies seen in holoprosencephaly represent true callosal dysgenesis (defective development) (fig. 2) rather than the more common callosal hypogenesis (incomplete formation). in holoprosencephaly the defect in the corpus callosum is seen anteriorly rather than posteriorly.1 1. barkovich aj. pediatric neuroimaging, 3rd ed. philadelphia: lippencott williams & wilkins, 2000: 254 255, 323-327. corpus callosum hypogenesis versus dysgenesis s j przybojewski, mb chb, mmed (rad d), fcr diag (sa), dip pec (sa) s andronikou, mb bch, fcr diag (sa), frcr (lond), phd department of radiology, tygerberg hospital and university of stellenbosch pictorial interlude 24 sa journal of radiology • june 2006 fig. 1. incomplete formation (hypogenesis) of the corpus callosum. fig. 2. defective development (dysgenesis) of the corpus callosum in a patient with lobar holoprosencephaly. pg24.indd 24 7/11/06 12:49:39 pm http://www.sajr.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the sa journal of radiology, we ask that you take a moment to update your electronic portfolio on https:// sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajr. org.za 2. in your ‘user home’ [https://sajr.org.za/index. php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this volume of the sa journal of radiology. we appreciate the time taken to perform your review(s) successfully. aadil a. ahmed abdu h. dambatta abubakar farate ahmed o.a. krim ajit k. reddy akhilanand chaurasia andre rose anil bhaya anith chacko aruna patil ashesh ranchod benjamin taragin bukunmi m. idowu chinky h. patel chris trauernicht cornelia r. minne dahiru m. yunsa dibuseng ramaema dipesh jogi farhana e. suleman fourie bezuidenhout frank a. imarhiagbe gareth bydawell halvani moodley hamid o. hamid heleen hanekom jacobus moller jacqueline s. smilg james stutterheim jamie frost jenny edge john r. ouma linda t. hlabangana mala modi mariam q. said-hartley mary hammes miranda durand muhammad a. makusidi nausheen khan nondumiso n. dlamini ntombizakhona mthalane peter mercouris peter k. schoub rajiv kapur sally e. candy samia ahmad sandeep jakhere shalendra k. misser sonay aydin stanley makgere sudeep roplekar suresh k. chamarthi thomas g. walker venkatraman indiran vikram patil viresh bhagwandas werner s. harmse willem a. groenewald zarina lockhat http://www.sajr.org.za� https://sajr.org.za� https://sajr.org.za� https://sajr.org.za� https://sajr.org.za� https://sajr.org.za/index.php/sajr/user https://sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za sajr radioactive news international day of radiology – 8 november 2013 a vital part of medical care since x-rays were discovered in 1895 by wilhelm röntgen, radiology and the new technologies developed around it have hugely facilitated better care as well as minimally invasive surgery. in recognition of radiology’s impact, radiological societies across the world celebrated the second international day of radiology (idor) on 8 november 2013. the idor was established to build greater awareness of the value that radiology contributes to patient care, and to improve the understanding of the vital role that radiologists play in the healthcare continuum. medical imaging is one of the most exciting and progressive disciplines in healthcare and a field of great activity in technological and biological research. the day is a joint initiative of the esr, the rsna and the acr, with the full co-operation and involvement of the international society of radiology (isr), as well as umbrella organisations on all continents, including the asian oceanian society of radiology (aosr), the colegio interamericano de radiología (cir), the royal australian and new zealand college of radiologists (ranzcr), and the radiological society of south africa (rssa – which also represents neighbouring countries). the european federation of radiographer societies (efrs) also supports idor 2013. information about the idor, including booklets about oncological imaging and the history of radiology, is on the day’s official website at http://www.internationaldayofradiology.com one can also keep up to date with the latest news by liking the idor facebook page. aospr congress report-back nishentha govender firstly, i wish to thank the rssa cme association for the generous sponsorship that afforded me the opportunity to attend the 13th asian & oceanic society for paediatric radiology (aospr) congress in hong kong from 14 15 september. it was held during the auspicious moon festival period, which is a wonderful cultural celebration, and was addressed by more than 30 renowned speakers, experts in their respective fields. the congress was not only an opportunity for new ideas and scientific knowledge to be shared, but also fostered collaboration among different specialists and healthcare professionals in pursuit of better healthcare for children worldwide. the organising committee put together a most comprehensive programme which dealt with a broad scope of paediatric radiology. the topics ranged from paediatric emergencies to subspecialist medical advances. i am always astounded at the advances in radiology and how the boundaries of science are being challenged. yet another example of this was covered in the interesting presentation by giles boland, professor of radiology at harvard medical school, on ‘precision imaging in the era of personalised medicine’, in which he discussed the use of imaging biomarkers in oncology and clinical trials. the aospr provides radiologists with a wonderful opportunity to make new friendships and share experiences with each other. i had the privilege of delivering both an oral and a poster presentation concerning our south african-based research papers. the aospr strongly encourages submission of abstracts and participation in the congress. i would advise registrars and interested researchers to take advantage of this opportunity to share their scientific contributions to an international audience. the next aospr meeting will be held in melbourne and is predicted to be even better. thanks again to the rssa for this much-appreciated, great experience. report on the 37th esnr annual meeting sally candy head of neuroradiology and mri groote schuur hospital and uct the 37th european society of neuroradiology/21st advanced course in diagnostic radiology and 5th course in interventional neuroradiology took place between 29 september and 1 october at the conference centre, westend campus of the goethe university, frankfurt. this well designed and modern venue served the conference well, with its emphasis on state-of-the-art neuro-intervention and diagnostics. professor anton valavanis gave a sparkling review of the microcirculation and collateral vascular supply of the brain that provided the framework for the subsequent talks on chronic ischaemia, cerebral haemodynamics nd the role of the many advanced imaging techniques now available to the neuroradiologist. susceptibility weighted imaging, mr perfusion and arterial spin labelling featured prominently. reference was made to the disappointing results of intra-arterial thrombolysis, but the beneficial role of reperfusion in clinical post-stroke outcome was emphasised. prospective studies using technologically advanced stent retrievers in ‘bridging’ treatment are ongoing, and the proponents of this form of acute stroke management are optimistic. despite the improvements in diffusion weighted imaging (dwi) and diffusion tensor imaging (dti) in tumour and infection of both the brain and the spine, accurate prediction of tumour grade and histology are still not within reach. a group in spain presented preliminary findings of dti in quantitative assessment of the degree of degeneration in intervertebral discs. dynamic fetal imaging now allows us to assess foetal cardiac and gastro-intestinal abnormalities to maximise pregnancy outcome and to plan delivery management and ‘exit’ strategy. 7 tesla imaging is now a clinical reality. professor pham (germany) elegantly demonstrated how high-tesla magnets offer exquisite visualisation of the internal architecture of previously impenetrable peripheral nerves and plexuses. professor rovira (spain) outlined the advantages of high-strength 3d flair, white matter-attenuated tfe, t2* gre and swi imaging in improving the conspicuity of demyelinating plaques in the cortex of patients with multiple sclerosis. functional imaging is finding use in the imaging of pre-clinical dementia and pain perception and control. the prize for futuristic possibility, though, must go to dr gobel of maastricht university, the netherlands, who expanded on the use of complex functional mr feedback loops to enable ‘locked-in’ patients to communicate. anne osborn gave two outstanding review lectures on tumours in epilepsy and the spectrum of lymphomatoid disorders. some of us in south africa will have been fortunate enough to have had a sneak preview of this lecture on a webinar arranged by the rssa earlier this year. congratulations to the president of the congress, prof. dr friedhelm zanella and to prof. turgat tali, esnr president, for a well-organised and stimulating meeting. wfnrs planning meeting for the xxth symposium neuroradiologicum sally candy head of neuroradiology and mri groote schuur hospital and uct the meeting, chaired by professor e turgat tali, was the second meeting of the organising committee for the symposium neuroradiologicum to be held in istanbul, turkey, from 8 12 september 2014. the first planning meeting was held in san diego at the asnr earlier this year. representatives from all over europe attended. drs candy, kilborn and janse van rensburg represented the subgroups of sasni and saspi rssa at the meeting, and indicated their willingness to review scientific abstracts and to chair sessions at the prestigious symposium, where several parallel sessions will cover the topics of stroke, head and neck, paediatric diagnostics, diagnostic and interventional spine, intravascular intervention and adult imaging. a decision was made at the meeting that the poster session will be conducted entirely electronically, and that the parallel scientific oral presentations will be preceded by a named speaker to provide coherence and to improve attendance. the website for abstract submission opened on 11 september this year and will close on 31 march 2014. delegates will be notified of abstract acceptance on 30 april 2014. on-line registration opens on 22 november 2013. the website url is http://www.wfnrs2014.com/en/ obituary obituary tobie rossouwdr tobie rossouwand i first met in 1996, when he took over senior tutorials following the death of professor eric samuel. his vast knowledge and enthusiasm for radiology impressed and immediately commanded respect. he was a hard taskmaster, dedicated to radiology and teaching and yet he retained a sense of empathy for his students. he honoured the responsibility that teaching carries at all times, despite the added burden it brought him. in time tobie became my good friend and mentor, an everpresent source of wise counsel and advice with regard to difficult cases and practice problems. three of tobie's most outstanding attributes were perfectionism, humility, and above all, generosity. he gave of himself beyond requirement, never allowing personal problems to detract from his duty toward his students or to hamper his willingness to help all who cared to ask. tobie's passion was the practice of radiology, no question, but he had other talents and interests too. he enjoyed motorcars and engines. he had a fascination for the chemistry of engine oils and conducted experiments with these. he has a passion for the outdoors. he was also an excellent cook and loved wine and biltong. he and his wife, lona were not blessed with children, but he often spoke of his sister's children and loved them as his own. tobie was also a deeply religious and god-fearing man. tobie practised radiology at union hospital and later at krugersdorp before joining the team at sunninghill, where he worked, taught and thrived for the last 16 months of his life. tobie rossouw was a man i came to know, love and admire. his untimely death has left a deep sense of loss and pain and the realisation that he significantly affected my life and indeed, the lives of all he touched. sheldon codinho tobie rossouw joined our practice in mid 2000, but the short period of 18 months with us led to a quantum leap in our knowledge, our level of expertise and our enthusiasm for radiology. he gave us a fresh view of our profession and, although mr! was his true love, his contribution to any aspect of radiology was always innovative, practical and topical. he read extensively, spent hours on the internet, and much time preparing lectures and teaching students. tobie was a true academic with a brilliant mind, but he had a unique ability to reach the level of his patient's 51 sa journal of radiology. october 2001 problems and the referring clinician's needs. his understanding of mr! physics and his ability to manipulate the mr! scanner to suit each problem set him apart from us ordinary radiologists, who use mr! superficially and mechanically. tobie's untimely death has been a severe blow to our practice, but more importantly it has created a void in the practice of medicine in our hospital and in areas far beyond. a dark cloud has descended on us all and tears have been shed without shame by our entire staff, by doctors, nurses and staff members throughout the hospital who loved, respected and admired tobie without exception. it is small consolation to know that tobie spent the happiest 16 months of his medical life in our department and that he died doing what he always wanted to do. i have come to know lona quite well since tobie joined us. their marriage was clearly built on a deep love and respect for each other and we know that our loss pales into insignificance alongside hers. perhaps her knowledge of our immense regard for tobie will help her a little in the weeks and months ahead and we collectively wish her and her whole family strength and healing. tobie, you can rest in peace in the knowledge that you touched the lives of many diverse souls during your short life, and that you truly made a difference. dr farrell spiro case report calcified mitral subannular left ventricular aneurysm i rma van de werke frcr zarina loekhat ffrad(d) sa betsie van der walt fcrad(diagnostic) sa rowaida abdullah mbchb radi%gy department, ka/afong hospita/, university of pretoria abstract mitral subannular left ventricular aneurysms are not frequently seen, and those described have occurred mostly in africa and india. this condition is rare in the caucasian population. in this case report we describe a mitral subannular left ventricular aneurysm which was calcified, in a pregnant, hiv-positive african woman. this condition should be suspected in patients of african or indian descent presenting with mitral incompetence and a localised bulge and ring calcification on the left cardiac border on a chest radiograph. case report a 33-year-old african woman presented with pain in the left arm, dyspnoea, and chest pain. she was 24 weeks pregnant and was sent for a chest x-ray by the antenatal clinic, with the history of cardiac disease in pregnancy. the chest x-ray (figs la + b) showed an enlarged heart with a mitralised configuration as well as a large left atrium extending past the right cardiac border on the pa view. a calcified ring (ap 4 cm x tv 5 em x ht 4 em) suggestive of an aneurysm of the left ventricle in the region of the mitral valvewas also present. the left main bronchus was displaced posteriorly due to the enlarged left atrium. the lung fields showed early pulmonary venous congestion. fig. 1a. pa view of the chest. 33 sa journal of radiology • march 2002 fig. 1b. lateral view of the chest. the patient then had a cardiac sonar (fig. 2) which showed severe left atrial dilatation and mitral imcompetence. the left ventricular walls were normal but the left ventricular function was low. the right atrium and right ventricle were normal and a small tricuspid incompetence was present. there was a 4 x 3 em well-outlined hypoechoic area protruding into the left atrium just below the posterior mitral leaflet. there was a connection between this area and the left ventricle. fig. 2. cardiac sonar demonstrating the relationship of the aneurysm arising just be/ow the posterior mitral valve leaflet. case report this was considered to be a mitral subvalvular lv aneurysm protruding into the left atrium. the walls of the aneurysm were calcified. laboratory investigations laboratory investigations included the following: (i) serology for syphilis (negative) (ii) blood culture for anaerobic organisms (negative); (iii) rheumatoid factor 10.6 (normal 0.0 15.0 iu/ml); (iv) aso titre 184.0 (0.0 200 iu/ml); (v) an hiv test (positive); and (vi) a sputum investigation, which showed no growth. the patient was referred to the cardiothoracic surgeons whose preoperative diagnosis was chronic rheumatic endocarditis with mitral stenosis/incompetence and pulmonary hypertension. at operation the mitral valve was replaced by a sorin prosthesis, and the mitral valve aneurysm was repaired. pathological report the pathological specimen included the anterior leaflet of the mitral valve and a single calcified nodule measuring 8 x 5 x 2 mm as well as multiple calcified fragments of the mitral valve and mitral valve ring tissue. histological examination showed multiple valve leaflet fragments with areas of nodular fibrosis, dystrophic calcification, as well as focal neovascularisation. there were areas of ossification with marrow elements present. the aneurysm as such could not be identified with certainty, but fragments probably of the wall of the aneurysm were present. the final pathological diagnosis was late-phase rheumatic valvulitis. postoperative follow-up five days after operation the patient delivered a premature baby who died 9 days later. the patient was dyspnoeic and received lasix. chest x-ray (fig. 3) still showed cardiomegaly, residual calcified aneurysm and the prosthetic mitral valve. fig. 3. immediate postoperative supine view of the chest. relationship of mitral valve prosthesis to residual calcified aneurysm. postoperative lung changes present. seven weeks later the patient was seen in casualty with cardiovascular collapse and a gcs of 3/15. a heart sonar was done which showed no lifethreatening abnormality. the international normalised ratio (inr) was 15 (therapeutic range 2 4.5) and as she was on anticoagulant therapy a cerebral haemorrhage w~s suspected. however the patient di~d before a brain scan could be done in spite of intensive resuscitation. discussion ventricular aneurysms can be classified as congenital or acquired. the congenital type, seldom with any 34 sa journal of radiology • march 2002 obvious aetiology, may affect any part of the heart. the acquired type may result from myocardial infarction, tb, syphilis, rheumatic fever,collagen vascular disease, takayasu's arteritis, mycotic emboli, myocarditis or trauma. the majority of ventricular aneurysms occur secondary to atherosclerosis of the coronary arteries. when the aneurysm is not attributed to ischaemie heart disease, syphilis has been noted as the next most common cause. in our case the cause was rheumatic fever. one previous case seen last year by the sonar department was due to syphilis. the clinical presentation varies. heart failure may present as acute pulmonary oedema or when murmurs of mi are present it may mimic heart failure seen in chronic rheumatic heart disease. chest pain may be due to stretching of the pericardium or coronary insufficiency. left ventricular aneurysms of the annular subvalvular type were described in the literature before 1962, when abrahams introduced the term 'annular subvalvular left ventricular aneurysm' for this unusual type arising in the fibrous rings below the mitral or aortic valves. the submitral type is more common than the subaortic type. submitral aneurysms occur in the epicardium related to the base of the left ventricle. they have ovoid ostia which are frequently multiple and located under the posterior leaflet of the mitral valve. the aneurysms are of the false type and may frequently reach enormous proportions. they may be calcified or contain case report mural thrombus. when the aneurysm walls are thin, rupture may occur. in contrast to the anterior leaflet of the mitral valve, which has fibrous continuity with the aortic root, the posterior mitral leaflet is attached to the myocardium of the left ventricle by the fibrous tissue of the mitral ring. it is this region where the ostia of submitral aneurysms occur, and here the mitral ring is directly related to the epicardium of the atrioventricular groove. sections through this leaflet and the ring reveal that the epicardium in this region contains abundant fat as well as the circumflex coronary artery and the coronary sinus. imaging 1. a chest radiograph may suggest the diagnosis of the submitral type. characteristically there is a bulge on the left cardiac border, the size and shape depending on the size and position of the aneurysm. it may also show partial or total calcification. 2. on fluoroscopy it can be seen to pulsate. 3. cardiac sonography is used for the detection, confirmation and assessment of the submitral type. 4. cardiac catheterisation helps to confirm the diagnosis and locate the origin of the aneurysm and assess the severity of the haemodynarnic disturbance. 5. recently three cases were described in india, using mr! as a modality for diagnosis. mr! has the unique capability of multiplanar imaging with multiple imaging parameters. the exact dimensions and extent of the lesion, especially the neck of the aneurysm and the degree of mitral regurgitation, were well seen on gradient echo cine images. complications complications include myocardial ischaemia and infarction, systemic embolisation, congestive cardiac failure and infective endocarditis as well as rupture of the aneurysm. treatment surgical resection of the aneurysm with or without valve replacement is indicated in severe valvular regurgitation or cardiac failure resistant to medical therapy. summary calcified mitral subannular left ventricular aneurysm can be suspected on a chest radiograph when there is a high index of suspicion of this condition in a relevant clinical setting. the purpose of this case report is to familiarise general radiologists with this rare condition which is more known to cardiologists, cardiothoracic surgeons and echocardiographers. therefore as we say in radiology: 'you only see what you look for and you only recognise what you know.' acknowledgement we would like to thank annelize gates for her help in the preparation of this case report. references 1. edelstein cl, blake rs, klopper jf. mitral subannular left ventricular aneurysm. 5 afr med j 1987; 71: 114-ll5. 2. chesler e, joffe n, schamroth l, meyers a. annular subvalvular left ventricular aneurysms in the south african bantu. circulation 1965; xxxii: 43-51. 3. edington gm, williams ao. left atrial aneurysms associated with annular subvalvular left ventricular aneurysms. jol/mal of pathology and bacteriology 1968; 96: 273-283. 4. chesler e. aneurysms of the left ventricle. cardiovascular clinics 1972; 4: 187-217. 5. taneja k, mathur a, sharma s, rajani m, das b, venugopal p. magnetic resonance imaging features of submitral left ventricular aneurysm. indian heart j 1998; 50: 453-455. 35 sajournal of radiology • march 2002 abstract introduction material and methods results discussion limitations conclusion acknowledgements references about the author(s) elkharbash abdurahman department of radiology, university of kwazulu-natal, durban, south africa khatija amod department of radiology, inkosi albert luthuli central hospital, university of kwazulu-natal, durban, south africa duncan royston lake, smit & partners, durban, south africa rohen harrichandparsad department of neurosurgery, inkosi albert luthuli central hospital, university of kwazulu-natal, durban, south africa citation abdurahman e, amod k, royston d, harrichandparsad r. recovery of oculomotor nerve palsy after endovascular management of posterior communicating artery aneurysms. s afr j rad. 2020;24(1), a1887. https://doi.org/10.4102/sajr.v24i1.1887 original research recovery of oculomotor nerve palsy after endovascular management of posterior communicating artery aneurysms elkharbash abdurahman, khatija amod, duncan royston, rohen harrichandparsad received: 08 apr. 2020; accepted: 27 may 2020; published: 31 aug. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: oculomotor nerve palsy (onp) is a common clinical presentation of posterior communicating artery (pcoma) aneurysms. it remains unclear if patients have a better rate of recovery after surgical clipping or endovascular coiling. objectives: the main objectives of this study were to assess the overall rate of onp recovery after endovascular coiling of pcoma aneurysms, as well as to determine the associated predictive factors of oculomotor nerve recovery. method: we retrospectively evaluated the demographic, clinical, and radiological characteristics and the outcome of consecutive patients presenting with pcoma aneurysms treated by endovascular coiling from january 2012 to november 2016 with at least 1 year clinical and radiological follow-up. statistical analysis was applied to determine the association between onp recovery and the demographic, clinical and radiological variables. results: a total of 91 patients with pcoma aneurysms were treated endovascularly. thirty-four patients (22 women and 12 men) with onp related to pcoma aneurysms were included. the mean age of the patients was 49.8 years. subarachnoid haemorrhage was present in 27 patients. the mean aneurysm size was 6.7 mm. the overall rate of recovery was 88.2%. complete nerve recovery was seen in 16 (47%) patients and partial recovery was observed in 14 (41.2%) patients, whilst 4 (11.8%) patients remained unchanged after treatment. the non-posterolateral direction of the aneurysm showed a tendency towards better recovery compared to the posterolateral projection (p = 0.06). conclusion: endovascular coiling of pcoma aneurysms in patients with onp resulted in a cure or improvement of oculomotor nerve dysfunction in the majority of patients. keywords: onp; pcoma; clipping versus coiling; diagnostic radiology; endovascular coiling; oculomotor nerve recovery. introduction posterior communicating artery (pcoma) aneurysms are one of the most common aneurysms encountered by neurosurgeons and neuro-interventional radiologists, representing 50% of all internal carotid artery (ica) aneurysms. they are the second most common aneurysms overall (25% of all aneurysms).1 oculomotor nerve palsy (onp) is a common clinical presentation of both ruptured and unruptured pcoma aneurysms and has been reported to vary from 35% to 45%.2,3 however, the exact pathophysiologic mechanisms underlying aneurysmal third nerve palsy, remain unknown. there are many theories published about the pathophysiologic mechanism of onp, including direct mechanical compression of the third nerve by enlargement of the aneurysmal sac in the suprasellar cistern, nerve injury by arterial pulsation of the aneurysm, as well as by pressure from arterial bleeding because of rupture of the aneurysm, and irritation from subarachnoid haemorrhage.4,5 the treatment of onp-related to pcoma aneurysms is still controversial and has been limited by the small series of cases. the first surgical series of aneurysmal third nerve palsy was published in 1947 by jefferson et al.,6 who recommended carotid ligation, principally to prevent recurrent haemorrhage. the later introduction of the operating microscope and the development of microneurosurgical techniques, resulted in clipping being considered the best option for the management of pcoma aneurysms.7,8 with advances in technology, endovascular therapy has been used more frequently, as efficiently and less invasively.9,10 however, it remains unclear if patients would have a better rate of recovery after surgical clipping or endovascular coiling.11,12,13,14 controversies exist regarding the predictive factors that might contribute to onp recovery after management, as there are many conflicting reports from previous studies. the primary aim of this study was to assess the rate of onp recovery related to pcoma aneurysms in an institution where coiling is the first policy. the secondary aim was to determine the predictive factors of oculomotor nerve recovery. material and methods study population this was a retrospective, descriptive and analytic study of patients who presented with oculomotor nerve palsies related to pcoma aneurysms and underwent endovascular treatment with coiling from january 2012 to november 2016 in the neurosurgery department at inkosi albert luthuli central hospital (ialch) in south africa. patients with at least 1 year clinical and radiological follow-up were included in the study. data collection patient data were obtained from the computer database of the hospital information system at ialch. demographics, clinical presentation and ophthalmologic examination were recorded from the patients’ medical files. images were accessed via the radiological information system and picture archiving and communication system. data on the endovascular procedure and the course of ophthalmologic and angiographic follow-up were obtained. pre-operative and postoperative evaluation complete onp was defined as patients with all of the following: diplopia, ptosis, ophthalmoplegia and pupillary dysfunction. partial (incomplete) onp was defined as patients with one or two of the above. the following factors were assessed: demographic data (gender and age), clinical data (co-morbidities, degree of onp at presentation, aneurysm rupture status before treatment and length of onp before treatment) and radiological data (size and aneurysm direction). postoperative evaluation of onp was classified as unchanged (no improvement), incomplete recovery or complete recovery. statistical analysis data are presented as means and ranges for continuous variables and as frequencies for categoric variables. statistical analyses were performed using the fisher’s exact test. the level of statistical significance used was p < 0.05 for the whole study. statistical analysis was performed using the statistical package for the social sciences (spss) version 26.0. ethical consideration ethical approval to conduct the study was obtained from the higher research committee at the university of kwazulu-natal (approval number: be510/17). results the study population consisted of 91 patients who each presented with a pcoma aneurysm. of the 91 patients, 40 (43.9%) had oculomotor palsy and were treated with endovascular coiling. thirty-four patients were included in this study as they had follow-up data. of the 34 patients, 30 patients (88.2%) had onp recovery, whilst 4 patients (11.8%) remained unchanged after endovascular treatment. of the 30 patients who had onp recovery, 16 patients had complete recovery of oculomotor nerve function, whilst 14 had an incomplete recovery. the demographic, clinical and radiographic data are presented in table 1. table 1: correlation between demographic, clinical and radiographic factors versus recovery of oculomotor nerve palsy after endovascular coiling. demographic data in correlation with oculomotor nerve palsy recovery of the 34 patients with onp, 22 (64.7%) were women and 12 (35.3%) were men. the mean age of the patients was 49.8 years (range 14–81 years). no relationship could be found between gender (p = 0.52) or age (p = 0.11) and onp recovery. clinical data in correlation with oculomotor nerve palsy recovery of the 34 patients who developed onp, co-morbidities (hypertension/diabetes mellitus) were found in 16 patients (47%), whereas 18 patients (53%) had no comorbidity. at the time of admission, onp was complete in 32 patients (94.1%) and partial in 2 patients (6.9%). subarachnoid haemorrhage (sah), in keeping with aneurysm rupture, was present in 27 patients (79.4%) with onp, whereas 7 patients (20.6%) had unruptured aneurysms. no statistically significant correlation was found between co-morbidities, the degree of onp at presentation or sah versus onp recovery. of the 34 patients, the length of onp before treatment was not documented in two patients. fifteen patients had early treatment (≤ 14 days), whilst late endovascular coiling (> 15 days) was performed in 17 patients. early treatment showed a slightly higher tendency towards better onp recovery compared with late treatment. nevertheless, the difference did not reach statistical significance (p = 0.28). radiological data in correlation with oculomotor nerve palsy recovery the mean size of the aneurysms was 6.7 mm (range 3 mm – 12.4 mm). small aneurysms showed a slightly higher tendency towards better onp recovery compared with larger aneurysms. nevertheless, the difference did not reach statistical significance (p = 0.26). for the 34 patients who developed onp, aneurysm direction was posterolateral in 19 patients (55.9%), lateral in 10 patients (29.4%), anterolateral in 2 patients (5.9%), inferolateral in 2 patients (5.9%) and medial in 1 patient (27.5%). patients with a non-posterolateral aneurysm direction indicated a higher tendency towards better onp recovery compared with the posterolateral group (p = 0.06). discussion the main objectives of this study were to assess the overall rate of onp recovery related to pcoma aneurysm after endovascular coiling, as well as to determine the associated predictive factors of oculomotor nerve recovery. in our study, we found that 43.9% of patients with pcoma aneurysms developed onp. this is comparable to most previous studies, where the range of onp varied from 34% to 56% amongst patients presenting with pcoma aneurysm.4,5 the onp results because of close anatomical proximity of the pcoma to the third cranial nerve, which may be caused by the pulsing and mass effect of the aneurysm sac, as well as by aneurysm rupture. during the early neurovascular conflict, a conduction block takes place, whilst after longer periods, continuous pulsing or mass effect is likely to affect intraneural circulation, thus leading to nerve ischaemia. if these phenomena become chronic, the occurrence of fibrosis, scarring and necrosis is probable. when sah is present, there may be several phases of neural damage, from minor axonolysis to direct damage to the nerve when severe bleeding occurs. we assessed the resolution of onp in a series of 34 patients after endovascular treatment. an overall improvement occurred in 88.2% of the patients. we found that endovascular therapy allowed complete nerve recovery in 47% and partial recovery in 41.2% of patients, whilst only 11.8% remained unchanged. these findings are also in agreement with previous studies that have reported favourable recovery rates with endovascular therapy, ranging from 80% to 90%. in these studies, complete recovery was observed in 40% – 50% of patients, whilst partial recovery was seen in 40% – 45% of patients after endovascular therapy.15,16 the exact mechanism by which coiling promotes oculomotor nerve recovery, is not well understood. a commonly proposed explanation is that coiling removes or decreases aneurysmal pulsations, thus enabling nerve recovery.17 on the other hand, surgical clipping is likely to cause direct compression or traction, thus offsetting more rapid reduction in pulsatility and mass effect. the recovery rates with surgical clipping have been reported to range between 77% and 87%.7,8,11,13 illustrative cases demonstrating simple coiling, balloon remodelling and stent-assisted coiling techniques are presented in figures 1–4. figure 1: a 65-year old man presented with sudden onset of severe headache. non-contrast computed tomography brain: (a) showed diffuse subarachnoid haemorrhage (sah) with a heavier blood load on the left. computed tomography angiogram (b) showed bilateral common clinical presentation of posterior communicating artery aneurysms. digital substraction angiography (dsa) of the left internal carotid artery in the lateral projection shows the multilobulated posteriorly directed aneurysm before (c) and after (d) simple coiling embolisation. figure 2: (r) internal carotid artery digital substraction angiography (dsa) of the same patient 3 months later in the working projection showing the contralateral common clinical presentation of a posterior communicating artery aneurysm: (a) before and (b) after balloon-assisted coiling. magnetic resonance angiogram at 3 months shows the coil masses bilaterally with no recurrence of the aneurysms. figure 3: a 64 year old male presents with a complete right third nerve palsy. 3d reconstruction of the (r) ica dsa shows a pcoma aneurysm with the origin of the artery at the neck of the aneurysm (a). lateral view (b) shows a bilobed pcoma aneurysm directed in the typical posterolateral and inferior projection towards the interpeduncular cistern that results in compression of the oculomotor nerve. unsubtracted view in the working projection (c) shows balloon assisted coiling, using a compliant balloon to protect the origin of the pcoma. control run (d) shows complete occlusion of the aneurysm and normal filling of the pcoma branch. figure 4: a 27-year-old woman presented with subarachnoid haemorrhage (sah) and (right) third cranial nerve palsy. computed tomography angiogram revealed bilateral common clinical presentation of posterior communicating artery aneurysms. the three-dimentional angiogram of the (right) internal carotid artery shows the larger symptomatic aneurysm (a). lateral view before (b) and after (c) simple coiling. 3d angiogram of the (left) internal carotid artery shows the small, incidental mirror common clinical presentation of posterior communicating artery aneurysm with a relatively wide neck (d). this was treated 3 months later with a stent-assisted coiling (e and f). control run (g) shows complete occlusion of the aneurysm with normal filling of the internal carotid artery and preservation of the common clinical presentation of the posterior communicating artery. correlation of demographic data with oculomotor nerve palsy recovery the effect of demographics on the final onp recovery has been shown in several studies. stiebel-kalish et al.18 and ahn et al.19 reported that older age might decrease the chances of onp recovery after endovascular coil treatment of pcoma aneurysms. in contrast, chen et al.20 noted that age had no significant effect on the complete resolution of onp after endovascular and surgical treatment. similarly, gu et al.15 and yanaka et al.21 showed that age and sex were not indicative of the recovery of onp. in our study, we found that gender and age were not significantly associated with the degree of postoperative resolution of onp (p = 0.52, p = 0.11, respectively). correlation of clinical data with oculomotor nerve palsy recovery stiebel-kalish et al.18 observed that patients with microvascular risk factors had lesser chances of nearly complete recovery, compared to non-vascular risk factor groups. however, another study did not find any correlation between vascular risk factors and onp recovery.22 in our study, we observed that co-morbidities did not play a key role in oculomotor nerve recovery (p = 0.64), and, most likely, recovery was dependent on other factors. previous researches have studied the effect of the pre-operative degree of oculomotor nerve paresis in determining eventual recovery. many studies noted that the degree of onp before treatment was an important factor in determining the eventual recovery of oculomotor nerve function.7,8,23,24 on the contrary, guresir et al.25 and patel et al.26 showed that the degree of onp at presentation was not indicative of neural function recovery. in our study, amongst the 32 patients who presented initially with complete onp, recovery of onp was complete in 43.75%, incomplete in 43.75% and no improvement was observed in 12.5% of patients. on the other hand, the two patients who presented with partial onp at presentation achieved complete recovery (100%). however, the differences were not statistically significant (p = 0.60). this is difficult to evaluate as we had only two patients who initially presented with partial onp at admission. the effect of aneurysm rupture status on oculomotor nerve recovery has been debated. some studies have noted that the aneurysm rupture status before treatment was not an important factor in determining the eventual recovery of onp.20,27 in contrast, other studies have found that sah was a statistically significant factor influencing recovery.28,29 in our study, we found that patients with ruptured aneurysms achieved more complete recovery of onp, compared to unruptured aneurysms (48.1% vs. 42.9%), whilst incomplete recovery was observed more in patients with unruptured aneurysm compared to the ruptured group (57.1% vs. 37%). however, the differences were not statistically significant (p = 0.60). the better ophthalmologic outcome with sah can be explained by the probable difference of the onp mechanism after sah, which is probably related to the irritating effect of subarachnoid blood on the nerve itself, rather than to direct mass effect. the influence of early aneurysm treatment after the onset of oculomotor nerve dysfunction and onp resolution has been debated. many studies have noted that the duration of onp before treatment was an important factor in determining the eventual recovery.30,31,32 however, other studies have found that the interval time between onp and the intervention did not affect the degree of post-intervention resolution of onp.33,34 in our study, we found that patients with early treatment (≤ 14 days) achieved more complete recovery of onp, compared to patients with late treatment (60% vs. 29.4%), whilst the incomplete recovery was observed more in patients with late treatment, compared to the early treatment group (53% vs. 33%). although, the early treatment showed a higher tendency towards better onp recovery compared to late treatment, the difference did not reach statistical significance (p = 0.28). this finding could be explained by the idea of neuropraxia which has an excellent prognosis with full recovery within the first few weeks, whilst recovery may not take place or occur only partially, when the third nerve palsy is of a long duration (a few months), because of intraneural scarring with axonal death and wallerian degeneration. correlation of radiological data with oculomotor nerve palsy recovery various studies have found that smaller aneurysms (< 10 mm in size) showed a higher tendency towards better onp recovery, although the difference in the outcome was not statistically significant.16,29,35 conversely, other authors have noted that the size of an aneurysm had no predictive value.5,20,34 in the current study, we found that patients with aneurysms of diameter ≤ 6.7 mm achieved more complete recovery of their onp compared to patients with aneurysms of diameter > 6.7 mm (57.9% vs. 33.3%), whilst incomplete recovery was observed more in patients with aneurysm diameters > 6.7 mm, compared to the smaller diameter aneurysm group (46.7% vs. 36.8%). in addition, 5.3% patients showed no improvement in the smaller diameter aneurysm group, compared to 20% in the larger diameter aneurysm group. although the smaller diameter aneurysm group showed a higher tendency towards better onp recovery compared to the larger diameter aneurysm group, the difference was not statistically significant (p = 0.26). although it seems intuitive that large pcoma aneurysms are more likely to generate mass effect and result in onp and would influence the degree of onp recovery, this is not supported by the literature. severe neurovascular compression can be seen even with small aneurysms because of nerve ischaemia. interestingly, anan et al.36 found that a short distance between the ica and the anterior-posterior clinoid process, may be associated with onp related to a pcoma aneurysm, and even relatively small unruptured pcoma aneurysms can cause third nerve palsy if the ica runs close to the skull base of the third nerve. hamer et al.37 have pointed out that the posterolateral-inferior direction of the aneurysmal fundus was the most frequently encountered in the presence of an oculomotor deficit. however, giombini et al.24 observed that there is no significant relationship between the radiological measurement, morphology or direction of ica-pcoma aneurysms and the clinical picture. the relationship between aneurysm direction and onp recovery has not been studied well.24 conversely, soni et al.2 believed that the shape and direction of the aneurysm sac could influence the recovery of the onp. in this study, we found that a posterolateral aneurysm direction was most frequently encountered in the presence of oculomotor deficit (55.9%). patients with non-posterolateral aneurysm directions achieved more complete recovery of their onp, compared to patients with posterolateral aneurysm directions (66.7% vs. 31.6%), whilst incomplete recovery was observed more in the posterolateral group, compared to the non-posterolateral group (47.4% vs. 33.3%). furthermore, 21% of the posterolateral group had no improvement, suggesting that the non-posterolateral aneurysm direction has a higher tendency towards better onp recovery, compared to posterolateral aneurysm direction (p = 0.06). this is an interesting finding, which might be because of the anatomical relationship between the aneurysm sac and the compression on the third nerve. with a posterolateral aneurysm direction, more compression of the nerve can be expected, which could lead to increased axonal damage and poor recovery later on. on the other hand, the non-posterolateral aneurysm direction might have less pressure effect on the third nerve and a subsequently better possibility of recovery. limitations the main limitations of our study are the retrospective nature of the research and the relatively small sample size, which might influence the statistical significance. conclusion this is the first study in south africa that examined the oculomotor recovery related to pcoma aneurysms after endovascular management. we found that the recovery of onp after coiling of pcoma aneurysms occurred in 88.3% of the patients. non-posterolateral aneurysm direction showed a higher tendency towards better recovery (p = 0.06). smaller aneurysm size and shorter length of time of onp before treatment, showed better recovery, but these factors were not of statistical significance. other possible factors, such as patient gender, co-morbidities and pre-operative degree of onp, had no predictive value in our patient group. for aneurysms amenable to both endovascular coiling and surgical clipping, including pcoma aneurysms with onp, we recommend endovascular management as the first option. acknowledgements the principal author (e.a.) would like to express his gratitude to his supervisor mr r. harrichandparsad, whose encouragement, guidance, tremendous assistance and support from the initial to the final stage enabled him to develop an understanding of the subject. he also expresses his deepest gratitude to dr k. amod for all the assistance in this study, without which this would not have been successful. lastly, the author offers his regards and blessing to all of those who supported him in any respect during the completion of this degree. competing interests the authors have declared that no competing interests exist. authors’ contributions e.a. was the principal investigator and wrote the manuscript. k.a. and r.h. were the supervisors of the study and made conceptual contributions to the study and participated in manuscript editing. d.r. assisted with the critical review of the manuscript and was directly involved in patient management. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sector. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ojemann rg, crowell rm. internal carotid artery aneurysms. 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aneurysms with cranial nerve symptoms: efficacy of endovascular guglielmi detachable coil treatment. korean j radiol. 2003;4(3):141–145. https://doi.org/10.3348/kjr.2003.4.3.141 anan m, nagai y, fudaba h, et al. third nerve palsy caused by compression of the posterior communicating artery aneurysm does not depend on the size of the aneurysm, but on the distance between the ica and the anterior-posterior clinoid process. clin neurol neurosurg. 2014;123:169–173. https://doi.org/10.1016/j.clineuro.2014.05.006 hamer j. prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery. acta neurochirurgica. 1982;66:173–185. https://doi.org/10.1007/bf02074504 case report melorheostosis in a 1 2-year-old child s andronikou b smith department of paediatric radiology, university of cape of cape town and institute of child hea/th, red cross war memoria/ children's hosp/ta/, rondebosch, cape town corresponding author sandronlkou department of paediatric radl%gy, red cross war memoria/ children's hosplta/. k/lpfonteln roa~rondebosch. 7700 tel: (021) 658-5422. fax: (021) 658-5101. e-mail: docsav@mweb.co.za abstract melorheostosis (of leri and joanny) is a rare, non-genetic sclerotic dysplatic bone disorder presenti ng at any age, usual ly from late childhood to adulthood. its aetiology is unknown. it affects mainly the long bones of the upper and lower limbs, but also the short bones of the hand and foot and, rarely, the axial skeleton. onset is usually insidious, with pai n, deform ity of the extremity, limb stiffness and limitation of joint motion, as well as thickening and fibrosis of the overlyi ng ski nand muscle atrophy being the common clinical featu res fou nd on presentation. in adults the characteristic radiographic appearance consists of irregular hyperostotic changes of the cortex, generally on one side of the bone, resembling melted wax dripping down one side of a candle, from which melorheostosis derives its name. this, however, is not a feature of the 42 sajournal of radiology. february 2001 radiographic appearance in children, where the external cortical margin retains its regular outline. children more often present with a discrepancy in limb size rather than with pain (as is seen in adults). we present our case of melorheostosis in a 12year-old child to highlight the main clinical and radiological differences found between children and adults. keywords sclerosis/ bone dysplasia/ cortical hyperostosis/ medullary encroachment limb asymmetry/ growth disturbances case report a 12-year-old male presented with a small left hand. on examination there was clinodactyly of all the fingers of the left hand. there was stiffness of the wrist and all the metacarpophalangeal joints, with restricted range of movement both in flexion and extension. the overlying skin was indurated and the first web space was tight. the patient was tender to palpation over the wrist joint and the third carpometacarpal joint. plain films of both hands and the left forearm were done. the right hand was normal. all the left carpal bones were smaller and diffusely sclerotic compared with the right side. the left hand was globally smaller than the right (figure 1). there was cortical sclerosis with thickening extending into the medullary cavities of all five metacarpals as well as of the proximal phalanx of the thumb. the phalanges of the left middle and ring topage43 mailto:docsav@mweb.co.za melorheostosis in a 12-year-olcj eh i id frompage42 figure 1: the right hand is normal. the left hand is globally smaller, with diffuse sclerosis of the carpal bones. the first web space on the left is smaller than on the right. fingers showed diffuse sclerosis.there was also expansion and loss of tubulation in two of the metacarpals involved and in all components of the ring finger. the cortical margin, howfigure 2: there is cortical sclerosis with thickening extending into the medullary cavities of all five metacarpals as well es in the proximal phalanx of the thumb. the phalanges of the left middle and ring fingers showed diffuse sclerosis. there is expansion and loss of tubulation in two of the metacarpals involved and in the components of the ring finger. the cortical margins retain their regular outline. ever, retained a regular outline throughout (figure 2). both the left radius and ulna showed cortical thickening in the diaphyseal region. the ulna was affected to a greater degree, with both anterior and posterior corthe diagnosis of melorheostosis was made radiologically on the basis of a mulnfocal unilateral sclerotic bone disease with retarded growth associated with the positive clinical features of a small limb, tenderness, joint stiffness with limited range of movement and overlying skin changes. discussion melorheostosis of leri and joanny, first described in 1922, is a rare non-genetic slowly progressive sclerosing skeletal dysplasia that usually presents late in childhood and affects the sexes equally. common clinical manifestations include bone pain (encountered more in adults), joint stiffness, asymmetry oflimb size and skin and soft tissue lesions. the asymmetry of limb size was the presenting feature in our patient. the bone pain is in contrast to other bone dysplasias. it may coexist with osteopoikolosis and osteopathia figure 3: both the left radius and ulna showed cortical thickening in the diaphyseal region, the ulna is affected to a greater degree, with both anterior and posterior cortices showing thickening, whilst the radial involvement is restricted to the medial aspect. there is extension into the medullary cavity in both bones, but the external cortical margin was largely undisturbed, tices showing thickening. the radial involvement was restricted to the medial cortical aspect. there was encroachment on the medullary cavity in both bones, but the external cortical margin was not disturbed (figure 3). 43 sa journal of radiology· february 2001 striata as well as with tumours or malformations of blood vessels or lymphatics. up to 1994,320 cases had been reported. to page 44 melorheostosis in a 12-year-old child frompage43 radiological features include monoor polyostotic limb involvement (including hands, feet, shoulder girdle and pelvis). the tubular bones of the lower limbs are the sites of predilection. less commonly the axial skeleton is involved. the abnormality is usually limited to a single bone or limb and sometimes may skip a segment. even when the disorder is seen bilaterally, the abnormalities are never symmetrical. linear cortical hyperostosis following the long axis of the bones is seen with extension into the medullary cavity.this is a predominant feature in our patient. usually only one side of the bone is affected, as is seen in the left radius of our patient. sclerosis may be complete in the carpal and tarsal bones, as was the case in the carpal bones of our patient. the epiphyseal growth plate may close prematurely, resulting in growth discrepancies. this is clearly demonstrated in our case,where all the bones of the left wrist and hand were smaller than those on the right. it is important to note that the "flowing wax" appearance seen in adults, when the linear density extends beyond the cortex as multiple periosteal outgrowths, is not a feature in children. in childhood the hyperostosis does not extend beyond the boundaries of the cortex and the external contours of the bone are undisturbed. conclusion the above features are so distinctive that the unilateral endosteal sclerosis (even when the "flowingwax" appearance is not present in children) is virtually diagnostic of melorheostosis. references 1. beighton p, cremin bj. sclerosing bone dysplasias. berlin, heidelberg: springerverlag. 1980: 143-148. 2. greenspan a. scoliosis and anomalies with general effect on the skeleton. in: orthopaedic radiology a practical approach. 3rd ed. philadelphia: lippincott williams & wilkins. 2000: 921-922. 3. kozlowski k, beighton p. gamut index of skeletal dysplasias. berlin, heidelberg: springer-verlag. 1984: 134. 4. rubin p. dynamic classification of bone dysplasias. chicago: year book medical publishers. 1964: 391. and radiological features. dynamic multi-phase ct scanning has revolutionised lesion characterisation and is currently the modality of choice for imaging hepatic masses. consideration of imaging characteristics in conjunction with clinical and laboratory data allows the formulation of a focused differential diagnosis. acknowledgements we would like to thank the ct staff for their assistance in collecting and sorting films. references 1. jabra aa, fishman ek, taylor ga. hepatic masses in infants and children: ct evaluation. air 1992; 158 (1): 143-149. 2. bellani ff, massimino m. liver tumours in childhood: epidemiology and clinics. i surg oncal supp11993; 3: 119-121. 3. jacobs je, birnbaum ba. computed tomography imaging of focal hepatic lesions. semin roentgen 1995; 30 (4): 308-323. 4. stevenson rj. abdominal masses. surg clin north am 1985; 65 (5): 1481-1504. 5. foley wd, jochem rl. computed tomography focal and diffuse liver disease. radiol clin north am 1991; 29 (6): 1213-1233. 6. donnelly lf, bisset gs. paediatric hepatic imaging. radiol clin north am 1998; 36 (2): 413427. evidence of infection patients with chd are more susceptible to lower respiratory tract infections. it is vitally important that any report on a chest x-ray of a child with chd mentions the presence or absence of features of infection. often a lower respiratory tract infection leads to decompensation and admission to hospital. infection may be acute or chronic and in the south african context features of tuberculosis must be excluded. conclusion with the above approach, the radiologist will hopefully be able to offer useful reports to the clinicians managing patients and thus play an integral role in the multidisciplinary management of patients with congenital heart disease. references 1. crowley jj. telltale signs of congenital heart disease. the radiologicalclinics of north amenca, 1993; 31: 573-582. 2. dow j, pearson m. congenital heart disease. in: sutton d. a textbookofradiology and imaging. 3'd ed. london: churchill livingstone.l980: 529-594. 3. graiger rg. congenital heart disease general principles. in: grainger rg, allison dj (eds). diagnostic radiology:a textbook of radiologyand imaging. 3,d ed. new york: churchill livingstone.l997: 657-673. 4. marowitz ri. the effects of congenital heart disease on the lungs. seminars in roengenology,1998; 33: 126-135. 44 sa journal of radiology. february 2001 case reports condensing osteitis of the clavicle gcooi frcr(uk) wcgpeh frcr(uk) department of diagnostic radiology, the university of hong kong, queen mary hospital, hong kong abstract condensing osteitis of the clavicle is a rare benign condition of unknown aetiology which afflicts women of child-bearing age. it is characterised radiologically by sclerosis of the infero-medial aspect of the clavicle, with preservation of the sternoclavicular joint in the early stages of the disease. the clinico-radiological features of this condition are discussed in this review, together with other conditions which resemble this entity. introduction condensing osteitis of the clavicle is a rare benign but painful disorder of unknown aetiology:it is characterised radiographically by sclerosis of the medial end of the clavicle, without involvement of the sternoclavicular joint. this term is actually a misnomer, as inflammation is not recognised to be a component of this disorder. i jurick (1994) in a recent comprehensive review of the literature, found 62 reported cases of what she termed "noninflammatory sclerosis of the clavicle", in addition to 14 of her own cases/ besides "condensing osteitis", other descriptive terms used include "friedrich's disease"," "post-traumatic reactive and resorptive lesions of the medial end of the clavicle"," "non-inflammatory sclerosis? and simply, "sclerotic changes" of the sternal end of the clavicle.this paper aims to review the clinical and imaging features of patients with condensing osteitis of the clavicle and other similar entities. corrclerrsirig osteitis condensing osteitis of the clavicle was first identified as a distinct entity by brower et al (1974),7 their original description of the clinical, radiographic and histological features of this lesion, with symptomatic relieffollowing surgical excision in two young women, has subsequently been recognised by several other workers. to date, about 30 cases of condensing osteitis, mainly in the 25 sa journal of radiology. may 1996 form of case reports, have been documentedinfnglishliterature'<-" nearly all affected patients were adult women (96%) aged between 26 to 69 years (mean age of 4 5 years). the majority complained of pain and! or swelling of the medial end of the clavicle. in some cases, the pain radiated to the supraclavicular fossa and ipsilateral shoulder; aggravated by abduction or forward movement of the shoulder. the pain was usually mild but could be severe, with duration of symptoms varying from 4 weeks to 5 years. in about half of the reported cases,there was an assedation with minor stress or repetitive physical activity, such as lifting of heavy weights or sportsrelatedactivity.,,2,7'22 van holsbeek (1992) postulated that the clavicular sclerosis may be secondary to chronic abrasion of a spontaneously subluxing sternoclavicular joint20 the radiographic features are characteristic, comprising dense sclerosis at the inferior aspect of the medial clavicle, often associated with mild bony expansion. a hook-like osteophyte arising from the infero-medial aspect of the clavicle has also been recognised as a feature of this condition (figure 1). the sternoclavicular joint space is not narrowed, at least in the early figure 1: 70-year old woman with dense sclerosis of the right medial clavicle. note associated inferior osteophyte (arrowed). the left clavicle is normal. stages of the disease, with preservation of the articular surfaces. periosteal reaction and bony destruction are absent. jurick (1994) in a follow-up study of il patients with condensing osteitis, demonstrated topage26 condensing osteitis of the clavicle regression of bony sclerosis and development of adjacent osteoarthritis with time. 2 computed tomography (cf) depicts accurately the extent and nature of bone involvement. it demonstrates the preservation of the sternoclavicular joint, the sclerotic involvement of the sternal end of the clavicle and excludes a destructive or aggressiveprocess. the bone marrow cavity is typically obliterated, with soft tissue swelling occasionallyreported (figures2 and 3).1,11,12,14-20these lesions also produce figure 2: 63-year old woman with condensing osteitis. (c) preservation of ihe adjacenl sternoclavicular joint. figure 3. reformatted oblique coronal ct image demonslrates typical site of clavicular sclerosis (arrowheads), as well as degeneralive changes at its articulation with the calcified right first costal carlilage (arrowed). the sternoclavicular joint is relatively unaffected. markedly increased focal tracer uptake on isotope bone scans, corresponding to the site ofbony sclerosis (figure 4).1,8-17,19,21magnetic resonance imaging is useful in figure 4: isotope bone scan (tc-99m methylene dlphosphonate, 2 hour delay) in a 67-year old woman with condensing osteitis. right anterior oblique projection of the chest shows an intense area of increased uptake at the medial end of the right clavicle (arrowhead). the sternum is arrowed. confirming the benign nature of the clavicular sclerosis, demonstrating areas of hypointense signal intensities on both spinecho tl andt2 weightedimages21,23which represent the regions of sclerotic bone. the histological features of condensing osteitis are an increased amount of normal bone with marrow obliteration, thickened cancellous bone and trabecular reinforcement.1,7,11,14-17,19,23someauthorshavealso~ ported marrow fibrosis and osteonecrosis, suggesting a low-grade ischaemie 26 sa journal of radiology. may 1996 process.i,14,17,23thetrue cause of condensing osteitis is unknown, although it is generally accepted as representing a response to mechanical stress which particularly affects women of child-bearing age. symptomatic patients should be managed with nonsteroidal anti-inflammatory drugs and limitation of physical activities. if the diagnosis is in doubt or ifthe patient is refractory to conservative treatment, excision of the medial end of the clavideisrecommended.v'é-" friedrich's disease friedrich's disease is ischaemie necrosis of the medial clavicular epiphysis. itis a rare disorder, with only 28 cases having been reported to date.2-4 clinically, the presenting signs and symptoms are similar to that of condensing osteitis. there is painful swelling over the sternoclavicular joint, which may be aggravated by movement. unlike condensing osteitis, however, friedrich's disease is not confined to the adult population, and in fact typically afflicts children and adolescents. the radiological appearances may resemble those of condensing osteitis but careful examination of plain radiographs will demonstrate that the entire medial end of the clavicle is sclerotic, with fragmentation and a notch-like defect at the articular surface.these lesions appear hot on isotope bone scans,hence are scintigraphically indistinguishable from condensing osteitis.the disease is often self limiting with eventual normalisation of radiographic appearance after conservative treatment. necrosis, with fibrosis of the marrow cavity and empty lacunae, is the main histological feature of friedrich' s disease. trauma or an embolic event at the medial clavicular epiphysis is believed to cause the ischaemie necrosis that isthe hallmark of this condition/" topage27 condensing osteitis of the clavicle other lesions which may resemble condensing osteitis chronic recurrent osteomyelitis is an unusual condition usually affecting children. with clavicular involvement, development of hyperostosis and bony enlargement may mimic condensing osteitis." appell et al (1983) used the term condensing osteitis to describe marked sclerotic enlargement of the medial two-thirds of the clavicle associated with periosteal reaction in seven girls (aged 7 to 15), three of whom had multifocal bone involvement. all cases had raised erythrocyte sedimentation rates,two had high white cell count while four responded to antibiotics." jones et al (1990) described radiographic findings of marked expansion and sclerosis of the medial two-thirds of the clavicle, with thick dense periosteal reaction, in 3 children. bone biopsies confirmed chronic osteomyelitis in one patient and non-specific inflammatory changes in the other two. the patients responded to antibiotics leading to the authors to suggest that condensing osteitis could be a form of low grade osteomyelitis. 25 the consensus in subsequent reviews was that these authors reported cases of chronic recurrent multifocal osteomyelitis, which differed clinically and radiologically from condensing osteitis,': 17,23,26 apter et al (1992) described posttraumatic reactive and resorptive lesions of the medial end of the clavicle in 3 young soldiers, biopsy of which showed new bone formation and chronic inflammation. these changes were thought to be stress-related.' stemocostoclavicular hyperostosis is another condition which typically affects the medial end of the clavicle, as well as other juxtasternal 8. teates cd, brower ac, williamson brj et al. bone scans in condensing osteitis of the clavicle. southem medical jouma/1978; 71: 736-738. 9. simpson ai. positive bone scintigraphy in cond nsing osteitis of the clavicle. clinical nuclear medicine 1978;3:204. 10. duro k, estrada p, ribas detal. condensing osteitis of the clavicle. anhritis and rheumatism 1981 ;24: 14541455. structures. unlike condensing osteitis, it afflicts older male patients who present with bilateral painful anterior chest wall swellings and pustular lesions of the palms and soles. about 200 cases have been reported to date." other differential diagnoses of medial clavicular lesions which may be considered include sternoclavicular joint pyoarthrosis, septic arthritis and osteoarthritis, and miscellaneous conditions like osteoid osteoma and fibrous dysplasia.v' summary despite some similarity in presenting signs and symptoms, with careful radiological assessment one should be able to differentiate condensing osteitis from friedrich's disease and the other conditions that resemble this entity. the selective sclerotic involvement of the inferomedial aspect of the claviclein women of child-bearing age,in the absence of constitutional symptoms, should lead one to the correct diagnosis.recognition of this condition should spare the patient from further unnecessary and potentially invasive investigations. references 1. greenspan a, gerscovich e, szabo rm et al. condensing osteitis of the clavicle: a rare but frequently misdiagnosed condition. american journal of rtxintgmology 1991; 156: 1oil-lois. 2. jurickag. noninflammatory sclerosis of the sternal end of the clavicle: a follow-up study and review of the literature. slleletalradiology 1994;23:373-378. 3. levy m, goldberg i, fischel re et al. friedrich's disease. ase~tic necrosis of the sternal end of the clavicle. journal at bone and joint surgery 1981 ;63b:539-541. 4. christensen pb and christensen i. a case of friedrich's disease of the clavicle. acta cmhopaedica scandinavica 1987;58:585-586. 5. apter s, hertz m, salai m et al. post-traumatic reactive and resorptive lesions of the medial end of the clavicle. clinical imaging 1992; 16:40-42. 6. jurickag, de carvalho a, graudal h. sclerotic changes of the sternal end of the clavicle. clinical radiology 1985;36:23-25. 7. brower ac, sweet de, keatste. cond nsing osteitis of the clavicle: a new entity. american journal of roentgmo!ogy 1974;121:17-21. 27 sa journal of radiology· may 1996 11 . cone ro, resnick 0, goergen tg et al. endensing osteitis of the clavicle. ame11can loumal a/roel1tgel1ology 1983;141:387-388. 12. weiner sn, levy m, bernstein r et al. condensing osteitis of the clavicle. journal of bone and joint surgery 1984;66a 1484-1486. 13. harnilton-wood c, hollingworth p, dieppe petal. the painful swollen sterno-clavicular joint. the british jou mal of radiology 1985;58:941-945. 14. franquet t lecumberri f, rivas a et al. cond nsing osteitis of the clavicle.skeletal rndiology 1985; 14: 184-187. 15. kruger gd, rock mg, munrotg. condensing osteitis of the clavicle. journal ofbol1e and joint surgery 1987;69a5so.557. 16. stewart ca, siegel me, king d et al. radionuclide and radiographic demonstration of condensing osteitis of the clavicle.cii11icalnudear medicine 1988; 13:177-178. 17. outwater e, oates e. condensing osteitis of the clavicle: case report and review of the literature. journal of nuclearmedicil1e 1988;29:1122-1125. 18. smith j, yuppa f, watson re. primary tumors and tumor-lik lesions of the clavicle. skeletal radiology 1988;17:235-246. 19. abdelwahab if, hermann g, ramos r t al. case report 623. skeletal radiology 1990; 19:387-389. 20. van holsbeek m, van melkebeke j, dequ ke.r jet al. radiographic findings of spontaneous subluxation of the sternoclavicular joint. clinical rheumatology 1992;11:376-381. 21. vierboom mac, steinberg jdj, mooyaart el et al. condensing osteitis of the clavicle: magnetic resonance imaging as an adjunct method for differential diagnosis.annals of the rheumatic diseases 1992;51:539-541. 22. latin hr, giiuia la. imaging rounds. orthopaedic review 1992;21:767-774. 23. resnick d. endocrine diseases. in: resnick 0 ed. diagnosis of bone and joim disorders, 3rd ed. philadelphia: we saunders co, 1995. 24.appell rg, oppermann hc, beckerwetal. condensing osteitis of the clavicle in childhood: a rare sclerotic bone lesion. pediatric radiology] 983;13:301-306. 25. jones m\n; carty h, taylor jf et al. cond nsing osteitis of the clavicle: does it exist? journal of balle and jointsurgety 1990;723:464-467. 26. kerr r, resnick d. condensing osteitis of the c1avicle.journalofboneand joint surgery 1992;74b: 163-164. 27. saghaf m, henderson mj, buchanan ww. sternocostoclavicular hyperostosis. semillars in anhritisal1drheumatism 1993;22:215-223. abstract introduction research methods and design results discussion study limitations conclusion acknowledgements references about the author(s) john fox department of radiology, universitas academic hospital complex, university of the free state, bloemfontein, south africa gina joubert department of biostatistics, university of the free state, bloemfontein, south africa eugene loggenberg department of radiology, universitas academic hospital complex, university of the free state, bloemfontein, south africa citation fox j, joubert g, loggenberg e. tunnelled haemodialysis catheters in central free state: epidemiology and complications. s afr j rad. 2019;23(1), a1791. https://doi.org/10.4102/sajr.v23i1.1791 original research tunnelled haemodialysis catheters in central free state: epidemiology and complications john fox, gina joubert, eugene loggenberg received: 09 aug. 2019; accepted: 03 oct. 2019; published: 27 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: end-stage renal disease (esrd) is a disease with profound impact on the patient, health system and economy. tunnelled haemodialysis catheters (tdc) are amongst the most common dialysis methods. it has been established internationally that certain demographic descriptors and aetiologies carry an increased risk of complications. there is a dearth of epidemiological profiling of esrd patients with tdc in south africa. objective: to establish the epidemiological profile of patients who received tdc and to establish the complication rate, with the goal of demonstrating associations between the epidemiological profiles and complications. method: this was a retrospective study of all patients who received tdc in an academic hospital interventional radiological suite over a period of 60 months between 01 march 2011 and 29 february 2016. results: a total of 179 patients received 231 catheters. the majority of patients were male (58.7%) and 35.8% of the patients resided in mangaung. the leading aetiologies of esrd included hypertensive nephropathy (43.6%), primary glomerular disease (17.3%) and hiv-associated nephropathy (6.1%). procedural complications occurred in 7/224 (3.1%) insertions, whilst 37/185 (20.0%) developed catheter-related infection and 54/185 (29.2%) developed dysfunctional catheters. there were no deaths linked to catheter-related complications. conclusion: our patients’ demographic profile, esrd aetiology, complication rate for procedural complications and catheter-related infections are roughly on par with international studies; however, the catheter dysfunction rate is higher than in the aforementioned studies. this possibly reflects the difficulty of accessing specialist care for our patients, the majority of whom reside outside the mangaung district. further studies with larger sample sizes are required to demonstrate statistically relevant associations. keywords: end-stage renal disease; tunnelled haemodialysis catheters; epidemiological profile; complication rate. introduction end-stage renal disease (esrd) is an increasing healthcare concern across the world with a high mortality rate and associated economic implications, particularly in southern africa, where it affects a younger demographic than in developed countries.1,2 an effective screening programme would assist in early nephrologist or renal centre referral which is shown to have an impact on decreasing the morbidity and mortality of these patients.3,4 in state healthcare, 44.1% of the dialysis population is managed with haemodialysis and at our institution a large portion of the dialysis population undergo tunnelled haemodialysis catheter insertion either for temporary vascular access (whilst grafts or fistulae mature or the peritoneum recovers) or when other vascular access routes are exhausted.5 tunnelled haemodialysis catheters (tdc) do offer some advantages, including immediate dialysis and no repeated venepuncture. however, they are associated with an increased risk of complications and significant mortality when compared with other types of vascular access, with a 1-year survival of patients on tdc of 75%.3,6 based on studies in china and croatia, multiple risk factors have been demonstrated to carry an increased risk of complications.3,7 however, no local study has assessed our complication rate and investigated epidemiological risk factors. filling this void would assist in the implementation of focused and effective screening programmes. the goal of this study was multifactorial. we aimed to establish the epidemiological profile of patients at an academic hospital, who received tdcs at the interventional radiological unit over a 60-month period, to establish the complication rate within that population group and to determine if associations between the risk factors, epidemiological data and complications could be established. research methods and design study design and setting this was a retrospective, analytic study conducted at an academic hospital interventional radiology unit, which serves the population of the free state province, as well as occasional out of province and private patients. study population and sampling strategy the study population consisted of all state patients who received tdcs at an academic hospital interventional radiology unit during the period of 01 march 2011 to 29 february 2016. all patients aged 18 years and older, who received their catheter at the interventional suite, were included. catheter insertion catheters were inserted by an experienced interventional radiologist in the interventional unit via percutaneous access. the procedure was performed under sterile theatre conditions with ultrasound guided venous access. all tdcs inserted in our centre are cuffed. the catheter is tunnelled subcutaneously for approximately 9 cm – 10 cm from the venous access site. the catheter is then placed under fluoroscopic control with tip positioning in the right atrium. cutaneous fixation is created with sutures until cuff adhesion – approximately 8–12 weeks. initial patency and positioning are confirmed during the procedure. the catheter is then locked with heparin (1000 μ/ml) the primary goal for access was the internal jugular vein. however, in patients with previous access and complications, other sites were used. subclavian access was used when no other access site was available. secondary intervention in patients where the catheter is unable to maintain adequate extracorporeal blood flow and thrombolytic therapy (alteplase) has been ineffective, brushing is performed in the interventional unit under fluoroscopic guidance and sterile conditions to displace and remove the fibrin sheath (a composite of cells and debris that forms a biofilm around catheters that can obstruct the lumen, acting as a valve) or thrombus by using a terumo guidewire to sound the catheter lumen and rinse the lumen with saline. the catheter is then locked with heparin, 1000 μ/ml. if brushing fails to restore patency, then snaring is employed – vascular access is gained from another site and mechanical stripping of the catheter tip is performed via a snare. data collection patients were identified using the procedural register and further information was gathered from existing electronic medical records. a comprehensive data sheet was completed. details captured included date of birth, age at catheter insertion and residence. aetiology was grouped into diabetes, primary glomerular disease (including nephrotic syndrome, acute glomerulonephritis and rapidly progressive glomerulonephritis), hypertensive nephropathy, acute renal failure, obstructive uropathy, renal tubular interstitial diseases (including acute tubular necrosis, tubulointerstitial nephritis, contrast nephropathy, reflux nephropathy and myeloma), human immunodeficiency virus associated nephropathy (hivan), drug induced nephropathy, polycystic kidney disease and unknown. for ease of analysis, complications were grouped into procedural complications (air embolism, bleeding and pneumothorax), catheter-related infection and catheter dysfunction (malposition, thrombosis, fibrin sheath, central vein stenosis and loosening or catheter breakage). further details recorded included whether the catheters underwent repair or brushing and if they were removed because of complications, fistula maturation or peritoneal dialysis catheter use. in the cases of patient demise, it was noted whether this was a result of catheter-related complications or other causes. primary and secondary patency was calculated. primary patency is regarded as the time duration of catheter patency until the first intervention required to maintain patency whilst secondary patency is regarded as the length of time from insertion until catheter removal because of complication or catheter failure.8 data analysis the primary researcher entered all the data onto an excel data sheet, which was then submitted for statistical analysis by the department of biostatistics at the university. results were summarised as frequencies and percentages (categorical variables) and means, standard deviations and percentiles (numerical variables). associations were investigated using appropriate hypothesis testing with p <0.05 considered statistically significant. ethical considerations ethical clearance was obtained from the health sciences research ethics committee of university of free state (hsrec 62/2017) and free state department of health (ufs-hsd2017/0478). results a total of 179 patients received tdcs during the study period and qualified for the study. in the study sample, 105 were male (58.7%) and 64 (35.8%) resided in mangaung district. the mean age at insertion was 40.4 years with a standard deviation of 12.05. the four leading aetiologies were hypertensive nephropathy, primary glomerular disease, hivan and unknown aetiology (see table 1 for more information). table 1: aetiology per patients (n = 179). the patients received 231 catheters. a hundred and fifty-eight patients had catheters inserted for the first time. the majority of patients (141, 77.3%) received one catheter, 25 patients (14.0%) received two, 10 patients (5.6%) received three, 1 patient (0.6%) received four and 1 patient (0.6%) received five catheters during the study period. of the 231 catheters inserted, 224 (97.0%) had information regarding insertion and 185 (80.1%) had information regarding follow up. the majority of lines were inserted in the right internal jugular vein, with the left internal jugular vein insertion being the second as per table 2. table 2: site of insertion (n = 224). procedural complications occurred in 3.1% of insertions whilst 20.0% developed catheter-related infections and 29.2% developed complications related to dysfunction (see table 3 for further breakdown). table 3: complications and incidence. the mean age at insertion varied between the complication groups: in the catheter-related infection group, the mean age was 37.5 years; in the procedural complication group, mean age was 40.2 years; and in the catheter dysfunction group, mean age was 39.8 years. table 4 summarises the patient characteristics, complications recorded and the associations between them. table 4: complications and associations per catheters. out of the 231 catheters, 45 catheters (19.5%) had incomplete follow up. of the catheters with adequate follow up, 4.3% went on to receive catheter repair, 17.7% required a single brushing, 5.4% received two brushings and 3.2% received three brushings, with a primary patency rate of 98 days. complications resulted in 27.9% of the catheters being removed whilst 32.3% were removed because of fistulas and 18.8% because of peritoneal dialysis being initiated or resumed. no patients demised because of catheter-related complications, whilst 10.2% of the patients demised because of other causes. secondary patency rate was 87.0% at 6 months and 76.1% at 12 months. discussion the high financial burden of esrd has a considerable impact on the limited resources of the south african health system. therefore, it would be of benefit if there was earlier diagnosis and efficient management of renal disease, preventing or delaying the progression to esrd. the academic hospital interventional radiology unit assists with tdc insertion for a large percentage of the free state dialysis population as it can be demonstrated by considering that in 2016 the free state had 235 patients on dialysis; our study population over the five year period numbered 179 patients.5 despite the increased risk of infection and mortality compared with fistulae or grafts, tdcs remain an important part of dialysis patient care.9,10,11 the epidemiological analysis of the study population revealed that the patient’s age (mean of 40.4 years) was in keeping with a local south african study on esrd, but younger than studies from other african countries and developed countries where renal failure is predominantly a diagnosis of the middle aged and the elderly.1,2 male patients formed 58.7% of the sample; this corresponds to previously reported rates in africa of 61% – 63% male gender in renal failure patients.1 the female proportion of the study population experienced the majority of the complications, however, the gender discrepancy was not found to be statistically significant, which is also in keeping with an international study which indicated that patient gender did not impact catheter survival.12 a significant percentage (64.2%) of the study population resided outside the mangaung district with implications in terms of ease of access to specialised medical services and further management of the tdc and the patient. the patients outside the mangaung district experienced the majority of the complications (57% – 68%) across all three complication groups although the discrepancies were not statistically significant. end-stage renal disease aetiology was similar to other studies in africa with hypertension being the most commonly recorded cause in 43.6% of patients versus 34.6% (sudan) and 30.9% (cameroon). further common causes in our study included primary glomerular disease and hivan. in cameroon, other aetiologies included glomerulonephritis (15.8%), diabetes (15.9%), hivan (6.6%) and unknown (14.7%).13 in a sudanese study the causes included chronic glomerulonephritis (17.6%), diabetes (12.8%) obstructive uropathy (9.6%) and in 10.7% no cause was identified.1 hypertension as an aetiology constituted a larger percentage of this study population than international studies although it is difficult to determine whether this was primary hypertension or secondary to chronic kidney disease. additionally, this study had a high percentage of patients with an unknown cause. these findings could be a reflection on the lack of efficient primary healthcare with many patients presenting late in the course of the disease and not receiving renal biopsies. the majority of catheters were inserted in the right jugular vein, with no statistically significant discrepancy between site of insertion and procedural or dysfunctional complication rate, however, there was a statistically significant correlation between catheter-related infection and insertion of the catheter in either femoral site. in a study by dewelter et al, it was demonstrated that right jugular insertion confers a significantly improved outcome as compared with other sites of insertion.14 this study, as compared with a study in pakistan, had a decreased incidence of procedure-related complications (3.2% vs. 5.6%) but an increased rate of catheter-related infection (20% vs. 17.3%) as well as dysfunction-related complications (29.2% vs. 16%).15 the increased incidence of catheter-related infection and complications causing dysfunction reflect perhaps the difficulty for our patients in accessing specialist care after the procedure, particularly if they reside in another district. in light of the above, it might be of value to consider a chronic low dose of aspirin to maintain tunnelled central venous catheter (cvc) patency.16 catheter-related infections remain a significant problem within the dialysis population with implications for cost of care and patient quality of life, as patients with catheter-related infections have an average hospital stay of 6.5 days, undergo several tests and receive treatment during the hospital stay.17 considering the incidence of catheter-related infections, future studies could analyse the benefit of antimicrobial barrier caps in reducing this rate, as per the kidney disease outcomes quality initiative (kdoqi) guidelines from the national kidney foundation.16 the secondary patency rate is better than a study in india at 6 months (87.0% compared with 55%) and the 12-month catheter survival rate falls within the wide range found in a previous review article of 2007 (between 25% – 75%).8,18 a high percentage of the catheters were removed because of initiating or resuming peritoneal dialysis or use of fistulae. this is perhaps because of the increased number of patients in state healthcare who are on peritoneal dialysis compared with private healthcare (27.8% vs. 6%).5 there were no deaths in our study because of catheter-related complications. the aetiology in the study population, on average, did not have a statistically significant impact on the complication rate although other studies have shown that diabetes conveys increased risk and that age can have an influence additionally.7 polycystic kidney disease was shown to have an increased risk of catheter-dysfunction-related complications. the reason for this is unknown and merits further investigation. although our study was unable to establish a statistically significant association between demographics, aetiology and complications in the majority of cases, we were, however, able to demonstrate an association between femoral site catheter insertion and the risk of catheter-related infection; and between patients with polycystic kidney disease and an increased risk of catheter dysfunction. studies have shown that associations exist between several patient characteristics (male gender, increased age, diabetic nephropathy, hypertensive nephropathy and glomerulonephritis) and their risk of complications.3,7 study limitations many patients who had their catheter inserted and were then managed further in other centres were lost to follow up, resulting in incomplete information, particularly with regards to catheter-related infection and dysfunctional catheter complications. a further challenge was the relative paucity of renal biopsies to confirm the esrd aetiology. conclusion our demographics, aetiology of esrd and complication profile largely correspond to other studies except for an increased complication incidence in females, an increased percentage of hypertension as the cause for esrd and an increased percentage of catheter dysfunction complications. these findings are perhaps a reflection on the challenges our primary healthcare system faces and the difficulty for these patients to access specialist care in the periphery. because of the limited number of patients and complications, this study was unable to establish statistically significant correlations between complications and epidemiological factors in many of the measured characteristics. in our setting, given pre-existing research that has demonstrated a decreased risk of complications with early referral to specialist care and dialysis initiation with other vascular access options (besides tdc),4 it would be optimal to create a screening programme for high risk patients (ht, dm).2 if a south african multicentre study with a larger study population was able to confirm local risk factors for complications, then appropriate care centres could implement protocols for increased vigilance and screening for complications in the vulnerable population groups. this could also lead to and assist with the formation of local guidelines for the management of dialysis such as the kodqi 2018 guidelines.16 together, these could assist in early identification of patients at risk of developing esrd and lead to earlier referral to specialist care which has been shown to have a positive effect on patient outcome.4,18,19,20 acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions j.f. was the principal investigator who designed the study, conducted the literature review, obtained ethical clearance and statistical input, captured the data, processed the data and wrote the final manuscript; e.l. was the study leader, who conceptualised the study, assisted with literature review, critically analysed the manuscript and approved the final version; g.j. was the third author who assisted with the study protocol, provided statistical analysis of the data and critical analysis of the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer any opinions and views expressed in this article are the authors’ own and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references banaga a, mohammed e, siddig r, et al. causes of end stage renal failure among haemodialysis patients in khartoum state/sudan. bmc res notes. 2015;8(1):1–7. https://doi.org/10.1186/s13104-015-1509-x naicker s. burden of end-stage renal disease in sub-saharan africa. clin nephrol. 2010;74(suppl. 1):s13–s16. https://doi.org/10.5414/cnp74s013 pašara v, maksimović b, gunjača m, et al. tunnelled haemodialysis catheter and haemodialysis outcomes: a retrospective cohort study in zagreb, croatia. bmj open. 2016;6(5):e009757. https://doi.org/10.1136/bmjopen-2015-009757 astor bc, eustace ja, powe nr, klag mj, fink ne, coresh j. type of vascular access and survival among incident hemodialysis patients: the choices for healthy outcomes in caring for esrd (choice) study. j am soc nephrol. 2005;16(5):1449–1455. https://doi.org/10.1681/asn.2004090748 davids mr, jardine t, marais n, jacobs jc. south african renal registry annual report 2016. afr j nephrol. 2018;21(1):60–72. https://doi.org/10.21804/21-1-3298 moist l, trpeski l, na y, lok ce. increased hemodialysis catheter use in canada and associated mortality risk: data from the canadian organ replacement registry 2001–2004. clin j am soc nephrol. 2008;3(6):1726–1732. https://doi.org/10.2215/cjn.01240308 wang k, wang p, liang x, lu x, liu z. epidemiology of haemodialysis catheter complications: a survey of 865 dialysis patients from 14 haemodialysis centres in henan province in china. bmj open. 2015;5(11):e007136. https://doi.org/10.1136/bmjopen-2014-007136 bagul a, brook n, kaushik m, nicholson m. tunnelled catheters for the haemodialysis patient. eur j vasc endovasc surg. 2007;33(1):105–112. https://doi.org/10.1016/j.ejvs.2006.08.004 lok ce, foley r. vascular access morbidity and mortality: trends of the last decade. clin j am soc nephrol. 2013;8(7):1213–1219. https://doi.org/10.2215/cjn.01690213 ravani p, palmer sc, oliver mj, et al. associations between hemodialysis access type and clinical outcomes: a systematic review. j am soc nephrol. 2013;24(3):465–473. https://doi.org/10.1681/asn.2012070643 napalkov p, felici dm, chu lk, jacobs jr, begelman s. incidence of catheter-related complications in patients with central venous or hemodialysis catheters: a health care claims database analysis. bmc cardiovasc disord. 2013;13:86. https://doi.org/10.1186/1471-2261-13-86 fry ac, stratton j, farrington k, et al. factors affecting long-term survival of tunneled haemodialysis catheters – a prospective audit of 812 tunnelled catheters. nephrol dial transplant. 2008;23(1):275–281. https://doi.org/10.1093/ndt/gfm582 halle mp, takongue c, kengne ap, kaze ff, ngu kb. epidemiological profile of patients with end stage renal disease in a referral hospital in cameroon. bmc nephrol. 2015;16:59. https://doi.org/10.1186/s12882-015-0044-2 develter w, de cubber a, van biesen w, vanholder r, lameire n. survival and complications of indwelling venous catheters for permanent use in hemodialysis patients. artif organs. 2005;29(5):399–405. https://doi.org/10.1111/j.1525-1594.2005.29067.x sayani r, anwar m, tanveer-ul-haq, al-qamari n, bilal ma. outcome of radiologically placed tunnelled haemodialysis catheters. j coll physicians surg pak. 2013;23(12):837–841. gilmore j. kdoqi clinical practice guidelines and clinical practice guideline for vascular access. ajkd submission draft. national kidney foundation [homepage on the internet]; 2019 [cited 25 sep 2019]. available from: https://www.kidney.org/sites/default/files/kdoqi_vasc-access-review2019_v2.pdf bisiwe f, van rensburg b, barrett c, van rooyen c, van vuuren c. haemodialysis catheter-related bloodstream infections at universitas academic hospital, bloemfontein: should we change our empiric antibiotics? s afr j infect dis. 2015;30(1):29–33. https://doi.org/10.1080/23120053.2015.1103960 sampathkumar k, ramakrishnan m, sah ak, sooraj y, mahaldhar a, ajeshkumar r. tunneled central venous catheters: experience from a single center. indian j nephrol. 2011;21(2):107–111. https://doi.org/10.4103/0971-4065.82133 lacson e, wang w, lazarus jm, hakim rm. change in vascular access and mortality in maintenance hemodialysis patients. am j kidney dis. 2009;54(5):912–921. https://doi.org/10.1053/j.ajkd.2009.07.008 ethier j, mendelssohn dc, elder sj, hasegawa t, akizawa t, akiba t et al. vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study. nephrol dial transplant. 2008;23(10):3219–3226. https://doi.org/10.1093/ndt/gfn261 pdf file case report neurofibromatosis type 2 a case study h g kritzinger mbchb department of diagnostic radiology university of the free state, bloemfontein case presentation a 56-year-old black male patient presented with bilateral neuronal deafuess as well as a large lump on his right forehead, subcutaneous nodules (5 in total and not very prominent) and axillary freckles were also visible on his skin. computed tomography (ct) and magnetic resonance imaging (mri) revealed intracranial masses against the skull roof (figs i, 2), bilateral masses at the internal acoustic channels (figs 3, 4) as well as a mass anterior to the right temporal lobe (fig. 5). splaying of the internal acoustic channels was present suggesting acoustic neuromas (fig. 3). prominent enhancement was visible after intravenous contrast. the lesions at the skull roof showed much more enhancement than the lesions at the skull base (cerebello-pontine angle). calcifications were also visible in the superior lesions. biopsy of the lesion on the patient's forehead confirmed this lesion to be a meningioma. a diagnosis of neurofibromatosis type 2 (nf-2) was made. the patient did not receive surgery due to the advanced stage of the disease and was irradiated palliatively.he is currently being treated at oncotherapy. what made this case interesting was the late age at which this patient presented and that he was the first black patient to present with nf-2 at our hospital complex. discussion disease the first probable case of nf-2 was reported in 1820 when a doctor named wishart described a patient with multiple tumours he had examined at postmortem. neurofibromatosis type 1 (nf-l) and nf-2 fig. 1. coronal n·weighted image showing protruding mass on forehead to be of intracranial origin. 37 sa journal of radiology • june 2002 are autosomal-dominant genetic disorders in which affected individuals develop both benign and malignant tumours at an increased frequency. nf-2 is a different disease from von recklinghausen's neurofibromatosis, nf-i. nf-2 is a rare multisystem genetic disorder associated with bilateral vestibular schwannomas, spinal cord schwannomas, meningiomas, gliomas, and juvenile cataracts with a paucity of cutaneous features. all fig. 2. axial n·weighted image with contrast showing meningiomas. fig. 3. axial t2·weighted image showing vestibular schwannomas; note splaying of internal auditory meati on both sides. case report fig. 4. axial n-welghted image with contrast showing vestibular schwannomas. fig. 5. axial n-welghted image with contrast showing mass anterior to right temporal lobe. races and ethnic groups are affected equally with nf-2.' although the genetic change causing nf-2 is present at conception, the clinical manifestations occur over many years. the typical age of onset of symptoms is in the late teens to early 20s, but the age range covers the entire life span. patients present before the age of 55 years. some evidence indicates that age of onset of clinical symptoms is lower in maternally transmitted nf2. while nf-2 is quite variable in severity from person to person, family studies have shown some intrafarnilial consistency in age of onset. 2.3 diagnosis in children is often difficult because of the absence of central nervous system (ens) involvement at young age.'.4 the severity of the disease ranges from appearance in childhood with large numbers of crippling and fatal tumours, to mild cases with slow-growing and fewer tumours appearing later in life. this seems to be related to the difference in the nf2 gene. data suggest that there are two types of nf-2 genes, one with later onset and bilateral vestibular schwannomas as the only usual feature and the other with earlier onset and multiple other tumours." vestibular schwannomas are the most common and well-recognised feature of nf-2 leading to significant morbidity. although unilateral hearing loss is the number one presenting symptom, eventually bilateral deafness would be expected in most affected individuals. untreated vestibular schwannomas can extend locally and may result in brainstem compression, hydrocephalus and occasionally facial nerve palsy.' dumbbell-shaped spinal cord schwannomas are quite common in nf-2 and result in significant morbidity; they present a great therapeutic challenge. spinal cord ependymomas, astrocytomas, and meningiomas also occur, but less frequently. intracranial meningiomas, on the other hand, are a frequent finding and may cause a variety of symptoms and ens deficits.' posterior subcapsular or so-called 'juvenile cataracts' can predate ens symptomatology. these cataracts may progress over time, leading to decreased visual acuity. a fair percentage of affected individuals are found 38 sa journal of radiology • june 2002 to have retinal hamartomas or epiretinal membranes that mayor may not be visually significant.' the most common ocular abnormalities are posterior subcapsular or capsular, cortical or mixed lens opacities.' the diagnosis ofnf2 in the paediatric age group requires a high degree of suspicion and should be considered in children with multiple ens or skin tumours without cafe-au-lait spots or lisch nodules," presenting symptoms include hearing loss, ringing in the ears, and balance problems associated with vestibular nerve lesions. individuals at risk for nf-2 should be screened carefully for early signs of hearing loss, motor or sensory changes, and visual deficits. deafness is sometimes accompanied by tinnitus.' rare clinical findings are muscle weakness or wasting, seizures, vertigo, numbness and tingling.' differentiating clinically between the relatively common nf-l and the rare nf-2 is occasionally problematic. patients with nf-2 almost never have a large number of cafe-au-lait spots (although rarely 6 or more may be seen), whereas cafe-au-lait spots are numerous and ubiquitous in nf-i. neither axillary nor inguinal freckles are common occurrences in nf2. malignant transformation of benign growths is almost unheard of in nf-2, unlike nf-i. however, individuals with either nf-l or nf-2 can develop multiple subcutaneous lesions that may be clinically indistinguishable. in nf-2 these lesions would most often be defined histologically as schwannomas or neurilemomas, while in nf-l these would be defined histologically as neurofibromas. subcutaneous neurofibromas are occasional findings in nf-2. a mixcase report ture between the two occurs in very rare cases.' the growth of tumours in nf-2 is unpredictable and growth rates are extremely variable.y" most are slow-growing and can cause minimal problems for years, while others may lead to increasing problems over a few weeks. genetics nf-2 is the result of an abnormal gene on chromosome 22 at q12 (nf2), with a resulting defect in the production of the tumour-suppressor protein schwannomin, also called merlin. like other tumour-suppressor genes (such as p53 and rb), the normal function of nf2 is to act as a brake on cell growth and division, ensuring that cells do not divide uncontrollably, as they do in tumours. the exact molecular function of nf2 in the cell is still unknown. schwannomin is a 595 amino acid protein. with only single amino acid abnormality, the disease is mild, whereas frame shift deletions or insertion and nonsense mutations causing truncation of schwannomin cause more severe disease.y" nf-2 is an autosomal-dominant genetic trait, meaning it affects both genders equally and that each child of an affected parent has a 50% chance ~f inheriting the gene. half of affected individuals have nf-2 as a result of a new (de novo) gene mutation. the estimated incidence ofnf-2 is 1 in 37 000 per year, with about onethird of affected individuals representing first cases in the family as a result of new dominant mutations. i i approximately 1 000 patients in the entire united states are affected.' there are no statistic data available for south africa. diagnosis plain films of the spine may be helpful in evaluating scoliosis but are of limited value in looking for spinal cord tumours that may occur in nf2. in general, mr! is the preferred technique for monitoring individuals with nf-2 who have symptoms of spinal cord lesions. i mr! remains the mainstay for diagnosis and screening of cns and spinal cord tumours. at-risk individuals may be monitored for cns tumours beginning in their teens, with annual mr!s of the head done through their late 50s. mr! of the spine is indicated diagnostically when an individual presents with motor or sensory changes suggestive of a spinal cord lesion or lesions. the key point here is early detection, which may result in prompt action and provide a better outcome. however, routine mr! imaging of the spinal cord is probably not indicated for asymptomatic affected or at-risk individuals.12,13 mr! findings for nf-2 are: 1. bilateral acoustic schwannomas. site: superior/inferior division of vestibular nerve usually asymmetric. 2. schwannomas of other cranial nerves. excluding nerves without schwann cells. 3. multiple meningiomas; intraventicular, parasagittal, sphenoid ridge, olfactory groove, along intracranial nerves. 4. meningiomatosis = dura studded with innumerable small meningiomas. 5. glioma of ependymal deriviation." 6. spinal cord lesions: (i) extamedullary multiple paraspinal nerofibromas, meningiomas, schwan39 sa journal of radiology • june 2002 nomas, syrinx associated with tumour; and (ii) intramedullary spinal cord ependymomas." the presence of multiple and different pathologic types of spinal tumours is highly suggestive of nf-2.13 clear molecular diagnosis may help to modify risks for family members and prevent unnecessary testing for asymptomatic individuals who are found not to carry a gene mutation." the diagnosis ofnf-2 is still based largely on clinical criteria. the updated nih consensus development conference criteria for confirmed or definite nf-2 differ from the original criteria only slightly and include individuals with: 1. bilateral vestibular schwannomas visualised by mr imaging, or 2. a parent, sibling, or child with nf-2, plus (i) unilateral vestibular schwannoma detected before the age of 30 years, or (ii) any 2 of the following: meningioma, glioma, schwannorna, or juvenile posterior subcapsular lenticular opacity?" in practice, these clinical criteria may be too rigid and may exclude individuals who should be evaluated for nf-2. the evaluation for nf-2 should never represent a single point in time, but should include long-term follow-up. if no further tumours develop during a 5 lo-year period or if nf-2 molecular testing becomes more reliable for exclusion, then screening for possible nf-2 can be relaxed. it is recommended that a distinction be made between a 'confirmed' and a 'presumptive' diagnosis of nf-2. individuals with multiple nf-2 manifestations and no bilateral vestibular schwannomas classified as presumptive nf-2 may represent developing nf-2, in which other case report nf-2 features have not yet manifested, or nf-2 mosaicism. it is often difficult to distinguish between nf-2 mosaicism and 'definite' nf-2.4 other groups of individuals to be considered at risk for nf-2 and examined further include those with a family history of nf-2, persons younger than 30 years who have a unilateral vestibular schwannoma or meningioma, and those with multiple spinal tumours. in addition, individuals who have the following clinical features should be evaluated for nf-2: 1. a unilateral vestibular schwannoma plus anyone of the following: meningioma, glioma, schwannoma, or juvenile posterior subcapsular lenticular opacity. 2. multiple meningiomas plus a unilateral vestibular schwannoma. 3. multiple meningiomas plus 1 or more of the following: glioma, schwannoma, or juvenile posterior subcapsular lenticular opacity.a highquality mr! should be performed to rule out bilateral vestibular schwannomas definitively,' peripheral tumours in nf-2 are usually schwannomas and not neurofibromas. both schwannomas and neurofibromas may be useful diagnostic adjuncts in the paediatric and adolescent age groups, when severe nf-2 phenotypes typically manifest.' cerebral calcifications have sometimes been suggested as a diagnostic feature of nf-2. there are no convincing data to justify their inclusion, as they represent relatively nonspecific findings. in addition, ct scans that routinely detect calcification are now not the investigation of choice in nf-2.4 now that the gene for nf-2 has been identified, analysis for diseasecausing mutations can be offered in some clinical settings. detection rates for molecular-based testing are approximately 65%; therefore, such testing is of limited use in making the diagnosis of nf-2. however, in a patient with suspected nf-2 who is still young, has a negative family history, and may eventually develop additional criteria, the identification of a specific mutation may be helpful.":" predictive diagnosis by linkage analysis using markers flanking the nf2 gene is now possible in the vast majority of families with 2 or more living affected individuals.' once a mutation has been identified in an affected individual, a 100% specific test is then available for that family. however, mutation detection is time-consuming and expensive and may not reveal the causative mutatien.":" currently these tests are not available in south africa. references i. pletcher ba, griesemer d, talavera f,mack kj, baker mj, lorenzo n. neurofibromatosis, type 2. emedicine journal 2002, 3: number 2. www.emedicine.comlneuro/ 2. kanter wr, eldridge r, fabricant r, allen jc, koerber t. central neurofibromatosis with bilateral acoustic neuroma: genetic, clinical and biochemical distinctions from peripheral neurofibromatosis. neurology 1980; 30: 851-859. 3. evans dg, huson sm, donnai d, et al. a clinical study of type 2 neurofibromatosis. qim 1992; 84: 603-618. 4. gutmann dh,aylsworth a, carey jc, et al. the diagnostic evaluation and multidisciplinary management of neurofibromatosis 1 and neurofibromatosis 2. jama 1997; 278: 51-57. 5. malis li. nuances in acoustic neuroma surgery. neurosurgery 2001; 49: 337-341. 6. evans dg, huson sm, donnai d, et al. a genetic study of type 2 neurofibromatosis in the united kingdom. l prevalence, mutation rate, fitness, and confirmation of maternal transmission effect on severity. j med genet 1992; 29: 841-846. comment in: j med genet 2001; 38: 783-784. 7. ruttledge mh, andermann aa, phelan cm, et al. type of mutation in the neurofibromatosis type 2 gene (nf2) frequently determines severity of disease. am j hum genet 1996; 59: 331342. 8. mautner vf, tatagiba m, guthoff r, samii m, pulst sm. neurofibromatosis 2 in the pediatric age group. neurosurgery 1993; 33(1): 92-96. 9. mautner vf, lindenau m, baser me, kluwe l, gottschalk j. skin abnormalities in neurofibromatosis 2. arch dermato11997; 133: 1539-1543. 10. parry dm, maccollin mm, kaiser-kupfer mi, et al. germ-line mutations in the neurofibromatosis 2 gene: correlations with disease verity and retinal abnormalities. am j hum genet 1996;59: 529-539. il. merel p, hoang-xuan k, sanson m, et al. screening for germ-line mutations in the nf2 gene. genes chromosomes cancer 1995;12: j17127. 12. mccormick pc, torres r, post kd, stein bm. intramedullary ependymoma of the spinal cord. j neurosurg 1990; 72: 523-532. 13. mautner vf, tatagiba m, lindenau m, et al. spinal tumours in patients with neurofibromatosis type 2: mr imaging study of frequency, multiplicity, and variety. am j roentgenol 1995; 165: 951-955. erratum in: afr am j roentgenol1996; 166: 1231. 14. danhert w. radiological review manual. 4th ed. philadelphia: williams and wilkins, 1999: 26l 15. sainio m, strachan t, blomstedt g, et al. presymptomatic dna and mr! diagnosis of neurofibromatosis 2 with mild clinical course in an extended pedigree. neurology 1995; 45: 1314-1322. 16. evans dgr, huson sm, donnai d, et al. a clinical study of type 2 neurofibromatosis. qim 1992; 304: 603-618. 17. evans dgr, bourn d, wallace a, ramsden rt, mitchell jd, strachan t. diagnostic issues in a fumilywith late onset type 2 neurofibromatosis. j med genet 1995; 32: 470-474. 18. bourn d, carter sa, mason s, gareth d, evans r, strachan t. germline mutations in the neurofibromatosis type 2 tumour suppressor gene. hum mol genet 1994; 3: 813-816. 19. merel p, hoang-xuan k, sanson m, et al. screening for germ-line mutations in the nf2 gene. genes chromosomes cancer 1995; 12: 117127. 40 sa journal of radiology. june 2002 http://www.emedicine.comlneuro/ radiology_may04 43 sa journal of radiology • may 2004 case report introduction this case emphasises the role of sonography in the diagnosis of a complete molar pregnancy. case report a 53-year-old female, para 13 gravid 13, presented to the casualty department of pretoria academic hospital with a complaint of pv (per vagina) bleeding. on clinical examination she was found to be anaemic and had an enlarged, 20 cm uterus, with adnexal tenderness. routine blood tests were normal, except for a b-hcg level of 843 636 iu/l. on transabdominal sonar the uterus measured approximately 23 cm in length x 12 cm in width with hyperechoic vesicular contents and densely packed multiple small cysts. no fetus was found. the rest of the abdomen and pelvis were normal. a diagnosis of complete molar pregnancy was made (figs 1a and b). the patient underwent a total abdominal hysterectomy and the diagnosis was subsequently confirmed on histological examination. discussion complete molar pregnancy is part of the spectrum of disorders characterised by abnormal proliferation of pregnancy-related trophoblasts. it is characterised by chromosomal dna exclusively of paternal origin. it occurs when a normal haploid sperm fertilises an ovum with absent or inactive maternal chromosomes. the aetiology is unknown, but several factors play a role. these include folic acid-deficient diet, age younger than 20 years or older than 40 years. the incidence among women older than 50 years is 1:2 pregnancies.1 at pathology there is no fetal development and the placenta is entirely replaced by abnormal, hydropic chorionic villi with excessive trophoblastic proliferation. it is characterised by excessive uterine size, as well as b-hcg levels in the 100 000s iu/l (normal pregnancy values are ± 60 000 iu/l), hyperemesis gravidarum, toxaemia, hyperthyroidism and respiratory failure. vaginal bleeding exists in over 90% of cases.2 sonographic features sonographic features include: (i) enlarged uterus containing echogenic tissue expanding into the endometrial cavity; (ii) uniformly distributed cystic spaces; (iii) no fetus; and (iv) bilateral greatly enlarged ovaries with multiple theca lutein cysts.2 treatment depends on the patient's age. in patients over 40 years the treatment of choice is total abdominal hysterectomy. patients younger than 40 years are treated with suction curettage. both groups are followed up with serial b-hcg measurements and ultrasound.1 references 1. nel jt. core obstetrics and gynaecology. johannesburg: heinemann, 1996: 599-606. 2. rumack cm, wilson sr, charboneau jw. diagnostic ultrasound. 2nd ed. usa: mosby, 1997: 1359-1362. complete molar pregnancy in a 53-year-old woman narosha adroos mb chb department of diagnostic radiology pretoria academic hospital fig. 1a. transabsominal transverse scan showing a vesicular echogenic mass filling the endometrial cavity. fig. 1b. transabdominal longitudinal scan. short report 13 sa journal of radiology • june 2006 vascular laboratories play an increasing part in treating patients via intravascular procedures. the diagnostic purpose of vascular laboratories is being somewhat diminished by excellent diagnostic imaging machines like the 64-slice ct scanner and three tesla mri scanners. thus, the emphasis falls on treating patients using intravascular procedures rather than performing diagnostic procedures. when planning a vascular laboratory it should be kept in mind that the main purpose of such a laboratory is to treat patients using various interventional skills. planning a vascular laboratory depends on various factors like the geographic environment of the radiology practice, the need for interventional procedures, types of angiography procedures, the number of patients, building size, and lastly the budget available for equipment and running costs. usually the suppliers of the angio-equipment will play an integral part in planning and developing a catheterisation laboratory. some of the practical planning aspects are discussed in this article. the vascular laboratory and surrounding rooms apart from fulfilling the requirements of the international commission on radiological protection (icrp) on x-ray protection, the vascular laboratory should be large enough to accommodate the angio-system. if enough space is available, the laboratory can be developed in such a way that a dual-plane system can be fitted. this will enable conversion of the laboratory into a surgical theatre where vascular procedures can be performed after the diagnostic work has been completed, especially in critical cases and where theatre space is a problem. the vascular laboratory should be planned in such a way that patient flow is optimum. incoming and outgoing patients should not interfere with each other. a waiting room for incoming patients, especially outpatients, is essential. this room can also be used to explain procedures to patients and their families. changing rooms and toilet facilities for patients should be close by. a recovery room equipped with oxygen connections, ecg machines and an anaesthetic machine must be in close proximity of the vascular lab, especially if patients receive anaesthesia during procedures. each vascular lab must have a computer room with separate airconditioning. this room hosts the c-arm power supply cabinets, as well as x-ray tube heat converters and any other computer hardware necessary for the vascular lab. the control room should be state of the art with huge glass windows that overlook the vascular laboratory so that effective handling of software occurs during a procedure. a separate entrance into the control room gives access to personnel without the risk of accidental radiation in the vascular laboratory. enough space must be available for the computer hardware needed for the angio-system. storerooms are required for bulky equipment, as well as products used in the vascular laboratory during procedures. one of these storerooms can be converted into a setting-up room where sterile trays are prepared for interventional procedures. a lockable cupboard in the setting-up room can be used for storing anaesthetic drugs. a separate entrance away from the waiting and recovery room is ideal for disposal of soiled linen and waste material. cleaning services can also use this entrance for access to clean the theatre after each procedure. changing rooms equipped with lockers and shower and scrubbing facilities for the radiologist/cardiologist should be available just outside the vascular laboratory. vascular laboratory the vascular laboratory should be equipped with excellent lighting. lights should automatically switch off during fluoroscopy. a small ceiling-mounted light is practical during difficult catheterisation procedures, i.e. when brachial artery entrance is used or when putting up iv canulas in patients with ‘difficult’ veins, i.e. children and cancer patients. a theatre light should be suspended from the ceiling in such a way that there is no interference with the c-arms but close enough so that the angiographic table can be used as an operating table. gas fittings should also be available to connect to an anaesthetic machine. enough power sockets are essential to connect different apparatus in the vascular theatre, i.e. ecg machine, ultrasound, heating equipment for contrast agents, etc. some of these power sockets should also be connected to an emergency power supply in case of power loss. angio-equipment there is a choice between a single-plane and dual-plane system. the dual-plane concept is gaining tremendous acceptance throughout the industry. numerous health-care facilities just do not have the patient volume to justify a separate cardiac lab and a separate vascular-imaging suite. dual-plane is the perfect solution. dual-plane incorporates the use of two hyperspeed c-arms that share a common angiographic table. one c-arm can then be equipped with a 9-inch image intensifier that is optimal for cardiac imaging and the second c-arm is equipped with a 16inch image intensifier that is optimal for complete vascular imaging. the c-arms and imaging systems are interfaced with a dual-plane software computer program and the result is complete and total optimisation for each physician specialist. the dual-plane c-arms can both be ceiling-suspended or one ceiling-suspended and the other floor-mounted. different c-arms are on the market with capabilities of producing 3d images with a recording speed of up to 30 frames per second. a ccd digital camera with 1 million-pixel images is now available for digital fluorography systems. the ccd camera makes it possible to gather extremely accurate image data at high speed using a 1024x1024 matrix. c-arms equipped with flat-panel detectors (fpds) are replacing the image-intensifying screens. the fpds have many advantages over the image intensifier: • uniform brightness across image • increased resolution and no distortion • high dynamic range • better technique control practical considerations in planning a cath-lab short report d h schulenburg, mb chb department of radiology, universitas hospital, bloemfontein and university of the free state pg13-14.indd 13 7/11/06 12:46:32 pm short report 14 sa journal of radiology • june 2006 • one powerful pc to review mr, ct, and vascular 3d images. radiation exposure is lower with fpd products. this is very important as any decrease in radiation makes a procedure safer for both screening personnel and patients. real-time smooth masking (rsm, shimadzu) is very useful when working with unco-operative patients. this offers dsa images that are never unreadable as a result of motion artifacts. using rsm, you can acquire dsa images in a pendulum motion, a precession motion, or even a c-arm ‘fast spin’ (60º per sec) acquisition all in real time. the magnetic navigation system (siemens), is the first magnetic catheter navigation system of its kind in the world. the system integrates an advanced digital fluoroscopic imaging system, with fpd system, to direct and digitally control catheterand guide wire-based devices along complex paths within the heart and coronary vasculature. the system uses computer-controlled permanent magnets external to the body for orientating the magnetic tip of specially designed medical devices, i.e. catheters. this approach has the potential to provide greater precision and better movement and outcomes for patients. additional equipment a dedicated ultrasound machine is very useful in a vascular laboratory. it can be very helpful during difficult catheterisations and when one is performing various interventional procedures, i.e. kidney biopsies or liver carcinoma ablations. additional equipment like a defibrillator, refrigerator, oven and light boxes should be available. the angiogram tables are not suitable for cpr and should be stabilised before commencing cpr. this stabilising device should be placed next to the defibrillator. a contrast pump is essential in the vascular laboratory. the choice between a ceilingor a floor-mounted unit depends on the size of the vascular laboratory and the type of equipment in the laboratory. the ceiling-mounted unit is practical but it can interfere with the ceilingsuspended c-arm. dicom and pacs angiographic equipment is available with a dicom network interface, meaning that the examination information leaving the system is already formatted according to the dicom standards. this has two advantages: (1) data equivalence is assured; and (2) any receiving system that supports this interface can be used for storing and reviewing images and data. the dicom system can be linked to the picture archiving and communications system (pacs). pacs digital images are stored in computer memory and can be retrieved in seconds. this reduces the time between exam and therapy, and has potential to impact on the overall length of hospital stay. with digital imaging, doctors can immediately look up a patient’s new and past images on a pc, instead of waiting for films to be de-archived from a shelf and delivered. in addition, a doctor can electronically transmit a digital x-ray or other images to a hospital or clinic anywhere in the world. the pacs system supports the ability to diagnose across various modalities and lab systems. the network system between dicom-compatible machines and a pacs should have a 1-gigabyte cable for efficient transfer of data. new technology exists which can send health-care information wirelessly to wherever it is needed. the system handles not only text, but also images, audio clips, streaming video, and digitised hand-written notes. this system with dicom-compliant pacs installations, includes an automatic return receipt, audible alerts for incoming messages, and the ability to log events. changing to a digital system creates a filmless network with the following advantages: • elimination of film • handling and storage costs reduced • increased efficiency and exam throughput • instant access to previous studies online • optimised diagnostic review with true 1024x1024 images acquisition transfer and storage. a voice-recognition system is a very practical program. this allows the radiologist to dictate directly onto a computer system. with the help of a radiological information system (ris)/pacs and the hospital information system interface, this report can be immediately available on the hospital network. this method is especially helpful during after-hour procedures when secretaries are not on duty. conclusion development of an angioor vascular laboratory should be planned according to the need for the specific laboratory. factors like space, the number of potential patients and the budget available for the project play a very important role. most of these angiographic systems have many upgrade facilities available, especially software products and the pacs system. the planning of the vascular laboratory should be done by a multidisciplinary panel, keeping these factors in mind. 14 sa journal of radiology • june 2006 short report pg13-14.indd 14 7/11/06 12:46:32 pm case report disappearing breast cysts i movson mbchb, dmrd(uk) pcorr mbchb, ffrad(d)sa deparlment of radi%gy, addington hospital, university of nata/, durban, south africa abstract the natural history of simple breast cysts is illustrated by our patient with multiple palpable cysts which disappeared completely over a six month period. interval mammography is all that is required in these patients. case report a 52 year-old woman was referred for a mammogram because of a palpable mass in the outer quadrant of the right breast. mammography (figure 1) demonstrated multiple, well defined masses bilaterally. there was no microcalcification or spicultation. ultrasound confirmed that these were simple cysts. cyst puncture was not figure 1,' initial crania caudal mammogram demonstrates bilateral breast cysts. performed. a repeat mammogram was advised after six months. this demonstrated that the previous cysts had resolved completely (figure 2). figure 2: follow-up mammogram after a six month interval confirms disappearance of the cysts. 20 sa journal of radiology. may 1998 discussion breast cysts are common, occurring in 30-50% of women at autopsy. i the peak incidence is between 40-49 years of age. the reason why cysts disappear is unknown but is probably due to changing oestrogen levels as they frequently regress after menopause. our patient is unusual as the cysts disappeared so rapidly. screening programmes have demonstrated that more than 50% of interval cysts resolve within one year and by two years, two-thirds had disappeared. at five years less than 12% of cysts were unchanged.2 the cause of simple breast cysts is unclear. they originate from the terminal ductule lobular unit. they are thought to result from coalescence of lobular acini during ductule involution or from ductule obstruction. the cyst wall is composed of cuboidal to columnar epithelium which is often multilayered but can be atrophic.' occasionally cysts develop following duct ectasia, fat necrosis, or oestrogen administration.' patients are often asymptomatic although pain and tenderness may occur from fluid tension in the cysts.the cysts vary in size with the menstrual cycle." on mammography, breast cysts are indistinguishable from other benign masses especially fibroadenomas however ultrasound confirmation of a simple cyst establishes the diagnosis. interval annual mammography is all that is required in these patients to confirm cyst regression. references 1. kopans d. breast imaging. philadelphia: lipincott. 1989; 266-267. 2. brenner rl, bein me, sarti da, vinstein al. spontaneous regression of interval benign cysts of the breast. radiology, 1994; 193: 365-368. 3. haagensen cd. disease of the breast. wb saunders, philadelphia 1986. 4. tucker ak. textbook of mammography. churchill livingstone, edinburgh, 1993; 120-167. abstract definition pathophysiology types of compartment syndromes diagnosis or differential diagnosis clinical presentation of chronic exertional compartment syndrome forearm compartments and anatomy magnetic resonance imaging protocol findings management conclusion acknowledgements references about the author(s) bishum rattan lake smit and partners inc., durban, south africa shalendra k. misser lake smit and partners inc., durban, south africa school of health sciences, university of kwazulu-natal, south africa citation rattan b, misser sk. magnetic resonance imaging in exertional compartment syndrome of the forearm: case-based pictorial review and approach to management. s afr j rad. 2018; 22(1), a1284. https://doi.org/10.4102/sajr.v22i1.1284 review article magnetic resonance imaging in exertional compartment syndrome of the forearm: case-based pictorial review and approach to management bishum rattan, shalendra k. misser received: 11 oct. 2017; accepted: 11 jan. 2018; published: 18 apr. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract exercise-related limb pain poses a management dilemma to the clinician. the term ‘chronic exertional compartment syndrome’ (cecs) (previously known as ‘anterior tibial syndrome’) refers to a condition characterised by exercise-induced pain in one or more muscle groups and is more commonly seen in the lower limbs. much less has been reported about the upper limbs where the muscular compartments are variably noted to be involved. a high index of clinical suspicion should therefore be maintained to avoid missing the diagnosis. although commonly noted in athletes, cecs can occur in any age group with any level of exercise activity. in addition, there is no age predilection and the syndrome may be bilateral. the exact prevalence is not known as many athletes modify their training methods, thus delaying or avoiding medical assistance and imaging. the pathophysiology of compartment syndrome is complex. in this review of the syndrome, we describe the cycle of intracellular events leading to cecs and the eventual destruction of muscle. there is considerable overlap with the many possible causes of limb pain. even the most experienced clinicians experience some difficulty in making this diagnosis of cecs, but with increasing awareness of this entity and availability of good-quality magnetic resonance imaging to confirm the suspicion, upper limb cecs is being more commonly diagnosed and patients more timeously managed. definition chronic exertional compartment syndrome is a debilitating and painful condition that results from abnormally increased pressure in a muscular compartment, enclosed by relatively non-compliant fascia, where increase in interstitial pressure compromises the vascular supply to the contents of the space. this leads to ischaemia, eventual muscle necrosis and nerve death. the predisposing cause is repeated activity involving specific muscle groups and is most commonly encountered with certain types of sport and less often associated with some vocations. pathophysiology the pathophysiology of compartment syndrome is complex. the common prerequisite is a soft tissue structure (usually fascia) that prevents muscle expansion when muscle is exposed to increased fluid volume. increased compartment pressure from either internal or external injury causes a decreased perfusion gradient between arteriolar and venous pressures and as a result, decrease in local tissue perfusion. decreased tissue perfusion results in further tissue insult, greater capillary leakage and further increment in intra-compartmental pressure. this causes a vicious cycle (shown in figure 1)1 of progressive cellular ischaemia, leading to further capillary leakage, swelling and increasing compartment pressure. in all cases, the final common pathway is cellular anoxia. figure 1: algorithm detailing the pathophysiology of compartment syndrome, based on the theory of matsen. ongoing ischaemia eventually (if not relieved by fasciotomy or prolonged rest as in the case of exertional compartment syndrome) leads to cell death and lysis of the myocyte. degradative enzymes are activated and released into the interstitial tissues causing further tissue necrosis. the extent of muscle injury depends on the duration of ischaemia and the metabolic rate of the tissue. types of compartment syndromes acute compartment syndrome2 is a medical emergency usually caused by injury and can lead to permanent muscle damage. in the acute setting, compartment syndrome may arise from extrinsic or intrinsic injuries. chronic exertional compartment syndrome (cecs) is not a medical emergency and is most often caused by long-standing athletic exertion. this is most commonly encountered in athletes with repetitive, severe stress involving muscle groups used for a specific action during sport. fortunately, chronic compartment syndrome less likely results in the severe complications of acute compartment syndrome, namely, myonecrosis, atrophy, disability and deformity; however, chronic pain is a constant debilitating phenomenon which can be relieved, pending a definitive diagnosis. the causes of acute and chronic compartment syndrome are listed in table 1.1 table 1: causes of compartment syndromes. diagnosis or differential diagnosis the cornerstone of diagnosis is based on a detailed history, high index of clinical suspicion and careful physical examination. even in the most astute clinician’s hands, the distinction between the different medical causes may be difficult, given the overlap of clinical features. there are several distinct entities that can present with limb pain (listed in box 1) and these may be clinically indistinguishable from cecs.3 box 1: the differential diagnosis for limb pain. intra-compartment pressure can be measured clinically via a slit catheter or similar pressure-transducing device. this method has been the gold standard of diagnosis of cecs; however, such pressure measurements are not without challenges.4 ideally, measurements should be obtained before, during and after exercise. the measurement is multifocal, painful, invasive and sometimes not available in some centres. in addition, there are potential risks of infection and bleeding. the compartment pressure measurement is not standardised and there is inter-observer variability in testing which impacts decision-making with regard to proceeding to surgery.4 consequently, diagnostic imaging, especially mri evaluation, is a useful tool in diagnosing cecs. over the last two decades, mri has been shown to have a very high accuracy in confirming the diagnosis of cecs.5 ultrasound has also been shown to be of value in the clinical work-up of patients with suspected cecs,6 especially of the lower limbs. the inter-observer variability as well as the reduced sensitivity and specificity of ultrasound lowers diagnostic efficacy when compared to mri. in addition, it is more difficult to demonstrate, in a reproducible manner, the dynamic muscular changes on ultrasound.7 these pathophysiological changes are more clearly shown on mri imaging sequences recorded before and after exercise. clinical presentation of chronic exertional compartment syndrome patients with cecs typically complain of pain that begins within the first 30 min of starting an activity.8 burning, cramping or aching pain progresses as the activity is continued. typically, the pain increases to a level of discomfort where the patient can no longer continue or where it adversely affects the patient’s performance.1 the key clinical features of cecs are listed in box 2. 8,9,10,11 activities associated with exertional compartment syndrome of the upper limb include sports such as rowing, cycling, motorcycle riding, cricket, body building (particularly those supplementing with creatine and anabolic steroid) or repeated episodes of manual labour requiring a prolonged grip or pinch.9 in the united states, cecs was documented in military recruits, especially those involved in battlefield training.10 in most instances, the pain and induration resolve spontaneously on cessation of the activities.1 box 2: clinical features of chronic exertional compartment syndrome. forearm compartments and anatomy the forearm can be divided into the volar and deep compartments, as listed in box 31. the volar compartment can be divided into the superficial and deep groups and the dorsal compartment can be divided into the mobile wad, the extensor group and the anconeus. it is delineated proximally by the lacertus fibrosus and pronator teres and distally by the carpal tunnel. box 3: the anatomical divisions of the forearm compartments.1 except for the strong interosseous membrane, forearm fascial planes often incompletely separate compartments, allowing some communication between muscle groups. in the setting of forearm compartment syndrome, surgical fasciotomy of one muscle compartment may thus be sufficient to decompress another.1 the anatomical considerations of chronic compartment syndrome in the lower limb have been well described in the literature. in the forearm, the volar and dorsal compartments are interconnected, unlike the leg compartments. several anatomical structures however limit the dorsal and volar compartments. the interosseous membrane, the radius and ulna separate the volar and dorsal compartments. the antebrachial fascia limits anteriorly the volar compartment and posteriorly the dorsal compartment, as shown in figure 2.1 figure 2: cross-sectional diagram of the mid forearm delineating the compartments of the volar and dorsal forearm: (1) brachioradialis; (2) flexor carpi radialis (fcr); (3) palmaris longus; (4) flexor digitorum superficialis; (5) flexor carpi ulnaris; (6) flexor digitorum profundus (fdp); (7) flexor pollicis longus (fpl); (8) extensor carpi radialis longus; (9) extensor carpi radialis brevis; (10) apl; (11) extensor pollicis brevis; (12) extensor pollicis longus (epl); (13) extensor digitorum communis (ed); (14) extensor digiti minimi; (15) extensor carpi ulnaris; (16) radius; (17) ulna. the thick aponeurosis of the fdp separates the superficial from the deep volar compartment. the median and ulnar nerves are located lateral and medial, respectively, relative to the fdp aponeurosis. interconnections between the superficial and deep volar compartments are not sufficient to prevent a large increase in pressure during continuous muscular contraction, especially within the flexor compartments. thus, chronic forearm compartment syndrome has been described in strength training, long distance rowing and motorcycle activities in which flexor muscle contraction is continuous, to control the brake lever and keep the motorbike on the road.11 magnetic resonance imaging the mri examination is often used as a problem-solving technique in certain circumstances and in patients refusing intra-compartmental measurements or in patients where such invasive measurements are contraindicated, for example, coagulopathies. it has been shown that mri findings are comparable to that of intra-compartmental pressure measurement, and this investigation is increasingly being used in the diagnostic evaluation of cecs.12 protocol patients are imaged before and after pain-inducing exercise with contrast, if not contraindicated.5 the basic sequences utilised are listed in box 4; however, the protocol may vary at different institutions. the axial and coronal scan planes are used. in most instances, the axial plane is preferred allowing for easier identification, and more accurate and reproducible labelling of the various muscle groups. box 4: the magnetic resonance imaging preand post-exercise protocol. findings a change in signal and sometimes an increase in volume on t2w imaging in an isolated compartment associated with increased activity, support the diagnosis of exercise-induced compartment syndrome. magnetic resonance imaging is a valuable adjunct to the clinical diagnosis as it serves to identify the affected compartment and provide a road map prior to surgery, if indicated. this is particularly important where there is involvement of more than one muscle compartment. interstitial haemorrhage can be demonstrated on gradient echo sequences and depending on the age of the haemorrhage may show hyperintensity on t1-weighted sequences and hyperor hypo-intensity on t2-weighted sequences. box 5 outlines the mri findings in cecs. these features are demonstrated in two case studies below (figures 2 and 3). box 5: the magnetic resonance imaging features of upper limb compartment syndrome. axial post-gadolinium, fat-saturated, t2-weighted turbo spin echo sequence, performed in a professional rower, as shown in figure 3, undertaken before (figure 3a) and after (figure 3b) exercising the right forearm. note the hyperintensity demonstrated within the proximal muscle belly of the right fdp muscle after exercising. there is marked swelling of the fdp muscle and associated effacement of the intramuscular vessels on the post-exercise image, indicative of elevated compartment pressure. it has been reported that in untrained individuals, intramuscular hyperintensity may be seen on the post-exercise mri studies, especially when irregular or eccentric training is practiced.13,14 this can mimic cecs and should be correlated with direct compartment pressure measurement.12 figure 3: (a) axial fat-suppressed t2-weighted magnetic resonance imaging of the right forearm, pre-exercise demonstrates iso-intensity of muscle groups. note the normal calibre of intramuscular vessels; (b) axial fat-suppressed t2-weighted magnetic resonance imaging of the right forearm, post-exercise – white arrow showing hyperintensity of the flexor digitorum profundus muscle and effaced intramuscular vessels. chronic exertional compartment syndrome of the forearm can involve multiple muscle compartments and variably involve individual muscles in a compartment, whilst sparing others. this is well demonstrated in the mri images of an elite endurance athlete in figure 4. the pre-exercise, fat-suppressed, t2-weighted image of the left forearm (figure 4a) shows moderate swelling of the muscles of both the flexor and extensor compartments with iso-intensity. this patient had pain in his forearm, even at rest, which progressed to excruciating pain on exercise. the hyperintensity involving multiple muscle groups of the flexor and extensor compartments is demonstrated in figure 4b. figure 4: (a) axial fat-suppressed, t2-weighted magnetic resonance imaging of the left forearm, pre-exercise demonstrates iso-intensity of muscle groups. note again the normal calibre of intramuscular vessels; (b) axial fat-suppressed, t2-weighted magnetic resonance imaging of the left forearm, post-exercise. arrows show hyperintensity of the muscle groups with effaced intramuscular vessels. the yellow arrow points to the flexor carpi radialis (fcr); the blue arrow points to the flexor pollicis longus (fpl); the red arrow points to the extensor compartment, including abductor pollicis longus (apl), extensor pollicis longus (epl) and extensor digitorum communis (ed). management in most cases prior to the firm diagnosis of cecs, some degree of conservative management is suggested. this includes non-steroidal anti-inflammatory drug (nsaid) therapy and activity modification through decreasing the duration and intensity of workouts. these may not offer significant relief. surgical management is definitive and elective fasciectomy or fasciotomy is the offered treatment option.15 it is noted that surgical treatment is not without risks of complications, which include infection, scarring, permanent nerve damage and numbness.12,15 there have been many surgical incisions of the forearm described with most being long and extensile, hence, most incisions can be used to decompress tense forearm compartments. figure 5 demonstrates open fasciotomy, exposing the intermuscular septum and fascia. generally, these incisions are left open, hence it is preferred to use one that minimises the exposure of the neurovascular structures and can be extended (if required) to the medial elbow proximally or to the carpal tunnel distally. figure 5: open fasciotomy of the left forearm exposing the intermuscular septum and fascia. on the volar aspect, the antebrachial fascia is released longitudinally from the lacertus fibrosus to the wrist flexion crease to release the superficial flexor compartment and an incision is made on the ulna side to release the deep flexor portion. during dissection, some of the muscular compartments may appear pale suggesting compromise, hence additional release of the epimysium is recommended. if the epimysium is not released, this muscle belly may run the risk of reperfusion injury which will lead to further muscle damage. figure 6 shows a completion fasciotomy and partial fasciectomy releasing the tense compartment. figure 6: completion fasciotomy. similarly, the extensor compartment is released through a midline dorsal longitudinal incision extending from the lateral epicondyle to the distal radioulnar joint. this allows for release of the mobile wad and the extensor compartment. once the swelling has subsided, either primary closure or skin grafting can be used to close the wound. in addition, physiotherapy or movement should be commenced immediately following surgery to promote active and passive ranges of movement. conclusion chronic exertional compartment syndrome has characteristic mri features and the radiologist plays a key role in facilitating a correlation between clinical presentation and confirmation of the diagnosis. with increasing awareness of this clinical entity and availability of good-quality mri studies to confirm the suspicion, upper limb cecs is being more commonly diagnosed and patients more timeously managed. acknowledgements the authors thank dr john zietkewicz and prof. john robbs for the intra-operative photographs. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions b.r. (diagnostic radiologist) was responsible for developing the concept, the initial draft of the publication and editing the manuscript. s.k.m. (diagnostic radiologist) assisted with literature review, development of diagrams, figure selection and/or preparation, the critical review and final approval of the manuscript. references stevanovic mv, sharpe f. compartment syndrome and volkmann ischemic contracture. in: wolfe sw, hotchkiss rn, pederson wc, kozin sh, cohen ms, editors. green’s operative hand surgery. philadelphia, pa: elsevier/churchill livingstone; 2011. kirsten g, elliot b, johnstone aj. review article – diagnosing acute compartment syndrome. j bone joint surg. 2003;85-b:625–632. hider sl, hilton rc, hutchinson c. chronic exertional compartmental syndrome as a cause of bilateral forearm pain. am coll rheumatol. 2002;46(8):2245–2246. hislop m, tierney p. intracompartmental pressure testing: results of an international survey of current clinical practice, highlighting the need for standardized protocols. br j sports med. 2011;45:956–958. https://doi.org/10.1136/bjsports-2011-090368 mattila kt, komu mes, dahlstrom s, koskinen sk, heikkela j. medial tibial pain: a dynamic contrast-enhanced mri study. magn reson imaging. 1999;17:947–954. https://doi.org/10.1016/s0730-725x(99)00030-2 wassermann d, oschmann z. role of ultrasound as a noninvasive method of diagnosis of chronic exertional compartment syndrome. sa orthop j. 2011;10(4):59–65. omar cy, truter r, suleman f, andronikou s. imaging diagnosis of muscle herniation of the forearm. s afr orthop j. 2014;13:39–42. kalyani bs, fisher be, roberts cs, giannoudis pv. compartment syndrome of the forearm: a systematic review. j hand surg. 2011;36a(3):535–543. https://doi.org/10.1016/j.jhsa.2010.12.007 seiler jg, olvey sp. compartment syndromes of the hand and forearm. j hand surg am. 2003;3(4):184–198. https://doi.org/10.1016/s1531-0914(03)00072-x george ca, hutchinson mr. chronic exertional compartment syndrome. clin sports med. 2012;31(2):307–319. https://doi.org/10.1016/j.csm.2011.09.013 goubier jn, sailant g. case report: chronic compartment syndrome of the forearm in competitive motor cyclists: a case report of two cases. br j sports med. 2003;37:452–454. https://doi.org/10.1136/bjsm.37.5.452 van den brand jgh, nelson t, verleisdonk ejmm, van der werken c. the diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. am j sports med. 2005;33:699–704. https://doi.org/10.1177/0363546504270565 gielen jl, peersman b, peersman g, et al. chronic exertional compartment syndrome of the forearm in motocross racers: findings on mri. skeletal radiol. 2009;38(12):1153–1161. https://doi.org/10.1007/s00256-009-0746-2 volcke p, kirby jh, viviers pl, viljoen jt. chronic exertional compartment syndrome in the forearm of a rower. s afr j sports med. 2014;26(2):62–63. https://doi.org/10.7196/sajsm.547 robbs jv, islam j. management of chronic exertional compartment syndrome. sajs. 2015;53(2):59–61. https://doi.org/10.7196/sajsnew.7855 by mala modi and shawn halpin we are at present performing t1 flair (fluid-attenuated inversion recovery) sequences for some brain and spinal imaging. it enhances the differentiation between grey and white matter, providing better anatomical definition. t1 flair further suppresses any signal from the csf which then appears black, rather than dark grey. indications for using the t1 flair sequence in the brain would include imaging for mesial temporal sclerosis, grey matter heterotopia, and primary epilepsy. spinal imaging using t1 flair is proving to be very helpful in assessing cord size; and separating cord from csf, csf pulsation artefact, and epiand extradural pathology. the disadvantage is that the t1 flair sequences do take longer, and it is not recommended for use with t1 contrast imaging. at present the scanning parameters we are using are a tr of 2000, a te of 20, and a ti of 760. bitar r, leung g, perng r, et al. mr pulse sequences: what every radiologist wants to know but is afraid to ask. radiographics 2006; 26:513-537 on paging through the latest radiographics, the above article caught my attention for obvious reasons. as mentioned in the article the use of magnetic resonance (mr) imaging is increasing exponentially, and as such it is not limited to senior residents, and it is being introduced to residents in their first and second years of training. mr physics is necessary for the part 1 of the radiology exam anyhow – therefore this article is highly recommended to all radiologists and radiologists-in-training. ‘a flair for t1’ contributors: m modi, s halpin 45 sa journal of radiology • september 2006 education exhibit journal review a figs 1 a and b: t1 and t1 flair images of the l-spine. b a figs 2 a and b: t1 and t1 flair images of the midbrain and hippocampus. b figs 3 a and b: t1 and t1 flair images of the basal ganglia. a b pg 45-47.indd 45 9/6/06 2:59:55 pm pearls 1. tissue contrast ↓ tr → t1 weighting (tr affects t1 contrast) ↑ te → t2 weighting (te affects t2 contrast) ↑ tr/↓te = proton density (t1 and t2 effects are minimised, and signal is predominantly due to differences in proton density) 2. pulse sequences two fundamental types: spin echo and gradient echo. spin echo (se) 90° rf pulse followed by a 180° rf rephasing pulse (at ½ te) to minimise magnetic field inhomogeneity se sequences fse-fast/turbo = single 90° rf pulse followed by multiple 180° rf rephrasing pulses (all echos together = echo train, the total 180° rf pulses + echos = echo train length) conventional inversion recovery sequence = a preparatory 180° pulse being applied to flip the net magnetisation vector thereby nullify the signal from a particular tissue, e.g. water, the 90° pulse is applied when the transverse plane is passed (null point for a particular tissue). uses: stir = short ir sequence used to nullify the signal from fat flair = fluid attenuated ir sequence used to nullify the signal from water gradient echo (gre) small (variable) angle rf pulse followed by gradients and not rf pulses (positive/ rephasing or negative/dephasing gradients). gre sequences are sensitive to magnetic field inhomogeneity (t2* signal decay) as there are no rephasing pulses. this feature is exploited for the detection of haemorrhage, for use in cerebral perfusion studies, for bold (blood oxygen-level dependant) imaging in brain function mapping and cardiac imaging. gre sequences partially refocused, fully refocused and spoiled 3. echo-planar imaging (epi) a single echo train is used to collect data from all lines of k-space during one tr (single-shot epi), or from multiple trs (multishot epi). it can be used with se or gre sequences. 4. diffusion-weighted imaging (dwi) dwi facilitates the differentiation of restricted diffusion from unrestricted diffusion. epi or fast gre is used. two equal gradient pulses (on either side of 180° pulse) are applied (dephasing and rephasing), if there is no net movement → ↑ signal; if there is net movement (i.e. undergoing dephasing but not rephasing or vice versa) → ↓ signal. apparent diffusion coefficient (adc) maps are usually applied with dwi sequences. two sets of images are necessary to calculate adc maps – one without a diffusion gradient (~t2 w image) and one with a diffusion gradient. area of restricted diffusion (eg. acute stroke) no diffusion gradient – arbitrary signal value = 10 diffusion gradient – arbitrary signal value = 5 (some but not profound signal loss) ratio = 0.5 (negative log of 0.5 = 0.7) area of normal brain no diffusion gradient – arbitrary signal value = 10 patient care optimum minimum risk of air bubble injection1 – optiray® is available in pre-filled syringes. non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 10/8/06 3:28 pm page 1 examination time1 optimise non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request in contrast to many agents optiray®, is available as a pre-filled syringe. tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 3/8/06 10:30 am page 2 pg 45-47.indd 46 9/6/06 2:59:57 pm diffusion gradient – arbitrary signal value = 2 ratio = 0.2 (negative log of 0.2 = 1.6) therefore areas of restricted diffusion appear darker on adc maps, and unrestricted diffusion appears bright. 5. mr angiography (mra) tof and motsa in time-of-flight (tof) imaging and multiple overlapping thin-slab acquisitions (motsa) stationary tissue signal is suppressed by repetitive rf pulses, but inflowing blood is unaffected and appears hyperintense. it can be in 2d or 3d. motsa = hybrid of 2d and 3d. phase contrast imaging information about the phase (or direction) and of flow and velocity (or magnitude of flow) is provided. it requires two measurements that are sensitised to flow in equal and opposite directions thereby eliminating any signal not arising from flow or motion. it can be in 2d or 3d. contrast-enhanced angiography an intravenous agent that shortens the t1 (hastening longitudinal recovery) of blood is used, so that there is a higher net magnetisation vector that can result in a high signal on t1w imaging. it can be in 2d or 3d. 6. fat-related imaging techniques fat signal suppression fat has a high signal on t1 as it has a short tr. there are many ways to suppress this high signal (to evaluate other tissues better). first – an rf pulse at the beginning of any sequence is applied followed immediately by a gradient that shifts the net magnetisation vector of fat so that it has no longitudinal magnetisation at the start of the image acquisition. as no transverse magnetisation from fat is generated, there is no signal from fat. second – an inversion recovery pulse sequence is used to nullify the signal from fat (e.g. stir). third – a water-excitation technique is applied so that only tissues containing water have transverse magnetisation. as no transverse magnetisation from fat is generated, there is no signal from fat. 7. in-phase and out-of-phase imaging hydrogen in fat and hydrogen in water have different chemical environments, they precess at different rates. a spoiled gre sequence is used. fat and water are imaged when their h nuclei are spinning in phase and out of phase with each other by using a tes of 4.2 and 2.1 msec at 1.5t respectively. if microscopic fat is present (e.g. adrenal adenoma versus carcinoma), its signal is nullified on the out-of-phase images. 8. specific absorption rate (sar) the rf pulse that flips the net magnetisation vector into the transverse plane is an energy pulse that is deposited in the patient. sar is a measure of the rate at which the rf energy (measured in watts) is dissipated in tissue, per unit of tissue mass (measured in kilograms). sar is proportional to b2 ∝2 d where b = field strength, ∝ = flip angle, and d = duty cycle (or tr). therefore if the field strength is doubled (1.5t to 3t) the sar increases fourfold, if the flip angle is doubled (15° vs 30°) the sar increases fourfold, and if the tr is halved, the sar is doubled. the above is just a short, select summary of the above article. patient care optimum minimum risk of air bubble injection1 – optiray® is available in pre-filled syringes. non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 10/8/06 3:28 pm page 1 examination time1 optimise non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request in contrast to many agents optiray®, is available as a pre-filled syringe. tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 3/8/06 10:30 am page 2 pg 45-47.indd 47 9/6/06 2:59:57 pm abstract introduction and review conclusion acknowledgements references about the author(s) jacqueline s. smilg evolutionary studies institute, university of the witwatersrand, south africa department of radiation sciences, university of the witwatersrand, south africa department of diagnostic radiology, charlotte maxeke johannesburg academic hospital, johannesburg, south africa citation smilg js. are you dense? the implications and imaging of the dense breast. s afr j rad. 2018; 22(2), a1356. https://doi.org/10.4102/sajr.v22i2.1356 review article are you dense? the implications and imaging of the dense breast jacqueline s. smilg received: 19 apr. 2018; accepted: 18 june 2018; published: 23 aug. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract mammography relies on a visual interpretation of imaging results that is often confounded by dense breast tissue. dense tissue affects the ability and accuracy with which the radiologist is able to detect cancer. dense tissue may mask the presence of a breast cancer, and breast density is well recognised as an independent risk factor for the development of breast cancer. in the dense breast, detected cancers tend to be larger, more often lymph node positive and of a higher stage than those diagnosed in fatty tissue. the incidence of tumour multifocality and multicentricity is higher, decreasing the chances for breast conserving treatment. the literature convincingly supports the use of supplemental imaging modalities in women who present with increased breast density. there are clear advantages and disadvantages to each set of diagnostic imaging tests. however, there is no simple, cost-effective solution for women with dense breasts to obtain a definitive detection status through imaging. suggestions are put forward as to what supplemental imaging choices should be included for the imaging of the dense breast with reference to the current south african setting. use of supplemental screening modalities should be tailored to individual risk assessment. in a resource-constrained environment, international recommendations may need to be adjusted. introduction and review breast cancer is the most common female cancer in south africa and is a leading cause of death amongst south african women.1 the increasing incidence of breast cancer is a major health concern with 19.4 million women aged 15 years and older at risk of contracting the disease.1 breast cancer is the most common form of cancer to affect women in south africa, and in 2013, it was responsible for 20.8% of female cancers and more than 10% of the entire cancer burden.1 breast cancer screening aims to detect the disease early and thereby reduce mortality from breast cancer.2 estimating an individual woman’s absolute risk for breast cancer is essential when decisions are being made about screening and preventive recommendations.3 the risk factors that are identified to play a role in predicting an individual’s potential breast cancer risk include current age, age at menarche, age at first live birth, number of previous breast biopsies and first-degree relatives with breast cancer.4 several studies have assessed the contribution of adding a measure of mammographic density to breast cancer risk prediction models.3,5 mammographic density is one of the strongest risk factors for breast cancer, with a high population attributable risk.6 the density of breast tissue is that portion of the breast that is composed of glandular and connective tissue. a dense breast is one in which there is more tissue than fat and this type of tissue is more common in younger women. about 40% of women over the age of 40 years have dense breasts.7 the breasts tend to become more replaced by fat as the glands involute after menopause. dense breast tissue reduces the effectiveness of mammography and increases the risk for developing breast cancer. the breast imaging reporting and data system (bi-rads) breast density categories are used in mammographic reports to indicate the degree of mammographic breast density (figure 1)8: the breasts are almost entirely fatty. there are scattered areas of fibroglandular density. the breasts are heterogeneously dense. the breasts are extremely dense. figure 1: mammographic demonstration of breast imaging reporting and data system (bi-rads) breast density categories: (a) < 25% density – fatty breast tissue; (b) < 50% density – scattered density; (c) > 50% density – heterogeneously dense; and (d) > 75% density – extremely dense. the last two categories are considered ‘dense’. when considering women aged in their early 40s, about 13% have extremely dense breasts and 44% have heterogeneously dense breasts. by the early 70s of age, 2% have extremely dense breasts and 24% have heterogeneously dense breasts.7 the fifth edition of bi-rads, when compared to the fourth edition, places more emphasis on the masking effects of breast density. this edition specifies that when there are regions of sufficient density to obscure small masses, the mammogram should be categorised as heterogeneously dense rather than with scattered fibroglandular tissue, even if the overall volume of density would not typically place that study in the heterogeneous category.9 because of inherent interand intra-reader variability of bi-rads density classification, computer-based methods have been developed to improve consistency. several automated density programmes have demonstrated high reproducibility10 and correlation with volumetric density as measured by magnetic resonance imaging (mri).11 many studies have concluded that there is at least a moderate association of mammographic breast density and the risk of breast cancer.12 extremely dense tissue poses a four to six times increased likelihood of developing breast cancer when compared to the risk with fatty involuted tissue and twice the likelihood when compared to scattered fibroglandular density type.12 women with dense breast tissue on mammogram are at increased risk for interval cancer (cancer that presents because of symptoms during the time between regular screening) because of the mammographic challenges and limitations of cancer detection for women with dense tissue. boyd et al.13 reported that women with extremely dense tissue were 17 times more likely to have an interval cancer than women with fatty involuted tissue. interval cancers represented 15.7% of cancers in extremely dense breasts compared with 4.5% of cancers in fatty tissue.14 it has been reported that cancers detected in dense tissue are larger, more likely to be lymph node positive and of a higher stage than in women without dense tissue, more often multifocal or multicentric, and mastectomy is more often performed.15,16,17 dense breast tissue increases the risk of breast cancer and impairs detection of non-calcified cancers on mammography, which can result in a more advanced stage at diagnosis. digital mammography improves cancer detection in dense tissue compared with film-screen mammography18; however, supplemental screening in addition to mammography may be indicated for women with dense tissue allowing for earlier detection of cancers in the dense breast. supplemental screening can include the following: digital breast tomosynthesis (dbt): many studies have shown that there is an improvement in invasive cancer detection with dbt, but fewer studies have addressed its performance in differing density categories. ciatto et al.19 showed an incremental cancer detection rate because of dbt of 2.8 per 1000 mammograms with fatty or scattered fibroglandular tissue and 2.5 per 1000 in dense tissue. digital breast tomosynthesis improves cancer detection compared to standard digital mammography in women with heterogeneously dense breasts but may be less effective in women with extremely dense breasts. a single centre study found that dbt reduced the interval cancer rate across all densities but most studies lack sufficient follow-up to substantiate this.20 ultrasound: ultrasound improves detection of early stage invasive breast cancer and is the most frequently used supplemental screening modality. data from many studies have revealed an increase in the rate of cancer detection each year when supplemental ultrasonography was utilised.21,22,23,24,25,26 the adjunct screening with tomosynthesis or ultrasound in mammography-negative dense breasts (astound) trial is the first published prospective trial directly comparing sonar and 3d mammography after negative 2d mammography in dense tissue.24 hesitation still exists in implementing routine, supplemental ultrasonography screening despite the data from the aforementioned studies. using handheld 2d ultrasonography to detect small masses is labour intensive. operator variability, shortages of trained personnel and reductions in radiologist efficiency for image acquisition all contribute to the widespread discouragement for whole-breast surveys.26 in order to combat some of these challenges, 3d automated whole-breast ultrasonography has been introduced as an alternative modality. multiple studies substantiate that supplemental breast ultrasonography – whether 2d handheld or 3d automated whole-breast ultrasonography – can improve rates of cancer detection.21,22,23,24,25,26 ultrasonography is in common use for diagnostic breast imaging, but its role in screening remains unclear. studies utilising screening ultrasonography demonstrate its capability for detecting invasive malignancies in dense breasts at small sizes and localised stages that could potentiate an increase in breast cancer survival rate; however, more studies are needed to determine the impact on mortality.26 the best indications for screening ultrasonography in dense breasts may be for women with intermediate risk or in those women at high risk but with a contraindication to mri.22 mri: the evidence supporting mri screening of the breast continues to evolve. a multicentre trial by sardanelli et al.27 determined mri to be more sensitive (91%) than clinical breast examination (18%), mammography (50%), ultrasonography (52%) or mammography plus ultrasonography (63%). in addition, 31% of cancers were detected by mri alone. many other studies have shown similar results.22,26 mri is recommended for supplemental screening in women at high risk of breast cancer regardless of breast density, but cost and availability limit its use for general screening. although cost, patient tolerance and accessibility are major detriments to using breast mri to screen women with the sole indication of dense breast tissue, some investigators are developing abbreviated examinations that show promising results.28 contrast enhanced digital mammography (cedm): this technology is being explored for screening. based on diagnostic work in women with known cancer,29,30 sensitivity is likely comparable to mri and specificity may be higher. in the diagnostic setting, cedm has been demonstrated to be superior to standard mammography in women with dense breasts.31,32 molecular breast imaging (mbi): studies using 99mtc-sestamibi have been performed for supplemental screening of women with dense breasts.33 studies are typically time consuming and the typical dose of about 740 mbq (20 mci) has been considered excessive for use as a screening test.34 the radiation exposure to the whole body, and not just the breast, is five times that of digital mammography, and twice that of combination digital mammography and dbt. these facts, taken in conjunction with the knowledge that there is no data on interval cancer rates, make it unlikely that mbi will be implemented in common practice.35 conclusion the use of supplemental imaging modalities has been shown to be advantageous in the assessment accuracy for dense breast tissue, and there are clear advantages and disadvantages to each type of diagnostic imaging test. awareness is increasing amongst the public and medical professionals regarding breast density as a risk factor for breast cancer, as well as the limitations of mammography in women with dense breasts. with this awareness comes legislation and notification laws in relation to breast density,36 particularly in countries with national screening protocols and programmes. south africa does not have a national screening programme for breast cancer, nor notification laws in connection to breast density. across south africa, in both the public and the private sectors of health care, there is a large discrepancy in breast imaging availability and quality. according to the south african national health policy document of 2017, screening mammography should not be introduced unless resources are available to ensure effective and reliable screening of at least 70% of the target group. lack of resources and infrastructure in the south african public health care system renders a national screening programme untenable.1 although neither clinical breast examination (cbe) nor breast self-examination (bse) has yet to be established as screening tools, the utility of these interventions in limited resource areas is advocated by this policy document, as they promote breast health awareness. breast self-examination as part of breast health awareness has been advocated for early detection in low-resource settings.1 unfortunately, breast density cannot be determined by touch, by feel or by the appearance of a breast during the physical examination. it can only be determined by evaluating a mammogram. understanding breast cancer risk conferred by density in the setting of a patient’s history, as well as an appreciation of the imaging tools available, will help aid clinicians in developing the most appropriate screening plan for each of their patients. mammography remains the most appropriate modality for population-based screening37 with the addition of one or more of the supplemental imaging modalities according to the patient’s individual breast cancer risk profile.36 acknowledgements competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this paper. references motsoaledi dp. health mo. breast cancer prevention and control policy. national department of health, pretoria, rsa; 2017. darabi h, czene k, zhao w, liu j, hall p, humphreys k. breast cancer risk prediction and individualised screening based on common genetic variation and breast density measurement. breast cancer res. 2012;14(1):r25. https://doi.org/10.1186/bcr3110 tice ja, cummings sr, ziv e, kerlikowske k. mammographic breast density and the gail model for breast cancer risk prediction in a screening population. breast cancer res treat. 2005;94(2):115–122. https://doi.org/10.1007/s10549-005-5152-4 gail mh, brinton la, byar dp, et al. projecting individualized probabilities of developing breast cancer for white females who are being examined annually. j natl cancer inst. 1989;81(24):1879–1886. https://doi.org/10.1093/jnci/81.24.1879 chen j, pee d, ayyagari r, et al. projecting absolute invasive breast cancer risk in white women with a model that includes mammographic density. j natl cancer inst. 2006;98(17):1215–1226. https://doi.org/10.1093/jnci/djj332 vachon cm, van gils ch, sellers ta, et al. mammographic density, breast cancer risk and risk prediction. breast cancer res. 2007;9(6):217. https://doi.org/10.1186/bcr1829 sprague bl, gangnon re, burt v, et al. prevalence of mammographically dense breasts in the united states. j natl cancer inst. 2014;106(10):dju255-dju. https://doi.org/10.1093/jnci/dju255 kaur sd. how to decrease breast density to reduce breast cancer risk 2016. [homepage on the internet]. c2016 [cited 2018 apr 7]. available from: http://mammalive.net/resources/decrease-breast-density-reduce-breast-cancer-risk/ d’orsi cj, sickles ea, mendelson eb, morris ea. acr bi-rads® atlas, breast imaging reporting and data system. 5 ed. reston, va: acr; 2013. alonzo-proulx o, mawdsley ge, patrie jt, yaffe mj, harvey ja. reliability of automated breast density measurements. radiology. 2015;275(2):366–376. https://doi.org/10.1148/radiol.15141686 gubern-mérida a, kallenberg m, platel b, mann rm, martí r, karssemeijer n. volumetric breast density estimation for full-field digital mammograms: a validation study. plos one 2014;9(1):e85952. harvey ja, bovbjerg ve. quantitative assessment of mammographic breast density: relationship with breast cancer risk. radiology. 2004;230(1):29–41. https://doi.org/10.1148/radiol.2301020870 boyd nf, guo h, martin lj, et al. mammographic density and the risk and detection of breast cancer. new engl j med. 2007;356(3):227–236. https://doi.org/10.1056/nejmoa062790 gierach gl, ichikawa l, kerlikowske k, et al. relationship between mammographic density and breast cancer death in the breast cancer surveillance consortium. j natl cancer inst. 2012;104(16):1218–1227. https://doi.org/10.1093/jnci/djs327 bertrand ka, tamimi rm, scott cg, et al. mammographic density and risk of breast cancer by age and tumor characteristics. breast cancer res. 2013;15(6):r104. https://doi.org/10.1186/bcr3570 chiu sy-h, duffy s, yen am-f, tabár l, smith ra, chen h-h. effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a swedish mammographic screening. cancer epidemiol biomarkers prev. 2010;19(5):1219–1228. https://doi.org/10.1158/1055-9965.epi-09-1028 arora n, king ta, jacks lm, et al. impact of breast density on the presenting features of malignancy. ann surg oncol. 2010;17(suppl 3):211–218. https://doi.org/10.1245/s10434-010-1237-3 pisano ed, gatsonis c, hendrick e, et al. digital mammographic imaging screening trial (dmist) investigators group. diagnostic performance of digital mammography versus film mammography for breast-cancer screening. new engl j med. 2005;353(17):1773–1783. https://doi.org/10.1056/nejmoa052911 ciatto s, houssami n, bernardi d, et al. integration of 3d digital mammography with tomosynthesis for population breast-cancer screening (storm): a prospective comparison study. lancet oncol. 2013;14(7):583–589. https://doi.org/10.1016/s1470-2045(13)70134-7 mcdonald es, oustimov a, weinstein sp, synnestvedt mb, schnall m, conant ef. effectiveness of digital breast tomosynthesis compared with digital mammography: outcomes analysis from 3 years of breast cancer screening. jama oncol. 2016;2(6):737–743. https://doi.org/10.1001/jamaoncol.2015.5536 corsetti v, ferrari a, ghirardi m, et al. role of ultrasonography in detecting mammographically occult breast carcinoma in women with dense breasts. radiol med. 2006;111(3):440–448. https://doi.org/10.1007/s11547-006-0040-5 berg wa, zhang z, lehrer d. et al. detection of breast cancer with addition of annual screening ultrasound or a single screening mri to mammography in women with elevated breast cancer risk. jama. 2012;307(13):1394–1404. https://doi.org/10.1001/jama.2012.388 ohuchi n, suzuki a, sobue t, et al. sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the japan strategic anti-cancer randomized trial (j-start): a randomised controlled trial. lancet. 2016;387(10016):341–348. https://doi.org/10.1016/s0140-6736(15)00774-6 tagliafico as, calabrese m, mariscotti g, et al. adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts: interim report of a prospective comparative trial. j clin oncol. 2016;34(16):1882–1888. https://doi.org/10.1200/jco.2015.63.4147 brem rf, tabár l, duffy sw, et al. assessing improvement in detection of breast cancer with three-dimensional automated breast us in women with dense breast tissue: the somoinsight study. radiology. 2015;274(3):663–673. https://doi.org/10.1148/radiol.14132832 berg wa, blume jd, cormack jb, et al. combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. jama. 2008; 299: 2151–2163. https://doi.org/10.1001/jama.299.18.2151 sardanelli f, podo f, santoro f, et al. multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk italian 1 study): final results. invest radiol. 2011;46:94–105. https://doi.org/10.1097/rli.0b013e3181f3fcdf kuhl ck, schrading s, strobel k, schild hh, hilgers r-d, bieling hb. abbreviated breast magnetic resonance imaging (mri): first postcontrast subtracted images and maximum-intensity projection – a novel approach to breast cancer screening with mri. j clin oncol. 2014;32(22):2304–2310. https://doi.org/10.1200/jco.2013.52.5386 jochelson ms, dershaw dd, sung js, et al. bilateral contrast-enhanced dual-energy digital mammography: feasibility and comparison with conventional digital mammography and mr imaging in women with known breast carcinoma. radiology. 2013;266:743–751. https://doi.org/10.1148/radiol.12121084 chou c-p, lewin jm, chiang c-l, et al. clinical evaluation of contrast-enhanced digital mammography and contrast enhanced tomosynthesis – comparison to contrast-enhanced breast mri. eur j radiol. 2015;84:2501–2508. https://doi.org/10.1016/j.ejrad.2015.09.019 mori m, akashi-tanaka s, suzuki s, et al. diagnostic accuracy of contrast-enhanced spectral mammography in comparison to conventional full-field digital mammography in a population of women with dense breasts. breast cancer. 2017;24(1):104–110. https://doi.org/10.1007/s12282-016-0681-8 tagliafico as, bignotti b, rossi f, et al. diagnostic performance of contrast-enhanced spectral mammography: systematic review and meta-analysis. breast. 2016; 28:13–19. https://doi.org/10.1016/j.breast.2016.04.008 shermis rb, wilson kd, doyle mt, et al. supplemental breast cancer screening with molecular breast imaging for women with dense breast tissue. am j roentgenol. 2016;207(2):450–457. https://doi.org/10.2214/ajr.15.15924 hendrick re. radiation doses and cancer risks from breast imaging studies. radiology. 2010;257(1):246–253. https://doi.org/10.1148/radiol.10100570 hendrick re, tredennick t. benefit to radiation risk of breast-specific gamma imaging compared with mammography in screening asymptomatic women with dense breasts. radiology. 2016;281(2):583–588. https://doi.org/10.1148/radiol.2016151581 falcon s, williams a, weinfurtner rj, drukteinis js. imaging management of breast density, a controversial risk factor for breast cancer. cancer control. 2017;24(2):125–136. https://doi.org/10.1177/107327481702400205 american college of obstetricians and gynecologists. committee opinion no. 625: management of women with dense breasts diagnosed by mammography. obstet gynecol. 2015;125(3):750–751. https://doi.org/10.1097/01.aog.0000461763.77781.79 about the author(s) maya patel radiological society of south africa, south africa national radiology services inc., johannesburg, south africa citation patel m. re-inventing the future of the radiological research footprint in south africa. s afr j rad. 2018; 22(1), a1665. https://doi.org/10.4102/sajr.v22i1.1665 editorial re-inventing the future of the radiological research footprint in south africa maya patel copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the accidental discovery of the usefulness of radiation in medical diagnostics in 1895 has changed the way healthcare is delivered and is associated with tremendous growth in the field of radiology, mainly because of advances in research. such advances have created a specialised and -sub-specialised discipline to such an extent that most clinicians rely on radiological imaging to confirm a diagnosis, monitor progress or predict an outcome for a patient. as a result, imaging is requested for almost every medical encounter. medical advances, both locally and internationally, have, however, far surpassed radiology, creating a new world, ranging from stem cell therapy to robotic and artificial intelligence, totally changing the landscape of practice. analogously, our profession needs to foster and encourage further research if we wish to remain at the forefront of innovation. cutting-edge radiology research should be driven and celebrated by everyone. admirably, the past two decades have witnessed a dramatic rise in radiology research in south africa. this is attributed mostly to the requirement of a master’s degree to fulfil university criteria for a postgraduate degree in radiology. simultaneously, there has also been a fair amount of radiology phd studies completed. this recent spark poses an interesting scenario where current research is highlighting the need for follow-up studies, protocols, policies and guidelines locally relevant to the south african context, but will it be enough to lead us into the rapidly changing future? as in any developing country, the south african stage faces limitations. one of the major factors is the huge divide between public and private services, both in terms of human and physical resources. the reality is that the public sector environment is severely restricted in its ability to provide modern imaging modalities, the international forefront of radiological research; thus, specialised modalities in the form of magnetic resonance imaging (mri) and positron emission tomography–computed tomography (pet/ct) are often only accessible in subspecialistand specialist-level hospitals in south africa. in addition, the large burden of disease increases the workload to such an extent that despite the disease profiles, offering a wealth of opportunities to conduct research, radiologists are often unable to dedicate the necessary time and energy required. furthermore, staffing and expertise are limited, with skilled staff often seeking alternate opportunities in the more lucrative private environment. consequently, the entire system presents an immense research challenge, ranging from infrastructural needs to availability of recorded data, loss to follow-up, lack of facilities, limited expertise and unavailability of several commercial medications and contrast agents. these local challenges are, however, not unique to radiologists and apply to all medical professions. within our small radiology community, the research quality is modest, focusing primarily on frequency statistics, retrospective data capture and auditing. comparatively, we appear to be strides behind our international counterparts who are documenting novel concepts such as new 3d imaging virtual platforms and conducting prospective clinical research trials. nevertheless, although basic, locally relevant research within our country’s limitations benefits both ourselves and other developing countries that may be facing similar challenges. international guidelines are available, tested and established, but as mentioned, more and more studies are highlighting the need for locally relevant criteria and service delivery improvement. in this respect, the south african footprint is being embedded and for now it seems that we are making steady progress. our research agenda should be driven in line with what is best for patient safety, efficacy in care and improved quality at a lower cost. this then incorporates the moral and ethical dimensions into research that is relevant to our context within south africa and can inform improved care for our patient population, addressing the disease profiles that we face. at the same time, we need not to lose sight of the modern role of medical imaging, as seen internationally, and promote some attention on the evolution of innovation in technology around us, and specifically in radiology. in this way, we can create a profession that our patients expect and that the medical profession demands. to achieve this, we need to lead research in conjunction with other medical teams. this agenda should become part of the strategy of the organisation for both the radiologists and other departments. private and public sectors need to collaborate to diminish the divide and inequity, thereby strengthening the health service delivery as a whole. such collaboration could also take place on the academic level, hence supporting research through offering assistance in terms of resources, infrastructure and expertise, while at the same time stimulating continuing professional development (cpd) for colleagues who are no longer exposed to the academic environment. another initiative would be to review the process of undergraduate and postgraduate teaching by encouraging research at these levels and stimulating interest at an early stage. within academic publishing, a journal’s research footprint is used to track its scholarly and scientific impact, setting it against other journals and marking its position in the academic literature world. although the impact of the journal is always in focus, the benefit that its research content offers will inevitably reflect a standard that can be shared and honoured. with the aid of research, we as radiologists can re-invent the future of radiology in our country and secure our place in the future of medicine. we certainly have the potential and the expertise to do so. report baci< frompage28 report on the second international breast imaging update ibus freiburg, germany, 15-17 october 1999 freiburg is a city of 200 000 inhabitants of which 10% are students. it is located in the south west of germany in the area where germany, france and switzerland meet. the congress was held in the konzerthaus. it was organised by the international breast ultrasound school in conjunction with the august ludwig university of freiburg. the congress covered the whole range of topics in mammography. it was also very interesting to see that a full series of hands-on workshops ranging from ultrasound to minimally invasive breast biopsies to pathology and breast intervention were held for all the delegates. a pathologist presented one of the most interesting sessions that i attended. there was an introductory course into breast cyto-pathology, which was very interesting. a practical demonstration with a wide range of slides demonstrating the problems of cytology was covered in this session of nearly two-and-a-halfhours. i think that all breast imagers should make an effort to get some basic exposure in pathology especially now that we are doing such a lot of breast intervention. it gives you insight into the practical problems of breast cytology and why the reports look the way they do. a large technical display was on at the same time. interesting developments as far as apparatus is concerned is from mamrnotome (which is marketed by johnson & johnson in south africa). the mamrnotome machine is well known to breast imagers. it is a vacuum biopsy device. the problem with this equipment in the past was that you had to have a 30 sa journal of radiologyjanuary 2000 special table and apparatus. they have now brought out a hand-held breast vacuum biopsy device. this has great potential in use under ultrasound guidance. the apparatus was practically demonstrated to us. it has all the advantages of the larger apparatus and prone tables with very few disadvantages. the apparatus is easy to use and practical with distinct advantages for the patient. on a practical video linked to the local hospital, excision of a fibro-adenoma under local anaesthetic with a hand-held mamrnotome machine, was performed within 15 minutes. the complete fibro-adenoma was removed. as far as ultrasound is concerned, a very interesting lecture was given about a standardised version of guidelines for use of ultrasound. worldwide it seems that we all have the same problems as far as the use of ultrasound is concerned. leus has now laid down criteria and invited comment on a set of standards whereby the user of ultrasound equipment will have to undergo a strict qualification and abide by the criteria before ultrasound can be performed. like in south africa, it is a big problem in europe that everybody can buy an ultrasound machine and use it whether they are qualified or not. i am glad to see that jack jellins and his group are now addressing this problem and i hope to see positive developments emerging from this. pictorial interlude normal variant striate calcification perpendicular to the lateral ventricles ralph drosten mfj bch, fcrad (d) eeg assessment. a pre-intravenous (n) contrast axial computed tomography (ct) scan of the brain (fig. 1) demonstrat ed multiple thin calcific striations perpendicular to the lateral ventricles, in the deep white matter of the corona radiata. no abnormal post-contrast enhancement, mass or mass effect was observed. department of thoracic imaging brigham and women's hospital boston, usa case presentation a 43-year-old man presented to his doctor after his second grand mal seizure. he was found to be entirely normal on clinical and neurological examination, laboratory testing and discussion striate calcification perpendicular fig. 1. pre-contrast axial ct of the brain at the level of the lateral ventricles showing striate calcifications perpendicular to the lateral ventricles in the deep white matter of the corona radiata. to the lateral ventricles is a recognised normal variant and has no known pathological or clinical relevance. 51 sa journal of radiology • march 2002 star abstract radiological management of skeletal metastases, multiple myeloma and lymphoma maximilian freiser md in malignant tumors distant metastases are of utmost importance for the choice among different treatment options. depending upon the primary tumor, lung, liver and the skeletal system are frequent sites of distant metastases. the diagnosis of multiple myeloma is based on laboratory findings. for staging of this disease, plain radiograms of the skeletal system are obtained in order to assess skeletal involvement and fracture risk, especially of the spinal column. lymphoma usually originates from the lymph nodes and staging is focussed on the visualization of the extent of lymph node involvement. in advanced stages of malignant lymphoma, the skeletal system may also be involved. skeletal metastases, multiple myeloma and lymphoma are mainly distributed via the arterial circulation and seed into the bone marrow. as the neoplastic cells proliferate the normal bone marrow elements are replaced. due to its better vascularization, the red marrow is more frequently affected. in advanced stages of bone marrow involvement, the yellow marrow is replaced by red marrow due to the demand in production of blood cells (reconversion) and peripheral skeletal elements are also prone to seeding of metastatic cells. various imaging modalities are used for the diagnostic workup of skeletal manifestations of metastases, multiple myeloma and lymphoma. their relative value depends on the principle of the particular imaging modality on one hand, and the biological properties of the underlying malignancy on the other hand. plain radiography, ct, mri, bone scanning and pet are adequate methods for the diagnosis of these disorders and frequently a combination of these techniques is employed. recently whole body mri, whole body ct and ct-pet have been described. radiography in order to detect bone destructions on plain radiograms about 30% of the bone substance has to be removed. cortical destructions are more apparent than purely trabecular lesions. in preexisting osteoporosis, lysis of the bone is more difficult to assess. numerous reports have shown that radiography is less sensitive than bone scanning, pet, ct and mri in 33 sa journal of radiology • december 2002 the detection of skeletal metastases, multiple myeloma and lymphoma. when neoplastic cells are invading the bone marrow without or with minor destruction of the bone trabecular, no radiographic abnormalities can be detected. radiography, on the other hand, allows one to differentiate lytic, sclerotic and mixed pattern of bone metastases and to establish differential diagnoses when other imaging modalities, e.g. bone scanning show suspicious findings. computed tomography with single slice ct only limited anatomical areas could be examined and ct was used to clarify ambiguous results obtained with other modalities. multislice ct enables one to scan large portions of the body within short acquisition times and with thin collimation. multiplanar reconstructions allow one to display the skeletal system in imaging planes adequate for diagnostic reading, e.g. sagittal and coronal mpr's of the spine and coronal mpr's of the pelvis. ct is also superior to radiography in the assessment of bones at risk of fracture. in the spine endplate fractures not visualized on radiograms can be detected. recently it was published that msct with coronal and sagittal mpr's is efficient in staging patients with multiple myeloma by demonstrating nodular destructions and also tiny trabecular and cortical defects. replacement of bone marrow by neoplastic tissue results in an increase of density as demonstrated by ct. this is better recognizable within the fatty marrow than the red marrow and does not allow for a reliable diagnosis. star abstract magnetic resonance imaging (mri) mr! has a unique soft tissue contrast and enables for the election of diffuse and focal bone marrow infiltration. ti-weighted spin echo, stir and fat sat proton density and t2weighted pulse sequences are most sensitive for the detection of neoplastic infiltration of the bone marrow. numerous reports underline the superior sensitivity of mr! in the detection of skeletal metastases, and manifestations of multiple myeloma and lymphoma respectively. whole body mr! has been performed in comparison to bone scanning in the detection of skeletal metastases. the total number of metastases detected with mr! was higher than that of bone scanning. mr! was particularly useful in the spine and pelvis, whereas bone scanning performed better in the skull and ribs. in addition to skeletal metastases mr! was able to detect metastases to other organs with high accuracy. in multiple myeloma mr! enables one to differentiate diffuse, nodular and mixed nodular and diffuse skeletal manifestations. for the assessment of diffuse bone marrow infiltration by myeloma, contrast enhanced mr! proved to be very valuable. enhancement within the bone marrow of 20% and more is indicative of moderate to high grade myeloma infiltration. low grade infiltration can not be diagnosed with mr! and bone biopsy is required. in addition to clinical parameters mr! findings are an independent prognostic factor in patients with multiple myeloma. bone scanning and pet in bone metastases with sclerotic or mixed pattern, bone scanning is very sensitive, whereas purely lytic metastases (renal cell carcinoma, thyroid cancer, multiple myeloma) are frequently not associated with tracer accumulation. while bone is highly sensitive, its specificity is limited. therefore, unless findings are specific for neoplastic infiltration, correlation with other imaging techniques is required. fdgpet is correlated to increased metabolism of tumor cells and enables one to diagnose increased cell turn over of neoplasms. however, false-positives and negatives have to be ruled out. suggested reading 1. bollow m, knauf w, korfel a, taupitz m, schilling a, wolf kj, hamm b. initial experience with dynamic mr imaging in evaluation of normal bone marrow versus malignant bone marrow infiltrations in humans. j magn reson imaging 1997 jan-feb; 7(1): 241-250. 2. byun wm, shin so, chang y, lee sj, finsterbusch j, frahm j. diffusion-weighted mr imaging of metastatic disease of the spine: assessment of response to therapy. ajnr am j neuroradiol2002 jun-jul; 23(6):906-912. 3. linden a, zankovich r, theissen p, diehl v, schicha h. malignant lymphoma: bone marrow imaging versus biopsy. radiology 1989 nov; 173(2): 335-339. 4. marcuzzi dw, cohen ek. role of mri bone marrow imaging in recurrent lymphoma. can assoc radiol j 1989 aug; 40(4): 216-218 comment in: can assoc radiol f. 1990 feb; 41(1): 51. 5. nyman r, rehn s, glimelius b, hagberg h, hemmingsson a, jung b, simonsson b, sundstrom c. magnetic resonance imaging in diffuse malignant bone marrow diseases. acta radiol1987 mar-apr; 28(2): 199-205. 6. rybak ld, rosenthal di. radiological imaging for the diagnosis of bone metastases. q j nucl med2001 mar; 45(1): 53-64. 7. thompson ja, shields af, polter ba, olson do, rubin e, kidd p, fefer a. magnetic resonance imaging of bone marrow in hairy cell leukemia: correlation with clinical response to alpha-interferon. leukemia 1987 apr; 1(4):315316. 34 sa journal of radiology • december 2002 editorial forensic radiology j l höll, mb chb, ffrad (d)sa department of radiology, pretoria academic hospital, and university of pretoria the radiological fraternity has played a significant role in the new south africa, but taking our previous history into account and living in an era of human rights and social change we must realise that far more will be expected of us, including in the field of forensic radiology. forensic pathology was the first field of medicine to use the new ray as described by roëntgen on 8 november 1895. long before any pathological diagnosis had been made, or the field of diagnostic radiology came to be a specialty, court cases were won or lost on exposures made within weeks of the official announcement lecture by wilhelm roëntgen on 23 january 1896.1 on 6 january 1896 a journalist in the new york sun erroneously but prophetically stated ‘... the professor [roëntgen] is already using this discovery to view broken limbs and bullets inside human bodies’.2 an exposure done on a certain tolson cunnings of montreal, canada on 7 february 1896 revealed a bullet lodged between the tibia and fibula. the bullet was extracted and used in testimony in court, which led to the imprisonment of a mr george holder for 14 years.1 all these facts are interesting, but our concern today must be the setting up of a civilised society where forensic radiology can and must play a role. we tend to think of forensic roentgenology as the discipline that helps to save battered children, but we are also expected to use this knowledge to help the police bring perpetrators to bay, to assist with age determination of criminals and people awaiting trial, and similarly to place patients into their correct age group surroundings in mental institutions. the curriculum for training radiologists includes forensic pathology, but are we really serious about this training? i know of only a small group of radiologists in south africa with some interest in this field. is it because of a lack of training, or are we hiding from the dead and resistant to experiencing the bad side of life in our own field of specialty? maybe we are afraid of courts and time spent in creating a more civilised society. those of us with interest in this field still use publications that are long overdue for revision. for instance we use the radiographic atlas of skeletal development of the hand and wrist by greulich and idell pyle published in 1959. as noted in the preface to this publication, these studies were done on white americans of north european descent between 1929 and 1950.3 to a certain extent modern publications still refer to classic texts such as that of paul hodges4 from 1933. some minor changes came about with the introduction of other work, e.g. that by girdang and golden published in 1952.5 however it is important to realise that while 50+ years in evolution is not a long time, living standards have changed tremendously over the last 2 3 generations and we must expect some changes in bone maturation. also the publication by gustofson6 on age determination using the third molar was done in the 1960s on north european children. while using all these publications and more recent additions, we are still working with a unique population in the southern tip of africa. my request to the radiological fraternity is to pay more attention to the curriculum, and to improve our knowledge on forensic work. maybe someone somewhere will start work on a publication or textbook that can fill the gap in forensic radiology and be used to benefit our very specific population. this publication will lead us into the 21st century. 1. brogdon bg. forensic radiology. boston: crc press, 1998: 16 20. 2. sprawls p, ed. the x-ray department of radiology centenary, emory university, georgia, atlanta. georgia: emory university press, 1995. 3. greulich ww, idell pyle s. radiographic atlas of skeletal development of the hand and wrist. stanford, california: university of california press, 1959. 4. hodges pc. development of the human skeleton. part 1. university of chicago press, 1933. 5. girdang br, goldon r. centers of ossification of the skeleton. am j radiol 1952; 68: 922. 6. gustofson g. forensic odontology. london: staple press, 1966: 12 14. julian l höll guest editor 2 sa journal of radiology • march 2006 editorial.indd 1 3/27/06 11:47:21 am case study ct features of rupture of the thoracic aorta and subsequent death f van gelderen md· a n 83-year-old man was found in a collapsed and dyspnoeic condition at his home and suffered a period of apnoea in transit to the hospital. on examination he was hypotensive with bradycardia and weak femoral pulses. chest radiographs revealed homogeneous opacification of the left hemithorax with relative sparing of the left base. the referring clinician considered the possibilities of rupture of the aorta or alternatively a mass in the left hemithorax; a left pleural tap revealed bloody fluid, and the patient was referred for computed tomography (ct). a limited non-contrast-enhanced ct examination confirmed the diagnosis of aortic rupture. a dynamic contrast-enhanced examination demonstrated the signs to better advantage, with a large posterior 'encapsulated' extrapleural haematoma displacing the convex parietal pleura anteriorly. a smaller left anterior pleural fluid am packer mocm** • department of radiology, •• department of pathology, wanganui base hospital, wanganui, new zealand collection and marked mediastinal shift to the right side were present. the descending aorta was displaced anteriorly (figure 1). an initially confusing feature was the absence of contrast medium in the aorta, and lingering of contrast in the venae cavae and azygos venous system. there was also extensive dense opacification of dilated veins, including the spinal epidural veins lining the inside of the bony vertebral column, with loss of the normal rounded contour. venous channels within the soft tissues posterior to the vertebral column and contrast filled intercostal, veins were also noted. figure 1,' ct chest at tb level demonstrates a vel}' large left extrapleural fluid col/ection posteriorly, separated by antenorly bowed convex pleura, with intrepleural haemoth~rax more anteriorly (pleura indicated by arrows). calcified aorta displaced anteriorly, and marked medlastmal shitt to the nght. dense contrast layering in superior vena cava and high density vessels in chest wal/ (arrows). the spinal canal has lost its nor';lal rounded contour due to . opacification of intraspinal veins. (pa!,ent s arms by his side. with resulting artefacts and simulated low attenuation in postenor mmlthorax ). 26 sa journal of radiology. november 1998 the dependent aspects of the hepatic veins (figure 2), portal venous system (figure 3) and right renal vein and radicles (figure 4) were distended with contrast as if diagnostic venography had been performed. a posterior hepatic 'sinusoidogram' appearance was noted, with contrast readily filling the sinusoids in the dependent parts of the liver in a homogeneous t:-'0-pa-g-e-=27=---ct features of rupture of the thoracic aorta and subsequent death frompage26 figure 2: ct at t10til disc level with very dense contrast medium in inferior vena cava (t/p of nasogastric tube to the left of the inferior vena cava), hepatic vein (arrow) and radic/es distended with contrast medium, and sinusoids in dependent part of right lobe of liver homogeneously opacified, note also opacification of venous channels related to posterior spinal elements at ti 0 level, within erector spinae muscles, the left extrapleuralilaematoma is again evident. figure 3: ct at t12 level demonstrating similar features with contrast layering in the inferior vena cava, the inferior aspect of the left extraplaural haamatoma still visible, contrast filled venous structures in the dependent erector spinae muscles, the sinusoidal opacification of the posterior aspect of the fiver and a contrast filled right portal vein (arrow), figure 4: ct image at l l-l2 disc level demonstrating contrast layering in the inferior vena cava, flattening of the aorta from front to back, and very dense opacifieat/on of the right renal veins with an appearance similar to that of a diagnostic contrast renal venogram. 27 sa journal of radiology. november 1998 fashion, the parenchyma of the right kidney was not opacified in the same manner, possibly as the renal parenchyma is of firmer consistency, the contrast medium layering in the suprarenal inferior vena cava was remarkable, but little filling of the infrarenal vena cava was present all veins and venous channels app ared to be dilated, but the aorta assumed a' collapsed' configuration, being wider from side to side (figure 4), the patient died during th ct examination, and the diagnosis of aortic rupture was confirmed at a subsequent post-mortem examination. the site of rupture was 9 cm inferior to the left subclavian artery, and the aorta was markedly atherosclerotic. two litres ofleft-sided posterior extra pleural blood was found; the pleura was bowed anteriorly in convex fashion, a further litre of intrapleural blood was found. the left lung was compressed and pale and weighed 340 g, and the right lung was rusty in colour, oedematous and weighed 760 g.there were signs of cardiomegaly and coronary atherosclerosis. the above case presentation includes some unusual features, with death during ct being an unusual event and documented thus in pictorial form. it is also worthy of note that a large extra pleural haemothorax is unusual following traumatic aortic rupture, with the apical cap sign and right paraspinalline displacement occurring in 10%, whereas a left haemothorax occurred in 16% of patients. i at post-mortem examination the distinction between extrapleural and pleural haemothorax is not usually made. the ct in the above case report was performed as an emergency procedure, but during the examination it was decided that the patient would not be considered for resuscitation as a pre-existent diagnosis of alzheimer's disease had been communicated at that stage. reference 1, stark p, traumatic rupture of the thoracic aorta; a review, crc critical relliew il1 diagnostic imaging 1984; 21(3): 229-255, casereport and mediastinal windows demonstrated the ct angiogram sign. i attenuation of the lobe was heterogeneous.' multiple air bronchograms were seen" there was dilatation, stretching, sweeping, widening of the angle and crowding of bronchi .1 a pleural effusion was noted. discussion our patient had specific signs of bronchoalveolar consolidation which include squeezing, stretching and sweeping patent air bronchograms within the consolidated lung.' the 'crazy paving' pattern is due to thickening of the interlobular septae.' all these changes, due to unique lepidic growth of the tumour were also noted.' our patient did not have satellite lesions or bulging tissues, which increase the likelihood of bronchoalveolar carcinoma (bac). other absent signs were pseudocavitation, air fluid level in cavities and marginal enhancement. 4,5 although the ct angiogram sign was present it is also seen in pneumonia, and is therefore nonspecific." references 1. akata s, fukushima a, kakizaki d, ase k, amino s. cr scanning of bronchioalveolar carcinoma: specific appearances. lung cancer 1995; 12: 221-230. 2. irn j, han mc, yu ej, et al. lobar bronchioalveolar carcinoma: 'angiogram sign' on cr scans. radiology 1990; 176: 749-753. 3. zeuthlin n, lasser ec, rigler lg. bronchographic abnormalities in alveolar cell carcinoma of the lung. dis chest 1954; 25: 542549. 4. im j, cho bl, park jh, et al. cr findings oflobar bronchioalveolar carcinoma. j comput assist tomogr 1986; 10: 320-322. 5. manning jt jr, spjut hj, tschen ja. bronchioloalveolar carcinoma: the significance of histopathologic types. cancer 1984; 54: 525534. 6. barsky sh, grossman da, ho j, holmes ec. the multifocality of bronchioloalveolar lung carcinoma: evidence and implications of a multiclonal origin. mod patho11994; 7: 633-640. occult spinal dysraphism l d r tsatsi mb chb, fcrad d)sa department of diagnostic radiology medical university of southern africa b okoli mbbs,mmed department of neurosurgery medical university of southern africa case presentation a 2-month-old male patient presented to our outpatient's department with a diffuse back swelling. the child is the fifth in a family with no history of congenital abnormalities. the pregnancy went full term and was a normal vaginal delivery. a diffuse swelling was noted in the midline in the lumbar region. the mass was covered with normal skin, with no discolouration, hair, sinus or ulceration. it had a soft, fatty feel on palpation. there was no neurological dysfunction. plain film x-rays of the spine demonstrated spina bifida involving the whole spine with sparing of only ti2, ll, l2 and l3 (figs 1 and 2). the defects were more pronounced in the upper cervical and sacral areas. the spinous processes in the thoracic and lumbar areas were visualised though they were not fused. a ct scan reconstruction of the 26 sa journal of radiology • september 2002 fig. 1 ap spinal x-ray of the cervical and thoracic spine showing the extensive spina bifida involving both regions. whole spine demonstrated the spina bifida (figs 3 and 4). mr! findings showed a normal cord from the cervical to the sacral level. case report fig. 2. ap spinal x-ray of the lumbo-sacral region demonstfating the spina bifida in the sacral region. fig. 3. cat scan reconstruction of the spine demonstrating the spina blfida in the cervical and thofacic region. a ct scan of the brain was not performed. to the best of our knowledge such an extensive occult spinal dysraphism has not been reported in the literature. discussion simple occult spinal dysraphism is often an incidental finding caused by an incomplete closure of the spinal arches of the posterior elements of the fig. 4. cat scan reconstruction of the sacrum demonstrating the open spinal canal in this region. it occurs in 5 36% of the population and is often asymptomatic. this report illustrates the presentation and radiological findings in a 2month-old boy. spinal dysraphism is explained by two theories. the first theory, called the neurulation defect theory, holds that there is a primary failure of closure of the neural folds. this occurs between days 18 and 21 of gestation. the other theory, called the post neurulation theory, postulates that there is a breakdown in the posterior elements of the fused tube.' some authors report a slight female predominance while others report equal sex distribution." there is a lower risk among blacks compared with the caucasian population and the risk in the general population is about 5 36%.4 the clinical pointers to the existence of an occult spinal dysraphism in the postnatal life are classical skin markers, which occur in 75 83% of patients. these include dimples, sinus tracts, hypertrichosis and capillary haemangiomas. there can be associated occult vertebrae. intraspinal lesions such as epidermoid 27 sa jou rnal of radiology • september 2002 and dermoid tumours, lipomas, diastematomyelia, dural bands and tethered spinal cord,' forty-five per cent of the lesions occur over the thoracolumbar junction, 20% over the lumbar segment, 20% over the lumbosacral junction and 10% over the sacral region. patients with occult spinal dysraphism of the simple type are usually asymptotic compared with the symptomatic ones whose clinical presentation is as a result of traction from a tethered cord or pressure effect from the associated lesions or a combination of both. these children present clinically at the time they start to walk with a combination of neurological problems like sphincter disturbances, neurological defects like motor weakness and sensory loss, and orthopaedic abnormalities like foot and ankle deformities. the classic roentgenographic appearance is a widened spinal canal with defects in the spinous process and a variable portion of the lamina. ct scan and mr! will elucidate the other associated intraspinal lesions. treatment is surgical and is reserved for patients with symptomatic occult spinal dysraphism. references 1. lemire ri, warkany i. normal development of the central nervous system. correlation with selected malformation. in: beckwith b, ed. pediatric neurosurgery: surgery of the developing nervous system. new york: grune and stratton, 1982: 1 22. 2. schmalohi d. spinal dysraphism. in: palmer id, ed. manual of neurosurgery. london: churchill livingstone, 1996: 646 651. 3. humphreys rp. spinal dysraphism. neurosurgery. new york: me graw-hill, 1996: 3453 3463 4. horwood nash dc, fitz cr. neuroradiology in infants and children. st louis: mosby, 1976. 5. bajpai m, kataria r, gupta dk, agarwala s. occult spinal dysraphism. indian j pediatr 1997 64: suppl, 62 67. correspon dence letter to the editor pica a barium enema look-alike a 15-month-old baby boy consumed a substantial amount of seasand while playing at the beach. twelve hours later he presented with diarrhoea and vomiting and was referred for an abdominal x-ray. the supine abdominal radiograph (figure 1) demonstrated partial opacification of the small bowel, and almost complete opacification of the large bowel so that the appearance resembled that of a barium enema film. a hernivertebra at l4 level, with a scoliosis convex to the left side, was also identified. geophagia [the habit of eating clay, (geo) or dirt]l is also known as pica (the latin word for magpie, an avian scavenger]! and describes the phenomenon of the ingestion of non-food substances such as clay,plaster and paint and, in this case report, of seasand. such dietary habits have figure 1: supine abdominal radiograph demonstrates column of radiopaque material fl/ling large bowel (and to a lesser degree sma/l bowel) due to ingestion of dark seasand twelve hours earlier. and not the result of a barium enema. in addition to pica, note hemivertebra at l, level with scoliosis convex to the left side. 18 sajournal of radiology. august 1998 been described since antiquity and persist in many primitive societies during pregnancy and lactation." in the paediatric population it occurs mainly during the second year when the toddler starts getting around, and it usually does not last beyond age four or five. a variety of evidence has associated pica with nutritional deficiency, especially of iron, zinc and calcium. pica is often seen to some degree in developmentally disabled children who are institutionalized. when the ingested material contains lead or other toxic material, detrimental or lethal consequences may ensue. the appearance in the case reported is unusual, in that a large amount of seasand was ingested, simulating the features of a barium enema study, and also because this was not the more usual white sand, but a dark seas and (almost black) containing large amounts of iron and other elements. the hemivertebra at l4level is due for further investigation and an orthopaedic opinion is to be sought. references 1. silverman fn, kuhn lp. essentials of caffey's pediatric x-ray diagnosis. year book medical publishers, chicago 1990; 633. 2. levine md, carey wb, crocker ac, gross rt. developmental behavioural pediatrics. w. b. saunders, philadelphia, 1983; 428, 536. from: dr fred van ge/deren ffrad(d)(sa) consultant radio/agist, taranaki base hosipta/, new zealand radiology_may04 review article 13 sa journal of radiology • may 2004 introduction in 1991 juan parodi et al.1 from buenos aires in argentina placed the first endoluminal dacron prosthetic graft in an abdominal aorta, excluding an aneurysm via retrograde cannulation of the common femoral artery. michael dake and his group from stanford reported the first cases of the treatment of thoracic aneurysms.2 shortly thereafter the same group started treating acute aortic dissections similarly.3 more reports of favourable results followed,4 which led to the obvious extension of the technique to the treatment of traumatic ruptures.5,6 these prosthetic stent graft devices have evolved from the initial homemade, large-profile ‘beasts’, to easily available, slick, readymade, low profile, user-friendly tools. the initial worldwide, contagious enthusiasm that followed parodi's first abdominal attempts slowly diminished, when more and more reports of late endoleaks and late ruptures surfaced. contrary to this, however, the application of this technique in the treatment of thoracic lesions has gained ground and is slowly becoming the treatment of choice in most developed countries. the relatively uncomplicated design of these thoracic stent grafts, when compared to the bifurcated design of the aortic devices, probably accounts for the lower endoleak rate. furthermore, the substantially higher mortality and morbidity associated with open thoracic surgery certainly swung the pendulum towards the endovascular route. thoracic aneurysms the natural history of a thoracic aortic aneurysm is poor, with a rupture rate of approximately 50% when untreated.7-9 the five-year survival rate ranges from 13% to 39%. the size of a thoracic aneurysm at the initial evaluation appears to be the most important predictor of rupture.8 thoracic aneurysms seem to enlarge at a more rapid rate than abdominal aneurysms. although surgical repair has improved, it still carries a high mortality, ranging between 10% and 16% and is associated with severe morbidity.10-13 advanced age and emergency procedures increase mortality and morbidity.11 complications of surgery include death, myocardial infarction, renal failure, haemorrhage, chest infections and paraplegia. spinal cord injury is reported in 2.3% 6.5% of patients. the morbidity can be reduced with a less invasive procedure that spares a thoracotomy, aortic cross clamping and cardiopulmonary bypass. (fig 1a, b). the mortality rate for endoluminal repair is usually 5% or less.14, 15 the anaesthesia-related risks can now be minimised with endoluminal treatment of thoracic aortic lesions leonie scholtz mb chb, mmedrad (d) department of radiology university of pretoria fig. 1a. pre-operative angiogram of a 70-year-old male patient with a degenerative aneurysm in the descending thoracic aorta. fig. 1b. post-procedural image after stent graft implantation. review article 14 sa journal of radiology • may 2004 more and more centres performing these procedures under local anaesthesia.16 thoracic aortic dissection acute aortic dissection is a challenging clinical emergency first described by morgagni more than 200 years ago.17 it is the most common acute aortic condition requiring urgent therapy.18 classification of aortic dissection is based on anatomical location. stanford type a dissections originate proximal to the left subclavian artery and type b dissections arise distal to the left subclavian artery. according to the international registry of acute aortic dissection (irad) the highest mortality occurred in patients with type a dissection not receiving surgery (58%), in contrast to surgically treated patients with type a dissection (26%). patients with type b dissections treated medically had the lowest mortality rate (10.7%). mortality rate for patients with type b dissection who underwent surgery was 31.4%.19 endoluminal stent grafts can be used to treat type b dissections and most authors report mortality rates of less than 16%.3, 20 medical therapy however remains the treatment of choice for type b dissections, unless complicated by rupture, impending rupture, end-organ ischaemia (mesenteric ischaemia, renal insufficiency or peripheral arterial insufficiency) or enlargement in the chronic phase.20 the predominant predictors for aortic enlargement in the chronic phase are the existence of a maximum aortic diameter of greater than or equal to 40 mm during the acute phase and a patent primary entry site in the thoracic aorta.21 (fig 2a,b).21 the risk of rupture is also higher in dissecting aneurysms when compared with degenerative aneurysms.22 older age, chronic obstructive pulmonary disease and an elevated mean blood pressure increase the risk of rupture.23 between 20% and 40% of patients who have passed their acute phase with medical hypotensive therapy will therefore require intervention during the chronic phase. surgery still remains the treatment of choice for type a dissection. acute traumatic rupture of the thoracic aorta most patients with acute traumatic rupture of the thoracic aorta are victims of motor vehicle accidents of which 75 90% die at the scene. approximately 15 20% of the victims reach the hospital alive where blood is precariously maintained within the vascular lumen by the adventitia and mediastinal surrounding tissues. current conventional thoracic repair is associated with a mortality rate as high as 18% and a paraplegia rate as high as 19%.6 where deliberate delayed repair is nowadays being advocated, endoluminal repair fig. 2a. stanford type b dissection in a 64-yearold male with the entry site in the descending aorta. fig. 2b. after coverage of the entry site with a stent graft device. fig. 3a. post-traumatic pseudo-aneurysm in a 22year-old male post motor vehicle accident. fig. 3b. successful occlusion of the pseudoaneurysm with an endoluminal device. offers the possibility of immediate repair avoiding the risk of rupture that could occur with the delayed approach (fig. 3a,b). diagnostic evaluation patients with suspected aneurismal disease, dissection or aortic rupture require immediate diagnostic evaluation and pre-procedural work-up if endoluminal treatment is contemplated. contrast-enhanced multi-slice computed tomography, if available, is the most widely used diagnostic tool in the diagnosis of thoracic aortic disease. it provides information about the size, location and extent of the disease. magnetic resonance angiography can be used although it has disadvantages in the acutely traumatised or unstable patient. diagnostic digital subtraction angiography is reserved for cases where none of the above is available. vital measurements and information, which have to be obtained, include: (i) the intraluminal diameter of the aorta above and below an aneurysm in perpendicular planes; (ii) locating the left subclavian artery; (iii) the length of the aorta from the origin of the left subclavian artery to where the aneurysm starts or the entry site of the dissection occurs, known as the cranial neck; (iv) the length of the aorta from below the aneurysm down to the origin of the celiac trunk, known as the distal landing zone; (v) the total length of the aneurysm, or pseudo-aneurysm in the case of rupture; (vi) involvement of mesenteric branches and their origin from either the false or true lumen in cases of dissection; (vii) localisation of the entry site in dissection; and (viii) note angulation, calcification and presence of any thrombus in the cranial neck or distal landing zone. exclusion criteria exclusion criteria are; (i) cranial neck and/or distal landing zones less than 15 mm in length; (ii) extensive thrombus in proximal or distal landing zones; (iii) inadequate femoral or iliac access; (iv) severe angulation of more than 90 degrees in both iliac vessels; and (v) severe tortuosity or angulation in the thoracic arch and descending aorta. the procedure since the initial implantation of the ‘first generation’ homemade device at stanford university medical center in 1992, major technical improvements have taken place with quite a number of commercial devices now available for deployment in the thoracic aorta. most systems are self-expanding devices composed of a polyester graft fabric and a stent frame made from nitinol wire. although thoracic aortic stent grafts are tube graft designs it is incorrect to conclude that they are less cumbersome to deliver and deploy. the management team comprises a thoracic or vascular surgeon and interventional radiologist assisted by the full range of supporting cathlab and theatre personnel. a number of anatomic caveats are relevant to the thoracic aorta and may cause procedural problems24: (i) the thoracic aorta is frequently larger in diameter distally in the descending aorta than proximally; (ii) the descending aorta is frequently not vertically oriented and may become almost horizontal; (iii) the threedimensional features of especially the arch may cause deployment difficulties; and (iv) the arch can be very angulated causing difficulty in tracking such a huge device for exact positioning. intra-operative procedural issues include: (i) all catheters and wires need to be longer and larger; (ii) intra-operative arteriography requires larger injection rates; and (iii) one needs to be particularly meticulous in avoiding the delivery of air bubbles during the procedure. important procedures that should be adhered to during thoracic deployment are: (i) a pigtail catheter should be inserted preferably through the left brachial artery and placed in the arch in order to continuously check the origin of the vessels in relation to the proximal struts of the stent graft before and during deployment; (ii) we prefer general anaesthesia, although some centres perform these under local anaesthetic; (iii) open vascular access is obtained through the common femoral artery; (iv) systemic heparinisation is recommended during the procedure; (v) the fluoroscopic tube should be angled to the left anterior oblique position so as to lay open the aortic neck and arch; (vi) lowering the blood pressure to a mean of 60 mmhg during deployment and balloon inflation is recommended; (vii) a ‘super stiff ’ guide wire is positioned across the arch of the aorta enabling stability during deployment; (viii) some centres perform pre-procedural cerebrospinal fluid drainage in an effort to minimise the risk of paraplegia; (ix) oversize the device by at least 10 15%; (x) only the entry site of a dissection needs to be covered; and (xi) the left subclavian artery origin may be covered by the stent and is well tolerated in the majority of patients. review article 15 sa journal of radiology • may 2004 complications of endovascular thoracic repair complications of stent-graft repair include: (i) death, (ii) stroke; (iii) paraplegia; (iv) myocardial infarction; (v) pulmonary insufficiency; (vi) mesenteric ischemia; (vii) renal failure; (viii) wound infection; and (ix) bleeding. in the traditional open repair paraplegia rates of up to 21% are quoted in the literature, even with the highest level of care including intraoperative cerebrospinal fluid drainage, hypothermia, distal aortic perfusion with distal bypass and reattachment of the critical intercostals arteries.24 most endovascular series report rates of less than 3%.3,4,24 preventative measures include intraoperative spinal fluid drainage as well as some centres experimenting with retrievable devices whilst monitoring evoked spinal cord potential.25 endoleak is defined as continued flow within the aneurismal sac after deployment of a stent-graft. type 1 endoleaks are defined as leaks at the proximal or distal attachment sites and these should be treated immediately. type 2 endoleaks occur in the setting of patent lumbar arteries or intercostals arteries and are believed to resolve spontaneously. late endoleaks are less common with thoracic aortic aneurysm (taa) repair in comparison with abdominal aortic aneurysim (aaa) repair. follow-up recommendations endovascular stent-graft placement has special procedure-specific complications including stent migration, kinking and leakage that require regular surveillance. currently, multislice ct, the imaging gold standard following endovascular repair, is performed prior to discharge and at 3, 6, 12, and 24 months after intervention, thus causing significant radiation to the patient as well as adding cost. mra has the potential to become an alternative imaging modality in the thoracic aorta, whereby the risk of radiation can be reduced. susceptibility artifacts associated with stents still pose problems as well as certain potential safety issues including magnetic field interactions that may move or dislodge the stent and heating of the endoprosthesis by radio frequency (rf) power deposition. the 3d turbo flash sequence provides the least susceptibility artifact due to a short echo time and a small effective slice thickness. conclusion endoluminal repair of thoracic aortic aneurysms, type b dissections and acute rupture is becoming the treatment of choice worldwide. more and more devices are now commercially available with designs continually being refined. lower profiles, flexibility and ease of deployment make them user-friendly, with low complication rates and high primary technical success rates. morbidity and mortality rates are substantially lower when compared with open surgical repair and endoleaks rare when compared with abdominal procedures. a definite disadvantage currently is the cost of the devices, which amounts up to anything between r50 000 and r100 000 depending on the amount of main devices or extensions used. if however, lengthy icu-stay and the overall cost implications in treating postoperative surgical complications are taken into account, the cost probably compares favourably with open repair. references 1. parodi jc, palmaz jc, barone h d. transfemoral intra-luminal graft implantation for abdominal aortic aneurysm. ann vasc surg 1991; 5: 491499. 2. dake md, miller dc, semba cp, et al. transluminal placement of endovascular stent grafts for the treatment of descending thoracic aortic aneurysms. n engl j med 1994; 331: 17291734. 3. dake md, kato n, mitchell rs, et al. endovascular stent-graft placement for the treatment of acute aortic dissections. n engl j med 1999; 340: 1524 1531. 4. nienaber ca, fattori r, lund g, et al. non surgical reconstruction of thoracic aortic dissection by stent graft placement. n engl j med 1999; 340: 1539 1545. 5. lachat m, phammatter t, witzke h, et al. acute traumatic aortic rupture: early stent graft repair. eur j cardiothorac surg 2002; 21: 959 963. 6. thompson cs, rodriguez ja, ramaiah vg, et al. acute traumatic rupture of the thoracic aorta treated with endo-luminal stent grafts. j trauma 2002; 52: 1173 1177. 7. pressler v, mcnamara jj. thoracic aortic aneurysm : natural history and treatment. j thorac cardiovasc surg 1980; 79: 489 498. 8. perko m j, norgaard m, herzog m, olsen ps, schröder tv, pettersson g. unoperated aortic aneurysms : a survey of 170 patients. ann thorac surg 1995; 59: 1204 1209. 9. pressler v, mcnamara jj. aneurysms of the thoracic aorta. j thorac cardiovasc surg 1985; 89: 50-54. 10. de bakey me, mccollum ch, graham jm. surgical treatment of aneurysms of the descending thoracic aorta. j cardiovasc surg 1978; 19: 571 576. 11. livesay jj, cooley ea, ventemiligia ra, et al. surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischeamia. ann thoracic surg 1985; 39: 3746. 12. borst h g, jurmann m, bühner b, laas j. risk of replacement of descending aorta with a standardized left bypass technique. j thorac cardiovasc surg 1994; 107: 126 133. 13. von segesser lk, killer i, jenny r, lutz u, turina mi. improved distal circulatory support for repair of descending thoracic aortic aneurysms. ann thorac surg 1993 ; 56: 1373 1380. 14. mitchell rs, dake md, semba cp, et al. endovascular stent-graft repair of thoracic aortic aneurysms. j thorac cardiovasc surg 1996; 111: 1054 1062. 15. ehrlich m, grabenwöger m, grimm m, et al. endo-vascular stent-graft repair for aneurysms of the descending thoracic aorta. ann thorac surg 1998; 66: 19-24. 16. lachat m, pfammatter t, turina m. transfemoral endografting of thoracic aortic aneurysms under local anaestheasia : a simple, safe and fast track procedure. vasa 1999; 28: 204 206. review article 16 sa journal of radiology • may 2004 review article 17 sa journal of radiology • may 2004 17. acierno lj. the history of cardiology. new york, parthenon publishing group, 1994. 18. pretre r, von segesser lk. aortic dissection. lancet 1997; 349: 1461-1464. 19. hagan pg, nienaber ca, isselbacher em, et al. the international registry of acute aortic dissection (irad). new insides into an old disease. jama 2000; 283: 897 903. 20. shimono t, kato n, yasuda f, et al. transluminal stent-graft placements for the treatment of acute onset and chronic aortic dissections. circulation 2002; 106: 241-247. 21. kato m, bai h, sato k, et al. determining surgical indications for acute type b dissection based on enlargement of aortic diameter during the chronic phase. circulation 1995; 92: suppl ii: 107 112. 22. griepp rb, ergin ma, galla jd, et al. natural history of descending thoracic and thoraco-abdominal aneurysms. ann thorac surg 1999; 67: 1927 1930. 23. juvonen t, ergin ma, galla jd, et al. risk factors for rupture of chronic type b dissections. j thorac cardiovasc surg 1999; 117: 777 786. 24. milner r, bavaria je, baum ra, et al. thoracic aortic stent grafts. semin roentgenol 2001; 4: 340-350. 25. ishimaru s, et al. preliminary report on prediction of spinal cord ischemia in endovascular repair of thoracic aortic aneurysm by retrievable stent graft. j thorac cardovasc surg 1998; 115: 811-818. further reading 1. ince h, rehders tc, nienaber ca. thoracic aneurysms and type b dissections should be treated by stent graft. in: greenhalgh rm, ed. the evidence for vascular or endovascular reconstructions. wb saunders, 2002: 119-125. 2. kouchoukos nt, dougenis d. surgery of the thoracic aorta. n engl j med 1997; 336: 1876 1888. 3. anagnostopoulos ce, prabhakar mj, kittle cf. aortic dissections and dissecting aneurysms. am j cardiol 1972; 30: 263 273. 4. vann ji, sarres ge, mitchell rs, et al. treatment of patients with aortic dissection presenting with peripheral vascular complications. ann surg 1990; 212: 705 713. 5. genoni m, paul m, tavakoli r, et al. predictors of complications in acute type b dissection. eur j cardiothorac surg 2002; 22: 59-63. 6. sueyoshi e, imana t, sakamoto i, et al. analysis of predictive factors for progression of type b aortic intra-mural heamatoma with computed tomography. j vasc surg 2002; 35: 1179 1185. 7. marui a, mochizuki t, mitsui n, et al. towards the best treatment for uncomplicated patients with type b acute aortic dissection. circulation 1999; 100: suppl ii, 275 280. 8. lansman sl, hagl c, fink d, et al. acute type b aortic dissection: surgical therapy. ann thorac surg 2002; 74: s1833 1835. 9. sasaki s, yasuda k, kunihara t, et al. surgical results of standard type b aortic dissection. comparison between partial and subtotal replacement of the dissected aorta. j cardiovasc surg 2000: 41: 227 -232. 10. umana jp, miller dc, mitchell rs. what is the best treatments for patients with acute type b aortic dissections. medical, surgical or endovascular stent grafting? ann thorac surg 2002; 74: s1840 1843. 11. lonn l, delle m, lepore v, et al. endograft therapy of the thoracic aorta in aortic dissections. cardiovasc intervent radiol 2002; 25: suppl ii s158. 12. lee dy, chou dh, shim wh, et al. elective endovascular treatment of aortic dissections with stent grafts. cardiovasc intervent radiol 2002; 25: suppl ii, s158. editorial sajr: quo vadis? drsavvas andronikou m88ch (wits), fcrad (sa), frcr (land) viou may have noticed that the sa journal of radiology (sajr) is now published in quarterly issues. this may serve a better purpose than the monthly editions currently struggling for interesting content, especially if the editorship is to be rotated through the major centres. i believe that such a rotation will encourage publication of material originating at the editorial centre and also create healthy competition among the academic territories. my objective as editor of this issue is twofold. first and foremost i want to introduce paediatric radiology as the dedicated and interesting field that it is. the second objective is to stimulate the writing of material by setting an example through a different strategy of publication. my intention is to encourage the host editor of each issue to select a topic of interest to which that issue will be dedicated. in this instance, because of my personal interest and inclination, the content deals almost exclusively with paediatric radiology. other centres may choose trauma, infectious diseases or even "new modalities". i have also tried to encourage didactic content and reviews from local experts on a topic that may have difficulty finding a home in international journals. the lesson regarding paediatric radiology is that diseases in children are different from those in adults and that pathology is often age-related. radiologists should always consider an extra category in their differential diagnosis, namely "congenital". protocols are introduced primarily to keep radiation at a minimum and procedures are targeted at identifying specific pathology. my hope is that, with enough interest, this journal will grow and eventually have enough permanent editors in differing fields to peer review submissions and thereby become a citable publication. at present the journal can be considered as material of a "popular nature" and we should take advantage of this. diseases commonly seen in south africa are not regularly published in european and american journals and we may be world experts in a particular field without realising it. our training programmes do not encourage, let alone insist on, registrars writing up case reports or undertaking research, many registrars telephone me regularly to ask how to go about writing a paper. my advice is to start locally with this journal, even if you are just submitting an interesting clinical image with a caption. remember, the days of needing expensive photographs and secretarial help are over! just get familiar with your computer and follow the instructions for authors (available from the production editor). electronic submissions are quick and easy. the editor is here to encourage writing and to help you. you will be surprised at your knowledge and at the amount you can learn on a topic by having to review the literature. in conclusion, i hope that you enjoy our paediatric edition. i hope that some of you will see the future in this field and will begin targeting paediatric imaging at those diseases peculiar to children while keeping radiation exposure at a minimum. i shout this to you all: "get onto your computers and write] radiology is the future and you are our future experts!" i would like to thank prof s beningfield for his assistance in editing this issue and all the contributors, who showed me that there is a lot of interest in research and publication. head: department of paediatric radiology red cross children's hospital university of cape town and institute of child health savvas andronikou editor 3 sa journal of radiology. february 2001 radiology_may04 case report 36 sa journal of radiology • may 2004 history a 15-year-old boy was referred from a peripheral clinic to pretoria academic hospital with the history of a lump in his neck. he also had a 6month history of malaise and weight loss. clinical examination on clinical examination he was found to be feverish and appeared cachectic. he had a fluctuating mass in the right anterior triangle of his neck. he had tenderness over the thoracic and lumbar spine and also tenderness over his liver. hepatomegaly was present. laboratory examinations some special examinations were done: c-reactive protein (crp) 120 mg/l, urea and electrolytes (u + e) normal, serum albumin 25 g/l, erythrocyte sedimentation rate (esr) 100 mm/h, haemoglobin (hb) 9.8 g/dl, white cell count (wcc) 10 x 109g/l and platelets 667 x 109g/l. no hiv test was performed. imaging findings chest radiograph posteroanterior (pa) and lateral views of the chest were taken. computed tomography figs 3-9 are selected images ranging from the cervical area down to the upper abdomen depicting the extent of involvement. diagnosis the histological diagnosis of tuberculosis (tb) was made on lymphnode biopsy. discussion in 1979 sir percival pott from england provided the first full written account of the skeletal manifestations of tuberculous infection, and his name continues in use to describe the spondylitis associated with this infection (pott’s disease). tuberculous spondylitis is defined as an infection caused by mycobacan unusual presentation of tuberculous lymphadenopathy, paraspinal masses with spondylitis in a young boy betsie van der walt fcrad (d) sa sonja raven mb chb zarina lockhat ffrad (d) sa irma van de werke frcr department of radiology university of pretoria figs 1 and 2. pa and lateral view of chest showing posterior mediastinal and paraspinal widening extending from thoracic inlet into the thoraco-lumbar region. the lung fields are normal. hepatomegaly is present. case report 37 sa journal of radiology • may 2004 terium tuberculosis involving one or more components of the spine, nameley the vertebra, intervertebral discs, paraspinal soft tissues and epidural space. clinical and pathological features symptoms and signs vary considerably and the medical history is not a reliable guide to the diagnosis. except in children, there is typically a long latent period between the first episode of pulmonary infection and musculoskeletal manifestations. approximately 50% of patients with extrapulmonary tb have normal chest films or the stigmata of old inactive pulmonary disease. patients with musculo-skeletal involement may be afebrile and free of systemic complaints until the late stage of infection. the illness typically pursues an indolent course. in spinal infections the presenting symptom is often persistent spinal pain and local tenderness, with limitation of spinal mobility on clinical examination. fever may be present at this stage. the erythrocyte sedimentation rate (esr) is elevated in more than 80% of cases and the tuberculin skin test is usually positive. paralysis results from spinal cord compression caused by epidural tuberculous abscess formation, epidural tuberculous granulomatous tissue and/or bony fragments profig. 3. axial view of the neck at the thyroid level showing left cervical lymphadenopathy with necrosis, as well as right subcutaneous hypodensities with rim enhancement due to tuberculous abscesses. figs 4 and 5. imaging done at the level of the thoracic inlet and superior mediastinum showing the massive paraspinal abscess displacing the oesophagus and trachea anteriorly. there is lymphadenopathy visible with necrosis and anterior vertebral body erosion. figs 6 and 7. images at the subcarinal and heart level showing continuation of the paraspinal abscess with necrotic mediastinal lymphadenopathy and associated pericardial effusion. figs 8 and 9. upper abdominal images demonstrating continuation of the paraspinal mass with a further abscess in the region of the spinous process. para-aortic necrotic lymph nodes are also present. these abscesses continue into the psoas muscles. case report 38 sa journal of radiology • may 2004 truding into the spinal canal. endarteritis of the spinal arteries or intramedullary granulomas are also observed occasionally. the vertebral column is affected in 25-60% of cases of skeletal tuberculosis with the thoracic and lumbar spine mainly involved, especially the thoraco-lumbar junction, with the sacrum and cervical spine being less frequently involved. solitary vertebral lesions can occur, but it is usual to find more than one vertebral level affected. skip lesions occur in up to 4% of cases. the anterior aspect of the vertebral body is affected more frequently than the posterior. the route of infection is usually haematogenous rather than contiguous or from direct implantation. the infective mycobacterium initially lodges in the vascular marrow. the arterial route generally is recognised as the more important method of transmission although batson’s plexus has been implicated in certain cases as the route of infection. direct involvement of the disc by bloodborne pathogens occurs only in the paediatric age group (< 20 years), because of the persistent fetal blood supply to the disc. paravertebral softtissue abscesses reach a maximum size within 2 months of presentation and can take up to 15 months to resolve. ct of tuberculous spondylitis axial ct cuts demonstrates bony destruction of the vertebral end plates with fragmentation. bony fragments may migrate into surrounding structures, e.g. the spinal canal, perivertebral soft tissue and psoas muscles. if a pedicle is involved there may be associated destruction of the posterior aspect of the adjoining rib. ct demonstrates disc space narrowing, paravertebral soft-tissue masses, multi-level involvement and kyphosis. associated soft-tissue masses are usually larger than the extent of bony destruction and are well demonstrated on axial scans. calcifications within or surrounding these abscesses are pathognomic of tb. these paraspinal soft-tissue lesions usually extend in an anterolateral direction, although direct posterior extension has been observed. the thick nodular rim of an abscess on a pre-contrast scan represents the hypervascular, hypercellular, fibrotic wall of the inflammatory cavity. following iv contrast strong rim enhancement is noted around low attenuation multiloculated fluid collections. these abscesses may extend into the superficial dorsal soft tissues, with loss of normal muscle/fat interfaces. abscesses may burrow for a distance before perforating an internal organ or the skin. tuberculous lumbar pus produces a psoas abscess that may extend inferiorly into the pelvis and penetrate into the groin. in summary, ct depicts disturbances of bony integrity and enables precise evaluation of paraspinal softtissue involement. this case is unusual in presenting with a cervical mass, whilst imaging showed massive tubercular abscess involvement from the cervical to the lumbar region. acknowledgement we would like to thank annelize gates for her assistance in the preparation of this article. reference 1. hassn s, sharif, john l. et al. imaging of tuberculosis and cranio spinal tuberculosis. radiol clin north am 1995; 33: 787-804. abstract introduction arthralgia painful articular syndrome hiv-associated arthritis reactive arthritis (reiter’s syndrome) psoriatic arthritis undifferentiated spondyloarthropathy rheumatoid arthritis conclusion acknowledgements references about the author(s) farhana e. suleman department of radiology, university of pretoria, south africa mahmood m.t.m. ally department of internal medicine, university of pretoria, south africa citation suleman fe, ally mmtm. human immunodeficiency virus infection and inflammatory arthritis: a review of clinical and imaging features. s afr j rad. 2017;21(2), a1261. https://doi.org/10.4102/sajr.v21i2.1261 review article human immunodeficiency virus infection and inflammatory arthritis: a review of clinical and imaging features farhana e. suleman, mahmood m.t.m. ally received: 01 aug. 2017; accepted: 17 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the reported prevalence of articular manifestations of human immunodeficiency virus (hiv) varies, but with sub-saharan africa accounting for almost 70% of the people living with hiv, this results in a considerable burden of disease in the region. the spectrum of clinical presentation described, includes articular pain syndrome, hiv-associated arthropathy and seronegative spondyloarthropathies, among others. this brief review serves to create awareness of the clinical and imaging presentation of this spectrum of disease as there is significant morbidity associated with these conditions if treatment is delayed. introduction the global human immunodeficiency virus (hiv) pandemic has impacted on the burden of disease seen in clinical practice, and this includes the spectrum of inflammatory arthritis. while the reported prevalence varies, patients with hiv are proven to be at higher risk of developing a large spectrum of these pathologies.1 a brief review of the clinical and radiological findings is presented in this article. arthralgia arthralgia is the most common but non-specific articular complaint of hiv-positive patients. it tends to occur in the acute phase of the infection and is the result of direct infection of the joint by the virus. the frequently affected joints are the knees, shoulders and elbows. it may manifest as a mono-, oligoor polyarticular disease. it can be transient or intermittent and may require analgesia.1,2,3 imaging features are normal. painful articular syndrome painful articular syndrome is described less commonly than arthralgia but is characterised by acute severe debilitating pain of short duration lasting less than 24 h. it has been reported to occur in the late stages of hiv infection2 and commonly affects the knees, shoulders and elbows.3 clinically there are no signs of synovitis.4 imaging features may be normal, but sometimes a joint effusion is noted. peri-articular osteopaenia may or may not be present.5 hiv-associated arthritis hiv-associated arthritis has been described more commonly in patients from sub-saharan africa.4 serological tests such as rheumatoid factor (rf) and anti-nuclear factor antibodies associated with inflammatory arthritides are negative, as is the hla b27 genotype. they also do not fulfil the criteria for the spondyloarthropathies.6,7 it may occur at any stage of hiv infection and most often presents as an asymmetric oligoarthritis more commonly in men.7 the lower limbs, especially the knees, are most commonly affected,1,2,3,4,5,6,7 and it is described as self-limiting, lasting less than 6 weeks.2,5,7 a symmetrical polyarthritis pattern resembling rheumatoid arthritis (ra) may also be seen.5,6,7 deformities similar to ra are described although the onset is more acute and less erosive (figures 1–3). a jaccoud arthropathy may also form part of this spectrum (figure 4).2,7 a small number of patients may progress to a chronic destructive arthritis and imaging findings similar to ra may be noted including peri-articular osteopaenia, erosions and joint space narrowing. periostitis and proliferative new bone formation helps to distinguish the condition from ra (figures 5 and 6).5,7 figure 1: frontal radiographs of both hands in an hiv-positive patient presenting with polyarthritis. rf was negative. radiographs demonstrate bilateral severe peri-articular osteopaenia, severe joint space narrowing involving almost all joints and subluxation at the 3rd, 4th and 5th proximal interphalangeal joints. figure 2: magnified view of the 2nd and 3rd distal interphalangeal joints of the same patient discussed in figure 1 demonstrates early erosions and irregularity of the distal phalanges (arrows). figure 3: magnified view of the phalanges of the left 2nd, 3rd and 4th phalanges of the left hand of the patient discussed in figure 1, demonstrating new bone formation of the proximal phalanx of the 4th finger and more clearly demonstrates the subluxations at the 3rd and 4th proximal interphalangeal joints. figure 4: (a) frontal and (b) lateral radiographs of both hands of an hiv-positive patient presenting clinically with reducible deformities and arthralgia. rheumatoid factor and anti-nuclear factor were negative. lateral radiographs show subluxations at the metacarpophalangeal joints bilaterally as well as the distal interphalangeal joints of both 5th fingers. the right hand is more affected than the left, with the left hand demonstrating more reducible deformities on the frontal radiograph compared to the right hand. figure 5: lateral radiographs (a and b) of both feet in an hiv-positive patient. the radiograph demonstrates periostitis and enthesitis affecting the right foot more than the left foot. figure 6: magnified view of the proximal metatarsals and tarsal bones of the right foot clearly demonstrating periostitis (short arrows) and enthesitis (long arrows). reactive arthritis (reiter’s syndrome) a typical presentation of seronegative peripheral oligoarthritis predominantly affecting the lower limbs as seen in the hiv-negative population is described in most of the literature. this is accompanied by marked enthesitis evidenced by archilles tendinitis, plantar fasciitis and tenderness at sites of entheses.2,3,4,5,6,7 involvement of the spine and sacroiliac joints is less commonly seen.6 mucocutaneous involvement is common (circinate balanitis and keratoderma blenorrhagicum).2,3,4,5,6,7 extensive psorasiform skin manifestations have been described, that may cause confusion with a diagnosis of psoriasis.2,3,4,7 a history of preceding gastrointestinal or genitourinary tract infection is also common.7 imaging changes are described predominantly in the joints of the lower limbs, including small joints of the foot with changes of erosion and adjacent new bone proliferation noted.5 these changes tend to be asymmetrical and may lead to progressive deformity and severe arthritis of the larger joints.2 erosions and spur formation are typically noted at entheseal sites.5 psoriatic arthritis an increased incidence as well as a more severe and persistent form of psoriasis has been described in hiv-positive patients.7 the associated arthritis has also been described as more destructive and erosive, as well as more refractory to treatment.7 it tends to occur late in the course of hiv infection and is usually a sign of subsequent opportunistic infections.6,7 patients may present with an asymmetrical oligoarthritis or polyarthritis predominantly affecting the lower limbs.2,6,7 involvement of the spine and sacroiliac joints is less common. patients may rapidly progress to a deforming and debilitating course. a symmetrical polyarthritis may also occur that may mimic ra.5,7 imaging features may include erosions, joint space narrowing, ankylosis, joint effusions, soft tissue swelling and deformities. soft tissue swelling is noted at entheseal sites such as at the insertion of the archilles tendon and digital swelling from dactylitis. the presence of periostitis, new bone formation and distal interphalangeal joint involvement helps to distinguish the condition from ra.5 undifferentiated spondyloarthropathy patients who do not exhibit a full spectrum of clinical manifestations that allow them to be classified as ankylosing spondylitis, psoriatic arthritis or reactive arthritis are labelled as undifferentiated spondyloarthropathy.2,4,6,7 the most common manifestation is enthesitis, adjacent osteitis, synovitis and spur formation with involvement of the knee, a common imaging finding.2,7 the epidemic of hiv infection has seen a marked increase in the incidence of this condition in sub-saharan africa.2 rheumatoid arthritis there is still ongoing debate about the effects of hiv on ra.2 some reports in the literature suggest that ra patients may go into remission with hiv infection, but there are also reports that suggest that the disease may flare or arise de novo during the immune reconstitution inflammatory syndrome.6 hiv-associated polyarthritis may also mimic ra clinically and radiographically, creating difficulties with diagnosis. biomarkers of ra have also been detected in low titres in patients who are hiv-positive.7 conclusion a large burden of hiv infection resides in sub-saharan africa. this has resulted in a changing spectrum of inflammatory arthritis seen in an hla b27 negative population, where it was previously, relatively uncommon. an awareness of the clinical and radiological manifestations of the variety of diseases is important for early diagnosis and management to prevent disability and further morbidity of a range of conditions that have the potential to cause severe incapacity. acknowledgements competing interests the authors declare no conflict of interest in the writing of this article. authors’ contributions f.e.s. wrote the document and prepared the images. m.m.t.m.a. provided images and edited the final document. references walker ua, tyndall a, daikeler t. rheumatic conditions in human immunodeficiency virus infection. rheumatology. 2008;47:952–959. https://doi.org/10.1093/rheumatology/ken132 mahajan a, tandon vr, verma s. rheumatological manifestations in hiv infection. jiacm. 2006;7(2):136–144. mody gm, parke fa, reveille jd. articular manifestations of human immunodeficiency virus infection. best pract res clin rheumatol. 2003;17(2):265–287. https://doi.org/10.1016/s1521-6942(03)00003-2 gupta n, mandal sk. joint manifestations in hiv infection: a review. j infect dis ther. 2015;3:249. https://doi.org/10.4172/2332-0877.1000249 restrepo cs, lemos df, gordillo h, et al. imaging findings in musculoskeletal complications of aids. radiographics. 2004;24:1029–1049. https://doi.org/10.1148/rg.244035151 mody gm, patel n. articular syndromes in association with hiv infection. cme. 2011;29(8):318–322. adizie t, moots rj, hodkinson b, french n, adebajo ao. inflammatory arthritis in hiv positive patients. a practical guide. bmc infect dis. 2016;16:100. https://doi.org/10.1186/s12879-016-1389-2 cas e _re por t paediatric calvarial tuberculosis s. andronikou fc rad dlag (sa) c. weiman mbchb e. kader mbchb department of patjdiatric radiology, university of cape town and institute of child health, red cross war memorial children ~ hospital, rondebosch, cape town co"esponding author s. andronikou department of patjdlatric radiology rtjd cross war memorial chlldren~ hospital cape town 7700 telephone: 021-6585442 fax: 021-6585101 e-mail: docsav@mweb.co.za abstract calvarial tubercu losis is a rare presentation of tubercu losis. we present two cases seen in the paediatric age group of tuberculosis involving the sphenoid bone. one of the patients was positive for the human immunodeficiency virus (hiv). the literature is reviewed in brief. key words calvarial/ skull, tuberculosis/ h/~ ct introduction while tuberculosis (tb) is common in south africa, it does not commonly affect bone. when it does, skull involvement is rare. we present two paediatric cases of calvarial tb with discussion of the relevant literature. case 1 a three-and-a-half year-old boy presented with a two-month history of a slowly increasing swelling over the right frontoparietal region of the skull. there were no constitutional symptoms oftb or tb contacts. the swelling was non-tender and was not fluctuant. a skull x-ray (figure la) and a subsequent ct brain (figures lb and c) were performed. the diagnostic differential at this stage included figure la: lucency involving the lateral right orbit with lytic destruction (open arrow) of the right greater wing of sphenoid. 20 sajournal of radiology. august 2000 tb, eosinophilic granuloma, neuroblastoma metastases and a primary bone tumour. the esr was raised (55 mm/hour) and the mantoux was strongly reactive. chest x -ray was suggestive of bilateral hilar adenopathy. full blood count and bone marrow aspirate were normal. biopsy demonstrated neerotising granulomatous inflammation in keeping with tb. figure 1b: coronal post-contrast ct of the head demonstrates lytic destruction of the right greater wing of sphenoid (open arrow) and lateral wall of orbit (arrowhead) with associated soft tissue mass extending into the temporal fossa. figure 1c: axial post·contrast ct of the head shows soft tissue swelling in the right frontoparietal region with contrast enhancing soft tissue on both sides of the calvarium and in the region of the right anterior temporal lobe. topage22 mailto:docsav@mweb.co.za cant lel: 27 12993-2474 27 12 998-7366 fa~:2712993-2478 7130ars10ntern park. 645 aequ ii e ijrim8 gars~on~eln east q0,60 further information on request from: anene harmaceuticals reg. no. 95/01988/07 paedi<ltric calvarialluberculosis from page 20 he was commenced on three-drug anti-tb treatment. at follow-up at three months, the child was well and the mass was decreasing in size. case 2 a 22-month-old hiv-positive boy presented with fever and cough. he had received four months of anti-tb treatment for pulmonary tb, ending six months prior to the current admission. there were no features of meningitis but he was noted to have marked developmental delay and a ct brain was performed (figures 2a and b). csf studies were supportive of a diagnosis of tuberculous meningitis.he was commenced on four-drug antituberculous therapy. discussion tb is endemic in developing countries and is becoming more prevalent with the rise in human immunodeficiency virus (hiv) infection. calvarial tb is rare, with only a few cases described in the current literature.!" about 0.01 % of mycobacterial infection involves the skull. it is a disease of children, with 50% of the cases under la years of age and 90% under 20 years of age. it usually presents with a painless scalp swelling (case i) or a discharging sinus.1 the outward expansion of the calvarium produces pott's puffy tumour. 5 lesions are usually single, well-circumscribed and lytic with involvement of the frontal or parietal bones, and rarely in the sphenoid (cases 1 and 2) and occipital bones. the calvarial lesions can penetrate both the inner and outer table and have an associated soft tissue component. they rarely penetrate the dura. there may occasionally be diffuse involvement of the calvarium or a single lytic lesion with surrounding sclerosis.' most skull involvement is seen figure 2a: axial post-contrast ct of the head demonstrates extracranial enhancing soft tissue (arrow) in the left frontotemporal region. figure 2b: axial post-contrast ct of the head shows that the focus of the enhancing tissue seen in figure 2a is associated with a lytic bone lesion (arrow). 22 sajournal of radiology. august 2000 in children with disseminated disease.' the differential diagnosis for a lytic lesion seen on the skull radiographs includes pyogenic osteomyelitis, metastasis, haemangioma, aneurysmal bone cyst, meningioma and histiocytosis.! ct is useful to exclude a concurrent intracranial tb component. i while isolation of acid fast bacilli from the lesion would be ideal, a combination of clinical, radiological and histopathological findings in association with a good response to antituberculous therapy are often used for diagnosis/ treatment is with four-drug anti-tb therapy for 18 months. surgery is reserved for cases of uncertain diagnosis or for those where the suspected calvarial tb, with an extradural collection, is associated with neurological deficits, sinus formation or a large pocket of caseating material. 1 conclusion calvarial tb is a rare manifestation of a disease that is endemic in south africa and may be imaged incidentally or because of symptomatology. changes in the bone will be seen on skull radiographs, but a ct head is required to exclude intracranial tb. references i. jadhav rn, palande da. calvarial tuberculosis. neurosurgery 1999; 45 (6):1345-1350. 2. uniivar e, oguz f, sidal m, ones, 0, tetekkurt s. calvarial tuberculosis. ] paediatr child health 1999; 35 221-222. 3. pelteret rm. tuberculous osteitis of the skull. ann trop paediatr 1989; 9 (1): 40-42. 4. echeverria j, kaude n multitocal tuberculous osteomyelitis.pediatrradioi1978; 7 (4): 238-240. 5. cremin bj, jamieson dh. imaging of skeletal tuberculosis. in: cremin bj, jamieson dh, childhood tuberculosis: modern imaging and clinical concepts. berlin: springer. 1995: 99-106. radiology_oct04 abstract the indications for the administration of intravenous contrast media to adult patients presenting with firsttime seizures and a normal pre-contrast study are not clear. a retrospective audit of such patients was done and compared with the post-contrast study. in our study sample of 205 patients all the post-contrast scans were reported as normal, indicating that contrast can be omitted if the precontrast study was normal. this only applies to computed tomography, and magnetic resonance imaging was not included. introduction there are few clear guidelines for registrars concerning the administration of intravenous (iv) contrast after a normal pre-contrast ct scan. the general consensus is that one has to administer contrast in order to ‘play it safe’ in case some obscure lesion is present that will only make itself visible when coaxed with iodine. however, this practice multiplies the radiation exposure to the patient, has cost implications, and lengthens the overbooked scan lists typical in most academic hospitals. the literature is not very helpful in this regard and a medline search revealed a single study1 commenting on the use of iv contrast in firstepisode seizure patients with a normal pre-contrast scan. this study, performed at the university hospital of the west indies, concluded that the addition of contrast agents added no diagnostic benefit and that their routine use is not justified. however, only 48 (15%) patients in this study sample had a preand post-contrast study, and these included neonates and children in whom congenital anomalies were more common and contrast administration was not essential. the extent to which post-contrast studies increased the detection rate when the pre-contrast scan was normal is not clear in the literature.2,3 greenberg et al.4 recommended that for studies in the emergency setting only pre-contrast scans should be done, the need for contrast or magnetic resonance imaging (mri) being determined at a later stage. in this study all the abnormalities were evident on the pre-contrast images. brain ct studies done in brazil5 revealed that vascular, neoplastic and infective causes did not contribute significantly to the overall incidence of first-episode seizures, but that neurocysticercosis, trauma and cryptogenic causes did. as part of the work-up for firstepisode seizures in adults at the pretoria academic hospital (pah), preand post-contrast ct is usually requested. the trend that seemed to emerge was that this subgroup of patients usually had normal post-contrast scans when the pre-contrast scan was also normal. it was decided to test this observation because of the benefit of reduced radiation to the patients and cost savings to the department. method a retrospective study was done from 1 april 2002 to 31 december 2004. exclusion criteria were age under 13 years, an abnormal pre-contrast study, acutely ill or post-traumatic patients, previously diagnosed epileptics, a history of carcinoma, urgent referrals from the casualty department, and status epilepsy. only patients referred from the 20 sa journal of radiology • october 2004 original article is the routine use of intravenous contrast justified in the workup of adult-onset seizure patients with a normal pre-contrast brain scan? j stipp mmedrad (d) j holl ffrad (d) l scholtz mmedrad (d) department of radiology pretoria academic hospital neurology outpatient department of the pah were included in this study. they were all asymptomatic at the time of the scan and had had their seizure(s) several weeks before. their reports were analysed and sorted into two groups: 1. normal post-contrast study (including age-related changes and normal variants). 2. clearly pathological post-contrast study. the sample size was 205 patients with a one-sided null hypothesis value of p = 0.95. results of the sample 100 (48.8%) were male and 105 (51.2%) female. the average age was 32.5 years. the most common seizure type was general tonic-clonic (179), followed by focal seizures (12), partial complex seizures (8) and absences (5). there was 1 case of temporal lobe epilepsy. the age and sex distribution for the above seizure types is summarised in table i. the patients were then classified into one of two groups according to their ct scan findings. all 205 fell into group 1, as had been expected from previous experience. the findings are summarised in table ii. age-related changes, found in 11 patients, were as follows: atrophy — 8 patients (mean age 54.8 years), periventricular ischaemic gliosis — 3 (65 years). normal variants, found in 8 patients, were as follows: falx calcification — 3 patients (mean age 45.7 years), cavum septum pellucidum — 2 (25.5 years), mega cisterna magna — 1 (13 years), asymmetrical lateral ventricles — 2 (28 years). discussion it is now widely accepted that the best imaging modality for suspected intracranial pathology is mri.6 unfortunately this modality is not yet available routinely for patients at pah. in april 2002 a siemens somatom multidetector ct was installed which significantly improved scanning duration and resolution compared with previous scanners. subtle differences in densities were much easier to appreciate and the powerful software made reconstructions in any plane quick and simple. the perception emerged among the radiological staff that if nothing abnormal was noted on the pre-contrast scan, a post-contrast study was probably unnecessary in all cases of adult-onset seizures. analysing the results of our retrospective audit yielded a highly significant 100% correlation between the preand post-contrast scans. the confidence interval was 0.99 (p < 0.0031), indicating that the chance of missing a lesion because a post-contrast scan was not done is less than 1%. we conclude that no real additional benefit is gained from administering iv contrast to a patient in whom no relevant abnormality is seen on a pre-contrast scan. general tonic-clonic convulsions were by far the commonest type of seizure seen in our study, which is in accordance with findings reported in the literature.7 no significant difference in prevalence was found between males and females. often no structural lesion is found in the generalised epilepsies, irrespective of the imaging modality used. however, patients with partial epilepsy tend to have structural lesions known pathologically to be associated with this disorder, e.g. hippocampal sclerosis, cortical malformations, lowto very low-grade neoplasms, angiomas or malformations and focal cortical damage.8 only the last two abnormalities can be imaged with any degree of certainty with ct, the rest requiring mri for definitive exclusion. lesions may therefore be missed when ct only is used in the original article 21 sa journal of radiology • october 2004 table i. seizure types tonic-clonic focal absence partial complex temporal lobe n 179 12 5 8 1 mean age (yrs) 36.8 30.9 41.6 25.3 28 males 87 4 1 4 females 92 8 4 4 1 table ii. scan findings normal post-contrast studies normal pre-contrast 186 age-related changes 11 normal variants 8 22 sa journal of radiology • october 2004 work-up, highlighting the necessity for mri under these circumstances. partial epilepsy also occurred in the youngest age group (mean age 25.3 years), in which any delay in establishing the diagnosis of a treatable cause will have a significant negative impact. as expected, the most common age-related changes were atrophy and periventricular ischaemic gliosis. the low mean age for atrophy in this series was influenced by 2 patients in their 30s with a history of alcohol abuse. normal variants were uncommon (3.9%) with cavum septum pellucidum, asymmetrical lateral ventricles and falx calcifications having an almost equal incidence and a 2.5:1 female/male ratio. financially the savings from only doing pre-contrast studies amounted to approximately r100 000 (205 × r487 per 50 ml ultravist). these savings are in fact an underestimate as costs for associated minor consumable items were not included. conclusion the definitive modality for work-up in patients with adultonset seizures is mri. failing that, it is reasonable to do a pre-contrast ct scan and not to administer iv contrast if this study is normal. the likelihood of missing significant pathology would be less than 1%. references 1. soares d, reid m, fenna a. ct in the evaluation of seizures at the university hospital of the west indies. west indian med j 2001; 50: 151154. 2. taveras j. neuroradiology. 3rd ed. baltimore: williams & wilkins; 1996. 3. heinz er, heinz tr, radtke r, et al. efficacy of mri vs ct in epilepsy. am j roentgenol 1989; 152: 347-52 4. greenberg mk, barsan wg, starkman s. neuroimaging in the emergency patient presenting with seizure. neurology 1996; 47: 26-32. 5. guerreiro cam, silveira dc, costa alc. classification and etiology of newly diagnosed epilepsies in southeast brazil. epilepsia 1993: 34: suppl 2, 14. 6. bronen r. epilepsy: the role of mr imaging. am j roentgenol 1992; 159: 1165-1174. 7. leppik i. contemporary diagnosis and management of the patient with epilepsy. (handbooks in healthcare). 1st ed. newtown, pa: 1993. 8. theodore wh, dorwart r, holmes m, porter rj, di chiro g. neuroimaging in refractory partial seizures: comparison of pet, ct and mri. neurology 1986; 36: 750-759. original article editorial world health report 2000: health system performance t he world health report 2000 is a review by the who of the world's health systems performance.' it makes sobering reading for south africans' south africa's overall health system performance was ranked 175 out of 191 countries. the best country was france, the uk was 18 and the usa stood at 37 on the list. the worst country was sierra leone at 191. what is surprising is how badly south africa performed in this global competition. most african countries were in the last quarter of the list. performance was measured in two ways: on the functions of service delivery, mbchb, ffrad(d)sa, frcr, m med(uct) the creation of resources (investment and training), stewardship and financing (collecting, pooling and purchasing), and on the objectives of responsiveness by the health care system to people's expectations, fair financial contribution and good health of the population. south africa's health system measured poorly in the following areas of responsiveness to people's expectations: promptness of service delivery, choice of service provider, respect of patients and institutional autonomy. for radiologists, an interesting comparison was the health care input mix in middle-income . countries like south africa, thailand, mexico and egypt. health care input mix is a measure of the financial resources invested in high technology such as mr and ct scanners, finance spent on hospital beds and finance spent on training of physicians and nurses. the authors' comment . on south africa is that it is "at the maximum of the group of middle income countries for . expenditure on health care, nurses, hospital beds and mr scanners, while it is the furthest from the maximum for drugs and physicians". what does this all mean in a global perspective? we are classified by the world bank as a middle-income country. our gross national product per capita in 1998 was usd3 310, making us the 83rd richest country in the worldl-we spend close to 8,5% of our gross domestic product . (gdp) on health care, which compares well with other middle-income countries: 6% in hungary, 3% in malaysia and 4,7% in chile, all of which have better performing health systems.' what is apparent is that we are not getting value for money in our health care system investment in south africa. now that our health system performance has been measured for the first time using international norms, we know where we stand in the international rankings. we also know we have to do better. peter corr head: department of radiology, university of natal peter corr editor references l . world health report 2000. health systems: improving performance. geneva: who, 2000 (www.who.org). 2. world bank atlas 2000. washington: world bank (www.worldbank.org). 3. mcintyre d, bloom g, doherty j, brijlal p. health expenditure and finance in south africa. durban: health systems trust & world bank, 1993 (www.hst.org.za/pubs/hstefsa/heftoc.htm). 3 sajournal of radiology· october 2000 radiology_aug04 abstract a 65-year-old man was referred to the gastroenterology department with complaints of longstanding upper abdominal discomfort and hepatomegaly. ultrasound of the liver revealed a massively enlarged liver with multiple cystic areas. aspiration of the largest cyst revealed 15 ml of yellow fluid without any organisms or malignant cells. a diagnosis of autosomal-dominant polycystic kidney disease was suspected, but could not initially be confirmed on ultrasound/ computed tomography imaging. magnetic resonance imaging confirmed the multiple hepatic cysts and revealed multiple smaller cysts in both kidneys. symptomatology subsided after aspiration of the largest cyst and the patient was discharged. the patient has subsequently been followed up and is currently symptom free. the case illustrates the importance of screening for associated kidney disease in patients with polycystic liver disease. introduction polycystic liver disease (pcld) occurs most commonly as a manifestation of all forms of polycystic kidney disease, but especially autosomaldominant polycystic kidney disease (adpkd).1-5 it also occurs much more rarely as a disease entity on its own and is termed autosomaldominant polycystic liver disease (adpld).4-6 the association of multiple hepatic cysts with kidney disease and the clinical implications thereof are, however, of primary relevance, as is demonstrated by our clinical case. radiologically, pcld must be differentiated from common hepatic cysts that occur in at least 2.5% of the population, multiple echinococcus cysts, cystic metastases, acquired cysts from trauma or infection, biliary cystadenoma and the clinically insignificant and rare von meyenburg complexes.7,8 case report a 65-year-old man was referred from a general practitioner to the gastroenterology department with vague complaints of longstanding upper abdominal discomfort and hepatomegaly. past history was unremarkable other than the intake of traditionally brewed beer. clinical examination revealed 21 cm hepatomegaly and the initial suspicion was that of alcoholic liver cirrhosis or haemosiderosis. biochemical investigations done before the ultrasound appointment were aimed at excluding infections, neoplasms and impaired liver and kidney function. liver enzymes and liver function tests were all normal other than a raised gammaglutamyl transpeptidase of 176 iu/l and a serum albumin slightly below normal at 35 g/dl. uric acid was increased to 0.48 mmol/l. protein electrophoresis was normal, as were tests for haemostasis. the erythrocyte sedimentation rate was 31 mm/h and c-reactive protein below 5 mg/l. virology for hepatitis a, b and c were all negative and serology was negative for echinococcus and bilharzia. tumour markers including carcinoembryonic antigen, alpha-fetoprotein and prostatespecific antigen were in the normal reference range. ultrasound (fig. 1) of the liver revealed a massively enlarged liver 10 cm below the ribs in the midaxillary line distending across the midline to the left hypochondrium. multiple cystic areas with posterior enhancement were visible without any obvious characteristics of echinococcus 34 sa journal of radiology • august 2004 case reports polycystic liver disease — a disease entity presenting as part of autosomaldominant polycystic kidney disease h boonzaier-botha mb chb department of diagnostic radiology university of the free state and universitas hospital bloemfontein c cock mb chb, mmed (int) department of gastroenterology university of the free state and universitas hospital bloemfontein cysts. a single simple cortical cyst measured 21 mm x 20 mm in the lower pole of the left kidney. helical computed tomography (ct) scan (ge prospeed sx advantage helical) pre iv contrast (fig. 2a) and post iv contrast (fig. 2b) with oral contrast confirmed the multiple hepatic cysts and single simple cortical cyst in the lower pole of the left kidney. the multiple liver cysts varied in size with a maximum diameter of approximately 8 cm and no enhancement post intravenous contrast injection. a single enlarged pre-aortic node was visible without notable abnormalities in the rest of the abdominal structures. aspiration of the largest cyst revealed 15 ml of yellow fluid without any organisms or malignant cells. magnetic resonance imaging (mri, ge signa twinspeed 1.5 t unit) confirmed the multiple hepatic cysts with low signal on t1-weighted images (fig. 3a) and high signal on t2-weighted images (figs 3b and 3c) without enhancement post gadolinium injection. the hepatic cysts were initially accurately imaged with ultrasound and no extra information regarding the characteristics of the hepatic cysts was revealed with ct or mr investigations. these investigations were done for comparative purposes and confirmation of initial diagnosis of pcld. mr imaging, however, revealed multiple smaller cysts in both kidneys (fig. 3d). a diagnosis of adpkd, which had not been suspected on clinical features or ultrasound/ct imaging, was made. based on the mri findings a 24hour urine protein concentration and creatinine clearance were done, but were found to be within normal limits. the patient was not hypertensive and fundoscopic examination was normal. symptomatology subsided after aspiration of the largest cyst and the patient was discharged with the addition of a short course of sucralfate. he has subsequently been followed up at the gastroenterology clinic and is case reports 35 sa journal of radiology • august 2004 fig.1. ultrasound of enlarged liver. fig. 2a. helical computerised tomography pre iv contrast confirming hepatic and cortical cysts. fig. 2b. helical computerised tomography post iv contrast confirming hepatic and cortical cysts. fig. 3a. mri confirming multiple hepatic cysts with low signal on t1-weighted images. fig. 3b. mri confirming multiple hepatic cysts with high signal on t2-weighted images. fig. 3c. mri confirming multiple hepatic cysts with high signal on t2-weighted images. currently symptom free. screening of his living relatives, by ultrasound and biochemistry, has revealed active adpkd in one of his three children. discussion pcld usually occurs as a manifestation of adpkd and can occur with adpkd-1 (type 1) and adpkd-2 (type 2).1-5 it can, however, also rarely occur as a separate entity distinct from adpkd4-6 or a manifestation of autosomal recessive polycystic kidney disease.2,9,10 in adult patients pcld is most commonly associated with adpkd types 1 and 2. in these disorders there is abnormal formation of the protein polycystin, coded for by chromosome 16 (adpkd type 1) and chromosome 4 (adpkd type 2).3-5 in primary pcld there is abnormal formation of hepatocystin coded for by chromosome19.11-13 polycystin and hepatocystin play a role in the processing of secretary and transmembrane proteins that include receptors for the control of cell proliferation in the liver, kidneys, pancreas and spleen (and abnormalities thereof may lead to cyst formation in these organs).4,14,15 in children pcld may be associated with congenital hepatic fibrosis and autosomal recessive polycystic kidney disease. the disease process in the recessive form is much more malignant and survival into adulthood is rare.4 radiologically the disease is characterised by the presence of multiple (4 or more) cysts imaged on ultrasound, ct or mri.7 hepatic cysts are presumed to occur in 2.5% of the population and can be single or multiple as part of adpkd-1 and 2. they are developmental anomalies originating from hamartomatous tissue. the cysts contain serous fluid and are lined by a thin wall of cuboidal epithelium, identical to that of the bile ducts, with a fibrous stroma underneath.7 most cysts are asymptomatic but onesixth of them cause symptoms due to liver enlargement or pressure on surrounding organs.16 malignant degeneration of hepatic cysts is very rare but has to be excluded by means of aspiration cytology before diagnosis is confirmed or symptomatic cysts are treated. simple cysts are round, oval lesions with posterior enhancement and are echo-free. thin septations can usually be seen on imaging.8 associated cysts can be found in the kidneys in 50% of cases as well as in the pancreas, spleen and other organs.8 ultrasound is usually superior to ct or mri and depicts the well-defined, anechoic, round or oval lesions with imperceptible walls, thin septae and good posterior enhancement or through transmission. ultrasound is also used for aspiration of cystic contents and interventional treatment of symptomatic cysts. the cysts can be inhomogeneous due to haemorrhage inside and must then be differentiated from cystic metastasis.7 haemorrhage and infection can cause debris-like echoes in the affected cysts on ultrasound which are then difficult to differentiate from cystic metastases that occur for example in squamous cell carcinoma and gastric stromal tumours.8 hydatid disease of the liver can usually be differentiated by the typical sonographic appearance of the cyst wall and due to visible bands of delaminated endocysts. this is usually described as a ‘water-lily sign’.8 calcification of the echinococcus cyst wall and daughter cysts that are surrounded by an echogenic debris, sometimes called hydatid sand, is frequently seen. on non-enhanced ct scans the multiple cysts appear mostly homogeneous and hypodense with no enhancement of the wall or cyst contents after contrast administration.7,17 on mri the hepatic cysts are characteristically of low image signal intensity on t1 and have very high signal intensity on t2-weighted images. no enhancement is seen of wall or cyst contents after injection of gadolinium chelates. once again slight variations can occur in signal intensity due to intracystic haemorrhage or infection. pcld is most commonly a clinically benign condition and in most cases presents as vague upper abdominal discomfort or abnormal liver enzyme tests detected incidentally. there is often a positive family history or previous diagnosis of polycystic kidneys. in a large number of cases liver function tests remain normal. the disease usually occurs in older patients who often present with nodular liver enlargement and a normal liver function test. when pcld occurs in association with adpkd the renal function may become case reports 36 sa journal of radiology • august 2004 fig. 3d. mri confirming multiple smaller cysts in both kidneys. abnormal. in rare cases cysts may become massively enlarged or may become infected. even rarer complications are budd-chiari syndrome, portal hypertension, or liver failure but these may be so severe that liver transplantation may be indicated.4,18 treatment initially consists of treating symptomatic cysts, which are usually the largest cysts imaged, with unroofing, excision or hepatic resection.16 in pcld it is, however, advisable to treat the symptomatic cyst with injection of 25 30% of the aspirated cyst volume using 99% ethanol, with re-aspiration after 20 minutes.16 sonography is usually the most accurate imaging method for evaluation and treatment of symptomatic cysts under ultrasound-guided aspiration and ethanol injection.16 arterial embolisation of liver disease represents a new and exciting development in the treatment of patients in poor physical condition. in one case symptomatic relief was achieved as well as a reduction in hepatomegaly and ascites with improvement in physical condition due to improved appetite.19 in summary, pcld occurs as part of the manifestation of adpkd in more than 50% of cases. where the association occurs it is clinically relevant as the patient will much more likely suffer renal complications, with the liver disease running a relatively benign course. radiologically, it must be distinguished from other cystic diseases of the liver. the most common of these are multiple metastases, hydatid disease, acquired cysts from trauma or infection and biliary cystadenoma.8 radiological investigations play a crucial role in suggesting and confirming the correct diagnosis and managing patients appropriately. references 1. gabow pa. autosomal dominant polycystic kidney disease. n engl j med 1993; 329: 332342. 2. d'agata id, jonas mm, perez-atayde ar, guay-woodford lm. combined cystic disease of the liver and kidney. semin liver dis 1994; 14: 215-228. 3. rizk d, chapman ab. cystic and inherited kidney diseases. am j kidney dis 2003; 42: 13051317. 4. sherlock sa, dooley j. diseases of the liver and biliary system. 11th ed. oxford: blackwell science, 2002: 584-586. 5. feldman m, friedman ls, sleisenger mh. sleisenger & fordtran's gastrointestinal and liver disease. 7th ed. philadelphia: wb saunders, 2002: 1596-1597. 6. karhunen pj, tenhu m. adult polycystic liver and kidney diseases are separate entities. clin genet 1986; 30(1): 29-37. 7. mortele kj, ros pr. imaging of diffuse liver disease. semin liver dis 2001; 21: 195-212. 8. ralls pw, jeffrey rb jr, kane ra, robbin m. ultrasonography. gastroenterol clin north am 2002; 31: 801-825. 9. lai ec, wong j. symptomatic nonparasitic cysts of the liver. world j surg 1990; 14: 452-456. 10. summerfield ja, nagafuchi y, sherlock s, cadafalch j, scheuer pj. hepatobiliary fibropolycystic diseases. a clinical and histological review of 51 patients. j hepatol 1986; 2: 141156. 11. drenth jp, te morsche rh, smink r, bonifacino js, jansen jb. germline mutations in prkcsh are associated with autosomal dominant polycystic liver disease. nat genet 2003; 33: 345-347. 12. li a, davila s, furu l, et al. mutations in prkcsh cause isolated autosomal dominant polycystic liver disease. am j hum genet 2003; 72: 691-703. 13. minoshima s, hirai m, sakai k, et al. assignment of the gene for a protein kinase c substrate, 80k protein, to human chromosome 19 (abstract). cytogenet cell genet 1989; 51: 1045. 14. hateboer n, v dijk ma, bogdanova n, et al. comparison of phenotypes of polycystic kidney disease types 1 and 2. european pkd1pkd2 study group. lancet 1999; 353: 103-107. 15. ibraghimov-beskrovnaya o, dackowski wr, foggensteiner l, et al. polycystin: in vitro synthesis, in vivo tissue expression, and subcellular localization identifies a large membrane-associated protein. proc natl acad sci usa 1997; 94: 6397-6402. 16. tikkakoski t, makela jt, leinonen s, et al. treatment of symptomatic congenital hepatic cysts with single-session percutaneous drainage and ethanol sclerosis: technique and outcome. j vasc interv radiol 1996; 7: 235-239. 17. murphy bj, casillas j, ros pr, morillo g, albores-saavedra j, rolfes db. the ct appearance of cystic masses of the liver. radiographics 1989; 9: 307-322. 18. uddin w, ramage jk, portmann b, et al. hepatic venous outflow obstruction in patients with polycystic liver disease: pathogenesis and treatment. gut 1995; 36: 142-145. 19. ubara y, takei r, hoshino j, et al. intravascular embolization therapy in a patient with an enlarged polycystic liver. am j kidney dis 2004; 43: 733-738. case reports 37 sa journal of radiology • august 2004 interesting images the computed tomography features of multifocal nephroblastomatosis s andronikou mbbch (wits), fcraddiag (sa), frcr (london) ewelman mbchb e kader mbchb department of paediatric radiology, university of gape town and institute of child health, red cross war memorial children's hospital, rondebosch, cape town corresponding author sandronlkou department of paediatric radiology, red cross war memorial children's hospital, gape town, 7700 tel: (021) 658-5422. fax: (021) 658-5101. e-mail: docsav@mweb.co.za nephroblastomatosis refers to persistent metanephric blastemal (nephrogenic) rests found within the kidneys after 34 weeks' gestation. autopsy studies have shown that they occur in up to 1% of children under 3 months of age. they are considered premalignant owing to their strong association with wilm's tumours. even though unifocal and diffuse disease occurs, multifocal nephroblastomatosis is the most common type encountered. lesions are located primarily at the periphery, but may occur anywhere within the kidney. effective management of these children requires identification of both the nephroblastomatosis and the wilm's tumours. imaging is critical, as surgical biopsy may be complicated by the multiplicity and small size of the lesions, as well as the risk of peritoneal seeding. 48 sa journal of radiology. february 2001 multifocal nephroblastomatosis has multiple smooth foci in the periphery of the renal cortex. these lesions are lenticular or ovoid, usually 5-20 mm in size and sharply demarcated. the kidneys are large and their contour is lobulated, often with significant bulges. in contrast, diffuse nephroblastomatosis produces a thick uniform peripheral rind of abnormal tissue in an enlarged kidney with preservation of the renal shape and contour. at computed tomography (ct), the density of the lesions resembles normal cortex. these lesions are poorly vascularised and after contrast administration are markedly hypodense when compared with normal renal cortex. the centrally located normal figures la and lb: preand post-contrast ct of the kidneys. on the pre-contrast image, the left kidney is enlarged more than the right, but both demonstrate a homogeneous density. after contrast administration, the cheracteristic centrally located enhancing normal parenchyma resembling "stag antlers" (arrows) is well demonstrated against the non-enhancing peripheral mult/focal nephrogenic rests (crosses). topage49 mailto:docsav@mweb.co.za the computed tomography features of multifocal nephroblastornatosis frompage48 renal tissue shows characteristic distortion resembling "stag antlers" after contrast administration. the most characteristic feature of the nephrogenic rests is their homogeneous appearance. in comparison, wilm's tumours are often heterogeneous both preand post-contrast administration. size and shape are unhelpful features in differentiation. lymphoma may produce homogeneously enlarged kidneys that may initially appear identical to diffuse or multifocal nephroblastomatosis, but will not demonstrate the central "stag antlers". ct is considered to have similar potential to gadolinium-enhanced mri in the diagnosis of nephroblastomatosis with regard to identification and differentiation from wilm's tumour. in our personal experience, however, mri has a greater sensitivity for the detection of small lesions. references goske mj, mitchell c, reslan wa. imaging of patients with wilms' tumor. sem ural oneal 1999; 17: 11-20. rohrschneider wk, weirich a, rieden k, darge k, trëger j, graf n. us, ct and mr imaging characteristics of nephroblastomatosis. pediatr radial 1998; 28: 435-443. figures 28 and 2b: before and after chemotherapy. typical homogeneous peripheral nephrogenic rests with central "stag antler" configuration of the contrast-enhancing normal parenchyma. the post-chemotherapy ct scan shows a reduction in the size of the nephroblastomatosis, with expansion of the previously compressed normal parenchyma. 49 sajournal of radiology· february 2001 radiology_may04 45 sa journal of radiology • may 2004 case report introduction the radiological detection of pulmonary air space consolidation opens up a broad differential diagnosis.1 in various pathological conditions alveoli may be filled with fluid, pus, blood, tumour, gastric contents or a phospholipoproteinaceous material.1,2 the latter condition is known as pulmonary alveolar proteinosis.2 i report on a case of acquired pulmonary alveolar proteinosis and give a short review of this fascinating disorder. case report a 51-year-old caucasian male patient presented with a 2-year history of progressive dyspnoea with a cough, productive of a yellow sputum. the patient had smoked 20 cigarettes a day for the past 30 years. one year ago the patient underwent a lung biopsy and a histological diagnosis of pneumonia was made. both his occupational and recreational history did not reveal any risk factors for pulmonary disease. clinical examination revealed cyanosis and bilateral inspiratory crackles. the chest radiograph demonstrated extensive, bilateral alveolar consolidation. a high-resolution computed tomography (hrct) scan confirmed widespread, bilateral air space consolidation, with thickened interlobular septae, producing the so called ‘crazy paving’ pattern (fig. 1). the patient was subjected to another thoracoscopic lung biopsy and this time the histological examination revealed alveoli and terminal bronchioles filled with granular, eosinophilic, proteinaceous material (fig. 2) with preservation of the alveolar architecture. the patient was treated by whole-lung lavage, followed by a 4-week trial of subcutaneous granulocyte-macrophage colony-stimulating factor (gm-csf). the trial of gm-csf failed, however, and the patient is currently being treated by monthly whole-lung lavages. discussion pulmonary alveolar proteinosis (pap) is a rare syndrome that was first described by rosen et al. in 1958.3 this disorder is characterised by abnormal intra-alveolar surfactant accumulation4 with a variable clinical course, ranging from respiratory failure to spontaneous resolution.5 three distinct clinical forms of pap can be distinguished:3-5 congenital, secondary, and primary (idiopathic) pulmonary alveolar proteinosis. congenital pap is a heterogeneous group of disorders caused by mutations in surfactant proteins b or c, or the receptor for gm-csf.3,6,7 secondary pap can develop in association with various conditions, such as immunodeficiency states, acute silicosis and other inhalational syndromes, haematologic malignancies and myelodysplastic syndromes.4, 5 in all of these conditions there is a reduction in the number and/or functional impairment of alveolar macrophages.5 more than 90% of all cases of pap occur as the primary (idiopathic) form.4 recent studies have led to the current concept that primary pap is an autoimmune disease, which produces neutralising immunoglobulin g (igg) antibodies against gm-csf.8 surfactant is normally cleared by uptake into alveolar macrophages and gm-csf is critical for this process, as it is a cytokine stimulating the production of alveolar macrophages by pulmonary alveolar proteinosis — a case report and review j ker mb chb, mmed (internal medicine) department of physiology university of pretoria and pretoria heart hospital fig. 1. widespread, bilateral areas of ground glass opacities with interand intralobular septal thickening leading to a ‘crazy paving’ pattern. fig. 2. alveoli filled with an eosinophilic, granular material, staining with periodic acid schiff (pas). note the preservation of the alveolar architecture. review article 46 sa journal of radiology • may 2004 the bone marrow. therefore, all three forms of pap share the feature of an impairment in the number and/or activity of alveolar macrophages leading to the alveolar accumulation of surfactant.1-8 the most common symptoms are dyspnoea and cough, and because of the impaired alveolar macrophage function these patients are susceptible to pneumonia.2,4,5 pulmonary function tests usually reveal a restrictive defect with a reduction in lung volume and diffusion capacity.2 the radiological feature is that of a non-specific pattern of air space consolidation, which is usually bilateral and patchy and can be very extensive.2 it has been reported that in up to 50% of cases this patchy consolidation is peri-hilar, giving a ‘bat’s wing’ pattern.2 however, the consolidation may also be predominantly peripheral or basal in distribution.2 hrct demonstrates patchy, ground-glass opacifications with superimposed inter, and intralobular septal thickening, and this pattern is commonly referred to as ‘crazy paving’.5 open-lung biopsy is the gold standard for the diagnosis and reveals alveoli filled with granular, eosinophilic material that stains with periodic acid schiff (pas)5 with preservation of the alveolar architecture.2 in secondary pap treatment depends on the underlying cause. successful lung transplantation has been reported in cases of congenital pap.5 whole-lung lavage remains the standard of care for primary pap, although some patients may respond to subcutaneous gm-csf at a dose of 5 µg/kg of body weight per day for 6 -12 weeks.5 the natural history of pap can follow one of three pathways: spontaneous improvement, stable with persistent symptoms, or progressive deterioration.5 references 1. manheimer e. chest roentgenography for cardiovascular evaluation. in: walker hk, hall wd, hurst jw, eds. clinical methods. the history, physical and laboratory examinations. new york: butterworth, 1990: 188. 2. shah pl, hansell d, lawson pr, reid kbm, morgan c. pulmonary alveolar proteinosis: clinical aspects and current concepts on pathogenesis. thorax 2000; 55: 67-77. 3. rosen sh, castleman b, liebow aa. pulmonary alveolar proteinosis. n engl j med 1958; 258: 1123-1142. 4. seymour jf, presneill jj. pulmonary alveolar proteinosis. progress in the first 44 years. am j respir crit care med 2002; 166: 215-235. 5. trapnell bc, whitsett ja, nakata k. pulmonary alveolar proteinosis. n engl j med 2003; 349: 2527-2539. 6. teja k, cooper ph, squires je, schnatterly pt. pulmonary alveolar proteinosis in four siblings. n engl j med 1981; 305: 1390-1392. 7. nogee lm, demello de, dehner lp, colten hr. deficiency of pulmonary surfactant protein b in congenital alveolar proteinosis. n engl j med 1993; 328: 406-410. 8. kitamura t, tanaka n, watanabe j. idiopathic pulmonary alveolar proteinosis as an autoimmune disease with neutralizing antibody against granulocyte-macrophage colony-stimulating factor. j exp med 1999; 190: 875-880. radiology_may04 review article 44 sa journal of radiology • may 2004 introduction very large fibroadenomas can occur in young patients with ominous looking features that can mimic malignancy. case report a 25-year-old woman complained about a large painful mass in her right breast. due to the fact that there was a positive family history of breast carcinoma and the mass was quite large, irregular and very firm on palpation, the patient was sent for mammography and ultrasound examination. on mammography a large, irregular and dense mass was noted in the superior lateral quadrant of the right breast. no calcifications were detected. on ultrasound examination an irregular, lobulated, large mass was detected in the superior lateral quadrant of the right breast. the mass had an inhomogeneous texture, more hyperechoic, with irregular posterior acoustic enhancement and shadowing, especially at the edges of the mass. the mass measured > 5 cm in length and > 3 cm in depth. no characteristic calcifications were detected (figs. 1a and b). due to the size, irregularity and density of the mass and the positive family history, the fear of malignancy was justified. an excision biopsy was performed. histological diagnosis confirmed a fibroadenoma. discussion fibroadenoma is an oestrogeninduced benign tumour, which develops during adolescence. pregnancy and lactation are growth stimulants, with regression after menopause. patients have a mean age of 39 years (range 13 80 years). these tumours may occur in postmenopausal women receiving oestrogen replacement therapy. clinically it is a firm, smooth, sometimes lobulated freely moveable mass, rarely tender or painful. sizes vary between 1 cm and 5 cm in diameter (in 60% of cases), tumours are multiple in 10 20%, and bilateral in 4% of cases.1 ultrasound characteristics ultrasound characteristics are as follows: (i) round or oval mass with length-to-depth ratio > 1.4 (carcinomas usually < 1.4); (ii) hypoechoic or hyperechoic or mixed pattern or anechoic or isoechoic compared with adjacent fibroglandular tissue; (iii) homogeneous or inhomogeneous texture with regular, lobulated or irregular contour; (iv) there can be posterior acoustic enhancement or acoustic shadowing without calcification; and (v) an echogenic halo with lateral shadowing can also be present. a giant fibroadenoma (> 6 cm) can occur in adolescents or young adults.2 differential diagnosis medullary, mucinous or papillary carcinoma or carcinoma within the fibroadenoma. references 1. sutton d, young jwr, a short textbook of clinical imaging. london: springer verlag, 1990: 415-424. 2. dahnert w. radiology review manual. 2nd ed. baltimore: williams and wilkins, 1993: 349. large fibroadenoma mimicking malignancy janet smal mb chb, mmed radd department of radiology univesrity of pretoria fig. 1a. transverse section of fibroadenoma on ultrasound. fig. 1b. longitudinal section of fibroadenoma on ultrasound. abstract introduction case report discussion conclusion learning points acknowledgements references about the author(s) andrew schapiro department of radiology, university of cincinnati, cincinnati children’s hospital medical center, cincinnati, oh, united states of america tal laor department of radiology, harvard medical school, boston children’s hospital, boston, ma, united states of america citation schapiro a, laor t. ‘soccer toe’: chronic physeal injury of the great toe metatarsal in a skeletally immature child – a case report. s afr j rad. 2020;24(1), a1834. https://doi.org/10.4102/sajr.v24i1.1834 note: special collection: paediatric radiology. case report ‘soccer toe’: chronic physeal injury of the great toe metatarsal in a skeletally immature child – a case report andrew schapiro, tal laor received: 06 jan. 2020; accepted: 23 feb. 2020; published: 22 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract chronic physeal stress injuries in children can result from ongoing, repetitive compression, distraction and/or shear forces during sports-related activity, and manifest as physeal widening on imaging. we present an 11-year-old soccer athlete with focal physeal widening of her great toe metatarsal and postulate that ongoing or repetitive stress from soccer play may manifest as this imaging appearance. we suggest that recognition of this entity in growing children might explain pain, if present, and guide conservative treatment. keywords: physis; growth plate; toe; mri; stress; musculoskeletal imaging; sports medicine. introduction in its most recent worldwide survey, the fédération internationale de football association (fifa) estimated that 265 million people play soccer worldwide, making it the world’s most popular sport. although recognised as a relatively safe sport for children to play, soccer is nevertheless associated with a substantial injury toll.1 most soccer-related musculoskeletal injuries in children are acute, but those that result from chronic overuse still account for 5% – 20% of the total and can result in weeks to months of missed playing time.1,2 injuries because of chronic musculoskeletal overuse most commonly encountered in paediatric soccer players occur at the apophyses of the pelvis and lower extremities1,2 as a result of recurrent or ongoing traction at sites of tendon and muscle origin or insertion, and may manifest upon imaging as widening of apophyseal physes.3 abnormal widening of the transverse physes of lower extremity long bones as a result of chronic compressive repetitive physeal stress injury has also been reported for the knee.4 we present a case report of an 11-year-old female soccer athlete who was imaged for lateral foot pain. she had no recognised or reported antecedent acute traumatic event to the great toe nor had any medial foot pain. on magnetic resonance (mr) imaging, there was focal dorsal widening of the great toe metatarsal physis in comparison to the unaffected portion of the physis and to the other physes in the same foot. we postulate that ongoing athletic activity that results in chronic physeal stress injury might manifest as dorsal physeal widening of the great toe metatarsal on mr imaging in a skeletally immature soccer player. case report an 11-year-old female soccer player presented to the orthopaedic clinic for acute lateral right ankle and foot pain after she rolled her ankle in a soccer game. she had no previous history of prior fracture in the foot, and apart from her current complaint, she was healthy. on physical examination, mild swelling with tenderness on palpation at the level of the lateral malleolus, inferior to the lateral malleolus, and along the lateral aspect of the foot was noted, but no pain was felt at the base of the great toe metatarsal. she had normal joint range of motion and no joint laxity. there were no associated skin changes. radiographs of her right foot and ankle obtained on the day of injury were initially interpreted as normal, although in retrospect, they showed subtle widening of the lateral portion of the great toe metatarsal physis (figure 1). because of symptoms that persisted for 6 weeks after injury, she was referred for mr imaging. the mr imaging examination revealed marrow oedema in the proximal aspect of the cuboid without a discrete fracture line, compatible with an osseous contusion (figure 2). focal widening of the dorsal one half of the great toe metatarsal physis with normal physeal signal intensity was noted for all sequences, but was most easily identified on gradient echo images (figure 3). no oedema-like signal was noted in the surrounding muscles or other soft tissues. figure 1: an 11-year-old female soccer player with lateral ankle and foot pain following a soccer injury. frontal view of the foot shows subtle widening (arrow) of the physis of the great toe metatarsal. the remainder of the imaging examination is normal. figure 2: cuboid contusion. sagittal fast spin echo t2-weighted image (repetition time [tr]/echo time [te] 3500/73 ms) of the lateral aspect of the foot shows focal oedema-like signal within the cuboid. no fracture line was evident. the finding presumably accounted for the patient’s lateral foot pain at presentation. figure 3: chronic physeal stress on magnetic resonance imaging. (a) sagittal gradient echo magnetic resonance image (959/14 ms, 20° flip angle) of the great toe in the same girl delineates abnormal widening of the dorsal physis (solid arrows) relative to the normal plantar physis (dotted arrows). the signal intensity is similar between the normal and the abnormal portions of the physis. (b) sagittal volumetric gradient echo magnetic resonance image (13.9/5.2 ms, 30° flip angle) of the proximal right humerus of a 12-year-old male baseball player shows a focal region of abnormal widening (arrow) of the lateral aspect of the proximal humeral physis, with a configuration similar to the great toe metatarsal physis in the patient shown in figure 2. this so-called ‘little leaguer’s shoulder’ is another example of physeal stress change attributed to a chronic traction injury. the patient had no pain or tenderness localised to the medial aspect of the foot. however, she continued to report substantial lateral ankle and foot pain after 10 weeks of conservative management, which included physical therapy, and referral to the pain clinic, but she was lost to follow-up. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. discussion physeal cartilage is the weakest structure in the developing skeleton and thus is most susceptible to injury. it is less resilient to stresses than its counterpart of adult articular cartilage, less resistant than the adjacent bone to shear and tensile forces, and two to five times weaker than surrounding ligamentous tissue.5 susceptibility to physeal injury is particularly pronounced during periods of rapid growth, as occurs during pubescence.5 chronic physeal stress injuries result from chronic, repetitive physeal microtrauma that can occur because of compression, distraction and/or shear forces.3,4,5 on imaging, chronic physeal stress injury manifests as abnormal physeal widening,3,4 which can often involve only a portion of the physis as a result of frequently non-uniform stress, as noted in our patient. at a histologic level, in the setting of a chronic, repetitive compression force, physeal widening results from impaired endochondral ossification possibly related to impaired metaphyseal perfusion that manifests as thickening of the hypertrophic zone with extension of physeal hypertrophic chondrocytes into the metaphysis.4 in the setting of a distraction force, physeal widening may be the result of persistence of hypertrophic chondrocytes that do not progress further in the process of endochondral ossification, the proliferation of chondrocytes in the hypertrophic zone6 and/or microscopic foci of physeal separation through the hypertrophic zone and/or at the junction of the hypertrophic zone and metaphysis.7 chronic physeal stress injury as a result of both compressive and distraction-related athletic activity has been reported in association with a number of sports, which include baseball, gymnastics, soccer, running, tennis, football, basketball and rugby.5 chronic physeal stress injuries can occur at several sites, including physes adjacent to the epiphyses and apophyses of the upper and lower extremities, and the apophyses of the pelvis,3,5 with the distribution of sites of involvement related to the specific sport. given the predominant use of the lower extremities in soccer, it is not surprising that reported soccer-related chronic physeal injuries involve the pelvis and lower extremities.3,5 however, to our knowledge, no prior cases of metatarsal chronic physeal stress injury have been reported in soccer players. the condition of most athletes suffering from chronic repetitive physeal injury improves with rest, and they can return to their sport,5 but premature physeal closure and deformity can occur with non-compliance.4 chronic physeal stress change may not be symptomatic. the widening of the dorsal aspect of the great toe metatarsal physis relative to the plantar aspect of the physis seen in our patient suggests that the abnormal force predominantly affects the dorsal aspect of the physis. given the manner in which the forefoot strikes the ball during repetitive kicking in soccer, we postulate that a repetitive distraction force acts on the dorsal aspect of the physis to manifest as asymmetric chronic physeal stress changes (figure 4). alternatively, it is conceivable that the physeal changes may result from a chronic compressive force on the dorsal aspect of the physis which could occur during running, as there is a single case report of great toe metatarsal chronic physeal stress injury that was reported in an avid long-distance runner.8 however, involvement of only the great toe metatarsal in our patient and the fact that we have not encountered these changes in patients involved in other activities with substantial running lead us to favour a kicking-related and, therefore, a distraction-based mechanism. figure 4: photograph (a) and diagram (b) illustrate a possible mechanism for the dorsal physeal widening seen in our patient. we postulate that kicking of a soccer ball imparts a tension force on the dorsal aspect of the physis. upon repetition, this can result in physeal distraction and subsequent stress injury, similar to other chronic physeal stress changes, such as the one shown in ‘little leaguer’s shoulder’ (figure 3b) or elbow. interestingly, chronic physeal stress injuries at other lower extremity sites have been reported in kickers.4 whether the injured physis in these cases was in the planting leg and resulted from compressive force, or in the kicking leg and resulted from distraction, was not reported in either instance; therefore, it is difficult to discern whether the mechanism of injury may have been similar to the current postulated causation, but involving a different physeal location. we were unable to determine foot dominance in this patient to correlate foot dominance with the side of injury; however, soccer training and play involves both feet; therefore, the presence or lack of similar findings in the contralateral foot would be non-contributory.9,10 we were also unable to ascertain how long or how frequently she had been playing soccer or what her training pattern was, although she was described as a high-level player. as distraction forces on the great toe might be present with other types of sports, additional studies to evaluate for similar chronic physeal stress changes in other child athletes would be helpful. conclusion in summary, we suggest that observed physeal widening of the great toe metatarsal in a skeletally immature soccer player may reflect asymptomatic or symptomatic chronic physeal stress changes akin to imaging findings previously described at other sites of skeletal growth in athletic children. this finding, whether associated with pain or not, should be brought to the attention of the ordering clinician by the radiologist so that activity limitation can be considered to allow the injury to heal. learning points physeal widening at the base of the great toe metatarsal may reflect a chronic physeal injury that may or may not be symptomatic. similar to physeal stress injuries in other locations of the growing skeleton in children, limitation of activity to allow for healing may be needed. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references paterson a. soccer injuries in children. pediatr radiol. 2009;39(12):1286–1298. https://doi.org/10.1007/s00247-009-1416-1 rossler r, junge a, chomiak j, dvorak j, faude o. soccer injuries in players aged 7 to 12 years: a descriptive epidemiological study over 2 seasons. am j sports med. 2016;44(2):309–317. https://doi.org/10.1177/0363546515614816 hebert kj, laor t, divine jg, emery kh, wall e. mri appearance of chronic stress injury of the iliac crest apophysis in adolescent athletes. am j roentgenol. 2008;190:1487–1491. https://doi.org/10.2214/ajr.07.3399 laor t, wall ej, vu lp. physeal widening in the knee due to stress injury in child athletes. am j roentgenol. 2006;186(5):1260–1264. https://doi.org/10.2214/ajr.04.1606 caine d, difiori j, maffulli n. physeal injuries in children’s and youth sports: reasons for concern? br j sports med. 2006;40(9):749–760. https://doi.org/10.1136/bjsm.2005.017822 apte ss, kenwright j. physeal distraction and cell proliferation in the growth plate. j bone joint surg br. 1994;76(5):837–843. https://doi.org/10.1302/0301-620x.76b5.8083281 alberty a, peltonen j, ritsila v. effects of distraction and compression on proliferation of growth plate chondrocytes. a study in rabbits. acta orthop scand. 1993;64(4):449–455. https://doi.org/10.3109/17453679308993665 percy ec, gamble fo. an epiphyseal stress fracture of the foot and shin splints in an anomalous calf muscle in a runner. br j sports med. 1980;14(2–3):110–113. https://doi.org/10.1136/bjsm.14.2-3.110 malina rm. maturity status and injury risk in youth soccer players. clin j sport med. 2010;20(20):131–132. https://doi.org/10.1097/01.jsm.0000369404.77182.60 delang md, rouissi m, bragazzi nl, chamari k, salamh pa. soccer footedness and between-limbs muscle strength: systemic review and meta-analysis. int j sports physiol perform. 2019;14(5):551–562. https://doi.org/10.1123/ijspp.2018-0336 introduction bilateral paramedian thalamic infarction is rare. the suggested mechanism is occlusion of a single central thalamic perforating artery – an anatomic variant described by percheron in 1977.1 bilateral paramedian thalamic infarctions may result in the classic triad of hypersomnolence (excessive sleepiness), ocular disturbances (supranuclear and vertical gaze palsy) and neuropsychological deficits (including an amnestic syndrome).2 the paramedian thalamus is believed to play an important role in the regulation of sleep and disturbances in sleep regulation are known to occur in paramedian thalamic stroke (pts). because of the absence of lateralising signs in pts (‘inobvious stroke’) disturbance of consciousness may initially be assumed to be of metabolic-toxic origin. however the triad of hypersomnia, neuropsychological deficits (frontal syndrome and amnesia) and eye-movement disturbance allows the recognition of the vascular syndrome. vertical gaze palsy is the best clinical predictor of the degree of hypersomnia, whereas severe amnesia can also occur in patients with mild hypersomnia. in mildly affected patients, hypersomnia usually resolves within a few months, whereas in severe cases a disabling hypersomnia may persist for > 1 year. eventually hypersomnia resolves, leaving some patients in a state of apathy, psychomotor slowing, intentional deficits and amnesia that has been called ‘thalamic dementia’.3 the word thalamus (from the greek thalamos), refers to an inner room or bridal chamber therefore the posterior part of the thalamus is appropriately named ‘pulvinar’ (pillow in greek).2 the thalami contain strategic nuclei and integrate several important cortical functions. these nuclei are involved with memory, emotion and maintenance of consciousness. thus infarcts at the mesencephalic diencephalic junctions may result in complex clinical syndromes with a wide range of symptoms varying from motor deficits to behavioural and sensory alterations. thalamic infarctions result in markedly different clinical syndromes on the basis of the location of the infarction in relation to the thalamic nuclei involved. the location of the infarction is determined by the blood supply distribution to the thalamus and midbrain. hence an understanding of the vascular supply to the thalami is highlighted. the arterial supply to these areas arises from many perforating blood vessels with a complex distribution for which many variations have been described. one rare variation, named the ‘artery of percheron’ is a solitary arterial trunk that arises from one of the proximal segments of a posterior cerebral artery and supplies the paramedian thalami and the rostral midbrain bilaterally.2 imaging findings a 48-year-old man presented with hypersomnia 5 days after stopping antihypertensive therapy. on examination he was very sleepy with vertical gaze paresis and short-term memory loss. mri demonstrated high signal intensity on t2 and flair in the thalami bilaterally (low t1 signal) which was positive on diffusion-weighted images (figs 1 4). discussion the thalamus is believed to play a role in the regulation of sleep. since the report of freund in 1913 pts has been known to be associated with hypersomnia. previously hypersomnia associated with pts has been attributed to diminished arousal signals ascending from the brain stem, however this is challenged by the suggestion that the thalamus also plays an important part not only in maintaining the wakeful state but also in producing sleep. the hypersomnia seems to arise from the simultaneous impairment of mechanisms for maintenance of arousal and for promotion of nonrem sleep, both of which depend on the integrity of the paramedian paramedian thalamic stroke syndrome z i lockhat, ffrad (d)sa s raven, mb chb department of radiology, pretoria academic hospital, university of pretoria m van rensburg, mb chb, mmed rad (d), frcr, franzcr private practice, wilgers mr, pretoria i van de werke, frcr department of radiology, kalafong hospital, university of pretoria short report 11 sa journal of radiology • march 2006 fig. 1. axial t2-weighted flair image shows high intensity lesions in thalami bilaterally. paramedian thalamic stroke.indd 11 3/27/06 12:07:30 pm 12 sa journal of radiology • march 2006 thalamus.2 the thalamus is vascularised by branches of four arterial pedicles that arise from the basilar artery bifurcation, the posterior communicating and posterior cerebral arteries. the paramedian aspect of the thalamus is supplied by the thalamic-subthalamic artery. four main thalamic vascular territories are recognised: (i) the territory supplied by the infero-lateral arteries, i.e. the ventral posterior group nuclei; (ii) the territory of the posterior choroidal arteries corresponding to the anterior region including the ventral anterior nucleus and the ventral lateral nucleus; (iii) the territory of the posterior choroidal arteries, supplying the lateral geniculate body; and (iv) the paramedian territory, supplying the medial thalamic nuclei. consequently, thalamic infarcts are classified anatomically into four distinct syndromes: the inferolateral, tuberothalamic, posterior choroidal, and paramedian stroke syndrome. the most frequent type of infarction corresponds to the inferolateral territory. the paramedian aspect of the thalamus is supplied by one or several paramedian thalamic arteries.2 percheron demonstrated that both paramedian thalami are vascularised by a single common vessel in approximately one-third of cases. occlusion of this vessel gives rise to bilateral lesions. occasionally a common vascular pedicle supplies both the paramedian thalamic arteries, and the paramedian mesencephalic arteries (also called posterior thalamo-subthalamic artery). such common origin explains the occurrence of paramedian infarction extending from the thalamus to the upper midbrain2 (fig. 5). the aetiology of thalamic strokes may vary; they can be due to lacunar infarction, large artery atherosclerosis, with artery-to-artery embolism, cardioembolism, deep venous thrombus and migrainous stroke.4 bilateral thalamic lesions can be caused by several other conditions such as thiamine deficiency, cerebral lupus, toxoplasmosis, cysticercosis, syphilis, tumours and fungal infections.1 patients with unilateral infarcts of the area supplied by the paramedian thalamic-subthalamic arteries frequently have a classic diencephalic triad of an acutely decreased level of consciousness, neuropsychological fig. 4. axial t2-weighted image with bilateral high signal intensity in the thalami. fig. 2. coronal t1-weighted image with bilateral low signal intensities in the thalami. fig. 3. axial diffusion-weighted image with bilateral high signal intensity in the thalami. short reportshort report paramedian thalamic stroke.indd 12 3/27/06 12:07:30 pm disturbances and vertical gaze palsy. the severity of disturbance of vigilance may range from simple lethargy to hypersomnia and coma, depending upon the extent of subthalamic involvement. conclusion from a practical standpoint bilateral paramedian thalamic infarcts should be recognised as due to occlusion of a possible single rare artery that is a normal anatomic variant. this should not be attributed to occlusion of multiple vascular territories or other pathologic conditions such as vasculitis or infectious disease. supratentorial bilateral symmetrical arterial distributions are unusual. occlusion of an azygous anterior cerebral artery may result in bilateral infarction. when bilateral medial thalamic infarcts are encountered the differential diagnosis should also include the top of the basilar artery syndrome. in this latter entity infarctions tend to involve also the territories supplied by the superior cerebellar and posterior cerebral arteries. when bilateral paramedian thalamic infarcts are found, occlusion of the artery of percheron should be considered as the main diagnosis. 1. raitberg b, tuccar e, alp m. bilateral paramedian thalamic infarct in the presence of an unpaired thalamic perforating artery. acta neuro chir (wien) 2002; 144: 301 304. 2. lövblad ko, basetti c, remanda l, schroth g. paramedian thalamic stroke syndrome. int j neurol 1997; 8: 116 122. 3. basetti c, mathis j, gugger m, lövblad ko, hess c. hypersomnia following paramedian thalamic stroke: a report of 12 patients. ann neurol 1996; 39: 471 480. 4. matheus g, castillo m. imaging of acute bilateral paramedian thalamic and mesencephalic infarcts. am j neuroradiol 2003; 24: 2005 2008. fig. 5. schematic diagram. (a). multiple small perforating arteries arising from the p1 segments of both posterior communicating arteries (most common). (b). a single perforating artery arising from only one of the p1 segments (the artery of percheron). (c) an arcade of perforating arteries arising from a bridging artery between the p1 segments of the posterior communicating arteries. 13 sa journal of radiology • march 2006 short report essential pathology third edition member: r440.00 non member: r470.00 to order contact carmen or avril: tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za the south african medical association, health & medical publishing group, suites 1-2 lonsdale building, gardener way, pinelands, 7405. health & medical books paramedian thalamic stroke.indd 13 3/27/06 12:07:34 pm 8001< review frompage20 uses, actions and side effects of the drugs used to treat the condition. this reviewer read through the book three times and gained a little more on each occasion. he enjoyed the experience and congratulates all the authors for an important contribution to the understanding and diagnosis of a most important condition. reviewer: prof hillel goodman, groote schuur hospital allan cormack clinical use of isotopes. he particularly acknowledged the contributions of professor rw james of the uct physics department, and dr muir grieve, a groote schuur hospital radiotherapist, in encouraging him to make his discovery. he was awarded the nobel prize for physiology and medicine together with sir godfrey hounsfield in 1979. he is only one of three south africans to have won a scientific nobel prize (with max theiler and aaron klug). he later worked at cambridge, harvard and subsequently tufts university, where he became chairman of the department of physics. the first ct scanner was placed into clinical service in london in 1971, and his insight has since gone on to revolutionise our profession. he died on 9 may this year at his home in winchester, massachusetts at the age of 74. acknowledgements uct monday paper, may 18-25, 1998, vol. 17: no 13; obituary, emeritus professor of physics, robin cherry, sunday times allan cormack shares the distinction of having founded the mathematical principles of the image reconstruction techniques used in computerised tomography and magnetic resonance, together with sir godfrey hounsfield. he also had close ties to the university of cape town physics and radiology departments, where he made his important mathematical deductions in 1957. born in johannesburg, he matriculated at rondebosch boys high, and received his msc in physics at uct in 1945. his original work on resolving the problems of axial imaging was based on a phantom made of an aluminium cylinder surrounded by a wooden cylinder, together with the use of radioisotopes to confirm his mathematical suspicions. he published these findings in 1963 and 1964, establishing the core logic of axial tomography, which hounsfield took to commercial completion. at the time of his momentous discovery he was working in the radiology department supervising the title: clinics in diagnostic imaging author: wilfred peh publisher: miller freeman price: uso 15 pages: 255 isbn 981 04 01337 this book consists of 30 case presentations with radiological images and a discussion with each case. the cases cover all important areas of imaging from head and neck to gynaecology. the images are of good quality. the discussions are excellent with current references. this book will be very useful for registrars preparing for the final fellowship examination. the university of pretoria is planning a congress for 10-12 february 2000. topic: "chest radiologyadult and paediatric" congress chairman: prof sf prinsloo venue: csir, pretoria tel: (012) 354-2406 please make a note of this in your diary if you are fax: (012) 329-6763 interested department of radiology,faculty of further details will he forthcoming medicine, university of pretoria, congress co-ordinator: dr ll sirkin po box 667,pretoria,oool advance notification of chest radiology congress 22 sa journal of radiology· february 1998 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) zakiyah gaibie division of urology, department of surgery, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of urology, helen joseph hospital, johannesburg, south africa department of paediatric urology, rahima moose mother and child hospital, johannesburg, south africa nasreen mahomed department of radiology, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa karen l. petersen division of paediatric nephrology, department of paediatrics and child health, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of paediatric nephrology, chris hani baragwanath hospital, johannesburg, south africa glenda moonsamy division of paediatric nephrology, department of paediatrics and child health, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of paediatric nephrology, charlotte maxeke academic hospital, johannesburg, south africa akram a.h. bokhari division of urology, department of surgery, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of urology, helen joseph hospital, johannesburg, south africa department of paediatric urology, rahima moose mother and child hospital, johannesburg, south africa department of urology, college of medicine, hail university, hail, saudi arabia department of urology, king fahad general hospital, jeddah, saudi arabia ahmed adam division of urology, department of surgery, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of urology, helen joseph hospital, johannesburg, south africa department of paediatric urology, rahima moose mother and child hospital, johannesburg, south africa citation gaibie z, mahomed n, petersen kl, et al. can the posterior:anterior urethral ratio on voiding cystourethrogram be used as a reliable predictor of successful posterior urethral valve ablation in male children?. s afr j rad. 2020;24(1), a1820. https://doi.org/10.4102/sajr.v24i1.1820 note: special collection: paediatric radiology. original research can the posterior:anterior urethral ratio on voiding cystourethrogram be used as a reliable predictor of successful posterior urethral valve ablation in male children? zakiyah gaibie, nasreen mahomed, karen l. petersen, glenda moonsamy, akram a.h. bokhari, ahmed adam received: 22 oct. 2019; accepted: 18 feb. 2020; published: 09 june 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the role of the voiding cystourethrogram (vcug) in the follow-up of children with posterior urethral valves (puvs) post-ablation has been considered a standard practice. the urethral ratio and gradient of change have proven to be useful. objectives: we aimed to review the role of the ‘ideal’ ratio on predicting residual puv post-ablation. methods: a systematic review of the pubmed, scopus and web of science databases was performed (april 2019). the search terms included ‘urethral ratio and posterior urethral valve ablation’. all cited reference lists were further evaluated for additional inclusive studies. results: eleven studies were identified, of which nine were relevant to the topic. case reports, comments and adult and animal studies were excluded, leaving four studies for critical review. in total, 338 patients were assessed. the control group consisted of 167 age-matched, male children. study regions included india and australia. the ages ranged from 15 days to 3.4 years. ablation methods included the use of a resectoscope with cutting diathermy, cold knife or bugbee electrode. the mean urethral ratios in the control group ranged from 1.04 to 1.73. the suggested predictive urethral cut-off ratios recommended include 2.2 (p = 0.001), 2.5–3 and 3.5. conclusion: although the precise cut-off ratio could not be clearly defined in this review, a urethral ratio less than a range of 2.2–3.5 has proven to be a beneficial predictor of ablation success and should thus be incorporated into standard vcug reporting templates in the follow-up of puvs in male children in resource-limited settings. keywords: posterior urethral valves; urethral ratio; posterior anterior urethral ratio; voiding cystourethrogram; golden ratio. introduction the role of the voiding cystourethrogram (vcug) in the follow-up of male children with posterior urethral valve (puv) ablation has been considered as standard practice in the treatment and follow-up algorithm. since 2006, the use of the posterior:anterior urethral ratio (pur) and gradient of change has proven to be beneficial.1,2,3,4 the urethral ratio is calculated on standard vcug images, as shown in figures 1a–d. in this systematic review, we aimed to determine the ‘ideal’ ratio and assess the role of this ratio in predicting residual puv in the follow-up of post-ablation male children. figure 1: on voiding cystourethrogram (vcu) the posterior urethra:anterior urethra ratio (par) was computed by dividing the maximum posterior urethral diameter by the anterior urethral diameter (in mm). distances were measured by an on-screen distance measurement tool in the radiology department, to avoid error. (a) normal voiding cystourethrogram – control: par = 6.02/4.85 = 1.24; (b) posterior urethral valve (puv) at the time of diagnosis: par = 12.7/3.3 = 3.84; (c) successful puv ablation: par = 5.32/4.62 = 1.15; (d) persistent obstruction because of a stricture or residual valve: par = 7.11/1.94 = 3.66. methods to illustrate and better define the role of calculating the urethral ratio as part of routine assessment during the reporting of the vcug study, a systematic review of the pubmed, web of science and scopus databases was performed in april 2019. the search terms ‘urethral ratio and posterior urethral valve ablation’ were utilised. the cited reference lists of studies were identified and deemed relevant and were further evaluated for additional inclusive studies assessing this parameter. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. results eleven studies were identified using search terms ‘urethral ratio and posterior urethral valve ablation’. there were 10 full-text reviews, of which two were animal studies, one was a case report, one was an adult study and two were letters to the editor; these were excluded (figure 2). the remaining four prospective studies in male children were evaluated in detail and the results are tabulated in table 1. figure 2: flow diagram demonstrating how the systematic review of the posterior:anterior urethral ratio on voiding cystourethrogram from the pubmed, web of science and scopus databases was performed. table 1: tabulation of studies assessed within this review. study regions included mumbai, chandigarh and chennai, india, as well as westmead, australia.1,2,3,4 in total, 338 patients with puvs were assessed. the control group consisted 167 patients, who were age-matched in most studies.1,2,3,4 the urethral ratios, for the control group, were calculated from vcugs being done as part of the workup for urinary tract infections (utis). the mean urethral ratios in these children ranged from 1.04 to 1.73.2,3,4 the median urethral ratio for the control group by bani hani1 was 2.6. the median age for male children with puvs ranged from 15 days to 13 months.1,2,4 menon et al.3 grouped patients into three groups on the basis of post-operative urethral ratios. group a consisted of patients whose post-operative urethral ratios were <2 sd from the control group mean, group b between 2 and 3 sd and group c >3 sd from the control mean urethral ratio. the mean age ranged from 10 months to 3.4 years. a single surgeon was used in three of the four studies to limit confounding factors.1,3,4 based on the surgeons’ preference and patient factors, the methods for ablation included the use of a resectoscope with cutting diathermy, cold knife or bugbee electrode.1,2,3 mean pre-operative ablation ratios ranged from 3.342 to 12.269. post-ablation ratios ranged from a mean of 1.026–3.69.2,3,4 other authors observed a median ratio of 8.6 preoperatively and 3.1 postoperatively.1 a total of 41 (12%) patients required a second ablation because of ongoing symptoms and residual valves.1,2,3,4 the urethral ratio prior to the second ablation ranged from a mean of 3.16 to 8.1,2,3,4 menon et al. demonstrated that in 50% of patients in whom the postoperative urethral ratio was >3 sd of the control group, repeat ablation was required. only 31.3% of patients in this group were asymptomatic. the cut-off ratios recommended include 2.2 (p = 0.001), 2.5–3, 3 and 3.5.1,2,3,4 method of ratio calculation all studies emphasise voiding films in oblique views. however, bani hani1 and gupta et al.2 measured the transverse diameter of the posterior urethra midpoint between bladder neck and distal membranous urethra which may not always be the point of maximal distension, whereas menon3 and babu4 used the maximum diameter of the posterior urethra. in addition, babu4 used an on-screen distance measuring tool. the anterior urethra transverse diameter was measured by all at the maximum distension of the bulbar urethra.1,2,3,4 meta-analysis a meta-analysis of the relevant data was precluded in this review study because the studies reviewed were performed by different surgeons, using different instruments, and were reported at different follow-up durations. discussion the prevalence of congenital puvs is 1 in 8000 in male children.5 posterior urethral valves account for one of the main causes of renal dysfunction in male children.6 posterior urethral valves cause bladder outlet obstruction because of an abnormality of the membranous urethra.7 diagnosis can be made on antenatal ultrasound. features include megacystis with a thickened bladder wall and poor emptying on 30-min ultrasound. the presence of oligohydramnios, echogenic kidneys, hydronephrosis and foetal ascites is indicative of a poor prognosis. diagnosis made before the end of the second trimester is associated with a higher perinatal mortality and end-stage renal disease.8 in south africa, post-natal diagnosis is made within the first year of life in most cases.9 this is in contrast to developed countries where the diagnosis is often made at antenatal visits. male children not only present with utis, palpable bladder and palpable kidney,9 but may also present with failure to thrive, dehydration, vomiting, fever, electrolyte imbalances and uraemia.8 male children over 5 years old may present with diurnal enuresis and obstructive urinary symptoms.8 the current suggested workup includes the following: renal function test and blood gas analysis urinalysis kidney-bladder ultrasound voiding cystourethrogram renal dynamic scan in male children older than a month (catheter to be left in situ if there is hydronephrosis) dimercaptosuccinic acid (dmsa) radionuclide scan to assess scarring in the presence of reflux. it is important that this scan is done 6 months after the last uti. primary management involves first stabilising the child, managing sepsis, obtaining adequate hydration, correcting electrolytes and relieving obstruction.8 once the child is optimised, definitive management is primary ablation of the urethral valves.8 urinary diversion has become less favourable with the availability of adequately sized resectoscopes, and the ability to primarily ablate valves in younger male children.9 children require close follow-up post-ablation. the aims of follow-up are to identify and manage voiding dysfunction early, monitor and optimise renal function, attain continence and minimise infections.8 recommended follow-up intervals are at 3, 6, 9 and 12 months post-ablation and then annually up to the age of 15, depending on the glomerular filtration rate (gfr). male children with chronic kidney disease (ckd) stages 4–5 are followed up more frequently. routine follow-up consists of urinalysis, urea, creatinine, electrolytes, uroflowmetry and ultrasound with measurement of any post-void residual urine volume.8 a routine vcug or cystoscope is done at 3 months post-ablation to assess structural anomalies of the bladder, posterior urethra and obstructive lesions such as residual valves and strictures.8 there is ongoing debate about the preferred method of assessment of valve ablation adequacy, regarding whether clinical, radiological or cystoscopic assessment is ideal. proponents for vcug argue against the need for invasive cystoscopy and general anaesthesia, while proponents for cystoscopy argue against the predictive value of vcug.10,11 international guidelines should be modified or adjusted depending on the resources of the country. routine post-operative cystoscopy on all patients is not feasible in a developing country. selecting patients on the basis of clinical and radiological parameters for referral for repeat cystoscopy may be necessary. in 10% – 30% of male children, there may be residual valves that require a second ablation. twelve per cent of patients in this review required repeat ablation. persistent symptoms of poor stream, nocturnal enuresis and persistent vesicoureteric reflux (vur) may be indicators of residual valves.12 younger age at ablation, echogenic kidneys, hydronephrosis and high-grade reflux preoperatively have been associated with residual valves.12 the urethral ratio has proven to be an objective and reproducible method in assessing the success of valve ablation.1,2 male children who showed normalisation of the urethral ratio had good clinical outcomes.3 there is a strong correlation with persistent symptoms and a urethral ratio >3 sd from the normal.3 indications for vcug include recurrent uti post-ablation, worsening creatinine, assessment for the presence and grade of vur, persistent or worsening hydro-ureteronephrosis (repeat done at 2, 5 and 10 years) or if further surgical management is being planned, that is, transplant, anti-reflux surgery or bladder augmentation.8 vesico-ureteric reflux is present in up to 50% of male children preoperatively, of which 60% persist postoperatively. high-grade reflux may require anti-reflux surgery, whereas low-grade reflux can be managed medically.8 bladder dysfunction persists in one-third of male patients and causes persistent hydronephrosis and vur.8 in one study, the shape, wall, reflux and diverticuli (swrd) score was found to be an objective tool in quantifying the severity of bladder dysfunction.13 the score was calculated on the basis of shape and wall of the bladder as well as the presence of reflux and diverticuli on cystograms taken during video-urodynamic studies. this had treatment and prognostic implications. scores >2 were found to be ‘hostile’ bladders requiring invasive intervention, whereas a score <2 was indicative of ‘compliant’ bladders or bladders with low-pressure detrusor overactivity that could be managed medically.13 bladder neck incision (bni) at the time of valve ablation has been proposed to improve outcomes of obstructive voiding symptoms post-ablation. this practice was previously abandoned as it was thought to cause incontinence, dry or retrograde ejaculation. however, a study by keihani et al.14 did not show ejaculatory dysfunction or incontinence at the follow-up assessments. ratios in anatomy have been explored in various previous reports. the concept of the ‘golden ratio’ is well known and has been derived from the fibonacci sequence, the numerical value being 1.618.15 over the years it has been studied and proven to represent the ‘settings’ of botanic structures, humans and their organ systems.15 we have reviewed a ratio in the context of the follow-up vcug. despite surgical intervention, renal outcomes may still be poor.9 in a retrospective study done by petersen et al.,9 34.8% of male children developed ckd despite early ablation. in a 5-year follow-up study done by uthup et al.,16 50% of patients were still symptomatic and 33% of patients had developed ckd and growth failure. mean time to development of end-stage renal disease was found to be 10.7 years post-ablation.6 conclusion the urethral ratio has proven beneficial in the international literature and should be incorporated into standard vcug reporting templates in the follow-up investigations of puv in male children. radiologists reporting on post-puv ablation vcug studies are requested to measure and report these ratios. a urethral ratio less than a range of 2.2–3.5 has been shown to be a beneficial predictor of ablation success. further prospective studies are required to better define an exact cut-off point, especially in resource limited settings. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bani hani o, prelog k, smith ghh. a method to assess posterior urethral valve ablation. j urol. 2006;176(1):303–305. https://doi.org/10.1016/s0022-5347(06)00562-3 gupta rk, shah hs, jadhav v, et al. urethral ratio on voiding cystourethrogram: a comparative method to assess success of posterior urethral valve ablation. j pediatr urol. 2010;6(1):32–36. https://doi.org/10.1016/j.jpurol.2009.05.009 menon p, rao kln, vijaymahantesh s, et al. posterior urethral valves: morphological normalization of posterior urethra after fulguration is a significant factor in prognosis. j indian assoc pediatr surg. 2010;15(3):80. https://doi.org/10.4103/0971-9261.71744 babu r, hariharasudhan s, ramesh c. posterior urethra: anterior urethra ratio in the evaluation of success following puv ablation. j pediatr urol [serial online]. 2016 [cited 2019 jun 19];12(6):385.e1–385.e5. available from: https://www.jpurol.com/article/s1477-5131(16)30120-6/fulltext#.xqm5vdmspli.mendeley. kumar s, fisk nm. distal urinary obstruction. clin perinatol. 2003;30(3):507–519. https://doi.org/10.1016/s0095-5108(03)00060-5 srivastava p. long term follow up result of posterior urethral valve management. joj urol nephrol [serial online]. 2018 [cited 2019 apr 01];5(1). available from: https://juniperpublishers.com/jojun/jojun.ms.id.555654.php. gordon l. urethral valves: an update. radiology. 1986;6(5):753–791. https://doi.org/10.1148/radiographics.6.5.3317550 sharma s, joshi m, gupta d, et al. consensus on the management of posterior urethral valves from antenatal period to puberty. j indian assoc pediatr surg. 2018;24(1):4. https://doi.org/10.4103/jiaps.jiaps_148_18 petersen kl, moore dp, kala uk. posterior urethral valves in south african boys: outcomes and challenges. s afr med j. 2018;108(8):667. https://doi.org/10.7196/samj.2018.v108i8.12934 yadav r, goel a, smeulders n, et al. the predictive value of a repeat micturating cystourethrogram for remnant leaflets after primary endoscopic ablation of posterior urethral valves. j pediatr urol. 2011;7(2):203–208. https://doi.org/10.1016/j.jpurol.2011.04.004 oktar t, salabas e, acar o, et al. residual valve and stricture after posterior urethral valve ablation: how to evaluate? j pediatr urol. 2013;9(2):184–187. https://doi.org/10.1016/j.jpurol.2012.01.016 shirazi m, farsiani m, natami m, izadpanah k, malekahmadi a, khakbaz a. which patients are at higher risk for residual valves after posterior urethral valve ablation? korean j urol. 2014;55(1):64–68. https://doi.org/10.4111/kju.2014.55.1.64 niyogi a, lumpkins k, robb a, mccarthy l. cystometrogram appearance in puv is reliably quantified by the shape, wall, reflux and diverticuli (swrd) score, and presages the need for intervention. j pediatr urol. 2017;13(3):265.e1–265.e6. https://doi.org/10.1016/j.jpurol.2016.12.005 keihani s, kajbafzadeh am, kameli sm, abbasioun r. long-term impacts of concurrent posterior urethral valve ablation and bladder neck incision on urinary continence and ejaculation. urology. 2017;99:278–280. https://doi.org/10.1016/j.urology.2016.09.036 yalta k, ozturk s, yetkin e. golden ratio and the heart: a review of divine aesthetics. int j cardiol. 2016;214:107–112. https://doi.org/10.1016/j.ijcard.2016.03.166 uthup s, binitha r, geetha s, hema r, kailas l. a follow-up study of children with posterior urethral valve. indian j nephrol. 2010;20(2):72. https://doi.org/10.4103/0971-4065.65298 case report large vein of galen malformation associated with an apical ventricular septal defect and a patent ductus • •arteriosus in an infant a case report abstract pszkup md a four month old male infant who had a transarterial embol ization of a large vein of galen malformation attempted is reported. the infant presented in cardiac failure and a hydrocephalus. in add ition the rare association of an apical ventricular septal defect and a patent ductus arteriosus with pulmonary hypertension was diagnosed. a staged transarterial coil embolisation using am cilliers mbbch, fcpaed (sa) divisions of radl%gy and paediatric cardl%gy, baragwanath hospita/, johannesburg. 28 sa journal of radiology. june 1997 microcoils was commenced. the first attempt was uneventful. this was fol lowed by the unfortunate demise of the patient from an intercurrent nosocomial pneumonia. introduction vein of galen malformations (vgm) are rare vascular anomalies in which a primary feature is the dilatation of the vein of galen which becomes dilated as a result of direct cerebral arterial connections bypassing the capillary network.' the cardiac output and venous return to the heart increases resulting in progressive heart failure and pulmonary hypertension. hydrocephalus may occur as a result of direct obstruction of the sylvian aqueduct by the malformation or a resorptive block of cerebrospinal fluid due to increased pressure within the sagittal sinus.' cranial bruits are audible in only a third of cases.' fewer than 300 cases of this anomaly have been reported between 1937 and 1994.2 case report a male infant presented to our institution at the age of four months with a history of cough and shortness of breath for eight days duration. clinical examination revealed a wasted infant in cardiac failure. in addition the patient had a large head (beyond the 97th centile for age) and a loud cranial bruit. the blood pressure was 70/50. biventricular hypertrophy was present clinically and a 3/6 pansystolic to page 29 large vein of galon nl;1lfoll11.ltion assoc.iarod ~ith an dpic<'ll vcruriculnr soptal defect arul (l patont ductus arteriosus ill é:hl infant <1 c;:lse report from page 28 murmur over the apex was audible. the liver measured 4 em below the right costal margin and the pulmonary component of the 2nd sound was loud indicating the presence of pulmonary hypertension. the chest radiograph showed a cardiothoracic ratio of 70% with biventricular enlargement and plethoric lung fields. right ventricular hypertrophy was the main feature electrographically. two dimensional echocardiography showed a 3 mm apical ventricular septal defect (vso), a 3 mm patent ductus arteriosus (pda) and severe pulmonary hypertension with an estimated pulmonary artery pressure of 70 mmhg. cardiac catheterization confirmed balanced pulmonary and systemic pressures with poor response of the pulmonary vasculature to the administration of oxygen. cranial ultrasonography (figure 1) and doppler flow studies revealed figure 1: sagittal view of the cranial ultrasound showing the vein of galen malformation and a dilated straight sinus. a vgm measuring 2.5 x 2.8 em draining into a dilated straight sinus. dilatation of the lateral and third ventricles was evident. preand postcontrast axial ct (figure 2) confirmed a vgm and mild hydrocephalus. cerebral angiography (figures 3 and 4) was performed via the transfemoral arterial route. there were major feeder arteries arising figure 2: contrast enhanced axial computerised tomography scan of the head showing the large vein of galen malformation, dilated straight sinus and mild hydrocephalus. from both the posterior cerebral arteries, both left and right middle cerebral arteries and the right anterior cerebral artery. other lesser arterial feeder arteries were apparent. despite medical treatment in the form of oxygen, digoxin and diuretics the patient remained in cardiac failure and failed to gain weight over the next month. in view of the major contribution of the cerebral pathology to the patient's morbidity it was decided to figure 3: lateral view of the cerebral angiogram showing multiple feeder vessels to the vein of galen malformation arising from the right middle cerebral artery and the anterior cerebral artery. 29 sa journal of radiology. june 1997 figure 4: lateral view of the cerebral angiogram showing muit/pie feeder vessels to the vein of galen malformation arising from the left middle cerebral artery. perform a staged transarterial embolization of the vgm. the first stage was performed under general anaesthesia and involved selective catheterization of a feeder artery to the malformation originating from the left middle cerebral artery. access to the feeder artery was accomplished using a fastracker 18mx micro catheter, together with dasher 14 and mach 16fix nitinol guidewires. the feeder artery was embolised (figure 5) with the placement of ten microcoils . the patient tolerated this first procedure well and suffered no complications. unfortunately before the second staged procedure could be attempted the patient demised from a nosocomially acquired pneumonia in the intensive care unit. permission for a post mortem examination was not granted. discussion congestive cardiac failure unresponsive to medical management in the infant is the primary indication for treatment.p the s vere cardiac failure and failure to thrive in our patient were the major motivational fa tors in attempting to treat the vgm. topage30 llrge vein of gellen rnalforrnation associated with dn apical ventricular septal defect and a palent duclus arteriosus in all infant a case report from page 29 figure 5: lsteral view of the left internal carotid artery angiogram following the embolisstion procedure showing microcails occluding the arterial feeder vessels to the vein of galen malformation. the cardiac lesions were deemed to be of minor significance not requiring treatment at the time. an endovascular approach was undertaken because of the lower anticipated mortality rate of 13%4, compared to a surgical approach.v" a staged transarterial occlusion was initiated to gradually reduce the flow through the fistula to control the cardiac failure, a partial occlusion frequently reverses the cardiovascular symptoms so that a complete occlusion may not be required.' a further rationale for a staged endovascular occlusion is to avoid "normal perfusion pressure breakthrough" which may occur with either a transveneusor transarterial approach in a large vgm le, the previously hypoperfused peripheral brain after embolisation of a large vgm may develop a sudden increase in blood flow associated with regional brain swelling and haemorrhage.' severe neurological damage may result. associated structural cardiac defects are rarely reported. pda,6,7,8 transposition of the great vessels," a vsd, and coarctation of the aorta? have been described. coarctation of the aorta may have a physiological explanation in that the developing foetus with an intracranial fistula has reduction of blood flow down the descending aorta which induces development of hypoplasia of the isthmus of the aorta." conclusion management of vein of galen aneurysmal malformations is a rare and challenging therapeutic problem for the neuroradiological interventionalist. while there is a higher risk of morbidity and mortality associated with a direct surgical approach, an endovascular approach has potential complications. cardiac lesions are rare associations and if significant may contribute substantially to the therapeutic dilemma. acknowledgements the authors wish to thank prof p fourie (pretoria heart hospital), prof rw urwin and prof van v hallbach (both from the department ofneurointerventional radiology, university of san francisco) for their advice in the management of the patient. 30 sa journal of radiology· june 1997 references i. musewe nn, burrows pe, culham jag and freedom rm. arteriovenous fistulae: a consideration of extracardiac causes of congestive cardiac failure. in: freedom rm, benson ln, smallhorn jf, eds. neonatal heart disease. london: springer-verlag, 1992: 759-772. 2. horowitz mb, jungries ca, quisling rg & pollack i. vein of galen aneurysms: a review and current perspective. ainr 1994; is: 1486-1496. 3. lylyk p, vinvela f, jacques e, df on e, duckwiter g, guglielmi g, peacock w, neil. therapeutic alternatives for the vein of galen vascular malformation. i neurosurg 1993; 78: 438-445. 4. lasjaunias p, rodesch g, terbrugge k, pruvost ph, devictor d, comoy j, landrieu p.vein of galen aneurysmal malformations: report of 36 cases managed between 1982 and 1988. acta neurochir 1989; 99: 26-37. 5. hoffman h, chvang s, hendrek e, humphreys r. aneurysm of the vein of galen. i neurosurg 1982; 57: 316-321. 6. eide j and foiling m. malformation of the great vein of galen with neonatal heart failure. a report of two cases. acta paediatr scand 1978; 67: 529-532. 7. kirsten gf, smith r, mckenzie j, kalis n and vermeulen. retrograde transtorenlar embolisation with thrombogenic coils of a vein of galen aneurysm in a neonate. cardiouasc i south afr 1993; 4: 160-163. 8. hirano a and solomon s. arteriovenous aneurysm of the vein of galen. arch neurol 1960; 3: 589-593. 9. tomlinson fh, piepgras dg, nichols da, ruffenacht da and kaste sc. remote congenital cerebral arteriovenous fistulae associated with aortic coarctation. i neurosurg 1992; 76: 137-42. 10. cumming gr. circulation in neonates with intracranial arteriovenous fistula and cardiac failure. am j cardiol1980; 45: 1019-1024. 8001< review pediatric neuroimaging savvas andronikou mb bch, fcrad(d), frcr (lond) department of paediatric radiology red cross children's hospital university of cape town and institute of child health by a james barkovich. third edition. philadelphia: lippincot, williams and wilkins, 2000. in his 3rd edition dr barkovich has provided us with a text that is not only a complete reference book, but also an easy read. i read the 800 pages from cover to cover as if they were an enjoyable novel, one section leading smoothly into the next. paediatric neuroimaging has never been this exciting! the setup is simple with a minimalist approach to chapter structure. to my delight whole chapters were dedicated to the controversial topic of hydrocephalus and the difficult subject of assessing age-related myelination. with regard to the latter, the author advises on the ideal imaging sequences and on the appropriate diagnostic landmarks for age. the chapter on toxic and metabolic diseases is complete and extensive but i was disappointed (perhaps with the subject matter or myself) in that, after studying the topic, i still have difficulty making diagnoses in practice. i had hoped that in this edition dr barkovich would have suggested a roadrnap for simplifying the approach to such conditions. there is, however, valuable embryologic and anatomic detail, which helped me to understand and approach congenital disease in a logical manner. also impressive is the simple description of new imaging techniques such as diffusion weighted imaging, magnetic resonance spectroscopy and magnetisation transfer. imaging features using these techniques are to be found throughout the text under the relevant pathologic processes. images are plentiful and are of the highest quality. they make the reading more enjoyable and more applicable to actual practice. little is left to the imagination as examples of almost all pathological entities in the field are represented. paediatric neuroimaging is now a detailed super-specialty that deserves dedicated radiologists and dedicated texts. i recommend this as an introductory reader, a learning text and a reference book useful to all dealing with this subject. barkovich's 3rd edition is cutting edge and complete. pediatric neuroimaging 3/e a. james barkovich thoroughly updated and substantially expanded, the third edition of this acclaimed reference covers the full range of pediatric diseases diagnosable by modern neuroimaging. coverage ranges from normal development to diseases and anomalies of the pediatric nervous system. most chapters include new diseases, as well as updates on entities previously described. this edition provides expanded coverage of the head and neck and significantly more information on inborn errors of metabolism. the chapter on normal development of the neonatal and infant brain, skull, and spine has been expanded to include fetal brain mri. this edition also includes new concepts on hypoxic-ischemic brain injury and malformations of cerebral cortical development. to facilitate fast, easy reference, this edition includes a "list of disorders," which lists the conditions discussed in each chapter and their corresponding page numbers. this new feature enables readers to quickly look up a disorder and is particularly helpful when a reader is unsure of the name of an entity. november 1999, 880 pp, 1192 illustrations, hardbound, lww, r2 990 orders: sa medical association, private bag x1, pinelands 7430. tel (021) 530-6527. fax (021) 531-4126. e-mail: fpalm@samedical.org please allow 4-6 weeks for delivery. prices subject to foreign exchange fluctuations. 52 sa journal of radiology. march 2002 mailto:fpalm@samedical.org for many the subject of vascular malformations remains shrouded in mystery and confusion resulting from a lack of understanding of the nature of the pathology compounded by the confusing nomenclature still associated with these lesions. for example, the term ‘haemangioma’ has been used to describe a variety of vascular lesions with different aetiologies and natural histories. names utilising a mixture of descriptive and histologic terms, such as ‘strawberry angioma’, ‘nevus flammus’, or ‘cavernous haemangioma’ still abound in current medical usage. the classification of vascular anomalies outside of the central nervous system (cns) is based on the seminal works of mulliken and glowacki.1,2 they divided vascular anomalies into those exhibiting rapid endothelial cell growth (proliferation) followed by a period of stabilisation (quiescence) and finally spontaneous involution, termed haemangiomas, and those having a rate of growth commensurate with the growth of the individual termed vascular malformations (vms). as opposed to haemangiomas, vms reach stability by adulthood or continue to grow by hypertrophy rather than cellular proliferation. the current classification of cns vascular anomalies remains primarily a pathoanatomically-based one and is based on the works of mccormick et al.3-5 and russel and rubenstein.6 in this review we will present a synopsis of cns and non-cns vascular anomalies based on the abovementioned classification schemes in the hope that this will dispel much of the confusion surrounding the subject of vascular malformations or anomalies. classification of cns vascular malformations the current classification is based on the pathoanatomic works of mccormick et al.3-5 and russel and rubenstein.6 this assumes vascular malformations to be congenital or developmental hamartomas rather than neoplasms, and is based on the microscopic and gross pathologic features of these lesions (table i). already confounding this classification is the identification of mixed malformation types,7 together with the identification of increased endothelial cell proliferation within cns vascular malformations further blurring the distinction between malformation (hamartoma) and tumour (proliferation).8 although intracranial arteriovenous shunts are similar angioarchitecturally to av shunts elsewhere in the body, the cerebral and spinal cavernous malformation (cavernoma) does not have a similar counterpart in the rest of the body. analysis of structural proteins within the wall of cavernomas shows these lesions to be developmentally immature unlike the walls of venous malformations elsewhere in the body. furthermore the so-called venous angiomas or developmental venous anomalies (dvas) of the brain actually represent persistent normal embryological venous drainage of regions of the brain rather than true vascular malformations.9 although most cns vascular malformations occur in isolation, some are found in association with cutaneous and mesodermal vascular anomalies. this mirrors the development of both the skin and nervous system from the ectodermal plate and neural crest of the early embryo, often review article 23 sa journal of radiology • may 2004 vascular malformations part 2 — current classification of vascular malformations ian c duncan ffrad (d) pieter a fourie m med rad(d) unitas interventional unit po box 14031 lytlelton 0410 table i. classification of cns vascular malformations arteriovenous shunts classical av malformations pial av fistulas dural av shunts galenic shunts cavernous malformations capillary telangiectasias venous malformations developmental venous anomalies mixed malformations also involving the adjacent subectodermal mesoderm. the most classic examples of such syndromes would include the wyburn-mason syndrome (or bonnet-dechaume-blanc syndrome) and the sturge-weber syndrome. the wyburn-mason syndrome is an association of cerebral (diencephalic), retinal and maxillofacial arteriovenous malformations, hence its alternative name of ‘unilateral retinocephalic vascular malformation’.10 recognition of the metameric nature of this disorder has led to a revised classification of such craniofacial vascular malformation syndromes as the cerebrofacial arteriovenous metameric syndromes (cams).11,12 a similar developmental metameric distribution would also explain the development of the rare type iii or juvenile spinal avm syndromes (cutaneomeningospinal angiomatosis, cobb syndrome), now termed the spinal arteriovenous metameric syndromes (sams).13 the sturge-weber syndrome, also ‘encephalo-trigeminal angiomatosis’, involves capillary-venous malformations of the brain, usually affecting a single cerebral hemisphere, associated with retinal vascular malformations and cutaneous facial capillary malformations (previously nevus flammeus, cutaneous angioma or port-wine stain). again the association of a telencephalic venous malformation with facial involvement usually within the v1 distribution suggests a venous metameric syndrome (cerebrofacial venous metameric syndrome (cvms) — lasjuanias, personal communication). however, often the cutaneous malformation involves the v2 or v3 distributions as well or may even extend to the neck and upper trunk, thus showing a spectrum of expressivity. forty-five per cent of children having v1 and v2 involvement will develop glaucoma due to associated venous malformations affecting the canal of schlemm or other disruption of the ocular venous drainage.14 other associations between cns and other vascular malformations include the association of craniofacial vascular malformations such as cutaneous capillary malformations and venous and lymphatic malformations with intracranial dvas,15,16 and the heritable association between cerebral cavernous malformations and cutaneous or other systemic venous malformations.17,18 finally there is the development of cns arteriovenous malformations as part of the spectrum of multisystemic vascular malformation development in hereditary haemorrhagic telangiectasia.19 these associations with non-cns vascular malformations suggest a particular phenotypic expression peculiar to the environment of the brain and spinal cord of the same underlying vascular malformative processes found elsewhere in the body, hinting that the classic pathoanatomical classification of cns vascular malformations may well later be revised along more biologically-orientated lines.20 non-cns vascular malformations as mentioned above the current classification of these disorders as adopted by the international society for the study of vascular anomalies (issva) is that described by mulliken and glowacki. initially they differentiated between true vascular malformations and haemangiomas, based upon endothelial cell growth characteristics.1 haemangiomas show initial rapid endothelial cell proliferation more typical of a tumour followed later by variable spontaneous regression in many cases. conversely vms show no (or rather minimal) endothelial cell proliferation and are characterised by a growth rate commensurate with the rate of growth and development of the child. they then divided the vms into high-flow (arteriovenous shunts) and low-flow vms. the low-flow vms were further subdivided according to their histological origins into the capillary, venous, lymphatic or mixed malformations (table ii). haemangiomas the term haemangioma has traditionally been used as a generic term to describe a large variety of vascular lesions with different aetiologies.1 currently the term haemangioma is restricted to a distinct proliferative lesion of early childhood being more a tumour than a vascular malformation. haemangiomas are the most common vascular tumour, with an incidence of 1 2.6%.21 thirty-three review article 24 sa journal of radiology • may 2004 table ii. classification of non-cns vascular malformations haemangiomas (proliferative lesions or tumours) vascular malformations (non-proliferative) high flow • arteriovenous malformations low flow: • capillary malformations • venous malformations • lymphatic malformations • mixed malformations review article 25 sa journal of radiology • may 2004 to 40% of lesions are apparent at birth, with 70 90% appearing during the first 4 weeks of life and none beyond the age of 5 years. haemangiomas may be superficial (cutaneous), deep (covered by normal overlying skin) or visceral.22 they can occur in any race, but are more common in girls (3:1), light-skinned whites and premature infants (20%) especially those with a birth weight < 1500 g.23 the superficial cutaneous lesions tend to show a bright red colour initially that deepens during the first year of life (fig. 1a). haemangiomas tend to show a firm, rubbery consistency compared with venous malformations that are compressible.22 the prevalence of haemangiomas is approximately 1 3% of neonates, increasing to about 10% of white children and 1.4% of black children at 1 year of age.21 sixty percent of haemangiomas occur in the head and neck region, with 25% on the trunk and 15% on the extremities. occasionally they may involve oral or genital mucosa. in about 15 20% of cases the lesions are multiple (benign neonatal haemangiomatosis). they initially present with an erythematous patch or pink macule often referred to as a ‘herald spot’. they then undergo a proliferative (growth) phase of 3 12 months followed by a variable plateau or stabilisation phase and finally by a phase of involution. all lesions inevitably show some degree of spontaneous involution or regression.1,22 approximately 30% of infantile haemangiomas will regress by the third birthday, about 50% by the fifth, and 70% by the seventh.24,25 if a haemangioma fails to show evidence of regression by 5 6 years of age, then it is unlikely to regress completely. lesions exhibiting early changes of involution are associated with more rapid disappearance and a better cosmetic result. regression is heralded by the appearance of white streaks (fibrosis) on the surface of the lesion. occasionally haemangiomas may ulcerate or bleed or develop secondary infections, mainly during the proliferative phase.22 the tumour in the proliferative phase is characterised by endothelial cell proliferation producing plump, hyperplastic endothelial cells together with a variable number of mast cells. during the involutional phase there is a conversion from proliferation to apoptosis of the endothelial cells with progressive deposition of perivascular and interlobular fibrous tissue.26 an increase in basic fibroblast growth factor (bfgf), proliferating cell nuclear antigen, type iv collagenase, e-selectin and monocytic chemoattractant protein is seen during the proliferative phase, whereas during the involutive phase there is an increase in metalloproteinase tissue inhibitor and a fall in bfgf levels.27 bfgf can thus be used as marker to assess the cessation of proliferation and onset of involution. most haemangiomas are recognised clinically. imaging is only required in cases where there is diagnostic uncertainty or where intervention is required. ultrasound (with doppler) will rapidly distinguish solid haemangiomas from vascular malformations. computed tomography (ct) and magnetic resonance imaging (mri) will help to assess the depth and extent of lesions. angiography, while showing a characteristic homogeneous contrast blush without evidence of av shunting, should rather be reserved for therapeutic purposes.27 in most cases no treatment is required because of spontaneous regression. however 10 20% of lesions will require treatment because of impending (or established) loss of function or a threat to life (fig. 1b). treatment for cosmetic reasons alone is a controversial indication given the natural history of these lesions. more often than not the parents are more affected by appearance than the children themselves except as the children approach school age. examples of indications for active treatment (i.e. ‘alarming’ fig. 1a. small cutaneous haemangioma on the cheek of an infant. fig. 1b. large maxillary and periorbital cutaneous haemangioma. its anatomical position threatens the function of the eye. review article 26 sa journal of radiology • may 2004 haemangiomas) would include:27,28 (i) periocular lesions threatening vision; (ii) lesions obstructing the airway; (iii) large lesions associated with high-output cardiac failure; (iv) facial lesions with rapid growth and distortion; (v) lesions with severe persistent cutaneous ulceration or haemorrhage (fig. 1c); and (vi) kasabach-merritt syndrome. the kasabach-merritt phenomenon or syndrome, first described in 1940, consists of very large haemangiomas complicated by severe thrombocytopoenia, microangiopathic haemolytic anaemia and consumption coagulopathy. it is seen most frequently in young infants during the first week of life and carries a mortality of 20-30%, thus requiring aggressive treatment when recognised. multiple cutaneous haemangiomas may rarely co-exist with visceral haemangiomas in a condition termed ‘diffuse neonatal hemangiomatosis’ or ‘disseminated haemangiomatosis’. visceral lesions may be found in the liver, git, spleen, pancreas, adrenals, lungs, heart, skeleton, muscle, salivary glands, kidney, bladder, testes, thymus, thyroid, bone, meninges, brain and eyes. the mortality rate is high, with extensive visceral involvement mainly during the first months of life and mainly due to high-output cardiac failure.22 large facial haemangiomas may be associated with posterior fossa brain malformations, arterial developmental anomalies, cardiac anomalies, aortic coarctation and eye anomalies in the phace syndrome, a strange association of proliferative and non-proliferative vascular anomalies.29,30 medical treatment for haemangiomas includes local and systemic steroids, interferon α-2a and α-2b, and pentoxifylline. other options include intralesion injection of sclerosing agents, cryotherapy, laser therapy, embolisation, radiation therapy and surgical excision.21,22 several groups, including the pretoria vascular malformation group, have reported successes in treating haemangiomas using the antiangiogenic properties of the antimitotic antibiotic derivative bleomycin.31 other treatment types used when other methods have failed included vincristine or radiation therapy. arteriovenous (high-flow) malformations arteriovenous malformations (avms) are high-flow lesions with direct communications between an artery (or arteries) and a vein (or veins) bypassing the capillary bed (fig. 2). the term ‘arteriovenous fistula’ is often reserved for direct single hole communications usually related to trauma or other acquired condition, whereas the term ‘arteriovenous malformation’ should be reserved for congenital lesions.32 they are much less common than low-flow malformations and often become symptomatic following trauma (including biopsy) or around puberty. clinically they can present as a pulsatile mass with a thrill, bruit and occasionally local hyperthermia, skeletal overgrowth, trophic changes with ulceration or bleeding, congestive heart failure or functional impairment due to arterial steal and ischaemia. the diagnosis is generally made clinically with deep lesions identified as being highflow with the aid of doppler ultrasound. ct, mri and angiography are all used to assess the extent of a lesion during the planning of therapy. avms are the most difficult and dangerous lesions to treat, and for this reason quiescent avms should be followed clinically, with treatment delayed until complications such as pain, ulceration, haemorrhage or cardiac failure intervene.21 treatment options include direct percutaneous and transarterial embolisation and surgical excision, with the treatment best left to those specialists well versed in the management of such lesions. fig. 1c. ulceration of scalp haemangioma. fig. 2. high-flow (arteriovenous) malformation of the scalp. this composite digital subtraction angiogram combines both the arterial and venous phases in one image. review article 27 sa journal of radiology • may 2004 venous malformations venous malformations (vms), often incorrectly termed cavernous haemangiomas, are low-pressure, low-flow malformations. they are present at birth, although not always visible at that stage, and undergo slow growth commensurate with the growth of the child.1,27 vms are soft, compressible, non-pulsatile masses that expand after a valsalva’s manoeuvre or in a dependent position. they have a bluish colour often with normal overlying skin (figs 3a, b). forty per cent are found in the head and neck region, 20% on the trunk and 40% on the extremities. vms can be superficial (cutaneous) or occur in buccal and intestinal mucosa and in other organs. sudden enlargement can occur after trauma, haemorrhage, surgery, or with hormonal changes. vms can become painful due to the development of thrombophlebitis or in cases with muscular or articular involvement. calcified phleboliths may be present in the lesions, hence the previous term phlebangioma. ultrasound features include low (or absent) flow and compressibility of the widened vascular spaces. in some lesions a biphasic flow pattern suggests the presence of a mixed malformation such as a capillary-venous or lymphatico-capillary-venous malformation.33 ct and mri are useful in delineating the full extent of the lesion.21,34 there is no role for angiography although direct puncture venography may be useful in documenting the extent of a lesion and pattern of its draining veins. vms may be associated with other anomalies as a component of several complex syndromes such as: (i) blue rubber bleb nevus syndrome or bean syndrome; (ii) maffucci’s syndrome; (iii) klippel-trenaunay syndrome; or (iv) gorham’s syndrome (gorhamstout syndrome). the blue rubber bleb nevus syndrome is a rare condition consisting of multiple vms involving several organ systems, especially the skin and git. most cases are sporadic, but some are inherited with an autosomal dominant inheritance pattern.35,36 the skin lesions are present at birth but other lesions only become apparent later in life. the klippel-trenaunay syndrome (kts) is a complex constellation of vms including abnormal development of the normal deep and superficial limb venous drainage, lymphatic malformations and limb asymmetry (hemi-hypertrophy).37 the lower limb is most commonly affected, rarely affecting the upper limb or both upper and lower limbs. the hypertrophy is mainly due to muscle hypertrophy, thickened skin and subcutaneous fat and occasionally lymphoedema. there is usually relatively little increase in bone size.36 this indicates a combined ectodermal and mesodermal maldevelopment. deep venous thrombosis (dvt) and pulmonary embolism are common in patients with kts. a variation of kts where limb hemihypertrophy is associated with a high-flow avm within the affected limb and also in other organ systems is the parkes-weber syndrome.20 vms may be associated with osseous abnormalities e.g. in maffucci’s syndrome and the gorham-stout syndrome. vms may be associated with a low-grade consumption coagulopathy.27,36,38,39 therefore prior to any intervention a full assessment of coagulability is required. as many vms are asymptomatic no treatment other than reassurance may be necessary in many cases. discomfort due to localised lesions may respond to external compression, e.g. with elasticated stockings. more aggressive treatment is indicated in lesions producing pain, discomfort, significant cosmetic disturbance or functional impairment. this generally involves either percutaneous sclerotherapy or surgical excision. percutaneous sclerotherapy involves the use of a number of agents including absolute alcohol, ethibloc, sodium morrhuate, sodium tetradecyl sulphate and fig. 3a. small venous malformation of an upper lip. note the characteristic bluish colouration. fig. 3a. large venous malformation of a lower limb. no leg length discrepancy was noted. review article 28 sa journal of radiology • may 2004 sotradecal.27,33,40-44 intralesional bleomycin injections have also recently been shown to be effective in treating vms.31,45 capillary malformations cutaneous capillary malformations (also termed port-wine stains or nevus flammeus) are due to ectatic vessels within the upper dermis. they are present at birth with an equal sex distribution. the are flat sharply demarcated lesions that are pink during infancy deepening in colour to red in young adulthood and purple in middle age.21 forty-five per cent of facial lesions are restricted to one of the three trigerminal sensory areas, whereas 55% overlap dermatomes, cross the midline or occur bilaterally.46 the malformation may extend over the trunk or extremities. port-wine stains are often associated with numerous malformative syndromes. the best known of these is the sturgeweber syndrome where they are associated with cerebral capillary-venous malformations (resulting in the socalled angiomatous lesions of the leptomeninges), retinal angiomas, cerebral atrophy and cortical calcifications. vms may also be found in other organs, and sturge-weber syndrome may also occur in association with klippel-trenaunay syndrome.36 clinically these patients develop seizures that are difficult to control medically, hemiparesis, hemisensory deficit, homonymous hemianopia and mental retardation. although the strict definition of sturge-weber syndrome includes vms of the brain, eye and upper facial skin, the disorder can present with considerable variation in expressivity, with skin lesions frequently covering the entire face, neck, trunk and extremities. overgrowth of facial soft-tissues and facial bones may occur under the area of the port-wine stain, although this overgrowth is rarely seen in black patients.14 other variations include the occurrence of facial skin lesions with ocular anomalies but without the intracranial abnormalities, or where the leptomeningeal angiomatosis occurs without the port-wine stain.47,48 portwine stains may also be found in association with a number of other congenital syndromes including cobb syndrome (spinal metameric arteriovenous malformation), wyburnmason syndrome (cams 2), von hippel-lindau disease, proteus syndrome, roberts’s syndrome and thranbocytopenia-absent radius (tar) syndrome.36 treatment of the port-wine stains includes dermabrasion, tattooing, laser and surgery. hereditary haemorrhagic telangiectasia is an inherited multisystemic vascular dysplasia syndrome in which the most commonly encountered vms are mucocutaneous capillary telangiectasias. (figs 4a-d).49-51 patients may also develop avms of the brain, spinal cord, lungs and liver. lymphatic malformations there are two types of lymphatic malformations (lms), firstly abnorfig. 4b. mucosal telangiectasias seen in the duodenum at endoscopy. fig. 4a. mucocutaneous telangiectasias on the tongue of a patient with hereditary hemorrhagic telangiectasia (hht). fig. 4c. selective facial arterial digital subtraction arteriogram showing multiple enhancing telangiectasias in the nasal mucosa of the same patient. fig. 4d. nasal endoscopic view showing multiple nasal telangiectasias seen through a septal perforation that has resulted from repeated surgical procedures for intractable epistaxis. review article 29 sa journal of radiology • may 2004 malities of lymph vessels and nodes leading to inadequate clearance of lymph (primary lymphoedema), and secondly solitary or multiple cystic lymphatic malformations.52 lms occur either due to defective origin of lymphatics together with the venous system or abnormal development of the lymphatics themselves. cystic lms result from sequestered lymphatic sacs that fail to communicate with normal lymphatic vessels.33 most (7080%) occur in the head and neck region where they tend to be more cystic. these were previously referred to as cystic hygromas (fig. 5a). twenty per cent of cystic lms are found in the axilla, with other uncommon sites being the superior mediastinum, mesentery, retroperitoneum, pelvis and extremities. cystic lms can be subdivided into macrocystic, microcystic and mixed types. microcystic lms were previously called lymphangiomas. although present at birth, cystic lms become clinically apparent later in life, usually before 2 years of age.33 sudden enlargement may be due to bleeding or inflammation.21 lms may be associated with a number of syndromes including turner’s syndrome, noonan’s syndrome, multiple pterygium syndrome, fetal alcohol syndrome, klinefelter's syndrome, down's syndrome, and klippel-trenaunay and parkes-weber syndromes.33,53 treatment is again dependent on the presence of functional impairment or cosmetic defect (fig. 5b). an upper respiratory tract infection may frequently cause enlargement of head and neck lms that may compromise the airway. macrocystic lesions are probably best treated with percutaneous sclerotherapy. various agents have been used including alcohol, ethibloc, hypertonic glucose, bleomycin, triamcinolone and more recently ok-432.27,31 microcystic lms have a high risk of recurrence after surgery and therefore conservative management is recommended for quiescent lesions.33,54 mixed vascular malformations given the common vasculogenic origin of arteries, capillaries, veins and lymphatics it is hardly surprising that mixed or combined malformation types occur.55 combinations include capillary-venous (e.g. sturge-weber) arteriovenous, lymphaticovenous, capillary-lymphatic, capillary-arteriovenous (parkes-weber), capillaryvenous-lymphatic (klippel-trenaunay) and more complex combined forms. conclusion mulliken and glowacki1 wrote: ‘a classification is clinically appropriate only when it provides clinicians with a common language through which ideas can be exchanged. a classification is necessary because there is such a large list of clinical congenital vascular lesions with a complex variability in signs, symptoms, and clinical behaviour. each lesion has its own little story of happiness or grief, particularly as to whether it will require conservative or aggressive management and whether it will become acceptable with this form of treatment. therefore we must continue to strive for an easy yet efficient method of labelling our patients’ problems’.1 a good working classification of any group of pathologies should thus be ‘a comprehensive and clinically relevant means of simply and uniformly describing (vascular) anomalies that occur within any human organ system’.20 each of the classification systems described above (cns and non-cns) is simple and easy to understand and follow, although each is far from complete. there are still lesions that do not comfortably fit into these classifications such as the hepatic cavernous haemangioma and the spinal osseous haemangioma, both of which are technically low-flow vascular malformations. and what of the aneurysmal bone cyst? these classifications will certainly change with a more thorfig. 5a. macrocystic lymphatic malformation of the neck. previously termed cystic hygroma. fig. 5b. lymphatic malformation of the upper lip. review article 30 sa journal of radiology • may 2004 ough understanding of the genetic and molecular biology underlying the development of vms, but for now they will suffice. references 1. mulliken jb, glowacki jg. hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. plast reconstr surg 1982; 69: 412-420. 2. mulliken jb, young ae. vascular birthmarks: hemangiomas and malformations. philadelphia: wb saunders. 1988. 3. mccormick wf. pathology of vascular malformations in the brain. in: wilson cb, stein bm eds. intracranial arteriovenous malformations. baltimore: williams and wilkins, 1984: 44-63. 4. mccormick wf. the pathology of vascular (‘arteriovenous’) malformations. j neurosurg 1966; 24: 807-816. 5. mccormick wf, hardman jm, boulter tr. vascular malformations (‘angiomas’) of the brain, with special reference to those occurring in the posterior fossa. j neurosurg 1968; 28: 241251. 6. russel ds, rubenstein lj. pathology of tumours of the nervous system. 3rd ed. b a l t i m o r e : williams and wilkins, 1971: 93102. 7. awad ia, robinson jr, mohanty s, estes ml. mixed vascular malformations of the brain: clinical and pathological considerations. neurosurgery 1993; 33: 179-188. 8. sure u, butz n, schlegal j, et al. endothelial proliferation, neoangiogenesis, and potential de novo generation of cerebrovascular malformations. j neurosurg 2001; 94: 972-977. 9. lasjaunias p, burrows p, planet c. developmental venous anomalies (dva): the so-called venous angioma. neurosurg rev 1986; 9: 233242. 10. theron j, newton th, hoyt wf. unilateral retinocephalic vascular malformations. neuroradiology 1974; 7: 185-196. 11. bhattacharya jj, luo cb, suh dc, alvarez h, rodesch g, lasuanias p. wyburn-mason or bonnet dechaume-blanc as cerebrofacial arteriovenous metameric syndromes (cams): a new concept and a new classification. interventional neuroradiology 2001; 7: 5-17. 12. wong iyc, barista ll, alvarez h, lasjaunias pl. craniofacial arteriovenous metameric syndrome (cams) 3 a transitional pattern between cam 1 and 2 and spinal arteriovenous metameric syndromes. neuroradiology 2003; 43: 611-615. 13. willinsky ra. spinal cord arteriovenous malformations. in: marks mp, do hm, eds. endovascular and percutaneous therapy of the brain and spine. philadelphia: lippincott willliams and wilkins, 2002: 415-448. 14. mulliken jb. capillary (port-wine) and other telangiectatic stains. in: mulliken jb, young ae, eds.vascular birthmarks: hemangiomas and malformations. philadelphia: wb saunders, 1988: 170-195. 15. lasjaunias p. venous anomalies and malformations. in: lasjaunias p, terbrugge k, eds. vascular disease in neonates, infants and children. berlin: springer, 1997: 445-471. 16. boukobza m, enjolras o, guichard jp, et al. cerebral development venous anomalies associated with head and neck venous malformations. am j neuroradiol 1996; 17: 987-994. 17. brouillard p, vikkula m. vascular malformations: localized defects in vascular morphogenesis. clin genet 2003; 63: 340-351. 18. vikkula m, boon lm, mulliken jb. molecular genetics of vascular malformations. matrix biol 2001; 20: 327-335. 19. shovlin cl. genetic aspects of cerebrovascular malformations. interventional neuroradiology 2000; 6: 107-111. 20. chaloupka jc, huddle dc. classification of vascular malformations of the central nervous system. neuroimaging clin n am 1998; 8: 295-321. 21. van aalst ja, bhullar a, sadove am. pediatric vascular lesions. j craniofac surg 2003; 14: 566583. 22. requina l, sangueza op. cutaneous vascular proliferations part ii: hyperplasias and benign neoplasms. j am acad dermatol 1997; 37: 887919. 23. chiller kg, passaro d, freiden ij. hemangiomas of infancy: clinical characteristics morphologic subtypes, and their relationship to race, ethnicity and sex. arch dermatol 2002; 138: 1567-1576 24. bowers re, graham ea, tomlinson km. the natural history of the strawberry nevus. arch dermatol 1960; 82: 667-680. 25. nakayama h. clinical and histological studies of the classification and the natural course of the strawberry mark. j dermatol 1960; 82: 667-680. 26. razon mj, kraling bm, mulliken jb, bischoff j. increased apoptosis coincides with onset of involution of infantile hemangioma. microcirculation 1998; 5: 189-195. 27. dubois j, garel l. practical aspects of intervention in vascular anomalies in children. semin intervent radiol 2002; 19: 73-87. 28. enjolras o, riche mc, merland jj, escande jp. management of alarming hemangiomas in infancy: a review of 25 cases. pediatrics 1990; 85: 491-498. 29. metry dw, dowd cf, barkovich aj, freiden jj. the many faces of phace syndrome. j pediatr 2001; 139: 117-123. 30. frieden if, reese v, cohen d. phace syndrome. the association of posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. arch dermatol 1996; 132: 307-311. 31. muir t, kirsten m, fourie p, dippenaar n, ionesco go. intralesonal bleomycin injection (ibi) treatment for haemangiomas and congenital vascular malformations. pediatr surg int 2004; 19: 766-773 32. young ae. arteriovenous malformations. in: mulliken jb, young ae, eds. vascular birthmarks: hemangiomas and malformations philadelphia: wb saunders, 1988: 228-245. 33. trop i, dubois j, guibard l, et al. soft-tissue venous malformations in pediatric and young adult patients: diagnosis with doppler us. radiology 1999; 212: 841-845. 34. dubois j, garel l. imaging and therapeutic approach of hemangiomas and vascular malformations in the pediatric age group. pediatr radiol 1999; 29: 879-893. 35. kassarjian a, fishman sj, fox vl, burrows pe. imaging characteristics of blue rubber bleb nevus syndrome. radiology 2003; 181: 10411048. 36. reqena l, sangueza op. cutaneous vascular anomalies. part i: hamatomas, malformations and dilatation of pre-existing vessels. j am acad dermatol 1997; 37: 523-549. 37. berry sa. peterson c, mize w, et al. klippeltrenaunay syndrome. am j med genet 1998; 79: 319-326. 38. enjolras o, mulliken jb. vascular tumours and vascular malformations (new issues). adv dermatol 1998; 13: 375-423. 39. enjolras o, ciabrini d, mazoyer e, lauriane c, herbreteau d. extensive pure venous malformations in the upper of lower limb. a review of 27 cases. j am acad dermatol 1997; 36: 219-225. 40. lasjaunias p, berenstein a. craniofacial hemangiomas, vascular malformations and angiomatosis. in: lasjaunias p, berenstein a, eds. surgical neuroangiography vol 2: endovascular treatment of craniofacial lesions. berlin, springer-verlag 1987: 341-397. 41. pappas dc, perskey ms, berenstein a. evaluation and treatment of head and neck venous vascular malformations. ear nose throat 1998; 77: 914-922. 42. berenguer b, burrows pe, zurakowski d, mulliken jb. sclerotherapy of craniofacial venous malformations: complications and results. plast reconstr surg 1999; 104: 1-11. 43. de lorimier aa. sclerotherapy for venous malformations. j pediatr surg 1995; 30: 185-194. 44. suh js, shin kh, na jb, won jy, hahn sb. venous malformations: sclerotherapy with a mixture of ethanol and lipiodol. cardiovasc intervent radiol 1997; 20: 268-273. 45. wang c, gao q, fu f, et al. treatment of hemangioma in oral and maxillofacial region with pingangmycin injection (abstract). hua xi kou qiang yi xue za zhi 2000; 18: 317-319. 46. enjolras o, riche mc, merland jj. facial portwine stains and sturge-weber syndrome. pediatrics 1985; 76: 48-51. 47. jacobs ah. sturge-weber syndrome without port-wine nevus. pediatrics 1977; 60: 785-786. 48. crosley cj, binet ef. sturge-weber syndrome: presentation as a focal seizure without nevus flammeus. clin pediatr 1978; 17: 606-609. 49. guttmacher ae, marchuk da, white rj. hereditary hemorrhagic telangeictasia. n engl j med 1995; 333: 918-924. 50. pau h, carney as, murty ge. hereditary haemorrhagic telangiectasia (osler-weber-rendu syndrome): otorhinolaryngological manifestations. clin otolaryngol 2001; 26: 93-98. 51. begbie me, wallace gmf, showlin cl. hereditary haemorrhagic telangiectasia (oslerweber-rendu syndrome): a view from the 21st century. postgrad med j 2003; 79: 18-24. 52. young ae, stewart g. lymphatic malformations in: mulliken jb, young ae, eds. vascular birthmarks: hemangiomas and malformations. philadelphia, wb saunders 1988: 215-227. 53. greenlee r, hoyme h, witte m, crowe p, witte c. developmental disorders of the lymphatic system. lymphology 1993; 26: 156-168. 54. sanlialp i, karnak i, tanyel fc, senocak me, buyukpamukcu n. sclerotherapy for lymphangioma in children. int j pediatr otorhinolaryngol 2003; 67: 795-800. 55. young ae, ackroyd j, baskerville p. combined vascular malformations. in: mulliken jb, young ae, eds. vascular birthmarks: hemangiomas and malformations. philadelphia. wb saunders, 1988: 246-274. abstract introduction discussion conclusion acknowledgements references about the author(s) raihaan m. ally private practitioner, pretoria, south africa mark d. velleman department of radiology, university of pretoria, pretoria, south africa farhana e. suleman department of radiology, university of pretoria, pretoria, south africa citation ally rm, velleman md, suleman fe. meralgia paresthetica: now showing on 3t magnetic resonance neurography. s afr j rad. 2019;23(1), a1745. https://doi.org/10.4102/sajr.v23i1.1745 clinical perspective meralgia paresthetica: now showing on 3t magnetic resonance neurography raihaan m. ally, mark d. velleman, farhana e. suleman received: 18 mar. 2019; accepted: 12 may 2019; published: 21 aug. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract meralgia paresthetica is a neuropathy of the lateral femoral cutaneous nerve. traditionally, the diagnosis is based on classical symptoms and signs. in cases where there is a diagnostic dilemma, the role of magnetic resonance imaging has been to exclude other causes for the patient’s presentation, as the small extraspinal peripheral nerves were not well visualised at imaging. the development of 3-tesla magnetic resonance neurography, however, has made pathology of these nerves more conspicuous. keywords: meralgia paresthetica; lateral femoral cutaneous nerve; neuropathy; magnetic resonance neurography; fluid-sensitive sequences. introduction meralgia paresthetica is a peripheral neuropathy of the lateral femoral cutaneous nerve (lfcn). the diagnosis is based on the classical symptoms and clinical findings of pain, an unpleasant sensation, numbness and paraesthesia on the anterolateral aspect of the thigh.1 occasionally, the condition may mimic other entities, causing clinical confusion and further investigation may be needed to confirm the diagnosis.2 traditionally, the small peripheral nerves have been difficult to assess on magnetic resonance imaging (mri), but the development of 3-tesla (3t) magnetic resonance neurography (mrn) now makes the pathology of these nerves more conspicuous.3,4,5 discussion the lfcn is a purely sensory nerve that may arise from the lumbar nerve roots of l3 alone or in a variable combination of l1, l2 and l3.4 it emerges from the lateral aspect of the psoas muscle and crosses the anterior surface of the iliacus muscle across the ilium towards the anterior superior iliac spine (asis). it enters the thigh by passing above, below or through the inguinal ligament (figure 1).4 figure 1: diagram illustrating the anatomy of the lateral femoral cutaneous nerve. meralgia paresthetica is a neuropathy of the lfcn that presents with characteristic symptoms and clinical findings. the combined symptoms of pain, numbness and tingling with clinical findings of paraesthesia in the anterolateral thigh is usually typical.1,4 the condition may be spontaneous or iatrogenic.1,6 spontaneous development can occur at any age but most commonly occurs in the 30–40-year age group.1 there is no consensus about gender predilection in the literature.4 spontaneous causes may be idiopathic, metabolic or due to mechanical compression.1 it is most vulnerable to mechanical compression at its most superficial point where it crosses the inguinal ligament.4 the wearing of tight clothing, belts and corsets, as well as causes of increased intraabdominal pressure such as pregnancy and obesity, may exert direct pressure on the nerve, resulting in an entrapment neuropathy.1,2,3,4 metabolic causes are associated with diabetes mellitus, alcoholism, lead poisoning and hypothyroidism.1,2 iatrogenic causes include various orthopaedic surgical procedures such as iliac-crest bone graft procedures, anterior pelvic surgery, prone position for spinal surgical procedures and total hip arthroplasty.1,4 anatomical variations of the lfcn occurs in up to 25% of patients and contributes to increased risk of damage during surgery.1,4 five different variations of the course of the lfcn have been described in the literature.7 the nerve may run posterior to the asis, anterior to the asis or medial to the asis. these three variations are most vulnerable to injury during surgery.1 further variations include a more medial course of the nerve. radiation treatment may also be implicated as an iatrogenic cause of lumbosacral neuropathies.5 while the diagnosis is based predominantly on history and examination of the patient, the condition may mimic other pathologies of the pelvis and lumbar spine, such as lumbar disc herniation and metastases to the iliac crest.1 investigations used to assist with the diagnosis include needle electrophysiology, nerve conduction studies and electromyography, but all have their limitations.2,5 previously, the role of mri has been to rule out other pathologies, but subsequent developments in 3t high resolution mrn have allowed better evaluation of pathology of the extraspinal nerves. thin-slice high resolution fluid-sensitive sequences such as t2 weighted fat saturation (t2fs) or proton density fat saturation (pdfs) are useful. short tau inversion recovery (stir), diffusion weighted imaging or diffusion-weighted whole-body imaging with background body signal suppression (dwibs) is also good for identifying signal abnormalities but usually has lower resolution. magnetic resonance neurography allows the detection of changes in perifascicular and endoneurial signal intensity, which may indicate nerve injury. an increase in nerve size, loss of the normal appearance of nerve fascicles and surrounding fat stranding support the findings of nerve injury, but these morphological changes may be more difficult to detect in smaller, more peripheral nerves such as the lfcn.3 motor neuropathies may also be supported by the findings of muscle oedema in a specific nerve distribution, in the acute phase of denervation. this finding will not be present in the purely sensory nerve neuropathy such as in the lfcn in meralgia paresthetica. the diagnosis then depends on findings of signal alteration in the lfcn (figure 2a and b). it is important to ensure that the skin and subcutaneous tissues are included in the imaging field (figure 3) to adequately visualise the nerve and its branches.3 figure 2: 3t proton density fat-saturated axial mr images at the level of the anterior superior iliac spine in a 54-year male patient presenting with a clinical suspicion of meralgia paresthetica on the left. note the high signal and prominence of the lateral femoral cutaneous nerve on the left (long arrow) as compared to the right (dashed arrow) as it runs over the (a) iliacus muscle (short arrow) and (b) anterior superior iliac spine. figure 3: 3t proton density fat-saturated axial mr image in the same patient described in figure 2 demonstrates the persistent high signal of the lateral femoral cutaneous nerve in the subcutaneous tissue where it divides into anterior and lateral branches. a study published by chhabra et al in 2013 investigated the diagnostic accuracy and observer performance of 3t mrn in the investigation of meralgia paresthetica. the study found a moderate inter-observer agreement between two readers for detecting signal alterations of the lfcn with a sensitivity and specificity of ≥71% and ≥94% for both readers, respectively. the authors concluded that 3t mrn was reliable and accurate in the diagnosis of meralgia paresthetica.2 conclusion meralgia paresthetica, a neuropathy of the lfcn, may be spontaneous or iatrogenic. the highly variable anatomy puts it at risk of compression, as well as injury during various surgical procedures. the diagnosis has traditionally been based on clinical findings, but occasionally a diagnostic dilemma may arise. the development of 3t mrn is now proving useful in assisting with the diagnosis of neuropathies of the smaller peripheral nerves. acknowledgements competing interests the authors declare no conflict of interest regarding the write up of this article. author’s contributions r.m.a. prepared the literature review and design, was responsible for the writing of article, and gave final approval of version to be submitted; m.d.v. provided the concept, images and gave final approval of version to be submitted; f.e.s. assisted with the literature review, critical revision and final editing, and gave final approval of version to be submitted. ethical consideration ethical approval was obtained for this manuscript from the university of pretoria ethics committee, with reference number 317/2019. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references patijn j, mekhail n, hayek s, lataster a, van cleef m, van zundert j. meralgia paresthetica. pain pract. 2011;11(3):302–308. https://doi.org/10.1111/j.1533-2500.2011.00458.x chhabra a, del grande f, soldatos t, et al. meralgia paresthetica: 3-tesla magnetic resonance neurogaphy. skeletal radiol. 2013;42(6):808–808. https://doi.org/10.1007/s00256-012-1557-4 petchprapa cn, rosenberg zs, sconfienza lm, cavalcanti cfa, la rocca vieira r, zember js. mr imaging of entrapment neuropathies of the lower extremity. part 1. the pelvis and hip. radiographics 2010;30:983–1000. https://doi.org/10.1148/rg.304095135 grossman mg, ducey sa, nadler ss, levy as. meralgia paresthetica: diagnosis and treatment. j am acad orthop surg. 2001;9:336–344. muniz neto fj, kihara filho en, miranda fc, rosemberg la, santos dcb, taneja ak. demystifying mm neurography of the lumbosacral plexus: from protocols to pathologies. biomed res int. 2018;9608947:20. https://doi.org/10.1155/2018/9608947 harney d, patijn j. meralgia paresthetica: diagnosis and management strategies. pain med. 2007;8:669–677. https://doi.org/10.1111/j.1526-4637.2006.00227.x de ridder va, de lange s, popta jv. anatomical variations of the lateral femoral cutaneous and the consequences for surgery. j orthop trauma. 1999;13:207–211. case report 30 sa journal of radiology • march 2006 the ‘twinkling sign’ is described as a colour doppler artifact in which a rapidly changing mixture of red and blue colours is displayed distal to a strongly, rough reflective structure (figs 1 and 2).1 this probably results from complex back scatter of the ultrasound waves with prolonged pulse duration, interpreted by doppler as movement.2 this sign is a fundamental artifact because it is well detected by the digital doppler system which has a higher noise immunity. the focal depth minimally affects the shape of the artifact by narrowing its focal width when the calculus is out of focus.1 there is a relationship between this artifact and the morphology (surface) and the chemical composition of the calculus. identification of the composition of the calculus can help for the management options used.2 an artifact on other imaging modalities, which results from an error in the imaging technique, may lead to misinterpretation of the image. the ‘twinkling sign’ may lead to misinterpretation by suggesting vascular flow. this particular artifact has a benefit in differentiating a very small calculus from other echogenic structures in the urinary tract particularly after lithotripsy.1,2 another application of the twinkling sign is for guiding transthoracic needle aspiration of lung and mediastinal masses. the needle is identified by using the twinkling sign (by moving the inner stylet gently). the needle tip is well located and the blood vessels are avoided.3 1. aytac sk , ozcan h. effect of color doppler system on the twinkling sign associated with urinary calculi. j clin ultrasound 1999; 27: 433-439. 2. darge k. be aware and beware of the twinkling sign. pediatr radiol 2005; 35: 351-352 3. gorguner m, misirlioglu f, polat p, et al. color doppler sonographically guided transthoracic needle aspiration of lung and mediastinal masses. j ultrasound med 2003; 22: 703-708. a useful ultrasound artifact and its application – the ‘twinkling sign’ h lameen, mb chb s theron, mb chb, mmed (rad) f steyn, mb chb m grobbelaar, mb chb a mapukata, mb chb s andronikou, mb bch, frcr, fcrad, phd department of radiology, tygerberg hospital and university of stellenbosch pictorial interlude fig. 1 (a) bmode ultrasound of the left kidney shows two echogenic structures in the lower pole without acoustic shadowing. applying the colour doppler for the same kidney (b) shows multi-coloured pixels, the 'twinkling sign', distal to the echogenic structures. a useful ultrasound artifact.ind30 30 3/27/06 2:22:19 pm report baci< rssa congress levovist presentations september 99 dr pat morton, consultant radiologist, city park hospital, cape town, presented his findings on the use of levovist for the detection of cancer in the prostate gland. he described his experience with endorectal ultrasound of the prostate and the difficulties in detecting early cancer. he demonstrated his technique for using levovist to improve the specificity of the examination. as the product enhances the vascularity of solid organs, such as the prostate, focal lesions are more easily detected after its administration. the optimum enhancement is attained with a slow infusion of levovist over 2 to 3 minutes while scanning. this requires an assistant or an injector pump. dr morton believes that the product improves the sensitivity of the examination in difficult cases, however the examination takes longer to perform. professor corr, radiologist from king edward hospital, durban and the university of natal presented his work on the applications of levovist for improving the specificity of liver lesions, the detection of portal vein patency and renal artery stenosis. levovist is useful to improve the sensitivity and specificity of ultrasound examinations of the liver when focal cancer and inflammatory disease is suspected. levovist can reliably differentiate hypervascular focal lesions such as hepatoma from hypovascular metastases and abscesses. it is very useful in difficult cases where portal vein stenosis or occlusion is suspected, and greatly improves detection of renovascular stenosis in difficult cases with suboptimal visualisation of the renal arteries. both presenters felt more local research was required and the cost effectiveness of the use of levovist must be assessed compared to other investigations such as mr and ct. peter corr department of radiology, university of natal the past rad iography in south africa before 1899 20. from our special correspondent. lancet 1899; 2:1558. 21. the royal navy and army medical services report. bmi 1899; 2:1450-1552. 22. maccormac w. the war in south africa. notes from sir william maccormac. lancet 1900; 1: 403-405. 23. royal navy and army services. lancet 1900; 1:795. 24. watson a. no.6 general hospital, johannesburg. bmi 1901; 1:946. 25. royal navy and army medical services. bmi 1900; 1:538. 26. hall edwards j. the roentgen rays in south africa. lancet 1901; 1:1755-1556. 27. report of the committee of the portland hospital. london john murray. 1901. 28. field force service abroad south africa. lancet 1900; 1: 724. 29. briggs ec. the staff work of the anglo-boer !var 1899-1902. london. grant richards 1901.pp219-225. frampage 19 14. transvaal archival depot. pretoria. (rk 18, pp151-152) (rk 18 p 128) (rk53 pp 114-116). 15. algemeen rijksargief the hague, col/ectie bas veth. 88-97. file 90(k). 16. hall edwards, j. the roentgen rays in military surgery. bmi 1899; 2: 1391. 17. stevenson wf (ed). (1905) report on the surgical cases noted in the south african war. london, harrison. pp 275-276. 18. hall edwards j. the x-rays in south africa. lancet 1901; 2: 130-131. 19. mccormack w. (1899) the war in south africa. notes from sir william maccormac. lancet 1899; 2:1755-1757. 32 sa journal of radiology. january 2000 30. douglas arj & williamson h. surgical report in: the imperial yeomanry hospitals in south africa. 19001902. ed. the countess howe. london. arthur humphreys. 1902. vo13, 243. 31. hall edwards j. report of the x-ray department in: the imperial yeomanry hospitals in south africa. 1900]902. ed. the countess howe. london. arthur humphreys. 1902. voi3,90-104. 32. report of the edinburgh and east of scotland south african hospital. ed. wallace 0 and boyd fd. edinburgh oliver and boyd. 1901. 33. report of the british central red cross committee on voluntary organisations in aid of the sick and wounded during the south african war. london: hmso, 1902. 34. the american hospital ship. bm] 1899; 2: 1761. case report 18 sa journal of radiology • march 2006 primitive neuroectodermal tumours (pnets) are tumours from pluripotent neural crest cells1-5 and may occur in the central or peripheral nervous system.4 pnet must be distinguished from other small round cell tumours like ewing’s sarcoma (es), extraosseous ewing’s sarcoma, neuroblastoma, lymphoma, rhabdomyosarcoma and small-cell carcinoma.3,4,6,7 although it can occur at any age, pnet occurs more frequently in adolescents and young adults,2,3,6 with a median age of 17 years.3,6 case report a 20-year-old black woman presented with a 3-month history of lower back pain, a 2-week history of paraplegia and paraparesis, and 1-week history of loss of sphincter control. a supine chest radiograph (cxr) showed a large mass in the right hemithorax (fig. 1); this posterior mass could be confirmed on the lateral lumbar spine x-ray. the t11 interpedicular distance was increased and the pedicles were flattened on the anteroposterior (ap) lumbar spine x-ray. computed tomography (ct) (fig. 2) and magnetic resonance imaging (mri) (figs 3 5) showed a well-defined lobulated paraspinal mass in the right hemithorax measuring 18 x 11 x 16 cm. the mass involved most of the lower chest cavity and extended into the spinal canal displacing and compressing the spinal cord anteriorly and to the left (figs 3 and 4) and expanding paraspinal primitive neuroectodermal tumour (pnet) of the chest c minné, mb chb, dip ec (sa) n khan, mb bs, fcrad (d) sa department of diagnostic radiology, university of limpopo, medunsa campus case report 18 sa journal of radiology • march 2006 fig. 1. a supine cxr shows a large mass in the right hemithorax. fig. 2. the post-contrast ct image through the lower chest and upper abdomen demonstrates heterogeneous enhancement of the mass. fig. 3. this t1-weighted axial image shows a right paraspinal mass isointense to muscle. haemorrhage can be seen as a hyperintense area in the mass. invasion of the chest wall and erector spinae muscles is seen on the right. the mass extends into the spinal canal via the intervertebral foramen with subsequent widening of the foramen. the spinal cord is compressed and displaced anteriorly and to the left. case report paraspinal.indd 18 3/27/06 12:25:52 pm the intervertebral foramina (figs 3 and 4). the superior portion of the mass had a large cystic component (fig. 5). the diaphragm could be seen clearly and was displaced antero-inferiorly by the mass, which was seen superiorly to it (fig. 5). no infiltration of the diaphragm could be demonstrated. the right kidney was subsequently also displaced anteroinferiorly. infiltration of the chest wall and erector spinae muscles was well demonstrated on both ct and mri (figs 3 and 4). the right ribs were splayed and intervertebral foraminae widened but no bony erosion was seen. no calcification was demonstrated on either ct or mri, but haemorrhage was seen on mri (figs 3 and 4). regional lymphadenopathy was not seen. the lesion was hypodense to muscle (26 hu) on ct and showed inhomogeneous enhancement post contrast (fig. 2). on t1-weighted images the mass was isointense to muscle (fig. 3) and enhancement post gadolinium was heterogeneous (fig. 5). t2-weighted images showed a hyperintense mass and the cystic component was well demonstrated (fig. 4). no lung or bony metastases were seen on ct and tc 99m-mdp bone scan respectively. at surgery an extradural mass was found. the spinal canal was decompressed and a laminectomy was performed on t10-l1, and pedicular screws were inserted to stabilise this region. histological examination revealed a tumour of small round cells with hyperchromatic nuclei and pale to clear cytoplasm. a few flexnerwintersteiner rosettes were seen. immunohistochemistry revealed the following: s100 was diffuse strong positive, vimentin was positive, cd99 had focal positivity, and chromogranin, synaptophysin and cytokeratin were negative. the diagnosis of pnet was made. the patient was started on a multidrug chemotherapy regimen. although follow-up scans were done early after treatment the response to chemotherapy was poor with hardly any reduction in tumour size after 3 months. discussion pnets are very rarely seen in the black population3 and comprise 4% of soft-tissue tumours2 peripheral primitive neuroectodermal tumours (ppnet) is a group of poorly differentiated small round blue cell tumours from neural crest origin.1-4,6 pnet and es are classified together into the ewing family of tumours,2,6 which is comprised of tumours with poorly differentiated small round cells.2,6 pnet is distinguished by neural differentiation,2 seen as homer-wright rosettes4-7 or flexner-wintersteiner rosettes.4,7 immunohistochemistry is used to detect expression of at least 2 of the following neural antigens in order to make the diagnosis of pnet, namely neuron-specific enolase (nse), protein s100, leucine 7, and neurofilaments protein, chromogranin a or synaptophysin.6,7 a highly specific antibody, cd99 (mic2), can be found in both pnet and es with immunostaining.5,7 pnet is seen mostly in the thoracopulmonary region and is also known as askins tumour when it is in the chest wall.2,3,6,8 other sites are the kidney, retroperitoneum/ paraspinal, head and neck region.2 uncommon sites are the uterus, ovary, bladder, testis, pancreas, parotid, skin, subcutaneous tissues, lung, adrenal glands, dura mater and small bowel.2 these tumours are rapid-growing masses but regional lymphadenopathy and metastases are uncommon. when they metastasise they tend to go to bone and lungs1-3,6,8 more often. the next most common sites documented are bone marrow,2,6 lymphnodes1 and brain.8 metastases have also been described in the liver,2 mediastinum3 and chest wall.3 imaging modalities used are ct, mri and nuclear medicine. ct and mri are done to demonstrate the size and extent of the lesion.2 soft tissue invasion can be demonstrated well on both modalities.8 ct showed soft tissue invasion just as well as mri in several cases8 and demonstrated bony erosion and lung metastases better than mri,8 but mri is the best modality to demonstrate spinal cord involvement. in our case case report fig. 4. a t2-weighted image on the same level as fig. 3 shows a hyperintense heterogeneous mass. the invasion of the chest wall and spinal canal with widened intervertebral foramen and displaced spinal cord is clearly seen. fig. 5. a coronal post-contrast t1-weighted sequence. the mass enters the spinal canal via numerous neural foramina. 19 sa journal of radiology • march 2006 paraspinal.indd 19 3/27/06 12:25:52 pm case report 20 sa journal of radiology • march 2006 the diaphragm was demonstrated more clearly on the mri sequences and infiltration of the diaphragm could not be excluded on ct. another important role of ct or mri is to determine resectability and to detect metastases.2,3 they are also used in follow up to determine response to treatment2 and to detect recurrences. tc 99m-mdp (bone scan) is of value in detecting distant bony metastases8 and 8 f-fluoro-2-deoxy-glucose (fdg)-position emission tomography (pet) scan can be used to detect recurrence of intraspinal pnet.1,9 ct the ct picture is usually of heterogeneous soft tissue density.2,3 the mass can be isodense or slightly hypodense to muscle3 and larger tumours commonly have hypodense necrotic/cystic areas.2,3,6,8 post-contrast enhancement is mostly inhomogeneous.3,6,8 calcifications are seen in less than 10% of cases, but could be faint and speckled or stippled.6,8 haemorrhage can be seen as a hyperdense area in the mass if present. regional lymphadenopathy is rarely seen but chest wall invasion is more common and would be evidenced by pleural effusion, bony destruction, tumour nodules in the muscles and abnormal enhancement of the chest wall.8 mri mri t1-weighted images would show a mass isointense or slightly hyperintense to muscle2,3,5,6,8 with low-intensity areas correlating to cystic/necrotic areas in the tumour and hyperintense areas correlating to haemorrhage. post-gadolinium enhancement may be seen uniformly or inhomogeneously.2,3,5,6,8 heterogeneous high signal intensity is typically seen on t2-weighted images;2,3,5,6,8 this sequence usually demonstrates the cystic components best. a stir sequence would also demonstrate a heterogeneous high signal intensity mass.3,6 conclusion pnets are aggressive neoplasms and should therefore be diagnosed accurately and as early as possible. the distinction between pnet and es cannot be made radiologically and could even be difficult on histological examination. neural differentiation, immunostaining and immunohistochemistry can help to distinguish these tumours. unfortunately a standard therapy does not exist yet and patients are offered a combination of surgery, chemoand radiotherapy. prognosis depends on the location of the tumour but pnet has a generally poor prognosis. alternative treatment should be investigated further. 1. virani mj, jain s. primary intraspinal primitive neuroectodermal tumor (pnet): a rare occurrence neurology india 2002; 50: 75-80. 2. khong pl, chan gcf, shek twh, tam pkh, chan fl. imaging of peripheral pnet: common and uncommon locations. clin radiol 2002; 57: 272-277. 3. ibarburen c, haberman jj, zerhouni ea. peripheral primitive neuroectodermal tumors. ct and mri evaluation. eur j radiol 1996; 21: 225-232. 4. mawrin c, synowitz hj, kirches e, kutz e, knut d, weis s. primary primitive neuroectodermal tumor of the spinal cord: case report and review of literature. clin neurol neurosurg 2002; 104: 36-40. 5. kim yw, jin bh, kim ts, cho ye. primary intraspinal primitive neuroectodermal tumor at conus medullaris. yonsei med j 2004; 45: 538. 6. dorfmuller g, wurtz fg, umschaden hw, kleinert r, ambros pf. intraspinal primitive neuroectodermal tumour: report of two cases and review of literature. acta neurochirur 1999; 141: 1169-1175. 7. isotalo pa, agbi c, davidson b, girard a, verma s, robertson sj. primitive neuroectodermal tumor of the cauda equina. hum pathol 2000; 31: 999-1001. 8. dick ea, mchugh k, kimber c, michalski a. imaging of non-central nervous system primitive neuroectodermal tumours: diagnostic features and correlation with outcome. clin radiol 2001; 56: 206-215. 9. meltzer cc, townsend dw, kottapally s, jadali f. fdg imaging of spinal cord primitive neuroectodermal tumor. j nucl med 1998; 39: 1207-1209. 20 sa journal of radiology • march 2006 price: r399.00 to order contact: the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za paraspinal.indd 20 3/27/06 12:25:57 pm case report an obscure cause of stroke basilar artery fenestration m hoffmann mbbch, fcp(sa)neuro d royston* mbchb,ffrad(d)sa pcorr* mbcm, ffrad(d)sa, frcr, mmed(uct) departments of neurology, 'radiologyand vascular surgery, university of natal, durban. introduction cerebral artery fenestrations or intravascular bridges represent developmental anomalies, that may be incidental findings but sometimes of clinical significance.' these embryological abnormalities may also take the form of duplication of an artery. for the basilar artery, the incidence has been cited as 5.3% for the general population," the most frequently involved intracerebral arterial system being the vertebrobasilar system." the most important consequence is the tendency to develop arterial aneurysms at the site of fenestrations with a 3% incidence in a retrospective analysis of 5 190 angiograms." current pathophysiological data has shown that medial defects of the arterial walls predispose to aneurysm formation. fenestrations have been described in the basilar, vertebral, middle cerebral, anterior cerebral, aortic arch and posterior cerebral arteries.l/ in addition to a propensity to form aneurysms, a number of other neurological presentations have been described in association with fenestrations including cerebral ischaemia,s,6,7trigeminal neuralgia," cervical myelopathy? and symptomatic arteriovenous malformations.'? case report a 71 year-old white man suffered progressively more debilitating attacks of dizziness, diplopia, imbalance and inco-ordination over a seven year period with several daily attacks occurring at time of presentation. history he first reported intermittent diplopia eight years prior to presentation, lasting about 90 minutes. a second attack occurred nine months later. he was seen by his general practitioner and ophthalmologist at the time with no abnormality noted. one year later the attacks increased in frequency to one every few months culminating in a much more severe attack with dizziness lasting two hours but without abnormality seen on a mri scan. during the next four years the diplopia increased dramatically varying from under one minute up to 30 minutes and could occur up to seven times per day. 22 sa journal of radiology. may 1998 an episode occurred subsequently with dysphasia, imbalance and dizziness lasting about 30 minutes but with complete return to normality. a second mr! brain scan done at the time was normal. he was given various diagnoses such as transient ischaemie attacks and migraine by different neurologists. an even more disabling attack occurred six years after his first symptoms wherefrom he awoke with speech impairment, inability to walk, loss of coordination and difficulty in handling objects. this time a stroke was diagnosed and he improved again only to have a marked exacerbation of his symptoms one month later with intermittent attacks of a similar nature occurring 2-3 times per day lasting about between 30-60 minutes. he was quite disabled by these and described the left sided image (referring to his diplopia) as "coming and going all the time". the most recent presentation was associated with almost continuous diplopia and dizziness. he was otherwise in good health and had no cerebrovascular or cardiovascular risk factors, no deleterious habits and no general or neurological illness. examination examination revealed a rational man of normal body habitus with a bp of 145/90 and a pulse of 68 per minute regular. the cardiac, chest and abdominal examinations were normal and no stigmata of generalized disease were noted. no cervical or supraclavicular bruits were heard. neurologically higher functions and cranial nerves were normal. motor testing was normal save for bilateral upper limb relative hyperreflexia, left more than right. sensation and limb co-ordination were normal and gait markedly ataxic with tandem gait impossible. to page 23 an obscure cause of stroke basi lar artery fenestration from page 22 clinical assessment the clinical assessment included a differential of posterior circulation ischaemia and/or infarction due to vertebrobasilar vascular abnormality. investigations routine blood tests, prothrombotic screen, chest radiograph and electrocardiogram were normal. doppler sonography of the cervicocephalic and intracranial vessels was normal. echocardiography and coronary angiography were normal. the third mri brain scan was also normal. cerebral mr angiography proved diagnostic in that a proximal basilar artery fenestration was seen. this was first suspected due to the presence of a dilated mid basilar section with intravascular hypointense signal (figure 1). figure 1: magnetic resonance angiogram of the vertebrobasilar arteries. a dilatation of the mid basilar artery with an intravascular hypointense signal (arrow). a trans axial magnetic resonance angiogram revealed a biconcave appearance of the basilar artery typical of a fenestration (figure 2). functional brain scanning with spect brain, revealed bi-occipito-parietal hypoperfusion. management he was initially treated with warfarin without relief of symptoms. subsequent treatment with aspirin figura 2: transaxial magnetic resonance angiogram revealing the biconcave appearance of the basilar artery typical of a fenestration (arrow). alleviated some of the symptoms which further decreased with the addition of persantin. discussion recognition of cerebral artery fenestrations in the context of cerebral ischaemia or stroke is important for at least three reasons:" 1. it may represent the mechanism for the ischaemia or stroke. 2. various treatment options are available which include medical, interventional radiological (guglielmi coils) 11 and surgical options such as aneurysm clipping. the realisation that aneurysms may be part of this developmental abnormality should demand a comprehensive appraisal of the cerebral circulation by angiography. 3. a precise diagnosis as early as possible will also save unnecessary costly investigations (in this patient three mri scans) and guide appropriate therapy. in the case under discussion, presumably turbulent blood flow at the site of the fenestration lead to in situ thrombosis with distal embolisation and/or intermittent haemodynamic disturbances. this scenario is especially likely in that all other causes of posterior circulation ischaemia were 23 sa journal of radiology. may 1998 excluded by a comprehensive stroke work up. in this patient warfarin failed to alleviate symptoms whereas antiaggregant therapy led to a marked improvement. with the advent of newer antiplatelet agents such as ticlopidine, clopidrogel and combination formulae such as asasantin, such high flow white thrombus type lesions are amenable to mechanism specific treatment. references i. finlay hm, canham pb. the layered fabric of cerebral artery fenestrations. stro/ze 1994; 25: 1799-1806. 2. berry ad, kepes jj, wentzel md. segmental duplication of the basilar artery with thrombosis. stroke 1988; 19: 256-260. 3. tasker ad, byrne jv. basilar artery fenestration in association with aneurysms of the posterior circulation. neuroradiology 1997; 39: 185-189 4. sanders wp, so rek pa, mehta ba. fenestration of intracranial arteries with special attention to associated aneurysms and other anomalies. ainr 1993; 14: 675680. 5. nakamura h, vamada h, nagao t, fujita k, tamaki n. fenestration of the internal carotid artery associated with an ischaemie attack. case report. neurol med chir (tokyo) 1993; 33: 306-308. 6. arai k, endo s, hirashima v, takaku a. posterior inferior cerebellar artery aneurysm associated with fenestration of the vertebral artery case report. neurol med chir (tokyo) 1989; 29: 29-31. 7. schievink wi, hunter sf, marsh wr, aksamit aj, jack cr. traumatic occlusion of one limb of an intracranial arterial fenestration; an uncommon cause of stroke. neurology 1996; 47: 277-278. 8. tran dinh ho, dorsch nw, soo vs. ectasia and fenestration of the anterior cerebral artery associated with persistent trigeminal neuralgia. neurosurgery 1992; 31: 125-128. 9. furumoto t, nagase j, takahashi k, itabashi t, lai h, ishige n. cervical myelopathy caused by anomalous vertebral artery. a case report. spine 1996; 21: 2280-2283. lo. kalia kk, ross da, gutin ph. multiple arterial fenestrations, multiple aneurysms and an arteriovenous malformation in a patient with subarachnoid haemorrhage. surg neuro11991; 35: 45-48. n. graves vb, strother cm, weir b, duffta. vertebrobasilar junction aneurysms ass.ociated with fenestration: treatment with guglielmi detachable coils. ainr 1996; 17: 35-40. original article s otto mb chb, llb, lld department of diagnostic radiology university of the free state bloemfontein abstract the following article serves as a guideline to the radiologist as to when, how and where consent should be obtained. it is clear that the full participation of the patient in decision-making must be obtained and that the right of the person to self-determination is of utmost importance. introduction obtaining a patient's consent is presently accepted as an obligatory prerequisite for the performance of any type of medical treatment, either therapeutic or diagnostic in nature. the doctrine of informed consent has dominated the doctor-patient relationship worldwide for the past 50 years. although this doctrine has been widely acknowledged, it is frequently ignored. human rights movements, especially in western societies, have placed a particularly high premium on an individual's personal integrity and right of self-determination. the important underlying objective that the doctrine of informed consent was designed to serve is often overlooked consent to treatment or ignored, namely the protection of the patient's fundamental rights of personal autonomy and bodily integrity. enabling patients to make treatment choices that are informed by their own and not their doctor's, the medical profession's or even the government's values and goals is and should be the objective of informed consent. this is of specific importance in south africa with its ethnically, economically and religiously heterogeneous population and its diverse cultural and belief systems. people's lives are richer and more complex than their physical existence and wellbeing, obtaining informed consent is a process of legal discussion including the nature, purpose, risks, effects, advantages and disadvantages of treatment. consent results in a contract between the doctor and the patient with correction of their unequal status and creation of a therapeutic alliance and symbiosis between law and medicine working for health and quality of life. south african law recognised a person's free will to make an informed decision in the case of stoffberg v. elliot.' 'in the eyes of the law,every person has certain absolute rights, which the law protects. they are not dependent on statute or upon contract, but they are rights to be respected and one of the rights is absolute security of the person ... any bodily interference with or restraint of a man's person, which is not justified in law, or excused in law 13 sa journal of radiology • june 2002 or consented to, is a wrong .. : the absolute right to security, dignity and privacy has also been recognised in the bill of rights of the soutl1 african constitution.' informed consent goes beyond a signed document or a list of disclosures. the document is mere evidence of the contract. in general, even where a physician intervenes to the benefit of a patient, s/he will not escape liability if s/he fails to obtain the patient's consent. a vocational right to treat and cure does not justify medical treatment. this was clearly stated in stoffberg v. elliot. legal aspects surrounding consent any therapeutic or diagnostic procedure fits the legal definition of assault and is an unlawful act. the mere fact that the interference with a persons body is in the nature of recognised medical treatment does not provide grounds for justification. consent can take two forms: 1. consent to injury, e.g. when an operation is performed, the patient consented to the wound being inflicted. 2. consent to tl1erisk of injury, e.g. consenting to the procedure well knowing that it might have complications or side-effects the patient voluntarilyassumes the risk. (valenti no fit iniurioï' requirements for consent the person giving consent in principle consent must be given by the prejudiced person himlhersel£ it can only be given by another person in exceptional circumstances. original article consent must be given voluntarily consent must be given freely and without any constraint. consent is invalid if obtained through using physical force or if a patient has been persuaded by fraudulent misrepresentation. if consent was obtained by an offer of financial gain, it will be considered not voluntary. nus raises the question of consent for participation in research projects where meal tickets or financial rewards are offered. the form of consent in south african law, no distinction is made between the validity of written or implied consent. written consent usually supplies adequate proof implied consent can be accepted in cases of non-invasive procedures when a person capable of forming an intent submits him/herself to treatment without resistance or protest. capacity the person who consents must be able to understand and retain information relevant to the decision, to believe and validate the information and to weigh the information in balance to arrive at a decision. the following aspects influence a person's capability: age: in south african law it is accepted that a child above the age of 14 can form an intent. thus any person above the age of 14 years can consent to non-invasive treatment. nus is the age prescribed in the termination of pregnancy act.' this implies that the confidentiality arising from the doctorpatient relationship must be respected from the age of 14 years. consent to operations and similar invasive procedures can only be given from the age of 18 years. this is prescribed by the child care act,' section 39(2) authorises the medical superintendent of an institution to consent in the case of a life-threatening or impairing condition that can lead to loss of life or serious and permanent physical injury or disability. pleasenote that this section does not allow consent when unreasonably withheld by parents. in these cases the supreme court, as upper guardian for all children, must be approached. mental capacity: mentally ill persons are not always incapable of making decisions regarding their self-determination. the mere fact that a person is institutionalised should not exclude that person from making decisions regarding his/her own person. where a patient is not able to form intent, the mental health ad prescribes a procedure in this regard. married women: south african law does not restrict married women from making their own decisions.' informed consent informed consent is more than getting a paper signed or a list of disclosures. the doctor has an obligation to educate the patient regarding the diagnosis and the therapeutic options available, including the option of doing nothing. it is a process in the form of a discussion including the nature of treatment, the purpose of the treatment, the risks involved and the effects, advantages and disadvantages of the procedures. it is insensitive to obtain consent the night before the procedure is performed when the patient is under emotional strain or even sedation. this is the time when the patient needs emotional support and encouragement and not the time to hear a fearsome list of possible complications. 14 sa journal of radiology • june 2002 during the discussion process the patient must be given the opportunity to reflect, to ask questions and to change his/her mind. the issue of language becomes most important. the patient has the right to have the information translated. the ability of the patient to understand the controversies surrounding the proposed treatment must be taken into account. the standard against which the duty is measured has always been a professional judgement measured by what reasonable practitioners would have disclosed after all surrounding factors had been considered. nus was confirmed by judge watermeyer in the case of richter and another v. estate hamman.' the emphasis has, however, shifted recently to accommodate the patient's participation. it requires that sufficient information should be furnished to a patient to enable him to make an intelligent decision relating to the treatment. nus has been accepted in south african law in recent unreported cases in the western cape supreme court as well as in the united kingdom and canada," a patient wants to hear five main things: • what is wrong with me? • what caused it? • what should i do about it? • how much will it cost in time, money, pain and disability? • how long will it take? the doctor obtaining the consent the referring doctor must obtain the consent of the patient for the referral as well as for the procedure this includes available alternatives." the radiologist accepting the patient takes full responsibility for the shaping the future together philips medical systems agilent technology hgs adac laboratories atl ultrasound marconi e philips lej~ jwjh, ~ b&ttpk tel: (011) 471-$050 website: www.philipsmedical.co.za http://www.philipsmedical.co.za original article treatment of the patient during the specific procedure. in lymberyv. jefferies,1 1 the patient was referred for deep x-ray treatment to a radiographer at pretoria hospital. the patient sustained serious burns that needed to be treated with skin transplants. it was claimed that the respondent had been negligent in referring the appellant for treatment well knowing that the person was not a qualified radiologist, but a radiographer. the appeal court upheld that: 'if a medical practitioner or surgeon advises his patient to be treated by some third person, either because it is a treatment he cannot carry out himself or which he is customary to entrust to a third person, then the latter does not as a general rule, act as the agent of the medical practitioner or surgeon." the 'captain of the ship doctrine' was not accepted in south african law, and it is according to strydom and strauss" insupportable and should not go further than the vicarious liability of the employer in the employer-employee relationship. treatment of a patient without consent a patient can be treated without consent in the following circumstances: 1. protection of the public interest, e.g. when a person is suffering from a contagious disease. treatment might even be given against the patient's wishes. 2. in case of an emergency where the patient is in a critical unconscious condition. the principle used is the doctrine of' negotiorum gestio' or spontaneous agency whereby the intervener acts on behalf of the other person. strydom and strauss" set out the requirements as follows: (l) there must be a real emergency; (il) the patient must be aware of the intervention; (iil) the intervention must not be against the desire of the patient; and (iv) treatment must be undertaken with the aim to serve the patient's best interests. the doctrine of informed refusal the patient also has the right to obtain, refuse or postpone the procedure and the physician must tolerate what to him/her may seem capricious. the patient's wishes must always be respected, e.g. in the case of jehovah's witnesses refusing blood transfusions. this was also confirmed in phillips v. de klerk, where the doctor approached the supreme court with an ex parte application to obtain permission to give blood and the court set it aside." consent is lacking when the patient is sedated, a language barrier exists, it is obtained in a rush, if alternatives are not discussed, if the procedure extends beyond the scope for which consent was obtained, if it is not understood and/or if any intimidation or misrepresentation occur. references 1. stoffberg v elliot 1923 cpd 148. 2. south african constitution: act 200 of 1993. 3. romeinse reg en romeins-hollandse reg: de groot 335, 8; voet 47, 10,4. 4. choice of termination of pregnancy act 92 of 1996. 5. child care act amendment 96 of 1996. 6. mental health act 18 of 1973. 7. mcquoid-mason and strauss 17 lawsa 1983: 147. 8. richter and another v estate hamman; 1976(3) sa226 (c) 232; 9-11. 9. reibl v hughes (1977) 78 dlr 3d 35, 52. male v hopmans (1965) 54 dlr 2d 592,595 (1967) dlr 2d los, 113. 10. strauss and strydom 1967: 221. il. limbery v jefferies 1925 ad 236. 12. strydom & strauss 1967: 283 footnote 112. 13. strydom & strauss 1967: 238. 14. phillips v de klerk (1983) tpd (unreported). bibliography 1. claassen nib,verschoor t. medical negligence in south africa. pretoria: digma, 1992. 2. deutsch e. the right not to be treated or to refuse treatment. med law 1989; 7: 433-438. 3. golan j,ben hur n. informed consent in plastic surgery. med law 1983; 2: 113-115. 4. green koopersmith er. informed consent. the problem of causation. med law 1984; 3: 231236. 5. mclean sam, mckay aj. consent in medical practice. in: mclean sam, ed. legal issues in medicine. aldershot: gower publishing, 1981: 96-113. 6. ott h. the right to know: informed consent. med law 1989; 7: 439-441. 7. snyman cr. strafreg.4th ed. durban: butterworths, 1986. 8. strauss sa. doctor, patient and the law. 2nd ed. pretoria: jl van schaik, 1984. 9. strauss sa, strydom mj. die suid-afrikaanse geneeskundige reg. pretoria: jl van schaik, 1967. 10. van der merwe nj, olivier pjj.die onregmatige daad in suid-afrika. 5th ed. pretoria: jp van der walt,1985. 11. van oosten ffn. informed consent: patient rights and the doctor's duty of disclosure in south africa. med law 1989; 7: 443-456. 12. lymbery v jefferies 1925ad 236. 13. richter and another v estate hamman; 1976 (3)sa226(c). 14. stoffberg v elliot; 1923 cpd 148. 15. chatterton v gerson (1981) 1 qb 432. 16. reibl v hughes (1977) 78 dur 3d 35; (1981) 114 dlr 3d 1. 17. male v hopmans (1965) 54 dlr 2d 592 (1967) 64 dcl 2d 105. 16 sa journal of radiology. june 2002 case report value of mri in paediatric closed head injury savvas andronikou mb bch, fcrad (sa), frcr (land) rudolf boeddinghaus mbchb chris j weiman mb chb, fcrad (sa) department of paediatric radiology red cross children's hospital cape town abstract children (and less commonly adults) with a low level of conciousness following acute head injury who have a normal ct sean are often assumed to have diffuse axonal injury of the brain. mri may be appropriate in the subacute setting as it may demonstrate findings highly suggestive of such injury, as well as other findings not identified on ct. these findings may aid clinicians in determining prognosis. we demonstrate typical findings on various mr sequences using an index case. a 2-year-old boy presented with a depressed level of consciousness (gcs 8/11) following a motor vehicle accident. the ct scan performed within 6 hours showed only a small subarachnoid haemorrhage, with intraventricular extension. he remained comatose, and mri was performed after 5 days. the t2-weighted images (figs la and lb) showed high signal intensity in the splenium of the corpus callosum, at the insular greywhite interface on the left, in both temp oro-occipital regions and in the right thalamus. it also demonstrated small bifrontal subdural collections, larger on the left. diffusion-weighted images (fig. 2a) demonstrated increased signal (restricted diffusion) in all of the same sites, except the right thalamus. on longtr gradient-echo (fig. 2b), the right thalamus showed marked hypointensity in keeping with blood breakdown products. on the basis of these findings, diffuse axonal llljury, non-haernorrhagic cortical contusions, small bifrontal subdural collections and a right thalamic haemorrhage were diagnosed. none of these was evident at ct. the patient's level of consciousness improved gradually, but he had residual right hemiparesis. shearing injuries are common in infants and young children, because the unmyelinated brain is less rigid and the subarachnoid spaces are large.i in the subacute phase, mr imaging is more sensitive than ct in detecting traumatic brain injury, such as diffuse axonal injury (dal), nonhaemorrhagic cortical contusions, haemorrhage and surface colleetions." in dal, t2-hyperintensity is found in typical locations (the corpus callosum, particularly the splenium and posterior body, the dorsolateral rostral brainstem, and hemispheric grey-white interfaces).' gradient-echo images are particularly helpful in demonstrating small petechial haemfigs 1a and b. conventional t2-weighted imaging. (a) s~g/ttal ,,:"2w ~ri demonstrates focal high-signal les/on in the splemum of the corpus callosum (arrow) and diffuse high signal intensity throughout the body of the corpus callosum (arrowheads). the sagittal is superior to the axial plane in showing corpus callosum abnormalities. these features are characteristic of dal. (b) axial t2w mri shows ill-defined bi/ateral occipito-temporal high-signal cortical lesions (arrows) in keeping with non-haemorrhagic contusions. they were not evident on ct. 38 sa journal of radiology. february 2003 case report figs 2a and b. special mr techniques. (a) diffusion-weighted image demonstrates high signal over the corpus callosum (star) and at the left insular grey-white interface (arrowheads) in keeping with cytotoxic oedema. these locations are characteristic of dal. (b) longtr gradient echo axial image clearly demonstrates the low signal of blood breakdown products in the right thalamus (arrow). also demonstrated are bilateral frontal subdural col/eetions (arrowheads) that were not shown on ct. orrhages associated with dal, with signal blooming, due to magnetic susceptibility effects," diffusion-weighted mr! has a role to play in distinguishing cytotoxic oedema (in dal) from vasa genic oedema (brain swelling).' in our patient, all the above sequences showed abnormalities, which were not evident at ct. mr! is an important prognostic tool in paediatric head injury. references l. barkovich at.pediatric neuronnaging. 3rd ed. philadelphia: lippincot williams and wilkins, 2000: 234-236. 2. woodcock rt,davis pc, hopkins kl. imaging of head trauma in infancy and childhood. sernin ultrasound ct mr 2001; 22 (2): 162182. 3. kampf! a, franz g, aichner f, et al. the persistent vegetative state after closed head injury: clinical and magnetic resonance imaging findings in 42 patients. j neurosurg 1998; 88: 8098l6. 39 sa journal of radiology • february 2003 case report a case of elongated cervical canal l d r tsatsi mb chb, fcrad(d)sa s ahmad mbss department of diagnostic radiology medica/ university of southern africa a 29-year-old black female patient presented to the gynaecology department at garankuwa hospital in february 2002 with a complaint of primary infertility. findings all haematological and clinical parameters were normal. ultrasound ultrasound examination revealed a large uterus with multiple intramural, submucosal and subserosal fibroids. two huge fibroids were noted. the dimensions were 10.3 cm x 8.9 cm and 8.9 cm x 5.7 cm. no localised area of cystic breakdown was noted (figs 1 and 2). ct an axial ct scan was performed in june 2002. the findings were as follows: a large myometous uterus was visible. multiple subserosal intramural and submucosal fibroids were noted. the dimensions of the two largest fibroids were 10.1 x 9.4 cm and 6.9 x 7.1 cm. density measurements were of soft tissue, le.30 40 hfu. no calcififig. 1. transverse sonar scans showing two huge fibrolds. fig. 2. transverse sonar scans of the largest fibroid. cation or areas of breakdown were noted. coronal and sagittal reconstructions were also performed (figs 3 and4). hysterosal pingography (hsg) this demonstrated an extremely elongated cervical canal (15 cm). a filling defect was demonstrated at the fundus of the uterus. the filling defect (fibroid) was demonstrated in all views of hysterosal pingography. the uterus was noted to extend to the extent of ll4 vertebra. 28 sa journal of radiology • september 2002 fig. 3. post hsg reconstructed coronal ct showing fibroid uterus with contrast in the peritonea/ cavity. fig. 4. coronal reconstructed ct images showing a long cervical canal interspersed between two huge flbroids. opacification of the left tubule system was demonstrated and an accompanying free spill was noted. the right tube showed a tapering proximal filling with complete blockage (figs 5 and 6). fig. 5. a very long cervical canal with the uterus becoming an abdominal organ. case report fig. 6. hsg performed in march 2002 showing a long cervical canal. a small filling in the area of fundus of the uten..ts with opacification of the left fallopian tube only, showing peritoneal spill as well. conclusion to the best of our knowledge similar elongation of the cervical canal has not been described previously. the cervical canal, which is best shown on hsg with the vaecum injector, is usually 30 40 mm long and tends to become shorter after childbirth." the cervical canal is about one-third of the entire length of the uterus and is often spindleshaped." the cervical canal extends upward 1 2 cm from the external os to the internal os, above which there is a short narrow isthmus, which opens into the general uterine cavity. the width of the cervical canal varies with the menstrual cycle, being wider in the proliferation than in secretory phase 2. references ). whitehouse gh, wright cho imaging in gynaecology. in: grainger rg, allison d. diagnostic radiology. 4th ed. london: churchill livingstone, 2001: 1827. 2. highman th, lees wr. gynaecological imaging. in: sutton d. textbook of radiology and imaging. 5th ed. london: churchill livingstone, 1993: 1212. 3. slezak 1', tillinger kg. the occurrence and signficance of broad longitudinal folds in the uterine cavity at hysterography. radiology 1973; 106: 87-90. 4. slezak p, tillinger kg. the incidence and clinica] importance of hysterographic evidence of cavities in the uterine wall. radiology, 1976: 581-586. 5. slezak p, tillinger kg. the significance of the spiculated outline of the uterine cavity on hysterography. radiology 1973; 107: 527-531. 6. slezak p, tillinger kg. the occurrence and significance of a double-outlined uterine cavity (douc) in the hysterographic picture. radiology 1968; 90: 756-760. 7. gerlock aj, hooser cwo oviduct response to glucagon during hysterosalpingography. radiology 1976; 119: 727-728. imaging of diseases of the chest 3/e peter armstrong, alan g wilson, p dee & dm hansell this comprehensive resource covers all imaging aspects of the lungs, the pleura and the mediastinum and integrates all available imaging modalities. both common and uncommon disorders are included, whilst the logical, clinical organisation of the text allows for fast, efficient access to the information you require. features • includes all you need to know in one convenient singlevolume resource. • multi-modality coverage ensures that all the modalities applicable to thoracic imaging are included. • includes nearly 2 000 high-quality images and illustrations, covering a wide variety of cases. • chapters are organised by diseases and disorders, allowing for fast navigation through the text. • chapter outlines, summary tables and key points boxes summarise the most important information. 2000, hardback, 1 056 pp, 1 800 illus., mosby, r2 990 special offer: buy imaging of diseases of the chest 3/e and receive a l!:!j.e. kumar and clarke clinical medicine 4/e orders: south african medical association, private bag x1, pinelands 7430. tel (021) 530-6527 fax (021) 531-4126 e-mail: fpalm@samedical.org limited local stock. at the gleneagles hotel, auchterarder, scotland organisers: professor janet e husband obe fmedsci frcp frcr & mrs tiba seear dcrr we are pleased to announce the 23rd course in whole body computed tomography and magnetic resonance imaging. the course is recognised by the royal college of radiologists for the continuing professional development accreditation of 26 rcr cpd credits and by the european accreditation council for 26 european cme credits. the course emphasises state of the art body ct and mr imaging. the course is designed for radiologists and may also interest radiographers. the programme consists of formal lectures along with a choice of special workshops. there will also be a technical exhibition and bookshop. for registration forms and further details, please contact: london ct course ltd, secretariat office, 36 portland place, london, wi b i at, uk. tel: +44 (0) 20 7307 1411, fax: +44 (0) 20 7307 1414, e-mail: enquiries@ctmricourse.co.uk or visit our website http://www.ctmricourse.co.uk 29 sa journal of radiology • september 2002 the 23rd course in computed tomography and magnetic resonance imaging 13 17 april 2003 mailto:fpalm@samedical.org mailto:enquiries@ctmricourse.co.uk http://www.ctmricourse.co.uk abstract introduction patient presentations discussion conclusion acknowledgements references about the author(s) younes el hassani department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco meriem haloua department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco badreeddine alami department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco meryem boubbou department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco mustapha maaroufi department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco moulay youssef alaoui lamrani department of radiology, faculty of medicine and pharmacy, sidi mohammed ben abdellah university, hassan ii university hospital, fez, morocco citation el hassani y, haloua m, alami b, et al. imaging of retroperitoneal haemorrhage revealing median arcuate ligament syndrome. s afr j rad. 2021;25(1), a1993. https://doi.org/10.4102/sajr.v25i1.1993 case series imaging of retroperitoneal haemorrhage revealing median arcuate ligament syndrome younes el hassani, meriem haloua, badreeddine alami, meryem boubbou, mustapha maaroufi, moulay youssef alaoui lamrani received: 16 sept. 2020; accepted: 30 oct. 2020; published: 15 jan. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract coeliac artery compression stenosis caused by the median arcuate ligament can lead to aneurysm formation in the pancreatico-duodenal arteries that can eventually result in a spontaneous rupture leading to retroperitoneal haemorrhage. in this case series, we describe the cases of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma, complicating a median arcuate ligament syndrome. keywords: median arcuate ligament syndrome; haematoma; pancreaticoduodenal aneurysm; retroperitoneal haemorrhage; epigastric pain. introduction median arcuate ligament syndrome (mals) is a rare condition related to symptoms that occur as a result of extraluminal compression of the coeliac artery (ca) by the median arcuate ligament (mal).1 in mals, blood flow to the splanchnic organs is diverted to the superior mesenteric artery (sma) and then to the pancreatico-duodenal arcades because of decreased flow in the coeliac trunk. the pancreatico-duodenal arteries (pdas) cannot sustain this high flow, leading to true-aneurysm formation, which can eventually result in spontaneous rupture.2,3 in this case series, we describe the case presentations of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma complicating mals. patient presentations case 1 a 65-year-old man presented to the emergency department for atraumatic acute abdominal pain and vomiting. he was a chronic tobacco user with no medical or surgical history or any regular medication. upon arrival, he presented with normal vital parameters. abdominal examination revealed epigastric tenderness. he was treated initially with intravenous paracetamol before performing an ultrasound (us) which demonstrated the presence of a heterogenous mass in the epigastric region and the presence of a hyperechoic, well-organised heteregenous mass within the right iliac fossa, with no doppler signal. thereafter, abdominal computed tomography (ct) with contrast was performed and demonstrated a well-organised and hyperdense mesenteric haematoma measuring with mean density of 57 hounsfield unit (hu) approximately 9 cm × 5 cm × 4 cm. two small aneurysms were identified originating from the upper and lower pdas. there was marked ca compression by the mal resulting in post-stenotic fusiform dilatation of the ca (figure 1). figure 1: a 65-year-old man with atraumatic acute abdominal pain and vomiting: arterial phase contrast enhanced computed tomography of the abdomen in the axial (a), coronal (b) and sagittal planes (c) show a well-orgnised mesenteric haematoma (asterix, a) of approximately 9 cm. two small aneurysms were identified (arrows, b) originating from the upper and lower pancreatico-duodenal arteries. there was significant coeliac artery compression by the median arcuate ligament (arrow, c) resulting in post-stenotic fusiform dilatation of the celiac artery. non-enhanced computed tomography in the axial plan (d), performed 2 months later, shows homogeous liquifecation of the haematoma with a well-distinguished regular and thin wall. case 2 a 64-year-old woman with persistent abdominal pain for two weeks was admitted to our emergency department. the patient complained of diffuse abdominal pain and haematemesis; digital rectal exam indicated melena. clinical abdominal examination revealed a peri-umbilical palpable mass with localised tenderness. eso-gastro-duodenal endoscopy (egde) displayed external compression of the second-part duodenum without any mucosal abnormality. biochemistry demonstrated regenerative microcytic and hypochromic anaemia. an abdominal us was performed, highlighting the presence of free hyperechoic fluid in the pouch of douglas. no mass was identified. subsequent abdominal ct demonstrated a homogenous hyperdense haematoma (43 hu) of approximately 14 cm × 10 cm × 8 cm with haemorrhage within the stomach (average density of 62 uh). there was moderate ca compression by the mal with no visible pda aneurysm (figure 2). figure 2: a 64-year-old woman with persistent diffuse abdominal pain, admitted for haematemesis and melena. axial non-enhanced computed tomography demonstrates a homogeneous hyperdense haematoma of approximately 14 cm (a), haemorrhage within the stomach (arrow, b) and haemoperitoneum (arrow, c). arterial phase sagittal reconstruction (d) demonstrates moderate coeliac artery compression by the median arcuate ligament with no visible pancreatico-duodenal artery aneurysms. case 3 a 44-year-old woman was admitted for acute abdominal and back pain, as well as haematemesis and melena. her previous medical and surgical history was unremarkable and she was not on any regular medication. upon arrival, the patient had a tachycardia and was tachypnoeic. she was normotensive, had normal oxygen saturation (98%) and was afebrile. abdominal examination elicited diffuse tenderness. eso-gastro-duodenal endoscopy did not show any abnormalities. her blood tests were normal apart from a modestly raised c-reactive protein (20 mg/dl) and mildly decreased haemoglobin levels (9 g/dl). abdominal ct revealed a retroperitoneal haematoma with rupture of a small aneurysm originating from the inferior pancreatic-duodenal artery (ipda), secondary to stenosis of the ca. additionally, there was also a standford b dissection of the aorta. it is postulated that the above scenario was caused by the decreased blood flow in the ca compressed by the intimal flap (causing dynamic ischaemia), which then resulted in further decreased flow in the coeliac trunk, increased blood flow in sma branches and finally rupture of the pre-existing aneurysm (figure 3). figure 3: a 44-year-old woman admitted with haematemesis and melena. non-enhanced computed tomography in the axial plane (a) showing a homogeneous hyperdense haematoma of approximately 11 cm. arterial phase in coronal (b), sagittal (c), axial (d) and oblique plan (e) revealed a small aneurysm (arrow, b) originating from the inferior pancreatic-duodenal artery (ipda) (arrow, b); moderate coeliac artery compression by the median arcuate ligament (arrow, c) is identified. there is a standford b aortic dissection (e) where the coeliac artery originantes from the false lumen (d). discussion median arcuate ligament syndrome or ca compression syndrome (cacs), also called dunbar syndrome, is a rare condition in which the mal causes compression of the ca. it is characterised clinically by weight loss, postprandial epigastric pain, nausea and vomiting.4 the mean age at diagnosis is 28 years with a 71% female preponderance.5 however, only 10% – 24% of patients with extrinsic compression of the ca by the mal will have the syndrome.6 the relation between the anatomic anomaly and clinical symptoms was first described by harjola in 1963, in a case study, and then by dunbar in 1965 in a larger case series of 15 subjects.7 pathophysiology the pathophysiology is clearly established. in mals, blood flow to the splanchnic organs is diverted to the sma and then to the pda because of decreased flow in the ca. the pdas cannot sustain this high flow, causing high-flow true aneurysms, which can eventually result in spontaneous rupture.2 aneurysm regression or stability is reported after ca reconstruction with stent placement, mal incision or bypass placement. there are other causes of pda aneurysms other than mals such as atherosclerosis, pancreatitis, mycotic and bacterial infection, trauma or fibromuscular hyperplasia.2,8 imaging findings the radiological diagnosis of mals is firstly based on detecting mal thickening equal to or greater than 4 mm,9 but the definitive finding for the diagnosis is focal narrowing of the proximal ca with a characteristic ‘hooked appearance’, best seen on a sagittal image.10 this sign helps differentiating mals from other causes of ca stenosis, such as atherosclerosis. associated findings include post-stenotic dilatation or collateral vessel formation from the sma branches.6 computed tomography and magnetic resonance imaging (mri) should ideally be performed in the end-inspiratory and expiratory phases. true and permanent compressions persist or increase during end-expiration, whereas transient physiological compression is seen only during end-inspiration.6 percutaneous angiography is the reference standard for the diagnosis of mal syndrome and shows findings similar to ct such as superior indentation, hooking and post-stenotic dilatation of the ca. furthermore, angiography can assess the stenosis in both end-inspiration and expiration. retrograde filling of the ca from the pda can also be assessed.6 doppler us can demonstrate peak systolic velocities greater than 200 cm/s correlating to a degree stenosis of at least 70% with a sensitivity of 75% and specificity of 89%.7,11 median arcuate ligament syndrome may cause true post-stenotic aneurysms, which can be located anywhere in the distal arteries, but appear to predominantly involve the pda and dorsal pancreatic artery (dpa) – the two main collateral networks between the ca and the sma.12,13 true aneurysms of the pda are rare, accounting for only 2% of all visceral aneurysms.13 almost half of all pda aneurysms are associated with ca stenosis.14 compression by the mal has been shown to be responsible for stenosis in about 10% – 30% of cases.14 they can also be induced by periarterial inflammation, usually associated with pancreatitis, trauma, infection or atherosclerosis.13 more than 60% of patients with pda aneurysms initially present with a rupture.13 rupture risk is not related to the aneurysm size, suggesting that all aneurysms should be treated, regardless of their size.15 in the literature, ruptured aneurysm diameters ranged between 0.7 cm and 2 cm. on the other hand, unruptured aneurysm sizes were between 0.7 cm and 6 cm.16 the rupture risk of pda aneurysms is about 65%. among the case histories of 88 patients with pda aneurysm published in the literature, 53 patients had rupture and 26 of them unfortunately died.15 in the third reported case, there was a standford b aortic dissection where the ca originated from the false lumen. we postulate that this caused dynamic ischaemia and reduction of blood flow through the ca. the intimal flap reduces the ca ostium size and potentiates blood reduction caused by the abnormal mal, resulting in further increased blood flow in the sma branches, and finally, rupture of the small ipda aneurysm. to the best of our knowledge, no such case was reported elsewhere. the issues of treatment options regarding pda aneurysms are still controversial. recently, endovascular treatment has become popular but open surgical repair is also an option for young patients with no malignancy, for whom long-term survival is expected.15 conclusion rupture of pda aneurysms caused by mals should always be considered in the differential diagnosis of acute abdominal pain and retroperitoneal haemorrhage, as the condition requires specific management. embolisation has been proven to be safe with a high success rate, with surgery reserved for unsuccessful embolisation. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions y.e.h. is the principal investigator and wrote the manuscript from acquisition of data to design and drafting. m.h., b.a., m.b. and m.m. were the supervisors of the study and made conceptual contributions to the study. m.y.a.l. was directly involved in patient care and made a substantial contribution in the conception, review, revision and approval of the article. ethical consideration this article followed all ethical standards for research.cases were all anonymised. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references hanaki t, fukuta s, okamoto m, et al. median arcuate ligament syndrome and aneurysm in the pancreaticoduodenal artery detected by retroperitoneal hemorrhage: a case report. clin case rep. 2018;6(8):1496–1500. https://doi.org/10.1002/ccr3.1643 rebelos e, cipriano a, ferrini l, et al. spontaneous bleeding of the inferior pancreatic-duodenal artery in median arcuate ligament syndrome: do not miss the diagnosis. oxf med case rep. 2019;2019(7):omz067. https://doi.org/10.1093/omcr/omz067 hughes t, chatzizacharias na, richards j, harper s. aorto-hepatic bypass graft for repair of an inferior pancreatico-duodenal artery aneurysm associated with coeliac axis occlusion: a case report. int j surg case rep. 2016;28:131–134. https://doi.org/10.1016/j.ijscr.2016.09.035 delis kt, gloviczki p, altuwaijri m, mckusick ma. median arcuate ligament syndrome: open celiac artery reconstruction and ligament division after endovascular failure. j vasc surg. 2007;46(4):799–802. https://doi.org/10.1016/j.jvs.2007.05.049 chou j-w, lin c-m, feng c-l, ting c-f, cheng k-s, chen y-f. celiac artery compression syndrome: an experience in a single institution in taiwan. gastroenterol res pract. 2012;2012:1–6. https://doi.org/10.1155/2012/935721 horton km, talamini ma, fishman ek. median arcuate ligament syndrome: evaluation with ct angiography. radiographics. 2005;25(5):1177–1182. https://doi.org/10.1148/rg.255055001 fong jkk, poh acc, tan ags, taneja r. imaging findings and clinical features of abdominal vascular compression syndromes. am j roentgenol. 2014;203(1):29–36. https://doi.org/10.2214/ajr.13.11598 stanley jc, whitehouse wm, martin s. clinical importance and management splanchnic artery aneurysms. j vasc surg. 1986;3(5):836–840. https://doi.org/10.1067/mva.1986.avs0030836 eliahou r, sosna j, bloom ai. between a rock and a hard place: clinical and imaging features of vascular compression syndromes. radiographics. 2012;32(1):e33–e49. https://doi.org/10.1148/rg.321115011 lee kh, yu ml, cheung m. the hooked proximal celiac artery. abdom radiol. 2018;43(3):753–754. https://doi.org/10.1007/s00261-017-1245-x scholbach t. celiac artery compression syndrome in children, adolescents, and young adults: clinical and color duplex sonographic features in a series of 59 cases. j ultrasound med. 2006;25(3):299–305. https://doi.org/10.7863/jum.2006.25.3.299 kalva sp, athanasoulis ca, greenfield aj, et al. inferior pancreaticoduodenal artery aneurysms in association with celiac axis stenosis or occlusion. eur j vasc endovasc surg. 2007;33(6):670–675. https://doi.org/10.1016/j.ejvs.2006.12.021 peyrottes a, mariage d, baqué p, massalou d. pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: what we need to know. surg radiol anat. 2018;40(4):401–405. https://doi.org/10.1007/s00276-017-1950-8 chivot c, rebibo l, robert b, regimbeau j-m, yzet t. ruptured pancreaticoduodenal artery aneurysms associated with celiac stenosis caused by the median arcuate ligament: a poorly known etiology of acute abdominal pain. eur j vasc endovasc surg. 2016;51(2):295–301. https://doi.org/10.1016/j.ejvs.2015.10.025 agalar c, egeli t, özbilgin m, et al. pancreaticoduodenal artery aneurysm secondary to median arcuate ligament syndrome treated with preserving pancreas and reimplantation of the celiac trunk. gen surg rep. 2017;1(1):6. kallamadi r, demoya m, kalva s. inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion. semin interv radiol. 2009;26(3):215–223. https://doi.org/10.1055/s-0029-1225671 http://www.sajr.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the sa journal of radiology, we ask that you take a moment to update your electronic portfolio on https:// sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajr. org.za 2. in your ‘user home’ [https://sajr.org.za/index. php/sajr/user] select ‘edit my profile’ under 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review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this volume of the sa journal of radiology. we appreciate the time taken to perform your review(s) successfully. aadil a. ahmed abraham h. dachman abubakar farate ahmed o.a. krim ajit k. reddy akhilanand chaurasia andre rose anil bhaya aruna patil ayesha mitha benjamin taragin bukunmi m. idowu chirag k. ahuja chris trauernicht cornelia r. minne dahiru m. yunsa farhana e. suleman fourie bezuidenhout franck girard frank a. imarhiagbe halvani moodley hamid o. hamid hansraj mangray heleen hanekom jacqueline s. smilg jacques janse van rensburg jagidesa moodley james warwick jenny edge kalpana r. sivalingam kathleen l. jacobs mariam q. said-hartley mike m. sathekge miranda durand muhammad a. makusidi nausheen khan nondumiso n. dlamini ntombizakhona mthalane pankaj watal peter mercouris rahul nikam rajiv kapur razaan davis rishi philip mathew sally e. candy sandeep jakhere sanjay prabhu shalendra k. misser sheree c. gray shirley lipschitz stanley makgere suresh k. chamarthi sushil g. kachewar thomas g. walker tim cain tracy l. westgarth-taylor werner s. harmse willem a. groenewald zakariya vawda zarina i. lockhat http://www.sajr.org.za� https://sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za/index.php/sajr/user https://sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za abstract introduction methods ethical consideration results discussion advantages and limitations implications and recommendations conclusion acknowledgements references about the author(s) daniel j. cloete dr george mukhari academic hospital, ga-rankuwa, south africa department of diagnostic radiology, sefako makgatho health sciences university, south africa cornelia minne dr george mukhari academic hospital, ga-rankuwa, south africa department of diagnostic radiology, sefako makgatho health sciences university, south africa peter k. schoub department of radiology, parklane radiology, johannesburg, south africa jan h.r becker dr george mukhari academic hospital, ga-rankuwa, south africa department of general surgery, sefako makgatho health sciences university, south africa citation cloete dj, minne c, schoub pk, becker jhr. magnetic resonance imaging of fibroadenoma-like lesions and correlation with breast imaging-reporting and data system and kaiser scoring system. s afr j rad. 2018;22(2), a1532. https://doi.org/10.4102/sajr.v22i2.1532 original research magnetic resonance imaging of fibroadenoma-like lesions and correlation with breast imaging-reporting and data system and kaiser scoring system daniel j. cloete, cornelia minne, peter k. schoub, jan h.r becker received: 01 aug. 2018; accepted: 14 sept. 2018; published: 07 nov. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: multiple breast lesions resembling fibroadenomas are a common imaging finding in patients presenting to the mammography unit at dr george mukhari academic hospital in the north-west district of tshwane, south africa. patients often present with multiple lesions, up to 20 lesions per breast. these lesions often have atypical features on ultrasound and/or a clinical history of growth is commonly given. phyllodes tumours may be indistinguishable from fibroadenomas and breast cancers may on occasion present with benign features, which can lead to misdiagnosis. breast magnetic resonance imaging (bmri) evaluation of lesions resembling fibroadenomas may improve accurate assessment and identification of lesions requiring biopsy. objectives: to assess the reliability of bmri to characterise lesions resembling fibroadenomas on ultrasound, using the breast imaging-reporting and data system (bi-rads) and kaiser scoring systems with histopathological correlation. method: a quantitative, prospective, investigative study was performed with a sample size of 100 breast lesions among a total of 35 patients at dr george mukhari academic hospital. patients were recruited after a breast ultrasound investigation revealed lesions resembling fibroadenomas, but with an indication for ultrasound-guided biopsy, for example, very large size, atypical features on ultrasound or a history of recent growth. the bmri was performed prior to the ultrasound-guided breast biopsies. three investigators independently evaluated the bmri and applied bi-rads descriptors to each lesion. the kaiser score was then calculated for each lesion. statistics were calculated using pearson’s and spearman’s coefficients for inter-reader variability, kappa scores for bi-rads and kaiser score correlation with histology. results: evaluation with bmri, bi-rads and the kaiser scoring system showed statistically significant correlation with each other and with histopathology results for each lesion. there was statistically significant agreement among the investigators regarding the interpretation of the lesions and allocation of appropriate bi-rads scores. conclusion: multiple lesions resembling fibroadenomas can be evaluated with bmri when multiple breast biopsies would not be feasible. with a good imaging protocol and technique, adequate interpretation skills by the radiologist and the use of the kaiser scoring system, an accurate diagnosis can be achieved. introduction fibroadenomas of the breast are one of the most common benign masses female patients present with to their health care practitioner. it affects women mostly of childbearing age and is a cause of concern for these patients, especially in the era of breast cancer awareness.1 some patients present with multiple and/or rapidly growing lesions.1 these findings warrant further investigation, resulting in referral to the radiologist. recent research is pointing towards safer imaging methods with reliable and reproducible results aiming to be more acceptable to patients. fibroadenomas comprise epithelial and stromal components. their growth patterns are described as intra-canalicular or peri-canalicular.2 fibroadenomas are abnormalities of normal development and involution of breast tissue and form part of the broader group of fibroepithelial lesions. different varieties of fibroadenomas exist, namely, giant, multiple successive, juvenile fibroadenoma and fibroadenoma in pregnancy and lactation. the malignant, recurring counterpart of the fibroadenoma, is the phyllodes tumour.3 although a small increase in the size of a fibroadenoma may be observed towards the end of each menstrual cycle because of hormonal responses and the presence of oestrogen and progesterone receptors, rapid growth of a lesion may be indicative of a breast cancer or phyllodes tumour.2 phyllodes tumours are considered rare; however, a higher incidence is observed among latin americans and asians.4 tan et al. reported seven phyllodes tumours for every 100 breast cancers diagnosed.3 another cohort from turkey investigated 72 phyllodes tumours that were diagnosed and treated over a 3-year time period and compared to fibroadenomas. they found significant atypical features on ultrasound and breast magnetic resonance imaging (bmri) in phyllodes tumours, as compared to fibroadenomas.5 patients with a family history of breast cancer, previous or current personal history of breast cancer, complex fibroadenomas or the presence of histological atypia have a higher risk for breast cancer. although there is still controversy in the literature whether fibroadenomas can undergo malignant transformation, some researchers opine that it is possible. the epithelial component of a fibroadenoma may develop a carcinoma in situ (ductal carcinoma in situ [dcis]) or an invasive carcinoma.6 it is also known that fibroadenomas can co-exist with carcinomas. wu et al. reported lesions with a benign appearance on imaging that proved to be invasive ductal carcinoma with ipsilateral nodal metastases.7 the breast imaging-reporting and data system (bi-rads) was developed to standardise nomenclature and recommendations used by radiologists. in addition, the recently developed kaiser score was put to the test in this research project to evaluate how it compares in accuracy with the bi-rads allocations for mri. the kaiser scoring system was developed to assist radiologists to accurately and consistently determine the bi-rads score of each lesion, using bmri characteristics, with respect to the morphology, dynamic contrast enhancement and diffusion-weighted imaging (dwi) features of the lesion.8 it also includes mammographic findings (if available), specifically the presence of micro-calcifications. a bi-rads score is then allocated according to the number of kaiser points allocated (figure 1 and table 1).8 figure 1: kaiser score flowchart*: the kaiser score is assigned by following a simple flowchart from the top to the bottom, which lets the reader assign the presence or absence of four diagnostic criteria. table 1: kaiser score categories with typical benign and malignant histopathological correlates. methods a quantitative, prospective, investigative study was performed with a sample size of 100 breast lesions among a total of 35 patients at dr george mukhari academic hospital. patients with breast masses who were referred to the mammography unit of dr george mukhari academic hospital in the north-west district of tshwane, south africa, between 01 july 2015 and 28 february 2017, were considered for the study. patients were recruited after a breast ultrasound investigation revealed lesions resembling fibroadenomas but with an indication for ultrasound-guided biopsy, for example, very large size, atypical features on ultrasound, a history of recent growth, age of first presentation above 35 or patient anxiety. patients were enrolled on a voluntary basis and consent was signed prior to workup. study participants were informed that they could withdraw from the research project at any time, without negatively impacting their further workup and management. breast ultrasound was performed on all patients with a philips epiq 5 ultrasound machine. breast imaging-reporting and data system scores were allocated to each lesion according to the ultrasound appearance. the ultrasound examinations were performed by the radiology residents and/or general radiologist on rotation in mammography at the time of the patient’s initial presentation. patients aged 40 and above also had a mammogram included in their workup. breast magnetic resonance imaging was acquired on a 1.5 t machine (toshiba vantage or philips multiva) using a dedicated double breast coil. all patients were examined in the prone position using an identical protocol. the bmri protocol included t2-weighted (t2w) and t2-weighted fat saturation (t2w fs) sequences in the axial orientation. diffusion-weighted imaging and apparent diffusion coefficient (adc) values were calculated using b-values of 0 and 800. diffusion-weighted imaging sequences were performed before the dynamic contrast-enhanced (dce) imaging sequences (see table 2). the dynamic study was obtained using a t1-weighted fat-saturated (t1w fs) sequence in the axial plane. after acquisition of the native t1w fs scan, gadopentetate dimeglumine (magnevist, schering, 0.1 mmol/kg of body weight) was administered intravenously as a rapid bolus (4 ml/s), followed by a 20 ml saline flush at a rate of 4 ml/s (see table 1 for the dynamic scan parameters). following the contrast bolus and saline administration, dce commenced after a 75 s delay and continued with the same sequence parameters and under identical tuning conditions at 1-min intervals for 6 min. post-processing of the dynamic study included the calculation of time–signal intensity curves and subtraction of unenhanced images from the contrast-enhanced dynamic images. table 2: dynamic t1-weighted fat saturation scan parameters. ultrasound-guided core needle biopsies were performed after the bmri. histology specimens were examined and reported by qualified national health laboratory services (nhls) pathologists based at sefako makgatho health sciences university. the histopathology results were captured on a datasheet and later compared with the allocated bi-rads scores for each lesion. the mri studies were interpreted by three independent readers, who were blinded to the histology results and clinical data of each patient. two of the readers have 10 years of experience each in general radiology, with a special interest in breast imaging, and one reader was a radiology resident with 10 months mammography experience. the data were interpreted on a hologic multiview workstation with multiview mm version 4.1 software. this programme uses the mri bi-rads format for reporting. breast imaging-reporting and data system scores were allocated to each lesion as interpreted by each reader. lesion size (two dimensions on axial image and one dimension on coronal image), location (clock position, quadrant of breast, left or right breast and whether axilla area or central breast area or retro areola area), morphology (circumscribed or non-circumscribed margins), shape (round or oval), enhancement pattern (persistent, plateau or washout) and diffusivity were recorded. the degree of enhancement determined at three (or more) time points during the dynamic bmri was used to draw a kinetic curve that reflected the vascularity of the lesion. three types of kinetic curves are in use (figure 2): type 1 (persistent) curves: generally, 95% of lesions with this type curve are benign. type 2 (plateau) curves are often equivocal; 50% of lesions with this curve will be malignant. type 3 (washout) curves are predictors of malignancy, with a malignant rate of 90%.8,9 figure 2: a diagram demonstrating the signal intensity–time curves. the kaiser clinical scoring system was used to allocate points that were translated to a bi-rads score for each lesion. the bi-rads scores according to the kaiser scoring system were captured on a datasheet and compared to the reader’s bi-rads allocations and histopathology results for each lesion.8 all data were transferred to a spreadsheet and interpreted by a statistician on the sas programme version 9.3 running under microsoft windows. ethical consideration approval was received from the institutional ethics review board and permission to conduct the study was obtained from the ceo and hospital management (ethics number smurec/m/15/2015: pg). participants were informed of the purpose of the study and examinations that would be performed. participation was voluntary, but without negatively impacting their management. results the age of the 35 patients ranged from 16 to 57 years, with a mean age of 28.5 (±11, 51 standard deviation [sd]) and a median age of 24 years (20–39 interquartile ratio [iqr]). lesion characteristics margin one fibroadenoma and one papilloma had a partially circumscribed margin. all the other lesions had circumscribed margins, including the two phyllodes tumours (figure 3). figure 3: (a) a maximum intensity projection image of the t1-weighted fat saturation post-contrast sequence of a patient with a proven intermediate phyllodes tumour in the right breast demonstrating multiple bilateral breast lesions. (b–d) the dynamic contrast-enhanced images of the same patient demonstrating multiple lesions with varying enhancement patterns. the superimposed colour map on each image reflects the enhancement curves of the pixels. pixels in red indicate areas with a washout curve, green a plateau curve and blue a persistent enhancement curve. the lesion demonstrated with an arrow in (b) shows a typically persistent enhancement curve. the lesion indicated with an arrow in (c) did not demonstrate any enhancement. the lesion shown with an arrow in (d) had a predominant washout curve and was proven to be a phyllodes tumour. (e) diffusion-weighted imaging demonstrating restricted diffusion in the phyllodes tumour (arrow). (f) the apparent diffusion coefficient (adc) map for the phyllodes tumour (arrow) demonstrated a low adc value of 1.33 mm2/s. shape as far as shape was concerned, three lesions had irregular shapes, 12 lesions were lobular, 72 lesions were oval and 13 lesions were round. mass enhancement patterns heterogeneous enhancement was observed in 16 lesions, homogeneous enhancement in 77 lesions, rim enhancement in three lesions and dark, non-enhancing internal septations in four lesions. enhancement curves in this study, 60% of lesions had type 1 curves (persistent enhancement), 23% of lesions demonstrated type 2 curves (plateau enhancement) and 17% of lesions had type 3 curves (washout). apparent diffusion coefficient a total of 19 lesions showed no restriction, 18 lesions demonstrated partial restriction and 63 lesions showed restricted diffusion. the adc of the intermediate phyllodes was 0.51 mm2/s and the benign phyllodes was 1.27 mm2/s. the adc values of 35 fibroadenomas fell within the range 1.41 × 10−3 mm2/s to 2.01 × 10−3 mm2/s (see table 3 for a summary of adc values for all lesion groups). table 3: summary of apparent diffusion coefficient values for all the different lesion groups. breast imaging-reporting and data system scores the bmri reader bi-rads assessment of the 100 lesions investigated revealed 75 bi-rads 2, 21 bi-rads 3 and four bi-rads 4 lesions. histologically, 87 of the lesions were fibroadenomas. a total of 73/87 (83.9%) histologically proven fibroadenomas were scored bi-rads 2 and 12/87 (13.8%) bi-rads 3 and 2/87 (2.3%) bi-rads 5. two phyllodes tumours received bi-rads scores of 3 and 4. using the kaiser scoring system changed the bi-rads allocation of 21 lesions. the kaiser scoring system upgraded one lesion from bi-rads 3 to bi-rads 5 (final histology was fibroadenoma); two bi-rads 4 lesions were upgraded to bi-rads 5 (final histology reports were intermediate phyllodes and fibroadenoma) and four bi-rads 2 lesions were upgraded to bi-rads 3 (all proven fibroadenomas). eleven lesions were downgraded from bi-rads 3 to bi-rads 2 (all proven fibroadenomas) and three bi-rads 4 lesions were downgraded to bi-rads 3 (two fibroadenomas and one lactating adenoma) (see table 4 for a summary of mri reader-allocated bi-rads compared to mri kaiser bi-rads). there was statistically significant correlation between the kaiser bi-rads scores and histopathology (p < 0.0001), with a confidence interval of 74% – 89%. table 4: summary of magnetic resonance imaging reader breast imaging-reporting and data system and magnetic resonance imaging kaiser bi-rads. inter-reader variability inter-reader agreement among the three readers was determined to be statistically significant using the mcnemar test (p = 0.317). kappa statistics were used to determine agreement between the readers and the kaiser scoring system. there was good (weighted kappa of 0.73) to very good (weighted kappa of 1.00) strength of agreement demonstrated. there was statistically significant correlation between the mri reader-allocated bi-rads and bi-rads score according to the kaiser score (p < 0.001). sensitivity, specificity, positive predictive values and negative predictive values the reader-allocated mri bi-rads had a sensitivity of 50%, specificity of 76.5%, positive predictive values (ppvs) of 4.17%, negative predictive values (npvs) of 98.6% and accuracy of 76%. in comparison, the kaiser-allocated bi-rads had a sensitivity of 50%, specificity of 84.6%, ppv of 6.25%, npv of 98.8% and an accuracy of 84%. the differences between the reader and kaiser-allocated bi-rads were not statistically significant (p = 0.55). a possible explanation for the low ppv was the absence of malignant lesions and the low number of high-risk lesions like phyllodes tumours. the value of bmri in detecting breast cancers has been proven in the literature. discussion patients with multiple breast lesions resembling fibroadenomas but with atypical ultrasound findings or other indications for biopsy are a common occurrence in daily practice in the south african public health sector. magnetic resonance imaging could be a valuable tool in identifying lesions that should be biopsied. to appreciate what mri could contribute to the assessment of the lesions in these patients, it is essential to understand the spectrum of mri findings of the lesions. magnetic resonance imaging is an expensive modality and utilisation must be carefully weighed against the risk of missing a breast cancer, phyllodes tumour or other high-risk lesions in a patient with numerous lesions. fibroadenomas are classically described as masses that occur in young patients in their reproductive years. this study has confirmed that most patients were in the under 30 age group but patients who were of a more advanced age were also imaged. one of the youngest patients (17 years) in the cohort had a rapidly growing lesion (3.4 cm × 2.6 cm) and had stopped breast feeding 5 months before she presented. ultrasound demonstrated a lesion with atypical features and a reactive axillary lymph node with borderline abnormal cortical thickness. the lesion biopsied proved to be a lactating adenoma. breast biopsies are sometimes performed in the institution on anxious patients who request biopsies. this deviation from the bi-rads guidelines is because the unit often experiences poor patient compliance with follow-up visits because of socio-economic reasons. during bmri assessment, morphology, margins, enhancement patterns and the kinetic curve are routinely used to allocate a bi-rads score to each lesion. most of the lesions in this study were circumscribed and oval, lobular or round, features consistent with those found in the literature for fibroadenomas (see figure 4 for the typical appearance of benign fibroadenoma on bmri). wurdinger et al. described 90% of fibroadenomas in their study having round or lobular shapes.10 they also found a smaller frequency of lesions with internal septations. evaluation of shape and morphology alone was not enough to ascertain benignity of lesions in previous studies.11 the same experience was encountered with the study reported here. figure 4: (a–f) demonstrate the appearance of a histologically proven fibroadenoma in the right breast (white and black arrows) on magnetic resonance imaging. (a) a post-contrast t1-weighted fat saturation axial image shows a circumscribed enhancing mass with thin non-enhancing septa. (b) on the apparent diffusion coefficient map, the lesion has an intermediate signal intensity with a value of 1.754 mm2/s. (c) a t2-weighted sequence demonstrates a heterogeneous mass that is hyperintense to glandular tissue with hypointense internal septation. (d) the diffusion-weighted imaging image reveals restricted diffusion. (e) the dynamic contrast-enhanced image with a superimposed colour map demonstrates areas of variable enhancement, and the majority of the lesion has a persistent enhancement curve. (f) a sagittal t2-weighted fat saturation image demonstrates a heterogeneously hyperintense lesion. diffusion-weighted imaging is gaining interest in breast imaging. although restricted diffusion may be a sign of malignancy, the adc value aids further in differentiating between benign and malignant lesions. the literature reports adc values of malignant breast tumours ranging from 0.9 × 10−3 mm2/s to 1.61 × 10−3 mm2/s.12 in this study, the phyllodes tumours had low adc values. the adc of the intermediate phyllodes was 0.51 mm2/s and that of the benign phyllodes was 1.27 mm2/s. the mean adc values of normal breast tissue acquired with b-values ranging between 0 and 1074 vary from 1.51 × 10−3 mm2/s to 2.37 × 10−3 mm2/s. an artificial reduction of adc values in woman with less dense breasts may occur because of partial voluming with fat tissue. fibroadenomas would be expected to have high rates of diffusion and adc values because of stromal myxoid changes and consequently increased mobility of water. however, fibroadenomas with a predominant fibrous component will have lower adc values.13 papillomas can also have low adc values because of high cellularity. as in current literature reports, the adc values of 35 histologically proven fibroadenomas fell within the reported benign range from 1.41 × 10−3 mm2/s to 2.01 × 10−3 mm2/s.12 these adc values can be explained by several factors: it may be because of the technique used, density of the patient’s breasts in the study population and the amount of fibrous tissue within the fibroadenomas. this study demonstrated that using adc in conjunction with other parameters in the kaiser flowchart increased the accuracy of the assessment. another significant observation was that the one patient who had the intermediate phyllodes, had seven benign appearing breast masses (figure 3). this confirms certain reports in the literature that multifocality does not always equal benignity, and lesions must always be assessed individually to identify potential breast cancer and/or high-risk lesions.10 there was good correlation between the reader mri bi-rads and kaiser scores. although the accuracy improved slightly when the kaiser scoring system was employed to allocate bi-rads scores to lesions. this underlines the value of using structured reporting and the kaiser scoring system. most lesions imaged were suspected benign lesions but with atypical ultrasound findings or another indication for biopsy, for example, recent growth, large size or advanced age at presentation. the mri evaluation confirmed benignity with a high npv. the indication for bmri should be based on clinical grounds and multifocality (figure 5). figure 5: a breast magnetic resonance imaging of a patient with a total of 15 fibroadenomas demonstrating different magnetic resonance imaging appearances: (a–c) the t2-weighted fat saturation images demonstrate multiple homogeneously hyperintense circumscribed oval lesions (white arrows). two circumscribed hypointense lesions (black arrows) can be seen in (b) and (c). in (d), a maximum intensity projection t1-weighted fat saturation post-contrast image, numerous breast masses are visualised. (e) the subtracted post-contrast t1-weighted fat saturation image with superimposed colour map demonstrates three lesions with different enhancement curves. one lesion with a predominant washout curve (white arrow), a lesion with a persistent enhancement curve (black arrow) and a lesion with mixed enhancement curve (arrowhead). advantages and limitations patients who present with multiple breast lesions that resemble fibroadenomas but with atypical features or other indications for a biopsy, create a dilemma in the workup. there is a paucity of studies addressing this dilemma. this research project specifically targeted this subset of patients. limitations of the study were the sample size of 100 lesions. a selection bias was created by selecting patients after an ultrasound investigation had revealed lesions resembling fibroadenomas. the study population was selected, however, to specifically study this group of patients. the spectrum of breast disease was limited with no malignant lesions, only two phyllodes tumours and few patients with papilloma. implications and recommendations triparametric bmri should not replace ultrasound and invasive evaluation methods of benign appearing breast lesions in patients with only a few breast lesions, but it is certainly beneficial in patients with multiple lesions (figure 5). triparametric bmri is recommended for patients with multiple breast lesions, with one or more atypical ultrasound features and age above 35, in whom multiple breast biopsies are not feasible. it will assist in determining whether a biopsy is indicated and to identify which lesions to biopsy. a structured reporting template and the use of the kaiser scoring system are recommended to improve the accuracy, confidence and reproducibility of the report. a tailored, well-structured bmri protocol in the hands of a trained technician can avoid time-consuming and unnecessary long scan times.9 conclusion although well-circumscribed, benign-appearing breast lesions are mostly benign, they cannot always be dismissed as such. selection of masses for biopsy based on patient history, clinical examination and imaging findings (ultrasound, mammogram and bmri when indicated) may diminish unnecessary biopsies in patients with multifocal breast lesions. this may be beneficial to reduce patient anxiety and improve compliance. acknowledgements competing interests the author declares that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution d.j.c. is the chief researcher, protocol developer and main data collector, and involved in data interpretation and writing of the article. c.m. assisted with study outline and protocol developing, and participated in data collection, writing of the article and compiling of images and tables. p.k.s. assisted in data interpretation. j.h.r.b. assisted in protocol development and academic and clinical input. references kuijper a, mommers ec, van der wall e, van diest pj. histopathology of fibroadenoma of the breast. am j clin pathol. 2001;115(5):736–742. https://doi.org/10.1309/f523-fmjv-w886-3j38 zhang y, kleer cg. phyllodes tumor of the breast histopathologic features, differential diagnosis, and molecular/genetic updates. arch pathol lab med. 2016;140(7):665–671. https://doi.org/10.5858/arpa.2016-0042-ra tan ph, jayabaskar t, chuah kl, et al. phyllodes tumors of the breast: the role of pathologic parameters. am j clin pathol. 2005;123(4):529–540. https://doi.org/10.1309/u6dvbfm81mljc1fn jara-lazaro ar, akhilesh m, thike aa, lui pcw, tse gmk, tan ph. predictors of phyllodes tumours on core biopsy specimens of fibroepithelial neoplasms. histopathology. 2010;57(2):220–232. https://doi.org/10.1111/j.1365-2559.2010.03607.x duman l, gezer ns, balcl p, et al. differentiation between phyllodes tumors and fibroadenomas based on mammographic sonographic and mri features. breast care. 2016;11:123–127. https://doi.org/10.1159/000444377 zeeshan s, siddique s, riaz n. ductal carcinoma-in-situ within fibroadenoma of the breast: a case report with literature review. int j case rep images. 2018;9:100916z01sz2018. wu y-t, wu h-k, chen s-t, chen c-j, chen d-r, lai h-w. fibroadenoma progress to ductal carcinoma in situ, infiltrating ductal carcinoma and lymph node metastasis? report an unusual case. j surg case reports. 2017;2017(5):1–4. https://doi.org/10.1093/jscr/rjx064 dietzel m, baltzer pat. how to use the kaiser score as a clinical decision rule for diagnosis in multiparametric breast mri: a pictorial essay. insights imaging. 2018;6(9):325–335. pinker k, bogner w, baltzer p, et al. improved diagnostic accuracy with multiparametric magnetic resonance imaging of the breast using dynamic magnetic resonance spectroscopic imaging. invest radiol. 2014;49(6):421–430. https://doi.org/10.1097/rli.0000000000000029 wurdinger s, herzog ab, fischer dr, et al. differentiation of phyllodes breast tumors from fibroadenomas on mri. am j roentgenol. 2005;185(5):1317–1321. https://doi.org/10.2214/ajr.04.1620 hochman g, schnall d, reynolds ca, white ln. fibroadenomas: mr imaging appearances with radiologic-histopathologic correlation. radiology. 1997;204(1):123–129. https://doi.org/10.1148/radiology.204.1.9205233 pereira fpa, martins g, carvalhaes de oliveira r de v. diffusion magnetic resonance imaging of the breast. magn reson imaging clin n am. 2011;19(1):95–110. https://doi.org/10.1016/j.mric.2010.09.001 parsian s, giannakopoulos nv, rahbar h, rendi mh, chai x, partridge sc. diffusion-weighted imaging reflects variable cellularity and stromal density present in breast fibroadenomas. clin imaging. 2016;40(5):1047–1054. https://doi.org/10.1016/j.clinimag.2016.06.002 pdf file case report pneurnocephalus complicating frontal sinus osteoma s simarak md b suraprasit md abstract asenatham md pneumocephalus is most frequently caused by head trauma, especially to the paranasal sinuses and mastoid areas. tumours of the skull base, such as osteoma or pituitary tumour, are less common causes. since osteoma is one of the more common benign tumours of the nose and paranasal area vvitb the frontal sinus being its most frequent location, special attention should be paid to the examination of this area for frontal osteoma in patients presenting \tvith spontaneous pneumocephalus. introduction department of radiology, chiang mai universify, thai/and pneumocephalus is defined as an intracranial gas collection in the extradural, subdural, subarachnoid, intraventricular or intracerebral compartment. head injury and cranial 29 sa journal of radiology. november 1998 -~-------------surgery were found to account for 74.5% of cases, followed by tumours in 12.9%.1 the majority of tumours implicated in pneumocephalus are sinus osteomas. although an osteoma is considered to be a benign tumour, it can demonstrate a slow growth pattern and may result in intracranial complications such as that demonstrated in our patient. case report a previously healthy 43-year-old man presented with a two-year history of right-sided headache and weakness of his left extremities. he was first admitted in december 1995 with right temporal and occipital headache for two weeks, followed by sudden weakness of the left upper and lower extremities one week later. cranial computed tomography (ct) scan demonstrated a large subdural pneumocephalus in the right superior frontal region. frontal osteoma was however not recognized at this examination (figure 1). the patient refused figure 1: cranial computed tomography demon strating a large subdural pneumocephalus in the right superior frontal region. topage30 pneun,ocephalus c.orripf ic.atirrg frontal sinus osteoma frompage29 proper treatment and was discharged with the clinical diagnosis of intracranial abscess. the patient still had headache and weakness of left extremities during the interval and was readmitted in december 1997 but again refused surgery and was discharged. because of aggravation of his symptoms with additional focal seizure of his left extremities, he was admitted again in april ] 998. the motor power of his upper and lower extremities gradually decreased until he was unable to walk. skull radiographs demonstrated a large subdural air collection in the right superior fronto-parietal region (figure 2). cranial ct scan during the figure 2: skul/ radiographs demonstrating a large subdural air col/ectlon in the right superior fronto-parietal region. figure 3: cranial computed tomography at last admission confirms the presence of subdural air at the right superior frontal region, and also reveals a large osteoma occupying most of the frontal sinus with extension to the left. figure 4: tumour fragments shown in the cranial cavity, with tracking of air from the frontal sinus to the subdural air col/ection. most recent admission (figure 3,4) confirmed the presence of subdural air and also demonstrated a large osteoma of the frontal sinus, with fragments of tumour in the cranial cavity and tracking of air from the frontal sinus to the subdural air collection. he finally had corrective surgery for removal of the osteoma and repair of dural defect with uneventful recovery. discussion although pneumocephalus is quite common following trauma to the 30 sa journal of radiology. november 1998 paranasal sinus and mastoid areas,spontaneous pneumocephalus, on the contrary, is quite rare. one cause of spontaneous pneumocephalus is the wellrecognized complication of osteoma of the paranasal sinuses which was first reported by cushing in 1927.2 osteoma of the paranasal sinuses is a histologically-benign neoplasm. the frontal sinus is the most frequent location, accounting for 75-80% of osteomas in the paranasal sinus region.3,4 the most common symptoms of osteon.a are pain and headache, but many osteomas are asymptomatic and are discovered accidentally on sinus radiographs. complications of osteoma are rare, but they may cause ocular or intracranial problems such as proptosis, meningitis, brain abscess, intracranial mucocoeles or intracranial pneumocephalus. in spite of their benign nature, osteomas may grow slowly and extension of the lesion posteriorly can breach the dura mater, allowing air to enter the cranium leading to life-threatening complications. koivunen et al4 studied the growth rate of osteomas of the paranasal sinuses in 44 patients. they found that the mean growth rate of 23 osteomas that were followed up (including 10 static tumours) was 0.91 mm per year, varying from 0 to 6.00 mm per year (sd 1.41) of the 13 that were growing,the mean growth rate was 1.61 mm per year. spencer and mitchell' concluded from a follow-up study of frontal sinus osteomas over 17 years that the growth rate varies remarkably. some were stable, while others may grow as much as 6 mm per year. there are two characteristic histologic types of osteomas. the most common type is ivory or compact osteoma (composed of hard dense bone to page 31 pneurnocephalus complicating frontal sinus osteoma. frompage30 with minimal fibrous tissue) and the other type is the spongy or fibrous osteoma (contained mature cancellous bone), which is less common. the diagnosis of intracranial pneumocephalus and paranasal sinus osteoma can be easily made by radiographs as well as by ct scans. on radiography, paranasal sinus osteomas appear as round or oval, well circumscribed, highly radiopaque structures. they rarely attain a sizelargerthan 2 cm. the fibrous osteoma, however, appears less dense on radiographs and thus may be confused with a cyst. ct scans demonstrate a homogenous hyperdense mass arising within a sinus cavity. radionuclide scanning with a bone agent usually demonstrates an area of homogenously intense uptake. shibata et alb performed magnetic resonance imaging in five patients with osteomas of the skull and found that all osteomas appeared as low signal intensity on tl w images.the t2w images correlated well with histological findings: dense osteomas showed homogenous low-intensity, while spongy osteomas had high signal intensity areas and mixed signal intensity corresponding to mixed spongy and dense osteoma. the management of pneumocephalus due to paranasal sinus osteoma is surgical with removal of the tumour and repair of the dural defect. opinions vary concerning the optimal management of paranasal sinus osteomas in the asymptomatic individual. noyek et al 7 performed radionuclide bone scans in frontal sinus osteomas and recommended surgery for patients with "hot" scans, while conservative and follow-up studies can be undertaken in "cold" lesions. koivunen" suggested that an osteoma in the paranasal sinus should be removed if it shows any sign of growth, if it fills more than 50% of the volume of the sinus or if it causes any symptoms. rappaport et al 8 also suggested removal of the tumour if it were located close to the nasolacrimal duct. conclusion although osteomas of the frontal sinus are benign histologically, they can cause serious intracranial complications. in complicated cases, surgery is indicated, while in asymptomatic lesions factors concerning the proper management have been suggested. acknowledgements the authors wish to thank prof malai muttarak and prof wilfred cg peh for their advice, encouragement and review of the manuscript. references 1. markham f. the clinical features of pneurnocephalus based upon a survey of 284 cases with report of 11 additional cases. acta neurochir, i 967; 16:1-78. 2. cu hing h. experiences with orb itoethmoidal osteoma having intracranial complications. slirg gynecol obstet, 1927; 44: 721-742. 3. montgomery ww. osteoma of the frontal sinus. anyl oto rlnno! laryngol, 1960; 69: 245-255. 4. koivunen p, lopponen h, fors ap, jokinen k. the growth rat of osteomas of the parariasal sinus s. clil1 otolaryngol, 1997; 22: 111-114. 5. spencer mg, mitchelli db. growth of a frontal sinus osteoma. ] laryl1gol otol, 1987; 95: 291-304. 6. shibata y, matsumura a, yoshii y, nose t. osteoma of th skull: comparison of magnetic resonance imaging and histological findings. nel/rol med chit (tokyo), l 995; 35(1) 13-6. 7. noyek am, ch ap n ik js, kirsh jc. radionuclide bone scan in frontal sinus osteoma. aust nz] surg, 1989; 59: 127-132. 8. rappaport jm, attia el. pneurnoccphalus in frontal sinus osteoma: a case report. ] cnolaryngo], 1994; 23: 430-436. british journal of radiology web site he british institute of radiology have recently announced the establishment of a web site at http://www.bir.org.uk, allowing access to the british journal of radiology articles before they are published. this is primarily intended for subscribers, but one can preview complete sample back issues at http://www.bir.org.uklonline/sample.html. or apply for a free three-month trial subscription. one is able to view complete articles with hyperlinks to figures and references. this site gives an excellent feel of what will be possible in the future, when more journals become available in electronic format on the internet. http://www.bir.org.uk 31 sa journal of radiology· november 1998 http://www.bir.org.uk, http://www.bir.org.uklonline/sample.html. http://www.bir.org.uk book review ti1le: childhood tuberculosis: modern imaging and clinical concepts principal authors: professor bryan cremin and dr douglas jamieson publisher: springer-verlag, london, 1995 pages: 122 this beautifully presented book containing 141 figures is pleasing to handle and to read. the headings of the eight chapters give a very fair indication of the content of the book. in an abbreviated form these read: • historical and pathological background • biology of the organism and the host pathogen response • pulmonary tuberculosis • central nervous system tuberculosis • abdominal tuberculosis • skeletal tuberculosis • clinical spectrum and diagnosis, and • drug treatment and resistance the book is extremely relevant to almost all disciplines of medical practice but is directed at the practising radiologist. the principal author has a long-standing interest in the radiology of tuberculosis in childhood and has built up a vast "hands on" experience. this fact is clearly discernible in the book. the four chapters which form the radiological focus of the book are based on system involvement by the disease. each chapter starts with a descriptive outline of the various forms of radiological investigation of that particular system. the approach is practical, with clearcut opinions. extremely useful information is given in the actual performance of certain examinations, such as the high kilo-voltage filtered chest radiographs. the accompanying pictures are mostly easy to interpret or are clearly labelled, and follow the text closely.the protean radiological manifestations of primary pulmonary tuberculosis are emphasised. this is especially evident in patients with immune deficient states. the authors stress the importance of reviewing the full series of chest radiographs as this often influences one in considering the likelihood of the disease being tuberculosis. the hallmark of the disease is lymphadenopathy which occurs in 63-95% of x-rays, especially in the younger child. they again emphasise that a normal chest radiograph does not exclude pulmonary tuberculosis. the radiological picture of disseminated pulmonary disease is usually not that of diffuse equalsized small nodules. there is often a linear component to the opacities, and confluent opacification. in the chapter on cerebral tuberculosis,the authors emphasize the difference between the two forms of necrosis which occur in tuberculomata: the gummatous type, and the purely cellular form which includes caseous necrosis. they describe the computer tomographic and magnetic resonance images of these various granulomata. 20 sa journal of radiology. february 1998 the authors often refer to the rim enhancement which occurs in nodes after intravenous contrast administration. they also emphasize that tuberculous osteo-arthritic disease is often an indolent, painless process, and hyperaemic loss of bone visualization is frequently an early manifestation. linear tomography may often show lytic bone areas not appreciated on plain films. these chapters on systemic tuberculosis end with a list of other conditions which could simulate the radiological changes seen in tuberculosis. practical tips are given in differentiating between these conditions. the approach is realistic and clearly based on actual experience. the four remaining chapters are each written by an expert in that field. the statistics are awesome. eight to ten million new cases and three to five hundred thousand deaths from tuberculosis occur each year. children are especially susceptible to disseminated disease, and the incidence in sub-saharan africa is particularly high. the pathological change which occurs in the disease is clearly explained, and the biological and host-pathogen relationship of myobacterium tuberculosis is vividly detailed with clear, well illustrated diagrams. it is generally accepted that the bacillus can remain dormant in a macrophage or in a granuloma for years or decades. the genetic basis of resistance and susceptibility to the bacillus is briefly explained. the possibility of developing a protective vaccine is discussed. professor kibel gives a brief but clear outline of the clinical spectrum and diagnosis of the disease, and professordonald emphasisesthe indications, topage22 siemens at the forefront of the constant evolution of medical technology, the challenge is to make the world of mr a better place for you and your patients. the innovative magnetom harmony 1.0t and magnetom symphony 1.5t is like music in the ears of the patient and doctor. they are the first new generation of compact magnets that do not compromise a 50cm field of view. the efficiency of the process is optimised by the use of the integrated panoramic arrav tm which introduces a new coil system that saves time, ensures the patient's comfortability and sets the future standard. these latest additions to the family come in attractive colours and the two machines share the same dimensions. this modular system can easily be upgraded which will last you well into the future. the magnetom open viva 0.2t is more comfortable in that it reduces patient claustrophobia and the attractive design warms the nervous patients up towards the therapy. the magnetom vision plus, pushing the limits of mr. the redesigned magnetom vision plus remains the research flagship of our product family. siemens mri always staying advanced, saving time, controlling costs and improving confidence and comfort. for more information contact: siemens medical engineering, tel: (011) 652-2344, fax: (011) 652-2322 e-mail: medical@siemens.co.za 1:':..'p: '" .... '" ,y ~ ,~ , • •• , " . ";'~;1'~~:')~~:~~:~" :~..,;>, <11 ::'<~,<~; :t i».. 3e :::s < <_. en_. e :::s "c-cen al bmed-056/1.98 mailto:medical@siemens.co.za 8001< review frompage20 uses, actions and side effects of the drugs used to treat the condition. this reviewer read through the book three times and gained a little more on each occasion. he enjoyed the experience and congratulates all the authors for an important contribution to the understanding and diagnosis of a most important condition. reviewer: prof hillel goodman, groote schuur hospital allan cormack clinical use of isotopes. he particularly acknowledged the contributions of professor rw james of the uct physics department, and dr muir grieve, a groote schuur hospital radiotherapist, in encouraging him to make his discovery. he was awarded the nobel prize for physiology and medicine together with sir godfrey hounsfield in 1979. he is only one of three south africans to have won a scientific nobel prize (with max theiler and aaron klug). he later worked at cambridge, harvard and subsequently tufts university, where he became chairman of the department of physics. the first ct scanner was placed into clinical service in london in 1971, and his insight has since gone on to revolutionise our profession. he died on 9 may this year at his home in winchester, massachusetts at the age of 74. acknowledgements uct monday paper, may 18-25, 1998, vol. 17: no 13; obituary, emeritus professor of physics, robin cherry, sunday times allan cormack shares the distinction of having founded the mathematical principles of the image reconstruction techniques used in computerised tomography and magnetic resonance, together with sir godfrey hounsfield. he also had close ties to the university of cape town physics and radiology departments, where he made his important mathematical deductions in 1957. born in johannesburg, he matriculated at rondebosch boys high, and received his msc in physics at uct in 1945. his original work on resolving the problems of axial imaging was based on a phantom made of an aluminium cylinder surrounded by a wooden cylinder, together with the use of radioisotopes to confirm his mathematical suspicions. he published these findings in 1963 and 1964, establishing the core logic of axial tomography, which hounsfield took to commercial completion. at the time of his momentous discovery he was working in the radiology department supervising the title: clinics in diagnostic imaging author: wilfred peh publisher: miller freeman price: uso 15 pages: 255 isbn 981 04 01337 this book consists of 30 case presentations with radiological images and a discussion with each case. the cases cover all important areas of imaging from head and neck to gynaecology. the images are of good quality. the discussions are excellent with current references. this book will be very useful for registrars preparing for the final fellowship examination. the university of pretoria is planning a congress for 10-12 february 2000. topic: "chest radiologyadult and paediatric" congress chairman: prof sf prinsloo venue: csir, pretoria tel: (012) 354-2406 please make a note of this in your diary if you are fax: (012) 329-6763 interested department of radiology,faculty of further details will he forthcoming medicine, university of pretoria, congress co-ordinator: dr ll sirkin po box 667,pretoria,oool advance notification of chest radiology congress 22 sa journal of radiology· february 1998 technology today i ntegration of the meditee system in the radiology department of the university of the free state j fourie mbchb r laubscher mbchb department of diagnostic radiology university of the free state bloemfontein history the meditec system is a hospital information system (his) comprising various modules. it was first incorporated into all three of the provincial hospitals in bloemfontein in 1996.at first only the laboratory module was installed to process blood results faster. the final aim was to move to a more assessible and paperless system. due to the success of the system it was decided to enlarge it to incorporate other modules.. the departmental module was incorporated at the beginning of 2000. the aim of the departmental module was not only to incorporate a paperless system, but also to give doctors permanent and immediate access to results obtained from special examinations done and previous patient data. implementation the departmental module of the meditec system consists of an empty shell that gives the person designing the system a free hand to customise the system to his/her department's individual needs. doctors from every department were involved in designing the system. in this article we will focus on how the system was customised to our department's individual needs and the advantages we get from using the system. the three main components of the system are the application forms, the report forms and the retrieval of statistics from the system. application forms the application form developed for the system was designed to be specific to the examination requested in that the questions on the form were appropriate to the examination done. the application form was designed to give the full details automatically for the patient as well as the 41 sa journal of radiology • june 2002 doctor requesting the examination. the advantage of this was that the requesting doctor could easily be reached. in a teaching hospital complex such as ours the doctors also vary from year to year. the advantage of this type of request form is that some of the fields are mandatory and doctors are only asked questions pertinent to the type of investigation. mandatory fields play a role in ensuring patient safety, for example fields enquiring about metallic implants in requests for mr! investigations, or fields relating to known allergies to iodine in requests for examinations where contrast is likely to be administered. these application forms can then be viewed on screen in the department or (as is the case in our department) they can be printed out automatically in the area where bookings for that examination are made. certain fields on the application form are examination-specific and are filled in by the radiographer who has done the procedure. these fields include the specific examinations done on the patient and the materials used. this enables the billing system to run smoothly. a statistical field was designed specifically for use in our department and includes the code of the radiographer and/or student who did the examination, and the number and type of films passed and rejected. report forms the reporting doctor has the advantage of having access, via the meditec database, to all previous results such as haematology, cytology, previous radiological examinations and previous patient notes to assist technology today him/her in making a diagnosis. as a lot of patients have to go back to the referring clinics after the examination the films can now be given directly to the patient after the examination, and the referring doctor has access to the report on the system. the average time from the reporting doctor receiving the films to the report being available in a draft format on the system is about 20 minutes. this report is available not only to the referring doctor, but to all other doctors involved in caring for the patient. the patient's information is accessed using a patient enquiry system. this system groups all the reports from all departments on one page and allows the doctor easy access to the relevant results. the report can be viewed at universitas and national hospitals (pelonorni hospital does not have the departmental module as yet) as soon as it is typed in our department. all reports are signed digitally on the system after they have been checked by the reporting doctor. all changes to reports are monitored by the system for medical-legal reasons. statistical use information provided by the doctor as weil as the attending radiographers is fed back into the system. these data can be recalled in any way depending on the statistics needed. for example: • ordering films in the department. the system can provide the exact amount and size of films used over any given time. • as such a wide spectrum of information is fed back into the system, the data can also be used for compiling studies. • machine use can be evaluated by the number of examinations done per machine over a specific time. • the work done by individual doctors can be monitored for individual statistics and work performance. if the need arises for specific information, the application forms on the system are flexible enough to be changed easily so that additional data can be gathered. the future although the system has already changed our department to a large extent there are other modules that can be added to the system. for example, the meditec offers a pacs system for the storage of digital film and an internet module that makes patient information as weil as x-ray films available to registered users. various other modules assist in booking patients and cost control for the hospital and departments. the implementation and continuous use of the system was and still is without any problems. it is one of the few complete hospital information systems in the country that not only covers the whole spectrum of needs in a large hospital but because of its modular design also gives the system' the ability to grow with the needs of the hospital. 42 sa journal of radiology • june 2002 case report carotid cavernous •aneurysm in an h iv-positive patient abstract an intracavernous carotid aneurysm in an hiv-positive patient with tuberculous meningitis is presented. hivassociated intracranial aneurysms are rarely detected in adults, unlike children. the aetiology is postulated. p corr frcr s nadvi* fcs (sa) depal1ments of rad/%gy and neurosurgery", university of nata/ & wentwol1h hosp/ta/, durban introduction cerebral aneurysms are increasingly being detected in children who are seropositive for the human immunodeficiency virus (hiv).1,2there has, however, to the best of our knowledge, been only one report in the literature of six adult hn-positive patients who presented with subarachnoid haemorrhage from berry aneurysms.' we present a caseof a woman who washnpositiveand developed an intracavemous carotid aneurysm while being treated for tuberculous meningitis. 4 sajournal of radiology. october 2000 case report a 27-year-old woman presented with a five-day history of headache, neck pain and confusion. clinical examination detected a slightly confused patient with a glasgow coma scale of 14 out of is, with definite neck stiffness. lumbar puncture detected 22 polymorphs, l82lymphocytes, 2 080 red blood cells, elevated protein level and slightly diminished glucose levels.the globulin levels were, however, elevated and the bacterial and cryptococcal antigens were negative. a clinical diagnosis of tuberculous meningitis (tbm) was made and antituberculous treatment was started. a ct scan was performed on admission to hospital, which demonstrated dilatation of all the ventricles, with basal cistern enhancement consistent with tuberculous meningitis. the hydrocephalus was treated with a ventriculoperitoneal shunt, with csf pressures returning to normal the next day. the hiv test (elisa) was positive in a titre of one in 37. no organisms were grown from the cerebrospinal fluid. on the 4th post-operative day, the patient developed a right 6th cranial nerve palsy. mr imaging performed on the 4th post-operative day demonstrated a right fusiform intracavernous carotid aneurysm on the t2 weighted axial image through the skull basel confirmed by the 3d time of flight sequences (figures la, ib and l c). this aneurysm was not identified on the admission ct scan study. the patient's confused state remained unchanged and she suffered a cardio-respiratory arrest and died on the 6th post-operative day. an autopsy was not performed. topage6 carotid cavernous arie urvst n in an h iv-positive patient from page 4 cerebral arteries." this patient developed an aneurysm of the intracavernous portion of the right internal carotid artery that was not identified on the first ct scan. as we do not have pathological proof of the aetiology of the aneurysm in this patient, we can only postulate that it could be due to hw infection or following tuberculous meningitis. tuberculous meningitis can cause a vasculitis of small arterioles, resulting in vascular occlusion, although mycotic aneurysms of large arteries such as the internal carotid artery are rare. hiv-associated fusiform cerebral artery aneurysms have been detected by imaging in two out of 250 hivpositive children presenting for routine imaging," in both these patients the aneurysms were silent, despite progressing to marked dilatation. fusiform dilatation of the arteries of the circle of willis has been described in three children." pathologically there is an inflammatory vasculopathy resulting in a panarteritis. the arteritis starts in the adventitia and involves the vasa vasorum, resulting in ischaemia of the vessel wall.' the ischaemia causes destruction of the elastic lamina and subintimal fibrosis, figure te: t2 weighted axial mr scan demonstrates hydrocephalus with a right ventricular peritoneal shunt in situ. note the aneurysm of the internal carotid artery (arrow). figures ib and te: mra time of flight sequence confirms the right inlracavemous carotid aneurysm in the axial and coronal planes (arrows). discussion vascular complications in patients who are infected with the hw virus include stroke from small vessel vasculitis, cerebral haemorrhage from thrombocytopenia and intratumoural bleeds, and granulomatous angiitis of the main 6 sa journal of radiologyoctober 2000 resulting in fusiform aneurysm formatien." using the monoclonal antibody staining techniques to gp 41, which is the major glycoprotein of the hw viral membrane, the aneurysm wall demonstrates positive staining of the intima but no staining of the media or adventitia for the viral glycoprotein.' aneurysms of medium and large arteries such as the common carotid, iliac and femoral arteries have also been recorded in hlv-positive patients. 7 the pathology is identical to the cerebral aneurysms identified with acute and chronic panarteritis with occluded vasa vasora.' these aneurysms tend to be multiple. the natural history of cerebral aneurysms in hlv-positive patients is unknown apart from the one report suggesting rapid growth in size," further research is required to determine the true incidence of cerebral aneurysms in hlv-positive patients and to further investigate the aetiology of the pathological changes identified. references 1. dubrovsky t, curless r, scott g, chaneles m, post mj,altman n, petito ck, start d, wood c. cerebral aneurysmal arteriopathy in childhood aids. neurology 1998; 51: 560-565. 2. fulmer bb, dillard sc, musulman em, palmer ca, oakes j. two cases of cerebral aneurysms in hlv+ children, pediair neurosurg 1998; 28: 31-34. 3. maniker ah, hunt cd, cerebral aneurysm in the hiv patient: a report of six cases. surg neuro11996; 46: 49-54. 4, shah ss, zimmerman ra, rorke lb,vezina lg. cerebrovascular complications of hiv in children.ajnr 1996; 17: 1913-1917. 5. yankner ba, skolnik pr, shoukirnas gm, gabuduzda dh, sobel ra, ho dd. cerebral granulomatous angiitis associated with isolation of human t lyrnphtropic virus type iii from the central nervous system. ann neuro11986; 20: 362-364. 6. husson rn, saini r, lewis ll, butler km, patron as n, pizzo pa. cerebral artery aneurysms in children infected with the human immunodeficiency virus. j peduur 1992; 121: 927-930. 7. nair r, abdool carrim a, chetty r, robbs 1. arterial aneurysms in patients infected with human immunodeficiency virus: a distinct clinicopathology entity? ) vase st/rg 1999; 29: 600-607. revievv article magnetic resonance features of intracranial tuberculosis in children s andronikou mbbch (w/ts), fcrado/ag, frcr (lond) e kader mbchb cjwelman mbchb department of paediatric rsd/ology, un/vers/ty of gape town and /nstttute of child hes/th, red cross children s hosplts/, rondebosch, cape town corresponding author or sawas andronlkou deparlmbnt of pb8diatr/c radiology, univ8rsity of cape town and jnstjtuts of ch/id heajth, rad cross chi/dr9n's hospital, rondbbosch, cape town, 7700 te/: (021) 658-5422. fax: (021) 658-5101. e-msil: docsav@mweb.co.za abstract accepted as a poster for the 37th conference of the european society of paediatric radi%gy, lisbon, portugal (22-26 may 2000) intracranial tuberculosis in children is seen as either parenchymal tuberculous lesions or tuberculous meningitis (tbm). this article demonstrates the mr features of tbm and the two varieties of tubercu lous (tb) granulomata. gummatous granulomata (tuberculomata) comprise 90% of presenting intracranial tb lesions. they have a characteristic low signal on t2-weighted sequences that differentiates them from other commonly encou ntered ri ngenhancing lesions such as neurocysticerci. tb abscesses are very rare and have the same 10 sa journal of radiology· february 2001 features as pyogenic abscesses. features of tbm include hydrocephalus, basal meningeal enhancement and basal ganglia infarctions. introduction the western cape has one of the highest incidences of intracranial tb in the world. this may take the form of tbm where the patient presents with a decreased level of consciousness, cranial nerve palsies and hemiplegia.' in contrast, intracranial granulomata usually manifest with seizures.' this article demonstrates the mr imaging features of these forms of intracranial tb. discussion in areas endemic for intracranial tb, neurocysticercosis may also be endemic/ and is regarded as a more common cause for childhood seizures. the management of these two entities differs and it is therefore crucial to differentiate between them,' especially as current antitb therapy has significant side-effects. not only is mri more sensitive in detecting lesions, but it is also able to differentiate the more common type of tb granuloma from a neurocysticercus. tuberculomata (gummatous granulomata) comprise approximately 90% of intracranial tb lesions and are hypo intense on t2weighted sequences'? (figure 1). neurocysticerci, in contrast, are t2 hyperintense." the t2 imaging characteristics are, however, not pathognomonic of tb, as syphilis' and densely cellular neoplasms such as germinomas and p-nets (medulloblastomas) can topage11 mailto:docsav@mweb.co.za magnetic resonance features of intracranial tuberculosis in children from page 10 figure 1: gummatous granuloma/tuberculoma a. ti-weighted mr shows a left-sided cerebellar lesion that is isointense to brain b. t2-weighted image shows a lesion that is hypointense to brain and is surrounded by high-signal oedema c. ti-welghted post-gadolinium mr shows ring enhancement of the lesion 11 sa journal of radiology. february 2001 figure 2: tuberculous abscess also be hypointense on t2-weighted images," the latter entities, however, can frequently be excluded, as they have additional imaging characteristics and do not show typical ring enhancement with gadolinium. tb abscesses are relatively rare (figure 2). pathologically they contain liquefied or caseous material that differentiates them from the gummatous material seen in tuberculomata (gummatous granulomataj.ê+' they are inseparable on mr imaging from neurocysticerci, cystic neoplasms and fungal and pyogenic abscesses, which are all t2 hyperintense.i" granulomata may occur in clusters or may exist simultaneouslyin multiple sites. s when granulomata abut the meningeal surface, they may rupture into the meninges and cause tbm2 (figure 3). the classic triad of tbm is basal meningeal enhancement, hydrocephalus and basal ganglia infarction.' the most consistent finding in tbm is hydrocephalus.l-" basal meningeal enhancement is often very pronounced (figure 4a), but can also be seen in bacterial meningitis and may sometimes be absent in confirmed cases of tbm.! angiitis of the small vessels passing through the inflamed meninges can lead to infarctions in the basal ganglia region (figures 4b and 4c). it is these infarcts that determine the morbidity and mortality associated with tbm.u,s mri is more sensitive than ct in detecting basal meningeal enhancement as well as the infarctions. the infarcts have a low signal on tl and are t2 hyperintense, while tuberculomata are isointense on tl and hypointense on t2, tuberculomata are only found in 10% of cases oftbm.2 conclusion mri can differentiate tb granulomata from neurocysticerci and other ring-enhancing lesions. this has a significant impact on therapy and avoids topags 12 magnel ic: resona nee feéllli res of inlracranial tuberculosis in children frampage 11 figure 3: clusters and multiple granulomata: clusters of granulomata are seen abutting the basal meninges the unnecessary use of potentially harmful medication. the detection of tbm and associated infarcts is improved. in our population, where the incidence of tb is very high, the clinical suspicion of intracranial tb, in the appropriate clinical setting, is always high. it is important to note that there is no single diagnostic feature of infigure 4: tbm and its complications a. t1-welghted post-gadolinium mr demonstrates basal meningeal enhancement, dilated temporal horns indicating hydrocephalus and a cerebellar tuberculoma b. t2-weighted image demonstrates hydrocephalus and areas of infarction in the right basal ganglia region 12 sa journal of radiology. february 2001 tracranial tb and the diagnosis should be based on a combination of imaging characteristics, clinical findings and laboratory data.' acknowledgements we would like to thank helen tomazos and medical graphics for their help in the preparation of this article. references 1. schoeman j, hewlett r, donald p. mr of childhood tuberculosis meningitis. neuroradiology 1988; 30: 473-477. 2. jamieson dh. imaging intracranial tuberculosis in childhood. pediair radial 1995; 25: 165-170. 3. gupta rk, pandey r, khan em, mittal p, gujral rb, chhabra dk. intracranial tuberculomas: mri signal intensity correlation with histopathology and localised proton spectroscopy. magn resan imag 1993; il: 443-449. 4. gupta rk, lena a, singh ak, sharma a, puri v, gupta m. role of magnetic resonance (mr) in the diagnosis and management of intracranial tuberculosis. clin radial 1990; 41: 120-127. 5. salgado p, del brutto oh, talamaso o, zenteno ma, rodriguez-carbajal j. intracranial tuberculoma: mr imaging. j neuraradialagy 1989; 31: 299-302. 6. barkovich aj. pediatric neuraimaging. baltimore: lippincott-raven. 1996: 331, 397. 7. whitener dr. tuberculous brain abscess. arch neural 1978; 35: 148-155. 8. waecker jr nj, connor jd. central nervous system tuberculosis in children: a review of30 cases. pediatr infect dis j 1990; 9: 539-543. abstract introduction research methods and design results discussion limitations conclusion acknowledgements references about the author(s) jacobus möller department of clinical imaging sciences, universitas academic hospital and university of the free state, south africa tiaan steyn department of clinical imaging sciences, universitas academic hospital and university of the free state, south africa nantes combrinck department of clinical imaging sciences, universitas academic hospital and university of the free state, south africa gina joubert department of biostatistics, university of the free state, south africa alicia sherriff department of oncology, universitas academic hospital and university of the free state, south africa jacques janse van rensburg department of radiology, universitas academic hospital and university of the free state, south africa citation möller j, steyn t, combrinck n, joubert g, sherriff a, janse van rensburg j. inter-observer variability influences the lugano classification when restaging lymphoma. s afr j rad. 2018; 22(1), a1357. https://doi.org/10.4102/sajr.v22i1.1357 original research inter-observer variability influences the lugano classification when restaging lymphoma jacobus möller, tiaan steyn, nantes combrinck, gina joubert, alicia sherriff, jacques janse van rensburg received: 24 apr. 2018; accepted: 20 may 2018; published: 31 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: lymphoma is an important and potentially curable oncological disease in south africa. the staging and restaging of lymphoma have evolved over the years, with the latest international consensus guideline being the lugano classification (lc). prior to routine implementation of the lc, its robustness in the local setting should be determined. objectives: to determine the inter-observer variability in response assignment when applying the lc in patients with lymphoma who were staged and restaged with computed tomography. in case of excessive discordance, specific mitigating measures will have to be taken before and during any proposed implementation of the lc. method: a total of 61 computed tomography scans in 21 patients were evaluated independently by four reviewers according to the lc, of which 21 scans were done at baseline, 21 at initial restaging and 19 at follow-up restaging. a retrospective comparative analysis was performed. kappa values were calculated to determine agreement between observers. results: only a moderate inter-observer agreement of 52% in the overall response classification was demonstrated. the most important sources of discrepancy were inconsistency in the assessment of target lesion regression to normal, determining the percentage change in the summed cross-sectional area of the target lesions and ascribing new lesions as either due to lymphoma or other causes. conclusion: implementing the lugano classification when restaging lymphoma is desirable to improve consistency and to conform to international guidelines. however, our study shows substantial inter-observer variability in response classification, potentially altering the treatment plan. dedicated training and continuous quality control should, therefore, accompany the process. introduction south africa has a high burden of cancer, of which lymphoma is an important and potentially curable condition.1 the oncological staging and restaging of patients with lymphoma have undergone several changes over the years, with the latest international consensus guideline being the lugano classification (lc).2,3 the lugano classification (lc) (figures 1 and 2) was conceived as an unambiguous and universally applicable lymphoma staging system, suitable for both clinical practice and trials, to enable multicentre investigative studies and facilitate the evaluation of new therapies by healthcare authorities.4 internationally, combined positron emission tomography and computed tomography (pet-ct) is considered to be the principal imaging method for staging and restaging of lymphoma, although stand-alone ct is regarded as an acceptable alternative when pet-ct is unavailable.5,6 figure 1: applying the lugano classification with computed tomography. figure 2: response to treatment according to the lugano classification. however, the south african circumstances, in general, and those of the free state province, in particular, differ significantly from the developed world.7,8,9 for instance, pet-ct is unavailable in government hospitals in the free state and four other south african provinces, at least in part because of limited financial resources. the situation is complicated further by the large rural population, which hampers regular follow-ups at centralised treatment centres and the advanced nature of the lymphoma at presentation, often with concomitant human immunodeficiency virus (hiv) and opportunistic infections, such as tuberculosis (tb).10 size measurement is a fundamental part of ct interpretation in both oncologic and non-oncologic settings.11 ct measurements are used as imaging biomarkers or surrogate endpoints for assessing treatment response when applying the lc with lymphoma. patients are then assigned to one of the following categories, predominantly based on the measurements obtained with ct: complete response (cr), partial response (pr), stable disease (sd) or progressive disease (pd).12,13 possible sources of error during ct analysis in lymphoma include intraand inter-observer variability and inconsistent application of measurement criteria, which may lead to discordance in the evaluation of the tumour response.14,15,16 furthermore, ford et al.17 described a number of errors that can lead to misclassification of the treatment response: firstly, human error, where lesions are missed during evaluation, incorrectly measured or inappropriately regarded as target lesions; secondly, data errors, where all the available imaging and clinical information were not considered; thirdly, application errors, where the response criteria were inconsistently applied; and fourthly, conclusion errors, where the reader makes an incorrect assessment of the otherwise valid data. to the best of our knowledge, there is no published research that specifically addresses inter-observer variability when applying the lc to ct-scans performed in patients with lymphoma. studies in a similar manner either used different ct criteria (international harmonization project [ihp]), a different imaging modality (pet-ct), or assessed the ct response criteria utilised for solid tumours (response evaluation criteria in solid tumours [recist]).18,19,20 the inconsistent assignment of response categories among different reviewers has obvious negative implications for patient management. assigning an erroneous response category will lead to either overtreatment or undertreatment, with its associated risks.17 the objective of this study was to determine the inter-observer reproducibility of the response to treatment assessment according to the lc when using ct in patients with lymphoma. this would demonstrate whether the lc is robust enough to be introduced directly into routine clinical practice in the south african public sector setting or whether additional measures, such as dedicated training and continuous quality control, would be necessary. research methods and design setting locally (bloemfontein), universitas hospital and its annexes serve as the oncology referral centre for central south africa and lesotho. standard practice with lymphoma is to perform a baseline ct-scan prior to the initiation of therapy. generally speaking, an initial restaging scan is performed after two to four cycles of chemotherapy with follow-up restaging scans performed after four to six cycles and at the completion of treatment. the result of the ct-scan is integrated with that of the bone marrow biopsy and clinical findings by the oncologist. patients who do not at least have a pr to therapy after four cycles of chemotherapy are considered for second-line chemotherapy. patients with radiological evidence of residual disease at the completion of treatment or interim pd may need histological confirmation, followed by consideration of salvage chemotherapy and/or radiotherapy. patients and materials adult patients with newly diagnosed lymphomas, who presented for their baseline and restaging ct-scans at universitas academic hospital complex between january and november 2017, were considered for inclusion in the study. a total of 21 patients met the aforementioned criteria and were included in the study. a total of 61 ct-scans were performed in these patients: 21 scans were done at baseline, 21 scans at initial restaging and a further 19 scans at subsequent follow-up restaging. nine patients had one follow-up restaging scan, while five patients had two follow-up restaging scans. most (54) of the scans were performed with general electric’s six-slice scanner; the other seven scans were performed with general electric’s 64-slice scanner. with the six-slice scanner, scans were acquired from the skull vertex to the pubic symphysis. multiplanar reconstructions of the neck were performed at 1.25 mm slice thickness and for the rest of the body at 2.5 mm. with the 64-slice scanner, the base of the skull to the symphysis was included, and 1.25 mm slice thickness multiplanar reconstructions were performed of the whole body. design, procedure and analysis a retrospective, comparative analysis was performed. four reviewers reviewed all the scans of every patient independently. three of the reviewers were registrars, with three to five years of experience in interpreting body ct, while one reviewer was a specialist with more than 10 years of experience. the reviewers were provided with the clinical information that is routinely available in normal practice such as the histological results, hiv-status, concurrent or previous conditions of relevance (e.g. tb) and the findings of the clinical evaluation. the reviewers were then requested to complete data sheets for the baseline and restaging ct-scans according to the lc, which is elucidated in figure 1. at baseline, the initial step was to identify and measure the target lesions and determine the sum of the product of the diameters (spd). each reviewer selected their own target lesions. the next step was to measure the craniocaudal length of the spleen on the coronal view, from its dome to its inferior tip (figure 3). the final step was to identify and describe non-target disease, if any. figure 3: splenomegaly with the spleen measuring > 13 cm in the craniocaudal dimension. note the splenic lesion due to lymphoma (arrow). with the restaging ct-scans, the reviewers had to analyse the restaging scan and compare it with the previous scans. the previously identified target lesions were remeasured, and the new spd and the percentage change from the baseline scan were calculated. the spleen was remeasured and compared to the previous results. with the change in the spd and splenic dimension, the analysed variable was binary in nature, that is, ≥ 50% or < 50% for the spd or ≤ or > 13 cm for the spleen. next, previously identified non-target disease was reassessed as worse, stable or smaller, or resolved. if any new lesions attributable to lymphoma were detected, it was described as such. in case of progression, the product of the diameters of a single lesion was calculated, and the change from the nadir determined. finally, a response was assigned according to the lc (figure 2), as cr, pr, sd or pd (figures 4 and 5). results were summarised by frequencies and percentages, with 95% confidence intervals for main outcomes. kappa values were calculated to determine agreement between pairs of observers for the initial and follow-up restaging response classification. figure 4: progressive disease in hodgkin’s lymphoma, initial computed tomography (ct) (a) and restaging ct (b). figure 5: hodgkin’s lymphoma, with the initial computed tomography (ct) (a) and restaging ct (b) complete response to therapy with the axillary nodes regressing to normal size. ethical considerations ethical approval for the study was obtained from the health sciences research ethics committee administration (ufs-hsd 2017/1118) and free state department of health (fs_201710_009). no patient consent was necessary as the study was a retrospective analysis of data with no alteration in medical management. patient data could only be accessed by authorised medical personnel and were kept confidential at all times. patient data were anonymised prior to data interpretation. results patient age, lymphoma histology and treatment regimens are shown in table 1. ages ranged from 18–91 years, with a median of 38 years. hodgkin’s lymphoma (nine cases) and diffuse large b-cell lymphoma (five cases) were the most common histological type. adriamycin, bleomycin, vinblastine and dacarbazine (abvd) and infusional cyclophosphamide, doxorubicin and etoposide (cde) were the most common and second most common chemotherapy regimens respectively. out of 21 patients, 14 were living with hiv. table 1: patient histology, chemotherapy regimen and age. the frequency of inter-observer agreement was determined for each step in the process as previously set out (figure 1) with the calculated percentages shown in table 2. the κ-values for the initial restaging response assessment between pairs of observers ranged from 0.39–0.72 (moderate agreement); the follow-up restaging scans were analysed as a group with κ-values of 0.61–0.93 (moderate to strong agreement) between pairs of observers. table 2: inter-observer agreement with staging and restaging. finally, the overall concordance with regard to the combined initial and follow-up restaging response assessment was determined. complete agreement during the whole cycle was seen in 11 out of 21 patients (52%; 95% confidence interval: 30% – 74%). the reasons for discordance in the remainder of the patients are summarised in table 3. a significant change in management was possible in 8 out of 10 patients where dissent in the response assessment was demonstrated. table 3: reasons for discordance with response assessment. discussion the relatively high incidence (almost 20% of the total) of the otherwise rare plasmablastic lymphoma (figure 6) in this study can be ascribed to the presence of hiv and oncogenic virus infection, such as epstein–barr and kaposi sarcoma herpes virus, as discussed by cesarman.21 non-hodgkin’s lymphomas are considered as an acquired immune deficiency syndrome (aids)-defining condition and related to persistent antigenic stimulation, immune suppression and genetic disruptions. hodgkin’s lymphoma also has a higher incidence in patients with aids. figure 6: plasmablastic lymphoma presenting as a maxillary mass. initial computed tomography (ct) (a) and restaging ct (b), demonstrating a partial response. the high incidence of hiv (67%) corresponds with previously published data in the south african context, where de witt et al.22 found that 80% of diffuse large b-cell lymphomas were hiv related. the presence of hiv-related lymphoma at a younger age and in advanced stages tends to be more aggressive and has a poorer prognosis overall. there are also other issues which complicate treatment, such as the higher prevalence of opportunistic infections and organ dysfunction for example bone marrow suppression and renal impairment. simultaneous treatment with retroviral therapy when administering chemotherapy improves the response of the lymphoma.9,21,23 it is important to note that lymph node enlargement or splenomegaly does not necessarily equate to active lymphoma, especially in patients living with aids. hiv-associated lymphadenopathy in patients with active viral replication may be metabolically active with pet-ct, as will lymphoma.5 assigning lung infiltrates, consolidation or nodules as either due to infection or lymphoma is particularly problematic in the local patient population, given the high burden of hiv and tb. the most common reason (in 4 out of 10 patients) for response assessment discordance was an inter-observer difference in evaluation of target lesion regression to normal. this occurred most frequently with bony lesions with a soft tissue component where it was difficult to measure the soft tissue component reproducibly (figure 7). it was also seen with irregular and ill-defined lymph node masses and with lymph nodes where the long-axis was not orientated parallel to the axial plane. figure 7: restaging ct (a) initial computed tomography (ct) (b) right iliac skeletal lesion with a soft tissue component (arrow) where the soft tissue lesion proved difficult to measure reproducibly, resulting in significant inter-observer variability. other common sources of discrepancy were defining the decrease in the spd as either3 ≥ 50% or < 50% and categorising new lesions as due to lymphoma or other causes (two and two patients, respectively, one with both). the former mainly occurred as a result of variability in the initial choice of target lesions. the latter was seen with lung lesions, where some reviewers regarded it as evidence of new or progressive lymphoma and others ascribed it to infectious or non-lymphoma-related causes. reassessment of spleen size and non-target disease led to variance in response classification in two patients. there are definite limitations to the assessment of tumour involvement when using ct in lymphoma. a residual post-treatment mass can represent fibrosis instead of an active tumour. lymphoma can also manifest without readily definable mass lesions, such as diffuse infiltration of the viscera or bone marrow.12 to the best of the authors’ knowledge, no published research specifically addresses inter-observer variability when applying the lc with ct in lymphoma. therefore, we made a comparison with studies where observer variability was described with different response criteria, imaging modalities or as applied to cancers other than lymphoma. obviously, response classification has to be precise and reproducible in order to guide clinical management and determine trial outcomes. skougaard et al.16 assessed the inter-observer consistency (among 17 reviewers) of recist application with ct in a phase ii trial in colon cancer and found that the overall response was differently classified in 17 out of 100 patients, although the change was potentially treatment altering in only six patients. sources of discrepancy were the incorrect use of recist in the selection of target lesions, measurement of the tumour burden and identifying new lesions. the latter two discrepancies were also experienced in our study. the resultant variance in response classification was potentially treatment altering in 38% of our patients overall, which was higher than that experienced with the aforementioned study, where it was 6%. muenzel et al.18 studied intraand inter-observer variability between four reviewers in the measurement of target lesions and its implication for response evaluation, specifically when applying the recist criteria with ct in 20 patients with various cancers. it was found that there was high variability in the sum of the measurements that potentially influenced the response classification, leading the researchers to suggest use of the mean results of all observers to improve consistency. such an approach; however, would not be practical in the local setting, given the limited resources and personnel. interestingly, the aforementioned authors18 used proprietary software (lesion management solutions) to facilitate computer-aided measurement of target lesions. although the incorporation of computer-aided detection did not improve accuracy in their study, it led to significant timesaving, which should encourage radiologists to implement standardised restaging systems. other investigators have shown that computer-aided volumetric tumour assessment is a promising technique in improving inter-observer variability, both with detection and diagnosis of lesions.24,25,26 han et al.19 performed a retrospective review of 112 pet-ct-scans in 59 patients, using both the lc and the previous ihp criteria for response assessment in lymphoma, and found strong inter-observer agreement for initial restaging response assessment between the two readers (cohen κ = 0.76) as applied to the ihp criteria but only moderate agreement with the lc (cohen κ = 0.43). most of the variability arose from an inconsistent interpretation of the residual fluorodeoxyglucose uptake. moreover, our study revealed only moderate inter-observer agreement when using the lc, albeit with a different imaging modality. intraand inter-observer variability of ct measurements in oncology was studied by mcerlean et al.13 a total of 17 radiologists with varying experience measured lymph nodes, pulmonary and hepatic lesions in 205 patients with various cancers at different time points. factors that positively correlated with measurement reproducibility were pulmonary location, smooth margins, larger lesion size and reader’s experience. irregular, ill-defined lesions also decreased measurement reproducibility in our experience. accurate determination of pd is of particular importance, as progression-free survival is often utilised as a surrogate endpoint in cancer trials. yoon et al.20 performed a meta-analysis to determine observer variability in the measurement of tumour burden with ct according to the recist criteria. determining the overall tumour burden and the interval change in response to treatment varied to such an extent that misclassification as pd was observed. variability decreased with an increase in the number of measured lesions. our own experience mirrors this, where 14% of patients were inconsistently classified as having pd. limitations the study had a number of limitations that may have been a source of bias. firstly, although all 21 patients had at least a baseline and initial restaging scan, seven patients’ subsequent follow-up restaging scans could not be included for analysis, because of the time constraints inherent to the study. secondly, the study included a relatively small number of patients and reviewers, because of the mentioned time limitations. despite these limitations; however, we regard the core conclusion of this research as valid, which is that there is significant inter-observer variability when applying the lc. thirdly, the reviewers reviewed the sequential scans in any given patient themselves. in routine daily practice, the baseline and restaging studies are most often reviewed by different readers, which can be expected to lead to even greater variability. in the fourth instance, there was a difference in the training level of the reviewers, varying from registrar to consultant level. however, no demonstrable trend, where any single reviewer was consistently at odds with the consensus, could be identified. conclusion this study demonstrated only moderate inter-observer agreement for response assignment when restaging lymphoma with computed tomography according to the lc. in at least one-third of patients, this would have led to a change in the treatment plan. these include switching to more toxic second-line chemotherapy, extended treatment with additional cycles of chemotherapy and invasive tissue biopsies. positron emission tomography-computed tomography has been established as the superior imaging modality when it comes to staging and restaging of most lymphomas. however, the reality in the developing world is that access to pet-ct is limited to academic referral centres in the largest metropolitan areas. outside of these areas, the majority of patients are staged with ct only. in the interest of consistency, and in keeping with the international guidelines, it is advisable for radiology departments to implement the lc when staging and restaging lymphoma. in our experience; however, there is a substantial risk of inter-observer variability with regard to response classification, which will influence patient management. therefore, dedicated training is advised prior to introducing the lc in daily practice. then, regular review and combined radiology–oncology meetings are recommended for quality control purposes. also, when a change of therapy is being contemplated based on the imaging findings or when the imaging findings are at odds with the clinical response, histological confirmation should be sought. acknowledgements the authors wish to thank the radiographic and administrative personnel at universitas annex hospital for their assistance in accessing the relevant data. they also thank dr bruce cheson for his valuable feedback and ms anneline bothma for her assistance with the proofreading of the manuscript. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.m. was the principal investigator, planned and initiated the study, reviewed the scans and completed the data forms, did data collection, analysis and interpretation and wrote the final manuscript. t.s. and n.c. reviewed the scans and completed the data forms, did data collection and analysis, critically evaluated the manuscript and approved the final version. g.j. did the statistical analysis and co-designed the data forms, contributed to the planning, did data analysis and interpretation, critically evaluated the manuscript and approved the final version. a.s. reviewed the oncological data and advised on the clinical relevance, contributed to the planning of the study and data interpretation, critically evaluated the manuscript and approved the final version. j.j.v.r. was the study leader, reviewed the scans and completed the data forms, did data collection, analysis and interpretation, critically evaluated the manuscript and approved the final 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interpretation of lung nodules at low-dose screening ct. invest radiol. 2012;47(8):457–61. https://doi.org/10.1097/rli.0b013e318250a5aa; pmid:22717879 pmcid:pmc3501405 el-baz a, beache gm, gimel’farb g, et al. computer-aided diagnosis systems for lung cancer: challenges and methodologies. int j biomed imaging. 2013;1–46. https://doi.org/10.1155/2013/942353 abstract introduction imaging features case series discussion conclusion acknowledgements references about the author(s) adziambei mudau department of radiology, university of pretoria, south africa farhana e. suleman department of radiology, university of pretoria, south africa clara m. schutte department of neurology, university of pretoria, south africa zarina i. lockhat department of radiology, university of pretoria, south africa citation mudau a, suleman fe, schutte cm, lockhat zi. isolated posterior fossa involvement of progressive multifocal leucoencephalopathy in hiv: a case series with review of the literature. s afr j rad. 2017;21(2), a1262. https://doi.org/10.4102/sajr.v21i2.1262 case series isolated posterior fossa involvement of progressive multifocal leucoencephalopathy in hiv: a case series with review of the literature adziambei mudau, farhana e. suleman, clara m. schutte, zarina i. lockhat received: 02 aug. 2017; accepted: 29 aug. 2017; published: 14 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract progressive multifocal leucoencephalopathy (pml) is a progressive demyelinating condition resulting from infection with the john cunningham virus and precipitated by immunocompromised states. the hiv pandemic, especially in sub-saharan africa, has resulted in an increase in the number of patients presenting with pml. imaging plays an important role in diagnosis and the distribution of the disease is predominantly supratentorial. isolated posterior fossa involvement is a rare finding with very few cases described in the literature. we present the largest case series of patients described in the literature, with isolated posterior fossa involvement of pml, in hiv-positive patients. introduction progressive multifocal leucoencephalopathy (pml) is a demyelinating disorder, which results from opportunistic infection of the central nervous system (cns) with the john cunningham (jc) virus. this virus is believed to infect up to 80% of the human population prior to adulthood without producing obvious illness, and it remains latent until reactivation by an immunodeficient state.1 hiv infection is the most common predisposing factor for symptomatic jc virus disease, and the hiv pandemic has resulted in an increased prevalence of pml, affecting 3% – 7% of hiv-infected individuals before the highly active antiretroviral therapy (haart) era.2 although the frequency of pml has decreased with haart, a more significant decrease has been noted with other cns opportunistic infections.3 pml is recognised as an aids-defining illness, and the vast majority of hiv-infected patients with pml have cd4 lymphocyte counts < 200 cells/mm3. jc virus reactivation can, however, also occur in other patients with compromised immunity as well as in patients on chronic immunosuppressive therapy. there are several studies that have demonstrated a high sensitivity and specificity of cerebrospinal fluid (csf) polymerase chain reaction (pcr) for jc virus in pml.3 many authorities regard the demonstration of jc viral dna coupled with the appropriate clinical and radiologic features sufficient to be diagnostic of pml.4 table 1 summarises the diagnostic criteria for pml.4 the diagnosis can also be confirmed with tissue histopathology after brain biopsy. table 1: diagnostic criteria for progressive multifocal leucoencephalopathy4: clinical, radiographic and laboratory data. imaging features typically pml is a confluent, bilateral but asymmetric, supratentorial white matter disease. although lesions may develop in any area of the brain, they are most common in the subcortical white matter and u-fibres, favouring the frontal and parietooccipital regions. pml can be unilateral or rarely there may be only a single lesion.2 the lesions exhibit no mass effect and infrequent contrast enhancement.3 there is no involvement of the optic nerves or spinal cord. isolated posterior fossa involvement is rare, but has been described.5,6 clinical presentation is non-specific with focal neurologic deficits dependant on the lesion location. symptoms worsen over time as the lesions progress. most often, pml presents with motor deficits, visual disturbances and cognitive impairment, in a subacute evolution.7 with regard to imaging, computed tomography (ct) scan of the brain in patients with pml may show hypodense lesions. these lesions exhibit no mass effect and infrequently enhance post contrast.1,3 magnetic resonance imaging (mri) is, however, more sensitive to the white matter lesions of pml. on mri, pml demonstrates hyperintense lesions on t2-weighted and fluid attenuation inversion recovery (flair) sequences; hypointense signal on t1-weighted sequences and no mass effect, despite their size.1,3 enhancement can be seen with pml associated with immune reconstitution inflammatory syndrome (pml-iris), which occurs as the immune system recovers in patients commenced on haart. it is reported to account for up to 18% of pml in hiv-infected patients.8 tan et al. noted contrast enhancement in 56.7% of pml-iris cases.9 enhancement suggests an inflammatory component, but absence of enhancement does not exclude the diagnosis. diffusion-weighted imaging (dwi) has been related with the stage of the disease. active lesions demonstrate an incomplete rim of restricted diffusion, with high apparent diffusion co-efficient (adc) values in the centre of the lesion. no restricted diffusion is appreciated with older lesions. a larger central core is associated with a worse prognosis.10 case series case 1 a 34-year-old hiv-positive woman with a cd4 cell count of 24 cells/µl and not on haart, presented with confusion and ataxia. on examination, she had nystagmus, severe dysarthria and a broad-based gait. she had a history of alcohol abuse, and the possibility of wernicke encephalopathy was considered, which was treated with thiamine. mri was requested, which showed high-signal on t2-weighted and flair sequences in the left cerebellar hemisphere, pons and midbrain (figure 1). there was no restricted diffusion, no associated mass effect nor enhancement on post contrast imaging. the csf yielded no growth, and the jc virus pcr was positive. the patient deteriorated in the ward and subsequently demised. figure 1: axial flair image of the patient discussed in case 1, at the level of the pons demonstrating high-signal in the entire pons and part of the left cerebellar hemisphere. images at a lower level (not shown) demonstrated more extensive involvement of the left cerebellum. case 2 a 34-year-old hiv-positive man on haart presented with 1-month history of cerebellar ataxia. his cd4 count was 30 cells/µl. a ct scan of the brain showed hypodensity in the left cerebellar hemisphere and generalised cerebral atrophy. mri was requested, which showed multiple high-signal changes on t2-weighted imaging involving the pons and right cerebellar hemisphere with some enhancement post contrast (figure 2). no restriction was noted on dwi. tests for toxoplasmosis were negative, and csf yielded no growth. the jc virus was positive in the csf. the patient was treated with triple antibiotic therapy, as well as anti-tuberculosis medication. the possibility of a cns iris was considered, and a course of steroids was added. the haart was optimised and the patient was discharged to a rehabilitation unit. figure 2: sagittal pre-(a) and post-contrast (b) t1w images of the patient discussed in case 2 at the level of the right cerebellar hemisphere demonstrating low signal intensity in the cerebellum with enhancement in the same region post-contrast administration. case 3 a 40-year-old hiv-positive male patient on haart and anti-tuberculosis medication presented with 3-week history of loss of balance, dizziness and difficulty in speaking. on examination, he had ataxia, nystagmus, dysmetria and dysdiadocokinesis. his cd4 count was 167 cells/µl. mri showed high-signal on t2-weighted and flair images bilaterally in the cerebellar hemispheres with the right more involved compared with the left (figure 3). the lesions did not demonstrate any restricted diffusion or enhancement post contrast. the csf was not active and demonstrated no growth. the patient’s anti-tuberculosis medication was continued, and the haart was optimised. he was discharged to the rehabilitation unit. figure 3: coronal t2 weighted image of the patient discussed in case 3, showing high-signal in both cerebellar hemispheres with greater involvement of the right hemisphere. case 4 a 38-year-old male patient, hiv-positive with a cd4 count of 143 cells/µl, presented with left hemiparesis, diplopia and ataxia. he was not on haart. a ct scan of the brain showed asymmetric hypodensities in the cerebellum with no enhancement post contrast. mri showed bilateral confluent non-enhancing, cerebellar high-signal changes on t2-weighted and flair sequences with patchy changes in the brainstem (figure 4). the patient was advised regarding antiretroviral therapy (art) and was discharged. figure 4: axial t2 weighted image of the patient discussed in case 4, at the level of the cerebellar pontine angles demonstrating confluent high-signal changes in both cerebellar hemispheres and patchy changes in the pons. case 5 a 35-year-old male patient presented with dizziness, speech problems and cerebellar ataxia. he was hiv-positive with a cd4 count of 90 cells/µl. he was not on haart and anti-tuberculosis treatment for pulmonary tuberculosis. on examination, he was chronically ill with nystagmus, dysarthria, dysmetria, ataxia and left-sided hemisensory loss. jc virus was found on examination of the csf. ct scan demonstrated low density in the left cerebellar hemisphere, which did not enhance on the post contrast imaging (figure 5). t2-weighted and flair sequences on mri demonstrated high-signal changes in the left cerebellar hemisphere, left superior cerebellar peduncle and diffusely in the pons. no enhancement or restricted diffusion was noted. the patient was discharged to the rehabilitation unit. figure 5: axial (a) preand (b) post-contrast ct scan of the patient discussed in case 5, demonstrating low density in the left cerebellar hemisphere with no contrast enhancement of the lesion. case 6 a 38-year-old hiv-positive woman, with a cd4 count of 28 cells/µl, on haart, presented with progressive right-sided dysmetria and ataxia. the patient was pregnant at 30 weeks gestation. ct showed low density area in the right cerebellar hemisphere, which was shown on mri to extend into the right cerebellar peduncle, pons and medulla (figure 6). no contrast was administered because of the pregnancy. no restricted diffusion was noted. csf studies revealed no abnormalities except positivity of jc virus. the patient underwent an emergency caesarean section for foetal distress and was discharged back to the referral hospital. figure 6: axial t2 weighted image of the patient in case 6, showing high-signal changes in the right cerebellum and cerebellar peduncle. table 2 summarises the clinical and mri findings of the patients presented in the case series. table 2: clinical and magnetic resonance imaging findings of the patients. discussion in 2015, the world health organization (who) reported that 36.7 million people were living with hiv.11 sub-saharan africa remains the most severely affected, with nearly 1 in every 25 adults (4.4%) infected and accounting for nearly 70% of the people living with hiv worldwide.11 the estimated overall hiv prevalence rate is approximately 12.7% of the total south african population. the total number of people living with hiv in south africa is estimated at approximately 7.03 million in 2016.12 the hiv pandemic led to a new population of immunocompromised patients. studies suggest that hiv accounts for approximately 80% of the pml cases.2 the parietal lobe is the most commonly involved, followed by the frontal lobe. supratentorial lesions typically involve the subcortical white matter with a scalloping appearance.2 white matter of the posterior fossa is the next common area of involvement; however, isolated cerebellar white matter or isolated medullary involvement is less common.2 one study of 47 hiv-positive patients with pml reported only two patients with isolated posterior fossa involvement.1 in this article, we describe a case series of six patients, from a south african tertiary hospital, with isolated posterior fossa involvement of pml in hiv-positive patients. all patients tested positive for jc pcr in the csf. imaging plays a pivotal role in the diagnosis and follow-up of patients with pml.2 mri is the technique of choice for evaluation of this condition. all our patients had cerebellar involvement and no supratentorial involvement. post contrast enhancement was demonstrated in only one of the patients. progressive multifocal leucoencephalopathy can be differentiated from hiv encephalopathy, which shows a combination of atrophy and symmetric periventricular or diffuse white matter disease on imaging.13,14 pml usually spares the periventricular and deep white matter and causes no atrophy in the active phase of the disease.2 in cytomegalovirus encephalitis, the distribution of white matter lesions is periventricular, and subependymal enhancement is seen.13,14 more recently, pml has been associated with the administration of natalizumab, an immunomodulating monoclonal antibody, for the treatment of multiple sclerosis. given the presence of two demyelinating disorders, the diagnosis of new lesions and pml are challenging. similar to pml-iris with haart, iris can also develop in multiple sclerosis, once natalizumab is discontinued.15 the vast majority of hiv-infected patients with pml have a cd4 lymphocyte count of < 200 cell/mm3.4 csf examination is very useful in excluding other diagnosis, however, the greatest value of csf analysis is demonstrating the presence of jc virus by pcr.4 jc virus assay is positive in approximately 70% – 90% of patients not taking art but only as few as 60% of patients on art.13 all our patients had a positive jc virus pcr. the main treatment approach in hiv-related pml involves combination art. the introduction of more potent antiretroviral regimens has led to a considerable decrease in incidence and mortality of pml.13 progressive multifocal leucoencephalopathy in hiv-infected patients is associated with a poor prognosis, with approximately 50% mortality within 2 years from disease onset.16 this factor is totally dependent on co-morbid diseases in hiv-infected patients. conclusion we describe a series of six patients with pml with isolated posterior fossa involvement. in our literature search, there were only seven reported cases of pml isolated to the posterior fossa in hiv-positive patients.4,10 in one review of 47 patients with proven pml, only two had isolated posterior fossa involvement.1 the high number in our series is probably because of the high incidence of hiv infection in our region as well as the difficulties experienced by large numbers of patients in accessing adequate treatment. acknowledgements competing interests the authors declare they have no personal or financial relationship which may have influenced them in writing this article. authors’ contributions a.m. did the literature review and wrote the article. f.e.s. assisted in the writing of the 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https://doi.org/10.1212/01.wnl.0000343510.08643.74 cosottini m, tavarelli c, del bono l, et al. diffusion-weighted imaging in patients with progressive multifocal leukoencephalopathy. eur radiol. 2008;18(5):1024–1030. https://doi.org/10.1007/s00330-007-0845-1 global health observatory. hiv/aids. 2015 [cited 2017 july 18]. available from: http://www.who.int/gho/hiv/en statistics south africa. mid year population estimates 2016. 2016 [cited 2017 july 18]. available from: http://www.statssa.gov.za/publications/p0302/p03022016.pdf aidsinfo. guidelines for prevention and treatment of opportunistic infection in hiv-infected adults and adolescents. 2013 [cited 2017 feb 15]. available from: http://www.aidsinfo.nih.gov/guidelines osborn a, blaser s, salzman k, et al. diagnostic imaging brain. salt lake city, ut: amirsys inc.; 2004. dahraian ma, radue ew, eshaghi a, besliu s, minagar a. progressive multifocal leukoencephalopathy: a review of the neuroimaging features and differential diagnosis. eur j neurol. 2012;19(8):1060–1069. https://doi.org/10.1111/j.1468-1331.2011.03597 pavlovic d, patera ac, nyberg f, gerber m, liu m. progressive multifocal leukoencephalopathy: current treatment options and future perspectives. ther adv neurol disord. 2015;8(6):255–273. https://doi.org/10.1177/1756285615602832 editorial time for subspecialisation '? steve 8eningfield mbchb(uct), ffrad(d)sa head: department of radiology, university of cape town i am unsure who coined the description of radiology as being "the general practice of the specialties", but the expression appears to be becoming less true in the usa and other leading countries as subspecialisation occurs. for some time, the trend toward organ-specific imaging has dominated over the technique-specific approach. in the usa the diagnostic and interventive radiologists have effectively parted company, with separate subspecialties being registered. even within interventive radiology, for example, the interventive neuroradiologist, the interventive vascular radiologist and the interventive hepatobiliary radiologist have little in common. similar trends are found in other radiological groupings such as paediatric radiology and ultrasonography. in south africa a number of other medical, disciplines already have or are contemplating subspecialty registration for their special interest groups. previously general surgeons now concentrate on specific areas of interest such as vascular, colorectal, .gastric, hepatopancreatobiliary, endocrine, oncological, or breast surgery. legislated certification is becoming more commonplace as the various groups crystallise. the difficulty in south africa is that in almost all private and most full-time practices, diverse demands are placed on radiologists who are called upon to be all things to all men. is this sustainable, when one is competing with highly skilled colleagues who have an exclusive focus that includes the relevant imaging in their field? is there a prospect for subspecialisation in south african radiology, and if so, how should this be orchestrated? should formal fellowship programs be developed? should a "grandfather" clause be allowed? as the turf wars flare, the need for a more specialised radiologist may become unavoidable. it appears likely that in the same way as the do-itall general practitioner is a vanishing breed, the generalist radiologist may become a scarce resource. 3 sajournal of radiology· november 1998 tips a nursing perspective on sedating children for ct scanning having been a professional nurse in the ct scanning department at the red cross children's hospital since 1987 and having had to prepare children for ct scanning, i have found that the following groups of children almost always need to be sedated for the investigation: infants, toddlers, uncooperative children, those having long examinations and those who are developmentally delayed. we try to reason with older children before the examination and if we feel they will not lie still, we then sedate them. preassessment of children who are at risk of respiratory arrest is undertaken and sedation for these patients is administered only by the attending physician. we use the following pharmacological agents: barbara duminiet chief professional nursa: ganeral nursing, midwifery, paediatric nursing science ct scanning department, red cross war memorial children:s hospital, rondebosch, 7700, cape town tal: (021) 858·5422. fax: (021) 658·5101. e-mail: rxcfscan@pawc.wcape.gov.za 1. chloral hydrate (not available commercially, but made up by our local pharmacy) 75 mg/kg. if the child has not fallen asleep after an hour, a top-up dose of 25 mg/kg is given, thus making a maximum dose of 100 mg/ kg that a child may receive. 2. vallergan forte (trimeprazine tartrate) 4 mg/kg (manufactured by rhóne-poulenc rorer sa (pty) ltd). 80 sa journal of radiology. february 2001 3. paxical5 mginjection (droperidol) 0,2 mg/kg given orally (manufactured by pharmacare ltd). neonates are not sedated. prior to the examination they are given a feed and wrapped up warmly. children with a history of hyperactivity are given vallergan and droperidol orally as this seems to work better than chloral hydrate. those children having long examinations, e.g. chest and abdominal scans, are also given vallergan and droperidol, as this is long-acting. children with trauma injuries are sedated only if they are restless and the sedation is administered only by the attending traumatologist. in my experience, sedating children requires a great deal of patience and an understanding that each child is different. some children take longer to fall asleep and others may react differently to various sedatives, e.g. some children become hyperactive after being given chloral hydrate, some children become very tearful and others will go to sleep peacefully. we try to create a child-friendly environment by having a play area with toys, books and puzzles. to assist us in our efforts to get the children to sleep, we darken the area by closing the curtains, switching the lights off and keeping the noise level down. parents play an important role in the management of children, helping with explanations about the examination and allaying any fears that the child may have. i hope these tips will assist clinicians and nurses in sedating children, thereby avoiding general anaesthesia or the dangerous use of intravenous benzodiazapines. mailto:rxcfscan@pawc.wcape.gov.za editorial past, present and future peter corr mbchb, ffrad(d)sa, frcr, m med(uct) head: department of radi%gy, university of nata/ welcome to the "new sajr".the society has decided to continue with the journal after a break of 12 months. there are many reasons why south african radiology needs a journal. perhaps the most important is to advertise to our colleagues the important role radiologists play in modern medical practice. i never cease to be amazed by how ignorant many of our colleagues are about what we do. this poor local perception is in contradistinction to the prestigious image radiology has in europe and north america. we have only ourselves to blame. i have taken the opportunity to invite a number of colleagues to write about the past, the present and more importantly the future of radiology both in a local south african and an international context. i hope you enjoy this millennial edition and that it stimulates you to write to us with your comments and suggestions] peter corr editor 3 sa journ-'1lof radiology. january 2000 tips for the radiologist looking for the 'pea in a pod' among the 'swiss cheese' to diagnose • •neurocysticercosis savvas andronikou mb bch, fcrad(d), frcr (lond) bruce mcivor mbchb bruce smith mbchb department of paediatric radiology, red cross war memorial children's hospital, univeristy of cape town and institute of child health usually humans act as the definitive hosts for the parasite taenia solium, but they can occasionally also act as the intermediate host where the larval stage (cysticercus cellulosae) lodges in many organs of the body. the computed tomography (ct) and magnetic resonance imaging (mri) appearances in brain tissue vary according to the stages of evolution of the parasite. on ct, live larvae (vesicular stage) are hypodense (cerebrospinal fluid (csf) equivalent] round cysts, most commonly at the grey/white interface (fig. i). the scolex may be visualised as an eccentric hyperdense nodule on the inner aspect of the cyst wallthe 'pea in a pod' appearance. on mri the cyst contents are isointense to csf on all sequences (fig. 2). mri is more sensitive for identifying the scolex, fig. 1. contrast-enhanced axial ct of the brain demonstrating the typical appearance of neurocysticercosis, with multiple cysts (thin arrows) situated predominantly at the grey-white interface. the cysts are in the vesicular stage, as there is no surrounding oedema. the scolices are hyperdense (thick arrow), owing to the presence of calcareous corpuscles. this gives rise to the 'pea in a pod' appearance. calcified foci are noted in the left cerebral hemisphere in keeping with the calcified nodular stage. which is hyperintense on tl in the vesicular stage. when the scolex is calcified it shows a signal void on all sequences. when a larva is dying a granuloma forms, and perilesional oedema is seen due to the host response (fig. 3). the lesion is then seen as a ring or disc-enhancing lesion (fig.4). with multifocal ring lesions, the brain may have the appearance of 'swiss cheese' (fig. 2). the mural nodule (scolex) also enhances with con40 sa journal of radiology • march 2002 fig. 2. contrast-enhanced axial mri scan of the brain demonstrating 'pea in a pod' (arrow head) among the swiss cheese. note the presence of lesions in different stages non-enhancing lesions in the vesicular stage (thin arrow), and discoid/ringenhancing lesions in the colloidal vesicular stage (curved arrow). fig. 3. contrast-enhanced axial ct of the brain demonstrating single, ring-enhancing granuloma (thin arrow), with a thick capsule, containing a calcifying scolex (arrow head). there is peri/esional oedema (curved arrow). these features are in keeping with a lesion in the granular nodular stage. tips for the radiologist fig. 4. contrast-enhanced axial brain ct demonstrating multiple ring-enhancing lesions (long arrow), with surrounding oedema. the 'pea in a pod' appearance of the cyst in the left frontal lobe (curved arrow) confirms cysticercosis as the aetiology. note also the discoid enhancement (short arrow) of some of the cysts in the colloidal vesicular phase. trast. at this stage (colloidal vesicular) the cyst content becomes slightly hyperintense to csf on tl weighted mri and hyperintense on t2 weighted mri. the nodule becomes more visible when gadolinium is used. the hypointense cyst wall is best seen on t2 against the hyperintense fluid content and surrounding oedema. the next stage of the cyst (granular nodular stage) involves calcification and retraction, with thickening of the cyst wall (fig. 3). on ct the cyst is isodense and the scolex is calcified. on mri the cyst is isointense on tl and hypo/isointense on t2. when the larvae are dead, cysts and scolices are seen as calcified lesions (fig. i), and when there are multiple lesions it is known as the 'starry night' appearance on ct. mri shows focal areas of signal void. all the above stages may be seen in combination or simultaneously in one patient (figs 1,2,4). ..___", é0y0) ( corinth healthcare worldly wise , b member of the coruun oroo o a member of the recruitment and employment confederation case report � sa journal of radiology • march 2006 abstract air embolus has always been a recognised hazard within the practice of diagnostic imaging. this is now, more than ever, the case with the advent of the widespread use of pump injectors for intravenous contrast delivery and the increasing use of percutaneous interventions in the lungs. the different clinical syndromes associated with air embolus in the systemic venous (right heart) circulation and the systemic arterial (left heart) circulation need to be clearly understood in order to diagnose and treat these conditions in the clinical setting. this article reviews the topic of air embolus, including diagnosis and treatment, as this specifically relates to the practice of diagnostic and interventional radiology. the article also includes images relating to the depiction of air embolus, with attention drawn to a commonly encountered imaging appearance or sign. introduction in no discipline does the maxim: ‘first do no harm’, have greater significance than in diagnostic radiology. for a patient to suffer morbidity or even death during a diagnostic procedure is the embodiment of a medical tragedy. the hazards of ionizing radiation and the potential for contrast media to cause life-threatening allergic reactions and nephropathy, have for many years constituted the most well-recognised dangers of non-invasive diagnostic radiological imaging. invasive diagnostic procedures such as angiography, carry the risk of adverse events related specifically to the nature of the procedure (and for angiography, include thrombosis, embolisation, dissection and perforation). invasive diagnostic procedures and interventional radiological procedures fall more within the province of surgery in terms of the risks associated with the procedure. it is generally accepted that all surgical procedures carry some risk. new technologies have brought new dangers, perhaps the best example being the dangers posed by the super magnets of magnetic resonance imaging (mri). new technologies have also in certain instances brought with them an increased potential for already-known dangers. in this setting, two developments, namely the advent of the widespread use of pump injectors for intravenous injection of contrast (in association with helical ct scanning); and the increasing number of percutaneous interventions that are being performed within the lungs; make it imperative that the well-known hazard of air embolism should be revisited, in the context of the way in which it pertains to the current practice of diagnostic and interventional radiology. pathophysiology central to the understanding of the dangers posed by air embolisation and to the diagnosis and management of air embolus, is an understanding of the 2 different clinical syndromes that occur with air embolus within the right heart circulation, and air embolus within the left heart circulation. air within the right heart circulation this occurs when air enters the systemic venous circulation. air may enter a peripheral vein (and thereby the systemic venous circulation) if the air within the intravenous line of a pump injector or a drip infusion is not properly removed before the intravenous line is attached to an intravenous canula. similarly, air may enter the systemic circulation if it has not been meticulously removed from the vascular tubing of a haemodialysis circuit.1 there are a number of other well-recognised mechanisms whereby air may enter the systemic venous system. air may enter the vascular system through lacerations to major veins, due to the sucking effect of the negative intrathoracic pressure created by inspiration (sucking wounds). this is also a well-recognised danger during thoracic and cervical surgery. it should also be noted that a central venous catheter, which becomes disconnected, provides a similar potential opportunity for air to be sucked into the central venous system.2 the danger of air entering the vascular system through incision of a dural sinus is a well recognised hazard of intracranial surgery, particularly during craniotomy with the patient in the sitting position.3 gas may also enter the venous system following air insufflation of body cavities for endoscopic surgery.4 it is also well documented that air may enter the veins of the myometrium during pregnancy and after childbirth.5,6 small volumes of air entering the right atrium from the systemic venous system, generally pass through the right atrium and right ventricle into the pulmonary arterial circulation. the lungs appear to have a large capacity to compensate for air embolus within the pulmonary arterial circulation. the lungs can filter micro bubbles if these enter the pulmonary arterial circulation at a slow rate.7 larger volumes of air accumulating within the pulmonary arterial circulation cause right ventricular strain. pulmonary arterial pressure increases and increased resistance to right ventricular outflow causes decreased pulmonary venous return. this results in diminished cardiac output and if allowed to continue, ultimately leads to systemic cardiovascular collapse.8 large volumes of air, which rapidly enter the right heart can cause foaming within the right ventricle, so that no liquid blood is available air embolus revisited – a diagnostic and interventional radiological perspective (bubble trouble and the dynamic mercedes benz sign) d j emby, mb bch, ffrad (d) sa k ho, mb bch, fcp (sa) western deep levels hospital, po box 8425, western levels, 2501 review article air embolus revisited.indd 3 3/27/06 11:51:34 am � sa journal of radiology • march 2006 for propulsion into the main pulmonary artery.9 in such circumstances circulatory collapse would rapidly ensue. both the volume of gas and the rate of infusion appear to be important. a large volume of 50 ml or greater infused at a rapid rate is potentially fatal.10 small volumes and slow rates can be tolerated. in dogs the lung can cope with up to approximately 0.3 ml per kilogram per minute.7 a few small air bubbles in the injector tubing are therefore unlikely to produce any adverse effects on the right heart circulation. air within the left heart circulation this occurs when air enters the systemic arterial circulation. air bubbles may be injected directly into a systemic artery during angiographic arterial catheterisation. any cardiac surgical procedure that is performed under extracorporeal bypass can cause arterial gas embolism.11 importantly, in the iatrogenic context, percutaneous interventions in the lung parenchyma may allow air bubbles to enter the pulmonary veins. from there the air bubbles travel via the left atrium and left ventricle into the systemic arterial circulation, causing systemic air embolus. there are now numerous reports in the literature describing systemic arterial air embolisation following percutaneous procedures in the lung.12-20 a further, indirect mechanism of systemic arterial air embolus is recognised. where there is a connection between the right and left heart circulation, air emboli may bypass the filtering mechanism of the lungs and pass directly from the right heart circulation to the left heart circulation. this is known as paradoxical embolism. the classic example of this phenomenon is where there is a patent foramen ovale present. in this setting, air that enters the systemic venous system has the potential to cause systemic arterial embolisation. some estimates suggest that the incidence of a patent foramen ovale in the general population may be as high as 30%.8 any discussion of arterial air embolism would not be complete without mention of the well-known association between underwater diving and air embolus (decompression sickness or caisson disease). with rapid ascent from depth, nitrogen gas, which has become dissolved in the body tissues, including the blood plasma, comes out of solution to form bubbles of gas within tissues and within the circulatory system.9 air bubbles within the arterial system behave in a similar way to solid emboli and cause occlusion of end arteries, leading to tissue infarction. in the cerebral and coronary circulations, this has been associated with death.19,21,22 discussion air embolus in the systemic venous system despite meticulous technique, small air bubbles may occasionally enter the systemic venous system in association with injection of intravenous contrast by a pressure injector. small venous air emboli from intravenous lines probably in fact, occur often.23 in a series reported by groell et al.24, small air embolism was visible in 10 out of 208 patients (4.8%) who underwent computed tomography (ct) scan after insertion of a peripheral venous cannula. the small air emboli were most commonly seen in the pulmonary trunk (6 patients), followed by the right ventricle (2 patients). in the remaining 2 patients, the small air embolus was detected in the right atrium in 1 and in the left brachiocephalic vein in the other. the embolism was asymptomatic in all the patients. air loculations within a pulsating major mediastinal vascular structure frequently demonstrate a tri-radiate appearance (figs 1 3). we call this the dynamic mercedes benz sign. pulsation offshoot artefact from central venous catheters is a wellrecognised phenomenon, and although variable in appearance, is characteristically also seen as a tri-radiate configuration (dynamic mercedes benz sign) (fig. 4). the similarity in the pattern of offshoot artefact between intravascular air bubbles and intravascular cannulas, is clearly shown in these images. review article fig. 1. axial ct slice through level of main pulmonary outflow tract showing tri-radiate offshoot artifact (due to pulsation) from air bubble in main pulmonary outflow tract (dynamic mercedes benz sign) (arrow). this could be mistaken for an intimal flap. fig. 2. axial ct slice through heart showing tri-radiate offshoot artifact (due to pulsation) from air bubble lying anteriorly in right ventricle (dynamic mercedes benz sign) (arrow). review article air embolus revisited.indd 4 3/27/06 11:51:36 am when the tri-radiate offshoot artefact is not seen, diminished (or even absent) pulsation is suggested (figs 5 and 6). the tri-radiate streak offshoot artefact from small air emboli can be mistaken for an intimal flap (fig. 1), if the observer is not familiar with this appearance. small air loculations may occasionally be detected within the veins and venous pathways of the head and neck, particularly the cavernous sinuses, in patients with intravenous cannulation. (figs 7a and b). in the absence of infection, trauma or previous surgery, and if there are no systemic features of venous air embolus, these small air bubbles represent only minimal venous air embolism, and are of no clinical significance.23,25 recognition of air embolus on ct scan images is important for a number of reasons: (i) so that the typical appearance of small air bubbles in the central vascular system is identified and not mistaken for other pathology; (ii) so that where small air emboli are detected, an audit of the pressure injection equipment and technique can be carried out in order to avoid the potential injection of larger (more dangerous) volumes of air; (iii) so that appropriate measures can be taken to treat air embolus, should larger volumes of air be detected on the ct scan images or should the patient display clinical signs or symptoms of air embolus; and (iv) finally, so that those concerned can be reassured of the generally benign nature of small volumes air within the systemic venous system. a large iatrogenic venous air embolism due to a pump injection with intravenous contrast for ct scan is described by shigekedi et al.26 images through the heart showed a large amount of air in the right ventricle. the patient was given oxygen and placed in the left lateral decubitus position. he suffered no adverse effects. fig. 3. axial ct slice through level of aortic arch showing tri-radiate artifact (due to pulsation) from air bubble in left brachiocephalic vein (dynamic mercedes benz sign) (black arrow). likely a result of transmitted pulsation from the aorta. note also air bubble with no offshoot artifact in distal right bracheocephalic vein (open arrow). fig. 4. axial ct slice through upper thorax showing typical tri-radiate offshoot artifact (due to pulsation) from the central venous catheter in the superior vena cava (dynamic mercedes benz sign) (arrow). fig. 5. axial ct slice through main pulmonary outflow tract showing air bubble situated anteriorly in main pulmonary outflow tract with no offshoot artifact (arrow). fig. 6. axial ct slice through level of thoracic inlet showing large air bubble, without pulsation offshoot artifact, in left internal jugular vein (arrow). review article � sa journal of radiology • march 2006 air embolus revisited.indd 5 3/27/06 11:51:38 am � sa journal of radiology • march 2006 air embolus in the systemic arterial system there are 2 mechanisms by which air may enter the pulmonary veins and cause systemic arterial embolus during percutaneous interventions in the lungs. the first of these mechanisms is by direct puncture of a pulmonary vein with a hollow bore needle that is open to the atmosphere. the negative intrathoracic pressure during inspiration may then suck air through the needle into the vein. careful technique, ensuring that the hollow bore of the needle is sealed at all times, should avoid this. the second mechanism by which air may enter the pulmonary veins is by the inadvertant creation of a fistula between a small airway and a pulmonary vein. clearly, the operator has less control over the potential creation of such a fistulous connection. this is considered to be the mechanism by which systemic air embolisation occurred in the recently reported case by ashizawa et al.13,27 radiofrequency ablation is believed to generate microbubbles around the radiofrequency probe, which flow into the draining venous circulation. yamamoto et al.28 investigated the possibility that microbubbles generated during radiofrequency ablation of lung tumours might be distributed via the pulmonary veins and left heart to the systemic arterial circulation. they found evidence of microbubble generation but no evidence of cerebral infarction. among the reasons discussed for the lack of any adverse effect, is the fact that the microbubbles generated by radiofrequency ablation appeared to be extremely small, on average less than one-quarter of the size of the microbubbles used as sonographic contrast agents (3 8 µmm verses approximately 35.5 µmm). it should be noted that despite the reported incidence of the presence of a patent foramen ovale being as high as 30% in the general population, paradoxical embolus appears to be rare. this is in spite of the seemingly common occurrence of infusion of a few small air bubbles, in association with intravenous lines. the risk of potential paradoxical arterial embolus from small volumes of systemic venous air embolus can probably be regarded as remote, although the risk with larger volumes of air should be considered significant. in a recumbent patient the intra-atrial pressure gradient is from left to right, so that even if a small patent foramen ovale is present, the physiological status quo would tend to prevent paradoxical embolus. with systemic venous air embolus large enough to cause pulmonary arterial hypertension, an associated rise in right atrial pressure would predispose to right-to-left shunting through a patent foramen ovale. it is also of note that the use of the sitting position in neurosurgery (in addition to predisposing to direct entry of air into a dural sinus), inherently predisposes neurosurgical patients to paradoxical air embolism, since the normal intra-atrial pressure gradient frequently becomes reversed in the upright position.29 signs and symptoms of air embolus clinical symptoms of air embolism are evident when a significant amount of air is introduced into the circulation, and thus most cases of minor air embolism are asymptomatic.30 in addition, symptoms and signs may be nonspecific, often present in other medical conditions such as pulmonary embolism, pneumothorax, cardiogenic and anaphylactic shock and cerebrovascular accidents,31 and so a high index of suspicion is required should these symptoms occur in a patient in the ‘at risk’ clinical setting. venous air embolism sudden onset of dyspnoea and chest pain occur in significant venous air embolism and this accompanies signs of tachypnoea, wheezes, rales, tachycardia and hypotension. signs of right-sided heart failure may be present and cardiac auscultation may reveal a ‘mill-wheel murmur’; a splashing sound audible due to air in the right ventricle.8 doppler sonography can be used as a sensitive and practical means of detecting intracardiac air.32 arterial air embolism coronary and central nervous system vasculature air embolism manifest with ischaemic-type chest pain and acute neurological deterioration respectively, with symptoms of the latter ranging from a sense of doom and altered mental state to focal neurological deficits. fundoscopy may fig. 7a. axial ct slice through level of floor of sella turcica showing air loculations in left cavernous sinus (arrows). fig. 7b. direct coronal ct slice through cavernous sinuses showing bilateral small air loculations within cavernous sinuses (arrows). review article review article air embolus revisited.indd 6 3/27/06 11:51:40 am reveal retinal arterial bubbles. small emboli to other organs are generally well tolerated.8 treatment of air embolism when air embolism is suspected, further air entry into the vasculature must be prevented. standard cardiopulmonary resuscitation is offered in cases of cardiovascular and respiratory collapse and inotropic support may be required. oxygenation with high flow rates is recommended in order to reverse ischaemia and reduce the air bubble size via nitrogen resorption (this applies to both venous and arterial air embolism).33 venous air embolism the trendelenberg or left lateral positioning of the patient with an ‘air lock’ obstructing the right ventricular outflow tract, may be useful as this may displace the air bubble to a more buoyant position in the right ventricle and allow blood to flow dependent to the air bubble.34 air aspiration from the right ventricle via an already-established central venous catheter has been described, but it is thought that the benefit of this manoeuvre is limited.10 arterial air embolism the flat supine position is recommended for 2 reasons: first the pressure haemodynamics of the left ventricle appear to outweigh the effect of attempting to displace the air bubble via trendelenberg positioning; and second, in the event of cerebral air embolism, cerebral oedema is aggravated by the head-down position.35,36 cerebral air embolism may present with seizures, and therapy with benzodiazepines or barbiturates may be required. hyperbaric oxygen therapy with 100% oxygen is advocated for those patients with clinical features of arterial air embolism, in particular cardiopulmonary compromise or neurological deficits,37 as it further promotes nitrogen resorption from the air bubble and improves the oxygen supply to the tissues. benefit is greatest when administered early, but may still be useful up till 30 hours post event.38 conclusion air embolus has always been a recognised hazard within the practice of diagnostic imaging. this is now, more than ever, the case with the advent of the widespread use of pump injectors for intravenous contrast delivery and the increasing use of percutaneous interventions in the lungs. the different clinical syndromes that are associated with air embolus in the systemic venous (right heart) circulation and the systemic arterial (left heart) circulation, need to be clearly understood in order to diagnose and treat these conditions in the clinical setting. these differences between systemic venous and systemic arterial air embolus have been highlighted, and the diagnosis and treatment, based on the pathophysiological differences between venous and arterial air embolus, have been set out. 1. yu as, levy e. paradoxical cerebral air embolism from a haemodialysis catheter. am j kidney dis 1997;29:453-455. 2. halliday p, anderson dn, davidson al, page jg. management of cerebral air embolism secondary to a disconnected central venous catheter. br j surg 1994;81:71. 3. porter jm, pidgeon c, cunningham aj. the sitting position in neurosurgery: a critical appraisal. br j anaesth 1999;82:117-128. 4. muth cm, shank es. gas embolism. n engl j med 2000; 7:477. 5. hill bf, jones js. venous air embolism following orogenital sex during pregnancy. am j emerg med 1993;11:155-157. 6. weissman a, kol s, peretz ba. gas embolism in obstetrics and gynaecology: a review. j reprod med 1996;41:103-111. 7. butler bd, hills ba. transpulmonary passage of venous air emboli. j. appl physiol 1985;59:543-547. 8. muth cm, shank es. gas embolism. n engl j med 2000; 7:476-482. 9. berkow r, fletcher aj, eds. merck manual of diagnosis and therapy. 16th ed. rahway, nj: merck research laboratories, 1991. 10. palmon sc, moore le, lundberg j, toung t. venous air embolism: a review. j clin anesth 1997;9:251257. 11. ziser a, adiry, lavon h, shupaka. hyperbaric oxygen therapy for massive arterial air embolism during cardiac operations. j thorac cardiovasc surg 1999;117:818-821. 12. arnold bw, zweiber wj. percutaneous transthorracic needle biopsy complicated by air embolism. am j roentgenol 2002;178:1400-1402. 13. ashizawa k, wantanabe h, morooka h, et al. hyperbaric oxygen therapy for air embolism complicating ct-guided needle biopsy of the lung. am j roentgenol 2004;182:1606-1607. 14. tolly tl, feldmeier je, czarnecki d. air embolism complicating percutaneous lung biopsy. am j roentgenol 1988:150:555-556. 15. omenaas e, moerkve o, thomassen l, et al. cerebral air embolism after transthoracic aspiration with a 0,6 mm (23 gauge) needle. eur respir j 1989;2:908-910. 16. regge d, gallo t, galli j, bertinetti a, gallino c, scappaticci e. systemic arterial air embolism and tension pneumothorax: two complications of transthoracic percutaneous thin-needle biopsy in the same patient. eur radiol j 1997; 7:173-175. 17. cianci p, posin jp, shimshak rr, singzon j. air embolism complicating percutaneous thin needle biopsy of lung. chest 1987;92:749-751. 18. pereira p. a fatal case of cerebral artery gas embolism following fine needle biopsy of the lung. med j aust 1993;159:755-757. 19. kodama f, ogawa t, hashimoto m, tanabe y, suto y, kato t. fatal air embolism as a complication of ct-guided needle biopsy of the lung. j comput assist tomogr 1999;23:949-951. 20. wong rs, ketai l, temes l, follis fm, ashby r. air embolus complicating transthoracic percutaneous needle biopsy. ann thorac surg 1995;59:1010-1011. 21. mokhelesi b, ansaarie i, bader m, tareen m, boatman j. coronary artery air embolism complicating a ct-guided transthoracic needle biopsy of the lung. chest 2002;121:993-996. 22. moon re. gas embolism in: oriani g, marroni a, wattel f, eds. handbook on hyperbaric medicine, milan, italy: springer 1996:229-248. 23. rubinstein d, dangleis k, damiano tr. venous air emboli identified on head and neck ct scans. j comput assist tomogr 1996;20:559-562. 24. groell r, schaffler gj, rienueller r. the peripheral intravenous cannula: a cause of venous air embolism. am j med sci 1997;314:300-302. 25. adams m, quint dj, eldeuk p. iatrogenic air in the cavernous sinus. am j roentgenol 1992;159:189190. 26. shigekedi i, tsutomu t, masayuki g, takenori y, yasumasa k. iatrogenic venous air embolism caused by ct injector from a risk management point of view. radiat med 2004;22:269-271. 27. ashizawa k. question and answer. am j roentgenol 2005;185:553. 28. yamamoto a, toshiyuki m, masami t, et al. assessment of cerebral microembolism during percutaneous radiofrequency ablation of lung tumours using diffusion-weighted imaging. am j roentgenol 2004;183:1785-1789. 29. stoelting rk, dierdorf sf, eds. anesthesia and co-existing disease. 3rd ed. new york: churchill livingstone 1993:194-196. 30. o’dowd lc, kelley ma. air embolism. uptodate 2004,version 12.2. www.uptodate.com 31. orebaugh sl. venus air emboli: clinical and experimental considerations. crit care med 1992;20:1169. 32. gildenberg pl, o’brien rp, britt wj, frost ea. the efficacy of doppler monitoring for the detection of venous air embolism. j neurosurg 1981;54:75-78. 33. van liew hd, conkin j, burkard me. the oxygen window and decompression bubbles: estimates and significance. aviat space environ med 1993;64:859-865. 34. raskin jm, benjamine e, iberti tj. venous air embolism: case report and review. mt sinae j med 1985;52:367. 35. workshop panel. final summary of recommendations: diving accident workshop 1990. in: bennett pb, moon re, eds. diving accident management. bethesda, md.: undersea and hyperbaric medical society,1990:366-369. 36. moon re, dear gl, stolp bw. treatment of decompression illness and iatrogenic gas embolism. respir care clin n am 1999;5:93-135. 37. leach rm, rees pj, wilmshurst p. abc of oxygen: hyperbaric oxygen therapy. bmj 1998;317:1140. 38. armon c, deschamps c, adkinson c, fealey rd, orszulak ta. hyperbaric treatment of cerebral air embolism sustained during an open-heart surgical procedure. mayo clin proc 1991;66:565-571. review article � sa journal of radiology • march 2006 air embolus revisited.indd 7 3/27/06 11:51:40 am abstract introduction case report discussion conclusion acknowledgements references about the author(s) pankaj nepal department of radiology, st. vincent’s medical center, bridgeport, united states syed i. alam department of clinical imaging, hamad medical corporation, doha, qatar sadia sajid department of clinical imaging, hamad medical corporation, doha, qatar syeda s. intakhab jawaharlal institute of postgraduate medical education and research (jipmer), puducherry, india vijayanadh ojili department of radiology, university of texas health, san antonio, united states citation nepal p, alam si, sajid s, intakhab ss, ojili v. agenesis of the piriformis muscle: a case report with review of literature. s afr j rad. 2020;24(1), a1838. https://doi.org/10.4102/sajr.v24i1.1838 case report agenesis of the piriformis muscle: a case report with review of literature pankaj nepal, syed i. alam, sadia sajid, syeda s. intakhab, vijayanadh ojili received: 16 dec. 2019; accepted: 04 feb. 2020; published: 16 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract agenesis of the piriformis muscle is an extremely rare occurrence. knowledge about this anatomic variant is important because of its close proximity with the sciatic nerve and sacral plexus. the piriformis muscle also serves as an important anatomic landmark for image-guided intervention and hip surgery. we report a case of piriformis muscle agenesis in a 28-year-old woman, incidentally detected on magnetic resonance imaging of the lumbosacral spine and pelvis, performed for low back pain. keywords: piriformis muscle; agenesis; mri; orthopaedics; lower back pain. introduction the piriformis muscle is a pear-shaped structure located in the deep pelvis that functions as one of the six short external rotators of the hip, as well as the proximal abductor of thigh during hip flexion.1 the most accepted classification of piriformis variation by beaton and anson has described several variations of this muscle, but not agenesis.1,2,3 piriformis agenesis is extremely rare, and thus the associated symptoms, clinical findings and therapeutic options remain elusive. by far, the importance of the piriformis muscle is related to its close proximity to the sacral plexus which is anterior to the muscle and the sciatic nerve, intimately positioned at the sciatic notch.4 case report a 28-year-old woman presented to her primary care physician with progressive worsening of intermittent low back pain radiating into both legs over a 1-month period. the pain was described as a dull ache, aggravated by activity and relieved by rest. she also experienced perineal discomfort. physical examination was unremarkable, with no neurological compromise. the range of motion of the lower lumbar spine was limited by pain and the hip movements were normal. basic laboratory examinations were unremarkable. an initial radiograph of the lumbar spine was normal and a lumbosacral magnetic resonance imaging (mri) was performed. the imaging findings were negative for disc disease, radiculopathy or cord abnormalities. the visualised skeleton and bilateral sacroiliac joints were also normal. given the history of perineal discomfort, mr neurography of the pelvis was subsequently performed to evaluate the pudendal nerve and demonstrated absence of the left piriformis muscle (figure 1). the sciatic nerve and lumbosacral plexuses were normal in configuration and signal intensity with no signs of neuritis (figure 2). the patient was referred for physiotherapy along with a short course of analgesics. her symptoms improved and she recovered completely at her 2-week follow-up assessment. figure 1: a 28-year-old woman who presented with low back pain for a month without neurological symptoms: (a) axial and (b) coronal t1-weighted images of the pelvis show congenital absence of the left piriformis muscle (yellow arrows point to the expected location). figure 2: (a) axial t2 fat-saturated (b) and coronal short tau inversion recovery images again reveal the same findings. discussion although piriformis agenesis is rare, a recent meta-analysis in 2017 by smoll et al.,3 suggested that other anatomic variations related to piriformis and the sciatic nerve complex are common, seen approximately in 17% of cadavers.5 to understand the congenital variants of the piriformis muscles, it is prudent to understand the basic anatomy. piriformis originates from multiple deep pelvic structures, including the anterior surface of the lateral process of the sacrum, the gluteal surface of the ilium, the gluteal muscles and the capsule of the sacroiliac joint. it then passes through the greater sciatic notch, where the muscle is intimately related to the sciatic nerve. the tendon of the piriformis merges with tendons of the obturator internus and the superior and inferior gemilli to form a conjoint tendon that eventually inserts onto the greater trochanter of the femur.1,2 different anatomic variants of the piriformis may exist. the most common variations are related to the anatomic relationship with the sciatic nerve.4 an accessory piriformis can exist, which may present as piriformis syndrome because of entrapment of the sciatic nerve at the sciatic notch.4,6 other anatomic variants include a bifid piriformis and fusion with the adjacent gluteal, obturator or gemilli muscles. clinical presentation of such variants is unknown. following an extensive literature review, only a handful of case reports on the absence or agenesis of the piriformis muscle are documented.5,7,8 only two cases have been reported in living human subjects.5,8 because of the rarity in incidence, not much is known about the presenting symptoms, clinical findings and sequelae of piriform agenesis. none of the cases reported in the literature were suspected clinically but were discovered incidentally during imaging or cadaveric dissection. abduction of the hip during walking is an important function not to overlook, as it prevents falling by shifting the body weight to the contralateral side.1 it is unknown whether this disturbed biomechanics influences stress on the spine and pelvis. caetano et al.5 presented a case with neurologic symptoms of progressively worsening left buttock pain radiating to the left leg and localised tenderness of the ipsilateral ischiogluteal bursa on deep palpation; their patient demonstrated piriformis agenesis on the same side. however, ikidag8 presented a case with left flank pain but with contralateral piriformis agenesis. brenner et al.7 reported in a cadaveric dissection case, piriformis agenesis, an ipsilateral common gluteal artery and an absent inferior gemellus muscle. in our case, the patient had progressively worsening low back pain radiating to both legs without neurological deficits on examination. she also had perineal pain which improved after treatment of symptomatic pelvic inflammatory disease. because of the limited presentations, it remains elusive whether piriformis agenesis is clinically relevant. there is no definite data about the incidence of neurovascular complications during surgery or image-guided interventions associated with piriformis agenesis or its variations.3 definitely, the piriformis is considered as an important landmark for image-guided interventions such as superior gluteal nerve block and sacral plexus block. it is also an important reference for the surgeon performing tendon release of various pelvic muscles and the posterior surgical approach in total hip arthroplasty.7 it can be postulated that the variation in the anatomy of such an important landmark definitely increases the risk of complications if the surgeon or interventionist is not aware. differential diagnoses for piriformis muscle agenesis may be congenital fusion with overlapping muscles, most commonly the superior gemellus and gluteus medius muscles, which can be differentiated with mri. other differentials include muscle involution or atrophy after injection of botulinum toxin, iatrogenic damage after tenotomy or accidental rupture during total hip arthroplasty.5 typical mr imaging features of chronic muscle tear are focal tendon thickening and peritendinous muscle atrophy which is not seen with muscle agenesis. fatty involution after chronic muscle tear is seen characteristically as hyperintense on t1-weighted images. in doubtful cases, relevant clinical history of trauma or injury from intervention can rule out the same. conclusion agenesis of the piriformis muscle is extremely rare. it is necessary for the radiologist and surgeon to be aware about this anatomical finding to avoid neurovascular mishaps whilst performing surgery or image-guided intervention. because of the limited number of cases presented, it remains elusive whether it is an incidental finding on imaging or whether there may be altered biomechanics related to this variant. acknowledgements the authors acknowledge their patients as a great source of learning. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. ethical consideration this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in the study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official or position of any affiliated agency of the authors. references chang c, jeno sh, varacallo m. anatomy, bony pelvis and lower limb, piriformis muscle. treasure island, fl: statpearls publishing; 2019. ferrero em, pastor jf, fernandes fdp, cachorro mb, diogo r, wood b. comparative anatomy of the lower limb muscles of hominoids: attachments, relative weights, innervation, functional morphology and evolution. in: hughes ef, hill me, editors. primates: classification, evolution and behaviour. hauppauge, ny: nova science publishers, 2012; p. 1–70. smoll nr. variations of the piriformis and sciatic nerve with clinical consequences. clin anat. 2017;23(1):8–17. https://doi.org/10.1002/ca.20893 petchprapa cn, rosenberg zs, sconfienza lm, cavalcanti cf, vieira rl, zember js. mr imaging of entrapment neuropathies of the lower extremity. part 1. the pelvis and hip. radiographics. 2010;30(4):983–1000. https://doi.org/10.1148/rg.304095135 caetano ap, seeger ll. a rare anatomical variant of unilateral piriformis muscle agenesis: a case report. cureus. 2019;11(6):e4887. https://doi.org/10.7759/cureus.4887 sen a, rajesh s. accessory piriformis muscle: an easily identifiable cause of piriformis syndrome on magnetic resonance imaging. neurol india. 2011;59(5):769–771. https://doi.org/10.4103/0028-3886.86562 brenner e, tripoli m, scavo e, cordova a. case report: absence of the right piriformis muscle in a woman. surg radiol anat. 2019;41(7):845–848. https://doi.org/10.1007/s00276-018-02176-6 ikidag ma. ectopic appendix vermiformis located in the right deep gluteal region due to unilateral piriformis agenesis. surg radiol anat. 2019;41(1):141–142. https://doi.org/10.1007/s00276-018-2125-y technology update a picture paints 5 000 (pages of) words those who have, and many who have not, read the previous article in this series will be familiar with the relationship between files and folders. while folders are the houses on your computer, files are the software citizens that live in them: they are unique individuals, each has its own function, but few can do anything without the co-operation of others. files are essentially of two types program files and data files.most of you will not have direct dealings with program files. they will, hopefully, live a peaceful life in your computer, not bothering you and doing their joh. data filesare the ones you deal with they contain your letters, spreadsheets, digital pictures and so on. despite being a very heterogeneous bunch on the outside, they all look the same internally: as with anything else on a computer, they consist, at their most basic level, merely of a long string of o's and 1'sothere is potential for confusion here: the same string ofo's and 1's that tells your graphics program to make a particular spot on the screen dark grey might be used by a music program to denote middle c. how does the computer know what to do when it encounters il data file containing this string? dr russel whitehorn consultant radiologist, lake smit & partners, durban. 24 sajournal of radiology. august 2000 the answer is that the data file not only contains data but also contains a little information about itself telling the computer how to handle it. imagine a un get-together: each attendee's jacket bears a label stating the person's name, occupation and country of origin. just enough information for you to know how to approach the person and what language to speak, for example: "hi, i'm vladimir and i'm a tractor aesthetist from the ukraine" no good talking to him in polish about guided missile systems. well, each data file has a similar little label telling the computer how to process its o's and 1'so having acknowledged the existence of the "hi, i'm ..." part of a data file, let us turn our attention to the 'guts' of this type of file the data. in particular, let us look at a file type of great importance to radiologists: a graphics file. these are of two basic types: vector and bitmapped. a vector graphics file contains a series of instructions telling the computer how to draw a picture, similar to the way you would teach a child how to draw a stick man: draw a circle this big for the head, then a line this long for his body, ete. bitmap graphics files are more reminiscent of the way seurat painted: they contain instructions describing a two-dimensional array of pixels (picture elements) and stipulate the colour (or shade of grey) of each element in that array. imagine an exceedinglysimple bitmap picture: it has only four pixels, two across and two down. the graphics file for this picture would have to have two bits devoted to spatial information. "why two? what are bits?," you may ask. a bit is the most basic informational unit of a computer. it is a 'thing' that can be either 0 or 1 no other choices. topage26 advert-orial philips medical systems: successfully starting off the millennium with a completely new mr program reporting records orders for its gyroscan intera mr scanners introduced at the 1999 rsna, philips medical systems is using the european congress of radiology to announce yet another system introduction, the gyroscan panorama, featuring the most patientfriendly of all open magnet designs: ac-arm. the gyroscan intera is philips' new general-purpose family. this new generation ofmr scanners makes truly interactive scanning a reality. recently installed at a number of hospitals in europe, the usa and japan, its users are thrilled by the very significant advances in image acquisition and reconstruction speed, as well as improvements in user interface and patient environment. in addition, philips' new gyroscan intera cv, dedicated to cardiovascular mr, has been launched alongside the gyroscan intera lit that is especially suited to inrervenrional procedures and assistance in therapy. intera's flexibility and advanced capabilities replaces traditional imaging exams with faster, less coscly and more informative mr studies such as high-resolution contrast-enhanced peripheral angiograms, comprehensive stroke and cardiac exams and whole body screening. intera's new rapidview reconstructor is the industry's fastest, with up to 196 images per second reconstruction speed. acquisition and reconstruction speed combine with the industry's most flexible rf spectrometer to provide truly interactive scanning: the ability to change geometry and contrast parameters in real time. this brings the equivalent of x-ray fluoroscopy to mr. furthermore, its magnet is believed to be the shortest, the most open and lightest presently on the market: a great help in eliminating patient anxiety, providing free patient access and facilitating installation. "we're truly excited about showcasing our new mri solutions for the first time," explained jacques coumans, phd, global marketing manager for mr at philips medical systems. "we believe that mr continuously changes how the world looks at diagnostic imaging and that our new gyroscan intera changes how the world looks at mr." this statement will be even further substantiated by the introduction of syncrascan and explorer gradients. philips' new syncrascan package (based on the sensitivity encoding (sense) principle), provides for an immediate doubling of acquisition speed. with explorer gradients delivering up to 60 mtlm, diffusion imaging becomes an even more sensitive diagnostic tool for stroke than previously. the dedicated gyroscan intera cv helps physicians diagnose cardiovascular disease more quickly, accurately and economically. using this new system, scanning most patients can be completed in one hour and diagnosis is possible the same day. this contrasts with the. traditional diagnostic pathway of ultrasound, nuclear medicine and x-ray studies that take several days of scheduling and cost far more. vectorcardiogram (vcg) triggering separates the true ecg from distortion caused by the magnetic field and rf effects, raising triggering accmacy to nearly 100 percent. furthermore, the system's motiontrak technology allows patients to breathe freely while being examined a definite plus for patients who are chronically short of breath. assistance in complex interventional and therapeutic procedures is made possible with rhe new gyroscan intera lit, developed by philips in partnership wirh leading medical research institutions. the image quality and high field capabilities of the intera iit, such as spectroscopy, functional mri (fmri) and diffusion, offer all the tools required for such applications as image-guided neuro surgery, biopsy guidance, molecular therapy imaging, mr-guided ablation therapy and endovascualr interventions. in the latest addition to this range is the gyroscan panorama, a high quality open mr system. with a patient-friendly c-arm design, the 0.23 tesla panorama provides excellent all-round patient access and easy sideways patient entry. the attractive features of the gyroscan panorama aren't limited to its openness advanced technology ensures that it provides superb image quality across a wide range of applications. "fast, strong gradients combined with an extensive range of imaging techniques make it an ideal workhorse for the general imaging department" coumans said. "we are confident," he continued "that the inclusion of phased array coil technology as standard in the system will be seen as an indication of its intrinsic quality." the application bandwidth of the system is enhanced by a wide range of rf coils for head, neck, spine, body and extremities. departmental efficiency is assured by its easy-touse interface, the ability to prepare patients on the tabletop outside the examination room and reliable pre-set protocols. the gyroscan panorama complements philips' existing gyroscan intera family thereby offering customers the widest choice of systems and performance. contact: wayne smith tel (011) 471-5259 website: www.medical.philips.com/ms http://www.medical.philips.com/ms technology upda-re from page 24 if i have two bits available i can describe a four-pixel picture: pixeloo, pixel ol , pixello and pixelll. now, if all those pixels were the same colour it would not be much of a picture. associated with each pixel we need to have more bits describing the colour which that pixel is to be. let us say, in keeping with the minimalist elegance of the picture, we decide to allow each pixel to have two bits of colour information. "you,jones, wake up how many colours can be described by two bits? yes, four: colour 00, colour gl, colour 10 and colour il." in general the number of pixels (or shades) available is 2" where in' is the number of bits availableto describe spatial (or colour) information. a more realistic example: say you want to digitise an x -ray. to achieve adequate quality you want to have a 'resolution' (more about the meaning of this tricky word another time) of more than 2000 pixels in both dimensions. if the breadth and height of the picture are both represented by 2 048 pixels, the total number of pixels will be 2048x2048 = 4 194304 pixels. if it is further required that the picture is represented by 4 096 different shades of grey then each of the above pixels will need to be associated with 12 bits (212 = 4096) of colour information. the total number of bits needed to describe the bitrnapped graphic will be 4 194304 x 12 = 50 331648 bits. (a few liberties have been taken for ease of calculation and explanation, and because some of the complexities are beyond the intellect of the author.) if you are to transmit this uncompressed picture to somebody by means of a modem capable of transmitting 50 000 bits per second (for ease of calculation, and unlikely to be regularly achieved on a '56 kbps' modem) the transmission time (ignoring overheads) will be 50 331 648/50 000 seconds = 1007 sec = 17 minutes. text requires about 10 000 bits per page. a small calculation shows that a text file as large as the graphics file described above for a single x-ray would hold about 5000 pages of words. company news pi-iil1i)s mel )ical systems new technology offers health care providers access to an electronic patient folder solution the annoucement by philips medical systems of the netherlands of the acquisition of cardiologica tm, the cardiology information system (cis) for electronic patient folder (epf) creation from milwaukeebased cardiovascular computer systems, inc (ccs), takes technology another step forward. cardiologica™ is a specialised information system designed for the cardiology department, where cardiac images and clinical and administrative data are brought together via a centralised software solution. the system provides modules for patient scheduling, automated report generation and distribution, and other administrative functions that can further improve workflow and efficiency throughout the cardiology department. other benefits of the system include the merging of invasive and non-invasive modality data into one electronic patient folder, integrated modules across all diagnostic imaging modalities for flexible customisation and unique anatomical data structure for fast access to clinical information. the system also integrates images with reports, other records and haemodynamic data and can interface 26 sa jou rnal of radiology. august 2000 with hospital information systems (his), allowing access by appropriate health care providers. the modular design of cardiologica™ allows for easy upgrades which facilitate the rapid transfer of information, ultimately enhancing patient care. the system will be incorporated into inturis for cardiology, philips' integrated image and information management system for cardiovascular care environments. the addition of cardiologica tm to its product offerings strengthens the company's heartcare programme portfolio of cardiovascular imaging modalities, connectivity solutions and consulting services that maximise patient care and workflow efficiency. information from philips medical systems. tel: (011) 471-5000. sajr 788 transitional cell carcinoma developing in a bladder diverticulum: early diagnosis by computed tomography j shah department of radiology, gt hospital, mumbai, india j shah, md corresponding author: j shah (shahjeshil@yahoo.com) computed tomography confirmed a left-sided narrow neck urinary bladder diverticulum, with wall thickening, in a 56-year-old man. these findings were initially detected on ultrasonographic investigation. transitional cell carcinoma was confirmed histologically. there is an increased incidence of neoplastic transformation in urinary bladder diverticuli, and therefore an early search for subtle imaging signs should be implemented. s afr j rad 2013;17(1):39-40. doi:10.7196/sajr.788 a 56-year-old man presented with painless haematuria and occasional right-sided flank pain. routine investigations were non-contributory, with serum creatinine levels of 1.4 mg/dl. sonography showed left-sided grade 1 hydronephrosis and a dilated left ureter. a narrow neck urinary bladder diverticulum was identified near the left vesico-ureteric junction. the left terminal ureter tapered abruptly, medial to the bladder diverticulum. the patient was referred for a ct scan, which confirmed the narrow neck bladder diverticulum and identified minimal thickening of the medial wall, resulting in left ureteric dilatation with hydronephrosis. there was minimal enhancement of the medial diverticular wall, which was initially not appreciated on the 5-minute delayed phase scan, owing to the layering effect of excreted contrast in the bladder lumen. however, it was identified on the prone delayed-phase ct examination (fig. 1d). the finding on this image prompted cystoscopy and guided biopsy. subsequent histopathological examination confirmed a transitional cell carcinoma (tcc). the diverticulum was surgically removed, with wide margins, and the left ureter was re-anastomosed onto the bladder. the histopathology report suggested a stage ta tumor. the postoperative stay was uneventful, and the patient was discharged on the 7th day post surgery. fig. 1. axial post-contrast ct scans obtained in supine (a, b, c) and prone (d) positions show minimal thickening and enhancement of the medial wall of a left-sided narrow neck bladder diverticulum. the asterisk indicates the dilated lower left ureter. discussion neoplasms arising in urinary bladder diverticulae are uncommon, but not rare. two to 7 per cent of patients with vesical diverticulae show neoplasm development within the diverticulae.1 although cystoscopy is a reliable method for diagnosing most bladder neoplasms, certain diverticulae are inaccessible or may be missed, particularly those with a narrow orifice. imaging is therefore an important diagnostic tool.1 bladder diverticulum neoplasms are characterised by early transmural invasion and a tendency for higher histopathological grades, which make prompt diagnosis and treatment crucial. filling defects caused by these tumours are not always visualised on intravenous urography and/or cystography. cross-sectional imaging methods, including ultrasonography, ct and magnetic resonance imaging (mri) have to be used singly or in combination, in neoplasms of the lower urinary tract.1 , 2 urinary stasis with chronic infection and inflammation leads to the development of dysplasia, leukoplakia and squamous cell metaplasia in approximately 80% of all diverticulae.2 these histological abnormalities may precede the development of vesical diverticular neoplasia. the most common histological tumour type is tcc (about 78%), followed by squamous cell carcinoma (scc) (17%), a combination of tcc and scc types (2%) and adenocarcinoma (2%). rarer forms such as metastases, sarcoma, etc. have also been described.1 , 2 , 4 bladder tumours are more common in men, the incidence increasing with age.5 local endoscopic transurethral resection and intravesical instillation of adjuvant chemotherapeutic agents/bacillus calmette-guérin, an immune-modulating agent, are employed for superficial lesions. more invasive tumours are treated with cystectomy, chemotherapy and/or radiation. transurethral resection can be complicated by narrow ostia and thin diverticular walls. diverticulectomy, partial cystectomy and radical cystectomy with or without intravesical instillations are other modes of treatment.5 in view of an increased incidence of malignant transformation within bladder diverticulae, periodic screening should be considered in such patients. further research is required to determine which imaging modality (ultrasound or ct) would be the most appropriate. appropriate screening intervals must be determined. any suspicious early thickening or enhancement of the walls, as seen in this case, should be followed with cystoscopic biopsy. 1. dondalski m, white em, ghahremani gg, patel sk. carcinoma arising in urinary bladder diverticula: imaging findings in six patients. ajr 1993;161(4):817-820. 1. dondalski m, white em, ghahremani gg, patel sk. carcinoma arising in urinary bladder diverticula: imaging findings in six patients. ajr 1993;161(4):817-820. 2. rincon vjm, mdel prc, nivia mb, et al. intradiverticular bladder tumor: ct assessment. arch esp urol 2002;55(10):1235-1240. 2. rincon vjm, mdel prc, nivia mb, et al. intradiverticular bladder tumor: ct assessment. arch esp urol 2002;55(10):1235-1240. 3. baniel j, vishna t. primary transitional cell carcinoma in vesical diverticula. urology 1997;50(5):697-699. [http://dx.doi.org/10.1016/s0090-4295(97)00319-1] 3. baniel j, vishna t. primary transitional cell carcinoma in vesical diverticula. urology 1997;50(5):697-699. [http://dx.doi.org/10.1016/s0090-4295(97)00319-1] 4. cheng cw, tat mng, cheung hy, et al. case report: carcinosarcoma of the bladder diverticulum and a review of the literature. tt[http://dx.doi.org/10.1111/j.1442-2042.2004.00956.x] 4. cheng cw, tat mng, cheung hy, et al. case report: carcinosarcoma of the bladder diverticulum and a review of the literature. tt[http://dx.doi.org/10.1111/j.1442-2042.2004.00956.x] 5. matta ej, kenney ak, barré gm, vanlangendonck jr rm. intradiverticular bladder carcinoma. radiographics 2005;25:1397-1403. [http://dx.doi.org/10.1148/rg.255045205] 5. matta ej, kenney ak, barré gm, vanlangendonck jr rm. intradiverticular bladder carcinoma. radiographics 2005;25:1397-1403. [http://dx.doi.org/10.1148/rg.255045205] a 1-year 5-month-old boy presented to the casualty department at kalafong hospital with diarrhoea, coughing, fever and weight loss. on examination he was found to be anaemic, peripherally cyanotic and had clubbing of his fingers. on auscultation there were crepitations in the right axilla and a pansystolic murmur over the entire chest. he had a pulse rate of 170/min, a respiratory rate of 44/min and the oxygen saturation at room air was 60 70% and on 100% oxygen, 60 80%. on the chest radiograph (cxr) a right middle and lower lobe consolidation was noted (fig. 1). the diagnosis of multi-lobar pneumonia was made, and intravenous antibiotics were commenced. follow-up radiographs were done which showed no change within a period of 1 week. on echocardiography a mild tricuspid incompetence was found, which did not explain the loud pansystolic murmur. on re-examination a separate murmur was heard over the anterior fontanelle. computed tomography (ct) examination of the brain with intravenous contrast revealed multiple arteriovenous malformations (avms), predominantly involving the left cerebral hemisphere and thalamic region (fig. 2). on magnetic resonance imaging (mri) multiple tightly packed masses of flow voids were found (figs 3 and 4). ct examination of the chest was also done which revealed a large right pulmonary avm (fig. 5). cerebral and pulmonary arteriovenous malformations n adroos, mb chb department of diagnostic radiology, university of pretoria case report fig. 1. frontal radiograph demonstrating right lower and middle lobe consolidation. fig. 2. contrast-enhanced axial ct images demonstrating hyperdense serpiginous enlarged feeding and draining vessels with a strongly enhancing nidus. multiple avms are demonstrated in the thalamic region. fig. 3. t2-weighted mri image demonstrating multiple flow voids with enlarged feeding and draining vessels. there is minimal mass effect as avms replace cerebral tissue and do not displace it.1 21 sa journal of radiology • march 2006 cerebral and pulmonary.indd 21 3/27/06 12:26:56 pm 22 sa journal of radiology • march 2006 discussion an avm is a congenital abnormality consisting of a nidus of abnormal dilated tortuous arteries and veins resulting in shunting of blood from an arterial to a venous vessel without the intermediary capillary bed.2 patients with cerebral avms present with headaches, seizures, mental deterioration, progressive hemispheric neurological deficits and ictus from acute intracranial haemorrhages. eighty per cent of lesions occur by the end of the fourth decade; 20% occur in patients younger than 20 years.2 congenital pulmonary avms are thought to occur secondary to failure of development of the pulmonary capillary network, with persistence of the primitive arteriovenous communications. the avm is usually fed by a single artery and drained by a single vein, although multiple vessels have been reported. the association of a partial anomalous pulmonary venous return and a hypogenetic lung is perhaps more wellrecognised as the scimitar syndrome (congenital pulmonary venolobar syndrome). in these cases the scimitar vein most commonly empties into the infradiaphragmatic inferior vena cava. pulmonary avms may be asymptomatic or present with haemoptysis, clubbing, cyanosis or polycythaemia. although pulmonary avms are congenital, only about 5 10% present in childhood. nearly twothirds of pulmonary avms occur in patients with rendu-osler-weber syndrome (hereditary telangiectasia). this autosomal-dominant condition is characterised by telangiectatic lesions in the mucous membranes, the skin, and in about 20% of patients, the lungs.3 the current classification of central nervous system vascular anomalies is pathoanatomically based. this assumes that vascular malformations are congenital or developmental hamartomas, rather than neoplasms. this classification is based on microscopic and gross pathological features of the lesions. although most cns vascular malformations occur in isolation, some are also found in association with cutaneous and mesodermal vascular anomalies; examples include the wyburnmason syndrome (cerebral, retinal and maxillofacial avms) and the alternative name of ‘unilateral retinocephalic vascular malformation’. due to the metameric nature of this disorder there has been a revised classification of such craniofacial vascular malformation syndromes as the cerebrofacial arteriovenous metameric syndromes (cams). the sturge-weber syndrome involves capillary-venous malformations of the brain due to a lack of a cortical draining vein. it usually affects a single cerebral hemisphere, and is associated with retinal vascular malformations and cutaneous facial capillary malformations.4 conclusion since this patient displayed no other ancillary findings, these features were thought to be due to isolated cerebral and pulmonary vascular malformations. 1. osborn ag. diagnostic imaging: brain. 1st ed. salt lake city: amirsys, 2004:i 5 4 – 7. 2. dahnert w. radiology review manual. 5th ed. philadelphia: lippincott williams and wilkins, 2002: 263. 3. kuhn jp. caffey’s paediatric diagnostic imaging. 10th ed. philadelphia: mosby, 2004: 1077. 4. duncan ic. vascular malformations part 2 – current classification of vascular malformations. south african journal of radiology 2004; 8: 23 30. case report fig. 4. mra image demonstrating an extensive network of blood vessels crossing the midline. fig. 5. contrast-enhanced axial ct image of the chest demonstrating a large right pulmonary avm. cerebral and pulmonary.indd 22 3/27/06 12:26:57 pm sajr 24-1_2020_contents.indd http://www.sajr.org.za open access table of contents original research the efficacy of pineapple juice as a negative oral contrast agent in magnetic resonance cholangiopancreatography sheryl mohabir, richard d. pitcher, rubeshan perumal, matthew d.m. goodier south african journal of radiology | vol 24, no 1 | a1875 | 29 july 2020 original research recovery of oculomotor nerve palsy after endovascular management of posterior communicating artery aneurysms elkharbash abdurahman, khatija amod, duncan royston, rohen harrichandparsad south african journal of radiology | vol 24, no 1 | a1887 | 31 august 2020 original research breast imaging at chris hani baragwanath academic hospital: a clinically relevant audit ilonka warnich, ilana m. viljoen, marianne kuehnast south african journal of radiology | vol 24, no 1 | a1921 | 15 october 2020 original research the cinderellas of the scanner: magnetic resonance imaging ‘pre-scan’ and ‘post-scan’ times: their determinants and impact on patient throughput marthinus b. van rooyen, richard d. pitcher south african journal of radiology | vol 24, no 1 | a1946 | 01 december 2020 original research diagnostic role of shear wave elastography for differentiating benign and malignant breast masses nichanametla sravani, ananthakrishnan ramesh, sathasivam sureshkumar, chellappa vijayakumar, k.m. abdulbasith, gopal balasubramanian, pampa ch toi south african journal of radiology | vol 24, no 1 | a1999 | 21 december 2020 case report incidental amniocele in a case of antepartum haemorrhage sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese, ilonka warnich south african journal of radiology | vol 24, no 1 | a1817 | 06 february 2020 case report agenesis of the piriformis muscle: a case report with review of literature pankaj nepal, syed i. alam, sadia sajid, syeda s. intakhab, vijayanadh ojili south african journal of radiology | vol 24, no 1 | a1838 | 16 april 2020 case report chronic gallbladder wall thickening: is it always malignancy? anjuna reghunath, suchana kushvaha, rohini g. ghasi, geetika khanna, apurva surana south african journal of radiology | vol 24, no 1 | a1844 | 18 may 2020 43 49 56 67 73 83 87 90 page i of ii table of contents editorial the culture of radiology: learning, teaching and curiosity maya patel south african journal of radiology | vol 24, no 1 | a2045 | 21 december 2020 letter to the editor in honour of the extraordinary career of prof. a. james barkovich shalendra k. misser, clive sperryn south african journal of radiology | vol 24, no 1 | a2001 | 20 november 2020 opinion paper the need for nationally accepted guidelines for undergraduate nuclear medicine teaching in mbchb programmes in south africa anthonio o. adefuye, henry a. adeola, stuart more, zainab mohamed south african journal of radiology | vol 24, no 1 | a1874 | 28 july 2020 original research american college of radiology thyroid imaging reporting and data system standardises reporting of thyroid ultrasounds mariska botha, margaret kisansa, wim greeff south african journal of radiology | vol 24, no 1 | a1804 | 06 february 2020 original research the knowledge, awareness and practices of radiation safety amongst orthopaedic surgeons louis w.a. van papendorp, farhana e. suleman, heleen hanekom south african journal of radiology | vol 24, no 1 | a1806 | 27 february 2020 original research hysterosalpingographic evaluation of human immunodeficiency virus-infected and uninfected infertile women dolongo c. onyangunga, jagidesa moodley south african journal of radiology | vol 24, no 1 | a1767 | 24 march 2020 original research how useful are clinical details in blunt trauma referrals for computed tomography of the abdomen? kenneth b. beviss-challinor, martin kidd, richard d. pitcher south african journal of radiology | vol 24, no 1 | a1837 | 22 april 2020 original research knowledge and practices of cardiopulmonary arrest and anaphylactic reactions in the radiology department sarah k. osiemo, callen k. onyambu, angeline a. aywak south african journal of radiology | vol 24, no 1 | a1841 | 28 may 2020 original research simple erosion narrowing score of the hands as a predictor of cervical spine subluxation in rheumatoid arthritis eric gous, mahmood m.t.m. ally, pieter w.a. meyer, farhana e. suleman south african journal of radiology | vol 24, no 1 | a1876 | 27 july 2020 1 3 5 10 17 22 26 32 37 vol 24, no 1 (2020) issn: 1027-202x (print) | issn: 2078-6778 (online)south african journal of radiology http://www.sajr.org.za open access table of contents case report fish bone perforation mimicking colon cancer: a case report thokozani sibanda, pria pakkiri, anne ndlovu south african journal of radiology | vol 24, no 1 | a1885 | 29 september 2020 case report vigorous achalasia: zebra amongst horses jayaranjeetham jayabalan, nithin theckumparampil, aravintho natarajan, dilip s. phansalkar, george kurian south african journal of radiology | vol 24, no 1 | a1953 | 30 november 2020 case report bilateral hutch diverticula in an elderly male: revelation of an unknown past siddhi chawla, shuchi bhatt, anupama tandon, gaurav meena, saumya dangwal south african journal of radiology | vol 24, no 1 | a1963 | 11 december 2020 95 99 103 case report hydatid disease of the interventricular septum: echocardiographic and computed tomography findings brett wegner, ruchika meel, tamarin nell, lamla nqwata, michelle wong south african journal of radiology | vol 24, no 1 | a1986 | 15 december 2020 case report not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases jaanri brugman, gerard de bruyn, komeela naidoo, marc merven, johan opperman, leon janse van rensburg south african journal of radiology | vol 24, no 1 | a1978 | 17 december 2020 case series tuberculosis, a great masquerader: a case series unveiling rare sites of musculoskeletal involvement through imaging m. sarthak swarup, shuchi bhatt, rajesh rawal, anupama tandon, saumya dangwal south african journal of radiology | vol 24, no 1 | a1919 | 29 september 2020 108 112 116 page ii of ii vol 24, no 1 (2020) special collection: paediatric radiology original research can the posterior:anterior urethral ratio on voiding cystourethrogram be used as a reliable predictor of successful posterior urethral valve ablation in male children? zakiyah gaibie, nasreen mahomed, karen l. petersen, glenda moonsamy, akram a.h. bokhari, ahmed adam south african journal of radiology | vol 24, no 1 | a1820 | 09 june 2020 original research reference indices for evaluating kidney dimensions in children using anthropometric measurements salome n. ezeofor, godson e. anyanwu, emmanuel n. obikili south african journal of radiology | vol 24, no 1 | a1882 | 05 august 2020 original research an audit of radiation doses received by paediatric patients undergoing computed tomography investigations at academic hospitals in south africa cornelis m. van der merwe, nasreen mahomed south african journal of radiology | vol 24, no 1 | a1823 | 16 october 2020 case study ‘soccer toe’: chronic physeal injury of the great toe metatarsal in a skeletally immature child – a case report andrew schapiro, tal laor south african journal of radiology | vol 24, no 1 | a1834 | 22 april 2020 case study complicated spontaneous pneumoparotid mimicking a neck mass in a child with down’s syndrome sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese south african journal of radiology | vol 24, no 1 | a1883 | 13 july 2020 122 127 133 141 145 case report hepatic mesenchymal hamartoma: an uncommon but important paediatric diagnosis sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese, ilonka warnich south african journal of radiology | vol 24, no 1 | a1891 | 27 july 2020 case study herniation of the uterus, ovaries and fallopian tubes into the canal of nuck in a 4-month-old child: a rare entity dharmendra kumar, saurabh maheshwari, uddandam rajesh, darshan grewal, vibhuti maria south african journal of radiology | vol 24, no 1 | a1935 | 04 november 2020 pictorial review a pictorial review of the pathophysiology and classification of the magnetic resonance imaging patterns of perinatal term hypoxic ischemic brain injury – what the radiologist needs to know… shalendra k. misser, anthony j. barkovich, jan w. lotz, moherndran archary south african journal of radiology | vol 24, no 1 | a1915 | 30 october 2020 reviewer acknowledgement south african journal of radiology | vol 24, no 1 | a2049 | 22 december 2020 149 154 158 175 case report perforated peptic ulcer imaged directly by computed tomography abstract perforation occu rs in 10% of patients with peptic ulcer. computed tomography (ct) may show free intraperitoneal gas and/or extravasation of oral contrast. while the location of the free gas or contrast may suggest the site of perforation, the perforation itself is difficult to demonstrate. we present a case of perforated ulcer in which the perforation was imaged directly byct. wk loftus fracr *,' ltc chow frcpa#; c metreweli frcr • * dept. of diagnostic radiology and organ imaging, # dept. of pathology, prince of wales hospital, chinese university of hong kong, shatin, n. t. hong kong 31 sa journal of radiology· june 1997 introduction perforation is said to occur in 5-10% of the overall population who have peptic ulcer (pu).i recurrent ulceration following surgery for pu is well recognized and in 95% is secondary to surgery for duodenal rather than gastric ulcer. itis seen in about 3% of cases. recurrent ulceration usually occurs following a gastrojejunal anastomosis but can develop even after vagotomy alone. typically, however, th se ulcers develop at an anastomotic site and perforation of these recurrent ulcers occurs in about 10%.2 while ct has no role in uncomplicated pu, it is useful in detecting perforation or penetration. the principal ct signs of perforation are extraluminal gas or, when administered, extravasated oral contrast. the location of a focal gas or contrast collection indicates a perforation in that area although the actual perforation itself is unlikely to be seen,' even when contrast is used.' the direct demonstration of an actual perforation does not seem to have been previously reported. we present a case in which the perforation was imaged by ct. case report a 79 year old man presented with sudden onset of severe abdominal pain for 12 hours. relevant past medical history included a billroth type ii gastrectomy for pu more than 10 years before. clinically the patient had an acute abdomen. there was an elevated serum amylase and the clinical differential diagnosis was between pancreatitis and a perforated peptic ulcer. plain films were unremarkable and did not reveal free gas. us showed free fluid in the abdomen consistent with either diagnosis.the gallbladder was norma] with no gallstones but as the pancreas could topagb32 perforzlled peptic ulcer irn<lged directly by oornpr.nc-d tolllography frompage31 not be visualised, due to bowel gas,the patient was referred for ct. this demonstrated intraperitoneal free gas and fluid (figure 1). there was a focal figure 1: axial ct image shows free intraperitoneal gas anteriorly and in the porta and extensive free fluid. note the nasogastric tube in the stomach remnant. defect in the posterior wall of the gastric remnant consistent with a perforated pu (figures 2 and 3). the patient refused surgery and died within 24 hours. post mortem confirmed the figure 2: more caudal image directly imaging the perforation (arrow) and showing an adjacent gas bubble. figure 3: enlargement of fig. 2 demonstrating the perforation more clearly. presence of a perforated peptic ulcer measuring 15 x 20 mm (mean 17.5 mm) on the posterior stomach wall at the site of the gastrojejunostomy (figure 4) as well as extensive peritonitis. discussion there are several reports on the ct findings in perforated pu. these findings are of extraluminal gas and/or extraluminal oral contrast. in a retrospective study involving 35 patients with pu, two had perforation demonstrated on ct although the actual perforation itself could not be identified.' similarly, in a report of three cases of perforated pu, the site of perforation, i.e. gastric or duodenal, could be identified by the location of extraluminal gas or oral contrast, but not the actual perforation itself" however, fultz et al could identify a discontinuity of the bowel wall at the site of perforation in three of nine patients with perforation due to continuity of intraand extraluminal oral contrast through the defect.' in our case the actual perforation itself was clearly seen even without the use of oral contrast. it is not clear why, given the incidence of perforation in pu, direct visualization of the defect does not appear to have been reported before. this perforation was no larger than normal; its size (17.5 mm) was the same as the mean diameter (17.6 mm) reported in a series of 80 cases of perforated pu.s allowing for the role of non-operative management of a sealed-off perforated pu, the presence of free gas or extravasated oral contrast in the appropriate clinical setting indicates the need for operative intervention to repair the perforated viscus. actual visualisation of the perforation itself as in this case, however, unequivocally confirms the need for urgent surgery. in 32 sa journal of radiology· june 1997 figure 4: fixed, post mortem specimen of the opened gastrojejunostomy seen from the front. the large perforated anastamotic ulcer is clearly demonstrated. addition the knowledge of the exact site of the perforation will enable the surgeon to locate and repair it as quickly as possible. we feel that this case also suggests that in patients with an acute abdomen of uncertain cause, where perforated pu is suspected, there may be a role for helical scanning with reconstructions in the sagittal and coronal planes. this should increase the likelihood of directly demonstrating these often sizeable defects. references i. jacobs jm, hill mc, steinberg wm. peptic ulcer disease: ct evaluation. radiology 1991; 178:7 45-748 2. nyhus lm, sheaff cm. recurrent ulcer. in: wasteil c, ed. surgery of the esophagus, stomach and small intestine 5th ed. boston: little brown, 1995:531-540 3. fultz pj, skucas j, weiss slo ct in upper gastrointestinal tract perforations secondary to peptic ulcer disease. gastrointest radiol 1992; 17:58 4. jeffrey rb, federle mp, wall s. value of computed tomography in detecting occult gastrointestinal perforation. j computassisttomog 1983; 7 (5): 825827. 5. horowitz 1, kukora is, ritchie wp. all perforated ulcers are not alike. ann surg 1989;209(6):693-697. radiology_may04 47 sa journal of radiology • may 2004 the world health organization (who), the national cancer institute and the european organisation for research and treatment of cancer have recently adopted a new set of tumour response criteria response evaluation criteria for solid tumours (recist). monitoring response of tumours to treatment is an integral and increasingly important function of radiologists working in oncologic imaging. imaging studies play a pivotal, objective role in quantifying tumour response to a variety of physical and pharmaceutical treatments. the recist criteria have been introduced to unify response assessment criteria, to define how to choose measurable lesions, and to enable the use of new imaging technologies (spiral computed tomography (ct) and magnetic resonance imaging (mri)). definitions and measurements the four categories of response are: (i) complete response (cr); (ii) partial response (pr); (iii) stable disease (sd); and (iv) progressive disease (pd). recist criteria rely on size change of lesions to make response assessments. unidimensional measurements and the sum of the longest diameters are now used, instead of the conventional method using two measurements and the sum of the products. at baseline, lesions are to be categorised as measurable or non-measurable. measurable lesions are defined as those that can be measured accurately in at least one diameter, that is ≥ 20 mm using conventional imaging techniques (including incremental ct) or ≥ 10 mm using spiral ct. non-measurable lesions are discrete lesions with smaller dimensions. these lesions include bony metastases, leptomeningeal disease, ascites, pleural/pericardial effusions, inflammatory breast cancer, lymphangitis carcinomatosa (cutis/pulmonis), abdominal masses that are not confirmed and followed by imaging techniques, heavily calcified and cystic/ necrotic lesions. interestingly, tumour lesions situated in a previously irradiated area may also not be considered as measurable disease. the term ‘evaluable’ which refers to lesions that can be viewed but cannot be measured, has been dropped. after establishing that measurable disease exists, it is necessary to document ‘target’ lesions and non-target lesions. measurable lesions up to a maximum of five lesions per organ and 10 lesions in total, representative of all involved organs, should be identified as ‘target lesions’. these target lesions should be selected on the basis of size and suitability for accurate repeated measurements. a sum of the longest diameter of all target lesions constitutes the baseline sum longest diameter. changes in the sum of the longest diameter are to be used to categorise ‘target tumour response’. non-target lesions need not be measured on follow-up studies but any change should be noted. final response should take into account changes in both target and non-target lesions as well as noting the presence or absence of new disease. it is noteworthy that for stable disease and for progressive disease, the pre-treatment study no longer serves as the baseline study, instead the reference study is one where the smallest sum of the longest diameter was recorded. baseline evaluations are to be performed as close as possible to the beginning of treatment, but not more practical guidelines practical guidelines in the application of response evaluation criteria for solid tumours (recist) in oncology imaging zarina lockhat ffrad(d)sa irma van de werke frcr betsie van der walt fcrad(d) department of radiology university of pretoria review article 48 sa journal of radiology • may 2004 than 4 weeks before treatment starts. with re-evaluation studies there is flexibility — it is recommended that follow-up every other cycle be performed — every 6 8 weeks. an end of treatment study enables overall treatment response assessment. in patients with partial response (pr) or complete response (cr) confirmatory imaging is required at 4 weeks after the criteria for cr or pr have been met. practical imaging recommendations the same method of assessment and same technique should be used to characterise each identified and reported lesion at baseline and during follow-up. imaging-based evaluation is preferred to evaluation by clinical examination when both methods have been used to assess the anti-tumour effect of a treatment. chest x-ray except for the chest radiograph, the role of radiography is not that important. lesions are considered measurable when they are clearly defined and surrounded by aerated lung. however ct is preferable. radiographs cannot be used to assess bone lesions because bony metastases are classified as non-measurable lesions. ultrasound this is not used routinely to assess response of lesions because it is operator-dependent and cannot be reproduced for independent review at a later date. however ultrasound may be used as an alternative to clinical measurement — for superficially palpable lymph nodes, subcutaneous lesions and thyroid nodules. ct and mri these are the best currently available modalities and the most reproducible. for mri assessment the same anatomical plane is used for subsequent examinations. there are no specific sequence recommendations. for ct, when choosing measurable lesions, the basic rule to be followed is that the minimum size should be not less than double the slice thickness. this is to minimise partial volume averaging that can lead to underestimation of lesion size. the longest diameter of the target lesion should be table i. definition of best response according to who or recist criteria best response who change in sum of products recist change in the sum of the longest diameter complete response (cr) disappearance of all target lesions disappearance of all without any residual lesion; confirmed target lesions; confirmed at 4 weeks at 4 weeks partial response (pr) 50% or more decrease in target lesions, at least 30% reduction in the sum without a 25% increase in any one of the longest diameter of target target lesion; confirmed at 4 weeks lesions, taking as reference the baseline study; confirmed at 4 weeks stable disease (sd) neither pr nor pd criteria are met neither pr nor pd criteria are met, taking as reference the smallest sum of the longest diameter recorded since treatment started progressive disease (pd) 25% or more increase in the size of at least 20% increase in the sum measurable lesion or appearance of of the longest diameter of target new lesions lesions, taking as reference the smallest sum of the longest diameter recorded since treatment started or appearance of new lesions 49 sa journal of radiology • may 2004 practical guidelines obtained in the axial plane only. for spiral ct the minimum size of a lesion may be 10 mm provided that a 10 mm collimation is used and reconstructions are at 5 mm intervals. for conventional incremental ct, the minimum size of lesions should be 20 mm with the use of contiguous 10 mm thick slices. contrast medium usage is recommended. oral contrast medium is used routinely — some studies have shown that water is a better contrast agent when evaluating stomach and bowel lesions. iv contrast is also used routinely some lesions become measurable only after iv contrast administration; however contrast may not be necessary when evaluating discrete lung disease. another important recommendation is that all images should be filmed, not just selected images of target lesions. lesions should be measured on the same window setting at each examination. conclusion with the introduction of recist criteria the role of imaging has become more important. ct examinations are performed at an increasing frequency, however the use of plain radiographs and ultrasound has declined. the method of assessing lesions, i.e. unidimensional measurement instead of bidimensional diameters has now been recommended. the measurement of lesions has previously been regarded as laborious and time -consuming. thus radiologists should be familiar with the recist criteria so that measurements are easier to make, more accurate, relevant and less time-consuming to guide clinical decision-making. acknowledgement we would like to thank annelize gates for her assistance in the preparation of this article. references 1. padhani ar, ollivier l. the recist criteria: implications for diagnostic radiologists. br j radiol 2001: 74: 983 -986. 2. mchugh k, kao s. response evaluation criteria in solid tumours (recist) problems and need for modifications in paediatric oncology? br j radiol 2003: 76: 433-436. 3. padhani ar, husbano je. are current tumour response criteria relevant for the 21st century? br j radiol 2000: 73: 1031-1033. 4. therasse p, arbuck sg, et al. special article: new guidelines to evaluate the response to treatment in solid tumours. j natl cancer institute 2002; 92: 205-215. abstract introduction central nervous system tuberculosis head and neck tuberculosis breast tuberculosis cardiovascular tuberculosis abdominal tuberculosis musculoskeletal conclusion acknowledgements references about the author(s) camilla e. le roux department of medical imaging and clinical oncology, medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa sucari s.c. vlok department of medical imaging and clinical oncology, medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa citation le roux ce, vlok ssc. the silent pandemic in south africa: extra-pulmonary tuberculosis from head to heel. s afr j rad. 2021;25(1), a2026. https://doi.org/10.4102/sajr.v25i1.2026 pictorial review the silent pandemic in south africa: extra-pulmonary tuberculosis from head to heel camilla e. le roux, sucari s.c. vlok received: 16 oct. 2020; accepted: 10 feb. 2021; published: 16 apr. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract extra-pulmonary tuberculosis (eptb), caused by mycobacterium tuberculosis, is the leading cause of communicable disease-related deaths in people with human immunodeficiency virus (hiv) worldwide and in south africa. mycobacterium tuberculosis disseminates haematogenously from an active primary lung focus and may affect extra-pulmonary sites in up to 15% of patients. extra-pulmonary tb may present with a normal chest radiograph, which often causes a significant diagnostic dilemma. this review describes the main sites of involvement in eptb, which is illustrated by local imaging examples. keywords: extra-pulmonary tb; circulatory system; lungs; organ systems; chest radiograph; diagnosis. introduction worldwide and in south africa, tuberculosis (tb), a communicable airborne disease caused by mycobacterium tuberculosis, remains the leading cause of death, followed closely by circulatory system diseases. in addition, it is one of the main causes of mortality amongst patients with human immunodeficiency virus (hiv) infection worldwide.1,2 tuberculosis predominantly affects the lungs; however, in up to 15% of patients, extra-pulmonary sites may be involved. extra-pulmonary tuberculosis (eptb) may be the result of haematogenous dissemination from an active primary focus in the lung to other organ system(s) in the body, and this may present years after the initial pulmonary infection.3 a normal chest radiograph or negative laboratory tests do not exclude eptb, a diagnosis that necessitates a high index of suspicion, especially when the patient also tests hiv positive.3,4 this review briefly outlines the main radiological findings of tb in extra-pulmonary sites, of which pleural and lymph node involvement was found to be the most prevalent in this research setting. central nervous system tuberculosis tuberculosis may involve the parenchyma, meninges or spine. parenchyma parenchymal tuberculosis can result from direct spread of infection via the cerebrospinal fluid (csf) or haematogenous dissemination.5,6 a tuberculoma – also known as the tb granuloma – is the most frequent manifestation of parenchymal involvement, with both computed tomography (ct) and magnetic resonance imaging (mri) signal characteristics depending on the stage of infection. tuberculomas, whether caseating or non-caseating, are usually surrounded by moderate to marked oedema on all modalities. tuberculomas may be hypoor hyperdense on uncontrasted ct and reveal avid, homogeneous or rim enhancement on post-contrast ct (figure 1a). at mri, the non-caseating granulomas are t1-weighted (t1w) hypointense (figure 1b) and t2-weighted (t2w) hyperintense (figure 1c) with solid, homogeneous t1w post-gadolinium-contrast enhancement. a solid caseating granuloma is hypointense on both t1w and t2w sequences, and reveals ring enhancement. caseating granulomas demonstrate diffusion restriction, with hyperintense signal at diffusion-weighted imaging (dwi) and corresponding hypointense signal on apparent diffusion coefficient map (adc), because of their central viscous nature.5,6,7 figure 1: a 28-year-old female with disseminated tuberculosis who presented with a 3-month history of weakness and horizontal nystagmus. (a) axial post-contrast computed tomography brain through the cerebellum reveals several hypodense supraand infra-tentorial rim-enhancing tuberculomas (white solid arrows) of which some are clustered (white arrow with dashed line) with surrounding oedema (white arrow head). (b) axial magnetic resonance imaging of the brain through the centrum semiovale of the same patient reveals a non-caseating granuloma, t1-weighted hypointense (white solid arrow) and (c) t2-weighted hyperintense (white solid arrow) with minimal surrounding oedema (white arrow with dashed line). tuberculosis was confirmed on cerebrospinal fluid analysis. a tuberculoma may rarely progress to a tuberculous abscess.3 a tuberculous abscess is usually solitary, can become very large, is often multiloculated with rim enhancement on post-contrast imaging and surrounded by marked oedema on all modalities. on mri, a tuberculous abscess is hypointense on t1w, hyperintense with a hypointense rim on t2w and reveals rim enhancement on t1w post-gadolinium-contrasted imaging.5,6,7 infarcts typically involve the deep grey nuclei, that is, basal ganglia, thalamus and internal capsule.5,6,7 meninges meningeal spread occurs because of either rupture of a subpial focus or haematogenous spread via the meningeal vessels, resulting in a thick basal leptomeningeal exudate that enhances avidly on post-contrast imaging (figure 2). dural involvement with pachymeningitis is also possible. figure 2: a 50-year-old patient with human immunodeficiency virus presented with new onset seizures and a reduced glasgow coma scale (11/15). post-contrasted computed tomography of the brain revealed diffuse leptomeningeal enhancement (white arrows) consistent with tuberculosis meningitis, which was confirmed based on cerebrospinal fluid analysis. the sequelae of meningeal involvement include hydrocephalus, infarcts, vasculitis and cranial nerve palsies. hydrocephalus is caused by reduced csf absorption at the level of the arachnoid villi. cerebrospinal fluid analysis and typical imaging findings aid in distinguishing tuberculous meningitis from other infective aetiologies.3,4,5 spine the bacilli spread haematogenously via batson’s venous plexus or as a result of reactivation of dormant foci.5 in severe cases, multiple microabscesses may be scattered throughout the spine with involvement of the meninges (figure 3). figure 3: a 37-year-old female with advanced human immunodeficiency virus and disseminated tuberculosis presented with a 3-week history of bilateral lower limb weakness, urinary retention and loss of bowel control. (a) sagittal t1-weighted pre-contrasted magnetic resonance imaging of the spine reveals inflammatory exudate along the posterior cord (white arrow with dashed line). (b) sagittal t1-weighted post-contrasted magnetic resonance imaging of the spine reveals multiple enhancing microabscesses throughout the spine (solid white arrows), diffuse leptomeningeal enhancement along the brainstem and spinal cord (white arrow head) and long-segment enhancing inflammatory exudate along the posterior cord, which compresses the cord against the vertebral column (white arrows with dashed line) and contains central necrosis (white arrow with dotted dash line). the vertebral spine is the most common site of musculoskeletal involvement, with the lower thoracic and upper lumbar spine being the most frequently affected sites. classic findings of tuberculous spondylitis (pott disease) are contiguous involvement of more than one vertebral level, with a predilection for the anterior vertebral body adjacent to the end plates. involvement of the posterior elements is rare in comparison with the end plate changes.6,8 presentation with ivory vertebra or complete vertebral collapse (plana) is possible. subsequent spread of infection is beneath the anterior or posterior longitudinal ligament or through the vertebral end plates (figure 4).6,8 paraspinal and extradural soft tissue and gibbus formation are the most common findings reported. on mri, the paraspinal or subligamentous abscesses demonstrate t2-weighted (t2w) hyperintense and t1w hypointense signal.6,8 figure 4: a 48-year-old human immunodeficiency virus-positive female who presented with progressive back pain. (a) sagittal t2-weighted magnetic resonance imaging of the cervical and thoracic spine revealed spondylodiscitis centred at the t7/t8 level with destruction of the anteroinferior end plate of t7 and superoanterior end plate of t8 vertebrae with early destruction of the t7/t8 intervertebral disc (white arrow with dotted line) and t2w hyperintense subligamentous abscess spread (solid white arrow), extending from levels t6 to t10. (b) sagittal t1-weighted post-contrast magnetic resonance imaging of the cervical and thoracic spine revealed enhancement of an anterior extra-dural collection (white arrow with dotted line). tissue gene xpert confirmed tuberculosis. extradural abscess may cause cord compression with neurological fallout (figure 5).6,8 psoas abscess formation with possible associated calcifications is often a clue to the diagnosis.6,8 figure 5: a 3-year-old girl, human immunodeficiency virus negative, presented with weight loss, acute onset of back pain in the lumbar region and refusal to walk. chest radiograph findings were suggestive of pulmonary tuberculosis. sagittal t2-weighted magnetic resonance imaging of the spine demonstrates near-complete destruction of the l2 vertebral body with gibbus formation at this site and t2w hyperintense subligamentous abscess (solid white arrow) extending from levels l1 to l3, with compounded compression of the conus medullaris and cauda equina nerve roots (white arrow with dotted line). tuberculosis was confirmed on tissue genexpert. mycobacterium tuberculosis preferentially affects end plates, with relative sparing of the intervertebral disc, whilst pyogenic infection affects the intervertebral disc during the early stage of the disease. metastases typically involve the posterior elements more commonly with expansion of the vertebral body. intra-medullary tuberculoma intra-medullary tuberculomas demonstrate signal intensities identical to intracranial tuberculomas (figure 6).6,7,8 figure 6: a 27-year-old human immunodeficiency virus-positive female, on antiretroviral treatment, presented with paraplegia. sagittal t1-weighted post-contrasted magnetic resonance imaging revealed multiple round, intra-medullary rim-enhancing t1w hypointense lesions scattered throughout the spinal cord, consistent with tuberculomas (solid white arrows). cerebrospinal fluid analysis confirmed tuberculosis. arachnoiditis arachnoiditis is characterised by clumped, thickened, and enhancing nerve roots adherent to the dura, with csf loculation and attenuation of the csf spaces as typical features on both ct and mri.6,7 head and neck tuberculosis the lymphatic system is the second most common extra-pulmonary site affected by tb in this study setting. the most common presentation is matted, painless lymphadenitis (scrofula), with only mild inflammatory superficial skin changes. cervical lymph nodes are typically involved.5,6,8 central necrosis is a typical finding and may be seen as hypoechoic lymph node centres on ultrasound and low-density central attenuation on ct, depending on the degree of caseation, with possible rim enhancement on post-contrast imaging (figure 7).6,8 figure 7: a 24-year-old human immunodeficiency virus-negative male with aplastic anaemia presented with bilateral neck swelling. lymph node biopsy confirmed tuberculous lymphadenitis. coronal post-contrasted computed tomography of the neck demonstrated multiple, bilateral cervical (solid white arrows) and paratracheal (solid black arrows) lymph nodes with necrotic centres consistent with tuberculous lymphadenitis. paradoxical transient nodal enlargement during treatment is usually observed in hiv patients.9 lymphoma and other infective causes of lymph node enlargement must be excluded, usually by fine needle aspiration or core biopsy of the involved lymph nodes. the sinonasal cavity, larynx and glottis may also be involved, with non-specific imaging findings.10 breast tuberculosis breast involvement occurs rarely, with the most frequent presentation being a hard painless mass or mastalgia in a young, multiparous woman. sinus tracts and abscesses are the associated findings.8 three types of breast involvement are recognised: nodular, diffuse and sclerosing. the nodular form presents as a dense round area, which represents a caseating lesion, whilst the diffuse form leads to sinus tracts and ulceration. fibrosis with nipple retraction is the dominant feature of the sclerosing form.11 cardiovascular tuberculosis pericardium spread of infection to the pericardium may occur via haematogenous dissemination or direct thoracic lymph node extention. the typical findings include a globular cardiac configuration on chest radiography related to pericardial effusion, with late-stage pericardial calcifications (figure 8a). figure 8: (a) a 68-year-old human immunodeficiency virus-negative male presented with features of pericarditis. genexpert and bronchial washings confirmed tuberculosis. a lateral chest radiograph demonstrates pericardial calcification (solid white arrows) and multiple pulmonary nodules (black arrow). (b) a 37-year-old male, human immunodeficiency virus positive with pulmonary and pericardial tuberculosis, confirmed with genexpert on both sputum and pericardial fluid. coronal post-contrasted computed tomography of the chest demonstrates pericardial thickening (solid white arrow), small pericardial effusion (black arrow), large necrotic right axillary (black arrow with dashed line), smaller necrotic mediastinal (black arrow with dotted line) lymph nodes and right apical post-infective bronchiectasis (white arrow with dashed line). echocardiography may demonstrate a fibrinous effusion. slow accumulation of pericardial effusion is typically seen without tamponade. mild pericardial thickening and enhancement may be evident on ct (figure 8b).8 constrictive pericarditis is a consequence of pericardial involvement, with typical pericardial calcifications seen at chest radiography. myocardium although very rare, three types of involvement are recognised, which include the miliary, infiltrating interstitial and caseating nodular types.12 aortic secondary involvement from contiguous mediastinal lymphadenopathy, empyema, pericarditis or haematogenous dissemination. pseudo-aneurysms may occur because of contiguous vertebral involvement.13 abdominal tuberculosis spread of infection may occur via ingestion of mycobacteria, haematogenous dissemination, contiguous spread from adjacent organs or lymphatic involvement.5,6 peritoneal involvement three types of peritoneal involvement can occur, namely, the wet, fibrotic and dry. the wet type is the most common, presenting as free ascites or loculated pockets of high-protein content fluid. the dry type leads to fibrous adhesions with mesenteric thickening. the fibrous type may manifest as omental or mesenteric masses.5,6 omentum omental involvement may result in a combination of omental caking or mass formation.5 differential diagnosis includes carcinomatosis in the case of a known primary neoplasm or mesothelioma, if possible asbestos exposure is present. lymph nodes, liver and spleen intra-abdominal lymph nodes demonstrate the typical low-density, central caseous necrosis and rim enhancement at ct, similar to lymph node involvement in the neck or chest. hepato-splenic involvement may be in the form of organomegaly, with microor rarely macroabscesses, which can calcify (figure 9a).5,6,8 figure 9: (a) a 34-year-old human immunodeficiency virus-positive female, on retroviral treatment, with previously treated multidrug-resistant tuberculosis presented with acute on chronic gastroenteritis and loss of weight. axial post-contrasted computed tomography through the upper abdomen revealed multiple splenic micro(solid white arrows) and macro(white arrow with dashed line) abscesses with enlarged necrotic right paraspinal (solid black arrow) and clustered necrotic left para-aortic lymph nodes. (b) axial slices through the pelvis of the same patient revealed diffuse, irregular thickening and enhancement of the terminal ileum (solid white arrow) and caecum (white arrow with dotted line) with peri-caecal fat stranding (white solid arrow head). gastrointestinal tract there is a predilection for the terminal ileum and caecum, with acute findings including mural thickening, narrowed terminal ileum and adjacent lymphadenopathy (often necrotic).5,6,8 a widely gaping, iliocaecal valve (fleischner sign, figure 9b) and a shrunken conical caecum (figure 9b) are seen in the chronic stages. differential diagnoses include crohn’s disease and lymphoma. adrenal glands the adrenal glands typically demonstrate bilateral involvement. there is gland enlargement and rim enhancement with central low-density necrosis in keeping with adrenalitis.5 the acute gland enlargement may either resolve or lead to small, dystrophic calcified glands. tuberculosis is the most common cause of addison’s disease (figure 10), and the patient may present with an acute addisonian crisis.5,6 figure 10: a 33-year-old male, with human immunodeficiency virus and previous tuberculosis status unknown, presented with newly diagnosed addison’s disease. coronal uncontrasted computed tomography of the abdomen centred over the kidneys revealed a small, echogenic, near complete calcified right kidney (‘putty kidney’; solid white arrows) and scattered calcifications throughout both adrenal glands (solid black arrows). the diagnosis of tuberculosis was made on the basis of the computed tomography findings. genito-urinary irregular renal cortical calcifications (figure 10) and focal caliectasis are the common findings. other possible findings include renal papillary necrosis, ureteric stenosis (pipe stem), ureteric calcifications (figure 11a) and pelviureteric junction narrowing (kerr’s kink, figure 11b). renal atrophy with ground glass calcifications (putty kidney, figure 10) are late sequelae.5,6,8 figure 11: (a) a 43-year-old man known with human immunodeficiency virus and pulmonary tuberculosis, on both antiretroviral and tuberculosis treatment presented with a 3-month history of dysuria and right epididymal swelling. at intravenous pyelography, the control radiograph demonstrated diffuse urothelial calcification of the left pelvi-calyceal system (solid white arrow) and proximal left ureter (white arrow with dashed line). (b) a post-micturition view during intravenous pyelography in the same patient demonstrated bilateral blunting of the calyces (solid white arrows), a kerr’s kink (white arrow with dotted line), focal stenosis in the distal right ureter (black arrow with dotted line), a small calibre bladder which contains residual contrast on the post-micturition view (black arrow head) and calcification of the left pelvi-calyceal system (solid black arrow). bladder wall irregularity, with peripheral calcifications and a small-volume (‘thimble’) bladder, may be found, which may result in vesico-ureteric reflux with hydronephrosis related to fibrosis at the ureteric orifice.8 epididymal and testicular involvement may cause epididymo-orchitis. seminal vesicles and vas deferens may be affected with wall thickening or calcifications. prostatic involvement may take the form of abscess or prostatitis. diffuse dystrophic calcification is seen in the chronic form.14 salpingitis, with a fallopian stricture, typically occurs at the junction of the isthmus and ampulla.6,7 endometrial adhesions or synechiae formation may develop.6,8 musculoskeletal monoarthritis of weight-bearing joints is common.6,8 patterns of involvement include spondylitis, tuberculous arthritis (figure 12 – knee), osteitis or osteomyelitis (figure 13), soft tissue involvement, bursitis (figure 14), tenosynovitis (figure 15) and dactylitis.5,6,8 periarticular osteopenia, marginal erosions and subtle joint space loss are seen with articular involvement and are called the phemister triad (figure 12).5,6,8 a recent case series by swarap et al.,15 demonstrates atypical sites of musculoskeletal involvement, and emphasises the need for maintaining a high index of suspicion in order to make the correct diagnosis. figure 12: a 41-year-old male, with human immunodeficiency virus status unknown, presented with a 2-year history of chronic right knee pain and a draining sinus. erythrocyte sedimentation rate at the initial visit was raised. conventional radiograph of the knee demonstrates joint space narrowing (solid white arrow), subchondral cyst formation (white arrows with dotted lines) and juxta-articular osteopenia (white arrow heads). the constellation of findings is known as the phemister triad. figure 13: a 23-year-old male, human immunodeficiency virus status unknown, presented with left heel pain and a draining sinus. sagittal t1-weighted fat sat, post-contrasted magnetic resonance imaging of the left hind foot demonstrates a small rim-enhancing collection in the calcaneus (solid white arrow) with enhancing inflammatory changes in the remainder of the calcaneus (white arrow with dotted line) and surrounding soft tissues (white arrow with dashed line). a draining sinus was demonstrated on t2w sequences. tuberculosis was confirmed on gene xpert of calcaneal tissue. figure 14: a 20-year-old human immunodeficiency virus-negative female presented with chronic hip pain, which progressively worsened over 3 months. coronal t1-weighted fat sat post-contrasted magnetic resonance imaging of the pelvis demonstrates rim-enhancing masses within the greater trochanter and intertrochanteric space (images not included), which communicates with the right trochanteric bursa. rim-enhancing abscesses (solid white arrows) extend from the bursa, inferiorly underneath the ilio-tibial band. tuberculous osteitis with overlying bursitis and cold abscess formation was confirmed on tissue gene expert. figure 15: a 40-year-old human immunodeficiency virus-negative male presented with a 2-month history of unilateral right hand swelling. a conventional radiograph of the hands demonstrates diffuse periarticular osteopenia (solid white arrows) and right-sided soft tissue swelling (white arrow with dotted line). no erosions or joint space narrowing were observed. synovial biopsy confirmed tuberculous tenosynovitis. conclusion tuberculosis remains a common diagnosis made on a daily basis by radiologists in south africa, and hence, is known to be a silent pandemic when misdiagnosed. extra-pulmonary tb remains underdiagnosed, with patients often presenting at advanced stages of the disease with extensive destruction of the organ system(s) involved, which is mainly because of the stigma and its association with hiv infection. tuberculosis is known as the great mimicker and remains the leading cause of communicable-disease-related deaths in our country. it must be considered as a differential when evaluating patients with sequelae of chronic infection in all pandemic areas. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.e.l.r. drafted the original article and legends, which were modified and edited by s.s.c.v. c.e.l.r. and s.s.c.v. chose the images together and made annotations. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, c.e.l.r., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references stats sa. mortality and causes of death in south africa. findings from death notification [homepage on the internet]. stats sa; 2017 [cited 2020 sep 2]. available from: http://www.statssa.gov.za/publications/p03093/p030932017.pdf world health organization. tuberculosis and hiv [homepage on the internet]. world health organization; 2020 [cited 2020 sep 2]. available from: https://www.who.int/hiv/topics/tb/about_tb/en/ rodriguez-takeuchi sy, renjifo me, josé f. extrapulmonary tuberculosis: pathophysiology and imaging findings. radiographics. 2019;39(7):2023–2037. https://doi.org/10.1148/rg.2019190109 gounden s, perumal r, magula np. extrapulmonary tuberculosis in the setting of hiv hyperendemicity at a tertiary hospital in durban, south africa. s afr j infect dis. 2017;33(3):57–64. https://doi.org/10.1080/23120053.2017.1403207 gambhir s, ravina m, rangan k, dixit m, barai s, bomaji j. imaging in extrapulmonary tuberculosis. infect dis. 2017;56(3):237–247. https://doi.org/10.1016/j.ijid.2016.11.003 maclean k, becker a, chang s, harris a. extra-pulmonary tuberculosis-imaging features beyond the chest. can ass rad j. 2013;64(4):319–324. https://doi.org/10.1016/j.carj.2012.07.002 miral d, osborn a, salzman k. diagnostic imaging brain. 3rd ed. philadelphia, pa: elsevier, 2016; p. 712–713. engin g, acunas b, acunas g, tunaci m. imaging of extra-pulmonary tuberculosis. radiographics. 2000;20(2):471–488. https://doi.org/10.1148/radiographics.20.2.g00mc07471 gandhare a, mahashur a. tuberculosis of the lymph nodes: many facets, many hues. astrocyte. 2017:4(2):80–86. https://doi.org/10.4103/astrocyte.astrocyte_65_17 kaufmann s, rubin e, zumla a. imaging in tuberculosis. cold spring harb perspect med. 2015;5(6):a017814. https://doi.org/10.1101/cshperspect.a017814 popli m. pictorial essay: tuberculosis of the breast. indian j radiol imaging. 1999;9(3):127–132. dixit r, chowdhury v, singh s. case report: myocardial tuberculosis-mri. indian j radiol imaging. 2009:19(1):57–59. https://doi.org/10.4103/0971-3026.45347 retrepo c, ocazionez d, suri r, vargas d. aortitis: imaging spectrum of the infectious and inflammatory conditions of the aorta. radiographics. 2011;31(2):435–451. https://doi.org/10.1148/rg.312105069 yung y, kim j, cho k. genito-urinary tuberculosis: comprehensive cross-sectional imaging. am j roentgenol. 2005;184(1):143–150. https://doi.org/10.2214/ajr.184.1.01840143 swarap s. tuberculosis, a great masquerader: a case series unveiling rare sites of musculoskeletal involvement through imaging. s afr j radiol. 2020;24(1):1–6. https://doi.org/10.4102/sajr.v24i1.1919 editoi~ial international college of radiology petercorr mbchb, ffrad(d)sa, frcr, m med(uct) department of radiology, university of natal t he international college of radiology (icr) is the international body representing the national societies of europe, north ahd south america, middle east and africa, " asia and australasia. lts major function in recent years is education, particularly at the registrar level. the emphasis is on developing countries where interest in radiology is growing rapidly. regions where there has been rapid growth in radiology include china, india, south america andafrica. the radiological society of south africa is currently bidding to hold this prestigious international meeting in the year 2002, probably in cape town. it will be a great honour for the society to host this meeting at a time when there is rapid change in health care and improved economic growth in many sub-saharan countries. the meeting will also cement relationships with radiologists in other countries of africa especially the francophone and arab countries. many of the health care problems facing south africa are similar to those of other developing 'countries and by interacting with radiologists at a national level or through organizations such as the who and the icr we can learn from other countries' successes and mistakes. 3 sa journal of radiology· may 1998 interesting images an unusual wig masquerading as calcific • •neurocysticercosis a 26-year-old black woman, who had been involved in a motor vehicle accident, was referred for radiography of the skull (figure 1). x-rays did not demonstrate any signs of bony injury, but did reveal multiple rounded opacities related to the cranial vault, initially thought possibly to be due to calcific neurocysticercosis or alternatively multiple sclerotic bony wfc van gelderen ffrad(d)(sa) consultant radiologist. taranaki base hospital, new zealand figure 1: lateral radiograph of the skull demonstrating multiple small opacities simulating calcific neurocysticercosis but due to tufts of hair within 8 wig seen end-on.metastases. when the patient was examined clinically by the reporting radiologist, she was found to be wearing a most impressive and very realistic black wig with strands of hair woven around small hooks within the confines of the wig. these small hooks, containing tight knots of hair, were responsible for the multiple cranial opacities when seen end-on. ama/pra category 1 accredited course category a ce (asrt) accredited course 1999 cmrs annual society meetingclinical magnetic resonance society date: june 24-27, 1999 venue: disney's yacht & beach club resorts. lake buena vista, florida, usa topic: clinical magnetic resonance imaging attendees: physicians and radiologic technologists technical exhffiits contact: caren theuring clinical magnetic resonance society 800-823-2677,513-221-0070 fax:513-221-0825 email: cmrs@one.net 36 sa journal of radiology. november 1998 mailto:cmrs@one.net abstract introduction case presentation discussion conclusions acknowledgements references about the author(s) sheree c. gray department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa jacobus a. pienaar department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa zelia sofianos department of radiology, faculty of radiology, university of the witwatersrand, klerksdorp, south africa jacob varghese department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, johannesburg, south africa ilonka warnich department of radiology, faculty of radiology, university of the witwatersrand, johannesburg, south africa citation gray sc, pienaar ja, sofianos z, varghese j, warnich i. hepatic mesenchymal hamartoma: an uncommon but important paediatric diagnosis. s afr j rad. 2020;24(1), a1891. https://doi.org/10.4102/sajr.v24i1.1891 note: special collection: paediatric radiology. case report hepatic mesenchymal hamartoma: an uncommon but important paediatric diagnosis sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese, ilonka warnich received: 19 apr. 2020; accepted: 19 may 2020; published: 27 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract hepatic mesenchymal hamartoma is a rare hepatic tumour seen in the paediatric population. although this entity has a variable imaging appearance, it has a favourable prognosis if diagnosed and managed correctly. this case presents the ultrasound and computed tomography findings of an 11-month-old patient who presented with a history of progressive abdominal distension and an elevated alfa fetoprotein level on biochemistry. the case describes how a confident perioperative diagnosis could be made on the basis of characteristic imaging features. keywords: hepatic mesenchymal hamartoma; paediatric population; cystic liver masses; hepatic tumours; paediatric alfa fetoprotein levels; computed tomography; ultrasound. introduction hepatic mesenchymal hamartoma is an uncommon, benign, paediatric tumour, most commonly encountered during the first 24 months of life. because of an excellent prognosis, distinguishing this tumour type from other liver masses is essential, and confident perioperative diagnosis could be made on the basis of characteristic imaging features. case presentation an 11-month-old male patient presented at the department of paediatrics with a 3-month history of progressive abdominal distension. the child was otherwise systemically well, born at term and had no significant background medical history. clinical examination revealed an upper abdominal mass lesion, non-tender and firm to palpation. ensuing abdominal ultrasound showed a complex solid-cystic upper abdominal mass lesion, with concern for possible hydatid disease. initial biochemistry revealed mild elevation in gamma-glutamyl transferase (ggt) with a marginally elevated alfa fetoprotein (afp) level of 44.4 µg/l (reference range: 0.6 µg/l – 7.9 µg/l, as per the national health laboratory service [nhls]). hydatid serology, blood cultures and confirmatory human immunodeficiency virus (hiv) testing were negative. further imaging was then preformed. contrast-enhanced abdominal computed tomography (ct) in the portal venous phase demonstrated a large, well-demarcated intraperitoneal mass (figure 1), measuring approximately 17 cm × 16 cm × 15 cm. the mass was localised within the right abdomen, displacing the bowel to the left. it was abutting the inferior border of the liver with a poor plane of separation. however, there was no hepatic parenchymal claw sign, precluding a confident diagnosis of hepatic origin. the mass extended into the central abdomen as well as into the flank and pelvis on the right. it showed an inhomogeneous attenuation pattern with moderately enhancing soft tissue components, large low attenuating cystic areas and low attenuating tubular structures. no overt calcification or fat elements were demonstrable. the lesion significantly displaced the surrounding viscera, with a degree of bowel attenuation, but there was no bowel obstruction or features of direct local invasion. minimal abdominopelvic free fluid was noted and no significant lymphadenopathy was visualised. the gall bladder, hepatic artery and portal venous system were normal, with other imaged structures unremarkable. figure 1: initial imaging – axial and coronal contrast-enhanced computed tomography of the abdomen (portal venous phase) demonstrates a large, complex mass lesion in the right abdomen. it abuts the inferior liver border with a poor plane of separation and displaces the bowel to the left (arrowheads). there is a lack of peripheral hepatic parenchymal extension along the edges of the mass (claw sign); therefore, hepatic origin cannot confidently be suggested. solid and cystic elements are clearly distinguishable (arrow) with the classic ‘swiss cheese appearance’. based on the above-mentioned imaging findings, the initial differential diagnoses included that of primary hepatic lesions as well as extra-hepatic mesenteric lesions. the most likely diagnosis within each category was a hepatic mesenchymal hamartoma and mesenteric lymphatic malformation respectively. the child was referred to a tertiary institution for further management. because of delay in follow-up, a repeat abdominal ct was performed approximately 4 weeks after the initial study. this was carried out to evaluate for interval growth and assist in surgical planning. it revealed the mass to have shifted into the left-sided abdomen, completely separable from the right and left liver lobes, with displacement of the bowel to the right (figure 2). a thin pedicle could now be identified connecting the mass to the caudate lobe of the liver (figure 3). the mass showed no interval change in size. a pedunculated hepatic mesenchymal hamartoma was confidently diagnosed, with no need for further imaging. given the lack of markedly raised afp levels, a hepatoblastoma was a less likely, however, still important in the differential diagnosis. figure 2: follow-up imaging – abdominal computed tomography scout image and coronal contrast-enhanced imaging (portal venous phase) demonstrates the mass to have shifted into the left abdomen (arrow), causing displacement of the bowel to the right (arrowheads). this reveals the mass to be mobile and separable from the right and left liver lobes. figure 3: follow-up imaging – axial contrast-enhanced computed tomography of the abdomen (portal venous phase) shows the mass within the left upper abdomen. a thin pedicle is seen connecting the mass to the caudate lobe of the liver (arrowheads). this confirms a pedunculated mass of hepatic origin. subsequent laparotomy confirmed a large pedunculated mass arising from the caudate lobe of the liver. the lesion was excised and sent for histological evaluation. macroscopic pathological assessment showed solid components with the appearance of haemorrhagic liver parenchyma with areas of haemorrhage as well as cystic components, the largest measuring 30 mm × 25 mm × 20 mm. the cysts contained yellow serous fluid with a smooth, unilocular inner cystic wall. areas of necrosis and calcification were not identified. microscopic and immunohistochemical evaluation showed clusters of hepatocytes, without cellular atypia, along with numerous bile ducts of variable proportions, haphazardly arranged within an oedematous fibromyxoid stroma. the stroma consisted of spindled fibroblasts with numerous vascular spaces interspersed with the bile duct. the cysts were lined with a single layer of columnar epithelium, also without atypia. areas of acute haemorrhage were noted, with prominent vascular ectasia. no granulomatous inflammation, viral cytopathy, parasites, protozoa or features of invasive malignancy were visualised. these findings are in keeping with a histological diagnosis of hepatic mesenchymal hamartoma. a 3-month follow-up ultrasound revealed a normal liver with no residual or recurrent tumour. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. discussion hepatic mesenchymal hamartoma is an uncommon, benign tumour with an excellent prognosis, which may be encountered during paediatric imaging, typically in patients aged between 1 month and 4–5 years.1 a slight male predominance is documented. as the term ‘hamartoma’ implies, it should rather be considered a developmental malformation than a true neoplasm. very rarely these hamartomas can undergo malignant degeneration into undifferentiated embryonal sarcoma. mesenchymal hamartomas were first described in the literature by edmondson in 1956.2 initially, these lesions were variably named as hepatic or giant lymphangiomas, bile duct fibroadenomas, and cavernous lympangiomatoid tumours before being grouped together under the term ‘mesenchymal hamartoma’. association with polycystic kidney disease, congenital hepatic fibrosis and biliary hamartomas has been described.1,3,4 clinical presentation varies on the basis of tumour size. smaller hamartomas are usually asymptomatic, with a painless mass lesion incidentally discovered on abdominal examination. pathologically, the neoplasm develops and progressively enlarges because of mesenchymal proliferation, with the development of multiple fluid-containing cysts contributing to the rapid enlargement of mass. whilst well-circumscribed, this mass is unencapsulated.5,6 serum afp levels can be within the normal limits, but can also be elevated because of the proliferation of hepatocytes in the neoplasm.5,7 elevated ggt, but otherwise normal liver function tests, is also reported.1,3 regarding serum afp levels in the paediatric population, these levels are routinely used as an important biomarker for hepatoblastoma, where values are typically very elevated (up to approximately 100 000 times the normal value). however, this is limited in terms of sensitivity and specificity for the diagnosis of malignancy, as it is a tumour-associated and not a tumour-specific protein. a mild elevation in serum levels can be seen with other malignant and non-malignant conditions, such as hepatocellular carcinoma, mesenchymal hamartoma, cirrhosis, viral and chronic active hepatitis, and ulcerative colitis, to name but a few. in patients with hepatoblastoma, 5%–10% of these may have a low or even normal afp level. concentrations are also age-specific, with high levels observed in neonates and exceedingly high levels in preterm neonates. levels usually decline and reach normal concentrations at 8–12 months of age. alfa fetoprotein levels should thus be correlated with imaging and histopathology findings whilst taking the patient’s age into account.8,9,10 mesenchymal hamartomas are commonly large at the time of diagnosis, weighing over 1 kg, and most commonly arise from the right lobe of the liver. these lesions arise from the mesoderm within portal tracts. pathological hallmarks are clusters of normal hepatocytes in a matrix of porous mesenchyme, which allows accumulation of fluid as it degenerates, predisposing to cyst formation. additional cystic elements are attributable to dilated biliary ducts.1 radiological imaging plays a major role in both diagnosis and planning the surgical approach to the lesion, as clinical and biochemical features are nonspecific.2 plain abdominal radiographs may show hepatomegaly or a paucity of bowel gas in the right upper quadrant, suggesting a hepatic mass lesion. sonography is the modality of choice for initial assessment in the paediatric age group. right upper quadrant findings can vary from large, septated cysts to small cysts with thick septations, with varying degrees of associated solid echogenic tissue, in relation to the liver and separable from the biliary tree. computed tomography confirms sonographic findings, and better delineates the extent of the mass lesion and relationship to other intra-abdominal viscera. the appearance is commonly that of a well-defined solitary mass lesion of hepatic origin, either completely intrahepatic, partially extrahepatic, and with an exophytic or pedunculated pattern of growth. enhancing soft tissue elements are usually seen surrounding a central area of simple fluid attenuation, with variable degrees of internal septation and loculation. this multi-cystic configuration is commonly labelled as a ‘swiss cheese appearance’. completely solid, stromal predominant tumours are rarely seen and are usually smaller lesions. haemorrhage is uncommon. calcification, although it may very rarely occur in these lesions, is much more commonly seen in other tumours. computed tomography appearance may be deceiving in instances where cysts mimic tumour necrosis seen in malignant hepatic neoplasms, and ultrasound or magnetic resonance imaging (mri) is helpful to differentiate simple anechoic cysts from liquefied tissue.1,3,4 scintigraphy with technetium-labelled sulphur colloid confirms the presence and position of either a solitary or multiple photopenic masses, as the hamartoma lacks kupffer cells. this modality is otherwise non-specific regarding further delineation.1 magnetic resonance imaging has a value in confidently establishing hepatic origin in cases of large, pedunculated, predominantly cystic lesions and to accurately delineate solid and cystic components, septations and relations to surrounding structures – especially the intrahepatic vasculature and the biliary system. appearance may vary depending on composition. the t1 signal intensity of cystic components may differ based on the concentration of protein in the fluid but usually approximates water intensity on t2-weighted imaging. solid components may appear hypointense to adjacent liver on both t1and t2-weighted sequences because of fibrosis. enhancement post-gadolinium is usually mild and confined to the septal and stromal elements.3,4 differential diagnoses include benign and malignant hepatic or intra-abdominal masses, as summarised in table 1. occasionally, when the mass is large, the organ of origin is difficult to identify. as such, extrahepatic considerations of other cystic intra-abdominal mass lesions are often included in the differential diagnosis. these include hydatid cysts, mesenteric lymphatic malformations, gastrointestinal duplication cysts and cystic teratomas of the mesentery.11 intrahepatic considerations are simple congenital hepatic cysts, which are generally rare in children and are not septated, or form part of the spectrum of polycystic kidney disease, where renal cysts are also present. choledochal cysts are also not septated but are coupled with a degree of biliary dilation. infectious foci, such as abscesses, have a different clinical picture with more complex internal content. amoebic abscesses and hydatid diseases are also considered, but biochemical assessment helps in the diagnosis. mesenchymal hamartomas with a larger degree of soft tissue may mimic cystic hepatoblastomas, the focal form of infantile hepatic haemangiomas, cavernous haemangiomas (adult-type hepatic haemangiomas), teratomas or hepatocellular carcinomas in older patients. cavernous haemangiomas usually demonstrate a typical pattern of avid peripheral enhancement with centripetal fill-in, but differentiation could be challenging. teratomas commonly contain fat and calcification. calcification is also common in hepatoblastomas and infantile hepatic haemangiomas, which are more solid in nature. alfa fetoprotein is significantly elevated with hepatoblastoma. generally, the relatively poor enhancement of the solid components of cystic mesenchymal hamartomas helps in differentiation from these lesions. undifferentiated embryonal sarcomas, an even rarer entity, may be indistinguishable from cystic mesenchymal hamartomas.1,2,3,4 table 1: differential diagnoses for a hepatic mass in a child. these neoplasms may undergo malignant transformation, and, as a result, complete surgical excision, with clear margins, remains the mainstay of treatment.6 there is a strong association with undifferentiated embryonal sarcomas, which are especially aggressive and have a poor prognosis.12,13 long-term follow-up is necessary post-resection. treatment with surgical resection is usually curative and yields admirable results. partial lobectomy is commonly needed to remove larger tumours. the large size of these tumours makes the surgery technically challenging. if respiratory distress is the presenting complaint, percutaneous catheter drainage of large cystic elements is frequently performed as a temporising measure prior to surgical intervention.1,3 conclusions hepatic mesenchymal hamartoma is a rare hepatic tumour with a variable imaging appearance that has an excellent prognosis if identified and managed appropriately. in rare instances, malignant degeneration to undifferentiated embryonal sarcoma could arise whilst having a similar imaging appearance. a high index of suspicion should be asserted in all cases of asymptomatic, cystic liver masses in children and a clear understanding of the most important differential diagnoses is imperative. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.c.g. made substantial contribution to the conception and design, drafting and revision of the article; i.w. made substantial contribution to the conception and design, literature review, imaging and revision of the article; z.s. made substantial contribution to the acquisition of data, literature review and drafting of case report; j.a.p. made substantial contribution to the acquisition of data, literature review and drafting of case report; j.v. made substantial contribution to the conception and design, revision and approval of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references stanley p, hall tr, woolley mm, et al. mesenchymal hamartomas of the liver in childhood: sonographic and ct findings. ajr am j roentgenol. 1986 nov;147(5):1035–1039. https://doi.org/10.2214/ajr.147.5.1035 khan m, binkovitz l, smyrk t, potter d, furuya k. mesenchymal hamartoma in children: a diagnostic challenge. case rep pediatr. 2019;2019(4132842):1–3. https://doi.org/10.1155/2019/4132842 anil g, fortier m, low y. cystic hepatic mesenchymal hamartoma: the role of radiology in diagnosis and perioperative management. brit j radiol. 2011;84(1001):91–94. https://doi.org/10.1259/bjr/41579091 rosado e, cabral p, campo m, tavares a. mesenchymal hamartoma of the liver: a case report and literature review. j radiol case rep. 2013;7(5):35–43. https://doi.org/10.3941/jrcr.v7i5.1334 chung em, cube r, lewis rb, conran rm. from the archives of the afip: pediatric liver masses: radiologic-pathologic correlation part 1. benign tumors. radiographics. 2010 may;30(3):801–826. https://doi.org/10.1148/rg.303095173 koganti sb, thumma vm, nagari b. mesenchymal hamartoma of the liver: complete excision always necessary. case rep surg. 2017;2017:8314102. https://doi.org/10.1155/2017/8314102 ito h, kishikawa t, toda t, arai m, muro h. hepatic mensenchymal hamartoma of an infant. j pediatr surg. 1984 jun;19(3):315–317. https://doi.org/10.1016/s0022-3468(84)80197-9 kelli s. serum markers in tumour diagnosis and treatment. in: pinkerton r, plowan pn, pieters r, editors. paediatric oncology: clinical practice and controversies. 3rd ed. london: edward arnold, 2004; p. 169–188. van houwelingen l, sandoval ja. alpha-fetoprotein in malignant pediatric conditions. in: shailendra k. saxena, editor. proof and concepts in rapid diagnostic tests and technologies [e-book online]. 2016 sep 07. available from intechopen. https://doi.org/10.5772/63911 wu jt, book l, sudar k. serum alfa-fetoprotein (afp) levels in normal infants. pediatr res 1982;15:50–52. https://doi.org/10.1203/00006450-198101000-00012 stoupis c, ros pr, abbitt pl, burton ss, gauger j. bubbles in the belly: imaging of cystic mesenteric or omental masses. radiographics. 1994 jul;14(4):729–737. https://doi.org/10.1148/radiographics.14.4.7938764 stringer md, alizai nk. mesenchymal hamartoma of the liver: a systematic review. j pediatr surg. 2005 nov;40(11):1681–1690. https://doi.org/10.1016/j.jpedsurg.2005.07.052 ramanujam tm, ramesh jc, goh dw, et al. malignant transformation of mesenchymal hamartoma of the liver: case report and review of the literature. j pediatr surg. 1999 nov;34(11):1684–1686. https://doi.org/10.1016/s0022-3468(99)90644-9 editorial ",ho should do interventional radiology? petercorr mbchb, ffrad(d)sa, frcr, m med(uc7) department of radiology, university of natal with rapid technical advances in interventional techniques over the last five years the role of the interventional radiologist in patient management is changing. the whole new speciality of "minimally invasive surgery" is developing led by the increased use of direct endoscopic techniques and is encroaching on many of the procedures that have been developed in part by the interventional radiologist. this is seen particularly in vascular and neurovascular interventional procedures where vascular surgeons, cardiologists and neurosurgeons are developing interest in endovascular therapy. the cross-over between radiology, cardiology and surgery has a number of important implications in training, skills development and accreditation both internationally and in the south african context. training in interventional radiology in north america usually entails a 12 month fellowship for general body intervention and 24 months for neurointervention. in the united kingdom, the royal college of radiologists recommends a minimum of 12 months of full time post fellowship training in a recognised centre, of which there are 12 in the uk. in south africa there is no training course although some departments have excellent registrar rotations in interventional radiology. development of interventional radiology is dependent on communication to both clinical colleagues and our own radiology colleagues of the benefits and applications of interventional techniques to patient management. from personal experience, convincing one's surgical colleagues of the advantages of interventional radiology can be a long and arduous process. the society ofinterventional radiology has been formed locally and should be able to focus attention and improve education in this very important speciality. who should perform it? this is a very contentious question in europe and north america; however in south africa where we have a significant skills shortage, perhaps the most honest local answer is: "the most capable skilled specialist available". to develop interventional skills, it is very important to understand the disease process and clinical problems that the surgeon faces in patient management. only by working in a team environment where there is a healthy collegial relationship between the radiologist and surgeon, will interventional radiology develop and prosper. the radiologist must be available 24 hours a day and must be prepared to be involved with management of the complications related to the procedures. we need, as radiologists, to be aware of not only the rapid developments in this exciting field but also the added responsibilities to ensure that we do not lose our potential to contribute to patient care. the editor 2 sajournal of radiology. june 1997 case report klippel-feil syndrome the hospital and discharged the folj 0 ozoh lowing day. bsc, mb bs, fmcr (rad) nigeria mb chb, fcrad (diag) l d r tsatsi case report department of diagnostic radiology medical university of southern africa h b broudie mbchb, dmrd (london) department of diagnostic radiology and imaging tembisa hospital pretoria abstract we present a 38-year-old male patient who sustained a minor and superficial stab injury in the left flank as well as a laceration on the scalp overlying the right parietal bone. on examination the classical triad of klippel-feil syndrome (short neck, low posterior hair line, limitation of neck movements) were observed. further investigations revealed a plethora of congenital anomalies, including atlanto-occipital fusion, basilar impression, congenital fusion of cs and c6 vertebrae, scoliosis with convexity to the right side, complete situs inversus, and bilateral pelvic kidneys. despite these multiple anomalies our patient still lives a relatively normal life and only sought medical help after minor injuries sustained during a brawl, for which he was treated in a 38-year-old man presented with a stab injury in the left flank and laceration of the head. on examination he was short statured, with a short neck, low posterior hairline, and severe restriction of neck movement. there was no loss of consciousness. a stab injury in the left flank, and scalp laceration overlying the right parietal region of the skull were observed. blood pressure was 120 mmhg, and pulse 72 beats/ minute and regular. blood analysis showed sedimentation rate of 6 mm in the first hour, haemoglobin 11.0 g/dl. urinalysis and hearing tests were normal. the presence of the classical clinical triad of klippel-feil syndrome, namely fig. 1. lateral view of the skull and cervical spine. this shows atlanto-occipital fusion, and fusion of the cs and cb vertebrae, as well as basilar impress/on. 30 sa journal of radiology • september 2002 short neck, limitation of neck movement and low posterior hairline, stimulated a search for associated anomalies in this patient. lateral skull and cervical spine x-ray showed atlantooccipital fusion, congenital fusion of cs and c6 and basilar impression (fig. i). the atlanto-occipital fusion was better demonstrated by the tomogram of the lateral skull and cervical spine (fig. 2). fig. 2. tomogram of the lateral view of the skull and cervical spine showing euemooccipital fusion. fig 3. chest x-ray, pa-view. this shows marked chest x-ray revealed complete situs inversus scoliosis, and x-ray of the thoracic spine showed convexity to the right side (fig. 3). intravenous case report fig. 4. nephrotomogram, demonstrating the bilateral pelvic kidneys. urography disclosed bilateral pelvic kidneys, illustrated by the tomogram of the intravenous urography (fig. 4). the superficial stab injury in the left flank was sutured and the patient was admitted. he was however discharged from the ward the next day. subsequent follow-up visits were uneventful. discussion it is perhaps noteworthy that our patient presented with such a range of congenital mesodermal abnormalities and yet was still living a relatively normal life. to the best of our knowledge this case of klippel-feil syndrome with a plurality of other anomalies is the first to be documented. klippelfeil syndrome occurs in 1 of 42 000 births, with equal male to female ratio, and it is believed to have been recognised in an egyptian mummy in 500 bc,i the classifications as described by klippel-feil are: (i) type 1 a block fusion of all the cervical and upper thoracic vertebrae; (ii) type 2 fusion of one or two pairs of cervical vertebrae, frequently the second to the third or the fifth to the sixth, which is the most common type; and (iii) type 3 fusion of the cervical and lower thoracic or lumbar spine.' the syndrome appears to be genetically determined, and with type 2 anomalies there may be occipitilisation of the atlas,' as was seen in this patient. chamberlain's line is drawn from the back of the hard palate to the posterior lip of the foramen magnum, and basilar impression is implied when more than half the odontoid peg lies above it. our patient had basilar impression because almost all the c2 vertebrae lay above chamberlain's line (fig. i). basilar impression implies an elevation of the floor of the posterior fossa, which is congenital in origin and is associated with klippel-feil syndrome or atlanta-occipital fusion.' other conditions include fragilitas ossium and cleidocranial dysostosis. the main significance of basilar impression, which is usually symptomless, is in the neurological symptoms, which may sometimes result from pressure on and distortion of the brainstem, and obstruction of free cerebrospinal fluid circulation.' the fusion of cs and c6 vertebrae seen in our patient is common. the association of klippel-feil syndrome with complete situs inversus is a rarity. in 505 cases of klippel-feil syndrome reviewed, only two patients had complete situs inversus.' in a review of 50 patients with klippel-feil syndrome, 60% had scoliosis, believed to be the most frequent anomaly,' unilateral renal anomaly is the most common renal anomaly, followed by malrotation of the kidneys, renal pelvic and ureteral duplication, and simple renal ectopia.' bilateral pelvic kidneys as found in this patient are very rare. all the five pelvic kidneys studied by moore et al.2 in klippel-feil syndrome patients were unilateral. other serious but less apparent anomalies include sprengel's deformity, synkinesia," hearing impairment,3.5.6and congenital heart disease+" the cervical vertebrae and genitourinary tract differentiate at the same time and in the same vicinity (between the seventh and fourteenth mesodermal sornites) in the embryo, therefore insult to the fetus between the fourth and eighth weeks of development could produce both genitourinary anomalies and the klippelfeil syndrome.' references 1. gray sw, romaine, cê, skanaalkis je. congenital fusion of cervical vertebrae. sutgico! gynaecological obstetrics 1964; 118: 373-385. 2. moore wb, matthews tj, rabinowitz r. genitourinary anomalies associated with klippel-peil syndrome. j bone joint surg 1975; 57a: 355-357. 3. ramsey j, bliznak j. klippel-feil syndrome with renal agenesis, and other anomalies. american journal of roentgenology, radium therapy and nuclear medicine 1971; 113: 460-463. 4. david sutton. textbook of radiology and imaging. 6th ed. london: churchill livingstone, 1998: 1469-1470. 5. hensinger rn, lang je, macewen gd. klippelfeil syndrome. a constellation of associated anomalies. j bone joint surg 1974; 56a: 12461253. 6. stark ew; borton te. klippel-feil syndrome and associated hearing loss. archives of otolaryngology 1973; 97: 415-419. 7. nora jj, cohen m, maxwell gm. klippel-feil syndrome with congenital heart disease. american journal of diseases of children. 1961; 102: 858-864. 31 sa journal of radiology • september 2002 abstract introduction methods ethical consideration findings discussion conclusion and implications for practice acknowledgements references about the author(s) andré rose department of community health, university of the free state, south africa kerry e. uebel department of internal medicine, university of the free state, south africa william i. rae department of medical physics, university of the free state, south africa citation rose a, uebel ke, rae wi. interventionalists’ perceptions on a culture of radiation protection. s afr j rad. 2018;22(1), a1285. https://doi.org/10.4102/sajr.v22i1.1285 original research interventionalists’ perceptions on a culture of radiation protection andré rose, kerry e. uebel, william i. rae received: 29 oct. 2017; accepted: 21 nov. 2017; published: 19 mar. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational exposure to ionising radiation poses potential health risks to radiation workers unless adequate protection is in place. the catheterisation laboratory is a highly contextualised workplace with a distinctive organisational and workplace culture. objective: this study was conducted to understand the culture of radiation protection (crp). methods: this study was a qualitative study and data were collected through 30 in-depth and 6 group interviews with 54 purposively selected south african interventionalists (interventional radiologists and cardiologists). the participants included a diversity of interventionalists who varied in sex, geographic location and years of experience with fluoroscopy. the transcribed data were analysed thematically using a deductive and inductive approach. results: ‘culture of radiation protection’ emerged as a complex theme that intersected with other themes: ‘knowledge and awareness of radiation’, ‘radiation safety practice’, ‘personal protective equipment (ppe) utilisation’ and ‘education and training’. conclusion: establishing and sustaining a crp provides an opportunity to mitigate the potentially detrimental health effects of occupational radiation exposure. education and training are pivotal to establishing a crp. the time to establish a culture of radiation in the catheterisation laboratory is now. introduction ionising radiation is a modality that is neither seen nor heard and is intangible. it is a health hazard for patients and radiation healthcare workers (hcws). interventionalists are doctors who perform fluoroscopically guided procedures for diagnosing or treating patients. they include interventional cardiologists and interventional radiologists. vascular surgeons, urologists, orthopaedic surgeons and anaesthesiologists may also perform fluoroscopic procedures as part of their practice. interventionalists are not always aware of the detrimental long-term effects that radiation exposure may have on their health and may be negligent in implementing and consistently applying radiation safety practices. the increasing use of fluoroscopy for diagnostic, therapeutic and interventional procedures necessitates greater vigilance in the use of this modality within the workplace. the increasing trend in ionising radiation utilisation in medical procedures has increased diagnostic exposure from x-rays, computed tomography (ct) scans, mammography and nuclear medicine scans.1 therapeutic use includes angioplasty, radiation therapy for tumours and therapeutic use of radioisotopes. interventional practices include fluoroscopic procedures like radio-ablation, pacemaker insertion and embolisation.1 there has been an increase in the duration and complexity of these procedures, resulting in greater cumulative occupational exposure to operators.2 the most at risk professions include interventional radiologists and cardiologists.3 operators performing fluoroscopic work have an increased occupational risk of developing ionising radiation-induced health detriments.4 the effects of ionising radiation exposure may be stochastic or deterministic.5 stochastic effects have no threshold limit and occur randomly; for example, genetic aberrations and cancers. deterministic effects occur when an exposure threshold is exceeded and the outcomes include skin changes; they may also occur in patients who are overexposed.6 protection of radiation hcws in the workplace is essential because they may experience effects such as cataracts.7 protection from ionising radiation in the workplace hinges on providing an enabling environment for radiation safety, application of the as low as reasonably achievable (alara) principle, monitoring of the radiation dose received (dosimetry), complying with international occupational dose limits and regular and consistent use of personal protective equipment (ppe). all of these aid in creating a culture of radiation protection (crp) in the workplace.8,9 this culture is underpinned by a set of norms and values that shape how it is developed, implemented and maintained.10 it is thus vital that a crp should be developed, implemented and sustained to protect radiation healthcare professionals.11 a crp is imperative for protecting hcws from the effects of radiation. such a culture includes compliance with the radiation regulations, use of ppe, compliance by all of the radiation team and adequate monitoring and evaluation.2 the genesis of such a culture is sparked and sustained by adequate education and training.12 personal protective equipment is used to reduce the exposure to radiation for hcws, thereby minimising the risk of radiation health effects.13 the range of ppe includes ceiling suspended screens, lead aprons, lead caps, thyroid guards and lead glasses or visors.14 the effectiveness of ppe depends on its consistent use. consistency of use depends on availability, fit of the ppe and the comfort when performing procedures.15 a recent study has shown that when workers have access to ppe, it is more likely to increase their utilisation of it.16 in a survey on attitudes of ppe usage, it was found that certain devices such as lead aprons and thyroid shields were widely used and considered ‘standard practice’, while other devices that protected more radiosensitive organs such as the lenses of the eyes were used inconsistently.17 the behaviour in an environment like the catheterisation laboratory depends on the interplay between the attitude of individuals, the comportment of professionals and the engagement between administrative and managerial staff.18 organisational culture in a health facility is shaped by four key factors: responsiveness, team hierarchy, care philosophy and communication.19 these dynamic interactions are a conduit to the barriers and facilitators which shape a crp. formal training in radiation safety reduces the dose to patients and hcws in the catheterisation laboratory.12 formalised training and continued education on radiation safety help establish and sustain a crp in the workplace. radiation safety training and education needs to form part of the formalised curriculum of radiation hcws in order for it to be taken seriously.20 continued medical education (cme) can help consolidate and sustain the training and preservation of a crp to ensure a safer workplace.21 this cme programme should be consistent and reinforced regularly to maintain its effectiveness.12 the aim of this article is to present the perceptions of interventionalists on what constitutes a crp. the findings reflect on the challenges for developing a crp in the workplace, how to establish such a culture and how to continue to foster it. we reflect on how these principles can be universally applied. methods study design this study had a qualitative design which formed part of a larger multiple methods study which is described elsewhere.22 participant selection the participants were all interventionalists and included adult cardiologists, paediatric cardiologists and interventional radiologists with different levels of expertise. they included specialists in training, junior and senior specialists and heads of departments. we purposefully included a diversity of participants to reflect the gender, number of years worked, different professional categories, sectors worked in, levels of training and cities worked in south africa – a total of 54 participants (see table 1). table 1: the characteristics of 54 participants in six group interviews and 30 in-depth interviews. the participants were purposively selected because they worked in the catheterisation laboratory and offered insights into radiation protection issues in this workplace. they were interviewed at conferences or at a suitable location, usually their workplaces, based on appointments scheduled. snowball sampling was employed and participants were asked to recommend interventionalists they thought would be willing to participate in the study and these were followed up.23 we also targeted specific informants, such as the heads of departments, to participate in the study.24 data collection we conducted six group interviews of between two and six people and 30 in-depth interviews with individuals. data collection started in may 2015 and ceased in july 2016 when we determined that data saturation had been reached. data were collected at four conferences and three workshops in south africa. these included one paediatric interventional cardiology workshop and two interventional radiology workshops. the conferences included two annual conferences for the cardiology society of south africa, one annual conference for the radiological society of south africa and two additional radiology conferences aimed at special interest groups for radiologists. individuals at radiology, cardiology and paediatric cardiology departments at the university training centres were contacted directly. selected interventionalists in the private sector were also contacted directly. a semi-structured interview schedule was used. the questions were open-ended which prompted participants to express their perceptions on the effects of radiation on health, what a culture of radiation safety meant and whether it existed in their workplace, their utilisation of ppe and their thoughts on radiation safety and training and how this could be improved for their respective specialties. probing questions were asked to get a deeper understanding of participants’ responses. analysis thematic analysis using a deductive and inductive approach was used.25,26 this analysis was chosen because we wanted to describe and interpret the depth of the experiences of the participants.27 we decided on some themes based on the literature (deductive approach) and allowed other codes and themes to emerge from the content of the data (inductive approach). the interviews were audio-recorded and transcribed verbatim. the transcripts were checked against audio recordings for accuracy. data included the researcher’s field notes. the data were analysed on an ongoing basis, which included the following steps27: two researchers (andré rose and kerry e. uebel) independently read the transcripts and coded the data. we developed a code book as we analysed the data. the codes were organised into categories and the categories were grouped into themes. the interpretations were discussed as they emerged, and the researchers reflected on the disparities and relationships and debated the themes that arose and then reached consensus on the findings. this was an iterative process and the researchers met several times to discuss codes and categories as they emerged. context of the study radiologists receive 4 years of training which includes radiobiology and medical physics and it is prescribed in their formal curriculum. they are examined on it as part of their first qualifying examination (usually within their first 18 months of study). it is usually not re-examined in their exit examination.28 there is inconsistent coverage of radiation safety in their cme seminars. cardiologists have a 3-year training programme to subspecialise in the discipline following qualification as physicians or paediatricians. radiation safety is mentioned in the syllabus of cardiologists as a learning objective, but it is not formally taught and there is usually poor coverage of it in cme seminars.28 south africa has a two-tiered health system, with an ailing public health system and a thriving and well-established private health system. interventional radiology and cardiology services are offered in both sectors. it is not uncommon that doctors work in both sectors. both sectors have challenges, but shortage of equipment such as ppe is common in the public sector. the public sector often has a high patient load with a poor staff complement which does not match the workload. trustworthiness our findings are congruent with what is truly happening in practice, based on the researcher’s observations, the data obtained and what is reported in the literature.29 the researcher is a (medical) doctor, has worked in a catheterisation laboratory previously and has insight into this work environment. he also spent time observing interventionalists in their workplace.29 we conducted in-depth interviews and group interviews which are acceptable and well-described techniques widely reported in the literature.30 we achieved site triangulation by including a variety of different interventionalists from different hospitals, cities and from both public and private sectors.29 the participants were also at different levels of expertise and included specialists in training to senior specialists and heads of departments. this allowed us to get a better understanding of how the different views converge on an understanding of radiation safety culture in the workplace.31 this study has good representation of different categories of interventionalists from across south africa and offers important qualitative insights into how interventionalists understand what a crp is. the findings, although not generalisable, can be transferred to the broader south african interventionalist community and similar contexts elsewhere.29,32 limitations the qualitative design of the study allowed us to generate hypotheses but not to test them. the study did not investigate the reasons of differences between the cardiologists’ and radiologists’ knowledge of radiation. it also did not fully explore the complexity of what constitutes a crp and the factors facilitating the creation and establishment of a successful crp. the sampling strategy restricted the participants in the study and as such offers only the perspectives of the interventionalists and not that of all members of the catheterisation laboratory team. future studies would add value by exploring these areas and including other members of the catheterisation laboratory team, such as nurses and medical radiation technologists (radiographers). ethical consideration the study was approved by the human research ethics committee of the faculty of health sciences of the university of the free state (ecufs 44/2015). written informed consent was obtained from all participants. in the group interviews, the participants were asked not to divulge the responses outside the group. the recordings and transcribed data were stored in a secure place. findings in this section, we report on the following themes that were identified in the data: ‘culture of radiation protection’, ‘knowledge and awareness of radiation’, ‘radiation safety practice’, ‘ppe utilisation’, ‘monitoring of safety practices’ and ‘education and training’. crp emerged as an overall theme that intersects with the other themes. the following notations are used in the article to denote the participants: hod for head of department r for radiologists, ac for adult cardiologists and pc for paediatric cardiologists. cardiologists may refer to either adult or paediatric cardiologists. we use the term ‘resident’ to refer to a doctor who is in the process of specialising. in south africa, residents are referred to as registrars. culture of radiation protection culture of radiation protection is a complex overarching theme. it has many facets that intersect with several of the other themes. participants offered a plethora of perspectives on what constituted a crp, on how to establish it and how to sustain it. participants mentioned that it depended on the education and training they received, the role of various stakeholders, monitoring structures, policies and how they were enforced and the dynamics between team members in the catheterisation laboratory. radiologists generally expressed the view that they were well informed about radiation safety and felt that they had a well-established crp within their work environments: ‘but in radiology departments it [crp] is engrained in us. the problem is the rest [other disciplines using ionizing radiation]; it’s not engrained in them.’ [r, hod] ‘i think we’re more aware than many others. when you take an orthopaedic surgeon or urologist who is using ionising radiation they certainly are not nearly as aware as we are. so, the culture of radiation safety would, i think, depend on all workers, everyone involved in the procedure, everyone in the room all working together to reduce radiation exposure.’ [r] cardiologists expressed heterogeneous opinions on the crp in their workplaces. some cardiologists stated there was very little attention given to the issue, while others stated they recognised the importance of it, but it was not diligently enforced in the workplace: ‘radiation control is strictly controlled by guidelines and the problem is we ignore [these] guidelines.’ [r] the consensus amongst most interventionalists was that the responsibility of creating a crp lies with several stakeholders. these stakeholders included scrub nurses, radiographers and doctors working in the catheterisation laboratory. there was a general opinion that a top down approach was necessary and that the head interventionalist had to take the lead to establish, maintain and enforce a crp within the work environment. this view is reflected in the understanding of a radiology resident as follows: ‘it’s about enforcing, and it needs to be top down though, i do agree about that. your hod needs to drive it, your consultants need to set good examples and then your registrars who join the program will automatically follow it. no exceptions.’ [r] knowledge and awareness of radiation there was generally a distinct difference between the knowledge and awareness of cardiologists and that of radiologists pertaining to the effects of radiation. cardiologists were not unaware that ionising radiation was a hazard, whereas radiologists seemed to engage more easily on how radiation could affect their health and that of their patients. although the knowledge of these two groups was not quantified, the radiologists appeared to be more knowledgeable: ‘there are two labs, the catheterisation laboratory and the electrophysiology lab and i don’t know the difference in radiation exposure between the two. it would be nice to know the difference. it is a gap in my education.’ [ac] many participants commented that because radiation was invisible and the health effects were often long term, proper vigilance was lacking. this resulted in poor radiation safety practices, which potentially compromised their health and that of their patients. the knowledge and awareness about the effects of radiation appeared to be linked with formal training. one cardiologist reflected on awareness of the dangers of radiation only after having had bilateral cataracts removed. there were participants who reflected that they knew colleagues who had experienced negative effects possibly attributed to radiation such as brain tumours: ‘no, i am much more aware after i got the cataracts, i actually had to look at [the situation]. because i thought why am i getting cataracts and then i thought and said whoa, it must be radiation you know. so, i actually look at radiation now with different eyes.’ [ac] radiation safety practice participants were generally not familiar with the policies and legislation that regulate radiation safety. it was of particular concern that heads of department (especially cardiologists) were not well acquainted with the necessary policies, legislation and regulatory bodies: ‘i am not even aware of that [radiation regulations]. so, i don’t know who draws up these guidelines. i don’t know where they’ve been published. uhm, so if there are any guidelines then it needs to be distributed to the user. it’s pointless drawing up guidelines without uhm, you know informing people, making people aware that these guidelines exist. i am a professor of cardiology and i am not sure where these guidelines are.’ [ac, hod] ‘so there probably are some policies and regulations [but] we don’t know what they are.’ [pc, senior] participants reflected that radiation safety practice hinged on applying basic principles such as justification for a procedure, the distance maintained from the patient during operation and the x-ray beam, and utilisation of ppe. strong opinions were expressed that the practice of radiation safety in the catheterisation laboratory was the responsibility of the individual as well as the entire team. they noted that while individuals were responsible to ensure they had applied principles such as the inverse square law, the alara rule and the use of ppe, there also needed to be senior team leaders responsible to check that all staff members complied with standard practice. they generally agreed that the team should have the freedom to challenge other members within the team about radiation safety practices, but recognised that this was complicated by the power dynamic that existed between differently ranked professionals within the team. this power disparity was particularly evident in the private sector where participants reported that the rest of the team was unlikely to challenge the doctor. it appeared that the public sector doctors were willing to abide by structures put in place to ensure their safety and were more willing to be instructed by, for example, a scrub nurse or radiographer. the attitudes of some doctors and an unwillingness to listen to others in the team were noted as barriers to good radiation safety practice: ‘and part of their bad habits is their egos because they don’t want to be told by the radiographer take your foot off the pedal. “i’m in charge, i am the big doctor here.”’ [r, hod] participants expressed the view that radiation safety practice was also the responsibility of stakeholders that did not ordinarily form part of the catheterisation laboratory team. these actors included the radiation safety officers, the medical physics department and the hospital management. participants also mentioned the critical role of hospital management in ensuring adequate quality control, maintenance and timely replacement of machines and ppe: ‘the hod and ceo need to be responsible for ensuring equipment works and is fixed.’ [r] ‘hospital management needs to ensure equipment is kept up to date and maintained properly.’ [ac] there was poor awareness about the existence, role and function of radiation safety officers. participants were not always sure what role the medical physics department played or should play. in some instances, they were not even aware of the existence and function of such a department within their facilities: ‘i don’t know the name of the radiation control board.’ [ac] ‘there is no communication between us and the radiation control board.’ [ac] a dominant view that emerged from the study was that the participants felt a strong sense of responsibility to their patients, even if performing a procedure without adequate radiation protection would jeopardise their own safety and health. this attitude underpins the culture of care that exists with some doctors. procedures were sometimes performed self-sacrificially in the interest of the patient, but at the cost of compliance with standardised radiation safety practices: ‘[be]cause our job is about the patient and that’s why we do what we do. and that’s actually how the whole of medicine generally works. […] so, it’s simply not in our makeup [to think about ourselves]. […], but you know ninety-nine percent of our focus is for the patient and then the other one percent is for maybe a few other things.’ [pc] personal protective equipment utilisation participants noted both barriers and facilitators to ppe utilisation. barriers included poor availability and quality control, poor fit, inadequate size ranges and equipment being cumbersome to use. factors that facilitated the use of ppe included the hospital management accepting responsibility to supply ppe and individual interventionalists also taking responsibility to use ppe and to purchase their own ppe in cases where it is not readily available in their facility. personal protective equipment utilisation was not quantified in this study, but the most commonly reported ppe used were lead aprons. thyroid guards were less commonly used. lead glasses were either used very infrequently or not at all. ceiling suspended shields were hardly ever used, but were frequently reported not to be available. there was generally very poor awareness of ceiling suspended shields and mobile shields. only one participant indicated that he used lead gloves and a lead cap. participants reported that ppe was not always available. they usually had sufficient lead aprons, but other ppe was frequently unavailable in the public sector, with a notable shortage or absence of lead glasses and thyroid shields. lead glasses were particularly in short supply and were often not replaced when damaged or lost: ‘it becomes such a hassle to try and get a thyroid shield and to try and get goggles that you just don’t. you don’t have enough time in a day to try and look for it [be]cause you never gonna find it in any case. so, then you just ignore it and you go with the lead apron only. that’s what most of us do.’ [r, resident] participants who worked mainly in the public sector also noted the lack of availability of different sizes and designs of ppe as a problem. they noted that they did not have access to newer more ergonomically designed ppe and were often forced to settle for equipment that was too heavy or ill-fitting. the participants generally held the opinion that they wanted a range of choices for ppe. women participants stated that some equipment was inappropriate for their physique. a female radiologist made the following remark: ‘the problem is the size, [be]cause we have one pair or two pairs. there’s […] one size for everyone, we [are] not all the same sizes so for some of us it may not fit. [r] the ability to perform procedures dexterously strongly influenced ppe utilisation. many participants described that lead glasses were awkward to use during procedures and cannot be used over prescription glasses. one participant stated: ‘they [lead glasses] are bulky, they mist up and they cause pressure on the nose.’ [ac] ‘[…] the challenges are if you using prescription glasses. because then you have to make yourself a set of lead prescription glasses. it’s a bit expensive, but if you realise the environment that you [are] working in uhm, [then] you could invest bit of money towards your own safety. […]. cardiologists are making a lot of money, but a blind cardiologist doesn’t mean anything.’ [r] there was consensus amongst participants that hospital management was responsible for supplying adequate ppe for their staff and for ensuring adequate and continuous quality control of ppe: ‘so, i would imagine it’s the hospital’s responsibility [to provide ppe]. i mean we’re employed by the hospital. the hospital has a responsibility to all its employees to maintain [their] safety.’ [pc] ‘it’s the hospital’s responsibility to provide that [ppe]. it’s my responsibility to use it.’ [r] many participants also reflected that individuals had a responsibility to use ppe regularly and that owning their own personal ppe could act as a stimulus for consistent utilisation: ‘hmm, it becomes second nature, i mean it comes with the turf, hmm, it’s almost like my uniform i mean you don’t even think about having to put on your lead apron when you [are] going to do a procedure, to put on your thyroid shield, your collar. i mean those things come almost automatic to you now.’ [ac] monitoring of safety practices participants raised the issue of monitoring of radiation safety and stated there was inconsistent use of dosimeters, lack of feedback on the radiation they were exposed to and there was a need for more regular occupational medical examinations. many participants reported inconsistent utilisation of personal dosimetry badges either because they forgot to wear their dosimeters, they were not held accountable to wear them, they received no feedback about previous readings, or worryingly because high readings might limit the work they could do in the catheterisation laboratory: ‘no, i must tell you honestly sometimes i am working so hard that’s [radiation safety] really the last thing on my mind. you always wear protective gear, but i can honestly tell you i don’t wear my radiation badge at all, never. it’s in my bag and that’s it. i don’t wear it when i’m doing screening, i don’t wear it when i’m doing angiography and i don’t wear it, no.’ [r, resident] ‘we don’t get regular reports of our radiation doses.’ [pc] most participants commented that they did not receive sufficient regular feedback on doses they were exposed to. many were unaware of the medical physics departments at their facilities or what role these departments should be playing in monitoring their dose exposure. this lack of feedback on their dosimetry readings not only influenced their inconsistent use of dosimeters but also denied them of the opportunity to improve their radiation safety practices by being able to check monthly doses received: ‘you wear dosimeters and it seems as if nobody checks them or does anything.’ [ac] participants commented that real-time monitoring would improve their radiation safety practice, as it would give an immediate indication of their own and the patients’ radiation exposure and aid to plan future procedures. some participants reflected that they almost never received regular periodic occupational health examinations. this was especially true for the private sector. education and training we identified two broad categories with respect to education and training. firstly, formal education and cme, which interventionalists receive as part of their training. radiologists received formal instruction in radiobiology and radiation physics, which was part of their core curriculum, while cardiologists received little or no formal instruction in it. radiologists were generally satisfied with the level of formal education they received in the discipline but noted that they thought that other medical disciplines using ionising radiation such as cardiology, orthopaedics and urology were undertrained in the subject. a head of the department (hod) in radiology reflected on the discrepancy in training between different medical disciplines using radiation as follows: ‘the interventional group and people that i work with, there are no bad habits in that group. the bad habits are with our friends the cardiology group, orthopods and vascular surgeons. because the vascular surgeons that are doing interventional work are not being trained as a radiation worker so they’ve got bad habits.’ [r, hod] ‘many other disciplines do not have the training in radiation that radiologists have.’ [r] the cardiologists expressed differing views on their formal training ranging from not deeming it necessary to receive formal instruction to expressing a definite need to have such instruction. a senior paediatric cardiologist stated, ‘we can add some training [on radiation safety] because at the moment there isn’t any’. in contrast, an hod in cardiology expressed the view that there was no need to formally train cardiologists in radiation safety. many of the cardiologists and radiologists described the need for proper induction and that radiation safety should be comprehensively covered in cme activities and at conferences. a radiologist from new zealand reflected that work induction in the radiation workplace was lacking and is needed: ‘ah, i think it [induction] often gets forgotten, i think the nurses are orientated, ah, i think it is probably needed; we need a more formal process. and i think in particular the doctors, they go into the lab and it is assumed that the doctors understand about radiation [but] that isn’t the case.’ [r] secondly, the issue of mentorship by more senior specialists was a way for fostering a culture of education and radiation safety training. junior participants expressed the view that it was the responsibility of senior specialists to provide guidance on education and training in radiation safety: ‘well, it’s not senior people’s responsibility [to get junior doctors to wear ppe], but junior doctors often will take the lead if the more senior doctors do so, if you are a junior interventionalist and your mentor doesn’t wear that [ppe] you’re less likely to wear them.’ [ac] we have included the views of three international interventionalists who were interviewed at the conferences because they corroborate the views of the south african interventionalists. the experiences of the international interventionalists and their south african counterparts were similar. discussion in this section, we offer a synthesis of what constitutes a crp based on the themes that emerged. we explore organisational and workplace culture, safety culture and how training and education fosters development of a crp. organisational and workplace culture organisational culture in a health facility is a complicated construct that is built on the values, attitudes and norms within an organisation.10 it is these beliefs, norms, attitudes and values that create the governance framework that prescribes acceptable and expected behaviour within an organisation.33 the behaviour evolves because of the social constructs of the employees, their professional background and its underpinning ethos, the rules and regulations that govern their workplace and the influence of managerial and administrative structures.18,19 organisational behaviour shapes the culture within an organisation and determines the success of the health facility.34 the behaviour in the organisation is moulded at an individual and group level.35 the catheterisation laboratory is a highly contextualised work environment. in this workplace, doctors often leverage a power dynamic over other members of the team. there may also be a gender disparity between team members as the interventionalists are still mainly males and the nurses and radiographers (radiology technicians) are predominately females. this may hinder members of the team such as nurses and radiographers from challenging the non-compliant safety practices of interventionalists. this interdisciplinary power dynamic and gender disparity are characteristics of many workplaces (catheterisation laboratories) in south africa. in our findings, participants highlighted this difference, illustrating that other members of the catheterisation laboratory team like nurses and radiographers may feel like they could not challenge doctors. interventionalists stated that this power imbalance may be a barrier to fostering a crp in the workplace. changing this behaviour is difficult and poses a hurdle to establishing a healthy and inclusive responsibility in developing a crp. however, culture is a dynamic construct and malleable to change.19 it is this strength that should be leveraged to challenge and change the prevailing culture within the catheterisation laboratory. change management principles can help disrupt this hierarchal behaviour. there are several change management strategies that can be used to bring about this change. the steps in the change process proposed by kotter’s model underpin several of these change strategies, making it an ideal change management strategy.36,37 these steps include: (1) creating urgency for the change process, (2) forming the partnerships needed for the change, (3) formulating a vision and strategy, (4) communicating the change vision, (5) empowering the key stakeholders for the change and action required, (6) establishing short-term goals, (7) consolidating the change and facilitating further change and (8) cementing these attitudes within the culture.36,37 negotiating this change involves communicating the message that every member of the catheterisation laboratory team has a responsibility to their personal safety, the team’s safety and the patient’s safety. radiation safety is a collective effort. the change needed to create a crp depends on everyone’s participation and not solely on an individual.35 a crp hinges on a symbiotic relationship between the catheterisation laboratory team and the facility’s managerial team. how this relationship forges itself is indicative of the resulting crp. the relationship between healthcare managers and clinical staff is often contentious because of competing priorities. healthcare managers often prioritise cost-saving measures, which may compete with safety measures.38 health budgets, profit margins and cost-saving measures are an important consideration for health managers, which may shape decisions about procurement of new equipment, maintenance of existing machines and the acquisition of ppe. these objectives can be a barrier to a culture of safety. it is thus important that the head of the catheterisation laboratory must be astute in negotiating resources for safety. this is especially pertinent in resource-constrained environments. the south african regulations stipulate what type of ppe must be worn and this can also be leveraged when negotiating for resources. different values compete to create one of the following four organisational cultures (or a combination of them): clan culture (cohesive, participatory leadership), developmental culture (creative, adaptive leadership), hierarchical culture (leadership bound by rules and policies) and rational culture (competitive and goal orientated).33 participants suggested that a hierarchical structure should be fostered. this may, however, hinder rather than facilitate a crp. a hierarchal structure favours tension between doctors and other professionals and between managerial structures and clinicians.19 a participatory and inclusive approach would be an enabling approach in the co-creation of a crp between the various team members.39 safety culture a culture of safety is imperative in any workplace. the attitude towards safety is part of the underpinning values of an organisation and the cornerstone for developing good radiation safety practices. a safety culture is cultivated by the response of hcws to ppe utilisation and the monitoring structures that keep these practices in check. safety and care should interact synergistically with each other. a culture of care is a balance between the science and humanity of medicine.40 doctors (and other hcws) wrestle with the challenge of balancing patient-centred care (pcc) with sophisticated technologies and the necessary safety precautions that accompany it. participants indicated that they would rather perform interventional procedures without ppe than compromise the care of patients. this action, though seemingly noble, is a breach of safety practices and places the hcw and the patient at risk and in so doing compromises the safety and quality of care. pcc has to be holistic, placing the patients’ safety and the quality of care at its centre and drawing on collaboration of all members of the health team.41 the occupational health risks associated with ionising radiation may be offset with consistent and appropriate ppe utilisation.42 consistent use depends on the availability and fit of the ppe, education in using it correctly and the dexterity to perform procedures with it in place.15,43 interventionalists reported attitudes and behaviour to ppe use congruent with findings in the literature and compliance depended on availability and proper fit. there are personal and systemic factors that influence the use of ppe. the individual primarily makes the decision to use the ppe, but this behaviour may be influenced by the prevailing safety culture within the organisation. a strong safety culture will positively affect the use of ppe.44 it is thus crucial that the culture within the catheterisation laboratory embraces and encourages such a culture as a norm. participants expressed the view that managerial structures were responsible for ensuring provision of ppe. managerial structures are an important enabler to ensure availability of ppe and to foster a crp.8 together with the person designated to oversee radiation safety in the catheterisation laboratory and the radiation officer, they can ensure that appropriately fitting ppe is procured timely for the catheterisation laboratory team. provision of ppe facilitates increased uptake of utilisation of ppe.16 dosimeter monitoring is an important component of regulating radiation exposure in the workplace.7 the monitoring offers the users an opportunity to know the radiation exposure they are receiving and to adjust operating procedures’ exposure time to reduce the dose exposure to themselves and the patients.8 interventionalists are notorious for poor compliance and inconsistently using their dosimeter badges.45 developments in individual dosimetry monitoring such as real-time and wireless monitoring systems will promote better compliance.2 a crp would help encourage a different attitude towards using dosimeters and facilitate radiation monitoring in the workplace. incorporation of an occupational health surveillance system would be integral to radiation safety monitoring. the unique nature of occupational radiation exposure would require a bespoke medical system for this category of work.46 education and training interventionalists need to be educated and trained so that they can understand the risks and benefits of using ionising radiation.47 education and training helps stimulate and sustain a crp. however, training should be regular and consistent to ensure reinforcement and continued adherence.12 training aids in instilling autonomy towards radiation safety in radiation operators.48 the training curriculum on radiation safety is inadequate for south african cardiologists and the gap in this training requires urgent attention.49,50 the training needs to be included in the formal training curriculum and in the cme programme to ensure consistency in practice.12 training provokes improvement in the radiation management skills of operators, which improves the safety of all team members and patients in the catheterisation laboratory.51 the theme of education and training related to this study is extensively explored elsewhere.49 the results from this study are significant because they provide insights into the work and organisational culture in this highly contextualised work environment. they highlight risky occupational practices that can be mitigated with change management strategies. africa is acquiring high-tech imaging equipment at an accelerated rate, but the workplace culture that should match this change is lagging and poses a potential health risk to a highly skilled workforce and the patients they serve. furthermore, the study is significant because it offers insights for establishing policies and practice guidelines for developing a crp in this work environment. these insights are universally applicable. conclusion and implications for practice the increased utilisation of ionising radiation in modern medicine is likely to remain unabated, but the escalation in the number of procedures performed and the increase in the complexity of the procedures will result in operators being exposed to larger cumulative radiation doses. mitigating this occupational risk will require greater vigilance in promoting a crp. developing and strengthening this culture requires a change in organisational and workplace culture towards radiation safety. a well-developed and continuous education programme is imperative to initiating and sustaining a crp. a well-developed crp promotes patient safety and improves quality of care. it requires commitment from both the radiology and cardiology fraternities to embrace a paradigm shift towards garnering support for radiation safety in the workplace. acknowledgements the research (phd) from which this study emanated was funded by the medical research council of south africa under the south african medical research council (samrc) clinician researcher programme. a.r. received the discovery foundation scholarship, which funded the data collection of this project. south african (sa) heart (free state branch) partially funded data collection of this project. w.i.r. is recipient of a national research foundation (nrf) incentive grant. competing interests the authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article. authors’ contributions w.i.r. and a.r. conceptualised the study. a.r., w.i.r. and k.e.u. analysed the data. a.r. wrote the first draft of this article. all authors provided input for the article and read and approved the final version. they thank dr asta rau from the centre for health systems research and development (university of the free state), who read the manuscript and offered technical insights into the qualitative methodology. they also thank rothea pelser and annamarie du preez for library assistance. references bhargavan m. trends in the utilization of medical procedures that use ionizing radiation. health phys. 2008;95:612–627. https://doi.org/10.1097/01.hp.0000327659.42618.c1 le heron j, padovani r, smith i, czarwinski r. radiation protection of medical staff. eur j radiol. 2010;76:20–23. https://doi.org/10.1016/j.ejrad.2010.06.034 ciraj-bjelac o, rehani mm, sim kh, liew hb, vano e, 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https://doi.org/10.1097/hp.0b013e31829c355a editorial j h labuscagne mb chb, mmed (rad dj congress co-ordinator, rssa star advances in oncological imaging on the weekend of 30th august 1 september 2002 the starmeeting was held in the boe auditorium in the clock tower complex of the v & a waterfront in cape town. the meeting was attended by almost 200 delegates. radiologists, radiographers, clinical oncologists, radiation oncologists and surgeons attended the meeting. several professionals working for medical aid companies also attended. the meeting was aimed at discussing current and possible future trends in imaging of cancer patients, with emphasis on the chest, abdomen and pelvic malignancies. as such the meeting addressed a wide range of topics, all of which were enthusiastically received. star is the acronym for 'schering/siemens training in advances in radiology' and is an international programme sponsored by schering ag in berlin and siemens ag, medical division in erlangen, germany. the programme is co-ordinated by mr ludwig halm from schering and mr a lortz from siemens, and has as a scientific director the legendary professor alexander margulis. star is hosted in various countries around the world every year and south africa was indeed lucky to be able to host such a meeting. the meeting was organised by dr jan labuscagne from the radiological society of south africa together with professor hedvig hricak from new york. professor hricak is chairman of the imaging department of the memorial sloan kettering cancer centre in new york. she is a world renowned expert in pelvic imaging. in addition to professor margulis and professor hricak, a team of internationally acclaimed experts in radiology was invited. professor philip grenier from paris, professor maximilian reiser from germany and professor lawrence schwartz from new york, usa, formed the rest of the faculty. professor philip grenier is chairman of the department of radiology at the hospital pitié-salpêtriére of the university of paris and is a leading expert in chest imaging. professor reiser is chairman of the department of radiology at the grosshadern hospital and ludwig-maximillians university of munich. he is an expert in musculo-skeletal imaging as well as a leader in developments in crosssectional imaging. professor schwartz is a gastro-intestinal radiologist with a special interest in medical informatics and is also associated with the memorial sloan kettering cancer centre in new york. the programme comprised basic topics such as the imaging of the unknown primary and measuring therapeutic response to futuristic outlooks on imaging in oncology. the programme was enthusiastically received by all concerned and the overall impression was one of a superbly organised conference. 3 sa journal of radiology • december 2002 editorial radiologists involved in imaging of cancer patients sat through four sessions of highly informative lectures. old friends met again and new acquaintances were made. this starmeeting was also very well attended by clinical colleagues and three clinically oriented lectures were delivered. these were given by an oncologist, dr graham cohen from pretoria who spoke about therapy response, professor johan van wyk from stellenbosch who gave an overview of surgical needs in imaging, and professor lynn denny from cape town who spoke on pelvic malignancies in women. these lectures were well integrated into the rest of the programme and provided an interesting backdrop for the international guests. as noted above, star is the acronym for schering/siemens training and advances in radiology. the programme is therefore sponsored by schering and siemens and the local subsidiaries of these companies were also involved in the organisation and funding of the meeting. the radiological society and all the delegates are deeply indebted to these companies. use of the beautiful auditorium facility at the boe auditorium was sponsored by boe corporates and sincere thanks also go out to them. special mention must be made of the contributions of mr gert wilke from schering, mr william sikes from siemens, and mr trevor cronje and mr mark seedy from boe for their personal involvement. reprints of the extended abstracts from the syllabus of the star meeting appear in this issue of the [ournal. the rest of the syllabus may be reprinted in future issues. j h labuscagne editor 4 sajournalof radiology. december2002 original article an audit of percutaneous biliary stenting for the palliation of pancreatic cancer results, post-procedural survival period, and comparison of plastic and mental stents mj marais mbchb c s de vries mmed rad (d) wall stents (mean age 59.8 years, range 32 77 years), and 43 patients received (plastic) carey coons stents (mean age 62.3 years, range 31 87 years). in 12 patients the stent had to be replaced due to complications and 1 patient had a second replacement. all replacement stents were plastic except in 2 cases. two out of 17 (11.7%) metal stents and 10 out of 43 (23.2%) plastic stents had to be replaced. the median post-procedural survival period was determined between the date of procedure and the date of death. there was a marked clinical improvement of jaundice in all patients with their follow-up within a few days. more plastic stents were replaced. the average post-procedural survival period for 41 patients was 85.6 days, which is on par with internationally accepted survival periods. department of diagnostic radiology university of the free state bloemfontein abstract the purpose of this retrospective study was to assessthe patient survival period after palliative biliary stenting and to compare different kinds of stents used. during a 27-month period, 60 patients received palliative percutaneous biliary stents for obstructive jaundice due to carcinoma of the head of the pancreas. during the first procedure 17 patients received (metal) 18 sa journal of radiology. june 2002 the most cost-effective biliary stent must be used for palliation because of the very short survival rate of this disease. for patients with no surgical options this procedure yields excellent results in comparison with the high morbidity and mortality rates of palliative surgical bypass procedures. introduction pancreatic carcinoma, cholangiocarcinoma, ampullary or duodenal carcinoma, metastatic disease of the stomach, pancreas, lung, breast, colon and lymphoma cause malignant obstructive jaundice." the most common cause, however, remains carcinoma of the head of the pancreas. adenocarcinoma of the pancreas is one of the deadliest forms of cancer because of its relatively late clinical d di , 34presentation an lagnosls. ' pancreatic ductal adenocarcinomas are responsible for 80 95% of nonendocrine neoplasms. radiological diagnosis is usually made by a combination of investigations, including ultrasound, barium investigation, and computed tomography (ct) scanning.' percutaneous transhepatic cholangiography (ptc) and endoscopic retrograde cholangio-pancreatography (ercp) are also helpful in intraductal tumours. adenocarcinoma of the pancreas affects about 10 individuals per 100000 population per year in western countries. surgical excision of the tumour is attainable in 10 15% of patients.' for those patients without a clear curative option, surgical palliative procedures can be performed.' these procedures have, however, a high morbidity and mortality rate. original article biliary stents have become an accepted alternative method for palliation of malignant biliary obstruction.' in cases where endoscopic placement of stents is not possible, the percutaneous method is a good alternative." the percutaneous method is, however, believed to have a higher incidence of complications," plastic stents are used more than metal stents, especially for patients with metastatic disease. in this study we report on patients with pancreatic cancer who were treated by the percutaneous placement of plastic and metal stents. in these patients curative and other palliative options were not possible. we analysed the patency between plastic and metal stents and determined the post-procedural survival period. methods setting the angiography/intervention suite in the department of radiology at universitas hospital, bloemfontein. percutaneous procedure the procedure was performed under general anaesthesia, except in high-risk cases where local anaesthetic and sedation was used. after a diagnostic ptc was performed to evaluate the intraand extrahepatic ducts, as well as the obstruction, a peripheral intrahepatic duct was selected and a 22 g,15 em shiba needle was inserted percutaneously into the selected duct. a guide wire was then placed into the duct whereafter a 5.5 french micropuncture set was inserted. the guide wire was then removed, after which a 5 french renal double curve diagnostic catheter and a 0.035 inch terumo were used to cannulate the stenotic duct in the area of the obstruction. an amplatz guide wire (180 or 260 em length) replaced the terumo. the distal end of the guide wire was positioned in the duodenum. the diagnostic catheter was removed and a dilator was used to dilate the area of obstruction. the size of the dilator correlated with the size of the stent. a 12 french carey coons plastic stent was placed in the area of obstruction. all stents were evaluated for effectiveness after one week. in cases where the area of obstruction could not be cannulated, an 8 14 french biliary drainage catheter was placed so that bile could drain externally. patients from november 1998 to january 2001 (27-month period) 60 patients received percutaneous biliary stents for malignant biliary obstruction due to pancreatic carcinoma. the patients' ages ranged from 32 to 87 years, with a mean age of 61.9 years. all patients were presented because surgical and endoscopic procedures were not possible. details, including treatment indication, special investigative results and clinical diagnosis were supplied. diagnosis of pancreatic carcinoma was made on typical clinical findings and investigations. these patients' radiological reports and files were drawn from the computer database and retrospectively investigated. the percutaneous procedure was then performed. all patients received a cholangiogram within one week of stent placement to evaluate its position and effectiveness. successful stenting was defined as passage of the prosthesis across the obstruction with good radiological positioning, nonobstructive bile flow and clinical improvement of jaundice. with the 19 sa journal of radiology • june 2002 first procedure 17 patients received metal stents (mean age 59.8 years), and 43 patients received plastic stents (mean age 62.3 years). plastic stent sizes 12-14f were used. one patient died the same day after the first procedure. in 12 patients the first stent had to be replaced due to complications, mainly caused by blockage of the stents and a repeat obstruction of bile flow. all replaced stents were plastic except in 2 cases where metal stents were used. one patient received a third placement. stent patency was considered on the basis of the type of stent and the time interval between first and second placement. price differences between different stents used were also considered. patient survival period was determined retrospectively between the date of the first procedure and the date of death. incomplete or unavailable personal data in some cases made the investigation difficult, as some of these patients were from rural areas and without identification numbers and addresses. survival period was measured 6 months after the last procedure and again 6 months later. results clinical improvement could only be evaluated after the first procedure, because no bilirubin values were available when the study was undertaken. more plastic stents were replaced than metal stents. only 2 metal stents had to be replaced out of a total of 17 (11.7%), but 10 plastic stents out of a total of 43 (23.2%) had to be replaced. all replaced stents were plastic except in 2 cases. the time period between the placement-replacement dates of the different stents could not be compared because some of the. patients died before their first stents had to be original article replaced. the median survival period for patients who received plastic stents was 37 days, and for those who received metal stents 72 days. discussion an audit or retrospective study always compromises an investigation because only the available information can be used. to make useful assumptions from available data can be very difficult. although fewer metal stents were replaced a combined investigation between the surgeon and interventionalist, with clinical and biochemical information and proper staging of the disease, is needed. there is, however, a significant price difference between metal (very expensive) and plastic stents (less expensive). as patients have very short mean survival periods, the most cost-effective stents should be used. all patients with metastatic disease must be considered for plastic stents if percutaneous biliary stenting is indicated. percutaneous biliary stenting is invaluable to patients with no surgical or endoscopic options and yields excellent palliation for these patients in comparison with the high morbidity and mortality rates of conventional surgical bypass procedures. references 1. dahnert w. radiology review manual. 4th ed. baltimore: williams and wilkins, 1999: 552, 599. 2. reisman y, gips ch, lavelle sm, wilson jh. clinical presentation of jaundice. hepatogastroenterology 1996; 43: 1190-1195. 3. johnson r. pancreatic cancer. hepatogastroenterology 1995; 42: 294-297. 4. pereira-lima jc, iakobs r, miaer m, benz c, kohler b, riemann jp. endoscopic biliary stenting of pancreatic cancer. am j gastroenterol 1996; 91: 2179-2184. 5. potts jr iii, brongham ta, herman re. palliative operations for pancreatic cancer. am j surg 1990; 159: 72-78. 6. haq tu, sanaullah m, mohsin h, sheikh my, ahmed b. percutaneous biliary stenting. jpma 2001; 51: 308-312. 7. sung hy, chung scs. endoscopic stenting for palliation of malignant biliary obstruction. dig dis sci 1995; 40: 1167-1173. 8. giovanini m, moutardier v, pesenti c, bories e, lejong b, dejpero jr. endoscopic ultasoundguided bijioduodenal anastomosis. endoscopy 2001; 33: 898-900. 20 sa journal of radiology • june 2002 commentary free intraperitoneal air on paediatric plain radiographs and differentiating this from a 'food mound' t he detection of free intraperitoneal air is an important indicator of a perforated hollow viscus}which has a variety of causes in childhood. there are also}however} numerous causes of a pneumoperitoneum in children that may not be due to a perforated hollow viscus. these may be differentiated by their clinical setting. on occasion a child with a perforated viscus may show pneumoperitoneum on radiographs} but have none of the classical features of an acute abdomen clinicallyl-' it is in such situations that the surgeon may rely on the radiologist's findings. there are also situations where pneumoperitoneum is seen as a surprise finding on chest radiographs performed for intrathoracic disease (e.g. pneumomediastinum). the best known xray finding of free intraperitoneal air is free subphrenic air seen on an erect chest film. this sandronikou mbbch (wits), fcraddiag (sa), frcr (london) ewelman mbchb e kader mbchb department of paediatric radiology, universily of gape town and institute of child health, red cross war memorial children's hospital, rondebosch, cape town corresponding author s andronlkou department of paediatric radiology, red cross war memorial children s hospital, cape town, 7700 tel: (021) 658·5422. fax: (021) 658·5101. e-mall;docsav@mweb.co.za figure 1: erect film showing right subphrenic free air (arrow) 29 sa journal of radiology· february 2001 is especially so when noted on the right above the liver (figure i)} but also when situated between the diaphragm and stomach (figure 2).1 figure 2: erect film showing both right and left subphrenic free air (arrows) more difficult is the detection of free air on a supine film where air may present around the falciform ligament (figure 3) or in the subhepatic space figure 3: supine film with free air outlining the falciform ligament (arrowheads) topage30 mailto:e-mall;docsav@mweb.co.za free intraperitoneal air on paediatric plain radiographs and differentiating this frorn a 'food mound' from page 29 figure 9: horizontal beam supine film shows the free air just deep to the anterior surface with a visible "rigler's" sign (arrow) figure 5: the "rigler's" sign, with air outlining both sides of the bowel wall (arrows) (figure 4) or may delineate both sides of the bowel wall as the "rigler's sign" (figure 5).1,2 larger volumes of air may be seen as the "lucent liver sign" (figure 6) and small children may show large amounts of free intraperitoneal air as the "football" sign (figure 7).1 a decubitus film with the right side up (figure 8) and a horizontal beam shoot-through (figure 9) are useful techniques for identifying free airy especially in the leu setting. every so often we are shown a radiograph like figures 10 or ii, where there is suspicion of free air under the left hemidiaphragm. these radiographs are deceptive in the erect position, as a specific food type or consistency may result in what we have termed the "food mound" sign. food figure 8: lateral decubitus film with the right side up, showing free air around the lateral aspect of the liver (arrow) topage38 30 sa journal of radiology. february 2001 abstract introduction anatomy and magnetic resonance imaging appearance of the normal infrapatellar plica causes of anterior knee pain plica injury plica tear mimickers other causes of symptomatic plica conclusion acknowledgements references about the author(s) dharmendra k. singh department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india heena rajani department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india mukul sinha department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india amit katyan department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india saurabh suman department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india aayushi mishra department of radiology, vardhman mahavir medical college, safdarjung hospital, new delhi, india bibhu k. nayak department of sport’s medicine, vardhman mahavir medical college, safdarjung hospital, new delhi, india citation singh dk, rajani h, sinha m, et al. infrapatellar plica injury: magnetic resonance imaging review of a neglected cause of anterior knee pain. s afr j rad. 2021;25(1), a1973. https://doi.org/10.4102/sajr.v25i1.1973 pictorial review infrapatellar plica injury: magnetic resonance imaging review of a neglected cause of anterior knee pain dharmendra k. singh, heena rajani, mukul sinha, amit katyan, saurabh suman, aayushi mishra, bibhu k. nayak received: 29 aug. 2020; accepted: 06 nov. 2020; published: 19 feb. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract synovial plicae are normal remnants of synovial membranes within the knee joint cavity and are usually asymptomatic. pathological infrapatellar plica, which is mostly due to plica injury, may be a potential cause of anterior knee pain, but is often overlooked and under-reported on magnetic resonance imaging (mri). this pictorial review illustrates the mri findings of infrapatellar plica injury and associated knee injuries, with emphasis on its differentiation from the mimics of plica injury. keywords: mr imaging; knee; synovial plica; infrapatellar plica injury; anterior knee pain. introduction synovial plicae are normal folds of synovial tissue within a joint cavity, which represent normal remnants of synovial membranes during embryological development of the knee joint. there are four main plicae in the knee joint, namely infrapatellar plica (ipp) or ligamentum mucosum, suprapatellar plica, medio-patellar plica and lateral patellar plica, in decreasing order of occurrence.1 these may become symptomatic because of plica syndrome or injury. although ipp is the most commonly encountered plica, present in about 65% of patients, traditionally, it is considered least likely to be symptomatic.2,3 this review illustrates a series of cases where patients presented to the radiology department of a tertiary care hospital with knee pain, often with a history of known trauma. the cases demonstrated abnormality along the course of the ipp, interpreted as either plica sprain or tear. magnetic resonance imaging (mri) was performed on a 3t unit (discovery mr 750w 3tge healthcare) in all cases. the t1w images were acquired in the coronal plane; pdfs (proton density fat-saturated) images in the axial, oblique sagittal and coronal planes; and t2w images were acquired in the oblique sagittal plane. anatomy and magnetic resonance imaging appearance of the normal infrapatellar plica the ipp originates from the anterior part of inter-condylar notch and courses parallel to the anterior cruciate ligament (acl) along its anterior aspect. it further courses through hoffa’s fat pad to finally insert on the inferior pole of patella (figure 1). its dimensions vary from being very thin to being as thick as the acl. however, its course in hoffa’s fat pad is more delicate. it may attach to the transverse inter-meniscal ligament before coursing through hoffa’s fat pad.4 it is classified anatomically based on the degree of regression shape as: (1) having a vertical septum, (2) separate from the acl, (3) split or bipartite or (4) fenestrated.1 figure 1: schematic diagram of the anatomy of the infrapatellar plica and anterior cruciate ligament (acl). the antero-medial meniscofemoral ligament (ammfl) is an accessory ligament with a prevalence of 0.77% in knee mri studies. although its course in the inter-condylar notch may be similar to the ipp, it attaches to the anterior horn of the medial meniscus and does not course through hoffa’s fat pad. injuries to the ammfl are not clinically significant.5 on the mri, the plicae appear as low-signal intensity linear structures on all pulse sequences (figures 2 and 3).4 the surrounding hoffa’s fat pad shows normal signal intensity. figure 2: magnetic resonance imaging of a normal infrapatellar plica: sagittal t2-weighted image (t2wi) (a) and sagittal proton density fat-saturated (pdfs) image (b) revealing the normal infrapatellar plica as a thin low-signal intensity structure anterior to anterior cruciate ligament in the inter-condylar notch (arrow) and in hoffa’s fat pad (arrow head). figure 3: magnetic resonance imaging of a normal infrapatellar plica: oblique sagittal t2wi (a) and oblique sagittal pdfs image (b) demonstrating the normal infrapatellar plica (arrow head) as a thin low-signal intensity structure within hoffa’s fat pad, inserting into the inferior pole of patella. causes of anterior knee pain the spatial approach described by flores et al.6 provides a systematic approach to anterior knee pain and is summarised in table 1 under the four anatomic layers of the knee joint. it is beyond the scope of the present article to describe in detail the imaging findings of all the above-mentioned pathologies. in this review, we intend to emphasise on the imaging appearances of ipp injury. table 1: spatial approach to anterior knee pain.6 plica injury plica tear is known to cause anterior knee pain, if it is complicated by haemorrhagic rupture, thickening or fibrosis.2,3,7 biomechanics of infrapatellar plica injury the ipp has two components: an anterior component within hoffa’s fat pad and a posterior component located anterior to the acl. at arthroscopy, only the portion of the ipp anterior to the acl is visualised and normally remains horizontal in both flexion and extension. on the contrary, radiologically appreciable ipp sprain or tear is detected in the portion of the ipp within hoffa’s fat pad. it is noteworthy that a radiologically abnormal plica in hoffa’s fat pad, detected by mri, may not be symptomatic until it alters the position of the ipp anterior to acl on dynamic arthroscopic evaluation, appearing horizontal on flexion but vertical on extension. this alteration in dynamics, presumably because of fibrosis or stiffness in the ipp, ultimately causes chondral lesions on the superior portion of the inter-condylar notch and patellofemoral sulcus as a result of friction and compression forces, consequently resulting in chronic anterior knee pain.8 magnetic resonance imaging appearance of infrapatellar plica injury an injured or diseased ipp is suggested when a significant amount of curvilinear high t2-signal is seen along the expected course of the ipp in hoffa’s fat pad, or if a markedly thickened plica is visualised, or both.3,9 sagittal pdfs is the minimum sequence required for the optimal evaluation of an ipp injury. plica injuries can be either a sprain or tear: sprain: increase in signal along the ipp on fluid-sensitive sequences, not corresponding to (less than) fluid signal intensity (figures 4 and 5). tear: increased signal along the course of ipp having fluid signal intensity on fluid-sensitive sequences (figures 6–9). figure 4: magnetic resonance imaging (mri) of infrapatellar plica sprain in a 50-year-old female with a history of twisting the knee: oblique sagittal pdfs image (a), t2wi (b) and axial pdfs image (c) indicate hyperintense signal along the entire course of infrapatellar plica (arrow), from the transverse inter-meniscal ligament to the inferior pole of patella, with its margins appearing ragged. note the signal is less hyperintense than that of the synovial fluid. no other abnormality was noted on the patient’s knee mri. figure 5: magnetic resonance imaging of infrapatellar plica sprain in a 45-year-old male with a history of a fall: serial pdfs oblique sagittal images (a and b), oblique coronal pdfs (c) and axial pdfs (d) demonstrates hyperintense signal along the entire course of infrapatellar plica (white arrows in a, b and d) having ragged margins, with oedema in the surrounding hoffa’s fat pad and oedema in the prepatellar subcutaneous plane (d). note mild sprain in the middle third of the postero-lateral bundle of the anterior cruciate ligament in (c) (black arrow), associated bucket handle tear of the medial meniscus with the displaced fragment lying within the inter-condylar notch (c) (asterisk), small baker’s cyst posteriorly (d) (arrow head). figure 6: magnetic resonance imaging of an infrapatellar plica tear in a 53-year-old female with a history of anterior knee pain: oblique sagittal pdfs image (a) and t2wi (b) reveal a hyperintense fluid collection along the entire course of the infrapatellar plica (arrows), with ragged margins. oblique sagittal pdfs image (c) indicates a normal anterior cruciate ligament and posterior cruciate ligament in the patient. figure 7: magnetic resonance imaging of an infrapatellar plica tear in a 60-year-old female with a history of anterior knee pain: pdfs oblique sagittal image (a) shows a hyperintense fluid collection along the entire course of infrapatellar plica (arrow head) with oedema in the surrounding hoffa’s fat pad. oblique coronal pdfs (b) shows that the patient also had a high-grade partial thickness tear of the middle and upper thirds of both bundles of the anterior cruciate ligament (arrow). figure 8: magnetic resonance imaging of an infrapatellar plica tear in a 46-year-old male with a history of falling from a bike and knee pain: serial oblique sagittal pdfs images (a) and (b) demonstrate a hyperintense fluid collection along the entire course of infrapatellar plica (arrow heads), with ragged margins. oblique sagittal pdfs image (c) revealed that the patient also had an avulsion injury of the posterior cruciate ligament (arrows). sagittal pdfs (d) indicated a complex tear of the posterior horn of the medial meniscus (asterisk). figure 9: magnetic resonance imaging of an infrapatellar plica tear in a 33-year-old patient with a twisting injury to the knee and clinically-suspected anterior cruciate ligament (acl) injury: oblique sagittal pdfs image (a) revealed a hyperintense fluid collection along the entire course of the infrapatellar plica (arrow head), with irregular margins. coronal pdfs image shows hyperintense signal along the acl with intact fibres suggestive of mild sprain in the postero-lateral bundle of the acl (arrow). corresponding signal alteration on t1wi is shown in (c-arrow). in spite of plica injury being a known entity in both the orthopaedic and radiology literature, it continues to remain under-reported and often neglected as a cause of anterior knee pain. an abnormal appearing plica in hoffa’s fat pad by mri may alert the orthopaedic surgeon to look for abnormality in the segment of ipp anterior to acl. it is important to mention plica injuries in the mri report because with timely diagnosis, treatment in the form of arthroscopic resection can be offered to the patient, especially if conservative treatment fails.2,10,11 although often associated with other ligamentous and meniscal injuries that contribute to internal knee derangements (figures 7–9), it is noteworthy that plica tears may be the only abnormality detected by mri to explain the patient’s symptoms (figures 4 and 6). plica tear can often co-exist with acl injuries, as illustrated in the case shown in figure 9. in the absence of any internal derangements and presence of mr evidence of plica abnormality, plica injury should be considered as the potential cause of anterior knee pain.10,11 even if associated with other injuries, an injured ipp merits attention and resection on arthroscopy to prevent persisting pain. plica tear mimickers the abnormal signal in hoffa’s fat pad along the ipp may also be found in the following conditions: synovial clefts in hoffa’s fat pad: two synovium-lined clefts that communicate with the knee cavity are present along the posterior margin of the ipp, a vertical cleft located superiorly and a larger horizontal cleft located inferiorly. these can be identified in up to 70% and 90% of knee mri examinations, respectively.5,12 the horizontal cleft is continuous with the joint cavity and its roof is formed by the ipp (figures 10 and 11). it is not pathological, unless associated with ganglion cysts, loose bodies or other synovial pathologies like nodular synovitis or pigmented villonodular synovitis (pvns). horizontal synovial clefts can be differentiated from an ipp tear, which has a more cephalad extension up to the inferior pole of patella.3,13 moreover, in our experience, the hyper-intensity in the case of sprain or plica tear typically has ragged/irregular margins as opposed to synovial clefts which are smoothly marginated and follow a continuous curvilinear pattern along the entire course of ipp (compare figures 10 and 11 with figures 6–9). sometimes one may be able to appreciate an intact plica separately in the case of synovial clefts (figure 11). post traumatic clefting/fragmentation of hoffa’s fat pad: fluid-filled clefts may be noted within hoffa’s fat pad related to knee trauma.12 however, the presence of a curvilinear shaped hyper-intensity, limited to the course of the ipp, favours a plica injury, often associated with hoffa’s fat oedema and injury. figure 10: magnetic resonance imaging of normal synovial clefts in hoffa’s fat pad: schematic diagram (a) of the vertical (supra-hoffotic) cleft and horizontal (infra-hoffotic) cleft in relation to the infrapatellar plica. magnetic resonance imaging, images (b–d) of normal supra-hoffotic and infra-hoffotic recesses in a 29-year-old boy with a history of a fall and clinically-suspected anterior cruciate ligament (acl) injury. oblique sagittal pdfs image (b) and oblique sagittal t2wi image (c) indicate hyperintense fluid-filled synovial clefts, contiguous with the joint fluid. note the mild sprain in middle third of the acl in (d), sagital pdfs (arrowhead). figure 11: magnetic resonance imaging of a normal horizontal cleft in hoffa’s fat pad in a 14-year-old girl with a history of a fall: oblique sagittal pdfs image (a) shows the fluid-filled cleft (arrow) inferior to the infrapatellar plica (arrow head) in the posterior part of hoffa’s fat pad, communicating with the joint cavity. the schematic representation of the horizontal cleft is shown in blue in the inset in (a). oblique sagittal pdfs image (b) shows the separate intact infrapatellar plica (arrow head). note the anterior cruciate ligament avulsion fracture which was the cause of pain in this case. other causes of symptomatic plica plica syndromes: plica syndrome refers to painful impairment of knee function in which the only finding that helps explain the symptoms is the presence of a thickened and fibrotic plica, which becomes unyielding and snaps against the femoral condyle with repeated movement leading to erosive changes, degeneration and softening of the articular cartilage, resulting in synovitis or chondromalacia.1,2 the inciting event causing thickening of the plica may be acute trauma, repetitive stress injury, meniscal tears, osteochondritis dissecans, or loose bodies. the medial patellar plica is most likely to cause plica syndrome, followed by the superior plica. infrapatellar plica may rarely be associated with trochlear groove chondromalacia.4 imperforate superior plica may lead to loculation of joint effusion in the suprapatellar recess and the patient may present with soft tissue swelling in this region.3 conclusion infrapatellar plica injuries are often overlooked as a cause of anterior knee pain and appear to have greater prevalence, much higher than previously expected. it is essential to include such injuries in knee mri reports so that the surgeon can be alerted to arthroscopically remove the torn or abnormally-positioned plica which may otherwise continue to cause discomfort to the patient. the limitation of this review is the lack of arthroscopic correlation. however, our observations open avenues for further research in a larger cohort of patients with arthroscopic correlation to confirm the same. teaching points infrapatellar plica injury is an under-reported cause of anterior knee pain and merits attention of the reporting radiologist as it is a treatable condition. normal synovial clefts within hoffa’s fat pad can mimic an ipp tear and can be differentiated based on location and margins. in plica tear, fluid signal within the hoffa’s fat pad extends throughout the curvilinear course of ipp, has ragged margins, often with oedematous changes in the surrounding fat, which is not seen along synovial clefts. plica injury can clinically mimic an acl injury and the two often co-exist. hence, in all cases of an acl injury, an ipp tear should be sought for. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. ethical consideration this article followed all ethical standards for research. funding information the research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy of any affiliated agency of the authors. references garcía-valtuille r, abascal f, cerezal l, et al. anatomy and mr imaging appearances of synovial plicae of the knee. radiographics. 2002;22(4):775–784. https://doi.org/10.1148/radiographics.22.4.g02jl03775 al-hadithy n, gikas p, mahapatra a, dowd g. review article: plica syndrome of the knee. j orthop surg. 2011;19(3):354–358. https://doi.org/10.1177/230949901101900319 cothran r, mcguire p, helms c, major n, attarian d. mr imaging of infrapatellar plica injury. am j roentgenol. 2003;180(5):1443–1447. https://doi.org/10.2214/ajr.180.5.1801443 stoller d. magnetic resonance imaging in orthopaedics and sports medicine. 3rd ed. philadelphia, pa: lippincott williams & wilkins, 2007; p. 677–680. trinh j, de verbizier j, lecocq texeira s, et al. imaging appearance and prevalence of the anteromedial meniscofemoral ligament: a potential pitfall to anterior cruciate ligament analysis on mri. eur j radiol. 2019;119:108645. https://doi.org/10.1016/j.ejrad.2019.108645 flores d, mejía gómez c, pathria m. layered approach to the anterior knee: normal anatomy and disorders associated with anterior knee pain. radiographics. 2018;38(7):2069–2101. https://doi.org/10.1148/rg.2018180048 lee y, song h, kim s, kim s, suh j. infrapatellar plica of the knee: revisited with mr arthrographies undertaken in the knee flexion position mimicking operative arthroscopic posture. eur j radiol. 2012;81(10):2783–2787. https://doi.org/10.1016/j.ejrad.2011.12.028 ozcan m, copurog˘lu c, ciftdemir m, turan fn, calpur ou. does an abnormal infrapatellar plica increase the risk of chondral damage in the knee. knee surg sports traumatol arthrosc. 2010;19(2):218–221. https://doi.org/10.1007/s00167-010-1273-3 vassiou k, vlychou m, zibis a, nikolopoulou a, fezoulidis i, arvanitis d. synovial plicae of the knee joint: the role of advanced mri. postgrad med j. 2014;91(1071):35–40. https://doi.org/10.1136/postgradmedj-2013-132176 demirag b, ozturk c, karakayali m. symptomatic infrapatellar plica. knee surg sports traumatol arthrosc. 2005;14(2):156–160. https://doi.org/10.1007/s00167-005-0643-8 boyd c, eakin c, matheson g. infrapatellar plica as a cause of anterior knee pain. clin j sport med. 2005;15(2):98–103. https://doi.org/10.1097/01.jsm.0000152706.43395.68 draghi f, ferrozzi g, urciuoli l, bortolotto c, bianchi s. hoffa’s fat pad abnormalities, knee pain and magnetic resonance imaging in daily practice. insights imaging. 2016;7(3):373–383. https://doi.org/10.1007/s13244-016-0483-8 patel s, kaplan p, dussault r, kahler d. anatomy and clinical significance of the horizontal cleft in the infrapatellar fat pad of the knee: mr imaging. am j roentgenol. 1998;170(6):1551–1555. https://doi.org/10.2214/ajr.170.6.9609172 sajr 734 agenesis of the dorsal mesentery presenting in an adolescent a chacko, f ismail, s ellemdin department of radiology, steve biko academic hospital and university of pretoria a chacko, mb bch f ismail, fcrad (d) sa, mmed rad (d) department of internal medicine, steve biko academic hospital and university of pretoria s ellemdin, mb bch, mmed (int med) corresponding author: f ismail (drfismail@yahoo.com) agenesis of the dorsal mesentery is a rare occurrence that usually presents in children. it is associated with proximal small-bowel malrotation as well as high jejunal atresia with discontinuity of the small bowel. we present a case report of an adolescent presenting with clinical features of proximal small-bowel obstruction (confirmed on imaging) as well as acute pancreatitis. at laparotomy, he was found to have no dorsal mesentery, without small-bowel atresia, and the duodenum was fixed to the posterior abdominal wall. the patient recovered well and remained symptom-free. s afr j rad 2013;17(1):16-18. doi:10.7196/sajr.734 clinical presentation a 16-year-old boy presented with acute pancreatitis. his serum amylase level was raised at 292 u/l (normal 25 125 u/l) and serum lipase level was raised at 142 u/l (normal 0 60 u/l). he also presented with severe vomiting causing dehydration and clinical features in keeping with obstruction of the proximal gastro-intestinal tract. at this stage he was thought to have a congenital abnormality such as a pancreas divisum or an auto-immune pancreatitis. antibody tests were negative. there was no previous medical or surgical history or any previous presentations to healthcare facilities with similar episodes. erect abdominal radiographs (fig. 1) confirmed proximal bowel obstruction with the presence of dilated small-bowel loops and multiple dynamic air-fluid levels. a contrast meal and follow-through was performed which showed an abnormal configuration of the duodenum at the d2 d3 junction suggestive of a malrotation with volvulus. the visible proximal duodenum was dilated and the mucosal pattern demonstrated a ‘stacked coin’ appearance that might have been due to ischaemia (fig. 2). on delayed images, many small-bowel loops were clustered in the right hypochondrium (fig. 3). computed tomography (ct) with intravenous contrast (fig. 4) demonstrated the classic sign of whirling of the mesenteric vessels around the superior mesenteric artery (sma). the normal relationship of the superior mesenteric vein (smv) on the right of the sma was also distorted. the proximal duodenal bowel loops were distended and demonstrated diffuse wall enhancement. the pancreatic duct was also found to be prominent (not shown) and this was thought to be secondary to obstruction from the midgut volvulus. at laparotomy, it was found that the dorsal mesentery was absent, which caused spontaneous intermittent volvulus of the duodenum with intermittent occlusion of the common bile duct, causing pancreatitis. the duodenum was surgically fixed to the posterior abdominal wall and the patient remained asymptomatic thereafter. he has subsequently done well and has had no further recurrence or further symptoms or complications.   fig. 1. erect abdominal radiograph demonstrates dilated proximal small-bowel loops with multiple dynamic air-fluid levels in keeping with proximal small-bowel obstruction.   fig. 2. iodine contrast meal and follow-through demonstrates malrotation and volvulus of the proximal small bowel with dilation of the proximal duodenum with a ‘stacked coin’ mucosal pattern, possibly owing to ischaemia. fig. 3. iodine contrast meal and follow-through (delayed images). a collection of small-bowel loops is noted in the right hypochondrium. fig. 4. computed tomography (ct) with intravenous contrast in (a) the arterial phase and (b) the portal venous phase demonstrates the classic sign of whirling of the mesenteric vessels around the superior mesenteric artery (sma), in keeping with volvulus. discussion the development of the mesentery starts when the foregut, midgut and hindgut are in broad contact with mesenchyme of the posterior abdominal wall in the fetus. in the embryo, the connecting tissue bridge then becomes narrow, and the caudal part of the foregut, midgut and most of the hindgut are then suspended from the posterior abdominal wall by the dorsal mesentery.1 a ventral mesentery only exists in the terminal part of the oesophagus, stomach and the proximal part of the duodenum. this ventral mesentery gives rise to the lesser omentum, falciform ligament and the visceral peritoneum of the liver.1 the dorsal mesentery extends from the distal end of the oesophagus to the cloaca distally. it is known as the dorsal mesogastrium or greater omentum in the region of the stomach, the dorsal mesoduodenum in the region of the duodenum, and the dorsal mesocolon in the region of the colon. it is known as the mesentery proper in the region of the jejunal and ileal loops of the small bowel.1 mesenteric defects/absences can lead to volvulus of the associated parts of the bowel. these defects can vary from lesions involving a well-defined short segment of the small bowel (known as segmental defects) to lesions involving the entire base of the mesentery (basilar defects).2 usually, agenesis of the dorsal mesentery is associated with a high jejunal atresia owing to the vascular ischaemic aetiology of such agenesis.3-6 this condition then also can present as the entity known as ‘apple peel small bowel’ which consists of a high jejunal atresia with a discontinuity of the small bowel and a wide gap in the mesentery. 2 , 3 the distal segment of the ileum is shortened and assumes a helical configuration around a retrograde perfusing vessel, which compensates for the partially absent superior mesenteric artery.3 an intra-uterine vascular accident in late gestation has been accepted as the cause of apple peel atresia and presents with a spectrum of occlusions of one or more branches of the superior mesenteric artery.3-6 there was a report of isolated agenesis of the dorsal mesentery in 1960 by blandy6 and subsequently by hull et al.7 in 1975. however, in the second report, this was associated with the apple peel deformity without small-bowel atresia. a case of absent dorsal mesentery without small-bowel atresia and without apple peel deformity was described by salvatore et al. in 2006,8 in which there was complete absence of the dorsal mesentery of the small bowel. intermittent volvulus of the duodenum without malrotation is rare and is not easily recognisable. delays in diagnosis can lead to complications and high morbidity. our case is believed to be unique owing to the relatively late presentation of the patient (adolescence versus early childhood) and also highlights the possibility of midgut volvulus occurring outside the neonatal period. aetiology of the absence of the dorsal mesentery of the duodenum is not clear; an ischaemic cause is unlikely, owing to the absence of atresia. conclusion our case report describes a rare entity of absence of the dorsal mesentery in an adolescent, complicated by proximal small-bowel malrotation, volvulus and the absence of small-bowel atresia. 1. sadler tw. langman’s medical embryology, 11th ed. philadelphia: lippincott williams & wilkinson, 2010:155, 209-213. 1. sadler tw. langman’s medical embryology, 11th ed. philadelphia: lippincott williams & wilkinson, 2010:155, 209-213. 2. black pr, muller d, crow j, et al. mesenteric defects as a cause of intestinal volvulus without malrotation and as the possible primary etiology of intestinal atresia. j pediatr surg 1994;29:1339-1343. 2. black pr, muller d, crow j, et al. mesenteric defects as a cause of intestinal volvulus without malrotation and as the possible primary etiology of intestinal atresia. j pediatr surg 1994;29:1339-1343. 3. zwiren gt, andrews hg, ahmann p. jejunal atresia with agenesis of the dorsal mesentery (apple peel small bowel). j pediatr surg 1972;7:414-419. 3. zwiren gt, andrews hg, ahmann p. jejunal atresia with agenesis of the dorsal mesentery (apple peel small bowel). j pediatr surg 1972;7:414-419. 4. shorter na, georges a, perenyi a, garrow e. a proposed classification system for familial intestinal atresia and its relevance to the understanding of the etiology of jejunoileal atresia. j pediatr surg 2006;41:1822-1825. 4. shorter na, georges a, perenyi a, garrow e. a proposed classification system for familial intestinal atresia and its relevance to the understanding of the etiology of jejunoileal atresia. j pediatr surg 2006;41:1822-1825. 5. arbella d, orkina b, navehb y, gurb i, udassina r. duodenojejunal atresia with absent dorsal mesentery, choledochal cyst, and malrotation in a premature newborn − a case report. j pediatr surg 2006;41:e11-e13. 5. arbella d, orkina b, navehb y, gurb i, udassina r. duodenojejunal atresia with absent dorsal mesentery, choledochal cyst, and malrotation in a premature newborn − a case report. j pediatr surg 2006;41:e11-e13. 6. weber dm, freeman nv. duodenojejunal atresia with apple peel configuration of the ileum and absent superior mesenteric artery: observations on pathogenesis. j pediatr surg 1999;34(9):1427-1429. 6. weber dm, freeman nv. duodenojejunal atresia with apple peel configuration of the ileum and absent superior mesenteric artery: observations on pathogenesis. j pediatr surg 1999;34(9):1427-1429. 7. blandy jp. neonatal intestinal obstruction from a congenital hole in the mesentery. br j surg 1960;48:133. 7. blandy jp. neonatal intestinal obstruction from a congenital hole in the mesentery. br j surg 1960;48:133. 8. hull jd, kiesel jl, warren h, et al. agenesis of the dorsal mesentery without jejunoileal atresia (apple peel small bowel). j pediatr surg 1975;10:277-279. 8. hull jd, kiesel jl, warren h, et al. agenesis of the dorsal mesentery without jejunoileal atresia (apple peel small bowel). j pediatr surg 1975;10:277-279. 9. salvatore c, alan slt, prakash a, hock lt. dorsal mesenteric agenesis without small bowel atresia: a rare cause of midgut volvulus in children. j pediatr surg 2006 41:e5-e7. 9. salvatore c, alan slt, prakash a, hock lt. dorsal mesenteric agenesis without small bowel atresia: a rare cause of midgut volvulus in children. j pediatr surg 2006 41:e5-e7. acknowledgements about the author(s) shalendra k. misser nelson r mandela, school of medicine, faculty of radiology, university of kwazulu-natal, durban, south africa department of radiology, faculty of radiology, lake, smit and partners inc, durban, south africa clive sperryn department of radiology, faculty of radiology, morton and partners, cape town, south africa citation misser sk, sperryn c. in honour of the extraordinary career of prof. a. james barkovich. s afr j rad. 2020;24(1), a2001. https://doi.org/10.4102/sajr.v24i1.2001 letter to the editor in honour of the extraordinary career of prof. a. james barkovich shalendra k. misser, clive sperryn copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. professor jim barkovich is recognised as one of the world’s leading paediatric neuroradiologists of our time. his curriculum vitae is over 100 pages long and spans a distinguished career which began in the 1970s when he graduated with a chemistry degree (magna cum laude) and thereafter branched into medicine. he obtained his medical degree in 1980 at the george washington university, washington, dc. upon completion of his radiology residency at letterman amc, san francisco, in 1984, he proceeded to undertake a fellowship in neuroradiology from walter reed amc, which he obtained in 1986. he has written neuroradiology textbooks and authored many book chapters, which are referred to by radiologists, the world over, in our daily practice. his book, paediatric neuroradiology, is held in exceptionally high esteem internationally. his particular contributions pertain to extensive research in brain development, neonatal brain injury, childhood epilepsy and in the last two decades the evolution of magnetic resonance imaging, especially advanced techniques such as spectroscopy. throughout his commendable career, prof. barkovich has received numerous accolades, awards and recognitions from international radiological, neuroradiological and scientific societies. he has been listed as one of america’s most honoured professionals and appeared on america’s top doctors list every year since 2001. an interesting fact, less known to many, is his service on active duty in the us army from 1976 to 1989. figure 1: photograph taken by antfarm, 06 february 2020, johannesburg, published with permission from antfarm. south african radiologists are fortunate that that the congress organising committee was able to persuade prof. barkovich to make the long journey to south africa on two occasions (the first and third saspi-rssa meetings in 2012 and 2020, respectively). on both occasions he made time in his busy schedule to fly in and out of the country primarily to participate in the meetings with very little time for any personal travel or sight-seeing. his engagement with the audience is worthy of commendation and he is always happy to answer questions. the mark of greatness is the ability of a person of stature to be able to communicate equally with a training registrar as he would with a renowned fellow scientist. prof. barkovich was always seen chatting to attendees at our conferences irrespective of their level of training. as an incredibly modest man he serves as a role model for south african radiologists. in his laid back way he casually related to the obvious amusement of the audience, how he had used dr google when he came across something he had never seen before! he normalised what many of us might find ourselves doing. apart from his excellent lectures as a keynote speaker, he contributed greatly to the stature of our meetings. of course, many of us have been privileged to hear him speak at european and other meetings, especially through our interaction with the european society of neuroradiology (esnr) over the last decade. his most recent contribution has been to act as promoter for a research project on hypoxic–ischemic injury currently being undertaken in south africa. figure 2: photograph taken by antfarm, 08 february 2020, johannesburg, published with permission from antfarm. we are indeed proud of our association with prof. barkovich, made possible through the various societies. we take this opportunity, on behalf of all south african radiologists, to offer our congratulations in honour of his fascinating and illustrious career and we wish him well on his retirement. he is a living legend in neuroradiology circles, a humble man and a compass directing young scientists along whose path we should be walking. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this letter. disclaimer the views and opinions expressed in this letter to the editor are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. editorial academic radiology quo vadis? department of radiology university of pretoria we all know that academic radiology has come to a major crossroad, but as once noted by a great social commentator, dr martin luther king junior, 'it is through difficulty that we learn our greatest lessons: as radiologists we stand well into the first days of the 21st century, but in general we still work and think as subjects of the 20th century. the radiologist in the private sector obtains new equipment, and this is used to the advantage of those who can financially afford the cost. but spare a moment for academic institutions, the place where the next generation of 21st century radiologists is trained. as so well put by a previous editor of the sa]r (february 2001) quo vadis? as part of the academic sector i now ask: quo vadis academic radiology? it is sad for me to note that the entire panel of examinors for the mmed (where it still exists) and the fer (rad) (d) sa consists of only a few people. where do our interests lie? we all expect good qualified radiologists as partners, but find it difficult to find people to be part of their training and preparation, enabling them to follow in our footsteps when we leave for greener pastures. quo vadis radiology when we are 46 fewer practising radiologists than 9 years ago, with a population growth of nearly 4.8 million people and a pandemic of aids awaiting us. i ask why the government keeps our salaries and budgets cut so that the academic sector can't even pay close to what can be earned in the private sector. turf wars are the name of the game and fighting between radiologists continues, while the other fields of specialists chip away at our field of work. it is known that in certain parts of europe 50% of radiology is done by non-radiologists. we use old equipment in training young radiologists, as minimal funds are available for new equipment. in academic radiology we fight to keep some of the newly qualified radiologists to ensure that radiologists of a high calibre can be trained for the public and private sector. i am sure that every radiologist in this country would prefer to see strong academic units so that we can maintain the standard of training and make it possible for young graduates to remain in these units for a period and help with training. the reason so often given for leaving the country is to obtain more knowledge, utilising scholarships and then often not returning. i am sure we want to have subspecialist units, centres of excellence, and to register these with saqa. my quest for the 21st century and for radiology is for us to be the best we can, but in the words of jan brandt, a previous president of south africa, this can only become true if we all play our part. sadly i must keep on repeating the words for everyone's ears, minds and souls to be touched. in our specialist field radiology, you the radiologist must decide. quo vadis academic radiology? julian holl mb chb, ffrad (d) sa julian holl editor 3 sajournal of radiology • march 2002 abstract introduction the benefits of screening the harms of screening screening guidelines screening interval guidelines screening mammography in the 40–50 years age group screening mammography in south africa conclusion acknowledgements references about the author(s) shirley lipschitz dr shirley lipschitz and associates, sunninghill, sandton, south africa citation lipschitz s. screening mammography with special reference to guidelines in south africa. s afr j rad. 2018;22(2), a1370. https://doi.org/10.4102/sajr.v22i2.1370 review article screening mammography with special reference to guidelines in south africa shirley lipschitz received: 31 may 2018; accepted: 27 july 2018; published: 31 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract screening mammography is known to reduce mortality from breast cancer. controversy regarding screening has led to much confusion in the medical fraternity. the purpose of this review is to point out the ‘pros and cons’ of screening. the benefits and perceived harms of screening will be discussed using evidence-based literature from the past 30 years. the literature was obtained from various journals sourced from the internet. general findings are that screening mammography from the age of 40 saves lives, but that the problem of overdiagnosis and overtreatment of certain breast cancers overrides the benefit of screening. the article also covers the debate on what age to begin screening. screening in the south african context is discussed. screening in the future will need to be more selective of patients and of which cancers to treat less aggressively, if at all. introduction screening mammography by means of x-ray imaging studies is the universal standard used to locate preclinical breast cancers. there is strong evidence that mammography screening results in a reduction of breast cancer deaths, principally through the effect of reducing the incidence of advanced and inoperable breast cancer with metastases.1 screening leads to less morbidity and more effective treatment. it has been shown that a lower histological grade, smaller tumour size and absence of lymph node disease are factors associated with a better prognosis.1 localised disease is associated with a 98.6% five-year relative survival rate, as compared with an 84.9% rate for cancers with lymph node positivity and a 25.9% rate for those with metastases.2,3 proponents and detractors of screening have different interpretations and extrapolations from evidence-based statistics and this has caused confusion with regards to screening recommendations in particular. different countries, medical societies, referring physicians and funders have varying guidelines for screening mammography. the following review of some of the literature includes those studies that concern the benefits and disadvantages of screening, the controversies of screening in the 40–50 age group and the issues around screening intervals. reference will also be made to screening in the south african context. the benefits of screening evidence-based studies have shown that screening mammography saves lives.1,2,3 this has been demonstrated through randomised control trials (rcts)4,5 and numerous observational studies.6,7,8,9,10 a meta-analysis of rcts has shown a 15% – 30% reduction in breast cancer mortality in the 40–74-year-old age group who were invited to screening. the rct with the longest follow-up (29 years) is the swedish two-county trial, which was the first trial to demonstrate a breast cancer mortality reduction associated with an invitation to mammographic screening without clinical breast examination.1 however, these historical rcts may not be relevant today because of the new screening technologies and reported bias in the trials (as certain women invited to screening were not compliant, while other women in the control group had opportunistic screening). case-control studies, cohort studies and trend analyses have been used to evaluate the effects of screening. gabe and duffy6 summarised ways of evaluating screening in a non-experimental setting, as well as the findings from 38 non-randomised studies on breast cancer screening. their study results showed breast cancer mortality reductions in the order of 30% – 40% associated with screening. broeders et al.7 summarised the findings from the evaluations of modern, organised mammography programmes in europe. they showed a 25% decrease in mortality with those invited to screening and a 38% reduction in those actually exposed to screening in a meta-analyses of the incidence-based mortality studies. the norwegian breast cancer screening programme began in 1996 with biennial screening of the 50–69-year-old group. breast cancer mortality was assessed among women who were exposed and not exposed to screening between 1996 and 2009, and followed for breast cancer death through to 2010 (average follow-up was 5.7 years). a 43% mortality reduction was shown after 15 years of follow-up. the results in this follow-up were adjusted for age, years in the programme and selection bias.8 coldman et al.9 showed, in the pan-canadian study of mammography screening and mortality from breast cancer, lower mortality rates in participants of the trial, compared with expected rates among non-participants. those who participated in the trial at 40–49 showed a 44% decrease in mortality, those in the 50–59 group showed a 40% decrease, those in the 60–69 age group showed a 42% decrease and those in the 70–79 age group showed a 35% decrease. the average reduction in mortality in all age groups and provinces was 40% in the exposed group. the cancer intervention and surveillance modelling network (cisnet)10 assessed that screening and treatment contributed to a 46% reduction in breast cancer deaths over the 1975–2000 period in the united states, and later estimated that if there was full compliance with screening and treatment, there would have been a 68% – 74% reduction in mortality. in summary, the rct and observational trials have shown a significant decrease in mortality rates in those screened. possible reasons why greater reductions have been reported in observational studies, compared with rcts, include bias, improved treatment of early-stage breast cancer, improved screening technology and a difference between actual participation versus invitation. those opposed to screening believe rcts were biased and observation trials do not allow for the positive impact of new treatments. the harms of screening those against screening believe that it has led to overdiagnosis and overtreatment, and that there has not been a sufficient reduction in late-stage disease to justify screening.11 the cost and benefit of lives saved versus the harms of screening and potential overdiagnosis are the core issues underpinning the controversies raging for the past 10–15 years. funding of screening is significant and economic considerations may have an impact on decision-making. screening leads to an average recall rate of around 10%.12 these women are usually recalled for extra views and sonography. most of these women are subjected to minor, mostly psychological stresses. some of these women (1% – 2%) need a biopsy, which can lead to the concept of false positivity before the results reveal otherwise. the extra stress and funding for these tests are perceived as harms of screening. furthermore, cumulative radiation exposure is thought by many to be harmful. however, radiation doses for each mammogram are well below acceptable limits, while the real impact of years of mammography on an individual cannot be readily quantified and is only estimated.11 overdiagnosis of a cancer is a perceived harm of screening. the commonly accepted definition is that of a diagnosed preclinical cancer, which would not have led to a life-threatening situation, had it not been detected on mammography. screened women are diagnosed with breast cancer before unscreened women because of lead time, which is defined as the time between the screening-detected cancer and the time it would present clinically. only a long-term follow-up between screened and unscreened women would correct the issue of perceived overdiagnosis. older women, already screened, would presumably have fewer cancers based on their long-term history of screening. it is generally thought that lead time results in an overestimation of overdiagnosis.12 the counterargument to the overdiagnosis theory13 is that screening picks up more cancers because of lead time and this should not be termed overdiagnosis. estimates of an overdiagnosis rate of 1% – 10% with screening mammography are generally accepted as the benchmark.12 the eurosceen (european breast cancer service screening) group has calculated that with proper adjustment for known confounders, the most accurate estimate of overdiagnosis ranged from 1% to 10%. long-term follow-up of rct data suggests that overdiagnosis is mostly because of ductal carcinoma in situ (dcis).14 most of the papers on the topic have been performed by epidemiologists and showed a wide variation of reports of overdiagnosis, ranging from 0% to 30%.15 bleyer and welch16 collected data from the us national cancer institute’s surveillance epidemiology, and end results (seer) program. they said that the imbalance between early-stage and late-stage breast cancers between the pre-screening era (1976–1978) and the current era (2006–2008) shows that screening led to overdiagnosis. the accuracy was questioned as they also did not account for lead time and underestimated the background cancer incidence rate in the 30-year period they were observing. marmot et al.17 used three rct late follow-up studies of mainly older women, with both in situ and invasive disease, to estimate the approximate rate of overdiagnosis as 10.7% and also postulated a 1% lifetime risk of overdiagnosis in women screened between the ages of 50 and 70. in an age trial in the united kingdom (uk), gunsoy et al.14 showed a rate of overdiagnosis of 0.7%. helquist et al.18 in sweden reviewed 3.8 million people aged 40–49 and found an overdiagnosis rate of 1%. in a currently published trial by hendrick,13 seer data were used to calculate overdiagnosis rates based on lead time estimations of 24 months for pre-menopausal women and 40 months for post-menopausal women. this showed the general overdiagnosis for dcis to be 9%, and for invasive and other tumours to be 7%. however, in the 40–49 age group, overdiagnosis rates were the lowest, being 0.15% for dcis and below 0.1% for invasive and other breast cancers. overdiagnosis rates increased progressively with age. the cancer intervention and surveillance modelling network10 estimates showed similar results of overdiagnosis whether screening was biennial for ages 50–74 or annual for ages 40–74. post-mortem studies have shown that about 1.3% of women have undetected invasive breast cancer and 8.9% have dcis, suggesting that cases of dcis are largely responsible for the overdiagnosis.19 the only ethical way to measure overdiagnosis is by using statistics to compare incidence in a screened population with that in an unscreened population. nonetheless, large estimates of overdiagnosis have been shown to be a function of a failure to correct a bias because of certain statistical confounders, such as lead time and trends in breast cancer risk and incidence over time.15 arleo et al.10 showed that screening-detected cancers, including all overdiagnosis cancers, do not disappear spontaneously without excision or treatment. these cancers will be seen at the next screen, and hence they deduced that starting screening at a later age or increasing the screening intervals will delay but not reduce the number of over-diagnosed cancers. overtreatment of breast cancers found at screening mammography is of great concern, this being unnecessary surgery, radiation and sometimes even chemotherapy. the so-called overtreatment of patients may be compounded by the side effects of these drastic treatments. this could occur with the diagnosis of an indolent tumour or if a patient dies from another disease after the diagnosis, usually seen in older patients or in patients with comorbidities. there are no direct ways of measuring which cases will be overtreated. screening-detected dcis may or may not lead to invasive cancers, making the selection to treat these difficult. studies have proven that dcis diagnosis and treatment has led to a decrease in invasive tumours. duffy et al.20 estimated that for every three cases of dcis discovered, there was one less case of invasive cancer over a three-year follow-up period. in reality, it is overtreatment that is the greatest harm of overdiagnosis, with all of the other harms (extra views, sonography and biopsies, as well as the cost and psychological stress involved) being comparatively minor. as such, a diagnosis in itself is not per se the problem; it is the decision to treat every positive diagnosis aggressively, that is more debatable. however, there is currently no known way to decide which lesions at mammography or which histological diagnosis (particularly with invasive disease) would be associated with overtreatment. furthermore, no disappearance or decrease in size of tumours has been detected in retrospective studies over long screening intervals.12 screening guidelines currently, the screening recommendations for the average-risk woman are indicated for: women with no personal history of breast cancer, no known or suspected brca mutation, no previous radiotherapy to the chest, less than a 15% lifetime risk and non-dense breast tissue.21 current screening protocols for an average-risk woman are similar worldwide. no programmes begin screening women before age 50 and few have shorter than 12–18 month screening intervals. most advocate screening from age 50 and longer screening intervals (24–36 months). the american college of radiology (acr) has the longest recommended age range for screening and is the only one recommending annual screening. the uk has the longest recommended screening interval at three years.22 the world health organization (who) recommends two-yearly screening in large, national-based screening programmes. in countries with limited resources in public hospitals (where most patients are diagnosed with advanced cancers), women need to be educated and should ideally have access to screening mammography and appropriate treatment.23 south african recommendations have historically been based on american guidelines, some of which changed in 2009 and again in 2016. until 2009, most of the american societies recommended annual mammography starting from 40. the current guidelines in the united states are as follows: the acr and the national comprehensive cancer institute recommend annual screening from age 40. the stated reasons are that annual screening is associated with the greatest mortality reduction, an increase in life years gained, less chance of advanced disease at diagnosis and better treatment options.24 the american cancer society (acs) suggests annual mammography from 45 to 54 years, biennial studies from 55 and ongoing screening thereafter, depending on the individual’s health. a choice can be made by a woman to have yearly screening from the age of 40 onwards, following a discussion with a healthcare adviser and after being informed of the benefits and harms of screening.25 the american society of breast surgeons has the same recommendations26 as the acs. the american college of obstetricians and gynaecologists recommends annual or biennial screening mammography from 40 until 75.27 the united states preventative services task force (uspstf), updated in 2016,28 recommends biennial screening from age 50 to 74. women from 40 to 49 years can discuss options to screen with their healthcare provider. they believe there is insufficient evidence to support screening in women older than 75. the factors influencing the united sates screening guidelines include the following: the acs and uspstf consider mortality reduction to be the only benefit of screening. the uspstf has adopted the statistic of a 15% mortality reduction from their rct analysis, albeit using one interpretation of the trials rather than the overall long-term analysis. the acr and acs both base their guidelines on more recent observational trial data, but these results may underestimate the benefits of screening with modern technology. harms of screening are calculated by the uspstf and acs through studies showing the results on population groups and not individuals. the acr and acs question the accuracy of overdiagnosis rates saying that estimates have not accounted for changing trends in incidence, differences in populations and the presence of differing lead times of cancers found at screening.29,30 the uspstf recommends that the age of screening starts at 50 and not 40 in order to reduce overdiagnosis. it also recommends biennial screening for the same reason. nonetheless, all the organisations acknowledge the benefits of starting screening mammography at 40 and broadly concur with the results of the cisnet data,6 which shows the largest reduction in mortality. they also all recommend allowing women the choice to start screening at age 40 and to end screening at an appropriate time for each person. they are all in agreement about individual discussions with primary healthcare physicians with respect to the benefits and harms of screening, so that each person can make their own decisions. quality control standards are in place in all screening programmes. these should be used to assess accuracy of screening in any given programme. these include an almost universal use of the breast imaging reporting and data system (bi-rads) programme, which allows for a set format of reporting and auditing for radiologists.31 the current bi-rads atlas allows scientific assessment as to whether a result of screening is a true-positive (tp), a true-negative (tn), a false-positive (fp) or a false-negative (fn). the sensitivity (tp / [tp + fn]) of the mammogram exam, the specificity (tn / [tn + fp]) and positive predictive value (tp / [tp + fp]) can then be calculated. together, these are deemed the cancer detection rate (cdr). the efficacy of screening is dependent on the recall rate, the cdr and the percentage of early cancers. the cdr has traditionally been approximately 4–6 per 1000 women. the recall rate recommendation has been 10% or less; however, in a recent publication by grabler et al.,32 recall rates of 12% – 14% were found to be associated with more cancer detection. the cdr can be used in assessing screening results, but it has limitations for low-volume practices and radiologists; as low numbers are not statistically significant and therefore cannot accurately assess performance in these situations.33 screening interval guidelines screening intervals should be optimised and this is related to differences in tumour growth. tumour growth rate is variable and the time taken between initiation of tumour growth and its clinical manifestation is known as the sojourn time. screening intervals according to eby34 should be influenced by knowing about the heterogeneity of tumours and their sojourn time, and also by the fact that earlier tumour detection would be associated with lower staging and a lower death rate, and in turn lead to lowering treatment costs. the longer the screening interval, the larger the fast-growing tumours will be when detected and these in turn will be associated with later-stage disease.35 biennial mammography is recommended by those who believe that the false positive results can be materially reduced and other harms too can be reduced.34 however, according to destounis et al.,36 two-yearly screening in the 40–50 age group is too long, as tumours in this age group have a shorter sojourn time. a study carried out on patients in their 40s, who had annual screening before cancer diagnosis versus those diagnosed symptomatically, showed that those screened had a better chance of survival. screening mammography in the 40–50 years age group screening in the 40s is currently not recommended in screening guidelines in most countries. this is because it is thought that the harms outweigh the benefits of screening. specifically, younger women have denser breast tissue and this leads to higher recall rates, more investigations and more biopsies. however, this false positivity is offset by the fact that tumours reported in younger-aged women are typically more aggressive and have a shorter lead time (of less than two years). accordingly, the delay of screening in this age group leads to the finding of more and larger later-stage tumours.37,38,39 it is generally thought that there is a lower prevalence of cancer at this age. however, it has been shown that there is not much of a difference in cancer incidence between the 40–50 and the 50–60 age groups, as shown in the seer study of 2009–2013.40 in this study, the prevalence of cancer was shown to be 0.3–0.6 per 1000 women between 30 and 39 years; 1.2–1.9 per 1000 women between 40 and 49 years; 2.2–2.6 per 1000 women between 50 and 59 years and 3.4–4.2 per 1000 women between 60 and 69 years. in 2015, the diagnosis of breast cancer in the united states in the 40s age group was shown to comprise about 17% of the total number of breast cancer diagnoses.41 in addition, it has been estimated that 40% of years of life lost will occur in women diagnosed with breasts cancer in the 40–50 year age group.42 on the other hand, the early results of rcts did not show benefit in the 40–50 age group. this has been thought to be because of technical errors and biases as shown in the next paragraph. in the two-county trial, it was shown that there was an increase in the interval cancers (those cancers presenting clinically between screenings) of women in their 40s with only one-view screening and two-year intervals.1,4 furthermore, the canadian national breast screening study (‘cnbss’)13 did not show any significant decrease in breast cancer mortality in the 40–50-year-old screened group and this was attributed mainly to flaws in the way it was set up.3,4 it is thought that the poor results of the rcts in the 40–49-year-old group were because of: longer interval screening. in this age group, tumours have a shorter sojourn time (time taken for breast cancer from its appearance on imaging to its clinical presentation). in an article by duffy et al.,14 it was found that the mean sojourn time in 40–49 age group was 2.44 years compared with 3.70 years for the 50–59 age group and 4.17 years for the 60–69 age group. inadequate screening technology. single-view mammography was not good enough in the early days of screening to detect tumours in young, dense breasts.38 in 1997, a meta-analysis of long-term follow-ups on the eight rct trials screening women in the 40–50 age group over 10.5 to 18 years showed: a mortality decrease of 18% in the group of women invited to screen. a 29% mortality reduction in the five swedish rcts.6 a 24% mortality reduction was shown when excluding the cnbss from the meta-analysis of the eight trials. the cnbss was excluded as it showed a mortality increase. critics of this trial say there was a selection bias based on the fact that clinical examinations were carried out and those with disease were selected to be in the screening programme.7,8 coldman et al.,9 in the pan-canadian study of mammography screening and mortality from breast cancer between 1990 and 2009, showed a 44% reduction in mortality in the 40–50 age group, compared to those in the 50–59 (40%), 60–69 (42%) and 70–79 (35%) age groups. the uspstf uses a figure of 15% mortality reduction benefit for women in their 40s, based on the early results of their rct.43 engel jr et al.44 showed a better prognosis in women in their 40s who undertake annual screening. webb ml et al.45 showed those who have interval cancers diagnosed between a two-year screening period have a 47% increase in mortality relative to those screened annually. in the same study, they also demonstrated that in women 50 years and older, the interval cancer detection between two-yearly screening intervals was associated with a 34% lower mortality rate compared to women in the 40–50 age group. most women prefer annual screening in their 40s and most physicians still recommend screening in this age group.33 it has been suggested in all the new guidelines that only those at high risk in the 40–50-year-old age group should undergo screening. however, this would still miss most of the cancers in the age group, as many studies show that most cancers found in this age group are in women of an average-risk profile.35,46,47,48 in summary, the data mentioned show unequivocally the benefit of screening in the 40–50-year-old age group, in both the long-term follow-up of rct and in the numerous observational studies. screening mammography in south africa a national breast cancer screening programme in south africa does not currently exist because of insufficient funds to warrant screening when it is deemed that more important health issues exist. moreover, there has been little epidemiological research carried out in this field, and as such, south africa’s statistics of breast cancer incidence in the population may not reflect all the cancers occurring over a given period. nonetheless, there is a breast cancer registry (at the national institute for occupational health) and current statistics are available on the 2014 data, albeit that these could be incomplete and do not specify whether the cancers were screen detected.49 although the variation in demography is huge in south africa, it is interesting to note that there was no racial difference in the incidence of breast cancer.49 a relatively small percentage of women, generally those in the cities, have access to private medical insurance and are thus funded for screening mammograms. south africa’s account of statistics is poor, mainly because screening occurs opportunistically in small practices scattered throughout the country. these individual practices generally do not keep audits of screening activity, albeit such statistics could be collected and collated, which is thought by the author and colleagues to be of great benefit to both national and private health providers and to the medical aid funders. breast cancer screening and diagnosis is complex. the potential breast cancer diagnosis engenders great fear in many south african women, while information is neither always available nor is it adequately disseminated. it tends to be believed that breast cancer is a uniformly bad diagnosis, and that life-threatening outcomes will be averted by having regular mammograms. in this regard, women have unrealistic expectations of the accuracy of a single mammogram, as well as the benefits and the harms of screening. furthermore, much screening mammography occurs in regular radiology practices, as opposed to dedicated screening practices that have better facilities. these latter practices are arguably more qualified than others, which women are not necessarily aware of. currently, the radiological society of south africa (rssa) and breast imaging society of south africa (‘bissa’) recommend annual screening from 40 to 70 and regular selfand clinical examination. the largest private medical aid group, discovery health, currently funds biennial mammography starting from the age of 45 but will fund annual mammography from 40 in those with specified risk factors. the cancer association of south africa (cansa) recommends annual screening for women of 40–54 years, and biennial mammography for women of 55 years and older. it also says that it is an individual’s choice to continue annual mammograms from 55 years and that a woman should have the option to continue as long as there is a life expectancy of 10 years or more. the cancer association of south africa also recommends discussion of any breast health problems with primary physicians. it also states that every woman should be provided with data concerning the benefits and harms of screening mammography (cansa fact sheet april 2017). conclusion screening has been shown through studies to reduce the breast cancer mortality rate by 30% – 40%. current screening guidelines universally endorse screening in the 40–50-year-old age group and it has been proven in the literature that mammography starting from age 40 reduces mortality from breast cancer. therefore, in light of the general guidelines suggesting that screening should start after 50, women in the 40–50 age group should be given the option to have screening after being made aware of the pros and cons of the screening process. the benefit of regular mammography today is thought to be better than that showed in the early rct trials. improved technology, especially with digital breast tomosynthesis (dbt), will enable more screening-detected cancers with less callbacks and biopsies. individual screening protocols may be more beneficial than standardised ones and will lead to less morbidity with treatment. some may be able to have no radiation, some low-fractionated radiation, some adjuvant chemotherapy and, with learning the implications of different tumour biology, less treatment for low-grade dcis. in the south african setting, there should be a published guideline clearly defining recommendations for all types of risk groups. moreover, where access to mammography is difficult domestically, screening by breast examination (performed by nursing staff and field workers), although contentious, may be an option together with ready access to further investigations and treatment. however, this is definitely not the best practice and one should continue recommending screening for all south africans, this being a situation that in the long run would be most beneficial to all south african women, and would in fact be the most economically sensible one (given the healthcare cost savings from early cancer detection and treatment). acknowledgements competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. references tabar l, vitak b, chen hh, et al. the swedish two-county trial twenty years later. updated mortality results and new insights from long-term follow-up [in process of citation]. radiol clin north am. 2000;38(4):625–651. https://doi.org/10.1016/s0033-8389(05)70191-3 howlander n, noone a, krapcho m, et al. seer cancer statistics review, 1975–2012. bethesda, md: national cancer institute; 2015. shapiro s, strax p, venet l. periodic breast cancer screening in reducing mortality from breast cancer. jama. 1971;215(11):1777–1785. https://doi.org/10.1001/jama.1971.03180240027005 smith ra, duffy sw, gabe r, tabar l, yen am, chen th. the randomized trials of breast cancer screening: what have we learned? 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modelling the overdiagnosis of breast cancer due to mammography screening in women aged 40 to 49 in the united kingdom. breast cancer res. 2012;14:r15253. https://doi.org/10.1186/bcr3365 monticciolo dl, mark a, helvie r, hendrick e. current issues in the overdiagnosis and overtreatment of breast cancer. ajr. 2018;210:285–291. https://doi.org/10.2214/ajr.17.18629 bleyer a, welch hg. effect of three decades of screening mammography on breast-cancer incidence. n eng j med. 2012;367:1998–2005. https://doi.org/10.1056/nejmoa1206809 marmot mg, altman dg, cameron da, dewar ja, thompson sg, wilcox m. the benefits and harms of breast cancer screening: an independent review. br j cancer. 2013;108:2205–2240. https://doi.org/10.1038/bjc.2013.177 helquist bn, duffy sw, abdsaleh s, et al. effectiveness of population-based screening with mammography for women ages 40 to 49 years: evaluation of the breast cancer mortality amongst women ages 40–49 at diagnosis in counties that offered swedish mammography screening in young women (scry) cohort. cancer. 2011;117:714–722. francis a, fallowfield l, rea d. the loris trial: addressing overtreatment of ductal carcinoma in situ. clin oncol (r coll radiol). 2015;27:6–8. https://doi.org/10.1016/j.clon.2014.09.015 duffy sw, dibden a, michalopoulos d, et al. screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. lancet oncol. 2016; 17:109–114. https://doi.org/10.1016/s1470-2045(15)00446-5 monticciolo dl, newell ms, hendrick re, et al. breast cancer screening for average-risk women: recommendations from the acr commission on breast imaging. j am coll radiol. 2017;14:1137–1143. https://doi.org/10.1016/j.jacr.2017.06.001 international cancer screening network. breast cancer screening programs in 26 icsn countries. organization, policies, and program reach. bethesda, md: national cancer institute; 2012 [updated 18 august 2015] healthcare delivery. cancer. gov/icsn/breast /screening. ebell m, thai tn, royalty kj. cancer screening recommendations: an international comparison of high income countries. public health rev. 2018;39(7), ecollection 2018. doi: https://doi.org/10.1186/s40985-018-0080-0 national comprehensive cancer network. ‘nccn’ guidelines for breast cancer screening and diagnosis [june 29, 2017] and the society of breast imaging [american college of radiology website [homepage on the internet]. acr and sbi continue to recommend regular mammography starting age 40. 2015 [cited 2017 jun 29]. available from: acr.org oeffinger kc, fontham et, etzioni r, et al. breast cancer screening for women at average risk: 2015 guideline update from the american cancer society. jama. 2015;314:1599–1614. https://doi.org/10.1001/jama.2015.12783 american society of breast surgeons website. consensus statement on screening mammography [homepage on the internet]. 2015 [cited 2017 jun 29]. available from: breastsurgeons.org/new_layout/about/statements/pdf_statements/screening_mammography.pdf committee on practice bulletins – gynecology. practice bulletin number 179: breast cancer risk assessment and screening in average-risk women. obstet gynecol. 2017;130:e1–e16. https://doi.org/10.1097/aog.0000000000002158 siu al, u.s. preventive services task force. screening for breast cancer: u.s. preventive services task force recommendation statement. ann intern med. 2016;164:279–29616. https://doi.org/10.7326/m15-2886 shen n, hammonds ls, madsen d, et al. mammography in 40-year old women: what difference does it make? the potential impact of the u.s. preventative services task force [uspstf] mammography guidelines. ann surg oncol. 2011;18:3066. https://doi.org/10.1245/s10434-011-2009-4 saadatmand s, bretveld r, sieslind s, tilanus-linthorst m. influence of tumour stage at breast cancer detection on survival in modern times: population based study in 173,797 patients. bmj 2015;351:h4901. sickles ea, d’orsi cj. acr bi-rads follow-up and outcome monitoring. in: d’orsi cj, sickles ea, mendelson eb, et al. (editors). acrbi-rads atlas, breast imaging reporting and data system. reston, va: american college of radiology; 2013. grabler p, sighoko d, wang l, allgood k, ansell d. cancer detection rates for screening mammography: finding the sweet spot. ajr. 2017;208:208–213. https://doi.org/10.2214/ajr.15.15987 surveillance epidemiology and end results program website. seer data, 1973–2014 [homepage on the internet]. [cited 2017 oct 01]. available from: seer.cancer.gov/data/ eby pr. radiological clinics of north america 55 [2017] 441–456] ‘age to begin and intervals for breast cancer screening: balancing benefits and harms’. ajr. 2018;210:1–6. smith-bindeman r, chu pw, miglioretti dl, et al. comparison of screening mammography in the united states and the united kingdom. jama. 2003;290[16]:2129–2137. https://doi.org/10.1001/jama.290.16.2129 destounis sv, arieno al, morgan rc, et al. comparison of breast cancers diagnosed in screening patients in their 40s with and without family history of breast cancer in a community outpatient facility. ajr. 2014;202:928–932. https://doi.org/10.2214/ajr.13.11194 lee cs, sengupta d, bhargavan-chatfield m, sickles ea, burnside es, zuley ml. analysis of data from the national mammography database. jama oncol. 2017;3:1134–1136. arleo ek, dashevsky bz, reichman m, babagbemi k, drotman m, rosenblatt r. screening mammography for women in their 40s: a retrospective study of the potential impact of the u.s. preventive service task force’s 2009 breast cancer screening recommendations. ajr. 2013;201:1401–1406. https://doi.org/10.2214/ajr.12.10390 curpen bn, sickles ea, sollitto ra, ominsky sh, galvin hb, frankel sd. the comparative value of mammographic screening for women 40–49 years old versus women 50–64 years old. ajr. 1995;164:1099–1103. https://doi.org/10.2214/ajr.164.5.7717212 howlader n, noone am, krapcho m, et al, editors. seer cancer statistics review, 1975–2013 [homepage on the internet]. bethesda (md): national cancer institute. 2015 [cited 2016 may 01]. available from: http://seer.cancer.gov/csr/1975_2013/. based on november 2015 seer data submission american cancer society. breast cancer facts & figures 2015–2016 [homepage on the internet]. 2015 [cited 2016 may 01]. available from: http://www.cancer.org/acs/groups/content/@research/documents/document/acspc046381.pdf shapiro s, venet w, strax p, et al. periodic screening for breast cancer, the health insurance plan project and its sequelae 1963–1976. baltimore, md: johns hopkins university press; 1988. u.s. preventive services task force. screening for breast cancer: u.s. preventive services task force recommendation statement. ann intern med. 2009;151:716–726. https://doi.org/10.7326/0003-4819-151-10-200911170-00008 engel jm, stankowski-drengler tj, stankowski rv, liang h, doi sa, onitilo aa. all-cause mortality is decreased in women undergoing annual mammography before breast cancer diagnosis. ajr. 2015;204:898–902. https://doi.org/10.2214/ajr.14.12666 webb ml, cady b, michaelson js, et al. a failure analysis of invasive breast cancer: most deaths from disease occur in women not regularly screened. cancer. 2014;120:2839–2846. https://doi.org/10.1002/cncr.28199 hellquist bn, duffy sw, abdasalen s, et al. effectiveness of population based service screening with mammography for women ages 40 to 49 years. cancer. 2011;117:714–722. https://doi.org/10.1002/cncr.28199 miglioretti dl, zhu w, kerlikowske k, et al. breast tumour prognostic characteristics and biennial vs annual mammography, age, and menopausal status. jama oncol. 2015;1[18]:1069–1077. https://doi.org/10.1001/jamaoncol.2015.3084 nelson hd, tyne k, naik a, bougatsos c, chan bk, humphrey l. screening for breast cancer: systematic evidence review update for the u. s. preventive services task force. ann intern med. 2009;151:727–737. https://doi.org/10.7326/0003-4819-151-10-200911170-00009 national cancer registry. ‘ncs’_ 2014 cancer statistics full report [homepage on the internet]. [cited n.d.]. available from: www.nioh.ac.za/?page=national_cancer_registry&id=41 case report case report 28 sa journal of radiology • march 200628 sa journal of radiology • december 2006 this case report demonstrates the mri findings of atypical tuberculosis (tb) of the knee joint, caused by mycobacterium kansasii. osteoarticular tb caused by atypical mycobacteria is rare; instead, it is predominantly a synovial disease affecting the tendon sheaths rather than bone. predisposing factors are immunocompromised individuals, including the elderly, alcoholics, those with hiv, diabetes mellitus, malnutrition and other chronic debilitating illnesses, and local factors, such as preexisting trauma, rheumatoid arthritis, systemic lupus erythematosis, and prosthetic joints. we present a case that occurred in an individual without any predisposing factors, which is also a rare occurrence. case report a 26-year-old woman presented with a 6-year history of knee pain and swelling. her daily activities were affected, and the pain also kept her up at night. there was some response to analgesics. she had no history of trauma, and the onset has been insidious. no other joints were affected. there was a background of possible pulmonary tb, but treatment for this had been started and subsequently stopped. some weight loss had occurred. clinically she had a monoarthritis with evidence of synovitis and an effusion. laboratory tests revealed a raised erythrocyte sedimentation rate and c-reactive protein. rheumatoid factor was negative. plain radiographs revealed peri-articular osteopaenia and a joint effusion. an mri was performed to further evaluate these changes (fig. 1). the mri showed extensive synovitis, with bone marrow oedema and erosions. the erosions involved both bone and meniscal margins. multiple lymph nodes were noted in the popliteal fossa. the overall appearance is non-specific, with the differential diagnosis including all inflammatory arthritides, such as rheumatoid arthritis, pigmented villonodular synovitis and tb. the patient underwent both synovial fluid aspiration and biopsy. the joint fluid was serous, with lymphocytes present, but there was no culture growth after 6 weeks. the synovial biopsy was normal on microscopy and ziehl-nielsen stain, but after 24 hours of incubation for acid-fast bacilli, mycobacterium kansasii was cultured. the patient was placed on tb treatment for 12 months and is presently still being followed up. radiological findings of tb arthritis plain radiographs only demonstrate changes after 3 4 weeks. early findings are a joint effusion and soft tissue swelling. later findings encompass the classic ‘phemister triad’, which comprises joint space narrowing, juxta-articular osteopaenia and erosions. an important feature of tb of the joints can be seen in superficial joints, e.g. hands, where reactive subperiosteal new bone formation appears around lytic areas.1 mri of tb arthritis can present with a wide range of findings.2 these include bone marrow oedema, synovitis, cartilage/bony destruction, myositis, cellulitis, granulation tissue, abscess-fistula, tenosynovitis, bursitis, fibrosis, etc.2 findings which should alert one to the possibility of tb include t1wi hyperintense soft tissue, which may represent caseous material, and a t1wi hyperintense lining of a bursitis, a smooth, thin enhancing bursal margin, and bone destruction with new bone formation. atypical tb of joints is unusual and when it does occur, it involves synovial sheaths more than bones. often there are underlying predisposing conditions, most commonly, hiv or aids. mycobacterium kansasii is the commonest atypical organism found in osteoarticular tb. others reported include m. xenopi and m. avium intracellulare. the diagnosis is often not made on clinical and imaging grounds. any patient with a persistent monoarthritis which does not respond to intra-articular steroid injection, requires a synovial biopsy for definitive diagnosis. adequate synovial biopsy has a yield of 90%. primary management is anti-tb medication.1 surgical management is occasionally indicated where there has been an unsatisfactory response to drug treatment, extensive bone involvement, or cold abscess formation, when synovectomy, drainage or debridement may be required. in later stages, where there is residual joint deformity, instability or subluxation, splinting, osteotomy or arthroplasty may be indicated. partial synovectomy and more complex surgical procedures are restricted to joints that demonstrate severe cartilage destruction, joint deformity, abscess formation, multi-drug resistance or atypical mycobacteria. conclusion atypical tb of the joints is a rare finding and a high index of suspicion is required to make the diagnosis. radiological features are often non-specific, and histopathology is required to confirm the diagnosis. radiological features that may alert one to the presence of tb, include t1wi hyperintensity within the joint and bursal margins, representing caseation. 1. malaviya an, kotwal pp. arthritis associated with tuberculosis. best pract res clin rheumatol 2003; 17: 319-343. 2. parmar h, shah j, patkar d, singrakhia m, patankar t, hutchinson c. tuberculous arthritis of the appen dicular skeleton: mr imaging appearances. eur j radiol 2004; 52: 300-309. atypical tuberculosis of the knee joint g albuquerque-jonathan, mb chb, fcrad (d) department of radiology, groote schuur hospital, cape town case report fig. 1. proton density fat-saturated mri. coronal image demonstrating marginal bone and cartilage erosions, synovial proliferation (arrow) and joint effusion. pg28.indd 28 12/11/06 11:00:15 am 27 sa journal of radiology • june 2006 several conditions may present with a small cerebellum on mri. these can be classified into 3 categories.1 an atrophic cerebellum is a small cerebellum with enlarged fissures. a cerebellum is also considered to be atrophic if it has been shown to have undergone progressive loss of volume (fig. 1).1 this can occur with children in the hereditary condition of friedrich’s or spinocerebellar ataxia. a hypoplastic cerebellum has folia which are in proportion to the fissures: a uniformly small perfectly proportioned structure (fig. 2). examples of cerebellar hypoplasia include pontocerebellar hypoplasia and wolfram syndrome.1 lastly, a hypogenetic cerebellum has a formed superior portion, but an absent inferior portion (figs 3 and 4). in the dandy walker complex a focal insult to the developing cerebellum causes variable hypoplasia of the postero-inferior portion of the cerebellar vermis and dysgenesis the small cerebellum in children – a useful approach on mri pictorial interlude s richards, mb chb s adronikou, mb bch, fcr diag (sa), frcr (lond), phd department of paediatric radiology, tygerberg hospital and university of stellenbosch fig. 1. cerebellar atrophy. sagittal t1 image shows deepened cerebellar fissures relative to folial size. fig. 3. cerebellar hypogenesis. sagittal t1 image shows almost complete absence of the vermis and an enlarged posterior fossa with associated hydrocephalus. fig. 2. cerebellar hypoplasia. sagittal t1 image shows the folia and fissures to be in proportion in a small cerebellum. pg27-28.indd 27 7/11/06 12:50:37 pm case report 28 sa journal of radiology • june 2006 of the hemispheres. there is communication between the 4th ventricle and cisterna magna, and cystic dilatation of the 4th ventricle in the true dandy walker syndrome.2 the dandy walker complex is a spectrum of posterior fossa cystic anomalies.1 1. barkovich ja. paediatric neuroimaging, 3rd ed. philadelphia: lippincott williams & wilkins, 2000: 143145, 339-341. 2. dahnert w. radiology review manual, 5th ed. philadelphia: lippincott, williams & wilkins, 2003: 274. fig. 4. cerebellar hypogenesis. sagittal t1 image with cerebellum demonstrating dysgenesis with a formed superior and absent inferior portion. case report price: r380.00 sama members: r360.00 to order contact: south african medical association health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405 tel: (021) 530-6520/27 • fax: (021) 531-4126 email: books@samedical.org hmpg quarter clinical medicine ad 10/14/05 12:54 pm page 1 pg27-28.indd 28 7/11/06 12:50:40 pm • •continuing professional development the way forward jan labuscagne mbchb, mmed (pret) chairman, congress committee, rssa, and radiologist in private practice, pretoria continuing professional development (cpd) has moved into a new era with the acceptance by the health professions council of a formal cpd points system. it is now necessary to accumulate points in order to stay eligible to practise medicine. previously the attendance of congresses, symposia and workshops was a voluntary exercise. this has changed now and the need for a structured continuing professional development program is greater than ever. the radiological society of south africa regards the organization of cpd programs as part of its core business. the south african radiological congress is set to become a regular event. discussions are under way to decide the frequency and format of this event. the aim is to accommodate in this meeting a combination of didactic and scientific sessions in order also to stimulate local research. a second initiative is the formation of the continuing professional development trust fund of the society. the aim is to accrue a capital sum of three million rand. the income from this fund will provide the necessary finances to organize two to three radiological workshops a year. these workshops will address various radiological topics as well as new techniques or modalities. several of the international companies that sell radiology equipment, film, and contrast media in south africa have been approached to become contributors to this fund, and quite a few have already pledged their contributions. the fund is however principally the property of and to the benefit of the members of the rssa. it is therefore imperative that all members of the society contribute to this fund in order to make cpd in radiology accessible to all members. as stated above, the income of the fund will be used to organize workshops on various topics. contributors to the fund will be able to attend these workshops free of charge. these workshops will be held on consecutive weekends in two different locations in the country. as travel and accommodation 4 sa journal of radiology· january 2000 usually constitute by far the greatest part of the cost of attending a meeting, this arrangement should result in substantial state savings to radiologists. a board of trustees representative of all contributors will govern the fund. an independent administrator will be appointed by the board to ensure proper and safe investment of the fund. the fund will be registered as a non-profit organization and, according to law, a certain percentage of the income of the fund will have to be reinvested in order to ensure the long-term growth of the fund. all stakeholders will be able to propose topics for the workshops. an educational committee will be established to control the standard and content of the workshops. the venues and topics will be decided upon well in advance and will be advertised on the fund's web page. letters will soon be sent to all members of the society, explaining the fund and its mission. a five-year pledge of less than r200 per month will ensure free access to all the workshops for the rest of the contributor's working life. in addition, a lasting asset will be established for the society. this may expand into other projects such as scholarships for young radiologists to attend institutions abroad, as well as funding of radiologists to attend other local meetings. as chairman of the congress committee of the rssa, i am proud to be associated with this initiative. i urge all members of the society to become contributors to their own cpd fund and in so doing, ensure their own future. tips the adenoid and snoring m klein respiratory unit, department of paed/atrlcs and child hea/th, university of cape town mk/eln@;ch.uct.ac.za thus, radiology has almost nothing to say about the severity of airway obstruction in children who snore. however, radiology can define the anatomical size of the airways and the degree to which the adenoid encroaches on the airway. the absolute size of the adenoid has little importance. if the adenoid can be identified by radiography it is resectable, and if the history is that the child snores, then the child suffers from airway obstruction when it sleeps whether the airway appears to be patent when it is awake or not. radiology can also be helpful in those children in whom adenoidectomy has failed to cure the snoring or in whom snoring has recurred after adenoidectomy. because adenoidectomy is often done "blind", some adenoid may be left behind. so, what should a radiologist say when reporting on the adenoid? before reading on, try to formulate your own opinion on figures 1 to 4. reports the radiograph in figure 1 was taken with the child awake. the nose background the adenoid is of particular interest in childhood because adenoidectomy with or without tonsillectomy cures snoring in over 95% of infants and children, even when the adenoid appears to be normal in size by radiography or by endoscopy. snoring is of concern because it means that the airway is obstructed during sleep. why and how this occurs is beyond the scope of this brief presentation. the sleep-associated airway obstruction disrupts the architecture of normal sleep and may cause asphyxia. snoring almost every night can have severe effects, including death. the most easily recognised adverse effects include failure to thrive, cor pulmonale and systemic hypertension. but more common and more difficult to recognise are neurodevelopmental delay, behaviour disorders and school problems. of cardinal importance in the investigation of infants and children who snore is the fact that snoring occurs during sleep, whereas investigations are genfigure 1: soft tissue lateral neck radiograph. erally done in awake infants. elght-year-old boy. snoring a/most every night. 81 sa journal of radiology. february 2001 to page 52 mailto:mk/eln@;ch.uct.ac.za the adenoid and snoring from page 51 and paranasal sinusesare patent. a welldefined adenoid (pharyngeal tonsil) is visible between the palate and the base of the skull. the adenoid occupies about 70% of the potential airway lumen in the area of the hard palate. even though the airway appears to be patent, removal of the adenoidal tissue can be expected to cure this child's snoring. the radiograph in figure 2 was also taken with the child awake. the nose, paranasal sinuses and pharyngeal remnant is sufficient to explain the recurrence of snoring following previous adenoidectomies in this child. [note: permanent curing of the snoring followed endoscopic removal of the adenoidal remnant: fourth time luckyl] figure 3 shows a double-contrast barium study of the nasopharynx. the previous adenoidectomy (presumably blind curettage) has failed to remove the superior pole of the adenoid. in this view it appears to occlude the airway completely. this residual adenoidal tissue is sufficient to account for the failure of adenoidectomy to cure the snoring. [note: a cure followed endoscopic removal. adenoids are often said to have regrown, but organs do not regrow after removal. "regrowth" of an adenoid signifies incomplete prior removal.] the ct in figure 4 shows homogeneous soft tissue mass (adenoid) between the base of the skull and the posterior margin of the nasal septum the internal nares. occlusion of the internal nares by this residual adenoidal tissue figure 2: soft tissue lateral neck radiograph. elevenyear-old girl. three previous adenoidectomies for snoring. relief of snoring after each procedure, but snoring recurred within months of each procedure. airway are patent. the adenoid has been removed incompletely by previous surgery (almost certainly blind curettage) and there is a small pea-sized piece of adenoidal remnant at the superior pole of the adenoid at the point of the internal nares. because of the critical position at the internal nares (see example, figure 4), regrowth of this small adenoidal almost certainly accounts for the failure of the adenoidectomy (blind curettage) to cure this child's symptoms. [note: cts are rarely required to confirm the presence of adenoidal tissue] in this instance the surgeon was reluctant to consider that a "small piece" of adenoid could account for the failure of the operation. the ct was supplied courtesy of prof so 82 sajournal of radiology. february 2001 figure 3: soft tissue lateral neck radiograph after instillation of di/uta barium to outline airway. figure 4: ct of nasopharynx. approximately five-year-old chi/d. previous adenoidectomy failed to cure snoring. conventional radiograph similar to figure 2. delport, university of pretoria. the case was reported in the south african medical journal.] reference: delport so, mulder aa. obstructive sleep apnoea persisting after adenoidectomy. safr med j. 1987;71: 194-5. editorial status of mr in south africa magnetic resonance imaging (mri) has developed from an experimental imaging modality in the late seventies to an essential imaging investigation in radiology at the beginning of the millennium. the first mr scanner was installed by the medical research council in cape town in 1986. as part of the winter school of the south african association of physicists in medicin and biology, we sent out questionnaires to the main mr vendors in south africa to determine the current status of mr in this country. in the questionnaire we asked questions about the number, type, field strength of scanners and their geographic distribution. we recorded the number of patients scanned per week, the breakdown per anatomical region, and the mbchb, ffrad(d)sa, frcr, m med(ucn manpower of radiologists, radiographers and physicists involved in mr. we received replies from all five mr vendors. in june 2000 there were 56 mr scanners, although this is likely to be increased to 60 by the end of 2000. fifty-four are in the private sector (96%) and two are in the public sector (universitas and wentworth hospitals). the number of mr scanners in public hospitals is likely to be increased by two to a total of four by year-end. most scanners are relatively new, with an average age of around three years. the oldest, which is now 10 years old, is being replaced. there have been two trends in the mr market in recent years: a trend towards open systems and a recent trend towards high field, high gradient mr systems. there are 17 1.st strength scanners (30%), many with strong gradients with fast slew rates. there are ii open 0.2t systems (20%), many in smaller cities and towns. currently 24 scanners (43%) are in gauteng, nine in the cape town area and four in durban. the remaining 29 (52%) are evenly distributed in the smaller cities and towns throughout the country. the patient workload varied from 15 to 60 patients per five-day week for each scanner. anatomical regions scanned in an average week were: spine 50%, brain 20%, musculoskeletal 20%, cardiac and peripheral vessels 10%. it was difficult to assess how many radiologists and radiographers were actively performing mr imaging as this information was not forthcoming. there are about 10-12 medical physicists interested in and involved with mr. there are a number of encouraging features from this small survey. south africa is well placed internationally with almost 60 scanners working, many of which are relatively new technology. many practices have formed alliances with public/academic departments to provide public patient imaging services and training of registrars and radiographers. the installed base is relatively new and many of the high field systems are capable of performing advanced cardiac and neurovascular sequences like cerebral diffusion and perfusion imaging for stroke investigations. the future growth in mr will be in cardiac and peripheral vascular applications. coronary mr imaging is becoming a reality and the role of cardiology in mr imaging will have to be addressed by the radiology society and speciality. will mr go the same way as echocardiography? for radiologists to protect their referral base, they will have to keep up-to-date with the recent advances in mr technology and ultra fast imaging. this is no easy task considering the rapid advance of technology with new developments in hardware and software sequences arriving on the market almost monthly. peter corr head: department of radi%gy, university of nata/ peter corr editor 3 sajournal of radiology. augus12000 -~---______!...:..__--------original article original article 76 sa journal of radiology • december 2007 original article abstract involvement of the basal ganglia in aids encephalopathy is well documented in both adults and children. the pathology remains obscure. a type of inflammation with increased vascularity and disruption of the blood-brain barrier has been postulated. calcification of the basal ganglia in encephalopathic hiv/aids children has been relatively well documented. only two adult hiv cases with basal ganglion calcification (bgc) have been reported in the literature. at our institution over the past few years, we have noted an increasing number of adult aids patients with neurological complications, demonstrating bgc on ct examination. a retrospective review was done. ninety-six adult cases were identified with bgc. of these, 38 patients were hiv positive. review of the 38 hiv-positive cases revealed that all of the patients presented clinically with encephalopathic symptoms, and all showed bgc associated with varying degrees of atrophy on ct scan. reports of paediatric hiv cases with bgc and encephalopathy have suggested that the bgc is the end-stage phenomenon of a type of vasculopathy associated with blood-brain barrier disruption. the calcifications were seen to be progressive, as was the encephalopathy. the presence of bgc was deemed to be a poor prognostic indicator. our study shows that bgc is not uncommon in aids encephalopathic adults. further, since the radiological findings and clinical presentations in adults are the same as in children, we suggest that the pathological processes are also the same and that, in adults, as in children, bgc is the end-stage manifestation of an hiv vasculopathy. introduction computed axial tomographic (ct) demonstration of basal ganglion calcification (bgc) in children suffering from acquired immune deficiency syndrome (aids) with neurological complications, was first described by belman et al.1 in 1985. later in 1985, belman et al. reported on an additional 3 cases.2 this was followed by a report in 1986, also by belman et al.3 of a further 17 children, all of whom presented with progressive, ultimately fatal, encephalopathy and ct demonstration of bgc. there are only 2 reported cases of bgc in hiv-positive adults, both patients presenting with progressive dementia and eventual spastic quadriparesis.2 following the reports of bgc in children in 1985, lantos et al.4 reviewed over 100 adult aids patients’ ct scans, but no additional cases of adults with bgc were found. no further accounts of bgc, in either children or adults have since been reported. objective bgc is known to occur in paediatric cases of aids encephalopathy. the only 2 reported adult cases were drug addicts and it was unclear whether the bgc was related to the hiv disease or due to a drug-induced vasculitis.2 at our institution an increasing number of adult hiv patients, presented for ct scan of the brain for neurological symptoms, were reported to have bgc. a retrospective study of these cases was undertaken. our first aim was to confirm our suspicion that bgc in adult aids patients is not as uncommon as the literature implies. we also wished to document associated radiological and clinical findings with a view to finding whether there were any similarities to the reported paediatric cases. patients and methods a 13-month period, january 2006 to february 2007, was selected. all reports of bgc were extracted after ethics approval had been granted. patient files were not consistently available and clinical information was obtained from details provided on the ct scan request forms on which the reports are also written. only those patients stated to have clinically ct brain demonstration of basal ganglion calcification in adult hiv/aids patients e joseph, mb bch, ffrad (diag) k spiegel, mb bch, fcrad diag helen joseph hospital, auckland park, johannesburg fig. 1. non-contrast ct scan of a 37-year-old male retroviral disease (rvd) positive patient showing basal ganglia calcification (arrows) and atrophy. pg76-78.indd 76 12/11/07 2:23:47 pm original articleoriginal article 77 sa journal of radiology • december 2007 proven hiv disease were included in the study. results there were 96 reported cases of bgc in both hiv-positive and hiv-negative patients over a 13-month period. the patients fell into three groups: group 1: 38 patients who presented with stroke or senile dementia, with no evidence of hiv disease. this group was excluded. group 2: 20 patients, some of whom had symptoms suggesting hiv-related disease, but their hiv status had not been proven. this group was excluded. group 3: 38 patients who were clinically proven to be hiv positive. these cases were reviewed for the purpose of our study. clinical findings the age of the patients in the hiv-positive group varied between 20 and 59, with an average age of 38.34. all (100%) of the patients presented with confusion; 25 patients had additional neurological or psychiatric symptoms. lumbar punctures (lp) had been performed on 20 of the 38 patients and 3 were indicative of meningitis (table i). radiological findings all patients (100%) showed bilateral, fine, punctate calcifications of the basal ganglia, associated with moderate to severe atrophy (figs 1 and 2). additional findings are listed in table ii. none of the patients suspected of having meningitis showed any radiological evidence to support the diagnosis, or to suggest the presence of an associated vasculitis. the radiological reports most frequently noted the bgc without suggesting a cause. since there was nothing in the history provided on the patients’ ct scan request forms to suggest any of the known causes of bgc, in those instances where a cause was suggested, the most frequent report was of ‘idiopathic bgc’. discussion the first 6 children with aids encephalopathy and ct-demonstrated bgc were reported by belman et al.1 in 1985. they were followed up for a period of 14 months using ct imaging.1 ct examinations showed progressive cortical atrophy with ventricular dilatation and bgc. postmortems were done on 3 of the children. all showed a calcific vasculopathy of the basal ganglia in addition to other degenerative changes. one case in addition was shown to have cytomegalovirus encephalitis. later in 1985 belman et al.2 reported bgc in 3 children and 2 adults with hiv. the paediatric cases all showed progressive calcification on serial ct examination. none of the cases had evidence of endocrinopathy or mitochondrial cytopathy. postmortem studies on 1 child and 1 adult showed calcification of small and large vessels of the basal ganglia, with no evidence of inflammatory change. in 1986 belman et al.3 reported 8 and then 9 paediatric cases of ct-demonstrated bgc where none of these cases had any evidence of opportunistic brain infection. postmortem studies on 4 of the cases showed variable degrees of calcification of vessels of the basal ganglia. punctate capillary changes with focal deposits in the walls of small vessels were the most frequent form of calcification although larger vessels were occasionally involved. mri studies done at the same time as ct imaging on these cases, when the bgc was still mild, showed features of oedema or inflammation consistent with disruption of the blood-brain barrier within the basal ganglia. the authors postulated, on the basis of the ct and mri imaging and subsequent postmortem findings, that fig. 2. non-contrast ct scan brain of a 28-year-old rvd-positive male patient showing significant atrophy and basal ganglia calcification. table i. clinical presentations no. of patients findings 38 (100%) confusion 6 confusion + seizures 7 confusion + hemiplegia 3 confusion + psychotic behaviour 9 confusion + dyskinetic features 1 confusion + cryptococcal meningitis deteriorating on treatment 1 confusion + abnormal lumbar puncture, suspected to be tuberculous meningitis 1 confusion + cryptococcal meningitis on lumbar puncture table ii. radiological findings additional to basal ganglion calcification and atrophy no. of patients findings 1 bilateral focal hypodense lesions in the head of the left caudate nucleus 1 scattered hypodensities (at grey/white matter interface and in deep white matter) 1 chronic subdural collections pg76-78.indd 77 12/11/07 2:23:48 pm original article original article 78 sa journal of radiology • december 2007 there was an acquired vascular insult with calcium deposition as an endstage phenomenon. serial studies showed a progression of the calcification as well as the atrophy.3 in 1998 melzer et al.5 published a retrospective review of mri studies on 9 adult hiv cases with neurological complications. the mri studies showed symmetrical bilateral caudate nuclei punctuate hyperintensities on t2-weighted imaging. all the above patients presented with new onset seizures or a change in mental state. postmortem studies on 2 of these patients showed neuro-infarcts in a distribution similar to the mr abnormalities. the proposal was that the hyperintensities represented ischaemic tissue injury. it was noted however that 7 of the 9 patients were drug abusers, and it was unclear what contribution this made to the findings. in 2000 berger et al.6 studied early and late enhancement patterns of the basal ganglia in adult aids demented and non-demented patients using mri. they found increased early enhancement as well as an increase in late enhancement in the basal ganglia in the demented as compared with the non-demented group. they concluded that the increased early enhancement shown in the demented group indicated increased regional cerebral blood flow, and an increase in late enhancement in the same group suggested disruption of the blood-brain barrier. there is no doubt as to the importance of the basal ganglia in hiv/ aids encephalopathy in both adults and children. it is known that the hiv virus enters the cns early in the course of infection and that the virus shows a preference for the basal ganglia.5,7 basal ganglion dysfunction is thought to be a major contributing factor in the development of hiv dementia.6-9 the exact pathology remains obscure. a type of inflammation with increased vascularity and disruption of the bloodbrain barrier has been postulated.6-9 it is thought that the bgc is an end stage of a vasculopathic process which itself is not due to other infections or a true vasculitis. in those paediatric cases that were followed up, the calcifications were progressive, as was the encephalopathy, ending with the patients’ eventual demise.1-3 since only 2 adult hiv-positive cases of bgc have been reported, it was suggested that the reason for bgc being more common in paediatric encephalopathic aids patients was the greater vulnerability of the immature neural system and blood-brain barrier. furthermore the 2 adult bgc cases reported were drug abusers, raising the possibility that the drugs may have been responsible for disrupting the blood-brain barrier and causing the bgc. patients with bgc in group 1 of our study, sent for investigation of stroke or dementia, were aged between 57 and 92, with average age of 72. there was no evidence to suggest hiv pathology in the group, and the bgc was most likely to be age related. the patients in group 2 had an age variation between 35 and 60, with average age of 43. of these 1 was an alcoholic patient, 1 was a drug addict, 2 suffered renal failure and 2 sustained a head injury. the remaining 14 cases were thought to be hiv positive, but this was not proven. their main presenting symptom and reason for the ct request was confusion. it is unlikely that the bgc in this group was age related. renal failure and drug-abuse-induced vasculitis could account for the bgc in 3 of the patients in this group. in our study group (group 3), the average age was 38, varying between 20 and 59. there were no drug abuse cases and only 3 cases showed clinical evidence of meningitis (without radiological correlation). all our cases showed bgc and atrophy, associated with encephalopathy of variable degree. the previous studies of hiv-positive paediatric cases with the same clinical and radiological findings have been evaluated as being due to a vasculopathy associated with disruption of the blood-brain barrier, with the calcifications being an end-stage phenomenon and a poor prognostic indicator. we propose that the pathological process in adults is the same. conclusion there have been only 2 reported cases of bgc in encephalopathic adult aids patients in the literature. we have reported on 38 cases of adult aids patients with encephalopathic symptoms, who have ct-demonstrated bgc and atrophy – the same findings as have been reported in children. in view of our results, the absence of reports of bgc in adult encephalopathic aids patients is puzzling. possibly fine punctate calcifications have been missed, or are disregarded as ‘idiopathic’. additionally, our assumption is that the pathology in adults is the same as that seen in children (with aids encephalopathy and bgc), and that bgc in encephalopathic adult aids patients represents the end stages of an acquired vasculopathy. in children, bgc is regarded as an indicator of poor prognosis. further studies would be required to confirm this in adults. addendum note since the date of completion of our review, we have seen 24 more cases of hiv patients with encephalopathic symptoms showing bgc on ct examination. eleven of these patients showed bgc with atrophic changes only. in addition to the bgc and atrophy, 13 patients had various other findings including hydrocephalus, old infarctions and ringenhancing lesions.. 1. belman al, ultmann mh, haroupian d et al. neurological complications in infants and children with acquired immune deficiency syndrome. ann neurol 1985; 18: 560-566. 2. belman al, lantos g, horoupian d, et al. basal ganglia calcification in patients with aids. neurology 1985; 35(suppl 1), 308. 3. belman al, lantos g, horoupian d, et al. aids: calcification of the basal ganglia in infants and children. neurology 1986; 36: 1192-1199. 4. lantos g, schonberger er, leeds ne, et al. head ct in patients with acquired immune deficiency syndrome. ajnr 1985; 6: 470. 5. meltzer cc, wells sw, becher mw, et al. aids related hyperintensity of the basal ganglia. ajnr 1998; 19: 83-89. 6. berger jr, nath a, greenberg r, et al. cerebrovascular changes in the basal ganglia with hiv dementia. neurology 2000; 54: 921-926. 7. jreismana gj, kaplina ai. depression cognitive impairment: neurological and psychological complications in hiv and anti-retroviral drugs. aids 2002; 16: 1201-1215. 8. ghafouri m, athius s, khalili k, sawaya b. hiv-1 associated dementia: symptoms and causes. retrovirology 2006; 3: 28. 9. hanna l (associate editor beta). hiv/aids in children: overview and guidelines for disease management. bulletin of experimental treatment for aids, june 1996; no.29 [http://www.oegis.com/pub/beta/1996/ be962905.html] date last accessed: 20 october 2007. pg76-78.indd 78 12/11/07 2:23:48 pm original article five cases of paediatric cervical spine distraction • •injury abstract cervical spi ne distraction injury was considered rare in children, but current literature claims that atlanto-occipital distraction is a major contri butor to paediatric trauma mortal ity. lower cervical spine distraction is considered rare and usually results in quadriplegia. three cases of atlantooccipital distraction are presented here, supporting these claims. the two cases of lower cervical spine distraction are presented as good examples of a rare injury that is sustained in the same s andronikou red cross children's hospital university of cape town department of paediatric radiology s dix-peek red cross children's hospital university of gape town d meerkotter johannesburg hospital university of the witwatersrand department of radi%gy a sa journal of radiology. october 2000 manner as atlantooccipital distraction, but may result in survival of the patient with quadriplegia. case report case 1 a three-year-old female was involved in a motor vehicle accident as a passenger. she was removed from the vehicle without prior stabilisation of the cervical spine. she presented to the emergency unit with quadriparesis, but stable vital signs. examination revealed absent motor and sensory activity in all four limbs. the lateral cervical spine film and chest x-ray demonstrated a widened interspace at the c6/7 level with posterior listhesis of c6 on c7. mri showed complete transection of the cord at the c4 and c6/7 levels associated with disruption of the posterior longitudinal and interspinous ligaments. the child's condition deteriorated and mechanical ventilation was instituted. at the time of this report the patient remains quadriplegic. figure 1: (case 1) ap plain radiograph showing a widened interspace at c6/7 (arrow) topageg five cases of paediatric cervical spine distraction injury (rompage8 figure 2: (case 1) lateral plain radiograph showing a wide interspace at c6/7 and subluxation of c6 on c7 (arrow) figure 3: (case 1) saggital t2 weighted mri showing complete cord transecton (closed arrow) and disruption of the posterior longitudinal (arrowhead) and interspinous ligament (open arrow) case 2 a three-year-old male was caught under a reversing vehicle. on examination the vital signs were stable but there was flaccid quadriparesis. lateral cervical radiograph revealed distraction of the lower cervical spine at the c617 interspace. the patient died as a result of cardiorespiratory arrest 48 hours later. and the coma scale was calculated at its minimum (2t). a ct scan was performed to assess the intracranial compartment and a scanogram and ct of the cervical spine was obtained figure 4: (case 2) plain radiograph demonstrates wide interspace at c6/7 (arrow) case 3 a five-year-and-ten-month-old female patient was involved in a motor vehicle accident as an unrestrained passenger. bystanders attempted resuscitation and paramedics intubated the child and transferred her to the emergency department. on arrival the patient's pupils were fixed and dilated figure 5: (case 3) digital ct scanogram demonstrating cranio-cervlcal distraction (arrow) 9 sajournal of radiology. october 2000 figure 6: (case 3) multi-planar reconstruction showing a wide atlanto-occipital interspace (open arrow) and good visualisation of the basion (b), opisthion (0) and dens (d) at the same examination. the scanogram demonstrated distraction at the eranic-cervical junction. bradycardia ensued, but no further resuscitation was undertaken and the patient was declared dead at cardiac arrest. case 4 a nine-year-old female was involved in a motor vehicle accident as a pedestrian. she was intubated at the scene and was brought to the emergency department. her blood pressure was low and temperature was decreased. her coma scale was calculated at the minimum and her pupils were fixed and dilated. her respiration was spontaneous. there were also numerous injuries to the appendicular skeleton. neurosurgical assessment revealed no brainstem or spinal reflexes.the lateral cervical spine radiograph revealed massive prevertebral soft tissue swelling, and an increased interspace at the eranic-cervical articulation in keeping with a distraction injury. the patient then required assisted ventilation. the blood pressure dropped further the following-----to page 10 five casos of pdedizllric cervical spi n(-~cj ist r<lcl ion inj li ry frompage9 day and when mechanical ventilation was terminated, the patient died. figure 7: (case 4) plain radiograph demonstrating an increased cranio-cervical interval (open arrow) case 5 this four-year-old female was involved in a motor vehicle accident as a pedestrian. she was intubated by ambulance personnel and brought to the accident unit with fixed dilated pupils and a minimum score on the glasgow coma scale. lateral cervical spine film showed distraction at the eranic-cervical junction assisted venfigure 8: (case 5) plain lateral radiograph showing cranio-cervical distraction (open arrow) tilation was discontinued and no spontaneous respiration was noted. cardiac arrest ensued and the patient was pronounced dead. discussion the cervical spines of children differ from those of adults. adult configuration is attained only at about eight years of age.' children are more prone to sustaining distractions, subluxation injuries and dislocations than adults. there are numerous factors accounting for this, including increased ligamentous laxity, horizontally oriented facets, hypoplastic occipital condyles and large head to body ratio.!,2,3the fulcrum of motion in a child's cervical spine is around c2/3 and c3/4, whereas that of adults is lower. injury to the atlas and axis is reported to represent 70% of cervical spine injuries in children, while only forming 16% of adult cervical spine injuries.' more commonly, these injuries include odontoid fractures, atlanto-occipital dislocation/subluxation and 'hangman' fractures (of the neural arch of c2).! the ligaments most responsible for primary stabilisation of the cranium on the spine are the tectorial membrane (the continuation of the posterior longitudinalligament up to the basion) and the paired alar ligaments (from the odontoid process to the occipital condyles) .4,5atlanto-occipital dislocation (aod) occurs more frequently in children than in adults.!,3,6aod was considered rare, but new reports claim that it is a major contributor to mortality in paediatric trauma.t-'" lower cervical spine distraction is,however;not as frequently described in children under eight years of age.' the mechanism of injury involvescombined hyperextension and distraction.' 10 sa journal of radiology· october 2000 the youngest patients with aod are seen following difficult obstetrical deliveries using forceps and after vigorous shaking of neonates in nonaccidental injury.' children beyond the neonatal period almost invariably sustain ao d as a result of motor vehicle accidents either as passengers or as pedestrians.p/ the clinical findings are varied, but aod usually results in death from brainstem or cord transaction with resultant cardiorespiratory arrest. eighteen cases have been reported where the patients survived more than 48 hours, as researched and reported by shamoun et al.3 less severe injuries with instability rather than distraction have also been described with minimal neurological deficit. 4,5lower cervical spine distraction injury can lead to quadriplegia+" at least 25 reports of aod have been made, but no significant series of lower cervical spine distraction was found.2,3,4,5,6 methods of imaging include lateral cervical spine radiographs and ct scanning (using the digital 'scanogram' and multiplanar reconstruction), and mri is used to assess cord damage in survivors. mri may also provide accurate identification of the cranio-cervicalligaments injured. it may also be useful in differentiating between full and partial ligament injury. measurements and techniques to aid diagnosis have been controversial. the method of powers et al calculates a ratio of the distance between the basion and the posterior arch of atlas over the distance between the opisthion and the anterior arch of the atlas. a normal value is considered to be < 7.7, while any value> 1 is considered diagnostic of aod.2,3,4kaufman et al measure the distance from the to page 12 • convenience schering understands that timing, accuracy and efficacy are of essence inmri • simplicity pre-filled syringes offer fast and easy application • ease of use injected volume instantly visible through reverse scaling magnevist • another innovative product in the schering diagnosties range.enhancing mri schering (ply) ltd (reg. no. : 64/09072/07) 106 sixteenth road, randjespark, midrand 1685. p.o. box 5278, halfway house 1685. ulo 3198 tel: (011) 313-9700. fax: (011) 313·9793. e-mail: schering@icon.co.za lsi] magnevist20 ml. 1 ml solution contains gadopentetic acid, dimeglumine salt 469,01 mg dtpa, meglumine sail max. 1,02 mg. reg. no.: w/281199. 32851 mailto:schering@icon.co.za five cases of paediatric cervical spine distraction injury frampage 10 superior facets of the atlas to the occipital condyles, and consider any value >5 mm as abnormal.' the bd distance is that between the basion (b) and the dens (d) and is recorded by georgopoulos et al to be 5 mm in a normal adult." bulas et al compared the different methods and concluded that the bd distance is the most reliable, with a mean measurement of 8.3 mm in children.ê the post mortem work by bucholz and burkhead is misrepresented by both bulas et al and shamoun et al. only three of the 20 children in the bucholz and burkhead study hadaod (15%), and not nine as reported by bulas et ap,6 shamoun et al quote that 33% of the cervical spine injuries in the same series were ao ds, but fail to add that this figure included adult patients.v however, a five-year review by shamoun et al reports locases of aod, representing 18% of all trauma deaths in their institution. there is also a comment in the same paper that one quarter of patients dying from cervical spine injuries have aod.3 conclusion we present five cases of paediatric cervical spine distraction injury accumulated randomly over a twoyear period. three of the children had aod and died within 12 hours of admission to hospital. one of these was a nine-year-old, who should have attained adult characteristics to the cervical spine. the other two cases presented are rare, as they involve distraction occurring at lower cervical spine in children less than four years of age. one of these children died, while the other survives as a quadriplegic. reports oflower cervical spine distraction in children are scarce, but this case report supports the modern literature, which claims thataod is not rare and that it is a significant contributor to paediatric mortality in cervical spine trauma. the cases of lower cervical spine distraction in children younger than eight years are presented as examples of a rarer form of the same process. references i. sherek hh, schut l, lane jm. fractures and dislocations of the cervical spine in children. orthop clin northam 1976; 9 (3): 593-604. 2. bulas di, fitz cr, johnson dl. traumatic atlanto-occipital dislocation in children. radiology 1993; 188 (1): 155-157. 3. shamoun jm, riddick l, powell rw. atlante-occipital subluxation/dislocation: a "survivable" injury in children. am surg 1999; 65: 317-320. 4. georgopoulos g, pizzutillo po, lee ms. occipito-atlantal instability in children. j bone and joint surg 1987; 69a (3): 429-436. 5. grabb bc, frye ta, hedlund gl, vaid yn, grabb pa, royal sa. mri diagnosis of suspected atlanto-occipital dissociation in childhood. pediair radial 1999; 29: 275281. 6. bucholz rw, burkhead wz. the pathological anatomy of fatal atlanteoccipital dislocations. j bone and joint surg 1979; 61a (2): 248-250. abstract introduction case history discussion conclusion acknowledgements references about the author(s) ranjan k. patel department of interventional radiology, institute of liver and biliary sciences, new delhi, india shruti mittal department of radiodiagnosis, maulana azad medical college, new delhi, india citation patel rk, mittal s. hepatic larva migrans presenting with upper gastrointestinal haemorrhage: a case report. s afr j rad. 2021;25(1), a2200. https://doi.org/10.4102/sajr.v25i1.2200 case report hepatic larva migrans presenting with upper gastrointestinal haemorrhage: a case report ranjan k. patel, shruti mittal received: 31 may 2021; accepted: 12 sept. 2021; published: 26 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract visceral larva migrans (vlm) occurs because of a host inflammatory response to the migrating larvae of a nematode. patients usually present with fever, hepatomegaly and abdominal pain; vascular arterial complications are uncommon. a 19-year female presented with fever, jaundice, abdominal discomfort and melena. computed tomography (ct) revealed multiple discrete, clustered, complex hepatic cystic lesions consistent with vlm, along with an arterial pseudoaneurysm from the right hepatic artery which was managed with endovascular coil embolisation. keywords: visceral larva migrans (vlm); hepatic larva migrans; pseudoaneurysm; hepatic artery; portal vein thrombosis; coil embolisation. introduction visceral larva migrans (vlm) results from the migratory larva of nematodes, with the lungs and liver being the most common organs involved. presentation varies depending on the site of involvement.1,2 pulmonary involvement manifests as fever, cough, wheezing and chest pain, whereas hepatic involvement presents with fever, hepatomegaly and abdominal pain. hepatic larva migrans presenting with gastrointestinal bleeding is very uncommon.2 this report describes a case of hepatic larva migrans in a 19-year female, manifesting as upper gastrointestinal (gi) bleeding secondary to a hepatic artery pseudoaneurysm, which was successfully managed with endovascular coil embolisation. case history a 19-year-old female presented with complaints of intermittent low-grade fever for two months, associated with right-sided mild upper abdominal discomfort, yellowish discolouration of the sclera and a history of black-coloured stool for 7–10 days. the patient belonged to a lower socio-economic status and was living in an overcrowded area. there was no obvious history of exposure to any pet animals. on examination, she was afebrile and hemodynamically stable with a pulse rate of 80 beats/min and a blood pressure of 112/64 millimeter of mercury (mmhg). she also had pallor and icterus. abdominal examination revealed mildly tender hepatomegaly. the rest of the systemic examination findings were unremarkable. the relevant laboratory parameters were: low haemoglobin (6.1 gm/dl), leucocytosis (14 200/mm3), eosinophilia (1.26 × 109/l), mildly elevated bilirubin (total −1.7 mg/dl, direct −1.3 mg/dl), elevated alkaline phosphatase (620 iu/l) and gamma-glutamyl transferase (364 iu/l); the remaining results were within normal limits. there was no previous history of any hepatic intervention. emergency ultrasonography of the abdomen revealed multiple discrete and clustered hypo to anechoic lesions with a mildly hyperechoic irregular rim in the right lobe of the liver and mildly prominent central biliary radicles (figure 1a, b). the gall bladder was mildly distended with an oedematous wall (figure 1c). no obvious hematoma or pseudoaneurysm was found at ultrasonography (usg). the patient was started on empiric broad-spectrum intravenous antibiotics and transfused two units of blood. figure 1: ultrasonography of the liver. image (a and b) showing multiple clustered hypo and anechoic complex cystic lesions (red arrows) with a mildly hyperechoic rim. image (c) showing an oedematous gall bladder wall (yellow arrow). dual-phase computed tomography (ct) of the abdomen revealed multiple discrete and clustered variable-sized hypoechoic lesions with an enhancing rim in the right lobe of the liver, predominantly along the peripheral hepatic parenchyma (figure 2). a few linear hypodense tracks were also depicted, consistent with the migration of larvae (figure 2a and 2c). small segmental portal thrombosis was found in segment viii along with a few geographical areas of hypoperfusion noted as hypodensity on the portal-venous phase (figure 2c). mildly dilated biliary radicles were demonstrated on the minimum intensity projection (minip) images (figure 2d). additionally, there was a well-defined pseudoaneurysm of 1.1 cm size along the anterior branch of the right hepatic artery; however, no apparent active contrast extravasation was seen (figure 3a, b). figure 2: axial (a, b) and sagittal (c) portal venous phase ct images showing multiple clustered hypodense lesions (red arrows) in the right lobe of the liver with indistinct margins. few linear hypodense tracks (white arrows a, c) are also seen, consistent with the migration of larvae. there is hyperdense content within the gall bladder (gb) lumen (yellow arrow b) sludge or haemorrhage. a small non-enhancing portal vein (pv) segment is noted on sagittal image c in segment viii, suggestive of segmental pv thrombosis (thin black arrow c). associated transient hepatic arterial difference (thad) is also found (open white arrow c). coronal minimum intensity projection (minip) image (d) showing mildly dilated central biliary radicles (open black arrow). figure 3: axial arterial phase (a) image showing a well-defined contrast pooling (black arrow) in segment viii with its attenuation parallel to that of the abdominal aorta without any change in morphology as seen in the axial portal venous phase image (black arrow b). it remains isodense to the aorta in the portal venous phase as well, suggestive of hepatic arterial pseudoaneurysm without any apparent active contrast extravasation. a geographical peripheral hypodense area is noted in segment viii (open white arrow b), representing a transient hepatic arterial difference (thad). subsequent upper gi endoscopy showed haemobilia without any varices. thus, pseudoaneurysm was suspected to be the cause for haemobilia. the branch of the right hepatic artery from which pseudoaneurysm originated was selectively catheterised with a microcatheter through a right femoral artery approach and the pseudoaneurysm was embolised with microcoils using a sandwich technique (figure 4). figure 4: coronal ct maximum intensity projection image (a) shows a well-defined pseudoaneurysm in close proximity to the segment viii artery (red arrow a). angiography via a microcatheter (b) shows a small pseudoaneurysm arising from the segment viii artery (red arrow b) which was embolised (c) by placing a microcoil across the neck of pseudoaneurysm using the sandwich technique (yellow arrow c). the following differential diagnoses were considered in view of the clinical and imaging findings: pyogenic liver abscesses, vlm, fascioliasis, cat-scratch disease, disseminated tuberculosis and atypical hydatid disease. further investigations revealed positive toxocara immunoglobulin g (igg) serology. stool examination, hydatid serology mantoux test were negative. fluid aspirated from the lesions was negative for bacterial and fungal pathogens. histopathological examination of fine needle aspiration showed eosinophilic abscesses with poorly defined eosinophilic granulomas and charcot-leyden crystals, suggestive of a parasitic infection. based on clinical, imaging and pathological findings with a positive toxocara igg serology, a diagnosis of hepatic larva migrans was made and the patient was treated with albendazole (400 mg twice a day for two weeks). oral prednisone (20 mg/day) was also added for one week and tapered gradually. the patient was discharged in a stable condition after the resolution of fever and abdominal pain. there was no sign of any further gi bleeding. follow-up imaging was not available; however, she was clinically fine at six months follow-up on teleconsultation. discussion visceral larva migrans, also known as toxocariasis, represents the migratory phase of the 2nd stage larvae of nematodes through the different visceral organs. toxocara canis is the most common causative organism. the other less common causative organisms include toxocara catis, baylisascaris procyonis, capillaria hepatica, ascaris sum and some ancylostoma species.1 as humans are not the definitive host, larvae cannot mature and continue migrating through the different visceral organs for months to years. these migratory larvae initiate a host inflammatory response along with eosinophilic infiltration, resulting in tissue destruction and variable clinical manifestations.3 visceral larva migrans is more common in children.4 the liver and lungs are the most common sites of involvement.1,4 as seen in this case, hepatic involvement manifests as fever, hepatomegaly, decrease in appetite and abdominal pain. there is no characteristic imaging feature of vlm; however, some features on imaging are suggestive, and it often needs correlation with laboratory and pathological findings.5,6,7 imaging findings reflect the pathological process. periportal eosinophilic infiltration, granulomas and abscesses with central necrosis caused by migration of larvae appear as multiple variable-sized, ill-defined discrete and conglomerating, oval or elongated focal lesions on imaging.3,5,7,8 lesions are hypoechoic on ultrasonography. they are best depicted on portal venous phase ct images, appearing as hypodense discrete and clustered complex cystic lesions, likely along the portal vein (pv) branches or liver periphery.5,6,9 in larger lesions, the pv seems to traverse through the lesions.9 at mri, lesions show variable signal intensities on t1 and t2 weighted images. a t1 hyperintense rim around the abscess cavity may be an important imaging feature, indicating a layer of granulation tissue and thus the inflammatory nature of the lesion. the abscess cavity shows variable diffusion restriction.5,6,7 lesions may show a change in morphology and position on follow-up imaging, a finding consistent with the migration of larvae. sometimes, linear tracts are also seen, as noted in this case, which could be a very useful imaging feature that raises a suspicion of vlm.2 cytotoxic eosinophil-derived proteins may damage nearby vessels that lead to different vascular complications.10 desai et al. reported two cases of vlm, complicated with pv thrombosis.11 laroia et al. and kaur et al. described hepatic vein thrombosis in patients with vlm.5,12 segmental pv thrombosis was also seen in this case that resulted in sub-segmental geographical hypodensity in the portal-venous phase. arterial complications are even rarer. only one case has been reported to date by ritu et al.13 they illustrated a case of vlm presenting with haemobilia because of a pseudoaneurysm of the right hepatic artery, which was embolised using n-butyl cyanoacrylate (nbca) glue.13 similarly, this case demonstrated a pseudoaneurysm arising from the segment viii artery which was managed with coil embolisation. new generation elisa-based serological tests form the mainstay of diagnosis. additional useful findings are the presence of eosinophilia and elevated immunoglobulin e (ige) levels. cytology or histology helps in excluding other differential diagnoses.9 oral albendazole is the treatment of choice with concomitant steroid and antihistaminic therapy to reduce inflammation. however, long-term therapy is often needed, and in some cases, lobar or segmental hepatic resection is required depending on the extent of hepatic involvement.5,7,13,14 conclusion multiple ill-defined clustered lesions along the pv branches in the proper clinical background should raise the suspicion of vlm. arterial pseudoaneurysm is an infrequent complication of vlm. dual-phase ct is essential in the characterisation of lesions and detection of vascular complications. emergency endovascular embolisation is an effective treatment in cases with a bleeding pseudoaneurysm. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.k.p. was the primary author. s.m. also contributed equally to this work. ethical considerations this article followed all ethical standards for research. informed consent was obtained from the patient for publication of this case. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article. disclaimer the views and opinions expressed in this article are those of the authors and do not reflect the official policy of any affiliated agency of the authors. references beaver pc. larva migrans. exp parasitol. 1956 nov 1;5(6):587–621. https://doi.org/10.1016/0014-4894(56)90032-7 lim jh. toxocariasis of the liver: visceral larva migrans. abdom imag. 2008 mar;33(2):151–156. https://doi.org/10.1007/s00261-007-9325-y kaplan kj, goodman zd, ishak kg. eosinophilic granuloma of the liver: a characteristic lesion with relationship to visceral larva migrans. am j surg pathol. 2001 oct 1;25(10):1316–1321. https://doi.org/10.1097/00000478-200110000-00014 ortega cd, ogawa ny, rocha ms, et al. helminthic diseases in the abdomen: an epidemiologic and radiologic overview. radiographics. 2010 jan;30(1):253–267. https://doi.org/10.1148/rg.301095092 laroia st, rastogi a, bihari c, bhadoria as, sarin sk. hepatic visceral larva migrans, a resilient entity on imaging: experience from a tertiary liver center. trop parasitol. 2016 jan;6(1):56. https://doi.org/10.4103/2229-5070.175100 chang s, lim jh, choi d, et al. hepatic visceral larva migrans of toxocara canis: ct and sonographic findings. am j roentgenol. 2006 dec;187(6):w622–w629. https://doi.org/10.2214/ajr.05.1416 mukund a, arora a, patidar y, et al. eosinophilic abscesses: a new facet of hepatic visceral larva migrans. abdom imag. 2013 aug;38(4):774–777. https://doi.org/10.1007/s00261-012-9935-x hartleb m, januszewski k. severe hepatic involvement in visceral larva migrans. eur j gastroenterol hepatol. 2001 oct 1;13(10):1245–1249. https://doi.org/10.1097/00042737-200110000-00020 rohilla s, jain n, yadav r, dhaulakhandi db. hepatic visceral larva migrans. bmj case rep. 2013 jul 13;2013:bcr2013009288. https://doi.org/10.1136/bcr-2013-009288 young jd, peterson cg, venge p, cohn za. mechanism of membrane damage mediated by human eosinophil cationic protein. nature. 1986 jun;321(6070):613–616. https://doi.org/10.1038/321613a0 desai sn, pargewar ss, agrawal n, bihari c, rajesh s. hepatic visceral larva migrans with atypical manifestations: a report of three cases. trop gastroenterol. 2020 may 18;39(4):211–214. kaur j, gupta a, wadhwa n. hepatic visceral larva migrans causing hepatic venous thrombosis and prolonged fever. indian pediatr. 2017 oct 1;54:882–884. https://doi.org/10.1007/s13312-017-1155-6 ritu ks, malik r. hepatic visceral larva migrans causing hepatic artery pseudo-aneurysm. indian pediatr. 2021;58(2):184. https://doi.org/10.1007/s13312-021-2141-6 takács i, pákozdi a, szekanecz z, et al. liver resection for a rare parasitic infection – visceral larva migrans syndrome. orv hetil. 2004 jun 1;145(25):1333–1336. sajr 771 xanthogranulomatous pyelonephritis in a horseshoe kidney c basson, j de witt division of radiodiagnosis, tygerberg academic hospital, bellville, western cape c basson, mb chb j de witt, mb chb corresponding author: j de witt (juruandewitt@gmail.com) a rare case of xanthogranulomatous pyelonephritis in a horseshoe kidney is presented, with emphasis on the computed tomography findings. this very rare combination has only been reported twice in an adult, and never been published with images. s afr j rad 2013;17(1):24-25. doi:10.7196/sajr.771 a rare case of xanthogranulomatous pyelonephritis (xgpn) in a horseshoe kidney is presented with emphasis on the computed tomography (ct) findings. this exceedingly rare combination has only been reported on two previous occasions in an adult1 and has never before been published with images. radiographic findings are demonstrated in fig. 1, while figs 2 and 3 demonstrate some of the distinctive features seen on ct imaging. fig. 1. anterior x-ray demonstrating numerous well-defined densities (white arrows) projecting over the middle and upper aspects of the right abdomen. fig. 2. coronal reformatted cect of the abdomen, confirming the densities to be right-sided renal calculi within a horseshoe kidney (long arrows). note the isthmus, where the two kidneys are connected at their inferior poles (short arrow). multiple focal hypo-attenuating lesions are scattered throughout the right aspect of the horseshoe kidney (arrowheads). fig. 3. axial reformatted cect of the abdomen revealing right-sided inflammatory perinephric fat stranding (arrow). xanthogranulomatous pyelonephritis is an uncommon form of chronic pyelonephritis characterised by a destructive granulomatous process of the renal parenchyma with abscess formation. xgpn occurs in approximately 1% of all renal infections. xgpn is four times more common in women than men, and is usually noted in the 5th and 6th decades of life. xgpn displays neoplasm-like properties capable of local tissue invasion and destruction, and is occasionally referred to as a pseudotumour.2 most cases occur in the setting of infected obstruction owing to renal calculi. the pathognomonic microscopic feature is that of lipid-laden, foamy macrophages;3 hence the prefix xantho-, from the greek xanthos, meaning yellow. a horseshoe kidney represents the most common renal fusion anomaly, where the two kidneys are connected across the midline by an isthmus. horseshoe kidneys are frequently complicated by obstruction, infection and calculus formation, and have an increased risk of renal malignancy development, especially wilms’ tumour. ct findings the combination of a nonfunctioning enlarged kidney, a central calculus within a contracted renal pelvis, expansion of the calyces, and inflammatory changes in the perinephric fat is strongly suggestive of xgpn.4 the contracted renal pelvis with dilated calyces has been likened to the pawprint of a bear; hence the diagnostic bear paw sign.5 although the branching pattern of hypoattenuation that extends from the contracted renal pelvis may suggest hydronephrosis, it actually corresponds to an extensive inflammatory infiltrate rather than fluid in almost all cases. renal function (excretion) is rarely seen at the time of diagnosis, although variable rim-enhancement surrounding the central branching inflammatory process is common. the majority of cases demonstrate a highly specific set of findings that allows the radiologist to diagnose the condition confidently. surgical planning depends on the accurate assessment of the extrarenal extent of disease, further supporting ct investigation as the imaging modality of choice. 1. mongha r, dutta a, vijay m, chatterjee u, chakraborty sc. xanthogranulomatous pyelonephritis in a horseshoe kidney. saudi j kidney dis transpl 2010;21:515-517. 1. mongha r, dutta a, vijay m, chatterjee u, chakraborty sc. xanthogranulomatous pyelonephritis in a horseshoe kidney. saudi j kidney dis transpl 2010;21:515-517. 2. lorentzen m, nielsen ho. xanthogranulomatous pyelonephritis. scand j urol nephrol 1980;14(2):193-200. 2. lorentzen m, nielsen ho. xanthogranulomatous pyelonephritis. scand j urol nephrol 1980;14(2):193-200. 3. learning radiology.com. xanthogranulomatous pyelonephritis. http://www.learningradiology.com/archives2010/cow%20393-xgpn/xgpncorrect.htm (accessed 18 july 2012). 3. learning radiology.com. xanthogranulomatous pyelonephritis. http://www.learningradiology.com/archives2010/cow%20393-xgpn/xgpncorrect.htm (accessed 18 july 2012). 4. craig wd, wagner bj, travis md. pyelonephritis: radiologic-pathologic review. radiographics 2008;28(1):255-277. 4. craig wd, wagner bj, travis md. pyelonephritis: radiologic-pathologic review. radiographics 2008;28(1):255-277. 5. dyer rb, chen my, zagoria rj. classic signs in uroradiology. radiographics 2004;24(1):247-280. 5. dyer rb, chen my, zagoria rj. classic signs in uroradiology. radiographics 2004;24(1):247-280. abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) cornelis m. van der merwe department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa nasreen mahomed department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation van der merwe cm, mahomed n. an audit of radiation doses received by paediatric patients undergoing computed tomography investigations at academic hospitals in south africa. s afr j rad. 2020;24(1), a1823. https://doi.org/10.4102/sajr.v24i1.1823 note: special collection: paediatric radiology. original research an audit of radiation doses received by paediatric patients undergoing computed tomography investigations at academic hospitals in south africa cornelis m. van der merwe, nasreen mahomed received: 13 nov. 2019; accepted: 29 may 2020; published: 16 oct. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: diagnostic reference levels (drls) are a crucial element of auditing radiation doses in paediatric computed tomography (ct). currently, there are no national paediatric ct drls in south africa. objectives: the aim of this article was to establish local paediatric drls for ct examinations at two academic hospitals and to compare paediatric ct radiation output levels with established drls in the developed and developing world. method: computed tomography dose indexvolume (ctdivol) and dose length product (dlp) values were collected from ct examinations performed at two university hospitals for patients aged 0–15 years, during 01 november 2016–30 april 2017. the 75th percentile of the data distribution was calculated for each ct examination type and age group, further categorised into routine working hours and after-hours for both hospitals and statistically compared. results: of the 1031 ct examinations performed, ct brain examination was the most common (755/1031; 72.23%). dlp values were increased in the after-hours categories compared to regular working hours at both hospitals. the largest increase was in the 0–1 year age group (150.56%). with the exception of ct chest and ct abdomen in the 0–1 year age group, the ctdivol and dlp values compared favourably to international standards. conclusion: most of the calculated drls are acceptable and internationally comparable. this likely indicates effective reduction techniques and protocols. computed tomography body examination protocols for 0–1 year patients should be reviewed. strategies should be implemented to limit higher doses in after-hours examinations. keywords: radiation dose; computed tomography (ct); paediatric patients; diagnostic reference level (drl); computed tomography dose indexvolume (ctdivolume). introduction since its advent in 1971, computed tomography (ct) has added tremendous value for diagnosis and establishing treatment plans for patients. since then, there has been an exponential increase in the usage of ct.1 this increase is because of several factors, including, but not limited to, rapid evolvement of technology and advancements in hardware and software, which led to improved image quality and reduced duration for ct examinations.2,3 in addition, the geopolitical and socio-economic trends since the late 1990s also contributed to greater access to medical resources and equipment, specifically in the industrialised world.4 the number of ct scanners per million people in japan increased from 14.36 in 1980 to 107.14 in 2017. this increase has been the most significant in the developed world; however, an increase in the amount of ct scanners was also observable in the developing world, for example, in turkey, where the number of ct scanners increased from 4.89 per million people in 2002 to 14.53 per million people in 2016.4 the advances in availability and increase in applications also made ct investigations popular in the paediatric patient population. in the netherlands, the total number of paediatric ct scan examinations increased from 7731 in 1990 to 26 023 in 2012.5 similar trends were established in the rest of the developed world.6 even though there was suspicion about harmful effects of ionising radiation on the human body shortly after roentgen took his first radiograph in 1895, the first international radiation congress only discussed possible radiation protection standards in 1925. in the aftermath of the second world war, the international commission on radiation protection (icrp) and the united nations scientific committee on the effects of atomic radiation were formed and have since then played a major role in radiation research and protection.7 the concept of keeping radiation dose ‘as low as reasonably achievable’ (alara) has been around since 1915 and is compatible with the medical ethical mantra of ‘first do no harm’.8 furthermore, evidence from the second world war and radiation incidents has proved that the younger the patient is, the higher is the risk for adverse radiation effects. the increased risk is because of the presence of more undifferentiated cells, and the cells have a higher mitotic rate as well as a longer mitotic future.1,9 the icrp has recommended diagnostic reference levels (drls) for all diagnostic and interventional radiological procedures since 1991 as a measure to ensure radiation protection.6 the image gently alliance and campaign, which started in 2007, promoted the alara principle and since then has become one of the primary considerations in paediatric imaging.3 since 2007, there has been a reduction in the annual increase of paediatric ct examinations in the developed world.5 this reduction is likely because of the successes of radiation awareness programmes. following recommendations by the icrp to establish drls, there have been a significant number of audits and drl proposals in the developed world.10 as of 2013, the european diagnostic reference levels for paediatric imaging (pidrl) workshop has driven a campaign to establish european drls.10 there have been very few studies or audits on paediatric ct doses to establish ct-specific drls in the developing world. there is only one study from south africa auditing ct doses in a tertiary hospital on non-contrasted paediatric brain ct scans.11 south africa is considered the most industrialised country and the second largest economy in africa but has one of the highest levels of inequality. most of the population is medically underserviced because of resource constraints in the public health sector.12 apart from a heavy workload required from the radiological equipment, there are also restraints on human resources and quality control. in addition, the absence of established drls limits the ability to do routine audits to ensure optimal radiation protection. it is therefore of utmost importance to audit paediatric ct doses in south africa to establish drls. the aim of this study was to establish local paediatric drls for ct examinations in two major academic hospitals affiliated to the university of the witwatersrand, johannesburg, south africa. other objectives were to audit radiation doses and compare paediatric ct investigations’ radiation output levels to established drls in the developed and developing world. an additional objective was to evaluate whether there was any difference between the hospitals, as well as between regular work hours and after-hours. materials and methods design the study was designed as a retrospective, descriptive study. dosimetry european guidelines suggest the usage of the computed tomography dose indexvolume (ctdivol) and dose length product (dlp) as ct dose descriptors.10 ctdi100 is a linear measure of the dose distribution in a 10 cm ionization chamber inserted into a 16 cm phantom for paediatric ct. the weighted ctdi (ctdiw) is calculated by establishing the ctdi100 for the centre and the periphery of a cylinder and combining these. in helical ct scanning, the dose is inversely related to the pitch (number of rotations of the gantry per distance moved by the examination bed). computed tomography dose indexw divided by the pitch equals ctdivol, which is expressed in the international system of units (si units) as milligray (mgy). dose length product is the product of the length of the scanned area with the ctdivol13 and is expressed in milligray-centimetre (mgy*cm). study population the data collected were the ctdivol and dlp values for each ct examination in paediatric patients (age less than 15 years) during the 6-month period from 01 november 2016 to 30 april 2017 at the following hospitals: charlotte maxeke johannesburg academic hospital (cmjah) and rahima moosa mother and child hospital (rmmch). these hospitals are situated within the city of johannesburg municipality in gauteng province, south africa. data collection data were retrieved from the picture archiving and communication system (pacs) from cmjah and the local area network at rmmch. data were categorised and tabled for each ct scanner and further categorised according to the type of study and the age group. the ct brain data were also categorised into three different time categories as follows: weekdays (monday to friday from 08:00 to 16:00), after-hours (00:00–08:00 and 16:00–24:00 from monday to friday) and weekends and public holidays (00:00–24:00 on saturday and sunday, as well as on public holidays). the categories were chosen as per recommendations made by the european diagnostic reference levels for paediatric imaging workshop in 2013.10 all ct investigations were included and categorised according to the anatomical region of interest. the data could not be categorised according to indication, as the indication was not available on the database. the age groups were divided into 0 to < 1 year; 1 year to < 5 years, 5 years to < 10 years and 10 years to < 15 years. the european commission suggests categorising the ct body examinations according to weight, but patients’ weight was not available from the database. the time of day and day of the week was recorded for each study. data analysis the distribution of the ct examinations in this study sample was calculated using frequencies. for statistical analysis of the ctdivol and dlp values, only the single-phase ct examinations were included in the study sample. radiation output data for ct orbits, ct paranasal sinuses, ct musculoskeletal, ct whole spine and ct peripheral angiography were excluded from further analysis as the sample sizes were too small for statistical significance. data sets were categorised for ct brain, ct temporal bones, ct neck, ct cervical spine, ct chest, ct trunk and ct abdomen. the dose distribution for ct brain in each age category was determined for each hospital. data for each of the other ct examination types were combined for the two hospitals. the mean, average, median and 75th percentile of the data distribution, with confidence intervals (cis), were then calculated for each category for each examination type. local drls are defined as the 75th percentile of the data distribution.10 the local drls in this study were the 75th percentile value for each category, rounded up to the nearest single digit for ctdi and the nearest 5 for dlp. the data were then compared to similar studies with local and national drls. in addition, the ct brain results were compared between the two hospitals according to the difference in ctdivol and dlp 75th percentile values between the two hospitals for each age group and time category, using the fisher’s exact test. furthermore, the quantile regression method was used to compare the 75th percentiles in different groups by calculating the 95% ci for the difference between percentiles. if the 95% ci for the difference did not contain 0, the percentiles were significantly different. ethical considerations ethical approval to conduct the study was obtained from the human research ethics committee (medical) of the university of the witswatersrand (approval number: m170634). results distribution and frequency of computed tomography examinations the audit period for the 6 months from 01 november 2016 to 30 april 2017 included 1031 paediatric ct examinations from rmmch and cmjah. computed tomography brain examinations (755/1031; 73.23%) were the most common ct examination, followed by ct of the abdomen, which amounted to 82/1031 (7.95%) (see table 1). table 1: total number of scans included in the study per computed tomography examination type for each age category (n = 1031). radiation doses from all the study types conducted during the study period, there were only seven study types with enough cases in different age groups to allow data distribution calculation. these included ct brain, ct temporal bones, ct neck, ct cervical spine, ct trunk, ct chest and ct abdomen (total number for analysis = 905). the 75th percentile of both the ctdivol and dlp of each of these examination types in the various age groups is demonstrated in table 2, with a 95% ci. table 2: 75th percentile of computed tomography dose indexvol and dose length product for each computed tomography examination type, in each age group, as well as total number of contributing studies per category (n = 905). the ct brain data sets were used to compare the two different hospitals, as well as to evaluate for potential variation in different time categories. at cmjah, there was an increase in the 75th percentile of the data distribution in the weekend and after-hours group compared to regular weekdays. the greatest increase in dose was in the 0–1-year after-hours group with a 150.56% (691.3 mgy*cm vs. 275.9 mgy*cm) increase in dlp compared to the 0–1-year group during routine weekdays. the second most significant increase in dosage was in the 5–10-year weekend group. here, there was a 78.07% (760.7 mgy*cm vs. 427.2 mgy*cm) increase in dlp compared to 5–10 years routine weekday group (see tables 3 and 4). table 3: 75th percentile computed tomography dose indexvol (mgy) of data distribution, categorised for time and age for computed tomography brain examinations at charlotte maxeke johannesburg academic hospital (n = 515). table 4: 75th percentile of dose length product (mgy*cm) data distribution, categorised for time and age for computed tomography brain examinations at charlotte maxeke johannesburg academic hospital (n = 515). similarly, the data from rmmch demonstrated an increase in ctdivol and drl for after-hours and weekends compared to regular weekdays, although the increase was not as significant as it was at cmjah. the most pronounced increase in dose was in the 1–5-year after-hours group, with an increase in dlp of 40.46% (570.7 mgy*cm vs. 406.3 mgy*cm). the second highest increase in dose compared to routine weekdays was in the 0–1-year after-hours category, with an increase of 25.92% (418.3 mgy*cm vs. 332.2 mgy*cm) in dlp (see tables 5 and 6). table 5: 75th percentile computed tomography dose indexvol (mgy) of data distribution, categorised for time and age for computed tomography brain examinations at rahima moosa mother and child hospital (n = 172). table 6: 75th percentile of dose length product (mgy*cm) data distribution, categorised for time and age for computed tomography brain examinations at rahima moosa mother and child hospital (n = 172). the comparison of the dosages during ct brain investigation between the two hospitals revealed in general a lower dlp at a lower dlp at cmjah for the 0–1y, 1–5y and 5–10y groups, compared to rmmh (statistically significant in the 0–1y and 5–10y groups only, as 0 is not included in the 95% ci). the 10–15-year stratified groups demonstrated lower dlp values at rmmch compared to cmjah (see figure 1). figure 1: comparative 75th percentile for dose length product in mgy*cm for each time category for computed tomography brain at charlotte maxeke johannesburg academic hospital and rahima moosa mother and child hospital (n = 687). comparison to other studies and diagnostic reference levels the combined dlp and ctdivol 75th percentile values were compared to drls from the european guidelines, uk, germany, japan, kenya and brazil10,14,15,16,17,18 (see tables 7 and 8). table 7: computed tomography dose indexvolume 75th percentiles (mgy) of johannesburg hospitals compared to international diagnostic reference levels. table 8: dose length product 75th percentile (mgy*cm) of johannesburg hospitals compared to international diagnostic reference levels. the ctdivol and dlp values for ct brain were found to be less than the comparative drl values in most cases, except for the dlp values compared to the european drl in the age category for 10–15 years. the ctdivol and dlp values for ct chest were higher than the european drls, but better than those from japan, kenya and brazil. the exception was the increased value compared to brazil in the 0–1-year age category. the ctdivol values for ct abdomen were lower than the international drls, except for the 0–1-year category, which was higher than the european diagnostic reference levels (edrl) and brazilian values. the 0–1-year category for ct abdomen dlp values was also higher than those from brazil. although only the 10–15-year category dlp values were within the edrl range, the rest of the values were lower than that of the other international drls. discussion distribution and frequency of computed tomography examinations the higher number of investigations at the cmjah compared to rmmch was expected, as it is considered a central hospital in south africa, a level 1 trauma centre and major referral centre in the country.19 the ct brain percentage of total investigations was marginally higher in comparison to international studies in the developed world, whereas the ct abdomen percentage compared to the ct utilisation trends in other countries was similar.5,6,20 the reason for the higher percentage of ct brains performed at the studied facilities is likely because the initial neuroimaging investigation in the public health sector of south africa for a child presenting with the first episode of convulsion is a ct brain instead of a magnetic resonance imaging (mri) brain, as recommended by the american academy of neurology.21 computed tomography brain for neurological disease in south africa is a reasonable initial radiological investigation, as the incidence of neurological infections is higher than that of developed countries.22 magnetic resonance imaging availability and anaesthetic support are limited in the south african public health sector. furthermore, cmjah is a level 1 trauma centre and will have an increased percentage of ct brains for trauma indications. the increase in ct of the cervical spine after the age of 1 year is expected in a level 1 trauma centre. the number of temporal bone ct investigations in the 5–10and 10–15-year age groups is consistent with previous studies, which demonstrated the majority of patients with temporal bone pathology to be between the ages of 11 and 20 years.23 radiation doses both hospitals demonstrated an increase in the dlp values of ct brain during after-hours and some of the weekend categories. during after-hours, there is less staff present on the floor and often fewer senior staff to guide procedures, which could lead to an incorrect choice of parameters or selection of scan area, with a resultant increase in radiation dose to the patient. the increase in values is more significant in cmjah than in rmmch. the radiology department at rmmch is almost an exclusive paediatric radiology department, with staff trained in paediatric radiology. on the contrary, the radiology department at cmjah is a large combined adult and paediatric academic radiology department. at cmjah, there are dedicated time slots for paediatric ct examinations during the week, but after-hours urgent paediatric cts are performed in between adult patient cts, which could lead to an incorrect parameter and ct protocol selection when examining children. previous research has shown that probability exists for a significant dlp variation between radiographers even in the setting of a dedicated paediatric hospital.24 although the finding of increased dlp values in the 0–1-year age group was considered not to be statistically significant, follow-up investigation in this age group is suggested, as the findings might suggest clinical significance. the increased ctdivol and dlp values for rmmch compared to cmjah could be ascribed to hardware and software variables between the two departments. charlotte maxeke johannesburg academic hospital philips machines have more detector rows (64 and 128) as well as utilisation of the i-dose software by philips.25,26 comparison to other studies and diagnostic reference levels the ctdivol and dlp values for ct brain compare well against previously established drls and suggest consistent application of well-developed protocols at the different facilities. most of the higher ctdivol and dlp values in the 0–1-year age group for ct abdomen were associated with higher kv settings. the south african society of paediatric imaging suggests the reduction of kv settings in paediatric examinations.27 the ct abdomen studies with ctdivol and dlp values comparable to international drl ranges were performed with a reduction of kv from 120 to 100. it is suggested that the ct abdomen protocol for both rmmch and cmjah should be reviewed, adjusted and applied to all cases. although the ctdivol and dlp values for ct chest compare well against some of the international drls, it is also suggested that the protocols for ct chest should be reviewed and adjusted. a discrepancy in the comparison of ctdivol and dlp values for a specific examination in a specific age category is likely because of a larger-than-expected pre-selected scan area for the particular study.24,25 this and the fact that the ct brain values compared better than the ct chest and abdomen values could be a result of using age, rather than weight, as an input parameter for ct chest and abdomen examination in children.10 outcome from the data analysis, drls are proposed for the most frequent examinations. local drls are not suggested for 0–1-year age group, except for ct brain, as the 75th percentile values are higher than the older age groups and compare unfavourably to international drls (table 9). table 9: proposed local diagnostic reference levels for computed tomography dose indexvolume and dose length product for paediatric computed tomography examinations. in recent similar international studies and according to the european guidelines, it is proposed that drls could be presented in a graph format instead of tabular format. see the drl graph and curve for ct abdomen in figure 2 and for ct brain in figure 3. this type of graph is created by plotting all the different values for each age on an x:y scatter plot, establishing the 75th percentile for each age and creating a polynomial, exponential graph.28 figure 2: polynomial exponential curve for the purpose of presenting diagnostic reference levels for computed tomography abdomen for specific ages. the data set used in this graph was the dose length product for computed tomography abdomen examinations, corrected for each year in age (n = 82). figure 3: polynomial exponential curve for the purpose of presenting diagnostic reference levels for computed tomography brain for specific ages. the data set used in this graph was the dose length product for computed tomography brain examinations, corrected for each year in age (n = 687). presentation of a drl in a graph format can aid in the comparison of results and also could be an easy visual reference in the department. limitations one of the limitations of this study is that the european guidelines suggest that body cts should be categorised according to weight, but the weights were not documented on pacs for rmmch and cmjah during the study period. further limitations included the significant percentage of multi-phasic ct scans, specifically in the 0–1-year age group, which limited the statistical significance of the findings. conclusion overall, the ctdivol and dlp values for the studies are comparable with most of the international drls. computed tomography chest and abdomen protocols should be revised, specifically in the 0–1-year age groups. a suggestion would be to use weight as an input parameter instead of age for ct chest and abdomen examinations. the drl values in table 9 are suggested as local drls for the university of the witwatersrand academically affiliated hospitals as well as their referral hospitals. the results of this study will be presented to the south african society of paediatric imaging to aid in the establishment of national drls for paediatric ct examinations. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article. authors’ contributions dr c.m. van der merwe is the principal investigator for the master of medicine (mmed) study at the university of the witwatersrand. prof. n. mahomed is the mmed supervisor of this study at the university of the witwatersrand. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement full data sharing is available for all aspects of this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references brenner dj, hall ej. computed tomography – an increasing source of radiation exposure. n engl j med. 2007;357(1):2277–2284. https://doi.org/10.1056/nejmra072149 rubin gd. computed tomography: revolutionizing the practice of medicine for 40 years. radiology. 2014;273(2 suppl):s45–s74. https://doi.org/10.1148/radiol.14141356 power sp, moloney f, twomey m, et al. computed tomography and patient risk: facts, perceptions and uncertainties. world j radiol. 2016;8(12):902–915. https://doi.org/10.4329/wjr.v8.i12.902 oecd. health care resources [homepage on the internet]. oecd health statistics (database). 2019 [cited 2019 jul 28]. available from: https://doi.org/10.1787/data-00541-en meulepas jm, smets amjb, nievelstein raj, et al. trends and patterns of computed tomography scan use among children in the netherlands: 1990–2012. eur radiol. 2017(1);27:2426–2433. https://doi.org/10.1007/s00330-016-4566-1 bosch de basea m, salotti ja, pearce ms, et al. trends and patterns in the use of computed tomography in children and young adults in catalonia – results from the epi-ct study. pediatr radiol. 2016;46(1):119–129. https://doi.org/10.1007/s00247-015-3434-5 clarke r, valentin j, international commission on radiological protection task group. icrp publication 109. application of the commission’s recommendations for protection of people in emergency exposure situations. ann icrp. 2009;39(1):1–110. https://doi.org/10.1016/j.itcp.2009.05.004 oestreich ae. alara 1912: ‘as low a dose as possible’ a century ago. radiographics. 2014;34(1):1457–1460. https://doi.org/10.1148/rg.345130136 bushberg jt, siebert ja, leidholdt jr, em, boone jm. radiation biology. in: bushberg jt, editor. the essential physics of medical imaging. 3rd ed. philadelphia, pa: lippincott williams & wilkins, 2012; p. 751–836. european commision. radiation protection no 185: european guidelines on diagnostic reference levels for paediatric imaging. luxembourg: publications office of the european union, 2018; p. 1–122. vawda z, pitcher r, akugudu j, groenewald w. diagnostic reference levels for paediatric computed tomography. s afr j rad. 2015;19(2) art #846, 4. the world bank. south africa economic update. 11th ed. washington, dc: the international bank for reconstruction and development, 2018; p. 1–52. bushberg jt, siebert ja, leidholdt jr, em, boone jm. x-ray dosimetry in projection imaging and computed tomography. in: bushberg jt. editor. the essential physics of medical imaging. 3rd ed. philadelphia, pa: lippincott williams & wilkins, 2012; p. 375–401. shrimpton pc, hillier mc, meeson s, golding sj. doses from computed tomography (ct) examinations in the uk – 2011 review. chilton: public health england, 2014; p. 1–129. bundesamt fur strahlenschutz. bekanntmachung der aktualisierten diagnostischen referezwerte fur diagnostische und interventionelle rontgenanwendungen. bundesanzeiger (banz. s. 2594): bundesamt fur strahlenschutz; 2016. japan network for research and information on medical exposures. diagnostic reference levels based on latest surveys in japan – japan drls 2015. japan: japan medical imaging and radiological systems industries association, 2015. korir gk, wambani js, korir ik, tries ma, boen pk. national diagnostic reference level initiative for computed tomography examinations in kenya. rad prot dosimetry. 2016;168(2):242–252. https://doi.org/10.1093/rpd/ncv020 narciso l, lima n, dartora c, marques da silva a. a contribution to the establishment of diagnostic reference levels in computed tomography in brazil. world congress on medical physics and biomedical engineering, june 7–12, 2015, toronto, canada. ifmbe proceedings, vol 51; pp 737–740. cham: springer. 2015; https://doi.org/10.1007/978-3-319-19387-8_181 department of health: republic of south africa. regulations relating to categories of hospitals. national health act 2003. government gazette no r. 185, 02 march 2012; pp. 5–8. mettler fa jr, thomadsen b, chatfield m, gilley d. medical radiation exposure in the u.s. in 2006: preliminary results. health phys. 2008;95(5):502–507. https://doi.org/10.1097/01.hp.0000326333.42284a2 lyons tw, johnson kb, michelson ka, et al. yield of emergent neuroimaging in children with new-onset seizure and status epilepticus. seizure. 2016;35(1):4–10. https://doi.org/10.1016/j.seizure.2015.12.009 global death and daly estimates for countries [homepage on the internet]. department of measurement and health information. world health organization; 2004. [cited 2019 aug 03] available from: https://who.int/healthinfo/global_burden_disease/estimates_country/en/ bagul m. high-resolution computed tomography study of temporal bone pathologies. int j sci stud. 2016;4(4):60–65. bibbo g, brown s, linke r. diagnostic reference level of paediatric computed tomography examinations performed at a dedicated australian paediatric hospital. j med imaging and radiat oncol. 2016;60(4):475–484. https://doi.org/10.1111/1754-9485.12488 raman sp, mahesh m, blasko rv, fishman ek. ct scan parameters and radiation dose: practical advice for radiologists. j am coll radiol. 2013;10(11):840–846. https://doi.org/10.1016/j.jacr.2013.05.032 arapakis i, efstathopoulos e, tsitsia v, et al. using ‘idose4’ iterative reconstruction algorithm in adults’ chest-abdomen-pelvis ct examinations: effect on image quality in relation to patient radiation exposure. br j radiol. 2014;87(1036):20130613. https://doi.org/10.1259/bjr.20130613 south african paediatric society of south africa. paediatric imaging guidelines. radiological society of south africa. south africa. 2013, p. 1–58. jarvinen h, seuri r, kortesnuemi a, lajunen a, hallinen e, savikurki-heikkila p. indication based national diagnostic reference levels for paediatric ct: a new approach with proposed values. rad prot dosimetry. 2015;165(1–4):75–90. https://doi.org/10.1093/rpd/ncv044 correspon dence letter to the editor whither breast imaging in sa t he opinion titled "whither breast imaging in sn] mentioned a number of important aspects. we would like to expand on them, as well as share some additional ideas. it is heartening to know that mammography is being taken seriously and with the necessary dedication it deserves. mammography has long been a neglected part of radiology and that sadly has done mammography serious damage. we agree that it is impossible to do mammography justice without dedicated equipment and a trained and enthusiastic team. a standard of excellence is more easily achievable with a dedicated team under the supervision of a dedicated radiologist. the author mentioned the need for a dedicated radiographer but we would also like to include a medical physicist who takes care of the technical and physics aspects. the medical physicist will ensure optimum image quality at the lowest possible average glandular dose", as the benefit of mammography must outweigh the risk, this factor is of utmost importance. this is also the reason why the support of a medical physicist is compulsory in countries where mammography screening is in place. 34 sa journal of radiologyjune 1997 quality control (qc) programmes are well documented but the task lies in implementing these qc programmes effectively in this country. when approaching a mammography screening programme, the absolute importance of this aspect is overwhelming. we would like to suggest that peer review of the quality of phantom images be included in a qc programme for mammography screening. our experience of the implementation of a team approach and peer review resulted in an improvement in clinical image quality. this improvement is demonstrated in figures 1 and 2. figure 1 was taken two to three months after the commissioning of a state of the art mammography system and an extended dedicated film processing system. figure 2 was taken six months after figure 1 and after implementation of suggestions by the dedicated qc team and peer review. figure 1: mammogram acquired on mammography system two months after commissioning. topage35 frompage34 figure 2: this mammogram, of the same petient as in figure 1, only six months later and after implementation of suggestions by the dedicated quality control team and peer review. a few additional comments in connection with procedures: • ultrasound is a very important part of the breast examination it is the modality of choice in patients under the age of 30 years approximately 90% of all invasive biopsies and fine needle aspirations are carried out under sonar guidance it often allows definitive diagnosis when there is uncertainty concerning the mammogram and palpation • a dedicated viewing box is essential. if light shielding devices are not available and ambient light is present a viewer can be used to great advantage. we now manufacture these viewers which can be obtained from us at an inexpensive charge. • in the literature it is the radiologist using mammography, fine needle aspiration and core biopsies under ultrasound and stereotactic control that is very prominent in the diagnostic work-up of the patient with breast pathology. preoperative diagnosis has lead to a decrease in invasive surgical procedures on benign pathology. in south africa it is up to us to prove to the surgeon and to the patient that it is the radiologist who should be making this preoperative diagnosis. we would like to propose a mammography forum that 1. sets up procedures and protocols 2. insists on quality assurance 3. provides training in interventional procedures (fine needle aspirations and biopsies) let us set a uniform standard for mammography in south africa. the department of health is busy moving in this direction. however it would be best if the initiative remains in our hands. your comments and suggestions would be most welcome. chris markgraaf consultant radiologist department of radiology, universitas hospital, bloemfontein ann sweetlove principal medical physicist department of biophysics, ups, bloemfontein references 1. movson ij. whither breast imaging in south africa. south african journal of radiology. 1996; 1(4): 4-6. 2. american college of radiology. committee on quality assurance in mammography. mammography quality control manual. 1994; revised edition: 43-52. 35 sa journal of radiologyjune 1997 company news i'hiui's philips introduces 1 .5 tesla mobile mrsystem in europe philips medical systems recently delivered europe's first high-field mobile magnetic resonance imaging system to the cobalt unit appeal fund in england, a charity that specializesin medical services and in particular the prevention and treatment of cancer. delivered in december 1996, the philips gyroscan acs-nt 1.5 tesla mobile enables the medical organization to provide high quality imaging to patients in hospitals in the areas served by the charity. the short magnet, wide bore and flared ends of the philips systems ensure high patient acceptance and reduce claustrophobic reaction. the fast scanning sequences, superb image quality and good patient throughput are important considerations. installed in a 24-ton trailer, the gyroscan nt mobile system has the same compact magnet with an open, patientfriendly design as its stationary counterpart. in addition, it offers the same functionality and high performance, including gradient spin echo (grase), echo planar imaging (ept) and 1024 acquisition. the low weight of the nt system (which uses a 3 100 kg magnet versus a conventional 7 to 8 000 kg magnet) and the limited need for magnetic shielding, leads to reduced fuel costs and less wear on the tractor and trailer. information from philips medical systems, the netherlands. ---topage39 editorial ethiopian radiology steve beninl!field mbchb(ucr;, ffrac!(6jsa head: department of radiology, university of cape town earlier this year i was fortunate enough to be invited to addis ababa (which means "new flower", founded 1887) in ethiopia for a week. not only was this a great opportunity to learn more about this country's fascinating historical and religious background, especially its connections to the middle east, but it also gave me the chance to see for myself the state of radiology in another african country. ethiopia (formerly abyssinia) has had a prominent role throughout african and world history, including delivering early mankind in the form of "lucy" (australopithecus afarensis 2 million years old) in 1974, and giving rise to that other vital ingredient of any radiology practice coffee] strongly reminiscent of the midlands of natal with green rolling hills, their use of the unconventional julian calendar (12 months of 30 days and the balance of 5 or 6 days in a 13th month) gives rise to their advertising slogan "the only country with thirteen months of sunshine". there are three medical schools in the country, including in addis ababa. these schools are modelled on the american system, with associate professors appointed early in their careers. concerning radiology, at the time of my visit there were no functioning ct scanners, mri scanners, angiography tables or nuclear medicine cameras in this country of 60 million people. there had been a single refurbished ct machine in one of the state hospitals in 1997, but it had since broken down and could not easily be repaired. much the same applied to other equipment) with a number of obsolete screening tables and mobile units in evidence. chemicals for automatic processors are not available, and wet film processing is the rule. i was able to speak with colleagues from other african states, and heard that their diagnostic imaging services face similar problems. the major radiological centres in africa at present are perceived to be egypt, south africa, kenya, nigeria and zimbabwe. on the positive side, plans are afoot to develop a major new private diagnostic imaging unit in addis ababa, with significant south african involvement. from the state hospital perspective, sponsors appear to play an important role in equipment provision, and ethiopia as a prominent african country has the capacity to draw their support. despite the hardships, the overall mood and the quality of radiology in my host department (black lion hospital, department of radiology, university of addis ababa) were very good. i left ethiopia feeling humbled, but also grateful for our relative fortune, even in state hospitals. 3 sajournal of radiology· august 1998 sajr 792 percutaneous thrombin injection for pseudoaneurysm treatment g bydawell lake, smit & partners, durban g bydawell, mb chb, frcr corresponding author: g bydawell (bydawell@lakesmit.co.za) pseudoaneurysm of the femoral artery is a well-documented complication following arterial access. there are several treatment options, but percutaneous injection of thrombin, using ultrasound guidance, has become increasingly popular worldwide and is the therapy of choice in most vascular centres. this short review highlights the procedure and provides step-by-step guidance for radiologists who are interested in performing thrombin injection. s afr j rad 2013;17(1):41-42. doi:10.7196/sajr.792 pseudoaneurysm of the common femoral artery (cfa) is a wellrecognised complication following angiography.1 incidence rates of up to 0.2% of diagnostic angiograms and 8% of interventional procedures have been reported.2 , 3 the incidence increases with cardiac procedures owing to several factors, including longer procedure time, larger sheath sizes (7f and higher) and anti-platelet treatment. the main treatment options for symptomatic pseudoaneurysms include ultrasound-guided compression, percutaneous thrombin injection or surgical repair. ultrasound-guided compression is easy to perform and is often successful in thrombosing the aneurysm sac, but is very time-consuming and painful and has a high recurrence rate.4 surgical closure is technically straightforward, but usually requires theatre time and general anaesthetic, and is not without complications such as wound infection or nerve damage.5 in the last decade, percutaneous thrombin injection has become the treatment of choice for iatrogenic femoral artery pseudoaneurysm.6 , 7 this was first described in 1986 by cope et al., but has gained increasing popularity in the last 2 decades.8 the technique is simple to perform for any practitioner with ultrasound intervention skills and is usually done in the ultrasound suite, or even at the patient’s bedside, using a portable ultrasound unit. procedural time normally does not exceed 15 minutes. technique the first step is careful sonographic assessment of the pseudoaneurysm and the adjacent common femoral artery. flow within the pseudoaneurysm sac has a typical ‘yin-yang’ sign. the neck is normally seen posteriorly and is usually thin and longitudinal. a large neck diameter (e.g. >10 mm) is a relative contra-indication for thrombin injection because of a slightly higher risk of distal embolisation. there are several thrombin preparations available. in our centre, we use human thrombin from the tisseel kit (baxter us) where the thrombin powder is mixed with the calcium chloride solution and drawn up into a 1ml syringe. next, the pseudoaneurysm sac is punctured under ultrasound guidance, using a thin-calibre needle (e.g. 21g). the tip of the needle is positioned in the anterior aspect of the sac, i.e. as far away from the neck as possible. thrombin is then carefully injected in 0.1 ml increments using continuous b mode ultrasound imaging. thrombus will begin to form around the tip of the needle within a few seconds, and then the remainder of the sac should progressively thrombose. usually between 0.1 and 0.3 ml is adequate to achieve haemostasis. thereafter the native cfa is assessed with doppler ultrasound to confirm patency and the patient is returned to the ward for observations and 4 6 hours bed rest. an ultrasound scan should ideally be performed the following day to confirm haemostasis. most recent studies report success rates between 95 and 100%.3 on rare occasions, a repeat injection is necessary. complications are rare, estimated between 0 and 4%, and include distal embolisation, allergic reaction and infection. regarding thromboembolic complications, it is estimated that small thrombi enter the native arterial circulation in approximately 2% of cases although the vast majority of these patients remain asymptomatic, and it is accepted that most of the thrombus is lysed by the natural circulating lytic agents.3 fig. 1. a pseudoaneurysm (closed arrow), with a thin longitudinal neck (arrowhead), is seen adjacent to the common femoral artery and is well depicted on (a) 3d reformatted ct. note the typical yin-yang sign indicating turbulent flow on (b) ultrasound doppler evaluation. this aneurysm was treated successfully with thrombin injection with complete haemostasis on follow-up ultrasound evaluation, as noted by (c) the lack of duplex doppler signal. fig. 2. a larger pseudoaneurysm is confirmed on ultrasound (a). percutaneous thrombin injection was performed. (b) tip of the needle (closed arrow) positioned superficially within the aneurysm sac. (c) complete haemostasis. conclusion the incidence of arterial access site complication is likely to increase in this era of minimal access intervention. percutaneous thrombin injection is a simple, safe and effective technique for managing femoral pseudoaneurysms. the procedure is evidenced-based and is endorsed by large regulatory bodies such as the national institute for clinical excellence (nice) in the uk.9 there is a short learning curve, and the risks associated with the procedure are very low, with recent prospective studies showing no significant complications.10 radiologists need to be aware of the various management options for this condition and, with the benefit of image-guidance skills, are encouraged to familiarise themselves with the technique of thrombin injection. 1. katzenschlager r, ugurluoglu a, ahmadi a, et al. incidence of pseudoaneurysm after diagnostic and therapeutic angiography. radiology 1995;195:463-466. 1. katzenschlager r, ugurluoglu a, ahmadi a, et al. incidence of pseudoaneurysm after diagnostic and therapeutic angiography. radiology 1995;195:463-466. 2. messina lm, brothers te, wakefield tw, et al. clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional vs diagnostic procedures. j vascsurg 1991;13:593-600. 2. messina lm, brothers te, wakefield tw, et al. clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional vs diagnostic procedures. j vascsurg 1991;13:593-600. 3. morgan r, belli am. current treatment methods for postcatheterization pseudoaneurysms. j vascradiol 2003;14:697-710. [http://dx.doi.org/10.1097/01.rvi.0000071089.76348.6a] 3. morgan r, belli am. current treatment methods for postcatheterization pseudoaneurysms. j vascradiol 2003;14:697-710. [http://dx.doi.org/10.1097/01.rvi.0000071089.76348.6a] 4. eisenberg l, paulson ek, kliewer ma, et al. sonographically guided compression repair of pseudoaneurysms: further experience from a single institution. am j roentgenol1999;173:1567-1573. 4. eisenberg l, paulson ek, kliewer ma, et al. sonographically guided compression repair of pseudoaneurysms: further experience from a single institution. am j roentgenol1999;173:1567-1573. 5. lumsden ab, miller jm, kosinski as, et al. a prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. am surg 1994;60:132-137. 5. lumsden ab, miller jm, kosinski as, et al. a prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. am surg 1994;60:132-137. 6. paulson ek, sheafor dh, kliewer ma, et al. treatment of iatrogenic femoral arterial pseudoaneurysms: comparison of us-guided thrombin injection with compression repair. radiology 2000;215:403-408. 6. paulson ek, sheafor dh, kliewer ma, et al. treatment of iatrogenic femoral arterial pseudoaneurysms: comparison of us-guided thrombin injection with compression repair. radiology 2000;215:403-408. 7. brophy dp, sheiman rg, amatulle p, et al. iatrogenic femoral pseudoaneurysms: thrombin injection after failed us-guided compression. radiology 2000;214:278-282. 7. brophy dp, sheiman rg, amatulle p, et al. iatrogenic femoral pseudoaneurysms: thrombin injection after failed us-guided compression. radiology 2000;214:278-282. 8. cope c, zeit r. coagulation of aneurysms by direct percutaneous thrombin injection. am j roentgenol 1986;147:383-387. 8. cope c, zeit r. coagulation of aneurysms by direct percutaneous thrombin injection. am j roentgenol 1986;147:383-387. 9. ipg060 thrombin injections for pseudoaneurysm guidance may 2004. london: national institute for health and clinical excellence, 2004. 9. ipg060 thrombin injections for pseudoaneurysm guidance may 2004. london: national institute for health and clinical excellence, 2004. 10. schneider c, malisius r,küchler r, et al. a prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterisation femoral pseudoaneurysms. int j cardiol 2009;131(3):356-361. [http://dx.doi.org/10.1016/j.ijcard.2007.10.052] 10. schneider c, malisius r,küchler r, et al. a prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterisation femoral pseudoaneurysms. int j cardiol 2009;131(3):356-361. [http://dx.doi.org/10.1016/j.ijcard.2007.10.052] abstract introduction patient presentation management and outcome discussion conclusion acknowledgements references about the author(s) dharmendra kumar department of radiodiagnosis and imaging, armed forces medical college, pune, india saurabh maheshwari department of radiodiagnosis and imaging, armed forces medical college, pune, india uddandam rajesh department of radiodiagnosis and imaging, armed forces medical college, pune, india darshan grewal department of radiodiagnosis and imaging, armed forces medical college, pune, india vibhuti maria department of radiodiagnosis and imaging, armed forces medical college, pune, india citation kumar d, maheshwari s, rajesh u, grewal d, maria v. herniation of the uterus, ovaries and fallopian tubes into the canal of nuck in a 4-month-old child: a rare entity. s afr j rad. 2020;24(1), a1935. https://doi.org/10.4102/sajr.v24i1.1935 note: special collection: paediatric radiology. case study herniation of the uterus, ovaries and fallopian tubes into the canal of nuck in a 4-month-old child: a rare entity dharmendra kumar, saurabh maheshwari, uddandam rajesh, darshan grewal, vibhuti maria received: 28 june 2020; accepted: 20 aug. 2020; published: 04 nov. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract partial or complete failure of obliteration of the processus vaginalis in the female results in the formation of a potential space known as the canal of nuck, into which various organs and/or collections can herniate. a 4-month-old female presented with a left labial mass related to herniation of the uterus, ovaries and fallopian tubes through the canal of nuck. early diagnosis is important as there is a high risk of ovarian torsion and incarceration. keywords: canal of nuck; canal of nuck hernia; uterine herniation; pediatric hernia; uterine herniation; ovarian herniation. introduction the canal of nuck is a potential space because of patency of the processus vaginalis in females. this was first described by the dutch anatomist, anton nuck, in 1691.1 the processus vaginalis is a tubular fold of parietal peritoneum, which is seen in both sexes during foetal development. it is seen after 12 weeks of gestation and usually obliterates in early life. this obliteration occurs gradually from a superior to an inferior direction.2 the patency of the processus vaginalis in females leads to the presence of a potential space between the peritoneum, inguinal canal and labia majora, which is known as the canal of nuck. its distal part remains patent in males and forms the tunica vaginalis of the testis. the gubernaculum is another structure that is closely associated with the processus vaginalis and lies anterior to it in the inguinal canal. in females, it attaches to the midpoint of the uterus and prevents the descent of the ovary into the inguinal canal.3 it also assists in maintaining the normal anteverted and anteflexed position of the uterus.2 its adult homologues are the round ligament and the ovarian ligament. the gubernaculum plays a key role in testicular descent in males. there may be herniation of various organs and/or collections through the canal of nuck. the contents of the hernial sac may include omental fat, bowel loops, ovary, fluid, fallopian tube and urinary bladder. in extremely rare cases, the uterus can also herniate. it usually presents as a groin swelling or a labial mass, which may or may not be associated with pain.3 here, we report a case study of a female infant, who presented with a left labial swelling and was found to have herniation of the uterus and bilateral adnexa into the canal of nuck. patient presentation a 4-month-old female infant presented with a left labial swelling that increased in size upon crying. the swelling was gradually increasing in size and was noticed by her parents whilst bathing her. they brought the child to the hospital 2 weeks after they first noticed the swelling. the infant was born by natural vaginal delivery at 34 weeks of gestation and had a birth weight of 1.6 kilograms (kg) with an uneventful post-natal course. on physical examination, a soft lump was seen in the left inguinal region with extension to the left labia majora (figure 1). the lump was non-tender and the overlying skin was normal. it was reducible on manual compression but recurred upon crying. the infant was referred for a sonographic examination to assess the cause and contents of the left inguinal mass. figure 1: frontal photograph of the pelvic region of the patient shows the swelling in the left inguinal region (solid arrow). she was examined with a nextgen logiq e portable ultrasound (ge medical systems, milwaukee, wisconsin, usa) with a 12.5 megahertz (mhz) frequency transducer. the sonographic examination revealed a 9.6 millimetre (mm) defect in the left inguinal fascia with herniation of the pelvic organs through it (figure 2a and b). its contents included the uterus, which was identified by the presence of an endometrial lining. two oval masses with multiple small cystic structures representing ovaries were also seen herniated through this defect (figure 2c and d). minimal free fluid was present in the sac. these structures were not seen in the pelvis, which confirmed their herniation into the sac. figure 2: ultrasound images of the left inguinal region (a to d) show a 9.6 mm size defect (dotted line in [a]) with the uterus herniating through it (void yellow arrow in[b]). the endometrial cavity (et) can be seen within the uterus (b). figure c and figure d demonstrate the herniated right (ro) and left ovaries (lo) along with fallopian tubes (white solid arrows). on probe compression, a part of the uterus was seen to reduce into the inguinal canal. doppler ultrasound demonstrated normal blood flow to all herniated organs (figure 3). a final diagnosis of a left-sided canal of nuck hernia containing the uterus, both ovaries and fallopian tubes was made. figure 3: colour doppler ultrasound images (a and b) of the herniated contents show preserved vascularity (void black arrow) in the right (a) and left (b) ovaries. management and outcome the patient was managed with an elective repair of the hernia. the ultrasound findings were confirmed intraoperatively. the hernia sac contained the uterus, bilateral ovaries and bilateral fallopian tubes. the broad ligament of the uterus was stretched. the herniated organs were mildly congested without any evidence of ischaemia. they were reduced, the hernial sac was ligated and the deep inguinal ring was closed. the contralateral side was explored and was found to be normal. the surgery and the post-operative course were free of complications. discussion a palpable mass in the inguinal region of female infants has a relatively narrow range of differentials, including lymphadenopathy, canal of nuck hernia, hydrocele of canal of nuck, lipoma, bartholin gland cyst, lymphatic malformations, haemangiomas, epidermal cysts and rhabdomyosarcoma. the incidence of paediatric inguinal hernia ranges from 0.8% to 4.4%.4 however, they are 6–10 times more common in male infants and are predominantly of the indirect variety.4 in females, the hernia through a patent inguinal canal is known as the canal of nuck hernia. in one study of 22 cases of canal of nuck hernias, the patient ages ranged from 1 to 137 months, with a mean age of 51 months.5 prematurity is a well-known risk factor for this condition.6 other risk factors include lung disease and mechanical ventilation, where herniation is related to increased intra-abdominal pressure.7 herniation of the uterus through the canal of nuck is extremely rare. there have been only nine reported cases of herniation of the uterus with only three reported cases of herniation of both adnexa.8 interestingly, all the cases with bilateral herniation have been reported to be on the left side, including our case study. the etiopathogenesis of herniation of the uterus is not clear. okada et al. suggested multiple hypotheses, including traction induced by broad ligament, weakness of the pelvic suspensory ligaments and crying leading to high intra-abdominal pressures.9 although clinical examination can help in narrowing the differential diagnosis, ultrasound is the primary modality of choice for evaluation of these inguinal masses. ultrasound is easy and non-invasive, without carrying the risks associated with ionising radiation. it can characterise the mass and provides information regarding its size, shape, location, internal contents and vascularity. it can also provide a dynamic evaluation of the mass in real-time. magnetic resonance imaging (mri) may be used in difficult cases. however, it has inherent challenges because of the need for sedation or anaesthesia in young patients and the long examination time. herniation of the ovary through the canal of nuck should be diagnosed early, as there is a high risk of ovarian torsion as well as incarceration in these cases, and therefore prompt surgical intervention is necessary.10 various approaches have been described in the literature regarding the surgical management of these cases. these include a simple herniorrhaphy (high ligation of the sac followed by tissue repair),9 with or without the closure of the deep inguinal ring.11 some authors have also recommended the anterior repair of the inguinal canal in these cases.12 the mesh repair is contraindicated in the paediatric hernia repair because of an increased risk of complications.13 there is a high risk of surgical complications in this entity due to the adhesions between the herniated organs and the wall of the hernia sac.11 conclusion hernia of the canal of nuck is an uncommon entity that should be always be considered in a young female presenting with an inguinal or labial mass. radiologists should be well aware of this condition and ultrasound is the modality of choice for initial investigation. the knowledge of the anatomy and embryology of the canal of nuck is essential for interpretation and a correct diagnosis. the present case study illustrates a rare variant of this condition containing the uterus and bilateral adnexa. early diagnosis of this condition is essential for prompt surgical management. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case study. authors’ contributions d.k. and s.m. conceived of the presented idea. d.k. acquired the patient data and images. d.g. performed the literature search. s.m. and v.m. drafted the manuscript. u.r. finalised the manuscript. all authors contributed to the final manuscript. ethical considerations ethical approval for this study was obtained from the institutional ethics committee, armed forces medical college, pune, p/29/2020. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author (s.m.) upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references nuck a. adenographia curiosa et uteri foeminei anatome nova: cum epistola ad amicum de inventis novis [curious and of the womb of the female anatomy a new adenographia] (in latin). 1691; p. 130. shadbolt cl, heinze sbj, dietrich rb. imaging of groin masses: inguinal anatomy and pathologic conditions revisited. radiographics. 2001;21(spec.iss). https://doi.org/10.1148/radiographics.21.suppl_1.g01oc17s261 rees ma, squires je, tadros s, squires jh. canal of nuck hernia: a multimodality imaging review. pediatr radiol. 2017;47(8):893–898. https://doi.org/10.1007/s00247-017-3853-6 kapur p, caty mg, glick pl. pediatric hernias and hydroceles. pediatr clin north am. 1998;45(4):773–789. https://doi.org/10.1016/s0031-3955(05)70044-4 dal mo yang hck, kim sw, lim sj, park sj, lim jw. ultrasonographic diagnosis of ovary-containing hernias of the canal of nuck. ultrasonography. 2014;33(3):178. https://doi.org/10.14366/usg.14010 grosfeld jl. current concepts in inguinal hernia in infants and children. world j surg. 1989;13(5):506–515. https://doi.org/10.1007/bf01658863 fu y-w, pan m-l, hsu y-j, chin t-w. a nationwide survey of incidence rates and risk factors of inguinal hernia in preterm children. pediatr surg int. 2018;34(1):91–95. https://doi.org/10.1007/s00383-017-4222-0 chan d, kwon jk, lagomarsino em, veltkamp jg, yang ms, pfeifer cm. canal of nuck hernias. acta radiol open. 2019;8(12). https://doi.org/10.1177/2058460119889867 okada t, sasaki s, honda s, miyagi h, minato m, todo s. irreducible indirect inguinal hernia containing uterus, ovaries, and fallopian tubes. hernia. 2012 aug;16(4):471–473. https://doi.org/10.1007/s10029-010-0764-y boley sj, cahn d, lauer t, weinberg g, kleinhaus s. the irreducible ovary: a true emergency. j pediatr surg. 1991;26(9):1035–1038. https://doi.org/10.1016/0022-3468(91)90668-j karadeniz cerit k, ergelen r, colak e, dagli te. inguinal hernia containing uterus, fallopian tube, and ovary in a premature newborn. case rep pediatr. 2015;2015. https://doi.org/10.1155/2015/807309 fowler cl. sliding indirect hernia containing both ovaries. j pediatr surg. 2005;40(9):e13–e14. https://doi.org/10.1016/j.jpedsurg.2005.05.066 brandt ml. pediatric hernias. surg clin north am. 2008;88(1):27–43. https://doi.org/10.1016/j.suc.2007.11.006 tips for the radiologist why videofluoroscopy? a r lloyd-jones mcommpath department of speech therapy and audiology pretoria academic hospital swallowing may be defined as a highly complex and co-ordinated sequence of neuromuscular events designed to transport food and liquids from the oral cavity, through the pharynx and oesophagus, to the stomach. during this process, the respiratory function ceases briefly to allow the digestive function to take place and resumes once the swallowing sequence has been completed.' when this complex sequence of events becomes disordered and the transportation of material is no longer efficient or effective,then dysphagia is present. dysphagia may manifest in varying degrees, from mild symptoms such as the sensation of food sticking in the throat, to severe dysphagia where the oral intake of food or liquids is impossible. dysphagia can also occur at any stage of life,from the premature infant who cannot suck and swallow, to the geriatric patient, and can have a profound effect on the quality oflife experienced. symptoms such as coughing and choking, drooling, nasal regurgitation and oesophageal reflux may cause the sufferer to withdraw from society and experience feelings of isolation and depression.' in addition, dysphagia carries the sequelae of malnutrition, dehydration and aspiration if left undiagnosed and untreated.' in view of the serious mortality and morbidity associated with dysphagia it is important to differentiate between the symptoms of dysphagia and the causes of dysphagia, as the causative factor may be an underlying disease or disorder that may be debilitating or life threatening.' this process of differentiation involves a comprehensive evaluation of the patient and the expertise of a number of medical and allied medical disciplines in order to provide the detailed information that is crucial to diagnosis and management of this condition.' the speech pathologist and the radiologist are essential members of this multidisciplinary dysphagia team. evaluation of dysphagia as with any patient the evaluation commences with a case history followed by a clinical evaluation but 'the literature clearly indicates that clinical, bedside evaluation is an inadequate and poor predictor of pharyngeal dysphagia" consequently other more objective means of evaluating swallowing, and especially the pharyngeal phase of swallowing, have been sought. as the ability to visualise the phases of swallowing aids in evaluation, radiographic techniques have been used since the early 1900s. the development of fluorography during the 1930s allowed the examination of the movement patterns of the oral 42 sa journal of radiology • march 2002 cavity, pharynx and oesophagus/ with the development of technology the fluorographic technique has been refined and now fluorographic studies are recorded on videotape, reducing the exposure to radiation by making the examination time shorter, and by offering the opportunity for immediate review of the examination. another imaging technique that can be used is ultrasonography. ultrasound clearly visualises muscles, and depicts the surfaces between muscles, organs and blood vessels, and a variety of other tissues as well as the motion of these structures. however, the ultrasound does not visualise bone.' there is a further limitation to ultrasound as not all the phases of swallowing can be visualised, the ultrasound cannot demarcate the bolus after it has passed into the hypopharynx and cannot track the bolus during the oesophageal phase," ultrasound does not hold any danger from radiation and can be used over and over again with impunity. many other methods of objective evaluation of the swallowing mechanism exist. of these methods fibreoptic endoscopy coupled with videorecording facilities appear to be the most popular. manometry, scintigraphy, electromyography and cervical auscultation are also utilised but no other method matches the advantages of video fluoroscopy. video-fluoroscopy has become known as the gold standard for swallowing evaluation. rationale for this choice in order to choose the most economical and efficacious method of evaluating swallowing some important factors must be taken into contips for the radiologist sideration. the examination should offer the means to track the bolus as well as the motions of the swallowing mechanism, while allowing the ability to observe if any bolus enters the airway and at what time during the swallowing event the aspiration takes place. another factor to be considered is whether the examination allows for the use of real food bolusses that correspond to a natural diet which would facilitate the management of the dysphagia. if a procedure can be utilised in treatment and follow-up of the dysphagic patient it is an added benefit." with videofluoroscopy, the procedure produces a clear pictorial image of all the phases of swallowing, namely oral preparatory, oral prepulsive, pharyngeal as well as oesophageal. this procedure provides a complete image of the bony structures of the oropharynx, airway and digestive tract, while the use of high-density barium contrast material outlines the surface and the soft tissue of the tongue, velum, pharynx, larynx and the oesophagus. this means that videofluoroscopy is easy to interpret as it gives a clear likeness of the anatomical structures in their actual form and proportion. in addition, the procedure is dynamic and allows a clear image of the bolus flow through the aerodigestive tract while providing valuable information regarding the patterns of movement as well as the timing of events during swallowing. this makes diagnosing the physiologic and temporospatial components of dysphagia much more accurate and efficient.s with regard to the other factors such .as the bolus type and management of dysphagia, video fluoroscopy also offers the most information. the protocol used during videofluoroscopy can utilise food from the normal diet in different textures and consistency in order to examine the effects of the various bolus characteristics on the mechanism of swallowing. information gained from using different bolus textures will clearly indicate if, for example, a patient aspirates on thin fluids or on a solid particulate bolus. this will aid in managing the dysphagia as the diet of the patient may be manipulated to provide all foods in a texture and consistency compatible with aspiration-free oral feeding," further management of swallowing disorders is facilitated by using videofluoroscopy as airway protection manoeuvres and various postural techniques can be used during the examination and the efficacy of the strategy evaluated immediately. the video recording can be used later as an instructional aid for the patient demonstrating that the techniques work in providing him or her with a safe oral swallow.' in summary, 'video fluoroscopy is not designed to determine whether someone aspirates, but rather to understand why they aspirate. further, the study is designed to define optimal eating strategies to enable the patient to continue at least partial intake," who to refer any patient who complains of a swallowing disorder should at the very least be referred to a speech therapist who can utilise screening instruments to identify the extent of the problem/ this will avoid doing a videofluoroscopy on patients who have mild oral phase dysphagia. however, 'if the 43 sa journal of radiology • march 2002 main complaint is indicative of respiratory difficulty or suggests the likelihood of aspiration or laryngeal penetration, videofluoroscopy is indicated.' as a result of the varied aetiology of dysphagia which encompasses neurogenic causes, as well as neoplastic and structural causes, the symptoms presented by the patient also indicate whether a video fluoroscopic examination should be performed. a patient who complains of a gradual onset, difficulty in swallowing pills and fluids as well as an increase in eating time probably has a neurogenic disorder as the underlying cause and the complaint should be investigated using videofluoroscopy. a patient who complains of a more sudden onset, painful swallowing, food sticking in the throat and weight loss may have a tumour or a mass and should undergo a videofluoroscopy" it is important to remember that video fluoroscopy is not an exclusive procedure but that the result obtained from videofluoroscopy will indicate the selection of further tests and procedures to confirm or dispute the findings. it appears to be a common misperception that the videofluoroscopy means that no other tests need to be performed. however, should a tumour or mass be identified further examinations such as a ct scan or mri will be needed to investigate further. if an oesophageal component is identified during the videofluoroscopy then clear-tests such as manometry, ph monitoring, ba swallow, etc. are the next investigations required. the videofluoroscopy can aid in diagnosing the swallowing disorder but also saves time and money by indicating which other procedures will be necessary. tips for the radiologist who should do the videofluoroscopy? as the purpose of a videofluoroscopy is to determine the deficits in the swallowing mechanism that produce the symptoms as well as the therapeutic strategies necessary to compensate for the deficits, it is logical that both a radiologist and a speech therapist should be involved in this procedure. the radiologist contributes expertise from many fields such as neuroradiology as well the knowledge to identify structural abnormalities. the radiologist is able to help tie together the information from various studies in order to arrive at a diagnosis. furthermore, the radiologist is responsible for the technical aspects of the procedure such as exposure and the identification and reduction of image artifacts ensuring the quality of the imaging." the speech therapist has specialist knowledge of the movement patterns of the oral structures, pharynx and larynx during deglution and complements the radiologist's knowledge of structural deficits. the speech therapist also has knowledge of the effects of bolus characteristics on swallowing as well as the various postural changes and airway protection manoeuvres. therefore, she can determine which techniques would facilitate safe oral feeding. in this way the combination of the skills of both these professionals leads to effective and efficient decision-making regarding diagnosis and management of the patient's problem.' in conclusion, videofluoroscopy is a short, relatively cheap, easy-to-interpret test that provides comprehensive information regarding all the phases of swallowing, the deficits and structural defects of the swallowing mechanism and lends itself to the evaluation of the therapeutic techniques employed to overcome the swallowing problem. this procedure involves the combination of the radiologist's skills and the speech therapist's skills to diagnose and manage dysphagia successfully. for in the words of virginia woolf: 'one cannot think well, love well, sleep well, if one has not dined well: references 1. bradley pj, evaluation of the normal swallowing mechanism. cme bulletin otorhinolaryngology, head and neck surgery 1998; 2 (1): 4-8. 2. mathog rh, fleming sm. a clinical approach to dysphagia. am ] otolaryngol 1992; 13: 133138. 3. veldee ms, peth ld. can protein-calorie malnutrition cause dysphagia. dysphagia 1992; 7: 86-101. 4. fleming sm. treatment of mechanical swallowing disorders, in: groher me, ed. dysphagia diagnosis and management. 2nd ed. boston: butterworth-heineman, 1992: 237-253. 5. miller rm. clinical examination for dysphagia. in: grober me, ed. dysphagia. diagnosis and management. 2nd ed. boston: butterworthheineman, 1992: 143-163. 6. leder sb, sasaki ct, burrel mi. fibreoptic endoscopic evaluation of dysphagia to identify silent aspiration. dysphagia 1988; 13: 19-21. 7. logeman ja. evaluation and treatment of swallowing disorders. 2nd ed. austin, texas: pro-ed,1998. 8. sonies be. dysphagia: a model for differential diagnosis for adults and children. in: cherney lr, ed. clinical management of dysphagia in adults and children. 2nd ed. chicago, illinois: aspen publications, 1994. 9. ekberg o. evaluation of swallowing. in: groher me, ed. dysphagia diagnosis and management. 2nd ed, boston: butterworth-heineman, 1994: 163-196. 44 sa journal of radiology. march 2002 editorial the diaspora of radiologists in a quest for fellowships an easy way out, or is there a gap in our training programmes'? savvas andronikou mb bch, fcrad (d)sa, frcr (land) head: department of paediatric radiology red cross war memorial children's hospital, university of cape town and institute of child health the option of training as a fellow in another country is being entertained more frequently by radiologists who have just completed their training in south africa. is this just fashionable, a vehicle for immigration, or is there justification for this behaviour? this has become a personal issue for me recently as i, too, am about to embark on a fellowship in paediatric radiology in melbourne, australia. what is a fellowship then? i have no definition for you, but this is the broad idea: once a registrar has graduated as a specialist radiologist with good general skills there is no official training programme for further sub/superspecialisation in a specific field. such fields include cross-sectional imaging, neuroradiology, muskuloskeletal radiology, paediatric radiology and even more refined areas such as paediatric neuroradiology. south african graduates have proved beyond doubt that our general training is of the highest standard and regional hospitals abroad are regularly impressed by our wide range of skills. in contrast to american graduates in particular, we lack expertise in certain fields, especially those involving magnetic resonance imaging (mri), complex ultrasound techniques and mammography. even in interventional radiology where many of our registrars have extensive hands-on experience, we probably lack the details of a formal training and definitely suffer the consequences of budget-related technological inexperience. this is all the more topical with the acquisition of new mri units in the academic departments of the western cape where such knowledge is now to be put to use. a fellowship offers a postgraduate radiologist the opportunity to attain expertise in a field of personal choosing. such posts are usually offered and sponsored by universities that have a resident expert with skill and expertise in a particular field of radiology. the candidate is considered favourable when not only is he/she to benefit personally because of an inclination or desire to attain the expertise, but also when his/her country of origin has a need. fellows are paid salaries and are incorporated in the host department's daily functioning, but they are also required to enter the full training programme to learn and teach others. candidates are expected to apply themselves fully and to engage in the running research programmes of their mentors. such fellowsrups extend from 1 to 2 years, after which time candidates can be considered experts in their fields of choice. they are then 3 sajournalof radiology. october 2001 editorial expected to return to their countries of origin, pass on knowledge and apply themselves to patient needs. with that in mind, a prospective fellow should select his/her field, a reputable institution offering fellowships, and even a renowned radiologist of his/her choosing to learn from. the other side of the coin is that fellowships have created an avenue for radiologists to escape the uncertain social and health-related future of south africa. indeed, a fellowship is often a prerequisite for entry into consultant posts in the usa, canada and the uk. currently seven cape town graduates have already or are about to enter fellowship posts in the above countries. let us pray that they (including yours truly) will return to south africa with the expertise that is desperately needed, and let us hope that the health administration recognises that radiology is an indispensable service requiring not only expensive technologically advanced equipment, but also highly specialised staff capable of using it. it's a catch-22 situation in which south africa needs us to seek knowledge abroad, which in turn makes us less likely to return. savvas andronikou editor 4 sa journal of radiology • october 2001 case report abstract neuroblastoma occurs mainly in childhood and approximately 20% of cases have orbital metastases. proptosis can be the only manifestation of metastatic neuroblastoma. early investigation is important, as metastatic disease requires aggressive management. we present a case of a 7-yearold girl initially presenting with proptosis. introduction neuroblastoma is an uncommon tumour of early childhood which can metastasise to the orbits. neuroblastoma accounts for 7.5% of all cancers in children less than 15 years of age, with 90% of all neuroblastomas occurring before the age of 10 years.1 approximately 1% of patients present initially with evidence of metastatic disease without a readily identifiable primary lesion. neuroblastoma commonly metastasizes to bone (60%), regional lymph nodes (45%), orbit (20%), liver (15%), intracranially (14%), and lung (10%).2 there is little published work detailing the orbital and ophthalmic manifestations of neuroblastoma. this case report addresses the features of a 7-year-old girl presenting initially with proptosis. case report a 7-year-old girl presented to the ophthalmology department with a 3week history of progressive, painless left-sided proptosis. there was no history of visual disturbance. the mother also reported that the patient had difficulty walking due to discomfort in her right hip. there was also no history of recent illness, allergies or trauma. examination of the eyes showed a left axial, non-pulsatile proptosis with full range of movements. abdominal examination did not show any abnormality. she had a tachycardia of with a pulse rate of 115 beats per minute. haematological results revealed a haemoglobin of 8.6 g/dl, with a normocytic normochromic anaemia. the brain ct and mri scans demonstrated enhancing mass lesions in the left sphenoid wing and lateral orbital wall, with an associated hyperostosis (figs 1 – 2). there was also opacification of the right maxillary and ethmoid sinuses. biopsy of a cervical lymph node confirmed the diagnosis of neuroblastoma. the patient was referred to the oncology department for chemotherapy and to the psychologist for support and counselling as her prognosis was assessed to be very poor. discussion neuroblastoma occurs mainly in childhood and approximately 20% of cases have orbital metastases.1 the primary tumour can arise from anywhere along the sympathetic chain, but the adrenal medulla is a common site (35%). usually one adrenal gland is involved; bilateral involvement is rare.2 symptoms may be due to tumour mass or bone pain from metastases. proptosis and periorbital ecchymosis (raccoon eyes) which can mimic child abuse, are common signs and arise from retrobulbar metastases. subconjunctival haemorrhages may occur as a consequence of pancytopaenia resulting from bone marrow metastases.1 in a study of 57 cases of childhood proptosis, metastatic neuroblastoma was the cause in 31 sa journal of radiology • december 2006 proptosis as a manifestation of neuroblastoma s t hlongwane, mb chb m pienaar, bsc, mb chb g dekker, mb chb, mfammed a brandt, mb chb d van der merwe, mb chb h b louw, mb chb, mfammed s dajee, mb chb, da, mmed rad (d) department of radiology, tygerberg hospital and stellenbosch university case report fig. 1(a) and (b). t1 axial preand post-contrast mri showing bilateral retrobulbar enhancing masses (white arrows) with sphenoid bone involvement (black arrows). an intracranial component is also noted projecting into the left middle cranial fossa (open arrow). a b pg31-32.indd 31 12/11/06 11:02:32 am 4 of the cases. the most common cause was orbital cellulitis, followed by thyroid eye disease and optic nerve/chiasm glioma.3 ophthalmic involvement by neuroblastoma is defined by the international neuroblastoma staging system (inss)2 as stage 4 disease. treatment of the primary disease is based on the children’s oncology group neuroblastoma risk group asssignment schema of low, intermediate, or high. orbital involvement belongs in the high-risk category; therefore treatment involves very high doses of aggressive multiagent chemotherapy. conclusion proptosis in children can be the only manifestation of metastatic neuroblastoma. early investigation is important, as metastatic disease requires aggressive management. 1. ahmed s, goel s, khandwala m, agrawal a, chang b, simmons ig. neuroblastoma with orbital metast sis: ophthalmic presentation and role of ophthalmologists. eye 2006; 20: 466-470. 2. west s, correa jd, germain m, balsam d, rosen j. neuroblastoma 2005; emedicine.com/radio/topic472. htm 3. sindhu k, downie j, ghabrial r, martin f. aetiology of childhood proptosis. j paediatric child health 1998; 34: 374-376. case report fig. 2. t2 axial mri image showing retrobulbar metastases originating in the sphenoid bone. 32 sa journal of radiology • december 2006 imaging of cancer, an issue of radiologic clinics by david m. panicek, md, facr to enquire contact: health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za isbn 1416039023 · hardback · 240 pages saunders · forthcoming title (january 2007) pg31-32.indd 32 12/11/06 11:02:34 am case report arteriovenous shunting and early cortical venous filling in subacute cerebral infarction an old angiographic finding revisited ian c duncan ffrad(d)sa unitas interventional unit pobox 14031 lyttelton 0140 abstract demonstrated in this report is an example of arteriovenous shunting and early venous filling in an area of cerebral infarction recorded on digital subtraction angiography. this angiographic appearance is largely ofhistorical interest given the current use of sectional imaging (ct and mr) and altered role of angiography in the imaging of stroke, but should nevertheless still be considered amongst the differential causes of cerebral arteriovenous shunting. introduction since the 1970s sectional imaging with computed tomography (ct) and later magnetic resonance imaging (mrl) have replaced cerebral angiographyas the methods of choice in the acute and follow-up imaging of cerebral infarction. angiography tends to be performed early either to identify any treatable underlying pathology or for direct transarterial treatment by thrombolysis. as a result few cerebral angiograms are done nowadays in the subacute and chronic stages of an infarction and so many of the related angiographic changes during these stages are no longer seen. the case reported here is shown primarily to demonstrate the changes of luxury perfusion and arteriovenous shunting and early cerebral cortical venous filling as captured on digital subtraction angiography. case report a 39-year-old male patient presented to a local academic hospital with clinical evidence of an acute subarachnoid haemorrhage. he was stuporose on admission. an unenhanced ct sean done on the day of admission showed a small clot in the basal subarachnoid cisterns and an area of nonhaemorrhagic infarction in the right 32 sa journal of radiology • september 2002 fig. 1. unenhanced axial ct scan showing the area of infarction in the right parietal lobe. parietal lobe and posterosuperior aspect of the right temporal lobe. cerebral angiography was performed 6 days after this admission. selective right internal carotid angiography showed the presence of an elongated saccular aneurysm arising from the communicating segment of the right internal carotid artery (ica). vasospasm was seen in the region of the right middle cerebral bifurcation and in the right posterior communicating artery. a vascular blush was apparent in the region of the cerebral infarction during the late arterial and capillary phases of the selective right lca run. early filling of cortical veins in this region was noted during the late capillary phase prior to the normal venous return phase from the rest of the right cerebral hemisphere. this appearance is in keeping with luxury perfusion and rapid arteriovenous shunting through the infarcted area. discussion the angiographic pattern of arteriovenous shunting with early filling of cortical veins related to an area of cerebral infarction will be well known to radiologists who performed cerebral angiography in the era prior to crosscase report sectional imaging. in 1966, lassen' introduced the term 'luxury perfusion' to describe hyperaemia within damaged brain tissue. regional loss of autoregulation was thought to be due to lactic acid and carbon dioxide accumulation. this reaction could occur within or around an infarcted area. these changes resulted in the shunting of blood, either through dilated capillaries or arteriolo-venular shunts. angiographically this was visible as an enhanced early capillary blush and early venous filling. these angiographic changes are particularly evident in the second to third weeks post-ictus, but early venous filling can occasionally be seen very soon after an infarct." in 1973, leeds and goldberg' identified a host of pathologies that could exhibit 'luxury perfusion' including cerebral infarction, cerebral trauma, inflammatory diseases (including encephalitis, meningitis and abscess), vasculitis, parenchymal degenerative disease, encephalopathy, compression of brain around a space-occupying lesion, vascular spasm (secondary to subarachnoid haemorrhage), and repeated seizures or status epilepticus. today brain infarcts are diagnosed and followed up either with ct or mr!. angiography is usually done early either to exclude an underlying arterial pathology in the neck or brain, or it is done for endovascular treatment with thrombolytic agents. as a result, angiography is not routinely done within days to weeks post-ictus. in our case there was an unknown period of delay before reaching a hospital with scanning and neuro33 sa journal of radiology • september 2002 f/g. 2. serial dig/tal subtractionimages taken dur· ing a select/ve right internal carotid arteriogram showing images at 2.4 sec (a), 3.7 sec (b), 4.5 sec (c). 5.8 sec (d) and 8.8 sec (e). these show the early venous return due to arteriovenous shunting through the infarcted ares (d) prior to the normal venous return from the rest of the brain (e). surgical facilities. even after admission there was a further 6-day delay before angiography was performed with the result that we saw the cerebrovascular changes at least 1 week post-ictus. thus we were able to show by means of high-quality digital subtraction angiography this excellent example of luxury perfusion with arteriovenous shunting and early venous filling related to cerebral infarction, an angiographic appearance seldom seen nowadays. references 1. lassen na. the luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. lancet 1966;2: 1113-1115. 2. huber p. krayenbuhl h, yasargil mg. circulation in cerebrovascular disease and infarcts. in: huber p, krayenbuhl h, yasargil mg, eds. cerebral angiography. 2nd ed. new york: thieme, 1982: 260-263. 3. burrows eh, leeds ne. supratentorial hemispherical lesions. in: burrows eh, leeds ne, eds. neuroradiology. vol. 1. new york:churchill livingstone, 1981:245-294. 4. leeds ne, goldberg hi. abnormal vascular patterns in benign intracranial lesions: pseudotumaul's of the brain. am j roentgenol radium tiler ni/cl med 1973; 118: 576-585. case report intertrochanteric stress fractu re following the comrades marathon ralph drosten mb bch, fcrad d;ag department of thoracic imaging brigham and women's hospital boston, usa case presentation a 33-year-old man presented to the x-ray department complaining of right hip pain 3 days after completing the 2000 comrades marathon. he had experienced significant pain during the last third of the marathon. the pelvic and right hip x-rays on the day of presentation (fig. 1) demonstrated no visible fracture, sclerosis, medullary irregularity or effusions. fig. 1. pelvic x-rayon presentation (normal) 3 days after the comrades marathon. ultrasound of the right hip demonstrated no joint effusion or collection. oedema of the proximal vastus medialis and intermedialis muscles, consistent with tendinitis, was diagnosed. a pro deo magnetic resonance image (mri) performed at this time figs 2 and 3. fluid suppression mri of the right hip showing oedema in the vastus muscle group (arrow), but no intramedullary signsl changes 3 days after the comrades marathon. 42 sa journal of radiology • october 2001 (figs 2 and 3) confirmed the ultrasonographic findings. no cortical or medullary bone changes, fracture lines or asymmetry were detected, and no hip effusion was visible. fluid was noted tracking medial to the proximal right femur. oedema of the proximal vastus medialis and intermedialis muscles was confirmed. the patient was treated conservatively.he presented 10 days later complaining of unremitting pain in the right hip. he had been for two short 'leg stretching' runs in the interim. repeat x-rays of the right hip (figs 4 and 5) demonstrated an obvious illdefined area of sclerosis traversing the right femoral intertrochanteric region consistent with a stress fracture. no clearly defined lucent fracture line was noted. figs 4 and 5. right hip x-rays 10 days after the comrades marathon showing ill-defined sclerosis in the intertrochanteric region (arrows). a 99mtcmdp isotope study was performed (fig. 6). prominent uptake in the right intertrochanteric region confirmed the x-ray findings of a right intertrochanteric stress fracture. discussion stress fractures occur as a result of chronic repetitive trauma to normal bone (abnormal stresses to normal bone). a stress fracture occurring in an otherwise normal bone as a result of normal activity is termed a fatigue fracture (normal stress to normal bone). a fracture occurring as a result case report ... i': pf!.vlt figs 6. ""'tc mop isotope study 10 days after the comrades marathon demonstrating uptake in the right intertrochanteric region (arrow), consistent with a stress fracture. of normal stresses applied to abnormal bone is an insufficiency fracture (normal stress to abnormal bone). the repetitive trauma causing the stress fracture ultimately results in structural failure of the bone.' such injuries may be difficult to diagnose at the initial presentation. a subtle periosteal reaction or a transverse band of linear sclerosis may develop 2 3 weeks after the onset of symptoms. the fracture line, as in our example, is often never identified. our patient's day 10 x-ray demonstrated sclerosis perhaps secondary to the repeated trauma experienced during the post-marathon 'leg stretching' runs. common sites for stress fractures include the metatarsal shafts ('march fractures'), pubic rami, femoral neck, tibial and fibular shafts and the calcaneal tuberosity. indirect radiological signs are often useful in suggesting an acute fracture. soft tissue swelling is usually present adjacent to the fracture site. displacement or obliteration of normal fat pads can be a clue to acute fracture haematoma or joint distension. the presence of lipohaemoarthrosis is prima-facie evidence of an intra-articular fracture, and is best assessed using cross table x-rays, i.e. a horizontal beam. isotope bone scans and mr! are very sensitive methods of detection of this type of injury, and may be positive at the time of initial presentation. mr! is much more sensitive than conventional radiography in the detection of stress and occult fractures and will usually be diagnostic immediately after the injury.' the absence of medullary marrow changes on our patient's day 3 mr! gives further credence to the possibility that the stress fracture developed, or extended, during the days after the marathon. stress fractures produce a pattern of bone marrow oedema similar to that seen with acute trauma. a fracture line, if seen, is a persistent low signal band on all pulse sequences.' isotope scans are a sensitive modality in the assessment of a suspected stress fracture. with chronic stress, mild diffuse cortical thickening is often seen; however, a focus of increased uptake on one or other cortical margin indicates the presence of a stress microfracture. within the first few hours following the injury there is a post-traumatic inflammatory reaction and the blood flow and blood pool images show hyperaemia around the site of injury. within 24 hours early osteoblastic activity commences within the callus and the delayed scan will be positive.' this repair may be retarded in patients with marked osteoporosis. for the next few weeks all three phases of the bone scan will be intensely hot, but eventually the increased blood flow returns to normal. the hyperaemia of repair will be visible on the blood pool imaging as long as there is active callus formation. the hyperaemia of repair subsides during the late remodelling phase, or when non-union has occurred, but the delayed scan remains hot for several months, as long as remodelling continues. 43 sa journal of radiology • october 2001 thus the age and severity of trauma can be estimated by observing the relative uptake in the three phases of the bone scan. a bone scan is not recommended as the primary imaging modality in detecting fractures, but it is useful when the radiographs are negative despite symptoms, or to assess patients with multiple trauma. fractures in radiologically elusive sites, such as the sacro-iliac (si) joints, anterior ribs, sternum, base of skull, etc. may be visualised. conclusion the stress fracture (sclerosis in the right intertrochanteric region) became radiologically evident by the tenth day. the absence of medullary marrow changes on our patient's day 3 mr! gives further credence to the possibility that the stress fracture developed, or extended, during the days after the marathon, secondary to the 'leg-stretching' runs. long-distance athletes have a notoriously stoical attitude to pain and discomfort. tins attitude, combined with the sacrifices made during months of training, contributes to the discounting of warning signals offered by the body, and results in the 'abnormal stresses to normal bone: and bone and organ failure. if symptoms persist, despite conservative treatment and normal initial imaging, further imaging investigations are indicated. references 1. daffner rh, pavlov h. stress fractures: current concepts. afr 1992; 158: 245-252. 2. grainger rg, allison d. diagnostic radiology. 3rd ed. churchill livingstone, 1999: 1574, 1901 1921. 3. holder le. bone scintigraphy in skeletal trauma. radial clin north am 1994; 31: 739-781. 4. holder le, schwartz c, wernicke pg, michael 1u-i.~adionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. radiology 1990; 152: 509-515. original article percutaneous kidney stone removal history, anatomy and statistical analysis of a group of patients j p van der merwe bmedsc (hons), mb chb c s de vries mmedrad(d) department ot diagnostic radiology university ol the free state bloemfontein history rupel and brown removed the first kidney stone by surgical nephrostomy tract in 1941. a percutaneous tract was developed by ferntrëm and johnson (1976) with the specific aim of removing the kidney stone via the mature tract. inthe latter part of 1970, smith and co-workers developed reliable methods for percutaneous entrance to the pelvis and ureter, and started removing renal pelvic and ureter stones. rathert and aiken removed selective stones via a mature percutaneous tract during the same time.':' anatomy it is necessary to understand the infundibular and calix anatomy, as well as the position and orientation of the kidney inside the body before a percutaneous kidney stone removal is performed. according to kaye and reinke,' brëdel (1901) described the anatomy as follows: 'the posterior calyces point to a line just a little posterior to the lateral convex border of the kidney, while the anterior calyces are directed straight forward into the convex anterior region of the organ'. brodel's illustrations indicate that the anterior calices project ± 700 from the coronal plane of the kidney, while the posterior calices are longer and are projected ± 200 posterior to the coronal plane (fig. i). hodson's model indicates that the posterior calices project to the mid posterior part of the kidney and the anterior calices are longer and are projected just anterior to the convex lateral renal margin (fig. i). on a standard excretory urogram the anterior row calices are usually viewed peripherally from the side as cup-like structures. the posterior rows are viewed more 24 sa journal of radiology • june 2002 hodson anterior posterior fig. 1. models ol kidney anatomy. medially end-on as round concentrations of contrast medium (fig. 2).3 fig. 2, position ol anterior and posterior calices (~ anterior calices, ~ posterior calices), in the case of a brëdel type of kidney the posterior calices are viewed more laterally as cup-like structures, while the anterior calices are situated more medially and are viewed as round concentrations of contrast medium. original article kaye and rienke' studied the renal anatomy of a number of patients using computerised tomography (ct) scans and concluded that the right kidney resembled mostly a brëdel type and the left kidney resembled more a hodson type. statistical analysis the statistical analysis is for data collected during the period 1998 2001 in the intervention unit of the diagnostic radiology department, university of the free state. eighty-five cases were treated. the patients' ages ranged from il to 79 years (average 48 years), 58.5% were male and 41.5% were female. the percentage of patients treated per year is as follows: 18.8% in 1998, 16.5% in 1999, 25.9% in 2000 and 38.8% in 2001. kidney stones were present in one kidney in 97.6% of the patients and bilaterally in 2.4% of the patients. one kidney stone was present in 68.3% of the patients and more than one kidney stone in 31.7% of the patients. the kidney stones were situated in the posterior calix system in all patients except one, where it was situated in the anterior calix system. the position of the kidney stones in the posterior calix system was as follows: 8.8% in the top section, 8.8% in the mid section and 42.5% in the lower section. the kidney stones of only one patient were present intraparenchymally. kidney stones were situated in the pelvis in 35% of the cases and in the ureter in 15% of the cases. more than half (58.8%) of the stones were successfully removed, 23.4% were removed incompletely in a single treatment, and 18.8% of the stones could not be removed. incomplete stone removal was as a result of intraoperative bleeding, extravasation, multiple stones which could not be reached with a single tract, transference of stones to unreachable calices and small residual fragments smaller than 3 mm. wong' reported a success rate of 97% after the following technique refinements: (1) single stadium percutaneous nephrostomy in theatre; (ii) use of a flexible endoscope to judge the entire pelvic-calix system; and (iit) liberal use of secondary percutaneous kidney stone removal to ensure a stonefree status. conclusions percutaneous kidney stone removal is conducted with a high success rate, minimal morbidity and is the procedure of choice for kidney stone removal in most patients as well as children." references 1. ramakumar s, segura tw.renal calculi percutaneous management. ural clin north am 2000; 27: 617-622. 2. . segura tw. endourology. jura! 1984; 132: 1079-1084. 3. kaye kw, reinke db. detailed caliceal anatomy for endourology. j ural 1984; 132: 1085-1088. 4. wong my. evolving technique of percutaneous nephrolithotomy in a developing country: singapore general hospital experience. j endouro!1998; 12: 397-401. 5. badaway h, salama a, eissa m, kotb e, moro h, shoukiri i. percutaneous management of renal calculi: experience with percutaneous nephrolithotomy in 60 children. jural 1999; 162: 1710j 713. 6. maheshwarz pn, andondken m, hegde s, bansal m. bilateral single session percutane nephrolithotomy: a feasible and safe treatment. jendourol2000; 14: 285-287. 25 sa journal of radiology • june 2002 pdf file so the international society of radiology congress blew through the foreshore like the south-easter – hopefully it went well for you? after the lead-up of years of preparation and planning, the actual event passed in a flash. what with the multiple tracks, many outstanding speakers, the generous exhibitor’s displays and catching up with the diaspora, we were truly spoilt for choice. speaking of which, it is really gratifying to see what top-quality exports the country’s graduates make – maybe too good! as with the rsna, it wasn’t remotely possible to get to all the talks one would have liked to attend; the considerable and cosmopolitan array of excellent big-name speakers left many uncertain how best to optimise the experience. another of the consequences of the multiple tracks was that, other than at the impressive opening and closing ceremonies, there was little opportunity for the whole group to gather professionally – it was almost a case of different sub-specialists happening to hold meetings at the same venue, although at least there was the opportunity to cross over to see what the others were talking about. one wonders how many people ran true to form and stuck only to their specific fields? this got me thinking about the various groupings and how compartmentalised we are becoming – the paediatric radiologists, the neuroradiologists, the msk fundis, the vascular, abdomen, ent, chest and emergency groups all have their own identities and, no doubt, idiosyncrasies! maybe we pick some of these up from our interacting clinicians? where is cardiac going to fit in – a hybrid vascular and chest crossover? there do seem to be some natural clusterings – neuroradiology and vascular march to similar beats, git and urological link easily; the same applies to most interventive groupings – vascular and neuro are close, although not in all centres. this highlights a point made by coert de vries and others – after 4 years of training, should there not be another more in-depth year of say two 6-month fellowships? it may ultimately transpire that we split into different sections, much as the surgeons have done. think back to the era of the general surgeon, and how more knowledgeable and skilled today’s surgical subspecialists are. the turnouts of speakers and audience at the free paper sessions were a little mixed and variable, but considering the competition, not surprising! the increasing impact of digital technology in our specialty was brought home in a number of areas; not only by the manufacturers, but by the increasingly critical role of pacs, and the academic benefits of projects such as mypacs.net (http://www.mypacs.net/) and rick hansberger and ann osborn’s new digital, peer-reviewed ‘statdx’ archive (https://my.statdx.com/), evolving from the wonderfully organised and illustrated pocket radiology and diagnostic radiology series. added to which, i saw my first 4g usb stick (loaded with 1 200 cases, from tanzania!) the african sessions starkly juxtaposed the imbalances between and within continents, with some areas lagging sadly. training of medical officer radiologist-equivalents as alternatives to radiologists, and role extension for radiographers were scrutinised as possible solutions in the african and radiography sessions. a continental radiology society is another ongoing initiative. academically the congress was an outstanding success – a minirsna, for a fraction of the cost! the congress executive did a great favour to us, enabling our profession to be exposed to many of the greats for such a reasonable fee. the fact that the rssa executive had the idea of bidding for the congress so many years back, speaks of their foresight – i was proud of the society! the remarkable work by the ever-energetic jan labuscagne over the protracted lead-in period was a major boost to the international profile of south african radiology – thank you, jan! thanks also to my co-track chairs for shepherding their own programs through sometimes uncertain waters. the support by the overseas track chairs was outstanding, with their vital personal contacts and liaison greatly facilitating the strong international representation for all the tracks. we also owe a huge thank you to the congress organising staff, and the exhibitors for their excellent support and superb displays that added great value to the congress. the whole experience was rounded off by a superb african dinner at spier’s moyo restaurant although, for some, by saturday congress fatigue was setting in! so here we are, yet to see the impact of ct/pet rolling out in southern africa, increasing roles in cardiology and oncology, while losing ground in other areas. what do we carry away – contacts, ideas and hope? it was great to network with the leaders in the various fields, and to see our own doing so well. consequences should hopefully be increased professional assurance and appetite for more major international interaction. the process is rolling again, with the next destination the romantic city of marrakesh, morocco, in 2008, june 1-5. by straddling the continent with successive congresses, hopefully this will act as a catalyst to spur on the potential giant of african radiology. hope to see you there?! editorial isr congress: cape town 2006 steve beningfield, mb chb, ffrad (d) department of radiology, university of cape town 2 sa journal of radiology • december 2006 steve beningfield guest editor pg2.indd 1 12/11/06 10:52:50 am case report linear diaphragmatic calcification in a two year-old child with tuberculosis i rachman mb, frcp principal medical officer, brooklyn chest hospital, cape town if he incidental finding, on a chest x-ray, of dense, linear shadows lying above and parallel to one or both domes of the diaphragm, is widely regarded as pathognomonic of calcification due to previous exposure to asbestos. features of asbestos-related pleural thickening differ from the changes seen following tuberculosis pleurisy, even in the absence of symptomatic or radiographic underlying lung disease. in the former, bilateral, fingerlike shadows project from the axilliary margins of one or both lungs, often with bizarre, characteristically' antler' shaped opacities lying more medially. these tend gradually to enlarge and calcify. rarely, there is progression to invasive malignancy, mesothelioma; this may also present as a 'pleural effusion for diagnosis'. in tb, unilateral sheets of diffuse, often hazy shadowing, may be seen, which becomes dense as calcification develops; the diaphragmatic pleura is traditionally spared. g boss mb,och retired chest physician, london 4 sajournal of radiology· may 1998 we describe the case of a young child with x-ray changes typical of pleural asbestosis, in which the mineral could not be reasonably implicated. case report jj, born 21/7/74, was admitted to al stals hospital, cape town, on 14/6/76 with extensive pulmonary tb and paratracheal and hilar lymphadenopathy. the diagnosis was based on a mantoux reaction greater than 10 mm, the presence of afb in gastric washings, and the appearance of the chest x-ray, which showed extensive bilateral pulmonary consolidation, more on the left, and widening of the upper mediastinum (figure 1). she figure 1: admission chest radiograph demonstrating bilateral pulmonary consolidation more marked on the left, and mediastinal widening. no diaphragmatic calcification is seen. was treated with streptomycin, isoniazid, rifampicin and pyrazinamide and made good progress until her discharge on 9/3/77. she had needed transfusing on admission, hb 4. og.an attack of chicken pox two months later did not halt her progress; in particular, no related lung involvement was evident. topage6 enhancing mri • another innovative product in the schering diagnosties range. • convenience schering understands that timing, accuracy and efficacy are of essence inmri • simplicity pre-filled syringes offer fast and easy application magnevist • ease of use injected volume instantly visible through reverse scaling schering (ply) ltd (reg. no. : 64/09072/07) 106 sixteenth road, randjespark, midrand 1685. p.o. box 5278, halfway house 1685. ulo 3198 tel: (011) 313-9700. fax: (011) 313-9793. e-mail: schertngolcon.co.za ~ magnevls" 20 ml. 1 ml solution contelns gadopentetlc acid, dlmeglumlne salt 469,01 mg dtpa, meglumlne salt max. 1,02 mg. reg. no.: w/281199. 32851 linear diaphr<1gnldtic calcificc:1lioll ill d two year old child with tuberculosis frompage4 a fleck of calcification on the right diaphragm can be seen two months after treatment was begun (figure 2), and well marked bilateral linear calcific shadows at the time of discharge from hospital (figure 3). figure 2: chest radiograph two months after commencement of therapy demonstrating partial clearing of lung opacification and small fleck of calcification (arrow) on the right diaphragmatic pleura. figure 3: note linear diaphragmatic pleural calcification (arrows) on chest radiograph 9 months after commencement of therapy. also note calcified mediastinal (open arrow) and cervical (curved arrows) lymphadenopathy. discussion the little girl came from gordon's bay, a coastal village near cape town. no evidence of exposure to asbestos could be obtained. contact with the mineral would, in any case, be most unlikely to cause this x-ray appearance in so young a patient. company news sci-ierinc pre-filled syringes for mr. magnevist® was the first paramagnetic mri contrast agent for intravenous injection. since its introduction, radiologists all over the world have made it the most widely used and extensively documented contrast agent for mr!, according to a spokesperson for schering (pty) ltd. to complement the existing range of magnevist" vials and magnevist simon' cites tuberculosis rheumatoid pleurisy and haemothorax following trauma, as well as asbestos exposure, as possible causes of linear diaphragmatic calcification. the reason for the rarity of diaphragmatic pleurisy leading to calcification in the relatively common diseases cited by simon is not clear. a subpneumonie inflammatory effusion could conceivably be affected by reduced or altered movement of the diaphragm, leading to a more rapid resolution, with fewer sequelae. on the other hand, the ability of the asbestos fibres to penetrate the pleura causing an asymptomatic inflammatory reaction leading finally to calcification, could presumably be related to the extreme chronicity of the process, said to be not less than about 20 years and often much longer. perhaps we should revise our interpretation of linear diaphragmatic calcification seen on the chest x-ray. reference i. simon g. chest x-ray diagnosis. 3'" ed, 1971, p109. enteral", the company has introduced magnevist" in prefilled syringes. launched on april l ", magnevist pre-filled syringes present a new era in mri convenience. the syringes are available in readyto-use l o, is, and 20 ml sizes, and the injection volume is instantly visible through reverse scaling. the syringes are competitively priced and available in prepacked boxes of s syringes. the magnevis~ pre-filled syringes from schering 6 sajournal of radiology· may 1998 information from schering (pty) ltd, tel (011) 313-9700. http://www.sajr.org.za open access sa journal of radiology issn: (online) 2078-6778, (print) 1027-202x page 1 of 1 corrigendum read online: scan this qr code with your smart phone or mobile device to read online. authors: gopolang magano1 tanyia pillay1 susan lucas1 affiliations: 1department of diagnostic radiology, university of the witwatersrand, south africa corresponding author: gopolang magano, maganogopolang01@gmail. com dates: published: 27 nov. 2017 how to cite this article: magano g, pillay t, lucas s. corrigendum: paediatric doctors’ error rate in detection of paediatric elbow injuries in rahima moosa mother and child hospital. s afr j rad. 2017;21(1), a1287. https://doi. org/10.4102/sajr.v21i1.1287 copyright: © 2017. the authors. licensee: aosis. this work is licensed under the creative commons attribution license. in the version of this article initially published, susan lucas’s last name was misspelled as ‘lucus’. the error has been corrected in the pdf version of the article. corrigendum: paediatric doctors’ error rate in detection of paediatric elbow injuries in rahima moosa mother and child hospital read online: scan this qr code with your smart phone or mobile device to read online. note: doi of original article: https://doi.org/10.4102/sajr.v21i1.1124 http://www.sajr.org.za mailto:maganogopolang01@gmail.com mailto:maganogopolang01@gmail.com https://doi.org/10.4102/sajr.v21i1.1287 https://doi.org/10.4102/sajr.v21i1.1287 http://crossmark.crossref.org/dialog/?doi=10.4102/sajr.v21i1.1287=pdf&date_stamp=2017-11-27 https://doi.org/10.4102/sajr.v21i1.1124 case report 29 sa journal of radiology • december 2006 brown tumours are an end-stage complication of hyperparathyroidism. they are relatively rare today, due to earlier diagnosis and prompt treatment of hyperparathyroidism.1 common locations are the mandible, pelvis, ribs and long bones of the axial skeleton.2 the skull base is an extremely rare site and, for obvious reasons, it is difficult to confirm the diagnosis in the absence of other lesions. in the face of a solitary lesion, a histological diagnosis of a ‘giant-cell tumour’ of benign nature should only be made once hyperparathyroidism has been actively excluded. brown tumours, solid aneurysmal bone cysts, giant-cell reparative granuloma and giant cell tumour can all appear identical both macro and microscopically.2 case report the middle-aged female patient had presented initially 2 years before with a pathological fracture of her left proximal humerus. radiographs revealed a large lytic and expansile lesion of the left humeral diaphysis, complicated by a pathological fracture. histology reported a ‘giant cell tumour’ after surgical resection. a prosthesis was inserted, with no record of further follow-up. one year later she re-presented with pain in her left shoulder, hip and anterior tibia, and x-rays and bone scans suggestive of ‘metastases’. a raised serum calcium was documented, but without any further investigation. she then received radiotherapy, presumably for pain palliation. after several follow-up visits, a persistently elevated serum calcium (3.51 mmol/l) caused concern and she was admitted for further investigations. these revealed an elevated parathyroid hormone level of 156 pmol/l, with raised alkaline phosphatase (457 u/l) and lacate dehydrogenase (489 u/l). a repeat bone scan showed the classic appearance of a ‘bearded’ superscan, due to mandibular involvement (fig. 1). a sestamibi scan revealed a lesion in the inferior left parathyroid. numerous other hotspots in the left tibia, pelvis and skull consistent with brown tumours were noted. prior to her most recent admission, she presented with headaches and cranial nerve 3, 4 and 5 palsies. ct demonstrated a destructive base of skull lesion (fig. 2), as well as the maxillary and mandibular lesions shown on the bone scan. mri t1-weighted post-gadolinium sequences confirmed that this enhancing base of skull lesion invaded the right cavernous sinus and optic canal (figs 3 5). based on the above findings, a presumptive diagnosis of a brown tumour of the skull base was made. discussion as mentioned, brown tumour of the base of skull is exceedingly rare, with only four cases with sellar involvement reported in the english literature on hyperparathyroidism, and two with optic nerve involvement.3,4 the differential diagnosis of an expansile, erosive sellar-parahyperparathyroidism with presumed sellar-parasellar brown tumour based on imaging findings q said-hartley, mb chb s candy, mb chb, fcrad (d) department of radiology, groote schuur hospital, cape town case report fig. 1. involvement of maxilla, mandible and skull base on bone scan. fig. 2. ct shows expansile, lytic lesion of the right skull base and anterior clinoid process. pg29-30.indd 29 12/11/06 11:01:26 am case report case report 30 sa journal of radiology • december 2006 sellar mass with optic nerve involvement includes pituitary pathology, metastatic carcinoma, sarcoidosis, fibrous dysplasia, giant-cell reparative granuloma, chordoma, chondrosarcoma, plasma cell tumour and osteosarcoma. hyperparathyroidism should be included when subperiosteal bone resorption is present. in view of the histological appearance and similarity to other giant-cell tumours and similar lesions, brown tumour must always be considered in the differential diagnosis and active steps be undertaken to exclude hyperparathyroidism. 1. goswami p, sarma pk, sethi s, hazarika s. skeletal manifestations in a case of primary hyperparathyroid -ism caused by parathyroid adenoma. ind j radiol imag 2002; 12: 267-270. 2. bone tumours: clinical, radiologic and pathologic correlations. philadelphia: lea and febiger, 2006. 3. magu s, mathur sk, gulati sp, yadav a, kaushal v. giant cell reparative granuloma of the base of the skull presenting as a parapharyngeal mass. neurol india 2003; 51: 260-262. 4. yilmazlar s, arslan e, aksoy k, tolunay s. sellar-parasellar brown tumor: case report and review of litera ture. skull base 2004; 14: 163-168. fig. 3. t1w gadolinium-enhanced mri shows enhancing right parasellar mass. fig. 4. enhancing right parasellar/paracavernous mass on coronal postgadolinium imaging. fig. 5. extension into right cavernous sinus. pg29-30.indd 30 12/11/06 11:01:26 am case report bronchiolitis obliterans an illustrative case following toxic fume exposure basil j sher fcrad(d)sa ian c duncan ffrad(d)sa sunninghili medical institute johannesburg abstract bronchiolitis obliterans is a condition where irreversible narrowing of small airways leads to chronic airflow obstruction. usually an associated underlying condition can be identified. the diagnosis depends upon this together with the appropriate lung function abnormalities and radiological features. we describe a case of bronchiolitis obliterans that developed after toxic fume inhalation and which demonstrates the typical clinical, physiological and radiological features on which the diagnosis of this condition is made. introduction bronchiolitis obliterans is a condition where chronic irreversible airflow obstruction develops in the small airways in response to some associated noxious stimulus. making the diagnosis depends upon a constellation of diagnostic features including: (l) the appropriate history of an associated underlying causative pathology or noxious stimulus; (ii) clinical evidence of diminished lung function; and (ii1) the appropriate correlative radiological features. case report a previously healthy 26-year-old male presented with shortness of breath and wheezing. an industrial accident had involved toxic fume inhalation some 5 months prior to this. an obstructive picture was obtained on lung function testing. a high-resolution ct scan of the chest was requested to investigate the lung abnormality further. inspiratory and expiratory chest radiographs were normal (fig. i). high-resolution ct images of the lungs were obtained using 1.5 mm collimation and 10 mm spacing during both end-inspiration and endexpiration. the images were initially viewed at a window level of -645 hounsfield units (hu) and a window width of 1 660 hu, and the appearance suggested a mosaic attenuation pattern accentuated with end-expiration compatible with areas of air trapping (fig. 2). this appearance was further exaggerated by decreasing the window level to -902 hu and the window width to 1 023 hu (fig. 3). bronchiectasis was present involving the lower lobe segmental bronchi (fig. 4). there were no areas of consolidation, and no reticulonodular opacities were noted. on the basis of the lung function testing and the ct appearance, and given the history of toxic fume exposure, a diagnosis of bronchiolitis obliterans was made. discussion bronchiolitis obliterans (also termed constructive bronchiolitis, or obliterative bronchiolitis) is characb figs te and lb. inspiratory (1a) and expiratory (ib) frontal chest radiographs appear normal, particularly with a normal pulmonary vascular appearance and no evidence of air trapping. 43 sa journal of radiology • december 2002 case report figs 2a and b. high-resolution scan slices taken during inspiration (2a) and expiration (2b). areas of mosaic attenuation are apparent on the expiratory phase scan. figs sa and b. the same scan slices as in fig. 2 taken at different window settings that further accentuate the mosaic attenuation pattern. the darker areas are the normal ones indicating areas of air trapping and hypoperfusion. fig. 4. bronch/al dl/ation and wall thickening are also present. terised histologically by fibrosis of the submucosal and peribronchial tissues of terminal and respiratory bronchioles producing concentric narrowing of the bronchiolar lumen. characteristically there is very little associated inflammation. the clinical severity is dependent upon the number of bronchioles involved as well as the degree of narrowing of their lumina. it is non-uniform in distribution. no inflammatory or infiltrative changes are seen in the adjacent parenchyma. the development of bronchiolitis obliterans is closely related to a number of associated pathologies (table i). it is very rarely truly idiopathic. the diagnosis is extremely difficult to make at open lung biopsy, and relies more upon the combination of clinical features, lung function testing and the radiographic findings. usually there is a history of some relevant associated pathology. lung function testing shows irreversible airflow obstruction with a forced expiratory volume in 1 second (fevi) of less 44 sa journal of radiology • december 2002 table i. aetiological associations of bronchiolitis obliterans i. post infective viral adenovirus respiratory syncytial virus influenza parainfluenza cytomegalovirus hiv non viral mycoplasma pneumonia pneumocystis carinii bacterial pneumonia 2. toxic fume inhalation nitrogen dioxide (silo-filler's disease) sulphur dioxide ammonia chlorine phosgene 3. drug reaction penicillamine gold lomustine 4. connective tissue disorders rheumatoid arthritis sjogren's syndrome polymyositis 5. transplantation bone marrow transplant (graftversus-host rejection) lung transplant heart and lung transplant 6. miscellaneous inflammatory bowel disease pulmonary neuroendocrine cell hyperplasia/carcinoid microtumours bronchopulmonary dysplasia s. androgynus ingestion bronchiectasis, cystic fibrosis cryptogenic very rare than 60% of the predicted value in the absence of any other cause of airway obstruction. plain film chest radiography may show either no abnormalities or evidence of mild air trapping or hyperincase report flation and mild peripheral pulmonary vascular attenuation. the high resolution ct (hrct) findings include the following: 1. the 'mosaic attenuation' or 'mosaic perfusion' pattern. this consists of multifocal areas of decreased lung attenuation, i.e. 'darker areas, which may be either poorly or sharply defined. these areas of decreased attenuation result from a combination of air-trapping secondary to the bronchiolar narrowing as well as reduced perfusion due to secondary hypoxic vasoconstriction in these poorly ventilated areas. as a result there is a preferential shunting of blood to the normally ventilated areas of the lung which accentuates the mosaic appearance. with more extensive lung involvement the mosaic pattern is replaced by a more homogeneous hypoattenuation pattern. the term 'mosaic attenuation' is somewhat of a misnomer as the pathological areas of the lung parenchyma are actually the darker ones, i.e. the areas of reduced beam attenuation. the mosiac pattern becomes even more exaggerated on expiratory hrct images as the areas of air trapping remain dark whereas the normally perfused areas (which are relatively hyperperfused) become relatively denser and smaller in crosssectional area. 2. decreased calibre of the pulmonary vasculature in affected areas. there is a reflex hypoxic vasoconstriction in the areas where air trapping is found. with larger confluent areas of involvement this results in the narrowing of macroscopic pulmonary arterial branches. eventually this vascular constriction becomes permanent. 3. bronchiectasis and bronchial wall thickening. in many cases both bronchial dilation and wall thickening are seen in the affected areas. occasionally the obstructed bronchioles can fill with inspissated secretions creating small centrilobular branching opacities or the 'tree-in-bud' appearance. finally it is important to note the following points concerning bronchiolitis obliterans. firstly, if the areas of air-trapping are extensive enough the characteristic mosaic pattern may not be seen and the lungs may appear homogeneously dark on end-expiratory scans. on the other hand, subtle changes may require manipulation of the image window levels and widths to show the affected areas adequately. secondly, the signs mentioned above are not unique to bronchiolitis obliterans and may be seen in other obstructive pulmonary diseases. therefore the diagnosis is made based upon a combination of the clinical features, hrct findings, and history or clinical evidence of any relevant associated cause or underlying condition. thirdly, the swyer-lames or macleod's syndrome is probably the same pathological process occurring in the relatively immature lungs of infants and young children, usually in response to a viral lung infection. and lastly, as the anatomical changes related to bronchiolitis obliterans are permanent due to bronchiolar fibrosis with little or no associated inflammatory component there is generally a poor clinical response to steroid therapy. conclusion the diagnosis of bronchiolitis obliterans cannot be made on the radiological features alone but requires correlation with the lung function testing and relevant clinical information as well. hrct scanning is useful in showing areas of air-trapping, secondary circulatory shunting and vascular attenuation, but requires meticulous attention to the acquisition and presentation of the images so as to optimise and accentuate the mosaic attenuation pattern and other associated features. recommended reading i. webb wr, muller nl, naidich op. airway's diseases. in: webb wr, muller nl, naidich op, eds. high resolution ct of the lung. 3rd ed. philadelphia: lippincott, williams and wilkins, 2001: 467-546. 2. worthy sa, muller nl. small airway diseases. radial clin north am 1998; 36: 163-173. 3. arakawa h, webb wr. expiratory high-resolution ct scan. radial clin north am j 998; 36:189-209. 4. hansell om. hrct of obliterative bronchiolitis and other small airways diseases. sernin roelltgenol200 i; 36: 51-65. 5. collins j, stern ei. 'tree-in-bud' pattern of bronchiolar disease. tile radiologist 1999; 6: 173-181. 45 sa journal of radiology • december 2002 abstract epigraph introduction methods results discussion conclusion acknowledgements references about the author(s) efosa p. iyawe college of medicine, university of ibadan, ibadan, oyo state, nigeria bukunmi m. idowu department of radiology, union diagnostics and clinical services plc, yaba, lagos state, nigeria olasubomi j. omoleye department of general medicine, louismed hospital and fertility centre, lekki phase 1, lagos state, nigeria citation iyawe ep, idowu bm, omoleye oj. radiology subspecialisation in africa: a review of the current status. s afr j rad. 2021;25(1), a2168. https://doi.org/10.4102/sajr.v25i1.2168 review article radiology subspecialisation in africa: a review of the current status efosa p. iyawe, bukunmi m. idowu, olasubomi j. omoleye received: 20 apr. 2021; accepted: 04 july 2021; published: 30 aug. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: radiology subspecialisation is well-established in much of europe, north america, and australasia. it is a natural evolution of the radiology speciality catalysed by multiple factors. objectives: the aim of this article is to analyse and provide an overview of the current status of radiology subspecialisation in african countries. methods: we reviewed english-language articles, reports, and other documents on radiology specialisation and subspecialisation in africa. results: there are 54 sovereign countries in africa (discounting disputed territories). eighteen african countries with well-established radiology residency training were assessed for the availability of formal subspecialisation training locally. eight (egypt, ethiopia, kenya, morocco, nigeria, south africa, tanzania, and tunisia) out of the 18 countries have local subspecialist training programmes. data and/or information on subspecialisation were unavailable for three (algeria, libya, and senegal) of the 18 countries. paediatric radiology (ethiopia, nigeria, south africa, tunisia) and interventional radiology (egypt, kenya, south africa, tanzania) were the most frequently available subspecialist training programmes. except tanzania, all the countries with subspecialisation training programmes have ≥ 100 radiologists in their workforce. conclusion: there is limited availability of subspecialist radiology training programmes in african countries. alternative models of subspecialist radiology training are suggested to address this deficit. keywords: africa; curriculum; education; radiology; specialist training; subspecialisation; web-based learning. epigraph ‘a radiologist is a clinician who has sacrificed one of the greatest glories of the practice of medicine and its greatest responsibility – the daily contact with the ill and their families – in order to concentrate more on the essence of our profession, the pathology of the living. this he sees through the medium of shadows which has left him open to the charge of not quite being a clinician. but shadows after all are real. seeing is done with the mind. the camera does not see, it records. the clinician at the bedside sees the patient and imagines the lesion. the radiologist sees the lesion and imagines the patient’. [harry z. mellins, md (1921 – 2009); former professor of radiology, harvard medical school] introduction clinical and non-clinical knowledge, procedural expertise, computer literacy/proficiency in information technology, knowledge of diagnostics, and non-interpretive skills are an integral part of postgraduate training in radiology:1,2,3 a radiologist is a specialist medical doctor who has had postgraduate training in performing and interpreting diagnostic imaging tests, and carrying out interventional procedures or treatments, using x-ray, ultrasound, and magnetic resonance imaging equipment.4,5 a medical speciality is a branch/subdivision/subset of medicine that focuses on or is devoted to a specific or defined category of patients, illnesses or disorders, expertise or skills, or philosophy or theory.6 radiology, internal medicine, paediatrics, otorhinolaryngology (orl), ophthalmology, surgery, and so on, are examples of medical specialities. a physician who has specialised in a medical speciality is a specialist. in contrast, a generalist’s competencies, proficiency, interests, and skills/expertise are diverse, eclectic, comprehensive, and unspecialised. in other words, a generalist maintains a broad scope of practice.7,8 a general radiologist is one who has undergone a radiology residency without completing a fellowship or any other subspeciality training.9 a subspeciality is a narrow field of professional knowledge, skills, expertise, and focus within a broader medical speciality:10 subspecialisation entails the devotion of intellectual energies to understand more and more about a narrower aspect of a speciality. it provides an intense exposure to a subspeciality area allowing a focused development of clinical and surgical skills related to that subspeciality area.11,12 subspecialisation requires knowledge, expertise, and practice beyond that of a specialisation. specific personnel, equipment, technology, dedicated curriculum, accredited training centres, logbooks, exposure to complex cases, high case volumes, subspecialist international journals, international subspecialist societies/associations, and relevant scientific breakthroughs in the field are the sine qua non of subspecialisation.13 in essence, a radiology subspeciality should have a unique body of knowledge that cannot be subsumed under general radiology, a peculiar applicability distinct from general radiology, an evidence of improved patient care because of subspecialist input, a structured formal training, and accruable benefits which outweigh any negative impact on the extant general radiology or other radiology subspeciality.14 factors such as the expansive and multifaceted nature of radiology, rapid development of new imaging modalities, the need for subspecialist radiology interpretation for subspecialist referring physicians, more competitive job market, increased prospects of better remuneration, improved professional standing (status symbol), and so on, are the chief drivers of the quest for subspecialisation in radiology.15 existing radiology subspecialities include system-based subspecialities (cardiovascular imaging, chest imaging, orl/dental imaging, breast imaging, musculoskeletal imaging, gastrointestinal imaging, uroradiology, obstetric & gynaecological imaging, neuroradiology); technique-based subspecialities (nuclear medicine/radionuclide radiology, interventional radiology [ir]); disease-based subspecialities (oncological imaging, trauma imaging, emergency radiology); age-based subspecialities (paediatric imaging); and emerging subspecialities (global radiology, radiology informatics, forensic radiology).16 in general, ‘radiology’ arrived in africa, not too long after roentgen discovered x-rays in 1895, when x-ray machines became available in south africa (1896),17 egypt (1906),18 uganda (1907),19 nigeria (1913),20 and so on. however, the commencement of radiology postgraduate residency and subspecialisation in african countries seems to have lagged behind the rest of the world. an article published in 2019 reported that subspeciality training was available in 0%, 55%, and 74% of african, european, and asian countries, respectively.21 the pros and cons of radiology subspecialisation had been discussed comprehensively by other authors.9,22,23,24,25,26 this research aims to investigate the current status of radiology subspecialisation training programmes in africa and to identify the obstacles to the actualisation of this laudable aspiration. the focus is on the availability of local formal training programmes rather than the presence or absence of practising subspecialist radiologists in the health workforce of the countries evaluated. methods we searched the literature using google search engine (primarily), google scholar, and african journal online. the keywords comprised the name of the countries together with the words radiology, specialisation, and subspecialisation in various combinations. the references cited in the retrieved articles provided additional information. the country reports published by rad-aid international (https://rad-aid.org/resource-center/country-reports) were invaluable sources of data. the last search was performed on 20th april 2021. a few north african radiologists were also contacted by email to provide information about their countries, but we received a response from only one of them. results a summary of available subspecialist radiology training programmes in different african countries is presented in table 1. only those countries with well-established radiology residency training were assessed for the availability of formal subspecialisation training locally. eight (egypt, ethiopia, kenya, morocco, nigeria, south africa, tanzania, and tunisia) out of the 18 african countries with well-established radiology residency training have local subspecialist training programmes. east africa (three countries), north africa (three countries), southern africa (one country), and west africa (one country) make up the regional spread. data/information on subspecialisation were unavailable for three of the 18 countries (algeria, libya, and senegal). except for tanzania, all the countries with subspecialisation training programmes have ≥ 100 radiologists in their workforce. table 1: current status of radiology subspecialisation in africa. paediatric radiology paediatric radiology subspeciality training is available in south africa, ethiopia, and possibly, tunisia. south africa in south africa, paediatric radiology subspeciality training began in 2009 at the red cross war memorial hospital in cape town. it is a 1-year programme after which successful candidates are awarded a postgraduate diploma in paediatric radiology by the university of cape town. subspeciality training in paediatric imaging is also available at the nelson mandela children’s hospital in johannesburg (opened officially in december 2016).27 also in south africa, the world federation for paediatric imaging (wfpi), under the auspices of the william shiels memorial foundation, offers a 3-month funded paediatric radiology observership in south africa, at either the red cross war memorial children’s hospital in cape town or the nelson mandela children’s hospital in johannesburg. the first wfpi observer/fellow completed her observership in 2018. the 2020 programme was shelved because of the covid-19 pandemic.28 ethiopia efforts to set up a paediatric radiology subspeciality training programme at the department of radiology, addis ababa university, ethiopia commenced in 2012 as a 4-year outreach programme by paediatric radiology staff of the children’s hospital of philadelphia (chop), perelman school of medicine, university of pennsylvania, usa (chop paediatric radiology international outreach programme) in collaboration with the wfpi. the 2-year-long subspeciality fellowship programme finally took off in 2015 and has already produced two locally trained paediatric radiologists (graduated in 2017). there are three new trainees in the programme as of 2019.50,51,52 tunisia professor hassen el-akeba gharbi is a celebrated tunisian paediatric radiologist and past president of the world federation for ultrasound in medicine and biology (wfumb), who started a paediatric radiology department at the children’s hospital, tunis, tunisia, in 1970. he taught paediatric radiology at the hospital, and the programme still exists.53 only the radiology department of the children’s hospital in tunis can train paediatric radiologists (prof. ibtissem bellagha, 2020, personal email communication, 08 october) nigeria a recent article from nigeria indicates that paediatric radiology subspeciality training became available under the auspices of the west african postgraduate medical college in 2019. it appears that the programme is still nascent and the details are sketchy.54 continental professional association/society the african society of paediatric imaging (afspi) was formalised on 30th october 2012.55 interventional radiology subspeciality training in ir is available in egypt, south africa, kenya, tanzania, tunisia, and morocco.29,56,57 south africa formal 1-year subspeciality training in ir was established at the university of the orange free state (uofs), bloemfontein, in 2002. a diploma in ir of the uofs is conferred at the successful completion of the programme.57 more training centres may have been established in south africa thereafter. egypt in egypt, there is no structured nationwide ir fellowship yet; however, ir subspeciality certification is currently organised via two pathways for doctors who have already completed their diagnostic radiology training. firstly, there is institution-based training in which fellows rotate through 4–5 self-selected training centres from a pool of 10 accredited training institutes/university hospitals. secondly, candidates can apply to the egyptian board of interventional radiology (currently the only official ir specialty board certificate in egypt) for a 2-year training program.56,58,59 tanzania the tanzanian 2-year ir subspeciality curriculum took off in october 2019 at the muhimbili national hospital (mnh) in dar es salaam.60 the first class of three fellows is expected to graduate by september 2021 with a master of science in interventional radiology to be awarded by the muhimbili university of health and allied sciences (muhas). the tanzanian ir project was midwifed by the rad-aid international ir program in collaboration with academic institutions in the united states and europe.47,60,61 kenya in june 2020, the university of nairobi’s senate approved a 2-year ir fellowship domiciled at the university’s department of diagnostic imaging and radiation medicine. the inaugural class of kenyan diagnostic radiologists would be enrolled later in 2020. this programme was established with the help of the university of north carolina at chapel hill (division of vascular-interventional radiology & division of radiologic science) and rad-aid international.62 finally, there is circumstantial evidence of ir subspeciality training in morocco and tunisia,59 but details of the programmes could not be obtained. continental professional association/society the society of african interventional radiology and endovascular therapy (safire) is the continental professional association of interventional radiologists in africa. some of the north african countries are also members of the pan arab interventional radiology society (pairs). women’s imaging there is anecdotal evidence of institution-based subspeciality training in women’s imaging at cairo university in egypt. discussion as stated at the introduction, a previous article published in 2019 reported inaccurately that subspeciality training was available in 0% of african countries. this misinformation is likely because of the general paucity of information on the evolution of radiology in african countries. as can be seen from our data, ir training had been available in south africa since 2002. the quest for radiology subspecialisation seems to have accelerated in the last 5 years across the continent. in spite of this positive development, many hurdles still remain. obstacles to the establishment of radiology subspecialisation in africa africa, being a continent of mostly developing and underdeveloped countries, faces many challenges to the smooth implementation of radiology subspecialisation. some of these obstacles include lack of funding, equipment and infrastructure deficit, unavailability of expertise, politics, emigration of radiologists, perfectionism, and so on. funding generally, the health sector is not adequately funded by many african governments and other stakeholders. the improvement of any field or speciality requires adequate funding for optimal growth and development. sufficient funding allows for proper training of radiologists and scholarly research in the field of radiology. equipment and infrastructure modern equipment and infrastructure are crucial to the training of competent subspecialist radiologists. the poor funding of health care in many african nations has made it impossible to acquire new equipment. these inadequacies impede the creation of the top-level educational environment required for specialist and subspecialist tutoring.63 expertise the quality of experts in a field is a product of the training that the specialists had received. it takes a subspecialist to train a subspecialist. currently, many african countries have insufficient subspecialist manpower, which makes it difficult to initiate subspecialisation training programmes. emigration many african medical graduates aim to leave the continent for greener pastures abroad. this medical exodus robs the continent of critically needed expertise.64,65 the mass emigration further worsens the already low radiologist-to-population ratio in many african countries. african radiologists seeking subspecialisation often travel outside africa to train, but many of them do not return to their home country once they find better opportunities abroad. if subspecialisation programmes are established locally, the attrition of african radiologists might be mitigated.66,67 politics sometimes, obtaining approval for new programmes requires savvy political manoeuvring, lobbying, and horse-trading. bureaucratic red tape is a feature of governmental regulatory agencies worldwide, and african nations are no different. radiology is a relatively ‘invisible’/‘behind-the-scenes’ medical speciality. consequently, it might be an uphill task to secure governmental backing and funding for programmes without accruable political mileage.68 interprofessional rivalries at the universities and teaching hospitals could also derail the successful take-off of new training programmes.69 recommendations given the perennial obstacles to subspecialisation enumerated above, especially funding constraints, african radiologists (with foreign collaboration when needed) can leverage existing and emerging technologies and innovative training/learning methods to streamline the training of subspecialist radiologists. web-based training was piloted in ethiopia over a 20-month period using pre-recorded online lectures, case reviews, and learning modules, overseen by subspeciality-trained radiologists of the johns hopkins university school of medicine.21 a similar web-based learning tool for paediatric radiology (with users all over the united states and 53 other countries) is used to deliver paediatric radiology curriculum internationally by paediatric radiologists in the usa.70,71 web-based training is cheaper, adaptable, more accessible, and effective.21,72 the european diploma in emergency radiology subspeciality is delivered using a combination of self-directed learning, webinars, workshops, research & teaching, as well as on-the-job training.73 electronic teaching files and internet-accessible case collections are also being used increasingly for radiology subspecialisation training in other european countries with limited access to complex equipment.25 simulation-based technology and immersive training environment for ir have also been proposed.74,75 a complementary business model of medical subspeciality training that incorporates the private sector has been developed for reproductive medicine in south africa by dalmeyer et al.76,77 the authors are convinced that the model can be applied to other subspecialities. conclusion there is limited availability of subspecialist radiology training in african countries. cost-effective and innovative approaches to training are needed to address this deficit. this study was limited by unavailability of data on subspecialisation in algeria, libya, and senegal. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them 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in nigeria’s health sector: a comparison of doctors and other health workers’ views at a secondary care center. int q community health educ. 2017;38(1):9–16. https://doi.org/10.1177/0272684x17748892 chudakoff j, obuchowski n, mehta n, reid j. worldwide utilization of a web-based learning tool for pediatric radiology. ajr am j roentgenol. 2013;200:974–979. https://doi.org/10.2214/ajr.12.10443 reid jr, goske mj, hewson mg, obuchowski n. creating an international comprehensive web-based curriculum in pediatric radiology. ajr am j roentgenol. 2004;182(3):797–801. https://doi.org/10.2214/ajr.182.3.1820797 hoa d, micheau a, gahide g. creating an interactive web-based e-learning course: a practical introduction for radiologists. radiographics. 2006;26(6):e25–e25. https://doi.org/10.1148/rg.e25 wagner mg, fischer mr, scaglione m, et al. subspecialisation in emergency radiology: proposal for a harmonised european curriculum. gms j med educ. 2017; 34:61. mandal i, ojha u. training in interventional radiology: a simulation-based approach. j med educ curric dev. 2020;7:2382120520912744. https://doi.org/10.1177/2382120520912744 mccarthy cj, yu ayc, synho d, dawson sl, uppot rn. interventional radiology training using a dynamic medical immersive training environment (dynamite). j am coll radiol. 2018;15:789–793. https://doi.org/10.1016/j.jacr.2017.12.038 dalmeyer p, struwig m, kruger t. a trial model for medical subspecialty training in south africa. facts views vis obgyn. 2016;8:55–58. dalmeyer jpf. a business model for medical subspecialist education in south africa [homepage on the internet] [phd thesis]. south africa, port elizabeth: at the nelson mandela metropolitan university of south africa; 2015 [cited 2020 apr 20]. available from: https://tinyurl.com/8u3kjedy abstract introduction case report discussion conclusion acknowledgements references about the author(s) atish vanmali department of diagnostic radiology, jackpersad and partners, durban, south africa kamlesh d. daji department of diagnostic radiology, jackpersad and partners, durban, south africa citation vanmali a, daji kd. pneumorrhachis: an uncommon radiological entity. s afr j rad. 2021;25(1), a2255. https://doi.org/10.4102/sajr.v25i1.2255 case report pneumorrhachis: an uncommon radiological entity atish vanmali, kamlesh d. daji received: 26 july 2021; accepted: 13 sept. 2021; published: 29 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract pneumorrhachis (pr) is a rare and interesting phenomenon, in which air is present within the spinal canal. the aetiologies are varied, broadly grouped as traumatic, non-traumatic or iatrogenic. pneumorrhachis secondary to spontaneous pneumomediastinum (spm) and barotrauma of the lungs is uncommon and even rarer within the paediatric group. this report describes a paediatric patient presenting with a persistent cough who developed a spm and subsequent pr. keywords: pnuemorrhachis; spontaneous pneumomediastinum; epidural air. introduction pneumorrhachis (pr) is a rare clinical entity in which air is present within the extradural or intradural compartments of the spinal canal.1 it is rarely associated with pneumomediastinum, particularly in young children.2 the common causes listed include epidural trauma from spinal fracture, epidural instrumentation for lumbar puncture, epidural anaesthesia or ‘spontaneous pneumomediastinum’.1 case reports have described pr in the setting of direct trauma to the spine or skull and within the context of pneumomediastinum, pneumopericadium and pneumoperitoneum.3 awareness of the benign nature of the evolution of pr in the presence of pneumomediastinum is important to prevent additional imaging, instrumentation and other unnecessary measures.3 case report an 8-year-old female presented to the family medicine specialist with a 2-day history of persistent cough, fever and dyspnoea. her past medical history was insignificant, with no history of asthma or prior hospital admissions. her immunisation complied with the national immunisation schedule. on admission, her oxygen saturation, measured by pulse oximetry (spo2) was normal (99% – 100%). a chest radiograph (figure 1) demonstrated pneumomediastinum and subcutaneous emphysema. figure 1: chest radiograph on admission demonstrating subcutaneous emphysema (red arrow) and pneumomediastinum (blue arrow). for improved delineation of the extent of the spontaneous pneumomediastinum (spm), an urgent ct scan of the chest (figure 2a and 2b) was performed. extensive pneumomediastinum and subcutaneous emphysema was demonstrated. figure 2: (a and b) axial post contrast (ct) scan, soft tissue and lung settings, respectively, demonstrating subcutaneous emphysema (red arrow), pneumomediastinum (blue arrow) and epidural emphysema (green arrow). air tracking into the posterior epidural space (pneumorrhachis) at multiple levels of the cervical and thoracic spinal canal was also observed (figure 3a and b). bilateral lower lobe bronchial wall thickening was noted but there were no features of atelectasis or air trapping. figure 3: (a and b) sagittal reconstructed image through the thoracic spine and axial image at level of carina, lung settings, demonstrating epidural emphysema (green arrow). a water-soluble contrast swallow excluded any oesophageal perforation (figure 4). the patient remained comfortable and was managed conservatively with medical treatment demonstrating improvement of symptoms. the patient was subsequently discharged and follow up was scheduled in three weeks. figure 4: (a, b and c) contrast swallow of the cervical and thoracic oesophagus excluded oesophageal perforation. discussion pneumomediastinum is a benign entity, defined as free air within the mediastinum and classified as spontaneous or secondary.4 secondary pneumomediastinum that requires urgent intervention is secondary to recent intervention, history of aero-digestive organ injury, cervico-thoracic infection, pneumothorax or mechanical ventilator-related injury. spontaneous pneumomediastinum is diagnosed without any cause.4 although spm is associated with a benign clinical course, an important and difficult differential to exclude is oesophageal perforation or boerhaave’s syndrome. oesophageal perforation that arises from spontaneous rupture is associated with higher mortality than the iatrogenic or traumatic causes.5 spontaneous pneumomediastinum and subcutaneous emphysema (hamman syndrome) results from rupture of the alveoli secondary to increased intrabronchial pressure that may occur in the background of coughing, shouting, vomiting or after labour.6 the macklin effect refers to the increase in alveolar pressure that results in alveolar rupture. the alveolar air dissects through the pulmonary interstitium along the bronchovascular sheaths towards the hila and mediastinum.7 the most common symptoms of spm are dyspnoea, cough, neck pain, chest pain and dysphagia. subcutaneous emphysema is the commonest clinical finding followed by hamman’s sign, which is pathognomonic of pneumomediastinum.8 hamman’s sign refers to the crunching sound over the mediastinum, synchronous with the heartbeat.8 a rare complication of spm is pr, which was demonstrated in the case presented. air within the cervical subarachnoid space producing a ‘pneumomyelogram’ was initially described by gordon et al.9 this was documented on the background of trauma and subsequently described under various terms. the term pr was first applied 10 years later by newbold et al.10 pneumorrhachis is anatomically classified into intradural (intraspinal air within the subdural or subarachnoid space) and extradural (intraspinal, epidural air). intradural pr is associated with major trauma and suggestive of severe injury, and extradural pr is usually innocuous.11 the aetiology of pr may be classified into traumatic, non-traumatic and iatrogenic. air can enter the spinal canal from traumatic spinal leaks or penetrating injuries. iatrogenic causes are related to recent surgical or anaesthetic manipulations. non-traumatic causes occur as a result of respiratory complications secondary to high intrathoracic pressure and barotrauma.11 the other non-traumatic aetiologies are associated with degenerative, malignant, inflammatory and infectious disease by a gas forming organism.12 pneumorrhachis in the context of trauma indicates severe injury.8 in 1989, tsuji et al. described the first ct demonstration of spinal epidural emphysema following bronchial asthma and violent coughing.13 pneumorrhachis secondary to spm occurs as a result of communication of the posterior mediastinum and the epidural space and the absence of a fascial barrier.8 air typically accumulates along the posterior epidural space because of its lower resistance compared with the anterior vascular network.8 in 1993 balachandran et al. hypothesised that the absence of fascial barriers between the posterior mediastinum and the epidural space facilitated free mediastinal air to dissect into the paraspinal tissues and subsequently travel through the neural foramina alongside the neurovascular bundle into the epidural space (figure 5).14 figure 5: diagram of the lower cervical and upper thoracic cross sections illustrating the pathway of air dissection (arrows) leading to epidural pneumatosis. epidural air is usually benign, however pr related neurological symptoms have been documented.3 yaginuma et al. presented two cases of pr associated with pneumomediastinum in young patients.2 their literature search of children less than 15 years documented 25 articles reporting 32 cases, in which pr associated with pneumomediastinum occurred in all cases.2 the investigations of choice for a patient with pr include plain radiographs and ct.11 in the setting of a traumatic aetiology, radiographs are essential to detect possible associated injuries. a linear lucency projected over the spinal canal on a lateral chest radiograph is suggestive of pr. ct is the gold standard for reliable detection of pr and its wider application in the assessment of adjacent anatomy in a non-traumatic or traumatic cause.11 following assessment of the primary cause, treatment is primarily directed to the aetiology. this patient presented with spm and pr. upon exclusion of an oesophageal perforation and history of trauma, she was managed conservatively. the expectation was that the air would reabsorb over 2 to 3 weeks and the administration of a high concentration of inspiratory oxygen would promote the absorption of air. conclusion in the absence of trauma, aero digestive organ injury and iatrogenic causes, pr represents a rare benign association of pneumomediastinum that commonly occurs secondary to barotrauma of the lung and the macklin effect. understanding the mechanism in which air reaches the epidural space allows a conservative approach to treatment without unnecessary investigations. neurological symptoms are rare and most patients experience reabsorption of the epidural air over two to three weeks without long-term complications, emphasising the innocuous course of this phenomenon. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions a.v. and k.d.d. contributed equally to the article. ethical considerations this article followed all ethical standards for research. consent was acquired from the patient’s parents to include the data and images in the manuscript. data and images in the manuscript were anonymised. funding information this study received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references gill i, edhi ai, cappell ms. proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report. medicine (baltimore). 2020;99(35):e21001. https://doi.org/10.1097/md.0000000000021001 yaginuma k, watanabe m, saito y, et al. pneumorrhachis in children: a report of two cases and review of the literature. radiol case rep. 2019;14(11):1325–1329. https://doi.org/10.1016/j.radcr.2019.08.010 behr g, mema e, costa k, garg a. proportion and clinical relevance of intraspinal air in patients with 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cavallo fm. epidural pneumatosis associated with spontaneous pneumomediastinum. am j neuroradiol. 1993;14(1):271–272. abstract introduction case presentation surgical management histopathology discussion conclusion acknowledgements references about the author(s) jaanri brugman division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa gerard de bruyn division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa komeela naidoo division of radiation oncology, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa marc merven division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa johan opperman division of anatomical pathology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa leon janse van rensburg division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation brugman j, de bruyn g, naidoo k, et al. not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases. s afr j rad. 2020;24(1), a1978. https://doi.org/10.4102/sajr.v24i1.1978 case report not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases jaanri brugman, gerard de bruyn, komeela naidoo, marc merven, johan opperman, leon janse van rensburg received: 01 sept. 2020; accepted: 05 oct. 2020; published: 17 dec. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract although squamous cell carcinoma accounts for the overwhelming majority of head and neck malignant neoplasms, extranodal follicular dendritic cell sarcoma (fdcs) of the pharyngeal region can have a similar clinical presentation. the histopathological features of this rare entity have been described and emphasised in the literature. we present the case of a 65-year-old male patient with fdcs of the tonsil to illustrate the radiologic findings of fdcs and also highlight this infrequent but salient differential diagnosis for adult head and neck neoplasia. keywords: follicular dendritic cell sarcoma; magnetic resonance; tonsil; nodal metastasis; squamous cell carcinoma; head and neck neoplasm; oropharynx. introduction follicular dendritic cell sarcoma (fdcs) is an exceedingly rare malignant neoplasm of follicular dendritic cells, first characterised by monda et al. in 1986.1 follicular dendritic cells are immune accessory cells widely distributed in both nodal and extranodal lymphoid tissue, presenting antigens to b-lymphocytes.2 thus, uncontrolled proliferation of these cells affects lymph nodes, primarily of the mediastinum and cervical and axillary regions.3 when primary extranodal disease occurs, the pharyngeal region is one of the preferred sites, in particular the tonsils.4 case presentation a 65-year-old man presented with a 5-month history of an enlarged and growing left-sided neck mass. the patient reported no weight loss, odynodysphagia, dysphonia or otalgia. on examination of the neck, it was observed that the mass measured 10 × 10 cm, was non-tender to palpation and was of a mixed consistency (both cystic and solid). furthermore, the mass appeared to be mobile but felt attached to the inferior aspect of the ipsilateral parotid gland. oropharyngeal examination revealed a small (< 1 cm) submucosal sessile polyp on the left tonsil. the rest of the clinical examination was normal. biopsy of the left tonsil and cell block obtained from fine-needle aspiration of the left-sided neck mass revealed fdcs using immunohistochemical staining. computed tomography (ct) of the neck and chest with intravenous contrast administration was carried out, followed by magnetic resonance (mr) imaging of the neck with intravenous gadolinium administration to further delineate the extent of the tumour and its relation to adjacent structures, in particular the parotid gland and the cervical vasculature. the neck ct demonstrated an ovoid iso-attenuating mass in the left tonsil, measuring 16 mm × 12 mm × 24 mm in diameter (anteroposterior × transverse × craniocaudal, figure 1a). in addition, a large, mixed solid–cystic nodal-mass conglomerate was present in the left side of the neck, with a solid and enhancing component at its cranial aspect and, inferiorly, a multiseptated cystic component (figure 1b). the solid cranial component of the cervical nodal-mass demonstrated diffusion restriction with low apparent diffusion coefficient values. on mr imaging, left parotid gland invasion by the cervical nodal conglomerate was strongly suspected (figure 2a). the carotid artery and internal jugular vein were not infiltrated. the tonsillar mass demonstrated t1-weighted isoto hyperintense signal to cervical muscles, t2-weighted and fluid attenuated inversion recovery (flair) hyperintense signal to muscle and minimal post-contrast enhancement (figure 2b and 2c). no distant metastasis was present in the chest or upper abdomen. a neck ultrasound was not carried out prior to cross-sectional imaging. figure 1: (a) axial contrasted computed tomography (ct) scan demonstrates a small ovoid iso-attenuating mass in the left tonsil. the large mixed solid–cystic nodal-mass conglomerate in the left side of the neck exerts mass effect on the left carotid space and displaces it medially. (b) coronal contrasted ct scan demonstrates the cranio-caudal extent of the nodal-mass conglomerate in the left side of the neck. the cranial aspect is solid and enhancing, and the caudal portion is cystic and multiseptated. figure 2: (a) sagittal t1-weighted, post-gadolinium, fat-saturated magnetic resonance (mr) image shows the mixed solid–cystic nature of the cervical nodal-mass with enhancement of the cranial solid portion. superficial parotid gland infiltration was suspected based on mr imaging findings. axial t1-weighted mr images with (b) gadolinium and (c) fat suppression demonstrating heterogenous enhancement of the solid cranial portion of the cervical nodal-mass conglomerate. the left carotid arteries and internal jugular vein were not infiltrated. surgical management after discussion at the head and neck and oncology multidisciplinary meetings, the patient was staged with having a clinical t2n1m0 sarcoma (american joint committee on cancer tumor-node-metastasis [ajcc tnm] 8th edition). the patient underwent a left-sided, modified radical neck dissection with a superficial partial parotidectomy (‘en block’) and bilateral tonsillectomy (figure 3). the post-operative course was uncomplicated, and the patient was discharged on day 5 post surgery. figure 3: intra-operative image of the left cervical nodal-mass conglomerate. it was dissected off the left common carotid artery, with ligation of the left internal jugular vein. histopathology gross macroscopic examination showed a solid and firm, well-circumscribed tumour involving the left tonsil, measuring approximately 2 cm. left neck level ii and iii nodal metastases were present with most of the nodes in level iii involved by tumour comprising solid and cystic spaces filled with gelatinous material. the tumour abutted the parotid gland capsule; however, frank invasion was not observed macroscopically. microscopic examination revealed a malignant neoplasm partially involving the left tonsil, with intact overlying surface epithelium. the tumour comprised spindle-to-ovoid cells arranged in fascicles, in whorled and storiform patterns, demonstrating a pushing invasive front (figure 4a). occasional mitosis was noted (1–2 per 10 hpf), but necrosis was absent. the left cervical lymph nodes showed a conglomerate of nodes involved by tumour, with extracapsular tumour spread and extension into the surrounding muscle, fat and adjacent parotid gland. the tumour cells were positive for follicular dendritic cell markers such as cd21, cd23, cd35 and d2-40 (podoplanin) but negative for cytokeratin markers (figure 4b). based on the morphology and immunohistochemistry, the diagnosis of an extranodal fdcs was rendered. figure 4: follicular dendritic cell sarcoma of the left tonsil: (a) the tumour appears very cellular, displaying a typical storiform and whorled growth pattern (haematoxylin and eosin, 100×); (b) by immunohistochemistry, the tumour shows diffuse membranous positivity with follicular dendritic cell markers d2-40 (haematoxylin and eosin, 400×), as well as cd21, cd23, cd35 (not shown). following the histological review, the patient’s pathological staging was t2n1. the role of adjuvant radiotherapy in sarcoma of the head and neck is controversial, with indications being extrapolated from the treatment guidelines of extremity sarcoma. in view of the large nodal disease with extracapsular extension, the multidisciplinary team’s decision was to offer adjuvant radiotherapy. the patient received 66 gy in 2 gy/# to the tumour bed and left level ib-v. this was delivered via volumetric modulated radiotherapy. radiotherapy was tolerated well with minimal side effects, and during the last assessment, the patient was still in remission. discussion duan et al.4 identified a total of 41 cases of extranodal fdcs in the english literature, 51% of which were tonsillar in origin. other primary extranodal sites of disease include the spleen, gastro-intestinal tract, liver, soft tissue, skin, lung and breast. follicular dendritic cell sarcoma has a slight female predominance (1.2:1) and a wide patient age range for disease presentation, although it most often presents in the fifth decade of life.2 the world health organisation classification of haematopoietic and lymphoid neoplasms includes fdcs in the group of histiocytic and dendritic cell neoplasms.5 because of the rarity of dendritic cell sarcoma (dcs), its clinical behaviour and optimal management has not been consolidated. de pas et al.3 reviewed 189 cases of dcs (including both fdcs and interdigitating dcs) and found that dcs was most often localised at diagnosis. in our case report, the patient’s tumour had metastasized to regional lymph nodes, with clinical and pathological features of extranodal invasion, suggesting a more aggressive biological nature of the tumour. anecdotal evidence suggests that abdominal tumours or those measuring more than 5 cm relate to an unfavourable prognosis. in addition, specific histopathological features, such as a high mitotic count and the presence of necrosis, have been studied in other soft-tissue sarcomas and proven their value in prognostication.3 of note, our patient’s tumour demonstrated a low mitotic rate and absence of necrosis, despite its large nodal metastases with extranodal invasion. the histological features of fdcs have been emphasised more often than the imaging findings. as of yet, characteristic findings of fdcs on 18f-fluoro-deoxyglucose positron emission tomography (fdg-pet) have not been established, as a variable radiotracer uptake has been found, presumably as a result of the diverse histological grade features demonstrated in these tumours.6 the use of 18f-fdg-pet in surveillance imaging, recurrence detection and response to therapy has been highlighted in case report studies on parotid gland and cervical node fdcs.7,8 conclusion due to its rarity, extranodal fdcs of the pharyngeal region is often not considered as part of the differential diagnosis in adult head and neck neoplasia.4 our case not only highlights the clinical and histopathological findings of fdcs but also illustrates the imaging findings of the condition, in particular, the use of mr imaging, of which there is a scarcity in the literature. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions j.b. made substantial contributions to the conception, drafting and revision of the manuscript; l.j.v.r., to the radiologic content and approval of the report; k.n. and m.m., to the acquisition of data and drafting of the report; g.d.b., to the acquisition of data, drafting and revision of the report, and j.o., to design, literature review and drafting of the report. ethical consideration ethical approval was obtained from the health research and ethics committee, c20/07/025. written informed consent was obtained from the patient. funding information the research received no specific grant from any funding agency in the public, commercial or non-for-profit sectors. data availability statement the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references monda i, warnke j, rosai r. a primary lymph node malignancy with features suggestive of dendritic reticulum cell differentiation, a report of 4 cases. am j pathol. 1986;122(3):562–572. youens ke, waugh ms. extranodal follicular dendritic cell sarcoma. arch pathol lab med. 2008;132(10):1683–1687. de pas t, spitaleri g, pruneri g, et al. dendritic cell sarcoma: an analytic overview of the literature and presentation of original five cases. crit rev oncol hematol. 2008;65(1):1–7. https://doi.org/10.1016/j.critrevonc.2007.06.003 duan g, wu f, zhu j, guo d, zhang r. extranodal follicular dendritic cell sarcoma of the pharyngeal region. am j clin pathol. 2010;133(1):49–58. https://doi.org/10.1309/ajcp7u8yisbuavnw vardiman jw. the world health organization (who) classification of tumors of the hematopoietic and lymphoid tissues: an overview with emphasis on the myeloid neoplasms. chem biol interact. 2010;184(1–2):16–20. https://doi.org/10.1016/j.cbi.2009.10.009 kim h, park cm, jeon yk, paeng jc, goo jm, lee h. follicular dendritic cell sarcoma of the mediastinum: ct and f-fluoro-2-deoxyglucose pet findings. thorac cancer. 2013;4(2):203–206. https://doi.org/10.1111/j.1759-7714.2012.00143.x makis w, hudson ew, chiu b. recurrent follicular dendritic cell sarcoma of the parotid gland imaged with 18f-fdg pet/ct. nuc med mol imaging. 2017;51(4):354–356. https://doi.org/10.1007/s13139-016-0465-2 albano d, bosio g, bertagna f. f-fdg pet/ct follow-up of follicular dendritic cell sarcoma. rev español med nucl imagen mol. 2017;36(3):194–196. https://doi.org/10.1016/j.remnie.2017.02.006 abstract introduction historical perspective of nuclear medicine diagnostic and therapeutic applications of radionuclides global state of undergraduate nuclear medicine education the south african perspective conclusion acknowledgements references about the author(s) anthonio o. adefuye division of health sciences education, university of the free state, bloemfontein, south africa henry a. adeola division of dermatology, department of medicine, faculty of health sciences, groote schuur hospital, university of cape town, cape town, south africa stuart more division of nuclear medicine, department of radiation medicine, university of cape town, cape town, south africa zainab mohamed division of radiation oncology, university of cape town, cape town, south africa citation adefuye ao, adeola ha, more s, mohamed z. the need for nationally accepted guidelines for undergraduate nuclear medicine teaching in mbchb programmes in south africa. s afr j rad. 2020;24(1), a1874. https://doi.org/10.4102/sajr.v24i1.1874 opinion paper the need for nationally accepted guidelines for undergraduate nuclear medicine teaching in mbchb programmes in south africa anthonio o. adefuye, henry a. adeola, stuart more, zainab mohamed received: 25 feb. 2020; accepted: 14 apr. 2020; published: 28 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract according to the south african health professions act no. 56 of 1974, specific skills outcomes of mbchb programmes are that a medical graduate must be able to utilise diagnostic aids, interpret findings and make diagnoses. imaging techniques are an integral part of the numerous diagnostic and therapeutic aids used in contemporary medical practice; however, in south africa, no formal directives exist to guide programme directors or nuclear medicine departments regarding an appropriate undergraduate nuclear medicine educational module. as of 2013, six south african schools of medicine are involved in undergraduate nuclear medicine teaching, in which it forms part of clinical modules taught at varying stages in the academic curriculum. against this backdrop is the inequitable distribution of nuclear medicine resources, training facilities and staffing in the local state health sector. inadequate undergraduate teaching and provincial differences in nuclear medicine service provision suggest that many clinicians and graduating medical students are unaware of how radionuclide techniques can facilitate patient management. this high level of imaging illiteracy has been associated with lack of patient referral, poor quality and inadequate referral, poor knowledge of radiation doses and poor awareness of radiation risks. here we highlight the challenges of undergraduate nuclear medicine teaching in south africa, emphasising the need for the implementation of guidelines for undergraduate nuclear medicine education. employing nationally accepted guidelines for undergraduate nuclear medicine teaching in south african mbchb programmes will contribute to the effective utilisation of nuclear medicine and molecular imaging as a diagnostic and therapeutic modality by newly qualified medical practitioners. keywords: nuclear medicine, south africa, medical school curricula, education, undergraduate. introduction the practice of medical radiation science (mrs) involves the administration of trace amounts of radionuclides and ionising radiation energy in the diagnosis, treatment and follow-up of medical and surgical pathologic conditions.1 the use of electromagnetic radiation led to the creation of the two major medical radiation sub-divisions: diagnostic radiology and clinical radiation therapy.2 the discovery of artificial radionuclides led to the development of nuclear medicine (nm).2 in its elementary form, the practice of nm involves the injection of radiopharmaceuticals or radiotracers (tracers – compounds labelled with a gamma-ray-emitting or positron-emitting radionuclide) into the body for the purposes of diagnosis. these pharmaceuticals can also be labelled with alphaor beta-emitting radio-isotopes for targeted radionuclide therapy in a variety of benign and malignant conditions.1,3 nuclear medicine encompasses both diagnostic and therapeutic aspects of disease management and thus differs from other clinical medical imaging modalities. the use of nm in the diagnosis of disease conditions is centred in its ability to detect changes in biological and physiological processes rather than changes in morphology and anatomy.4,5 numerous studies have reported on the high level of imaging illiteracy amongst practising physicians and graduating medical students.6,7,8 this has been associated with lack of patient referral,9 poor quality and inadequate referral,10 poor knowledge of radiation doses for routine imaging procedures,7 and poor awareness of radiation risks.8 here, we highlight the challenges of undergraduate nuclear medicine teaching, particularly in south africa, and emphasise the need for the implementation of guidelines for undergraduate nuclear medicine education in mbchb programmes in south africa. employing nationally accepted guidelines for undergraduate nuclear medicine teaching in south africa will contribute to the effective utilisation of nuclear medicine and molecular imaging as a diagnostic and therapeutic modality by newly qualified medical practitioners. historical perspective of nuclear medicine the origin of nm can be traced to the discovery of x-rays, radioactivity and radium between 1895 and 1898.11 x-rays became the preferred method due to better contrast and speed of obtaining radiographic images. in 1913, george de hevesy pioneered the tracer principle,12 using natural isotopes, which he applied to study biological (plant and animal) systems in 1923.13 the first human application of the active radiotracer was carried out by blumgart and yens in 1926.14 with the invention of the cyclotron by ernest lawrence in the 1930s, it became possible to artificially produce radionuclides and obtain images of distribution of radionuclides in the human body.15 benedict cassen invented the rectilinear scanner in 1951,16 while in 1958 hal anger invented the predecessor (anger) camera for the modern gamma cameras.17 in the early 1960s, a more effective, revolutionary, metastable nuclear isomer of technetium-99 was produced to replace iodine-131 (131i) for thyroid disorder.18 the mathematical algorithms used to reconstruct tomographic images from a set of angular views around the patient led to the invention of pet (positron emission tomography) and spect (single photon emission computed tomography) by phelps et al.19 and kuhl et al.20 respectively. from 1980 both pet and spect have evolved and become widely available, demonstrating much clinical benefit to justify its continued medical use.21 integrated hybrid imaging combining computed tomography (ct) such as spect/ct, pet/ct and pet/magnetic resonance imaging (mri) have become standard practice in nm. diagnostic and therapeutic applications of radionuclides widespread clinical use of nm imaging procedures started in the early 1950s. nuclear medicine techniques used as diagnostic tools include radioactive iodine scans (or 99mtc pertechnetate scan); octreotide-scans; metaiodo-benzyl-guanidine (mibg) and parathyroid imaging for endocrinopathies. positron emission tomography/computed tomography imaging using 2-[18f] fluoro-2-deoxyglucose (18f-fdg) has also evolved and it is being utilised in oncological, infective, vascular and neurodegenerative disorders.22 other pet tracers used include [68ga]-dota-noc used for somatostatin receptor imaging in neuroendocrine tumours,23 68ga prostate specific membrane antigen (psma) in prostate cancer,24 and 18f-dihydroxyphenylalanine (dopa) in the imaging of dopaminergic pathways in motor disorders, neuroendocrine tumours (nets) and congenital hyperinsulinism.25 nm imaging procedures are thus an essential part of patient care in most medical specialties.26 more recently, with the advent of peptide receptor radionuclide therapy (prrt), radiopharmaceuticals linked to beta emitters such as lutetium 177(177lu) in treating neuroendocrine tumours have gained much traction.3 however, it should be noted that the diagnostic and therapeutic application of ionising radiation in clinical medicine, should be kept within a safe limit according to the alara (as low as reasonably achievable) principle.27 it is therefore the responsibility of all healthcare providers to equip themselves with current and appropriate knowledge about radiation safety. global state of undergraduate nuclear medicine education over the years, the practice of clinical medicine and surgery has changed dramatically with an increasing reliance on diagnostic tests.10 the current era of sophisticated radiological imaging techniques (including nuclear medicine) has put radiation medicine at the forefront of modern medicine with an increasing demand for these services in patient management.28 it is therefore essential that medical practitioners and specialists, as well as medical students, be provided with a basic knowledge and understanding of clinical imaging procedures. medical practitioners should understand the values, procedures, indications, benefits and also the contraindications and financial implications of these technologies in order to optimise their use in improving patient outcomes.29 although radiological imaging has undergone significant changes, these changes are still not fully incorporated and implemented in undergraduate medical school curricula.30 radiological and nm training is considered an adjunct or ancillary subject to clinical modalities and not a ‘core’ subject in medical school curricula.30 in a study comprising of 77 european countries, lass and scheffler reported that there is a high level of variation in the undergraduate teaching of nuclear medicine across countries, with undergraduate teaching integrated into one of the clinical modules and in some cases presented in clinical physiology.31,32 similarly, using an electronic survey on undergraduate teaching distributed by the european society of radiology (esr) to 38 national delegates of the esr education committee, kourdioukova et al.33 revealed a large number of differences in curriculum content and teaching methods throughout europe. furthermore, moloney et al.34 reported a minimal improvement in the knowledge of medical students in requesting radiological investigations over the course of the final medical year in the usa, and this was attributed to a relatively short period of learning in the clinical setting. moloney and colleagues further suggested that emphasis on education and appropriateness may offer an improvement in the utilisation of radiology services and improve patient care. defining the problem despite the obvious clinical importance of imaging and imaging techniques (e.g. interventional radiology) in the management of disease conditions in patients, undergraduate medical students receive little or no formal training in clinical imaging (including nm) for which the students must show proficiency by passing a test in the subject.6 in most medical colleges, courses in imaging or nm education are presented as electives with no formal assessment.6,10 rogers6 stated that medical students often perceive radiology and nm electives as a little vacation from demanding clinical assignments and study, thus leading to a high level of imaging illiteracy amongst graduating medical students.6 commander et al.35 showed that 84% (n = 217 of 259) of preclinical students and 62% of clinical students (n = 110 of 177) at two medical schools in the usa lacked adequate knowledge of interventional radiology. poorly coordinated and abbreviated periods of learning can have a detrimental effect on patient management as the majority of new medical graduates have limited knowledge of various aspects of imaging and imaging techniques.36 hence, providing medical students with sufficient and precise knowledge regarding different aspects of radiation and nm is a necessity.36 the european society of radiology recommendations according to the white paper by the european society of radiology (esr) on undergraduate radiological education, a ‘critical core’ curriculum for undergraduate radiological imaging was recommended to be integrated across the existing medical curricula.37 the esr also suggested that medical schools should ensure that such an important undergraduate imaging ‘core’ curriculum must be delivered to students according to outcome-based education (obe) strategies. they suggested that a ‘core plus’ curriculum option might also be included.37 it is therefore essential for the radiology/nm departments in various colleges of medicine to contribute to the education of the next generation of medical doctors, and no longer ‘willingly cede’ teaching of clinical imaging procedures to other clinical disciplines involved in medical education.38 the alliance of medical student educators in radiology (amser) has also recommended core topics within nuclear medicine that need to be covered during the training of undergraduate medical students.39 the south african perspective medical education in south africa commenced in 1912 in cape town, south africa, after the first medical school opened its doors in 1900. undergraduate medical education in south africa is offered at eight schools of medicine located within campus-based universities.40 according to burch,41 all south african schools of medicine have undertaken major curriculum reform over the past 10 years. despite curriculum differences, the exit-level outcomes for healthcare professionals are the same, as prescribed by the various regulatory bodies. the introduction of the outcome-based education (obe) approach to education in south africa brought about major changes in the traditional way teachers approach the teaching process.42 this educational strategy revolves around learner-centred, outcome-orientated activities. emphasis is placed on an integrated teaching and training approach, human development and lifelong learning.43 specific skills outcomes of mbchb programmes as described by the health professions act 56 of 1974 (act no. 56 of 1974) are that a medical graduate must be able to utilise diagnostic aids, interpret findings and make diagnoses.44 imaging and imaging techniques are an integral part of the numerous diagnostic and therapeutic aids used in contemporary medical practice. however, no formal directives exist in south africa to guide programme directors or nuclear medicine departments with regard to an appropriate undergraduate medical nuclear medicine educational module.10 six schools of medicine in south africa are currently involved in undergraduate nuclear medicine education,10,45 where it is taught as part of clinical modules at varying stages in the academic curriculum.10 these differences in medical curricula and the absence of structured undergraduate nuclear medicine education in two schools of medicine implies that newly qualified doctors with limited or no exposure to undergraduate nuclear medicine teaching may lack the necessary knowledge, skills and right attitude towards imaging modalities and how to use them appropriately to solve patients’ problems. this is evident in the poor quality and inadequate referrals sent by newly qualified medical interns and some community-service doctors to nuclear medicine departments.10 in a survey done to ascertain the knowledge of interns and registrars working at two academic hospitals (charlotte maxeke johannesburg academic hospital and chris hani baragwanath academic hospital) on the basic principles and clinical applications of nm, dhoodhat et al.46 reported that only 41% of the cohort had undergraduate nuclear medicine exposure. according to dhoodhat and colleagues, more than half of the respondents (52%) had less than 5 h of nm training in their entire curriculum and only 9.9% of them deemed their undergraduate nm education exposure to have been sufficient.46 their findings also showed that the mean nm knowledge score of those participants who had undergraduate nm exposure was significantly higher than those who had no exposure. they also commented on the need to improve undergraduate nm training in south africa.46 similarly, in a study done to investigate doctors’ awareness of diagnostic radiation exposure at dr george mukhari academic hospital ga-rankuwa, pretoria, dauda et al.8 reported that 80% of the 217 participants had no formal training on radiation exposure. dauda and colleagues also advocated for improved teaching on radiation medicine at undergraduate level.8 at present, there is only one unpublished study on the development of a guideline for teaching and learning nuclear medicine in undergraduate medical education in south africa that could be useful in curriculum development.10 however, the guidelines proposed by the author of this study have never been implemented. conclusion in conclusion, this article highlights the challenges of undergraduate nuclear medicine education, more particularly in south africa, and recognises the need for the implementation of formal guidelines for undergraduate medical nuclear medicine education in mbchb programmes in south africa. the present status quo, i.e. limited undergraduate teaching, suggests that clinicians are not as knowledgeable on how radionuclide techniques can help in the management of patients.9 therefore, patients who could benefit from these procedures are not referred.9 we hope that this article will generate a wider and more robust conversation between curriculum planners at the various universities and the nuclear medicine community as a whole on the need for a holistic (countrywide) study on the development of a national guideline for teaching nuclear medicine in undergraduate medical education in south africa. implementation of nationally accepted guidelines for undergraduate medical nuclear medicine education in south africa will contribute to the effective utilisation of nuclear medicine and molecular imaging as a modality by newly qualified medical practitioners (interns and community-service doctors) in the country. recommendations in order to change the present status quo and enhance the teaching and learning of nm in the undergraduate mbchb programmes in south africa, the researchers propose the following implementable recommendations: form a nationwide consortium to investigate or research the educational needs and current challenges of teaching nm in undergraduate medical education in south africa: such a study should obtain perspectives of students, educators, curriculum planners and deans of the various medical schools in the country. recommendations made can inform the development of nationwide guidelines. develop nationwide guidelines for teaching and learning nm in undergraduate medical education in south africa: curriculum planners at the various universities and the various nm or radiation medicine departments countrywide can do this. such guidelines should be internationally benchmarked, locally relevant and must be approved by the regulatory bodies in charge of undergraduate medical training (i.e. health professions council of south africa and the department of higher education and training). these guidelines can inform the development of teaching and learning outcomes, as well as the mode of teaching. development of a case-based learning (cbl) module for nm: a cbl module can be developed and integrated into the current mbchb curricula. the integration of cbl into the current mbchb curricula provides medical students with the opportunity to learn nm in a practical and interactive manner,47 and avert unnecessary lengthening of training duration. develop a training-platform-sharing model: medical colleges with a well-established training platform should be encouraged to share their training-platforms with colleges lacking such training platforms. this can be arranged as directed electives. acknowledgements competing interests all authors declare that they have no conflict of interests. authors’ contributions aoa conceptualised and drafted the manuscript. haa, sm and zm gave expert review and contributed to the different sections of the manuscript. all authors approved the final copy of the manuscript. ethical consideration this article followed all ethical standards for carrying out research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this manuscript as no new data were created. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references cherry sr, sorenson ja, phelps me. physics in nuclear medicine. amsterdam, netherlands. elsevier health sciences; 2012. morgan r. protecting and improving health through the radiological sciences. a report to the surgeon general, prepared by the national advisory committee on radiation. washington, dc: us public health service; 1966. yordanova a, eppard e, kürpig s, et al. theranostics in nuclear medicine practice. onco targets ther. 2017;10:4821. https://doi.org/10.2147/ott.s140671 sarkar sd, editor. benign thyroid disease: what is the role of nuclear medicine? seminars in nuclear medicine. elsevier; 2006. györke t, duffek l, bártfai k, et al. the role of nuclear medicine in inflammatory bowel disease. a review with 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guidelines for tumour imaging: version 2.0. eur j nucl med mol imag. 2015;42(2):328–354. https://doi.org/10.1007/s00259-014-2961-x chopra a. 68ga-labeled (1, 4, 7, 10-tetraazacyclododecane-n, n’, n’’, n’’’-tetraacetic acid)-1-nai3-octreotide. molecular imaging and contrast agent database (micad). bethesda, md. national center for biotechnology information (us); 2009. corfield j, perera m, bolton d, lawrentschuk n. 68 ga-prostate specific membrane antigen (psma) positron emission tomography (pet) for primary staging of high-risk prostate cancer: a systematic review. world j urol. 2018;36(4):519–527. https://doi.org/10.1007/s00345-018-2182-1 chondrogiannis s, marzola mc, al-nahhas a, et al. normal biodistribution pattern and physiologic variants of 18f-dopa pet imaging. nucl med comm. 2013;34(12):1141. https://doi.org/10.1097/mnm.0000000000000008 brink a. more about … nuclear medicine: the use of nuclear medicine in childhood. 2013. continuing medical education. 31(8):1–2. ostensen h, ingolfsdottir g, munro l, diagrammes al, conway m, walters f. basics of radiation protection for everyday use how to achieve alara: working tips and guidelines. geneva: who; 2004. shaikh m, shaygi b, asadi h, et al. the introduction of an undergraduate interventional radiology (ir) curriculum: impact on medical student knowledge and interest in ir. cardiovasc interventional radiology. 2016;39(4):514–521. https://doi.org/10.1007/s00270-015-1215-z pascual tn, chhem r, wang s-c, vujnovic s. undergraduate radiology education in the era of dynamism in medical curriculum: an educational perspective. eur j radiol. 2011;78(3):319–325. https://doi.org/10.1016/j.ejrad.2010.08.039 subramaniam r, hall t, chou t, sheehan d. radiology knowledge in new medical graduates in new zealand. 2005. n z med j. 118(1224):u1699. pmid: 16258575 lass p, scheffler j. undergraduate teaching of nuclear medicine in european universities. eur j nucl med mol imag. 2003;30(7):1018–1023. https://doi.org/10.1007/s00259-003-1191-4 ell pj. undergraduate teaching of radiology and nuclear medicine. eur j nucl med. 1997;24(9):1081. https://doi.org/10.1007/bf01254236 kourdioukova ev, valcke m, derese a, verstraete kl. analysis of radiology education in undergraduate medical doctors training in europe. eur j radiol. 2011;78(3):309–318. https://doi.org/10.1016/j.ejrad.2010.08.026 moloney bm, mccarthy ce, byrne d, mcveigh tp, kerin mj, mccarthy pa. teaching radiology to medical students – there is a need for change to better prepare students for clinical practice. elsevier; 2017. academic radiology. 24(4):506–513. commander cw, pabon-ramos wm, isaacson aj, yu h, burke ct, dixon rg. assessing medical students’ knowledge of ir at two american medical schools. j vasc intervent radiol. 2014;25(11):1801–1807. https://doi.org/10.1016/j.jvir.2014.06.008 mubeen sm, abbas q, nisar n. knowledge about ionising and non-ionising radiation among medical students. j ayub med coll abbottabad. 2008;20(1):118–121. radiology eso. undergraduate education in radiology. a white paper by the european society of radiology. insights imaging. 2011;2(4):363–374. https://doi.org/10.1007/s13244-011-0104-5 gunderman rb, siddiqui ar, heitkamp de, kipfer hd. the vital role of radiology in the medical school curriculum. am j roentgenol. 2003;180(5):1239–1242. https://doi.org/10.2214/ajr.180.5.1801239 association of university radiologist. amser national medical student curriculum in radiology [homepage on the internet]. 2012 [cited 2020 feb 04]. available from: https://www.aur.org/uploadedfiles/alliances/amser/amser_learning_objectives_by_course.pdf van der merwe, l.j., van zyl, g.j., gibson, a.s.c., viljoen, a., iputo, j.e., mammen, m., chitha, w., perez, a.m., hartman, n., fonn, s. and green-thompson, l., 2016. south african medical schools: current state of selection criteria and medical students’ demographic profile. south african medical journal, 106(1), pp. 76–81. https://doi.org/10.7196/samj.2016.v106i1.9913 burch vc. medical education in south africa: assessment practices in a developing country. psychology. 2007. department of psychology, erasmus school of social and behavioural sciences. erasmus university rotterdam, rotterdam, netherlands. beets p, le grange l. africanising’ assessment practices: does the notion of ubuntu hold any promise? s afr j higher educ. 2005;19(special edition 1):1197–1207. https://doi.org/10.4314/sajhe.v19i7.50216 de vos as. research at grass roots: for the social sciences and human services professions. van schaik; 2002. pretoria: van schaik. health professions council of south africa. the health professions act, 1974 (act no. 56 of 1974): regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine [homepage on the internet]. 2020 [cited 2020 feb 04]. available from: https://www.hpcsa.co.za/uploads/mdb/rules%20%26%20regulations/regulations_gnr_139_2009.pdf ellmann a, editor. getting the interest of students into the specialty: promoting nuclear medicine in the undergraduate curriculum and clinical rotations. in: 9th asia-oceania congress in nuclear medicine education and training. 2008 november 01. new delhi. dhoodhat s. assessment of doctors in training – at two academic hospitals – knowledge of the basic principles and clinical applications of nuclear medicine. johannesburg: university of the witwatersrand; 2016. lee b-f, chiu n-t, li c-y. value of case-based learning in a nuclear medicine clerkship. j am coll radiol. 2013;10(2):135–141. https://doi.org/10.1016/j.jacr.2012.07.015 abstract introduction case report discussion conclusion acknowledgements references about the author(s) atish vanmali department of radiology, jackpersad and partners inc., durban, south africa mario haines department of radiology, jackpersad and partners inc., durban, south africa citation vanmali a, haines m. prostate abscess in a paediatric patient: a rare diagnosis. s afr j rad. 2021;25(1), a2053. https://doi.org/10.4102/sajr.v25i1.2053 case report prostate abscess in a paediatric patient: a rare diagnosis atish vanmali, mario haines received: 26 nov. 2020; accepted: 03 jan. 2021; published: 25 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract prostate abscess (pa) is an uncommon clinical manifestation that typically presents in the fifth to sixth decade of age and sporadically affects neonates. these characteristics, coupled with the atypical presentation, represent a clinical dilemma and a challenging diagnosis. a detailed history depicting the clinical course and the presence of risk factors is imperative to alert the clinician of the possibility of a pa. in this case report, we present a surgically confirmed pa, a diagnosis that is rarely encountered within the paediatric age group. keywords: paediatric; prostate; abscess; obstructive uropathy; paediatric imaging. introduction prostate abscess (pa) occurs as a result of the focal accumulation of pus in the prostate gland and is commonly related to the spread of gram-negative bacilli from the urinary tracts.1 w. allison in 1842 initially described a fatal case of a pa complicated by spontaneous urethral rupture into the recto prostatic fascia.2 prior to the use of antibiotics, gonorrhoeal infection was the most prevalent aetiology. however, with the advent of antibiotic use, gram-negative bacteria are the most common organisms encountered and are responsible for 60% – 80% of cases.3 new at-risk populations and the wide range of local and systemic symptoms present a clinical challenge in diagnosis.3 case report a 6-year-old male with a medical history of post streptococcal glomerulonephritis presented to the hospital with clinical symptoms of headache and pelvic pain for 2 days. haematuria was noted in his urinalysis. the patient’s symptoms persisted over 2 days progressing to fever and suprapubic pain. an ultrasound of the lower renal tracts (figure 1) revealed a bladder volume of 82.05 millilitres (ml), bladder wall thickening and fine mobile echoes within the bladder. the upper renal tracts demonstrated bilateral hydronephrosis (figure 2) and bilateral renal enlargement (right kidney 11.61 centimetres [cm], left kidney 10.94 cm). minimal free fluid was noted in the pelvis; however, no prostatic lesion was appreciated on the transabdominal ultrasound. figure 1: ultrasound images of the bladder in the sagittal planes (a) and transverse (b) indicate multiple intravesical low-level echoes. these were mobile on real time b-mode scan. figure 2: ultrasound of the right kidney (a) and left kidney (b) demonstrating bilateral hydronephrosis and enlarged kidneys. the voiding cysto-urethrogram was normal with no features of vesicoureteral reflux or posterior urethral valves. magnetic resonance imaging (mri) of the thoracic and lumbar spine (figure 3) was conducted to exclude a neurological aetiology. this demonstrated no features of spinal dysraphism or spinal cord abnormality; however, bilateral hydronephrosis was evident as documented on ultrasound. incidentally, the mri also demonstrated a homogenous cystic lesion within the prostate gland (figure 4) with mass effect on the bladder base. only limited sequences through the prostate were obtained and contrast was not administered. given the background of failure to respond to medical treatment and the progressive symptoms, a pa was considered as the likely aetiology for the obstructive uropathy. figure 3: sagittal t2-weighted magnetic resonance imaging sequence of the lower thoracic and lumbar spine demonstrating normal signal intensity in the spinal cord and conus medullaris. figure 4: magnetic resonance imaging: sagittal t2-weighted sequence (a) of the thoracic and lumbar spine. incidental cyst of the prostate gland was noted. sagittal and coronal t2-weighted sequences (b and c, respectively) of the pelvis demonstrate a well-defined homogenous cystic lesion within the prostate gland in keeping with a prostatic cyst. the patient underwent drainage of the abscess. staphylococcus aureus was cultured and intravenous antibiotics were administered. the blood cultures and nasal swabs excluded haematogenous and distant focus of infection. improvement in symptoms was noted following drainage of the abscess. on follow-up, the patient demonstrated a clinical response to treatment with resolution of the symptoms. follow-up sonographic images were not available as they were performed at another institution, however the clinician documented resolution of the hydronephrosis. paediatric prostatic abscess is an uncommon condition and continues to remain a difficult clinical diagnosis to consider. in this case, it was only considered as an incidental finding on the limited images through the bladder base. this highlights the importance of considering pa formation in paediatric patients who present with signs and symptoms of renal tract infection and bladder outlet obstruction. early diagnosis and treatment of the condition has significant benefits in terms of the relief of patient symptoms and prevents further damage to the renal tracts. ethical considerations this article followed all ethical standards for research. data and images in the manuscript were anonymised. discussion urinary tract obstruction can result from congenital or acquired lesions that may occur at any point from the calyx to the tip of the urethra. most childhood obstructive lesions are congenital.4 in the presence of bilateral hydronephrosis, vesicoureteral reflux and bladder outlet obstruction are the most likely causes. the common causes of bladder outlet obstruction may be divided according to the level of the obstruction. at the level of the bladder, bladder neck hypertrophy and neuropathic bladder may be considered.4 urethral valves, strictures and polyps are common causes for the urethral cause of obstruction.4 prostatic abscess with mass effect and obstructive uropathy represents a rare cause of obstructive uropathy. other causes of cystic prostate lesions in the paediatric age group include a prostatic utricle cyst and a müllerian duct cyst.5 prostatic abscess is a rare clinical entity and typically presents in the fifth to sixth decade of life. the diagnosis is often challenging as it mimics a lower urinary tract infection.6 the symptoms include dysuria, increase in frequency, fever, urinary retention and leucocytosis.6 the persistence of the symptoms despite antibiotic treatment should alert the clinician to the possibility of a pa.6 in the background of a low prevalence of the clinical entity, as well as the wide range of local and systemic symptoms, it is imperative to understand the risk factors and maintain a high index of suspicion within these patient profiles. in adults, diabetes mellitus has been identified as the most common co-morbidity, with a reported co-prevalence of 63%.1 other causes of immunosuppression including human immunodeficiency virus (hiv), liver cirrhosis, renal failure and haemodialysis have been cited as predisposing factors for prostatic abscess.1 chemotherapy, organ transplant or previous genitourinary procedures also present a higher risk of prostatic abscess.3 two mechanisms for the pathogenesis of prostatic abscess have been described. the first is via the retrograde flow of contaminated urine through the prostatic duct and subsequent infection of the prostate. bladder outflow obstruction and immunosuppression are predisposing factors and enteric organisms such as escherichia coli and other coliform bacteria are the commonest causative organisms. the less common mechanism of infection is secondary to haematogenous spread from a distant focus. this includes a variety of organisms, including s. aureus, mycobacterium tuberculosis, e. coli, klebsiella pneumoniae, pseudomonas aeruginosa, burkholderia pseudomallei and candida spp.1 the symptoms overlap with symptoms of other lower urinary tract pathology, and the diagnosis of a prostatic abscess is often delayed. hence it is often only diagnosed after the failure to respond to medical treatment.1 the diagnosis may be difficult because flocculence is present in only one third of patients. in addition, rectal examinations are not routine for infants.7 more than 90% of patients will present with a leucocytosis and almost all patients will demonstrate a leukocyturia.8 a prostatic abscess may complicate, fistulate and drain into one of the surrounding pelvic structures. abscesses located at the base of the prostate gland commonly fistulate to the bladder or prostatic urethra, and those near the apex result in a rectal or perianal fistula. severe cases of a prostatic abscess may extend into the seminal vesicle and spermatic cord.1 in the paediatric population, ultrasound is the initial diagnostic modality of choice to evaluate the paediatric lower urinary tract. a 5-megahertz (mhz) to 7-mhz transducer is used transabdominally and, when high resolution is required, a 7-mhz to 12-mhz transducer may be used transperineally. the paediatric prostate is visualised through a full bladder as a hypoechoic, elliptically shaped, soft tissue structure at the bladder base.9 a prostatic abscess appears as a hypoechoic or anechoic lesion with more or less defined edges and a peripheral hyperechoic halo.10 they are often of varying sizes, contain internal septations and are typically located in the transitional and central zones.3 magnetic resonance imaging defines the cross-sectional anatomy of the prostate with greater tissue differentiation compared to computed tomography (ct). the prostate shows homogenous signal intensity on mri imaging that is isointense to muscle on t1-weighted images and isoto hyper-intense to muscle on t2-weighted images before puberty. after puberty, the signal characteristics resemble those of the adult prostate.9 a prostate abscess appears hypointense on t1-weighted mri and hyper-intense on t2-weighted images.1 reports of prostatic abscesses in neonates have been published. mann described three cases of acute staphylococcal prostatitis causing urinary obstruction in neonates.11 collins et al.7 reviewed 13 cases of neonatal prostatic abscess and described staphylococcus spp. in 77% (10 out of 13) of the reviewed cases. staphylococcus spp. is a rare cause of paediatric urinary tract infection, suggesting that paediatric prostatic infection likely arises from haematogenous spread rather than an ascending urinary tract infection.6,7 chao and yang12 described a case of a large prostatic abscess in an adolescent successfully treated with antibiotics. prior to this, only three cases of prostatic abscess in adolescents have been reported.12 reports of prostatic abscess secondary to s. aureus, specifically methicillin resistant s. aureus (mrsa), have increased recently.13 kiehl et al.6 reported the case of a 15-year-old male with an mrsa prostatic abscess. in that case, the patient was noted to have a history of mrsa abscesses and recent hospitalisation.6 foster et al.13 documented the first reported case of methicillin-susceptible s. aureus (mssa) prostatic abscess in a paediatric patient beyond the neonatal period. prostatic abscess in the paediatric population is a rare occurrence. the referenced cases and our case report highlight the importance of a systematic radiological analysis of the upper and lower urinary tracts in a patient presenting with bilateral obstructive uropathy. interestingly, our index patient did not demonstrate haematogenous spread or a distant focus of infection and responded completely to medical and surgical intervention. upon exclusion of the common causes for bilateral obstructive uropathy, a high level of clinical suspicion is needed to diagnose this entity, which in the paediatric population likely arises secondary to haematogenous spread.13 conclusion although rare, few cases of paediatric pa have been reported in neonates and the finding of a pa in a 6-year-old is an even rarer event. the few case reports describing this clinical entity suggest that prostate infection likely arises from haematogenous spread. prostatic abscess represents a diagnostic and therapeutic challenge, and in the systematic evaluation of an obstructive or non-obstructive aetiology of bilateral hydronephrosis, it is imperative to consider a pa or prostatic lesion as a possible aetiology, as it is often overlooked because of its rarity. acknowledgements the authors would like to thank dr doshen naidoo for the clinical information provided. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.v. created the manuscript and collected the data. m.h. assisted with data collection and reviewing the manuscript with additions, where required. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ridgway aj, luk aco, pearce i. prostate abscess: a comprehensive review of the literature. j clin urol. 2019;12(6):441–448. https://doi.org/10.1177/2051415819850996 allison w. abscess of the prostate gland. prov med surg j. 1842 oct 1;5(105):11–12. https://doi.org/10.1136/bmj.s1-5.105.11 ackerman al, parameshwar ps, anger jt. diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era. int j urol. 2018;25(2):103–110. https://doi.org/10.1111/iju.13451 roy rr, anjum mf, ferdous s. obstructive uropathy in children – an update. bangladesh j child health. 2018;41(2):117–124. https://doi.org/10.3329/bjch.v41i2.36108 shebel hm, farg hm, kolokythas o, el-diasty t. cysts of the lower male genitourinary tract: embryologic and anatomic considerations and differential diagnosis. radiographics. 2013;36(5):1373–1389. https://doi.org/10.1148/rg.334125129 kiehl n, kinsey s, ramakrishnan v, dajusta dg. pediatric prostatic abscess. urology. 2012;80(6):1364–1365. https://doi.org/10.1016/j.urology.2012.08.022 collins sm, correa h, ortenberg j. prostatic abscess in the newborn: an unrecognized source of urosepsis. urology. 2001;57(3):554. https://doi.org/10.1016/s0090-4295(00)01069-4 göǧüş ç, özden e, karaboǧa r, yaǧci c. the value of transrectal ultrasound guided needle aspiration in treatment of prostatic abscess. eur j radiol. 2004;52(1):94–98. https://doi.org/10.1016/s0720-048x(03)00231-6 mong a, bellah r. imaging the pediatric prostate. radiol clin north am. 2006;44(5):749–756. https://doi.org/10.1016/j.rcl.2006.07.007 dell’atti l. a new ultrasound and clinical classification for management of prostatic abscess. arch ital urol androl. 2015;87(3):246–249. https://doi.org/10.4081/aiua.2015.3.246 mann s. prostatic abscess in the newborn. arch dis child. 1960;35(182):396–398. https://doi.org/10.1136/adc.35.182.396 chao tc, yang ssd. case – prostatic abscess in an adolescent. can urol assoc j. 2019;13(7):e229–e231. https://doi.org/10.5489/cuaj.5542 foster ce, hulten kg, janzen nk, kaplan sl. pediatric prostatic abscess caused by methicillin-susceptible staphylococcus aureus. pediatr infect dis j. 2017;36(4):426–427. https://doi.org/10.1097/inf.0000000000001458 interesting clinical images computed tomography features of •venous sinus thrombosis and infarction children venous •in dural sinus and cortical venous thrombosis occurs regularly in paediatric practice, more often as the result of dehydration than of infective meningitis. on non-contrast computed tomography (ct) scanning in the acute phase, clot is seen as a high-density within a venous sinus and is especially well seen in the s andronikou fc rad d/ag (sa), frcr (london) c weiman mschs e kader mschs r joubert mschs department of paediatric radiology, university of cape town and institute of child health, red cross war memoria/ children's hospital, rondebosch, cape town corresponding author: sandronlkou department of paediatric radiology, red cross war memor/a/ children's hospita/, cape town, 7700 te/: (021) 658-5422 (w) fax: (021) 658-5101 e-mail: docsav@mweb.co.za figure 1: post-contrast shows a 'delta' sign (/arge arrow) as well as a fill/ng defect within the straight sinus (small arrow). the subcortical white matter is of low density bilaterally, in keeping with venous infarction. 14 sa journal of radiology. october 2000 figure 2: non-haemorrhagic venous infarct is seen as bilateral symmetrical subcortical white matter low-density involving the centrum semiovale figure 3: bilateral temporal venous infarcts resulting from thrombosis in both transverse sinuses (circles) su perior sagittal, transverse and straight sinuses as well as the vein of galen. during the first few months of life, however, high signal within the venous sinuses is a normal finding. these patients therefore need followup ct to allow differentiation between this normal finding and a thrombus, which will show progressive decrease in density over time. beyond the acute phase, the administration of intravenous contrast may to page 15 mailto:docsav@mweb.co.za computed torrmgrnp hv features of venous sinus thrombosis and venous infarction in children (rom page 14 figure 4: 'flame'-shaped densities representing haemorrhage along thrombosed cortical veins on the low-density background of oedema demonstrate the 'delta' sign. this is contrast-enhanced blood around the hypodense clot and has the appearance of a hollowed-out triangle. venous infarcts are diagnosed by their characteristic appearance and figure 5: follow-up non-contrasted ct shows bilateral low-density infarction after resolution of the haemorrhage location. sagittal sinus thrombosis results in parasagittal infarcts. straight sinus and vein of galen thrombosis involve the thalami. thrombosis of the vein of labbe, the transverse and hot topics, debates, subjects covered in the sigmoid sinuses involve the temporallobe. on ct scanning, venous infarcts are poorly demarcated, often multi-focal areas oflow or mixed density that involve the subcortical white matter. these may produce mild mass effect on the ventricles. low density probably represents oedema, while high density represents haemorrhage. twenty-five per cent of venous infarcts are haemorrhagie. haemorrhagie areas may vary in size and occasionally may be linear, indicating haematoma within and around a vein. after administration of intravenous contrast, gyral enhancement is seen overlying the areas of infarction. reference barkovich al. paediatric neutoimaging. 2nd ed. philadelphia: lippincott-raven. 1996; 138,577583. abstract deadlines proffered work 20 november 2000 work in progress 19 february 2001 early registration deadline 5 march 2001 +44 (0)20 7307 +44 (0)20 7307 1414 ukrc is a joint congress between the british institute of radiology, college of radiographers, institute of physics et medicine in engineering et royal college of radiologists. references about the author(s) maya patel national radiology services inc, johannesburg, south africa department of radiology, school of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation patel m. the power of indexers. s afr j rad. 2019;23(1), a1827. https://doi.org/10.4102/sajr.v23i1.1827 editiorial the power of indexers maya patel copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. academic journalism is a competitive and complex realm. it is a world of unrelenting struggle for recognition, reputability and acceptance where promoted research is constantly exposed to criticism over quality and relevance to bolster journal metrics. there are three main aspects of scholarly metrics: impact, speed and reach. impact factors are based on the number of journal citations, usually over a 2-year period. speed is related to review turnaround time and time to publication. reach pertains to global authorship and readership.1,2 indexing on the other hand reflects on the journal’s scientific quality. it places the journal on a database, allowing increased visibility, accessibility and readership, and ultimately reputability as a respectable and reliable source in the field of research. the prestige associated with indexing holds relevance for several reasons. firstly, several academic institutions only recognise indexed publications, particularly for teaching and medical colleagues. thus, an indexed journal is likely to receive more manuscripts than a non-indexed journal. secondly, not all indexers are considered equal, despite the availability of several established, well-known databases.3 as such, indexing services worldwide have strict inclusion criteria and stringent evaluations prior to acceptance. the difficulty faced by authors and journals is deciding on which indexers to aim for. based on the report on the evaluation of the 2017 universities’ research output released in march 2019, there has been a steady increase in research productivity across all local universities over the 11-year period evaluated. this is attributed, in part, to institutional strategies and policies that encourage global exposure of local research. the report also documents significant publication growth in south african journals.4 these findings affirm a positive research outlook for south africa and south african journalism, despite the challenges we face. supported by the radiological society of south africa, local radiology publishing was first commenced as imaging-south africa/suid afrika in 1990. this was subsequently named the sa journal of radiology (sajr) in 1996 and is currently available as an open access digital journal, running its 23rd volume. the sajr is indexed with scopus (managed by elsevier); scielo sa; web of science other coverage, emerging sources citation index (esci); directory of open access journals (doaj); ebsco host; gale, cengage learning; google scholar; hinari; proquest; african index medicus; norwegian register for scientific journals, level 1; and has most recently been accepted for inclusion in pubmed central (maintained by the united states national library of medicine). this broad exposure places the journal at an advantage to evolve on multiple platforms. the journal’s new association with the esteemed and established pubmed central is a significant milestone for carving the future of the sajr in more ways than ever before. thank you to all those who have engaged with the sajr, to all those who fostered belief and pride in the journal and to all those who pledged to sustain the journal. today we are proud to have a radiological journal that continues to reach new heights with a promising future ahead. i stand firm in my goal as the editor to promote the journal and share our research with the world. ‘if we knew what we were doing it would not be called research, would it?’ – albert einstein references fenner m. what can article-level metrics do for you? plos biol. 2013;11(10):e1001687. https://doi.org/10.1371/journal.pbio.1001687 rajgopalan j. journal indexing 101: understanding the basics. [serial on the internet]. editage insights; [cited 2019 nov 20]. available from: https://doi.org/10.34193/ei-a-5449 balhara yps. indexed journal: what does it mean? lung india. 2012;29(2):193. https://doi.org/10.4103/0970-2113.95345 department of higher education and training. report on the evaluation of the 2017 universities’ research output [homepage on the internet]. pretoria: department of higher education and training; 2019 [cited 2019 nov 20]. available from: http://bit.ly/34x9h8q review article consent in radiology g r howarth mb chb, mmed (0 + g), mphil (bioethics) department of obstetrics and gynaee%gy, and department of bioethies ka/afong hospita/ and university of pretoria medicine has undergone a revolution, from the paternalistic approach where the doctor was considered to know best and expected to make decisions on behalf of the patient to the contemporary approach where the patient's autonomy is respected. i it is now realised that under normal circumstances patients are best equipped to make decisions on their own behalf, based on their own values and beliefs. i philosophically the paradigmatic example of respecting an individual's autonomy is taking informed consent from them prior to an examination or procedure.' the concept of informed consent before intervention is now not only a moral obligation, but has become a professional necessity and legal imperative.':" once one has accepted that informed consent is mandatory, the basic structure of the consent process should be understood and followed (table i).! under normal conditions where the threshold elements (voluntariness and decision-making capacity) are not in dispute, the major issues surround disclosure of information (table ii)." taking informed consent in radiology represents a challenge due to the large array of imaging modalities (transmission, reflection and emission) and techniques. risks may be inherent in the imaging modality (i.e. of radiation), in the technique (i.e. myelography) or in contrast agents utilised. radiologists also have to contend with the nuances of both screening and diagnostic tests. radiologists perform screening tests (e.g. marnmography), diagnostic tests (e.g. diagnosing fractures) and tests such as early obstetric ultrasound which is both a screening (nuchal translucency for chromosomal abnormalities, identification of structural abnormalities) and diagnostic (for viability of pregnancy, placental localisation, evaluating chorionicity and the number of fetuses in the case of multiple pregnancies and fetal measurements to confirm or establish gestational age) procedure." among other things table ii shows the general medical table i. the basic structure of the informed consent process (from beauchamp and childress') informed consent is not only a moral but also a legal obligation. common law has established the general principle of informed consent. touching a patient without valid consent could constitute assault.' further, if a health professional fails to obtain adequate consent and the patient subsequently suffers harm as a result of the treatment, albeit it as a result of adequate treatment and inherent risk, this may be a factor in a claim of negligence against the health professional involved.' 1. threshold elements 1.1 voluntariness: any decisions made should be free of undue pressure. 1.2 decision-making capacity: the patient should have the mental capacity to understand and make a decision about the procedure for which consent is being taken, as well as the ability to communicate that decision. in adults, in the absence of compelling evidence to the contrary decision-making capacity should be assumed to be intact. 2. informational elements 2.1 disclosure of information: legallythe doctor has to exercise due care by giving the necessary information. morally the doctor has to give the necessary information for the patient to make an autonomous decision. the patient should also be informed that the purpose of the consent process is to facilitate autonomous choice. 2.2 recommendations: the doctor may give his/her recommendations, based on what the doctor perceives to be in the patient's best interests. 2.3 understanding: prior to accepting a patient's authorisation the doctor should ascertain whether the patient has a substantial understanding of the salient facts. 3. consent elements 3.1 decision: the patient makes a decision based on the information disclosed. the decision is made according on the patient's own value system. the patient may decide to consent or decline the procedure. 3.2 authorisation: if the patient decides to consent to the intervention, authorisation is given. there is no obligation for written authorisation; however, the greater the risk the more prudent it is to have signed authorisation. it should be emphasised that the individual responsible for performing the investigation (in this case the radiologist) is morally and legally responsible for ensuring that the patient has given valid consent before treatment begins.' 6 sajournalof radiology. march 2002 review article table ii. disclosure of information when a doctor's diagnostic or therapeutic skills are evaluated in court, should they comply with what a body of reasonable medical practice considers good practice, then they must be accepted. this is not the case as regards the disclosure of information for informed consent. i i although the evidence of expert medical practitioners as to the completeness of disclosure may be persuasive, it will not be conclusive if the court finds that the standard of disclosure does not comply with the doctor's legal duty. what the law is saying is that the level of disclosure is not dependent on the professional practice standard of disclosure as determined by the profession, but what the court considers a reasonable person would want to know prior to intervention. the standards of disclosure expected by health professionals' regulatory bodies might be higher than the minimum required by law."the general medical council in the united kingdom advises that the doctor should try to ascertain the patient's individual needs and priorities when providing information on management options. for them the standard of disclosure is dependent on the subjective standard of the individual on whom the procedure is to be performed." legal disclosure should include:" advantages and disadvantages of the intervention, including 'material' and 'significant' risks of the intervention. alternatives to the intervention. risks incurred by declining the intervention. the option of a second opinion. the term informed consent was initially legal in origin. from a moral viewpoint, taking informed consent has less to do with legal liability of disclosure and more to do with respecting the autonomous choice of the patient.' ethically the doctor should also try to ascertain the patient's individual needs and priorities when providing information on management options. disclosure should include informing the patient that the reason for taking informed consent is to facilitate the patient's autonomy. also explain that consent has limitations and that the patient may change his or her mind. the quality of informed consent as a process is more important than the quantity of information disclosed. i the general medical council in the united kingdom has given guidelines with regard to obtaining informed consent from patients undergoing medical procedures, including screening or diagnostic tests,' the guidelines are specific and state that the following should be explained. the purpose of the test and whether it is a screening or diagnostic test and the distinction between the two. the likelihood of a positive and negative test. the concepts of sensitivity, specificity, false-negative and false-positive findings. the uncertainties and risks of the screening. the significant medical, social or financial consequences of screening. follow-up plans, including counselling and support services. council's guidelines for information to be disclosed pertaining to screening and diagnostic tests. taking informed consent in radiology is further complicated by the need to discuss alternative options. usually more than one imaging modality can be used to image for a particular condition and the different modalities and techniques each have their own unique risks and different sensitivities and specificities. when performing these examinations we often forget the detrimental 7 sa journal of radiology • march 2002 side-effects of screening, the anxieties, false alarms, unnecessary interventions and over-management, and from a potential medico-legal point of view, false reassurances.":" understanding screening and diagnostic tests not detecting an abnormality is often equated with negligence as most patients have unrealistic expectations of screening and diagnostic tests.":" doctors must try to establish a reasonable level of understanding and expectation in their patients.?" patients need to acquire a basic conceptual understanding of the concepts of prevalence, sensitivity, specificity, and positive and negative predictive values. prevalence of a condition is probably the easiest to understand and may be presented as either percentages or ratios. sensitivity, specificity, positive and negative predictive values are more difficult concepts to comprehend. patients may grasp them more intuitively if one utilises the concepts of true-positives, false-positives, true-negatives and false-negatives. a patient should understand that a test may be positive; if positive it may be a true-positive or a false-positive. false-positives are a reality of any screening programme; they are alarming and anxiety-provoking and usually lead to further testing, which if invasive constitutes a potential risk to the normal fetus. if the test is negative it may be a truenegative or a false-negative. like falsepositives, false-negatives are a reality of any screening programme; they are falsely reassuring and if not explained and understood may lead to subsequent litigation. the patient should review article also understand that where the prevalence of a condition is low, the majority of positive screening results will be falsely positive, while fortunately the overwhelming majority of negative screening results are true-negatives. as in other areas of medicine one has the problem of extrapolating population-based risks to an individual patient. as an example, should nuchal translucency screening indicate a high risk of trisomy 21, the populationbased risk of losing a pregnancy due to an amniocentesis is between 0.5% (1:200) and 1% (1:100), but in reality the risk for the individual patient is all or nothing.>" the woman either retains or loses the baby. ironically due to the low prevalence of the condition, most of the babies lost during amniocentesis will be chromosomally normal. conclusion it would appear that unhappiness with mammography is a common cause for litigation." practitioners who would possibly like to take refuge behind the fact that many of their colleagues do not take informed consent prior to radiological investigation should beware." a patient is entitled to informed consent and failure to take adequate consent may result in admonishment. the courts are under no obligation to compare the practitioner's practice with contemporary practice or the opinion of experts. i i the precedent has been set in south african law and the standard of disclosure is dependent on the information that a reasonable patient would require prior to intervention." the standards of disclosure expected by the health professionals' regulatory bodies might be higher than the minimum required by law. the general medical council in the united kingdom advises that the doctor should try to ascertain the patient's individual needs and priorities when providing information on management options." for them the standard of disclosure is dependent on the subjective standard of the individual on whom the procedure is to be performed. surely any true moral agent would also feel obliged to inform a patient fully before any intervention? obtaining informed consent also serves the interests of the radiologist by reducing the risk that subjects will pursue legal action when their expectations about the intervention are not met. the possibility of later unhappiness and even litigation may be greatly reduced by early disclosure, discussion, and the opportunity to decline intervention. the importance of informed consent in radiology cannot be over-emphasised. informed consent should be seen as a friend not a fiend, a help not a hindrance. references j. beauchamp tl, childress je principles of biomedical ethics. 5th ed. oxford: oxford universitypress,2001: 77-104. 2. south african medical association. doctors' code of conduct. cape town: sama, 1998. http://www.samedical.orgl 3. south african medical association. patients' rights, 1998. http://www.samedical.orgl 4. department of health (south africa). national patients' rights charter. pretoria: doh, 1999. http://www.samedical.orgl 5. general medical council (uk). seeking patients' consent: the ethical considerations. london: general medical council, 1999. 6. department of health (uk). reference guide to consent for examination or treatment. london: doh, 2001. http://www.doh.gov.ukl consent.htrn 7. the royal college of radiologists. consent by patients to examination or treatment. london: rcr, 1991. http://www.rcr.ac.uklpubtop.asp? publicationtd=121 8. the royal college of radiologists. guidance on consent by patientsto examination or treatment in departments of clinicalradiology. london: rcr, 1999.http://www.rcr.ac.uklpubtop.asp?publication id=62 9. the royal college of radiologists. good practice for clinical radiologists. london: rcr, 1999. http://www.rcr.ac.uklpubtop.asp? publicationtd=59 10. the royal college of radiologists. making your radiology services more patient friendly. london: rcr, 2000. http://www.rcr.ac.uki pubtop.asp?publicationid= 147 1j. brahams l. doctor's duty to inform patient of substantial or special risks when offering treatment. lancet 1985; i: 528-530. 12. constitution of the republic of south africa (act 108, 1996), chapter 2, the bill of rights. http://www.polity.org.za/govdocs/ consti tution/saconst.html 13. castell v. de greef 1994 (4) sa 408 (c). 14. seed rw. the routine or screening obstetrical ultrasound examination. clin obstet gynecol 1996; 39: 814-830. 15. hall s, bobrow m, marteau t. psychological consequences for parents of false-negative results on prenatal screening for down's syndrome: retrospective interview study. bm! 2000; 320: 407-412. 16. stewart-brown s, farmer a. screening could seriously damage your health (editorial). bm! 1997; 314: 533. 17. mcfayden a, gledhill j, whitloa b, economides d. first trimester ultrasound screening; carries ethical and psychological implications (editorial). bmjl998; 317: 694-695. 18. cockburn j, redman s, hill d, henry e. public understanding of medical screening. i med screen 1995; 2: 224-227. 19. anonymous. the gap between expectations and reality, bm! 2000; 320: 1348. http://bmj.com/cgi/content/full/320/7246/0 20. the right to a perfect baby. independent, 22 august 1992: 3. 21. mccall smith a. obtaining consent for examination and treatment (editorial). bm! 2001; 322: 810-811. 22. austoker j. gaining informed consent for screening. bm! 1999; 319: 722-723. 23. royal college of obstetricians and gynaecologists. report of the working party on ultrasound screening for fetal abnormalities. london: rcog press, 1997. 24. tabor a, philip j, madsen m, bang j, obel eb, norgaard-pedersen b. randomised controlled trial of genetic amniocentesis in 4 606 low-risk women. lancet 1986; 1:1287-1293. 25. wilson rm. screening for breast and cervical cancer as a common cause for litigation. bm! 2000; 320: 1352-1353. 8 sajournal of radiology • march 2002 http://www.samedical.orgl http://www.samedical.orgl http://www.samedical.orgl http://www.doh.gov.ukl http://www.rcr.ac.uklpubtop.asp? http://www.rcr.ac.uklpubtop.asp?publication http://www.rcr.ac.uklpubtop.asp? http://www.rcr.ac.uki http://www.polity.org.za/govdocs/ http://bmj.com/cgi/content/full/320/7246/0 the future part 1 the part 1:future technological advances based on the consistent and stellar evolution of our specialty over the last 30 years, it is virtually a certainty that there will be further dramatic breakthroughs in diagnostic radiology.the bets are off, however, when trying to predict what these changes could be. certain general trends are fairly clear, including refinements of existing technology leading to smaller, faster and friendlier machinery with more facilities. less striking but highly practical is the increasingly modular approach to machine design, permitting easy upgrading of equipment. more attention is also being paid to functional and quantitative evaluation. invasive devices and procedures are more dependable, with their appropriateness in the clinical arena being clarified and formalised. s beningfield mbchb(uct), ffrad(d)sa professor and head.· department of radiology, university of cape town medical informatics most information technology benefits to radiology ride on the back of commercial and consumer demand. ultra-high speed wireless connections will make it possible to report from any location, at any time. the transfer of all but the largest images will be possible in the magical time of two seconds, the time it takes to extract a 6 sa journal of radiology· january 2000 film from its jacket and snap it up on the viewing box. the predicted demise of film, however, may take a lot longer than expected, and it may persist indefinitely in some hospitals. electronic patient records with organised, intelligent, integrated and confidential medical data storage have been identified as a key growth node, with good reason. this area is subject to intense interest at present, although the complexity is highly challenging. a watertight universal patient identifier system will be critical. computer-aided diagnosis will probably take many years to achieve, and may then only serve as a support system, providing a cost-effective means of double-reading images. images and reports (verbal or written) sent immediately to the referring clinician's desktop monitor will be the norm. cost-cutting pressures could be firmly implemented with instant computer analysis and preauthorisation. closer integration of the various data standards is inevitable, with the combining of scheduling, clinical, imaging and financial information. medical science genetic and molecular advances appear set to dominate medicine in the next century. will atherosclerosis and cancer vanish? can viral illness be uniformly overcome? patientcentric pressure will feature strongly in the directions taken by future research. and what of the proposed ability to suspend aging by centromere intervention? will families have to limit offspring to one person, in return for immortality? will the usual diseases of the elderly manifest if aging is arrested at 30? to page 7 the future part 1 frompage6 the modalities are we running out of new methods to view and guide our invasion of the interior of the human body? although science appears to be approaching a more comprehensive understanding of atomic structure and physical phenomena, does this diminish the likelihood of spectacular advances? it is interesting to remember that the principles of ct and mri were known for many years before they were applied to clinical imaging. what about the other parts of the electromagnetic spectrum, such as the infrared, ultraviolet, and microwave wavelengths? and laser, electrical conductivity or forms of sound other than ultrasound? could we see images based on subatomic particles or quantum phenomena, with the arrival of "quark tomography" or "boson resonance imaging"?surely no less strange than positron emission tomography: direct digital acquisition, high acquisition speed, radiation dose reduction and real-time 3d post-processing are certain, as are many potential variations of functional and quantitative imaging. viewing monitors and operating consoles high-resolution, high-intensity, all-purpose workstations permitting reporting of all modalities are largely the consequence of commercial 3-dimensional data display and manipulation. viewer location will be immaterial, and multi-reading by a number of radiologists may become the rule. these w~rkstations could be head-mounted devices (possiblytermed "headstations"], with low-power laser beams scanning highly detailed images directly onto the retina. the entire workstation could be a remotely connected wallet-sized unit. vendor-specific viewing and operating consoles could make way for software-based systems running on off-the-shelf hardware, facilitating generic replacements and upgrades. the "front end" the detector/acquisition system may become the single proprietary component of imaging equipment manufacturers. vendors may focus exclusively on acquisition modules, leaving the data processing and display to standard computers run with customised software. the open standards paradigm led by the dicom 3 protocols will hopefully lead to similar electromechanical standards, permitting compatibility for inter-vendor component and module interchange. for example, an integrated x -ray tube and generator in a shoebox-size unit could simply be clipped into position when replacement is required. x-rays huge amounts of research and development finance have gone into attempting to design commercial direct digital systems. the problem in manufacturing large area detectors or alternate systems appears more challenging than initially thought. some flat plate detectors exceed 15 kilograms, precluding their use as mobile receptors. for the time being, the intermediate technology photostimulable phosphor computed radiography (cr) systems dominate this sector. angiography although digital subtraction angiography appears to be holding its own against the onslaught of magnetic resonance angiography and computed tomographic angiography 7 sa journal of radiology. january 2000 when intervention is planned, there appears to be little that is revolutionary on the horizon. computed tomography (ct) virtual colonoscopy, bronchoscopy and other 3-dimensional displays could become the standard if consumer-driven demand escalates. combined multipurpose fluoroscopic, angiographic and ct units should be possible when large flat panel detectors arrive. cone beam computed tomography (cbct) using the full area of flat plate detectors for data acquisition in a ct gantry should allow almost instantaneous volumetric acquisitions. ultrasound three-dimensional ultrasound with volumetric display has yet to be widely used, but refinements of existing technology promise ongoing development. modular replaceable ultrasound units integrated into interventive fluoroscopic and ct units should be standard issue. nuclear medicine positron emission tomography (pet) and single photon emission computed tomography (spect) imaging may merge further. targeted imaging with monoclonal antibodies will be extended, paving the way for other organ-specific contrast agents. magnetic resonance imaging diffusion and perfusion imaging may be followed by the re-popularisation of metabolic imaging and spectroscopy. ceramic mri may resurface, but major developments could take a back seat to incremental improvements. organ specific and targeted imaging topageb the future part 1 from page 7 are beginning to appear commercially, and may set the scene for the future. interventive radiology smaller, smarter, slicker will be the bywords here, but political pressure and the relationship with other minimally invasive procedures may be the pivotal aspects. the number of invasive procedures may well expand, despite the increased involvement of clinical colleagues. this may be partly as a result of the incorporation of previously unguided procedures. the promise of routine remotely-performed procedures appears a long way off, despite huge investments in the technology, particularly feedback transducers. the specialty turf wars, clinical re-alignments, and reimbursement issues may overshadow technical advances. a major split of the specialty into the hands-on and remotely conducted components may occur, with centralised or home reporting facilitated for the latter. organ-specific teams will probably emerge from the turf wars, becoming the rule in the bigger centres. medical training may adjust to this concept, with, for example, a career neuroradiologist or technique specialist commencing training straight after school, in the same way that dentistry splits from general medicine. could we witness a backlash against the sterile and remote digital environment, with close personal attention and professional interaction becoming a selling point for some centres, rather than technical prowess? conclusion tissue-specificimaging remains our unreachable objective.non-harmful intervention is the ideal. in the attempt, many promising new technologies will go the way of kymography, electron radiography and thermography, while others, at present unknown, may dominate. gradual stepwise progress will hopefully be interspersed by exciting new developments, sending us all back to being students again. the future part 2 the future part 2: training radiologistspast, present and future peter corr mbchb, ffrad(d)sa, frcr, mmed(uct) professor and head: department of radiology, university of natal, durban radiology is one of the most popular specialities in medicine. it is not difficult to understand why. few radiologists regret making the decision: however the future is not what it used to be: radiology faces challenges both in south africa and internationally a sa journal of radiology. january 2000 which will certainly affect the number and profile of future trainees entering the speciality. has the "golden age of radiology" truly gone? doctors training in radiology in south africa have followed a traditional postgraduate programme as registrars in departments of radiology at the three english language medical schools. they write the college of medicine fellowship exam within four years of training. at the three afrikaans language medical schools, registrars write the mmed exams within four years. the medical council requires four years of training in an academic department for specialist registration. in many ways the current south african fellowship follows the uk fellowship exam structure in the late seventies and early eighties with essay type questions, film viewing and long cases. today 'the south african qualifying authority (saqa) will effect the curriculum structure, entry and exit points and to page 10 revie\n article introduction to mr hl spectroscopy p corr mbchb, ffrad(d)sa, frcr, mmed(uct) single voxel mr spectroscopy (mrs) of hydrogen protons is a useful investigation to characterize lesions of the central nervous system. imaging findings of mass lesions in the brain are often non-specific. contrast enhancement indicates breakdown of the blood brain barrier and is often useful in diagnosing certain mass lesions such as meningiomas. however, many ring enhancing lesions such as abscesses, granulomas and tumours cannot be differentiated using ct or mr imaging. single voxel spectroscopy of hydrogen protons can establish the chemical spectrum of masses and assist in their characterization. introduction professor and head: department of radi%gy, university of nata/, durban methods mrs is essentially the same process as mr imaging, only the presentation of the data obtained is different.' in mr imaging the signal obtained in the time domain is used to produce a two-dimensional image, in mrs the signal in the time domain is used to produce a frequency domain spectrum of the molecules in the 12 sa journal of radiology· april 2000 voxel. hl protons resonate at 63.86 mhz at 1.5 t chemical bonds in and between molecules exist in the form of electron clouds around protons. these electron clouds have their own magnetic moment thus changing the net resonant frequency of each nucleus from its neighbour. this is called chemical shift and is the foundation of mrs. chemical shifts are measured relative to the peak position of a reference chemical. in the brain the reference is n acetyl group of n acetyl aspartate (naa), one of the brain's major constituents. this reference is set at 2 ppm. molecules that can be detected by mrs are:' • methyl groups ch3 found in fatty acids, n acetyl aspartate, lactate • methylene groups ch2 found in fatty acids, glutamate, creatine and glycerol • methyne group from alcohols found in glucose and myoinositol • vinyl or olefinic protons of unsaturated fatty acids the concentration of most molecules in cells are very small while the concentration of water is very large by comparison, in the region of 10000 to 100 000 larger. therefore the mr spectrum is totally dominated by water and the other molecules cannot be detected. suppression of the water spectra is necessary to visualise the other molecules by mrs. water is suppressed by two different methods: chemical shift selective method (chess) or water elimination fourier transform method. to identify the metabolites or molecules in a single voxel, two methods are used. stimulated echo acquisition mode (steam) and point resolver spectroscopy method (press) can be used. both have their advantages and topage 13 introduction to mr h i spectroscopy from page 12 disadvantages. steam is particularly useful for detecting the spectra of fatty acids and amino acids in small concentrations while press is more accurate for detecting larger metabolite concentrations such as lactate, choline and n acetyl aspartate. we use the probe software from ge medical systems which is semi-automated. we find it works best using the press technique where there is a better signal to noise ratio than steam. the voxels are scm' in size (2x2x2 cm). magnetic field homogeneity is essential for good mrs. inhomogeneity leads to molecules having slightly different spin dephasing and broadening of the spectra. this makes it difficult to differentiate spectra from different metabolites. care must be taken in placing the voxels on the brain scan. if the voxel is too close to the skull or ventricles, field homogeneity is affected. the choice of time to echo (te) is critical as it determines which metabolites are detected. amino acids,long chain fatty acids and myoinositol are best detected at a short te around 20 msec while choline and naa and lactate at a 10ngte of around 270 msec. lactate has a double peak at te of 135 msec and 270 msec due to a phenomenon called j coupling. normal spectrum (figure 1) naa is the main peak at 2 ppm. this is due to the acetyl group and is a measure of neuronal density and viability? any pathological process where neurones die will decrease the naa peak. the next largest peak is due to creatine. this is a marker of energy metabolism within neurones and is diminished in malignant tumours. it is found at 3.03 ppm. choline at 3.2 figure 1: normal h' mrs brain spectrum naan acetyl aspartate, chcholine, crcreatine ppm is a building block of neuronal cell membranes and is an indicator of cell membrane turnover. it is increased in all tumours. lactate is detected at 1.32 ppm. normally lactate is not found. lactate is present in anaerobic glycolysis where there is reduced blood oxygen and is seen when lesions outgrow their blood supply or if there is ischaemia. with steam, metabolites with short relaxation times such as myoinositol at 3.56 ppm and alanine can be detected. they are involved in neurotransmitter production. multiple volume mrs two and three dimensions and both press and steam methods can be used.' app-lications of single voxel mr spectroscopy (mrs) mrs using the single voxel technique is useful in characterising intracerebral masses. we have used it successfully in patients with aids to determine whether lesions were inflammatory or neoplastic before considering treatment. neoplasms will cause an elevated choline peak due to increased cell membrane production but decreased n acetyl aspartate and multiple volume mrs is used to determine spectra from multiple voxels in the brain. this is also called chemical shift imaging (csi). this allows comparison of spectra for multiple regions of a tumour especially on treatment. this is in one, 13 sajournal of radiology. april 2000 figure 2a, b: single voxel h' spectroscopy of non-hodgkin's lymphoma of the left basal ganglia demonstrates an elevated cholme peak end diminished naa and creatine to page 14 introducl ion lo mr h i spectroscopy frompsg",3 creatine peaks from destruction of neurones. occasionally elevated lactate peak in areas of ischaemia are detected within the tumour. choline peaks are highest in tumours with high cellularity such as lymphoma and primitive neuroectodermal tumours such as medulloblastoma (figure 2). mrs is useful in evaluating tumour response to radiotherapy or chemotherapy by monitoring peaks. mrs in particular can distinguish between recurrent tumour and gliosis." recurrent tumour will figure 3a, b: single voxel h' spectroscopy of e left basal ganglia tuberculoma demonstrates a merkedly elevated lactate peak and diminished naa and choline peaks using press technique demonstrate elevated choline peaks while gliosiswill show depression of all metabolite peaks. inflammatory lesions will have decreased naa and creatine levels and increased lactate from anaerobic glycolysis. both tuberculomas, pyogenic and toxoplasma abscesses often have markedly elevated lactate conclusions mrs is a relatively new technique that provides additional information that is useful in the treatment of many patients with brain tumours, inflammatory diseases, metabolic disorders and demyelination. figure 4a, b: single voxel h' spectroscopy of a 9-year-old child's brain with advanced canavan's djsea~e with . marked white matter hyperintensity and cerebral atrophy. mrs shows markedly elevated naa peak typical of this disorder peaks (figure 3).5 tuberculomas also have elevated levels of lipids and fatty acids, best detected on steam sequences. recent work shows that mrs is useful for differentiating cerebral abscesses from necrotic tumour," mrs has an important role in the diagnosis and monitoring the treatment response in certain metabolic brain disorders in children. these include disorders of lipid metabolism such as adrenal leukodystrophy, mitochondrial disorders (leigh' s disease), and white matter disorders (canavan's disease)? (figure 4). 14 sajournal of radiologyapril 2000 references i. kwock l. localised mr spectroscopy. neuroimaging clinof namerica 1999;8:713-731. 2. castillo m, kwock l. proton mr spectroscopy of common brain tumours. neuroimaging clin of n america 1999;8:733-752. 3. salibi n, brown m. in: clinical mr spectroscopy. 1998. john wiley, new york. 4. castillo m, kwock l. proton mr spectroscopy of common brain tumours. neuroimag clin n america 1998;8:733-752. s. cecil k, lenkinski r. proton mr spectroscopy in inflammatory and infectious brain disorders. neuroimag clin n america 1998;863-880. 6. grand s, passaro g, ziegler a, et al. necrotic tumour vs brain abscess:importance of amino adds detected at h' spectroscopyinitial results. radiology 1999;213:785-793. 7. wang z, zimmerman r. proton mr spectroscopy of paediatric brain disorders. neuroimag clin n america 1998;8:781-807. clinical images chiari type i a~d ii malformations s andronikou mb bch, fcrad(d), frcr (lond) c weiman mbchb e kader mbchb department of paediatric radiology university of cape town and institute of child health, red cross war memorial children's hospital, cape town despite the same name, chiari types i and ii are unrelated entities. chiari ii malformation is initially encountered in children, occurring in virtually all those who have myelomeningocoele. chiari type ii malformation this is also known as the arnoldchiari malformation. once a myelomeningocoele has been closed surgically after birth, most patients develop hydrocephalus. this is the commonest indication for radiological evaluation at which time the features of chiari type ii will be visualised. this anomaly is formed when the posterior neuropore fails to close resulting in failure of the ventricles to expand and so create a normal size posterior fossa with subsequent failing in separation of the thalami.' intra-uterine surgical closure of the myelomeningocoele (http://www.fetalsurgery.com) prevents development of this malformation. the imaging features result from fig. 1. chiari type " malformation. sagittal t1 weighted mri image shows the small posterior fossa, tonsillar vermian herniation through foramen magnum (1), low-lying venous confluence with a steep (vertically orientated) straight sinus (2), lowlying 4th ventricle with a narrow ap diameter (3), tectal (quadrigeminal plate) beaking (4), scalloped clivus (5) and corpus callosum hypogenesis (6). many of the supratentorial features (not shown here) are best seen on axial images. squeezing of the growing cerebellum out of a small posterior fossa. the radiological features are best demonstrated on a sagittal tl weighted mr! image. chiari type i this is usually an isolated abnormality but can be seen with conditions that have a small posterior fossa. the subgroups of this entity relate to various craniocervical junction abnormalities. caudal cerebellar tonsillar ectopia is the primary abnormality. in adults and children less than 5 years of age, projection of the cerebellar tonsils below the foramen magnum of greater than 5 mm is abnormal. between the ages of 5 and 15 45 sa journal of radiology • march 2002 fig. 2. axial ct scan through the high parietal region shows marked cerebral interdigitation (arrows) through a fenestrated falx cerebri. note the parallel lateral ventricles which are prominent posteriorly. fig. 3. chiarl type i malfomation. sagittal tt weighted mri image shows the tonsillar ectopia (long arrow). associated syringohydromyelia (short arrows) can be found in 20 25% of these patients. years tonsillar ectopia is only pathological when there is more than 6 mm projecting through the foramen magnum. reference i. barkovich aj. paediatric neuroimaging. 2nd ed. philadelphia: lippincott-raven, 1996: 238-247, 455-488. introduction central pontine myelinolysis is a demyelinating disease of the pons characterised by loss of myelin and oligodendroglia with relative neuron sparing. this condition classically occurs in alcoholics, malnourished or chronically debilitated adults1 and usually occurs in the hospital setting, a few days following rapid correction of hyponatraemia.we report a case of central pontine myelinolysis in a chronic alcoholic, malnourished patient following rapid correction of hyponatraemia. case report a 44-year-old man presented to the emergency department with generalised weakness and altered speech of 1 week’s duration. there was a history of an accidental fall at home with scalp injury. the patient was known to have alcoholic liver disease. on clinical examination the patient was found to be malnourished and anaemic. the liver was palpable. serum electrolyte analysis revealed hypokalaemia (2 meq/l) and hyponatraemia (10 meq /l). ultrasound scan of the abdomen showed an enlarged liver with diffuse fatty infiltration. computed tomography (ct) scan of the brain was normal. electrolyte imbalance was corrected using potassium chloride in dextrose saline and 3% normal saline. following this treatment the patient improved and was discharged from the hospital. one week later he presented again with confusion and altered levels of consciousness. repeat ct scan of brain was normal. the patient was then sent for magnetic resonance imaging (mri) examination of the brain. mri was done using a 3t magnet. scanning was performed in the three orthogonal planes and diffusion imaging/apparent diffusion coefficient (adc) mapping was also done. mri images revealed an area of altered signal intensity in the pons, predominantly central, with sparing of the periphery. the lesion was hypointense on t1-weighted images (t1wi) and hyperintense on t2wi (figs 1 and 2), flair and diffusion images. adc mapping demonstrated low signal in the pons. there was predominant involvement of the transverse pontine fibres, with relative sparing of the descending corticospinal tracts. the rest of the brain parenchyma showed normal signal intensity. the patient’s condition gradually deteriorated further, with development of quadriparesis and pseudobulbar palsy due to the involvement of the corticospinal and corticobulbar tracts. discussion central pontine myelinolysis is a non-inflammatory demyelinating disease characterised by loss of myelin with relative neuron sparing. it may be associated with demyelination elsewhere in the central nervous system. the common extrapontine sites are the putamen, caudate nucleus, midbrain, thalamus and subcortical white matter (extrapontine myelinolysis).2 over 75% of cases are associated with chronic alcoholism or rapid correction of hyponaetraemia and sometimes hypernaetraemia.3,4 a good correlation was found between development of central pontine myelinolysis and the correction of sodium more rapidly than 12 meq/day.5 a number of other conditions have been associated with central pontine myelinolysis such as orthotopic liver transplantation, chronic renal failure, dehydration, diabetes mellitus, sepsis, advanced malignancy and acute haemorrhagic pancreatitis.5 central pontine myelinolysis s k chamarthi department of radiodiagnosis, apollo hospitals, narehenpita, colombo, sri-lanka a l kiranmayi a m mukarrab department of radiodiagnosis, yashoda hospitals, malakpet, hyderbad, india case report fig. 1. axial-t2w mr scan showing hyperintense signal in the central pons with predominant involvement of transverse pontine fibres and relative sparing of descending corticospinal tracts. fig. 2. sagittal t1wi showing hypointense lesion in the central pons. 23 sa journal of radiology • march 2006 central pontine myelinolysis.ind23 23 3/27/06 2:19:29 pm 24 sa journal of radiology • march 2006 the pathophysiological mechanism is unknown. since both the pontine and extrapontine sites involved have a rich grey and white matter interface, it has been hypothesised that a rapid osmotic change causes an endothelial injury in the more vascular grey and white matter which induces the release of myelinolytic factors that damage the adjacent white matter.6 the term osmotic myelinolysis is currently favoured for this condition. the initial symptoms may be weakness, confusion and dysarthria. in severe cases there is spastic quadriparesis and pseudobulbar palsy. this may evolve within 3 10 days into a locked-in-state (pseudo coma). death within 2 3 months is the usual outcome. the 6-month survival rate is 5 10%.5 the imaging features are due to increased water content in the affected areas. transverse pontine fibres are more severely affected, compared with descending corticospinal tracts. nect scans are normal or disclose nonspecific hypodense areas. lesions appear hypointense on t1wi and hyperintense on t2wi and show varied enhancement following contrast administration.6 differential diagnosis of central pontine myelinolysis includes infarct, metastasis, glioma, multiple sclerosis, encephalitis, radiotherapy and chemotherapy.3 however concomitant involvement of the pons and basal ganglia is specific for osmotic myelinolysis.7 in such cases the imaging differential diagnosis includes hypoxia, leigh disease and wilson’s disease. the classical history combined with imaging findings distinguishes osmotic myelinolysis from the rest of the conditions. a number of therapeutic approaches have been tested, although no specific therapy exists. correction of serum sodium should not exceed 12 meq/24h. recovery varies from no improvement to substantial recovery, although the outcome of this condition is frequently fatal. 1. ho vb, fitz cr, yoder cc, geyer ca: resolving mr features in osmotic myelinolysis (central pontine and extrapontine myelinolysis). am j neuroradiol 1993; 14:163-167. 2. koci tm, chiang f, chow p, et al. thalamic extrapontine lesions in central pontine myelinolysis. am j neuroradiol 1990;11: 1229-1233. 3. miller gm, baker hl jun.., okozaki h, whisnant jp. central pontine myelinolysis and its imitators: mr findings. radiology 1988; 168:795-802. 4. clark wr. diffuse demyelinating lesions of the brain after the rapid development of hypernaetremia. west j med 1992;157:571-573. 5. howard ls, krishna rao cvg, zimmerman ra. cranial mri and ct. mc graw-hill, 1999:606-608. 6. koragi y, takahashi m, shinzaho j, et al. mr findings in two presumed cases of mild central pontine myelinolysis, am j neuoradiol 1995;14:651-654. 7. osborn ag. diagnostic neuroradiology. mosby, 1994:761-763. case report price: r380.00 sama members: r360.00 to order contact: south african medical association health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405 tel: (021) 530-6520/27 • fax: (021) 531-4126 email: books@samedical.org hmpg quarter clinical medicine ad 10/14/05 12:54 pm page 1 central pontine myelinolysis.ind24 24 3/27/06 2:19:30 pm revie\n article diffusion weightedmr • •imaging abstract bramsing mbchb, fcrad diffusion vveighted imaging (owl) al lovvs the measu rement of molecular motion in tissue. this technique has significant clinical appl ications. recent technological developments in fast mr imaging have brought diffusion imaging into clinical practice. this revievv vvill explain the physical principles, and cu rrent and futu re potential appl ications of diffusion imaging in medicine. pcorr mbchb, ffrad basic theory diffusion is the physical property of molecules which leads them to move randomly at a rate in proportion to their thermal energy.' a useful analogy is if we drop some ink into a glass of water, the ink will slowly distribute itself throughout the water and change its colour. this movement of ink molecules from a region of higher concentration to a region of 4 sajournal of radiology· august 1998 lower concentration along a gradient is called diffusion. however, even when the ink has distributed itself throughout the water and there are no concentration gradients, there are still random movements of ink molecules. this intrinsic kinetic energy of molecules is called brownian motion. water within tissues displays brownian motion. the diffusion process is three dimensional and is distributed in all directions perpendicular to its origin. this is called isotropic distribution. however, in tissues water molecule movement is determined by the local molecular environment and cannot distribute itself in an isotropic manner. this distribution is called anisotropy. an example is water molecules within neurones, in which the molecules move parallel to the axons rather than at right angles to them. because of anisotropy, a three dimensional data acquisition is performed during imaging. using conventional spin echo imaging, diffusion causes minimal signal reduction, but with very strong gradients it is possible to obtain diffusion weighted images (owl). owl is very sensitive to motion artefacts such as breathing and cardiac pulsation. fast imaging using echo planar techniques will reduce motion artefacts and improve image quality. the images have a poor signal-to-noise ratio compared to conventional spin echo sequences of the brain, with susceptibility artefacts adjacent to the skull and sinuses. regions of high diffusion have a low intensity and appear dark on the scan, while regions of low diffusion have a relatively increased intensity and appear bright on the scan. the apparent diffusion coefficient (aoc) is a quantitative to page 5 diffusion weighted mr inlaging frompage4 measure of the degree of diffusion in a tissue or organ. the average value for the brain is 2 100xi06 mmvs.' the other important concept is the b value.this is a measure of the strength and duration of the mr gradient's pulses, as well as the time between gradient pulses and the gyromagnetic ratio. the higher the b value, the better the differentiation between tissues of different diffusion coefficients and hence lesion conspicuity. owl is best between a b value of 600 to 1000 mm//sec.' owl is essentially a cellular energy test. owl indicates cell osmolality which is dependent on the integrity of the cell membrane pump and cell energy levels of atp. with depletion of cell energy supplies of atp, the cellular pump fails and the cell swells resulting in cytotoxic oedema. this results in a marked decrease in diffusion (aoc) and a focal bright signal on the scan. clinical applications acute stroke wi th acute stroke, cytotoxic oedema develops in the neurones and the diffusion of water molecules decreases. this is thought to be due to decreased na k-atpase enzyme activity in the cell membrane, and therefore decreased water transport. water becomes trapped within the cell. water viscosity is increased due to the dissociation of large macromolecules and the cellular fluid becomes a gel. this also decreases water diffusion. in animal models, the decreased diffusion is detected as a high intensity focal lesion within 45 minutes of experimental vascular occlusion? after two days, diffusion returns to normal and then increases. in humans owl detects changes as early as 38 minutes and diffusion decreases over 24 hours to 4 days (figure 1). diffusion figure 1: diffusion mr scan shows a focal hyperintense infarct in the posterior limb of the l internal capsule (arrow) in a patient with a 6 hour history of r hemiparesis. t2 mr and ct scans were both normal. returns to normal at 5 to 10 days post ictus. the slow return to normal (mfusion levels is due to persistent cytotoxic oedema as well as vasogenic oedema. this is a consequence of cell membrane disruption and resultant extracellular oedema which increases diffusion levels. reversibility of diffusion to normal levels can be consistently detected in the animal model, with a threshold aoc above which no permanent tissue injury is detected. in humans this has yet to be achieved.' ct and mr cannot detect cerebral infarction before 8 hours when thrombolytic therapy is most effective; however owl is able to provide this information." a lesion with decreased diffusion correlates strongly with cytotoxic oedema and infarction. the absence of decreased diffusion correlates with the absence of infarction, and rather suggests stroke mimics 5 sa journal of radiology· august 1998 such as transient ischaemie attacks, migraine, and metabolic causes. subacute stroke owl is useful in differentiating white matter infarcts from the t2 hyperintensities associated with aging. on owl, infarcts are hyperintense while the aging changes demonstrate no diffusion change. owl is also useful to distinguish subacute from chronic infarction, which is impossible with spin echo t2 imaging. subacute infarcts are hyperintense on owl due to decreased diffusion from cytotoxic oedema, while chronic infarcts are hypointense as a result of increased diffusion from vasogenic oedema and increased extracellular water. 5 t2* susceptibility effects are more readily detected with owl as opposed to spin echo imaging, so that haemorrhagic infarction is more easily identified. neonatal ischaemia owl is useful in imaging hypoxic ischaemie encephalopathy in neonates. the white matter is unmyelinated and ct and mr detection of infarction are difficult. owl easily detects infarcted brain where diffusion is decreased compared to normal brain. owl can differentiate between embolic infarcts and cortical laminar necrosis. this is important clinically as neonates with embolic infarcts have a better prognosis.' venous infarct owl distinguishes between venous infarction and extracellular oedema resulting from occluded cortical veins and venous sinuses. infarction is hyperintense while the surrounding extracellular vasogenic oedema is hypointense. topage6 [)iffusioll \ncighteci mr inl<elging trom page 5 stroke mimics dwi can detect disorders that may mimic acute stroke or cerebral infarction. included in this group are atypical migraine and transient ischaemie attacks (tla). in these patients diffusion is normal and infarction can be excluded. there are also disorders with both vasogenic oedema and sometimes cytotoxic oedema that can mimic stroke.' only dwi can distinguish between cytotoxic and vasogenic oedema. this group includes: eclampsia, hypertensive encephalopathy, posterior leucoencephalopathy and hyperperfusion injury (figures 2a,b,c). figure 28: patient with eclampsia. t2 mr demonstrates hyperintense lesions in both occipital poles representing focal oedema (arrows). figure 2c: follow-up diffusion scan at 48 hours after start of treatment confirms resolved vasogenlc oedema. vasogenic oedema is characterized by increased diffusion of water. this is due to increased extracellular water and increased membrane permeability to water. neoplasms dwi is most useful in characterizing extra-axial tumours, especially differentiating arachnoid cysts from epidermoids." both have low intensity on tl and high intensity on t2. however, epidermoids have decreased diffusion and appear hyperintense on dwi; arachnoid cysts have increased diffusion and appear hypointense on dwi. intra-axial tumour morphology has been investigated using dwi. dwi can distinguish between solid and cystic components of tumours as well as tumour and surrounding vasogenic oedema.' 6 sajournal of radiology· august 1998 trauma and haemorrhage dwi may have an important role in the detection of ischaemia related to cerebral trauma." trauma causes increased cortical diffusion due to increased extracellular water. however, with severe head injury, ischaemia due to decreased cerebral blood flow can be detected as cytotoxic oedema and as hyperintense parenchymal lesions on dwi. dwi is very sensitive to parenchymal haemorrhage due to t2* susceptibility effects. infection pyogenic infection, such as abscesses, have decreased diffusion and appear as hyperintense lesions on dwi. 5 other ring enhancing lesions such as tumours have increased diffusion and thus appear hypointense.' this allows characterization of inflammatory masses. empyemas have very low diffusion and appear hyperintense compared to extraxial hygromas which have increased diffusion and appear hypointense on dwi. spine dwi of the spine successfully differentiates benign osteoporotic from malignant fractures. osteoporotic fractures have hypointense bone marrow signal, while metastases are hyperintense to the normal bone marrow signal." conclusion dwi is an important new mr technique which allows investigation of tissues at a molecular level. it has enhanced our understanding of the pathophysiology of stroke and will probably become the most important imaging modality in early detection of infarction. dwi shows promise in ta page 28 abstract introduction methods results cardiopulmonary resuscitation and contrast media anaphylaxis knowledge discussion conclusion acknowledgements references about the author(s) sarah k. osiemo department of radiology, the mater hospital, nairobi, kenya callen k. onyambu department of diagnostic imaging and radiation medicine, faculty of medicine, university of nairobi, nairobi, kenya angeline a. aywak department of diagnostic imaging and radiation medicine, faculty of medicine, university of nairobi, nairobi, kenya citation osiemo sk, onyambu ck, aywak aa. knowledge and practices of cardiopulmonary arrest and anaphylactic reactions in the radiology department. s afr j rad. 2020;24(1), a1841. https://doi.org/10.4102/sajr.v24i1.1841 original research knowledge and practices of cardiopulmonary arrest and anaphylactic reactions in the radiology department sarah k. osiemo, callen k. onyambu, angeline a. aywak received: 18 dec. 2019; accepted: 13 mar. 2020; published: 28 may 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: emergencies in the radiology department may arise in critically ill patients who are brought to the department for imaging, interventional procedures or as a result of adverse reactions to contrast media used for imaging. adverse reactions to contrast media range from minor to severe life-threatening effects and initial, prompt management decreases complications. radiology staff must possess knowledge of the management of anaphylactic or anaphylactoid contrast reactions and cardiopulmonary arrest (cpa) as they are likely to be the first responders. objectives: to determine the knowledge and practices amongst radiologists, radiology residents and radiographers in the management of cpa and adverse reactions to contrast media. method: this cross-sectional study was performed between march and august 2016 at kenyatta national hospital using a questionnaire. results: eighty participants were enrolled. none answered all the questions correctly, with only 55% of radiologists, 35% of residents and 39% of radiographers scoring above 50%. the majority (82%) of participants had adequate knowledge regarding the symptoms, signs and risk factors of adverse reactions to contrast media; however, only 30% knew that intravenous epinephrine is the recommended therapy for a severe anaphylactic reaction. shortcomings in terms of adequate training were found in this study, with the majority of respondents having not attended any life support course in the preceding 5 years. conclusion: health providers within the radiology unit had knowledge about identifying both mild and severe symptoms of anaphylactic reactions. however, there were knowledge gaps regarding the management of these reactions. keywords: cardiopulmonary arrest; anaphylactic reactions; management; radiologists; residents; radiographers. introduction cardiopulmonary arrest (cpa) refers to the cessation of cardiac activity and breathing, leading to hemodynamic collapse and interruption of pulmonary gaseous exchange.1 resuscitation is a pivotal lifesaving skill, which, if administered quickly and correctly, greatly improves the chances of survival following cpa. the practice of cardiopulmonary resuscitation (cpr) has evolved over the years with significant changes that have a great impact on the patient’s outcome. the american heart association’s (aha) basic life support (bls) and advanced cardiac life support (acls) algorithms are widely accepted as standard resuscitation guidelines. basic life support forms the foundation for the management of cpa and emphasises high-quality cpr and use of an automated external defibrillator.2 advanced cardiac life support focuses on additional algorithms tailored to deal with different causes of cardiac arrest, like ventricular fibrillation, ventricular tachycardia, pulseless electrical activity and asystole. emphasis is also given to the use of drugs, for example, epinephrine, advanced airway support and recognition and treatment of reversible causes of cpa. iodine-based contrast media and gadolinium chelates are the main contrast agents used to enhance the differentiation of tissues during imaging. adverse effects, although infrequent, can occur after contrast administration. the prevalence of such effects has been shown to be 0.6% for iodinated contrast media3,4 and 0.12% for gadolinium-based contrast agents.5 these adverse effects can be classified into organ specific and non-organ specific, acute and delayed reactions. the acute reactions can be divided into anaphylactoid or idiosyncratic and physiologic or non-idiosyncratic reactions. further subdivision into mild, moderate and severe is based on severity, with mild reactions being more common (71%).4 there are recognised risk factors that increase the likelihood of the occurence of adverse reactions, for example, prior allergic-like reaction to intravenous contrast media, asthma and significant cardiovascular disease.6 however, the majority are non-specific. despite their infrequent occurrence, the radiology department staff members need to be aware of the presentation, risk factors and management of these conditions to ensure optimal patient care. the american college of radiology (acr) has set up guidelines that govern the management of such reactions depending on their severity. the main aim of this study was to assess the theoretical knowledge and practice amongst the radiology staff, based on the most current bls, acls and acr guidelines. methods in this observational, cross-sectional study, a total of 82 participants were selected; however, two declined to contribute. the participants included radiologists, radiology residents and radiographers in the radiology department of a tertiary teaching and referral hospital. the study was carried out from 01 march to 31 august 2016. a sample size of 82 was calculated using the formula for estimating prevalence in cross-sectional studies (cochran 1963) with a precision of 0.05, and assuming a prevalence of 50%, a 95% level of confidence and a finite population of 103 radiology healthcare providers. a simple random sampling method was used to select the participants, excluding visiting staff and those who declined consent. data collection was performed through administration of a validated quantitative questionnaire, which was completed in the presence of the researcher. there were five questions allotted to demographic data. there were also 15 multiple-choice and six closed-ended questions assessing the knowledge and practice of cpr, as well as the recognition and management of contrast media reactions. these were based on the current bls, acls and acr guidelines updated in 2015, 2016 and 2015, respectively. data collected were analysed using the statistical package for the social sciences (spss) version 20.0 for windows® and chi-squared tests were performed to determine the statistical significance (p < 0.05) of the results. ethical consideration the study was approved by the kenyatta national hospital/university of nairobi ethics and scientific review committee (reference no.: knh-erc/a/51 and approval number p763/12/2015). all the participants signed an informed consent form before participating in the study. results the total number of participants was 80, of which 18 (22.5%) were consultant radiologists, 39 (48.8%) were residents and 23 (28.8%) were radiographers. the ages of the participants ranged between 23–65 years. there were 43 (53.8%) male and 37 (46.3%) female participants. none of the participants answered all the questions correctly, with only 55% of radiologists, 35% of residents and 39% of radiographers scoring above 50%. among the 18 consultants interviewed, seven had more than 15 years of working experience, seven had between 1 and 4 years and the rest had between 5 and 15 years of experience. the majority (43.5%) of the radiographers had between 1 and 4 years of working experience. the residents, being in a 4-year training programme, had between 1 and 4 years of experience in the radiology department, with 12 of the 38 being in their second year of training. the majority of the participants (83%) had attended at least one life support training course but not in the preceding 5 years. there was a significant association between health workers’ level of expertise and their attendance of life support courses (p = 0.024) (table 1). table 1: life support training course attendance according to health providers’ level of expertise. cardiopulmonary resuscitation and contrast media anaphylaxis knowledge nine items on cpr and six anaphylaxis reaction items were used to assess participants’ knowledge. the responses to these knowledge questions are presented in figure 1. in terms of comparison of the two areas, participants displayed higher knowledge scores in anaphylaxis reactions than in cpr. the modal (most frequent) score on anaphylaxis reactions was 4 out of 6, with 33 (41.3%) participants scoring four items correctly. nine (11.3%) participants scored all six anaphylaxis reaction items correctly. for cpr knowledge, the modal score was 3 out of 9 correct items (n = 16 [20%]). figure 1: number of correct health worker responses to knowledge items regarding cardiopulmonary resuscitation and anaphylaxis reaction. knowledge of cardiopulmonary resuscitation regarding the knowledge of cpr and the current acls and bls guidelines, at least half of the participants responded correctly to four of the nine items: head tilt-chin lift manoeuvre for opening the airway (63; 78.8%), appropriate to administer rescue breaths if pulse is present (54; 67.5%), appropriate to initiate compressions if pulse is absent (51; 63.8%) and correct adrenaline administration (1 mg) during cardiac arrest (43; 53.8%). of the respondents, 77.8% incorrectly provided the bls sequence as airway-breathing-compression (a-b-c) instead of compression-airway-breathing (c-a-b) and only 36.7% gave the correct chest compression to rescue breaths ratio at 30:2. knowledge was not significantly associated with the level of expertise (p = 0.364) or surprisingly, the years since attendance of life support training (p = 0.128). knowledge was however significantly associated with the years of work experience (p = 0.016), with most of the participants who had 10 or more years of experience scoring at least 50%, compared to those with 1–4 years of experience (38.2%) and 5–9 years of experience (0%) (table 2). table 2: cardiopulmonary resuscitation knowledge scores according to participants’ years of practice (p = 0.016). knowledge of anaphylactic reactions to contrast media the majority of participants (82%) had adequate knowledge of the symptoms, signs and risk factors of adverse reactions to contrast media; however, only 24 (30%) of the 80 participants correctly gave epinephrine as the recommended drug for the treatment of severe anaphylaxis. the majority of participants (60%) incorrectly gave hydrocortisone as the drug of choice. for the remaining items, good performance was noted, with 82% of participants correctly responding to the questions: pruritus is a symptom of mild anaphylactic reaction, laryngeal oedema is a symptom of severe anaphylactic reaction and asthma is a risk factor for adverse contrast reactions. there was a significant association between health workers’ level of expertise (p < 0.001) and years of practice (p < 0.05) with knowledge of anaphylaxis. there was a significant association between the level of expertise (p < 0.001) and knowledge of anaphylaxis, with regard to the majority of radiology residents (35; 89.7%) and consultants (15; 83.3%) scoring at least 50% compared to the radiographers (7; 30.4%) who also scored 50%. knowledge of contrast anaphylaxis was significantly (p < 0.05) associated with the years of practice, with all health workers with >15 years’ experience scoring at least 50%. attendance of life support training and the year of attendance was not significantly associated with anaphylaxis knowledge (p = 0.86 and p = 0.251, respectively). amongst the anaphylactic reaction knowledge items that showed poor health worker understanding, the radiographers scored the least knowledge. only 21.7% of radiographers knew that epinephrine is the drug of choice compared to 33.3% of residents and radiologists. practices of the 80 participants, 32 (40%) reported that they had seen a patient experiencing an adverse reaction to contrast within the radiology department. seven (20.6%) of the health workers who had managed a patient experiencing an adverse reaction indicated that they had done so according to acr guidelines. there were 31 (38.8%) participants who had ever witnessed a patient experiencing a cpa in the radiology department, and in 23 (71.9%) of cases, bls/acls guidelines were applied for patient management. most of the participants (51; 63.8%) reported that they knew where the emergency trolley was located within the department; however, only 10 (12.5%) checked it before performing radiological procedures. discussion this research has shown that the theoretical knowledge of bls and acls pertaining to the management of cpa amongst radiologists, residents and radiographers is poor to moderate. more than half of the respondents (58.8; 57.8%) scored <50% in the assessment of cpr knowledge and none answered all questions correctly. this was an unexpected finding as available evidence from high-quality systematic reviews suggests that life support knowledge and skills decay within 6 months to 1 year after training and that skills decay faster than knowledge.7 for anaphylaxis knowledge, the performance was good, with 71.3% (57 out of 80) of health workers responding correctly to at least four of the six questions on adverse reactions. the mean score on the knowledge questions was 52.4%, which was below the recommended pass mark by the aha. our finding is similar to that of o’neill et al.8 who reported that their study participants had a mean score of 50%, which was below the acceptable level set at 70%. this was because of inadequate training and lack of refresher courses, a finding similar to the current study in which 50.6% of the staff members had not received any acls training. the attendance of life support courses was not significantly associated with knowledge (p > 0.05), nor was the duration since the last training. this is consistent with the study finding by alam et al.9 who found that only 28% of those who had attended a life support course more recently were more likely to respond correctly. in addition, the lack of course attendance on knowledge in the present study could be explained by two factors: rapid decay of knowledge and duration since attendance of these courses. recent changes in guideline recommendations impacted the performance in knowledge assessment. for example, in 2000, aha changed the recommended ratio of chest compressions: ventilation from 15:2 to 30:2.10 in this study, only 36% responded to this question correctly, with those who had attended life support training before 2005 more likely to indicate a ratio of 15:2. tapping et al.11 also found that respondents who had done life support training prior to 2005 stated the cpr ratio to be 15:2. cardiopulmonary resuscitation steps are another area of resuscitation training that was recently revised and also examined in this study. in 2010, the aha re-arranged the order of cpr steps from a-b-c to c-a-b.12 this question was amongst the most poorly answered, with only 15% giving the correct response. the current findings highlight the need for refresher training because of the constant evolution of life support algorithms with significant changes and the documented rapid decay of knowledge acquired in life support courses. this is of particular concern in this study, as most of the participants who had attended a bls course had done so more than 5 years before this study. the same applied to acls attendance. schellhammer et al.13 found that only 41.8% of the radiologists in their study had ever attended training courses and of these, 69% were trained > 5 years prior to the study.13 the aha recommends that the interval between initial cpr training and a refresher course should not be more than 2 years; however, studies evaluating the deterioration of cpr skills amongst medical personnel have shown a decline at 2–12 months following completion of training.14,15,16,17,18,19 with regard to contrast media reactions and management, most of the radiologists, residents and radiographers performed relatively well in the identification of mild and severe anaphylactic reactions and in their knowledge of the risk factors for an adverse reaction. at least 82% of health workers correctly identified a symptom of mild reaction, a symptom of severe reaction and a risk factor for anaphylactic reaction. however, responses on pharmacological management of severe reactions were poor. health workers commonly stated that they would administer hydrocortisone as the drug of choice (60%), with only 30% correctly identifying epinephrine as the drug of choice and 28.8% stating the correct dose. this shows that there is a great misconception regarding the drug of choice in the emergency management of severe contrast anaphylaxis. our findings are in contrast to that of lightfoot et al.20 who had 91% of the radiologists choosing epinephrine as the most important medication for the management of a severe contrast reaction; however, none provided the correct dosage. the disparity in findings could be attributed to the fact that our study included radiographers (28.8%), with the majority achieving diploma and higher diploma qualifications. there is limited emphasis on the pharmacological management of contrast reactions in radiographer training. in our data, this group consistently scored lower than radiologists and residents in identifying the recommended drug of choice for contrast reactions and its dose. even after excluding radiographers, the clinicians (residents and radiologists) in our setting were approximately 60% less likely to correctly identify the most important medication compared to canadian and american radiologists, possibly reflecting inadequate recent training in bls and acls. in general, radiology staff members are not involved in the practice of acute clinical medicine and do not manage emergencies on a day-to-day basis unlike their physician counterparts. this could explain why the questions on knowledge of the recommended drug (epinephrine) and its correct dose were poorly answered. the need for prompt and effective cpr and management of cpa cannot be over-emphasised as it is known to significantly decrease morbidity and mortality.21 of the patients brought to the radiology department, some may deteriorate and suffer cpa because of their primary condition or as a result of a severe anaphylactic reaction to contrast media.22 in this study, the majority of respondents (71.9%) who had witnessed cpa within the department managed the patient according to bls/acls guidelines. this is similar to the study conducted by schellhammer et al.,13 who found that most of the radiologists had performed at least one cpr during their time of practice. similarly, few (38.8%) of the respondents had witnessed a patient experiencing an adverse reaction to contrast media and most did not provide management according to the guidelines provide by the acr. the low rate of observation of these reactions is attributed to the liberal use of non-ionic contrast media which have a lower risk of complications. also, most of the respondents were radiology residents who had been in the radiology department for less than 4 years and thus were more likely to have witnessed fewer, if any, reactions. the low response on the use of the recommended acr guidelines is probably because of the infrequent and inadequate training on these reactions and their management. most (63.8%) of the participants knew where the emergency trolley was located in the department and these findings are similar to that of lightfoot et al.,20 where 62% participants knew the location of the emergency drug epinephrine in the computed tomography imaging rooms. despite awareness of the location of the emergency trolley, very few of the respondents (12.5%) checked it before performing any procedure in the department. this translates to a lack of knowledge regarding the contents of the trolley and may create a crisis when an emergency arises. lightfoot et al.20 also found that only 11% knew the concentration of the epinephrine in their emergency trolleys and the type of equipment stocked for its administration. conclusion healthcare providers within the radiology unit had knowledge of identifying both mild and severe symptoms of anaphylactic reactions to contrast media. there were however knowledge gaps regarding the management of such reactions. they also demonstrated inadequate knowledge of the fundamental and critical components of bls and acls. the fact that the knowledge of lifesaving skills is inadequate amongst the health workers in the radiology department is alarming and there is a need for encouraging formal training (bls and acls) and awareness of evidence-based recommendations contained in clinical guidelines. this should be supplemented with regular in-service training and re-certification to ensure retention of knowledge. acknowledgements competing interests the authors declare that no competing interests exist. authors’ contributions s.k.o., c.k.o. and a.a.a. reviewed the literature and made critical contributions at each stage of the process. s.k.o. collected the data and wrote the first draft. s.k.o., c.k.o. and a.a.a. did critical analysis of the findings. c.k.o. did the final summary of the article for publication. all the authors read and agreed on the final article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sets are available in the university of nairobi repository and can be shared upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references zipes dp, camm aj, borggrefe m, et al. acc/aha/esc 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the american college of cardiology/american heart association task force and the european society of cardiology committee for practice guidelines (writing committee to develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death). j am coll cardiol. 2006;48(5):90. https://doi.org/10.1016/j.jacc.2006.07.010 epstein jl, markenson d, quan l, et al. american red cross basic life support for healthcare providers handbook. staywell; 2015. daftary a, singh j. iodinated contrast media and their adverse reactions. j nucl med technol. 2008;36(2):69–74. https://doi.org/10.2967/jnmt.107.047621 wang cl, cohan rh, ellis jh, caoili em, wang g, francis ir. frequency, outcome, and appropriateness of treatment of nonionic iodinated contrast media reactions. am j roentgenol. 2008;191(2):409–415. https://doi.org/10.2214/ajr.07.3421 gaeta tj, clark s, pelletier aj, camargo ca. national study of us emergency department visits for acute allergic reactions, 1993 to 2004. ann allergy asthma immunol. 2007;98(4):360–365. https://doi.org/10.1016/s1081-1206(10)60883-6 american college of radiology. manual on contrast media. vol. 10.1. american college of radiology; 2015. yang cw, yen zs, mcgowan je, et al. a systematic review of retention of adult advanced life support knowledge and skills in the healthcare providers. resuscitation. 2012;83(9):1055–1060. https://doi.org/10.1016/j.resuscitation.2012.02.027 o’neill jm, mcbride kd. cardiopulmonary resuscitation and contrast media reactions in a radiology department. clin radiol. 2001;56(4):321–325. https://doi.org/10.1053/crad.2000.0669 alam t, jamil khattak y, anwar m, khan aa. basic life support: a questionnaire survey to assess proficiency of radiologists and radiology residents in managing adult life support in cardiopulmonary arrest and acute anaphylactic reaction. emerg med int. 2014;2014:356967–356971. https://doi.org/10.1155/2014/356967 american heart association (aha). advanced cardiovascular life support provider manual. dallas: american heart association; 2006. tapping cr, culverwell ad. are radiologists able to manage serious anaphylactic reactions and cardiopulmonary arrest? br j radiol. 2009;82(982):793–799. https://doi.org/10.1259/bjr/30798974 neumar rw, otto cw, link ms, et al. 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. circulation. 2010;122(18 suppl 3):s729–s767. schellhammer f. do radiologists want/need training in cardiopulmonary resuscitation? results of an internet questionnaire. acta radiol. 2003;44(1):56–58. https://doi.org/10.1258/rsmacta.44.1.56 berden hj, willems ff, hendrick jm, pijls nh, knape jt. how frequently should basic cardiopulmonary resuscitation training be repeated to maintain adequate skills? bmj. 1993;306(6892):1576–1577. https://doi.org/10.1136/bmj.306.6892.1576 spooner bb, fallaha jf, kocierz l, smith cm, smith sc, perkins gd. an evaluation of objective feedback in basic life support (bls) training. resuscitation. 2007;73(4):417–424. https://doi.org/10.1016/j.resuscitation.2006.10.017 smith kk, gilcreast d, pierce k. evaluation of staff’s retention of acls and bls skills. resuscitation. 2008;78(1):59–65. https://doi.org/10.1016/j.resuscitation.2008.02.007 o’steen ds, kee cc, minick mp. the retention of advanced life support knowledge among registered nurses. j nurs staff dev. 1996;12(2):66–72. semeraro f, signore l, cerchiari el. retention of cpr performance in anaesthetists. resuscitation. 2006;68(1):101–108. https://doi.org/10.1016/j.resuscitation.2005.06.011 behroozi h, alboghbeish m, khalafi a, azizi a, tahmasebi m, aghasi s. knowledge and attitude of radiology technologists towards cardiopulmonary resuscitation. jundishapur j health sci. 2015;7(2):1–6. https://doi.org/10.5812/jjhs.7(2)2015.27996 lightfoot cb, abraham rj, mammen t, abdolell m, kapur s, abraham rj. survey of radiologists’ knowledge regarding the management of severe contrast material-induced allergic reactions. radiology. 2009;251(3):691–696. https://doi.org/10.1148/radiol.2513081651 mclean-tooke ap, bethune ca, fay ac, spickett gp. adrenaline in the treatment of anaphylaxis: what is the evidence? bmj. 2003;327(7427):1332–1335. https://doi.org/10.1136/bmj.327.7427.1332 trout at, cohan rh, ellis jh, khalatbari s. teaching management of contrast reactions: does it work and how often do we need to refresh? acad radiol. 2012;19(4):498–503. https://doi.org/10.1016/j.acra.2011.11.016 case report hepatocerebral degeneration a case report bjsher fcrad(d)sa i c duncan ffrad(d)sa sunninghi/l hospital sandton abstract acquired hepatocerebral degeneration is a subtype of chronic recurrent hepatic encephalopathy and is characterised by movement disorders and increased signal intensity in the basal ganglia on tl-weighted mr! images. case report a 49-year-old female patient was admitted to a local hospital casualty department after having had a grandmal seizure. clinically she was found to have hepatomegaly, anaemia and stigmata of chronic alcohol abuse. biochemical analysis showed deranged liver enzymes and haematological analysis showed anaemia but a normal clotting profile. radiological investigations included unenhanced mr! and ct scans of the brain, and an abdominal ultrasound. on the mr! scan the tl-weighted scans showed high signal intensity in the lenticular nuclei bilaterally and fig. 1. axial unenhanced t1 mr scan showing the increased signal intensity within the lenticular nuclei in a symmetrical distribution. fig. 2. sagittal unenhanced t1 mr scan showing increased signal intensity within the mesencephalon with sparing of the red nuclei. symmetrically, primarily within the globus pallidus (fig. i), as well as in the midbrain with sparing of the red nuclei (fig. 2). t2-weighted scans showed subtle hypointensity in the same areas (fig. 3). an unenhanced 34 sa journal of radiology • september 2002 rg. 3. axial t2 mr scan at the same level as fig 1. showing the subtle signal hypointensity within the same areas of the lentiform nuclei. fig. 4. axial unenhanced ct scan shows no calcification or other visible changes within the basal ganglia. ct scan of the brain revealed no basal ganglia calcification (fig.4). ultrasound examination of the abdomen showed a diffuse increase in echogenicity of the liver parenchyma indicating fatty infiltration and mild splenomegaly. there was no evidence of portal hypertension. the patient had no seizures while case report table i. causes of increased signal intensity in the basal ganglia on tl-weighted images calcification neurofibromatosis parenteral nutrition hepatocerebral degeneration in hospital and was discharged a week later. discussion the causes for increased tiweighted signal intensity in the basal ganglia on mri scans of the brain are shown in table i. in our patient, calcification as a cause was ruled out on the unenhanced ct scan of the brain and there was no history of neurofibromatosis or previous parenteral nutrition. given the history of alcohol abuse with the related biochemical and imaging findings the diagnosis in this case was probably hepatocerebral degeneration. acquired hepatocerebral degeneration is an irreversible neuro-degenerative syndrome occurring in association with chronic liver disease such as alcoholic cirrhosis and chronic hepatitis as well as with portosystemic shunts. positive imaging findings correlate strongly with plasma ammonia levels or brain magnesium levels." mr spectroscopic studies have shown elevated glutamine levels and reduced choline metabolite and myo-inositol levels in patients with chronic hepatic encephalopathy.' due to financial constraints, these tests were not performed in our patient. in addition to the areas in the brain described above, the anterior pituitary, caudate nucleus, quadrigeminal plate and subthalamic regions may also show signal intensity alterations. hepatocerebral degeneration is a clinical syndrome and a subtype of chronic recurrent hepatic encephalopathy. in some cases the development of the cerebral dysfunction is rapid, developing over a matter of days resulting in altered consciousness from confusion through stupor, coma and death. in other cases the clinical picture is largely progressive and is characterised by movement disorders, dysarthria, tremor and ataxia. pathologically, the brain shows enlargement and hyperplasia of astrocytes as well as neuronal abnormalities in the cerebral and cerebellar cortices, basal ganglia and diencephalic nuclei. necrosis with cavitation, gliosis and myelin breakdown occur at these sites, medical treatment is often disappointing, but in selected cases liver transplantation may be curative. the basal ganglia hyperintensity may resolve following liver transplantation. references 1. osborn ac. acquired metabolic, white matter, and degenerative diseases of the brain. in: osborn ac, ed. diagnostic neuroradiology. st lollis: mosby, 1994: 748-781. 2. layrargues gp. movement dysfunction and hepatic encephalopathy. metab bmir' dis 2001; 16: 27-35. 3. kreis r, ross bo, parrow na, et al. metabolic disorders of the brain in chronic hepatic encephalopathy detected with h-l mr spectroscopy. radiology 1992; 182: 19-27. primary pediatric radiology ------+----f susan williamson this text encompasses the most essential information in the field of pediatric radiology in a concise, easy-to-use source. highly focused, succinct chapters, organized by symptom, help readers to select the most appropriate imaging approaches and arrive at correct diagnoses based on patients' presenting signs. most significantly, the book separates coverage of neonates from material on older infants and children, since radiographic presentation differs so dramatically between these two groups. it includes valuable chapters on the neonate with respiratory distress, the neonate with birth trauma, the child and adolescent with abdominal pain and recognising cases of child abuse. it describes all relevant imaging modalities used in pediatric radiology, including conventional radiology, computed tomography, ultrasonography, magnetic resonance imaging and nuclear medicine. each section begins with images and descriptions of normal anatomy as a foundation for better understanding of abnormal radiologic images. it discusses specific technical considerations and common mistakes, and provides memory hints and charts for quick reference, and features over 525 outstanding, never-before-published illustrations that cover the entire gamut of pediatric imaging findings. oct 2001 , paperback, 246 pp, 527 illustrations, wbs, r799 orders: sa medical association, private bag x1, pinelands 7430. tel (021) 530-6527. fax (021) 531-4126. e-mail: fpalm@samedlcal.org prices subject to foreign exchange fluctuations. allow 2-3 weeks for delivery. 35 sa jou rnal of radiology • september 2002 mailto:fpalm@samedlcal.org sajr 747 interpretation and value of mr csf flow studies for paediatric neurosurgery s mbonane, s andronikou department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg s mbonane, mb chb, dip hiv man (sa) s andronikou, mb bch, fcrad, frcr (lond), phd corresponding author: s mbonane (nkalankala@yahoo.com) imaging techniques may be underutilised when clinicians are unaware of the technique or do not recognise its potential. phase-contrast mr imaging (pc-mri) is a rapid, simple and non-invasive technique that is sensitive to csf flow. it demonstrates a mechanical coupling between cerebral blood and csf flow throughout the cardiac cycle. neurosurgeons should be able to request this procedure routinely as part of an mri request. this paper gives an overview of the indications, technical requirements, technique and interpretation, using image examples. indications for csf flow studies in children include assessment and functionality of shunt treatment in patients with hydrocephalus; hydrocephalus associated with achondroplasia; chiari i malformation; confirmation of aqueductal stenosis; and determining patency of a third ventriculostomy. s afr j rad 2013;17(1):26-29. doi:10.7196/sajr.747 new techniques in one discipline are often slow to filter to another. in particular, imaging techniques may be underutilised because the end user is unaware of the technique, does not recognise the potential, or is led to believe that it is an unavailable or unreasonable service. phase-contrast mr imaging (pc-mri) is a rapid, simple and non-invasive technique, and is sensitive to csf flow.1 , 2 it has been available for some time, and been used in the past decade in the evaluation of cranial and spinal csf flow, demonstrating a mechanical ‘coupling between cerebral blood and csf flows throughout the cardiac cycle and the temporal coordinated succession of these flows’ in normal people.1 the technique may lead to a better understanding of the pathophysiological basis of diseases with dysfunction of csf flow.2 neurosurgeons, neurologists and in particular those working with children should be able to request this procedure from any mr imaging department, and should also see this sequence routinely as part of the battery of sequences provided for certain indications. this paper aims to familiarise clinicians and radiologists working with children with the indications and technique, and also discusses interpretation of the information provided. indications for csf flow studies in paediatrics there is good reason to demonstrate csf flow dynamics routinely in children undergoing mri because their evolving and maturing brain creates a changing volume of csf in relation to the brain parenchyma. the absence of flow-void signal intensity on sagittal t2 mr images has been proposed as a direct sign of csf pathway obstruction, but the flow-void signal intensity depends on numerous parameters that make it unreliable (fig. 1a).1 there are also some clear indications for csf flow studies without which routine mri offers only limited and mainly structural information. it may be useful for better assessment and functionality of shunt treatment in patients with hydrocephalus.2 one of the more specific uses of csf flow studies is to gain information relating to hydrocephalus associated with achondroplasia (fig. 1b).3 csf studies also provide a better understanding of the pathophysiology of chiari i malformation regarding the spatial and temporal foramen magnum csf flow patterns (figs 1c e). comparison of csf flow patterns between symptomatic and asymptomatic patients, those with or without syringomyelia, and those with syringomyelia but with or without tonsillar herniation, is possible.4 pc-mri is able to confirm aqueductal stenosis suspected on morphological sequences and is sensitive even to slow csf flows at the aqueductal level.1 efforts to visualise the patency of a third ventriculostomy begin with the detection of a flow void in the floor of the third ventricle on t2-weighted mr images and later confirmation with the use of cine 2-dimensional (2d) phase-contrast (pc) mr images.5 patency on cine pc mr images correlates well with clinical prognosis, but whether patency as perceived on mr images represents actual anatomic patency has never been proved.5 figs 1(a e) (structural sagittal mri imaging of csf flow) follow below. fig. 1(a). normal sagittal t2-weighted mri demonstrates csf flow-related signal void at the aqueduct of sylvius (long black arrow), foramen of magendie (thick black arrow), and foramen magnum (white arrows). fig. 1(b). sagittal t2 view in a child with achondroplasia demonstrates a funnel-shaped posterior fossa with lack of csf signal and flow void at the foramen magnum (arrows). fig. 1(c e). sagittal (c) t2and (d and e) t1-weighted mri demonstrates tonsillar herniation in keeping with a chiari i malformation (black arrow). there is resultant crowding of the foramen magnum with compression of the anterior csf space (white arrow). table 1. indications for performing csf flow studies in children hydrocephalus2 • aqueductal stenosis • specific causes of flow obstruction at the craniocervical junction: • achondroplasia3 • chiari i malformation6 • patency of third ventriculostomy.5 no special hardware is required, and imaging can be performed on all modern 1.5t scanners equipped with standard software and phase contrast magnetic resonance (pcmr) capabilities and analysis packages.6 imaging requires routine localiser images, sagittal t1and t2-weighted images of the cervical spine, and a series of head and axial spine images as performed for clinical indications.6 axial and sagittal pcmr images are acquired additionally.6 the images are gated to the cardiac cycle by electrocardiography, which is available routinely on modern scanners.6 pcmr technique and acquisitions time-resolved 2d pc-mri with velocity encoding in one spatial direction is the method of choice for investigation of csf flow.2 for sagittal pcmr, the midline sagittal plane is chosen from the regular imaging.6 for the axial images, a plane transverse to the axis of the spinal canal immediately below the tonsillar tips is selected most commonly, but this can be performed in any area of interest e.g. the aqueductal level or the level of the foramen magnum.6 (recommended acquisition parameters are flip angle 20°; tr/te 20/5 ms; section thickness 5 mm; fov 180 mm; matrix 256×256; and encoding velocity 10 cm/s.)6 in each subject, the csf flow images can first be acquired with the patient’s neck in a neutral position, then in a flexed, and finally in an extended position.6 interpretation of the information provided intracranial blood and csf ‘flush’ and ‘fill’ flows through the cardiac cycle are initiated by the systolic intracerebral arterial inflow. studies, using pc-mri, proposed a dynamic model for a mechanical coupling between blood and csf intracranial flows. the systolic arterial fill flow peak in the carotid arteries results in an instantaneous increase in intracranial pressure. the first and fastest way to decrease intracranial pressure is a large csf venting from the subarachnoid spaces, which drops the cerebral subarachnoid space pressure. then flush flows occur in the cerebral venous and aqueductal csf compartments. an imbalance in this mechanical coupling is presumed to be responsible for pathological cerebral states, such as normal pressure hydrocephalus (nph) or alzheimer disease.1 line graphs demonstrating different time courses for csf flow use the y-axis to show the magnitude of flow in positive and negative directions in ml/s; the x-axis shows time as a decimal fraction of the cardiac cycle. time courses may illustrate csf flowing in a sinusoidal manner, or in a less symmetric manner. the maximal velocity may be in a positive or a negative direction (systolic flow). a change in direction (e.g. from a positive to a negative flow) then demonstrates the diastolic flow. systolic flow lasts a shorter time and has a greater magnitude than diastolic flow. net flow during the cardiac cycle is zero (figs 2a d and 3a d).7 figs 2(a d). time-resolved 2d pc-mri csf flow study in a normal subject. fig. 2 (a). single sagittal midline slice of csf flow during systole is demonstrated as low signal, anterior and posterior at the foramen magnum (black arrows). there is also a subtle csf flow at the foramen of magendie and aqueduct of sylvius. (b) single sagittal midline slice during diastole demonstrates csf flow as a high signal at the foramen magnum and more obvious flow at the aqueduct of sylvius (short white arrow) and foramen of magendie (long white arrow). (c) csf flow sequence through the cardiac cycle represented in the midline sagittal view at the foramen magnum that demonstrates the bidirectional flow as high and low signal in turn. the oval region of interest (roi) has been placed in the normal posterior csf space on all images throughout the cardiac cycle to generate the graphic representation seen in 2d. (d) the graphic representation of csf flow through the cardiac cycle is generated using a roi placed on all slices by the investigator in any part where csf is identified (on the sagittal or axial images). the graph generated reflects velocity in cm/s on the y-axis and time in ms on the x-axis. in this normal study, the diastolic flow is represented above the x-axis and has a maximum velocity of 3 cm/s and lasts for 260 ms. systole in this instance is represented below the baseline and shows a maximum velocity of 5 cm/s; it lasts for a shorter period than diastole – in this instance 190 ms. note that the black or white signal for systole and diastole or representation above or below the baseline on the graph is only relevant for demonstrating the direction of flow, and not the magnitude. fig. 3. axial csf flow study at the foramen magnum demonstrating normal bidirectional flow with graphic representation of a roi in the anterior thecal sac. csf flow is classified as hypermotile if it shows increased dynamics, and as hypomotile if it shows attenuated dynamics.2 the maximum peak value (v peak) and the mean value (v mean) of the magnitude of the velocity vector can be determined directly from the line graphs produced.2 mr data analysis in achondroplasia in achondroplasia, the cine mode mr imaging demonstrates csf flow disturbance at the cervicospinal junction resulting from foramen magnum stenosis and medullary compression.3 attenuated flow is often noted between the suboccipital subarachnoid space and the craniocervical junction, which improves after craniotomy. mr data analysis in chiari i malformation in children with symptomatic chiari i malformation, even though bulk flow or velocity is often normal, there is marked heterogeneity of flow at the foramen magnum.4 this manifests in several ways: (i) an increase in cephalad and caudad peak velocities; (ii) spatial inhomogeneity in velocities; (iii) simultaneous bidirectional flow; and (iv) substantial net craniad or caudad flows within particular voxels and sub regions during the cardiac cycle (figs 4a d and 5a f).4 fig. 4. a patient with chiari i demonstrates (a) crowding of the foramen magnum by cerebellar tonsillar descent with (b) bi-directional flow that is severely restricted at the foramen magnum (white arrows). graphic representation (c) demonstrates low peak velocities of equal volume during systole and diastole as well as short systolic duration. fig. 5. (a d) axial phase contrast csf flow study demonstrating baseline and follow-up imaging in a patient with chiari i malformation. (e f) baseline axial and sagittal pc-mri demonstrates absence of flow posteriorly at the foramen magnum, and limited flow at the midline anteriorly (black arrow). follow-up imaging demonstrates change in csf flow to a unidirectional pattern represented as only high signal on the sagittal pc-mri and with high flow velocity above the baseline on the graphic representation. aqueductal stenosis diagnosis of aqueductal stenosis may be difficult because of the various clinical, aetiological and radiological features. it is also difficult to determine complete obstruction of the aqueduct, which is relevant because third ventriculostomy is most successful in true obstructive hydrocephalus. the absence of flow void signal intensity on standard sagittal t2 mr images is unreliable as it depends on several parameters (aqueductal diameter, csf velocity, section thickness) and may be weak or absent if the aqueduct is physiologically narrow but not obstructed.1 pc-mri can confirm the diagnosis of csf flow blockage at the aqueductal level in a reliable, reproducible and rapid manner.1 in addition, even though fourth ventricular stroke volumes are similar to normal patients, the csf flush peak occurs significantly earlier in patients with aqueductal stenosis.1 there is also a 50% reduction of atrioventricular delay (representing the latency between the arterial systolic inflow peak and the outflow venous peak) in patients with aqueductal stenosis.1 mr interpretation post ventriculostomy cine pc-mri for third ventriculostomy should show patency by demonstrating continuous flow from the third ventricle to the pre-pontine cistern through a small discontinuation in the floor of the third ventricle.5 postoperative follow-up after posterior fossa decompression in chiari i, the severity of flow abnormalities decreases.4 recommendations pc-mri is an available and relatively simple method of determining true csf flow, and that also provides directional and additional physiological information. in paediatric practice, it is an extremely useful tool for evaluating causes of hydrocephalus and csf obstruction at the level of the aqueduct, the fourth ventricle, the outlet foramina of the fourth ventricle and the foramen magnum. it should form part of the routine arsenal of sequences performed in children with clinical or radiological suspicion of csf flow obstruction, and radiologists must be familiar with determining the level at which imaging should be performed and interpreting both the images and graphic physiological representation for directing management. 1. stoquart-el s, sankari p, lehmann c, et al. phase-contrast mr imaging support for the diagnosis of aqueductal stenosis. j neuroradiol 2009;30:209-214. 1. stoquart-el s, sankari p, lehmann c, et al. phase-contrast mr imaging support for the diagnosis of aqueductal stenosis. j neuroradiol 2009;30:209-214. 2. stadlbauer a, salomonowitz e, brenneis c, et al. magnetic resonance velocity mapping of 3d cerebrospinal fluid flow dynamics in hydrocephalus: preliminary results. eur radiol 2012;22(1):232-242. doi10.1007/00330-011-2247-7. 2. stadlbauer a, salomonowitz e, brenneis c, et al. magnetic resonance velocity mapping of 3d cerebrospinal fluid flow dynamics in hydrocephalus: preliminary results. eur radiol 2012;22(1):232-242. doi10.1007/00330-011-2247-7. 3. miyamoto j, tatsuzawa k, sasamija h, mineuria k. usefulness of phase contrast cine mode magnetic resonance imaging for surgical decision making in patients with hydrocephalus combined with achondroplasia. neurol med chir (tokyo) 2010;50:1116-1118. 3. miyamoto j, tatsuzawa k, sasamija h, mineuria k. usefulness of phase contrast cine mode magnetic resonance imaging for surgical decision making in patients with hydrocephalus combined with achondroplasia. neurol med chir (tokyo) 2010;50:1116-1118. 4. iskandar j, quigley m, haughton m. foramen magnum cerebrospinal fluid flow characteristics in children with chiari i malformation before and after craniocervical decompression. j neurosurg pediatr 2004; 01:169-178. 4. iskandar j, quigley m, haughton m. foramen magnum cerebrospinal fluid flow characteristics in children with chiari i malformation before and after craniocervical decompression. j neurosurg pediatr 2004; 01:169-178. 5. fukuhara t, vorster s, ruggieri p, luciano g. third ventriculostomy patency: comparison of findings at cine phase-contrast mr imaging and at direct exploration. am j neuroradiol 2009;20:1560-1566. 5. fukuhara t, vorster s, ruggieri p, luciano g. third ventriculostomy patency: comparison of findings at cine phase-contrast mr imaging and at direct exploration. am j neuroradiol 2009;20:1560-1566. 6. bhadelia r, frederick e, patz s, dubey p. cough-associated headache in patients with chiari i malformation: csf flow analysis by means of cine phase-contrast mr imaging. j neuroradiol 2011;32:739-742. 6. bhadelia r, frederick e, patz s, dubey p. cough-associated headache in patients with chiari i malformation: csf flow analysis by means of cine phase-contrast mr imaging. j neuroradiol 2011;32:739-742. 7. hentschel s, mardal k, løvgren a, linge s, haughton v. characterization of cyclic csf flow in the foramen magnum and upper cervical spinal canal with mr flow imaging and computational fluid dynamics. j neuroradiol 2010;31:997-1002. 7. hentschel s, mardal k, løvgren a, linge s, haughton v. characterization of cyclic csf flow in the foramen magnum and upper cervical spinal canal with mr flow imaging and computational fluid dynamics. j neuroradiol 2010;31:997-1002. abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) louis w.a. van papendorp department of radiology, faculty of health sciences, university of pretoria and steve biko academic hospital, pretoria, south africa farhana e. suleman department of radiology, faculty of health sciences, university of pretoria and kalafong hospital, pretoria, south africa heleen hanekom department of radiology, faculty of health sciences, university of pretoria and steve biko academic hospital, pretoria, south africa citation van papendorp lwa, suleman fe, hanekom h. the knowledge, awareness and practices of radiation safety amongst orthopaedic surgeons. s afr j rad. 2020; 24(1), a1806. https://doi.org/10.4102/sajr.v24i1.1806 note: additional supporting information may be found in the online version of this article as online appendix 1: https://doi.org/10.4102/sajr.v24i1.1806-1 original research the knowledge, awareness and practices of radiation safety amongst orthopaedic surgeons louis w.a. van papendorp, farhana e. suleman, heleen hanekom received: 02 oct. 2019; accepted: 11 jan. 2020; published: 27 feb. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: fluoroscopic imaging in orthopaedic theatres is increasing, with added risk to the orthopaedic surgeon who is increasingly being exposed to ionising radiation. it is thus crucial for orthopaedic surgeons to have a working knowledge of radiation safety. in spite of these concerns, however, many orthopaedic surgeons do not receive standard training in radiation safety. objectives: the evaluation of orthopaedic surgeons’ knowledge, awareness and everyday practices regarding radiation safety in an academic hospital. methods: a questionnaire with multiple-choice-type questions was developed by a panel of experts and used to conduct a descriptive study. the questionnaire had multiple dimensions, each evaluating orthopaedic knowledge, awareness and practices, respectively. the study population included orthopaedic surgeons rotating within the orthopaedic circuit of the university of pretoria. results: orthopaedic surgeons regularly make use of fluoroscopic imaging in theatre, with 34 (77%) participants indicating that they use fluoroscopy in more than half of all their procedures performed. most participants have insufficient knowledge of radiation safety, with the majority failing to correctly answer basic questions on radiation safety. forty (91%) participants do not wear personal dosimeters, in spite of 39 participants (89%) believing that they are vulnerable to adverse effects. basic radiation protection devices are underutilised, with 32 (73%) participants indicating that they have not received adequate training in radiation safety. conclusion: the majority of orthopaedic surgeons regularly use fluoroscopic imaging in theatre yet lack in-depth knowledge and awareness regarding radiation safety associated with this imaging modality. implementation of a radiation safety training programme is thus recommended. keywords: radiation protection; orthopaedic surgeon; radiation safety; knowledge; awareness; practices. introduction the use of fluoroscopic imaging is increasing in the modern orthopaedic theatre.1 benefits of intra-operative fluoroscopy include the indirect visualisation of anatomy, enabling many orthopaedic procedures to be performed with greater ease, in less time and with less traumatisation of patient tissues, thus reducing patient morbidity.2,3,4 results from a survey analysis conducted by tunçer et al.4 confirmed that the need for fluoroscopy was indeed very high in the orthopaedic theatre. placement of internal and external fixation devices, as well as long bone fracture reductions, are amongst the orthopaedic procedures frequently performed under fluoroscopic guidance.1 fluoroscopic use in the theatre setting is, however, not without risk to the orthopaedic surgeon, the biological effects of ionising radiation being well-known.3,5 these effects include dose-dependent deterministic effects and dose-independent stochastic effects.5,6 deterministic effects are unlikely to occur below a specific dose threshold and include cataracts, alopecia, headache, dermal ulceration and infertility. stochastic effects do not have a threshold dose and may include the induction of malignancy in radiosensitive organs such as the breasts, lungs, thyroid and red bone marrow.1 troisi et al.1 proved that the annual dosimeter readings from a group of orthopaedic registrars in the pietermaritzburg complex did not exceed the recommended dose limits, as set out by the international commission on radiological protection. this renders the orthopaedic registrars of the pietermaritzburg complex unlikely to develop deterministic effects but does not exclude their risk of developing stochastic effects secondary to chronic exposure to low levels of ionising radiation in the orthopaedic theatre. the linear no-threshold model states that the long-term risk of cancer induction is directly proportional to the sum of all the dosages acquired in an individual’s lifetime and that all exposures to ionising radiation, no matter how small, should be regarded as harmful.6 it is thus crucial for orthopaedic surgeons to have a working knowledge of radiation safety, in order to keep exposure in theatre as low as reasonably possible. furthermore, ionising radiation is both invisible and intangible, rendering it a hazard, difficult to stay aware of. it unfortunately remains unavoidable for the orthopaedic surgeon who operates in close proximity to the x-ray beam.7,8 in spite of the above-mentioned concerns, many orthopaedic surgeons do not receive standard training in radiation safety.9 similar previous studies by tunçer et al.,4 saroki et al.7 and nugent et al.10 all concluded that orthopaedic surgeons have inadequate knowledge concerning the use and risks of ionising radiation, as well as lack the necessary radioprotective knowledge for preventing damage caused by ionising radiation. study objectives thus included the assessment of orthopaedic surgeons’ knowledge, awareness and everyday practices regarding radiation safety in an academic hospital. research methods and design study design and population a descriptive study was conducted. the questionnaire was completed by 44 of the 56 orthopaedic surgeons actively working within the university of pretoria’s orthopaedic circuit, yielding a response rate of 79%. participants included five medical officers, nine junior registrars, 20 senior registrars, nine consultants and one professor. the majority of the participants (46%) were senior registrars; participants were considered as senior on completion of at least 2 years of training. exclusion criteria included female participants who were pregnant at the time of data collection. five questionnaires were incompletely filled in and were excluded from the study. study setting and sample size the study was set within the orthopaedic circuit of the university of pretoria, which included participants from steve biko, kalafong and one military hospitals in pretoria. all participants were included (total of 56 orthopaedic surgeons working within the circuit) and no sampling was done. data collection tools a panel of experts, including radiologists, orthopaedic surgeons, a biological statistician, and previous literature helped develop our questionnaire, which is available as online appendix 1. the questionnaire is non-validated and the correct answers are indicated by an asterisk adjacent to the corresponding option. the final questionnaire included 14 questions with responses framed in the following ways: multiple choice with single answer, multiple choice with single answer and text entry, multiple choice with multiple answers and multiple choice with multiple answers and text entry. the questionnaire had multiple dimensions – the first part included questions pertaining to participant level of training, the frequency of and the necessity for the use of fluoroscopy in theatre. the second part assessed adequacy of radiation safety training, while the third part evaluated participant knowledge. questions evaluating radiation safety knowledge tested participants on fundamental radiation principles, some of which could directly be applied in the orthopaedic theatre to reduce radiation dose. these included basic principles such as knowledge of the ‘as low as reasonably achievable’ (alara) principle, the inverse square law, annual radiation dose limits for radiation workers and the methods of radiation dose reduction. the last part assessed participant radiation safety awareness, personal dosimeter use and everyday practices regarding radiation protection devices. questionnaires were distributed at weekly orthopaedic academic meetings over a period of 1 month – data collection started on 04 september 2018 and was terminated on 02 october 2018. participants were allowed 1 h to complete the questionnaire. data analysis a descriptive, univariate analysis was performed, with assessment of one variable at a time. focus was on the distribution of participants for each individual variable, with data expressed as percentages of the total study population, and displayed graphically. study limitations five questionnaires were left partially completed after termination of data collection. this is a limitation of using the hard copy mode of delivery, as participants may decide to leave specific questions unanswered. incomplete questionnaires were excluded, thus resulting in a smaller study population. a further limitation was not including a more widespread group of professionals (radiographers, medical physicists and radiation safety officers) in the development of the questionnaire. this would have added more depth in terms of radiation safety expertise and thus question relevance. ethical consideration participation in this study was completely voluntary, and questionnaires were completed anonymously. no incentives were offered to participants. the study received ethical clearance from the university of pretoria’s health ethics committee, with ethics number 211/2018. results orthopaedic surgeons regularly use fluoroscopic imaging in theatre, with 34 (77%) participants indicating that they use fluoroscopy in over 50% of their daily operations. all participants indicated that fluoroscopic imaging is necessary to more effectively execute certain orthopaedic procedures (figure 1). figure 1: total amount of fluoroscopic use in theatre (n = 44). of the surveyed orthopaedic surgeons, 32 (73%) felt that they had not received adequate training on radiation safety. a question evaluating which prior sources of radiation safety training the participants had accessed allowed multiple options to be marked. options included a radiation protection course, lecture by someone with training in radiation safety, discussion with colleagues, undergraduate training, internet, none and other. ‘discussion with colleagues’ was the source most indicated to obtain knowledge on radiation safety, accounting for 15 (34%) of the participants. ten (23%) participants indicated that they had not accessed any sources on radiation safety whatsoever. questions evaluating radiation safety knowledge revealed that 34 (77%) participants did not know the meaning of the alara principle. thirty-five (80%) participants were unable to correctly identify the annual dose limit for classified radiation workers, in spite of 40 (91%) participants indicating that orthopaedic surgeons should be classified as radiation workers. thirty-one (70%) participants were able to identify the correct definition of the inverse square law. another question asked participants to identify basic methods of dose reduction in the orthopaedic theatre. nine different options were provided at random, and participants were urged to mark all the relevant options. the different question options along with the percentage of participants who indicated each option are demonstrated in figure 2. figure 2: different options of dose reduction in the orthopaedic theatre. seventeen (39%) participants did not know that lowering the dose to the patient would lower the dose to the fluoroscopy operator, while 16 (36%) participants did not know that the use of highly attenuating shielding devices would similarly lower the dose. the focus should, however, not be on the above participants who failed to identify the correct methods of dose reduction but rather on the participants who indicated incorrect methods that they thought would reduce dose, rendering more harm. twenty-four (55%) participants thought that the use of an anti-scatter grid would reduce dose, while 22 (50%) of them thought that standing closer to the x-ray tube itself will be more protective. there were no participants who correctly answered all of the questions on radiation safety knowledge. the section on radiation awareness revealed that 39 (89%) participants believed that they were at risk of developing adverse effects secondary to fluoroscopic radiation exposure. this while only two (5%) participants always checked the amount of screening time after completing their procedures. pertaining to the everyday practices of the study participants, only three (7%) made use of personal dosimeters. most participants (93%) always made use of lead aprons and 11 (25%) participants always made use of thyroid shields when screening in theatre. two (5%) participants only sometimes made use of lead aprons and 13 (30%) participants only sometimes made use of thyroid shields, as depicted in figure 3. this while lead aprons and thyroid shields are the most basic forms of radiation protection devices and are considered indispensable in primary radiation protection. figure 3: orthopaedic use of radiation protection devices. personal protective devices like lead glasses, lead gloves, lead table skirts, and fixed and mobile lead shields were mostly deemed unavailable. other reasons indicated for not using certain radiation protection devices included discomfort and impracticality, as demonstrated in figure 4. included in the figure are the number of orthopaedic participants who were unaware that a particular device was meant for radiation protection. figure 4: reasons for not using radiation protection devices. discussion the use of fluoroscopic imaging in the orthopaedic theatre is necessary but not without the risk of exposure to ionising radiation. in order to minimise the risk to the fluoroscopic operator and the theatre staff, adequate knowledge and awareness pertaining to radiation safety are required. based on this study’s findings, radiation safety knowledge is clearly insufficient amongst orthopaedic surgical staff. gendelberg et al.11 showed that after attending a structured radiation safety programme, orthopaedic registrars were able to reduce radiation time and exposure while operating, resulting in decreased radiation exposure to registrars and patients. similarly, the implementation of such a radiation safety training programme might benefit the participants of this study. the results of this study reveal a lack of radiation safety awareness amongst the participants, with radiation-shielding devices being underutilised, the majority of participants not monitoring their amount of screening time and very few actually wearing personal dosimeters when screening. this complacent attitude amongst participants may have originated from a sense of safety as proclaimed by certain previous studies. a related study performed in the pietermaritzburg training circuit by troisi et al.1 measured the exposure on orthopaedic surgeons’ personal dosimeters and concluded that orthopaedic dosages were still within international safety limits. results like these are, however, not a justification to be less aware about radiation safety. with many radiation protection devices deemed unavailable, it leaves the following question open for further discussion: ‘would the orthopaedic surgeons have used these devices if they were readily available?’ furthermore, participants indicating that they were unaware that certain devices were an option for radiation protection, substantiates both the participants’ lack of radiation knowledge and awareness. a study conducted by meisinger et al.12 revealed possible reasons for operators not making use of certain radiation protection devices. amongst others, awkward positioning of shields, heavy weight of garments, tight-fitting thyroid collars and rigid lead gloves complement the findings of impracticality and discomfort demonstrated in this study. similar studies conducted in the united states, ireland and turkey confirmed analogous results, concluding that the need for fluoroscopy was very high in the orthopaedic theatre but that orthopaedic surgeons have inadequate knowledge about the risks of fluoroscopy and the methods for preventing biological damage.4,7,10 conclusion the majority of orthopaedic surgeons regularly use fluoroscopic imaging in theatre, yet lack in-depth knowledge and awareness regarding radiation safety associated with this imaging modality. this while personal protective equipment are either unavailable or underutilised when present. it can thus be recommended that a radiation safety and protection training programme be implemented within the orthopaedic circuit of the university of pretoria. acknowledgements dissertation was completed at the university of pretoria: prof. m. ngcelwane (orthopaedic surgery) was involved with study guidance, questionnaire review and facilitation. prof. p. becker (biological statistician) was involved with statistical guidance, questionnaire review and data analysis. prof. z. lockhat (diagnostic radiology) was the guarantor. electronic poster – voice of electronic presentation online system (epos) (european congress of radiology 2019) – https://doi.org/10.26044/ecr2019/c-0210. competing interests the authors have declared that no competing interests exist. authors’ contributions l.w.a.v.p. was the main author and was responsible for the literature review, study protocol, data collection and analysis, write-up and discussion. f.e.s. acted as the primary supervisor and was responsible for study guidance, protocol and dissertation review, and collaboration. h.h. acted as the co-supervisor and assisted with study guidance, protocol and dissertation review, and collaboration. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references troisi k, ferreira n. radiation exposure to orthopaedic registrars in the pietermaritzburg metropolitan complex. s afr orthop j. 2016;15(2):38–42. https://doi.org/10.17159/2309-8309/2016/v15n2a6 miller dl, society for interventional radiology. interventional fluoroscopy: reducing radiation risks for patients and staff. j vasc interv radiol. 2009;20(7 suppl):s274. https://doi.org/10.1016/j.jvir.2009.04.057 tsalafoutas ia, tsapaki v, kaliakmanis a, et al. estimation of radiation doses to patients and surgeons from various fluoroscopically guided orthopaedic surgeries. radiat prot dosimetry. 2008;128(1):112–119. https://doi.org/10.1093/rpd/ncm234 tunçer n, kuyucu e, sayar ş, polat g, erdil i̇, tuncay i̇. orthopedic surgeons’ knowledge regarding risk of radiation exposition: a survey analysis. sicot-j. 2017;3:29. https://doi.org/10.1051/sicotj/2017008 johnson dr, kyriou j, morton ej, clifton a, fitzgerald m, macsweeney e. radiation protection in interventional radiology. clin radiol. 2001;56(2):99–106. https://doi.org/10.1053/crad.2000.0640 mahajan a, samuel s, saran ak, mahajan mk, mam mk. occupational radiation exposure from c-arm fluoroscopy during common orthopaedic surgical procedures and its prevention. j clin diagn res. 2015;9(3):rc01–rc04. https://doi.org/10.7860/jcdr/2015/10520.5672 saroki aj, wijdicks c, philippon mj, bedi a. orthopaedic surgeons’ use and knowledge of ionizing radiation during surgical treatment for femoroacetabular impingement. knee surg sports traumatol arthrosc. 2016;24(12):3962–3970. https://doi.org/10.1007/s00167-015-3734-1 van der merwe b. radiation dose to surgeons in theatre. s afr j surg. 2012;50(2):26–29. hafez ma, smith rm, matthews sj, kalap g, sherman kp. radiation exposure to the hands of orthopaedic surgeons: are we underestimating the risk? arch orthop trauma surg. 2005;125(5):330–335. https://doi.org/10.1007/s00402-005-0807-5 nugent m, carmody o, dudeney s. radiation safety knowledge and practices among irish orthopaedic trainees. ir j med sci. 2015;184(2):369–373. https://doi.org/10.1007/s11845-014-1121-4 gendelberg d, hennrikus w, slough j, armstrong d, king s. a radiation safety training program results in reduced radiation exposure for orthopaedic residents using the mini c-arm. clin orthop relat res. 2016;474(2):580–584. https://doi.org/10.1007/s11999-015-4631-0 meisinger qc, stahl cm, andre mp, kinney tb, newton ig. radiation protection for the fluoroscopy operator and staff. ajr am j roentgenol. 2016;207(4):745–754. https://doi.org/10.2214/ajr.16.16556 technology update film digitizers vs. ccd scanners laser digitizers have a long history of use in medical applications such as teleradiology, image management, pacs, even computer-aided diagnosis. a new-technology ccd-based film digitizer introduced at the 1995 rsna now provides an alternative worth considering. the basics let's examine the basics: how does a digitizer convert film densities into digital values? it is important to know that optical density (od) is a log function which means that measuring higher densities with meaningful precision is not easy. at optical density 0,100% of the incident photons (the light going through the film) is transmitted; at 1.0 od, only 10% make it through; at 2.0 od, only 1% , and at3.0 00 only 0.1 %. laser digitizers the advantage of using a laser as a light source is that a tremendous number of photons are produced, all the same wavelength, and the light is coherent, subject to less scatter. the point is, with such a large supply of photons, the laser film digitizer can accurately measure optical density from 0.03 to 3.6 or even 4.1 od with 0.001 od precision. 36 sa journal of radiology· june 1997 the transmitted photons are measured at a given location on the film (pixel) and there are typically 2 048 pixels per line, 2 500 lines on a rectangular film (8ixl0" up to 14ixi7"). the photons are detected by a very efficient photomultiplier tube (pmt) and the resulting output voltage is conditioned by a log amplifier. the log amplifier normalizes the extremely high number of photons (high voltage) detected at low optical densities versus the relatively low number of photons (lower voltages) detected at high optical densities. since the source is a laser, maintaining very high signal/noise is straightforward and the result is a scanning densitometer. density precision the laser film digitizer converts each density measurement into a pixel value which is 1000 x the optical density at that point. optical density 2=2000,3.2=3200, etc. to put it another way, this means that there are 1000 levels from 0 to 1 od, 1000 levels from 1 to 2 00, and so on. as an example the lumiscan 75 converts 2 048 pixels into digital density values 115 times per second which is over 235 000 12-bit measurements per second. it digitizes a 14" x 17" film in less than 25 seconds. the end result what does this really mean? it means that a radiologist can be confident that almost every nuance in a film will be captured by a laser film digitizer. a confident diagnosis can almost always be made with a laserdigitized film. topage38 teleradiology and pacs systems? important questions which need to be addressed when considering these are: • is it dicom 3.0 compliant? • am i locked in to one supplier? • what can the system grow into? • am i locked into one support company? with windows nt being specified as the standard throughout the world, you need a system that can grow with your practise without being limited by any of the above considerations. imed are distributors of teleradiology, pacs, laser and ccd scanners, of which radworks and lumisys have been declared the gold standard for the industry. point to point 2k teleradiology systems includin scanner and r100000's. filrn digitizers vs. ccd scanners frompage36 the various models of laser film digitizers are designed to provide the end-user with the best system for specific applications. newccd digitizer now let's consider a "new-technology" ccd digitizer. "new" because some innovative technology is incorporated into a basic ccd design which results in a lower cost digitizer with acceptable clinical performance certainly much better than typical ccd scanners, for some easy to understand reasons. first, a proprietary solid-state illuminator is used rather than a light bulb to produce more photons which are also of the same wavelength. advantages: it doesn't burn out every six months, there's less scatter, and more photons means higher signal/ noise (more accurate density measurements) at higher optical densities. second, high quality optics are used to focus the transmitted light onto the ccd chip. a more efficient lens means more photons (higher signal/noise) and less optical noise. third, an aerospace quality ccd chip is used to maximize signal/noise. the particular chip utilized has been selected for its low noise characteristics and to further reduce noise (crosstalk), the detector elements are averaged so that 2 048 pixels are collected over 14". density resolution because of all this attention to noise reduction, the output can be normalised by a log amplifier, just as it is in the laser film digitizer. this means once again that very precise density measurements are produced over the dynamic range of the system: • 1000 levels from 0 to 1 00, • 1000 levels from 1 to 2 00, • 1000 levels from 2 to 3 00, • 200 levels from 3 to 3.2 od. typical ccd scanner now let's look at a typical ccd scanner. it should be recognized that all those available on the market share essentially the same performance characteristics because the laws of physics are equally applicable. a common claim is that spatial resolution is much better. this is because all ccd chips (detectors) have a large number of elements (4000, 6000, even 8000), so in theory a line of film can be digitized into a like number of pixels. in fact, two inherent characteristics of ccd chips are electronic (dark current) noise and "crosstalk" (photons which should be detected by one element are detected by two or more elements). so most ccd scanners are practically limited to 1000-2000 pixels per line (by averaging) to circumvent these problems. this is usually regarded as acceptable since most radiologists do not want to deal with larger image files anyway. the more relevant issue surrounds claims of optical density range. note that all manufacturers say they measure optical densities up to 3.0 or 3.2 or 3.5, but are unwilling to specify with what precision density is measured over that range. a ccd element is designed to produce voltage when it detects light (photons). this voltage level is digitized and the resulting digital value is 38 sa journal of radiology· june 1997 supposed to be related to the density of the film at a given point. at optical density a, maximum light passes through the film, so maximum voltage is produced by the ccd element. this is typically calibrated to be 10volts. at optical density i, only 10% of the light transmitted at optical density 0 will be detected (optical density is a log function). this means the voltage output density 1 is 1.0 volt. if the ccd output is being digitized into 12 bits or 4 096 density levels, then the number of density levels between optical density 0 and optical density 1 is 3 686. this is calculated knowing that the full range of the ccd output is io volts = 4 096 density levels and 9 volts = 3 686 density levels (90% of 4 096). this gets more interesting now. from optical density 1 (l volt) to optical density 2 (0.1 volt), the output of the ccd element is 0.9 volts which equals 369 density levels (9% of 4 096). from optical density 2 (0.1 volt) to optical density 3 (0.01), the output is 0.09 volt or 37 density levels. from optical density 3 to optical density 4, only 4 density levels are possible, which is meaningless. in other words, • 3 686 levels from 0-1 00, • 369levels from 1-2 00, • 37 levels from 2-3 00, • 4 levels from 3-4 od. in fact, it is generally accepted that typical ccd scanners are limited to a useful optical density range of 0 to 2.3, maybe 2.5. camcorders use ccd detectors to record images on video tape. when the light level is topage39 frompage38 very low, the image becomes fuzzy, contrast is poor, and colour quality is significantly degraded. the same phenomena occur when scanning a dark film with a typical ccd scanner there just aren't enough photons to provide useful information. diagnostic quality radiologists based many of their diagnoses on very small changes in optical densities which they see on film and which they should want to see on digitized images. how to compare a very simple but telling test is to digitize a calibrated step wedge with densities ranging as high as you feel appropriate to your particular application (for diagnostic teleradiology, 0-3.6 is a good range; 0-3.2 is fine for convenience teleradiology; 0-4.1 is required for mammography films). if you place a strip of scotch tape perpendicular to the density bars, you will created a density differential of about 0.03 od. the idea is to demonstrate performance using known input: (a) what is the dynamic range of the system (when do the density bars begin to be difficult to differentiate), and (b) what is the density precision of the system (at what density level can you no longer see the tape). it should be noted that comparisons of digi-, tized clinical images are not very meaningful because the density range and the density differentials are not known. you will find that the lumiscan 20 will differentiate the bars up to 3.200 and the tape is visible at the 3.2 00 level, although the data is noisy as would be expected. most other ccd scanners will not exceed 2.4 to 2.5 od, which is almost an order of magnitude lower performance than the lurniscan 20 (remember 00 is a log function). the lumiscan 75 will differentiate the bars up to 3.6 00 and you can see the tape without much noise as expected. and the lurniscan 85 performs well up to 4.1 00, again per specification. the final analysis in the final analysis, much of the decision is economics. if patient volume/critical need justifies a laser film digitizer, then it is absolutely the best choice of all. the primary reason for buying a ccd-based scanner is because price is more important than quality as in low volume, convenience teleradiology, etc. this information was supplied by imed. company news elseint the elseint select sp wins ct spiral kwazulu natal tender the kwazulu natal department of health and welfare has announced elscint, south africa, as the successful tenderer for the supply of ct spiral scanners and teleradiology to the kwazulu natal province. itis the largest single ct order of its kind in south africa.the select sp ct scanners will be situated in rural and urban sites servicing the +8 million population of the province. hospitals recommended for installation include: ngwelazana hospital, madadeni hospital, r.k.khan hospital, ladysmith hospital, greys hospital and port shepstone hospital. in addition, these sites will all be linked to wentworth hospital, durban, for diagnosis referral. the omnipro system is to be used as the basis for teleradiology using telkom digmet routers with 64kbaud/s transfer rates. the tender was won on a performance and cost basis with competition from all major ct manufacturers in south africa. evaluation and adjudication was unique in that all suppliers were invited to an open adjudication of the tender submissions and were provided opportunities to question comp tition on various aspects of their systems. according to elseint the select sp is unique in its class, in that it utilizes the premium technology of the elseint ct spiral family of systems. this spiral scanner with its short geometry, low voltage slip rings and solid state detectors has the highest efficiency in respect of dose utilization. this translates into excellent image quality and significant operating cost savings to the users. furthermore, it is capable of large patient topage40 39 sa journal of radiology. june 1997 editorial radiology in kenya peter corr mbchb, ffrad(d)sa, frcr, m med(uct) head: depal1ment of radiology, university of natal on a recent visit as external examiner to the department of radiology,university of nairobi, i had the opportunity to meet a number of radiologists at their practices and give a lecture to the kenyan association of radiologists. kenya, with tanzania and uganda, forms part of the east african region. kenya has a population of 25 million people, most of whom live in the central highlands, the coastal region, the rift valley and around nairobi. nairobi is the capital city with a population of 3 million. there are 35 radiologists in kenya, most of whom are resident in nairobi. the jomo kenyatta hospital is the main teaching hospital of the university of nairobi. the hospital is only 20 years old with 2 000 beds and full specialist services. the radiology department has both university and government sectors with ten consultants, a professor and senior lecturers. the department has been training radiologists from east africa since the mid-seventies. fifty radiologists have graduated with the master of medicine degree. it is a three-year programme, very similar to the royal college of radiologists training. the hospital has a ct scanner, biplanar angiography unit, ten bucky rooms, three fluoroscopy rooms and a gamma camera. a new colour flow ultrasound unit has been installed. the hospital is very busy with a large out-patient workload. as in many african countries, the paediatric patient load is very heavy. the registrars and doctors are keen to learn and expand services, especially in interventional work and doppler ultrasound. the chairman of the department is very keen to receive radiologists who would like to give a lecture or spend some time teaching in the department. the private diagnostic clinics and the aga khan hospital in the city are w 11 run and extremely well equipped with two mr scanners, and a third scanner is likely to be installed next year. the kenyan association of radiologists is a small but active radiology society with monthly academic meetings and an annual academic meeting. the last annual meeting was in mombasa, held in conjunction with the scottish radiology society. the association is keen to foster links with our society and possibly have a joint meeting in the future. my impression of kenyan radiology was very positive. the kenyan association is led by young dynamic radiologists who are keen to encourage the development of radiology in kenya despite the many financial difficulties that the country faces. kenya is undoubtedly one of the most beautiful countries on the african continent to visit. i feel that our society should encourage links with the kenyan association with future visits and joint meetings. 5 sajournal of radiology· november 1998 about the author(s) rishi p. mathew department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada timothy alexander department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada citation mathew rp, alexander t, patel v, low g. erratum: chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices. s afr j rad. 2021;25(1), a2256. https://doi.org/10.4102/sajr.v25i1.2256 note: doi of original article published: https://doi.org/10.4102/sajr.v23i1.1730 correction erratum: chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices rishi p. mathew, timothy alexander, vimal patel, gavin low published: 17 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the version of this article initially published, mathew rp, alexander t, patel v, low g. chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices. s afr j rad. 2019;23(1), a1730. https://doi.org/10.4102/sajr.v23i1.1730, the article section was given incorrectly. the correct section should be review article instead of original research. this correction does not alter the study’s findings of significance or overall interpretation of the study’s results. the publisher apologises for any inconvenience caused. case report a classical presentation of peyronie's disease ralph drosten mb bch, fcrsd disg department of thoracic imaging brigham and women's hospital boston, usa case presentation a 47-year-old man presented to his urologist complaining of painful erections that had increasingly deviated to the right over the previous 6 months. he experienced some difficulty, but no pain, during intercourse. no episode of trauma was recalled. a 'hardness' related to the subcutaneous tissue of the dorsum of the penis was noted 2 months prior to this presentation. extension towards the glans occurred over the intervening 2 months. clinical examination confirmed a mobile, non-tender, firm plate of tissue, tracking subcutaneously along the dorsum of the penis, from the base to within 10 mm of the glans. high-resolution ultrasound examination (fig. l.saggital plane, and fig. 2. axial plane) confirmed a sheet of calcification throwing an acoustic shadow, tracking over the dorsal surface of the mid-right corpus cavernosum. no soft-tissue mass or architectural distorsion was associated. the corpora cavernosa and the corpus spongiosum were normal and symmetrical, bilaterally. a soft-tissue exposure lateral x-ray of the penis (fig. 3) confirmed sharply defined tubular calcification in the subcutaneous tissues of the dorsum of the penis. discussion a french surgeon, francois de la peyronie, first described this ailment in 1743. the problem was noted in print as early as 1687. early writers classified it as a form of impotence. experts now recognise impotence as figs 1 and 2. saggltal and axial ultrasound images showing tubular calcification (arrows) and associated acoustic shadow. 44 sa journal of radiology. october 2001 fig. 3. lateral soft-tissue x-ray of the penis confirming tubular calcification related to the dorsum of the penis (arrows). one factor associated with the disease, a factor that is not always present,' men with peyronie's disease usually seek medical attention because of difficulty experienced during intercourse the presenting feature of our patient and painful erections.' peyronie's disease is classically described as induration of the cavernous bodies of the penis, causing fibrosis. it often occurs in a mild form that heals within 6 15 months, without treatment. in severe cases, the hardened plaque reduces flexibility, causing pain, and forcing the penis to bend or arc during erection. about 30% of men with peryonie's disease develop fibrosis in other elastic tissues, such as th~ hand (dupuytren's contracture) and foot. familial factors have also been postulated." some believe that the plaque of peyronie's disease develops following local trauma.':' the traumatised area may heal slowly or abnormally in the case of recent trauma, or due to the case report minimal amount of blood-flow in the sheath-like fibres. in cases that heal, the plaque does not advance beyond the inflammatory phase. in cases that persist, the plaque undergoes fibrosis, or even calcification. while trauma might explain acute cases of peyronie's disease, it does not explain why most cases develop slowly and with no apparent traumatic event.' it also does not explain why some cases disappear quickly, and why similar conditions such as dupuytren's contracture do not seem to result from significant trauma. imaging high-resolution ultrasound is the initial imaging modality of choice.' it dearly demonstrates the corporal bodies, corpus spongiosum and tunica albuginea. the cavernous bodies should have a homogeneous, uniform echotexture. the findings of hyperechoic foci or calcification within the corpora cavernosa or spongiosum may represent a peyronie's plaque (figs 1 and 2). computerised tomography (ct) is rarely indicated, but its excellent contrast and anatomical resolution better demonstrates the extent of the disease.' it is more sensitive in the assessment of calcification than plain films. the corpora cavernosa are usually seen as round structures of homogeneous intensity, surrounded by a thin hyperdense margin the tunica albuginea. in patients with peyronie's disease, areas of diminished density and thickness of the tunica albuginea secondary to inflammatory oedema are noted. calcified areas are also well seen (ct is more sensitive than ultrasound with regard to calcification). ct can show disease that cannot be palpated or demonstrated clinically.a diffuse increase in the thickness of the tunica albuginea indicates generalised disease of the entire penis. magnetic resonance imaging (mri) clearly demonstrates changes in the tunica albuginea and corpora cavernosa, as well as the anatomical relationship between the plaques and the penile arteries. treatment since the cause and progression of the disease are not well understood, the disease is treated empirically, i.e. methods that appear to help are persisted with. the goal of therapy is to keep the peyronie's patient sexually active. providing education about the disease and its course is often all that is required. the plaque of peyronie's disease often shrinks or disappears without treatment, and medical experts suggest waiting 1 2 years, or longer, before attempting to correct it surgically. during that wait, patients are often willing to undergo treatments that have unproven effectiveness. our patient is currently being treated conservatively. conclusion peyronie's disease is a condition with prominent psychosocial implications. it offers a clinical management challenge. ultrasound, and occasionally ct assessment of the penis delineates the extent of the disease and contributes to the monitoring of disease progression and resolution. references 1. resnick d, boutin rd, andersson 1. encyclopaedia of medical imaging. isis medical meclia, 1999: 474-475. 2. http://www.niddk.nih.gov/health/urologl pubs/peyrooje/peyronie.htm 3. http://www,urolog:ycbannelcom/peyrojljes/ index.shtml 4. hm>:/iwww.aafp,orglafp/990800ap/549 html 2, http://www.umm edu/urologyinfo/peyroni.htm 45 sa journal of radiology. october 2001 http://www.niddk.nih.gov/health/urologl http://www.umm case repoi~t sphenochoanal polyp: radiological diagnosis mwpak* frcs(ed) j kew# ffrad, (d) sa abstract * division of otorhinolaryngology, depal1ment of surgery, # depal1ment of diagnostic radiology and organ imaging, prince ofwa/es hosp/ta/, chinese university of hong kong a sphenochoanal polyp is seen as an isolated soft tissue density mass that arises from the sphenoid sinus and extends to the choana on computed tomograph ic scans. distinction from its more cornrnon counterpart, antrochoanal polyp vvbich arises from the maxillary sinus, is essential prior to surgery. a case is presented to i ii ustrate that ct scan of paranasal sinus plays an important role in the identification of the sinus of origin. case report a 47-year-old male presented to prince of wales hospital with a one year history of right sided progressive nasal obstruction following an episode of upper respiratory tract infection. the obstruction was worse on forced expiration and more noticeable during 7 sajournal of radiology. may 1998 swimming. nasal endoscopy revealed a right sided solitary polypoid mass with a slender pedicle extending from the sphenoethmoidal recess to the choana. an unenhanced ct scan of paranasal sinuses (5 x 5 mm coronal scans) was performed on a ge 8800 scanner (milwaukee, usa). a soft tissue polyp extending from the right sphenoid sinus/sphenoethmoidal recess to the right choana was demonstrated. chronic right sphenoid sinusitis with reactive sclerosis was seen. inside the sphenoid sinus there was a convex upper margin to the soft tissue which indicated the presence of either a mucous retention cyst or a polyp. the other paranasal sinuseswere clear (figures 1-4). the clinical and radiological findings indicated a sphenochoanal polyp. the patient was admitted for excision under general anaesthesia. under endoscopic control, the anterior wall of the sphenoid sinus was opened and the polyp, together with its sphenoidal component, was removed. no recurrence was noted two years after surgery. discussion a choanal polyp results from prolapsed mucosa of an isolated paranasal sinus and accounts for 3-6% of nasal polyps.p characteristically, it passes through the enlarged sinus ostium and protrudes into the choana leading to unilateral nasal obstruction, rhinorrhea and sinusitis. choanal polyps from sphenoid sinus are rare but share the characteristic similarity with the more common counterparts which arise from the maxillary sinus. they are invariablyunilateral in distribution and common in males between the second and fourth decades.'? contrary to conventional nasal polyps, choanal polyps are believed to be topageb (rom page 7 figure 1: coronal ct scan showing normal maxillary and ethmoid sinuses. no nasal polyposis is evident and the osteomeatal units are patent. figure 2: coronal ct scan through the posterior maxillary sinuses which are clear. a soft tissue opacity with a convex upper margin is seen in the sphenoid sinus (arrowhead). there is soft tissue in the sphenoethmoldal recess representing the stalk of the polyp (arrow). determine. if the sphenoid sinus is the only opaque sinus, a choanal polyp is probably sphenochoanal, even if the connection cannot be demonstrated. if both the maxillary antrum and the sphenoid sinus are opaque, continuity between the polyp and the correct sinus of origin is important to document. in the case of an antrochoanal polyp, the polyp can be followed passing between the middle turbinate and the lateral wall of the nasal cavity. with a sphenochoanal polyp, the polyp is between the nasal septum and middle turbinate. the differential diagnosis of a soft tissue mass in the sphenoethmoidal recess/choana could include nasal polyp with sphenoid sinusitis, nasopharyngeal carcinoma and lymphoma. as simple avulsion of the intranasal portion alone is associated with recurrence of at least 20% within two years, the polyp should be resected together with the pedicle and its intrasphenoidal portion. 1·3 to decrease the morbidity associated with external approaches to the sphenoid sinus, endoscopic removal of the polyp together with sphenoidotomy remains the treatment of choice. references figure 4: coronal ct scan showing the polyp in the right choana. polyp may arise from the blocked acinous mucous gland and present as an extension of a mucocele.' however, more evidence has suggested that the polyp is an extension of an asymptomatic intramural cyst from within a sinus through its natural ostium.' the sinus of origin can be identified clinically and radiologically. with a 4 mm, zero degree nasal endoscope, the sphenochoanal polyp is readily recognized as a solitary polypoid mass extending posteriorly from the recess between septum and middle turbinate to the choana. further identification of a long pedicle protruding through the sphenoid ostium in the sphenoethmoidal recess is essential to confirm the diagnosis. apart from endoscopy, ct scans of paranasal sinus is indispensable to the evaluation of an isolated nasal polyp of unknown origin. the radiological findings of sphenochoanal polyps are characteristic. the ct appearance of the polyp is of a hypoattenuated mass arising from an isolated opaque sphenoid sinus without evidence of bony erosion. the natural ostium of the sphenoid sinus is usually enlarged.ê? occasionally, the sinus of origin may be difficult to figure ~: the polyp (arrow) is seen in the right nasopharynx. the right sphenoid sinus is opaque and there is associated reactive osteitis. of inflammatory or infectious rather than allergic nature. 1·3 the origin of the polyps is controversial. mills has suggested that the a sa journal of radiology. may 1998 1. heck we, hallberg 0, williams hl. antrochoanal polyp. arch otolaryngol1950, 52: 538·548. 2. sirola r. choana i polyps. acta otolaryngol (stockh) 1996; 61: 42·48. 3. hardy g. the choanal polyp. ann oto laryngol rhinol 1957; 66: 306·326. 4. mills cp. secretory cysts of the maxillary antrum and their relation to the development of antrochoanal polyp j laryngol oto 1959; 52: 84-1 do. . 5. berg 0, carenfelt c, silfversward c, sobin a. origin of the choanal polyp. arch otolaryngol head neck surg 1988; 114: 1270-1271. 6. hayes e, lavelle w. sphenochoanal polyp. ct findings j computer assisted tomography 1989; 13: 365-366.' 7. weissman jk, tabor ek, curtin hd. sphenochoanal polyps: evaluation with ct and mr imaging. radiology 1991; 178: 145-148. revie\n article standardised ultrasound technique for evaluation of urinary tract infection in south african children highlighting the capabi iities and pitfalls of this modality savvas andronikou mb bch, fcrad(d), frcr (land) ebrahim kader mbchb ject with divergent imaging protocols existing in the current literature. as ultrasound (us) is a cheap, non-invasive, non-ionizing procedure, it is almost universally accepted as the initial investigation of choice in children with uti. us reliably demonstrates many important features of the urinary system, including renal size, congenital abnormalities, calculi and, in particular, obstruction to flow of urine (pelvicalyceal dilation). due to the subjective, user-dependent nature of us, we suggest the adoption of a standardised scanning approach to improve diagnostic accuracy and reproducibility, thereby facilitating patient follow-up. we also hope that standardisation will limit the misinchris weiman mbchb department of paediatric radiology, university of cape town and institute of child health, red cross war memorial children's hospital, cape town abstract urinary tract infection (uti) is one of the commonest bacterial infections in childhood and has potentially disastrous consequences. the imaging of uti in children is a controversial sub35 sa journal of radiology • october 2001 terpretation of us findings that are not evidence-based. this is a pictorial review of the standardised us technique used in the investigation of uti in children at the red cross war memorial children's hospital. introduction urinary tract infection (uti) is considered the most common invasive bacterial infection in childhood and may result in permanent renal damage, especially hypertension and chronic renal failure, prompting the routine investigation of these children in order to identify those at risk."?the investigation of uti in childhood is a controversial topic in current literature with little consensus as to the ideal investigation protocol." however, the availability, low cost and absence of significant biological sideeffects of ultrasound (us) have made it the most popular initial investigation of uti in childhood." us elegantly demonstrates many features of the urinary tract including renal size, congenital abnormalities, calculi and, in particular, obstruction to flow (pelvicalyceal dilation), a treatable though relatively rare cause of utp4 as is well recognised, the diagnostic accuracy and reproducibility of us findings are user-dependent," standardisation of us technique not only improves its diagnostic power, but also facilitates easy and reliable patient follow-up. in addition, it highlights the limitations of us and discourages over-zealous comment on these parameters.' this pictorial summary of the standardised us teclmique at the red cross war memorial children's hospital (rxh) also highlights a few abnormalities demonstrated by this modality. review article fig. te. the bladder should always be studied first in order to image it when distended. the transverse view is important to assess for possible nyatoureter. the bladder is demonstrated in the axial plane and its transverse diameter measured. vesical wall thickness is measured on the lateral wall in this view. there is good through·transmis· sion and visualisation of structures posterior to the bladder. fig. 1b. abnormal, bilaterally dilated ureters. this appearance, especially if unilateral, may be municked by a transient ureteric peristaltic wave. capabilities and limitations of us us is complementary to radionuelide scanning and radiographic imaging in the investigation of uti in children.' while it cheaply, effectively and safely provides information regarding many facets of the urinary tract, cognizance should be taken of its limitations.' the principal benefits of us lie in fig. ze. the bladder is shown in the sagittal plane. assess for sediment and calculi. fig. 2b. parasagittal image of the patient shown in fig. 1b (above) confirms the persistent ureteric dilatation. its ability to elucidate: (i) the presence of two kidneys in their correct position; (ii) renal sizes small kidneys in chronic renal failure, large kidneys e.g. duplex kidneys and multicystic dysplastic kidneys; (iii) congenital abnormalities horseshoe or duplex kidneys; (iv) hydronephrosis and/or hydro-ureter suggests obstruction; (v) calculi; and (vi) post-micturition vesical residual volume (figs 1 9).2,4.6 us cannot provide reliable assessment of: (i) vesico-ureteric reflux; (il) renal scars; (iii) current renal infection; and (iv) renal function.':" standardisation (figs 1 9) while many operators are com36 sa journal of radiology • october 2001 fig. 3a. right parasagittal plane this image shows the kidney inferior to the liver and al/ows comparison of their echogenicities. normal echogenicity of the liver is greater than that of the spleen and in turn, the spleen is more echogenic than the kidneys. the neonatal kidney is an exception (see fig. 6a below). fig. 3b. this kidney is hyperechoic relative to the liver and is abnormal. fortable with a free-scanning us technique, the standardisation of us technique involves adherence to a definite sequence. the ultrasonographer/ ultrasonologist, in the course of the examination, aims to measure preset parameters in predetermined views or planes. this improves diagnostic accuracy, allows for reproducibility and encourages a comprehensive examination," the aim is to record data pertinent to the investigation of uti objectively, while limiting comment on parameters that are inadequately assessed on us. a pro forma data sheet for recording the scan results reinforces the standardised review article fig. 4a. right coronal/sagittal plane renal length is recorded as the greatest cephalo-caudal dimension. comparison is made with standardised centile charts of renal size versus age. fig. sa. axial plane the renal pelvis should be measured in the ap axis at the position indicated (x • x) this is the most reliable measurement in the assessment of hydronephrosis and the most reproducible indicator of serial change especially in pelvi-ureteric junction (pw) obstruction follow-up. fig. 6a. left parasagittal plane this image demonstrates the left kidney in relation to the spleen and permits comparison of their echogenicities. the kidney should be less echogenie than the spleen. the neonatal kidney may have a normally echogenie cortex. note the prominence of the relatively hypo-echoic medullary pyramids; this appearance must not be misinterpreted as hydronephrosis. in hydronephrosis, connection can be demonstrated between the dilated calyces. fig. 4b. a duplex kidney is usually larger than normal and may show an obstructed upper pole with a shrunken lower pole. fig. sb. increased ap renal pelvis measurement. a measurement of < 10 mm is normal and> 20 mm is abnormal. a value between 10 and 20 mm represents an equivocal finding. fig. 6b. echogenie infantile polycystic kidney disease. 37 sa journal of radiology • october 2001 fig. 7a. left coronal/sagittal plane the length of the left kidney is measured on this image (compare with fig. 4a above). fig. 7b. hydronephrotic left kidney. fig. ba. axial plane as on the right, the pelvis of the left kidney is measured in the ap axis. fig. bb. an extrarenal pelvis is a normal variant and is measured at the position indicated (+ • f). revie\n article fig. ba. the petlent is allowed to micturate and any post·micturltlon residual volume is measured. this is not a reliable assessment in neonates as they do not void completely. fig. bb. enlarged, trabeculated bladder with a sig· nificant residual volume and visibly di/ated ureters posterior to it. table i. an example of a standard data sheet that can be used to encourage uniformity of reporting of ultrasound studies between various operators and allow longterm follow-up urinary tract ultrasound assessment pro forma data sheet patient name . folder number age .. renal size 50th centile for age (from standardised charts) .. right kidney left kidney length (mm) echogenicity pelvicalyceal system normal hydronephrosis (mild/moderate/severe) ap pelvis measurement ureter seen? other (e.g. calculus, renal anomaly) bladder: wall thickness post micturition measurement and volume dilated ureters posterior to the bladder: other: comment: approach. an example of a standardised data sheet is shown in table i. conclusion a standardised examination is essential to detect relevant pathological states related to uti consistently, and to enhance reproducibility for long-term patient follow-up. it promotes objective data recording on urinary parameters pertinent to the investigation of uti, which are reliably demonstrated on us, and limits over-zealous comment on findings attributed to us that are not evidencebased. references 1. larcombe j. urinary tract infection in children. bmji999;319: 1173·1175. 2. craig j. urinary tract infection in children: investigation and management. modern medicine of south africa 1998;nov: 14·25. 3. sreenarasimhaiah v, alon us. uroradiologic evaluation of children with urinary tract infection: are both ultrasonography and renal cortical scintigraphy necessary? j pediatr 1995; 127: 373·377. 4. smellie jm, rigden spa, prescod np. urinary tract infection: a comparison of four methods of investigation. arch dis child 1995; 72: 247· 250. 5. fidler k, hyer w. a strategy for uti in chilo dren. practitioner 1998; 242: 538·541. 6. smellie jm, rigden spa. pitfalls in the investigation of children with urinary tract infection. arch dis child 1995; 72: 251·258. 38 sajournalof radiology. october 2001 opinion magnetic resonance • •imaglngwhere is it going to take us? t here is no doubt that mr provides a number of capabilities superior to any other imaging technology including ultrasonography and ct. the multiplanar soft tissue contrast, the wide choice of sequences and its noninvasiveness have helped propel the modality into the foreground of radiological decision making and has gathered a large number of fervent followers among our clinical colleagues. this trend or momentum, if you wilt has been dominating the tenure of the radiological literature over the last dozen or so years. the majority of papers in today's literature still reflect this thinking. it is the "can do" part of it, as evidenced by the large volume of technology assessment evaluation studies, that were and still are bound to become obsolete sooner rather than later by the rapid advances in software technology, affecting both mri and rival technologies alike. nothing, it seems, can dampen our enthusiasm, or that of our clinical followers. we all strongly believe a rijke visiting professor un/versilf of natal, professor of radiology, umverslty of virginia, charlottesville, usa 6 sa journal of radiology. june 1997 and i am one of them that mri, particularly that of the cns and the musculoskeletal system holds the ultimate capability of uncovering any morphology or pathology needed to direct therapeutic approach. but will it? within a decade of its clinical introduction mri has become the imaging test of choice for meniscal pathology of the knee. today, mri of the menisci is one of the most frequent uses of the technology showing the fibrocartilagic as well as muscle, tendon, and ligament pathology in exquisite detail reliably dictating therapy and directing the surgeon to the site of injury. but does it? mri has emerged as the leading imaging modality for diagnosing aseptic necrosis, evaluating soft tissue masses and staging tumours in the wrist and ankle. ongoing improvements in surface coil design have rendered mri the most powerful tool for imaging structural abnormalities of the elbow and shoulder including numerous disorders that may clinically mimic pathology of the lateral epicondyle and rotator cuff. for instance, unsuspected ruptures of the lateral ulnar collateral ligament (lucl) or its iatrogenic tearing secondary overaggressive release of the common extensor tendon, can be visualised on mri and point to subtle posterolateral elbow destabilisation. but should it? the answers to these queries are, of course, anybody's guess, but it is worth taking a closer look. they will, after all, affect us all by determining nothing less than the future of our speciality. first then, technological advancement, particularly in the software sector, in the next 10 years or so is likely to further imaging capability topage8 siemens sonoline the benchmark in ultrasound siemens new ultrasound family breaks new ground in ultrasound technology. designed in collaboration with clinicians, the sonoline prima, versa, and elegra features state-of-the-art digital electronics making higher levels of imaging performance possible. sonoline prima the highest performing system in its class, the prima integrates innovation and power in a compact and mobile design. sonoline versa pro offers the widest variety of applications and performance levels and with its innovative design it allows you to expand and upgrade as your needs grow. sonoline elegra technological advantages that have never before existed in a single system have been combined in the elegra, to produce image quality that exceeds the imaginable. the platform technology utilised in the sonoline generation makes software upgrades simple, thereby protecting your investment as your business grows. all the products in the range can be networked, making telemedicine solutions possible and affordable for both urban and rural environments. qualified technicians will ensure you of the best service and support, while siemens further meets your requirement by offering finance/leasing packages and comprehensive insurance at an excellent rate. for more information, contact us on: tel: (011) 652-2383 fax: (011) 652-2322 siemens technology in caring hands magnetic resonance imagingwhere is it going to take us? frompage6 with emphasis on diagnostic and pathological criteria. it is, however, far less likely to dictate clinical strategy. there are several reasons for this. one of them is related to the inherent shortcomings of mri, some of which are euphemistically referred to as pitfalls, wrongly suggesting that they can be avoided if one is aware of them. other, more important reasons are to be found in the area of health care delivery economics, patient population base/dynamics and of who will be the key players in the future. it is interesting to note in this context, that in the last five years, mri equipment manufacturers have spent a significant part of their research dollar on the development oflow-field permanent magnet systems as part of both open-configuration and dedicated extremity scanners. although only two such systems have so far been approved by the united states food and drug administration and only a few are in actual clinical use today, more are sure to enter the market place soon. they offer a number of practical and economic advantages including increased patient comfort and risk at much lower cost. it is wise to take note of manufacturers' thinking because they have a keen eye on future potential and development. targeting clinicians in private practice with affordable permanent magnet equipment is definitely on their short-list agenda. and that will set the stage for who will image what, in whom and for whom. yet another reason why mri technology is unlikely to dictate clinical approach is the concurrent technological development in other areas of diagnostic expertise. arthroscopy is a case in point: in the same time period that mr imaging of the internally deranged knee approached near-perfection, the arthroscope has seen ever so much development in fibroscopic and manipulative sophistication. add to this the capability of intra-articular excision and reconstruction and you can see why economic considerations aside no orthopaedic surgeon would ever let go of this tool, regardless of what the mr radiologist may have to offer. if mri by itself does not dictate therapy, it will surely help to direct the arthroscopist to the site of suspected injury. well, no, not in practice, that is: for some anatomical reasons that are not coincidental, those regions of the knee joint that are most difficult to visualise by arthroscopy are also the most difficult to image. it is only small consolation that injury to the posterolateral aspect of the lateral meniscus rarely needs treatment. the superb imaging capability of mri is often the cause of discussion with clinicians about findings that mayor may not relate to the patient's symptoms. one classical example is spinal stenosis with mri showing details of spinal canal bony dimensions and soft tissue alike, often prompting surgeons to presumptive conclusions. another is the continuity of the lucl in relation to subtle posterolateral instability. while it is the radiologist's duty to comment on the integrity of the lucl in the context of postoperative elbow imaging, it is clearly the surgeon's preoperative understanding of lateral elbow stabilisers that is required to prevent accidental disruption of this ligament. in fact, the orthopaedic literature had documented the significance of the lucl in elbow stability well before this ligament attracted the attention of mr radiologists. a sa journal of radiology. june 1997 so with the technological future of mri including three-dimensional rendering capability foreseeable, the actual clinical role and how that is going to be played out and by whom is far less predictable. one scenario foreshadows mr radiologists to be increasingly involved in the departments of their subspeciality to the point of joining their faculty/staff as the imaging specialist. likely candidates would be neuro-, musculoskeletal and cardiothoracic radiologists. such developments, while possibly better serving the imaging requirements of clinical departments, would not fail to severely strain the organisational and administrative capabilities of radiology departments as we know them today. interesting •images at the suggestion of one of our readers, we will reserve space in the sa journal of radiology for the publication of interesting cases with the emphasis on images. the images are to be of excellent quality in order to be suitable for publication, and the publisher reserves the right to reject any which would not reproduce satisfactorily. pathological pictures are also welcome. a heading and a brief explanation, together with picture legends, should accompany the images. the editor abstract introduction discussion conclusion acknowledgements references about the author(s) rishi p. mathew department of radiology, rajagiri hospital, aluva, india teresa i-han liang department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta hospital, edmonton, canada ahamed kabeer department of pediatric surgery, rajagiri hospital, aluva, india vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta hospital, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta hospital, edmonton, canada citation mathew rp, liang ti-h, kabeer a, patel v, low g. clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: part 2. s afr j rad. 2021;25(1), a2027. https://doi.org/10.4102/sajr.v25i1.2027 pictorial review clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: part 2 rishi p. mathew, teresa i-han liang, ahamed kabeer, vimal patel, gavin low received: 22 oct. 2020; accepted: 22 dec. 2020; published: 23 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract children, especially toddlers, because of their behaviour, physiology and anatomical characteristics such as oral exploration of their surroundings, have a tendency to place objects in their mouth. therefore, ingestion or aspiration of foreign bodies (fbs) in children is a potentially life-threatening and common problem seen across the world. in this second part of our pictorial review on ingested and aspirated fbs, we focus on the paediatric population, reviewing the current literature and examining the epidemiology, clinical presentation, anatomic considerations, appropriate imaging modalities, key imaging characteristics associated with clinically relevant fbs in the emergency department (ed) and current management protocols. keywords: bronchoscopy; button battery; endoscopy; foreign bodies; ingestion; magnet. introduction aerodigestive foreign bodies (fbs) in the paediatric population are potentially life threatening and are frequently encountered in hospital emergency rooms (ers). identification of these fbs in the aerodigestive tract can be challenging because of non-specific symptoms, lack of a clear history or a combination of both. imaging plays a crucial role in the diagnosis of ingested and aspirated fbs in children and can be vital in guiding the clinical management of these patients. this article reviews the current literature for common presentations of both fb ingestion and aspiration, as well as the current recommendations for their appropriate evaluation and management. discussion foreign body ingestion children aged 5 years and below account for approximately 70 000 cases of fb ingestion annually in the united states alone, with a peak incidence reported between 6 months and 3 years.1 in most cases (80% – 90%), although the fb will pass through the gastrointestinal tract (git) without requiring intervention, 10% – 20% will require endoscopically assisted fb retrieval and 1% will require surgical intervention for the extraction of a fb or to treat a complication.2,3 clinical symptoms vary with the age of the patient, size and location of the fb. symptoms such as drooling, gagging and poor feeding are common presentations in infants affected with ingested fbs, whilst older children may present with odynophagia, dysphagia and chest pain. when the fb is in the proximal or mid-oesophagus and close to the airways, children may present with cough, wheezing or symptoms of respiratory distress. in the absence of mucosal injury or obstruction, fbs in the stomach or bowel are less likely to cause symptoms; when symptoms present, these include abdominal pain, vomiting and hematemesis. in most cases, retained fbs in the paediatric age group are not dramatic.4 the most commonly ingested fbs in descending order are as follows: coins, magnets, batteries, small toys, jewellery, buttons and bones.5 coins coins are the most commonly ingested fbs in children. the initial evaluation of a child suspected of coin ingestion is radiography of the neck, chest and abdomen. apart from regular anterior–posterior (ap) views, a lateral view of the neck can be obtained to better localise the coin. a coin is recognised on a radiograph by its metallic density and flat disk shape. on ap and lateral views, a coin in the oesophagus will appear as a radiodense circular object (‘en face’) and as a thick line (‘on edge or in profile’), respectively (figure 1a and b). in comparison, a coin in the trachea will appear as a dense circular object on the lateral view and as a thick line on the ap view, as the cartilage prevents the alternate appearance that would be expected with an fb in the oesophagus. it is of utmost importance for the radiologist to differentiate between an ingested coin and a button battery (bb), as the latter requires emergency removal. a bb lodged in the oesophagus can be immediately recognised as it has a ‘halo sign’ or a double density at its periphery en face, whilst a coin appears as a discoid radiodense object of uniform density (figure 2a and b).6 figure 1: frontal (a) and lateral (b) radiographs of the neck reveal a swallowed coin in the proximal oesophagus of a 10-month-old child who presented with respiratory distress and drooling. figure 2: magnified frontal radiographic images of the neck of two different patients with an ingested button battery (a) and a coin (b). a button battery has a ‘halo sign’ or a double density at its periphery en face, whilst a coin appears as a discoid radiodense object of uniform density. as coins lack sharp edges and are generally non-toxic, in most cases they pass into the stomach and through the git without any complications. nearly 75% of coins in the distal oesophagus pass spontaneously into the stomach within the first 6–10 h following ingestion. the spontaneous passage rates for coins in the midand proximal oesophagus into the stomach are reportedly estimated to be 43% and 14%, respectively.6 coins with a diameter of > 2.3 cm (e.g. an american quarter) are at risk for oesophageal retention.7 asymptomatic children can be managed conservatively once the coin has reached the stomach with anticipatory advice provided to the parents or caregivers to check the stool for confirmation of coin passage (figures 3a, b and 4a–c).6,7 if passage of the coin has not been observed in the stool, a radiograph of the abdomen should be performed, and if it is retained in the stomach 4 weeks post ingestion, the coin should be removed endoscopically.6 figure 3: initial frontal (a) and lateral (b) chest radiographs demonstrate a coin in the mid oesophagus of a 4-year-old male child. a follow-up radiograph (c) indicates that the coin has passed into the stomach. the child was managed conservatively. figure 4: serial abdominal radiographs frontal (a and b) and lateral (c) views of a 16-year-old female patient with a psychiatric history who presented with multiple coin ingestions and was managed conservatively. magnets given the extensive availability of magnets in toys, ingestion of paediatric magnetic fb remains a serious and increasing public health hazard. when multiple magnets are ingested, they can become attached to each other in-between intestinal bowel loops. as these are unlikely to become disengaged, the resultant pressure can cause necrosis within a couple of hours leading to complications, such as bowel obstruction or perforation, fistula formation, volvulus, peritonitis and sepsis.6,8 the risks are especially high when more than one magnet has been ingested. identification of one or more magnets can be challenging on a single radiograph, and it is recommended that at least two views (frontal and lateral) should be acquired (figure 5a–f). the identification of a gap between the magnets should raise concerns for bowel entrapment and the risk of ischaemic injury, necessitating the need for an urgent surgical intervention.8 figure 5: serial abdominal radiographs and computed tomography (ct) images of a 12-year-old asymptomatic male child who swallowed five small magnets, shows the magnets initially in (a) the stomach, (b) then in the left lower quadrant and (c, d and e) later in the right lower quadrant. the multiplicity of magnets can be better appreciated on ct (c and f). the magnets were subsequently removed by colonoscopy. indications and the timing for intervention are dependent on several factors, such as, patient age, anatomic location, symptoms and time since ingestion. in the case of a single-magnet ingestion, confirmed by radiography and without any complications, an endoscopic removal may not be necessary, but should be considered when radiography cannot confirm the number of the magnets ingested, the patient is at risk for further ingestion, there is a lack of means for close follow-up or the patient demonstrates clinical features of obstruction (e.g. pain, vomiting, tachycardia, etc.). in centres lacking an endoscopy service, the caregivers should be instructed to assess the progress and confirm passage of the magnet by obtaining serial radiographs of the abdomen along with stool surveillance. once a solitary magnet has traversed the oesophagus, spontaneous passage through the git is highly likely. stool softeners or polyethylene glycol can mitigate a delayed transit. urgent endoscopy or surgery should be considered in those in whom the magnet has remained stationary.9,10 in children with multiple ingested magnets, even if asymptomatic, current guidelines stipulate their urgent removal when the location is approachable endoscopically, either by oesophagogastroduodenoscopy or by colonoscopy. the type of retrieval device used varies depending on the size and shape of the ingested magnet, although the preferred instrument for small, round magnets is a retrieval net (roth net, us endoscopy). no clear consensus exists for the management of multiple magnets in asymptomatic children, which have crossed the duodenal–jejunal flexure but remain proximal to the small bowel. the options for management in such cases include endoscopic removal by small bowel enteroscopy (single or double balloon), removal by laparotomy or laparoscopy with concurrent increased morbidity, mortality and costs, or conservative management.10 a 2012 survey involving 424 children with magnetic fb ingestion over a 10-year period revealed that 52% of the patients were managed by endoscopy alone, 20% required both endoscopic and surgical intervention, 8% were managed surgically and 15% were managed conservatively. perforation or fistula repair was required in 41% of the surgically managed cases and 22% necessitated partial bowel resection.10 button or disk batteries button batteries are now commonly used in many items, such as watches, key fobs, toys and remote controls. of all the sites, impaction of a bb at the oesophagus poses the highest risk, and as a result, oesophageal bbs are the most critical indication for emergency endoscopy in the paediatric population,10 with the risk of clinically significant oesophageal injury within 1–2 h.11 in addition to the low-voltage currents and pressure necrosis, the leaking alkaline solution from the bb has a direct corrosive effect, capable of causing rapid liquefactive necrosis, leading to oesophageal mucosal injury as early as 1 h post-ingestion, forming the main mechanism of injury in bb ingestion.12 oesophageal perforation can occur as early as 6 h, with other complications including oesophageal stricture (figure 6a–d), scarring, tracheo-oesophageal fistula or oesophageal–aortic fistula with life-threatening haemorrhage.13 figure 6: frontal (a) and lateral (b) radiographs of the neck reveal a button battery in the cervical oesophagus. an initial radiograph (c) carried out 3 days post ingestion shows mild irregularity at the site of the button battery impaction, but no contrast extravasation was observed. follow-up fluoroscopy (d) performed 3 months later demonstrates a stricture (arrow) involving the cricopharyngeal portion. studies have shown that the outcome of bb ingestion is mainly dependent on the battery size. minor and moderate complications were more commonly reported in children who swallowed batteries with diameters > 15 mm, and major complications were seen in those who swallowed batteries > 20 mm in diameter.13 because of the inherent danger associated with it, the radiologist needs to immediately distinguish radiographically a bb from a coin, a common mimicker. when evaluating a child suspected of bb ingestion, it is important to obtain both frontal and lateral radiographs from the nasopharynx to the anus, as the two views can help to differentiate a bb from a coin.14 as mentioned earlier, bbs have a distinctive appearance on radiographs. on frontal radiographs, bbs have a halo or double-density shadow caused by the bilaminar structure of the battery. additionally, on the lateral view, a bb may show the step-off at the junction of the cathode and anode, whereas a coin on ap and lateral radiograph appears as a radiodense circular object and a thick line, respectively.4,6,13,14 once the battery has passed into the stomach or beyond, the need for endoscopic intervention is dependent on multiple factors, such as the age of the child, presence of symptoms and time since the ingestion. endoscopic intervention is required for bbs > 15 mm – 20 mm in diameter, children < 5 years of age, presence of symptoms and longer time after ingestion because of the increased risk of morbidity. asymptomatic older children with ingested bbs < 20 mm in size may be managed conservatively (figure 7a–c) by outpatient observation with repeated radiographs every 3 – 4 days.6,13,15 figure 7: lateral radiograph of the neck (a) and abdominal radiograph (b) of a 3-year-old child taken 3 days after ingestion of a button battery shows mild thickening of the retropharyngeal soft tissue with the foreign body located in the distal ileum. computed tomography (c) revealed that the retropharyngeal soft tissue noted on the neck radiograph was actually collapsed oesophagus with no collection. the child was managed conservatively without any complications. in contrast to bbs, ingestion of cylindrical batteries is less commonly seen in children. in a study involving 8648 cases of battery ingestion over an 18-year period, more than 94% of the ingested cells were bbs, whilst less than 6% of cases included cylindrical battery ingestion.16 cylindrical batteries are infrequently associated with minor or moderate symptoms, and major life-threatening complications are rare. batteries retained in the stomach > 48 h should be removed endoscopically. asymptomatic children with cylindrical batteries located beyond the stomach may be managed conservatively by checking the stool for its passage and with follow-up radiographs over 10 – 14 days.17 glass and sharp objects sharp objects account for approximately 5% – 30% of all swallowed objects, such as pins, needles and paper clips.18 children may also swallow glass pieces or its products, such as beads and marbles. most sharp objects, including glass, are radio-opaque and will be visible on a radiograph, all though the size and location of the glass can affect its visibility. because of the risk of oesophageal perforation, sharp objects located proximal to the gastric pylorus are removed endoscopically (figure 8a and b).18 even if a sharp object has passed into the small bowel, it needs to be followed daily with radiographs until it passes through the git (figure 9a–d) because of the 35% risk of complications.18 surgery is recommended if the sharp object fails to move through the bowel after 72 h, indicating impaction. although perforation can occur anywhere, the most common site is the ileo-caecal region, especially at the appendix or a meckel’s diverticulum. in the absence of symptoms, blunt glass objects such as marbles and beads may be managed conservatively. however, glass pieces with sharp margins located in the oesophagus or stomach should be removed endoscopically.18 figure 8: frontal (a) and lateral (b) radiographs of the neck indicates a crucifix impacted in the cervical oesophagus of a 2-year-old child. the foreign body was retrieved by rigid oesophagoscopy. radiolucent foreign bodies at least ≥ 35% of the fbs ingested are radiolucent, and these include plastic objects (e.g. majority of the toys) (figure 10a–c), some fish bones and plant materials (e.g. wort, thorns, splinters, etc.). in these cases, radiographs will be unhelpful, and management is guided mainly by clinical presentation. in such situations, imaging with fluoroscopy or ct may prove useful, especially in patients with suspected complications. asymptomatic patients can be managed conservatively.18 figure 9: serial radiographs of a 14-year-old-female patient who accidentally swallowed a loose metallic fragment (arrow) from her dental braces. the foreign body had been transmitted from the oesophagus (a) through the gastric pylorus (b), and later into the right lower quadrant (c and d) on follow-up serial radiographs. the patient was managed conservatively without any complications. figure 10: images of a 3-year-old child who ingested a toy part (toy car tyre). the chest radiograph (a) was unremarkable. upper oesophagogram, frontal (b) and oblique (c) views, showed a ring-shaped filling defect in the lower oesophagus, immediately proximal to the gastro-oesophageal junction with contrast traversing into the stomach without any delay. a summary of the various indications for a conservative approach, endoscopy or surgery in the management of ingested fbs in the paediatric population as per literature review has been shown in table 1.10,15,19 table 1: indications for ingested foreign body management in the paediatric population by conservative approach, endoscopy or surgery according to literature review. foreign body aspiration foreign body aspiration (fba) is a serious condition commonly reported in childhood, which requires urgent intervention to prevent complications and irreversible lung injuries. foreign body aspiration globally remains the fourth most common cause of accidental deaths amongst infants and preschool children,20 and the third most common cause of death amongst infants in the united states.21 children under the age of 3 years are most commonly affected. the enhanced risk for this age group is attributed to poorly developed posterior dentition, underdeveloped mechanism of deglutition and airway protection, and the inherent tendency of this age group to place objects into their mouth.22 the clinical presentation and complications associated with fba depend on the location of the fb, extent of airway obstruction, age of the child, fb type and the time elapsed following aspiration. hence, the classic triad of cough, wheeze and reduced breath sounds is not always present. most aspirated fbs are organic, primarily nuts (40%, such as peanuts) and seeds, with the remaining being non-organic materials such as coins, toys and balloons. however, the type of fbs aspirated varies amongst countries, and are largely dependent on cultural and socio-economic factors, as well as parental influence, eating habits and patient age.23 for example, sunflower, pumpkin and watermelon seeds are the most commonly aspirated fbs in the paediatric population from countries, such as egypt, turkey and greece, whilst bones are more commonly reported in patients from china and south asian countries.24 recently, an increasing incidence of ‘scarf pin-related hijab syndrome’ has been reported in the literature amongst female adolescent patients from countries with a large muslim population who wear headscarves and place the safety pin in their mouth prior to securing the veils. accidental aspiration of the pins occurs with talking, laughing or coughing.25,26 unlike in adults in whom the majority of the aspirated fbs lodge in the right main bronchus, the left main bronchus is equally affected if not more involved in children, especially in those aged ≤ 3 years (figure 11a and b).26 the type of fb aspirated also plays a decisive role in the site of lodgement. for example, scarf pins more often lodge in the left bronchial tree. many have attributed this to the bernoulli phenomenon, which states that coughing, laughing or talking creates a strong negative pressure within the narrow-left bronchus in comparison with the much wider right bronchus.26 figure 11: frontal (a) and lateral (b) radiographs in a 3-year-old child who aspirated a light emitting diode bulb into the left main stem bronchus. diagnosis of fba may be complicated by a delay in presentation or from an inaccurate diagnosis in asymptomatic children or in those presenting with non-specific symptoms. delayed diagnosis or retained fbs in the airways can result in chronic cough or wheezing, or lead to complications ranging from recurrent pneumonia, bronchiectasis, asthma, lung collapse and lung abscess to potentially fatal airway obstruction.27,28 in older children, the most commonly presenting symptom is cough, whilst wheezing and stridor, excessive crying, seizures and loss of consciousness are more commonly reported in infants. episodes of choking or coughing spells have a reported sensitivity of 80% – 82% and a specificity of 34% for fba.29 currently, the three main imaging modalities used for evaluating paediatric patients with fba include radiography (figure 12a and b), fluoroscopy and multi-detector computed tomography (mdct).30 as the majority of the aspirated fbs are organic, with the most common being a peanut, these tend to be radiolucent and unidentifiable on a radiograph.31 plain radiography is the first-line imaging modality for evaluating patients with fba, and the reported sensitivities and specificities range from 66% – 88% and 30.0% – 71.4%, respectively. figure 12: frontal (a) and lateral (b) radiographs of the neck in a 2-year-old child with an aspirated safety pin in the subglottic region. the most common findings include air trapping or hyperinflation (35%) and atelectasis (16%).31 a normal chest radiograph does not exclude fba, and a high index of suspicion is required especially in patients with a suggestive history, witnessed choking episodes by a caregiver or clinical signs on examination. both inspiratory and expiratory chest radiographs should be requested when evaluating for fba; conventional chest radiographs are taken in full inspiration. in the absence of fba, both lungs will appear well inflated and uniformly radiolucent on an inspiratory film, whilst on the expiratory film, the lung volumes will be reduced with symmetric mildly increased radiodensity. an airway fb can partially obstruct the airway by creating a ‘ball-valve’ mechanism, allowing air to enter the lung as the bronchus dilates during inspiration permitting sufficient patency of the lumen at the site of obstruction, whilst during expiration, the lumen narrows, occluding the affected bronchus resulting in obstructive emphysema, sometimes referred to as ‘air trapping’ (figures 13a and b and 14a and b).32,33 figure 13: chest radiograph (a) of a 2-year-old child who aspirated a peanut into the left main bronchus with resultant air trapping and hyperinflation of the left lung. bronchoscopy (b) confirmed the aspirated peanut in the left main bronchus. figure 14: images of a 6-year-old child who aspirated a candy wrapper into the left upper and lower segments of the left bronchus whilst eating a chocolate. the left lung appears to be hyperlucent on inspiration (a) and shows air trapping with mediastinal shift to the right on expiration (b). obtaining satisfactory chest radiographs during the desired phases of respiration may not be possible in some younger children, especially in infants from a lack of cooperation. such situations may be overcome by demonstrating air trapping on the lateral decubitus film. when a child is placed on his or her side, the dependent hemithorax gets splinted, preventing movement of the dependent lung, thereby causing it to be under aerated, as well as resulting in narrowing of the intercostal spaces and elevation of the hemidiaphragm, whilst the contralateral or anti-dependent lung remains well aerated. if air trapping is present, the affected lung, lobe or segment will remain hyperlucent when that side of the thorax is in the dependent position (figure 15a–c).33 however, one must keep in mind that air trapping is not specific for fba, as it can also be seen with any lesion partially obstructing the airways such as asthma with mucus plugging or pulmonary infections, both of which can simulate fba.34 as a result, some experts argue the clinical benefit of expiratory films. a recent cohort involving 328 paediatric patients with suspected fb aspiration found that the addition of expiratory views increased the false positives with the test accuracy remaining low, thereby questioning the benefit of the additional technique.35 radiographic findings apart from air trapping that may be seen in patients with fba include identification of a radio-opaque fb, consolidation, atelectasis, bilateral hyperinflation, pleural effusion, pneumothorax and bronchiectasis. about 24% – 30% of the patients with fba may have a normal chest radiograph.30,34,35 figure 15: images of a 30-month-old child with a history of almond aspiration. although the foreign body was not radiographically visible, the chest radiograph (a) showed a hyperinflated right lung, and right lateral decubitus inspiratory (b) and expiratory films (c) demonstrated air trapping, suggesting foreign body aspiration into the right main bronchus. in the past, fluoroscopy was used in paediatric patients with suspected fba to document mediastinal shift or reduced movement of the diaphragm from air trapping, especially in patients with inconclusive or normal chest radiographs or non-cooperative patients. this operator-dependent modality now has only a limited role because of the wider availability of mdct, although fluoroscopy may still prove useful in centres where mdct is unavailable. during the examination, the child is placed in a supine position on the fluoroscopy table with the upper and lower limbs stabilised by an assistant. the field of view is adjusted to cover both thoraces appropriately, whilst the chest is carefully examined in real time during various phases of breathing to detect abnormal side-to-side mediastinal shift or reduced diaphragmatic movement.35 fluoroscopy is normal in 53.0% of the patients with fba, and the reported sensitivities and specificities of fluoroscopy for fba are 46.9% – 80.0% and 55.0% – 94.6%, respectively.36 multi-detector computed tomography is the most sensitive imaging modality for diagnosing fba; however, because of increased radiation exposure, it is generally reserved for elusive cases. unlike radiography, the advantage of mdct is that it can demonstrate and precisely locate both radiolucent and radio-opaque fbs in the tracheo-bronchial tree prior to bronchoscopy, as well as identify subtle air trapping (figure 16a and b). an additional advantage of mdct is that it can be used for the evaluation of patients with suspected residual fb after bronchoscopy removal, which is thought to occur 1% – 18% of cases.37 figure 16: images of a 6-year-old child with severe anoxic encephalopathy who presented with a history of teeth aspiration. the aspirated teeth are barely visible (arrow) on the chest radiograph (a). multi-detector computed tomography axial (b) and sagittal reformatted (c) images confirmed the location of the aspirated teeth in the left lower lobe bronchus. nasal and posterior nasopharyngeal foreign bodies foreign bodies in the nasal cavity make up approximately 0.1% of paediatric presentations to the er.38 children place fbs in their nasal orifices for various reasons, such as curiosity, ease of availability and intellectual disability (in older children).38 the majority of the children who present with nasal fb insertion are between 3 and 4 years of age, and these fbs come in various sizes and shapes. approximately 23% – 46% of all paediatric nasal fbs are toys and 12% – 27% are organic (food-related).38 the right nasal cavity (60%) is more commonly affected than the left (34.9%), mostly attributed to the predominance of right-handedness.39 the majority of the fbs are immediately removed in the er or out-patient clinic itself, as anterior rhinoscopy allows direct visualisation to localise and identify the fb.39 paediatric patients with nasal fbs are referred to ent specialists when the objects are not visualised in the er following anterior rhinoscopy. of all the fbs, bbs can pose a serious challenge requiring general anaesthesia and specialised instruments for extraction. complications associated with bb insertion into the nose include nasal cavity adhesion, septal perforation and saddle nose. diagnostic imaging is generally reserved for those cases where nasal fbs are clinically suspected but careful physical examination and nasal endoscopy failed to reveal the same.39 the posterior nasopharynx is a rare site for fb lodgement and hardly receives mention even in standard textbooks. most of the documented literature available on posterior nasopharyngeal fbs are case reports, and reported objects include a ring, a tooth, a leech and even a fish.40 the transit and subsequent impaction of a fb into the posterior nasopharynx can occur from various cases, such as forceful emesis and coughing causing an upward migration of the fb from the pharynx or oesophagus into the posterior nasopharynx, migration of a fb into the posterior nasopharynx during extraction attempts, traumatic penetration into the posterior nasopharyngeal space or an iatrogenically placed posterior nasopharyngeal fb after surgery. the diagnosis of a posterior nasopharyngeal fb can be challenging as the symptoms are variable and some patients may remain asymptomatic.40,41 radiologists need to be aware of the posterior nasopharynx as a possible site for fb impaction, especially in patients with a presenting history of aspiration, as in rare situations, fbs may be discovered in the posterior nasopharynx on imaging studies performed for evaluation of other regions of the body (figure 17a and b). figure 17: sagittal reformatted magnetic resonance imaging brain image (a) shows the first documented case of nasopharyngeal lodgement of an aspirated rambutan fruit (b) in a 6-month-old child who was brought to the emergency room with asphyxiation and cardiac arrest. magnetic resonance imaging brain was performed to evaluate for encephalopathy-related changes when the exotic fruit was identified in the nasopharynx. rigid bronchoscopy is considered the gold standard for both the diagnosis and management of fba in the paediatric population, especially for fbs lodged within the trachea. however, many consider optimal two-step approach, whereby the diagnosis of fba is confirmed using flexible bronchoscopy followed by a therapeutic rigid bronchoscopy, whilst some favour flexible bronchoscopy for both diagnosis and management. both techniques have advantages and disadvantages, as elaborated in table 2.42 the incidence of complications associated with bronchoscopy ranges from 2.9% to 9% with a reported mortality rate of 0% – 1.5%. the reported complications include hypoxemia, tracheal or bronchial laceration or haemorrhage, laryngeal oedema, broncholaryngospasm, pneumothorax, pneumomediastinum, re-intubation, mechanical ventilation, pneumonia, cardiac arrest and anoxic brain injury.43 table 2: rigid bronchoscopy versus flexible bronchoscopy, the advantages and disadvantages. medical devices medical tubes and devices are intentionally placed in the aerodigestive tract (tracheostomy tube, feeding tube, stents, gastrostomy tube, etc.) for various support and life-saving purposes. however, very rarely these devices can become fractured or migrate to unintended areas. such complications are very rarely reported in the paediatric population, and only limited literature exists on this subject. most of the devices that have fractured and/or migrated are either tracheostomy tubes44,45 or oesophageal stents.46 to the best of our knowledge, we document the first case of a fractured and migrated gastrostomy tube component into the cervical oesophagus (figure 18a and b). it is important for radiologists to recognise and immediately report such complications to prevent unwarranted complications. figure 18: chest radiograph (a) of a 4-year-old child showing a fractured and migrated gastrostomy tube (g-tube) component (b) in the cervical oesophagus. note that the tracheal air shadow is seen separately, as the migrated g-tube component can mimic a tracheostomy tube. conclusion radiography is the initial and most commonly used imaging modality for the evaluation of ingested or aspirated fbs in paediatric patients, with fluoroscopy and mdct providing ancillary support in complex cases. it is essential for the radiologist to differentiate bb ingestion from coins, as the former requires an emergency diagnosis and removal to prevent life-threatening injury. it is prudent to remember that not all patients with fba present with a straightforward history, and hence, prompt recognition of the secondary radiographic signs of fba is essential to avoid unwarranted morbidity and mortality. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this pictorial review. authors’ contributions r.p.m. was responsible for the conceptualisation, visualisation and writing of the original draft. t.i-h.l. was responsible for reviewing, editing and resources. a.k. was responsible for supervision and validation. v.p. was responsible for project administration and supervision. g.l. was responsible for reviewing, editing and validation. ethical considerations this article followed all ethical standards for research. funding information this research article received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references gummin dd, mowry jb, spyker da, brooks de, fraser mo, banner w. 2016 annual report of the american association of poison control centers’ national poison data system (npds): 34th annual report [published correction appears in clin toxicol (phila). 2017;55(10):1256]. clin toxicol (phila). 2017;55(10):1072–1252. lee jh, lee js, kim mj, choe yh. initial location determines spontaneous passage of foreign bodies from the gastrointestinal tract in children. pediatr emerg care. 2011;27(4):284–289. https://doi.org/10.1097/pec.0b013e318213131a dray x, cattan p. foreign bodies and caustic lesions. best pract res clin gastroenterol. 2013;27(5):679–689. https://doi.org/10.1016/j.bpg.2013.08.009 berdan ea, sato tt. pediatric airway and esophageal foreign bodies. surg clin north am. 2017;97(1):85–91. https://doi.org/10.1016/j.suc.2016.08.006 kay m, wyllie r. pediatric foreign bodies and their management. curr gastroenterol rep. 2005;7(3):212–218. https://doi.org/10.1007/s11894-005-0037-6 green ss. ingested and aspirated foreign bodies. pediatr rev. 2015;36(10):430–437. https://doi.org/10.1542/pir.36-10-430 tander b, yazici m, rizalar r, et al. coin ingestion in children: which size is more risky? j laparoendosc adv surg tech. 2009;19(2):241–243. https://doi.org/10.1089/lap.2008.0206 centers for disease control and prevention (cdc). gastrointestinal injuries from magnet ingestion in children–united states, 2003–2006. mmwr morb mortal wkly rep. 2006;55(48):1296–1300. alfonzo mj, baum cr. magnetic foreign body ingestions. pediatr emerg care. 2016;32(10):698–702. https://doi.org/10.1097/pec.0000000000000927 kramer re, lerner dg, lin t, et al. management of ingested foreign bodies in children: a clinical report of the naspghan endoscopy committee. j pediatr gastroenterol nutr. 2015;60(4):562–574. https://doi.org/10.1097/mpg.0000000000000729 votteler tp, nash jc, rutledge jc. the hazard of ingested alkaline disk batteries in children. jama. 1983;249(18):2504–2506. webb wa. management of foreign bodies of the upper gastrointestinal tract: update. gastrointest endosc. 1995;41(1):39–51. https://doi.org/10.1016/s0016-5107(95)70274-1 litovitz t, schmitz bf. ingestion of cylindrical and button batteries: an analysis of 2382 cases. pediatrics. 1992;89(4):747–757. maves md, lloyd tv, carithers js. radiographic identification of ingested disc batteries. pediatr radiol. 1986;16(2):154–156. https://doi.org/10.1007/bf02386643 gurevich y, sahn b, weinstein t. foreign body ingestion in pediatric patients. curr opin pediatr. 2018;30(5):677–682. https://doi.org/10.1097/mop.0000000000000670 tien t, tanwar s. ingestion of cylindrical batteries and its management. bmj case rep. 2017;2017:bcr2016218448. https://doi.org/10.1136/bcr-2016-218448 ikenberry so, jue tl, anderson ma, et al. management of ingested foreign bodies and food impactions. gastrointest endosc. 2011;73(6):1085–1091. https://doi.org/10.1016/j.gie.2010.11.010 pugmire bs, lim r, avery ll. review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. radiographics. 2015;35(5):1528–1538. https://doi.org/10.1148/rg.2015140287 guelfguat m, kaplinskiy v, reddy sh, dipoce j. clinical guidelines for imaging and reporting ingested foreign bodies. ajr am j roentgenol. 2014;203(1):37–53. salih am, alfaki m, alam-elhuda dm. airway foreign bodies: a critical review for a common pediatric emergency. world j emerg med. 2016;7(1):5–12. https://doi.org/10.5847/wjem.j.1920-8642.2016.01.001 national safety council. injury, death and fatality statistics [homepage on the internet]. 2020 [cited 2020 oct 2]. available from: https://www.nsc.org/news_resources/injury_and_death_statistics/pages/injurydeathstatistics.aspx oguz f, citak a, unuvar e, et al. airway foreign bodies in childhood. int j pediatr otorhinolaryngol. 2000;52(1):11–16. https://doi.org/10.1016/s0165-5876(99)00283-9 ding g, wu b, vinturache a, cai c, lu m, gu h. tracheobronchial foreign body aspiration in children: a retrospective single-center cross-sectional study. medicine (baltimore). 2020;99(22):e20480. https://doi.org/10.1097/md.0000000000020480 salih am, alfaki m, alam-elhuda dm. airway foreign bodies: a critical review for a common pediatric emergency. world j emerg med. 2016;7(1):5–12. https://doi.org/10.5847/wjem.j.1920-8642.2016.01.001 aslan n, yıldızdaş d, özden ö, yöntem a, horoz öö, kılıç s. evaluation of foreign body aspiration cases in our pediatric intensive care unit: single-center experience. turk pediatri ars. 2019;54(1):44–48. https://doi.org/10.14744/turkpediatriars.2019.60251 baram a, kakamad fh, bakir da. scarf pin-related hijab syndrome: a new name for an unusual type of foreign body aspiration. j int med res. 2017;45(6):2078–2084. https://doi.org/10.1177/0300060517711086 sersar si, rizk wh, bilal m, et al. inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. otolaryngol head neck surg. 2006;134(1):92–99. https://doi.org/10.1016/j.otohns.2005.08.019 karakoc f, karadag b, akbenlioglu c, et al. foreign body aspiration: what is the outcome? pediatr pulmonol. 2002;34(1):30–36. https://doi.org/10.1002/ppul.10094 na’ara s, vainer i, amit m, gordin a. foreign body aspiration in infants and older children: a comparative study. ear nose throat j. 2020;99(1):47–51. https://doi.org/10.1177/0145561319839900 applegate ke, dardinger jt, lieber ml, et al. spiral ct scanning technique in the detection of aspiration of lego foreign bodies. pediatr radiol. 2001;31(12):836–840. https://doi.org/10.1007/s002470100001 sink jr, kitsko dj, georg mw, winger dg, simons jp. predictors of foreign body aspiration in children. otolaryngol head neck surg. 2016;155(3):501–507. https://doi.org/10.1177/0194599816644410 williams h. inhaled foreign bodies. arch dis child. 2005;90(1):ep31–ep33. capitanio ma, kirkpatrick ja. the lateral decubitus film. an aid in determining air-trapping in children. radiology. 1972;103(2):460–462. https://doi.org/10.1148/103.2.460 svedström e, puhakka h, kero p. how accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? pediatr radiol. 1989;19(8):520–522. https://doi.org/10.1007/bf02389562 hegde sv, hui pk, lee ey. tracheobronchial foreign bodies in children: imaging assessment. semin ultrasound ct mri. 2015;36(1):8–20. https://doi.org/10.1053/j.sult.2014.10.001 even l, heno n, talmon y, samet e, zonis z, kugelman a. diagnostic evaluation of foreign body aspiration in children: a prospective study. j pediatr surg. 2005;40(7):1122–1127. https://doi.org/10.1016/j.jpedsurg.2005.03.049. erratum in: j pediatr surg. 2005;40(11):1815. lea, even [corrected to even lea]; nawaf, heno [corrected to heno, nawaf]; yoav, talmon [corrected to talmon, yoav]; elvin, samet [corrected to samet, elvin]; ze’ev, zonis [corrected to zonis, ze’ev]; amir, kugelman [corrected to kugelman, amir]. shin sm, kim ws, cheon je, et al. ct in children with suspected residual foreign body in airway after bronchoscopy. ajr am j roentgenol. 2009;192(6):1744–1751. https://doi.org/10.2214/ajr.07.3770 dann l, doody j, howard r, blackburn c, russell j, barrett m. nasal foreign bodies in the paediatric emergency department. ir j med sci. 2019;188(4):1401–1405. https://doi.org/10.1007/s11845-019-02000-z oh h, min hj, yang hs, kim ks. is radiologic evaluation necessary to find out foreign bodies in nasal cavity? j craniofac surg. 2016;27(1):e62–e64. alshehri wm, al-qahtani b. a rare incidental finding of a foreign body in the nasopharynx during adenotonsillectomy. case rep otolaryngol. 2018;2018:8361806. https://doi.org/10.1155/2018/8361806 briggs rd, pou am, friedman nr. an unusual catch in the nasopharynx. am j otolaryngol. 2001;22(5):354–357. https://doi.org/10.1053/ajot.2001.26496 de palma a, brascia d, fiorella a, et al. endoscopic removal of tracheobronchial foreign bodies: results on a series of 51 pediatric patients. pediatr surg int. 2020;36(8):941–951. https://doi.org/10.1007/s00383-020-04685-1 tan gx, boss ef, rhee ds. bronchoscopy for pediatric airway foreign body: thirty-day adverse outcomes in the acs nsqip-p. otolaryngol head neck surg. 2019;160(2):326–331. https://doi.org/10.1177/0194599818800470 parida pk, kalaiarasi r, gopalakrishnan s, saxena sk. fractured and migrated tracheostomy tube in the tracheobronchial tree. int j pediatr otorhinolaryngol. 2014;78(9):1472–1475. https://doi.org/10.1016/j.ijporl.2014.06.011 gupta sl, swaminathan s, ramya r, parida s. fractured tracheostomy tube presenting as a foreign body in a paediatric patient. bmj case rep. 2016;2016:bcr2015213963. https://doi.org/10.1136/bcr-2015-213963 lange b, demirakca s, kähler g, weiß c, wessel l, kubiak r. experience with fully covered self-expandable metal stents for esophageal leakage in children. klin padiatr. 2020;232(1):13–19. https://doi.org/10.1055/a-1014-3179 sajr 841 first rssa/saspi imaging congress (johannesburg, 9 11 november 2012) this first official congress devoted to paediatric radiology incorporated the third ismrm global outreach program (gop) to south africa. the stellar international faculty of ismrm members consisted of professors james barkovich(ucsf, usa), pia sundgren (lund, sweden), and diego jaramillo and edward lee (boston, usa). they worked tirelessly to inspire the audience of predominantly general radiologists, and were supported by several local paediatric radiologists (tracy kilborn, savvas andronikou, nicky wieselthaler, richard pitcher and jaishree naidoo) who added expert local experience and expertise on topics ranging from interpretation of chest x-rays to spinal injuries and mri findings in tb meningitis. the lectures covered neuroradiology and thoracic and musculoskeletal imaging, giving insight and guidelines into the management of both common and challenging conditions in these areas in the paediatric patient, with a strong emphasis on the use of mri in this radiosensitive group. basic mri applications, appearances and sequences were stressed as well as the use and indications for more advanced techniques such as epilepsy imaging at 7t that were eloquently explained. in addition to the didactic lectures, the international faculty treated the audience to a case-based interactive learning session. the conference concluded with lectures on new horizons in paediatric imaging with specific reference to the future applications that mri will provide in brain and lung imaging. a highlight was the oral paper presentations for the rssa travel award of $5 000 that is annually awarded for the best scientific paper by a resident or radiologist less than 5 years qualified. the ismrm faculty were the adjudicators. the winner was dr tanya pillay (red cross war memorial children’s hospital in cape town) for the paper ‘assessment of the accuracy of mri in predicting operability and tumour staging in wilms’ tumour (nephroblastoma) when correlated with surgical findings and histopathology’. (this was, incidentally, the second year in succession that a paper from red cross children’s war memorial hospital won the rssa travel award.) the international judges also gave very useful feedback and constructive criticism regarding research methodology and the ‘do’s and don’ts’ of scientific oral presentations. the audience of 350 delegates ( one of the largest in south african radiology history) pronounced the congress a resounding success; this can be directly attributed to the high quality and international reputation of the ismrm faculty. the financial support received from the ismrm and the international sponsors (siemens, philips and ge), who support the gop, was gratefully acknowledged. (from left to right) proff leon j van rensburg (rssa congress chair, ismrm gop co-ordinator, africa and middle east); pia c sundgren  (sweden, ismrm trustee); a james barkovich (ucsf, usa); dr tracy kilborn (co-organiser, hod, red cross war memorial children’s hospital, cape town); and dr edward lee (boston children’s hospital, usa). second rssa/icis cancer imaging course (stellenbosch, 25 27 january 2013) razaan davis tygerberg hospital/university of stellenbosch the spier hotel and conference centre near stellenbosch hosted the second joint venture between the radiological society of south africa (rssa) and the international cancer imaging society (icis). the internationally renowned faculty included representatives from the usa, canada, the uk, austria, the netherlands and italy, with dr philip jansen van rensburg representing south africa. a comprehensive syllabus of lectures was delivered most successfully. the efforts of both societies in striving to improve the quality of radiological education and practice in southern africa are gratefully acknowledged. advances in modern radiological techniques, including whole body dwi and advanced mri sequences in glioblastoma multiforme, were among the many highlights. professor anwar padhani, on his return visit to spier for a rssa/icis collaboration, and professor jelle barentsz, educated and entertained delegates with their humorous delivery of the imaging of prostate carcinoma, ensuring that the essence of their lectures would be remembered long after the laughter dissipated. unfortunately, renowned neuroradiologist professor anne osborne was unable to make the transatlantic crossing owing to sudden illness. however, modern technology allowed her lecture series to be delivered in real time, in the format of a live webinar, from salt lake city, utah. professor richard hewlett stepped in at short notice and delivered 2 lectures; this was just 4 days following the death of his beloved wife. notwithstanding this blow, his audience were, as generations of radiologists before, privileged to benefit from his wisdom and wit. he has the distinction of being the first honourary member of the rssa. in september 2012, professor robert hermans of ku leuven was admitted as the second member. during the course, proff anne osborne and jay p heiken were added to this distinguished list, each also receiving a gold kruger rand from the rssa. professor heiken (icis secretary and chair) has collaborated with professor leon janse van rensburg, rssa congress chairman, for 2 years in bringing a world-class cancer imaging course to our doorstep. professor heiken was not only instrumental in arranging the first and second rssa/icis cancer imaging courses, but also the highly successful first rssa/sgr gastrointestinal radiology course at spier estate in august 2010. it is hoped that continuing collaboration between our society and international societies, such as the icis and sgr, will be fostered. the faculty (from left to right): prof. j goldin (usa), drs r smith (canada), g morana (italy), proff m thurner (austria), l j van rensburg (rsa), l quint (usa), drs p janse van rensburg (rsa), a sahdev (uk), proff j heiken (usa), r hewlett (rsa), a padhani (uk) and dr c sperryn (rsa). references references about the author(s) bates alheit private radiology, cape town, south africa citation alheit b. letter to the editor: addressing radiological terminology of basal ganglia and thalamic injury in hypoxic ischaemic injury. s afr j rad. 2021;25(1), a2146. https://doi.org/10.4102/sajr.v25i1.2146 letter to the editor letter to the editor: addressing radiological terminology of basal ganglia and thalamic injury in hypoxic ischaemic injury bates alheit received: 12 mar. 2021; accepted: 18 apr. 2021; published: 26 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. i refer to a recent webinar presented by prof. savvas andronikou on the patterns of hypoxic ischaemic brain injury (hibi) in children when scanned by magnetic resonance (mr) at an older age. i write this letter in support of prof. andronikou’s suggested approach to the basal ganglia and thalamus (bgt) pattern of injury and the conditions under which the terminology of an ‘acute profound’ injury should be used. i refer to the pictorial review by misser et al. on the correlation of the pathophysiology and magnetic resonance imaging (mri) patterns in children with hibi that appeared in the south african journal of radiology (sajr) in october 2020.1 in this article, the authors classify mri patterns and ascribe pathogenetic mechanisms to each. they refer to classic bilateral hypoxic ischaemic insults of the posterior putamina and ventrolateral thalami as an ‘acute profound pattern’1 and specify that the description of acute profound injury links this particular diagnosis with sentinel events, which include ruptured uterus, abruption of the placenta and prolapsed cord.2,3,4 a large number of cases with the bgt injury pattern have no record of having suffered a sentinel event; that is, naming these as an acute profound hypoxic ischaemic injury is inappropriate. i draw the attention of the readership to the evolution of this particular terminology, which has come about in an effort to just avoid such pathogenetic assumptions associated with the involvement of the deep nuclei on mri. although it is widely accepted that watershed injuries occur as a result of partial and prolonged (usually over 1 h) hypoxic ischaemic injury to the term foetus,5,6 injury to the bgt has been shown to also occur without any sentinel event having occurred.7 hence, the currently preferred term ‘bgt pattern of injury’ has emerged in publications dating from as far back as 2011, which does not contain any reference to the duration or severity of the injury.8,9,10,11,12 a recent article by smith et al.7 specifically addresses this issue through a patient cohort carefully selected for good clinical documentation, who had an mri pattern of ‘bgt pattern of injury’, but did not have any sentinel event or clinical acute profound hibi. the authors concluded therefore that the terms ‘acute profound pattern’ and ‘bgt pattern’ are not synonymous. these authors demonstrated that a prolonged non-reassuring foetal status (nrfs) during labour, leading to a pathological tracing in the absence of a perinatal sentinel event, can result in a ‘bgt pattern of injury’ on mri. these cases should not erroneously be referred to as having an ‘acute profound injury’. a number of other scientific publications support the findings of smith et al. harteman et al. reported that 11 of the 18 cases with ‘bgt pattern of injury’ did not have sentinel events. all had abnormal foetal heart rate (fhr) patterns before birth, suggesting that injury to the deep nuclei was most probably because of foetal distress.10 bonifacio et al. reported that a perinatal sentinel event was present in only 10 of the 60 hypoxic ischeamic encephalopathy (hie) cases, but that 14 cases overall had a ‘bgt pattern of injury’ as the predominant pattern on mri – therefore, four cases of bgt injury (28.5%) did not have a sentinel event.11 barnette et al. reported 36 cases of hie with a ‘bgt pattern of injury’ without a perinatal sentinel event or shoulder dystocia.13 miller et al. demonstrated that foetal distress was the probable cause of hie in 23 of the 44 babies with bgt predominant injury.14 naeye et al. reported two cases of bgt injury that were clearly not related to a sentinel event – one had a bradycardia for 2 h before delivery and the other had cessation of foetal movements for 28 h before birth.15 martinez-biarge et al. reported that at least 230 (59.5%) of the 393 cases with ‘acute hypoxia ischaemia’ on mri had no sentinel event. an abnormal cardiotocograph (ctg) was present in at least 276 of the total cohort, which strongly suggests that foetal distress was the cause for acute hypoxic injury in as many as 113 (276−163 = 113) cases (28%).16 why is it important for us not to report the involvement of the deep nuclei in perinatal hypoxic ischaemic as an ‘acute profound’ pattern? smith et al. draw attention to a medicolegal lexicon, which has evolved in south africa specifically, where it is implied that ‘acute profound hibi’ is ‘always’ sudden (acute) and ‘always’ profound (severe and total). this view has fostered the belief in the courts that very little could have ‘ever’ been done to arrest the process of foetal neurological injury where that injury is reported as ‘acute profound’ on mri. in the light of the above, the author of this letter recommends that abnormalities of the posterior putamina and ventrolateral thalami, as described by misser et al. in term perinatal hypoxic ischaemic injury, should be reported as a ‘bgt pattern of injury’ in the absence of a documented sentinel event, as was elegantly explained in the seminar alluded to above. if there is no definitive confirmation of a preceding sentinel event, a radiologist is not in a position to deduce from the structural damage identified on mr images under what clinical or obstetrical conditions this type of injury occurred. it is also noted that the use of the term ‘acute profound’ remains valid, provided it is used in accordance with the acog 2014 definition of an acute profound injury and that there is definitive obstetrical evidence of a sentinel event that preceded the insult.17 so what can the radiologist say about the timing of the injury? some indications that the injury occurred in a brain of ‘term maturity’ are provided by the presence of glial strands in multicystic encephalomalacia,9,18,19 ulegyria in watershed injury20,21 and involvement of the peri-rolandic region,5,21 but radiologists are not able to determine the exact timing of the injury during the peri-partum period. in this context, it is notable that the vast majority of hypoxic ischaemic injuries occur during the peri-partum period.9,22 radiologists should defer to clinical and obstetrical experts to advise on the clinical context, the probable causation, timing and severity of the insult. dr b. alheit mb. chb. mmed diag. radiology (stellenbosch) references misser sk, barkovich aj, lotz jw, archary m. a pictorial review of the pathophysiology and classification of the magnetic resonance imaging patterns of perinatal term hypoxic ischemic brain injury – what the radiologist needs to know…. sa j radiol. 2020 oct 30;24(1):1915. https://doi.org/10.4102/sajr.v24i1.1915 de vries ls, groenendaal f. patterns of neonatal hypoxic-ischaemic brain injury. neuroradiology. 2010 jun;52(6):555–566. https://doi.org/10.1007/s00234-010-0674-9 rutherford m, srinivasan l, dyet l, et al. magnetic resonance imaging in perinatal brain injury: clinical presentation, lesions and outcome. pediatr radiol. 2006 jul;36(7):582–592. https://doi.org/10.1007/s00247-006-0164-8 rutherford m, malamateniou c, mcguinness a, allsop j, biarge mm, counsell s. magnetic resonance imaging in hypoxic-ischaemic encephalopathy. early hum dev. 2010 jun 12;86(6):351–360. https://doi.org/10.1016/j.earlhumdev.2010.05.014 reid sm, dagia cd, ditchfield mr, reddihough ds. grey matter injury patterns in cerebral palsy: associations between structural involvement on mri and clinical outcomes. dev med child neurol. 2015 dec;57(12):1159–1167. https://doi.org/10.1111/dmcn.12800 robertson cm, perlman m. follow-up of the term infant after hypoxic-ischemic encephalopathy. paediatr child health. 2006 may;11(5):278–282. smith j, solomons r, vollmer l, et al. intrapartum basal ganglia-thalamic pattern injury and radiologically termed ‘acute profound hypoxic-ischemic brain injury’ are not synonymous. am j perinatol. in press 2020 dec 15. https://doi.org/10.1055/s-0040-1721692 hayakawa k, tanda k, koshino s, nishimura a, kizaki z, ohno k. pontine and cerebellar injury in neonatal hypoxic-ischemic encephalopathy: mri features and clinical outcomes. acta radiol. 2020 oct;61(10):1398–1405. ghei sk, zan e, nathan je, et al. mr imaging of hypoxic-ischemic injury in term neonates: pearls and pitfalls. radiographics. 2014 aug;34(4):1047–1061. https://doi.org/10.1148/rg.344130080 harteman jc, nikkels pgj, benders mjnl, kwee a, groenendaal f, de vries ls. placental pathology in full-term infants with hypoxic-ischemic neonatal encephalopathy and association with magnetic resonance imaging pattern of brain injury. j pediatr. 2013 oct;163(4):968.e2–995.e2. https://doi.org/10.1016/j.jpeds.2013.06.010 bonifacio sl, glass hc, vanderpluym j, et al. perinatal events and early magnetic resonance imaging in therapeutic hypothermia. j pediatr. 2011 mar;158(3):360–365. lakatos a, kolossváry m, szabó m, et al. neurodevelopmental effect of intracranial hemorrhage observed in hypoxic ischemic brain injury in hypothermia-treated asphyxiated neonates – an mri study. bmc pediatr. 2019 nov 12;19(1):430. https://doi.org/10.1186/s12887-019-1777-z barnette ar, horbar jd, soll rf, et al. neuroimaging in the evaluation of neonatal encephalopathy. pediatrics. 2014 jun;133(6):e1508–e1517. miller sp, ramaswamy v, michelson d, et al. patterns of brain injury in term neonatal encephalopathy. j pediatr. 2005 apr;146(4):453–460. https://doi.org/10.1016/j.jpeds.2004.12.026 naeye rl, lin hm. determination of the timing of fetal brain damage from hypoxemia-ischemia. am j obstet gynecol. 2001 jan;184(2):217–224. https://doi.org/10.1067/mob.2001.108996 martinez-biarge m, diez-sebastian j, wusthoff cj, mercuri e, cowan fm. antepartum and intrapartum factors preceding neonatal hypoxic-ischemic encephalopathy. pediatrics. 2013 oct;132(4):e952–e959. https://doi.org/10.1542/peds.2013-0511 executive summary: neonatal encephalopathy and neurologic outcome, second edition. report of the american college of obstetricians and gynecologists’ task force on neonatal encephalopathy. obstet gynecol. 2014 apr;123(4):896–901. barkovich aj, truwit cl. brain damage from perinatal asphyxia: correlation of mr findings with gestational age. ajnr am j neuroradiol. 1990 dec;11(6):1087–1096. counsell sj, tranter sl, rutherford ma. magnetic resonance imaging of brain injury in the high-risk term infant. semin perinatol. 2010 feb;34(1):67–78. https://doi.org/10.1053/j.semperi.2009.10.007 nikas i, dermentzoglou v, theofanopoulou m, theodoropoulos v. parasagittal lesions and ulegyria in hypoxic-ischemic encephalopathy: neuroimaging findings and review of the pathogenesis. j child neurol. 2008 jan;23(1):51–58. https://doi.org/10.1177/0883073807308694 shroff mm, soares-fernandes jp, whyte h, raybaud c. mr imaging for diagnostic evaluation of encephalopathy in the newborn. radiographics. 2010 may;30(3):763–780. https://doi.org/10.1148/rg.303095126 cowan f, rutherford m, groenendaal f, et al. origin and timing of brain lesions in term infants with neonatal encephalopathy. lancet. 2003 mar 1;361(9359):736–742. https://doi.org/10.1016/s0140-6736(03)12658-x response to letter to editor dear editor, your request for a response to the letter to editor by dr alheit, dated march 2021, refers. challenges to the existing theories of perinatal hypoxic ischaemic brain injury (hibi) are ongoing and continue to contribute to the body of knowledge in this sphere of paediatric neuroradiology. we have tried to address dr alheit’s query; however, we feel that the scope and intent of our publication have been misunderstood. for the purpose of clarity, the reader is referred to the abstract and conclusion of the article. the cases in our article1 that we described as acute profound hibi were children who had suffered sentinel events, examples of which we cited as abruptio placentae, cord prolapse or uterine rupture. these clinical factors were clearly described in our article along with the relevant pathophysiological processes. nomenclature and classifications are increasingly being referenced in medicolegal matters in south africa. the classification we have described has been widely accepted and in use up to the time of publishing. further support was confirmed through article review by peer-review process. our purpose, as radiologists, is to describe the pattern we see on imaging and not be drawn into a debate on medicolegal terminology. up until october 2020, when our article was published, radiological reporting of the central pattern of injury (including basal ganglia, thalamus and rolandic injury), which we have called acute profound injury, has previously been ascribed to an acute pathophysiology. cognisance is taken of the recent article quoted,2 showing that a basal ganglia thalamus (bgt) pattern may also occur in the absence of sentinel events and is therefore not synonymous with acute profound hibi. we are not opposed to the use of the anatomical description proposed, to call this injury a bgt pattern, where there is no correlative sentinel event documented. structured research studies interrogating these propositions are encouraged. the fact is that the full extent of any perinatal event is not fully understood. the patterns that have been described (by my group and others) are most certainly real, but a close monitoring of ongoing physiological changes in human babies during the delivery is rare, especially in resource-constrained settings. we can only surmise what has happened later, after the child has been delivered. physicians make observations, based upon the information that they obtain before, during and after delivery and then work retrospectively to try to understand what happened. frankly, nobody completely understands all of the processes that take place in these cases. a very important concept is that every hibi episode is different. indeed, it is likely that every one of them is a little different from all the others. added to that is the fact that each body probably reacts a little differently to an ischaemic insult. when one considers all the different physiological processes ongoing in these babies, and the fact that everyone’s physiology is slightly different, it is not surprising that the pattern of injury in each one is a little different from all the others. in science, one cannot be too dogmatic when describing expected findings. everyone has a slightly different physiology and is going to have slightly different responses to an event. however, our findings indicate that what we have published is true for a large (perhaps even a vast) majority of affected patients. references misser sk, barkovich aj, lotz jw, archary m. a pictorial review of the pathophysiology and classification of the magnetic resonance imaging patterns of perinatal term hypoxic ischemic brain injury – what the radiologist needs to know…. sa j radiol. 2020 oct 30;24(1):1915. https://doi.org/10.4102/sajr.v24i1.1915 smith j, solomons r, vollmer l, et al. intrapartum basal ganglia-thalamic pattern injury and radiologically termed ‘acute profound hypoxic-ischemic brain injury’ are not synonymous. am j perinatol. in press 2020. https://doi.org/10.1055/s-0040-1721692 dr shalendra k. misser (corresponding author) radiologist, lakesmit and partners inc, durban, south africa tips clarifying lucent oval skull markings in children: craniolacunia, convolutional markings and copperbeaten skull sandronikou mssch (wits), fcraddlag (sa), frcr (london) ewelman mschs e kader mschs department of patjdlatrtc radiology, university of caps town and institute of child h88ith, red cross war memorial children's hosp/tal, rondebosch, capa town corresponding author s andronlkou department of paediatric radiology, red cross war memorial children's hospital, cape town, 7700 tel: (021) 658-5422. fax: (021) 658-5101. e-mail: docsav®mweb.co.za abstract large oval iucencies seen on the paediatric skull radiograph (sxr) may be normal or pathological. the radiologist, however, must be clear about which findings are pathological and the appropriate terminology when reporti ng on a paediatric sxr. by noting the clinical setting, the age of the patient and associated sku ii abnormal ities, the appropriate terms can be used so that normal convol utional marki ngs can be distinguished from accentuated marki ngs of copper (silver)55 sajournal of radiology. february2001 beaten sku" in raised intracranial pressure (icp) and the lacunae in patients with luckenschadel accompanying spinal dysraphism. keywords craniolecurtie, convolutional markings" copper-beaten skull introduction large ovallucencies seen on the paediatric skull radiograph (sxr) may be normal or pathological. differentiation of these does not usually affect management in current radiology practice, where an sxr is not commonly performed. the radiologist, however, must be clear about which findings are pathological and what the appropriate terminology is when reporting on a paediatric sxr. by noting the clinical setting, the age of the patient and associated skull abnormalities, the appropriate terms can be used so that normal convolutional markings can be distinguished from accentuated markings of copper (silver)-beaten skull in raised intracranial pressure (iep) and the lacunae in patients with liickenschadel accompanying spinal dysraphism. discussion liickenschadelllacunar skull/ craniolacunia these numerous oval, lucent defects of the skull vault, varying in size, shape, number and degree, are due to a mesenchymal dysplasia (figure la). they are found in association with myelomeningocoele, meningocoele and encephalocoele (figure 1b). only to page 56 clarifying lucent oval skull rnarlciruzs in children from page 55 figure la: frontal sxr in a three-day-old child with spinal dysraphlsm demonstrating ovallucencles surrounded by dense ridges. this is the mesenchymal dysplasia termed uickenschade/. very rarely does this occur without dysraphism or cranioschisis.the process begins in utero but disappears at six months of age (whether or not a ventriculo-peritoneal shunt has been placed). appearances vary from shallow depressions on the inner vault of the skull to deep cavitations (lacunae) that extend to the outer skull surface. the lacunae do not correspond to the underlying convolutional pattern of the brain. between the lacunae, linear ridges of higher density bone are seen. the parietal and upper occipital bones are commonly involved. the skull base is usually spared. as these features occur independently of raised icp, the sutures and sella turcica are usually normal."? convolutional markings/ digital impressions these are normal markings seen as areas of decreased density in the calvarium (figure 2). they correspond closely to the location and configura tion of the underlying cerebral convolutions. theyoccur throughout the calvaria and those seen involving the floor of the anterior and middle fossae are most closely related to cerebral gyri. the rest of the lacunae on the vault are probably affected by pulsation of cerebrospinal fluid (csf) in the sulci of a normal growing brain, which causes impressions on the inner table. even though convolutional markings may be seen as early as eight months of age (in premature infants), they usually appear after the first year of life. they are most marked during the periods of rapid brain growth, which occur between 2-3 years and 5-7 years of age. they usually disappear by eight years of age.the sutures and sella turcica remain normal.p figure 1b: a thoracic spine radiograph in the same child as in figure la demonstrates the dorsal dysraphism (arrows) with widening of the spinal canal and numerous vertebral anomalies. this patient had a clinically visible thoracic myelomeningocoele present at birth hammer/ copper/silveri pewter-beaten skull 58 sajournal of radiology. february 2001 figure 2: this six-year-old boy shows normal convolutional markings during the period of rapid brain growth. note that the sutures (arrow) are visible and normal and that there are no changes involving the sella turcica (open arrow). figure 3: this six-year-old boy shows accentuation of convolutional markings of a silver/copperbeaten skull the sagittal (not shown on this radiograph) and coronal sutures are completely fused, in keeping with craniosynostosis. the sellar demineralisation is in keeping with the resultant chronically raised icp. this terminology is used when there are deep or accentuated convolutional markings in long-standing severely raised icp (figure 3). such markings are not present at birth and do not occur before two months of age. associated with this are features of raised icp such as sutural diastasis and/or sellar demineralisation. the sutural changes are more common in younger children, while the sellar changes occur more commonly in older children. the copper-beaten to page 57 clarifying lucent oval skull markings in children from page 56 skull is most marked when multiple sutures are fused, as occurs in primary craniosynostosis.ê-' conclusion the differentiation of oval skull lucencies seen on children's sxrs can be undertaken by assessing the age of the child, clinical features and associated sxr findings (tables 1 and 2). acknowledgements the authors would like to thank jessica bertelsmann for her help in the preparation of this article. references 1. robertson rl, ball ws jr, barnes pd. skull and brain. in: kirks dr, griscom nt (eds). practical paediatric imaging. 3rd ed. philadelphia: lippincott-raven. 1998: 7891. 2. silverman fn, byrd se, fitz cr. the skull. in: silverman fn, kuhn jp (eds). caffey's paediatric x-ray diagnosis: an integrated imaging approach. 9th ed. st. louis: mosby. 1993: 20-34. 3. chasler cn. atlas of roentgen anatomy of the newborn and infant skull. st. louis: warren h green. 1972 59-64. table 1: differentiation of lucent oval skull markings based on the age of the child present at birth but disappear by 6 months of age ! luckenschadel usually appear after 1st year of life and disappear by 8 ~arsofage. ost marked between 2 and 7 years of age ! normal convolutional markings occur in later childhood and adolescence (usually after 10 years of age) ! accentuated abnormal convolutional markings (copper-beaten skull) table 2: differentiation of lucent oval skull markings in children associated with spinal dysraphism ! loekenschadei s7 sa journal of radiology· february 2001 normal sutures are easily visible and not prematurely closed. normal pituitary fossa. no clinical features of raised intracranial pressure. ! normal convolutional markings associated with craniosynostosis. clinical and radiological features of raised intracranial pressure such as pituitary sella demlnerallsation and sometimes sutural diastasis ! accentuated abnormal convolutional markings (copper-beaten skull) case report radiographic imaging following the use of absorbable internal fixation devices in orthopaedic surgery the 'invisible' screws ian c duncan ffrad(d)sa hans h volkersz fes orth (sa) sunninghili medical institute johannesburg abstract we describe a single case report of the use of polylactic acid absorbable internal fixation screws (biofix, bioscience ltd, tampere, finland) for the operative repair of a pipkin type n hip fracture. five months later a diagnosis of secondary avascular necrosis of the same femoral head was made on magnetic resonance imaging with no image degradation due to the presence of the screws. the use of biodegradable internal fixation devices therefore has the added advantage of allowing artefact-free postoperative imaging. introduction many radiologists today are unaware of the use of absorbable internal fixation devices in orthopaedicsurger~ these absorbable or biodegradable internal fixation devices or implants are being used in the place of the more traditional metallic rods, wires and screws. the presence of metallic devices can result in significant imaging artefacts particularly with magnetic resonance imaging, which can result in sub-optimal postoperative imaging. the use of absorbable fixation devices allows the radiologist the opportunity of obtaining optimal artefact-free postoperative imaging as an additional advantage. case report an adult male patient was admitted following a motor vehicle accident having sustained a pipkin type n fracture of the left femoral head and acetabulum (fig. ia), at surgery, the acetabular fragment was removed and the femoral head fragment was reduced and fixed with two absorbable polylactic acid (pla) screws (biofix, bioscience ltd, tampere, finland). the postoperative control radiograph showed good reduction of the hip. the bioabsorbable screws were not visible radiographically (fig. 1b). five months later the patient presented with progressive pain in the same hip. plain films taken at this stage showed maintenance of reducfigs. 1a and b. pipkin type iv fracture before (a) and after (b) operative reduction and intemal fixation. the screw tracts are invisible. 46 sa journal of radiology • december 2002 case report fig. 2 a. several months later plain film studies show healing of the fracture with normal alignment but no features of avascular necrosis. fig. 2b. coronal ti-weighted mr image obtained 5 months later showing evidence of avascular necrosis in the superior aspect of the femoral head. there is no artifact due to the screws ai/owing clear visualisation of these changes. tion and evidence of healing of the femoral head with no evidence of avascular necrosis (fig. 2a). a magnetic resonance (mr) scan was obtained which showed no magnetic susceptibility artefact due to the presence of the polylactic acid screws (fig.2b). discussion the first reported clinical use of . absorbable internal fixation devices occurred in finland in 1984 in a number of ankle fracture repairs. i since then, the use of these devices as well as the spectrum of available implants have increased considerably. the materials used in the manufacture of these devices are synthetic polymeric composites, the most important of these being polyglycolic acid (pga) and polylactic acid (pla). in vivo these two substances are altered by hydrolysis to glycolic acid and lactic acid, both of which are naturally occurring metabolic products. these are then incorporated into various normal biochemical pathways including protein synthesis and energy production. the shear strength values of these materials are 20 30 times those of cancellous bone, making them strong enough for orthopaedic fixation and weight-bearing. they demonstrate a flexibility part way between cancellous and cortical bone to allow micromovements essential for rapid bone healing. the speed of absorption of these devices is related to implant size and site, degree of metabolic activity and patient age. with absorption, the implants soften (pga within 1 3 months and pla within 3 12 months) and total resorption occurs within 1 6 years. these devices include a number of fully-threaded and lag screws, rods, expansion plugs and anchors (fig. 3). the rods are available in diameters of 1.1 4.5 mm and are used in the place of the more commonly implanted metallic rods and k-wires. the devices are easily trimmed to an fig. 3. two examples of the biodegradable polylactic acid screws simi/arto those used in the case described. 47 sa journal of radiology • december 2002 appropriate length. indications for the use of these devices would include the repair of any fracture or other orthopaedic procedure where a wire, small rod, screw or tissue anchor would be used for internal fixation.' there are even small devices available for the repair of certain meniscal tears in knee injuries. one major advantage of using these absorbable implants is the lack of any need for a secondary device removal procedure, resulting in reduced cost and risk of infection.' unlike other metallic implants, the absorbable devices can be used in an infected area. these devices are especially useful for intraarticular fractures as a repeat surgery for removal of the screws or rods is not required. of interest to radiologists is that these devices are fully mri compatible and do not degrade the mr image quality at all,' allowing optimal postsurgical imaging where required. this adds yet another significant advantage to their usage. they are also completely non-opaque to x-ray imaging and thus cannot be seen on plain film or computed tomographic imaging, making them truly 'invisible' screws. a faint sclerotic margin to the screw tracts may sometimes be seen over time. references 1. rokkanen p, bóstman 0, vainionpaa s, et nl. biodegradable implants in fracture fixation: early results of treatment of fractures of the ankle. lancet 1985; 22: 1422-1424. 2. rokkanen p, bóstman 0, vanionpaë s, et nl. absorbable devices in the fixation of fractures. j 7jml1nn 1996; 40: 123-127. 3. bóstman 0, hirvensalo e, partio e, 'iormala p, rokkanen p. impact of the use of absorbable fracture fixation implants on consumption of hospital resources and economic costs. j trauma 1991; 31: 1400-1403. 4. viljanen j, kinnunen j. bondestarn s, majola a, rokkanen p, tormala p. bone changes after experimental osteotomies fixed with absorbable self-reinforced poly-llactide screws or metallic screws studied by plain radiographs, quantitative computed tomography and magnetic resonance imaging. biomaterials 1995; j 6: 13531358. abstract introduction methodology ethical consideration results discussion conclusion acknowledgements references about the author(s) hira lal department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india anuradha singh department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india raghunandan prasad department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india priyank yadav department of urology and renal transplantation, faculty health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india javed akhtar department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india sukanta barai department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india prabhakar mishra department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india dharmendra bhadauria department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india anupma kaul department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india narayan prasad department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india pragati verma department of radiology, faculty of health sciences, sanjay gandhi post graduate institute of medical sciences, lucknow, india citation lal h, singh a, prasad r, et al. determination of split renal function in voluntary renal donors by multidetector computed tomography and nuclear renography: how well do they correlate? s afr j rad. 2021;25(1), a2009. https://doi.org/10.4102/sajr.v25i1.2009 original research determination of split renal function in voluntary renal donors by multidetector computed tomography and nuclear renography: how well do they correlate? hira lal, anuradha singh, raghunandan prasad, priyank yadav, javed akhtar, sukanta barai, prabhakar mishra, dharmendra bhadauria, anupma kaul, narayan prasad, pragati verma received: 03 oct. 2020; accepted: 22 dec. 2020; published: 05 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the use of computed tomography (ct) for estimation of split renal function (srf) has been reported previously. however, most of these studies have small samples, and many do not account for the renal attenuation at ct. objective: the aim of this study was to compare multidetector computed tomography (mdct) volumetry-attenuation-based srf with that obtained via tc99m-diethylenetriaminepentaacetic acid (dtpa) renal scintigraphy in voluntary renal donors. methods: between january 2017 and january 2020, 526 voluntary renal donors were enrolled prospectively. all donors underwent contrast ct and dtpa scan before surgery. the semiautomatic region of interest (roi) tool was applied slice by slice on axial ct images acquired in the arterial phase. the renal contour was drawn semiautomatically with mouse clicks around the renal parenchyma, and the renal volume was ascertained. using renal volume and attenuation, srf was determined and compared with results obtained at dtpa imaging. results: the mean age was 44.91 ± 10.97 years (mean ± s.d.). there was no significant difference in srf based on dtpa and mdct volumetry for the left kidney (49.18% ± 3.40% vs. 49.15% ± 3.38%, p = 0.540) and for the right kidney (50.82% ± 3.40% vs. 50.86% ± 3.39%, p = 0.358). a very good correlation was observed between the two methods for the left kidney (r = 0.953, p = 0.000) and the right kidney (r = 0.955, p = 0.000). on simple linear regression analysis, 90.8% of dtpa srf values for the left kidney and 91.3% of dtpa srf values for the right kidney could be predicted correctly using the corresponding mdct srf values. conclusion: mdct volumetry-attenuation-derived estimation of srf for living renal donors could be an alternative to renal scintigraphy-based srf estimation. keywords: nuclear renography; split renal function; computed tomography; volumetry; attenuation. introduction the incidence of end-stage renal disease is increasing steadily, resulting in an escalated number of renal transplantations worldwide in recent years.1 live renal donors are the most common source of renal allografts even now, and they typically undergo extensive preoperative evaluation to gain information about their renal vascular anatomy, as well as function. renal scintigraphy is typically used for assessment of split renal function (srf), and contrast-enhanced computed tomography (ct) is used for vasculature and anatomical details. however, renal scintigraphy is not absolutely error free, and the results differ with changes in distance of the kidney from the gamma camera (such as in obese patients).2 furthermore, there exists considerable interobserver and intraobserver variability in nuclear scintigraphy reports, which can be estimated up to 8%.3 the renal excretion of iodinated contrast materials used for contrast-enhanced ct occurs in a manner similar to the reference for estimation of glomerular filtration rate (gfr) – inulin; calculation of clearance of such contrast provides an accurate measurement of the gfr. a comparison of contrast accumulation and/or excretion by the kidneys can thus accurately provide the srf of individual kidneys. the concept of ct-based estimation of srf evolved more than two decades ago when dawson and peter based their proposition on the plasma clearance of contrast according to the rutland-patlak plot.4 recent studies in living kidney donors (lkd) have shown that srf can be evaluated preoperatively by ct-based analysis of the kidney volume.5,6 in these studies, srf was calculated by ct and compared with the technetium-99m – diethylenetriaminepentaacetic acid (dtpa)-srf. multidetector computed tomography (mdct) accurately determines the relative contribution of each kidney to overall kidney function, which is of critical importance in the preoperative evaluation of a lkd. if a disparity in kidney function exists, the donor should be left with the better functioning kidney to optimise donor safety.7 several authors have reported the use of ct for estimation of srf, using different principles and algorithms; however, most of them are unpopular owing to complicated protocols, inaccurate attenuation correction or multiple assumptions and interpolations. the aim of this study was to compare ct volumetry-attenuation based srf with that obtained at tc99m-dtpa renal scintigraphy using a simplified standardised protocol. methodology this study was a hospital-based analytical study conducted at a tertiary care hospital in northern india from 01 january 2017 to 31 january 2020. all prospective renal donors who were able to follow breathing and scanning instructions were included in the study. computed tomography volumetry was performed using post-processing software. additionally, each donor underwent a technetium-99m dtpa renal scan before surgery. considering a 5% margin of error and a confidence interval of 98%, for a modest 40% acceptance rate (considering the standard discard rate of > 50% for expanded donor criteria),8 the estimated sample size was 522. computed tomography imaging was acquired with a 64-channel multidetector scanner (brilliance, philips medical system, eindhoven, the netherlands) at our institution. the study was performed using a split bolus of contrast for combined arterial and nephrographic phase imaging followed by ct urography. each donor was required to drink 1000 ml of plain water, 45 min prior to the examination. unenhanced ct acquisition was extended from above the kidney to the pubic symphysis with breath-hold in inspiration. the enhanced ct acquisition included the area from above the diaphragm to below the pubic symphysis with breath-hold in inspiration. about 40 ml of non-ionic contrast medium (visipaque, ge healthcare, 320 mg/ml) was administered intravenously using an automatic injector (stellant-medrad version 102.osh) at a rate of 2 ml/s through an 18 g canula placed in the antecubital fossa. after a 25 s delay, another 60 ml of contrast medium was injected at a rate of 4 ml/s, followed by 30 ml of normal saline at 3.5 ml/s. the region of interest (roi) was kept outside the body to avoid misinterpretation of the roi with high-density structures (vertebrae) adjacent to aorta because of patient movements; the monitoring scan started 5 s after the second phase of contrast injection. subsequently, image acquisition was commenced manually, when high-density contrast was seen in the abdominal aorta at the level of diaphragm. after 7 min – 10 min, another acquisition was performed for the excretory phase extending from above the kidney to the pubic symphysis with breath-hold in inspiration. radiation dose was recorded for each patient. in order to further reduce the radiation dose, tube current was reduced from 250 mas to 150 mas, and slice thickness was kept at 3.0 mm on unenhanced and excretory phase acquisitions without affecting the image quality. slice thickness was 0.9 mm on the combined arterial-venous phase. the acquisition times for the unenhanced phase, combined arterial-venous phase and the excretory phase were 5 s – 7 s, 6 s – 8 s and 5 s – 7 s, respectively. split renal function the semiautomatic roi tool was applied slice by slice in the axial plane on arterial phase images. the renal contour was drawn semiautomatically with mouse clicks around the renal parenchyma (figure 1a–d), and the software estimated the renal volume (figure 1e–f). the collecting system, fat in the renal sinus and renal space occupying lesions of fluid density (cysts) were excluded by pre-set software thresholds. pelvicalyceal and perirenal fat, cysts and hydronephrotic pelvicalyceal fluid were excluded by applying a lower window limit of 40 hu. any calculi and opacified intrarenal collecting systems were excluded by applying an upper window limit of 350 hu. the pre-set soft-tissue window (window width, 350 hu; window level, 40 hu) could be changed at will. finally, the software calculated the renal volume (v) for each kidney separately. figure 1: the process of measuring kidney volume. the semiautomatic region of interest tool was applied slice by slice on axial arterial phase images (a) and (b), as well as on coronal arterial phase images (c) and (d). the semiautomated software estimated the kidney volume (e) and (f). the mean attenuation of the kidney was recorded on the unenhanced images and subtracted from the mean attenuation taken at the same level on combined arterial and nephrographic phase images to attain the enhancing attenuation of the kidney (a). the total attenuation value contributed by the contrast medium in each kidney was calculated and assumed to be proportional to that kidney’s relative function. right kidney srf was then calculated as the product of volume and attenuation for the right kidney divided by the sum of the product of volume and attenuation for both kidneys. srfr = (rv × ra)/ (rv × ra) + (lv × la).9 similarly, srfl was also calculated. estimaton of split renal function by renal scintigraphy for differential renal function, an angiographic perfusion study was performed using 1 mci of tc99m – dtpa. after ensuring adequate hydration and voiding before the commencement of the study, the donors were placed in a supine position, and the scintillation camera detector was positioned so that the bifurcation of the aorta, iliac arteries, urinary bladder and kidneys appeared in the camera field. three-second sequential exposures were obtained, whilst activity was clearly localised in the arterial system and kidney. this was followed by a 40-s static image to evaluate renal size and shape. subsequently, activity was quantified over the individual kidneys and bladder using either the split crystal or the roi mode. the static dtpa scintigrams were used to compare the size and shape of the kidney between studies, as well as to assess the tissue to background ratio, which decreased with the deterioration of renal function.10 the rois plotted around each kidney were used to generate renograms after subtracting the area-normalised background rois. the uptake part of the renogram was used to calculate the srf. statistical analysis normality of continuous variables was assessed, and variables were normally distributed when the standard normal variate (z) value of the skewness was ±3.29. continuous variables were presented as mean ± standard deviation (s.d.), median (inter-quartile range) and range (minimum-maximum), whilst categorical variables were presented as frequency (percentage). the paired sample t-test was used to test the change in the mean score between paired observations (pre-post). for comparison of the means between two unpaired groups, the independent sample t-test was used, whilst to compare the means for more than two groups, the one-way analysis of variance (anova) test was used, followed by multiple comparisons using the bonferroni method. in order to compare the proportions between the groups, the chi-square test was used, and to assess the linear relationship between two continuous variables, the pearson correlation coefficient was used. similarly, to predict one continuous variable from another continuous variable, simple (univariate) linear regression analysis was utilised. a scatter diagram was used to test the linear relationship between the two continuous variables and the bland altman plot to test the linear relationship between one variable (dtpa) and the difference between two variables (dtpa – mdct). a p-value < 0.05 was considered as statistically significant. the statistical package for social sciences, version 23 (spss-23, ibm, chicago, usa) was used for data analysis. ethical consideration the study was approved by the institutional ethics committee of sanjay gandhi post graduate institute of medical sciences (iec code: 2017-94-md-exp), and the procedures followed were in accordance with the helsinki declaration of 1975, as revised in 2000.11 after obtaining proper informed consent, multiphasic ct was performed in each case. results during the study period, 550 kidney donors were enrolled. of these donors, 24 were excluded from the study as they were unable to adequately hold their breath during the ct scanning, leading to motion artefacts. the mean age of the remaining 526 donors was 44.91 ± 10.97 years (mean ± s.d.) and the age range was 18–76 years. the majority of the participating donors were women (n = 429, 81.6%). renal volume measurements using mdct the mean volumes of the left and right kidneys were 112.65 cc ± 16.08 cc and 114.74 cc ± 16.14 cc, respectively. there was a significantly higher volume in men when compared with women for the left and right kidneys (table 1). the mean volumes of the left and right kidneys were also assessed per age group of the kidney donors. there was a linear trend (negative correlation) in the volume and age, indicating a decrease in volume with increasing age for the left kidney (r = −0.219, p = 0.000) and for the right kidney (r = −0.178, p = 0.000). table 1: kidney volume and gender. split renal function measurement using computed tomography volumetry and dtpa the mean (± s.d.) ct-derived srf for left renal donors was 49.15% ± 3.38% (range: 35.8% – 58%), whilst that for right renal donors was 50.86% ± 3.39% (range: 41.2% – 64.2%). the mean (±s.d.) dtpa-derived srf for left renal donors was 49.18% ± 3.40% (range: 37% – 60%), whilst that for right renal donors was 50.82% ± 3.40% (range: 40% – 63%). when we analysed the measurements between the two methods, there was no significant difference in srf based on dtpa and mdct volumetry for the left kidney (49.18% ± 3.40% vs. 49.15% ± 3.38%, p = 0.540) nor for the right kidney (50.82% ± 3.40% vs. 50.86% ± 3.39%, p = 0.358; table 2). table 2: split renal function (%) measurements with multidetector computed tomography and diethylenetriaminepentaacetic acid. the pearson correlation coefficient was calculated for the srf measurements between the two methods. the results revealed that there was a very good correlation between the two methods for the left kidney (r = 0.953, p = 0.000) and the right kidney (r = 0.955, p = 0.000; table 2, figure 2). the mean difference and 95% confidence intervals (cis) were calculated using the paired sample t-test (table 2); 95% ci of the absolute limits of agreement between dtpa and difference between the two methods (dtpa and mdct) was calculated using the bland altman plot for left kidney (figure 3a) and right kidney (figure 3b) individually. figure 3 shows that most of the values of dtpa and mdct differences were within ± 1.96 s.d. and only a few values of differences were outside or above ± 1.96 s.d. no significant differences were observed between men and women in dtpa-derived srf and mdct-derived srf for the left and right kidneys individually (table 3, figure 4). figure 2: scatter diagram showing a strong linear relationship between diethylenetriaminepentaacetic acid and multidetector computed tomography measurements: (a) left kidney and (b) right kidney. figure 3: the bland altman plot showing a strong linear relationship between diethylenetriaminepentaacetic acid and multidetector computed tomography measurements for (a) the left kidney and (b) the right kidney. figure 4: an error bar graph depicting the comparison of split renal function between diethylenetriaminepentaacetic acid and multidetector computed tomography for male and female in (a) the left kidney and (b) the right kidney. table 3: comparison of split renal function between diethylenetriaminepentaacetic acid and multidetector computed tomography. prediction of dtpa derived split renal function value using mdct volumetry-based split renal function in order to predict the dtpa srf using mdct srf, simple linear regression analysis was used. for the left kidney, 90.8% (table 4, figure 5a) and for the right kidney, 91.3% (table 4, figure 5b) of the dtpa srf could be predicted correctly using the corresponding mdct srf values. figure 5: scatter diagram showing multidetector computed tomography prediction of the diethylenetriaminepentaacetic acid split renal function (outcome) by linear regression analysis for (a) the left kidney and (b) the right kidney. table 4: projection of nuclear renography (dtpa) split renal function (srf) using radiological split renal function (mdct). discussion in this study, most of the donors belonged to the 40–49 year age group (n = 172, 32.7%), and the majority of them included women (n = 429, 81.6%). in the study by deiz et al.12, the mean age was 39.5 ± 11.0 years and over half of the donors in their group were women. in a similar study by barbas et al.,7 the average age was 49.8 years, and 64.8% of patients were women. the left kidney was donated in 78.4% of cases. the mean volumes of the left and right kidneys were 112.65 ± 16.08 and 114.74 ± 16.14, respectively. a significantly higher renal volume was observed in the men compared with women for the left kidney (126.03 ± 13.99 vs. 109.63 ± 14.96, p = 0.000) as well as the right kidney (127.03 ± 15.46 vs. 111.97 ± 14.96, p = 0.000). similar differences in kidney volume amongst men and women were found in the study by poggio et al.13 who also reported similar age-related changes in renal volumes. this study attempted to present a method for ct-based estimation of srf in renal donors using a method that is easy to reproduce and accurate for its intended purpose. a closer look at the different measurement methods used in previous studies formed the basis of the current methodology used. these can be broadly categorised into simple volumetry-based and volumetry-attenuation-based methods. simple volumetry-based methods one of the simplest methods used to calculate renal volume is the ellipsoid method. however, the limitations of such a simplified approach to renal volumetry were highlighted by breau et al.14 who compared the ellipsoid method with specialised volumetric software. in their study, just over half of the volumes estimated with the ellipsoid formula were within 10% of the 3d software measured volume. in a later study, zakhari et al.15 proposed that the usual correction factor underestimated the renal volume. most authors, subsequently, shifted to other techniques for estimation of renal volume. diez et al.12 carried out a retrospective review of renal donors to assess the utility of ct for determining the srf. amongst the 65 donors who underwent both ct and nuclear renography, the mean difference between ct and nuclear scan srf was 0.65 ± 3.46. they reported a significant correlation between the two modalities (r = 0.59; p = 0.000). yanishi et al.16 also estimated ct-based srf by calculating split renal volume without considering renal attenuation before and after contrast administration in 35 live renal donors. compared with mercaptoacetyltriglycine (mag3)-based srf, ct renal volume-based srf was found to correlate strongly (r = 0.714). mitsui et al.5 in a later study found a strong correlation between both types of volumes and mag3-measured srf (r = 0.921 for renal cortical volume; r = 0.942 for renal parenchymal volume) using an automated volume analyser software for ct renal volumetry (synapse vincent version 4, fujifilm, tokyo, japan). despite the strong correlation demonstrated in the studies mentioned earlier, there remains a lack of consensus on the ideal volumetry method. to answer this problem, wahba et al.6 compared three ct volumetry techniques (modified ellipsoid volume [melv], smart roi volume and renal cortex volume [rcv]) in 101 lkd for calculating the srf. after comparing the results with mag3 scans, they concluded that although the highest level of agreement in the study was for roi, the rcv had a low deviation and was adjudged the most accurate technique for pre-donation srf. modified ellipsoid volume was also shown to have a high level of agreement with mag3 by soga et al.17 similarly, gardan et al.18 reported that whilst total kidney volume correlates well with pre-donation global gfr and post-donation gfr (p = 0.000), renal cortical volume has a stronger correlation for estimating pre-donation srf and post-donation renal outcome at 1 year. recently, siedek et al.19 compared ctand mri-based srf using rcv and melv and found that rcv is more accurate and reliable than melv for ct as well as mri-based srf. similarly, nakamura et al.20 reported equivalence of ct volumetry to dtpa for preoperative srf in 34 renal donors. in this study, using the semiautomatic roi tool for determination of the renal volume helped us to decrease the time required for completing the volumetry for both kidneys. however, volumetry was only one part of srf estimation, the other being measurement of attenuation. from the study by yanishi et al.16, the mean (±s.d.) volumes of the right and left kidneys were found to be 138.8 ml ± 29.4 ml and 136.1 ml ± 29.2 ml, respectively. wahba et al.6 had reported in their study the mean (±s.d.) volume of the preserved kidney as 148.0 cm3 ± 29.1 cm3 (roi) and the donated kidney as 149.5 cm3 ± 30.8 cm3 (roi), respectively. mitsui et al.5 used the total renal parenchymal volume and preserved parenchymal volume in place of separate left and right kidney volumes. the median total parenchymal volume was 278.4 ml, and the preserved parenchymal volume was 131.8 ml. this study is comparable with previous studies with regards to ct volumetry parameters. volumetry-attenuation-based methods volumetry-based srf estimation considers only the anatomical appearance of the kidneys without any functional implications. in patients with renal parenchymal disease, the change in volume occurs later in the disease and functional deterioration occurs earlier. contrast uptake by the kidney is a measure of its function, and consequently, attenuation on ct after administration of contrast may be a better indicator of renal function. the use of attenuation along with renal volume stems from the modification of the initial description by frennby et al.21 el-diasty et al.22 compared the gfr calculated from the ct scan with that from the mag3 scan of 80 renal donors and proved that the two correlated (r = 0.54, p < 0.001), and that selective gfr calculation of each kidney was possible with ct alone. their calculation of ct gfr took into account the mean attenuation value (mav) of each kidney as well. around the same period, nilsson et al.2 retrospectively reviewed 27 renal donors, calculated the renal volume as well as the mav using the slice summation method, and compared ct and mag3 based on srf. in their study, the total function of the kidney correlated very well with the volume (r = 0.90) and the srf calculated from ct scan, using the difference in attenuation between excretory phase and pre-contrast scans, correlated closely with the srf from the mag3 scans. knox et al.9 compared mdct-derived srf with dimercapto succinic acid (dmsa)-derived srf in 27 donors who underwent nephrectomy. renal volume was calculated using voxar 3d imaging software (version 6.3, toshiba medical visualization systems, uk), and srf was estimated in a manner similar to that used in this study. the mean difference between mdct-derived drf and dmsa was 0.8% (95% ci 0.1–1.6) as reported by them. summerlin et al.3 compared ct-based srf and radionuclide-based srf in 152 renal donors. computed tomography-based srf was calculated using four methods: arterial phase contrast accumulation, excretory phase contrast accumulation, simple volumetry and the patlak method. amongst these, it was found that excretory phase and renal volume-based srf were most accurate and correlated well with radionuclide renography (r = 0.58 and 0.63, respectively). patankar et al.23 used the same calculations as summerlin et al.3 used for the arterial phase and excretory phase for estimation of srf. the mean srf of the right kidney was 50.2 ± 3.3 (range, 44.1% – 54.0%) based on the nuclear scan and was 49.0 ± 2.9 (range, 46.4% – 52.3%) based on ct with a moderate correlation between the two (r = 0.46). the accuracy of volume-attenuation-based srf on ct is high, and this allows for reduction of the radiation exposure that is otherwise associated with the ct protocol for the patlak method.24 in this study, there was no significant difference in srf between tc99m dtpa and the mdct method for the left kidney (mean ± s.d.: 49.18 ± 3.40 vs. 49.15 ± 3.38, p = 0.540) as well as for the right kidney (50.82 ± 3.40 vs. 50.86 ± 3.39, p = 0.358). we preferred to use volumetry-attenuation-based srf on ct rather than volumetry alone based on the premise mentioned earlier. pearson’s correlation coefficient was also calculated for srf measurements between the two methods. the results revealed that there was a very good correlation between the two methods for the left kidney (r = 0.953, p = 0.000) as well as for the right kidney (r = 0.955, p = 0.000), which were also statistically significant. for the left kidney, most of the values of dtpa and mdct differences were between ± 1.96 s.d. and only few values of these differences were outside ± 1.96 s.d. a similar result was also observed in the right kidney, which is consistent with other previous studies.3,5,6,9,16 summerlin et al.3 had reported in their study the mean (±s.d.) renography determined right split function in a sample of 152 was 49.2% ± 4.3% and ranged from 29% to 63%. comparable to our study, they observed a strong correlation between the mdct-derived srf and renal scintigraphy srf. habbous et al.25 performed a systemic review and meta-analysis to answer whether ct srf can replace nuclear srf in lkd. they reviewed 19 studies and obtained a pooled correlation of r = 0.74. importantly, they found that for every 1% increase in the split renal volume, the srf increased by 0.76%. a marked difference was noted, however, in the practice of obtaining a diuretic renogram before renal donation, with some centres performing a renogram for all patients, whilst others performing it only when the gfr is below the donation threshold. as a result, they reported a false negative rate of 14% for predicting srf for renal donation. however, this is because of the selective use of diuretic renogram when the discrepancy is > 1 cm in renal size or > 10% in srf. if all the candidates were tested, this rate would be much less. limitations this study has a large sample size unlike most earlier studies and is adequately powered. being a prospective study from a single institute, the selection criteria and follow-up protocols are well defined, and there is no attrition. the main limitation of this study is that post-nephrectomy outcomes of all donors were not compared with preoperative ct srf/ gfr, which could have yielded more insights into the role of ct in the prediction of residual renal function after donor nephrectomy. conclusion multidetector computed tomography volumetry-attenuation derived estimation of srf for living renal donors could be an alternative to renal scintigraphy-based srf estimation. in addition, it makes the evaluation faster, more cost effective with reduced utilisation of imaging resources, and avoids additional radiation and nuclear pharmaceutical hazards. = acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.l. and r.p. designed the model and the computational framework and analysed the data. j.a., p.v., n.p., d.b. and a.k. carried out the implementation. p.m. performed the calculations. p.y. and a.s. wrote the manuscript with input from all authors. h.l. and s.b. conceived the study and were in charge of overall direction and planning. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data are available from the corresponding author, h.l., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references jha v. esrd burden in south asia: the challenges we are facing. clin nephrol. 2015;83(7 suppl 1):7–10. https://doi.org/10.5414/cnp83s007 nilsson h, wadström j, andersson lg, raland h, magnusson a. measuring split renal function in renal donors: can computed tomography replace renography? acta radiol. 2004;45(4):474–480. https://doi.org/10.1080/02841850410005282 summerlin al, lockhart me, strang am, kolettis pn, fineberg ns, smith jk. determination of split renal function by 3d reconstruction of ct angiograms: a comparison with gamma camera renography. ajr am j roentgenol. 2008;191(5):1552–1558. https://doi.org/10.2214/ajr.07.4023 dawson p, peters am. functional imaging in computed tomography. the use of contrast-enhanced computed tomography for the study of renal function and physiology. invest radiol. 1993;28(suppl 5):s79–s84. https://doi.org/10.1097/00004424-199311001-00025 mitsui y, sadahira t, araki m, et al. the assessment of renal cortex and parenchymal volume using automated ct volumetry for predicting renal function after donor nephrectomy. clin exp nephrol. 2018;22(2):453–458. https://doi.org/10.1007/s10157-017-1454-1 wahba r, franke m, hellmich m, et al. computed tomography volumetry in preoperative living kidney donor assessment for prediction of split renal function. transplant. 2016;100(6):1270–1277. https://doi.org/10.1097/tp.0000000000000889 barbas as, li y, zair m, et al. ct volumetry is superior to nuclear renography for prediction of residual kidney function in living donors. clin transplant. 2016;30(9):1028–1035. https://doi.org/10.1111/ctr.12784 singh sk, kim sj. epidemiology of kidney discard from expanded criteria donors undergoing donation after circulatory death. clin j am soc nephrol. 2016;11(2):317–323. https://doi.org/10.2215/cjn.07190715 knox mk, rivers-bowerman md, bardgett hp, cowan nc. multidetector computed tomography with triple-bolus contrast medium administration protocol for preoperative anatomical and functional assessment of potential living renal donors. eur radiol. 2010;20(11):2590–2599. https://doi.org/10.1007/s00330-010-1855-y taylor at. radionuclides in nephrourology, part 1: radiopharmaceuticals, quality control, and quantitative indices. j nucl med. 2014;55(4):608–615. https://doi.org/10.2967/jnumed.113.133447 world medical association. world medical association declaration of helsinki: ethical principles for medical research involving human subjects. jama. 2013;310(20):2191–2194. https://doi.org/10.1001/jama.2013.281053 diez a, powelson j, sundaram cp, et al. correlation between ct-based measured renal volumes and nuclear-renography-based split renal function in living kidney donors. clinical diagnostic utility and practice patterns. clin transplant. 2014;28(6):675–682. https://doi.org/10.1111/ctr.12365 poggio ed, hila s, stephany b, et al. donor kidney volume and outcomes following live donor kidney transplantation. am j transplant. 2006;6(3):616–624. https://doi.org/10.1111/j.1600-6143.2005.01225.x breau rh, clark e, bruner b, et al. a simple method to estimate renal volume from computed tomography. can urol assoc j. 2013;7(5–6):189–192. https://doi.org/10.5489/cuaj.1338 zakhari n, blew b, shabana w. simplified method to measure renal volume: the best correction factor for the ellipsoid formula volume calculation in pretransplant computed tomographic live donor. urol. 2014;83(6):1444.e15–1444.e19. https://doi.org/10.1016/j.urology.2014.03.005 yanishi m, kinoshita h, yoshida t, et al. comparison of renal scintigraphy and computed tomographic renal volumetry for determining split renal function and estimating post-transplant renal function. transplant proc. 2015;47(9):2700–2702. https://doi.org/10.1016/j.transproceed.2015.07.037 soga s, britz-cunningham s, kumamaru kk, malek sk, tullius sg, rybicki fj. comprehensive comparative study of computed tomography-based estimates of split renal function for potential renal donors: modified ellipsoid method and other ct-based methods. j comput assist tomogr. 2012;36(3):323–329. https://doi.org/10.1097/rct.0b013e318251db15 gardan e, jacquemont l, perret c, et al. renal cortical volume: high correlation with pre – and post-operative renal function in living kidney donors. eur j radiol. 2018;99:118–123. https://doi.org/10.1016/j.ejrad.2017.12.013 siedek f, haneder s, dörner j, et al. estimation of split renal function using different volumetric methods: interand intraindividual comparison between mri and ct. abdom radiol (ny). 2019;44(4):1481–1492. https://doi.org/10.1007/s00261-018-1857-9 nakamura n, aoyagi c, matsuzaki h, et al. role of computed tomography volumetry in preoperative donor renal function evaluation of living related kidney transplantation. transplant proc. 2019;51(5):1314–1316. https://doi.org/10.1016/j.transproceed.2019.01.130 frennby b, almén t, lilja b, et al. determination of the relative glomerular filtration rate of each kidney in man. comparison between iohexol ct and 99mtc-dtpa scintigraphy. acta radiol. 1995;36(4):410–417. https://doi.org/10.1080/02841859509173399 el-diasty ta, shokeir aa, el-ghar me, gad hm, refaie af, el-din ab. contrast enhanced spiral computerized tomography in live kidney donors: a single session for anatomical and functional assessment. j urol. 2004;171(1):31–34. https://doi.org/10.1097/01.ju.0000099784.52825.8e patankar k, low rs, blakeway d, ferrari p. comparison of computer tomographic volumetry versus nuclear split renal function to determine residual renal function after living kidney donation. acta radiol. 2014;55(6):753–760. https://doi.org/10.1177/0284185113504195 hackstein n, wiegand c, rau ws, langheinrich ac. glomerular filtration rate measured by using triphasic helical ct with a two-point patlak plot technique. radiology. 2004;230(1):221–226. https://doi.org/10.1148/radiol.2301021266 habbous s, garcia-ochoa c, brahm g, nguan c, garg ax. can split renal volume assessment by computed tomography replace nuclear split renal function in living kidney donor evaluations? a systematic review and meta-analysis. can j kidney health dis. 2019;6:2054358119875459. https://doi.org/10.1177/2054358119875459 original article technical success rate of uterine artery embolisation for treatment of uterine leiomyomas at the university of the free state h f potgieter mbchb c s de vries mmedrad(d) e loggenberg mmedrad(d) department of diagnostic radiology university of the free state bloemfontein abstract the technical success rate of uterine artery embolisations at the department of diagnostic radiology, university of the free state (ufs) is reported. from november 1998 to july 2001, 67 women, aged 35 75 years, received uterine artery embolisation. the procedure was usually performed through a single 4-french sheath set which was introduced into the right femoral artery using a 4french catheter and injecting pvc particles (150 550 micron). embolisation was performed successfully in 85.5% of the women. the mean total fluoroscopy time was 16.8 minutes, ranging from 4.8 minutes to 47.3 minutes. introduction uterine leiomyomas occur in 20 50% of women above the age of 40 years making it the most frequent tumour of the female genital tract." metromenorrhagia, acute bleeding, pelvic pain, heaviness and discomfort are amongst the symptoms caused by uterine leiomyomas. uterine artery embolisation has been reported to be a minimally invasive, safe and effective alternative to traditional uterine leiomyoma treatment. traditional treatments include the less invasive medical hormonal therapy and the more invasive surgical options such as myomectomy and hysterectomy. uterine artery embolisation improved the clinical symptoms ofleiomyomas, reduced tumour and uterine size, and caused few complications in the follow-up period.':" uterine artery embolisation was first used in the 1970s to treat post26 sa journal of radiology • june 2002 partum haemorrhage." in a benchmark study done in 1995, ravina et al.ilproposed uterine artery embolisa tion as an alternative to surgery for treating uterine leiomyomas. results published in 1999 were very promising. a 30 60% reduction in uterine size, and patient satisfaction rates ranging from 80% to 90% regarding reduction in uterine bulk symptoms and menorrhagia were reported. an estimated 6 000 procedures were performed with minimal serious infective morbidity and only two reported deaths.":" patients and methods from november 1998 to july 2001 (33 months), 67 uterine artery embolisations were performed at the department of diagnostic radiology (ufs) by two invasive radiologists (dr e loggenberg and dr c s de vries). women diagnosed with leiomyomas and referred for uterine artery embolisation by gynaecologists from the department of obstetrics and gynaecology (ups) were included in the treatment. magnetic resonance imaging (mrl) was done before the angiography and at 3 and 6 months after the procedure. the procedures were done on a siemens multistar angiography unit (siemens, erlangen). all patients underwent angiographies under local anaesthesia. routinely, puncture of the right femoral artery with introduction of a 4-french sheath was used. a 4-french renal double curve catheter with a 0.35 terurno guidewire was used to select the left uterine artery, which was then embolised with pva-particles (150 550 micron). the catheter was then removed, flushed original article and the right uterine artery selected with repetition of the embolisation. embolisation was done until complete cessation of blood flow in the leiomyoma was achieved (figs 1 4). the patients then went back to the ward for overnight observation and were discharged the next day. results procedure a total of 67 patients received uterine artery embolisation over the 33month period and 5 patients were lost to follow-up. in 55 patients only a right femoral artery puncture was needed. in 4 patients bilateral femoral artery punctures were needed as it was difficult to select the right uterine artery from the ipsilateral side. the left femoral artery approach alone was used in 2 patients as 1patient had enlarged lymph nodes on the right and there was difficulty in palpating the right femoral pulse of the other. the transbrachial approach was used in 1 patient because of the acute angle of the internal iliac artery, the uterine arteries could not be selected. the radiologist (dr e loggenberg) performing the procedure found the transbrachial approach to be surprisingly easy. fluoroscopy time ranged from 4.8 to 47.3 minutes, with a mean of 16.8 minutes. pulse fluoroscopy (15 pulses per second) was used to minimise radiation. in all 67 patients the procedure was performed with a 4-french catheter and 0.35 terumo guidewire. only 8 patients required an additional 4-french catheter and in 4 patients .an additional guidewire was used. fig. 1. selection of left uterine artery showing the blush of the fibroid and uterus. fig. 2. arteriogram after embolisatlon. r fig. 3. selection of right uterine artery showing the blush of the fibroid and uterus. analysis of outcome in 2 patients it was impossible to select either the right or the left uter27 sa journal of radiology • june 2002 fig. 4. arteriogram after embolisation. ine artery. one patient had unusually small uterine arteries and a microcatheter would have been helpful. the other patient was a 75-year-old woman with congestive heart failure, type 2 diabetes mellitus, hypertension, on warfarin therapy with dysfunctional uterine bleeding. both her iliac arteries were very tortuous, she had a tight stenosis of the left internal iliac artery and plaques in the left uterine artery. when the right internal iliac artery was selected no right uterine artery could be demonstrated. the left uterine artery of 1 patient could not be demonstrated by angiography and therefore the radiologist was unable to select it. inability to select the right uterine artery occurred in 6 patients. in a 47year-old patient, the right internal iliac artery was tortuous; however, the case was completed successfully 2 days later via the transbrachial approach. severe vasospasm occurred in 1 patient, and in another selection of the uterine artery was successfully done but no vessels supplying the leiomyoma could be identified. in 1 patient, the procedure failed because of the anatomical variation of where the superficial femoral artery originated from the right internal iliac artery, making the risk for embolisation to ..__...... (_g>v0) . fcorlnthhealthcareworldly wisea member of the corinth group it pays to talk to the healthcare specia lists call corinth, your fast track to the uk 0800 20 11 20 e-mail corinth@icon.co.za or corinthdrs@icon.co.za radiographers a dlolog'st biomedical sctenttsts cardlogr pher cso/cardi c te hn ei n dental nurse dieticians. doctors/special! ts m dl al admm and clerical medical laboratory t chmc n med cal secreterte occupation i therapist phlebotomists phy other pists radiographers social workers spe c.hand nqu ge therapi ts the tr m&d 7564 a member of the recruitment and employment confederation ~!!d[",,10'111'101.........28 sa journal of radiology • june 2002 original article the foot substantial. in the last 2 patients it was impossible to select the right internal iliac artery because of anatomical difficulties. conclusion successful embolisation of the uterine arteries was performed in 85.5% of the patients. in 86.6% of the patients only a single 4-french catheter was used and in only 2 patients, a micro-catheter could have altered the outcome. the mean fluoroscopy time was 16.8 minutes. an ordinary diagnostic 4-french catheter is sufficient for uterine artery embolisation in the majority of cases. use of expensive micro-catheters, guidewires or glide-catheters should not routinely be neccessary. references 1. buttram yc, reiter re. uterine leiomyomata: etiology, symptomatology, and management. fertil steri11981; 36: 433-445. 2. verkauf bs. myomectomy for infertility enhancement and preservation. fertil steri11992; 58 (1): 1-15. 3. ravina jh, bouret jm, ciraru-vigneron n, et al. recourse to particular arterial embolization in the treatment of some uterine leimyoma. bull acad natl med 1997; 181: 233·243. 4. worthington-kirsch rl, popky gl, hutchins fl jr. uterine arterial embolization for the management of leiomyomas: quality-oflife assessment and clinical response. radiology 1998; 208: 625-629. 5. bradley ea, reidy jf, forman rg, jarosz j, braude pr. transcatheter uterine artery embolisation to treat large utrerine fibroids. br l obste: gynaecol1998; 105: 235-240. 6. goodwin sc, mc lucas b, lee m, et al. uteri.ne artery embolization for the treatment of uterine leiomyomata midterm results. i vasc interv radial 1999; 10: 1159-1165. 7. spies jb, sciali ar, iha rc, et al. initial results from uterine fibroid embolization for symptomatic leiomyomata. i vasc interv radio11999; 10: 1149-1157. 8. hutchins fl jr, worthington-kirsch rl, berkowitz rp. selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. i am assoe gynecol laparose 1999; 6: 279-284. 9. pelage jp, le dref 0, soyer p, et al. fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. radiology2000; 215: 428-431. 10. brunereau l, herbreteau d, gallas s, et al. uterine artery embolization in the primary treatment of uterine leiomyomas: technical features and prospective follow-up with clinical and sonographic examinations in 58 patients. air 2000; 175: 1267·1272. il. sisken gp, stainken bf, dowling k, meo p, alm j. outpatient uterine artery embolization for symptomatic fibroids: experience in 49 patients. i vase interv radio12000; 11: 305·311. 12. heaston dk. mineau de, brown bj,miller fj jr. transcatheter arterial ernbolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation. air 1979; 133: 152-154. 13. ravina jh, herbreteau 0, cicaru-yigneron n. arterial embolization to treat uterine myomata. lancet 1995; 346: 671-672. 14. vashist a, studd j, carey a, burn p. fatal septicaemia after fibroid embolization. lancet 1999; 354: 307-308. 15. lanocita r, frigerio lf,patelli g, et al. a fatal complication of percutaneous transcatheter embolization for the treatment fibroids. in: proceedings of the second international symposium on embolization of uterine myomata/society for minimally invasive therapy eleventh international conference; 16· 18 september 1999, boston, usa. 16. walker w, worthington-kirsch rl. fatal septicaemia after fibroid embolization. lancet 1999; 354: 1730. mailto:corinth@icon.co.za mailto:corinthdrs@icon.co.za case report osteochondritis dissecans in adolescence r de villiers mbchb (ste/l), mmed (raddiag) (ste/l) radl%gy practice: van wageningen and partners med/-c/inic verge/egen main road, somerset west, 7130 tel: (021) 851-5595. fax (021) 852-2697 abstract osteochondritis dissecans (00) involves the adolescent radio-capitellar joint and is due to chronic, compressive forces on the capitellum, ultimately causing injuries ranging from an articular cartilage injury to an osteochondral avulsion fracture. plain fi ims are often negative, while ct, mri and mr arthrography are the examinations of choice. 00 should not be confused with a pseudodefect of the capitellum or panner's disease. staging of the lesion is important for its management, which is conservative for stages 1 and 2, while surgery is indicated for stages 3 and 4. osteoarthritis is a late complication in 500/0 of patients with advanced disease. 36 sa journal of radiologyfebruary 2001 case report a ls-year-old elite downhill mountain-biker presented with a painful elbow after falling off his bike on a descent. on clinical examination he had a suspected fracture of the capitellum with associated soft tissue swelling. there was also limited range of movement, but no crepitus was present. on further questioning, there was a history of a few minor falls and intermittent pain. plain films show defect of the lateral aspect of the capitellum (figure 1). figure 1: ap plain radiograph of the left elbow showing 8 defect in the capitellum (arrowheads) axial ct showed a deep defect of the capitellum and loose bodies in the coronoid and olecranon fossae (figure 2). mri t2 fat saturation (figure 3a) and tl coronal images (figure 3b) showed the capitellar defect with fluid partially surrounding the fragment, as well as associated rnicrotrabecular bone marrow oedema. the clinician decided to treat the patient conservatively, as it was felt that the elbow is a non-weight-beartopage37 osteochondritis dissecans in adolescence frompage36 ing joint. rest was advised and further weight-bearing and compressive trauma to the elbow discouraged. discussion repeated valgus stress producing lateral compartment compression may lead to osteochondritis dissecans of the capitellum 1• osteochondritis dissecans represents a trans chondral fracture secondary to a transmission of tangential shearing forces across the joint space. the stress compresses the bone and may result in a spectrum of injury ranging from articular cartilage injury to an osteochondral avulsion fracture. this injury is thought to be traumatic in origin, owing to either a single major event or repeated minor injuries." abnormal stress owing to malalignment or ligamentous laxity may be a predisposing factor. other proposed causes include a hereditary ossification defect, familial localised abnormality in cartilage nutrition, or micro emboli with peripheral necrosis of bone. the age range is four to 15 years, but patients are predominantly within the second decade oflife, most children with this condition are active. boys are three times more likely to have this entity than girls. the knee, elbow and talus are the most common sites infigure 2: axial ct of the left elbow viewed from the eraniad aspect. arrowheads indicate both the site of the capitellar defect and the loose bodies in the olecranon fossa. (b) t1 coronal mri of the left elbow. both images show the capitellar defect (arrowheads), with joint fluid axtending into the lesion. 37 sa journal of radiologyfebruary 2001 volved. gymnasts, pitchers and downhill mountain-bikers are predisposed to 0 d of the capitellum or radial head due to chronic lateral impaction.' plain films may show a fracture line, a fragment with a surrounding lucent zone or a concave defect. the fragment may be dense, suggesting necrosis, or may resorb.l+' an anteroposterior plain film of the elbow with 45% flexion is also suggested to show the pathological process. s the use of ultrasound is also suggested by certain authors. localised subchondral bone flattening with overlying cartilaginous thickening is seen in early disease.s ct, mrt and mr arthrography are used to diagnose and stage osteochondritis, as the staging affects the management.1,2,4 it is important to stress that different classifications for od exist for the elbow and the talus. this often leads to confusion.'> mrt stage 1 od of the elbow demonstrates signal changes consistent with cartilage injury, without disruption, and a normal subchondral bone. stage 2 shows high signal breach of articular cartilage, but with a stable subchondral fragment. stage 3 demonstrates a partial chondral attachment associated with a thin bright t2 signal behind the osteochondral fragment, probably representing synovial fluid around the fragment. stage 4 represents a loose body within the centre of the osteochondral bed or free in the joint space.2,s care should be taken not to confuse an osteochondral defect of the elbow with the pseudodefect on mri, owing to the abrupt transition between the posterolateral margin of the capitellum and the non-articular portion of the lateral humeral condyle.' topage38 crstecictioridritis dissecans in adolescence frompage37 osteochondritis dissecans should also be distinguished from osteochondrosis of the capitellum, which is known as panner's disease. age is an important discriminator, because panner's disease typically occurs in children five to il years of age, compared with the 13 to 16 years of age for od. panner's disease is thought to represent avascular necrosis of the capitellar ossification centre that occurs secondary to trauma. plain films may show subtle fragmentation, while mri shows abnormally decreased signal intensity within the ossifying capitellar epiphysis. subsequent scans reveal normalisation of these changes with little or no residual deformity of the capitellar articular surface.' conservative treatment is indicated for stages 1 and 2, as the bone fragment may revascularise and heal. surgery is indicated for stages 3 and 4, where the bone fragment is either fixed to the parent bone or removed and the osteochondral crater debrided or fixed. osteoarthritis develops in 50% of patients with od of the elbow.1,2,4 conclusion osteochondritis dissecans of the elbow is a post-traumatic injury to the radio-capitellar joint caused by either a single major traumatic event or chronic lateral compressive forces. plain film findings (in contrast to the index case) are usually negative, while ct and mr! show the different stages of the pathological process optimally. the diagnosis and staging are important, as the management and long-term prognosis are dependent on accurate imaging. aknowledgement i would like to thank dr andy du toit for help regarding the subject matter in this paper. allied health/clinical su ort radiologists toowoomba health service district, queensland, australia. remuneration value up to a$207 039 p.a. or up to a$215 900 p.a. for director position, comprising salary between a$86 876 a$116 354 p.a., employer contribution to superannuation (up to 12.75%), annual leave loading (17.5%), option a private practice allowance (45%), private use of a fully maintained vehicle, communications package, study and conference leave on full pay with expenses paid and professional indemnity cover. (mol-i to m02-2) (two permanent full time positions available: one director and one staff specialist) vrn: 1lisd 312/00. duties/abilities: the department of medical imaging provides general, emergency and procedural radiology, angiography (including interventional), ultrasound, ct services and general radiology. there are 14 radiographers including two full time sonographers, two staff specialists, visiting medical officers, six administrative officers and three registered nurses staff the department. over 45 000 examinations are performed in a financial year. director's allowance will be provided for the director's position. toowoomba health service district is the referral centre for southern inland queensland. the city of toowoomba is located i'j, hours west of brisbane and has a reputation of being the garden city, with excellent amenities/facilities available for recreation, cultural, educational, social and commercial activities. toowoomba has a beautiful environment and excellent climate. toowoomba hospital will sponsor temporary visits for successful applicants, and will proceed to sponsor suitable, successful applicants and their families for permanent residency in australia. enquiries: dr andrew cumming +61 7 4631 6151 or e-mail: andrew_cumming@health.qld.gov.au appucation kit: +61 7 4631 6258. closing date: open. 38 sajournal of radiology. february 2001 references 1. anderson if, read j, sternweg 1. atlas of imaging in sports medicine. sydney: mcgrawhill companies, inc. 1998. 2. fritz re. mri of sports injuries of the elbow. mrt clinics of north america 1999; 7: 5169. 3. beltran j, rosenburg zs. mri of paediatric elbow fractures. mri clinics of north america 1997; 5: 575-577. 4. fritz re.mri of osteochondral and articular lesions. mri clinics of north america 1997; 5: 586-593. 5. takahara m, ogino t, et al. natural progression of osteochondritis dissecans of the humeral capitellum: initial observations. radiology 2000; 216: 207-212. frompage30 free intraperitonea i air on paediatric plain radiographs and differentiating this from a 'food mound" in the gastric fundus accumulates in a mound instead of as the expected airfluid level. when faced with a surgeon concerned about this finding, re-evaluation of the patient's clinical status is recommended together with re-assessment of the radiographs for free air in other recognised locations.we also keep examples of previous normal patients with the "food mound" sign, which we show to doubtful surgeons. if the radiologist is familiar with this finding, such a radiograph will cause less distress to him/herself the surgeon and the parents of the recently fed child. may the "food mound" be with youl references i. parker br. the abdomen and gastrointestinal tract: the peritoneal cavity. in: silverman fn, kuhn jp (eds). caffey's paediatric x-ray diagnosis. 9th ed. st. louis: mosby. 1993: 906-909. 2. buonomo c,taylor ga, share jc, kirks dr. the gastrointestinal tract. in: kirks dr. practical paediatric imaging. 2nd ed. philadelphia: lippencott-raven. 1998: 828-829, 890-895. mailto:andrew_cumming@health.qld.gov.au revie\n article mammographic density of breasts the effect of iror'rrtorte therapy a n increase in the density of the breast parenchyma is a well described entity as a result of hormone therapy.' when an increase in mammographic density occurs, this is an early event which will start directly after the administration of hrt. the most common cause of a diffuse increase in the breast density, is weight loss.' the reason for this seems to be a relative reduction in the mass of fatty tissue in relation to the gland. generally speaking, it is unusual to see variation in the density of breasts in the same patient as a function of time. oza reported in 1993 that alcohol use has a positive independent effect on mammographic density. this is due to alcohol's effect of increasing oestrogen levels.' two cases are presented of patients who received baseline mammograms before the commencement of hormone therapy and then underwent follow up mammograms. g kruger mmed(pret)radiology material two female patients of ages 58 and 62 years respectively received baseline mammograms before the commencement of hormone replacement therapy. the first patient received a mammogram after a year and the second patient after approximately 9 months. on both follow-up mammograms there was a diffuse non-specific increase in the relative density of the breasts with an absolute increase in the glandular element of the mammograms (figures 1a and 1b) . neither patient experienced any weight loss during the interval. it has been reported that between 17 and 27% of patients will develop a denser pattern on hrt. in practice however, the incidence seems to be much lower. according to kopans the incidence approaches 5% of cases. kopans further reports that in exceptional cases, cysts may form in the breasts as a result ofhrt. the increase 16 sajournal of radiology. april 2000 figure 1(a) and (b): the images on the top half of the figures illustrate breast density before hrt, and the bottom half after hrt. in density of the breasts as a result of hormone replacement can also follow the administration of vaginal creams. discussion the cases described are two examples of a diffuse increase in the glandular element of breast tissue following hormone replacement therapy in postmenopausal women. according to the latest literature, the finding is more topage23 case report a 44-year-old woman presented with abdominal pain, clinical findings of peritonism, and raised inflammatory markers. the patient was referred for ct scanning. the diagnosis of superior mesenteric vein (smv) thrombosis was made with the aid of multidetector ct, after intravenous contrast, with reconstruction in the sagittal and coronal planes (figs 1 and 2). clinical presentation of smv thrombosis may be quite variable. although it may mimic acute mesenteric arterial ischaemia, presentation is often less menacing with nonspecific and non-localising symptoms and signs dominating the picture.1 the most common symptoms are abdominal pain (nonspecific), anorexia and diarrhoea.2 studies have reported that most patients are symptomatic for a period of more than 48 hours at the time of diagnosis.1, 2 predisposing factors include recent abdominal surgery, infection/ inflammation (appendicitis, pancreatitis), and hypercoagulation.1 ct has been found to be effective in the diagnosis of smv thrombosis,2-4 with ct findings of mesenteric congestion and bowel wall thickening associated with ischaemia.1 1. warshauer dm, lee jkt, mauro ma, white gc 2nd. superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases. am j roentgenol 2001; 177:837-841. 2. rhee ry, gloviczki p, mendonca ct, et al. mesenteric venous thrombosis: still a lethal disease in the 1990s. j vasc surg 1994; 20:688-697. 3. schmutz gr, benko a, billiard js, fournier l, peron jm, fisch-ponsot c. computed tomography of superior mesenteric vein thrombosis following appendicectomy. abdom imaging 1998; 23:563-567. 4. franquet t, bescos jm, reparaz b. noninvasive methods in the diagnosis of isolated superior mesenteric vein thrombosis: us and ct. gastrointest radiol 1989; 14:321-325. superior mesenteric vein thrombosis a brandt, mb chb b louw, mb chb g dekker, mb chb s hlongwane, mb chb m pienaar, mb chb department of radiology, tygerberg hospital and university of stellenbosch pictorial interlude 26 sa journal of radiology • june 2006 fig. 2. the porto-venous phase of a contrast-enhanced reconstructed coronal ct study. the smv thrombosis is extending up to the confluence with the splenic vein. the top arrow indicates the thrombosis. note the mesenteric congestion (middle arrow) and the dilated bowel (bottom arrow). fig. 1. the porto-venous phase of a contrast-enhanced reconstructed sagittal ct study. the smv thrombosis is labelled with an arrow and is seen as an area of decreased enhancement in the smv. pg26.indd 26 7/11/06 12:50:05 pm clinical images computed tomography •appearances in paediatric tuberous sclerosis s andronikou mb chb, fcrad(d), frcr (lond) c weiman mbchb e kader mbchb r joubert mbchb department of paediatric radiology university of cape town and institute of child health, red cross war memorial children's hospital, cape town identification of one or more of three characteristic imaging findings may make the radiological diagnosis of tuberous sclerosis in childhood. the computed tomography (ct) scan appearances vary according to age and it is important that the radiologist be aware of this, so as to make the correct diagnosis. subependymal hamartomas these are noted on the ventricular surface of the caudate nucleus. less common sites include the frontal and temporal portions of the lateral ventricles as well as around the 3rd and 4th ventricles. these lesions change with patient age in the first year of life they are rarely calcified, but after 1 year of age they calcify commonly. variable contrast enhancement is noted, ranging from not at all to marked enhancement. giant cell tumour is an enlarging subependymal nodule at the foramen of monro and is recognised by its location and evidence of growth on serial studies. these only rarely degenerate into high-grade infiltrating lesions, when they are seen to invade parenchyma or show rapid enlargement. fig. 1. bilateral calcified subependymal hamartomas at the foraminae of monro (arrows) in an older child. these lesions may also occlude the foraminae resulting in hydrocephalus. cortical hamartomas/tubers calcification of these lesions increases with increasing age. they may be gyriform simulating sturgefigs 2a and 2b. pre and post-contrast ct scans show a left-sided, partially calcified subependymal nodule at the foramen of monro, which shows marked contrast enhancement (closed arrows). the open arrows indicate white matter lesions of low density with partial calcification (high-density focus). these do not enhance with contrast. 46 sa journal of radiology. march 2002 clinical images fig. 3. subependymal calcified hamatomas (arrows) are seen along the sutiece of the bodies of the lateral ventricles. a cortical tuber, which is partially calcified, is also present (open arrow). weber syndrome. these do not usually enhance (unlike subependymal nodules) unless they are degenerating. they also vary in appearance with age fig. 4. a large enhancing midline mass at the foramen of monro developed at the site of previously identified harmatomas. this is now termed a giant cell astrocytoma. below 1 year of age they are oflow density and are associated with broad gyri. with increasing age the density increases, until adulthood where differentiation from normal cortex can be difficult unless they are calcified. white matter lesions these are low-density well-defined areas in the cerebral white matter which do not enhance but can calcify,' mri is more sensitrve in identifying all the above lesions. varying signal intensities on tl, t2 and gadolinium-enhanced stuclies are noted according to the patient's age. mri also shows characteristic curvilinear high t2 signal intensity extensions from subependymal hamartomas to cortical tumours which represent unmyelinated, disordered cells along the path of the glial-neuronal units (figs 2-4). reference i. barkovich a]. paediatric neuroimaging. 2nd ed. philadelphia: lippincott-raven, 1996: 296-304. 47 sa journal of radiology • march 2002 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) diane wiese department of radiology, faculty of medicine, chris hani baragwanath hospital, university of the witwatersrand, johannesburg, south africa leisha rajkumar department of radiology, faculty of medicine, helen joseph hospital, university of the witwatersrand, johannesburg, south africa susan lucas department of radiology, faculty of medicine, chris hani baragwanath hospital, university of the witwatersrand, johannesburg, south africa david clopton department of radiology, faculty of medicine, james h. quillien va healthcare system, east tennessee state university, johnson city, tennessee, united states of america jacob benfield department of radiology, faculty of medicine, james h. quillien va healthcare system, east tennessee state university, johnson city, tennessee, united states of america jason deberry department of radiology, faculty of medicine, elizabeth and claire laplante foundation, west virginia university, morgantown, west virginia, united states of america citation wiese d, rajkumar l, lucas s, clopton d, benfield j, deberry j. ct pulmonary angiography findings in hiv-infected patients referred for suspected pulmonary thrombo-embolic disease. s afr j rad. 2022;26(1), a2273. https://doi.org/10.4102/sajr.v26i1.2273 original research ct pulmonary angiography findings in hiv-infected patients referred for suspected pulmonary thrombo-embolic disease diane wiese, leisha rajkumar, susan lucas, david clopton, jacob benfield, jason deberry received: 16 aug. 2021; accepted: 10 oct. 2021; published: 31 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa bares a significant burden of hiv and imaging is commonly performed as part of the workup for respiratory distress. objectives: the aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (pted) and other findings in hiv-infected patients referred for ct pulmonary angiography (ctpa) for suspected pted. method: forty ctpa studies of documented hiv-infected individuals investigated for suspected pted during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. inter-reader reliability was calculated using free marginal multi-rater kappa. results: fourteen of the forty cases (35%) were positive for pted. in the pulmonary embolism (pe)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. associated findings in the pe-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). the most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). thirty per cent of the study population had findings related directly to the presence of pted, whilst most cases in the study (77.5%) had pulmonary findings unrelated to pted. in the pe-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention. conclusion: computed tomography pulmonary angiography imaging is critical for diagnosing pe. however, further investigation into the judicious application of ctpa in hiv-infected patients with suspected pted is required, as ctpa findings in most of the cases in this study were unrelated to pe. keywords: ctpa; hiv; pulmonary embolism; imaging findings; radiological; prevalence. introduction multiple aetiological factors account for respiratory distress in the population affected by hiv, and many pathologies encountered share signs and symptoms of pulmonary embolism (pe). in the clinical setting of this study, ct pulmonary angiography (ctpa) is frequently requested in the workup of respiratory distress in these individuals to exclude pe. hiv has been reported to increase the risk of venous thrombo-embolism (vte) by 2–10 fold, with a frequency reaching up to 7.6% per year.1 a retrospective study in johannesburg, south africa showed hiv to be the commonest associated risk factor for vte.2 the general prevalence of pe is estimated to be 600 000 cases per year in the united states,3 ranging between 0.14% and 61.5% in medical patients in different african countries.4 mortality is largely preventable, and thus, diagnosis of pe in hospitalised patients remains paramount to patient care and outcomes. a positive case of pe with parenchymal and pleural complications is shown in figure 1b. figure 1: axial ct of two different patients with pulmonary embolism. (a) demonstrating a large saddle embolus; (b) demonstrating a filling defect in the right descending pulmonary artery complicated by bilateral pleural effusions, peripheral consolidations and a wedge-shaped pulmonary infarct on the left. paradoxically, studies of ctpa findings for suspected pe have also demonstrated that many alternate findings do not provide a strong rationale for its increased use.5,6 a study conducted in brazil in 2016 revealed that a significant proportion of patients who had undergone ctpa for suspected pe had reported alternate findings compatible with an different diagnosis.7 this is a relevant consideration for resource-poor settings such as that of south africa. the aim of this study was to document the ct findings and the ctpa findings for the prevalence of pulmonary thrombo-embolic disease (pted) in hiv-infected patients, given that limited data on this exist in the current literature and ctpas are frequently ordered for the workup of respiratory distress in these individuals, which contributes further to the currently overloaded healthcare system. methods a cross-sectional, retrospective, descriptive study was conducted in the department of radiology at helen joseph hospital, based in johannesburg, south africa. convenience sampling was utilised whereby all adult hiv-infected patients who had undergone a ctpa for suspected pted during the study period (january–december 2018) were considered for inclusion in the study. ctpa records with inaccessible digital imaging or request forms with illegible information were excluded. patient demographics and presenting symptoms were collected from the ctpa request forms. the hiv status was collected from request forms and/or the national health laboratory service database. patient identifiers were removed from the ctpa studies using anonymisation software. patients in the study were scanned on a phillips 16 slice ct scanner. 100 ml omnipaque 350 was injected via 18 g or 20 g intravenous cannulas in the antecubital fossa using an automated pressure injector at a rate of four millilitres per second, followed immediately by a 50 ml saline bolus chaser. the anonymised studies were read by three radiologists, each with experience exceeding four years. readers assessed 15 criteria via questionnaire-format tick sheets for each ctpa study on research electronic data capture (redcap). the study finding descriptors are detailed in table 1. ct pulmonary angiography findings were classified as pe-positive by a reader based on the presence of pulmonary artery filling defects and determined overall to be pe positive if two of the three readers agreed it was positive. table 1: description of terms. descriptive data in terms of frequencies and percentages were logged for all findings present using sas 9.2 statistical software. inter-rater reliability (using randolph’s free marginal multi-rater kappa) was utilised to investigate the level of agreement between the three readers. ethical considerations this study was approved by the human research ethics committee (medical) of the university of the witwatersrand, reference number m200256. results a total of 241 ctpas were identified for the study period, of which 179 were excluded based on a negative or unknown hiv status, 2 were also excluded due to illegible request forms and 20 due to irretrievable digital images. the final analytical sample consisted of 40 patients. fourteen of the 40 patients (35%) who underwent ctpa had reported pted. the 95% confidence interval for this population proportion was between 20.63% and 51.58%. the mean and median ages overall were 39 and 38 years, respectively, in men, and 42 and 37 years, respectively, in women. the mean and median ages of pe-positive cases were 40 and 42 years, respectively, in men, and 38 and 37 years, respectively, in women. there was a higher frequency of women compared with men, with a total of 27 women overall (67.5%). of the 14 pe-positive cases, nine (64.3%) were women. the major presenting symptoms included shortness of breath (29.85%), chest pain (8.23%), cough (11.8%) and haemoptysis (8.8%). table 2 provides a detailed summary of the pe-positive ctpa findings. twenty-seven percent had features of right heart strain, with 22.5% having a right ventricle to left ventricle (rv:lv) ratio > 1. table 2: ctpa findings in pulmonary embolism positive cases. a complete list of the incidental findings on ctpa is summarised in table 3 and the pulmonary findings in pe-negative cases are illustrated in figure 2. the most common parenchymal findings in pe-negative cases were as follows: solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%) (figure 2a, b, c), emphysematous changes (17.5%) (figure 2d) and lung cavities (10%) (figure 2e, 2f). pleural effusion was also found in 17% of pe-negative studies (figure 3). one of the patients in the study had a pneumothorax (figure 4). the most common incidental cardiac finding was cardiomegaly (52.5%). various examples of extra-pulmonary incidental findings are demonstrated in figure 5, including a case of extensive pneumobilia (figure 5b) and a patient found to have multiple rib fractures (figure 5c). the most common other intra-thoracic finding in pe-negative cases was enlarged mediastinal or hilar lymph nodes without significant mass effect (52.5%), whilst 7.5% had reported an oesophageal abnormality (figure 5a); the most common extra-thoracic finding was hiatus hernia (7.5%). figure 2: axial (a, c, e, f) and coronal (b, d) ct slices of incidental parenchymal findings in patients without pulmonary embolism. (a–c) extensive consolidations in three different patients, (d) diffuse emphysema, (e) cavitary multi-lobar pneumonia, and (f) left lower lobe lung cavitation with bilateral background tree-in-bud nodules in a patient with pulmonary tuberculosis. figure 3: axial ct of a patient with a large right and smaller left pleural effusion. figure 4: left pneumothorax, extensive ground-glass opacities and posterior consolidations in a patient with respiratory distress. figure 5: axial (a, b) and sagittal (c) ct images of incidental extra-pulmonary findings in three pulmonary embolism-negative patients. (a) a patient with circumferential lower oesophageal wall thickening, (b) extensive pneumobilia in a post-surgical patient and (c) patient with multiple chronic rib fractures. table 3: incidental findings on ctpa for hiv-infected patients referred for suspected pulmonary thrombo-embolic disease. the readers were 86.67% agreeable that of the pe-negative patients in the study, 55% had emergent findings that warranted immediate or urgent medical attention. thirty percent of the study population also had associated findings related directly to the presence of pe and 77.5% had pulmonary findings unrelated to pe (table 4). in terms of inter-rater reliability, the readers had a ‘good-to-excellent’ overall agreement, with kappa exceeding 0.60. specifically, for 12 out of the 15 criteria assessed, the readers had an excellent overall agreement, with kappa exceeding 0.75. table 4: frequency and percentages for the presence of emergent findings and study impression. discussion south africa has one of the highest hiv burdens worldwide. statistics in south africa indicates the estimated total population infected with hiv in 2020 to be 13% with a steady increase of cases (from 3.8 million in 2002 to 7.8 million in 2020).8 one-fifth of those affected are women in their reproductive ages (15–49 years).8 a lowered immune system renders these individuals susceptible to a myriad of typical and atypical diseases, including bacterial pneumonias, mycobacterium tuberculosis (tb), pneumocystis pneumonia (pcp), malignancies and pe.1 pathology encountered on imaging was therefore expected to be severe or atypical, and indeed, this study demonstrated many such cases. figure 2 (c and f) illustrates diffuse ground glass opacities and cavitary disease with tree-in-bud nodules respectively – imaging findings found commonly in patients affected by atypical fungal infections such as pcp or atypical mycobacterial infections such as tb. in terms of demographics, most patients with pe in this study were women and the average age in men and women with pe ranged from 38 to 42 years. this finding shows that pe is seen two decades earlier than in non-hiv patients where the mean age of presentation is 67–62 years.5,6,7,9 this is in keeping with other literature on hiv-infected patients where the mean ages for pe were younger than the general population, ranging from 40 to 45 years.2,3,10,11,12 presenting symptoms in this study were typical of that described in the prospective investigation of pulmonary embolism diagnosis (pioped ii) trial, including shortness of breath, syncope, chest pain and haemoptysis – all of which are non-specific.13 the ctpa prevalence of pe in an hiv-infected study population in this study was found to be 35%. a few previous studies on the hiv prevalence in pe-positive patients have reported much lower percentages in the general population of other countries, ranging from 9.5% to 24.6%.5,6,7,9,14 this indicates that ctpas are, indeed, a relevant investigation in the evaluation of respiratory distress in both hiv-infected and hiv-negative patients. pulmonary thrombo-embolic disease is commonly described as being ‘central’ or ‘peripheral’ in terms of location. a study conducted in china by zhu et al. in 2012 specifically assessed the anatomical distribution of emboli on ctpas in patients with suspected pe; they reported the central and peripheral (mixed) pattern in 55.6% and the peripheral pattern in 40.9%.15 the current study found more patients with a peripheral pattern (57.14%) compared to the mixed pattern (42.86%). zhu et al also demonstrated that the right lung was more affected than the left and the lower lobes more than the upper lobes.15 this was echoed in a south african analysis, where lower lobes were also more commonly affected compared with upper lobes in hiv-infected patients.11 we reported the rll to be most affected (20%) with a near even distribution of pe within the other lobes (table 2), the reasons for this not being clear. pleural effusion was present in 57% of the pe-positive cases in this study. this is higher than the 45% in the study on hiv-infected patients by ramlakhan et al.11, as well as higher than the 25.8% in the study by sharma et al.14 which did not include patients’ hiv status. the most common parenchymal findings in our pe-positive group were pulmonary infarcts and mosaic attenuation (17.5% each), which is comparable with other studies carried out on both hiv-infected and -negative populations.7,11,14 these findings are traditionally thought to be due to pe. this study demonstrated an increased rv:lv ratio in nine of the 14 pe-positive patients (22.5%). there are no available data in the literature on the frequency of this finding in an hiv-infected study population with pe to compare with. while our pe findings did not deviate substantially from reported literature on general populations, the incidental findings in this study were quite varied and many were significant. most of the cases in this study (77.5%) had reported abnormal lung parenchymal findings unrelated to pe, consistent with other literature.7,9,11,14,16 these findings are expected in immunocompromised individuals presenting with respiratory distress. importantly, it was demonstrated that of the 26 pe-negative cases, 55% had emergent findings that warranted urgent medical attention (table 4). this is significantly higher than other studies,6,7,9 and may, in part, be because of the injudicious use of ctpas whereby patients with respiratory distress are referred for ctpa even when the diagnosis may not likely be that of pe. it is expected that the severity of lung changes encountered in this study is likely to have been more extensive than that found in studies on hiv-negative populations. previous studies in general populations demonstrated lower percentages of major findings in pe-negative scans.6,7,9 however, the current study was limited by the smaller sample size. the prevalence of non-wedge-shaped consolidation in this study (45%) was higher than similar studies carried out by ferreira et al.7 and sharma et al.14 (21.5% and 25%, respectively). these two studies examined incidental findings on ctpa for suspected pe in general populations (not hiv specific), which may account for the differences seen. the current study also documented a lower prevalence of non-wedge-shaped consolidation (45%) when compared with the 68% reported by ramlakhan et al. which was undertaken in the western cape in a region known with a high tb prevalence.11 only one case in this study was rated normal (2.5%) with no alternate findings, which is lower than that found in other studies.17 while some findings did not require immediate medical attention, they were still significant in that their presence would have likely resulted in further workup or follow-up. obvious limitations exist in this study. due to its retrospective nature and small sample size, this study was mainly descriptive. conclusion pulmonary embolism is a cause of respiratory distress in hiv-infected patients and ctpa imaging is the gold standard for evaluation. however, further investigations into the prudent use and the efficacy of pe-risk determining scores should be performed regarding the request of ctpas. hiv-infected patients presenting with symptoms of respiratory distress are not always straightforward pe cases with a multitude of other important pathologies incidentally encountered on ctpa imaging. while there is an obvious benefit to detecting a variety of emergent conditions on ctpa, further investigation into whether such conditions found in this study could be determined on other appropriate investigations, such as chest radiographs, will be of value in curbing the widespread application of ctpas. recommendation consideration for a future study would be to compare the chest radiograph findings in hiv-infected patients referred for suspected pe to their ctpa findings to correlate if findings on initial radiographs and ctpas lead to markedly different diagnoses and whether this affects the treatment outcome in any significant way. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.l. and l.r. conceived the original idea and supervised the project. d.w. developed the study design, data collection and analysis. d.c., j.b. and j.d. interpreted and analysed the data. d.w. took the lead in writing the manuscript with s.l. and l.r., supervising and contributing to the final version submitted, which was approved by all authors. funding information this research received no special grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data supporting the findings of this study are available from the corresponding author, d.w. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bibas m, biava g, antinori a. hiv-associated venous thromboembolism. mediterr j hematol infect dis. 2011;3(1):e2011030. https://doi.org/10.4084/mjhid.2011.030 goldstein ln, wu m-t. a one year audit of patients with venous thromboembolism presenting to a tertiary hospital in johannesburg, south africa. afr j emerg med. 2018;8(1):12–15. https://doi.org/10.1016/j.afjem.2017.08.006 meel s, peter a, menezes c. the clinical features and management of pulmonary embolism at chris hani baragwanath academic hospital. afr j thoracic crit care med. 2018;24(3):113–117. danwang c, temgoua mn, agbor vn, tankeu at, noubiap jj. epidemiology of venous thromboembolism in africa: a systematic review. j thromb haemost. 2017;15(9):1770–1781. https://doi.org/10.1111/jth.13769 chandra s, sarkar pk, chandra d, ginsberg ne, cohen ri. finding an alternative diagnosis does not justify increased use of ct-pulmonary angiography. bmc pulm med. 2013;13:9. https://doi.org/10.1186/1471-2466-13-9 perelas a, dimou a, saenz a, et al. incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism. ann am thorac soc. 2015;12(5):689–695. https://doi.org/10.1513/annalsats.201404-144oc ferreira ev, gazzana mb, sarmento mb, et al. alternative diagnoses based on ct angiography of the chest in patients with suspected pulmonary thromboembolism. j bras pneumol. 2016;42(1):35–41. https://doi.org/10.1590/s1806-37562016000000105 statistics south africa. mid-year population estimates, 2020 [serial online]. [cited 2 jun 2021]. publication 0302. available from: http://www.statssa.gov.za/?page_id=1854&ppn=p0302&sch=72634 anjum o, bleeker h, ohle r. computed tomography for suspected pulmonary embolism results in a large number of non-significant incidental findings and follow-up investigations. emerg radiol. 2019;26(1):29–35. https://doi.org/10.1007/s10140-018-1641-8 ogeng’o ja, obimbo mm, olabu bo, gatonga pm, ong’era d. pulmonary thromboembolism in an east african tertiary referral hospital. j thromb thrombolysis. 2011;32(3):386–391. https://doi.org/10.1007/s11239-011-0607-4 ramlakhan r, andronikou s, rajkumar a. the prevalence and radiological findings of pulmonary embolism in hiv-positive patients referred for computed tomography pulmonary angiography in the western cape of south africa. cardiovasc j afr. 2017;28(4):221–228. https://doi.org/10.5830/cvja-2016-083 bulajic b, welzel t, vallabh k. clinical presentation and diagnostic work up of suspected pulmonary embolism in a district hospital emergency centre serving a high hiv/tb burden population. afr j emerg med. 2019;9(3):134–139. https://doi.org/10.1016/j.afjem.2019.05.003 miniati m, cenci c, monti s, poli d. clinical presentation of acute pulmonary embolism: survey of 800 cases. plos one. 2012;7(2):e30891. https://doi.org/10.1371/journal.pone.0030891 sharma s, lucas cd. increasing use of ctpa for the investigation of suspected pulmonary embolism. postgrad med. 2017;129(2):193–197. https://doi.org/10.1080/00325481.2017.1281084 zhu l, wang j-g, liu m, et al. anatomic distribution of embolus at ct pulmonary angiography in patients suspected acute pulmonary embolism. zhonghua jie he he hu xi za zhi. 2012;35(11):833–836. perelas a, dimou a, saenz a, et al. incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism. ann am thorac soc. 2015;12(5):689–695. https://doi.org/10.1513/annalsats.201404-144oc venkatesh sk, wang sc. central clot score at computed tomography as a predictor of 30-day mortality after acute pulmonary embolism. ann acad med singap. 2010;39(6):442–447. ghaye b, ghuysen a, bruyere p-j, d’orio v, dondelinger rf. can ct pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? what the radiologist needs to know. radiographics. 2006;26(1):23–39. https://doi.org/10.1148/rg.261055062 castañer e, gallardo x, ballesteros e, et al. ct diagnosis of chronic pulmonary thromboembolism. radiographics. 2009;29(1):31–50. https://doi.org/10.1148/rg.291085061 sajr 760 gastric trichobezoar: food for thought n maharaj, p naidoo, v naidu, j maharajh department of diagnostic radiology, nelson r mandela school of medicine, university of kwa-zulu natal, and king edward viii hospital, durban n maharaj, mb chb, fcrad diag (sa) p naidoo, mb bch, fcrad diag (sa) v naidu, mb chb, fcrad diag (sa) j maharajh, mb chb, ffrad (d) (sa), mmed rad (d) corresponding author: n maharaj (narishamaharaj@hotmail.com) a bezoar is an agglomeration of food or indigestible foreign material in the gastro-intestinal tract. it is an uncommon cause of abdominal symptomatology and can result in intestinal obstruction.this report is of an adolescent girl with a history of abdominal distension and trichophagia. s afr j rad 2013;17(1):19-20. doi:10.7196/sajr.760 a 16-year-old girl with no past medical or surgical history presented with a 3-month history of abdominal pain and distension with weight loss. computerised tomography (ct) scans (figs 1 and 2) of the abdomen revealed a well-defined heterogeneous intraluminal gastric mass with interspersed air bubbles conforming to the shape of the stomach. no further intestinal lesions were noted. a diagnosis of gastric bezoar was made. a trichobezoar was confirmed on endoscopy, with subsequent successful surgical removal. a history of trichophagia was elicited post-surgery and the patient was subsequently referred for psychiatric evaluation and supportive psychotherapy to treat the impulse control disorder and prevent bezoar recurrence. discussion bezoars are agglomerations of food or indigestible material in the gastro-intestinal (gi) tract.1 the term ‘bezoar’ is thought to originate from the arabic badzehr which implies a substance that acts as an antidote or counterpoison.2 bezoars are classified according to their primary constituent, the most common types being trichobezoars (hair) or phytobezoars (plant material).3 trichobezoars occur primarily in girls who ingest their own hair, and are usually confined within the stomach.3 bezoar formation is uncommon in healthy individuals and is generally associated with pica, mental retardation and psychiatric disorders.1 patients are invariably teenage girls with pica or trichophagia/trichotillomania with focal alopecia.2 bezoars may occur following gastric surgery such as pyloroplasty or partial gastrectomy in association with vagotomy.3 they may occur too in cases of delayed gastric emptying secondary to diabetes mellitus, hypothyroidism or mixed connective tissue diseases. the clinical spectrum in gi bezoars varies, depending on the stage of bezoar formation, the length of time that it has been present, and the location within the gi tract.4 common clinical features are: abdominal pain/mass, intestinal obstruction, weight loss, poor appetite or vomiting. 1 as the bezoar enlarges, it causes compression and mechanical irritation of the intestinal mucosa, leading to complications such as chronic inflammation, ulceration, perforation, intussusception and obstruction.1 intramural pneumatosis and emphysematous gastritis have been reported in association with gastric bezoars. the rapunzel syndrome is a rare clinical entity where a long tail of hair strands from the gastric trichobezoar extends along the small bowel to reach the caecum and beyond. there have been only 13 published cases of this entity.1 , 2 , 4 imaging findings at conventional radiography, the characteristic appearance of a gastric trichobezoar is mottled soft-tissue opacity in the shape of a distended stomach. a calcified rim may be visualised.1 , 4 fluoroscopic studies may outline a large mottled intraluminal filling defect in the stomach and duodenum that may extend into the small bowel with barium often trapped within the interstices.2 there may be additional filling defects throughout the bowel owing to breakage of the bezoar.4 bezoars may be mobile. ultrasonic appearance is that of curvilinear bright echogenic bands with posterior acoustic shadowing with no through-transmissions. ultrasonography is, however, of limited sensitivity in revealing gastric bezoars.1 , 3 , 4 ct reveals a well-defined mesh-like oval intraluminal mass of low attenuation with air bubbles/oral contrast retained within the interstices. the intraluminal mass may be outlined by orally administered contrast. 1 , 4 occasionally, it may be difficult to differentiate a bezoar from retained food; however, bezoars tend to be round/oval or fill the lumen with air bubbles distributed diffusely through the mass.3 complications such as perforation, obstruction, intussusception and abscess formation may be demonstrated on ct.4 the mri appearance varies depending on the content of air, fat, water or retained food debris within a gastric bezoar.4 bezoars may demonstrate low signal intensity on t1, t2 and fat-suppressed t2 images owing to interspersed air loculi, or they may show high signal intensity on t1and t2-weighted images because of food debris and water within the bezoar. focal areas of fat within the lesion may be high signal on t1 and inversion recovery sequences.4 the bezoar does not enhance post-gadolinium administration. these techniques are expensive, time-consuming and generally less useful because bezoars can be easily confused with air on mri owing to their signal characteristics.2 fig. 1. well-defined heterogeneous intraluminal gastric mass on axial post-contrast ct. fig. 2. coronal post-contrast ct showing a heterogeneous intraluminal mass conforming to the configuration of the stomach with intrinsic interspersed air loculi outlined by oral contrast. fig. 3. specimen retrieved at surgery. treatment the primary treatment is surgical removal. gastrostomy/enterotomy is the modality of choice for removal of large solid bezoars; however, preliminary endoscopy is advised to confirm the diagnosis.2 newer techniques with variable success rates include dormia basket extraction, direct large channel endosopic fragmentation and aspiration, bedside coca cola lavage, water jet, forceps and polypectomy snare.2 endoscopic retrieval of smaller lesions, extracorporeal shock wave lithotripsy, and endoscopy with utilisation of laser ignition or fragmentation with a bezotome have been suggested as alternative therapies.1 , 4 of paramount importance to prevent recurrence is correction of the underlying impulse control disorder via behavioural training, pharmacotherapy and regular follow-up.2 conclusion trichobezoars are an uncommon cause of abdominal symptoms in africa; however, they are well documented in the literature. in the past, bezoars were rarely diagnosed prior to surgery, but advances in imaging suggest that ultrasonography and ct can help radiologists to diagnose bezoars prior to surgery, which improves clinical management.3 1. o’ sullivan mj, mcgreal g, walsh jg, redmond hp. trichobezoar. j r soc med 2001;94:68-70. 1. o’ sullivan mj, mcgreal g, walsh jg, redmond hp. trichobezoar. j r soc med 2001;94:68-70. 2. sharma ak, vyas cs, porwal s. bezoars a variety of presentations in tricobezoars. int j biol med res 2012;3(3):2287-2292. 2. sharma ak, vyas cs, porwal s. bezoars a variety of presentations in tricobezoars. int j biol med res 2012;3(3):2287-2292. 3. ripolles t, garcia-aguayo j, martinez mj, gil p. gastrointestinal bezoars sonographic and ct characteristics. ajr 2001;177(1):65-69. 3. ripolles t, garcia-aguayo j, martinez mj, gil p. gastrointestinal bezoars sonographic and ct characteristics. ajr 2001;177(1):65-69. 4. koplewitz bz, daneman a, fields s, udassin r, ein sh. case 29: gastric trichobezoar and subphrenic abscess. radiology 2000;217:739-742. 4. koplewitz bz, daneman a, fields s, udassin r, ein sh. case 29: gastric trichobezoar and subphrenic abscess. radiology 2000;217:739-742. abstract introduction case report ethical consideration discussion conclusion acknowledgements references about the author(s) atish vanmali jackpersad and partners inc., private practice, durban, south africa jaynund maharajh department of radiology, faculty of medicine, king edward viii hospital, durban, south africa mario haines jackpersad and partners inc., private practice, durban, south africa citation vanmali a, maharajh j, haines m. left paraduodenal hernia: embryological and radiological findings. s afr j rad. 2021;25(1), a1979. https://doi.org/10.4102/sajr.v25i1.1979 case report left paraduodenal hernia: embryological and radiological findings atish vanmali, jaynund maharajh, mario haines received: 01 sept. 2020; accepted: 06 nov. 2020; published: 17 feb. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract left paraduodenal hernia (pdh), may present as a surgical emergency with an increased risk of strangulation and incarceration. the diagnosis is challenging because of the non-specific presentation. in the absence of common epigastric or upper abdominal pathology and non-resolving symptoms, a high index of suspicion is required to diagnose left pdh. this report describes a case of radiologically diagnosed left paraduodenal hernia and subsequent successful surgery. it also includes a review of midgut embryology, and the anatomy and radiology of left pdh. keywords: internal hernia; paraduodenal hernia; diagnosis; upper abdominal pathology; surgery. introduction abdominal hernias are categorised into external and internal hernias. external hernia represents herniation of intestinal loops through a defect in the wall of the abdomen or pelvis. an internal hernia is defined by herniation of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the peritoneal cavity. internal hernias are rarely encountered in general practice, however, on the background of increased liver transplantations and gastric bypass surgery for bariatric treatment, the incidence of internal hernia is becoming more prevalent.1 internal hernia can be asymptomatic or cause significant discomfort, dependent on the duration and reducibility of the hernia. hence, this entity may present a clinical challenge and imaging, especially if symptomatic, is imperative. paraduodenal hernias (pdh) are the commonest of the internal hernias and are classified into left and right, with the former being more prevalent.1 case report the index patient was a 57-year-old male who presented with vague, intermittent, recurrent abdominal pain. the pain evolved into a worsening epigastric pain radiating to the back with associated vomiting. the supine plain radiograph of the abdomen (figure 1) demonstrated a well-circumscribed mass projected in the left upper quadrant of the abdomen. free intraperitoneal air was excluded on the erect radiograph (not shown). additionally, ultrasound excluded cholelithiasis, peripancreatic fluid, a left renal lesion and obstructive uropathy. markers of infection were minimally increased. amylase levels were normal. figure 1: supine anterior–posterior radiograph of the abdomen, demonstrating a well-circumscribed mass (arrow) projected in the left upper quadrant of the abdomen, representing the left paraduodenal hernia. given the presence of a left upper quadrant mass on plain radiography that was suboptimally appreciated on ultrasound, computed tomography (ct) was requested. multiphase contrasted ct imaging was performed with prior administration of oral contrast (figure 2). a cluster of jejunal bowel loops was noted within a sac in the left upper quadrant of the abdomen. dilatation of the proximal duodenum and jejunal loops within the sac was evident with loss of the normal duodenal and jejunal configuration. failure of transit of oral contrast into the terminal ileum was noted. engorgement of the mesenteric vessels entering the hernial sac was visualised with surrounding fat stranding. there were no features of pneumatosis intestinalis. the inferior mesenteric vein and the ascending branch of the left colic artery were seen along the anterior margin of the hernial sac (figure 3). these collective findings were in keeping with a left pdh and bowel obstruction. figure 2: (a) axial and (b) sagittal portal venous imaging of the abdomen, demonstrating jejunal loops within the left paraduodenal hernia (black arrow) and stretched mesenteric vessels (white arrow) entering the hernial sac. dilatation of the proximal duodenum (star) is seen with non-visualisation of a normal duodenal jejunal flexure. note the position of the left paraduodenal hernia, approximating the posterior margin of the stomach. figure 3: (a) axial portal venous phase and (b) sagittal reformatted maximum intensity projection images demonstrating the left paraduodenal hernia in relation to the vascular landmarks. ascending branch of the left colic artery (white arrow) noted on the axial portal venous phase and sagittal reformatted maximum intensity projection image, as well as the inferior mesenteric vein (black arrow) on the axial portal venous phase, approximating the anterior margin of the left paraduodenal hernia. intraoperative findings (figure 4) confirmed the congenital defect (white arrow), presence of fossa of landzert, and jejunal bowel loops within the left pdh. the patient recovered without further complications or recurrence of symptoms. figure 4: intraoperative findings demonstrating the congenital defect, fossa of landzert and the left paraduodenal hernia. ethical consideration this article followed all ethical standards for research.consent was acquired from the patient to include the data and images in the manuscript. data and images in the manuscript were anonymised. discussion left paraduodenal hernia represents an internal abdominal hernia. internal hernias are defined by the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the peritoneal cavity. the orifice may be congenital or acquired, secondary to post-surgical, post-inflammatory or a traumatic defect. congenital defects include normal apertures, such as foramen of winslow, and abnormal apertures arising from anomalies of internal rotation and peritoneal attachments.1 in understanding the pathogenesis and clinical manifestations of left pdh, it would be imperative to review the embryology of the normal sequence of events relating to the midgut position. the midgut is suspended in the midline by its dorsal mesentery and undergoes a sequential pattern of rotations that is divided into three stages (figure 5). figure 5: simplified illustration of midgut reorganisation to establish the normal anatomical position: (a) 6 weeks gestation, (b) 8 weeks gestation, (c) 9 weeks gestation, (d) 11 weeks gestation, (e) 12 weeks gestation.3 this was well described by bartlett et al.2 who reported the first stage beginning at the 5th week in the life of the embryo, in which rapid growth of the abdominal viscera forces a greater component of the midgut external to the abdominal cavity. in the 10th week of the life of the embryo, the abdominal cavity increases in size and the midgut gradually returns into the abdominal cavity, beginning the second stage of rotations. the midgut has now rotated 90 degrees in a counterclockwise direction on the axis of the superior mesenteric artery, with the pre-arterial segment occupying the right side and the post-arterial segment occupying the left side of the abdominal cavity. the pre-arterial segment rotates an additional 180 degrees counterclockwise, initially posteriorly and subsequently to the left of the superior mesenteric artery, coming to lie to the left of the midline in the abdominal cavity. the post-arterial segment rotates, led by the caecum, which passes counterclockwise, anterior to the superior mesenteric artery into the right upper quadrant of the abdomen, occurring between the 10th and 11th week. the caecum may not completely descend into the right lower quadrant until the end of the 5th month in the life of the embryo. the third stage represents the fusion of mesenteries and fixation of the midgut. a leaf of the mesentery of the colonic portion of the midgut that has a posterior position, fuses with the peritoneum of the posterior abdominal wall and the space is obliterated. the mesentery of the small bowel is fixed to the posterior abdominal wall and mesentery of the duodenum fuses with the posterior parietal peritoneum. the mechanism of formation of the left pdh was best described by callander et al.4 abnormalities in the rotation of the pre-arterial segment in the second stage as it rotates posteriorly and then to the left of the superior mesenteric artery results in a left pdh. during this process, the bowel invaginates into an unsupported area of the descending mesocolon resulting in the anterior margin being formed by the ascending branch of the left colic artery and the inferior mesenteric vein. the small bowel comes to lie in a sac, lined by peritoneum, posterior to the mesentery of the descending colon. the terminal ileum enters the peritoneal cavity through the neck of the sac to reach the caecum (figure 6). figure 6: graphic illustration of a left paraduodenal hernia demonstrating jejunal loops prolapsing into the fossa of landzert, lateral to ligament of treitz and posterior to the inferior mesenteric vein and ascending branch of left colic artery.6 treitz has dictated three prereqsuisites for the occurrence of a left pdh: (1) the presence of a fossa (fossa of landzert), (2) the presence of the inferior mesenteric vein in the neck of the sac and (3) sufficient mobility of the small bowel to allow it into this sac derived from this fossa.5 the fossa of landzert is located to the left of the fourth part of the duodenum, extending posteriorly to the descending mesocolon. the opening is immediately inferior to the duodenojejunal junction and bordered anteriorly by the inferior mesenteric vein and ascending branch of the left colic artery. paraduodenal hernias are the most common type of internal hernias, accounting for 50% of cases.7 left pdh is three times more common than right pdh with a male predilection of 3:1.7 left pdhs usually present in the fourth to sixth decade, with a mean age of presentation at 38.5 years.7 paraduodenal hernias often present a clinical challenge. presentation may range from acute intestinal obstruction, which is the most common presentation, to vague abdominal pain, often relieved by changes in position.8 patients commonly present with postprandial pain typically chronic in nature and dating back to childhood.1 plain radiographs may demonstrate a circumscribed ovoid mass of jejunal loops occupying the left upper quadrant of the abdomen immediately lateral to the fourth component of the duodenum.8 our patient demonstrated a well-circumscribed ‘mass’ projected in the left upper quadrant of the abdomen, with preservation of the left psoas outline and no left lower rib lesions. the associated risk of strangulation and intestinal infarction of more than 50% over the course of a lifetime, makes it necessary to investigate symptomatic patients. the high rate of mortality associated with these complications justifies the role of ct early in the pre-operative diagnosis of pdh.9 the characteristic ct appearance consists of an abnormal cluster or sac-like mass of dilated small bowel loops lying between the stomach and pancreas, to the left of ligament of treitz. there is usually mass effect that displaces the posterior wall of the stomach, the duodenal flexure inferiorly and the transverse colon inferiorly. the mesenteric vessels supplying the herniated small bowel, appear crowded, engorged and stretched at the entrance of the hernial sac.10 the ascending branch of the left colic artery and the inferior mesenteric vein form an important ct landmark along the anterior margin of the hernia. our patient presented with vague, intermittent and recurrent abdominal pain that was progressively worsening. the impression of a mass within the left upper quadrant of the abdomen on plain radiography was characterised at ct, which demonstrated pathognomonic features of a left pdh. urgent surgical intervention confirmed the diagnosis and the patient recovered without complications. this case report aimed to highlight the importance of plain radiograph interpretation in the background of an internal hernia, which if present, will allude to underlying pathology. although this may be non-specific, it will support the need for further cross-sectional imaging to delineate the pathology. the case report further describes and diagrammatically illustrates the pertinent aspects of midgut embryology, allowing the radiologist to appreciate the pathogenesis of a left pdh. identifying the abnormal configuration of the proximal small bowel and associated vascular landmarks assists in the correct interpretation and diagnosis. internal hernias are rarely seen in clinical practice and it is important for radiologists to familiarise themselves with this concept, as the adverse outcome of an unsuspected or unidentified pdh can result in ischaemia, strangulation and obstruction with mortality between 20% and 50% due to delayed management.11 conclusion left pdh represents a clinically challenging and elusive diagnosis. an understanding of the mesenteric, peritoneal folds, anatomy of the duodenal fossa and embryology of the midgut is important to make the diagnosis. it is imperative for radiologists and surgeons to familiarise themselves with this uncommon condition, especially in patients presenting with non-resolving vague epigastric pain. plain radiograph may be suggestive, however, ct remains the gold standard for the diagnosis. acknowledgements the authors would like to thank mr. w. rahaman for providing intra-operative images. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to the article. funding information this study received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability statement the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references martin lc, merkle em, thompson wm. review of internal hernias: radiographic and clinical findings. am j roentgenol 2006;186(3):703–717. https://doi.org/10.2214/ajr.05.0644 bartlett mk, wang c, williams wh. the surgical management of paraduodenal hernia. ann surg. 1968;168(2):249–254. https://doi.org/10.1097/00000658-196808000-00010 hill ma. embryology bgd lecture – gastrointestinal system development [homepage on the internet]. 2020 [cited 2020 sep 01]. available from: https://embryology.med.unsw.edu.au/embryology/index.php/bgd_lecture_-_gastrointestinal_system_development callander cl, rusk gy, nemir a. mechanism symptoms and treatment of hernia into the descending mesocolon (left duodenal hernia.). a plea for a change in nomenclature. surg gynec obstet. 1935;60:1052–1071. abhijit j, vinitkumar d, deepak n. left paraduodenal hernia: a tricky situation. int j anat radiol surg. 2018;7(1):sc01. https://doi.org/10.7860/ijars/2018/34018:2338 gökçal f, akdamar f, çelenk y, akdemir z. a case report of left paraduodenal hernia diagnosed preoperatively and treated laparoscopically. turkish j surg. 2018;34(3):243–246. https://doi.org/10.5152/turkjsurg.2017.3322 falk ga, yurcisin bj, sell hs. left paraduodenal hernia: case report and review of the literature. bmj case rep. 2010;2010:bcr0420102936. https://doi.org/10.1136/bcr.04.2010.2936 manji r, warnock gl. left paraduodenal hernia: an unusual cause of small-bowel obstruction. can j surg. 2001;44(6):455–457. shadhu k, ramlagun d, ping x. para-duodenal hernia: a report of five cases and review of literature. bmc surg. 2018;18:a32. https://doi.org/10.1186/s12893-018-0365-8 takeyama n, gokan t, ohgiya y, et al. ct of internal hernias. radiographics. 2005;25(4):879–880. https://doi.org/10.1148/rg.254045035 john m, michael h, matthew s, et al. identification and repair of left-sided paraduodenal hernia using both laparoscopic and robotic techniques. case rep surg. 2020;2020:a7569530. https://doi.org/10.1155/2020/7569530 about the author(s) rishi p. mathew department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada timothy alexander department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada vimal patel department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada gavin low department of radiology and diagnostic imaging, faculty of medicine and dentistry, university of alberta, edmonton, canada citation mathew rp, alexander t, patel v, low g. erratum: chest radiographs – lines, tubes, non-cardiac medical devices and materials. s afr j rad. 2019;23(1), a1808. https://doi.org/10.4102/sajr.v23i1.1808 note: doi of original article: https://doi.org/10.4102/sajr.v23i1.1729 erratum erratum: chest radiographs – lines, tubes, non-cardiac medical devices and materials rishi p. mathew, timothy alexander, vimal patel, gavin low published: 05 dec. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the initial version of this article published earlier, the article title was incorrect. the title is hereby updated as ‘chest radiographs – lines, tubes, non-cardiac medical devices and materials’. this correction does not alter the study’s findings of significance or the overall interpretation of the study results. the publisher apologises for any inconvenience caused. the future part 1 from page 7 are beginning to appear commercially, and may set the scene for the future. interventive radiology smaller, smarter, slicker will be the bywords here, but political pressure and the relationship with other minimally invasive procedures may be the pivotal aspects. the number of invasive procedures may well expand, despite the increased involvement of clinical colleagues. this may be partly as a result of the incorporation of previously unguided procedures. the promise of routine remotely-performed procedures appears a long way off, despite huge investments in the technology, particularly feedback transducers. the specialty turf wars, clinical re-alignments, and reimbursement issues may overshadow technical advances. a major split of the specialty into the hands-on and remotely conducted components may occur, with centralised or home reporting facilitated for the latter. organ-specific teams will probably emerge from the turf wars, becoming the rule in the bigger centres. medical training may adjust to this concept, with, for example, a career neuroradiologist or technique specialist commencing training straight after school, in the same way that dentistry splits from general medicine. could we witness a backlash against the sterile and remote digital environment, with close personal attention and professional interaction becoming a selling point for some centres, rather than technical prowess? conclusion tissue-specificimaging remains our unreachable objective.non-harmful intervention is the ideal. in the attempt, many promising new technologies will go the way of kymography, electron radiography and thermography, while others, at present unknown, may dominate. gradual stepwise progress will hopefully be interspersed by exciting new developments, sending us all back to being students again. the future part 2 the future part 2: training radiologistspast, present and future peter corr mbchb, ffrad(d)sa, frcr, mmed(uct) professor and head: department of radiology, university of natal, durban radiology is one of the most popular specialities in medicine. it is not difficult to understand why. few radiologists regret making the decision: however the future is not what it used to be: radiology faces challenges both in south africa and internationally a sa journal of radiology. january 2000 which will certainly affect the number and profile of future trainees entering the speciality. has the "golden age of radiology" truly gone? doctors training in radiology in south africa have followed a traditional postgraduate programme as registrars in departments of radiology at the three english language medical schools. they write the college of medicine fellowship exam within four years of training. at the three afrikaans language medical schools, registrars write the mmed exams within four years. the medical council requires four years of training in an academic department for specialist registration. in many ways the current south african fellowship follows the uk fellowship exam structure in the late seventies and early eighties with essay type questions, film viewing and long cases. today 'the south african qualifying authority (saqa) will effect the curriculum structure, entry and exit points and to page 10 • exemplary track record first and original gadolinium approved for ens and whole-body • a benchmark safety record more than 20 000 000 applications worldwide" • comprehensive dosage applications' iv: pre-filled syringes and vials in 10, 15 and 20 ml enteral: 100 ml bottle nïiignevisf [§] magnevlsto 20 ml: 1 ml solution contains gadopentetlc acid, dlmeglumlne salt 469,01 mg, dtpa meglumlne salt max 1,02 mg. reg.no,:w/281199. further information available on request from schering (pty) ltd, reg. no. 64/09072/07 • pobox 5278, halfway house 1685 • e-mail: scherlng@lcon.co.za (1) data on file enhancing mri mailto:scherlng@lcon.co.za the future part 2 (rompages student assessment of all postgraduate training, such as the radiology fellowship. one important change will be the necessity for continual assessment as part of the final exam mark. another major impact is the move by the overseas colleges, especially the uk college, to introduce accreditation as the exit qualification after five years as a registrar in training posts. the uk fellowship exam therefore becomes an intermediate and not an exit qualification as it is in south africa. accreditation is compulsory for specialist registration in the uk. currently many south african exam candidates are writing the college fellowship exam in their fifth year of training, so making the training in this country de facto five years. the volume and depth of knowledge required to pass the fellowship today requires at least four years training. it is heartening to see that many registrars from the afrikaans speaking medical schools are writing the college fellowship in addition to the mmed this is a very positive sign and bodes well for the future of the college. the college is looking at introducing a number of changes to the syllabus and exam structure to update the course and examination. a log book will shortly be introduced to ensure candidates have performed or at least observed a number of radiological procedures before writing the final exams. macropathology will be introduced into the final exam to ensure that exam candidates have a good foundation in pathology. more multiple choice questions and short essay questions will be introduced into the final written exam. the number of long cases has been increased from the traditional four to eight and possibly ten cases in future. many candidates are weak in plain film interpretation and exam emphasis on this area of radiology is required. what of the future? there is no doubt that south africa and most western countries will require increased numbers of radiologists, not less as was anticipated recently in the united states. i predict that the "brain drain" of radiologists from south africa will continue and may increase. currently there are 450 radiologists registered here, however it is likely that south africa will face a shortage of newly qualified radiologists within the next five years unless the number of radiology training posts available is increased. a natural trend will be training registrars in private sector hospitals. it is my belief that the tremendous knowledge and experience of private radiologists needs to be better utilised by medical schools to train registrars especially in high technology areas such as mr imaging. future radiologists will work increasingly with digital images on workstations to improve productivity and cost effectiveness. the widespread enthusiasm for teleradiology in this country is the forerunner of our move to the digital world. with these rapid technological advances, the future registrar will need to be computer literate and be comfortable working and learning in the digital world. the days of swotting from three volumes of "grainger and allison" will disappear and be replaced by one cd-rom~ perhaps registrars will be tutored or lectured by academic radiologists from a us medical school via a videoconference or satellite link, making the dwindling number of local professors of radiology obsolete] such is the price of progress. neurology sasmo (medical oncology) the xxiii biennial congress of the urological association south african society of anaesthesiologists congress 8-11 march 17-19 march 2000 2000 26-30 march champagne 19·23 march 2000sports resort, csir centre, baxter theatre drakensberg pretoria 2000 complex, rondebosch, icc durban cape town weody grootveld ronelle van loggereoberg tel: (011) 803-9169 tel: (012) 354-1514 neville muoieo sally elliott tel: (031) 260-1607 tel: (021) 448-6381 10 sa journal of radiology. january 2000 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) eric gous department of radiology, faculty of health sciences, university of pretoria, pretoria, south africa mahmood m.t.m. ally department of rheumatology, faculty of health sciences, university of pretoria, pretoria, south africa pieter w.a. meyer department of medical immunology, faculty of health sciences, university of pretoria, pretoria, south africa farhana e. suleman department of radiology, faculty of health sciences, university of pretoria, pretoria, south africa citation gous e, ally mmtm, meyer pwa, suleman fe. simple erosion narrowing score of the hands as a predictor of cervical spine subluxation in rheumatoid arthritis. s afr j rad. 2020;24(1), a1876. https://doi.org/10.4102/sajr.v24i1.1876 original research simple erosion narrowing score of the hands as a predictor of cervical spine subluxation in rheumatoid arthritis eric gous, mahmood m.t.m. ally, pieter w.a. meyer, farhana e. suleman received: 26 feb. 2020; accepted: 13 may 2020; published: 27 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: involvement of the cervical spine is common in patients with rheumatoid arthritis and can lead to devastating or even fatal consequences. currently no guidelines exist as to whether radiographs of the cervical spine should be included in follow-up visits. objectives: to determine whether the simple erosion narrowing score (sens) of the hands correlate with the presence of cervical spine subluxation in patients with rheumatoid arthritis. method: this was a retrospective, observational, cross-sectional study. a total of 56 rheumatoid arthritis patients with hand radiographs and lateral radiographs of the cervical spine were evaluated. the sens of the hands and the presence of cervical spine subluxation were compared. the sens of the hands was correlated with the prevalence of cervical spine subluxation, as was the erosion and joint space narrowing scores of the hands. results: a correlation between the sens of the hands and the prevalence of cervical spine subluxation was confirmed. a higher prevalence of cervical spine subluxation correlated with an increase in the sens of the hands (p = 0.0002). the erosion and joint space narrowing scores of the hands also correlated with the prevalence of cervical spine subluxation (p = 0.0001). conclusion: this study confirmed that a correlation exists between cervical spine subluxation, peripheral joint space erosions and joint space narrowing in patients with rheumatoid arthritis and sens may therefore be used as a predictor of cervical spine disease. keywords: rheumatoid arthritis; sens; cervical spine; subluxations; hands. introduction rheumatoid arthritis (ra) is an autoimmune mediated disease characterised by chronic inflammation of synovial joints and involvement of the cervical spine.1,2,3,4,5,6,7 the chronic inflammation of ra leads to damage in cartilage and subchondral bone which leads to joint destruction.8,9 cervical spine damage due to ra may give rise to myelopathy and sudden death due to spinal cord and brain stem compression.10 the most common and notable patterns of cervical spine instability in ra include: atlantoaxial subluxation; cranial settling; sub-axial subluxation; or a combination of the above.2,4,5,6,7,10 atlantoaxial subluxation occurs as the result of an incompetent transverse ligament or erosion of the dens. it usually occurs in the anterior direction but may be in a posterior or lateral direction. cranial settling decreases the vertical distance between the brainstem and the dens and is caused by erosion in the occipito-atlanto articulation, the atlantoaxial articulation or both. sub-axial subluxation is caused by facet joint erosion and ligament incompetence and can occur at multiple levels.4,5,6 the association between peripheral joint destruction and cervical spine subluxation in ra is known,2 but only one previous study has correlated the simple erosion narrowing score (sens) of both the hands and feet with the prevalence of cervical spine subluxation.11 our study is the first to correlate sens of the hands only with cervical spine subluxation. scoring methods are used to evaluate the severity and monitor the progression of ra.8,12 simple erosion narrowing score is a radiological scoring method for peripheral joints based on the presence or absence of erosions and joint space narrowing.8,9,13 this study evaluated the sens of the hands as a predictor of cervical spine subluxation in patients with ra and may provide clinicians with a rapid method of predicting cervical spine subluxation in ra patients.8,9 currently, no guidelines exist as to whether radiographs of the cervical spine should be performed on a regular basis,10 but predicting cervical spine subluxation with the sens of the hands may serve as a guideline, which might lead to decreased radiation exposure for patients, more efficient utilisation of available resources, as well as cost limitation. the aim of the study was to determine whether the sens of the hands can be used to predict the presence of cervical spine subluxation in patients with ra and the objectives were to assess whether there is correlation between the sens of the hands and the prevalence of cervical spine subluxation (atlantoaxial subluxation/cranial settling/sub-axial subluxation) in patients with ra, as well as to develop a guideline based on the sens of the hands in patients with ra for radiological investigation of the cervical spine. methods this was a retrospective, observational, cross-sectional study set in the department of radiology and department of rheumatology, steve biko academic hospital, pretoria. radiographs of 56 ra patients at steve biko academic hospital’s rheumatology clinic were evaluated. to be eligible, radiographs needed to include at least one set of anterior-posterior (ap) radiographs of both hands, as well as lateral radiographs of the cervical spine in the neutral, flexion and extension positions taken on the same day. the simple erosion narrowing score is used to score radiographs of both hands and feet,8,9 but in this study, only the sens of the hands was used.8,9,13 a total of 32 joints were scored for erosions and 30 for joint space narrowing (figure 1). a joint is scored 1 point if there is erosion at least at one location and another 1 point if joint space narrowing is present. the maximum erosion score was 32, the maximum joint space narrowing score was 30 and the maximum total sens was 62 for the hands.8,9,13 figure 1: diagram illustrating joints of the hand assessed for (a) erosions and (b) joint space narrowing for simple erosion narrowing score. lateral radiographs of the cervical spine in the neutral, flexion and extension positions were evaluated to determine the presence of cervical spine subluxation. atlantoaxial subluxation was diagnosed if the anterior atlanto-dental interval (aadi) was > 3 mm on any of the lateral cervical spine radiographs. for the evaluation of cranial settling, the redlund-johnell measurement was used, which measures the distance between the inferior border of the c2 vertebral body and a line drawn from the posterior tip of the hard palate to the inferior cortical margin of the occiput (known as the mcgregor line). a result of less than 34 mm in males and less than 29 mm in females was used to diagnose cranial settling.4,5 a diagnosis of sub-axial subluxation was made if a vertebra was displaced > 3 mm anteriorly or posteriorly in relation to the next vertebra when measured from the posterior line of the vertebral bodies in flexion or extension.7 radiographs were evaluated by a single radiologist; a senior registrar in the department who had completed his fellowship of the college of diagnostic radiologists of south africa (fc rad diag sa) part 2 exam and had an interest in musculoskeletal radiology. separate diagrams for scoring erosions and joint space narrowing of the hands were used to determine the sens of each patient and the result was combined with the cervical spine subluxation measurements on a single chart for each patient. the prediction equation of interest was a logistic regression function with dependant variable ‘outcome’, i.e. zero if all three types of cervical spine subluxation were absent and one if at least one of the three types of cervical spine subluxations were present. sample size calculation was based on the number of events per variable (the sample size is adequate when the events per variable [epv] > 5.16). three prediction variables were evaluated with the sens (hands along with sex and age). to reach the expected proportion of cervical spine subluxation of 32.5%, the required sample size was 47 in which the number of events were more than 15 (3 × 5).14 data summary included mean, standard deviation, range and 95% confidence intervals (ci). for discrete data, frequencies, percentage, cross-tabulation and 95% ci were used. intra-reader reliability was derived as the intra-class correlation coefficient (icc) from a random-effects maximum likelihood regression analysis. the relationship between the sens of the hands and the cervical spine subluxation outcome (present/absent) was assessed using diagnostic statistics (sensitivity, specificity, positive predictive and negative predictive values). the main aim of the study was to evaluate the relationship between the sens of the hands and cervical spine subluxation, but the erosion and joint space narrowing scores of the hands and cervical spine subluxation were also assessed separately. a post-hoc logistic regression analysis was employed to derive the diagnostic statistics. ethical consideration this was a retrospective, observational, cross-sectional study. ethics approval was obtained from the ethics committee of the health sciences faculty at the university of pretoria (ethics number 69/2016). custodian consent was obtained from steve biko academic hospital’s chief executive officer to access patient files. results a total of 56 patients with ra at steve biko academic hospital’s rheumatology clinic were evaluated. the sens of the hands was determined on ap radiographs of the hands and the presence of cervical spine subluxation was determined on lateral radiographs of the cervical spine in the neutral-, flexionand extension positions. the sens of the hands was correlated with the prevalence of cervical spine subluxation to determine whether it can be used as a possible predictor of cervical spine subluxation. a random-effects maximum likelihood regression analysis was used to determine an icc, which is used as a measure of intra-reader reliability. a result of 0.91 was obtained, which shows excellent repeatability (maximum icc = 1). descriptive statistics for continuous variables are summarised in table 1. proportions, as well as 95% ci for binary variables are summarised in table 2. table 1: descriptive statistics for continuous variables. table 2: proportions, as well as 95% confidence interval for binary variables. cervical spine subluxation (a single subluxation or a combination of subluxations) was present in a total of 16 (28.6%) of the 56 patients. atlantoaxial subluxation, cranial settling and sub-axial subluxation was present in 11 (19.6%), 4 (7.1%) and 6 (10.7%) patients respectively. in the 16 patients with cervical spine subluxation, atlantoaxial subluxation was present in 6 (37.5%) patients, cranial settling in 2 (12.5%) patients, sub-axial subluxation in 3 (18.8%) patients and a combination of subluxations in 5 (31.3%) patients. a correlation between the sens of the hands and cervical spine subluxation (p = 0.0002) was found and is demonstrated in figure 2. a higher prevalence of cervical spine subluxation was found with an increase in the sens. the same result was obtained for the erosion and joint space narrowing scores of the hands when correlated with the prevalence of cervical spine subluxation separately (p = 0001). the correlations between the increase in the sens, erosion, and joint space narrowing scores of the hands and the prevalence of cervical spine subluxation are demonstrated in figures 2, 3 and 4 respectively. figure 2: correlation between the simple erosion narrowing score of the hands and the prevalence of cervical spine subluxation. figure 3: correlation between the erosion score of the hands and the prevalence of cervical spine subluxation. figure 4: correlation between the joint space narrowing score of the hands and the prevalence of cervical spine subluxation. study results using the sens of the hands as a predictor of cervical spine subluxation are summarised in table 3. table 3: simplified erosion narrowing score of hands, presence of erosions and joint space narrowing as predictors of cervical spine subluxation. the sens of the hands serves as a relatively good predictor of cervical spine subluxation in patients with ra. out of the 16 patients in which cervical spine subluxation was present, 14 had a sens of the hands > 9 (true positives) and 2 had a sens of the hands ≤ 9 (false negatives). of the 40 patients with no cervical spine subluxation, 3 had a sens of the hands > 9 (false positives) and 37 had a sens of the hands ≤ 9 (true negatives). a sens of the hands > 9 as a predictor of cervical spine subluxation in this study population demonstrated a sensitivity of 87.5 %, specificity of 92.5 %, positive predictive value (ppv) of 82.4 % and negative predictive value (npv) of 94.9 %. study results using the erosionand joint space narrowing scores of the hands as predictors of cervical spine subluxation, as well as the sensitivity, specificity, ppv and npv of the sens, erosion and joint space narrowing scores of the hands as predictors of cervical spine subluxation are summarised in table 3. discussion the patients with cervical spine subluxation generally had higher sens scores, and erosion and joint space narrowing scores of the hands, when compared to patients where cervical spine subluxation was absent. the majority of patients with a relatively low sens of the hands did not have cervical spine subluxation, with the exception of a small percentage of patients with a low sens who presented with cervical spine subluxation. in general, a higher sens correlated with a higher prevalence of cervical spine subluxation, but a low sens did not necessarily exclude cervical spine subluxation. this study confirmed the correlation between sens of the hands and the prevalence of cervical spine subluxation in patients with ra (p = 0.0002). this is in accordance with other studies.2,3,7,10,11,12,13,14,15 the other objective of this study was to develop a guideline regarding the radiological investigation of the cervical spine based on the sens in patients with ra. the purpose of such a guideline would be to take only an image of the cervical spine in patients where cervical spine subluxation is more likely, based on the sens of the hands. diagnostic statistics to predict cervical spine subluxation were found to be most optimal for a sens of the hands > 9 and absent where the sens of the hands was ≤ 9. if this guideline is to be implemented in clinical practice, the cervical spine would only be imaged in those patients where the sens of the hands are > 9. however, a sens of the hands > 9 as a predictor of cervical spine subluxation in this study population produced 2 false negatives, thus slightly lowering the sensitivity to 87.5 % and the ppv to 82.4 %. this means that 2 out of the 16 cervical spine subluxations would not be diagnosed if imaging based on the sens of the hands alone were to be used for diagnosing cervical spine subluxation. the 2 patients (false negatives) in this study with a low sens of the hands (0) and cervical spine subluxation both had atlantoaxial subluxation. the erosionand joint space narrowing scores of the hands as predictors of cervical spine subluxation in patients with ra were also evaluated separately. while a higher prevalence of cervical spine subluxation was found with an increase in the sens, the same result was obtained for the erosion and joint space narrowing scores of the hands when correlated with the prevalence of cervical spine subluxation separately (p = 0.0001). for the erosion score of the hands, diagnostic statistics for predicting cervical spine subluxation were found to be most optimal for a score > 5, that is, cervical spine subluxation present where the erosion score of the hands was > 5 and absent where the erosion score of the hands was ≤ 5. for the joint space narrowing score of the hands, diagnostic statistics for predicting cervical spine subluxation were found to be most optimal for a score of > 3, that is, cervical spine subluxation present where the joint space narrowing score of the hands was > 3 and absent where the joint space narrowing score of the hands was ≤ 3. the erosion score of the hands as a predictor of cervical spine subluxation was equally effective compared to the sens with identical sensitivity, specificity, ppv and npv. the erosion score of the hands might thus serve as an easier and quicker but equally effective predictor of cervical spine subluxation than the sens in patients with ra. the joint space narrowing score was not as effective in predicting cervical spine subluxation as the sens or the erosion score with a lower sensitivity, specificity, ppv and npv. conclusion this study confirmed a correlation between the sens of the hands and the prevalence of cervical spine subluxation in patients with ra. a higher prevalence of cervical spine subluxation was found with an increase in the sens. the same results were obtained with the erosion and joint space narrowing scores of the hands when correlated with the prevalence of cervical spine subluxation separately. the sens of the hands correlates with the prevalence of cervical spine subluxation in patients with ra, and may be used as a relatively reliable predictor of cervical spine subluxation in patients with ra, but sens alone should not be the only predictive factor taken into account when making decisions regarding the imaging of the cervical spine in patients with ra. other predictive factors of cervical spine subluxation such as biochemical markers, clinical features, patient demographics and treatment in conjunction with the sens of the hands should be considered as well. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions e.g. primary researcher, wrote the manuscript; m.m.t.m.a. conception and design of project, revisions and editing of manuscript; p.w.a.m. statistical analysis and contribution to writing of results, revisions and editing of manuscript; f.e.s. assisted in conception and design, supervised the research, assisted with writing of the manuscript, revisions and editing of manuscript. funding information this research received no specific grant from any funding agency in the 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fatenejad s, van der heijde d. reliability and sensitivity to change of the simple erosion narrowing score compared with the sharp-van der heijde method for scoring radiographs in rheumatoid arthritis. ann rheum dis. 2008;67(3):375–379. https://doi.org/10.1136/ard.2007.072785 blom m, creemers mcw, kievit w, lemmens jam, van riel plcm. long-term follow-up of the cervical spine with conventional radiographs in patients with rheumatoid arthritis. scand j rheumatol. 2013;42(4):281–288. https://doi.org/10.3109/03009742.2012.747625 carotti m, salaffi f, di carlo m, francesco s, andrea g. magnetic resonance imaging of the craniovertebral junction in early rheumatoid arthritis. skeletal radiol. 2019;48:553–561. https://doi.org/10.1007/s00256-018-3055-9 van der heijde dmfm. plain x-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. baillieres clin rheumatol. 1996;10(3):435–453. https://doi.org/10.1016/s0950-3579(96)80043-4 boini s, guillemin f. radiographic scoring methods as outcome measures in rheumatoid arthritis: properties and advantages. ann rheum dis. 2001;60(9):817–827. alcala jmf, douat d, pinheiro dl, et al. radiographic changes of the cervical spine in rheumatoid arthritis. rev bras rheumatol. 2013;53(5):388–393. https://doi.org/10.1016/s2255-5021(13)70108-1 akman mn, dinçer g. hand radiography: an indicator of upper cervical disease in rheumatoid arthritis. ann rheum dis. 1992;51(4):573. https://doi.org/10.1136/ard.51.4.573-a short report hepatic 'pseudo lesions' still an unrecognised pitfall i c duncan ffrad(d)sa p a fourie mmed(rad)d(pret) unitas interventional unit po box 14031 lyttleton 0140 in recent months we have had two referrals for biopsies of 'multiple hepatic lesions' in known cancer patients. both patients were referred from distant practices and both presented with ct examinations which included a pre-contrast series and a single helical post-contrast series. on the post-contrast scans a number of unenhanced low density lesions were noticed in the liver.in neither case was a dual phase or a delayed scan series performed. upon review we noticed that each post-contrast scan had been performed during the early hepatic contrast enhancement stage and that the 'lesions' were normal unenhanced hepatic veins. to confirm this we then repeated the scans with pre-contrast, helical and delayed post-contrast phases. no other hepatic abnormalities were found. discussion the advent of helical scanning of the liver has led to enhanced lesion detection, including the more ready differentiation between hypervascular and hypovascular lesions." in general, post-contrast helical scans are considered to be 'early' or 'arterial' phase scans when done during the hepatic arterial enhancement stage, roughly between 20 and 40 seconds after administering an iv contrast bolus, and 'late' or 'venous' phase scans are obtained during the peak of portal vein enhancement at approximately 60 90 seconds post bolus. a delayed scan done 3 5 minutes or later after the bolus shows the 'interstitial' or 'equilibrium' phase during which some focal liver lesions may not be seen becoming isodense with normal parenchyma.' although helical scanning has led to increased lesion detectability it has also produced some artifacts unique to this technique. one of these is the production of hepatic 'pseudolesions' during the early arterial phase scans due to non-enhancement of the hepatic veins (fig. 1).4 these are then seen to enhance on later (venous) phase scanning (fig. 2). another feature that helps to distinguish these 'pseudo lesions' as hepatic veins is that they can be followed sequentially on adjacent slicesin keeping with tubular structures. many south african radiologists are aware of this phenomenon with the current widespread usage of helical scanning, but as has been shown here there are still those who are unaware of this pitfall. to avoid this our recommendation is to perform at 36 sa journal of radiology • september 2002 fig. 1. early (arterial) phase contrast-enhanced ct image showing unenhanced hepatic veins. fig. 2. late (venous) phase seen at the same level now showing hepatic vein enhancement. least a three-phase scan (pre-contrast, late phase helical post-contrast and delayed post-contrast series) of the liver in all cases of suspected focal hepatic abnormalities. in some cases an additional early arterial phase scan may also be useful in identifying hypervascular lesions. references 1. heiken jp' brink ja,vannier mw. spiral (helical) ct. radiology 1993; 189: 647-656. 2. zeman rk, fox sh, silverman pm, et al helical (spiral) ct of the abdomen. afr 1993; 160: 719-725. 3. heiken jp. liver. in: lee hcr, sage! ss, stanley rj, heiken jp' eds. computed body tomography with mrl correlation. 3rd ed. lippincottraven, 1998: 707-714. 4. herts br, einstein dm, paushter dm. spiral ct of the abdomen: artifacts and potential pitfalls.afr 1993; 161: 1185-1190. review article mounier-kuhn syndrome a case study m j trollip mmedrad(ó) po box, 1695, heidelberg, 1438 clinical information a 21-year-old male presented to the casualty department complaining of swelling of both feet for 2 weeks and persistent headache. on further inquiry he also reported a 3-year history of coughing and a course of treatment for tuberculosis during the 6 months immediately preceding this presentation. on examination the patient was found to be dyspnoeic and orthopnoeic with a productive cough and abdominal distension. anaemia, peripheral oedema and digital clubbing were also noted as well as cyanosis which improved on oxygen. urinalysis revealed no abnormality. he was apyrexial (36°c), awake and fully oriented. respiratory system a tachypnoea of 26/min was noted. bilateral basal crepitations were found and an area of bronchial breathing, dull to percussion, in the left base. no respiratory distress was present. cardiovascular system the patient's blood pressure was 113/73 mmhg and pulse 120 bpm. a hyperdynamic circulation was found with a loud si, right ventricular s3 gallop and loud p2. suspected bruits of mitral and tricuspid valve incompetence were noted. jugular venous pressure was raised. the apex of the heart was displaced laterally into the 6th intercostal space. abdomen examination revealed ascites and liver enlargement of 2 cm. no rebound tenderness was present. a vasculitic skin rash could be seen over most of the torso and legs. radiological examination chest x-ray a grossly dilatated appearance of the trachea and main bronchi was observed. the right lung field showed an interstitial infiltrate including kerley b lines, and also confluent shadowing in the perihilar areas and upper lobe. bronchiectatic changes could be seen in the right lower zone. right apical pleural thickening was present (fig. i). on the left, lower lobe bronchiectasis and volume loss were noted with compensatory hyperinflation of the upper lobe. blunting of the left costophrenic angle was present with some kerley b lines. enlargement of the cardiac shadow was also present 12 sa journal of radiology • march 2002 fig. i. the grossly dilated trachea and main bronchi are clearly seen with bronchiectatic changes in the right lower zone. the heart is also enlarged. with prominence of upper-lobe vasculature. ct chest high resolution and mediastinal cuts tracheobronchial ectasia was again observed. the trachea measured 4.13 x 4.65 cm in diameter, while mainstem bronchial dilatation of 2.19 cm and 2.00 cm were noted on the right and left side respectively (fig.2). thymic hyperplasia and right jugular prominence could also be seen. the rest of the mediastinum and both hilar regions were felt to be normal. fig. 2. marked ectasia of the trachea is clearly seen. ground-glass infiltrates suggest underlying mfect/on. revie\tv article a pleural effusion had formed on the right. volume loss on the left resulted in ipsilateral cardiac shift. both upper lobes and the middle lobe showed ground-glass infiltrates. bronchiectasis was confirmed bilaterally in the peri -hilar regions and bases. advanced fibrotic changes were seen in the left lower lobe, causing 'shagginess' of the pleuro-pericardial surfaces. a confident diagnosis of tracheobronchomegaly (mounier-kuhn syndrome) was made. complications of acute and chronic infection included visible pneumonitis, bronchiectasis and fibrosis. thymic hyperplasia was likely reactive, due to repeated infections. cardiac ultrasound examination a massive right ventricle was found with enlargement of the right atrium. mild tricuspid incompetence was demonstrated with an increased pressure gradient. a pulmonary pressure of 70 mmhg was measured, indicating severe pulmonary hypertension. final diagnosis 1. mounier-kuhn syndrome (tracheobronchomegaly), complicated by: (i) pneumonia; (ii) bronchiectasis and fibrosis; and (iii) cor pulmonale with tricuspid incompetence. 2. hyperplasia of the thymus due to chronic infection. the patient was treated with lasix, berotec inhalations, ciprobay and physiotherapy. discussion tracheobronchomegaly was originally recognised at autopsy by czyhlaz in 1897, but the first clinical description by mounierkuhn was given in 1932.1,2 mounier-kuhn syndrome primarilyaffects the supporting structures of the trachea and major bronchi, weakening them and leading to ectasia. bronchi abruptly revert to normal by the 4th to 5th divisions.' the syndrome is characterised by marked ectasia of the trachea and main bronchi, bronchiectasis and repeated lower respiratory tract infections.' presentation is typically during the 3rd or 4th decade, with a preponderance in males of african -american origin." a familial tendency is observed with an autosomal resessive inheritance pattern.' tracheobronchomegaly is the underlying cause in virtually all observed instances of tracheal dilatation. it is regarded as a primary dysplasia rather than a complication of recurrent infection; this is in keeping with the acute transition to normal calibre bronchi." symptoms include recurrent respiratory infections, chronic productive cough and exertional dyspnoea.' weakness of proximal airway walls results in flaccidity and collapse, ineffective cough, retention of mucus and consequently, repeated infections.' as the cartilagenous rings of the trachea and larger bronchi dilate, the intervening soft tissues bulge outward, forming diverticular, extraluminal protrusions of the air column. these lesions are best seen on the lateral chest view. in severe cases, associated tracheobronchomalacia leads to proximal airway collapse during expiration. the increase in tracheal diameter can be pronounced as in this case or subtle enough to be easily over100ked.4,5 widening of the trachea beyond 30 mm or mainstem bronchial diameters over 20 mm on the right or 18 mm on the left indicate tracheobronchomegaly,' peri-hilar emphysema and bullae can also be found (fig. 3).4 secondary tracheobronchomegaly has been described in patients with ehlers-danlos syndrome, marfan syndrome, kenny-caffey syndrome, brachmann-de lange syndrome, connective tissue diseases, ankylosing spondylitis, long-chain deposition disease and following prolonged ventilation in premature infants. other sources give a shorter differential for fig. 3. the trachea measured 4.13 x 4.65 em in diameter while mainstem bronchial dilatation of 2.19 em and 2.00 em were noted on the right and left side respectively. 13 sa journal of radiology • march 2002 revie\n article tracheobronchomegaly, consisting of mounier-kuhn syndrome, ehlersdanlos syndrome, cutis laxa and relapsing polychondritis." tracheal stenting has proved of great benefit in patients with advanced stages of mounier-kuhn disease (fig. 4).4 summary measurement of the dilated trachea on a chest x-ray can make the diagnosis of tracheobronchomegaly. normal tracheal diameter on a postera-anterior radiograph is 20 mm, with a standard deviation of 2 mm. in cases of tracheobronchomegaly the fig. 4. bilateral basal bronchiectasis with left lower lobe fibrosis causing 'shagginess' of the pleuropericardial surfaces, measurement exceeds three standard deviations. a tracheal diameter of more than 25 mm is consistent with the diagnosis of tracheobronchornegaly,' references ). ker ja, prinsloo h, tracheobronchomegaly associated with recurrent pneumonia, trop doet 2000; 30: 242 -243. 2, dee pm, chest case of the day. tracheobronchomegaly the mounier-kahn syndrome, am j roentgenoll996; 167(1): 235, 238. 3, dahnert w. radiology review manual, 4th ed. baltimore: williams and wilkins, 1999:443. 4. blake ma, clarke pd, fenlon hm. thoracic case of the day. mounierkuhn syndrome (tracheobronchomegaly). am j roentgenol 1999; 173: 822, 824 825. 5, choplin rh, wehunt wd, theros eg, diffuse lesions of the trachea, semin roentgenol1983; 18: 38-50, imaging of diseases of the chest 3/e peter armstrong, alan g. wilson, paul dee and david m. hansell this comprehensive resource covers all imaging aspects of the lungs, the pleura and the mediastinum and integrates all available imaging modalities, both common and uncommon disorders are included, whilst the logical, clinical organisation of the text allows for fast, efficient access to the information you require. reviews of the second edition "never has a 'point source' on focused imaging managed to be so thoroughly concise and complete.i.lt belongs in every radiology resident's personal llbrary.jvtarvetoua" radiology "few single-volume textbooks on thoracic imaging can compare with this book" american journal of roentgenology "the writing is straightforward and succinct with careful attention to detail. "the illustrations are uniformly excellent and well chosen" clinical radiology april 2000, hardback, 1056 pp, 1 800 illustrations mosby, r3 050r-------~------------------------------4 features orders sa medical association private bag x1, pinelands 7430. tel (021) 530-6527 fax (021) 531-4126 e-mail: fpalm@samedical.org please allow 4 weeks for delivery. prices subject to foreign exchange fluctuations. • includes all you need to know in one convenient single-volume resource, • written clearly and concisely by renowned authors from the uk and usa, • multi-modality coverage ensures that all the modalities applicable to thoracic imaging are included. • includes nearly 2 000 high-quality images and illustrations an image bank that covers a wide variety of cases. • chapters are organised by diseases and disorders, allowing for fast navigation through the text. • chapter outlines, summary tables and key points boxes summarise the most important information. 14 sa journal of radiology • march 2002 mailto:fpalm@samedical.org case report a trio of multiple \nilms' tumours s. andronikou fc rad diag (sa) c. weiman mbchb e. kader mbchb department of paediatric radiology, university of cape town and institute of child health, red cross war memorial children s hospital, rondebosch, cape town corresponding author s. andronlkou department of paediatric radiology red cross war memorial children's hospital capetown 7700 telephone: 021-6585442 fax: 021-6585101 e-mail: docsav@mweb.co.za abstract wilms' tumour is the commonest mal ignant abdominal tumour in children. unilateral mu iticentric, and bilateral wilms' tumours are, however, lesscommon, occu rri ng in 7<yo and 5% of cases respectively. these are often associated with sporadic aniridia, genitourinary anomalies, hem ihypertrophy and nephroblastomatosis. nephroblastomatosis is a separate entity that may act as a precursor of wilms' tumours. we present th ree cases of multiple wilms' tumours. two cases also had nephroblastomatosis which was not seen on pre-operative ct imagi ng but was identified in one case 4 sajournal of radiology. august 2000 at mri. in cases of multiple wilms' tumours, mri provides better delineation of the tumours and may, therefore, affect management. key words wilms' tumour, nephroblastomatosis, magnetic resonance imaging (mr!), computed tornogrephy (ct), horseshoe kidney. introduction wilms' tumour (wt) is the commonest malignant abdominal tumour in children.' unilateral multicentric, and bilateral wt are less common. we present three cases of multiple wt and their imaging features. case 1 a 2-year-01d boy presented with a month's history of weight loss and a palpable right-sided abdominal mass. ultrasound (us) and computed tomography (ct) showed large upper pole and smaller lower pole masses in the right kidney (figures 1a and b). a right nephrectomy was performed and histology demonstrated nephrob1astomatosis and three wt of favourable histology. case 2 a 4-year-old boy with multiple congenital anomalies, including a horseshoe kidney, presented with macroscopic haematuria. a palpable abdominal mass was sonographically shown to arise from the left side of the horseshoe kidney. on ct, bilateral renal masses were seen in keeping with wt (figures za and b). in topage6 mailto:docsav@mweb.co.za a trio of multiple vvi lrns+u.rrncnrrs from page 4 figures la and b: two tumours in a single kidney case 3 a 4-yearold boy presented with a lo-day history of anorexia, abdominal pain and intermittent fever.an us and ct scan (figure 3a) demonstrated bilatb. a lowe~ ct slice demonstrates the enhancing midline isthmus (arrow) br/dglng the tumour masses. a, post-contrast ct shows a low den~ity mass (arrow) in the posterolateral upper pole of the fight kidney with a typical claw sign (arrowheads). eral renal masses (two in the right kidney and one on the left), after chemotherapy, the left wt was removed by partial nephrectomy. a dmsa scan demonstrated a differential function of 68% on the right and 32% on the left, repeat ct showed more than one mass in the right kidney, in view of possible view of the clinical setting, the child salvage surgery in the was managed conservatively until his better functioning right kidney, an death, mri was performed to delineate the figures 211 and b: bilateral tumours in a horseshoe kidney extent of the masses, at least five masses were demonstrated (figures 3b,c,d), three of which were histologically proven nephroblastomatosis, a repeat course of chemotherapy was instituted, mour of children between one and eight years of age and is the third commonest cause for a renal mass in childhood after hydronephrosis and multicystic dysplastic kidney.' the commonest presentation is with an asymptomatic abdominal mass. uncommon presentations include abdominal pain, fever, anorexia, haematuria and hypertension, although mostly sporadic, wt are associated with several conditions, including horseshoe kidneys, beckwithwiedemann syndrome and sporadic aniridia.? bilateral tumours occur in 5% of cases and unilateral multicentric tumours in 7%. bilateral tumours are often associated with sporadic aniridia, genitourinary anomalies, hemihypertrophy and nephroblastoma to sis (persistent metanephric blastemal rests found after 34 weeks' gestation). nephroblastomatosis is considered an intermediate between a malformation and neoplasrn.ê' these nephrogenic rests are seen in 1% of autopsies of children under three months of age.' they are associated with synchronous bilateral wt in 99%, and with metachronous bilateral wt in 94% of cases, nephroblastomatosis therefore has to page 7 b. post-contrast ct,of tlje same patient shows another mass with cystic components in the anteromediallower pole of the right kidney, discussion wilms' tumour is the commonest malignant abdominal tua, post~contrast ct shows masses in both kidneys with a contrastenhancing isthmus (arrow) of the horseshoe kidney. sajournal of radiology. august 20006 a trio of multiple wilms'turllours frompage6 a. post-contrast ct shows bilateral low density renal masses with cystic components. note the thrombus in the ivc (arrow). e. axial t2-weighted mri shows clear differentiation between the inhomogeneous wilms' mass (arrow) with increased central t2 signal intensity, and the peripheral, flatter nodules of nephroblastomatosis (arrowhead) that are iso-intense to cortex. malignant potential and is hence a precursor of wt.3 while ultrasound is often the initial investigation and provides good detail of ivc tumour thrombus, ct scanning provides better detail of the tumours. post-treatment imaging is necessary to detect recurrence and metachronous tumours especially with associations known to develop multiple wt.2 on ct, the tumour is typically of inhomogeneous low-density with increased inhomogeneity post-contrast. a 'claw sign' confirms the renal origin of the mass. the mass is usually solid but haemorrhage and necrosis may cause cystic areas. calcification b. axial t2-weighted mri post left partial nephrectomy shows an anteromedial upper pole renal mass (arrowheads) that is iso-intense to the rest of the kidney. d. t2-weighted mrlln the coronal plane al/ows evalualion of multiple masses (open arrows) with greater ease. is seen in up to ] 5% of cases. mr! is helpful in difficult cases as coronal imaging allows better tumour delineation. generally wt are heterogeneous with low signal intensity on tlweighting, high signal on t2-weighting and show inhomogeneous contrast enhancement. haemorrhage and necrosis may alter these appearances.' differential diagnosis includes neuroblastoma, nephroblastcmatosis, mesoblastic nephroma, multilocular cystic renal tumours, renal cell carcinoma, renal lymphoma, renal leukaemia, clear-cell sarcoma and rhabdoid tumours of the kidney. nephrogenic rests may either be perilobar (periph7 sajournal of radiology. august 2000 eral) or intralobar (central). the intralobar rests are associated with more frequent development ofwt and at a younger age.' on ct, the nephrogenic rests are typically well-defined plaque-like or nodular subcapsular masses that are homogenously isodense to renal cortex. they enhance poorly and hence appear hypo-dense relative to renal cortex. on mr! they are isoto hypo-intense to renal cortex on both tland t2-weighted sequences. they enhance poorly with gadolinium and are hypo-intense relative to renal cortex. both nephroblastomatosis and wt are best seen on post-gadolinium images. the topage8 a trio of rriu lt.ipf e wilms'tumours (rompage7 most reliable differentiation between them is based on their homogeneity? in practice, the imaging" and surgery' for wr often differs from the national wilms' tumour study group (nwrsg) protocol. controversial points include radiological or surgical staging, timing of chemotherapy, the adequacy of partial nephrectomy, and the optimum follow-up surveillance.v' this is especially so for multiple wr where the surgical approach and need for accurate follow-up surveillance is complicated by the presence of multiple potentially malignant nephrogenic rests. cases one and three had nephroblastomatosis which was not seen on pre-operative ct imaging, in case three it was, however, identified on the pre-operative mri scan, in view of these problems, it may be advisable to consider mri in complicated cases with multiple wr. conclusion in cases of multiple wr, mri provides better delineation of the tumours and increased sensitivity for detecting nephroblastomatosis. it should be considered in the tumour work-up as it may affect management. references 1. chapman s, nakielny r. aids to radiological differential diagnosis. 3rd ed. london: wb sanders. 1995:309·310, 317. 2. barnewolt ce, paltiel hj, lebowitz rl, kirks dr. genitourinary tract. fn: kirks dr & griscom nt, eds. practical paediatric imaging. 3rd ed. philadelphia: lippincottraven. 1998:1111·1126. 3. rohrschneider wk, weirich a, rieden k, darge k, trëger j, graf n. us, ct and mr imaging characteristics of ne p hr oblastomatosis. paediatr radial, 1998; 28:435·443. 4. goske mj, mitchell c, reslan wa. imaging of patients with wilms' tumour. sem ural onco11999; 17:11·20. 5. ross jh, kay r. surgical considerations for patients with wilms' tumour. sem ural onco11999; 17:33·39. medical arts exhibition 2000 dates: venue: viewing: 28th august 3rd september 2000 pharmaceutical society of south africa 52 glenhove street, houghton 08:00 17:00 weekdays 09:00 12:00 saturday for more information or if you are interested in exhibiting, please contact heide deane at (011) 463-4100 a sajournal of radiology. august 2000 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) alexander g.g. doruyter numeri node for infection imaging, central analytical facilities, stellenbosch university, cape town, south africadivision of nuclear medicine, faculty of medicine and health sciences, stellenbosch university, cape town, south africa jeannette parkes division of radiation oncology, faculty of health sciences, university of cape town, cape town, south africa jonathan carr division of neurology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa james m. warwick division of nuclear medicine, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation doruyter agg, parkes j, carr j, warwick jm. pet-ct in brain disorders: the south african context. s afr j rad. 2021;25(1), a2201. https://doi.org/10.4102/sajr.v25i1.2201 review article pet-ct in brain disorders: the south african context alexander g.g. doruyter, jeannette parkes, jonathan carr, james m. warwick received: 01 june 2021; accepted: 12 aug. 2021; published: 10 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract positron emission tomography combined with x-ray computed tomography (pet-ct) has an established role in the management of brain disorders, but may be underutilised in south africa. possible barriers to access include the limited number of pet-ct facilities and the lack of contemporary guidelines for the use of brain pet-ct in south africa. the current review aims to highlight the evidence-based usage of brain positron emission tomography (pet) in dementia, movement disorders, brain tumours, epilepsy, neuropsychiatric lupus, immune-mediated encephalitides, and brain infections. while being areas of research, there is currently no clinical role for the use of pet-ct in traumatic brain injury or in psychiatric or neurodevelopmental disorders. strategies to expand the appropriate use of pet-ct in brain disorders are discussed in this article. keywords: brain; positron emission tomography; f-18 fluorodeoxyglucose; f-18 fluoro-dihydroxyphenylalanine; dementia; brain tumour; parkinson’s disease. introduction neurological diseases have a high worldwide and local prevalence. in 2015, the age-standardised rate of disability-adjusted life years attributable to neurological conditions in south africa was estimated at 3549 (95% confidence interval [ci]: 3176–3953) per 100 000.1 when neuroimaging is indicated in neurological conditions, this is typically initiated with anatomical techniques such as ct and/or mri, with or without contrast. in most clinical circumstances, nuclear imaging techniques such as positron emission tomography combined with conventional x-ray computed tomography (pet-ct) are reserved for cases in which the diagnosis remains in doubt after inconclusive anatomical imaging. the strengths and limitations of anatomical and functional techniques (including pet-ct) have previously been reviewed.2 pet-ct is now a mature imaging modality in clinical medicine, and has been available in south africa for more than 15 years. after the injection of a radioactive tracer molecule, pet-ct allows for the non-invasive imaging of (patho)physiological processes for the diagnosis of disease. because of its inherently lower spatial resolution, pet-ct provides only limited anatomical detail but may provide valuable functional information complementary to that provided by modalities such as ct and mri. because functional disruptions frequently precede anatomical abnormalities, pet-ct is frequently able to detect abnormalities before conventional neuroimaging techniques.2 pet-ct has made a major impact on the management of several tumours; it also plays an important role in other clinical fields, including infectious disease, rheumatology, cardiology, and neurology. south africa currently has 21 pet-ct cameras of which five (24%) are in the state sector (which manages at least 82% of the country’s patients),3 13 (62%) are in the private sector (serving 18% of the country’s patients), and three (14%) are in dedicated research units (table 1). excluding research tracers that are compounded on site, these institutions have access to two commercially available radiotracers with neurological applications; these are fluorine-18 fluorodeoxyglucose (fdg), and fluorine-18 fluoro-dihydroxyphenylalanine (fdopa). table 1: provincial distribution of pet-ct scanners in south africa. fdg is a radiolabelled analogue of glucose that is transported into cells via the same transporters before being trapped after conversion to fdg-6-phosphate.4 since neurons are almost exclusively reliant on glucose to meet their energy requirements, fdg is a useful marker of regional neuronal activity, which is disrupted in many neurological conditions.4 fdopa is a radiolabelled amino acid that is transported into presynaptic dopaminergic neurons via the large amino acid transporter before being converted to fluorodopamine which is then stored in presynaptic vesicles by the type-2 vesicular monoamine transporter.5 uptake of fdopa is a marker of presynaptic dopaminergic neuron integrity which is impacted early in the course of several degenerative movement disorders.5 depending on their level of differentiation, both primary brain tumours and metastases exhibit variable upregulation of transporters for fdg and fdopa.6 neither of these tracers are associated with significant adverse effects, and the effective radiation dose from brain pet-cts using fdg and fdopa is low, typically in the order of 3.0 millisieverts (msv) – 5.0 msv, approximately equivalent to two ct brain studies.4,5 proper patient preparation, standardisation of pre-scan conditions and attention to quality control are of paramount importance in brain pet-ct. comprehensive recommendations for performing brain pet-ct studies have been published.4,5 while it is appropriate to investigate only a minority of neurological problems with pet-ct, for particular clinical indications, based on information available to the authors, pet-ct is underutilised in south africa, especially in the private sector. barriers to access may include the high cost of a brain pet-cts (~r2000.00 – r12000.00) and pet tracers (~r6500.00 – r9000.00 per dose), the scarcity of pet-ct scanners, and the fact that many medical insurers do not cover these imaging studies under plan benefits. this is unfortunate, because in several specific scenarios, pet-ct can play an invaluable role in the correct diagnosis and hence management of many neurological conditions. underutilisation may at least be in part attributable to lack of contemporary, evidence-based guidelines for the use of brain pet-ct in south africa. this article aims to briefly review the most common indications for pet-ct in neurological disorders in the south african context. while several applications for brain pet-ct were dealt with in the south african appropriateness guideline,7 this guideline was limited in its recommendations for neurological indications, and is now more than five years old – during which time additional evidence for the use of pet-ct in neurological conditions has accumulated. strategies to improve access to pet-ct in the management of neurological conditions are discussed in this article. methods a topical approach was taken for this narrative review, which relied on pivotal papers known to the authors. additional supporting meta-analyses, original research articles, reviews, and society endorsed practice guidelines were identified in targeted pubmed and google scholar searches using medical subject headings (mesh) terms such as (‘positron-emission tomography’ or ‘positron emission tomography computed tomography’) and (‘fluorodeoxyglucose f18’ or ‘fluorodopa f18’) and the condition in question, for example, ‘dementia’, where relevant search results were further filtered by article type. summaries were then prepared for the selected conditions. ethical considerations this article followed all ethical standards for research. results dementia in 2015, it was estimated that 186 000 south africans suffered from dementia8 which includes alzheimer’s (ad), frontotemporal dementia (ftd), vascular dementia (vad), dementia with lewy bodies (dlb), and dementia secondary to parkinson’s disease (pd). hiv-associated dementia (had) is also relatively frequently encountered in the south african context, and is especially common in late stages of the disease. exclusion of potentially surgically addressable causes of dementia justifies structural imaging with either ct or mri (preferred), at least once in the workup of patients with cognitive impairment.9 pet-ct is, however, increasingly used as a complementary investigation, especially when structural imaging is normal. professional society endorsed guidelines on the use of fdg pet-ct in neurodegenerative conditions have also recently been published.10 fdg pet-ct in the context of mild cognitive impairment, fdg pet-ct may be valuable as a baseline investigation to diagnose early ad, ftd, or dlb, principally because of its high negative predictive value.10 in the context of established dementia, there is evidence to support the use of fdg pet-ct to diagnose ad when the clinical presentation is atypical, and to distinguish between the dementia subtypes (ad vs. ftd; dlb vs. ad; dlb vs. ftd; ad vs. vad) when an alternate diagnosis is considered.10 interpretation of fdg pet-ct scans performed to assist in diagnosis is aimed at identifying characteristic patterns of hypometabolism (as a result of neuronal degeneration) that assist in distinguishing dementia subtypes. for example, ad is predominantly a posterior dementia, with early involvement of the posterior cingulate cortex/precuneus region and adjacent temporoparietal association, progressing to greater frontal cortical involvement later, at which time characteristic sparing of sensorimotor and visual cortices may be evident.10 dlb is also a posterior dementia, but frequently spares the posterior cingulate (leading to the characteristic ‘cingulate island sign’) and may involve the primary visual cortex.10 without clinical context, it may be impossible to distinguish the hypometabolic pattern in pd from ad or dlb.10 ftd, as the name implies, is associated with hypometabolism of the frontal lobes, with or without involvement of the temporal lobes, with spread to the parietal regions later in the course of the disease.10 the pattern of vad is variable, depending on the location, severity, and extent of ischaemia. pet with fdg currently plays only a limited clinical role in the diagnosis of had, though the test may be beneficial in older patients, to distinguish the condition from other dementing diseases. examples of fdg pet scans in different dementia subtypes are illustrated in figure 1. whether fdg pet-ct is performed for mild cognitive impairment (suspected dementia) or in established dementia, single-subject statistical analysis should be performed to support nuclear physician interpretation.10 during such analyses, a patient’s pet scan is re-oriented, normalised for intensity, and then spatially warped to fit a standard template, before it is compared to an age-appropriate database of normal brain scans in order to generate maps of statistical deviation from the mean (figure 2). figure 1: fluorine-18 fdg pet scans in dementia. maximum intensity projections of the pet scan (in the right lateral position) are shown on the top row (individually scaled for comparability). corresponding statistical images (reductions compared to a normal database) are shown in the bottom row. figure 2: example of a single-subject statistical analysis (decreases) for a fdg pet scan of a patient with dementia with lewy bodies. the top row represents surface projections of both brain hemispheres from different angles. subsequent rows represent negative deviations from the normal database mean (z-score) for all brain regions, normalised to global counts (glb), thalamus (thl), cerebellum (cbl), and pons (pns). similar outputs are generated for statistical increases (not shown). in this example, reduced metabolism in bilateral parietal occipital vortices is evident. such analyses are highly recommended to support the interpretation of brain pets. fdopa pet-ct fdopa pet-ct is a sensitive and specific tool to evaluate the integrity of nigrostriatal dopaminergic structures.5 in addition to its main role in the selective evaluation of patients with movement disorders (see the following section), it may be clinically valuable to distinguish between ad and dlb (pd and dlb) in difficult cases,11 occasionally in combination with the results of fdg pet-ct. the distinction between these two clinical entities is important, since patients with dlb have heightened sensitivity to neuroleptics, occasionally with lethal consequences.11 movement disorders the crude prevalence of idiopathic pd in sub-saharan africa varies between countries, from 7 to 20 per 100 000.12 the prevalence of other parkinsonian disorders and essential tremor is unknown. the diagnosis of pd is primarily a clinical one, with neuroimaging typically reserved as ancillary, when there are atypical clinical features.13 in such cases, transcranial sonography, mri, and nuclear techniques such as single photon emission computed tomography (spect) and pet may all play a role.13 pet-ct is most useful in confirming dopaminergic degeneration and to a limited degree in differentiating between pd and pd mimics, especially when invasive intervention in considered. importantly, pet-ct does not currently play a clinical role in non-parkinsonian movement disorders such as dystonia, hereditary spastic paraplegias, or paroxysmal dyskinesias. fdopa pet-ct fdopa is an analogue of dihydroxyphenylalanine – an amino acid precursor used in the synthesis of endogenous dopamine. as such, it has emerged as a sensitive biomarker of presynaptic dopaminergic degeneration in the caudate and putamen. evidence suggests that fdopa pet-ct can be substituted for iodine-123-n-fluoropropyl-2-beta-carbomethoxy-3-(4-iodophenyl)nortropane (i-123 fp-cit) or i-123 beta-cit spect to evaluate presynaptic dopaminergic integrity.5 when patients present with typical features of pd and respond to levodopa therapy, there is usually no need for nuclear neuroimaging. however, even in expert hands, approximately 25% of the patients with pd are misdiagnosed on clinical grounds,14 and thus if the clinical phenotype is atypical, or there is little or no response to levodopa, fdopa pet-ct can be of benefit to confirm or exclude the presence of dopaminergic degeneration, with a high sensitivity and specificity.5 this is true of distinguishing non-degenerative parkinsonian mimics such as psychogenic, vascular, and drug-induced parkinsonism and essential tremor from degenerative dopaminergic disorders, which include pd, corticobasal degeneration (cbd), progressive supranuclear palsy (psp) and multisystem atrophy (msa).5 in degenerative conditions, such as pd, there is progressive loss first of putaminal and then caudate uptake. frequently these changes are asymmetrical, typically worse on the side contralateral to the most affected limb.5 examples of fdopa scans in patients investigated for movement disorders are illustrated in figure 3. figure 3: fluorine-18 fdopa pet scans in five patients with movement disorders demonstrating absence of dopaminergic deficit (a) in a patient with essential tremor, and progressive stages of dopaminergic deficit (b – e) in patients with neurodegenerative disorders of the striatum. it should be noted that fdopa pet-ct, like all presynaptic dopaminergic imaging techniques, is unable to distinguish between the different degenerative dopaminergic disorders. evidence suggests that in the event that this is potentially of clinical importance, fdg pet-ct performs better than post-synaptic dopaminergic imaging,15 tracers for which are in any case not currently available in south africa. example scans of a patient investigated for a movement disorder with fdopa and fdg pet are provided in figure 4. figure 4: fluorine-18 fdopa (a) and fdg (b) pet scans in a patient with a movement disorder. the fdopa pet convincingly demonstrates dopaminergic loss in bilateral putamina, while the fdg study demonstrates normal metabolism. these features are consistent with a diagnosis of idiopathic parkinson’s disease. fdg pet-ct dopaminergic degenerative conditions other than pd, the so-called ‘parkinson-plus’ syndromes are difficult to treat and have a poor prognosis. there is evidence-based guideline endorsement for the use of fdg pet-ct to distinguish pd from psp10 and to support the diagnosis of cbd.10 characteristic reduction in metabolism on fdg pet-ct is one of the diagnostic criteria for possible msa.16 the fdg pet-ct features of the different parkinsonian syndromes are complex, and beyond the scope of this review.17 epilepsy the prevalence of epilepsy in south africa is unknown, but is likely high. approximately one-third of the patients with epilepsy suffer from seizures that are refractory to medication18 and may be suitable for surgical management. fdg pet-ct mri is the imaging modality of choice in identifying potentially resectable epileptogenic lesions, but will be negative or inconclusive in up to half of the patients.19 interictal pet-ct with fdg is a useful complementary tool in the workup of such patients, in whom the causal lesion is typically associated with a focal region of hypometabolism.19 evidence suggests that fdg pet-ct is able to lateralise the epileptogenic origin (figure 5) in more than 80% of temporal lobe epilepsy cases and while less sensitive in extra-temporal lobe variants, still plays an important role in guiding subdural electrode placement in invasive stereo-electroencephalography and is highly prognostic of seizure-free status post-surgery.19 best results using pet-ct are achieved with a combination of expert visual analysis and statistical methods with specialised neuro-analysis software tools.20 it is important, when performing pet-ct for this indication, that patients are correctly prepared and that interictal status is confirmed prior to radiopharmaceutical injection.4 figure 5: interictal fdg pet scan in a patient with intractable temporal lobe epilepsy being worked up for epilepsy surgery. the scan demonstrates marked hypometabolism in the left temporal lobe, confirming lateralisation of the epileptogenic focus. the right panel demonstrates the pet maximum intensity projection; top row pet orthogonal slices; bottom row fused (pet-ct) orthogonal slices. brain tumours brain tumour epidemiology in south africa is uncertain. the high prevalence of hiv in south africa likely influences primary brain tumour incidence, since there is evidence that meningiomas occur at a younger age, and glioblastomas occur at a greater frequency in hiv-positive individuals.21 certainly, primary central nervous system lymphoma (pcnsl) in south africa is mostly seen in the context of hiv, in which group it accounts for up to 15% of non-hodgkin’s lymphomas.22 brain metastases are known to develop in almost 30% of patients with solid tumours.23 there are many different brain tumours, but the clinical role for pet-ct is confined principally to three broad pathological subtypes which are considered here, namely gliomas, pcnsl, and brain metastases. management of most gliomas relies on a multidisciplinary combination of surgery, radiotherapy and chemotherapy.24 primary central nervous system lymphoma is managed with chemotherapy and, in hiv-positive patients, the addition of antiretroviral therapy.22 surgery or radiosurgery and/or radiotherapy are often considered to locally address brain metastases since many systemic cytotoxic medications fail to penetrate the blood-brain barrier.23 several second-line options are available to treat both recurrent gliomas and recurrent metastases, making the identification of recurrence important. mri is the primary modality for assessing primary and secondary brain tumours at all disease stages. assessing treatment response and identifying recurrence of brain tumours may however prove challenging on mri, because of the effects of tumour oedema and radiation necrosis post-therapy.25 fdopa pet-ct in contrast to fdg, the physiological uptake of fdopa in normal brain tissue is (except for in the striatum) low, which makes even subtle increases in uptake appreciable. in addition, increased fdopa uptake in inflammatory processes appears to be less of an issue compared to that seen with fdg. increased signal on fdopa pet-ct is thus a sensitive and specific marker for pathologies with upregulated expression large amino-acid transporters 1 and 2 (lat1 and lat2), which include gliomas and cancers that metastasise to brain.6 evidence supports the use of fdopa pet-ct in gliomas in evaluating tumour extent at baseline for the purpose of surgery and radiotherapy planning, and in evaluating treatment response in patients treated with antiangiogenic therapy (bevacizumab),26 as well as in identifying tumour recurrence post-therapy in both gliomas and brain metastases.6,26 there is currently insufficient evidence to support the use of fdopa pet-ct in distinguishing between neoplastic and non-neoplastic tissue or in establishing tumour grade. an example of fdopa pet in the evaluation of recurrent glioma is provided in figure 6. figure 6: fluorine-18 fdg (a) and fdopa (b) pet-ct (fusion) and pet images of a patient with suspected recurrence of a low-grade glioma. the fdg pet-ct study was normal, while fdopa pet-ct (preferred) demonstrates clear recurrence in the right putamen. this recurrent lesion was initially missed on mri. fdg pet-ct for the assessment of recurrence in all glial tumours, and in brain metastases, fdopa pet-ct is preferred over fdg pet-ct when mri is equivocal.6,26 however, when fdopa is not available, localised increase in fdg uptake may be useful in identifying tumour recurrence in patients with anaplastic glial and glioblastoma histologies,24 and in patients with brain metastases with high fdg avidity.27 evidence suggests that when used to detect recurrence of low-grade gliomas, fdg pet-ct is less sensitive,28 and by a similar rationale, fdg pet-ct should not be used to detect recurrence of treated brain metastases when these occur in the setting of a primary tumour with low fdg avidity. neither should fdg pet-ct be used for the primary diagnosis nor for grading of gliomas. whole-body fdg pet-ct is occasionally used in the workup of an unknown primary in a patient with brain metastases.24 although fdg pet-ct may play a role in differentiating pcnsl from toxoplasmosis in hiv-positive patients (avid uptake is described in pcsnl vs. typically minimal to absent uptake in toxoplasmosis), the evidence for this indication is limited.29 in the context of confirmed pcnsl, the performance of whole body pet-ct is appropriate to exclude the presence of synchronous systemic lymphoma, and to evaluate suspected systemic progression.24 neuropsychiatric lupus and immune-mediated encephalitides the incidence and prevalence of lupus in south africa are unknown, but it is likely that the disease is common, and frequently severe. throughout the world, paraneoplastic and autoimmune encephalitis are rare but represent important, treatable conditions. brain involvement in systemic lupus erythematosus (sle) is not unusual, and represents a serious but treatable complication.30 up to 80% of sle patients will develop psychiatric or neurological symptoms.31 in about 40% of such cases, symptoms occur by secondary mechanisms (e.g. related to infection or systemic organ dysfunction), with the remaining 60% being attributable to direct disease involvement of the brain.32 the diagnosis of neuropsychiatric-sle (npsle) is difficult and should be based on both the clinical presentation as well as the results of special investigations, which may include lumbar puncture; nerve conduction tests (for peripheral neuropathies); and electroencephalography.30 in terms of neuroimaging, mri is the preferred first-line imaging method, with nuclear medicine imaging techniques such as perfusion spect and fdg pet considered as ancillary.30 part of the difficulty in diagnosing npsle is that its pathophysiology is very likely multifactorial, related to autoantibodies, pro-inflammatory cytokines, microangiopathy and vasculitis.30 similarly, pet-ct may play a complementary role to mri in antibody-mediated encephalitides, whether these occur because of antibodies to intracellular neuronal proteins (paraneoplastic encephalitis syndromes), or due to antibodies targeting neuronal cell membrane/synaptic proteins (autoimmune encephalitis syndromes).33 fdg pet-ct fdg pet-ct may be considered to assist in the diagnosis of npsle when the clinical picture is strongly suggestive, but mri is normal or doubtful.30 one study identified abnormalities on fdg pet-ct in 75% of such cases.34 parieto-occipital hypometabolism is most frequently described, though hypometabolism in other regions and occasional hypermetabolic lesions may also be observed.30 increased uptake in the striatal nuclei has been described in patients with antiphospholipid syndrome and chorea (figure 7).35 figure 7: fluorine-18 fdg pet (maximum intensity projection) in a patient known with systemic lupus erythematosus who presented with new-onset of choreoathetoid movements. intense, symmetrical uptake in the striatal nuclei is consistent with a known neurological manifestation of systemic lupus erythematosus. mri in this case reported non-specific features of microangiopathy. in autoimmune encephalitis, fdg pet-ct of the brain may play an important role in establishing the diagnosis, especially when mri is negative or equivocal, and in antibody negative cases.36 often, characteristic hypermetabolism is seen in the limbic regions in these patients, although abnormalities in the brainstem, cerebellum and cerebral cortex are also described.36 in paraneoplastic encephalitis, whole body fdg pet-ct may be warranted in identifying the site of the primary tumour depending on the clinical syndrome, the type of antibodies present and the results of conventional anatomical imaging.33 brain infections africa has the world’s highest incidence of central nervous system (cns) infections in the region of 770/100 000 per year.37 the worldwide incidence of opportunistic cns infections in hiv-positive patients has fallen drastically since the widespread rollout of antiretroviral therapy but remains a problem in africa, including south africa. pet-ct plays a minimal role in brain infections but is occasionally useful when structural imaging is inconclusive. limited evidence suggests possible roles for fdg pet-ct to distinguish between toxoplasmosis and pcnsl in hiv-positive patients,29 and as an occasional adjunct in the diagnosis of encephalitis.38 research demonstrating a clear benefit of fdg pet-ct in patients with infective meningitis is lacking. there are currently no recognised clinical indications for fdopa pet-ct in the management of brain infections. traumatic brain injury south africa has high rates of interpersonal violence and road traffic accidents. while there are no figures on the epidemiology of either severe or mild traumatic brain injury (tbi), the contribution of tbi to morbidity and mortality is likely substantial. regional uptake of fdg is frequently reduced after tbi, even when the injury is mild39 making it an attractive research tool in the study of this condition. there is however insufficient evidence to support the use of fdg pet-ct in tbi for clinical or medicolegal purposes. nuclear physicians should always enquire about previous history of head injury when interpreting fdg pet-cts performed for other indications, to avoid this potential confound. psychiatric and neurodevelopmental disorders with the possible exception of using fdg pet-ct to distinguish depressive pseudo-dementia (anecdotally supported by an expert panel),10 pet-ct currently plays no role in the clinical management of these disorders on a single-subject level. discussion there is evidence that brain pet-ct with fdopa or fdg is frequently clinically invaluable. south africa is in many respects fortunate to have an established pet-ct infrastructure and access to these two pet tracers which have well-defined applications in neurological disorders. despite this and the opportunity to improve patient care, pet-ct likely remains underutilised. this article has reviewed the most common clinical applications for brain pet-ct. it is important to emphasise that indications exist outside the scope of this review for which pet-ct may be appropriate, and that these indications evolve with emerging evidence and as new tracers become available. there is a need for evidence-based south african guidelines to assist clinicians, nuclear medicine physicians and medical insurers. in addition, it is incumbent on clinicians to incorporate brain pet-ct into professional societal guidelines when there is sufficient evidence to support doing so. several barriers exist to accessing pet-ct scans, which must be overcome. one of these is the scarcity of pet-ct scanners in some regions. this is most apparent in the state sector and will only be addressed through high-level strategic planning by provincial health departments engaging with nuclear physicians and clinicians. it is important that as part of such consultations, doctors provide the necessary evidence supporting the use of pet-ct as well as (ideally) cost-effectiveness data. given that most pet-ct work is performed for oncological indications, such data would necessarily need to focus predominantly on pet-ct’s utility and its cost-effectiveness in cancer management. related to this, prices for brain pet-cts may frequently be prohibitive and there is a need to explore strategies that might reduce costs and so improve patient access. in the authors’ experience, many south african nuclear physicians believe they lack the expertise and/or confidence to report these studies. there are several possible strategies to address this. firstly, nuclear medicine practitioners should familiarise themselves with the main guidelines.4,5,10,26 brain pet-ct requires careful attention to study indication, patient preparation, acquisition and quality control, and interpretation as detailed in these documents. secondly, interpretation of brain pet-cts should be limited to nuclear physicians with adequate training and expertise in this field, and with access to the necessary quantitative tools. thirdly, nuclear physicians should arrange additional training in the performance and interpretation of nuclear neuroimaging by petitioning their professional societies for workshops or other educational forums in which their requirements are addressed. finally, during interpretation of brain pet-cts, the use of semiquantitative statistical scoring tools enhance specificity, accuracy and reader confidence, and are especially valuable for less experienced readers.40 the main strength of pet-ct is its ability to image biological processes, which are typically disturbed before appreciable anatomical changes occur in disease.2 the main limitations of pet are its lower spatial resolution when compared to mri and ct, and its limited specificity, especially with respect to fdg pet. these weaknesses are circumvented when pet is used in combination with structural techniques, in the appropriate clinical context. nuclear neuroimaging techniques such as pet-ct should in other words be considered as complementary to mri and ct. in such an ancillary capacity, brain pet-ct has several evidence-based applications in the fields of gerontology, neurology, neuro-oncology, rheumatology and infectious disease. the value of multidisciplinary team management is now widely accepted in clinical medicine and in the authors’ opinion there is a growing rationale to include nuclear physicians as partners in improving patient care. this will become even more important as neurological radiotracers already available internationally become available in south africa in the future. conclusion brain pet-ct with fdg or fdopa may be currently underutilised in south africa. nuclear neuroimaging techniques have several evidence-based applications which may warrant greater use in clinical practice. there is a need for evidence-based south african guidelines to assist clinicians, nuclear medicine physicians and medical insurers in selecting patients appropriately imaged with pet-ct. acknowledgements the authors wish to thank the patients whose scan images were used in this article. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions the first author (a.g.g.d.) was the principal author of this work. all other authors provided input in their respective areas of expertise. all authors have read and agreed to the submitted version. funding information the authors received no financial support for the research, authorship, and/or publication of this article. data availability figures 1–7 have associated reconstructed medical imaging data. the associated data are classified as protected health information under the protection of personal information act of 2013. disclaimer the views expressed in the submitted article are the authors’ own and not an official position of their institutions. references gbd, neurological disorders collaborator group. global, regional, and national burden of neurological disorders during 1990–2015: a systematic analysis for the global burden of disease study 2015. lancet neurol. 2017;16(11):877–897. 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newberg ab, liebeskind ds, kung j, alavi a. fdg-pet findings in patients with suspected encephalitis. clin nucl med. 2004;29(10):620–625. https://doi.org/10.1097/00003072-200410000-00004 byrnes kr, wilson cm, brabazon f, et al. fdg-pet imaging in mild traumatic brain injury: a critical review. front neuroenergetics. 2014;5:1–13. https://doi.org/10.3389/fnene.2013.00013 nobili f, festari c, altomare d, et al. automated assessment of fdg-pet for differential diagnosis in patients with neurodegenerative disorders. eur j nucl med mol imaging. 2018;45(9):1557–1566. https://doi.org/10.1007/s00259-018-4030-3 case report botryomycosis is a rare condition that involves the skin and viscera. it is multifactorial in its development, characterised by granulomatous bacterial infection. the organisms form granules composed of bacterial masses that are adhered to each other. we present a case of botryomycosis with calvarial destruction. case report a 53-year-old woman presented with a slow-growing mass lesion on the right temporal area. the lesion had started about 14 years previously as a small nodule. there were no other associated complaints at that time. there was a history of being assaulted on the head 17 years prior to the presentation, for which the patient underwent craniotomy. on examination, there was a nodular fungating mass overlying the right temporal area with draining sinuses. vital signs were normal. systemic examination did not reveal anything of note. investigations full blood count showed normochromic, normocytic anaemia. the patient had a haemoglobin level of 10.8 g/dl and was hiv-negative. blood cultures were also negative. on tissue culture, there were coagulase-negative staphylococci, klebsiella pneumonia, and staphylococci group d. chest x-ray was normal. a skull x-ray was performed (fig. 1), which showed a right frontal bone defect. an axial computed tomography (ct) scan of the brain performed with contrast (figs 2 and 3) revealed an obvious right frontal bone defect with irregular margins. an associated soft-tissue mass was noted involving the right fronto-parietal area with an associated intracranial component. the mass had a sinus containing air running across it. there was post-contrast dense homogeneous enhancement of both the extra-and intracranial components of the mass. there was an area of hypodensity in the right frontal lobe in keeping with gliosis secondary to the old insult. an assessment of botryomycosis was made. actinomycosis was also a considered differential diagnosis. the patient was further sent to plastic surgeons for incisional biopsy. results came back as botryomycosis. discussion botryomycosis was first reported in 1870. it occurred in a horse as a result of post-castration complications which later spread to the lungs. les formes actinomycotiques du staphylocoque, the first paper published on botryomycosis involvement in humans, appeared in 1914 1919.1,2 it stated that the causal agent was staphylococcus aureus. contrary to initial thoughts on the subject, the granules were not composed of mycotic masses, but were composed of bacteria that adhered to each other. despite the fact that the term botryomycosis is not appropriate as it implies a fungal and not a bacterial infection, it is the term most accepted in the literature. botryomycosis is caused by multiple bacteria, with s. aureus usually the major causal agent (approximately 40%) and pseudomonas aeruginosa ranking second in frequency (approximately 20%) (table i).1 the pathogenesis of botryomycosis is not well known. it is associated with defects of cellular immunity, particularly with low lymphocyte counts.1,3 botryomycosis requires a delicate balance between the number of microorganisms inoculated, their low virulence and the host’s tissue response, for it to occur.1-3 with a relative impairment of cellular immunity, all of these conditions result in a sort of ‘symbiosis’ between the two. the major predisposing factors are skin trauma, postoperative complications, diabetes mellitus, liver disorders, treatment with steroids1,4 alcoholism and cystic fibrosis.1,3,5 less common factors are malnutrition, glomerulonephritis, aids, and bronchial asthma.1 the condition may present in cutaneous or visceral form. in the cutaneous form, patients present with a suppurative, granulomatous and usually chronic condition, as in our patient. it may be initiated by trauma.1 most cases present with nodules, sinuses (also similar to our patient), fistulae, abscesses and ulcers with purulent secretions. in the visceral variety, it occurs in surgical patients, in those undergoing prolonged hospital stay, or in immunosuppressed patients. it is mostly localised in the lungs. differential diagnosis botryomycosis of the skin should be differentiated from mycetoma, actinomycosis, abscesses, and tuberculosis. it also depends on the site of infection. treatment depends on the causal microorganism isolated. botryomycosis j z makama, mb chb n khan, mb bs, fcrad (d) sa n z makhanya, mb chb department of diagnostic radiology, university of limpopo, medunsa campus h motswaledi, mb chb, mmed (derm), fcderm department of dermatology, university of limpopo, medunsa campus case report fig. 1. lateral skull x-ray: a right frontal bone defect. 14 sa journal of radiology • march 2006 case report botryomycosis.indd 14 3/27/06 12:09:48 pm conclusion botryomycosis is a rare condition, but the infection rate appears to be increasing. cases may still be missed or mistakenly identified, mainly confused with fungal infections. it is advised that when a patient presents, all investigations be correlated to reach the proper diagnosis. 1. bonifaz a, carrasco e, botryomycosis. int j dermatol 1996; 35: 381-388. 2. findlay gh, vismer hf. botryomycosis, some african cases. int j dermatol 1990; 29: 340-344. 3. brunken cr, lichon-chao n, van der broek h. immunologic abnormalities in botryomycosis. j am acad dermatol 1983; 9: 428-434. 4. schlossberg d, kerney ge, lifton lj, azizhkan rg. anaerobic botryomycosis. j clin microbiol 1980; 11:184-185. 5. wu wq, cattaneo ea, lapi a, halde c. botryomycosis: first report of human brain involvement. south med j 1978; 71: 1530-1533. case report table i. incidence of causal organisms aetiology % staphylococcus aureus 42.9 pseudomonas aeruginosa 19.9 micrococcus pyogenes 7.2 streptococcus spp. 4.8 escherichia coli 3.6 staphylococcus epidermidis 2.4 proteus vulgaris 2.4 propionibacterium acnes 2.4 pseudomonas cepacia 1.1 neisseria spp. 1.1 neisseria mucosa 1.1 fig. 2. non-contrast axial ct scan: right fronto-parietal soft-tissue mass, with an intracranial component. the scan also confirmed the bone defect. fig. 3. post-contrast axial ct scan: dense homogeneous enhancement of both the extra-and intracranial components of the mass. 15 sa journal of radiology • march 2006 botryomycosis.indd 15 3/27/06 12:09:49 pm tips the case of the •regenerating cortex w hen shown the scan of a patient with gross hydrocephalus, colleagues often ask whether there is any point in treating the patient. the ct scans reproduced here dramatically show the process of cortical regeneration in a neonate presenting with congenital hydrocephalus .the first scan is two days post-delivery, the second immediately after insertion of a ventriculo-peritoneal shunt, and the final scan at age two. the child is developmentally normal on clinical testing. d carter mbchb department of neurosurgery, university of cape town sb sa journal of radiology· february 2001 until recently there were few studies concerning reversal of the patholological changes following shunting. newer animal models are showing that there is indeed a reversal in at least some of the deficits occurring with hydrocephalus, if treated early: remyelination can occur, cortical vasculature may return to a normal configuration, there may be restoration of ependyma and peri ventricular capillaries, and there is at least partial restoration of cortical gray matter cytoarchitecture. these processes are as yet still poorly explained, but these scans demonstrate well the macroscopic regeneration of the cerebral cortex with early treatment of hydrocephalus reference choux m et al. paediatric neurosurgery. churchill livingstone. 1999. abstract introduction case description discussion conclusion acknowledgements references about the author(s) jayaranjeetham jayabalan department of radiodiagnosis, pondicherry institute of medical sciences, puducherry, india nithin theckumparampil department of radiodiagnosis, pondicherry institute of medical sciences, puducherry, india aravintho natarajan department of radiodiagnosis, pondicherry institute of medical sciences, puducherry, india dilip s. phansalkar department of radiodiagnosis, pondicherry institute of medical sciences, puducherry, india george kurian department of gastroenterology, pondicherry institute of medical sciences, puducherry, india citation jayabalan j, theckumparampil n, natarajan a, phansalkar ds, kurian g. vigorous achalasia: zebra amongst horses. s afr j rad. 2020;24(1), a1953. https://doi.org/10.4102/sajr.v24i1.1953 case report vigorous achalasia: zebra amongst horses jayaranjeetham jayabalan, nithin theckumparampil, aravintho natarajan, dilip s. phansalkar, george kurian received: 21 july 2020; accepted: 09 sept. 2020; published: 30 nov. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract vigorous achalasia is an oesophageal disorder with clinical and radiological characteristics of classic achalasia and diffuse oesophageal spasm. it is a rarely reported variant. a 60-year-old gentleman presented with complaints of difficulty in swallowing, regurgitation and chest pain for the past 10 years. his symptoms persisted despite the use of proton pump inhibitors. on endoscopy and barium swallow, the diagnosis of vigorous achalasia was confirmed. it is a rare variant of classic achalasia usually misdiagnosed as diffuse oesophageal spasm. keywords: vigorous achalasia; diffuse oesophageal spasm; classic achalasia; barium swallow; proton pump inhibitors. introduction classic achalasia and diffuse oesophageal spasm (des) both have different clinical, radiological and manometric features.1 chest pain is more common in des, whereas it is uncommon in classic achalasia. regurgitation and retention are more common in classic achalasia, whereas they are uncommon in des.2 at barium swallow imaging, classic achalasia shows dilatation and des demonstrates a corkscrew appearance. motility studies indicate that des and classic achalasia are at opposite ends of a spectrum.3 diffuse oesophageal spasm responds less to treatment, unlike classic achalasia.4 some individuals have a combination of the above-mentioned symptoms and cannot be placed under already established entities.2 in 1957, olsen et al. first described the term vigorous achalasia in a group of individuals with classic achalasia whose clinical features and manometric features demonstrated common features of both classic achalasia and des.5 according to millan et al.,3 vigorous achalasia falls in-between the two extremes (des and classic achalasia) of the oesophageal motility disorder spectrum.3 this case illustrates the unusual oesophageal disorder of vigorous achalasia. case description a 60-year-old male with no known comorbidities, presented with a 10-year history of difficulty in swallowing (liquids more than solids) and chest pain, which persisted despite the use of proton pump inhibitors. his physical examination and laboratory parameters were unremarkable. a barium swallow study was recommended, followed by upper gastro-intestinal (ugi) endoscopy. during the barium swallow study (using baritop powder 100% w/v 250 ml), the cervical and proximal part of the thoracic oesophagus showed normal passage of barium (figure 1). the distal part of the thoracic oesophagus exhibited a few areas of narrowing and areas of dilatation proximal to the narrowed segments (figure 2). tertiary contractions were noted and the distal end of the esophagus displayed spindle-shaped tapering (figure 3). figure 1: (a, b) barium swallow antero -posterior (ap) view and lateral view, barium passed down the cervical and upper thoracic oesophagus smoothly and normally. figure 2: (a) barium swallow left anterior oblique (lao) view – arrows denote the areas of narrowing in the lower thoracic oesophagus. (b) barium swallow antero – posterior (ap) view – arrows denote the areas of dilatation of the oesophagus proximal to the areas of narrowing. figure 3: barium swallow antero – posterior (ap) view – arrow denotes the spindle-shaped tapering of the lower end of the esophagus. arrowhead denotes the tertiary contractions. at ugi-endoscopy, (olympus scope – size 2.8 mm), the upper part of the oesophagus was mildly dilated but otherwise normal. the distal part revealed lower oesophageal sphincter (les) stenosis with pooling of saliva proximal to it. there was difficulty in passing the ugi scope beyond the site of the stenosis (figure 4). figure 4: (a) upper gastro-intestinal endoscopy – shows the dilated proximal esophagus and stenotic lower oesophageal sphincter (b) difficulty in passing the endoscope beyond the stenosis (c) pooling of saliva above the stenotic lower oesophageal sphincter. discussion vigorous achalasia is an unusual oesophageal disorder that has clinical and radiological characteristics of both achalasia and des.5 according to one study, vigorous achalasia falls in-between the two extremes (des and classic achalasia) of the oesophageal motility disorder spectrum.3 although manometry is the gold standard test for motility disorders, it is time consuming and not easily available.6,7 in this case the radiological findings were very clear. classic achalasia versus vigorous achalasia achalasia is an uncommon disorder that involves loss of inhibitory ganglions in the myenteric plexus of the les and the body of the oesophagus. over time, the progressive loss of cholinergic neurons results in dilation and low amplitude simultaneous contractions in the oesophageal body, resulting in classic achalasia.8 regurgitation and retention are the most common symptoms in classic achalasia, whereas chest pain is uncommon.2 at barium swallow imaging there will be proximal dilatation of the oesophagus with tapering (‘bird beaking’) of the lower end of the oesophagus. classic achalasia is characterised by the complete absence of peristalsis.9 the diameter of the oesophageal body in vigorous achalasia is generally less than that of classic achalasia. as in our case of vigorous achalasia, there is minimal oesophageal dilatation with tertiary contractions and spindle-shaped tapering of the lower end of the oesophagus10 (figure 3). endoscopy of classic achalasia shows a dilated tortuous oesophagus with retention of fluid or food.11 the manometry study by goldenberg et al. revealed that the amplitude is less than 37 mm hg in achalasia, whereas it is greater than or equal to 37 mm hg in patients with vigorous achalasia.12 previous studies on the management of these conditions revealed that vigorous achalasia is less responsive to pneumatic dilatation when compared with achalasia and have recommended surgery.2,13 in a study by okike et al.,14 the thoracic approach of an extended oesophageal myotomy of the oesophagus to the point where there are excess pressures and/or repetitive waves, was found to be better than pneumatic dilatation. later, a study by paricio et al.15 showed that heller’s myotomy, not extended to the oesophageal body, via an abdominal approach, also yields better results in vigorous achalasia as compared with classic achalasia.15 peroral endoscopic myotomy (poem) is a minimally invasive endoscopic treatment for symptomatic oesophageal achalasia.16 it was found to be effective in nearly 93.7% of patients with type iii or vigorous achalasia.17 diffuse oesophageal spasm versus vigorous achalasia diffuse oesophageal spasm (des) is a rare motility disorder characterised by chest pain, dysphagia and intermittent increased simultaneous contractions.18 impairment of the oesophageal inhibitory pathway results in premature contractions in the distal muscularis propria. thus, the pathophysiology is similar to achalasia.19 chest pain is the most common symptom in des, whereas it is uncommon in vigorous achalasia.2 in our case, the patient experienced both dysphagia and chest pain. physiologically, the studies on motility revealed that des is the opposite of achalasia.3 diffuse oesophageal spasm responds less to treatment, unlike achalasia.4 endoscopy can sometimes show simultaneous ring-shaped contractions.20 at barium swallow imaging, des shows interruption of the normal peristalsis by multiple, repetitive, non-propulsive oesophageal contractions (tertiary peristaltic waves) resulting in the characteristic corkscrew oesophagus.21 manometric criteria includes the presence of simultaneous contractions in the distal (smooth muscle) oesophagus in more than 10% of wet swallows with an amplitude contraction of at least 30 mm hg, alternating with normal peristalsis.22 comparatively, vigorous achalasia is an atypical variant with non-peristaltic contractions giving the appearance of a corkscrew oesophagus on barium swallow23 (figure 3). the clinical features, imaging findings, endoscopic and manometric findings of oesophageal motility disorders are summarised in table 1. table 1: characteristic features of the oesophageal motility disorders. conclusion vigorous achalasia is a rare oesophageal motility disorder, commonly misdiagnosed as des. knowledge and recognition of this uncommon entity will help in early recognition and optimal management. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. ethical consideration this article followed all ethical standards for carrying out research. data availability statement the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references castell do. achalasia and diffuse esophageal spasm. arch intern med. 1976;136(5):571–579. https://doi.org/10.1001/archinte.1976.03630050053010 sanderson dr, ellis fh, schlegel jf, olsen am. syndrome of vigorous achalasia: clinical and physiologic observations. dis chest. 1967; 52(4):508–517. https://doi.org/10.1378/chest.52.4.508 millan ms, bourdages r, beck it, dacosta lr. transition from diffuse esophageal spasm to achalasia. j clin gastroenterol. 1979;1(2):107–117. https://doi.org/10.1097/00004836-197906000-00003 olsen am, ellis fh, creamer b. cardiospasm (achalasia of the cardia). am j surg. 1957;93(2):299–307. https://doi.org/10.1016/0002-9610(57)90782-1 what is vigorous achalasia ? 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[cited 2020 may 19]. available from: http://www.oeso.org/oeso/books/vol_4_prim_motility/articles/art122.html cohen s, motor disorders of the esophagus. n engl j med. 1979;301(20):1124–1125. https://doi.org/10.1056/nejm197911153012016 schima w, ryan jm, harisinghani m, et al. radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy. clin radiol. 1998;53(5):372–375. https://doi.org/10.1016/s0009-9260(98)80012-3 ghoshal uc, daschakraborty sb, singh r. pathogenesis of achalasia cardia. world j gastroenterol. 2012;18(24):3050–3057. https://doi.org/10.3748/wjg.v18.i24.3050 camacho-lobato l, katz po, eveland j, vela m, castell do. vigorous achalasia: original description requires minor change. j clin gastroenterol. 2001;33(5):375–377. https://doi.org/10.1097/00004836-200111000-00006(1) rhee k, jeon h, kim j-h, yoon yh, park h, lee si. an evidence of esophageal decompensation in patients with achalasia in the view of its subtype: a retrospective study. j neurogastroenterol motil. 2013;19(3):319–323. https://doi.org/10.5056/jnm.2013.19.3.319 mccormick se, kozarek ra. endoscopic evaluation of esophageal motility disorders. gi motil online [serial online]. 2006 [cited 2020 may 25]. available from: https://www.nature.com/gimo/contents/pt1/full/gimo29.html goldenberg sp, burrell m, fette gg, vos c, traube m. classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings. gastroenterology. 1991;101(3):743–748. https://doi.org/10.1016/0016-5085(91)90534-r giuli r. o.e.s.o. the esophagogastric: the esophagogastric junction. arcueil: john libbey eurotext; 1998, p. 1674. okike n, payne ws, neufeld dm, bernatz pe, pairolero pc, sanderson dr. esophagomyotomy versus forceful dilation for achalasia of the esophagus: results in 899 patients. ann thorac surg. 1979;28(2):119–125. https://doi.org/10.1016/s0003-4975(10)63767-8 parrilla paricio p, martinez de haro lf, ortiz escandell a, morales cuenca g, molina martinez j. short myotomy for vigorous achalasia. br j surg. 1993;80(12):1540–1542. https://doi.org/10.1002/bjs.1800801215 eleftheriadis n, inoue h, ikeda h, et al. training in peroral endoscopic myotomy (poem) for esophageal achalasia. ther clin risk manag. 2012;8:329–342. https://doi.org/10.2147/tcrm.s32666 poem effective in spastic esophageal disorders [homepage on the internet]. [cited 2020 sep 4]. available from: https://www.healio.com/news/gastroenterology/20190613/poem-effective-in-spastic-esophageal-disorders patel da, vaezi mf. a spiraling case of persistent dysphagia. gastroenterology. 2015;149(2):298–299. https://doi.org/10.1053/j.gastro.2015.04.049 roman s, kahrilas pj. distal esophageal spasm. curr opin gastroenterol. 2015;31(4):328–333. https://doi.org/10.1097/mog.0000000000000187 kato t, naiki t, araki h, nagaki m, moriwaki h. diffuse esophageal spasm. gastrointest endosc. 2004;60(4):428. https://doi.org/10.1016/s0016-5107(04)01706-7 carucci lr, turner ma. dysphagia revisited: common and unusual causes. radiogr rev publ radiol soc n am inc. 2015;35(1):105–122. https://doi.org/10.1148/rg.351130150 achem sr. diffuse esophageal spasm in the era of high-resolution manometry. gastroenterol hepatol. 2014;10(2):130–133. del pozocalzada c, molina llorente h, gonzález gutiérrez m. vigorous achalasia. med clin (barc). 2018;150(3):124. https://doi.org/10.1016/j.medcli.2017.03.019 case report a bizarre cause of gastric outlet obstruction s allopi fes b singh fes j moodley fes j maharaj* frad departments of general surgery and radiology· university of natal, nelson r mandela school of medicine, durban abstract gastric outlet obstruction (goo) is invariably consequent upon intrinsic gastroduodenal pathology. ingested foreign bodies are rarely considered to be a cause of this condition. we report possibly the first case of goo caused by metallic foreign bodies occluding the pyloro-duodenal junction. case report a 40-year-old inmate of a mental sanatorium was referred with epigastric pain of 2 weeks' duration, postprandial vomiting and loss of weight of 6 weeks' duration. apart from being treated for schizoprenia, there was no history of peptic ulcer disease or other medical ailments. at the sanatorium, he did duty in the workshop. on examination, the patient was found to be dehydrated. the systemic examination, including abdominal examination, was normal. biochemical evaluation revealed a mild hypochloraemic metabolic alkalosis, in keeping with goo. in view of the clinical suspicion of goo, upper endoscopy was performed; this revealed several metallic objects tamponading the pylorus of a capacious stomach. endoscopic retrieval of these foreign bodies was unsuccessful. presence of these metallic objects was confirmed on plain abdominal x-rays (fig. i), and their location was confirmed using barium contrast study. at surgery, a contained perforation of the anterior gastric wall was noted; a total of 15 metallic objects fig. 1. plain abdominal radiograph demonstrating cluster of metallic foreign objects lodged along pyloro-antral region of a capacious stomach. 39 sa journal of radiology • october 2001 f/g. 2. metallic objects (weighing 678 g) retrieved via gastrotomy. ranging in length from 5 to 15 cm were dislodged from the antropyloric region via gastrotomy. these objects weighed a total of 678 g (fig. 2). the stomach was noted to be grossly dilated. the patient's postoperative recovery was uneventful, with satisfactory resolution of his presenting complaints. discussion chronic peptic ulcer disease is arguably the most likely cause of goo. untreated or unsuspected peptic ulcer disease accounts for up to 10% of goo. other causes include distal gastric cancer and benign strictures (of the antropyloro-duodenum) caused by caustic injury, tuberculosis or crohn's disease. foreign bodies causing goo are extremely rare. possibly the most recognised gastric foreign body is the bezoar, a tightly packed mass of fruit or vegetable matter, hair or other material that forms in the gastrointestinal tract. most bezoars form in the stomachs of patients with impaired gastric emptying due to effects of previous gastric surgery or other conditions associated with gastric stasis." bezoars are usually radioopaque. given the tendency for these to increase in size, removal is effected case report by means of gastrotomy. eighty per cent of foreign bodies in the upper gastro-intestinal tract occur in paediatric patients, followed by edentulous adults, prisoners and psychiatric patients.' most objects (80 90%) pass spontaneously, but 10 20% have to be removed endoscopically, and about 1% require surgery," objects thicker than 2 cm and longer than 5 cm tend to lodge in the stomach.' long foreign bodies (> 10 cm) tend to lodge in the duodenum, where perforations may develop. in addition to causing ulceration, bleeding and perforation, it is conceivable that they predispose to goo, as demonstrated in this patient. the spectrum and size of the foreign body noted on the imaging studies served as the reason for our early recourse to surgery, rather than anticipating the spontaneous passage of these foreign bodies. recurrent episodes of foreign body ingestion may occur, especially in prisoners, psychiatric patients and patients with peptic strictures. references 1. goldstein ss, lewis jh, rothstein r. intestinal obstruction due to bezoars. am j gastroenterol 1984; 79: 313-318. 2. mit am, mir ma. phytobezoar after vagotomy with drainage or resection. br j surg 1973; 60: 846-849. 3. webb wa. management of foreign bodies of the upper gastrointestinal tract. gastroenterology 1988; 94: 204-206. 4. schwartz ge polsky hs. ingested foreign bodies of the oesophagus. ann surg 1985; 51: 173178. 5. perelman h. toothpick perforation of the gastrointestinal tract. j abdom surg 1962; 4: 51-53. 6. kock h. operative endoscopy. gastrointest endosc 1977; 24: 65-68. a midline nasopharyngeal cystic structure thornwaldt's cyst ralph drosten mb bch, fcrad d/ag department of thoracic imaging brigham and women's hospital boston, usa case presentation a 39-year-old woman presented to her doctor complaining of a non-productive cough. on examination, the clinician identified a non-inflamed cystic lesion in the soft tissues of the posterior nasopharynx, slightly to the right of the midline. magnetic resonance imaging (mri) examination of the region of interest confirmed a 12 x 11 mm welldefined cystic lesion in the posterior nasopharynx, slightly to the right of centre. it demonstrated a homogeneously hyperintense signal on t1weighted images, fat suppression and stir sequences (figs 1, 2 and 3). it had a thin wall and did not infiltrate the adjacent soft tissues. 40 sa journal of radiology. october 2001 on the basis of these imaging characteristics, the diagnosis of a thornwaldt's cyst was made. discussion thornwaldt's cyst is a midline congenital pouch or cyst, lined by ectoderm, within the nasopharyngeal mucosal space. it is present in 4% of autopsy specimens and develops from an ectopic portion of notochordal remnants in the nasopharynx. the peak age of presentation is 15 30 years.i clinical symptoms range from it being completely asymptomatic and an incidental finding, to persistent nasopharyngeal drainage, halitosis and a foul taste in the mouth. the presenting cough in our patient's case was presumably secondary to nasopharyngeal drainage and irritation. mri is the imaging modality of choice. cysts measure from 1 to 30 mm in diameter and have a high signal intensity on tl and t2-weighted images, probably editorial we are in this together l d r tsatsi mb chb, fcrad(d)sa head: department of diagnostic radiology medical university of southern africa the subject invokes memories of a story i heard recently on the radio. a farmer decided to lay traps for mice in his farmhouse. the mouse heard of the plan and called on the farm animals for help, fearing for its life. regrettably the cow, the pig and the hen stated very clearly that this did not involve them. as it would happen the mouse was killed in one of the traps, and the farmer's wife, on seeing a dead mouse, got such a fright that she fell down the steps to her death. the hen had to be killed to make lunch for relatives who came to console the farmer. the pig was sold to the abattoir in order for the farmer to purchase the coffin. the pig did not last a day and was slaughtered for bacon. the cow suffered the same fate so tbat the guests could be fed at the funeral. the moral of the story is that what may appear far removed from you may influence you directly. the appalling state of equipment and service within the public service today is of great concern to us all. we have to train young radiologists in this art under very trying circumstances. it is my hope and prayer that none of us will be managed by a radiologist who is inadequately trained in certain procedures, for e.g. angiography. the flip side of the coin involves hardships experienced by practitioners in the private sector. colleagues have had to endure low tariffs and non-payment of services by medical aids and government institutions for services rendered. again, this will indirectly have a bearing on people far removed from the coalface. radiation doses it is of concern that while the radiology trainee has to undergo relatively stringent examinations in physics and the importance of dose reduction, it would appear that some of our colleagues in other disciplines need not concern themselves with these factors. clinicians use x-ray facilities with minimal if any protection for themselves, the support staff who work with them and the patients. few, if any of the clinicians wear radiation badges for recording radiation doses. it is hoped that the radiation board or some government institution will take responsibility lest our population doses get out of control. congratulations congratulations to professor peter corr who was awarded the antoine beclere medal for service to radiology at the international society of radiology (isr) 2002 meeting, held in cancun, mexico. professor corr also delivered a lecture entitled 'aids, a global problem', which was highly acclaimed. i am sure i am speaking for the south african radiological community in applauding his achievements, commitment and service to the greater radiological conununity and humanity. dr jan labuscagne is also to be congratulated on his re-election to the isr executive committee at cancun. dr jan labuscagne and professor raymond glynn thomas both delivered papers at cancun. congratulations and sterkte. l d r tsatsi editor 3 sa journal of radiology • september2002 case report intervertebral disc calcification in children abstractkg maj!nus bsc(uct), mbchb(uct), mmed(radd, stell) symptomatic cervical intervertebral disc calcification in children presents vvith characteristic signs and symptoms, and usually has a benign, self-limiting and predictable course. the radiological images of the spine likevvise have typical appearances, vvith a recognisable pattern and fof lovvirig a predetermined course. a case report of this uncommon condition in an 8-year-old boy i ii ustrates most of the clinical and radiological findings in th is entity. department of paediatric radiology, red cross war memorial children's hospital, capetown introduction intervertebral disc calcification (ivdc) is uncommon in children.t'? first described by baron in 1924,14 numerous articles have since appeared. few of these reports have appeared in the radiological literature, and the majority of these have been published in paediatric radiology journals. the b sa journal of radiology. august 1998 aim of this article is to bring this uncommon but important subject to the attention of all radiologists. case report a lo-year-old boy presented at red cross children's hospital with a two-day history of an extremely painful neck. the onset was spontaneous and was not associated with any injury. dysphagia without regurgitation of food had been periodically experienced. no other symptoms were elicited from the patient. examin ation revealed a wellgrown, apyrexial boy with a marked torticollis. the patient's head was tilted and rotated to the left as a result of severe left-sided sternocleidomastoid muscle spasm. any form of head or neck movement produced acute neck pain and consequently mobility was totally restricted. both upper limbs were neurologically normal, with no evidence of radiculopathy. an ear, nose and throat examination was normal. plain x-rays of the cervical spine were performed at the time of the initial consultation. the anteroposterior (ap) (figure 1) and lateral (figure 2) figure 1: ap cervical spine x-ray. chin tilted and rotated to the left. scoliosis convex to the right. dense, oval shaped, central calcified intervertebral disc (arrow) at c5/6 level. topageg intervertebral disc calcification in children figure 2: lateral cervical spine x-ray. the slight rotation and scoliosis results in poor lateral positioning. linear, layered, densely calcified c5/6 intervertebral disc (arrow). anterior wedging of the c5 vertebral body also present. projections demonstrated scoliosis convex to the right, with tilting and rotation of the head towards the left, plus dense, irregular, layered calcification of the intervertebral disc at the cs/c6 level. loss of height of the anterior cs vertebral body was present, giving it a wedge shape. the paravertebral soft tissues plus the remainder of the cervical vertebral bodies and their posterior elements were normal in appearance. computed tomography (ct) of the cervical spine followed the plain x-rays. ct confirmed the dense calcification in the nucleus pulposus of the cs/c6 intervertebral disc (figure 3). unsuspected central posterior herniation of the calcified nucleus pulposus through the annulus fibrosis was present, with slight midline protrusion of the calcified material into the spinal canal. the subligamentous (anterior to the posterior longitudinal ligament) calcified disc herniation indented the dural sac without compressing the spinal cord. sagittal reconstruction confirmed the anterior wedging of the vertebral body of cs. the remainder of the vertebral bodies and their posterior elements, as well as the surrounding paraspinal soft tissue structures appeared normal. scoliosis and rotation of the cervical spine were confirmed. n on -steroidal anti -inf amma tory drugs plus analgesic medication were instituted for a month. the patient's neck was immobilised in a soft cervical collar. all vigorous activity was suspended. at the follow-up consultation two weeks later, the patient was totally pain-free and clinically normal in appearance. the patient remained symptom-free and normal on examination at a further follow-up examination three months later. repeat ap (figure 4) and lateral (figure 5) cervical spine x-rays on this occasion showed normal alignment. the previously noted dense calcification in of c5/6 disc space central, posterior, subligamentous herniation of the densely calcified nucleus pulposus of the intervertebral disc. no spinal cord or nerve root compression. 9 sajournal of radiology. august 1998 figure 4: ap cervical spine fol/ow-up x-ray. normal alignment. two, small, poorly visible calcifications (arrow) in the c5/6 intervertebral disc immediately to the right of the cs spinous process. figure 5: lateral cervical spine fol/ow-up view. normal alignment. multiple, poorly visible, small calcifications (arrow) scattered in the cs/6 intervertebral disc. anterior wedging of the cs vertebral body stil/ present. the cs/c6 intervertebral disc was 1 ss easily visible, with multiple, small, poorly seen residual calcifications evident the anterior wedging of the vertebral body of cs was unchanged after three and a half months. the patient was considered to have been adequately treated, and was discharged from further follow-up. to page 10 intervertebral disc calcification in children frompage9 discussion this case report is a good example of some of the characteristic clinical and imaging findings of symptomatic ivdc in the cervical spine in a child. few conditions can mimic this presentation.' the incidence of ivdc is greater in boys than it is in girls. i,9,12,15-18the affected age range varies from series to series cervical ivdc has been described in young infants, i,2 including a premature newborn baby," with a maximum recorded age of 13 years.' 15,20 the peak age of presentation is between 5 to 10 years.2,4,9,12,13,18 clinically, the patient with symptomatic cervical ivdc is usually in good health generally, and presents with an acute onset of severe neck pain and torticollis, accompanied by limited neck and head movement.': 2. 4-7,9,il, 12,15-17,21-25some patients will have evidence of inflammation 1,2,4-7, 11,12,15,16,20,21,25with a low-grade fever at the onset of symptoms, possibly accompanied by a leucocytosis and raised esr.i,2,4-7,12,15,16,20,25dysphagia may be present.': 2,4 if anterior herniation of the calcified disc occurs, it may be responsible for the dysphagia.l" 26 the history of dysphagia in our patient was not associated with anterior disc herniation, but may rather have been related to the painful neck muscle spasm. posterior disc protrusion or herniation can occur when the calcified nucleus pulposus herniates through the annulus fibrosis. the resultant disc deformity may not impinge on the spinal cord or cervical roots, as was the case in this patient. should this occur, the patient may present with a painful upper limb radiculopathy.'r-" 7,15,16,2022,25,27the incidence of associated disc protrusion or herniation with cervical ivdc is 30% to 38%.1,2,6,15,16,28it is postulated that the greater mobility of the cervical spine predisposes to disc calcification and herniation. i it is uncertain why the patients without disc herniation are symptomatic, but one explanation is that there may be a change in the hydrophilic properties of the calcified disc, raising intradiscal pressure and thereby producing symptoms.2,9,15 patients with ivdc found co-incidentally on x-ray 2,4-7,9,15,16,20represent either an asymptomatic or dormant form of the disorder.2,5curiously, patients with multiple levels of calcification are less likely to present with pain.? 18the incidence of asymptomatic patients is approximately 17 to 30%.6,13,16,20 ivdc has been associated with congenital malformations such as cardiac and bone anomalies, but this is the exception rather than the rule.2,9,18 in children, intervertebral disc calcification occurs within the nucleus pulposus, whereas in adults disc calcification occurs in the annulus fibrosis i, 2,6,9,16the aetiology of the calcification in children remains uncertain 1,2,4, 6-8,10,12,15,18,20,23causes found in adults such as ochronosis, amyloidosis, acromegaly and metabolic defects such as chondrocalcinosis, hyperparathyroidism, hypervitaminosis d, haemochromatosis, gout and pseudogout have not been implicated in children.': 2,4,6,9, 12,13,15,18,20thirty to forty percent of symptomatic patients give a history of injury to the neck. i,2,4-6,15,20vertebral body fractures in children are not associated with ivdc.1,5 the majority ofivdcs occur in the cervical spine 1,2,4-6,12,13,15,16,20and most frequently in the c4 to c7 area.': 2,6,9, 10,15the calcification usually involves a single cervical disc, but multiple 10 sajournal of radiology. august 1998 calcified discs are recorded 1,2,5,6,9,12,13, 15,16,20,21with a prevalence which is estimated to be 30 to 40% of all ivdc cases.' the thoracic and lumbar discs may occasionally calcify in children, but ivdc in these regions is usually asymptomatic and the calcifications are not absorbed, remaining unaltered for many years,': 2,4,9,12,24,29in the thoracic spine, disc protrusions are less likely to occur, possibly due to reduced thoracic mobility. in the lumbar spine, ivdc is found on the convex side of the curve in idiopathic scoliosis.' plain radiographs, ct and magnetic resonance imaging (mri) are the imaging modalities of choice for this condition. all three examinations show the ivdc located in the nucleus pulposus. the disc calcification usually occupies most of the disc space and has a round, oval 1,9,16or linear shape." imaging may also demonstrate anterior wedging of the vertebral body adjacent to the calcified disc. 1,2,5,6,7,16,25posterior wedging has also been documerited." ct and mr! are able to demonstrate the presence of calcified disc protrusion or herniation with or without spinal cord and/or nerve root involvement.':" follow-up x-rays can be used to confirm the resolution of the calcification. a good case can be made for the use of plain x-rays alone to make the initial diagnosis,20,24and for ct to be restricted to investigating those patients with radiculopathy" linear tomography of the spine is felt to be totally unnecessary. 20 ivdc in children is usually a selflimiting disease with an excellent prognosis.':" 6-8,10,11,15,16,18,20-24the clinical response to a regimen of nonsteroidal anti-inflammatory drugs, analgesics and a cervical collar 1,2,4,9, 11,18,21,24is usually rapid, with the child becoming asymptomatic within days to page 11 intervertebral disc c,-1lcificatiol1 in eh i ldre n from page 10 to weeks 2,4,6,9,11,12,is, 16,18,21as occurred in this patient. rarely, the presence of the symptoms can be prolonged and the clinical condition can persist for months or years." 9, 30 the disc calcification gradually disappears within weeks to months, with minor radiographic abnormalities remaining.': 2,4,6,12,15-17,18,20,21this is borne out in this patient, who showed almost total disappearance of the c5/6 lvdc and the persistence of anterior wedging of the cs vertebral body, after three and a half months. sometimes the ivdc can persist for years, but this is rare,2,5,6,12,16,15,18on occasion, neck traction is required to aid response to conservative therapy. surgery for disc herniation with cord and/ or nerve root compression has been recorded, but is rare.l' 15,27the recent trend is to persevere with conservative treatment, even with discrelated symptoms, there is increasing evidence that the clinical picture and radiculopathy in image-proven disc herniation with root or cord compression resolve with medical treatment and immobilisation. surgical decompression should be reserved for patients who are refractory to conservative treatment.v 4,6,7,28 the intermediate-term changes which are recorded with ivdc take the form of loss of vertebral body height adjacent to the disc calcification, disc space narrowing at the involved site, scoliosis and osteophyte development. 2,5,16the long term consequences of lvdc are poorly documented, since patients are seldom closely followed into adulthood, references i. ventura n, huguet r, salvador a, terricabras l, cabrera am. intervertebral disc calcification in childhood. international orthopaedics 1995; 19 (5): 291-294. 2. mel li o n bt, laurent jp, watters wc. childhood intervertebral disc calcification. child's nervous system 1993; 9 (4): 233238. 3. mohanty s, sutter b, mokry m, ascher pw. herniation of calcified cervical intervertebral disc in children. surgical neurology 1992; 38 (6): 407 -410. 4. bhcttay e, joubert 0, meyers ol, cremin b. intervertebral disc calcification, clinical paediatrics 1992; 31 (7): 446-447, 5. wong cc, pereira b, pho rw. cervical disc calcification in children. a long term review. spine 1992; 17 (2): 139-144. 6. dias ms, pang d. juvenile intervertebral disc calcification: recognition, management, and pathogenesis. neurosurgery 1991; 28 (1): 130-135. 7. bradford r, rice-edwards m, shawden h. herniation of a calelfled nucleus pulposus in a child: case report. british journal of neurosurgery 1989; 3 (6): 699-703. 8. patusapu jv, evans ob, blumenthal bj. intervertebral disc calcification in children, pediatric neurology 1987; 3 (2): 108-110. 9. hahn ys, mclone dg, uden d. cervical intervertebral disc calcification in children. child's nervous system 1987; 3 (5): 274277. 10. mcgregor jc, butler p disc calcification in childhood: computed tomographic and magnetic resonance imaging appearances. british journal of radiology 1986; 59 (698): 180-]82. ii. pilhard 0, masse p, taussig g. intervertebral disc calcification in childhood. rev chir orthop reparatrice appar mot 1980; 66 (8): 515-521. 12. son blomquist hk, lindqvist m, mattsson s. calcification of intervertebral discs in childhood. pediatric radiology 1979; 8 (1): 23-26. 13. henry mj, grimes ha, lane lw. intervertebral disc calcification in childhood. radiology 1967; 89 (1): 81-84. 14. baron a. uber eine neue erkrankung der wlrbelsaule. lahrb kinderheillid 1924; 104: 357-360. 15. sonnabend dh, taylor tkf, chapman gk. intervertebral disc calcification syndromes in children. journal of bone and joint surgery 1982; 64 (1): 25-31. 16. girodias jb, azouz em, marton d. intervertebral disc space calcification. pediatric radiology 1991; 21 (8): 541-546. 11 sajournal of radiologyaugust 1998 17. jawish r, rigault p, padovani lp, mouterde p, touzet p, chaumien jp. intervertebral disc calcif ation in children. rev chir orthop 1989; 75 (5): 308-317 18. swick hm. calcification of intervertebral discs in childhood. loumal of pediatrics 1975; 86 (3): 364-369. 19. ho ps, ho kc, yu s, et al. calcification of the nucleus pulpasus with pathologie confirmation in a premature infant. americail journal of neuroradiology 1989; 10 (1): 201-202. 20. ginalski jm, landry m, gudinchet p, schnyder p. is tomography of intervertebral disc calcification useful in children? pediatric radiology 1992; 22 (i): 59-61. 21. zhang k, dang g, lou s. cervical intervertebral disc calcification in children: report of 10 patients. chung ttl/a wai ko rsa chih 1996; 34 (4): 197-200. 22. causey al, evans ob, lewis-abney k. intervertebral disc calcification: an unusual cause of acquired torticol1is in childhood. pediatric emergency care 1996; 12 (5): 356359. 23. oulebsir a, derdar t, maiza eh, khati b. calcification of the intervertebral discs in children apropos of a case. pediatrie 1989; 44 (4): 327-329. 24. herring ja, hensinger rn. cervical disc calcification. journal of pediatric orthopaedics. 1988; 8 (5): 613-616. 25. ursa s, colajacomo m, migliorini a, fassari fm. calcifying di copathy in infancy in the cervical spine: valuation of vertebral alterations over a period of time. pediatric radiology 1987; 17 (5): 387-391. 26. jawish r, ponet m. dysphagia disclosing a ervical disc calcification in a child. apropos of a case and review of the literature. chir pediatric 1990; 3j (2): 127-130. 27. oga m, terada k, kikuchi n, oda y, sugioka y. herniation of cal ifie d cervical intervertebral disc causes dissociated motor loss in a child. spine 1993; 18 (15): 23472350. 28. hoeffel jc, bernard c, schmit p, denardaud l. herniation of calcifying discopathy in childhood: report of three cases. european journal of pediatrics 1990; 149 (10): 695697. 29. bol1ini g, bergoin m, choux m, padovani j. disc calcifications in children. apropos of 17 cases. rev chir orthop reparamee appar mot 1984; 70 (5): 377-382. 30. morris 1m, sheppard l. the p rsistence of clinical and radiological features a ter interv rtebral disc calcification of childhood. british joumal of rheumatology 1986; 25 (2): 219-221. abstract introduction case report discussion conclusion acknowledgements references about the author(s) anjuna reghunath department of radiodiagnosis, vardhman mahavir medical college and safdarjung hospital, new delhi, india suchana kushvaha department of radiodiagnosis, vardhman mahavir medical college and safdarjung hospital, new delhi, india rohini g. ghasi department of radiodiagnosis, vardhman mahavir medical college and safdarjung hospital, new delhi, india geetika khanna department of radiodiagnosis, vardhman mahavir medical college and safdarjung hospital, new delhi, india apurva surana department of radiodiagnosis, vardhman mahavir medical college and safdarjung hospital, new delhi, india citation reghunath a, kushvaha s, ghasi rg, khanna g, surana a. chronic gallbladder wall thickening: is it always malignancy? s afr j rad. 2020;24(1), a1844. https://doi.org/10.4102/sajr.v24i1.1844 case report chronic gallbladder wall thickening: is it always malignancy? anjuna reghunath, suchana kushvaha, rohini g. ghasi, geetika khanna, apurva surana received: 29 dec. 2019; accepted: 09 mar. 2020; published: 18 may 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract gallbladder wall thickening, associated with features like perforation, fistula formation and invasion of adjacent organs, is often assumed to be malignant. xanthogranulomatous cholecystitis (xgc) causes gallbladder wall thickening with similar aggressive features and closely mimics gallbladder carcinoma clinically, radiologically and surgically. differentiating between these two is crucial for management as misdiagnosis of gallbladder cancer can lead to unnecessary radical surgery. we report a case of chronic gallbladder wall thickening, initially suspected to be malignant, but subsequently diagnosed as xgc. keywords: xanthogranulomatous cholecystitis; gallbladder cancer; ultrasound; computed tomography; magnetic resonance imaging. introduction xanthogranulomatous cholecystitis (xgc) is a lesser known variant of chronic cholecystitis which causes gallbladder (gb) wall thickening with aggressive features similar to gb carcinoma, such as gb wall perforation, fistula formation and invasion of adjacent organs. xanthogranulomatous cholecystitis is a chronic, focal or diffuse, destructive, fibro-inflammatory disease of the gb that results from intramural accumulation of foamy macrophages and inflammatory cells, with proliferative fibrosis in later stages.1 the pathogenesis of this uncommon condition is not fully understood.2 xanthogranulomatous cholecystitis is often confused with gb carcinoma because of its aggressive nature and overlapping clinical, imaging and surgical features.3 it is crucial to differentiate between these two entities from a management perspective since a misdiagnosis of xgc as gb cancer can lead to unnecessary radical surgery. the purpose of this article was to highlight the fact that not every chronic gb wall thickening is malignant and to review the distinguishing imaging features of xgc. case report a 74-year-old woman presented with right upper quadrant pain for 6 months. there was neither a history of fever or jaundice nor any significant past history. clinical examination was insignificant, with a negative murphy’s sign. her liver function tests were within normal limits. an ultrasound abdomen conducted elsewhere had revealed thickening of gb wall, and the patient was therefore referred for a contrast-enhanced computed tomography (cect) to exclude any underlying malignancy. a pre-computed tomography (ct) ultrasound scan, performed at our institute, demonstrated a distended gb, filled with echogenic sludge (figure 1a). diffuse, asymmetrical, hyperechoic wall thickening was noted with two well-defined hypoechoic intramural nodules within the wall of gb (figure 1). no comet-tail artefacts were seen in the wall. figure 1: (a) ultrasound abdomen revealing a distended gallbladder filled with echogenic sludge (asterisk), (b) with asymmetrical wall thickening and intramural hypoechoic nodules (arrows). contrast-enhanced computed tomography revealed homogeneous enhancement of the thickened gb wall with multiple intramural cystic areas (figure 2a). mucosal enhancement was relatively well preserved, except for a focal breach in the region of the body of the gb adjacent to the liver (figure 2b); however, fat planes between the remaining organs were maintained. minimal fat stranding was noted surrounding the gb fundus. no gallstones, significant periportal lymphadenopathy or intrahepatic biliary radical dilatation was observed. based on the ultrasound and cect findings, the differential diagnoses considered were xgc and gb carcinoma. figure 2: (a) nodules appear hypodense on contrast-enhanced computed tomography images (arrow). (b) focal breach in mucosal lining (white arrow) and indistinctiveness with adjacent liver noted (black arrow). we further performed magnetic resonance imaging (mri) of the abdomen to differentiate between xgc and gb cancer. magnetic resonance imaging demonstrated a few intramural t2 hyperintense nodules within the wall of gb, confirming the diagnosis of xgc (figure 3a–c). after intravenous gadolinium administration, the gb wall showed uniform enhancement with focal discontinuous mucosal enhancement. although the adjacent liver had shown t2 hyperintense signal suggestive of oedema, post-contrast images indicated a maintained boundary between the enhanced gb wall and liver (figure 3), suggesting inflammatory changes rather than invasion. figure 3: (a and b) axial t2w magnetic resonance imaging images demonstrating hyperintense intramural nodules (arrows), which on post-contrast t1w sequence (c) shows peripheral enhancement (black arrow), suggestive of a microabscess. tissue sampling was obtained with ultrasound-guided fine needle aspiration cytology (fnac) from the fundus of gb. histology showed polymorphs and foamy histiocytes, in keeping with xgc (figure 4). the patient subsequently underwent an open simple cholecystectomy. figure 4: fine needle aspiration cytology specimen from the fundus showing foamy macrophages (arrow) and polymorphs on may–grunwald–giemsa stain, consistent with the diagnosis of xanthogranulomatous cholecystitis. ethical consideration consent was taken from the patient to include the data in the study. discussion xanthogranulomatous cholecystitis is an uncommon variant of chronic cholecystitis, characterised by intramural xanthogranulomatous (accumulation of lipid-laden macrophages) inflammation (with both acute and chronic inflammatory cells) of the gb.1 its incidence varies from 0.7% to 10%1 and men are affected twice as commonly as women, with a peak incidence occurring around the sixth to seventh decade of life.1 this case describes xgc in a female patient, an unusual presentation. the most important association with xgc is cholelithiasis, seen in approximately 66.6% of patients.4 the hypothesis behind the pathogenesis of this condition is gb outflow or cystic duct obstruction by calculi, leading to a rupture of the rokitansky–aschoff sinuses, causing bile leakage into the wall of the gb.5 bile is then engulfed by macrophages and foamy histiocytes, resulting in a chronic granulomatous response, microabscess formation, subsequent wall fibrosis and scarring. this results in a high complication rate (up to 32%)5 and includes gb perforation, adhesions, peritoneal scar formation and fistulous tracts to the stomach, duodenum, hepatic flexure or transverse colon and anterior abdominal wall.5 xanthogranulomatous cholecystitis presents clinically as chronic (88%) or acute cholecystitis (22%).1 common clinical features include abdominal pain, obstructive jaundice or cholangitis.1 occasionally, there may be a palpable mass or a positive murphy’s sign. laboratory parameters are usually normal, with no associated specific liver function test discordance.6 xanthogranulomatous cholecystitis can have co-existing gb carcinoma in 8.5% – 30.5% of cases or infection with escherichia coli, klebsiella, enterococcus, pseudomonas or staphylococcus.1 imaging modalities play a major role in the detection of xgc. the typical sonographic findings include diffuse, symmetrical, hyperechoic wall thickening, intramural hypoechoic nodules, associated cholelithiasis or choledocholithiasis.5 on cect, the wall thickening is always > 3mm and shows homogeneous enhancement3. intramural hypoattenuating nodules are present in 85% of cases.6 these nodules may represent xanthogranulomas or microabscesses depending on the phase of inflammation. luminal surface enhancement (lse) with continuous mucosal lines is seen in 66% of cases, and a focal breach in the mucosal line is not uncommon.1 pericholecystic fat stranding, blurring of the interface with liver, oedema, transient hepatic attenuation differences or early enhancement may be appreciated in the adjacent liver parenchyma.4 zhao et al.6 observed that the co-existence of at least four out of the five ct features (diffuse gb wall thickening, hypoattenuating intramural nodules, continuous mucosal line, lse and gallstones) was found in 80% cases of histologically proven xgc.6 on dynamic contrast-enhanced mri, areas of t2 isointensity showing early and strong delayed enhancement suggest xanthogranulomas, whereas high t2 signal lesions without enhancement suggest microabscesses.1 on diffusion weighted imaging, xgcs can show hyperintensity with corresponding hypointensity on apparent diffusion coefficient (adc) map; however, restriction is more common in carcinoma (mean adc:1.076) than in xgc (mean adc: 1.637).7 in-phase/out-phase chemical shift imaging demonstrates fat in the gb wall in about 77.7% of cases,8 suggesting the presence of fat-containing xanthogranulomas in the wall of the gb. common differential diagnoses of xgc include carcinoma of the gb and adenomyomatosis.6,9 features differentiating xgc from gb cancer are presented in table 1. both xgc and adenomyomatosis demonstrate wall thickening with sonographic hypoechoic intramural nodules and gallstones.5 rokitansky–aschoff sinuses are also visualised on t2-weighted mri as the ‘pearl necklace sign’ and cholesterol crystals within them show comet-tail artefact.5 complications due to scar formation in xgc are typically absent in adenomyomatosis.5 another differential diagnosis of xgc includes actinomycosis of the gb, which presents as an infiltrative mass with multiple abscesses, draining sinuses and dense fibrous tissue, making differentiation challenging, except when associated with abdomino-pelvic actinomycosis.10 table 1: differences in imaging features of carcinoma gallbladder and xanthogranulomatous cholecystitis. other conditions with overlapping features, such as wall thickening and mass-forming lesions of the gb with adhesions, are collectively labelled as inflammatory pseudo tumours of the gb. these include inflammatory myofibroblastic tumours, inflammatory tumours developing as a foreign body reaction and immunoglobulin g4 (igg4)-related cholecystitis.11 in a study performed by hong et al.12 in 2018, significant concurrence of histopathologic features of igg4-related disease like dense lymphoplasmocytic and igg4 plasma cell infiltration, storiform fibrosis and obliterative phlebitis was observed in surgically resected specimens of gb, with pathologic evidence suggesting xgc. the authors concluded that the conditions may co-exist, especially when igg4-related disease involves other organs.12 a comparison of the imaging features in various inflammatory causes of gallbladder wall thickening is presented in table 2. table 2: comparison of imaging features in inflammatory causes of gallbladder wall thickening. contrast-enhanced computed tomography is the best modality for the evaluation of gb wall thickening and a systematic approach may be beneficial in arriving at an accurate diagnosis, as follows: is the thickening focal or diffuse? focal thickening may be seen in gb carcinoma, focal xgc or focal adenomyomatosis. pathologies with diffuse thickening may or may not be associated with cholelithiasis. gallstones are associated with acute or chronic cholecystitis, gb cancer, xgc and adenomyomatosis, while calculi are usually absent in actinomycosis, igg4-related disease, acalculous cholecystitis and gb wall thickening secondary to hepatitis, liver cirrhosis, congestive heart failure, renal failure, pancreatitis or dengue fever. is the diffuse thickening symmetrical or asymmetrical? asymmetrical thickening is more common in malignancies as compared to inflammatory conditions. the presence of intramural nodules: intramural nodules may be seen in xgc, as well as in adenomyomatosis. however, ultrasound would distinguish between the two by the presence of comet-tail artefacts. mucosal enhancement pattern: kim et al.13 described five patterns of gb wall enhancement in 2008. type 1 is a homogeneously or heterogeneously enhancing thick single layer pattern, seen in xgc and gb carcinoma. type 2 pattern shows intense inner layer enhancement with a weakly enhanced or unenhanced outer layer, seen in gb cancer. in type 3 pattern, the inner layer enhances similar to hepatic parenchyma with a weakly enhancing outer layer, as seen in adenomyomatosis. the type 4 pattern is typically seen in chronic calculous cholecystitis, with a weakly enhancing, fuzzy, inner layer and a thin non-enhancing outer layer along with a collapsed lumen. however, this pattern may also be seen in cirrhosis and viral hepatitis.14 the type 5 pattern is depicted by a weakly enhancing, fuzzy, inner layer with a non-enhancing thick outer layer of submucosal oedema, as seen in acute calculous cholecystitis and dengue fever.13,14 secondary bile duct dilatation: seen in gb cancer and igg4-related disease. pericholecystic inflammation, adhesions, fistulisation with bowel: gb cancer, xgc, actinomycosis. liver invasion and nodal involvement: common in gb carcinoma. involvement of other organs: metastasis in gb cancer, pelvic disease in actinomycosis and multi-organ involvement in igg4 disease. ideal management of xgc is open cholecystectomy with excision of the inflammatory tissue. this is not the case for gb carcinoma, which requires a more radical wider excision for a tumour-free resection margin and regional lymph node dissection.7 conclusion xanthogranulomatous cholecystitis closely simulates gb carcinoma clinically and radiologically. a less aggressive surgical approach like simple cholecystectomy is warranted in xgc and its correct diagnosis may avert aggressive surgeries like whipple’s or partial or segmental hepatectomy.2 however, one should remember that xgc may co-exist with gb cancer as well and a definitive diagnosis necessitates histopathologic analysis. a combination of clinico-radiological factors combined with intra-operative frozen-section examination9 aids in deciding further management and planning the surgical approach, thus improving patient care. acknowledgements the authors would like to thank dr ritu nair misra, head of department of radiology, vardhman mahavir medical college and safdarjung hospital, for providing the opportunity and encouragement to enhance academic interests of residents. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. funding information this study received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and don not necessarily reflect the official policy or position of any affiliated agency of the authors. references singh vp, rajesh s, bihari c, desai sn, pargewar ss, arora a. xanthogranulomatous cholecystitis: what every radiologist should know. world j radiol. 2016;8(2):183–191. https://doi.org/10.4329/wjr.v8.i2.183 chun ka, ha hk, yu es, et al. xanthogranulomatous cholecystitis: ct features with emphasis on differentiation from gallbladder carcinoma. radiology. 1997;203(1):93–97. https://doi.org/10.1148/radiology.203.1.9122422 deng y-l. xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: an analysis of 42 cases. world j gastroenterol. 2015;21(44):12653–12659. https://doi.org/10.3748/wjg.v21.i44.12653 sureka b, singh vp, rajesh sr, et al. computed tomography (ct) and magnetic resonance (mr) findings in xanthogranulomatous cholecystitis: retrospective analysis of pathologically proven 30 cases – tertiary care experience. pol j radiol. 2017;82:327. https://doi.org/10.12659/pjr.901728 cecava nd, andrews r. case report of xanthogranulomatous cholecystitis, review of its sonographic and magnetic resonance findings, and distinction from other gallbladder pathology. j radiol case rep. 2011;5(4):19–24. https://doi.org/10.3941/jrcr.v5i4.696 zhao f, lu p-x, yan s-x, et al. ct and mr features of xanthogranulomatous cholecystitis: an analysis of consecutive 49 cases. eur j radiol. 2013;82(9):1391–1397. https://doi.org/10.1016/j.ejrad.2013.04.026 kang tw, kim sh, park hj, et al. differentiating xanthogranulomatous cholecystitis from wall-thickening type of gallbladder cancer: added value of diffusion-weighted mri. clin radiol. 2013;68(10):992–1001. https://doi.org/10.1016/j.crad.2013.03.022 hatakenaka m, adachi t, matsuyama a, mori m, yoshikawa y. xanthogranulomatous cholecystitis: importance of chemical-shift gradient-echo mr imaging. eur radiol. 2003;13(9):2233–2235. https://doi.org/10.1007/s00330-002-1731-5 rammohan a, cherukuri sd, sathyanesan j, palaniappan r, govindan m. xanthogranulomatous cholecystitis masquerading as gallbladder cancer: can it be diagnosed preoperatively? gastroenterol res pract. 2014;2014:1–5. https://doi.org/10.1155/2014/253645 lee yh, kim sh, cho m-y, rhoe bs, kim ms. actinomycosis of the gallbladder mimicking carcinoma: a case report with us and ct findings. korean j radiol. 2007;8(2):169. https://doi.org/10.3348/kjr.2007.8.2.169 zimmermann a. tumor-like inflammatory changes of the gallbladder. in: zimmermann a, editor. tumors and tumor-like lesions of the hepatobiliary tract. cham: springer international publishing, 2016; p. 1–17. https://doi.org/10.1007/978-3-319-26587-2_158-1 hong s, sung y, kim h, et al. xanthogranulomatous cholecystitis shows overlapping histological features with igg4-related cholecystitis. histopathology. 2017;72(4):569–579. https://doi.org/10.1111/his.13413 kim sj, lee jm, lee jy, et al. analysis of enhancement pattern of flat gallbladder wall thickening on mdct to differentiate gallbladder cancer from cholecystitis. am j roentgenol. 2008;191(3):765–771. https://doi.org/10.2214/ajr.07.3331 mathur m, singh j, singh dp, kaur n, gupta s, haq s. imaging evaluation of enhancement patterns of flat gallbladder wall thickening and its correlation with clinical and histopathological findings. j clin diagn res. 2017;11(4):tc07–tc11. https://doi.org/10.7860/jcdr/2017/25472.9624 tips for the radiologist ultrasound evaluation of occult spinal dysraphism s adronikou mb bch, fcrsd(d), frcr (lond) b smith mbchb department of paediatric radiology university of cape town and institute of child health red cross war memorial children's hospital cape town introduction occult spinal dysraphic lesions include midline fusion defects that are skin covered and have no exposed neural tissue or visible cystic mass. a palpable mass mayor may not be present. i high frequency ultrasound provides an ideal non-invasive technique for the evaluation of these lesions in children under 6 months of age. the aim of this article is to give practical advice on both the imaging technique used and the interpretation of abnormal findings. ultrasound technique ultrasound evaluation of the spinal cord and the surrounding contents of the spinal canal in children under 6 months makes use of the window provided by the unossified posterior elements of the vertebral column.' in our department we use the following technique: 1. the patient is placed prone with the hips and knees slightly flexed and a small cloth roll is placed under the pelvis to minimise the lumbar lordotic curve.' 2. a 7 mhz linear-array transducer is used to evaluate the lumbo-sacral region in both the longitudinal and transverse scan planes.the probe frequency is set at 7 mhz. 3. the distal spinal cord is identified in the thoracolumbar region and is followed caudally to its termination at the conus. the level of the conus is recorded in the following manner: • by identifying the first sacral segment, it is then possible to count up from this reference point to the vertebral body/disc space adjacent to the conus. the first sacral segment is identified by the orientation of its spinous process which is the first to be angled dorsally. • if it is not possible to identify this landmark, then a metal marker such as an unfolded paper clip can be placed under ultrasonic guidance on the skin overlying the site of the conus and then taped into position. thereafter plain anteroposterior (ap) and lateral radiographs are taken with the marker in situ, and the level at which the conus terminates is assessed according to the vertebral level of the marker. 4. the morphology of the taper46 sa journal of radiology. october 2001 ing of the conus is recorded. the position of the cord in the spinal canal and the presence or absense of spinal cord pulsation are noted.' 5. visualisation of the internal structure of the spinal cord and the overlying dura, cerebrospinal fluid (esf), cauda equina, filum terminale, bony elements, paraspinal muscles, subcutaneous tissues and skin is possible.' normal ultrasound anatomy the normal structures identified are depicted in figs la and lb, and include the following: (l) a homogeneously hypo echoic spinal cord with a central hyperechoic line representing the depth of the paramedian sulcus,' (il) the cord surrounded by the hyperechoic pia mater and the hypoechoic esf; (iii) esf is usually seen only dorsal to the cord as a normal untethered cord is dependent and lies in a ventral position against the posterior aspect of the vertebral bodies when the patient is prone; (iv) hyperechoic dura surrounding the esf and the unossified bony elements dorsal to this are identifiable; (v) the paraspinal muscles are seen in a paramedian position covered by a continuous layer of subcutaneous fat and skin:' (vl) the conus is recognised as a smooth tapering structure that ends at the lower end of l3 in a normal infant:' (vil) the filum terminale is seen extending as a hyperechoic line from the tip of the conus in a caudal direction to the back of the first coccygeal segment and should never be more than 3 mm in diameter or have any structures within it;' and (viil) the fine echogenie strands extending from the caudal portion of the conus represent the cauda equina.' tips for the radiologist il -c1 ,. • fig. 1. structure of the normal cord on ultra· sound fig.la. linear ultrasound demonstration of the lower lumbar cord demonstrates the hypoechoic cord substance (white x), the echogenie line of the paramedian sulcus (curved arrow), the echogenie line of the pia mater lining the cord surface (straight arrow), the dorsal hypoechoic esf (white dot) and the echo shadows originating at the spinous processes (white snow-heed). fig. lb. the normal cord tapers to form the conus medullaris (thick arrow), and the nerve roots are seen as a mass of echogenie structures running caudally (thin arrow), the position of the conus is assessed as described by evaluating its verterbral level according to the echo shadowing of the spin· ous processes (white arrow·head). interpretation of abnormal ultrasound findings tethered cord (fig. 2) diagnose a tethered cord if the following findings are present: (i) a lowlying conus, i.e. a conus that termifig. 2. tethered cord. this scan shows that the cord does not taper to a normal conus and that it is low·lying. esf is seen both dorsally and ventrally (thin arrow) indicating that the cord is suspended due to tethering and cannot lie in a dependent posttlon. an associated distal cord syrinx (thick arrow) is a common association. nates below the lower end of l3 or a non-tapering cord extending to the sacrum;' (it) a cord that is suspended in the spinal canal when the patient is lying prone, i.e. there is esf both ventral and dorsal to the cord; (iii) absense of cord pulsation; (iv) a thickened filum terminale (> 3 mm in diameter);' (v) a lipoma within the filum;' (vi) other dysraphic anomalies such as lipomyelomeningocoele, myelocystocoele, non-tapering of the cord; (vii) a distal cord syrinx;' and (viii) an intra-spinal lipoma, a dermoid or a sacral teratoma.' lipomyelomeningocoele (fig.3) diagnose a lipomyelomeningocoele if the following findings are present: (i) a subcutaneous lipoma that extends via a posterior bony defect and is attached to the cord, i (it) a low-lying conus or non-tapering cord (tethered cord); and (iii) a esfcontaining sac extending from the spinal canal into the adjacent soft tissue (meningocoele). the presence and size of the meningocoele are variable.' 47 sa journal of radiology. october 2001 fig. 3. llpomyelomenlngocoele. the cystic por· tlon of the iipomyelomeningocoele is seen as an ecno-tre« area (white x) protruding from a dorsal bony defect and is covered by skin (curved arrow). there is an associated dorsal lipoma (thick straight arrow) and there are also cord elements protruding through the bony defect (white arrow·head), an associated distal cord syrinx is also present (thin straight arrow). myelocystocoele diagnose a myelocystocoele if the following findings are present: (i) a trumpet-shaped distal cord; and (il) a syrinx that herniates through a dorsal bony defect into the subcutaneous tissue the esf-containing mass can be seen just under the skin.i diastomatomyelia diagnose diastomatomyelia if the following findings are present: (i) partial or complete split of the cord with an intervening fibrous or bony septum, and hemicords (often of unequal size);' (ii) features of cord tethering;' and (iii) multiple clefts within the cord along its length with a normal cord in between these clefts.i intraspinal lipoma diagnose an intraspinal lipoma if the following findings are present: (i) an echogenie intraspinal mass that mayor may not extend through a bony defect into the subcutaneous tissue; (ii) the cord is attached to this either dorsally or at its terminal end; and (iii) no associated covered meningocoele is present. tips for the radiologist dorsal dermal sinus diagnose a dorsal dermal sinus if the following findings are present: (t) a tract that connects the skin to the intracanalicular space which may be median or paramedian; this may communicate with the subarachnoid space; 1 and (it) an associated lipoma, epidermoid or dermoid with the sinus tract. i conclusion high-resolution spinal ultrasound is a valuable means of diagnosing suspected occult spinal dysraphic lesions in neonates and infants before the posterior spinal elements ossify. ultrasound has numerous advantages: it is portable and available with high-resolution capabilities, it is safe and requires no sedation, and it is relatively inexpensive. when findings are confusing, abnormal or equivocal, then mr! must be performed to delineate the pathology more accurately. references 1. korsvik h, kellerm. sonography of occult dysraphism in neonates and infants with mr imaging correlation. radiographies 1992; 12: 297-306. 2. nelson m jun. ultrasonic evaluation of the tethered cord syndrome. in: yamada s, ed. tethered cord syndrome. american association of neurological surgeons publications committee, 1996. 3. hinshaw d jun., engelhart j, kaminsky c. imaging of the tethered spinal cord. in: yamada s, ed. tethered cord syndrome. american association of neurological surgeons publications committee, 1996. hypertrophic pyloric stenosis •an overview h grove nst. cert. rsd. ultrssound department of paediatric radiology, red cross war memorial children's hospital, university of cape town and institute of child health definition the term hypertrophic pyloric stenosis (hps) refers to hypertrophy of the circular muscle of the pylorus that can cause obstruction (hpo). clinical findings clinical findings include the following: (i) non-bilious projectile vomiting; (it) peristaltic waves that can be seen travelling across the left upper quandrant to the right and terminating beyond the midline; i (iii) a palpable 'olive' (pseudotumour) over an empty stomach;' (iv) age typically 2 8 weeks; (v) male-to-female ratio 5:1; (vi) uncommon in black patients; (vit) often the male offspring of an affected mother; (viii) gastric residual > 10 ml;' and (ix) an association with oesophageal atresia.' plain film findings plain film findings include the following: (i) gastric dilatation; (ii) paucity of small bowel and colonic air; (iii) frothy gastric contents; (iv) absence of an air-filled duodenal bulb; (v) gastric pneumatosis; and (vi) normal appearance. 48 sa journal of radiology. october 2001 ultrasound technique a high frequency transducer (7 mhz) is used, preferably a linear or vector probe (acuson 128 xp/lo). with the patient in the supine position start off scanning in the longitudinal section until the gall bladder is located,' the 'olive' of the hypertrophied musculature should be located medial to it. visualisation is good when the 'olive' has a foreshortened appearance (fig. i). the transducer now has to be rotated and angled so that it is aligned with the long axis of the channel (fig. 2). on this view, the beak sign can be identified as on a contrast meal. if the stomach is too full, the channel is distorted and accurate measurements won't be possible. in such a case a nasogastric tube can be passed to empty some of the contents. once the long axis is obtained, one should note the position of the transducer and turn it 90 degrees. this way the bull's eye of the pyloric channel can be identified end-on (fig. 3). sajr 842 abdominal imaging: diagnosis s beningfield, p scholtz, s misser division of radiology, groote schuur hospital and university of cape town s beningfield, mb chb, ffrad (d) sa p scholtz, mb chb, fcrad (d) sa lake smit and partners, durban s misser, mb chb, fcrad (d) sa corresponding author: s misser (misser@lakesmit.co.za) we congratulate dr omar (details not to hand at time of going to press) for his close to spot-on diagnosis, for which he receives the award of r1 000 from the rssa. professor beningfield et al. elaborate below on the condition and its imaging. please refer to page 152 of the december 2012 issue of the sajr (http://dx.doi.org/10.7196/sajr.795) for the presentation details and unannotated images. diagnosis the 40-year-old man underwent partial gastrectomy with roux-en-y gastrojejunostomy for gastro-oesophageal reflux unresponsive to fundoplication. ten days after the operation, he began vomiting and also complained of epigastric pain. a ct scan (figs 1, 2 and 3) was performed. the scout image (fig. 1) demonstrated the presence of a post-operative drainage catheter (broad blue arrow), isolated distended loop of the small bowel, probably jejunum (thin blue arrow), as well as a fixed hiatus hernia in a gastric remnant (broad grey arrow). the final diagnosis was afferent loop obstruction in a patient following recent partial gastrectomy and roux-en-y anastomosis, as well as a prior fundoplication. the roux-en-y anatomy was suggested by the lack of the afferent loop ascending to the stomach. fig. 1. planning view showing surgical drain (thin arrow), isolated distended small bowel loop (broad blue arrow), and small hiatus hernia (broad grey arrow). fig. 2. axial post-contrast ct images of the abdomen. (a) fundoplication sutures (thin arrow), empty stomach (broad blue arrow) and collapsed splenic flexure of colon (broad grey arrow). (b) suture in duodenal stump (thin blue arrow), distended duodeno-jejunal afferent limb (*), undistended pre-colic efferent limb from gastric remnant (broad blue arrow), collapsed transverse colon (broad grey arrow) and descending colon (+). (c) distended duodeno-jejunal afferent limb (*) crossing between sma and aorta and minimally distended pre-colic efferent limb (broad blue arrow) from gastric remnant, with transition point (broad grey arrow) in region of anastomotic staple (thin arrow). (d) undistended gastrojejunostomy blind limb with sutures (broad grey arrow) and surgical scar (broad blue arrow), drain (thin arrow) and no other distended bowel. fig. 3.  coronal multiplanar reconstructions showing distended duodeno-jejunal afferent limb (*) with transition point (arrow). background although first reported in 1881, afferent and efferent loop obstructions have been better understood since the 1950s1 following the popularity of billroth ii gastrectomy with gastrojejunostomy (fig. 4). while afferent means carrying inwards or toward a centre, efferent means carrying outward or away from a centre. the afferent loop syndrome is due to chronic partial obstruction causing distension of the proximal duodenum and jejunum, with discomfort and nausea. afferent loop obstruction is a specific form of closed loop obstruction with the proximal component being the surgically closed-off duodenal stump (figs 4 and 5), and the distal/downstream obstruction due to a variety of causes. efferent loop obstruction is a form of high small bowel obstruction that may also divert gastric content into the afferent loop. as roux-en-y anastomoses have become popular with partial gastrectomies and whipple’s procedures, they too are prone to both forms of obstruction around the jejuno-jejunal roux-en-y anastomosis (figs 2b and 5), possibly even more so.2 they also may develop a blind-pouch syndrome affecting the closed stump at the side-to-side anastomosis.3 fig. 4. (a) bilroth ii gastrectomy with gastro-jejunostomy. (b) partial gastrectomy with roux-en-y jejuno-jejunostomy anastomosis. fig. 5. transition point (broad arrow) with distended afferent duodeno-jejunal limb (*). frequency and causes the occurrence of afferent loop obstruction depends on length of follow-up, ranging between 0.2% and 20%.4 where gastric carcinoma was the indication for the initial operation,5 tumour recurrence was noted to outweigh other usual causes such as adhesions, anastomotic ulcers, stenoses, internal hernias in surgically created foraminae (including in the mesentery), twisting foci, or intussusceptions.2 , 6 clinical presentation the non-specific symptoms classically occur either in the postoperative period or much later e.g. owing to tumour recurrence. epigastric pain owing to distension of the duodeno-jejunal loop dominates clinically. vomiting, often without bile, is somewhat surprisingly found in 25% of cases and is thought to occur owing to sudden decompression of the afferent loop into the stomach; this is less plausible with the distance of the roux-en-y anastomosis from the stomach and may be related to nausea arising from loop distension. biochemically, there may be slight elevations of amylase and obstructive liver enzymes. diagnosis a clear understanding of the preceding surgical procedures and resultant anatomy facilitate interpretation of what may initially be confusing images. plain films seldom provide helpful information as the loop is commonly fluid-filled. however, a small amount of gas in the loop, as in the case reported, can reveal distended valvulae conniventes. oral contrast can occasionally reflux into the afferent loop. ultrasound has been used to detect the large fluid-filled c-loop between the sma and aorta, with the presence of valvulae conniventes helpful in distinguishing these loops from acute pancreatic fluid collections, as pancreatitis often enters the differential diagnosis because of the pain and elevated amylase.4 biliary dilatation may also occasionally be noted. ct in this condition was first reported in the 1980s,7 and is now the preferred modality, particularly multislice ct.2 oral contrast is helpful; iv contrast distinguishes vessel, nodes and tumour recurrence, as well as bowel viability. coronal and sagittal views frequently clarify the anatomy (fig. 3). the ‘keyboard sign’ produced by the valvulae conniventes is further supportive evidence. 5 the presence of bowel ischaemia can be determined with arterial and venous phase ct, and the detection the ‘whirl sign’ points to internal herniation. seeking subtle features of adhesive obstruction such as anterior peritoneal thickening, small bowel loops closely applied to the anterior peritoneum, acute bowel loop kinks, fine mesenteric lines and bowel wall asymmetry may assist in complicated cases.3 mri is also helpful where ct is not readily accessible, with mrcp an additional option.6 complications as a closed-loop obstruction, there is a risk of ischaemia and perforation owing to wall tension, with a mortality rate of up to 35% at 36 hours, so there is urgency in management.3 treatment the standard therapy is surgical de compression, often by means of entero-enterostomy, as was done in this case; this can also be achieved by laparoscopic or endoscopic intervention, and interventive radiology can offer temporary duodeno-jejunal decompression by means of internal-external biliary drainage. conclusion in the context of a patient with the appropriate surgical background (either given clinically or deduced by imaging evidence) presenting with epigastric discomfort, nausea or vomiting, the preferred imaging by multi-slice ct should allow accurate detection and rapid resolution of the afferent loop syndrome. 1. warren rp. acute obstruction of afferent or efferent loop, following antecolic partial gastrectomy, with report of three cases. ann surg 1954;139(2):202-205. 1. warren rp. acute obstruction of afferent or efferent loop, following antecolic partial gastrectomy, with report of three cases. ann surg 1954;139(2):202-205. 2. juan y-h, yu c-y, hsu h-h, et al. using multidetector-row ct for the diagnosis of afferent loop syndrome following gastroenterostomy reconstruction. yonsei med j 2011;52(4):574-580. 2. juan y-h, yu c-y, hsu h-h, et al. using multidetector-row ct for the diagnosis of afferent loop syndrome following gastroenterostomy reconstruction. yonsei med j 2011;52(4):574-580. 3. sandrasegaran k, maglinte ddt. imaging of small bowel-related complications following major abdominal surgery. eur j radiol 2005;53(3):374-386. 3. sandrasegaran k, maglinte ddt. imaging of small bowel-related complications following major abdominal surgery. eur j radiol 2005;53(3):374-386. 4. lee dh, lim jh, ko yt. afferent loop syndrome: sonographic findings in seven cases. am j roentgenol 1991;157(1):41-43. 4. lee dh, lim jh, ko yt. afferent loop syndrome: sonographic findings in seven cases. am j roentgenol 1991;157(1):41-43. 5. kim hc, han jk, kim kw, et al. afferent loop obstruction after gastric cancer surgery: helical ct findings. abdom imaging 2003;28(5):624-630. 5. kim hc, han jk, kim kw, et al. afferent loop obstruction after gastric cancer surgery: helical ct findings. abdom imaging 2003;28(5):624-630. 6. aoki m, saka m, morita s, fukagawa t, katai h. afferent loop obstruction after distal gastrectomy with roux-en-y reconstruction. world j surg 2010;34(10):2389-2392. 6. aoki m, saka m, morita s, fukagawa t, katai h. afferent loop obstruction after distal gastrectomy with roux-en-y reconstruction. world j surg 2010;34(10):2389-2392. 7. gale me, gerzof sg, kiser lc, et al. ct appearance of afferent loop obstruction. am j roentgenol 1982;138(6):1085-1088. 7. gale me, gerzof sg, kiser lc, et al. ct appearance of afferent loop obstruction. am j roentgenol 1982;138(6):1085-1088. s afr j rad 2013;17(1):43-45. doi:10.7196/sajr.842 sajr 790 the role of imaging in the evaluation of extraskeletal ewing’s sarcoma p barnardt, f roux division of clinical oncology, department of medical imaging and clinical oncology, stellenbosch university p barnardt, mb chb, dip onc division of radiology, department of medical imaging and clinical oncology, stellenbosch university f roux, mb chb, da (sa) corresponding author: p barnardt (pieterb@sun.ac.za) primary bone tumours account for 5% of all adolescent and child cancers. when ewing’s sarcoma arises in soft tissue rather than bone, it is referred to as extraskeletal ewing’s sarcoma (ess). computed tomography (ct) scanning and magnetic resonance imaging (mri) features of ewing’s sarcoma are non-specific, and a radiological differential diagnosis should be considered. ewing’s sarcoma is confirmed by features on histological analysis. in young people who present with soft-tissue tumours, ess should be considered. in the management of patients with tumours, imaging techniques are useful for biopsy guidance, evaluating the possibility of resection, and tumour response to treatment. s afr j rad 2013;17(1):30-33. doi:10.7196/sajr.790 primary bone tumours account for 5% of all adolescent and child cancers. the ewing’s sarcoma family of tumours is an aggressive form of childhood cancer and comprises the second most common primary bone tumour that includes ewing’s sarcoma, askin’s tumour and peripheral primitive neuro-ectodermal tumour (pnet). when ewing’s sarcoma arises in soft tissue (25%) rather than bone, it is referred to as extraskeletal ewing’s sarcoma (ees). before the introduction of chemotherapy, only 10% of patients survived but, with current management, 75% with localised disease will survive.1 , 2 we describe the presentation and outcome of 2 cases of ees. case 1 a 17-year-old boy presented with chronic lower backache for 6 months. the pain was located in the lower lumbar region and associated with right-sided l3 radiculopathy. on physical examination, a right paravertebral swelling was noted. the neurological examination was intact, with no loss of sphincter control. special investigations included normal blood work and chest x-ray (cxr). lumbar spine x-ray confirmed a subtle sclerotic change, isolated to the right pedicle of l3 (fig. 1). a 99mtcmdp whole-body bone scintigraphy study reported abnormal osteoblastic activity in l2/l3 not typical of ewing’s sarcoma. computed tomography (ct) and magnetic resonance imaging (mri) were performed. the selected axial ct slice at level l3 noted sclerosis and smooth volumetric expansion of the right pedicle. these bony changes were not in keeping with a primary bony neoplasm and thought to be reactive change secondary to the large associated soft-tissue tumour (fig. 2). numerous small pulmonary nodules in the peripheral lung zones of the lower lobes suggested pulmonary metastases. a mri gadolinium-enhanced t1-weighted fat-saturated axial slice at l2/l3 level showed a lobulated avidly enhancing right paraspinal soft-tissue mass displacing and invading the psoas muscle and erector spinae muscle group and extended to insinuate into the spinal canal, displacing and compressing the thecal sac to the left (fig. 3). fig. 1. ap lumbar radiograph. note the subtle isolated sclerotic change to the right l3 pedicle. fig. 2. a selected l3 axial ct slice (bony window). note the sclerosis and smooth volumetric expansion of the the right pedicle. fig. 3. a gadolinium-enhanced t1-weighted fat-saturated axial slice at l2/l3 level showing an avidly lobulated enhancing right paraspinal soft-tissue mass displacing and invading the psoas and erector spinae muscle group and extended into the spinal canal, displacing and compressing the thecal sac to the left. histology revealed a solidly packed, lobular pattern of uniform small round malignant blue cells. the individual cells had round-to-ovoid nuclei and fine powdery chromatin with small nucleoli. the cytoplasm was scant and vacuolated. immunohistochemistry stained strongly positive for the tumour membranous cells (cd99). based on the available evidence, a pnet/ewing’s sarcoma was the most likely diagnosis. at a multidisciplinary team meeting, a clinico-pathological and radiological correlation of the mri and ct confirmed the large paraspinal mass of the right l3 pedicle and transverse process with soft-tissue mass in the extradural space. these findings were consistent with a malignant tumour and suggested pnet/ewing’s sarcoma. according to the american joint committee on cancer (ajcc) classification system, the patient was staged as a g3t2n0m1, stage iv ewing’s sarcoma. systemic multi-agent chemotherapy consisted of vaia (vincristine, doxorubicin alternated with actinomycin-d and ifosphamide) every 4 weeks. he completed 6 cycles, and restaging investigations included a post-treatment mri that reported anterior end plate irregularity at l2/l3 level with herniation of disc material within the vertebral body. there was loss of disc height at l1 and l2 and a small area of ill-defined enhancement related to the right pedicle of the l3 vertebral segment. no obvious overt enhancing tumour with volumetric gain was visualised on the mri examination. a post-chemotherapy chest ct confirmed complete resolution of the lung metastases. the patient completed definitive external beam radiotherapy that included the gross tumour volume with a 2 cm margin (45 gray in 1.8 fractions) but no boost owing to the spinal cord dose limitation. this was followed by 6 months of maintenance chemotherapy for a total of 12 cycles. he is currently in complete clinico-radiological remission and disease-free for 24 months and continues with a normal active life. case 2 a 22-year-old man presented with a history of intermittent but progressive pain located in the pelvic region and associated left leg weakness for 8 months. physical examination revealed chronic illness with localised pain to the left pubic rami. special investigations included normal blood work and a normal cxr; a whole-body bone scintigraphy study demonstrated multiple osteoblastic metastases in the skull, ribs, both scapulae, the superior and inferior pubic rami on the left, both femurs and the proximal two-thirds of the right humerus (fig. 4a). focused radiological work-up started with plain film of the pelvis followed by ct of the abdomen and pelvis. findings on the plain ap pelvis film included a predominantly permeated lytic process that involved the body, superior and inferior rami of the left pubic bone with an associated diffuse interrupted laminated periosteal reaction. increased surrounding soft-tissue involvement was noted when compared with the contralateral side (fig. 5). sequential ct images illustrated the extent of the large heterogeneously enhanced soft-tissue tumour that infiltrated the obturator internis muscle and proximal adductor compartment, invaded the pelvic floor on the left, elevated and also infiltrated the bladder base. the included bony window eloquently depicted the aggressive permeated infiltration and associated periosteal reaction (fig. 6). the additional finding of multiple pulmonary nodules in the included lung basis was consistent with metastatic deposits. fig. 4. 99mtcmdp whole-body bone scintigraphy study. (a) pre-chemotherapy noting multiple osteoblastic metastases in the skull, ribs, both scapulae, the inferior left pubic rami, both femurs and the proximal right humerus. (b) post-chemotherapy study shows no visible metastases, representing a response to chemotherapy. fig. 5. ap plain film of the pelvis. note the predominantly permeated lytic process that involves the body, superior and inferior rami of the left pubic bone with an associated diffuse interrupted laminated periosteal reaction. fig. 6. sequence of ct images illustrate the extent of the large heterogeneously enhanced soft-tissue tumour that infiltrates the obturator internis muscle and proximal adductor compartment and invades the pelvic floor on the left, also elevated and infiltrating the bladder base. (a) axial post contrast cut through the pelvis. (b) sagittal post contrast ct. (c) oblique coronal ct (bony window depicts the aggressive permeated infiltration and associated periosteal reaction). (d)volumetric oblique coronal ct. a cystoscopy confirmed tumour in the left bladder neck/dome and was resected for histological investigation. microscopy revealed a highly necrotic and malignant small blue cell tumour. homer wright-like rosettes were present with high mitotic activity evident. the nuclei contained powdery chromatin, very scanty eosinophilic cytoplasm, inconspicuous nuclei and numerous small vessels. the morphology and immunohistochemistry suggested a possible ewing’s/pnet tumour, more towards the latter, in view of the rosettes. some entities were ruled out, such as rhabdomyosarcoma (desmin and myogenin negative), neuroblastoma and lymhoblastic lymphoma (tdt negative). a fluorescence in situ hybridisation test (fish) was requested for the t(11;22) encoding for ews-fl11 gene fusion but the outcome was uncertain. according to the ajcc classification, the patient was staged as a g3t2n0m1, stage iv ewing’s sarcoma. palliative systemic chemotherapy with vaia was offered. he completed 6 cycles with dramatic clinical benefit. restaging ct was compared with his baseline investigation and the sequential axial post-contrast ct slices through the pelvis confirmed complete resolution of the soft-tissue component as well as the pulmonary nodules. however, residual permeated changes involving the pelvic bones were noted (figs 7a and b). fig. 7. (a) preand (b) post-chemotherapy. sequential axial post-contrast ct slices through the pelvis confirm complete resolution of the soft-tissue component. note the residual permeated changes involving the pelvic bones. follow-up scintigraphy study revealed that the previously described metastases were either not visible or far less prominent, most probably representing a response to chemotherapy (fig. 4b). he completed 12 cycles of chemotherapy and is currently in clinico-radiological remission and disease-free for 6 months. discussion the ewing’s sarcoma family of tumours is an aggressive form of childhood cancer. about 25% of sufferers will present with metastatic disease, the most common sites for metastases being the lung (50%), bone (25%) and bone marrow (20%). around 25% of ewing’s sarcoma arises in soft tissue rather than bone and is referred to as extraskeletal ewing’s sarcoma (ess); it affects the 10 20 years age group (range 4 25 years), involving the extremities (32%), paravertebral (15%), head and neck region (11%) and the chest in 11% of cases.1 , 3 however, it has also been reported to arise in the small intestine, kidney, pelvis, skin, oesophagus and paravertebral region or epidural space. involvement of the spinal epidural space is unusual; only 32 cases have been reported, with a mean age of 19.1 years and a slight predominance in males. the lumbar epidural space (41%) has been the most commonly reported site. the clinical presentation of spinal ess relates to compression of the spinal cord, nerve roots or cauda equina, and presents clinically as back pain with or without radicular pain, limb paresis, and bladder and bowel dysfunction.4 in the literature, primary prostate ess/pnet is extremely rare, with only 6 cases described. patient ages ranged from 20 to 30 years. in all cases, the prostate gland was replaced by a large tumour with extra-prostatic involvement. the most common ct or mri finding was a heterogeneously enhanced mass.5 clinical differences between ess and ewing’s sarcoma are few. the long-term prognosis of ess has not been described but response to chemotherapy has been good and remains palliative for patients with unresectable or metastatic disease. prognostic indicators in most series include metastatic disease and extraskeletal involvement at presentation. most patients will succumb to their disease within 2 years.6 on imaging, features of ewing’s sarcoma are nonspecific and a radiological differential diagnosis should be considered (table 1).5 ct can show a sharply delineated hypodense soft-tissue mass adjacent to muscle. enhancement is usually intense and heterogeneous. hypodense foci are frequent in a large mass and are due to intra-tumour necrosis. 7 on mri t1-weighted images, the tumour is of low to intermediate signal intensity, and on t2-weighted images high signal intensity with heterogeneous contrast enhancement. tumour haemorrhage and adjacent bone destruction have been reported. if the mass is located near bone, it might result in cortical erosion and/or a periosteal reaction.8 a study by volker et al. found whole-body positron emission computer tomography (pet) and conventional imaging were equivalent in detecting primary ewing’s sarcoma, but pet was better at detecting lymph node and bony metastases involvement.2 table 1. pathological and radiological differential diagnosis small round blue cell tumour radiological non-hodgkin’s lymphoma rhabdomyosarcoma small cell lung cancer merkel cell cancer haemangiopericytoma neuroblastoma ewing’s sarcoma primitive neuro-ectodermal tumour (pnet) rhabdomyosarcoma myosarcoma malignant fibrous histiocytoma (mfh) dedifferentiated liposarcoma ewing’s sarcoma in our patients, the radiological ct observed bony changes in the first case were not in keeping with a primary bony neoplasm and thought to be reactive change secondary to the large associated soft-tissue tumor, confirming an ess. in case 2, the top radiological consideration would rather be a primary ewing’s sarcoma of the pelvic bone with extension into the adjacent soft tissue; radiologically, it is impossible to differentiate from the other members of the ewing’s family. the differential in this case is limited. however, primary bone lymphoma can give similar imaging findings, considering the permeated bony changes and large soft-tissue component. conclusion ess arising from soft tissue is rare and has non-specific features on imaging. both ewing’s sarcoma and ess are confirmed by features on histological analysis and should be differentiated from other round blue cell tumours and members of the ewing’s family of tumours. in young people who present with soft-tissue tumours, ess should be considered in the differential diagnosis. many imaging techniques are available and are most useful in the guidance for biopsy, the evaluation of possible resectability and tumour response to treatment. 1. grier he. the ewing family of tumours: ewing’s sarcoma and primitive neuroectodermal tumours. pediatr clin north am 1997;44:991-1004. 1. grier he. the ewing family of tumours: ewing’s sarcoma and primitive neuroectodermal tumours. pediatr clin north am 1997;44:991-1004. 2. balamuth nj, womer rb. ewing’s sarcoma. lancet oncol 2010;11:184-192. [http://dx.doi.org/10.1016/s1470-2045(09)70286-4] 2. balamuth nj, womer rb. ewing’s sarcoma. lancet oncol 2010;11:184-192. [http://dx.doi.org/10.1016/s1470-2045(09)70286-4] 3. shirkhoda a, peuchot m. extraosseous ewing’s sarcoma computed tomography evaluation before and after chemotherapy. clinical imaging 1989;13:142-146. 3. shirkhoda a, peuchot m. extraosseous ewing’s sarcoma computed tomography evaluation before and after chemotherapy. clinical imaging 1989;13:142-146. 4. ozturk e, mutlu h, sonmez g, et al. spinal epidural extraskeletal ewing sarcoma. j neurorad 2007;34:63-67. [http://dx.doi.org/10.4103/2152-7806.96154] 4. ozturk e, mutlu h, sonmez g, et al. spinal epidural extraskeletal ewing sarcoma. j neurorad 2007;34:63-67. [http://dx.doi.org/10.4103/2152-7806.96154] 5. funahasi y, yoshino y. ewing’s sarcoma/primitive neuroectodermal tumour of the prostate. int j urol 2009;16:769. [http://dx.doi.org/10.1111/j.1442-2042.2009.02339.x.] 5. funahasi y, yoshino y. ewing’s sarcoma/primitive neuroectodermal tumour of the prostate. int j urol 2009;16:769. [http://dx.doi.org/10.1111/j.1442-2042.2009.02339.x.] 6. toh kl, tan ph, cheng ws. primary extraskeletal ewing’s sarcoma of the external genitalia. j urol 1999;162:159-160. 6. toh kl, tan ph, cheng ws. primary extraskeletal ewing’s sarcoma of the external genitalia. j urol 1999;162:159-160. 7. perouli e, chrysikopoulos h, vlachos a, et al. imaging findings in paraspinal extra osseous sarcoma. jbrt-btr 2006;89:310-312. 7. perouli e, chrysikopoulos h, vlachos a, et al. imaging findings in paraspinal extra osseous sarcoma. jbrt-btr 2006;89:310-312. 8. ahmad r, mayol br, davids m, rougraff bt. extraskeletal ewing’s sarcoma. cancer 1999; 85:725-731. 8. ahmad r, mayol br, davids m, rougraff bt. extraskeletal ewing’s sarcoma. cancer 1999; 85:725-731. abstract introduction case report discussion conclusion acknowledgements references about the author(s) pankaj nepal department of radiology, faculty of sciences, st. vincent’s medical center, bridgeport, united states of america syed i. alam department of clinical imaging, faculty of sciences, hamad medical corporation, doha, qatar sadia sajid department of clinical imaging, faculty of sciences, hamad medical corporation, doha, qatar joshua sapire department of radiology, faculty of sciences, st. vincent’s medical center, bridgeport, united states of america vijayanadh ojili department of radiology, university of texas health, san antonio, texas, united states of america citation nepal p, alam si, sajid s, sapire j, ojili v. rare presentation of chronic recurrent multifocal osteomyelitis of the iliac wing mimicking ewing’s sarcoma. s afr j rad. 2021;25(1), a2030. https://doi.org/10.4102/sajr.v25i1.2030 case report rare presentation of chronic recurrent multifocal osteomyelitis of the iliac wing mimicking ewing’s sarcoma pankaj nepal, syed i. alam, sadia sajid, joshua sapire, vijayanadh ojili received: 20 oct. 2020; accepted: 26 nov. 2020; published: 18 feb. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this report describes a case of chronic recurrent multifocal osteomyelitis (crmo) in an 11-year-old girl, involving the iliac bone as an initial, solitary site. atypical imaging features were suspicious of a bone tumour, such as ewing’s sarcoma. chronic recurrent multifocal osteomyelitis is a great masquerader and can present atypically. radiologists should be familiar with both typical and atypical presentations, to determine an accurate diagnosis and guide appropriate management. timely diagnosis may avoid invasive bone biopsy and inappropriate long-term antibiotic prescription for children. keywords: chronic recurrent multifocal osteomyelitis; crmo; mri; ilium; rare. introduction chronic recurrent multifocal osteomyelitis (crmo) is a rare idiopathic inflammatory skeletal disorder, which is also known as chronic non-bacterial osteomyelitis. it commonly affects children and adolescents with predominant involvement of the metaphysis of long bones. several cases have been reported worldwide affecting every age group and almost all the bones.1 chronic recurrent multifocal osteomyelitis is a diagnosis of exclusion, and atypical cases demand additional investigations to exclude major differentials, such as infection and bone tumours. magnetic resonance imaging (mri) is the modality of choice for investigation, and the diagnosis is based on combined clinical and imaging follow-up to demonstrate relapsing and remitting episodes.2 case report an 11-year-old girl presented to the orthopaedic clinic with relapsing and remitting chronic right hip pain for 2 years, especially at night. this gradually led to limitation in her daily activities. there were no associated symptoms of weakness, numbness or paraesthesia. her medical history was unremarkable. she denied any trauma, fever or swelling. laboratory work-up was normal except for an elevated erythrocyte sedimentation rate (esr) (55 mm/h). leucocytosis was characteristically absent. on physical examination, she had localised tenderness over the right iliac wing. hip flexion, extension and other ranges of motion were unremarkable. initial imaging included a plain radiograph of the pelvis including both hip joints (figure 1). the right iliac wing demonstrated diffuse sclerosis and the hip joints were normal. magnetic resonance imaging of the pelvis was then performed both without and with gadolinium contrast (figure 2). heterogeneous marrow signal was seen within the iliac wing with marrow expansion. diffuse periosteal reaction was noted with increased t2 signal in the adjacent part of the iliacus and gluteal muscles. layers of periosteal enhancement was evident with enhancement of adjacent involved muscles. the mass could be seen extending close to the acetabular roof, but no intra-articular extension was noted. mild sacroiliitis was present with post-contrast enhancement. the imaging findings were suspicious for a bone tumour such as ewing’s sarcoma, considering the patient’s age. absence of fever, leucocytosis and negative blood cultures were clinically less suspicious for osteomyelitis. biopsy of the iliac bone was performed, which showed reactive bone formation with chronic inflammation. specimens were negative for malignancy and infection. the patient was managed conservatively with anti-inflammatory therapy and local treatment. figure 1: an 11-year-old-girl with chronic recurrent multifocal osteomyelitis: initial plain radiograph of the pelvis demonstrated diffuse sclerosis of the right iliac wing (arrows). figure 2: magnetic resonance imaging of the pelvis performed without and with gadolinium: (a) axial t2 fat-saturated image of the pelvis showing heterogeneous marrow signal within the right iliac wing with marrow expansion (red arrows). diffuse layered periosteal reaction was noted with increased t2 signal in the adjacent part of the iliacus and gluteal muscles (yellow arrow). (b) coronal short tau inversion recovery (stir) image of the pelvis showing layers of periosteal reaction (yellow arrow). increased marrow signal could be seen extending close to the acetabular roof but without intra-articular extension (red arrows). (c) coronal fat-saturated image gadolinium enhanced t1 weighted image indicated mild sacroiliitis with post contrast enhancement (green arrow) and heterogeneous marrow enhancement (blue arrow). in addition, there was enhancement of the adjacent muscles. follow-up imaging with a pelvic radiograph and whole-body mri were performed 3 months after treatment (figure 3). there was redemonstration of the heterogeneous marrow signal involving the iliac bone, which showed improvement. the periosteal thickening and reaction were also improved. abnormal t2 hyperintensity of the adjacent gluteus and iliacus muscles appeared significantly regressed. there was increased t2 marrow signal involving the inferior talus, cuboid and base of 5th metatarsal bones. this involvement of multiple bones with regression of inflammation in the ilium confirmed the diagnosis of crmo. figure 3: follow-up imaging with a radiograph of the pelvis and whole-body magnetic resonance imaging (mri) performed 3 months after treatment: (a) plain radiograph of the pelvis showing similar findings of sclerosis of right iliac wing. (b) magnified fat-saturated t2 weighted coronal image on whole-body mri shows significant improvement of the oedema and surrounding periosteal reaction (arrow). note the absence of adjacent muscle inflammation. (c) magnified section of the whole-body mri, coronal t2 weighted fat-saturated mr image of the left lower leg showing increased marrow signal involving the inferior talus, cuboid (arrows) and base of 5th metatarsal bone (not shown). this involvement of multiple bones with regression of inflammation in the ilium after conservative treatment confirms the diagnosis of chronic recurrent multifocal osteomyelitis. discussion chronic recurrent multifocal osteomyelitis is an idiopathic inflammatory disease, mostly prevalent in children and adolescents, that results in episodic bone pain.3,4,5,6 it is an uncommon condition with an estimated prevalence of one in a million.6 interestingly, for some unknown reasons, literature indicates that up to 85% of the affected are females.6 chronic recurrent multifocal osteomyelitis is also known as chronic non-bacterial osteomyelitis as no pathogens grow on blood culture and antibiotics do not relieve the symptoms.6,7 the aetiology remains elusive but has been associated with many dermatological and autoimmune disorders such as psoriasis, takayasu’s arteritis, crohn’s disease, ulcerative colitis, sapho (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome and some genetic disorders.8,9,10 clinically, patients present with non-specific symptoms of pain, swelling and limited range of motion. systemic symptoms such as fever, chills and lethargy are unusual.2 chronic recurrent multifocal osteomyelitis lesions are often multifocal with typical involvement of the distal metaphysis of the long bones, which undergo sclerosis or hyperostosis over time. common skeletal sites include long tubular bones and the clavicle, but cases have been described throughout the skeleton including the spine, pelvis, sternum, scapula, mandible, hands and feet.2 the lower extremity is involved three times more frequently than the upper extremity, with the most common bone involvement being the tibia. a study by andronikou et al.11 described the pattern as multifocal with predominantly tibial involvement or pauci-focal clavicular and spinal disease. the condition typically affects the metaphysis more commonly, with epiphyseal involvement in a third of the cases.11 although the disease is multifocal, the condition may present with involvement at a single site. thus, further evaluation of the entire skeleton is indicated to identify multifocal lesions that may be clinically silent.2 whole-body imaging may be performed both with 99mtc bone scintigraphy or whole-body mri, each with their own limitations, considering cost versus radiation. involvement of the ilium as a potential site for crmo has been reported infrequently.2,6,12,13 chronic recurrent multifocal osteomyelitis of the pelvic bone itself is rare and the site of predilection in pelvis includes metaphyseal equivalents such as the ischiopubic synchondrosis and sacroiliac joints.2,14,15 pelvic crmo can rarely manifest as sclerosis of the iliac wings.2,6 there is considerable overlap in the imaging findings, which are not pathognomonic. metaphyseal involvement without periosteal reaction is the typical presentation of crmo.6 significant periosteal reaction and adjacent soft tissue component, as in our case, delayed the diagnosis as the initial impression was either ewing’s sarcoma or langerhans cell histiocytosis. osteomyelitis was low in clinical suspicion because of the absence of systemic findings, leucocytosis and negative blood culture. the unusual location of the initial solitary lesion in the right iliac wing in our case added to difficulties in the diagnosis of crmo. although a prolonged and fluctuating relapsing-remitting course is pathognomonic, the typical history may be lacking unless sought for or absent as in our case. a team approach of clinicians, orthopaedic surgeons, radiologists and pathologists is crucial in reaching the diagnosis such as in our case. as a result of the overlapping imaging features, atypical cases are often biopsied. the biopsy may show inflammation and absence of culture of causative organisms. it will also help in excluding bone tumours. inflammatory disease with absence of a positive culture is a clue for crmo if this differential is in mind, otherwise it may be mismanaged with prolonged antibiotics. few points to consider from our case are: (1) chronic 2-year history of bone pain (2) diffuse sclerosis of the iliac bone on plain radiography (3) involvement of the sacroiliac joint with features of sacroiliitis (4) multifocal involvement of the talus, cuboid and metatarsal bones and (5) interval improvement of inflammation involving the bone marrow and adjacent muscles with anti-inflammatory treatment. a recent update in the treatment approach recommends using either bisphosphonate or biological therapy in addition to the anti-inflammatory and local treatment.1,13 conclusion chronic recurrent multifocal osteomyelitis as a solitary lesion at an uncommon site may masquerade as various forms of infection or bone tumours. the diagnosis depends on a multidisciplinary approach; thus, the radiologist must be familiar with this diagnosis and should recommend additional whole-body imaging to aid in diagnosis, if suspected. acknowledgements the authors would like to acknowledge their patient as a great source of learning. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. authors’ contributions p.n., s.i.a., s.s., j.s. and v.o. contributed equally to this case report. ethical consideration this article followed all ethical standards for research. funding information this case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable in this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references buch k, thuesen acb, brøns c, schwarz p. chronic non-bacterial osteomyelitis: a review. calcif tissue int. 2019;104(5):544–553. https://doi.org/10.1007/s00223-018-0495-0 khanna g, sato ts, ferguson p. imaging of chronic recurrent multifocal osteomyelitis. radiographics. 2009;29(4):1159–1177. https://doi.org/10.1148/rg.294085244 costa-reis p, sullivan ke. chronic recurrent multifocal osteomyelitis. j clin immunol. 2013;33:1043–1056. https://doi.org/10.1007/s10875-013-9902-5 jansson a, renner ed, ramser j, et al. classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients. rheumatology. 2007;46(1):154–160. https://doi.org/10.1093/rheumatology/kel190 catalano-pons c, comte a, wipff j, et al. clinical outcome in children with chronic recurrent multifocal osteomyelitis. rheumatology. 2008;47(9):1397–1399. https://doi.org/10.1093/rheumatology/ken249 zhang p, jia xy, zhang y, morelli j, zhang zk. chronic recurrent multifocal osteomyelitis beginning with a solitary lesion of the ilium. bmc musculoskelet disord. 2017;18:245. https://doi.org/10.1186/s12891-017-1611-4 cyrlak d, pais mj. chronic recurrent multifocal osteomyelitis. skeletal radiol. 1986;1:32–39. https://doi.org/10.1007/bf00355071 laxer rm, shore ad, manson d, king s, silverman ed, wilmot dm. chronic recurrent multifocal osteomyelitis and psoriasis: a report of a new association and review of related disorders. semin arthritis rheum. 1988;17(4):260–270. https://doi.org/10.1016/0049-0172(88)90011-x dagan o, barak y, metzker a. pyoderma gangrenosum and sterile multifocal osteomyelitis preceding the appearance of takayasu arteritis. pediatr dermatol. 1995;12(1):39–42. https://doi.org/10.1111/j.1525-1470.1995.tb00122.x bousvaros a, marcon m, treem w, et al. chronic recurrent multifocal osteomyelitis associated with chronic inflammatory bowel disease in children. dig dis sci. 1999;44(12):2500–2507. https://doi.org/10.1023/a:1026695224019 andronikou s, mendes da costa t, hussien m, ramanan av. radiological diagnosis of chronic recurrent multifocal osteomyelitis using whole-body mri-based lesion distribution patterns. clin radiol. 2019;74(9):737.e3–737.e15. https://doi.org/10.1016/j.crad.2019.02.021 jurik ag, møller sh, mosekilde l. chronic sclerosing osteomyelitis of the iliac bone. etiological possibilities. skeletal radiol. 1988;17(2):114–118. https://doi.org/10.1007/bf00365138 moll c, hernández mv, cañete jd, et al. ilium osteitis as the main manifestation of the sapho syndrome: response to infliximab therapy and review of the literature. semin arthritis rheum. 2008;37(5):299–306. https://doi.org/10.1016/j.semarthrit.2007.08.004 jurik ag, helmig o, ternowitz t, moller bn. chronic recurrent multifocal osteomyelitis: a a follow-up study pediatr orthop. 1988;8(1):49–58. https://doi.org/10.1097/01241398-198801000-00012 vittecoq o, said la, michot c, et al. evolution of chronic recurrent multifocal osteitis toward spondylarthropathy over the long term. arthritis rheum. 2000;43(1):109–119. https://doi.org/10.1002/1529-0131(200001)43:1<109::aid-anr14>3.0.co;2-3 case report intermittent intestinal obstruction due to chronic colo-colic • •intussusception abstract a two year old boy presented with a two month history of intermittent bloody diarrhoea, and associated intermittent colicky abdominal pain and weight loss. a small mass was pal pable over the left abdomen. abdominal rad iograph showed colon ic obstruction and barium enema revealed colo-col ic intussusception. at laparotomy, the intussusception had reduced spontaneously and was found to be caused by a ben ign juvenile polyp. the clinical and imaging wcgpeh mbbs, dmrd, frcr, fams associate professor wcheng* mbbs, frcse, frcsg, fracs assistant professor departments of diagnostic radiology and 'surgery (paediatric surgery division), the university of hong kong, queen mary hospital, hong kong 19 sa journal of radiology. june 1997 features, and management of the chronic form of intussusception are discussed. case report a two year old chinese boy presented with a two month history of intermittent diarrhoea. mucus and blood was occasionally noted in the stools. there was associated intermittent colicky abdominal pain and weight loss of 2 kg.the child enjoyed previous good health. prior to admission, he was seen by a private practitioner and had been treated with antibiotics without improvement. on examination, a small firm mass was palpable over the left upper abdomen. ultrasound scan did not however show any abnormality. stool cultures for various micro-organisms, and blood serology and cultures, were all negative. abdominal radiograph (figure i), done during the next severe episode figure 1: supine abdominal radiograph shows dl/atatlon of the small bowel and the proxima/ hemi-c%n. topage22 ready for everything. announcing imagepoint, from hewlett-packard" the innovative, ergonomic keyboard is designed for comfort and ease of use. imagepoint is the multispecialty, high-performance digital ultrasound system that covers a wide range of ultrasound examinations. whatever your needs abdominal, vascular, ob/gyn, small parts, cardiac, paediatric imagepoint brings hewlett-packard's tradition of innovation and performance to ultrasound. and imagepoint comes complete with all these applications, without compromise in image quality. imagepoint's exceptional digital imaging provides outstanding resolution. its simple, ergonomic design is comfortable and efficient. global, comprehensive training and support are available when you need them. and imagepoint is affordable to buy and cost-effective to operate. it's easy to learn, easy to use, easy to upgrade and easy to move. in short, easy to own. filahewlett a!~ packard imagepoint from hewlett-packard" •.:..1.• • •.. .... hiperformance systems for more information please contact lynnehe lewis at hiperformance systems, sole authorised distributor of hewleh·packard medical equipment, at (011) 806-1229 or glen strike in durban (031) 207-2073 or diane romburgh in cape town (021) 658-6202 inlermittent intestinal obstruction due lo chronic colo-colic intussusception (rom page 19 of abdominal pain, showed dilated loops of gas-filled small bowel, as well as distention of the ascending and transverse colon. an urgent barium enema was performed on suspicion of colonic obstruction in the region of the splenic flexure. complete obstruction at the proximal descending colon was confirmed, with a concave defect at the head of the barium column and a classic "coiled-spring" appearance, typical of intussusception, beyond that (figure 2). combination of plain radiographic and barium enema findings were highly suggestive of the colo-colic type of intussusception. in addition, there was a polypoidal filling defect located just distal to the intussusception site on the barium study (figure 2). attempted hydrostatic reduction of intussusception using barium was unsuccessful. figure 2: enema coned to show the descending colon and proximal sigmoid colon shows the "coiled-spring" appearance of intussusception (arrowheads), 85 well as a polypoidal filling defect (arrows). laparotomy was performed later the same day.at surgery however, the colo-colic intussusception was found to have reduced spontaneously. a mass was palpable within the proximal descending colon and colotomy revealed a 3.5 x 2.5 x 1.7 cm polyp (figures 3a and b), corresponding in is usually considered early in the differential diagnosis of a young child presenting with a short history of abdominal pain and vomiting. chronic intestinal intussusception of greater than two weeks duration is uncommon, occurring in 6.5% of patients in one large series.' chronic intussusception behaves differently from the acute form in that abdominal pain and vomiting are less severe, with diarrhoea and weight loss being recognized features. chronic intussusception may even rarely present as failure to thrive. except for the typical intermittent colicky abdominal pain, symptoms of chronic intussusception are generally rather non-specific. 2-4 chronic intussusception tends to be found in older children and it has been suggested that at an older age, the anatomy is such that intussusception occurs without significant impairment of the blood supply.' ultrasound is now regarded as an accurate method to diagnose intussusception, offering the advantages of being quick, simple, non-invasive and radiation-free. it has been recommended that contrast enema should be reserved for ultrasonically-equivocal cases or for therapeutic reduction. 5 spontaneous reduction of intussusception has been reported to cccur/" on retrospect, the clinical picture of this patient fitted that of a chronic, intermittent-occurring and spontaneously-reducing intussusception. at the figure 3: intraoperative photographs show (a) a palpable mass within the proximal descending colon, and (b) colotomy revealing the lead point, a juvenile polyp. site to the polypoidal filling defect seen on barium enema. histopathology of the excised specimen showed features of a benign juvenile polyp. the patient recovered uneventfully and has remained well to date. discussion intestinal intussusception is á common surgical emergency in children, requiring urgent diagnosis and treatment. acute intussusception 22 sajournal of radiology. june 1997 topage23 intermittent intestinal obstruction due to chronic colo-col ic intussusception from page 22 time of ultrasound and at surgery, the intussusceptum was not identified, while in-between, it produced the characteristic barium enema appearances of intussusception. colo-colic intussusception is the least frequently encountered type of intussusception, while the ileo-colic type is by far the commonest form." although detection oflead points using ultrasound has been reported," the site of the polyp within a gasand faecal-filled colon and absence of the spontaneously-reduced intussusceptum probably made ultrasonic assessment difficult in this patient. causative lead points are not detected in the majority of intussusceptions, being reported in only 2.5-10% of cases.l''!' the presence of barium interposed between the intussusceptum and intussuscipiens, the so-called "dissection sign", could have contributed to failure of hydrostatic reduction in this patient. the "dissection sign" causes concentric compression of the intussusceptum and hence a decrease in the reductive force, due to fluid dynamics of the dissected barium. there is evidence that this sign may be a reliable predictor of failure of hydrostatic reduction." in any case, even successful reduction of an intussusception does not exclude a lead point. careful review of all imaging studies and meticulous examination during laparotomy should be carried out to diagnose lead points in order that they may be adequately treated. as chronic intussusception is frequently associated with a predisposing lesion and a low success rate of hydrostatic reduction, early surgical intervention is recommended for this form of intussusception." references 1. reijnen jam, festen c, joosten hjm. chronic intussusception in children. br i surg. 1989;76815-816. 2. page ac, price jf, salibury jr, howard er, karani 1. chronic intussusception. arch dis child ]990;65:134-135. the renal transplant scorea different way of evaluating renal transplant pathology from page 18 2. dubovsky ev, russel cd, erbas b. radionuclide evaluation of renal transplants. seminars in nuclear medicine 1995; 25: 4959. 3. nicoletti r. evaluation of renal transplant perfusion by functional imaging. eur ] nucl med 1990; 16: 733-739. 4. mizuiri s, hayoshi i, takano m, ban r, ohara t, susiki y, hasegawa a. fractional mean transit time in transplanted kidneys studied by technetium-99m-dtpa: comparison of clinical and biopsy findings. ] nucl med 1994; 35 84-89. 5. ash j, de souza m, peters m, wilmont 0, hansen d, gilday d. quantitative assessment of blood flow in pediatric recipients of renal transplants. i nucl med 1990; 31: 580-585. 6. dubovsky ev, russel cd. radionuclide evaluation of renal transplants. seminars in nuclear medicine 1988; 18(3): 181-198. 7. kittner ch, esther g, finck w, bast r, templin r, wizze h, broekmoller s. der trendverteilungs quotient, ein neues werkzeug z u r auswertung der nierenperfusionsszintigrafie mit 99mtc dtpa nach nieren transplantation. nucl med 1993; 32: 37-41. 23 sa journal of radiology. june 1997 3. watson na, bisset ral. intussusception a cause of chronic abdominal symptoms and weight loss. clin radial 1994;64:723-726. 4. rees bl, lari j. chronic intussusception in children. br] surg 1976;63:33-35. 5. shanbhogue rlk, hussain sm, meradji m, robben sgf, vernooij lem, molenaar jc. ultrasonography is accurate enough for the diagnosis of intussusception. ] pediair surg 1994;29:324-328. 6. morrison sl, stork e. documentation of spontaneous reduction of childhood intussusception by ultrasound. pediatr radial 1990;20:358-359. 7. swischuk le, john so, swischuk pn. spontaneous reduction of intussusception: verification with ultrasound. radiology 1994;192:269-271. 8. bissett gs ll!, kirks dr. intussusception in infants and children: diagnosis and therapy. radiology 1988;168: 141-145. 9. lam ai, firman k. ultrasound of intussusception with lead points. australas radioi1991;35:343-345. 10. ein sh. leading points in childhood intussusception. ] pediair surg 1976; 1 1:209211. 11. miller sf, landes ab, dautenhahn lw, et al. intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities. radiology j 995; 197:493-496. 12. fishman mc, borden s, cooper a. the dissection sign of nonreducible ileocolic intussusception. air 1984; 143:5-8. 8. lear jl, raff u, jain r, horgen jg. quantitative measurement of renal perfusion following transplant surgery. 1 nucl. med. 1988; 29: 1656-1661. 9. smith sb, wombolt dg. histologie correlation of transplant rejection diagnosed by computer assisted sulphur colloid scan. urology 1983; 21 (2): 151-153. 10. kim ee, pjura g, lowry p, verani r, sandler c, flechner s, kahan b. cy losporin a nephrotoxicity and a ute cellular rejection in renal transplant recipients: correlation between radionuclide and histologic findings. radiology 1986; ) 59: 443-446. clinical images delayed computed tomography appearances of hypoxic ischaemie •• •injury in premature neonates savvas andronikon mb bch, fcrad(d), frcr (lond) chris weiman mbchb ebrahim kader mbchb . department of paediatric radiology umverslty of cape town and institute of child health red cross war memorial children's hospital, cape town unlike full-term neonates, the periventricular region of premature neonates is considered at high risk for ischaemia due to the immaturity of the vascular supply. the end result of an ischaemie insult in this region is termed leukomalacia. the most commonly affected periventricular white matter locations are those around the trigone and those adjacent to the foraminae of monro. cavitation fig. 1. marked supratentorial white matter loss seen as cystic (low-density) areas of liquefaction abutting the ventncles. this area of leukomalacia is circumscribed by a thin ribbon of cortex (arrowheads). the grey matter and cerebellum are both spared in keeping with a hypoxic rather than a more severe anoxic episode. occurs only 2 6 weeks after injury and the cystic change approaches the fig. 2. leukomalacia affecting the centrum semiovale with prominent csf spaces around the brain and only a thin remaining rim of cortex (arrowheads). ventricular walls until these can no longer be identified on imaging. in premature neonates, these cystic areas represent liquefaction without glial response. after an anoxic episode, e.g. cardiovascular arrest, grey matter nuclei and brain stem nuclei also show low density.' uliraso~d (us) should be used when the anterior fontanelle is open. computed tomography (ct) is indicated after fontanelle closure and when there is non-specific ventricular enlargement found at us. reference 1. barkovich ai. paediatric neuroimaging. 2nd ed. philadelphia: lippincott-raven, 1996: 113-145. 48 sa journal of radiology. march 2002 revievv article occupational infection risks in interventional radiology abstract south african radiologists performing interventional and angiographic procedures are at risk of occupational exposure to hepatitis band c and the human immunodeficiency virus (hiv). simple precautions reduce this risk substantlallv, it is important that radiologists and personnel working in the interventional suite are aware of the risk of infection, how to reduce the risk and how to prevent seroconversion after need ie stick injuries. pcorr mbchb, ffrad 17 sa journal of radiology· november 1998 occupational exposure to viral material during invasive procedures is a major concern to health professionals in many countries. i south africa has a particularly high prevalence of hivand hepatitis band c infection in the population.p radiologists, radiographers and nurses who perform and assist with angiography or interventional procedures are at risk through needle stick injuries or corneal splashes from blood.'> it is important that radiologists be aware of the risk, how to reduce the risk and what to do after needle stick injuries." risk of hiv infection south africa currently has an epidemic of hiv infection from heterosexual spread. the latent period from sera conversion to the development of the acquired immunodeficiency syndrome (aids) is approximately ten years. many of our patients requiring interventional or invasive procedures will be incidentally seropositive. the hiv positivity rate varies from less than 5% in the western cape to 23% in routine antenatal clinic screening in kwazulu natal.' patients with clinical aids are more likely than other patients to have invasive procedures such as biopsies, drainage of intra-abdominal collections or abscesses and angiography for arterial occlusions and an urysms. it is very important for the radiologist, radiographer and nurse to be aware of the occupational risk from hiv. data about the risk of seroconversion are derived mostly from studies in the united states reported by the center for disease control and prevention (cdc). occupational infection has been definitely to page 18 occupational infection risks in interventiona i rad iology from page 17 documented in 52 health professionals and probably in iii other workers.' the majority of the documented cases (90%) involved blood exposure. eighty-seven percent of all these cases followed needle stick injuries. the cdc reviewed 25 studies of hiv seroconversion from 1983 to 1994 recently.'" the documented risk for percutaneous exposure is 0.3% (21 infections in 6498 documented exposures) .7 a retrospective review comparing incidents involving seroconversion versus those workers who did not seroconvert, found that those workers who seroconverted had the following increased risks: a deep percutaneous injury, visible blood on the instrument or needle, the instrument was used for arterial or venous access, and the patient was terminally ill.? seroconversion is more likely with a large volume of blood and a high viral load," the risk for mucous membrane exposure was estimated to be 0.] % and for intact skin exposure less than 0.] %.8 risk of hepatitis b infection hepatitis b is the most common occupational infection world-wide.' in south africa the prevalence of hepatitis envelope antigen (hbeag) is particularly high, in the region of 10%.3 hepatitis b is extremely infectious because of much higher circulating blood viral antigen levels ( 1013 viral particles per ml) than with hiv. the virus survives in dried blood for up to a week, unlike hiv, which dies within minutes. the risk of seroconversion is 12% in non-immunised workers after percutaneous inoculation of the hepatitis surface antigen (hbsag) . the risk increases to 30% after exposure to the envelope antigen of the virus (hbeag).9 however the risk of seroconversion is minimal in the fully immunised worker." it is essential that all health workers have full immunisation for hepatitis b. the recombinant dna vaccine is proven to be extremely safe and effective. it is critically important that a protective antibody level greater than 10 miu/ml be documented in all workers to ensure effective immunisation. immunisation failure is due to a variety of reasons, usually including incorrect administration of the vaccine or failure to receive the 6 month and 5 year boosters. health workers should not be allowed to work in the interventional room without immunisation. infection with hepatitis b may result in chronic hepatitis in 10-25% of patients. the risk of resultant cirrhosis and hepatoma is about 10%. the cdc estimates that in the united states 8 700 health professionals are infected every year with hepatitis b. this results in up to 190 deaths from hepatitis per year." risk of hepatitis c infection hepatitis c is the most common cause of non-a and non-b hepatitis infections from blood transfusions. the prevalence of hepatitis c is in the region of 1.2% in donated blood in south africa.' in the usa the prevalence is 0.6%. the risk of developing chronic liver disease is much higher than with hepatitis b, with 85% of patients with acute infections remaining chronically infected. twenty percent of these patients develop chronic liver disease and cirrhosis. the estimated risk of infection following a percutaneous injury is between 6 and 18 sa journal of radiologynovember 1998 10%, making it more infectious than hiv but far less infectious than hepatitis b. no vaccine has been developed yet and there is no obvious benefit in giving hyperimmune globulin for post exposure prophylaxis. precautions most precautions involve common sense. remember to treat every patient as infectious until proven otherwise. normal precautions include: 1. do not recap needles this is the single most important precaution you can take. most needle sticks occur during recapping of the needle. great care must be used when reinserting the stylet of the potts needle into the cannula. never hand a sharp needle or instrument to an assistant. always place sharps on the tray first. 2. do not use glass syringes for contrast injections because of the risk of shattering. polycarbonate syringes are much stronger than conventional plastic syringes. 3. ensure adequate lighting over the working area during the procedure. there has been shown to be a risk in many interventional rooms where lighting is poor. 4. always wear latex gloves, preferably double-gloving. occult perforations occur in 10% of gloves during interventional procedures, increasing to 23% in those procedures lasting more than two hours. double gloving reduces this risk substantially, particularly during long procedures. 5. always wear a sterile gown, mask and transparent face shield when performing procedures, particularly angiography. it is extremely important to remember to use facemasks with to page 19 occupational infection risks in interventional radiology from page 18 the attached plastic shield to cover the eyes to prevent corneal splashes. 6. the modified arteriography pott's needle with a vacuum side arm prevents blood splashes during arterial puncture. it is now available in south africa and costs ris more than the conventional needle. 7. a closed angiographic flush system avoids blood splashes when flushing syringes. one can aspirate heparinised saline and contrast and dispose of bloody fluid into a closed drainage container. try to avoid using open bowls on the tray, as there is a substantial risk of splashes. the closed flush system is available commercially. however one could probably make one's own from drip tubing, a three way tap, a vacolitre of normal saline and a urine bag for blood disposal. 8. remember to cover the image intensifier with sterile plastic to prevent blood splashes. exp'osure to blood if you are splashed with blood, wash the exposed skin with soap and water, and flush mucous membranes and eyes with water. if a sharp injury occurs, you must notify the infection control officer in your hospital. take blood from the patient with his or her written consent to check the hiv status. your blood will be required for baseline hiv testing. if the patient is hiv positive, postexposure prophylaxis should be started as soon as possible, preferably within 1 to 2 hours. early prophylaxis is critical in preventing seroconversion. the window of opportunity to prevent viral spread is a few hours. zidovudine (azt) 200 mg tds and lamivudine (epivir) 150 mg bd for four weeks is currently recommended by the cdc in the usa (cdc website address for current information is http:// www.cdc.gov j.lt it is important that early counselling of the risks of seroconversion commences as soon as possible. testing for hiv should be repeated at 6 weeks, 3 months and 6 months. this prophylaxis is highly effective, reducing the risk of seroconversion by 79%. if the patient is positive for hepatitis b, and you are not fully immunised, immune globulin must be administered within 24 hours and the hepatitis b booster given. there is no evidence that hyperimmune globulin prevents hepatitis c infection. conclusions it is critically important that all health care workers, especially radiologists performing interventional procedures, be aware of the risk of infection in their daily practice. precautions involve common sense and care when handling sharps. you must be aware of your local hospital policy on post exposure prophylaxis, whom to contact and try to educate your working colleagues on safe working conditions in the interventional room. acknowledgements i would like to thank professor susan wall, interventional radiology, university of california, san francisco, usa for permission to use her data in preparation for this article. references 1. gerberding jl. management of occupational exposures to blood borne viruses. neim 1995; 332: 444-51. 2. williams b, campbell c. understanding the epidemic of hiv in south africa: analysis of the antenatal clinic screening data. s afr med i 1998; 88(3): 249-51. 19 sa journal of radiologynovember 1998 3. kew me. progress towards the compr hensive control of hepatitis bin africa: a view from south africa. gut 1996; 38(supp 2: s31-36). 4. mcwilliams rg, blanshard ks. the risk of blood splash contamination during angiography. clinical radiology 1994; 49: 59-60. 5. hansen me, miller gl, redman hc, mcintire dd. needle stick injuries and blood contacts during invasive radiologic procedures: frequ ncy and risk factors. air 1993; 160: 1119-22. 6. wall sd, howe jm, sawhney r. human immunodeficiency virus infection and hepatitis: biosafety in radiology. radiology j997; 205(3): 619-28. 7. centers for disease control and prevention. case control study of hiv seroconversion in health care workers after percutaneous exposure to hivinfected bloodfrance, uk, usa january 1988-august 1994. mmwr 1995; 44: 929-933. 8. centers for disease control and preventionhiv/aids surveillance report: us hivand aids cases reported through december 1996-97; 8(2): 20-21. 9. zuckerman ai. occupational exposure to hepatitis b virus and human immunodeficiency virus. a comparative risk analysis. am i lniect colltro11995; 23: 28. 10. center for disease control and prev ntion. recommendations for prevention of transmission of immunodeficiency virus and hepatitis b virus to patients during exposure prone invasive procedures. mmwr 1991;40:1-9. 11. center for disease control and prevention. public health servi e guidelines for the management of health care worker exposure to hiv and recommendations for post exposure prophylaxis. mmwr 1998; 47:1-10. http://www.cdc.gov case report dysphagia aortica dual aortic • •impressions on barium swallow m n van der ness mbchb lwstassen dmrd (land) department of diagnostic radiology university of the free state bloemfontein abstract transient intermittent oesophageal obstruction in an elderly patient is described. barium swallow showed an extrinsic impression of the oesophagus by an aneurysmal aortic arch as well as the descending aorta. the aetiology and likely differential considerations are discussed. introduction aneurysms of the aortic arch and descending aorta can cause considerable localised displacement of the oesophagus. dysphagia due to all types of thoracic aortic aneurysm is uncommon but well documented. the incidence has been reported to approximate 5%.\ we present a patient with two separate impressions on either side of the oesophagus due to a thoracic aortic dilatation. case report an 84-year-old woman on treatment for hypertension, ischaemie heart disease and osteoporosis, presented with a 6-month history of dysphagia and weight loss. on examination the patient had kyphosis and a pulsatile epigastric mass. a barium swallow clearly demonstrated a leftsided extrinsic impression, which was due to aneurysmal dilatation of the aortic arch. a second right-sided extrinsic impression of the lower oesophagus was also demonstrated (figs la and lb). the impression was pulsatile and was caused by the descending aorta. discussion the aorta is attached to the oesophagus by fibrous tissue. elongation and unfolding of the ageing-descending aorta is accompanied by displacement of the oesophagus from its usual course. dysphagia aortica can be caused by compression of either the upper oesophagus by a thoracic aneurysm or the lower oesophagus by an aneurysmal or atherosclerotic aorta. in our patient both these impressions could be demonstrated. dysphagia aortica is associated with hypertension, old age, and kyphoscoliosis.' only 10 cases of dysphagia aortica were identified from a medline search of the last 10 years and a litera33 sa journal of radiology • june 2002 figs te and lb. ap view barium swallow demonstrates dual aortic impressions. ture review compared with 40 cases of compression by an aberrant subclavian artery,' fluoroscopy of the barium-filled oesophagus shows transmitted pulsations. the distal oesophagus is narrowed in one plane by this extrinsic compression, and obstruction in the erect and supine positions may be relieved by turning the patient prone. complete occlusion of the distal oesophagus is a rare manifestation of a saccular thoracic aortic aneurysm.' the barium swallow will show a classic feature of achalasia, that is a dilated atonic oesophagus with a narrow tapered point at the cardia. manometry, which differentiates dysphagia aortica from achalasia, shows low amplitude propagated peristaltic waves in the proximal part of the oesophagus and a high-pressure band at the site of the vascular compression. this contrasts with true achalasia in which there are no propagated contractions and no superimposed pulsations. it is important to remember that diffuse infiltrating adenocarcinomas of the gastro-oesophageal junction can mimic the radiological and manometric features of true achalasia case report by mechanical obstruction of the distal oesophagus, as weu as infiltration and destruction of the myenteric plexus by the tumour,' this condition, termed pseudoachalasia, must be excluded before making a diagnosis of either classic achalasia or dysphagia aortica. there is no single test for pseudoachalasia, but high resolution ct, mri, endoscopic ultrasound and careful endoscopic biopsy specimens from the area can be used to make the diagnosis. dysphagia aortica should be considered in any elderly patient with dysphagia who also has an aortic aneurysm. the radiographic appearance, however, needs to be distinguished from achalasia or an obstructing distal oesophageal neoplasm. references 1. de bakey me, mccollum ch, graham jm. surgical treatment of anuerysm of the descending thoracic aorta. j cardiovasc surg 1978; 19: 571-576. 2. mcmillian ikr, hyde 1. compression of oesophagus by aorta. thorax 1969; 24: 32-38. 3. taylor cw, sinha a, nightingale jmd. dysphagia and thoracoabdominal aneurysm. postgrad med ]2001; 77: 257-258. 4. mayer rc. frank e. saccular aortic aneurysm causing complete distal esophageal obstruction. sal/th med 11993; 86: 1408-1410. 5. robertson cs, gri.ffith cdm, atkinson m, hardcastle jd. pseudoachalasia of the cardia: a review. jr soc med 1988; 81: 399-402. ct of the head and spine nowinski this book provides the essential information needed for formulating findings in ct of the head and spine. the book is conceived as a highly practical guide for use in routine ct diagnosis. as well as in critical oneall emergency situations. features: • condenses information to the core questions of the diagnostic problem at 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peripheral musculoskeletal ultrasound atlas dondelinger / daenen / ferrara straightforward commentary and 750 illustrations including sonograms and line drawings combine to make this book an authoritative review of high-definition ultrasonography in diagnosing musculoskeletal pathology of the extremities. this innovative, applications-oriented guide systematically covers: • state-of-the-art instrumentation and examination techniques, with expert advice on probe positioning • common technical problems, diagnostic pitfalls, useful preventive and corrective actions • normal and pathologic ultrasound findings for muscle, tendon, ligament, periosteum and bone, joint capsule, bursa and synovium, cartilage, vessel, nerves, fat, and skin • pathologic regional ultrasound findings for the shoulder, arm, elbow, forearm, wrist, hand, hip, thigh, knee, leg, ankle, and foot • a wide range of specific diagnostic applications, including diagnosis of tendon tears, hematomas, fractures, joint effusions, foreign bodies, and more. 1996,213 pp, 750 illustrations, hardcover, r1 550 orders: the sa medical association, private bag x1, pinelands 7430. tel (021) 530-6527. fax (021) 531-4126. e-mail: fpalm@samedical.org please allow 3-4 weeks for delivery. prices subject to foreign exchange fluctuations. 34 sajournal of radiology. june2002 mailto:fpalm@samedical.org case report rupture of renal artery •aneurysms in pregnancy introduction we present a case of a 35-year-old female who presented at ten weeks gestation with lower abdominal and right flank pain and gross haematuria. a preoperative diagnosis of ruptured right renal artery aneurysm was made with colour doppler ultrasound and is the first reported case in a pregnant female. the high maternal and fetal mortality of ruptured renal artery aneurysm in pregnancy can partly be attributed to an incorrect preoperative diagnosis. in only one reported case was a diagnosis made preoperatively using computer tomography (ct) scanning. i most of the patients were managed as obstetric emergencies with abruptio placentae being the commonest preoperative diagnosis. in addition, hypertension and haematuria during pregnancy add to the diagnostic dilemma.' recent advances in ultrasound technology have meant that colour doppler ultrasound can now be used as a quick non-invasive method for assessing the kidneys, renal arteries and retroperitoneal spaces. y solwa mbchb zb bereczky'" md, fcs(urol) pcorr ffradsa j maharajh ffrad(d)sa c sanyika fcrad(d)sa departments of radiology and urology·, faculty of medicine, university of natal medical school case report a 35-year-old african female, gravida iv, para iii, was referred by a 10 sa journal of radiologymay 1998 general practitioner with a two week history of lower abdominal pain, and frank haematuria. the patient was 10 weeks pregnant. there was no significant past medical history and her previous pregnancies were all normal. examination revealed a blood pressure of 150/1 00 mmhg and a pulse of 82 beats/min. the patient had suprapubic and right flank pain on palpation of the abdomen. a bruit was audible on auscultation of the epigastrium. catheterisation of the bladder demonstrated frank haematuria with clots. haemoglobin was 8.4 g/dl and haematocrit was 24.3%. an emergency ultrasound examination demonstrated a normal, viable intrauterine pregnancy and blood clots were noted in the bladder. the left kidney was normal. examination of the right kidney demonstrated a large 7.3 cm by 5.6 cm hypoechoic lesion in the lower pole (figure 1a). colour doppler and duplex doppler demonstrated extensive blood flow within figure 1a: ultrasound of the lower pole of the right kidney demonstrating a 7.3 em by 5.6 em hypoechoie lesion the lesion (figure 1b). a diagnosis of right renal artery aneurysm was made and arrangements were made to perform an emergency angiogram. the patient was counselled and agreed to to page 11 rupture of renal artery aneurysms in pregnancy figure tb: duplex doppler and colour doppler ultrasound demonstrating extensive blood flow within the lesion have a termination of pregnancy. at angiography, a large saccular aneurysm arising from the lower primary division was detected (figure 2). there did not appear to be any other feeding vessels. in addition, a fistula tract into the right renal vein was noted. figure 2: selective arteriogrem of the right renal artery demonstreting a large saccular aneurysm arising from the lower primary division and early venous filling of the renal vein and inferior vena cava an attempt was made to embolise the feeding artery after discussion with the vascular surgeon. this however, was unsuccessful as the diameter of the artery proved to be much larger than the diameter of the endovascular coil. the coil entered the inferior vena cava via the arteriovenous fistula and lodged in the right lung. the patient was taken to theatre where a right eleventh rib resection was performed and the kidney and its vascular pedicle were explored. the feeding artery was mobilised and ligated with silk suture and this resulted in collapse of the aneurysm and disappearance of the bruit. the postoperative period and recovery were uneventful. the patient had a termination of the pregnancy and a follow-up angiogram performed two weeks later demonstrated no evidence of the aneurysm or arteriovenous fistula. discussion incidence the true incidence of renal artery aneurysms is still unknown. the incidence based on autopsy studies is 0.01 %.3 however, angiographic studies suggest a much higher incidence (9.7%).4,5 in addition, harrison et al6 reported that 1.5% of all potential kidney donors who underwent angiographic evaluation had renal artery aneurysms. only 24 cases of renal artery aneurysm rupture have been reported in pregnancy (table i) and a further three cases7,8,9 have been diagnosed post parturn. aetiology the formation and rupture of a renal artery aneurysm in pregnancy is still not fully understood, but is thought to be multifactorial. the aneurysm may be classified either as true or false. true aneurysms may be congenital or acquired and are either saccular or fusiform. false aneurysms usually arise secondary to trauma. the combination of hormonal and haemodynamic changes that occur during pregnancy are considered to play a 11 sa journal of radiology. may 1998 major role in the development and rupture of renal artery aneurysms in pregnancy. wexler" has described the various changes that occur in the arterial wall of breeder rats during successive pregnancies and manalo-estrella and baker" have documented connective tissue changes in the aortic media of pregnant females in 16 autopsy specimens. intimal thickening has also been seen in the arteries of rats treated with synthetic steroids." histopathological examinations were conducted on 12 of the 24 cases of renal artery aneurysm that ruptured during pregnancy, atherosclerosis was demonstrated in three cases, fibromuscular dysplasia in three cases and neurofibromatosis in one case (table i), in five cases no specific changes of atherosclerosis or fibromuscular dysplasia were seen. these findings are in contrast to lacombe's study where 90% of his 123 patients operated for renal artery aneurysms had evidence of fibromuscular dysplasia.p the haemodynamic factors include an increased cardiac output and hence increased renal blood flow that occurs during pregnancy and compression of the aorta by the gravid uterus." patient profile and clinical presentation review of the 24 previously published cases indicates that there is no relationship between maternal age or parity and the formation and rupture of a renal artery aneurysm in pregnancy, only one of the patients was being managed for essential hypertension prior to her pregnancy" and none of the other patients had any significant medical history. topage12 rupture of renal artery aneurysms in pregnancy from page 11 this is the second reported case of rupture in the first trimester of pregnancy" and there appears to be no correlation between fetal gestational age and rupture in this review." patients with unruptured renal artery aneurysms are usually asymptomatic. abdominal bruits, murmurs or abnormal pulsations may occasionally be detected. calcification is noted in 30 to 40% of saccular aneurysms':" and may be detected on abdominal x-ray. in the presence of a rupture however, acute abdominal and unilateral flank pain together with hypovolaemic shock, appear to be the commonest presenting symptoms. it is interesting to note that gross haematuria, indicating rupture into the renal pelvis, was the presenting symptom in only two other cases.is,lg diagnosis the preoperative diagnosis of a ruptured renal artery aneurysm was made in only one of the 24 previously reported cases. i the presence of haemorrhagic shock in the pregnant patient is usually presumed to be due to an obstetric cause such as an ectopic pregnancy, abruptio placentae and ruptured uterus. this is confirmed by the fact that abruptio placentae was the commonest preoperative diagnosis in the cases reviewed. rupture of a splenic artery aneurysm-? and rupture of a thoracic aorta aneurysm" may also present with spontaneous retroperitoneal and intraabdominal bleeding and mimic an obstetric emergency. the use of pulsed doppler and colour doppler ultrasound to diagnose renal artery aneurysms is well documented.22,23 colour doppler ultrasound provides a quick non-invasive table i: reported cases of ruptured renal artery aneurysm in pregnancy case authors year preoperative histology no published diagnosis chisholm ae 30 1926 abruptio placentae none 2 ostling k 31 1938 not stated non specific 3 lennie & sheehan 32 1942 not stated atherosclerosis 4 lennie & sheehan 32 1942 not stated none 5 low dm 33 1944 ruptured uterus none 6 kenny & doniach 34 1945 not stated none 7 zummo et al20 1952 abruptio placentae none 8 hack rw3s 1953 left pyelonephritis atherosclerosis 9 ward & martins 36 1955 not stated none 10 burt rl et a/37 1956 not stated atherosclerosis 11 tapp & hickling 36 1968 ruptured aortic artery neurofibromatosis aneurysm 12 thomas & gillis 39 1970 ruptured uterine none artery 13 cohen sg et al ,g 1972 not stated non specific 14 patterson wm 40 1973 abruptio placentae non specific 15 saleh & mclead 41 1977 not stated fibromuscular dysplasia 16 love wk et a/2' 1981 abruptio placentae none 17 barrett jm et a/42 1981 ?ruptured renal artery non specific aneurysm 18 hidai h et a/43 1985 ectopic pregnancy fibromuscular dysplasia 19 cohen & shamash 4' 1987 abruptio placentae none stated 20 schoon 1met al2s 1988 abruptio placentae non specific 21 dayton b et a/ 1 1990 ruptured rt renal artery none aneurysm post arteriography 22 murakami m '5 1993 not stated 23 whiteley ms et a/'6 1994 ruptured ectopic none pregnancy 24 rijbroek a et al 15 1994 not stated fibromuscular dysplasia 25 current study 1997 ruptured rt renal artery none aneurysm method of assessing the kidneys, rethe management of an unruptured nal arteries and retroperitoneal spaces renal artery aneurysm in pregnancy or and should be used more routinely in in the woman of child-bearing age who the pregnant female who presents in may become pregnant is elective surhaemorrhagic shock. gery because of the increased risk of treatment rupture with potentially fatal consequences. the management differs howbecause of the late diagnosis of ever, in the nonpregnant patient. conrupture in the antepartum period, 10 servative management for calcified renephrectomies were performed in the nal artery aneurysms less than 1.5 cm 24 caseswe reviewed. in only four cases in diameter in the asymptomatic, was repair of the renal artery pernonhypertensive patient has been formed. i,i6,24 ,2s to page 13 12 sa journal of radiology· may 1998 rupture of renal artery aneurysrns in pregnancy from page 12 recommended.26,27,28 indications for surgery include renovascular hypertension, flank pain attributable to the aneurysm, haematuria, aneurysm more than 2 cm in size (with or without calcification) ,renal infarction and lack of calcification in an aneurysm.27,29 when elective surgery is performed, kidney sparing procedures are recommended. these would include excision of the aneurysm and primary or patch closure. autotransplantation and bypass grafting are other options that are available. conclusion since chisholm" reported the first case of rupture of renal artery aneurysm in pregnancy, 23 other cases have been published. the high maternal and fetal mortality rates have mainly been due to incorrect preoperative diagnosis, with most cases being managed as obstetric emergencies. we have provided the first case in which colour doppler ultrasound was used to make a preoperative diagnosis and recommend its routine use in assessing the pregnant patient who presents with gross haematuria, acute flank pain and haemorrhagic shock. references 1. dayton b, helgerson rb, sollinger hw, acher cw. ruptured renal artery aneurysm in a pregnant uninephric patient: successful ex vivo repair and autotransplantation. surgery 1990 jun; 107 (6): 708·11. 2. klimberg 1, wilson j, davis k, finlayson b. haemorrhage from congenital arteriovenous malformation in pregnancy. urology 1984; 23: 381-4. 3. howard hh, suby hi, harberson j aneurysm of the renal artery. ibid 1941; 45: 41. 4. schwartz cj, whiteta. aneurysm of renal artery. i. pathol. bacteriol. 1965; 89: 349. 5. kincaid ow, et al. fibromuscular dysplasia of the renal arteries, air. 1968;104: 271. 6. harrison lh, flye mw, seiger ht. incidence of anatomic variants in renal vasculature in the presence of normal renal function. ann surg 1978; 188: 83. 7. pliskin mj, dresner ml, hassell lh, gusz jr, balkin pw, lerud ks, larson aw. a giant renal artery aneurysm diagnosed post parturn. i urol 1990 dec; 144(6): 1459-61. 8. smith ja, macleish dg. postpartum rupture of a renal artery aneurysm to a solitary kidney: australia» & new zealand joumal of surgery 1985 jan; 55(3): 299-300. 9. baker wj, huckleberry ni. a ruptured intrarenal aneurysm. i uro11953; 70: 20-25. 10. wexler bc. spontaneous arteriosclerosis of the mesenteric, renal and peripheral arteries of repeatedly bred rats. circ res 1964; 15: 485. 11. manalo-estrella p, barker ae. histopathological findings in human aortic media associated with pregnancy. arch patho/1967: 83: 336-34 i. 12. carnmal eb. intimal thickening in arteries of rats treated with syntheti sex steroids. br i exp pathol 1996; 57: 248. ij lacombe m. aneurysms of the renal arteries. joumal des mnlaies \fasculaires 1995; 20(4): 257-63. 14. ohlson l. effects of the pregnant uterus on the abdominal aorta and its branches. acta radiel diagn 1978: 19: 369-376. 15. rijbroek a, van dijk ha, roex al rupture of renal artery aneurysm during pregnancy. euro j vase surg 1994 may; 8(3): 375-6. 16. whiteley ms, katoch r, kennedy rh, bidgood ka, baird rn. ruptured renal artery aneurysm in the first trimester of pregnancy. euro .i vase surg 1994 march; 8(2): 238-9. 17. richardson aj, liddington m, jaskowski a, murie ja, gillmer m, morris pj pregnancy in a renal transplant recipient complicated by rupture of a transplant renal artery aneurysm. br 1 surg 1990 feb; 77(2) 228-9. 18. harrow vr, sloane ja. aneurysm of renal artery. 1 uro11959; 81: 35. 19. cohen sg, cashdan a, burger r. spontaneous ruputure of a renal artery aneurysm in pregnancy. obstet gyneeoi1972; 39: 897. 20. zummo bp, williams pc, uznanski m. retroperitonal hemorrhage complicating pregnancy. surg gyl1ecol obstet 1952; 95: 512. 21. pedowitz p, perel! a. aneurysms complicated by pregnancy. am jobstet gynecol 19:i7; 73: 720. 22. brondum v, fiirgaard b. renal artery aneurysm detected by pulsed doppler ultrasound. roentgenblatter 1990 dec; 43(12): 510-1. 2j okamoto m, hashimoto m, sueda t, munemori m, yamada t. renal artery aneurysm: the significance of abdominal bruit and use of colour doppler. internal medicine 1992 oct; 31(10): 1217-9. 24. love wk, robinette ma, vernon cp. i urol1981 dec; 126(6): 809-1. 25. schoon 1m, seeman t, niemand 0, lindel! 0, andresch b, bjorkerud s. rupture of renal arterial aneurysm in pregnancy. case report. acta chir scand 1988 oct; 154(10): 593-7. 26. poutasse ef. renal artery aneurysm: report of 12 cases, two treated by excision of the aneurysm and repair of renal artery. i uro11957; 77: 697. 27. hubert jp jnr, pairolero pc, kazmier fj solitary renal artery aneurysm. surg 1980; 88: 557. 28. bergentz se, ericsson bf. renal artery problems. surg ann 1985; 17: 199. 13 sa journal of radiology. may 1998 29. pollak ew, miehas ca. massive spontaneous hemoperitoneum due to rupture of visceral branches of the abdominal aorta. am surg 1979; 45: 62 i. 30. chisholm ae. rupture of anuerysrn on branch of left renal artery, complicating pregnancy. br med j 1926; 1: 419. 31. ostling k. uber: aneurysm in der a. renalis, linolis und hepatica: drei faile von ruptur im anschluss lind gravitat. acta obslet gynaecol seand 1938; 18: 444. 32. lennie ra, sheehan hl. splenic and renal aneurysms complicating pregnancy. gbnet gyllecol [br] 1945; 52: 259. 33, low om. spontaneous retroperitoneal haemorrhage complicating pregnancy. cml med assoc i 1944; 50 554. 34. kenny m, donlach j. case of retroperitoneal haemorrhage causing death in late pregnancy. obstet gynecol {br] 1945; 52: 259. 35. hack rw. rupture of an aneurysm of the left renal artery during pregnancy. am i obstel gylleco11953; 65: 1142. 36. ward gh, martins sm. a six year survey of maternal mortality in the city of los angeles, california (1945i 950). am i obstet gynecol1955; 70: 308. 37. burt rl, johnston fr, silverthorn rg, loek fr, dickerson aj ruptured renal artery aneurysm in pregnancy. report of a case with survival. obstet gynecol1956; 7: 229. 38. tapp e, hickling rs. renal artery rupture in a pregnant woman with neurofibromatosis. j pathol 1969; 97: 398. 39. thomas pg, gillis os. spontaneous rupture of 0 renal artery associated with pregnancy. am jobstet gynecol1970; 106: 628. 40. patterson wm. maternal death due to undiagnosed left renal artery aneurysm associated with an absent right kidney. proe r soc med 1973; 66: 761. 41. saleh yz, mcleod fn. ruptured renal artery aneurysm in pregnancy: case report. br i obstet gyl1ecol 1977; 84: 391. 42. barrett jm, van hooydonk je, boehm fh. pregnancy-related rupture of arterial aneurysm. obstel gynecol sun11982; 37: 557. 43. hidai k, kinoshita y, murayama t, miyai k, matsumoto a, ide k, sato s. rupture of renal artery aneurysm. eur ural 1985; 11: 249-253. 44. cohen jr, sham ash fs. ruptured renal artery aneurysms during pregnancy. i vase surg i 87 6: 51-59. 45. murakami m. rupture of renal arterial aneurysm in pregnancy. masui-japan j aneslh 1993 sep; 42(9) 1367-70. abstract introduction case history discussion conclusion acknowledgements references about the author(s) priya singh department of radiodiagnosis, sanjay gandhi postgraduate institute of medical science, lucknow, india surya p. singh department of radiodiagnosis, sanjay gandhi postgraduate institute of medical science, lucknow, india department of radiodiagnosis, all india institute of medical sciences (aiims), new delhi, india citation singh p, singh sp. a case of racemose and intraventricular neurocysticercosis in an unusual location. s afr j rad. 2021;25(1), a2171. https://doi.org/10.4102/sajr.v25i1.2171 case report a case of racemose and intraventricular neurocysticercosis in an unusual location priya singh, surya p. singh received: 27 apr. 2021; accepted: 16 aug. 2021; published: 06 dec. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract racemose and intraventricular neurocysticercosis are uncommon types of neurocysticercosis, resulting in a multiloculated, grape-like cluster appearance in the cerebrospinal fluid (csf) spaces. a male patient presented with symptoms of raised intracranial pressure and demonstrated racemose neurocysticercosis at an atypical location involving the region of the crus of the fornix at the level of the body of lateral ventricles on magnetic resonance imaging. associated intraventricular neurocysticercosis was seen in the atrium of the left lateral ventricle and fourth ventricle. keywords: neurocysticercosis; racemose neurocysticercosis; grape-like clusters; hydrocephalus; intraventricular neurocysticercosis. introduction neurocysticercosis is the most common parasitic infection of the central nervous system. it is more prevalent in latin america, asia and africa. it can affect the brain parenchyma, subarachnoid spaces and ventricles. in racemose neurocysticercosis, cysticerci are located in basal cisterns, subarachnoid spaces and ventricles producing multiloculated cystic lesions with mass effect and a surrounding inflammatory reaction.1 previously reported cases of racemose neurocysticercosis demonstrated these lesions mostly in the basal cisterns, sylvian fissure and a few of them in anterior interhemispheric fissure.2,3,4,5 this report describes an unusual location of racemose neurocysticercosis located anterior and inferior to the splenium of the corpus callosum and between the fornixes associated with intraventricular neurocysticercosis in the atrium of the left lateral ventricle and fourth ventricle. case history a 34-year male presented with a history of gradually progressive headache, nausea, vomiting and dizziness for 15 days. there was no history of seizures or visual symptoms and neurological examination did not reveal any focal neurological deficits or signs of meningitis. initially, a non-contrast ct scan was performed, which revealed moderate dilatation of both lateral ventricles, as well as the third and fourth ventricles with a few cystic lesions in the forniceal region. no calcified lesions were appreciated at ct imaging. for further evaluation, mri with contrast was acquired using a 3 tesla (t) magnetic resonance (mr) scanner at our institute. magnetic resonance imaging revealed multiple small clustered thin-walled cystic lesions in the region of crus of fornix at the level of the body of lateral ventricles. the lesions were hypointense on t1 weighted imaging (wi), hyperintense on t2wi and revealed suppression on fluid attenuated inversion recovery (flair) sequence images. no post-contrast enhancement of the cyst wall was seen. surrounding parenchymal t2 and flair hyperintensity was observed (figure 1). multiple similar small clustered cysts were also noticed in the atrium of the left lateral ventricle with enhancement of the cyst walls on post-contrast t1w images (figure 2). cyst walls were more conspicuous on the 3-d constructive interference in steady-state (ciss) sequence (figures 1d and 2d). the ventricles were moderately dilated and associated with increased periventricular t2 and flair signal intensity (figures 3a and 3b). ventricular dilatation extended up to the level of obex of the fourth ventricle. a few thin membranes or septations were seen in the fourth ventricle on the 3-d spoiled gradient recalled echo (sgpgr bravo) t1 post-contrast sequence, obstructing the outlet of the fourth ventricle (figure 3c). however, these intraventricular membranes were not well delineated on other conventional sequences. no eccentric dot was seen within any of these lesions. no other focal brain parenchymal lesions were noticed. there were no blooming foci seen on susceptibility-weighted imaging (swi). figure 1: magnetic resonance imaging of the brain in the axial plane. t2w(a), t1w (b), fluid attenuated inversion recovery (c), 3-d constructive interference in steady-state (d), t1 post-contrast (e) images reveal multiple small t2 hyperintense, t1 hypointense cystic lesions (white arrows) clustered together in the region of the crus of the fornix, anterior to the splenium of the corpus callosum. these lesions were suppressed on fluid attenuated inversion recovery and followed cerebrospinal fluid signal intensity. there was no enhancement of the cyst with no eccentric enhancing dot within the cyst. axial 3-d constructive interference in steady-state magnetic resonance (d) image better delineates the cystic lesions producing a grape cluster-like appearance. figure 2: magnetic resonance imaging of the brain. axial t2 weighted (a), t1 weighted (b), fluid attenuated inversion recovery (c), 3-d constructive interference in steady-state (d), t1 post-contrast (e) and (f) sagittal magnetic resonance imaging 3-d t1 weighted post-contrast images demonstrate a t2 hyperintense, t1 hypointense lobulated multi-cystic lesion (white arrow) in the atrium of the left lateral ventricle. the lesion supresses on fluid attenuated inversion recovery and reveals post-contrast enhancement of the cyst wall with no eccentric enhancing foci. cystic lesions were better delineated on the axial 3-d constructive interference in steady-state magnetic resonance image (d). figure 3: magnetic resonance imaging of the brain. axial t2 weighted (a) and fluid attenuated inversion recovery (b) images indicate asymmetrically dilated lateral ventricles (yellow arrows) and fourth ventricle (red arrow) with surrounding periventricular signal. sagittal magnetic resonance imaging 3-d spoiled gradient recalled echo sequence (sgpgr bravo) post-contrast sequence image (c) demonstrates the dilated lateral ventricle, third ventricle, aqueduct of sylvius and fourth ventricle. an abrupt narrowing was observed at the obex of the fourth ventricle (yellow arrow). a thin membrane-like structure (white arrow) was seen in the fourth ventricle, which possibly represented non-enhancing intraventricular cyst or a post-inflammatory membrane in the fourth ventricle, causing obstruction and upstream dilatation. based on these mri findings, a presumptive diagnosis of racemose and intraventricular neurocysticercosis with obstructive hydrocephalus was made. differentials considered were ependymal cyst, choroid plexus cyst and colloid cyst. the possibility of an intraventricular neurocysticercosis cyst or post-inflammatory membrane was considered for the fourth ventricle lesion causing upstream obstruction. the patient underwent right ventriculoperitoneal shunting. cerebrospinal fluid (csf) was evaluated with enzyme-linked immunoassay (elisa) was positive for neurocysticercosis. the patient was treated with albendazole and steroids and follow-up imaging was advised. discussion neurocysticercosis is endemic in many developing countries, especially in latin america, south-east asia, the indian subcontinent and sub-saharan africa. with increasing immigration and travel, the incidence of neurocysticercosis is also growing in developed countries. true disease prevalence is not well known because of the scarcity of case notification systems, systematic population studies and the absence of a gold standard test for screening and detection of asymptomatic disease. data from different studies have shown that the prevalence of human taeniasis varies from 2.5% to 8.0% in india and the disease burden of neurocysticercosis causing active epilepsy is about one per 1000 population.6 neurocysticercosis is a parasitic disease caused by taenia solium. humans are the only known definitive host for the organism and neurocysticercosis occurs when the human acts as an intermediate host after ingestion of its egg present in food contaminated with faeces of the tapeworm carrier. no inflammatory response is elicited when the cyst wall is intact, but when the parasite dies, then cyst contents are released, causing oedema and surrounding inflammatory changes.7,8 neurocysticercosis is classified based on its location, namely subarachnoid-cisternal space, parenchymal, ventricles, spinal and mixed form.8 these different forms may also co-exist. parenchymal is the most common location where it can be seen in any of the four stages, namely vesicular, colloid vesicular, granular nodular and nodular calcified.8 cysticerci can reach the ventricles through the choroid plexus, moving freely within the ventricles or attaching to the ependyma. from the ventricles, it can travel to the basal cisterns, cerebral and spinal subarachnoid spaces and become lodged in these regions. the most common site of intraventricular neurocysticercosis is the fourth ventricle, followed by the third ventricle, lateral ventricle and cerebral aqueduct, respectively.9 racemose neurocysticercosis is a type of extra-parenchymal neurocysticercosis characterised by the rapid growth of cyst walls forming grape-like clusters associated with degenerating scolices. bickerstaff et al. suggested that in cisterns, there is no limiting host response of encapsulation leading to uncontrolled proliferation.10 in different studies, the presence of the racemose variant is reported in 15.0% – 54.0% of patients.1 a study by sierra et al., evaluated 125 extra parenchymal neurocysticercosis cases in which 51.6% were in basal subarachnoid cisterns, 33.7% in the ventricular system, 12.5% in sylvian fissure and 2.2% in subarachnoid space of the medulla.11 spinal neurocysticercosis is the rarest type of neurocysticercosis, which is most commonly associated with concomitant intracranial neurocysticercosis. clinical symptoms depend on the stage of the lesions, their location and the host immune response. neurocysticercosis is one of the most common causes of recurrent seizures in both the parenchymal and subarachnoid forms because of oedema and encephalitis.12 in the extra parenchymal form, degeneration elicits an inflammatory response, causing arachnoiditis and ventriculitis.13 hydrocephalus may also develop because of mass effect of the cyst, arachnoiditis (in subarachnoid neurocysticercosis) and ventriculitis (intraventricular neurocysticercosis), leading to adhesions and obstruction.13 an intraventricular cyst may be freely mobile, or it can attach to the ependymal wall of the ventricle. if a cyst is freely mobile in the ventricular cavities, it can cause bruns syndrome characterised by episodes of sudden headaches, papilloedema and loss of consciousness, developing upon cephalic movement and followed by rapid clinical recovery.14 it develops as a result of intermittent obstructive hydrocephalus caused by a freely mobile intraventricular cyst that acts as a ball-valve mechanism.14 ependymitis following cyst degeneration may also lead to intraventricular loculation, which is often challenging to treat. inflammatory response surrounding subarachnoid neurocysticercosis may progress to vasculitis resulting in cerebrovascular accidents.15 spinal neurocysticercosis can present with paresis, paralysis and polyradiculopathy. the diagnosis is confirmed by neuroimaging and serological tests. computed tomography (ct) is the initial imaging study that can identify active neurocysticercosis and the calcified stage of the disease. however, identifying racemose and intraventricular neurocysticercosis is difficult on ct because the cysts are iso-dense to csf and usually non-enhancing. magnetic resonance imaging with contrast is the imaging modality of choice for neurocysticercosis.8 magnetic resonance imaging can show the pathological evolution of the disease, namely the vesicular, colloidal, granular nodular and calcified nodular stages. typical neurocysticercosis lesions are smooth ring enhancing cystic lesions with an eccentric enhancing dot representing the scolex. racemose neurocysticercosis is mainly seen around the rostral brainstem or sylvian fissure and usually lacks a scolex with mild or no surrounding oedema.1 asymmetrically widened subarachnoid spaces and ventricles in a known case of cysticerci or neurocysticercosis can be a clue to the presence of racemose neurocysticercosis. t2 weighted imaging and flair sequences in the racemose variant show multiloculated clustered cystic lesions in the subarachnoid spaces that follow csf signal intensity and exert mass effect on surrounding structures.8 surrounding wall enhancement may occasionally be seen in racemose neurocysticercosis because of associated arachnoiditis.1 in this report, similar clustered cysts without any scolices or post-contrast enhancement was observed but at an atypical location. the differential diagnosis for racemose variant includes tubercular meningitis; however, basilar exudates of tuberculosis (tb) are solid and are not entirely suppressed on flair. carcinomatous meningitis and neuro-sarcoid are also differentials for racemose neurocysticercosis but they are rarely cystic. intraventricular neurocysticercosis is usually appreciated on flair imaging when csf is suppressed. on post-contrast t1w images, intraventricular neurocysticercosis appears as an enhancing lobulated cystic lesion with or without adjoining ventriculitis. obstructive membranes and adhesions can also develop in ventricles because of ependymitis. additionally, complications such as ventricular dilatation and vasculitis can be seen on mri. in this case, similar intraventricular cysts were illustrated in the atrium of the left lateral ventricle associated with an obstructive membrane in the fourth ventricle. differential diagnosis includes ependymal cyst, choroid plexus cyst, choroid plexus papilloma, colloid cyst, arachnoid cyst and cystic metastasis. an ependymal cyst is usually unilocular, non-enhancing, behaves like csf and displaces the choroid plexus. choroid plexus cysts are generally bilateral and most commonly seen in the atrium of lateral ventricles within the choroid plexus glomus. the colloid cyst contains mucin and is not completely suppressed on flair. choroid plexus papilloma is usually seen below five years of age and has a solid enhancing component. arachnoid cysts and cystic metastasis are very rarely seen in the ventricles.16 newer mr sequences are now being utilised for demonstrating intraventricular and subarachnoid space neurocysticercosis. three-dimensional ciss is a fully refocussed steady-state gradient-echo mri sequence. this is a heavy t2w sequence that increases lesion visibility in ventricles, cisterns and subarachnoid spaces.17 intraventricular neurocysticercosis, which is not well visualised on conventional mr sequences is better delineated with this sequence. another advanced mr sequence is the 3-d spoiled gradient recalled echo sequence (spgr), where both preand post-contrast t1w images are obtained. both these sequences can identify missed obstructive membranes in intraventricular neurocysticercosis.18 in this report an obstructive membrane was only visualised on the 3-d spgr sequence. amongst the serological tests available for neurocysticercosis, enzyme linked electro-immuno transfer blot (eitb) using lentil lectin glycoproteins (llgps) has a sensitivity of >90% and a specificity of 100% for detection of ncc. this assay can be performed on both serum and csf samples and it has outperformed the classic elisa test.7 medical management of neurocysticercosis includes cysticidal drugs such as albendazole and praziquantel, steroids and antiepileptic drugs. medical management is highly effective in the parenchymal and subarachnoid forms. surgical management in the form of a ventriculoperitoneal shunt is required in cases of symptomatic hydrocephalus. as a result of recurrent blockage of a ventriculoperitoneal shunt, the endoscopic approach for removal of an intraventricular cyst is nowadays the preferred method of treatment.19,20 however, intraventricular cysts that are tightly adherent to the ependyma because of chronic ependymitis are difficult to remove endoscopically and can lead to injury.20 conclusion racemose neurocysticercosis and intraventricular neurocysticercosis are both rare types of neurocysticercosis. the presence of these cysts in the region of the crus of the fornix, anterior to the splenium of the corpus callosum, is very rare. for intraventricular neurocysticercosis, the atrium of the lateral ventricle is also quite an unusual location. knowledge of the imaging appearance of racemose neurocysticercosis and the different locations where it can develop will prevent overlooking the diagnosis and excluding other differentials. moreover, newer mr sequences like ciss and 3-d spgr should also be acquired, in addition to conventional mr sequences, for better delineation of any cyst or membrane obstructing the ventricles and csf spaces. acknowledgements competing interests the authors declare that they have no personal or financial relationships that may have inappropriately influenced them in writing of this article. author’s contributions p.s. was the primary author. all other authors supervised and contributed equally to the final version of the 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symptoms, diagnosis, and treatment of neurocysticercosis. lancet neurol. 2014;13(12):1202–1215. https://doi.org/10.1016/s1474-4422(14)70094-8 del brutto o. neurocysticercosis. semin neurol. 2005;25(3):243–251. https://doi.org/10.1055/s-2005-917661 case report spontaneous subcapsular renal haematoma abstract oj solomon mbchb, ffrad(d)sa spontaneous subcapsular renal haematoma is a rare condition caused by bleeding into the subcapsular or perinephric space in the absence of trauma, bleeding diathesis or anticoagulation. if the contralateral kidney is normal, radical nephrectomy is recommended due to a high incidence of small occu it tumours. case report constantiaberg medi-clinic, plumstead, cape town no history of trauma and he was not taking anti-coagulant therapy. clinically,he was noted to be undistressed, apyrexial and normotensive. the left kidney was feit to be slightly enlarged and 1+ haematuria was noted. his general practitioner suspected renal colic and he was referred for an excretory urogram. there were no apparent calcifications on the survey and the right kidney, collecting system and ureter appeared normal. on the left there was no identifiable nephrogram and no excretion was noted at 1 hour. an ultrasound examination revealed alo em solid appearing left renal mass replacing almost the entire left kidney, with only a small rim of renal tissue noted anteriorly. this was thought to represent a large renal tumour and computed tomography (ct) was performed approximately four hours after the excretory urogram. on the pre con trast images, a persisten t nephrogram was noted in the compressed and anteriorly displaced kidney. this was due to alo em subcapsular mass showing minor extension into the pararenal spaces (figures 1-2). no focal abnormality was seen in relation a 74-year-old man presented with a three day history ofleft loin pain radiating to the groin. the pain was not typically colicky in nature and there were no associated constitutional symptoms. he had been previously well and besides mild hypertension, there was no past medical history of note. there was figure 1: image obtained four hours after ivu showed persistent left nephrogram with kidney compressed and anteriorly displaced by large subcapsular haematoma. note extension into posterior pararenal space. 18 sajournal of radiology. april 2000 to the renal parenchyma and the right kidney appeared normal. a large perinephric haematoma was suspected to page 20 cant tel: 27 12993 ..2474 27 12 998-7366 fax: 27 12993-2478 17b garsfontein park 645 jacqueline drive garsfontein east 0060 further information on request from: anene harmaceuticals reg. no. 95/01988/07 spontaneous subcapsular rena i baerriarorna (rom page 18 nephrotomography may reveal a displaced kidney with the parenchyma compressed by haematoma. ultrasound findings are usually non-specific and differentiation of a renal mass from a nephric haematoma may be difficult. ct scan is the investigation of choice and will reveal an abnormal soft tissue mass confined by the renal capsule and compressing the renal parenchyma. this may extend into the perinephric and pararenal spaces with effacement of the normal retroperitoneal structures. renal angiography to exclude vascular lesions such as arteritis, arteriosclerotic aneurysms, arteriovenous malformations or a small renal cell carcinoma may reveal flattening of the renal parenchyma and displacement of the capsular vessels. of the eight cases reported by kendall et all six were shown after nephrectomy to have small peripheral carcinomas. only one of these had suspicious angiographic findings whereas the other five tumours were undetectable pre-operatively. in the other two cases no cause was found. pollack and popky' reported small peripheral tumours in five of nine patients with spontaneous figure 2: post contrast showing compression of renal parenchyma. and confirmed surgically. a radical nephrectomy was performed and close histological examination of the resected kidney failed to reveal a cause for the bleeding. post-operative course was uneventful and the patient remains well. discussion spontaneous subcapsular or perinephric haematoma is an uncommon clinical problem and occurs in the absence of anti-coagulation, arteritis or trauma. the clinical presentation is variable and depends on the severity and duration of bleeding. this may be sudden with acute onset of upper abdominal or flank pain, nausea and vomiting or subacute, as in our patient, with symptoms suggestive of renal colic. a low-grade temperature may be present and urinalysis is usually normal. excretory urography with 20 sajournal of radiologyapril 2000 subcapsular haematoma, four of which measured less than 1 cm in diameter. due to this high incidence of small peripheral carcinomas, radical nephrectomy with meticulous histological examination of the resected specimen is the recommended treatment. however, pre-operative angiography is considered warranted to exclude vascular disease which may affect the contralateral kidney and prompt a more conservative approach. conclusion the diagnosis of spontaneous subcapsular haematoma of the kidney is best made with ct, showing a subcapsular mass compressing the renal parenchyma and often extending into the pararenal space. treatment is usually radical nephrectomy due to the high incidence of small peripheral carcinomas. pre-operative angiography, although unreliable in the exclusion of small tumours is indicated to exclude other vascular causes which may prompt a more conservative approach. references 1. kendall ra, senay ba, coli me, spontaneous subcapsular renal haematoma: diagnosis and management, journal of urology 1988, 139: 246-250. 2. pollack hm, popky gl. roentgenographic manifestations of spontaneous renal haemorrhage: radiology 1974,110:1. bleomycin.html bleomycin toxicity post injection into cranio-pharyngioma ivan l norval, mb chb jennifer r tynan, md, frcp (c) department of medical imaging, royal university hospital, university of saskatchewan, saskatoon, canada evan m frangou, md department of neurosurgery, royal university hospital corresponding author: i norval (ivan.norval@gmail.com) abstract craniopharyngioma is a common suprasellar mass that is frequently encountered in radiology. these tumours are difficult to treat, with a combination of resection and radiation therapy having been the gold standard. our case highlights a complication of a newer approach to treatment in which bleomycin is administered into the tumour via a catheter, usually an ommaya reservoir that is surgically placed. presentation a 41-year-old woman was diagnosed with craniopharyngioma in 2002. three separate surgical resections were performed in the course of 2002 and 2003. the patient subsequently developed panhypopituitarism, diabetes insipidus and total blindness. following radiation therapy, she regained vision in her right eye. she also developed hydrocephalus post radiotherapy, for which a vp shunt was placed. an ommaya reservoir was also placed. in july 2010, she was started on intra-tumoural bleomycin injections. a total of only 5 doses were administered. doses of 5 mg bleomycin were administered 3 times a week on an outpatient basis. after the second dose, the patient developed transient headaches, and the third dose was omitted. three further doses were administered as scheduled. after the fifth dose, she presented with worsening confusion, headache and agitation, and was admitted to hospital for further care; no further bleomycin was injected. magnetic resonance imaging (mri) was performed 12 days after the final injection. this showed extensive vasogenic oedema in the basal ganglia and midbrain surrounding the tumour. a diagnosis of bleomycin toxicity post intra-tumoural injection into her craniopharyngioma was subsequently made on the basis of the imaging findings and exclusion of other aetiologies. the oedema progressed on a subsequent mri performed a week later. on 4-month follow-up, the patient’s condition had improved, and repeat mri revealed a significant decrease in the amount of oedema. discussion craniopharyngiomas are suprasellar tumours that are believed to arise from craniopharyngeal duct remnants.1 these tumours are common and represent 50% of all suprasellar tumours in childhood, with a peak incidence between the ages of 8 and 12 years and a second, smaller, peak in middle-aged adults.2 the tumours are typically lobulated, cystic masses with a mural nodule.2 the cystic component is often the predominant portion and occurs in over 90% of cases.3 the fluid content of the tumour is usually thick and yellow, and can be reminiscent of engine oil on gross pathology.2 typical features on computed tomography (ct) include a cystic component with attenuation slightly higher than csf, and calcification, which may be thin and peripheral or coarse within the solid portion.2 calcification is seen in about 50% of adult patients and in as much as 90% of paediatric patients.1 contrast enhancement of the cyst walls and other solid components is present in more than 90% of cases.2 the mr appearance of the cystic component is varied, but commonly the content is hypo-intense on t1 and hyperintense on t2. the solid components usually enhance heterogeneously.2 symptoms relate to mass effect on suprasellar structures, as well as local invasion,3 and often include headache, endocrine deficiencies and visual disturbances.4 although these tumours show benign histology, their location, as well as their intimate relationship with delicate sellar structures, complicates management. management generally consists of either aggressive surgery or a combination of limited surgical resection and radiation therapy.5 newer treatment options now include placement of an ommaya catheter into the cystic portion with instillation of bleomycin into the tumour. less commonly, other sclerosing agents or isotopes have also been used. the ommaya catheter is usually placed and tested postoperatively by means of instillation of x-ray contrast, followed by non-enhanced ct to assess for leakage.3 in the case of bleomycin, there is variability in the schedule of administration, but a dose of 3 mg is typically given 3 times weekly for 5 weeks, followed by once weekly for 10 weeks.5 doses can be temporarily discontinued or stopped if the patient becomes symptomatic, as in our case. acute side-effects include transient mild fever, nausea, vomiting and headaches. these occur in up to 70% of patients within the first 24 hours after each administration, and are usually self-limiting.3 more severe delayed side-effects are highly varied, but much more rare, and occurred in only 2 out of 17 cases in a canadian series.4 intravenous corticosteroid administration is often used for treatment of peri-tumoural oedema and seems effective, although it is not well researched as to whether supportive therapy alone would have a much different outcome.5 mri – in particular, flair – is the modality of choice for diagnosing bleomycin toxicity.5 findings usually consist of varying degrees of peri-tumoural vasogenic oedema in the midbrain and basal ganglia,6 which is thought to be the result of local bleomycin effect in combination with a small amount of peri-tumoural leakage, and are predominantly reversible.5 this treatment option is used in combination with traditional modalities, and can be of significant value if surgery can be deferred as long as possible, because the intra-tumoural instillation of bleomycin has a decreased morbidity for the patient compared with surgery.4 conclusion intralesional bleomycin injection is becoming an increasingly more popular treatment option for cystic craniopharyngioma. although this procedure is less invasive compared to open resection and is relatively safe, there are still significant risks involved with this form of treatment. it is of the utmost importance that radiologists are aware of possible complications and are able to identify them early to ensure prompt management. 1. barkovich j. pediatric neuroimaging. 4th ed. philadelphia: lippincot williams & wilkins, 2005:580-584. 1. barkovich j. pediatric neuroimaging. 4th ed. philadelphia: lippincot williams & wilkins, 2005:580-584. 2. osborn a. diagnostic neuroradiology. st. louis: mosby, 1994:654-656. 2. osborn a. diagnostic neuroradiology. st. louis: mosby, 1994:654-656. 3. steinbok p, hukin j. inracystic treatments for craniopharyngioma. neurosurg focus 2010;28(4):1-5. 3. steinbok p, hukin j. inracystic treatments for craniopharyngioma. neurosurg focus 2010;28(4):1-5. 4. hukin j, steinbok p, lafay-cousin l, et al. intracystic bleomycin therapy for craniopharyngioma in children. cancer 2007;109:2124-2131. 4. hukin j, steinbok p, lafay-cousin l, et al. intracystic bleomycin therapy for craniopharyngioma in children. cancer 2007;109:2124-2131. 5. lafay-cousin l, bartels u, raybaud c, et al. neuroradiological findings of bleomycin leakage in cystic craniopharyngioma. j neurosurg 2007;107:318-323. 5. lafay-cousin l, bartels u, raybaud c, et al. neuroradiological findings of bleomycin leakage in cystic craniopharyngioma. j neurosurg 2007;107:318-323. 6. kim s, park j, park j, et al. radiological findings following postsurgical intra tumoural bleomycin injection for cystic craniopharyngioma. clin neurol neurosurg 2007;109:236-241. 6. kim s, park j, park j, et al. radiological findings following postsurgical intra tumoural bleomycin injection for cystic craniopharyngioma. clin neurol neurosurg 2007;109:236-241. fig. 1. axial flair image through the level of the midbrain pre bleomycin administration. fig. 2. axial flair image through the level of the midbrain 3 weeks post bleomycin administration, which shows significant peri-tumoural vasogenic oedema. fig. 3. axial ct image shows an ommaya catheter in place with contrast instilled into the tumoural cavity to check for any leakage of contrast pre bleomycin instillation. review article shoulder impingement richard de villiers mb chb, mmed (rad dj drs van wageningen & partners po box 317 somerset west 7129 introduction shoulder impingement syndrome is probably the most common painful condition of the shoulder. dynamic compression of the rotator cuff tendons in the subacromial space with arm elevation causes intlammation and pain. three types of shoulder impingement occur: subacromial, posterior and subcoracoid. subacromial impingement is by far the most common, while the latter two are rare and will not be discussed further. clinical aspects the patient with subacromial impingement complains of night pain and pain with certain movements, e.g. abduction of the arm. on examination pain is felt through a range of 60° 120° when the arm is elevated (the painful arc). neer's sign,' elicited by stabilising the scapula and abducting the arm to above 90°, is positive. neer's test,' where local anaesthetic is injected into the subacromial bursa, relieves the symptoms. pathophysiology neer' described three progressive stages of shoulder impingement: (t) stage 1 reversible oedema and haemorrhage about the rotator cuff, typically affecting patients below 25 years of age; (it) stage 2 fibrosis and tendinosis in the rotator cuff, usually seen in patients between the ages of 25 and 40 years; and (iii) stage 3 tendon rupture and subacromial spurs occurring in the older patient. the basis for the shoulder impingement syndrome is the restricted space that exists between the coracohumeral arch above and the humeral head and tuberosities below. the rotator cuff tendons, biceps tendon and the coracohumeral ligament pass through this space. the subacromial bursa aids in passage of these structures. compression of these structures is also minimised by a normal acromioclavicular joint, a coracoacromial arch that allows free passage of the rotator cuff mechanism and normal capsular laxity. laxity may be increased or decreased, and both may cause secondary impingement due to altered biomechanics of the shoulder during movement. anterior instability allows the humeral head to translate anteriorly with mechanical impingement of the supraspinatus tendon on the coracoacromial arch. the supraspinatus tendon is vulnerable to injury because of a relatively avascular critical zone near the site of attachment of the tendon to the greater tuberosity and anatomical variations in the anterior excursion and slope of the acromion and the shape of its inferior margin.' 26 sa journal of radiology • february 2003 rotator cuff calcification rotator cuff calcification affects about 7% of the population and is a common mechanical cause of subacromial impingement. the calcification may also cause pain, tenderness, swelling and restricted movement. the cause of the calcification is unknown, but may be related to metabolic abnormalities and trauma. the calcification is most commonly in the supraspinatus tendon, but may involve the bursa or infraspinatus, teres minor, subscapularis, biceps and pectoralis major tendons. the following sequence of rotator cuff calcification may occur: (t) silent (asymptomatic deposition of calcium hydroxyapatite); (ii) mechanical phase (tendinous calcification causes elevation of the bursa with subacromial bursitis, subbursal or intrabursal rupture); or (iit) adhesive periarthritis. there is no significant correlation between the size of the calcification, radiographic appearance and the clinical symptoms. irregular, poorly defined calcification is associated with acute tlares of pain, while well-defined calcification is not." classification of shoulder impingement several attempts at classification of impingement have been made. matsen' classifies causative factors of impingement into two groups, viz. structural and functional factors. structural factors relate to ac joint (osteophytes and congenital anomalies), acromion (shape, os acromiale or osteophytes), coracoid process (congenital or post-traumatic), subreview article acromial bursa (inflammation or thickening), rotator cuff (calcification, thickening or post-traumatic thickening) or humerus (congenital or fracture with varus malunion or superior malunion of the greater tuberosity). functional factors include abnormalities in position or motion of the scapula, disruption of the mechanism leading to normal depression of the humeral head, capsular laxity and capsular stiffness. fu and associates" also divided impingement disorders into two groups, namely primary and secondary impingement. primary impingement occurs mainly in nonathletic persons and is related to alterations in the coracoacromial arch. secondary impingement occurs mainly in athletes involved in sports requiring overhead movement of the arm and related to either glenohumeral or scapular instability. x-ray views shoulder impingement a standard impingement series should include the following: (i) ap shoulder with internal rotation; (it) ap shoulder with external rotation; (iit) true ap shoulder; (iv) neer's supraspinatus outlet view (fig. i); and (v) axial view. ap shoulder with internal rotation this view shows the greater tuberosity in profile and is important to demonstrate a fracture of the greater tuberosity in a patient who has fallen on the tip of the shoulder. ap shoulder with external rotation this view shows the posterolateral fig. 1. outlet view. type 3 or hooked acromion (arrow). aspect of the humeral head in profile and demonstrates the hill-sachs deformity of the humeral head after a dislocation. true ap shoulder this view shows the glenohumeral joint space optimally. the blade of the scapula is at 90° to the primary beam. neer's supraspinatus outlet view this view demonstrates the type of acromion as well as bony causes of supraspinatus impingement, e.g. acromial spur formation. an os aeromiale may also be seen. axial view this view demonstrates the relationship of the glenoid and the humeral head. abnormalities of the acromion, coracoid and ac joint are well demonstrated. additional views 1. westpoint view: the anteroinferior aspect of the glenoid rim is well assessed for the presence of a bony bankart lesion or calcification suggesting a chronic soft tissue injury. 27 sa journal of radiology • february 2003 2. angled ap view of the acromion: ac joint osteophytes, os acromiale and a type 3, hooked acromion can be demonstrated. 3. bicipital groove view: osteophytic spurs or calcification causing biceps tenosynovitis may be seen.' review of local.. . opinions in shoulder impingement reporting a questionnaire was sent to a group of 35 radiologists and orthopaedic surgeons. they were asked to comment on the style of reporting acceptable in their working environment and relevance of the standard impingement series of the shoulder. respondents varied in their response to the need for mentioning positive or negative findings in the report. they most often commented on the width of the subacromial space and the presence or absence of acromial spurs. the orthopaedic surgeons made special note of the importance of bony spurs. the ac joint, glenohumeral joint, rotator cuff calcification and bone texture were all part of the routine radiological assessment. one observer made a very in1por-· tant statement: 'my philosophy in reporting shoulder films is to ensure that even if the x-rays are not available at the time of performing a subsequent examination, e.g. shoulder mr! or ultrasound, the report of the x-rays should be detailed enough to give one a good mental picture. ideally the x-rays should be available before a , scan. revtew article recommended report on shoulder impingement series prior to dictating a meaningful report, the radiologist assesses the following features on the films. the acromion 1. profile: types 1, 2 and 3. high association between rotator cuff tears and type 3 acromions. 2. os acromiale. 3. lateral downsloping of the acromion. 4. acromial osteophyte formation. acromioclavicular joint acromioclavicular joint arthrosis and osteophyte formation may be the primary cause of the patient's pain, or may cause supraspinatus impingement or subacromial bursitis. greater tuberosity and glenohumeral joint sclerosis and irregularity of the greater tuberosity is associated with chronic impingement. assess for fractures, hill-sachs deformity and loose bodies. acromiohumeral interval (ahi) ahi less than 1 cm with a break in the 'shenton line' of the shoulder implies rotator cuff dysfunction (weakness or tear). rotator cuff calcification position of the calcification is important. it may follow acute trauma or represent the result of ischaemie tendinosis after chronic impingement (fig. 2). fig. 2. calcification in supraspinatus tendon (arrow) with subbursal rupture. post -traumatic osteolysis this is a post-traumatic inflammatory arthritis and is cured by debridement. a suggested normal report is as follows: 'the acromioclavicular and glenohumeral joints are normal. there is no rotator cuff calcification or bony spur formation'. with the appropriate films and a knowledge of the implications of the various radiological findings, positive findings are conveyed by the report and may establish the cause of the painful shoulder. references 1. neer cs. anterior acromioplasty for chronic impingement syndrome in the shoulder: a preliminary report. j bone joint surg 1972; 54: 41. 2. resnick d, kang h. shoulder. in: resnick d, kang h, eds. internal derangements of joints: emphasis on mr imaging. philadelphia: we saunders, 1997: 182-214. 3. rupp s, seil r. tendinosis calcarea of the rotator cuff. orthpade 2000; 29: 852-857. 4. uhthoff hk, loehr lw. tendinopathy of the rotator cuff. pathogenesis, diagnosis and management. jam acad orthop surg 1997; 5: 183191. 5. matsen fa, arntz ct. the shoulder. philadelphia: we saunders, 1990: 623. 6. fu fh, harner cd, klein ah. shoulder impingement syndrome. a critical review. clin orthop 1991; 269: 162. 7. anderson if, read lw, steinweg j. atlas of imaging in sports medicine. sydney: mcgrawhill, 1998: 96-100. 28 sa journal of radiology • february 2003 case report an unusual congenital pulmonary •arterlo-venous fistula abstract jq davies s andronikou j lawrenson pulmonary arteriovenous malformations (avm) are rare causes of a cardiac murmur in the paediatric population. they are caused by abnormal communications betvveen pulmonary arteries and veins that are most common ly congenital in nature. although these lesions are fairly uncommon, they are an important differential diagnosis to consider in patients with common pulmonary problems such as hypoxaemia and/or a pu imonary nodule(s). this report illustrates the clinical presentation, radiological features and pathological findings in an eightmonth-old boy. keywords fistula" arteriovenous" congenital" trisorny 21 departments of paediatric pathology, radiology and cardiology red cross war memorial children's hospital rondebosch, cape town 39 sa journal of radiology· february 2001 case report an eight-month-old male patient with down's syndrome was referred for cardiac catheterisation at the red cross children's hospital. he had signs of a left-to-right shunt with bounding pulses and a machinery murmur at the upper left sternal border. both on clinical grounds and on echocardiographic examination it was felt that he had a pda. cardiac catheterisation (with a view to possible coil embolisation) was performed. at catheterisation, a duct was seen but was noted to be small. the larger feeding vessel was noted during the same angiogram. a contrast ct scan confirmed that there was a pulmonary arteriovenous malformation occupying the lower lobe of the left lung (figures i, 2 and 3). an artery originating from slice above figure idemonstrates vascular malformation draining into the left atrium via a large draining vein (arrow) topage40 an unusual congenital pulrnonary arterio-venous fistula frompage39 patic cirrhosis" and bronchiectasis' and should always be considered in the management of such patients. pavms occur twice as often in women as in men, but there is a male predominance in new-borns (as in the index case), where symptoms may vary from being totally absent to severe with cyanosis, congestive heart failure and even fulminant respiratory failure." around 10% of cases ofpavm are identified in infancy or childhood, figure 3: a 3d reconstruction elegantly demonstrates the group of abnormal vessels (arrow) and its arter/al blood supply from the descending thoracic aorta the descending aorta, just above the diaphragm, supplied this lesion, which was seen to drain into the left atrium. the feeder vessel was ligated and a left lower lobe lobectomy was performed. this showed a vascular malformation composed of large, dilated interconnected vessels, many of them histologically resembling arterialised veins (figure 4). discussion since their first description at autopsy in 1897,1 these lesions have also been called pulmonary arteriovenous "fistulae", pulmonary arteriovenous "aneurysms", "hemangiomas" of the lung, "cavernous angiomas" of the lung, pulmonary "telangiectases" and pulmonary arteriovenous malformations.? the term "pulmonary arteriovenous malformations" (pavm) appears to be most widely accepted in modern literature.' although most commonly a congenital abnormality, abnormal communications between blood vessels of the lung may also be found in a variety of acquired conditions, such as hean inherited disorder of autosomal dominant inheritance, characterised by arteriovenous malformations of the skin, mucous membranes and visceral organs.' patients with a pavm should therefore be screened for this syndrome. there were no such features in our patient, despite an extensive search that included contrast ct scan of the brain. the classic clinical triad of dyspnoea, clubbing and cyanosis is rarely seen, with adult patients presenting most commonly with epistaxis, reflecting the strong association with hht. dyspnoea and haemoptysis are also common symptoms and in half of cases a bruit or murmur can be heard, most audible during inspiration.' our patient had a particularly loud murmur that was clinically thought to be a large pda. pavm usually occurs in the lower lobes and is solitary in 75% of cases." it can be classified as either simple or complex. the simple type (80-90% of cases) is defined as having a single feeding segmental artery and a single draining vein. the rest are complex, with two or more feeding arteries or draining veins." in the majority of patients ( about 95%), the avms are supplied by pulmonary arteries. avms are supplied by systemic arteries less frequently." figure 4: pulmonary avm an interconnected arrangement of thick-walled vascular channels (arrow) within the lung parenchyma (h&e x 4) with a peak incidence occurring in the fourth to sixth decades of life. approximately 70% of the cases of pavm are associated with hereditary haemorrhagic telangiectasia (hht), 40 sa journal of radiologyfebruary 2001 topage41 an unusual congenital pt.rfrriorrarv arterio-venous fistu la from page 40 such avms need to be differentiated from true sequestrations. drainage is usually to the left atrium, but anomalous drainage to the inferior vena cava or innominate veins has been reported. 2, ii pathological examination shows that pavms are similar to avms occurring elsewhere in the body. the malformations may have one of three typical appearances: (1) a large, single sac, (2) a plexiform mass of dilated vascular channels, or (3) a dilated and often tortuous direct communication between artery and vein.9,11 mural thrombi or calcifications are also occasionally seen.' the classic roentgenographic appearance of a pavm is that of a round or oval mass of uniform density, frequently lobulated but sharply defined and more commonly in the lower lobes.' although uncommon, multiple lesions may be identified." solitary pavms will often show feeding vessels on chest radiography, with the artery radiating from the hilus and the vein deviating towards the left atrium." despite advances in diagnostic techniques mentioned thus far, contrast pulmonary angiography remains the gold standard in the diagnosis of pavm. contrast echocardiography, computed tomography, radionuclide perfusion lung scanning, pulmonary angiography and magnetic resonance imaging are all further useful modalities.' treatment depends on the clinical symptoms, signs and size of the lesion and includes surgical resection, embolisation therapy or hormonal manipulation. in summary, therefore, pavms are uncommon paediatric problems, but should be considered in patients with (1) one or more pulmonary nodules, (2) mucocutaneous telangiectases and (3) unexplained clinical findings such as dyspnoea, haemoptysis, hypoxaemia, a machinery heart murmur, clubbing or cyanosis. references i. churn t. multiple aneurysms of the pulmonary artery. bm] 1897; 1: 1223-1225. 2. slogan, rd, coolly rn. congenital pulmonary arteriovenous aneurysm. a]r 1953; 70: 183-210. 3. gossage jr, ghassan k, pulmonary arteriovenous malformations: a state of the art review. am ] respir crit care med 1998; 158 (2): 643-661. 4. el gamal m, stoker jb, spiers em, whitaker w. cyanosis complicating hepatic cirrhosis: report of a case due to multiple fulmonary arteriovenous fistulas, am ] cardia 1970; 25: 490-494. 5, liebow aa, hales mr, lindskog ge. enlargement of the bronchial arteries and their anastomoses with the pulmonary arteries in bronchiectasis. am] patho11949; 25: 211-231. 6, allen sw, whitfield jm, clarke dr et al. pulmonary arteriovenous malformation in the newborn: a familial case. pediair cardiol1993; 14: 58-61. 7. vase p, holm m, arendrup h. pulmonary arteriovenous fistulas in hereditary hemorrhagic telangiectasia. acta med scand 1985; 218: 105109, 8. bosher lh jr, blake da, byrd br. an analysis of the pathologic anatomy of pulmonary arteriovenous aneurysms with particular reference to the applicability of local excision. surgery 1959; 45: 91-104. 9, white ri, mitchell se, barth kh, kaufman s et al. angioarchitecture of pulmonary arteriovenous malformations: an important consideration before embolotherapy. afr 1983; 140: 681-686. 10. dines de, arms ra, bernatz pe, gomes mr. pulmonary arteriovenous fistulas, mayo clin proc 1974; 49: 460-465. il. anabtawi in, ellison rg, ellison lt.pulmonary arteriovenous aneurysms and fistulas: anatomical variations, embryology and classification. ann thoracsurg 1965; j: 277-285, 12. hales mr. multiple small arteriovenous fistulae of the lungs. am] patho11956; 32: 927-943. 13. dines de, seward jb, bernatz pe. pulmonary arteriovenous fistula. mayo clin proe 1983; 58: 176-181. from page 21 a review of paediatric abciorninal rnasscs conclusion any abdominal organ may develop a mass. the spectrum of clinical presentations is broad and assessment of the child with an abdominal mass may, at first, seem daunting. a small proportion of entities account for the vast majority of cases and a knowledge of the statistical distribution, age and sex of the patient, clinical presentation (notably pain or pyrexia) and imaging characteristics (especially solid vs cystic nature) allows the formulation of a focused differential diagnosis. ultrasound has proved to be an invaluable tool in the assessment of paediatric abdominal masses because it is safe and efficacious, but the diagnostic capabilities of ct may often outweigh the radiation risk, especially in the older child. mri is increasingly more useful and may be the modality of choice in the future. references i. stevenson rj. abdominal masses. surg clin nam, 1985; 65 (5): 1481-1504. 2. hilton svw, edwards ok, practical paediatric radiology. philadelphia: wb saunders co, 1994: 357-387. 41 sa journal of radiology· february 2001 3. schwartz mz, shaul db. abdominal masses in the new-born. paedr rev, 1989; 11 (6): 172-179. 4. brodeur a, brodeur g, abdominal masses in children: neuroblastoma, wilm's tumour and other considerations. paedr rev, 1991; 12 (7): 196-207. 5. wedge jw, grosfeld jl, smith jp. abdominal masses in the new-born: 63 cases. j of urology, 1971; j 06: 770-775. 6. swischuk le, hayden ck. abdominal masses in children, paed clin nam, 1985; 32 (5): 1281-1298. 7, hartman ge, shochat sj. abdominal mass lesions in the new-born: diagnosis and treatment. clin perinat, 1989; 16 (i): 123135, 8, merten of, kirks dr, diagnostic imaging of paediatric abdominal masses. paed clin nam, 1985; 32 (6): 1397-1425. parotid gland enlargement may be the presenting clinical manifestation of systemic hiv infection in children as well as adults.1 comprehensive salivary gland evaluation is therefore mandatory in patients with unior bilateral parotid gland swelling. this article highlights the imaging techniques (ultrasound, computed tomography (ct), magnetic resonance imaging (mri)) used in the investigation of salivary gland enlargement and identifies the specific radiological signs found in hiv infection. the presence of diffuse, multiple cysts in one or both enlarged parotid glands represents benign lymphoepithelial proliferation with cyst formation and is found in systemic hiv infection. concurrent hyperplastic cervical and intraparotid lymphadenopathy may also be seen.2,3 the aetiology of parotid gland enlargement is extensive and it may be the presenting clinical manifestation of systemic hiv infection in children as well as adults. comprehensive salivary gland evaluation is therefore mandatory in patients with unior bilateral parotid gland swelling. the specific radiological signs of parotid gland enlargement in hiv infection are discussed here. usual findings during ultrasound examination would be an enlarged parotid gland with diffuse, multiple, small (1 4 mm) to medium-sized (5 8 mm) hypoechoic or anechoic (cystic) areas. less commonly, large anehoic (cystic) areas almost totally replacing the gland are seen. focal intra-parotid solid lesions and extra-parotid lymph nodes may also be identified (fig. 1). ct images show enlarged parotid glands with diffuse, multiple, variably sized, intraglandular cysts with low attenuation values (10 18 hounsfield units). the presence of solid focal intra-parotid mass lesions may suggest lymphadenopathy or concurrent kaposi’s sarcoma. enlarged peri-parotid and cervical lymph nodes may also be demonstrated (fig. 2). mri supports the ct findings noted above. the high water content of the intra-parotid cysts is responsible for the different signal intensities obtained, with t1-weighted images having low or mixed signal intensity. the cysts have intermediate signal intensity on proton density-weighted images and bright signal intensity t2-weighted images (fig. 3). the histological features include a diffuse lymphocytic infiltration of the parotid gland with formation of lymphoepithelial cysts and follicular hyperplasia of intraand peri-parotid lymph nodes4 (fig. 4). ultrasound, ct and mri demonstrate diffuse, multiple cysts in one or both enlarged parotid glands with associated hyperplastic cervical and intra-parotid lymphadenopathy seen mostly on ct and mri images. on histological examination these lesions represent benign lymphoepithelial proliferation with cyst formation. the pathogenesis of benign lymphoepithelial cysts remains unclear although a reactive lymphoid tissue infiltration of salivary glands associated with the hyperactivity of the immune system in hiv has been suggested. salivary gland duct obstruction secondary to the exuberant cellular process could also account for the cyst formation. ultrasound is not as accurate as ct or mri, but offers a rapid, simple, relatively inexpensive imaging technique to ascertain the nature of salivary gland pathology. imaging of hiv-associated parotid gland enlargement g rozendaal, mb chb department of radiology, pretoria academic hospital pictorial interlude fig. 1. ultrasound: multiple sonolucent areas representing lymphoepithelial cysts. fig. 2. axial ct (post contrast): enlarged bilateral parotid glands with multiple small cysts and posterior cervical lymphadenopathy.5 31 sa journal of radiology • march 2006 imagining of hiv associated.indd31 31 3/27/06 3:37:24 pm 32 sa journal of radiology • march 2006 mri demonstrates the key features of multi-cystic disease more clearly than ct scan. conclusion current imaging techniques used in visualising hiv-associated parotid gland enlargement include ultrasound, ct and mri. the characteristic radiological picture identifies diffuse, multiple, small cysts in one or both enlarged parotid glands which, on histological examination, represent benign lymphoepithelial proliferation with cyst formation. concurrent hyperplastic cervical and intra-parotid lymphadenopathy may also be seen. although ultrasound offers rapid and inexpensive imaging, ct and mri demonstrate the pathological findings more clearly. 1. chapnik js, noyek am, berris b, et al. parotid gland enlargement in hiv infection: clinical/imaging findings. j otolaryngol 1990; 19:189-194. 2. kirshenbaum kj, nadimpalli sr, friedman m, kirshenbaum gl, cavallino rp. benign lymphoepithelial parotid tumors in aids patients: ct and mri findings in nine cases. am j neuroradiol 1991; 12:271274. 3. trunkel de, loury m, fox c, goins m, johns m. bilateral parotid enlargement in hiv-seropositive patients. laryngoscope 1989; 99:590-595. 4. rupp m, chambersburg md. case 08-2002. hiv-associated salivary gland disease. http://www.afip. org/departments/omaxpath 5. department of radiology, chaing mai university. pediatric radiology case 2. http://www.medicine. cmu.ac.th/dept/radiology pictorial interlude fig. 3. mri (t2-weighted image): multiple variable sized cysts in both parotid glands. fig. 4. histology: benign lymphoepithelial lesion. to order contact carmen or avril: tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. price: r1600.00 member: r1440.00 high risk pregnancly.indd 1 2/16/06 2:58:23 pm to order contact carmen or avril: tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. price: r1600.00 member: r1440.00 high risk pregnancly.indd 1 2/16/06 2:58:23 pm imagining of hiv associated.indd32 32 3/27/06 3:37:28 pm radioactive news2.html report on the introduction to research for international young academics (iriya) seminar, 27 nov. 1 dec. 2011, rsna scientific assembly & annual meeting, mccormick place, chicago vicci du plessis (grey’s hospital, pietermaritzburg) chicago! ‘perhaps the most typically american place in america.’ (james bryce, 1888) my chicago experience started off with an order of ‘deep-dish pizza’ from pizzeria due (the spillover restaurant of the original pizzeria uno where this authentic chicago-style pizza has been served since 1943). there followed an evening of shopping along the stylish ‘magnificent mile’ on north michigan avenue! with little time to spare before the orientation tour of the iriya seminar, i attempted some sightseeing on a very blustery sunday morning. fighting the rain and chilly gusts off lake michigan with my newly-acquired, rather flimsy umbrella, i discovered first-hand how the city of chicago earned the nickname ‘the windy city’! i passed the chicago tribune, crossed the chicago river and explored millennium park, admiring the graceful ice-skaters and contemporary outdoor sculptures. a convenient and superbly organised bus system (compliments of the rsna) transferred me from the chicago marriott hotel to mccormick place on the shore of lake michigan – home to the annual rsna meeting and the largest conference venue in the united states. our orientation tour was led by diane tokarski, manager of the department of international relations and education of the rsna, whom we finally met in person after months of efficient e-mail organisation. at the sunday evening reception function, we met the other course organisers and our fellow iriya participants (16 young radiologists selected from 13 different countries). the seminar programme was well-structured, highly relevant and effectively run. we covered various topics concerning research, ranging from research question design to statistics to manuscript preparation. these were presented by lecturers from esteemed institutions such as johns hopkins and thomas jefferson universities and the harvard children’s hospital. there was an interesting panel discussion during which we, the iriya participants, could ask a team of academic radiologists any question pertaining to research or a career in academic radiology. we were also given the unique opportunity to present our own current research projects to a panel of experts at a research workshop; the sessions were co-ordinated by fiona miller, director of the department of research of the rsna. what a privilege to receive valuable comments and constructive criticism from world-renowned radiology professors such as william brant, william mayo-smith, winfried willinek, stephan voss and johan blickman! time was also allocated for our choice of the ever-popular rsna refresher courses, as well as to explore the conference independently. with 59 097 attendees overall, a record-breaking 16 272 radiologists and 681 exhibiting companies at rsna 2011, the experience was completely overwhelming! we were also given access to the residents and fellows’ lounge where we were able to meet american and international colleagues, and enjoy complimentary breakfasts, lunches and beverages. a formal, closing dinner was held at the chicago marriott magnificent mile hotel for the iriya and introduction to academic radiology course participants (second-year american radiology residents), during which an american radiologist in private practice entertained us with a speech entitled career choices – a comical address discussing the pros and cons of careers in academic and private radiology. the iriya seminar provided a vital foundation for our future careers in academic radiology. not only did we gain theoretical knowledge, but more importantly, iriya also facilitated the development of valuable relationships with international colleagues sharing an interest in research, as well as with potential professional mentors. on behalf of all the iriya participants, i express heartfelt gratitude to the radiological society of north america for granting us this extraordinary opportunity. i also thank the president of the rssa, dr clive sperryn, as the opportunity to participate was made possible by virtue of the rssa being an affiliated/collaborating society of the rsna. iriya participants with organisers fiona miller, john eng and diane tokarski (front centre, left to right) interesting images a truly duplex renal system c sanyika l marishane department of rad/%gy university of nata! !s9 sa journal of radiologyfebruary 2001 t he angiogram of a 34-year old male prospective living renal donor in figure 1 demonstrates two right renal arteries. a delayed digital abdominal radiograph (figure 2) demonstrated a complete right duplex renal collecting system. case report sheldon godinho fcrad(o) sa, frcr department of radiology, university of pretoria a 38-year-old woman became nauseous while driving in a car. she began retching before her husband could pull over, and attempted to swallow down. severe chest pain ensued and gradually worsened overnight. medical assistance was sought the following morning and the patient was referred to a local hospital for a barium swallow.an incarcerated para-oesophageal hernia was diagnosed. the patient was then referred to a general surgeon in our hospital. noting the severity of her pain and shallow tachypnoea, we were approached for a second opinion. the control chest radiograph showed subtle medial basal veiling on the left and a little pleural fluid (fig. i). an irregular outpouehing could be seen on the left posterolateral aspect of the oesophagus, above the diaphragm on the swallow series fig. 1. control chest before barium swallow. note left basal infiltrate, loss of medial diaphragmatic contour and blunted costophrenic recess. boerhaave's syndrome (fig. 2). this did not appear continuous with the gastric fundus as with a para-oesophageal hernia. repeat chest radiograph showed progression of the basal lung and pleural changes and a collection of extraluminal barium (fig. 3). no pneumomediastinum could be seen. a presumptive diagnosis of spontaneous oesophageal rupture (boerhaave's syndrome) was made. this was confirmed on noncontrast chest ct, which clearly showed the barium-lined cavity, perioesophageal inflammation, pleuropulmonary changes and also a small pneumomediastinum. a few pockets of upper retroperitoneal air were also visible below the hiatus (fig.4). at thoractomy a 5 ern vertical rent was found in the left posterolateral wall of the distal oesophagus, and repaired. hospitalisation was uncomplicated and the patient was discharged 4 days later. discussion hermann boerhaave described spontaneous rupture of the oesophagus of lord high admiral wassenaer of the royal dutch navy in 1724, now known as boerhaave's syndrome. this is a rare cause for oesophageal perforation, usually found in males 40 60 years of age secondary to forceful vomiting and often related to binge eating, drinking and alcoholism. rare instances have been caused by straining, childbirth, severe coughing, hiccuping, seizures, asthma, and forceful swallowing. chest pain, epigastric pain and dyspnoea are common symptoms. hematemesis occurs in about 50% of cases and is usually not profuse. in 90% of cases a vertical tear of 1 8 cm occurs along the left posterolateral wall of the distal third of fig. 2. barium swallow. extravasation of barium into a cavity located above the diaphragm, on the posterolateral aspect. 22 sa journal of radiology • march 2002 case report fig. 3. fol/ow·up chest radiograph. leaked barium fol/owing earlier swallow. more extensive basal vei/· ing and pleural fluid. fig. 4. ct chest. left·sided pleural effusion and basal pulmonary infiltrate. note mediastinal air pockets between aorta and left atrium and betiur» lined leakage cavity. the oesophagus. other clinical considerations should include a malloryweiss mucosal tear, aortic dissection and peptic-reflux disease. clinical signs are mostly nonspecific. subcutaneous emphysema may be found in the neck or chest. mackler's triad of vomiting, chest pain and subcutaneous emphysema is uncommon and therefore unreliable. tachycardia, tachypnoea, fever, hypotension and shock can occur with late presentation. rarity, unfamiliarity and a sometimes undramatic history often delay diagnosis. up to 50% are not diagnosed at initial presentation! prognosis is grave: 30 50% mortality can be expected despite prompt treatment and over 90% when delayed diagnosis leads to mediastinitis. chest x-ray findings may suggest perforation in boerhaave's syndrome; however x-ray findings are normal in 10 15% of cases. signs include mediastinal emphysema or frank pneumomediastinum (60%), mediastinal widening or air fluid level, pleural effusion (90%, usually left), pneumothorax, or hydropneumothorax. the 'v' sign of naclerio describes a pocket of mediastinal air lodged between the aorta and diaphragm. gastrografin swallows are useful and must be performed in both left and right decubitus positions. falsenegative results occur in 10 25% of cases, however. some authorities suggest barium oesophagography if a high suspicion of oesophageal perforation exists and gastrografin swallow is negative. in one study, 22% of cases with a high clinical suspicion and normal water-soluble contrast swallow were found to be positive for rupture when barium was used. non-contrast ct scan offers a number of advantages, including evaluation of the pleurae, mediastinum, and aorta. the exact perforation site is usually not visible but extravasation may be seen if scanned after oral contrast, as in this case. complications of oesophageal rupture include mediastinitis, empyema and septic shock. tension pyopneumothorax and vertebral osteomyelitis from a posterior perforation have been described. patients who recover are predisposed to repeat 23 sa journal of radiology • march 2002 spontaneous rupture. the best clinical outcomes occur with primary closure within 24 hours. prompt diagnosis is therefore critical! a nonspecific clinical picture shifts additional responsibility onto the radiologist. while mediastinal emphysema will surely call to mind this diagnosis, it only occurs in some 60% of cases. any basal pleuropulmonary changes must therefore be viewed with great suspicion when there is a history of vomiting and also in inebriated patients unable to give a history. aspiration would probably be the first logical diagnostic consideration but oesophageal rupture must be borne in mind. oesophageal andlor ct should be considered where even the slightest suspicion exists. bibliography 1. adamek h. management of esophageal perforations after therapeutic upper gastrointestinal endoscopy. scand j gastroenterol1997; 32: 411· 414. 2. altorjay a, kiss j, voros a. nonoperative management of esophageal perforations. is it justified? ann surg 1997; 225: 415·421. 3. borotto e. risk factors of oesophageal perforation during pneumatic dilatation for achalasia. gut 1996; 39(1): 9-12. 4. bufkin bl, miller ii jun., mansour ka. esophageal perforation: emphasis on management. ann thorae surg 1996; 61: 1447-1451; discussion 1451-1452. 5. cordero jq. distal esophageal rupture after external blunt trauma: report of two cases. j trauma 1997; 42: 321-322. 6. inculet r, clark c, girvan d. boerhaave's syndrome and children: a rare and unexpected combination. j pediatr surg 1996; 31: 13001301. 7. iagminas l. boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. am j emerg med 1996; 14(1): 53-56. 8. lujan h. recurrent spontaneous rupture of the esophagus: an unusual late complication of boerhaave's syndrome. surgery 1997; 122: 634636. 9. panieri e, millar ai, rode h, et al. iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome. j pediatr surg 1996; 31: 890-895. 10. ring d. vertebral osteomyelitis after blunt traumatic esophageal rupture. spine 1995; 20(1): 98-101. 11. sabanathan s. surgical management of intrathoracic oesophageal rupture. br j suig 1994; 81: 863-865. 12. troum s. surviving boerbaave's syndrome without thoracotomy. chest 1994; 106(1): 297299. case report 99 sa journal of radiology • december 2007 introduction lipofibromatosis is a rare paediatric tumour described by fetsch et al.1 in 2000. they documented 45 cases of this soft-tissue entity. since then there have been a few reports of this tumour and its imaging characteristics.2 lipofibromatosis is a poorly demarcated mass involving the subcutis or deep soft tissues.1 the histology is that of abundant mature adipose tissue with a spindled fibroblastic element involving the septa of fat tissue.1 it forms a slowly growing painless mass arising in children and in some cases like the one described below – congenitally.1 fetsch et al.1 documented ages ranging from 11 days to 12 years (median age 1 year) at the time of initial biopsy and resection as well as a 2:1 male predominance. this case report serves to describe the clinicoradiological features of this condition as well as the radiological differential diagnosis. case report a male infant presented at birth with diffuse swelling of his right thigh and upper leg. antenatal and family history proved unremarkable. the patient was born via normal vaginal delivery with good birth apgar scores. examination revealed enlargement of the right upper leg extending from the thigh to the mid lower leg spanning a distance of 24 cm. there was overlying skin hypertrichosis. the leg was firm with no pulsatility or bruit. there was no obvious tenderness and no other lesions could be detected. on plain radiography (fig. 1) there was marked increase of limb lipofibromatosis – a case report l naidoo, mb chb, fcrad (d) helen joseph and coronation hospitals, johannesburg fig. 2. sagittal axial ct showing the fatty interdigitation into poorly marginated bulky musculature. fig. 3. coronal ct with fatty infiltration of musculature. fig. 1. lateral x-ray of the limb demonstrating its enlargement. the thickened subcutaneous fat is well demonstrated. pg99-100.indd 99 12/11/07 2:21:32 pm case report case report 100 sa journal of radiology • december 2007 diameter with diffuse thickening of the fatty subcutaneous tissue. the underlying muscular compartment was bulky with radiolucencies – that appeared isodense to adjacent subcutaneous fat – suggestive of a fatty infiltration. no calcifications could be detected. bony outlines appeared intact. computed tomography (ct) scans (figs 2 4) demonstrated a softtissue mass with diffuse thickening of the subcutaneous adipose tissue and fibrous stranding. there was interdigitation of the fatty tissue into the musculature. fatty tumour components were interspersed in part through musculature that appeared infiltrated and poorly defined. there was no vascular component, nor nerve infiltration. no bony overgrowth was demonstrated. although infiltrating, the adipose tissue overgrowth was clinically slow growing and the radiological differential was for that of superficial adipocytic peripheral benign tumours of infancy. wedge biopsies from the upper thigh and knee were submitted for histology. the findings were those of a tumour composed of alternating streaks of mature adipose tissue as well as a fibrous spindle-cell component consistent with lipofibromatosis. radiological differential diagnosis the differential diagnoses for lipofibromatosis that were considered included lipofibromatosis hamartoma of the nerves, proteus syndrome and lipoblastoma(tosis). lipofibromatosis hamartoma of the nerves is a slow growing mass of fibrofatty tissue surrounding and infiltrating major nerves.3 when this condition is associated with macrodactyly and bone overgrowth it is described by the term ‘macrodystrophia lipomatosa’.3 owing to absence of nerve infiltration in the described case, this possibilty was considered unlikely. proteus syndrome is a disorder characterised by progressive overgrowth of multiple tissues with a propensity to develop particular neoplasms.4 the clinical criteria include the presence of a connective tissue nevus, ovarian cystadenomas or parotid adenomas as well as disproportionate overgrowth of specific tissue, vascular malformations and specific facial phenotypes.4 this differential was a consideration on the basis of the adipose tissue overgrowth as well as the prescence of hypertrichosis.3 although other criteria could not be met, one has to consider this as the abnormalities described above tend to increase with age.4 lipoblastomas are benign mesenchymal tumours of embryonal white fat.5 histologically the well-circumscribed and encapsulated features of lipoblastoma differentiate it from the multicentric and infiltrative nature of lipoblastomatosis.5 this tumour has a wide anatomical distribution but chiefly affects the extremities.5 imaging differentiation from lipofibromatosis is often impossible because of the predominance of fatty tissue component in both tumours. biopsy forms the mainstay of diagnosis and displays mainly immature fat cells (unlike lipofibromatosis).5 discussion lipofibromatosis has previously been interpreted as a form of infantile fibromatosis.1 in 2000, fetsch et al.1 proposed that although the tumour is likely to be a part of the infantile fibromatosis spectra, it should be considered a distinctive entity because of its histology. fibromatosis exhibits a more sheet-like growth and does not contain fat as an integral component.1,2 although biopsy offers a definitive diagnosis, imaging modalities are useful adjuncts for diagnosis as well as management. imaging is especially useful in determining the degree and depth of anatomical involvement which is helpful for evaluation prior to complete removal of the tumour, reconstruction or excision of recurrent diffuse lesions. imaging generally reveals fat that appears exaggerated, adipose tissue that is more disorganised than normal with poorly demarcated lobules, infiltration and entrapment as well as displacement of muscle with fibroblastic elements within the fat septa.5 ultrasound usually demonstrates poor musculature planes with hyperechoic content. ct is useful in outlining the tumour and demonstrating a low-density non-enhancing mass measuring fat in hounsfield units. magnetic resonance imaging (mri), though not available in the case described above, plays an important role in tissue characterisation with increased t1 and t2 signals that are consistent with fat. intralesional areas of signal change that are increased on t1 and become fat saturated on t2 are also reflective of fatty content.2,5 mri can also be useful in differentiating between lipofibromatosis and lipoblastoma(tosis) on the basis of the immature cell content of the latter. this finding sometimes results in the isointense t1 signal of lipoblastoma(tosis).5 lipofibromatosis is best managed by complete removal because of its predeliction for recurrence in incompletely excised lesions.2 however there are some cases where long-term follow-up has shown no progress.2 metastases have not been reported. conclusion although biopsies form the mainstay of diagnosis in peripheral fatty tumours of infancy, ct and mri form valuable adjuncts in differentiating fatty tumours from other soft-tissue tumours. these imaging modalities also serve to delineate lesions for surgical excision and reconstruction procedures. 1. fetsch jf, miettinen m, laskin wb, michal m, enzinger fm. a clinicopathologic study of 45 pediatric soft tissue tumours with an admixture of adipose tissue and fibroblastic elements, and a proposal for classification as lipofibromatosis. am j surg pathol 2000; 24: 1491-1500. 2. sasaki d, hatori m, hosaka m, watanabe m, kokubun s. lipofibromatosis arising in a pediatric forearm – a case report. upsala j med sci 2005; 11: 81-106. 3. kameh d, perez-berenguer j, pearl g. lipofibromatous hamartoma and related peripheral nerve lesions. south med j 2000; 93: 800-802. 4. barclay l, vogin g, vega c. cutaneous manifestations of proteus syndrome reflect general severity. arch dermatol 2004; 140: 947-953,1001-1002. 5. chien a, song d, stein s. two young girls with lipoblastoma and a review of the literature pediatr dermatol 2006; 23: 152-156. fig. 4. axial ct demonstrating fibrous stranding within the thickened subcutaneous fatty tissue. pg99-100.indd 100 12/11/07 2:21:33 pm abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) sunaina ramdass department of diagnostic radiology, faculty of health sciences, steve biko academic hospital, university of pretoria, pretoria, south africa sumaiya adam department of foeto-maternal medicine, faculty of health sciences, steve biko academic hospital, university of pretoria, pretoria, south africa zarina lockhat department of diagnostic radiology, faculty of health sciences, steve biko academic hospital, university of pretoria, pretoria, south africa andries masenge department of biostatistics, faculty of statistics, university of pretoria, pretoria, south africa farhana e. suleman department of diagnostic radiology, faculty of health sciences, steve biko academic hospital, university of pretoria, pretoria, south africa citation ramdass s, adam s, lockhat z, masenge a, suleman fe. foetal magnetic resonance imaging: a necessity or adjunct? a modality comparison of in-utero ultrasound and ultrafast foetal magnetic resonance imaging. s afr j rad. 2021;25(1), a2010. https://doi.org/10.4102/sajr.v25i1.2010 original research foetal magnetic resonance imaging: a necessity or adjunct? a modality comparison of in-utero ultrasound and ultrafast foetal magnetic resonance imaging sunaina ramdass, sumaiya adam, zarina lockhat, andries masenge, farhana e. suleman received: 04 oct. 2020; accepted: 01 dec. 2020; published: 19 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: congenital anomalies occur in approximately 2% of newborns, resulting in severe medical, physical and social disabilities. managing clinicians, therefore, require more confidence in their diagnosis and prognostic accuracy before appropriately counselling the parents regarding termination of pregnancy. objective: the aim of this study was to investigate the role of magnetic resonance imaging (mri) following the diagnosis of foetal anomalies at a foetomaternal unit of a tertiary south african institution. methods: eighty-eight pregnant women in their late second/third trimester who underwent both an ultrasound (us) at the foetomaternal unit and foetal mri at the radiology department from 01 july 2013 to 30 september 2019 were included in this clinical study conducted at steve biko academic hospital. results: despite the high degree of concurrence (73.9%) between both modalities regarding the main diagnoses, mri provided additional information in 45.5% of patients and changed the diagnosis in 25% of the patients. it further demonstrated superiority in providing diagnostic information in 97% of cases where the us alone was inadequate to counsel parents regarding the termination of pregnancy, and it completely changed the clinical management in 42% of cases. conclusion: it is clearly evident from this study that foetal mri is a necessity when termination of pregnancy is being considered following an us conducted by the foetomaternal unit. this allows for a complete foetal assessment and gives the managing clinician sufficient diagnostic confidence to prognosticate the future quality of life of the child. keywords: foetal mri; ultrafast foetal mri; in-utero ultrasound; antenatal sonar; comparison; congenital anomalies. introduction congenital anomalies are reported in approximately 2% of newborn children often because of an unknown aetiology, resulting in severe medical, physical and social disabilities.1 the choice of termination of pregnancy act (1996) of south africa allows for termination of pregnancy after the 20th week, until term essentially, as agreed upon by two medical practitioners for major structural anomalies that would result in poor quality of life.2 managing clinicians, therefore, require more diagnostic confidence and prognostic accuracy on the anomaly or complex anomalies present before appropriately counselling the parents.1,3 ultrasound (us) is the current global method for screening congenital anomalies, which has many limitations. ultrafast foetal magnetic resonance imaging (mri) could potentially play a significant role as a new modality in comprehensively diagnosing and prognosticating congenital abnormalities detected at us. considering the cost, waiting lists and personnel required for an mri, we need to be certain that it adds considerable value to the outcome of the pregnancy. ultrasound is relatively inexpensive, easily accessible and reliant on a single-trained sonographer. the development of new technology in us has been revolutionary in the past decade, allowing for even four-dimensional in-utero assessment. there is, however, very little consensus as to the sensitivity as well as the specificity of us, with studies showing sensitivity ranging from 14% to 92% for major structural abnormalities within the second trimester.4,5 ultrasound is a safe, real-time imaging technique that provides assessment of foetal and placental health.1 however, it is dependent on the operator and the foetal position, and is of little value in obese mothers and in oligohydramnios.1,6 transvaginal sonography has a role to play in obese patients, early pregnancy dating and first trimester bleeding. neurosonography is performed by specially trained individuals at tertiary centres depending on the gestational age at the time of referral. foetal mri is a highly specialised investigation, which was not initially used in obstetrics because of the long acquisition times. however, with the advancement of ultrafast imaging, mri allows for three-dimensional imaging of the whole foetus in-utero with extremely short acquisition times.1 magnetic resonance imaging is an extremely expensive study, which also requires trained radiographers for acquisition and radiologists for interpretation. it is a very limited resource, especially within our centre. foetal mris are usually conducted after 18 weeks of gestation as certain organ systems are only fully developed after this gestational age, and the foetus is large enough to allow visualisation of almost all of the anomalies present. the corpus callosum, for example, is a common indication for mri referral and is only fully formed after 20 weeks. at this gestation, foetal motion is also less of a factor. vimercati et al.5 correlated the us diagnoses and autopsy findings over 7 years. they observed that in 49% of cases, us and autopsy findings were in complete agreement with one another. an additional 22% of anomalies that occurred were not detected on us, and in 4% of cases there was a complete lack of agreement. of significance, they also noted that the degree of agreement was higher when ultrasounds were performed at tertiary centres. there are many published studies on the comparison of these modalities for neurological anomalies, and in particular the brain.1,3,7,8,9 fewer studies assess all the organ systems, and fewer studies still look at focused non-neurological systems. they all agree that for posterior fossa assessment, mri is superior. it was determined in specialised units that the combination of neurosonography and foetal mri enables accurate diagnosis of most posterior fossa anomalies.10 a study assessing the contribution of mri to foetal us by kul et al.11 determined that us was superior in 4% of cases and mri in 39% of cases. another comparative study over a 10-year period observed that mri changed the findings of foetal us, resulting in a change of parental counselling in 68.4% of cases.12 the overall consensus, however, is that mri is best viewed as an adjunct to us.1,4,6,8,12,13,14 it is also clear that even just the confirmation of the us findings by mri and the exclusion of other anomalies should be viewed as clinically relevant as it assists clinicians with the counselling of parents. the results vary in other studies; consensus between us and mri was observed in 13% – 50% of cases, mri was found to provide additional information in 17% – 100% of cases and change the diagnosis in 11.9% – 100% of cases.1,4,7,8,9,13,14,15 it is also clear that mri proves to be superior in assessment of imaging and delineating pathologies of the thorax, abdomen and urogenital systems.4,16,17 a recent study observed an increase from 2.9% to 5.1% in parental request for termination of pregnancy following an mri, which confirmed and/or provided additional information.18 a single south african study noted in the literature, comparing us to mri and postnatal outcomes noted that the commonest reason for referral to mri at their centre was ventriculomegaly, with good agreement between foetal us and mri but poor agreement with postnatal findings due to the resolution of the ventriculomegaly.19 given the varying statistics and the importance of diagnostic accuracy and prognostication, it was prudent to assess the role of foetal mri in comparison with prenatal in-utero ultrasonography at a local tertiary institute, steve biko academic hospital. materials and methods eighty-eight pregnant women in their late second or third trimester who underwent both an us at the foetomaternal unit and a foetal mri at steve biko academic hospital radiology department from 01 july 2013 to 30 september 2019 were included in this clinical study. patients were only referred for a foetal mri scan when the foetomaternal specialists came to a conclusion that us was inadequate for formulating a decision. the foetomaternal unit used a phillips affiniti 70 sonar machine with an abdominal probe or transvaginal probe. the patients were examined in the supine or left lateral position. the foetomaternal specialists and fellows in training performed the us examinations. whilst the us were conducted by various people during the study period, all us were reviewed by one or more of the three foetomaternal specialists in the department. patients were then referred for mri and scans were performed within the late second and third trimester. a 1.5t philips mri scanner with a body coil was used for all the foetal mris performed at our facility. no sedation was provided to the mother. all patients were scanned in a supine position, and sequences were obtained in a three-dimensional plane. sequences included balanced fast field echo (time of repetition 3.8 and time to echo 1.9) and single-shot turbo spin echo (time of repetition 15 000 and time to echo 120) in three planes. the slice thickness used was 4 mm. the total acquisition time was usually 10–15 min. patients were subsequently followed up at the foetomaternal unit, counselled regarding the mri findings and advised on termination of pregnancy where appropriate. a direct comparison was made between the findings at us and mri. the data analysis included frequency tables (counts and percentages), performed to describe the mri and us diagnoses and inferential statistics using the mcnemar (two sample) and cochran’s (k sample) test to measure whether the combinations of categorical values between mri and us were equally likely. ethical considerations this protocol was approved by the ethics committee of a gauteng university (reference no. 547/2019). as this was a retrospective study, the ethics committee agreed to waive patients’ consent. results a total of 88 patients underwent a prenatal in-utero us and an mri from 01 july 2013 to 30 september 2019. the maternal age ranged from 16 to 43 years with an average age of 29 years, and the gestational age ranged between 17 to 41 weeks with an average gestational age of 28 weeks at the time of referral for mri. ultrasound and mri findings were in concordance in 73.9% of cases and were in discordance in 25% of cases (table 1). only one of the mris was inconclusive because of rapid foetal movement. the mri scans confirmed the us findings in 26.1% of patients and provided additional information in 45.5% of patients (table 2). the findings at mri changed the diagnosis in 27.3% of patients. in 16.7% of these cases, mri findings changed the diagnosis to normal, whereas us detected 24 false positives and 7 false negatives (table 3). table 1: frequency and percentage agreement between ultrasound and magnetic resonance imaging. table 2: magnetic resonance imaging contribution. table 3: abnormalities on ultrasound when compared with magnetic resonance imaging. following a review of the mri findings (table 4), 36.4% of parents were counselled in favour of termination of pregnancy. in 22.7% of cases, parents were counselled not to terminate the pregnancy, and 38.6% are unknown. table 4: frequency and percentage of termination of pregnancy. upon retrospective analysis, mri changed the decision for proceeding with termination of pregnancy in 25% of patients where us had initially advised against termination. one such example included a patient referred for assessment of foetal ventriculomegaly noted on the us. the findings at mri revealed alobar holoprosencephaly, and hence, termination was advised. in 13.8% of patients, mri changed the decision against proceeding with termination, where us had initially advised for termination (table 5). one such example included a patient referred for possible dandy walker malformation, corpus callosal agenesis and ventriculomegaly on the us. magnetic resonance imaging noted prominent ventricles with no other associated abnormalities. overall mri allowed clinicians to counsel parents regarding the termination of pregnancy in 97% of cases where us was insufficient. the findings at mri had a direct impact on the clinical management in 42% of cases either by providing the complete diagnostic picture to allow a decision to be made or by changing the initial decision. table 5: late termination of pregnancy ultrasound compared to magnetic resonance imaging. cohen’s kappa score is a measure of inter-rater reliability. this is a robust measure as kappa takes into account the possibility of the agreement occurring by chance. the overall cohen’s kappa score between us and mri regarding the late-term termination of pregnancy was fair (kappa = 0.229). the central nervous system, thoracic, abdominal and gestational systems showed a cohen’s kappa score that was substantial (table 6). whilst the spinal and urogenital systems indicated the highest score of almost perfect, the musculoskeletal system revealed the lowest score of moderate agreement. table 6: cohen’s kappa scores per organ system. discussion the gestational age at the time of the scan is of importance, as there is less foetal movement and better delineation of anatomy in the older foetus. there is, therefore, consensus that mri must be performed in or after the second trimester. the mean gestational age of 28.13 weeks in this study is within the range of the other studies, which allows for comparative assessments. the mean gestational age in the literature ranged from 24.8 to 32.2 weeks.7,11,13,15 it can be observed from the study by di masicio et al.18 that a difference in the rate of central nervous system abnormalities was not detected clinically at birth when foetal mri was carried out before, compared with after, 24 weeks of gestation. there was a much higher percentage of agreement between us and mri in this study (73.9%) than that noted in the reviewed literature (28.6% – 52.0%).4,9,12 there was a much lower percentage of disagreement of 25% between modalities when compared with the varying statistics of other studies ranging from 35.0% to 47.6%.4,9,11 us is an operator-dependent modality, and the foetomaternal specialists and fellows are all highly trained and specialised. these outcomes may reflect a high standard of sonography performed at steve biko academic hospital’s tertiary unit. the findings of mri confirmed the us findings in 26.1% of patients and provided additional information in 45.5% of patients, which is a significant percentage, when one considers the importance of a clinician needing to be as well informed as possible to accurately prognosticate the quality of life and counsel parents regarding the termination of pregnancy. carbone et al.12 evaluated 328 patients over a period of 10 years and found that mri changed the diagnosis in 68.4% of patients, compared with just 27.3% in this study, and altered that diagnosis to normal in 11.9% of patients, compared with 16.7% in this study. in order to establish whether mri changed the counselling of parents regarding the late-term termination of pregnancy, a senior foetomaternal specialist, who was blinded to the outcomes, reviewed the us and mr findings independently and noted whether she would have advised termination of pregnancy. whilst many other studies mentioned the difficulty in being able to assess the clinical impact of mri, it was observed in this study that mri allowed clinicians to counsel parents regarding the termination of pregnancy in 97% of cases where us, as a standalone modality, proved inadequate. the mri findings had an impact on clinical management in 42% of cases in this study, which was a lower percentage when compared with the 55% – 68.4%5,14 reported in the reviewed literature. this may be attributable to the higher degree of agreement between the modalities at our hospital. further assessments were made in evaluating the ability of both modalities in assessing anomalies of each organ system. the overall organ system reported a cohen’s kappa score of 0.839, which is almost perfect. this reflects a high degree of inter-rater reliability between the two modalities. this correlates with the overall agreement of 73.9% between us and mri. the central nervous system is the commonest system evaluated in the literature, as ventriculomegaly is the most frequent anomaly detected at sonography, and therefore, the usual indication for an mri. magnetic resonance imaging has well established its superior role in visualising the posterior fossa. levine et al.3 showed that whilst us may also demonstrate ventriculomegaly, it fails to demonstrate the underlying aetiology, as well as associated abnormalities. an example of this includes when us demonstrates the characteristic massive ventriculomegaly and fails to demonstrate the cerebral aqueductal stenosis. ultrasound is poor at delineating the thorax as evidenced by the detection of six false positives and two false negatives in this study. magnetic resonance imaging also proves to be superior in abdominal and urogenital assessment as it provides a much larger field of view, and therefore, a complete system assessment. kul et al.11 revealed that additional information provided by mri on thoracic and abdominal anomalies detected at us was 43.8% and 37.5%, respectively. the lowest score was noted in the musculoskeletal system, which demonstrated moderate agreement, probably because of the superior soft tissue delineation of mri. ultrasound has the advantage of being real time and is able to assess placental health. it is also superior in assessing the vascularity of masses, and because of its cost effectiveness, allows for multiple follow-up studies to assess interval change. magnetic resonance imaging is a three-dimensional evaluation that allows for the assessment of masses in the context of the foetus as a whole whilst assisting with surgical planning. as a result of the cost and personnel required, it cannot be used to assess interval changes. it is important to note that foetal imaging is not available in many antenatal clinics across south africa. as a result, many foetal abnormalities may be missed and patients are never referred for tertiary care. in addition, patients with discerned anomalies who are referred for assessment may fail to follow up under socio-economic circumstances, and this may account for the 38.6% of unknown outcomes in this study. one of the limitations of this study was that patients were not followed up at postmortem or birth or in the subsequent neonatal period to review and compare the anomalies with those noted at us and mri. this would have been an important criterion for assessment regarding the diagnostic accuracy of both these modalities. however, postmortems are not possible on all foetuses at delivery because of consent issues, macerated foetuses at delivery and resource constraints. a second limitation includes the technical system failure in the foetomaternal unit, which did not allow for access to older foetal us reports preceding july 2013, limiting the study population to a smaller number. future recommendations include the use of foetal (four dimensional [4d)] neurosonography, which may decrease the referral burden on mri, the appointment of a dedicated radiologist interpreting all foetal mris, which will improve reporting at combined departmental discussions, and better post-mortem or birth follow-up (neonatal and childhood) to allow for the correlation of findings. conclusion it is clearly evident from this study, as in other studies from the literature, that foetal mri is a necessity and not merely an adjunct, when termination of pregnancy is being considered following an us conducted by the foetomaternal unit. this allows for the most complete foetal assessment and allows the managing clinician to have enough diagnostic confidence to prognosticate the quality of life that the child will have. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article. authors’ contributions s.r. made substantial contributions towards the study design, data acquisition, interpretation, manuscript writing and revision. f.e.s. made substantial contributions to the study concept, design and manuscript writing. s.m. made contributions towards the study design, data acquisitions and manuscript writing. z.i. contributed to the study conception and manuscript writing. a.m. made contributions to data analysis and interpretation. funding information this research article received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, s.r., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references brown sd, estroff ja, barnewolt ce. fetal mri. appl radiol. 2004;33(2):9. choice on termination of pregnancy act of 1996 [statute on the internet]. 1996 [cited n.d.]. available from: www.saflii.org/za/legis/num_act/cotopa1996325 levine d. ultrasound versus magnetic resonance imaging in fetal evaluation. top magn reson imaging. 2001;12(1):25–38. https://doi.org/10.1097/00002142-200102000-00004 whitby e, paley mn, davies n, sprigg a, griffiths pd. ultrafast magnetic resonance imaging of central nervous system abnormalities in utero in the second and third trimester of pregnancy: comparison with ultrasound. bjog. 2001;108(5):519–526. https://doi.org/10.1111/j.1471-0528.2001.00115.x vimercati a, grasso s, abruzzese m, et al. correlation between ultrasound diagnosis and autopsy findings of fetal malformations. j prenat med. 2012;6(2):13–17. pistorius lr, hellmann pm, visser gha, malinger g, prayer d. fetal neuroimaging: ultrasound, mri, or both? obstet gynecol surv. 2008;63(11):733–745. https://doi.org/10.1097/ogx.0b013e318186d3ea millischer ae, sonigo p, attie t, et al. fetal mri findings in a retrospective cohort of 26 cases of prenatally diagnosed charge syndrome individuals. prenat diagn. 2019;39(9):781–791. https://doi.org/10.1002/pd.5429 manevich-mazor m, weissmann-brenner a, mazor rd, et al. added value of fetal mri in the evaluation of fetal anomalies of the corpus callosum: a retrospective analysis of 78 cases. ultraschall med. 2018;39(5):513–525. https://doi.org/10.1055/s-0043-113820 whitby eh, paley mnj, sprigg a, et al. comparison of ultrasound and magnetic resonance imaging in 100 singleton pregnancies with suspected brain abnormalities. bjog. 2004;111(8):784–792. https://doi.org/10.1111/j.1471-0528.2004.00149.x lerman-sagie t, prayer d, stöcklein s, malinger g. chapter 1 – fetal cerebellar disorders. handb clin neurol. 2018;155:3–23. https://doi.org/10.1016/b978-0-444-64189-2.00001-9 kul s, korkmaz ha, cansu a, et al. contribution of mri to ultrasound in the diagnosis of fetal anomalies. j magn reson imaging. 2012; 35(4):882–890. https://doi.org/10.1002/jmri.23502 carbone j, amundson p, shanks a, et al. 345: does fetal mri impact clinical decision making of ultrasound-diagnosed fetal lesions? a center’s 10 year experience. am j obstet gynecol. 2012;206(1 suppl):s162–s163. https://doi.org/10.1016/j.ajog.2011.10.363 breysem l, bosmans h, dymarkowski s, et al. the value of fast mr imaging as an adjunct to ultrasound in prenatal diagnosis. eur radiol. 2003;13(7):1538–1548. https://doi.org/10.1007/s00330-002-1811-6 baldacchino i, saliba i, gatt as. fetal mri: an essential step in interpreting complex ultrasound findings. malta med j. 2016;28(3):35. kandula t, fahey m, chalmers r, et al. isolated ventriculomegaly on prenatal ultrasound: what does fetal mri add? j med imaging radiat oncol. 2015;59(2):154–162. https://doi.org/10.1111/1754-9485.12287 griffiths pd, widjaja e, paley mnj, whitby eh. imaging the fetal spine using in utero mr: diagnostic accuracy and impact on management. pediat radiol. 2006;36(9):927–933. https://doi.org/10.1007/s00247-006-0234-y millischer ae, grevent d, rousseau v, et al. fetal mri compared with ultrasound for the diagnosis of obstructive genital malformations. prenat diagn. 2017;37(11):1138–1145. https://doi.org/10.1002/pd.5155 di mascio d, sileo fg, khalil a, et al. systematic review and meta-analysis on the role of prenatal magnetic resonance imaging in the era of fetal neurosonography: mild and moderate ventriculomegaly. ultrasound obstet gynecol. 2018; 52(6):685–820. boutall a, andronikou s, candy se, constantatos s, stewart c, daire a. evaluation of fetal mri in a south african referral centre: research. s afr med j. 2015;105(11):930–933. https://doi.org/10.7196/samj.2015.v105i11.9415 case report 28 sa journal of radiology • march 2006 a variety of pips and chewed nuts can simulate disease by appearing as multiple filling defects on the double-contrast barium enema. the unwary and untrained eye might interpret these filling defects as multiple polyps, leading to the wrong diagnosis and unnecessary further investigations or treatment. a case of multiple linseeds mimicking polyposis coli on doublecontrast barium enema has been described by petty and mannion.1 the following similar cases were noted. case 1. a 73-year-old woman presented with abdominal pain. a double-contrast barium enema showed multiple pointed oval-shaped filling defects (fig. 1a, white arrows). on retrospective enquiry, the patient confirmed taking linseed regularly for constipation and also ingested grapes during the 3 days prior to the examination. the filling defects noted were not consistent with linseed size and shape, and most likely represent filling defects from grape seed. to simulate the picture of linseed and grape pip filling defects, linseeds (figs 1b and c), grape pips (fig. 1d) and liquid barium were placed in latex surgical gloves and xrayed to simulate double-contrast barium study. prior to the study, the linseeds and grape pips were soaked overnight in tepid water to account for natural seed swelling occurring during bowel transit. case 2: two cases of mealie pips simulating polyps (figs 2a c, white arrows) were seen during double-contrast barium enema studies. both male patients confirmed ingestion of mealies prior to the investigation. case 3: a 54-year-old-female patient underwent a double-contrast barium enema study for rectal bleeding and change in bowel habits folpotential pitfalls – pips or polyps? i van de werke, frcr a t du plessis, mb chb department of radiology, kalafong hospital, university of pretoria z lockhat, ffrad (d) department of radiology, pretoria academic hospital, university of pretoria fig. 1a. grape pips (arrows) simulating polyps. pictorial interlude fig. 1b. multiple linseed shadows during simulation in latex glove. fig. 1c. multiple linseed shadows during simulation in latex glove. fig. 1d. multiple grape pip shadows during simulation in latex glove. 28 sa journal of radiology • march 2006 pictorial interlude potential pitfalls pips or pol28 28 3/27/06 12:37:48 pm lowing strangulated incisional hernia repair. multiple small, irregular filling defects (fig. 3, white arrows) were noted in the dependent parts of the colon. the patient confirmed that large amounts of cashew nuts were ingested during the 2 days prior to the investigation. as illustrated by the above cases, seed and pip filling defects mimicking multiple polyps must be kept in mind when interpreting doublecontrast barium enema studies. this underlines the importance of proper history taking and retrospective enquiry about the dietary habits of patients, after identifying such filling defects during interpretation of double-contrast barium enema studies. 1. petty d, mannion r. case of multiple linseeds mimicking poliposis coli on double contrast barium enema. clin radiol 2003; 58: 87-88. fig. 2b. mealie pips (arrows) simulating polyps. fig. 3. chewed cashew nuts (arrows) simulating polyps.fig. 2c. mealie pips (arrows) simulating polyps. fig. 2a. mealie pips (arrows) simulating polyps. pictorial interlude 29 sa journal of radiology • march 2006 potential pitfalls pips or pol29 29 3/27/06 12:37:51 pm abstract introduction chemical shift imaging physics the role of opposed-phase imaging in various osseous and periarticular pathologies conclusion acknowledgements references about the author(s) vandana jahanvi department of radiodiagnosis, bharati vidyapeeth medical college, pune, india abhimanyu kelkar department of radiodiagnosis, bharati vidyapeeth medical college, pune, india citation jahanvi v, kelkar a. chemical shift imaging: an indispensable tool in diagnosing musculoskeletal pathologies. s afr j rad. 2021;25(1), a2061. https://doi.org/10.4102/sajr.v25i1.2061 pictorial review chemical shift imaging: an indispensable tool in diagnosing musculoskeletal pathologies vandana jahanvi, abhimanyu kelkar received: 07 dec. 2020; accepted: 01 mar. 2021; published: 06 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract chemical shift imaging (csi) is an important fat-suppression technique in magnetic resonance imaging (mri); it is used routinely in abdominal imaging to detect the presence of intralesional fat. its utility in musculoskeletal imaging has recently gained interest as a technique that is complementary to routine imaging. it is believed to aid in diagnosing and differentiating various osseous pathologies. this review describes the role of csi as an imaging technique for diagnosing various osseous and periarticular pathologies in different clinical scenarios. keywords: mri; chemical shift imaging; musculoskeletal; in-phase imaging; opposed-phase imaging; bone marrow. introduction magnetic resonance imaging (mri) is a sensitive imaging modality for the evaluation of bony lesions. it is frequently used after routine radiographs for the diagnosis of musculoskeletal disorders. the loss of normal fatty marrow can be the result of many pathologies, which can be focal or diffuse, benign or malignant. the diagnosis and differentiation of various marrow pathologies can be challenging and require the use of various sequences other than the routine t1and t2-weighted images, which include fat-suppression sequences, diffusion-weighted imaging, mr spectroscopy and post-contrast imaging. various fat-suppression techniques are available to aid in musculoskeletal imaging. these sequences include frequency-selective fat saturation techniques, inversion recovery, hybrid technique, chemical shift imaging (csi) and the related dixon-based approach.1 different techniques have their advantages and disadvantages, which make them suitable in various settings for different protocols and varying magnet strengths. chemical shift imaging with in-phase (ip) and opposed-phase (op) imaging is a routinely used sequence for the detection and characterisation of hepatic, renal and adrenal lesions.2 the use of csi in the diagnosis of localised and diffuse bone marrow lesions has recently become a topic of keen interest. however, there are still only a limited number of studies that highlight the importance of this technique in the assessment of musculoskeletal disorders. in this review, we aim to illustrate the utility of csi as a problem-solving tool for the identification of various osseous and periarticular pathologies. chemical shift imaging physics the main principle behind csi is that it utilises the difference in the precession frequencies of fat and water molecules. compared to water molecules, fat molecules have higher shielding of protons.3 thus, protons in fat molecules precess at a slightly lower frequency than protons in water.4 this frequency difference is known as the chemical shift effect. this effect is exploited during ip and op imaging in csi. the difference in phase between the images acquired at different echo times (te) is the basis of op imaging.5,6,7,8,9 the phase is the angle of magnetisation vector in the transverse plane. because fat and water protons have different precession frequencies, the phase of these protons, with respect to each other, changes a few milliseconds after the initial excitation.10 immediately after the excitation, fat and water protons are in-phase with each other. however, because fat protons precess at a slower rate compared to water protons, after a few milliseconds, the phase difference between them becomes 180°, that is, they become out of phase. a few milliseconds after the out-of-phase state, water protons complete a 360° rotation relative to fat protons; thus, they are again in-phase. the signals from the fat and water molecules add onto each other in the ip images. however, in the op images, the signal is the difference between the signals from the fat and water molecules. therefore, op imaging reduces or suppresses the signal from fatty tissue.10 at the margins between fat and non-fatty tissue, signals from adjacent water and lipids can be equal. this results in a signal void at the interface of fatty–normal tissue, which is termed the india ink artefact or black boundary artefact (figure 1).8 the op images can be recognised on account of this feature. figure 1: sequence comparison between in-phase (a) and opposed-phase (b) images. the opposed-phase image (b) is easily identified, owing to the india ink artefact that is present at the interface of the different anatomical structures (observed as a signal void [hypointensity]). because precession frequency and magnetic field strength are related, the te at which the ip and op images are acquired depends on the magnetic field strength. using the 1.5t scanner installed at our institute, the ip images are acquired at 4.6 ms and the op images at 2.3 ms. opposed-phase imaging is simple and quick. chemical shift imaging is mainly able to demonstrate microscopic or intracellular fat. the op images show a reduced signal from voxels that contain both fat and water. however, it does not suppress the macroscopic fat. the ability to demonstrate a small amount of fat and fat–water mixtures is the strongest advantage of this technique.5,7,8,9 on the other hand, imaging techniques such as short tau inversion recovery (stir) and spectral attenuated inversion recovery (spair) suppress only the macroscopic fat. because it is dependent on the phase difference between fat and water protons, this imaging technique is independent of static field heterogeneity. the role of opposed-phase imaging in various osseous and periarticular pathologies marrow lesions the maturation of normal marrow involves the replacement of red marrow with yellow marrow, which progresses in a centripetal fashion with a near-total loss of red marrow by adulthood.1 the reversal of marrow maturation in response to increased hematopoietic demand results in marrow reconversion. in adults, the chemical composition of yellow marrow is primarily fat, which is approximately 80% fat and 15% water. in contrast, red marrow contains approximately equal portions of fat and water (approximately 40% each).11 owing to this division in chemical composition, mr can sensitively detect marrow changes.12 fat-suppressed proton density-weighted images may show focal islands of reconverted red marrow, which may mimic neoplastic lesions.13 this occurs because red marrow exhibits incomplete suppression on routine fat-suppression sequences compared to yellow marrow. in csi, normal and reconverted marrow demonstrate a greater than 20% signal loss on op compared to ip images.9 this reduction in signal intensity is calculated by placing a region of interest (roi) in the involved area on the ip and corresponding op images. to determine if there is signal suppression, we determine the signal intensity ratio. this is calculated by dividing the signal intensity value at the roi on the op by the signal intensity at the roi on the ip images. red marrow islands in children appear as hyperintense areas on spair and stir images and may be confused with marrow oedema or marrow infiltrative disorders. because red marrow demonstrates signal suppression, this property is utilised at csi to differentiate it from other sinister pathologies; since they do not contain microscopic fat, there is no signal suppression on op images. similarly, in adult patients with marrow reconversion, csi may help us to differentiate this entity from marrow infiltrative disorders like leukaemia. this confusion arises because in both marrow infiltrative disorders and marrow reconversion, bone marrow appears hypointense on t1w images (in contrast to t1w hyperintensity in normal yellow marrow) and hyperintense on routine fat-suppressed images. chemical shift imaging may also help us to differentiate neoplastic versus non-neoplastic lesions depending on the amount of fat suppression at op imaging. if the signal loss is less than 20% on op images, this indicates replacement of normal fat, which could be the result of the presence of benign or malignant lesions in the marrow (figures 2 and 3).14 however, in a study on 50 patients with intermediate bone marrow lesions in the pelvis,15 it was determined that the criterion of less than 20% raises the suspicion for a malignant lesion; this approach allowed for the correct diagnosis of 27/27 malignant lesions and 14/23 benign lesions, which yielded 100% sensitivity, 61% specificity, 75% positive predictive value, 100% negative predictive value and 82% accuracy. figure 2: a 77-year-old man experienced back pain for two weeks. magnetic resonance imaging revealed marrow oedema (white arrow) involving the l1 vertebra on the t2w spectral attenuated inversion recovery (a) image. a horizontal fracture line (white arrowhead) was evident on the t1w image (b). by comparing the in-phase (c) and opposed-phase (d) images, it was determined that the decrease in signal intensity on the opposed-phase image was 71% (>20%), which ruled out an underlying small metastatic lesion. the final interpreted diagnosis was that of an osteoporotic compression fracture. figure 3: vertebral metastases. a 67-year-old man complained of back pain for 1 month. magnetic resonance imaging showed multiple areas of abnormal signal within the thoracolumbar vertebrae, which were hyperintense on coronal t2w spectral attenuated inversion recovery (a) images. by comparing the in-phase (b, d) and opposed-phase (c, e) images, it was determined that the decrease in signal intensity on the opposed-phase images was 13% and 10% (<20%) at two different vertebral levels, which indicated the probability of metastases. upon screening the abdomen, it was observed that the patient also had multiple lesions in the spleen (white arrowhead) and a lesion in the liver within segment vi (white arrow), as seen on the axial t2w spectral attenuated inversion recovery image of the abdomen (f). we therefore concluded that the vertebral lesions were metastases. however, the patient did not undergo a biopsy. healed and active neoplastic lesions after chemoradiotherapy (e.g. metastasis or myeloma) may appear similar when conventional mr imaging is used, which may cause confusion. healed lesions exhibit intraor perilesional fatty signal intensity on csi. by identifying otherwise inconspicuous fat on op imaging, one can avoid misdiagnosing these lesions as active lesions and correctly guide patient management.1 fractures trabecular fractures may be masked on fat-suppressing techniques (such as stir) owing to marrow oedema, but can be identified at op imaging. it is believed that op imaging is more sensitive than conventional pd-weighted (proton-density) and t1-weighted imaging in demonstrating trabecular distortion and the extent of microfractures (figure 4).1 in addition, csi can differentiate between benign and pathologic fractures by the loss of signal on op imaging.16,17 in pathologic fractures, the signal loss is believed to be less than 20%. figure 4: trabecular fracture, better demonstrated by chemical shift imaging. computed tomography (ct) and magnetic resonance imaging of a patient with trauma to the knee. no obvious fracture line was observed at ct (a). on the proton-density-weighted spectral attenuated inversion recovery image (b), an irregular vertical hyperintensity was present with associated marrow oedema (white arrow). on the opposed-phase image (c), a clear irregular zigzag vertical fracture (white arrowhead) was seen. subchondral degenerative changes and -epi-metaphyseal lesions cartilaginous end-plate contour changes are observed on op images with good differentiation of cartilage from the bone (figure 5). figure 5: degenerative changes. a 49-year-old female presented with a history of chronic right knee pain. the proton-density-weighted spectral attenuated inversion recovery image (a) showed areas of subchondral hyperintensity, which was suggestive of marrow oedema. on the t1w (b) image, subchondral marrow hypointensity was observed. on the opposed-phase image (c), thinning of the cartilage (white arrows) at the site of the subchondral signal change was observed, which was consistent with changes of osteoarthritis. subcortical cysts or geodes may sometimes mimic more sinister epiphyseal lytic lesions, including giant cell tumours and chondroblastoma. moreover, in children, islands of red marrow (figure 6) at the epi-metaphysis may be confused with marrow pathologies. the presence of fat within lesions helps to confirm benign aetiology. figure 6: differentiating islands of red marrow from other sinister pathology. a 10-year-old boy presented with a 10-day history of pain and swelling over the left ankle. magnetic resonance imaging showed soft tissue oedema (white arrow) over the medial aspect of the tibia on the axial proton-density-weighted (pdw) spectral attenuated inversion recovery (spair) image (a). areas of hyperintensity were observed on pdw spair (b) within the epiphysis and metaphysis of the distal tibia (white arrowhead). on comparing the in-phase (c) and opposed-phase (d) images, it was determined that the decrease in signal intensity on the opposed-phase images was 55% (>20%), which suggested the presence of red marrow and ruled out any sinister intraosseous pathological lesions such as osteomyelitis. avascular necrosis and sclerotic foci the zones of avascular necrosis (avn) and sclerosis are easily appreciated on op images with a clear demarcation of the infarcted marrow.1 figure 7 demonstrates how the op image (figure 7c) clearly delineates the infarcted marrow in avn of the right femoral head. similarly, figure 8 illustrates the utility of op imaging (figure 8c) in demarcation of an infarcted lunate bone in kienbock’s disease. figure 7: avascular necrosis of the right femoral head. a 28-year-old man presented with pain in the right hip over a period of 3 months. the t1w image (a) showed subchondral hypointensity (white arrow) and contour irregularity of the right femoral head. on the proton-density-weighted spectral attenuated inversion recovery (b) image, hyperintensity was observed within the involved bone, which was suggestive of marrow oedema. the opposed-phase image (c) revealed a clear demarcation of the infarcted zone. figure 8: kienbock’s disease. a 32-year-old man underwent magnetic resonance imaging of the left wrist for the evaluation of chronic pain. the t1w image (a) revealed hypointensity (white arrow) within the lunate; the proton-density-weighted spectral attenuated inversion recovery (b) image indicated hyperintensity (white arrowhead), which was suggestive of marrow oedema. the opposed-phase image (c) revealed a clear flattening of the lunate bone, with the sclerosed bone (white asterisk) demonstrating considerable hypointensity. pigmented villonodular synovitis paramagnetic effects owing to iron accumulation within tissues distort magnetic field microenvironments, with a resultant loss of signal intensity in the affected organs. this signal loss is proportional to the severity of iron deposition and other metallic structures.18 in csi, there is a decrease in signal intensity in the affected tissues on images with longer te, primarily owing to the t2* decay.17 this typically results in increased signal intensity on op (te, 2.3 ms) images compared to ip (te, 4.6 ms) images, which is the opposite of what is observed with fat deposition.1 this occurs because the longer te in the ip sequence allows protons more time to dephase, and hence paramagnetic substances show a decrease in signal intensity in this sequence. thus, there is an apparent increase in signal on the op sequence. hence, the detection of pigmented villonodular synovitis (pvns) is possible on op images (figure 9). similarly, marrow hemosiderosis, hemarthrosis and haemophiliac arthropathy (hemosiderin deposition in synovium) can be detected on op images. figure 9: pigmented villonodular synovitis. a 19-year-old male presented with a history of right knee pain. the t2 gre (gradient echo) image (a) showed hyperintense nodular soft tissue in hoffa’s fat pad with a few areas of peripheral blooming on the gre image (white arrow). at chemical shift imaging, the signal intensity of the nodular soft tissue was lower on the in-phase image (b) compared to the opposed-phase image (c), confirming the diagnosis of nodular pigmented villonodular synovitis. conclusion chemical shift imaging is an important imaging technique that helps to assess various bony pathologies. it aids in detecting and differentiating osseous lesions owing to added tissue contrast without a significant increase in imaging time. chemical shift imaging could therefore be included as a routine imaging sequence when performing mri for musculoskeletal disorders. acknowledgements the authors are deeply indebted to dr priscilla joshi, professor and head of the department of radiodiagnosis, bharati vidyapeeth medical college, pune, for her affectionate guidance, meticulous attention and invaluable cooperation during the preparation of this pictorial essay, which helped the authors proceed in the right direction. the authors thank dr anand rahalkar and dr mangal mahajan for their support and encouragement. the authors are grateful to all the staff of the department of radiodiagnosis, bharati vidyapeeth medical college, pune, for their unconditional and timely help. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.k. conceptualised this article. he supervised the data collection and reviewed and edited the final draft of the manuscript. v.j. collected the relevant data and reference articles, and prepared the primary manuscript draft. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references pezeshk p, alian a, chhabra a. role of chemical shift and dixon based techniques in musculoskeletal mr imaging. eur j radiol. 2017;94:93–100. https://doi.org/10.1016/j.ejrad.2017.06.011 haider ma, ghai s, jhaveri k, lockwood g. chemical shift mr imaging of hyperattenuating (> 10 hu) adrenal masses: does it still have a role? radiology. 2004;231(3):711–716. https://doi.org/10.1148/radiol.2313030676 del grande f, santini f, herzka da, et al. fat-suppression techniques for 3-t mr imaging of the musculoskeletal system. radiographics. 2014;34(1):217–233. https://doi.org/10.1148/rg.341135130 bley ta, wieben o, françois cj, et al. fat and water magnetic resonance imaging. j magn reson imag. 2010;31(1):4–18. https://doi.org/10.1002/jmri.21895 yamashita y, torashima m, hatanaka y, et al. value of phase-shift gradient-echo mr imaging in the differentiation of pelvic lesions with high signal intensity at t1-weighted imaging. radiology. 1994;191(3):759–764. https://doi.org/10.1148/radiology.191.3.8184059 mitchell dg, kim i, chang ts, et al. fatty liver: chemical shift phase-difference and suppression magnetic resonance imaging techniques in animals, phantoms, and humans. investig radiol. 1991;26(12):1041–1052. https://doi.org/10.1097/00004424-199112000-00002 mitchell dg, crovello m, matteucci t, et al. benign adrenocortical masses: diagnosis with chemical shift mr imaging. radiology. 1992;185(2):345–351. https://doi.org/10.1148/radiology.185.2.1410337 earls jp, krinsky ga. abdominal and pelvic applications of opposed-phase mr imaging. am j roentgenol. 1997;169(4):1071–1077. https://doi.org/10.2214/ajr.169.4.9308467 disler dg, mccauley tr, ratner lm, et al. in-phase and out-of-phase mr imaging of bone marrow: prediction of neoplasia based on the detection of coexistent fat and water. am j roentgenol. 1997;169(5):1439–1447. https://doi.org/10.2214/ajr.169.5.9353477 delfaut em, beltran j, johnson g, et al. fat suppression in mr imaging: techniques and pitfalls. radiographics. 1999;19(2):373–382. https://doi.org/10.1148/radiographics.19.2.g99mr03373 małkiewicz a, dziedzic m. bone marrow reconversion–imaging of physiological changes in bone marrow. pol j radiol. 2012;77(4):45. https://doi.org/10.12659/pjr.883628 berg bc, malghem j, lecouvet fe, et al. magnetic resonance imaging of the normal bone marrow. skelprocessetal radiol. 1998;27(9):471–483. https://doi.org/10.1007/s002560050423 del grande f, farahani sj, carrino ja, et al. bone marrow lesions: a systematic diagnostic approach. indian j radiol imag. 2014;24(3):279. https://doi.org/10.4103/0971-3026.137049 zajick jr dc, morrison wb, schweitzer me, et al. benign and malignant processes: normal values and differentiation with chemical shift mr imaging in vertebral marrow. radiology. 2005;237(2):590–596. https://doi.org/10.1148/radiol.2372040990 kohl ca, chivers fs, lorans r, et al. accuracy of chemical shift mr imaging in diagnosing indeterminate bone marrow lesions in the pelvis: review of a single institution’s experience. skeletal radiol. 2014;43:1079–1084. erly wk, oh es, outwater ek. the utility of in-phase/opposed-phase imaging in differentiating malignancy from acute benign compression fractures of the spine. am j neuroradiol. 2006;27(6):1183–1188. eito k, waka s, naoko n, makoto a, et al. vertebral neoplastic compression fractures: assessment by dual-phase chemical shift imaging. j magn reson imag. 2004;20(6):1020–1024. https://doi.org/10.1002/jmri.20213 westphalen ac, qayyum a, yeh bm, et al. liver fat: effect of hepatic iron deposition on evaluation with opposed-phase mr imaging. radiology. 2007;242(2):450–455. https://doi.org/10.1148/radiol.2422052024 (~ase repoi~t metastatic osteosarcoma in the inferior vena cava and the right atrium abstractw.). burger mbchb (stell) registrar at uofs osteosarcoma commonly metastasize to the lung, lymph nodes, liver and brain. in this case we describe a rare presentation of direct infiltration, by an osteosarcoma, of the iliac veins that continued into the inferior vena cava (tv'c)and cou id be seen up to the right atrium. introduction osteosarcoma metastases are common and may often present in an uncommon place and fashion. metastatic cardiac tumours are more common than primary sarcomas of the heart. the incidence is higher in children and young adults and the commonest tumours to metastasize are wilms' tumours and neuroblastomas. other abdominal tumours, including secreting and non-secreting adrenal tumours, retroperitoneal sarcomas, hepatocellular carcinomas, teratomas and lymphomas, can involve the ive. 10 sa journal of radiologyaugust 2000 there have been reports of metastatic osteosarcomas involving the ivc and cardiac chambers. case report a 31-year-old black woman from lesotho, southern africa, presented with a local recurrence of osteosarcoma in her right leg approximately a year-and-a-half after initial diagnosis. the patient had an above knee amputation in december 1998. oneand-a-half years later she presented with a swollen, firm amputation stump of her right leg. the patient looked chronically ill. the stump showed two small ulcers and a hard mass that could be palpated up to the inguinal area. the patient also had decreased movement of her right hip and on vaginal examination the uterus was immobile. a vague abdominal mass could be felt in the right lower quadrant. no clear lymphadenopathy was found but the patient was slightly anaemic clinically. previous medical history the patient presented in december 1998 with a swollen mass in her right distal femur that was histologically confirmed to be an osteosarcoma and an above knee amputation was performed. she received chemotherapy. initially the chest xray showed no metastases, but she presented three months later with a single pulmonary nodule in her left lung. a metastatectomy was performed. due to financial constraints , the patient was unable to attend the follow-up oncology clinic and presented only six months later with a local recurrence in the area proximal to the amputation of her right leg. a to page 11 metastatic osteosarcorna in the inferior vena cava and the right atrium (rom page 10 chest x-ray also showed new lung metastases in the right lung. (fig. 1) the tumour was deemed to be unresectable and the patient received three courses of chemotherapy with mixed response. again the patient had financial difficulty and only arrived at the oncology clinic four months later. initially, a scintigram was done that was normal. the fbc, smac,vdrl, and hiv blood tests were normal. on the patient's last admission the chest x-ray showed three metastatic nodules in the right lung. fig. 2 pre-contrast ct pelvis. (a) the initial pre-contrast ct shows a mass with minimal calcifications in the right inguinal area. there are already signs of infiltration of the right femoral vein and collateral veins. fig. 1 chest x-ray with a single metastatic nodule in the right lung. a ct chest, abdomen and pelvis was done before and after intravenous contrast, using a ge spiral scanner with 7 mm slices and a pitch of 1,7. oral gastrografin was also administered one hour before the examination. the ct showed extensive local infiltration of the recurring osteosarcoma in the right upper thigh, inguinal area and right pelvis. it was easily identified by the characteristic calcifications of the osteosarcoma. the bladder, uterus and rectum were displaced to the left. (fig.2) tumour thrombus filled the iliac vein and the ivc and could be traced up to the right atrium. there was clear (b) six months later the ct was repeated and extensive infiltration into the soft tissue, right femoral vein and collateral veins are seen. the characteristic osteoid calcifications of osteosarcoma are easily identified. expansion of the ivc, especially in the upper abdomen. infiltration of the ivc wall and extension beyond could not be excluded on ct. on the pre-contrast study the tumour thrombus was filled with calcifications. the tumour thrombus could be seen as a hypodense filling defect, mixed with calcifications in the ivc on the post contrast studies. the tumour also infiltrated the collateral veins (ascending lumbar veins) that could be seen displacing the right psoasmuscle ventrally.dilated collateral 11 sajournal of radiologyaugust 2000 veins could be seen throughout the abdomen. there was also hydro-nephrosis and hydro-ureter seen in the right kidney. the right kidney showed a decrease in contrast enhancement and a venous infarct was suspected. (figj) the spleen and portal vein appeared to be prominent. the ct chest showed eight small metastatic nodules (fig.4), in both the upper and lower lobes of the right lung. there were some postoperative pleuritic changes on the left from the previous metastatectomy. no clear infiltration of the endocardium of the right atrium could be shown. a prominent azygos vein was seen in the posterior mediastinum. no pleural effusion, liveror kidneymetastases could be seen. an ultrasound of the abdomen was done that confirmed the hydro-nephrosis of the right kidney and fig. 3 post-contrast ct abdomen. an under enhanced right kidney with a dilated renal pelvis and a degree of hydro-nephrosis could be seen. topags 12 metastatic osteosarcorna in the inferior vena cava and the right atrium /' -,~"-,'''', ,, ". ~ ~~. ' ~/ discontinuous tumour foci may be seen in bone marrow in up to 10%. other rare sites include the kidneys,' skeletal muscles' and the nc and heart.' an isolated brain metastases of osteosarcoma in a patient presenting with a patent foramen ovale has been reported.' tumour extension to the ive represents an important complication in abdominal carcinomas, although very rare in osteosarcomas. the pre-operative diagnosis of vena caval and cardiac involvement is an important consideration in surgical planning and future treatment. the surgical approach and procedure are dependent on the level of superior extension of the tumour thrombus. the following points should be clarified before surgery: • whether the nc is involved by tumour thrombus and, if so, the nature of the primary tumour; • the cranial limit of the tumour thrombus extension, whether it involves the intra-hepatic ive, the hepatic veins, or the right atrium; and • the presence or absence of tumour invasion of the wall of the nc 6 in patients with musculoskeletal malignancies, thrombosis of the ive may occur secondary to compression by adjacent adenopathy or by a paraneoplastic hypercoagulable state. direct extension of the bone tumours into adjacent vessels is, however, rare. the site of tumour entrance into the vessels is not definitely known, although some speculate that with bone tumours the malignant cells enter the fig. 4 post-contrast ct chest. a single metastatic nodule is seen on this slice in the right lung. the tumour thrombus extending into the right ventricle could also be seen. also showed a thrombus in the nc, stretching the whole of the ivc the thrombus could be visualised in the right atrium. discussion osteosarcoma is the most common tumour of bone in adolescents and young adults and the second most common primary bone tumour after multiple myeloma. it accounts for approximately 15% of all primary bone tumours confirmed at biopsy. there are numerous types of primary osteosarcomas, including intra medullary (high grade, telangiectatic, low grade, small cell, osteosarcornatosis, and gnathic), surface (intracortical, parosteal, periosteal and high grade surface), and extra-skeletal. i approximately 2% of patients have metastases at presentation with osteosarcoma. the most common site for metastases is the lung (15%) via hematogenous spread. other sites include lymph nodes, liver and brain. the metastatic lesions may be calcified, although this is rare (10%). unlike ewing's sarcoma, skeletal metastases are uncommon (< 1%). 12 sajournal of radiologyaugust 2000 veins via intramedullary channels within the bone similar to the entrance route of normal blood-forming elements." since the number of patients who benefit from relapse therapy is still low, it remains to be shown whether an increased frequency of lung c'lscans or mrls of the primary tumour site will improve early detection of relapse and, if so, whether that will enhance the chance for successful relapse treatment. chest x-rays, lung ct and a clinical examination should be performed routinely for at least three years after completion of therapy or relapse diagnosis. in contrast, bone scintigraphy and local xrays appear not to be useful as routine follow-up investigations.' references 1, atra a, shankar ag, padhani ar, metastatic cardiac osteosarcoma imaging features, the british journal of radiology 1998' 71:336339. ' 2, ogose a, morita t, emura i, nemoto k hirata y. osteosarcoma metastatic to th~ kidneys without lung involvement [review [. japanese journal of clinical oncology 1999; 29(8):395-398, 3, pe~ wc, shek tw, wang sc, wong jw, chien ep, osteogenic sarcoma with skeletal muscle metastases, skeletal radiology 1999· 28(5):298-304. ' 4, giuliano ct, kauffman wm, haller jo, fletcher bo, rao sp, inferior vena cava-right atrium tumour thrombus in malignant pelvic bone tumours in children, paediatric radiology 1992; 22:206-208. 5. menassa l, haddad s, aoun n, slaba s, atallah n. isolated brain metastases in a patient with a patent foramen ovale, european radiology 1997; 7(3):365-7. 6, didier 0, racle a, etienvent jp, weill f. tumour thrombus of the inferior vena cava secondary to malignant abdominal neoplasms: us and ct evaluation, radiology 1987;162:83-89. 7. korholz d, verheyen j, kemperdick hf, gobel u. evaluation of follow-up investigations in osteosarcoma patients: suggestions for an effective follow-up program. medical and paediatric oncology 1998; 30(1): 52-8. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) mohammed y. tahir department of telehealth, college of health sciences, school of nursing and public health, university of kwazulu-natal, durban, south africa medical imaging informatics isid, king abdulaziz medical city, jeddah, saudi arabia maurice mars department of telehealth, college of health sciences, school of nursing and public health, university of kwazulu-natal, durban, south africa richard e. scott department of telehealth, college of health sciences, school of nursing and public health, university of kwazulu-natal, durban, south africa department of community health sciences, cumming school of medicine, university of calgary, calgary, canada citation tahir my, mars m, scott re. a review of teleradiology in africa – towards mobile teleradiology in nigeria. s afr j rad. 2022;26(1), a2257. https://doi.org/10.4102/sajr.v26i1.2257 review article a review of teleradiology in africa – towards mobile teleradiology in nigeria mohammed y. tahir, maurice mars, richard e. scott received: 29 july 2021; accepted: 18 oct. 2021; published: 11 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract ehealth is promoted as a means to strengthen health systems and facilitate universal health coverage. sub-components (e.g. telehealth, telemedicine, mhealth) are seen as mitigators of healthcare provider shortages and poor rural and remote access. teleradiology (including mobile teleradiology), widespread in developed nations, is uncommon in developing nations. decisionand policy-makers require evidence to inform their decisions regarding implementation of mobile teleradiology in nigeria and other sub-saharan countries. to gather evidence, scopus and pubmed were searched using defined search strings (september 2020). duplicates were removed, and titles and abstracts reviewed using specified selection criteria. full-text papers of selected resources were retrieved and reviewed against the criteria. insight from included studies was charted for eight a priori categories of information: needs assessment, implementation, connectivity, evaluation, costing, image display, image capture and concordance. fifty-seven articles were identified, duplicates removed and titles and abstracts of remaining articles reviewed against study criteria. twenty-six papers remained. after review of full-texts, ten met the study criteria. these were summarised, and key insights for the eight categories were charted. few papers have been published on teleradiology in sub-saharan africa. teleradiology, including mobile teleradiology, is feasible in sub-saharan africa for routine x-ray support of patients and healthcare providers in rural and remote locations. former technical issues (image quality, transmission speed, image compression) have been largely obviated through the high-speed, high-resolution digital imaging and network transmission capabilities of contemporary smartphones and mobile networks, where accessible. comprehensive studies within the region are needed to guide the widespread introduction of mobile teleradiology. keywords: teleradiology; mobile teleradiology; cellphone; nigeria; developing country. introduction ehealth, the cost-effective and secure use of information and communication technologies (icts) for health and health-related fields,1 can contribute to health systems’ strengthening in several ways. it can improve the availability, quality and use of information and evidence through strengthened health information systems and public health surveillance systems, as well as increase access to healthcare services by reducing distance and time barriers through telemedicine. this is particularly beneficial for rural and underserved communities in developing countries – groups that traditionally suffer from a lack of access to healthcare.2 the term ehealth, more recently digital health, is an umbrella term that covers a variety of activities such as: e-commerce (the business side), e-learning (the training – awareness, teaching, instruction, and education – side), health informatics (the data gathering, storage, analysis, and distribution side), and telehealth including telemedicine (the interactive – real-time or store-and-forward – side).3 more recent applications such as mhealth, the use of mobile devices such as cell phones, can incorporate elements of each.2 one such use is teleradiology. the benefits of teleradiology include earlier diagnosis, leading to quicker treatment and better patient care, and ultimately less burden on the healthcare system, plus less travel and reduced expense for the mainly poverty stricken, rural population and especially for the chronically ill.4 however, conventional radiology is still common in the developing world. the evolution of conventional radiology to digital radiology and then to teleradiology has also been described.4 with the advent of the internet, www, smartphones and cellular networks, teleradiology and mobile teleradiology have emerged. teleradiology is the electronic capture (using digital detectors or digital photography of x-ray films), transmission (from one location to another), storage (often within erecords) and retrieval and display (on monitors) of radiological patient images. mobile teleradiology is effectively teleradiology facilitated through the use of mobile devices, primarily smartphones, although related approaches using instant messaging (e.g. whatsapp) are becoming popular.5 regardless, these approaches allow for simultaneous sharing of images with other clinicians in other locations, obviating lost images and facilitating remote interpretation and consultation. if not ubiquitous, teleradiology is at least considered ‘widespread throughout modern radiology practice’6 and to be amongst the most established and widely used telemedicine specialties.4 nigeria, located in west africa, is the most populous country in africa and seventh in the world with a population of 206.1 million in 2020 spread across 923 768 km2,7 with 48.8% of people living in rural areas in 2019.8 health indicators in nigeria are some of the worst in africa. the country has faced constant health threats because of civil unrest and a lack of adequate funding, deteriorating healthcare facilities, concentration of healthcare providers and services in urban centres, poor patient access to healthcare and inadequate numbers of healthcare providers.2,9 private healthcare providers have filled some gaps and account for up to 70% of health services coverage in nigeria, with limited involvement of non-government organisations (ngos).9 indeed, the sub-saharan africa (ssa) region averages fewer than 22 doctors per 100 000 people, and 14 countries within the region do not have a single radiologist, whilst nigeria has just 250–300 or about one radiologist for every 600 000 people.2,9 nigeria has one of the fastest growing populations globally, estimated to reach 440 million people by 2050. the country’s healthcare system is organised into primary, secondary and tertiary healthcare levels.9 the local government areas (lgas) are responsible for primary healthcare, the state governments are responsible for providing secondary care and the federal government is responsible for policy development, regulation, overall stewardship and providing tertiary care.9,10 this pre-existing situation is now compounded by the impact of coronavirus disease 2019 (covid-19), with nigeria being one of the first nine african countries reporting cases by the first week of march 2020.11 similar to many countries, the pandemic has caused greater socioeconomic hardship, further stretching of its ill equipped and underprepared healthcare system, rising misand dis-information negatively impacting behaviour and impaired access to essential medicines potentially worsening chronic conditions.12,13,14 amidst this disarray, practical solutions to address known health needs are required. in nigeria, because of the scarcity of radiologists, many imaging investigations are performed and interpreted by hospital medical officers or perhaps radiographers.15 for example, at zambuk general hospital in zambuk, gombe state (north-eastern nigeria, ~450 km from abuja), when a medical officer requests an x-ray study, the patient is referred to the radiology department. there, they will be charged a fee for the imaging procedure only. after the x-ray study is completed, the patient takes the films back to the medical officer who then decides whether or not a radiologist’s report is needed. if a report is required, the patient must make up to a 100 km round trip to the state capital, gombe city, for the film to be reported and pay a fee for the report. teleradiology would avoid patient travel, reduce out of pocket travel expenses, provide more rapid diagnosis and improve diagnostic accuracy and reliability. this may also reduce patient transfer, re-hospitalisation and length of in-hospital stay. although teleradiology has been used in the developing world, it remains relatively rare in nigeria.2,9 given the proven benefits of teleradiology, and the scarcity and maldistribution of radiologists, growing populations, the challenges of poor health and the still developing technological infrastructure in developing countries, is teleradiology, particularly mobile teleradiology, a feasible and suitable solution, in particular for nigeria? whilst many clinical modalities of radiology exist (e.g. ultrasound [us], computerised tomography [ct], magnetic resonance imaging [mri]), this paper is focused on mobile teleradiology for routine x-rays within ssa. the aim of this study was to review the literature on contemporary applications of teleradiology in african countries and to provide insight and perspective upon which to base informed decisions on if and how mobile teleradiology could be implemented in nigeria. methods for this scoping review, a series of focused searches of scopus and pubmed were performed in september 2020 (m.y.t. and m.m.). the pubmed search string was (‘radiology’ [mesh] and ‘telemedicine’ [mesh]) or teleradiology [all fields]) or ‘mobile teleradiology’ or ‘mobile tele-radiology’ or (‘radiology’ [mesh] and [mhealth or m-health or ‘mobile health’]) and ‘africa’ [mesh], and in scopus, the following search string was used (title-abs-key [radiology and telemedicine] or teleradiology or ‘mobile teleradiology’ or ‘mobile tele-radiology’) or title-abs-key (radiology and [mhealth or m-health or ‘mobile health’]) and title-abs-key [africa]). duplicates were removed. all authors then reviewed titles and abstracts applying the following inclusion criteria: english language, resource addressed use of teleradiology in africa. papers were excluded if they were published before 2009 (to ensure currency in this rapidly evolving area) or primarily addressed more sophisticated imaging approaches: picture archiving and communication system (pacs), ct, mri, us or nuclear medicine (nm). any disagreements were resolved by consensus. full papers of remaining resources were retrieved, and each paper again reviewed applying the inclusion and exclusion criteria, with disagreements resolved by consensus. data from the final selected resources were charted into an excel spreadsheet (microsoft® excel®; redmond, washington, united states) by two authors (m.y.t. and r.e.s.) and cross-checked. charted data included citation details (authors, title, year), country or region and insight provided regarding eight a priori categories: needs assessment, implementation, connectivity, evaluation, costing, image display, image capture and concordance. ethical considerations approval was provided by the humanities and social sciences research ethics committee, university of kwazulu-natal; protocol reference number – hss/0508/017d. results a total of 59 articles were generated from the searches (figure 1). ten met the inclusion criteria for the study after a full-text review.16,17,18,19,20,21,22,23,24,25 these papers examined aspects of teleradiology from throughout ssa,16,24 regions (west africa)25 or specific countries: angola,19 ethiopia,20 malawi,21 mali,18 south africa17 and zambia.23 the study in one paper was performed in the united states but was intended to emulate the setting and process in botswana and was included.22 each paper was reviewed, summarised and the presence of insight regarding the eight categories noted (table 1); the results for each category are presented below. figure 1: preferred reporting items for systematic reviews and meta-analyses (prisma) flowchart for literature search. table 1: summary of each resource and presence of material relevant to the eight categories. after a preliminary review of the papers, major findings under the eight categories were charted independently by two authors (m.y.t. and r.e.s.). the findings were jointly reviewed and finalised by consensus and are reported below. needs assessment needs assessment has been described as a systematic process for determining the gap between the current condition and the desired condition (called a need) and how to address the need and close the gap.26 no retrieved paper provided such a structured needs assessment although most identified human resource shortages (even an absence of radiologists in some countries), implying a self-evident need. for example, one identified teleradiology as a ‘viable option to alleviate radiologist shortages in underserved areas’.17 implementation implementation was described as the process of putting a decision or plan into effect, describing the step-by-step stages of execution for the plan. no paper provided such a structured description for a project or intervention programme. simplistic descriptions of some aspects of an intervention for implementations were noted. thus, the provision of required infrastructure (internet access and a digital camera) was described to initiate a low-cost telemedicine service linking doctors at hospitals in the developing world with volunteer consultants in the developed world.17 three papers described clearer examples of implementation18,19,20 although specific implementation plans were not described. the first addressed a national teleradiology programme in mali, which required 3–6 months for implementation, undertaking local consultation, training, installation of very small aperture terminal (vsat) antennae at three remote hospitals and testing of connectivity. the importance of local management and ownership was highlighted.18 the second described how the implementation of a low-cost digital x-ray device was feasible in low resource settings and included a computer system and software configuration and installation, as well as a training course for local staff in local languages.19 the third described an unsuccessful implementation in ethiopia and highlighted lessons learnt related to implementation, including the importance of peripheral issues such as e-government readiness, enabling policies, multi-sectoral involvement and capacity building processes, as well as more practical issues such as understanding existing referral practice and experiences, developing guidelines and ensuring ict security protocols are established.20 connectivity papers were examined to determine whether a description was provided of the mode of connection between the source of the image and a reporting station. six papers addressed connectivity,16,17,18,19,20,21 with e-mail as the predominant mode using transmission through broadband, cellular networks, vsat, asymmetric digital subscriber line (adsl) or dial-up internet access, either transmitted directly, to a website, or using a virtual private network (vpn). one described the use of a slow internet connection and downloading of images in compressed format and e-mail to send them for reporting as an attachment.17 another described evolution from the use of e-mail to a web-based telemedicine service that allowed data uploading and downloading directly to and from the website with e-mail used only for creating notification alerts.21 a third paper examined use of jpeg radiographic images sent by e-mail as jpg files to reduce file size.16 other options used in mali included broadband connectivity or, for remote sites, vsat.18 in ethiopia, transmission of images initially used dial-up internet access, but this frequently experienced ‘download time expired’ errors. this was subsequently resolved using open source software that collated and compressed a minimal clinical dataset for transmission.20 finally, in angola, an existing adsl internet connection using a secured vpn was used for file transfer.19 evaluation evaluation was considered to be a formal process by which a body of information was systematically gathered and used to make a judgement about the overall value of a teleradiology intervention. although several papers spoke of ‘evaluation’, none provided a detailed and structured description for a project or programme evaluation. an ‘evaluation’ for a teleradiology programme training course noted that those actually taking the x-rays but who were not trained radiographers, gained little from the course as they lacked the necessary background knowledge.17 another paper ‘evaluated’ the success of a teleradiology programme by simply observing that it ‘provide[d] care to an underserved population in a cost-efficient way that surpasses the many existing technical, legal and language barriers, leads to improved outcomes and shows promise for sustainability’.16 a review of the national teleradiology programme in mali found that it improved the diagnosis of patients and improved the referring doctor’s ability to give an accurate diagnosis.18 use of the teleradiology service varied widely between hospitals and successful implementation depended on local ownership and close collaboration of stakeholders. a survey conducted as part of the review of the mali programme identified benefits of teleradiology as better patient diagnosis (91%), improved treatment (30%), opportunity for learning for healthcare personnel (39%), time and cost savings for patients (31%) and better rural healthcare (26%). challenges were identified as unreliable internet connections (42%), conflicts (8%), insufficient support from hospital directors (20%) and the cost of the service to patients (12%). it was noted that referral for specialist diagnosis was simply too difficult (up to 1000 km on insecure roads) and prohibitively expensive for many patients (with over 40% of the population living below the international poverty line of $1.25 per day).18 although not a formal evaluation, one study assessed the diagnostic accuracy of digital photographs of plain film chest x-rays (cxrs) obtained using a mobile phone and demonstrated non-inferiority with plain film cxrs. the authors noted this finding had important implications for resource-constrained countries with limited access to radiologists.22 findings from a telemedicine implementation (which included a teleradiology component) concluded there is no perfect ‘one-size-fits-all’ technology and local context and non-technological factors are influential.20 finally, an angolan study ‘evaluated’ local feasibility of digital radiology by examining implementation difficulties, continued on-site training needs, maintenance difficulties over two years, changes in work volumes over time and x-ray quality (assessed by two external radiologists).19 costing costing was described as evidence of a structured process being undertaken to determine the expense incurred in establishing a teleradiology program. five papers addressed some aspects of cost,16,18,19,20,23 but none used a formal costing (e.g. activity-based costing) or economic evaluation (e.g. cost–benefit analysis) method. simple low-cost solutions have been successfully employed although in 2011 and 2015 the capital cost of technology remained a major barrier.17,18 one hospital charged patients 1500.00 – 2500.00 west african cfa franc (approximately $2.00 – $5.00) to cover technician allowance, electricity, internet connection, technology maintenance and a small payment to the radiologist, whilst a private health clinic charged about $8.00 to a mining company for routine cxrs and emergency procedures.18 the opportunity cost of telecom services was noted in an ethiopian study (competing with basic priorities such as food, clothing and school fees) that made internet and mobile phones unaffordable although increasing penetration rates of mobile technology in ssa may ease this.20 a fourth paper highlighted how donations from faith-based organisations could fund initial setup costs, with an ongoing equipment service contract largely offset by savings on film, processing chemicals, film bags and storage.23 this was supported by another paper that noted their initial digital radiology investment (considered ‘much more affordable’ as equipment costs dropped over time) was paid back in two years by eliminating the need for radiographic films and reagents and might even provide a net cost saving in the middle to long term.19 image display papers were examined to determine whether they described the means by which visual presentation of images was achieved. four papers provided some insights. importantly, one report noted that ‘several studies’ have shown jpeg images obtained by digital photography of film radiographs, using limited image compression, were sufficient for diagnosis in most instances.21 shiferaw and zolfo also reported taking photographs of radiographs with a camera, using natural light on a white glared window, produced good-quality images.20 similarly, a third paper reported that diagnostic accuracy of common pathologies and normal findings in cxrs was comparable using a light box for viewing of films compared to photographs taken by a digital camera.22 another paper also noted image visualisation time was reduced to about half when images were viewed on a 1600 × 900 dots per inch (dpi) monitor versus traditional viewing, due to the higher resolution.19 image capture for capture, papers were required to describe the means by which images were captured for transfer to or from a device connected to the computer or the network. eight papers described elements related to this, with noted approaches including the use of digital cameras, document scanners, specialised digitisers or computerised radiography systems that directly produced digital images.17,18,19,20,21,22,24,25 use of digital cameras was common,16,18,21,22,24 but only one paper specifically identified the use of a phone-based digital camera.22 concordance for concordance, papers were expected to describe formal and focused assessments of the degree of clinical agreement obtained when using teleradiology or mobile teleradiology versus traditional radiology. none of the papers provided any description of formal ‘concordance studies’ although equivalence or diagnostic accuracy was assessed. one study addressed mobile teleradiology and demonstrated non-inferiority of mobile phone digital photographs of cxrs compared to plain film cxrs for some pathologies.22 these authors concluded ‘the non-inferiority of mobile teleradiology compared to interpretation of plain films has important implications for health care in resource-poor countries with limited access to radiologists’. discussion this study has identified that there are currently few published papers reporting national teleradiology networks within ssa despite the repeatedly stated need to establish these services and overcome the sub-continent’s lack of health human resources (including radiologists).1,20,21 other contributing arguments are widespread poor radiologic interpretation and the negative impact on morbidity and mortality of shortages in radiology services.18 in 2014, it was reported that shortages in radiology services affected 3.5–4.7 billion people worldwide – about one-half of the global population.16 the establishment of teleradiology services, in particular relatively inexpensive mobile teleradiology, in ssa, could mitigate some health systems and healthcare needs. however, there is a lack of comprehensive and published studies to guide the introduction of teleradiology or mobile teleradiology. in particular, none of the selected studies thoroughly addressed needs assessment, implementation, connectivity, evaluation, costing, image display, image capture or concordance in relation to mobile teleradiology. surprisingly, only one paper specifically identified the use of a phone-based digital camera, as used for mobile teleradiology.22 typically physicians will use their own smartphone to capture images, and significant advances have been made in recent years with smartphones allowing capture and transmission of high-resolution images in jpeg, png or gif file formats. a limitation is that these file formats do not have steganographic data embedded in them. if needed for storage in a pacs, they could be converted to digital imaging and communications in medicine (dicom) but without any embedded data. limitations to the study exist. only two databases were searched: a subject database (pubmed; biomedical literature) and a citation database (scopus; life sciences, social sciences, physical sciences and health sciences). a further limitation was the a priori selection of the eight categories for charting. additional issues relevant to mobile-teleradiology arose but were not charted. for example, the following were not charted: legal, regulatory and ethical issues; the quality and quantity of information provided at consultation; data security during transmission; data storage and record keeping and patient identification. such issues must be considered when establishing any clinical programme. moreover, more teleradiology focussed issues, such as camera and screen resolution, file format and the use of ris and pacs, were not charted in depth. although some of the above issues were noted in a few papers (table 1), they were not addressed or debated in detail in these literature sources, except by mars.24 all of the selected papers justified ‘need’ on the basis of the shortage or absence of radiologists in each setting.16,17,20,21 however, services developed without appropriate planning and without clear understanding of community needs, local clinical requirements and available infrastructure may fail to be sustained and/or scaled. yet there is little guidance on practical ‘needs assessment’.27 for example, satisfactory connectivity must be demonstrated and affordable whether through wired or wireless internet or cellular networks or both.20 similarly, a reliable electricity supply is desirable9,17,20,21 but is a longstanding issue in ssa that negatively impacts healthcare delivery.28,29 for mobile teleradiology, smartphone use must be available and a reliable cellular network infrastructure capable of inexpensively providing real-time connectivity is a prerequisite. increasingly, both are the case in ssa.20,28,29,30,31 despite the above, the papers did show that various teleradiology solutions, including mobile teleradiology, are feasible and satisfactory for most routine x-ray needs. conventional x-ray radiography (with attendant shortcomings: controlled temperature and humidity, water use, chemical use, incomplete drying and films sticking together17) is still one of the most widely used medical diagnostic techniques in rural healthcare centres in the developing world. these locations do not usually have radiologists on hand, making teleradiology a useful tool. this includes mobile teleradiology where smartphones with digital cameras are used to capture plain film images for transmission to and interpretation by consultant radiologists at a distance.22 leveraging teleradiology, in particular mobile teleradiology, could mitigate the shortage of radiologists outside major centres, improve patient diagnosis and care, reduce the travel burden for patients and do so inexpensively18,27 but requires local buy-in, multi-sectoral support and capacity building.20 of interest was the suggestion that the primary role of teleradiology should be facilitating training and capacity building and not consultation19 and that reliance on external resources or north-south collaborations for support should be reduced through local training and capacity building.16 certainly, radiology training varies significantly between countries in africa,32 and teleradiology training and skill building could, with some provisos, be mediated through technology.33,34 available literature from outside ssa indicates diagnostic imaging reduces mortality and improves the quality of life, is necessary for global health and teleradiology improves specialist access and reduces travel time and cost for patients.35,36,37,38 given that decisionand policy-makers need local evidence to inform their decisions, and based on the findings of this review, it is recommended that: a small number of well-designed and comprehensive studies be performed in ssa to confirm the utility and cost of mobile teleradiology versus conventional radiology and provide clear evidence-based guidelines for implementing mobile teleradiology programmes. these studies are published in open-access journals to ensure free availability to the developing world, in particular ssa. given that any e-health solution is an opportunity cost and (when competing with vaccination, safe water supply and other primary healthcare priorities) must fill a justified and compelling need, any rural or remote healthcare facility where mobile teleradiology is considered must perform a local needs assessment to confirm projected viability. where viability is determined, mobile teleradiology should be phased in with appropriate training and support. conclusion teleradiology, the transmission of radiological patient images (x-rays, cts, mris) from one location to another in order to share these studies with other clinicians for consultation or interpretation, is considered one of the oldest, most established, successful and widely used clinical telemedicine specialties. this study confirms that improvements in device and information technology have enabled advances in teleradiology and also opened the field of mobile teleradiology. with contemporary smartphones and mobile networks, technical issues such as image quality, transmission speed and image compression are no longer major barriers although issues such as adequate and reliable local connectivity and electricity remain. it has also shown that teleradiology, including the use of mobile teleradiology, is simple, feasible and appropriate for routine x-ray support of patients and healthcare providers in rural and remote locations, but woefully underused in ssa, although regional evidence to adequately demonstrate this is limited. nonetheless, teleradiology has proven benefits for healthcare delivery (e.g. improved referring doctor’s diagnostic accuracy) and patient care (e.g. reduced travel and associated expense) and offers a solution to settings where there are few or no radiologists. the almost routine application of teleradiology and mobile teleradiology for routine imaging tasks elsewhere reflects the changing world of clinical practice, service delivery and technology. the limited mobile teleradiology in ssa, as evidenced in the literature, hampers patient access to basic essential radiological services. there is an urgent need for rigorous published research that will produce high quality and evidence-based guidance for the establishment of mobile teleradiology programmes in ssa. this would both align with the world health organization’s (whos) support of mhealth, the achievement of universal health coverage (uhc) and the united nation’s sustainable development goals (sdgs),39 as well as support nigeria’s renewed interest in digital health.40 successful programmes are likely to be one aspect of a holistic national ehealth strategy that will guide innovation to address evidence-based needs and result in broader user adoption. furthermore, successful implementation of teleradiology may encourage more widespread and successful adoption of other e-health solutions. acknowledgements competing interests the authors declare they have no financial or personal relationships that may have inappropriately influenced the writing of this paper. authors’ contributions m.y.t., m.m. and r.e.s. conceived of the need for the study. m.y.t. and m.m. contributed to the literature search, all authors to resource selection, and m.y.t. and r.e.s. to the literature charting. m.y.t. drafted the first article, and all authors critically reviewed further revisions. all authors approved the final article. funding information research reported in this publication was supported by the fogarty international center of the national institutes of health under award number d43tw007004-13. data availability data sharing is not applicable; all data are in the public domain – no new data were created or analysed. disclaimer the views expressed in this manuscript are solely those of the authors and not an official position of their institutions or the fogarty international center of the national institutes of health or any other affiliated agency of the authors. references regional committee for africa, 60. ehealth solutions in the african region current context and perspectives [homepage on the internet]. regional committee for africa sixtieth session malabo, equatorial guinea, 30 august–3 september 2010: provisional agenda item 7.3. 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health organization; 2019. ibeneme s, ukor n, ongom m, dasa t, muneene d, okeibunor j. strengthening capacities among digital health leaders for the development and implementation of national digital health programs in nigeria. bmc proc. 2020 jul;14(10):1–12. https://doi.org/10.1186/s12919-020-00193-1 how i do it how to perform a temporary balloon test occlusion dd royston mbchb, ffrad(d) introduction honorary senior lecturer. university of natal, and consultant radiologist in private practice, durban a temporary balloon test occlusion is performed prior to endovascular occlusion of carotid or vertebral arteries. it may also be performed preoperatively when vascular sacrifice is intended or possibly during surgical therapy for tumours of the cervical region or skull base. i the indications for parent artery vessel occlusion include certain giant aneurysms, pseudoaneurysms and carotid cavernous fistulae which cannot be treated with preservation of the parent vessel.' tests used to predict tolerance to permanent occlusion a temporary balloon test occlusion is performed to predict the ability of the patient to tolerate permanent occlusion. the risks of ipsilateral hemispheric ischaemia or infarction largely depend on the adequacy of collateral circulation. various tests have been used to assess tolerance during temporary occlusion. 21 sa journal of radiology. january 2000 assessment of neurological status (motor, sensory, speech and level of alertness) during trial occlusion is used in all patients unless it is not possible, or desirable to perform the procedure under local anaesthesia. it does not however, identify all patients at risk for post occlusion infarction. this is probably because there is a group of patients with marginal cerebral blood flow reserves who are able to tolerate temporary occlusion, but who are at risk for developing flow related infarction during episodes of hypo tension, anaemia, hypoxaemia or hypoglycaemia. various other tests have been used in combination with clinical testing during trial occlusion. stump pressure is not an accurate predictor of stroke risk." anglograpbic evidence of cross filling via cellaterals is a poor indicator of whether the patient will tolerate permanent occlusion. the venous phases of an angiogram are a better predictor of tolerance to permanent occlusion.' if there is less than a 1.5 second delay in the appearance of the venous phase, following an injection figure 1: left internal carotid angiogram. pseudoaneurysm with cef arising from the carotid syphon topage22 how i do it frompage21 into the opposite carotid or vertebral artery, permanent occlusion is probably safe.' transcranial doppler has not been used extensively. the disadvantage of using transcranial doppler is that only flow in major vessels is assessed. permanent occlusion is considered to be relatively safe if the peak systolic velocity in the middle cerebral artery decreases by no more than 65%.4 figure 2: trial occlusion test. arterial phase of the right internal carotid angiogram with balloon inflated in the left internal carotid artery several tests have been used in an attempt to identify patients with marginal ebf reserves speet, pe1: xenon cl' ebf and tolerance to induced hypotension during trial occlusion. s single-photon emission cl' (speet) and stable xenon cf ebf take direct intracranial measurements of parameters linked to ebf to assess ebf reserves. although pet scanning has been used to assess cerebral blood flow quantitatively during balloon occlusion, the technology is not widely available.f xenon cl' ebf is performed by placing and inflating the balloon in the angiography suite and performing a trial occlusion with neurological monitoring. if the patient experiences no deficit, the balloon is deflated and the patient transferred to the ci' scanner where the balloon is reinflated (without fluoroscopic guidance) and the xenon ebf study performed. quantitative information can be obtained using regions of interest. it is considered safe to proceed with permanent occlusion if the cerebral blood flow is greater than 30 ml/wo g/min. ten to fifteen per cent of patients will pass the clinical occlusion test, but will have a ebf of less than 30 ml/wo g/min and this group of patients is thought to be at moderate risk for infarction after permanent occlusion. patients with a ebf ofless than 23 mliioo g/min are at high risk for ischaemia during balloon oeelusion.' to perform a speet scan, 99mtchmpao (hexamethyl propylene amine oxime) is injected intravenously during temporary occlusion. the balloon is then deflated and the speet scan performed. a baseline study can be performed prior to the test occlusion, or in patients showing hypoperfusion, 24 hrs later. areas of asymmetric hypoperfusion not present on the baseline study are considered to be abnormal and place the patient in a high risk category for cerebral infarction following permanent occlusion." induced hypotension, where the systolic blood pressure is decreased by 30% for a period during trial occlusion has also been used to assess tolerance to parent vessel occlusion.' balloons used for trial occlusion test several methods have been described for performing trial occlusions. one uses a detachable balloon which is detached in the same position, without deflation, if the patient passes the occlusion test. this has the advantage of simulating the effect of permanent occlusion most closely as the balloon 22 sa journal of radiologyjanuary 2000 is inflated in its detachment position. there is however a risk of premature detachment. the second method uses a non-detachable balloon. this is more time consuming and necessitates deflating the balloon and reinflating the detachable balloon if the patient passes figure 3: trial occlusion test. venous phase of the right internal carotid angiogram with balloon inflated in the left internal carotid artery the venous phase of the left cerebral hemisphere appeared about 1.5 seconds after the venous phase of the right cerebral hemisphere the trial occlusion test. a double lumen balloon catheter, which allows perfusion of the distal stump with heparinised saline has also been used. although the double lumen balloon catheter has the theoretical advantage of preventing thrombus formation in the distal stump, it seems unnecessary in practice." there are proponents of each of these methods. complications trial occlusion has a complication rate of about 3%. some of the complications are asymptomatic (dissections, pseudo aneurysm and embolus) and the remainder ischaemie (although usually transient). i the incidence of stroke following permanent occlusion in patients who have passed the temporary balloon occlusion test is reported to be topage23 how i do it frompage22 between 10 and 20%.10 about 4% of ischaemie events are permanent and 10% are transient.' they may be due to thromboembolism or secondary to decreased flow. hypoperfusion is a particular problem in the elderly, whose blood pressure and cardiac output may be less stable than in younger patients. procedure many different techniques are utilised in performing a trial occlusion test. the following is the technique used by the author. the patient is fully conscious for the trial occlusion test. bilateral femoral artery punctures are performed. a sfr sheath is placed in the left femoral artery. a sheath to match the chosen guiding catheter is placed in the right femoral artery. a diagnostic angiogram is then performed. the patient is heparinised. a loading dose of 5000 iu is given. the act (activated clotting time) is maintained above 300 seconds for the duration of the procedure by giving additional boluses of heparin during the procedure. the diagnostic catheter is positioned in the artery on which the trial occlusion test is to be performed. this is exchanged over a 260 cm exchange wire for the chosen guiding catheter. the guiding catheter selected will depend on the balloon size. it is important to keep the tip of the wire below the skull base, and stationary during the exchange to prevent spasm. the guiding catheter is connected to a rotating haemostat valve (rhv) and continuously flushed with heparinised saline (3000 iu in il nis). the diagnostic catheter is then placed in the contralateral internal carotid artery. if a permanent occlusion is going to be performed after a successful trial occlusion test, a detachable balloon is used to perform the trial occlusion test. only if it seems unlikely that the patient will pass the trial occlusion test, or if a permanent occlusion is not planned, is a non-detachable balloon used. the detachable balloon is filled with isoosmolar solution of contrast and sterile water. it is inflated and checked for a figure 4: left carotid angiogram post detachment of the bal/aan and post detachment of a second bal/aan leak. the rhv is disconnected from the guiding catheter and the delivery catheter advanced through the rhv the balloon is then mounted on the tip of the delivery catheter. it is inflated and air purged from the system. it is then deflated. it is important to perform this step to be certain that it is properly mounted and that the balloon will in fact deflate (if the tip of the delivery catheter does not extend beyond the valve it will not deflate). the rhv is reconnected to the guiding catheter and the balloon is advanced beyond the tip of the guiding catheter under fluoroscopic contro1. ideally this should be done using a roadmap image (subtracted fluoroscopy). the balloon is positioned at the site of the anticipated permanent occlusion. the author uses transcraniaj doppler as part of the assessment and a baseline velocity in the 23 sa journal of radiology. january 2000 middle cerebral artery is obtained. the act is checked immediately prior to inflation of the balloon. the balloon is progressively inflated until it completely occludes the artery.a check angiogram through the guiding catheter is done to confirm occlusion.the velocity in the middle cerebral artery is checked. a check angiogram is performed from the opposite side and the timing of the venous phase of the angiogram in the two cerebral hemispheres compared. a neurological assessment is performed. if no deficit has developed, the middle cerebral artery velocity has decreased by no more then 50% and the venous phases are separated by less than 2 seconds, the test is continued for 30 minutes. the above parameters are checked intermittently during this period. if a neurological deficit develops, the test is immediately terminated. if the patient passes the test, the balloon is detached and a second 'safety' balloon placed proximally.patients often experience headache and retro-orbitalpainduringthe procedurewhich can be treated with opioid analgesia. references i. mathis jm, barr jd and horton ja. therapeutic occlusion of major vessels, test occlusion and techniques. neurosurg c/ill nam 1994;5:393·401. 2. barker-ow, jungreis-ca, horton-ja el r!l. balloon test occlusion of the internal carotid artery: change in stump pressure over is minutes and its correlation with xenon ct cerebral blood now. ajnr 1993; 14:587-90. 3: houdart e. gdc 7raining course, oxford. december 1998. 4. giller ca, mathews d, walker b el al. prediction of tolerance to carotid occlusion using transeraniel doppler ultrasound. j nellyosllrg 1994;81:15-19. 5. larson jl, tew mj, tomsick at el al. treatment of aneurysms of the internal carotid artery by intravascular balloon occlusion: long-term follow-up of 58 patients. nellrosllrgery 1995;36:26-30. 6 brunberg-jx: frey-ka; horton-ja et al. (150]h,o positron emission tomography determination of cerebral blood flow during balloon test occlusion of the internal carotid artery.ajnr 1994;15. 7. linskey-me; jungreis-ca; yenss-h er nl. stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced ct. ainr. 1994; 15:829-43. 8. peterman sb,taylor a and hoffman jc.lmproved detection of cerebral hypoperfusion with internal carotid balloon test occlusion and 99m tc-hmpao cerebral perfusion speer imagingajnr 1991;12:1035-41. 9: foxaj, vinuela f, pelz dm etal. use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. 1 neurosurg 1987;66:4046. 10. eskridge jm. the challenge of carotid occlusion. ajnr 1991; 12: 1053-1 054. case report abstract mammography is the most widely used diagnostic imaging method for screening and diagnosing breast cancer. nevertheless, this technique has some limitations in that not all breast cancers are evident on mammograms, especially in dense or dysplastic breasts, patients with breast prosthesis or if the patient has previously undergone radiation, surgery or biopsy. scintimammography (sm) is the functional imaging study of the breast with radiopharmaceuticals, such as 99mtc-labelled methoxyisobutylisonitrile (99mtc-mibi). sm is currently used as a complementary test to mammography in patients with suspected breast cancers. this study was undertaken to evaluate the impact of sm on the management of patients with a suspicious lesion detected by palpation or mammography. methods. we performed a prospective study of 53 patients with a suggestion of breast cancer, either on palpation or mammography. planar imaging was performed after injection of 99mtc-mibi. results were compared with histopathological analysis in all cases. results. breast cancer was proven in 11 cases. sm had a sensitivity of 90.9% and a specificity of 97.6%. sm correctly evaluated multicentricity or bilaterality in 3 of 11 patients and detected axillary lymph node in 1 patient. sm made the diagnosis of benign lesions in 41 cases with doubtful diagnosis, thus potentially avoiding biopsy in 77% of cases. conclusion. sm is a useful complementary tool for the diagnosis and evaluation of disease extent in patients with an inconclusive diagnosis and can decrease the number of negative breast biopsies. introduction in south africa breast cancer is one of the leading causes of diseaserelated mortality. one woman in 10 will suffer from breast cancer in her lifetime, and 1 woman in 20 will die from breast cancer. several imaging techniques are used to evaluate women for breast cancer. mammography is the most frequently used screening method, and a decrease in mortality of 21% has been observed for breast cancer in women who have undergone mammographic screening.1 mammographic screening in women older than 40 years provides an effective early diagnosis. subsequent prompt treatment reduces the mortality rate. however, this technique has limitations with regard to sensitivity and specificity,2,3 especially in dense breasts, lumpy breasts, fibrocystic breasts, previous breast surgery, breast implants, and multifocal or multicentric lesions. all of these situations make other tests necessary to confirm the nature of the lesion observed on the screening mammogram. approximately 1 in 4 women undergo surgical biopsy to rule out malignant breast lesion, but most of these women will not have cancer. for this reason, additional techniques are required to obtain a more accurate diagnosis, that differentiates between malignant and benign masses.4 breast cancer, like other cancers, shows significant affinity for the radiopharmaceutical technetium-99m methoxyisobutylisonitrile (99mtc-mibi), with high tumour/non-tumour ratios.5 99mtc-mibi is a lipophilic agent and is furthermore a substrate of p-glycoprotein (pgp), which is considered one of the multi-drug resistant (mdr) agents.6 sm has been demonstrated to be useful in the diagnosis of primary breast tumours in patients with dense breasts,7 and its value has been especially emphasised in the evaluation of therapeutic response.8,9 moreover, scintimammography (sm) may be considered a non-invasive method for the identification of mdr-positive patients, assisting in the choice of the most suitable therapy.8-10 objective the aim of this study was to review the diagnostic accuracy of sm using 99mtc-mibi as a marker and its place in the diagnostic algorithm of breast cancer management. materials and methods we examined 53 consecutive patients (age range 20 79 years, mean age 53 years) with a suspicious breast lesion detected by self-examination, physical examination or screening mammography. afterwards most patients underwent ultrasound (us). mammography and us were performed according to standard procedures. all patients underwent sm prior to fine-needle aspiration biopsy (fnab). the patients with breast cancer at fnab underwent surgery. mammograms were performed on dedicated mammography machines: a digital mammography unit. mammography was performed with both mediolateral oblique and craniocaudal views in every case, and an additional lateromedial oblique view if indicated. us was performed using the direct contact method with real-time equipment and a broadband linear probe (6 12 mhz). us-guided fnab was performed freehand with a syringe holder connected to a 10 ml syringe and a 22-gauge needle. sm was performed with a single head gamma camera, equipped impact of scintimammography in management of breast cancer f naude, mb chb w van vuuren, mb chb k venter, mb chb, mmed (nucl med) b j meyer, mb chb, mmed (nucl med), md m m sathekge, mb chb, mmed (nucl med) department of nuclear medicine, pretoria academic hospital and university of pretoria v pellegrin, mb chb, mmed (gen surg) department of general surgery, pretoria academic hospital and university of pretoria j l höll, mb chb, fcr department of radiology, pretoria academic hospital and university of pretoria original article original article � sa journal of radiology • march 2006 impact of scintimammography.indd8 8 3/27/06 2:17:31 pm � sa journal of radiology • march 2006 with a parallel-hole, low-energy, high-resolution collimator. the test was performed using the standard technique: 740 mbq 99mtc-mibi was injected intravenously in the opposite arm to the breast with the suspected lesion. in all patients, planar imaging was performed using a 256 × 256 matrix with an acquisition time of 10 15 minutes, in both lateral and anterior views, at 20 30 minutes after injection. patients were examined in the prone position using an imaging table with breast ‘cut-outs’. to avoid interference from the opposite breast, a layer of lead was used as a shield. the sm images were classified based on visual interpretation. focal tracer accumulation in the breast was interpreted as suspicious or probably malignant and such scintigrams were classified as positive. the suspicious or probably malignant images were considered true positive when confirmed by histopathology. the sm was interpreted as true negative if the images and histopathology excluded breast cancer. sm images were interpreted separately by 3 expert nuclear medicine physicians who worked independently. they were blinded to the results of mammography, us and physical examination. results a total of 53 patients were investigated. ten of 11 histopathologically proven malignant tumours could be detected by sm with 99mtc-mibi. in 1 case, scintigraphy was false-negative. there were 41 benign lesions of the breast, with 1 being false-positive. this gives an outstanding sensitivity of 90.9%, a specificity of 97.6%, a positive predictive value (ppv) of 90.9%, and a negative predictive value (npv) of 97.6%. the lesion size in the entire patient group ranged from 0.1 cm to 15 cm, with a mean of 1.3 cm. the smallest detectable tumour had a size of 1.2 cm. fig. 1 shows a true negative scan while fig. 2 demonstrates cancer in a patient in whom mammography was negative. axillary lymph node metastases were histopatologically confirmed in 2 patients. scintigraphy with 99mtc-mibi was positive in the axillary region in 1 case (fig. 3). discussion in accordance with numerous previous studies, our results showed high sensitivity and specificity of sm for detection of breast cancer. in our study, 90.9% of carcinomas with a diameter of 1.2 cm could be detected. our results show that 1 case of fibroadenoma presented as a false positive. in comparison with mammogragraphy, sm showed a better diagnostic accuracy. this supports the numerous studies that have been published on the clinical usefulness of sm. the aggregated overall summary estimates of a recent meta-analysis selecting 64 unique studies,11 with data on 5 340 patients, including 5 354 breast lesions, showed a sensitivity of 85.2%, specificity of 86.6%, npv of 81.8%, a ppv of 88.2% and accuracy of 85.9%. it is worth noting that 80% of the studies yielded sensitivity and specificity values of > 80%, and nearly half of them were values of > 90%. moreover, in > 5 660 cases reported to date, the sensitivity and specificity of 99mtc-sestamibi sm in detecting primary breast cancer were 83.8% and 86.4%, respectively.12 a comprehensive review of sm indications was published in 2004 documenting the impressive performance of this modality in the management of breast cancer. table i lists appropriate clinical indications for sm. because the uptake of the radiopharmaceutical by the breast is independent of the breast density, and the accuracy of sm is similar for fatty original article fig. 1. normal biodistribution of 99mtc-mibi sm on both anterior and lateral images. fig. 2. a 52-year-old woman with inclusive mammography where planar anterior and left lateral sm clearly shows carcinoma with two adjacent sites of abnormal accumulation in the left breast. fig. 3. anterior and right lateral sm shows a single area of increased abnormal uptake in the right breast and also focal uptake in the right axilla of a 34-year-old patient. table i.  clinical indications for sm equivocal mammograms dense breast palpable abnormalities that cannot be imaged well with mammography axillary lymph node metastases of an adenocarcinoma of unknown primary origin breast implants parenchymal distortions of the breast doubtful microcalcifications assessment of multicentric disease breast iatrogenic architectural distortion suspected recurrent breast cancer monitoring the response to neoadjuvant chemotherapy � sa journal of radiology • march 2006 impact of scintimammography.indd9 9 3/27/06 2:17:31 pm case report 10 sa journal of radiology • march 2006 and dense breasts, scintigraphy is indicated for patients with a palpable mass not detected on mammography due to dense breast tissue in particular, when the other diagnostic tests are inconclusive. furthermore, sm is particularly useful in patients with doubtful microcalcifications or parenchymal distortions, in the presence of scar tissue after surgery or biopsy and in breasts with implants.13 it is well known that mammography is less accurate in evaluating breasts that have previously been submitted to surgery, biopsy, radiation therapy, or chemotherapy. cases where there is a scar within the breast due to these iatrogenic interventions are often difficult to interpret using mammographic imaging, whereas sm is not affected by these morphological changes. furthermore, a few studies8-10 have shown this technique to be useful in predicting and monitoring the response to chemotherapy. 99mtc-mibi is taken up by the tumour cells and stored in mitochondria and cytoplasm. therefore, it is an appropriate indicator of cells with high metabolism, such as cancer cells. it is also a substrate for pgp, the most widely studied multidrug-resistant factor, which actively transports 99mtc-mibi and chemotherapeutic agents outside of the cell. a good correlation has been found between the efflux rate of 99mtc-mibi and the cell content of pgp. thus, cells that show a high release of tc-99m mibi would be less responsive to chemotherapy treatment.10 despite these very encouraging results suggesting that sm could be a useful adjunct to mammography, the precise role of this technique in the algorithm of breast cancer diagnosis and its specific clinical indications are still being debated and have not been definitively assessed. one of the reasons is that it is well known that planar sm has a low sensitivity for non-palpable and ≤ 1 cm cancers, as indicated by several reports. in particular, in a multicentre study on 420 patients, scopinaro et al.14 reported a sensitivity of 62% for non-palpable tumours and of 46% for ones ≤ 1 cm, whereas the values for palpable and > 1 cm cancers were 98% and 96%, respectively. therefore, increasing the sensitivity of planar sm for small-sized tumours is clinically very relevant, and the role of spect in this task could be significant. the main drawback of single photon emission computed tomography (spect) is that, despite its better contrast resolution, it can be difficult to obtain a precise definition of the sites of radiopharmaceutical uptake, whereas prone lateral planar views provide natural landmarks of breast contours, which are useful for the localisation of lesions. this limitation can be overcome by the recent availability of hybrid spect/ct systems which allow – through the co-registration of spect and ct – for the precise correlation of functional and anatomical data on the same image. the first clinical applications of this new technology in breast imaging indicate that spect/ct can increase the accuracy of spect by a more accurate anatomical assessment of the sites of abnormal activity.15 conclusion breast scintigraphy is not a screening tool for breast cancer, but may supply important information, after a physical breast examination, mammography and us have been performed. sm studies may be particularly appropriate in the case of a suspicious breast lesion that requires a biopsy, thus decreasing the number of negative breast biopsies. hence, the south african community should make sm part of the algorithm in the management of breast cancer. 1. nystrom l, andersson i, bjurstam n, frisell j, nordenskjold b, rutqvist le. long-term effects of mammography screening: updated overview of the swedish randomised trials. lancet 2002; 359:909-919. 2. fletcher sw, black w, harris r, et al. report of the international workshop on screening of breast cancer. j natl cancer inst 1993; 85: 1621. 3. waxman ad. the role of 99mtc-methoxyisobutylisonitrile in imaging breast cancer. semin nucl med 1997; 27: 40. 4. kelsey jl, gammon md. the epidemiology of breast cancer. cancer 1991; 41: 146. 5. khalkhali i, mena i, jouanne e, et al. prone scintimammography in patients with suspicion of carcinoma of the breast. j am coll surg 1994; 178:491-497. 6. goldstein lj, galski h, fojo a, et al. expression of a multi-drug resistance gene in human cancers. j natl cancer inst 1989; 81:116-120. 7. khalkhali i, baum jk, villanueva-meyer j, et al. 99m tc sestamibi breast imaging for the examination of patients with dense and fatty breasts: multicentre study. radiology 2002; 222:149-155. 8. cayre a, cachin f, maublant j, et al. single static view 99m tc-sestamibi scintimammography predicts response to neoadjuvant chemotherapy and is related to mdr expression. int j oncol 2002; 20:10491055. 9. mubashar m, harrington kj, chaudhary ks, et al. 99m tc-sestamibi imaging in the assessment of toremifene as a modulator of multidrug resistance in patients with breast cancer. j nucl med 2002; 43:519-525. 10. palmedo h. what can we expect from mdr breast cancer imaging with sestamibi? j nucl med 2002; 43:526-530. 11. liberman m, sampalis f, mulder ds, sampalis js. breast cancer diagnosis by scintimammography: a meta-analysis and review of the literature. breast cancer res treat 2003;80:115-126. 12. taillefer r. clinical applications of 99m tc-sestamibi scintimammography. semin nucl med 2005;35:100115. 13. schillaci o, buscombe jr. breast scintigraphy today: indications and limitations. eur j nucl med mol imaging 2004; 31: suppl 1:s35-s45. 14. scopinaro f, schillaci o, ussof w, et al. a three center study on the diagnostic accuracy of 99m tc-mibi scintimammography. anticancer res 1997;17:1631-1634. 15. schillaci o, danieli r, manni c, simonetti g. is spect/ct with a hybrid camera useful to improve scintigraphic imaging interpretation? nucl med commun 2004;25:705-710. 10 sa journal of radiology • march 2006 original article impact of scintimammography.indd10 10 3/27/06 2:17:32 pm sajr 25-1_2021_contents.indd http://www.sajr.org.za open access table of contents original research foetal magnetic resonance imaging: a necessity or adjunct? a modality comparison of in-utero ultrasound and ultrafast foetal magnetic resonance imaging sunaina ramdass, sumaiya adam, zarina lockhat, andries masenge, farhana e. suleman south african journal of radiology | vol 25, no 1 | a2010 | 19 march 2021 original research correlation of blunt cervical spinal cord injury magnetic resonance imaging tractography with the american spinal injury association impairment scale motor scores orapeleng seboco, fekade gebremariam, gina joubert south african journal of radiology | vol 25, no 1 | a2038 | 01 april 2021 original research preliminary experience with 3t magnetic resonance elastography imaging of the liver anagha joshi, mridula m. muthe, vikrant firke, harshal badgujar south african journal of radiology | vol 25, no 1 | a2072 | 12 may 2021 original research mri characteristics of intracranial masses in the paediatric population of kwazulu-natal: a neuroimaging-based study nompumelelo p. gumede, sithembiso m. langa, basil enicker south african journal of radiology | vol 25, no 1 | a2042 | 28 may 2021 original research cost awareness of radiological studies among doctors at universitas academic hospital in bloemfontein, south africa khanyisa n. mrwetyana, jacques janse van rensburg, gina joubert south african journal of radiology | vol 25, no 1 | a2188 | 20 september 2021 original research mri findings in chronic exertional compartment syndrome of the forearm: using signal intensity ratio as a diagnostic tool jacques badenhorst, mark velleman, audrey jansen van rensburg, tanita botha, nikki van der walt, christa janse van rensburg south african journal of radiology | vol 25, no 1 | a2219 | 06 october 2021 original research trends in public sector radiological usage in the western cape province, south africa: 2009–2019 monica van wijk, michelle m. barnard, amanda fernandez, keith cloete, matodzi mukosi, richard d. pitcher south african journal of radiology | vol 25, no 1 | a2251 | 30 november 2021 case series imaging of retroperitoneal haemorrhage revealing median arcuate ligament syndrome younes el hassani, meriem haloua, badreeddine alami, meryem boubbou, mustapha maaroufi, moulay youssef alaoui lamrani south african journal of radiology | vol 25, no 1 | a1993 | 15 january 2021 59 65 70 78 88 94 101 108 page i of iii table of contents editorial journalism – de-constructing the jigsaw maya patel south african journal of radiology | vol 25, no 1 | a2356 | 09 december 2021 letter to the editor letter to the editor: addressing radiological terminology of basal ganglia and thalamic injury in hypoxic ischaemic injury bates alheit south african journal of radiology | vol 25, no 1 | a2146 | 26 may 2021 review article pi-rads v2.1: what has changed and how to report robin scott, shalendra k. misser, dania cioni, emanuele neri south african journal of radiology | vol 25, no 1 | a2062 | 01 june 2021 review article radiology subspecialisation in africa: a review of the current status efosa p. iyawe, bukunmi m. idowu, olasubomi j. omoleye south african journal of radiology | vol 25, no 1 | a2168 | 30 august 2021 review article pet-ct in brain disorders: the south african context alexander g.g. doruyter, jeannette parkes, jonathan carr, james m. warwick south african journal of radiology | vol 25, no 1 | a2201 | 10 november 2021 original research the prevalence of anatomical variants of the coeliac trunk and renal arteries on contrast-enhanced abdominal computed tomography scans at dr george mukhari academic hospital raeesa omar, margaret kisansa, alireza d. dehnavi south african journal of radiology | vol 25, no 1 | a1990 | 25 january 2021 original research magnetic resonance imaging for paediatric retroperitoneal masses: diagnostic accuracy of the claw sign lisa combrink, kenneth b. beviss-challinor south african journal of radiology | vol 25, no 1 | a2012 | 26 february 2021 original research a silver bullet? the role of radiology information system data mining in defining gunshot injury trends at a south african tertiary-level hospital dale k. creamer, asif bagadia, clive daniels, richard d. pitcher south african journal of radiology | vol 25, no 1 | a2018 | 02 march 2021 original research determination of split renal function in voluntary renal donors by multidetector computed tomography and nuclear renography: how well do they correlate? hira lal, anuradha singh, raghunandan prasad, priyank yadav, javed akhtar, sukanta barai, prabhakar mishra, dharmendra bhadauria, anupma kaul, narayan prasad, pragati verma south african journal of radiology | vol 25, no 1 | a2009 | 05 march 2021 1 2 5 18 25 34 41 46 51 vol 25, no 1 (2021) issn: 1027-202x (print) | issn: 2078-6778 (online)south african journal of radiology http://www.sajr.org.za open access table of contents case series traumatic aortic injury: computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries richard edwards, nausheen khan south african journal of radiology | vol 25, no 1 | a2044 | 12 march 2021 case series unilateral opaque chest 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vinayak jayaram, vimal patel, gavin low south african journal of radiology | vol 25, no 1 | a2022 | 23 march 2021 pictorial review clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: part 2 rishi p. mathew, teresa i-han liang, ahamed kabeer, vimal patel, gavin low south african journal of radiology | vol 25, no 1 | a2027 | 23 march 2021 pictorial review the silent pandemic in south africa: extra-pulmonary tuberculosis from head to heel camilla e. le roux, sucari s.c. vlok south african journal of radiology | vol 25, no 1 | a2026 | 16 april 2021 pictorial review chemical shift imaging: an indispensable tool in diagnosing musculoskeletal pathologies vandana jahanvi, abhimanyu kelkar south african journal of radiology | vol 25, no 1 | a2061 | 06 may 2021 case report left paraduodenal hernia: embryological and radiological findings atish vanmali, jaynund maharajh, mario haines south african journal of radiology | vol 25, no 1 | a1979 | 17 february 2021 case report rare presentation of chronic recurrent multifocal osteomyelitis of the iliac wing mimicking ewing’s sarcoma pankaj nepal, syed i. alam, sadia sajid, joshua sapire, vijayanadh ojili south african journal of radiology | vol 25, no 1 | a2030 | 18 february 2021 113 120 125 134 142 155 169 178 186 191 case report high presacral collection approached through the perineal route: a novel computed tomography-guided technique shuchi bhatt, harshit bansal, sagar nayak, saumya dangwal south african journal of radiology | vol 25, no 1 | a2014 | 11 march 2021 case report metronidazole-induced encephalopathy vikash g. lala, bilal bobat, mark haagensen, prakash kathan, adam mahomed south african journal of radiology | vol 25, no 1 | a2016 | 18 march 2021 case report prostate abscess in a paediatric patient: a rare diagnosis atish vanmali, mario haines south african journal of radiology | vol 25, no 1 | a2053 | 25 march 2021 case report primary squamous cell carcinoma of the urinary bladder presenting as an inguinal mass zahra qaiyumi, pankaj nepal, christopher iannuzzi, joshua sapire south african journal of radiology | vol 25, no 1 | a2048 | 29 march 2021 case report tuberous sclerosis complex: the critical role of the interventional radiologist in management puneet garg, anuradha sharma, heena rajani, apratim r. choudhary, rajkumar meena south african journal of radiology | vol 25, no 1 | a2034 | 30 march 2021 case report a unique case of miliary pulmonary tuberculosis induced by bacillus calmette-guérin intravesical instillation with covid-19 superinfection nicolò brandi, laura bartalena, cristina mosconi, rita golfieri south african journal of radiology | vol 25, no 1 | a2122 | 17 june 2021 case report maximum intensity projection aids in diagnosing acute appendicitis and mobile caecum: a case report and literature review kakia a.f. namugenyi, ferdinand m. oompie, kasandji f. kabambi south african journal of radiology | vol 25, no 1 | a2153 | 28 july 2021 case report angiosarcoma of the pulmonary artery mimicking pulmonary thromboembolism sitang nirattisaikul, arunee dechaphunkul, keerati hongsakul south african journal of radiology | vol 25, no 1 | a2150 | 10 august 2021 case report undifferentiated embryonal sarcoma masquerading as liver abscess: a case report with typical imaging features ranjan k. patel, swasti pathak south african journal of radiology | vol 25, no 1 | a2179 | 31 august 2021 case report hepatic larva migrans presenting with upper gastrointestinal haemorrhage: a case report ranjan k. patel, shruti mittal south african journal of radiology | vol 25, no 1 | a2200 | 26 november 2021 195 201 206 211 216 222 225 229 233 237 page ii of iii http://www.sajr.org.za open access table of contents case report pneumorrhachis: an uncommon radiological entity atish vanmali, kamlesh d. daji south african journal of radiology | vol 25, no 1 | a2255 | 29 november 2021 case report a case of racemose and intraventricular neurocysticercosis in an unusual location priya singh, surya p. singh south african journal of radiology | vol 25, no 1 | a2171 | 06 december 2021 correction erratum: chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices rishi p. mathew, timothy alexander, vimal patel, gavin low south african journal of radiology | vol 25, no 1 | a2256 | 17 november 2021 242 246 251 correction corrigendum: not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases jaanri brugman, gerard de bruyn, komeela naidoo, marc merven, johan opperman, leon janse van rensburg south african journal of radiology | vol 25, no 1 | a2268 | 01 december 2021 correction corrigendum: evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region isak d. vorster, steve beningfield south african journal of radiology | vol 25, no 1 | a2269 | 01 december 2021 reviewer acknowledgement south african journal of radiology | vol 25, no 1 | a2376 | 22 december 2021 252 253 254 page iii of iii pdf file case report primary hydatidosis of the thyroid gland: a case report abstract mmsathekge mbchb, mmed hydatid disease is caused by the parasitic tapeworm, echinococcus granulosus. this parasite in the larval stage can thrive in many parts of the body, most commonly in the liver and the lungs. hydatid disease in the head and neck region is rare. an unusual location for hydatid disease in the thyroid gland is presented. the patient did not have other cysts postoperatively. the authors state the diagnostic difficulties caused by the omission of sonography during the diagnostic approach. mn muthuphei* mmed, ffpath i mandiwana* nat.dip.hist, nat.dip.cyt., nat.higherdip.cyt. department of nuclear medicine, 'department of anatomical pathology, medunsa 13 sa journal of radiologyaugust 1998 echinococcosis, or hydatidosis, has a characteristic geographic distribution, occurring most frequently in sheep-rearing regions such as the mediterranean countries, oceania and south africa. i the cysts are most commonly seen in the liver and lungs, although involvement of other organs is possible but rare.' hydatid disease in the head and neck region is rare and to our knowledge no english report of such cases in the thyroid gland has been published. the aim of this report is to discuss the importance of the combination of scintigraphy and ultrasonography prior to fine needle aspiration (fna) in the diagnosis and management of swellings of the thyroid gland. case report a 29-year-old woman presented with a single thyroid nodule of 6 months duration. for the past 3 weeks the swelling was noticed to be increasing in size. progressive swelling was associated with increased pressure, mild pain on palpation of the mass and dysphagia. physical examination at the time of presentation revealed a 6 em diameter soft mass in the left mid neck which was mildly tender on palpation. the mass was mobile during swallowing. laboratory evaluation including complete blood count, erythrocyte sedimentation rate, t3, t4, tsh and lft were all normal. thyroid scintigraphy with tc-99m pertechnetate revealed a focal area of photopenia in the upper zone of the left thyroid lobe on both flow and static images (figure 1). the scintiscan findings correlated well with the clinical impression. ultrasonography was not performed because the thyroid swelling was not to page 14 prirriarv hydatidosis ot the thyroid glzlncl: zl-case report (rom page 13 figure 1: (a) perfusion scan: a photopenlc area (arrow) in the left upper zone. figure 2: a scolex of echinococcus granulosus. figure 1(b): uptake scan: focal area of photopenla in the upper zone (arrow) of the left lobe persists. thought to be a cyst on clinical or scintigraphic analysis.cytology was undertaken based on the scintigraphic results. this showed multiple calcified bodies and very few cells. there were groups of scolices resembling those of echinococcus granulosus (figure 2). the resected specimen showed thyroid partially replaced by a large cyst with a gelatinous appearance. histological examination revealed a parasitic membrane with degenerated scolices and hooklets. extensive dystrophic calcification was present (figure 3). the surrounding thyroid tissue was severely inflamed with many foreign body giant cells being seen. a diagnosis of hydatid cyst was made. postlobectomy thyroid scintigraphy and ultrasound showed no residual thyroid tissue on the left side. 14 sa journal of radiology. august 1998 discussion an unusual location for hydatid disease in the thyroid gland has to our knowledge not been presented before. ultrasonography and ct usually easily detect hydatid disease, with the exception of hydatid cysts in uncommon sites of the body.' the diagnosis of the disease prior to surgery is crucial so as to avoid spillage of the parasitic cyst's contents. in our patient, some diagnostic difficulty was experienced as ultrasonography was not performed. it is generally agreed that the routine use of ultrasound in the evaluation of thyroid nodules is not cost effective." however the patient underwent thyroid scintigraphy because it is routine in all our patients with thyroid disease. the essential objective of thyroid scanning is to identify whether a nodule is hypofunctioning, not only because this is the most likely finding, but because a solitary nodule is associated with an increased probability of malignancy.' the quoted incidence of thyroid malignancy varies considerably in the literature, but is such that it should be excluded in every nodule shown to be nonfunctioning. in our figure 3: a section from the cyst wall showing a degenerated scolex (arrow). to page 17 original article original articleoriginal article abstract background. extradural spinal cord compression in children may be the result of infection/inflammation or neoplasia. it is vital to differentiate between the two as there is considerable difference in the management of these entities. objective. the aim of this paper is to determine whether there are significant differences between tb spondylitis and neoplasia causing extradural compression of the cord with regard to the anatomical distribution and compartmentalisation. materials and methods. a group of 16 children between the ages of 4 months and 14.2 years who had magnetic resonance (mr) evaluation of the spine consecutively were analysed retrospectively. results. a wide variety of neoplasms demonstrated an anatomical site and compartment on mri that is ‘characteristic’ of tb spondylitis. conclusion. anatomical distribution alone does not assist in narrowing the differential diagnosis. there is still need for biopsy in children with extradural compression by a mass. introduction extradural spinal cord compression may be the result of infection, inflammation or neoplasia. masses may arise from the thoracic and abdominal cavities, from the vertebral column (and discs) as well as both sympathetic and exiting nerves. categorisation of lesions according to the level involved (cervical, thoracic, lumbar, sacral) and according to the compartments involved, in combination or singly (extraspinal, vertebral, intraspinal extradural, intradural extramedullary and intradural intramedullary), is routinely performed with the aim of narrowing the differential diagnosis.1 in particular, in the developing world (and with the advent of hiv in the developed world), it is necessary to distinguish tb spondylitis from neoplastic causes, to avoid biopsy.2 tb spondylitis is treated medically in most cases2 while neoplastic lesions require any combination of surgery, chemotherapy and radiotherapy to alleviate the cord compression. using signal characteristics on magnetic resonance imaging (mri) to distinguish infective lesions from neoplasia does not usually resolve the differential diagnosis, with the majority of lesions (infective and neoplastic) demonstrating low or intermediate signal on t1 and high signal on t2 with abscess formation in tb spondylitis2,3 and cyst formation in some neoplasms (ewing’s sarcoma, neuroblastoma).4,5 rim enhancement of the soft-tissue mass is a feature that most strongly supports a diagnosis of tb spondylitis2,3 but this is also seen in pyogenic spondylitis5 and may occur when enhancing neoplasms show cystic degeneration.5 involvement of a disc in conjunction with a vertebral body is considered a strong pointer to an infective spondylitis2 but has been shown with metastatic disease3 and other neoplasms. subligamentous spread is seen in tb spondylitis demonstrating extension above and below the level of involvement but this extension is also seen with neuroblastoma5 and lymphoma involving the spinal canal. the aim of this paper is to determine whether there are significant differences between tb spondylitis and neoplasia causing extradural compression of the cord with regard to the anatomical distribution and compartmentalisation without considering the signal characteristics or contrast enhancement. aim the aim was to determine if the demonstration of anatomical distribution/compartmentalisation on magnetic resonance imaging (mri) can differentiate tb spondylitis from neoplasia in extradural cord compression in children. materials and methods a subgroup of patients who had a diagnosis of extradural spinal cord compression was extracted from a database of mri scans performed of the spine in children at one institution over one year. incomplete or inadequate studies, inadequate clinical notes and patients imaged for trauma or congenital anomalies (such as tethered cord/dysraphism) were excluded. a paediatric radiologist and a registrar, both blinded to the final diagnoses, reviewed images. features recorded included vertebral level involved (cervical, thoracic, lumbosacral), unior multifocal involvement, involvement over numerous vertebral levels and the compartments involved in combination (extraspinal, vertebral, intraspinal extradural). the final diagnoses reached through biopsy, trial of therapy and associated clinical findings were used to categorise the patients after the blinded ct review into a ‘tb spondylitis group’ and a ‘neoplastic group’. only the anatomical distribution and compartment information was then used to determine differences between the two groups. results from a total of 67 patients who had undergone mri of the spine, 16 had a diagnosis of extradural spinal pathology (24%) and were included in the study. there were 9 males and 7 females and ages ranged from is anatomical distribution helpful for differentiating tb spondylitis from neoplastic causes of extradural spinal cord compression in children? a pilot study reena george, md, mmed rad, frcr (uk) savvas andronikou, mb bch, fcrad, frcr, phd hassan lameen, mb chb ayanda mapukata, mb chb salomine theron, mb chb, mmed rad, fcrad jaco du plessis, mb chb deapartment of radiology, tygerberg hospital and stellenbosch university, tygerberg 80 sa journal of radiology • december 2007 pg80-84.indd 80 12/11/07 2:24:02 pm original articleoriginal article 81 sa journal of radiology • december 2007 4 months to 14 years and 2 months (average 97 months/8 years and 1 month). final diagnosis comprised 8 cases of neoplastic disease, 6 cases of infection and 2 cases of inflammation. the two cases of non-specific inflammation were excluded for the purposes of this study. neoplastic lesions included neurofibromas (2), ganglioneuroma (1), lymphoma (1), pulmonary blastoma (1) (fig. 1), ewing‘s sarcoma (1) (fig. 2a & b), infantile fibromatosis (1) (fig. 3a & b) and haemangioma (1) (fig. 4). table i compares the 2 groups. the site was primarily thoracic for both groups and cervical location was uncommon for tb. both groups involved multiple vertebral levels in contiguity (tb 6/6, neoplasm 7/8) but tb was often multifocal (6/6) whereas no neoplastic process was seen multifocally. both tb and neoplasia involved the extraspinal compartment regularly (tb 4/6, neoplasia 6/8) and tb always involved the vertebral body (6/6) while neoplasia only involved the vertebral body in half the cases (4/8). discussion it is reported and taught that an effective and commonly used approach to interpretation of disease involving the spine is to categorise the disease as extradural, intradural extramedullary or intradural intramedullary.1 this is best achieved using axial and sagittal mri sequences.1 the intent is to narrow the differential diagnosis in the hope of reaching an imaging diagnosis, thereby avoiding biopsy in addition to planning surgery/management in the case of neoplasia. the pattern of bone and disc involvement is insufficient grounds for differentiating tb spondylitis from metastatic disease in adults3 and this is also sometimes the case with paediatric imaging. multiple destructive vertebral bone lesions in children other than tb spondylitis include: (i) malignancies, particularly neuroblastoma metastases, lymphoma and ewing’s sarcoma; (ii) benign bone tumours such as aneurysmal bone cysts; and (iii) infections including pyogenic, brucella, fungal and echinococcal lesions.2 by far the most common diagnosis in the developing world is infective spondylitis.2 although computed tomography (ct) and mri features of tb spondylitis have been reported in adults and children there is significant overlap with neoplastic disease.2,3 fig 1. a 4-month-old boy with pulmonary blastoma coronal t1-weighted post-gadolinium-enhanced image shows the mass extending into the spinal canal with a large extradural component. fig. 2. an 11-year-old girl with ewing’s sarcoma of the sacrum. axial (a), and sagittal (b) t1-weighted gadolinium-enhanced images. extradural extension of the iso-intense mass through the neural foramen. a b pg80-84.indd 81 12/11/07 2:24:04 pm original article original article 82 sa journal of radiology • december 2007 original article neoplasms extradural neoplasms in children are usually an extension of neoplasms in the paravertebral soft tissues or anterior vertebral column, most commonly neuroblastoma.6 neuroblastoma, ganglioneuroblastoma and ganglioneuroma arise wherever there is sympathetic tissue.5 mri is the preferred modality for demonstrating intraspinal extension of the primary tumour through the neural foramina – dumbbell neuroblastoma.5,6 this occurs in 10% of abdominal and 28% of thoracic neuroblastomas.5 neuroblastoma may also result in vertebral body metastases, which can also result in cord compression. lymphoma may involve the paravertebral lymph nodes and cause adjacent vertebral invasion, may show malignant vertebral infiltration with or without intraand para-spinal involvement, may involve the epidural space in isolation and may present as an intramedullary mass. spinal cord compression as the presenting feature is rare however (0.13.3%). it is less frequent in childhood than in adulthood and usually affects the cervical region. when spinal localisation is the sole manifestation of lymphoma, the imaging characteristics are not sufficient to make a diagnosis and it is reported that this can only be made by means of biopsy.7 eosinophilic granuloma lesions affect the vertebral body primarily but may extend into the adjacent epidural space to compress the thecal sac.6 ewing sarcoma (primitive neuroectodermal tumour) often originates in the paravertebral soft tissue and extends through the neural foramina, but may also infiltrate other surrounding structures.4 spinal tumours form part of the spectrum of both neurofibromatosis i and ii and occur in a large number of patients in all segments of the spine. these are often intraforaminal (57%) and are surrounded by soft-tissue tumour.8,9 infection a common location for infection in the paediatric spine is the anterior vertebral column; this may involve the vertebral body in isolation, the vertebral body and intervening disc, or the disc alone.6 infection may extend into the epidural space causing compression of the thecal sac.6 the imaging features characteristic of tb spondylitis in addition to fig. 3. a one-and-a-half-year-old boy with infantile fibromatosis. axial (a) and coronal (b) t2-weighted studies show a hyperintense mass with extradural extension via the neural foramina. a b table i. comparison of tb spondylitis with neoplasia for anatomical distribution tb spondylitis (6) neoplasia (8) age 109.8 months 87.5 months male 2 6 female 4 2 cervical 1 3 thoracic 5 4 lumbar 1 3 sacral 1 2 multiple vertebral segments (contiguous) 6 7 multifocal involvement (distant) 3 0 extraspinal with intraspinal extradural 4 6 vertebral with intraspinal extradural 6 4 pg80-84.indd 82 12/11/07 2:24:05 pm original articleoriginal article 83 sa journal of radiology • december 2007 vertebral body involvement include involvement of multiple vertebral segments (contiguously or far apart), presence of a pre/paravertebral mass/abscess; rim enhancement of the abscess; involvement of the disc; and subligamentous spread above and below the level of bone destruction (figs 5, 6a & b).2,3 the thoracolumbar region is reported to be the commonest involved.2,3 one author reports that bony fragments (low signal on all sequences) only occur with tb,3 but the other characteristics listed above may be mimicked by neoplastic disease (table ii). conclusion a small number of patients were evaluated in this paper, but even with this small sample a wide variety of neoplasms demonstrated features fig. 5. a 12-year-old boy with tb spondylitis. sagittal t2-weighted image shows contiguous vertebral body and disc destruction with a large anterior mass and a posterior extradural component compressing the spinal cord. fig. 4. a 10-year-old boy with capillary haemangioma of the vertebral body. sagittal t1-weighted image shows a mottled pattern of increased intensity with a large extradural component. table ii. neoplastic mimickers of characteristic features of tb spondylitis tb spondylitis characteristic neoplastic mimicker pre/paravertebral abscess ewing's cystic degeneration4 rim enhancement of abscess cystic neuroblastoma/ewing's5,4 extension beyond level of bone destruction neuroblastoma5 multifocal neurofibromatosis,8 neuroblastoma5 disc involvement metastases3 pg80-84.indd 83 12/11/07 2:24:06 pm original article original article 84 sa journal of radiology • december 2007 fig. 6. a 10-year-old boy with tb spondylitis. (a) sagittal t1 post-gadolinium and (b) coronal t2-weighted images show multiple contiguous vertebral bodies which have abnormal signal and enhancement as well as disc destruction. there is a predominantly anterior ring-enhancing soft-tissue mass but the smaller posterior extradural component causes spinal cord compression. on mri with regard to their anatomical site and compartment that are characteristic of tb spondylitis. it is not likely that anatomical distribution alone will assist in narrowing the differential diagnosis and obviate the need for biopsy in children with extradural compression by a mass. more research into new mri sequences and use of tissue characterisation as well as gadolinium enhancement patterns are necessary to reach this goal, as current signal and enhancement characteristics for tb spondylitis and neoplasia also overlap. 1. khanna aj, bruce a, paul d. magnetic resonance imaging of the pediatric spine. journal of the american academy of orthopedic surgeons 2003; 11: 248-259. 2. andronikou s, jadwat s, douis h. patterns of disease on mri in 53 children with tuberculous spondylitis and the role of gadolinium. pediatr radiol 2002; 32: 798-805. 3. gupta rk, agawal p, rastogi h, kumar s, phadke rv, krishnani n. problems in distinguishing spinal tuberculosis from neoplasia on mri. neuroradiology 1996; 38: s97-s104. 4. tateishi u, gladish g, kusumoto m, et al. chest wall tumours: radiologic findings and pathologic correlation. radiographics 2003; 23: 1491-1508. 5. lonergan gj, schwab cm, suarez es, carlson cl. neuroblastoma, ganglioneuroblastoma and ganglioneuroma: radiologic-pathologic correlation. radiographics 2002; 22: 911-934. 6. prenger e. magnetic resonance imaging of the pediatric spine. semin ultrasound, ct mr 1991; 12(5): 410-428. 7 acquaviva a, marconcini s, municchi g, vallome i, palma i. non-hodgkin lymphoma in a child presenting with acute paraplegia; a case report. pediatr hematol oncol 2003; 20: 245-251. 8. thakkar sd, feigen u, mautner vf. spinal tumours in neurofibromatosis type i: an mri study of frequency, multiplicity and variety. neuroradiology 1999; 41: 635-629. 9. mautner v-f, tatagiba m, lindenau m, et al. spinal tumours in patients with neurofibromatosis type ii: mr imaging study of frequency, multiplicity and variety. ajr 1995; 165: 951-955. pg80-84.indd 84 12/11/07 2:24:07 pm sajr 23-1_2019_contents.indd http://www.sajr.org.za open access table of contents i original research imaging findings of penetrating spinal cord injuries secondary to stab wounds on magnetic resonance imaging in a tertiary trauma unit, south africa jacolien m. rall, fekade a. gebremariam, gina joubert south african journal of radiology | vol 23, no 1 | a1761 | 19 september 2019 original research the accuracy of magnetic resonance imaging diagnosis of non-osseous knee injury at steve biko academic hospital nashil singh, heleen hanekom, farhana e. suleman south african journal of radiology | vol 23, no 1 | a1754 | 25 september 2019 original research normal measurements of the optic nerve, optic nerve sheath and optic chiasm in the adult population sanele s. mncube, matthew d. goodier south african journal of radiology | vol 23, no 1 | a1772 | 05 november 2019 original research evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region isak d. vorster, steve beningfield south african journal of radiology | vol 23, no 1 | a1720 | 20 november 2019 original research tunnelled haemodialysis catheters in central free state: epidemiology and complications john fox, gina joubert, eugene loggenberg south african journal of radiology | vol 23, no 1 | a1791 | 27 november 2019 original research accuracy of plain radiographs in diagnosing biopsy-proven malignant bone lesions erhardt gerber, qonita said-hartley, rufkah gamieldien, tharbit hartley, sally candy south african journal of radiology | vol 23, no 1 | a1768 | 06 december 2019 case report embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient – a rare cause of obstructive jaundice denny mathew, heliodora de lima, nasreen mahomed south african journal of radiology | vol 23, no 1 | a1662 | 10 january 2019 case report solid to cystic: a case report of imaging findings of atypical lung metastases tanusha sewchuran south african journal of radiology | vol 23, no 1 | a1663 | 28 january 2019 case report vanishing white matter disease imaged over 3 years denny mathew, nasreen mahomed south african journal of radiology | vol 23, no 1 | a1661 | 27 february 2019 60 68 74 81 86 92 99 103 106 page i of ii table of contents i editorial the power of indexers maya patel south african journal of radiology | vol 23, no 1 | a1827 | 10 december 2019 original research cost analysis of violence-related medical imaging in a free state tertiary trauma unit tiaan p. steyn, fekade a. gebremariam south african journal of radiology | vol 23, no 1 | a1664 | 08 january 2019 original research outcomes of prostate artery embolisation for benign prostatic hyperplasia in 10 cases at steve biko academic hospital hatty g. fischer, farhana e. suleman, samia ahmad south african journal of radiology | vol 23, no 1 | a1349 | 11 february 2019 original research prevalence and pattern of basal skull fracture in head injury patients in an academic hospital ntjeke s. mokolane, cornelia minne, alireza dehnavi south african journal of radiology | vol 23, no 1 | a1677 | 13 march 2019 original research medical doctors’ awareness of radiation exposure in diagnostic radiology investigations in a south african academic institution akingboye m. dauda, john o. ozoh, olakunle a. towobola south african journal of radiology | vol 23, no 1 | a1707 | 30 april 2019 original research multicentre study on dynamic contrast computed tomography findings of focal liver lesions with clinical and histological correlation sheila t. ominde, timothy m. mutala south african journal of radiology | vol 23, no 1 | a1667 | 21 may 2019 original research preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: a prospective study dar m. saleem, wani a. haseeb, arshed h. parry, robbani irfan, najar m. muzaffar, gojwari tariq, shah o. javed, imza feroz south african journal of radiology | vol 23, no 1 | a1727 | 10 june 2019 original research a retrospective study correlating sonographic features of thyroid nodules with fine-needle aspiration cytology in a south african setting mark a. nicolaou, kathleen jacobs, sindeep bhana, kershlin naidu, veronique nicolaou south african journal of radiology | vol 23, no 1 | a1749 | 26 june 2019 original research spectrum of multi-detector computed tomography imaging findings of thoracic vascular injuries secondary to blunt chest trauma: correlation with vascular intervention and patient outcomes sithembiso m. langa, nondumiso n.m. dlamini, balasoobramanien pillay south african journal of radiology | vol 23, no 1 | a1709 | 23 july 2019 1 2 7 13 20 27 34 43 49 vol 23, no 1 (2019) issn: 1027-202x (print) | issn: 2078-6778 (online)south african journal of radiology http://www.sajr.org.za open access table of contents ii case report atypical exophytic liver mass: giant pedunculated hepatic haemangioma masquerading as a gastrointestinal stromal tumour of the gastric wall venkatram krishnan, sunil k. bajaj, abhilash sethy, neetika gupta south african journal of radiology | vol 23, no 1 | a1697 | 18 march 2019 case report cystic pelvi-abdominal mass in pregnancy: an uncommon presentation of a subserosal leiomyoma natasha sobey, lauren raubenheimer south african journal of radiology | vol 23, no 1 | a1683 | 18 april 2019 case report renal arteriovenous malformation: an unusual pathology alain m. mukendi, amer rauf, sean doherty, florence mahlobo, peter afolayan, shabina dawadi south african journal of radiology | vol 23, no 1 | a1704 | 30 may 2019 case report extra-skeletal ewing sarcoma of the chest wall in a child denny mathew, daniel n. prince, nasreen mahomed south african journal of radiology | vol 23, no 1 | a1733 | 27 june 2019 110 117 122 127 case report pancreatic kaposiform hemangioendothelioma complicated by kasabach–merritt phenomenon: a rare entity denny mathew, nasreen mahomed south african journal of radiology | vol 23, no 1 | a1760 | 19 august 2019 case report page kidney: a rare cause of secondary hypertension ilonka warnich, mark nicolaou, zelia sofianos, jacobus a. pienaar, jacob varghese south african journal of radiology | vol 23, no 1 | a1762 | 23 september 2019 clinical perspective meralgia paresthetica: now showing on 3t magnetic resonance neurography raihaan m. ally, mark d. velleman, farhana e. suleman south african journal of radiology | vol 23, no 1 | a1745 | 21 august 2019 132 137 141 page ii of ii vol 23, no 1 (2019) special collection: lines, tubes and devices review article chest radiographs of cardiac devices (part 1): lines, tubes, non-cardiac medical devices and materials* rishi p. mathew, timothy alexander, vimal patel, gavin low *refer to the correction section for more information regarding this article south african journal of radiology | vol 23, no 1 | a1729 | 29 july 2019 review article chest radiographs of cardiac devices (part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and amplatzer occluder devices rishi p. mathew, timothy alexander, vimal patel, gavin low south african journal of radiology | vol 23, no 1 | a1730 | 31 july 2019 144 153 review article chest radiographs of cardiac devices (part 2): ventricular assist devices rishi p. mathew, timothy alexander, vimal patel, gavin low south african journal of radiology | vol 23, no 1 | a1732 | 31 july 2019 correction erratum: chest radiographs – lines, tubes, non-cardiac medical devices and materials rishi p. mathew, timothy alexander, vimal patel, gavin low south african journal of radiology | vol 23, no 1 | a1808 | 05 december 2019 reviewer acknowledgement south african journal of radiology | vol 23, no 1 | a1830 | 11 december 2019 166 174 175 radiology_may04 review article 50 sa journal of radiology • may 2004 a 74-year-old man with a productive cough was referred from a peripheral hospital. the referral diagnosis queried a calcified echinococcus cyst in the left hemithorax. chest x-ray figs 1 and 2 show pa and lateral views. what are the relevant findings? the patient was then referred for an echocardiogram (figs 3 and 4) and mri study (figs 5 8). what is your diagnosis? the big-hearted man now in trouble irma van de werke frcr zarina lockhat ffrad(d)sa betsie van der walt fcrad(d)sa rowaida abdullah mb chb department of radiology university of pretoria fig. 1. fig. 2. fig. 3. fig. 4. fig. 5. fig. 6. fig. 7. fig. 8. 51 sa journal of radiology • may 2004 quiz case discussion pa and lateral chest x-rays demonstrate cardiomegaly with an ovalshaped mass with rim calcification in the region of the left atrium and ventricle. echocardiogram a large aneurysm is noted in the region of the left ventricle, at the submitral valve level. mri the four chamber view shows a large aneurysm in the postero-lateral wall of the left ventricle. it is situated just inferior to the posterior mitral valve cusp. rim calcification is present. on the two chamber view the aneurysm is again noted in the left ventricular region. discussion mitral subannular left ventricular aneurysms are not seen frequently. those described have occurred mostly in africa and india.4 these aneurysms arise in the fibrous ring below the mitral or aortic valve. the submitral type is more common than the subaortic type. submitral aneurysms occur in the epicardium, related to the base of the left ventricle.5 these aneurysms have ovoid ostia which are frequently multiple and located under the posterior leaflet of the mitral valve. the aetiology is unknown though a congenital defect in the posterior mitral valve annulus has been postulated. these aneurysms are false and may reach enormous proportions. they may calcify or contain mural thrombus. complications include myocardial ischaemia and infarction, systemic embolisation, congestive cardiac failure and infective endocarditis as well as rupture of the aneurysm. surgical resection of the aneurysm with or without valve replacement is indicated in severe valvular regurgitation or cardiac failure resistant to medical therapy. the acquired causes may be due to infection, myocardial infarction, collagen vascular disease, takayasu's arteritis, myocarditis or trauma. addendum we refer to the publication of our first case in the south african journal of radiology of march 2002.6 the subsequent case demonstrates the different plain chest film and ultrasound appearances of the subannular left ventricular aneurysms (figs 9 12). acknowledgement we would like to thank annelize gates for her assistance in preparation of this article. fig. 10. fig. 11. fig. 12. fig. 9. review article 52 sa journal of radiology • may 2004 references 1. edelstein cl, blake rs, klopper jf. mitral subannular left ventricular aneurysm. s afr med j 1987; 71: 114 115. 2. chesler e, joffe n, schamroth c, meyers a. annular subvalvular left ventricular aneurysms in the south african bantu. circulation 1965; xxxii: 43 51. 3. edington gm, williams ao. left atrial aneurysms associated with annular subvalvular left ventricular aneurysms. journal of pathology and bacteriology 1968; 96: 273 -283. 4. taneja k, mathur a, sharma s, rajani m, das b, venugopal p. magnetic resonance imaging features of submitral left ventricular aneurysm. indian heart j 1998; 50: 453 455. 5. chesler e. aneurysms of the left ventricle. cardiovascular clinics 1972; 4: 187 217. 6. van de werke i, lockhat z, van der walt e, abdulla r. calcified mitral subannular left ventricular aneurysm. south african journal of radiology 2000; 6: 33 35. erratum in the case report entitled ‘recurrent life-threatening haemoptysis in pulmonary tuberculosis — the importance of pulmonary angiography’ from the november 2003 sajr, vol 7 no 4, page 23, the third author (r naidoo, department of thoracic surgery, wentworth hospital) was unfortunately omitted in error. the authors should be: s msimang, p corr, r naidoo. sajr 836 primary extradural meningioma arising from the calvarium n ravi,1 md; w x yi,1 phd; l yu,1 md; h j ping,2 mb bs; d z hao,3 phd 1 department of radiology, xiangya hospital, central south university, changsha, hunan, china 2 department of radiology, changsha eighth hospital, changsha, hunan, china 3 department of pathology, xiangya hospital, central south university, changsha, hunan, china corresponding author: w x yi (cjr.wangxiaoyi@vip.163.com) meningiomas are the most common intracranial tumours. meningiomas arising at other locations are termed primary extradural meningiomas (edms) and are rare. here we report a case of edm arising from the calvarium – a primary calvarial meningioma (pcm). s afr j rad 2013;17(2):70-71. doi:10.7196/sajr.836 a 45-year-old woman presented with a left-sided scalp lump of 3 years’ duration. the lump began as a small swelling and gradually increased in size. it was not associated with headache or any other neurological deficits. her past medical history was unremarkable. on examination, the swelling was seen to be situated in the left frontoparietal aspect of the skull, was approximately 5 cm x 5 cm x 0.7 cm in size, with well-defined borders and a bony consistency. it was non-mobile, non-tender and non-pulsatile. computed tomography (ct) and magnetic resonance imaging (mri) of the head (figs 1 4) was performed to further characterise the lesion. the patient then underwent a wide resection of the mass, followed by cranioplasty using a titanium mesh. the histopathological diagnosis was a who grade i meningioma. fig. 1. axial non-contrast ct image of 2   mm thickness in bone window settings demonstrates a focal expansile hyperosteotic bony lesion on the left fronto-parietal portion of the skull. the lesion is seen along the course of the coronal suture on the left. there are no evident intracranial abnormalities. fig. 2. axial t1-weighted mr image demonstrates a focal expansile hypo-intense bone lesion in the superior left fronto-parietal region of the skull. there are no radiologically evident intracranial abnormalities. fig. 3. axial t2-weighted mr image demonstrates a focal expansile hypo-intense bone lesion in the superior left frontoparietal region of the skull. fig. 4. axial t1-weighted mr image post gadolinium contrast administration shows a bony lesion measuring approximately 7   cm x 7.2   cm x 2   cm in size with minimal homogenous contrast enhancement. however, the underlying dura demonstrates an intense contrast enhancement. discussion primary extradural meningiomas (edms) can arise in any tissue without direct extension from an intracranial tumour. primary edms have a reported incidence of less than 2% of all meningiomas, and have been reported to arise from scalp tissue, the orbit, paranasal sinuses, nasopharynx, neck, skin, lung, mediastinum, adrenal and paraspinal regions, and fingers.1 previously, these tumours were called extracranial, ectopic, extradural, extraneuraxial, cutaneous, calvarial or intraosseous meningiomas.1-3 however, it has been suggested that the appropriate nomenclature should be primary edm, to avoid confusion.1 primary edms have a slight female preponderance (1:1.4)2-4 with a bimodal age distribution: the first peak is in the 2nd decade and the next in the 5th 7th decades.1 primary edms have been classified as extracalvarial (type i), purely calvarial (type ii) and calvarial with extracalvarial extension (type iii). types ii and iii have been further sub-classified into skull convexity (c) and skull base (b) tumours, depending on their location.1 the most common presenting feature of primary calvarial meningioma (pcm) is a painless, gradually expanding mass lesion.2 , 3 on ct examination, the part of the skull that is involved usually has a hyperdense osteoblastic appearance and demonstrates intense contrast enhancement.1-5 the most common mri appearance is a hypo-intense t1 and hyperintense t2 bone lesion, which shows intense homogenous contrast enhancement following iv gadolinium administration.1-5 the dura underlying the tumour might show contrast enhancement; this is thought to be due to either dural irritation by the tumour or to dural invasion by tumour cells. recent studies have suggested that the management strategy for pcm should be based on the histological grade.2 the treatment strategy for world health organization (who) grade i (benign) pcms is complete excision with wide margins.2 who grade ii (atypical) and grade iii (malignant) tumours are treated with wide excision, followed by adjuvant radiotherapy and/or chemotherapy.2 1. lang ff, macdonald ok, fuller gn, demonte f. primary extradural meningiomas: a report on nine cases and review of literature from the era of computerized tomography scanning. j neurosurg 2000;93(6):940-950. [http://dx.doi.org/10.3171/jns.2000.93.6.0940] 1. lang ff, macdonald ok, fuller gn, demonte f. primary extradural meningiomas: a report on nine cases and review of literature from the era of computerized tomography scanning. j neurosurg 2000;93(6):940-950. [http://dx.doi.org/10.3171/jns.2000.93.6.0940] 2. mattox a, hughes b, oleson j, reardon d, mclendon r, adamson c. treatment recommendations for primary extradural meningiomas. cancer 2011;117(1):24-38. [http://dx.doi.org/10.1002/cncr.25384] 2. mattox a, hughes b, oleson j, reardon d, mclendon r, adamson c. treatment recommendations for primary extradural meningiomas. cancer 2011;117(1):24-38. [http://dx.doi.org/10.1002/cncr.25384] 3. elder jb, atkinson r, zee cs, chen tc. primary intraosseous meningioma. chin med j (engl) 2013;126(7):1390-1391. 3. elder jb, atkinson r, zee cs, chen tc. primary intraosseous meningioma. chin med j (engl) 2013;126(7):1390-1391. 4. al-khawaja d, murali r, sindler p. primary calvarial meningioma. j clin neurosci 2007;14(12):1235-1239. [http://dx.doi.org/10.1016/j.jocn.2006.08.010] 4. al-khawaja d, murali r, sindler p. primary calvarial meningioma. j clin neurosci 2007;14(12):1235-1239. [http://dx.doi.org/10.1016/j.jocn.2006.08.010] 5. mcguire tp, palme ce, perez-ordonez b, gilbert rw, sándor gk. primary intraosseous meningioma of the calvaria: analysis of the literature and case report. oral surg oral med oral pathol oral radiol endod 2007;104:e34-e41. 5. mcguire tp, palme ce, perez-ordonez b, gilbert rw, sándor gk. primary intraosseous meningioma of the calvaria: analysis of the literature and case report. oral surg oral med oral pathol oral radiol endod 2007;104:e34-e41. abstract introduction case discussion conclusion acknowledgements references about the author(s) sitang nirattisaikul department of radiology, faculty of medicine, prince of songkla university, hatyai, thailand arunee dechaphunkul department of internal medicine, faculty of medicine, prince of songkla university, hatyai, thailand keerati hongsakul department of radiology, faculty of medicine, prince of songkla university, hatyai, thailand citation nirattisaikul s, dechaphunkul a, hongsakul k. angiosarcoma of the pulmonary artery mimicking pulmonary thromboembolism. s afr j rad. 2021;25(1), a2150. https://doi.org/10.4102/sajr.v25i1.2150 case report angiosarcoma of the pulmonary artery mimicking pulmonary thromboembolism sitang nirattisaikul, arunee dechaphunkul, keerati hongsakul received: 16 mar. 2021; accepted: 25 may 2021; published: 10 aug. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract primary pulmonary angiosarcomas (ppas) are rare, and often, their diagnosis is delayed because of insidious clinical symptoms and imaging findings mimicking pulmonary thromboembolism (pe). a 33-year-old female patient presented with chest pain and progressive dyspnoea. her initial diagnosis, based on clinical symptoms and ct pulmonary angiography (pa) findings, was pe. however, after treatment with anticoagulants, the patient failed to improve. a follow-up ctpa and further ct-guided biopsy results were compatible with angiosarcoma. keywords: angiosarcoma; pulmonary thromboembolism; ct pulmonary angiography; pulmonary sarcoma; pulmonary artery. introduction primary pulmonary angiosarcoma (ppa) is a rare tumour with a poor prognosis. the rarity of this condition and the difficulty in distinguishing the clinical and imaging findings from pulmonary thromboembolism (pe) often result in a delayed diagnosis, usually with local invasion or metastases and therefore, a poor prognosis. at present, advanced imaging techniques such as computed tomography pulmonary angiography (ctpa) help improve the rate of detection and diagnostic accuracy of ppa. this report describes a case of ppa and reviews the literature on the imaging findings, using various modalities to distinguish between ppa and pe. case a 33-year-old female non-smoker presented with a 1-month history of cough, chest pain and progressive dyspnoea. she had no fever, haemoptysis or lower limb oedema. the frontal radiograph revealed normal sizes of the main, right and left pulmonary arteries with a minimal left pleural effusion (figure 1a). computed tomography pulmonary angiography was performed because of suspected pe, which demonstrated a poorly enhancing hypodense lesion involving a dilated left main pulmonary artery and pulmonary trunk and subpleural consolidation in the left upper lobe (figure 1b). figure 1: (a) frontal chest radiograph demonstrates normal sized main, right and left pulmonary arteries with a small left basal pleural effusion (arrow). (b) axial computed tomography pulmonary angiography demonstrated a filling defect extending from a dilated main pulmonary artery into the left pulmonary artery (arrows). the patient was diagnosed with acute pe and pulmonary infarction in the left upper lobe. although she was subsequently treated with anticoagulants, her clinical condition failed to improve. follow-up frontal radiograph and ctpa was repeated three months after treatment. the frontal chest radiograph indicated new findings of an enlarged main pulmonary artery and a left hilar mass (figure 2a). computed tomography pa revealed progressive enlargement of the previous poorly enhancing lesion, now involving the right and left pulmonary arteries and main pulmonary trunk with extraluminal extension into the mediastinum (figure 2b). computed tomography-guided biopsy of the mediastinal lesion was performed. histopathologic analysis of the specimen revealed high-grade malignancy with massive haemorrhage and necrosis, consistent with angiosarcoma (figure 3). unfortunately, the patient demised before completing treatment with chemoradiation therapy. figure 2: (a) follow-up frontal chest radiograph revealed an enlarged main pulmonary artery and a left hilar mass (arrows). (b) axial computed tomography pulmonary angiography demonstrated a large lobulated rim enhancing exophytic mediastinal mass extending from the dilated main pulmonary artery and the left pulmonary artery (arrows). figure 3: microscopic examination demonstrated high-grade malignant cells (small arrows) with massive haemorrhage (large arrows) and necrosis (asterisks). discussion primary sarcoma of the great vessels is a rare malignant tumour with less than 1% prevalence amongst all sarcomas, usually only documented in case reports and case series studies.1,2 it is more common in middle-aged patients with no sex predominance.1 primary sarcoma of the pulmonary artery is classified by location into the intimal and mural types, with the intimal type more commonly encountered than the mural type. the most common locations of ppa are at the pulmonary artery trunk3 and proximal pulmonary artery. unilateral involvement of the pulmonary vessels is frequently observed in ppa compared with embolic disease.1,2 patients with ppa may present with clinical symptoms resembling those frequently seen in pe including dyspnoea, chest pain, cough and haemoptysis.1 consequently, an initial diagnosis of pe is usually made, before lung cancer and even more rarely ppa. however, if clinical symptoms progress in the absence of predisposing factors for pe, ppa should be considered. imaging modalities used to diagnose ppa include ctpa, mri, transthoracic echocardiography (tte) and positron emission tomography with 2-deoxy-2[fluorine-18]fluoro-d-glucose integrated with ct (18f-fdg pet/ct). however, definite diagnosis with imaging alone is difficult because of the imaging findings of ppa mimicking pe. chest radiography may be normal or appear similar to pulmonary arterial hypertension or a hilar mass. computed tomography pulmonary angiography is the initial modality of choice when pe is suspected. both ppa and pe have similar cross-sectional imaging findings, usually a filling defect in the pulmonary artery. a retrospective review of the initial ctpa in this case revealed a poorly enhancing filling defect in the dilated left main pulmonary artery and pulmonary trunk, resulting in an initial misdiagnosis of pe. imaging findings that may suggest the diagnosis of ppa over pe include a unilateral filling defect occupying the entire luminal diameter of the main or proximal pulmonary arteries, distension of the portion of the involved pulmonary artery, extraluminal extension of the tumour, heterogeneous enhancement and smooth vascular tapering without abrupt narrowing or cut-off as well as mosaic attenuation in the lung parenchyma and metastasis to the lung or distant organs.1,2,4 the attenuation of ppa on ctpa may be homogeneous, similar to bland thrombus in pe. heterogeneous density could be related to areas of haemorrhage, necrosis or cyst formation within the tumour. stable or progressive filling defects seen at follow-up ctpa after adequate anticoagulant therapy for pe may favour alternative diagnoses such as ppa.2,5 in the case presented, progressive enlargement of the previous filling defect was observed, with involvement of the dilated right and left pulmonary arteries and main pulmonary trunk and extraluminal extension into the mediastinum, all findings suggestive of pulmonary artery sarcoma. the diagnosis of ppa was confirmed at ct-guided biopsy and histopathological diagnosis of angiosarcoma. magnetic resonance imaging and 18f-fdg pet/ct are advanced imaging techniques used to diagnose ppa. mri demonstrates high signal intensity on t2-weighted short-tau inversion recovery imaging (stir) and is superior to ctpa in the evaluation of vascularisation seen as heterogeneous enhancement.6 18f-fdg pet/ct helps distinguish between benign conditions and malignant tumours. in ppa, 18f-fdg pet/ct shows increased uptake because of hypermetabolic activity whilst negative uptake in pe.2,7 however, very few cases of 18f-fdg pet/ct for ppa have been performed thus far. at tte, mass mobility, attachment to the pulmonary artery wall or pulmonary artery valve, absence of echolucent areas and bulging rather than linear morphology favour the diagnosis of ppa over pe.6 the primary management of ppa is surgical, and options include pulmonary endarterectomy, lobectomy and pneumonectomy and/or a combination of chemotherapy and radiation. however, the prognosis is poor with a median survival of 26 months after surgery.8 conclusion this report describes a case of ppa where clinical and imaging findings overlapped with pe resulting in an initial misdiagnosis and therefore delayed treatment and poor prognosis. although ppa is a rare disease, clinicians and radiologists should keep this differential diagnosis in mind when there is filling defect in an expanded pulmonary artery with chronic gradual progression of the disease, absence of risk factors for thromboembolism, lack of clinical improvement after adequate treatment with anticoagulants and lung metastases but no known primary or features of other primary malignancy. computed tomography pulmonary angiography helps differentiate between ppa and pe, and pulmonary artery sarcoma should be considered when there is a heterogeneously enhancing lesion in a distended pulmonary artery with extraluminal extension. moreover, the patient should return for an unenhanced scan to confirm enhancement if ppa is suspected. acknowledgements the authors would like to thank laksika bhuthathorn for the english editing of the article. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. authors’ contributions s.n., a.d. and k.h. contributed equally to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. ethical considerations this article followed all ethical standards for research. funding information the authors received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references yi ca, lee ks, choe yh, et al. computed tomography in pulmonary artery sarcoma: distinguishing features from pulmonary embolic disease. j comput assist tomogr. 2004;28(1):34–39. https://doi.org/10.1097/00004728-200401000-00005 von falck c, meyer b, fegbeutel c, et al. imaging features of primary sarcomas of the great vessels in ct, mri and pet/ct: a single-center experience. bmc med imaging. 2013;13:25. https://doi.org/10.1186/1471-2342-13-25 yi es. tumors of the pulmonary vasculature. cardiol clin. 2004;22(3):431–440. https://doi.org/10.1016/j.ccl.2004.05.001 ishiguro t, kasahara k, matsumoto i, et al. primary pulmonary artery sarcoma detected with a pulmonary infarction. intern med. 2007;46(9):601–604. https://doi.org/10.2169/internalmedicine.46.6292 bendel ec, maleszewski jj, araoz pa. imaging sarcomas of the great vessels and heart. semin ultrasound ct mri. 2011;32(5):377–404. https://doi.org/10.1053/j.sult.2011.06.001 al-mehisen r, al-halees z, alnemri k, et al. primary pulmonary artery sarcoma: a rare and overlooked differential diagnosis of pulmonary embolism. clues to diagnosis. int j surg case rep. 2019;65:15–19. https://doi.org/10.1016/j.ijscr.2019.10.014 chong s, kim ts, kim b-t, et al. pulmonary artery sarcoma mimicking pulmonary thromboembolism: integrated fdg pet/ct. am j roentgenol. 2007;188(6):1691–1693. https://doi.org/10.2214/ajr.05.0874 secondino s, grazioli v, valentino f, et al. multimodal approach of pulmonary artery intimal sarcoma: a single-institution experience. sarcoma. 2017;2017:7941432. https://doi.org/10.1155/2017/7941432 abstract introduction case report discussion conclusion acknowledgements references about the author(s) pavel burko department of diagnostic radiology, national medical research center of rehabilitation and balneology, moscow, russian federation department of diagnostic radiology, clinic for diagnostics and management on izmaylova, penza, russian federation nitin juggath department of radiation medicine, faculty of health sciences, university of cape town, cape town, south africa ruslan iliasov department of surgery, clinic for diagnostics and management on izmaylova, penza, russian federation mariya fedorova department of morphology, faculty of general medicine, penza state university, institute of medicine, penza, russian federation natalia nazarova department of radiology, penza institute for further training of physicians branch campus of the russian medical academy of continuous professional education, penza, russian federation department of diagnostic radiology, clinical hospital №6 named after g.a. zakharyin, penza, russian federation citation burko p, juggath n, iliasov r, fedorova m, nazarova n. a case report of multinodular hepatic steatosis mimicking pseudotumors of the liver. s afr j rad. 2022;26(1), a2410. https://doi.org/10.4102/sajr.v26i1.2410 case report a case report of multinodular hepatic steatosis mimicking pseudotumors of the liver pavel burko, nitin juggath, ruslan iliasov, mariya fedorova, natalia nazarova received: 25 jan. 2022; accepted: 28 mar. 2022; published: 27 june 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract fatty liver disease (fld) is a common, benign pathology often found incidentally. we present a clinical case in which metastatic liver disease was suspected on initial imaging studies. following further investigations, a diagnosis of ‘non-alcoholic fatty liver disease (nafld), multinodular type’ was postulated. subsequent histology confirmed the presence of liver steatosis. multinodular type hepatic steatosis is a rare, but clinically important pathology to identify and differentiate from other multifocal lesions of the liver parenchyma. keywords: liver; hepatic steatosis; pseudotumours; magnetic resonance imaging; computed tomography; fatty liver disease. introduction fatty liver disease (fld) is an excessive accumulation of fatty acids in hepatocytes in the form of triacylglycerol, usually predominantly around the central veins (hypoxic area) in the absence of inflammation or liver damage. it is one of the most common chronic liver diseases. according to a large meta-analysis performed in 2016, which included more than 8 million people from 22 countries, fatty liver infiltration occurs in 25.24% of the world’s inhabitants.1 according to the data of the largest russian study direg 2, nafld occurs amongst outpatients of medical preventive institutions in 37.30%.2 there is also evidence that this is the most common disease of the internal organs in the russian federation.3 simple steatosis (excessive accumulation of fat in the form of triglycerides in the liver), observed in nafld, is often benign. however, progression of the disease to non-alcoholic steatohepatitis increases the risk of developing fibrosis, cirrhosis, liver failure, hepatocellular carcinoma and, accordingly, increases the risk of death.1 the gold standard for diagnosing fld is a percutaneous puncture biopsy followed by histological analysis.4,5 however, this is an invasive technique, at risk of various complications. accordingly, the systematisation of non-invasive diagnostic algorithms is one of the most pressing problems of modern hepatology and internal medicine. although it should be noted that none of the techniques, such as ultrasound (the appearance of increased echogenicity of the liver due to fatty infiltration, resulting in increased hepatic/renal and hepatic/vascular gradient; can have other aetiologies), ct (hypodensity of the liver parenchyma is not completely specific for fatty tissue, especially in cases of the ‘patchy’ type and with indolent lipid accumulation) and mri (decrease of signal on out-of-phase gradient echo images is characteristic for fld; however, during analysis of the diffuse form, global signal decrease may be a pitfall in interpretation) in isolation cannot provide an absolute certainty in the diagnosis of fld in all clinical cases. the diagnosis of fld based on images is usually straightforward, but sometimes fat accumulation can show unusual structural patterns that can mimic neoplastic, inflammatory or vascular pathology. in these cases, the macrostructure of the liver visualised by imaging techniques can lead to an incorrect diagnosis, unnecessary diagnostic tests and invasive procedures. this report describes a case of multinodular (‘patchy’) type of steatosis, confirmed by radiological and pathological analysis. the imaging appearance of the disease mimicked metastatic liver disease, which led to clinical dissonance in determining the strategy of patient management. case report a 34-year-old male patient sought consultation in the clinic for diagnostics and management on izmaylova (penza, russia) in accordance with a previously completed workup in order to determine the next management steps. physical examination revealed no abnormalities. recorded vital signs were: blood pressure 115/85 mm hg, heart rate 75 beats/min, temperature 36.7 °c and respiratory rate 20 breaths/min.  his saturation was 98%. results of abdominal examinations were normal. there was no history of alcohol consumption, diabetes mellitus, drug therapy or viral hepatitis c. chest ct was performed independently at another clinic. a cd archive of the ct scan without contrast enhancement was provided for a second-opinion. ct analysis demonstrated no pathological changes in the lung parenchyma. at the lower margin of the field of view, a heterogeneous liver parenchyma was noted with numerous variable-sized hypodense nodular foci of round or oval shape in an unequal distribution. the maximum diameter was 2.5 cm. density reading of these liver lesions was about +30 hu (absolute low attenuation), with background liver parenchyma density measuring +50 hu. furthermore, there was no associated mass effect. vascular structures (hepatic veins and portal branches) traversed the nodules without disruption (figure 1). the obvious etiological identity of the lesions was not determined. in accordance with the data from the ct scans, elastography for assessment of the degree of liver fibrosis, mri with contrast for further characterisation of the nodules and evaluation of the laboratory profile was planned. figure 1: non-contrast ct imaging of the chest revealed a multinodular (‘patchy’) pattern of the lesions in the hepatic parenchyma. laboratory analysis data included alpha-fetoprotein, carcino-embryonic antigen, ca19-9, ca 72-4, neuron-specific enolase and cyfra 21-1, which were not abnormal. other laboratory findings were as follows: alanine transaminase (alt): 43.8 iu/l, aspartate transaminase (ast): 36.7 iu/l, ast/alt ratio (de ritis coefficient): 0.8, total bilirubin: 8.9 µmol/l. platelets were 267 × 103/µl. ast to platelet ratio index (apri) was 0.35 (negative predictive value for cirrhosis). the real-time shear wave elastography (swe) data was obtained. the area of interest was located at a depth of 2 cm – 4 cm from the liver capsule. the stage of liver fibrosis was assessed using the metavir f0-f4 scale in accordance with the recommendations of the european federation for ultrasound in medicine and biology. the distribution of colour shades in all segments was relatively uniform. the average elasticity was 7.67 kpa (1.6 m/s), which corresponded with stage f2 (moderate fibrosis). contrast-enhanced abdominal mri was performed. similar findings were appreciated as described earlier on ct. the multiple foci in the hepatic parenchyma were slightly hyperintense on t2and t1-weighted images. there was some suppression on t2-fatsat. on dual gradient echo in-phase and opposed phase (chemical shift selective imaging sequences), a characteristic inversion of the mr signal was detectable due to the intracellular lipid content in the structure of the foci (mr signal drop from pathological (microscopic) fat on the t1-weighted out-of-phase). a quantitative assessment of the fat in the liver was carried out on the basis of the two-point dixon method with flexible echo times, followed by a grading of liver steatosis depending on the percentage of fat according to the schema outlined by kleiner et al.6 a reading of 34% was obtained, which corresponds to grade 2 (moderate fatty hepatosis). the lesions demonstrated no contrast enhancement or diffusion restriction and there was no mass effect from the foci (figure 2). figure 2: contrast-enhanced abdominal mri demonstrated a multinodular (‘patchy’) appearance in the hepatic parenchyma: (a) t2-weighted image; (b) in-phase gradient echo image; (c) t2-fatsat-weighted image; (d) out-of-phase gradient echo image; (e) t1-weighted 3d gradient echo lava-flex sequence (post-gadolinium) and (f) subtracted image. in accordance with the data obtained, a preliminary diagnosis of non-alcoholic fatty liver disease was made which led to the decision to execute a percutaneous liver biopsy followed by histological analysis. pathological analysis in accordance with the scoring system recommended by brunt et al. (2001)7 was performed. primarily, the analysis was focused on determining the degree of steatosis, the activity of inflammation and the stage of liver fibrosis. histologically, the specimen stained with hematoxylin and eosin, (× 100) showed pronounced fatty degeneration. more than 66% of hepatocytes were affected, which corresponded to third-degree macrovesicular (large droplet) steatosis (figure 3) – a very pronounced steatosis, but at the same time, the inflammatory changes are moderate. focal round-cell infiltration in the area of the periportal tracts was also identified. these changes corresponded to the second degree of steatohepatitis. focal fibrosis was differentiated in the third acinus zone, defined as the first stage of fibrosis. figure 3: sectioned slides. macrovesicular globules of fat, inflammation in the area of the periportal tract, focal fibrosis (hematoxylin and eosin, × 100). after histopathological analysis, a clinical diagnosis of non-alcoholic fatty liver disease: steatohepatitis (second degree) and fibrosis of liver (first stage) was made. discussion fatty liver disease is caused by abnormal lipid accumulation in liver cells. it has a relatively benign course, however, as soon as inflammation occurs, the risk of developing fibrosis and cirrhosis increases.8 of note, there is a widespread prevalence of this pathological condition in the population and a rather frequent identification when performing imaging. of greatest interest is ‘patchy’ or multinodular hepatic steatosis, which is the rarest in comparison with focal and diffuse forms, and quite often causes difficulties in differential diagnosis as it mimics metastatic liver disease or pseudotumours.9,10 the pathogenesis of liver steatosis is based on the accumulation of an excessive amount of hepatocellular lipids, represented by triglycerides and other cholesterol derivatives in hepatocytes, due to an imbalance between the synthesis and utilisation of these organic molecules.11 the accumulation of fatty droplets in the liver may be the result of an excessive supply of free fatty acids in the liver or their own increased synthesis by the liver from acetylcoenzyme a, especially in the case of a surplus of the acetylated form of coenzyme a.12 the main clinical feature of fld is asymptomaticity. most often, the disease is detected randomly on the basis of laboratory or instrumental data. in some, clinical symptoms can be recognised as manifestations of metabolic syndrome, such as visceral obesity, signs of impaired glucose metabolism, dyslipidemia and arterial hypertension. the physical examination has no pathognomonic features. the key points in the diagnosis of fld are attributed to imaging techniques. sensitivity and specificity for ct without contrast in the identification of liver steatosis are 33% and 100%, respectively, for ct with contrast, 50% and 83%, respectively, and for mri, 88% and 63%, respectively.13 ultimately, a histological analysis remains the gold standard for the diagnosis of fld.4,5 this is relevant in view of the possibility of obtaining detailed information about the histopathology of the liver, despite the disadvantages of the method, such as invasiveness, high cost and limited study area (especially with respect to diffuse lesions). the diagnosis depends on the qualifications of the pathologist, the risks of complications, and the possibility of erroneous interpretation in the case of an unsatisfactory sample. we collectively decided to execute histological verification, rather than dynamic observation, based on clinical features. from our point of view, it was more ideal for the patient discussed in this report. in addition, this made it possible to confirm the nafld with a high degree of reliability, to make a differential diagnosis between steatosis and steatohepatitis, to evaluate the stage of fibrosis and, based on the results of histological analysis, to make a forecast on the further course of the disease. as a result, our preliminary diagnosis coincided with the pathologist’s opinion. this suggests that fld can be diagnosed at the preinvasive stage of management with a high degree of probability by the rational organisation of laboratory and instrumental techniques, even if an abnormal pattern of fld is detected. conclusion fatty liver disease is a widespread pathological condition, which is often detected at imaging. the most prevalent imaging pattern is diffuse. less common types of hepatic steatosis are focal, perivascular, subcapsular and multinodular. they can mimic neoplastic, inflammatory or vascular conditions, which can lead to confusion, unnecessary diagnostic tests and invasive procedures. therefore, multinodular (‘patchy’) hepatic steatosis is a pathology that we must include in the differential diagnosis of nodular liver lesions. the gold standard for diagnosis is percutaneous liver biopsy with histological analysis. however, it should be noted that liver fat deposition can be diagnosed non-invasively by ultrasound, ct or mri if the established criteria are used. in many cases, this allows the diagnosis of fld without the need for invasive procedures. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.b., n.j., r.i., m.f. and n.n. contributed to the analysis of the results and to the writing of the manuscript. ethical considerations this article followed all ethical standards for research. the patient voluntarily signed informed consent to the publication of a personal medical report in an impersonal form in the journal south african journal of radiology. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability all information pertaining to this study is available within the case report. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references younossi zm, koenig ab, abdelatif d, fazel y, henry l, wymer m. global epidemiology of nonalcoholic fatty liver disease – meta-analytic assessment of prevalence, incidence, and outcomes. hepatology. 2016;64(1):73–84. https://doi.org/10.1002/hep.28431 ivashkin vt, drapkina om, mayev iv, et al. prevalence of non-alcoholic fatty liver disease in out-patients of the russian federation: direg 2 study results. russ j gastroenterol hepatol coloproctol. 2015;6:31–41. (in russian.) https://doi.org/10.17116/terarkh201688859-66 lazebnik lb, golovanova yev, turkina sv, et al. non-alcoholic fatty liver disease in adults: clinic, diagnostics, treatment. guidelines for therapists, third version. clin exp gastroenterol. 2021;1(1):4–52. (in russian.) https://doi.org/10.31146/1682-8658-ecg-185-1-4-52 bedogni g, bellentani s, miglioli l, et al. the fatty liver index: a simple and accurate predictor of hepatic steatosis in the general population. bmc gastroenterol. 2006;6:33. https://doi.org/10.1186/1471-230x-6-33 bedossa p, flip pathology consortium. utility and appropriateness of the fatty liver inhibition of progression (flip) algorithm and steatosis, activity, and fibrosis (saf) score in the evaluation of biopsies of nonalcoholic fatty liver disease. hepatology. 2014;60(2):565–575. https://doi.org/10.1002/hep.27173 kleiner de, brunt em, van natta m, et al. design and validation of a histological scoring system for nonalcoholic fatty liver disease. hepatology. 2005;41(6):1313–1321. https://doi.org/10.1002/hep.20701 brunt em. histopathology of non-alcoholic fatty liver disease. clin liver dis. 2009;13(4):533–544. https://doi.org/10.1016/j.cld.2009.07.008. nassir f, rector rs, hammoud gm, ibdah ja. pathogenesis and prevention of hepatic steatosis. gastroenterol hepatol (ny). 2015;11(3):167–175. tom ww, yeh bm, cheng jc, qayyum a, joe b, coakley fv. hepatic pseudotumor due to nodular fatty sparing: the diagnostic role of opposed-phase mri. ajr am j roentgenol. 2004;183(3):721–724. https://doi.org/10.2214/ajr.183.3.1830721 tebala gd, jwad a, khan aq, long e, sissons g. multifocal nodular fatty infiltration of the liver: a case report of a challenging diagnostic problem. am j case rep. 2016;17:196–202. https://doi.org/10.12659/ajcr.897283 ivashkin vt. disease of the liver and biliary tracts: manual for doctors. m-vesti, moscow. 2005;2:536. (in russian.) buyeverov ao, mayevskaya mv. some pathogenetic and clinical issues of non-alcoholic steatohepatitis. clin perspect gastroenterol hepatol. 2003;3:2–7. (in russian.) kosobyan ep, smirnova om. current concepts of the pathogenesis of non-alcoholic fatty liver disease. diabetes mellitus. 2010;13(1):55–64. (in russian.) https://doi.org/10.14341/2072-0351-6018 mandibulofacial.html mandibulofacial dysostosis hein els, mb chb, mfammed, ccfp shaun scheepers, mb bch department of diagnostic radiology, tygerberg academic hospital, tygerberg, w cape corresponding author: h els (els.hein@gmail.com) two cases of children with treacher collins syndrome (mandibulofacial dysostosis) are presented, to illustrate the features of the syndrome. the cranial computed tomography (ct) scanning was performed to assist with surgical planning. figs 1 and 2 demonstrate some of the features associated with the syndrome. the syndrome known as treacher collins, or franceschetti-zwahlen-klein, syndrome is a rare genetic disorder with an autosomal-dominant pattern of inheritance. it is named after the british ophthalmologist edward treacher collins (1862 1932) who described the essential traits in 1900.1 this developmental disorder has an estimated prevalence of between 1 in 40 000 and 1 in 70 000 live births.2 in most cases, the diagnosis is evident at birth. the features may range from unnoticeable to severe. there are various dysmorphic features and signs affecting the face, skull, ears, eyes, nose, mouth, throat and mental status. among others, these include hypoplastic zygomas, downward sloping palpebral fissures, malformed pinnae, abnormalities of the external auditory canal (stenosis or atresia), maldevelopment of the ossicles, absence of middle ear and tympanic spaces, pharyngeal hypoplasia, deficient mandibular rami and a cleft palate. the inner ears are usually normal, but these children may have conductive hearing loss owing to the absence of the middle ears. although persons with mandibulofacial dysostosis usually have normal intelligence, developmental delay may occur if the hearing loss is not diagnosed. the differential diagnosis includes acrofacial dysostosis, oculoauriculovertebral spectrum and x-linked dominant maxillofacial dysostosis.3 ct or magnetic resonance imaging (mri) is usually pursued prior to any surgical intervention. treatment may require intubation after birth if the airway is compromised. the focus of the intervention is on symptom treatment and correction of anatomical deformities, which will inevitably require a multidisciplinary team approach with quite specific timing of interventions. 1. http://www.whonamedit.com/doctor.cfm/1393.html (accessed 3 november 2010). 1. http://www.whonamedit.com/doctor.cfm/1393.html (accessed 3 november 2010). 2. gorlin rj, cohen mm jr, hennekam rcm. syndromes of the head and neck. 4th ed. oxford, uk: oxford university press, 2001. 2. gorlin rj, cohen mm jr, hennekam rcm. syndromes of the head and neck. 4th ed. oxford, uk: oxford university press, 2001. 3. http://emedicine.medscape.com/article/946143-overview (accessed 3 november 2010). 3. http://emedicine.medscape.com/article/946143-overview (accessed 3 november 2010). fig. 1. a 10-year-old girl. the 3d image demonstrates hypoplastic zygomas with downward sloping orbits and atresia of the external auditory canals. the mandible is also hypoplastic with a concave inferior border. there is an artefact in the midline frontal. fig. 2. an 11-month-old girl. the 3d image demonstrates the hypoplastic zygomas and mandibilar ramus. the orbits are down-sloping. abstract introduction methods data capturing results discussion conclusion acknowledgements references about the author(s) jacques badenhorst department of diagnostic radiology, faculty of health sciences, university of pretoria, pretoria, south africa mark velleman department of diagnostic radiology, faculty of health sciences, university of pretoria, pretoria, south africa radiologist, private practice, capital radiology, pretoria, south africa audrey jansen van rensburg section sports medicine, faculty of health sciences, university of pretoria, pretoria, south africa tanita botha department of statistics, faculty of natural and agricultural sciences, university of pretoria, pretoria, south africa nikki van der walt orthopaedic specialist, private practice, unitas hospital, pretoria, south africa christa janse van rensburg section sports medicine, faculty of health sciences, university of pretoria, pretoria, south africa citation badenhorst j, velleman m, jansen van rensburg a, botha t, van der walt n, janse van rensburg c. mri findings in chronic exertional compartment syndrome of the forearm: using signal intensity ratio as a diagnostic tool. s afr j rad. 2021;25(1), a2219. https://doi.org/10.4102/sajr.v25i1.2219 original research mri findings in chronic exertional compartment syndrome of the forearm: using signal intensity ratio as a diagnostic tool jacques badenhorst, mark velleman, audrey jansen van rensburg, tanita botha, nikki van der walt, christa janse van rensburg received: 21 june 2021; accepted: 27 july 2021; published: 06 oct. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: chronic exertional compartment syndrome (cecs) of the forearm is a rare but important cause of morbidity amongst athletes involved in strenuous upper limb activities. the diagnosis remains challenging due to the absence of objective, reproducible diagnostic studies. objectives: to assess and quantify signal intensity (si) changes of involved muscles in patients with cecs of the forearm compared to healthy control subjects competing in similar sporting disciplines. also, to objectively measure mri sis within muscle compartments when using a preand post-exercise regime and calculating a signal intensity ratio (sir) between postand pre-exercise studies. method: the study retrospectively examined mri scans of patients treated for cecs of the forearm and compared these to the mri scans of asymptomatic high-level rowers. a specific, reproducible preand post-exercise mri scanning protocol was utilised in both patient and control subjects between 2011 and 2020. signal intensities were evaluated preand post-exercise in involved muscle groups and ratios were calculated. results: a total of 86 sis were measured (43 preand 43 post-exercise) in nine study participants (five patients and four controls). after post:pre-exercise comparisons, a statistically significant difference was found between control and patient groups (p = 0.0010). the extensor carpi radialis, flexor digitorum profundus and flexor digitorum superficialis muscles were most commonly involved. conclusion: this study confirms that significant si changes are apparent in patients with cecs of the forearm when making use of a standardised preand post-exercise mri protocol. furthermore, sir may be used to accurately diagnose cecs of the forearm. keywords: forearm compartment syndrome; chronic exertional compartment syndrome; cecs; exercise mri; forearm pain; compartment syndrome; athletes. introduction chronic exertional compartment syndrome (cecs) of the forearm is a rare entity with the first case only being described in 1983.1 most of the literature regarding this condition is in the form of case studies or case series, and mostly include patients such as rowers, motorcyclists, rock-climbers, resistance trainers, etc., who undertake strenuous, repetitive forearm movements.2,3,4,5,6,7,8,9,10,11,12,13,14 symptoms in patients with cecs typically occur during exertion and resolve with rest. symptoms include pain, paraesthesia, cramping, a ‘stiff’ feeling of the involved compartment as well as loss of grip strength.2,4,7,8,10,11,12,14,15 the pathophysiology of the condition remains incompletely understood but is based on the premise of raised intra-compartmental pressures within a relatively rigid fascial compartment, causing reduced tissue perfusion and subsequent ischaemia.2,8,15,16,17,18,19,20 during exercise, it is normal for intra-compartmental pressures to rise; however, this increased pressure does not usually cause symptoms or altered tissue oxygenation as in patients with cecs.2,9,19 patients with cecs have relatively greater increases in pressure and these pressures also take longer to return to normal after cessation of exercise.21 furthermore, there is evidence that patients with cecs have relatively low levels of oxygenation within muscle compartments during exercise and recovery, as well as deoxygenation early on in exercise, before intra-compartmental pressures rise significantly.18 this points to altered oxygen extraction from the blood by affected muscles as well as altered muscle metabolism, likely because of a chronic state of low-grade ischaemia during exercise.18 despite the growing amount of available literature on cecs, controversy remains on how best to diagnose the condition, as well as what diagnostic parameters to use within each specific modality.1,2,3,7,10,12,22,23 currently, the most widely used method is based on intra-compartmental pressure testing and the values proposed in 1990.21 these values were proposed for lower leg cecs, and various modifications of the values have been suggested for diagnosis of forearm cecs; however, none are universally accepted.8,12,24 various studies confirmed that a significant proportion of patients with clinical and surgically responsive cecs may be misdiagnosed with the use of current intra-compartmental pressure values.10,12,23,24 moreover, there is an ever-changing variation in the proposed ‘normal’ compartmental pressure values of the forearm.1,23,25 furthermore, the invasive nature of testing, the associated risks and the lack of an accepted testing technique make intra-compartmental pressure manometry a far from ideal diagnostic tool.7,10,12,17,18,20,23,26 mri in chronic compartment syndrome is based on the premise that ischaemic muscle will become oedematous and thus exhibit a more intense t2-weighted (t2w) signal compared with normal muscle.15,17,26 additionally, mri can accurately exclude other conditions that may mimic cecs, for example, tendonitis, muscle tears and nerve impingements. mri scanning has been utilised for the past 30 years in the diagnosis of cecs, with numerous studies and case reports published at testing to its usefulness.4,9,13,16,17,19,26,27,28,29 despite the relatively strong evidence for the use of a pre-post exercise mri protocol in cecs, no standardised methods regarding exact exercise protocols and imaging acquisition have been published.6,15,17,26,28,30 furthermore, in the absence of t2w mapping software, signal intensity (si) is graded subjectively, presenting the possibility for greater inter-observer variations.6 the ever-increasing competitiveness and demands faced by top-level and professional athletes require that timeous and accurate diagnosis of any sporting-related symptoms is paramount to the longevity and success of an athlete. in our setting, several rowers have been treated for cecs, necessitating the need for future accurate, reproducible and reliable diagnostic methods. this study aimed to quantify si changes in patients with cecs of the forearm and compare them with healthy control subjects participating in similar sporting disciplines. a further aim was to objectively measure mri si within muscle compartments when using a preand post-exercise regime and calculate a signal intensity ratio (sir) between postand pre-exercise studies. methods study design the study makes use of a cross-sectional descriptive pilot study design. study findings in a cecs patient group were compared to a control group. setting a private radiology practice based at both the life groenkloof hospital (part of pretoria mr trust) and the sport, exercise medicine and lifestyle institute (semli), university of pretoria, south africa was the setting for this study. sport, exercise medicine and lifestyle institute is located at the high-performance centre31 in pretoria, south africa, which is a high-level specialist sporting centre and served as training base for all our control subjects. patients were assessed by an experienced upper limb orthopaedic surgeon in private practice. study population and sampling strategy patients (n = 5) included in the study all received fasciotomy surgery for treatment of cecs of the forearm, with symptoms improving or resolving after surgery. patients who underwent concurrent nerve release surgery, had a history of additional previous surgery to the forearm, or who had a history of significant trauma to the forearm, were excluded patients all underwent mr imaging at the above centres between 2009 and 2020. the control subjects (n = 4) were athletes enrolled in the university of pretoria rowing team and included individuals who were symptom-free when rowing, did not undergo any previous forearm surgery and had not previously sustained significant trauma to the forearms. control subjects were screened for eligibility by completing a questionnaire that excluded any of the above conditions.32 evaluation procedure a novel, custom preand post-exercise scan protocol was followed to reproduce cecs symptoms in both patient and control subjects. initially, an mri scan was performed on all participants (patients and controls) at rest. they were then asked to do a repetitive exercise (concentric hand squeezes of a foam ball up to the point of symptom onset or exhaustion), after which the forearm(s) was immediately scanned again. patient scans were performed on either a 1.5-t mri scanner (1.5t) or a 3-t mri scanner (3t). control subjects were scanned on a 3t scanner. both 1.5-t and 3-t scanners were used because of the equipment changes during the research period, as well as different machines being used at the different imaging sites. the patient group was imaged using fat-sensitive t1-weighted (t1w) sequences as well as fluid-sensitive t2w sequences with fat-suppression short-tau inversion recovery (stir). control subjects only underwent fat-suppressed t2w (stir) imaging both before and after exercise. as a result of the time constraints in the mri suite, the control group had their forearms scanned simultaneously. this resulted in differing imaging parameters and a modest decrease in image resolution. the sequences used are listed in table 1. table 1: mri sequences obtained in patients and control groups. data capturing anonymous mris were evaluated using dedicated radiological workstations and agfa picture and archiving system (pacs) for both patient and control subjects. muscles that exhibited an increase in stir signal on post-exercise contrast imaging were further investigated by placing a circular region of interest (roi) within the respective muscles for both the post-exercise and the corresponding pre-exercise stir images. region of interests used were either 10 mm or 5 mm in diameter depending on the size of the area suitable for measurement. tendons, vascular structures, nerves and surrounding fat were excluded from the roi. absolute si was measured both preand post-exercise, and results were entered into an microsoft excel data table alongside the corresponding arm, age and sex of the participant. muscles involved were also recorded and included extensor carpi radialis (ecr), extensor carpi ulnaris (ecu), extensor digitorum (ed), brachioradialis (br), supinator (sup), abductor pollicis (ap), flexor digitorum profundus (fdp), flexor digitorum superficialis (fds), flexor pollicis longus (fpl) and flexor carpi radialis (fcr). findings were validated by a musculoskeletal radiologist with more than 20 years of experience. moreover, the preand post-exercise si of involved muscles was compared, and a post:pre-exercise sir was calculated. this ratio was obtained by dividing the measured si of the post-exercise study by the measured si of the pre-exercise study. statistical analysis demographic data including age and sex of participants were analysed as were the arms and muscles affected. descriptive statistics included measurements such as mean, standard deviations, frequencies and proportions to describe the results. tabulated and graphical representations were made where applicable to assist in visualising aspects of the data. the shapiro–wilk test was used to determine whether the data were normally distributed, followed by the independent t-test that investigated whether a significant difference existed between the sir values in the control and patient groups. all significance tests were performed at a 5% level of significance. results the participant group consisted of a total of four (44.4%) males and five (55.6%) females. demographics of all study participants, as well as the arm(s) that exhibited si changes on post-exercise imaging, are detailed in table 2 and figure 1. as both arms were involved in some individuals, the sum of individual arms affected is more than the total number of participants. the number of muscles involved per sex and arm are listed in table 3. figure 1: individual muscles involved per record. table 2: demographic profile of participants by age, sex and arm(s) involved. table 3: number of muscles involved by sex and arm. a total of 86 sis were collected (43 pre-exercise and 43 post-exercise measurements). the si in 43 different muscles across the control (n = 27; 62.8%) and patient (n = 16; 37.2%) groups was measured. muscle si values were collected in the right arm (n = 22; 51.2%) and the left arm (n = 21; 48.8%) of males (n = 13; 30.2%) and females (n = 30; 69.8%). the number of specific muscles involved are listed in table 4 and figure 1. muscles involved were predominantly the ecr (n = 12; 27.9%), fdp (n = 11; 25.6%) and fds (n = 10; 23.3%). in the patient group, the ecr (n = 5; 31.2%) followed by the fdp(n = 3; 18.8%) was mostly involved. in the control group, fdp and fds were equally involved (n = 8; 29.6% each) followed by ecr (n = 7; 25.9%). table 4: specific muscles involved. the post:pre-exercise sir measurements are depicted in table 5 and figure 2. the sir in the control group had a range between 1.0 and 1.84 whilst for the patient group the sir range varied between 1.20 and 2.23. there was a statistically significant difference (p = 0.0010) in the sir between the control (1.30 ± 0.18) and patient (1.57 ± 0.25) groups. examples of preand post-contrast imaging studies in both control (figure 3) and patient (figure 4) groups are depicted below. figure 2: signal intensity ratio plotted per data record. figure 3: pre-exercise (a) and post-exercise (b) sequences in a control subject revealing subtle increases in signal within the flexor digitorum superficialis (*) and flexor digitorum profundus (#) muscles. figure 4: pre-exercise (a) and post-exercise (b) sequences in a cecs patient demonstrating clear signal increase in the flexor digitorum superficialis (*) and flexor digitorum profundus (#) muscles after exertion. table 5: post:pre-exercise signal intensity ratio measurements. discussion this study confirms that there are objectively measurable si changes in the forearm muscles of both control and patient subjects when making use of a preand post-exercise imaging protocol. furthermore, the study illustrated a statistically significant difference in sir when utilising a preand post-exercise mri protocol in patients with confirmed cecs compared with normal control subjects (p = 0.001). to our knowledge, this study was the first to make use of sirs to evaluate for the presence of cecs. we believe that in the absence of more expensive t2w mapping software, this method is an excellent surrogate to objectively measure signal changes in musculature when using a preand post-exercise imaging protocol. the statistically significant difference in control and patient groups suggests that this method can be used to accurately diagnose the condition. the findings in this study are in concordance with current literature regarding the normal physiological changes expected in normal muscle during exertion, as well as the pathological changes that occur in patients with cecs.2,13,15,17,19,28,29,30 although the study sample was small, the statistically significant differences in sir provide a means to objectively evaluate mri findings in patients where cecs is expected. in some instances, we experienced an overlap in sir between the patient and control group; however, assessing the interquartile range, no overlap existed between the two groups. mean sis of 1.57 and 1.30, respectively, for the patient and control groups were found, and we suggest a correlation with these values when evaluating patients for cecs of the forearm. the fairly equal si distribution between the left and right arms likely suggests that no specific predilection exists; however, larger sample groups are required to evaluate this further. the three main muscles involved in our study were the ecr (27.9%), fdp (25.6%) and fds (23.3%). these muscles were the dominant muscles affected in both the patient and the control groups. repetitive concentric hand squeezes were undertaken by both the patient and control groups as part of their imaging protocols, which logically explain the involvement of the two large flexor muscle groups; however, the frequent involvement of the ecr muscle was a surprising finding. we believe that this may be because of the continual opposition forces applied by this extensor muscle in maintaining wrist and hand position and stability in the presence of strong flexor forces. to a smaller degree, the br (4.7%), ap (4.7%), ecu (2.3%), ed (2.3%), flexor pollicis longus (2.3%) and supinator (4.7%) muscles were occasionally involved. the muscles affected in this study correlate well with the muscles affected in the available literature.2,13,17,19,29,30 as all study participants did the same forearm exercise actions as part of their imaging protocol, it is unclear whether this distribution of muscular involvement is specific to the disease process or simply to the exercises performed. further studies utilising different methods of exerting patients between preand post-exercise studies are necessary to evaluate patterns of muscle involvement. the main limitation of this study is the small sample size. the rarity of the condition as well as our strict inclusion and exclusion criteria limited the number of candidates eligible for the study. secondly, the control group consisted only of female athletes. this was a complete chance occurrence because of potential male candidates not fulfilling the eligibility criteria. to our knowledge, only a single previous study compared differences in male and female athletes, and the differences reported between the sexes were of dubious significance.30 further research in this area is necessary to determine whether true differences exist between muscle physiology in male and female athletes. as this study evaluated retrospective data collected over 9 years, differences in equipment and imaging protocols can be expected. the control group also had their forearms scanned simultaneously because of the time constraints in the mri suite used. we believe that as we were comparing preand post-exercise studies performed on the same day with the same machines and protocols, this should have no significant outcome on our results. the control group was all investigated on a 3-t mri machine. to our knowledge, there are no studies comparing the accuracy between 1.5t and 3t in diagnosing muscle oedema. the 3t machines can lead to higher signal-to-noise ratios, shorter scanning times and thinner slices, all of which should not make a difference in detecting muscle oedema.33 conclusion this study confirms that si changes are present in the forearms of both patients confirmed with cecs of the forearm as well as in healthy control subjects who partake in similar high-intensity forearm activities. in patients in whom cecs of the forearm is clinically suspected, we suggest a preand post-exercise mri protocol as part of the patient work up. by calculating the sir when using a post:pre-exercise imaging protocol, we were able to identify a statistically significant, objectively measured difference between patients and controls. we propose calculation of a sir to assist in diagnosis of cecs. further studies with a larger sample size are required to determine specific inclusion and exclusion values. future research in the field should include studying a larger number of patients and control subjects to further validate these results. the inclusion of study subjects participating in a greater variety of forearm activities will augment the relevance of our findings. acknowledgements the authors would like to thank capital radiology, the pretoria mr trust and the university of pretoria’s rowing team for participating in the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions j.b. was lead investigator and author involved in study concept, study design, data collection and interpretation as well as manuscript writing (first draft), editing and review for submission. c.j.v.r. was the study supervisor. also involved in conceptual study design, data interpretation and final manuscript review and editing. a.j.v.r was co-author and involved in study design, manuscript editing and design, as well as final manuscript review. m.v. and n.v.d.w. were co-authors and legal custodians of data, involved in study design, validation of results and final manuscript editing and review. t.b. was co-author and statistical advisor, involved in final manuscript editing and review. ethical considerations this research was approved by the ethics committee of the university of pretoria (rec #380/2020). all participants (patients and controls) were personally contacted to explain the study and to obtain signed informed consent and assent. funding information control subject scans were donated to the research project by the capital radiology practice and the pretoria mr trust. remainder of funding was done privately by the principal investigator. data availability the data that support the findings are available from the corresponding author, j.b. disclaimer the results and recommendations of the study do not necessarily represent the views of the institutions at which the authors are based, nor any professional bodies affiliated to them. references rydholm u, werner co, ohlin p. intracompartmental forearm pressure during rest and exercise. clin orthop relat res. 1983;175:213–215. https://doi.org/10.1097/00003086-198305000-00034 liu b, barrazueta g, ruchelsman de. chronic exertional compartment syndrome in athletes. j hand surg am. 42(11):917–923. goubier jn, saillant g. chronic compartment syndrome of the forearm in competitive motor cyclists: a report of two cases. br j sports med. 2003;37(5):452–453; discussion 3–4. garcia-mata smd. chronic exertional compartment syndrome of the forearm in adolescents. j pediatr orthop. 2013;33(8):832–837. https://doi.org/10.1097/bpo.0b013e3182a0078b o’heireamhoin s, baker jf, neligan m. chronic exertional compartment syndrome of the forearm in an elite rower. case rep orthop. 2011;2011:497854. https://doi.org/10.1155/2011/497854 gielen jl, peersman b, peersman g, et al. chronic exertional compartment syndrome of the forearm in motocross racers: findings on mri. skeletal radiol. 2009;38(12):1153–1161. https://doi.org/10.1007/s00256-009-0746-2 brown js, wheeler pc, boyd kt, barnes mr, allen mj. chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy. j hand surg eur vol. 2011;36(5):413–419. https://doi.org/10.1177/1753193410397900 humpherys j, lum z, cohen j. diagnosis and treatment of chronic exertional compartment syndrome of the forearm in motocross riders. jbjs rev. 2018;6(1):e3. gondolini g, schiavi p, pogliacomi f, ceccarelli f, antonetti t, zasa m. long-term outcome of mini-open surgical decompression for chronic exertional compartment syndrome of the forearm in professional motorcycling riders. clin j sport med. 2019;29(6):476–481. barrera-ochoa s, haddad s, correa-vazquez e, et al. surgical decompression of exertional compartment syndrome of the forearm in professional motorcycling racers: comparative long-term results of wide-open versus mini-open fasciotomy. clin j sport med. 2016;26(2):108–114. https://doi.org/10.1097/jsm.0000000000000216 harrison jw, thomas p, aster a, wilkes g, hayton mj. chronic exertional compartment syndrome of the forearm in elite rowers: a technique for mini-open fasciotomy and a report of six cases. hand. 2013;8(4):450–453. https://doi.org/10.1007/s11552-013-9543-4 barrera-ochoa s, correa-vazquez e, gallardo-calero i, et al. trest as a new diagnostic variable for chronic exertional compartment syndrome of the forearm: a prospective cohort analysis of 124 athletes. clin j sport med. 2018;28(6):516–523. https://doi.org/10.1097/jsm.0000000000000482 hider sl, hilton rc, hutchinson c. chronic exertional compartment syndrome as a cause of bilateral forearm pain. arthritis rheum. 2002;46(8):2245–2246. https://doi.org/10.1002/art.10437 willick se, deluigi aj, taskaynatan m, petron dj, coleman d. bilateral chronic exertional compartment syndrome of the forearm: a case report and review of the literature. curr sports med rep. 2013;12(3):170–174. flick d, flick r. chronic exertional compartment syndrome testing. curr sports med rep. 2015;14(5):380–385. https://doi.org/10.1249/jsr.0000000000000187 cole a, hiatt jl, arnold c, sites t, ylanon r. chronic exertional compartment syndrome in the forearm of a collegiate softball pitcher. sports medicine open. 2017;3(1):11. rattan b, misser sk. magnetic resonance imaging in exertional compartment syndrome of the forearm: case-based pictorial review and approach to management. sa j radiol. 2018;22(1):1284. https://doi.org/10.4102/sajr.v22i1.1284 mohler lr, styf jr, pedowitz ra, hargens ar, gershuni dh. intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg. j bone joint surg am. 1997;79(6):844–849. kumar prm, jenkins jpr, hodgson sp. bilateral chronic exertional compartment syndrome of the dorsal part of the forearm: the role of magnetic resonance imaging in diagnosis: a case report. j bone joint surg am. 2003;85(8):1557–1559. https://doi.org/10.2106/00004623-200308000-00019 van den brand jgh, nelson t, verleisdonk ejmm, van der werken c. the diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome – a prospective study in 50 patients. am j sports med. 2005;33(5):699–704. pedowitz ra, hargens ar, mubarak sj, gershuni dh. modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. am j sports med. 1990;18(1):35–40. https://doi.org/10.1177/036354659001800106 winkes mb, tseng cm, pasmans hl, van der cruijsen-raaijmakers m, hoogeveen ar, scheltinga mr. accuracy of palpation-guided catheter placement for muscle pressure measurements in suspected deep posterior chronic exertional compartment syndrome of the lower leg: a magnetic resonance imaging study. am j sports med. 2016;44(10):2659–2666. https://doi.org/10.1177/0363546516652113 schoeffl v, klee s, strecker w. evaluation of physiological standard pressures of the forearm flexor muscles during sport-specific ergometry in sport climbers. br j sports med. 2004;38(4):422–425. https://doi.org/10.1136/bjsm.2002.003996 whitesides te, heckman mm. acute compartment syndrome: update on diagnosis and treatment. j am acad orthop surg. 1996;4(4):209–218. https://doi.org/10.5435/00124635-199607000-00005 ardolino a, zeineh n, o’connor d. experimental study into forearm compartmental pressures. br j sports med. 2011;45(2):e1. ringler md, litwiller dv, felmlee jp, et al. mri accurately detects chronic exertional compartment syndrome: a validation study. skeletal radiol. 2013;42(3):385–392. https://doi.org/10.1007/s00256-012-1487-1 amendola a, rorabeck ch, vellett d, vezina w, rutt b, nott l. the use of magnetic resonance imaging in exertional compartment syndromes. am j sports med. 1990;18(1):29–34. https://doi.org/10.1177/036354659001800105 verleisdonk ej, van gils a, van der werken c. the diagnostic value of mri scans for the diagnosis of chronic exertional compartment syndrome of the lower leg. skeletal radiol. 2001;30(6):321–325. https://doi.org/10.1007/s002560100361 tominaga a, shimada k, temporin k, noguchi r. post-exertional mri is useful as a tool for diagnosis and treatment evaluation for chronic exertional compartment syndrome of forearms. j hand surg asian pac vol. 2019;24(3):311–316. https://doi.org/10.1142/s2424835519500395 drew mk, trease l, caneiro jp, et al. normative mri, ultrasound and muscle functional mri findings in the forearms of asymptomatic elite rowers. j sci med sport. 2016;19(2):103–108. https://doi.org/10.1016/j.jsams.2015.02.002 university of pretoria. university of pretoria – high performance centre [homepage on the internet]. 2021. [cited 2020 feb] available from: https://www.up.ac.za/high-performance-centre badenhorst j. questionnaire rowers, control subjects [homepage on the internet]. 2020. [cited 2020 feb] available from: https://forms.office.com/pages/responsepage.aspx?id=dqsikwdsw0yxejajblztrqaaaaaaaaaaaanaarucq_xuntdyqkjarjuwm0rzstrzt1hdstyzm0hlsi4u kuo r, panchal m, tanenbaum l, crues iii jv. 3.0 tesla imaging of the musculoskeletal system. j magn reson imaging. 2007;25(2):245–261. https://doi.org/10.1002/jmri.20815 case series case series 92 sa journal of radiology • december 2007 case series abstract williams-beuren syndrome is a multisystem disorder caused by the deletion of multiple genes on chromosome 7. many patients are identified through the presence of dysmorphic features and associated cardiac abnormalities. we report two cases demonstrating supravalvular aortic stenosis (a common feature of williams syndrome) and coarctation of the aorta on computed tomography (ct) aortogram. introduction williams-beuren syndrome is a complex developmental disorder characterised by congenital heart and vascular disease, mental retardation, a characteristic learning profile, a hypersocial personality and infantile hypercalcaemia. its prevalence has been estimated to range from 1:13 700 to 1:25 000 live births.1 this syndrome is associated with a microdeletion in the chromosomal region 7q11.23, encompassing the elastin gene. confirmation of this syndrome can be made by detecting elastin hemizygosity by flourescence in situ hybridisation (fish).1-3 reports suggest that this microdeletion of the elastin gene is responsible for the typical vasculopathy of the williams syndrome, namely supravalvular aortic stenosis (svas) and pulmonary artery stenosis.2,3 cardiovascular abnormalities occur in approximately 80% of reported cases, with svas being the most common cardiac anomaly, present in 64% of patients.1 other cardiopathies include pulmonary artery stenosis, aortic hypoplasia, coarctation of the aorta, mitral valve prolapse, and septal defects.1 imaging plays an important role in demonstrating these vascular disorders. magnetic resonanace (mr) and computed tomography (ct) angiography with three-dimensional (3d) reconstruction provides excellent visualisation of the ascending aorta and aortic arch and should be used to delineate the extent of svas and other arteriopathies.4 case reports patient 1 was a 3-month-old female infant referred by a general practitioner for an incidental murmur. on clinical examination, the child was acyanotic and had the typical facies of williams-beuren syndrome. the systolic blood pressure readings in the right upper limb compared with the right leg showed a gradient of 40 mmhg. in addition there was cardiomegaly and a systolic murmur was heard. hence a clinical diagnosis of aortic stenosis and a coarctation of the aorta were suspected. on echocardiography, there was a hypertrophied left ventricle, with a hypoplastic aortic valve annulus (diameter 7 8 mm), with bilateral peripheral pulmonary stenosis. the chest x-ray revealed an enlarged left ventricle and there was no evidence of cardiac failure. ct aortogram with 3d reformats confirmed supravalvular aortic narrowing, coarctation of the aorta just distal to the left subclavian artery (long segment 6 mm) as well as coarctation distally of the descending aorta (figs 1 a & b, severe aortic obstruction in williams-beuren syndrome – a short case series jaishree naidoo, mb chb, fc rad (diag) department of radiology, helen joseph and coronation hospitals, johannesburg willy hendson, mb chb, fc paed (sa) paed cardiology coronation women and child hospital, department of paediatrics, division of paediatric cardiology, johannesburg fig. 1 (a) 3d ct aortogram ap view demonstrating supravalvular aortic stenosis at the level of the sinotubular junction (short arrow), coarctation of the aorta distal to the left subclavian (long arrow), coarctation distally of the descending abdominal aorta (double arrows). (b) lateral 3d ct aortogram showing poststenotic dilatation of the aorta (short arrows) and coarctation of the aorta (long arrow). a b pg92-94.indd 92 1/30/08 12:37:32 pm case seriescase series 93 sa journal of radiology • december 2007 2 & 3). it also showed an absent renogram on the left (confirmed absent left kidney on ultrasound). patient 2 was seen initially as a 3-month-old female with an incidental murmur, dysmorphic features and clinical features of immunosuppression. the patient was however lost to follow-up until 2 years of age when she was again referred for a cardiac assessment. on examination the child was very friendly and approachable, but was clearly dysmorphic. she was acyanotic with a systolic blood pressure of 110 mmhg in the right upper limb. all the pulses were easily felt and of normal volume. echocardiography showed mild supravalvular aortic narrowing. the aortic valve annulus was normal. in addition there was mild bilateral branch pulmonary stenosis. the chest x-ray revealed a normal heart size and no features of cardiac failure. ct aortogram with multiplanar reformats (mpr) confirmed severe svas, however the rest of the abdominal aorta and its branches were normal (fig. 4). in comparison to patient 1, both kidneys were present and normal. genetic (fish) analysis on both patients showed the 7q11.23 chromosomal deletion, confirming the diagnosis of williamsbeuren syndrome. discussion the williams-beuren syndrome, a rare congenital anomaly involving the vascular system, connective tissue, and central nervous system, was initially described by williams et al. in 1961, and then by beuren in 1962.5 aside from the common vascular anomalies found in this syndrome, other organ systems are also affected. renal anomalies are present in up to 17% of cases; these anomalies may be cystic, with hydronephrosis, agenesis, hypoplasia, reflux, diverticula, nephrocalcinosis and ischaemia.5 in our patient 1, ct findings revealed an absent left renogram, consistent with agenesis. other abnormalities described include cerebral vessel stenosis, coronary artery stenosis and myocardial infarction, diverticular disease, rectal prolapse, hypercalcaemia, hypercalciuria and hypothyroidism. intracardiac abnormalities are less common but include ventricular septal defects and rarely mitral insufficiency.5 the distinctive facial appearance of patients with williams-beuren syndrome is characterised by hypertelorism, saddle nose, excessive periorbital tissue, thick lips, full open mouth, stellate iris pattern and dental abnormalities (figs 5 a-c). these patients are almost always communicative and sociable. in our cases we observed facial and behavioural characteristics of this syndrome. the diagnosis of svas and other vasculopathies of the williamsbeuren syndrome can be made by multiple imaging modalities. the defining feature of this malformation is an aortic narrowing at the level of the sinotubular junction, but in some cases there is narrowing of the entire abdominal aorta and arch branches (see fig. 1). mri and ct fig 2. sagittal maximum intensity projection image (arrows) depicting coarctation of the aorta. fig. 3. sagittal mip image – demonstrating svas (short arrow) and poststenotic dilatation (long arrow). fig. 4. coronal mip image – arrows depicting the localised area of narrowing visible above the aortic sinuses. the origins of the brachiocephalic vessels are normal. pg92-94.indd 93 1/30/08 12:37:33 pm case series aortography provide excellent visualisation of the abdominal aorta and aortic arch and should therefore be used to delineate the extent of svas. it can also demonstrate the degree and extent of coarctation and collateral formation. in coarctation of the aorta, characteristic rib notching is often present on chest x-ray or ct scan and is indicative of extensive arterial collateral formation bypassing the area of coarctation; a characteristic ‘3’ sign is often also seen on chest x-ray.4 rib notching is rare in the first 5 years of life; the ct scan of patient 1 revealed multiple areas of aortic coarctation without rib notching and collateral formation. mri is potentially the most comprehensive cardiac and vascular imaging modality available without the use of ionising radiation or contrast media. paediatric patients usually require general anaesthesia. both our patients had severe aortic stenosis and were regarded as high anaesthetic risk for sudden death, therefore ct aortography was chosen as the modality of choice. the vascular abnormalities in williams-beuren syndrome must be distinguished from other congenital or acquired arteriopathies such as fibromuscular dysplasia or takayasu’s arteritis, respectively. the results of a previous study by kim et al., show that with time pulmonary artery stenosis tends to improve and svas to progress.2,6 svas often presents in childhood, and if not corrected by surgery can lead to heart failure and death.3 case reports of sudden death in patients with williams-beuren syndrome date back to when the first cases were published in 1961.7 the majority of sudden death cases have been associated with myocardial infarction.7 as a result of the severity of the svas and coartations, patient 1 died shortly after. patient 2 is awaiting surgery. surgical treatment of supravalvular stenosis is by resection of the obstructed segment. surgical enlargement of the narrowed sinotubular region and adjacent ascending aorta is recommended if symptoms (angina, dyspnoea, syncope) or a mean pressure gradient of > 50 mmhg are present.4 coarctation of the aorta is treated with either percutaneous transluminal angioplasty with or without endovascular stent placement or surgery. surgery comprises reconstruction of the aorta with resection of the stenotic segment, interposition of grafts or aorta-aortic bypasses or enlargement with patches. conclusion arteriopathy in williams-beuren syndrome is generalised and may involve any artery of the body, caused by elastin deficiency, and is the most common cause of morbidity and mortality. both ct and mri assist in operative planning and to visualise the extent of the disease. a detailed cardiac evaluation must be performed in all patients demonstrating the characteristic features of williams syndrome because of the high frequency of cardiovascular anomalies and sudden death. 1. sugayama s, moises r, wagenfur j, et al. williams beuren syndrome. cardiovascular abnormalities in 20 patients diagnosed with fluorescence in situ hybridization. arq bras cardiol 2003; 81: 468-473. 2. eranon m, peippo m, hiippula a, et al. cardiovascular manifestation in 75 patients with williams syndrome. j med genet 2002; 39: 554-558. 3. keating m. genetic approaches to cardiovascular disease – supravalvular aortic stenosis, williams syndrome and long qt syndrome. circulation 1995; 92: 142-147. 4. aboulhosen j, child js. left ventricular outflow obstruction: subaortic stenosis, bicuspid aortic valve, supravalvular aortic stenosis and coarctation of the aorta. circulation 2006; 114: 2412-2422. 5. sylos c, pereira ac, azeka e, miara n, mesquita smf, ebard m. arterial hypertension in a child with williams beuren syndrome. arq bras cardiol 2002; 79: 177-180. 6. zalzstein e, moes ca, musewe nn, et al. spectrum of cardiovascular anomalies in williams beuren syndrome. paediatr cardiol 1991; 12: 219-223. 7. monfared a, messner a. death following tonsillectomy in a child with williams syndrome. int j pediatr otorhinolaryngol 2006; 70: 1133-1135. 94 sa journal of radiology • december 2007 fig. 5. photographs demonstrating distinctive facial appearances of williams-beuren syndrome: (a) stellate irises, (b) microdontia – widely spaced teeth, (c) malocclusion. 5a 5b 5c pg92-94.indd 94 1/30/08 12:37:34 pm short report short report 24 sa journal of radiology • december 2006 short report 24 sa journal of radiology • december 2006 magnetic resonance imaging (mri) of the orbits occasionally demonstrates retinal detachment (rd); this may be as an incidental finding, as a separate entity related to orbital pathology with differing local causes, or as a part of other congenital systemic or metabolic diseases. one congenital ocular disease which could be misdiagnosed as rd is persistent hyperplastic primary vitreous (phpv), which itself can be associated with rd. mri scanning features of retinal detachment and associated causes can assist in differentiating both entities effectively, allowing the radiologist to reach the proper conclusions with resultant benefits in subsequent management. persistent hyperplastic primary vitreous (phpv) this is a congenital ocular lesion due to incomplete regression of embryonic ocular blood supply. the primary vitreous is supplied by the embryonic hyaloid vasculature, including the hyaloid artery (a branch of the ophthalmic artery of the developing globe), and should normally have disappeared by the time of birth.1,2 phpv is usually isolated and unilateral; bilateral lesions tend to be associated with systemic or syndromic conditions. the most common presenting signs and symptoms are leukocoria, poor vision and small eye. anterior phpv has the best prognosis for vision, but approximately half of these patients also have an associated posterior phpv. abnormalities of the lens and anterior chamber are signs of a combined anterior and posterior variant of phpv; the isolated forms are roughly equal in incidence.1 repeated episodes of intravitreal haemorrhage in patients with phpv can lead to retraction of the posterior hyaloid membrane and retina by intravitreal fibrovascular tissue. this can then cause detachment of the posterior hyaloid membrane and retina.3 retinal detachment is common and may be associated with layering of blood or debris (subretinal hemorrhage) (fig. 1).1, 2 mri findings phpv typically appears as a triangular, retrolental vascular soft tissue mass, often with a central tissue stalk of hyaloid remnant connected to the optic disc. the overall shape of phpv has been likened to a martini glass. the globe is usually small, with the vitreous typically abnormally hyperintense on both t1 and t2-weighted sequences. the signal intensity of layered haemorrhage in vitreous can vary with the age of blood (fig. 1). retinal detachment (rd) separation of the inner sensory retina from the pigmented retinal epithelium is referred to as retinal detachment. the sensory retina is part of the central nervous system, so that if there is a tear, the sensory retina cannot heal.3 patients typically will present with symptoms such as light flashes, floaters, peripheral visual field loss and blurred vision. rd should be considered in the differential diagnosis of any visual loss. risk factors for rd include advancing age, previous cataract surgery, myopia, and trauma.4 mostly, rd is the result of separation caused by a mass (neoplastic, such as melanoma), a fibroproliferative disease in the vitreous such as vitreo-retinopathy, often either due to prematurity or diabetes, or an inflammatory process (such as uveitis). rd may also result from retinal vascular leakage (lipoproteinaceous exudates), as seen in patients with coats’ disease, a vascular anomaly of retina (telangiectasis), or due to congenital diseases such as phpv.3 mri findings of rd as the retina itself is beyond the limits of resolution of mri scanning, it is only seen when outlined by the significant contrast differences between the signal intensities of subretinal effusions and of the vitreous cavity. the mri appearance of rd varies depending on the amount of exudate and the organisation of subretinal changes. mri can differentiate exudative rd (rich in protein; hyperintense on both t1 and t2-weighted sequences) from subretinal fluid formation as in a rhegmatogenous rd (transudate fluid; hyperintense on t2 and hypointense on t1-weighted imaging sequences). in the case of haemorrhagic rd, the mri signal persistent hyperplastic primary vitreous versus retinal detachment h lameen, mb chb s andronikou, mb bch, fcrad (d), frcr (lond), phd c ackermann, mb chb, mmed rad (d), mrcs (uk) g cilliers, mb chb, mmed rad (d) o c schulze, mb chb a erlank, mb chb j j parsons, mb chb p j greyling, mb chb, bsc (hons) department of radiology, tygerberg hospital and stellenbosch university fig. 1. axial t2-weighted image demonstrates bilateral anterior and posterior phpv. left eye: (posterior phpv) most of the globe content gives a very high signal that could be due to intraocular haemorrhage accompanying retinal detachment. note canal of cloquet (hyaloid canal) connecting the optic disc to the lens. right eye: the displaced retina appears as a thin black line (arrow). the low signal represents subretinal haematoma that extends to the anterior chamber. pg24-25.indd 24 12/11/06 10:59:19 am short reportshort report 25 sa journal of radiology • december 2006 depends on the age of the haematoma. total rd characteristically has a v-shaped appearance, with its apex at the optic disk and its extremities toward the cilliary body (fig. 2). retinal detachment in axial sections obtained above or below the lens will appear as a homogeneous increase in density of the globe.3 1. küker w, ramaekers v. persistent hyperplastic primary vitreous: mri. neuroradiology 1999; 41: 520-522. 2. harnsberger hr. diagnostic imaging, head and neck. 1st ed. manitoba, canada: altona, 2004; 11:1-10 to 11:1-11 3. mafee mf, peyman ga. retinal and choroidal detachments: role of magnetic resonance imaging and computed tomography. radiol clin north am 1987; 25; 487-507. 4. mcgehee be, chaljub g, shah rk, et al. bilateral retinal detachment in a patient with vogt-koyanagi harada syndrome. am soc emerg radiol 2005; 11: 366-371. a b c fig. 2. (a) t1-weighted, (b) t2-weighted and (c) flair sequences through the orbit. a ‘v’-shaped abnormal signal is present posteriorly in the left eye with its apex at the optic disc and the arms of the ‘v’ angled towards the ciliary body. note signal increase in the space outside the ‘v’ on both t1-weighted and flair sequences, in keeping with haemorrhage. basic atlas of sectional anatomy, 4th edition with correlated imaging by walter j. bo, phd; j. jeffrey carr, md; wayne a. krueger, phd; neil t. wolfman, md; and robert l. bowden, ba. isbn 1416001212 · hardback · 434 pages · 1600 illustrations saunders gain a rich, 3-dimensional grasp of radiologic anatomy! features • pairs digital-quality mr, ct, and ultrasound images with color photographs of the corresponding sagittal and crosssectional anatomy for every area of the body, showing you how to identify bone, muscle, fat, and other tissues. • displays diagnostic images and corresponding anatomic photographs on facing pages, making it easy to correlate anatomy with imaging. • offers more than 1,600 illustrations 300 in full color, almost 1,000 more than the previous edition to explore sectional anatomy in greater detail than ever before. • presents coronal sections of the head, thorax, abdomen, female pelvis, and male pelvis; oblique coronal and oblique sagittal sections of the shoulder joint; and coronal and sagittal sections of the knee joint. clinical neurology for psychiatrists, 6th edition to order contact: health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za by david myland kaufman, md, professor of neurology and psychiatry, albert einstein college of medicine; director of neurology, montefiore medical center, bronx, ny, usa isbn 1416030743 ä hardback ä 680 pages ä 316 illustrations saunders ä forthcoming title (december 2006) the sixth edition of this popular favorite is ideal for board review, as well as for clinical reference on neurologic illnesses that can cause or mimic psychiatric symptoms. first it reviews anatomic neurology, describes how to approach patients with suspected neurologic disorders or nervous system diseases, and correlates physical signs. then it addresses clinical areas such as relevant history, easily performed examinations, differential diagnosis, and management approaches. abundant line drawings, cts, mris, and eegs demonstrate key clinical findings to facilitate diagnosis. and, more than 1,600 review questions help you to test and enhance your mastery of the material. reviews review of previous edition: "this is an excellent, comprehensive textbook that should be in the library of every practicing psychiatrist. thorough review of this book is more than adequate preparation for the neurology segments of the general psychiatry and geriatric psychiatry examinations. practicing psychiatrists will find this book extremely useful to have available when they need to look up a neurology complaint or differential diagnosis or simply want to remind themselves of some aspect of the neurological examination or the presentation and management of common neurological diseases. "� the american journal of psychiatry features  describes each condition's relevant history, neurologic and psychiatric findings, easily performed office and bedside examinations, appropriate lab tests, differential diagnosis, and management options.  includes over 1,600 review questions and cases to help you prepare for the neurology section of the psychiatry board exam.  uses an accessible writing style and a logical, easy-to-reference organization.  includes frank discussions of public policy, addressing the important practice issues you face daily. new in this edition  offers thorough updates to reflect the latest information in the field.  provides an improved art program which better captures the visual clues that lead to diagnosis.  features a new two-color format to enhance the book's design and artwork. clinical neurology for psychiatrists, 6th edition to order contact: health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za by david myland kaufman, md, professor of neurology and psychiatry, albert einstein college of medicine; director of neurology, montefiore medical center, bronx, ny, usa isbn 1416030743 ä hardback ä 680 pages ä 316 illustrations saunders ä forthcoming title (december 2006) the sixth edition of this popular favorite is ideal for board review, as well as for clinical reference on neurologic illnesses that can cause or mimic psychiatric symptoms. first it reviews anatomic neurology, describes how to approach patients with suspected neurologic disorders or nervous system diseases, and correlates physical signs. then it addresses clinical areas such as relevant history, easily performed examinations, differential diagnosis, and management approaches. abundant line drawings, cts, mris, and eegs demonstrate key clinical findings to facilitate diagnosis. and, more than 1,600 review questions help you to test and enhance your mastery of the material. reviews review of previous edition: "this is an excellent, comprehensive textbook that should be in the library of every practicing psychiatrist. thorough review of this book is more than adequate preparation for the neurology segments of the general psychiatry and geriatric psychiatry examinations. practicing psychiatrists will find this book extremely useful to have available when they need to look up a neurology complaint or differential diagnosis or simply want to remind themselves of some aspect of the neurological examination or the presentation and management of common neurological diseases. "� the american journal of psychiatry features  describes each condition's relevant history, neurologic and psychiatric findings, easily performed office and bedside examinations, appropriate lab tests, differential diagnosis, and management options.  includes over 1,600 review questions and cases to help you prepare for the neurology section of the psychiatry board exam.  uses an accessible writing style and a logical, easy-to-reference organization.  includes frank discussions of public policy, addressing the important practice issues you face daily. new in this edition  offers thorough updates to reflect the latest information in the field.  provides an improved art program which better captures the visual clues that lead to diagnosis.  features a new two-color format to enhance the book's design and artwork. pg24-25.indd 25 12/11/06 10:59:22 am case i~eport differentiation between sigmoid volvulus and free air on supine abdominal radiographs: the 'liver overlap sign' versus the 'football sign' abstractwfc van gelderen two cases are presented which emphasize the difficulty of d ifferenti ati ng between a sigmoid volvu ius, where the 'iiver overlap sign' is the on ly sign present, and perforation of a hollow viscus where the only sign on a supine abdominal radiograph may be the 'football sign' simulating a 'liver overlap sign'. in the case of sigmoid volvulus described in' this report, the correct diagnosis was mbchb, ffrad(d)(sa), consultant radiologist, wanganul base hospital, wanganui, new zealand 24 sa journal of radiology. june 1997 established only with much difficulty and after fu rther conventional rad iographs and contrast studies. case reports an 89 year old man presented with a three day history of marked abdominal distention and pain. clinical diagnoses of subacute intestinal obstruction or perforation were considered. a supine abdominal radiograph revealed a curvilinear demarcation, convex to lateral, overlying the liver with the area lateral the demarcating line uniformly dense and the area medial to this of relatively low attenuation (figure 1a). this was thought to represent the superolateral aspect of the 'football sign' overlying the liver, but upright chest radiographs failed to reveal any subdiaphragmatic free air. figure 1a: supine abdominal radiograph with 'liver overlap sign' (arrows) of sigmoid volvulus masquerading as 'football sign' of intraperitoneal free air. confirmed as sigmoid volvulus (cf. figure 1cl. to page 25 differentiation bct\ncen signloid volvulus and free air on supine abdorninal radiographs: the 'i iver overlap sign' versus the 'footba" sign' of faecal material following the gastrografin enema. the sigmoid volvulus was repaired surgically on an elective basis with good results. a supine abdominal radiograph of a 63 year old man revealed intraperitoneal free air due to a perforated duodenal ulcer, also demonstrated on chest radiographs, and is shown as comparison to the previous case (figure 2). the similarity of free air with a 'football sign' overlying the liver to the previous case is remarkable. discussion approximately one-third of 40 confirmed cases of sigmoid volvulus were considered to be difficult to diagnose on conventional radiographs' and the above case belongs to this category. the 'liver overlap sign' was found to be of considerable diagnostic aid in those cases where the greater part of the sigmoid loop was obscured by proximal colonic distension. the sign was positive in 27 out of 40 patients with the right side of the distended sigmoid loop overlying the liver in curvilinear fashion. in the above case of sigmoid vol-i.~~~;;;;:===;::=======:::;ivulus the 'liver overlap sign' was the only obvious sign of sigmoid volvulus and even in retrospect the other described signs'? were difficult to detect. the absence of subdiaphragmatic free air on upright chest radiographs should have militated strongly against the 'football sign' on the supine abdominal film, but the findings on decubitus radiographs with air on both sides of bowel from page 24 a left side down decubitus x-ray did not show any free air, but a right side down decubitus film demonstrated apparent air outlining bowel wall (figure 1b) which retrospectively was due to a large distended loop of overlying large bowel simulating the figure lb: right side down decubitus radiograph of abdomen with free air on both sides of small bowel wall (arrows) being simulated by overlying distended loop of large bowel. appearance of air on both sides of the walls of small bowel loops. the 'triangle sign' was also present with multiple triangles of'free air' between bowel loops masquerading in a similar way. a gastrografin meal did not reveal any evidence of perforation. a subsequent gastrografin enema, however, demonstrated the typical appearance of a partially obstructed sigmoid volvulus (figure 1c). the patient felt most relieved after a massive evacuation figure 1c: gastrografln enema demonstrating typical signs of partially obstructed sigmoid volvulus. 2g sa journal of radiology. june 1997 wall and multiple triangles of air between bowel loops being simulated, added to the confusion. gastrografin studies excluded a source of perforation. radiological signs of free air in the abdomen on supine radiographs have been well documented in the literature, but it is of interest that the 'football sign' (a large loculus of air in the shape of a rugby or soccer ball, situated anteriorly in the abdomen with figure 2: part of 'football sign'seen overlying liver (arrows) on supine abdominal radiograph, due to intraperitoneal free air which was shown to be subdiaphragmatic in position on chest x-rays. no distended large bowel loops to suggest sigmoid volvulus. the similarity of the 'liver overlap sign' of sigmoid volvulus (figure la) and the 'football sign' of intraperitoneal free air (figure 2) on supine abdominal radiographs is remarkable. the string of the football represented by air outlining the falciform ligament), is reported as an uncommon feature in adults'. other signs described include the 'inverted v sign' (with air outlining the lateral umbilical ligaments overlying the sacrum) and a sign with air outlining a full urinary bladder. to page 26 differentiation betvvcen sigrnoid volvulus and free air on supine abdonlinal radiographs: the 'i iver overlap sign' versus the 'football sign' from page 25 in conclusion it must be stated that having seen many cases of free air with a 'football sign' and a few cases of sigmoid volvulus with a 'liver overlap sign', the former diagnosis was favoured. this was also a provisional clinical diagnosis.the fact that free air was conclusively excluded on chest radiographs and a left side down decubitus abdominal radiograph, should have made gastrografin studies of the upper and lower gastrointestinal tract to search for a perforation unnecessary. the gastrografin enema was, however, of considerable benefit in the diagnosis and treatment of the sigmoid volvulus. if only a supine abdominal radiograph had been available,which might sometimes be the case, it would have been very difficult to distinguish between a ruptured hollow viscus and sigmoid volvulus. other signsof pneumoperitoneum or sigmoid volvulus also proved to be unhelpful. (in the first case of possible free air they added to the confusion). the clinical features did not aid in differentiating between case report unusual foreign bodies in the oesophagus wfc van gelderen ffrad(d), consultant radiologist kscheng frcs(ed),fracs, consultant surgeon, department of radiology, wanganul base hospital, new zealand. a 70 year old man with a known long segment benign stricture of the lower oesophagus, presented again with dysphagia and the stricture was dilated. subsequent chest radiographs demonstrated signs of a pneumomediastinum. an ultravist 300 non-ionic contrast (schering ag, germany) swallow demonstrated a localized, contained perforation of the left lower these two conditions and without further conventional radiographs and contrast studies the diagnosis could not have been made. this case illustrates that neither the 'football sign' nor the 'liver overlap sign' are invariable, infallible indicators. references i. young ws, engelbrecht he, stoker a. plain film analysis in sigmoid volvulus. cli" radio11978; 29: 553560. 2. janzen dl, heap sw. organo-axial volvulus of the sigmoid colon. australas radiol; 1992: 332-333. 3. rice rp,thompson wm, gedgaudas rk.the diagnosis and significance of extraluminal gas in the abdomen. radiol cli" north am 1982: 20(4): 819-837. oesophagus. half a dozen rectangular low attenuation foreign bodies were noted within the area of rupture and within the distal oesophagus (figure 1). the patient had not been permitted to have anything by mouth and denied having had anything to eat or drink. on more persistent questioning, however, he admitted to being rather partial to lozenges and had not thought that these would be contraindicated. he had surreptitiously sucked the lozenges one by one in the ward, and subsequently the nucleus of each lozenge, a thin hard square wafer, had found its way down to the oesophagus fully intact 26 sa journal of radiology. june 1997 in shape, though reduced in size. these wafers were eloquently demonstrated on ultravist swallow. the remains of the lozenges were removed at subsequent oesophagoscopy and the patient made an unremarkable recovery with a follow-up contrast swallow demonstrating resolution of the contained rupture. figure 1: localized contained rupture left lower oesophagus shown at contrast swallow. note multiple rectangular low attenuation foreign bodies (arrows) which are the residue of lozenges sucked by the patient over the preceding hours. case study regional lung spirometry rpclauss mbchb, mmed (nuc med), md w pilloy mbchb, mmed (nuc med), md nuclear medicine department, medical university of southern africa abstract forty con senti ng patients took part in a study to determine lobar, segmental and regional lung volumes and flows as reflected by changes in lung radioactivity measured by nuclear medicine techniques. two hundred mbq of the gaseous radioisotope i nxe were injected into are-breathing circuit spirometer with an 8 litre capacity and an equilibrium activity of 25 mbq/litre. a posterior dynamic acquisition of 400 frames at 0.125 seconds per frame for the determination of lung volumes and flows was completed, followed by a gas washout period. the acquisition recorded both tidal breathing and 3-6 cycles of maximal inhalation and exhalation after homogenous mixing of the radioactive xenon inside the lungs and the spirometer, but before significant diffusion of the tracer into the blood. the conversion from millilitres to counts was accomplished by matching a representative breath cycle on the spirometric graph with the same cycle on the radioactivity curve generated on the processed scintigram of the whole lung. a change in volume was hence matched to a change in radioactivity, and a specific radioactivity per millilitre of lung volume was calculated. a region of interest was drawn on the scintigram over a lung lobe or segment. the regional radioactivity change represented a regional breath cycle in this area, with regional volume and flow changes. spirometric parameters such as lobar vital capacity, tidal volume, residual volume and forced expiratory volume after 1 second were derived by using the previously calculated radioactivity per millilitre of lung volume. total lung volumes and flows derived from radioactivity changes were compared to the concurrent volumes and flows measured on the attached spirometer, and a close correlation was found. 21 sa jou rnal of radiology. november 1998 introduction conventional lung function tests measure the combined volumes and flows of both lungs and compare them to established normal values for the investigated population. this measurement is however insensitive to lobar or regional functional changes that may occur with localized pathology. hamilton et al,l applied a mathematical model to tidal breathing, using 8lmkr,and wernly et af predicted postoperative lung function from preoperative lung function tests by weighting these results according to the preoperative lung distribution of99mtc maa and 133xe.amis et ap calculated a flow/volume ratio for specific lung regions in patients with diaphragmatic paralysis using 81l11kr and 851111(rconcentrations at tidal breathing. holli et al4 and miërner" used computerised multidetector radiospirometrie methods to determine regional lung function. kauppinen-walin et alg used similar techniques to compare i33xe radiospirometry with helium spirometry and whole-body plethysmography in the determination of functional residual capacity and the effect of body position on this parameter. seeker-walker et af calculated regional lung ventilation from mean functional air exchange in selected lung regions. the above tests measure lung function either indirectly or make us of sp cialized equipment or isotopes that are not generally available. the aim of this study was to ratify a simple and reproducible method to measure lung function by radioisotopes, for application to small lung regions such as lung lob s or segments. using the radiospirometrie method described below, lung function was derived from gaseous lung 133xe topage22 regional lung sp+rorrietrv from page 21 radioactivity, as measured by an anger gamma camera that is readily available in any nuclear medicine department. the radioactivity was correlated with the actual lung function, as measured on a concurrently generated spirometric volume curve. method investigations were performed on 40 consenting patients. thirty-one were males and nine were females. ages ranged between 12 and 73 years. two hundred mbq of 133xegas was introduced into a lead-shielded, re-breathing circuit bell spirometer, where it was homogeneously mixed with ambient air. the capacity of the spirometer was 8 litres and the activity of its gas mixture was 25 mbq per litre. the patient was connected to the spirometer and proceeded with 5-10 tidal breathing cycles to achieve a dynamic equilibrium between the lung and spirometer gas concentrations (figure 1). four hundred images ofo.i2s seconds each were recorded over the lung from a posteriorly positioned anger gamma camera while the patient continued with tidal breathing, followed by 3-6 maximal forced inhalations and exhalations before the end of the recording. the patient then continued with tidal breathing to wash the gas mixture out of the lungs. the whole investigation and washout was completed in less than 3 minutes. measurements were completed before any significant diffusion of the tracer into the blood. the lung radioactivity graph that was recorded by the gamma camera was compared to the concurrent volume graph that was recorded by the spirometer. a specific radioactivity per unit volume was then calculated: count/millilitre = change in lung radioactivity over any breathing cycle change in lung volume over the same breathing cycle once a count/lung millilitre was available, a region of interest could be outlined on the lung seinti-image and radioactivity changes in this region could be expressed as volume changes. for instance, if a lung lobe was outlined on the scinti-image, a total volume for graph lesion counts ~, . :..... volume figure 1: schematic presentation of the apparatus used for the r33xe radiospirometry. 22 sajournal of radiology. november 1998 this lobe could be derived. similarly any lobar volume changes, for instance lobar tidal breathing or maximal inhalation and exhalation volumes for lobar vital capacity could be measured. hence it was possible to derive lobar spirometric parameters (volumes and flows). the following spirometric parameters were correlated with total lung radioactivity changes: tidal volume (tv), vital capacity (vc), expiratory reserve volume (erv), inspiratory capacity (i~) and forced expiratory volume after 1 second (fevi). other parameters that were measured but not correlated were: residual capacity, fiv 0.5, fiv i, fiv 3, fev 0.5 and fev 3. results figure 2 shows the graph of radioactivity changes over both lungs while performing tidal breathing and during a number of maximal inhalation and exhalation cycles in a patient with empyaema. table i shows the correlation of radioactivity to the volume changes in the tested patients. discussion there is a good correlation between spirometric parameters and lung parameters derived from radioactivity changes. we used the method for determination of regional lung function in various groups. for instance, we compared the function of the affected lung in patients with unilateral haemoor pneumothorax, before and after physiotherapy. a significant improvement in unilateral lung function was detected after physiotherapy, while total lung function before and after physiotherapy did not change." this topage23 regional lung spirornetry frompage22 regional flow/volume loops were generated over the left and the right lungs of one of our patients with bullous lung disease. in this patient, air was shunted from the left lung to the right during an expiratory cycle. such shunting was however not apparent on the global (total lung) flow/ volume loop (figure 3). on the practical side,there are some pitfalls that have to be borne in mind. xenon is a gas that diffuses from the lung into the bloed." hence, the longer radioxenon is in the lung, the more background activity is present in the blood. this may lead to an over-estimation of the residual volume. as the spirometer is a closed circuit, accumulation of co 2 could occur; this is however absorbed by soda lime crystals in the circuit. the clinical condition of the patient should allow co-operation during tidal breathing and maximal inspiratory and expiratory manoeuvres. non co-operation may result in leakage of the radioactive gas from the patient's mouth into the surrounding air. when using a bell/fluid spirometer, spillage of water into the spirometer pipes may occur. this results in poor gas mixing and may give misleading results. the piping of the spirometer should therefore be regularly inspected, together with routine calibration. met ."c sec figure 2: radioactivity curve representing tidal and maximal inhalation and exhalation manoeuvres. table i: comparison of total lung radiospirometry and concurrent conventional spirometry (n=40) parameters mean std. dev. spearman correlation (ml) rr p tidal '~xe 605 252 0.905 0.0001 volume cony. 540 222 vital i~xe 1941 860 0.912 0.0001 capacity cony. 1768 616 exp. '''xe 348 218 0.887 0.0001 reserve cony. 334 212 insp. i~xe 1593 758 0.884 0.0001 capacity cony. 1328 498 fevi 133xe 1187 551 0.882 o.qooi cony. 1081 368 was due to compensation by the healthy lung for the incapacitated lung. we have also applied the method to preoperative empyaema patients to predict postoperative lung function. the determination of regional lung function may be more important than is generally realized. conventional lung function tests show only global air movements. when the same air movements are followed onto a regional level, it appears that there are ongoing dynamic regional changes in air flows and pressures. for example, while most segments decrease their volumes during expiration, there are some segments that may actually increase their volume. however, these small paradoxical discrepancies cannot be seen on conventional spirometric curves. for example, 23 sa journal of radiology· november 1998 another aspect that appears to influence the spirometric curves is the inertia of the spirometer bell. the radioactivity changes and curve edges are sharper and better defined than those on the spirometric graph. volume changes and the rate of volume change may be under-estimated by conventional spirometry. the smallest lung region size that could be reasonably evaluated by the above method was approximately 20 ml. in smaller regions, there is a problem of insufficient count statistics. we are at the moment modifying our techniques to obtain list mode c. posterior lung image showing the flow-volume loop of both lungs (excluding trachea). to page 24 regional lung sp irorrtetrv trom page 23 rather than frame mode acquisitions, so that framing time can be chosen by the processing operator after completion of the radiospirometry. this helps in the smoothing of curves and in the selection of the activity peaks that are used for determination of lung parameters. conclusion the above method is practical and can be applied in any nuclear medicine department. there is a good correlation between conventional spirometry and j33xe radiospirometry. there should be further exploration of paradoxic lobar and segmental air movements and investigation into possible local lung reflexes. regional inca-ordination of such air movements may influence respiratory disease. references 1. hamilton 0, godfrey kr, causer da mcintosh ja. regional specific mean expiratory gas flow from ri"kr equilibrium inhalation data. eur j nucl med 1985; 10:321-331. wernly ja, demeester tr, kirchner pt, myerowitz p, oxford de, golomb hm. clinical value of quantitative ventilation-perfusion lung scans in the surgical management of bronchogenic carcinoma. j thorac cardiollasc surg 1980;80:535-543. amistc, ciofetta g, hughesjmb, loh l. regional lung function in bilateral diaphragmatic paralysis. clinical science 1980;59:485-492. 4. holli h, muittart a, paakkala t, poyhonen l, seppanen a, uusitalo a. comparison between conventional examinations and radiospirometry measured by computerized multidetector unitkefut bl 1200 in evaluations of regional lung function pre-operatively and after cobalt therapy. radioaki isop klin forsell 1976; 12:23. 5. miërner g. "'xe radiospirometry: a clinical method for studying lung function. scand j respir dis 1968;suppi64: 17-43. 6. kauppinen-walin k, sovijarui ara, muittari a, uusitalo a. determination of residual capacity with 111xenonradiospirometry. comparison with whole body plethysmography and helium spirometry. effect of body position. scand j clin lab invest 1980;40:347-354. 7. secker-walker rh, hili ri, markharn j, baker l,wilhelm j,alderson po, potehen ej. the measurement of regional ventilation in man: a new method of quantification. j nucmed 1973;14:725-731. 8. mji m, clauss ri'.the eftects of expiratory and incentive expiratory spirometry on young males with traumatic haemo-pneumo-thorax. medunsa abstracts 1991;12th academic day. 9. ahmad m, perrillo rp, sunwoo yc, donati rm. xenon-i ~3 retenlion in hepatic steatosis correlation with liver biopsl in 45 patients: concise communication. jnm 1979;20l5):397-401. frampage 15 2 a mini rev ievv of paragangliornas vvitl : presentation of tvvo cases surgical cure rates of 66-85 % have been reported with a 5-10 % recurrence rate.2,3 the five year survival is 80-95 % with surgery, and less than 50 % in malignant disease.v" the hypertension cure rate is 75 % if total tumour excision is accomplished. in 25 % of cases the hypertension persists either due to unmasking of primary hypertension, intraoperative renal ischaemia, damage to the renal vessels, or catecholamine-induced vascular damage. conclusion paragangliomas are rare tumours that are potentially lethal if undiagnosed or discovered incidentally. their early diagnosis requires a high index of suspicion and appropriate biochemical tests. accurate radiological localisation of the tumour is best accomplished using mri as a first line investigation with mibg scans being reserved for cases of recurrence, multicentricity, metastatic disease or equivocal mri. where the tumour is biochemically inactive, mr! scanning is the best option. octreotide is emerging as a promising agent, but its long-term performance remains to be fully evaluated. appropriate and early intervention carries a favourable prognosis in an otherwise dangerous tumour. acknowledgements the author wishes to thank prof s beningfield for his assistance in the preparation of this review, dr p szkup for the use of illustrative figures and miss l heyburgh for manuscript preparation. references 1. van gijs apg, van erkel ar, falke thm. et al. magnetic resonance imaging or metaiodobenzylguanidine scintigraphy for the demonstration of paragangliomas? european joumal of nuclear medicine 1994; 21 (3): 239-253. 2. wilson, braunwald, isselbacher, petersderf et al. harrison's principles of internal medicine 12'" ed. mcgraw-hili 1991: 1735-1739 3. felig, baxter, frohman. e'ldocrinology and tvïetobolïsm. )'" ed. mcgraw-hili 1995: 713-731. 4. williams, warwick, dyson el nl grays anatomy 37'" ed. churchill livingstone 1987: 200,201,1465-1467. 5. o'riordain ds, young wf, grant cs et al. clinical spectrum of functional extra-adrenal paraganglioma. world joumal of surgery 1996; 20(7): 916-921. 24 sa journal of radiology. november 1998 6. dunn gd, brown mj, sapsford rn et al. functioning middle mediastinal paraganglioma associated with intercarotid paraganglioma. lancel 1986; (l): 10611064. 7. rehm a, williams rj. case report: an intra-abdominal tumour. posigraduate medicaljoumal 1997; 73(860): 353-355. 8. hayes ws, davidson aj, grimley pm el al. extraadrenal retroperitoneal paraganglioma: clinical pathological and ct findings. limericail joumal of roenlglillology 1990; 155(6): 1247-1250. 9. kwekkeboom dj, van urk h, pauw bkh el al. octreotide scintigraphy for the detection of paragangliomas. jol/mal of nuclear medicine. 1993; 34(6) 873-878. 10. grainger rg, allison oj. diagnostic radiology 3'" ed churchill livingstone 1997: 293-294, 2451. 11. bloodworth j endocrine palhology general and surgical. 2"" cd. williams and williams 1981: 482-505. 12. harach hr, wheatley t, smellie wab el al. phaeochromocytoma of the organ of zuckerkandl invading the inferior vena cava. histopalhology. 1996; 28(6): 556-559. 13. altergott r, barbato a, lawrence a et al. spectrum of catecholamine-secreting tumours of the organ of zuckerkandl. surgery 1985-98; (6): 1121-1126. 14. shapiro b, copp je, sisson lc el al. iodine 131 metaiodobenzylguanidine for the locating of suspected rhaeochromocytoma: experience in 400 cases. joumal of nuclear medicine 1995; 26: 576-585. 15. maurea s, cuocolo a, reynolds jc el al. i'" mibg scintigraphy in preoperative and postoperative evaluation of paragangliomas: comparison with ct and mrt. loumal of nuclear medicine 1993; 34(1): 173179. 16. schmedtje jf, sax s pool jl et al. localisation of ectopie phaeochromocytoma by magnetic resonance imaging. american journal of medicine 1987; 83: 770-772. 17. van geldert,verhoeven gt, delong p et al. dopamine producing paraganglioma not visualised by 1m scintigraphy. loumal of nuclear medicine 1995; 36(4): 620-622. abstract introduction patient presentation management and outcomes discussion conclusion acknowledgements references about the author(s) brett wegner department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa ruchika meel division of cardiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa division of cardiology, faculty of health sciences, chris hani baragwanath academic hospital, johannesburg, south africa tamarin nell department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of diagnostic radiology, chris hani baragwanath academic hospital, johannesburg, south africa lamla nqwata division of pulmonology, department of medicine, chris hani baragwanath academic hospital, johannesburg, south africa department of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa michelle wong division of pulmonology, department of medicine, chris hani baragwanath academic hospital, johannesburg, south africa department of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation wegner b, meel r, nell t, nqwata l, wong m. hydatid disease of the interventricular septum: echocardiographic and computed tomography findings. s afr j rad. 2020;24(1), a1986. https://doi.org/10.4102/sajr.v24i1.1986 case report hydatid disease of the interventricular septum: echocardiographic and computed tomography findings brett wegner, ruchika meel, tamarin nell, lamla nqwata, michelle wong received: 08 sept. 2020; accepted: 29 sept. 2020; published: 15 dec. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract hydatid disease (hd) is prevalent in south africa, with cardiac hd being a rare but important manifestation to recognise and diagnose. an incidental finding on computed tomography (ct) of the chest in a patient with pulmonary hd prompted further multimodality imaging, which confirmed the presence of cardiac hd involving the interventricular septum. this case report focuses on imaging findings related to cardiac hd, as demonstrated by the ct of the chest and twoand three-dimensional transoesophageal echocardiography. multimodality imaging is essential to assist in making a diagnosis and providing a detailed assessment of patients with cardiac hd. keywords: cardiac hydatid disease; interventricular septum; transoesophageal echocardiography; computer tomography; sub-saharan africa. introduction hydatid disease (hd) is a parasitic infestation caused by the echinococcus species. it is endemic in areas of the world where livestock is raised, which include europe, middle east, south america, australasia and sub-saharan africa.1 the disease is reported to affect men and women equally, with the average age reported to be 32 years.2 human hd commonly affects the liver (50% – 70%) and lungs (20% – 30%).3 cardiac hd is a rare manifestation of human hd and accounts for 0.5% – 2% of all hydatid cases.4 this case report presents a rare case of cardiac hd and the imaging findings demonstrated on computed tomography (ct) of the chest and three-dimensional (3d) transoesophageal echocardiography (toe) imaging. patient presentation a 43-year-old woman with no comorbidities presented to an academic hospital in cape town in 2010 with respiratory symptoms. she previously resided in a rural area of south africa. in cape town, she was diagnosed with pulmonary hd and received medical management with albendazole for 1 year with resolution of her symptoms. from 2010 to 2017, she was lost to follow-up, but was reportedly symptom free. in 2018, she presented to chris hani baragwanath academic hospital (chbah) with acute onset respiratory symptoms. laboratory investigation and imaging suggested hd. albendazole was commenced with rapid resolution of her symptoms. a chest ct confirmed bilateral pulmonary hd in addition to a hypodense mass located in the interventricular septum (ivs), resulting in partial effacement of the right ventricle. a provisional diagnosis of ventricular thrombus and further investigation with echocardiography was recommended. however, the patient was lost to follow-up for the next 2 years. in may 2020, she again presented to chbah complaining of respiratory symptoms. she denied any cardiac symptoms. the general cardiovascular examinations were normal. laboratory investigations showed normal cardiac enzymes, liver and renal function, and no evidence of sepsis. the echinococcus indirect haemagglutination test was positive (titre of 1:500). a 12-lead electrocardiogram (ecg) was normal. the chest radiograph demonstrated findings consistent with pulmonary hd, which was confirmed at chest ct. in addition to the pulmonary hd findings, the chest ct also demonstrated a hypodensity within the ivs, resulting in partial effacement of the right ventricle and a finger-like protrusion of the hydatid cyst into the right atrium (figure 1).5 further imaging with 3d toe confirmed an infiltrating cystic lesion involving the ivs, resulting in expansion of the ivs towards the right ventricle with partial effacement of the right ventricle into a slit-like cavity and protrusion of the cystic lesion into the right atrium without tricuspid valve dysfunction. the cyst demonstrated mixed echogenicity and calcified components (figure 2).6 figure 1: computed tomography of the chest: (a) axial; (b) coronal; (c) sagittal demonstrating a well-defined interventricular hypodensity protruding into the right ventricle and right atrium (arrows). figure 2: (a) twoand three-dimensional transoesophageal echocardiography view of the heart at the mid-oesophageal level showing infiltration of the entire interventricular septum (open white arrow) by the hydatid cyst and reduction of the right ventricle to a slit-like cavity. (b) the hydatid cyst protrudes into the right atrium without causing tricuspid valve dysfunction. (c and d) two-dimensional transoesophageal echocardiography trans-gastric view showing infiltration of the interventricular septum by the hydatid cyst (solid white arrow) and its relation to the tricuspid valve (open arrow, c). deep trans-gastric view depicting septal hypertrophy due to hydatid disease (white arrow) mimicking asymmetrical septal hypertrophic cardiomyopathy (d). (e and f) three-dimensional echocardiographic reconstruction of the right atrium (ra) and right ventricle (rv) showing the anterior location of the hydatid cyst protruding into the right atrium (white arrow) relative to the tricuspid valve (black arrow) at the base of the heart (e), and unobstructed blood flow through the tricuspid valve (white arrow) (f). imaging techniques used were as follows: contrast-enhanced multi-detector computed tomography (mdct) was performed on a canon aquilion prime sp (canon medical systems): helical scan mode, 0.35s gantry rotation, collimation 0.5 mm × 80, sure exposure tm automatic exposure control, kvp 120, mas 40–90. philips epiq 7c, toe probe 5–7 mhz x7-2t (philips healthcare, usa): 2d and 3d toe. management and outcomes the patient is currently being managed by a multidisciplinary team (pulmonologist, cardiologist and radiologist). the patient was deemed inoperable because of the extent of the hd. in addition, attempted surgical removal of the cardiac hydatid cysts within the ivs would be technically challenging and would carry a high risk of morbidity and mortality. because the patient has not had any cardiac complications for at least 2 years, there is no indication for surgical intervention. the patient is receiving medical therapy and is being followed up by specialists of the pulmonology and cardiology services. she remains asymptomatic. ethical consideration ethical approval was granted by the university of witwatersrand human research ethics committee (hrec) on 26 august 2020 (reference number: r14/49). consent was obtained from the patient for the purpose of this case report. discussion cardiac hd is a rare manifestation of human hydatidosis as the heart boasts natural resistance to parasitic invasion given the mechanical action of the myocardium.5 humans are considered accidental hosts in the complex life cycle of echinococcus species. humans acquire the disease after ingestion of parasitic ova found in contaminated food sources.6 the parasitic ova hatch in the intestines with subsequent invasion of the mucosa, entering the portal and later the systemic circulation, with the potential to infiltrate any soft tissue within the human body.7 echinococcus species gain access to the heart via the coronary circulation and lymphatic networks.8 the left ventricle is involved in 60% of cardiac hydatid cases; right ventricle, 10%; ivs, 9%; pericardium, 7%, and left atrial appendage, 6%.5 the growth and development of hydatid cysts in the myocardial tissue is slow, and as a result, patients are often asymptomatic.8 symptoms are related to the growth, invasion and size of the hydatid cysts within the myocardial tissue.5 cardiac symptoms range from space-occupying effects causing low cardiac output states, heart failure or valvular dysfunction.9 invasion and irritation of the conduction pathways lead to dysrhythmias, palpitations, syncope or sudden death.9 hydatid cysts can rupture causing pericardial tamponade, pericarditis or systemic dissemination of antigenic material with life-threatening anaphylaxis.2,9 clinical diagnosis of cardiac hd is often difficult as patients may present with no cardiac symptoms, a normal ecg and a normal chest radiograph,7 as is the case with this patient. serological markers can assist with making a diagnosis with a reported sensitivity for hydatid disease in the range of 20% – 60%.3 advanced imaging assists in making the diagnosis of cardiac hd and is mostly reliant on toe and magnetic resonance imaging (mri), and to a lesser extent on ct.4,10 this is evident in this case with ct identifying an abnormal cardiac lesion with a list of differential diagnoses, including infiltrative cardiomyopathy, hypertrophic cardiomyopathy, tumours and hd of the heart. imaging with toe narrowed the differential diagnosis, and in combination with a history of confirmed pulmonary hd and positive serology, cardiac hd was considered the most likely diagnosis. tissue biopsy and polymerase chain reaction assay identify nucleic acids specific to the echinococcus species; these are regarded as the confirmatory tests for the diagnosis of hd.11 a tissue biopsy was not carried out for this patient because of the potential adverse outcome in the setting where tissue confirmation of the diagnosis was considered unnecessary, given the high confidence of an accurate diagnosis carried out by the investigating team using the information gathered through history, laboratory investigations and multimodality imaging. transoesophageal echocardiography is an excellent diagnostic tool that is accurate, available, cost-effective and safe to use.10 echocardiography technology continues to improve and allows real-time 3d imaging of the heart, demonstrates the characteristics of a lesion and the anatomical location and assesses the haemodynamic function of the heart in a single examination.2,12 the appearance of cardiac hd on toe is variable, with the majority of cases demonstrating solitary, intramyocardial, oval-shaped cystic lesions with well-defined walls and measuring an average of 3 cm – 5 cm in diameter.10 internal septations are characteristic of daughter cysts.10 hydatid cysts are viable if filled with clear fluid, whilst non-viable cysts are calcified.13 both ct and mri provide information on the extent and anatomical relationship of the cysts within the heart.4 computed tomography imaging commonly demonstrates well-defined, low-attenuation, spherical cystic lesions (average hounsfield unit, 0), with smooth thin walls and variable contrast wall enhancement. cyst wall calcification and daughter cysts are considered specific imaging features for hd.4 magnetic resonance imaging provides detailed information on the anatomical location, tissue planes and internal characteristics of the cysts.4,8 the differential diagnosis to consider with ct and toe imaging includes intraventricular thrombus, intramyocardial cysts, a variety of cardiac tumours and asymmetrical septal hypertrophic cardiomyopathy.2 magnetic resonance imaging and echocardiography are the preferred modalities for follow-up and assessment of treatment outcomes.10 the management of patients with cardiac hd is medical, surgical or a combination of both.2 surgical treatment may be preferable because medical treatment alone does not provide assurance against rupture of a hydatid cyst and life-threatening complications that may follow.9 the management of cardiac hd is multidisciplinary, with therapeutic decisions based on the characteristics of the cardiac hd, patients’ symptoms and comorbidities, as well as the surgical expertise available at the treating institution.14 conclusion this case report highlights that cardiac hd as a rare, but important, manifestation of human hydatidosis that is often silent and overlooked. patients known to have hd and presenting with cardiac pathology should always be referred for advanced multimodality imaging, with particular reference to toe in order to appropriately assess for cardiac involvement. patient-specific treatment is guided by the clinical presentation, multimodality cardiac imaging and a multidisciplinary team. acknowledgements the authors would like to thank the ceo of chris hani baragwanath academic hospital and the patient for permission to publish this case report. competing interests the authors declare that they have no personal or financial conflicts of interest in the writing of this case report. authors’ contributions b.w. wrote the manuscript. t.n. supervised and assisted in editing the write-up. r.m. provided the transoesophageal echocardiography images with descriptions and reviewed the manuscript. l.n. and m.w. provided clinical case information, reviewed the manuscript and obtained consent from the patient. funding information this study received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability statement the data that support the findings of this study are available from the corresponding author, b.w., upon reasonable request. disclaimer the views expressed in this case report are those of the authors and not an official position of any institution affiliated to the authors. references abu-eshy sa. some rare presentations of hydatid cyst (echinococcus granulosus). j r coll surg edinb. 1998;43(5):347–352. fennira s, kamoun s, besbes b, et al. cardiac hydatid cyst in the interventricular septum: a literature review. int j infect dis. 2019;88(2019):120–126. https://doi.org/10.1016/j.ijid.2019.09.004 sensoz y, ozkokeli m, ates m, akcar m. right ventricle hydatid cyst requiring tricuspid valve excision. int j cardiol. 2005;101(2):339–341. https://doi.org/10.1016/j.ijcard.2004.01.043 dursun m, terzibasioglu e, yilmaz r, et al. cardiac hydatid disease: ct and mri findings. ajr am j roentgenol. 2008;190(1):226–232. https://doi.org/10.2214/ajr.07.2035 shojaei e, yassin z, rezahosseini o. case report cardiac hydatid cyst: a case report. iran j public health. 2016;45(11):1507–1510. moro p, schantz pm. echinococcosis: a review. int j infect dis. 2009;13(2):125–133. https://doi.org/10.1016/j.ijid.2008.03.037 i̇yigün t, kyaruzi mm, kutay v, karakurt st. asymptomatic huge cardiac hydatid cyst located in the interventricular septum. braz j cardiovasc surg. 2020;35(2):235–238. https://doi.org/10.21470/1678-9741-2018-0368 cantoni s, frola c, gatto r, loria f, terzi mi, vallebona a. hydatid cyst of the interventricular septum of the heart: mr findings. am j roentgenol. 1993;161(4):753–754. https://doi.org/10.2214/ajr.161.4.8372751 tefera e, knapp j, teodori m. hydatid cyst of the interventricular septum. glob cardiol sci pract. 2015;2015(5):52. https://doi.org/10.5339/gcsp.2015.52 barbetseas j, lambrou s, aggeli c, et al. cardiac hydatid cysts: echocardiographic findings. j clin ultrasound. 2005;33(4):201–205. https://doi.org/10.1002/jcu.20108 mcmanus dp, gray dj, zhang w, yang y. diagnosis, treatment, and management of echinococcosis. bmj. 2012;344(7861):1–13. https://doi.org/10.1136/bmj.e3866 kwon sh, gopal as. 3d and 4d ultrasound: current progress and future perspectives. curr cardiovasc imaging rep. 2017;10(12):43. https://doi.org/10.1007/s12410-017-9440-2 wahlers k, menezes cn, wong ml, et al. cystic echinococcosis in sub-saharan africa. lancet infect dis. 2012;12(11):871–880. https://doi.org/10.1016/s1473-3099(12)70155-x gocen u, atalay a, basturk y, topcuoglu ms, yaliniz h, salih ok. urgent surgery for cardiac hydatid cyst located in interventricular septum. asian cardiovasc thorac ann. 2014;22(8):965–967. https://doi.org/10.1177/0218492313489562 sajr 675 rigler’s sign and the football sign s daya, n mahomed, s andronikou   department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg s daya, mb bch n mahomed, mb bch fcrad (d) s andronikou, mb chb, fcrad, frcr (lond), phd   corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) rigler’s sign was first described in 1941 by l g rigler as a new radiological sign for recognising free air in the peritoneal cavity on supine radiograph. the presence of pneumoperitoneum allows free intraperitoneal air to be contrasted with intraluminal gas, accentuating the wall of gas-containing viscera. it is observed in infants and very ill patients where only limited radiographs of the abdomen are possible. the football sign was first described by r e miller in the 1960s. seen on supine abdominal radiographs, this describes an oval radiolucency resembling an american football. it is important for the radiologist to recognise the supporting signs of pneumoperitoneum, such as rigler’s sign and the football sign, on supine abdominal radiographs, especially in neonates and infants, where erect chest/abdominal radiographs are not always possible. s afr j rad 2012;16(4):147-148. doi:10.7196/sajr.675 case history a 3-day-old premature neonate presented with significant abdominal distension. the patient had a history of a difficult intubation for respiratory distress a few hours prior to this presentation. on clinical examination, the abdomen was significantly distended with absent bowel sounds. a portable supine abdominal radiograph demonstrated the rigler’s and football signs in keeping with a pneumoperitoneum (fig. 1a). this was confirmed on a lateral decubitus view (fig. 1b). at surgery, an iatrogenic gastric perforation was repaired. a b fig. 1. (a) supine abdominal radiograph demonstrating rigler’s sign (closed arrows) and the football sign (arrow heads) in a patient with iatrogenic gastric perforation. rigler’s sign is the visualisation of the inner and outer bowel wall owing to pneumoperitoneum, also known as the double-wall sign. the football sign is described as an oval radiolucency owing to pneumoperitoneum that resembles an american football. the vertical opacity of the falciform ligament (open arrow) represents the laces, and the remaining abdomen represents the reaming portion of an american football. (b) the lateral decubitus view confirms the pneumoperitoneum. note rigler’s sign (closed arrow). signs of pneumoperitoneum rigler’s sign was first described in 1941 by l g rigler as a new radiological sign for recognising free air in the peritoneal cavity on supine radiograph.1 normally, the mucosal surface of the bowel wall is seen as it is lined by intraluminal gas. the serosal surface of the bowel wall is surrounded by abdominal tissue and not delineated.2 the presence of pneumoperitoneum allows free intra-peritoneal air to be contrasted with intraluminal gas, accentuating the wall of gas-containing viscera.3 both the inner and outer bowel wall are therefore visible; therefore, it is also known as the double-wall sign.2 it is observed in infants and very ill patients where only limited radiographs of the abdomen are possible.3 according to some authors, rigler’s sign is present in 14 – 32% of patients with gastro-intestinal perforation.2 a pseudo-rigler’s sign may be visualised when neighbouring walls of distended bowel loops are outlined by intraluminal gas without any free intra-abdominal air.2 the football sign was first described by r e miller in the 1960s.5 seen on supine abdominal radiographs, it describes an oval radiolucency that resembles an american football. the long axis of the football runs supero-inferiorly, with the blunted edges formed by the diaphragm and the pelvic floor.6 the oval shadow seen in the football sign is due to a large pneumoperitoneum, which distends the peritoneal cavity. the free intraperitoneal air also outlines the falciform ligament which may be seen in the right upper abdomen as a faint linear opacity positioned longitudinally. the vertical opacity of the falciform ligament represents the laces and the remaining abdomen represents the reaming portion of an american football.7 the visualisation of the football sign is indicative of a large amount of intraperitoneal air relative to the patient size, while rigler’s sign can be seen with a small amount of intraperitoneal air and is a more sensitive sign for early pneumoperitoneum.6 as infants are unable to communicate their symptoms, which may result in delayed detection, they commonly present with the football sign, as opposed to adults, with a 2% incidence of the football sign.6 other signs of pneumoperitoneum on supine abdominal film include the doge’s cap sign (triangular collection of gas in morrison’s pouch), large area of hyperlucency over the liver shadow, parahepatic air (gas bubble lateral to the right edge of the liver), air outlining the fissure of ligamentum teres and the cupola sign (gas trapped below central tendon of diaphragm).4 causes of pneumoperitoneum in neonates and infants while there are numerous causes of pneumoperitoneum, gastric perforation is more likely to result in the football sign than small bowel perforation, because gastric perforations are usually associated with release of a larger amount of free air.6 however, small bowel perforation owing to necrotising enterocolitis is a far more common cause of perforation in south african clinical practice. a large pneumoperitoneum may not be identified with small bowel perforation or ruptured appendicitis owing to the localised inflammatory process adjacent to the perforation.6 causes of neonatal gastro-intestinal perforation include necrotising enterocolitis, bowel obstruction (i.e. malrotation with midgut volvulus, hirschsprung’s disease, meconium ileus or bowel atresia) and inflammatory causes such as gastric or duodenal ulcers.6 gastric perforation, as described in our patient, accounts for 10 – 16% of all gastro-intestinal perforations in neonates.8 traumatic causes secondary to feeding tube placement or vigorous respiratory resuscitation are described.8 , 9 other factors include mechanical pressure by nasogastric or orogastric catheters and excessive gastric distension owing to positive pressure ventilation.9 drug-associated perforation has been associated with dexamethasone and indomethacin treatment.10 conclusion it is important for the radiologist to recognise the supporting signs of pneumoperitoneum such as rigler’s sign and the football sign on supine abdominal radiographs, especially in neonates and infants where erect chest/abdominal radiographs are not always possible. 1. rigler l. spontaneous pneumoperitoneum: a roentgenologic sign found in the supine position. radiology 1941;37: 604-607. 1. rigler l. spontaneous pneumoperitoneum: a roentgenologic sign found in the supine position. radiology 1941;37: 604-607. 2. williams n, everson nw. radiological confirmation of intraperitoneal free gas. ann r coll surg engl 1997;79:8-12. 2. williams n, everson nw. radiological confirmation of intraperitoneal free gas. ann r coll surg engl 1997;79:8-12. 3. lewicki am. the rigler sign and leo g rigler. rsna 2004;233:7-12. 3. lewicki am. the rigler sign and leo g rigler. rsna 2004;233:7-12. 4. chiu hs, chung ch. pneumoperitonuem on supine abdominal x-ray: case report & review of the radiological signs. hong kong journal of emergency medicine 2005;12: 46-49. 4. chiu hs, chung ch. pneumoperitonuem on supine abdominal x-ray: case report & review of the radiological signs. hong kong journal of emergency medicine 2005;12: 46-49. 5. miller re. perforated viscus in infants: a new roentgen sign. radiology 1960;74:65-67. 5. miller re. perforated viscus in infants: a new roentgen sign. radiology 1960;74:65-67. 6. rampton jw. the football sgn. radiology 2004; 31:81-82. 6. rampton jw. the football sgn. radiology 2004; 31:81-82. 7. hull a, buckley p, wills b. massive pneumoperitoneum. western journal of emergency medicine 2010;11:91-92. 7. hull a, buckley p, wills b. massive pneumoperitoneum. western journal of emergency medicine 2010;11:91-92. 8. holgersen lo. the aetiology of spontaneous gastric perforation of the newborn: reevaluation. j pediatr surg 1981;16:608-613. 8. holgersen lo. the aetiology of spontaneous gastric perforation of the newborn: reevaluation. j pediatr surg 1981;16:608-613. 9. aydin m, zenciroglu a, hakan n, erdogan d, okumus n, ipek ms. gastric perforation in an extremely low birth weight infant recovered with percutaneous peritoneal drainage. turkish journal of pediatrics 2011;3:467-470. 9. aydin m, zenciroglu a, hakan n, erdogan d, okumus n, ipek ms. gastric perforation in an extremely low birth weight infant recovered with percutaneous peritoneal drainage. turkish journal of pediatrics 2011;3:467-470. 10. o’neil ea, chwals wj, o’shea md, turner cs. dexamethasone treatment during ventilator dependency: possible life-threatening gastrointestinal complications. arch dis child 1992;67:10-11. 10. o’neil ea, chwals wj, o’shea md, turner cs. dexamethasone treatment during ventilator dependency: possible life-threatening gastrointestinal complications. arch dis child 1992;67:10-11. report baci< report on the breast ultrasound and mammography workshop held in pretoria, 23-26 september 1999 garth kruger mbchb, mmed(pret) chairman, mammography subgroup, rssa t he radiological society organised a breastultrasound and mammography workshop as part of the 1999 south african radiology congress at the csir conference centre from 23 to 26 september 1999. the congress was organised with the co-operation of the faculty members of the international breast ultrasound school (ibus). speakers attending the congress were dr edward azavedo and dr gunilla svane from the karolinska hospital in stockholm and dr roberta chersevani from gorizia in italy. a wide spectrum of topics was discussed starting with the basics of mammographic criteria and ending up with future developments in senology. the panel of speakers continued to reiterate the importance of quality assurance and quality control in senology as well as the accreditation of radiologists involved in breast imaging. these are two topics which will have to be addressed by the radiological society in the very near future. we cannot continue breast imaging in south africa without some form of accreditation of the people doing the imaging and some sort of control over whether there is any quality assurance in institutions doing breast imaging. a further fact that emerged from the congress, as well as from the discussions, is the continuing question of mr imaging of the breasts. there is a very long learning curve in mr imaging of the breasts and it seems that this examination should only be performed in institutions where they have a high turnover of cases and where they have experience. it is an open question whether this examination should be performed in south africa at all. the syllabus that was given out during the congress contains a handy number of lectures including some interesting lectures about fine needle 28 sa journal of radiology. january 2000 aspiration and the pathological correlation between pathology slides and mammography. more and more emphasis is today being placed on the importance of ultrasound. high-end equipment should be used with 7.5 or 10 mhz linear transducers. speaker after speaker confirmed the importance of the technical specifications of the machine. the importance of fine needle aspiration versus core biopsies and minimally invasive breast biopsy (mibb) was again discussed at the congress. the absolute importance of the availability of a dedicated breast cytologist was emphasized again and again. in fact, some of the speakers felt that if a dedicated breast cytology service was not available, that the radiologist should rather be doing core biopsies. the other advantage of core biopsies is that oestrogen receptor status can be done on a core specimen. this enables a definite pre-operative diagnosis to be made and different treatment modalities discussed with the patient. the ideal situation is where all breast surgery candidates have a pre-operative diagnosis. as far as possible the use of frozen sections in theatre should be limited by a proper preoperative work-up. the workshop sessions consisted of hands-on sessions with ultrasound as well as needle biopsies of the breasts. there were also interactive workshops demonstrating a wide variety of pathology in both mammography and pathological slides with correlation between the two. topage30 abstract introduction study design and methods results discussion conclusion acknowledgements references about the author(s) petri ahlers department of radiology, faculty of health sciences, university of cape town, cape town, south africa mariam q. said-hartley department of radiology, faculty of health sciences, university of cape town, cape town, south africa citation ahlers p, said-hartley mq. a retrospective review of ct pulmonary angiogram confirmed pulmonary emboli in covid-19 patients admitted to groote schuur hospital, cape town. s afr j rad. 2022;26(1), a2280. https://doi.org/10.4102/sajr.v26i1.2280 original research a retrospective review of ct pulmonary angiogram confirmed pulmonary emboli in covid-19 patients admitted to groote schuur hospital, cape town petri ahlers, mariam q. said-hartley received: 26 aug. 2021; accepted: 13 oct. 2021; published: 28 feb. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: a high incidence of thromboembolic phenomena has been widely reported in patients with coronavirus disease 2019 (covid-19) pneumonia. there is, however, a paucity of data detailing the incidence and characteristics of pulmonary emboli (pe) in covid-19 patients in the south african setting. objectives: to describe the incidence and characteristics of pe confirmed by ct pulmonary angiogram (ctpa) in patients with covid-19 pneumonia admitted to a tertiary hospital in the western cape, south africa. methods: this was a retrospective-, descriptive study of all adult patients with covid-19 pneumonia confirmed by polymerase chain reaction (pcr) undergoing ctpa for suspected pe while admitted to groote schuur hospital. the study period was from 01 april 2020 to 30 september 2020. results: the study cohort consisted of 116 patients, 59% being female, of whom 29% were pregnant or in the postpartum period. the median age for both genders combined was 49.5 years. the overall incidence of pe was 19%, with 20% in our subset of pregnant and postpartum patients. the majority (64%) of pe’s were reported as being segmental in anatomical location. conclusion: the noteworthy cohort included patients with pulmonary tuberculosis (ptb), hiv as well as pregnant and postpartum patients. the overall incidence of pe was 19% with no significant differences in demographics, comorbidities or d-dimer levels between patients with or without pe. the importance of a high clinical index of suspicion together with the role of ctpa in diagnosing pe in hospitalised covid-19 patients is emphasised. keywords: covid-19; pulmonary emboli; computed tomography pulmonary angiogram (ctpa); south africa; anticoagulation; pregnant; tb; hiv. introduction the strong association between coronavirus disease 2019 (covid-19) pneumonia and venous thromboembolism (vte) has been well described.1,2,3 venous thromboembolism and, specifically pulmonary emboli (pe), can have devastating outcomes if left untreated.4 a hypercoagulable state in patients with severe covid-19 pneumonia increases the risk of thrombosis.3 risk factors provoking vte include bed-bound patients, vascular lines, advanced age, high body mass index (bmi) and underlying cardiovascular abnormalities.4 evidence suggests that all hospitalised patients with covid-19 pneumonia should receive prophylactic anticoagulation in the absence of contraindications.1,2,3,5 yet, a surprisingly high incidence persists despite concurrent anticoagulation, also highlighting the need for different and more effective anticoagulation.1,6,7,8 pulmonary embolism presents with non-specific signs and symptoms, making the diagnosis of pe clinically challenging.4,9,10 this is particularly true in those with hypoxic covid-19 pneumonia, where there is considerable overlap between the systemic and respiratory symptoms associated with covid-19 and those of pe.11 an elevated d-dimer level on hospital admission and sudden worsening in clinical condition in patients with confirmed covid-19 pneumonia should raise the suspicion of pe and ct pulmonary angiogram (ctpa) should be considered.3,5,11 imaging with ctpa remains the gold standard in the diagnosis of pe.9,10 this study aimed to describe the incidence and characteristics of ctpa confirmed pe in patients with covid-19 pneumonia admitted to a tertiary hospital in the western cape, south africa. study design and methods a retrospective-, descriptive single-centre study design was used. the study included all adult patients admitted to groote schuur hospital (gsh) from 01 april 2020 to 30 september 2020 with confirmed covid-19 pneumonia who underwent ctpa scans. this was defined by a positive reverse transcriptase polymerase chain reaction (rt-pcr) test on a nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the indication for ctpa in all patients was suspected pe. radiological images and reports on scans performed in the division of radiology, groote schuur hospital are stored in the picture archiving and communications system (pacs) database system. a detailed search using query builder (philips, xiris 8.3.16) database search tool was used to access all ctpa reports/images on the pacs system for the study period. the search phrases ‘covid’, ‘sars’, ‘corona’, ‘cov 2’, ‘person under investigation (pui)’ and ‘pcr’ were used to refine the search results. the initial search results with these search phrases revealed 269 ctpa studies. the study investigators manually filtered all 269 ctpa studies, and those patients with a history of covid-19 and confirmed positive rt-pcr sars-cov-2 results were included in the search criteria. all pui patients with positive rt-pcr sars-cov-2 results were re-classified as covid-19 and included in the study. of the 269 studies, a total of 116 ctpa studies satisfied the search criteria and were enrolled in the study. the included cases either had a confirmed rt-pcr sars-cov-2 result on the national health laboratory service (nhls) or a confirmed result documented on the ctpa clinical request form. all ctpa studies were performed on a 160-slice toshiba aquillion prime (tochigi, japan) 160 multidetector computed tomography (mdct) scanner. the scans were acquired with intravenous injection of 100 ml of contrast (omnipaque 350), using a bolus tracking technique. the ctpa acquisition was initiated once the contrast bolus in the pulmonary trunk reached a hounsfield unit (hu) of 180. the ctpa images were transferred to the pacs database for viewing of both soft tissue and lung window reconstructions. all the ctpa studies were either reported by a radiology consultant or reported by radiology registrar, and the final report was approved by a radiology consultant. the final ctpa report was used to confirm the presence or absence of a pe. pulmonary embolism was defined as a filling defect within the main pulmonary artery/arteries, and/or their lobar, segmental or subsegmental branches on the ctpa study.9,10 the anatomical location of the pe was documented. in the case of multiple pes, the most proximal anatomical location was noted. we further retrospectively collected data on patient demographics (age, gender), whether the patient was admitted to a general ward, high care or intensive care unit (icu) and whether the patient had any recorded comorbidities on the clinical request form, such as diabetes, hypertension, cardiovascular disease, dyslipidaemia, hiv, malignancy, pulmonary tuberculosis, other respiratory diseases or a history of deep vein thrombosis (dvt). only d-dimer levels performed within three days of the ctpa study were included in the study. in a case where more than one d-dimer level was performed, the d-dimer result closest to the date of the ctpa study was recorded. in the absence of contraindications, all patients in the cohort received either prophylactic or therapeutic doses of enoxaparin according to our hospital protocol. as per hospital protocol at the time, therapeutic anticoagulation doses were reserved for patients who required high flow oxygen or mechanical ventilation, a high index of suspicion for pe or dvt, a rising d-dimer level on serial d-dimer measurements or a single d-dimer level > 1.5 times the upper limit of normal.11 statistical analysis we recorded the incidence of ctpa confirmed pe in all patients with proven covid-19 pneumonia with clinical suspicion for pe undergoing ctpa at tertiary hospital during the specified reporting period. furthermore, we investigated the association between demographic and clinical variables, and ctpa confirmed pe in patients with covid-19 pneumonia. the appropriate non-parametric tests were conducted where the data violated assumptions of normality. mann-whitney u tests were used to compare age and d-dimer levels between covid-19 patients with and without pe. chi-square tests investigated the association between pe (positive or negative) and gender, anatomical location of pe, whether the patient was admitted to the icu, high care or general ward, and whether the patient had comorbidities or not. sub-analyses compared the female patients who were pregnant or within the postpartum period, versus those who were not pregnant. data was analysed using statistical package for the social sciences (spss) version 27, with the significance level set at p = 0.05. ethical considerations ethical approval to conduct the study was obtained from the faculty of health sciences human research ethics committee of the university of cape town (hrec reference number: 109/2021) and from groote schuur hospital. all patient data were anonymised. results of the study cohort of 116 patients, 69 (59%) were female and of these, 18 (26%) were pregnant and two (3%) were in the postpartum period. the median age for both genders was 49.5 years. nineteen percent (19%) of patients undergoing ctpa for suspected pe had radiological confirmation of pe, with the majority (64%) reported as segmental in anatomical location. a large proportion (85%) of the patients in the study were admitted to general wards, with 13% admitted to a high care unit and only 2% patients in icu. (table 1) table 1: pulmonary emboli characteristics. the majority (71%) of patients in the cohort had comorbidities (table 2), with hypertension and diabetes being the most common. seventy two percent (72%) of patients with confirmed pe had more than one or multiple comorbidities compared to 47% in the non-pe group. table 2: comorbidities. there was no significant difference in demographic or clinical variables, including d-dimer levels between patients with and without pe (table 3). the incidence and characteristics of pe in the pregnant/postpartum and the non pregnant patients are presented in table 4. the pregnant and postpartum group was significantly younger compared to the non-pregnant females, and had fewer comorbidities. table 3: clinical characteristics of cohort. table 4: pulmonary emboli characteristics between pregnant, postpartum and non pregnant patients. discussion the incidence of pe in hospitalised patients with covid-19 pneumonia undergoing ctpa for clinical suspicion of pe at our institution was 19.0%. this is similar to the incidence of 23.9% reported in a meta-analysis by kwee et al. (2021). their pooled incidence included studies with similar study design, as well as similar indications for ctpa, and likewise only included studies with ctpa confirmed pe.12 the pooled incidence of those admitted to general wards was 23.9%, with a higher incidence (48.6%) of pe reported in patients admitted to icu.12 most of the patients in the studied cohort were admitted to general wards, with only 2.0% admitted to the icu. the general assumption was that patients with severe covid-19 pneumonia were admitted to either high care or icu, leading us to postulate that the majority had non-severe covid-19 pneumonia. peripheral pe was the most frequent anatomical location reported in international studies.12,13,14,15 this study had similar findings, with segmental pe the most common anatomical location. interestingly, the mean age of the study participants was younger than that reported in similar study populations undergoing ctpa for suspected pe.16,17 we observed a female predominance, which further consisted of a small subset of young pregnant patients and patients within the postpartum period. this could potentially explain and partially account for the difference in age observed in this study compared to the other studies. not surprisingly, the pregnant and postpartum group was significantly younger when compared to the non-pregnant females, and had less age-related comorbidities. other study populations with similar study designs have not commented on pregnant or postpartum patients. it is unclear whether pregnant patients were excluded from these studies or whether there were no pregnant patients in their respective study populations.12,17 pregnancy and the postpartum period in the general population are associated with an increased risk of vte, especially in the immediate postpartum period.18 however, there is a paucity of published work on the incidence and characteristics of pe in pregnant patients with covid-19 pneumonia. a literature review conducted by czeresnia et al. reported no difference in the severity of covid-19 infection or symptomatology in pregnant patients compared to the non-pregnant population.19 it is unclear whether, given the hypercoagulable state of pregnancy, covid-19 pneumonia or interplay between these two entities could have contributed to pe in this subgroup of patients. larger studies including post-mortem studies would need to be conducted to comment on the true underlying pathophysiology. the incidence of pe in the subset of pregnant and postpartum patients in this study was 20%. the mean d-dimer levels in the pe group were higher than in the non-pe group, but this was not statistically significant. no significant differences in demographic features or comorbidities between patients with and without pe were found. there was a median 13-day interval between positive rt-pcr results for sars-cov-2 and the diagnosis of pe on ctpa. in a study by s. meiler et al., the majority of pe’s were detected on days 11–20 after symptom onset.16 in addition, a similar study to assess pe in covid-19 patients undergoing ctpa reported a median of 14 days duration of symptoms prior to ctpa.17 this highlights the proposal for potentially using a lower threshold for requesting ctpa during the 2ndand 3rd week of covid 19 infection. unfortunately, we did not collect information on the delay between the onset of symptoms to the time of ctpa, and only reported on the number of days from the rt-pcr cov-2 test to ctpa. this precluded a direct comparison to the above mentioned studies with the assumption that symptom onset most likely preceded the date of rt-pcr cov-2 test.16,17 identifying a time period when patients are most at risk of developing pe during covid-19 infection could alert the clinician to have a lower threshold for requesting a ctpa study. this information would be invaluable, especially in view of the clinical challenges created by symptom overlap between pe and severe covid-19 pneumonia. study limitations sample size was limited by the retrospective nature of the study. caution should be taken regarding the true incidence of pe in hospitalised covid-19 patients, as only patients who underwent ctpa for suspicion of pe were included. the incidence reported does not reflect the true incidence in all hospitalised covid-19 patients. all patients included in the study received at least prophylactic anticoagulation, as per our institution guidelines at the time. however, no distinction was made between prophylactic or therapeutic doses, nor were exact doses included in the analysis. a small subset of pregnant and postpartum patients was included in our study. larger studies are required to comment on the true incidence and characteristics of pe in covid-19 pregnant and postpartum patients. we only included d-dimer levels performed within three days of the ctpa which resulted in a smaller sample size compared to our overall cohort. this was especially true for the non-pe group. we further acknowledge that d-dimer cut off levels used in the non-pregnant population are not reliable in pregnancy.18 conclusion according to our knowledge, this study is the first to describe the incidence and characteristics of pe confirmed on ctpa in hospitalised covid-19 patients in south africa. the incidence of pe in patients with covid-19 pneumonia undergoing ctpa for suspected pe at our institution was 19% with the majority of pe’s reported as segmental in anatomical location. the study cohort was unique as it included patients with pulmonary tuberculosis (ptb), hiv, as well as a subset of pregnant and postpartum patients. we report no significant differences in demographic features, comorbidities or d-dimer levels between patients with and without pe. our observations highlight the importance of ctpa, together with a high clinical index of suspicion, in diagnosing pe in hospitalised covid-19 patients at our institution. larger multi-centre studies exploring the characteristics of pe, together with laboratory markers and historical data to help identify a time interval during the course of covid-19 infection, when patients are most at risk of developing pe, could help with clinical decision making and in refining local hospital protocols, especially in resource constrained settings. acknowledgements the authors would like to acknowledge the division of radiology, gsh, university of cape town. we further acknowledge m. henry who conducted the statistical analysis and prof s. beningfield for critical appraisal of the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.a. the lead author, gathered the data and prepared the manuscript and q.s.-h. supervised the project, edited and approved the final manuscript for submission. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data is available from the corresponding author, p.a. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors or that of gsh. references klok f, kruip m, van der meer njm, et al. incidence of thrombotic complications in critically ill icu patients with covid-19. thromb res. 2020;191:145–147. https://doi.org/10.1016/j.thromres.2020.04.013 thachil j, tang n, gando s, et al. isth interim guidance on recognition and management of coagulopathy in covid-19. j thromb haemost. 2020;18(5):1023–1026. https://doi.org/10.1111/jth.14810 levi m, thachil j, iba t, et al. coagulation abnormalities and thrombosis in patients with covid-19. lancet haematol. 2020;7(6):438–440. https://doi.org/10.1016/s2352-3026(20)30145-9 giordano nj, jansson ps, young mn, et al. epidemiology, pathophysiology, stratification, and natural history of pulmonary embolism. tech vasc interv radiol. 2017;20(3):135–140. https://doi.org/10.1053/j.tvir.2017.07.002 rotzinger dc, beigelman-aubry c, von gc. pulmonary embolism in patients with covid-19: time to change the paradigm of computed tomography. thromb res. 2020;190:58–59. https://doi.org/10.1016/j.thromres.2020.04.011 llitjos jf, leclerc m, chochois c, et al. high incidence of venous thromboembolic events in anticoagulated severe covid-19 patients. j thromb haemost. 2020;18:1743–1746. https://doi.org/10.1111/jth.14869 helms jtc, tacquard c, severac f, et al. high risk of thrombosis in patients with severe sars cov-2 infection: a multicenter prospective cohort study. intensive care med. 2020;46(6):1089–1098. https://doi.org/10.1007/s00134-020-06062-x artifoni m, danic g, gautier g, et al. systematic assessment of venous thromboembolism in covid-19 patients receiving thromboprophylaxis: incidence and role of d-dimer as predictive factors. j thromb thrombolysis. 2020;50:211–216. https://doi.org/10.1007/s11239-020-02146-z palm v, rengier f, rajiah p, et al. acute pulmonary embolism: imaging techniques, findings, endovascular treatment and differential diagnoses. rofo. 2020;192(1):38–49. https://doi.org/10.1055/a-0900-4200 konstantinides sv, meyer g, becattini c, et al. 2019 esc guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the european respiratory society (ers). eur hear j. 2020;41(4):543–603. https://doi.org/10.1093/eurheartj/ehz405 mendelson m, boloko l, boutall a, et al. clinical management of covid-19: experiences of the covid-19 epidemic from groote schuur hospital, cape town, south africa. s afr med j. 2020;110(10):973–981. https://doi.org/10.7196/samj.2020.v110i10.15157 kwee rm, adams hja, kwee tc. pulmonary embolism in patients with covid-19 and value of d-dimer assessment: a meta-analysis. eur radiol. 2021;31:8168–8186. https://doi.org/10.1007/s00330-021-08003-8 suh yn, hong h, ohana m, et al. pulmonary embolism and deep vein thrombosis in covid-19: a systematic review and meta-analysis. radiology. 2021;298:70–80. https://doi.org/10.1148/radiol.2020203557 roncon l, zuin m, barco s, et al. incidence of acute pulmonary embolism in covid_19 patients: systemic review and meta-analysis. eur j intern med. 2020;82:29–37. https://doi.org/10.1016/j.ejim.2020.09.006 poyiadji n, cormier p, patel py, et al. acute pulmonary embolism and covid-19. radiology. 2020;297(3):5–8. https://doi.org/10.1016/j.ejim.2020.09.006 meiler s, hamer ow, schaible j, et al. computed tomography characterization and outcome evaluation of covid-19 pneumonia complicated by venous thromboembolism. plos one. 2020;15(11):1–16. https://doi.org/10.1371/journal.pone.0242475 ventura-díaz s, quintana-pérez jv, gil-boronat a, et al. a higher d-dimer threshold for predicting pulmonary embolism in patients with covid-19: a retrospective study. emerg radiol. 2020;27(6):679–689. https://doi.org/10.1007/s10140-020-01859-1 dado cd, levinson at, bourjeily g, et al. pregnancy and pulmonary embolism. clin chest med. 2018;39(3):525–537. https://doi.org/10.1016/j.ccm.2018.04.007 czeresnia rm, negrini r, nomura ml, et al. sars-cov-2 and pregnancy: a review of the facts. rev bras ginecol obs. 2020;42(9):562–568. https://doi.org/10.1055/s-0040-1715137 abstract introduction case report discussion conclusion acknowledgements references about the author(s) ranjan k. patel department of radiodiagnosis, maulana azad medical college, new delhi, india department of interventional radiology, institute of liver and biliary sciences, new delhi, india swasti pathak department of radiodiagnosis, maulana azad medical college, new delhi, india citation patel rk, pathak s. undifferentiated embryonal sarcoma masquerading as liver abscess: a case report with typical imaging features. s afr j rad. 2021;25(1), a2179. https://doi.org/10.4102/sajr.v25i1.2179 case report undifferentiated embryonal sarcoma masquerading as liver abscess: a case report with typical imaging features ranjan k. patel, swasti pathak received: 28 apr. 2021; accepted: 30 june 2021; published: 31 aug. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract undifferentiated embryonal sarcoma (ues) is an uncommon paediatric hepatic tumour that clinically simulates a liver abscess when present with fever. this report describes a case of ues in a 12-year-old boy, who presented with abdominal pain, swelling and fever, all simulating a liver abscess. the possibility of ues was considered at imaging, based on the solid appearance on ultrasound and cystic appearance with serpiginous peripheral vessels on computed tomography/magnetic resonance imaging. the diagnosis was confirmed at histopathology. keywords: undifferentiated embryonal sarcoma; paradoxical appearance; fever; liver abscess; serpiginous vessels; haemorrhage. introduction undifferentiated embryonal sarcoma (ues) of the liver is a rare malignant hepatic tumour of mesenchymal origin. it is primarily seen in children between 6 and 10 years of age.1 clinical manifestations are often non-specific, including abdominal pain and swelling, hepatomegaly, decreased appetite and weight loss. additionally, some patients present with intermittent and low-grade fever, making it difficult to distinguish from a liver abscess or a complicated hydatid cyst.2 however, an accurate diagnosis is essential to initiate appropriate management. imaging features can be variable; however, a peculiar paradoxical appearance on imaging, that is, solid on ultrasonography (usg) and cystic on ct or mri, can help in the early diagnosis of this entity.3,4 presented here is a case of ues of the liver in a 12-year-old boy who presented with abdominal pain, right-sided upper abdominal bulge and low-grade fever, masquerading as a liver abscess. case report a 12-year-old boy was admitted with complaints of mild abdominal pain and fever for one month. the intermittent and low-grade fever was relieved with analgesics. the mild and dull aching abdominal pain was confined to the right hypochondrium without any radiation. he also complained of a right upper abdominal bulge. there was a history of decreased appetite and weight loss of about 2–3 kg. the patient was haemodynamically stable. on abdominal examination, a firm and mildly tender mass was palpable 10 cm below the right costal margin, and the mass was not separately palpable from the liver. no prior history of hydatid disease, malignancy or any other comorbidity was found. at usg, a large well-defined mass was found in the right lobe of the liver. it was solid and iso to hyperechoic in appearance with a few cystic areas (figure 1a). no apparent internal vascularity was demonstrated on the colour doppler study (figure 1b). based on the fever and usg findings, the possibility of an organised liver abscess or complicated hydatid cyst was considered. empiric iv antibiotics and albendazole therapy were initiated. liver function tests (liver enzymes, serum bilirubin and albumin levels) and complete haemogram were within the normal limits except for a low haemoglobin of 9 gm/dl. total leucocyte counts and eosinophil counts were normal. both hydatid (immunoglobulin g [igg] titre-0.7; normal < 0.9) serology and amoebic serology (igg titre-0.51; normal < 0.9) were non-reactive. tumour markers were also within the normal limits. serum alfa-fetoprotein (afp), beta-human chorionic gonadotropin (beta-hcg) and carbohydrate antigen (ca-19-9) were 3.2 ng/ml (0–8.5), 0.8 iu/l (< 1.4) and 14 iu/ml (< 35), respectively. figure 1: (a) a well-defined heterogeneous lesion in the right lobe of liver with solid echogenic areas and anechoic cystic areas; (b) no obvious internal vascularity on doppler imaging. following failure to respond to antibiotic therapy, contrast-enhanced ct (cect) and ce-mri were requested for further evaluation of the lesion. contrast-enhanced ct demonstrated a cystic appearing mass (attenuation: 20–25 hu) with peripheral internal vascularity (figure 2a and b). mri revealed t2 hyperintensity with heterogeneous internal content and fluid-fluid levels (figure 3a and b). areas of variable t1 hyperintensity were also seen, possibly due to haemorrhagic components of varying ages (figure 3c). no enhancing solid tissue was seen within the lesion on post-contrast (gadopentetate dimeglumine) t1 weighted (t1w) images except for a few peripheral enhancing vessels as seen on cect (figure 3d). diffusion-weighted images (dwi) revealed variable signal with foci of restricted diffusion (figure 4a and b), corresponding to the haemorrhagic and necrotic areas. figure 2: (a) axial contrast-enhanced ct images demonstrating the cystic appearance of the mass with eccentric internal vascularity (red arrow heads); (b) sagittal maximum intensity projection image showing a tortuous artery supplying the periphery of the lesion as denoted by the black arrow. figure 3: (a) axial and (b) coronal t2w images showing a hyperintense cystic appearing lesion with heterogeneous internal components and fluid-fluid levels; (c) axial t1w image revealing hyperintense, internal haemorrhagic contents; (d) post-contrast t1w image indicating only peripheral vascularity (red arrow heads) with no obvious internal solid enhancing soft tissue. figure 4: (a) axial diffusion-weighted images image at b = 800 sec/mm2 shows heterogeneous content with hyperintensity areas that reveal low signal on the corresponding apparent diffusion coefficient map (b), indicating diffusion restriction. this was related to the internal haemorrhage and necrotic tissue. white arrows mark a focal haemorrhagic focus (marked t1 hyperintensity as seen in figure 3c), showing significant restricted diffusion. a core needle biopsy was performed under usg guidance, using an 18g semi-automatic gun; however, the pathology was inconclusive because of the predominant necrotic material obtained during the biopsy procedure. microbiological analysis of the biopsy sample was negative for bacteria, fungi, entamoeba and parasites. due to the non-resolving condition and inconclusive diagnosis, the patient finally underwent a right hepatectomy with removal of the lesion approximately 16 days after hospitalisation. the resected specimen revealed a large soft and friable tumour. the cut surface of the specimen revealed components of haemorrhage, necrosis and gelatinous material. there were no intra-operative or postoperative complications, and the patient was discharged on the 11th postoperative day in a stable condition. histopathological analysis of the resected specimen indicated that the tumour was composed of sheets of spindle cells with cellular pleomorphism, indistinct cytoplasm and hyperchromatic nuclei. immunohistochemistry showed cd10 membrane positivity, vimentin reactivity in spindle cells and negativity for myo d1. these findings were suggestive of ues. postoperatively, the patient received six cycles of chemotherapy (vincristine + cyclophosphamide + epirubicin). he was asymptomatic with no recurrence on the last follow-up at 11 months after surgery. discussion undifferentiated embryonal sarcoma is an uncommon malignancy of undifferentiated mesenchymal cells. it accounts for only 0.1% of surgically resected primary liver masses.1 undifferentiated embryonal sarcoma is most commonly seen between 6 and 10 years of age; however, it has been reported in adult patients as well.5 clinical manifestations are usually non-specific. children present with abdominal pain, loss of appetite and weight and a mildly tender abdominal lump. some patients may have fever and elevated leukocyte counts which cause difficulty in differentiating it from other hepatic pathologies, such as a liver abscess or complicated hepatic hydatid cyst.2,3 in a recent case series of 10 patients, fever was one of the manifestations in eight of 10 patients.6 a few patients present to the emergency department with acute abdominal pain because of tumour rupture and bleeding.2 unlike other common paediatric hepatic tumours such as hepatoblastoma and hepatocellular carcinoma (hcc), afp levels are usually not elevated in ues, which is an additional clue to its diagnosis. alternatively, ldh levels can be elevated in about 70% – 75% of cases; however, the cause is still unclear.2,3,6 the imaging appearance of ues may be inconsistent, varying from entirely cystic to entirely solid.7 characteristically, imaging shows a paradoxical appearance. on usg, ues shows solid-dominant mixed echogenic areas with variable anechoic cystic areas; however, it often appears as a cystic lesion with low attenuation on ct. this discrepancy in appearance is attributed to myxoid tissue, which usually appears hyperechoic on usg.3,4 a similar appearance was also seen in the patient presented. at times, lesions may be predominantly anechoic with multiple septa, simulating benign tumours such as mesenchymal hamartoma and biliary cystadenoma.8 nodular solid components and septations are also not uncommon, which show delayed enhancement.3 this case showed serpiginous vessels along the periphery of the lesion which has also been described in a previous study by gabor et al. serpiginous vessels were found in 9 of 15 patients in their study.3 undifferentiated embryonal sarcoma often shows areas of haemorrhage, and mr signal varies depending on ages of the bleeds. hyperintense signal on t1w images with fluid-fluid levels can occur because of internal haemorrhage and necrosis. haemorrhagic ascites or perihepatic fluid may be seen in cases of tumour rupture.3,8 neither was found in our patient. mesenchymal hamartoma is the most common imaging differential as both share common imaging features. although age may not be a reliable element, age < 2 years usually favours mesenchymal hamartoma and age > 5 years, usually favours ues. additionally, intralesional haemorrhage and serpiginous vessels favour ues.8 rhabdomyosarcoma is an alternative differential; however, it arises from the biliary tree and causes biliary obstruction, unlike ues.8 clinically and radiologically, ues simulates a liver abscess, particularly when fever and leukocytosis are present.6 another lesion that closely mimics ues on imaging is a hydatid cyst, especially in endemic regions. a complicated hydatid cyst can present with fever.9 amoebic serology, hydatid serology and fluid analysis may provide clues to the specific diagnosis. hepatoblastoma and hcc rarely have a cystic appearance; however, afp levels are often elevated in these tumours, unlike ues, where the afp level is often normal.8 a hepatic tumour in a child < 5 years old that shows lower enhancement than the adjacent hepatic parenchyma and elevated serum afp levels is more likely to be hepatoblastoma. hepatocellular carcinoma usually arises on a background of diffuse parenchymal liver diseases, such as glycogen storage disorders, tyrosinemia, wilson’s disease, etc.10 hepatocellular carcinoma appears as an arterially hyperenhancing mass with washout during the portal venous or delayed phases of imaging. it is commonly seen in children > 5-year-old.8,10 various salient features of the differential diagnoses of ues are summarised in table 1.2,3,4,6,8,9,11,12 table 1: differential diagnoses of undifferentiated embryonal sarcoma of liver. collection of inadequate specimens or sampling error usually leads to an incorrect histological diagnosis which often occurs in this condition because of the predominance of tumour necrosis and haemorrhage.13 image guidance helps procure a biopsy sample from the viable part of the tumour with a higher diagnostic yield and is also associated with a lower complication rate. an 18g biopsy needle suffices in most instances.3 however, because of the predominantly cystic nature of ues, percutaneous biopsy may not provide representative tissue and an open biopsy may be required for diagnostic confirmation.13 a definitive diagnosis of ues is made only on histopathology, supported by immunohistochemistry.7 in the past, the postoperative recurrence rate was high. however, advancement in current treatments has substantially improved the clinical outcome with a lower rate of recurrence.14,15 although there is no universal consensus regarding the management guidelines, complete resection of the tumour and combined adjuvant chemotherapy is the standard treatment strategy.13,15 liver transplantation may be an option for patients with unresectable tumours. imaging plays a vital role in post-treatment follow-up. it helps in the assessment of treatment response and to detect tumour recurrence early.10,13 conclusion the peculiar paradoxical appearance of a paediatric liver lesion, that is, solid on usg and cystic on ct/mri, should raise the possibility of ues, especially in the presence of normal afp levels, serpiginous vessels and intralesional haemorrhage. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.k.p. was the primary author. s.p. also contributed equally to this work. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this research article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy of any affiliated agency of the authors. references cong wm, dong h, tan l, sun xx, wu mc. surgicopathological classification of hepatic space-occupying lesions: a single-center experience with literature review. world j gastroenterol. 2011;17(19):2372. https://doi.org/10.3748/wjg.v17.i19.2372 wei zg, tang lf, chen zm, tang hf, li mj. childhood undifferentiated embryonal liver sarcoma: clinical features and immunohistochemistry analysis. j pediatr surg. 2008;43(10):1912–1919. https://doi.org/10.1016/j.jpedsurg.2008.06.016 gabor f, franchi-abella s, merli l, adamsbaum c, pariente d. imaging features of undifferentiated embryonal sarcoma of the liver: a series of 15 children. pediatr radiol. 2016;46(12):1694–1704. https://doi.org/10.1007/s00247-016-3670-3 buetow pc, buck jl, pantongrag-brown l, et al. undifferentiated (embryonal) sarcoma of the liver: pathologic basis of imaging findings in 28 cases. radiology. 1997;203(3):779–783. https://doi.org/10.1148/radiology.203.3.9169704 noguchi k, yokoo h, nakanishi k, et al. a long-term survival case of adult undifferentiated embryonal sarcoma of liver. world j surg oncol. 2012;10(1):1–5. https://doi.org/10.1186/1477-7819-10-65 zhang c, jia cj, xu c, sheng qj, dou xg, ding y. undifferentiated embryonal sarcoma of the liver: clinical characteristics and outcomes. world j clin cases. 2020;8(20):4763. https://doi.org/10.12998/wjcc.v8.i20.4763 wildhaber be, montaruli e, guérin f, branchereau s, martelli h, gauthier f. mesenchymal hamartoma or embryonal sarcoma of the liver in childhood: a difficult diagnosis before complete surgical excision. j pediatr surg. 2014;49(9):1372–1377. https://doi.org/10.1016/j.jpedsurg.2014.04.005 chung em, lattin jr ge, cube r, et al. from the archives of the afip: pediatric liver masses: radiologic-pathologic correlation part 2. malignant tumors. radiographics. 2011;31(2):483–507. https://doi.org/10.1148/rg.312105201 charfi s, ayadi l, toumi n, et al. cystic undifferentiated sarcoma of liver in children: a pitfall diagnosis in endemic hydatidosis areas. j pediatr surg. 2008;43(6):e1–e4. https://doi.org/10.1016/j.jpedsurg.2008.01.068 putra j, ornvold k. undifferentiated embryonal sarcoma of the liver: a concise review. arch pathol lab med. 2015;139(2):269–273. https://doi.org/10.5858/arpa.2013-0463-rs hu hm, zhang wl, li j, et al. report of seven children with undifferentiated embryonal sarcoma of the liver. chin med j. 2019;132(18):2244. https://doi.org/10.1097/cm9.0000000000000429 kim m, tireno b, slanetz pj. undifferentiated embryonal sarcoma of the liver. am j roentgenol. 2008;190(4):w261–w262. https://doi.org/10.2214/ajr.07.3058 geel ja, loveland ja, pitcher gj, beale p, kotzen j, poole je. management of undifferentiated embryonal sarcoma of the liver in children: a case series and management review. s afr med j. 2013;103(10):728–731. https://doi.org/10.7196/samj.6058 bisogno g, pilz t, perilongo g, et al. undifferentiated sarcoma of the liver in childhood: a curable disease. cancer. 2002;94(1):252–257. https://doi.org/10.1002/cncr.10191 walther a, geller j, coots a, et al. multimodal therapy including liver transplantation for hepatic undifferentiated embryonal sarcoma. liver transplant. 2014;20(2):191–199. abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) siddhi chawla department of radiology, faculty medical sciences, university college of medical sciences and gtb hospital, university of delhi, delhi, india shuchi bhatt department of radiology, faculty medical sciences, university college of medical sciences and gtb hospital, university of delhi, delhi, india anupama tandon department of radiology, faculty medical sciences, university college of medical sciences and gtb hospital, university of delhi, delhi, india gaurav meena department of radiology, faculty medical sciences, university college of medical sciences and gtb hospital, university of delhi, delhi, india saumya dangwal department of radiology, faculty medical sciences, university college of medical sciences and gtb hospital, university of delhi, delhi, india citation chawla s, bhatt s, tandon a, meena g, dangwal s. bilateral hutch diverticula in an elderly male: revelation of an unknown past. s afr j rad. 2020;24(1), a1963. https://doi.org/10.4102/sajr.v24i1.1963 case report bilateral hutch diverticula in an elderly male: revelation of an unknown past siddhi chawla, shuchi bhatt, anupama tandon, gaurav meena, saumya dangwal received: 05 aug. 2020; accepted: 22 oct. 2020; published: 11 dec. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract hutch diverticulum is a congenital diverticulum of the urinary bladder, reported infrequently in children and rare amongst adults. we present a 60-year-old male patient with bilateral hutch diverticula, detected incidentally during an abdominal ultrasound examination performed for blunt abdominal trauma. this rare case highlights an unusual incidental presentation and opportunity to learn how to differentiate it from acquired bladder diverticula. the available treatment options are also discussed varying from simple follow-up to aggressive surgery. keywords: bladder diverticulum; hutch diverticulum; ultrasound; intravenous pyelography; computed tomography. introduction urinary bladder (ub) diverticula are herniations of the bladder mucosa through muscular fibers of the bladder wall1 resulting in a thin-walled structure that poorly empties during micturition. they are classified as congenital or acquired. congenital diverticula are reported infrequently in children and are ever rarer in adults2 their incidence is reported to be 1.7%3 and peaks in children below 10 years of age.4 ninety percent of congenital bladder diverticula are located superolateral to the ureteral orifice, in proximity to the uretero-vesical junction.5 unlike the acquired adult form, in which outlet obstruction or neurogenic dysfunction is almost always present, congenital bladder diverticula result from hypoplasia of the muscular layer of the bladder wall.1 it may be unilateral and infrequently bilateral. patients may remain asymptomatic or may present with symptoms of urinary retention, obstruction, voiding dysfunction, recurrent urinary tract infection and calculi formation in the diverticulum.6 the symptoms are more pronounced in patients with a large diverticulum, whereas cases with a small diverticulum may remain undiagnosed. we present the rare case of bilateral asymptomatic congenital bladder diverticula discovered incidentally in an elderly male patient. case presentation a 60-year-old male patient presented with a history of a fall, followed by acute pain in the abdomen for which he was attended to in the emergency department. the patient was sent for focused assessment with sonography for trauma (usg fast), which was negative. incidental note was made of left hydronephrosis (figure 1) with a large well-defined outpouching from the left postero-lateral wall of the ub. it measured 4 cm × 5 cm. a similar smaller (1.2 cm × 1.6 cm) outpouching was also seen on the right side of the ub (figure 2). the bilateral vesicoureteric junctions (vujs) could not be seen separately. the wall of the bladder was mildly thickened but there was no evidence of trabeculations. the prostate gland measured 24 cubic centimetre (cc) with a normal shape and echotexture. there was only 40 cc of insignificant post-void residual urine in both the ub and the left diverticula together. figure 1: ultrasound images show (a) gross hydronephrosis affecting the left kidney. (b) a well-defined outpouching in region of left vesicoureteric junction. (c) the left ureter is seen to open into the outpouching. distal ureter appears dilated. figure 2: (a) ultrasound images of the normal right kidney (b) a small diverticulum is present in the region of the right vesicoureteric junction. a normal calibre right ureter is seen opening into it. focused detailed history taking revealed a complaint of difficulty in micturition with a subsequent sensation of incomplete voiding over the previous 1–2 years, resulting in a repetitive need to pass urine. intermittent dull pain was also present in left flank. there was no history of passage of blood or pus in the urine, urgency for micturition, hesitancy, poor stream or terminal dribbling of urine. there was no past history of any long standing illness in the patient. as the patient’s complains were directed towards a lower urinary tract infection, retrograde urethrography (rgu) and micturating cysto-urethrogram (mcu) were performed. the rgu was unremarkable. the mcu (figure 3) demonstrated a well-defined outpouching from the postero-lateral wall of the ub on both sides, the left being significantly larger in size and more well-defined than the right. there was grade 5 vesicoureteric reflux (vur) on the left side causing dilatation and tortuousity of the entire left ureter and moderate left hydronephrosis. no reflux was seen on the right. figure 3: sequential images of a micturating cysto-urethrogram: (a) anteroposterior image demonstrates well-defined outpouchings bilaterally in the postero-lateral wall of the bladder. (b) right anterior oblique shows the right contrast-filled outpouching. (c, d) left anterior oblique and supine images reveal the left diverticulum and reflux of contrast into the left dilated, tortuous ureter, extending up to the pelvicalyceal system, which appears hydronephrotic, consistent with (grade 5) vesicoureteric reflux. in view of the setting of blunt trauma and continuing pain in abdomen, contrast enhanced computed tomography (cect) (figures 4 and 5) was requested by the clinician. after obtaining a written informed consent, a non-contrast computed tomography (ct) followed by contrast enhanced ct scan of abdomen was performed using a 64 slice multi-detector computed tomopgraphy (mdct) scanner – siemens definition as, with non-ionic iodinated contrast medium (omnipaque 350 mg/ml) administered at a rate of 3 ml/s, acquiring portal venous phase and delayed scans. there were no significant findings suggestive of injury detected in the abdomen. both kidneys showed symmetrical uptake with normal corticomedullary enhancement and excretion of contrast. the 30 min delayed scan also allowed for assessment of the diverticula, ureters and the vujs. well-defined contrast-filled outpouchings were seen at the level of the bilateral vujs. there was moderate left-sided hydronephrosis with a dilated and tortuous left ureter opening into the diverticulum on the left side. the right kidney and ureter were normal with its distal end inserting into the diverticulum on the right. the wall of the diverticulum was of uniform thickness. the ub bladder did not reveal any wall irregularity, trabeculations or thickening. no debris or calculi were seen. the urine examination was also normal. figure 4: axial multiplanar reformatted section shows the diverticula bilaterally at the vesicoureteric junctions. the left contrast-filled diverticulum is larger and is causing mild compression and displacement of the rectum. the right is small and is not filled with contrast (arrow). figure 5: prone coronal multiplanar reformatted image (a) and sagittal curved maximum intensity projection reformatted images (b – left and c – right) confirm the findings of bilateral hutch diverticula with the ureters emptying into them. (right diverticula is not filled with contrast and is indicated by the arrow). there is gross hydro-uretero-nephrosis on the left side (secondary to vesicoureteric reflux). the patient was discharged with the advice of regular follow-up in the surgical outpatient department (opd) and to report earlier if any symptoms develop. discussion bladder diverticula are rare clinical entities in both the paediatric and adult populations. they are classified as congenital or acquired. the basic differences between the two are highlighted in table 1. the basic pathology in both types is herniation of the bladder mucosa through the muscular fibers of the wall,1 resulting in a thin-walled outpouching arising from the bladder lumen. histological examination of surgical specimens after resection show similar findings and further support the theory of ‘hypoplasia of the muscularis layer’ as a cause for the herniation. the wall of the diverticulum is thinned out and empties poorly during micturition due to lack of the muscular layer.1 this leads to increased post-void residue with paradoxical enlargement of the bladder diverticulum during micturition. congenital or primary bladder diverticula usually present during childhood4 and occur in the absence of bladder outlet obstruction as opposed to the acquired form. they are associated with congenital syndromes, namely ehlers–danlos (type 9) syndrome, menkeskinky hair syndrome, cutis laxa syndrome (sotos) and williams–beuren syndrome.3,6 in our patient a focused physical examination was performed to rule out these congenital syndromes. table 1: differences between congenital (hutch) diverticulum and acquired diverticulum. on cystoscopy, congenital diverticula reveal a smooth wall,7 whereas the acquired diverticula are associated with multiple bladder trabeculations. the congenital diverticula are usually unilateral but can be bilateral and are usually seen at the base of the trigone, in the vicinity of vuj (6). on the contrary, the acquired diverticula can arise from any portion of the bladder wall and are usually multiple in number. the congenital variety does not have any risk for malignancy as opposed to the secondary acquired type.8 diverticula located superolateral to the ureteral orifice, without involving the trigone, are referred to as ‘hutch diverticula’ and are usually associated with vesicoureteral reflux. it is a rare developmental anomaly that develops because of failure of muscle development at or near the ureteral orifice. initially, a small diverticulum is formed because of herniation of bladder mucosa through the weakest point of the bladder musculature,6 where waldeyers’ sheath anatomically covers the space between the intravesical ureter and muscular layer of bladder.9 the defect eventually enlarges with voiding and finally the ureteral orifices are incorporated into the diverticulum.10 there are very few reported cases, mostly in children. the presence of hutch diverticulum in adults is very rare.2,11 patients with hutch diverticulum can be asymptomatic or may have diverse symptoms, secondary to urinary stasis. the most common presentation is with urinary tract infections (uti). other presentations may include acute urinary retention, bladder stones, enuresis and possible bladder obstruction if the diverticulum enlarges and obstructs the bladder neck distally.1,7 since there is no risk of malignancy associated with the congenital form, if the patient is asymptomatic, no active intervention is required and advice is given regarding frequent micturation and complete evacuation. if the patient presents with recurrent symptoms, surgical management is warranted. the surgical options include open diverticulectomy (intraor extra-vesical) which may be beneficial in cases of concomitant prostatic enlargement, allowing simultaneous treatment of both entities. the extravesical approach is reserved for patients with large diverticula associated with peridiverticular adhesions or inflammation.8 laparoscopic approach may also be performed as it has the advantage of minimally invasive surgery. endoscopic transurethral incision of diverticular neck is the treatment option offered to non-surgical candidates.12 in patients with vur, congenital defects are treated with ureteral reimplantation surgery. however, as the acquired form is mostly secondary to an inappropriate increase in detrusor muscle pressure, reimplantation is never performed in these patients prior to managing the detrusor muscle abnormality. medical management with drugs to avoid recurrent uti and anticholinergics to maintain the bladder wall overactivity are available. conclusion congenital bladder diverticula are very rare in adults and the radiologist should be able to differentiate them from the commoner acquired conditions. if asymptomatic and uncomplicated, they are usually managed conservatively, but in cases with recurrent symptoms or complications, appropriate surgical intervention should be considered. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. ethical consideration this article followed all ethical standards for carrying out research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect official policy or position of any affiliated agency of the authors. references garat jm, angerri o, caffaratti j, moscatiello p, villavicencio h. primary congenital bladder diverticula in children. urology. 2007;70(5):984–988. https://doi.org/10.1016/j.urology.2007.06.1108 palmero martí jl, ramirez backhaus m, alvarez barrera a, amoros torres a, benedicto redon a. hutch bladder diverticula: a very uncommon entity in adults. arch esp urol. 2012;65(6):636–639. blane ce, zerin jm, bloom da. bladder diverticula in children. radiology. 1994;190(3):695–697. https://doi.org/10.1148/radiology.190.3.8115613 boechat mi, lebowitz rl. diverticula of the bladder in children. pediatr radiol. 1978;7(1):22–28. https://doi.org/10.1007/bf00975333 psutka sp, cendron m. bladder diverticula in children. j pediatr urol. 2013;9(2):129–138. https://doi.org/10.1016/j.jpurol.2012.02.013 telli o, guclu ag, haciyev p, burgu b, gogus c. a rare entity in adults: bilateral hutch diverticulum with calculi. can urol assoc j. 2015;9(5,6):e343–e344. https://doi.org/10.5489/cuaj.2327 oge o, gemalmaz h, ozeren b. acute urinary retention in a child caused by a congenital bladder diverticulum. j pediatr surg. 2002;37(6):926–927. https://doi.org/10.1053/jpsu.2002.32915 evangelidis e, castle p, ostlie dj, snyder cl, gatti jm, murphy jp. surgical management of primary bladder diverticula in children. j pediatr surg. 2005;40(4):701–703. https://doi.org/10.1016/j.jpedsurg.2005.01.003 hernanz-schulman m, lebowitz rl. the elusiveness and importance of bladder diverticula in children. pediatr radiol. 1995;15(6):399–402. https://doi.org/10.1007/bf02388360 pace am, powell c. congenital vesical diverticulum in a 38-year-old female. int urol nephrol. 2005;37(3):473–475. https://doi.org/10.1007/s11255-004-8074-x vite-velázquez ej, venegas-ocampo jj, robles-scott ma, ochoa-vázquez tn, morales-garcía a, macedo-gonzález aj. bilateral hutch periureteral diverticulum without reflux in an adult patient. rev mex urol. 2009;69(6):292–294. silay ms, koh cj, management of the bladder and calyceal diverticulum: options in the age of minimally invasive surgery. urol clin. 2015;42(1):77–87. https://doi.org/10.1016/j.ucl.2014.09.007 case report i barium peritonitis with barium entering the lymphatic system s. andronikou fc rad diag (sa) c. weiman mbchb e. kader mbchb department of paediatric radiology, university of cape townand institute of child health, red cross w.v mernori8j children's ~ital, rondebosch, cape town corresponding author s. andronikou department of paediatric radiology red cross war memorial children's hospital cape town 7700 teiepilone: 021-6585442 fax: 021-6585101 e-mail: docsav@mweb.co.za abstract barium is still widely used in developing countries for gastrointestinal investigation because it is cheap and relatively safe. most institutions however favour low-osmolar non-ionic contrast media for performance of childhood diagnostic enemas. these are relatively expensive and many developing countries reserve their use for cases where perforation is suspected. we present a case where bari um leaked into the peritoneum during an enema investigation where no initial features of perforation were present. the added unique campi ication of barium entering the 14 sajournal of radiology· august 2000 thoracic lymphatic system was noted. this campi ication was not found in a review of current literature. key words barium enema, lowosmolar non-ionic contrast media, campi ications. case report a lo-day-old neonate was delivered prematurely at 29 weeks gestation weighing 1 060 grams. he was referred to the radiology department for a barium enema examination with the diagnosis of small bowel atresia. the clinical evaluation revealed abdominal distention and plain film radiology showed proximally dilated small bowel with absent distal gas. no features of bowel perforation were present on this series. the objective of the study was to demonstrate any co-existing colonic strictures as these are difficult to assess at laparotomy. barium is still used as a contrast medium for enemas, when no bowel perforation is suspected, in countries where there are cost constraints on the use of low-osmolar non-ionic agents. the examination showed no colonic strictures, but barium flowed freely into the peritoneal cavity from the ileocaecal junction. the patient was taken immediately to laparotomy. the surgeon found a necrotic terminal ileum and a large amount of free barium in the peritoneal cavity. small bowel resection and re-anastomosis was performed and vigorous peritoneal washout was undertaken. subsequent chest and abdominal radiographs (figures 1 and 2) demonstrated to page 16 mailto:docsav@mweb.co.za bariun. peritonitis vvith barium entering the lymphatic system 'rom page 14 figure 1: post-operative anterior-posterior chest radiograph demonstrates barium coating the peritoneal surface and located as several foci along the left sternal border (arrowheads). figure 2: post-operative lateral chest radiograph confirms the retrosternal position of the barium (arrowheads) in keeping with its drainage via the internal thoracic lymphatic chain. barium tracking along the retrosternal part of the chest and at the thoracic duct. this represented barium entry into the internal thoracic chain of lymph nodes. at the time of this report the patient's condition was stable. discussion ture, 500 perforations during barium enema examination have been reported in a year, but these figures were obtained over 30 years ago.' most perforations are a result of the catheter tip at the ano-rectal portion of the bowel. 1 fatal complications have been described and some collective series report a figure of 50% mortality. others claim such figures are outdated and give lower figures such as 20% mortality. some authors report even lower mortality due to more effective and efficient staff training.ê? bowel perforation is reported to occur in 0.02-0.04% of patients undergoing barium investigations of the large bowel. i in the usa adult litera16 sajournal of radiology. august 2000 williams et al outline the recognised complications of intraperitoneal bowel perforation during barium enema investigations. these include intravascular volume depletion, sepsis, adhesions and peritoneal fibrosis. other reported complications are intramural intravasation, barium impaction, allergic reaction and cardiac arrhythmia.' we have found no reports in the current literature of barium entering the lymphatic system after intraperitoneal spill and this is reported as a unique feature. references 1. williams et al. recognition and prevention of barium enema complications. curr probl diagnradio1l991; 20(4): 123-151. 2. cordon et al. rectal perforation during barium enema. report of a case. dis colon rectum 1988; 31(7): 563-569. 3. rimarenleo et al. fatal complications related to diagnostic barium enema. am j forensic med patha11988; 9(1): 78-84. 4. grobmeyer et al. barium peritonitis. am surg 1984; 50(2): 116-120. 5. hardy et al. survival after colonic perforation during barium enema examination. modified radical surgical debridement. dis colon rectum 1983; 26(2): 116-118. 6. eklof et al. barium peritonitis. experience of five paediatric cases. paediatr radial 1983; 13(1): 5-9. tolosa.html tolosa-hunt syndrome ben barnard, mb chb delme hurter, mb chb, mmed (d rad) department of radiology, kimberley hospital complex, kimberley francois roux, mb chb, da (sa) tygerberg academic hospital, university of stellenbosch, tygerberg shaheer aboobaker, mb chb, dip opth (sa) department of ophthalmology, kimberley hospital complex, kimberley corresponding author: b barnard (benwbarnard@gmail.com) introduction tolosa-hunt syndrome (ths) is a rare disorder indicated by recurrent painful ophthalmoplegia caused by non-specific inflammation of the cavernous sinus or superior orbital fissure (sof). the disease shares histopathological features with idiopathic orbital pseudotumour; however, owing to its anatomical location, it produces characteristic clinical manifestations.1 recurrent retro-orbital pain, with palsies of the third, fourth or sixth cranial nerves as well as the first and second divisions of the trigeminal nerve, are typical. clinically, immediate response to steroid therapy is a hallmark of the condition. the clinical presentation of ths has a wide differential diagnosis, and timely and appropriate imaging – as an adjunct to pertinent laboratory investigations – can greatly assist clinicians with early accurate diagnosis and management. case report our patient was a 17-year-old girl who presented with a 2-week history of a sharp peri-ocular headache and drooping of the left eyelid. she also complained of a decrease in eye movement as well as visual acuity. she indicated that she had had similar episodes of headache preceded by blurring of vision in the same eye for more than a year. she was previously healthy. on clinical examination, her vitals were normal. she had a left-sided ptosis and impairment of adduction and elevation of the left eye, consistent with an oculomotor (iiird) nerve palsy. the left pupil was mildly dilated but responsive to light. no facial sensory or motor loss in the distribution of the trigeminal (vth) nerve was detected. fundoscopy was normal. bloodwork and lumbar puncture (lp) were non-specific. of note, the white cell count (wcc) was mildly elevated and the erythrocyte sedimentation rate (esr) significantly increased. she tested retroviral negative. the patient was referred for an urgent brain ct; this showed a diffusely thickened left optic nerve with associated dilatation of the left superior ophthalmic vein (sov). in addition, a soft-tissue mass was noted in the sof, extending into the left cavernous sinus. an mri of the brain and orbits was then performed on a 1.5t toshiba vantage machine. whole-brain flair and t2w imaging was done, followed by thin-slice (2.5 mm slice thickness) coronal, axial and sagittal ce (magnevist) fs t1w sequences through the cavernous sinus and orbits. this demonstrated an avidly enhancing mass lesion in the orbital apex extending into the left sof, causing compression on the neurovascular elements. the lesion extended into the cavernous sinus. the diffusely thickened optic nerve was secondary to oedema but was not infiltrated. there was no luminal narrowing of the intracavernous segment of the internal carotid artery (ica), and no evidence of cavernous sinus or sov thrombosis. the rest of the study was non-contributory. the patient was treated with oral steroids and showed significant relief of symptoms over the following 48 hours. she had complete resolution of the ptosis as well as the oculomotor nerve palsy within one month. further follow-up showed no recurrence of symptoms. discussion tolosa first described the condition in 1954, in a patient with unilateral recurrent painful ophthalmoplegia involving cranial nerves iii, iv, vi and v1. the patient was imaged using carotid angiography, and segmental narrowing of the carotid siphon was seen.1 hunt et al. described 6 patients with similar clinical findings in 1961, and proposed a low-grade non-specific inflammation of the cavernous sinus and its walls as the cause of the syndrome. pathologically, infiltration of lymphocytes and plasma cells as well as thickening of the dura mater was seen.1 the condition was termed tolosa-hunt syndrome by smith and taxdal in 1966.2 the latter authors stressed the importance of the dramatic rapid response to steroid therapy. in 1988, ths criteria were provided by the international headache society (ihs), and further revised in 2004 (table i).3 , 4 neuro-imaging – in particular mri – is an essential part of the workup of any patient presenting with features of ths, as these features are non-specific and have a wide differential diagnosis, including meningioma, sarcoidosis, pituitary tumours, tuberculous meningitis (tbm) and lymphoma.2 mri findings classically demonstrate a soft-tissue mass lesion involving the sof or cavernous sinus. signal characteristics are typically hypointense to fat and isointense to muscle on short tr/te sequences and isointense to fat on long tr/te sequences.5 significant enhancement of the mass lesion is demonstrated on ce sequences. of particular value is the post-contrast fat-saturated thin-slice coronal images through the orbital apex and cavernous sinus. ths essentially remains a diagnosis of exclusion. the role of the radiologist is to exclude other conditions causing similar clinical features. distinctive mri findings and rapid resolution of clinical symptoms with steroid therapy are characteristic. 1. som pd, curtin hd. head and neck imaging. 4th ed. st louis: mosby, 2003:587-591. 1. som pd, curtin hd. head and neck imaging. 4th ed. st louis: mosby, 2003:587-591. 2. sathyanathan bp, rajasundaram r, sankaravadivelu st, nadhamuni k. a case of tolosa-hunt syndrome – mr imaging appearance. ind j radiol imag 2006;16(1):97-98. 2. sathyanathan bp, rajasundaram r, sankaravadivelu st, nadhamuni k. a case of tolosa-hunt syndrome – mr imaging appearance. ind j radiol imag 2006;16(1):97-98. 3. mendez ja, arias cr, sanchez d, et al. painful ophthalomoplegia of the left eye in a 19-year-old female, with an emphasis on tolosa-hunt syndrome: a case report. cases journal 2009;2:8271. 3. mendez ja, arias cr, sanchez d, et al. painful ophthalomoplegia of the left eye in a 19-year-old female, with an emphasis on tolosa-hunt syndrome: a case report. cases journal 2009;2:8271. 4. mora-de-onate j, pascual-perez-alfaro r, izquierdo-vazquez c, gonzalez-ruiz m, aguirrebena-olmos a, diez-villalba r. painful ophthalmoplegia (pseudotumour of the orbit and tolosa-hunt syndrome). arch soc esp oftalmol 2007;82:509-512. 4. mora-de-onate j, pascual-perez-alfaro r, izquierdo-vazquez c, gonzalez-ruiz m, aguirrebena-olmos a, diez-villalba r. painful ophthalmoplegia (pseudotumour of the orbit and tolosa-hunt syndrome). arch soc esp oftalmol 2007;82:509-512. 5. yousem dm, atlas sw, grossman ri, sergott rc, savino pj, bosley tm. mr imaging of tolosa-hunt syndrome. ajnr 1990;154:167-170. 5. yousem dm, atlas sw, grossman ri, sergott rc, savino pj, bosley tm. mr imaging of tolosa-hunt syndrome. ajnr 1990;154:167-170. 6. dornam tl, espir mle, gale eam, tattersall rb, worthington bs. remittent painful ophthalmoplegia: the tolosa-hunt syndrome? j neurol neurosurg psychiatry 1979;42:270-275. 6. dornam tl, espir mle, gale eam, tattersall rb, worthington bs. remittent painful ophthalmoplegia: the tolosa-hunt syndrome? j neurol neurosurg psychiatry 1979;42:270-275. fig. 1. axial ct brain demonstrates a soft-tissue mass in the left superior orbital fissure. note also the thickened optic nerve. fig. 2. axial ce fs t1w image reveals intense enhancement of the soft-tissue mass within the left sof. the lesion extends into the cavernous sinus. fig. 3. coronal ce fs t1w image again shows the intensely enhancing soft-tissue mass. fig. 4. axial ce fs t1w follow-up image 4 months later demonstrates complete resolution of the enhancing soft-tissue mass. fig. 5. coronal ce fs t1w follow-up image again shows the resolution of the mass. table i. ths diagnostic criteria a one or more episodes of unilateral orbital pain persisting for weeks if untreated b paresis of one or more of the third, fourth and/or sixth cranial nerves and/or demonstration of granulomas by mri or biopsy c paresis coincides with the onset of pain or follows it within 2 weeks d pain and paresis resolve within 72 hours when treated adequately with corticosteroids e other causes have been excluded by appropriate investigations today's two signs today's two signs 106 sa journal of radiology • december 2007 today's two signs scapholunate instability (sli) (also known as scapholunate dissociation or rotary subluxation of the scaphoid) is caused by a tear in the interosseous ligaments of the lunate, scaphoid and the capitate bone with a tear in the dorsal radiocarpal ligaments by acute dorsifexion injury or fractures of the distal radius.1,2 the patient complains of wrist pain, weakness of grip and a clicking sensation in the wrist. sli is diagnosed with a gap or separation between the scaphoid and the lunate bones on a posterior anterior wrist x-ray. more than 2 mm is suspicious and 4 mm or more is diagnostic of sli.1,2 this scaphoidlunate gap is also referred to as the ‘terry thomas’ sign (fig. 1) referring to the distinctive gap between the upper incisors of the late british comedian. there is in addition foreshortening of the scaphoid, causing the cortical margin of the distal pole to become parallel to the central axis of the x-ray and appear as a ring called the the ‘ring sign’ (fig. 1). the gap is better demonstrated in ulnar deviation or clenched-hand position (fig. 2).1,2 treatment is dependent on the symptoms, ranging from rest to carpal fusion. 1. rogers lf. radiology of skeletal trauma, 2nd ed. edinburgh: churchill livingstone,.1992: 927-929. 2. hudson tm, caragol wj, kaye jj. isolated rotatory subluxation of the carpal navicular. ajr 1976; 126: 601-611. `terry thomas´ sign and the `ring sign´ of scapholunate instability a s bajwa, mb bs, fcs (sa) ortho brenthurst life health clinic, parktown, johannesburg a k bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg fig. 2. the gap is more pronounced in the clenched hand-position. fig. 1. posterior anterior wrist x-ray demonstrating the widened gap between the scaphoid and the lunate bone ‘terry thomas’ sign. there is in addition foreshortening of the scaphoid with a ‘ring sign’. underlying osteodegenerative changes are noted; these and the radio carpal joints are due to longstanding sli. pg106-107.indd 106 12/11/07 2:21:20 pm today's two signs today's two signs 107 sa journal of radiology • december 2007 the presence of faeculant material (colonlike material mixed with gas resembling stool) in the lumen of the distended (more than 2.5 cm) small bowel on computed tomography (ct) is defined as small bowel faeces sign (fig. 1).1 it is due to intraluminal stagnation of the enteric contents complicated by bacterial overgrowth and water absorption. it is an uncommon but highly specific sign of small bowel obstruction (sbo) on ct scan of the abdomen, particularly in patients with low-grade or intermittent obstruction.2 the adjacent transition zone and the distal collapsed bowel loops indicate the level of obstruction. the most common cause of the sbo is adhesions. other common causes are inflammation, tumours and hernias. small bowel faeces sign may also indicate severe metabolic or infectious pathology of the small bowel. the clinical signs of sbo are difficult to distinguish from local or generalised paralytic ileus; therefore an early radiological diagnosis is very important. 1. mayo-smith ww, wittenberg j, bennett gl, gervais da, gazelle gs, mueller pr. the ct small bowel faeces sign: description and clinical relevance. clin radiol 1995; 50: 765-767. 2. catalano o. the faeces sign: a ct finding in small bowel obstruction. radiology 1997; 37: 417-419. small bowel faeces sign amarjit kaur bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital, university of the witwatersrand, johannesburg fig. 1. axial ct in a 22-year-old female patient with history of crohn disease demonstrating the small bowel faeces sign in a distended ileal loop. adjacent transition zone with collapsed distal small bowel is seen. pg106-107.indd 107 12/11/07 2:21:20 pm abstract introduction case presentation management and outcome discussion conclusion acknowledgements references about the author(s) puneet garg department of radiology, vardhman mahavir medical college and safdarjung hospital, new delhi, india anuradha sharma department of radiology, vardhman mahavir medical college and safdarjung hospital, new delhi, india heena rajani department of radiology, vardhman mahavir medical college and safdarjung hospital, new delhi, india apratim r. choudhary department of radiology, vardhman mahavir medical college and safdarjung hospital, new delhi, india rajkumar meena department of radiology, vardhman mahavir medical college and safdarjung hospital, new delhi, india citation garg p, sharma a, rajani h, choudhary ar, meena r. tuberous sclerosis complex: the critical role of the interventional radiologist in management. s afr j rad. 2021;25(1), a2034. https://doi.org/10.4102/sajr.v25i1.2034 case report tuberous sclerosis complex: the critical role of the interventional radiologist in management puneet garg, anuradha sharma, heena rajani, apratim r. choudhary, rajkumar meena received: 25 oct. 2020; accepted: 23 dec. 2020; published: 30 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract tuberous sclerosis complex (tsc) is an autosomal dominant neurocutaneous syndrome that is characterised by hamartomas in multiple organs, the characteristic imaging features of which are illustrated in this case report. angiomyolipoma (aml) is the most common renal manifestation of tsc, which may present with life-threatening haemorrhage at the time of diagnosis. interventional management with selective renal embolisation is currently the treatment of choice for the safe and effective management of ruptured renal aml. keywords: tuberous sclerosis complex; angiomyolipoma; selective renal embolisation; hamartomas; ruptured angiomyolipoma; renal haemorrhage. introduction tuberous sclerosis complex (tsc) is the second most commonly reported neurocutaneous syndrome following neurofibromatosis type 1, with an incidence of one in 6000.1 it follows an autosomal dominant pattern of inheritance and is caused by mutations in two tumour-suppressor genes, tsc1 and tsc2, encoding hamartin and tuberin, respectively. two-thirds of these mutations may be sporadic.1,2 tuberous sclerosis complex is characterised by hamartomas in various organs, most commonly the skin, brain, eyes, lungs, kidneys, liver, heart and bones with characteristic clinico-radiological manifestations, illustrated herein. the radiologist plays a pivotal role in successful management of a ruptured renal angiomyolipoma (aml), a life-threatening emergency in patients with tsc, which is also highlighted. case presentation a 24-year-old female presented to the emergency department with complaints of left flank pain and gross haematuria, following a fall. she was conscious and oriented; however, her higher mental functions were subnormal for age. she was experiencing hypovolemic shock and hypotension (blood pressure 90/60 millimetre of mercury [mmhg]) with a feeble pulse and tachycardia (pulse rate of 110/min). her extremities were cold and clammy. the blood oxygen saturation was normal. she had a diffusely tender swelling over the left lumbar region. further examination revealed dark papulonodular lesions over her face in a butterfly distribution (adenoma sebaceum), multiple dark macules over her body and focal gigantism of the left thumb. the patient or her relatives did not have any current or prior history of neurological or respiratory complaints. after fluid resuscitation, she was referred for an abdominal ultrasound (us), which revealed massive left renal enlargement with a heterogenous lesion replacing the lower pole and inter-polar region of left kidney. the lesion demonstrated intense internal vascularity and a central avascular hyperechoic area (figure 1). multiple heterogeneously hyperechoic lesions were also seen in the right kidney and liver, with propagation velocity artefact causing apparent discontinuity of the right hemidiaphragm immediately superficial to a hepatic lesion. free fluid with low-level internal echoes was seen in the pelvis. an abdominal contrast-enhanced computed tomography (cect) scan confirmed a large lesion arising from the midand lower pole of the left kidney with an enhancing soft-tissue component, areas of fatty attenuation and bizarre dilated vascular channels. there was a round hyperdense non-enhancing area within the centre of the lesion, corresponding to a large intra-tumoural haematoma. similar, but smaller lesions were also seen in the right kidney along with fat-containing lesions in the liver (figure 2). the abdominal findings suggested multiple renal and hepatic amls with rupture of the large left renal aml causing a thin perinephric haematoma and associated haemoperitoneum. figure 1: grey scale (a) and colour doppler ultrasound (b) of the left kidney shows a large hetero-echoic left renal mass with intense vascularity at the periphery of the mass and a central avascular component (white arrow heads). figure 2: the axial pre-contrast (a) and post-contrast (b-d) and coronal reformatted pre-contrast (e) and post-contrast (f-h) computed tomography (ct) images demonstrating renal and hepatic angiomyolipomas (amls). multiple bilateral renal amls have small foci of fat attenuation within (white arrows; a, e). there is heterogeneous enhancement of these renal masses with multiple dilated vascular channels (black arrows) within the left renal mass suggestive of intra-lesional aneurysms and dilated draining venous channels at the periphery. a large hyperdense non-enhancing intra-tumoural haematoma (black arrowheads) is seen within the largest left-sided aml (measuring 17 cm in the largest dimension), which had ruptured. a thin perinephric haematoma (white arrowheads; c, h) was seen on the left. free fluid was also seen in the pelvis (yellow asterisks; d, h). well-defined fat attenuated round lesions scattered in the liver suggestive of lipid-rich hepatic amls (bent arrow; e-f). the study was extended to include computed tomography (ct) imaging of the brain and chest. a cect scan of the brain revealed multiple cerebral and cerebellar calicified, as well as non-calcified cortical tubers, subependymal calcified nodules and a large cystic lesion with an enhancing mural nodule in the subependymal region of the frontal horn of the right lateral ventricle, consistent with a subependymal giant cell tumour (figure 3). a cect of the thorax was performed to evaluate for thoracic manifestations of tsc, revealing multiple, round, thin-walled cysts and a few small randomly distributed nodules uniformly scattered across both lungs, without any pneumothorax or chylous effusions. the findings were consistent with lymphangioleiomyomatosis (lam) and multifocal micronodular pneumocyte hyperplasia (figure 3). bones showed diffuse calvarial thickening and sclerotic foci in the vertebrae, as well as in the pelvis. figure 3: the serial contrast-enhanced computed tomography (ct) brain images demonstrate coarsely calcified cortical tubers in both cerebellar hemispheres (arrowheads, a), multiple calcified subependymal nodules along the walls of both lateral ventricles (thick black arrows, b) with a subependymal giant cell tumour (segct) and associated peri-tumoural cyst in relation to the frontal horn of the right lateral ventricle, extending to the white matter of the right frontal lobe (thick white arrows, b) no hydrocephalus is seen as the tumour is away from the foramen of monro, the usual location of segct. multiple hypodense non-calcified cortical tubers were also seen in the cerebral parenchyma (thin white arrow, c). the axial (d) and coronal (e) ct thorax lung windows show multiple small thin-walled cysts scattered diffusely throughout the lung parenchyma without any zonal predilection, suggestive of lymphangioleiomyomatosis (lam). a few randomly distributed nodules are also seen in both upper lobes (black arrows) representing multifocal micronodular pneumocyte hyperplasia (mmph). radiographs of the left hand depicted phalangeal intra-osseous cysts and a large soft-tissue mass causing scalloping of the cortex in the underlying digits (figure 4). figure 4: bone manifestations of tuberous sclerosis complex. reformatted sagittal computed tomography (ct) in bone window (a) shows patchy and round sclerotic lesions (white arrows) involving the posterior elements and vertebral bodies at multiple levels in the thoracolumbar spine. the axial bone window of the ct head (b) demonstrates a diffusely thickened calvarium with patchy sclerosis. an oblique radiograph of the left hand (c) shows typical intra-osseous cysts in the terminal phalanges (white arrows). the left thumb and second digit (b) additionally show multiple cortical defects or scalloping (arrow heads) and periostitis with associated soft-tissue components, likely representing large cutaneous angiofibromas or hamartomas. the dermatological manifestations along with the typical radiological features in the brain, lungs, liver and kidneys helped us to establish the diagnosis of tsc manifesting with an initial presentation of a ruptured renal aml. management and outcome in view of persistent haematuria, the patient was transferred to the digital subtraction angiography (dsa) suite for emergency endovascular embolisation of the ruptured left renal aml, after obtaining informed consent. the pre-procedural investigations revealed a reduced haemoglobin level of 4.1 grams per decilitre (g/dl), normal platelet count (1 79 000/mm3), total leukocyte count (8400/mm3) and kidney function parameters (blood urea: 28 g/dl, serum creatinine 0.7 mg/dl). the coagulation profile was normal (prothrombin time: 12 s and international normalised ratio [inr]: 1.1). selective arterial embolisation procedure under sterile conditions and local anaesthesia, right common femoral arterial access was secured using a 6 french (fr) sheath. a 5fr-renal double curve catheter (cook medical, bloomington, usa) was used to obtain an angiogram of the left main renal artery which revealed massive enlargement of the renal outline, hypertrophy of the dorsal branch of the renal artery supplying the aml, multiple aneurysms at the lower pole and an associated bizarre pattern of tumoural hypervascularity (figure 5a). figure 5: digital subtraction angiography images of the selective renal embolisation procedure: (a) catheter angiogram of the left main renal artery shows a solitary aneurysm (solid white arrow) and multiple clustered aneurysms in the lower pole (open arrow), suggestive of abnormal intra-tumoural vascularity in a renal angiomyolipoma. (b) super-selective angiogram using a microcatheter (red arrow) indicates tumoural hypervascularity and clustered small aneurysms in the lower pole of the kidney (encircled). (c) super-selective angiogram reveals the rounded area of absent parenchymal blush (star) suggestive of haematoma. there is hypervascularity in the surrounding parenchyma. (d) post-embolisation catheter angiogram from the main renal artery demonstrated the de-vascularised arterial stump (white arrow). embolised tumoural vessels with glue cast and alcohol (encircled). the upper pole of the kidney is spared and shows normal enhancement. delayed frames indicated dilated venous channels along the margins of the kidney. the upper pole indicated preserved renal parenchymal vascularity with multiple small areas of tumoural blush. no accessory renal arteries were identified and no suprarenal or lumbar accessory supply to the lesion was demonstrated. using a 2.7fr-microcatheter, super-selective angiograms were obtained from multiple segmental branches of the dorsal branch of left renal artery, which revealed tumoural hypervascularity, multiple clustered aneurysms (figure 5b) and a hypo-vascular region in the centre of the renal outline, splaying the vasculature and corresponding to the intra-tumoural hematoma (figure 5c). a few of these branches were embolised using 10 ml absolute alcohol mixed with lipiodol® (guerbet, aulnay-sous-bois, france) at a ratio of 4:1 and poly-vinyl alcohol (pva) particles of size 500 µm –700 µm, and some were embolised with 0.6 ml 25% n-butyl-cyanoacrylate (nbca) mixture with lipiodol® at a ratio of 1:3. the post-embolisation angiogram revealed complete occlusion of the abnormal tumoural vessels with preservation of the normal renal parenchyma (figure 5d). local anaesthetic and intravenous analgesics were administered to the patient during the procedure. in the immediate post-procedure period, the patient’s blood pressure was 110/70 mm of hg with a pulse rate of 100 per minute. she received three units of packed red blood cells. on follow-up (after 72 h), the haematuria had resolved with stabilisation of the vitals and haemoglobin levels (8.2 g/dl). the kidney function tests remained normal (blood urea: 28 mg/dl, serum creatinine 0.8 mg/dl). she was referred to the department of respiratory medicine and neurosurgery for management of the pulmonary and central nervous system manifestations. a follow-up ct was planned for 3 months post-procedure. ethical considerations this article followed all ethical standards for research. discussion tuberous sclerosis complex is a syndrome with multisystem involvement. the classic vogt’s triad of seizures, mental retardation and adenoma sebaceum is found only in 30% – 40% of patients with tsc.1 the 2012 international tuberous sclerosis complex diagnostic criteria are summarised in figure 6.3 the patient fulfilled eight major criteria and one minor criterion, indicating a ‘definite’ diagnosis of tsc with the classic imaging features described above. imaging plays a crucial role not only in the diagnosis but also in the follow-up of patients with tsc. the guidelines for imaging surveillance in tsc are summarised in table 1.4 figure 6: summary of major and minor criteria for the diagnosis of tuberous sclerosis. table 1: guidelines for imaging surveillance of tuberous sclerosis complex. renal aml is the most common benign renal tumour with a prevalence rate of about 0.3% – 3% worldwide.5 approximately 20% of patients with renal aml are diagnosed with tsc, and conversely, 55% – 75% of patients with tsc have renal amls.2 as the nomenclature suggests, aml is composed of dysmorphic, tortuous vascular tissue with smooth muscle and fat components. sporadic cases are generally unilateral, whereas those associated with tsc are multiple, bilateral and more aggressive.6 blood vessels in aml are fragile as they lack internal elastic lamina, thus forming multiple aneurysms. although most renal amls are usually asymptomatic, patients with enlarged kidneys and aml are more susceptible to trauma and may present with spontaneous perinephric haematoma, a palpable flank mass with pain or haematuria.2,5,6 it has been reported that amls associated with tsc are more prone to rupture than sporadic amls.7,8 the following are the predictors of the risk of haemorrhage in aml: size >4 centimetres (cm) (in sporadic aml) and >3.5 cm in aml associated with tsc, intra-tumoural aneurysms measuring >5 mm, female sex, pregnancy and increased oestrogen levels.9,10 renal artery embolisation is established as the treatment of choice for a ruptured aml.10 the first case was described in the literature in 1984.11 embolisation may also be used as a prophylactic procedure in aml to prevent rupture or bleeding and preoperatively to reduce intraoperative bleeding.12 the widely accepted criteria for prophylactic nephron sparing treatment of asymptomatic aml is a size of >4 cm or other risk factors of tumoural rupture listed earlier, especially in female patients of child-bearing age and those with limited access to follow-up and emergency care.6,13 although historically, surgery was the accepted treatment of choice, the role of endovascular management has emerged as it is effective, has a low complication rate, preserves renal function and has ease of repeatability.14 however, if there is suspicion of malignancy in the renal mass or if the patient is pregnant, surgery is the treatment of choice.6,15 the goal of endovascular management in amls is to obliterate the tumoural capillaries and small arterioles harbouring the small aneurysms. surgical options like nephron sparing surgery carry the risk of increased morbidity, especially when lesions are multiple, as in tsc.9 super-selective embolisation is safe and highly effective, especially in those who harbour multiple amls in both kidneys. other interventional ablative procedures available involve radiofrequency ablation, microwave ablation and cryoablation.6 skilled super-selective embolisation procedures cause minimal collateral damage to the normal renal parenchyma. moreover, these minimally invasive procedures can be repeated in the case of recurrence or technical failure on an initial attempt. these procedures are carried out under local anaesthesia circumventing the risk of general anaesthesia, particularly in patients with tsc who may have pre-existing respiratory and hepatic compromise. classically, absolute alcohol with pva particles is the embolic agent of choice, which helps in achieving permanent devascularisation of the lesion with subsequent reduction in size and haemorrhage risk. alcohol causes permanent occlusion at the level of the arterioles and capillary bed by triggering perivascular necrosis and intravascular thrombosis.13 many studies have documented reduction in the size of aml after embolisation, ranging from 20% to 70%.14,15,16,17 balloon occlusion catheters are often used with absolute alcohol because it occludes the vessel proximally, thereby decreasing the blood flow and increasing the contact time of alcohol with the affected blood vessels. balloon occlusion also prevents reflux of ethanol, thereby avoiding non-target embolisation.18 n-butyl-cyanoacrylate or glue is a permanent liquid embolic agent, which is diluted in iodised oil, lipiodol. it flows into the tumoural vessels and aneurysms, forming a solid glue cast as it comes into contact with blood.17 the speed of polymerisation of the glue depends on the concentration of nbca in lipiodol. varying proportions (1:3 to 1:6) have been used to achieve safe and adequate embolisation.17 we used nbca with lipiodol) for embolisation at a 1:3 ratio in the patient to de-vascularise part of the tumour, in addition to alcohol and pva. a wide variety of embolic agents have been used for embolising renal aml (table 2).12,16,17 however, no study has revealed superiority of one over another.18 table 2: embolic agents used for embolisation of angiomyolipoma by various authors in the past. coils should be avoided in aml embolisation as they cause proximal occlusion, promoting formation of collaterals distal to the level of occlusion, thereby increasing the risk of recurrence. furthermore, using coils precludes a re-embolisation procedure by establishing loss of arterial access to the tumoural feeders. the short-term complications of embolisation include post-embolisation syndrome manifesting as pain and fever, which can be managed with analgesics. non-target embolisation is common with glue and alcohol and may cause renal parenchymal damage leading to hypertension and decreased renal function. renal abscess and tumoural rupture are other complications of embolisation. access-site complications such as groin haematoma and pseudoaneurysm may also occur, as observed with other catheter-based angiographic procedures.18 the main long-term complication includes recurrence of the lesion with a recurrence rate varying between 11% and 40%.18 ‘fat-poor’ amls respond better to endovascular management because of the larger proportion of angiomyogenic component with a lower rate of recurrence.13,17 conclusion the radiologist plays a central role not just in the diagnosis of tsc and detection of its multisystem involvement but also in the interventional management of renal aml, which may present with life-threatening haemorrhage. selective endovascular embolisation can be used to de-vascularise the lesion and control the bleeding, thus proving to be a safe and effective treatment option in such patients. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.g., a.s., h.r., a.r.c. and r.m. contributed equally to this article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this research article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references manoukian s, kowal d. comprehensive imaging manifestations of tuberous sclerosis. am j roentgenol. 2015;204(5):933–943. https://doi.org/10.2214/ajr.13.12235 umeoka s, koyama t, miki y, akai m, tsutsui k, togashi k. pictorial review of tuberous sclerosis in various organs. radiographics. 2008;28(7):e32. https://doi.org/10.1148/rg.e32 northrup h, krueger da. tuberous sclerosis complex surveillance and management: recommendations of the 2012 international tuberous sclerosis complex consensus conference. pediatr neurol. 2013;49(4):255–265. https://doi.org/10.1016/j.pediatrneurol.2013.08.001 amin s, kingswood j, bolton p, et al. the uk guidelines for management and surveillance of tuberous sclerosis complex. qjm. 2018;112(3):171–182. https://doi.org/10.1093/qjmed/hcy215 fittschen a, wendlik i, oeztuerk s, et al. prevalence of sporadic renal angiomyolipoma: a retrospective analysis of 61,389 inand out-patients. abdom imaging. 2014;39(5):1009–1013. https://doi.org/10.1007/s00261-014-0129-6 vos n, oyen r. 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j, paul l, cabrera m, alonso-burgos a, gómez d. elective and emergency renal angiomyolipoma embolization with ethylene vinyl alcohol copolymer: feasibility and initial experience. j vasc interv radiol. 2017;28(6):832–839. https://doi.org/10.1016/j.jvir.2017.01.017 rimon u, duvdevani m, garniek a, et al. ethanol and polyvinyl alcohol mixture for transcatheter embolization of renal angiomyolipoma. am j roentgenol. 2006;187(3):762–768. https://doi.org/10.2214/ajr.05.0629 planche o, correas jm, mader b, joly d, mejean a, helenon o. prophylactic embolization of renal angiomyolipomas: evaluation of therapeutic response using ct 3d volume calculation and density histograms. j vasc interv radiol. 2011;22(10):1388–1395. https://doi.org/10.1016/j.jvir.2011.05.016 kaufman ja, lee mj. vascular and interventional radiology: the requisites. 1st ed. philadelphia, pa: mosby, 2004; p. 83–118. wang c, li x, peng l, gou x, fan j. an update on recent developments in rupture of renal angiomyolipoma. medicine (baltimore). 2018;97(16):e0497. https://doi.org/10.1097/md.0000000000010497 lee sy, hsu hh, chen yc, et al. embolization of renal angiomyolipomas: short-term and long-term outcomes, complications and tumor shrinkage. cardiovasc intervent radiol. 2009;32(6):1171–1178. https://doi.org/10.1007/s00270-009-9637-0 bardin f, chevallier o, bertaut a, et al. selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction. quant imaging med surg. 2017;7(1):8–23. https://doi.org/10.21037/qims.2017.01.02 flum as, hamoui n, said ma, et al. update on the diagnosis and management of renal angiomyolipoma. j urol. 2016;195(4 pt 1):834–846. https://doi.org/10.1016/j.juro.2015.07.126 abstract introduction case presentation and procedure discussion conclusion acknowledgements references about the author(s) shuchi bhatt department of radiodiagnosis, faculty of health sciences, university college of medical sciences and gtb hospital, dilshad garden, delhi, india harshit bansal department of radiodiagnosis, faculty of health sciences, university college of medical sciences and gtb hospital, dilshad garden, delhi, india sagar nayak department of radiodiagnosis, faculty of health sciences, university college of medical sciences and gtb hospital, dilshad garden, delhi, india saumya dangwal department of orthopaedics, faculty of health sciences, university college of medical sciences and gtb hospital, dilshad garden, delhi, india citation bhatt s, bansal h, nayak s, dangwal s. high presacral collection approached through the perineal route: a novel computed tomography-guided technique. s afr j rad. 2021;25(1), a2014. https://doi.org/10.4102/sajr.v25i1.2014 case report high presacral collection approached through the perineal route: a novel computed tomography-guided technique shuchi bhatt, harshit bansal, sagar nayak, saumya dangwal received: 15 oct. 2020; accepted: 11 dec. 2020; published: 11 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract for a definitive diagnosis of abdomino-pelvic lesions, percutaneous aspiration or biopsy is often necessary; however, finding a safe ‘window’ for access is challenging. this case report discusses a novel method to approach a deep pelvic collection and also briefly reviews the various approaches to access such lesions. a sample was obtained from a non-resolving presacral collection using a ct-guided percutaneous, trans-perineal approach with repeated sessions of hydro-dissection. successful aspiration and analysis revealed multi-drug resistant tuberculosis, thus guiding appropriate management. keywords: mdr; tb; infectious medicine; interventional radiology; trans-perineal. introduction imaging diagnosis of presacral and deep pelvic lesions is usually non-specific and histo-pathological analysis is necessary for establishing the diagnosis. image-guided percutaneous aspiration or biopsy is a safe and effective procedure. however, deep pelvic lesions pose a challenge for interventional radiologists as the overlying bowel, bladder, vessels, bones and uterus, and adnexa in female patients often preclude safe access.1 organ displacement techniques, such as hydro-dissection, may provide ‘windows’ to safely access lesions that are blocked by overlying structures.2,3 fine needle aspiration is sufficient for evaluating infected collections and usually requires a small calibre needle. however, chronic collections (especially tubercular) are frequently dense and organised, requiring a large-bore needle (18g or more), thus precluding transgression of the bowel or bladder to approach deep-seated pelvic lesions. there is also a risk of fistula formation and spread of infection in cases of tubercular aetiology. in addition to establishing the diagnosis of tuberculosis, percutaneous aspiration may be required for drug sensitivity testing for multi-drug resistant tuberculosis (mdr-tb) in cases of inadequate or poor response to anti-tubercular treatment. a safe access route is, therefore, required in order to obtain the specimen and to prevent inadvertent complications, which can be achieved by scrupulous planning under image guidance. the success, effectiveness and safety of percutaneous pelvic needle aspiration or biopsy are dependent on a thorough understanding of the cross-sectional anatomy of the pelvis.4,5,6,7,8,9,10 both sonography and computed tomographic (ct) allow direct simultaneous visualisation of the pelvic structures and pathology. although relatively low-lying lesions in the pelvis may be approached transrectally, using ultrasound guidance makes it difficult to approach more cephalad lesions in the presacral space. several percutaneous approaches have been described for overcoming various challenges in accessing pelvic and/or perineal lesions under ct guidance. a radiologist should be aware of the technical and patient-related limitations to avoid injury of the vital intervening structures whilst approaching the lesion. a novel ct-guided technique specifically tailored to suit a difficult approach to a high presacral collection is discussed in detail. the challenges presented and the solutions devised to overcome them are detailed in this case report. successful aspiration of the collection avoided surgery, helped obtain the tissue sample and also permitted appropriate treatment to be instituted. case presentation and procedure a 38-year female patient with pott’s spine involving the l5-s1 vertebrae showed no significant clinical or imaging improvement after 15 months of anti-tubercular treatment. the possibility of mdr-tb or an alternative aetiology was considered. magnetic resonance imaging (mri) of the spine revealed a well-defined destructive lytic lesion involving the l5 and s1 vertebral bodies, along with a large presacral soft tissue component with internal calcifications. comparison with previous mr imaging indicated an increase in the collection size and associated-bone destruction. histo-pathological evaluation was deemed necessary and the patient was referred to the radiology department for image-guided aspiration. anatomy of the pelvic structures and standard percutaneous ct-guided approaches to detect deep pelvic lesions were carefully reviewed. use of the classic anterior or lateral trans-abdominal approach would require transgression of interposed bowel loops or a distended urinary bladder and was therefore considered inappropriate. a trans-gluteal approach was not considered, as the collection was located far above the greater sciatic foramen. an antero-lateral extra-peritoneal approach was rejected because of the location of the internal iliac neurovascular bundle along the proposed needle path. a trans-osseous approach through the sacrum was also not possible as the collection was anterior to the sacral promontory. a para-coccygeal-infragluteal approach was deemed impossible because of the high position of the collection. the high position of the presacral collection (mean hu 35) at the s1–2 level made conventional percutaneous techniques practically impossible to use. the greatest challenge was to negotiate the sacral curve to reach the collection without injuring the important structures. we, therefore, resolved to collect the sample using a novel trans-perineal approach. the distance of the collection from the expected site of needle entry into the perineum was approximately 9 cm and thus, required a large-bore needle of long length. however, as there was the potential to transgress the anal canal and rectum using this approach, another prerequisite was to displace the rectum off the sacro-coccygeal curve so as to provide a safe needle pathway. the patient was counselled about the procedure and written informed consent was obtained. the patient was positioned in the left lateral knee-chest position on the gantry table and a non-contrast computed tomography (ncct) scan was obtained from the level of the l5 vertebra to the inferior limit of the gluteal region. the 3d sections were reconstructed and images analysed again for the proposed needle pathway (figure 1). a review of the sagittal sections showed the rectum lying in the needle pathway and thus required anterior displacement in order to avoid injury. hydro-dissection seemed to be a viable option for achieving this. figure 1: (a and b) axial and sagittal images at the level of sacrum demonstrate an elongated hypodense collection in the high presacral region resulting in erosion of the anterior aspect of the upper sacral vertebrae. the collection was unapproachable anteriorly because of the presence of bladder and bowel loops and is located in close proximity to the rectum antero-inferiorly. the initial aim was to reach the presacral space at the s5 level. the tip of the coccyx was palpated and a point 3 cm lateral and 2 cm anterior to it was selected on the right buttock and marked. after cleaning and draping, 10 ml of local anaesthesia was infiltrated, and a 21g spinal needle was inserted and slowly advanced anteriorly, cranially and medially at an angle of 30 degrees along the lateral sacro-coccygeal border until the tip of the needle reached the retro-rectal space at the s5 level (figure 2). after confirming the position of the needle tip on limited axial cuts, 20 ml of 0.9% saline was instilled so as to displace the rectum anteriorly (figure 3). figure 2: (a and b) oblique axial and sagittal images show the tip of the needle (21g) at the level of the s5 vertebra in the presacral space with the rectum immediately antero-lateral to it. figure 3: (a and b) oblique axial and sagittal images after instillation of 0.9% saline showing anterior displacement of the rectum and widening of the presacral space. the spinal needle was then withdrawn and then re-inserted from a para-median point (to avoid injury to the midline ano-coccygeal ligament) to the same vertical level after infiltration with local anaesthetic. the needle was carefully advanced cranially and hydro-dissection was repeated with 20 ml saline to further displace the rectum anteriorly. this was repeated until the needle could reach the target point (figure 4). figure 4: sagittal image showing the progressive cranial advancement of the needle in the presacral space, made possible by anterior displacement of the rectum through repeated hydro-dissection. the needle is approximating the caudal extent of the collection. as the collection was viscous and deep, an 18 g co-axial needle was chosen and was introduced utilising the spinal needle as a guide. upon confirmation of accurate needle placement, the spinal needle was removed and the co-axial system was further advanced cranially into the collection (figure 5). upon removal of the stylet, 4 ml – 5 ml of thick purulent material was aspirated, placed into sterile containers and sent for histo-pathological confirmation and a cartridge-based nucleic acid amplification test (cb-naat). figure 5: oblique sagittal multiplanar reconstruction image indicating the 18g co-axial needle advanced cranially into the collection. upon aspiration, thick viscous content was obtained which was sent for histo-pathological analysis in a sterile container. once the procedure was completed, the needle was withdrawn and the puncture site was sealed with tincture iodine. no procedural or post-procedural complications were encountered. analysis of the sample revealed mdr-tb, resistant to both isoniazid and rifampicin. discussion image-guided percutaneous aspiration is a widely accepted and commonly performed minimally invasive procedure that provides a means of procuring tissue samples for a variety of diagnostic purposes.2 ultrasound-guided percutaneous fine needle aspiration is often considered to be the simplest and most efficient technique. however, ct-guided puncture has increased precision as it provides greater spatial resolution and is helpful in cases where us-guided puncture is not possible because of superimposed intestinal gas, bone or adipose tissue.7 various imaging guided approaches have been described in the literature. classic anterior or lateral trans-abdominal approach this approach is the most common. during this technique, the needle is inserted through the lower abdominal wall and peritoneum with the patient in the supine or lateral decubitus position, avoiding the inferior epigastric vessels, deep circumflex iliac vessels and bowel. however, if bowel transgression with a thin 22g needle occurs, this is considered safe. emptying the bladder allows access to deeper lesions. this technique is best suited for lesions cranial, anterior or lateral to the bladder. ultrasonography of a full bladder is required to visualise lesions behind it; the echoes traverse the bladder to reach the target. however, interventionally, peritoneal or urinary bladder puncture is painful and the presence of surgical dressings or colostomy bags may preclude access in post-operative patients. trans-gluteal or trans-sciatic approaches this method places the patient in the prone position and is used for posterior pelvic lesions located in the lower pelvis that are not safely accessible because of intervening bowel, bladder, uterus and iliac vessels. the needle trajectory is through the sacro-spinous ligament via the caudal part of the greater sciatic notch below the level of pyriformis and as close as possible to the edge of the sacrum in order to avoid damaging the neurovascular structures exiting the pelvis. the main drawback is the risk of injury to the sciatic nerve, gluteal vessels and sacral plexus. antero-lateral extra-peritoneal approach the technique involves needle transgression through the ilio-psoas muscle in the supine position. it is suited for lesions located along the medial aspect of the iliopsoas muscle, usually pelvic lymph nodes. masses or loculated fluid along the pelvic sidewall and adnexal masses located posterior to the vessels can also be sampled. contrast material administration is occasionally necessary with ct guidance in order to define the vascular structures. the major risk involves injury to iliac vessels, the femoral nerve and ureters. trans-osseous approach this procedure can be attained via the trans-sacral or trans-iliac routes. during the trans-sacral approach, the needle should be advanced through the medial (between the central canal and foramina) or extreme lateral part of the sacrum. in a trans-iliac approach, the needle is advanced through the narrow part of the iliac wing taking care to avoid injury to the ureters and gonadal vessels. this technique specifically targets presacral and posterior pelvic lesions not accessible by the trans-gluteal approach because of the location above the greater sciatic foramen or interposition of vascular structures. besides being painful, there is a risk of injuring the sacral nerves. needle stabilisation is better with the trans-gluteal, antero-lateral extra-peritoneal or trans-osseous approaches as compared to the trans-abdominal approach. trans-perineal, para-coccygeal or infra-gluteal approach this strategy has also been described for deep pelvic lesions located caudally in the presacral and ischio-rectal spaces. the coccyx is used as a palpable bony landmark for choosing the site of needle entry under ct guidance. most limitations of the trans-gluteal approach are overcome by this technique, other than minimal patient discomfort. the gluteal muscles and sciatic plexus are safely avoided. however, the insertion of the needle is considered more difficult as compared to the trans-gluteal approach.11 the close approximation of the rectum in the sacral concavity limits this approach for caudally placed presacral lesions. in our case, however, we approached a high presacral collection by modifying this technique at various stages. the trans-vaginal and trans-rectal approaches have also been described for drainage of collections lying in close proximity to the vaginal vault and in the ischio-rectal spaces. various non-invasive methods have been described to achieve safe needle trajectories for percutaneous puncture by adjusting angulation of the ct gantry, patient positioning, timing of respirations with needle passage and use of compression devices.3,12,13,14 several authors have also described various methods for physically displacing vital structures away from the target lesion to create percutaneous access routes using agents such as sterile water, 0.9% normal saline solution, 5% dextrose in water and carbon dioxide.12,13,14 although large presacral lesions (or smaller ones that are in the anterior and caudal aspect of the presacral space) may be approached via the greater sciatic foramen,4 adjacent to the coccyx11 or transrectally,15 a high, small lesion close to the anterior surface of the sacrum is a more difficult target. in our patient, we were able to avoid invasive surgical intervention by successfully using an innovative ct-guided technique to reach a high presacral collection for obtaining tissue samples for re-confirmation of the aetiology and detecting the reason for non-response to anti-tuberculous treatment. conclusion this case report discusses the various percutaneous image-guided techniques utilised for accessing deep pelvic lesions or collections with a focus on a novel technique used to approach a presacral collection through the percutaneous, trans-perineal, para-coccygeal approach. additionally, we adjusted the patient’s position and utilised hydro-dissection to achieve anterior displacement of the rectum and create a safe needle pathway in the sacral curve, making this case unique. familiarity with the cross-sectional pelvic anatomy and various percutaneous approaches facilitates planning of a safe access route to deep-seated pelvic/presacral lesions and helps avoid injury to major neurovascular structures and other viscera. knowledge of the advantages and disadvantages of each technique allows the radiologist to choose the optimal approach in a given setting.1 displacement of important structures by injecting saline can be achieved to create access routes for image-guided percutaneous abdominal or pelvic biopsies/ drainages of lesions that are otherwise inaccessible because of their depth or proximity to vital structures. tubercular collections, in particular, can create specific challenges, such as bowel, bladder and peritoneal transgression, which are not advisable because of the risk of persistent fistula formation and spread of infection. furthermore, the viscous nature of the collections limits the size of needle used for aspiration. as evident in this case, a tailor-made approach was deemed necessary, considering the location of the lesion and specific challenges posed. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. authors’ contributions s.b., h.b., s.n. and s.d. contributed equally to this case report. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is available from the corresponding author, h.b., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references gupsta s, nguyen hl, morello fa, et al. various approaches for ct-guided percutaneous biopsy of deep pelvic lesions: anatomic and technical considerations. radiographics. 2004;24(1):175–189. https://doi.org/10.1148/rg.241035063 asvadi nh, arellano rs. hydrodissection-assisted image-guided percutaneous biopsy of abdominal and pelvic lesions: experience with seven patients. ajr. 2015;204(4):865–867. https://doi.org/10.2214/ajr.14.13040 arellano rs, gervais da, mueller pr. ct-guided drainage of abdominal abscesses: hydrodissection to create access routes for percutaneous drainage. ajr. 2011;196(1):189–191. https://doi.org/10.2214/ajr.10.4731 butch rj, mueller pr, ferucci jt, et al. drainage of pelvic abscesses through the greater sciatic foramen. radiol. 1986;158(2):487–491. https://doi.org/10.1148/radiology.158.2.3941878 mcdowell r, mueller p. pelvic fluid collections: anatomy for interventional procedures. semin intervent radiol. 1995;12(2):177–190. https://doi.org/10.1055/s-2008-1061325 pardes jg, schneider m, koizumi j, engel ia, auh yh, rubenstein w. percutaneous needle biopsy 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https://doi.org/10.2214/ajr.162.5.8166015 interesting images vein of galen aneurysmal formation case report a three-year-old child presented with delayed developmental milestones and seizures. on examination the head circumference was below the l o" percentile. there was no cardiac failure or bruit. pcorr ffrad c sanyika fcrad d royston ffflad department of radiology, wentwortil hospital & university of natal discussion this patient has cerebral atrophy with evidence of chronic cerebral ischaemia resulting from the vascular steal and cerebral venous hypertension. this is the chronic phase of the disorder where endovascular occlusion of the fistula is unlikely to improve symptoms. figure te and b: ct scan pre· and post-contrast injections, demonstrated global cerebral atrophy with focal parenchymal calcification and a large central draining vein with serpiginous vessels suggesting a vein of galen aneurysmal malformation (vgam) 16 sa journal of radiology· august 1998 figure 2a and b: t2 weighted mr and time of flight mr confirms a central promesencephalic draining vein with a fistula arising from the anterior and posterior choroidal arteries in vgam, the large draining vein, the promesencephalic vein, is the embryonic precursor to the vein of galen. i the feeding arteries are the choroidal vessels and subependymal vessels from the posterior circle of willis. this disorder must be differentiated from the vein of galen malformation, in which the vein of galen is well-formed.! to page 17 vein of galen aneurysmal forrriat iori from page 16 a common presentation. in the infant, presentation with macrocrania and hydrocephalus are more common. these are due to venous congestion and / or thrombosis. in the child delayed developmental milestones andfigure 3: carotid angiogram confirms the fistula and draining vein of a vgam the natural history of vgam is variable. in the neonatal period, cardiac failure as a result of the fistula is convulsions are common, arising from the subependymal atrophy and chronic venous ischaemia.! the treatment in the neonatal period is endovascular occlusion of the fistula. from an arterial approach, the occlusion is achieved with glue and coils. a venous approach through the torcula is possible with coil occlusion, but is less favoured. references 1. raybaud ,strother c, haid j. aneurysms of the vein of galen: embryonic considerations and anatomical features relating to the pathogenesis of the malformation. neuroradiology 1989; 31: 109-128 2. lasjaunis p. vein of galen malformation. in: vaswlar diseases in neonates, tnfants, and children. publisher springer verlag berlin, 1997, p 67-202 primary hydatidosis of the thyroid gland: a case report from page 14 centre the incidence of carcinoma in patients with solitary nodules is 70%,5 compared to 17% found by mccall et al.6 we feel that the reason for this discrepancy is that at our centre we analyze the scan during both dynamic and static phases. the lesion is considered malignant if a photopenic area seen on static images shows perfusion during the dynamic phase of the study. the lesion is considered benign if a photopenic area on static image shows no vascularity during the perfusion phase of the investigation. our case displayed benign features on scintigraphy as shown on figure 1. evidence of diminished function in a tc-99m scan is an indication for fna of a nodule. aspiration cytology showed multiple calcified bodies and very few cells, with groups of scolices resembling echinococcus granulosus. . should ultrasound have been performed, the potential problem of spillage could have been avoided. ultrasound may confirm the diagnosis of hydatid disease by demonstration of a 'cyst within a cyst' or other features.' after the left thyroid lobectomy, histological examination revealed a parasite membrane with a degenerated germinal layer. many degenerated scolices and hooklets were seen with extensive dystrophic calcification. the surrounding thyroid tissue was severely inflamed with many foreign body giant cells being seen, thus allowing a diagnosis to be made. in conclusion although our results were satisfactory,we hope that this rare case of primary hydatidosis of the thyroid will prove useful to justify routine use of ultrasound in the evaluation of thyroid nodules, especially where a cystic lesion is suspected. with surgery still the treatment of choice, we believe that scintigraphy combined with ultrasound prior to fna will make the 17 sajournal of radiology. august 1998 surgeon aware of this possibility so as to follow the special therapeutic policy necessary to avoid dangerous spillage of the parasite. references 1. moreno ge, rico sp, martinez b, et al. results of surgical treatm nt of h patic hydatidosis: current therapeutic modifications. world] surg 1991: 15: 254. 2. karavias d, vagianos c, bouboulis n, rathosis s, androulakis j. improved techniques in the surgical treatment of hepatic hydatidosis. surg gynaecol obstet 1992; 174: 176. 4. prousaltdis j, tzardinoglou k, sgouradis l, katsohis c, aletras h. uncommon sites of hydatid disease. world] surg 1998; 22: 17-22. 5. rojeski mt, gharib h. nodular thyroid disease: evaluation and management. n eng] med 1985; 313:413-417. 6. mageza rb. the role of dynamic phase pertechnetate scanning in thyroid malignant disease. south african] surg 1994; 32: 91-93. 7. mccall a, jarosz h, lawr nee am, paloyan e. the incidence of thyroid carcinoma in solitary cold nodules and multinodular goitres. surgery 198~loo: 1128-1131. sajr 855 face of the giant panda sign in wilson disease s chakraborty,1 mb bs, md (radiodiagnosis); s mondal,2 mb bs, dmrd; d sinha,2 mb bs; a nag,2 mb bs 1 department of radiology and imaging, institute of post graduate medical education and research, kolkata, india 2 department of general medicine, institute of post graduate medical education and research, kolkata, india corresponding author: s mondal (drmsumantro@gmail.com) wilson disease usually presents with neurological or hepatic manifestations. magnetic resonance imaging (mri) of the brain is most informative in diagnosing this disease, especially in patients with neurological features. high t2 signal intensity in the corpus striatum is the most commonly encountered mri finding. the ‘face of the giant panda’ sign, seen on axial t2-weighted mri, results from abnormal signal intensities in the midbrain. though uncommon, the sign is regarded as the pathognomonic mri sign of wilson disease. s afr j rad 2013;17(3):104. doi:10.7196/sajr.855 an 18-year-old man was admitted with a gradually progressive tremor and abnormal movements of the limbs of 6 months’ duration. there was no evidence of sensory or pyramidal tract involvement. he had no past or family history of liver disease. examination revealed a coarse appendicular tremor (5 6 hz) and choreiform movements of the hands, along with mild hepatomegaly. wilson disease (wd) was confirmed by documentation of kayser-fleischer rings in both eyes, a low serum ceruloplasmin level (15 mg/dl) and increased 24-hour urinary copper excretion (430 µg/24 hr). axial t2-weighted mri of the brain showed the characteristic ‘face of the giant panda’ sign in the midbrain (fig. 1) and hyperintensity in the basal ganglia and thalamic regions bilaterally (fig. 2). fig. 1. axial t2-weighted mri of the brain at the level of the midbrain showing the characteristic ‘face of the giant panda’ sign, with normal red nuclei and substantia nigra (pars reticulata) against a background of hyperintensity in the tegmentum, as well as hypointensity of the superior colliculi. fig. 2. axial t2-weighted mri of the brain at the level of the basal ganglia showing hyperintensity in the putamina and thalami (white arrows). discussion mri of the brain is not only a useful diagnostic modality in wd but can also be used to assess disease severity and response to treatment. mri changes are seen in virtually all neurologically symptomatic patients.1 when patients have predominant hepatic involvement, t1 hyperintensity is noted in the globus pallidus, putamen and mesencephalon. in neurologically symptomatic patients, t2 hyperintensity is noted in the putamina, caudate nuclei, thalami, midbrain and pons. atrophy of the cerebrum and brainstem may be seen in long-standing cases.1 , 2 the ‘face of the giant panda’ sign, seen on axial t2-weighted images of the midbrain, is regarded as characteristic of wd.3 the sign was originally described by hitoshi et al.; it is produced as a result of high signal intensity in the tegmentum with preserved normal signal intensity in the red nuclei (eyes of the panda) and lateral portion of the pars reticulata of the substantia nigra (ears of the panda), and hypointensity of the superior colliculi (chin of the panda).3 the exact pathogenesis of the superior colliculus hypointensity is not known. it has been postulated that the paramagnetic effect of heavy metal deposition (e.g. iron, copper) may be responsible for this finding.4 in wd, iron deposition is more significant than copper for producing t2 hypointensity. the ‘face of the giant panda’ sign is not commonly encountered. in a study of 100 patients, it was present in 12%.1 however, the sign is pathognomonic of wd, being the only mri feature that distinguishes wd from other early onset extrapyramidal disorders.5 1. sinha s, taly ab, ravishankar s, et al. wilson’s disease: cranial mri observations and clinical correlation. neuroradiology 2006;48(9):613-621. epub 3 jun 2006. 1. sinha s, taly ab, ravishankar s, et al. wilson’s disease: cranial mri observations and clinical correlation. neuroradiology 2006;48(9):613-621. epub 3 jun 2006. 2. kim tj, kim io, kim ws, et al. mr imaging of the brain in wilson disease of childhood: findings before and after treatment with clinical correlation. am j neuroradiol 2006;27(6):1373-1378. 2. kim tj, kim io, kim ws, et al. mr imaging of the brain in wilson disease of childhood: findings before and after treatment with clinical correlation. am j neuroradiol 2006;27(6):1373-1378. 3. hitoshi s, iwata m, yoshikawa k. mid-brain pathology of wilson’s disease: mri analysis of three cases. j neurol neurosurg psychiatry 1991;54:624-626. 3. hitoshi s, iwata m, yoshikawa k. mid-brain pathology of wilson’s disease: mri analysis of three cases. j neurol neurosurg psychiatry 1991;54:624-626. 4. rutledge jn, hilal sk, silver aj, et al. study of movement disorders and brain iron by mr. am j roentgenol 1987;149:365-379. 4. rutledge jn, hilal sk, silver aj, et al. study of movement disorders and brain iron by mr. am j roentgenol 1987;149:365-379. 5. prashanth lk, sinha s, taly ab, et al. do mri features distinguish wilson’s disease from other early onset extrapyramidal disorders? an analysis of 100 cases. mov disord 2010;25(6):672-678. [http://dx.doi.org/10.1002/mds.22689] 5. prashanth lk, sinha s, taly ab, et al. do mri features distinguish wilson’s disease from other early onset extrapyramidal disorders? an analysis of 100 cases. mov disord 2010;25(6):672-678. [http://dx.doi.org/10.1002/mds.22689] abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) johan sothmann department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa shaun adam division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa gideon van tonder division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa razaan davis department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa leon janse van rensburg department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africadepartment of radiology and diagnostics, faculty of dentistry, university of the western cape, cape town, south africa citation sothmann j, adam s, van tonder g, davis r, janse van rensburg l. otosyphilis: a rare cause of acute bilateral sensorineural hearing loss in a hiv-negative patient. s afr j rad. 2022;26(1), a2351. https://doi.org/10.4102/sajr.v26i1.2351 research project registration: project number: 23509 case report otosyphilis: a rare cause of acute bilateral sensorineural hearing loss in a hiv-negative patient johan sothmann, shaun adam, gideon van tonder, razaan davis, leon janse van rensburg received: 24 nov. 2021; accepted: 26 jan. 2022; published: 29 mar. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract bilateral acute hearing loss is rare, and the aetiology is poorly defined. less common treatable pathologies such as otosyphilis must be part of the differential diagnosis and should be actively excluded. we present a case of a 23-year-old woman who developed acute bilateral hearing loss due to otosyphilis, confirmed on audiometry and laboratory tests. in this article, the ct, mri and clinical findings are presented and discussed. keywords: otosyphilis; sensorineural; computed tomography; magnetic resonance imaging; audiology; human immunodeficiency virus (hiv). introduction hearing loss is categorised as sensorineural, conductive or mixed. the differential diagnosis for each category is wide, and the combination of clinical evaluation, laboratory findings and imaging features are important in determining the diagnosis. in many patients, an underlying pathology is not found with a consequent diagnosis of idiopathic sudden hearing loss.1 bilateral acute hearing loss is rare and occurs in approximately 1% – 2% of cases.2 the aetiology is poorly defined and includes infective, vascular and neoplastic aetiologies.3 it is important in everyday practice to consider less common but treatable pathologies such as syphilis. case presentation a 23-year-old woman presented to a local emergency centre complaining of sudden onset of left-sided otalgia, headache and tinnitus two weeks prior. this was followed by the development of left facial weakness and sudden bilateral hearing loss a week before her presentation. there was no history of prior ear disease or surgery and no other medical illnesses. clinical examination revealed left lower motor neurone facial nerve paresis (house-brackmann grade 5), bilateral sensorineural hearing loss, a positive catch-up saccade on head impulse test and a macular rash on her torso and chest. there were no other neurological deficits or ear, nose and throat (ent) abnormalities and the gynaecological examination was normal. an empirical treatment regime consisting of ceftriaxone, prednisone and acyclovir was started. audiometry the audiogram confirmed bilateral severe-to-profound sensorineural hearing loss with type a tympanometry (figure 1). figure 1: audiogram at the time of admission demonstrated bilateral profound sensorineural hearing loss. computed tomography and magnetic resonance imaging a contrasted ct brain scan demonstrated a hyperattenuating mass at the porous acousticus of the left internal acoustic canal (iac) (figure 2a). there was mild contrast enhancement and the canal was not expanded. the right iac appeared normal. the provisional diagnosis was a left-sided vestibular schwannoma. figure 2: (a) axial ct brain scan demonstrated a hyperattenuating mass at the porous acousticus of the left internal acoustic canal (red arrow). there was mild contrast enhancement and the canal was not expanded. the right internal acoustic canal appeared normal (blue arrow). (b) axial, t2w mri of the iac demonstrated loss of the normal csf signal within the left iac (red arrow). the right iac demonstrated signal loss to a lesser extent (blue arrow). (c–d) axial, t2w, mri of the cochleae demonstrated partial loss of the normal csf signal in the basal turns of the cochleae bilaterally (blue arrow in c indicating the right and red arrow in d indicating the left cochlea). (e) axial, mri, constructive interference in steady state sequence, demonstrated a notable mass within the left internal acoustic canal, with loss of the normal csf signal (red arrow). this was seen to a lesser extent in the right internal acoustic canal (blue arrow). magnetic resonance imaging (mri) of the brain and iacs with intravenous gadolinium was performed. this demonstrated loss of the normal csf signal within the left iac on t2-weighted (t2w) imaging. the right iac demonstrated signal loss to a lesser extent (figure 2b). there was partial loss of the normal csf signal in the basal turns of the cochleae bilaterally (figure 2c and d). the three-dimensional constructive interference in steady state (ciss) revealed a hypointense mass within the left iac, with loss of the normal csf signal sequence. less obvious changes were present in the right iac (figure 2e). on t1-weighted (t1w) imaging the right-sided iac mass was isointense to brain parenchyma. t1-weighted post contrast imaging revealed vivid contrast enhancement in the left iac and facial nerve (figure 3a), as well as in the basal turns of the cochleae bilaterally (figure 3b). leptomeningeal enhancement anterior to the pons as well as the outline of the iac was demonstrated. the vertical segment of the left seventh cranial nerve (cn) demonstrated a nodular pattern of contrast enhancement (figure 3c). figure 3: (a) coronal, t1 weighted post contrast mri demonstrated enhancement in left internal acoustic canal and facial nerve (red arrow) as well as bilateral basal turns of the cochleae (blue arrows). (b) coronal, t1 weighted post contrast mri demonstrated enhancement of bilateral basal turns of the cochleae (only left side shown, indicated by red arrow). (c) coronal, t1 weighted post contrast mri demonstrated enhancement of the left 7th cranial nerve vertical segment with a nodular appearance (red arrow). laboratory findings serum tests indicated an elevated c-reactive protein (crp) 14 mg/l and an erythrocyte sedimentation rate (esr) of 28 mm/h. the hiv status of the patient was negative. the white blood cell count, renal and thyroid function tests were normal. the serum treponema pallidum haemagglutination (tpha) assay test and the rapid plasma reagin (rpr) were positive with an initial rpr titre of 1:128. serum viral studies for cytomegalovirus (cmv), epstein barr virus (ebv), mumps, enterovirus, herpes simplex virus 1 and 2, and human herpes virus type 6, were all negative. the lumbar puncture revealed a normal glucose level, mildly elevated protein, elevated lymphocytes, no bacteria nor bacterial growth and negative cryptococcal and viral panel tests. the fluorescent treponema pallidum antibody test (fta-abs) was positive. unfortunately, the venereal disease research laboratory (vdrl) test on csf was not available. sputum gene xpert was negative. the severe acute respiratory syndrome coronavirus 2 (sars‑cov‑2) swab was negative. management positive treponema pallidum serology with a high rpr titre (1:128) that reduced fourfold on treatment, confirmed current infection. the findings of csf with positive fta confirmed cns involvement with secondary syphilis. the audiological findings, clinical and radiological picture, together with the absence of another cause, confirmed otosyphilis in this case. initial ceftriaxone was changed to intravenous penicillin g 6 million units 6 hourly for 14 days, together with daily oral 1 mg/kg prednisone and eye care to prevent exposure keratitis due to her facial nerve palsy. repeat audiometry demonstrated no improvement in the hearing loss, but her facial nerve function improved to near normal (house-brackmann 1). her speech discrimination score was 0% bilaterally so she would not have derived any benefit from a hearing aid. her current social circumstances unfortunately preclude her candidacy for a cochlear implant at this time. she has been referred to the national institute for the deaf to learn sign language and for occupational training so she may be upskilled and obtain employment. discussion otosyphylis (syphilitic labyrinthitis) is a manifestation of neurosyphilis affecting the inner ear. the radiological features include severe endolymphatic hydrops, membranous labyrinth degeneration and diffuse osteitis.4 histopathological features of otosyphilis are secondary to obliterative endarteritis and lead to bone involvement with inflammatory resorptive osteitis and areas of resorption. the ct correlate of this process is otocapsule permeative and irregular lucencies, close to the labyrinth margins. lucencies within the malleus and incus may also be present.5 mri features may include gummas in the internal auditory canal, as well as other manifestations of neurosyphilis, which include leptomeningeal enhancement, cn 7 and 8 enhancement, cortical and subcortical infarctions, and also segmental vascular narrowing and beading (best seen on angiography). gummas appear as small nodules adjacent to the meninges which are t1w hypointense and t2w hyperintense, and demonstrate homogenous contrast enhancement. gummas may also demonstrate a dural tail sign or evidence of pachymeningitis. the mri findings of late neurosyphilis may reveal cerebral and cord atrophy.6 the differential diagnosis based on the mri findings should include ramsey hunt syndrome (herpes zoster oticus) and acoustic schwannoma, as the mri findings in these entities may overlap.7,8 serology and csf findings are, therefore, crucial to attribute the mri findings to neurosyphilis. in this patient, the mri features of acute-phase neurosy philis were present, without any radiographic features of osteitis and osteolysis of the adjacent temporal bone. the pertinent radiological findings were bilateral iac gadolinium contrast agent enhancement with a mass in the left iac, involvement of both inner ears with predominance on the left and a small t1w hyperintense focus in the basal turn consistent with proteinaceous content or a gumma, and post-contrast leptomeningeal and bilateral facial nerve enhancement. these findings were concordant with previous reports and interpreted as a result of the spread of the inflammatory process via the endolymphatic and/or the perilymphatic fluids. the diagnosis of bilateral otosyphilis with early syphilitic meningitis and bilateral vestibulocochlear and facial nerve neuritis was made. a high-resolution temporal bone ct was performed six weeks post-treatment, which revealed normal bilateral temporal bones. repeat mri was unchanged. this case highlights the importance of an expeditious and correct diagnosis by a multidisciplinary team as early and prompt treatment initiation may reverse the hearing loss.9 outcome is improved for younger patients, and also if unilateral hearing loss is present for a shorter period before the diagnosis. the outcome is generally poorer in bilateral or in complete hearing loss,1 as in the presented case. syphilis affects over 30 million people across the globe. primary syphylis occurs at the inoculation site and may present as a painless macule. secondary syphylis usually occurs 4–8 weeks later and may present with a rash involving the hands and feet. if left untreated, tertiary syphylis will develop in approximately 30% of cases and mainly manifests as cardiovascular and neurosyhylis. neurological involvement may present in both the early and late stages of the disease.10 most patients diagnosed with otosyphylis are usually co-infected with hiv.11 otosyphyllis in a hiv-negative patient is thought to be rare, and there are limited recent available data on this subject. eastern and southern africa is the region in the world most affected by hiv.12 the risk of being infected with syphilis is increased in the hiv-infected patient and the progression of disease is also faster.13 both syphylis and hiv have the highest prevalence in africa, and it would therefore be expected that neurosyphyllis would not be an uncommon manifestation of syphilis in africa.14 otosyphyllis is one of the clinical manifestations of neurosyphylis,15 and clinicians should have a high index of suspicion in patients who are at risk, particularly hiv-infected patients, who present with acute auditory and vestibular symptoms. the rising incidence of syphilis in the past two decades1,9 underscores the importance of including otosyphilis as part of the differential diagnosis for acute bilateral hearing loss, regardless of the hiv status. conclusion an accurate and definitive diagnosis of otosyphilis remains challenging and should be based on clinical imaging and laboratory (serological and csf) findings.7 the presented case demonstrates how imaging findings, correlated with clinical findings and laboratory results, assisted in confirmation of the diagnosis and determining the extent of the disease. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions j.s. wrote the original draft, literature review, finalised documentation and submission, supported by s.a. and l.j.v.r. s.a. and g.v.t. attended to clinical examination and evaluation of the patient, obtaining consent and assisting in clinical aspects of writing the original draft. r.d.and l.j.v.r. were involved in interpretation of imaging, supervision of the project, review and editing of the article. ethical considerations ethical approval to conduct the study was obtained from the university of stellenbosch (c21/08/031). funding information this research work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references de goffau mj, doelman jc, rijswijk jb. unilateral sudden hearing loss due to otosyphilis. clin pract. 2011;1:e133. https://doi.org/10.4081/cp.2011.e133 neeraj nm, carr mm. sudden hearing loss [homepage on the internet]. 2019 [cited 2021 jun 10]. available from: https://emedicine.medscape.com/article/856313-overview ferit a, umur y, mehmet y, et al. simultaneous idiopathic bilateral sudden hearing loss –characteristics and response to treatment. braz j otorhinolaryngol. 2018;84(1):95–101. https://doi.org/10.1016/j.bjorl.2016.12.003 hacking c, bullen b. otosyphilis [homepage on the internet]. [cited 2021 may 21]. available from: https://radiopaedia.org/articles/otosyphilis sonne je, zeifer b, linstrom c. manifestations of otosyphilis as visualized with computed tomography. otol neurotol. 2002;23(5):806–807. https://doi.org/10.1097/00129492-200209000-00033 rasuli b, sharma r. neurosyphilis [homepage on the internet]. [cited 2021 may 31]. available from: https://radiopaedia.org/articles/neurosyphilis maeda t, yoshizawa s, hirayama t, et al. neurosyphilis mimicking ramsey hunt syndrome. j nippon med sch. 2015;82(5):254–256. https://doi.org/10.1272/jnms.82.254 iqbal s, gaillard f. vestibular schwannoma [homepage on the internet]. [cited 2021 aug 28]. available from: https://radiopaedia.org/articles/otosyphilis amidou ak, silva l, perez j. a rare cause of acute bilateral hearing loss: otosyphilis. cureus. 2020;12(10):e11243. https://doi.org/10.7759/cureus.11243 moolla y, abdul j. revisiting an old foe: the face of psychosis in neurosyphilis. s afr med j. 2016 dec 1;106(12):1186–1187. https://doi.org/10.7196/samj.2016.v106.i12.11446 mckenzie bj, loock jw. otosyphilis and hiv: therapeutic dilemma and outcome of treatment. bmj case rep. 2009;2009:bcr01.2009.1464. https://doi.org/10.1136/bcr.01.2009.1464 global information and education on hiv and aids [homepage on the internet]. [cited 2021 oct 30]. available from: https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview haule a, msemwa b, mgaya e, masikini p, kalluvya s. prevalence of syphilis, neurosyphilis and associated factors in a cross-sectional analysis of hiv infected patients attending bugando medical centre, mwanza, tanzania. bmc public health. 2020 dec 4;20(1):1862. https://doi.org/10.1186/s12889-020-09984-9 marks m, jarvis jn, howlett w, mabey dcw. neurosyphilis in africa: a systematic review. plos negl trop dis. 2017 aug 31;11(8):e0005880. https://doi.org/10.1371/journal.pntd.0005880 weder s, senn p, caversaccio m, vibert d. cochleovestibular deficit as first manifestation of syphilis in a hiv-infected patient. case rep neurol. 2013 mar 29;5(1):62–67. https://doi.org/10.1159/000350574 sajr 884 scholarship and the research environment ‘teaching is the highest form of understanding.’ (aristotle; 384 322 bc) i recently attended a two-day course entitled ‘postgraduate supervision in health sciences’ and was intrigued by the considerable number of clinical staff who were involved in demanding doctoral degree research, supervising honours and masters degree students. the new exit requirements from the health professions council of south africa (hpcsa), alluded to in a previous editorial, place additional demands on radiologists in university-affiliated hospitals functioning in resource-limited environments. despite an additional limited commodity (the research supervisor), original work is consistently produced and submitted to the sajr, and other international journals, for consideration; this is a reflection of the practitioners’ dedication to scholarship. the american educator, ernest leroy boyer (1928 1995), president of the carnegie foundation for the advancement of teaching, classified four types of scholarship (viz. discovery, integration, application and teaching) in his report scholarship reconsidered: priorities of the professoriate. 1 the four domains of scholarship proposed by boyer described how the separate functions created a dynamic whole. the identification of teaching as scholarship allowed teaching to receive institutional recognition and gave rise to the scholarship of teaching, or scholarship of teaching and learning (sotl),2 as an essential activity in universities. although teaching today may at times be considered routine and yet another inconvenient duty, when defined as scholarship, teaching both ‘educates and entices future scholars’.1 it is this opportunity that is afforded to academics involved in supervising masters degree students. the supervisor must be well-informed. at times, the process of guiding a student may seem a selfless endeavour, but it also allows a supervisor to gain knowledge and take pride in the student’s success. sajr editorial board i am delighted to welcome dr farhana suleman to the editorial board, which operates to assist the editor in the manuscript adjudication and editing processes. dr suleman is a fulltime radiologist at steve biko hospital. her willingness to be involved reflects her dedication to scholarship and the radiological literature. razaan davis editor 1. boyer el. scholarship reconsidered: priorities of the professoriate. new york: the carnegie foundation for the advancement of teaching, 1997. 1. boyer el. scholarship reconsidered: priorities of the professoriate. new york: the carnegie foundation for the advancement of teaching, 1997. 2. hill pal. twenty years on: ernest boyer, scholarship and the scholarship of teaching. http://www.teaching-learning.utas.edu.au (accessed 25 april 2013). 2. hill pal. twenty years on: ernest boyer, scholarship and the scholarship of teaching. http://www.teaching-learning.utas.edu.au (accessed 25 april 2013). s afr j rad 2013;17(2):50. doi:10.7196/sajr.884 sajr 794 editorial presidential review of 2012 we live in complex, changing and challenging times. the leaders of our country are trying to manage a somewhat troublesome adolescent stage of our new democracy, while at the same time we are feeling the effects of a fragile international economy. the health industry in south africa is witnessing changes in both the public and private sectors. the national department of health has been tasked by government with the introduction of a national health insurance plan against a background of limited resources. the private health sector is facing a widening gap between the cost of providing a continued high level of healthcare services and the real, or alleged, ability of medical scheme members to pay for the services. against this background, i report on the activities of the rssa over the last 12 months. the society proudly represents over 95% of the registered radiologists in south africa, namibia and botswana. we have received a request from the association of radiologists and radiotherapists of zimbabwe for member status of the rssa for their diagnostic radiologists. this request will be tabled at the next council meeting in early 2013, and i have no doubt it will be approved in principle, after which the necessary amendments to our constitution will need to be drafted. the council is the policyand decision-making arm of the society, and in recent times has met once a year. between council meetings, the work of the rssa is done and managed by the executive committee, special interest groups and sub-committees, with assistance from the medical director and the secretariat. election of office bearers is held biennially, with the next election to be held in 2013. membership at this stage, there are 690 paid-up members of the rssa, of whom 90 are in government employment, 400 in private practice, and 70 retired/overseas members, and it is pleasing to note there are 130 registrar members. i thank all members for their continued financial contribution to the running of the business of the rssa. the annual subscriptions are not insignificant, but the role played and status acknowledged in the corridors of the health industry in south africa bear witness to the value that is added by the society. international affiliation the rssa is enjoying increased affiliation with international counterparts. we continue to be members of the international society of radiology and enjoy the ongoing gorad co-operation. the rssa is now also an official member of the african society of radiology. the aims of the asr are ‘to encourage and promote the development of radiology in africa, this being achieved through several activities such as meetings, publications, exchanges, prizes, bursaries, missions and any other adopted way’. recent activity and participation has been by savvas andronikou in egypt and thami mngoma in kenya. we continue to enjoy our association with the european society of radiology, and i am pleased to report that professor gabriel krestin, president of the esr, attended the rssa-saspi meeting in sandton. esr has generously opened up their educational programmes to the rssa. our society has been invited to present ‘ecr meets south africa’ at the 2013 ecr. a sub-committee headed by zarina lockhat is arranging the marketing and related activities. attendance by south africa radiologists at ecr in 2013 is encouraged. we are now a member of the america roentgen ray society global partnership, and the rssa receives and distributes to members one electronic american journal of radiology article per month. the arrs selects one article from each sajr and reviews it for possible inclusion in an issue of the ajr. under the auspices of the cme association, we are affiliated to the visiting professors program of the medical imaging partnership. academic training we have 10 teaching campuses in south africa, providing formal training of radiologists. on average, approximately 30 registrars qualify each year and, at any stage, about 150 registrar radiologists are undergoing training. under the guidance of coert de vries, our academic representative on council, a unified curriculum has been established and, although not yet formally adopted, it is used as a guideline by the universities. the quality of training of our new radiologists remains the cornerstone of continued value added by our profession in the medical work-up of patients, and our thanks and appreciation go to all our colleagues who have dedicated their careers to the teaching of others. special thanks to professor savvas andronikou who is president of the college and plays a significant role in teaching and initiating registrar research. continuing medical education leon janse van rensburg, the congress chairman of the rssa, needs no introduction. the rssa–saspi congress was one of the most successful to date, and we again have the privilege of attending another world-class radiology congress. while the society has for many years arranged local congresses for the radiology community, it is over the last 5 years that leon has taken this portfolio to a level that is the envy of most countries and radiology societies the world over. for all the right reasons, congress activities are now housed in a separate legal entity — the rssa-cme association, a not-for-profit organisation — meaning that any surplus funds generated by cme activities are used only to further its clear objectives. our radiological society is a beneficiary of the cme association in that we benefit from the latter’s activities. the cme association is managed by its designated ‘founders’: leon, zarina lockhat, johan basson and thami mngoma. thanks and congratulations to leon and his committee for the tireless, outstanding and selfless effort they put into arranging the cme activities. south africa journal of radiology our own journal, with 4 editions published per annum, continues to showcase important research and enlightening cases from both the academic and private sectors. editor jan lotz works tirelessly to ensure the high quality of the journal, and this year was joined in his efforts by sub-editor dr razaan davis. the journal is published by the sama-affiliated health and medical publishing group, who take the financial risk and reward of the publication. there are now 4 international advisers to the sajr, who give positive feedback, noting however that we need to improve the ratio of research articles to case reports. the affiliation with the gorad initiative of the isr has increased the exposure of the journal. the current journal size of 40 pages is optimal and can be maintained. the journal is sent out to 650+ members of the rssa free of charge. a big thank you to jan for his continued editorship of our journal. the government sector the government has instructed the national department of health to proceed with the implementation of national health insurance (nhi). the provision of healthcare services to the uninsured population in many parts of the country is sub-optimal, with severe shortages of basic facilities and trained management, systems and staff. we agree that the government must embark on a programme to uplift the provision of healthcare to those reliant on state services, but urge the government to ensure that any new interventions are achievable, affordable and sustainable. the first phase of the nhi initiative started this year and includes an audit of state healthcare facilities and resources, and the development of policy and legislative reform. also included is a pilot project that will see the introduction over the next 5 years of primary healthcare programmes in 10 of the poorest and most underserviced areas around the country, selected because most of them have no access to basic services such as piped water, electricity and refuse removal. the minister of health has advised that the focus of all these interventions is to ensure that south africans have access to quality health services, and experience a reduction in the burden of disease, particularly that borne by women and children. the rssa submitted comment on the green paper in december 2011, and is now in the process of forming a nhi sub-committee to work with, and make further proposals to, the government nhi policymakers. health professions council of south africa the exco has over the last 2 years intervened in and halted a process at the hpcsa that would have seen permission granted for other specialists to own and operate imaging equipment, and formally provided a report on the findings. upon request of the hpcsa, the rssa has recently tabled policy guidelines for radiographers performing iv cannulation under the responsibility of a radiologist, as well as policy documents on mammography and ct scanning. the rssa issued a formal complaint to, and is still waiting for, the hpcsa to take action in respect of its own findings regarding a breast surgeon reporting on mammography examinations on equipment owned by him. imaging guidelines the rssa concluded an agreement with the american college of radiology to use and amend the acr appropriateness guidelines for radiology for local conditions and local distribution. the content has been converted into an interactive electronic format, and a web link has been distributed to the funders and members of the society. the guidelines give both clinical and billing appropriateness ratings. coding and tariffs as you are all aware, there is currently no officially published coding structure or related ‘reference price list’. owing to court action, and scrutiny by the competition commissioner, the department of health has ceased to be the custodian of the reference price list (rpl). the industry is still using the coding structure developed in 2004, which is clearly outdated and in many cases no longer properly reflects imaging practice. over the last 2 years, the medical aids have announced their own individual tariff increases, and practices now have to deal with an ever-increasing complexity of prices and benefit structures. we are hamstrung by the rules of the competition commissioner and may not enter into any collective bargaining arrangements. it is our view that the absence of a rpl and an up-to-date tariff coding structure is counter-productive to properly priced medical services, and we await the outcome of the minister of health’s discussions with the competition commissioner in this regard. the many years of cost-based tariff determination projects have come to naught, and we look forward to having the legal framework to be able to rectify this situation in the future. the absence of a guideline tariff has created a vacuum for the hpcsa, who now have no reference for pronouncing on unethical billing. under instruction from the minister of health, the hpcsa in august this year tabled for comment a new set of ‘ethical tariffs’ which was based on the 2006 rpl (read ‘medical aid rate’) plus an incorrectly calculated inflation percentage. the rssa made a submission at a recent stakeholder meeting. the hpcsa has rescinded its decision on tariffs and the process will now restart. it is of interest to note, however, that no detailed ethical price list was tabled for specialist radiology. interaction with funders the medical director interacts with medical schemes and administrators and other funders on a regular and as-needed basis. discovery health and their administration arm have a 35% share of the market and remain the major player in the private sector funding industry. interestingly, the discovery holdings group is also the largest employer of actuaries in south africa. it therefore goes without saying that our interactions with discovery are not only the most important, but also that they are the most intricate and significant business partners on the one hand, but opponents on the other, as we as radiologists strive for best clinical care while discovery focus on ‘balancing the books’. the intended revision of coding structure and tariffs via department of health projects has not come about for reasons outlined above. to rectify the situation, partial removal of the inherent cross-subsidisation has been achieved with some of the funders in this year’s tariffs, and possibly next year as well, by applying differential increases to the high-tech and low-tech modalities. the affordability of high-tech imaging remains a concern, as well as the relatively low tariffs for general imaging and ultrasound. we continue to work on rectifying this situation. low-cost plans offered by the medial schemes are increasing in number and popularity. the insured population has increased from 7 million lives 4 years ago, to just over 8 million now. this growth has been brought about by the introduction of the low-cost plans, and the entrance of gems into the market, who have added approximately half a million previously uninsured government workers onto their medical aid, which now totals 1 million lives. the industry has seen the merger of metropolitan and momentum administrators into mmi, which now administers just over a million lives as well. consolidation of schemes and administrators is expected to continue. all medical schemes are witnessing an increase in the application of radiology — which matches international trends — and is mainly evident in ct and mri, where the major advances in technology are being made. it is unfortunate that there are currently no direct measures of what we believe are downstream savings in total medical costs resulting from the higher imaging utilisation. over the last 3 years, we have seen an increase in the detailed assessment of individual radiology claims by third-party agents or the medical schemes themselves, as well as an increase in practice billing profiling. overall practice profiling of radiology billing shows that, on the whole, most practices bill in accordance with accepted norms. the rssa cannot support unsubstantiated billing outliers and will work to ensure appropriate billing practices. payments from the compensation for occupational injuries and diseases act (coida) remain a major concern. the rssa met with the compensation fund in september as part of the annual review process, where representatives of the fund admitted that the change-over to the new sap it system had not gone as planned, and the system was not able to process in any measure iod cases from 1 october last year. the rssa has written to the compensation commissioner, urging intervention and requesting information on their plans going forward. sama and the sappf the rssa has over the last 3 years made financial contributions to the south african private practitioners forum to retain observer status. the sappf (an independent body) was formed by various specialist groups who were not satisfied that the south african medical association, and specifically its specialist private practice committee, were acting in the best interests of the specialists. the rssa remains an independent association with no formal affiliation to sama or sappf. clinical sub-groups the paediatric imaging society was formed 2 years ago at the urging of savvas andronikou, the current chairman. the committee are congratulated on their start-up and continued good work. tracy kilborn is congratulated for arranging the rssa-saspi conference in conjunction with the cme association. included in the conference pack was the ‘doc andy’ booklet, the brainchild of savvas. the rssa funded the first publication run of the booklet, and complimentary copies are being distributed to teaching hospitals and radiology practices. samsig, the musculoskeletal imaging sub-group, continues its excellent work in promoting the discipline and education of musculoskeletal imaging. samsig workshops provide a focused platform for this rapidly developing and growing sub-speciality. thank you to chairman richard de villiers and the committee for their continued commitment. sasni (south african society of neuroradiology  imaging), chaired by sally candy, was inaugurated last year. the society is very active and holds regular clinical meetings. in july, the sasni meeting in cape town was incorporated into the first rssa ‘webinar’, with 60 on-line participants from around the country. sasni is now also registered as a member of the world federation of neuroradiology societies. thank you to sally and the committee. the interventional sub-group, headed by coert de vries, meets annually to conduct important peer review. the pet-ct sub-committee challenged discovery health, via the council for medical schemes, on discovery’s abuse of the pmb regulations, and the matter was resolved in favour of the service providers. we hope that the webinar facility will encourage the activities of other groups. communication policy and decision making of the rssa is done at council level; in-between council meetings, the work is done at the executive committee level . the exco has remained unchanged for the last 4 years. debate within exco on matters to hand is robust. with the advent of electronic communication, the reliance in earlier years of holding face-to-face meetings has diminished, and communication on most levels within the rssa and its committees is done via email and teleconference. the rssa website has become the hub for communications to members and i have no doubt that all members are pleased with the frequency and level of communication. the constitution our constitution requires revision in many areas. electronic communication makes superfluous the requirements for dormant regional sub-groups of the rssa and related face-to-face meetings, each with their own committee structure. proper and regulated succession planning for the ex officio posts should be included in a revised constitution. this is work for the year ahead. secretary and secretariat patricia trietsch has sat at the secretary’s desk for 20 years. thank you, patricia, for the years of good work, for responding to the phone calls and emails, and also for attending congresses and manning the rssa desk in recent times. a&l management consultants have assisted the rssa for the last 12 years, and provide invaluable support to the exco and the medical director, and in recent times to the rssa cme association as well. trevor allnutt and jako calitz are well-versed and -experienced in a broad range of radiology matters and provide input at many levels. jako has been driving electronic communication of late, and we have all witnessed the increased communications via the website and the implementation of webinars for on-line workshop attendance. emails in and out of the secretariat exceed 500 per week, excluding bulk email communications to members, which average close to 1 per day. they administer too all financial aspects of the rssa and the cme association including tariff calculation work when necessary. in the last 2 years, the administration of the cme association has been added to their activities. they have worked closely with the medical director and congress chair for many years, and their skills and understanding of all aspects of society work is significant. their workload is growing, and they have increased their own support staff. a big thank you to trevor and jako and their team.  medical director bates alheit has held the post of medical director of the rssa since its inception in 2004. he has given notice that he will not be available for the post after january 2013. the post has been advertised via the website, and interested persons are invited to apply via the rssa office. we all need to takes our hats off and say a very big thank you to bates for the exceptional effort and good work that he has done on behalf of the members of the rssa, and the radiology community at large, for so many years. i cannot do proper justice in this review in thanking bates for the years of dedicated, selfless service. bates became, with good reason, the face of radiology over the last decade. his knowledge of coding structures and tariffs, of technology and good clinical practice, his understanding of the bigger picture, his empathy for others, while at the same time having the courage to tackle what he knows is wrong, and his presence, in the moment and behind the scenes, has helped to place radiology very firmly as a respected discipline in the south african medical landscape. bates, we thank you for all you have done for the profession, and wish you well in your retirement in this part of your career. in conclusion i stated at the beginning that we are experiencing changing times. education in this county is at a cross-roads at the undergraduate level, and our academic departments and teaching hospitals will, i am sure, meet the challenge of ensuring that the quality and quantity of trained radiologists is at the required level to meet the desperate need for imaging resources in both the public and private sectors. we all need to embrace whatever form the national health insurance will take. the current ratio of radiologists to the population does not support a healthy country, and we will no doubt all need to give, in the true sense of the word, in time and effort, until that ratio is corrected. academic programmes must continue to be supported by our world-class continuing medical education activities, at the cme association level, the clinical sub-group level, and with the continued publication of the sajr. keep up the good work. medical schemes remain the lifeblood of private practice. we need to partner with them, and at the same time challenge them, to ensure that our patients and their members receive appropriate clinical care while at the same time ensuring the sustainability of our cost-intensive practices. communication remains the key to any successful organisation. there will always be room for improvement. communication is a two-way process and made so much easier in today’s electronic environment. i encourage all members to contact the rssa executive, committees, sub-groups and the secretariat regularly and on any matter. by hearing from you, we can improve the service to you. my thanks again to bates alheit for his years of dedicated service on our council and as medical director of the rssa. my sincere thanks also to council members for their continued contribution, and special thanks to our executive committee members: vice president: sheldon godinho for his continued input in robust debate past president: richard tuft for his experience and governance role secretary: mark velleman for his work as secretary and as vice chair of samsig treasurer: thami mngoma for his experience and urging to keep the spirit of ubuntu alive at exco member without portfolio: ashesh ranchod for his continued voice of reason glen buchanan for representing gauteng radiologists academic representative: professor coert devries for academic input and reason congress chair: professor leon janse van rensburg again for his internationally recognised efforts in bringing us world-class congresses. 2013 will be another rssa election year, and i will not be standing again for president. i urge members interested in the work and governance of the rssa to put their names forward for office. we need member involvement to determine the future direction of the society, and we need those who are prepared to serve in official positions to volunteer. may i wish all rssa members in private and public posts success in 2013. clive sperryn (president, rssa) tips for the radiologist dorsal dermal sinus diagnose a dorsal dermal sinus if the following findings are present: (t) a tract that connects the skin to the intracanalicular space which may be median or paramedian; this may communicate with the subarachnoid space; 1 and (it) an associated lipoma, epidermoid or dermoid with the sinus tract. i conclusion high-resolution spinal ultrasound is a valuable means of diagnosing suspected occult spinal dysraphic lesions in neonates and infants before the posterior spinal elements ossify. ultrasound has numerous advantages: it is portable and available with high-resolution capabilities, it is safe and requires no sedation, and it is relatively inexpensive. when findings are confusing, abnormal or equivocal, then mr! must be performed to delineate the pathology more accurately. references 1. korsvik h, kellerm. sonography of occult dysraphism in neonates and infants with mr imaging correlation. radiographies 1992; 12: 297-306. 2. nelson m jun. ultrasonic evaluation of the tethered cord syndrome. in: yamada s, ed. tethered cord syndrome. american association of neurological surgeons publications committee, 1996. 3. hinshaw d jun., engelhart j, kaminsky c. imaging of the tethered spinal cord. in: yamada s, ed. tethered cord syndrome. american association of neurological surgeons publications committee, 1996. hypertrophic pyloric stenosis •an overview h grove nst. cert. rsd. ultrssound department of paediatric radiology, red cross war memorial children's hospital, university of cape town and institute of child health definition the term hypertrophic pyloric stenosis (hps) refers to hypertrophy of the circular muscle of the pylorus that can cause obstruction (hpo). clinical findings clinical findings include the following: (i) non-bilious projectile vomiting; (it) peristaltic waves that can be seen travelling across the left upper quandrant to the right and terminating beyond the midline; i (iii) a palpable 'olive' (pseudotumour) over an empty stomach;' (iv) age typically 2 8 weeks; (v) male-to-female ratio 5:1; (vi) uncommon in black patients; (vit) often the male offspring of an affected mother; (viii) gastric residual > 10 ml;' and (ix) an association with oesophageal atresia.' plain film findings plain film findings include the following: (i) gastric dilatation; (ii) paucity of small bowel and colonic air; (iii) frothy gastric contents; (iv) absence of an air-filled duodenal bulb; (v) gastric pneumatosis; and (vi) normal appearance. 48 sa journal of radiology. october 2001 ultrasound technique a high frequency transducer (7 mhz) is used, preferably a linear or vector probe (acuson 128 xp/lo). with the patient in the supine position start off scanning in the longitudinal section until the gall bladder is located,' the 'olive' of the hypertrophied musculature should be located medial to it. visualisation is good when the 'olive' has a foreshortened appearance (fig. i). the transducer now has to be rotated and angled so that it is aligned with the long axis of the channel (fig. 2). on this view, the beak sign can be identified as on a contrast meal. if the stomach is too full, the channel is distorted and accurate measurements won't be possible. in such a case a nasogastric tube can be passed to empty some of the contents. once the long axis is obtained, one should note the position of the transducer and turn it 90 degrees. this way the bull's eye of the pyloric channel can be identified end-on (fig. 3). tips for the radiologist fig. 1. obvious foreshortening of the pyloric channel (cursors indicate the superior muscle thickness adjacent to the gall bladder) (arrow). fig. 2. the long axis of the pyloric channel is the longest length that should be obtained. (gib '" gall bladder. st", stomach, x's define the pyloric diameter. +'s define the muscle wall thickness). measurements at the red cross war memorial children's hospital the following measurements are used: (lj > 4 mm muscle thickness; (ii) > 12 mm diameter (this includes two muscle walls and mucosa); and (iii) > 14 mm length (up to 26 mm). fig. 3. the bull's eye view of the pyloric channel in its short axis (x's define the pyloric diameter. +'s define the muscle thickness). the rule of thumb is 5, 15 and 20 mm. if there is uncertainty the pyloric index can be worked out. pyloric index the pyloric index may be calculated as follows: pyloric index = wall thickness x 2 x 100 maximum diameter values greater than 50% and wall thickness 4 mm or more indicate hps. values less than 35% and wall thickness 1 3 mm indicate the absence of hps. values greater than 50% and wall thickness 3 4 mm are equivocal for hps and should be followed up. recommendations although the patient can be scanned in the decubitus position, right side down,' we have been performing the study in a supine position at our institution. glucose water can be given to evaluate antral emptying, but we haven't been finding this necessary. conclusion while the upper gastro-intestinal (vgl) series has been found to be less expensive than ultrasound," the latter does not involve ionizing radiation and is a way of examining the pyloric muscle directly, rather than indirectly as in the vgl series. references 1. vw hilton s. edwards dk. practical pediatric radiology. 2nd ed. philadelphia: wb saunders. 1994: 303. 2. white mc. langer jc. don s. de baun m. sensitivity and cost minimization analysis of radiology versus olive palpation for the diagnosis of hypertrophic pyloric stenosis. j pediatr surg 1998; 33: 913-917. 3. finkelstein ms. mandell ga. tarbell k. hypertrophic pyloric stenosis: volumetric measurement of nasogastric aspirate to determine the inlage modality. radiology 1990; 177: 759-761. 4. kilic n. gurpinar a. kiristioglu t, dogruyol h. association of oesophageal atresia and hypertrophic pylorie stenosis. acta paediatr 2000; 89 (1):118-119. 5. teele rl. share j. gastro-duodenal ultrasonography. in: bradlaw l. ed. ultrasonography of infants and children. philadelphia: wb saunders. 1991: 351. 6. olson ad, hernandez r. hirsch] rb. the role of ultrasonography in the diagnosis of pylorie stenosis: a decision analysis. j pediatr surg 1998; 33: 76-681. 7. huike f.campbell jr. harrison mw. campbell tj. cost-effectiveness in diagnosing infantile hypertrophic pyloric stenosis. j pediatr surg 1997; 32: 1604-1608. 49 sa jou rnal of radiology • october 2001 abstract introduction case presentation discussion conclusions acknowledgements references about the author(s) sheree c. gray department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa jacobus a. pienaar department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa zelia sofianos department of radiology, faculty of radiology, university of the witwatersrand, johannesburg, south africa jacob varghese department of radiology, faculty of radiology, klerksdorp/tshepong hospital complex, klerksdorp, south africa citation gray sc, pienaar ja, sofianos z. & varghese j. complicated spontaneous pneumoparotid mimicking a neck mass in a child with down’s syndrome. s afr j rad. 2020;24(1), a1883. https://doi.org/10.4102/sajr.v24i1.1883 note: special collection: paediatric radiology. case report complicated spontaneous pneumoparotid mimicking a neck mass in a child with down’s syndrome sheree c. gray, jacobus a. pienaar, zelia sofianos, jacob varghese received: 21 mar. 2020; accepted: 08 may 2020; published: 13 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract spontaneous or self-induced pneumoparotid, which usually manifests as acute unilateral gland enlargement, is caused by insufflation of air from the oral cavity via stensen’s duct. a 9-year-old patient, with known down’s syndrome, presented with a progressively enlarging, painless, spontaneous, left neck mass. computed tomography showed features consistent with pneumoparotid, without underlying associated pathology. identification of true cases of spontaneous pneumoparotid is crucial, as these require a holistic management approach to prevent recurrence and complications. keywords: pneumoparotid; spontaneous; self-induced pneumoparotid; stensen’s duct; paediatric population. introduction self-induced or spontaneous pneumoparotid, usually manifesting as acute unilateral enlargement of the parotid gland, is caused by the insufflation of air from the oral cavity via stensen’s (parotid) duct. it is a rare but well-described condition and should be considered in cases of unexplained parotid swelling. occasionally, this phenomenon may only be detected on investigation of associated complications, making clinical diagnosis challenging. often, the condition will only be diagnosed after radiological imaging. given that conservative management and behavioural modification is the mainstay of care in uncomplicated cases, accurate and timely radiological diagnosis is essential to prevent unnecessary surgical intervention and guide appropriate management of subsequent complications. case presentation a 9-year-old female patient, known with trisomy 21, presented to the ear, nose and throat (ent) clinic with a large left-sided neck mass; this mass was progressively enlarging over a period of 1 month and began as a painless and spontaneous swelling. other than the pre-existing genetic anomaly, the child was healthy and thriving and had no documented medical co-morbidities, nor any history of recent dental procedures or hospitalisations. clinical examination revealed a firm, non-tender mass lesion on the left side of the neck, extending from below the pinna of the left ear to the submandibular region. systemic examination was otherwise unremarkable, with no fever or other features of septicaemia. the overlying skin was intact, and no lymphadenopathy was palpable. perfunctory ent and oral examination were normal. fine needle aspiration of the mass was attempted at the ent clinic whilst awaiting laboratory results and radiological investigations, in an attempt to expedite the diagnostic process and to exclude sepsis. only air was obtained. there was temporary subsidence of the mass post-aspiration, but it reformed within 24 h. clinical assessment clearly suggested local surgical emphysema. expeditious delineation of the cause and extent of the process was crucial, prompting the referring clinician to request a computed tomography (ct) scan of the head and neck to further delineate the lesion. whilst awaiting imaging in the radiology department, the patient was observed to be voluntarily blowing up her cheeks and making other uncharacteristic buccal and facial movements. non-contrast ct of the head and neck (performed with the patient under conscious sedation) demonstrated a circumscribed focus of subcutaneous surgical emphysema overlying the left parotid gland (figure 1). no complex fluid content or surrounding inflammatory changes were present to suggest abscess formation. gas was noted within the ductal system of the parotid gland (figure 2) as well as intraductal gas following the trajectory of the left stensen’s duct (figure 3). the right parotid gland and associated ductal system were normal. figure 1: axial non-contrasted computed tomography demonstrates a large, multiseptated focal collection of gas in the subcutaneous tissue overlying the left parotid gland (white arrowhead). underlying communication with branching gas pattern in the ductal system of the left parotid gland is shown (black arrow). no gas is present in the parapharyngeal fat space or deep neck spaces. figure 2: magnified axial non-contrasted computed tomography with soft tissue window again demonstrates the gas-filled branching parotid ductal pattern (white arrow). the left parotid gland appears otherwise morphologically normal, with no features of inflammation. figure 3: magnified axial non-contrasted computed tomography demonstrating gas in the mildly distended left stenson’s (parotid) duct (black arrowhead). no fluid collections or masses of the head or neck were observed. furthermore, there was no gas identified in the floor of the mouth, parapharyngeal spaces or deep soft tissue spaces of the neck. no foreign bodies or sialolithiasis was evident. the oral cavity, pharynx, larynx and trachea were unremarkable. the visualised lung apices and upper mediastinum showed no pneumothorax or pneumomediastinum. these imaging features are consistent with pneumoparotid, complicated by capsular perforation and overlying localised subcutaneous surgical emphysema, in the absence of underlying associated pathology. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. discussion pneumoparotid refers to the abnormal presence of air within the ducts and acini of the parotid gland and occurs when intra-oral pressure overwhelms the usual protective mechanism of the meatus of stensen’s duct.1 since the initial report of air in the parotid gland by hyrtl in 1865, a spectrum of different terminology has been used to denote the condition, including ‘pneumoparotitis’, ‘pneumoparotiditis’, ‘pneumosialoadenitis’, ‘wind parotiditis’, ‘anesthetic or surgical mumps’ and ‘pneumatocele glandulae parotis’. current consensus is that the term ‘pneumoparotid’ should be used in the absence of inflammatory changes of the gland and ‘pneumoparotitis’ should be used in the presence thereof.2 the pathogenesis of pneumoparotid starts with an abnormal increase in pressure in the oral cavity, which is normally as low as 2 mmhg – 3 mmhg. this rise in oral pressure leads to the reflux of air into stensen’s duct and subsequently into the ductal system of the parotid gland. if the intraductal pressures become sufficiently high, breakdown of glandular tissue can occur, leading to leakage of air into the surrounding soft tissue spaces and surgical emphysema if perforation of the parotid fascia occurs. infrequent complications that can develop in the setting of large volume or continuous leakage of air from the gland are pneumomediastinum, pneumothorax and airway obstruction because of focal collections of air. in addition, oral bacteria may also reflux, predisposing to recurrent episodes of parotitis, termed ‘pneumoparotitis’, which can lead to ductal ectasia if chronic, or associated abscess formation.2,3,4 the aetiology of pneumoparotid is commonly divided into occupational and non-occupational categories. occupational causes are most commonly glassblowing or the playing of wind instruments (which can increase the intra-oral pressure to more than 150 mmhg), as well as during rapid compression manoeuvres in scuba divers. non-occupational causes are commonly iatrogenic, associated with dental procedures (in which devices powered by compressed air are used), and following anaesthesia, if the patient coughs during extubation while simultaneously receiving positive pressure ventilation. cases of pneumoparotid post-pulmonary function testing have also been described. pneumoparotid as a consequence of facial trauma is commonly encountered.3,4 a phenomenon which is much less commonly documented is spontaneous pneumoparotid or self-induced pneumoparotid. in rare instances, this may be identified as the underlying primary cause and as a result of auto-insufflation of the gland. in the paediatric population, auto-insufflation is the most common cause of pneumoparotid.4 spontaneous pneumoparotid has been described after innocuous and common activities such as blowing up balloons, chewing gum, nose blowing or coughing, which are seen more frequently in individuals with underlying pathology such as cystic fibrosis. self-induced pneumoparotid has also been reported in conjunction with psychiatric and psychosomatic disorders or because of an unintentional adjustment reaction to achieve secondary gains (such as avoiding school), especially in adolescents.2,3,4 usually, inherent protective anatomical mechanisms are in place to prevent reflux from the oral cavity into the parotid glands, including mucosal folds that seal off the ductal orifice, the small diameter of the ductal orifice itself and contraction of the buccinator muscle to close the duct. it has been proposed that in children stensen’s duct has a more perpendicular insertion into the buccal mucosa than in adults, in whom the angle of insertion is more acute posteriorly. this allows a buccal mucosal fold to provide improved protection in adults against the retrograde air travelling in stensen’s duct when intra-oral pressure is increased.5 underlying anatomical abnormalities such as ectasia of the parotid duct, buccinator muscle weakness or masseter hypertrophy may predispose to the development of pneumoparotid.3 mild cases of spontaneous pneumoparotid may go completely unnoticed unless complications occur. the condition may have a chronic course with intermittent, short-lived episodes of painless or painful parotid swelling, which may become evident on clinical history. visualisation of an oedematous stensen’s papilla, air bubbles coming from stensen’s duct or foamy saliva after parotid gland massage and crepitus upon cheek or gland palpation may be identified with careful and thorough clinical examination.3,4 imaging can establish the diagnosis and delineate associated complications. plain film and fluoroscopic studies will likely be normal or demonstrate only complications such as surgical emphysema or pneumothorax and may not be sufficient to delineate the underlying cause.2 ultrasound, as a first line of radiological investigation in the paediatric population, is a valid consideration because it will demonstrate air bubbles as intraductal, mobile, comet-tail artefacts. high-frequency ultrasound may be useful in delineating potential associated ductal alterations and calculi. colour doppler may demonstrate hypervascularity with parotitis.6 however, the extent, distribution and origin of the gas, as well as concurrent deep compartment complications, may not be readily apparent, and interpretation of the study may somewhat depend on the operator. non-contrast ct is especially useful in this setting to demonstrate both air in the parotid gland and associated complications, whilst also ruling out underlying sialolithiasis. magnetic resonance imagining (mri) may show associated signal changes in the parotid gland related to complications, but air may not be easily identified.6 chronic pneumoparotitis is usually associated with ductal dilatation and stricturing because of associated episodes of bacterial superinfection. in this instance, sialography typically shows a markedly dilated stensen’s duct, but the use of invasive tests is discouraged because of potential complications.3 in most cases of spontaneous uncomplicated acute pneumoparotid, salivary gland enlargement resolves spontaneously within 1–3 days, with conservative management yielding good results. yet, in paediatric cases – as described above – treatment of the underlying cause for the abnormal buccal manoeuvres which result in the auto-insufflation may be very challenging as the patient’s understanding may somewhat be limited.3,4 alternate treatment options such as antibiotics, anti-inflammatory drugs, glandular massage or sialogogues are usually reserved for cases with confirmed complications, such as sialadenitis. in the event that conservative measures fail, surgical intervention should be considered. several surgical treatment options have been suggested for chronic and recurrent pneumoparotid, such as transposition of stensen’s duct to the tonsillar fossa, ligation of the duct or superficial parotidectomy if chronic or recurrent infection occurs.2,3 conclusions pneumoparotid and its associated complications can be accurately diagnosed radiologically, and ct should be considered as the initial investigation of choice. however, especially in the paediatric population, detailed history-taking and clinical assessment remain imperative to rule out any underlying causes. this allows for the identification of true cases of spontaneous pneumoparotid, which require a more holistic management approach based on behavioural modification and psychotherapy. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.c.g. made a substantial contribution to the conception and design, drafting and revision of the article. j.a.p. made a substantial contribution to the conception and design, acquisition of data, literature review and imaging of the article. z.s. made a substantial contribution to the literature review and drafting of the case report. j.v. made a substantial contribution to the conception and design, revision and approval of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references goguen la, april mm, karmody cs, carter bl. self-induced pneumoparotitis. arch otolaryngol head neck surg. 1995;121(12):1426–1429. https://doi.org/10.1001/archotol.1995.01890120082017 house l, lewis a. pneumoparotitis. clin exp emerg med. 2018;5(4):282–285. https://doi.org/10.15441/ceem.17.291 lagunas j, fuertes a. self-induced parapharyngeal and parotid emphysema: a case of pneumoparotitis. oral maxillofac surg cases. 2017;3(4):81–88. https://doi.org/10.1016/j.omsc.2017.06.002 faure f, plouin gaudon i, tavernier l, ayari khalfallah s, folia m. a rare presentation of recurrent parotid swelling: self-induced parotitis. int j pediatr otorhinolaryngol extra. 2009;4(1):29–31. https://doi.org/10.1016/j.pedex.2008.05.004 som pm, curtin hd. chapter 40: anatomy and pathology of the salivary glands. in: gaertner r, barnes l, editors. head and neck imaging. 5th ed. mosby: elsevier, 2003; p. 2520. potet j, arnaud f, valbousquet l, et al. pneumoparotid, a rare diagnosis to consider when faced with unexplained parotid swelling. diagn interv imaging. 2013;94(1):95–97. https://doi.org/10.1016/j.diii.2012.04.015 board exams.html board exams for south african radiology registrars: the playing fields are leveling the introduction of a single exit exam for all medical specialties is welcome and addresses the perceived incongruence between the examinations offered by the college of radiologists and the various universities in south africa. till now, the dual system in place has caused significant debate and offered examination candidates an alternative route for obtaining a degree acceptable to the health professionals council of south africa (hpcsa) allowing independent specialist practise. supporters of the university-based master of medicine (mmed) examinations have in the past consistently maintained that the standards of their examinations have been high, and possibly even of a higher standard than the college examinations. more importantly, however, the mmed examinations with the addition of a research component qualified for a government subsidy and often resulted in the only radiology research conducted in the country. lastly, the mmed examinations were often conducted in afrikaans, which gave afrikaans-speakers an equal opportunity. on the other hand, the ‘internal’ nature of the mmed examination lent itself to severe criticism, with allegations of leniency towards poor candidates. even with inviting an external examiner, the locally based examination, the weighted examination panel, internal convener and local examination material would create a particular style of examination that would sometimes not be considered unbiased. visiting examiners would also tend to be chosen from other universities offering the mmed examinations because of the convenience of reciprocating, and also because of the ability of those examiners to examine in afrikaans. complex scenarios would arise where a candidate failing the college examination would then attempt the local mmed examination. whether the candidate was better prepared for the second exam or happened to fare better ‘on the day’, would be ignored in favour of the supposition that the mmed examination was of a lower standard – a plainly unfair but unavoidable assumption. in response, some universities offering an mmed exam would set a more difficult exam or sometimes prevent a poor candidate from sitting the college examination for fear of this scenario discrediting their local examination. i personally am aware of 4 candidates who were prevented from sitting the college exam because they were not as well prepared as their local contemporaries, who were allowed to sit the college exam. the college of radiologists has been well positioned to take on the role of an independent examining body hosting a national single-exit examination, and has been awarded this responsibility. the college councils and examiner boards, however, are made up of heads of department and examiners who hail predominantly from the universities around the country. the individual colleges must therefore be careful not to replicate the mmed scenario, where examiners at a particular examination centre location originate from that very site or its close affiliates (e.g. pretoria with medunsa; stellenbosch and uct). the college of radiologists has recognised this (through previous experience) and opted to modify its examination process to include examiners from all universities and some from private practise at every examination, regardless of the location of the examination centre (at the significant cost of flying all of them to the examination centre). offering the examination in afrikaans is more of a problem than a solution. it begs the question ‘why is the exam not in other languages spoken by the majority of the south african population?’ the examination is best conducted in english, an international language widely spoken in south africa and the language in which most radiology textbooks currently in use in south africa are written. the strategic step of making a research component a prerequisite for registering as a specialist with the hpcsa lays to rest the argument of qualifying for government subsidies. the universities can now provide the infrastructure to produce mmed research which, together with the single-exit examination, qualify for an mmed degree, and therefore a subsidy. this is a greatly welcome mechanism of forcing research back into the training environment and into candidate registrars’ minds. there are significant challenges for meeting the new requirements. the college has to now demonstrate its ability to host a national exam in an independent and unbiased manner. it must also invest in modern examination techniques including digital platforms, internationally recognised examination methods, and a well trained and expanded examiner panel. universities also have significant challenges in providing training to ensure success of their candidates in an examination that will be perceived as a measure of the quality of training. furthermore, those universities without a research history will have to invest time, human resource and possibly money to provide the infrastructure for research. the main challenge for them will be to find adequate supervisors and mentors. registrar candidates will have to juggle their time to be able to learn ever-increasing radiological information and gain the experience required to practise independently while making time for their research component. the college applications to extend radiology training to a 5-year programme have gone unrewarded by the governing body. to compensate, the college has provided a part i examination that can be taken prior to entry into the registrar programme. this allows prospective registrars an opportunity to prepare themselves for the registrar programme, gives successful registrar applicants added credentials for being selected into a programme, and provides universities with candidates with proven track records who are ready to start preparing for part ii over a full 4 years. i am extremely confident that this is the correct way towards producing top-notch radiologists who have been adequately examined in an unbiased fashion. i am also excited at the future, which promises to yield a plethora of radiological publications emanating from local material. i look forward to having radiological leaders who work together under the banner of the college of radiology of south africa and alongside the radiological society of south africa, to secure our future. professor savvas andronikou department of radiology, university of the witwatersrand president of the college of radiologists of south africa chairman of the south african society of paediatric imaging case report abstract brown tumours are the end stage of primary or secondary hyperparathyroidism. clinically, brown tumours most often manifest as slowly growing, painful masses. these tumours can behave aggressively and be destructive. we report a patient with high accumulation of fluorodeoxyglucose (fdg) positron emission tomography/computed tomography (pet/ct) in brown tumours as the potential cause of false-positive results in the evaluation of a patient for malignant primary tumour or metastases. case report a 49-year-old man came to the hospital with a long-term history of painful right lower leg after trauma. the initial examination was unremarkable. x-ray of the right tibia demonstrated a cystic lesion in the middle third. magnetic resonance imaging (mri) demonstrated a t1-hypointense mass lesion with significant enhancement in the subcortical medulla with scalloping of the internal cortical rim. the t2-weighted images demonstrated a hypointense aspect of the centre of the lesion with some hyperintensity around the lesion. in the differential diagnosis chondromyxoid fibroma and osteitis fibrosa cystica were considered (figs 1 a & b). tc-99m methylene diphosphate (mdp) bone scintigraphy revealed abnormal uptake in the right tibial diaphysis, the proximal femur bilaterally, the sacrum and the right acetabulum. the multifocality on bone scan raised the suspicion of malignancy. the patient was referred for biopsy of the lesion in the right leg and a whole body positron emission tomography/computed tomography (petct) scan with 18f-fdg was performed. the ct scan revealed multifocal osteolytic lesions in both femora, the right acetabulum, both iliac bones, the right acromioclavicular joint and the left pubic bone (fig. 2).a nodular structure inferior to the left lobe of the thyroid gland was discovered. the pet scan showed increased fdg uptake in the osteolytic lesions (fig. 2). there was no increased fdg-uptake in the nodular structure inferior to the left lobe of the thyroid gland. the pet-ct results were in concordance with the pre-assumption of metastatic bone lesions. the biopsy results however revealed no signs of malignancy. in view of the lesion inferior to the left lobe of the thyroid, the patient was subsequently evaluated for hyperparathyroidism. his serum calcium level was 3.21 mmol/l (normal range: 2.10 2.55 mmol/l). his alkaline phosphatase concentration was 241 iu/l (normal range: 40 150 iu/l), and his parathyroid hormone level was 682 pg/ml (normal range: 12 72 pg/ml). tc-99m methoxy isobutyl isonitrile (mibi) parathyroid scintigraphy revealed a parathyroid adenoma inferior to the left thyroid lobe (fig. 3) and ultrasonography showed a 6 × 9 mm nodule of the inferior left parathyroid gland. parathyroidectomy was undertaken and histopathological examination revealed the presence of a parathyroid adenoma. postoperatively, plasma parathyroid hormone and calcium levels normalised. based on these results, the osteolytic fdg avid bone lesions were classified as multiple brown tumours caused by primary hyperparathyroidism. discussion this case demonstrates that increased fdg uptake in clinically occult brown tumours can be misleading in the evaluation of a patient for malignancy. kuwahara et al.1 have recently demonstrated a case of increased fdg uptake in brown tumours with primary hyperparathyroidism. brown tumours of bone or osteoclastomata are highly vascular, lytic bone lesions representing a reparative cellular process rather than a neoplastic process usually seen in patients with hyperparathyroidism with hypercalcaemia.2,3 these tumours occur less frequently than in the past, because of earlier detection of hypercalcaemia.3,4 pet/ct-positive brown tumour – a potentially misleading finding in the evaluation of a patient for malignant primary tumour or metastases m al-makhzomi,¹ md m sathekge,2 mb chb, mmed (nucl med) p seynaeve,3 md d nicolaij,¹ md a maes,¹ md, phd ¹department of nuclear medicine, az groeninge, kortrijk, belgium 2department of nuclear medicine, university of pretoria, pretoria, south africa 3department of radiology, az groeninge, kortrijk, belgium fig. 1. axial t1 (a) and axial postcontrast t1-weighted (b) mr image with fat suppression demonstrates a hypointense mass lesion at the corticomedullary junction of the tibial diaphysis. there is scalloping of the internal cortical rim without penetration of the cortex. significant contrast enhancement in the mass lesion and some reactive enhancement in the adjacent periosteum and soft tissues is noted. 103 sa journal of radiology • december 2007 pg103-104.indd 103 12/11/07 2:22:17 pm case report case report 104 sa journal of radiology • december 2007 the lesion localises in areas of intense bone resorption, and the bone defect becomes filled with fibroblastic tissue that can deform the bone and simulate a neoplastic process.5 these tumours have a brown or yellow hue.6 skeletal changes may represent the first manifestations of hyperparathyroidism, with a loss of cortical bone and an increase in trabecular bone. bone pain and arthralgia are the most common symptoms, such as in our case. brown tumours exhibit no pathognomonic histological changes. findings may include a dense fibroblastic stroma, areas of cystic degeneration, osteoid, microfractures, haemorrhage, macrophages with hemosiderin, and multinucleated osteoclastic giant cells. similar changes may occur in fibrous dysplasia, true giant-cell tumours, and reparative granulomas.5 histologically, brown tumours may be indistinguishable from giant-cell tumours of the bone, and correlation with clinical findings and imaging studies is essential in making the correct diagnosis. the presence of giant cells has been suggested as partially contributing to the high uptake of fdg in benign bone lesions such as brown tumours.7-9 another supporting mechanism for the elevated fdg uptake is that macrophages play a central role in the host response to injury, and their energy is predominantly supplied by means of intracellular glucose metabolism.10,11 in conclusion, pet-ct readers should be aware of the high accumulation of fdg in brown tumours as a potential cause of false-positive results in the evaluation of a patient for malignant primary tumour or metastases. 1. kuwahara k, izawa s, murabe h, et al. increased 18f-fluorodeoxyglucose uptake in a brown tumor in a patient with primary hyperparathyroidism. j clin endocrinol metab 2007; 92:2408-2409. 2. chew f s, huang-hellinger f. brown tumor. ajr 1993; 160:752. 3. yang c, seabold je, gurll nj. brown tumor of bone: a potential source of false-positive thallium-201 localization. j nucl med 1989; 30: 1264-1267. 4. nassar gm, ayus jc. images in clinical medicine. brown tumor in end stage renal disease. n engl j med 1999; 341: 1652. 5. keyser js, postma gn. brown tumor of the mandible. am j otolaryngol 1996; 17: 407-410. 6. friedman wh, pervez n, schwartz ae. brown tumor of the maxilla in secondary hyperparathyroidism. arch otolaryngol 1974; 100: 157-159. 7. johnston j. giant cell tumor of bone: the role of the giant cell in orthopedic pathology. orthop clin north am 1977; 8: 751-770. 8. ling l, klein mj, sissons ha, steiner gc, winchester rj. expression of ia and monocyte-macrophage lineage antigens in giant cell tumor of bone and related lesions. arch pathol lab med 1988; 112: 65-69. 9. aoki j, watanaba h, shinozaki t, et al. fdg pet of primary benign and malignant bone tumors: standardized uptake value in 52 lesions. radiology 2001 ; 219 :774-777. 10. meszaros k, lang ch, bagby gj, spitzer jj. contribution of different organs to increased glucose consumption after endotoxin administration. j biol chem 1987; 262: 10965-10970. 11. gamelli rl, liu h, he lk, hofmann ca. augmentations of glucose uptake and glucose transporter-1 in macrophages following thermal injury and sepsis in mice. j leukoc biol 1996; 59: 639-647. fig. 2. ct scan of the pelvis shows a large lytic mass associated with softtissue swelling in the left pubic bone (upper left photo: white arrow). pet scan: shows high uptake in the left pubic bone lesion (upper right photo and lower right photo: black arrow). fusion image: shows the exact site of high fdg-uptake (lower left photo: white arrow). fig. 3. tc-99m mibi parathyroid scintigraphy revealed a parathyroid adenoma in the inferior left lobe (arrow). pg103-104.indd 104 12/11/07 2:22:17 pm fetal mri.html fetal mri for characterising a variety of posterior fossa anomalies suspected on 3rd trimester ultrasound examination – a short series of 4 cases amaresh indravadan ranchod, mb bch, fcrad (d) savvas andronikou, mb bch, fcrad, frcr (lond), phd mala modi, mb bch, fcrad (d) department of diagnostic radiology, university of the witwatersrand, johannesburg corresponding author: a ranchod (airanchod@gmail.com) abstract fetal mri is increasingly being used to more accurately assess abnormalities detected on screening ultrasound. the procedure is more pertinent when the initial ultrasound is done late in the third trimester and when the abnormality involves the posterior fossa of the brain. four cases with a variety of unusual posterior fossa anomalies are presented. introduction prenatal ultrasound (us) is the investigation of choice when screening for fetal abnormalities. when an intracranial abnormality is detected on us specifically within the posterior fossa, a fetal mri is the next investigation of choice, to accurately characterise and diagnose the abnormality. in the developing world, patients often present as unbooked pregnancies in the third trimester. at this late stage of pregnancy, the sensitivity of us decreases owing to ossification of the cranium and the relative size of the fetus compared with the volume of liquor, making fetal mri more valuable. we present four instances where posterior fossa abnormalities were suspected on third trimester antenatal us. fetal mri scans diagnosed four specific posterior fossa abnormalities including a dandy-walker malformation, a joubert syndrome and related disorder, an occipital encephalocoele, and an occipital bone lesion. case reports antenatal us was performed for the first time during the third trimester in all the cases, owing to unbooked pregnancy, which is common in developing countries with poorly distributed resources. mri scans on all patients were performed at a referral unit on a 1.5 tesla machine (general electric signa excite, michigan, usa). routine sequences included t2, t2* and t1. case 1 a 28-year-old woman, 32 weeks pregnant, presented to the antenatal clinic and was referred for antenatal us for suspected polyhydramnios. antenatal us demonstrated polyhydramnios, an enlarged cisterna magna (>10 mm), a cavum septum pellucidum, and retarded long bone growth (at 5th percentile). there was no echogenic vermis visible but the lateral ventricles (7 mm) and aqueduct were normal. there were no features of spina bifida. fetal mri (fig. 1) confirmed the dandy-walker malformation on the basis of an absent vermis, cystic dilatation of the fourth ventricle, an enlarged posterior fossa, upward displacement of the torcula and splayed hypoplastic cerebellar hemispheres.1 there was no hydrocephalus, corpus callosum agenesis, a normal pontine bulge, no intracranial cysts or spinal abnormalities. the patient was counselled and the child was delivered by caesarian section and found to be a trisomy 18. the child did not survive. case 2 a 30-year-old woman, 39 weeks pregnant, presented for a late third trimester us with a history of decreased fetal movements. antenatal us demonstrated a possible occipital encephalocoele. the scan was considered suboptimal in view of the advanced gestational age. fetal mri (fig. 2) confirmed the encephalocoele by demonstrating continuity with the intracranial compartment and demonstrating brain tissue extracranially. the occipital bony defect of 3.6 cm was also demonstrated. there was no associated hydrocephalus, brain atrophy, spinal abnormality or other anomaly. the child was delivered by caesarean section a week later and proved to be blind and spastic, and the prognosis was poor. neurosurgical intervention was considered unfeasible. case 3 a 31-year-old woman who was 31 weeks pregnant presented at the antenatal clinic for us; this demonstrated hydrocephalus and an abnormal posterior fossa but did not provide a more specific diagnosis. on fetal mri (fig. 3), a diagnosis of joubert syndrome and related disorders2 was made by the pathognomic finding of a ‘molar tooth’ sign at the ponto-mesencephalic junction, representing vermian aplasia and stretched superior cerebellar peduncles with a deep interpeduncular fossa. case 4 a 37-year-old woman presented to the antenatal clinic at 28 weeks’ gestation. owing to her advanced maternal age, she was referred for an antenatal us. this demonstrated a cystic structure in the posterior fossa and possible dysplasia of the vermis. a dandy-walker complex was considered. fetal mri (fig. 4) showed a well-defined extra-axial lesion within the occipital bone. the vermis, cerebellar hemispheres and fourth ventricle were normal, therefore excluding a dandy-walker complex. the lesion was reported as either a haemangioma or a cyst of the occipital bone. discussion mri is increasingly used to evaluate the fetal brain, particularly when an abnormality has been detected on prenatal us or when a fetus is at increased risk for neurodevelopmental anomalies. fetal mri has several advantages over us. it has higher contrast resolution, is not affected by the shadowing from the calvarium or by low amniotic fluid volume, allows a larger field of view and can easily be performed using ultrafast t2-w sequences,3 making it more useful than us in late pregnancy. parents also better understand the images and therefore counselling is made easier. counselling of parents is important for obtaining appropriate knowledge of the potential outcomes in the neonate and child.4 disadvantages include limitations owing to fetal motion, poorer spatial resolution than us, cost, availability and lack of expertise. one of the primary reasons for performing fetal imaging is to gather accurate information about fetal structure on which to base reliable counseling. this parental counseling is important for making informed decisions regarding future management of the pregnancy, regarding offering termination, planning delivery, post-natal prognosis and genetic counseling and testing.4 in terms of the posterior fossa specifically, fetal us has limited specificity, and false-positive diagnoses are well described. a recent study showed a 33% false-positive rate for prenatal us compared with mri.4 the same study, however, also highlighted the limitations in both sensitivity and specificity of fetal mri compared with postnatal mri. in cases of posterior fossa anomalies, only 60% of prenatal mri diagnoses are confirmed postnatally. one of the main factors contributing to this low sensitivity and specificity is the poor spatial resolution for small structures such as the brainstem and vermis, especially in early gestation.4 this emphasises the need to perform fetal mri studies after 22weeks’ gestation and the need for postnatal mri to correlate fetal mri findings. the two cases of dandy-walker complex and joubert syndrome and related disorders highlight the superiority of mri in evaluating for vermian dysplasia or aplasia, the shape of the fourth ventricle, the insertion of the tentorium cerebelli and the presence of the pontine bulge. it is also essential to look for associated cerebral and extra-cerebral abnormalities when a posterior fossa anomaly has been detected; this additional information is more accurately obtained with fetal mri. associated migrational abnormalities and midline anomalies specifically, are more thoroughly assessed on mri.5 a posterior fossa cyst can severely hamper evaluation of the posterior fossa structures on ultrasound, as demonstrated in the fetus with the occipital encephalocele. conclusion our cases have highlighted the superiority of mri over antenatal us in diagnosing both common and unusual posterior fossa abnormalities. the value of mri is even more pertinent in developing countries where third trimester unbooked antenatal presentations are common; one should have a low threshold for performing mri at referral institutions in such patients. 1. klein o, pierre-khan a, boddaert n, parisot d, brunelle f. dandy walker malformation: prenatal diagnosis and prognosis. childs nerv syst 2003;19:484-489. 1. klein o, pierre-khan a, boddaert n, parisot d, brunelle f. dandy walker malformation: prenatal diagnosis and prognosis. childs nerv syst 2003;19:484-489. 2. fluss j, blaser s, chitayat d, et al. molar tooth sign in fetal brain magnetic resonance imaging leading to the prenatal diagnosis of joubert syndrome and related disorders. j child neurol 2006;21:320-324. 2. fluss j, blaser s, chitayat d, et al. molar tooth sign in fetal brain magnetic resonance imaging leading to the prenatal diagnosis of joubert syndrome and related disorders. j child neurol 2006;21:320-324. 3. glenn oa. mr imaging of the fetal brain. pediatr radiol 2010;40:68-81. 3. glenn oa. mr imaging of the fetal brain. pediatr radiol 2010;40:68-81. 4. limperopoulos c, robertson rl, khwaja, et al. how accurately does current fetal imaging identify posterior fossa anomalies? am j roentgenol 2008;190:1637-1643. 4. limperopoulos c, robertson rl, khwaja, et al. how accurately does current fetal imaging identify posterior fossa anomalies? am j roentgenol 2008;190:1637-1643. 5. pugash d, brugger pc, bettelheim d, prayer d. prenatal ultrasound and fetal mri: the comparative value of each modality in prenatal diagnosis. eur j radiol 2008;68:214-226. 5. pugash d, brugger pc, bettelheim d, prayer d. prenatal ultrasound and fetal mri: the comparative value of each modality in prenatal diagnosis. eur j radiol 2008;68:214-226. fig. 1. case 1: axial fetal mri: splayed hypoplastic cerebellar lobes, and an enlarged cisterna magna and vermian agenesis consistent with a dandy-walker complex. fig. 2. case 2: axial fetal mri: an occipital defect(long arrow) with large encephalocoele containing cerebellar tissue (arrow head) is demonstrated. fig. 3. case 3: axial fetal mri: ‘molar tooth’ sign consistent with joubert syndrome and related disorders. fig. 4. case 4: axial fetal mri: well-defined extra-axial lesion situated within the occipital bone. the intracranial posterior fossa structures are normal. abstract background introduction what pi-rads v2.1 aims to do3 major revisions in pi-rads v2.13 how to do it – with v2.1 modifiers prostate anatomy and revisions in the sector map image interpretation and how to report pitfalls reporting template summary acknowledgements references about the author(s) robin scott department of radiology, lake, smit and partners inc., durban, south africa shalendra k. misser department of radiology, lake, smit and partners inc., durban, south africa department of radiology, faculty of health sciences medicine, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, durban, south africa dania cioni department of translational research, academic radiology, university of pisa, pisa, italy emanuele neri department of translational research, academic radiology, university of pisa, pisa, italy citation scott r, misser sk, cioni d, neri e. pi-rads v2.1: what has changed and how to report. s afr j rad. 2021;25(1), a2062. https://doi.org/10.4102/sajr.v25i1.2062 review article pi-rads v2.1: what has changed and how to report robin scott, shalendra k. misser, dania cioni, emanuele neri received: 08 dec. 2020; accepted: 22 feb. 2021; published: 01 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract multiparametric magnetic resonance imaging (mri) of the prostate has become a vital imaging tool in daily radiological practice for the stratification of the risk of prostate cancer. there has been a recent update to the prostate imaging-reporting and data system (pi-rads). the updated changes in pi-rads, which is version 2.1, have been described with information pertaining to the recommended imaging protocols, the techniques on how to perform prostate mri and a simplified approach to interpreting and reporting mri of the prostate. explanatory tables, schematic diagrams and key representative images have been used to provide the reader with a useful approach to interpreting and then stratifying lesions in the four anatomical zones of the prostate gland. the intention of this article is to address challenges of interpretation and reporting of prostate lesions in daily practice. keywords: prostate carcinoma; pi-rads; magnetic resonance imaging; technical parameters for mpmri of prostate; assessment categories to stratify risk; structured reporting. background multiparametric magnetic resonance imaging (mpmri) of the prostate has an important role in the diagnostic work-up and staging of patients with suspected prostate cancer.1 prostate imaging and interpretation up until 2019 was based on prostate imaging-reporting and data system version 2 (pi-rads v2) which provided clinical guidelines for mpmri of the prostate. the aim of pi-rads v2 was to create a global standard in the acquisition, interpretation, and reporting of prostate mpmri examinations, as well as to enhance the detection, localisation and risk stratification in patients with treatment-naïve prostate glands.2 numerous studies have ratified the value of pi-rads v2 but have also shown inconsistencies and limitations especially relating to inter-observer variability for evaluation of the transition zone (tz).3 in an attempt to reduce inter-observer subjectivity, the pi-rads steering committee, recommended multiple modifications to pi-rads v2 by employing a consensus based system. the system maintains the same framework of assigning scores to individual sequences, and using these scores, to calculate an overall assessment category for each patient. the updated version is termed pi-rads v2.1 and provides an approach to interpretation and reporting. introduction prostate cancer (pca) is the second most common cancer in men worldwide. two thirds of pca cases are diagnosed in the more developed regions in the world.2,4 in south africa the age-adjusted risk of being diagnosed with pca is 30.96/100 000 and the lifetime risk in men is 1:2.5 traditional diagnostic tests for detecting pca, namely prostate-specific antigen (psa) and transrectal ultrasound-guided (trus) biopsy, lack both sensitivity and specificity. prostate-specific antigen is specific to the prostate gland but not to pca. transrectal ultrasound-guided biopsy can miss up to 30% of tumours and in approximately 30% of cases underestimates tumour aggressiveness.2,6,7 imaging with mri was initially used for loco-regional staging and computed tomography (ct) or bone scintigraphy for distant staging in patients with biopsy-proven cancer. recent advantages in mr technology that allows both anatomical and functional imaging to be performed simultaneously, mpmri, has improved our ability to both detect and characterise prostate tumours.1 in 2012 the european society of urogenital radiology (esur) released a standardised prostate mri assessment called pi-rads. this was pi-rads version 1 (v1). this established clinical guidelines for the acquisition, interpretation and reporting of mpmri of the prostate in order to facilitate a greater level of standardisation and consistency.1 these guidelines were based on the calculation of points for the evaluation of each focal lesion with different sequences, namely t2-weighted imaging (t2wi), diffusion-weighted imaging (dwi), dynamic contrast enhanced (dce) and selective spectroscopy.1 in 2015 these guidelines were updated (pi-rads v2) by the american college of radiology (acr) and eau section of urological research (esur). in the updated version, spectroscopy assessment was not included and dce imaging was rated less significant. prostate imaging-reporting and data system v2 introduced two important changes to pi-rads v1: the concept of a dominant sequence for each prostate zone (dwi for the periphery and t2w imaging for the transitional gland) and the relegation of dce to a tie-breaker role when a lesion remains indeterminate.8 it is important to note that pi-rads only indicates the ‘probability’ of a clinically significant cancer with a 5-point evaluation for a focal lesion. prostate imaging-reporting and data system v2 led to a more cogent scoring system for assigning an overall score (1–5) for a lesion – with a score of 1 indicating a low chance of significant disease, and a score of 5 indicating a high likelihood of significant disease. although pi-rads v2 has been taken up and used broadly worldwide, experience has highlighted ambiguities in the scoring and limitations in relation to inter-reader reproducibility. prostate imaging-reporting and data system v2.1 recommends several minor adjustments to try and simplify assessment and reduce inter-reader variability without changing the overall scope and principle of v2.1 what pi-rads v2.1 aims to do3 in patients with suspected pca, pi-rads v2.1 is configured to improve detection, accurately localise, characterise and risk stratify lesions in treatment-naïve prostate glands. there are a number of aims of the pi-rads v2.1 update. the basic acceptable technical parameters to perform prostate mpmri have been defined. simple and standardised terminology for concise reporting have been devised. this will assist radiologists in prostate mri reporting and help reduce inter-observer interpretative variability. assessment categories, summarising the level or suspicion of risk of a lesion have been calculated. the guidelines will stratify patients who would benefit from biopsy and management intervention versus an observation strategy of management. the use of data obtained from mpmri can be used to guide and perform mri biopsy of suspicious lesions. the streamlined and updated v2.1 will facilitate multi-disciplinary meetings and afford more effective communication between clinicians and radiologists. major revisions in pi-rads v2.13 image data acquisition − technical specifications: t2wi: it is recommended to perform a t2w sequence in the axial plane and at least one additional orthogonal plane. dwi: clarification of b-values to use for purposes of dwi acquisition and for apparent diffusion coefficient (adc). dce mri: temporal resolution < 15 s is advised to show early focal enhancement. 3d t1w gradient echo (ge) sequences are preferred. clarifications in interpretation criteria: further description of assessment of lesions in the central zone (cz) and the anterior fibromuscular stroma (afms). revision in criteria for t2wi scores of 1 and 2 in tz. revision in determination of overall assessment category in tz. revisions in criteria for dwi scores of 2 and 3. clarification of the distinction between −ve and +ve enhancement on dce. clarification in measurement of the prostate volume. revision to sector map. biparametric magnetic resonance imaging (bpmri) this is prostate mri without contrast enhancement. the pi-rads committee suggests bpmri be reserved for select clinical indications.3 if bpmri is performed, and dynamic contrast enhancement data not obtained, the tz evaluation remains unchanged. the pi-rads assessment category for a finding in the peripheral zone (pz) is primarily centred on the dwi score and the lesions that receive a score of 3 on dwi will not be upgraded. the proportion of men with pi-rads 3 lesions will likely increase and pi-rads 4 will decrease, hence changing the possibility of clinically significant pca in these categories. this will require additional documentation and subsequently, pathway modifications for biopsy-naïve and prior-negative biopsy men.3 multiparametric prostate magnetic resonance imaging is preferred over bpmri in patients with hip implants where artefactual degradation of the images, especially dwi, may be anticipated. how to do it – with v2.1 modifiers clinical considerations3 timing of mri after biopsy an interval of 6 weeks or longer between biopsy and mri (if feasible). patient preparation at present, there is no consensus regarding any patient preparation issues. consider: antispasmodic agents to reduce motion artefact from bowel peristalsis. light enema preparation or laxative to empty distal sigmoid colon and rectum of faeces. the rectum should be evacuated prior to the mri appointment. advise patients to refrain from ejaculation for 3 days prior to the study to maintain maximum distension of seminal vesicles. patient clinical information3 recent psa level, (preferably done within the preceding 6 weeks) and psa history (if available). date and result of biopsy. number of cores, locations, gleason scores of positive biopsies. other relevant clinical history: digital rectal examination (dre) findings medications (alpha-blockers, hormones or hormone ablations) prior prostate infection, pelvic surgery, radiotherapy family history technical specifications3 (table 1) table 1: parameters for multiparametric prostate magnetic resonance imaging sequences utilised on a 3t scanner at the authors’ institution. magnetic field strength. can use both 1.5 t and 3t devices. the latter is preferred. the pi-rads v2.1 assessment requires good quality t2wi, dwi and adc sequences as these are pivotal to the accurate grading of lesions. in addition, further sequences are required in the holistic evaluation of the patient with large field of view (fov) t1wi and t2wi sequences for loco-regional spread, extra-prostatic invasion, osseous and nodal metastases. magnetic resonance spectroscopy has no longer been supported by pi-rads since v2 and as such, is no longer a required sequence. a 3-tesla (3t) scan is recommended and has several advantages but these are balanced by some disadvantages that radiologists should be aware of. protocol detail isotropic t2 images: high resolution small field of view, in two planes axial (straight axial to the patient or an oblique axial perpendicular to the long axis of the prostate) and at least one orthogonal plane (either coronal or sagittal). we routinely also acquire the coronal plane a slice thickness of 3 mm with no inter-slice gap field of view up to 20 cm to include the margins of the gland and seminal vesicles. diffusion-weighted imaging and adc map calculation should be performed using: a low b-value of 0 s/mm2 – 100 s/mm2 (preference for 50 mm2 – 100 mm2) an intermediate b-value set at 800 s/mm2 – 1000 s/mm2 optionally, an additional b-value set in the range of 100 s/mm2 – 1000 s/mm2 a high b-value (≥ 1400 s/mm2) image set is also mandatory, preferably obtained from a separate acquisition or calculated using the above mentioned sequences (calculated from low and intermediate b-value images). t1 pre-contrast acquisition: a large fov t1w sequence, acquired in the axial plane, should be included to show the extended pelvis (lymph nodes, bones, etc.) dynamic contrast enhanced, 3d t1w ge acquisition: the axial plane is the preferred sequence high spatial resolution is advantageous (demonstrates peri-prostatic veins, enables differentiation between the pz and the tz at the apex, better for evaluating the more homogeneous enhancement, typically seen in tumours) temporal resolution of ≤ 15 s is advised. prostate anatomy and revisions in the sector map the prostate gland, from superior to inferior, comprises the base, the mid-gland and the apex. it is divided into four histologic zones, namely: the pz which contains 70% – 80% glandular tissue, the tz which contains 5% the glandular tissue, the cz which contains 20% of the glandular tissue and the afms which contains no glandular tissue.3 these zones are then further divided into 41 anatomical sectors for recording pathology: tz-anterior and posterior (tza, tzp on the left and right) pz-anterior, postero-medial, postero-lateral (pza, pzpm, pzpl on the left and the right) cz at the base (cz) afms urethra findings must be recorded on the sector map. the sector map divides the prostate into 41 sectors: 38 in the prostate (19 on each side) 2 in the seminal vesicles 1 in the external urethral sphincter prostate imaging-reporting and data system v2 had 39 sectors. two additional sectors have now been added, namely the right and left posterior medial pz (pzpm) at the base (see sector zone map in figure 1). figure 1: sector zone map demonstrating the named 41 zones of the prostate. image interpretation and how to report image display high resolution monitors (at least 3 megapixels) and a contrast ratio of at least 750:1 are required. single or dual monitors may be used. how images are displayed is a personal preference and will depend on whether one or two monitors are in use. if two monitors are being used, divide each monitor into 4. ideally, display images for ease of comparison between the important interpreting sequences, namely t2 images, high b-value dwi image, adc map alongside one another. layout of workstations is shown in figure 2. figure 2: workstation layout of four sequences used for multiparametric prostate magnetic resonance imaging evaluation of the prostate including (left to right) high b-value diffusion-weighted imaging, apparent diffusion coefficient (adc) map, axial and coronal t2-weighted imaging. large fov t1w sequence where available, this sequence should be used as an overview and to evaluate the soft tissues, the skeleton, lymph nodes and the prostate for signs of haemorrhage. calculate the prostate volume this is calculated using the ellipsoid formula i.e. maximum longitudinal diameter {mid-sagittal t2} × maximum antero-posterior (ap) diameter {mid-sagittal t2} × maximum transverse diameter {axial t2} × 0.52.3 (figure 3). figure 3: recommended measurements for calculation of prostate volume at magnetic resonance imaging. maximum longitudinal (l) diameter and maximum antero-posterior (ap) diameter measured on mid-sagittal t2-weighted imaging (t2wi) (a) and maximum transverse (t) diameter measured on axial t2wi (b). mapping lesions prostate cancer is often multifocal with the largest tumours yielding the highest gleason score and most likely contributing to extra-prostatic extension (epe), and positive surgical margins. for pi-rads v2.1, up to four lesions with a pi-rads assessment score of 3, 4 or 5 may be assigned in each sector map. the index lesion should be identified. the index lesion is the one with the highest pi-rads score. if there are two or more lesions with the same highest score, the index lesion will be the one with epe. a smaller lesion with epe (even if there are larger lesions) will be the index lesion. if there is no epe then the largest lesion will be the index lesion. if there are more than four lesions, then only report the four with the highest likelihood of clinically significant cancer. measurement of lesions multiparametric magnetic resonance imaging of the prostate underestimates tumour volume and extent when compared to histology. report the largest dimension of a suspicious lesion on an axial image. if the largest dimension is on another plane, then report this measurement too. if the lesion on the axial image is not clearly delineated then measure the lesion on the best image (best plane). peripheral zone lesions should be measured on adc and tz lesions on the t2w sequence. if the lesion is compromised on adc or t2wi, then use the sequence that shows the lesion best. peripheral zone interpretation (unchanged in v2.1) although the main sequence is dwi, start by assessing the pz on the t2w sequence; any t2 hypointensity needs further interrogation with dwi-adc. the complementary sequence to dwi is dce (tables 2–4 and figure 4). figure 4: typical peripheral zone prostate imaging-reporting and data system (pi-rads) v2.1 lesions. peripheral zone (pz) shows pi-rads assessment categories with diffusion-weighted imaging (dwi) as the dominant sequence. (1) no abnormality (normal) on all sequences. (2) iso-intense signal of the pz on the high b-value dw image with an indistinct linear hypointense lesion on the apparent diffusion coefficient (adc) map (arrow) with corresponding t2w linear hypointense lesion. (3) mildly hyperintense lesion of the pz on the high b-value dw image with focal mildly hypointense lesion on the adc map (arrow) and hyperintense non-circumscribed lesion on the t2w image. (4) focal markedly hyperintense lesion (arrow) on the high b-value dw image with corresponding markedly hypointense signal intensity lesion on the adc map. lesion size < 1.5 cm in greatest dimension. t2w image demonstrates a circumscribed, homogeneous hyperintense mass confined to the prostate. (5) same as (4) above but size > 1.5 cm in greatest dimension and could have extra-prostatic extension/invasive behaviour. table 2: pi-rads assessment of prostatic lesions according to diffusion-weighted imaging characterisation. table 3: pi-rads features of prostatic lesions according to dynamic contrast enhanced characterisation in the peripheral zone. table 4: combined evaluation of peripheral zone prostatic lesions using the diffusion-weighted imaging score, dynamic contrast enhanced score and t2 score to derive the overall pi-rads grading. transitional zone interpretation (changed in v2.1) interpreting the tz is always challenging in the presence of bph with the presence of hyperplastic nodules, cystic changes and both glandular and stromal components of mixed t2 signal intensities. t2 imaging remains the dominant sequence with dwi-adc the complimentary sequence. always assess the tz in at least two planes as morphological assessment of nodules and the background tissue is crucial (tables 5, 6 and figures 5–7). figure 5: typical transition zone prostate imaging-reporting and data system (pi-rads) v2.1 lesions. transition zone (tz) shows pi-rads assessment categories with t2-weighted imaging as dominant sequence. (1) homogeneous intermediate signal intensity or round, completely encapsulated nodule(s), that is, ‘typical nodule’. (2) mostly encapsulated nodule (arrow) or homogeneous circumscribed nodule without encapsulation or homogeneous mildly hypointense area between nodules. (3) heterogeneous, hypointense signal intensity with obscured margins. on apparent diffusion coefficient (adc) map, focal (discrete and different from background) hypointense and/or focal hyperintensity on high b-value diffusion-weighted image. (4) non-circumscribed (arrow) homogeneous moderately hypointense lesion on t2-weighted image. must be < 1.5 cm in its greatest dimension. on adc map, markedly hypointense and markedly hyperintense on high b-value dw image. (5) same as (4) above but >1.5 cm in greatest dimension or extra-prostatic extension/invasive behaviour. figure 6: schematic diagram of transition zone nodules, the corresponding t2-weighted imaging scores and description of acceptable variants.10 figure 7: schematic diagram detailing the multi-sequence evaluation of transition zone nodules including diffusion-weighted imaging. the dotted lines indicate a near-isointense lesion with indistinct borders.10 table 5: characterisation and scoring of a lesion in the tz. table 6: combined scoring system to evaluate a tz lesion. t2 morphology: shape of lesion especially if lenticular. marginal features: see figure 6 and 7. completely encapsulated nodule (score 1). no capsule, homogeneous circumscribed nodule (score 2). majority encapsulated circumscribed nodule (score 2). prostate imaging-reporting and data system v2.1 acknowledges that the age demographics of men undergoing mri to exclude/confirm pca will have an increased incidence of bph. it therefore reclassifies the classic appearing bph nodules (encapsulated) from pi-rads score 2 (previous) to pi-rads score 1. score 2 is now reserved for ‘atypical nodules’, that is, homogeneously circumscribed, partially encapsulated nodules or homogeneous mildly hyperintense areas between nodules (previously would have been scored 3). microcysts within nodules due to dilated hyperplastic acini are benign changes (score 1 or 2). nodules with scores of 2 or more must be further evaluated with diffusion-weighted imaging and adc if a score of 3 is established, then dwi-adc is used to assign a definitive pi-rads score. dwi-adc images should be interpreted using pz criteria. see combined scoring system in table 6. if on t2w images, a lesion has a score of 2, then: dwi-adc score 1–3 assigns established pi-rads score of 2. dwi-adc score 4–5 assigns established pi-rads score of 3. if on t2w images, a lesion has a score of 3, then: dwi-adc score 1–4 assigns a definitive pi-rads score of 3. dwi-adc score 5 assigns a definitive pi-rads score of 4. central zone interpretation a normal cz is seen in 93% of mri studies.1 it is recognised as low t2 signal intensity tissue surrounding the ejaculatory ducts, posterior to the tz at the prostatic base, coursing medially to the urethra at the level of the verumontanum. the cz is normally symmetrical and at high b-value dwi, is symmetrically mildly hyperintense. it does not demonstrate early enhancement on dce images and has type 1 enhancement.1 see figure 8. figure 8: central zone (a, b, c and d). at the prostate base the central zone is homogeneously t2 hypointense. key pointers symmetry at base level: can be compressed by the tz (especially if hyperplastic) posteriorly. ‘teardrop’ or ‘moustache’ shape.1 beware: can appear asymmetric in 18%.1 prostate cancer can occur in the cz in 5%. it tends to be more aggressive with a higher grade and increased incidence of epe and seminal vesicle invasion.1 suspect tumour when there is asymmetry, and the lesion extends beyond the verumontanum, especially if there is a mass-like change. dynamic contrast enhanced imaging is helpful. central zone tumours demonstrate early enhancement with type 3 (wash-out) curves, compared to the normal cz which has a type 1 wash-out curve, that is, progressive enhancement.1,11,12 anterior fibromuscular stroma interpretation normal afms has a bilaterally symmetric shape (crescentic) and symmetrically low si (equivalent to si of the pelvic floor muscles) on t2w, adc and high b-value dwi, that is, ‘low on all sequences’.1 see figure 9. figure 9: the anterior fibromuscular stroma shows marked homogeneously t2-hypointense signal (a). it is adc hypointense (b) and diffusion-weighted imaging iso-intense (c). prostate cancer does not arise in the afms but extends from either the pz or the tz. abnormalities in the afms with increased si and restricted diffusion when compared with pelvic floor muscles, asymmetric enlargement or a focal mass, increases the suspicion for tumour from the adjacent pz or tz. determine (may not always be possible) from where the tumour most likely arises and apply the scoring criteria for that area.1 assessment of extra-prostatic extension frank capsular breech by a suspicious lesion. must include possible invasion of rectum and bladder. broad capsular contact (10 mm – 20 mm). bulging capsule. irregular, spiculated, angular prostate margin adjacent to tumour. asymmetry, traction, thickening of neuro-vascular bundles. seminal vesicle invasion – asymmetric loss of normal t2 hyperintensity in the seminal vesicle lumen. pitfalls an extruded hyperplastic nodule from the tz into the pz, can masquerade as a pz lesion. a neurovascular bundle that is close to the capsule or projects into the pz with false restriction of diffusion can be falsely interpreted as a possible pz lesion. prostatitis can be falsely interpreted as a pz lesion. atypical anatomy of the central zone can masquerade as a lesion. reporting template see figure 10 – a template for reporting of multiparametric prostate mri studies using the algorithm outlined in figure 11, providing the reporting radiologist with a structured approach to lesions of the peripheral and transitional zones of the prostate. figure 10: sample reporting template devised using multiparametric prostate magnetic resonance imaging. figure 11: flow diagram outlining the interplay of findings on relevant multiparametric prostate magnetic resonance imaging sequences for scoring of prostatic lesions in the peripheral zone and transition zone regions.1,3,10 summary prostate imaging-reporting and data system v2 is being widely utilised in clinical practice. worldwide experience has highlighted the areas of ambiguity, poor performance and reduced inter-observer variability, necessitating the upgrade to pi-rads v2.1, which addresses these issues. there are some minor modifications including a simplified scoring system whilst maintaining the framework for acquisition and interpretation. this fine tuning of a well-established diagnostic imaging system further improves the stratification of risk in patients with suspected prostatic carcinoma. as mpmri becomes more widely available in developing countries it is expected that the use of risk stratification models, such as pi-rads will increase. the reporting radiologist who is able to apply the framework of pi-rads in daily practice will be well-positioned to contribute to the multi-disciplinary management of patients with prostate carcinoma. acknowledgements dr gareth bydawell for assistance with selection of mri images for classification of lesions. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this pictorial review. authors’ contributions r.s. was the guarantor of integrity of the entire study, performed the literature search, wrote the manuscript and selected patients. s.k.m. was the principal promoter and reviewer of the manuscript, designed and annotated all the images and tables. s.k.m., e.n. and d.c.m. all reviewed the manuscript and made key concept additions. all the authors read and agreed on the final article. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability all patient images used are available on the pacs system of lake smit and partners inc. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references barret t, rajesh a, rosenkrantz ab, choyke pl, turkbey b. pi-rads version 2.1: one small step for prostate mri. clin radiol. 2019;74(11):841–852. https://doi.org/10.1016/j.crad.2019.05.019 steiger p, thoeny hc. prostate mri based on pi-rads version 2: how we review and report. cancer imaging. 2016;16:9. https://doi.org/10.1186/s40644-016-0068-2 weinreb jc, barentz jo, choyke pl, et al. pi-rads prostate imaging-reporting and data system, v2.1 [homepage on the internet]. american college of radiology; 2019 [cited 2021 mar 15]. available from: https://www.acr.org/-/media/acr/files/rads/pi-rads/pirads-v2-1.pdf world cancer research fund international/american institute for cancer research. continuous update project report. diet, nutrition, physical activity, and prostate cancer [homepage on the internet]. 2014 [cited 2015 dec 01]. available from: www.wcrf.org/sites/default/files/prostate-cancer-2014-report.pdf singh e, motsuku l, sengayi-muchengeti m, chen w, abraham n. ekurhuleni population-based registry 2018 annual report. johannesburg, south africa, march 2020. national health laboratory service, national cancer registry, department of health. johannesburg; 2020. levine ma, ittman m, melamed j, et al. two consecutive sets of transrectal ultrasound guided sextant biopsies of the prostate for the detection of prostate cancer. j urol. 1998;159(2):471–475. https://doi.org/10.1016/s0022-5347(01)63951-x kvale r, moller b, wahlqvist r, et al. concordance between gleason scores of needle biopsies and radical prostatectomy specimens: a population-based study. bju int. 2009;103(12):1647–1654. https://doi.org/10.1111/j.1464-410x.2008.08255.x richenberg jl. pi-rads: past, present and future. clin radiol. 2016;71(1):23–24. https://doi.org/10.1016/j.crad.2015.10.019 the prostate sector diagram was modified by david a. rini, mfa, cmi, fami, associate professor in the department of art as applied to medicine at the johns hopkins university, based on previously published figures by villers et al. (curr opin urol. 2009;19:274–282) and dickinson et al. (eur urol. 2011;59:477–494) with anatomical correlation to the normal histology of the prostate by mcneal je (am j surg pathol. 1988 aug;12:619–633). mr prostate imaging reporting and data system version 2.1 [homepage on the internet]. [cited 2020 nov 23]. available from: https://www.acr.org/-/media/acr/files/rads/pi-rads/pirads-v2-1.pdf turkbey b, rosenkrantz ab, haider ma, et al. prostate imaging reporting and data system version 2.1: 2019 update of prostate imaging reporting and data system version 2. eur urol. 2019 sep;76(3):340–351. https://doi.org/10.1016/j.eururo.2019.02.033 vargas ha, akin o, franiel t, et al. normal central zone of the prostate and central zone involvement of prostate cancer: clinical and mr imaging implications. radiology. 2012;262(3):849–902. https://doi.org/10.1148/radiol.11110663 hansford bc, karademir i, peng y, et al. dynamic contrast-enhanced mr imaging features of the normal central zone of the prostate. acad radiol. 2014;21(5):569–577. https://doi.org/10.1016/j.acra.2014.01.013 abstract introduction ethical considerations study limitations acknowledgements references about the author(s) natasha alexander department of radiology, faculty of radiation sciences, university of the witwatersrand, johannesburg, south africa ilana viljoen department of radiology, faculty of radiation sciences, university of the witwatersrand, johannesburg, south africa susan lucas department of radiology, faculty of radiation sciences, university of the witwatersrand, johannesburg, south africa citation alexander n, viljoen i, lucas s. stereotactic breast biopsies: radiological-pathological concordance in a south african referral unit. s afr j rad. 2022;26(1), a2463. https://doi.org/10.4102/sajr.v26i1.2463 original research stereotactic breast biopsies: radiological-pathological concordance in a south african referral unit natasha alexander, ilana viljoen, susan lucas received: 15 apr. 2022; accepted: 07 june 2022; published: 26 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: stereotactic breast biopsies have become the gold standard for tissue diagnosis in non-palpable, sonographically occult breast abnormalities seen on mammogram. only limited data exist in south africa on the correlation between imaging findings and stereotactic biopsy histology. objectives: to describe the mammographic findings and histological diagnosis in patients who underwent stereotactic breast biopsy at a referral hospital. in addition, to evaluate the proportion of malignancy in each breast imaging reporting and data system (bi-rads) category. method: a retrospective review of stereotactic breast biopsies was performed. imaging characteristics (including bi-rads category) and histological diagnosis were recorded. using histopathology, cases were classified as benign, high-risk or malignant. results: a total of 131 biopsies, from 123 patients, were included in the study. most biopsies were performed on asymptomatic patients (79.3%, 104/131). the majority were categorised as bi-rads 4 and demonstrated calcifications. histology revealed a malignant diagnosis in 40 (30.5%) patients, a high-risk lesion in 8 (6.1%) patients and a benign diagnosis in 83 (63.4%) patients. there was a stepwise increase in the proportion of malignancy from bi-rads category 3 to 5. when compared with surgical histology, the stereotactic biopsies demonstrated an overall ductal carcinoma in situ (dcis) underestimation rate of 10.3%. conclusion: despite resource restrictions, stereotactic breast biopsies performed in a south african context produce radiological-pathological concordance in keeping with bi-rads guidelines, as well as with local and international studies. keywords: stereotactic breast biopsy; bi-rads; breast cancer; digital breast tomosynthesis; radiological-pathological concordance. introduction breast cancer screening has increased dramatically over the past 50 years.1 despite this, breast cancer remains the leading cause of death amongst south african women, and women worldwide.2,3 because of the implementation of screening programmes, radiologists are faced with a wide range of imaging findings (often in asymptomatic patients) and are expected to correctly identify high-risk lesions.4 the breast imaging reporting and data system (bi-rads) was developed to universalise the mammographic report and guide management. using all breast imaging modalities available at the time of assessment, the breast lesion or abnormality is given a score from 0 to 6. category 0 is considered an incomplete investigation. category 1 is a negative investigation. category 2 includes only typically benign findings. category 3 is considered probably benign (≤ 2% chance of malignancy) and imaging follow-up is recommended. category 4 includes suspicious lesions and is further subcategorised based on probabilities of malignancy (a = low, > 2% but ≤ 10%; b = moderate, > 10% but ≤ 50%, and c = high, > 50% but < 95%). category 4 lesions are usually referred for tissue diagnosis and form the bulk of minimally invasive breast biopsies. category 5 lesions are considered highly suggestive of malignancy (≥ 95% probability) and pre-operative tissue diagnosis is usually recommended.5 lesions seen on ultrasound are typically sampled with ultrasound-guided core needle biopsy (cnb).6 stereotactic methods of sampling are widely accepted as the gold standard for mammographically detected, sonographically occult breast lesions.7,8,9 this includes two-dimensional (2d) stereotactic biopsy, as well as the more recently developed digital breast tomosynthesis (dbt)-guided biopsy that has proven superior to mammography in detecting architectural distortions.10 digital breast tomosynthesis is now the preferred method for sampling non-calcified, mammographically detected abnormalities that do not have a sonographic correlate.11,12 options for sampling devices generally consist of cnb and vacuum-assisted biopsy (vab). the latter has proven to decrease procedure time and increase tissue yield, therefore increasing histological accuracy.13 to the best of our knowledge, there is only one previous study specifically addressing radiological-pathological concordance of stereotactic biopsies in south africa: cupido et al. retrospectively reviewed 67 stereotactic cnbs performed at addington hospital, durban, in 2013.14 the omission of bi-rads classifications, the absence of vab sampling technique (only cnb was included) and the lack of specimen radiography for calcified abnormalities are viewed as study limitations. we conducted this study to evaluate the radiological-pathological concordance of stereotactic breast biopsies in a referral hospital breast imaging unit in south africa with the objectives of describing the mammographic findings and histological diagnosis in patients who underwent stereotactic breast biopsy and evaluating the proportion of malignancy in each bi-rads category. research methods and design stereotactic breast biopsies performed at the charlotte maxeke johannesburg academic hospital mammography unit in johannesburg, south africa, between 01 august 2016 and 31 july 2019 were retrospectively reviewed. only lesions biopsied using stereotactic techniques were documented. for this article, the term ‘stereotactic biopsies’ includes both traditional stereotaxis and with tomosynthesis guidance. the vast majority of patients were seen and investigated by one of two experienced radiologists (with 17and 25-years’ experience, respectively). all potential biopsy patients underwent tomosynthesis mammographic imaging as well as bilateral breast and axilla ultrasound in order to plan the most appropriate biopsy method. stereotactic biopsy methods included prone stereotactic (ps) biopsy (with the multicare platinum prone breast biopsy table) and erect dbt-guided biopsy (with the selenia dimensions mammography system). sampling methods included cnb (usually using a 14-gauge needle) or vab (using a 9-gauge vacuum probe). if the target lesion included calcifications, post-procedure specimen radiography was performed to confirm their presence prior to radiographic marker insertion (which was then confirmed with a post-procedure mammogram). during the time of the data collection, the fourth version of the bi-rads lexicon was in use by the radiologists in the unit. as a result, the calcification morphology is described as benign, indeterminate or suspicious (and the definitions of each category are taken from that version of the lexicon). stereotactic samples that showed more than one diagnosis on histology were classified based on the highest risk lesion. benign findings included fibrocystic change, papillomas, fibroadenomatoid change, inflammatory changes (fat necrosis and mastitis), stromal fibrosis, adenosis/sclerosing adenosis, scar/surgical site changes, vascular proliferation and pseudoangiomatous stromal hyperplasia. in this study, high-risk lesions included lobular carcinoma in situ (lcis), radial scar/complex sclerosing lesion, intra-ductal papilloma, flat epithelial atypia (fea), fibrocystic change with atypia, atypical ductal hyperplasia (adh) and atypical lobular hyperplasia (alh). malignant lesions included ductal carcinoma in situ (dcis), invasive carcinoma of no specific type (nst), other invasive carcinomas (where type is specified) and other malignancies. according to nuclear grade, dcis is classified as low-, intermediateor high-grade.15 considering its malignant potential and proclivity for local recurrence (albeit over a longer period of time), low-grade dcis has been included in the malignancy category.15,16 patient data were collected from the biopsy procedural recording sheets, breast imaging records, the picture archiving and communication system (pacs) and the national health laboratory service (nhls). demographic information, biopsy indication, mammography findings (including bi-rads category) and histological findings were recorded. for patients with more than one lesion, who underwent multiple stereotactic biopsies, each lesion was documented separately. follow-up surgical excision histology was reviewed, when available. data were transferred to a data-capturing device (microsoft excel computer software) and analysed. further analysis was conducted using sas® version 9.2. descriptive statistics, namely, frequencies and percentages, were calculated for categorical data. malignancy rates per bi-rads category were calculated using cross tabulations. ethical considerations an application for full ethical approval was made to the human research ethics committee (medical) of the university of the witwatersrand and ethics consent was obtained on 19 february 2020 (approval number: m191197). all procedures performed were in accordance with the ethical standards of the institutional research committee. results a total of 146 stereotactic breast biopsies were considered for inclusion. fourteen biopsies were excluded because of incomplete records. one biopsy was identified as a repeat biopsy (with the same histological diagnosis). therefore, a total of 131 biopsies from 123 patients were included in the study. the mean age was 59.1 years (standard deviation 12.0 and range 33–84 years). all samples were retrieved from female patients. all patients were selected for biopsy using the bi-rads guidelines. the overwhelming majority were category 4 and 5 lesions. indications for biopsy and selected imaging features are presented in table 1. a large majority (79.4%) of patients had findings detected on screening or surveillance studies (i.e. on asymptomatic breasts). ultimately, most of the malignant lesions (72.5%) also came from patients with no breast-related symptoms. there was a marginal predominance of the dbt-guided biopsy technique, comprising 59.5% of samples. only two cnbs were performed (both with stereotactic guidance); the rest (98.5%) were performed with vab. most lesions (62.6%) demonstrated some form of calcification. five (3.8%) bi-rads 3 lesions were biopsied. in three of these cases, the patients had an additional bi-rads 4a lesion in the contralateral breast and underwent bilateral breast biopsies. the remaining two cases were performed at the patients’ request (one had a strong family history of breast cancer). table 1: lesion characteristics as per breast imaging reporting and data system category of the stereotactic breast biopsies. the distribution of benign, high-risk, and malignant histological diagnosis in each bi-rads category is shown in table 2, alongside the positive predictive value (ppv) for malignancy for each bi-rads category (as well as the expected ppv as per the bi-rads guidelines). for the purposes of comparison with the bi-rads guidelines, the ppv includes only malignant lesions as positive histology (i.e. does not include high-risk lesions). table 3 shows the range of histological findings in each bi-rads category. in four lesions (3.1% of the total sample population), the radiologist deemed the imaging findings and histology results discordant (radiological-pathological discordance). three of the four lesions were bi-rads 4c with benign histology on stereotactic biopsy. the first case had a repeat biopsy showing low-grade dcis (figure 1a and b), the second case had a wide-local excision showing fat necrosis (figure 1c and d) and the third case opted for a bilateral mastectomy for confirmed breast cancer in the contralateral breast (not shown, mammogram performed at another facility). the surgical histology revealed invasive carcinoma in both breasts. the remaining fourth lesion was categorised as bi-rads 5, and the stereotactic biopsy revealed a fibroepithelial lesion (figure 2). this was considered radiological-pathological discordant and wide-local excision was performed. the surgical specimen contained no neoplasm and histology showed benign breast tissue only. of the 11 masses or mass-like abnormalities that were biopsied, more than half (n = 6, 54.5%) yielded high-risk or malignant histology. of special note is that there was a solitary case of kaposi sarcoma recorded amongst the malignant diagnoses. table 2: distribution of histological diagnosis as per breast imaging reporting and data system category. table 3: histopathological findings in 131 stereotactic biopsies and frequency in each breast imaging reporting and data system category. figure 1: examples of lesions with radiological-pathological discordance based on stereotactic biopsy histology, which were thereafter upgraded. (a) craniocaudal view and (b) magnified image demonstrating grouped amorphous and pleomorphic microcalcifications in the outer left breast. these were new compared with previous imaging and categorised as breast imaging reporting and data system (bi-rads) 4c. stereotactic biopsy yielded benign histology, and this was considered discordant to imaging. repeat stereotactic biopsy yielded low-grade ductal carcinoma in situ. (c) right craniocaudal view demonstrating architectural distortion in the central retroareolar region of the right breast. (d) magnified image showing the associated microcalcifications. this was categorised as bi-rads 4c. stereotactic biopsy histology showed benign fibrocystic changes only. following a multidisciplinary team meeting, a wide-local excision was performed, and histology yielded fat necrosis. figure 2: a lesion with radiological-pathological discordance based on stereotactic biopsy histology. (a) mediolateral oblique reconstructed image from digital breast tomosynthesis revealing a spiculated mass in the retroareolar region of the right breast. (b) on close inspection, associated amorphous microcalcifications can be seen. this was categorised as breast imaging reporting and data system 5. stereotactic histology revealed a fibroepithelial lesion. wide-local excision after hook-wire placement yielded only benign breast tissue. for sensitivity and specificity, true-positive mammograms were defined as those with a bi-rads 4 or 5 classification and a malignant or high-risk diagnosis on stereotactic biopsy histology. a true-negative mammogram was defined as a bi-rads category 3 lesion with benign histology. false-positive mammograms were defined as any bi-rads 4 or 5 lesions that yielded a benign histology result. false-negative mammograms were defined as a bi-rads 3 lesion with a malignant or high-risk diagnosis on stereotactic biopsy histology. this study yielded an imaging assessment sensitivity of 100% (95% confidence interval [ci]: 93% – 100%) and a specificity of 6.0% (95% ci: 2% – 14%). of the 48 positive stereotactic biopsy results (including both high-risk and malignant lesions), 11 patients did not undergo surgery. they were either considered not suitable for surgery (for severe comorbid medical conditions or for the presence of metastatic disease), or the patient did not undergo surgery for personal reasons (defaulting follow-up or personally opting for conservative management). of the remaining 37 lesions, follow-up data were not available for eight lesions. it is likely that these patients returned to their referring clinician at a different facility. surgical histology was available for the remaining 29 lesions (29/37, 78.4%), which are presented in table 4. twenty lesions (67.9%) were concordant on stereotactic and surgical histology. of the nine remaining lesions, 33.3% (3/9) were clear upgrades from dcis to invasive carcinoma. the rest (66.7%, 6/9) were essentially ‘downgraded’, showing a greater degree of benignancy on surgical excision (see table 4). when surgical excision histology reveals a histological diagnosis with greater degree of malignancy, the stereotactic biopsy result is considered an underestimation of the true lesion. overall, the underestimation rate of histology obtained from stereotactic biopsies versus surgical excision was 10.3% (3/29). table 4: comparison of stereotactic biopsy histology with surgical excision histology. this study included 10 patients with high-risk lesions on stereotactic biopsy. two of the 10 patients had concurrent malignant findings on the same stereotactic biopsy sample and were managed as malignancies. of the remaining eight patients with high-risk lesions, follow-up data were available for six patients (75.0%). two of these six patients were managed conservatively (one had adh only and the other had an intra-ductal papilloma). both were reported as stable on follow-up imaging at 6 months and thereafter returned to annual follow-up. both cases showed radiological stability up to the date of writing. the remaining four patients with high-risk lesions underwent surgical excision, yielding concordance in one case and discordance in the other three cases. the three discordances included one case of atypical apocrine metaplasia and two cases of adh on stereotactic biopsy, all yielding fibrocystic change on surgical excision (table 4). following benign surgical results, all discordant cases were planned for 6-month imaging follow-up, and thereafter to return to annual follow-up. follow-up data were available for two of the three discordant cases. one case presented for her 6-month visit and the other only presented at 1 year; however, both showed imaging stability, with no new suspicious findings two years after biopsy. at the time of writing, the third case had not returned to our unit for follow-up. discussion stereotactic breast biopsies are performed on lesions with subtle imaging findings, no palpable mass and no sonographic correlate.7,8,9 they are performed in the hope of early breast cancer detection and better patient outcomes.7,8,9 the role of radiologists in breast imaging is to correctly identify high-risk lesions and therefore select patients who require further investigation. in this study, many stereotactic breast biopsies that resulted in a malignant diagnosis occurred in asymptomatic women. this highlights the value of screening and surveillance programmes for breast cancer. currently, in south africa, an organised national screening programme does not exist. however, there are centres where opportunistic screening is performed.17 international guidelines continue to advocate for the role of screening and surveillance in the reduction of breast cancer deaths.18,19 when comparing the imaging findings with early studies, we found several similarities. most of the target lesions had calcifications and were classified as bi-rads category 4.20,21,22,23,24,25 a later study making use of the bi-rads 4 subcategories reported 4a as their dominant subcategory, in comparison to our study in which 4b was the most prevalent.23 calcifications are well-recognised targets for stereotactic biopsies.24 many cases of typical suspicious calcifications resulted in positive diagnoses of malignancy (figure 3). indeterminate calcifications, although mainly occurring in category 4, featured across all bi-rads categories included in the study (see table 1). when categorised as bi-rads 3 (in a solitary case), there were no associated imaging findings and the lesion yielded benign histology. one of the two bi-rads 5 lesions with indeterminate calcifications also had other concerning imaging findings for malignancy (an associated spiculate mass and architectural distortion) and histology revealed an intra-ductal papilloma. in the other case of a bi-rads 5 lesion, the indeterminate calcifications were reported in a clustered distribution and yielded dcis on stereotactic histology. figure 3: examples of typical lesions that were suspicious for malignancy on breast imaging and confirmed malignancy on stereotactic biopsy histology. craniocaudal views demonstrating (a) grouped pleomorphic microcalcifications in the central retroareolar region of the left breast, which showed a high-grade ductal carcinoma in situ on histology, (b) a small group of pleomorphic microcalcifications in the outer right breast, which revealed high-grade ductal carcinoma in situ on histology, (c) architectural distortion with associated grouped pleomorphic microcalcifications in the outer left breast. histology yielded an invasive carcinoma of no specific type, (d) two groups of suspicious microcalcifications in the left breast. the central retroareolar group of microcalcifications had a positive ultrasound correlate and was sampled by ultrasound-guided biopsy. the group of pleomorphic microcalcifications in the outer breast (circled) yielded invasive carcinoma of no specific type on stereotactic biopsy histology. this widespread distribution of essentially ‘uncertain’ calcifications emphasises the diagnostic challenge that calcifications represent. digital breast tomosynthesis is superior in detecting non-calcified mammographic abnormalities for biopsy. the higher proportion of architectural distortions in this study may be explained by our routine use of dbt, in contrast to cupido et al.’s study, where dbt was not employed and no architectural distortions were reported.14 this is further supported by rochat et al., who reported architectural distortion in 2.0% of their digital mammography stereotactic biopsies versus 17.7% in their dbt-guided biopsies.25 mass-like lesions are also targeted with stereotaxis if there is no sonographic correlate. fifty-five percent (6/11) of the mass-like abnormalities biopsied in this study resulted in positive histology (malignancies or high-risk lesions). in comparison to mendez et al., with 25.0%, and bohan et al., with 12.5%, our malignancy rate amongst mass-like lesions is high.21,26 however, there were no circumscribed masses in our study (they were all described as having a spiculated or indistinct margin). when excluding the circumscribed masses from the study by mendez et al., the malignancy rate amongst mass-like lesions is 66.0%.21 nonetheless, the high malignancy rate in our study warrants a high degree of suspicion when confronting mammographically detected mass-like lesions in our setting. looking at the mammograms of patients that underwent stereotactic core biopsies in our unit (n = 131), the bi-rads suspicion for malignancy (category 4 or 5) was 100% sensitive, but with a very low specificity of 6.0%. in other words, every lesion that resulted in a histological diagnosis of a high-risk lesion or a malignancy had a mammogram that was assessed as either suspicious (category 4) or highly suspicious (category 5) for malignancy. the sensitivity is expected to be high in a screening tool like mammography, and this finding is reassuring when using bi-rads in our setting. in a comparable study that looked at 947 stereotactic vabs, mendez et al. reported a sensitivity of 94.7% and a specificity of 18.8%.21 our particularly low specificity is influenced by the high number of false positives (lesions assessed as bi-rads 4 or 5 that yielded benign histology). the patients that were likely to be included in the study were patients who had indeterminate lesions, like architectural distortions and indeterminate calcifications. bahl et al. demonstrated a ppv of 74.5% for malignancy in 369 cases of architectural distortions with sonographic correlates. however, when architectural distortion occurred without a positive sonographic correlate (like in our study), bahl et al. showed that the likelihood of it representing malignancy was only 27.9%.27 the other contributing factor was the low number of true negatives (mammographically benign lesions that resulted in benign histology) – in other words, bi-rads 3 lesions that were proven benign on histology. we had less than 4.0% bi-rads 3 lesions in our study (5/131). breast imaging reporting and data system 3 lesions are not usually managed with biopsy unless specifically requested by the patient and/or clinician.5,21 the bi-rads guidelines were developed to universalise and standardise reporting around the world. as part of the guidelines, an expected range of malignancy is given for each category.5 in our results, although there is a stepwise increase in the proportion of malignancy from category 3 to 5, the proportions in category 4c and especially in category 5, were lower than the range in the bi-rads guidelines (see table 2). a big contributor was our bi-rads 5 lesions with benign histology. on closer inspection of these false-positive cases, the imaging features were suspicious and included: a fibroadenoma with architectural distortion and suspicious calcifications (figure 2), fat necrosis with architectural distortion and suspicious calcifications (figure 4a and 4b) and an intra-ductal papilloma with an ill-defined density, architectural distortion and indeterminate calcifications (figure 4c). a single bi-rads 5 lesion yielded completely benign breast tissue (figure 4d). these cases contributed to the low specificity of our stereotactic biopsies. figure 4: examples of lesions that were suspicious for malignancy on breast imaging, but yielded benign histology. (a) craniocaudal view and (b) magnified image showing architectural distortion and suspicious microcalcifications in the inner right breast. histology revealed fat necrosis, (c) mediolateral oblique view indicating a poorly circumscribed mass with spiculated margins in the upper left breast, associated with architectural distortion and amorphous microcalcifications. histology revealed an intra-ductal papilloma, (d) mediolateral oblique view demonstrating architectural distortion in the upper right breast which yielded benign breast tissue on histology. high-risk lesions are a controversial topic amongst pathologists, breast surgeons and radiologists alike.28 this lack of consistency is apparent in the literature. while there is consensus on the malignant potential of adh, there remains uncertainty about the clinical importance and management of intra-ductal papillomas, radial scars, alh and lcis.28,29 underestimation rates are used to report discordances between surgical excision and stereotactic biopsy histology if the surgical histology shows a greater degree of malignancy than the stereotactic biopsy. along with dcis, high-risk lesions as mentioned above are listed as contributors to underestimation rates.20,23,26,30,31 our dcis underestimation rate of 10.3% (n = 3) is comparable to results from other studies (table 5). all three of our cases involved the upgrading of dcis to invasive carcinoma. pieters et al. conducted a study assessing underestimation rates in south africa32 and reported a dcis underestimation rate of 12.5%. however, as with our study, they also had a small number of lesions in this group and therefore this should be interpreted with caution. there were five lesions in our study that showed more aggressive histology on stereotactic biopsy than the surgical excision. one possible explanation is that these ‘downgraded’ lesions were completely removed by the stereotactic vab. the other consideration is that different areas were sampled during surgery. table 5: comparison table of studies evaluating radiological-pathological discordance or histological underestimation in stereotactic breast biopsies. several studies addressing radiological-pathological concordance or underestimation rates in stereotactic breast biopsies are shown in table 5.14,25,32,33,34,35,36,37,38 accurately comparing studies is difficult. studies dedicated specifically to investigating the radiological-pathological concordance do not always utilise the bi-rads categories and there is a wide range of sample sizes and biopsy techniques. radiological-pathological concordance has also been assessed by correlating malignancy rates with specific imaging features, rather than bi-rads categories.14,24 the categorisation of high-risk lesions is notoriously inconsistent.28 in our study, we had a small sample size, but the overall malignancy rate was comparable to most other studies (table 5). our radiological-pathological discordance rate of 3.1% is comparable to the findings of international studies. the dcis underestimation rate for our study is comparable to that of local and international studies, where specific dcis underestimation rates are reported or may be calculated, ranging from 10.3% to 14.2%.33,34,37 study limitations all biopsies were performed at a single tertiary breast imaging centre. most of the mammograms and biopsies were interpreted and performed by one of the two experienced radiologists. this is not representative of all clinical service centres. in our study, histology from stereotactic biopsy samples was used as the gold standard for sensitivity and specificity as not all patients had surgical excision or long-term follow-up. conclusion the stereotactic biopsies detected cancer in predominantly asymptomatic women during screening and surveillance studies. this study showed that stereotactic breast biopsies performed in a referral hospital in south africa were very sensitive, but not very specific. we produced a radiological-pathological concordance that is comparable to international studies, with similar discordance and underestimation rates. acknowledgements the authors thank prof. jacqueline smilg (charlotte maxeke johannesburg academic hospital) for useful discussions and support. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.a. was responsible for methodology, validation, investigation, data curation, formal analysis, provision of resources, writing (original draft) and project administration. i.v. was responsible for visualisation, writing (editing and reviewing) and supervision of the study. s.l. was responsible for conceptualisation, writing (editing and reviewing) and supervision of the study. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, n.a. the data are not openly available because of reasons of privacy (human data) and are located within a controlled access repository. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references berry da, cronin ka, plevritis sk, et al. effect of screening and adjuvant therapy on mortality from breast cancer. n engl j med. 2005;353(17):1784–1792. https://doi.org/10.1056/nejmoa050518 summary statistics of cancer diagnosed histologically in south africa in 2016: cancer association of south africa (cansa) [homepage on the internet]. 2016 [cited 2019 nov 20]. available from: https://cansa.org.za/south-african-cancer-statistics/ international agency for research on cancer – cancer today [document on the internet]. world health organisation; 2020 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frequency of discordant lesions and false-negative cancers at stereotactic vacuum-assisted biopsy. acad radiol. 2016;23(8):994–999. https://doi.org/10.1016/j.acra.2016.03.023 differentiation betvvcen sigrnoid volvulus and free air on supine abdonlinal radiographs: the 'i iver overlap sign' versus the 'football sign' from page 25 in conclusion it must be stated that having seen many cases of free air with a 'football sign' and a few cases of sigmoid volvulus with a 'liver overlap sign', the former diagnosis was favoured. this was also a provisional clinical diagnosis.the fact that free air was conclusively excluded on chest radiographs and a left side down decubitus abdominal radiograph, should have made gastrografin studies of the upper and lower gastrointestinal tract to search for a perforation unnecessary. the gastrografin enema was, however, of considerable benefit in the diagnosis and treatment of the sigmoid volvulus. if only a supine abdominal radiograph had been available,which might sometimes be the case, it would have been very difficult to distinguish between a ruptured hollow viscus and sigmoid volvulus. other signsof pneumoperitoneum or sigmoid volvulus also proved to be unhelpful. (in the first case of possible free air they added to the confusion). the clinical features did not aid in differentiating between case report unusual foreign bodies in the oesophagus wfc van gelderen ffrad(d), consultant radiologist kscheng frcs(ed),fracs, consultant surgeon, department of radiology, wanganul base hospital, new zealand. a 70 year old man with a known long segment benign stricture of the lower oesophagus, presented again with dysphagia and the stricture was dilated. subsequent chest radiographs demonstrated signs of a pneumomediastinum. an ultravist 300 non-ionic contrast (schering ag, germany) swallow demonstrated a localized, contained perforation of the left lower these two conditions and without further conventional radiographs and contrast studies the diagnosis could not have been made. this case illustrates that neither the 'football sign' nor the 'liver overlap sign' are invariable, infallible indicators. references i. young ws, engelbrecht he, stoker a. plain film analysis in sigmoid volvulus. cli" radio11978; 29: 553560. 2. janzen dl, heap sw. organo-axial volvulus of the sigmoid colon. australas radiol; 1992: 332-333. 3. rice rp,thompson wm, gedgaudas rk.the diagnosis and significance of extraluminal gas in the abdomen. radiol cli" north am 1982: 20(4): 819-837. oesophagus. half a dozen rectangular low attenuation foreign bodies were noted within the area of rupture and within the distal oesophagus (figure 1). the patient had not been permitted to have anything by mouth and denied having had anything to eat or drink. on more persistent questioning, however, he admitted to being rather partial to lozenges and had not thought that these would be contraindicated. he had surreptitiously sucked the lozenges one by one in the ward, and subsequently the nucleus of each lozenge, a thin hard square wafer, had found its way down to the oesophagus fully intact 26 sa journal of radiology. june 1997 in shape, though reduced in size. these wafers were eloquently demonstrated on ultravist swallow. the remains of the lozenges were removed at subsequent oesophagoscopy and the patient made an unremarkable recovery with a follow-up contrast swallow demonstrating resolution of the contained rupture. figure 1: localized contained rupture left lower oesophagus shown at contrast swallow. note multiple rectangular low attenuation foreign bodies (arrows) which are the residue of lozenges sucked by the patient over the preceding hours. abstract introduction case report discussion acknowledgements references about the author(s) sneha harish c department of radiodiagnosis, maulana azad medical college and associated lok nayak hospital, new delhi, india rashmi dixit department of radiodiagnosis, maulana azad medical college and associated lok nayak hospital, new delhi, india sapna singh department of radiodiagnosis, maulana azad medical college and associated lok nayak hospital, new delhi, india anjali prakash department of radiodiagnosis, maulana azad medical college and associated lok nayak hospital, new delhi, india citation harish c s, dixit r, singh s, prakash a. cervical extension of pancreatic pseudocyst: an unusual cause of neck stiffness and dysphagia. s afr j rad. 2022;26(1), a2385. https://doi.org/10.4102/sajr.v26i1.2385 case report cervical extension of pancreatic pseudocyst: an unusual cause of neck stiffness and dysphagia sneha harish c, rashmi dixit, sapna singh, anjali prakash received: 25 dec. 2021; accepted: 01 mar. 2022; published: 09 may 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract pancreatic pseudocyst is a common complication that can occur following acute or chronic pancreatitis. commonly, they are peripancreatic in location. rarely, they can extend to the mediastinum, and further extension to the neck is even rarer. a 55-year-old man who presented with neck stiffness and dysphagia and on imaging, was found to have a cystic lesion in the neck. aspiration of the lesion revealed raised amylase levels suggestive of a pancreatic pseudocyst. keywords: pancreatitis, pseudocyst, cervical extension, dysphagia, neck stiffness, mediastinal pseudocyst, computed tomography. introduction pancreatic pseudocyst is a very common complication that can occur following either acute or chronic pancreatitis. it is seen in about 30% – 40% of patients with chronic pancreatitis.1 commonly, these cysts are found in peripancreatic locations. rarely, they can extend into the mediastinum through anatomical defects in the diaphragm.2,3,4,5,6 further extension to the neck is even rarer and has been described in a few case reports only.7,8,9 these can present with neck swelling or mass effect on the adjacent structures, and patients may present with complaints of dysphagia, chest pain or shortness of breath. due to the varied clinical presentation, diagnosis is often challenging. cross-sectional imaging such as ct is an excellent tool to establish the diagnosis. this report describes the case of a 55-year-old man with cervical extension of a pancreatic pseudocyst. case report a 55-year-old male patient presented to the emergency department with complaints of neck stiffness and dysphagia for one week. there was no history of trauma or fever. occasional alcohol intake was documented. at examination, the patient had limited neck movements along with tachypnoea. however, the lung auscultation findings were normal. the abdomen was soft and non-tender with no obvious palpable lump. a radiograph of the neck and cervical spine was obtained (figure 1a and b), which indicated thickened prevertebral soft tissue causing anterior displacement of the airway. degenerative changes were seen in the cervical spine. no evidence of discitis or vertebral osteomyelitis was seen. a chest radiograph acquired at the same time (figure 1c) revealed a homogenous opacity causing displacement of the right paratracheal stripe and thickening of the paravertebral stripe. another near-homogenous opacity was seen in the retrocardiac region, silhouetting the left hemidiaphragm. given the radiographic findings and clinical scenario, the possibility of retropharyngeal abscess with mediastinal extension was considered. figure 1: radiograph of the neck, anteroposterior (a) and lateral (b), demonstrates anterior displacement of the airway and oesophagus (thick arrow) and widening of the prevertebral soft tissue (thin arrow). the frontal chest radiograph (c) indicates displacement of the right paraspinal stripe (thin arrows) and a retrocardiac opacity (thick arrow) indenting (curved arrow) the gastric fundus (asterisk). a contrast-enhanced ct scan of the neck and chest was conducted. it revealed a hypodense peripherally enhancing cystic lesion involving the prevertebral and retropharyngeal spaces of the neck, extending from the base of the skull to the level of the thoracic inlet (figure 2a and b). further caudally, it was seen to extend into the mediastinum, involving the visceral compartment, causing anterior displacement of the trachea and oesophagus (figure 3a–c). more distally, the lesion was seen to extend through the oesophageal hiatus of the diaphragm into the abdomen, involving the lesser sac and body of pancreas (figure 3d). figure 2: axial contrast-enhanced ct scan of the neck, at the level of the hyoid bone (a) and at the level of sixth cervical vertebra (b), reveals a peripherally enhancing cystic lesion (thin arrows in a and b) involving the retropharyngeal and prevertebral space with extension to the anterior cervical and visceral space (thick arrow in b). figure 3: axial sections of contrast-enhanced ct scan of the chest and abdomen (a–d) show the pseudocyst in the visceral compartment of the mediastinum abutting the superior vena cava (curved arrow in a) and descending thoracic aorta, with anterior displacement of the oesophagus (curved arrow in c). it is extending into the abdomen through the oesophageal hiatus (white arrow in c) where it is seen arising from the body of pancreas (white arrow in d). ascites (curved arrow in d), bilateral pleural effusions and left lower lobe consolidation (asterisk in c) are also noted. on subsequent probing, the patient provided a history of acute pain in the epigastric region eight weeks prior, which gradually subsided over a few days. hence, the diagnosis of pancreatic pseudocyst extending to the mediastinum and neck was made. as the patient was symptomatic, the cervical cyst was drained intraorally. analysis of the aspirate indicated leucocytes and raised amylase levels (55 043 u/l), confirming the diagnosis. the pseudocyst resolved and the patient’s recovery was uneventful. discussion pancreatic pseudocysts are common complications of both acute and chronic pancreatitis. the aetiology of pancreatitis and hence pseudocyst includes excessive alcohol consumption, biliary tract pathologies and trauma.1 in the paediatric population, additional causes include genetic abnormalities such as cystic fibrosis, pancreatic anomalies, ingestion of medications such as antiepileptics and metabolic disorders.10 following an episode of acute pancreatitis, up to four weeks from the onset of pain, fluid collections associated with interstitial oedematous pancreatitis are defined as acute peripancreatic fluid collections according to the revised atlanta classification for pancreatitis. if the fluid fails to resorb after four weeks and develops a mature wall, the term pseudocyst is used.11 pathologically, a pseudocyst of the pancreas consists of a fluid collection surrounded by fibrous tissue with no epithelial lining.12 the fluid is rich in amylase, lipase and other enzymes produced by the pancreas. the symptoms are usually non-specific, but the possibility of pseudocyst formation should be considered in patients with persistent abdominal pain or a palpable mass in the abdomen following an episode of pancreatitis.1 serum analysis is not reliable, as patients may or may not have elevated serum lipase and amylase levels and/or raised serum bilirubin levels.1 pancreatic pseudocysts are commonly peripancreatic in location, involving the lesser sac. occasionally, pancreatic pseudocysts can occur at atypical locations like the splenic hilum or within the spleen and mediastinum. extension further cranially to the neck resulting in retropharyngeal collections is fairly uncommon and has only been described in a few reports.6,8,9,13 one case report also describes a pseudocyst presenting as an inguinoscrotal swelling.14 these atypical locations cause a diagnostic dilemma due to the varied clinical presentations. hence a thorough clinical history along with cross-sectional imaging is required to make the diagnosis. mediastinal extension of a pancreatic pseudocyst although previously reported, is a relatively rare entity.2,3,4,5,6 a case of an isolated mediastinal pseudocyst with no obvious communication with the pancreas has also been reported.15 the most common location for a mediastinal pseudocyst is the posterior mediastinum, although they can be seen in the anterior or middle mediastinum. it occurs when there is extension of the fluid from the retroperitoneum through the aortic or oesophageal hiatus and sometimes through the diaphragmatic crura.5,6,13 patients may present with shortness of breath, chest pain, fever, palpitations or sometimes gastroesophageal reflux due to hiatal widening.3,5 occasionally, they may cause life-threatening complications due to mass effect or rupture of the pseudocysts in the pleural or pericardial cavity resulting in cardiac tamponade, circulatory failure or acute respiratory distress.6 pseudocysts extending to the neck can result in dysphagia or can present as a neck swelling. in the presented case, mediastinal extension of the pseudocyst was seen through the oesophageal hiatus with further extension to the neck. the patient presented with complaints of neck stiffness and dysphagia due to mass effect on the oesophagus along with retropharyngeal and prevertebral extension. cross-sectional imaging plays an important role in the diagnosis of a mediastinal/retropharyngeal pseudocyst. computed tomography demonstrates a hypodense thin-walled cystic lesion usually in the posterior mediastinum,16 along with its extension into the neck, when present. it is useful to evaluate the complete extent of the lesion and its relation to the visceral and vascular structures. magnetic resonance imaging is useful to demonstrate pancreatic ductal anatomy and its communication with the pseudocyst. ultrasonography can be used to guide the aspiration of fluid from the cyst for both diagnostic and therapeutic purposes. the presence of raised amylase levels in the fluid is highly sensitive and specific for the diagnosis of a pseudocyst of pancreatic origin.1 a mediastinal pseudocyst must be differentiated from a paravertebral abscess. pseudocysts extending to the neck can be misdiagnosed as a retropharyngeal or prevertebral abscess at the preliminary examination. the clinical history, patient presentation and imaging findings aid in the diagnosis. tuberculosis of the spine can cause paravertebral abscess formation, and patients present with long-standing history of fever, loss of appetite, weight loss, backache and localised tenderness. typically, there is the involvement of the vertebrae adjacent to the paravertebral collections.17 other differentials for mediastinal pseudocysts include neurofibroma, cystic schwannoma and other posterior mediastinal tumours, lymphoma, aortic aneurysm and extramedullary haematopoiesis.6 cervical pseudocysts may mimic other cystic lesions of the neck including cystic lymph nodes, cystic lesions of the thyroid or salivary glands and lymphatic malformations.13 management depends on several factors including the symptoms of the patient, location, extension of the lesion and its relation to major structures. in asymptomatic patients and patients with small lesions, medical management with octreotide may be useful. drainage of the fluid can be performed using percutaneous or endoscopic techniques. it has been reported that the recurrence rate is lower following endoscopic drainage compared with percutaneous drainage techniques. complications following percutaneous drainage include haemorrhage, infection and fistula formation.18 surgical drainage or excision is limited to pseudocysts that fail to resolve by the above techniques or when they become complicated.6 conclusion in any patient presenting with dysphagia along with a cystic lesion in the neck, cervical extension of a pancreatic pseudocyst must be considered as a differential under appropriate clinical settings. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. authors’ contributions s.hc., r.d., s.s. and a.p. contributed to the study conception and design. the first draft was written by s.h.c., which was reviewed and edited by s.h.c., r.d., s.s. and a.p. all authors read and approved the final case report. ethical considerations this case report followed all ethical standards for research. written informed consent was obtained from the patient for publication of this case report and all data were anonymised. funding information the authors received no financial support for the research, authorship and/or publication of this case report. data availability data supporting the findings of this case report are available upon request from the corresponding author, s.h.c. disclaimer the views and opinions expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references habashi s, draganov pv. pancreatic pseudocyst. world j gastroenterol. 2009 jan 7;15(1):38. https://doi.org/10.3748/wjg.15.38 nasa m, choudhary n, patil g, puri r. mediastinal pancreatic pseudocyst. j dig endosc. 2016 jan;7(01):20–23. https://doi.org/10.4103/0976-5042.180095 sadat u, jah a, huguet e. mediastinal extension of a complicated pancreatic pseudocyst; a case report and literature review. j med case rep. 2007 dec;1(1):1–3. https://doi.org/10.1186/1752-1947-1-12 drescher r, köster o, lukas c. mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report. j med case rep. 2008 dec;2(1):1–4. https://doi.org/10.1186/1752-1947-2-180 tan mh, kirk g, archibold p, kennedy p, regan mc. cardiac compromise due to a pancreatic mediastinal pseudocyst. eur j gastroenterol hepatol. 2002 nov 1;14(11):1279–1282. https://doi.org/10.1097/00042737-200211000-00020 ajmera av, judge ta. mediastinal extension of pancreatic pseudocyst – a case with review of topic and management guidelines. am j ther. 2012 sep 1;19(5):e152–e156. https://doi.org/10.1097/mjt.0b013e3181f62947 chhabra p, rana ss, sharma v, bhasin dk. an unusual neck swelling: extension of mediastinal pseudocyst into the neck. endosc ultrasound. 2017 jan 1;6(1):71–72. https://doi.org/10.4103/2303-9027.200210 wechalekar m, falodia s, gamanagatti s, makharia gk. an extension of pancreatic pseudocysts in the neck. pancreas. 2007 jan 1;34(1):171–173. https://doi.org/10.1097/01.mpa.0000246657.00257.e9 karantanas ah, sandris v, tsikrika a, karakousis k, karaiskou e. extension of pancreatic pseudocysts into the neck: ct and mr imaging findings. am j roentgenol. 2003 mar;180(3):843–845. https://doi.org/10.2214/ajr.180.3.1800843 uc a, husain sz. pancreatitis in children. gastroenterology. 2019 may 1;156(7):1969–1978. https://doi.org/10.1053/j.gastro.2018.12.043 foster br, jensen kk, bakis g, shaaban am, coakley fv. revised atlanta classification for acute pancreatitis: a pictorial essay. radiographics. 2016 may;36(3):675–687. https://doi.org/10.1148/rg.2016150097 lehman ga. pseudocysts. gastrointest endosc. 1999 mar 1;49(3):s81–s84. https://doi.org/10.1016/s0016-5107(99)70533-x bhasin dk, rana ss, nanda m, et al. endoscopic management of pancreatic pseudocysts at atypical locations. surg endosc. 2010 may;24(5):1085–1091. https://doi.org/10.1007/s00464-009-0732-8 skouras c, skouras t, pai m, zacharakis e, spalding d. inguinoscrotal extension of a pancreatic collection: a rare complication of pancreatitis – case report and review of the literature. updates surg. 2013 jun;65(2):153–159. https://doi.org/10.1007/s13304-012-0138-3 halder p, mandal kc, debnath b, mukherjee s. isolated mediastinal pseudocyst of the pancreas. indian pediatr. 2018 mar;55(3):251–253. https://doi.org/10.1007/s13312-018-1327-z jeung my, gasser b, gangi a, et al. imaging of cystic masses of the mediastinum. radiographics. 2002 oct;22(suppl_1):s79–s93. https://doi.org/10.1148/radiographics.22.suppl_1.g02oc09s79 garg rk, somvanshi ds. spinal tuberculosis: a review. j spinal cord med. 2011 sep 1;34(5):440–454. https://doi.org/10.1179/2045772311y.0000000023 giovannini m. what is the best endoscopic treatment for pancreatic pseudocysts? gastrointest endosc. 2007 apr 1;65(4):620–623. https://doi.org/10.1016/j.gie.2006.12.046 abstract introduction patient presentation discussion conclusion acknowledgements references about the author(s) kakia a.f. namugenyi department of surgery, faculty of health sciences, walter sisulu university, mthatha, south africa ferdinand m. oompie department of radiology, nelson mandela academic hospital, mthatha, south africa kasandji f. kabambi department of surgery, faculty of health sciences, walter sisulu university, mthatha, south africa citation namugenyi kaf, oompie fm, kabambi kf. maximum intensity projection aids in diagnosing acute appendicitis and mobile caecum: a case report and literature review. s afr j rad. 2021;25(1), a2153. https://doi.org/10.4102/sajr.v25i1.2153 case report maximum intensity projection aids in diagnosing acute appendicitis and mobile caecum: a case report and literature review kakia a.f. namugenyi, ferdinand m. oompie, kasandji f. kabambi received: 18 mar. 2021; accepted: 11 may 2021; published: 28 july 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract appendicitis is a common childhood condition requiring surgical intervention and delayed diagnosis can have serious consequences. this report describes the case of a child who presented with an acute abdomen and intestinal obstruction. multidetector (md) ct demonstrated a left-sided caecum and an inflamed appendix with a faecolith. maximum intensity projection (mip) post-processing was key in identifying the appendicular artery and determine the diagnosis. at surgery, however, a mobile caecum and the appendix were positioned on the right side. keywords: maximum intensity projection; multi detector computed tomography; childhood; acute appendicitis; mobile caecum. introduction acute appendicitis is a common condition in childhood, but a left-sided appendicitis related to a mobile caecum is rare.1 appendicitis is usually diagnosed on the basis of clinical presentation and laboratory results; however, an atypical presentation may pose a diagnostic dilemma. the position of the appendix varies considerably depending on the position of the caecum.2 in individuals with situs inversus, midgut malrotation or an unusually long appendix (more than 6.8 cm in children), the appendix may be found on the left side of the abdomen.1,3,4 there are a few case reports of ct scan findings demonstrating a perforated appendix in association with caecal redundancy.2,5 patient presentation a 12-year-old boy presented with generalised abdominal pain, abdominal distension and vomiting for 1 week. there was history of intermittent abdominal pain with constipation, which was managed at a nearby primary healthcare unit. there were no known comorbidities and no history of previous surgery. on clinical examination, the child was ill looking and febrile (38 °c) but fully conscious. the abdomen was distended with generalised tenderness and guarding. biochemistry was normal except for a raised white cell count of 15 500 mm3 (normal range: 5000 mm3 – 10 000 mm3). abdominal ultrasound demonstrated interloop free fluid and tenderness on probe compression. the appendix could not be identified because of overlying bowel gas in the distended bowel loops. post-contrast-enhanced abdominal ct scan showed distended small bowel loops with multiple pelvic collections. the caecum was left sided (figure 1a–c) with a 50 mm diameter collection in the left iliac fossa associated with a 7-mm long dense sausage-shaped structure, presumed to be the appendix with an appendicolith (figure 2a and b). differential diagnosis included a left-sided appendix with a faecolith, a foreign body complicated by perforated small bowel, infected mesenteric or duplication cyst and a meckel’s diverticulitis with a stone. the radiologist sought to follow the appendicular artery, a branch of the ileocolic artery from the superior mesenteric artery (sma) using maximum intensity projection (mip) post-processing on a philips intellispace workstation (philips healthcare netherlands b.v. veenpluis 8.0, the netherlands). the distal sma was seen coursing towards the left in the region where the high-density sausage-shaped structure was seen (figure 3). interloop and right paracolic gutter fluid was present. a radiological diagnosis of a ruptured left-sided acute appendicitis probably due to a mobile caecum or an unusually long appendix was made. figure 1: (a-c) (cephalad to caudad): a 12-year-old boy presented with abdominal distension, vomiting and a raised white cell count. axial ct revealed the abnormal caecal position (blue star) in the left lower quadrant with an anterior cephalad thickened appendix containing an appendicolith (arrow) and adjacent fat stranding. figure 2: (a and b) axial and coronal ct images demonstrating appendiceal wall thickening and enhancement with a faecolith (blue arrows) anterior and cephalad to the caecum (star). the right iliac fossa was unremarkable with fluid in the paracolic gutter (red arrow). note the liver (red circle) is in the normal anatomic position. figure 3: coronal reconstructed maximum intensity projection image demonstrating the superior mesenteric artery (blue arrow) and its branches including the ileocolic (black arrow) from which the appendicular artery arises. the vessels are seen coursing to the left, corresponding to the position of the caecum and appendicolith. this is in contrast to the normal course towards the right lower quadrant. differentials remained as given here. there were no features of midgut malrotation or situs inversus. the referring surgeons were informed and an emergency laparotomy was performed. the surgeons performed a midline incision extending from epigastrium to the suprapubic region. multiple dilated friable small bowel loops were found. accidental iatrogenic rupture of small bowel was primarily repaired. the dilated loops were decompressed and the caecum was found on a free mesentery on the right side. the appendix was inflamed with an appendicolith at the base and a ruptured gangrenous tip. appendectomy was performed and the specimen was sent for histology. interloop collections were drained followed by peritoneal lavage. there were no adhesions. the patient was discharged after four days later, following an uneventful recovery. histopathology reported a 7 cm × 3 cm appendix with an occluded lumen and a faecolith. discussion a mobile caecum is a congenital abnormality with a defective right colonic mesenteric attachment at the lateral peritoneum because of agenesis of the caecal mesocolon.6 the estimated prevalence of a mobile caecum and ascending colon is 10% – 20%.2,7,8 during embryological development, a mobile caecum arises from failure of fusion of the colonic mesentery with the posterolateral peritoneum. this results in a free mesentery of the caecum and occasionally the right colon, allowing them to freely move to any part of the abdominal cavity. occasionally, the caecum may rotate causing volvulus but most of the time it remains in the normal anatomic position.7 mobile caecum and right colon are commonly present in children as mobile caecal syndrome.9 patients with this syndrome may present with chronic intermittent abdominal pain, distension, flatulence, dyspareunia, caecal volvulus and partial or complete bowel obstruction.7 left-sided acute appendicitis may be difficult to differentiate from an infected duplication, mesenteric or urachal cyst or a meckel’s diverticulitis.10 meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, present in 2% of the population. it is usually asymptomatic, but 4% – 40% of people with meckel’s diverticulum may experience complications of diverticulitis, haemorrhage, intussusception, small-bowel obstruction, stone formation or neoplasm. a urachal cyst may become infected and present with abdominal pain, fever, nausea, vomiting, dysuria, voiding difficulty, epididymitis and orchitis. mesenteric cysts have an incidence of less than 1:100 000 cases in the general population. they may be located in the mesentery, peritoneum or retroperitoneum. most are benign but there is a 3% incidence of malignancy.11 patients with symptomatic mesenteric cysts present with abdominal pain and distension with cysts rarely becoming infected. duplication cysts of the gastrointestinal system are rare and often associated with vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies and limb abnormalities (vacterl anomalies), especially imperforate anus and hemivertebrae. if symptomatic, they present with abdominal distension, gastrointestinal obstruction or obstipation and caecal duplications, resulting in intussusception.12 the differential of a left-sided acute appendicitis may not be promptly established in the emergency setting and is often delayed because of atypical clinical signs.1 delayed diagnosis may result in complications such as perforation, abscess formation, peritonitis, sepsis, bowel obstruction, infertility and death.13 chest and abdominal radiographs may be helpful in excluding situs inversus with identification of the heart and gastric bubble in the correct anatomical position. midgut malrotation may need contrasted upper gastrointestinal studies or cross-sectional imaging. graded compression ultrasound plays a vital role in the diagnosis of acute appendicitis, especially in children. however, in the presence of bowel obstruction, this modality may be limited by bowel gas. multidetector ct is the gold standard for imaging acute appendicitis.14 by following the intestinal segments sequentially from the stomach to the anus or vice versa, one is able to demonstrate the location of the caecum and ascending colon. multidetector ct also has the capability to assess the vasculature.5,7 one limitation of mdct in acute appendicitis is the overlapping range in maximal appendiceal diameter between inflamed and non-inflamed appendices. the presence of fat stranding, abscesses and an appendicolith are valuable ancillary findings in confirming the diagnosis. in children with minimal abdominal fat, pericaecal fat stranding may not be present, limiting confidence in a definitive diagnosis. the current case demonstrated a left-sided caecum and faecolith associated with an abscess in the left iliac fossa (see figure 1a–c). the presence of multiple dilated bowel loops and collapsed large bowel with interloop collections provided challenges in tracing the bowel. the mip was very useful in helping to visualise the course of the appendicular vessels. the sma was followed to the ileocolic and the appendicular artery (figure 3). these vessels normally course towards the right iliac fossa. however, in our patient they deviated to the left where an abscess and the appendicolith were seen. this, combined with the left-sided caecum improved confidence in diagnosing appendicitis. maximum intensity projection software is available on most radiology workstations in south africa. the mip provides improved display of vascular maps, improving visualisation of most segments of the vessel including the intraparenchymal branches.15 source images are used to display the maximum intensities in the voxels with selection of optimum slab thickness depending on the orientation of the vessels and the density of the adjacent structures. as mip is not a 3d volume-rendered application, one of the pitfalls is the false interpretation of the relationship of the vessels and adjacent structures in the presence of high-intensity structures.15,16,17 this necessitates the user to adjust the display parameters to include the degree of opacification and slab thickness that correctly depicts the vasculature. the mip requires substantial editing in most cases to clearly depict the anatomical display of the vessels. the quality of the final product may vary according to the experience of the user and the vendor.15 conclusion this case report highlights mip as a diagnostic problem-solving tool in the atypical presentation of a mobile caecum. familiarity with this post-processing software is useful for advanced imaging application in clinical practice. this case report also increases awareness of the mobile caecum as an anatomic variant, which may result in an atypical presentation of acute appendicitis. acknowledgements the authors would like to acknowledge c. naidoo and p. kobo who diagnosed the patient at the radiology department and l.t. mtshabe and s. mduna who operated on the patient (division of general surgery). they are also grateful to z. njumba and a. ndabankulu who followed up with the patient for consent. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.a.f.n. drafted and wrote the article. f.m.o. and k.f.k. critically revised the article with important conceptual and editorial input. ethical considerations ethical approval to conduct the study was obtained from the walter sisulu university’s ethics committee (protocol number 002/2021). funding information this work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability original images, consent form and any required information are available on request from the corresponding author (k.a.f.n.). disclaimer the views and opinions expressed in this article are those of the authors and not an official position of the institution. references akbulut s, ulku a, senol a, tas m, yagmur y. left-sided appendicitis: review of 95 published cases and a case report. world j gastroenterol. 2010;16(44):5598. https://doi.org/10.3748/wjg.v16.i44.5598 rogers rl, harford fj. mobile cecum syndrome. dis colon rectum. 1984;27(6):399–402. https://doi.org/10.1007/bf02553011 yang cy, liu hy, lin hl, lin jn. left-sided acute appendicitis: a pitfall in the emergency department. j emerg med. 2012;43(6):980–982. https://doi.org/10.1016/j.jemermed.2010.11.056 alzaraa a, chaudhry s. an unusually long appendix in a child: a case report. cases j. 2009;2(1):7398. https://doi.org/10.4076/1757-1626-2-7398 yazawa k, azuma y, kurokawa t, yoshioka y, tsurita g, shinozaki m. abdominal ct-aided diagnosis of acute appendicitis in the presence of mobile cecum: a case report. int j surg case rep. 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c. colonic duplications: clinical presentation and radiologic features of five cases. eur j radiol. 2006;59(1):14–19. https://doi.org/10.1016/j.ejrad.2006.03.012 sivit cj, applegate ke. imaging of acute appendicitis in children. semin ultrasound ct mri. 2003;24(2):74–82. https://doi.org/10.1016/s0887-2171(03)90003-5 toprak h, bilgin m, atay m, kocakoc e. diagnosis of appendicitis in patients with abnormal position of the appendix due to mobile caecum. case rep surg. 2012;2012:921382. https://doi.org/10.1155/2012/921382 fishman ek, ney dr, heath dg, corl fm, horton km, johnson pt. volume rendering versus maximum intensity projection in ct angiography: what works best, when, and why. radiographics. 2006;26(3):905–922. https://doi.org/10.1148/rg.263055186 rubin gd, dake md, napel s, et al. spiral ct of renal artery stenosis: comparison of three-dimensional rendering techniques. radiology. 1994;190(1):181–189. https://doi.org/10.1148/radiology.190.1.8259402 dalrymple nc, prasad sr, freckleton mw, chintapalli kn. introduction to the language of three-dimensional imaging with multidetector ct. radiographics. 2005;25(5):1409–1428. https://doi.org/10.1148/rg.255055044 radioactive news sajr august 2013 vol. 17 no. 3 119 rssa cone beam ct workshop d wagenfeld ent specialist in private practice, somerset west a cone beam ct (cbct) workshop was held at the investec auditorium in cape town on 1 june 2013. the technique has been around for some time, but its use has been largely limited to dental and maxillofacial practices; its wider applications have not been embraced as yet by the radiological and medical fraternity at large. the workshop addressed this hiatus in a most informative way. over 60 professionals attended the day-long course, including radiologists, radiographers, dentists, maxillofacial surgeons, dental specialists and ent surgeons, with professor curly nortje introducing the topic, with a review of the principles of panoramic radiography. thereafter, most of the presentations were given by the visiting faculty, dr dale miles from arizona, whose wide experience brought the subject to life for the delegates. he explained the basic principles, then outlined the various applications by specific examples ranging from dental conditions, through soft-tissue images in the head and neck, to the most detailed micro-imaging of the temporal bone structures. the possibilities were most impressively demonstrated, and a sense of excitement arose from the prospects offered by cbct. of great importance was the point made by dr miles that having all this detailed information available on the periphery of the area being targeted, placed enormous responsibility on the clinician not to miss pathology in areas with which he might be unfamiliar. therefore, not only for ethical reasons, but especially also medicolegal consequences, the intimate involvement of a radiologist to scrutinise and report on such scans was emphasised. as a ‘going home message’, this aspect ranks in importance with the fact that cbct gives information comparable to conventional ct at a fraction of the radiation exposure, something especially important in the paediatric patient group. professor leon janse van rensburg then gave highly informative and entertaining talks on his own experiences with cbct, and the lessons he learnt (and is still learning!) in this most promising and challenging new field. in all, this was a superlative learning experience and introduction to an exciting advance in radiological imaging, and the rssa is congratulated on its contribution in promoting responsible use of a new diagnostic tool. south african society of paediatric imaging (saspi) report vicci du plessis grey’s hospital, pietermaritzburg we are proud to announce that the highly successful rssa/saspi paediatric imaging congress in november 2012 drew 328 delegates and boosted saspi membership from 36 to 107. report on spr and wfpi annual meetings − 2013 the 56th annual meeting and postgraduate course of the society of pediatric radiology (spr) were held in may in san antonio, texas. of the 590 delegates, 6 were from africa, of whom 4 were proudly south african. the spr postgraduate course outlined the current practice of paediatric imaging, covering basic principles, clinical applications and new frontiers in various subspecialties. there were dedicated sessions for cardiac, chest, interventional, gastrointestinal, genitourinary, neuroradiology, nuclear medicine, education and fetal imaging. at the scientific sessions, saspi members nasreen mohammed and savvas andronikou presented papers in the chest and neuroradiology categories respectively. dr james downing, scientific director of st jude children’s research hospital, presented this year’s innovative neuhauser lecture on the impact of genomic profiles on diagnosing and treating paediatric cancers. among the prestigious award recipients at the congress was our very own saspi chairman, professor savvas andronikou, who received honorary membership of the spr. as saspi vice-chair and secretary, respectively, jaishree naidoo and vicci du plessis represented south africa at the annual meeting of the world federation of paediatric imaging (wfpi). the wfpi is a non-profit organisation that provides an international platform for paediatric radiology societies united to address the challenges in global paediatric imaging training and the delivery of services. at the meeting, the president’s and treasurer’s annual report were presented, which included feedback on education, outreach and training in lowerresource settings and child imaging safety. the report on outreach in lower-resource settings was presented by savvas andronikou, chair of the wfpi outreach & training committee. he gave an update on the voluntary tele-reporting initiative at khayelitsha hospital, cape town, and new outreach movements in haiti, india, liberia and mozambique. he also put forward the justifications and strategy for the establishment of an international tb network, an upcoming and exciting new venture in paediatric imaging outreach. the saspi co-executive committee extend heartfelt thanks to the rssa, including the cme trustees, administrators, ceo and president, the spr, the wfpi and of course saspi for affording us the unique and valuable opportunity to attend spr 2013. the experience not only allowed us to improve our knowledge in paediatric radiology, but also to strengthen ties with international colleagues, with a view to keeping south african radiologists involved in future paediatric imaging activities and outreach projects. paediatric radiology roadshow as a saspi initiative, paediatric radiologists savvas andronikou, jaishree naidoo and tanyia pillay will visit 2 centres in kwazulu-natal, and present series of lectures at the inkosi albert luthuli community hospital in durban and at grey’s hospital in pietermaritzburg on 26th and 27th august 2013, and will also spend ‘hands-on’ time in the radiology departments, assisting with paediatric ultrasound and fluoroscopy procedures, and interpreting radiographs and mri cases. professor savvas andronikou receiving the honorary spr membership award, with kassa darge and sue kaste (spr president). abstract introduction primary solid mesenteric lesions primary cystic mesenteric lesions secondary mesenteric lesions infections inflammatory bowel disease role of imaging management of mesenteric lesions conclusion acknowledgements references about the author(s) snehal i. kose department of radiodiagnosis, maulana azad medical college, delhi, india sapna singh department of radiodiagnosis, maulana azad medical college, delhi, india anju garg department of radiodiagnosis, maulana azad medical college, delhi, india alpana manchanda department of radiodiagnosis, maulana azad medical college, delhi, india rajdeep singh department of surgery, maulana azad medical college, delhi, india citation kose si, singh s, garg a, manchanda a, singh r. ultrasound and computed tomography in the evaluation of mesenteric lesions: a pictorial review. s afr j rad. 2023;27(1), a2595. https://doi.org/10.4102/sajr.v27i1.2595 pictorial review ultrasound and computed tomography in the evaluation of mesenteric lesions: a pictorial review snehal i. kose, sapna singh, anju garg, alpana manchanda, rajdeep singh received: 22 nov. 2022; accepted: 22 mar. 2023; published: 24 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the mesentery is a broad fan-shaped fold of peritoneum that suspends the loops of small intestine from the posterior abdominal wall. although primary neoplasms arising in the mesentery are rare, the mesentery is a major avenue for the dissemination of tumours, which can spread through hematogenous, lymphatic, direct or peritoneal seeding. imaging helps in the diagnosis of these tumours and aids in directing appropriate treatment by assessing their size, extent and relationship with adjacent structures. the aim of this article is to describe the spectrum of imaging findings of the various mesenteric lesions using ultrasound and ct. contribution: evaluation of the mesentery is often neglected during routine ultrasound (us) because of inadequate training and unfamiliarity with the common us features encountered with mesenteric disease. ct plays an essential role in the diagnosis of mesenteric disease. knowledge of imaging characteristics of various mesenteric lesions helps in timely diagnosis and management. keywords: ct; computed tomography; ultrasound; inflammatory myofibroblastic tumour; gastrointestinal stromal tumour. introduction the mesentery is a broad, fan-shaped fold of peritoneum that suspends the loops of small intestine from the posterior abdominal wall. secondary involvement of the mesentery from tumours elsewhere is much more common than primary mesenteric neoplasms such as desmoid tumour, inflammatory myofibroblastic tumour (imft), and others. most patients with mesenteric lesions present with non-specific symptoms of abdominal pain, tenderness, palpable abdominal swelling, abdominal distension and weight loss. these symptoms are shared by pathologies of other abdominal organs and it is therefore very difficult to identify mesenteric lesions clinically. some mesenteric diseases present with distinctive imaging findings while others have similar findings, thereby complicating their differential diagnosis. understanding the characteristic radiological patterns on ultrasound (usg) and ct offers valuable insights for differential diagnoses of mesenteric lesions and their treatment. primary solid mesenteric lesions primary mesenteric solid neoplasms are rare and the majority of them are benign. desmoid tumour the most common soft tissue lesion in the mesentery is a desmoid tumour. it usually occurs in patients with familial adenomatous polyposis (fap) or gardner syndrome. trauma or surgery serves as a predisposing factor for the development of desmoid tumours.1 on usg, this tumour appears as a well-defined or ill-defined mass with heterogenous echotexture and internal vascularity. on ct, it appears as a well-defined or ill-defined mass showing heterogenous enhancement usually in the portal venous phase and it may infiltrate the adjacent organs.2 the mri appearance of desmoid tumours depends on the relative proportion of cellular, myxoid and fibrous components. inflammatory myofibroblastic tumour inflammatory myofibroblastic tumours usually occur in children and adolescents. they appear as solitary or multiple irregular hypoechoic masses with heterogeneous echotexture and increased echogenicity in the surrounding mesentery and omentum on usg and show increased internal vascularity on colour doppler.3 inflammatory myofibroblastic tumour appears as a hypo or iso-attenuating mass compared with skeletal muscle depending on the amount of myxoid or collagenous stroma, respectively. dense central calcification may be noticed. they demonstrate various contrast enhancement patterns including early peripheral enhancement because of vascular tissue (figure 1), delayed central enhancement of the fibrotic components, heterogenous, homogenous and absent enhancement.4 differential diagnosis includes desmoid tumour and solitary fibrous tumour. figure 1: mesenteric inflammatory myofibroblastic tumour. axial (a, b) and coronal (c) contrast enhanced ct images of the abdomen in a 14-year-old girl reveal multiple well-circumscribed heterogenously enhancing nodular lesions in the mesentery indenting the dome of the urinary bladder. the lesions have a peripheral enhancing rim and central non-enhancing core. few foci of punctate calcification (white arrow) are observed within one of the nodular lesions. photomicrograph of the histopathological specimen on igg4 immunochemistry (d) reveals spindle cells with areas of storiform fibrosis and infiltration by plasma cells (positive for igg4). lipoma and liposarcoma lipomas are benign tumours composed of mature adipose tissue, usually associated with obesity and hyperlipidaemia. on usg, they appear as well-defined echogenic lesions without internal vascularity. on ct, they appear as a well encapsulated fatty attenuation mass. differential diagnosis includes well-differentiated liposarcoma, which is characterised by larger size (usually greater than 10 cm), associated soft tissue component and thick irregular septations. liposarcomas are rare malignant tumours of the mesentery. liposarcomas are divided into five types histopathologically: well-differentiated, myxoid, pleomorphic, round cell and de-differentiated liposarcoma. well-differentiated liposarcomas have mixed fatty and soft tissue components while de-differentiated liposarcomas have clearly separated soft tissue and fatty components. myxoid liposarcomas have fluid density on ct with mixed soft tissue and fatty components. pleomorphic and round cell liposarcomas have soft tissue components only, with no identifiable fatty component on imaging. mesenteric castleman disease three patterns of mesenteric involvement have been described for castleman disease, namely a solitary non-invasive mass (most common), a dominant infiltrative mass with associated lymphadenopathy and matted lymphadenopathy without a dominant mass. these tumours show early, homogenous and intense enhancement (figure 2). tumours measuring > 5 cm in size may show heterogenous enhancement. calcification is seen in 10% of cases, which can be punctate or arborising in appearance. the arborising type of calcification (figure 2) is characteristic of castleman disease.5 figure 2: mesenteric castleman disease on histopathology. axial (a), coronal (b) and sagittal (c) contrast enhanced ct images of the abdomen in a 26-year-old male reveal a well-defined round homogenously enhancing mass in the mesentery in the left lumbar region anterior to the lower pole of left kidney with a mean attenuation of ~101 hu and central arborising calcification. photomicrograph of the histopathological specimen (d) shows acellular areas comprising vessels with dense sclerotic walls and cellular areas comprising spindle cells with bland nuclear morphology and inflammatory cell infiltrate comprising plasma cells. calcifying fibrous tumour of the mesentery calcifying fibrous tumours appear as round hypo or hyperdense masses on ct with various patterns of calcification: irregular, scattered, punctate, band-like, clustered and amorphous6 (figure 3). figure 3: calcifying fibrous tumour of the mesentery. transverse grey scale ultrasound image (a) reveals a calcified lesion in left lumbar region causing extensive posterior acoustic shadowing. axial contrast enhanced ct images (b, c) and coronal reformatted contrast enhanced ct image (d) reveal a well-defined oval smooth marginated mass lesion in the mesentery with near complete calcification, abutting the bowel loops. malignant mesothelioma malignant mesotheliomas tend to spread as sheets of tissue over the parietal and visceral peritoneal surfaces and become confluent, encasing the abdominal organs (figure 4). the ‘wet’ type presents as an irregular, nodular or sheet-like peritoneal thickening, omental mass and ascites while in the ‘dry’ type, peritoneal based masses are present with no ascites.7 imaging presentation of this tumour is similar to peritoneal carcinomatosis. the presence of asbestos exposure, calcified pleural plaques and relatively less ascites compared with soft tissue burden, favours the diagnosis of malignant mesothelioma over peritoneal carcinomatosis. figure 4: malignant peritoneal mesothelioma. contrast enhanced ct images – axial (a), coronal (b) and sagittal (c) reformatted ct images reveal gross ascites with a multilobulated heterogenously enhancing soft tissue mass lesion in the lower abdomen and pelvis. the lesion is encasing the uterus and bilateral adnexa and closely abutting the posterior and superior surface of urinary bladder. sheet like thickening and enhancement of the parietal peritoneum, visceral peritoneum and leaves of mesentery is noted (thin white arrows) causing encasement of the bowel loops. sheet like omental thickening (thick white arrows) and caking is seen. mild stranding is observed in the mesenteric fat. photomicrograph of the histopathological specimen shows cells arranged in a papillary pattern with a prominent fibrovascular core. on immunohistochemistry, these cells are positive for mesothelin (d). primary mesenteric gastrointestinal stromal tumour extraintestinal gastrointestinal stromal tumours usually appear as well-defined masses with lobulated contours. they usually reveal heterogenous enhancement with central low attenuation areas occupying more than half of the tumour area (figure 5) and increased peripheral attenuation. central gas or extravasation of oral contrast may be seen due to communication of the mass with the bowel lumen.8 calcification and lymphadenopathy are usually not present. figure 5: primary mesenteric gastrointestinal stromal tumour. transverse grey scale ultrasound image (a) in a 32-year-old female shows a large well-defined heterogenously hypoechoic mesenteric mass lesion measuring ~14 cm × 10 cm × 9.1 cm in size with lobulated margins. axial (b) and coronal (c) contrast enhanced ct images reveal a large well-defined heterogenously enhancing mass lesion in the mesentery. the lesion shows lobulated margins and non-enhancing central necrotic area occupying > 50% of the area of tumour. no calcification, gas foci or cavitation is observed within the lesion. no direct invasion into surrounding bowel loops is noticed. an enhancing vessel is seen traversing through the mass (white arrow) immunohistochemistry image of the surgical specimen (d) shows tumour cells positive for tumour marker for gastrointestinal stromal tumour (gist), that is dog-1 (discovered on gist-1). sclerosing mesenteritis mesenteric panniculitis presents as a well-defined fatty mass in the root of mesentery. diffuse homogenous hyperechogenicity with good sound transmission through it and non-deviated vessels is seen on ultrasound. it appears as a well-defined mass of inhomogenous fatty tissue encasing the superior mesenteric vessels with no invasion of surrounding bowel loops on ct (figure 6). well-defined soft tissue nodules with preservation of fatty halo around vessels and nodules (fat ring sign) may be seen. hyperattenuating stripe partly surrounding the mass (tumoural pseudocapsule sign) is seen in 59.2% cases.9 figure 6: mesenteric panniculitis. transverse grey scale ultrasound image (a) of the abdomen in a 63-year-old male reveals diffusely echogenic mesentery with no well-defined solid mass. axial contrast enhanced ct images of the abdomen (b, c) reveals an ill-defined inhomogenous mass of mean attenuation ~ 5.8 hu (greater than that of retroperitoneal fat). multiple hyperdense nodules are seen within the mass and surrounding mesentery. thin discontinuous slightly hyperattenuating soft tissue rim is seen on the anterior and posterior aspect of the mass limiting the mass from the surrounding mesentery (thick white arrow in b) – tumoural pseudocapsule sign. the mass is seen to encase superior mesenteric artery (sma), superior mesenteric vein (smv) and their branches with preservation of a ring of fat around mesenteric vessels and nodules (thin white arrows in c) – fat ring sign. coronal reformatted ct image (d) reveals an ill-defined inhomogenous mass in the mesentery encasing the sma, smv and their branches with preservation of a rim of fat around sma (thin white arrow – fat ring sign). retractile mesenteritis (sclerosing mesenteritis with predominant fibrotic component) is seen as one or more irregular fibrotic soft tissue mesenteric masses7, which may show calcification within and may encase adjacent bowel loops and vascular structures leading to signs of obstruction and hollow visceral ischaemia. an important differential for sclerosing mesenteritis is mesenteric metastases from carcinoid tumour, which also presents as a spiculated marginated mass in the mesentery; however, associated arterial phase hyperenhancing small bowel thickening is usually seen in carcinoid metastases. primary cystic mesenteric lesions lymphangiomas lymphangiomas are benign lymphatic proliferations that usually occur in childhood. they appear as thin-walled cystic lesions with multiple thin septa (honeycomb or cobweb pattern) on usg and as a unilocular or multilocular cyst with enhancement of the wall or septations on contrast enhanced ct.10 they show variable attenuation depending on their contents (chylous, serous or haemorrhagic contents) and may insinuate between the mesenteric vessels (figure 7). figure 7: mesenteric lymphangioma. transverse grey scale ultrasound images (a, b) of the abdomen in a 3-year-old male child reveal an ill-defined multiloculated irregular-shaped thin-walled cystic lesion in the mesentery showing posterior acoustic enhancement. the lesion is located anterior to bilateral kidneys, pancreas (white arrow) and aorta. multiple thin septations are noticed within the lesion creating a ‘cobweb’ appearance. echogenic contents are seen within few loculi resulting in differential echogenicity of loculi. no calcification is noticed within the lesion. axial contrast enhanced ct images (c, d) in the same patient reveal a multilobulated thin-walled fluid density cystic lesion in the mesentery anterior to pancreas and aorta. the lesion is insinuating between leaves of mesentery and bowel loops. mesenteric vessels can be seen traversing through the lesion. simple mesothelial cysts these appear as thin-walled anechoic unilocular cysts with posterior acoustic enhancement on usg and unilocular fluid attenuation lesions with no discernible wall on ct.11 benign cystic mesothelioma benign cystic mesotheliomas are also known as peritoneal inclusion cysts and they usually occur in premenopausal women. they are often associated with trauma, surgery, infection and endometriosis.2 they occur because of entrapment of fluid (secreted by the ovaries during ovulation) between peritoneal adhesions.7 they are seen as a fluid attenuation multilocular cystic lesion, multiple unilocular thin-walled cysts or unilocular cystic mass on ct with enhancing but non-calcified septa, which often surround the ovaries. on usg, they appear as unilocular or multilocular cystic lesions, which may be anechoic or may display contents of variable echogenicity (figure 8). figure 8: benign cystic mesothelioma. transverse grey scale ultrasound images (a, b) of the abdomen in a 38-year-old female reveal a well-defined cystic lesion around the right ovary with internal low-level echoes and a ground glass appearance suggestive of an endometrioma (white thick arrow in a). another ill-defined thin-walled multiloculated cystic lesion (white thin arrow in b) is seen in midline and left side of lower abdomen and pelvis encasing the left ovary in its posterior aspect. coronal ct image (c) of the abdomen reveals a well-defined hyperdense cyst of mean attenuation ~ 33 hu in the right adnexa (thick white arrow in c). multilobulated fluid attenuation (~18 hu) cystic lesion with thin imperceptible walls is noticed in left lower abdomen and pelvis (thin white arrow). sagittal reformatted cect image (d) reveals a thin-walled multilobulated cystic lesion anterior and superior to uterus, encasing the left ovary posteriorly (arrowhead). minimal fluid is observed within the endometrial cavity. no calcification or mural nodule is noted within the lesion. benign mucinous cystic neoplasm of the mesentery they usually arise from implantation of ovarian tissue during migration or metaplasia of mesothelial cells into ovarian tissue. they appear as thin-walled fluid attenuation unilocular cystic lesions in the mesentery (figure 9). figure 9: mesenteric cyst. grey scale ultrasound image (a) of the abdomen in a 26-year-old female reveal a well-defined thin walled unilocular anechoic cystic lesion (asterisks) showing posterior acoustic enhancement in the mesentery. no evidence of internal septations, calcification, mural nodule or internal vascularity noted. axial contrast enhanced ct image of the abdomen (b) shows a well-defined thin walled unilocular cystic lesion (asterisks) anterior to lower pole of left kidney. coronal reformatted contrast enhanced ct image (c) shows a well-defined unilocular cystic lesion (asterisks) in the left lumbar and iliac region displacing the descending colon medially (white arrow). photomicrograph of the histopathological specimen (d) reveals the cyst wall lined by flattened and mucin secreting tall columnar epithelium. there is no atypia, mitosis or necrosis. secondary mesenteric lesions secondary involvement of the mesentery by tumours elsewhere is much more common than primary mesenteric tumours. these neoplasms spread to the mesentery by the following routes: direct tumour spread several abdominal malignancies including biliary, pancreatic, gastric and colon cancers may invade directly into the mesentery.12 direct spread into the mesentery occurs in small bowel carcinoid, which appears as an intensely enhancing soft tissue mass with linear fibrous bands radiating in the surrounding fat. calcification occurs in 70% cases.13 associated thickening of the bowel wall and angulation of bowel loops might be noticed (figure 10). figure 10: carcinoid tumour of ileum with mesenteric metastases. axial (a, b) and coronal (c) contrast enhanced ct images of the abdomen in a 56-year-old male reveal nodular enhancing wall thickening of the distal ileum (thick white arrow) causing obstruction and dilation of proximal small bowel loops. a homogenously enhancing soft tissue lesion (thin white arrow) is seen in the mesentery adjacent to the bowel thickening. numerous fibrous strands are seen radiating from its periphery to the ileal loops with resultant kinking of ileal loops. an intensely enhancing nodular lesion is noted in the mesentery (arrowhead in b) likely a lymph node. photomicrograph of the histopathological specimen from the mesenteric mass (d) reveals regular small polygonal cells in an insular pattern with round nuclei, salt and pepper chromatin and lacking atypia and mitosis. lymphatic spread lymphoma appears as a lobulated sonolucent mass surrounding vascular trunks with maintained perivascular echogenic fat giving the ‘sandwich appearance’.14 lymph nodes may be small and discrete in early disease and later coalesce to form a conglomerate soft tissue mass, which grows around and displaces surrounding structures. involved lymph nodes have soft tissue attenuation (40 hu – 50 hu) and demonstrate homogeneous enhancement following contrast administration (figure 11). besides lymphoma, many other tumours such as lung, breast, colon, ovarian cancers, chronic lymphoid leukaemia, and others, can involve the mesentery via the lymphatics. figure 11: non-hodgkin’s lymphoma-follicular type. transverse grey scale ultrasound image of the abdomen (a) in a 62-year-old female reveals a well-defined homogenously hypoechoic mass encasing the mesenteric vessels anterior to the common iliac arteries. a few foci of calcification are seen within the lesion (thick white arrow). axial (b) and coronal (c) contrast enhanced ct images reveal a homogenously enhancing lymph nodal mass encasing the sma (thin white arrow in c), superior mesenteric vein (thick white arrow in c) and their branches without causing luminal attenuation (sandwich sign). another homogenously enhancing lymph nodal mass lesion is seen encasing the common iliac arteries (curved arrows in b). a few foci of calcification are seen within the lesion (asterisk in b). gross ascites is also seen. photomicrograph of the histopathological specimen (d) shows variable sized follicles replacing the entire lymph node. the follicles are comprised of follicular centre cells with an admixed large number of centroblasts (h&e, 200x). hematogenous spread melanoma, breast and lung carcinoma can involve the mesentery via the hematogenous route.12 these lesions are usually seen along the antimesenteric border because of the abundant submucosal vascular plexus. four patterns of peritoneal seeding are noted:12 infiltrative pattern leading to a misty mesentery. nodular pattern/caking (figure 12). retractile pattern seen as small bowel retraction, angulation and kinking. stellate mesentery: the straightened mesenteric blood vessels are held rigid within a thickened sheet such as the mesentery, producing the characteristic stellate appearance on ct because of infiltration of tumour along the mesenteric vessels. figure 12: bilateral ovarian granulosa cell tumour with metastatic deposits. axial contrast enhanced ct image (a) of the abdomen in a 45-year-old female reveals multiple heterogeneously enhancing predominantly solid nodular deposits in morison’s pouch (thick white arrow) and along the lateral surface of the liver (arrowhead). axial section in the pelvis (b) reveals heterogeneously enhancing, predominantly solid masses in both ovaries (asterisk) along with a nodular deposit in the mesentery (thin white arrow). sagittal reformatted ct image on bone window (c) shows a fracture and collapse of the l2 vertebral body (short thick white arrow), likely a pathological fracture related to metastases. photomicrograph of the histopathological specimen (d) of the mesenteric lesion [h & e stain] reveals scattered and clustered round plasmacytoid cells with central to eccentrically placed nuclei and a prominent microfollicular pattern. some of the follicles show central pinkish material (call–exner bodies) and moderate focal pleomorphism. infections abdominal tuberculosis abdominal lymphadenopathy is the most common finding associated with tuberculosis. involved lymph nodes appear enlarged, conglomerate and show ring enhancement (necrosis). other findings observed in cases of abdominal tuberculosis include mesenteric nodularity, fat stranding, peritoneal thickening, localised collections, free fluid, clumping of bowel loops, bowel wall thickening and solid organ involvement in the form of hepatomegaly, splenomegaly, liver and splenic granulomas.15 whipple’s disease it is an infectious condition caused by gram-positive bacterium, tropheryma whipplei. on imaging, small bowel wall thickening associated with enlarged mesenteric lymph nodes demonstrating hypoattenuating centres because of fat deposition can be seen. diagnosis is made by small intestinal mucosal biopsy.16 actinomycosis actinomyces israelii is an anaerobic gram-positive bacterium and is a normal inhabitant of the oral cavity, gastrointestinal tract and female genital tract. it spreads to involve the mesentery when a mucosal breach is present such as inflammation, surgery, trauma or intrauterine contraceptive device (iucd) use.17 on imaging, an ill-defined heterogeneously enhancing soft tissue mass infiltrating the mesentery and adjacent organs can be seen. septic embolism leading to hepatic, renal and splenic abscesses can occur.2 diagnosis is made based on aggressive imaging features and subtle clinical symptoms in predisposed individuals. biopsy should be performed in indeterminate imaging findings, which reveal sulphur granules representing bacterial colonies. hydatid cyst these usually occur because of intraperitoneal rupture of liver or splenic hydatid cysts (figure 13). hydatid cysts can appear as either unilocular cysts (type i cyst), multiloculated cystic lesions with daughter cysts at the periphery (type iia), multilocular lesions with irregular daughter cysts occupying almost the entire volume of the maternal cyst (rosette appearance – type iib) or high attenuation lesion containing occasional calcification and daughter cysts (type iic). type iii cysts are calcified cysts while complicated hydatid cysts are included in the type iv category.18 figure 13: hydatid cysts. axial contrast enhanced ct images (a, b) of the abdomen in a 6-year-old child reveal multiple, well-defined peripherally enhancing unilocular cystic lesions in the mesentery and pelvis (white arrows) with no internal septations, mural nodule or calcification within the lesions. coronal reformatted ct image (c) reveals well-defined unilocular cysts in the liver and spleen with no internal septations, calcifications or mural nodule. inflammatory bowel disease mesenteric changes in inflammatory bowel disease include mesenteric fibrofatty proliferation, mesenteric lymphadenopathy, fat stranding (figure 14), abscess and prominent vasa recta (comb sign). figure 14: crohn’s disease. axial (a, b) and coronal (c) contrast enhanced ct images of the abdomen in a 45-year-old female reveal mesenteric fibrofatty proliferation in the right iliac fossa (curved white arrow), mesenteric lymph nodes (thin white arrow), thickening of the caecal wall with submucosal fat proliferation ([fat target sign] – thick white arrow) and prominent and straightened vasa recta ([comb sign] – arrowheads). photomicrograph of the ileal biopsy specimen (d) shows transmural infiltration of the ileum by inflammatory cells with loss of the villous architecture. vascular anomalies acute mesenteric ischaemia findings in acute mesenteric ischaemia related to superior mesenteric artery (sma) thrombosis include dilated bowel loops with paper-thin walls, pneumatosis intestinalis, air within mesenteric vessels, mesenteric fat stranding and free fluid on cect19 (figure 15). figure 15: superior mesenteric artery (sma) thrombosis with acute mesenteric ischaemia. axial contrast enhanced ct images (a–d) reveal thrombus in the superior mesenteric artery (thick white arrow in a) at the level of its origin from aorta. the large and small bowel loops appear dilated and show paper-thin walls. few air foci are seen within wall bowel loops suggestive of pneumatosis intestinalis (thin white arrow in b). air is also noticed along the mesenteric vessels (arrowheads in c and d). sma-smv arteriovenous fistula on usg, tangled serpentine vessels can be seen, which show pulsatile waveforms on spectral doppler while on cect, tangled serpentine vessels can be seen with early opacification of venous channels in the arterial phase. direct communication between branches of the sma and superior mesenteric vein (smv) can be visualised on volume rendering technique (vrt) images. role of imaging ultrasound is the primary imaging modality in the evaluation of mesenteric lesions. it helps in characterising mesenteric lesions as solid or cystic. ultrasound guided percutaneous biopsy offers real time assessment of the needle tract to avoid vascular injury while performing biopsy.20 evaluation of lesions is limited on usg because of operator-dependence, obscuration of the mass in the presence of a gaseous abdomen and obese patients, and inadequate visualisation of the extent of large mesenteric lesions. contrast enhanced ct is the primary workhorse for evaluation of mesenteric lesions. it helps in determining the origin of the lesions, providing thoughtful differential diagnosis of masses, for selecting the site of biopsy, determining the extent of pathology and accessibility for resectability of lesion. ct, however, has several limitations including poor soft tissue contrast resolution, exposure to ionising radiation and contrast reactions. mri can be used as the next step in characterising mesenteric lesions. it has higher soft tissue contrast resolution and helps in characterising fluid content of cysts as serous, mucinous, chylous or haemorrhagic and the soft tissue component of solid lesions. fluoro-deoxyglucose (fdg) positron emission tomography (pet) ct is presently used to detect lymph nodes and distant metastases in mesenteric tumours and also for response assessment to chemotherapy. management of mesenteric lesions management of mesenteric lesions depends on symptoms and imaging findings. mesenteric lesions detected incidentally on imaging need classification as benign or malignant. definite diagnosis of a few pathologies such as mesenteric panniculitis, lymphoma, desmoid tumour in patients with fap and benign cystic lesions can be made on imaging. however, lesions with indeterminate imaging findings need to be biopsied to rule out malignancy. imaging helps in determining the site for percutaneous biopsy in such tumours. lesions that are inaccessible to percutaneous biopsy or show indeterminate histopathology findings on percutaneous biopsy require surgical biopsy to confirm the diagnosis.21 once confirmed by biopsy, management of the mesenteric lesions depends on the histopathology. lymphomas and desmoid tumours are managed conservatively with chemotherapy and hormonal therapy or imatinib, respectively. well-circumscribed lesions located in the periphery of the mesentery can be resected completely, without sacrificing significant bowel length or major mesenteric vessels. infiltrative mesenteric lesions, located in the root of mesentery are usually managed conservatively because of involvement of major vessels and the need for sacrificing a major portion of bowel, which may lead to small bowel syndrome. well-defined malignant tumours and symptomatic benign tumours are treated surgically. the goal of surgery is r0 resection (grossly as well as microscopically negative tumour margins), while r1 resection followed by adjuvant chemoradiotherapy can also be performed. well-defined asymptomatic benign lesions can be followed up and resection is performed when they become large or cause symptoms. symptomatic infiltrative benign or malignant lesions can be managed by debulking surgery to reduce tumour load and prevent complications such as bowel obstruction or mesenteric ischemia. conclusion although histopathology is the gold standard for diagnosis of mesenteric lesions, imaging plays an important role in diagnosis of mesenteric neoplasms, detection of complications and in deciding appropriate treatment options. ultrasound is inadequate for optimal visualisation of mesenteric neoplasms and in detecting their relation with other structures because of shadowing from bowel gas, calcification or inadequate penetration of sound beams in obese patients. ct is an excellent imaging modality in the characterisation of mesenteric lesions, detecting their extent and relations with surrounding structures, which is useful for surgical planning. however, ct too has several limitations and other imaging modalities such as mri and fdg-pet can be helpful in further characterisation of mesenteric lesions. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.k. conceptualised this article. s.s., a.g. and a.m. supervised the data collection. s.s., a.g., a.m. and r.s. reviewed and edited the final draft of the manuscript. s.k. collected the relevant data and reference articles and prepared the primary manuscript draft. ethical considerations ethical clearance to conduct this study was obtained from the maulana azad medical college (reference: f.no. 17/iec/mamc/2018/17). funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references shields cj, winter dc, kirwan wo, redmond hp. desmoid tumours. eur j surg oncol. 2001;27(8):701–706. https://doi.org/10.1053/ejso.2001.1169 dufay c, abdelli a, le pennec v, chiche l. mesenteric tumors: diagnosis and treatment. j visc surg. 2012;149(4):e239–e251. https://doi.org/10.1016/j.jviscsurg.2012.05.005 qian j, zhu k, ye j. ultrasonic manifestations of mesenteric inflammatory myofibroblastic tumors in children. front pediatr. 2019;7:39. https://doi.org/10.3389/fped.2019.00039 chung em, biko dm, arzamendi am, meldrum jt, stocker jt. solid tumors of the peritoneum, omentum, and mesentery in children: radiologic-pathologic correlation. radiographics. 2015;35(2):521–546. https://doi.org/10.1148/rg.352140273 bonekamp d, horton km, hruban rh, fishman ek. castleman disease: the great mimic. radiographics. 2011;31(6):1793–1807. https://doi.org/10.1148/rg.316115502 chorti a, papavramidis ts, michalopoulos a. calcifying fibrous tumor: review of 157 patients reported in international literature. medicine. 2016;95(20):e3690. https://doi.org/10.1097/md.0000000000003690 mclaughlin pd, filippone a, maher mm. neoplastic diseases of the peritoneum and mesentery. am j roentgenol. 2013;200(5):w420–w430. https://doi.org/10.2214/ajr.12.8494 kim hc, lee jm, kim sh, et al. primary gastrointestinal stromal tumors in the omentum and mesentery: ct findings and pathologic correlations. am j roentgenol. 2004;182(6):1463–1467. https://doi.org/10.2214/ajr.182.6.1821463 daskalogiannaki m, voloudaki a, prassopoulos p, et al. ct evaluation of mesenteric panniculitis: prevalence and associated diseases. am j roentgenol. 2000;174(2):427–431. https://doi.org/10.2214/ajr.174.2.1740427 gunasekaran g, naik d, kandhasamy sc, soren dn. giant mesenteric cystic lymphangioma: a rare cause of intra-abdominal catastrophe. int surg j. 2019;6(11):4184–4186. https://doi.org/10.18203/2349-2902.isj20195152 ros pr, olmsted ww, moser rp, dachman ah, hjermstad bh, sobin lh. mesenteric and omental cysts: histologic classification with imaging correlation. radiology. 1987;164(2):327–332. https://doi.org/10.1148/radiology.164.2.3299483 nougaret s, lakhman y, reinhold c, et al. the wheel of the mesentery: imaging spectrum of primary and secondary mesenteric neoplasms – how can radiologists help plan treatment?: resident and fellow education feature. radiographics. 2016;36(2):412–413. https://doi.org/10.1148/rg.2016150186 sheth s, horton km, garland mr, fishman ek. mesenteric neoplasms: ct appearances of primary and secondary tumors and differential diagnosis. radiographics. 2003;23(2):457–473. https://doi.org/10.1148/rg.232025081 mueller pr, ferrucci jr, jt, harbin wp, kirkpatrick rh, simeone jf, wittenberg j. appearance of lymphomatous involvement of the mesentery by ultrasonography and body computed tomography: the ‘sandwich sign’. radiology. 1980;134(2):467–473. https://doi.org/10.1148/radiology.134.2.7352232 burrill j, williams cj, bain g, conder g, hine al, misra rr. tuberculosis: a radiologic 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https://doi.org/10.1148/radiol.11103523 gottlieb rh, tan r, widjaja j, et al. extravisceral masses in the peritoneal cavity: sonographically guided biopsies in 52 patients. am j roentgenol. 1998;171(3):697–701. https://doi.org/10.2214/ajr.171.3.9725299 sajr 791 substantive incidental cardiac findings revealed by non-cardiac ct examination of the thorax m durand, n paul, a crean joint division of medical imaging, peter munk cardiac centre, toronto general hospital, toronto, canada m durand, mb chb, fcrad (diag) n paul, md, mrcp, frcr, frcrc joint division of medical imaging and division of cardiology, peter munk cardiac centre, toronto general hospital, toronto, canada a crean, md, mrcp, frcr corresponding author: m durand (mirandadurand@gmail.com) limitations inherent in ct imaging of the thorax left the heart as an ill-defined and largely ignored area. the advent of multi-detector ct scanning and shortened imaging times has allowed clear identification of cardiac structures and pathology. motion-free cardiac images require synchronisation of image acquisition with the cardiac cycle (cardiac ‘gating’ or ‘triggering’). however, significant information can be obtained from careful scrutiny of ungated chest ct images, which may then direct further imaging or investigation. we review 5 cases demonstrating interesting cardiac findings identified on non-cardiac scans. s afr j rad 2013;17(1):34-37. doi:10.7196/sajr.791 for years, the technological limitations inherent in ct imaging of the thorax meant that the heart was an ill-defined and largely ignored ‘space-filler’ between the lungs. with the advent of multi-detector ct scanning (mdct) in the late 1990s, and shortened imaging times, it has now become possible to clearly identify cardiac structures and pathology. motion-free cardiac images require synchronisation of image acquisition with the cardiac cycle (cardiac ‘gating’ or ‘triggering’). however, significant information can often be gleaned from careful scrutiny of ungated chest ct images, which may then direct further imaging or investigation. in the following examples, we review 5 cases demonstrating interesting cardiac findings identified on non-cardiac scans. case 1 history a 26-year-old woman presented to her referring physician with a history of abdominal pain, generalised swelling and bloating. her facial swelling was reported to be worse in the mornings, with subsequent improvement during the course of the day. she volunteered a history of congenital rubella. on examination, no ascites, hepatomegaly or peripheral oedema was identified. her blood results showed normal liver function with bilirubin 8 µmol/l, alt 29 units/litre, ast 32 units/litre and alp 92 units/litre. her albumin, however, was slightly decreased at 26 g/l. an abdominal ct scan was ordered to assess her symptoms. imaging abdominal ct scan demonstrated a mildly enlarged liver with dilated hepatic veins, dilated inferior vena cava (fig. 1a), and diffuse heterogeneous enhancement following administration of intravenous iodinated contrast medium (cm) (fig. 1b) − all in keeping with hepatic venous congestion. limited images of the chest demonstrated pericardial thickening and calcification adjacent to the right ventricle (fig. 1c). this raised the possibility of constrictive pericarditis, and a cardiac mri was requested. this demonstrated small ventricles with relative bi-atrial enlargement (fig. 1d). the pericardial thickening seen on the ct scan was confirmed on the mri scan (fig. 1d). the cine images demonstrated ‘septal bounce’ in keeping with constrictive physiology. the patient had invasive measurement of cardiac pressures which confirmed a constrictive physiology. fig. 1. axial post contrast-enhanced ct scans of the abdomen in a 26-year-old woman with a history of abdominal pain, generalised swelling and bloating. (a ) ct scan through the upper abdomen demonstrates dilated inferior vena cava (arrow) and hepatic veins (arrow heads). (b) ct scan through the upper liver demonstrates a mildly enlarged liver with diffuse heterogeneous enhancement in keeping with hepatic venous congestion. (c) post contrast images through the lower chest on abdominal ct scan demonstrate some pericardial thickening with foci of pericardial calcification adjacent to the basal right ventricle and atrio-ventricular groove (arrow).(d) the four-chamber cine steady-state free precession (ssfp) cardiac mri image demonstrates biatrial enlargement with small biventricular volumes. pericardial thickening is also noted adjacent to the atrio-ventricular groove (arrow). bilateral pleural effusions are also seen (la = left atrium; ra = right atrium). diagnosis pericardial thickening and calcification with a restrictive physiology was the diagnosis. the pericardial thickening and calcifications were most likely due to previous pericarditis. it is possible that the patient might have developed this as a consequence of her rubella infection,1 although it would be unusual for her to present with symptoms so long after a congenital infection. it is more probable that her presentation resulted from a recent episode of subclinical pericarditis that resulted in pericardial calcification. teaching point the normal pericardium measures less than 2 3 mm. pericardial thickening >4 mm together with clinical features of predominantly right-sided cardiac failure are suggestive of constrictive physiology. while ct can be particularly useful in assessing pericardium thickness and calcifications, mri is used to distinguish between constrictive pericardial disease and restrictive myocarditis.2 septal bounce can be demonstrated on free breathing cine mri images in patients with constrictive physiology, which distinguish it from restrictive cardiomyopathy. note, however, that although pericardial constriction and restrictive cardiomyopathy are very different pathologies, they give rise to a final common physiological appearance of impaired diastolic ventricular filling – so-called ‘restrictive filling pattern’ or ‘restrictive physiology’. hence, even pericardial constriction presents with a restrictive physiology: a source of much diagnostic confusion and a reason why ct and mri are so valuable. case 2 history a 63-year-old man was referred to our department for follow-up after right upper and middle lobe lobectomy for lung cancer. clinically, he was stable with no new symptoms. he volunteered a history of 3 myocardial infarctions after triple coronary bypass surgery in 1993. imaging the transaxial images from thoracic mdct demonstrated an aneurysm in the proximal (fig. 2a) and distal aspects (fig. 2b) of the saphenous venous graft to the right coronary artery (rca), with mural thrombi in both aneurysms. fig. 2. post contrast-enhanced chest ct scan in a 63-year-old man followed up post lobectomy for lung carcinoma. (a) transaxial ct image at the level of the aortic valve demonstrates an eccentric mural thombus within an aneurysm of the proximal saphenous vein to right coronary artery graft (arrow) (ao = aortic root; la = left atrium). (b) transaxial ct image to the left of the distal saphenous vein right coronary artery graft demonstrates concentric mural thrombus within a second aneurysm at the implantation site of the graft (arrow). diagnosis saphenous vein graft aneurysms were diagnosed. although the distal aneurysm was closely related to the suture line, the proximal aneurysm was distal to the suture line. both were felt to represent true aneurysms. owing to the patient’s underlying medical conditions, it was decided to treat these aneurysms with percutaneous deployment of amplatzer vascular plugs despite the associated risk of myocardial infarction. teaching point saphenous vein graft aneurysms are a rare complication of coronary bypass surgery and can be divided into true and pseudo-aneurysms. pseudo-aneurysms are associated with technical complications at the suture line or infections. the distinction is academic as surgical resection and revascularisation are the preferred treatment for both.3 case 3 history a 67-year-old man was admitted to an outlying hospital with a late presentation of an anterior st segment elevation myocardial infarction. at the time of admission, an attempted percutaneous coronary intervention was unsuccessful. three days later, he was transferred to the icu at our hospital with severe hypoxaemia and a clinical presentation suggestive of septic shock. a chest ct was requested to rule out pulmonary embolism or pneumonia. imaging thoracic mdct demonstrated an area of hypoperfusion in the inter-ventricular septum (fig. 3a), suggesting an area of infarction, and a muscular ventricular septal defect (vsd) apical and inferior to this (fig. 3b). bilateral basal atelectasis was noted with no evidence for pulmonary embolism. fig. 3. post contrast chest ct scan in a 67-year-old man performed to rule out pulmonary embolism or pneumonia. (a) transaxial ct image at the level of the interventricular septum demonstrates hypoperfusion of the mid-distal septum (arrow) in comparison with the basal septum (*). (b)transaxial ct image at the level of the inferior septum demonstrates a large defect in the muscular portion of the septum (arrow). (lv = left ventricle; rv = right ventricle.) diagnosis postmyocardial infarction ventricular septal defect was diagnosed. the patient had a myocardial infarction involving the muscular portion of the inter-ventricular septum complicated by a vsd. myocardial perfusion isotope studies and stress perfusion cardiac mri are often used to determine the extent of myocardial ischaemia and scarring in patients with ischaemic heart disease. it is less well appreciated that myocardial infarction can also be seen on even ungated mdct as a region of myocardial hypoperfusion. teaching point ventricular septal rupture after myocardial infarction is a rare complication with a reported incidence of 1 2%.4 rupture occurs 3 5 days after the myocardial infarction and the patient presents with sudden deterioration, new onset cardiac murmur, congestive heart failure, and often in cardiogenic shock. treatment is initial stabilisation with inotropes and often an intra-aortic balloon pump with subsequent surgical closure of the defect. there are, however, a few small case series reported in the literature where transcatheter closure of these defects has been successfully performed.5 case 4 history a 54-year-old man was referred for an abdominal ct for suspected cardiogenic liver cirrhosis. on examination, the patient had generalised oedema, and abdominal distention with mild ascites. the patient had had congenital valvular heart disease and had undergone several pulmonary valve surgeries since childhood. his pulmonary valve was replaced with a porcine root in 2002. imaging the abdominal images revealed chronic passive liver congestion with features of hepatic cirrhosis. venous phase axial images through the lower chest demonstrated a filling defect in the coronary sinus (fig. 4). fig. 4. venous phase transaxial image from a ct scan in a 54-year-old man demonstrates a filling defect in the coronary sinus in keeping with a thrombus. diagnosis coronary sinus thrombosis was diagnosed. the patient had a coronary sinus thrombosis that was subsequently resected during surgical replacement of the mitral valve and down-sizing of the right atrium. teaching point a few cases of primary coronary sinus thrombosis have been reported6 but coronary sinus thrombosis is mostly associated with previous invasive cardiac procedures such as central venous line placement, insertion of pacing wires, or coronary sinus catheterisation for ventricular lead placement during cardiac resynchronisation therapy.7 this patient had had several previous invasive cardiac procedures as well as a severely dilated right atrium, both predisposing to thrombosis formation. case 5 history a 65-year-old man, under disease surveillance for metastatic gastric carcinoma, was sent for routine chest, abdomen and pelvis ct. the patient had completed one cycle of chemotherapy 18 months previously and was clinically well with no new symptoms. imaging the venous phase chest ct demonstrated a mass lesion in the inferior aspect of the right ventricle (fig. 5a). this was better appreciated on the sagittal reconstructed images of the chest (fig. 5b). cardiac mri was performed to assess contrast enhancement of the lesion to determine whether this was a thrombus or intracardiac mass. the mass (fig. 5c) demonstrated gadolinium enhancement on the perfusion images (figs 5d and e). fig. 5. post contrast venous phase chest ct scan in a 65-year-old man with gastric carcinoma. (a) transaxial images demonstrate a filling defect (arrow) in the basal right ventricle (lv = left ventricle). (b) post contrast-enhanced sagittal reconstructed image of the chest demonstrates a filling defect in the basal right ventricle (lv = left ventricle). (c) cardiac mri steady-state free precession image obtained in a short axis orientation demonstrates a mass lesion in the basal right ventricle (arrow) (lv = left ventricle). (d) the right ventricular mass demonstrates gadolinium enhancment during perfusion imaging as demonstrated on (e) the enhancement curve display on the right. diagnosis enhancing right atrial mass was diagnosed; the mass most probably represents a metastasis from the known gastric carcinoma. teaching point cardiac masses are uncommon but, when they do occur, a metastatic origin is by far the most common cause. mri first-pass perfusion imaging with gadolinium is often used to distinguish between thrombus and masses. conventionally, thrombus does not enhance with gadolinium; however, large chronic thrombi may occasionally have peripheral enhancement, making differentiation between mass and thrombus challenging.8 typically, tumours demonstrate at the least partial uptake of gadolinium unless very avascular. the most common tumors metastasising to the heart are breast, kidney, oesophagus, lymphoma, leukaemia and melanoma.8 1. fink c, schaad ub, stocker fp. perikarditis als komplikation von roteln. [pericarditis as a complication of rubella]. schweizerische medizinische wochenschrift. 1987;117(1):28-32. 1. fink c, schaad ub, stocker fp. perikarditis als komplikation von roteln. [pericarditis as a complication of rubella]. schweizerische medizinische wochenschrift. 1987;117(1):28-32. 2. wang zj, reddy gp, gotway mb, yeh bm, hetts sw, higgins cb. ct and mr imaging of pericardial disease. radiographics 2003;23 spec no:s167-180. 2. wang zj, reddy gp, gotway mb, yeh bm, hetts sw, higgins cb. ct and mr imaging of pericardial disease. radiographics 2003;23 spec no:s167-180. 3. kalimi r, palazzo rs, graver lm. giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium. ann thorac surg 1999;68(4):1433-7143. [http://dx.doi.org/10.1016/s0003-4975(99)00848-6] 3. kalimi r, palazzo rs, graver lm. giant aneurysm of saphenous vein graft to coronary artery compressing the right atrium. ann thorac surg 1999;68(4):1433-7143. [http://dx.doi.org/10.1016/s0003-4975(99)00848-6] 4. crenshaw bs, granger cb, birnbaum y, et al. risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. gusto-i (global utilization of streptokinase and tpa for occluded coronary arteries) trial investigators. circulation 2000;101(1):27-32. [http://dx.doi.org/10.1161/01.cir.101.1.27] 4. crenshaw bs, granger cb, birnbaum y, et al. risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. gusto-i (global utilization of streptokinase and tpa for occluded coronary arteries) trial investigators. circulation 2000;101(1):27-32. [http://dx.doi.org/10.1161/01.cir.101.1.27] 5. moreno n, silva jc, andrade a. complicated transcatheter closure of postinfarction ventricular acute septal defect. j invasive cardiol 2011;23(10):e244-246. 5. moreno n, silva jc, andrade a. complicated transcatheter closure of postinfarction ventricular acute septal defect. j invasive cardiol 2011;23(10):e244-246. 6. ramsaran ek, sadigh m, miller d. sudden cardiac death due to primary coronary sinus thrombosis. south med j 1996;89(5):531-533. [http://dx.doi.org/10.1097/00007611-199605000-00019] 6. ramsaran ek, sadigh m, miller d. sudden cardiac death due to primary coronary sinus thrombosis. south med j 1996;89(5):531-533. [http://dx.doi.org/10.1097/00007611-199605000-00019] 7. parmar rc, kulkarni s, nayar s, shivaraman a. coronary sinus thrombosis. j postgrad med 2002;48(4):312-313. 7. parmar rc, kulkarni s, nayar s, shivaraman a. coronary sinus thrombosis. j postgrad med 2002;48(4):312-313. 8. o’donnell dh, abbara s, chaithiraphan v, et al. cardiac tumors: optimal cardiac mr sequences and spectrum of imaging appearances. ajr 2009;193(2):377-387. [http://dx.doi.org/10.2214/ajr.08.1895] 8. o’donnell dh, abbara s, chaithiraphan v, et al. cardiac tumors: optimal cardiac mr sequences and spectrum of imaging appearances. ajr 2009;193(2):377-387. [http://dx.doi.org/10.2214/ajr.08.1895] 42 sa journal of radiology • september 2007 so, you’ll notice an exciting new feature called today’s 2 signs (edited and managed by ami bajwa, a new addition to the editorial team). this is supposed to teach us some solid signs ‘by great example’ or some unusual and new signs… what a great idea! you will also note the emphasis of the review articles and specialty corner on pacs. these are simple, beginners’ guides to pacs written by otto schulze, who while still a registrar in radiology, leads the whole western cape pacs vision. it’s guys like otto who have both it and radiology insight, who help us understand and make better decisions. i hope that after completion of his thesis, also on radiology system and information that otto will lead the way for a new area of radiology specialisation in south africa (it in radiology is an existing following option in the usa). it is also time we brought to attention our imaging libraries and to liven the discussion around these. should the historical hard-copy libraries be preserved? should these be digitised? should we incorporate the library cases by demarcating them on our pacs? are we duplicating work already done, for example by amirsys (anne osborne & ric harnsberger), a new digital library source available on line. in a future issue, i will give you a clearer idea on ‘stat dx’ as we will get free access to this (expensive, but super) resource which was demonstrated to me in utah. lastly, just a word on the scholarship that i have completed. let me encourage you to apply. the award was $10 000 for 2 3 months at one of any of the recommended sites including ivy league universities, such as columbia in new york and harvard in boston. i did predominantly ‘diffusion tenor imaging (dit)’, started a number of collaborative research projects and got myself appointed as a research scientist at columbia for the next year. i hope this is the start of a long fruitful association. i will give a full report in the next issue. i hope you enjoy this issue because it’s full of wonderful bits of information! mixed bag savvas andronikou chief editor editorial pg42.indd 42 9/17/07 9:13:22 am abstract introduction methodology results discussion conclusion acknowledgements references about the author(s) mari wentzel department of clinical imaging science, faculty of health sciences, university of the free state, bloemfontein, south africa jacques janse van rensburg department of clinical imaging science, faculty of health sciences, university of the free state, bloemfontein, south africa jacobus j. terblans department of physics, faculty of natural and agricultural sciences, university of the free state, bloemfontein, south africa citation wentzel m, janse van rensburg j, terblans jj. radiology blues: comparing occupational blue-light exposure to recommended safety standards. s afr j rad. 2023;27(1), a2522. https://doi.org/10.4102/sajr.v27i1.2522 original research radiology blues: comparing occupational blue-light exposure to recommended safety standards mari wentzel, jacques janse van rensburg, jacobus j. terblans received: 25 july 2022; accepted: 28 nov. 2022; published: 31 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the blue-light hazard is a well-documented entity addressing the detrimental health effects of high-energy visible light photons in the range of 305 nm – 450 nm. radiologists spend long hours in front of multiple light-emitting diode (led)–based diagnostic monitors emitting blue light, predisposing them to potentially higher blue-light dosages than other health professionals. objectives: the authors aimed to quantify the blue light that radiology registrars are exposed to in daily viewing of diagnostic monitors and compared this with international occupational safety standards. method: a limited cross-sectional observational study was conducted. four radiology registrars at two academic hospitals in bloemfontein from 01 october 2021 to 30 november 2021 participated. diagnostic monitor viewing times on a standard workday were determined. different image modalities obtained from 01 june 2019 to 30 november 2019 were assessed, and blue-light radiance was determined using a spectroscope and image analysis software. blue-light radiance values were compared with international safety standards. results: radiology registrars spent on average 380 min in front of a diagnostic display unit daily. blue-light radiance from diagnostic monitors was elevated in higher-intensity images such as chest radiographs and lower for darker images like mri brain studies. the total blue-light radiance from diagnostic display units was more than 10 000 times below the recommended threshold value for blue-light exposure. conclusion: blue-light radiance from diagnostic displays measured well below the recommended values for occupational safety. hence, blue-light exposure from diagnostic monitors does not significantly add to the occupational health burden of radiologists. contribution: despite spending long hours in front of diagnostic monitors, radiologists’ exposure to effective blue-light radiance from monitors was far below hazardous values. this suggests that blue-light exposure from diagnostic monitors does not increase the occupational health burden of radiologists. keywords: blue-light hazard; ocular health radiology; blue-light radiance; occupational blue-light hazard; blue-light exposure; safe occupational exposure. introduction blue light and its relation to health swiftly became one of the buzzwords in a myriad of discussions on physical condition and well-being.1 detrimental health outcomes linked to increased screen time include a wide range of ocular effects, influence on hormone secretion (specifically melatonin and adrenocorticotrophic hormone [acth]), mental health illnesses, musculoskeletal ailments and skin conditions.2,3,4,5 as a result of the fundamental nature of their work, radiologists spend long hours scrutinising images on visual display units (vdus) – often up to five brightly illuminated monitors at a time. in addition to this, smartphones, tablets, personal computers and televisions for purposes of communication, referencing, administrative tasks at work, studying and leisure also add a significant component to the total daily screen time.6 an important contributing factor to the unfavourable effect of prolonged screen time is greater exposure to the short wavelength photons at the ultraviolet end of the visible light spectrum or blue light.6 increased exposure to vdus and other electronic devices potentially places the radiologist in a higher-risk group to experience negative outcomes related to blue light. it was previously demonstrated that eye strain among healthcare professionals is common but meaningfully increased amongst radiologists when compared with other specialists such as paediatricians.7 in the current era of digital radiology, where most duties are performed using electronic picture archiving and communication system (pacs) technology on computers and vdus, an increased prevalence of ocular health matters was identified among radiologists.8 this may lead to a temporary compromise in working and radiological diagnostic efficiency and ultimately individual visual acuity loss.9 from an occupational health perspective, the preservation of visual acuity of a radiologist should be considered a crucial concern.10 in order to obtain this goal, a good understanding of the contributing parameters and especially the ocular effects of blue light exposure when working on vdus is important. chronic eye strain and the subsequent symptoms that follow and affect ocular health and vision, as well as mental health illness and burnout, especially during residency or registrar periods, were identified as occupational hazards radiologists face that are unrelated to radiation.11 burnout among registrars occurs commonly. research has shown intricate relationships between mood states, mental health and exposure to blue light; hence, blue-light exposure may add to the mental health burden.12,13 the concept of potential phototoxic effects to the retina related to blue-light exposure is referred to as the blue-light hazard. blue light imparts retinal phototoxicity via energy deposition with direct subsequent damage to photoreceptor cells.14 the international commission on illumination (cie, derived from its french title, the commission internationale de l´eclairage) released a statement on the blue-light hazard in 2019, which specified that light sources used in general lighting and similar applications are not likely to pose any risk.15 in this study, the blue-light exposure from vdus of radiology registrars working in a training institution was quantified and compared with recommended international safety standards. by analysing this parameter, insight was gained into one of the main occupational health challenges in radiology. quantifying blue light the american conference of governmental industrial hygienists (acgih®) have developed a series of threshold limit values (tlvs®) and biological exposure indices (beis®) to serve as guidelines for safe occupational exposure to chemical substances and physical agents, including non-ionising radiation such as blue light.16 these values, in conjunction with the recommendations from the international commission on non-ionising radiation protection (icnirp) were used as directives for comparison in this study.17 the radiant luminance of blue light, lb, from the source in question is used to assess the amount of light incident on the retina. radiant luminance is a radiometric concept deduced from radiant flux, flux density and intensity. radiant flux, φe, is an indication of the amount of energy transmitted for a specific time period and is measured as energy units transferred per unit of time, or watts (j/s). flux density, €, is obtained when radiant flux is measured in a specific area unit. in the case of ocular photometry, it is the radiant flux at the retina (w/cm2). monitors of vdus consist of multiple arrays of light-emitting diode (led) light sources emitting light in a lambertian distribution. when looking at a monitor of a vdu, the sum of all the small sources combined is emitted in a diffuse manner, as illustrated. light emitted from vdus is considered to be originating from an extended source. emission occurs from the surface in all directions, hence the solid angle subtending the source must be considered to be accurate and include all light emissions (figure 1).18 figure 1: an area of the visual display unit is enlarged. the light emission occurs in a diffuse, three-dimensional distribution. when considering the flux per unit solid angle and diameter, the radiant luminance, lb, incident on the eye of the observer can be determined. the effective blue-light radiance, lb, is the unit of significance when evaluating radiance dose to the retina. it is attained by summating or integrating the product of the radiance of the source for every wavelength and the blue-light hazard weighting function b(λ):16,17 the blue-light hazard weighting function represents the relative sensitivity of the human eye and the potential of specific wavelengths in the blue-light range to induce photochemical injury. in the case of an aphakic eye, a hazard function, a(λ), with heavier weighting is used to compensate for the absence of the lens.17 when assessing typical workday exposures, viewing times will exceed 167 min (10 000 s), and the exposure limit of the blue light–weighted effective radiance lb is defined by the icnirp as:13 methodology a cross-sectional observational study was conducted to establish blue-light exposure. participants consisted of four radiology registrars working at two academic hospitals in central south africa from 01 october 2021 to 30 november 2021. measurements were performed for a total duration of 20 working days. only the registrars working at ct and mr imaging stations were included. reporting of daily scheduled ct and mr scans involves the prolonged evaluation of images on a minimum of three brightly lit computer monitors, which include two dedicated diagnostic display (ddd) units and one standard monitor. other workstations such as ultrasound, mammography, fluoroscopy and interventional radiology are less predictable than ct and mr, as they involve more active and procedural patient interaction. these stations automatically yield less screen time and subsequent blue-light exposure and were excluded. during conduction of this study, the department did not have a registrar allocated to full-time plain film reporting; hence, it was not possible to include a participant reporting only chest radiography (cxr). this study encompassed two pathways that were ultimately combined to obtain effective blue-light radiation (figure 2). current photometric systems used to evaluate blue light have restricted practical capabilities outside laboratory settings because of factors such as weight, bulky size, expensive components and difficulty in providing reproducible accuracy.19 an experimental setup to measure continuous, cumulative blue-light exposure from the whole surface of a ddd is not feasible in a practical diagnostic radiology setup. the authors relied on theoretical principles to deduce the values of interest from a range of spectroscopic greyscale measurements from ddd units, measured registrar viewing times and calculations of intensity values of images (figure 2). figure 2: the method used to determine blue-light radiance consisted of two parallel parts. registrar viewing time was measured and applied to determine acceptable threshold limits. spectral data measured for different greyscale values were used to calculate effective blue-light radiance. average image intensities for modalities were linked to greyscale values, providing a relation to deduce effective blue-light radiance. registrar viewing times the tlvs® as determined by the acgih® are provided as maximum values for different viewing time ranges (table 1).16 daily viewing times were measured to determine the tlvs® to be applied. table 1: accepted exposure limits for blue light according to the american conference of governmental industrial hygienists (acgih®), effective blue-light radiance, lb, measured in (w/cm2sr), and time, tb, measured in seconds. participants logged the time they spent viewing images on ddd units by means of a stopwatch application. they activated the stopwatch whenever viewing was started and stopped it when they left the workstation or stopped viewing images on the ddd unit. viewing times were recorded over the duration of 20 workdays to obtain an estimate of the total viewing time registrars spend in front of the ddd units per day. instrumentation the authors assessed a 3-mp diagnostic reporting monitor that was calibrated as per requirements for licence holders by the department of health in south africa.20 regular quality control tests were performed on these monitors by an accredited inspection body, and all results were within mandatory limits when the study was performed.21 the avaspec-uls2048cl spectrometer, with optimal efficiency for non-ionising radiation in the visible range, was used for measurements of blue-light emission from ddd units. this spectrometer uses a fibre optic system to measure light emission from a source by counting the number of photons for each wavelength in a specific range. the fibre optic detector was mounted in a fixed plastic envelope to ensure reproducibility of all measurements in terms of area of measurement, influence of ambient light and distance of detector from monitor. the measured data were delivered in spectral form for different wavelengths of light, displayed as the number of photons of each wavelength on a graph (figure 3). the spectrometer was calibrated to a standard source of white light using the principle of blackbody radiation and an incandescent tungsten lamp, emitting white light at a specific known temperature.22 figure 3: the spectroscope used for measurement, with attached plastic envelope to ensure reproducibility of measurements (a). indicated in image (b) is a representation of how measurements were obtained. a screenshot from the proprietary software package accompanying the avantes spectrometer demonstrates the curve, with spectral data obtained from the spectroscope indicating peaks at different wavelengths (c). establishing average intensities of different imaging modalities a radiological image displayed on a ddd unit comprises a matrix of different pixels. each pixel is allocated a number that gives it an ‘address’ in the matrix and displays a certain value of the greyscale to make up the final image. the greyscale is a range of different intensities varying from black to white. black is defined as no intensity and white is the highest intensity. a value of ‘0’ is assigned to black, and ‘255’ to white. a computer interprets an image as a range of different values allocated to each pixel in the matrix. each pixel displays a specific value of the greyscale to form the image (figure 4). these pixel values that make up an image can be displayed in a greyscale histogram, which is a graph that displays the number of pixels as a function for each intensity value of the greyscale.22 figure 4: the pixel matrix that forms an image. part (a) is a standard chest radiograph, with (b) a representation of an excerpt of the pixel matrix in the highlighted area. the numbers represent the different pixel ‘addresses’, and the different shades of grey correspond to the displayed image elements. part (c) demonstrates the greyscale values displayed in each pixel. darker pixels have lower values and brighter pixels higher values. an example of the histogram for the chest radiograph in figure 4 is demonstrated in figure 5. on the x-axis, greyscale values from 0 to 255 are presented, with the y-axis representing the number of pixels displaying each greyscale value. also demonstrated in figure 5 is a histogram of a single slice of an mr image. intuitively, the mr image demonstrates larger amounts of darker image elements, explaining the relative shift of the histogram towards the left-sided, darker end of the greyscale. this observation is based on the standard presentation presets of the pacs system in the department under study and without adjusting any window settings. the bright chest radiograph, with greyscale values in a wide range, demonstrates a broad histogram with large amounts of different intensity values. if the intensity values of all the pixels in the histogram are summated, an average number, iavg, indicating the intensity of the image as a whole, can be determined. figure 5: histogram of a normal chest radiograph (a) and a single mr brain t2 slice at the level of the brain stem (b), demonstrating the relative left shift of pixel greyscale values in the darker image. viewed content will play an important part in the dosage of blue light, as images with increased intensity will yield more bright light from the screen and, as a result, increased associated blue-range photons. for the purpose of this study, standard cxr, 5 mm axial slices of pre-contrasted ct images of the brain and 4 mm axial t1 and t2 pre-contrasted mr images of the brain were utilised. commonly used modalities were selected to provide an indication of how looking at different imaging modalities may influence blue-light exposure. the sample of assessed images was randomly selected and included 100 pa view chest radiographs, 30 pre-contrasted ct brain studies consisting of 5 mm slices and 25 pre-contrasted mri brain studies, t1 and t2 sequences, 4 mm slices. images were selected from all the studies performed at universitas academic hospital from june 2019 to november 2019. the authors purposely chose a 6-month period that fell outside the south african national lockdown (announced at the end of march 2020) as the lockdown regulations and practices significantly reduced patient numbers in the months following their implementation. arbitrary holiday periods of december and april were excluded to give a realistic representation of a standard workday. a list of total studies for the respective modalities during said time periods was obtained and entered into microsoft excel. every study was allocated a number, and from this, random samples were selected. images from the selected studies were assessed using imagej, a public domain java image processing software package.23 average intensity values for a chest radiograph, ct brain and mri brain were obtained. the average intensity value of an image correlates with a specific greyscale value. a range of greyscale values was then displayed on the ddd and spectroscopic measurements were performed. resultant spectral curves were used to determine the blue-light radiance for each greyscale value. as blue-light radiance for different greyscale values was known from spectral measurements, it was possible to deduce blue-light radiance for the different average image intensities of selected modalities (figure 6). figure 6: known greyscale values were displayed on dedicated diagnostic displays, and blue-light radiance, lb, and average intensity, iavg, were determined for each. the relation between lb and iavg for known greyscale values provided means to deduce lb values for assessed radiographic images. ethical considerations an application for full ethical approval was made to the health sciences research ethics committee of the university of the free state and ethical approval was received on 10 june 2021 (ref. no. ufs-hsd2021/0153/2906). all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. written informed consent was obtained from all individual participants involved in the study. results the average viewing time that registrars spent in front of ddds on a standard workday was determined as 6 h 20 min (380 min) with a median of 06 h15 min (375 min). this included time spent reporting and reviewing images on workstation monitors and excluded times when registrars were physically away from their stations. the average viewing time of 380 min was used for further calculations (table 2). all participants were considered senior registrars and were within 14 months from sitting for their final exit exams. table 2: average daily viewing times reported from participants. effective blue-light radiance, lb, was determined for a spectrum of different greyscale values according to equation 1. summation of measured spectral values and weighting with the blue-light hazard function to encompass sensitivity of the normal and aphakic human eye was performed. a paired-sample t-test was conducted to compare effective blue-light radiance, lb, with hazard function weighting for normal and aphakic eyes applied. there was no significant difference in the results of effective blue-light radiance, lb, between using normal eye hazard function (mean = 0.137, standard deviation [s.d.] = 0.117) and aphakic hazard function (mean = 0.137, s.d. = 0.118); t(13) = −0.081, p = 0.936. only normal hazard function weighting was thus used. using the relation of average image intensity (iavg) to a specific greyscale value, the effective blue-light radiance, lb, was determined for cxr, ct brain and mri brain (table 3). table 3: effective blue-light radiance values determined for average intensity values of different imaging modalities. average image intensities were determined as 56 for cxr, 38 for ct brain and 32 for mri brain. these values correspond to 56, 38 and 32 on the greyscale, respectively. for visual clarity, the authors represent this on a logarithmic scale, as the measured results were very small and the difference between the threshold and measured values was substantial (figure 7). figure 7: effective blue-light radiance, lb, as determined for each greyscale value ranging from 0 to 255. average image intensities for mri and ct brain and cxr indicated, with effective blue-light radiance between 0.01 w/cm2sr and 0.022 w/cm2sr, which is far below the recommended threshold limit value. according to icnirp and acgih® guidelines, as the average daily viewing time of registrars exceeds 167 min, recommended acceptable exposure falls in category 3 in table 1. according to equation 2, effective blue-light radiance in this group should be below 0.01 w/cm2sr.16,17 a one sample t-test was performed to compare the mean effective blue-light radiance, lb, to the threshold limit of acceptable blue-light exposure at viewing times exceeding 167 min per day. the mean value of effective blue-light radiance, lb, (mean = 0.137, s.d. = 0.118) was significantly different from the threshold limit of acceptable blue-light exposure at viewing times exceeding 167 min per day; t(13) = −318216.031, p < 0.001. it was clear that the determined blue-light radiance values were drastically lower than the recommended threshold limit value represented by the dotted line (figure 7). daily blue-light exposure in terms of blue-light radiance was concluded to be more than 10 000 times below the maximum limit. discussion according to the cie, light sources with luminance of less than 10 000 cd/m2 are not likely to exceed exposure limits.24 the monitors used for reporting at the institution under study all have a luminance of 500 cd/m2, which is markedly less than the values that the cie deem significant. the authors’ concern was that because of the prolonged time radiologists spend in front of these monitors, the radiance may be increased and exceed the recommended threshold values.25 unlike the well-defined deterministic dose ranges for ionising radiation dose effects, specific phototoxic retinal dosages have, according to the authors’ knowledge, mainly been described in animal models and in vitro studies thus far.15,26,27 exact values for non-ionising visible light dosages in terms of specific phototoxic effect, chronicity of exposure and possibility of subclinical disease in the human retina remain ambiguous.28 the acgih® and icnirp recommends exposure values in terms of ranges of acceptable effective blue-light radiance and maximum dose approximations, but exact dosages remain vague. the retinal dosage of blue light is determined by many factors, including properties of the eye itself, physiological and health status of the viewer and external influences. pupil diameter, focal length, eye movements and characteristics of the structures comprising the eye regulate the area of retina that is exposed.17,29 pupillary response is highly variable between individuals. age is an important parameter that determines how responsive an individual’s pupil reaction is. corneal thickness was found to be the main morphological determinant of pupillary response.30 noise levels, temperature, individual medication use and consumption of caffeine and other stimulants are also known to influence pupillary response.29 underlying medical conditions such as diabetes, glaucoma and neuropsychiatric disease can influence pupillary responsiveness and ultimately retinal blue-light dosage.29,31,32 ambient lighting plays a dual role in blue-light exposure. the lighting conditions will determine the level of pupillary dilatation, which will affect retinal dosage.33 consequently, one can expect a variety of individual experiences when it comes to the eventual retinal energy deposition from emitted blue light. effectively, eye movement will enlarge the area of the retina upon which blue light photons are incident. in case of prolonged viewing with decreased eye movements, such as intense evaluation of an image, the blue light dosage to the retina will thus be higher.17 general lighting may add to blue-light radiance because of the blue-light components in led and other incandescent light sources. previous studies, however, proved that blue-light exposure originating from light sources is unlikely to exceed any threshold limits.34 the authors only assessed direct ddd unit emission and did not include additional blue light from sources such as glare from other monitors, incandescent or fluorescent luminaires and mobile devices. when viewing ddds, the same optimal viewing distances and angles are not always used. it is advised that the ideal viewing distance should be approximately 60 cm, at a viewing angle directed slightly downward.35 in practice, these conditions are not always strictly adhered to, causing differences in the blue-light radiance that ultimately reach the retina. cognitive factors such as the content being viewed and the associated emotions that an individual links to it are postulated to also contribute to pupillary response.36 for simplification, the effect of these external factors was not considered in this study. an experimental setup to accurately mimic retinal blue-light deposition will be technically and logistically near impossible; hence, threshold limits, time ranges and estimates were used in this study. this assessment of blue-light exposure in registrars yielded effective blue-light radiance values of more than 10 000 times below the recommended safe value of 0.1 w/cm2sr. this is even more striking when comparing the measured results to other well-known sources of blue light. bullough et al. demonstrated blue-light radiance from the sun in less than 1 s as 1.2 × 106 0.1 w/cm2sr. a standard fluorescent light source (8 re 4100 k) yielded a blue-light radiance of 5.6 w/cm2sr.37 blue-light radiance from ddds in a radiological setting is not only much lower than threshold values but also markedly less than the blue-light exposure an individual would receive from the sun or a standard fluorescent light source. limitations of this study include the small study population, self-reported viewing times and the exclusion of the multitude of variables that may influence retinal blue-light deposition as described.the viewing time determined by the authors was carried out using a basic method of activating a stopwatch while reporting. independent verification of viewing times by means of an objective observer measuring time or assessment of login time data from pacs was not performed. although all registrars were dedicated and actively participating in the process, it should be considered that viewing times may have been either overor underestimated because of human error. the study’s evaluation was carried out using three common imaging modalities, that is, cxr, ct brain and mri brain. these modalities are often the workhorses in radiology, but a wide variety of other types of images are also read. the brightness of the viewed content will determine blue-light exposure; hence, brighter-appearing images such as fluoroscopic studies will most likely yield more blue light than a darker mammography study. other modalities were omitted for the sake of simplicity and reproducibility of the study. the ddd units at the institution under study are compliant with local regulatory standards, but each device remains unique. as a result of technical variances, different display units may, within limits, vary in their emission of blue light. it is also important to consider that ddd units are not the only devices emitting blue light that radiology practitioners are exposed to. often, practitioners will review images at machine terminals immediately after acquisition to decide whether further images or sequences are required. these monitors also emit blue light but were not included in our measurements. furthermore, in the current era of electronic device usage for a multitude professional and personal duties, a large component of blue-light exposure that will add to retinal dosage is assumed to come from these devices. although beyond the scope of this study, this method can be used in future research to quantify blue light from, for instance, cellular phones, tablets, personal computers and televisions. based on the current study’s results and the cie position on sources with a luminance of less than 10 000 cd/m2, however, the authors do not expect the component of blue-light exposure from above-mentioned devices to be significant at all.24 although measured values were well below threshold limits, a clear relation between the viewed content and blue-light radiance was determined. for darker images with lower average intensities such as mri, less blue-light radiance was determined than for brighter chest radiographs. thus, if brighter images with increased content in the upper ranges of the greyscale are viewed, more effective blue-light radiance will be measured. however, as evident from the higher greyscale values in figure 7, if an individual was viewing even maximal greyscale value content (i.e. a white screen) for the duration of one working day, blue light radiance would still be well within the ranges considered safe. recent studies were not able to establish clear evidence to advocate for the use of glasses with blue light–blocking lenses. available research on blue-blocking lenses is mainly based on animal data and laboratory-centred experiments rather than extensive human clinical trials, leaving potential paucities in clinical applications.38,39 a 2021 study performed by singh et al. established no change in digital eye strain when using blue light–blocking glasses among 120 study participants. moreover, the blue-light hazard in typical environments is being questioned recently as a speculative concept used to generate blue light–phobia among consumers and in clinical practice settings.40 this study’s findings support this notion. the authors established that the amount of blue light emitted from diagnostic workstation monitors to which participants in this study were exposed on a daily basis was well below the levels that are regarded as occupationally safe. future research in a study population consisting of a wider variety of practising radiologists, including the public and private sectors, may yield sensible information regarding the role that different work circumstances play. other imaging modalities can be assessed to provide a more exhaustive overview of blue-light exposure. independent observation of viewing time by means of computer login data or motion sensors can be considered to reduce human error that may occur with self-measured viewing times. with minor modifications, the methods and results of this study can essentially be extrapolated to any industry requiring employees to work on a vdu and where there is concern regarding occupational blue-light exposure. conclusion the dangers of blue light and its effect on ocular and general health are well documented. the scope of practice requires healthcare practitioners in diagnostic radiology to spend long hours in front of ddd units that use led technology, which emit high amounts of blue light. the authors’ concern was that this may predispose radiology practitioners to an occupational hazard related to blue light and its sequelae. it was found that the average time a radiology registrar spends in front of a monitor per workday is 380 min. the content that was being viewed played a part in the blue light exposure. brighter chest radiographs demonstrated more blue-light radiance than darker mri brain images. nonetheless, exposure to effective blue-light radiance from monitors during a standard working day was far below the ranges that are recognised as hazardous. acknowledgements the authors would like to thank ms c. stofile, department of medical physics, university of the free state, for helping with measurements and providing input regarding quality control standards; mr c. van rooyen, department of biostatistics, university of the free state, for his help with statistical analysis of the data; registrars from the department of clinical imaging sciences who participated in the study, namely dr lilanie biddulph, dr philip zeelie, dr francois van der merwe and dr jandus de villiers. competing interests the authors declare that they have no personal or financial incentives which may have influenced them in the writing of this article. authors’ contributions m.w. was the principal investigator and prepared the manuscript. j.j.t. contributed with conceptualising of measurements and the mathematical model. j.j.v.r. provided critical revision and the final draft overview of the article. 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https://doi.org/10.1007/s00417-016-3311-4 o’hagan jb, khazova m, price lla. low-energy light bulbs, computers, tablets and the blue light hazard. eye. 2016;30:230–233. https://doi.org/10.1038/eye.2015.261 jaschinski w, heuer h. preferred position of visual displays relative to the eyes: a field study of visual strain and individual differences. ergonomics. 1998;41(7):1034–1049. https://doi.org/10.1080/001401398186586 zekveld aa, koelewijn t, kramer se. the pupil dilation response to auditory stimuli: current state of knowledge. trends hear. 2018;22:1–25. https://doi.org/10.1177/2331216518777174 bullough jd, bierman a, rea ms. evaluating the blue-light hazard from solid state lighting. int j occup saf ergon. 2019;25(2):311–320. https://doi.org/10.1080/10803548.2017.1375172 vagge a, ferro desideri l, del noce c, di mola i, sindaco d, traverso ce. blue light filtering ophthalmic lenses: a systematic review. semin ophthalmol 36(7):541–548. https://doi.org/10.1080/08820538.2021.1900283 singh s, downie le, anderson aj. do blue-blocking lenses reduce eye strain from extended screen time? a double-masked randomized controlled trial. am j ophthalmol. 2021;226:243–251. https://doi.org/10.1016/j.ajo.2021.02.010 mainster ma, findl o, dick hb, et al. the blue-light hazard vs. blue-light-hype. am j ophthalmol. 2022;240:51–57. https://doi.org/10.1016/j.ajo.2022.02.016 sajr 702 unilateral axillary adenopathy with unremarkable breast imaging – differential diagnoses gudrun peters, md catherine m jones, mb bs, bsc, frcr franzcr regional imaging tasmania, tasmania, australia   corresponding author: g peters (gudrun.peters@i-med.com.au) unilateral axillary adenopathy may be caused by a wide range of both benign and malignant aetiologies. while the most common cause is inflammation, infection or trauma of the breast, thoracic wall or arm, a significant proportion of cases are due to occult malignancy. in female patients particularly, breast malignancy must be excluded with mammography and ultrasound. local inflammation, infection or trauma of the thoracic wall or arm should also be sought when deciding the most appropriate recommendation for management. this case report outlines the most significant pathologies and discusses the need to rule out sinister pathology, even when a benign local cause is evident. s afr j rad 2012;16(3):104-106. doi:10.7196/sajr.702 a 58-year-old woman was referred for diagnostic workup for lumpiness of her left breast. she had no history of malignancy, systemic disease or recent viral illness. bilateral mammograms (figs 1a d) showed a subtle asymmetrical density in the contralateral (right) breast, that was presumed to be asymmetrical breast tissue. ultrasound of both breasts demonstrated no suspicious abnormality. the right axillary ultrasound (fig. 2), however, revealed enlarged nodes with up to 6 mm cortical thickness but preserved fatty hila. figs 1a d. bilateral two-view mammogram shows fatty replaced breast tissue. a small asymmetrical density in the right upper central area of the breast on the mediolateral oblique view (arrow, upper left image) is presumed to be asymmetrical breast tissue. fig. 2. ultrasound of the right axilla shows an enlarged lymph node with cortical thickness of 6.6 mm. on examination, the patient’s right elbow was markedly inflamed. this had been initially overlooked as the patient’s arm was covered during ultrasound. further history of sub-acute chronic pain and limited range of movement in that joint led to a presumed diagnosis of bursitis. as a local inflammatory cause for the unilateral axillary adenopathy was presumed, no biopsy was performed. follow-up ultrasound was arranged for 4 weeks later. diagnosis after discussion with the patient’s family physician, she attended for consultation the same day. a clinical diagnosis of elbow bursitis was made and appropriate management commenced, including antibiotics for a presumed superimposed infection. follow-up ultrasound of the right axilla 4 weeks later revealed that the nodes had returned to normal size and cortical thickness (fig. 3). the bursitis had resolved in the interval. fig. 3. the follow-up ultrasound 4 weeks later documents that the cortical thickness of the lymph node has returned to the upper limits of normal (2.8 mm). discussion isolated unilateral axillary adenopathy is not an uncommon finding. from the radiologist’s perspective, the long list of possible causes can lead to a diagnostic and management dilemma. axillary adenopathy can be caused by either locoregional or systemic pathology. the breast, thoracic wall and arm have direct lymphatic drainage to the axilla. local infection, inflammation or malignancy in these regions may lead to unilateral axillary adenopathy.1 however, the most probable cause of unilateral axillary adenopathy is non-specific reactivity owing to upper extremity infection or injury.2 systemic illness can less commonly present as unilateral axillary adenopathy. malignancy such as lymphoma rarely presents as isolated unilateral axillary nodes,2 , 3 although melanoma, sarcoma and other metastatic malignancy may also present in this way.1 auto-immune diseases such as rheumatoid arthritis, lupus, sjögren’s syndrome and dermatomyositis are possible causes. other causes include sarcoidosis, hiv, kawasaki’s disease, serum sickness and drug reaction.2 , 4 in our patient, there was obvious local inflammation which led to the decision to perform short-term follow-up after treatment of the bursitis. as a radiologist, a targeted history and local examination can often elicit a locoregional cause for the adenopathy. additionally, correlation with previous imaging may give further information about chronicity and stability. if there is evidence of local infection, inflammation or trauma, short-term follow-up may be appropriate. in patients who have not had recent breast imaging, this should be performed to search for occult breast malignancy, as this is present in up to 12% of cases.5 in patients who have normal breast imaging, non-breast malignancy is found in 25 33%,4 , 6 most commonly lymphoma and melanoma. tissue sampling should be considered if no benign local cause is found. if the decision is made to perform short-term follow-up, there should be a low threshold for further investigation and tissue sampling if there is no improvement or resolution of the adenopathy. conclusion unilateral axillary adenopathy is most frequently due to local inflammation, infection or trauma, and resolves with appropriate treatment. however, in a significant proportion of patients, an underlying occult malignancy is the cause. for this reason, even with local infection or inflammation, short-term follow-up is recommended to ensure resolution. breast imaging should also be undertaken in female patients to exclude breast malignancy. if the adenopathy does not resolve at follow-up, investigation for a systemic illness such as lymphoma should be performed, and tissue sampling strongly considered.   1. ferrer r. lymphadenopathy: differential diagnosis and evaluation. am fam physician 1998;58(6):1313-1320. 1. ferrer r. lymphadenopathy: differential diagnosis and evaluation. am fam physician 1998;58(6):1313-1320. 2. bazemore aw, smucker dr. lymphadenopathy and malignancy. am fam physician 2002;66(11):2103-2110. 2. bazemore aw, smucker dr. lymphadenopathy and malignancy. am fam physician 2002;66(11):2103-2110. 3. jose bo, koerner p, spanos wj jr, et al. hodgkin’s lymphoma in adults – clinical features. j ky med assoc 2005;103(1):15-17. 3. jose bo, koerner p, spanos wj jr, et al. hodgkin’s lymphoma in adults – clinical features. j ky med assoc 2005;103(1):15-17. 4. schwab fd, burger h, isenschmid m, kuhn a, mueller md, günthert ar. suspicious axillary lymph nodes in patients with unremarkable imaging of the breast.eur j obstet gynecol reprod biol 2010;150(1):88-91. 4. schwab fd, burger h, isenschmid m, kuhn a, mueller md, günthert ar. suspicious axillary lymph nodes in patients with unremarkable imaging of the breast.eur j obstet gynecol reprod biol 2010;150(1):88-91. 5. muttarak m, chaiwun b, peh wc. role of mammography in diagnosis of axillary abnormalities in women with normal breast examination. australas radiol 2004;48(3):306-310. 5. muttarak m, chaiwun b, peh wc. role of mammography in diagnosis of axillary abnormalities in women with normal breast examination. australas radiol 2004;48(3):306-310. 6. brenin dr. the unknown primary tumor presenting with axillary lymphadenopathy. in: singletary es, robb gl, hortobagyi gn, eds. advanced therapy of breast disease. london: bc decker inc., 2004:659-665. 6. brenin dr. the unknown primary tumor presenting with axillary lymphadenopathy. in: singletary es, robb gl, hortobagyi gn, eds. advanced therapy of breast disease. london: bc decker inc., 2004:659-665. cpd questionnaire 48 sajr march 2013 vol. 17 no. 1 regarding multimodal magnetic resonance imaging and diagnostic accuracy in brain tumours: 1. multimodal mri techniques increase diagnostic accuracy and should be performed in the work-up of brain tumours. 2. conventional mri sequences provide anatomical and structural information about the relation of a brain tumour to the surrounding tissue. 3. multimodal mri techniques include diffusion-weighted imaging (dwi), perfusion-weighted imaging (pwi), mr spectroscopy (mrs), diffusion tensor imaging (dti) and functional mri (fmri). 4. pwi provides additional information about the metabolic properties of tumours and surrounding brain tissue, whereas mrs provides information about the blood volume (cbv) of the tumours and the peritumoural oedema. with regard to the value of apparent diffusion coefficient (adc) in evaluating the response of carcinoma of the cervix treated with chemoradiotherapy: 5. the study showed promising results in the ability of adc to identify early tumour response to therapy. 6. adc values for cervical carcinoma increased after treatment with chemoradiation with responders showing a larger change in adc values than nonresponders. 7. cervical carcinoma is the most common gynaecological malignancy in women. concerning agenesis of the dorsal mesentery presenting in an adolescent: 8. agenesis of the dorsal mesentery is a common occurrence that usually presents in children. 9. the dorsal mesentery gives rise to the lesser omentum, falciform ligament and the visceral peritoneum of the liver. in acute mesenteroaxial gastric volvulus: 10. acute gastric volvulus is an uncommon but easily recognised surgical emergency with highly specific clinical symptoms. 11. abdominal computed tomography (ct) has been underutilised in the diagnosis of gastric volvulus. regarding the interpretation and value of mr csf flow studies for paediatric neurosurgery: 12. phase-contrast mr imaging (pc-mri) is a rapid, simple and noninvasive technique that is sensitive to csf flow. 13. indications for csf flow studies in children include assessment and functionality of shunt treatment in patients with hydrocephalus, and hydrocephalus associated with achondroplasia. 14. there is no role for csf flow studies in chiari i malformation, confirmation of aqueductal stenosis or in determining patency of a third ventriculostomy. in the evaluation of extraskeletal ewing’s sarcoma: 15. when ewing’s sarcoma arises in soft tissue rather than bone, it is referred to as extraskeletal ewing’s sarcoma (ess). 16. if the mass is located near bone, it might result in cortical erosion and/or a periosteal reaction. with regard to incidental cardiac findings on non-cardiac ct examination of the thorax: 17. motion-free cardiac images require synchronisation of image acquisition with the cardiac cycle (cardiac ‘gating’ or ‘triggering’). 18. atrial septal rupture after myocardial infarction is a rare complication with a reported incidence of 1 2%. in computerised tomography brain (ctb) studies of the paediatric mandibular condyle: 19. the article highlights the importance of routinely reviewing the mandibular condyle on computerised tomography brain studies in a trauma setting. 20. overlooking mandibular fractures may have long-term consequences including facial asymmetry, malocclusion and ankylosis. mark each numbered statement as true (a) or false (b): cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb001/012/01/2013 (clinical) we are pleased to announce that the number of ceus per test has been increased to 5. about the author(s) maya patel department of radiology, school of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa national radiology services inc, johannesburg, south africa citation patel m. journalism – de-constructing the jigsaw s afr j rad. 2021;25(1), a2356. https://doi.org/10.4102/sajr.v25i1.2356 editorial journalism – de-constructing the jigsaw maya patel copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. academic journalism is akin to building a puzzle in many respects. every piece has a specific position and role to play and development occurs as the pieces interlock succinctly and mould into something recognisable. being openly accessible, published manuscripts are permanently under the scrutiny of the scholarly community microscope and therefore sound methodology, ethics, integrity and accuracy are vital components of literary journals. these pieces connect through four major cornerstones, namely: the authors, reviewers, editors and publishers. the interplay between these key role players is crucial in creating a solid framework on which to expand. with the foundation in place, growth can commence; but like a picturesque puzzle, the challenge lies in finding the correct place for all the elements. occasionally, pieces do not fit compactly and this can be likened to oversights and differing opinions. whilst these are not always welcome, they do indicate a positive interest in the published material and promote healthy constructive criticism. where do journal metrics fit? research journals are continually measured, compared and ranked. these numerical ratings provide a locus for the journal which can change depending on the journal’s performance. the more commonly known metric is the journal impact factor, but others include the citescore, the scimago journal rank (sjr), the eigen factor and the source normalised impact per paper (snip). the number of readers, downloads, citations and even popularity on social media, all affect these metrics and ultimately the journal’s prestige. closely linked to journal metrics is indexing, which involves a formal application for inclusion on a bibliographic or literature database, often linked to an affiliated institution. selecting the appropriate database for one’s journal is cardinal and inclusion depends on whether all the desired criteria are met. the process of indexing is similar to the peer review process that manuscripts undergo, except that the entire journal undergoes a technical review by an external advisory committee over a certain period, usually 2 years. ultimately, indexing is all about journal exposure. similar to matching puzzle pieces, author metrics are aligned with journal metrics and databases. authors are graded according to their publication numbers, citations and first author publications, amongst other criteria. most databases will provide authors with a profile calculation, such as the h-index, which allows them to gauge themselves against colleagues. an alternative is to consider author esteem and expertise. a broad range of influential editorial board members and collaborators are helpful in this regard. these pieces are like bridges between the focal point of the puzzle and the background. additionally, like a visually stimulating puzzle image, journal content should spark interest and relevance, capturing the reader’s attention. south africa is a niche geographic location in africa, and there is a wealth of information from our local disease burden that is unique to our country and worthy of dissemination. the south african journal of radiology puzzle is intricate and diverse and made up of several elements. although expanding the journal is an onerous task, all puzzles can be solved and the pieces are finding their places with time. maya patel 80 sa journal of radiology • june 2012 quiz case chest imaging by high-resolution computed tomography (hrct) s k misser, mb chb, fcrad (d) sa lake smit and partners, durban i a abdullah, mb chb, fcp (sa), fccp st augustine’s hospital, durban corresponding author: s misser (misser@lakesmit.co.za) presentation a 39-year-old man presents with subacute dyspnoea and intermittent cough. the following images were obtained. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 1 august 2012. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. fig. 1. plain pa chest radiograph. fig. 2. coronal reformat of lung fields. fig. 3. axial hrct at aortic arch level. fig. 4. axial hrct at pulmonary artery level. fig. 5. axial hrct at aortic root level. fig. 6. axial hrct at diaphragm level. sajr 935 nephrogenic systemic fibrosis (nsf) and gadolinium-based contrast media p s ngoya, md, msc; z vawda, mb bch; j w lotz, ma, msc, frcr radiodiagnosis division, university of stellenbosch and tygerberg academic hospital, parow, western cape, south africa. corresponding author: p s ngoya (pienems@yahoo.com) nephrogenic systemic fibrosis (nsf), unknown before march 1997 and first described in 2000, is a systemic disorder characterised by widespread tissue fibrosis. the first known case occurred in 1997, after the use of gadolinium-based contrast agents (gbcas) at high doses in patients with renal failure had become routine. an overwhelming majority occurred within weeks to months after injection of a gbca. the link between nephrogenic systemic fibrosis (nsf) and gbcas was recognised in 2006. this note comprises guidelines on the prevention of nsf. s afr j rad 2013;17(3):106-107. doi:10.7196/sajr.935 gadolinium-dtpa (gd-dtpa), introduced in 1988, is the first paramagnetic contrast agent approved for clinical use in mr imaging. the frequency of adverse reactions is low. nephrogenic systemic fibrosis (nsf), unknown before march 1997 and first described in 2000, is a systemic disorder characterised by widespread tissue fibrosis. originally known as nephrogenic fibrosing dermopathy (nfd) because of its dominant cutaneous findings, the nomenclature was revised in recent years to reflect an increased understanding of its systemic effects. typical is the unique histopathology of nsf that includes thickened collagen bundles with surrounding clefts, increased dermal mucin deposition, proliferation of dendritic cells and increased elastic fibers. 1 gadolinium in nsf although gadolinium is a rare-earth metal, with the atomic number 64 on the periodic table, it is in fact widespread in the earth’s crust. the first known case of nsf occurred in 1997, after the use of gadolinium-based contrast agents (gbcas) at high doses in patients with renal failure had become routine. nsf is only observed in patients with severe renal dysfunction, primarily patients undergoing or approaching dialysis, hence the use of nephrogenic in its name. gd-dtpa is a small complex and diffuses easily through the pores of the vessels. gd-containing contrast agents are rapidly cleared with a half-life of about 2 hours in patients with normal renal function. in chronic renal failure, however, the half-life is prolonged and may exceed 30 120 hours. possible side-effects occur owing to dissociation of the gd-ligand complex into the metal ion and ligand. the process is facilitated by a combination of endogenous metals (zinc, copper, iron), calcium and endogenous acids, destabilising the complex and leading to its dissociation. in renal failure, the combination of metabolic acidosis and the absence of adequate clearance of gd-containing agent results in precipitation of salts with anions which are then deposited in the interstitium of muscle, bone, liver and skin. more than 300 cases of nsf in patients with severe chronic renal insufficiency, acute renal failure or in those undergoing dialysis have been reported in peer-reviewed literature, with an overwhelming majority occurring within weeks to months after injection of a gbca. 2 recommendations to prevent nsf because there is no consistently effective treatment for nsf, prevention is important. screening to identify patients at high risk is essential.3 considerable controversy remains about what level of screening is necessary. because 70 80% of nsf cases occur in patients undergoing dialysis, screening for dialysis is important. data on the serum creatinine level should be looked up for all inpatients, and the glomerular filtration rate (gfr) should be calculated to identify patients with a gfr <30 ml/min. the gfr calculation can be done with any of the online calculators.4 the most up-to-date assessment and guidelines were reported by thomsen et al. in 2012. 5 guidelines of the contrast media safety committee (cmsc) of the european society of urogenital radiology (esur) on nephrogenic systemic fibrosis and gadolinium-based contrast media based on the evidence presented in this review, the esur cmsc’s new guidelines are summarised below, with their strength of evidence and recommendation ratings. clinical features onset: from the day of exposure for up to 2 3 months, and sometimes up to years, after exposure. initial syptoms are pain; pruritus; swelling; erythema; usually starting in the legs. later: thickened skin and subcutaneous tissues; ‘woody’ texture and brawny plaques; and fibrosis of internal organs, e.g. muscle, diaphragm, heart, liver, lungs. results: contractures; cachexia; and death, in a proportion of patients. confounded cases: if two different gd-cms have been injected, it is impossible to determine with certainty which agent triggered the development of nsf, and the situation is described as ‘confounded’. unconfounded cases: the patient has never been exposed to more than one agent. 1. grobner t. gadolinium — a specific trigger for the development of nephrogenic systemic fibrosis? nephron dial transplant 2006;21:1104-1108. 1. grobner t. gadolinium — a specific trigger for the development of nephrogenic systemic fibrosis? nephron dial transplant 2006;21:1104-1108. 2. prince mr, zhang hl, prowda jc, grossman me, silvers dn. gadolinium and neprogenic systemic fibrosis. radiographics 2009;29:1565-1574. [http://dx.doi.org/10.1148/rg.296095517] 2. prince mr, zhang hl, prowda jc, grossman me, silvers dn. gadolinium and neprogenic systemic fibrosis. radiographics 2009;29:1565-1574. [http://dx.doi.org/10.1148/rg.296095517] 3. kribben a, witzke o, hillen u, barkhausen j, daul ae, erbel r. nephrogenic systemic fibrosis: pathogenesis, diagnosis and therapy. j am coll cardiol 2009;53(18):1621-1628. [http://dx.doi.org/10.1016/j.jacc.2008.12.061] 3. kribben a, witzke o, hillen u, barkhausen j, daul ae, erbel r. nephrogenic systemic fibrosis: pathogenesis, diagnosis and therapy. j am coll cardiol 2009;53(18):1621-1628. [http://dx.doi.org/10.1016/j.jacc.2008.12.061] 4. fadem sz. gfr calculator (with si units): nephron information center website. http://www.mdrd.com. 4. fadem sz. gfr calculator (with si units): nephron information center website. http://www.mdrd.com. 5. thomsen hs, morcos sk, almén t, et al. nephrogenic systemic fibrosis and gadolinium-based contrast media: updated esur contrast medium safety committee guidelines. eur radiol 2013;23(2):307-318. [http://dx.doi.org/10.1007/s00330-012-2597-9] 5. thomsen hs, morcos sk, almén t, et al. nephrogenic systemic fibrosis and gadolinium-based contrast media: updated esur contrast medium safety committee guidelines. eur radiol 2013;23(2):307-318. [http://dx.doi.org/10.1007/s00330-012-2597-9] about the author(s) maya patel department of radiology, school of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa national radiology services inc, johannesburg, south africa citation patel m. ‘techtorial’: changing paradigms. s afr j rad. 2022;26(1), a2571. https://doi.org/10.4102/sajr.v26i1.2571 editorial ‘techtorial’: changing paradigms maya patel copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. long gone are the days of the film library and the tedious grind through packets of radiographs, heavy-weighted textbooks and stacks of printed journal articles. thanks to technology, there has been a revolutionalised approach to the way we learn and teach radiology. new generation radiologists are fully immersed in the realm of the internet where they self-learn remotely through online resource sites, courses, blogs and social media. trainees are also able to perform self-evaluation tasks, have imaging reports reviewed and attempt examination preparation scenarios. such services offer immediate gratification, convenient availability at any time or place, and the ability to learn from different institutions and experts from anywhere in the world. spurred on by the recent pandemic, when in-person teaching interaction was interrupted, new avenues for learning have sprouted and remain popular despite the return to ‘normality’. so, is medical journalism also veering off course? interestingly, apart from conversion to a digital platform, most journals still function like before, continuing in their role as the cornerstones of academia. on average, a research manuscript requires years of data acquisition, 3–6 months for data analysis and write-up, and another 6–9 months of reviewing, processing and editing by journal publishers before the reward of submission acceptance and printing. this painstaking process is undertaken with the aim of sharing derived findings and knowledge with the medical community. the information is weighted by statistics and matched with other research, deserving of attention. extrapolating from the sa journal of radiology (sajr), it is clear that readership has steadily increased over the past five years, but abstract views outnumber the full manuscript pdfs. trends seen in international journals suggest that this is probably not a unique phenomenon. in an attempt to improve dissemination of information, medical journalism too has taken to social media and blogs. authors are recording videos of themselves delivering their manuscript abstracts and academic journals are even being converted to audible formats. is this the way forward? our brains process an extraordinary amount of digital data on a daily basis and journalism needs to burrow its way into this data to reach more audiences. most radiologists would preferably opt to view a webinar or browse for a summarised chart on updated guidelines, rather than read the published article. similarly, interesting imaging findings are no longer published as case reports, but rather shared on teaching sites with a few citations or instantaneously communicated via social media. a brief title or image can easily be used to spark interest and persuade further reading via embedded links. as long as the research reaches the intended audience, probably no harm is incurred. while gaining experience from hands-on learning is ideal and well-referenced academic publishing is the preferred means of sharing knowledge with peers, technology has become intertwined and inseparable from medicine. embracing the use of alternative multifaceted avenues for dissemination of information seems to be a necessary paradigm adaptation as the world orbits with electronics and our brains favour a digitised landscape. ‘progress is impossible without change and those who cannot change their minds cannot change anything’ (george bernard shaw) case report gastropericardial fistula complicating an adenocarcinoma of the stomach introductionas shaik mbc/18 (natal), fcs (sa) of the various conditions affecting the stomach, gastric cancer invariably imparts a fatal outcome, death being usually due to the indolent yet relentless malignant process. rarely a complication such as a gastropericardial fistula may be the cause of the fatal event. gastropericardial fistula with the resultant pneumopericardium is an extremely rare condition with a high mortality.l,2,3this condition was first described by hallin in 1891.4 to date 57 cases of gastropericardial fistula due to a disparate group of conditions have been reported in the literature.',s,6,7,8,9 amongst the causes described are thoraco-abdominal trauma.v" systemic infections, previous gastro-oesophageal surgery': 10,ii adjacent inflammatory foci and benign gastric ulcers. i,3,12of the reported cases, 10 have been attributed to underlying gastric malignancy. i in this report we present a fatal case of gastropericardial fistula arising from the transdiaphragmatic invasion of a malignant gastric ulcer. b singh fcs(sat j maharajh ffrad (say j moodley fcs (sa) department of general surgery and' radiology, university of natal medical school, durban, south africa case report a 36-year-old man presented to the medical service at king edward viii 15 sa journal of radiology· may 1998 hospital in durban with a one month history of loss of appetite and weight, progressive breathlessness, swelling of the legs and dysphagia. on presentation he was found to be emaciated with a tinge of jaundice, left supraclavicular lymphadenopathy, pitting oedema of the lower limbs and in congestive cardiac failure. chest examination revealed fine crackles along both lung bases; auscultation of the heart revealed a pericardial friction rub. abdominal examination revealed no abnormalities. an admission chest x-ray revealed features of cardiac failure and the patient was initially managed for a pericarditis and cardiac failure. the haemoglobin was 10.2 g/dl and white cell count was 12.4 x 109. the urea and electrolytes revealed a mildly elevated serum urea. ecg changes were in keeping with cardiac failure and a pericarditis. over the ensuing two days no improvement was noted in the pati nt's general condition and the dysphagia persisted. a barium swallow performed showed a normal oesophagus. however a fistula between the lesser curve of the stomach and the pericardial cavity was easily demonstrated (figure 1). delayed radiographs depicted a large pneumopericardium (figure 2). the radiological features of the stomach suggested a malignant process. subsequently at gastroscopy, a shrunken stomach with a malignant appearing ulcer along the lesser curve of the stomach was noted and biopsied. the fistula was not identified. shortly after the gastroscopy the patient's condition rapidly deteriorated and he demised without any definitive treatment. histological assessment of the gastroscopic biopsy revealed an adenocarcinoma of the stomach. to page 18 ge macmed a new giant emerges in the medical equipment servicing market a new giant has emerged in south africa's r300 million p,a. medical equipment servicing market with the launch of a ge macmed joint venture targeting a r70 million turnover in its first year by breaking with tradition to launch servicing of competing brands of healthcare equipment. "general electric (ge) took a strategic decision to launch multivendor servicing of medical equipment south africa in partnership with a well established local company," says christopher austin, ge medical systems general sales manager for southern africa. "the pooling of resources with the listed macmed group combines the international strength and knowhow of general electric with macmed's accumulatad local knowledge and market penetration in south africa and other african countries. " strong growth austin predicts strong growth for multi-vendor servicing offered by ge macmed. "the entire healthcare industry in south africa is under enormous pressure to contain and even reduce costs. since we are able to show that multi-vendor servicing can lead to substantial savings in operating costs, we are bullish about growth prospects locally. 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" the majority shareholding in ge macmed is held by ge's medical systems division. ge macmed which at launch date will have more than 100 employees will also sell a range of high technology equipment, including diagnostic imaging systems, and vascular and nuclear medical equipment. austin says that the joint venture will provide a vehicle for ge medical systems to improve penetration of markets in southern africa and other african countries with ge's range of diagnostic imaging equipment. the existing macmed distribution network will be utilised. diagnostic imaging ge macmed will be in the top three suppliers of diagnostic imaging equipment in south africa, worth an estimated r160 million pa. the company's nationwide servicing capability will cover equipment ranging from imaging systems to incubators, defribulators, dialysis machines and operating tables. ge pioneered multi-vendor servicing in the united states several years ago. the comprecare (tm) service concept has since undergone rapid growth with more than 1 100 hospitals in america and europe now under contract with ge medical systems. reinforced commitment mike hendry, national executive of general electric southern africa, says the joint venture further reinforces ge's commitment to southern africa and "supports our undertaking to generate r2bn in industrial, commercial and economic benefits to the local economy. it also provides a strong avenue for growth into the rest of africa." general electric (ge) of the us is the number one company in the world in terms of market capitalisation, with revenues in excess of us$90 billion. 24 hour call centre ge macmed maintains a 24 hour call centre to provide a high level of services to its entire customer base nationwide. highly trained medical technical staff are available at all times to assist clients with queries. technical staff are able to provide support and assist with solving technical problems. where applicable, technical staff are despatched to customer sites. in appropriate instances, contact is made with the five insite facilities run by general electric medical systems around the world for assistance with remote diagnostics and corrective action. ge macmed's 24 hour call centre can be contacted at (011) 315 6625. insite advanced remote maintenance the highly successful insite service run by ge medical systems provides remote diagnostics and software corrections in minutes for a wide range of ge imaging systems. in instances where a problem cannot be resolved remotely, a field engineer is despatched to the customer site having been provided with a preliminary diagnosis. he is thus able to rectify a problem rapidly by confirming the diagnosis on site and replacing the part with a replacement which he drew from stores prior to visiting the customer'spremises. here's your complimentary easy-to-use dial to enable you to identify ge macmed's area of focus in southern africa and beyond. remove the dial from the page and use it at your leisure. don't forget to keep it in a safe place for future reference. v e gemacmed tel (011) 315-6625 gastropericardial fistula con'lplicating an adenocarcinoma of the stomach from page 15 figure 1: gastroperlcardial fistula (arrow) with barium outlining the pericardlal sac. figure 2: chest radiograph demonstrating pneumopericardium. discussion whilst the complications of malignant gastric ulcers are usually predictable, only awareness of the rare and invariably fatal gastropericardial fistula occurring as a result of this condition will result in its early recognition and treatment. the anatomical proximity of the lesser curve of the stomach to the pericardium readily predisposes to fistulation between these two structures. however, because of the strength of the fibrous central tendon, such fistulation is rare. in our patient it could be postulated that adhesion of the lesser curve of the stomach to the diaphragm with subsequent trans-serosal extension of the tumour and invasion of the central tendon gave rise to the fistula. the patient probably presented just prior to complete fistulation which would explain the absence of a pneumopericardium on the admission chest x-ray. it may be speculated that the gastroscopy actually exaggerated the pneumopericardium and hastened the patient's demise. chest pain, dyspnoea, cyanosis and shock with a pericardial friction rub or occasionally loud bruit or bruit de moulin are the cardinal symptoms and signs of pericarditis associated wi th a gastropericardial fistula. 3,i 0 occasionally these patients present with cardiac tamponade'" as a result of the pneumopericardium which maybe complicated by an empyaema if the diagnosis is delayed.v'"!' in the presence of a pneumopericardium, a chest x-ray is usually diagnostic. however a contrast study is indicated to identify the site of the fistula and sometimes as in our patient, to assist with the pathological diagnosis. gossof identified three features common to gastropericardial fistulae irrespective of the underlying causes previously mentioned: • frequency of hiatus hernia in the genesis of these lesions;2j,g,13either from an ulcer, oesophagitis or herniated stomach or from surgical complications • need for aggressive treatment • high mortality 68% regardless of the aetiology, the reported mortality from this condition ranges between 68 and 85%.1,2these extremely ill patients should be 18 sa journal of radiology· may 1998 aggressively resuscitated, admitted to an intensive care unit, given inotropic support and antibiotics and ventilatory support should be considered.' once the diagnosis has been confirmed, surgical intervention should take place as soon as possible. letoquart' reviewed 52 cases and found that 42 were related to benign conditions. the overall mortality was 85%, although one in two patients survived if urgent surgery was resorted to. the prognosis in this condition may be enhanced with aggressive resuscitation, pericardial drainage and appropriate gastro-intestinal surgery.i ,2,3,lo although the risks associated with surgery in these patients are extremely high, they are less likely to result in mortality which is almost invariable in the conservatively managed patient. references i. letoquartjp, fasquel jl, l'huillier jp, babatast g, gruel y, lauvin r, mambrini a. les fistules gastropericardiques. revue de la litterature a propos d'un cas original. 1 de chir 1990; 127 (1): 6-12. 2. gosser d, mariambourg g, assens p, sarfan e, celerier m, dubast c. fistule gastro-pericardique. complication tardive d'une cure de hernie hiatale. 1 de chir 1986; 123 (12) 704-8. 3. nicolaou n, katz g, conlan aa. gastropericardial fistula presenting as acute cardiac tamponade. s afr med 1 1984; 65 (2): 51-2 4. hallin, cited by pick l. z klill med 1891; 26: 452. 5. edwards jr, humeniuk v. castropericardlal fistula. austr and new zealj surg 1996; 66 (4): 257-9. 6. schneider f, schenk m, tempejd, thiry l. spontaneous gastropericardial fistula. aiiii emerg med 1995; 26 (3): 394. 7. prabhudev n, ramesh b, prabhakar, rao as. "gastropericardial fistula" presenting as cardiac tamponade. } assoc pltys india 1994; 42 (2): 157-8. 8. saloja, heikkila l, nemlander a, lindahl h, louhirno i, mattila s. barrett's oesophagus and perforation of gastric tube ulceration into the pericardium : a late complication after reconstruction of oesophageal atresia. alii! chir e: gynae 1995; 84 (1): 92-4. 9. mukai m, nimomiya t, ocji n, hamada m. an 80 year old female with pneumopericardium due to gastric perforation. nippon rom", igakkai zassilli lap} geriatr 1995; 32 (2): 123-7. 10. gieser ra. a case of gastroperieardial fistula. s afr med j1973; 39: 1799-801 il. ikard rw, jacobs jk. gastropericardial fistula and pericardtal abscess: unusual complications of subphrenic abscess following nissen fundoplication. south medj 1974; 67 (i): 17-9. 12. ghahremani gg, yaghmai s, brooks lw, hutton cf. pneumopericardium due to transdiaphragmatic perforation of a gastric ulcer. am } digest dis 1976; 21 (7): 586-91 13. monroll, nicholls rl, hatelyw, murray rs, flavell g. gastropericardial fistula a complication of hiatus hernia. brit} surg 1974; 61 (6): 445-7. abstract introduction case report discussion conclusion acknowledgements references about the author(s) mankirat s. dhillon department of radiodiagnosis, maulana azad medical college and lok nayak hospital, new delhi, india anju garg department of radiodiagnosis, maulana azad medical college and lok nayak hospital, new delhi, india apoorva sehgal department of radiodiagnosis, maulana azad medical college and lok nayak hospital, new delhi, india sangeeta bhasin department of obstetrics and gynaecology, maulana azad medical college and lok nayak hospital, new delhi, india citation dhillon ms, garg a, sehgal a, bhasin s. torsion of a huge subserosal uterine leiomyoma: a challenging case of acute abdomen. s afr j rad. 2023;27(1), a2641. https://doi.org/10.4102/sajr.v27i1.2641 case report torsion of a huge subserosal uterine leiomyoma: a challenging case of acute abdomen mankirat s. dhillon, anju garg, apoorva sehgal, sangeeta bhasin received: 13 jan. 2023; accepted: 22 mar. 2023; published: 11 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract torsion of a uterine leiomyoma is an extremely rare, albeit life-threatening surgical emergency. a 28-year-old woman presented with acute abdominal pain. imaging revealed a torsed subserosal uterine leiomyoma which was managed surgically and the diagnosis confirmed intraoperatively as well as on histopathology. contribution: while intraoperative findings remain the primary means of diagnosis, radiologists should be familiar with the potential imaging findings of leiomyoma torsion as timely intervention can greatly improve patient outcome. keywords: subserosal; uterine leiomyoma; fibroid; pedunculated fibroid; torsion; ultrasound; magnetic resonance imaging; acute abdomen. introduction uterine leiomyomas are the most common tumours in women of the reproductive age group.1 although the prevalence of leiomyomas is high, acute complications are quite rare. however, when they do occur, failure to recognise and deal with these acute complications expeditiously can lead to catastrophic outcomes.2 torsion of a pedunculated subserosal leiomyoma is considered an acute surgical emergency due to the high risk of ischaemic gangrene and subsequent peritonitis. it is often diagnosed intraoperatively as its imaging findings are non-specific and overlap with the more commonly encountered leiomyoma degeneration, thus making its pre-operative diagnosis rather difficult.3 this case report describes the imaging findings in a case of a torsed, pedunculated, subserosal uterine leiomyoma. case report a 28-year-old nulliparous woman was referred from gynaecology emergency with complaints of excruciating lower abdominal pain, vomiting and vaginal bleeding for 3 days with acute worsening over the last 1 day. on physical examination, the patient’s abdomen was distended with a firm and tender pelvic mass reaching just above the umbilicus. the patient’s vitals were stable and laboratory investigations revealed a microcytic, hypochromic anaemia. the rest of her laboratory results were within normal limits. a transabdominal ultrasound (us) of the pelvis was performed which demonstrated a large, well-circumscribed, heterogeneous, hypoechoic, solid abdomino-pelvic mass, measuring 11 cm × 16 cm × 12 cm with posterior beam attenuation, abutting the uterine fundus. the mass showed no colour flow on doppler evaluation. transvaginal us revealed a vascular pedicle at the junction of the mass and the uterine fundus which showed absence of venous flow but presence of arterial flow on spectral doppler. both ovaries were identified separate from the mass and appeared normal. a small amount of anechoic free fluid was seen in the pelvis (figure 1). figure 1: grey-scale and doppler ultrasound. transverse (a) and sagittal (b) grey scale transabdominal ultrasound images of the abdomen and pelvis depict a large, well-circumscribed, heterogeneous, solid abdomino-pelvic mass (arrow), abutting the uterine fundus (double arrow in b) with no internal colour flow on doppler evaluation (c). transvaginal sagittal doppler ultrasound image (d) demonstrates the vascular pedicle (curved arrow) between the uterus (arrowhead) and the mass, suggesting its uterine origin. both ovaries were normal (⋆) and visualised separate from the mass with a small amount of anechoic free fluid in pelvis (dashed arrow) on transvaginal transverse (e) and sagittal grey scale images (f). a provisional diagnosis of a subserosal uterine leiomyoma with possibilities of secondary torsion or degeneration were considered and contrast-enhanced mri of the pelvis was performed for further evaluation. mri confirmed the presence of a pedunculated, solid, abdomino-pelvic mass, continuous with the uterus in the region of the left cornua with flow voids at its site of the uterine attachment on t2-weighted images indicating the ‘bridging vessel sign’. the mass appeared isointense (to the myometrium) on t1 and heterogeneously hyperintense on t2-weighted images with no diffusion restriction. on the post-contrast images, the majority of the mass was non-enhancing with a thin enhancing rim and a small eccentric area of heterogeneous enhancement adjacent to its site of attachment with the uterus. a small amount of free fluid was seen in pelvis and both ovaries were unremarkable (figure 2). based on the clinical and imaging findings, a diagnosis of a torsed subserosal uterine leiomyoma was suggested. figure 2: mr imaging in torsion of a subserosal uterine leiomyoma. mr images depict a large solid abdomino-pelvic mass lesion (arrow in a, b) continuous with the uterus (arrowhead in b) in the region of the left cornua (double arrow in c). the mass appears hypointense on the axial t1-weighted image (a) and heterogeneous on sagittal (b) and axial (c) t2-weighted mr images compared to the uterine myometrium. the majority of the mass appears heterogeneously hyperintense on the t2-weighted image (curved arrow in c) with a thin enhancing rim and non-enhancing core on post-contrast axial (d, e) and sagittal (f) mr images (curved arrow). a small juxtauterine area of relatively homogeneous t2 isointense signal (⋆ in c) and post-contrast enhancement (⋆ in d–f) is seen adjacent to its site of uterine attachment. the mass showed no diffusion restriction on diffusion weighted imaging (g) and the corresponding apparent diffusion coefficient map (h). the patient was counselled, written informed consent was obtained and exploratory laparotomy was performed. intraoperatively, the mass was found to be a large subserosal leiomyoma attached to the uterus in the region of the left cornua by a narrow pedicle that was twisted around its axis. the mass was excised and subsequently sent for histopathological examination. both ovaries and fallopian tubes were normal. on gross examination, the pedunculated uterine mass showed a twisted congested vascular pedicle with viable tissue adjacent to its pedicle corresponding to the enhancing component of the leiomyoma on mri. on histopathology, the majority of the mass demonstrated necrosis with areas of internal haemorrhage, which corresponded to the non-enhancing component on mri (figure 3). the histopathogical results confirmed the diagnosis of a predominantly necrotic leiomyoma. the post-operative period was uneventful and the patient was symptom-free on follow-up. figure 3: gross specimen and cut section of the excised twisted subserosal leiomyoma. intraoperatively, the mass was found to be a large subserosal uterine fibroid with a twisted vascular pedicle (arrow in a). cut section of the gross specimen (b) revealed haemorrhagic necrosis in the majority of the mass (dashed arrows) which showed lack of contrast enhancement (dashed arrow) on the post-contrast mr image (c) with viable tissue at the site of uterine attachment which corresponded to the enhancement seen on the mr image (arrowhead in b, c). figure (c) shows the uterine attachment site of the fibroid (pedicle indicated by a curved arrow). discussion uterine fibroids or leiomyomas are benign, smooth-muscle neoplasms and are the most common gynaecologic tumours, found in 60% of women in their reproductive ages.3 uncomplicated fibroids are often asymptomatic; however, when symptomatic they may result in abdominal pain, menorrhagia, dysmenorrhoea and infertility. severe complications include torsion, degeneration, intraperitoneal haemorrhage, prolapse of submucosal fibroids, acute urinary retention and venous thrombosis.2 torsion of a uterine leiomyoma is a rare cause of acute abdomen with an incidence of less than 0.25% reported in a single-centre retrospective study of complicated subserosal fibroids requiring surgery. pedunculated subserosal fibroids carry the highest risk of torsion (as was seen in the presented case), particularly when the stalk is long and slender.4 owing to its low incidence and overlapping clinical presentation with other causes of acute abdomen, this diagnosis is usually not considered pre-operatively. even the imaging findings overlap with the more common leiomyoma degeneration, posing a diagnostic dilemma for the radiologist. this often leads to this uncommon condition being only diagnosed at the time of surgery.3 the clinical presentation is variable depending on the degree and speed at which the torsion develops. if the torsion is partial and intermittent with spontaneous untwisting, symptoms may be intermittent, constant or even resolve spontaneously. complete torsion of the pedicle results in circulatory stasis that is initially venous with oedema and congestion followed by compression of the arterial blood supply that produces haemorrhagic necrosis and gangrene giving rise to excruciating pain as was seen in the presented case. if left untreated, haemorrhagic infarction of the torsed leiomyoma may lead to infection and peritonitis.5 ultrasound is the primary imaging modality used to diagnose uterine leiomyomas, which appear as solid masses revealing a whorled appearance with posterior acoustic shadowing on grey-scale and a peripheral rim of vascularity on doppler examination.6 doppler interrogation can help identify the vascular pedicle in cases of subserosal leiomyomas (as depicted in figure 1d in this case); however, the diagnosis of torsion still remains elusive. some clinchers to the diagnosis of torsion include heterogeneity of the leiomyoma on grey scale, an abrupt cut off or twisting of its vascular pedicle and absent colour flow within the lesion even on power doppler examination (as displayed in figure 1c). however, these patterns are not regularly depicted.4 the congested pedicle in the presented case demonstrated an arterial waveform with absence of venous flow on doppler. however, adnexal and uterine arterial waveforms can be normal on doppler evaluation and this does not rule out torsion. associated ascites may be seen.5 thus, us has modest sensitivity and specificity not only in diagnosing torsion but also rarely in diagnosing subserosal leiomyomas, especially when the pedicle is thin. ultrasound can help rule out other causes of acute abdomen which are more commonly encountered.3 in cases of inconclusive us findings, mri is performed for its higher sensitivity and specificity. the vascular pedicle of a subserosal leiomyoma is better appreciated on mri in the form of t2 flow voids at the interface between the uterus and the mass indicating the ‘bridging vessel sign’, suggesting a uterine origin of the mass and thereby differentiating it from an adnexal mass. in this case, the attachment site of the pedicle with the uterus was well appreciated on mri (figure 2c and figure 3c). it is also important to identify normal ovaries separate from the mass.7 uncomplicated leiomyomas appear homogeneously hypointense on t1 and t2 weighted images. in contrast, torsed leiomyomas undergo necrosis and gangrene thereby exhibiting heterogeneous hyperintensity on t2 weighted images and intermediate to hyperintense signal on t1 weighted images corresponding to ischaemia and haemorrhagic necrosis respectively. diffusion restriction on diffusion weighted images can be seen (was not seen in this case) and a thin enhancing rim with lack of enhancement within the mass is seen on post-contrast images (as displayed in figure 2d, e in this case).6 the non-enhancing core is consistent with necrosis while the regular rim of enhancement corresponds to obstructed peripheral veins with oedema.8 ascites is an associated sensitive finding seen in the majority of the cases. the ‘dark fan sign’ is described as a fan-shaped area of poor contrast enhancement in the uterus adjacent to the torsed subserosal fibroid;9 however, this was not appreciated in this case. ct has a limited role in the evaluation of leiomyomas; however, it may be performed when other causes of acute abdomen are suspected. ct findings include an interval increase in size of the leiomyoma, a lack of central enhancement with an enhancing rim, the ‘dark fan sign’ and ascites.10 common differential diagnoses include leiomyoma with secondary degeneration and ovarian torsion. degeneration in leiomyoma is more common than its torsion. it presents with acute pain; however, the clinical presentation is less sinister. it should be differentiated from torsion as emergency surgical intervention is not needed in cases of degeneration. many types of fibroid degeneration are known to occur. in cystic degeneration, internal areas of fluid signal (hyperintense on t2 and hypointense on t1) are seen with a lack of enhancement on post-contrast images. haemorrhagic degeneration can show internal t1 hyperintense areas which can be confused with areas of haemorrhagic infarction in a torsed necrotic fibroid. fatty degeneration demonstrates fat signal intensity (hyperintense on t1 and intermediate to hyperintense on t2 weighted images) on mri with suppression on fat saturated sequences. hyaline degeneration appears similar to a non-degenerated myoma on t1and t2-weighted scans; however, after the administration of contrast, hyaline degeneration displays decreased enhancement. myxoid degeneration is more rare and shows marked hyperintensity on t2-weighted images with intense stromal enhancement and non-enhancement of the intervening mucinous lakes, the latter mimicking necrotic areas of a torsed fibroid.11additionally, the presence of t2 hyperintense areas with diffusion restriction and low mean apparent diffusion coefficient value in a cellular leiomyoma and leiomyosarcoma can be confused with ischaemic necrosis in a torsed leiomyoma.11 an enlarged oedematous ovary showing peripherally displaced follicles with or without haemorrhagic infarction and a co-existent ovarian mass positioned in the midline and superiorly in front of the uterus is seen in ovarian torsion which may mimic a subserosal leiomyoma. the presence of an ovarian vascular pedicle is a valuable sign that helps in differentiating an ovarian mass from a subserosal uterine myoma.12 other causes of acute pelvic pain such as endometriosis, pelvic inflammatory disease and appendicitis can easily be excluded with imaging. torsed uterine fibroids are managed surgically by myomectomy or hysterectomy depending on the age and desired fertility of the patient.13 the presented patient was in her reproductive age and, therefore, myomectomy was performed. it is important to consider the possibility of torsed fibroid in the differential diagnosis in any woman presenting with an intra-abdominal and pelvic mass. it is also important to recognise the need for prompt exploratory surgery in any patient presenting with acute abdominal pain and the clinical suspicion of torsion. this case highlights the complexity of the diagnosis of torsed fibroid. conclusion while direct intraoperative visualisation of a twisted vascular pedicle remains the mainstay of diagnosis of a torsed, pedunculated, uterine leiomyoma, the presence of a non-enhancing subserosal fibroid with only a thin enhancing rim on imaging in the appropriate clinical setting should raise concern for torsion. however, this is often missed even by the most experienced radiologist due to rarity of the diagnosis and significant overlap in imaging findings. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.s.d., a.g., a.s., and s.b. contributed to the study’s conception and design. the first draft was written by m.s.d. and a.s., which was reviewed and edited by a.g., a.s., and s.b. all authors read and approved the final case report. ethical considerations this case report followed all ethical standards for research. written informed consent was obtained from the patient for publication of this case report and all data were anonymised. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data supporting the findings of this case report are available upon request from the corresponding author, a.s. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references prayson ra, hart wr. pathologic considerations of uterine smoothmuscle tumors. obstetr gynecol clin n am. 1995;22(4):637–657. https://doi.org/10.1016/s0889-8545(21)00658-6 gupta s, manyonda it. acute complications of fibroids. best practres clin obstetgynaecol. 2009;23(5):609–617. https://doi.org/10.1016/j.bpobgyn.2009.01.012 le d, dey cb, byun k. imaging findings of a torsed pedunculated uterine leiomyoma: a case report. radiol case rep. 2020;15(2):144–149. https://doi.org/10.1016/j.radcr.2019.11.001 lai yl, chen yl, chen ca, cheng wf. torsion of pedunculated subserous uterine leiomyoma: a rare complication of a common disease. taiwan j obstet gynecol. 2018;57(2):300–303. https://doi.org/10.1016/j.tjog.2018.02.021 roy c, bierry g, ghali se, buy x, rossini a. acute torsion of uterine leiomyoma: ct features. abdom imaging. 2004;30(1):120–123. https://doi.org/10.1007/s00261-004-0240-1 wilde s, scott-barrett s. radiological appearances of uterine fibroids. indian j radiol imaging. 2009;19(03):222–231. https://doi.org/10.4103/0971-3026.54887 torashima m, yamashita y, matsuno y, et al. the value of detection of flow voids between the uterus and the leiomyoma with mri. j magn reson imaging. 1998;8(2):427–431. https://doi.org/10.1002/jmri.1880080224 ueda h, togashi k, konishi i, et al. unusual appearances of uterine leiomyomas: mr imaging findings and their histopathologic backgrounds. radiographics. 1999;19(suppl_1):s131–s145. https://doi.org/10.1148/radiographics.19.suppl_1.g99oc04s131 yamashita s, fujikawa h, yoshizawa t. a rare cause of acute abdomen: torsion of subserous uterine fibroid in a postmenopausal woman. balkan med j. 2022;39(5):378–379. https://doi.org/10.4274/balkanmedj.galenos.2022.2022-4-98 ohgiya y, seino n, miyamoto s, et al. ct features for diagnosing acute torsion of uterine subserosal leiomyoma. jpn j radiol. 2018;36(3):209–214. https://doi.org/10.1007/s11604-017-0712-1 arleo ek, schwartz pe, hui p, mccarthy s. review of leiomyoma variants. am jroentgenol. 2015;205(4):912–921. https://doi.org/10.2214/ajr.14.13946 dawood mt, naik m, bharwani n, sudderuddin sa, rockall ag, stewart vr. adnexal torsion: review of radiologic appearances. radiographics. 2021;41(2):609–624. https://doi.org/10.1148/rg.2021200118 donnez j, dolmans mm. uterine fibroid management: from the present to the future. hum reprod update. 2016;22(6):665–686. https://doi.org/10.1093/humupd/dmw023 ultrasound diagnosis.html ultrasound diagnosis of ulnar nerve dislocation and snapping triceps syndrome v b gupta, mbbs, dnb k b patankar, md, dmrd f paranjpe, md j patil, md, dnb department of radiology, apple hospital, kolhapur, maharashtra, india corresponding author: v gupta (vivekforever@lycos.com) dislocation of the ulnar nerve with snapping triceps syndrome has been implicated as a cause of cubital tunnel syndrome. patients with this condition may clinically present with a snapping sensation at the elbow upon flexion along with ulnar neuropathic symptoms. though demonstration of this condition is possible by static mri images, ultrasound can be used as a more accessible and inexpensive modality for attaining diagnosis. this pictorial essay emphasises the technique, findings and role of dynamic ultrasound in the diagnosis of this entity. s afr j rad 2012;16(2):65-67. introduction the preferred modality for imaging of the musculoskeletal system for suspected nerve entrapment is magnetic resonance imaging (mri). alternatively, high-resolution ultrasound (us) can be an inexpensive and more accessible modality. one of the assets of us in musculoskeletal imaging is its ability to image parts in dynamic motion, which may not be feasible for conventional mri or ct. this essay emphasises the role of us in the diagnosis of ulnar nerve dislocation and snapping triceps syndrome and describes the preferred technique, imaging findings and dynamic monitoring by us. the essay highlights the need for awareness of this entity when dealing with medial elbow pain and/or ulnar neuropathy. though the condition of ulnar nerve dislocation itself is not uncommon, the fact that it can be associated with triceps snapping is often overlooked, and the combination of ulnar nerve dislocation with triceps snapping syndrome has been implicated as one of the causes of cubital tunnel syndrome. once diagnosed, options of conservative as well as surgical management of the condition are available. clinical presentation a 35-year-old male manual labourer presented with pain in the left elbow region. he complained of a characteristic snapping sensation in the medial aspect of his elbow on flexion. the pain was along the ulnar nerve distribution and was often associated with tingling and numbness. the symptoms were of increasing severity over a 6-month period. there was no history of fever. his past history was unremarkable. on local examination, there was no visible swelling at the elbow. his basic laboratory investigations were normal. plain films were normal. an us of the left elbow was advised. ultrasound technique at sonography, the position of the ulnar nerve was noted with respect to the medial epicondyle. the patient was examined in the seated position with both elbows comfortably resting on a cushion placed on his lap. us of the left elbow was performed at the level of the cubital tunnel; this was achieved by placing the transducer over the medial epicondyle at one end and over the head of the olecranon at the other end of the transducer. a high-frequency (8.5 mhz) linear transducer was used. the elbow at the level of the cubital tunnel was examined initially in extension and then in flexion. the patient was made to externally rotate his shoulder for optimal visualisation of the cubital tunnel. dynamic us of the tunnel was performed while flexing the elbow. comparison was made with the asymptomatic right elbow. care should be taken not to exert too much pressure with the probe as this will prevent dislocation.1 findings with the arm in extension, the ulnar nerve was noted in the cubital tunnel and the adjacent triceps muscle was in the expected normal position posterior to the apex of the medial epicondyle on extension (figs 1 and 2). the site of the common origin of the flexor muscles of the forearm was identified at the apex of the medial epicondyle. there was no significant difference in the cross-sectional diameter of the ulnar nerves in comparison on extension measured at the level of the medial epicondyle. in the symptomatic left elbow, following flexion, the ulnar nerve dislocated over the medial epicondyle and lay anteromedially. the triceps muscle was also noted to dislocate and move over the medial epicondyle (figs 3 and 4). the ulnar nerve and adjacent triceps remained stable in the asymptomatic right side (fig. 5). there was separation of the ulnar nerve from the triceps while dislocating over the apex of the medial epicondyle. this phenomenon was well demonstrated using dynamic extension followed by flexion with the transducer held firmly with respect to the medial epicondyle continuously monitoring the movement in the cubital tunnel. the moment of dislocation of the ulnar nerve and triceps over the medial epicondyle that be felt by the patient as a snapping senstion was also noted by the observer. after flexion, the cross-sectional appearance of the dislocated ulnar nerve over the medial epicondyle appeared elongated and obtained a flattened shape instead of its normal rounded appearance in the cubital tunnel (fig. 4). after extension, the ulnar nerve and triceps were noted to revert back to their respective normal positions and morphology in the cubital tunnel. the us findings were consistent with ulnar nerve dislocation and associated triceps snapping syndrome. nerve conduction studies were positive for ulnar neuropathy at the elbow. the patient was initially managed conservatively on an analgesic regime but did not show significant clinical improvement, and subsequently underwent surgery. intra-operatively, on passive flexion and extension of the elbow, the ulnar nerve as well as the medial head of the triceps were noted to dislocate over the medial epicondyle, confirming the diagnosis. the ulnar nerve was transpositioned anteriorly and the medial head of the triceps was transpositioned laterally by the orthopaedic surgeon. on a post-surgery follow-up at 6 months, the patient reported significant relief from the symptoms. discussion cubital tunnel syndrome is a concise term for conditions that result in strain on the ulnar nerve at the elbow. patients with this condition typically complain of pain and tingling numbness in the distribution of the ulnar nerve, exaggerated on flexion of the elbow.2 one of the possible causes for cubital tunnel syndrome is ulnar nerve dislocation, which may be associated with triceps snapping syndrome. in this condition, the ulnar nerve dislocates over the medial epicondyle following flexion of the elbow which may or may not be accompanied by triceps dislocation. as the elbow moves from extension to flexion, the distance between the medial epicondyle and the olecranon increases by 5 mm for every 45° of elbow flexion. the cubital tunnel’s loss in height with flexion results in a 55% volume decrease in the canal, which doubles the mean ulnar intraneural pressure.3 , 4 subluxation of the nerve is common, and not every individual with this condition is symptomatic. friction generated with repeated subluxations may cause inflammation within the nerve and, in the subluxed position, the nerve may be more susceptible to inadvertent trauma.5 , 6 congenital absence of the cubital tunnel retinaculum, a fibrous band extending from the olecranon process to the medial epicondyle and forming roof of the cubital tunnel, is thought to be one of the causes of ulnar nerve dislocation with triceps snapping.7 other possibilities include bodybuilding, post-trauma effects, congenital accessory triceps tendon and abnormal medial triceps.8 dynamic us can help to demonstrate abnormal dislocation of the ulnar nerve, with and without snapping triceps syndrome through continual visualisation of the ulnar nerve and triceps muscle in active elbow flexion and extension.1 knowledge of this condition and the relevant anatomy is essential for diagnosis and for musculoskeletal us in general. the condition can also be demonstrated through mri and ct,9 which requires imaging the limb in static extension and flexion to diagnose the dislocation. however us is a cost-effective modality which has the superior advantage of demonstrating the condition dynamically. additionally, the snapping sensation on dislocation can be actively appreciated on us by the examiner. the technique for an us diagnosis of ulnar nerve dislocation and triceps snapping requires identification of the apex of the medial epicondyle as a landmark.1 on extension, the ulnar nerve is located posterior to the epicondyle which dislocates over it on flexion,reverting to its original position on extension. if the medial head of the triceps also dislocates over the medial epicondyle, triceps snapping is also associated, which may be felt as two snaps: the first when the ulnar nerve dislocates, followed by a second snap upon triceps dislocation. if the medial head of the triceps does not dislocate, isolated dislocation of the ulnar nerve should be considered. us findings suggest that dislocation is diagnosed conclusively on flexion. as appreciated in this case, it has been shown that the ulnar nerve flattens during elbow flexion, and this flattening is most marked with ulnar nerve subluxation.10 treatment for this condition depends on symptom severity. for milder cases, conservative treatment including physiotherapy and avoiding activities involving repeated flexion and extension may suffice. patients with persistent or severe symptoms may require surgery such as lateral repositioning, medial epicondylectomy or anterior transposition of the ulnar nerve.6 , 9 acknowledgements. we thank dr ajit patil, the orthopaedic surgeon managing this case, for his co-operation; miss geeta awate, general manager, apple hospital, for her keen interest in research projects at the institute; dr v degaonkar for his invaluable guidance; and mr yuvraj shinde for his contribution in preparing the manuscript and images. 1. jacobson ja, jebson pj, jeffers aw, fessell dp, hayes cw. ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography – report of three cases. radiology 2001;220(3):601-605. 1. jacobson ja, jebson pj, jeffers aw, fessell dp, hayes cw. ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography – report of three cases. radiology 2001;220(3):601-605. 2. cubital tunnel syndrome, information for public and patients. rosemont, il: american society for surgery of the hand, 2011. 2. cubital tunnel syndrome, information for public and patients. rosemont, il: american society for surgery of the hand, 2011. 3. watchmaker gp, lee g, mackinnon se. intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. j hand surg [am] 1994;19(6):915-922. 3. watchmaker gp, lee g, mackinnon se. intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. j hand surg [am] 1994;19(6):915-922. 4. pechan j, julis i. the pressure measurement in the ulnar nerve. a contribution to the pathophysiology of the cubital tunnel syndrome. j biomech 1975;8(1):75-79. 4. pechan j, julis i. the pressure measurement in the ulnar nerve. a contribution to the pathophysiology of the cubital tunnel syndrome. j biomech 1975;8(1):75-79. 5. childress hm. recurrent ulnar-nerve dislocation at the elbow.clin orthop 1975;108:168-173. 5. childress hm. recurrent ulnar-nerve dislocation at the elbow.clin orthop 1975;108:168-173. 6. verheyden jr, palmer ak. cubital tunnel syndrome. medscape, june 2011. http://emedicine.medscape.com/article/1231663-overview#a0104 (accessed 6 january 2012). 6. verheyden jr, palmer ak. cubital tunnel syndrome. medscape, june 2011. http://emedicine.medscape.com/article/1231663-overview#a0104 (accessed 6 january 2012). 7. o’driscoll sw, horii e, carmichael sw, morrey bf. the cubital tunnel and ulnar neuropathy. j bone joint surg br 1991;73:613-617. 7. o’driscoll sw, horii e, carmichael sw, morrey bf. the cubital tunnel and ulnar neuropathy. j bone joint surg br 1991;73:613-617. 8. spinner rj, goldner ro. snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve. j bone joint surg am 1998;80:239-247. 8. spinner rj, goldner ro. snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve. j bone joint surg am 1998;80:239-247. 9. spinner rj, hayden fr, hipps ct, goldner rd. imaging of snapping triceps. am j roentgenol 1996;167:1550-1551. 9. spinner rj, hayden fr, hipps ct, goldner rd. imaging of snapping triceps. am j roentgenol 1996;167:1550-1551. 10. okamoto m, abe m, shirai h, ueda n. morphology and dynamics of the ulnar nerve in the cubital tunnel: observation by ultrasonography. j hand surg [br] 2000;25:85-89. 10. okamoto m, abe m, shirai h, ueda n. morphology and dynamics of the ulnar nerve in the cubital tunnel: observation by ultrasonography. j hand surg [br] 2000;25:85-89. fig. 1. the asymptomatic right elbow at the level of the cubital tunnel. the elbow is in extension. the ulnar nerve (arrowhead) and the medial head of the triceps muscle (tr) are in the cubital tunnel posterior to the apex of the medial epicondyle (me). the common origin of the flexor muscles (fe) of the forearm is visualised at the apex of the medial epicondyle. one end of the transducer is at the medial epicondyle and the other at the head of the olecranon (ol). fig. 2. the symptomatic left elbow at the level of the cubital tunnel in extension. the ulnar nerve (arrowhead) and the medial head of triceps (tr) are in the cubital tunnel posterior to the medial epicondyle (me) similarly to the anatomy of the extended right elbow. note the round contour of the cross-section of the ulnar nerve. fig. 3. the symptomatic left elbow at the level of the cubital tunnel in mid-flexion. the ulnar nerve (arrowhead) has moved over the medial epicondyle (me). note the flattening of the contour of the ulnar nerve. in addition, the medial head of the triceps (tr) has moved towards the medial epicondyle. fig. 4. at full flexion, the ulnar nerve along with the medial head of the triceps have dislocated (shown by the arrowhead) over the medial epicondyle (me). the dislocation was perceived as a snapping sensation felt through the transducer. fig. 5. the asymptomatic right elbow at the level of the cubital tunnel is depicted at full flexion following continuous dynamic monitoring by keeping the transducer fixed over the medial epicondyle (me) during flexion. the ulnar nerve (arrowhead) and medial head of triceps (tr) remain in the cubital tunnel posterior to the medial epicondyle with no evidence of dislocation. abstract introduction and background pathophysiology acute profound ischemia partial prolonged ischemia mixed pattern multilobar cystic encephalomalacia/multicystic encephalopathy conclusion acknowledgements references about the author(s) shalendra k. misser department of radiology, faculty of health sciences medicine, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, durban, south africa department of radiology, faculty of radiology, lake, smit and partners inc, durban, south africa anthony j. barkovich department of radiology, faculty of medicine, neurology and neurosurgery, division of neuroradiology, university of california, san francisco, united states of america jan w. lotz department of radiology, faculty of medicine, university of stellenbosch, stellenbosch, south africa moherndran archary department of paediatrics, faculty of health sciences medicine, college of health sciences, nelson r. mandela school of medicine, university of kwazulu-natal, durban, south africa citation misser sk, barkovich aj, lotz jw, archary m. a pictorial review of the pathophysiology and classification of the magnetic resonance imaging patterns of perinatal term hypoxic ischemic brain injury – what the radiologist needs to know… s afr j rad. 2020;24(1), a1915. https://doi.org/10.4102/sajr.v24i1.1915 note: special collection: paediatric radiology. research project registration: project number: brec/00001036/2020 pictorial review a pictorial review of the pathophysiology and classification of the magnetic resonance imaging patterns of perinatal term hypoxic ischemic brain injury – what the radiologist needs to know… shalendra k. misser, anthony j. barkovich, jan w. lotz, moherndran archary received: 23 may 2020; accepted: 16 july 2020; published: 30 oct. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this article provides a correlation of the pathophysiology and magnetic resonance imaging (mri) patterns identified on imaging of children with hypoxic ischemic brain injury (hibi). the purpose of this pictorial review is to empower the reading radiologist with a simplified classification of the patterns of cerebral injury matched to images of patients demonstrating each subtype. a background narrative literature review was undertaken of the regional, continental and international databases looking at specific patterns of cerebral injury related to perinatal hibi. in addition, a database of mri studies accumulated over a decade (including a total of 314 studies) was analysed and subclassified into the various patterns of cerebral injury. selected cases were annotated to highlight the areas involved and for ease of identification of the affected substrate in daily practice. keywords: hypoxic ischemic encephalopathy; magnetic resonance imaging; acute profound; partial prolonged; hypoxic ischemic brain injury; ulegyria; multicystic; encephalopathy. introduction and background perinatal hypoxic ischemic brain injury (hibi) is the leading cause of neonatal encephalopathy1 and accounts for between 6% and 8% of cerebral palsy worldwide.2 in developed countries, the prevalence is estimated at 1.5–4 per 1000 live births,3 whereas in developing countries, including south africa, it is estimated to be much higher, up to 15.2 per 1000 births.4,5 whilst therapeutic hypothermia has been shown to be beneficial, it is still not readily available in resource-limited settings; despite its use, the mortality and morbidity associated with hibi remains high globally. by the age of 2 years, more than half of hibi-affected children would have either not survived or suffered severe disabilities.6 in addition to the poor outcome and social impact of hibi, there is grave concern internationally regarding the increase in medicolegal litigation in this aspect of medicine. the last decade has brought an explosion of cases against medical practitioners and institutions, particularly in children with cerebral palsy. in these cases, medical negligence is alleged and often the litigation is instituted a few, sometimes several, years after the delivery. neuroimaging has evolved significantly in the last 30 years and plays an important role in the evaluation of children with suspected perinatal hibi. magnetic resonance imaging is the key imaging modality in the evaluation of suspected hibi. as such, radiologists are increasingly being requested to lead pivotal evidence that may confirm a pattern of injury compatible with hibi, and mri has also been used in devising scoring systems for the evaluation of hibi.7,8 the neuroimaging patterns of cerebral hypoxic ischemic injury have also been shown to be quite different in term neonates and preterm/premature neonates.9 this review pertains to the imaging of term neonatal hypoxic brain injury. pathophysiology the basis of the injury demonstrated at mri follows from the duration of the event preceding the hypoxic outcome, the severity of the hypoxia/hypoperfusion and the length of time for each of the subsequent phases of injury. there are three stages of injury in perinatal asphyxia.10 the first stage is the primary neuronal injury occurring immediately following reduction or absence of oxygen and/or glucose to the foetus. the primary cerebral energy failure causes adenosine triphosphate–dependent (atp–dependent) sodium–potassium pump failure. this in turn results in cell swelling due to increased intracellular sodium and water. through a cascade of secondary intracellular micro-events mediated by glutamate and tumour necrosis factor–alpha (tnf-∞), further cell death is the eventuality by apoptosis and necroptosis pathways, respectively (see figure 1). in the second phase, there is a latent period which is variable, during which reperfusion occurs and some neurons can recover. in the subsequent 24 to 48 h, independent of the perinatal acidosis, secondary neuronal injury occurs due to dissemination of toxic neurotransmitters, largely because of reperfusion of affected brain regions.11 tertiary injury evolves over the subsequent weeks to months with delayed neuronal necrosis as the injured brain undergoes remodelling and repair through astrogliosis.12 figure 1: pathogenesis of hypoxic ischemic encephalopathy12 mediated by sodium potassium adenosine triphosphatase pump failure leading to cytotoxic oedema and early cell necrosis, apoptosis via glutamate-induced excitotoxicity and necroptosis by tumour necrosis factor-α-induced cascade. critical to the evaluation of the mri studies in a child with cerebral palsy is the ability to identify changes that would be attributable to a specific pattern of cerebral hibi. it is possible to categorise the brain injury pattern based on the observed phenotype identified on neuroimaging. there have been several classifications noted in the literature for differentiating hibi neuropathological imaging patterns. these, although named differently in multiple research studies, convey the same message in terms of the principal pathophysiology of injury demonstrable on mri. for simplification, we propose classification into acute profound ischemia (api), partial prolonged ischemia (ppi), mixed patterns of ischemia and multicystic encephalomalacia (see table 1).13 a similar classification of hibi into diffuse, cortical/subcortical (cerebral cortex and deep nuclear pattern) and deep nuclear/brainstem mri patterns correlates clinically with very severe/very prolonged, moderate to severe, prolonged/severe and abrupt insults, respectively.14 consequent to the initial cause of injury, the resultant pattern of injury would depend on the ability of the foetal cerebral autoregulation mechanisms supporting brain perfusion. with regard to the multicystic encephalopathy or cystic encephalomalacia group, noting that there are several causes of this pattern of injury, we propose two subtypes that could result from hypoxic ischemic injury depending on the timing and severity of the insult. in most such cases, the entire cerebrum is affected, only sparing some portions of the temporal lobes. the key distinguishing feature is the involvement of the basal ganglia, which indicates probable primary (or superadded) acute profound ischemic injury. table 1: the basic patterns of magnetic resonance imaging abnormalities in hypoxic ischemic encephalopathy. a literature review was undertaken and included an electronic search of english language articles on cerebral palsy published between january 2000 and december 2019 on the electronic databases of medline, google scholar, pubmed, african journals online (ajol) and sabinet (south african bibliographic information network). there is a significant difference in the availability of published literature from developed countries versus developing countries including sub-saharan africa. in this review, primary searches were performed using keywords such as ‘hypoxia/hypoxic, ischaemic/ischemic, neonatal, encephalopathy, brain injury, magnetic resonance imaging (mri) and cerebral palsy’. specific secondary searches included the terms acute profound, central, partial prolonged, total anoxia, asphyxia and cystic encephalomalacia. in addition to peer-reviewed literature, further articles were selected based on manual searches and cross references of cited key articles. figure 2 shows the framework of the review process followed in the literature search. figure 2: contextual framework of the narrative review process for term neonatal hypoxic ischemic encephalopathy and the resultant neuroimaging patterns. a review of google scholar for the selected period reveals a total of 545 articles in the english literature using the search terms ‘hypoxic ischemic encephalopathy/magnetic resonance imaging/acute profound/partial prolonged/cystic encephalomalacia’. on sabinet and ajol, a total of 77 and 13 articles were returned, respectively, on searching for hypoxic ischemic encephalopathy. there is relatively little published in the african literature looking at the mri features of hibi or correlation of neuroimaging with perinatal hibi. one such article is a pictorial review by dekker et al.,15 which described the patterns of brain injury identified on neuroimaging in term and preterm neonates within utero or perinatal hypoxia. variable incidences have been reported of these patterns of injury. for instance, a two-centre north american study16 performed at the university of california san francisco (ucsf) and loma linda university children’s hospital (lluch) showed in 173 neonates with encephalopathy, an incidence of watershed pattern/partial prolonged ischemic injury of 45% and basal ganglia/acute profound ischemic pattern in 25%. a comparative european study17 performed in the netherlands analysed mri studies in 2587 patients with neonatal encephalopathy and showed 104 patients had neuroimaging patterns of hibi. the acute profound subtype was seen in more than 20% and cystic encephalopathy subtype in approximately 10% of these 104 children with cerebral palsy. de vries and groenendaal13 also described the two main forms of hibi as the basal-ganglia-thalamus and watershed patterns with the former seen in cases of more severe hypoxia. each of the mri manifested subtypes of hibi is associated with clinically variable outcomes and degrees of severity. retrospective correlation with recorded clinical findings and the overall perinatal scenario including blood tests, apgar scores and neonatal measurements are key in demonstrating probable etiopathogenesis. important clinical criteria for diagnosis of neonatal hypoxic encephalopathy as well as sarnat and sarnat scoring systems are utilised in the grading of hibi and neonatal encephalopathy. by a calculated score, the severity of hibi is estimated and the neonate is classified as having sustained mild, moderate or severe hypoxic brain injury. congruent to the severity of the hypoxemia and duration thereof will be the emergent pattern of neuroimaging abnormalities detected by mri sequences. the protocol varies at each centre but a basic list of sequences is included in table 2. table 2: list of magnetic resonance imaging sequences in the scanning protocol at the principal author’s institution. acute profound ischemia in the setting of acute cessation of perfusion with rapid progression (e.g. in abruptio placentae), there is insufficient time for the cerebral autoregulatory mechanisms to adequately redirect blood flow to the high metabolic areas of the brain. these are areas of the brain that are actively myelinating with high n-methyl-d–aspartate (nmda) receptor presence. the failure to protect these areas will result in a primarily central injury pattern with selective neuronal necrosis. this pattern of injury shown in figure 3 involves the deep basal nuclei (especially the posterior putamina), thalami (particularly the ventrolateral nuclei), perirolandic sensorimotor cortex at the frontal/parietal lobe interface, hippocampal formations and, in some cases, the upper dorsal brainstem and anterior aspect of the superior cerebellar vermis (see list in table 3). this subtype is also referred to in the literature by the terms central type injury or basal ganglia-thalamus pattern. figure 3: diagrammatic representation showing redistribution of visceral blood supply to the brain, but failure of cerebral autoregulatory mechanisms to redirect perfusion to the high metabolic zones of the brain. table 3: high metabolic zones of the brain with highest concentration of n-methyl-d-aspartate receptors. in cases of hibi, mri performed in the first 3 days of life will demonstrate little, if any, change on the t1and t2-weighted conventional sequences.18 diffusion-weighted imaging in the neonate will, however, reveal restricted diffusion in the affected high metabolic zones with no associated paramagnetic signal loss on susceptibility weighted imaging (swi) sequences. in the latter half of the first week of life, t1-weighted hyperintensity may be seen at the ventral thalamus and dorsal putamina (see figures 4–6) along with loss of the expected t1-weighted hyperintense line of the posterior limb of the internal capsule in term neonates, known as the absent posterior limb sign. after the first week, the diffusion signal may become falsely negative and this is known as the pseudonormalisation phenomenon (see figure 5). in addition, it has been shown that diffusion signal abnormalities may re-appear in areas adjacent to foci of pseudonormalisation as the injury evolves in subsequent weeks or early neonatal life.18,19 figure 4: two-week-old neonate born with grade 3 hypoxic ischemic brain injury and neonatal seizures. (a) an axial t1-weighted sequence showing signal shortening at the dorsal putamina (yellow arrows) and ventral thalami (green arrows). (b) note, in addition to the basal ganglia and thalamic changes, the hyperintense signal and volume loss at both hippocampi (red arrows). figure 5: the same child as in figure 4. (a) the b1000 sequence and (b) the apparent diffusion coefficient (adc) map obtained after 1 week demonstrating pseudonormalisation phenomenon with trace remaining hyperintensity at the ventral thalamus (green arrow) and no associated adc shortening. figure 6: twenty-seven-day-old male child delivered after abruptio placentae. axial magnetic resonance imaging images at the level of the basal ganglia demonstrating bilateral fairly symmetrical dorsal putaminal (yellow arrows) and ventral thalamic (green arrows) hyperintensity because of t1 shortening (a) and corresponding t2-weighted hyperintensity and established atrophy of these structures (b). note that the changes have evolved within the first month of life. magnetic resonance spectroscopy has also been shown to be of value in demonstrating hibi prior to signal changes on the other conventional sequences19 as well as pre-empting diffusion changes in a few cases.20 a decrease in n-acetylaspartate (naa) and choline peaks and prominent lactate doublet peaks correlates with areas of selective neuronal necrosis. in addition, reduced naa/choline or naa/cr ratios associated with increased lac/naa ratio is predictive of a poor neurodevelopmental outcome.13 a t1-weighted hyperintense signal outlining the perirolandic cortex is an important feature of acute profound hypoxic injury in the neonate in the latter half of the first month of life (see figure 7). subsequent follow-up mri studies in later childhood reveal persistent t2-weighted and flair hyperintensity in the affected substrate. the degree of signal abnormality seen is extremely variable and can be quite subtle in some instances. in particular, the perirolandic sensorimotor cortex signal change may be limited to one lip of the fronto-parietal cortex interface (see figure 8). often, this subtle injury may not be well appreciated on the t2-weighted sequences and is better delineated on axial flair sequences. the dorsal putaminal signal changes may be pin-point sized, and also the ventral thalamic changes may be less obvious (see figures 9 and 10). figure 7: the same child as in figure 6. axial magnetic resonance imaging at the superior cerebral convexity demonstrating perirolandic cortical ribbon hyperintensity with t1 shortening (a) on both sides of the central sulcus and t2-weighted hyperintensity of the surrounding sensorimotor cortex (b). note associated localised parasagittal cortex (orange arrows) and paracentral lobule (cyanide arrows) involvement. figure 8: three-year-old male child with history of neonatal encephalopathy, low apgar scores and seizures. (a) an axial t2-weighted sequence image, which does not demonstrate the perirolandic changes adequately, and these changes would be difficult to diagnose without the axial flair sequence image (b) which shows that the changes are almost exclusively involving the precentral gyrus. figure 9: four-year-old male child with cerebral palsy. neonatal history of hypoxic ischemic brain injury-related encephalopathy, seizures, requiring ventilation and prolonged 4 week stay in icu. (a) an axial t2-weighted sequence and (b) an axial flair sequence image showing subtle flame shaped dorsal putaminal (yellow arrows) hyperintensity and smudge-like ventral thalamic (green arrows) hyperintensity bilaterally. figure 10: a 2-year-old female child with dystonic cerebral palsy. (a) an axial flair sequence image and (b) an axial t2-weighted image demonstrating even more subtle signal abnormalities at the dorsal putamina (yellow arrows) and ventral thalami (green arrows). these changes can be very difficult to detect and may be omitted by the unsuspecting reporter. post-hypoxic changes may also be identified in relation to the brainstem and cerebellum. in particular, injury may be seen at the mesencephalo-pontine tegmentum as well as the central tegmental tracts of the pons. symmetric central tegmental tract hyperintensity is a non-specific finding seen in children with cerebral palsy.21 it has been reported as a normal variation in some cases22 or attributed in the literature to metabolic and congenital causes. these brainstem and cerebellar changes are exceedingly rare and may be difficult to appreciate on conventional axial sequences. coronal plane imaging is valuable as shown in figures 11 and 12 to demonstrate the brainstem and cerebellar changes. note the propensity for subthalamic nucleus injury,23 especially in children with dyskinetic cerebral palsy (as shown in figure 12c and d). this group of subtle radiological biomarkers may be generally under-reported. figure 11: a 9-year-old male child who suffered grade 3 hypoxic ischemic brain injury with apgar scores of zero at 1 min and 7 at 5 min. (a) an axial t2-weighted, (b) a coronal t2-weighted and (c) a coronal inversion recovery (ir) sequence image demonstrating the left superior cerebellar cortex injury (cyan blue arrows) with localised atrophy involving the left half of the quadrangular lobule. this is an important review area, as in this case, the injury was omitted by the first reporter. figure 12: (a) and (b) are t2-weighted images in a 3-year-old female child with acute profound hibi. (a) dorsal midbrain tegmentum (cyan blue arrows) signal changes and (b) superior cerebellar (orange arrows) injury. (c) and (d) are coronal t2-weighted and ir sequences in a 7-year-old female child who presents with dyskinetic cerebral palsy after grade 2 hypoxic ischemic encephalopathy. (c) hyperintensity at the subthalamic nucleus (red arrows) of the upper midbrain and (d) corresponding low signal intensity (white arrows) extending close to the periaqueductal gray (yellow arrows indicate putamen and green arrows indicate thalamus). pearls of imaging… look for focal or flame-shaped dorsal putaminal and ventral thalamic hyperintensity. the central sulcus may be a site for hidden subtle perirolandic changes. dorsal brainstem and superior cerebellum are important review areas.the subthalamic nuclei may also show hyperintensity in dyskinetic cerebral palsy. don’t forget to check the hippocampi. partial prolonged ischemia when there is mild or moderate hypoxia (e.g. in occult cord prolapse or placental insufficiency), there is sufficient time available for the cerebral auto-regulatory mechanisms to redirect blood flow to the high metabolic areas of the brain, many of which have a greater proportion of nmda receptors.14 this results in sparing of these high metabolic areas at the expense of the watershed areas of the cerebral hemispheres between the major arterial territories, especially at the borders between perfused zones, shown in figure 13. for term neonates, the external or cortical watershed area is more peripherally positioned at the grey–white matter interface between the major branches of the anterior and posterior circulation24 (see figure 14). the internal watershed or boundary zones are at the parasagittal subcortical white matter secondary to the cerebral arterial tree arrangement with the junction of the ventriculofugal vessels coursing outward from the ventricles and ventriculopetal vessels coursing inward from the cortex (see figure 15). these boundary zones are susceptible to hypoperfusion injury secondary to autoregulatory shunting of blood to support the high metabolic zones. figure 13: diagrammatic representation of the redistribution of blood away from the visceral organ systems and cerebral cortex in favour of the most important central brain structures. figure 14: schematic representation of the interarterial external watershed regions (depicted in yellow overlay) at the centrum ovale. the red arrows indicate the border zone between anterior cerebral artery and middle cerebral artery territories. the green arrows indicate the border zone between middle cerebral artery and posterior cerebral artery territories. figure 15: schematic representation of the internal watershed regions (depicted in yellow overlay). the red arrows indicate the susceptible junction zones of the ventriculofugal vessels coursing away from the ventricles and ventriculopetal vessels coursing inward from the cortex (blue arrows). as with the apa pattern, in the neonate with ppi, in the first few days of life, there will be restricted diffusion in the affected parasagittal cortex and subcortical white matter at the border zones, shown in figures 16 and 17. note that the early diffusion changes may be asymmetric as will be the consequent cerebral encephalomalacia and atrophy (see figure 20). after a few days, t1-weighted shortening and subsequently t2-weighted hyperintensity is seen at the watershed areas. with progressive evolution of the injury, there is variable cortical thinning demonstrated particularly at the bottom of the sulci, which are more susceptible to ischemia because of the pial vascular supply having an external to internal direction of flow. this leads to pinching off at the base of the sulci with mushroom-shaped gyri known as the ulegyria phenomenon, a specific sign for ischemia.25 secondary features also evolve contiguous to the affected areas of cerebrum with deafferentation thinning of segments of the corpus callosum, hyperintensity and thinning of long tracts because of wallerian degeneration and ex vacuo dilatation of the lateral ventricles, especially of the trigones and occipital horns (see figures 18 and 19). figure 16: a 2-day-old baby boy presenting with grade 2 hypoxic ischemic brain injury. (a) the diffusion b-1000 trace sequences and (b) the corresponding adc maps at each level. there are focal areas of restricted diffusion involving the parasagittal watershed zones of both cerebral hemispheres. figure 17: a 3-day-old baby boy with neonatal seizures after grade 2 neonatal hypoxic ischemic brain injury. (a) the diffusion b-1000 trace sequence and (b) the corresponding adc map. note that the watershed territory involvement in this child is asymmetric, and this is often seen in partial prolonged ischemia subtype. figure 18: (a) sagittal t1-weighted image at the midline of the calvarium demonstrating advanced spongiosis of the parietal and occipital lobes (blue arrows) associated with deafferentation thinning of the splenium and isthmus of the corpus callosum (red arrows). note relatively normal calibre anterior body and genu of corpus callosum. (b) axial t2-weighted image showing severe biparietal atrophy with ex vacuo dilatation of the lateral ventricles and evidence of ulegyria (yellow arrows). note less marked changes in the frontal lobes. figure 19: axial t2-weighted magnetic resonance images demonstrating severe post-hypoxic injury because of partial prolonged ischemia in three different patients. note the spongiosis of the parietal lobes (blue arrows) (a) and frontal lobes (green arrows) (b) associated with ulegyria (yellow arrows) and secondary ventriculomegaly. (c) the level of centrum ovale demonstrating asymmetric hypoxic ischemic brain injury changes, greater in the left frontal and parietal lobes. this latter pattern of asymmetric involvement is not an uncommon finding. figure 20: two examples of parasagittal cerebral injury in children who suffered sentinel events of placental abruption leading to acute profound ischemia (api). (a) this figure shows a diamond-shaped expansion of the frontoparietal parasagittal surface convexity, widening the interhemispheric fissure and tapering bilaterally at the far edge of each central sulcus (red arrows). (b) this figure reveals similar broadening of the extra-axial space because of parasagittal cortex and paracentral lobule injury. note the contiguous corticospinal tract wallerian degeneration (orange arrows), the subsiding centrum ovale scaffold (cyan blue arrows) as well as api-related basal ganglia (yellow arrows) and thalamic (green arrows) injury. pearls of imaging… bilateral medial frontal, parietal and occipital watershed injuries may be asymmetric. look out for mushroom-shaped gyri of the ulegyria phenomenon. note secondary features of corpus callosum thinning and ex vacuo dilatation of ventricles. some authors have debated the pathogenesis of the parasagittal cerebral injury, which is often seen in children with hibi. according to myers study26 and in volpe et al.,27 parasagittal cerebral injury is characteristic of the full-term infant with perinatal asphyxia. the precise pathological evolution of parasagittal injury in the new-born is not known but atrophic gyri, ulegyria or both are the chronic neuropathological correlates. these parasagittal injuries are described at the overlapping and contiguous watershed zones between named vascular territories including the anterior watershed (between the anterior and middle cerebral artery territories), the perisylvian watershed and the posterior watershed (between the posterior and middle cerebral artery territories).24 we have however found that injury to the parasagittal cortex (of predominantly the frontal and parietal lobes) may also be because of severe acute profound hibi. in api parasagittal injuries, there is involvement of the perirolandic cortex as well as the paracentral lobule and the subsequent wallerian degeneration, which leads to subsidence of the parasagittal mantle. this may result in an inverted v-shaped or diamond-shaped pattern of superior fronto-parietal injury. in effect, parasagittal injuries probably represent a continuum of hypoxic brain destruction, which may be consequent on api or ppi dependent upon the clinical scenario and presence of primary or exacerbating sentinel events among other feto-maternal factors. injury may be limited to the perirolandic area (in the case of typical api as in figures 8 and 9) or may be more extensive in more severe forms of api, extending beyond the central sulcus (as in figure 20). if the hypoxic episode is more prolonged, cerebral destruction more remote from the central sulcus may ensue resulting in a ppi pattern of injury. certainly, this spectrum of injury may be seen in a combination of these pathophysiological processes (api and ppi as in figure 22), and this leads us to a discussion on the mixed subtype of hibi. mixed pattern in some cases, a period of prolonged poor perfusion or hypoxemia (e.g. recurrent antepartum haemorrhage because of placenta praevia) may be followed by a further sentinel event (e.g. in setting of type b nuchal cord) leading to acute profound hypoxic brain injury superimposed on a background of watershed zone partial prolonged asphyxia. this pattern of injury is not uncommon in the south african population and is being more frequently reported in our cases of perinatal hypoxic ischemic encephalopathy. there is a combination of mri findings referable to the basal nuclei, thalami, perirolandic cortex in addition to the variable watershed or parasagittal border zone injuries. in the acute postnatal period, diffusion signal abnormalities will be seen affecting both the watershed areas and high metabolic structures. some days later, there may be discordant diffusion signal changes with some areas showing normal diffusion signal, whereas there may be diffusion restriction with adc shortening in other areas as shown in figure 21. based on the degree of hypoxic injury to the watershed zones, there may be isolated ulegyria, localised or asymmetric cerebral atrophy, areas of necrosis or cystic encephalomalacia (figures 22–24). brainstem injury (figures 22 and 23) and cerebellar changes may also be seen, and these are usually correlative with the acute profound ischemic component of this mixed pattern of injury. figure 21: a 15-day-old female child born after abruptio placentae with poor apgar scores of 0/10 and 1/10 at 1 and 5 min, respectively. head and body cooling were instituted but the clinical condition remained poor with seizures. the diffusion sequence (a) shows resolving diffusion signal abnormality (white arrows) at the perirolandic cortex and paracentral lobules bilaterally but there is persistent restricted diffusion at the left frontal lobe (red arrows) with adc shortening in (b) because of watershed zone ischemia. (c) note the established ischemic injury of the thalami (green arrows) and lentiform nuclei (yellow arrows) with t1-weighted hyperintensity. this is in keeping with evolving mixed subtype of hypoxic ischemic brain injury in the early neonate. figure 22: a 2-year-old male child with severe mixed type hypoxic ischemic brain injury. t2-weighted axial images (a) at the level of the centrum ovale demonstrating parasagittal frontal lobe injury with atrophy beyond the central sulcus and paracentral lobule, involving the superior frontal gyri with ulegyria, (b) at the level of the basal ganglia shows the hyperintense signal change at the dorsal putamina (yellow arrows) and ventral thalami (green arrows) and (c) at the level of the superior cerebellar peduncles reveals prominent central tegmental tract (cyan blue arrows) hyperintensity at the dorsum of the pons. figure 23: a 7-year-old male child with mixed subtype hypoxic ischemic brain injury. axial t2-weighted sequence images through the midbrain and pons show dorsal tegmental (yellow arrows) and central tegmental tract (cyan blue arrows) hyperintensity. note severe cerebral atrophy and optic atrophy (orange arrows). figure 24: axial t2-weighted image at the level of the basal nuclei performed on a 7-year-old male child. there is bifrontal encephalomalacia involving the middle and inferior frontal gyri (orange arrows) with ulegyria. subtle hyperintensity is present at the posterior tips of the putamina (yellow arrows). note in addition, loss of volume and more extensive hyperintensity of both thalami (green arrows). the combination is indicative of a mixed pattern of cerebral injury. multilobar cystic encephalomalacia/multicystic encephalopathy in very severe cases of hypoxia or total anoxia, hibi can extend beyond the watershed or boundary zones to involve major vascular territories completely. the cerebrum becomes infarcted more globally and diffusion signal abnormality may be difficult to appreciate as the entire cerebrum can show restricted diffusion with relatively no normal cerebral lobe to compare with. comparison of the abnormal cerebral diffusion signal with the normal cerebellum is a useful tool to confirm the ‘white cerebrum’ sign. as this injury evolves, there is progressive loss of cerebral volume with extensive irreversible neuronal destruction, vacuolation, cystic change or spongiosis. multilobar cystic encephalomalacia (as in figure 25) is the result. there is usually marked ventriculomegaly because of ex vacuo dilatation from the extensive surrounding white matter destruction. relative sparing of the immediate periventricular white matter and the basal nuclei may be seen. this is classified as the first subtype of cystic encephalomalacia, which is probably an exaggerated form of ppi (as in figure 26a). in cases where the insult was an acute, severe and sustained hypoxic event, the basal nuclei are more likely to be involved, presenting with the second subtype of cystic encephalomalacia. depending on the severity of the hypoxia and the autoregulatory response, a variable degree of basal ganglia involvement will be seen (as seen in figure 26b and c). figure 25: a 3-year-old male child with spastic cerebral palsy and blindness. recorded neonatal encephalopathy with low apgar scores and neonatal seizures. axial t2-weighted, t1-weighted and flair sequence images show extensive cerebral destruction with grey and white matter injury, cystic encephalomalacia and ex vacuo dilatation of the lateral ventricles. figure 26: the spectrum of basal ganglia involvement in association with cystic encephalomalacia shown on coronal t2-weighted images in three children. (a) a 4--year-old female child with complete sparing of the basal ganglia, thalami and cerebellum. (b) a 2-year-old male child with necrosis of the putamen (yellow arrows) and ventral thalamus (green arrows) bilaterally. (c) a 4-year-old-male child who suffered severe total anoxia related to abruptio placentae, with birth weight of 3.35 kg and apgar scores of 1/10 and 3/10. note near-complete cerebral cystic encephalomalacia, atrophy of lentiform nuclei and severe thalamic destruction. with regard to the multicystic encephalopathy or cystic encephalomalacia group, noting that there are several causes of this pattern of injury, we propose two subtypes that would result from hypoxic ischemic injury depending on the timing and severity of the insult. in most such cases, the entire cerebrum is affected, only sparing some portions of the temporal lobes. the key distinguishing feature is the involvement of the basal ganglia, which indicates probable primary (or superadded) apa injury. the pattern of multicystic encephalopathy when demonstrated on an mri study performed several years later is a non-specific pattern of cerebral injury and can represent the result of late in utero or perinatal ischemia, infection or metabolic abnormalities. with the increased use of foetal mri, in utero causes of multicystic encephalomalacia may be more easily detected and these can be distinguished from perinatal hibi. in cases where this pattern is present in utero, most of the insults would have occurred prior to the 28th week of gestation leading to hydranencephaly or porencephaly. the pathophysiology of the cystic pattern in a term infant, however, has an underlying common factor of severe cerebral hypoxia, linking all possible aetiologies. these include foetal transfusion syndrome in monozygotic twin pregnancy, cerebritis (e.g. citrobacter), meningo-encephalitis (e.g. herpes simplex 2), severe maternal hypotension (e.g. abruptio placentae) or rarely in postnatal non-accidental injury. one must be mindful of the other possibilities; however, hibi has been shown to be the commonest cause of this cystic pattern.28 conclusion for almost three decades, mri has been utilised in the evaluation of hibi in children with cerebral palsy. mri is a clinically independent valuable biomarker of hibi in the setting of neonatal encephalopathy. additionally, as shown in this pictorial essay, mri can be used to retrospectively correlate the pattern of cerebral injury with possible clinicopathogenesis. radiologists therefore play a key role in confirming the presence of cerebral injury. using the proposed simplified classification of the subtypes of injury allows description of the pattern of injury shown on mri and enables correlation with the perinatal events leading to neonatal encephalopathy. the reporting radiologist who is familiar with these subtypes is therefore well-positioned to lead expert evidence and provide confirmation of the injury pattern in medicolegal cases. w acknowledgements the authors would like to thank dr usha chhagan for reviewing the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this pictorial review. authors’ contributions s.k.m. was the guarantor of integrity of the entire study. a.j.b. was the principal promoter and reviewer of the manuscript. s.k.m., m.a. and j.w.l. were responsible for key concepts, design and literature research. all authors reviewed the literature and made critical contributions at each stage of the process. s.k.m. did the final manuscript of the article for publication. all the authors read and agreed on the final article. ethical considerations ethical approval was obtained from the ukzn biomedical research ethics committee. ethical clearance number: brec/00001036/2020. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability images utilised for this review are available on the pacs system of lake, smit & partners inc. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references volpe jj. neurology of the newborn. 6th ed. philadelphia, pa: saunders; 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accepted: 01 dec. 2020; published: 18 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract metronidazole is a widely used antibacterial and antiprotozoal agent for a number of conditions. whilst its more common gastrointestinal side effects are well known, neurotoxicity remains under-recognised. both central and peripheral neurological side effects have been described. this report describes a case of radiologically confirmed metronidazole-induced cerebellar ataxia in a cirrhotic patient with a review of the literature. awareness of this side effect is essential for prompt recognition as early drug withdrawal leads to resolution in the majority of cases. keywords: metronidazole; metronidazole-induced cerebellar ataxia; metronidazole-induced neurotoxicity; metronidazole adverse events; metronidazole-induced encephalopathy; dentate nucleus lesions; splenium lesions; corpus callosum lesions. introduction background metronidazole is commonly used as an antibacterial and antiprotozoal agent belonging to the nitroimidazole class of antibiotics, which is particularly useful in the treatment of anaerobic infections.1 furthermore, it is frequently used in the management of hepatic encephalopathy,2,3,4 clostridioides (formerly clostridium) difficile-associated diarrhoea,5,6 helicobacter pylori eradication,7 suppurative complications of inflammatory bowel disease (ibd) and in the prevention of the postoperative re-occurrence of ibd.8,9 the adverse effects of metronidazole include nausea, vomiting, diarrhoea, abdominal cramping, anorexia, hypersensitivity, a metallic taste and a disulfiram-type reaction with ethanol. neurological adverse effects include a peripheral neuropathy, optic neuropathy, autonomic neuropathy, seizures, encephalopathy and cerebellar toxicity. case presentation a 68-year-old male, with no prior comorbidities, was referred to our institution with hepatic cirrhosis for further management and evaluation for liver transplantation. his work-up revealed the most likely aetiology for his cirrhosis to be a combination of alcoholic and non-alcoholic fatty liver disease. whilst under our care he was admitted with decompensated cirrhosis manifested by hepatic encephalopathy, and responded favourably to treatment with lactulose and rifaximin. after being discharged, he subsequently presented with a week history of progressive ataxia and imbalance. he admitted to self-medicating with metronidazole; however, the exact cumulative dose and duration of treatment remained unknown. he described that the ataxia fluctuated during the day but, in general, was worsening. upon clinical examination, he appeared to be generally well with voluntary ptosis and slurred speech. he had an intention tremor and mild dysdiadochokinesia with severe ataxia. he was considered to have an acute onset of ataxia, which was thought to be most likely because of drugs or toxins. wernicke’s encephalopathy was excluded. inflammatory and structural causes were considered as a differential diagnosis, which prompted us to image the brain with magnetic resonance imaging (mri). the mri brain sequences included t2 turbospin echo, fluid attenuated inversion recovery (flair) and echo-planar diffusion-weighted sequences, which all showed increased signal in the dentate nuclei (figure 1). these changes were not seen on a previous mr brain scan, obtained 3 weeks earlier for non-specific headaches. the diffusion signal in the dentate nuclei showed no restriction on the apparent diffusion coefficient (adc) map and was suggestive of vasogenic oedema. diffusion signal was, however, also noted in the splenium of the corpus callosum, which showed no discernible t2 or flair signal, and in this location there was evidence of diffusion restriction with low signal on the adc map suggesting cytotoxic oedema (figure 2). no abnormal enhancement was noted postcontrast. no signal change was observed in the posterior pons or midbrain, which has been described previously in cases of metronidazole toxicity.10 figure 1: fluid attenuated inversion recovery (a) and t2 turbospin echo sequence (b) demonstrating high signal intensity in the dentate nuclei bilaterally (white arrows). figure 2: diffusion-weigthed imaging (a) indicating increased signal in the splenium of the corpus callosum and corresponding apparent diffusion coefficient map (b) showing a decreased signal in this area in keeping with restriction. a follow-up scan approximately 7 weeks later (figures 3–4), after cessation of metronidazole, showed complete clearing of the previous signal in the dentate nuclei and splenium of the corpus callosum. no interval atrophy of the splenium, cerebral hemispheres or cerebellum was observed. this was mirrored by clinical resolution of his signs and symptoms. figure 3: fluid attenuated inversion recovery imaging at the 7-week follow-up imaging, demonstrating resolution of the previous dentate nuclei high signal; compare with figure 1. figure 4: (a) diffusion sequence showing resolution of the splenium lesion at follow up (b) apparent diffusion coefficient map showing complete resolution of the splenium lesion at follow up imaging; compare with figure 2. discussion the role of antibiotics in the management of hepatic encephalopathy has been described with the proposed mechanism of effect being a reduction in gut-derived neurotoxins, endotoxins and inflammation. antimicrobial agents used in the management of hepatic encephalopathy include metronidazole, neomycin, vancomycin, paromomycin and rifaximin.11 metronidazole has been shown to be equally efficacious to neomycin in small studies2 and a newer study has shown comparable efficacy to rifaximin in acute hepatic encephalopathy.4 its use, however, is limited by its side effect profile, which may be compounded by its reduced elimination amongst patients with cirrhosis.12 despite this, it is still commonly used, particularly in resource-limited settings where access to newer agents may be limited. metronidazole-induced neurotoxicity is likely an under-recognized and under-reported entity, with its true incidence remaining unknown. despite this, a number of case reports documenting both metronidazole-induced peripheral neuropathies13 and encephalopathy14,15,16,17,18 have been published. a recent systematic review identified 136 patients with metronidazole-induced encephalopathy.19 in this study, encephalopathy was reported across a wide range of age groups; although, most case studies were documented in patients above the age of 40. the average cumulative dose amongst these patients was found to be 125.7 g. however, a broad range in the cumulative dose was noted, with the lowest documented dose being as low as 5 g. similarly, the duration of metronidazole used also varied from 2 days to several years.19 in contrast, smaller literature reviews suggested that neurotoxicity was related to the prolonged use of metronidazole and high cumulative doses.20 the total cumulative dose in our patient remains unknown but prolonged use of metronidazole was reported. amongst patients with metronidazole-induced peripheral neuropathies, most had received a cumulative dose of > 42 g in a systematic review.13 whilst the exact pathogenetic mechanism underlying the development of encephalopathy remains unknown, several mechanisms have been hypothesised. early work postulated the binding of metronidazole or metabolites to ribonucleic acid (rna) in neurons with the resultant degeneration of axons.21 furthermore, the generation of superoxide radicals leading to myelin oedema and vacuolation is thought to be contributory.22 other proposed mechanisms include focal ischaemia and the possible role of mitochondrial dysfunction.23 most patients with metronidazole-induced encephalopathy present with cerebellar signs, the most frequent being dysarthria, gait instability and ataxia.19 patients may less commonly present with changes in mental state, vertigo, dizziness, seizures and lateralising signs.19,20 other conditions such as wernicke’s encephalopathy, toxic encephalopathies, other drug encephalopathies, enteroviral encephalomyelitis, hepatic encephalopathy and some leukodystrophies should be considered in the differential diagnosis. radiological imaging plays an important role in the diagnosis of metronidazole-induced encephalopathy. furthermore, imaging studies may be useful in excluding other causes of neurological dysfunction. magnetic resonance imaging changes are typically bilateral and symmetrical, with hyperintensities on t2-weighted images in the cerebellar dentate nuclei being the most commonly involved area.19,10 other locations commonly involved include the splenium of the corpus callosum, the midbrain, the pons and the medulla. involvement of splenium with t2-weighted hyperintensities warrants the exclusion of other conditions, such as epilepsy, marchiafava–bignami disease, acute disseminated encephalitis, infective encephalitis, extra-pontine myelinolysis, systemic lupus erythematosus, renal failure and vitamin b12 deficiency.23 the subcortical white matter and basal ganglia are less commonly involved.19,10 the findings on diffusion-weighted imaging (dwi) and the adc vary according to the anatomical areas involved, suggesting cytotoxic oedema in some areas and vasogenic oedema in others.19,10 the majority of patients with metronidazole-induced encephalopathy have clinical resolution within 2 weeks of drug cessation.16,18,19,20 in addition, the majority of patients with clinical resolution have some degree of radiological improvement. radiological resolution upon drug withdrawal may thus further support the diagnosis. a small percentage of patients (4%) had documented residual neurological deficits in a systematic review.19 amongst these patients, the total cumulative dose was not related to residual symptomatology; however, all were found to have white matter hyperintensities on the initial mri. failure of radiological improvement may be related to the anatomical areas involved and in instances with a low adc and diffusion restriction.23 death was uncommon (5%) and unlikely to be primarily attributed to metronidazole-induced encephalopathy, with most of the deceased having significant premorbid conditions.19 conclusion the true incidence of metronidazole-induced neurotoxicity remains unknown. despite under-recognition, the disease is rare and largely confined to case reports, case series and systematic reviews. to our knowledge, this is the first documented case report in south africa. metronidazole is a commonly used antimicrobial agent especially in resource constraint areas where access to other newer agents is limited. awareness of this important side effect is essential for its early diagnosis and management. the importance of recognising the condition early is emphasised by the resolution of disease, in the majority of cases, with drug cessation. metronidazole remains to be an effective therapeutic agent, which should be judiciously prescribed where indicated and cautiously used in those with significant co-morbid illnesses. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.g.l. was the primary author. all other authors, b.b., m.h., p.k. and a.m., contributed equally to this work. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this research article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy of any affiliated agency of the authors. references edlund c, löfmark s, nord ce. metronidazole is still the drug of choice for treatment of anaerobic infections. clin infect dis. 2010 feb 1;50(supplement_1):s16–s23. https://doi.org/10.1086/647939 morgan mh, read ae, speller dc. treatment of hepatic encephalopathy with metronidazole. gut. 1982 jan;23(1):1–7. https://doi.org/10.1136/gut.23.1.1 maddrey wc. role of antibiotics in the management of hepatic encephalophathy. rev gastroenterol disord [serial online]. [cited 2020 apr 09]. 2005;5(suppl. 1):s3–s9. available from: http://www.scopus.com/inward/record.url?eid=2-s2.0-20544439543&partnerid=40&md5=17acc1a161910c17ddf22e2f42b3613e mekky ma, riad ar, gaber ma, et al. rifaximin versus metronidazole in management of acute episode of hepatic encephalopathy: an open labeled randomized clinical trial. arab j gastroenterol. 2018;19(2):76–79. https://doi.org/10.1016/j.ajg.2018.06.001 mcdonald lc, gerding dn, johnson s, et al. clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the infectious diseases society of america (idsa) and society for healthcare epidemiology of america (shea). clin infect dis. 2018;66(7):e1–e48. https://doi.org/10.1093/cid/cix1085 gupta a, cifu as, khanna s. diagnosis and treatment of clostridium difficile infection diagnosis and treatment of clostridium difficile infection diagnosis and treatment of clostridium difficile infection. jama. 2018 sep 11;320(10):1031–1032. https://doi.org/10.1001/jama.2018.12194 chey wd, leontiadis gi, howden cw, et al. acg clinical guideline: treatment of helicobacter pylori infection. am j gastroenterol. 2017;112(2):212–239. https://doi.org/10.1038/ajg.2016.563 nitzan o, elias m, peretz a, et al. role of antibiotics for treatment of inflammatory bowel disease. world j gastroenterol. 2016 jan 21;22(3):1078–1087. https://doi.org/10.3748/wjg.v22.i3.1078 glick l, sossenheimer p, hirsch a, et al. low-dose metronidazole is associated with a decreased rate of endoscopic recurrence of crohn’s disease after ileal resection. gastroenterology. 2017;152(5):774–775. https://doi.org/10.1016/s0016-5085(17)32687-2 kim e, na dg, kim ey, et al. mr imaging of metronidazole-induced encephalopathy: lesion distribution and diffusion-weighted imaging findings. am j neuroradiol. 2007 oct 1;28(9):1652–1658. https://doi.org/10.3174/ajnr.a0655 patidar kr, bajaj js. antibiotics for the treatment of hepatic encephalopathy. metab brain dis. 2013 jun;28(2):307–312. https://doi.org/10.1007/s11011-013-9383-5 loft s, sonne j, døssing m, et al. metronidazole pharmacokinetics in patients with hepatic encephalopathy. scand j gastroenterol. 1987 jan;22(1):117–123. https://doi.org/10.3109/00365528708991867 goolsby ta, jakeman b, gaynes rp. clinical relevance of metronidazole and peripheral neuropathy: a systematic review of the literature. int j antimicrob agents. 2018;51(3):319–325. https://doi.org/10.1016/j.ijantimicag.2017.08.033 farmakiotis d, zeluff b. metronidazole-associated encephalopathy. n engl j med. 2016;374(15):1465. https://doi.org/10.1056/nejmicm1505174 neki ns, joshi n, rana d, et al. metronidazole toxicity presenting with cerebellar ataxia. int j curr res med sci. 2017;3(5):10–13. clements a. case report of metronidazole-induced encephalopathy. wmj. 2015;116(5):65–68. pmid: 29357212 agarwal a, kanekar s, sabat s, et al. metronidazole-induced cerebellar toxicity. neurol int. 2016;8(1):4–6. https://doi.org/10.4081/ni.2016.6365 sarna jr, brownell akw, furtado s. reversible cerebellar syndrome caused by metronidazole. cmaj. 2009;181(9):611–613. https://doi.org/10.1503/cmaj.090591 sørensen cg, karlsson wk, amin fm, et al. metronidazole-induced encephalopathy: a systematic review. j neurol. 2020;267(1):1–13. https://doi.org/10.1007/s00415-018-9147-6 patel k, green-hopkins i, lu s, et al. cerebellar ataxia following prolonged use of metronidazole: case report and literature review. int j infect dis. 2008;12(6):e111–e114. https://doi.org/10.1016/j.ijid.2008.03.006 ahmed a, loes dj, bressler el. reversible magnetic imaging findings in metronidazole-induced encephalopathy. neurology. 1995;45(3):588–589. https://doi.org/10.1212/wnl.45.3.588 rao dn, mason rp. generation of nitro radical anions of some 5-nitrofurans, 2and 5-nitroimidazoles by norepinephrine, dopamine, and serotonin. a possible mechanism for neurotoxicity caused by nitroheterocyclic drugs. j biol chem. 1987;262(24):11731–11736. https://doi.org/10.1016/s0021-9258(18)60872-5 roy u, panwar a, pandit a, et al. clinical and neuroradiological spectrum of metronidazole induced encephalopathy: our experience and the review of literature. j clin diagn res. 2016 jun;10(6):oe01–oe09. https://doi.org/10.7860/jcdr/2016/19032.8054 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) stuti chandola department of radiodiagnosis, maulana azad medical college, new delhi, india m. sarthak swarup department of radiodiagnosis, maulana azad medical college, new delhi, india radhika batra department of radiodiagnosis, maulana azad medical college, new delhi, india alpana manchanda department of radiodiagnosis, maulana azad medical college, new delhi, india citation chandola s, swarup sm, batra r, manchanda a. spinal chloroma – herald of blast crisis in a patient with chronic myeloid leukaemia: a case report. s afr j rad. 2022;26(1), a2286. https://doi.org/10.4102/sajr.v26i1.2286 case report spinal chloroma – herald of blast crisis in a patient with chronic myeloid leukaemia: a case report stuti chandola, m. sarthak swarup, radhika batra, alpana manchanda received: 30 aug. 2021; accepted: 10 oct. 2021; published: 27 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract myeloid sarcoma or chloroma is a localised tumour characterised by extramedullary proliferation of precursor myeloid cells. commonly occurring in association with acute myeloid leukaemia, chloroma can occasionally be seen in myeloproliferative disorders with subsequent blastic transformation. imaging plays an important role in the diagnosis and evaluation of this entity. a case of chloroma involving the dorso-lumbar vertebral region is presented in a patient with chronic myeloid leukaemia with subsequent blastic transformation. keywords: myeloid sarcoma; chronic myeloid leukaemia; blast crises; acute myeloid leukaemia, chloroma. introduction myeloid sarcoma, also known as granulocytic sarcoma or chloroma, refers to a solid tumour representing extramedullary proliferation of precursor myeloid cells.1 it affects children more commonly than adults and is equally seen in both sexes. chloroma most commonly occurs in association with acute myeloid leukaemia (aml); however, it can also be seen in myeloproliferative disorders like polycythaemia vera and chronic myeloid leukaemia (cml) and in myelodysplastic syndromes.2 although the lesion largely occurs in the active phase of aml, it can also arise when the disease is in remission. the appearance of chloroma may indicate relapse or herald a blast crisis, especially in myeloproliferative disorders. bones, including the spine, are typically involved because of direct extension from the affected marrow.3 the most common bones to be affected include the appendicular bones and spine with near equal incidence being reported in both.1,3 occasionally, there can be further extension of the lesion into the spinal canal and along the nerve roots with subsequent compressive myelopathy. a case of chloroma involving the dorso-lumbar vertebral region with associated involvement of the epidural space in a patient with cml is presented. although the epidural region is a common location for chloroma, this disease entity itself is uncommon and occurs mostly in association with aml. the presentation of chloroma in the setting of cml with ultimate blastic conversion is a relatively rare phenomenon. case presentation a 35-year-old gentleman presented with progressive paraparesis over 15 days. he was known with chronic myeloid leukaemia (bcr-aml gene positive) and in remission for four years on imatinib therapy. laboratory findings revealed anaemia with a haemoglobin of 8 g/dl. other laboratory tests were normal and bone marrow aspirate did not reveal blast cells. magnetic resonance imaging (mri) of the spine was performed on a 3t scanner (siemens magnetom skyra) in view of the complaints. the mri examination revealed altered signal intensity involving the bodies and posterior elements of the t12 vertebra and l1 vertebra which showed hypointense signal on t1 weighted (t1w) and hyperintense signal on t2w and short tau inversion recovery (stir) sequences (figures 1 and 2) with mild enhancement on post contrast images. on chemical shift imaging, the involved vertebral body did not show reduction in signal on opposed phase images (figure 3). there was a homogeneously enhancing soft tissue mass in the posterior epidural space extending from the t12 to l2 vertebral levels appearing isointense on t1w and hyperintense on t2w and stir images (figures 2 and 4). the lesion caused narrowing of the spinal canal with marked compression of the conus medullaris and cauda equina nerve roots. there was associated widening of bilateral neural foramina (right > left) at the t12–l1 and l1–l2 levels, with infiltration of the soft tissue lesion into bilateral paraspinal muscles. a possibility of myeloid sarcoma was suggested given the clinical profile and imaging findings. figure 1: sagittal t1w (a) and short tau inversion recovery (stir) sequence (b) images reveal altered signal intensity involving the t12 vertebral body and spinous processes of the t12 and l1 vertebrae (white asterisks, a and b) which appear hypointense on t1w and hyperintense on stir images. an ill-defined soft tissue mass of similar signal intensity is seen in the posterior epidural space extending from the t12 to l2 vertebral levels (arrows) with further extension into the interspinous soft tissue (yellow asterisks, a and b). figure 2: serial axial t2w images (a and b) at the level of the l1 vertebra show hyperintense signal in both pedicles and transverse processes (arrows, a) indicating involvement. the soft tissue mass (yellow asterisk, a and b) is causing anterior displacement of the conus medullaris with marked compression (b). there is extension through and widening of bilateral neural foramina (arrows, b). the paraspinal muscles on the right side appear heterogeneously hyperintense suggestive of infiltration (yellow arrow, b). figure 3: sagittal t1w sequences acquired in phase (a) and opposed phase (b) show that the involved t12 vertebral body does not show reduction in signal on opposed phase images. this finding suggests a bone marrow infiltrating disorder as opposed to red marrow conversion, where signal reduction is expected due to presence of microscopic fat in red marrow. figure 4: sagittal (a) and axial (b) post contrast images demonstrate mild enhancement of the involved vertebral body (t12) and posterior elements (asterisks, a) with avid homogeneous enhancement of the infiltrative soft tissue (arrows). the patient underwent decompressive surgery with a laminectomy and debulking of the epidural lesion. microscopic examination of the tissue showed multiple myeloblasts with large oval nuclei and prominent nucleoli scattered in a background of myelocytes (figure 4). in addition, the neoplastic cells showed strong positivity for cd34 and myeloperoxidase enzyme (figure 5) suggestive of myeloid lineage which confirmed the diagnosis of a granulocytic sarcoma. figure 5: (a) the epidural lesion was subsequently biopsied and subjected to microscopic examination. high power field microscopic examination (100× magnification) with hematoxylin and eosin stain shows multiple myeloblasts (arrows) revealing large oval nuclei with a high nucleus:cytoplasmic ratio and prominent nucleoli with intermingled myelocytes showing abundant eosinophillic cytoplasm. high power field examination (100× magnification with special stains reveals that the neoplastic cells show strong positivity for cd34 (b brown cells) and also stain positive for myeloperoxidase (arrow, c) suggestive of myeloid lineage thereby confirming the diagnosis of granulocytic sarcoma. the patient was then started on a combination of imatinib and steroids. however, the patient progressed into a blast crisis and full-blown aml (blast cells in bone marrow > 20%) in a span of four weeks. despite an initial minimal improvement with steroids, no further change was seen in the paraparesis. the patient developed severe pancytopenia with hospital acquired pneumonia and succumbed to his illness two months later. discussion first described by burns in 1811, myeloid sarcoma or chloroma is characterised by the presence of myeloperoxidase enzyme which imparts a greenish tint to it, a feature seen in two thirds of cases. at immunohistochemical staining, it is characterised by the expression of cd68, lysozyme, cd34, and cd43 with variable expression of myeloperoxidase enzyme. children are affected more commonly than adults and 60% of the patients are younger than 15-years of age.1 clinically, chloroma most commonly occurs in the active phase of aml, particularly the m4 and m5 subtypes. however, it can occasionally occur in the setting of chronic myeloproliferative disorders (including chronic idiopathic myelofibrosis, essential thrombocythemia, polycythaemia vera and cml) or myelodysplastic syndrome, with the appearance of the tumour often corresponding with blastic conversion.2 in addition, chloroma may also be a manifestation of relapse in formerly treated patients of primary or secondary acute leukaemia, especially post bone marrow transplantation. in a small number of cases, it occurs in patients without any manifestations of acute leukaemia and is later heralded by the appearance of aml after an interval of weeks, months, or even years. isolated chloromas without the evidence of leukaemia are frequently misdiagnosed because of the lack of typical ct or mr findings and need for biopsy.4 the cortical bone and periosteum are typically involved due to the direct spread from the affected marrow. although any site may be involved, other common areas of involvement include the skin, lymph nodes, orbit, muscles, central nervous system, head and neck and retroperitoneum.3 in addition, the peritoneum and adrenals have also been documented as unusual sites.5 in the spine, the most commonly affected site includes the vertebral body. in addition, there can be spread of myeloid cells from the haversian canals into the extra-osseous region with resultant involvement of the epidural space, which is the most frequent area affected.4 it may appear similar to spinal tumours when the tumour tracks along the paraspinal nerve roots. pre-/paravertebral chloroma may also result as an extension from retroperitoneal lymphadenopathy. a precise and prompt diagnosis of chloroma is crucial as it allows the institution of definitive radiotherapy or adjuvant chemotherapy for local control of the disease, which helps in relieving cord compression and obviates any unnecessary surgery. magnetic resonance imaging forms the cornerstone in the evaluation and diagnosis of spinal involvement in chloroma by aiding in spatial localisation (i.e. vertebral, epidural, intradural extramedullary and intramedullary), determining its extent and assessing the degree of cord compression, if present. at mri, vertebral involvement in chloroma manifests as focal, multifocal or diffuse leukaemic infiltration of the vertebral marrow with low signal intensity on t1w, high signal intensity on t2w images and avid enhancement on post contrast images. chemical shift imaging remains a useful entity when differentiating this condition from red marrow conversion. a propensity for ligamentous and subperiosteal involvement is also seen as a result of spread via the haversian canals.6 however, this non-specific appearance can be confused with marrow infiltrating disorders such as multiple myeloma and lymphoma; hence, a thorough clinical history of haematological disease is imperative in establishing the diagnosis. epidural involvement in chloroma can often occur in conjunction with vertebral body involvement. these often present as multiple masses which may be either contiguous or discrete, involving different vertebral levels. they usually show isointense and intermediate signal on t1w and t2w images respectively, with homogeneous post contrast enhancement.7,8 central non-enhancing necrotic areas may be identified and diffusion restriction may be noted on diffusion weighted images. the lesions can cause effacement of the epidural fat with inward displacement of the dura mater and compression of the spinal cord with partial or complete obliteration of the cerebrospinal fluid (csf) space. frequent association with compressive myelopathy or neuronopathy, regardless of lesion location, is also seen. the combined intra-extraspinal form of chloroma, with a resultant ‘dumb bell configuration’, may simulate the appearance of a nerve sheath tumour on imaging. in such scenarios, absence of intense t2 hyperintensity without secondary bony changes (destruction or remodelling) favours chloroma.4 intramedullary chloroma is a relatively rare entity which manifests as diffuse expansion of the cord and shows low signal intensity on t1w and high signal intensity on t2w with homogeneous post contrast enhancement. there may also be associated leptomeningeal enhancement. the appearance is non-specific and biopsy is required for final diagnosis. extranodal lymphoma remains an important differential diagnosis of chloroma due to similar imaging findings. it typically shows low to intermediate signal intensity on t1w images and mild hyperintense signal on t2w images with restricted diffusion on diffusion weighted sequences. extraosseous myeloma may also mimic chloroma. this appears as a homogeneous soft-tissue mass on ct and shows low signal on t2w images. these entities may be indistinguishable from chloroma on the basis of imaging features alone and a sound knowledge of the clinical and haematological profile helps in arriving at an accurate diagnosis. it is therefore critical for the radiologist to consider the possibility of chloroma as a differential diagnosis especially in the setting of leukaemia and other myeloproliferative disorders. the appearance of a new mass almost anywhere in the body of a leukaemic patient should raise concern for chloroma and accordingly histologic diagnosis should be sought. the diagnosis remains challenging in patients without a history of hematologic malignancy. conclusion although commonly seen in aml, chloroma is a disease which can occur in association with a myriad of myeloproliferative and myelodisplastic disorders and is often the first manifestation of the progression of these disorders into aml (blast crisis) as seen in the presented case. spinal involvement in chloroma may manifest as osseous infiltration with or without spinal cord involvement and is often associated with compressive myelopathy. although the disease is associated with a poor prognosis and is treated by systemic chemotherapy, irrespective of the site or marrow status, a localised treatment plan consisting of focused radiotherapy and surgery may be formulated for relieving compressive symptoms. radiologists play a key role in suggesting the possibility of this disease entity, which calls for the need to familiarise oneself with the imaging features and to have a high index of suspicion, especially in patients with a history of hematologic disease. a combined multidisciplinary approach consisting of clinical features, imaging and pathological findings, including immunohistochemistry, is imperative for correct diagnosis. acknowledgements we would like to acknowledge the department of medicine, lok nayak hospital for providing clinical inputs and the department of pathology, govind ballabh pant hospital, new delhi for providing the histo-pathological images. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.c., m.s.s., r.b., and a.m. contributed to the design and implementation of the report, to the analysis of the findings and to the writing of the manuscript. ethical considerations this article followed all ethical standards research. consent was obtained from the patient to include the data and images in the publication. patient anonymity was maintained. funding information the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. data availability all data pertaining to this case are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references neiman rs, barcos m, berard c, et al. granulocytic sarcoma: a clinicopathologic study of 61 biopsied cases. cancer. 1981;48(6):1426–1437. https://doi.org/10.1002/1097-0142(19810915)48:6%3c1426::aid-cncr2820480626%3e3.0.co;2-g audouin j, comperat e, le tourneau a, et al. myeloid sarcoma: clinical and morphologic criteria useful for diagnosis. int j surg pathol. 2003;11(4):271–282. https://doi.org/10.1177/106689690301100404 shinagare ab, krajewski km, hornick jl, et al. mri for evaluation of myeloid sarcoma in adults: a single-institution 10-year experience. am j roentgenol. 2012;199(6):1193–1198. https://doi.org/10.2214/ajr.12.9057 singh a, kumar p, chandrashekhara sh, kumar a. unravelling chloroma: review of imaging findings. bjr suppl. 2017;90(1075):20160710. https://doi.org/10.1259/bjr.20160710 pfannenberg ac, lengerke c, kröber sm, horger m, claussen cd. chloroma of the adrenal gland and the peritoneum: ct diagnosis of an unusual presentation of acute myeloid leukemia. eur j radiol. 2006;58(1):23–26. https://doi.org/10.1016/j.ejrex.2006.01.009 fritz j, vogel w, bares r, horger m. radiologic spectrum of extramedullary relapse of myelogenous leukemia in adults. am j roentgenol. 2007;189(1):209–218. https://doi.org/10.2214/ajr.06.1500 guermazi a, feger c, rousselot p, et al. granulocytic sarcoma (chloroma) imaging findings in adults and children. am j roentgenol. 2002;178(2):319–325. https://doi.org/10.2214/ajr.178.2.1780319 meyer hj, beimler m, borte g, pönisch w, surov a. radiological and clinical patterns of myeloid sarcoma. radiol oncol. 2019;53(2):213. https://doi.org/10.2478/raon-2019-0014 abstract introduction case report discussion conclusion acknowledgements references about the author(s) thokozani sibanda department of radiology, baines imaging group, harare, zimbabwe pria pakkiri department of pathology, baines pathology, harare, zimbabwe anne ndlovu department of radiology, baines imaging group, harare, zimbabwe citation sibanda t, pakkiri p, ndlovu a. fish bone perforation mimicking colon cancer: a case report. s afr j rad. 2020;24(1), a1885. https://doi.org/10.4102/sajr.v24i1.1885 case report fish bone perforation mimicking colon cancer: a case report thokozani sibanda, pria pakkiri, anne ndlovu received: 15 apr. 2020; accepted: 10 july 2020; published: 29 sept. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract most patients who ingest fish bones do not develop any complications. the small proportion of patients who do complicate, present with non-specific symptoms. a 64-year-old female patient presented with a 2-month history of abdominal pain. following clinical evaluation and computed tomography scan of the abdomen, a provisional diagnosis of colon cancer was made. histology of the resected bowel at hemicolectomy demonstrated a perforation by fish bone with an associated abscess. the case illustrates how fish bone perforation may mislead unsuspecting clinicians and may be misdiagnosed as colonic cancer. keywords: bowel perforation; fish bone; hemicolectomy; colonic malignancy; abscess; computed tomography. introduction fish bone ingestion is a common problem, particularly in populations who consume unfilleted fish.1 it accounts for 84% of accidentally ingested foreign bodies. in most cases, accidentally ingested fish bones are eliminated from the gastrointestinal tract (git) without complications.2 complications, however, do occur and these include entrapment in the upper aerodigestive tract, git perforation, sepsis and bowel obstruction.1 bowel perforation is one of the serious complications, resulting mainly from the sharp or pointed edges of the fish bone.3 however, the incidence is less than 1%.4 we present a patient whose symptoms and clinical findings were commensurate with perforated colon cancer. a definitive diagnosis of fish bone perforation was made after hemicolectomy and histopathology analysis. case report a 64-year-old female patient presented to her general practitioner with a 2-month history of left upper quadrant pain. there had been no history of trauma or any specific precipitating event. no change in bowel habit was documented. on examination, she was a well-looking lady with mild left upper quadrant tenderness. no other significant findings were elicited at this time. following a non-conclusive ultrasound, the general practitioner referred the patient to a general surgeon for further investigation. after review of the history and examination, the general surgeon’s differentials were diverticulosis, inflammatory bowel disease and colon cancer. the patient was investigated with a computed tomography (ct) scan of the abdomen. limited biochemical tests were ordered, mainly urea and electrolytes, which were essentially normal. helical ct images were acquired from the lung bases to the symphysis pubis with multiplanar reformats, post intravenous and oral contrast administration (figures 1 and 2). figure 1: selected axial computed tomography images demonstrated (a) an eccentric thickened wall of the distal transverse colon (black arrow) (b) with a focal, walled-off intra-abdominal fluid collection, extending from the wall of the transverse colon to the left anterior abdominal wall (white arrow). invasion and thickening of the transversalis and rectus abdominis muscles was noted (white arrow). there was associated increased density and stranding in the pericolic fat and adjacent abdominal wall fat from the inflammation (arrowhead). figure 2: selected coronal (a) and sagittal (b) images of the patient demonstrates the thick-walled distal transverse colon and associated walled-off collection closely related to normal appearing small bowel loops (white arrows). given the concern for a possible colonic adenocarcinoma, the patient was taken to theatre for surgical exploration. drainage of the collection and a hemicolectomy was performed. intraoperatively, a distal transverse colon ‘tumour’ with an abscess was identified. there were adhesions between the colon and jejunal loops in the left upper quadrant with an associated collection. the collection was drained and the resected bowel was sent for histological analysis. the patient had an uneventful recovery and was discharged home after a week. upon opening the large bowel, gross pathology indicated a mass lesion (figure 3). the cut surface was variegated and an abscess cavity was noted. there was no extension of the lesion into the adherent small bowel. figure 3: multiple sections were sampled, all of which revealed soft tissue, consistent with inflammatory granulation tissue, and an abscess. since the histologic findings did not correlate with the clinical diagnosis, the specimen was re-examined to exclude a sampling error. a small opening was identified in the bowel wall and further sectioning revealed a fish bone (figures 4 and 5). figure 4: a small opening was identified in the bowel wall (arrow). figure 5: further sectioning in this area revealed a 3 cm fish bone (arrow). ethical consideration this article followed all ethical standards for carrying out research. discussion fish bone perforation is a challenging diagnosis to make and frequently results in misdiagnosis. this is brought about by its bizarre presentation and the fact that patients may not recall ingestion of the fish bone. a time lag of weeks to months prior to presentation further compounds the problem.1 perforation of the git distal to the oesophagus occurs in less than 1% of otherwise healthy patients.4,5 patients with git perforation present with a myriad of symptoms, which include abdominal pain (which may be acute or chronic), gi haemorrhage, intestinal obstruction and ureteric colic.3 the preoperative diagnosis of fish bone perforation is confirmed in as little as 23% of cases. this can be attributed to the non-specific clinical presentation and the low sensitivity of radiological investigations.6 plain film radiography plays a limited role in the detection of fish bones, especially below the hemidiaphragm. the sensitivity for detection of a fish bone in the aerodigestive tract is as low as 32%.7 false negatives are seen in up to 47% of cases.8,9 sensitivity is influenced by the fish bone type as fish bones with a high calcium are more easily identified. fish bones with less calcium may be obscured by soft tissue and fluid, thereby reducing sensitivity. low kilovoltage supine radiographs demonstrate fish bones better than high kilovoltage techniques. in a study by goh et al.,3 chest and abdominal radiographs failed to demonstrate the fish bone foreign body and pneumoperitoneum.3 in cases of fish bone related git perforation, pneumoperitoneum is rarely seen because there is limited passage of air and intraluminal fluid into the peritoneum as a result of the perforation being covered by omentum.5 with plain film radiography and ct, pneumoperitoneum is observed in 16% and 50% of cases, respectively.3,4,10,11 the imaging modality of choice is ct. a sensitivity of 100% has been shown in some previous studies. computed tomography sensitivity is greatly influenced by a high index of suspicion. in the absence of a positive history of fish bone ingestion, there is the possibility of another structure such as a blood vessel being mistaken for a fish bone. thin ct slice thickness and non-enhanced studies can better assist the radiologist to differentiate fish bones from other structures.3,4 a fish bone on ct may be seen as a linear calcified lesion. associated ct findings at the site of perforation include: mucosal wall thickening of the bowel, intestinal obstruction, pericolic fat stranding and at times, there may be abscess formation. inflammatory reaction can masquerade as a tumour. in the literature, cases of fish bone perforation have been misdiagnosed as appendicitis, pancreatic cancers, gastric submucosal tumour and crohn’s disease.12,13,14 cases of large bowel perforation in elderly patients may mimic colonic malignancy. in the absence of positive radiological identification of a foreign body, the non-specific symptoms and ct findings may simulate malignancy. in our 64-year-old patient, no fish bone was identified radiologically within the abnormally thickened colonic wall. histology confirmed an inflammatory process at the area of perforation and no malignant cells were identified. a 3-cm fish bone was seen buried within the resected loops of bowel, confirming the diagnosis of complicated fish bone bowel perforation. conclusion fish bone perforation in the lower git is an uncommon complication that may present with unusual symptoms and signs. diagnosis requires a high index of suspicion from the treating clinicians. a thorough clinical history and radiological evaluation may help. this case highlights the fact that perforation by foreign bodies might have an indolent course rather than an acute presentation and highlights how fish bone perforation can mimic a malignancy. acknowledgements dr o.b. chihaka mbchb (uz), mmed (surg) (zim), cert gastroenterology surg (sa), university of zimbabwe, department of surgery. dr chihaka was the surgeon managing the patient. competing interests the authors have declared that no competing interest exists. authors’ contributions all authors contributed equally to this work. funding information this case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable in this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bathla g, teo ll, dhanda s. pictorial essay: complications of a swallowed fish bone. indian j radiol imag. 2011;21(1):63. https://doi.org/10.4103/0971-3026.76061 venkatesh sh, karaddi nk. ct findings of accidental fish bone ingestion and its complications. diagn interv radiol. 2016;22(2):156. https://doi.org/10.5152/dir.2015.15187 goh bk, tan ym, lin se, et al. ct in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. am j roentgenol. 2006;187(3):710–714. https://doi.org/10.2214/ajr.05.0178 coulier b, tancredi mh, ramboux a. spiral ct and multidetector-row ct diagnosis of perforation of the small intestine caused by ingested foreign bodies. eur radiol. 2004;14(10):1918–1925. https://doi.org/10.1007/s00330-004-2430-1 choi y, kim g, shim c, kim d, kim d. peritonitis with small bowel perforation caused by a fish bone in a healthy patient. world j gastroenterol. 2014;20(6):1626. https://doi.org/10.3748/wjg.v20.i6.1626 sharma r, padhy bp, kumar s, hareesh m, suchithra gl. gastric perforation due to fish bone ingestion presenting as gastric outlet obstruction: a case report. int surg j. 2018;5(12):4081–4084. https://doi.org/10.18203/2349-2902.isj20185050 ngan jh, fok pj, lai ec, branicki fj, wong jo. a prospective study on fish bone ingestion. experience of 358 patients. ann surg. 1990;211(4):459. https://doi.org/10.1097/00000658-199004000-00012 kim hu. oroesophageal fish bone foreign body. clin endoscopy. 2016;49(4):318. https://doi.org/10.5946/ce.2016.087 qureshi ta, awan ms, hussain m, wasif m. effectiveness of plain x-ray in detection of fish and chicken bone foreign body in upper aerodigestive tract. j pakistan med assoc. 2017;67(4):544. drakonaki e, chatziioannou m, spiridakis k, panagiotakis g. acute abdomen caused by a small bowel perforation due to a clinically unsuspected fish bone. diagn interv radiol. 2011;17(2):160. https://doi.org/10.4261/1305-3825.dir.3236-09.1 goh bk, chow pk, quah hm, et al. perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. world j surg. 2006;30(3):372–377. https://doi.org/10.1007/s00268-005-0490-2 goh bk, jeyaraj pr, chan hs, et al. a case of fish bone perforation of the stomach mimicking a locally advanced pancreatic carcinoma. dig dis sci. 2004;49(11/12):1935–1937. https://doi.org/10.1007/s10620-004-9595-y bajwa a, seth h, hughes f. ingested fishbone mimicking a gastric submucosal tumour. grand rounds. 2007;7:42–44. https://doi.org/10.1102/1470-5206.2007.0014 beecher sm, o’leary dp, mclaughlin r. diagnostic dilemmas due to fish bone ingestion: case report & literature review. int j surg case rep. 2015;13:112–115. https://doi.org/10.1016/j.ijscr.2015.06.034 50 sa journal of radiology • june 2011 case report are not visible on standard radiographs but are clearly shown on ct scan include faintly calcified ureteric calculi and low-density foreign bodies such as certain types of glass4 and also fish bones.4 the two cases described clearly show that ct scanning is the modality of choice for demonstrating teflon felt when this has been used as an implant. following these incidents, a case can be made to lobby the manufacturers of teflon felt to investigate colouring the felt in such a way that it is readily macroscopically distinguishable from other implantable materials. 1. textiles in medicine. http://surgicalmesh.com/sldindex_files/slide0001.htm (accessed 18 march 2010). 2. bard ptfe felt. http://www.bardpv.com/_vascular/product.php?p=30 (accessed 17 march 2010. 3. de la fuente a, augudo o, sanchez r, fernandez jl, moriones i. repair of left ventricular rupture after mitral valve replacement: use of teflon patch and glue. ann thoral surg 1999;67:1082-1083. 4. emby dj. retained glass fragments in body tissues. s afr med j 2009;99(12):858-859. introduction ruptured ovarian artery aneurysms are extremely rare, occurring during the peripartum or early postpartum periods. only 11 cases have been reported in the english literature; the following represents the 12th. case report a 30-year-old woman presented at the casualty department 12 days after having given birth to a healthy baby via normal vaginal delivery. she complained of increasing pain and a mass in her right flank. there were no complaints of nausea, vomiting, dysuria or abnormal bowel habits. on examination, the patient was acutely distressed, in severe pain and anaemic with an hb of 5 g/dl. her blood pressure was 151/71 mmhg and her pulse 125/minute. physical examination revealed a severely distended abdomen with features of peritonitis. abdominal ultrasound revealed a large abdominal fluid collection; a ct scan was therefore requested. a contrast-enhanced ct scan demonstrated a large homogenous retroperitoneal fluid collection in the right flank, with a 25mm rounded, intensely enhancing focus located close to the inferior border of the collection (fig. 1). the collection displaced the bowel to the left and inferiorly, and the liver superiorly. the differential diagnosis included a ruptured ovarian artery aneurysm. as soon as the patient was stable, she was taken for ovarian rupture of an ovarian artery aneurysm following normal vaginal delivery francois van schouwenburg, mb chb hassan lameen, mb chb, md, fcrad (diag) sa department of radiology, grey’s hospital, pietermaritzburg corresponding author: h lameen (h.alameen1@yahoo.com) figs 1a and b. axial and coronal contrast-enhanced ct image of the abdomen demonstrating large right retroperitoneal abdominal and pelvic haematoma (stars) with right-sided focal area of contrast extravasation at the expected location of the right ovarian artery (arrow). ascites also present. a b * → * sa journal of radiology • june 2011 51 case report artery embolisation, which was successfully accomplished (fig. 2). she recovered well in the ward. discussion in their review of pregnancy-related ruptured arterial aneurysms, barret et al. list in decreasing order of frequency those of intracranial, aortic, splenic, renal and ovarian artery origin. of these, the ovarian artery location is by far the least frequent, with only 11 cases recorded in the english-language literature.1 the pathogenesis of these lesions is poorly understood, with homodynamic and hormonal factors suggested.2-4 systemic haemodynamic changes that occur in pregnancy include increased cardiac output and blood volume. systemic hypertension is common, and significant swings in blood pressure are thought to result from compression of the abdominal aorta by the gravid uterus in the supine position. also, enlargement of the uterus with dilatation of the pelvis arteries cause increased uterine blood flow. burnett and carfrae2 have postulated that during the normal process of involution that occurs during the postpartum period, a segment or segments of the ovarian circulation may fail to involute, predisposing to aneurysm formation in subsequent pregnancy. concerning hormonal factors, barret et al.1 noted the results of both animal and human studies suggesting that the pregnancy-related alterations in steroid hormones may cause a variety of arterial changes, including intimal hyperplasia, thickening of the media associated with smooth muscle hyperplasia, fragmentation of reticular fibres and loss of normal corrugation of elastic fibres. the most common symptom of rupture of ovarian artery aneurysm is acute flank pain or abdominal pain.3,4 a ruptured ovarian artery aneurysm may be surgically treated by adnexectomy or ligation proximal and distal to the point of rupture.1,3 arterial embolisation is now developing as an alternative therapy.5 conclusion although rupture of an ovarian artery aneurysm is an extremely rare event, it is life-threatening and is often associated with a non-specific clinical picture. awareness of this entity and a high index of suspicion may lead to early diagnosis and treatment. intravenous contrastenhanced multidetector ct with two-dimensional reconstructions is an excellent imaging technique for rapid and safe evaluation, and may be the examination of choice for such patients. 1. barret jm, van hooydonk je, boehm fh. pregnancy-related rupture of arterial aneurysms. obstet gynecol surv 1982;37:557-560. 2. burnett ra, carfrae dc. spontaneous rupture of ovarian artery aneurysm in the puerperium. two case reports and a review of the literature. br j obstet gynaecol 1976;83:744-750. 3. blachar a, bloom a.i, golan g, et al. case reports. spiral ct imaging of a ruptured postpartum ovarian artery aneurysm. clin radiol 2000;55:718-720. 4. king wl. ruptured ovarian artery aneurysm: a case report. j vasc surg 1999;13:445-448. 5. guillem p, bondue x, chambon jp, et al. spontaneous retroperitoneal haematoma from rupturing of an aneurysm of the ovarian artery following delivery. ann vasc surg 1999;13:445-448. fig. 2a. angiogram demonstrating ovarian artery aneurysm/contrast extravasation (arrow). fig. 2b. following successful coil embolisation of the right ovarian artery (arrow). a b → → radiological findings.html radiological findings at a south african forensic pathology laboratory in cases of sudden unexpected death in infants t s douglas, phd n fenton-muir, btech k kewana, mb chb y ngema, mb chb mrc/uct medical imaging research unit, department of human biology, university of cape town l liebenberg, mb chb, dip for med (sa), mmedpath(foren) division of forensic medicine and toxicology, university of cape town corresponding author: t douglas (tania@ieee.org) abstract objectives. the work serves as a preliminary evaluation of the utility of full-body radiography in examining cases of sudden unexpected death in infants (sudi). setting. this paper reviews findings from full-body digital radiography in cases of sudi in 2008 at the salt river forensic pathology laboratory in cape town. subjects. one hundred and ninety-two cases of sudi referred to the mortuary and undergoing full-body digital radiography were reviewed. design. imaging reports were cross-referenced with death registry data. manner of death, cause of death, whether an autopsy had taken place, and radiological findings, were recorded and analysed. results. the absence of bone fractures was recorded as an imaging finding in 40% of cases. the most common type of imaging pathology was lung disease. in cases where autopsies were performed and pathology was found on imaging, the findings of the two methods of examination were consistent. conclusions. imaging might have served to assist cause-of-death determination based on case history, and therefore full-body radiography could improve the workflow in busy forensic pathology laboratories. more detailed and consistent recording of imaging findings is required before stronger conclusions may be drawn regarding the utility of full-body digital imaging of paediatric cases in forensic pathology laboratories. introduction radiographs have been used in forensic examinations since the discovery of x-rays,1 and have contributed to forensic autopsy by providing a permanent, but incomplete, record of the anatomy and pathology of the deceased prior to autopsy, particularly documenting fractures and the localisation of foreign material such as bullet fragments.2 the significance of radiographic soft-tissue findings in forensic pathology has been the subject of only a few studies.3 full-body digital radiography has been shown to be useful for the rapid detection of unsuspected fractures4 and multiple injuries5 in a trauma unit; the same benefits would apply to forensic pathology investigation. forensic radiography is currently not a regular feature of the management of sudden unexpected death in infants (sudi) in south africa. a retrospective audit of 512 cases comparing the investigation of sudi at two large medico-legal mortuaries in south africa found that no radiological investigations were done as part of the post mortem examination.6 the absence of additional investigations such as radiology was attributed to probable financial and resource constraints. a full-body low-dose digital x-ray system has, however, been used in medico-legal autopsies in south africa for a number of reasons.7 it allows rapid localisation of foreign bodies with the aid of multiple views, which has benefits where fast burial is dictated by religious practice and in criminal investigation. it is easily operated by trained staff. its low radiation dose does not pose a major risk to staff. this paper reviews the findings from full-body radiography in sudi, with reference to autopsy results and causes of death, over a one-year period at the salt river forensic pathology laboratory in cape town. the incidence of sudi and the circumstances surrounding it have received little research attention in south africa. no nationally accepted protocol exists for the investigation of sudi; and in instances where an infant had an underlying medical condition/disease, the opinion of the treating clinician often determines whether or not a sudden/unexplained infant death is referred to a medico-legal facility.6 this paper serves as a preliminary evaluation of the utility of full-body radiography in examining cases of sudi. methods a lodox statscan full-body digital radiography system8 was installed at the salt river forensic pathology laboratory in 2007. cases that had undergone imaging between 1 january and 31 december 2008 were cross-referenced with data from the death registry at the division of forensic medicine and toxicology at the university of cape town. the following were recorded: manner of death – of interest in this study was sudi; age – only cases two years or younger were included; cause of death (cod); whether an autopsy had taken place; and the radiological findings. data had been entered by 4 consultant pathologists, 6 registrars and a medical officer. not all cases seen at the laboratory undergo imaging; the pathologist determines whether or not imaging is required. no protocol exists for the recording of radiological findings. the study was approved by the human research ethics committee of the faculty of health sciences of the university of cape town. results an antero-posterior (ap) radiograph was taken in all cases, while additional views were taken in some cases. no information was recorded on the reason for imaging. a total of 1 033 recorded cases were imaged in 2008, among them 197 cases of sudi. two of the sudi cases had no associated notes or death registry information, and the files for 3 cases were unavailable because of criminal investigation; these were excluded. therefore 192 cases were included in the study. cod, determined with or without autopsy, is shown in fig. 1. the majority of pathology involved the lungs. the imaging notes referred to bone fractures in 77 (40%) cases; no bone fractures were recorded. autopsies were performed on 121 sudi cases. for the 71 cases that were not autopsied, the reported death was due to natural causes (in some cases the natural cod was specified, and in others not – cf. fig. 1). in cases where pathology was found on imaging, the notes did not indicate whether or not the imaging findings contributed to cod determination. however, a larger percentage of autopsied cases showed no pathology on imaging, while a larger percentage of non-autopsied cases showed pathology on imaging (fig. 2), which suggests that imaging might have assisted in the determination of natural causes based on case history, without autopsy. twenty-two autopsied cases for which cod was specified had corresponding imaging findings; a comparison of imaging and autopsy findings is shown in table 1. imaging findings for cases without autopsy are shown in table 2. fig. 3 shows an example of a full-body image of one of the cases. the findings revealed right upper lobe opacification of the lung. fig. 4 shows a chest image extracted from a full-body scan; lung disease is evident and the findings were reported as bilateral pulmonary infiltrates. discussion the absence of bone fractures was frequently recorded as an imaging finding. skeletal surveys by x-ray imaging are part of the sudi protocol in some centres to rule out the possibility of non-accidental injury or to detect rib fractures associated with resuscitation.9 such surveys typically require several images to cover the entire skeleton. full-body imaging facilitates a complete skeletal survey from one orientation in one image, regardless of subject size, as the imaging field of view on the lodox statscan is adjustable from 100 mm x 100 mm to 1800 x 680 mm. while additional views may be required, the full-body ap image replaces a number of smaller ap views, and therefore would reduce the time taken for a skeletal survey. for the majority of sudi cases, the cod was lung disease. the majority of imaging pathology findings reflected lung disease. this is consistent with the results of other studies3 and with the limitations of radiographs in showing soft tissue pathology. in cases where autopsies were performed and pathology was found on imaging, the findings of the two methods of examination were consistent. in contrast, de lange et al.3 found poor agreement between autopsy and radiological findings owing to the presence of post mortem artefacts, which could not readily be differentiated from true pathology and were more likely to occur with long time intervals between death and imaging. our study did not show radiological findings that were unaccounted for on autopsy, and did not record the time interval between death and imaging. future work should include a prospective comparison of autopsy and radiological findings, with recording of time intervals between the two types of study, to ascertain the extent and time dependence of post mortem artefacts. although individual case reports contained no indication of the extent to which imaging contributed to cod determination, findings on imaging without autopsy in cases of death owing to natural causes suggest that imaging might have served to assist cod determination based on case history. full-body radiography may improve the workflow in a busy forensic pathology laboratory, such as the one in salt river, which receives more than 3 500 cases annually and has to maintain a large daily turnover to prevent overflow, given limited storage capacity,10 however, more detailed and consistent recoding of imaging findings is required before stronger conclusions may be drawn regarding the utility of full-body digital imaging in cases of sudi. acknowledgements. funding was provided by lodox systems and the technology and human resources for industry programme (thrip) of the national research foundation in south africa. 1. harcke ht. the case for postmortem imaging. pediatric radiology 2010;40:138-140. 1. harcke ht. the case for postmortem imaging. pediatric radiology 2010;40:138-140. 2. o’donnell c, woodford n. post-mortem radiology – a new sub-speciality? clin radiol 2008;63(11):1189-1194. 2. o’donnell c, woodford n. post-mortem radiology – a new sub-speciality? clin radiol 2008;63(11):1189-1194. 3. lange c de, vege a, stake g. radiography after unexpected death in infants and children compared to autopsy. pediatr radiol 2007;37(2):159-165. 3. lange c de, vege a, stake g. radiography after unexpected death in infants and children compared to autopsy. pediatr radiol 2007;37(2):159-165. 4. douglas ts, sanders v, pitcher r, van as ab. early detection of fractures with low-dose digital x-ray images in a pediatric trauma unit. j trauma 2008;65(1):e4-e7. 4. douglas ts, sanders v, pitcher r, van as ab. early detection of fractures with low-dose digital x-ray images in a pediatric trauma unit. j trauma 2008;65(1):e4-e7. 5. van as a, douglas t, kilborn t, pitcher r, rode h. multiple injuries diagnosed using full-body digital x-ray. j pediatr surg 2006;41(7):e25-e28. 5. van as a, douglas t, kilborn t, pitcher r, rode h. multiple injuries diagnosed using full-body digital x-ray. j pediatr surg 2006;41(7):e25-e28. 6. du toit-prinsloo l, dempers jj, wadee sa, saayman g. the medico-legal investigation of sudden, unexpected and/or unexplained infant deaths in south africa: where are we – and where are we going? forensic sci med pathol 2011;7(1):14-20. 6. du toit-prinsloo l, dempers jj, wadee sa, saayman g. the medico-legal investigation of sudden, unexpected and/or unexplained infant deaths in south africa: where are we – and where are we going? forensic sci med pathol 2011;7(1):14-20. 7. knobel g, flash g, bowie g. lodox statscan proves to be invaluable in forensic medicine forensic laboratory. s afr med j 2006;96(7):593-596. 7. knobel g, flash g, bowie g. lodox statscan proves to be invaluable in forensic medicine forensic laboratory. s afr med j 2006;96(7):593-596. 8. pitcher rd, wilde jch, douglas ts, van as ab. the use of the statscan digital x-ray unit in paediatric polytrauma. pediatr radiol 2009;39(5):433-437. 8. pitcher rd, wilde jch, douglas ts, van as ab. the use of the statscan digital x-ray unit in paediatric polytrauma. pediatr radiol 2009;39(5):433-437. 9. weber ma, risdon ra, offiah ac, malone m, sebire nj. rib fractures identified at post-mortem examination in sudden unexpected deaths in infancy (sudi). forensic sci int 2009;189(1-3):75-81. 9. weber ma, risdon ra, offiah ac, malone m, sebire nj. rib fractures identified at post-mortem examination in sudden unexpected deaths in infancy (sudi). forensic sci int 2009;189(1-3):75-81. 10. bateman c. new local scanners transform forensic pathology. s afr med j 2008;98(2):75-76. 10. bateman c. new local scanners transform forensic pathology. s afr med j 2008;98(2):75-76. fig. 1. cause of death in 192 infant cases designated as sudi on entering the forensics laboratory. fig. 2. imaging findings for autopsied and non-autopsied cases; autopsies were performed on 121 cases; 71 cases were not autopsied. fig. 3. full body image with opacification in the right upper lobe of the lung. fig. 4. cropped chest image with bilateral pulmonary infiltrates. table 1. comparison of imaging findings and autopsy results for 22 cases for which pathology was found on imaging no. of cases imaging findings cause of death (cod) 7 opacification in lung fields pneumonia/lung pathology/aspiration 7 consolidated lung fields lower respiratory tract infection/bronchopneumonia/sepsis 2 air bronchograms pneumonia 2 obscured heart margins congenital cardiac disease 1 bilateral pleural effusions pneumonia 1 hyperinflation of lungs bronchiolitis 1 lymphadenopathy disseminated tuberculosis 1 infiltrates pneumonia table 2. imaging findings for 32 non-autopsied cases where pathology was found on imaging no. of cases imaging findings lung disease 14 opacification 4 pneumonia/bronchopneumonia 4 pulmonary pathology 2 infiltrates 2 air bronchograms 1 lower respiratory tract infection 1 pleural effusion other 4 distended bowel 1 enlarged liver abstract introduction case report discussion conclusion acknowledgements references about the author(s) sanjay m. khaladkar department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, pune, india tejvir singh department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, pune, india karthik mohanan department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, pune, india rajesh kuber department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, pune, india satvik dhirawani department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, pune, india citation khaladkar sm, singh t, mohanan k, kuber r, dhirawani s. a case of leiomyosarcoma of the ovarian vein with obstructive uropathy and hepatic metastasis. s afr j rad. 2022;26(1), a2501. https://doi.org/10.4102/sajr.v26i1.2501 case report a case of leiomyosarcoma of the ovarian vein with obstructive uropathy and hepatic metastasis sanjay m. khaladkar, tejvir singh, karthik mohanan, rajesh kuber, satvik dhirawani received: 22 june 2022; accepted: 19 aug. 2022; published: 28 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract leiomyosarcoma (lms) is a smooth muscle-derived malignant mesenchymal tumour. primary lms arising from the ovarian vein is uncommon. a 51-year-old female presented with left loin pain and was diagnosed with a lms arising from the gonadal vein. the patient refused any treatment. early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. ct imaging plays an important role in diagnosis. contribution: retroperitoneal leiomyosarcoma of vascular origin is a rare entity. ct plays crucial role in diagnosing them by demonstrating the extent of the tumor along the gonadal vein. early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. keywords: leiomyosarcoma; gonadal vein; ovarian vein; retroperitoneal mass; vascular origin; claw sign; obstructive uropathy; hepatic metastasis. introduction leiomyosarcoma (lms) is a sarcoma derived from smooth muscles. it is a malignant mesenchymal tumour that may have a vascular or non-vascular origin. primary lms of vascular origin is uncommon, representing less than 1 in 100 000 of all malignant tumours.1 venous lmss account for 5% – 7% of soft tissue sarcomas. about 50% of cases arise from the inferior vena cava (ivc) and at least 200 cases have been reported to date.2 they can also arise from the renal, mesenteric, hepatic, saphenous or gonadal veins.3 the ovarian veins are an uncommon site of lms there have been 15 cases described in the literature to date.4 leiomyosarcoma from other origins have a relatively better prognosis than lms of vascular origin.1 this report describes a biopsy confirmed case of lms arising from the left ovarian vein and discusses the imaging findings on ultrasonography and multidetector ct. case report a 51-year-old female presented with left sided loin pain for 6 months. there was no history of urinary complaints, haematuria, weight loss, loss of appetite or cough. ultrasonography of the abdomen and pelvis demonstrated a well-defined solid mass in the left retroperitoneum with a lobulated outline, anterolateral to the adjoining left psoas muscle, causing compression of the left upper ureter with resultant moderate proximal hydronephrosis and hydroureter (figures 1a–c). figure 1: (a–c) ultrasound abdomen showing retroperitoneal mass of heterogeneous echotexture along the course of the left gonadal vein involving adjoining left ureter with proximal hydroureter. ct of the abdomen and pelvis revealed multiple well-defined lesions in the right hepatic lobe, with enhancement in the arterial phase, appearing hypodense in the portal phase and becoming isodense on venous and delayed phases – suggestive of hypervascular metastases. the largest lesion measured 16 mm × 12 mm in segment vi (figures 2a, b). figure 2: (a–b) axial ct abdomenarterial (a) and portal phase (b) revealing a hepatic metastasis (white arrow) in segment vi appearing hyperdense in the arterial and hypodense in the portal phase. a large solid mass with a lobulated outline, measuring approximately 82 mm × 52 mm × 64 mm (craniocaudal × anteroposterior × transverse), was identified in the retroperitoneum along the anterior surface of the left psoas muscle from the l3 to the l5 levels, demonstrating heterogeneous post-contrast enhancement with central non-enhancing hypodense areas of necrosis. no calcification was observed. the fat plane between the mass and the left psoas muscle was obscured. the adjacent left ureter was markedly compressed and involved by the mass with resultant proximal obstructive uropathy (figures 3a–c). figure 3: (a–c) axial ct of abdomen showing a well defined solid retroperitoneal mass (white arrow) anterior to the left psoas and medial to the descending colon appearing isodense to muscle on pre-contrast (a), showing heterogeneous post contrast enhancement (b), causing proximal left hydronephrosis and hydroureter (red arrow) (c). the left gonadal vein revealed a filling defect at the l3 level. the mass appeared elongated and oblong-shaped along the course of the left gonadal vein, which was indistinctly visible from the l3 to the l5 levels. mass effect was noted on the adjacent descending colon and small bowel loops with maintained intervening fat planes. the left kidney showed marked hydronephrosis with thinning of the renal parenchyma and a dilated renal pelvis with an ap diameter of 3 cm. the left ureter was dilated in its upper portion and could be traced up to the inferior endplate of the l3 vertebral body, where it appeared compressed and involved by the retroperitoneal mass. there was no excretion of contrast by the left kidney on the delayed phase (figure 4a–d). figure 4: coronal oblique (a), showing a well-defined heterogeneous mass (red arrow) along the course of left gonadal vein causing hydronephrosis and hydroureter. coronal (b–c) and sagittal (d) reformatted ct abdomen reveal a well defined heterogeneously enhancing retroperitoneal mass (red arrow) along the course of the left gonadal vein causing filling defect (yellow arrow)(c–d). mild ascites and small bilateral pleural effusions were noted. the rest of the abdomen was unremarkable. a diagnosis of a neoplastic retroperitoneal mass within the left gonadal vein was considered. a needle aspirate sample taken from the retroperitoneal lesion revealed a tumour composed of interlacing bundles of spindle cells with mild atypia. mitosis was observed at 3 to 4 per 10 high power field. a histological diagnosis of lms was ascertained. the patient refused biopsy of the hepatic lesions. the patient was advised to have surgery with radiotherapy and chemotherapy as adjuvant therapy but refused any treatment and demised two months later. discussion leiomyosarcoma is the second most common retroperitoneal sarcoma in adults. smooth muscles present in the walls of retroperitoneal veins or embryonic remnants are the sites of origin.1 the ovarian vein is the eighth most usually afflicted vessel among vascular lms. until now, there are six known cases of lms (40%) from the left ovarian vein and nine cases of known lms (60%) from the right ovarian vein that have been published.4 retroperitoneal lms has three major growth patterns: completely extravascular or extra luminal (62%), completely intravascular or intraluminal (5%) and a combination of extra luminal and intraluminal patterns (mixed – 33% of cases). extra luminal lms is usually detected late, while those with intraluminal and mixed patterns usually show early symptoms depending on the affected vein.1 retroperitoneal lms is typically solid with cystic areas related to necrosis. the characteristic imaging features of lms arising from the gonadal vein are the presence of a solid or necrotic extraor intra-luminal retroperitoneal mass, not arising from a retroperitoneal organ and its continuity with the enhancing gonadal vein along its course. rarely, there may be extensive vascular proliferation and dilatation within the mass. in such cases, the differential would include haemangioma, haemangiopericytoma and angiolipoma.5 contrast enhanced ct is superior to ultrasound and is the diagnostic test of choice for gonadal vein lms. it is extremely useful in the preoperative diagnosis, assessing the boundaries and extent of the lms.6 a large lobulated, retroperitoneal mass with heterogeneous enhancement, extending in a longitudinal direction along the course of gonadal vein, which may have internal necrotic components, is suggestive of the diagnosis. ct depicts the exact origin of mass from the vessel and excludes masses arising from the other retroperitoneal structures. with multidetector ct, multi-planar reconstruction is extremely useful in demonstrating the relationship of the mass to the vessel, the tumour extent, the relationship with adjacent structures and the presence of necrotic/cystic components and hypertrophied vessels within the mass. demonstration of the claw sign indicates a vascular origin of the mass.6 imaging with fluorodeoxyglucose positron emission tomography (fdg-pet) will show increased uptake within the mass. haematological metastases occur more commonly than lymphatic metastases, and may occur in the liver, lung, peritoneum and brain.7 histopathological examination shows bundles of spindle-shaped cells, perinuclear vacuoles, eosinophilic cytoplasm and mitotic figures. immunohistochemistry is positive for smooth cell actin, vimentin, desmin and negative for s-100 protein or neuron specific enolase.3 up to 60% of adjacent organs are microscopically invaded by the tumour at pathology.8 en bloc resection with histopathological free margins is the surgical gold standard with good prognosis.6,9 retroperitoneal sarcomas have a more than 50% recurrence rate and a 5-year-survival of 52% – 60%, despite complete resection.10 consequently, adjuvant chemotherapy and radiotherapy is recommended. diagnosis can be incidental in a third of cases and is often delayed, resulting in a worse prognosis. cases seldom present with symptoms unless they have progressed to a large size as with other retroperitoneal tumours.3 none of the previously published ovarian vein lms cases reported hepatic metastases. although the hepatic lesion in the current case was not biopsied, metastases were highly probable and portended a worse prognosis for the patient. conclusion leiomyosarcoma arising from the gonadal vein is a rare retroperitoneal tumour and diagnosis is often delayed because of non-specific symptoms. it should be suspected when tumour is seen along the course of the gonadal vein and extends in a longitudinal manner. both ultrasound and ct are useful in demonstrating the relationship of the mass with the gonadal vein along with its extent. multidetector ct is useful in preoperative evaluation of the mass with respect to location, extent, growth patterns and the relationship of the tumour and vessel. acknowledgements competing interests the authors declare that there are no financial or personal relationships that may have inappropriately influenced the writing of this article. authors’ contributions s.m.k. diagnosed and helped t.s. in writing and drafting the article and finalising it. t.s. drafted and wrote the article. k.m., r.k. and s.d. critically revised the article with important conceptual and editorial input. ethical considerations this article followed all ethical standards of research. written informed consent was obtained from the patient for publication along with relevant images. patient identity is not disclosed. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability original images, consent form and any required information are available on request from the corresponding author, t.s. disclaimer the views and opinions expressed in this article are those of the authors and not an official position of the institution. references hirano t, okumura h, maeda s, et al. vascular leiomyosarcoma originating from the right ovarian vein: a case report and literature review. surg case rep. 2019;5(1):1–6. https://doi.org/10.1186/s40792-019-0679-5 dzsinich c, gloviczki p, van heerden ja, et al. primary venous leiomyosarcoma: a rare but lethal disease. j vasc surg. 1992;15(4):595–603. https://doi.org/10.1016/0741-5214(92)90003-q de la fuente n, rodríguez blanco m, cerdán g, moral a, artigas v. leiomyosarcoma of the right gonadal vein: review of the approach and prognostic in a rare case. case rep surg. 2019;2019:4042689. https://doi.org/10.1155/2019/4042689 lópez-ruiz me, yébenes l, berjón a, hardisson d. primary leiomyosarcoma of the ovarian vein: case report and literature review. int j surg pathol. 2017;25(4):339–343. https://doi.org/10.1177/1066896916679888 kim sh, kwon hj, cho jh, et al. atypical radiological features of a leiomyosarcoma that arose from the ovarian vein and mimicked a vascular tumour. br j radiol. 2010;83(989):e95–e97. https://doi.org/10.1259/bjr/50917539 matsuzono t, chan cy, chan my. gonadal vein leiomyosarcoma: a case report with radiological findings. intractable rare dis res. 2015;4(3):152–154. https://doi.org/10.5582/irdr.2015.01016 cho hj, kim hk, suh jh, et al. leiomyosarcoma of the ovarian vein: a case report with radiological findings. korean j radiol. 2008;9(suppl):s14–s17. https://doi.org/10.3348/kjr.2008.9.s.s14 tsuyoshi h, yoshida y, kurokawa t, kotsuji f. diagnosis and management of leiomyosarcoma arising from ovarian vein: case report and literature review. j obstet gynaecol res. 2012;38(2):466–470. https://doi.org/10.1111/j.1447-0756.2011.01725.x dalainas i. vascular smooth muscle tumors: review of the literature. int j surg. 2008;6(2):157–163. https://doi.org/10.1016/j.ijsu.2007.03.004 bautista n, su w, o’connell tx. retroperitoneal soft-tissue sarcomas: prognosis and treatment of primary and recurrent disease. am surg. 2000;66(9):832. sajr 779 coronal views of the paediatric mandibular condyle on computerised tomography brain (ctb) studies: an important review area t peedikayil, n wieselthaler department of radiology, groote schuur hospital, cape town t peedikayil, mb chb department of radiology, red cross war memorial children’s hospital, cape town n wieselthaler, mb chb, fcrad (diag) sa corresponding author: t peedikayil (mustardcp@yahoo.com) this article highlights the importance of routinely reviewing the mandibular condyle on computerised tomography brain studies in a trauma setting, that often extends to involve the mandibular condyles in the scan parameters. we discuss 4 cases seen over the last 18 months at our institution, and review the relevant literature regarding paediatric mandibular fractures. s afr j rad 2013;17(1):38-39. doi:10.7196/sajr.779 we discuss 4 cases seen over the last 18 months at red cross war memorial children’s hospital in an effort to highlight the importance of routinely reviewing coronal views of the mandibular condyle when interpreting trauma-related computerised tomography brain (ctb) studies in a paediatric setting. the mandible is the second most commonly fractured facial bone in children, after nasal bone fractures.1 , 2 the condyle is the most frequently fractured region of the mandible owing to its prominent vascularisation and medullary bone and relatively thin surrounding cortical bone.3 the 4 patients who presented to the trauma unit varied in age from 2 12 years. two of them presented after a motor vehicle accident (mva), 1 fell after a bath, and the other fell from a height of about 2 metres. one patient had documented loss of consciousness. all of them had a glasgow coma score (gcs) of 15/15 at the time of ct imaging. none of the cases subsequently revealed any evidence of traumatic brain injury on ctb but they all demonstrated mandibular condyle fractures best appreciated on coronal views. axial (fig. 1) and coronal (fig. 2) images demonstrate a subtle fracture (arrows) of the mandible on the axial which is better appreciated on the coronal images. fig. 1. axial ct demonstrates a subtle left mandibular fracture (arrow). fig. 2. the left mandibular fracture (arrowed) in the same patient is better appreciated in the coronal plane. in young children, symptoms of condylar fractures are subtle and may be overlooked.4 clinical signs and symptoms described for mandibular fractures include haemorrhage from the external auditory meatus.4 one of the 4 patients had haemotympanum on clinical examination, and a ctb was requested to exclude a base of skull fracture, but instead revealed a mandibular condyle fracture as the cause of the haemotympanum. lacerations involving the chin are a commonly associated clinical finding with mandibular fractures.4 chin lacerations were documented in 2 of the 4 cases. overlooking mandibular fractures may have long-term consequences including facial asymmetry, malocclusion and ankylosis requiring invasive surgery for correction.1 , 4 panoramic radiography is still recommended as first-line evaluation for mandibular fractures in children.3 ctb imaging often extends to involve the upper mandible/mandibular condyle in the imaging field. routine review of the mandibular condyle particularly on the coronal views is advocated to avoid overlooking such fractures, particularly given the subtle clinical signs of mandibular fractures4 that may not always be appreciated or suspected by referring clinicians. 1. alcala-galiano a, arribas-garcia ij, martin-perez ma, et al. pediatric facial fractures: children are not just small adults. radiographics 2008;28:441-461. 1. alcala-galiano a, arribas-garcia ij, martin-perez ma, et al. pediatric facial fractures: children are not just small adults. radiographics 2008;28:441-461. 2. oslon ra, fonseca rj, zeitler dl, et al. fractures of the mandible: a review of 580 cases. j oral maxillofac surg 1982;40:23-28. 2. oslon ra, fonseca rj, zeitler dl, et al. fractures of the mandible: a review of 580 cases. j oral maxillofac surg 1982;40:23-28. 3. zimmerman ce, troulis mj, kaban lb. paediatric facial fractures: recent advances in prevention, diagnosis and management. int j oral maxillofac surg 2006;35(1):2-13. 3. zimmerman ce, troulis mj, kaban lb. paediatric facial fractures: recent advances in prevention, diagnosis and management. int j oral maxillofac surg 2006;35(1):2-13. 4. myall rw, sandor gk, crystal eb. are you overlooking fractures of the mandibular condyle. pediatrics 1987;79(4):639-641. 4. myall rw, sandor gk, crystal eb. are you overlooking fractures of the mandibular condyle. pediatrics 1987;79(4):639-641. sajr 842 paediatric neuro-imaging s misser lake smit and partners, durban s misser, mb chb, fcrad (d) sa corresponding author: s misser (misser@lakesmit.co.za) a 2-year-old boy presented with microcephaly and developmental delay. below are the mri images obtained. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 3 may 2013. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. s afr j rad 2013;17(1):45. doi:10.7196/sajr.843 fig. 1. sagittal t1-weighted midline mr image. fig. 2. axial t2-weighted image at level of thalami. fig. 3. axial inversion recovery image of frontal lobes. fig. 4. coronal t1 image at level of the third ventricle. fig. 5. tof mra of circle of willis and intracranial circulation. by aadil ahmed and mala modi soboleski d, therialt c, acker a. unnecessary irradiation to non thoracic structures during pediatric chest radiography. pediatr radiol 2006; 36: 22 – 25. this article highlights the fact that our present positioning techniques for paediatric chest radiographs result in unnecessary radiation exposure to non-thoracic structures. pearls: • infants and young children have a higher sensitivity than older children and adults to radiation exposure and the potential for harmful side-effects. • the ratio of radiation exposure to nonthoracic structures increases as the age of the patient decreases. • ± 43% of the length of the chest radiographs in this study was of non-thoracic structures and it was also demonstrated that no significant additional information was obtained by including the neck or abdomen in chest radiographs done for cardiorespiratory pathology. defining new landmarks for positioning/ collimation is necessary to eliminate this problem and also to satisfy the alara (as low as reasonably acceptable) principle. fung e, ganesan v, cox tsc. complication rates of diagnostic cerebral arteriography in children. pediatr radiol 2005; 35: 1174 – 1177. cerebral arteriography (ca) in children is investigated, and the differences between adults and children in terms of local and neurological complications are compared. this article is particularly relevant as most ca articles either have an adult bias, or are relatively outdated – and there have been significant technological advances. ca is useful in the evaluation of cerebral arteriovenous malformations and aneurysms and has a continuing role to play in the detection and characterisation of arteriopathies in children with arterial ischaemic stroke, for example, moyamoya syndrome, embolic disease and inflammatory processes. pearls: • ca can be technically challenging in a small infant with extra adipose tissue so that local complications may be more common than in adults. • conversely, the absence of co-morbid factors, such as diabetes and hypertension, or of widespread arterial disease, means that neurological complications are likely to be less common in children than in adults. • ca is a superior technique to standard mra sequences as it provides dynamic information regarding the cerebral circulation. • cta is more freely available, and its value has been proven in adults, even though it uses both iodinated contrast and ionizing radiation • a comparative study of helical cta, mra and dsa in children has demonstrated that helical cta is superior to mra in the identification of the intracranial vasculature (venous and arterial) and is almost as good as dsa. the author and his group performed cas under gas which in itself can be a deterrent, as well as the fact that patients require a 2-day admission. this retrospective study carried out in a tertiary care institution concluded that ca has a continuing role to play in evaluating cerebrovascular pathologies in kids. in experienced hands neurological complications are rare and local complications are not uncommon (around 5% in this study) but are not usually serious (the commonest being groin haematomas and bleeding at the puncture site). by savvas andronikou a doctor was struck from the general medical register in the uk after he pleaded guilty to making indecent images of children. a panel found that he downloaded images from the internet deliberately. ‘the public interest includes protecting patients and maintaining public confidence in the profession and maintaining proper standards of professional behaviour and conduct.’ children’s rights must be protected on their behalf and medical practitioners including radiologists should be instrumental in bringing injustices to light particularly with regard to abuse and sexual abuse. child pornography is sexual abuse! reference: gmc newsletter issue 5 december 2005. on saturday 25 february the first workshop for paediatric imaging in south africa took place in johannesburg under the auspices and sponsorship of the college of radiology of south africa and the paediatric imaging society of south africa (pissa). this was organised by mala modi and her team of registrars (lee kramer and jeanie jennings). over 75 doctors attended this compact course which answered practical issues relating to procedure performance. these included mcug, contrast swallow/ meal, tube oesophagogram, ultrasound for uti, head ultrasound and imaging of hypertrophic pyloric obstruction. there was also a speak-off on the current management of intussusception by dr aadil ahmed of baragwanath hospital and professor savvas andronikou of tygerberg hospital, which is mirrored in this publication. there was also an interactive session on interpretation of neonatal icu films including tube and line placement and recognition. the workshop was free to delegates and pissa is grateful to the president of the college of radiologists for its new educational initiative in sponsoring the airfare for professor andronikou to run the course. aadil ahmed and mala modi, dept of radiology, university of the witwatersrand and chris hani baragwanath hospital intussusception is the invagination of a segment of bowel (the intussusceptum) into the contiguous segment (the intussuscipiens). the peak incidence is between 6 months and 2 years.1 most cases are idiopathic, but in a small number there is a pathological lead point. common sites are ileocolic and ileoileocolic.1,2 the classic clinical triad of abdominal pain, red currant jelly stool and palpable abdominal mass is present in less than 50% of children.2 journal review by savvas andronikou figs 1 and 2 demonstrate the contrast meal in a child with alleged ‘bile-stained’ vomiting. the second part of the duodenum shows a loop to the right of the spine prior to crossing to the left of the spine, suggesting malrotation. a falsepositive diagnosis was made by the reporting registrar because a normal duodeno-jejunal flexure is expected to be located to the left of the spine, behind the stomach at the level of the duodenal bulb. the above images are consistent with a duodenum inversum or a duodenum reflexum.1 this subtle variation of normal demonstrates the distal duodenum to ascend to the right of the spinal column up to the level of the duodenal bulb and crossing the spine horizontally where it is fixed in a normal location by the ligament of treitz. it may result in delayed gastric emptying which gives rise to the presenting symptoms but is not associated with midgut volvulus. an accurate diagnosis is imperative to avoid unnecessary surgery.1 1. long fr, kramer ss, markowitz ri, taylor ge, liacouras ca. intestinal malrotation in children: tutorial on radiographic diagnosis in difficult cases. radiology 1996; 198: 775-780. pediatric radiology october 2005; 35: 947-979. the minisymposium consists of 2 articles on the evaluation of vascular rings and slings and the imaging thereof. a vascular ring refers to any vascular or ligamentous anomaly that encircles the trachea or oesophagus. there are 2 groups: complete and incomplete. complete vascular rings include double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum. incomplete vascular rings include pulmonary artery sling and innominate artery compressive syndrome. the first article written by m oddone et al. is: ‘multi-modality evaluation of the abnormalities of the aortic arches in children: techniques and imaging spectrum with emphasis on mri’. a fantastic article discussing embryology and classification as well as the imaging with chest radiography, barium oesophagography and mri. each subtype is then comprehensively described under separate sections with great images and additional line diagrams. the second article, written by m hernanzschulman, is ‘vascular rings: a practical approach to imaging diagnosis’. this article also discusses imaging techniques in detail and includes modalities such as ultrasound and multislice ct. specific subtypes are also described in detail with superb images. the articles combined are 30 pages but well worth the read. by nicky wieselthaler girst tm, thornton fj. mra in children: technique, indications and imaging findings. pediatric radiology 2005; 25: 26-39. this article explains the conventional mra techniques that can be used in children as well as contrast-enhanced 3d mra with rapid t1 spoiled gradient-recalled echo (fspgr). injection parameters and indications are discussed in detail. rating: ***. comment: very educational and practical. taylor chung. mra of the body in pediatric patients: experience with a contrast-enhanced time resolved technique. pediatric radiology 2005; 35:3-10. this article compares ct angiography with other available modalities and techniques. it also provides valuable and practical scan parameters that can be used in practice. dose-specific parameters are discussed with useful suggestions for radiation reduction. applications in paediatric practice are listed. by savvas andronikou • espr – 2005 the european society for pediatric radiologists held its annual conference in dublin. the members of pissa who attended (s andronikou and n wieselthaler) presented 2 papers and 1 paper which were well received. the long papers were delivered by s andronikou on behalf of carey makenzie and stefan przybojewski and dealt with physeal bar and objective features of basal enhancement in tbm respectively. the main focus and keynote speakers dealt with increasing scientific evidence of the decreasing importance of vescicoureteric reflux. abstracts were published in a supplement issue of pediatric radiology. • espr/ ipr 2006 in 2006 there is a combined meeting of north american, european and oceanic societies of pediatric radiologists at ipr in montreal. abstracts have already closed. pissa has entered 4 abstracts including long papers on radiographer reporting in ct brain and correlation of infants with outcome in tbm. • isr 2006 jan labuschagne has secured this massive international conference to be held at the cape town icc in september 2006. good news for pissa is that there is a dedicated pediatric tract for thursday 14 september, friday 15 september and saturday 16 september with over 8 hours of talks and over 30 invited international speakers just for the pediatric tract. these will be from europe, the usa, canada, australia, asia and africa and include the likes of j barkovich, susan blaser, steven chapman, francis brunelle, alan daneman, marilyn siegel, isky gordon, kieran mchugh and douglas jamieson. one session is dedicated to neuroimaging, one to abdominal imaging and one to tb/hiv in children. the last day will be jam-packed with internationally renowned tb/hib experts. abstracts for posters and long papers are welcome: docsav@mweb.co.za. check out the programme: www.isr2006.co.za. baby steps into pediatric neuro imaging. s andronikou, n wieselthaler, e kader (2004) sama health and medical publishing group (cape town). a product of pissa, this national collaboration is finally in print, but has already run out of print! the massive demand has prompted another print of 200 books for 2006. feedback has shown this to be an excellent quick reference, particularly for the myelin maturation and standardised us imaging of the head. pissa intends to produce its next book ‘a guide to pediatric imaging procedures’ sometime in 2006. the rssa and college of radiologists are collaborating to produce a free imaging atlas for radiologists and clinicians. the publishing team of pissa is heading the project even though most of the atlas will deal with adult anatomy. an excellent chapter in paediatric imaging anatomy is in progress and will form an integral part of the book. the rssa has donated over r120 000 for the publication which is sanctioned by the college of radiologists of south africa. a pre-exam course is held annually by the college of radiology. this year paediatric imaging was given as much emphasis as imaging of all the other body systems and the conference was a huge success. vivas, spot tests and long cases were added to the programme of physics and written question preparation lectures. the next course will be held in cape town in 2006. enquiries contact the organiser: dr savvas andronikou at docsav@mweb.co.za. the october 2005 college of radiology exams have just taken place. paediatric imaging was a focus of 2 written questions and 2 of the 10 long cases. it also formed a large proportion of the oral exam as one examiner asked only paediatric radiology-related questions. written by s andronikou & n wieselthaler 36 sa journal of radiology • december 2005 specialty corner produced by: pissa figs 1 and 2. images demonstrating the course of the duodenum, consistent with duodenum inversum. case of the day an unusual duodenal cloop journal review – hermes conference news books pre-exam course college of radiology newspaper2 11/25/05 1:50 pm page 36 contributors: a ahmed, m modi, s andronikou, a erlank news: indecent ‘imaging’ of children workshop on paediatric fluroscopic imaging and paediatric ultrasound technique controversy and consensus on the management of intussusception. guidelines to diagnosis and management for suggested safe practice – a literature review 33 sa journal of radiology • march 2006 speciality corner.indd 33 3/27/06 3:26:35 pm 34 sa journal of radiology • march 2006 imaging diagnosis 1. sonography is reported to be sensitive. a 100% negative predictive value has been reported in some series and is used as the modality of choice for diagnosis and exclusion in many centres. intussusception has a characteristic appearance. a 3 5 cm soft-tissue mass is demonstrated, more often on the right side of the abdomen, and usually found just deep to the abdominal wall. the ‘crescent in doughnut’ sign and ‘pseudokidney’ sign have been described. sonography is also useful in documenting the presence or absence of a pathological lead point or excluding other abdominal pathology. the presence of free fluid is a common finding and is not a contraindication to reduction. non-visualisation of blood flow in the intussusception by colour doppler is not a contraindication to reduction, but cautious reduction should be undertaken.2 2. no reported study has demonstrated plain radiographs to be as good as sonography, however, its importance, especially a horizontal beam radiograph, in detecting free air, cannot be overemphasised.1,2 some characteristic signs include the ‘meniscus’ sign and the ‘target’ sign. 3. a diagnostic enema was considered the gold standard until the value of sonography was recognised. it is more invasive, requires radiation exposure and may not demonstrate the presence of other intra-abdominal pathology. radiological management the major advantages of radiological management are decreased invasiveness and morbidity, lower costs and shorter hospital stays.3 the general contraindications include: (i) clinical evidence of dehydration, shock or peritonitis; and (ii) radiographical evidence of a perforation with free air. pneumatic reduction will be discussed as this technique is used in many centres worldwide as well as in our institution, and is generally considered the optimal technique.3-5 • the patient must be fully resuscitated with an iv line in situ. • informed consent must be obtained from a parent or guardian. • the local paediatric surgeon should be aware of the procedure and a doctor trained in paediatric resuscitation should be in the room. • fluoroscopically guided reduction is used due to ease of use and familiarity. • ultrasound guidance has the advantage of no radiation, but can be technically challenging, and recognition of perforation may also be difficult. • methods to improve reduction success are variable and of limited use with no significant increase in reduction rates: • medications: (i) antispasmodics are not routinely indicated; (ii) sedation is of questionable value, may have an unpredictable response and has the disadvantage of masking the patient’s condition; and (iii) consider analgesia as an alternative.3,4 • delayed repeated attempts; the time interval varies from 30 minutes to 24 hours and is only applicable in a minority of patients and depends on local and clinical circumstances. • the catheter used is a local decision, but a large-bore tube or catheter is suggested • meticulous strapping of buttocks is suggested, as a good anal seal is of utmost importance in maintaining a sustained pressure. • the initial attempt should be at pressures of 60 80 mmhg. • three attempts of 3 minutes each are usually sufficient and safe. • it is generally recommended that each attempt at reduction should be for a maximum of 3 minutes, with approximate 3minute intervals between attempts (rule of 3’s).1,4,5 • increasing pressure with subsequent attempts, to a maximum pressure of 120 mmhg is recommended.4,5 • a pressure release valve with a cut-off at 120 mmhg is an alternative in the absence of a pressure manometer. • successful reduction is usually defined as free flow of air into the distal ileum. if no reflux of air into the ileum is seen, the patient may be observed and management decided on the child’s clinical state. • complications: (i) the major complication is bowel perforation, a large pneumoperitoneum can be relieved by needle puncture of the abdomen to prevent the rare complication of tension pneumoperitoneum; (ii) hypovolaemic shock requiring resuscitation; and (iii) the risk of bacteraemia. • in some instances sonography may play a role, post reduction or attempted reduction: (i) to confirm reduction; (ii) to assess for pathological lead point; and (iii) to delineate the presence of unreduced component. • regular audits of intussusception figures should be undertaken. successful reduction rates of > 50% should be aimed for.4 1. dahnert w. radiology review manual. 5th ed. lippincott williams and wilkins, 2003:835 – 837. 2. daneman a, navarro o. intussusception: a review of diagnostic approaches. pediatr radiol 2003; 33: 79 85. 3. daneman a, navarro o. intussusception: an update on the evolution of management. pediatr radiol 2004; 34: 97 108. 4. british society of paediatric radiology. guidelines for intussusception reduction. 2003. 5. rosenfeld k, mchugh k. survey of intussusception reduction in england, scotland and wales: how and why we could do better. clin radiol 1999; 54: 452 458. by s andronikou, a erlank, m strachan, g dekker: radiology department, tygerberg hospital and university of stellenbosch in view of your review article on air reduction of intussusception, we would like to comment as follows: precautions and preparations • if you do use ultrasound for the diagnosis, be confident about a positive diagnosis; if you are confident about the diagnosis of exclusion of an intussusception do not proceed with any procedure. • no positive ultrasound finding for intussusception is a contraindication for air reduction. • only proceed to air reduction if a paediatric surgeon and adequate resuscitation equipment are available on site. • check films for features of bowel perforation (free air) and for features of colitis (mural air) and cancel the procedure if present. • insist on attendance of surgical staff. • insist on intravenous access. • have large-bore needles available – place in the attending surgeon’s hands. • we do not wait for fluid resuscitation because we lose valuable time. • do not sedate the patient; it only confuses patient monitoring. some advice on the procedure itself • use a balloon catheter (24 f) to get a good seal and keep it neat1 (figs 1a and b) comments on intussusception reduction – the tygerberg hospital experience fig. 1a. a little finger which is accepted for pr examinations in young children is much larger than a 24f foley catheter. speciality corner.indd 34 3/27/06 3:26:36 pm • store an image before air is going in – it helps to see the central gas paucity later when confused about free flow into the small bowel (fig. 2) • prone position helps hand grasp seal • be prepared for direction of sigmoid when prone (figs 3 5) • do not infuse air until watching with fluoroscopy • rotate tasks with many people • try hard. procedure rules • there are no rules • try as many times as you like • come back as may times as you like • 120 mmhg is not an absolute; you can go more but we do not recommend this; do not panic about small elevations above this. caution • when perforation occurs remember the air is white on fluoroscopy – take a spot film to look for free air (fig. 6); deflate the balloon; turn the patient; stick needles in the abdomen and resuscitate the patient • move fast because diaphragms are high in the chest due to high pressure. why are we not succeeding? • we do not try long enough or hard enough • our patients present late (anecdotal success rate in the uk is about 90% and in sa about 60%) • perforation probably happens in patients with bowel necrosis and not from too high pressures. 1. mcalister wh, parker b. apropriateness criteria for imaging and treatment decisions. expert panel on pediatric imaging. possible acute or chronic sinusitis. radiology 1998; 206: 595-598. according to regulation 17 of the regulations relating to the specialties and subspecialties in medicine, which were published in government notice no. r590 of june 2001, any specialist may treat any person who comes to him or her directly, without referral by another medical practitioner. in essence this means that a patient can present to a radiologist and request a ct scan. the radiologist is the best person to decide on the appropriate investigation, and this may seem completely logical and ethical. there are many pitfalls, however when the radiologist has not or cannot perform the full clinical examination and take the complete history into account. appropriate use of this regulation is for example for mammography, which is usually a screening test. referral of a patient to the clinical specialist can occur if pathology is identified. fig. 1b. the balloon that is inflated in the rectum acts as a seal to prevent air leakage. fig. 2. we recommend this preliminary film which shows the amount of central gas prior to reduction attempt and is a valuable record when the free flow into the small bowel is not actually visualised. fig. 3. an early image stored as a ‘grab’ is of low quality but is sufficient to demonstrate the intussusception being forced back by the column of air. note that air on fluoroscopy is ‘white’ and that the sigmoid is in a ‘mirror image’ position because the procedure is performed prone by our team. fig. 4. later during the procedure the intussusceptum is driven even further. note that this image was recorded as a spot film resulting in a high quality image. note the reversed position of the sigmoid once again, due to prone positioning. fig. 6. full exposure has been performed and the image contrast reversed to demonstrate free air in the recognisable ‘black’ form after perforation. reportage: can the radiologist consult directly with the patient? fig. 5. post reduction, there has been free flow of air into the small bowel indicating success of the procedure. comparison with the initial image (fig. 2) is useful. 35 sa journal of radiology • march 2006 speciality corner.indd 35 3/27/06 3:26:40 pm sajr 699 correspondence experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection 1 to the editor: in my article entitled ‘experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection’ that was published in the sajr vol. 15, no. 4 (december 2011), i emphasised that we had not gained experience in this technique with renal pathologies such as pyelonephritis and small renal tumours. at a ct congress in south africa last year, an international speaker and expert in ct also raised his concern about missing small renal tumours when questioned about this technique. i have had further experience since, and would like to share the following 2 cases, suggesting that this technique will demonstrate these 2 pathologies adequately. case 1 a 70-year-old man was diagnosed with a small right renal mass, using the classic post-contrast scan technique (arterial, nephrographic and delay excretory series). i performed a 6-month follow-up using the single post-contrast scan after a triphasic contrast injection. fig. 1 (a d) shows the lesion identified at original scan and provi-sionally diagnosed as an oncocytoma. fig. 2 (a b) shows the lesion (arrow) at 6-month follow-up, unchanged. the lesion was a subtle lesion, difficult to identify on both examinations, but it is my opinion that it is seen as easily using the single post-triphasic contrast injection technique (fig. 2) as on the classical 3 post-contrast series technique (fig. 1). case 2 a 76-year-old woman presented with symptoms of urinary tract pathology. pyelonephritis was diagnosed after a ct scan using the single-series post-triphasic contrast injection technique. we include a 3-hour post-contrast study on our patients if we suspect pyelonephritis. these two cases show that this modified post-contrast technique is sensitive to small focal lesions and diffuse lesions within the kidneys. i acknowledge that a few cases do not constitute definitive scientific evidence that subtle lesions will not be missed; however, these types of case add to the radiologist’s confidence in using this technique, bearing in mind that this technique replaces 3 post-contrast scans with a single scan and also effectively halves the overall radiation dose to the patient. i thank my partners dr jaco parsons for his initial diagnosis of the small renal mass (case 1) and dr etienne steenkamp for his case of pyelonephritis (case 2). phil pretorius drs visser, erasmus, vawda & partners port elizabeth ppret@telkomsa.net   1. pretorius, p. experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection. south african journal of radiography 2011;15(4):140-145. 1. pretorius, p. experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection. south african journal of radiography 2011;15(4):140-145.   s afr j rad 2012;16(3):122-123. doi:10.7196/sajr.699 fig. 1a. pre contrast fig. 1b. arterial phase. fig. 1c. nephrographic phase. fig. 1d. delay excretory phase. fig. 2a. axial view after single post-triphasic contrast injection series. fig. 2b. sagittal reconstruction. fig. 3a. axial left kidney. fig. 3b. axial left kidney after 3-hour post-contrast delay. fig. 3. the left kidney shows an area of inhomogenous poor contrast enhancement antero-medially on the initial scan (black arrow in fig. 3a) after the triphasic contrast injection. on the 3-hour delay post-contrast scan, there is retention of contrast in the tubules, causing streaky contrast staining in the area of inflammation, typical of pyelonephritis (black arrow in fig. 3b). cpd questionnaire 120 sajr august 2013 vol. 17 no. 3 a maximum of 5 ceus will be awarded per correctly completed test. regarding imaging of the paediatric paranasal sinuses: 1. the maxillary sinus is the first paranasal sinus to develop from the ethmoid sinuses. 2. aeration of the sphenoid sinuses usually begins at about age 3 years, with aeration beginning anteriorly and progresses in an inferior posterolateral direction and with the sinus attaining its mature size by the age of 14 years. 3. the ostiomeatal complex (omc) is a functional entity of the anterior ethmoid complex that represents the final common pathway for drainage and ventilation of the frontal, maxillary and anterior ethmoid cells. 4. the maxilla is the most frequent facial bone affected by fibrous dysplasia. 5. an antrochoanal polyp refers to a solitary lesion that arises in the maxillary antrum of an atopic person, increases in size to widen the sinus ostium, and then extends into the nasal cavity. regarding quality management systems in radiology: 6. quality management of patient radiation dose monitoring is fundamental to safety and quality improvement of radiological services. 7. the radiologists or medical practitioners in charge should oversee the establishment of local quality systems, guided by local practice as well as international standards that are currently available in most developed countries. regarding the face of the giant panda sign in wilson disease: 8. when patients with wilson disease have predominant hepatic involvement, t2 hyperintensity is noted in the globus pallidus, putamen and mesencephalon. 9. in neurologically symptomatic patients, t1 hyperintensity is noted in the putamina, caudate nuclei, thalami, midbrain and pons. 10. the face of the giant panda sign is produced as a result of high signal intensity in the tegmentum with preserved normal signal intensity in the red nuclei and lateral portion of the pars reticulata of the substantia nigra as well as hypointensity of the superior colliculi. regarding extramedullary haematopoiesis: an uncommon posterior mediastinal mass: 11. extramedullary haemotopoiesis is seen in a variety of haematological disorders, including severe haemolytic anaemias (thalassaemia, sicklecell anaemia, spherocytosis), leukaemia, lymphoma, myelodysplasia and myelofibrosis. 12. main considerations in the differential diagnosis of emh are tumours of the middle and posterior mediastinum, including neurogenic masses, lymphoma, paravertebral abscesses, pleural cysts, lateral meningoceles, mediastinal lymph node hyperplasia, and primary and metastatic malignant neoplasms. regarding imaging of disease progression in a case of idiopathic moyamoya: 13. disorders associated with secondary moyamoya include down syndrome, neurofibromatosis type 1, tuberous sclerosis and sickle cell disease. 14. the typical angiographic appearance is narrowing of the supraclinoid internal carotid artery, proximal anterior cerebral artery and proximal middle cerebral artery. regarding thymic masses: a radiological review: 15. normal thymic thickness should be <13 mm before 20 years of age and <18 mm after 20 years of age. 16. true thymic hyperplasia is diagnosed when there is >50% increase in thymic volume over baseline, usually within a year of the stress period, with preserved microscopic features. 17. lymphoma is the most common cause of an anterior mediastinal mass in children and the most common cause of an anterior mediastinal mass in adults. 18. thymomas are classified into noninvasive (benign) or invasive (malignant), and are usually seen in adults in the 5th 6th decade and commonly seen in children. regarding nasolabial cysts – a rare case: 19. nasolabial cysts comprise approximately 0.6% of all jaw cysts, most commonly affect patients in the 4th and 5th decades of life, and have a male predominance. 20. nasolabial cysts are benign, slow-growing developmental cysts occurring in the nasolabial folds below the alae nasi and are nonodontogenic, extraosseous and locally expansile. instructions: 1. cpd questionnaires must be completed online by registering with www.cpdjournals.co.za. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your cpd certificate(s). 4. please contact the online manager (021 681 7200 or publishing@hmpg.co.za) in the event of queries. accreditation number: mdb001/012/01/2013 (clinical) cpd questionnaire mark each numbered statement as true (a) or false (b). c m y cm my cy cmy k mph513 clarity iq advert dosewise fa.pdf 1 2013/08/06 11:54:02 am http://www.cpdjournals.co.za mailto:publishing@hmpg.co.za abstract introduction case presentations discussion conclusion acknowledgements references about the author(s) manish kumar department of radiodiagnosis, mayo institute of medical science, barabanki, india priya singh department of radiodiagnosis, mayo institute of medical science, barabanki, india priti kumari department of radiodiagnosis, bps government medical college for women, sonepat, india rohit kaushik department of radiodiagnosis, house of diagnostics, new delhi, india citation kumar m, singh p, kumari p, kaushik r. revisiting the forgotten remnant: imaging spectrum of meckel’s diverticulum. s afr j rad. 2022;26(1), a2431. https://doi.org/10.4102/sajr.v26i1.2431 case series revisiting the forgotten remnant: imaging spectrum of meckel’s diverticulum manish kumar, priya singh, priti kumari, rohit kaushik received: 05 mar. 2022; accepted: 11 apr. 2022; published: 19 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract meckel’s diverticulum is a true diverticulum of the alimentary tract occurring resulting from the persistence of remnants of the vitello-intestinal duct. they are often asymptomatic and incidentally diagnosed during surgery. complications such as intestinal obstruction, diverticulitis, intestinal haemorrhage and perforation may occur with meckel’s diverticulum, which renders them symptomatic. the clinical and imaging diagnosis of meckel’s diverticulum is very challenging. as a result of the rare occurrence of complicated meckel’s diverticulum and the difficult preoperative diagnosis, knowledge of its imaging features is limited. the presented case series describes a spectrum of complications caused by meckel’s diverticulum and its ct imaging features. it highlights the importance of a high clinical suspicion by carefully searching for a meckel’s diverticulum on ct in its characteristic location to avoid missing it preoperatively. keywords: meckel’s diverticulum; computed tomography; imaging; complications; meckel’s acute abdomen. introduction meckel’s diverticulum (md) is the commonest structural congenital anomaly of the gastrointestinal tract. it is part of the spectrum of abnormalities that occur because of the persistence of remnants of the vitellointestinal duct. it is a true diverticulum of the alimentary tract consisting of all layers of the intestinal wall and lined by normal intestinal mucosa, which frequently contains heterotopic gastric or pancreatic mucosa.1 the incidence of md is about 2% – 3% in the population with a similar occurrence in both sexes; however, it often becomes symptomatic in males. although it is mainly asymptomatic, a myriad of complications may develop with a lifetime risk of about 4.2% – 6.4%.2 the common complications include intestinal obstruction, diverticulitis, intestinal haemorrhage and perforation. thus, knowledge of the embryology, anatomy, clinical presentation and diverse complications is of paramount importance. the diagnosis of md and its related complications is often challenging to establish preoperatively. however, identification of md and its various complications can be reliably achieved with improved ct scan techniques. case presentations case 1 a 25-year-old man presented with complaints of left lower abdominal pain radiating to the back. on ultrasound, multiple renal calculi were present in the left kidney with mild hydronephrosis. a contrast enhanced ct (cect) and urography were performed for further evaluation, confirming left lower ureteric and left renal calculi with mild left hydronephrosis. in addition, a tubular diverticulum was seen arising from the antimesenteric border of the distal ileum, just proximal to the ileocecal junction (figure 1). a diagnosis of incidentally diagnosed md was made. the patient was treated for ureteric calculi and as the md was asymptomatic, no surgical treatment was performed and follow-up was advised. figure 1: contrast enhanced computed tomography in the coronal (a) and sagittal (b) planes demonstrating a tubular, blind-ending structure arising from antimesenteric border of the distal ileum with enhancing walls, suggestive of meckel’s diverticulum (white arrows). no abnormal wall thickening or surrounding fat inflammation was present. case 2 a 30-year-old man presented with abdominal distension, vomiting and obstipation for three days. on ultrasound, the small bowel loops were dilated and fluid-filled, with to and fro movements. an erect abdominal x-ray demonstrated dilated central bowel loops with multiple air-fluid levels suggestive of small bowel obstruction. the cect abdomen revealed small bowel dilatation with multiple fluid levels and a transition point at the level of the distal ileum. a tubular blind-ended structure arising from the antimesenteric border was seen at the transition point (figure 2). the diagnosis of a md causing small bowel obstruction was made on imaging. the patient immediately proceeded to laparotomy, where an inflamed md was found, causing a stricture in the adjoining distal ileum (figure 3). surgical resection of the md and small bowel was performed. figure 2: x-ray abdomen (a) erect anteroposterior view shows dilated gas-filled bowel loops with multiple air-fluid levels. contrast enhanced computed tomography in the axial (b) and coronal (c, d) planes shows dilated small bowel loops with an inflamed meckel’s diverticulum (white arrows) arising at the level of the transition point. figure 3: intraoperative image demonstrated the inflamed meckel’s diverticulum (white arrow) causing a stricture of the distal ileum resulting in intestinal obstruction. case 3 a 36-year-old male presented with right lower quadrant and periumbilical abdominal pain for 1 month. ultrasound of abdomen was within normal limits. contrast enhanced ct abdomen revealed the presence of a md with thickened, enhancing walls associated with inflammatory changes in the adjacent fat (figure 4). the normal appendix was identified separately on ct, resulting in a diagnosis of meckel’s diverticulitis. the patient underwent laparoscopically assisted trans-umbilical meckel’s diverticulectomy. histopathology confirmed the imaging diagnosis. figure 4: contrast enhanced computed tomography in the axial (a, b) and sagittal (c) planes revealed a meckel’s diverticulum (white arrows) with wall thickening and enhancement, surrounded by fat inflammation suggestive of meckel’s diverticulitis. case 4 a 40-year-old male patient presented with complaints of acute severe abdominal pain and swelling predominately towards the right side, associated with fever and obstipation. his general examination revealed marked tenderness of the abdomen, guarding and rigidity, raising the suspicion of perforation with peritonitis. an erect plain x-ray abdomen revealed free air under the diaphragm. an urgent cect abdomen was performed, which indicated an inflamed perforated md arising from the distal ileum with free extraluminal air (figure 5). surrounding marked inflammation and fat stranding was seen. an urgent laparotomy was performed, which confirmed the imaging findings. figure 5: contrast enhanced computed tomography in the axial plane shows a tubular blind-ending structure arising from antimesenteric border of the distal ileum with surrounding free air suggestive of a perforated meckel’s diverticulum (white arrow). case 5 a 29-year-old male patient presented with acute abdominal pain in the mid-abdomen associated with vomiting. abdominal x-ray revealed air-filled distended bowel with multiple air-fluid levels in the central abdomen. contrast enhanced ct abdomen demonstrated dilated small bowel loops with a transition at the level of the distal ileum. a md was seen at the level of the transition point, with its tip reaching up to the umbilicus (figure 6). diagnostic laparoscopy revealed the presence of adhesions at the site of origin of the md, leading to distal ileal luminal narrowing. an urgent trans-umbilical laparoscopic removal of the md and small bowel resection was performed. figure 6: contrast enhanced computed tomography in the axial (a, b, c) and coronal (d, e and f) planes show dilated small bowel loops with air-fluid levels. an inflamed meckel’s diverticulum (white arrows) was seen arising at the level of the transition point (red arrow). an enhancing linear band was seen arising from the meckel’s diverticulum, extending towards umbilicus (white arrow in f). this case series describes the varied presentations of md on cect. one of the cases was incidentally diagnosed and the diverticulum was asymptomatic. two patients presented with an intestinal obstruction, one with diverticulitis and one with perforation. discussion in 1809, johann friedrich meckel, the younger, described the most common congenital anomaly of the gastrointestinal tract and its anatomy, embryology and clinical features.3 the omphalomesenteric duct (omd) connects the yolk sac with the developing midgut in foetal life. during the 10th to 12th week of the intrauterine period, this duct gradually involutes when the midgut returns to its normal position.4 depending on the degree of failure of involution of the omd, different types of anomalies develop. omphalomesenteric duct anomalies include umbilical sinus, meckel’s diverticulum, omphalomesenteric cyst, a fibrous cord connecting the ileum to the umbilicus and ileo-umbilical fistula. umbilical-ileal fistula is the least common anomaly presenting in the newborn period, resulting from a completely patent omd.4 meckel’s diverticulum is the most common, accounting for 98% of omd anomalies, which occurs as a result of persistence of the duct at its ileal end.4 people with md remain mostly asymptomatic during their lifetime. asymptomatic md is often incidentally diagnosed on imaging studies or intraoperatively during surgeries. only about 16% – 20% md becomes symptomatic secondary to one or other complications.5 complications are also more common in the paediatric age group before 10 years.5 different studies have shown that the lifetime risk of complications varies between 4% – 6%.6 meckel’s diverticulum is generally composed of small intestinal mucosa; however, they frequently develop heterotopic tissue, especially gastric and pancreatic mucosa, which leads to peptic ulceration and other complications. rarely duodenal, colonic, jejunal and biliary ectopic tissue may be present in them. the most common complication of md is lower gastrointestinal tract haemorrhage presenting as painless rectal bleeding, especially in paediatric patients.7 sometimes this can clinically present as prolonged anaemia with a positive occult stool blood test or episodic per rectal bleeding. haemorrhage occurs secondary to peptic ulceration of the md and adjoining ileal mucosa from the acidic or alkaline secretions of gastric or pancreatic ectopic tissue in the md.7 intestinal obstruction is the second most common complication, particularly in adults. clinically, it manifests as bilious vomiting, constipation, abdominal pain and distension. the mechanism for the development of intestinal obstruction in md may be intussusception, volvulus or internal herniation secondary to a fibrous band connecting the md with the umbilicus, diverticular inversion, meso-diverticular band, adhesions or diverticulitis leading to stricture. the inclusion of md in an inguinal hernia is known as littre hernia. foreign body or stone impaction and a neoplastic lesion can also cause obstruction.8 acute meckel’s diverticulitis is the third most common complication presenting as acute abdominal pain, fever and vomiting. its clinical symptoms closely mimic acute appendicitis and present a diagnostic challenge. it is often misdiagnosed preoperatively and only identified during surgery. it develops because of narrowing of the md at its origin by a faecolith, foreign body, calculus, neoplasm, secretions or inflammation and stricture formation secondary to peptic ulceration.8 enteroliths are seen in up to 10% of cases of md, especially in the adult age group and clinically present as chronic dull aching paraumbilical pain.8 perforation is a less common but severe and life-threatening complication of md. it occurs secondary to peptic ulceration, diverticulitis and gangrene. patients present with severe abdominal pain, tenderness, rigidity and poor general condition. thus, the clinical suspicion of md should always be kept in mind in a young patient presenting with clinical features related to its complication. imaging plays a crucial role in the diagnosis of a md. plain x-ray abdomen and fluoroscopic studies have a limited role in identifying md except for identifying complications such as perforation, bowel obstruction, intussusception and volvulus. on barium studies, the characteristic findings described are a triradiate bowel fold of the diverticulum in the presence of collapsed bowel, mucosal triangular plateau appearance in the presence of distended bowel and as bulbous or triangular area in the setting of intussusception or inverted diverticulum.9 however, these findings are difficult to interpret and not confirmatory. ultrasound is a part of the initial radiological evaluation of md complications. on ultrasound, an inflamed md appears as a non-compressible, irregular, thick-walled, cystic mass with increased vascularity and echogenicity of the surrounding fat.9 the typical gut signature appearance of its wall is seen on ultrasound. this appearance can be easily confused with acute appendicitis; therefore, identification of a normal appendix on ultrasound is essential. an inverted md with intussusception produces a target-like appearance on ultrasound; however, these findings lack specificity for md. the ct scan is the modality of choice for identifying a md presenting with complications, especially in adults. when combined with enteroclysis or enterography, ct has added benefits in the delineation of md.10 meckel’s diverticulum is usually identified as a blind-ending thick-walled tubular structure arising from the antimesenteric border of the ileum, usually within 100 cm of the ileocaecal valve on ct. it is supplied by a persistent vitellointestinal artery arising from the superior mesenteric artery.11 connection of this blind-ending structure with the umbilicus through a thin linear track also favours the diagnosis of md. identification of a normal appendix on ct makes the diagnosis of md more confident. meckel’s diverticulitis presents as an irregular thickened enhancing wall of a dilated md with surrounding mesenteric fat inflammation at ct. surrounding abscess, fluid collection and enlarged lymph nodes may be seen. enteroliths can also be seen in the md, causing diverticulitis and obstruction. chronic meckel’s diverticulitis can produce a mucocele-like appearance on ct. enteric duplication cyst can have a similar appearance on ct; however, there is no bowel communication and smooth walls are seen with duplication cysts. the typical antimesenteric location of md differentiates it from enteric diverticulitis. in the case of an inverted meckel, a central core of fat attenuation surrounded by a rim of soft-tissue attenuation differentiate it from lipoma. obstruction occurring secondary to md requires a high degree of suspicion and careful evaluation of the site of transition. the ct angiogram has moderate sensitivity in identifying active extravasation of contrast from an actively bleeding md.8 a tc-99m pertechnetate scan is the modality of choice and most specific diagnostic test for evaluating haemorrhage if there is a suspected md, especially in the paediatric population.7 the tracer accumulates in the ectopic gastric mucosa of the md, which is responsible for the bleeding. the tc-99m–labelled sulfur colloid or red blood cell scintigraphy is sensitive for the localisation of the site of gastrointestinal haemorrhage occurring at a very low rate; however, these methods are not specific for md. conventional angiography is very useful in adults with intermittent gastrointestinal bleeding.11 it can localise the site of active bleeding, confirm the presence of md by demonstrating its blood supply from the vitellointestinal artery arising from a distal ileal branch of the superior mesenteric artery and allow access for therapeutic embolisation. laparoscopic resection of the diverticulum is the treatment of choice for symptomatic md.12 in some complicated conditions, laparotomy and resection may be required. treatment of asymptomatic and incidentally diagnosed md is controversial. whilst some authors advocate prophylactic resection because of the risk of complication later in life, others disagree.13 a published study reported a risk score for prophylactic resection of asymptomatic md, which included risk factors of developing complications such as male gender, age younger than 40, diverticula over 2 cm in diameter, suspected heterotopic tissue, associated meso-diverticular band and wide diverticula with thin walls.14 conclusion although md is the most common gastrointestinal tract anomaly, its preoperative diagnosis is rarely made. a myriad of complications can develop in md, making them symptomatic. clinical symptoms of complicated md are non-specific and mimic other common pathologies of the abdomen causing acute or subacute pain. therefore, a high clinical index of suspicion of md should always be maintained in patients in whom the cause of acute abdomen, obstruction, lower gastro-intestinal (gi) haemorrhage and perforation is not found. computed tomography combined with enteroclysis or enterography is the investigation of choice for the preoperative diagnosis of complicated md. this case series highlights the importance of ct in demonstrating md and its complications. knowledge of the clinical features, characteristic imaging appearance of md and its different complications will aid in its accurate and early preoperative diagnosis. acknowledgements competing interests the authors declare that they have no personal or financial relationship that may have inappropriately influenced the writing of this article. authors’ contributions m.k. and p.s. were the primary authors and have contributed equally to share the first authorship. all other authors (p.k. and r.k.) supervised and contributed equally to the final version of the manuscript. ethical considerations this article followed all ethical standards of research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data supporting the findings of this study are available from the corresponding author, p.s. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the author. references matsagas m. incidence, complications, and management of meckel’s diverticulum. arch surg. 1995;130(2):143. https://doi.org/10.1001/archsurg.1995.01430020033003 kotecha m, bellah r, pena a, jaimes c, mattei p. multimodality imaging manifestations of the meckel diverticulum in children. pediatr radiol. 2011;42(1):95–103. https://doi.org/10.1007/s00247-011-2252-7 sakellaris g, partalis n, blevrakis e, seremeti c. meckel’s diverticulum in pediatric practice on crete (greece): a 10-year review. afr j paediatr surg. 2011;8(3):279. https://doi.org/10.4103/0189-6725.91665 bauer s, retik a. urachal anomalies and related umbilical disorders. urol clin n am. 1978;5(1):195–211. https://doi.org/10.1016/s0094-0143(21)00028-8 schwartz mz. meckel’s diverticulum and other omphalomesenteric duct remnants. in: wyllie r, hyams js, editors. pediatric gastrointestinal disease: pathophysiology, diagnosis, management. philadelphia, pa: saunders, 1999; p. 483–488. soltero m, bill a. the natural history of meckel’s diverticulum and its relation to incidental removal. am j surg. 1976;132(2):168–173. https://doi.org/10.1016/0002-9610(76)90043-x zhang h, yang z, wang y, et al. typical gastric mucosa with ulcer found by endoscopy in meckel’s diverticulum. endoscopy. 2022;54(4):e154–155. https://doi.org/10.1055/a-1471-1857 kotha v, khandelwal a, saboo s, et al. radiologist’s perspective for the meckel’s diverticulum and its complications. br j radiol. 2014;87(1037):20130743. https://doi.org/10.1259/bjr.20130743 thurley p, halliday k, somers j, al-daraji w, ilyas m, broderick n. radiological features of meckel’s diverticulum and its complications. clin radiol. 2009;64(2):109–118. https://doi.org/10.1016/j.crad.2008.07.012 paulsen s, huprich j, fletcher j, et al. ct enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. radiographics. 2006;26(3):641–657. https://doi.org/10.1148/rg.263055162 mitchell a, spencer j, allison d, jackson j. meckel’s diverticulum: angiographic findings in 16 patients. am j roentgenol. 1998;170(5):1329–1333. https://doi.org/10.2214/ajr.170.5.9574611 rivas h, cacchione r, allen j. laparoscopic management of meckel’s diverticulum in adults. surg endosc. 2003;17(4):620–622. https://doi.org/10.1007/s00464-002-8613-4 zani a, eaton s, rees c, pierro a. incidentally detected meckel diverticulum. ann surg. 2008;247(2):276–281. https://doi.org/10.1097/sla.0b013e31815aaaf8 robijn j, sebrechts e, miserez m. management of incidentally found meckel’s diverticulum a new approach: resection based on a risk score. acta chirurgica belgica. 2006;106(4):467–470. https://doi.org/10.1080/00015458.2006.11679933 sajr 837 urachal remnant carcinoma a rare entity v naidu,1 mb chb, fc rad diag (sa); n maharaj,1 mb chb, fc rad diag (sa); a mitha,1 mb chb, fc rad diag (sa); j maharajh,1 mb chb, ff rad (d) (sa), mmedrad (d); b singh,2 mb chb, fcs (sa), md 1 department of radiology, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 2 department of surgery, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: v naidu (vanesha@mweb.co.za) primary malignancy of the urachal remnant is a rare neoplasm that accounts for less than 0.01% of all adult cancers, with an estimated annual incidence of 1:5 million. the tumour carries a grave prognosis that attests to its highly aggressive nature. owing to its extra-peritoneal location, the tumour runs a relatively silent clinical course until late presentation, when most patients display extensive local invasion and metastatic spread. in this report, we highlight a case of primary malignancy of the urachus that on initial clinical evaluation masqueraded as a sister mary joseph’s nodule. characteristic imaging features, however, proved decisive in establishing the diagnosis of a urachal carcinoma. s afr j rad 2013;17(2):63-64. doi:10.7196/sajr.837 a 51-year-old man presented to the surgical department with bleeding from an ulcerated umbilical mass, associated with lower abdominal discomfort and painless haematuria. abdominal examination revealed an irregular umbilical mass with central ulceration. a provisional clinical diagnosis of a sister mary joseph’s (smj) nodule was made. blood results, abdominal x-rays and a barium enema study proved unremarkable in determining a primary lesion. computed tomography (ct) of the chest and abdomen demonstrated an irregular soft-tissue mass extending from the urinary bladder dome to the umbilicus, with localised infiltration of the anterior abdominal wall and cutaneous surface (fig. 1). the tumour displayed punctate calcification and heterogenous enhancement (fig. 2). bilateral pulmonary nodules were indicative of metastatic lung deposits. a voiding cystogram revealed an elongated ‘teardrop’ bladder with constant indentation and irregularity of the vesical dome suggestive of extrinsic compression with possible mural invasion (fig. 3). a radiological diagnosis of a urachal malignancy was made. magnetic resonance imaging (mri) was not undertaken as it was thought to confer little benefit in the setting of advanced disease. following histological confirmation of moderately differentiated invasive adenocarcinoma of the urachal remnant, and administration of chemotherapy, the patient developed cerebral metastasis and died within a year of diagnosis. fig. 1. midline sagittal ct of the lower abdomen and pelvis demonstrates a heterogeneously enhancing soft tissue mass involving the bladder dome extending to the umbilicus with infiltration of the adjacent anterior abdominal wall (arrow). note the elongated ‘teardrop’ bladder (circle). fig. 2. axial ct image through the superior aspect of the pelvis demonstrates a midline mass at the umbilicus (thick arrow) with fine punctate calcification (thin arrow). fig. 3. lateral cystogram view demonstrates irregular nodular indentation of the bladder dome (arrow) and elongated urinary bladder (circle). discussion in early fetal development, the ventral cloaca (the precursor of the fetal bladder) is connected to the allantois via the urachus. the tubular urachus undergoes progressive involution, resulting in an obliterated, fibrous cord by 32 weeks’ gestation. this vestigial remnant, also known as the median umbilical ligament, extends in the midline from the bladder apex to the umbilicus. it is located in the extraperitoneal space of retzius, which is bounded by the parietal peritoneum posteriorly and the tranversalis fascia anteriorly.1 , 2 incomplete regression of the urachus results in 4 recognisable anomalies, which are indicated in fig. 4. fig. 4. four types of congenital urachal anomaly. b = bladder; p = peritoneal cavity; r = rectum; s = symphysis; umb = umbilicus (by courtesy of dr jeong-sik yu [1]). acquired urachal conditions include infection and, rarely, malig­nancy.1 , 2 malignant urachal neoplasms account for less than 0.5% of all bladder malignancies, affecting mainly men of 40 70 years’ age. although the urachus is normally lined by transitional epithelium, almost 90% of urachal tumours are adenocarcinomas, 75% of which are mucin producing.1 the pathophysiology is unclear; it has been proposed that metaplasia of the urachal mucosa into columnar epithelium followed by malignant transformation is the most probable aetiology.3 patients with urachal carcinoma present with haematuria, dysuria, abdominal pain, umbilical mass or bloody, mucoid discharge.4 urachal tumours arise in the juxtavesical portion of the urachus and extend inferiorly into the bladder and superiorly towards the umbilicus.1 owing to its extraperitoneal location, the tumour has a silent clinical course. the late clinical presentation often delays appropriate therapeutic intervention;5 surgery is the mainstay, encompassing en bloc resection of the urachus, umbilicus, surrounding soft tissues, bilateral pelvic lymphadenectomy and partial/radical cystectomy. radiotherapy and chemotherapy have shown no definitive success.6 radiology plays an integral role in the diagnosis and staging of urachal malignancies. ct demonstrates a solitary midline mass located anterosuperiorly to the vesical dome, which may be solid, cystic or mixed. heterogenous enhancement with intratumoral areas of low attenuation may be seen, representing pools of mucin or necrosis. psammomatous calcification is a hallmark feature occuring in 50 70% of lesions.4 stippled, punctate or curvilinear calcification is usually detected on the peripheral aspect of the tumour mass. ct is pivotal in tumour staging, demonstrating local extent of disease, pelvic lymph node involvement and systemic metastastic spread, commonly to lung, liver, brain or bone. perilesional fat stranding is suggestive but not specific for malignancy as infection may display similar features.1 mri confers similar findings to ct with regard to tumour location. the lesion is characteristically t2 hyperintense owing to the presence of intratumoural mucin. mri also helps to determine the intravesical extent of tumour.5 on ultrasound, urachal carcinomas appear as cystic lesions with mixed echogenicity or as a solid mass. areas of echogenicity are reflective of calcification or mucin.4 haematuria is the most common presenting symptom in both urachal carcinoma and primary malignancy of the bladder. considerable overlap in presentation makes it difficult to clinically differentiate between these two entities. it is imperative that optimal distinction be made as urachal carcinoma carries a worse prognosis and therapeutic management differs for both cancers. even at cystoscopy, it is a clinical challenge to distinguish primary bladder tumour arising at the bladder apex from a urachal carcinoma. a tumour in the location of the bladder apex should alert the clinician to the possibility of a urachal malignancy and prompt further investigations. the characteristic imaging features and location of tumour assists accurate differentiation. primary bladder carcinoma has a large intravesical component compared with urachal carcinomas that have a large extra-vesical component and a tendency to spread extraperitoneally into the space of retzius and the umbilical region.5 similarly to our reported case, urachal carcinoma can manifest as a mass in the region of the umbilicus. clinically, it can closely resemble a smj nodule. emphasis must be made that primary urachal carcinoma and a smj nodule are two very different pathologies. the eponymous nodule has been ascribed to umbilical or para-umbilical metastatic nodules that could be the first sign of malignancy from the gastro-intestinal tract, the female genital tract or the genito-urinary tract. the radiological features of the nodule differ considerably from that of a primary urachal tumour, which is crucial in differentiating these umbilical entities. on imaging, a smj nodule appears as a discrete, well-defined mass confined to the subcutaneous tissues or intradermal layers of the anterior abdominal wall at the umbilical/periumbilical region. unlike an urachal tumour, it does not demonstrate contiguity with the bladder dome or tumour extension along the urachal remnant. conclusion owing to its location and presentation, urachal carcinoma can clinically mimic a smj nodule. a sound understanding of the anatomy, a high index of clinical suspicion, and the radiological features of this tumour are crucial to an accurate diagnosis. as urachal carcinoma carries an unfavourable prognosis, early detection and accurate staging is imperative to expedite treatment and improve clinical outcome. 1. yu js, kim kw, lee hj, lee yj, yoon cs, kim mj. urachal remnant diseases: spectrum of ct and us findings. radiographics 2001;21(2):451-461. 1. yu js, kim kw, lee hj, lee yj, yoon cs, kim mj. urachal remnant diseases: spectrum of ct and us findings. radiographics 2001;21(2):451-461. 2. isaacs gs, singh b. the micturating umbilicus. s afr med j 2010;100(1):22-23. 2. isaacs gs, singh b. the micturating umbilicus. s afr med j 2010;100(1):22-23. 3. nimmonrat a, na-chiang mai w, muttarak m. urachal abnormalities: clinical and imaging features. singapore med j 2008; 49(11):930-935. 3. nimmonrat a, na-chiang mai w, muttarak m. urachal abnormalities: clinical and imaging features. singapore med j 2008; 49(11):930-935. 4. mengiardi b, weisner w, stoffel f, et al. case 44: adenocarcinomaof the urachus. radiology 2002;222:744-747. 4. mengiardi b, weisner w, stoffel f, et al. case 44: adenocarcinomaof the urachus. radiology 2002;222:744-747. 5. koster im, cleyndert p, giard rw. best cases from the afip: urachal carcinoma. radiographics 2009; 29(3):939-942. [http//dx.doi.org/10.1148/rg.293085152] 5. koster im, cleyndert p, giard rw. best cases from the afip: urachal carcinoma. radiographics 2009; 29(3):939-942. [http//dx.doi.org/10.1148/rg.293085152] 6. ashley ra, inman ba, sebo tj, et al. urachal carcinoma: clinicopathologic features and long-term outcomes of an aggressive malignancy. cancer 2006;107(4):712-720. [http//dx.doi.org/10.1002/cncr.22060] 6. ashley ra, inman ba, sebo tj, et al. urachal carcinoma: clinicopathologic features and long-term outcomes of an aggressive malignancy. cancer 2006;107(4):712-720. [http//dx.doi.org/10.1002/cncr.22060] abstract background technique normal imaging appearance urethral pathologies bladder pathologies miscellaneous pathologies radiation issues conclusion acknowledgements references about the author(s) shuchi bhatt department of radiology, university college of medical sciences and gtb hospital, delhi, india avinaba banerjee department of radiology, university college of medical sciences and gtb hospital, delhi, india anupama tandon department of radiology, university college of medical sciences and gtb hospital, delhi, india saumya dangwal department of radiology, university college of medical sciences and gtb hospital, delhi, india arun gupta department of surgery, university college of medical sciences and gtb hospital, delhi, india citation bhatt s, banerjee a, tandon a, dangwal s, gupta a. a kaleidoscopic view of male urethral pathologies on 64-slice multidetector computed tomographic urethrography: a novel technique. s afr j rad. 2021;25(1), a1964. https://doi.org/10.4102/sajr.v25i1.1964 pictorial review a kaleidoscopic view of male urethral pathologies on 64-slice multidetector computed tomographic urethrography: a novel technique shuchi bhatt, avinaba banerjee, anupama tandon, saumya dangwal, arun gupta received: 07 aug. 2020; accepted: 29 sep. 2020; published: 29 jan. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract pathologies of the male urethra are mostly obstructive in nature and require imaging to delineate the lesion type, site, extent and associated abnormality of the urinary bladder. contrast urethrography (cu) is the gold standard investigation for urethral assessment but has many limitations. cross-sectional imaging is infrequently used for the evaluation of the urethra but has been gaining importance recently. multidetector computed tomographic urethrography (mdctu) has the capability of evaluating the entire length of a male urethra in a single setting and overcomes many technical and patient limitations of cu. being a novel technique, most radiologists are not familiar with mdctu and the imaging spectrum of various urethral and bladder pathologies. this pictorial review attempts to present the imaging appearance of the normal male urethra and spectrum of pathological findings, with highlights on its advantages over the cu technique. keywords: male urethra; urethrography; computed tomography; stricture; 3d imaging. background contrast urethrography (cu) – retrograde urethrography and micturating cystourethrography – evaluates the anterior and posterior male urethra, respectively, and is the gold standard for urethral assessment.1 cross-sectional techniques – sonourethrography, transrectal voiding sonourethrography and magnetic resonance urethrography – delineate the urethral pathologies but have inherent limitations. sonourethrography has a small field of view, assesses only the anterior urethra and is operator dependent.2 transrectal voiding sonourethrography3 evaluates the posterior urethra with much patient discomfort. magnetic resonance imaging is not frequently used because of its cost and complexity. multidetector computed tomographic urethrography (mdctu) is obtained using a multidetector computed tomographic scanner to acquire fast, thin slices of a distended urethra as the patient voids4 a contrast-filled urinary bladder. better sensitivity to the contrast and post-processing of iso-volumetric axial images to obtain reformatted two-dimensional (2d) and 3d images explicitly demonstrate a plethora of urethral pathologies. comprehensive evaluation of the entire length of the urethral lumen, periurethral, pelvic soft tissues and bones is possible with mdctu.4 the possibility of post-processing in mdctu allows the patient to micturate in a comfortable position with representation of non-distorted urethral anatomy, leading to better patient compliance. therefore, mdctu proves useful in uncooperative patients or in the following clinical situations: when procedural failure is expected because of technical difficulties: unsuccessful catheterisation, inadequate bladder filling and inability to assume an oblique position during micturition because of a pelvic fracture following suboptimal examination on cu resulting in inadequate urethral evaluation: failure to delineate the pathology, especially of the posterior urethra because of obscuration from the pelvic bones; faint contrast density in the urethra and contrast extravasation into periurethral tissues, hindering urethral visualisation if surgical intervention is planned: improved surgical planning can be done in cases such as pelvic trauma with suspected posterior urethral distraction defects; accurate measurement of the stricture length ensures optimal treatment decisions, especially when associated periurethral diseases such as fistula and false passages are present. technique initially, bladder filling is achieved either directly by instillation of contrast (250 millilitres [ml] – 400 ml of 10% diluted ionic or non-ionic contrast media) through a supra-pubic catheter or a foley’s catheter or indirectly by intravenous contrast administration. thin axial computed tomography (ct) sections (e.g. 64 × 0.6 with a 64-slice ct) are obtained as the patient voids into a condom catheter in a comfortable position (supine, prone, oblique or lateral). multiplanar reformatting (mpr), maximum intensity projection (mip) and volume rendering technique (vrt) images are used for vivid representation of the urethra and its pathology. multiplanar reformatting images depict the urethra and periurethral soft tissues, enabling visualisation of normal anatomy and pathology simultaneously. curved mpr images show the entire length of the curved urethra and thus delineates a stricture, if present. thick mip reconstructions clearly depict the capacity, outline of the contrast-filled bladder, vesico-ureteric reflux into the lower ureters as well as the urethral outline and calibre. the volume rendering technique is used to provide a 3d external view of the bladder and urethra. bone removal algorithms help in the optimal visualisation of the posterior urethra. a 64-slice multidetector computed tomography scanner, somatom definition as (m/s siemens ag healthcare sector, germany), was used to acquire all the scans presented in this review. the various types of images present exquisite details of the common urethral pathologies encountered in a male patient. normal imaging appearance the urethra can be visualised on vrt (figure 1a), mip (figure 1b) and curved mpr (figure 1c) images as a contrast-filled tubular structure, arising from the neck of the bladder and opening into the external urethral meatus. the bulbar urethra is the widest portion, having a normal coned appearance at the bulbomembranous junction. the membranous urethra is the narrowest part with near-parallel walls, at the level of the external urethral sphincter (figures 1a, b and c). distally, the bulbar urethra continues as the penile urethra with a normal ‘kink’ or ‘bend’ at the penoscrotal junction, which should not be confused with a stricture (figures 1a, b and c). figure 1: multidetector computed tomographic urethrography (mdctu) of a normal urethra: (a) volume rendering technique image in the sagittal view, (b) maximum intensity projection image in the sagittal view and (c) curved multiplanar reformatted (mpr) image. the urethra is seen arising from the bladder neck as a contrast-filled tubular structure and opening into the external urethral meatus. the membranous urethra is the narrowest part with near-parallel walls, at the level of the external urethral sphincter. the bulbar urethra is the widest portion having a normal coned appearance at the bulbomembranous junction (arrow). the bend or kink at the peno-scrotal junction (arrowhead) is normal since the penis is not stretched on mdctu. the curved mpr image (c) confirms the kink as normal calibre. the vrt and mip images can be represented with bone subtraction for depicting a clear 3d volumetric view (vrt) of the urethra, whilst the mip image shows the contrast-filled urethra and bladder as a composite cu image without the overlapping pelvic bones. this provides a clear understanding of any abnormal morphology of the urethra. urethral pathologies stricture a urethral stricture is the commonest obstructive lesion, appearing as narrowing or abrupt change in calibre of the contrast-filled urethral lumen. a shortor long-segment stricture is less than or more than 2 cm, respectively1 (figures 2 and 3). the definitive treatment is urethroplasty, and surgical planning requires accurate demonstration of the stricture length.5,6,7 the mean stricture length can be more accurately measured on mdctu than on cu.1 greater sensitivity for contrast in an antegrade urethrographic study on mdctu1,4 allows for posterior urethral evaluation as well, unlike in micturating cystourethrography. partial urethral strictures (figures 2–4) and multiple urethral strictures (figure 4) can be delineated on mdctu. a posterior urethral stricture, its length, extent and the associated reflux of contrast into the prostatic glands and seminal vesicles is also well demonstrated on mdctu (figure 5). figure 2: (a) volume rendering technique and (b) curved multiplanar reformatted image. images demonstrate a tight penobulbar stricture (arrow), with a dilated posterior urethra. the opacified distal ureters (arrowheads) are visible as the patient was administered intravenous contrast, and they should not be interpreted as vesico-ureteric reflux (vur). this patient could not be catheterised at retrograde urethrography because of the tight stricture. figure 3: (a) volume rendering technique image (multidetector computed tomographic urethrography [mdctu]) showing a long-segment anterior urethral stricture (arrow) with adequate visualisation of the urinary bladder and posterior urethra (double arrows); both lower ureters (arrowheads) are opacified because of intravenous contrast administration. (b) sagittal maximum intensity projection (mdctu) showing the long-segment anterior urethral stricture (arrow) with adequate visualisation of the urinary bladder and posterior urethra (double arrows). (c) retrograde urethrography image of the same patient indicating the long-segment anterior urethral stricture (arrow), with no passage of contrast into posterior urethra. micturating cystourethrography could not be performed in this patient due to unsuccessful catheterisation. figure 4: (a) volume rendering technique image (multidetector computed tomographic urethrography [mdctu]) showing two strictures, one at the penobulbar junction (arrow) and the other in the bulbar urethra (arrowhead). (b) curved multiplanar reformatted image (mdctu) of the same patient showing the two strictures. (c) retrograde urethrography image of the same patient demonstrating the stricture at the penobulbar junction (arrow), with no distal passage of contrast into the posterior urethra. figure 5: sagittal maximum intensity projection (multidetector computed tomographic urethrography) showing reflux into the prostatic glands and seminal vesicles (arrow) and a urethral stricture of the entire posterior urethra. (arrowhead). urethritis urethral inflammation on mdctu is seen as irregularity in the urethral wall (figure 6). it is often associated with contrast extravasation into the periurethral soft tissues or littre’s glands. cystitis is commonly seen with urethritis and urethral strictures (figure 7). figure 6: (a) retrograde urethrography (rgu) image (right lateral view) showed an outpouching from the prostatic urethra (arrow), likely a urethral diverticulum. anterior urethritis and a false tract (arrowhead) in the bulbar urethra were also noted. (b) axial section (multidetector computed tomographic urethrography [mdctu]) of the same patient showed reflux into both ejaculatory ducts (arrows), which mimicked the appearance of urethral diverticulum on rgu. (c, d) volume rendered technique (vrt) and maximum intensity projection (mip) images, respectively (mdctu), of the same patient also showed reflux into bilateral ejaculatory ducts (arrows), which mimicked the appearance of a urethral diverticulum on rgu. anterior urethritis and a false tract in the bulbar urethra (arrowhead) were also noted on vrt and mip. figure 7: sagittal multiplanar reformatted images: (a) partial stricture (short arrow) at the bulbomembranous junction, with a dilated proximal urethra. small-sized bladder with cystitis (arrow) and posterior urethritic changes (irregularities in urethral wall) (arrowhead) are noted. (b) extravasation into the periurethral soft tissues noted at the level of mid-penile urethra (double arrows). false tract a false tract may result from an attempt to dilate the urethral stricture. false tracts are seen as contrast-filled linear tracts, separate from the main urethra but communicating with the main urethral lumen (figures 6 and 8). multidetector computed tomographic urethrography accurately helps to differentiate it from reflux into any normal anatomical structures (figure 6). figure 8: (a) sagittal maximum intensity projection image showing a partial penobulbar stricture (arrowhead), anterior urethritis, with a false tract in the bulbar urethra (long arrow), cystitis and prostatic calcification (short arrow). (b) volume rendered technique image showing partial penobulbar stricture (arrowhead) and anterior urethritis, with a false tract in the bulbar urethra (long arrow). posterior urethral distraction defects these defects are difficult to evaluate on cu as associated pelvic fractures result in suboptimal radiographs.8 soft tissues are well demonstrated by selective removal of overlapping bones on mdctu, thus enhancing visualisation of the posterior urethra. posterior urethral distraction defects are best seen on 3d-vrt images8 (figures 9 and 10). figure 9: volume rendered technique image (a) before bone removal and (b) after bone removal, showing the posterior urethral distraction defect (arrowhead) at the level of the membranous urethra. the part of the urethra proximal to the defect is dilated. right-sided vesico-ureteric reflux (vur) (arrow) and the fractures of bilateral superior pubic rami and left inferior pubic rami (arrows) are noted. figure 10: (a, b) volume rendered technique images (multidetector computed tomographic urethrography) showing a posterior urethral distraction defect (arrowhead) and a urethral diverticulum (arrow) in different planes. (c) maximum intensity projection image of the same patient showing the posterior urethral distraction defect (arrowhead) and urethral diverticulum (arrow) clearly. urethral diverticulum a urethral diverticulum is uncommon and classified as congenital or acquired or as primary or secondary.9 recurrent infections, instrumentation or surgery, inflammation and trauma of the periurethral glands or ducts result in secondary diverticula formation.10 it appears as a focal contrast-filled outpouching from the urethra (figure 10) and is continuous with the urethral lumen. associated complications such as calculi are also well demonstrated on mdctu. urethral calculi primary urethral stones may occur in the urethra proximal to an obstruction, related to chronic infective strictures and meatal stenosis in young boys.11 an isolated stone is often a migrated stone from the upper urinary tract.12 a calculus is a well-defined, sharply marginated hyperdensity within the urethral lumen. occasionally the high density of contrast may obscure a calculus on cu unless supplemented by a control plain radiograph (figure 11). in mdctu, alteration of the window levels and width enables detection of the calculus within the contrast column. figure 11: (a) retrograde urethrography (rgu) image showing a normal anterior urethra with tapering at the bulbomembranous junction (arrow) and no distal passage of contrast into the posterior urethra. micturating cystourethrography could not be performed because of unsuccessful catheterisation. a confident diagnosis of a stricture could not be made. two calculi (asterisks) were noted, but exact localisation was difficult on rgu. (b) sagittal maximum intensity projection image (multidetector computed tomographic urethrography [mdctu]) demonstrates the membranous urethral stricture, posterior urethral calculus (short arrow), vesical calculus (arrowhead), irregular shaped bladder with contrast leakage into the perivesical tissues (double arrows) and bilateral vesico-ureteric reflux (vur) (long arrow). (c) sagittal multiplanar reformatting image (mdctu) of the same patient showing part of the rectum in close proximity to the dome of the bladder, with loss of intervening fat planes and contrast noted inside the rectum (arrow), suggestive of rectovesical fistula. urethral foreign bodies a urethral foreign body is demonstrated on mdctu due to the inherent high-contrast resolution of ct (figure 12). figure 12: (a–c) a stricture at the bulbomembranous junction (arrow) with multiple smooth, tubular and linear hyperdensities noted in the posterior urethra (arrowheads) in all sections and also in the bladder in (c). altering the window settings in (c), the hyperdensities not visible in (b) become markedly visible in (c). these were confirmed to be broken pieces of catheter with encrustations at surgery. bladder pathologies cystitis bladder outlet obstruction and bladder calculus are common causes of secondary cystitis and are mostly seen as generalised and uniform bladder wall thickening. extravasation of contrast may be identified from the inflamed bladder wall. chronic cystitis appears as a small capacity bladder (figure 7). other bladder pathologies observed are sacculations, diverticula and calculi. a focal outpouching within the bladder wall is a sacculation, and when it extends outside the wall, it is a diverticulum (figure 13). associated urinary stasis may lead to calculus formation within the diverticulum (figure 13). figure 13: (a) volume rendered technique, (b) maximum intensity projection and (c) axial multiplanar reformatted (mpr) images of multidetector computed tomographic urethrography. all the images are of the same patient, showing multiple bladder diverticula (arrows). a calculus (asterisks) is noted within the diverticulum on coronal and axial mpr images. bladder rupture bladder rupture is seen in the context of significant trauma13,14 and may be of two types: extra-peritoneal (80% – 90%) is the result of pelvic fractures or penetrating trauma. multidetector computed tomographic urethrography reveals a variable path of extravasated contrast material. intra-peritoneal (10% – 20%) typically results from a direct blow to a distended bladder and demonstrates intra-peritoneal contrast material around the bowel loops, between mesenteric folds and in the paracolic gutters (figure 14). figure 14: (a, b) multidetector computed tomography coronal and sagittal reformatted images indicate rupture of the urinary bladder (arrow) with contrast material leaking into the peritoneal cavity, surrounding the bowel loops, along the paracolic gutters and reaching up to the subphrenic space (asterisks). the patient also had localised urethral injury (not shown in this image), for which he underwent mdctu. vesical fistula a fistulous communication between the bladder and an adjacent structure, such as the rectum (rectovesical), colon (colovesical) or small bowel (enterovesical), is better seen on mdctu as an irregular contrast-filled tract from the bladder to the adjacent organ. sometimes, only a nipple-like projection outside the bladder lumen may suggest the presence of a fistulous tract (figure 11c). miscellaneous pathologies additional findings in the periurethral, vesical and pelvic soft tissues and bones may also be observed on mdctu, including vesico-ureteric reflux (figure 15), prostatomegaly (figure 16), prostatic and soft-tissue calcifications, bone abnormalities and hydrocele. figure 15: vesico-ureteric reflux can be seen on both sides (arrows) in a patient with a posterior urethral distraction defect. contrast in the bladder was filled through the supra-pubic catheter seen in situ (star). retrograde filling revealed a normal anterior urethra. figure 16: multidetector computed tomographic urethrography: sagittal multiplanar reformatted image showing prostatomegaly (star), with the median lobe seen bulging into the bladder base and compressing the posterior urethra, creating a false impression of a posterior urethral stricture. radiation issues the effective radiation dose on mdctu varies between 5 millisievert (msv) and 6 msv,14 whereas in cu, it is less than 1 msv. radiation exposure can be further reduced on mdctu by using a low-dose protocol, single acquisition, ma tube modulation and iterative reconstruction techniques. although the radiation dose is higher with mdctu, radiation exposure to the operator can be avoided, unlike in cu. conclusion this pictorial assay apprises radiologists and clinicians about the novel technique of mdctu, its advantages over cu and appropriate patient selection to justify the increased radiation exposure, a shortcoming associated with it. multidetector computed tomographic urethrography is capable of comprehensive evaluation of both the anterior and posterior male urethra, periurethral tissues, urinary bladder, pelvic soft tissues and bones in a single scan, thus rendering it an effective diagnostic tool. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. ethical consideration due institutional ethical clearance was obtained (iec-hr 126) and written informed consent was taken from all patients. the ethical standards of the declaration of helsinki were followed. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data was created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references zhang xm, hu wl, he hx, et al. diagnosis of male posterior urethral stricture: comparison of 64-mdct urethrography vs. standard urethrography. abdom imaging. 2011;36(6):771–775. https://doi.org/10.1007/s00261-010-9676-7 chou cp, huang js, wu mt, et al. ct voiding urethrography and virtual urethroscopy: preliminary study with 16-mdct. am j roentgenol. 2005;184(6):1882–1888. https://doi.org/10.2214/ajr.184.6.01841882 mandal sk, bhattacharyya sk, mandal a, deoghuria d, mandal pk. sonourethrography in the evaluation of anterior urethral stricture: correlation with retrograde urethrography in male. int j pharm biomed res. 2012;3(2):77–80. https://doi.org/10.1002/jcu.1870210404 mihmanli i, kantarci f, gulsen f, kadioglu a. transrectal voiding sonourethrography for diagnosis of a prostatic urethral calculus. j ultrasound med. 2006;25(11):1455–1457. https://doi.org/10.7863/jum.2006.25.11.1455 heyns cf, steenkamp jw, de kock mls, whitaker p. treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? j urol. 1998;160(2):356–368. https://doi.org/10.1016/s0022-5347(01)62894-5 pansadoro v, emiliozzi p. internal urethrotomy in the management of anterior urethral strictures: long-term followup. j urol. 1996;156(1):73–75. https://doi.org/10.1016/s0022-5347(01)65942-1 greenwell tj, castle c, andrich de, macdonald jt, nicol dl, mundy ar. repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. j urol. 2004;172(1):275–277. https://doi.org/10.1097/01.ju.0000132156.76403.8f el-kassaby aw, osman t, abdel-aal a, sadek m, nayef n. dynamic three-dimensional spiral computed tomographic cysto-urethrography: a novel technique for evaluating post-traumatic posterior urethral defects. bju int. 2003;92(9):993–996. https://doi.org/10.1111/j.1464-410x.2004.4949a.x lee jws, fynes mm. female urethral diverticula. best pract res clin obstet gynaecol. 2005;19(6):875–993. https://doi.org/10.1016/j.bpobgyn.2005.08.008 venkatanarasimha n, freeman sj, dubbins pa. posterior urethral diverticulum on transrectal sonography. j ultrasound med. 2009;28(6):827–829. https://doi.org/10.7863/jum.2009.28.6.827 frick j, kunit g. operations on previously operated patients with hypospadias. prog pediatr surg. 1984;17:57–63. https://doi.org/10.1016/s0022-3468(85)80353-5 vashishtha s, sureka sk, agarwal s, et al. urethral stricture and stone: their coexistence and management. urol j. 2014;11(1):1204–1210. https://doi.org/10.22037/uj.v11i1.1645 vaccaro jp, brody jm. ct cystography in the evaluation of major bladder trauma. radiographics. 2000;20(5):1373–1381. https://doi.org/10.1148/radiographics.20.5.g00se111373 avery ll, scheinfeld mh. imaging of male pelvic trauma. radiol clin north am. 2012;50(6):1201–1217. https://doi.org/10.1016/j.rcl.2012.08.010 sajr 756 multi-detector computer tomography venography (mdctv) as a diagnostic tool in the management of patients with atypical, complicated and/or recurrent varicose veins a lawson, p rischbieter, j owen, t peedikayil, s beningfield   department of radiology, groote schuur hospital, cape town a lawson, mb bch, fc rad diag (sa), mmed rad p rischbieter, mb bch j owen, mb bch t peedikayil, mb bch s beningfield, mb chb, ffrad (d) sa   corresponding author: a lawson (drajlawson@gmail.com) aim. to evaluate the role of multi-detector computer tomography venography (mdctv), compared with conventional venography, as a diagnostic tool in the management of patients with atypical, complicated and/or recurrent varicose veins. materials and methods. retrospective review of 21 patients who had undergone both mdctv and conventional transfemoral or transpopliteal venography between january 2008 and april 2011 for the management of recurrent varicose veins and/or chronic venous ulcers. mdctv was performed using a 16-slice ct scanner. spiral acquisition was commenced 180 seconds after intravenous injection of 150 ml of 350 mmol/l iodinated contrast medium. a reconstruction interval of 1.5 mm was used. conventional venography was performed by the resident vascular surgeon and was followed by stenting or coiling where appropriate. results. mdctv and venography were compared in 21 patients (6 male, 15 female; average age 55 years, range 33 78 years); 8 also underwent endovascular iliac vein stenting. the area under the receiver operator curve (roc) for percentage iliac vein stenosis determined on mdctv versus venography was 0.75. four (19%) false-positive iliac vein stenoses were reported on mdctv. ten patients underwent gonadal vein coil embolisation. gonadal vein size >5.2 mm (range 1 11 mm) on mdctv predicted significant venographic reflux requiring coil embolisation. three (30%) patients who underwent embolisation did not have gonadal vein enlargement on mdctv. conclusion. mdctv plays an important adjunctive role in the diagnostic workup of patients with complex venous disease. the findings at mdctv correlate well with conventional venography. s afr j rad 2012;16(4):136-138. doi:10.7196/sajr.756 varicose veins is one of the most common pathologies among people around the world; since the introduction of less-invasive treatments such as laser ablation and radiofrequency thermal ablation, interest in this condition has increased.1 routine surgical intervention remains the principal definitive management for large, unsightly varicose veins. a trendelenburg strip is performed, entailing ligation of the common femoral vein at the saphenofemoral junction and removal of the native vein in its entirety from the leg. a sub-group of patients develop recurrent varicose veins post surgery, or have atypical or complicated varicose veins. it is this group of patients who might benefit from multi-modality imaging to address the underlying causative lesion not addressed at the primary intervention or presentation. we evaluated the role of multi-detector computer tomography venography (mdctv) as a diagnostic tool in the management of this sub-group of patients, and compared it with conventional venography, which is considered the gold standard of venous imaging. methods and materials we performed a retrospective review of 21 patients who had undergone both mdctv and conventional transfemoral, transjugular or transpopliteal venography between january 2008 and april 2011 for the management of recurrent varicose veins and/or chronic venous ulcers. the study was approved by our institutional review board. mdctv was performed using a 16-slice ct scanner. spiral acquisition was commenced 180 seconds after intravenous injection of 150 ml of 350 mmol/l iodinated contrast medium. a reconstruction interval of 1.5 mm was used. subset data reconstruction was performed in the curved coronal plane with particular reference to the course of the common and external iliac veins through the pelvis. axial venous calibre measurements were performed and stenotic segments were measured on the reconstructed images. readers were blinded to the findings from the conventional venography datasets. secondary imaging outcomes were to identify anatomical anomalies, pelvic masses or compression of venous structures by native vessels. conventional venography was performed by the resident vascular surgeon. after a diagnostic flush, endovascular stenting (figs 1 and 2) or coiling was performed if a significant stenosis was verified or significant venous reflux was demonstrated. fig. 1. selected frame of a subtracted venogram with self-expanding metallic stent across the left common iliac vein stenosis pre-deployment. fig. 2. frame grab during deployment and balloon dilatation of the stent in fig. 1. results mdctv and venography were compared in 21 patients (6 male, 15 female; average age 55 years, range 33 78 years); 8 also underwent endovascular iliac vein stenting. the area under the receiver operator curve (roc) for percentage iliac vein stenosis determined on mdctv versus venography was 0.75. four false-positive (19%) iliac vein stenoses were reported on mdctv. aetiologically, these stenoses were attributed to post-phlebitic changes in 6 patients, may-thurner syndrome in 1 patient, and were idiopathic in 1 patient (fig. 3). ten patients underwent gonadal vein coil embolisation. gonadal vein size >5.2 mm (range 1 11 mm) on mdctv predicted significant venographic reflux requiring coil embolisation. three (30%) patients who underwent embolisation did not have gonadal vein enlargement on mdctv. fig. 3. aetiology of iliac vein stenosis. conclusion currently, limited data exist on the use of mdctv and its role in complex varicose venous disease. we present a small cohort of cases where mdctv findings correlate well with conventional venographic findings. our study focuses on a subset of patients with complex venous disease where the underlying causative lesions are above the level of the inguinal canal and involve mainly the common/external iliac veins or gonadal veins. the mainstay of imaging was to reveal pathology that could be managed endovascularly either by iliac vein stenting2 , 3 or gonadal vein coil embolisation. preoperative evaluation of varicose veins must reveal the primary cause of varicosity, secondary reflux, and the distribution of varicosity, including perforating veins.1 handheld doppler and duplex sonography have become the modern non-invasive gold standard.4 sonography can evaluate haemodynamic information and anatomical data; its main limitation is the lack of adequate visualisation above the inguinal ligament. mdctv provides excellent information on the deep venous system above and below the inguinal canal. multiplanar reformations and volume rendering provide both an assessment of venous compression and overall varicosity distribution.5 the major limitation of mdctv is the lack of dynamic venous flow information, limiting the interrogation of points of reflux. furthermore, mdctv requires contrast medium administration and ionising radiation (1.6 3.9 msv1 ) and no insight to venous valvular function can be gained. a clinical scoring system documenting the severity of venous disease is described by eklöf et al.6 (fig. 4). in our study, patients with clinical stage c6 venous disease were more likely to require iliac stenting. it was in this group that an almost 20% false-positive rate was recorded at mdctv. in light of the clinical severity score, these patients may still benefit from diagnostic conventional venography with the adjunctive use of endovascular ultrasound to delineate potential stenoses missed at both conventional catheter venography and mdctv. patients with c4 disease were more likely to require gonadal vein coiling. selecting the latter group of patients purely on mdctv findings is not recommended. fig. 4. clinical disease severity index. varicose venous disease is a complex entity; careful patient selection and intervention is required for successful and curative management. this study indicates that, although mdctv contributes to the multi-modality approach in venous disease, more extensive work needs to be done before it can play a larger role in definitive interventional decision making.   1. lee w, chung jw, yin yh, et al. three-dimensional ct venography of varicose veins of the lower extremity: image quality and comparison with doppler sonography. am j roentgenol 2008;191(4):1186-1191. 1. lee w, chung jw, yin yh, et al. three-dimensional ct venography of varicose veins of the lower extremity: image quality and comparison with doppler sonography. am j roentgenol 2008;191(4):1186-1191. 2. titus jm, moise ma, bena j, lyden sp, clair dg. iliofemoral stenting for venous occlusive disease. j vasc surg 2011;53(3):706-712. 2. titus jm, moise ma, bena j, lyden sp, clair dg. iliofemoral stenting for venous occlusive disease. j vasc surg 2011;53(3):706-712. 3. rosales a, sandbæk g, jørgensen jj. stenting for chronic post-thrombotic vena cava and iliofemoral venous occlusions: mid-term patency and clinical outcome. eur j vasc endovasc surg 2009;40(2):234-240. 3. rosales a, sandbæk g, jørgensen jj. stenting for chronic post-thrombotic vena cava and iliofemoral venous occlusions: mid-term patency and clinical outcome. eur j vasc endovasc surg 2009;40(2):234-240. 4. meissner mh, eklof b, smith pc, et al. secondary chronic venous disorders. j vasc surg 2007;46(6, supplement 1):s68-s83. 4. meissner mh, eklof b, smith pc, et al. secondary chronic venous disorders. j vasc surg 2007;46(6, supplement 1):s68-s83. 5. min s-k, kim s-y, park yj, et al. role of three-dimensional computed tomography venography as a powerful navigator for varicose vein surgery. j vasc surg 2010;51(4):893-899. 5. min s-k, kim s-y, park yj, et al. role of three-dimensional computed tomography venography as a powerful navigator for varicose vein surgery. j vasc surg 2010;51(4):893-899. 6. eklöf b, rutherford rb, bergan jj, et al. revision of the ceap classification for chronic venous disorders: consensus statement. j vasc surg 2004;40(6):1248-1252. 6. eklöf b, rutherford rb, bergan jj, et al. revision of the ceap classification for chronic venous disorders: consensus statement. j vasc surg 2004;40(6):1248-1252. abstract introduction method statistical analysis results discussion study limitations conclusion acknowledgements references about the author(s) sereesh moodley department of radiology, school of clinical medicine, grey’s hospital, university of kwazulu-natal, pietermaritzburg, south africa tanusha sewchuran department of radiology, school of clinical medicine, grey’s hospital, university of kwazulu-natal, pietermaritzburg, south africa citation moodley s, sewchuran t. chest radiography evaluation in patients admitted with confirmed covid-19 infection, in a resource limited south african isolation hospital. s afr j rad. 2022;26(1), a2262. https://doi.org/10.4102/sajr.v26i1.2262 original research chest radiography evaluation in patients admitted with confirmed covid-19 infection, in a resource limited south african isolation hospital sereesh moodley, tanusha sewchuran received: 01 aug. 2021; accepted: 19 oct. 2021; published: 17 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and the subsequent global outbreak (coronavirus disease 2019 [covid-19]) was declared a public health emergency in january 2020. recent radiologic literature regarding covid-19 has primarily focused on computed tomography (ct) chest findings, with chest radiography lacking in comparison. objectives: to describe the demographic profile of adult patients with covid-19 pneumonia requiring hospital admission. to describe and quantify the imaging spectrum on chest radiography using a severity index, and to correlate the severity of disease with prognosis. method: retrospective review of chest radiographs and laboratory records in patients admitted to a south african tertiary hospital with confirmed covid-19 infection. the chest x-rays were systematically reviewed for several radiographic features, which were then quantified using the brixia scoring system, and correlated to the patient’s outcome. results: a total of 175 patients (mean age: 53.34 years) admitted with covid-19 were included. ground glass opacification (98.9%), consolidation (86.3%), and pleural effusion (29.1%) was commonly found. involvement of bilateral lung fields (96.6%) with no zonal predominance (61.7%), was most prevalent. correlation between the brixia score and outcome was found between severe disease and death (odds ratio [or]: 12.86; 95% confidence interval [ci]: 1.58–104.61). many patients had unknown tb (71.4%) and hiv (72.6%) statuses. conclusion: in this study population, ground glass opacification, consolidation, and pleural effusions, with bilateral lung involvement and no zonal predominance were the most prevalent findings in proven covid-19 infection. quantification using the brixia scoring system may assist with timeous assessment of disease severity in covid-19 positive patients, as an overall predicator of clinical outcome. keywords: chest radiography; chest x-ray; sars-cov-2; covid-19; chest x-ray scoring system; brixia scoring system; resource limited setting; south africa. introduction severe acute respiratory syndrome coronavirus 2 (sars-cov-2) emerged in wuhan, hubei province, china in december 2019.1 coronaviruses can cause multi-system infections in various animals; and mainly affects the respiratory tract in humans.1 the resultant pneumonia resembles sars and middle east respiratory syndrome (mers). the genome of sars-cov-2, however, differs from sars and mers, and therefore this virus may lead to unconventional clinical presentations, with differing imaging findings.2 the subsequent global outbreak (coronavirus disease 2019 [covid-19]) was declared a public health emergency internationally by the world health organization (who) on 30 january 2020.3 as of 03 december 2021, south africa’s total confirmed cases were 3 004 203 with 89 944 deaths, according to statistics from the national institute for communicable diseases (nicd). whilst a portion of patients infected with covid-19 may be largely asymptomatic, the predominant clinical manifestation of covid-19 is a lower respiratory tract infection which is evident in 17% – 29% of infected patients. the mortality rate is estimated at approximately 2.3%.4 it is suggested that covid-19 is more likely to infect older adult males, especially when chronic comorbidities and weakened immunity are present. weakened immunity further predisposes affected patients to co-infections with bacteria and fungi.1 covid-19 can be specifically detected in respiratory secretions or plasma samples by reverse transcription polymerase chain reaction (rt-pcr).5 the rt-pcr testing is, however, limited as a diagnostic tool; when the viral load is low then detection rates are also low, thus leading to false negative results.6 many studies have proposed chest ct as a routine imaging tool for covid-19 pneumonia diagnosis, as it is quick and relatively easy to perform.7 the imaging findings of pneumonia caused by covid-19 may, however, present its own diagnostic dilemma because of a potential overlap with other viral pneumonias, especially pneumocystis jirovecii pneumonia (pjp) in our immunosuppressed population. despite this, covid-19 ct chest imaging has been proven beneficial particularly in symptomatic patients with negative rt-pcr tests, in patients with low viral loads, as well as in patients in the early stages of infection.2 furthermore, rt-pcr only permits the diagnosis of a positive result, and as such the severity of covid-19 disease as well as disease progression cannot be ascertained. this is where ct imaging has been shown to be beneficial and particularly assistive with disease progression.6 in most rt-pcr positive presumed symptomatic patients, ct examinations depict a typical pattern with a sensitivity of 97.0%.8 typical ct features include ground glass opacities which may be accompanied by peripheral consolidation noted in proximity to visceral pleural surfaces, including fissures and usually with a multifocal bilateral distribution. subpleural sparing can be visualised.9 one study demonstrated 30.2% of patients with single lobe involvement, whilst 44.4% of patients had all lobes involved.10 consolidation, air bronchograms, ‘white lung’ appearance, and pleural effusions were more frequently seen in patients with severe disease. in these patients, a ‘crazy-paving’ pattern, linear densities, bronchiectasis, nodules, and tree-in-bud opacities were also more frequent.2 several standardised reporting lexicons have been developed in an attempt to efficiently organise and grade ct imaging findings. examples of these grading systems are co-rads and covid-rads.8,9 high incidences of thrombotic events (especially pulmonary embolism) have been found in intensive care unit (icu) patients, with the european society of cardiology (esc) recommending that ct pulmonary angiography (ctpa) be performed to exclude the presence of a pulmonary embolus when unenhanced ct findings cannot explain the severity of respiratory failure.11 recent radiologic literature regarding covid-19 has primarily been focused on ct chest findings, with information pertaining to chest radiography lacking in comparison. chest radiography, especially when performed on portable machines, is considered to be a viable alternative as they are thought to pose a lower risk of cross infection and can be performed at the bedside. chest radiography is currently deemed to be a useful first line triage tool for covid-19, as well as an adjuvant to ct chest imaging, with a 69% sensitivity rate for chest x-rays (cxrs) in covid-19, as reported by wong et al.12 the most common feature of covid-19 pneumonia detected on chest radiography is consolidation, with ground glass opacities being a close second. patterns of peripheral, lower zone and bilateral distributions were predominant. pleural effusions were seldom seen. proposed severity scores peaked at 10–12 days from the onset of symptoms.12 the grading of cxrs can be done using a radiographic severity index, the brixia score, which is a semi-quantitative assessment of lung disease in covid-19 infection that ranks pulmonary cxr findings using an 18-point severity score, according to the characteristics and extent of lung abnormalities.13,14 this has proven to be a beneficial prognostic indicator in some european countries.14 studies focusing on chest radiography findings of covid-19 pneumonia provided little information regarding the presence of underlying pulmonary sequelae of other common infectious diseases such as tuberculosis (tb) and hiv. features of superimposed infection (generally pleural effusions and lymphadenopathy) have also been described.4 this study aims to retrospectively analyse and quantify chest radiograph findings of confirmed covid-19 patients admitted to a south african isolation hospital, where concomitant pulmonary manifestations of infectious diseases such and hiv and tb may pose an additional diagnostic dilemma. the objectives of the study were: to describe the demographic profile of covid-19 patients requiring admission during the first and second waves of the pandemic, dated from march 2020 to december 2020; to describe and quantify the imaging spectrum seen on chest radiography in admitted covid-19 patients with the aid of a data collection tool; to evaluate for the presence of other co-morbidities, specifically hiv and tb on chest radiography; and to correlate the severity of disease, as determined by the brixia scoring system, to the patients’ prognosis. method study design and participants this was a single-centre, retrospective study conducted at a tertiary level south african isolation hospital. a review of chest radiographs as well as patient records was performed on patients with confirmed covid-19 infection, who required hospital admission at grey’s hospital, pietermaritzburg between march 2020 and december 2020. all adult inpatients (> 18 years) admitted at grey’s hospital, pietermaritzburg with a positive rt-pcr covid-19 nasopharyngeal swab who received cxrs were included in the study. data collection all covid-19 positive patients admitted during the stipulated time, who underwent cxrs were recorded on a database using the picture archiving and communications system (pacs). epidemiological data was collected from this database, which included age and sex. confirmation of positive covid-19 infection, as well as associated medical co-morbidities, such as the hiv status and tb infection, was performed using the national health and laboratory services (nhls) system. outcomes data was collected from the covid-19 mortality database and correlated to discharge data from the hospital isolation wards. all data was then recorded on a standardised data collection form created by the authors. digital chest radiographs were acquired by a portable x-ray unit (axim roller 30 portable unit) in various isolation wards in the hospital. the cxrs were evaluated by a consultant radiologist with specific thoracic imaging sub-specialty training and 10 years of experience, and a radiology registrar with two years of experience, with the aid of a data collection sheet. the reporting radiologists were blinded to the clinical (hiv and tb statuses) and prognostic (de-isolated or demised) data of the study population. where there was disagreement between the reporting radiologists, a mutual consensus was reached and this value was used for analysis. chest x-rays were reviewed for several radiographic features, including ground-glass opacities, consolidation, bronchiectasis, cavitation, lymphadenopathy and masses/nodules as defined by the fleischner society glossary of terms.15 the distribution of lung changes was categorised into: upper zone, lower zone, or no zonal predominance; unilateral or bilateral lung involvement; as well as the number of pulmonary lobes involved. the presence of pleural effusions, volume loss, and probability of tb (e.g., cavities), was also documented. these findings were then quantified using the brixia score.13,14 the brixia scoring system involves two steps for image analysis. the first step involves dividing the lung on a frontal cxr into six zones namely upper zones (a and d), middle zones (b and e), and lower zones (c and f) (see figure 1).13 the second step involves assigning a score (from 0 to 3) based on the lung abnormalities.13 a score of 0 indicates no lung abnormalities; a score of 1 indicates interstitial infiltrates; a score of 2 indicates interstitial and alveolar infiltrates with interstitial predominance; and a score of 3 indicates interstitial and alveolar infiltrates with alveolar predominance.13 the scores are then tallied and a final score (out of 18) is determined.13 finally, a comparison with previous baseline cxrs as well as repeat cxrs, if available on the pacs, was also assessed. the patient’s cxr with the highest brixia score was used for final analysis and the date of this x-ray was recorded for correlation with mortality data. figure 1: division of lungs into six zones on frontal chest radiograph. statistical analysis data were analysed using stata version 15 statistical software. for continuous variables like age, the mean, median, and range were calculated. the results were recorded as frequencies and percentages for categorical variables. with regards to comparing the four categories of the brixia score, the categories are on an ordinal scale and overall comparisons were performed using kruskal-wallis, followed by dunn tests for pairwise comparisons. age was categorised into three age groups and chisquare tests were used to compare outcome. sex comparisons were made using chi-square tests. statistical significance was set at p < 0.05. the odds ratio (or) and 95% confidence interval (ci) limits were estimated using univariate logistic regression in stata version 15. inter-observer agreement for radiographical features, including the brixia score, were evaluated and expressed with the kappa statistic. the agreement was classified as follows: perfect, kappa = 0.81–1.0; substantial, kappa = 0.61–0.80; moderate, kappa = 0.41–0.60; fair, kappa = 0.21–0.40; slight, kappa = 0–0.21; no agreement, kappa < 0. the median number of days between the patient’s most severe x-ray and death was determined and interquartile ranges (iqr) were calculated. ethical considerations ethical approval was obtained from the biomedical research ethics committee of the university of kwazulu-natal (brec/00002590/2021) and site approval was obtained from the hospital. informed consent was not required for this retrospective, descriptive study. results demographics during the study period a total of 308 portable cxrs were performed on 197 inpatients with confirmed covid-19 infection. four patients were duplicates, and 18 patients under the age of 18 were excluded, resulting in a final study population of 175 patients for the analysis. of the total number of cxrs performed, 111 x-rays were repeat x-rays, and despite not being included in the final study population, were evaluated for disease progression or regression. the mean age was 53.34 years, with an age range between 19 years and 98 years. the study population was subdivided into three age categories: 19–30 years; 31–60 years; and > 61 years. twelve patients (6.9%) were in the 19–30 age group, with 106 patients (60.6%) in the 31–60 age group and 57 patients (32.6%) in the > 60 age group. eighty-three patients (47.4%) were male, and 92 patients (52.6%) were female. the hiv and tb statuses of the included participants is presented in figure 2. according to the nhls database, hiv infection was present in 17.70%, absent in 9.70% and unknown in 72.6%. tb infection was positive in 0.65%, negative in 28.00% and unknown in 71.40%. figure 2: graphical representation of patients with underlying human immunodeficiency virus and tuberculosis. radiological findings ground glass opacification (98.9%) was the most common cxr finding, followed by consolidation (86.3%), and pleural effusion (29.1%) (see table 1). involvement of bilateral lung fields (96.6%), no zonal predominance (61.7%) and 2–5 lobar involvement (99.4%) were the most frequent lung distribution patterns (see table 1). baseline cxrs were available in only 25 patients (14.3%) and 21 (84%) had a normal baseline x-ray. multiple x-rays were performed on 97 patients (55.4%), and 56 of these (57.7%) demonstrated radiological disease progression. while 41 patients (42.3%) demonstrated disease regression. table 1: summary of chest x-ray findings and patterns of disease. quantification of the cxr findings using the brixia score revealed moderate disease most frequently with a score between 13 and 16 (33.7%), followed by severe disease scoring between 16 and 18 (29.7%), less severe disease scoring between 7 and 12 (27.4%), and lastly mild disease scoring between 0 and 6 (9.1%). the kappa statistic for inter-observer agreement was evaluated as substantial (kappa = 0.64) for grading of cxr findings using the brixia score. disease outcomes of the final study population of 175, 118 patients (67.4%) were de-isolated into general wards or directly discharged from isolation, with the remaining 57 patients (32.6%) noted to have demised. comparison of this outcomes data with the patient’s cxr brixia score is summarised in table 2. table 2: summary of outcomes data and severity index using the brixia scoring system. a pairwise comparison was performed when evaluating the brixia score with outcome (table 2). using the lowest brixia score 0–6 as a comparison reference, the percentage demised at 7–12 was an 8.3% increase. the or was 2.56 indicating a relative increase in the odds of death, but this was not statistically significant (p = 0.40). score group 13–16, and 16–18 demonstrated a statistically significant (p = 0.02 respectively) percentage increase (42.4% and 46.2% respectively) in the number of patients who demised. the number of days between death and the patient’s most severe cxr is outlined in figure 3/table 3. the median days between x-ray and death was lowest (1 day) in the brixia score 13–16 group, followed by the 16–18 group (2 days), the 7–12 group (3 days), and the 0–6 group (5 days). however, these values were not deemed statistically significant with a p-value of 0.13. figure 3: graphical representation of days to death and brixia score. table 3: number of days between x-ray and demise. discussion the covid-19 pandemic is an ongoing international public health emergency,3 with many countries now entrenched in the third and fourth waves of the disease. there are 3 004 203 confirmed cases, with 89 944 deaths recorded and 26 263 590 vaccine doses administered in south africa as of 03 december 2021 (nicd). chest imaging, particularly using computed tomography has proven beneficial in patients with early infection.2 chest radiography has primarily been seen as a triage and adjuvant imaging tool.12 this study analysed the chest radiographic findings of confirmed covid-19 patients admitted to a resource limited south african isolation hospital, where concomitant pulmonary manifestations of hiv and tb may pose an additional diagnostic dilemma. unfortunately, the vast majority of our patient population had unknown laboratory confirmation of hiv and tb, which may be attributed to a number of factors, such as avoiding health facilities for voluntary counselling and testing (vct) for hiv because of covid-19, low confirmed tb as a result of initiation onto tb treatment on the basis of clinical tb symptoms and a suggestive cxr, and/or lastly confirmation of tb and hiv at other base hospitals. the most frequent cxr findings of covid-19 pneumonia were ground glass opacification, followed by consolidation, and pleural effusion. whilst the prevalence of ground glass opacification and consolidation are consistent with the literature, the frequency of pleural effusions (see figure 4) is considered unusual; with zhang et al. reporting pleural effusions mainly in cases of severe infection.2,12 the majority of the pleural effusions assessed were small in size, and were either considered reactive in aetiology or an indication of superadded infection. cavitation (see figure 5), lymphadenopathy, and bronchiectasis, which are findings that may be present in tb, were inconsistently reported in this study. this correlates to the low prevalence of confirmed tb as noted from the laboratory data in our study population and is thought to be a consequence of our relatively small sample size. figure 4: a 36-year-old female admitted to an isolation ward with covid-19 pneumonia. portable antero-posterior (ap) chest radiograph demonstrates blunting of the left costophrenic angle suggesting a pleural effusion as well as bilateral air space opacities. brixia score: 13. figure 5: a 27-year-old male admitted to an isolation ward with covid-19 pneumonia. portable chest radiograph shows fibrosis and cavitation in the apical segment of the right upper lobe. further bilateral right lung and left lingular air space opacities are noted. brixia score: 15. in line with other available literature, the predominant disease distribution was a bilateral lung pattern with 2–5 lobes involved. whilst other studies demonstrated lower zone predominance12; a diffuse disease process with no zonal predominance was most frequently seen (see figure 6). a higher frequency of disease progression in the patients with multiple imaging (see figure 7), was also noted in the studied sample. this may be attributed to the fact that the study population comprised exclusively admitted inpatients in which increased disease severity or rapid symptom progression was thought to necessitate admission. figure 6: a 69-year-old female admitted to an isolation ward with covid-19 pneumonia. portable chest radiograph demonstrates air space opacification with no zonal predominance. brixia score: 18. figure 7: chest radiographs from (a) 03 october 2013, (b) 27 june 2020, (c) 03 july 2020 and (d) 11 july 2020): 2013 normal baseline radiograph. serial images demonstrate progressive unilateral left lower lobe and lingular air space opacification, consolidation and volume loss. focal right upper lobe consolidation with ‘air bronchograms’. substantial inter-observer agreement was demonstrated when applying the brixia cxr scoring system to the cxr findings. this is encouraging because of the large gap in experience levels between the observers and suggests that the brixia score is an easily applicable quantification tool which may prove beneficial to clinicians without extensive radiological experience, especially where chest radiographs are more readily accessible than ct scans. the study by borghesi et al.14 examined the relationship between severity of lung disease, using the brixia score and demographics like age and sex in a european population. whilst limited literature is available in our unique south african setting, a study by du bruyn et al.16 demonstrated that co-morbidities like tb co-exist with covid-19 infection, and likely exacerbate each other. whilst their study focused predominantly on clinical presentation and laboratory markers, the current study further examined the relationship between demographics, cxr findings with a severity scoring system, and outcome, in covid-19 infection. when comparing age and outcome, a borderline association was evident, with younger patients (between 19 and 30 years) more likely to recover, and older patients (> 60 years) at greater risk of death in comparison to their respective counterparts. a relatively even distribution of outcomes was noted between males and females and there was no significant association between sex and outcome. in the 16–18 brixia score range, the percentage of patients who demised as a subgroup of this group was 46.2%, more than seven times the percentage of the 0–6 group and was found to be statistically significant at p = 0.02. this implies that the risk of death from covid-19 infection is more than twelve times greater if you have a severity score (brixia score) of 16–18, compared to those with a milder imaging severity (score group of 0–6). this relationship between lung severity scoring and outcome is validated by clinical outcomes, as patients with low brixia scores are likely expected to recover, whilst those with high severity indices are at higher risk for mortality. the highest frequency of overall patients that demised had brixia scores between 13 and 16, followed by the 16–18 brixia range. a possible explanation for this is that the 13–16 group had the highest frequency of patients overall, despite their worst cxr (and thus highest brixia severity score) being used for analysis. study limitations the limitations of this study include its retrospective study design and relatively small sample size. this was also a single centre study; therefore, patients admitted to other facilities were not included. furthermore, only inpatients with confirmed covid-19 disease were included. a lack of analysis and comparison between co-morbidities like hiv and tb and cxr findings was also a limiting factor, which is attributed to relevant laboratory data being available for only a small percentage of patients. lack of knowledge of symptom onset was another limiting factor. the x-rays evaluated were taken at an unknown time during the patients covid-19 disease timeline, and if the x-ray was performed early in disease, and no later x-ray was performed, the brixia score and consequently the correlation between the brixia score and outcome may have been underestimated. finally, only a portable x-ray unit was used to obtain cxrs, as all patients with covid-19 were admitted to isolation wards. elements of poor inspiration, rotation, and positioning (supine versus seated) likely limit the diagnostic accuracy of cxr interpretation. conclusion when evaluating chest radiography in patients with covid-19 infection, features of ground glass opacification, consolidation and pleural effusions, with bilateral lung involvement and no zonal predominance were most frequently found. thus, the radiological presence of these features must raise awareness of suspected covid-19 infection. whilst only a small percentage of patients in our study had laboratory confirmed or radiological evidence of co-morbid conditions like hiv and tb, further studies with larger sample sizes are required to assess the impact that the pulmonary manifestations of these conditions have on the cxr findings of covid-19 pneumonia in the south african setting. of note, the application of a severity index on an easily accessible imaging modality such as a cxr, the brixia scoring system, can be used to prognosticate covid-19 disease severity. it seemingly requires minimal clinician training, and may assist with timeous assessment of the disease severity in covid-19 positive patients, as an overall indicator of clinical outcome, suggesting the use of early intervention strategies to improve overall patient prognosis. acknowledgements dr catherine connolly, biostatistician at the university of kwazulu-natal, for assistance with the statistical analysis of data. competing interests the authors declare that they have no personal or financial incentives which may have inappropriately influenced them in the writing of this article. authors’ contributions s.m. was the principal investigator and prepared the manuscript. t.s. made a conceptual contribution, was involved with the editing of the manuscript, and is the supervisor of s.m.’s master’s research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data pertaining to this research are available from the corresponding author, s.m. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. the lancet. 2020;395(10223):507–513. https://doi.org/10.1016/s0140-6736(20)30211-7 zhang r, ouyang h, fu l, et al. ct features of sars-cov-2 pneumonia according to clinical presentation: a retrospective analysis of 120 consecutive patients from wuhan city. eur radiol. 2020;30(8):4417–4426. https://doi.org/10.1007/s00330-020-06854-1 li k, fang y, li w, et al. ct image visual quantitative evaluation and clinical classification of coronavirus disease (covid-19). eur radiol. 2020;30(8):4407–4416. https://doi.org/10.1007/s00330-020-06817-6 kanne jp, little bp, chung jh, elicker bm, ketai lh. essentials for radiologists on covid-19: an update-radiology scientific expert panel. radiology. 2020;296(2):e113–e114. https://doi.org/10.1148/radiol.2020200527 zhou z, guo d, li c, et al. coronavirus disease 2019: initial chest ct findings. eur radiol. 2020;30(8):4398–4406. https://doi.org/10.1007/s00330-020-06816-7 dai wc, zhang hw, yu j, et al. ct imaging and differential diagnosis of covid-19. can assoc radiol j. 2020;71(2):195–200. https://doi.org/10.1177/0846537120913033 ai t, yang z, hou h, et al. correlation of chest ct and rt-pcr testing for coronavirus disease 2019 (covid-19) in china: a report of 1014 cases. radiology. 2020;296(2):e32–e40. https://doi.org/10.1148/radiol.2020200642 salehi s, abedi a, balakrishnan s, gholamrezanezhad a. coronavirus disease 2019 (covid-19) imaging reporting and data system (covid-rads) and common lexicon: a proposal based on the imaging data of 37 studies. eur radiol. 2020;30(9):4930–4942. https://doi.org/10.1007/s00330-020-06863-0 prokop m, van everdingen w, van rees vellinga t, et al. co-rads: a categorical ct assessment scheme for patients suspected of having covid-19-definition and evaluation. radiology. 2020;296(2):e97–e104. https://doi.org/10.1148/radiol.2020201473 pan y, guan h, zhou s, et al. initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan, china. eur radiol. 2020;30(6):3306–3309. https://doi.org/10.1007/s00330-020-06731-x bompard f, monnier h, saab i, et al. pulmonary embolism in patients with covid-19 pneumonia. eur respir j. 2020;56(1):2001365. https://doi.org/10.1183/13993003.01365-2020 wong hyf, lam hys, fong ah, et al. frequency and distribution of chest radiographic findings in patients positive for covid-19. radiology. 2020;296(2):e72–e78. https://doi.org/10.1148/radiol.2020201160 borghesi a, maroldi r. covid-19 outbreak in italy: experimental chest x-ray scoring system for quantifying and monitoring disease progression. radiol med. 2020;125(5):509–513. https://doi.org/10.1007/s11547-020-01200-3 borghesi a, zigliani a, masciullo r, et al. radiographic severity index in covid-19 pneumonia: relationship to age and sex in 783 italian patients. radiol med. 2020;125(5):461–464. https://doi.org/10.1007/s11547-020-01202-1 hansell dm, bankier aa, macmahon h, mcloud tc, muller nl, remy j. fleischner society: glossary of terms for thoracic imaging. 2008 mar;246(3):697–722. https://doi.org/10.1148/radiol.2462070712 du bruyn e, stek c, daroowala r, et al. communicable and non-communicable co-morbidities and the presentation of covid-19 in an african setting of high hiv-1 and tuberculosis prevalence. medrxiv. in press 2021:2021.05.11.21256479. radioactive news2.html another view of iriya 2011 nasreen mahomed (university of the wiwatersrand) the radiological society of north america (rsna) provides international radiologists and radiology residents the opportunity to attend a special research seminar held in conjunction with the rsna scientific assembly and annual meeting at mccormick place, chicago, illinois. the focus of this seminar is to encourage radiologists from outside north america to pursue careers in academic radiology, and is supported by the rsna. i was privileged to be one of 16 radiologists from around the world accepted for the iriya 2011 programme. mccormick place is one of the largest conference centres in the world, with around 60 000 delegates attending the 2011 congress, so the orientation and welcome reception by d tokarski and f miller for the iriya delegates was most helpful. the iriya programme directed by dr j eng and dr w mayo-smith was very well organised. a detailed programme and relevant reading material were sent to all iriya participants well in advance, facilitating more interactive sessions. some sessions were combined with the introduction to academic radiology seminar for north american residents, while other sessions were dedicated to iriya participants. particularly relevant lectures included opportunities in translational research and quantitative imaging by professor k macura; research opportunities in informatics by dr n safdar; statistics by a frangos; and radiology research: deductions from the literature and how they may be applied to your research by professor r hichwa. the rsna grant programs and education resources seminar by f miller, e pietrzak and s walter introduced delegates to the many research grants, opportunities and resources offered by the rsna to international radiologists. during the research seminar, all iriya delegates were given the opportunity to present a current research proposal, which was critically evaluated by a panel. i found this particularly useful as my moderator professor j blickman and panelists professor s voss and dr w willinek were experienced and objective. the iriya programme was an excellent opportunity to network and meet international mentors, researchers and colleagues, facilitating opportunities for future collaborative research projects. it was also most inspiring to meet previous attendees of the iriya programme and hear of their accomplishments in research internationally, since their attendance. in addition to the iriya programme (where all sessions were compulsory), i was able to attend the early morning and late afternoon refresher and multisession courses. i found the paediatric imaging and breast imaging series to be particularly relevant. the information gained is already being used to update certain protocols – in particular, breast mri imaging at my institution. i take this opportunity to thank professor v mngomezulu for nominating me for this programme, the rsna for providing me with this outstanding opportunity, and the radiological society of south africa (rssa), president dr c sperryn and congress chairman professor l j van rensburg, for facilitating this opportunity through the rssa’s affiliation and collaboration with the rsna. i also thank professors v mngomezulu and s andronikou and dr i nagdee for supporting me with research. as i am currently working on several research projects with radiologists, registrars and clinicians, this programme will help to strengthen research in our institution. to conclude: the 2011 iriya programme was an excellent platform for building a successful career as a south african researcher and academic in diagnostic radiology and collaborating at an international level. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) pilasande hlwatika department of radiology, inkosi albert luthuli hospital, university of kwazulu-natal, durban, south africa timothy c. hardcastle trauma service and trauma icu, inkosi albert luthuli central hospital, durban, south africa department of surgical sciences, university of kwazulu-natal, durban, south africa citation hlwatika p, hardcastle tc. concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients. s afr j rad. 2022;26(1), a2321. https://doi.org/10.4102/sajr.v26i1.2321 original research concurrent cranial and cervical spine injuries by associated injury mechanisms in traumatic brain injury patients pilasande hlwatika, timothy c. hardcastle received: 14 oct. 2021; accepted: 16 jan. 2022; published: 24 mar. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the incidence of concurrent traumatic brain injury (tbi) and cervical spine injury (c-spine) is relatively high, with a variety of risk factors. objectives: the purpose of this study was to determine the incidence and related factors associated with combined cranial and c-spine injury in tbi patients by assessing their demographics and clinical profiles. method: a retrospective study of patients attending the trauma centre at the inkosi albert luthuli hospital as post head trauma emergencies and their ct brain and c-spine imaging performed between january 2018 and december 2018. results: a total of 236 patients met the criteria for the study; 30 (12.7%) patients presented with concurrent c-spine injury. most tbi patients were males (75%) and accounted for 70% of the c-spine injured patients. the most common mechanism of injury with a relationship to c-spine injury was motor vehicle collisions (mvcs) and/or pedestrian vehicle collisions (70%). the risk factors associated with c-spine injury in tbi patients were cerebral contusions (40%), traumatic subarachnoid haematomas (36%) and skull fractures (33.3%). the statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury (p = 0.04). conclusion: the results suggest that concurrent tbi and c-spine injury should be considered in patients presenting with a contusion, traumatic subarachnoid haematoma and skull fracture. the high incidence of c-spinal injury and more than 1% incidence of spinal cord injury suggests that c-spine scanning should be employed as a routine for post mvc patients with cranial injury. keywords: concurrent cranial injury; cervical spine injury; post-traumatic coma; radiation; computed tomography scan. introduction trauma is one of the major causes of morbidity and mortality in children and young adults in south africa (sa). according to a study by norman et al., the injury-related mortality rate in sa is reported to be six times higher and road traffic injuries two times higher, compared with the global rate.1 traumatic brain injuries (tbis) are among the most common injuries that lead to hospitalisation, surgical interventions, permanent disabilities and, in severe cases, death.2 according to the united states of america’s centre for disease control and prevention, most tbis are due to motor vehicle collisions (mvcs), sports and firearm-related injuries and other assaults.2,3 a study in pietermaritzburg, kwazulu-natal (kzn), in 2014, reported that the most common cause associated with tbi was interpersonal violence (39.4%), with a male-to-female ratio of 4.7:1.4,5 kong and clarke analysed 5 years (2008–2011 and 2012–2014) of morbidity and mortality conferences (mmcs) performed in the pietermaritzburg metropolitan trauma service (pmts) and reported that the highest percentage of patients were isolated tbi post-blunt trauma at 56.5%, with multiregional injuries in 21.3% thereof and isolated neck injuries at 1.5%.6 milby et al. reported that there was a high prevalence of cervical spinal injury (c-spine) in tbi patients post-blunt trauma with 3.7% overall.7 a study by fujii et al. estimated that the incidence of concurrent tbi and c-spine injury was between 1.7% and 8.0% in all trauma cases.8 another study by tian et al. found that patients who had tbi as a result of mvcs and a low glasgow coma scale (gcs) score of less than or equal to 8 were associated with an increased risk of c-spine injury. the clinical evaluation of the tbi level using the gcs is scored as follows: mild (gcs: 13–15), moderate (gcs: 9–12) and severe (gcs: 3–8).9 according to malale et al., the chance of an abnormal imaging finding increases with a decreasing gcs score.10 the other risk factors for concurrent c-spine injury and tbi included an older age group in mvcs, skull or facial fractures and chest, pelvic, upper limb or other spinal injuries.8 the incidence of concurrent head and c-spine injuries was documented as high as 9.3% by thesleff et al. in an article published in 2017, with the retrospective data collected for cases between august 2010 and 2012.11 failure to diagnose c-spine injury in a tbi patient can result in irreversible and devastating neurological damage. therefore, the diagnosis of a c-spine injury in all patients presenting with tbi is an essential aspect of the trauma evaluation process.7 using the general guideline, all patients presenting with a tbi and with an altered level of consciousness are treated as having a concurrent c-spine injury. many c-spine injuries may be diagnosed utilising conventional cervical radiography. although plain radiographs are relatively inexpensive and readily available in rural hospitals in sa, they are, however, associated with up to 15% missed injury rate compared with ct,12 which is currently considered as the gold standard for diagnosing a c-spine injury, with a better sensitivity of 98% compared with that of plain radiography at 54%.13 the high incidence of c-spine injury in patients with tbi led to ct evaluation of tbi and c-spine injuries in a government healthcare facility in pietermaritzburg13 based on retrospective data collected from all the trauma patients from january 2016 to june 2016. interestingly, the results showed that a combined diagnosis of tbi and c-spine injuries was relatively uncommon affecting 4.76% of the overall study population and was found mostly in patients involved in mvcs and pedestrian vehicle collisions (pvcs). the aim of this study was to determine the incidence of and the associated risk factors for c-spine injuries in patients undergoing head scans for tbi, by describing the demographic and clinical profile of the patients, determining the predictive mechanism of injury, level of injury, severity of intracranial injuries and the site and nature of the cervical injuries in a trauma society of south africa accredited level 1 trauma centre at inkosi albert luthuli central hospital (ialch) in durban, kwazulu-natal, sa. methods this retrospective study was conducted between 01 january 2018 and 31 december 2018 at ialch and included all patients attended to at the trauma centre as post head trauma emergencies. during this period, 272 patients had an initial ct brain and c-spine scan performed or, subsequent to the brain scan, had a ct cervical spine scan performed up to a week later. however, 36 of those patients were excluded from the study due to factors including lack of adequate history in their charts, no history of trauma and unavailability of images. data acquisition covered age, sex, mechanism of injury and level of consciousness (gcs) on arrival at the trauma and emergency department; ct brain findings of acute traumatic intracranial abnormalities (primary and secondary injuries); ct cervical spine findings of trauma (fracture or subluxation) and the level of injury and extra-cranial injuries. the data were collected from the picture archiving and communication system (pacs), radiology information system (ris) and hospital information system (his) at ialch. images were re-reviewed by a single radiologist with more than 5 years of experience. descriptive statistics were used to summarise the data. frequencies and percentages were used for categorical data such as the mode and severity of the injury (reported as median and interquartile range [iqr]). frequency distributions of numerical data such as age were examined for normality and means (standard deviation [s.d.]) or medians (iqr). group comparisons of risk factors among patients with and without c-spine injuries were tested with the chi-square or fisher’s exact tests for categorical data and t-tests or wilcoxon rank sum test for numerical data. a 5% significance level was used (p < 0.05). ethical considerations the study was registered as a sub-study of the existing research ethics approval by the ukzn biomedical research ethics committee (bca207/09 – class approval for trauma and burns data at ialch). the requirement for informed consent was waived because of the retrospective nature of the study. patient anonymity was assured by the use of de-identified data. results the number of the patients who met the criteria for the study was 236. of these, 30 (12.7%) presented with concurrent c-spine injury. the demographic and clinical profiles of all 236 tbi patients and the 30 patients with positive findings of a c-spine injury on a ct scan are summarised in table 1. the predominant age group in both the total study population and in the c-spine injured patients was the 25to 59-year age group and the majority were male. there were similar initial levels of consciousness of the total population versus the c-spine injured patients. most patients had a severely decreased level of consciousness. table 1: frequency distribution of age group, sex and level of consciousness in the total study population (n = 236) and the patients with a c-spine injury (n = 30). table 2 shows the different mechanisms of injury. the mechanism of injury associated with the highest number of admitted patients was mvc (including pvc), accounting for 66.1% (156/236). in patients with c-spine injuries, mvc accounted for 70.0% versus 65.5% in patients without a c-spine injury. there was no statistically significant association between mvc (including pvc) and a c-spine injury (p = 0.887). table 2: mechanism of injury in patients with a c-spine injury versus patients with no c-spine injury. all 30 of the c-spine injured patients had a cervical vertebral fracture, with 6 of the 30 (20%) having a concomitant subluxation. in terms of the level of injury, 11 cases had an injury in the upper cervical spine (base of the skull to the c2 level), 15 cases in the sub-axial c-spine (c3 to t1) and 4 cases in both the upper cervical spine and sub-axial spine. nineteen (63.3%) of the patients with a c-spine injury had only a bone injury, while six (20.0%) also had a symptomatic spinal cord injury. this was equal to the overall incidence of the symptomatic spinal cord injury of 6 of 236 (2.54%). there was insufficient information in the charts of 16.7% (5/30) to determine the presence of a cord injury. the only statistically significant intracranial injury type more likely to have an associated c-spine injury was diffuse axonal injury (p = 0.04). the other intracranial injury types, as depicted in table 3, which were more common than diffuse axonal injury in terms of percentage, were similarly equally common in patients without c-spine injury. the extra-cranial injuries commonly found in the patients with a positive c-spine injury included chest injury (56.7%), lower limb injury (30.0%) and facial injury (26.7%). table 3: intracranial injury types associated with a c-spine injury. discussion the demographic profile of the patient group indicated that males accounted for over 75% of the group. males generally constitute a higher percentage of those exposed to intracranial injuries.14 young men may often be involved in vehicle-related incidents, substance abuse and interpersonal violence leading to tbis. several modes of injury have been implicated in concurrent cranial and c-spine injury patients, including mvcs, pvcs, assaults, falls and gunshot wounds.15 in a study conducted by hardcastle et al. in 2013, the authors report that interpersonal violence and mvcs constitute a major healthcare burden on the south african public healthcare system, constituting 18.0% of the emergency care burden.16 in this study, mvc (including pvc) and assault were the most common mechanism of injury (70.0%) followed by fall (8.1%) and penetrating/gun/stab wounds (5.9%). according to frye et al. in 2002, intracranial haemorrhage is a common finding in moderate and severe head injuries, but it is not a predictor of occult c-spine injury.17 in this study, most patients presented with cerebral contusions (51.7%) and skull fractures (43.2%). hills and deanne reported the gcs scores in head injuries associated with a c-spine injury. traumatic brain injury patients with gcs scores of 8 or less were at a higher risk of spine injuries.18 similarly, this study confirmed that 41.5% of patients who presented with a severe gcs score of 8 had a greater chance of abnormal ct findings and/or were at the highest risk for c-spine injuries. south africa has a very high prevalence of trauma that necessitates many ct examinations. although ialch, located in durban, kzn, provides level 1 trauma services, the province needs more hospital facilities that provide such specialised trauma care services. however, the increase in ct imaging may expose tbi patients to radiation and may increase the lifetime risk of cancer, which may lead to greater public health problems.19,20,21,22,23,24 to reduce the complications of radiation, the as low as reasonably achievable (alara) principle must be applied to reduce radiation exposure. the limitation of this retrospective chart review study was that the study was performed only in one setting at the regional neurosurgical centre (iaclh, kzn). therefore, the results cannot be necessarily generalised to less severe injuries; however, it confirms that in cases with severe tbi, the c-spine should be imaged at the same time as the brain, as the incidence of c-spine injury and cord injury both exceed the ‘1%’ medicolegal risk rule.25 in the case of the ct imaging reports, the expertise or experience of the reporting radiologist could also affect the outcome of the results of the study, which was reduced by the image review performed by the lead investigator. conclusion the early diagnosis of both a tbi and c-spine injury is essential to manage the c-spine injury and minimise adverse events. poor management of c-spine injuries may result in irreversible and devastating neurological damage. motor vehicle collisions and tbi patients with gcs scores of 8 or less and specific intracranial injuries have a greater chance of abnormal ct findings and are at high risk for c-spine injuries. given the high incidence of c-spinal injuries and the more than 1% incidence of spinal cord injury, combined brain and c-spine scanning should be performed routinely in mvc and pvc. acknowledgements the authors would like to thank the inkosi albert luthuli central hospital radiology department staff. this study was performed as a partial completion of the degree mmed (radiology) at the university of kwazulu-natal (ukzn). competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.h. was the principal investigator and prepared the manuscript. t.c.h. provided supervisory roles, made conceptual contributions towards the study and participated in the manuscript editing. funding information this research received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, p.h. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references norman r, matzopoulos r, groenewald p, brashaw d. the high burden of injuries in south africa. bull world health organ. 2007;85(9):695–702. https://doi.org/10.2471/blt.06.037184 naidoo d. traumatic brain injury: the south african landscape. s afr med j. 2013;103(9):613–614. https://doi.org/10.7196/samj.7325 centers for disease control and prevention. surveillance report of traumatic brain injury -related hospitalisations and deaths by age group, sex, and mechanism of injuryunited states, 2016 and 2017. centres for disease control and prevention, atlanta, u.s. department of health and human services; 2021. miller gf, kegler sr, stone dm. traumatic brain injury-related deaths from firearm suicide: united states, 2008–2017. am j public health. 2020;110(6):897–899. https://doi.org/10.2105/ajph.2020.305622 jerome e, laing gl, bruce jl, sartorius b, brysiewicz p, clarke dl. an audit of traumatic brain injury (tbi) in a busy developing-world trauma service exposes a significant deficit in resources available to manage severe tbi. s afr med j. 2017;107(7):621–625. https://doi.org/10.7196/samj.2017.v107i7.10562 kong vy, clarke dl. analysis of 5 years of morbidity and mortality conferences in a metropolitan south african trauma service. s afr med j. 2016;106(7):695–698. https://doi.org/10.7196/samj.2016.v106i7.10549 milby ah, halpern ch, guo w, stein sc. prevalence of cervical spinal injury in trauma. neurosurg focus. 2008;25(5):e10. https://doi.org/10.3171/foc.2008.25.11.e10 fujii t, faul m, sasser s. risk factors for cervical spine injury among patients with traumatic brain injury. j emerg trauma shock. 2013;6(4):252–258. https://doi.org/10.4103/0974-2700.120365 tian hl, guo y, hu j, et al. clinical characterization of comatose patients with cervical spine injury and traumatic brain injury. j trauma. 2009;67(6):1305–1310. https://doi.org/10.1097/ta.0b013e31819db57c malale ml, dufourq n, parag n. a profile of traumatic brain injuries and associated cervical spine injuries at a regional hospital in the kwazulu-natal province. s afr fam pract (2004). 2020;62(1):e1–e6. https://doi.org/10.4102/safp.v62i1.5136 thesleff t, kataja a, ohman j, luoto tm. head injuries and the risk of concurrent cervical spine fractures. acta neurochir (wien). 2017;159(5):907–904. https://doi.org/10.1007/s00701-017-3133-0 mung’omba b, botha adh. core competencies of radiographers working in rural hospitals of kwazulu-natal, south africa. afr j prim health care fam med. 2017;9(1):e1–e8. https://doi.org/10.4102/phcfm.v9i1.1389 holmes jf, akkinepalli r. computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. j trauma. 2005;58(5):902–905. https://doi.org/10.1097/01.ta.0000162138.36519.2a santamarina-rubio e, perez k, olabarria m, novoa am. gender differences in road traffic injury rate using time travelled as a measure of exposure. accid anal prev. 2014;65:1–7. https://doi.org/10.1016/j.aap.2013.11.015 holly lt, kelly df, counelis gj, blinman t, mcarthur dl, cryer hg. cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. j neurosurg. 2002;96(3 suppl):285–291. https://doi.org/10.3171/spi.2002.96.3.0285 hardcastle tc, samuels c, muckart dj. an assessment of the hospital disease burden and the facilities for the in-hospital care of trauma in kwazulu-natal, south africa. world j surg. 2013;37(7):1550–1561. https://doi.org/10.1007/s00268-012-1889-1 frye g, wolfe t, knopp r, lesperance r, williams j. intracranial hemorrhage as a predictor of occult cervical-spine fracture. ann emerg med. 1994;23(4):797–801. https://doi.org/10.1016/s0196-0644(94)70316-7 hills mw, deane sa. head injury and facial injury: is there an increased risk of cervical spine injury? j trauma. 1993;34(4):549–553; discussion 53–54. https://doi.org/10.1097/00005373-199304000-00011 broder j, warshauer dm. increasing utilization of computed tomography in the adult emergency department, 2000–2005. emerg radiol. 2006;13(1):25–30. https://doi.org/10.1007/s10140-006-0493-9 tien hc, tremblay ln, rizoli sb, et al. radiation exposure from diagnostic imaging in severely injured trauma patients. j trauma. 2007;62(1):151–156. https://doi.org/10.1097/ta.0b013e31802d9700 berrington de gonzalez a, mahesh m, kim kp, et al. projected cancer risks from computed tomographic scans performed in the united states in 2007. arch intern med. 2009;169(22):2071–2077. https://doi.org/10.1001/archinternmed.2009.440 hardcastle tc, finlayson m, van heerden m, johnson b, samuel c, muckart dj. the prehospital burden of disease due to trauma in kwazulu-natal: the need for afrocentric trauma systems. world j surg. 2013;37(7):1513–1525. https://doi.org/10.1007/s00268-012-1852-1 lutge e, moodley n, tefera a, sartorius b, hardcastle t, clarke d. a hospital based surveillance system to assess the burden of trauma in kwazulu-natal province south africa. injury. 2016;47(1):135–140. https://doi.org/10.1016/j.injury.2015.08.020 hardcastle tc, reeds mg, muckart dj. utilisation of a level 1 trauma centre in kwazulu-natal: appropriateness of referral determines trauma patient access. world j surg. 2013;37(7):1544–1549. https://doi.org/10.1007/s00268-012-1890-8 tunstall-pedoe h. acceptable cardiovascular risk in aircrew. the concept of risk. eur heart j. 1988;9(suppl_g):13–15. https://doi.org/10.1093/eurheartj/9.suppl_g.13 sajr 817 acute mesenteroaxial gastric volvulus on computed tomography a ahmed visser, erasmus, vawda & partners, port elizabeth a ahmed, mb bch, fcrad (diag) corresponding author: a ahmed (docaadil@gmail.com) acute gastric volvulus is a rare, but potentially life-threatening, cause of upper gastro-intestinal obstruction. the diagnosis can prove clinically challenging, and hence there is increased reliance on imaging. there are different types of gastric volvulus, with the variant presented in our case being the less commonly encountered mesenteroaxial gastric volvulus. some of the ct features of gastric volvulus are described, and the usefulness of ct in assisting with the diagnosis is highlighted. s afr j rad 2013;17(1):21-23. doi:10.7196/sajr.817 gastric volvulus is a rare clinical entity, and a clinically relevant cause of acute abdominal pain in adults. it may prove to be a diagnostic dilemma for clinicians in view of the nonspecific clinical symptoms. the imaging diagnosis also remains challenging.1 abdominal computed tomography (ct) has been underutilised in the diagnosis of gastric volvulus in previously reported series.2 the present case illustrates the value and importance of abdominal ct in the rapid diagnosis of acute abdominal pathology and, in particular, acute gastric volvulus. it is imperative that the diagnosis is made early in the course of the disease, to allow prompt surgical intervention and prevention of life-threatening complications. case presentation a 41-year-old woman presented to the emergency department with a 1-day history of severe upper abdominal pain and nausea. examination revealed features of an acute abdomen with the clinical suspicion of a bowel perforation. she had no other gastro-intestinal tract symptoms. she was not on any chronic medication and had no history of prior abdominal surgery or trauma. in view of the acute but non-specific symptoms, a ct of the abdomen was requested. no oral or iv contrast was administered in view of the clinical condition of the patient and the diagnosis being evident on the initial uncontrasted scan. the patient was taken for emergency surgery soon thereafter. the diagnosis of mesenteroaxial gastric volvulus was confirmed; fortunately there were no signs of ischaemia, necrosis or perforation. the patient had an uneventful recovery. ct demonstrated an unusually high-positioned stomach with loss of the normal gastric axis and appearance. the axial set of images in fig. 1 demonstrates this unusual-appearing stomach with the pylorus and gastro-oesophageal (go) junction closely approximated to each other. the pylorus and antrum are positioned superior to the gastric fundus. the stomach had an abnormal transverse orientation, best demonstrated on the sagittal reformatted images (fig. 2). gastric folds that form secondary to twisting of the stomach are also seen on the axial and coronal images (fig. 3). the spleen is also displaced inferiorly, in keeping with the described ‘wandering spleen’ (fig. 3). no diaphragmatic hernia/defect or pneumoperitoneum was present. no additional abnormalities were seen on the ct examination of the abdomen. fig. 1. axial series of images through the abnormally orientated, distended stomach, progressing caudally from image a to i. (a) distal oesophagus (solid arrow), gastrohepatic ligament (broken arrow). (b)go junction (solid arrow), gastric fold (broken arrow). (c) pylorus (solid arrow). (d) go junction/gastric cardia (solid arrow), gastroduodenal junction (broken arrow). the go junction and gastroduodenal junction are closely approximated. (e) greater curvature of the stomach (arrows). the greater and lesser curvatures maintain their normal relationship. (f) go junction (arrow). (g) gastric suspensory ligament (arrow). (h) first part of the duodenum (arrow), hepatoduodenal ligament. (i) duodenum (solid arrow), displaced spleen (broken arrow). fig. 2. sagittal ct image demonstrating the abnormal horizontal orientation of the stomach (solid arrow). the spleen is indicated (broken arrow). fig. 3. coronal ct image showing abnormal gastric fold (solid arrow). the inferiorly displaced ‘wandering spleen’ is also seen (broken arrow). discussion gastric volvulus is defined as an abnormal, acquired rotation of the stomach of more than 180 degrees, creating a closed loop obstruction. acute gastric volvulus is less common and is an acute, life-threatening, surgical emergency. if not recognised and treated quickly, it can result in complications such as gastric ischaemia, necrosis and perforation.3 the borchardt clinical triad of symptoms (epigastric pain, retching and inability to pass a nasogastric tube) are useful and valuable pointers to the suspected diagnosis.1 , 4 , 5 gastric volvulus can be classified based on axis of rotation, severity (acute or chronic), extent (total or partial) or aetiology (primary or idiopathic).6 the most frequently used classification system describes 3 types of gastric volvulus: organoaxial, mesenteroaxial and combination-unclassified.5 , 6 this is based on the axis of rotation. organoaxial is the most common variant, accounting for approximately two-thirds of cases, and occurs when the stomach rotates along its long axis (fig. 4).1 , 6 the greater curvature is displaced superiorly, and the lesser curvature lies more caudally in the abdomen. if the twist is >180o, gastric outlet obstruction occurs. the go junction and pylorus maintain their normal anatomical positions and are not in close proximity. there is also less risk of ischaemia in organoaxial volvulus.7 one of the predisposing factors for volvulus is the presence of a diaphragmatic defect; in adults, organoaxial volvulus occurs commonly in the setting of a post-traumatic diaphragmatic defect or a para-oesophageal hernia.1 , 6 another predisposing factor for volvulus is the presence of an abnormality relating to the anchoring of the stomach and the surrounding ligaments.6 this is thought to be one predisposing factor in the development of the second type of volvulus, and the variant encountered in our patient – mesenteroaxial volvulus. the gastrohepatic ligament is demonstrated on the coronal and axial images (fig. 1a). an unusually long gastro-hepatic mesentery has been mentioned as a predisposing factor for the development of mesenteroaxial gastric volvulus.8 mesenteroaxial volvulus is much less common, accounting for approximately 29% of cases, and occurs when the stomach rotates around the transgastric/short axis (a line connecting the middle of the lesser curvature with the middle of the greater curvature) (fig. 4).6 the anterior gastric wall flips on itself and the antrum is displaced above the go junction. the greater and lesser curvatures are in their usual positions relative to each other.7 there is reversal of the relationship of the go junction and pylorus, and they may lie in close proximity to each other (fig. 1); this creates a tapered pedicle about which the stomach can twist, making gastric ischaemia more likely in mesenteroaxial volvulus. the third type of volvulus is the combined type that exhibits features of both mesenteroaxial and organoaxial volvulus.3 , 5 , 6 mesenteroaxial and the combined type tend to present acutely.3 , 7 fig. 4. sketch demonstrating the mechanism of both (a) organoaxial and (b) mesenteroaxial volvulus. in (a), organoaxial volvulus develops secondary to twisting of the stomach along its long axis (red line). in (b), there is rotation of the stomach around the short axis (red line) resulting in mesenteroaxial volvulus. fig. 5. coronal ct image demonstrating the close relationship of the go junction (broken arrow) and gastroduodenal junction secondary to the volvulus. the first part of the duodenum is shown by the solid arrow. imaging gastric volvulus may have a nonspecific clinical presentation, hence increasing the reliance on imaging to assist in coming to the correct diagnosis. it is also imperative that, in the acute setting, imaging studies do not result in delays in coming to a diagnosis and subsequent management.3 radiography, upper gastro-intestinal tract contrast studies and ct are the imaging modalities most often used to make the diagnosis of volvulus. ct has been underutilised in previously reported series of gastric volvulus, and has not been advocated as the primary imaging study. there are reports in the literature demonstrating use of ct in the diagnosis of gastric volvulus. the acutely ill patient may also not tolerate oral contrast for the fluoroscopic examination, making ct a viable alternative. in our patient, the ct scan was performed early, and expedited diagnosis and management. abdominal ct is often done in the setting of abdominal pain and vomiting and can help in confirming abnormal rotation of the stomach.1 ct findings of a stomach that has an unusually high position, an abnormal axis, or an abnormal go junction and pylorus relationship, should raise suspicion of gastric volvulus (figs 1 and 5).6 , 8 the multi-planar reconstructions facilitate display of torsion of the stomach in various planes, assisting in confirming the diagnosis (figs 2 and 5). the above-mentioned close approximation of the go junction and pylorus, and the abnormal antral folds that can develop secondary to the twisting, are best seen on coronal images (figs 3 and 5). the wandering spleen is frequently associated with gastric volvulus and is easily identified on ct (fig. 3);3 this is secondary to absence of a ligamentous connection between the stomach and the spleen.8 there are further advantages that ct has over other imaging modalities: 1. detection of gastric pneumatosis and pneumoperitoneum, suggestive of necrosis and perforation, respectively 2. detection of predisposing factors, e.g. diaphragmatic defects or hernias, dense adhesions 3. detection of other abnormalities associated with gastric volvulus, viz. wandering spleen, intrathoracic kidney, malrotation with asplenia 4. excluding other extra-gastric or vascular causes of gastric ischaemia 5. detection of other causes of abdominal pain in the absence of gastric volvulus.2 , 6 occasionally, the findings may be equivocal on ct. in such cases, an upper gastro-intestinal tract contrast study may be performed for confirmation. chronic or intermittent volvulus (predominantly the organoaxial variant), which accounts for two-thirds of adult cases, may be asymptomatic and may be reported as an incidental finding on routine imaging studies.5 importantly, ct scans performed in the asymptomatic interval (‘untwisted’ state) may miss the diagnosis completely.2 conclusion acute gastric volvulus is an uncommon, and often unrecognised, surgical emergency that should be considered in patients who present to the emergency department with severe epigastric pain and evidence of gastric outlet obstruction. if the diagnosis is in doubt (and this is often the case), imaging studies are important. this case report highlights the usefulness of an abdominal ct in assisting in diagnosing this life-threatening condition. the ct allows for multi-planar demonstration of abnormal torsion of the stomach and also provides valuable insights into possible aetiologies, and predisposing factors. ct is readily available nowadays, and should be considered the diagnostic tool of choice in any suspected gastric volvulus. 1. peterson mc, anderson js, hara ak, et al. volvulus of the gastrointestinal tract: appearances at multi-modality imaging. radiographics 2009;29:1281-1293. [http://dx.doi.org/10.1148/rg.295095011] 1. peterson mc, anderson js, hara ak, et al. volvulus of the gastrointestinal tract: appearances at multi-modality imaging. radiographics 2009;29:1281-1293. [http://dx.doi.org/10.1148/rg.295095011] 2. woon cy, chung ay, low as, wong w. delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by ct: a case report. journal of medical case reports 2008;2:343. [http://dx.doi.org/10.1186/1752-1947-2-343] 2. woon cy, chung ay, low as, wong w. delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by ct: a case report. journal of medical case reports 2008;2:343. [http://dx.doi.org/10.1186/1752-1947-2-343] 3. casella v, avitabile g, segreto s, mainenti pp. ct findings in a mixed-type acute gastric volvulus. emergency radiol 2011;18:483-486. [http://dx.doi.org/10.1007/s10140-011-0963-6] 3. casella v, avitabile g, segreto s, mainenti pp. ct findings in a mixed-type acute gastric volvulus. emergency radiol 2011;18:483-486. [http://dx.doi.org/10.1007/s10140-011-0963-6] 4. chandrasekhar c, khanejaa s, banullab p, scheina m. ct diagnosis of acute gastric volvulus. dig surg 2003;20:497-499. [http://dx.doi.org/10.1159/000073536] 4. chandrasekhar c, khanejaa s, banullab p, scheina m. ct diagnosis of acute gastric volvulus. dig surg 2003;20:497-499. [http://dx.doi.org/10.1159/000073536] 5. van der merwe dj, louw hb, dekker g. gastric volvulus – an explanation through imaging. s afr j radiol 2007;11(4):105. 5. van der merwe dj, louw hb, dekker g. gastric volvulus – an explanation through imaging. s afr j radiol 2007;11(4):105. 6. sevcik we, steiner ip. acute gastric volvulus: case report and review of the literature. cjem 1999;1:200-203. 6. sevcik we, steiner ip. acute gastric volvulus: case report and review of the literature. cjem 1999;1:200-203. 7. oh sk, hon bk, levin tl, et al. gastric volvulus in children: the twists and turns of an unusual entity. pediatr radiol 2008;38(3):297-304. [http://dx.doi.org/10.1007/s00247-007-0709-5] 7. oh sk, hon bk, levin tl, et al. gastric volvulus in children: the twists and turns of an unusual entity. pediatr radiol 2008;38(3):297-304. [http://dx.doi.org/10.1007/s00247-007-0709-5] 8. dahnert w. radiology review manual. 7th ed. philadelphia: lippincott williams & wilkins, 2011:852-853. 8. dahnert w. radiology review manual. 7th ed. philadelphia: lippincott williams & wilkins, 2011:852-853. abstract introduction research method and design results discussion limitations of the study conclusion acknowledgements references about the author(s) nompumelelo p. gumede department of radiology, college of health sciences, university of kwazulu-natal, durban, south africa sithembiso m. langa department of radiology, jackpersad and partners inc., durban, south africa basil enicker department of neurosurgery, college of health sciences, university of kwazulu-natal, durban, south africa citation gumede np, langa sm, enicker b. mri characteristics of intracranial masses in the paediatric population of kwazulu-natal: a neuroimaging-based study. s afr j rad. 2021;25(1), a2042. https://doi.org/10.4102/sajr.v25i1.2042 original research mri characteristics of intracranial masses in the paediatric population of kwazulu-natal: a neuroimaging-based study nompumelelo p. gumede, sithembiso m. langa, basil enicker received: 04 nov. 2020; accepted: 15 mar. 2021; published: 28 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: mri is the imaging modality of choice for the assessment of intracranial masses in children. imaging is vital in planning further management. objectives: the purpose of this study was to describe the common intracranial masses and their imaging characteristics in the paediatric population referred to inkosi albert luthuli central hospital for mri of the brain. method: we retrospectively reviewed the medical records of paediatric patients (aged from birth to 18 years) who underwent mri investigations for intracranial masses between january 2010 and december 2016. results: a total of 931 mri brain scans were performed. one hundred and seven scans met the inclusion criteria, of which 92 were primary brain tumours and 15 were inflammatory masses. the majority were females (56%). the mean age was 12 ± 4.52 (range of 3–18 years). the most common presenting symptom was seizures (70/107, 65.4%). we categorised the masses according to supraand infratentorial compartments. the most common site for masses was the supratentorial compartment (n = 56, 52%). the most common masses in the supratentorial compartment were craniopharyngiomas (14/45, 31.1%), whilst in the infratentorial compartment, the most common masses were medulloblastomas (24/47, 51.1%). conclusion: in our series, the supratentorial compartment was the commonest site for intracranial masses. the most common tumour in the infratentorial compartment was medulloblastoma. this information is vital in formulating differential diagnoses of intracranial masses. keywords: intracranial masses; brain tumours; brain abscess; tuberculosis; magnetic resonance imaging. introduction in lowand middle-income countries (lmics) such as south africa, brain tumours are the second most common tumours in the paediatric population, after leukaemia.1,2,3 they are responsible for the most common cancer-related deaths in paediatric patients.2,3 in high-income countries, brain tumour incidence ranges from 1.15 to 5.14 cases per 100 000 children, with the highest rates reported in the united states.4 the recent south african tumour registry dated 1997–2007 reported the annual incidence of tumours in children aged 0–14 years to be between 33.4 and 47.2 per million from 2003 to 2007.1 brain tumours represented 13.45% of all diagnosed childhood tumours.1 overall, the most common paediatric tumour in the supratentorial compartment is astrocytoma (68%), followed by craniopharyngioma (50%). medulloblastoma (35% – 40%) and pilocytic astrocytoma (30%) are the common tumours in the infratentorial compartment.5,6 intracranial infections are a major burden in lmics because of poverty, overcrowding, inadequate access to clean water and proper sanitation systems, and insufficient access to healthcare. in a recent meta-analysis study by robertson et al., sub-saharan africa had the highest rates of bacterial meningitis, neurocysticercosis and tuberculosis-related disease, with an incidence of 65 to 650 per 100 000. this is in contrast to high-income countries, with an incidence ranging from 0.56 to 2 per 100 000.7 the clinical symptoms and signs of intracranial masses should never be underestimated, no matter how subtle, as they are clues that assist the clinicians in performing appropriate radiological investigations. mri is the investigation of choice in children with intracranial masses. the advantages of mri include a lack of ionising radiation (when compared to computed tomography [ct] scans), and the best contrast resolution, especially with higher magnetic field scanners such as 3.0 tesla (3.0t) scanners.8 advanced imaging techniques, such as dynamic intravenous post-contrast evaluation, diffusion-weighted imaging (dwi), functional imaging, susceptibility-weighted imaging (swi) and magnetic resonance spectroscopy (mrs), significantly improve diagnostic sensitivity and specificity.9 to our knowledge, no previous studies have reported on the mri characteristics of intracranial masses in the paediatric population in kwazulu-natal (kzn), south africa. the purpose of this study is to report these characteristics in paediatric patients managed at a tertiary state referral hospital. research method and design the study was performed at inkosi albert luthuli central hospital, which is a tertiary hospital located in durban, kzn. inkosi albert luthuli central hospital is one of three hospitals that perform mris in the province of kzn that houses both the departments of neurosurgery and paediatric neurology, in a province of approximately 11 million.10 this was a retrospective, analytic, cross-sectional study design conducted between 01 january 2010 and 31 december 2016. the clinical and radiological data of paediatric patients referred to the radiology department for an mri scan who fulfilled our inclusion criteria were obtained from the hospital information system (meditec). radiology reports and image archives were obtained from the radiology information system and picture archiving and communication system. we included all children from birth to 18 years old with reported intracranial masses. patients above the age of 18 years, children with mri scans not performed at our institution, patients with no formal radiology reports and patients with intracranial masses secondary to trauma, congenital and vascular masses were excluded from the study. the data collected included demographics, clinical features and mri characteristics. all the studies were acquired on 3.0 tesla skyra siemens mri scanner. the scanning protocol for conventional sequences included t1-weighted (t1w), t2w, fluid-attenuated inversion recovery (flair) and t1w post-contrast images. susceptibility-weighted imaging was performed where haemorrhage and calcifications were suspected, and dwi was performed whenever it was deemed necessary by the consultant radiologist. magnetic resonance spectroscopy was not routinely performed. the data frequencies relating to the demographics and spectrum of masses were analysed. the analysis of the mri characteristics was documented and correlated with the histological findings. further correlation with the mass topography and clinical presentation was made. all analyses were performed using spss version 25 software. ethical considerations ethics approval for this study was granted by the biomedical research ethics committee (brec) of the university of kwazulu-natal (ref. no. be027/18). results a total of 931 mri brain scans were performed during the 6-year period. one hundred and seven scans fulfilled the inclusion criteria. there were a total of 92 (86%) primary brain tumours and 15 (14%) infective or inflammatory masses. the majority of the children were females (n = 61, 56%) with a mean age of 12 ± 4.52 (range, 3–18 years). the most common presenting symptom was seizures (65.4%). of the 70 patients who presented with seizures, 30 (43%) had masses located in the supratentorial compartment and 40 (57%) in the infratentorial compartment. the clinical presentations are demonstrated in figure 1. figure 1: the clinical presentation of paediatric patients with intracranial masses. the locations and diagnoses of the intracranial masses are summarised in table 1. magnetic resonance imaging features of the intracranial masses are shown in figures 2, 3, 4 and 5. the associated features on mri are also displayed in table 2. figure 2: morphologic appearance of paediatric brain tumours. figure 3: magnetic resonance imaging features of paediatric brain tumours. figure 4: morphologic features of paediatric infective or inflammatory intracranial masses. figure 5: magnetic resonance imaging features of paediatric infective or inflammatory intracranial masses. table 1: intracranial mass diagnosis, location and age groups. table 2: intracranial masses with pathological features. discussion according to numerous case series studies, medulloblastoma is the commonest infratentorial tumour, which is a similar finding in this study.5,6 a south african study conducted in johannesburg also reported similar results.3 tuberculomas, in the current study, commonly occurred in the supratentorial compartment, which differed from the literature where the infratentorial compartment was most common.11,12 clinical presentation we noted a variable pattern of clinical presentations, but the most frequent presentations, regardless of the mass characteristics or mass location, were seizures (65.4%) and headaches (33%). the majority of our patients who presented with seizures had tumours located in the infratentorial compartment, which is contrary to the reported literature, which states that seizures are more common with supratentorial tumours than infratentorial tumours.13 however, almost all of our infratentorial tumours had associated features of raised intracranial pressure (icp), which is known to have a non-specific association with seizures. the majority (80%) of inflammatory masses also presented with seizures, which is a known clinical presentation.14,15 tumour-related seizures result from metabolic, neurotransmitter and morphologic changes in the peritumoural brain, as well as the presence of peritumoural products, gliosis and necrosis. neurological excitation from pro-inflammatory signals causes seizures from inflammatory masses.16 tumour characteristics and location infratentorial tumours these were common in the 11–18 year-old age group, contrary to the other studies, that report an age group of less than 3 years.17 the most common infratentorial tumours were medulloblastoma (24/47, 51.1%) and pilocytic astrocytoma (14/47, 30.0%), which are consistent with the literature.3,5,6 this study found medulloblastoma to have the typical described morphology of heterogeneity with mixed solid and cystic areas, the solid areas appearing hypointense to grey matter on t2wi, restriction on dwi owing to the dense cellularity, heterogeneous enhancement on post-iv gadolinium t1wi and occasional blooming artefact from calcification on swi.7 these features matched the majority of findings as depicted in figures 3 and 6, except that swi was only performed in two cases, where there was evidence of calcification and blooming artefact. figure 6: (a–f) medulloblastoma, predominantly centred in the fourth ventricle. the mass is predominantly solid (arrows) with tiny cystic areas (*) and avid enhancement of the solid areas (b). two images (c, d) show t2 and flair low signal of dense hypercellular solid areas and fluid restriction on dwi and adc map. supratentorial hydrocephalus is also seen (star). pilocytic astrocytoma was the second common intracranial tumour in the infratentorial compartment. the majority appeared heterogeneous with solid and cystic components that demonstrated heterogeneous post-contrast enhancement. according to the literature, this is not typical of the classic appearance of a rim-enhancing cyst with an enhancing mural nodule. other appearances include a non-enhancing cyst wall with an enhancing mural nodule, a solid mass with necrotic centre (16%) and a solid mass with minimal or no cystic component (17%).6,18,19 these three appearances were not evident in this series. appearances on additional sequences did not differ from the already-described literature. the cystic component was isointense to cerebral spinal fluid (csf) on t1w and t2w sequences, and hyperintense on flair. the solid component was hypoto isointense on t1wi, hyperintense on t2wi and flair and post-contrast showed variable enhancement patterns19 (figure 7). at dwi, pilocytic astrocytomas do not restrict because of the low tumour cellularity. figure 7: (a–e) right cerebellar pilocytic astrocytoma. this is a large cystic mass (*) with an eccentric solid nodule (long arrow). there is enhancement of the tumour wall (short and long arrows [d]) and surrounding vasogenic oedema (star). there is no remarkable diffusion restriction (e). brainstem gliomas and the ependymomas were the least common infratentorial tumours. the findings of brainstem gliomas in this study matched the described literature of being hypointense on t1wi and hyperintense on t2wi and flair. post-contrast imaging varied from no enhancement to minimal, patchy or heterogeneous (figure 8) enhancement. absent restricted diffusion is noted at dwi.6 figure 8: (a–d) typical diffuse intrinsic pontine glioma that expands the pons (*) and encases the patent basilar artery (arrow). it is hypointense on t1wi, hyperintense on t2wi and flair and does not enhance post-gadolinium. there was no restricted diffusion (not shown). ependymomas can occur anywhere in the central nervous system (cns). they arise along the ventricular walls in the brain. they are reported to be most common in the fourth ventricle, typically heterogeneous, mixed, solid and cystic tumours, with heterogeneous enhancement and blooming artifact secondary to calcifications.6 in our small cohort, we observed imaging appearances matching the descriptions in the literature (figures 9 a–d). figure 9: (a, b) heterogeneously enhancing supratentorial ependymoma with solid (arrows) and cystic (*) components and heterogeneously enhancing solid areas. associated subfalcine herniation with midline shift is seen (arrowhead). two images in another patient (c, d) show an infratentorial ependymoma with a similar heterogeneous imaging appearance, which is lacking restricted diffusion in (d). differentiating infratentorial tumours common posterior fossa mass differentials in paediatric patients include medulloblastoma, ependymoma and pilocytic astrocytoma. medulloblastoma and ependymoma share several morphologic features of a solid and cystic nature and some differences in mri signal appearances. like most tumours with low cellularity, the ependymomas are commonly of t1 low signal and t2 and flair high signal with variable dwi signal in contrast to earlier described medulloblastoma features. location and local tumour growth behaviour offer additional input in making the distinction. medulloblastoma grows into the fourth ventricle from the vermis whilst ependymoma grows within the fourth ventricle, hence expanding the ventricle. the ependymoma typically extends into the foramina or luschka and magendie, which is not usual for medulloblastoma. pilocytic astrocytoma, by contrast, is typically located in the cerebellar hemisphere and is commonly cystic with a mural nodule.20 supratentorial tumours the most common tumour in the supratentorial compartment was craniopharyngioma. it is commonly a suprasellar mass but can arise anywhere between the third ventricle and the pituitary gland. the adamantinomatous craniopharyngioma generally appears as a mixed solid and cystic mass with calcifications. the papillary type is commonly solid with fewer calcifications.21,22 solid components may appear isoto hypointense on t1wi, isoto hyperintense on t2wi and hyperintense on flair imaging in relation to grey matter. the cystic component can be hypointense or hyperintense on t1wi, owing to the presence of cholesterol, proteinaceous fluid or methaemoglobin. on flair imaging, it is hyperintense. calcifications on the solid components or the rim of the cyst appear hypointense on t2wi and demonstrate blooming artefacts on swi.6 post-contrast, the solid component enhances, and the cystic component demonstrates rim enhancement. on dwi, they do not restrict.21 the findings in our series matched those typically described appearance (figures 3 and 10). figure 10: (a–c) heterogeneous craniopharyngioma in the sellar and suprasellar region with solid and cystic components (triangles). the solid components enhance post-gadolinium (*), and swi shows blooming artefact (arrow) secondary to calcifications. differentials for craniopharyngioma include a pituitary adenoma, hypothalamic or optic pathway glioma and a rathke’s cleft cyst. a pituitary adenoma is usually an intrasellar mass that expands the sellar with suprasellar extension, has no calcifications and possesses variable cystic components. hypothalamic or optic pathway gliomas may have cystic areas but are largely dominated by solid components and rarely have an intrasellar component or calcifications. large rathke’s cleft cysts are usually easier to differentiate from the smaller ones because they usually do not have a solid component or calcifications and do not enhance post-contrast.21 choroid plexus carcinoma (cpc) and choroid plexus papilloma (cpp) are commonly located in the atrium of lateral ventricle (50%), followed by the fourth and third ventricles, with an incidence of 40% and 5%, respectively.23 in this study, both tumours were located in the lateral ventricles, followed by the third ventricle (figure 11) and the extra-ventricular location of cpc and cpp was found in the frontal lobe (cpc) and the parieto-occipital lobe (cpp). the extra-ventricular location of these tumours is rare. both tumours were classically heterogeneous with solid and cystic components as well as calcifications. they typically enhance avidly on post-contrast imaging because of their high vascular nature. the signal intensities of both tumours are isoto hypointense on t1wi and isoto hyperintense on t2wi.23 most of our findings match the above signal characteristics on preand post-gadolinium sequences. on swi, most had calcification related blooming artefacts. the restricted diffusion feature can be used to differentiate cpc from cpp; however, in our cohort, dwi was only performed in cpc cases, and most demonstrated no restriction, except for one case. figure 11: choroid plexus carcinoma (a–d). there is a large t1 and t2 isointense mass with intense heterogeneous enhancement within the left lateral ventricle causing midline shift to the right. it shows no restriction at dwi. the differential diagnosis for intraventricular choroid plexus tumours includes ependymoma, central neurocytoma and subependymal giant cell astrocytoma. central neurocytoma is usually located in the body of the lateral ventricle arising from the septum pellucidum or ventricular wall. it frequently has multicystic components and may have calcifications as well as areas of haemorrhage. it is hypointense on t1wi, hyperintense on t2wi and has a variable enhancement pattern. it is common in elderly patients.23 a subependymal giant cell astrocytoma occurs almost exclusively in association with tuberous sclerosis located in the foramen of monro, appearing as a lobulated enhancing mass with a t1 low signal and t2 high signal and containing calcifications. world health organization classification of central nervous system tumours the world health organization (who) classification of cns tumours is a worldwide well-recognised system of classifying cns tumours that is based on histological and molecular tumour characteristics. it is worth noting that dwi offers a potential volatile tool as a practical imaging guide to the who tumour grade. mustafa et al.24 and several other authors noted significant differences of paediatric cns tumour water diffusion properties utilising apparent diffusion coefficient (adc) map values, which somewhat correlate with the who tumour grade. significant differences regarding fluid diffusion restriction were noted in pilocytic astrocytoma, ependymoma, medulloblastoma and brainstem glioma. pilocytic astrocytoma, a known who grade 1 tumour, showed no fluid restriction (high adc map values) in contrast to a medulloblastoma, a known who grade 4 tumour that had restricted diffusion (very low adc map values). tumours with low cellularity (i.e. no diffusion restriction) and less aggressiveness, including pilocytic astrocytoma, cpp, pineocytoma and craniopharyngioma, are known to be classified as who grade 1 tumours. the moderately cellular ependymoma, a known who grade 2 tumour, has variable restricted diffusion according to imaging literature.24,26 it was only between pilocytic astrocytoma and ependymoma where mustafa et al.24 did not find a significant difference on adc map values. further contrasts of other densely cellular tumours with restricted diffusion such as cpc and pineoblastoma are known grades 3 and 4 who classifications, respectively. several studies in the literature have demonstrated high adc map values (no restriction) in who grade 1 and 2 gliomas and low adc map values (fluid restriction) in who grade 3 and 4 gliomas.24,25,26 infective or inflammatory masses the most common infective masses were secondary to tuberculosis (tb). tuberculosis and malaria are reported as common infections in sub-saharan africa.16 these parenchymal tb masses manifest as tuberculomas and tb abscesses. tuberculomas are the most common manifestation of cns tb, and, in paediatric patients, they are said to be more common infratentorially within the cerebellum.27 in contrast, most of our patients had granulomas in the supratentorial region within the cerebral lobes. tuberculomas have different stages, which make them appear differently on mri sequences. these stages include a non-caseating granuloma, a caseating granuloma with a solid centre, a caseating granuloma with central liquefaction and a calcified granuloma. a non-caseating granuloma is isoto hypointense on t1wi, hyperintense on t2wi, hyperintense on flair and has solid enhancement on post-contrast imaging. a caseating granuloma is isoto hypointense with a hyperintense rim on t1wi, hypointense on t2wi, hyperintense on flair and shows rim enhancement on post-contrast imaging (figures 4 and 12). a caseating granuloma with central liquefaction is isoto hypointense with a hyperintense rim on t1wi, a hypointense rim with a central hyperintense signal on t2wi, with partial suppression on flair and rim enhancement on post-contrast images. all these active granulomas show no restriction on dwi, except for the caseating granuloma with central liquefaction, which may restrict.27 figure 12: caseating tuberculoma with a solid centre (a–c). two high parietal masses that are isointense to grey matter on t2wi with a slightly hyperintense rim (arrow), hypointense on t1wi and demonstrate rim enhancement post-gadolinium. note the significant perilesional oedema with increased white matter signal intensity (b). tuberculous abscesses were not common in our series. they are mostly seen in immunocompromised patients. the appearance in the current series was that of hypo-intensity on t1wi, heterogeneous hyperintensity on t2wi, variable suppression on flair and rim enhancement on post-contrast imaging. at dwi, they demonstrate restricted diffusion. it is vital to differentiate granulomas from abscesses, because their management is different. the management of granulomas is medical, with anti-tuberculosis drugs, whilst abscesses often require both surgical drainage and medical therapy.27 the differential diagnosis of tuberculosis includes a variety of rim-enhancing masses, which may be another infection, such as toxoplasmosis and neurocysticercosis, as well as malignancy, such as cns lymphoma, a primary tumour (glioblastoma multiforme) or metastasis.27 the associated features, such as meningeal enhancement, basal ganglia infarcts and communicating hydrocephalus, are more likely to occur with tb masses compared to the described differential. toxoplasmosis can be a single or multifocal masses, with a predilection for basal ganglia and grey–white matter junctions. toxoplasmosis masses are somewhat small with an irregular rim of enhancement and a high dwi signal. neurocysticercosis can be located at the grey–white matter junctions, in the subarachnoid csf spaces and within the ventricles. there are various stages affecting mri features; however, the typical small cystic appearance with an internal eccentric scolex offers more confidence in making the diagnosis. primary cns lymphoma tends to be a larger infiltrating enhancing solid mass lining the ventricular wall, although it can have a necrotic centre. the high dwi signal within the mass is related to the dense cellularity in lymphomas. the use of mr spectroscopy imaging can help discriminate tumours (lymphoma and metastasis) from infective masses as tumours demonstrate an elevated choline peak.28,29 pathological features of intracranial masses oedema vasogenic oedema was present with all the infective masses and most tumours (n = 77/92 = 83.7%). the most common tumours associated with the oedema were in the infratentorial compartment. these results correlate with literature that reports that both brain pathologies, tumours and infective masses, cause damage to the blood-brain barrier (bbb). in tumours, bbb damage is secondary to tumour angiogenesis. infections actually result in both vasogenic and cytotoxic oedema (combined oedema), with cytotoxic oedema initially occurring from the derangement of the adenosine-dependent triphosphate (atp) –transmembrane sodium-potassium and calcium pumps. initially, the bbb is spared, but with increasing insult severity, cell death occurs, which then damages the bbb and results in vasogenic oedema.30 hydrocephalus within the infratentorial group, the majority of tumours, (n = 45/47, 96%) and infections, (n = 2/4, 50%) were associated with hydrocephalus, compared to the supratentorial group (tumours, n = 35/45, 77.8%; infections, n = 1/11, 9%). this is not surprising because of the anatomical relationship of infratentorial masses with csf drainage pathways, which result in obstruction of csf flow attributable to compression of the fourth ventricle. this finding corresponds with the literature.31 sindi lam et al. reported that hydrocephalus occurs in 71% – 90% of infratentorial tumours.32 hydrocephalus in supratentorial masses is secondary to obstruction of the third ventricle and cerebral aqueduct. herniation thirty-nine percent of the patients had associated herniation, secondary to raised icp. most masses were located in the infratentorial compartment (n = 22/51, 43.1%), causing tonsillar herniation. this occurs when there is increased pressure in the posterior fossa, causing herniation of the cerebellar tonsil through the foramen magnum.33 this can be attributable to the size of the mass (large mass) and the presence of significant associated vasogenic oedema. supratentorial masses were associated with subfalcine herniation (n = 18/56, 32.1%), where increased pressure caused herniation of the cingulate gyrus beneath the falx cerebri.33 limitations of the study the limitation of this study was the retrospective design and the single centre study. however, all paediatric patients with intracranial mass masses were managed at a single tertiary centre in the province of kzn. a larger cohort may have provided more information. conclusion in this series, the supratentorial compartment was the most common site for intracranial masses overall. the most common tumour was, however, a medulloblastoma, located in the infratentorial compartment. this information is an important guide when developing the differential diagnosis of common intracranial masses in paediatric patients referred to our institution and in planning further management. acknowledgements the authors acknowledge the ialch radiology staff for all their support relating to data collection and the support of the department of health authority gatekeepers. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.p.g. was the principal investigator and prepared the manuscript. b.e. and s.m.l. provided supervisory roles, made conceptual contributions towards the study and participated in the manuscript editing. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data that support the findings of this study are available from the corresponding author, upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references stefan dc, stones dk. the south african paediatric tumour registry 25 years of activity. samj. 2012;102(7):605–606. https://doi.org/10.7196/samj.5719 stones dk, de bruin gp, esterhuizen tm, stefan dc. childhood cancer 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2020 [cited 2021 feb 8]. available from: https://www.ncbi.nlm.nih.gov/books/nbk542246/ abstract introduction case report discussion conclusion acknowledgements references about the author(s) saumya pandey department of radiodiagnosis, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india nitin agarwal department of radiodiagnosis, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india vidushi gupta department of radiodiagnosis, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india ashok sharma department of radiodiagnosis, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india anil aggarwal department of gastrointestinal surgery, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india sunita gupta department of gastrointestinal surgery, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india ram krishan department of pathology, govind ballabh pant institute of post graduate medical education and research, delhi university, new delhi, india citation pandey s, agarwal n, gupta v, et al. diagnosing rare intraductal biliary neoplasms – intraductal papillary neoplasm of the bile duct: a case report with typical imaging findings. s afr j rad. 2022;26(1), a2387. https://doi.org/10.4102/sajr.v26i1.2387 case report diagnosing rare intraductal biliary neoplasms – intraductal papillary neoplasm of the bile duct: a case report with typical imaging findings saumya pandey, nitin agarwal, vidushi gupta, ashok sharma, anil aggarwal, sunita gupta, ram krishan received: 27 dec. 2021; accepted: 18 feb. 2022; published: 29 apr. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract intraductal papillary neoplasm of the bile duct (ipn-b) is a rare preinvasive intraductal pathology of the biliary tract. it should be differentiated from other more common benign or malignant causes of biliary obstruction and dilatation such as calculi or cholangiocarcinoma because the management and prognosis of this condition differs significantly. this case report describes a case of ipn-b in a 45-year-old female patient who presented with non-specific complaints of chronic abdominal pain without jaundice for three months. keywords: intraductal neoplasms; solid-cystic; papillary growth; biliary dilatation; mucin production; communicating; hyperenhancing. introduction intraductal papillary neoplasm of the bile duct (ipn-b) is a rare intraductal pathology of the biliary tract, accounting for 10% – 15% of biliary tract neoplasms.1,2 classically, the term has been used to describe lesions that present as an intraluminal papillary growth around a fibrovascular core, with evidence of intracellular and/or extracellular mucin. excessive mucin production often causes dilatation of the biliary tracts.3,4 while 5% – 20% patients may be asymptomatic, most present with non-specific complaints of chronic abdominal pain, intermittent jaundice and fever.2,3 according to the who classification of intraductal pathologies found in the biliary system, ipn-b is a type of preinvasive intraductal neoplastic entity, which is often a precursor lesion to invasive adenocarcinoma.2,5 it is important to rule out commoner causes of biliary duct dilatation, including stones and more sinister neoplastic aetiologies like invasive cholangiocarcinoma (intraductal type) as they carry different management and prognosis. we herein report a rare case of incidentally detected, intrahepatic ipn-b causing cystic dilatation of the left ductal system. case report a 45-year-old female patient presented to our gastroenterology outpatient department with complaints of a ‘dragging’ type, chronic abdominal pain for the past three months. there was no accompanying history of weight loss, yellowish discoloration (jaundice) or fever. there was no history of pruritis, loss of appetite or discoloration of stools. on clinical examination, the presence of hepatomegaly was observed; however, there was no evidence of a gall bladder lump on palpation. laboratory investigations revealed mild elevation of the serum total (~1.5 mg/dl) and direct bilirubin (~0.9 mg/dl) levels. hepatic aminotransferase enzymes also showed some elevation (alanine aminotransferase [alt]~100 iu/l; aspartate aminotransferase [ast]~90 iu/l). there was also a mild elevation of the alkaline phosphatase (alp) levels (~198 iu/l). however, tumour markers, carcinoembryonic antigen (cea) (~1.5 ng/ml), alpha-foetoprotein (afp) (~13 ng/ml) and carbohydrate antigen (ca) 19–9 (~18 iu/ml) were well within normal limits. there was no evidence of leucocytosis (total leukocyte count [tlc]~ 6000/µl) or eosinophilia (differential leukocyte count [dlc] revealed eosinophils < 5%). suspecting a low-grade biliary obstructive condition, the patient was initially referred for abdominal ultrasonography (usg). trans-abdominal usg of abdomen revealed a large, well-defined cyst in relation to the left segmental bile ducts, which appeared to be dilated. an irregular, isoechoic, papillary mural thickening was observed arising from one of the cyst walls, projecting into the lumen. no significant vascularity was appreciated on colour doppler scans. however, due to the large cyst size and limited acoustic window, biliary connection with the cyst could not be ascertained. given the solid-cystic nature of the lesion at usg, hydatid (immunoglobulin g [igg] titre-0.3; normal < 0.9) and amoebic serology (igg titre-0.47; normal < 0.9) was requested, which were both non-reactive. due to the limited information on usg and to further evaluate the status of the biliary radicles, contrast-enhanced magnetic resonance imaging (ce-mri) of the upper abdomen was performed. t1-weighted imaging demonstrated a well-defined cyst at the hilum with an isointense frond-like soft tissue lesion projecting into the cyst and extending into the common hepatic duct (chd)/common bile duct (cbd). upstream bilobar intrahepatic biliary radicles appeared to be mildly dilated. t2-weighted and magnetic resonance pancreatico-cholangiography (mrcp) sequences revealed the lesion to be a cystic, focal expansion of right hepatic duct and primary confluence with upstream minimal biliary dilatation. downstream cbd also showed mild dilatation (calibre ~7.8 mm). the mural soft tissue appeared to be heterogeneously hyperintense on t2-weighted sequences and showed diffusion restriction. triple phase contrast enhanced sequences showed late arterial enhancement in the mural soft tissue, with reduced enhancement on the porto-venous and delayed phases (figure 1, figure 2, figure 3 and figure 4). figure 1: t2w–tse axial sections showing cystic dilatation (black arrow) at the primary confluence with internal, mural-based, frond-like hypointense contents (white arrow), extending to the common hepatic duct/cbd. upstream dilated biliary radicles (green arrow) are observed with a mildly dilated cbd distally (red arrow). figure 2: axial t2w–tse (a) and t1-ffe (b) sections demonstrating an iso to hypointense mural-based growth (white arrow) projecting into the lumen of the common hepatic duct or cbd. high signal is observed within the lesion on the axial b-1000 dwi image (c) with low signal on the corresponding adc map (d). figure 3: dynamic post-contrast axial sequences revealing iso-intensity of the tumour (white arrow) on noncontrast (a), hyperenhancement on the late arterial phase (b), reduced hyperintensity on the porto-venous (c) and delayed (d) phases. figure 4: (a) balanced turbo field echo (btfe) coronal section showing the dilated downstream common hepatic duct and cbd (black arrow), separate from the lesion at the primary confluence. the site and extent of the intraductal tumour is best seen on the volumetric mip of the magnetic resonance pancreatico-cholangiography (b), indicating extension of the tumour into the common hepatic duct (white arrow) with upstream and downstream ductal dilatation. the patient subsequently underwent open hilar resection with standard lymphadenectomy. the right and left hepatic ducts were individually anastomosed to a jejunal loop by roux-en-y hepaticojejunostomy. gross examination of the resected cyst revealed mucinous material. histopathological analysis and immunohistochemistry staining of the resected specimen confirmed the lesion to be an ipn-b (intestinal subtype, histological type 2 with high-grade dysplasia) restricted to the primary confluence and right hepatic duct, with tumour-free cbd, left hepatic duct and hepatic margins (figure 5). figure 5: (a) the patient underwent open hilar resection with standard lymphadenectomy and right and left roux-en-y-cholangiojejunostomy. papillary growth was seen at the primary confluence, extending into the right hepatic duct. (b) low–power photomicrograph (hematoxylin & eosin [h & e] stain; magnification 10×) of the resected specimen showing papillary projections (black arrow) with a central fibrovascular core (green arrow). (c) high-power photomicrograph (h & e stain; magnification20×) showing irregular papillae with features of high-grade dysplasia and hyperchromatic nuclei (black arrow); goblet cells are also seen (white arrow). (d) positive immunohistochemistry staining (brown) for muc2 and muc5 using recombinant antibodies. discussion intraductal papillary neoplasm of the bile duct is a rare intraductal preinvasive neoplasm, which is analogous to intraductal papillary mucinous neoplasm of the pancreas. histologically, it is found to arise from the biliary tree stem cells in peribiliary glands, which can differentiate along the pancreatico-biliary, gastric, intestinal or oncocytic lines.2,4,6 the intestinal subtype expressing mucin core protein muc2 and muc5ac is more commonly found in the asian population, while the pancreatico-biliary subtype expressing muc1 is more frequent in the western population and carries a higher risk of malignant conversion. within the pancreatico-biliary histological type, the biliary type is more linked with malignant conversion, while the pancreatic subtype shows more mucin production.2 the disease is commonly found in men aged 40–80 years and patients often present with symptoms related to biliary obstruction caused by the tumour itself (upstream dilatation) or by the excessive mucin production (downstream dilatation).2,7 within the asian population, it most commonly involves the intrahepatic system (left lobe>right lobe), with risk factors including hepatolithiasis and clonorchis infection.2 morphologically, ying et al.8 divided ipn-b into seven sub-types, depending on the presence of intraductal polypoidal mass and site of dilatation an intraductal, polypoidal mass with minimal (type 1) or abundant (type 2) mucin production showing ectatic upstream biliary dilatation. mucin production (type 2) was also associated with downstream biliary dilatation. no intraluminal polypoidal mass with abundant mucin production causing diffuse dilatation of upstream and downstream biliary radicles (type 3 and 4). type 3 showed a superficial spreading, cast-like mural thickness on resection, whereas type 4 showed no evidence of any growth. polypoidal intraluminal growth causing cystic, focal, aneurysmal dilatation of the intrahepatic (type 5) or extrahepatic biliary system (type 6). this morphology is considered typical of ipn-b and is found in the presented case as well. infiltrating mass showing extraductal spread with biliary dilatation, upstream and/or downstream. this morphology is difficult to distinguish from mass forming, invasive cholangiocarcinoma. a large extraductal mass with evidence of invasion of adjacent organs is suggestive of malignancy.9 depending on the histological grade, ipn-b can be further divided into (1) type 1 including mild to intermediate grade dysplasia and (2) type 2 including high-grade dysplasia.2,5 at ultrasound examination, the intraductal mass is commonly seen as a hypo or hyperechoic mass inside anechoic-dilated bile ducts.10 mucin cannot be differentiated from bile on ultrasound. contrast-enhanced ultrasound cannot help us in distinguishing benign, preinvasive lesions from malignant lesions. at ct, the solid components appear hyperattenuating compared with the surrounding hepatic parenchyma. at mri, the solid component appears to be hypointense on t1 and hyperintense on t2-weighted images. multiphasic contrast-enhanced scans are most important in differentiating ipn-b from other intraluminal neoplastic and nonneoplastic aetiologies. the solid component of ipn-b tumours tends to show contrast uptake in the late arterial phase, with reduced enhancement on porto-venous and delayed phases due to lack of a fibrous component.2,11 this is consistent with the findings in this case report. intraductal mucin may be seen as string-like filling defects on mrcp or on the hepato-biliary phase of contrast-enhanced mri. endoscopic pancreatico-cholangiography (ercp) helps in the confirmation of the diagnosis by visualisation of mucin discharge from the major papilla and obtaining a biopsy.12,13 given the type 5 morphology of the lesion in the presented case, important differentials and imaging characteristics for consideration are presented in table 1. table 1: differential diagnoses of intrahepatic, intraductal solid-cystic tumours. since a malignant component can be found in nearly 33% – 80% of cases of ipn-b, the primary management is surgical resection with a tumour-free margin. depending on the extent and site of the lesion, surgery can be either partial hepatectomy with cbd resection (intrahepatic lesions) similar to the case presented or isolated cbd resection with a hepatico-jejunostomy (extrahepatic lesions).2 the 5-year survival rate of ipn-b has been found to be as high as 80.9%, with the surgical outcome mainly dependent on the tumour site, size and obtaining a free surgical resection margin (r0).16,17 although the 5-year survival rate is relatively better than cholangiocarcinoma, due to the high rate of recurrence, long-term follow-up with mrcp is advised.18 conclusion intraductal papillary neoplasm of the bile duct is a relatively rare but important differential to consider while assessing a case of cystic biliary dilatation and biliary intraductal masses. characterised by mucin production causing upstream and downstream biliary dilatation, patients usually present with symptoms of biliary obstruction. it is important to rule out malignant mimics like intraductal cholangiocarcinoma, which have a worse prognosis, more radical management and poorer patient outcome. acknowledgements the authors acknowledge dr vidya sharada bhat (senior resident, department of gastrointestinal surgery) for providing the clinical details and laboratory findings of the patient. they also thank dr priyanka garg and dr dinesh meher (junior residents, department of radiodiagnosis) for academic discussions related to the case. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. authors’ contributions s.p. was the primary author who prepared the manuscript. v.g. sourced the images. n.a. wrote the figure legends and edited the manuscript. a.s. reviewed and finalised the manuscript. a.a. and s.g. operated on the patient and provided the intra-op findings. r.k. provided the histopathological images and diagnosis. ethical considerations all information in this study involved accessing archived records is in accordance with the ethical standards of the institutional and/or national research committee. informed consent on the nature of study and publication of case details was obtained from the patient involved in the study. funding information this research work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this research article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ainechi s, lee h. updates on precancerous lesions of the biliary tract: biliary precancerous lesion. arch pathol lab med. 2016;140(11):1285–1289. https://doi.org/10.5858/arpa.2015-0396-rs chatterjee a, vendrami cl, nikolaidis p, et al. uncommon intraluminal tumors of the gallbladder and biliary tract: spectrum of imaging appearances. radiographics. 2019;39(2):388–412. https://doi.org/10.1148/rg.2019180164 wan x-s, xu y-y, qian j-y, et al. intraductal papillary neoplasm of the bile duct. world j gastroenterol. 2013;19(46):8595–8604. https://doi.org/10.3748/wjg.v19.i46.8595 lingegowda d, gehani a, mukhopadhyay s, midha d, banerjee s, gupta b. intraductal papillary neoplasm of the bile ducts: case reports with review of the literature. j gastrointest abdominal radiol. 2020;4(1):58–61. bosman ft, carneiro f, hruban rh, theise nd. who classification of tumours of the digestive system. geneva: world health organization; 2010. nakanuma y, sato y. cystic and papillary neoplasm involving peribiliary glands: a biliary counterpart of branch-type intraductal papillary mucinous [corrected] neoplasm? hepatology. 2012;55(6):2040–2041. https://doi.org/10.1002/hep.25590 adibi a, shabanikia n, taheri a. intraductal papillary mucinous neoplasm of biliary ducts: literature review and a case report with emphasis on radiological manifestation. j res med sci. 2020;25(1):114. https://doi.org/10.4103/jrms.jrms_119_20 ying s, ying m, liang w, et al. morphological classification of intraductal papillary neoplasm of the bile duct. eur radiol. 2018;28(4):1568–1578. https://doi.org/10.1007/s00330-017-5123-2 gordon-weeks an, jones k, harriss e, smith a, silva m. systematic review and meta-analysis of current experience in treating ipnb: clinical and pathological correlates. ann surg. 2016;263(4):656–663. https://doi.org/10.1097/sla.0000000000001426 lee ss, kim mh, lee sk, et al. clinicopathologic review of 58 patients with biliary papillomatosis. cancer. 2004;100(4):783–793. https://doi.org/10.1002/cncr.20031 ogawa h, itoh s, nagasaka t, suzuki k, ota t, naganawa s. ct findings of intraductal papillary neoplasm of the bile duct: assessment with multiphase contrast-enhanced examination using multi-detector ct. clin radiol. 2012;67(3):224–231. https://doi.org/10.1016/j.crad.2011.08.015 lim jh, yoon k-h, kim sh, et al. intraductal papillary mucinous tumor of the bile ducts. radiographics. 2004;24(1):53–66. https://doi.org/10.1148/rg.241035002 subhash r, valiyaveettil i, natesh b, raji l. biliary tract intraductal papillary mucinous neoplasm: a brief report and review of literature. indian j pathol microbiol. 2014;57(4):588–590. https://doi.org/10.4103/0377-4929.142676 komori t, inoue d, zen y, et al. ct imaging comparison between intraductal papillary neoplasms of the bile duct and papillary cholangiocarcinomas. eur radiol. 2019;29(6):3132–3140. https://doi.org/10.1007/s00330-018-5841-0 kim ay, jeong wk. intraductal malignant tumors in the liver mimicking cholangiocarcinoma: imaging features for differential diagnosis. clin mol hepatol. 2016;22(1):192–197. https://doi.org/10.3350/cmh.2016.22.1.192 kim jr, jang kt, jang jy, et al. clinicopathologic analysis of intraductal papillary neoplasm of bile duct: korean multicenter cohort study. hpb (oxford). 2020;22(8):1139–1148. https://doi.org/10.1016/j.hpb.2019.11.007 matono r, ninomiya m, morita k, et al. branch-type intraductal papillary neoplasm of the bile duct treated with laparoscopic anatomical resection: a case report. surg case rep. 2020;6(1):103. https://doi.org/10.1186/s40792-020-00864-3 luvira v, pugkhem a, bhudhisawasdi v, et al. long-term outcome of surgical resection for intraductal papillary neoplasm of the bile duct. j gastroenterol hepatol. 2017;32(2):527–533. https://doi.org/10.1111/jgh.13481 abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) francois a. van der merwe department of clinical imaging sciences, faculty of health sciences, university of the free state, bloemfontein, south africa eugene loggenberg department of clinical imaging sciences, faculty of health sciences, university of the free state, bloemfontein, south africa citation van der merwe fa, loggenberg e. dual-energy index variation when evaluating the potential ferromagnetism of ex vivo bullets. s afr j rad. 2023;27(1), a2701. https://doi.org/10.4102/sajr.v27i1.2701 original research dual-energy index variation when evaluating the potential ferromagnetism of ex vivo bullets francois a. van der merwe, eugene loggenberg received: 21 apr. 2023; accepted: 13 june 2023; published: 27 july 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: an mri is potentially hazardous for patients with retained ferromagnetic bullets. recent studies have aimed to develop dual-energy computed tomography (dect) as a screening tool for recognising highly ferromagnetic bullets. inconsistent findings have been ascribed to inherent ct technology differences. previous research demonstrated significant hounsfield unit (hu) measurement variation among single-source ct machines. objectives: this study investigated the theoretical dual-energy index (dei) variation between dect machines when evaluating the potential ferromagnetic properties within the same sample of ex vivo bullets and metal phantoms. method: an experimental ex vivo study was conducted on eight metal phantoms and 10 unused bullets individually positioned in the same perspex head phantom and scanned on two dect machines. two senior radiology registrars independently recorded the hu readings, and dei values were calculated. statistical analysis was performed using non-parametric methods for paired data, namely the signed rank test. the dei values based on mean hu readings between the dect machines were compared. results: interand intra-reader agreement was not statistically significant. the metal phantoms had poor interscanner agreement, with an overlap of the ferromagnetic and non-ferromagnetic ranges. the bullets had good interscanner agreement, with a similar ferromagnetic to non-ferromagnetic relationship. conclusion: the use of dei values negates the previous assumption that significant interscanner variability exists among different dect technologies while assessing highly attenuative ex vivo bullets. contribution: this investigation demonstrated that even though hu readings may be variable, the implementation of the dei equation translates this into comparable values with good interscanner agreement. keywords: dual-energy computed tomography; ferromagnetic bullets; dect machines; interand intra-reader agreement; mri safety. introduction south africa has a very high violent crime burden, related to high morbidity and mortality rates. according to the south african crime statistics released for 2019–2020, firearm violence resulted in 7351 murders (of a total 21 325) and 12 718 attempted murder cases (of a total 18 635). firearms were further implicated as the main tool of intimidation in most other crime categories and established relations with multiple murders.1 law enforcement and criminal interactions are not the only source of gunshot injuries, as these may also occur during sport and hunting. non-fatal gunshot injuries are widespread, and as a result, penetrating trauma makes up a large portion of the trauma population requiring medical care.2,3 recent research highlighted gunshot wounds as a leading cause of spinal cord injuries, mostly involving younger males. patients experienced a higher rate of adverse medical complications and morbidity, often required surgery, and had prolonged hospital admissions.4 continuous advances and improvements in emergency medical care and technology will likely decrease trauma fatalities. it can reasonably be concluded that secondary evaluation techniques and residual lesion identification will become increasingly important as patients require further and definitive care.5 an mri was previously deemed an absolute contraindication for patients with retained bullets, especially if these were close to vital structures. the main concerns are the potential hazards of in vivo position shift and the heating effect of the bullet within the mri magnetic field. a recent investigation found that ferromagnetic mri-related incidents are underreported and that there is a definite desire among radiology staff to broaden and advance the knowledge base and culture regarding the safety aspects of ferromagnetic materials related to mri investigations.6 a recent study found that only highly ferromagnetic bullets can potentially shift in vivo position within mri magnetic fields and that most bullets are non-ferromagnetic.5 it was concluded that bullet migration within the static magnetic field is minimal and related to the shape and orientation of the bullet.7 it was further shown that the potential ferromagnetic heating effect does not appear significant.8 this indicates that mri might not be an absolute contraindication if the bullet (and composition) is known.5 highly ferromagnetic bullets cause large amounts of mri susceptibility artefacts, which degrade image quality and thus reduce clinical relevance.5 the shellock mri safety list is an invaluable resource if the bullet in question is known. unfortunately, the current list of bullets is very limited and mostly rated for 1.5 tesla (t) mri fields. clinical 3t and 7t mri machines are becoming more widely utilised and the increased magnetic fields may elicit different or more dramatic interactions.9 dual-energy computed tomography (dect) has in recent years demonstrated its ability to characterise urinary calculi,10 quantify coronary calcification,11 contrast agent uptake measurements,12 ventilation-perfusion assessment with xenon gas,13 and discriminate intracranial haemorrhage from contrast medium.14 materials composed of different elemental compositions may produce very similar hounsfield units (hus) at a given energy, which significantly complicates the differentiation and classification of such materials. each voxel’s hu represents a linear attenuation coefficient, which is not unique to any given material but rather a function of the material’s composition, its photon energy interaction and its mass density.15 there are no minimum or maximum limitations to the hounsfield scale.16 the dect can be defined as the use of attenuation measurements acquired with different energy spectra, in addition to the known changes in attenuation between those spectra, to differentiate and quantify material composition.15 this was initially explored and described by godfrey hounsfield, who stated in 1973, ‘two pictures are taken of the same slice, one at 100 kev and the other at 140 kev … so that areas of high atomic numbers can be enhanced’.17 alvarez and macovski further investigated dect in 197617 and demonstrated that even with polyenergetic x-ray spectra, one could still separate the measured attenuation coefficients into their contributions from the principal forms of photon interaction with matter, namely photoelectric effect and compton scatter.18 forensic medicine studies have found dect capable of differentiating between commonly found foreign materials,19 and identified a potential relationship between a bullet’s ferromagnetic properties and dual-energy index (dei) value. the dect has been proven superior to single-source ct while attempting to differentiate between high-density materials because of acquiring data sets at different x-ray beam energies.20 bullets are made of a variety of materials. traditionally, bullet cores contain lead, or an antimony-lead alloy, while bullet jackets are made of copper or gilding metal (copper-zinc alloy). various materials are commonly used in modern bullets, including bismuth, aluminium, bronze, copper, steel, tin, tungsten, plastics and rubber. the different high-density metals that constitute bullets might be discernible with industrial ct equipment (> 320 kv), but the radiation doses are not compatible with clinical applications in healthcare.21 bullet characterisation with clinical ct machines has multiple obstacles pertaining to both artefact generation (e.g., high anatomic number, projectile size, metal interfaces, beam hardening and scatter) and reconstruction algorithms.22 the cupping artefact encountered with metals is a subcategory of beam hardening and scatter, leading to misinterpreting the obtained image as a representation of the bullet jacket and core. the ‘core’ portion of the bullet image is a combination of high attenuation and photon starvation, whereas the ‘jacket’ portion is the outer layer composed of scatter artefacts.23 recent studies have aimed to combine dect with the extended hu scale (ehus) to discriminate between highly ferromagnetic and non-ferromagnetic bullets.24,25 the end goal is to determine mri safety in patients with retained bullets, especially when close to vital structures. most of these studies have identified a potential relationship, although the results have been inconsistent. a commonly identified limiting factor has been ct technology differences. the ct machine manufacturer has been constant, but models and machine service ages differed.20,26,27 these studies demonstrated that highly ferromagnetic and non-ferromagnetic bullet dei numbers clustered together within respected, although inconsistent, ranges.20,26,27 interscanner variability has not been evaluated among different dect machines utilising dei values. the purpose of this study was to investigate the theoretical dei variation between different dect machines while evaluating the potential ferromagnetic properties within the same sample of ex vivo bullets and metal phantoms. materials and methods study design, settings and projectiles this experimental ex vivo study comparatively examined metal phantoms and bullets on two different dect machines. eight solid rod metal phantoms (12 mm diameter, 5 cm length) were investigated, representing the wide range of metals used in bullet production. the solid rods were bright bar steel, dark bar steel, tungsten, stainless steel, brass, lead, aluminium and copper. the copper rod was excluded from the study after the mri testing, as it demonstrated strong magnetism and thus represented an alloy rather than pure copper. ten unused bullets of various calibres were examined (table 1). the main elemental composition of projectiles was derived from physical examination. specific manufacturers and composition were not available at the time of the investigation. these bullets represented commonly available firearm calibres. the individual bullet composition did not factor into the end study results, as each bullet’s magnetic properties were compared with its dei value. table 1: details of the bullets investigated. according to suggestions from previous research, some ballistic projectile categories were excluded from the study because of size, composition, and ct spatial resolution restrictions.28 these were air rifle projectiles, shotgun pellets, paintballs and bb gun pellets. empirical ferromagnetic testing for each bullet and metal phantom was performed according to methods described in multiple previous studies concerning the deflection angle.29 the projectiles and metal phantoms were individually suspended on a string in front of a marked non-ferrous vertical board at the portal of an mri machine (philips 3t ingenia, universitas academic hospital’s clinical imaging department), and the deflection angles from vertical were documented. torque value investigation was not performed, as previous studies have indicated a linear relation between deflection angle and torque propensity.24 three metal phantoms were non-ferrous, three demonstrated marked ferromagnetic properties, and one had intermediate ferromagnetic properties. the copper metal phantom was found to be a ferromagnetic copper alloy and was excluded from further testing. five bullets were non-ferromagnetic, one demonstrated mild ferromagnetic properties, and four were markedly ferromagnetic. two ferromagnetic bullets had a larger deflection angle (exceeding 90°) compared with the ferromagnetic metal phantoms. a realistic and reproducible study environment was achieved using a perspex head phantom (large cylinder 16 cm diameter) while evaluating all metal phantoms and bullets. a central cylindrical cavity within the perspex phantom enabled a reproducible perpendicular central placement of metal phantoms and bullets within the ct machine gantries. methods and measurement the metal phantoms and bullets were individually scanned on two different single-source dect machines, which varied in manufacturer, production date, operational time, software and post-processing capabilities: general electric ct discovery 750 hd 64-slice installed at universitas academic hospital, clinical imaging sciences department (december 2011). acquisition and processing were performed on the accompanying workstation (aw volume share 4). data collection was carried out on agfa pacs because of technical limitations on the aw volume share workstation. siemens healthcare somatom definition as+ 128-slice installed at pelonomi academic hospital, clinical imaging sciences department (december 2020). acquisition and processing were performed on the aw. data collection was performed on the syngo.via workstation. the siemens somatom ct scanner allowed the ehus (−10 240 to +30 710) activation during reconstruction. the ge discovery required a complete system restart after activating the ehus function, following which the ehus was continuously active till manually deactivated. temporal sequential scanning of the entire scan volume was performed with tube strength at 100 kv and 140 kv on each metal phantom and projectile to allow for similar machine settings. this approach was used because the dual-energy programme settings did not allow for individual tube setting alterations, nor did the siemens somatom allow activation of the ehus within the dual-energy programmes. metal phantoms and bullets were scanned with the following parameters26: tube voltage 100 kv and 140 kv, exposure 400 mas, rotation time 0.5 s, pitch 0.6, slice collimation 2 mm × 64 mm × 0.6 mm, slice acquisition 2 mm × 64 mm × 0.6 mm. reconstruction was on a sharp tissue kernel with ehus activated. slice thickness was 1.5 mm on the siemens somatom and 1.25 mm on the ge discovery. both were set to 1 mm increments.26 the region of interest (roi) placement30 was central, without incorporating the edge, and covering more than one pixel. two sets of readings were obtained per bullet and examination, at least five slices apart. the hu readings were recorded for mean, maximum, minimum and standard deviation (s.d.). figure 1 illustrates the comparative roi placement for a metal phantom and 9 mm bullets. figure 1: the comparative region of interest (roi) placement for a (a) bright bar metal phantom, (b) 9 mm browning (non-ferrous) bullet, and (c) 9 mm lugar (ferromagnetic). tube voltage at 100 kv (left) and 140 kv (right); siemans somatom (top) and ge discovery (bottom). two independent senior radiology registrars performed all the readings, one of whom was blinded to the ferromagnetic testing. metal phantoms and bullets were allocated a specific description used throughout the investigation period. to evaluate intra-reader agreement, a second round of scans and readings were performed on the bullets 2–4 weeks after the initial scans. dual-energy index the dect data were reconstructed and measured using an ehus at two different energy levels. these readings were then converted to a dei value using a standard equation26: for the low kv, the ehus reading was at 100 kv and the high kv at 140 kv. the dei was calculated for all measured hu readings (mean, maximum, minimum). the mean hu readings and the corresponding dei values were submitted for statistical analyses and used for further interpretation. statistical analysis descriptive statistics, namely frequencies and percentages for categorical data and medians and percentiles for numerical data, per type of bullet and metal phantom, were calculated. as a result of the small sample sizes, the bootstrap methodology was not appropriate; therefore, the bullet types were compared by means of non-parametric methods. interand intra-rater reliabilities were calculated and described by means of non-parametric methods for paired data, namely the signed rank test. intraclass correlations (icc) using the shrout-fleiss formula were calculated. the analysis was performed by the department of biostatistics, faculty of the health sciences, university of the free state. ethical considerations ethical approval to conduct the study was obtained from the university of the free state health sciences research ethics committee (hsrec) and permission to conduct the study at a state hospital was obtained from the free state department of health (ethics approval no.: ufs-hsd2020/0996/2508-0002). no consent was required in this study. results intra-reader and inter-reader agreement inter-reader agreement for the mean dei values was not statistically significant. the siemens somatom had excellent icc (p-values: icc for roi1 = 0.65:0.90900, roi2 = 1.00:0.92990, roi3 = 0.64:0.86502, roi4 = 0.19:−0.00536) and the ge discovery had good p-values with poor icc (p-values: icc for roi1 = 0.43:−0.65466, roi2 = 0.92:0.99177, roi3 = 0.49:−0.29474, roi4 = 0.56:−0.69093).31 the poor iccs were negative and correlated with a wider s.d. on the ge discovery. the metal phantoms demonstrated a wide p-value range and excellent icc on the siemens somatom (p-values: icc for roi1 = 0.94:0.99720, roi2 = 0.08:0.99856), but poor icc for the ge discovery (p-values: icc for roi1 = 0.47:0.38143, roi2 = 0.02:0.78236),31 which had a statistically significant variation on the second roi readings obtained on the ge discovery. intra-reader agreement was not statistically significant for the bullets’ mean dei values between the two radiology registrars (r1 and r2) with similar p-value ranges on the siemens somatom (r1 roi1 = 0.71, roi2 = 0.49; r2 roi1 = 0.56, roi2 = 0.32), and ge discovery (r1 roi1 = 0.06, roi2 = 0.63; r2 roi1 = 0.63, roi2 = 0.2). the proposed reason for the smaller p-values on the ge discovery is likely because of the wider s.d. range obtained for the mean rois. the metal phantoms demonstrated reduced intra-reader agreement with investigator 2 (r2) obtaining higher p-values on both siemens somatom (r1, p = 0.03; r2, p = 0.92) and ge discovery (r1, p = 0.22; r2, p = 0.69). investigator 1 (r1) obtained statistically significant roi readings on the siemens somatom. metal phantoms metal phantoms (table 2) were used to evaluate the variable dei values pertaining to the anatomic number of different metals and demonstrated the identified cupping artefact that these high-density materials create. metal phantoms consisted of single metal solid rods; thus, no core and jacket combination was often encountered with bullets. the obtained images dramatically demonstrated cupping artefacts, and the outer rim varied because of tube voltage and anatomic number. cupping artefacts can serve as a visual demonstration of beam hardening and photon starvation. table 2: metal phantom average hounsfield unit and dual-energy index values. figure 2 indicates all the metal phantom mean dei values obtained at the test sites, differentiating between investigators. figure 3 and figure 4 demonstrate the magnetic and non-magnetic metal phantom mean dei values at each site, differentiating between investigators. figure 2: overall findings for all metal phantom mean dual-energy index values (distinction is made between investigators and each ct machine). figure 3: metal phantom mean dual-energy index values obtained at pelonomi academic hospital on siemens somatom ct machine (distinction is made between investigators and ferromagnetic properties). figure 4: metal phantom mean dual-energy index values obtained at universitas academic hospital on ge discovery ct machine (distinction is made between investigators and ferromagnetic properties). siemens somatom metal phantom findings metal phantom dei values for both investigators were within similar ranges (r1: −0.0569 to 0.0546 with average −0.0070; r2: −0.0558 to 0.0547 with average −0.0060). further analysis of the dei values demonstrated that the ferromagnetic metals’ dei ranges were centrally located within the non-ferromagnetic ranges, which is different from previous studies. the average dei values for the ferromagnetic and non-ferromagnetic metals differed slightly (r1 ferromagnetic: −0.0488, non-ferromagnetic: −0.0569; r2 ferromagnetic: −0.0487, non-ferromagnetic: −0.0558). ge discovery metal phantom findings metal phantom dei values for both investigators were once more within similar ranges, although r2 obtained a narrower range (r1: −0.0737 to 0.0064 with average −0.0299; r2: −0.0679 to 0.0006 with average −0.0240). further analysis of the dei values demonstrated that the ferromagnetic metals’ dei ranges were within the upper half of non-ferromagnetic ranges, which is different from previous studies. the average dei values for the ferromagnetic and non-ferromagnetic metals differed more pronounced (r1 ferromagnetic: −0.0279, non-ferromagnetic −0.0737; r2 ferromagnetic: −0.0142, non-ferromagnetic: −0.0679). investigator 1 (r1) had a single significant outlier point (−0.1992), which significantly decreased the average dei value for the ferromagnetic metals. ballistic projectiles the hu measurements (table 3) were obtained from the central region of each bullet. the ‘jacket’ readings approached humax, even with the ehus. the measured areas of each bullet and phantom depended on the overall diameter and the thickness of the beam hardening artefacts. thus, the measured areas around the bullet centre varied between most readings. table 3: bullet average hounsfield unit and dual-energy index values. figure 5 indicates all the bullet mean dei values obtained at the test sites, differentiating between investigators. figure 6 and figure 7 demonstrate the magnetic and non-magnetic bullet mean dei values at each site, differentiating between investigators. figure 5: overall findings for all bullet mean dual-energy index values (distinction is made between investigators and each ct machine). figure 6: bullet mean dual-energy index values obtained at pelonomi academic hospital on siemens somatom ct machine (distinction is made between investigators and ferromagnetic properties). figure 7: bullet mean dual-energy index values obtained at universitas academic hospital on ge discovery ct machine. distinction is made between investigators and ferromagnetic properties. siemens somatom bullet findings the bullet mean dei values of both investigators had wider ranges compared with the metal phantoms (r1: −0.0635 to 0.178 with average −0.0419; r2: −0.1239 to 0.1589 with average −0.0509). further analysis of the dei values demonstrated that the ferromagnetic bullet dei ranges were within the non-ferromagnetic ranges, which was different from previous studies. the average dei values for the ferromagnetic and non-ferromagnetic bullets differed more significantly than the metal phantoms (r1 ferromagnetic: −0.0574, non-ferromagnetic: −0.0283; r2 ferromagnetic: −0.0658, non-ferromagnetic: −0.0395). the non-ferromagnetic bullets had more pronounced positive outlier dei values, which increased the average dei values. ge discovery bullet findings the bullet mean dei values of both investigators were once more within similar ranges (r1: −0.0787 to 0.1914 with average −0.0417; r2: −0.0796 to 0.2101 with average −0.0511). further analysis of the dei values demonstrated that the ferromagnetic bullet dei ranges were within the non-ferromagnetic ranges, which was different from previous studies. the average dei values for the ferromagnetic and non-ferromagnetic bullets differed more pronounced (r1 ferromagnetic: −0.0630, non-ferromagnetic: −0.0239; r2 ferromagnetic: −0.0635, non-ferromagnetic: −0.0358). the non-ferromagnetic bullets had more pronounced positive outlier dei values, which increased the average dei values. discussion this study aimed to investigate the proposed interscanner variability described as a limiting factor in previous literature pertaining to dect as a screening tool for ferromagnetic ballistic projectiles because of previous inconsistent findings.20,26,27,30 ruder et al.30 demonstrated a considerable hu variability between different ct machines, except for brass, which was found to completely attenuate x-ray beams and thought to obscure the differences observed with other materials. ruder et al.30 also showed that dect-capable machines had the lowest hu readings among the researched ct machines, although dual-energy was not utilised. the researchers used 80 kv tube voltage and a fixed tube current time product of 130 mas. these settings were a practical decision because of the ct machine limitations, as 80 kv was the only tube voltage available on all the machines.30 paulis et al.23 concluded that higher tube voltages and current time products reduce artefact influences on material differentiation, following which they recommended 150 kv tube voltage and 400 mas exposure. the conclusion of ruder et al.30 holds for single-source hu readings, and the current investigation also had variable individual hu readings among the studied dect machines. however, the use of dei values was found to be more consistent between the investigated dect readings. the dei values are functions of the hu readings and require different energy levels to calculate, which has the result that the ct technology differences are negated. it can be deduced that the ct technology differences affecting the low kv readings, similarly, influence the high kv readings and that this is annulled during the dei value calculation. winklhofer et al.20 concluded that dect was more reliable at differentiating materials than single-energy ct. they found that the optimal tube voltage combination was 100 kv/140 kv, although exposure was adjusted to produce constant radiation doses. diallo et al.26 used the same scan parameters and ct manufacturers, although the models differed (somatom definition flash vs somatom as+). both studies identified a dei difference between ferromagnetic and non-ferromagnetic bullets, although the relations were opposite. multiple other research studies19,20,23,26,27,30 have been conducted using siemens models, which do not account for the proposed inter-manufacturer variability. the reason for the variability among results has been ascribed to individual machine differences. our investigation was conducted with two completely different dect machines, which currently appears to be the only study to utilise other manufacturers. we believe the machines represent a broad enough ct technology variation to represent the proposed limitations previously identified in the tabled articles. our research advances the literature by evaluating this previously suggested interscanner variability. the machines had variable dei ranges for the metal phantoms (figure 2, figure 3 and figure 4), with considerable overlap. the siemens somatom dei averaged more positive (−0.0065) compared with the ge discovery (−0.027), although the latter had narrower ranges. the ferromagnetic phantom dei ranges (siemens somatom average: −0.0488; ge discovery average: −0.0211) were within the non-ferromagnetic phantoms’ dei ranges (siemens somatom average: −0.0564; ge discovery average: −0.0708). this is further complicated by the siemens ferromagnetic readings occupying the middle ranges and the ge ferromagnetic readings occupying the upper half of the non-ferromagnetic ranges. these findings indicate that the machines have a significant variation, and the individual machines might not be able to clearly distinguish ferromagnetic from non-ferromagnetic metals without individually calibrated reference ranges. the bullets (figure 5, figure 6 and figure 7) had a much better average dei value agreement between the two dect machines, with even the outlier points demonstrating similar values. the bullets showed a much narrower dei range, with a similar ferromagnetic to non-ferromagnetic relationship. the average ferromagnetic dei values were significantly lower than the average non-ferromagnetic values, similar to diallo et al.26 and the opposite to winklhofer et al.30 the current findings demonstrate a more pronounced overlap of dei values while comparing ferromagnetic to non-ferromagnetic bullets, whereas previous studies had a more pronounced difference with less overlap. despite these variations with previous similar research, the main objective of this investigation was to assess variability between different dect machines. the average bullet dei values were comparable between the machines (siemens somatom: −0.0464; ge discovery: −0.0464). furthermore, even the average ferromagnetic (siemens somatom: −0.0616; ge discovery: −0.0633) and non-ferromagnetic (siemens somatom: −0.0339; ge discovery: −0.0299) bullet dei values were comparable and within close proximity to each other. the average dei values give a false impression of a wide difference between ferromagnetic and non-ferromagnetic values, as the ranges largely overlap. significant outlier values for the non-ferromagnetic bullets increase the average dei values, however, the outlier dei values are similar between the dect scanners. limitations this research investigation had a couple of limitations worth mentioning and may require future study. small projectiles and fragments were excluded based on ct spatial resolution limitations.20 core readings were used for dei value calculation and analysis, as the ‘jackets’ have previously been shown to be unhelpful.20,23 undamaged unused bullets were used, and optimally placed within the centre of the gantries at perpendicular angles to the x-ray beams. this was done to limit projectile variables and test the research question in isolation. we are aware that bullets will orientate randomly and deform upon impact, and the position related to the gantry and surrounding structures may be different in real life situations. the metal phantom and bullet samples were small; however, we believe that these were sufficiently representative. larger metal phantom and projectile samples may have increased statistical relevance, although larger studies have been conducted on single machines. finally, ex vivo analysis is still under investigation and not yet applicable to emergency radiology. further research and agreement are required before implementation on the living should be considered. conclusion in conclusion, the use of dei values negates the previous assumption that significant interscanner variability exists among different dect technologies while assessing highly attenuative ex vivo ballistic projectiles. previous research indicated that different hu measurements are obtained with different ct machines, but this has not yet been reassessed on dect machines utilising dei values. this investigation has demonstrated that even though hu readings may be variable, the implementation of the dei equation translates this into comparable values with good interscanner agreement. future research on dect implementation for mri safety prediction related to bullets should use dei as a reference rather than hu only. acknowledgements the authors would like to acknowledge ms t. mulder, medical editor and writer, faculty of health sciences, university of the free state, for editorial and technical preparation of the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions f.a.v.d.m. was the primary researcher of this article and e.l. was the supervisor of the study. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data supporting the findings of this study are available from the corresponding author, f.a.v.d.m. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references south african police service. saps crime 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https://doi.org/10.1016/j.forsciint.2012.03.004 koo tk, li my. a guideline of selecting and reporting intraclass correlation coefficients for reliability research [published correction appears in j chiropr med. 2017;16(4):346]. j chiropr med. 2016;15(2):155–163. https://doi.org/10.1016/j.jcm.2016.02.012 sajr 709 functional mri in pre-surgical planning: case study and cautionary notes b s spottiswoode, phd mrc/uct medical imaging research unit, department of human biology, university of cape town, and division of radiology, stellenbosch university   s du plessis, mb chb division of psychiatry, stellenbosch university   a gretschel, mb chb, m med (neurosurg) division of neurosurgery, stellenbosch university   j lotz, ma, msc, frcr division of radiodiagnosis, stellenbosch university   corresponding author: s du plessis (stefandup@sun.ac.za) background. since its inception almost 20 years ago, functional magnetic resonance imaging (fmri) has greatly advanced our knowledge of human brain function. although the clinical applications of fmri are still limited, there have recently been encouraging advances for its use in pre-operative functional cortical mapping to identify potentially eloquent areas prior to neurosurgery. objectives. we explore the potential use of this emerging technique by presenting a neurosurgical case study, as performed at the cape universities brain imaging centre (cubic), tygerberg, cape town. we conclude with a brief summary of the potential pitfalls of this technique, as well as cautionary guidelines based on our experience. methods and results. a 22-year-old male patient from tygerberg hospital underwent the successful resection of an anaplastic astrocytoma after fmri presurgical planning at our facility. the subject was able to leave the ward unassisted. conclusion. if consideration is given to the many limitations of this emerging technique, fmri can be useful in aiding the neurosurgeon in pre-operative planning of his surgical approach.  s afr j rad 2012;16(3):107-110. doi:10.7196/sajr.709 functional magnetic resonance imaging (fmri) is an mri technique capable of estimating regional brain activity during a predefined cognitive task. the number of publications using fmri has increased exponentially1 since the technique was first introduced over 20 years ago.2 a pubmed search using the keywords ‘fmri or (‘functional mri’)’ at the time of writing, identified 31 176 results, with 28 882 of these having been published in 2011. although fmri has contributed significantly to our understanding of neurocognitive function, the number of resulting clinical applications has been limited. currently, the most promising direct clinical application is in pre-surgical planning, where fmri is used to identify the spatial relationship between important functional areas in the brain and the area to be resected.3 the fmri results can thus influence the entry point and trajectory of the surgical intervention to avoid damaging eloquent cortical areas. these are cortical areas in which injury causes symptomatic cognitive or motor deficits and therefore, if avoided, could greatly influence surgical outcome. the basis of fmri is that deoxygenated blood is magnetic whereas oxygenated blood is not. the presence of deoxyhaemoglobin in the tissue being imaged therefore perturbs the magnetic field, resulting in a signal loss as measured by t2*-weighted mr imaging. performing a task in the mri scanner causes increased neuronal activity, resulting in increased energy utilisation at the synapse, and consequently local increases in blood flow to the brain regions that are recruited during the task. this characteristic is known as the blood oxygen level dependent (bold) effect. the signal change measured by fmri is consequently not a direct measure of neuronal activity, but rather a combination of flow, metabolism, blood volume and blood oxygenation. this signal change is very small, in the order of 1 2% of the total signal. fmri scans typically involve alternating periods of rest and activity over a total scan period of 5 10 minutes, to improve the sensitivity of the technique. the colourful activation patterns associated with fmri indicate the statistical likelihood that the regional blood flow is synchronous with the predefined periods of rest and activity. the most commonly used fmri tasks for neurosurgical planning are tactile, motor, language and visual.4 active motor tasks are the most robust and established, although it is interesting to note that recent studies have also reliably identified motor regions using passive tasks5 and even at rest using functional connectivity fmri.6 language tasks can be used to determine speech dominance,7 although mixed results have been reported for preoperative mapping.8 even auditory tasks provide surprisingly robust results given the inherent mri scanner acoustic noise.9 , 10 all modern commercial mri systems offer functional mri sequences and data processing packages. these fmri results are limited to the grey matter, but they can be integrated with diffusion tensor imaging (dti), which is an mri technique for assessing white matter integrity11 and for tracking white matter fiber bundles.12 a number of vendors also provide stereotactic planning systems which integrate fmri (and dti) results for surgical planning. objectives the interpretation of fmri results is complex and the technique has still not been adopted as a mainstream clinical tool, even in the developed world. in south africa, the use of fmri is not yet officially recognised as a diagnostic radiological technique, yet a number of radiology practices have obtained fmri capability in anticipation of this. this report presents a surgical planning fmri case study performed at the cape universities brain imaging centre (cubic) in cape town, and discusses the limitations and some cautionary measures to consider when processing and interpreting the fmri data. methods a 22-year-old male patient presented to the emergency department at tygerberg hospital with a history of new-onset focal seizures with secondary generalisation. the patient admitted to alcohol and cannabis use. he was otherwise well and no further relevant history was obtained; on examination he was neurologically intact. an mri scan performed on the 1.5 tesla system (siemens magnetom symphony) at tygerberg hospital showed a t1-hypo-intense, t2-hyperintense well-circumscribed lesion with no surrounding vasogenic oedema in the left fronto-parietal area. there was minimal heterogenous contrast enhancement. the proximity of the tumour to the primary motor cortex was of particular concern, so the patient was referred to cubic for an fmri scan that was deemed crucial to establish safe resection margins and avoid injury to these eloquent cortical areas during surgery. the patient was scanned on a 3 tesla mri (siemens magnetom allegra). a sagittal t1-weighted 3d mprage image was acquired, followed by a dti sequence with diffusion-weighted volumes in 12 directions and b=1000 s/mm2. fmri motor tasks were performed separately for the left and right side. thirty-second periods of activity were alternated with equal periods of rest for the duration of the scan. for the lower limb, both the ankle and toes were flexed and extended repeatedly. for the upper limb, elbow and wrist flexion and extension was performed repeatedly while tapping consecutive forefingers against the thumb. the patient was requested to keep his upper arm as stationary as possible to minimise motion artifacts. the identical t2*-weighted epi sequence was run for all 4 fmri tasks, with the following parameters: tr=2000 ms, te=30 ms, slices=34, spatial resolution=3.8×3.8×3.5 mm3, matrix size=64×64, fov=240 mm, measurements/volumes=121, and scan time=4:06. the images were analysed using the brainlab iplan cranial 3.0 software (brainlab ag, feldkirchen, germany). the fmri data were preprocessed to correct for subject motion, and the dti data were preprocessed to correct for distortions owing to eddy currents. both the fmri and dti images were co-registered to the high resolution mprage image. the fmri activation patterns for the 4 motor tasks were displayed with a statistical significance of p<0.001. fibre tractography was performed from a manually defined volume around the tumour. the minimum fibre length was set to 40 mm; tracking was halted when the fractional anisotropy dropped below 0.15. the tumour volume was semi-automatically demarcated on the mprage images. results fig. 1 shows the rendered surface of the patient’s brain from the mprage image and the relative positions of the tumour (pink) and regions activated by the fmri motor tasks. the motor region associated with the patient’s right hand (red) lies immediately supero-lateral to the tumour. note the clear symmetrical contralateral activation patterns in the cerebellum, and the reduced right foot activation compared with the left foot activation. fig. 1. rendered brain surface showing the tumour (pink) and fmri motor regions in (a) oblique-posterior, and (b) lateral views. red is right hand/wrist/forearm; blue is left hand/wrist/forearm; orange is right foot/toes; green is left foot/toes. note the contralateral activation in the cerebellum. fig. 2 shows the fibre tracts stemming from the manually defined region around the tumour (yellow box in fig. 2b). corticospinal tracts are shown to be pushed laterally by the tumour and also to extend around to the superior aspect of the tumour. fig. 2. dti fibre tractography and fmri activation (a) overlaid onto an axial slice of the mprage image at the level of the tumour, and (b) rendered in 3 dimensions. the corona radiata fibres in the left hemisphere in (a) are pushed laterally by the tumour. some of the fibres deviated by the tumour can be seen in (b) to pass posteriorly and even superiorly to the tumour. the yellow box in (b) shows the manually-defined region used to seed the fibre tracking. the fibre colours correspond to the predominant fibre direction (green is antero-posterior; blue is crano-caudal; red is left-right). the patient was taken to theatre and the mass lesion was resected. according to the fmri data, the tumour was located just deep to the motor cortex. a cortical incision through the gyrus directly overlying the tumour would have injured the hand and foot area of the motor cortex. a more posterior approach through the sulcus just posterior of the motor strip was deemed safe. the motor cortex was identified clinically by evaluating the surface markings of the brain. unfortunately, stereotaxis and cortical mapping were unavailable to further delineate the areas of interest. surgery was uneventful and a good resection was achieved. post-operatively, the patient was noted to have a right-sided drop foot (0/5 power) but the right hand function was intact. the foot drop improved and power was documented as 3/5 at discharge on day 7 post surgery. the patient was able to leave the ward unassisted. histology showed the tumour to be an anaplastic astrocytoma. the patient was referred to our oncology department and received electron beam radiation therapy (ebrt). a follow-up scan showed no recurrence of tumour. discussion the use of fmri as a surgical planning tool continues to receive attention, as it could prove extremely valuable in many neurosurgical cases. intra-operative cortical mapping (iom), although invasive, can greatly aid the surgeon’s ability to remove mass lesions in proximity to eloquent areas. although fmri has not yet proven to be a reliable replacement for iom,8 it is a non-invasive and safe procedure that can aid in planning the surgical approaches needed for lesional resection by identifying eloquent areas. fmri also has application in assessing the feasibility of tumor resection,3 , 13 , 14 and in identifying suitable candidates who might benefit from iom.15 , 16 the bold effect improves with the square of the strength of the magnetic field, therefore higher field strength mri scanners are beneficial.17 however, susceptibility artifacts are also more pronounced at higher field strengths, which may result in incorrect spatial localisation. although fmri shows much promise in pre-surgical planning, processing and interpreting the results should be done with care. we advocate the following initial guidelines:   1. the output from each fmri experiment is a statistical parametric map describing the probability of activation. it is important to realise that setting the threshold too high will include cortical activation that could be due to mere chance, and a low setting could lead to false negative findings, consequently missing eloquent cortical areas. the activation threshold should be based on the clinician’s experience with the specific task, and should preferably be ascertained using a normal control sample. 2. fmri uses blood flow as a surrogate marker for cortical activation; therefore blood vessels leading to the activated region may also cause signal changes. 3. any tumour that interferes with the functional haemodynamic coupling could result in erroneous findings. the type of tumour may differentially affect the accuracy of the fmri findings.18 other factors such as tumour extent, histology and presence of vasogenic oedema still need to be adequately explored at high field strengths (3t and above).14 a recent article20 highlights such factors, where they report falsely localised fmri results in the presence of an arteriovenous malformation in a paediatric neurosurgical case study. 4. the echo planar images (epi) used in fmri are prone to susceptibility artifacts; consequently, co-registration with the high-resolution structural mri image will be imperfect, in particular near air-tissue interfaces (e.g. the inferior frontal regions). activation patterns in these areas should be interpreted with care. 5. during an fmri scan, numerous whole brain epi volumes are acquired at intervals of 1 2 seconds, making the technique susceptible to motion-related artifacts. the motion correction step in the fmri pre-processing quantifies the head translations and rotations as a function of time, and the data should be discarded for translations more than about 2 3 mm. 6. quality assurance scans20 should be performed routinely to ensure that the long-term signal drift in the epi images is within vendor-specified limits. 7. the presence of adjacent surgical clips or metallic implants from previous interventions also causes significant distortions and signal dropout in the epi images, and will probably render the fmri data useless. 8. the ability of fmri to show reliable activation crucially depends on the task design and the appropriateness of the task for the target patient population, including factors such as age, education, culture and a host of other factors. such factors might be even more relevant in low-income settings where patients’ level of education could also influence task performance, which makes it crucial that each functional imaging centre rigorously pursues the validation of their own fmri protocols tailored specifically to the eloquent region of interest, tumour type as well as patient population. conclusion we have presented a case study where fmri was used to identify the motor areas in relation to a tumour. the fmri results provided useful information to guide resection of the tumour, and the surgery was successful. however, this was a relatively straightforward case using a well-established fmri task. a detailed understanding of fmri and appropriate precautionary measures should be taken when using fmri to plan neurosurgical interventions.   acknowledgements. we thank siemens medical solutions south africa; brainlab south africa; and the staff at the cape universities brain imaging centre.   1. bandettini p. functional mri today. int j psychophysiol 2007;63:138-145. 1. bandettini p. functional mri today. int j psychophysiol 2007;63:138-145. 2. ogawa s, lee tm, kay ar, tank dw. brain magnetic resonance imaging with contrast dependent on blood oxygenation. proc natl acad sci usa 1990;87:9868-9872. 2. ogawa s, lee tm, kay ar, tank dw. brain magnetic resonance imaging with contrast dependent on blood oxygenation. proc natl acad sci usa 1990;87:9868-9872. 3. håberg a, kvistad ka, unsgård g, haraldseth o. preoperative blood oxygen level-dependent functional magnetic resonance imaging in patients with primary brain tumors: clinical application and outcome. neurosurgery 2004;54(4):902-915. 3. håberg a, kvistad ka, unsgård g, haraldseth o. preoperative blood oxygen level-dependent functional magnetic resonance imaging in patients with primary brain tumors: clinical application and outcome. neurosurgery 2004;54(4):902-915. 4. hirsch j, ruge mi, kim khs, et al. an integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions. neurosurgery 2000;47(3):711-722. 4. hirsch j, ruge mi, kim khs, et al. an integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions. neurosurgery 2000;47(3):711-722. 5. blatow m, reinhardt j, riffel k, nennig e, wengenroth m, stippich c. clinical functional mri of sensorimotor cortex using passive motor and sensory stimulation at 3 tesla. jmri 2011;34:429-437. 5. blatow m, reinhardt j, riffel k, nennig e, wengenroth m, stippich c. clinical functional mri of sensorimotor cortex using passive motor and sensory stimulation at 3 tesla. jmri 2011;34:429-437. 6. biswal b, yetkin fz, haughton vm, hyde js. functional connectivity in the motor cortex of resting human brain using echo-planar mri. magn reson med 1995;34:537-541. 6. biswal b, yetkin fz, haughton vm, hyde js. functional connectivity in the motor cortex of resting human brain using echo-planar mri. magn reson med 1995;34:537-541. 7. mahdavi a, houshmand s, oghabian ma, et al. developing optimized fmri protocol for clinical use: comparison of different language paradigms. j magn reson imaging 2011;34:413-419. 7. mahdavi a, houshmand s, oghabian ma, et al. developing optimized fmri protocol for clinical use: comparison of different language paradigms. j magn reson imaging 2011;34:413-419. 8. giussani c, roux f, ojemann j, sganzerla ep, pirillo d, papagno c. is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. neurosurgery 2010;66(1):113-120. 8. giussani c, roux f, ojemann j, sganzerla ep, pirillo d, papagno c. is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. neurosurgery 2010;66(1):113-120. 9. suzuki m, kitano h, kitanishi t, et al. cortical and subcortical activation with monaural monosyllabic stimulation by functional mri hearing research 2002;163:37-45. 9. suzuki m, kitano h, kitanishi t, et al. cortical and subcortical activation with monaural monosyllabic stimulation by functional mri hearing research 2002;163:37-45. 10. lanting cp, de kleine e, bartels h, van dijk p. functional imaging of unilateral tinnitus using fmri. acta otolaryngol 2008;128(4):415-421. 10. lanting cp, de kleine e, bartels h, van dijk p. functional imaging of unilateral tinnitus using fmri. acta otolaryngol 2008;128(4):415-421. 11. basser pj, mattiello j, lebihan d. mr diffusion tensor spectroscopy and imaging. biophysical j 1994;66:259-267. 11. basser pj, mattiello j, lebihan d. mr diffusion tensor spectroscopy and imaging. biophysical j 1994;66:259-267. 12. mori s, van zijl p. fiber tracking – principles and strategies: a technical review. nmr biomed 2002;15:468-480. 12. mori s, van zijl p. fiber tracking – principles and strategies: a technical review. nmr biomed 2002;15:468-480. 13. stippich c, rapps n, dreyhaupt j, et al. localizing and lateralizing language in patients with brain tumors: feasibility of routine preoperative functional mr imaging in 81 consecutive patients. radiology;243(3):828-836. 13. stippich c, rapps n, dreyhaupt j, et al. localizing and lateralizing language in patients with brain tumors: feasibility of routine preoperative functional mr imaging in 81 consecutive patients. radiology;243(3):828-836. 14. bizzi a, blasi v, falini a, et al. presurgical functional mr imaging of language and motor functions: validation with intraoperative electrocortical mapping. radiology 2008;248(2):579-589. 14. bizzi a, blasi v, falini a, et al. presurgical functional mr imaging of language and motor functions: validation with intraoperative electrocortical mapping. radiology 2008;248(2):579-589. 15. picht t, kombos t, gramm hj, brock m, suess o. multimodal protocol for awake craniotomy in language cortex tumour surgery. acta neurochir (wien) 2005;148(2):127-138. 15. picht t, kombos t, gramm hj, brock m, suess o. multimodal protocol for awake craniotomy in language cortex tumour surgery. acta neurochir (wien) 2005;148(2):127-138. 16. sherman jh, hoes k, marcus j, komotar rj, brennan cw, gutin ph. neurosurgery for brain tumors: update on recent technical advances. curr neurol neurosci rep. 2011 jun.;11(3):313-319. 16. sherman jh, hoes k, marcus j, komotar rj, brennan cw, gutin ph. neurosurgery for brain tumors: update on recent technical advances. curr neurol neurosci rep. 2011 jun.;11(3):313-319. 17. li s-w, wang j-f, jiang t, et al. preoperative 3t high field blood oxygen level dependent functional magnetic resonance imaging for glioma involving sensory cortical areas. chin med j 2010;123(8):1006-1010. 17. li s-w, wang j-f, jiang t, et al. preoperative 3t high field blood oxygen level dependent functional magnetic resonance imaging for glioma involving sensory cortical areas. chin med j 2010;123(8):1006-1010. 18. jiang z, krainik a, david o, et al. impaired fmri activation in patients with primary brain tumors. neuroimage 2010;52(2):538-548. 18. jiang z, krainik a, david o, et al. impaired fmri activation in patients with primary brain tumors. neuroimage 2010;52(2):538-548. 19. juenger h, ressel v, braun c, et al. misleading functional magnetic resonance imaging mapping of the cortical hand representation in a 4-year-old boy with an arteriovenous malformation of the central region. j neurosurg pediatr 2009;4(4):333-338. 19. juenger h, ressel v, braun c, et al. misleading functional magnetic resonance imaging mapping of the cortical hand representation in a 4-year-old boy with an arteriovenous malformation of the central region. j neurosurg pediatr 2009;4(4):333-338. 20. weisskoff rm. simple measurement of scanner stability for functional nmr imaging of activation in the brain. magn reson med 1996;26:643-645. 20. weisskoff rm. simple measurement of scanner stability for functional nmr imaging of activation in the brain. magn reson med 1996;26:643-645. abstract introduction methods results discussion limitations conclusion acknowledgements references about the author(s) khanyisa n. mrwetyana department of clinical imaging sciences, faculty of health sciences, university of the free state, bloemfontein, south africa jacques janse van rensburg department of clinical imaging sciences, faculty of health sciences, university of the free state, bloemfontein, south africa gina joubert department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa citation mrwetyana kn, janse van rensburg j, joubert g. cost awareness of radiological studies among doctors at universitas academic hospital in bloemfontein, south africa. s afr j rad. 2021;25(1), a2188. https://doi.org/10.4102/sajr.v25i1.2188 original research cost awareness of radiological studies among doctors at universitas academic hospital in bloemfontein, south africa khanyisa n. mrwetyana, jacques janse van rensburg, gina joubert received: 12 may 2021; accepted: 19 july 2021; published: 20 sept. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa has high healthcare expenses. improving cost-consciousness could decrease government expenditure on healthcare. objectives: to determine cost awareness of radiological studies among doctors at a tertiary hospital. the objective was met by assessing the accuracy of cost estimation according to the level of training and speciality, whether participants had received prior education/training related to cost awareness and if they had a desire to learn more about the cost of radiological imaging. method: a cross-sectional survey was conducted in six clinical departments at universitas academic hospital using an anonymous questionnaire that determined doctors’ cost awareness of five radiological studies. each radiological study was answered using six different cost ranges, with one correct option. costs were based on the department of health’s 2019 uniform patients fee schedule (upfs). results: in total, 131 (67.2%) of 195 questionnaires distributed to registrars and consultants were returned. overall, low accuracy of cost estimation was observed, with 45.2% of the participants choosing only incorrect options. no participant estimated all five costs correctly. only the internal medicine clinicians demonstrated a significant difference between registrars and consultants for the number of correct answers (median 0 and 1, respectively) (p = 0.04). no significant differences were found between specialities stratified by registrars/consultants. most participants (88.6%) would like to learn about imaging costs. only 2.3% of the participants had received prior education/training related to cost awareness of radiological studies. conclusion: doctors were consistently inaccurate in estimating the cost of radiological studies. educating doctors about the cost of radiological imaging could have a positive effect on healthcare expenditure. keywords: cost awareness; radiological studies; imaging; estimation; accuracy. introduction it is estimated that patient-care decisions made by doctors are responsible for more than 80% of the healthcare expenditure.1 doctors are responsible for the radiological studies requested and can act as gatekeepers to ensure that resources are used judiciously and efficiently. south africa, a developing country, has limited resources and a high burden of disease. with the current economic situation, the south african government will benefit from mitigating fruitless and wasteful expenditure on healthcare costs. for this to be realised, it has to start with incorporating cost-consciousness into medical practice.2 when doctors are aware of the costs of radiological studies, it may reduce the number of studies requested, which would translate into reduced healthcare costs.3,4 decreasing unnecessary costs would mean that funds could be saved and reallocated to other critical healthcare burdens in south africa such as tuberculosis, hiv and aids.5 inappropriate use of radiological studies adds to healthcare costs without improving the quality of care provided to patients. according to the south african competition commission’s health market inquiry, claims submitted to medical schemes for radiological studies increased by approximately 11% per year between 2011 and 2014.6 international studies report that the number of radiological studies requested has increased drastically in the past 20 years. medical imaging utilisation has grown faster than any other medical service, which puts a massive strain on the healthcare expenditure, and can result in the unsustainability of the healthcare system. the increase in medical imaging is partially due to the use of new imaging techniques but could mostly be attributed to overutilisation of radiological studies. overutilisation of radiological studies adds to unnecessary expenditure and contributes to unwarranted costs to the healthcare system.7,8,9,10 it also exposes patients to unnecessary radiation, which in turn predisposes patients to increased cancer risk. it has been reported that approximately 33% of healthcare spending is duplicative, pointless and avoidable. they may also aggravate the patient’s clinical condition.9 yet, the majority of doctors are unaware of the costs of radiological studies they request. several studies have also shown that doctors inaccurately estimate the cost of radiological studies they request and are unlikely to consider the effects of over-investigation on patients and the healthcare system.2,11,12,13 in saudi arabia, only 3.4% of surgeons were cognizant of the costs of imaging investigations.2 a canadian study13 found that emergency physicians had limited awareness of the costs of pharmaceutical, laboratory and radiological studies. these physicians overestimated pharmaceutical agents and laboratory costs, opposed to frequently underestimating the costs of radiological studies. a disregard for costs related to radiological imaging was attributed to a lack of health economics teaching in medical schools and insufficient training on costs during residency.13 steyn and gebremariam,14 in a recent study, reported on the cost of violence-related medical imaging in a trauma unit of a tertiary hospital in the free state province. however, to the best of the authors’ knowledge, no studies specifically focussing on radiological cost awareness have been published in south africa. this study aimed to determine cost awareness of radiological studies among doctors at universitas academic hospital, bloemfontein, south africa. the objectives were to assess (1) whether there were differences in the accuracy of cost estimations according to different levels of training and speciality and (2) whether the participants had received any prior education or training related to cost awareness of radiological studies, and if they desired to learn about the cost of radiological imaging. methods study design a cross-sectional observational study was conducted to assess the cost awareness of radiological studies among registrars and consultants at universitas academic hospital, bloemfontein, south africa. research setting and sampling method the study was conducted among medical professionals employed in six clinical departments at universitas academic hospital, bloemfontein, south africa. the participants were recruited from the departments of clinical imaging sciences, internal medicine, paediatrics and child health, general surgery, oncology and obstetrics and gynaecology. data collection a questionnaire, which was in english, was developed to collect the data. the questionnaire consisted of three sections: (1) demographic information including age, sex, speciality, level of training, involvement in private practice; (2) estimation of radiological study cost and (3) the participant’s desire to learn about imaging costs and any prior education or training related to cost awareness of radiological studies. the uniform patients fee schedule (upfs) is a fee schedule used to bill externally funded patients using public hospitals across south africa. imaging studies on the upfs are categorised from category a to e according to the complexity of the investigation, with category a procedures characterised as least expensive and category e most expensive. each category has two prices: a facility fee (depending on the level of the hospital, which may be level 1, 2 or 3 as determined by the extent of services rendered by the specific hospital) and a professional fee (depending on the level of training of the healthcare professional who performs or interprets the radiological study).14,15 the 2019 upfs radiological fees are presented in table 1.15 table 1: south african department of health 2019 uniform patient fee schedule: tariffs for radiological studies according to hospital level.15 concerning the estimation of the cost of radiological studies, five different imaging modalities were included: (1) two-view chest x-ray (posteroanterior and lateral projections), (2) non-contrasted ct of the brain, (3) mri of the brain without contrast, (4) contrast-enhanced ct of the abdomen and pelvis and (5) abdominal ultrasound. these modalities were chosen because they were among the most frequently requested radiological studies. doctors were provided with six different cost ranges to choose from for each modality, with only one correct option. the costs were based on the south african national department of health’s 2019 upfs.15 figure 1 represents the section of the questionnaire pertaining to cost estimation of radiological studies. an open-ended question on why they would want to learn about the cost of radiological studies was also included in the questionnaire. figure 1: cost estimation component of the questionnaire with radiological costs from which the participants had to select one correct option (the correct options are indicated by x). in total, 195 doctors qualified to participate in this study. the questionnaires were distributed and collected by the principal researcher at the academic meetings of the various departments. participation was voluntary. the questionnaires were completed immediately and anonymously, after which the completed forms were placed in a sealed box. data analysis the principal researcher entered the data into a microsoft excel spread sheet designed for the purpose of the study. analysis was done by the department of biostatistics, faculty of health sciences, university of free state. in cases where a cost estimation question was not answered, it was assumed that the respondent did not know the correct answer. categorical variables were summarised by frequencies and percentages and numerical variables by medians and percentiles. subgroups were compared using chi-square or fisher’s exact tests (categorical variables) and median tests (numerical variables). ethical considerations ethical approval was obtained from the health sciences research ethics committee (hsrec) of the university of the free state (ethics clearance number: ufs-hsd2018/1588/2304). permission to perform the study was obtained from the appropriate university of free state authorities and the heads of departments involved in this study. all questionnaires were anonymous and completion of the questionnaire implied consent. results of the 195 questionnaires distributed, 131 (67.2%) were completed and returned. as shown in table 2, approximately 60% of the participants were male (n = 74/125; 59.2%; missing data: n = 6), and approximately half were between 26 and 35 years of age (n = 64; 48.9%). most respondents were from the departments of paediatrics and child health and internal medicine, with both at 22.9% (n = 30), followed by general surgery (n = 27; 20.6%). participants from clinical imaging sciences represented only 12.2% (n = 16) of the study sample. table 2: demographic information of participating doctors. table 3 summarises the distribution of registrars and consultants per department. proportionally, the department of clinical imaging sciences had the most registrars among the total participants (n = 15/16; 93.8%) compared to consultants, while internal medicine had 30 participants of whom 16 (53.3%) were registrars. table 3: position of respondents per department. most of the participating doctors were registrars (n = 89; 67.9%), with 25 (28.1%) being in their fourth year of training. approximately one-third (n = 42; 32.1%) of the study sample were consultants, of whom 39% (n = 16) were also involved in private practice, in addition to their public sector commitments. the department of clinical imaging sciences had three consultants of which only one (33.3%) participated in the study. out of 25 consultants in internal medicine, 14 (56.0%) participated, while 13 (59.1%) of the 22 consultants in paediatrics and child health department participated in the study. the response rate of consultants in obstetrics and gynaecology, surgery and oncology was 30.0% (3/10), 70.0% (7/10) and 100.0% (4/4), respectively. there was a 100% (15/15) response rate of clinical imaging sciences registrars, while paediatrics and child health had the lowest response rate of registrars (n = 17/30; 56.7%). surgery, obstetrics and gynaecology, oncology and internal medicine registrars’ response rate was 83.3%, 82.4%, 77.8% and 61.5%, respectively. an overall low level of accuracy in cost estimation was observed, with 45.0% (n = 59) of the participants estimating none of the costs correctly. none of the participants made more than three correct estimations. a total of 49 (37.4%) participants estimated only one radiological study cost correctly, with only 3.1% estimating three costs correctly. the median number of correct responses was one, with an interquartile range of 0–1. the only significant difference between registrars and consultants on the number of correct estimations (median 0 and 1, respectively; p = 0.04), was observed among the department of internal medicine participants. no significant differences were found between specialities stratified by registrars/consultants. table 4 summarises the results of the cost estimation for the five different radiological studies. the two-view chest radiography was the study with the highest number of participants underestimating the cost (n = 99; 75.6%), while the cost of abdominal and pelvic ct with contrast was overestimated by 84.7% (n = 111) of the participants. the cost of non-contrasted brain ct was estimated correctly by 32 (24.4%) participants, while only 7 (5.3%) participants gave a correct estimation of the cost of abdominal/pelvic ct with contrast. table 4: accuracy of cost estimation of radiological studies by participating doctors (n = 131). the majority of participants (n = 116; 88.5%) indicated an interest in obtaining more information on the cost of radiological studies. twenty-three (17.2%) participants did not provide a reason for wanting to learn more about the cost of radiological studies, and 38 (29.2%) of those who did answer the question indicated that they wanted to manage resources effectively and be more cost-effective and better gatekeepers. only 6.3% of the participants indicated that they wanted to be better advisors for the patients and the clinicians. of those participants who would like to learn about the cost of radiological studies, 7.3% said that they wanted to be cost-conscious or cost-aware, 3.2% indicated that it would improve patient care and clinical judgement. there were 2.1% participants who wanted to learn about the cost of radiological studies because this information would be beneficial for them when they work in private practice. of the 15 participants who indicated that they did not have an interest in learning about the cost of radiological studies, 4 (26.7%) indicated that cost was irrelevant when a radiological study is indicated. only 3 (2.3%) of the participants had received prior education or training related to cost awareness of radiological studies. discussion the results of this study were similar to international studies conducted on cost awareness of radiological studies and a johannesburg-based south african study done on the cost awareness of medical consumables among healthcare professionals.2,11,12,13 these studies have shown that healthcare professionals are unaware of the costs.2,11,12,13 vijayasarathi et al.11 showed that radiology trainees had poor knowledge of the cost of radiological studies, with 45.1% of the participants not estimating any of the costs correctly, which was comparable with the findings from our study. in their study, only 0.3% of the participants estimated all five examinations correctly,11 which was negligibly better than 0.0% of the participants in our study. poor knowledge of costs could probably be attributed to the lack of cost awareness education in medical schools and postgraduate registrar training programmes. in our study, two of the three participants who indicated that they had received prior education or training related to cost awareness of radiological studies, were consultants. physicians should be the gatekeepers of healthcare expenditure and should play a critical role in the use of healthcare resources. they have an ethical obligation to render high-value, high-quality healthcare and limit unnecessary costs that do not improve a patient’s clinical outcome.16 healthcare professionals should be informed regarding not only the benefits or effectiveness of diagnostic investigations and drugs but also about their costs. when requesting a radiological investigation, cost should be taken into consideration. when cost consciousness is incorporated in the medical school curriculum, physicians will better understand the need for financial resource management, consequently curbing unnecessary and improper diagnostic investigations and therapies that do not improve patient care, but rather add to healthcare expenditure. medical school programmes should also expose their students and registrars to knowledge of healthcare management, health service delivery and how medical care is financed to increase their consciousness of the healthcare systems they work in, thereby empowering them to make informed decisions.16 when doctors are aware of the costs of radiological studies, it may lead to a more judicious use of radiological studies, reducing the number of unnecessary investigations, which translates into a reduction in the healthcare expenditure.3,4 an educational intervention study on abdominal imaging performed by covington et al.4 incorporated the american college of radiology appropriateness criteria, lectures on general principles of cost-conscious medicine and discussions of actual hospital costs for commonly ordered abdominal investigations. they compared the number of abdominal investigations requested before and after the study and found a statistically significant reduction in the average abdominal ct scans ordered per patient. they also reported a substantial cut in expenditure of more than $80 000.00.4 kruger et al.17 conducted a preand post-interventional study where they displayed radiation exposure and cost of diagnostic imaging on the electronic order form. they reported a decrease in the number of ct scans and mris ordered compared to ultrasound, after the radiation exposure and costs related to the investigations were known. most of the surveyed clinicians wanted the displays to continue, as it influenced their ordering behaviour, though most of them admitted that the radiation exposure influenced their decision more than the cost.17 these two studies4,17 prove that cost-consciousness among healthcare professionals does reduce costs. the increase in radiological studies usage is partly due to the availability of more advanced and high-tech imaging modalities, but overutilisation also plays a role7,18 and contributes to excessive expenditure and unjustifiable costs to the healthcare system. among many reasons for overutilisation, uncertainty or a lack of knowledge among requesting doctors about imaging indications and costs that result in the inappropriate use of imaging studies plays an important role.18,19,20 several clinical imaging guidelines are available that clinicians can use to justify the performance of a particular radiological study. justification in radiology refers to the appropriate application of radiologic imaging modalities.20 we do not have guidelines specifically applicable to the south african setting. however, guidelines that have been developed in the united kingdom and the united states of america are the royal college of radiologists guidelines21 and the american college of radiology appropriateness criteria,22 respectively. familiarising themselves with one of these clinical imaging guidelines appropriate for different medical or surgical conditions will assist clinicians in choosing the imaging study most suitable for a particular medical condition. individual hospitals or the radiological society of south africa (rssa) can decide which of these guidelines can be followed in south african hospitals to ensure uniformity. these are evidence-based guidelines that have been developed to assist primary physicians in making the most appropriate decisions about imaging and patient management. applying these guidelines will assist clinicians to improve the quality of care, guarantee advantageous use of radiological investigations and reduce healthcare expenditure.10,23 a report by the american health insurance plans alleged that up to 50.0% of all high-tech imaging is unnecessary because it does not provide beneficial information.8 a retrospective international study24 analysed outpatient ct and mri appropriateness based on the american college of radiology appropriateness criteria. it was found that 26.0% of the studies were inappropriate.24 in contrast, a south african study conducted in the western cape province showed that 6.4% of scans were inappropriate,10 which was remarkably less than the findings of the american study.24 limitations the objectives of the study were to assess whether differences occurred in the accuracy of cost estimations according to the level of training, involvement in private practice and the number of years in practice. however, the numbers were too small to investigate these issues and the number of participants representing the respective specialities differed vastly. conclusion doctors were consistently inaccurate in estimating the cost of the radiological studies. as doctors are largely responsible for healthcare expenditure, the results of this research suggest that educating doctors about the cost of radiological imaging can positively affect healthcare expenditure. it is encouraging that the majority of doctors indicated an interest in learning about the cost of imaging, which would have a positive impact on resource management. previous studies have proven that incorporating cost-consciousness into medical practice does reduce the number of requested imaging, which ultimately translates into a reduction in healthcare costs. developing or using existing clinical imaging guidelines to justify the performance of a particular radiological study will also contribute to a reduction in wasteful expenditure. acknowledgements the authors acknowledge noxolo mrwetyana for designing the questionnaire for the study; mpendulo mamba, department of biostatistics, university of the free state, for assistance with data analysis; and dr. daleen struwig, medical writer/editor, for technical and editorial preparation of the manuscript. the article is based on research conducted by khanyisa n. mrwetyana in partial fulfilment of the requirements for the master’s degree (mmed) in clinical imaging sciences. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions k.n.m., j.j.v.r. and g.j. conceptualised the study and planned the implementation of the research. k.n.m. wrote the research protocol, executed the data collection and wrote the first draft of the article. j.j.v.r. was the study supervisor and contributed to editing of the article. g.j. conducted the statistical analysis, assisted with interpretation of data and contributed to editing of the article. all the authors reviewed the results and approved the final version of the manuscript. funding information the authors received no financial support for the research, authorship and/or publication of this article. data availability data are available from the corresponding author, k.n.m., upon reasonable request. disclaimer the views expressed in the article are those of the authors and do not represent the official position of the institution or funding agencies. references fred hl. cutting the cost of health care: the physician’s role. tex heart inst j. 2016;43(1):4–6. https://doi.org/10.14503/thij-15-5646 al zamil ma, arafa ma. awareness of surgeons in saudi arabia about the surgical costs and investigations: multicenter study. j surg educ. 2017;74(2):187–190. https://doi.org/10.1016/j.jsurg.2016.08.013 tierney wm, miller me, mcdonald cj. the effects on test ordering of informing physicians of the charges for outpatient diagnostic tests. n engl j med. 1990;322(21):1499–1504. https://doi.org/10.1056/nejm199005243222105 covington mf, agan dl, liu y, johnson jo, shaw dj. teaching cost-conscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital. j grad med educ. 2013;5(2):284–288. https://doi.org/10.4300/jgme-d-12-00117.1 mayosi bm, benatar sr. health and health care in south africa – 20 years after mandela. n engl j med. 2014;371(14):1344–1353. https://doi.org/10.1056/nejmsr1405012 competition commission south africa. report on analysis of medical schemes claims data – a focus on practitioners [homepage on the internet]. 2017 [cited 2021 apr 06]. available from: http://www.compcom.co.za/wp-content/uploads/2014/09/practitioners_report-on-analysis-medical-scheme-claims-data.pdf bercovich e, javitt mc. medical imaging: from roentgen to the digital revolution, and beyond. rambam maimonides med j. 2018;9(4):e0034. https://doi.org/10.5041/rmmj.10355 chan ss, francavilla ml, iyer rs, rigsby ck, kurth d, karmazyn bk. clinical decision support: the role of acr appropriateness criteria. pediatr radiol. 2019;49(4):479–485. https://doi.org/10.1007/s00247-018-4298-2 armao d, semelka rc, elias j jr. radiology’s ethical responsibility for healthcare reform: tempering the overutilization of medical imaging and trimming down a heavyweight. j magn reson imaging. 2012;35(3):512–517. https://doi.org/10.1002/jmri.23530 becker j, jenkins ls, de swardt m, sayed r, viljoen m. appropriateness of computed tomography and magnetic resonance imaging scans in the eden and central karoo districts of the western cape province, south africa. s afr med j. 2014;104(11):762–765. https://doi.org/10.7196/samj.8158 vijayasarathi a, hawkins cm, hughes dr, mullins me, duszak r jr. how much do common imaging studies cost? a nationwide survey of radiology trainees. am j roentgenol. 2015;205(5):929–935. https://doi.org/10.2214/ajr.14.14167 nethathe gd, tshukutsoane s, denny kj. cost awareness among healthcare professionals at south african hospital: a cross-sectional survey. s afr med j. 2017;107(11):1010–1014. https://doi.org/10.7196/samj.2017.v107i11.12513 innes g, grafstein e, mcgrogan j. do emergency physicians know the costs of medical care? can j emerg med. 2000;2(2):95–102. https://doi.org/10.1017/s148180350000467x steyn tp, gebremariam fa. cost analysis of violence-related medical imaging in a free state tertiary trauma unit. s afr j radiol. 2019;23(1):1664. https://doi.org/10.4102/sajr.v23i1.1664 department of health, province of the western cape. provincial gazette extraordinary no. 8069 [homepage on the internet]. uniform patient fee schedule regulations for health care services rendered by the western cape department of health; 2019 [cited 2021 apr 10]. available from: https://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahukewjjoa_hwvpvahvcq0eahcoschmqfjaaegqibrad&url=https%3a%2f%2farchive.opengazettes.org.za%2farchive%2fza-wc%2f2019%2fprovincial-gazette-za-wc-no-8069-dated-2019-03-29.pdf&usg=aovvaw1v6ixy2rccg4jpldlx7rqj cooke m. cost consciousness in patient care – what is medical education’s responsibility? n engl j med. 2010;362(14):1253–1255. https://doi.org/10.1056/nejmp0911502 kruger jf, chen ah, rybkin a, et al. displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering. bmj qual saf. 2016;25(12):977–985. https://doi.org/10.1136/bmjqs-2015-004242 hendee wr, becker gj, borgstede jp, et al. addressing overutilization in medical imaging. radiology. 2010;257(1):240–245. https://doi.org/10.1148/radiol.10100063 ip ik, schneider li, hanson r, et al. adoption and meaningful use of computerized physician order entry with an integrated clinical decision support system for radiology: ten-year analysis in an urban teaching hospital. j am coll radiol. 2012;9(2):129–136. https://doi.org/10.1016/j.jacr.2011.10.010 jeong wk, baek jh, jung se, et al. imaging guidelines for enhancing justifications for radiologic studies. j korean med sci. 2016;31(suppl 1):s38–s44. https://doi.org/10.3346/jkms.2016.31.s1.s38 royal college of radiologists. irefer guidelines: making the best of clinical radiology [homepage on the internet]. version 8.0.1. [cited 2021 apr 06]. available from: https://www.irefer.org.uk/ american college of radiology. acr appropriateness criteria [homepage on the internet]. [cited 2021 apr 06]. available from: https://www.acr.org/clinical-resources/acr-appropriateness-criteria subramaniam rm, kurth da, waldrip ca, rybicki fj. american college of radiology appropriateness criteria: advancing evidence-based imaging practice. semin nucl med. 2019;49(2):161–165. https://doi.org/10.1053/j.semnuclmed.2018.11.011 lehnert be, bree rl. analysis of appropriateness of outpatient ct and mri referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? j am coll radiol. 2010;7(3):192–197. https://doi.org/10.1016/j.jacr.2009.11.010 abstract introduction discussion conclusion acknowledgements references about the author(s) varsha rangankar department of radiodiagnosis, dr d.y. patil medical college, hospital and research centre, pune, india divyajat kumar department of radiodiagnosis, dr d.y. patil medical college, hospital and research centre, pune, india rajesh kuber department of radiodiagnosis, dr d.y. patil medical college, hospital and research centre, pune, india tushar kalekar department of radiodiagnosis, dr d.y. patil medical college, hospital and research centre, pune, india citation rangankar v, kumar d, kuber r, kalekar t. imaging of the neurological manifestations of dengue: a case series. s afr j rad. 2022;26(1), a2528. https://doi.org/10.4102/sajr.v26i1.2528 case series imaging of the neurological manifestations of dengue: a case series varsha rangankar, divyajat kumar, rajesh kuber, tushar kalekar received: 04 aug. 2022; accepted: 30 sept. 2022; published: 29 nov. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract dengue fever, the most common arboviral tropical disease, has shown a rapid increase in incidence over the last few decades. increasing evidence of the various neurological manifestations in dengue has been documented in the literature. patients positive for dengue on serology and with neurological manifestations were analysed and included in the present case series and brief review. the cases reveal a spectrum of neurological findings in dengue infection and include dengue haemorrhagic encephalitis, acute disseminated encephalomyelitis (adem), reversible splenial lesion syndrome (resles), intracranial haematoma, and posterior reversible encephalopathy syndrome (pres), with a focus on the relevant imaging features. contribution: the present case series emphasises the importance of understanding the relevant imaging findings and potential aetiopathogenesis of neurological involvement in dengue infected patients in order to make the correct diagnosis for effective treatment and improved outcome. keywords: dengue; haemorrhagic encephalitis; pres; adem; subdural haemorrhage; splenium; resles; cytotoxic lesions of the corpus callosum. introduction dengue fever, with its rapid spread to previously unaffected areas and increasing severity, has become the world’s most common arthropod-borne arboviral illness. the incidence has grown 30-fold over the past 50 years as a result of increased geographic expansion with over 2.5 billion people residing in dengue-endemic nations. the reported estimate is 390 million dengue infections with more than 90 million apparent illnesses each year.1 the world health organization (who) has assigned india to endemicity group a, where dengue infection is a significant health problem, accounting for one-third of the global disease burden, with an estimated caseload of 33 million per year.1 the dengue virus was previously considered a non-neurotropic virus with uncommon neurological complications. however, it was later proven to be neurovirulent with documented presence in cerebrospinal fluid (csf) on the polymerase chain reaction (pcr) test.2 the dengue virus is a small single-stranded rna virus, which belongs to the genus flavivirus, family flaviviridae. there are four distinct serotypes, designated denv1 to denv4 on the basis of their interaction with antibodies in human blood serum. denv2 and denv3 are the most implicated in the varied neurologic manifestations of dengue virus infection.3 dengue-associated encephalopathy and encephalitis, dengue-related immune-mediated syndromes, and ophthalmic neurological disorders are some of the examples of the neurological manifestations of dengue virus infection. the imaging features of some of the interesting and unusual spectra of neurological manifestations of dengue virus infection with possible aetiopathogenesis and differential diagnoses are documented in this case series. case 1 a 25-year-old man presented with a 5-day history of high-grade fever, chills and one episode of vomiting. on admission, he had a single seizure episode, followed by an altered sensorium and deteriorating neurological status. he also had an erythematous macular rash over his body. the patient tested positive for dengue non-structural (ns1) antigen and immunoglobulin m (igm) dengue antibody, while the test for dengue immunoglobulin g (igg) antibody was negative. the haematological investigations at the time of presentation revealed a reduced haemoglobin (7 gm/dl) and thrombocytopaenia with a platelet count of 60 000/µl, which reduced to 40 000/µl over the subsequent two days. the platelet count steadily improved thereafter and was 80 000/µl on the sixth day. ct imaging of the brain (figures 1a–c) revealed ill-defined symmetrical bilateral hypodensities in the thalami, cerebellar white matter and bilateral frontal subcortical and deep white matter. tiny hyperdense haemorrhagic foci were observed within some of these hypodense areas (figure 1c). repeat ct brain imaging (figures 1d–f), performed a day later due to the patient’s clinical deterioration, revealed an increase in the haemorrhagic foci with intraventricular extension, obstructive hydrocephalus and generalized cerebral oedema. figure 1: [case 1]: axial ct section in a 25-year-old male demonstrating ill-defined symmetric hypodense areas involving the bilateral thalami, cerebellar white matter and bilateral frontal subcortical and deep white matter (a–c). tiny hyperdense foci were seen within some of these regions (white arrow). a repeat ct study performed a day later revealed an increase in the hypodensities and the haemorrhagic foci with intraventricular extension of the haemorrhage and resultant obstructive hydrocephalus (d–f). mri of the brain (figures 2a–i) performed on the second day of admission revealed multiple, bilaterally symmetrical, hyperintense areas on fluid attenuated inversion recovery (flair) and t2-weighted images involving the thalami, cerebellum, bilateral frontal and parietal subcortical and deep white matter, with patchy restricted diffusion at diffusion-weighted imaging (dwi) and apparent diffusion coefficient (adc) (figure 2g). multiple internal foci of blooming were seen on gradient recalled echoplanar (gre) images, representing haemorrhages (figures 2h and 2i). figure 2: [case 1]: brain mri in a 25-year-old male diagnosed with dengue infection indicates symmetric flair (a-c) and t2 hyperintense areas of altered signal intensity in the vermis, bilateral cerebellar hemispheres, thalami and bifrontal and biparietal white matter (d-f) with patchy diffusion restriction at dwi (g) – adc not presented. areas of blooming on gre images (h, i), representing haemorrhages, are seen. a diagnosis of dengue-associated haemorrhagic encephalitis was made based on the clinical presentation, imaging and laboratory findings. case 2 a 10-year-old male presented with a 12-day history of high-grade fever and chills. he also had headaches, retro-orbital pain and occasional episodes of vomiting. he developed an acute onset of right upper and lower limb weakness five days later, followed by weakness of the left upper limb and a decreased level of consciousness. haematological investigations revealed a platelet count of 80 000/µl with anti-dengue positive igm and negative igg status. dual antigen for malaria and serology markers for japanese encephalitis and herpes simplex virus (hsv-1) were negative. brain mri revealed multiple patchy hyperintense areas on t2-weighted and flair images in the left temporoparietal lobe and bilateral cerebellar hemispheres, involving the cortex and subcortical white matter, the body of the corpus callosum and the lower medulla (figures 3a–e). the lesions showed no diffusion restriction and no enhancement on post-contrast t1fs images (figure 3f). mri screening of the spine revealed t2 hyperintense signal in the inferior part of the medulla, at the cervicomedullary junction and spinal cord up to the c3 vertebral level as well as in the terminal dorsal cord and conus medullaris from the t11 to the l1 vertebral level (figure 4a–c). figure 3: [case 2]: brain mri in a 10-year-old male showing multiple patchy flair (a-c) and t2 hyperintense areas of altered signal intensity in the cerebellar hemispheres, left temporoparietal lobe and body of the corpus callosum, (d, e) with no post-contrast enhancement (f). subtle flair hyperintense signals were also seen in the inferior part of the medulla (a). figure 4: (a–c) [case 2]: mri screening of the spine in a 10-year-old male demonstrating t2 hyperintense signal in the inferior part of the medulla, cervicomedullary junction, upper cervical spinal cord, lower dorsal cord and conus medullaris. a diagnosis of acute disseminated encephalomyelitis (adem) secondary to dengue infection was made based on the clinical history, laboratory findings and typical mri findings. case 3 a 20-year-old male presented with a 1-day history of fever, chills and severe vomiting, associated with myalgia, frontal headache and arthralgia. he tested positive for dengue ns1 antigen and was dengue igm positive on the second day of fever. the patient progressed to a lower level of consciousness over 12 h after admission. brain mri revealed an oval-shaped lesion in the splenium of the corpus callosum, which was hyperintense on t2-weighted and flair images and showed no post-contrast enhancement (figures 5a–c). the lesion revealed increased signal on diffusion imaging with corresponding low values on adc and no blooming on gre images (figures 5e–f). figure 5: [case 3]: brain mri of a 25-year-old male diagnosed with dengue fever showing a non-enhancing oval shaped t2 (a) and flair (b) hyperintense lesion (white arrow) in the splenium of the corpus callosum. the lesion demonstrated no enhancement (c) and bright signal at dwi (d) and corresponding low values on apparent diffusion coefficient (e) with no blooming on the gre images (f). the patient was managed conservatively with intravenous fluid, antipyretics and close clinical monitoring. he recovered completely and was released from the hospital on the 14th day of his illness. a follow-up mri revealed complete resolution of the splenial lesion. a diagnosis of transient lesion of the splenium of corpus callosum, also known as reversible splenial lesion syndrome (resles), was made. case 4 a 55-year-old male presented with a 1-day history of left hand and right leg weakness, slurred speech, occipital headache and giddiness. he also had a single episode of convulsions. he reported intermittent high-grade fever with chills five days prior to presentation and was subsequently diagnosed with dengue fever with a platelet count of 75 000/µl. the patient was normotensive with no recent trauma or bleeding from any site. mri of the brain revealed a well-defined crescent-shaped extra-axial collection overlying the right cerebral convexity which appeared iso to hyperintense on t1-weighted and flair images and of mixed signal intensity on t2-weighted images (figure 6a–f). the collection demonstrated blooming on gre images, suggestive of an acute to subacute subdural haematoma (figures 6g and 6h). figure 6: [case 4]: brain mri in a 55-year-old male patient with dengue fever showing a crescent-shaped extra-axial collection overlying the right cerebral convexity, appearing hyperintense on flair (a, b) and t1-weighted (c, d) images and of mixed signal intensity on t2-weighted images (e, f) with blooming on gre images (g, h), suggestive of an acute to subacute subdural haematoma. a diagnosis of spontaneous subdural haematoma secondary to dengue virus fever was made. case 5 a 10-year-old female presented to our hospital in a drowsy state with a history of intermittent moderate-grade fever for four days, not associated with chills or rigor. her blood pressure was 96/66 mm hg on admission. she tested positive for ns1 antigen and had a platelet count of 35 000/µl. no rashes or bleeding manifestations were present. mri of the brain demonstrated multiple, symmetrical, patchy hyperintense areas on t2-weighted and flair images in both temporo-occipital lobes and to a lesser extent in the frontoparietal regions, involving the cortex and subcortical white matter (figures 7a–f). these areas revealed no diffusion restriction, no blooming on gre images and no post-contrast enhancement (figures 7f–i). figure 7: [case 5]: brain mri of a 10-year-old female with ns1 antigen seropositive status showing multiple symmetrical patchy areas of flair (a-c) and t2-weighted (d-f) hyperintensities in the bilateral temporo-occipital regions and to a lesser extent in the frontoparietal regions, involving the cortex and subcortical white matter. these areas showed t1 iso to hypointense signal (g) with no post-contrast enhancement (h) and no blooming on gre images (i). based on the clinical and imaging findings, posterior reversible encephalopathy syndrome (pres) and dengue encephalitis were considered as possible diagnoses. the patient was managed conservatively and was given dopamine for blood pressure regulation along with methylprednisolone. there was no recorded hypertensive episode throughout the clinical course of the patient in our hospital. the child recovered well and was discharged from the hospital after seven days. a follow-up brain mri four months later revealed complete resolution of the signal abnormalities in the bilateral temporo-occipital and frontoparietal regions (figures 8a–f). in view of the characteristic imaging findings that resolved on follow-up, clinical and laboratory investigations, a final diagnosis of pres secondary to dengue fever was made. figure 8: [case 5]: repeat brain mri of a dengue seropositive 10-year-old female diagnosed with posterior reversible encephalopathy syndrome after 4 months showing complete resolution of the symmetrical signal abnormalities in the bilateral temporo-occipital and frontoparietal regions on axial flair (a, d), t2-weighted (b, e) and t1-weighted (c, f) images. discussion neurological involvement in dengue infection is caused by direct virus invasion of the central nervous system (cns), via an autoimmune reaction and/or metabolic changes.2 although the dengue virus was once considered to have no neurotropism, neurological involvement as evidenced by viral particles found in csf and disruption of the blood–brain barrier brought on by dengue infection, have all proven otherwise, with frequently reported neurological manifestations.2,3,4,5,6,7,8 the incidence of neurological manifestations varies between 2.63% and 40.0%.2 the dengue virus may infect both the central and peripheral nervous systems, resulting in varied clinical symptoms. the various neurological manifestations of the dengue virus are classified based on pathogenetic mechanisms in the recent literature, which also seek to distinguish between dengue-associated cns and eye involvement, peripheral nervous system involvement and post-dengue immune-mediated or convalescent syndromes.2,5,6,7,8 murthy divided the neurological involvement in dengue infection into three categories in his review of dengue-associated neurological complications.6 the first category was due to the neurotropism of the dengue virus, which results in encephalitis, meningitis, myelitis, myositis and rhabdomyolysis. the second category included neurological complications due to systemic effects of dengue infection leading to encephalopathy, haemorrhagic or ischemic stroke, hypokalaemic paralysis and papilloedema. the third category comprised post-infectious immune-mediated complications, which included guillain-barré syndrome, adem, encephalomyelitis, optic neuritis, neuromyelitis optica and other neuropathies. however, the exact classification might be difficult in reality since these categories overlap and clinical data and adequate investigations may be unavailable.2 central nervous system invasion by the dengue virus and its neurotropic effects have increased the clinical spectrum of encephalitis over the last decade, making it one of the most prevalent neurological presentations. the most common serotypes implicated in creating an encephalitic appearance are den-2 and den-3.3 according to recent data from several researchers, the prevalence of dengue encephalitis ranges between 4.2% and 13.0% of infections of the cns.5,7 the common imaging manifestations of dengue encephalitis include bilateral symmetrical hyperintensities in the thalami, pons and medulla on flair and t2-weighted images, some of which may also show diffusion restriction and petechial haemorrhages.8 these show heterogenous or peripheral enhancement after contrast administration. diffuse cerebral oedema is also often present in these patients. similar imaging findings and non-specific signs can be seen in patients with japanese encephalitis, chikungunya encephalitis and herpes encephalitis.8,9 serological testing and the specific anatomical sites of involvement can help to distinguish dengue encephalitis from other infections in challenging instances. focal lesions on imaging can help to differentiate encephalitis from encephalopathy, which occurs due to multisystem derangement and shows diffuse brain involvement.6,8 in the aforementioned case of dengue-associated haemorrhagic encephalitis showing bilateral symmetrical involvement with haemorrhagic foci, the findings are likely secondary to direct neuronal invasion by the dengue virus, as earlier stated by solomon et al.5 their conclusion was based on the presence of igm dengue antibody and dengue viruses in the csf of the dengue patients with encephalitis analysed in their study. acute disseminated encephalomyelitis is an immune complex-mediated brain injury that occurs after a viral infection or following immunisation. the proposed pathophysiology is secondary to a transient autoimmune response directed at myelin or other self-antigens, which could be triggered by molecular mimicry and non-specific activation of auto-reactive t-cell clones.10 acute disseminated encephalomyelitis secondary to dengue is relatively rarely encountered with paucity of literature. three types of lesions may be identified on the brain mri in patients with adem: (1) multifocal white matter lesions with or without basal ganglia involvement, (2) single or multifocal lesions exclusively in the grey matter and (3) localised lesions in the brain stem, basal ganglia or cerebellum.11 the presence of hyperintense focal lesions scattered throughout the cortical and subcortical white matter with bilateral cerebellar involvement and associated t2 hyperintensity in the spinal cord in our patient, combined with a history of fever and positive dengue status, lends credence to the diagnosis of adem. japanese encephalitis, herpes simplex encephalitis and adem are all typical differential diagnoses for neuroimaging abnormalities in patients with dengue encephalitis. the involvement of the bilateral basal ganglia and thalami in japanese encephalitis and the bilateral temporal and frontal lobes in herpes simplex encephalitis help to distinguish these pathologies.11 demyelinating lesions on mri with or without haemorrhagic foci after dengue infection are most likely pathognomonic for adem.10 reversible splenial lesion syndrome is a radiological diagnosis marked by a reversible lesion in the splenium of the corpus callosum, caused by both infectious and non-infectious pathologies. similar imaging findings have been reported in mild encephalitis with reversible splenial lesions (mers) in cases of contagious aetiologies. based on the pathophysiology associated with cytotoxic oedema, these transient splenial lesions are sometimes known as cytotoxic lesions of the corpus callosum (cloccs).12 although the reason for the preference for the splenium of the corpus callosum is unknown, one theory links it to an absent adrenergic tone and failure of autoregulation in this region.12,13 the resles or mers after dengue virus infection was also reported by fong et al. in which the patient had dengue virus serotype 2 infection with delirium that progressed to ophthalmoplegia.14 complete clinical and imaging resolution of the splenial lesion was also seen in the case reported by fong et al., which is consistent with the good prognosis associated with this unusual clinical-radiological entity. non-traumatic intracranial haemorrhage (ich) without any other cerebral intracranial complication can be seen in dengue haemorrhagic fever (dhf) and dengue shock syndrome (dss). dengue-related ich can be localised or widespread, typically affecting the cerebrum, ventricles, and less frequently, the cerebellum. subarachnoid, extradural and subdural haemorrhages (sdh) have also been reported with dengue infection.15 plasma leakage and bleeding are the most common pathophysiological anomalies in dhf and dss. capillary fragility and thrombocytopenia lead to bleeding. the majority of people who develop dhf or dss and have ich have previously been infected with one or more dengue serotypes.15 however, ichs are still rare compared with frequent dengue fever haemorrhagic symptoms such as haematemesis, melena or epistaxis.16,17 preoperative and postoperative platelet transfusion may be required in patients with ich requiring operative management. posterior reversible encephalopathy syndrome (pres) is a neurotoxic state that presents with a myriad of features such as seizures, encephalopathy, visual disturbances and headache, typically associated with blood pressure fluctuations or metabolic derangement.18 posterior reversible encephalopathy syndrome can also occur as a complication of various infections or sepsis in normotensive patients.19 mri classically shows vasogenic oedema, typically affecting the subcortical white matter of the bilateral parieto-occipital regions, and less frequently the frontal or temporal lobes and watershed regions, with or without haemorrhagic foci.18,19 posterior reversible encephalopathy syndrome is a rare neurological complication of dengue with a few reported cases. sawant et al. postulated fluid overload and hypertension due to fluid resuscitation of the hypotensive shock in dengue along with inflammatory cytokine response as likely causes of pres.20 because the ns1 antigen has a proclivity to act directly on endothelial cells, it causes the release of cytokines and chemokines, which disrupt the integrity of endothelial cell monolayers, resulting in vascular permeability syndrome, which has been proposed as the primary mechanism of pres in dengue.18,19 this theory provides the most likely explanation of pres in our patient who was in dengue shock. it is critical to distinguish pres from dengue encephalitis and adem because patients with pres recover well with supportive care.19,20 as a word of caution, the characteristic imaging findings described in the various entities in the present case series are not directly pathognomic of dengue. however, dengue should be considered as a strong differential diagnosis in such cases in the appropriate setting of endemicity, clinical presentation and supportive laboratory findings. conclusion dengue fever is a major public health issue around the world, particularly in endemic countries such as india. dengue virus has been shown to be a neurotropic virus with a variety of neurological manifestations. neuroimaging, particularly mri, is an essential tool for the early assessment and evaluation of dengue fever neurological manifestations. all the neuroimaging entities described in this report should have dengue as one of the differential diagnoses in the appropriate clinical setting and with supporting laboratory findings. knowledge of the various dengue infection-related neurological complications and their imaging features can aid in the identification of underlying pathological processes and making the correct diagnosis in an appropriate clinical setting, allowing for proper management and improved prognosis. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.r. conceived the original idea and supervised the project. d.k. wrote the manuscript with support from v.r. and r.k.d.k. worked out most of the case data and technical details with support from v.r. and t.k. v.r., d.k, r.k. and t.k. critically revised the article with conceptual and editorial input. all authors have read and approved the manuscript. ethical considerations this article followed all ethical standards for research. the authors have followed the guidelines given by the institutional ethical committee for the publication of the case series. written informed consent was obtained from the patients for publication along with relevant images. patients’ identities are not disclosed. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability any required information is available upon request from the corresponding author, d.k. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors, and the publisher. references bhatt s, gething pw, brady oj, et al. the global distribution and burden of dengue. nature. 2013 apr;496(7446):504–507. https://doi.org/10.1038/nature12060 kulkarni r, pujari s, gupta d. neurological manifestations of dengue fever. ann indian acad neurol. 2021 sep;24(5):693. https://doi.org/10.4103/aian.aian_157_21 madi d, achappa b, ramapuram jt, chowta n, laxman m, mahalingam s. dengue encephalitis – a rare manifestation of dengue fever. asian pac j trop biomed. 2014 may 1;4(suppl. 1):s70–s72. https://doi.org/10.12980/apjtb.4.2014c1006 li gh, ning zj, liu ym, li xh. neurological manifestations of dengue infection. front cell infect microbiol. 2017 oct 25;7:449. https://doi.org/10.3389/fcimb.2017.00449 solomon t, dung nm, vaughn dw, et al. neurological manifestations of dengue infection. lancet. 2000 mar 25;355(9209):1053–1059. https://doi.org/10.1016/s0140-6736(00)02036-5 murthy jm. neurological complications of dengue infection. neurology india. 2010 jul 1;58(4):581. https://doi.org/10.4103/0028-3886.68654 jackson st, mullings a, bennett f, khan c, gordon-strachan g, rhoden t. dengue infection in patients presenting with neurological manifestations in a dengue endemic population. west indian med j. 2008 sep 1;57(4):373–376. soni bk, das ds, george ra, aggarwal r, sivasankar r. mri features in dengue encephalitis: a case series in south indian tertiary care hospital. indian j radiol imaging. 2017 apr;27(2):125–128. https://doi.org/10.4103/ijri.ijri_322_16 mehta r, gerardin p, de brito ca, soares cn, ferreira ml, solomon t. the neurological complications of chikungunya virus: a systematic review. rev med virol. 2018 may;28(3):e1978. https://doi.org/10.1002/rmv.1978 murthy jm. acute disseminated encephalomyelitis. neurol india. 2002 sep;50(3):238–243. pal s, sen k, biswas nm, ghosal a, jaman sr, kumar ky. clinico-radiological profile and outcome of dengue patients with central nervous system manifestations: a case series in an eastern india tertiary care hospital. j neurosci rural pract. 2016 jan;7(1):114–124. https://doi.org/10.4103/0976-3147.165410 zhu y, zheng j, zhang l, et al. reversible splenial lesion syndrome associated with encephalitis/encephalopathy presenting with great clinical heterogeneity. bmc neurol. 2016 dec;16(1):1–8. https://doi.org/10.1186/s12883-016-0572-9 hackett ph, yarnell pr, hill r, reynard k, heit j, mccormick j. high-altitude cerebral edema evaluated with magnetic resonance imaging: clinical correlation and pathophysiology. jama. 1998 dec 9;280(22):1920–1925. https://doi.org/10.1001/jama.280.22.1920 fong cy, khine mm, peter ab, lim wk, rozalli fi, rahmat k. mild encephalitis/encephalopathy with reversible splenial lesion (mers) due to dengue virus. j clin neurosci. 2017 feb 1;36:73–75. https://doi.org/10.1016/j.jocn.2016.10.050 singh a, balasubramanian v, gupta n. spontaneous intracranial hemorrhage associated with dengue fever: an emerging concern for general physicians. j fam med prim care. 2018 may;7(3):618. https://doi.org/10.4103/jfmpc.jfmpc_56_18 jensenius m, berild d, ormaasen v, maehlen j, lindegren g, falk ki. fatal subarachnoidal haemorrhage in a norwegian traveller with dengue virus infection. scand j infect dis. 2007 jan 1;39(3):272–274. https://doi.org/10.1080/00365540600891307 dar l, gupta e, narang p, broor s. cocirculation of dengue serotypes, delhi, india, 2003. emerg infect dis. 2006 feb;12(2):352. https://doi.org/10.3201/eid1202.050767 fugate je, rabinstein aa. posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. lancet neurol. 2015 sep 1;14(9):914–925. https://doi.org/10.1016/s1474-4422(15)00111-8 mai nth, phu nh, nghia hdt, et al. dengue-associated posterior reversible encephalopathy syndrome, vietnam. emerg infect dis. 2018 feb;24(2):402–404. https://doi.org/10.3201/eid2402.171634 sawant y, birajdar s, doshi h, soni p, patkar d, joshi nc. posterior reversible encephalopathy (pres) in a child with severe dengue. j trop pediatr. 2020 jun;66(3):322–326. https://doi.org/10.1093/tropej/fmz060 traumatic.html traumatic brown-sequard syndrome– clinico-radiological correlation on mri s dlangamandla, mb bch n mahomed, mb bch, fcrad(d) department of radiology, university of the witwatersrand, johannesburg corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) a 34-year-old man presented with a history of a stab wound to the left side of the neck. physical examination revealed an ipsilateral left-sided hemiplegia and contralateral loss of sensation. a clinical diagnosis of brown-sequard syndrome was made. magnetic resonance imaging (mri) findings demonstrated hyperintensity at c4 and c5 levels on sagittal t2-weighted sequence of the cervical spine (fig. 1) with limitation to the left hemicord demonstrated in the axial plane (fig. 2), accounting for the brown-sequard syndrome. the patient was managed with supportive treatment. discussion brown-sequard syndrome, first reported in 1849, is characterised by hemisection of the cord with disruption of the descending lateral corticospinal tracts resulting in ipsilateral hemiplegia, and damage of the ascending lateral spinothalamic tracts (which cross within one or two levels of the dorsal root entrance) resulting in contralateral loss of pain and temperature. damage to the dorsal columns results in ipsilateral loss of proprioception and fine touch below the level of the lesion.1 , 2 the most common cause of brown-sequard syndrome is penetrating trauma to the spinal cord, but it can also occur with blunt trauma, disc herniation, syringomyelia and spinal tumours.1 , 2 in our patient, the high signal on mri in the left hemicord at the level of the transection correlates well with the clinical features. 1. sathirapanya p, taweelarp a, sae heng s, riabroi k. brown-sequard syndrome from cervical disc herniation, a case report and review of literature. neurology asia 2007;12:65-67. 1. sathirapanya p, taweelarp a, sae heng s, riabroi k. brown-sequard syndrome from cervical disc herniation, a case report and review of literature. neurology asia 2007;12:65-67. 2. pablo m, pedro g, rafael a, ariel k, ana r. brown-sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. eur spine j 2007;16:1165-1170. 2. pablo m, pedro g, rafael a, ariel k, ana r. brown-sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. eur spine j 2007;16:1165-1170. fig. 1. sagittal t2-weighted mri of cervical spine demonstrates spinal cord hyperintensity at c 4 and c5 levels. fig. 2. axial t2-weighted mri at c4 and c5 levels demonstrates the extent of spinal cord hyperintensity limited to the left hemicord in keeping with the clinical features of brown-sequard syndrome. 2 sa journal of radiology • march 2011 editorial south africa is on the threshold of a new era in postgraduate medical education. registrars commencing training from 2011 will have to meet the new specialist registration requirements of our health professions council.1 in addition to completing 4 years in an accredited teaching programme, new recruits will have to: 1. pass the final fellowship examination of the colleges of medicine of south africa 2. complete a research dissertation under the aegis of their university. the ‘college final’ will thus supersede the university-based master of medicine (mmed) part ll examination. the mmed degree will be conferred only after candidates have been awarded the college fellowship and have completed a dissertation. all ‘new generation’ specialists will therefore be both college fellows and masters graduates. the uniformity and quality assurance inherent in a unitary exit examination are welcome and arguably overdue. in this respect, the college fellowship enjoys widespread acceptance as the ‘final common pathway’. the compulsory research component can be seen as a bold and visionary policy. it has the potential to add a rich new texture to postgraduate education and to strengthen the academic fibre of health sciences faculties via substantially enhanced postgraduate research outputs and increased university subsidies for accredited journal article publications and completed master’s degrees. the ramifications of the new policy could therefore be far-reaching and positive. however, there is concern about the capacity of both registrar and supervisor to deliver in the face of an already overwhelming clinical workload (s beningfield, a stoker, z lockhat, m govind, i juhnke-targonska; personal communications). there is a realisation that, for many faculties, successful delivery will require fundamental change. it is therefore salutary to note that the new hpcsa requirements were not promulgated in isolation. parallel documentation provides guidelines for the minimum conditions of service, education and training of registrars,2,3 highlighting the need for all role players (departments of health, universities, hpcsa) to negotiate a new registrar dispensation, with protection of study time and a balance between service and educational imperatives. the true significance of the research component is therefore a potential catalyst for change. to meet the required outputs, health science faculties will have to protect or ‘ring-fence’ research time, modify registrar rotations and develop research support capacity, including ethics review, student supervision, clinical record keeping, project funding, statistical analysis and dissertation evaluation criteria. the latter will need particular attention if uniformity and quality assurance are to be adequately addressed. broadly, research evaluation in this country currently takes one of two paths: 1. dissertations submitted to university-convened review panels that include internal and external examiners 2. journal articles submitted to accredited international peer-reviewed journals. articles accepted for publication are then further subject to internal university review. accredited journals consequently play an important, if indirect, role in our research evaluation process. this begs the question of the future role of the south african journal of radiology (sajr), which enjoys accreditation by the national department of education for university subsidy purposes. now is the time for the academic heads of our radiology departments to formally constitute an ‘hod committee’ to guide the process of dissertation evaluation towards uniformity and quality control, while capturing the synergy of our situation. the dissertation generation sajr – the new vision this new-look and one-third larger edition of the sajr heralds the onset of a new era in the history and future of radiology and the radiological society of south africa (rssa). firstly, the rssa cme association (not for gain) was officially constituted on 31 december 2010 and is now the custodian of the cme programme and congress portfolio of the rssa. the broader vision is that the rssa cme association will support and provide a sustainable, affordable, appropriate, visionary and constantly expanding programme of education, teaching and training; going hand-in-hand with support for academic research and making resources available, wherever possible. as outlined in the editorial of the september 2010 issue of this journal, this new initiative is only possible with the support of all stakeholders in radiology in southern africa, viz. reliable and prestigious international societies, institutions and leading radiologists as partners. the indispensible ingredient is the support of the industry, who came on board without any hesitation. the new-look and larger sajr is a direct result of such a strategic partnership with philips healthcare southern africa. philips healthcare has made an educational grant available to immediately increase the size of the journal by approximately 30%. the cover and layout have been redesigned under the enthusiastic leadership of the editor, professor jan lotz. the immediate goal is to have the sajr, which is already peer reviewed, included in large databases such as pubmed. another direct advantage will be the increased capacity to publish original research, which is now required by the hpcsa for registration on the specialist register. an original research dissertation or peer-reviewed published article is also a requirement in partial fulfilment of the requirements for the mmed (radd) degree offered by south african universities. on behalf of all involved in radiology in southern africa, we extend our most sincere appreciation and gratitude to philips healthcare and in particular mr marlon burgess, managing director, for this visionary leadership. in the adapted words of the first man on the moon, this first new edition of the sajr is by no means a small step for radiology in southern africa. leon j van rensburg rssa congress chair continued on page 13 sajr 793 trauma imaging of the cranio-cervical junction: diagnosis s k misser, t z mngoma, m roux   lake smit and partners, durban s k misser, mb chb, fc rad (d) sa t z mngoma, mba, mb chb, ffrad (sa)   entabeni hospital, durban m roux, mb chb, fcs (sa)   corresponding author: s misser (misser@lakesmit.co.za) we congratulate dr jolandi van heerden (neuroradiology fellow, neurological intervention and imaging service of western australia (niiswa), sir charles gairdner hospital, nedlands, western australia) for a most precise diagnosis, for which she receives the award of r1 000 from the rssa. drs misser et al. elaborate below on the condition and its imaging. please refer to page 120 of the september 2012 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/view/773/598) for the presentation details and images. diagnosis a 5-year-old boy presented to a&e with quadriparesis after a motor vehicle accident. initial plain radiographs were normal. the ct images of the cranio-cervical junction (ccj) obtained on admission showed a large acute prepontine retroclival extradural haematoma (reh). there is posterior displacement of the tectorial membrane and compression of the lower pons and medulla. no fractures of the clivus or the upper cervical vertebrae is noted. the craniocervical junction bony elements retain their normal alignment with preservation of the powers ratio. mri sequences performed (including sagittal t1, sagittal t2 and axial t2-weighted sequences) demonstrated the reh compressing the pontomedullary junction of the brainstem. there is also t2-weighted low-signal posterior to the medulla (fig. 4) in keeping with peri-medullary localised subarachnoid haemorrhage. ventral medullary hyperintensities in the pyramids seen best on the axial t2-weighted image (fig. 4) are in keeping with oedema. there is no t1-weighted shortening or t2* abnormal signal to indicate contusion. compression of the vertebrobasilar vessels is noted. subtle t2 hyperintensity was identified in the upper border of c6 (fig. 6), suggesting superior end plate marrow oedema from hyperflexion injury. a diagnosis of tectorial membrane injury associated with reh, venous perimedullary subrachnoid haemorrhage and compressive oedema of the ventral medulla was made. in view of the suspected instability and the size of the reh, surgical internal fixation was undertaken. the child responded very well following surgical fixation and the quadriparesis resolved. discussion the principal stabilisers of the ccj are the tectorial membrane, transverse ligament and the alar ligaments1 (see fig. 1). of these, the tectorial membrane is the most important. tectorial membrane injury associated with reh is rarely seen. this type of injury occurs most frequently in children following abrupt acceleration/deceleration high-velocity motor vehicle accidents. the consequent ccj hyperextension/hyperflexion is the patho-mechanism resulting in antero-posterior dens subluxation.the poorly adherent dura and ligaments in children are more easily disrupted at the osseo-ligamentous attachment with subsequent prepontine venous plexus damage and reh. there are several reasons why children are more at risk for ccj injury (table 1). table 1. factors predisposing to childhood ccj injury lax ligaments large calvarium-to-body ratio poorly developed neck musculature smaller occipital condyles to support head relative ccj hypermobility in acute paediatric ccj injury, mri is the imaging modality of choice for detailed assessment of the integrity of the ligaments, presence of reh and relations of the components of the ccj. tectorial membrane injury is manifest by discontinuity of the normal t2 hypo-intense signal of the ligament, increase of the t2 signal intensity or if the intact membrane is elevated by a reh.2 complete assessment of the ccj ligaments must include those listed in fig 1. fig. 1. sketch showing the key ligaments assessed at the ccj. 1. tectorial membrane 2. apical ligament of the dens 3. transverse ligament of the atlas 4. anterior occipito-atlantal membrane 5. anterior atlanto-axial membrane 6. anterior longitudinal ligament 7. posterior longitudinal ligament 8. posterior atlanto-occipital membrane 9. posterior atlanto-axial membrane 10. cervical ligamentum flavum review of the literature indicates that this entity is under-diagnosed. suspicion by the treating clinician and equally by the reporting radiologist is crucial. assessment of children injured in high-velocity traffic accidents usually includes plain radiographs of the cervical spine initially and possibly a ct scan of the brain if there is suggestion of loss of consciousness or decreased alertness. radiography in the setting of isolated ligamentous injury of the ccj rarely yields an abnormality. ct scans focussed primarily on the brain structures and performed after hours with sub-optimal inclusion of the foramen magnum/ccj area will result in inadequate demonstration of the reh. only a few of these patients proceed to have mri studies performed, where direct demonstration of tectorial membrane injury and reh is made possible. non-dislocated ccj injuries without fractures are usually managed conservatively. injury of the ccj ligaments including tectorial membrane, inadvertently influences ccj stability. the decision to proceed to surgical fixation may be influenced by overt mri features of tectorial membrane disruption or large(>4 mm) reh. it is imperative that the retroclival area be well-included in the ct and mr imaging fields and that the reporting radiologist purposefully adds the ccj as a review area.2   1. benedetti pf, fahr lm, kuhns lr, hayman la. mr imaging findings in spinal ligamentous injury. ajr 2000;75:661-665. 1. benedetti pf, fahr lm, kuhns lr, hayman la. mr imaging findings in spinal ligamentous injury. ajr 2000;75:661-665. 2. meoded a, singhi s, poretti a, eran a, tekes a, huisman tagm. tectorial membrane injury: frequently overlooked in pediatric traumatic head injury. ajnr 2011;32:1806-1811. 2. meoded a, singhi s, poretti a, eran a, tekes a, huisman tagm. tectorial membrane injury: frequently overlooked in pediatric traumatic head injury. ajnr 2011;32:1806-1811.   s afr j rad 2012;16(4):149-150. doi:10.7196/sajr.793 sajr 840 editorial onwards and upwards the endeavors of my predecessor, professor jan lotz, a committed visionary who served the south african journal of radiology (sajr) in a permanent capacity for 5 years (2008 2012), are gratefully acknowledged. under his stewardship, the sajr benefited from a consistent editorial policy. the journal grew in size to an average of 40 pages per issue, with broader editorial variety accordingly. the online manuscript management system revolutionised the submission and review process. the promised cpd programme was delivered and the journal took major steps toward international recognition, being invited to join go rad (global outreach radiology), a global outreach programme of the international society of radiology. on the eve of assuming the mantle as editor-in-chief of the sajr, there are challenges ahead to be considered. the ultimate ambition is for the sajr to achieve international indexing. this is possible, providing inter alia that 3 5 original articles are published quarterly. the exiting requirements of the health professions council of south africa (hpcsa) now include the completion of original research. currently there are 2 accepted pathways to meet this exit requirement: (i) submission of a full research dissertation that must pass a university grading process, and (ii) publication of an original research article by a reputable, peer-reviewed journal. which pathway would academic radiologists be capable of sustaining, and which should we advocate? it is envisaged that the latter will be the preferred conduit; but how is an appropriate academic standard to be maintained? the international advisory board has made a number of critical observations and valuable suggestions for strengthening the journal. it is essential that the sajr, and its contributors, work towards defining the focus and content of the journal. publishing research related to pathologies endemic to sub-saharan africa would have both regional and international appeal. i encourage specialist societies to work in conjunction with the sajr towards producing special issues devoted to such topics. a further recommendation is to publish practical content, including articles related to best practices, protocols and guidelines. by including content related to appropriate imaging in a resource-limited environment, the south african radiological community could serve as a guide to our more affluent international counterparts. the advisory board advocates a transition to an online-only version of the journal. although this appears to have overwhelming support from members of the rssa, as polled at a recent congress, there are technical and financial considerations. the sajr reaffirms its commitment to south african and african researchers, providing those taking their first tentative steps into research and publication with an accessible platform. the sajr has enjoyed heartening support from researchers, both local and foreign, and contributions from the private sector have been steady. these are further encouraged. so, onwards and upwards we go. with the support of an inspired new era of radiologists, mentored by experienced colleagues, the sajr will find direction, define its focus and make its mark as proudly south african. razaan davis editor-in-chief calcinosis.html calcinosis cutis universalis – a rare manifestation of systemic lupus erthyematosus f e suleman, mb chb, fc rad (diag), m med rad (diag) department of radiology, university of pretoria m m t m ally, mb chb, fcp department of internal medicine, university of pretoria corresponding author: f suleman (fesuleman@gmail.com) abstract calcinosis cutis (or skin and subcutaneous calcification) is a feature of a variety of rheumatic conditions (most commonly dermatomyositis and scleroderma), but is rarely reported in systemic lupus erythematosus (sle ). when calcinosis cutis does occur in patients with sle, it tends to be localised (circumscripta) rather than generalised (universalis). we report a case of a 21-year-old woman who presented to us with a 6-year history of sle and the rare occurrence of calcinosis cutis universalis. introduction calcinosis cutis is a well-known phenomenon in a variety of rheumatic conditions, particularly dermatomyositis, scleroderma and crest (calcinosis, raynaud’s phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia) but is rarely described in systemic lupus erythematosus (sle).1 , 2 a review of the literature reveals that, up to 2010, only 37 cases were reported in the english-language literature.1 calcinosis cutis associated with sle is dystrophic in nature and nearly always localised (calcinosis cutis circumscripta) but may infrequently occur as a generalised form referred to as calcinosis cutis universalis.1 it is described predominantly in females and may manifest anytime from 6 months to 18 years after the diagnosis of sle.3 we describe the case of a 21-year-old woman presenting with calcinosis cutis universalis, 6 years after being diagnosed with sle. case report a 21-year-old woman was referred to our rheumatology clinic for management of known active sle. she had been diagnosed at her local hospital 6 years previously but had not received any specialist care. she was again admitted to her local hospital 6 months prior to the current referral with a diagnosis of pneumonia, but claimed to have had no improvement with therapy and she continued to cough and lose weight. her current complaints were polyarthritis involving the small joints of her hands,elbows and knees with associated morning stiffness. on examination, she appeared chronically affected. she had a malar rash and widespread hyperpigmented skin lesions with palpable hard deposits in the soft tissue. she was pale, had muscle weakness, was tender around most joints and demonstrated evidence of healed vasculitic lesions on both hands and feet. ulcers were noted on her thighs. the rest of the physical examination was within normal limits. blood results came back positive for antinuclear antibodies and double-stranded dna antibodies. this, in combination with clinical findings, fulfilled the american rheumatism association criteria for a diagnosis of sle. raised inflammatory markers were in keeping with active disease. her serum calcium and phosphate levels were within normal limits. her renal function was normal but urine dipstix demonstrated proteinuria, and a renal biopsy confirmed class 3 lupus nephritis. her chest radiograph showed a right pleural effusion with cardiomegaly (fig. 1), and radiographs of the hips and hands demonstrated widespread calcifications in the soft tissue and no evidence of arthropathy (figs 2a and b). a computer tomography (ct) scan confirmed the findings noted on the chest radiograph and further demonstrated calcifications around the shoulder and in the breast and back (fig. 3). the soft tissue calcifications noted on the other radiographs were confirmed to be in the subcutaneous tissue and found to be more widespread in the lower limbs than noted on the plain film radiographs (fig. 4). the dermatologists confirmed that the skin lesions were in keeping with sle. a diagnosis of calcifying panniculitis owing to sle was considered, but a skin biopsy showed no significant inflammatory infiltrate; a final diagnosis of calcinosis cutis universalis associated with sle was made. discussion soft-tissue calcifications may be classified into metastatic (abnormal serum calcium-phosphorus levels), tumoral (elevated phosphorus but normal calcium levels), dystrophic including calcinosis (normal serum calcium-phosphorus levels but damaged tissue), idiopathic (no abnormalities detected) and calciphylaxis (chronic renal failure with abnormal calcium-phosphorus levels).4 calcifications occurring in the skin and subcutaneous tissue of patients with sle are dystrophic/calcinotic in nature.1 , 2 , 5 the mechanism of this complication is poorly understood, and it is not known why some patients with sle develop this condition and others do not.3 calcinosis cutis may involve a localised region, in which case it is referred to as calcinosis cutis circumscripta and, in its more generalised form, as calcinosis cutis universalis. only 37 cases have been described in the english-language literature in patients with sle, and nearly always circumscripta in distribution.1 the condition typically occurs in females with a predilection for the extremities, buttocks and peri-articular extensor surfaces.2 , 4 our patient had involvement of her extremities, buttocks, trunk and breast, with peri-articular deposits around the knees and shoulders. commonly, the skin and subcutaneous fat are involved but the deeper soft tissues may also be affected.2 the calcified material may form palpable nodules, induce muscle atrophy and predispose to the formation of contractures.4 local inflammation may occur, leading to ulceration and extrusion of calcified material.2 , 4 our patient had ulcerative, discharging lesions on her thighs. soft tissue calcifications may be easily demonstrated on plain radiographs, but ct scan is more effective in demonstrating the location and extent of calcifications. in our patient, a ct scan confirmed the subcutaneous distribution of calcifications and demonstrated far more extensive involvement than initially suspected clinically and on plain films. calcinosis cutis has been described as severe, damaging,6 disfiguring and painful.5 it rarely resolves spontaneously, and the various pharmocological treatment options have had poor success rates.4 surgery may be an option for symptomatic relief or very large lesions,3 , 4 but further research is necessary to develop effective treatment. conclusion calcinosis cutis universalis is a rare complication of sle that can be demonstrated on plain radiographs and more easily on ct. clinically, it may be confused with a diagnosis of lupus panniculitis, and a biopsy is essential to confirm the diagnosis. it may be a source of pain and significant disability; no effective therapy is available at present. 1. kim ms, choi kc, kim hs, song ig, shin bs. calcinosis cutis in systemic lupus erythematosis: a case report and review of the published work. j dermatol 2010;37:815-818. 1. kim ms, choi kc, kim hs, song ig, shin bs. calcinosis cutis in systemic lupus erythematosis: a case report and review of the published work. j dermatol 2010;37:815-818. 2. tristano ag, villarroel jl, rodriguez ma, millan a. calcinosis cutis universalis in a patient with systemic lupus erythematosus. clin rheumatol 2005;25:70-74. 2. tristano ag, villarroel jl, rodriguez ma, millan a. calcinosis cutis universalis in a patient with systemic lupus erythematosus. clin rheumatol 2005;25:70-74. 3. minami a, suda k, kaneda k, kumakiri m. extensive subcutaneous calcifications of the forearm in systemic lupus erythematosus. j hand surg (br) 1994;5:638-641. 3. minami a, suda k, kaneda k, kumakiri m. extensive subcutaneous calcifications of the forearm in systemic lupus erythematosus. j hand surg (br) 1994;5:638-641. 4. boulman n, slobodin g, rozenbaum m, rosner i. calcinosis in rheumatic diseases. semin arthritis rheum 2005;34:805-812. 4. boulman n, slobodin g, rozenbaum m, rosner i. calcinosis in rheumatic diseases. semin arthritis rheum 2005;34:805-812. 5. mandelbrot da, santos pw, burt rk, et al. resolution of sle-related soft-tissue calcification following haemopoetic stem cell transplantation. nephrol dial transplant 2008;23:2679-2684. 5. mandelbrot da, santos pw, burt rk, et al. resolution of sle-related soft-tissue calcification following haemopoetic stem cell transplantation. nephrol dial transplant 2008;23:2679-2684. 6. wollina u, hein g. lupus erythematosus: uncommon presentations. clin dermatol 2005;23:470-479. 6. wollina u, hein g. lupus erythematosus: uncommon presentations. clin dermatol 2005;23:470-479. fig. 1. chest radiograph demonstrates cardiomegaly with a right pleural effusion. fig. 2a. frontal radiograph of the pelvis demonstrating extensive soft-tissue calcification. fig. 2b. lateral radiograph of the hands including the wrists demonstrates soft-tissue calcifications of the forearm. fig. 3. axial ct scan at the level of the shoulders demonstrates soft-tissue calcifications in the subcutaneous tissue around the shoulders. fig. 4. coronal ct scan of the proximal lower limbs demonstrate extensive calcifications in the subcutaneous tissue around both knees as well as both thighs. sajr 874 thymic masses: a radiological review m k mittal, md, ficr; b sureka, md, dnb; m sinha, md; a mittal, md, dnb; b b thukral, md, ficr department of radiodiagnosis and imaging, vardhman mahavir medical college and safdarjung hospital, new delhi, india corresponding author: b sureka (binitsurekapgi@gmail.com) various thymic masses and their normal variations have different pathological and management consequences. radiologists and clinicians should be aware of these entities so that appropriate and timely treatment can be given. s afr j rad 2013;17(3):108-111. doi:10.7196/sajr.874 the thymus is a lymphatic organ that plays a vital role in the development and maturation of the immune system during childhood. it is bilobal, each lobe having a separate fibrous capsule that is connected to the inferior lobes of the thyroid gland by the thyrothymic ligament. despite the advances made in imaging technology, errors tend to occur when reporting thymic pathologies that may result in unnecessary biopsy, surgery and radiation. the thymus is located in the anterior mediastinum. it overlies the pericardium, aortic arch, left innominate vein, and trachea. differentiating normal from hyperplastic thymus can be difficult. on imaging, normal thymus shows the following features: absence of rounded soft-tissue masses >7 mm; absence of a convex contour/soft-tissue lobulation of the thymus after age 19 years and normal thymic thickness (should be <18 mm before 20 years of age and <13 mm after 20 years of age).1 linear correlation between increased fatty infiltration of the thymus on computed tomography (ct) and decreased 18f-fdg uptake on positron emission tomography-computed tomography (pet-ct) is seen with increasing age.2 various disorders can affect the thymus, e.g. epithelial, lymphoid and germ cell neoplasms; thymic cysts; hyperplasia; and hamartomatous lesions. on chest x-ray, thymic abnormalities typically manifest as focal or diffuse thickening of the anterior junction line and obliteration of retrosternal clear space.3 ct is the primary imaging technique for evaluating suspected thymic abnormalities seen on chest radiographs as well as for detecting occult thymic masses. rebound thymic hyperplasia histologically, thymic hyperplasia can be divided into two distinct types: true hyperplasia and lymphoid (follicular) hyperplasia. the thymus commonly involutes during periods of stress. true thymic hyperplasia is diagnosed when there is >50% increase in thymic volume over baseline, usually within a year of the stress period, with preserved microscopic features (fig. 1).4 lymphoid hyperplasia typically shows diffuse enlargement with a fine mixture of fat and lymphoid tissue, a smooth contour, and normal vessels; this in contrast to thymic tumour that is associated with a nodular contour and frequently contains necrotic or calcific foci.5 thymic lymphoid hyperplasia is commonly associated with myasthenia gravis, thyrotoxicosis, addison disease, acromegaly, thyroid cancer, connective tissue disease and early stages of human immunodeficiency virus (hiv) infection. pet-ct shows decreased uptake with standardised uptake value (suvmax) ≤3.4 in thymic hyperplasia.2 chemical-shift magnetic resonance imaging (mri) is also helpful in differentiating thymic hyperplasia from thymic neoplasms. non-neoplastic thymic tissue shows normal fat infiltration and manifests as loss of signal on opposed-phase images relative to in-phase images.3 fig.1. computed tomography scan showing rebound thymic hyperplasia (arrows) in a 45-year-old woman post chemotherapy for cervical cancer. thymic cysts thymic cysts can be found in the neck and/or mediastinum. they can be congenital, degenerative, inflammatory and neoplastic. congenital cysts are usually unilocular, arise from a persistent patent thymopharyngeal duct, and usually present as a unilocular cystic mass confined to the mediastinum or extending inferiorly within the neck, paralleling the sternocleidomastoid muscle as a dumbbell-shaped left cervicothoracic cystic mass (fig. 2).6 cysts associated with neoplasms usually have a soft-tissue component. fig. 2. thymic cyst: (a) axial contrast-enhanced ct scan shows a cystic lesion (arrows) in the right side of the neck caudal to the thyroid gland, displacing the trachea to the left. (b) coronal reformatted image shows the lesion (arrow) is parallel to the sternocleidomastoid muscle and extends into the upper mediastinum. thymic tumours thymoma thymomas are the most common primary neoplasm of the anterior mediastinum. rarely, they can be found in ectopic locations such as the neck, or middle or posterior mediastinum. thymomas are classified into noninvasive (benign) or invasive (malignant), and are usually seen in adults in the 5th 6th decade but rarely in children. on imaging, noninvasive thymomas usually grow towards one side of the mediastinum, and are usually homogenous, with mild contrast enhancement (fig. 3). findings indicative of invasive thymoma are: encasement of mediastinal structures, infiltration of fat planes, and an irregular interface between the mass and lung parenchyma; pleural thickening or nodularity; or effusion, multifocal calcification and cystic change (figs 4, 5).7 associations of thymoma are red blood cell aplasia, hypogammaglobulinaemia, myasthenia gravis, connective tissue diseases, autoimmune disease or inflammatory bowel disease. approximately one-third of patients with thymomas have myasthenia gravis, and approximately 10 15% of patients with myasthenia gravis have a thymoma. dynamic mri is used to differentiate thymomas from other anterior mediastinal masses. thymomas tend to reach peak enhancement earlier than other mediastinal neoplasms. noninvasive thymomas attain peak enhancement earlier than invasive thymomas.3 , 8 fig. 3. axial ct image shows homogenous 3 cm soft-tissue mass with mild enhancement in the anterior mediastinum in a case of noninvasive thymoma. fig. 4. (a) chest radiograph showing an anterior mediastinal mass silhouetting the ascending aorta. (b) axial ct image showing solid anterior mediastinal mass (arrow) with direct invasion of the superior vena cava (arrowhead) in a case of invasive thymoma. fig. 5. axial ct images showing a heterogenously enhancing anterior mediastinal mass with mild left pleural effusion and pleural implants in another case of invasive thymoma. thymic carcinoma thymic carcinomas account for about 20% of thymic epithelial tumours. the mean age of patients with thymic carcinomas is 50 years. it is difficult to distinguish thymic carcinomas from thymomas on the sole basis of imaging findings. on imaging, aggressive features such as central necrosis, vascular encasement, pleural/pericardial invasion, distant metastasis or mediastinal lymphadenopathy suggest thymic carcinoma.9 features of vascular invasion are irregular contours of the contrast-filled vascular lumen and frank endoluminal soft tissue.3 , 4 unlike thymomas, thymic carcinomas rarely cause paraneoplastic syndromes. pet-ct shows suvmax >7 in cases of thymic carcinoma.2 thymic lymphoma lymphoma is the most common cause of an anterior mediastinal mass in children and the second most common cause of an anterior mediastinal mass in adults. the average age of a patient with mediastinal lymphoma is 30 years. the thymus may be enlarged from primary involvement or secondary nodal invasion by lymphoma. the most common type is nodular sclerosing hodgkin lymphoma. homogeneous enlargement of the thymus in the presence of mediastinal or hilar lymphadenopathy is suggestive of lymphoma (fig. 6). differentiating recurrent lymphoma from thymic rebound hyperplasia is challenging. in thymic rebound hyperplasia, the thymic enlargement is usually symmetrical, and the contour is smooth and nonlobulated and conforms to the shape of neighbouring structures; while in recurrent thymic lymphoma,the patient is symptomatic, and the thymus is generally asymmetric and nodular and shows heterogeneous signal intensity on mri.10 pet-ct shows increased uptake, with suvmax ≥3.4 in lymphoma.2 fig. 6. axial ct image showing homogenously enhancing soft tissue anterior mediastinal mass (arrow) replacing the thymus in a case of thymic lymphoma. thymolipoma thymolipomas are rare, benign, well-encapsulated thymic tumours that account for about 5% of thymic neoplasms. they usually are seen in young adults and are very large at presentation. on ct, thymolipomas predominantly show fat attenuation interspersed with fibrous septa and a connection with the thymic bed (fig. 7).11 differentials of fat-containing mediastinal lesions are lipoma, liposarcoma, mediastinal lipomatosis, teratoma, diaphragmatic hernias, extramedullary erythropoiesis, lipoid pneumonia, lipoblastoma and cardiac liposarcomas. demonstration of continuity of the mass with thymus clinches the diagnosis. surgical resection is the treatment of choice. fig. 7. (a) chest skiagram reveals non-homogeneous opacities in bilateral mid and lower zones predominantly in central regions silhouetting the cardiac borders with blunting of bilateral costophrenic and cardiophrenic angles. (b) axial ct image of the same patient showing a well-marginated fat attenuation mass with thin strands of fibrous septa on both sides of the hemithorax. thymic carcinoid thymic carcinoids are rare, well-differentiated neuro-endocrine tumours. patients with thymic carcinoids often present with endocrine disorders such as cushing syndrome or multiple endocrine neoplasia types i and ii. on imaging, they present similarly to invasive thymoma with or without calcification (fig. 8). thymic carcinoids are more aggressive than thymomas and cause more superior vena cava obstruction.12 thymic carcinoids show avid uptake of 18f-fdg on pet-ct. fig. 8. axial ct image in a patient with cushing’s syndrome showing ectopic thymic neuroendocrine tumour (arrow). thymic germ cell tumours primary extragonadal germ cell tumours (gcts) are considered of primary mediastinal origin if there is neither a detectable gonadal primary nor retroperitoneal lymphadenopathy. they are usually seen during the 2nd to 4th decades of life. lesions may be divided into seminomatous and nonseminomatous types. the most common benign mediastinal gcts are mature teratomas. malignant tumours are almost exclusively seen in males. mature teratomas do not show elevation of tumour markers, while afp elevation is diagnostic of a nonseminomatous gct. on imaging, a combination of fluid, fat, calcification and soft-tissue component is highly specific for teratoma (fig. 9). calcification is seen in 50% and fat in 50 75% of cases of teratoma. malignant gct usually shows aggressive features with the presence of solid components and absence of fat/calcification with elevation of tumour markers. seminomatous gct grows slowly, is usually large and homogenous, and has a good prognosis (fig. 10). nonseminomatous malignant gcts are aggressive tumours thatgrow rapidly and are more heterogenous, with cystic/necrotic changes (fig. 11).9 fig. 9. axial ct image in a 30-year-old man showing complex anterior mediastinal mass containing cystic, fat and soft-tissue components in a case of mature teratoma. fig. 10. axial ct image in a 24-year-old woman showing homogenously enhancing anterior mediastinal mass in a case of seminomatous germ cell tumour. fig. 11. axial ct image in a 30-year-old woman showing heterogenously enhancing anterior mediastinal mass with cystic/necrotic changes in a proven case of nonseminomatous germ cell tumour. thymic sarcomas thymic sarcomas are extremely rare. they have a nonspecific appearance at cross-sectional imaging with more aggressive features at initial presentation, and carry a poor prognosis. secondary tumours of the thymus secondary tumours of the thymus include invasion of the thymus by lung carcinoma and involvement of the thymus via lymphatic pathways in cancers of the head, neck, abdomen and pelvis. langerhans cell histiocytosis also frequently involves the thymus in the form of an anterior mediastinal mass and may be visible at imaging.13 1. baron rl, lee jk, sagel ss, peterson rr. computed tomography of the normal thymus. radiology 1982;142(1):121-125. 1. baron rl, lee jk, sagel ss, peterson rr. computed tomography of the normal thymus. radiology 1982;142(1):121-125. 2. sharma p, singhal a, kumar a, bal c, malhotra a, kumar r. evaluation of thymic tumours with 18f-fdg pet-ct: a pictorial review. acta radiol 2013;54(1):14-21. [http://dx.doi.org/10.1258/ar.2012.120536] 2. sharma p, singhal a, kumar a, bal c, malhotra a, kumar r. evaluation of thymic tumours with 18f-fdg pet-ct: a pictorial review. acta radiol 2013;54(1):14-21. [http://dx.doi.org/10.1258/ar.2012.120536] 3. rosado-de-christenson ml, strollo dc, marom em. imaging of thymic epithelial neoplasms. hematol oncol clin north am 2008;22(3):409-431. [http://dx.doi.org/10.1016/j.hoc.2008.03.011] 3. rosado-de-christenson ml, strollo dc, marom em. imaging of thymic epithelial neoplasms. hematol oncol clin north am 2008;22(3):409-431. [http://dx.doi.org/10.1016/j.hoc.2008.03.011] 4. peters r, peters o, braak s, verschakelen j. pathology of the thymus on ct imaging. jbr-btr 2012;95(5):281-288. 4. peters r, peters o, braak s, verschakelen j. pathology of the thymus on ct imaging. jbr-btr 2012;95(5):281-288. 5. kissin cm, husband je, nicholas d, eversman w. benign thymic enlargement in adults after chemotherapy: ct demonstration. radiology 1987;163(1):67-70. 5. kissin cm, husband je, nicholas d, eversman w. benign thymic enlargement in adults after chemotherapy: ct demonstration. radiology 1987;163(1):67-70. 6. ibrahim m, hammoud k, maheshwari m, pandya a. congenital cystic lesions of the head and neck. neuroimag clin n am 2011;21(3):621-639. [http://dx.doi.org/10.1016/j.nic.2011.05.006] 6. ibrahim m, hammoud k, maheshwari m, pandya a. congenital cystic lesions of the head and neck. neuroimag clin n am 2011;21(3):621-639. [http://dx.doi.org/10.1016/j.nic.2011.05.006] 7. nasseri f, eftekhari f. clinical and radiologic review of the normal and abnormal thymus: pearls and pitfalls. radiographics 2010;30(2):413-428. [http://dx.doi.org/10.1148/rg.302095131] 7. nasseri f, eftekhari f. clinical and radiologic review of the normal and abnormal thymus: pearls and pitfalls. radiographics 2010;30(2):413-428. [http://dx.doi.org/10.1148/rg.302095131] 8. sakai s, murayama s, soeda h, et al. differential diagnosis between thymoma and non-thymoma by dynamic mr imaging. acta radiol 2002;43(3):262-268. 8. sakai s, murayama s, soeda h, et al. differential diagnosis between thymoma and non-thymoma by dynamic mr imaging. acta radiol 2002;43(3):262-268. 9. webb rw. the mediastinum: mediastinal masses. in: webb rw, higgins c, eds. thoracic imaging: pulmonary and cardiovascular radiology. philadelphia, pa: lippincott, williams & wilkins, 2005:212-270. 9. webb rw. the mediastinum: mediastinal masses. in: webb rw, higgins c, eds. thoracic imaging: pulmonary and cardiovascular radiology. philadelphia, pa: lippincott, williams & wilkins, 2005:212-270. 10. wernecke k, vassallo p, rutsch f, peters pe, potter r. thymic involvement in hodgkin disease: ct and sonographic findings. radiology 1991;181(2):375-383. 10. wernecke k, vassallo p, rutsch f, peters pe, potter r. thymic involvement in hodgkin disease: ct and sonographic findings. radiology 1991;181(2):375-383. 11. molinari f, bankier aa, eisenberg rl. fat-containing lesions in adult thoracic imaging. ajr 2011;197(5):w795-w813. [http://dx.doi.org/10.2214/ajr.11.6932] 11. molinari f, bankier aa, eisenberg rl. fat-containing lesions in adult thoracic imaging. ajr 2011;197(5):w795-w813. [http://dx.doi.org/10.2214/ajr.11.6932] 12. kogan j. carcinoid tumour of the thymus. postgrad med 1984;75(1):291-296. 12. kogan j. carcinoid tumour of the thymus. postgrad med 1984;75(1):291-296. 13. junewick jj, fitzgerald ne. the thymus in langerhans’ cell histiocytosis. pediatr radiol 1999;29(12):904-907. 13. junewick jj, fitzgerald ne. the thymus in langerhans’ cell histiocytosis. pediatr radiol 1999;29(12):904-907. sa journal of radiology • june 2012 81 radioactive news cme fund donates books to red cross war memorial children’s hospital clive sperryn (president, rssa) the cme fund, now formally constituted with trustees professors zarina lockhat and leon janse van rensburg and drs thami ngomam and johan basson, made funds available during 2011 to the academic institutions for purchasing books for departmental libraries. however, professor steve beningfield advised that the library at uct was well stocked, and their funds were therefore re-allocated across the other institutions. we were very appreciative of this generous gesture. however, leon janse van rensburg recently became aware that red cross war memorial children’s hospital (rcwmch) was in need of books; as a result, an additional allocation of funds was made so that the rcwmch might acquire the needed books. i recently had the pleasure of handing over these books to dr tracy kilborn and her team on behalf of the rssa cme fund. at my visit, i was pleased to note that the paediatric radiology fellowship programme is once again active and to meet dr tanya pillay who is the current paediatric radiology fellow. the rssa hopes to further strengthen radiology training and academic radiology within south africa, and it is anticipated that further fellowships will be initiated through the subspeciality groups, the college and academic institutions. the active congress programme of the rssa organised by leon janse van rensburg covers major areas of the syllabus over a 5-year cycle, giving all radiologists, and particularly those in training, the opportunity to continually update knowledge, with renowned international speakers coming to south africa. first rssa/saspi paediatric imaging congress the first rssa/south african society of paediatric imaging (saspi) paediatric imaging congress takes place at the sandton sun hotel conference centre, johannesburg, from 9 11 november 2012. registration details are on the rssa website (http://www.rssa.co.za). the international faculty of four renowned paediatric radiologists comprises professors a james barkovich (neuroradiology, university of california, san francisco), diego jaramillo (body imaging and msk, university of pennsylvania), edward lee (thoracic imaging, harvard university) and pia sundgren (neuroradiology, university of lund, sweden), supported by south african paediatric radiologists and co-ordinated by dr tracy kilborn, head of the department of radiology, red cross children’s war memorial hospital, cape town. radiologists and radiographers require comprehensive knowledge of advances in all imaging modalities pertaining to children. the renewed emphasis and public awareness of issues about radiation exposure and dose reduction techniques, makes this event very timely and relevant to our daily practice. the programme covers three categories: neuroradiology, and thoracic and musculoskeletal imaging. the chosen topics will give insight and guidelines into the management of common and challenging conditions encountered in paediatric patients. there will also be an interactive casebased interpretation session led by the international faculty, and lectures on new horizons in paediatric neurological and thoracic imaging. the free paper session for the 2012 rssa travel award of r40 000 will take place during the course. there will also be a scientific and poster exhibition with prizes of r15 000, r10 000 and r5 000. the scientific committee chair is dr jaishree naidoo (university of the witwatersrand); the other members are professors zarina lockhat (university of pretoria), victor mngomezulu (university of the witwatersrand) and richard pitcher (university of stellenbosch). we are grateful for their time and effort in taking on a difficult task. the rssa has a vibrant cme programme which is forged upon partnerships with leading international societies, radiologists and scientists. one of the prestigious partners is the international society of magnetic resonance in medicine (ismrm), thanks to whose global outreach programme, funding was received to facilitate this event. all members of the international faculty are also members of the ismrm, whose generous support is greatly appreciated, as is that of other sponsors whose commitment to radiology training and teaching is indispensable. european congress of radiology 2013 ecr 2013, which is organised by the european society of radiology, will be held at the austria center, bruno kreisky platz, vienna, from 7 11 march 2013. the deadlines and requirements for abstract submission are on the esr website. representing the medical specialty of radiology throughout europe, this major event is well worth planning to attend. go to http://www.alliance-for-mri.org/cms/website. php?id=/en/ecr_2013.htm for more information. registrars and young radiologists who are members of the rssa are encouraged to take up corresponding membership of the esr via the link in the rssa website and to consider attending ecr 2013. rssa cme educational grants the rssa cme association is pleased to announce that it has made available 6 educational grants for 2012, up to a value of r10 000 each, of which 3 have been awarded to date. rssa members (specifically registrars or radiologists with less than 5 years’ experience) who will be making oral or poster presentations at an international congress are eligible for these grants. contact patricia trietsch at the rssa (see below) for back row, left to right: nicky wieselthaler, ebrahim banderker (consultants); zukisa mabusela, zonah khumalo (registrars); tanya pillay (paediatric radiology fellow) and kristin lorenc-henning (registrar). front row: tracy kilborn (hod), clive sperryn (rssa president). 82 sa journal of radiology • june 2012 radioactive news more information. all decisions regarding the applications will be made by the trustees of the rssa cme association at their sole discretion. the first three grant recipients are: dr nishentha govender, a radiology registrar at the university of the witwatersrand, who was selected to deliver an oral presentation, entitled adequacy of paediatric renal tract ultrasound requests and reports, at the european society of paediatric congress (espr) 2012 in athens  from 30 may 1 june. dr nasreen mahomed, a radiologist at chris hani baragwanath hospital, also attending espr 2012, for three  poster presentations entitled vanishing white matter disease, mri imaging over 3 years; non-accidental injury – a south african experience; and disseminated rhabdomyosarcoma with spinal metastases. dr pieter janse van rensburg, a fellow in the department of neuroradiology, university of utah, salt lake city, usa. dr janse van rensburg was selected from more than 1 570 applicants  to present an oral paper at the american society of neuroradiology (asnr) 50th anniversary annual meeting in new york from 23 26 april this year. the title was mild aural dysplasia: identifying the subtle findings. the rssa congratulates the recipients on their outstanding achievements. we again encourage all registrars who are not members to join the rssa. fees are low and members enjoy the free journal and lower rates at our congresses. contact patricia trietsch, radiological society of south africa, email: radsoc@iafrica.com, website: www.rssa.co.za, phone 011 794 4395, fax 011 794 4313. pet/ct scanner in service at tygerberg hospital on 19 april 2012 the provincial government of the western cape, ntp radioisotopes (pty) ltd and its parent company necsa (south african nuclear energy corporation) celebrated the official opening of the positron emission tomography/computed tomography (pet/ ct) centre at tygerberg hospital. the r15.6 million pet/ct scanner was donated to the people of the western cape by ntp radioisotopes, with the contribution of the western cape department of health to this project being r14.75 million (r11 million for infrastructure and r3.75 million for equipment accessories). western cape health minister, theuns botha, said, ‘the cost-saving implications of this technology are phenomenal, and it also means that greater numbers of patients will be treated more appropriately, with improved outcomes for all.  this is such a great example of the public and private sector working together for the well-being of the people of the western cape.’   don robertson, ntp’s md and acting ceo of necsa, said. ‘ntp is in the business of actively enhancing lives and is really proud to have made an additional scanner available to the western cape. this will now ease the strain of utilising the scanner at the cape pet/ct centre, where only two afternoon sessions per week were allocated to tygerberg, groote schuur and red cross war memorial children’s hospital patients.’ the first patient had the privilege of utilising the new scanner by undergoing the first scan earlier in april. robertson explained that millions of patients throughout the world benefit from nuclear medicine scans and other procedures performed using products supplied by ntp. ‘early detection of most diseases assisted by using nuclear medicine scans greatly enhances the possibility of early and accurate diagnosis. the commercially produced radioactive isotope known as molybdenum-99 (mo-99) is used globally in nuclear medical procedures. this allows prompt and proper treatment, and therefore a better chance of a saved life.’ the tender to provide the pet/ct scanner was awarded to philips medical systems. professor james warwick of the nuclear medicine department at tygerberg hospital, and the project leader, said that the system meant more accurate detection, better image quality and detection of smaller lesions, and that it enables the scanning of more patients. report on the first rssaleuven hrct lung course: 24 26 february 2012, spier estate, stellenbosch darius tsatsi (department of radiology, polokwane campus, university of limpopo) ‘we have over 95% of the attendees present at the end of a 2-and-ahalf-day intensive course, and those who left had unavoidable reasons to depart early’, announced professor leon janse van rensburg, rssa congress chairman, at the end of the last lecture of the interactive hrct course. the 92-strong audience thoroughly enjoyed the course and fully participated in the interactive sessions, lectures and questionand-answer sessions. the second of two back-to-back courses, this dedicated and most comprehensive high resolution computed resolution (hrct) course, under the auspices of the rssa and leuven university, took place at the serene and historic spier wine estate. professor leon janse van rensburg, chairman of the congress committee, welcomed all and made the necessary introductions. the course has been presented annually for 22 years in leuven, and is usually limited to 60 partcipants. leon, as he is affectionately known, managed to negotiate an additional 32 and 20 participants respectively for the cape town and johannesburg sessions. this was a major feat; congratulations to leon for his superb organisational skills. since his chairmanship, he has not only increased the number of congresses but also improved the content and quality to keep us on par with the rest of the world. this was the first time the course was presented outside leuven – another major achievement for leon and the rssa. despite having reserved 30% of the places for registrars, these were not taken up and were released only when early registration closed. this is an area we all need to work on to improve the lot of those who will advance our discipline and society in the years ahead. professor drs johny verschakelen and walter de wever of the department of radiology, university hospitals, catholic university of leuven (k.u. leuven), dazzled and impressed local diagnostic radiologists as they teased apart the complex concepts of hrct. the course began with an intricate outline of lung anatomy, using sketches and drawings superimposed on ct lung anatomy. the latter formed the basis for the pathological variations from ground glass, nodular, cystic, linear and other changes. time was also given to a more detailed analysis of some of the complex conditions of the lungs. fortunately, the lectures will be available to all on the rssa website. a major regret is that, despite the chairman pushing for more seats for the congress, interactive spots could not be provided for all the delegates wanting them. i close by thanking the rssa, sa journal of radiology • june 2012 83 radioactive news and professors verschakelen and de wever for their time and presenting and simplifying for all of us the performance, analysis, interpretation and reporting of hrct diseases. and thanks to the attendees, christelle snyman of consultus, and professor leon janse van rensburg. asnr 50th annual meeting, 21-26 april 2012, new york, ny, usa pieter janse van rensburg (fellow in neuroradiology, department of radiology, university of utah health sciences center, salt lake city, utah) i had the privilege of attending, and delivering an oral presentation (mild congenital external and middle ear malformations: identifying the subtle findings) at, the 50th meeting of the american society of neuroradiology (asnr) in new york this year. it was a most prestigious and well-attended meeting, with many simultaneous presentations and lectures on various topics of interest on all aspects of neuroradiology. one particularly important topic was the assessment of true progression and pseudoprogression in the age of anti-angiogenic therapies. the revised assessment in neuro-oncology (rano) criteria is the latest, albeit imperfect, system to address this issue. radiologists are advised to report their neuro-oncology imaging studies according to the rano criteria. it is also important to be aware of the drastic changes in the imaging appearance of brain tumours that may result within 24 hours after the administration of anti-angiogenic therapies such as bevacizumab (avastin). another topic of interest was the imaging of human papillomavirus (hpv)-associated oropharyngeal squamous cell carcinoma. this is an increasingly recognised entity, often affecting younger patients without traditional risk factors such as smoking and alcohol use. it is, however, associated with certain sexual practices. these tumours appear to have a better prognosis than conventional oropharyngeal squamous cell carcinomas. the educational exhibitions, electronic posters and cases of the day were also highly interesting, and i encourage south african residents and radiologists to consider submitting their research or educational projects to international meetings such as that of the asnr. i express my gratitude to the rssa, who awarded me an educational grant to attend the asnr and to present my research. acalculous.html acalculous cholecystitis presenting in an out-patient with no risk factors m goodier, mb chb s mulira, mb chb s andronikou, mb bch, fcrad, frcr (lond), phd department of radiology, university of the witwatersrand, johannesburg corresponding author: m goodier (goodiermatt@gmail.com) abstract acute acalculous cholecystitis (aac) is recognised to occur in patients with serious co-morbid illnesses such as after major surgery, severe trauma, burns, multi-organ failure, systemic sepsis and prolonged intravenous hyperalimentation. the development of aac in outpatients with none of the traditional risk factors appears to be increasing. the incidence of this form of aac in south africa has not yet been established. prompt recognition of this condition and appropriate surgical management is necessary to minimise morbidity and mortality. this report describes a 52-year-old man who developed aac in the absence of the usual risk factors. background acute acalculous cholecystitis (aac) is acute inflammation of the gallbladder in the absence of gallstones. the condition has previously been regarded as occurring in the context of the intensive care unit in patients who are post major surgery or who have major systemic illnesses. according to international reports, the incidence of aac developing in outpatients with none of the traditional risk factors appears to be increasing.1 to date, there have been no reports from south africa regarding the local incidence of this form of aac. case report we present the case of a 52-year-old man presenting from home with right upper quadrant pain. he had a history of hypertension and was on hydrochlorothiazide 12.5 mg daily. he was otherwise well with no history of diabetes mellitus, auto-immune disease or any other significant illness. on examination, the patient was pyrexial and tachycardic. there was tenderness and peritonism localised to the right upper quadrant. there was laboratory evidence of a systemic inflammatory process, with a white cell count of 20.4x109 cells/l and a c-reactive protein (crp) of 231.7 mg/l. electrolytes and liver enzymes were within normal limits. he tested hiv-negative. plain films of the abdomen were considered non-specific at the time. ultrasound of the abdomen failed to demonstrate the gallbladder with prominent gas shadowing in the gallbladder fossa. the sonographic murphy’s sign was positive. a computed tomogram (ct) of the abdomen performed on admission showed a thickened gallbladder wall with surrounding inflammatory fatty stranding. the gallbladder lumen was noted to contain a significant amount of gas suggestive of a complicated cholecystitis (fig. 1). an open cholecystectomy was performed on day 2 post admission. the gallbladder appeared inflamed, gangrenous and necrotic (fig. 2a). no gallbladder calculi were noted at operation. pathological examination of the resected specimen showed features of an acute gangrenous cholecystitis (fig. 2b). postoperative recovery was complicated with a repeat ct done on day 10 showing a small subhepatic collection that was treated conservatively. the patient was discharged on day 25. discussion acalculous cholecystitis has traditionally been recognised to occur in patients with serious co-morbid illnesses especially after major surgery, severe trauma, burns, multi-organ failure, systemic sepsis and prolonged intravenous hyperalimentation.2 diabetes and auto-immune conditions are also known risk factors. patients with acquired immune deficiency syndrome (aids) may develop a cholecystitis secondary to opportunistic infection of the gallbladder. 3 however, there have recently been an increasing number of reports in the literature of the occurrence of aac in patients with none of the established risk factors. two recent series suggest that, in some settings, a significant number of patients with acalculous cholecystitis present from home with no evidence of predisposing illness or trauma. this group of patients may comprise up to 14% of all outpatients with acute cholecystitis4 and as many as 77% of all patients finally diagnosed with aac.5 the development of gallbladder inflammation in aac is traditionally believed to be secondary to ischaemia.6 the cystic artery is an end artery with no significant source of collateral supply to the gallbladder. ischaemia of the gallbladder in critically ill patients is often multifactorial, with dehydration, sepsis, gallbladder stasis with the accumulation of sludge and multiple transfusions being possible predisposing factors. the pathogenetic mechanisms of aac in patients with no risk factors is as yet unclear; however, as many as 72% of these patients have evidence of atherosclerotic vascular disease.5 these patients are also commonly hypertensive (as was our patient), further suggesting that vascular disease may play a role in the pathogenesis of this condition.5 acalculous cholecystitis had been considered to have a poor prognosis, but this most probably reflects the severity of the underlying condition. in patients with no major systemic illness, an increased incidence of gangrenous cholecystitis (as much as 59%) has been reported, but this is possibly owing to diagnostic uncertainty and delay in performing surgery in this group of patients.4 with prompt and appropriate treatment, the outcome in the group of patents with no underlying systemic illness appears to be similar to patients with calculous cholecystitis.7 conclusion although acalculous cholecystitis often occurs in the context of the intensive care unit in patients with major underlying illnesses, it should be recognised that a significant proportion of patients with this condition present as outpatients with no underlying risk factors. the incidence of this form of aac in south africa has not been established. prompt recognition of this condition and surgical management is necessary to minimise the associated morbidity and mortality. 1. parithivel vs, gerst ph, banerjee s, parikh v, albu e. acute acalculous cholecystitis in young patients without predisposing factors. am surg 1999;65:366-368. 1. parithivel vs, gerst ph, banerjee s, parikh v, albu e. acute acalculous cholecystitis in young patients without predisposing factors. am surg 1999;65:366-368. 2. kalliafas s, ziegler dw, flancbaum l, choban ps. acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. am surg 1998;64:471-475. 2. kalliafas s, ziegler dw, flancbaum l, choban ps. acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. am surg 1998;64:471-475. 3. yusuf te, baron th. aids cholangiopathy. curr treat options gastroenterol 2004;7:111-117. 3. yusuf te, baron th. aids cholangiopathy. curr treat options gastroenterol 2004;7:111-117. 4. ryu jk, ryu kh, kim kh. clinical features of acute acalculous cholecystitis. j clin gastroenterol 2003;36:166-169. 4. ryu jk, ryu kh, kim kh. clinical features of acute acalculous cholecystitis. j clin gastroenterol 2003;36:166-169. 5. savoca pe, longo we, zucker ka, mcmillen mm, modlin im. the increasing prevalence of acalculous cholecystitis in outpatients. results of a 7-year study. ann surg 1990;211:433-437. 5. savoca pe, longo we, zucker ka, mcmillen mm, modlin im. the increasing prevalence of acalculous cholecystitis in outpatients. results of a 7-year study. ann surg 1990;211:433-437. 6. warren bl. small vessel occlusion in acute acalculous cholecystitis. surgery 1992;111:163-168. 6. warren bl. small vessel occlusion in acute acalculous cholecystitis. surgery 1992;111:163-168. 7. shridhar ganpathi i, diddapur rk, eugene h, karim m. acute acalculous cholecystitis: challenging the myths. hpb 2007;9:131-134. 7. shridhar ganpathi i, diddapur rk, eugene h, karim m. acute acalculous cholecystitis: challenging the myths. hpb 2007;9:131-134. fig. 1. axial computed tomogram demonstrating the thick-walled gallbladder (arrow) which contains air. there is stranding in the surrounding mesenteric fat. fig. 2a. intraoperative image demonstrating the inflamed gallbladder. fig. 2b. gross pathological specimen showing necrosis and gangrene of the gallbladder wall. no calculi were present within the gallbladder. 124 sajr september 2012 vol. 16 no. 3 cpd questionaire 1. regarding alcapa, which one of the following statements is false? a. the acronym alcapa stands for ‘anomalous left coronary artery originating from the pulmonary artery’. b. it is not usually associated with a high infant mortality rate. c. it presents with myocardial ischaemia and/or cardiac failure in infants. d. the treatment of choice is surgical correction to re-establish a twocoronary artery perfusion system. 2. which one of the following is true concerning the diagnosis of pulmonary tuberculosis (ptb) in children? a. the diagnosis of pulmonary tuberculosis in children presents no challenge. b. lateral chest radiographs are infrequently utilised to assist with the diagnosis of ptb in children. c. most attention should be paid to the area anterior to a line extended from the anterior tracheal wall and below the right upper lobe bronchus when assessing the cxr for lymphadenopathy in children with suspected ptb. d. the precarinal zone on cxr has a low sensitivity and specificity. 3. which one of the following statements is false? a. alexander disease was originally described by alexander in 1949. b. it typically presents with parieto-occipital preponderance of white matter abnormalities and microencephaly. c. it is a rare, fatal, nonfamilial leucoencephalopathy. d. alexander disease is caused by astrocyte dysfunction characterised by missense mutation in the genes coding for glial fibrillary acidic protein (gfap). 4. identify one false statement. a. aortic stenosis is the most commonly encountered valvular disease in developed countries. b. patients unfit for surgical valve replacement may require transcatheter aortic valve implantation (tavi). c. tavi involves the delivery of a prosthetic valve, through the femoral artery, by means of a retroflex delivery system. d. tavi is no longer a popular treatment for symptomatic aortic stenosis in patients unfit for conventional surgery. 5. which of the following statements is false? a. glioblastoma multiforme (gbm) is a class of highly aggressive central nervous system tumours. b. gliomas are subdivided into astrocytomas and oligodendrogliomas. c. surgery, chemotherapy and radiation therapy achieve great success in the management of glioblastoma. d. glioblastoma multiforme demonstrates a high degree of heterogeneity in both its pathological and radiological appearance. 6. identify the one correct statement among the following choices. a. ankylosing spondylitis is a debilitating disease, affecting mostly white men, with a male:female ratio of about 6:1, within the age group of 15 35 years of age. b. early lumbar axial ankylosis and spinal involvement is less marked in male patients with early radiographic signs of hip involvement. c. ankylosing spondylitis is not associated with diseases such as ulcerative colitis, iritis and aortic insufficiency. d. the prognosis is not affected by age at first presentation, or the radiological grade, as defined by either the bath ankylosing spondylitis radiology index (basri) – for cervical-, lumbar spine and hips – or the modified new york criteria for the extent of sacro-iliitis. 7. regarding ankylosing spondylitis, all the following are true except: a. classic joint involvement includes: bilateral sacro-iliac, thoraco-lumbar and lumbo-sacral joints (early) and cervical spine (late). b. cardiac manifestations, such as aortic valve and root abnormalities, together with conduction and rhythm abnormalities, are unheard of. c. genetic susceptibility is a causative factor, with 96% of these patients, testing positive for the hla-b27 gene. d. apical fibrosis of the lung is only reported in 1% of patients. 8. identify the one false statement among the following. a. isolated unilateral axillary adenopathy is not an uncommon finding. b. axillary adenopathy can be caused by either locoregional or systemic pathology. c. the breast, thoracic wall and arm have direct lymphatic drainage to the axilla. local infection, inflammation or malignancy in these regions may lead to unilateral axillary adenopathy. d. auto-immune diseases such as rheumatoid arthritis, lupus, sjögren’s syndrome and dermatomyositis are unheard of as causes of isolated axillary lymphadenopathy. 9. regarding pulmonary tuberculosis, identify the single false statement. a. the western cape in south africa had an incidence of 468 cases per 100 000 people in 1998, which is among the highest in the world. b. diagnosing the disease in children is a challenge, as 56 65% of children are asymptomatic at the time of diagnosis. c. the mantoux test reaction lags behind radiological findings. d. mycobacterium tuberculosis is isolated in more than 70% of paediatric cases. 10. identify one false statement. a. functional magnetic resonance imaging (fmri) is an mri technique capable of estimating regional brain activity during a predefined cognitive task. b. currently, the most promising direct clinical application is in pre-surgical planning, where fmri is used to identify the spatial relationship between important functional areas in the brain and the area to be resected. c. functional mri works on the principle that deoxygenated blood is magnetic whereas oxygenated blood is not. d. the presence of deoxyhaemoglobin in the tissue being imaged has no effect on the local magnetic field. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/027/10/2011 give one correct answer for each question editorial editorial a new journey my recent appointment as deputy editor 5 months ago has afforded me the opportunity to observe, and be involved in, the editorial process. my initiation into the publishing of scholarly journals was marked by a visit to the health and medical publishing group (hmpg) office in rondebosch, cape town, where i was introduced to the publishing team responsible for delivering the completed journal, in print and online, to the radiology community each quarter. hmpg publishes not only the south african journal of radiology (sajr), but also the south african medical journal (samj), the journal of continuing medical education (cme) and the official journals for a number of specialist societies. accessing the hmpg webpages allows the researcher access to the full stable of journals, current and past. advances in information technology have inter alia resulted in an online manuscript management system, which has revolutionised the submission and review process, improving the reviewing and editing interface for all journals. i take this opportunity to acknowledge the efforts of a talented and committed team. as part of my continuing editorial education, i attended the 6th annual meeting of the national scholarly editor’s forum (nsef) of south africa, convened at belmont square convention centre, cape town, on 25 july 2012. the diverse topics on the agenda were informative, and i share a selected few in this editorial. the nsef is a consultative and advisory body managed by the academy of science of south africa (assaf). assaf was inaugurated in may 1996 by former president nelson mandela, and officially represents the country in the international community of scientific academies. it includes distinguished scientists from diverse fields. in 2008, assaf adopted and approved the national code of best practice in editorial discretion and peer review for south african scholarly journals. the fundamental principles of research publishing, the core role of editors, and the indispensable task performed by peer reviewers, were included. colleagues employed in challenging fulltime academic positions, who accept the task as editor in the absence of financial incentives, receive alternative rewards that include continuing education and networking opportunities. the essential requirement is for responsible editorial supervision, ensuring that an editorial policy exists and is accessible to authors. it is pertinent to mention that, although the sajr is in the position to publish suitable material that has passed a peer review process, it is not an examining body. the sajr has received requests to review manuscripts, submitted as case reports, for the purposes of meeting the research requirements of the master of medicine (mmed) degree. the hierarchy of scientific data dictates that a case report has a lower level of scientific impact. to maintain a high standard for the master of medicine degree in radiology, the submitted manuscripts, intended for degree purposes, should have a high scientific impact and undergo peer review by highly regarded university academics. selected peer reviewers, as suggested by the national code of best practice, must have the expertise and specialised knowledge pertaining to the topic addressed in a submitted paper if they are to complete their role in the system of universal knowledge accumulation. for the sajr to publish manuscripts of highest quality, we require the continued, and valued, support of those individuals in the south african radiology community who are experts in their respective radiological disciplines. mmed students should be encouraged to distribute their scholarly research through journal publication. strong mentorship, constructive criticism and commitment to publication are key elements for preparing a manuscript for publication. to receive subsidy or recognition for an article, an author should select a journal that is accredited. accredited journals are recognised research publications that meet specific criteria and therefore qualify for financial subsidy by the department of higher education and training (dhet). lists acknowledged by the dhet include the isi (institute of scientific information), the ibss (international bibliography of social sciences), accredited open access journals, and the approved south african journal list. the thomson reuters institute of scientific information (isi) web of science database contains just over 12 200 journals. although all subject fields are covered, over 8 000 are in the sciences. the ibss list contains fewer than 2 800 journals and focuses on the social sciences. the dhet list contains approximately 250 south african journals in various subject fields. the sajr is accredited by the dhet. however, problems encountered with isi and ibss, which include non-listing of top journals in certain fields, extensive coverage of certain academic fields above others, and non-transparency of the listing process, have been reported. the dhet has therefore recommended that the isi, ibss and sa approved list be retained and the norwegian list and scielo south africa be considered. scielo sa (scientific electronic library online south africa) is an integral part of the scielo portal, which had its origins in brazil and is now distributed across most south american countries. editors at the 6th nsef meeting in july 2012 were informed that, as of april 2012, scielo sa had been independent from scielo brazil. it is a national open access database managed by the assaf, funded by the south african department of science and technology, and endorsed by the dhet. it is hoped that scielo sa will strengthen the scholarly journal evaluation and accreditations systems in south africa. in addition, editors were informed that assaf and the dhet were prompted to review the journals on the sa list after concerns were raised regarding the quality of several listed journals. the proposed recommendation is that a journal will only be listed for 5 years. this would provide the time necessary to develop the journal to international standards and to apply for listing on any of the accredited indices. journals removed after this 5-year period would be able to re-apply after a minimum of 2 years, but evidence that the journal had been published uninterrupted for a minimum of 3 years, would have to be submitted. i experienced the diverse matters tabled for discussion at the 6th annual nsef meeting as an enlightening education. the last 5 months have been an interesting journey. i hope to be involved in many more successful volumes of the sajr, and encourage its continued support and participation from the south african radiology community. thank you for this opportunity.   razaan davis deputy editor about the author(s) jaanri brugman division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa gerard de bruyn division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa komeela naidoo division of radiation oncology, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa marc merven division of otorhinolaryngology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa johan opperman division of anatomical pathology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa leon janse van rensburg division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation brugman j, de bruyn g, naidoo k, et al. corrigendum: not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases. s afr j rad. 2021;25(1), a2268. https://doi.org/10.4102/sajr.v25i1.2268 note: doi of original article published: https://doi.org/10.4102/sajr.v24i1.1978 correction corrigendum: not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases jaanri brugman, gerard de bruyn, komeela naidoo, marc merven, johan opperman, leon janse van rensburg published: 01 dec. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the version of the article initially published, brugman j, de bruyn g, naidoo k, et al. not always ‘squame’: the rare entity of follicular dendritic cell sarcoma of the tonsil presenting with cervical nodal metastases. s afr j rad. 2020;24(1), a1978. https://doi.org/10.4102/sajr.v24i1.1978, the orcid of the last author was given incorrectly. the correct orcid should be https://orcid.org/0000-0003-1549-6785 instead of https://orcid.org/0000-0003-1317-2699 in the ‘authors’ section. this correction does not alter the study’s findings of significance or overall interpretation of the study’s results. the authors apologise for any inconvenience caused. abstract introduction case report discussion conclusion learning points acknowledgements references about the author(s) poonam sherwani department of radiodiagnosis, all india institute of medical sciences rishikesh, rishikesh, india khanak k. nandolia department of radiodiagnosis, all india institute of medical sciences rishikesh, rishikesh, india kirti joshi department of paediatrics, all india institute of medical sciences rishikesh, rishikesh, india radhapyari lourembam department of paediatrics, all india institute of medical sciences rishikesh, rishikesh, india citation sherwani p, nandolia kk, joshi k, lourembam r. imaging in van wyk grumbach syndrome: an uncommon presentation of hypothyroidism. s afr j rad. 2023;27(1), a2572. https://doi.org/10.4102/sajr.v27i1.2572 case report imaging in van wyk grumbach syndrome: an uncommon presentation of hypothyroidism poonam sherwani, khanak k. nandolia, kirti joshi, radhapyari lourembam received: 21 oct. 2022; accepted: 27 jan. 2023; published: 15 mar. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract isosexual precocious puberty with ovarian masses in long-standing juvenile hypothyroidism is well described in the literature as van wyk grumbach syndrome (vwgs). the present case reports this rare entity in a 4-year-old girl who was referred for imaging to evaluate the cause of non-traumatic bleeding per vagina. antecedent history, clinical features and thyroid function tests were consistent with long-standing juvenile hypothyroidism with documented clinical response to thyroxine replacement therapy. contribution: typical clinical and radiological features of the syndrome are reported, which helps in the early diagnosis and management, henceforth avoiding the associated complications. keywords: galactorrhoea; hypothyroidism; isosexual precocious puberty; pituitary; ovarian mass; thyroid stimulating hormone (tsh); per vagina; van wyk grumbach syndrome (vwgs). introduction van wyk grumbach syndrome (vwgs) is a rare presentation of untreated hypothyroidism which is the most commonly encountered endocrine disorder in children. classic clinical features of vwgs are precocious puberty, galactorrhoea and cystic ovarian lesions that are remarkably extenuated following thyroxine replacement therapy.1 precocious puberty is due to high levels of thyroid stimulating hormone (tsh) causing stimulation of the follicle-stimulating hormone (fsh) receptors. pituitary hyperplasia is also often seen in vwgs. comprehensive knowledge about imaging in vwgs is imperative for radiologists who can advise against unnecessary surgical interventions. case report a 4-year-old girl presented to the emergency department of a tertiary care institute with heavy fresh, red-coloured bleeding per vagina in the absence of trauma or sexual assault. short stature, short and stubby hands, delayed dentition, bradycardia and various other general features on physical examination were suggestive of hypothyroidism. the thyroid gland was not palpable. haematological investigations revealed macrocytic anaemia and a normal coagulation profile. thyroid profile showed elevated levels of tsh (699 iu/ml, normal range 0.35 iu/ml – 4.9 iu/ml) with low levels of serum t3 (< 1 pg/ml, normal range 2.6 pg/ml – 4.8 pg/ml) and serum t4 (< 0.4 ng/dl) along with a markedly elevated level of thyroid peroxidase oxidase (2152 u/ml normal range 0–60). basal fsh was elevated; however, luteinizing hormone (lh) and prolactin levels were normal. based on the biochemical findings, a diagnosis of autoimmune hypothyroidism was made. greyscale ultrasonography and colour flow doppler imaging of the pelvis revealed a post-pubertal sized uterus, measuring 6.3 cm × 1.3 cm (length × transverse) with a tri-layered endometrium. a septated cystic lesion, measuring 5.7 cm × 3.7 cm, was seen in the right adnexa with no peripheral or septal colour flow. the right ovary was not separately visualised. a dominant follicle was seen in the bulky left ovary (figure 1). figure 1: (a-b) pelvic ultrasound in the sagittal plane depicting an enlarged uterus for a 4-year-old girl with a trilaminar endometrium similar to the post-pubertal uterus. (c) septated cystic lesion in the right adnexa. (d) the left ovary is bulky with a dominant follicle. ultrasonography of the neck revealed bilateral hypoplastic thyroid lobes in the normal position. the right thyroid lobe measured 6.5 mm × 5.5 mm and the left lobe measured 8.8 mm × 6 mm. the isthmus was not visualised. there were no thyroid nodules or cysts (figure 2). figure 2: axial ultrasound images of the thyroid gland showing a hypoplastic right lobe (arrow in a) and left lobe (arrow in b). the isthmus is not visible in the midline. a skeletal survey was performed to assess bone age. a wrist radiograph revealed ossification centres for the hamate and capitate, consistent with a bone age of 3–4 months. the appearance of the epiphysis at the distal end of the radius was consistent with a bone age of 1 year. triquetral and lunate bone ossification centres were not seen indicating that the bone age of the child corresponded to more than 1 year but less than 4 years (figure 3b).2 a lateral radiograph of the skull revealed the presence of multiple wormian bones and an enlarged sella (figure 3a). radiographs of the pelvis and hip joints exhibited diffuse cortical thickening along the meta-diaphyseal region of both proximal femora (figure 3c). the lateral radiograph of the left knee was unremarkable (figure 3d). contrast-enhanced magnetic resonance imaging for the pituitary gland revealed hyperplasia of the anterior pituitary with homogeneous enhancement. the posterior pituitary was unremarkable (figure 4). figure 3: lateral radiograph of the skull (a) showing multiple wormian bones in the coronal and lambdoid sutures (*). frontal radiograph of the right wrist (b) showing a delayed appearance of ossification centres for the carpal bones. bone age corresponded to more than 1 year and less than 4 years. metacarpal epiphyseal ends show a small spike-like projection extending into the growth plate (long white arrow). irregularity of the growth plate is seen along the distal end of the radius and ulna (black arrows) and there is soft tissue hypertrophy (small white arrow). (c) frontal radiograph of the pelvis and proximal femurs shows fragmented epiphysis (black arrow) with cortical thickening of both proximal femoral diaphysis (arrow in c). (d) the lateral radiograph of the left knee is unremarkable. figure 4: (a) sagittal t1w images show a t1 iso-intense sellar and suprasellar mass (long white arrow). the posterior pituitary is seen separate from the mass as a t1 bright spot (small white arrow in a). (b) gadolinium-enhanced coronal images demonstrate the homogeneous enhancement of the mass with elevation of the optic chiasm anteriosuperiorly (arrow in b). most of the causes of precocious puberty are associated with advanced bone age except for vwgs where delayed bone age is seen which leans towards the diagnosis.3,4 therefore, based on the clinical, biochemical, and radiological findings, a diagnosis of vwgs was made and the child was treated with thyroxine. five days after initiation of therapy, the vaginal bleeding stopped and the child was discharged with recommendation for follow-up. at follow-up after 2 months, the child showed significant improvement in clinical symptoms. there was a substantial reduction in weight, with marked improvement in appetite and constipation. facial features also showed marked improvement. ultrasound pelvis revealed a significant decrease in the size of the uterus, which measured 3.8 cm × 1.3 cm. regression in the size of the ovaries was seen with the complete resolution of the cyst and follicle. the right ovary measured 2.2 cm × 1.5 cm and the left ovary measured 2 cm × 0.8 cm. (figure 5) figure 5: (a-d) a follow-up ultrasound after 2 months showed a significant reduction in the size of the uterus and regression in the size of both ovaries, with almost complete resolution of the cysts. discussion van wyk and grumbach described the syndrome of precocious puberty, galactorrhoea, and bilateral ovarian masses in primary hypothyroidism with complete reversal of the symptoms after thyroid replacement in 1960.5 bilateral ovarian masses and precocious puberty suggest the diagnosis of an oestrogen secreting neoplasm. a possible diagnosis of vwgs should be considered when bilateral cystic ovarian masses are associated with long-standing hypothyroidism, and long-term complications can be avoided by the timely initiation of thyroid replacement therapy.6 patients usually present with typical clinical features of hypothyroidism which include weight gain, poor concentration, depression, fatigue and menstrual irregularities. the index case also presented with thelarche, early menarche and precocious puberty. most of the cases are reported in females7 and very few cases have been reported in boys.8 long-standing hypothyroidism, high levels of tsh, precocious isosexual puberty and delayed bone age are the pertinent features of this syndrome which were seen in the presented case.1 bone changes in hypothyroidism generally include delayed bone age, sellar enlargement secondary to pituitary hyperplasia, multiple wormian bones, and hypoplastic sinuses. childhood hypothyroidism can be either congenital or acquired, primary or secondary, or due to central or peripheral causes. primary hypothyroidism is due to abnormality at the level of thyroid, which includes either defective thyroid gland development, termed dysgenesis, or thyroid hormone dysgenesis known as dyshormonogenesis. secondary hypothyroidism is due to deficiency of tsh, which can be either isolated or seen in panhypopituitarism. peripheral hypothyroidism is due to a defect in transport, metabolism or action. in the presented case, hypothyroidism was due to autoimmune thyroiditis, the most common cause of acquired hypothyroidism in children and adolescents and is most commonly associated with the syndrome.9 hypothyroidism can be either permanent or transient. transient hypothyroidism is either due to iodine deficiency or maternal blocking antibodies.10 various theories have been postulated regarding precocious puberty in congenital hypothyroidism. the proposed mechanism by van wyk and grumbach was high levels of tsh, leading to the elevated levels of gonadotrophins through the pituitary hypothalamic axis. however, some studies have also postulated that there is no elevation of gonadotrophins from the pituitary. instead, there is stimulation of the follicle-stimulating hormone receptor and not the leutinizing hormone receptor, which accounts for isosexual precocious puberty in these cases, which causes multicystic ovaries, uterine enlargement, bleeding per vagina and thelarche. precocious puberty is disconsonant in these cases as there is no stimulation of adrenarche, and axillary and pubic hair growth does not occur. another theory of prolactin relates well with the discordance of fsh and lh. due to the unopposed action of thyrotropin-releasing hormone (trh), there is hyperprolactinaemia which causes increased ovarian sensitivity to gonadotrophins which in turn causes a slow release of gonadotropin-releasing hormone, which suppresses lh while producing fsh.4 myxoedematous infiltration of the ovary also accounts for its enlargement.11 continuous trh leading to increased fsh secretion is also one of the proposed theories for precocious puberty.12 an algorithmic approach for the child with precocious puberty is presented for the radiologist in the flow chart (figure 6).4 figure 6: flow chart depicting an algorithm for the radiological approach to a child with precocious puberty. precocious puberty in vwgs presents with unique features of delayed bone age as well as short stature, which differs from other causes of precocious puberty where growth acceleration is the criteria as the thyroid hormone causes bone maturation directly through t3 and indirectly through the growth hormone regulation gene.13 long-standing hypothyroidism leads to thyrotroph hyperplasia leading to pituitary hyperplasia. pituitary macroadenoma remains a close differential diagnosis,14 although macroadenoma is rare in children. imaging features such as homogenous enhancement, midline location with a smooth bulge and the presence of posterior bright spot favour hyperplasia. in contrast, heterogeneous enhancement, off midline location, and the absence of pituitary bright spot in up to 20%, favour macroadenoma.14 conclusion the triad of precocious puberty, delayed bone age, and bilateral cystic ovarian lesions with features of hypothyroidism suggest the diagnosis of vwgs. early recognition of symptoms and treatment with thyroxine show clinical and radiological improvement and also avert the delayed complications associated with hypothyroidism. learning points precocious puberty, delayed bone age and cystic ovarian masses in long-standing juvenile hypothyroidism propose the diagnosis of vwgs. various clinical features seen in vwgs syndrome resolve with thyroxine replacement therapy and once diagnosed, medical treatment can be initiated early by the referring doctor. early recognition can avoid the delayed complications of the syndrome which include short stature and psychosocial impairment. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.s. was responsible for conception and design of the work, drafting the article, and critical revision of the article. k.n. was responsible for literature search, writing the initial draft and figures. r.l. was involved in clinical inputs, data collection. k.j. was responsible for clinical inputs and drafting the clinical part and the discussion. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references anne b, simhadri v, yerramneni vk, neusha d. an uncommon presentation of a common disorder: van wyk–grumbach syndrome. thyroid res pract. 2019;16(1):36. https://doi.org/10.4103/trp.trp_3_19 sutton d, editor. centres of ossification appendix a in: textbook of radiology and imaging, volume 2. 7th ed. london: elseiver, 2017; p. 1848. gupta j, lin-su k. van wyk-grumbach syndrome in a female pediatric patient with trisomy 21: a case report. int j pediatr endocrinol. 2020;2020(1):20–22. https://doi.org/10.1186/s13633-020-0072-y chung em, biko dm, schroeder jw, cube r, conran rm. from the radiologic pathology archives: precocious puberty: radiologic-pathologic correlation. radiographics. 2012;32(7):2071–2099. https://doi.org/10.1148/rg.327125146 van wyk jj, grumbach mm. syndrome of precocious menstruation and galactorrhea in juvenile hypothyroidism: an example of hormonal overlap in pituitary feedback. j pediatr. 1960;57(3):416–435. https://doi.org/10.1016/s0022-3476(60)80250-8 egodawaththe ns, seneviratne sn, gunasekara s, amarasekara sm, weerasekara k. van wyk-grumbach syndrome and oligosyndactyly in a 6-year-old girl: a case report. j med case rep. 2020;14(1):1–7. https://doi.org/10.1186/s13256-020-02472-z baranowski e, högler w. an unusual presentation of acquired hypothyroidism: the van wyk-grumbach syndrome. eur j endocrinol. 2012;166(3):537–542. https://doi.org/10.1530/eje-11-0494 esen i, demirel f. hypothyroidism-associated testicular enlargement: is it a form of precocious puberty or not? a case report. turkish j pediatrics. 2011;53(2):210. bhadada s, rastogi a, bhansali a. an unusual presentation of a usual disorder: van wyk-grumbach syndrome. indian j endocrinol metab. 2011;15(suppl 2):141. https://doi.org/10.4103/2230-8210.83356 rastogi mv, lafranchi sh. congenital hypothyroidism. orphanet j rare dis. 2010;5(1):1–22. https://doi.org/10.1186/1750-1172-5-17 hansen ka, tho spt, hanly m, moretuzzo rw, mcdonough pg. massive ovarian enlargement in primary hypothyroidism. fertil steril. 1997;67(1):169–171. https://doi.org/10.1016/s0015-0282(97)81876-6 chemaitilly w, thalassinos c, emond s, thibaud e. metrorrhagia and precocious puberty revealing primary hypothyroidism in a child with down’s syndrome. arch dis child. 2003;88(4):330–331. https://doi.org/10.1136/adc.88.4.330 robson h, siebler t, stevens da, shalet sm, williams gr. thyroid hormone acts directly on growth plate chondrocytes to promote hypertrophic differentiation and inhibit clonal expansion and cell proliferation. endocrinology. 2000;141(10):3887–3897. https://doi.org/10.1210/endo.141.10.7733 eom ks, see-sung c, kim jd, kim jm, kim ty. primary hypothyroidism mimicking a pituitary macroadenoma: regression after thyroid hormone replacement therapy. pediatr radiol. 2009;39(2):164–167. https://doi.org/10.1007/s00247-008-1012-9 sa journal of radiology • june 2011 53 pictorial essay mri imaging of vein of galen malformations at steve biko academic hospital: a mini case series liesel davel, mb chb, da (sa), mmed rad (d) janet smal, mb chb, mmed rad (d) z i lockhat, fcrad (d) department of radiology, steve biko academic hospital, pretoria corresponding author: l davel (liesel-davel@hotmail.com) introduction vein of galen aneurysmal malformation (vogm) is an arterio-venous fistula involving aneurysmal dilatation of the median prosencephalic vein of markowski. dilated arteries drain into a large midline venous pouch in the region of the quadrigeminal cistern. it is a rare condition and is demonstrated in less than 1% of cerebral vascular malformations at any age and up to 30% of paediatric vascular malformations. associated clinical findings may include cardiomegaly, widened mediastinum, pulmonary oedema and cyanosis.1-3 heart failure and cyanosis in infants almost always results from congenital heart disease, but systemic arteriovenous malformations are a rare cause for such a presentation and the diagnosis is often missed or delayed.4 the following is a discussion and presentation of mri images of 4 patients with this rare condition who presented at steve biko academic hospital within a 2-year period. case 1 an 8-month old baby presented to the paediatric department with increasing head circumference, above the 97th percentile, delayed motor milestones with an inability to sit, and neuro-developmental delay. on clinical examination, an audible cranial bruit and cardiac ejection systolic murmur were found. the child was in cardiac failure. mri examination confirmed a vein of galen malformation (fig. 1). a well-defined midline pouch was demonstrated in the posterior fossa, communicating with the left posterior cerebral artery. the circle of willis demonstrated large congested arteries owing to the arteriovenous fistula. smaller feeding arteries were noted adjacent to the vein of galen. a ventriculo-peritoneal shunt was inserted, and the child’s neurological condition improved. this was followed by endovascular intervention. the child is being followed up and is currently doing well. case 2 a 4-week-old baby was referred from a peripheral clinic with clinical signs and symptoms of cardiac failure and an incidental cranial bruit. this prompted further evaluation to exclude an associated intracranial shunt. mri confirmed a vein of galen malformation (fig. 2) with several dilated intracranial arteries (branches of the anterior cerebral artery) communicating with a large midline venous pouch. this in turn drained via falcine veins into the large transverse and sigmoid sinuses. an unusual associated finding of large bilateral chronic subdural effusions was demonstrated, with significant cortical atrophy. cystic encephalomalacia was present, mainly on the right. the child subsequently died before any interventional procedures could be performed. case 3 a 2-year-old child with neuro-developmental delay presented acutely with convulsions and opisthotonus. the child had been unable to stand or walk prior to the seizure. the child’s general condition was good but, on examination, a left hemiparesis was present. initially, a ct scan was performed and revealed a left temporal lobe intra cranial bleed and acute hydrocephalus. mri (fig. 3) confirmed a left temporal lobe arterio-venous malformation with secondary intracerebral bleeding as well as a well-defined, enlarged venous pouch in keeping with a vein of galen malformation. case 4 this case was of a more typical vein of galen malformation with an atypical clinical presentation. the child presented at 2 months of age with the sole clinical problem of hypotonia. the only significant history at that stage was that the child had been born with a low apgar score. skull sonar was the initial examination and revealed dilated lateral and 3rd ventricles, which prompted a request for a ct scan that was initially diagnosed as hydrocephalus secondary to a pituitary gland cyst. to confirm the diagnosis, an mri was performed, which revealed a large posterior midline venous pouch with arteries draining into the pouch; the diagnosis of a vein of galen malformation was made (fig. 4). discussion a vein of galen aneurysm is a rare condition, demonstrated in less than 1% of cerebral vascular malformations at any age and up to 30% of paediatric vascular malformations. the vein of galen (formed from the median vein of the prosencephalon) is formed by the union of the two internal cerebral veins and goes on to drain into the straight sinus. an arterio-venous malformation (avm) occurs when the vein of galen has an arterial input from one or more major intracranial arteries, either directly or via an interposed angiomatous malformation.4 clinical presentation neonates with vein of galen malformations characteristically have multiple fistulae. up to 25% of their cardiac output passes through the fistulas, causing high-output congestive cardiac failure. depending on the size of the shunt, adequacy of venous drainage, complexity of arterial 54 sa journal of radiology • june 2011 pictorial essay supply and the host response, the cardiac manifestations can range from asymptomatic cardiomegaly to severe cardiac failure that is refractory to medical management. cyanosis may be seen in these patients, and the presentation may be mistaken for congenital cyanotic heart disease.4,5 older children and adults usually have low-flow fistulae. these patients usually present with headache and seizures. a small number of patients may also present with developmental delay, focal neurological deficits, proptosis and epistaxis. subarachnoid haemorrhage and intracerebral haemorrhage can occur in this age group, owing to re-routing of blood into the pial veins.4,5 in cases 1 and 4, the children presented with less acute clinical symptoms. neuro-developmental delay, increased head circumference and hypotonia were some of the presenting features, and symptoms of cardiac failure were more subtle. these two cases also had more typical mri features suspected in vein of galen malformations. in case 1, the large left posterior cerebral artery feeder is less typical. arterial feeders are usually one of two types. the choroidal type occurs when arterial feeders originate from the pericallosal, choroidal or thalamoperforaters. if the arterial feeders originate from the collicular or posterior choroidal arteries, they are classified as the mural type.1 in case 2, the baby presented with typical clinical findings of severe cardiac failure. the associated mri findings were less typical. bilateral subdural effusion, cerebral atrophy and cystic encephalomalacia are most likely attributed to either hypoxic ischaemic incident at birth, vascular steal or chronic venous hypertension. in case 3, the child was already 2 years old when he presented with convulsions and opisthotonus. before the seizure, there was a background history of neuro-developmental delay. the atypical imaging feature in this patient was the finding of a second arteriovenous malformation in the left temporal lobe. this is the malformation that bled and caused the acute neurological impairment. in all 4 cases, there was some degree of hydrocephalus present. hydrocephalus in this condition is due to decreased resorption of cerebrospinal fluid secondary to chronic venous hypertension or tectal compression.1 in 2 of the 4 cases, the babies presented with cardiac failure. developmental delay, hydrocephalus and seizures were also presenting symptoms. imaging radiography. plain radiography of the skull contributes little to the diagnosis of vogms beyond the demonstration of a rim of calcification within the wall of the aneurysmal sac. chest radiographs may reveal features of congestive heart failure. ultrasound. antenatal ultrasound scans demonstrate the venous sac as a sonolucent mass located posterior to the third ventricle. ultrasonic demonstration of pulsatile flow within it helps in differentiating vogms from other midline cystic lesions. associated venous anomalies can often be visualized. evidence of hydrocephalus and cardiac dysfunction can also be obtained on antenatal ultrasonography.4,5 computed tomography (ct). contrast-enhanced axial ct scan of the brain usually demonstrates a well-defined, multilobulated, intensely enhancing lesion, located within the cistern of velum interpositum. dilatation of the ventricular system, periventricular white matter hypodensities, as well as diffuse cerebral atrophy are the commonly associated findings.4,5 magnetic resonance imaging (mri). mri is gaining popularity as the modality of choice for initial assessment of vogms. it can demonstrate the location of fistula, presence of any nidus, the arterial components, the venous sac and the status of venous drainage. thrombosis of the venous sac is also depicted well on mri. mr angiography is being increasingly used as a non-invasive alternative to diagnostic angiographic studies in the initial evaluation of these lesions.4,5 angiography. angiography remains the gold standard for the evaluation of vogms. it scores over non-invasive modalities such as ct angiography and mr angiography in demonstrating small feeders supplying the fistula, as well as the dynamic aspects of the venous drainage of the normal brain, and haemodynamic relationships with the venous drainage of the arteriovenous shunt.4,5 management despite technological advances in micro-neurosurgery, complete elimination of the lesion by surgery is rarely achieved.4,5 though these lesions are extremely uncommon, they are of special interest to the interventional neuroradiologist because endovascular therapy has proved itself to be an effective, and often the only safe, therapeutic modality available to treat these patients.4,5 the timing of endovascular fig. 1a. t2-weighted tse axial view. fig. 1b. t2-weighted tse sagittal view. fig. 1c. t2-weighted tse coronal view. fig. 1d. mr maximum intensity projection (mip) venogram. fig. 1. a midline dilated venous pouch with characteristic flow void is seen on axial (fig. 1a) and sagittal (fig 1b) images. there are multiple small arterial feeders in the midline with a prominent left posterior cerebral artery communicating with the venous pouch (fig. 1c). this direct posterior cerebral artery shunt is causing dilatation of the circle of willis (figs 1a and 1d). sa journal of radiology • june 2011 55 pictorial essay management is determined by the clinical presentation. congestive cardiac failure in a neonate that is refractory to medical treatment is an indication for emergency embolisation. the goal of therapy in such patients would be to arrest the congestive cardiac failure rather than to achieve complete obliteration of the shunt. in such children, it may be acceptable to perform partial embolisation to reduce the arteriovenous shunt and facilitate normal systemic and neurological development, even with the presence of a residual shunt. the procedure can be performed in a staged manner to minimise complications.4,5 1. moore kr, barkovich aj, grant e, et al. diagnostic imaging: pediatric neuroradiology. 1st ed. salt lake city: amirsys, 2007: i:7:26-29. 2. barkovich aj. paediatric neuroimaging. 4th ed. philadelphia: lippincott williams & wilkins, 2005:875884. 3. atlas sw. magnetic resonance imaging of the brain and spine. 3rd ed. philadelphia: lippincott williams & wilkins, 2002:337-339. 4. kothari ss, naik n, juneja r, saxena a. aneurysm of vein of galen in the neonates: report of four cases. indian heart journal 2001;53:499-502. 5. gupta ak, varma dr. vein of galen malformations: review. neurol india 2004;52:43-53. fig. 2a. t2-weighted tse sagittal image. fig. 2b. t2-weighted tse axial image. fig. 2c. t2-weighted tse coronal image. fig. 2. multiple arterial feeders drain into a large dilated midline venous pouch (figs 2a c). the large midline venous pouch in turn drains via falcine veins into the large transverse and sigmoid sinuses. large bilateral chronic subdural effusions are demonstrated, with significant cortical atrophy (fig. 2c). fig. 3a. t1-weighted tse axial image. fig. 3b. t1-weighted postgadolinium coronal image. figure 3c. t1-weighted post-gadolinium coronal image. fig. 3d. t1-weighted postgadolinium sagittal image. fig. 3e. t1-weighted postgadolinium axial image. fig. 3. an atypical case demonstrating an arteriovenous malformation in the left temporal lobe complicated by haemorrhage (figure 3a and 3b) as well as the enhancing midline venous pouch of the vein of galen malformation (figs 3c e). fig. 4a. t2-weighted tse coronal image. fig. 4b. t1-weighted post-gadolinium sagittal image. fig. 4c. mr angiogram axial image. fig. 4. a typical case of a large posterior midline venous pouch (figs 4a and 4c) with multiple arterial feeding vessels draining into the midline pouch. dilated lateral ventricles are due to non-obstructive communicating hydrocephalus. enhancement of the venous pouch is demonstrated post-gadolinium (fig. 4b) and by mr angiography (fig. 4c). today's two signs today's two signs 106 sa journal of radiology • december 2007 today's two signs scapholunate instability (sli) (also known as scapholunate dissociation or rotary subluxation of the scaphoid) is caused by a tear in the interosseous ligaments of the lunate, scaphoid and the capitate bone with a tear in the dorsal radiocarpal ligaments by acute dorsifexion injury or fractures of the distal radius.1,2 the patient complains of wrist pain, weakness of grip and a clicking sensation in the wrist. sli is diagnosed with a gap or separation between the scaphoid and the lunate bones on a posterior anterior wrist x-ray. more than 2 mm is suspicious and 4 mm or more is diagnostic of sli.1,2 this scaphoidlunate gap is also referred to as the ‘terry thomas’ sign (fig. 1) referring to the distinctive gap between the upper incisors of the late british comedian. there is in addition foreshortening of the scaphoid, causing the cortical margin of the distal pole to become parallel to the central axis of the x-ray and appear as a ring called the the ‘ring sign’ (fig. 1). the gap is better demonstrated in ulnar deviation or clenched-hand position (fig. 2).1,2 treatment is dependent on the symptoms, ranging from rest to carpal fusion. 1. rogers lf. radiology of skeletal trauma, 2nd ed. edinburgh: churchill livingstone,.1992: 927-929. 2. hudson tm, caragol wj, kaye jj. isolated rotatory subluxation of the carpal navicular. ajr 1976; 126: 601-611. `terry thomas´ sign and the `ring sign´ of scapholunate instability a s bajwa, mb bs, fcs (sa) ortho brenthurst life health clinic, parktown, johannesburg a k bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg fig. 2. the gap is more pronounced in the clenched hand-position. fig. 1. posterior anterior wrist x-ray demonstrating the widened gap between the scaphoid and the lunate bone ‘terry thomas’ sign. there is in addition foreshortening of the scaphoid with a ‘ring sign’. underlying osteodegenerative changes are noted; these and the radio carpal joints are due to longstanding sli. pg106-107.indd 106 12/11/07 2:21:20 pm today's two signs today's two signs 107 sa journal of radiology • december 2007 the presence of faeculant material (colonlike material mixed with gas resembling stool) in the lumen of the distended (more than 2.5 cm) small bowel on computed tomography (ct) is defined as small bowel faeces sign (fig. 1).1 it is due to intraluminal stagnation of the enteric contents complicated by bacterial overgrowth and water absorption. it is an uncommon but highly specific sign of small bowel obstruction (sbo) on ct scan of the abdomen, particularly in patients with low-grade or intermittent obstruction.2 the adjacent transition zone and the distal collapsed bowel loops indicate the level of obstruction. the most common cause of the sbo is adhesions. other common causes are inflammation, tumours and hernias. small bowel faeces sign may also indicate severe metabolic or infectious pathology of the small bowel. the clinical signs of sbo are difficult to distinguish from local or generalised paralytic ileus; therefore an early radiological diagnosis is very important. 1. mayo-smith ww, wittenberg j, bennett gl, gervais da, gazelle gs, mueller pr. the ct small bowel faeces sign: description and clinical relevance. clin radiol 1995; 50: 765-767. 2. catalano o. the faeces sign: a ct finding in small bowel obstruction. radiology 1997; 37: 417-419. small bowel faeces sign amarjit kaur bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital, university of the witwatersrand, johannesburg fig. 1. axial ct in a 22-year-old female patient with history of crohn disease demonstrating the small bowel faeces sign in a distended ileal loop. adjacent transition zone with collapsed distal small bowel is seen. pg106-107.indd 107 12/11/07 2:21:20 pm radioactive news2.html necsa and ntp donate pet-ct scanner to tygerberg hospital on 25 november 2011, the western cape health department, ntp radioisotopes and its parent company, the south african nuclear energy corporation (necsa), marked the intermediate phase of installing a r15.6 million positron emission tomography computed tomography (pet-ct) scanner at tygerberg hospital. mapula letsoalo, ntp’s executive director, pointed out that, of the 9 functioning pet-ct scanners in the country, most are in gauteng province, with only one in the western cape. ‘the scanner owned by the cape pet-ct centre is currently shared between one private clinic and three state hospitals,’ she explained. ‘this scenario has caused strain as tygerberg and groote schuur hospitals as well as red cross war memorial children’s hospital are only allocated two afternoon sessions per week. the need for an additional pet-ct scanner in the province was imminent as the use of f-18 fdg has grown by 109% in 2009/10 compared to 2008/09 for tygerberg hospital alone.’ western cape health minister theuns botha said: ‘western cape provincial government is so thankful for the pet-ct scanner, which will bring enormous relief to the staff and capacity at tygerberg hospital. we have more than 2 000 new oncology patients at tygerberg each year who depend on our services, as well as thousands more who come for follow-up. patients from groote schuur and red cross war memorial children’s hospital will also be scanned at the facility. our health budget does not allow us to invest in the advanced technology offered by the scanner, and with this generous donation the hospital is now able to offer this service to more than 10 patients per day.’ the tender to provide the pet-ct scanner was awarded to philips medical systems. professor james warwick of the nuclear medicine department at tygerberg hospital, and project leader, commented: ‘the philips pet-ct system met all our main requirements as a dedicated oncology machine with time-of-flight technology enabling low fdg doses, and its suitability for radiotherapy planning including its large bore and full integration with the existing pacs and radiotherapy planning systems at academic hospitals in the western cape. clinically, this means more accurate detection, better resolution, detection of smaller lesions and faster scanning.’ positron emission tomography (pet) is a modern medical functional imaging technique used in the management of patients with cancer; it is also used in infection and inflammation, cardiology and neurology. pet provides accurate diagnosis, staging and re-staging in certain cancers, and allows rapid evaluation of the efficacy of therapy. pet has led to changes in treatment options and prevention of unnecessary surgical procedures in a significant number of patients. millions of patients throughout the world benefit from nuclear medicine scans and other procedures performed using products supplied by ntp. letsoalo added that ntp manufactures, among other products, isotopes used to enable diagnostic imaging as well as several used in treating diseases. ‘early detection of most diseases assisted by nuclear medicine scans greatly enhances the possibility of early and accurate diagnosis. this allows prompt and proper treatment and, therefore, a better chance of a saved life.’ the contribution of the western cape department of health to this pet-ct project is around r14.75 million (r11 million for infrastructure and r3.75 million for equipment accessories). the new pet-ct scanner will be fully functional by the middle of this year. abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) nicolò brandi department of radiology, irccs university hospital of bologna, bologna, italy laura bartalena department of radiology, irccs university hospital of bologna, bologna, italy cristina mosconi department of radiology, irccs university hospital of bologna, bologna, italy rita golfieri department of radiology, irccs university hospital of bologna, bologna, italy citation brandi n, bartalena l, mosconi c, golfieri r. a unique case of miliary pulmonary tuberculosis induced by bacillus calmette-guérin intravesical instillation with covid-19 superinfection. s afr j rad. 2021;25(1), a2122. https://doi.org/10.4102/sajr.v25i1.2122 case report a unique case of miliary pulmonary tuberculosis induced by bacillus calmette-guérin intravesical instillation with covid-19 superinfection nicolò brandi, laura bartalena, cristina mosconi, rita golfieri received: 03 mar. 2021; accepted: 05 may 2021; published: 17 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract intravesical instillation of bacillus calmette-guérin (bcg) is used as an adjuvant treatment of bladder cancer. systemic bcg infection occurs in less than 1% of cases, and pulmonary involvement is even rarer (0.3% – 0.7%), with a favourable prognosis. a 78-year-old male developed miliary tuberculosis (tb) secondary to intravesical bcg treatment and subsequent coronavirus disease 2019 (covid-19) superinfection that led to patient death. high awareness amongst clinicians is needed to proceed with immediate appropriate therapy in these patients, especially during the covid-19 pandemic keywords: tuberculosis; bcg; covid-19; sars-cov-2; ct. introduction bacillus calmette-guérin (bcg) is a live, attenuated strain of mycobacterium bovis, which is widely used as adjuvant treatment for bladder cancer. intravesical instillations of bcg are generally well tolerated by patients, with some minor and self-limiting side effects. systemic bcg infection is reported in less than 1% of cases, and pulmonary involvement is even rarer (0.3% – 0.7%). pulmonary bcg infection may present as interstitial pneumonitis or miliary dissemination, and its prognosis is generally favourable, with complete resolution after anti-tubercular treatment.1 the ongoing coronavirus disease 2019 (covid-19) pandemic, which started in december 2019 in china, has overwhelmed healthcare systems globally and proved to be a new menace because of its devastating effect on lung function, especially in the more fragile patient.2 this report describes the first case of miliary tuberculosis (tb) secondary to intravesical treatment with bcg with sudden worsening of respiratory function caused by covid-19 superinfection. case presentation a 78-year-old male with a history of high-grade pta bladder cancer, treated by transurethral resection and two intravesical instillations of bcg, was admitted to the emergency department because of the onset of fever (38 °c), cough, arthralgia, dysuria and pollakiuria. symptoms started after the last instillation of bcg 10 days earlier. the patient had been empirically treated with co-trimoxazole prescribed by his primary care physician without improvement. medical history included type 2 diabetes mellitus (on therapy with oral metformin), abdominal aortic aneurysm and chronic obstructive pulmonary disease. auscultation revealed generalised decreased vesicular breathing sounds. blood tests showed increased levels of ferritin (1390 ng/ml), c-reactive protein (8.29 mg/dl) and transaminases (alt 85 u/l and ast 86 u/l) with normal urinalysis. the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) reverse transcription polymerase chain reaction (rt-pcr) test was found to be negative. upon suspicion of atypical lung infection, a chest ct scan was requested, the result of which was compared with previously obtained normal chest ct findings of the same patient performed a year before his access to the emergency department (figure 1a). the ct scan demonstrated signs of severe centrilobular and paraseptal emphysema, and innumerable lung micronodules (1 mm – 2 mm in size) distributed in the non-emphysematous lung parenchyma as a random pattern (figure 1b). since these radiological findings were compatible with numerous diseases, including miliary tuberculosis, sarcoidosis, pneumoconiosis and hematogenous metastases from primary cancers of the thyroid or kidney,3 bronchoscopy with bronchoalveolar lavage (bal) was performed. the cytological examination of the bal was negative for malignant cells, and samples were negative for bacterial detection, in particular for acid-alcohol-resistant bacilli (both direct and culture), as well as for fungi and other microorganisms. figure 1: a normal ct of the chest performed before the patient’s access to the emergency department (a). a ct scan of the same patient performed 10 days after the last bacillus calmette-guérin instillation, showing 1 mm – 2 mm diameter nodules disseminated throughout the lung and distributed randomly with respect to the lobular structures in a miliary pattern (b). after two weeks of antibiotic therapy, ct imaging revealed a numerical and dimensional increase in the multiple micronodules (c). despite the administration of anti-tubercular therapy, the patient’s clinical condition deteriorated again, requiring a new ct scan that revealed the presence of bilateral ground-glass opacities localised mainly in the middle and lower parts of the lungs, partially superimposed on the previously seen multiple lung micronodules, compatible with coronavirus disease 2019 superinfection (d). given the persistence of fever and dyspnoea after two weeks, meropenem was administered in the place of the previous antibiotic, and a radiological re-evaluation was carried out with another chest ct, which demonstrated a numerical and dimensional increase in the multiple micronodules (figure 1c). the patient successively underwent a repeat bronchoscopy with bal, documenting a positive tb pcr result this time. bacillus calmette-guérin-itis with pulmonary localisation was finally diagnosed, and therapy with isoniazid, rifampicin and ethambutol was administered with an improvement in the patient’s clinical condition after a few days. one week after the start of anti-tubercular therapy, the patient’s clinical condition deteriorated again, with a sudden onset of dyspnoea and respiratory distress. auscultation revealed bilateral diffuse fine crackles and wheezes. a contrast-enhanced chest ct excluded pulmonary embolism but revealed the presence of diffuse ground-glass opacities localised mainly in the middle and lower zones of the lungs, partially superimposed on the previously seen multiple lung micronodules (figure 1d). as these radiological findings were suggestive of sars-cov-2 infection, rt-pcr was repeated again, and this time tested positive, confirming covid-19 superinfection. the patient succumbed after two days, following respiratory complications. discussion immunotherapy with an attenuated live strain of m. bovis is the most effective adjunctive therapy for high-risk superficial bladder cancer, which is even more effective than intravesical chemotherapy.4 the intravesical instillation of bcg promotes the local activation and migration of numerous polymorphonuclear cells with the consequent release of inflammatory cytokines, ultimately leading to the death of tumour cells. due to this inflammatory challenge, minor side effects are commonly reported, including cystitis, haematuria, fever, chills and malaise, usually self-limiting within a few hours or days.1 miliary tb as a manifestation of pulmonary involvement of bcg infection is very rare, and only a very few cases have been reported thus far.1,5,6,7 although its pathogenesis remains incompletely understood, some authors consider pulmonary bcgitis to be a type of hypersensitivity reaction as serological tests and cultures are negative in approximately 60% of cases. however, some case reports support the theory of haematogenous spread from an active mycobacterial infection based on the isolation of mycobacteria or the detection of its genome by pcr, as in this case. the presence of underlying immunosuppression, bladder mucosal damage and other patient characteristics are risk factors for disseminated infection.4 imaging plays a key role in the diagnosis of miliary tb and, as in the present case, ct findings guided the diagnosis, even when microbiological and histopathological evidence of mycobacterial infection were negative.6 in this case, a presumptive diagnosis of disseminated bcg infection was justified by the clinical presentation consistent with active tb, associated with radiological findings consistent with miliary dissemination of mycobacterium tuberculosis and high ferritin levels, commonly reported amongst pulmonary tb patients7; finally, the evidence of mycobacterial genome by pcr confirmed the diagnosis. in disseminated bcg infection, the prognosis is generally favourable, and the combination of isoniazid, rifampicin and ethambutol is suggested, with the addition of steroids in severe cases. in this patient however, the sudden superinfection with covid-19 resulted in a rapid worsening of respiratory function and, eventually, death. a recent review2 suggested that tuberculosis and a previous history of tuberculosis seem to be related to an increased susceptibility to covid-19, as well as worsening of the infection prognosis possibly because of a synergism between the two pathogens. this could explain the poor prognosis of our patient who, moreover, had already two important co-morbidities (i.e. type 2 diabetes mellitus and chronic obstructive pulmonary disease). conclusion miliary tb is a very rare complication of intravesical bcg instillation, with unclear aetiopathogenesis, and thus, a high level of suspicion is required for early diagnosis. chest ct imaging is essential for the diagnosis of this complication because of the high rate of negative microbiological isolations. finally, high awareness amongst clinicians is necessary to commence appropriate therapy in these patients immediately, especially in the era of the covid-19 pandemic, as they already present with compromised lung function. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article. author’s contributions m.b., l.b., c.m. and r.g. contributed equally to the manuscript, and read and approved the final version of the manuscript. ethical considerations this article followed all ethical standards for research. funding information the authors report no involvement in the research study by the sponsor, which could have influenced the outcome of this work. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references cabas p, rizzo m, giuffrè m, et al. bcg infection (bcgitis) following intravesical instillation for bladder cancer and time interval between treatment and presentation: a systematic review. urol oncol. 2021;39(2):85–92. https://doi.org/10.1016/j.urolonc.2020.11.037 mousquer gt, peres a, fiegenbaum m. pathology of tb/covid-19 co-infection: the phantom menace. tuberculosis. 2020 nov 17;126:102020. https://doi.org/10.1016/j.tube.2020.102020 furqan m, butler j. miliary pattern on chest radiography: tb or not tb? mayo clin proc. 2010 feb;85(2):108. https://doi.org/10.4065/mcp.2009.0523 pérez-jacoiste asín ma, fernández-ruiz m, lópez-medrano f, et al. bacillus calmette-guérin (bcg) infection following intravesical bcg administration as adjunctive therapy for bladder cancer: incidence, risk factors, and outcome in a single-institution series and review of the literature. medicine (baltimore). 2014 oct;93(17):236–254. https://doi.org/10.1097/md.0000000000000119 marques m, vazquez d, sousa s, mesquita g, duarte m, ferreira r. disseminated bacillus calmette-guérin (bcg) infection with pulmonary and renal involvement: a rare complication of bcg immunotherapy. a case report and narrative review. pulmonology. 2020 nov–dec;26(6):346–352. https://doi.org/10.1016/j.pulmoe.2019.10.001 gupta rc, lavengood jr. r, smith jp. miliary tuberculosis due to intravesical bacillus calmette-guerin therapy. chest. 1988 dec;94(6):1296–1398. https://doi.org/10.1378/chest.94.6.1296 cunha ba, apostolopoulou a, gian j. fever of unknown origin (fuo) due to miliary bcg: the diagnostic importance of morning temperature spikes and highly elevated ferritin levels. heart lung. 2017 may–jun;46(3):205–207. https://doi.org/10.1016/j.hrtlng.2017.01.009 abstract introduction outcomes discussion conclusion acknowledgements references about the author(s) tengku a. raja mamat department of radiology, school of medical sciences, university sains malaysia, kubang kerian, kelantan, malaysiadepartment of radiology, hospital university sains malaysia, kubang keria, kelantan, malaysia khairil a. sayuti department of radiology, school of medical sciences, university sains malaysia, kubang kerian, kelantan, malaysiadepartment of radiology, hospital university sains malaysia, kubang keria, kelantan, malaysia chandran nadarajan department of radiology, school of medical sciences, university sains malaysia, kubang kerian, kelantan, malaysiadepartment of radiology, hospital university sains malaysia, kubang keria, kelantan, malaysia mohd r. mohd zain department of paediatrics, school of medical sciences, university sains malaysia, kubang kerian, kelantan, malaysiadepartment of paediatrics, hospital university sains malaysia, kubang kerian, kelantan, malaysia citation raja mamat ta, sayuti ka, nadarajan c, mohd zain mr. unilateral opaque chest radiograph in paediatrics: a case series. s afr j rad. 2021;25(1), a2164. https://doi.org/10.4102/sajr.v25i1.2164 case series unilateral opaque chest radiograph in paediatrics: a case series tengku a. raja mamat, khairil a. sayuti, chandran nadarajan, mohd r. mohd zain received: 06 apr. 2021; accepted: 11 june 2021; published: 31 aug. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract pulmonary underdevelopment is a rare congenital disease which manifests as persistent hemithorax opacification at chest radiography. we present three patients with different types of pulmonary underdevelopment, their imaging features and associated anomalies. case 1 is a premature neonate with persistent respiratory distress. further imaging confirmed right pulmonary hypoplasia, associated with a patent foramen ovale, patent ductus arteriosus and vertebral anomalies. case 2 is a 6-year-old child with corrected anorectal malformation, and recurrent pneumonia. further imaging confirmed left pulmonary aplasia, associated with an aberrant right subclavian artery and vertebral anomaly. case 3 is a full term neonate who developed excessive drooling of saliva and respiratory distress. further imaging confirmed right pulmonary agenesis, associated with an atrial septal defect, patent ductus arteriosus and tracheo-oesophageal fistula. pulmonary underdevelopment is classified into three types: hypoplasia, aplasia and agenesis. the majority of them have associated anomalies. this condition should be considered a differential diagnosis in paediatric patients with an opaque hemithorax on chest radiography. keywords: pulmonary underdevelopment; pulmonary agenesis; pulmonary aplasia; pulmonary hypoplasia; congenital disease. introduction pulmonary underdevelopment is a spectrum of rare malformations, consisting of agenesis, aplasia and hypoplasia.1 it is a result of developmental failure of the respiratory system from the foregut. the incidence of pulmonary agenesis and aplasia is between 0.0034% and 0.0097%,2 whilst the true prevalence of pulmonary hypoplasia is unknown.3 in newborns and children with a unilateral opaque lung and ipsilateral shift of the mediastinum, pulmonary underdevelopment should be included in the differential diagnosis.2 we present three cases of pulmonary underdevelopment with a spectrum of imaging findings. case 1 a premature baby boy, born at 28 weeks via breech assisted delivery, was the first twin of a monochorionic diamniotic pair. he was born non-vigorous with poor breathing and weak muscle tone. intubation was necessary post-delivery because of oxygen desaturation. he was initially treated for respiratory distress syndrome and later complicated with pseudomonas aeruginosa septicaemia. serial chest radiographs (cxr) showed persistent right homogeneous opacity. echocardiography demonstrated a patent foramen ovale (pfo), a large patent ductus arteriosus (pda) and mild tricuspid regurgitation. computed tomography angiography (cta) of the thorax (figure 1) revealed a small right hemithorax volume with a hypoplastic right pulmonary artery (rpa) and vein as well as the right segmental bronchi consistent with pulmonary hypoplasia. pfo and a large pda were present. at thoracic spine radiography, there was levoscoliosis with lateral left hemivertebrae at c7/t1 and t8/t9, butterfly vertebrae of t5 and t7, and a left c7/t1 cervical rib (figure 1). figure 1: computed tomography angiography thorax (a) demonstrates hypoplastic right lung, right lower lobe bronchi (rlb), right pulmonary artery (rpa) and veins (rpv). the right hemithorax volume is reduced with ipsilateral mediastinal shift. large patent ductus arteriosus (pda) connecting with the aorta (ao). posterior ct imaging (b) demonstrates left hemivertebrae at c7/t1 and t8/t9, butterfly vertebrae of t5 and t7, and left c7/t1 cervical rib. case 2 a 6-year-old girl underwent an anorectal malformation correction at another hospital when she was very young. she also presented with recurrent episodes of pneumonia. in view of persistent homogeneous opacification of the left hemithorax on cxr, she underwent ct thorax at 4 months of age which revealed a congenital anomaly of the left lung. she was referred to our hospital with gradually increasing exertional dyspnoea, which restricted her physical activities. cta thorax (figure 2) revealed reduced left hemithoracic volume, a hyperexpanded right lung and total mediastinal shift to the left. the left lung, pulmonary artery and vein were completely absent. the left main bronchus (lmb) showed abrupt termination, about 0.5 cm from the carina. there was an aberrant right subclavian artery with a retro-oesophageal course at the t4 level. the c2/c3 vertebral bodies were fused (figure 2). figure 2: coronal computed tomography angiography thorax demonstrates absence of the left lung and pulmonary vessels. the lmb shows abrupt termination after the carina (thick black arrow). the mediastinum is completely displaced to the left side. there is associated fusion of the c2–c3 vertebrae (thin white arrow). case 3 a full term baby boy was born with good apgar scores. antenatal ultrasound had revealed polyhydramnios. several hours after delivery, the baby developed excessive drooling of saliva and increasing respiratory distress, requiring intubation. the right breath sounds were absent with limited advancement of the feeding tube. cxr revealed complete opacity of the right hemithorax, ipsilateral mediastinal shift, contralateral lung hyperinflation and looping of the feeding tube at mid upper thoracic level. echocardiography demonstrated dextrocardia, an atrial septal defect (asd) and a pda. cta thorax (figure 3) revealed total absence of the right lung, right main bronchus and right pulmonary vessels in keeping with pulmonary agenesis. the upper oesophagus was atretic. figure 3: computed tomography angiography thorax in the axial (a) and oblique coronal (b) planes reveals absence of the right lung, bronchus and pulmonary vessels with ipsilateral mediastinal shift. the left pulmonary artery (lpa) and veins (lpv) are present with a hyperinflated left lung. the trachea (t) divides into the left main bronchus (lmb) and communicates with the lower oesophagus (oe) via a fistula (f) consistent with a tracheo-oesophageal fistula. the patent ductus arteriosus (pda) is large. the tip of the central venous catheter (cvc) is in the right atrium (ra). the lower oesophagus communicated directly with the carina in keeping with a tracheo-oesophageal fistula. the main pulmonary artery was 1.5 times larger than the ascending aorta suggestive of pulmonary hypertension (figure 3). the baby underwent thoracostomy and the fistula below the lmb was ligated, followed by gastrostomy tube insertion. outcomes both cases 1 and 3 succumbed at very young ages. case 1 had recurrent oxygen desaturation episodes and passed away at 32 weeks of age. case 3 died 1 week post-surgery because of a nosocomial lung infection and deteriorated cardiac function. case 2 was discharged home with a salbutamol metered-dose inhaler (mdi) as required. she had occasional rapid breathing and wheezing during strenuous physical activities, and also when experiencing an upper respiratory tract infection. the symptoms resolved with the salbutamol mdi. she displayed failure to thrive despite having a good appetite. discussion pulmonary underdevelopment is classified into three groups.3 it was originally classified by schneider and schawatbe4 and has been modified by boyden.5 type 1 is called agenesis, and it refers to complete absence of the lung, bronchus and vascular supply to the affected side. type 2 is aplasia, where the pulmonary parenchyma and pulmonary vessels are completely absent with the presence of a rudimentary bronchus. type 3 is named hypoplasia, which is characterised by the presence of a bronchus and rudimentary lung, with decreased size and number of the airways, alveoli, and pulmonary vasculature.6 in this case series, case 1 would be classified as hypoplasia, case 2 as aplasia, and case 3 as agenesis. it is suggested that pulmonary agenesis and aplasia may be considered as one entity clinically and developmentally.1 pulmonary agenesis was first discovered by de pozze in 1673 during an autopsy of an adult woman.7 it was first described as a clinical entity by klebs in 1874, when he described it as a ‘missing lung’.8 the exact aetiology of pulmonary agenesis is unknown.9 it is hypothesised that pulmonary agenesis is caused by an abnormal blood supply in the dorsal arch during the 4th week of gestation.6 another suggested hypothesis is that the disease is caused by the disruption of the epithelial-mesenchymal cross-talk, which is important in pulmonary differentiation.10 some of the suggested factors include genetic, viral agents, and vitamin a deficiency during pregnancy.2 pulmonary agenesis is generally sporadic, with only a few reported cases of autosomal recessive inheritance. it has no gender predilection, and it affects both lungs equally.11 it has a wide range of clinical features ranging from asymptomatic to variable respiratory symptoms and recurrent lung infection. the onset of the symptoms is variable. the symptoms may start in neonates or later during childhood or even in adulthood;12 the oldest reported case is a 72-year-old.9 more than 50% of cases have associated abnormalities involving the cardiovascular, gastrointestinal, genitourinary and skeletal systems6 as well as ipsilateral facial asymmetry.8 about 50% of babies with pulmonary agenesis are either stillborn or die in the 1st month of life.13 in this case series, cardiovascular and gastrointestinal anomalies were seen in cases 2 and 3, whilst vertebral anomalies were present in case 2. on the other hand, pulmonary hypoplasia can be thought as either primary or secondary. primary pulmonary hypoplasia is less common, and it is when the cause cannot be identified.6 an embryological defect of the lung, or in-vitro lung injury are some of the suggested aetiologies.3 secondary pulmonary hypoplasia is because of conditions that limit the thoracic space for lung development, which can either be extrathoracic or intrathoracic. congenital diaphragmatic hernia is the most common intrathoracic cause. severe oligohydromnios is the most common extrathoracic cause, which can be either secondary to genitourinary abnormalities or prolonged rupture of membranes.6 other causes include congenital heart diseases, neuromuscular disorders, thoracic cage abnormalities (jeune syndrome, asphyxiating thoracic dystrophy), genitourinary tract anomalies and scimitar syndrome. patients with pulmonary hypoplasia typically present with early respiratory distress after birth, or with life-threatening symptoms such as cyanosis and hypoxia in childhood.3 this is similar to case 1 where the patient was found to have associated cardiovascular and vertebral anomalies, and died at 32 weeks after recurrent episodes of oxygen desaturation. the aetiologies of unilateral thorax opacification vary according to age. the five most common aetiologies are large pleural effusion, obstruction of the main bronchus, pneumonia, intrathoracic tumours and pulmonary underdevelopment. in neonates, congenital diaphragmatic hernia, congenital large hyperlucent lobe and congenital thoracic malformation should also be considered as the differential diagnoses.14 the position of the mediastinum provides important clues to the underlying conditions. contralateral mediastinal shift is seen in space occupying entities like intrathoracic tumours and large pleural effusion.14 in neonates, the pleural effusion is usually chylous. if the density of the involved hemithorax is heterogeneous, the diagnosis of volume-occupying congenital malformations such as cystic pulmonary airway malformation, congenital diaphragmatic hernia and pulmonary sequestration should be entertained.15 ipsilateral mediastinal shift is seen in conditions where the lung volume is reduced or absent, such as lung collapse and pulmonary underdevelopment. apart from the ipsilateral mediastinal displacement, additional signs for reduced lung volume include crowding of the ribs and elevated ipsilateral hemidiaphragm.14 the common causes of unilateral lung collapse in neonates include a malpositioned endotracheal tube and post extubation collapse. in conditions where the lung volume is preserved, such as pneumonia, the mediastinal structures typically remain at a central position.14 in patients with reduced or absent breath sounds, a decrease or absence of movement of the unilateral chest wall and an opaque hemithorax on chest radiograph, the diagnosis of pulmonary agenesis should be considered.12 in pulmonary hypoplasia, a typical finding is ipsilateral mediastinal shift which is accentuated on inspiration because of increased compensatory hyperinflation of the contralateral lung.3 bronchoscopy and bronchography may be necessary to confirm the diagnosis, whilst angiography is also required in some cases.9 in all our patients, cxrs showed homogeneous opacity of the involved hemi-thoraces. the prognosis of pulmonary underdevelopment is largely dependent upon the remaining functional lung parenchyma, as well as the presence and severity of the associated abnormalities.9 one of the complications of the disease is pulmonary fibrosis as a result of recurrent chest infection.12 right-sided pulmonary underdevelopment has been reported to have a worse prognosis because of the greater distortion of the heart and mediastinum,11 and compression of the tracheo-bronchial tree.2 in this case series, cases 1 and 3 died at very young ages. these patients had right-sided involvement of the disease, and both of them had associated cardiovascular anomalies. case 2 had recurrent pneumonia and occasional exertional dyspnoea on vigorous physical activities, which resolved with medication. conclusion pulmonary underdevelopment has a wide range of clinical presentations and can occur at any age. the severity of the disease ranges from hypoplasia to agenesis, and there may be variable degrees of associated anomalies. even though it is rare, it should be considered as one of the differential diagnoses, especially in patients with an opaque unilateral hemithorax on plain film radiography. an early diagnosis is important for early initiation of the treatment, thereby preventing possible complications. acknowledgements the authors would like to thank ooi kieam lim and noor syarida ayu mohamed sukeri for their expertise in acquiring the radiological images. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions t.a.r.m. prepared the whole manuscript including designing and drafting. k.a.s. was the author who interpreted the radiological images, suggested the overall concepts, proofread and edited the manuscript. c.n. was the supervisor for the case report. m.r.m.z. provided the case and contributed to the clinical discussion. ethical considerations this article followed all ethical standards for research. the cases were all anonymised. verbal consent for inclusion in the publication was obtained from the carers. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing is not applicable to this article, as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references shenoy rd, sindgikar sp, upadyaya v, shetty v. pulmonary underdevelopment malformation with cleft lip and palate – a case report. j anat soc india. 2014;63(suppl 2):s43–s45. https://doi.org/10.1016/j.jasi.2014.08.006 chawla rk, madan a, chawla a, arora h, chawla k. pulmonary agenesis. indian j chest dis allied sci. 2015;57(4):251–253. katsenos s, antonogiannaki em, tsintiris k. unilateral primary lung hypoplasia diagnosed in adulthood. respir care. 2014;59(4):e47–e50. https://doi.org/10.4187/respcare.02740 schneider p, schawatbe e. die morphologie der missbildungen des menschen under thiere. jena: gustav fischer. 1912;3:817–822. boyden e. developmental anomalies of lung. am j surg. 1955;89(1):79–88. https://doi.org/10.1016/0002-9610(55)90510-9 biyyam d, chapman t, ferguson m, deutsch g, dighe mk. congenital lung abnormalities: embryologic features, prenatal diagnosis, and postnatal radiologic-pathologic correlation. radiographics. 2010;30(6):1721–1738. https://doi.org/10.1148/rg.306105508 muensterer o, abellar r, otterburn d, mathew r. pulmonary agenesis and associated pulmonary hypertension: a case report and review on variability, therapy, and outcome. eur j pediatr surg rep. 2015;3(1):33–39. https://doi.org/10.1055/s-0034-1395986 bentsianov b, goldstein n, giuste r, har-el g. unilateral pulmonary agenesis presenting as an airway lesion. arch otolaryngol head neck surg. 2000;126(11):1386–1389. https://doi.org/10.1001/archotol.126.11.1386 kisku k, panigrahi m, sudhakar r, nagarajan a, ravikumar r, daniel j. agenesis of lung – a report of two cases. lung india. 2008;25(1):28–30. https://doi.org/10.4103/0970-2113.44136 thomas m, robertson n, miller n, rankin j, mckean m, brodlie m. congenital lung agenesis: incidence and outcome in the north of england. birth defects res. 2017;109(11):857–589. https://doi.org/10.1002/bdr2.1011 lee p, westra s, baba t, mccauley r. right pulmonary aplasia, aberrant left pulmonary artery, and bronchopulmonary sequestration with an esophageal bronchus. pediatr radiol. 2006;36(5):449–452. https://doi.org/10.1007/s00247-006-0122-5 sadiqi j, hamidi h. ct features of lung agenesis – a case series (6 cases). bmc med imaging. 2018;18(1):37. https://doi.org/10.1186/s12880-018-0281-5 miyano g, morita k, kaneshiro m, et al. unilateral pulmonary agenesis associated with oesophageal atresia and tracheoesophageal fistula: a case report with prenatal diagnosis. afr j paediatr surg. 2015;12(1):86–88. https://doi.org/10.4103/0189-6725.151000 iwama i, kohama m. unilateral lung whiteout in children: four cases and a discussion of management. pediatr emerg care. 2019;35(1):e1–e5. https://doi.org/10.1097/pec.0000000000000916 lucaya j, garces-inigo e, garcia-pena p, piqueras j, enriquez g. white hemithorax in children. pediatr radiol. 2011;41(7):916–924. https://doi.org/10.1007/s00247-011-2065-8 abstract introduction case presentation discussion conclusion acknowledgements references about the author(s) binit sureka department of radiology, all india institute of medical sciences jodhpur, jodhpur, india siddhi chawla department of radiology, all india institute of medical sciences jodhpur, jodhpur, india sudeep khera department of pathology, all india institute of medical sciences jodhpur, jodhpur, india ashish agarwal department of gastroenterology, all india institute of medical sciences jodhpur, jodhpur, india chhagan l. birda department of gastroenterology, all india institute of medical sciences jodhpur, jodhpur, india sandeep bairwa department of medical oncology, all india institute of medical sciences jodhpur, jodhpur, india citation sureka b, chawla s, khera s, agarwal a, birda cl, bairwa s. a lumpy bumpy stomach: the more the murkier. s afr j rad. 2022;26(1), a2437. https://doi.org/10.4102/sajr.v26i1.2437 case report a lumpy bumpy stomach: the more the murkier binit sureka, siddhi chawla, sudeep khera, ashish agarwal, chhagan l. birda, sandeep bairwa received: 10 mar. 2022; accepted: 29 mar. 2022; published: 28 june 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this report describes the radiological and endoscopic findings in a 54-year-old male who presented with epigastric pain. the patient underwent an upper gastrointestinal (gi) barium study followed by axial imaging, which demonstrated nodular gastric wall thickening. the classic findings of aggressive primary gastric diffuse large b-cell lymphoma are presented with a brief review differentiating the pathological subtypes, important for patient prognostication and planning of therapy. keywords: primary gastric lymphoma; dlbcl; malt lymphoma; stomach thickening; gastric wall thickening; computed tomography. introduction primary gastric lymphomas are rare, however, the stomach is the most common gastrointestinal (gi) site of involvement in extra-nodal disease.1 lymphomas may have diverse radiological manifestations, which can mimic a variety of benign diseases and malignant pathologies as enumerated in box 1.2 most of the lymphomas are either of the two most common types of b-cell non-hodgkin lymphoma (nhl), that is, mucosa-associated lymphoid tissue (malt) lymphoma and diffuse large b-cell lymphoma (dlbcl). the radiological differentiation between the two types is difficult but necessary because the prognosis and management differs accordingly.3 various imaging modalities such as fluoroscopic upper gi barium imaging, ultrasonography, ct and mri are used for the pre-treatment assessment and staging of upper gi malignant pathologies. this report describes the classic imaging findings of primary gastric lymphoma and possible differentials with a special emphasis on differentiating between the dlbcl and malt subtypes. box 1: causes of gastric wall thickening. case presentation a 54-year-old male patient presented to our hospital with symptoms of chronic epigastric pain accompanied by postprandial discomfort, early satiety and 2 kg of weight loss in the previous three months. there was no history of haematemesis, melena or vomiting. the liver and kidney function tests were within normal limits. as a result of the predominant upper gi complaints, the patient underwent an upper gi barium study, which demonstrated circumferential gastric luminal narrowing in the region of the fundus and body without obvious mucosal irregularity (figure 1a). at a subsequent contrast enhanced ct scan, homogenous minimally enhancing circumferential thickening of the gastric wall (measuring ~2.5 cm) in the region of fundus and body was seen (figure 1b, c) with associated multiple discrete similarly enhancing supraand infra-diaphragmatic lymph nodes (figure 1c). the mri scan revealed isointense thickening on t1 weighted fat saturated images (figure 1d), showing homogenous enhancement on post-contrast t1 weighed images (figure 1e) in the same region with prominent diffusion restriction (figure 1f, g). in view of the degree of thickening and associated lymphadenopathy, gastric lymphoma was presented as an imaging differential. figure 1: (a) narrowing of the gastric lumen in the fundus and proximal body. (b, c) axial and coronal contrast enhanced ct sections reveal significant gastric wall thickening with effacement of the mucosal folds (red arrows) and multiple enlarged discrete lymphnodes (yellow arrow). (d–g) axial mri preand post-contrast t1 weighted images, diffusion weighted image and adc images demonstrate the gastric wall thickening with significant restriction (red arrows). (h) upper gi endoscopy: nodular thickening in the fundus of the stomach causing luminal stenosis. upper gi endoscopy (figure 1h) demonstrated a thickened and lobulated appearance of the fundus causing moderate luminal narrowing, however, no ulcerations or mucosal erosions were seen. histology on the biopsy acquired reported sheets of atypical lymphoid cells in the subepithelium (figure 2a), intermediate to large in size, exhibiting moderate nuclear pleomorphism, a high nuclear-cytoplasmic ratio, vesicular chromatin, conspicuous nucleoli and a scant amount of cytoplasm (figure 2b). these cells were found to infiltrate the submucosal glands. on immunohistochemistry, the tumour cells were positive for cd45 (leucocyte common antigen [lca]) (figure 2c) and cd20 (figure 2d) and negative for ck & cd3. ki-67 labelling index was 90% – 95% (figure 2e). these findings supported a primary high-grade gastric lymphoma – dlbcl type. figure 2: (a) hematoxilin and eosin stain (h&e), 4× fragmented gastric biopsy shows a cellular fragment, (b) h&e, 10×: higher magnification of the cellular fragment comprising of high nuclear/cytoplasmic (n/c) ratio cells, (c) immunohistochemistry (ihc), cd45: atypical lymphoid cells show diffuse membranous expression of cd45, (d) ihc, cd20: atypical lymphoid cells show diffuse membranous expression of cd20, (e) ihc, ki-67: high labelling index of ki-67 expressed by the atypical lymphoid cells. the patient was initiated on r-chop regimen (rituximab, cyclophosphamide, doxorubicin, oncovin [vincristine], and prednisone) chemotherapy. discussion primary gastric lymphomas are diagnosed using the criteria by dawson et al.4, which includes predominant involvement of the stomach along with nodal involvement confined to its drainage area, no other palpable superficial lymphnodes, a normal chest radiograph, normal total leukocyte counts and no involvement of the other organs such as the liver or spleen. most gi lymphomas represent the non-hodgkin’s subtype with the previous studies reporting hodgkin’s lymphoma only in few cases.5,6 the incidence of nhl has been increasing over time because of various risk factors, which include hiv infection, helicobacter pylori infection, coeliac disease, inflammatory bowel disease and immunosuppression after solid organ transplantation.7 under normal circumstances gastric mucosa is devoid of lymphoid tissue, however, with chronic h. pylori infection there is reactive development of lymphoid tissue within the lamina propria. mucosa-associated lymphoid tissue lymphoma is a low-grade lymphoma and more than 70% of cases are secondary to chronic h. pylori infection whilst dlbcl, in contrast, is an aggressive and high-grade lymphoma, which has a poor prognosis with high rates of recurrence.3,8 conventional upper gi barium studies and upper gi endoscopy are limited as they only assess luminal characteristics. this limitation is overcome in upper gi endoscopy by accompanying endoscopic ultrasound, which can assess the extra-luminal characteristics of the lumen and also assist in acquiring targeted biopsies. multiplanar reconstruction ct can better assess the gastric wall thickness, mucosal enhancement, lymph node involvement and other organ involvement and thus has become the investigation of choice for assessing lesions of the stomach.9 mri is used for evaluation of lesions that are difficult to characterise at multidetentor ct. lymphomas demonstrate significant restriction on diffusion weighted images (dwi) and corresponding apparent diffusion coefficient (adc) maps because of their hypercellular nature. positron emission tomography with computed tomography (pet/ct) scan is helpful in disease staging and treatment response assessment due to its high sensitivity. gastric wall thickness > 1 cm favours the diagnosis of lymphoma.10 in both dlbcl and malt lymphoma, the antrum and body are the most common areas of involvement, however, heterogeneity of contrast enhancement, extensive thickening, serosal involvement and extra-nodal disease is more common with dlbcl. multifocal involvement of the stomach, nodular and ulcerative morphology of lesions, which can lead to subsequent gastric stenosis, are more common in dlbcl. mucosa-associated lymphoid tissue lymphoma on the other hand has an infiltrative nature and thus luminal stenosis is uncommon. differences between these two types of lymphoma are documented in table 1. table 1: important differentiating features between diffuse large b-cell lymphoma and mucosa-associated lymphoid tissue-lymphomas of stomach. differentiation of lymphomatous gastric wall thickening from other malignant conditions, like adenocarcinoma, is essential. adenocarcinoma is more likely to infiltrate the gastric wall and infiltrate the adjacent structures, whilst preservation of the perigastric fat planes is more probable in lymphoma.7 the lumen of the stomach remains patent even with extensive lymphomatous infiltration of the wall whilst in cases of adenocarcinoma the patient can present with gastric outlet obstruction because of the constricting and scirrhous nature of the pathology.11 the linitus plastica appearance related to infiltration of the submucosa of the gastric wall in scirrhous adenocarcinoma leading to decreased capacity and rigidity of stomach wall can also be seen in non-hodgkin gastric lymphoma, however, in these cases lymphomatous cells are seen within the submucosa on pathological evaluation.12 transpyloric spread of disease is also more common in lymphoma than adenocarcinoma however the higher incidence of carcinoma decreases the specificity of this differentiation.13 lymph nodes in cases of lymphomas are homogenously enhancing and bulky and often seen to extend below the level of the renal hilum whereas they are smaller, necrotic and localised to the local drainage site of the stomach in cases of adenocarcinoma.14,15 in suspected cases of lymphoma and in cases where a diagnostic dilemma persistsupper gi endoscopy investigation is warranted. it can delineate the extent of the pathology and guided biopsy from suspicious areas will allow a histopathological diagnosis. immunohistochemistry stains can further differentiate the subtypes of lymphoma as was described in the presented case. once the diagnosis is confirmed, treatment of malt lymphoma consists of anti-h. pylori medication, which is initiated as early as possible once the diagnosis is confirmed.9,16 with dlbcl a combination of chemotherapy and radiation therapy can result in complete remission in up to 90% of cases.16 conclusion this case demonstrates the usefulness of multimodality imaging and describes the classic imaging findings in the dlbcl type of gastric lymphoma. it is quintessential for radiologists and clinicians to be aware of this entity, differentiating it from other types of lymphomas and other malignant pathologies so that appropriate treatment is not delayed. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. was responsible for conceptualisation and supervision. s.c. wrote the original draft. s.k., a.a., c.l.b., s.b. helped in proving the necessary investigations and reviewing the original draft to its final form. ethical considerations informed consent was obtained from the patient for publication. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no data sets were generated or analysed during this study. disclaimer the views expressed in the submitted article are the author’s own and not an official position of their institution. references kelessis ng, vassilopoulos pp, tsamakidis kg, bai mg, avital s, rosenthal rj. is gastroscopy still a valid diagnostic tool in detecting gastric malt lymphomas? a dilemma beyond the eye mucosa-associated lymphoid tissue. surg endosc. 2003;17:469–474. https://doi.org/10.1007/s00464-002-8544-0 agarwala r, shah j, dutta u. thickened gastric folds: approach. j dig endosc. 2018;09(04):149–154. https://doi.org/10.4103/jde.jde_72_18 de jong d, boot h, van heerde p, hart ga, taal bg. histological grading in gastric lymphoma: pretreatment criteria and clinical relevance. gastroenterology. 1997;112:1466–1474. https://doi.org/10.1016/s0016-5085(97)70026-x dawson im, cornes js, morson bc. primary malignant tumors of the intestinal tract. br j surg. 1961;49(213):80–89. https://doi.org/10.1002/bjs.18004921319 crump m, gospodarowicz m, shepherd fa. lymphoma of the gastrointestinal tract. semin oncol. 1999;26:324–337. isaacson pg. gastrointestinal lymphomas of t and b-cell types. mod pathol. 1999;12:151–158. ghai s, pattison j, ghai s, o’malley me, khalili k, stephens m. primary gastrointestinal lymphoma: spectrum of imaging findings with pathologic correlation. radiographics. 2007 sep-oct;27(5):1371–1388. https://doi.org/10.1148/rg.275065151 boot h. diagnosis and staging in gastrointestinal lymphoma. best pract res clin gastroenterol. 2010;24(1):3–12. https://doi.org/10.1016/j.bpg.2009.12.003 choi d, lim hk, lee sj, et al. gastric mucosa-associated lymphoid tissue lymphoma: helical ct findings and pathologic correlation. ajr am j roentgenol. 2002;178(5):1117–1122. https://doi.org/10.2214/ajr.178.5.1781117 asai s, miyachi h, hara m, fukagawa s, shimamura k, ando y. extensive wall thickening in intestinal burkitt lymphoma. j ultrasound med. 2002;21(6):657–661. https://doi.org/10.7863/jum.2002.21.6.657 ciftci ao, tanyel fc, kotiloglu e, hicsonmez a. gastric lymphoma causing gastric outlet obstruction. j pediatr surg. 1996;31(10):1424–1426. https://doi.org/10.1016/s0022-3468(96)90845-3 levine ms, pantongrag-brown l, aguilera ns, buck jl, buetow pc. non-hodgkin lymphoma of the stomach: a cause of linitis plastica. radiology. 1996;201(2):375–378. https://doi.org/10.1148/radiology.201.2.8888226 cho kc, baker sr, altemann dd, fuscoo jm, cho s. transpyloric spread of gastric tumors: comparison of adenocarcinoma and lymphomas. ajr am j roentgenol. 1996;167(2):467–469. https://doi.org/10.2214/ajr.167.2.8686627 buy jn, moss a. computed tomography of gastric lymphoma. ajr am j roentgenol. 1982;138(5):859–865. https://doi.org/10.2214/ajr.138.5.859 miller fh, kochman ml, talamonti ms, ghahremani gg, gore rm. gastric cancer: radiologic staging. radiol clin north am. 1997;35:331–349. hellmig s, bartscht t, fischbach w, et al. germline variations of the malt1 gene as risk factors in the development of primary gastric b-cell lymphoma. eur j cancer. 2009;45(10):1865–1870. https://doi.org/10.1016/j.ejca.2009.03.010 musculoskeletal.html musculoskeletal imaging of a painful knee s k misser, mb chb, fcrad (d) sa lake smit and partners, durban corresponding author: s misser (misser@lakesmit.co.za) presentation a middle-aged woman presented with acute-on-chronic right knee pain. fig. 1 is a plain radiograph of the right knee 3 weeks before admission. fig. 2 is a plain radiograph of the right knee on admission. fig. 3 is a sagittal proton density (pd) fat-saturated image of the right knee. fig. 4 is a coronal t2-weighted fat-saturated image of the right knee. fig. 5 is an axial pd fat-saturated image of the right knee. fig. 6 is a coronal pd fat-saturated image of the right knee. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 1 april 2012. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. fig. 1.  fig. 2.  fig. 3. fig. 4.  fig. 5. fig. 6. sajr 767 pseudoachondroplasia: report on a south african family s moosa,1 mb bch, dch (sa); g nishimura,2 md 1 division of human genetics, national health laboratory service and school of pathology, university of the witwatersrand, johannesburg, south africa 2 department of pediatric imaging, tokyo metropolitan children’s medical center, tokyo, japan corresponding author: s moosa (shahidamoosa@gmail.com) pseudoachondroplasia is an autosomal dominant skeletal dysplasia that results in disproportionately short stature, severe brachydactyly with strikingly lax small joints, malalignments of the lower limbs, and characteristic radiological features. although named ‘false achondroplasia’, the entity is a distinct condition, in which affected individuals are born with normal length and have a normal facies, but is often only recognised after the age of 2 years, when the disproportion and waddling gait become evident. we report on an affected south african father and daughter, and highlight their clinical and radiographic features. s afr j rad 2013;17(2):65-67. doi:10.7196/sajr.767 pseudoachondroplasia (omim 177170) is an autosomal dominant skeletal dysplasia that results in disproportionately (micromelic) short stature, severe brachydactyly with strikingly lax small joints, various malalignments of the lower limbs owing to laxity of the large joints, and characteristic radiological features. although named ‘false achondroplasia’, the entity is a distinct condition in which affected individuals are born with normal length and have a normal facies. it is often only recognised after the age of 2 years, when the disproportion and waddling gait become evident. the radiological manifestations are descriptively termed spondylo-epi-metaphyseal dysplasia (semd). significant retardation of epiphyseal ossification manifests with small, round epiphyses. the epiphyseal dysplasia leads to premature degenerative joint disease. the metaphyses are irregularly ossified. the vertebral bodies appear mildly flat with biconvex endplates. the distinctive vertebral anomalies, apparent in pre-pubertal individuals, often resolve with age, thus emphasising the importance of correct diagnosis in childhood. we present a south african (sa) family with an affected father and daughter, and highlight their clinical and radiographic features. clinical features the proband was a 12-year-old girl who presented with short stature and painful knees and ankles (fig. 1). she was reported to have normal birth length and was of average intelligence. her height was 104.5 cm (<<3rd centile), and her upper-to-lower segment ratio 1.6 (increased) and arm span was 92.5 cm (decreased). weight and head circumference were normal. she stood with an exaggerated lumbar lordosis and had a waddling gait. she had no facial dysmorphic features. the upper limbs showed shortening of all segments with prominent joints of the elbow and wrists. the elbow joints were restricted, while the wrist and finger joints showed hyperlaxity. brachydactyly with squared fingertips and deepset nails was found. the lower limbs showed marked genu varus, shortening of all limb segments and flat, short feet. mild lumbar scoliosis was evident. fig. 1. clinical photograph of the proband showing her disproportionate short stature, lack of facial dysmorphic features, marked genu varus and significant brachydactyly. her 48-year-old father was found to have a very similar phenotype (fig. 2). he presented with difficulty in walking and with painful knee and hip joints. genu valgus (l>r) was noted, and all joints were stiff. his face, upper limbs and feet resembled those of his daughter. his height was 125.5 cm (<<3rd centile), with a decreased arm span and increased upper-to-lower segment ratio. fig. 2. clinical photograph of the proband’s father showing similar clinical phenotype, normal facies, genu valgus deformities and brachydactyly. radiographic features radiographs of these two affected individuals showed skeletal changes involving the spine, metaphyses and epiphyses of tubular bones descriptively termed semd (figs 3 7). the proband exhibited biconvex deformity with anterior beaking of the vertebral bodies, but platyspondyly was not evident. mild thoracolumbar gibbus was noted, with hypoplasia of the first vertebral body (fig. 3). the ilia were somewhat hypoplastic along with mildly short greater sciatic notches and steep, irregular acetabulae. the proximal femoral epiphyses were small and round. ossification of the greater trochanters was irregular (fig. 6). the epiphyses of other long bones were also small and irregular in ossification. the metaphyses of the long bones were flared and irregular. spur-like projections were noted in some of the metaphyseal margins, particularly of the proximal tibiae (figs 5 and 6). carpal bones showed delayed ossification and irregular margins. the short tubular bones showed significant shortening along with epiphyseal irregularities (fig. 7). spinal radiographs of the father demonstrated thoracolumbar scoliosis with mild modification of the vertebral bodies (fig. 4). fig. 3. spine x-rays (ap and lateral) of the proband show mild scoliosis, anterior beaking and tonguing of vertebral bodies. fig. 4. spine x-rays (ap and lateral) of the proband’s father show marked scoliosis, degenerative changes, platyspondyly (probably secondary to compression fractures) and less beaking and tonguing of anterior vertebral bodies than in the proband. fig. 5. proband’s knee x-rays (ap) show significant metaphyseal irregularities (flaring and splaying) and small epiphyses. fig. 6. proband’s pelvic x-ray (ap) shows small capital femoral epiphyses, short femoral necks, and irregular flared femoral metaphyseal borders and poorly modelled acetabulae with irregular margins. fig. 7. proband’s ap hand x-ray shows significant brachydactyly, short metacarpals and phalanges with irregular metaphyses, and small, irregular carpal bones. discussion pseudoachondroplasia was first described by maroteaux and lamy in 1959.1 as the most common of the semd group of disorders, it is estimated to affect 1 in every 20 000 individuals.2 typically, affected individuals have a normal birth length and no facial dysmorphic features. joint laxity, particularly of the small joints of the hand, is another clinical hallmark. as in this family, joint pain is a common presenting symptom. the lower limbs may show genu valgus, varus or a windswept deformity. the characteristic radiographic features include: (i) delayed epiphyseal ossification and irregular metaphyses of the long bones with small capital femoral epiphyses, short femoral necks and irregular, flared metaphyseal borders, and small pelvis and poorly modelled acetabulae with irregular margins that may be sclerotic, especially in older individuals; (ii) significant brachydactyly, particularly short metacarpals and phalanges with irregular metaphyses and small, irregular carpal bones; and (iii) anterior beaking or tonguing of the vertebral bodies, biconvex vertebral endplates, and platyspondyly in childhood. this distinctive appearance of the vertebrae normalises with age, emphasising the importance of obtaining the necessary images in childhood, to aid in making a definitive diagnosis. the proband was 12 years old at the time that the accompanying radiographs were taken, and the platyspondyly had already resolved. unfortunately, no earlier spinal images were available. the natural history of pseudoachondroplasia includes osteoarthritic changes of the extremities and the spine, which are related to abnormal epiphyseal development, along with joint laxity, and may occur in early adult life. spinal osteoarthropathy may be associated with scoliosis. degenerative joint disease is progressive; approximately half of all affected individuals eventually require hip replacement surgery.3 pseudoachondroplasia is inherited in an autosomal dominant manner. therefore, an affected individual has a 50% chance at every pregnancy of passing the condition on to the next generation. mutations in the comp gene, which encodes the cartilage oligomeric matrix protein, cause pseudoachondroplasia. this protein is a normal constituent of the extracellular matrix in cartilage, ligaments and tendons. when the gene is mutated, an abnormal accumulation of proteoglycans within cartilage cells occurs, which leads to early death of these cells and ultimately to defective bone growth and modelling.2 as molecular genetic testing is not yet available in sa, the diagnosis remains clinico-radiological. ongoing care of affected individuals requires the participation of a multidisciplinary team to address their joint pain, limb deformities, scoliosis and psychosocial issues related to short stature. timeous referral for evaluation by a medical geneticist is invaluable in confirming the diagnosis, providing genetic counselling to affected families and directing future management. 1. maroteaux, p, lamy m. les formes pseudo-achondroplastiques des dysplasies spondylo-epiphysaires. presse med 1959;67:383-386. 1. maroteaux, p, lamy m. les formes pseudo-achondroplastiques des dysplasies spondylo-epiphysaires. presse med 1959;67:383-386. 2. tufan ac, satiroglu-tufan nl, jackson gc, semerci cn, solak s, yagci b. serum or plasma cartilage oligomeric matrix protein concentration as a diagnostic marker in pseudoachondroplasia: differential diagnosis of a family. eur j hum genet 2007;15:1023-1028. 2. tufan ac, satiroglu-tufan nl, jackson gc, semerci cn, solak s, yagci b. serum or plasma cartilage oligomeric matrix protein concentration as a diagnostic marker in pseudoachondroplasia: differential diagnosis of a family. eur j hum genet 2007;15:1023-1028. 3. online mendelian inheritance in man. mim number: 177170. baltimore, usa: johns hopkins university, 13 april 2010. http://omim.org (accessed 16 june 2012). 3. online mendelian inheritance in man. mim number: 177170. baltimore, usa: johns hopkins university, 13 april 2010. http://omim.org (accessed 16 june 2012). sajr 939 the impact of the digital revolution on the sajr thank you to those members of the rssa who participated in the recent april 2013 rssa/sajr poll conducted to obtain a formal record indicating their preferences when accessing journal content. of the 213 responses, 55% indicated a preference for a digital-only format that includes online journal access and digital applications for mobile devices. interestingly, 45% indicated a preference for the printed journal along with either online access (21%) or digital applications for mobile devices (24%). the first issue of the sajr was published on 6 april 1963 as a supplement to the south african medical journal, and was recognised as the official journal of the rssa. issues were printed on ‘special art paper, so necessary for the reproduction of radiographs’ as the need for high-resolution print images was required.1 today, the digital revolution aids this desire for high-resolution radiology images. the propagation of gadgets, digital applications and web-based information has given clinicians and radiologists new methods to obtain and share information. the proliferation of the electronic distribution of media has in the past decade been accompanied by a rapid decline in demand for print material. the american journal of roentgenology (ajr) has witnessed a recent shift of approximately 30% of the journal’s content from print to web exclusively.2 however, the printed edition of the ajr continues to be delivered to 52% of current subscribers, suggesting the persistent appeal of the hard copy, even in this digital era of hand-held mobile devices. the rssa/sajr april 2013 poll similarly reflected a 45% readership preference for the printed journal format. currently, all articles published by the sajr are freely and permanently accessible online immediately on publication, without subscription charges or registration obstacles. the journal provides immediate open access to its content, supporting the global exchange of knowledge by making research freely available. the first available issue of the sajr that was electronically accessible on archive is volume 8 issue 1 (2004). online access simultaneously provides journals with a platform to make content available that cannot be included in print format because of costly page restrictions. the sajr intends to move in line with international trends, embracing the digital media revolution that is rapidly changing the way we approach scholarly journalism. razaan davis editor 1. komins c. message from the chairman of the radiological society of south africa. s afr med j suppl 1963; vol xxxvii jan-june. 1. komins c. message from the chairman of the radiological society of south africa. s afr med j suppl 1963; vol xxxvii jan-june. 2. kanne jp. the digital media revolution: what it means for the ajr. ajr 2011;197:6-7. http://www.ajronline.org/doi/pdf/10.2214/ajr.10.6048 (accessed 3 august 2013). 2. kanne jp. the digital media revolution: what it means for the ajr. ajr 2011;197:6-7. http://www.ajronline.org/doi/pdf/10.2214/ajr.10.6048 (accessed 3 august 2013). s afr j rad 2013;17(3):83. doi:10.7196/sajr.939 paranasal.html paranasal sinus variants zaeem i ebrahim, mb bch zarina i lockhat, ffrad (d) (sa) department of radiology, university of pretoria corresponding author: z ebrahim (zaeem@iafrica.com) abstract normal variations of the the paranasal sinuses tend to be overlooked but can have pathological consequences, making identification important. introduction the paranasal sinuses have many variations of their normal anatomy. the variants are usually revealed as incidental findings that are overlooked. the aetiology is congenital or developmental. although the variations are normal, they can have pathological consequences, therefore making identification important. this pictorial essay was created from the records of patients attending kalafong hospital’s ct scanning department. the patients presented with pathology not related to the paranasal sinuses. agger nasi cells the agger nasi cells (latin for ‘nasal mound’) are the most anterior ethmoid cells. they are extramural cells (not confined within the ethmoid bone) and extend anteriorly into the lacrimal bone. they are anterior to the anterior attachment of the middle turbinate to the skull base. viewed in the sagittal plane, they are located anteriorly and inferiorly to the frontal recess. on coronal ct, they appear as inferior to the frontal recess and lateral to the middle turbinate (figs 1 and 2). the bulla ethmoidalis is a prominent anterior ethmoid air cell (fig. 3). a degree of pneumatisation may vary, and failure to pneumatise is termed torus ethmoidalis. haller cells are located below the bulla ethmoidalis and extend beneath the floor of the orbit (figs 4 and 5). the intersphenoid septum is often deflected to one side, attaching to the bony wall covering the carotid artery (fig. 6). this artery can be injured if the septum is avulsed during surgery. pneumatisation of the uncinate process may be encountered in up to 4% of the population (fig. 9). a concha bullosa is a pneumatised middle turbinate and has a reported prevalence of 34%. concha bullosa is readily identified on ct (fig. 10). 1. dahnert w. radiology review manual. 5th ed. philadelphia, usa: lippincott williams and wilkins, 2003. 1. dahnert w. radiology review manual. 5th ed. philadelphia, usa: lippincott williams and wilkins, 2003. 2. chong vfh, fan yf, sethi ds. pictorial review functional endoscopic sinus surgery (fess). clinical radiology 1998; 53(9):650-658. 2. chong vfh, fan yf, sethi ds. pictorial review functional endoscopic sinus surgery (fess). clinical radiology 1998; 53(9):650-658. 3. weissleder r, wittenberg j, mukesh gh, et al. primer of diagnostic imaging. philadelphia, usa: mosby elsevier, 2011. 3. weissleder r, wittenberg j, mukesh gh, et al. primer of diagnostic imaging. philadelphia, usa: mosby elsevier, 2011. fig. 1. agger nasi – left (x). fig. 2. agger nasi – sagittal (x). fig. 3. bilateral bulla ethmoidalis (x) fig. 4. haller cells – left (arrow). fig. 5. haller cells – right (star). fig. 6. intersphenoid septum (arrow). fig. 7. pneumatised anterior clinoid process (star). fig. 8. pneumatised clinoid processes (star – anterior; triangle – posterior). fig. 9. pneumatised uncinate processes, bilaterally (dots). fig. 10. bilateral concha bullosa (x). fig. 11. pneumatised superior nasal turbinate (arrow). sajr 795 abdominal imaging s k misser, s beningfield, p scholtz   lake smit and partners, durban s k misser, mb chb, fc rad (d) sa   department of radiology, university of cape town s beningfield, mb chb, ffrad (d) sa p scholtz, mb chb, fc rad (d) sa   corresponding author: s misser (misser@lakesmit.co.za) presentation a 40-year-old man presented with acute onset of severe vomiting. from the images provided, describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 11 january 2013. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. fig. 1. plain abdominal radiograph. fig. 2 (a d). selected axial post-contrast ct images of the abdomen. s afr j rad 2012;16(4):152. doi:10.7196/sajr.795 abstract introduction method results discussion conclusion acknowledgements references about the author(s) m. sarthak swarup department of radiology, university college of medical sciences and gtb hospital, delhi, india shuchi bhatt department of radiology, university college of medical sciences and gtb hospital, delhi, india rajesh rawal department of radiology, university college of medical sciences and gtb hospital, delhi, india anupama tandon department of radiology, university college of medical sciences and gtb hospital, delhi, india saumya dangwal himalayan institute of medical sciences, swami rama himalayan university, dehradun, india citation swarup ms, bhatt s, rawal r, tandon a, dangwal s. tuberculosis, a great masquerader: a case series unveiling rare sites of musculoskeletal involvement through imaging. s afr j rad. 2020;24(1), a1919. https://doi.org/10.4102/sajr.v24i1.1919 case series tuberculosis, a great masquerader: a case series unveiling rare sites of musculoskeletal involvement through imaging m. sarthak swarup, shuchi bhatt, rajesh rawal, anupama tandon, saumya dangwal received: 30 may 2020; accepted: 06 aug. 2020; published: 29 sept. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract skeletal tubercular infections that do not involve the spine or large joints are rarely encountered. this case series aims to highlight the importance of imaging in diagnosing skeletal tuberculosis (tb) at uncommon sites in clinically unsuspected patients by demonstrating specific imaging findings. we present the clinical details and imaging findings of seven pathologically confirmed cases of extraspinal skeletal tb. a multimodality imaging approach including radiography, ultrasonography (usg) and computed tomography (ct) scan was used in most cases. the imaging studies revealed an infective soft tissue collection over different sites including the sternoclavicular joint, acromion process, chest wall and temporo-mandibular joint, along with destruction and erosion of the underlying or adjacent bones. in tubercular endemic countries, strong clinical suspicion should be entertained in cases presenting with a soft tissue collection, even around unusual skeletal sites. keywords: tuberculosis; chest wall; ultrasonography; computed tomography; sternoclavicular joint. introduction tuberculosis (tb) continues to be a major health problem in developing countries; however, the occurrence of skeletal tb is relatively uncommon. musculoskeletal tb accounts for 1% – 3% of all the cases of tb and 15% of the extra-pulmonary variety.1,2,3 the involvement of the vertebra (pott’s spine) is the most common form of skeletal tb, constituting about 50% of all cases.1,2 other common sites of skeletal involvement are at the hip, knee, foot, elbow, hand and shoulder, in descending order of frequency.1 the sternum, ribs and the sternoclavicular joints are uncommonly affected.3,4,5,6 the mandible and temporo-mandibular joint appear to be the least common location affected by tb.1 this case series reports seven patients who presented to our department with rare sites of tb involvement such as the clavicle, sternum, acromion, chest wall and temporo-mandibular joint, most of whom had a provisional clinical diagnosis other than tb. the cases highlight the importance of imaging in establishing the diagnosis of tb, especially in clinically unsuspected cases of musculoskeletal tb. the pertinent diagnosis of musculoskeletal tb in these patients guides the extended duration of the treatment regime for these patients. method pathologically proven cases of musculoskeletal tb were retrospectively reviewed over a 6-month period with regard to their clinical presentation, imaging findings and clinical diagnosis at the time of presentation to the radiology department. cases of vertebral or spinal and appendicular tb were excluded and only those with an uncommon site of involvement were selected. imaging studies pertaining to these patients included radiographs, ultrasonography (usg) and computed tomography (ct) scans. radiographs of the chest and involved site were present for all patients. ultrasonography had also been acquired in each case to evaluate the associated soft tissue swelling. available non-contrast or contrast-enhanced ct scans of the chest and involved site were reviewed for evaluation of the extent of soft tissue and the underlying bone involvement. magnetic resonance imaging (mri) of the involved site was not performed in any of these cases, as an institutional mri facility was not available. ultrasonography had been used for aspiration or obtaining samples for pathological and microbiological correlation. results all the patients were immunocompetent and had no prior history of tubercular infection of any organ system. most of the patients had been referred for a radiological work-up, with a clinical diagnosis other than tb. none had a history of close contacts of tb in the family. the chest radiographs did not reveal any discernible pulmonary lesions consistent with the diagnosis of tb. the presenting clinical symptoms and imaging findings are described for the seven patients in table 1. all the patients were treated with multidrug anti-tubercular chemotherapy with a significant clinical response. table 1: clinical presentations and imaging findings in seven cases. figure 1: a 13-year-old female with swelling over the right sternoclavicular joint. ultrasonography (a) of the affected area shows a hypo-echoic collection (white arrow) with internal echoes, reaching up to the skin surface. post-contrast axial computed tomography bone window images (b, c) revealed the involvement of the medial end of the clavicle (white arrow) and adjacent hypodense collection with sparing of the sternal aspect. fine needle aspirate (d) shows a well-formed caseating granuloma composed of the epithelioid cells with characteristic slipper-shaped nuclei and indistinct cell boundaries (may-grünwald-giemsa x 200). figure 2: a 23-year-old female with swelling in the right parotid region. post-contrast axial (a) and coronal (b) computed tomography images demonstrate a hypodense collection in the right masseter extending into the temporo-mandibular joint. axial computed tomography bone window image (c) shows the involvement of the right mandibular condyle with partial lysis of the bone and cortical erosion (white arrow). figure 3: a 32-year-old male with swelling over the right shoulder region. axial computed tomography images (a, b) show bony destruction of the right acromion process (white arrow) with an adjacent bulky subscapularis muscle. subsequent ultrasound image (c) shows a hypo-echoic collection in between subscapularis and deltoid muscles. fine needle aspirate (d) from an associated enlarged axillary lymph node shows caseous necrosis seen as acellular debris against a pauci-cellular background (papanicolaou stain x 400). figure 4: a 15-year-old female with a subtle swelling on the chest wall. ultrasonography image (a) shows a hypo-echoic collection (arrow) in the upper anterior chest wall in relation to the left sternoclavicular joint. axial lung window computed tomography image (b) shows tree in bud nodular opacities in the right lower lobe superior segment. axial soft tissue (c) and bone (d) window computed tomography images show necrotic mediastinal nodes and involvement of both sternoclavicular joints with hypodense collections and adjacent bony erosions. figure 5: a 23-year-old female with swelling over the right chest wall. post-contrast computed tomography axial soft tissue and bone window images (a, b) show a peripherally enhancing, hypodense soft tissue collection in the right chest wall with no obvious involvement of the underlying ribs or pleural cavity. figure 6: a 14-year-old female presenting with a left breast swelling. axial post-contrast computed tomography image shows a large chest wall abscess involving the left pectoralis muscle with involvement of the costal cartilage and 5th rib. a similar but smaller collection was seen in the left subscapularis muscle (white arrow). figure 7: an 18-year-old male with swelling on the left chest wall. post-contrast axial computed tomography soft tissue and bone window images (a, b) illustrate the chest wall collection on the left side with underlying subtle rib erosion (white arrow). discussion although tb remains a major health hazard in the developing world, it is not uncommonly encountered in developed countries in recent times. the increase in the prevalence of tb worldwide, especially the involvement of unusual sites, is because of immigration from endemic areas, increased prevalence of immunosuppression (human immune deficiency virus [hiv] infection and use of immunosuppressive drugs), and the emergence of multidrug and extensively drug-resistant strains of mycobacterium tuberculosis. however, none of the patients were found to be hiv positive in this series. the other speculations about the increase in such cases might be because of the easy accessibility to healthcare facilities, increased use of cross-sectional imaging modalities and confirmation of the diagnosis by better diagnostic laboratory services. although the manifestations of tb are usually limited to the chest, the disease can affect virtually any organ system in the body. musculoskeletal tb constitutes a relatively uncommon group of tb. the common sites of skeletal involvement are the spine, hip joint, knee joint, foot, elbow, hand and shoulder joint.1 the affection of the chest wall with the involvement of sternum, ribs and the sternoclavicular joints are uncommonly encountered.3,4,5,6 tuberculosis of the chest wall constitutes 1% to 5% of all cases of musculoskeletal tb.7 sternoclavicular joint tb accounts for only 1% – 2% of all cases of peripheral tubercular arthritis.4 tuberculosis of the ribs constitutes 2% of the total cases of musculoskeletal tb.6 tuberculous osteomyelitis of the sternum and scapula are exceedingly rare.8,9 tubercular arthritis of the temporo-mandibular joints are very rare; only a few cases have been reported.10 multimodality imaging with usg, multidetector computed tomography (mdct) and mri play an important role in the diagnosis of tb, as lesions may be subtle in the initial stage and, therefore, mostly not appreciated on radiographs. however, imaging alone is insufficient in reaching a conclusive diagnosis and pathological/microbiological analysis of the tissue sample is required for making a definitive diagnosis. the cartridge-based nucleic acid amplification test (cb-naat/genexpert) is an automated molecular technique, which not only detects m. tuberculosis, but also rifampicin resistance. it has been increasingly used for bacteriological confirmation from different tissue samples both in pulmonary and specific forms of extra-pulmonary tb. this is particularly useful in cases with extra-pulmonary involvement and paucibacillary disease.11 the unusual locations depicted in this case series are sternum, sternoclavicular joint, ribs, acromion and mandible. positive radiographic signs occur much later than the presenting clinical features. abscesses or sinuses are usually present before the focus can be detected radiologically. computed tomography demonstrates abnormalities earlier than plain radiography and therefore detects the bony changes, which may be missed on radiography. computed tomography scan is especially helpful in evaluating the extent of osseous and joint involvement, degree of bone destruction and demonstration of periosteal reaction or sequestrum.12 besides this, it can also demonstrate the extension of the infection into the surrounding soft tissue, presence and extent of associated soft tissue abscesses and calcifications within the cold abscess.12 the ct features of sternoclavicular tb include bony destruction, soft tissue masses crossing fascial planes with rim enhancement representing an abscess or diffuse enhancement representing granulation tissue and the presence of calcifications.3,4 the condition usually starts from the medial extremity of the clavicle.1 underlying pleuro-parenchymal tubercular involvement is also commonly seen. similar findings are demonstrated on ct in cases with acromio-clavicular joint involvement. the disease may start from the lateral extremity of the clavicle or from the tip of the acromion.1 tubercular involvement of ribs presents as either bony erosions with disruption of the cortical margin or frank destruction, with adjacent abscess formation.6,7 there may be focal expansion of the involved rib with or without periosteal reaction. tuberculous abscesses of the chest wall can involve the sternum, costochondral junctions, rib shafts, costovertebral joints and the vertebrae.7 they are most frequently found at the margins of the sternum and along the rib shafts. a tuberculous retromammary abscess appears as a focal, smoothly marginated, inhomogeneous, hypodense lesion with a surrounding enhancing rim.13 a direct fistulous communication with the pleura or a destroyed rib fragment found in a tuberculous abscess can be helpful in differentiating it from other types of retromammary abscess.13,14 in the case of chest wall tb, the detection of underlying pleuro-parenchymal disease is often helpful in suggesting the diagnosis.3 computed tomography demonstration of tubercular involvement of osseous and soft tissue in these rare sites has important management implications as this will determine the total duration of anti-tubercular treatment in a patient with pulmonary tb. patients with only pulmonary tb are usually treated with 6 months of multidrug chemotherapy, whereas patients with osteoarticular tb are treated for a minimum period of 9 to 12 months. it may extend up to 18 to 24 months depending upon the site of skeletal involvement, clinico radiological response and national/local management guidelines.12 therefore, a careful scrutiny of the bones on ct is warranted. in patients without any clinical suspicion of pulmonary tb, detecting typical pulmonary lesions of tb (active or old healed) acts as supportive evidence of tubercular involvement of bone and soft tissue of the chest wall. our patients demonstrated similar imaging findings, better documented on ct as lytic destruction or erosion of the sternum, clavicle, acromion, ribs and mandibular condyle. soft tissue collections were detected around the bony involvement and this was also demonstrated on usg, where accessible. ultrasonography showed the abscess as a hypo-echoic collection with posterior acoustic enhancement and varying degrees of internal heterogeneity. some authors have also highlighted the use of usg as a cost-effective and useful modality to assess rib destruction/irregularity and associated soft tissue abscess in chest wall tb.6 in addition, usg provides real-time guidance for obtaining a tissue sample for pathological confirmation. the need for image guidance in accurately obtaining the tissue specimen from deep-seated collections/pathology, which is not appreciated clinically, is an important aspect of management, as the histopathological demonstration of caseous necrosis in the granulomas and microbiological identification in culture provides definite evidence of tb.2 musculoskeletal tb demonstrates a variety of clinical and radiologic features and can mimic several other disease entities.15 common conditions in the differential diagnosis are low-grade pyogenic infection, rheumatoid disease, myeloma or secondary metastatic deposits. most of our patients were suspected to have a clinical diagnosis other than tb, reiterating the fact that tb is the great masquerader. imaging was required to unveil the diagnosis or to confirm the clinical diagnosis. only two patients (cases 4 and 5) had a clinical suspicion of pulmonary tb and ct scans were performed primarily for the evaluation of pulmonary involvement, which also revealed the associated bony and soft tissue involvement of chest wall. computed tomography plays a principal role in the detection of an unsuspected lesion or in demonstrating the true nature of the lesion. we would like to highlight the importance of mdct, which could change the clinical diagnosis (as in cases 1, 2, 3, 6 and 7), and detect the associated rib or bony lesion thereby changing the duration of anti-tubercular treatment instituted to the patients (as in cases 4 and 5). hence, in resource-limited settings where mri is unavailable, as in our facility, the imaging modality of greatest importance in detecting musculoskeletal tb at unusual locations is ct as it can show the extent of the bony involvement in great detail, as well as the associated soft tissue collections. although usg can be a useful modality in evaluating the soft tissue affection especially in accessible sites, it is limited in its ability to demonstrate the underlying bony involvement. magnetic resonance imaging (with gadolinium enhancement) is the modality of choice for early detection of tubercular arthritis and osteomyelitis, even if its early findings are non-specific.12 magnetic resonance imaging can reveal intraosseous involvement earlier than the other imaging modalities by demonstrating marrow changes in osteomyelitis. magnetic resonance imaging can easily identify soft-tissue masses, differentiate between granulation tissue and an abscess and assess the degree of marrow involvement and cortical erosion. however, bone anatomy and the extent of bony destruction, calcifications and sequestra are better appreciated at ct scan.2,12 although the majority of earlier investigators have highlighted the role of ct scan in various unusual sites of tubercular osteomyelitis and arthritis, few workers have also described the mri abnormalities in musculoskeletal tb. magnetic resonance imaging shows the marrow changes in the sternum, clavicle and other bones as a hypo-intense area on t1-weighted and hyper-intense area on t2-weighted sequences, along with an associated enhancing soft tissue abscesses. in cases of arthritis, mri can also demonstrate joint effusion, abnormalities within the articular cartilage and subchondral bone. although mri has the advantage of non-exposure to ionising radiation, as well as excellent delineation of soft tissue and marrow pathology, clinicians in some parts of the developing world, similar to our facility, still prefer a ct study because of accessibility and affordability issues. computed tomography can raise the suspicion in clinically unsuspected cases or support the diagnosis in clinically suspected patients, thereby guiding the clinical management in most cases. conclusion a non-specific, often indolent clinical presentation along with a low index of suspicion may result in a delayed diagnosis of extraspinal musculoskeletal tb. therefore, the possibility of tb should be considered even if the site of involvement is atypical such as at the sternoclavicular joint, clavicle, acromion, chest wall or temporo-mandibular joint, particularly in endemic regions or in the immigrant population from endemic areas. undertaking appropriate imaging helps the radiologist to raise the suspicion of tubercular aetiology when a non-specific soft tissue collection is discovered adjacent to bones and joints, even in unusual locations. imaging has important management implications by providing guidance to obtain a tissue sample and determining the total duration of anti-tubercular treatment by demonstrating associated skeletal involvement in cases of pulmonary tb. computed tomography can be an immensely useful modality in resource-constrained environments where mri is unavailable. ultrasound remains an easy, cost-effective initial imaging option. the final diagnosis is usually established by pathological and/or microbiological tests. tuberculosis should be considered even in the presence of atypical radiologic findings in high-risk populations in an appropriate clinical setting. typical radiologic manifestations help to diagnose musculoskeletal tb in unusual locations and in clinically unsuspected cases. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed significantly and equally to this work. ethical consideration this article followed all ethical standards for carrying out research. consent has been obtained from all the patients to include their data in the study and publication. funding information this study received no specific grant from any funding agency in the public, commercial or non-profit sectors. data availability statement data sharing does not apply to this article, as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references tuli sm. tuberculosis of the skeletal system (bones, joints, spine, and bursal sheaths). 4th ed. new delhi: jaypee brothers medical publishers (p) ltd; 2000. vanhoenacker fm, sanghvi da, de backer ai. imaging features of extra-axial musculoskeletal tuberculosis. indian j radiol imaging. 2009;19(3):176–186. https://doi.org/10.4103/0971-3026.54873 shah j, patkar d, parikh b, et al. tuberculosis of the sternum and clavicle: imaging findings in 15 patients. skeletal radiol. 2000;29(8):447–453. https://doi.org/10.1007/s002560000207 bezza a, niamane r, benbouazza k, et al. tuberculosis of the sternoclavicular joint: report of two cases. rev rhum engl ed. 1998;65(12):791–794. khalil a, le breton c, tassart m, korzec j, bigot jm, carette m. utility of ct scan for the diagnosis of chest wall tuberculosis. eur radiol. 1999;9(8):1638–1642. https://doi.org/10.1007/s003300050900 grover sb, jain m, dumeer s, sirari n, bansal m, badgujar d. chest wall tuberculosis – a clinical and imaging experience. indian j radiol imaging. 2011;21(1):28–33. https://doi.org/10.4103/0971-3026.76051 morris bs, maheshwari m, chalwa a. chest wall tuberculosis: a review of ct appearances. br j radiol. 2004;77(917):449–457. https://doi.org/10.1259/bjr/82634045 atasoy c, oztekin ps, ozdemir n, sak sd, erden i, akyar s. ct, and mri in tuberculous sternal osteomyelitis: a case report. clin imaging. 2002;26(2):112–115. https://doi.org/10.1016/s0899-7071(01)00374-6 sambharia ak, goel a, karkhur y, tiwari a, sharma s, kataria a. isolated tubercular osteomyelitis of acromion: a case report and review of literature. j clin orthop trauma. 2016;7(suppl. 1):55–57. https://doi.org/10.1016/j.jcot.2016.08.009 helbling ca, lieger o, smolka w, iizuka t, kuttenberger j. primary tuberculosis of the tmj: presentation of a case and literature review. int j oral maxillofac surg. 2010;39(8):834–838. https://doi.org/10.1016/j.ijom.2010.03.023 komanapalli sk, prasad, atla b, vasundhara n, yendluri d. role of cb-naat in diagnosing extra pulmonary tuberculosis in correlation with fna in a tertiary care center. int j res med sci. 2018;6(12):4039–4045. https://doi.org/10.18203/2320-6012.ijrms20184904 procopie i, popescu el, huplea v, et al. osteoraticular tuberculosis-brief review of clinical morphological and therapeutic profiles. curr health sci j. 2017;43(3):171–190. https://doi.org/10.12865/chsj.43.03.01 chung sy, yang i, bae sh, et al. tuberculous abscess in retromammary region: ct findings. j comp assist tomogr. 1996;20(5):766–769. https://doi.org/10.1097/00004728-199609000-00015 supe an, prabhu ry, priya h. role of computed tomography in the diagnosis of rib and lung involvement in tuberculous retro mammary abscesses. skeletal radiol. 2002;31(2):96–98. https://doi.org/10.1007/s00256-001-0451-2 venkat b, aggarwal v, aggarwal n, sharma s. imaging features of extraspinal osteoarticular tuberculosis and its mimickers: a review. j clin diagn res. 2018;12(7):te01–te07. https://doi.org/10.7860/jcdr/2018/32131.11815 20 sa journal of radiology • march 2011 pictorial essay introduction camurati-engelmann disease (ced), or progressive diaphyseal dysplasia, is a rare sclerosing dysplasia of which 250 cases have been described in the english literature.1 the disease affects one in a million people and is autosomal dominant with variable penetrance.2-5 it was initially described by cockayne in 1920; camurati was the first to suggest its hereditary nature in 1922.6-8 a single case of muscular wasting and marked bone involvement was reported by engelmann in 1929.6,9 as the name suggests, there is progressive hyperostosis and predominant involvement of the diaphyses.6,10 the onset of the disease is usually during childhood; patients usually present by puberty and usually before age 30, with limb pain, muscular weakness, waddling gait and easy fatigue. other symptoms and signs may include delayed growth, reduced muscle mass, anorexia and enlargement of the arms and legs.6,11 systemic manifestations of hepatosplenomegaly, bone marrow dysfunction (anaemia and leucopaenia) and delayed sexual development occasionally occur.4-6,12,13 in a few patients, abnormal values of bone resorption and formation have been described.10 radiologically, the hallmark of the disorder is bilateral, symmetrical cortical thickening of the diaphyses of the long bones14,15 on both the periosteal and endosteal sides of the diaphyses. in decreasing order of frequency, the tibia, femur, fibula, humerus, ulna and radius are affected. ced results from disturbance of intramembranous ossification (fig.1) affecting the long bones, calvaria, mandible and facial camurati-engelmann disease neil bellew, mb bch, da (sa), fcrad diag (sa) department of radiology, steve biko academic hospital and univerity of pretoria georg wagener, mb chb, bsc hon (biochem), mmed (rad) department of radiology, stellenbosch university fig. 1. both clavicles demonstrate marked bony cortical thickening with sparing of the distal ends. the humeral epiphyses are spared. figs 2 a f. the diaphyses of the long bones demonstrate endosteal and periosteal thickening with narrowing of the medullary cavity. note the typical sparring of the epiphyses. a b c d e f sa journal of radiology • march 2011 21 pictorial essay bones.11,16 there are a few reported cases of involvement of the skull base (a site of endochondral ossification), but these occur in advanced stages.3,11,17,18 radioclinical features according to a retrospective study of 24 families done by janssens et al.,6 clinical symptoms were documented in 74% of the patients. the most frequent clinical symptoms were pain in the extremities (63%), easy fatigue (44%), waddling gait (48%), muscle weakness (39%), reduced subcutaneous fat (21%) and hearing loss (15%). radiographically, endosteal and periosteal thickening of the diaphyses of long bones (figs. 2a f ) is seen in ced.3,11,17,18 the result is narrowing of the medullary cavity (figs 3a, b).4 the metaphyses can become affected, but typically the epiphyses are spared (figs 4a, b).4,6 sclerosis of the skull base (figs 5a, b) can be present, leading to hearing impairment owing to progressive stenosis of the external auditory canal (eac), and foraminal stenosis causing cranial nerve dysfunction.6,11,19 increased osteoblastic activity detected scintigraphically with 99tc-hmdp (hyfroxymethylene diphosphonate) is seen bilaterally symmetrical in the upper and lower limb long bones, longitudinally figs 3a and b. the marked cortical thickening results in narrowing of the medullary cavity. a b figs 4a and b. classical sparing of the epiphysis and metaphysis of the proximal femora. a b 22 sa journal of radiology • march 2011 pictorial essay table i. classification of dysplasias with increased bone density according to international nomenclature and classifications of the osteochondrodysplasias (modified from vanhoenacker fm et al.13) disorder radiological pattern of sclerosis mode of inheritance 1. increased bone density without modification of bone shape osteopetrosis precocious type delayed type intermediate type with renal tubular acidosis generalised type 1 uniform type 2 endobones generalised similar other types ar ad ar ar axial osteosclerosis osteomesopyknosis with bamboo hair focal sclerosis in vertebrae/pelvis ad ar pycnodysostosis generalised ar osteosclerosis stanesu type cortical thickening of long bones, deficient facial sinus development ad osteopathia striata isolated with cranial sclerosis radiodense striations on all bones with cranial sclerosis sp xld sponastrime dysplasia striated metaphysis ar melorheostosis flowing hyperostosis sp osteopoikilosis radiodense spots ad mixed sclerosing bone dysplasia combined pattern sp 2. increased bone density with diaphyseal involvement diaphyseal dysplasia, camurati-engelmann craniotubular sclerosis, symmetrical ad craniodiaphyseal dysplasia craniotubular ar, ad lenz majewski dysplasia craniotubular sp endosteal hyperostosis van buchem type worth type sclerosteosis with cerebellar hypoplasia craniotubular sclerosis, symmetrical ar ad ar ar kenny caffey dysplasia diaphyseal cortex ad, ar osteoectasia with hyperphosphatasia (juvenile pagets) craniotubular sclerosis, bowing ar diaphyseal dysplasia with anaemia diaphyseal cortex ar diaphyseal medullary stenosis with bone malignancy (hardcastle) diaphyseal cortex ad 3. increased bone density with metaphyseal involvement pyle dysplasia erlenmeyer ar craniometaphyseal dysplasia severe type mild type other type pyle-like, but cranial bones more affected ar ad frontometaphyseal dysplasia frontal bones xlr dysosteosclerosis generalised platyspondyly ar xlr oculodento-osseous dysplasia craniotubular and mandible ad trichodento-osseous craniotubular ad 4. neonatal severe osteosclerotic dysplasia blomstrand generalised ar raine dysplasia mild craniofacial sclerosis undermodelled long bones ? prenatal onset caffey disease diaphyseal cortical thickening, bowed long bones ?ar ad=autosomal dominant; ar=autosomal recessive; sp=sporadic; xld=x-linked dominant; xlr=x-linked recessive. sa journal of radiology • march 2011 23 pictorial essay along the bone cortices.6,15 before sclerosis is seen radiologically, increased tracer uptake can be seen and is thus valuable in the early diagnosis.6 diagnosis ten different mutations of the tgfb1 (transforming growth factor b1) were identified in an analysis of 46 ced families.6,20-27 the tgfb1 gene is located on the chromosomal region 19q13.1.4 all investigated mutations increase the activity of tgfb1.6 under physiological conditions, tgfb1 has been shown to suppress bone formation and the mutation stimulates bone formation6 thus disrupting bone turnover, causing increased bone formation. tgfb1 also inhibits myogenesis, causing muscle wasting as well as lipogensis.6 ced is classified as a sclerosing bone dysplasia with diaphyseal involvement (table i). the differential diagnosis is endosteal hyperostosis – van buchem sclerosteosis, kenny-caffey disease or worth type. owing to inheritance, one can rule out van buchem sclerosteosis (autosomal recessive (ar)), and worth type is a more benign form and has associated mandible enlargement.4,13 a combination of clinical, radiological, scintigraphic and molecular data are mandatory for a definitive diagnosis. treatment immunosuppressive agents such as anti-inflammatories and glucocorticosteroids have the negative side-effect of decreasing bone density; and this is used in ced as treatment. the role of the agents is to increase the apoptosis rate of osteoblasts and osteocytes and at the same time to suppress osteoblast proliferation, differentiation and bone matrix synthesis.6 further effects are to enhance proliferation and differentiation of osteoclast precursors6 and also to decrease intestinal calcium absorption.6 glucocorticosteroids as well as counteracting bone formation exert a direct effect on tgfb expression. prednisolone has been described as an effective treatment in a number of cases.6 long-term treatment is not advisable owing to its unfavourable sideeffects such as impaired growth and spinal osteoporosis. a good starting dose is 1mg/kg/day, but should be lowered in long-term treatment. an alternative to medication is surgery. reaming of the medullary cavity may be done to decrease the narrowing of the canal, or an osteotomy can be performed.6,28 further decompression in optic nerve compression has also been done. gene therapy is a possibility in the future. conclusion camurati-engelmann disease (ced), or progressive diaphyseal dysplasia, is a rare sclerosing dysplasia whose onset is usually during childhood. patients usually present by puberty or before age 30. radiologically, the hallmark of the disorder is bilateral, symmetrical cortical thickening of the diaphyses of the long bones occuring on both the periosteal and endosteal sides of the diaphyses. the differential diagnosis is of ced is endosteal hyperostosis – van buchem, sclerosteosis, kenny-caffey disease and worth type. inheritance can rule out van buchem and sclerosteosis (ar), whereas worth type is a more benign form and has associated mandible enlargement. a combination of clinical, radiological, scintigraphic and molecular data may be necessary for a definitive diagnosis. 1. brat hg, hamoir x, matthijs p, et al. camurati-engelmann disease: a late 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2006;43:1-11. 7. cockayne ea. case for diagnosis. proc r soc med 1920;13:132-136. 8. camurati m. di un raro caso di osteite simmetrica ereditaria degli arti inferiori. chirurgia degli organi di movimento 1922;6:662-665. 9. engelmann g. ein fall von ostheopathia hyperostotica (sclerotisans) multiplex infantilis. forschritte auf dem gebiete der rontgenstrahlen und der nuklearmedizin 1929;39:1101-1106. 10. smith r, walton rj, corner bd, gordon ir. clinical and biochemical studies in engelmann’s disease (progressive diaphyseal dysplasia). qjm 1977;46:273-294. figs 5a and b. the skull radiographs demonstrate sclerosis of the skull base and temporal bone, particularly of the external auditory canal. a b 24 sa journal of radiology • march 2011 pictorial essay 11. stasolla a, magliulo g, bellussi a, et al. imaging of the temporal bone in camuratiengelmann dysplasia with an 11-year follow-up. otology & neurology. 2005;26:773-777. 12. crisp aj, brenton dp. engelmann’s disease of bone – a systemic disorder? ann rheum dis 1982;41:183188. 13. vanhoenacker fm, de beuckeleer lh, van hul w, et al. sclerosing bone dysplasias: genetic and radioclinical features. eur radiol. 2000;10:1423-1433. 14. rimoin dl. international nomenclature of constitutional diseases of bone. j pediat 1978;93:614-616. 15. momose m, yoshida k, yanagisawa s, et al. camurati-engelmann disease on a 99mtc-hmdp bone scan. eur j nucl med mol imaging 2008;35:214. 16. greenspan a. sclerosing bone dysplasias: a target-site approach. skeletal radiol 1991;20:561-583. 17. vanhoenacker fm, debeuckeleer lh, van hul w, et al. sclerosing bone dysplasias: genetic and radioclinical features. eur radiol 2000;10:1423-1433. 18. kaftori jk, kleinhaus u, naveh y. progressive diaphyseal dysplasia (camurati-engelmann): radiographic follow-up and ct findings. radiology 1987;164:777-782. 19. cheung sw, jackler rk. diffuse osseous lesions of the temporal bone. in: jackler rk, brackmann de, eds. neurotology. st. louis: mosby year book, 1994:1189-1202. 20. campos-xavier b, saraiva jm, savarirayan r, et al. phenotypic variability at the tgfbeta1 locus in camurati-engelmann disease. hum genet 2001;109:653-658. 21. wallace se, lachman rs, mekikian pb, bui kk, wilcox wr. marked phenotypic variability in progressive diaphyseal dysplasia (camurati-engelmann disease): report of a four-generation pedigree, identification of a mutation in tgfb1, and review. am j med genet 2004;129a:235-247. 22. janssens k, gershoni-baruch r, guanabens n, et al. mutations in the gene encoding the latency-associated peptide of tgf-beta 1 cause camurati-engelmann disease. nat genet 2000;26:273-275. 23. kinoshita a, saito t, tomita h, et al. domain-specific mutations in tgfb1 result in camurati-engelmann disease. nat genet 2000;26:19,20. 24. hecht jt, blanton sh, broussard s, scott a, rhoades hall c, milunsky jm. evidence for locus heterogeneity in the camurati-engelmann (dpd1) syndrome. clin genet 2001;59:198–200. 25. mumm sr, obrecht s, podgornik mn, whyte mp. camurati-engelmann disease: new mutations in the latency-associated peptide of the transforming growth factor beta-1 gene. j bone miner res 2001;16(suppl 1):s223. 26. janssens k, ten dijke p, ralston sh, bergmann c, van hul w. transforming growth factor-beta 1 mutations in camurati-engelmann disease lead to increased signaling by altering either activation or secretion of the mutant protein. j biol chem 2003;278:7718-7724. 27. kinoshita a, fukumaki y, shirahama s, et al. tgfb1 mutations in four new families with camuratiengelmann disease: confirmation of independently arising lap-domain-specific mutations. am j med genet 2004;127a:104-107. 28. raffaelli p, ronzini mf. camurati-engelmann’s disease. a case report. ital j orthop traumatol 1988;14:267-271. published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines. the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition � ninth edition produced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f the essential reference for ever y healthcare professional! the carefully and thoroughly updated 9th edition of the south african medicines formulary (samf) can now be ordered. it is your essential reference to rational, safe and cost-efficient use of medicines. that is why you should not prescribe without it. the newly published samf provides easy access to the latest, most scientifically accurate information – including full drug profiles, clinical notes and special prescriber’s points. the convenient pocket-size design enables you to fit it comfortably into your bag or hospital coat pocket – always at hand for ready reference. w h y yo u s h o u l d n ’ t b e w i t h o u t t h e s a m f 9 t h e d i t i o n the new 9th edition of samf provides expanded information on key issues facing south african healthcare professionals today, including antiretrovirals, tb treatment guidelines, management guidelines for asthma and chronic heart failure, other common chronic conditions and prescribing in sport. • it presents practical, new approaches to the management of venomous bites and stings. • it outlines extensively the acute adverse reactions to drugs of abuse, and their management. • it features new as well as existing drugs, indexed by both trade and generic names. • it offers fresh insights into informed prescribing and carries cautionary guidelines on drug interactions and a range of special risk patients and conditions. and, as always, you can rely on... • the professional compilation and editing by a team from the division of clinical pharmacology, uct • an independent and unbiased guide on prescribing in south africa today • the indication of agents included in the sa and who essential drug lists • support of the sa national drug policy • guidance for prescribing during pregnancy and lactation, and in patients with porphyria, liver disease and renal impairment (including tables with drug dosage adjustments); and • indexed and page tabs for quick and easy access to each section. y o u r s a t i s f a c t i o n i s g u a r a n t e e d 3 e a s y o r d e r o p t i o n s : 1. phone edward or byron 021 6817000 2. fax the completed samf order form to 0866006218 3. email: edwardm@hmpg.co.za or byronm@hmpg.co.za guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agentsmusculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines.the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn ����������������� ����������������� s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition � ninth editionproduced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f fast.html fast as a predictor of clinical outcome in blunt abdominal trauma benjamin m terry, md, mph david blehar, md romolo gaspari, md department of emergency medicine, university of massachusetts medical school, worcester, massachusetts, usa arthur maydell, mb chb, dip pec (sa) fourie bezuidenhout, mb chb department of radiology, tygerberg hospital, university of stellenbosch savvas andronikou, mb bch, fcrad, frcr (lond), phd department of radiology, university of the witwatersrand corresponding author: a maydell (atmaydell@hotmail.com) abstract background. peer-reviewed literature demonstrates increasing support for the use of focused abdominal sonography in trauma (fast) in the setting of blunt trauma, one study demonstrating the sensitivity and specificity of fast for the detection of free fluid to be 0.64 0.98 and 0.86 1.00, respectively, compared with abdominal ct. utilising ultrasound in trauma triage increases efficiency and cost-effectiveness and reduces reliance on ct, compared with using ct alone. there is little evidence to support relying solely on a negative fast and physical examination for patient management. method. a retrospective descriptive study of 172 adult patients who received fast for the evaluation of blunt abdominal trauma between 22 july 2007 and 21 january 2008 at tygerberg hospital was performed. ultrasound findings were correlated with ct scan findings, operative findings if managed surgically, clinical outcomes whether managed surgically or conservatively, as well as postmortem findings in deceased patients. results. fast was negative in 147 (85.5%) patients. twenty-four (16.3%) of these patients died from all-cause mortality, none of which was due to intra-abdominal injury. seven patients with negative fast underwent ct scan owing to change in clinical course, and 3 patients with negative fast underwent laparotomy owing to change in clinical course, with positive findings in 2 patients – a bowel injury requiring resection (not seen on ct) and a diaphragmatic rupture seen on cxr. a negative fast was shown to be an excellent predictor for the absence of significant intra-abdominal trauma. the mortality rate among 25 fast positive patients was 24% (n=6). only one of these patients (with a splenic rupture) was suspected to have died from abdominal pathology. introduction peer-reviewed literature demonstrates an increasing trend of support for focused abdominal sonography for trauma (fast) in the setting of blunt trauma. it is used as the initial screening tool to detect the presence of intra-abdominal free fluid and to indirectly confirm abdominal injury as the source of haemorrhage in haemodynamically unstable patients who would then require emergency laparotomy before further time is spent on imaging. previous studies have demonstrated the sensitivity and specificity of fast for the detection of free fluid to be 0.64 0.98 and 0.86 1.00, respectively, compared with abdominal computed tomography (ct).1 some authors in fact argue that fast is more sensitive than ct for free fluid.2 randomised controlled trials now show that triage pathways incorporating ultrasonography result in increased efficiency, cost-effective evaluation and reduced reliance on ct, compared with pathways that exclusively utilise ct.3 however, there is much less evidence to support sole reliance on a negative fast scan and physical examination for patient management.7 , 8 haemodynamically stable, negative fast patients routinely receive ct scans out of literature-based concern that ultrasonography may miss solid organ injury. the sensitivity of ultrasonography for solid organ injury ranges from 0.4 0.8, even after the administration of intravenous contrast agent.9 despite evidence that the missed solid organ injuries are not clinically significant, or would be detected during observation without incurred morbidity, much of the trauma community maintains the necessity of routine whole-body ct imaging, even without obvious signs of injury.10 attributable factors include over-investigation by clinicians motivated by a fear of litigation, institutional financial gain from ct scanning, and patient demand for advanced imaging to rule out injury. routine whole-body ct imaging is costly and exposes millions of patients to ionising radiation that could have immediate and long-term consequences, including the development of fatal cancers. ct has become central to the evaluation of trauma, with improvements in speed and resolution leading to lower thresholds for the use of ct.11 , 12 according to the report by the national council on radiation protection and measurements (ncrp) on population exposure, americans were exposed to more than seven times as much ionising radiation from medical procedures in 2006 as was the case in the early 1980s, with ct and nuclear medicine studies being the most significant contributors, with the effective radiation dose from all sources per individual in the usa population nearly doubling from 3.6 to 6.2 millisievert (msv) over this period.13 longstanding controversy exists about the level of carcinogenic risk attributable to low-level ionising radiation.14 the seventh biologic effects of ionizing radiation report (beir vii) predicts that, for a standardised us population, an average lifetime attributable risk exists of one radiation-induced cancer per 1 000 patients receiving a 10msv effective dose (average abdominal ct), with approximately half of these cancers expected to be fatal.15 the number of ct scans performed in the us increased from 3.6 million in 1980 to 67 million in 2006. studies have demonstrated a significant cancer risk to the pelvic and abdominal organs as a result of trauma whole-body imaging, although the risk-benefit is yet unclear. in addition, ct is a much more expensive investment than ultrasound – a notable factor in countries with limited resources. it is important, both from a clinical and cost-effectiveness perspective, to not only establish the utility of ultrasound, but also to demonstrate when ct incurs risk and expense without compensatory benefit in patient outcomes. this is a preliminary investigation of a triage pathway that relies on the fast exam to rule out the need for further imaging or intervention. it establishes, in a retrospective manner, that this triage pathway accurately predicts good clinical outcome without ct. methods a retrospective study was done of 172 patients receiving fast for blunt abdominal trauma at tygerberg hospital, the academic tertiary referral centre of stellenbosch university. tygerberg hospital is the second-largest hospital in south africa, with 22 500 trauma cases per year. the trauma (emergency) department is staffed by full-time medical officers, with urgent referrals available 24 hours a day to in-house radiology residents for ultrasonagraphy and ct, and a general surgery trauma service for operative intervention. patients requiring urgent ct are prioritised and scanned promptly. emergency medicine is a nascent specialty in south africa, with formal recognition in 2003 and the first residency programme established in 2004. residents in emergency medicine rotate among various services at the universities of cape town and stellenbosch, but were not an integral part of the current study. all patients from the trauma (emergency) department between 22 july 2007 and 21 january 2008 who received a fast scan as part of the triage protocol were retrospectively enrolled in the study by utilising the ultrasound request forms submitted by trauma department personnel. patients sustaining blunt abdominal trauma are evaluated using a diagnostic tree (fig. 1), designed to triage the use of ct to those who would obtain the most clinical benefit, based on peer-reviewed literature.1 patients with blunt abdominal trauma, stable vital signs and no obvious injury underwent serial fast and physical examinations for 24 hours without undergoing ct. patients with positive fast scans received a contrasted ct of the abdomen as long as they remained haemodynamically stable,to identify injuries which would require surgical management. at any point in the triage pathway, unstable patients underwent immediate exploratory laparotomy. inclusion criteria included patients who were 18 years and older who suffered blunt abdominal trauma and received a fast scan within 24 hours of presentation. charts were reviewed for operative findings, ct findings and patient outcome, including postmortem data. patients were excluded if chart review, including patient outcome, could not be completed. institutional approval was obtained from stellenbosch university’s committee for human research. the primary outcome in this investigation was safe discharge or transfer without mortality or morbidity attributable to abdominal pathology. secondary outcomes included need for laparotomy, surgical findings and ct findings. patients enrolled by ultrasound request forms were recorded by medical record number into a microsoft excel spreadsheet that was matched to locate patient charts and record outcome data. these results were then provided to the primary author, who analysed the outcome information and categorised patients’ morbidity and mortality according to aetiology. results a total of 172 patients met inclusion criteria during the selection period. the predominant population involved was young males, with 131 (76%) male and 41 (24%) female patients. there were 118 (68.6%) patients between the ages of 20 and 39. racial characteristics and socio-economic status were not recorded. results are presented in fig. 2. the fast exam was negative in 147 (85.5%) patients. twenty-four (16.3%) of these patients died from all-cause mortality. the cause of death was neurological in 18 patients (intracranial injury), infectious in 4 patients (hospital-acquired pneumonia etc.), orthopaedic in 1 patient (pelvic fractures) and unclear in 1 patient, who underwent a postmortem examination that showed no abdominal organ injury or free fluid within the abdomen. seven patients (4.8%) with negative fast received a ct scan owing to change in clinical course. two of these patients had ct findings, namely a splenic contusion and a kidney laceration, neither requiring surgical repair. three patients with negative fast underwent laparotomy owing to a change in clinical course with positive findings in 2 patients, i.e. a bowel injury requiring resection that was not detected on ct, and a diaphragmatic rupture seen on chest x-ray with no other operative abdominal findings. the mortality rate among 25 fast positive patients was 24% (n=6), only slightly higher than the fast-negative patients. fig. 3a shows a fast-positive ultrasound, with fig. 3b as a comparison of a fast-negative ultrasound. one of the fast-positive patients sustaining a splenic rupture was suspected to have died from abdominal trauma. three patients died due to neurological injury – one from multi-organ failure, and one from respiratory failure. eleven patients (44%) underwent laparotomy, which showed free fluid with or without major organ trauma in 91%, and a negative laparotomy in one patient where ct had indicated a bowel injury. ten patients (40%) received a ct scan which reported free fluid in 80% with or without the presence of major organ trauma. ten patients (40%) receiving ct underwent laparotomy with one negative laparotomy performed for a ct report of bowel injury. discussion our study demonstrates that the algorithm for managing blunt abdominal trauma according to current evidence (as shown in fig. 1) at tygerberg hospital is safe and effective, with the appropriate use of ct as indicated by fast and clinical parameters. ct of the abdomen was not performed routinely for fast-negative patients who showed no clinical sign of intra-abdominal trauma, which suggests that performing ct in this group would incur unnecessary cost and risk from ionising radiation, while showing no benefit to the patient. a negative fast scan was an excellent predictor of the absence of significant intra-abdominal injury. while the mortality rates of patients in the fast-negative group was disconcertingly high, the cause of death, after thorough chart review, was not attributable to missed injury. two missed injuries that were found on ct (i.e. a splenic contusion and a minor renal laceration) did not require operative intervention and were successfully managed conservatively. there were 2 injuries in the fast-negative group that received a laparotomy: a bowel injury that was missed on ct and a diaphragmatic hernia that was found on screening chest radiography. these injuries must be kept in the differential for any patient who sustains blunt abdominal trauma, but do not obviate the triage algorithm in question. ct showed the presence of free fluid in 80% of fast-positive patients, with free fluid or blood in the peritoneal cavity found at laparotomy in 91% of fast-positive patients, confirming the superior sensitivity of ultrasound to ct for detecting the presence of free fluid. limitations the study has several limitations that limit the generalisability of the findings: (i) it is a retrospective analysis. many of the traditional biases incurred by retrospective analyses are therefore applicable here; (ii) the study was developed without strict guidelines of how to categorise outcome. the process of categorising the cause of mortality did not utilise predetermined criteria, which limits its scientific validity. in addition, the chart review process and the morbidity/mortality attribution process was performed by separate authors; (iii) the study was designed and carried out within the span of a month in a country with numerous logistical, cultural and language barriers. while various omissions were included at a later point via email communication with on-site personnel, this also incurred limitations; (iv) patients were not followed up after discharge or transfer to determine if any missed injuries presented at a later stage. future direction this study should be repeated in a prospective, randomised manner, where the control group is triaged according to current protocol and an intervention group receives abdominal ct. in that way, one could determine which injuries are missed according to the current protocol, and if locating these injuries would improve patient outcome. the triage pathway needs to be more rigorously delineated, information collected more objectively, and outcome groupings given standard definitions. in addition, patients should be contacted at a defined, future point and interviewed using a systematic questionnaire to provide delayed outcome information. ethics approval was obtained from the university of stellenbosch research development and support department committee for human research; project number n08/10/295, irb number irb0005239. this paper was an oral presentation at the emssa emergency medicine in the developing world conference in cape town, on 25 november 2009. 1. körner m, krötz mm, degenhart c, pfeifer kj, reiser mf, linsenmaier u. current role of emergency us in patients with major trauma. radiographics 2008;28(1):225-242. 1. körner m, krötz mm, degenhart c, pfeifer kj, reiser mf, linsenmaier u. current role of emergency us in patients with major trauma. radiographics 2008;28(1):225-242. 2. emery kh, mcaneney cm, racadio jm, johnson nd, evora dk, garcia vf. absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. j pediatr surg 2001;36(4):565-569. 2. emery kh, mcaneney cm, racadio jm, johnson nd, evora dk, garcia vf. absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. j pediatr surg 2001;36(4):565-569. 3. arrillaga a, graham r, york jw, miller rs. increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. j trauma 1999;46(6):1126-1129. 3. arrillaga a, graham r, york jw, miller rs. increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. j trauma 1999;46(6):1126-1129. 4. boulanger br, mclellan ba, brenneman fd, ochoa j, kirkpatrick aw. prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. j trauma 1999;47(4):632-637. 4. boulanger br, mclellan ba, brenneman fd, ochoa j, kirkpatrick aw. prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. j trauma 1999;47(4):632-637. 5. melniker la, leibner e, mckenney mg, lopez p, briggs wm, mancuso ca. randomized control trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. ann emerg med 2006;48(3):227-235. 5. melniker la, leibner e, mckenney mg, lopez p, briggs wm, mancuso ca. randomized control trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. ann emerg med 2006;48(3):227-235. 6. rose js, bair ae, mandavia d, kinser dj. the uhp ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. am j emerg med 2001;19:299-302. 6. rose js, bair ae, mandavia d, kinser dj. the uhp ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. am j emerg med 2001;19:299-302. 7. bode pj, edwards mj, kruit mc, van vugt ab. sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. am j roentgenol 1999;172:905-911. 7. bode pj, edwards mj, kruit mc, van vugt ab. sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. am j roentgenol 1999;172:905-911. 8. lingawi s, buckley a. focused abdominal us in patients with trauma. radiology 2000;217:426-429. 8. lingawi s, buckley a. focused abdominal us in patients with trauma. radiology 2000;217:426-429. 9. poletti pa, kinkel k, vermeulen b, irmay f, unger pf, terrier f. blunt abdominal trauma: should us be used to detect both free fluid and organ injuries? radiology 2003;227(1):95-103. 9. poletti pa, kinkel k, vermeulen b, irmay f, unger pf, terrier f. blunt abdominal trauma: should us be used to detect both free fluid and organ injuries? radiology 2003;227(1):95-103. 10. salim a, sangthong b, martin m, brown c, plurad d, demetriades d. whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. arch surg 2006;141(5):468-473. 10. salim a, sangthong b, martin m, brown c, plurad d, demetriades d. whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. arch surg 2006;141(5):468-473. 11. mayo jr, aldrich j, muller nl. radiation exposure at chest ct: a statement of the fleischner society. radiology 2003;228:15-21. 11. mayo jr, aldrich j, muller nl. radiation exposure at chest ct: a statement of the fleischner society. radiology 2003;228:15-21. 12. frush dp. review of radiation issues for computed tomography. semin ultrasound ct mr 2004;25:17-24. 12. frush dp. review of radiation issues for computed tomography. semin ultrasound ct mr 2004;25:17-24. 13. national council on radiation protection and measurements. ionizing radiation exposure of the population of the united states . bethesda, md: ncrp report no.160, 2009. 13. national council on radiation protection and measurements. ionizing radiation exposure of the population of the united states . bethesda, md: ncrp report no.160, 2009. 14. brenner dj, doll r, goodhead dt, et al. cancer risks attributable to low doses of ionizing radiation: assessing what we really know. proc natl acad sci usa 2003;100:13761-13766. 14. brenner dj, doll r, goodhead dt, et al. cancer risks attributable to low doses of ionizing radiation: assessing what we really know. proc natl acad sci usa 2003;100:13761-13766. 15. committee to assess health risks from exposure to low levels of ionizing radiation; national research council (u.s.). health risks from exposure to low levels of ionizing radiation: beir vii phase 2. washington, dc: national academies press,2006. 15. committee to assess health risks from exposure to low levels of ionizing radiation; national research council (u.s.). health risks from exposure to low levels of ionizing radiation: beir vii phase 2. washington, dc: national academies press,2006. fig. 1. diagram showing triage pathways for patients with blunt abdominal trauma. patients with stable vital signs and no sign of intra-abdominal injury underwent serial fast and physical examination without undergoing ct. patients with positive fast scans received ct if they remained haemodynamically stable. at any point in the triage pathway, unstable patients underwent immediate exploratory laparotomy. fig. 2. main results for the whole group, and breakdown for fast-positive and -negative clinical outcomes. fig. 3a. positive fast in a 31-year-old male patient involved in a pedestrian-motor vehicle accident shows free fluid in the hepatorenal recess (rliver=right liver lobe, ff=free fluid, rk=right kidney). fig. 3b. ultrasound for comparison of a normal hepatorenal recess (morrison’s pouch) demonstrating the absence of free fluid between the right liver lobe (black arrow) and right kidney (white arrow). fig. 4. axial ct of the abdomen at the level of the superior liver segments, in the same patient whose images appear in fig. 3, shows a grade iv liver laceration (white arrows) with free fluid surrounding the liver. fig. 5. ct oblique coronal reformat of the same patient whose images appear in figs 3 and 4 shows free fluid in the hepatorenal recess (white arrow) with free fluid surrounding the liver. 4 sa journal of radiology • march 2011 case report abstract the rare condition of idiopathic granulomatous mastitis (igm) is presented here, unusually, in a 54-year-old woman. igm mimics breast carcinoma and further differentials include tuberculosis and fungal infections of the breast together with other chronic granulomatous conditions. of note is its characteristic ultrasound features that can suggest the diagnosis. diagnosis is made by core biopsy and histology. patients have been shown to respond to steroid and other immunosuppressive therapy, with surgical excision reserved for those whose condition is recurrent and unresponsive to medical treatment. case report a 54-year-old woman presented with a 3-week history of a painful right retro-areolar mass which was unresponsive to a course of antibiotics. she had no significant past medical history, including no previous history of tuberculosis. she was not on any chronic medication, and in particular had not used the oral contraceptive pill. she had no history of breast trauma, and there was no family history of breast cancer. she had breastfed her two children for 3 months each. her first child was born when she was 24 years old and her second child when she was 36. she was currently peri-menopausal. clinically, there was a unilateral firm right retro-areolar breast mass which was tender to palpation. the overlying skin was thickened and slightly warm. there was no associated nipple discharge or skin sinus. idiopathic granulomatous mastitis fig. 1. right cranio-caudal mammogram. fig. 2. ultrasound image of the breast. fig. 3. histological stain from the core biopsy. grace rubin, mb bch, da (sa), fcrad (d) sa department of radiology, helen joseph hospital, johannesburg debra ardath meerkotter, mb bch, fcrad (d) sa regional imaging, st vincents hospital, launceston, tasmania, australia sa journal of radiology • march 2011 5 case report mammography revealed bilateral moderately dense fibroglandular breast parenchyma in the right retro-areolar region was a poorly defined area of increased density (fig. 1). ultrasound revealed an irregularly outlined, hypoechoic mass measuring 19 mm x 17 mm x 20 mm. hypoechoic tubular extensions into the breast parenchyma were noted. there were no posterior acoustic features. colour doppler demonstrated increased vascularity in the surrounding tissue but not in the mass (fig. 2). associated with these findings was a right axillary lymph node measuring 14 mm x 10 mm. it was round, with a thickened cortex and minimal visible fatty hilum. the imaging features raised suspicion for a carcinoma, and ultrasoundguided core biopsy of the mass and fine-needle aspiration of the right axillary lymph node were performed. the core biopsy demonstrated features of granulomatous mastitis. stains for demonstrating acid-fast bacilli (ziehl-neelsen) and fungal elements (pas, grocott’s) were negative (fig. 3). the fine-needle aspirate of the right axillary lymph node was consistent with a reactive lymph node. the patient was treated conservatively without steroids and showed good resolution of her symptoms with expectant management. discussion idiopathic granulomatous mastitis (igm) is a granulomatous inflammation of the breast lobules of unknown aetiology. it was first described by kessler and wolloch in 1972.1 clinically, it most commonly affects parous women, aged 22 421-5 who have had their children between 62,4 and 15 years1,3 before diagnosis. unusually, our patient presented at 54 years of age, having delivered her last child 18 years prior to her breast condition. the pathological findings of igm are unrelated to specific infection, trauma or foreign body reaction.2 no consistent history of breast feeding or oral contraceptives can be associated with the condition.3 the response of igm to steroids implies an autoimmune process.5 however, histological features of an immune-mediated inflammation, such as vasculitis and predominantly plasma cell and lymphoid aggregates, are not seen in igm.4 in a large series of 54 women reviewed between january 2000 and april 2008, the histological result of igm represented less than 1% of all breast biopsies done at that institution,1 confirming as in other reports that igm is a rare disease. most commonly, igm presents as a unilateral breast mass which can, as in our patient, be tender.1,4 while in some series no skin and nipple changes were reported,2 others report erythema and draining sinus tracts to the skin.1,3 since most patients present with a fixed, immobile non-tender mass, the main differential diagnosis of concern is that of carcinoma of the breast. this proves to be of further concern as the mammographic appearance of igm is commonly an asymmetric increase in density1,3 in either outer or medial quadrants and peripherally,1 or less commonly (as in this patient) retro-areolar in position.1,3 igm may also present as an irregular lobulated mass on mammogram. diffuse increase in breast density of the affected side may be the only mammographic indicator of pathology, but this is the least common presentation;1,3 in dense breasts, pathology may be masked. ultrasonography is helpful in characterising igm. in one case series, the most common ultrasound feature is that of a hypoechoic or heterogeneously hypoechoic mass. the distinguishing characteristic of igm, as is demonstrated in this case, is that of tubular hypoechoic extensions from the dominant mass that may connect to other nearby masses if there are any.1-3 parenchymal distortion with acoustic shadowing and no discreet mass may be seen on ultrasound instead of the findings of a dominant mass.1 benign regional axillary adenopathy may be present.1-3 pathologically, inflammation affecting breast lobules or lobulitis and the formation of non-caseating granulomas composed of clustered epitheloid histiocytes is present. in addition, lymphocytes, plasma cells, neutrophils and giant cells comprise the inflammatory infiltrate.1,2,4 the granulomas can become confluent and liquefy. these positive findings need to be associated with the negative findings of tuberculosis or any other possible infectious cause of inflammation in the specimen.1-5 the differential diagnosis of igm remains carcinoma of the breast, tuberculosis and fungal infections, especially when the mass is associated with sinus tracts to the skin1-3,5 other considerations include sarcoidosis, fat necrosis,wegener’s granulomatosis, plasma cell mastitis and a ruptured cyst.1 sarcoidosis of the breast can give a similar histological picture to igm, and it may be difficult in the absence of systemic disease to differentiate between the two.4 treatment of igm has been conservative, allowing mild disease to recover. this was the management and outcome to date of the patient presented here. surgical excision has proved more successful than incision and drainage in the past, with cases of poor wound healing with incision and drainage being reported. post surgery, a course of steroids may be prescribed.1,2,5 antibiotics are unhelpful, and a persistent mass unresponsive to antibiotics prompts patients to seek further care.1-3 current therapy favours a course of steroids, repeated if necessary, and followed by immunosuppressive therapy with methotrexate. surgical excision should be reserved for recurrent disease that does not respond to medical therapy.1,5 in conclusion: igm is a rare benign breast condition. it mimics breast carcinoma both clinically and radiographically. infective mastitis and inflammatory breast disease of known aetiology must also be considered in the differential diagnosis. recognising the condition and obtaining histology is essential in making the diagnosis. the value of making this diagnosis is that the prognosis and treatment differ significantly from that of breast carcinoma, and the radiologist can be pivotal in the diagnosis of this rare condition. 1. hovanessian larsen lj, peyvandi b, klipfel n, grant e, iyengar g. granulomatous lobular mastitis: imaging, diagnosis and treatment. ajr 2009;193:574-581. 2. han b, choe yh, park jm, et al. granulomatous mastitis: mammographic and sonographic appearances. ajr 1999;173:317-320. 3. lee jh, oh kk,kim e, kwaek ks, jung wh, lee hk. radiologic and clinical features of idiopathic granulomatous mastitis mimicking advanced breast cancer. yonsei med j; 2006;47(1):78-84. 4. fletcher a, magrath im, riddell rh, talbot ic. granulomatous mastitis: a report of seven cases. j clin pathol 1982;35:941-945. 5. raj n, macmillan rd, ellis io, deighton cm.rheumatologists and breasts: immunosuppressive therapy for granulomatous mastitis. rheumatology 2004;43(8):1055-1056. sajr 887 nasci cardiac ct angiography course lourens erasmus drs w e scribante & partners, george, w cape the course was the first joint venture between the rssa and the north american society of cardiac imaging (nasci), and comprised 40 hours of training over 2 consecutive weekends: 15 17 march at the radisson blu hotel, v&a waterfront, cape town, and the second from 22 24 march at the sandton sun hotel, johannesburg. the course was unique in many respects. firstly, it was presented over consecutive weekends, with delegates required to attend both weekends in their entirety to obtain the necessary accreditation. so-called ‘essential pre-course reading’ was also provided in the form of 5 published articles that covered the basics of cardiac anatomy, the cardiac conduction system, ct physics, image acquisition, post-processing, and atherosclerotic plaque characterisation. didactic lectures were presented at the start of each session, followed by supervised case study reviews under supervision of the esteemed faculty, which included professor charles white, and drs harold litt, shawn teague and suhny abbara, under the leadership of professor jill jacobs. fully equipped ct workstations were provided, with only two attendees per workstation, which facilitated a true hands-on experience. after each case, questions were posted to the audience, and answers from delegates recorded with an electronic audience response system, provided by nasci, and expertly handled by ms michele wittling. at the end of the course, each delegate was credited with 70 supervised case reviews. i must emphasise the logistical challenges of this event in setting up about 50 workstations and integration between the different vendors (ge healthcare, philips, siemens, tecmed africa). these challenges were met and handled expertly by the representatives from these companies, who worked together towards the common goal for the course. as a novice in the field of interpretation of coronary cta, i found the training course to be of the highest quality, providing me with essential basic knowledge and some practical experience for providing this service to our patients. the challenge now lies in continued education and service provision. special thanks to all involved in organising and presenting this course, with professor leon janse van rensburg, as usual, at the helm. from l to r: dr harold litt; proff charles white, leon janse van rensburg, jill jacobs; drs gregory kicksa, shawn teag, and (inset) suhny abbara. harold litt presenting. rssa honorary membership award rounding off the nasci course, the rssa and south african community had the privilege of presenting professor jill jacobs with honorary rssa membership. a well-published academic and professor in the department of radiology of new york university, professor jacobs is also a director of the cardiac imaging programme at the nyu langone medical center. the honour was awarded in recognition and appreciation of her value and outstanding contribution to the south african radiological community. she has been a regular visitor to south africa, an ardent and passionate supporter of teaching academic radiology in the country, instrumental in bringing foremost international radiologists to participate in rssa cme teaching courses, and played a leading role in presenting the rssa/nasci cardiac accreditation course in south africa and establishing official ties between the rssa and nasci. we proudly welcome professor jill jacobs as our fifth esteemed rssa honorary member, and extend our sincerest gratitude for her commitment and dedication towards south african radiology. dr thami mngoma (rssa treasurer and rssa cme association trustee) presents professor jill jacobs with her honorary membership certificate. ecr 2013 lili huang medical officer in radiology, steve biko academic hospital and university of pretoria the 25th european congress of radiology (ecr) took place in vienna, austria, from 7 11 march 2013. a wide range of relevant and controversial topics from paediatric to adult radiology, physics and professional issues were covered in parallel sessions in the short span of 5 days. the presentations included juniorand senior-level radiology, as well as those suitable for students and radiographers. numerous interactive sessions, and refresher and practical courses, were held. over 300 exhibitors from around the world were present to display the latest medical imaging developments and services. the annual programme features sessions held by 3 countries; this year, the rssa was one of the guests of honour among chile and spain. hiv/aids and tb, two of south africa’s major health issues, were discussed by several renowned radiologists including proff zarina lockhat, victor mngomezulu and congress director leon janse van rensburg; and drs tracy kilborn, pieter janse van rensburg, richard pitcher and rssa president clive sperryn. i was privileged to present 3 e-posters on paediatric cardiology: walking the tight rope: when to intervene in rheumatic heart disease; this is the left, right?; and assessing a broken heart. my colleague at steve biko academic hospital, dr anith chacko, also attended the congress and presented 2 e-posters. my attendance at ecr 2013 was made possible by the generosity of an rssa cme association grant. i sincerely thank the trustees of the association for providing me with the opportunity to attend the congress. esr meets south africa: ecr 2013 report-back clive sperryn rssa president the rssa had the opportunity to participate in the ‘esr meets’ programme at ecr 2013 − the second african country to do so after egypt in 2012. there were two elements to participation: the academic programme and the rssa booth and entertainment programme. the academic programme: esr meets south africa clive sperryn and the ecr president, professor jose ignatio bilbao, chaired the session. we were welcomed by professor gabriel krestin, president of the esr. dr sperryn introduced the audience to south african radiology, comparing radiologist:population ratios with other countries, and introduced the topics of hiv and tb before introducing the speakers. in south africa, hiv infection is a high risk factor for stroke in young patients. professor victor mngomezulu presented ‘hiv-related cerebrovascular disease: the south african experience’, a systematic review of published literature from 3 major south african academic centres in the last 12 years, and ended with some unique angiographic images. the concept of the rich focus as the cause of tuberculous meningitis is controversial. using original images from arnold rich’s work, as well as from the south african physician j n coetzee’s thesis on tuberculous meningitis, dr pieter janse van rensburg illustrated why there is doubt concerning the role of the rich focus as the cause of basal cisternal tuberculous meningitis, and proposed a more likely pathogenetic mechanism based on radiological-pathological correlations using mr imaging. the incidence of tb is increasing in both the developing and developed worlds, and is complicated by the emergence of multidrug-resistant disease and co-infection with hiv. dr tracy kilborn covered the varied presentations of tb in the spine, and discussed the mri features. south africa has the highest global hiv prevalence, estimated at 5.6 million people, including 377 000 children. professor richard pitcher described the 5-year findings of a cape town-based usa-uct collaborative paediatric pulmonology hiv-research group focusing on severe cxr abnormalities in hiv-infected children. professor zarina lockhat gave an inspirational overview of radiology training, showing some fascinating camouflage images by art wolfe to highlight the way we perceive images. the final session was a celebration of south africa: the country, its people, its diversity, and its attractions. on behalf of the rssa, we thank all our speakers for their excellent presentations. we had excellent feedback from several european radiologists. clive sperryn later participated as a panellist in the ecr 2013 image interpretation quiz, facing some challenging cases as part of a successful international team. the booth and cultural activities the south african booth was impressive. we had assistance from sa tourism, and carmen and pranusha provided impressive artwork. patricia trietsch (rssa secretary) manned the booth which acted as a meeting point. she made the following comments: ‘it was a wonderful experience and certainly different from our sa congresses. it is huge − although many doctors told me it was nothing compared with the rsna, so that must be mind-boggling! i was fascinated by the continuous comings and goings of the delegates. it was great to meet many of our registrars whom i’ve spoken to on so many occasions but am now able to put a name to a face and also actually chat face-to-face and find out so much about them.’ thanks to dr lili huang, a radiologist from pretoria, for her exceptional piano recital on the grand piano. lunchtime cultural entertainment was provided by thabiso serobanyane and sibongiseni ndlovu who gave an energetic performance and managed to entice leon janse van rensburg onto the stage for an impromptu performance that found its way onto youtube! the booth was visited by mrs bongoza mabhongo, wife of the sa ambassador in vienna. the evening’s wine tasting was well attended, including ms lydia greyling, minister plenipotentiary, from the sa embassy in vienna. ogilvie provided a great team from london and everything ran smoothly; overall, it was a great success. thanks to patricia for manning the booth, to zarina for the leading role she played in the organisation of the artwork for the booth and the entertainment programme, and to all the sa radiologists who supported us. and thanks to leon janse van rensburg for the initial contact and for support and involvement in the organisation throughout. we believe we have been able to gain positive exposure that will benefit south african radiology in the future. from l to r: tracy kilborn, patricia trietsch (back), clive sperryn and zarina lockhat. from l to r: clive sperryn, bongoza mabhongo (wife of the sa ambassador in vienna) and leon janse van rensburg. ----------- a reminder ... ... of the sorsa/rssa congress from 23 25 august 2013 at the international convention centre in durban; the advanced msk imaging course from 21 23 february 2014 at the table bay hotel, v&a waterfront, cape town; and – retrospectively by now – the cone beam ct workshop in cape town on 1 june, which we hope to report on in the next sajr. further details are on the rssa website. about the author(s) isak d. vorster department of diagnostic radiology, faculty of health sciences, university of cape town, cape town, south africa steve beningfield division of radiology, faculty of health sciences, university of cape town, cape town, south africa citation vorster id, beningfield s. corrigendum: evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region. s afr j rad. 2021;25(1), a2269. https://doi.org/10.4102/sajr.v25i1.2269 note: doi of original article published: https://doi.org/10.4102/sajr.v23i1.1720 correction corrigendum: evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region isak d. vorster, steve beningfield published: 01 dec. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the version of the article initially published, vorster id, beningfield s. evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the cape town metropole west region. s afr j rad. 2019;23(1), a1720. https://doi.org/10.4102/sajr.v23i1.1720, the orcid of the second author was given incorrectly. the correct orcid should be https://orcid.org/0000-0003-0727-2650 instead of https://orcid.org/0000-0001-7805-7347 in the ‘authors’ section. this correction does not alter the study’s findings of significance or overall interpretation of the study’s results. the authors apologise for any inconvenience caused. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) raeesa omar department of diagnostic radiology & imaging, faculty of health sciences, dr george mukhari academic hospital, sefako makgatho health sciences university, pretoria, south africa margaret kisansa department of diagnostic radiology & imaging, faculty of health sciences, dr george mukhari academic hospital, sefako makgatho health sciences university, pretoria, south africa alireza d. dehnavi department of diagnostic radiology & imaging, faculty of health sciences, dr george mukhari academic hospital, sefako makgatho health sciences university, pretoria, south africa citation omar r, kisansa m, dehnavi ad. the prevalence of anatomical variants of the coeliac trunk and renal arteries on contrast-enhanced abdominal computed tomography scans at dr george mukhari academic hospital. s afr j rad. 2021;25(1), a1990. https://doi.org/10.4102/sajr.v25i1.1990 original research the prevalence of anatomical variants of the coeliac trunk and renal arteries on contrast-enhanced abdominal computed tomography scans at dr george mukhari academic hospital raeesa omar, margaret kisansa, alireza d. dehnavi received: 12 sept. 2020; accepted: 02 nov. 2020; published: 25 jan. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: anatomical variations of the coeliac trunk and renal arteries should be radiologically reported as they affect the surgical approach and subsequent outcome in patients. objectives: the aim of this study was to determine the prevalence of anatomical variations of the coeliac trunk and renal arteries and whether there is a relationship between the occurrence of these variations at dr george mukhari academic hospital. method: arterial phase abdominal computed tomography (ct) or ct abdominal angiograms performed during january and december 2017 were analysed. the variations of the coeliac trunk and renal arteries were classified according to accepted classification systems and expressed as a percentage of the study population. results: a normal classical coeliac trunk was present in 82.2% and a non-classical pattern was present in 9.7%. the most common variation of the coeliac trunk other than the non-classical pattern was a hepatosplenic trunk, which was present in 3% of the study population. a normal right and left renal artery was present in 88.2% and 83.7%, respectively. the most common variations of the renal arteries were bilateral hilar arteries seen in 3.4% on the right and 9.1% on the left. renal artery variations were more prevalent on the left than on the right. concurrent variations of both the right and the left renal arteries were present in 2.4% and variations of both the coeliac trunk and renal arteries were present in 5% of the study population. conclusion: the most common variation of the coeliac trunk in this study is comparable to other studies in non-african populations. concurrent vascular variations between the renal arteries and between the coeliac trunk and renal arteries may co-exist. keywords: anatomical; variants; coeliac; trunk; renal; arteries; ct; scan. introduction vascular variations in the coeliac trunk and renal arteries are commonly encountered. these variations directly affect the surgical approach, should patients undergo surgical interventions such as organ transplantation or organ/tumour resection. it is therefore important to recognise these variations and give an accurate concise description thereof in the report when assessing a contrasted abdominal computed tomography (ct) scan or a ct angiogram of the abdominal aorta. several studies, which signified the importance of identifying these variations, have been analysed, and they emphasise the importance of correctly reporting upon these variations as a radiologist. the identification and correct classification of these variations aid in the subsequent management and may result in more favourable surgical outcomes. the coeliac trunk is the first major branch of the abdominal aorta and arises anteriorly from the abdominal aorta at the level of t12 behind the median arcuate ligament. normal coeliac trunk anatomy includes the division of the coeliac trunk into three branches – the common hepatic artery (cha), the left gastric artery and the splenic artery. the left gastric artery is usually the first branch, after which the coeliac artery bifurcates into the splenic artery and the cha. this is known as the classic trifurcation.1,2 the aorta is connected to the ventral longitudinal anastomosis by the 10th, 11th, 12th and 13th vitelline arteries in primitive vasculature. usually, the coeliac trunk and the superior mesenteric artery are formed by the 10th and 13th vitelline arteries with the remaining segments regressing before birth. variants arise when this process does not occur in the prescribed order. for example, if the 10th and 12th vitelline arteries regress but there is abnormal persistence of the ventral anastomoses, a coeliaco-mesenteric trunk occurs.3 in the literature, a variable number of variations of the coeliac trunk have been documented. for ease of reference, ulflacker’s classification will be used to classify the type of variation encountered (table 1, figure 1).4 this classification was chosen as it is simple but provides adequate detail of each variant type. according to the classification in table 1, eight types of coeliac trunk variations have been classified thus far. an example of a type 1 classic trifurcation is illustrated in figure 2 and a non-classic trifurcation is illustrated in figure 3 by osman et al.4 figure 1: schematic representation of the different types of coeliac trunk variants according to ulflacker’s classification: (a) type i; (b) type ii; (c) type ii; (d) type iii; (e) type v; (f) type v; (g) type vi; (h) type viii. figure 2: type 1 classic trifurcation. coronal multi-planar reconstruction image (a) and three-dimensional reconstruction images (b) show a type i coeliac classic trifurcation. additionally, there is a replaced right hepatic artery. figure 3: sagittal multiplanar reconstruction (a) and three-dimensional (b) images show ulflacker’s type 1 non-classic pattern. table 1: ulflacker’s classification. the anatomy of the coeliac trunk was found to be highly variable when analysed in a number of different studies. the ct scans and digital subtraction angiograms (dsas) of 5002 patients were retrospectively analysed by song et al.5, in seoul, south korea, who found that 89.1% of these patients had normal coeliac trunk anatomy represented by a hepatogastrosplenic trunk (includes classic and non-classic trifurcation). in 9.64% of the patients, 12 specific types of variations of the coeliac trunk were identified. the study further redefined the cha as an arterial trunk from which at least one segmental hepatic artery and the gastroduodenal artery originates from, regardless of the origin or path of this trunk. in another study by prakash et al.6 in india, variations in the coeliac trunk were studied in 50 cadavers. of these, 86% demonstrated normal coeliac trunk anatomy with the classic trifurcation. the most common pattern observed in 76% of subjects was that of the left gastric artery originating from the coeliac trunk proximal to the bifurcation into the common hepatic and splenic arteries.6 a further study performed on cadavers by chitra et al, found that the branching pattern of the coeliac trunk varied from the classic trifurcation to an abnormal trifurcation and even to four, five and six branching patterns of the coeliac trunk.7 when classifying the different types of hepatic artery variations according to the michels and hiatt classification (which classifies hepatic artery variations into 10 and 6 types, respectively), it was found that normal anatomy was found in 79.1% of patients, whilst variant or anomalous anatomy was found in 20.9% of patients. the authors concluded that identification of the variant types were vital in the pre-operative and intra-operative planning and technique and was thus of importance to both the radiologist and the surgeon.8 the identification of variants of the coeliac axis was shown to be important prior to surgical procedures such as liver transplantation or angiographic procedures, and knowledge thereof is thus necessary in preventing intra-operative complications. furthermore, knowledge of variations of the coeliac trunk is essential to ensure correct vascular anastomosis during liver transplant surgery, as well as in surgeries involving the pancreas, stomach and duodenum.5,6 coeliac trunk variations are also of importance during endovascular intervention such as coeliac artery embolisation, which may be performed in patients with coeliac artery aneurysms or in repair of thoracoabdominal aortic aneurysms in the region of the coeliac artery. studies have shown that certain variations such as a type iv or type vi trunk, wherein the coeliac artery shares an origin with the superior mesenteric artery, make coeliac artery embolisation impossible. thus, it is essential for the vascular surgeon to be made aware if such variations exist.9 interestingly, a correlation between the presence of accessory renal arteries and a higher incidence of variations in the coeliac and/or hepatic arteries in patients was found. urgurel et al. 10, assessed variations in the hepatic arteries, coeliac trunk and renal arteries in 100 patients on multidetector ct angiography. in 89% of these patients, normal coeliac trifurcation was found in 48% of the patients also demonstrating hepatic artery variation. however, coeliac trunk and/or hepatic artery variation was found in 39.7% of the 58 patients with normal renal arteries and in 64.3% of the 42 patients with accessory renal arteries. there was thus a significant correlation between variations in the coeliac trunk and/or hepatic arteries and variations in the renal arteries. it can therefore be assumed that when an anatomic variation in the vascular supply of a single organ system is encountered, one should be mindful that anatomical variation of the vascular supply to other organ systems may co-exist. the renal arteries usually arise as branches of the abdominal aorta below the level of the superior mesenteric artery. normal renal arterial anatomy comprises a single renal artery supplying each kidney. beregi et al11. found that in the vast majority of the 100 patients in whom spiral ct angiograms were assessed, the left (87%) and the right (88%) renal arteries originated between the lower border of the l1 and lower border of the l2 vertebral bodies. the right renal was found to most frequently originate at the lower border of l1 and the left renal artery at the l1/l2 intervertebral disc space. the renal arteries are located anterior to the renal pelvis and enter each kidney at the medial aspect of the hilum. the renal veins are located posterior to the renal arteries. the right renal artery has a more prominent downward course and propagates behind the inferior vena cava to enter at the hilum of the more inferiorly located right kidney, whilst the left renal artery has a more prominent horizontal course to enter at the hilum of the superiorly located left kidney.12 in a study by sampaio et al.13, in brazil, the renal arteries of 266 kidneys of 133 subjects were dissected and analysed in order to illustrate the different variations (figure 4). the variations depicted in figure 4 will be used in the classification and description of the type of renal artery variation. a three-dimensional ct reconstructed image of accessory renal arteries as depicted by urgurel et al.10 is demonstrated in figure 5. figure 4: variations in renal arteries: (a) type 1a – 1 hilar artery, (b) type 1b – 1 hilar with 1 superior pole extra-hilar branch, (c) type 1c – 2 hilar arteries, (d) type 1d – 1 hilar with 1 superior polar artery, (e) type 2a – 1 hilar with 1 inferior polar artery, (f) type 2b – 2 hilar arteries with 1 superior pole extrahilar branch, (g) type 2c – 1 hilar with a precocious bifurcation, and (h) type 2d – 3 hilar arteries. figure 5: accessory renal arteries – three-dimensional volume rendered image shows two renal arteries on the right – there is an accessory inferior polar artery (thick arrows) arising from the aorta below the inferior mesenteric artery (thin arrow). there are three renal arteries on the left. it is important to identify variations in the renal vasculature especially in surgical procedures such as renal transplantation, nephrectomy, surgical treatment of renal artery stenosis or abdominal aortic aneurysm repair.14 the most common cause of renal artery stenosis is atherosclerosis followed by fibromuscular dysplasia. the surgical treatment of renal artery stenosis includes endovascular stenting of the renal arteries.12 multidetector ct provides crucial information of the vasculature of interest and can thus be used as an alternative to invasive procedures such as conventional angiography for pre-operative planning of surgical procedures.15 multidetector ct is a thus a reliable, non-invasive method to assess the anatomy and possible variations of the renal vasculature. the above studies highlight the importance of identifying the vascular variations of the coeliac-hepatic axis together with that of the renal arteries. it has been observed that registrars in the department of diagnostic radiology at dr george mukhari academic hospital often fail to mention the vascular variants encountered in the coeliac trunk and renal arteries when reporting on ct scans or ct angiograms. this omission negatively affects any surgical intervention that may follow when the indication of the ct scan is one which would aid in such intervention. this study was conducted to assess the prevalence of the vascular variations of the coeliac trunk and renal arteries expressed as a percentage of the study population and to determine whether there was a significant relationship between the occurrence of these variations. this study emphasises the importance of radiologists reporting on these variations to better aid the surgeon in the subsequent surgical management at dr george mukhari academic hospital. methods this was a retrospective, descriptive and quantitative study. data was collected for the period january 2017 to december 2017. a sample size of 312 cases was initially calculated based on estimation of the average number of abdominal ct scans/ct angiograms done per week at dr george mukhari academic hospital. the inclusion criteria included male and female adult patients above the age of 18 years old who had undergone a contrast-enhanced ct abdomen – specifically an arterial phase ct or a ct angiogram of the abdominal aorta during the study time period. the exclusion criteria included patients below 18 years of age, as image quality is reduced in paediatric patients because of a lower radiation dose. the coeliac trunk and renal arteries were analysed on multi-planar reconstruction (mpr) and maximum intensity projection (mip) images (axial, coronal and sagittal views) with a slice thickness of 10 mm on mip images. this was acquired on the carestream picture archiving and communication system (pacs) in the department of radiology at dr george mukhari academic hospital. the scans were analysed separately by two individual readers. the readers included a senior radiology registrar and a junior consultant radiologist. the readings were then reviewed and compared for congruency. incongruent findings were identified and then subjected to analysis by a third reader who is a senior consultant radiologist. in order to eliminate bias, the third reader performed the readings blindly without knowledge of the other readers’ findings. in these cases, readings were considered valid and included in the results if congruency was established between two of the three readers. of the starting 312 cases, a total of 301 cases were adequate and selected for analysis. furthermore, three cases were omitted because of the lack of consensus between the readers. because of the discrepancies amongst the readers, the sample sizes were then adjusted to represent each vessel as follows: coeliac trunk 298 cases; right renal artery 297 cases; and left renal artery 296 cases. all statistical analyses were performed on sas statistical analysis software (sas institute inc, carey, nc, usa), release 9.4. ethical consideration ethical clearance was received from sefako makgatho health sciences university research ethics committee (smurec). ethical clearance number: smurec/m/280/2018: pg. results of the study population, 82.2% demonstrated the classic type i coeliac trunk (normal anatomy) with 9.7% of the study population demonstrating type i non-classic coeliac trunk anatomy (p < 0.001). furthermore, 3% of the study population demonstrated a type ii (hepatosplenic trunk) anatomic configuration (p < 0.001), 1% of the study population demonstrated a type iii (hepatogastric trunk) and 2.7% of the study population demonstrated a type v (gastrosplenic trunk) anatomy (p < 0.001) (figure 6). the most common variant of the coeliac trunk other than the non-classical pattern was a type ii (hepatosplenic trunk) closely followed by a type v (gastrosplenic trunk) anatomic configuration. the occurrence between a type ii and type v was statistically insignificant (p = 1). the other coeliac trunk variations were either not present or, if present, observed in less than or equal to 1% of the study population. figure 6: coeliac trunk variations: the most common variant types are expressed as a percentage. the anatomic configuration of the right renal artery was observed in the study population as follows: a type 1a (normal anatomy) right renal artery was seen in 88.2%; type 1b in 2.3%; type 1c in 3.4%; type 1d in 1.3%; type 2a in 2% and type 2c in 2.3% of the study population. the most common variant of the right renal artery was therefore a type 1c (2 hilar arteries) anatomy (p < 0.001). other right renal artery variations were not observed in this study (figure 7). figure 7: right renal artery variations: the most common variant types are expressed as a percentage. the anatomic configuration of the left renal artery was observed in the study population as follows: a type 1a (normal anatomy) left renal artery was seen in 83.7%; type 1b in 1%; type 1c in 9.1%; type 1d in 1.3%; type 2a in 2.7% and type 2c in 1.3% of the study population. the most common variant of the left renal artery was therefore a type 1c (2 hilar arteries) anatomy (p < 0.001). the other left renal artery variations were either not present or, if present, observed in less than 1% of the study population (figure 8). figure 8: left renal artery variations: the most common variant types are expressed as a percentage. concurrent variations of both the left and the right renal arteries were observed in 2.4% of the investigated cases. further, variations of the coeliac trunk associated with either variations of the left renal artery, right renal artery or bilateral renal arteries were present in 5% of the investigated cases (95% confidence interval is 3.1% – 8.1%.). this shows that there might be a correlation between variations of the coeliac trunk and variations of the renal arteries, and further investigation may be warranted with future studies. discussion the importance of anatomical variations of the coeliac trunk and renal arteries and the importance of accurate radiological assessment and relevant reporting thereof lie in the surgical implications of such variations. these variations are often overlooked and are not routinely reported at dr george mukhari academic hospital. in a study comparing findings from pre-operative ct angiography to intra-operative findings, it was observed that the correlation of anatomical similarities between the ct findings and the intra-operative findings was 98%.16 this reiterates that ct scan is an excellent modality for the assessment of the vascular anatomy. it is also postulated that anatomical variations may also be the source of certain pathological conditions such as vascular compression syndromes, which once again highlights the importance of identifying anatomical variations through the use of imaging modalities.17 in this study population, the most common variant of the coeliac trunk other than the non-classic pattern was a type ii (hepatosplenic trunk) closely followed by a type v (gastrosplenic trunk) configuration. this is similar to the findings from a study conducted by iezzi et al18. in italy published in 2008, which also documented that a type ii (hepatosplenic trunk) was the most common variation of the coeliac trunk. various other studies have indicated that a type v (gastrosplenic trunk) was the most common variant of the coeliac trunk as summarised later. in the study conducted by arifuzzaman et al.19, a type v (gastrosplenic trunk) was the most common variant of the coeliac trunk followed by a type iii (hepatogastric trunk) in the study population at the dow institute of radiology in pakistan whilst torres et al.20 established that a type v (gastrosplenic trunk) was the most common variant of the coeliac trunk in the study population at a lublin hospital in poland. lastly, urgurel et al10. also established a type v (gastrosplenic trunk), was the most common variant of the coeliac trunk followed by a type ii (hepatosplenic trunk) in the study population in ankara hospital, turkey. overall, the left renal artery showed a higher percentage of variant anatomy compared to the right renal artery in the current study. the most common variation of both the left and the right renal arteries was a type 1c (2 hilar arteries). furthermore, this variant was seen more commonly in the left renal artery (9.1%) compared to the right renal artery (3.4%). this is in contrast to the study by urgurel et al.10, which showed that variant anatomy of the right renal artery was more prevalent than the left renal artery in the study population in ankara hospital, turkey. variations of both renal arteries were present in 2.4% of the study population. the above illustrates that the most common variations of the coeliac trunk in this study was comparable to the findings of other studies conducted. the presence of variant anatomy in the renal arteries was more prevalent on the left compared to the right. concurrent variations of the coeliac trunk and the renal arteries were observed in 5% of the study population. these results show that multiple vascular variations may co-exist, confirming previous findings that when a vascular variation is found in one organ system, vascular variations in other organ systems should be sought. although the presence of multiple variations in this study population was only 5%, it is important as the presence of multiple vascular variations may influence the surgical approach or surgical outcome in patients. conclusion knowledge of anatomical variations of the coeliac trunk and renal arteries is of significant importance in the surgical approach and influences the subsequent surgical outcome in patients. it is therefore vital for radiologists to recognise, classify and report these anatomical variations. the most common coeliac trunk variations encountered in this study were comparable to other non-african populations. this illustrates that the most common variations of the coeliac trunk appear to be independent of factors such as race and ethnicity. renal artery variations were more prevalent on the left than the right. furthermore, concurrent variations of the coeliac trunk and the renal arteries were observed in 5% of the study population. the presence of concurrent variations should be sought as the presence of multiple vascular variations may significantly influence the surgical approach chosen and aid in a reduction of surgical complications in patients. acknowledgements the authors thank dr waheed mahomed, who provided insight and assisted in editing of the manuscript; dr wim greeff, who assisted as a reader with my data collection, and prof. herman schoeman, who assisted with statistical analysis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.o. was the guarantor of the integrity of the entire study. r.o. and a.d.d. contributed to the collection of data. r.o. analysed the data and compiled the results. r.o. prepared the manuscript and a.d.d. contributed towards manuscript editing. m.k. provided insight throughout the project and contributed towards manuscript editing. funding information this study received no funding from any public, private or commercial sector. data availability statement all data were obtained from the picture archiving and communication system (pacs) at dr george mukhari academic hospital and is available upon request from the first author. disclaimer the views expressed in this article are those of the authors and do not necessarily reflect those of any affiliated agencies of the authors. references williams pl, bannister lh, berry mm, et al. the anatomical basis of medicine and surgery. gray’s anatomy. 38th ed. london: churchill livingston, 1995; p. 619–622. vandamme jpj, bonte j. the branches of the celiac trunk. cells tissues organs. 1985;122(2):110–114. https://doi.org/10.1159/000145991 sangster g, ramirez s, previgliano c, al aa, hamidian aj, simoncini a. celiacomesenteric trunk: a rare anatomical variation with potential clinical and surgical implications. j la state med soc. 2014;166(2):53–55. osman am, abdrabou a. celiac trunk and hepatic artery variants: a retrospective preliminary msct report among egyptian patients. egypt j radiol nucl med. 2016;47(4):1451–1458. https://doi.org/10.1016/j.ejrnm.2016.09.011 song s-y, chung jw, yin, yh, et al. celiac axis and common hepatic artery variations in 5002 patients: systematic analysis with spiral ct and dsa. radiology. 2010;255(1):278–288. https://doi.org/10.1148/radiol.09090389 prakash, rajini t, mokhasi v, geethanjali bs, sivacharan pv, shashirekha m. coeliac trunk and its branches: anatomical variations and clinical implications. singapore med j. 2012;53(5):329–331. chitra r. clinically relevant variations of the coeliac trunk. singapore med j. 2010;51(3):216–219. koops a, wojciechowski b, broering dc, adam g, krupski-berdien g. anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. surg radiol anat. 2004;26(3):239–244. https://doi.org/10.1007/s00276-004-0229-z waldenberger p, bendix n, petersen j, tauscher t, glodny b. clinical outcome of endovascular therapeutic occlusion of the celiac artery. j vasc surg. 2007;46(4):655–661. https://doi.org/10.1016/j.jvs.2007.05.033 ugurel ms, battal b, bozlar u, et al. anatomical variations of hepatic arterial system, coeliac trunk and renal arteries: an analysis with multidetector ct angiography. br j radiol. 2010;83(992):661–667. https://doi.org/10.1259/bjr/21236482 beregi jp, mauroy b, willoteaux s, mounier-vehier c, rémy-jardin m, francke jp. anatomic variation in the origin of the main renal arteries: spiral cta evaluation. eur radiol. 1999;9(7):1330–1334. https://doi.org/10.1007/s003300050843 urban ba, ratner le, fishman ek. three-dimensional volume-rendered ct angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications. radiographics. 2001;21:373–386. https://doi.org/10.1148/radiographics.21.2.g01mr19373 sampaio fjb, passos marf. renal arteries: anatomic study for surgical and radiological practice. surg radiol anat. 1992;14(2):113–117. https://doi.org/10.1007/bf01794885 türkvatan a, özdemir m, cumhur t, ölçer t. multidetector ct angiography of renal vasculature: normal anatomy and variants. eur radiol. 2009;19(1):236–244. https://doi.org/10.1007/s00330-008-1126-3 sahani d, saini s, pena c, et al. using multidetector ct for preoperative vascular evaluation of liver neoplasms: technique and results. am j roentgenol. 2002;179(1):53–59. https://doi.org/10.2214/ajr.179.1.1790053 rawat k. ct angiography in evaluation of vascular anatomy and prevalence of vascular variants in upper abdomen in cancer patients. indian j radiol imaging. 2006;16(4):457–461. https://doi.org/10.4103/0971-3026.32246 babu d, khrab p. coeliac trunk variations: review with proposed new classification. int j anat res. 2013;1(3):165–170. iezzi r, cotroneo ar, giancristofaro d, santoro m, storto ml. multidetector-row ct angiographic imaging of the celiac trunk: anatomy and normal variants. surg radiol anat. 2008;30(4):303–310. https://doi.org/10.1007/s00276-008-0324-7 arifuzzaman m, sawaira s, naqvi n, et al. anatomical variants of celiac trunk, hepatic and renal arteries in a population of developing country using multidetector computed tomography angiography. j ayub med coll abbottabad. 2017;29(3):450–454. torres k, stákiewicz g, denisow m, et al. anatomical variations of the coeliac trunk in the homogeneous polish population. folia morphol. 2015;74(1):93–99. https://doi.org/10.5603/fm.2014.0059 52 sa journal of radiology • june 2011 cme the rssa and cme with the establishment of an international advisory board consisting of joshua farber, jonathan kruskal, walter kucharczyk and pia sundgren (see the radioactive news section) who have undertaken to provide objective and constructive criticism of the sajr, and more specifically concerning its content in relation to international work, the journal continues on the growth path that was largely catalysed by the co-operative initiative between the radiological society of south africa (rssa) and philips sa. to place these developments in perspective, it is necessary to understand the scope of our professional society’s commitment to continuing medical education (cme) in this country. historically, the rssa congress portfolio was established to provide congresses, courses and workshops for the pupose of cme. the rssa cme association (not for gain) was officially constituted on 31 december 2010 as a separate entity. it is now the custodian of the cme programme and congress portfolio of the rssa. founder members are professors leon janse van rensburg (chair) and zarina lockhat, and drs tami mngoma and johan basson. the broader vision is that the rssa cme association will support and provide a sustainable, affordable, appropriate, visionary and constantly expanding programme of education, teaching and training. this is evisaged as going hand-in-hand with support for academic research and making resources available to academic institutions. at the heart of the philosophy is a need for establishing long-term relationships and partnerships with prestigious and leading international radiological/imaging societies, universities and individuals. the support of commercial vendors and companies involved in radiology and imaging has provided the solid foundation for this far-reaching and ambitious programme. in this edition of the sajr is a report on the rssa cme association’s book donation to academic departments to the value of r270 000 (with grateful acknowledgement of a substantial discount by pb mayer of bloemfontein). other recent and future initiatives and associations include: • the rssa travel award of r40 000 • the breast mri course (ismrm) • the physiological processes workshop (ismrm, nrf, bmbf and freiburg university) • the third rssa ethics course (covidien) • august 2011 – the mdct/cta course (professor elliot fishman (john hopkins university school of medicine)) • february 2012 – the hrct lung hands-on workshops (university of leuven, belgium) • september 2012 – the head and neck cancer hands-on workshop (university of leuven) • early 2013 – the second cancer imaging course (rssa/international cancer imaging society (icis)) the sajr is proud to share in such a prestigious programme. jan lotz editor-in-chief sajr 684 bamboo spine – x-ray findings of ankylosing spondylitis revisited antoinette reinders, mb chb matthys j van wyk, mb chb, fcrad diag (sa) department of diagnostic and interventional radiology, university of the free state, bloemfontein   corresponding author: a reinders (antoinette.reinders@gmail .com) ankylosing spondylitis is a debilitating disease that is one of the sero-negative spondylarthropathies, affecting more males than females in the proportion of about 6:1 in the age group 15 35 years of age. early radiographic findings include bilateral sacro-iliitis and early axial (lower lumbar spine) ankylosis. typical x-ray findings are florid spondylitis (romanus lesions), florid diskitis (andersson lesions), early axial ankylosis, enthesitis, syndesmophytes and insufficiency fractures. typical radiological abnormalities are pointed out on conventional x-rays and reviewed for early diagnosis and prompt treatment of patients at risk. s afr j rad 2012;16(3):111-113. doi:10.7196/sajr.684 ankylosing spondylitis (as) is one of the sero-negative spondylo-arthropathies.1 this group of arthritides is characterised by specific skeletal imaging findings and, biochemically, by the absence of rheumatoid factor or nodules, and the presence of the hla-b27 gene. these spondylo-arthropathies can be divided into 5 major groups: (i) ankylosing spondylitis, (ii) reactive arthritis/reiter’s syndrome, (iii) arthritis associated with inflammatory bowel disease, (iv) psoriatic arthritis and (v) undifferentiated spondylo-arthropathy.1 as is a debilitating disease, affecting mostly white men, with a male:female ratio of about 6:1 within the age group 15 35 years of age. early lumbar axial ankylosis and spinal involvement is more marked in male patients than female, with early radiographic signs of hip involvement.2-4 classic joint involvement includes: bilateral sacro-iliac, thoraco-lumbar and lumbo-sacral joints (early) and cervical spine (late).5 the peripheral skeleton is involved in 10 20% of cases, with apical fibrosis of the lung parenchyma reported in only 1% of as patients.6 additional cardiac manifestations, such as aortic valve and root abnormalities, and with conduction and rhythm abnormalities, have also been reported in 2 10% of patients.6 genetic susceptibility has been mentioned as a causative factor, with 96% of patients testing positive for the hla-b27 gene.1 associated diseases include: ulcerative colitis, iritis and aortic insufficiency. prognosis depends on age at first presentation, as well as the radiological grade, as defined by either the bath ankylosing spondylitis radiology index (basri) – for cervical and lumbar spine and hips – or the modified new york criteria for the extent of sacro-iliitis, with lumbar and bilateral sacro-iliac joint involvement being marked in the early years of the disease.6 pathology and imaging characteristics in this pictorial essay, we focus on the characteristic axial skeleton imaging findings of as, as it presents on conventional x-ray:1 • florid anterior spondylitis (romanus lesions) • florid diskitis (andersson lesions) • insufficiency fractures of the ankylosed spine • syndesmophytes • enthesitis of the interspinal ligaments • ankylosis. romanus lesions (florid anterior spondylitis) it is best to describe these lesions in terms of a disco-vertebral unit (dvu). this ‘unit’ comprises the superior half of the inferior vertebrae, plus the intervertebral disc, plus the inferior half of the superior vertebrae.1 typical romanus lesions are situated at the attachment of the annulus fibrosis to the vertebral endplate, and can be in the anterior, posterior or marginal regions of the dvu. irregularities and erosions of the vertebral endplates are characteristic of acute inflammation. post-inflammatory changes are known as ‘shiny corners’, which appear as sclerotic lesions in the same anatomical location on the vertebral endplate.1 when these lesions are present, ‘squaring’ of the vertebrae can be appreciated, with progressive loss of the lumbar lordosis (fig. 1). fig 1. lateral lumbar spine view. note the ‘squaring’ of the lumbar vertebrae (open arrowhead), together with the central radio-dense region in the vertebral endplate of the 5th lumbar vertebra, superiorly (white arrowhead). this is known as an andersson lesion. andersson lesions (florid diskitis) these appear as irregularities and erosions of the vertebral endplates (fig. 1), not related to the anterior or posterior edge but rather to the central portions of the intervertebral discs. these are better visualised by mr images of the spine, but can be seen on conventional x-ray and are indicative of active inflammation.1 insufficiency fractures these can be referred to as ‘non inflammatory andersson lesions’ and are a not uncommon complication of advanced disease.1 they can be classified into 2 basic categories: (i) spontaneous or (ii) following minimal trauma.7 the fractures are typically 3-column, involving either the disc space or juxta-articular endplate. the second category typically occur near the cervico-thoracic or thoraco-lumbar junctions. delay in treatment can cause pseudoarthrosis, which can be seen on conventional x-rays as subchondral sclerosis and vertebral endplate erosions.7 syndesmosphytes these are paravertebral ossifications that resemble an osteophyte, but run in the vertical rather than the horizontal plane (fig. 2).8 they are not due to calcification of the anterior longitudinal ligament but rather ossification of the anterior portion of the annulus fibrosis of the intervertebral disc. the lesions are preceded by a romanus lesion, and are symmetrical and marginal. about 15% of affected patients show evidence of syndesmophytes.1 fig. 2. lateral cervical spine x-ray. the white arrowhead indicates syndesmophytes, representing calcification of the anterior portion of the annulus fibrosis. calcification of the interspinous ligaments can also be seen (open arrowhead). enthesitis (trolley track and dagger signs) 9 ossification of the supraspinous and interspinous ligaments produces a characteristic single or double radio-dense sign on the ap view of the spine (fig. 3). the trolley track sign derives from the 2 lateral lines of ossification representing the apophyseal joint capsules, and the dagger sign from the central line of ossification visible on the ap view. enthesitis precedes ossification of the ligaments.9 fig. 3. antero-posterior view of the thoracic and lumbar spine. note the calcification of the interspinous ligaments secondary to enthesitis, with the classic dagger sign (white arrowheads) stretching into the pelvis. the trolley track sign can also be seen in the lower lumbar spine and thoracic spine (open arrowheads), lateral to the calcified interspinous ligaments, representing the calcified apophyseal joint capsules. ankylosis ankylosis of several of the joints causes structural abnormalities of the axial skeleton. marked ankylosis is seen at the sacro-iliac joints (fig. 4) and facet joints of the thoracic spine, and costovertebral and costotransverse joints1 that causes an exaggerated kyphosis with decreased chest expansion during inhalation and increased susceptibility to respiratory tract infections. fig. 4. antero-posterior view of the pelvis. the open arrowheads indicate marked ankylosis of the hips and sacro-iliac joints. conclusion as is a debilitating disease with very specific radiological abnormalities that can, if detected early, be successfully managed by medical and physical therapy. it remains the role of the radiologist to keep a look-out for early radiological abnormalities in susceptible patients.   1. hermann kga, althoff ce, schneider u, et al. spinal changes in patients with spondylarthritis: comparison of mr imaging and radiographic appearances. radiographics 2005;25:559-570. 1. hermann kga, althoff ce, schneider u, et al. spinal changes in patients with spondylarthritis: comparison of mr imaging and radiographic appearances. radiographics 2005;25:559-570. 2. boonen a, van der cruyssen b, de vlam k, et al. spinal radiographic changes in ankylosing spondylitis: association with clinical characteristics and functional outcome. j rheumatol 2009;36(6):1249-1255. 2. boonen a, van der cruyssen b, de vlam k, et al. spinal radiographic changes in ankylosing spondylitis: association with clinical characteristics and functional outcome. j rheumatol 2009;36(6):1249-1255. 3. atagunduz p, aydin sz, bahadir c, et al. determinants of early radiographic progression in ankylosing spondylitis. j rheumatol 2010;37(11):2356-2361. 3. atagunduz p, aydin sz, bahadir c, et al. determinants of early radiographic progression in ankylosing spondylitis. j rheumatol 2010;37(11):2356-2361. 4. cansu du, calisir c, savas yavas u, et al. predictors of radiographic severity and functional disability in turkish patients with ankylosing spondylitis. clin rheumatol 2011;30(4):557-562. 4. cansu du, calisir c, savas yavas u, et al. predictors of radiographic severity and functional disability in turkish patients with ankylosing spondylitis. clin rheumatol 2011;30(4):557-562. 5. jang hj, ward mm, rucker an, et al. ankylosing spondylitis: patterns of radiographic involvement – a re-examination of accepted principles in a cohort of 769 patients. radiology 2011;258(1):192-198. 5. jang hj, ward mm, rucker an, et al. ankylosing spondylitis: patterns of radiographic involvement – a re-examination of accepted principles in a cohort of 769 patients. radiology 2011;258(1):192-198. 6. momeni m, taylor n, tehrani m, et al. cardiopulmonary manifestations of ankylosing spondylitis. int j rheumatol 2011;1:1-6. 6. momeni m, taylor n, tehrani m, et al. cardiopulmonary manifestations of ankylosing spondylitis. int j rheumatol 2011;1:1-6. 7. hong sh, ja-young c, joon woo l, et al. mr imaging assessment of the spine: infection or an imitation? radiographics 2009;29:599-612. 7. hong sh, ja-young c, joon woo l, et al. mr imaging assessment of the spine: infection or an imitation? radiographics 2009;29:599-612. 8. helms ca. arthritis. in: brant we, helms ca, eds. fundamentals of diagnostic radiology. 3rd ed. philadelphia: lippincott williams & wilkins, 2007:1136-1140. 8. helms ca. arthritis. in: brant we, helms ca, eds. fundamentals of diagnostic radiology. 3rd ed. philadelphia: lippincott williams & wilkins, 2007:1136-1140. 9. olivieri i, ciancio g, scarano e, et al. the extension of the ankylosing spondylitis “dagger sign” into the sacrum. j rheumatol 2000;27(12):2944-2945. 9. olivieri i, ciancio g, scarano e, et al. the extension of the ankylosing spondylitis “dagger sign” into the sacrum. j rheumatol 2000;27(12):2944-2945. http://www.sajr.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the sa journal of radiology, we ask that you take a moment to update your electronic portfolio on https:// sajr.org.za for our files, allowing us better access to your areas of 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of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank and recognise the following reviewers for their precious time and dedication, regardless of whether the papers they reviewed were finally published. we apologise for any names that have been inadvertently left out. these individuals provided their services to the journal as a reviewer from 01 october 2021 to 30 september 2022. aadil a. ahmed ahmed o.a. krim ajit k. reddy akhilanand chaurasia andre rose anil bhaya ankita aggarwal aravintho natarajan arshed h. parry aruna r. patil bukunmi m. idowu chris trauernicht cornelia r. minne dahiru m. yunsa diteboho khalema ekta dhamija f.a. gebremariam farhana e. suleman gaurav sundar hafsa essop halvani moodley hamid osman heena rajani ilana m. viljoen jagidesa moodley jayaranjeetham jayabalan jenny edge john r. ouma kalluraya suprasanna khairil a. sayuti leisha rajkumar linda t. hlabangana mariam q. said-hartley mariska botha mohd z. roslly monica van wijk mridula m. muthe narendra k. bodhey nausheen khan nicolò brandi nompumelelo e. mlambo nondumiso n. dlamini osman öcal pavel burko pieter janse van rensburg pranav ajmera radhika batra rajiv kapur ranjan k. patel ranjit singh rishi p. mathew robyn m. wessels sally e. candy salman s. ahmed salome n. ezeofor samanta dhulipala sanjay m. khaladkar saurabh maheshwari shalendra k. misser sheree c. gray shirley lipschitz shivesh maharaj siddhi chawla siphumule b. thwala sithembiso m. langa siviwe s. mpateni sonay aydin stanley makgere susan w. karanja tamarin c. nell thokozani sibanda tiaan p. steyn tracy l. westgarth-taylor varsha p. rangankar werner s. harmse william i.d. rae yusuf parak zakariya vawda zarina i. lockhat http://www.sajr.org.za� https://sajr.org.za https://sajr.org.za mailto:submissions@sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za/index.php/sajr/user https://sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za acknowledgement to reviewers cpd questionnaire 84 sa journal of radiology • june 2012 1. identify one false statement. a. brown-sequard syndrome, first reported in 1849, is characterised by hemisection of the cord. b. brown-sequard syndrome is characterised by disruption of the descending lateral corticospinal tracts resulting in ipsilateral hemiplegia. c. brown-sequard syndrome is characterised by damage of the ascending lateral spinothalamic tracts (which cross within one or two levels of the dorsal root entrance) resulting in contralateral loss of pain and temperature. d. damage to the dorsal columns results in contralateral loss of proprioception and fine touch below the level of the lesion. 2. which of the following statements is false? a. image post-processing gives computed radiography (cr) a considerable advantage over film-screen systems. b. musica has slightly improved image quality over musica2. c. image quality is usually evaluated on the basis of three measures of imaging performance, namely: spatial resolution, contrast and noise. d. making accurate and efficient diagnoses from radiological images requires good image contrast and sufficient spatial resolution at acceptable noise levels. 3. which of the following statements is false? a. the role of mri in screening for breast cancer and its use after the diagnosis of breast cancer is an enormous topic, with over 5 000 papers published in the last 10 years. b. findings have consistently shown that high-risk young women (whose disease tends to be missed with mammography) do not benefit from the addition of an mri. c. within the context of high-risk breast screening, mri should be used as an adjunct to, and not as a replacement for, mammography. d. the low ppv of mri (20 40%), leads to a high rate of biopsies and further investigations – acceptable in women with a high risk of breast cancer, but potentially harmful to women in lower-risk categories. 4. which of the following statements is false? a. the hazardous substances act has been undermined by poor administration and uncertainty about regulations and licensing conditions. b. effective and legal radiation control is possible by activating the national advisory committee on electronic products. c. the training and accreditation of the technicians, responsible for a single quality assurance test per year, should be emphasised. d. constructive engagement with the professional bodies involved in the medical use of x-rays through a national advisory committee on electronic products may be a cost-effective solution for lowering radiation dosage to the population. 5. which of the following is true? a. the comparative effectiveness of mri in breast cancer (comice) trial was a multicentre trial based in sweden. b. twenty-five breast centres took part in a prospective randomised study. c. over 1 600 women who had been diagnosed with breast cancer and selected for breast conservation therapy (bct) were enrolled. d. they were randomised into 2 groups: half received an mri preoperatively, and half received breast elastography. 6. identify the false statement among the following statements: a. cubital tunnel syndrome is the second most common peripheral neuropathy of the upper limb. b. cubital tunnel syndrome occurs as a result of compression of the ulnar nerve between the medial epicondyle, the olecranon and the roof of the tunnel that is formed by the retinaculum which is also known as osborne’s band or the arcuate ligament. c. physiological compression occurs during elbow flexion. d. most commonly compression has been attributed to the presence of an accessory muscle – the anconeus epitrochlearis. 7. the following are true, except: a. retrograde jejunogastric intussusception is a well-recognised, rare, but potentially fatal long-term complication of gastrojejunostomy or billroth ii reconstruction. b. diagnosis of this condition is difficult in most cases. c. early diagnosis and prompt surgical intervention is not critical as most cases reduce spontaneously over 12 hours. d. since gastrojejunostomies with vagotomy are on a declining trend, it is extremely rare to come across such a complication. 8. identify the false statement among the following. a. protocols for chest ct surveys for mediastinal pathology, lung masses and ‘rule out pathology’ chest scans traditionally dictate a post-contrast scan beginning 60 s after initiating an intravenous contrast injection. b. in numerous practices, 100 120 cc of contrast is traditionally used. this process usually results in adequate contrast throughout the vascular structures in the mediastinum and lungs and enhancement of pathologic masses or lymph nodes. c. when there are clinical indications of vascular pathology (i.e. aortic or pulmonary arteries and their respective branch vessels), it is imperative to add a dedicated arterial phase scan before the 60 s scan series. d. even if there are no clinical indications to include an arterial study, an arterial phase should always be performed 9. identify the true statement. a. patients with dislocation of the ulnar nerve never present clinically with a snapping sensation at the elbow upon flexion. b. dislocation of the ulnar nerve with snapping triceps syndrome has been implicated as a cause of cubital tunnel syndrome. c. dislocation of the ulnar nerve can only be demonstrated by mri. d. once diagnosed, conservative management is the only option. 10. identify one true statement. a. the stormers rugby team now play in shocking pink outfits. b. the rssa will scale down its contribution to cme in radiology over the next two years. c. the cpd quiz in sajr is the least read section of the journal. d. razaan davis is the newly appointed deputy editor of the south african journal of radiology. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/027/10/2011 give one correct answer for each question. ir e l a n d /d a v e n p o r t 6 9 8 7 8 private banking cash investments | foreign exchange | personal finance | transactional banking partnering with medical professionals, we offer complete personal and business banking that is structured to meet your specific needs. this, combined with a team of dedicated private bankers and a 24-hour client support centre ensures our expertise is only matched by our extraordinary service. for more information call 0860 222 377, email bank@investec.co.za or visit www.investec.co.za investec private bank, a division of investec bank limited. registration number 1969/004763/06. investec bank limited is committed to the code of banking practice as regulated by the ombudsman for banking services. a registered credit provider registration number ncrcp9. terms and conditions apply. cape town 021 416 1000 durban 031 575 4000 johannesburg 011 286 7000 pretoria 012 427 8300 from one specialist to another s p e c i a l i s t b a n k 69878 sa journal of radiology a4.indd 1 2012/05/09 10:59 am abstract introduction case report discussion conclusion acknowledgements references about the author(s) sanjay m. khaladkar department of radiodiagnosis, dr. dy patil medical college, hospital and research centre, pune, india darshana dilip department of radiodiagnosis, dr. dy patil medical college, hospital and research centre, pune, india rahul arkar department of radiodiagnosis, dr. dy patil medical college, hospital and research centre, pune, india vijetha chanabasanavar department of radiodiagnosis, dr. dy patil medical college, hospital and research centre, pune, india purnachandra lamghare department of radiodiagnosis, dr. dy patil medical college, hospital and research centre, pune, india citation khaladkar sm, dilip d, arkar r, chanabasanavar v, lamghare p. a case of carotid web: cause of stroke in healthy and young patients. s afr j rad. 2022;26(1), a2291. https://doi.org/10.4102/sajr.v26i1.2291 case report a case of carotid web: cause of stroke in healthy and young patients sanjay m. khaladkar, darshana dilip, rahul arkar, vijetha chanabasanavar, purnachandra lamghare received: 01 sept. 2021; accepted: 01 oct. 2021; published: 28 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract carotid webs are important, often undiagnosed causes of cryptogenic and recurrent strokes. ct angiography and digital subtraction angiography adequately demonstrate webs as linear filling defects in the carotid bulb. however, findings are overlooked unless viewed in optimal planes and easily misdiagnosed as dissection flaps or atheromatous plaques, altering management and outcome. a case of unilateral carotid web is presented, detected during imaging in a young lady presenting with hemiparesis without other risk factors for stroke. keywords: carotid web; atypical fibromuscular dysplasia; cerebral angiography; recurrent cerebrovascular accident; unilateral or bilateral; embolic stroke; non-atheromatous; carotid stenosis. introduction carotid web is a term used by radiologists for describing a membranous filling defect in the carotid bulb, seen in its posterior wall. it was first used in 1973 to describe a poorly understood entity causing non-atheromatous internal carotid artery (ica) stenosis. since then, they have been variably referred to as carotid bulb shelf, diaphragm, septum, pseudo-valvular folds and atypical fibro-muscular dysplasia (fmd)/hyperplasia.1 regardless of the nomenclature, they have been found to be an important causative factor in cryptogenic and recurrent strokes, especially in young and otherwise healthy patients. case report a 44-year-old women presented to our centre, 8 h after acute onset of left upper and lower limb weakness, associated with ipsilateral facial weakness. she had no other neurological complaints, fever, trauma, vomiting or headache. there was no previous history of transient ischaemic attacks (tias), angina, hypertension, dyslipidaemia, diabetes or surgeries. the patient was a teetotaller and non-smoker. examination revealed an average build woman with a body mass index of 20.5 kg/m2; normal vital parameters; grade 2 power in the left upper and lower limbs with hyperreflexia, an extensor plantar reflex on the left side and deviation of the angle of mouth to the left. clinically, these features indicated an acute stroke, likely related to a right middle cerebral artery (mca) territory infarct. initial non-contrast computed tomography (ncct) of the brain demonstrated an acute non-haemorrhagic infarct in the right parieto-temporal region, with regional loss of grey-white matter differentiation and effacement of the sulci (figure 1a). figure 1: (a) ncct brain illustrating an ill-defined hypodense infarcted area in the right fronto-parieto-temporal region, with loss of the insular ribbon and effacement of the adjacent sulci and right sylvian cistern. (b) mri brain revealed a flair hyperintense acute non-haemorrhagic infarct in the right mca territory. dwi (c) and adc (d) shows diffusion restriction with corresponding low adc values. magnetic resonance imaging (mri) of the brain revealed fluid attenuated inversion recovery (flair) hyperintense signal and restricted diffusion in the right mca territory, confirming the initial diagnosis (figure 1b, c, d). in addition, at mra, the right mca was not visualised along its entire length, indicating likely thrombosis (figure 2a, b). furthermore, a suspicious curvilinear filling defect was detected along the posterior wall of right ica, distal to the carotid bifurcation, in a single transverse section (figure 2c). figure 2: magnetic resonance angiography tof axial (a) and reformatted axial (b) demonstrating absent flow in all segments of the right mca (star). axial plane mra of the neck vessels (c) revealed a curvilinear intra-luminal filling defect along the posterior wall of the right ica at its origin (arrow) – suspicious of possible dissection or focal atherosclerotic plaque/thrombus. mip coronal (d) exhibits subtle narrowing at the right carotid bifurcation.(arrow) computed tomography angiography (cta) was acquired to accurately characterise the filling defect observed in the right ica and it successfully depicted a partial circumferential shelf-like filling defect, measuring 2 mm × 8 mm, along the posterior wall of right ica at its origin – establishing the diagnosis of a carotid web (figure 3a and b). thrombosis of the right mca was confirmed. the left ica and the rest of the major head and neck vessels were normal. figure 3: axial (a) computed tomography angiography (cta) demonstrating a subtle linear flap (arrow) at the posterior wall of right ica origin. oblique (b) and sagittal (c) reformats of the cta indicating a distinct shelf-like 2 mm thickness filling defect, protruding into the right ica lumen from the posterior wall, at its origin, suggestive of a carotid web. doppler screening of the neck vessels revealed a focal intimal projection at the same site, not causing significant alteration to the flow of blood in the vessel (figure 4a and b). there was no evidence of a lodged thrombus at the carotid web. figure 4: (a) ultrasound of right carotid bulb in longitudinal section revealed a shelf-like intimal projection from the posterior wall (arrow); no calcification or thrombus seen. (b) patent flow on colour doppler. the patient was unwilling to undergo invasive imaging or definitive management by stenting or endarterectomy at our interventional radiology department. currently, she is being treated conservatively with dual oral antiplatelet therapy, anticoagulant injections and statins. discussion carotid webs are non-atheromatous bands of 1 mm – 2 mm thickness seen along the posterior wall of proximal ica. the reported incidence of carotid web is less than 1%, which is likely an underestimation, as the majority of diagnosed carotid webs have been in patients imaged for stroke. carotid bulb webs more commonly affect women.2 while the precise aetiology is uncertain, genetic and hormonal influence, oral contraceptive use, chronic intimal insult and abnormal trophoblastic activity are all likely factors in the development of carotid webs.3 histologically, they are formed by fibrosis, myxoid degeneration and smooth muscle hyperplasia of the tunica intima. hence, they have also been called atypical fmd, in contrast to typical fmd, which affects the tunica media of the renal, vertebral, mid to distal carotid arteries.1,4 stasis of blood downstream to the carotid web results in a thrombogenic niche, which leads to recurrent systemic embolism, presenting as tia or stroke, most commonly affecting the ipsilateral mca or anterior cerebral artery (aca) territories. causation is not identified in roughly a third of all cases of stroke, referred to as cryptogenic strokes. sajedi et al. reported that 21.2% cases of cryptogenic stroke had carotid webs, with a fairly uniform distribution of cases with unilateral and bilateral pathology in the study group. in addition, a lesser mean age for stroke was detected in patients with a carotid web (38.3 years) than among those without webs (48.7 years).4 hu et al. determined a strong association between carotid webs and tia in patients having no other vascular risk factors. they also reported a staggering 83.3% short-term recurrence rate of stroke/tia among patients having carotid webs versus patients without carotid webs (12.2%).5 thus, patients with carotid webs suffering cardiovascular accidents were younger, commonly female and less frequently had vascular risk factors such as hypertension, diabetes, dyslipidaemia or smoking.6 digital subtraction angiography (dsa) because of its higher spatial and temporal resolution, has till date been the accepted gold standard in diagnosing carotid webs. however, recent studies have proven equivalent performance by cta with multiplanar reformatting. this is over and above the general advantages of cta being cost-effective, easily available and non-invasive. magnetic resonance angiography, although superior in delineating vessel wall anatomy, has lower sensitivity and specificity compared with cta and dsa.3,4,6 at ultrasound, carotid webs appear as echogenic intimal projections from the posterior carotid bulb, which are less reliably distinguished from atherosclerotic plaques.6 however, the degree of stenosis is more accurately determined by ultrasonography and haemodynamic alterations are better assessed using doppler. carotid webs appear as triangular, linear or membranous filling defects protruding into the lumen from the posterior wall of the proximal ica or carotid bulb at cta, dsa and mra. contrast pooling maybe observed within the web at dsa. calcification or thickening should be absent within 3 mm of its location. associated thrombosis may be seen as a focal filling defect lodged downstream of the web. as a result of their film-like thinness (1 mm – 2 mm) and transverse placement, they are seen as a subtle septum on axial views. therefore, oblique sagittal views obtained by cta multiplanar reformats are the best tool for identification.1,2,3,4 carotid dissection, focal atherosclerotic plaques (fap) and typical fmd are the imaging mimics of carotid webs.2,3 focal atherosclerotic plaque appears as an irregular concentric calcification or hypoattenuating wall thickening, causing variable degrees of luminal stenosis and proportional velocity changes on doppler, findings, which are not seen with a carotid web.2 dissection flaps typically propagate distally from the carotid bulb, have irregular borders, may show intra-mural haematoma or vessel widening related to pseudoaneurysm formation and have the classic ‘double lumen’ appearance.3,4,7 typical fmd is usually multisegmental, giving the characteristic string of beads appearance to the vessel.1,2,3 opinions on optimal management of carotid webs vary because of lack of clear guidelines at present. prophylactic dual antiplatelet and anticoagulant therapies are being used in the setting of an acute stroke/tia and in some asymptomatic cases. nevertheless, they have been found to be ineffective in preventing recurrent cerebrovascular accidents in about 30% cases.3,7,8 hence, carotid stenting or endarterectomy have been favoured by physicians for treating carotid webs in symptomatic cases, with no consensus as to which is the optimal curative option.7,8 conclusion carotid webs are a cause of recurrent stroke, especially among young patients with no other vascular risk factors. a high clinical suspicion should be borne in mind during imaging cases of cryptogenic stroke. to aid in accurate diagnosis, multimodality imaging using cta or dsa should be performed for suspicious lesions that have been detected at ultrasound or mra. timely diagnosis can have long-reaching effects in disability prevention and survival among patients. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions s.m.k. diagnosed and helped d.d. in writing and drafting the article and finalising it. d.d. drafted and wrote the article. p.l., r.a. and v.c. critically revised the article with important conceptual and editorial input. ethical considerations this article followed all ethical standards for research. written informed consent was obtained from patient for publication along with relevant images. patient identity is not disclosed. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability any required information is available upon request from the corresponding author, d.d. disclaimer the views and opinions expressed in this article are those of the authors and not an official position of the institution. references kyaw k, latt h, aung ss, babu j, rangaswamy r. a rare case of carotid web presenting with ischemic stroke in a young woman and a brief review of the literature. case rep med. 2018 feb 19;2018:3195679. https://doi.org/10.1155/2018/3195679 wojcik k, milburn j, vidal g, steven a. carotid webs: radiographic appearance and significance. ochsner j. 2018 jun 20;18(2):115–120. https://doi.org/10.31486/toj.18.0001 gao m, lei j. image and clinical analysis of common carotid web: a case report. bmc med imaging. 2021 dec;21(1):1–4. https://doi.org/10.1186/s12880-020-00536-6 sajedi pi, gonzalez jn, cronin ca, et al. carotid bulb webs as a cause of ‘cryptogenic’ ischemic stroke. am j neuroradiol. 2017 jul 1;38(7):1399–1404. https://doi.org/10.3174/ajnr.a5208 hu h, zhang x, zhao j, li y, zhao y. transient ischemic attack and carotid web. am j neuroradiol. 2019 feb 1;40(2):313–318. https://doi.org/10.3174/ajnr.a5946 madaelil tp, grossberg ja, nogueira rg, et al. multimodality imaging in carotid web. front neurol. 2019 mar 12;10:220. https://doi.org/10.3389/fneur.2019.00220 kim sj, nogueira rg, haussen dc. current understanding and gaps in research of carotid webs in ischemic strokes: a review. jama neurol. 2019 mar 1;76(3):355–361. https://doi.org/10.1001/jamaneurol.2018.3366 wojcik k, milburn j, vidal g, tarsia j, steven a. survey of current management practices for carotid webs. ochsner j. 2019 dec 21;19(4):296–302. https://doi.org/10.31486/toj.18.0114 spontaneous.html spontaneous lateral sphenoid cerebrospinal fluid fistula: mri diagnosis matthew goodier, mb chb darlene lubbe, savvas andronikou, mb bch, fcrad, frcr (lond), phd rene truter, mb chb, mmed (radiol) department of radiology, university of the witwatersrand, johannesburg corresponding author: m goodier (goodiermatt@gmail.com) abstract spontaneous or primary cerebrospinal fluid (csf) fistula is a rare cause of csf rhinorrhoea. magnetic resonance imaging with high-resolution highly t2-weighted images is valuable in pre-operative localisation and characterisation of the defect, particularly if a transnasal endoscopic approach is planned. this report describes the radiological evaluation and surgical management of a 53-year-old man who presented with a spontaneous lateral sphenoid csf fistula. case report we present the case of a 53-year-old man who presented with a primary complaint of a lateral tongue tumour. during admission for surgery, a large lesion was noticed on his occiput. an mri revealed a large occipital meningioma for which he had a subtotal resection. postoperatively he presented with an unexplained spontaneous csf leak through the right sphenoid sinus. the patient never had documented raised pressures, and it was felt that the remaining tumour residue could not be responsible for causing raised intracranial pressure. the mri performed at the time demonstrated a herniation of meninges through a bony defect in the lateral wall of the right sphenoid sinus and subtle features of encephalomalacia of the adjacent temporal lobe (figs 1a c). an endoscopic transsphenoidal reduction of the meningocoele and obliteration of the right sphenoid sinus was performed. at surgery, a 1x1 cm dehiscent area in the right sphenoid sinus was present. there was some mucosal thickening with visible dura which was cauterised to identify the actual leak. the sinus was cleared of all mucosa and obliterated with fat. six weeks post-operatively, the patient was well, with no further csf leak. discussion the presence of csf rhinorrhoea indicates the existence of an abnormal communication between the intracranial csf spaces and the nasal cavity (or via the eustachian tube from a temporal bone fracture and csf-leak). post-traumatic csf rhinorrhoea as a complication of a base of skull fracture is the most common cause. non-traumatic causes of csf rhinorrhoea make up only 3 4% of cases1 and comprise several causes such as skull base tumours, destructive granulomatous processes such as wegener’s granulomatosis, and complicated sinonasal infections.1 spontaneous, or primary, csf fistula is a separate entity with no underlying cause of the csf leak. spontaneous leaks are more common in obese middle-aged women, and there is commonly a co-existing encephalocele of variable size.2 the pathogenesis of this condition is thought to be due to a combination of embryological and acquired factors. the medial aspect of the temporal bone may fail to develop, resulting in a persistent lateral craniopharyngeal canal (also known as the sternberg canal) between the middle cranial fossa and the pneumatised inferolateral recess of the sphenoid sinus.3 idiopathic intracranial hypertension (pseudotumour cerebri) and empty sella syndrome are also known to occur in these patients,2 suggesting that chronically increased intracranial pressure with localised thinning of the bone may also play a role in the pathogenesis of this condition.4 spontaneous csf fistulae are most common in the anterior cranial fossa, at the ethmoid roof and cribriform plate. less common sites include the sphenoid sinus, around the sella or at the inferolateral or pterygoid recesses.2 the goals of imaging in csf fistulae are to confirm the diagnosis, evaluate any underlying cause, localise the defect site and exclude an associated meningoencephalocoele at the defect.2 successful treatment depends on the accurate pre-operative localisation of the site of the fistula. this is especially true as most defects are now repaired by means of endoscopic surgery. an open approach via a craniotomy may be required in large defects or in well pneumatised sphenoid sinuses where the defect is located in the lateral recess of the sphenoid sinus. pure obliteration of the sphenoid sinus would rarely be successful in large defects, and a vascularised flap is often needed in these instances. the mucoperichondrial septal flap, pedicled on the posterior septal artery, is a useful flap when endoscopic repair is considered. high-resolution ct scanning alone has a low sensitivity for the detection of the osseous-dural defect. accuracy may be increased by introducing low-oslomar contrast materal into the subarachnoid space (ct cisternography), which improves the sensitivity for active leaks to 80 85%.3 inactive or intermittent fistulae may not be demonstrated, however. ct is best for bony anatomical detail and is useful in pre-operative planning. magnetic resonance imaging (mri) provides complementary information and appears to have a higher sensitivity than ct scanning, with accuracy rates for detection of the site of even inactive fistulae as high as 100%.5 high-resolution highly t2-weighted images such as are obtained by the constructive interference in the steady state (ciss) sequence are the most useful. mri is also able to depict the contents of any associated encephalocoele. subtle encephalomalacia as seen in our patient is often present at the site of the leak.2 mri was sufficient to allow accurate pre-operative assessment in our patient. surgery for spontaneous csf leaks has traditionally been performed transcranially. success rates of up to 80%2 have been reported; however, there is additional morbidity related to the craniotomy as well as the risk of anosmia owing to damage to the olfactory tracts. transnasal endoscopic surgical techniques are now increasingly performed, especially for small defects.6 in experienced hands, the reported success rates approach 90%, which is superior to open repair.2 some cases, however, are not amenable to endoscopic techniques; these include high-pressure leaks, patients with multiple defects, large defects or very well pneumatised sphenoid sinuses with lateral recesses.2 conclusion spontaneous or primary csf fistula is a rare cause of csf rhinorrhoea. various imaging modalities including ct, ct cisternography, mri and radio-isotope scanning may be used for preoperative evaluation. mri with high-resolution and highly t2-weighted images are most valuable in preoperative localisation and characterisation of the defect, especially if a transnasal endoscopic approach is planned. 1. pandey ak. case report: anteromedial temporosphenoidal encephalocele with a clinically silent lateral bony defect in the greater wing of the sphenoid. indian j radiol imaging 2009;19:311-313. 1. pandey ak. case report: anteromedial temporosphenoidal encephalocele with a clinically silent lateral bony defect in the greater wing of the sphenoid. indian j radiol imaging 2009;19:311-313. 2. lloyd km, delgaudio jm, hudgins pa. imaging of skull base cerebrospinal fluid leaks in adults. radiology 2008;248:725-736. 2. lloyd km, delgaudio jm, hudgins pa. imaging of skull base cerebrospinal fluid leaks in adults. radiology 2008;248:725-736. 3. wind jj, caputy aj, roberti f. spontaneous encephaloceles of the temporal lobe. neurosurg focus 2008;25:1-6. 3. wind jj, caputy aj, roberti f. spontaneous encephaloceles of the temporal lobe. neurosurg focus 2008;25:1-6. 4. schuknecht b, simmen d, briner hr, holzmann d. nontraumatic skull base defects with spontaneous csf rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. am j neuroradiol 2008;29:542-549. 4. schuknecht b, simmen d, briner hr, holzmann d. nontraumatic skull base defects with spontaneous csf rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. am j neuroradiol 2008;29:542-549. 5. johnson db, brennan p, toland j, o’dwyer aj. magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. clin radiol 1996;51:837-841. 5. johnson db, brennan p, toland j, o’dwyer aj. magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. clin radiol 1996;51:837-841. 6. arai a, mizukawa k, nishihara m, fujita a, hosoda k, kohmura e. spontaneous cerebrospinal fluid rhinorrhea associated with a far lateral temporal encephalocele – case report. neurol med chir (tokyo) 2010;50:243-245. 6. arai a, mizukawa k, nishihara m, fujita a, hosoda k, kohmura e. spontaneous cerebrospinal fluid rhinorrhea associated with a far lateral temporal encephalocele – case report. neurol med chir (tokyo) 2010;50:243-245. figs 1a 1c. mri scans of the brain and sphenoid sinus in a patient with lateral sphenoidal csf fistula. (1a) coronal (1b)sagittal and (1c) high-resolution axial t2-weighted images demonstrate a herniation of csf-filled meninges from the right middle temporal fossa into the right sphenoid sinus through a bony defect (arrow). there is subtle encephalomalacia of the right temporal pole. abstract introduction case presentations discussion conclusion acknowledgements references about the author(s) richard edwards department of diagnostic and interventional radiology, faculty of radiology, university of pretoria, pretoria, south africa nausheen khan department of diagnostic radiology and imaging, faculty of radiology, university of pretoria, pretoria, south africa citation edwards r, khan n. traumatic aortic injury: computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries. s afr j rad. 2021;25(1), a2044. https://doi.org/10.4102/sajr.v25i1.2044 case series traumatic aortic injury: computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries richard edwards, nausheen khan received: 05 nov. 2020; accepted: 15 dec. 2020; published: 12 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract blunt chest trauma related acute thoracic aortic injury (tai) is a life-threatening condition that requires prompt diagnosis and appropriate management because of high mortality. computed tomography angiography (cta) is the imaging of choice for evaluation of patients with major chest trauma findings suspicious of tai on chest radiography. this case series describes the cta findings in four high-velocity incident survivors with associated tais, discusses the injury type and treatment, and reviews the literature. keywords: tai; traumatic aortic injury; computed tomography angiography; major chest trauma; thoracic aortic injuries. introduction acute thoracic aortic injury (tai) is a sequela of blunt thoracic injury with a high mortality rate of 90% if left untreated.1 multi-detector computed tomography (mdct) with a sensitivity of 98% and a negative predictive value of 100% is the imaging modality of choice for evaluating tai. the site of attachment of the thoracic aorta determines the severity of rupture, with the isthmus being involved in 90% of cases because of its immobile position, fixed by the ligamentum arteriosum, a congenital remnant of the ductus arteriosum.2 ascending aortic lesions are rarely seen (5% – 8%), but may be complicated by involvement of the aortic valve resulting in haemopericardium. the descending thoracic aorta is only involved in 1% – 12% of cases.2 as mentioned earlier, most vascular injuries sustained to the thoracic aorta are fatal. this case series reveals the findings in four survivors of high-velocity incidents with associated tais, including a review of the type of injuries, computed tomography angiography (cta) findings and a review of the literature. case presentations four male patients, aged between 22 years and 45 years, presented to the emergency unit of our hospital, and were suspected of having acute aortic injury on the basis of a widened mediastinum on chest radiography. there was a history of two of them being involved in a motor vehicle accident (mva), one in a pedestrian vehicle accident (pva), whilst the fourth patient fell from the fourth floor. signs of mediastinal haemorrhage on chest radiography were observed in the first patient (figure 1a). computed tomography angiography was proposed by the emergency physician, and it clearly confirmed the site of traumatic aortic injury at the region of aortic isthmus, a grade 2 injury of the aorta with formation of a false aneurysm (figure 1b). the digital subtraction angiogram (dsa) confirmed the presence of a false aneurysm, which was treated surgically with endovascular aneurysm repair (evar) (figure 1c & 1d). the patient recovered completely, and a follow-up cta (figure 1e) after 6 months revealed no complications. figure 1: (a) chest radiography in a 36-year-old male patient involved in a motor vehicle accident. there is widening of the mediastinum (arrow) with a left apical pleural cap (star) and veiling of the left lung field in keeping with a left haemothorax. there is depression of the left main bronchus (triangle), and the silhouette of the aortic knuckle is maintained. (b) computed tomography angiography demonstrating a mediastinal haematoma (star) and a type 2 aortic injury with an intimal flap and a pseudoaneurysm (arrow). (c) digital subtraction angiogram image prior to stenting delineating the false aneurysm (arrows) beyond the origin of the left subclavian artery. (d) digital subtraction angiogram image post successful endovascular aneurysm repair with the stent in place (arrow). (e) follow-up computed tomography angiography indicates the stent in place with no complications (arrow). case 2 relates to a patient involved in a pva, with multiple other injuries, including intra-cranial haemorrhage and lower limb fractures. the initial chest radiograph revealed signs of aortic injury (figure 2a), which was confirmed by cta as a grade 2 injury at the aortic isthmus (figure 2b), followed by successful dsa and evar (figure 2c & 2d). the patient, however, later developed complications secondary to emboli from the evar site with peripheral thrombosis in the coeliac artery and its distribution and an infarction in the right kidney, from which he partially recovered (figure 2e & 2f). figure 2: (a) chest radiography in a 23-year-old male involved in a pedestrian vehicle accident indicates a widened mediastinum (arrow), loss of the aortic knuckle (star), retro-cardiac double density and a widened right paraspinal line (triangle). (b) coronal computed tomography angiography image with a type 2 aortic injury, complicated by thrombus formation (arrow). also note the large mediastinal haematoma (star). (c) sagittal digital subtraction angiogram after endovascular aneurysm repair with the stent in place (arrow). (d) follow-up computed tomography angiography post stenting. (e) sagittal computed tomography angiography abdomen demonstrating subtle thrombus within the coeliac artery (arrow). (f) segmental infarction revealed within the right kidney (arrow). the third patient presented with a type 2 aortic injury (figure 3 a-d), developed an endoleak after evar and had to be re-stented (figure 3e & 3f). figure 3: (a) chest radiography in a 22-year-old male involved in a motor vehicle accident as a front passenger with a widened right paraspinal line (arrow), widened mediastinum (star) and depression of the left main bronchus, all signs pointing towards a vascular injury. also note the tension pneumothorax on the left (circle) with contralateral mediastinal shift. (b) computed tomography angiography in the same patient indicating the aortic injury and false aneurysm (arrow) at the isthmus. (c) initial digital subtraction angiogram image pre-stenting revealing the pseudoaneurysm (arrow). (d) digital subtraction angiogram image with the stent in place (arrow). (e) follow-up computed tomography angiography demonstrating a leak around the stent (arrow). (f) a second endovascular stent was placed to treat the endoleak, sagittal oblique digital subtraction angiogram image with double stents (arrow). the fourth patient fell from the fourth floor and sustained multiple additional injuries. he was stented for a type 2 aortic injury (figure 4a & 4b), which was complicated by a leak, and he required stent repositioning and balloon angioplasty. complications were not observed at follow-up cta after the repositioninig, not included within this case series. figure 4: (a) a 45-year-old male jumped from the fourth floor and sustained multiple injuries. initial computed tomography angiography revealed a traumatic type 2 aortic injury with an intimal flap, thrombus and false aneurysm (arrow). (b) sagittal oblique digital subtraction angiogram image with the stent in place (arrow). no complications seen. this case series describes three different types of blunt chest trauma (mva, pva and a fall from height) complicated by type 2 traumatic aortic injury, an area amenable to surgical or endovascular treatment. because of the unstable condition of the patients and the complexities of additional injuries, evar was considered as a therapeutic option. although two of the cases in this case series developed endoleak complications and one further reported complications of local and distal thrombosis, all four patients recovered completely. discussion thoracic aortic injury secondary to blunt chest trauma is a life-threatening emergency with a very high morbidity and mortality rate, which requires urgent medical attention and management. in missed or untreated cases, the mortality has been estimated to be 80% – 90%.1 the thoracic aorta is anatomically divided into four segments (figure 5).2 the first two portions are intra-pericardial; hence, their involvement results in haemopericardium.2 figure 5: annotated diagram of different aortic segments. aortic root (0 in red), segment 1 in blue, segment 2 in green and segment 3 in orange. isthmus represents the area at the orange and green junction. there are several mechanisms that act either in isolation or in combination in tai, one of the main mechanisms being deceleration with displacement of the heart and displacement, torsion and shearing forces acting on the immobile aorta. other proposed methods include associated osseous pinch and hydrostatic forces, also known as the water-hammer phenomenon.2,3,4 rapid deceleration including the associated shearing forces exerted, particularly within the frontal and lateral direction, affects front seat passengers in high-velocity mvas, resulting in injury to the relatively immobile aortic isthmus (ligamentum arteriosum), aortic root and aorta at the region of the diaphragm, contributing to the majority of cases reported.3 ninety per cent of the aortic injuries have shown the involvement of the isthmus.1,2 crass et al.4 proposed the theory regarding the ‘osseous pinch’ based on the compression of the aorta between the spine and manubrium, first rib, and/or the medial aspects of the clavicles. the water-hammer effect is secondary to a sudden increase in intra-thoracic pressure that results in a sudden increase in intra-aortic pressure with subsequent rupture of the pericardium and cardiac tamponade.1,3 the survival of these patients mainly depends on the site of rupture; the extent of the rupture did not have any bearing on survival. a periaortic haematoma contained by other mediastinal structures and development of a false aneurysm may prolong survival from months to years. only 2% of the patients live to develop a chronic false aneurysm.1,5 initial imaging in these patients at our institution is a trauma series of radiographs, which includes a chest, abdominal and pelvic radiograph. chest radiographic signs of tai have low specificity and include the following: mediastinal widening > 8 cm, abnormal aortic contour, shift of the endotracheal tube and/or trachea to the right, depression of the left or right main stem bronchus, deviation of the nasogastric tube to the right, presence of an apical pleural cap, first rib fracture, acute left-sided haemothorax, retro-cardiac density, loss of the aorto-pulmonary window, widening of the right paraspinal interface, right paratracheal stripe (> 4 mm) and a pneumothorax.5,6 furthermore, if clinically indicated in a polytrauma patient, the emergency physician usually requests a non-enhanced cerebral and cervical computed tomography (ct) scan together with a thoraco-abdominal and pelvic ct scan in the arterial phase followed by an abdominal-pelvic ct scan in the portal phase after injection of 100 (ml) of iodinated contrast agent (omnipaque 300) at a rate of 4 ml/s – 5 ml/s. currently, scans at our institute are acquired with a 128-slice phillips ingenuity ct scanner and multiplanar reconstruction (mpr), maximum intensity projection (mip), curved mpr and volume rendering (vr) 3d reconstruction are also used to analyse the available imaging. the cta findings of acute tai have been categorised into direct and indirect or associated findings. direct findings include intramural haematoma formation, an intimal flap as well as pseudoaneurysmal formation. indirect or associated findings include periaortic haematoma formation, change in the normal aortic calibre and normal aortic contour.1,2,3,6,7,8 in the case of equivocal findings, it becomes a diagnostic challenge for the radiologist if the direct and indirect signs of tai are absent; in such cases, direct catheter angiography is warranted. periaortic haematoma in the absence of associated vascular injury may represent injury to the aortic adventitia.7 in 1958, parmley et al.1 pathologically classified traumatic aortic injuries into six groups: (1) intimal haemorrhage, (2) intimal haemorrhage with laceration, (3) medial laceration, (4) complete transection, (5) pseudoaneurysmal formation and (6) periaortic haemorrhage. heiberg et al.9 were the first to describe the appearance of traumatic aortic injury on ct in 1983. goarin et al.10 later classified traumatic aortic lesions into three groups (figure 6) based on the cta findings. figure 6: drawing of aortic injury grading findings at computed tomography angiography: (a) grade 1: isolated intramural haematoma, (b) grade 2: involvement of the intima and media, and (c) grade 3: involvement of intima, media and adventitia. grade 2 lesions, in which both the intima and media are involved, define injuries that include pseudoaneurysm formation and haemomediastinum. grade 3 lesions are fatal involving all three layers of the tunicae with rapid extravasation of blood.10 all of the patients in this case series sustained grade 2 injuries and survived. thoracic aortic injury is uncommon in the paediatric population and accounts for only 2% of paediatric deaths from trauma. this is because of the increased compliance of the chest wall in children, elasticity of the tissues, decreased body mass and lack of atherosclerotic disease.11 the pitfalls of cta in trauma patients include artefacts related to patient movement and breathing, cardiac motion and aortic pulsation, partial volume averaging and support devices. these may cause difficulty in the interpretation of findings in some cases.2,3,12 aortic pulsations may simulate a dissection, which can be avoided by performing a cardiac-gated study.2,3 the current problem with routine cardiac gating in cases of chest trauma is the presence of ‘band artefacts’ in patients with a heart rate of over 80 beats per minute, which distorts the findings on mpr and vr images. in the case of ascending aortic pulsatile artefact, a second gated scan after a routine trauma ct chest with 60 ml of intravenous contrast can be performed. axial scans are best to exclude ascending aortic injury.13 anatomical variants that a reporting radiologist should be aware of include a ‘ductal remnant’ located at the inferior surface of aorta near the isthmus, as well as the ‘infundibulum’, which is a cone-shaped lesion found at the origin of bronchial or intercostal arteries.2,3 treatment options include three categories, namely, open surgical repair, endovascular repair and medical management. although open repair of injuries to the aortic root, ascending aorta and aortic arch remains the procedure of choice in recent times, injuries to the aortic isthmus, descending and abdominal aorta have shown successful outcomes with evar.2,3,6 advantages of evar include a lower mortality rate, a lower risk of paraplegia and no need for invasive open thoracic surgery. however, disadvantages include regular imaging follow-up to asses for graft complications, which include graft migration, graft fracture, endoleak, graft infection and complications related to vascular access.2,3,6,14 the patients described in this case series underwent successful endovascular repair with an uneventful follow-up. medical management with frequent imaging follow-up is regarded as safe in cases with minimal aortic injuries, defined as intimal flaps measuring < 1 cm with no or minimal periaortic haematoma formation.15 chronic untreated false aneurysms eventually undergo extensive dense calcification. densely calcified, pain-free aneurysms detected years after the initial trauma have a stable course and may not require surgical intervention.16 conclusion thoracic aortic injury is a serious complication with devastating consequences in untreated patients. a high index of suspicion and careful evaluation are needed for accurate diagnosis of tai. computed tomography angiography is the gold standard for diagnosis and -post-treatment monitoring. ct with its high accuracy, negative predictive value, and multiplanar and volumetric abilities can clearly display the aortic and associated injuries and any anatomical variations that may simulate pathology. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution r.e. did the research of literature, collection of published articles; write up of the article, collection of patients and imaging, editing of images with drawing of illustrations from referenced articles. n.k. did the collection of published articles, collection of patients and imaging, editing of the written article, including selection of proposed images by r.e. ethical considerations ethical approval for this care series was obtained from the university of pretoria based on the anonymisation of patient information, ethics number 485/2020. funding information this research article received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability raw data were generated supporting the findings of this study are available from the corresponding author r.e. on reasonable request. disclaimer the views and opinions expressed in this research article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references parmley lf, mattingly tw, manion wc, jahnke jr ej. non penetrating traumatic injury of the aorta. circ. 1958;17(6):1086–1101. https://doi.org/10.1161/01.cir.17.6.1086 yahia aa, bouvier a, nedelcu c, et al. imaging of thoracic aortic injury. diagn interv imaging. 2015;96(1):79–88. https://doi.org/10.1016/j.diii.2014.02.003 cullen el, lantz ej, johnson cm, young pm. traumatic aortic injury: ct findings, mimcs, and therapeutic options. cardiovasc diagn ther. 2014;4(3):238–244. crass jr, cohen am, motta ao, tomashefshi jr jf, wiesen ej. a proposed new mechanism of traumatic aortic rupture. radiol. 1990;176(3):645–649. https://doi.org/10.1148/radiology.176.3.2389022 woodring jh, dillon ml. radiographic manifestations of mediastinal hemorrhage from blunt chest trauma. ann thorac surg. 1984;37(2):171–177. https://doi.org/10.1016/s0003-4975(10)60311-6 bansal v, lee j, coimbra r. current diagnosis and management of blunt traumatic rupture of the thoracic aorta. j vasc bras. 2007;6(1):64–73. https://doi.org/10.1590/s1677-54492007000100009 steenburg se, ravenel jg. acute traumatic thoracic aortic injuries: experience with 64-mdct. ajr. 2008;191(5):1564–1569. https://doi.org/10.2214/ajr.07.3349 fishman je, nunez jr d, kane a, rivas la, jacobs we. direct versus indirect signs of traumatic aortic injury revealed by helical ct: performance characteristics and interobserver agreement. ajr. 1999;172(4):1027–1031. https://doi.org/10.2214/ajr.172.4.10587141 heiberg e, wolverson wk, sundaram m, shields jb. ct in aortic trauma. ajr. 1983;140(6):1119–1124. https://doi.org/10.2214/ajr.140.6.1119 goarin jp, cluzel m, gosgnanch m, et al. evaluation of transesophageal echocardiology for diagnosis of traumatic aortic injury. anesthesiology. 2000;93(6):1373–1377. https://doi.org/10.1097/00000542-200012000-00005 pabon-ramos wm, williams dm, strouse pj. radiologic evaluation of blunt thoracic aortic injury in pediatric patients. ajr. 2010;194(5):1197–1203. https://doi.org/10.2214/ajr.09.2544 creasy jd, chiles c, routh wd, dyer rb. overview of traumatic injury of thoracic aorta. radiographics. 1997;17(1):27–45. https://doi.org/10.1148/radiographics.17.1.9017797 kaewlai k, avery ll, asrani av, novelline ra. multidetector ct of blunt thoracic trauma. radiographics. 2008;28(6):1555–1570. https://doi.org/10.1148/rg.286085510 lee wa, matsummura js, mitchel rs, et al. endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of society of vascular surgery. j vasc surg. 2011;53(1):187–192. https://doi.org/10.1016/j.jvs.2010.08.027 paul js, neideen t, tutton s, et al. minimal aortic injury after blunt trauma: selective nonoperative masnagement is safe. j trauma. 2011;71(6):1519–1523. https://doi.org/10.1097/ta.0b013e31823b9811 katsumata t, shinfeld a, westaby s. operation for chronic traumatic aortic aneurysm: when and how? ann thorac surg. 1998;66(3):774–778. https://doi.org/10.1016/s0003-4975(98)00519-0 sajr 846 nasolabial cysts − a rare case a f bezuidenhout,1 mb chb; n s stofberg,2 mb chb 1 department of diagnostic radiology, stellenbosch university, parow, cape town, south africa 2 department of otorhinolaryngology, stellenbosch university, parow, cape town, south africa corresponding author: a f bezuidenhout (fouriebez@yahoo.com) nasolabial cysts are benign, slow-growing cysts occurring in the nasolabial folds below the alae nasi. we report on a rare case of bilateral nasolabial cysts, of which only 30 cases have been described previously. s afr j rad 2013;17(3):113-114. doi:10.7196/sajr.846 nasolabial cysts are benign, slow-growing cysts occurring in the nasolabial folds below the alae nasi.1 these developmental cysts are nonodontogenic, extraosseous and locally expansile.2 after initial description by zukerkandl in 1882, approximately 300 cases have been reported in the english literature, with only an estimated 10% occurring bilaterally.3 the topographical term ‘naso-labial’ was initially coined by rao in 1955 and is the preferred term as the cyst does not originate from the alveolus.1 , 4 synonyms include klestadt’s cyst, nasal vestibule cyst, nasal wing cyst and nasoalveolar cyst. we report on a rare case of bilateral nasolabial cysts, of which only 30 cases have been described previously. case report a 48-year-old woman presented with a 3-year history of painless, bilateral, infranasal swellings that caused limited anterior nasal blocking. the right-sided mass had previously ruptured into the right nostril, draining a sero-mucoid material. as plain film does not show the full extent of these lesions, and does not obviate the utility of computed tomogrpahy (ct) scanning, plain film radiography was not performed. ct showed bilateral, well demarcated, ovoid soft tissue lesions anterior to the premaxilla (fig. 1). there was subtle smooth remodeling of the adjacent maxilla (fig. 2). no inferior turbinate involvement or nasolacrimal duct extension was present. management took the form of surgical excision via a sublabial incision (fig. 3). histological sections revealed fibrocollagenous cyst walls bilaterally, lined by pseudostratified ciliated columnar epithelium with areas of squamous metaplasia. fig. 1. bilateral well-demarcated ovoid lesions of soft tissue density anterior to the premaxilla. fig. 2. subtle smooth remodeling of the adjacent premaxilla and no inferior turbinate involvement. fig. 3. surgical approach via a sublabial incision demonstrates the bilateral soft tissue nasolabial cysts. discussion nasolabial cysts comprise approximately 0.6% of all jaw cysts. they most commonly affect patients in the 4th and 5th decades of life, and have a female predominance of 3.7:1. the presentation is usually that of localised painless swelling, sometimes associated with numbness and loosening of incisor teeth. slow growth and development of symptoms over months to years is typical. spontaneous rupture into the nose or oral cavity may occur. pain may be a feature during secondary infection. malignant transformation is rare, documented in only one case.5 the favoured aetiological theory, posited by bruggeman in 1920, suggests an origin from the remnant of the embryonic nasolacrimal duct, and is is supported by the fact that both the nasolacrimal duct and nasolabial cysts are lined by the same pseudostratified columnar epithelium, and also by the fact that the cyst is located subjacent to the wing of the nose, in line with the naso-optic fissure.3 the differential diagnosis includes naso­lacrimal duct cysts, periapical cysts and dermoid or epidermoid cysts of the oral cavity. treatment usually comprises in toto surgical enucleation via a sublabial incision, although open and edoscopic transnasal approaches have been described.6 1. shear m, speight p. cysts of the oral and maxillofacial regions. 4th ed. oxford, uk: blackwell munksgaard, 2007:119-122. 1. shear m, speight p. cysts of the oral and maxillofacial regions. 4th ed. oxford, uk: blackwell munksgaard, 2007:119-122. 2. toribio y, roehrl mh. the nasolabial cyst: a nonodontogenic oral cyst related to nasolacrimal duct epithelium. arch pathol lab med 2011;135(11):1499-1503. [http://dx.doi.org/10.5858/arpa.2010-0338-rs] 2. toribio y, roehrl mh. the nasolabial cyst: a nonodontogenic oral cyst related to nasolacrimal duct epithelium. arch pathol lab med 2011;135(11):1499-1503. [http://dx.doi.org/10.5858/arpa.2010-0338-rs] 3. patil k, mahima vg, divya a. klestadt’s cyst: a rarity. indian j dent res 2007;18:23-26. [http://dx.doi.org/10.4103/0970-9290.30918] 3. patil k, mahima vg, divya a. klestadt’s cyst: a rarity. indian j dent res 2007;18:23-26. [http://dx.doi.org/10.4103/0970-9290.30918] 4. rao rv. naso-labial cyst. j laryngol otol 1955;69:352-355. 4. rao rv. naso-labial cyst. j laryngol otol 1955;69:352-355. 5. lopez-rios f, lassaletta-atienza l, domingo-carrasco c, martinez-tello fj. nasolabial cyst: report of a case with extensive apocrine change. oral surg oral med oral pathol oral radiol endod 1997;84:404-406. 5. lopez-rios f, lassaletta-atienza l, domingo-carrasco c, martinez-tello fj. nasolabial cyst: report of a case with extensive apocrine change. oral surg oral med oral pathol oral radiol endod 1997;84:404-406. 6. chao wc, huang cc, chang ph, chen yl, chen cw, lee tj. management of nasolabial cysts by transnasal endoscopic marsupialization. arch otolaryngol head neck surg 2009;135(9):932-935. [http://dx.doi.org/10.1001/archoto.2009.111.] 6. chao wc, huang cc, chang ph, chen yl, chen cw, lee tj. management of nasolabial cysts by transnasal endoscopic marsupialization. arch otolaryngol head neck surg 2009;135(9):932-935. [http://dx.doi.org/10.1001/archoto.2009.111.] unusual.html unusual cause of breast lump: a csf pseudocyst sandeep gopal jakhere, md, dnb raju kumbhar, md harshal dhongade, md department of radiology, b y l nair charitable hospital and topiwala national medical college, mumbai, maharashtra, india corresponding author: s jakhere (drsandeepjakhere@gmail.com) a ventriculoperitoneal (vp) shunt is a fairly common and useful procedure to reduce intracranial pressure in patients with hydrocephalus. complications associated with vp shunts are usually related to either shunt obstruction or infection. a pseudocyst formation owing to leakage of csf into the breast tissue as a complication of vp shunting is a rare entity, with few cases in the literature. nonetheless, it is an important cause of cystic breast lump and should be kept in mind in a patient with an indwelling vp shunt. we describe the case of a 16-year-old girl patient with an indwelling vp shunt who presented with a gradually increasing breast lump, and was diagnosed to have a csf pseudocyst based on characteristic imaging findings. s afr j rad 2012;16(2):69-71. a breast lump is an uncommon occurrence in the paediatric and adolescent patient;1 a majority of cases are either related to endocrine function or benign masses.2 the common benign causes are gynaecomastia, simple cyst, fibroadenoma, lymphnode, galactocoele, duct ectasia and infection.1 malignant lesions are extremely rare in the paediatric and adolescent population, with an age-specific incidence of less than 25 cases per 100 000 per year among patients younger than 19 years.3 cystic lesions account for approximately 7.2% of breast lesions on ultrasound; an overwhelming majority are of benign aetiology (approximately 88%).4 the common causes of cystic breast lesion include simple cyst, abscess, galactocoele and papilloma. a csf pseudocyst of the breast has rarely been described in the literature, with only a few cases to date.5 case report a 16-year-old girl presented with pain in the right breast and a gradually increasing breast lump over the last 15 days. there was no history of fever. she was mentally retarded and had a history of tuberculous meningitis with multiple intraparenchymal tuberculomas at the age of 6 months. she had developed moderate hydrocephalus with thinning of the neuroparenchyma at that time, which was treated with a ventriculoperitoneal (vp) shunt. she was referred for ultrasound study of the breast which showed a well-defined, thin-walled cystic lesion in the right breast. moving internal echoes were seen within it. the vp shunt was seen passing through the cystic lesion. since the cystic lesion was seen surrounding the vp shunt, a possibility of csf leakage with resultant cyst formation was considered, and the patient was referred for ct scan of the brain, chest and abdomen to look for any other sites of csf leakage. the brain ct revealed moderate hydrocephalus with several areas of encephalomalacia. the vp shunt was seen traversing the frontal horn of the right lateral ventricle, with its tip in the region of the suprasellar cistern. the chest ct showed a well-defined fluid collection in the right breast, measuring approximately 4.9 x 2.9 cm with the vp shunt passing through it. similar collections were also seen along the tract of the vp shunt in the right supraclavicular region and the lower anterior chest wall. the abdominal ct showed an intraperitoneal fluid collection adjacent to the tip of the vp shunt measuring 7.9 x 3.9 cm. the collection appeared thin-walled and localised and displaced the adjacent bowel loops. in view of several fluid collections along the tract of the vp shunt, intraperitoneal collection adjacent to the tip of vp shunt and moderate hydrocephalus, a diagnosis of a csf pseudocyst of the breast was made. discussion shunting of csf into the peritoneal cavity in patients with hydrocephalus was advocated as far back as 1898 by ferguson et al.12 however, it was only in 1905 that the first vp shunt was placed for csf diversion.13 although vp shunting has significantly improved outcomes in patients with hydrocephalus, it has been estimated that 40 50% of children and 29% of adults will suffer a shunt failure within the first year of placement.14 complications associated with vp shunts are usually related to either shunt infection or obstruction. obstruction of a vp shunt usually occurs at the proximal end, maybe caused by plugging of the catheter by brain parenchyma, the choroid plexus or tumour cells. patients usually complain of headache, nausea, vomiting, lethargy, irritability and sometimes increasing head size with bulging fontanelles. distal obstruction is usually caused by adhesions in the peritoneal cavity or apposition of solid abdominal organs against the shunt tip, which may lead to formation of abdominal pseudocysts that may present with increasing abdominal size and pain. migration of a vp shunt may occur along the tract of its placement, and subsequent csf drainage into the soft tissues occurs, leading to formation of csf collections. the distal end of a vp shunt may migrate to unusual sites including the anus, umbilicus, vagina, scrotum, pulmonary artery or even the oral cavity.15 thoracic complications associated with vp shunt placement are not very common, although they can sometimes be life-threatening. they are classified into 3 broad groups:15 1. complications occurring during shunt placement 2. complications related to catheter migration 3. pleural effusions. complications under the first group are infrequent, with only 3 cases reported up to 2007. a typical example is lung apex perforation while advancing the catheter during shunt placement, leading to pneumothorax. thoracic migration of a vp shunt is also rather uncommon, with 12 cases reported. the distal tip of the vp shunt may migrate proximally along the chest wall, and may end up either in the pleural cavity or the lung parenchyma, with a few cases of bronchial perforation also being reported. pleural effusions are produced either due to supra diaphragmatic or transdiaphragmatic migration of the vp shunt; the treatment of choice is thoracocentesis. breast-related complications of a vp shunt include formation of pseudocysts and csf galactorhea. csf pseudocysts maybe formed in the breast either by migration of the catheter tip into the breast tissue or by fracture of the shunt followed by seepage of csf and fluid accumulation. a few cases of a vp shunt wrapped around a breast prosthesis with subsequent csf pseudocyst formation have also been reported.16 spector et al.9 believed that migration of the vp shunt in their patient was related to lifting heavy weights, compounded by adhesions between the pectoralis major muscle and capsular tissues along the shunt tunnel, which caused significant traction force on the vp shunt. however, in our patient, there was no migration of the vp shunt tip, which remained in the abdominal cavity, and the csf pseudocyst formation was probably due to inadequate csf drainage, as evidenced by abdominal pseudocysts and hydrocephalus, following a micro-fracture of the vp shunt in the region of the breast, and subsequent slow seepage of csf. in conclusion: csf pseudocyst formation is a rare cause of a gradually enlarging breast lump, and should be borne in mind in patients with an indwelling vp shunt catheter. ultrasound and ct evaluation would be diagnostic for this condition. acknowledgements. we thank dr bhakti yeragi and dr vipul chemburkar for evaluating the report for its content and accuracy. 1. weinstein sp, conant ef, orel sg, zuckerman ja, bellah r. spectrum of us findings in pediatric and adolescent patients with palpable breast masses. radiographics 2000;20:1613-1621. 1. weinstein sp, conant ef, orel sg, zuckerman ja, bellah r. spectrum of us findings in pediatric and adolescent patients with palpable breast masses. radiographics 2000;20:1613-1621. 2. amshell ce, sibley e. multiple unilateral fibroadenomas. breast j 2001;7:189-191. 2. amshell ce, sibley e. multiple unilateral fibroadenomas. breast j 2001;7:189-191. 3. ries la, eisner mp, kosary cl, et al., eds. seer cancer statistics review, 1975-2002. bethesda, md: national cancer institute, 2005. 3. ries la, eisner mp, kosary cl, et al., eds. seer cancer statistics review, 1975-2002. bethesda, md: national cancer institute, 2005. 4. berg wa, campassi ci, ioffe ob. cystic lesions of the breast: sonographic-pathologic correlation. radiology 2003;227:183-191. 4. berg wa, campassi ci, ioffe ob. cystic lesions of the breast: sonographic-pathologic correlation. radiology 2003;227:183-191. 5. kalra n, mani nb, jain m, et al. cerebrospinal fluid pseudocyst of the breast. australas radiol 2002;46:76-79. 5. kalra n, mani nb, jain m, et al. cerebrospinal fluid pseudocyst of the breast. australas radiol 2002;46:76-79. 6. lazarus e, nebres m, spencer p, et al. iatrogenic breast mass associated with a malfunctioning ventriculoperitoneal shunt in a patient with neurosarcoidosis. am j roentgenol 1998;171:529-530. 6. lazarus e, nebres m, spencer p, et al. iatrogenic breast mass associated with a malfunctioning ventriculoperitoneal shunt in a patient with neurosarcoidosis. am j roentgenol 1998;171:529-530. 7. vimalachandran d, martin l, lafi m, et al. cerebrospinal fluid pseudocyst of the breast. breast 2003;12:215-216. 7. vimalachandran d, martin l, lafi m, et al. cerebrospinal fluid pseudocyst of the breast. breast 2003;12:215-216. 8. iyer hp, jacob lp, chaudhry na. breast cerebrospinal fluid pseudocyst. plast reconstr surg 2006;118:87e–89e. 8. iyer hp, jacob lp, chaudhry na. breast cerebrospinal fluid pseudocyst. plast reconstr surg 2006;118:87e–89e. 9. spector ja, culliford at, post nh, et al. an unusual case of cerebrospinal fluid pseudocyst in a previously augmented breast. ann plast surg 2005;54:85-87. 9. spector ja, culliford at, post nh, et al. an unusual case of cerebrospinal fluid pseudocyst in a previously augmented breast. ann plast surg 2005;54:85-87. 10. spector ja, culliford iv at, levine jp. breast cerebrospinal fluid pseudocyst. plast reconstr surg 2007;120:357-358. 10. spector ja, culliford iv at, levine jp. breast cerebrospinal fluid pseudocyst. plast reconstr surg 2007;120:357-358. 11. torres an, barraquer el, salvador sanz jf, et al. late complication of a ventriculoperitoneal shunt in a patient with mammary prosthesis. j plast reconstr aesthet surg 2008;61:212-214. 11. torres an, barraquer el, salvador sanz jf, et al. late complication of a ventriculoperitoneal shunt in a patient with mammary prosthesis. j plast reconstr aesthet surg 2008;61:212-214. 12. ferguson ah. intraperitoneal diversion of the cerebrospinal fluid in cases of hydrocephalus. ny med j 1898;67:902. 12. ferguson ah. intraperitoneal diversion of the cerebrospinal fluid in cases of hydrocephalus. ny med j 1898;67:902. 13. harsh gr. peritoneal shunt for hydrocephalus utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. neurosurgery 1954;11:284-294. 13. harsh gr. peritoneal shunt for hydrocephalus utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. neurosurgery 1954;11:284-294. 14. kupeli e, yilmaz c, akcay s. pleural effusion following ventriculo-pleural shunt: case reports and review of the literature. ann thorac med 2010;5:166-170. 14. kupeli e, yilmaz c, akcay s. pleural effusion following ventriculo-pleural shunt: case reports and review of the literature. ann thorac med 2010;5:166-170. 15. taub e, lavyne mh. thoracic complications of ventriculoperitoneal shunts: case report and review of the literature. neurosurgery 1994;34:181-183. 15. taub e, lavyne mh. thoracic complications of ventriculoperitoneal shunts: case report and review of the literature. neurosurgery 1994;34:181-183. 16. chu yt, chuang hc, lee hc, cho dy. a ventriculoperitoneal shunt catheter wrapped around a right mammary prosthesis forming a pseudocyst. j clin neurosci 2010;17(6):801-803. 16. chu yt, chuang hc, lee hc, cho dy. a ventriculoperitoneal shunt catheter wrapped around a right mammary prosthesis forming a pseudocyst. j clin neurosci 2010;17(6):801-803. fig. 1. axial ct scan image of brain showing encephalomalacic changes in the right temporal lobe. ex vacuo dilatation of the left frontal horn is seen. the vp shunt traverses the temporal lobe neuroparenchyma. fig. 2. contrast-enhanced axial ct scan of the thorax showing a cystic lesion in the right breast (thick arrow) with the vp shunt (thin arrow) passing through it. fig. 3. a similar cystic lesion (arrow) surrounding the vp shunt is also seen in the right supra-clavicular region. fig. 4. axial contrast-enhanced ct scan of the abdomen shows a well-defined thick-walled intra-peritoneal fluid collection (thick arrow) with the vp shunt (thin arrow) traversing it. fig. 5. sagittal reformatted image showing the cystic lesion in the breast (thin arrow) and the intraperitoneal fluid collection (thick arrow). case report 61 sa journal of radiology • september 2007 we present a case of a 2-year-old child who fell and injured his elbow. plain films were taken and had the appearance of an elbow dislocation (fig. 1). subsequent mri confirmed a salter harris i fracture of the distal humeral epiphysis (figs 2a & b). discussion pure dislocation of the elbow is uncommon. it involves a disarticulation of the radial head from the capitellum and the semi-lunar notch of the olecranon from the trochlea.1 in this instance, the child’s radius head and proximal ulna are displaced as a unit with the distal cartilagenous humerus. this is obvious on mri (especially ge sequence) because it demonstrates the cartilagenous components which are not visible on plain radiograph. separation of the entire distal humeral epiphysis is classified into three groups based on the age of the child and the degree of ossification of the lateral condyle:2 • group a includes infants whose lateral condyle ossification centre has not appeared. • group b cases are between ages 1 and 3 years when the ossification centre is present (our patient). • group c includes older children and produces a metaphyseal fragment. the distal epiphysis is usually displaced posteromedially.3 diagnosis of this type of fracture can be challenging. x-rays are usually taken of both elbows but further imaging is usually needed. modalities that have been used are ultrasound4 and arthrography. although they help to make the diagnosis, ultrasound is operatordependent and not consistently accurate. arthrography is associated with the risks of an invasive procedure. mri, as demonstrated in this patient, is an excellent modality to obtain the diagnosis of separation of the distal humeral epiphysis and avoid misdiagnosis of dislocated elbow when the elbow epiphyses are largely unossified. 1. rasool mn. elbow dislocation with lateral condyle fracture in children. sa orthopaedic journal 2006; aug: 72-78. 2. campbell wc. fractures and dislocations in children. in: crenshaw ah, ed. campbell’s operative orthopedics. st louis: mosby, 1987: 1885-1886. 3. ruo gy. radiographic diagnosis of fracture-separation of the entire distal humeral epiphysis. clin radiol 1987; 38: 635-637. 4. dias jj, lamont ac, jones jm. ultrasonic diagnosis of neonatal separation of the distal humeral epiphysis. j bone joint surg br 1988; 70: 825-828. elbow fracture in a child d j van der merwe, mb chb s andronikou, mb bch, fc rad (sa), frcr (lond), phd department of radiology, tygerberg hospital g j vlok, mb chb, mmed (orth), fc orth (sa) department of orthopaedics, tygerberg hospital g dekker, mb chb, mmed (fam) m pienaar, mb chb, bsc s hlongwane, mb chb a brandt, mbchb department of radiology, tygerberg hospital fig. 1. plain film of the elbow demonstrates malalignment of the distal humeral metaphysis with the proximal radial and ulnar metaphyses. the unossified epiphyses are not visible. pg61-62.indd 61 9/17/07 8:56:34 am case report case report 62 sa journal of radiology • september 2007 figs 2 a & b. sagittal stir mri of the elbow demonstrates good alignment of the capitellum (a) (showing a small ossified centre) with the radial head epiphysis and a well-positioned trochlea at the trochlear notch of the ulna. (b) malalignment is therefore due to a salter harris fracture through the distal humeral physis with posterior displacement of the distal epiphysis which is articulating with the trochlear notch. a b pg61-62.indd 62 9/17/07 8:56:36 am abstract introduction methods ethical considerations results discussion recommendations conclusion acknowledgements references about the author(s) anagha joshi department of radiology, lokmanya tilak municipal medical college, lokmanya tilak municipal general hospital, mumbai, india mridula m. muthe department of radiology, lokmanya tilak municipal medical college, lokmanya tilak municipal general hospital, mumbai, india vikrant firke department of radiology, lokmanya tilak municipal medical college, lokmanya tilak municipal general hospital, mumbai, india harshal badgujar department of radiology, lokmanya tilak municipal medical college, lokmanya tilak municipal general hospital, mumbai, india citation joshi a, muthe mm, firke v, badgujar h. preliminary experience with 3t magnetic resonance elastography imaging of the liver. s afr j rad. 2021;25(1), a2072. https://doi.org/10.4102/sajr.v25i1.2072 original research preliminary experience with 3t magnetic resonance elastography imaging of the liver anagha joshi, mridula m. muthe, vikrant firke, harshal badgujar received: 25 dec. 2020; accepted: 10 mar. 2021; published: 12 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: magnetic resonance elastography (mre) is a promising non-invasive technique for the identification and quantification of hepatic fibrosis. this manuscript describes our early experience with mre for the assessment of the presence and staging of liver fibrosis on a 3t magnetic resonance imaging (mri) system. objectives: the purpose of this study was to describe the mre physics, procedure, interpretation and drawbacks, along with a few recommendations as per our experience. method: magnetic resonance elastography was performed on 85 patients with a 3t mri and the images were analysed both qualitatively and quantitatively. liver stiffness was assessed by drawing freehand geographic regions of interest on the elastograms to cover the maximum portion of the hepatic parenchyma within the 95% confidence maps on each slice. correlation with histopathology was performed whenever available. results: of the 80 patients who met the inclusion criteria, 41 patients displayed a normal liver stiffness measurement (lsm) and 39 patients had a raised lsm. in the patients who had a raised lsm, 14 patients had stage i–ii fibrosis, 8 patients had stage ii–iii fibrosis, 6 patients had stage iii–iv fibrosis, 4 patients had stage iv fibrosis or cirrhosis and 7 patients had non-alcoholic steatohepatitis. the mean thickness of the waves increased with increasing stages of fibrosis. the waves became gradually darker medially in patients with normal lsm as compared to the patients with raised lsm. histopathology with metavir scoring was available in 46 patients, which agreed with the mre findings in all except two patients. conclusion: magnetic resonance elastography is a suitable non-invasive modality for the identification and quantification of hepatic fibrosis. keywords: magnetic resonance elastography; liver fibrosis; 3t; cirrhosis; stiffness; liver stiffness measurement; chronic liver disease; non-alcoholic steatohepatitis. introduction chronic liver diseases (clds) are a major cause of morbidity and mortality in the world. hepatic fibrosis is the result of different clds caused by viral infections like hepatitis b (hbv) and hepatitis c (hcv), alcohol abuse, non-alcoholic fatty liver disease (nafld), autoimmune disease and metabolic disorders. alcoholic liver disease (ald) is the commonest cause of cirrhosis in india.1 the development of fibrosis is proven to be the strongest predictor of prognosis in patients with nafld.2 abnormal fibrinogenesis in response to chronic liver injury results in hepatic fibrosis, which, in advanced stages, further leads to cirrhosis. hepatic fibrosis is a dynamic process that can be reversed with effective treatment if detected early. untreated, it can progress to cirrhosis causing hepatic failure and its complications like variceal bleeding, ascites, portal hypertension and hepatocellular carcinoma.3,4,5 therefore, the early detection of the development and extent of liver fibrosis and recognition of cirrhosis is critical for determining the prognosis and appropriate clinical management of cld.6,7 liver fibrosis is a predictor of liver function and preoperative assessment of fibrosis is an important predictor of the risk of liver failure after surgery.8 liver biopsy is the current gold standard for the detection and staging of fibrosis.1,4,8,9 however, it is an invasive method, has poor patient acceptance, evaluates a small volume of liver parenchyma and can cause undesired complications, such as bleeding and mortality in some instances.1,8,10 sampling variability resulting from heterogeneity in the liver parenchyma and interobserver variability in the assessment of the histopathological specimens also add to its limitations.11,12 during the last several years, new non-invasive methods of assessing liver fibrosis have been developed and investigated, including serum tests, diffusion-weighted imaging, ultrasound-based transient elastography and magnetic resonance elastography (mre).7,8 of these, mre is the most accurate method to date for detecting and staging liver fibrosis, especially in the early stages of fibrosis.13,14 it is also useful in the follow-up staging evaluation and for the assessment of response to treatment. this article describes our early experience with mre for the assessment of the presence and staging of liver fibrosis at 3t magnetic resonance imaging (mri). it also ellaborates on the related physics, procedure, interpretation and drawbacks, along with a few recommendations. methods this was a retrospective, observational study performed at the lokmanya tilak municipal general hospital spanning from 20 june 2020 to 20 november 2020. all patients with suspected liver disease referred for the presence and quantification of liver fibrosis were included. magnetic resonance elastography examinations were performed on 85 patients using a 3.0t whole-body mr imager (philips ingenia) with a phased-array torso coil. excluded patients were those with hepatic iron overload, acute hepatitis and congestive cardiac failure, patients with a history of claustrophobia and patients with contraindications for mri, such as the presence of a pacemaker or cochlear impants. four patients were excluded from the study because of poor breath-hold, leading to poor image quality and a region of interest (roi) of less than 700 pixels. one patient was excluded because of significant iron overload with t2* values of 6.32 ms. of the 80 patients who underwent mre, 26 patients were known to have hbv infection, ald was suspected in 30 patients, 8 patients were known cases of hcv, 15 patients were suspected cases of non-alcoholic steatohepatitis and 1 patient was a case of bechet’s disease on treatment with methotrexate. technique magnetic resonance elastography was performed on a philips ingenia 3.0t whole-body mr scanner. all examinations were performed after the patient fasted for at least 6 h. because mre is a breath-hold sequence, it was acquired with the patient holding breath, preferably in end expiration over 18 s. four axial slices, each 10 mm thick, were placed in the upper middle part (widest part) of the liver to obtain the largest cross-section of liver parenchyma for liver stiffness measurement (lsm). the mre sequence in our 3.0t mri system (philips ingenia) is a modified gradient recalled echo (gre) sequence with the following parameters: repetition time/echo time (te), 50/21.1 ms; flip angle, 30°; bandwidth, 250 hz/pixel; field of view, 450 × 403 and matrix, 300 × 86. the scan was commenced with the acquisition of a t2-weighted sequence in the axial plane to assess the morphology, signal intensity characteristics of the liver parenchyma, presence of focal lesions, if any, and associated findings. if diffuse hypointensity of the liver was observed on t2-weighted images (t2wi), an iron storage disorder was suspected and a t2* sequence was added to the protocol to assess for iron overload. the study was aborted in the case of hepatic iron overload to avoid spurious results. in-phase and out-of-phase images were acquired to detect fatty infiltration of the liver, after which an mre sequence was acquired. in the case of focal hepatic lesions identified on t2wi, the study was further modified to assess these lesions in detail including acquisition of post-contrast imaging. magnetic resonance elastography acquisition was processed to generate quantitative maps displaying the stiffness of the tissue. the acquired mre data were processed automatically using software with an inversion algorithm to generate greyscale and colour elastograms with superimposed confidence maps. image analysis all studies were evaluated independently by a radiologist with 30 years of experience and two radiologists with 7 years of experience as well as a senior resident. correlation with histopathology was performed when available, with the pathologist blinded to the mre results. initially, the quality of the mre images obtained was assessed to confirm proper technique and reportability. the application and transmission of mechanical waves were verified during the scanning itself. the application of mechanical waves by the passive driver through the liver was confirmed by the presence of a signal void in the subcutaneous region on the magnitude images at the site of the passive driver placement. the transmission of mechanical waves through the hepatic parenchyma was confirmed by the presence of alternate black and grey waves seen on the phase images. in the case of failure to visualise these waves, the connection between the plastic tube connecting the active and passive drivers and the status of the active driver were checked. furthermore, the wave images were checked to look for adequate propagation of the waves parallel to the hepatic surface with adequate amplitude, having a good signal-to-noise ratio. finally, the elastogram images with superimposed 95% confidence maps were studied to validate the diagnostic quality. both qualitative and quantitative evaluation of the mre images was performed. for qualitative assessment, the wave images were studied for the thickness of each wave and the brightness. the colour elastograms were reviewed on a scale of 0 kpa – 8 kpa. liver stiffness was assessed qualitatively on the mri console by drawing freehand geographic rois on the elastograms to cover the maximum portion of the hepatic parenchyma within the 95% confidence maps on each slice (figure 1). the rois were placed 1 cm away from and parallel to the liver margin. large vessels, fissures, gall bladder fossa and any areas affected by cardiac and vascular artefacts were excluded. cross-hatched areas of 95% confidence map overlay and artefactual areas were avoided. regions of interest were drawn on magnitude images with confidence map overlay. the mean of all the values obtained from four different slices, which were automatically calculated using the in-built software, were reported. the stage of fibrosis was interpreted in accordance with the guidelines suggested by sk venkatesh et al.15 (table 1). the presence or absence of fibrosis was correlated with liver histopathology whenever available. figure 1: depiction of the measurement of liver stiffness (a–d), by drawing free-hand regions of interest on all four slices of the magnitude images to cover the maximum hepatic parenchyma not covered by the 95% confidence maps. table 1: interpretation of the stage of fibrosis based on the liver stiffness measurement as suggested by venkatesh et al. ethical considerations this retrospective study was performed with de-identified patient data. the institutional ethics committee human research at the lokmanya tilak municipal medical college and general hospital granted ethics approval for this study (reference d020190117). written informed consent was obtained from all patients before mre. results the final study population included 80 patients, 34 females and 51 males, with ages ranging from 17 to 67 years. a normal lsm was recorded in 41 of the 80 patients who underwent liver mre. of the 39 patients who had raised lsms, 14 patients had stage i–ii fibrosis, 8 patients had stage ii–iii fibrosis, 6 patients had stage iii–iv fibrosis, 4 patients had stage iv fibrosis or cirrhosis (figure 2) and 7 patients had hepatic steatosis with lsm values between 2.5 and 2.9, which indicated either normal stiffness or inflammation (figure 3). sixty-eight patients had fatty infiltration of liver on in-phase and out-of-phase images. figure 2: wave and colour images of patients ranging from normal liver stiffness measurement to stage 4 fibrosis. figure 3: non-alcoholic steatohepatitis. in-phase (a) and out-of-phase (b) images reveal a drop in signal on the out-of-phase image, indicating the presence of elevated hepatic fat. the colour (c) and magnitude (d) images reveal a liver stiffness measurement of 2.78 kpa. it was observed that the mean thickness of the waves on the wave images was 10.7 mm in patients with a normal lsm (n = 41). the mean wave thickness in patients with stage i–ii fibrosis (n = 14) was 11.9 mm and in those with stage iv fibrosis (n = 4), it was 22.25 mm. the thickness of the waves in patients with stage ii–iii fibrosis (n = 8) was 14.4 mm and in patients with stage iii–iv fibrosis (n = 6), it was 15.7 mm. thus, the thickness of the waves increased with increasing stages of fibrosis (figure 4). it was also observed that the waves were darker medially in patients with a normal lsm as compared to the patients with a raised lsm. (figure 5). figure 4: wave images from a patient with normal liver stiffness measurement (a) and raised liver stiffness measurement (b) show an increase in the thickness of the waves (11.5 mm – 22.9 mm) as the liver stiffness measurement increases. figure 5: wave images of a patient with a normal liver stiffness measurement (a) and raised liver stiffness measurement (b) show darker medial waves in the patient with a normal liver stiffness measurement as compared to the patient with a raised liver stiffness measurement. histopathology with metavir scoring was available in 46 patients, which agreed with the mre findings in all except two patients. in both these patients, the fibrosis was overestimated. the histopathology of one of these patients revealed ballooning degeneration representing changes of hepatitis and no fibrosis, which could explain the spuriously elevated lsm of 3.3 kpa (stage i–ii fibrosis), whilst in another patient, the histopathology was normal and mre revealed an lsm of 3.1 kpa (stage i–ii fibrosis). discussion magnetic resonance elastography is emerging as the most reliable non-invasive alternative to biopsy in patients with suspected liver fibrosis. it is safe, cost-effective and devoid of sampling errors seen with biopsy. most patients are fit to undergo mre of the liver, including those with ascites or obesity.16 magnetic resonance elastography can also be used for monitoring liver fibrosis in such patients and the results of mre are reproducible.17,18,19 the staging of fibrosis with mre is comparable with biopsy.20,21,22 in addition, a few studies have shown that the interobserver variability between different radiologists reading mre studies is less than that between different pathologists reading histopathology specimens.23,24 physics the stiffness of tissues can be characterised using mre non-invasively. in this technique, mechanical waves are applied to the tissues, producing small displacements in the tissue. these displacements, which occur in the horizontal plane, are called ‘shear waves’. the difference in the wavelengths of shear waves propagated through tissue depends on the stiffness of the tissue and is used to produce liver stiffness maps. low-frequency shear waves in the range of 20 hz – 200 hz can be used because they undergo less attenuation and their wavelengths are in a measurable range in tissue.25,26 typically, a 60-hz shear wave frequency is used across vendors as the low frequency of these waves aids in better tissue transmission as compared to high-frequency waves and is also comfortable for the patients.6,15,27 apart from the frequency, the amplitude of the passive driver is also important as it determines the intensity of the vibrations produced on the anterior abdominal wall.28 procedure the technique can be easily implemented on a 1.5t or 3t mr system with additional hardware to generate the mechanical shear waves and software for processing the elastogram maps. the lsm depends on the frequency used, and hence, the lsm is the same with 1.5t or 3.0t as long as the same frequency is used for mre.15,29 magnetic resonance elastography involves three major steps: (1) use of an external driver (vibration source) to generate mechanical waves in tissue, (2) imaging the waves with a special mri sequence that is sensitive to motion and (3) processing the resultant data using an inversion algorithm to generate quantitative maps displaying the stiffness of tissue. the active driver, which produces a continuous acoustic vibration of 60 hz, is placed outside the scanner room. a 25-foot-long plastic tube connects the active driver to the passive driver, which is in close contact with the body and through which the acoustic vibrations are transmitted to the liver. the passive driver is an mr-compatible plastic disc, 19 cm in diameter. it has a flexible membrane that transmits the vibrations into the body, inducing the mechanical shear waves. the sequences that can be used for mre are gre, spin echo, balanced steady-state free precession and echo-planar imaging.30 these sequences are used to track the shear waves traversing through the hepatic parenchyma.27 various mri vendors have different parameters for mre sequences, which have been outlined in detail by the radiological society of north america quantitative imaging biomarkers alliance.28 the continuous mechanical shear waves transmitted in the tissues result in tissue displacement, which induces cyclical motion of the spins, generating a measurable phase shift in the presence of motion-encoded gradients.25 wave images at different time points are obtained by adjusting the phase offset between the mechanical motion and the oscillating motion-encoded gradients. a magnitude and phase image is produced for each phase offset.15,30 four phase offsets evenly placed over one cycle of motion are used in the 2d-gre mre sequence. magnitude images provide anatomic information and phase images provide wave motion information.28,30 these magnitude and phase images are raw data images. an inversion algorithm is applied to these images, which measure the magnitude of the complex shear modulus.6 elastograms or stiffness maps, which include a colour wave image, a greyscale elastogram and a colour elastogram image, are generated automatically by the scanner computer within 2 min of the mre sequence. the colour wave image depicts the propagation of the mechanical shear waves through the liver parenchyma. the greyscale elastogram is used for quantitative assessment, whereas the colour elastogram is used for qualitative assessment. the correlation coefficient of polynomial fits is used with the inversion algorithm to generate 95% confidence maps, which differentiate between accurate and less accurate lsm resulting from low-wave amplitude using a ‘checker board’ overlay.28,31 greyscale and colour elastograms with and without superimposed confidence maps are generated. the lsm is depicted in kpa units on greyscale images. the colour elastogram maps depict the stiffness in the range of 0 kpa – 8 kpa. magnetic resonance elastography is performed with the patients in a state of at least 4–6 h of fasting.31 fasting is important because, after eating food, the portal blood supply to the liver increases, which is compensated for by autoregulation of sinusoidal resistance to maintain normal portal pressure; however, in the presence of fibrosis, autoregulation is faulty, leading to postprandial elevation of portal pressure, which increases liver stiffness.15,32,33 similarly, in patients undergoing repeat follow-up mre examinations, fasting is essential to ensure optimum comparison.28 interpretation the interpretation should first begin with assessing the quality of the elastogram. in a good study, the maximum part of the liver is not covered by 95% confidence maps (figure 6), and on wave images, the waves are formed parallel to the outer surface of the liver and each other (figure 7). in a poor-quality study, the waves are of low amplitude (dark) and irregular or chaotic in pattern. in a non-diagnostic study, the maximum part of the liver is covered by the 95% confidence maps. figure 6: magnitude (a) and colour images (b) reveal an optimum study with the maximum part of the liver not covered by the 95% confidence map. figure 7: good quality elastogram with regular waves formed parallel to the liver surface. the thickness of the waves on colour wave images continues to increase in patients with progressive grades of fibrosis. in patients with a normal lsm, the waves become darker medially as compared to patients with a raised lsm. this occurs as a result of the increased attenuation of the shear waves by the normal hepatic parenchyma.28 the lsm is obtained by drawing geographic rois to cover the maximum hepatic parenchyma with superimposed 95% confidence maps on each of the four elastogram slices. regions of interest should be placed only in regions of the liver that have adequate wave amplitude, avoiding large vessels, fissures, the gall bladder fossa, any areas affected by cardiac and vascular artefacts, areas covered by cross-hatched areas of 95% confidence map overlay and artefactual areas. the mean value obtained from four different levels of the liver along with the stage of fibrosis, if present, is reported. depending on the aetiology of the cld, the degree and extent of fibrosis can vary. hence, the thresholds used to determine the degree of fibrosis may also vary depending on the aetiology. there have been many research studies with variable cut-off values for different stages of fibrosis in patients with liver parenchymal disease because of various aetiologies. however, most studies have concluded that a cut-off value of 3 kpa is reliable to distinguish patients with normal liver parenchyma from those with fibrosis.31 drawbacks spuriously elevated lsms are seen in patients with acute hepatitis, biliary obstruction, passive venous congestion, diffuse infiltrative diseases such as sarcoidosis or amyloidosis and neoplastic causes such as lymphoma or multifocal metastasis.34 in patients with moderate to severe iron storage disorder, mre results may be inconclusive because of the low signal-to-noise ratio, especially in gre-based sequences.8 a t2* of 20 ms or lower reflects a higher likelihood of non-diagnostic elastography.35 recommendations as mre is a breath-hold sequence, it is useful to practise breath hold techniques with the patient before placing the patient on the mr table, especially when performing mre on scanners with a gre sequence. optimum monitoring of image quality during the scanning is of utmost importance to avoid repeat studies and non-diagnostic examinations. a t2-weighted axial sequence should be incorporated in the mre protocol, which enables evaluation of the hepatic parenchyma for possible iron overload, apart from the detection of other abnormalities such as focal lesions, biliary dilatation, focal areas of fibrosis related to confluent hepatic fibrosis or healing lesions. in the case of suspected iron overload, it is worthwhile to perform a t2* sequence for quantification of iron overload and defer the imaging in the case of moderate to severe iron overload. liver stiffness measurements should always be evaluated in conjunction with clinical and laboratory parameters to avoid errors in reporting, as spuriously raised lsms are seen in conditions such as acute hepatitis, hepatic congestion, cholestasis secondary to biliary obstruction and hepatic infiltrative disorders. conclusion quantification of liver fibrosis is rapidly gaining importance in view of the recent evidence supporting reversal of the early stages of fibrosis by medical therapy. magnetic resonance elastography has emerged as a reliable non-invasive modality for the assessment of liver fibrosis because of its excellent correlation with histopathology, reproducibility, repeatability, good inter-observer agreement, assessment of a large volume of hepatic parenchyma as opposed to biopsy, the possibility of examination in obese patients and examination of patients with gross ascites. radiologists need to be aware of this technique, how to assess for and interpret an optimum study and understand the drawbacks of mre. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.j., m.m.m., v.k. and h.b. contributed equally to this article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, m.m.m., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or 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complications associated with percutaneous needle biopsy of the liver when one, two or three specimens are taken. postgraduate med j. 1992;68(806):964–967. https://doi.org/10.1136/pgmj.68.806.964 gawrieh s, knoedler dm, saeian k, wallace jr, komorowski ra. effects of interventions on intra-and interobserver agreement on interpretation of nonalcoholic fatty liver disease histology. ann diagn pathol. 2011;15(1):19–24. https://doi.org/10.1016/j.anndiagpath.2010.08.001 juluri r, vuppalanchi r, olson j, et al. generalizability of the nonalcoholic steatohepatitis clinical research network histologic scoring system for nonalcoholic fatty liver disease. j clin gastroenterol. 2011;45(1):55–58. https://doi.org/10.1097/mcg.0b013e3181dd1348 singh s, venkatesh sk, wang z, et al. diagnostic performance of magnetic resonance elastography in staging liver fibrosis: a systematic review and meta-analysis of individual participant data. clin gastroenterol hepatol. 2015;13(3):440–451. https://doi.org/10.1016/j.cgh.2014.09.046 venkatesh sk, ehman rl. magnetic resonance elastography of abdomen. abdom imag. 2015;40(4):745–759. https://doi.org/10.1007/s00261-014-0315-6 venkatesh sk, yin m, ehman rl. magnetic resonance elastography of liver: technique, analysis, and clinical applications. j magn reson imag. 2013;37(3):544–555. https://doi.org/10.1002/jmri.23731 chen j, yin m, glaser kj, talwalkar ja, ehman rl. mr elastography of liver disease: state of the art. appl radiol. 2013;42(4):5. shire nj, yin m, chen j, et al. test–retest repeatability of mr elastography for noninvasive liver fibrosis assessment in hepatitis c. j magn reson imag. 2011;34(4):947–955. https://doi.org/10.1002/jmri.22716 hines cd, bley ta, lindstrom mj, reeder sb. repeatability of magnetic resonance elastography for quantification of hepatic stiffness. j magn reson imag. 2010;31(3):725–731. https://doi.org/10.1002/jmri.22066 lee yj, lee jm, lee je, et al. mr elastography for noninvasive assessment of hepatic fibrosis: reproducibility of the examination and reproducibility and repeatability of the liver stiffness value measurement. j magn reson imag. 2014;39(2):326–331. https://doi.org/10.1002/jmri.24147 mumtaz s, schomaker n, von roenn n. pro: noninvasive imaging has replaced biopsy as the gold standard in the evaluation of nonalcoholic fatty liver disease. clin liver dis. 2019;13(4):111. https://doi.org/10.1002/cld.750 imajo k, kessoku t, honda y, et al. magnetic resonance imaging more accurately classifies steatosis and fibrosis in patients with nonalcoholic fatty liver disease than transient elastography. gastroenterology. 2016;150(3):626–637. https://doi.org/10.1053/j.gastro.2015.11.048 loomba r, wolfson t, ang b, et al. magnetic resonance elastography predicts advanced fibrosis in patients with nonalcoholic fatty liver disease: a prospective study. hepatology. 2014;60(6):1920–1928. https://doi.org/10.1002/hep.27362 rustogi r, horowitz j, harmath c, et al. accuracy of mr 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https://doi.org/10.1111/j.1478-3231.2009.02100.x yin m, talwalkar ja, glaser kj, et al. dynamic postprandial hepatic stiffness augmentation assessed with mr elastography in patients with chronic liver disease. am j roentgenol. 2011;197(1):64–70. https://doi.org/10.2214/ajr.10.5989 venkatesh sk, wells ml, miller fh, et al. magnetic resonance elastography: beyond liver fibrosis – a case-based pictorial review. abdom radiol. 2018;43(7):1590–1611. https://doi.org/10.1007/s00261-017-1383-1 ghoz hm, kröner pt, stancampiano ff, et al. hepatic iron overload identified by magnetic resonance imaging-based t2* is a predictor of non-diagnostic elastography. quant imag med surg. 2019;9(6):921. https://doi.org/10.21037/qims.2019.05.13 sajr 725 + 710 flake-shaped rice bodies j r kichari, r bezooijen   department of radiology, medisch spectrum twente, enschede, the netherlands j r kichari, md r bezooijen, md corresponding author: j kichari (j.kichari@mst.nl) rice body formation is a common complication of rheumatoid arthritis but can also occur without any underlying systemic disorder. mri is the modality of choice for discriminating this pathology from synovial chondromatosis.  s afr j rad 2012;16(4):140-141. doi:10.7196/sajr.725 a 47-year-old man was examined because of a 2-month history of a non-painful swelling of the right shoulder. physical examination showed a non-tender mass over the right deltoid region and a normal range of movement. laboratory findings were unremarkable. the shoulder radiograph demonstrated a soft tissue mass in the deltoid region without calcifications or erosions. ultrasound showed numerous flake-shaped lesions (fig. 1). after radiography and ultrasound, the differential diagnosis was rice body formation or synovial chondromatosis. subsequent mri demonstrated numerous flake-shaped lesions, iso-intense on t1 and t2-weighted images with clear delineation of the flake-shaped lesions on the t2-weighted images (fig. 2). the flake-shaped lesions showed no enhancement after intravenous gadolinium. the bursa wall was thickened, with marked enhancement representing bursitis. at surgery, the bursa and numerous flake-shaped lesions were resected. the pathological appearances were consistent with rice bodies. the patient recovered well and, at one-year follow-up, no underlying disorder was identified. fig. 1. ultrasound (linear 12 mhz transducer) of the left shoulder shows numerous well-defined iso-echoic oval lesions with no acoustic shadowing in a distended subacromial-subdeltoid bursa. there was marked bursa wall thickening and a moderate amount of hypoechoic fluid. fig. 2. axial t2-weighted image of the right shoulder shows numerous well-delineated oval nodules with an iso-intense signal intensity relative to skeletal muscle and a large amount of bursa fluid in a markedly distended subacromial-subdeltoid bursa. discussion the aetiology of rice body formation is still unknown. cheung et al. suggested synovial origin with micro-infarction of synovial cells after inflammation and ischaemia,¹ whereas popert et al. proposed a de novo formation of rice bodies in synovial fluid independently of synovial elements.² formation of rice bodies has been reported in joints,1 , 2 bursae3-6 and tendon sheaths,5 and are commonly observed in chronic rheumatoid arthritis, seronegative inflammatory arthritis and tuberculous joints.3 different-shaped rice bodies are described, varying from nodules and teardrops to angular and flake-shaped with variable sizes.4 , 5 on mri, rice bodies have been described as having isoor hypo-intense signal intensities relative to skeletal muscle on t1and t2-weighted images, and the rice bodies were less discernible from the surrounding bursa fluid on t1-weighted image and clearly discernible on t2-weighted image.3-5 synovial chondromatosis was a differential diagnosis in the above case. synovial chondromatosis usually has an iso-intense or slightly hyperintense signal intensity on t1-weighted image, and hyperintense signal intensity on t2-weighted image relative to the signal intensity of skeletal muscles. hence, differentiation of the unmineralised nodules in synovial chondromatosis from surrounding fluid on both sequences is difficult, whereas rice bodies can clearly be differentiated from surrounding fluid on t2-weighted image.3 , 5 , 6 treatment consists of removing the rice bodies and the bursa.3 in summary: rice bodies can occur without underlying systemic disorder, have different shapes and sizes, and have specific signal characteristics on mri that allow discrimination from synovial chondromatosis.   1. cheung hs, ryan lm, kozin f, mccarty dj. synovial origins of rice bodies in joint fluid. arthritis rheum 1980;23:72-76. 1. cheung hs, ryan lm, kozin f, mccarty dj. synovial origins of rice bodies in joint fluid. arthritis rheum 1980;23:72-76. 2. popert aj, scott dl, wainwright ac, walton kw, williamson n, chapman jh. frequency of occurrence, mode of development, and significance of rice bodies in rheumatoid joints. ann rheum dis 1982;41:109-117. 2. popert aj, scott dl, wainwright ac, walton kw, williamson n, chapman jh. frequency of occurrence, mode of development, and significance of rice bodies in rheumatoid joints. ann rheum dis 1982;41:109-117. 3. chen a, wong ly, sheu cy, chen bf. distinguishing multiple rice body formation in chronic subacromial-subdeltoid bursitis from synovial chondromatosis. skeletal radiol 2002;31:119-121. 3. chen a, wong ly, sheu cy, chen bf. distinguishing multiple rice body formation in chronic subacromial-subdeltoid bursitis from synovial chondromatosis. skeletal radiol 2002;31:119-121. 4. law tc, chong sf, lu pp, mak kh. bilateral subacromial bursitis with macroscopic rice bodies: ultrasound, ct and mr appearance. australas radiol 1998;42(2):161-163. 4. law tc, chong sf, lu pp, mak kh. bilateral subacromial bursitis with macroscopic rice bodies: ultrasound, ct and mr appearance. australas radiol 1998;42(2):161-163. 5. sugano i, nagao t, tajima y, et al. variation among giant rice bodies: report of four cases and their clinicopathological features. skeletal radiol 2000;29(9):525-529. 5. sugano i, nagao t, tajima y, et al. variation among giant rice bodies: report of four cases and their clinicopathological features. skeletal radiol 2000;29(9):525-529. 6. griffith jf, peh wc, evans ns, smallman la, wong rw, thomas am. multiple rice body formation in chronic subacromial/subdeltoid bursitis: mr appearances. clin radiol 1996;51(7):511. 6. griffith jf, peh wc, evans ns, smallman la, wong rw, thomas am. multiple rice body formation in chronic subacromial/subdeltoid bursitis: mr appearances. clin radiol 1996;51(7):511. 94 sa journal of radiology • september 2011 pictorial interlude recurrent primary fallopian tube carcinoma presenting with an appendiceal metastasis j s möller, fcnp j i basson, mmed (rad d) free state pet/ct centre, bloemfontein j l duminy, mmed (rad onc) wilmed park oncology centre, bloemfontein e potgieter, fc path (anat) pathcare laboratories, bloemfontein corresponding author: j moller (jakesmoller@hotmail.com) a 61-year-old woman presented with a moderately differentiated serous papillary adenocarcinoma of the left fallopian tube in 2004. the tumour infiltrated the tube to the external surface. the uterus, cervix, right fallopian tube and ovaries were free of tumour, but peritoneal washings revealed the presence of metastatic tumour. the patient underwent chemotherapy but relapsed in 2009. the ov125 tumour marker at this stage was 2 685 u/ml (normal range: 0 35), which decreased to 9.6 u/ ml following chemotherapy, and had increased again to 57.4 u/ml. a f-18 fdg pet/ct scan was requested for restaging, and demonstrated a retro-caecal appendix with a fdg-avid nodule in its tip, measuring 13 mm in the long axis (fig. 1; see next page). at the time, the differential diagnosis was carcinoid tumour, primary carcinoma and a metastatic lesion (from the known primary tubal carcinoma). no further macroscopic tumour sites could be imaged. histopathological analysis of the appendix revealed a metastatic serous papillary adenocarcinoma infiltrating through to the serosal surface (fig. 2). discussion primary fallopian tube carcinoma is a rare tumour, comprising less than 2% of female genital tract malignancies.1 the incidence peaks between the fourth and sixth decades of life, with a median age of 55. its presenting symptoms may be non-specific, and it is therefore not often diagnosed pre-operatively.2 clinical features include vaginal bleeding, abdominal pain, a pelvic mass and ascites. imaging (most commonly ultrasound) may demonstrate a tubal mass. the diagnosis is usually made by histopathological examination. tubal carcinoma spreads in much the same way as ovarian carcinoma, primarily by exfoliation of malignant cells that implant throughout the peritoneal cavity.3 the initial staging of tubal carcinoma is based on the surgical findings at laparotomy. treatment is similar to that of ovarian carcinoma, with surgery being the primary therapy aiming at tumour debulking and cytoreduction. adjuvant chemotherapy is recommended for all but the earliest tumours, owing to the high propensity for microscopic distant metastases with subsequent recurrence. literature on the utility of pet/ct in tubal carcinoma is understandably sparse and limited to case reports, where it was able to localise the site of tumour recurrence.4,5 however, pet/ct is expected to be of value, especially in the context of a rising tumour marker and negative conventional imaging, considering the clinical and pathological similarities between it and ovarian carcinoma, where the role of pet/ct is more clearly defined.6 1. ng p, lawton f. fallopian tube carcinoma – a review. ann acad med singapore 1998;27:693-697. 2. pectasides d, pectasides e, economopoulos t. fallopian tube carcinoma: a review. oncologist 2006;11:902-912. 3. riska a, leminen a. updating on primary fallopian tube carcinoma. acta obstet gynecol scand 2007;86:1419-1426. 4. takanami k, kaneta t, yamada s, et al. f-18 fdg pet/ct findings of primary carcinoma of the fallopian tube. clin nucl med;34:378. 5. patel pv, cohae c, chin bb. pet-ct localizes previously undetected metastatic lesion in recurrent fallopian tube carcinoma. gynecol oncol 2002;87:323-326. 6. prakash p, cronin cg, blake ma. role of pet/ct in ovarian cancer. am j roentgenol 2010;194:464-470. fig. 2. metastatic papillary serous adenocarcinoma in the appendix. sa journal of radiology • september 2011 95 pictorial interlude fig. 1. transaxial ct, pet and fusion images with the fdg-avid nodule in the tip of the appendix. 66 sa journal of radiology • september 2011 editorial cardiovascular imaging in south africa ‘humanity has but three enemies: heart failure, famine and war; by far the greatest, by far the most terrible, is heart failure.’ [sir william osler] background the role of the radiologist in cardiovascular imaging has followed a tortuous and often uphill road worldwide, with certainly no exception in south africa. since the discovery of x-rays by röntgen in 1895, the turf war between clinicians and radiologists regarding their ownership has always been fiercest around the imaging of the heart and great vessels. i vividly remember the meetings, during my preand post-graduate training years, between radiologists, cardiologists and thoracic surgeons, at which coronary angiograms, chest x-rays, ct scans (in their infancy) and, much later, echocardiograms were discussed. input from radiologists was valued during these discussions. this interdisciplinary contact has dwindled and petered out in most academic and private institutions. nowadays, a conventional coronary angiogram rarely finds its way into the x-ray department. initially, most echocardiograms were performed by radiologists, but this procedure rapidly settled snugly inside the cardiologist’s consulting room and became part of his or her routine examination. the radiologist or sonographer currently plays a minor role: mainly to exclude or confirm the presence of congenital, valvular or functional abnormalities referred by general practitioners, paediatricians, and others. the birth of multislice ct, especially 32and 64-slice scanners, sparked renewed enthusiasm among radiologists to delve into the coronary vessels (which had become the sole domain of the cardiologist). this occurrence did not go unnoticed among the cardiology community, resulting in them purchasing their own ct equipment – leading to a renewed turf battle between the two groups. but because of the ominous potential for self-referral (resulting in escalating costs), cta studies remained in the hands of radiologists. despite arguments pointing to the fact that a non-invasive procedure might increase the detection of important lesions and increase referrals for intervention (and in the process decrease unnecessary invasive coronary angiograms), referrals from cardiologists remained low. taking into consideration that this was a unique situation in which an imaging procedure needed to change hands, the result was probably predictable: serious under-utilisation of this exciting new non-invasive technique. peripheral angiography, however, historically belonged to radiology, and imaging of the carotid, renal and peripheral vessels simply became non-invasive procedures, performed in the radiology department and referred by vascular surgeons, physicians and neurosurgeons. cardiac magnetic resonance (cmr) imaging is the latest technique among the modalities used for imaging of the heart and great vessels. huge research interest led to an enormous number of publications presenting a clear understanding of its absolute value, especially when assessing myocardial perfusion, viability and function in ischaemic heart disease. cmr is also very valuable in the diagnosis of the cardiomyopathies, arrhythmogenic conditions, tumours etc. there is unfortunately a growing trend for publications to be authored solely by cardiologists. in the usa, 37.7% of studies are by cardiologists, according to a survey published in the journal of the american college of radiology (jacr) in 2006, indicating a decreasing involvement by the radiology community. despite the significant technical advances of the past 20 years, and growing research interest, relatively few cardiac mri studies are performed by radiologists, compared with competing and often inferior tests. alongside coronary cta, cardiovascular mri has become another orphan in our imaging armamentarium. the current economic climate worldwide as well as increasing pressures to curb the escalation in medical costs, are factors that clearly discourage the growth of cmr. it is furthermore not easy to prove to medical aid companies that a single, accurate and highly diagnostic – albeit expensive – modality would in many instances eliminate further additional and invasive tests. the future the problems outlined are not susceptible to easy resolution. however, as a first step, better communication between the parties involved would obviously help. renewed interest in cardiovascular imaging among radiologists in south africa, and the possible establishment of a fellowship in cardiac imaging locally, would naturally assist in enhancing our credibility. guidelines for cmr have been drawn up and task force criteria published. these need to be discussed among referring clinicians, radiologists and medical aid companies. the argument against self-referral is a very valid one: it has undeniably led to escalating medical costs worldwide. according to a metaanalysis published in the jacr recently (july 2011), the estimated cost in the usa in 2006 of increased imaging from self-referral was $3.6 billion. from 1996 to 2006, the total outpatient imaging rate by non-radiologists has increased by 71%. to attribute the rise in cardiac imaging exclusively to self-referral would be a distortion of the facts, as the escalation in costs is largely due to burgeoning technical advances in addition to a notable professional and academic career (and provincial colours for squash and swimming), leonie scholtz established her own radiology practice in 1993, which has subsequently expanded to 8 partners and 15 practices in pretoria and the lowveld. she has authored and co-authored numerous articles published in peer-reviewed and accredited journals, and has been an invited speaker at national and international conferences and workshops. she was professor and head of the department of diagnostic radiology and nuclear medicine at the university of pretoria from 2002 2005, and vice-president of the radiological society of south africa from 2004 2007. her interests and pastimes include art, photography and cinematography, french and english literature, and cycling. editorial 68 sa journal of radiology • september 2011 in recent years. this rise has furthermore paralleled a decline in the rate of death from heart disease as well as improvement in the quality of life for those living longer with heart disease. this is a fact often overlooked by governments and reimbursement companies. if we want to move to a proactive model of disease management, earlier and more advanced imaging is necessary, and government bodies and medical aid companies need to be involved in future discussions. the unique situation necessitating diagnostic procedures to be performed by radiologists, which traditionally belonged in the catheterisation laboratory, needs to be understood by the radiology community, and more tolerance between the groups is necessary. the emphasis should be on finding a reasonable solution while steering away from a territorial dispute that will tend to result in total exclusion of the cardiologist’s input in order to protect the radiologist’s domain. since cardiovascular disease is the leading cause of death worldwide, imaging of its core component – the heart – can hardly be regarded as unimportant by the radiology community. conclusion approximately 17 million people die every year from cardiovascular disease or stroke. south africa has a very high incidence of ischaemic heart disease. we have access to superb diagnostic tools that enable us to play a pivotal role in the non-invasive diagnosis of heart disease. i believe that the time is ripe for renewed discussions between the roleplayers (the rssa, cardiologists, radiologists and reimbursing companies) so as to elevate coronary cta and cmr to the level where they belong: undoubtedly enormously valuable diagnostic tools that are currently shamelessly underutilised, to the detriment of all too many patients who have an enhanced chance of dying of a cardiovascular condition as a result of being investigated by inferior and/or invasive tests. why do we get passionate about imaging everything else, from cortical white matter down to the ligaments of the feet, and in the process bypass the heart? why are we turning our backs on the largest pandemic in the world? are we too busy, too comfortable, too consumed with protecting our ‘economic turf ’, or have we simply given up on matters of the heart? leonie scholtz pretoria heart hospital pretoria scholtzleonie@gmail.com appointment.html appointment of deputy editor we extend a hearty welcome to dr razaan davis who joins the editorial board of the sajr as deputy editor. razaan became a fellow of the college of diagnostic radiologists of south africa in october 2009, qualifying as a master of medicine, specialising in radiology, at the university of cape town. she commenced duties as a senior consultant in the division of diagnostic radiology at tygerberg hospital in august 2010. she is an excellent teacher and competent administrator, and also at present a moderator for the stellenbosch university modular course in diagnostic radiology. at the time of assuming the sajr editorship with volume 12, issue 1 in 2008, i alluded to the necessity of always being aware of the need to bring in new blood, and am delighted at razaan’s appointment accordingly. at the time, i drew on a line from the aeneid by virgil (70 19 bc): vires acquirit eundo [gathering strength as it goes.]. i wish to reconfirm this, and we look forward to ongoing gathering of strength as we proceed into the next half-decade. jan lotz editor-in-chief in memoriam bryan joseph cremin bryan cremin was a great friend and a phenomenal teacher. i could easily write a series of articles about a trip to the okavango delta with bryan and richard hewlett – an experience that i’d never wish to repeat, but that i wouldn’t want to have missed for all the money in the world. kindly allow me to dedicate this issue of the sajr to an exceptional man and a great radiologist. the following is a tribute from one irishman to another. let others recall his academic achievements, but here let us listen to sean conway on bryan cremin, the man. jan lotz editor-in-chief tribute to bryan cremin by sean conway bryan joseph cremin was born in london on 2 september 1929 to a limerick gp father and a kerry mother, both of the province of munster, ireland. he was the baby of the family, with 2 elder sisters and an older brother, desmond, who is 92. having an eye for detail, he noted that he was conceived in ireland though born in england (‘of irish insertion but english extraction’, in his own words) as his family had emigrated to london during this period. by his admission, his father’s one failing was a penchant for gambling on the horses, which contributed to bryan’s fairly shrewd financial sense in life. he went to prep school in london – possibly the oratory – and i recall a photograph he had of himself in his house in school uniform with lopsided school cap and a cheeky, somewhat pugnacious grin. he attended guy’s hospital for his medical training and represented the hospital in both boxing and rugby football, at which he excelled; he also had a run with london irish and a rugby trial for ireland. on qualification, he underwent his national service in the royal army medical corps of the british army and was posted to malaya, where i first came across him when i was about 4 years old, around the time of the coronation (june 1953), while he was doing his national service as captain cremin in the 16th field ambulance in kuala lumpur, whose then co was my father, lieutenant-colonel steve conway. my first unknowing encounter with him was being thrown into the deep end of the swimming pool at the selangore club in kl on the instructions of my father – the order having been given for me to sink or swim; i’ve been doggy paddling ever since. during his time with the field ambulance, my father had him pegged as a most competent and ambitious officer with great charm, and both my parents became very fond of him; there were many hilarious and enjoyable sessions in the officers’ mess and elsewhere. he also tried his hand at ear piercing and charmed his way into my mother’s ear lobes which, apparently, was not immediately successful as the first attempt became slightly septic but with no lasting ill-effect. he was of adventurous spirit and, for the latter half of his national service, was attached to the sas as a medical officer. during this time my father, not lacking in spirit himself, underwent parachute training in the jungle. on one of these jumps, cremin and the others landed safely on the jungle floor, but my father was trapped and suspended up high from the branch of a tree. although uninjured, my father called out, ‘cremin [kreeman], have you got the medicinal brandy? pass it along now, if you please.’ – which bryan managed to achieve by means of a jungle vine. it took another 40 minutes to extricate my dad from the tree, but everyone was most relaxed and stress free – i’m told. an interesting sequela of the parachute jumps was the first article written by bryan: on the medical aspects of parachuting into the jungle from very low height – a technique pioneered in malaya at the time. it was the only article entirely written by cremin himself – but in which he appeared as second author, my father achieving first author status merely by virtue of army rank: (1). lt. col. s.m.p. conway, mc, ramc; (2). capt. b.j. cremin, ramc. following his national service, our family lost contact with bryan for many years. during this time he held a number of positions including gp work in the uk and an extended sojourn as ship’s surgeon on the p & o line. during one of these trips, he had a liaison with his nursing staff sister, which resulted in the birth of his daughter – although he was not aware of these details until much later in life when contact was made with him by her in the midto late-1990s. then and since, he made every effort to erase the time lost. he then underwent radiology training in london and further postgraduate radiology in australia. around 1967 he went to rhodesia, to mpilo hospital in bulawayo, where by chance i myself went in 1972 to do my internship followed by paediatrics, but i was unaware of his movements. he moved to south africa in 1968 to the red cross war memorial children’s hospital as a senior radiologist, and it was there that he made his mark as a paediatric radiologist of world renown. it was purely by chance that i ended up as a trainee radiologist at groote schuur hospital in june 1976, having finished my own national service in rhodesia and having started radiology in harare hospital, salisbury. at the time, bryan had established a worldwide reputation in paediatric radiology. he was honoured with the position of the chair of radiology at uct/groote schuur concurrent with his position as head of radiology at red cross hospital. as already said, he was ambitious but he deserved to be as this drive was backed up by enormous talent, hard work, academia and excellent organisation. groote schuur and red cross were staffed at the time by very talented and bright radiologists – i refer to the consultant staff specifically. these consultants were attracted from elsewhere largely on the reputation that bryan had established in international radiology. he was the author and co-author of literally hundreds of articles in the radiological literature. a criticism was that some of the co-authored articles were penned by his more junior staff, but he was indeed the sole author of many articles and a number of specialised paediatric textbooks and the genuine co-author of others including, with professor jannie louw, on neonatal paediatric git, and with aaronson on paediatric urology, among others. in the early 1980s he relinquished his position as professor of radiology at uct and returned to his first love of paediatric radiology at red cross hospital, maintaining his position as head of department. he continued to be an innovator and to attract doctors from all corners to the hospital. he had a special soft spot for the underdog and so-called ‘outsiders’ – he had not a trace of academic xenophobia and welcomed the fresh air that others could introduce into his department, and he went to great lengths to welcome, be hospitable to, and to discourse with, them at his house. he was still penning articles when he retired from red cross in 1995. he had a reputation as a lady’s man and was the master of well-chosen phrases; women seemed to treat him well. his companion in the most ambitious period of his life was sybil, whom i met only once or twice, and she passed on in the mid-1980s. but the love and stalwart of his life was edwina, whom i first met in 1988 shortly after they got together. at this time my parents had come to live in south africa and renewed their friendship. they saw quite a lot of bryan and edwina and always thoroughly enjoyed their company. after retiring from red cross, bryan and edwina maintained their adventurous spirit and lifestyle, travelling locally and abroad in a camper van. bryan also volunteered to do occasional unpaid saturday morning locums in our practice, which he did (and we paid him). he had a talent for occasionally saying or doing the somewhat outlandish, which antagonised some but which those of us who knew him learnt to take in our stride. i think edwina’s family had some initial reservations about him but soon welcomed him into their hearts. he was always most kind to me but never shy to state his mind. he stepped into the breach on several occasions: • he gave a best-man-type speech at 2 minutes’ notice at my chaotic garden wedding many years ago. • he kept a watching brief over me during the short and somewhat peculiar divorce period. • he gave an oration at my former wife’s funeral. • he also accepted gracefully when i hijacked him to be godfather to giselle. he was gentle and kind to giselle and was never short of a packet of jelly tots – she describes him as having an eccentric sense of humour and a kind fondness in his eyes. she always had a familiar and special feeling when stepping over the threshold of conor close to visit bryan and edwina and to play with the tabby cat and tortoise in the garden – a feature for many years. bryan maintained a beautiful garden and took delight in nurturing and seeing things grow and develop. he had the same attitude in life: never stopping still, erudite, eloquent, inquisitive, and questioning the why and the whereto. he had great humanity, was a brilliant orator, and entertaining company at all times. in recent years, when his mobility was reduced and he was losing some of his faculties, particularly memory, he was very lucky to have edwina who nurtured and looked after him with tremendous personal effort but, even as these faculties dwindled, he would always pop up out of the blue with an appreciative gesture or meaningful statement of his love and gratitude to her. i was not present at his passing in april, but edwina tells me he still mustered all his dignity as he died in her arms. he was succinct and direct to the last. this ends my somewhat personal contribution to the life of bryan – bryan joseph cremin – with apologies where indicated. we shall miss his indomitable nature, but his generous spirit lives on. 26 sa journal of radiology • march 2011 signs abstract total anomalous pulmonary venous return (tapvr) is a rare congenital cardiac defect that may present with cyanosis, cardiac failure and failure to thrive in infancy. tapvr type 1 has a typical radiographic appearance of the heart termed the snowman. we present a case of an infant with tapvr type 1 with injuries in keeping with non-accidental injury (nai) to highlight that children with chronic diseases are at greater risk of this kind of injury and that radiographic evaluation of the chest in cardiac disease plays a role beyond demonstrating the heart and vasculature of the chest. case report a 2-month-old boy presented to the paediatric casualty unit with a fluctuating level of consciousness after allegedly falling from a bed. a ct brain scan (figs 1 and 2) demonstrated a subarachnoid bleed associated with a right linear parietal skull fracture and an overlying scalp haematoma. on admission to the paediatric ward, hospital records identified the patient as belonging to the cardiac clinic for a cyanotic heart disease with a diagnosis of total anomalous pulmonary venous return (tapvr) type 1. further investigation into the history revealed inconsistencies with the mechanism of injury and the suspicion of non-accidental injury (nai) arose. a full skeletal survey was done. a chest x-ray (fig. 3) demonstrated the classic snowman sign, in keeping with tapvr type 1. the chest x-ray also showed multiple, predominantly left-sided, posterior and lateral rib fractures with callus formation. no long bone fractures were identified. discussion our patient demonstrated radiographic features of tapvr (the snowman sign) and of nai. tapvr results from the failure of pulmonary veins to connect to the left atrium. the pulmonary veins make an abnormal connection to the right atrium, with coronary sinus or systemic veins resulting physiologically in an extracardiac left-to-right shunt. this anomaly is accompanied by an intracardiac right-to-left shunt through a patent foramen ovale or an atrial septal the injured snowman fig.1. non-contrast ct of the brain at the level of the sylvian fissures demonstrates a subarachnoid bleed with the pseudo-delta sign. fig. 2. ct of the brain with bone windows demonstrates a linear right parietal skull fracture. n mahomed, mb bch, fcrad (d) m goodier, mb chb m modi, mb bch, fcrad (sa), mmed s andronikou, mb bch, fcrad, frcr (lond), phd department of radiology, university of the witwatersrand, johannesburg sa journal of radiology • march 2011 27 signs defect.1 clinical and radiological features depend on the location of the anomalous pulmonary venous connection. in tapvr type 1, the abnormal common pulmonary veins converge behind the heart to form the common pulmonary vein that connects to the vertical vein which drains in the left brachiocephalic vein. this results in the characteristic snowman appearance on chest x-ray. the head of the snowman is formed by the dilated vertical vein on the left, the superior vena cava on the right and the left brachiocephalic vein on top, while the body of the snowman is formed by the enlarged right atrium.1 plasticity of the infant’s skeleton and rib cage allows skeletal structures to deform rather than break until a threshold is reached. in infants without metabolic bone disease, rib fractures strongly correlate with nai because the mechanism that generates these fractures is specific.2,3 tight squeezing of the immature infant’s chest results in a complex array of compressive and levering forces resulting in fractures of the posterior, lateral and anterior ribs. the pattern of rib fractures depends on the forces distributed in an area dependent on the size of the perpetrator’s hands, and can be seen in similar locations in multiple adjacent ribs.2 in view of the underlying co-morbidity of a congenital cyanotic heart disease described in our patient, viewing the chest x-ray in isolation could result in misinterpretation of the multiple rib fractures as caused by cardiopulmonary resuscitation (cpr). use of back supports previously used in cpr, limited the excursion of the posterior rib arc relative to the spine, therefore limiting levering of the posterior rib head over the transverse process and preventing posterior rib fractures. however, the recent development of the two-handed infant cpr technique allows the hands to encircle the chest similarly to how a perpetrator holds a child when shaking him. therefore, posterior rib fractures, though uncommon, can occur with cpr.3 according to our patient’s medical records, there was no history of cpr. non-accidental head injury (nahi) occurs in approximately 12% of cases of physical abuse in children.2 in the absence of significant trauma, a skull fracture in an infant, as in our patient, suggests a higher likelihood of nai.3 subdural haemorrhage (sdh) and subarachnoid haemorrhage (sah) are common abusive injuries.2 shaking of the infant results in angular acceleration and deceleration shear forces that may tear the cortical bridging veins, resulting in sah or sdh.4 sah may also occur from direct contact forces which cause tearing of vessels.2 although there is no direct relationship between our patient’s specific cardiac defect and the physical abuse, a study by ammerman and patz indicates that children with disabilities and chronic illnesses may be at higher risk for nai.5 possible mechanisms for this include overwhelming demands on the parent in caring for the child and disruptions in the attachment process caused by long periods spent in hospital.5 conclusion a radiologist should look further than the obvious pathology on a radiograph. when imaging children, radiologists should always look for features of nai, in particular in children with chronic diseases or disabilities. 1. ferguson e, krishnamurthy r, oldham. classic imaging signs of congenital cardiovascular abnormalities. radiographics 2007; 27:1323-1334. 2. lonergan gj, baker am, morey mk, boos sc. child abuse: radiographic-pathologic correlation. radiographics 2003; 23:811-845. 3. offiah a, van rijn r, perez-rossello jm, kleinman pk. skeletal imaging of child abuse (non-accidental injury). pediatr radiol 2009; 39:461-470. 4. tung g, monica kumar m, richardson rc, jenny c, brown w. comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. pediatrics 2006; 118:626-633. 5. ammerman rt, patz rj. determinants of child abuse potential: contribution of parent and child factors. j clin child psychol 1996; 25(3):300-307. fig. 3. frontal chest x-ray demonstrating the classic snowman sign, in keeping with tapvr type1 and multiple, predominantly left-sided, posterior and lateral rib fractures with callus formation. abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) mirko trentadue radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy plinio calligaro intensive care unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy gianluigi lazzarini independent researcher, occupational medicine specialist, peschiera del garda, italy fabio bonomi boseggia radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy elena residori radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy jennifer hu radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy silvana vanti radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy linda lillo occupational medicine service, palazzo della sanità, aulss 9 scaligera, verona, italy giovanna varischi hospital medical management district 4, professional staff organization, aulss 9 scaligera, villafranca di verona, italy roberto cerini radiology unit, m. magalini hospital, aulss 9 scaligera, villafranca di verona, italy citation trentadue m, calligaro p, lazzarini g, et al. spontaneous bleeding in covid-19: a retrospective experience of an italian covid-19 hospital. s afr j rad. 2022;26(1), a2509. https://doi.org/10.4102/sajr.v26i1.2509 original research spontaneous bleeding in covid-19: a retrospective experience of an italian covid-19 hospital mirko trentadue, plinio calligaro, gianluigi lazzarini, fabio bonomi boseggia, elena residori, jennifer hu, silvana vanti, linda lillo, giovanna varischi, roberto cerini received: 22 july 2022; accepted: 18 sept. 2022; published: 31 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: haemorrhages in coronavirus disease 2019 (covid-19) patients require proper knowledge and management. objectives: to highlight the characteristics of haemorrhages in patients with covid-19 infection. method: a retrospective study examined ct scans performed over a 13-month period in patients hospitalised with covid-19 infection to determine those who developed spontaneous bleeding. the authors also investigated correlations between the bleeding events and the patients’ characteristics. results: haemorrhages occurred in 2.22% (31/1396) of patients hospitalised with covid-19 infection (7.88%, 19/241 in the intensive care unit). bleeding, major in most cases, occurred in anticoagulated patients, especially males with multiple comorbidities, aged between 60 and 79 years and mainly appeared in a single anatomical region (especially retroperitoneal), with the most voluminous in the chest wall. the complication was diagnosed on average 16.7 days after admission and occurred predominantly in critically ill patients undergoing invasive ventilation and pronation-supination cycles. in just under half of the cases, the haematomas were active, and in these cases, mainly with a single contrast blush and with earlier onset after the start of anticoagulation than in non-active bleeding. major bleeding was also earlier in the presence of multiple morbidity. the vast majority of patients were treated conservatively and survived. conclusion: at covid-19 hospital centres, it is advisable that there is knowledge of such a complication for which ct imaging is essential for diagnosis and proper management. although some authors have expressed doubts about anticoagulant treatment in patients with covid-19, the bleeding complication in this study did not significantly affect the outcome. contribution: spontaneous haemorrhage did not significantly affect the outcome in this series. keywords: covid-19; bleeding; haemorrhage; haematoma; retroperitoneum. introduction haemorrhagic complications in coronavirus disease 2019 (covid-19) patients require management referral from spoke facilities and biocontainment measures to central facilities (hub).1 ct imaging plays a pivotal role in the management of covid-19 infection, particularly in critically ill patients. since the onset of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic, ct has been the dominant modality in defining the severity of pulmonary involvement by allowing a rapid and preliminary stratification of patients into risk categories, providing useful elements for therapeutic planning and prognostic evaluation. ct imaging also has a fundamental role in the diagnosis and monitoring of complications, most of which are life-threatening, such as neurological, vascular, gastrointestinal or renal complications, thus improving the outcome of covid-19 patients.2,3 this research describes the characteristics of spontaneous haematomas found on ct scans in a cohort of patients with covid-19 infection, admitted to a covid-19 hospital (‘m. magalini’ hospital, villafranca di verona aulss 9 scaligera, verona, italy) and to search for any correlations between the bleeding events and any anamnestic, clinical and laboratory patient characteristics. materials and methods this was a single-centre retrospective observational study. the radiology information system-picture archiving and communication system (ris-pacs) database was analysed by examining all the ct scans performed from 01 march 2020 to 30 april 2021 in patients hospitalised with covid-19 infection at ‘m. magalini’ hospital, villafranca di verona – aulss 9 scaligera, verona, veneto, italy. male and female patients affected by covid-19 (confirmed with molecular research of viral dna using a nasopharyngeal swab) and who developed one or more haematomas during hospitalisation, were included. the ct examinations performed in both the unenhanced and post-contrast phases, involving at least one of the following body areas, were included in the evaluation: neck, thorax, abdomen, upper and lower limbs and pelvis. any examinations targeting the spine, skull, and facial bones as well as those performed on patients with pathologies other than covid-19 were excluded. imaging, clinical, laboratory and therapeutic aspects all studies were performed with a 16-layer multidetector ct scanner (toshiba astelion 16, japan), 120 kv. the acquisition protocols involved an unenhanced phase, and when completed with intravenous iodenated contrast administration (iopromide, ultravist 370 mg/ml, 1.2 mg/kg, bayer healthcare pharmaceuticals inc., berlin, germany), they were performed with bolus tracking, using an infusion flow of not less than 3.5 ml/s, with arterial (15–20 s), venous (60–70 s) and sometimes late (3–5 min) phase scans. the images were transmitted to the pacs for post-processing. multiplanar reconstruction (mpr) and reprocessing was carried out with impax client software version 6.6.1.0 (agfa healthcare nv, mortsel, belgium). data recorded included whether the detected haematomas were single or multiple, noting the specific anatomical structures where the bleeding was located and grouping them into the following locations: thoracic wall, thoracic cavity, abdominal wall, retroperitoneum, intraperitoneal, pelvis, neck, upper and lower limbs. for each haematoma, the latero-lateral, craniocaudal and anteroposterior diameters were measured by means of mpr reconstructions, expressed in centimetres, approximating the measurements to the nearest whole number. the shape of the haematomas was qualitatively evaluated equivalent to ellipsoids, estimating their volume in cubic cm = ml with the formula: using the online tool https://keisan.casio.com/exec/system/1223392149. for each haematoma, the presence of contrast blush, unior multifocal, in the arterial and venous phase was investigated. additional data included patient age and sex, hospitalisation date, discharge date, start of anticoagulant treatment date, length of hospitalisation, date of the first ct examination diagnostic for haematoma and number of days elapsed between this examination and the date of hospitalisation and initiation of anticoagulation, and whether during the hospitalisation they were admitted to the intensive care unit (icu). these patients were standardised to receive enoxaparin twice a day (bid) based on body weight: 4000 u bid if < 80 kg, 6000 u bid if between 80 kg and 120 kg, 8000 u bid if > 120 kg. the enoxaparin dosage was modulated in relation to the d-dimer trend, creatinine clearance (< 30 ml/min), occurrence of bleeding and anaemia. all icu patients who developed haematomas were transfused with at least one bag of concentrated red blood cells to ensure adequate oxygen delivery. in cases with thrombocytosis (platelets [plt] > 450*103/µl), treatment with acetylsalicylic acid 75 mg/day – 100 mg/day was started, if not contraindicated. in relation to the haemodynamic stability/instability and the blood count trend, a conservative approach was implemented with remodelling of the anticoagulant therapy using calcium heparin suspension of anti-aggregation and transfusion of multiple bags of red blood cells. if invasive management was necessary, the patients were transferred to the reference hub. the data of patients who underwent invasive mechanical ventilation, reported trauma and major bleeding during hospitalisation, defined according to the criteria of the international society on thrombosis and haemostasis (isth), were recorded.4 for each patient, previous comorbidities, any anticoagulant or antiplatelet treatments in place at the time of admission and some laboratory parameters measured at the time of both admission and the first diagnostic ct study were deduced from the electronic medical records. the appearance of other relevant complications, particularly of a thromboembolic ischaemic nature, diagnosed by ct, was also investigated. finally, the outcome in patients discharged and deceased (from any cause) was recorded. statistical analysis the study utilised the ibm® spss® statistics software package, version 28.0 (ibm corp., armonk, ny, united states [us]). results population among the 931 ct studies performed in the hospital from 01 march 2020 – 30 april 2021, the authors identified a cohort of 31 patients meeting the inclusion criteria (23 males [74.20%] and 8 females [25.80%]), 19 of whom (61.3%) were hospitalised in the icu and 12 (38.7%) in non-intensive wards. the average age was 71.12 years (range 52–93 years; males: 69.90, range 53–83 years; females: 74.11, range 52–93 years) for a total of 14 (45.16%) in the age group 70–79; 11 (35.48%) in the 60–69 age group; 3 (9.67%) in the 50–59 age group; 3 over 80 (9.67%): patients in the 60–79 age group represented 80.64% of the sample (25/31). there was a significant correlation (p = 0.01 with pearson’s coefficient r = 0.44) between the male gender and the age group 60–79 years. bleeding occurred in 2.22% of patients hospitalised for covid-19 (31/1396) while in the subpopulation of patients hospitalised in the icu, the percentage was 7.88% (19/241). in 29/31 cases (93.6%), the bleeding was major according to isth criteria. the average length of hospitalisation was 37.58 days (range: 9–138 days), with a mean of 42 days (range: 13–138) for patients admitted to icu and 30.58 days (range: 9–48) for the others. imaging haematomas were diagnosed on contrast ct scans in 30/31 cases (96.78%) while in 1/31 cases (3.22%) the diagnosis was reached by unenhanced ct imaging in a patient with reduced glomerular filtration rate; given the haemodynamic stability, a contrast medium injection was not necessary for the investigation. the first ct diagnosis of haematoma was made on average at 16.70 days from hospitalisation (range 0–33 days), at 18.7 days in icu patients (range 5–33) and at 13.6 days in patients admitted to other units (range 0–31 days). the diagnosis was made at admission in two patients. in all cases, unenhanced ct images revealed the presence of volumetric increase of the anatomical structures involved, which were inhomogeneously hyperdense (~ 60 hounsfield units). none of the cases raised differential diagnostic doubts with other pathologies (e.g. abscesses or sarcomas), given the clinical history (e.g. anaemia, hypotension, anticoagulant treatment) and imaging characteristics (e.g. absence of gas within the lesions, absence of calcifications or contrast enhancement, presence of contrast medium spillage) (figures 1–8). figure 1: a 65-year-old man with a retroperitoneal haematoma in the left iliopsoas muscle, diagnosed 17 days after hospital admission. (a) parasagittal plane, arterial phase: a contrast blush (arrowhead) can be seen in the lower part of the haematoma (arrow). (b) axial plane, venous phase: the patient later developed a minor splenic infarct (asterisk). the patient underwent endovascular embolisation and survived. figure 2: a 74-year-old woman with multiple haematomas, the first diagnosed 28 days after hospital admission. (a) coronal plane, venous phase: the image shows the haematomas in the right iliopsoas muscle (arrowhead), in the right retius’ space (arrow) and in the vastus medialis muscle of the right thigh (asterisk). (b) axial plane, venous phase: the image shows the haematoma in the retius’ space on the right side (arrow), displacing the bladder with urinary catheter inside the lumen (asterisk). the same patient later developed pulmonary thrombo-embolism (not shown). figure 3: a 65-year-old man with multiple haematomas, the first diagnosed 22 days after hospital admission. (a) axial plane, venous phase: haematoma (arrow) in the left psoas muscle. (b) coronal plane, pulmonary arterial phase: endoluminal filling defect in the right pulmonary artery (arrowhead). the patient underwent endovascular treatment and survived. figure 4: a 73-year-old man with multiple haematomas, the first diagnosed 18 days after hospital admission. (a) axial plane, venous phase: right subscapular haematoma (arrow). (b) axial plane, arterial phase: left gluteal haematoma (arrow) with a small blush in the inner part (arrowhead). (c) coronal plane, venous phase shows the right subscapular haematoma (arrow) and a haematoma in the abdominal wall (asterisk). figure 5: a 79-year-old man with a chest haematoma diagnosed 10 days after hospital admission. (a) axial plane, not-enhanced phase demonstrates a huge inhomogeneous haematoma in the right chest wall (arrow). (b) axial arterial phase image shows an active arterial bleed (arrowhead) in the medial part of the haematoma (arrow). (c) parasagittal plane, arterial phase indicates the ellipsoid shape of the haematoma (asterisk). some other small contrast blushes can be seen in the posterior part of the haematoma (arrowheads). the patient underwent endovascular embolisation and survived. figure 6: a 59-year-old man with a left retroperitoneal haematoma diagnosed 19 days after hospital admission. (a) coronal plane, venous phase image shows a retroperitoneal haematoma (arrow) and an extensive thrombus in the left iliac vein extending into the inferior vena cava (asterisk). the left kidney is displaced by the haematoma (arrowhead). (b) axial plane, pulmonary arterial phase demonstrates pulmonary thrombo-embolism (arrowheads). the patient underwent endovascular embolisation and survived. figure 7: a 76-year-old woman with an abdominal wall haematoma diagnosed 8 days after hospital admission. (a) axial arterial phase image reveals the haematoma in the left rectus muscle (arrowhead). no contrast blushes were detected. (b) parasagittal venous phase image shows the longitudinal extent of the haematoma in the abdominal wall (arrow), with a layered fluid–fluid blood level. the same patient later developed pulmonary thrombo-embolism (not shown). figure 8: a 71-year-old man with a huge arterial feeder in an abdominal wall haematoma diagnosed 14 days after hospital admission. (a) axial arterial phase, mip reconstruction image demonstrates a bilobed-shaped left abdominal wall haematoma (arrow) with multiple foci of arterial blushes (arrowheads). (b) arterial parasagittal and (c) coronal planes, mip reconstruction images show the longitudinal extent of the haematoma (arrowheads) and the arterial blushes in its lower part (arrows). the patient, also developed pulmonary thrombo-embolism (not shown) and required endovascular embolisation twice, but later demised. in 3/31 cases (9.67%) there was a history of trauma: two cases of accidental falls with minor injury and with an unclear correlation with bleeding diagnosed after a few days (retroperitoneal haematoma of 1900 ml, haematoma of 824 ml of the rectus femoris muscle), while in the third case, a small haematoma developed adjacent to the access site of a jugular central venous catheter. iatrogenic significance was attributed to this bleeding (p = 0.001; r = 0.56), however, a retroperitoneal haematoma developed the next day without any trauma correlation. in 22/31 patients (70.96%) the haematomas were single, while in 9/31 patients (29.04%), multiple haematomas were found with a total of 43 anatomical sites affected, listed in table 1. there was a significant correlation between the presence of bleeding in the retroperitoneal space (p = 0.019; r = 0.42) and in the pelvis (p = 0.022; r = 0.41) and the development of multiple haematomas. table 1: imaging characteristics. in 46.66% ct exams (14/30 performed with contrast medium), the authors found active arterial contrast extravasation (table 1) a correlation was found between active haematomas and a unifocal blush (p = 0.000; r = 0.65) and with multifocal contrast extravasations (p = 0.002; r = 0.54). significant correlations were observed between the presence of active arterial blush and male sex (p = 0.031; r = 0.39) and between the same event and a history of antiplatelet therapy for previous comorbidities (p = 0.022; r = 0.41). finally, a significant inverse correlation was observed between bleeding with active contrast extravasation and the time elapsed from the start of anticoagulant treatment (p = 0.03; r = −0.43); haematomas with active bleeding occurred earlier. laboratory result averages at admission and at ct diagnosis are listed in table 2. there was a significant inverse correlation between major bleeding and haemoglobinaemia at the time of diagnosis (p = 0.004; r = −0.51), while a significant inverse correlation was found between platelet blood count at the time of diagnosis and the development of multiple haematomas (p = 0.027; r = −0.39). a significant inverse correlation was observed between the development of active bleeding and the activated partial thromboplastin time (aptt) ratio on the day of hospitalisation (p = 0.05; r = −0.36). table 2: patient characteristics, clinical features, treatment, outcome and laboratory tests. comorbidities the presence and/or absence of comorbidities is listed in table 2. the most frequent comorbidities were hypertension in 27/31 cases (87.09%), body mass index (bmi) > 30 in 15/31 cases (48.38%) and heart disease in 15/31 cases (48.38%). less frequent were dyslipidaemia in 12/31 cases (38.70%), type ii diabetes in 8/31 cases (25.80%), non-covid-19 respiratory disease in 5/31 cases (16.13%), neurological pathology in 4/31 cases (12.9%), liver disease in 3/31 cases (9.67%), chronic kidney disease in 2/31 cases (6.45%) and known chronic infectious diseases, rheumatological, haematological, oncological conditions and endocrinopathies in one case each. the authors found a significant direct correlation between the presence of multiple comorbidities and arterial hypertension (p = 0.002; r = 0.52), while obesity was more significant in males (p = 0.018; r = 0.42). the inverse correlations between age and obesity (p = 0.000; r = −0.69) and age and type ii diabetes (p = 0.01; r = −0.45) were very significant. a significant inverse correlation between the presence of multiple comorbidities and the time elapsed from hospitalisation to diagnosis (p = 0.046; r = −0.36) was also observed; in these patients, the haematomas developed earlier. other complications of the 31 patients, 10 (32.25%) developed thromboembolic ischaemic complications during hospitalisation despite all being anticoagulated patients; 7/31 patients (22.58%) developed pubmonary thromboembolism (pte) (figures 3 and 6), in one case with deep vein thrombosis (dvt) (figure 6), one subtotal splenic infarction (figure 1), one subtotal renal ischaemia and one dvt. treatment of the 31 patients, 17 (54.83%) underwent invasive ventilation manoeuvres with pronation and supination cycles, while 14/31 (47.17%) underwent c-pap ventilation. all patients received anticoagulant therapy during hospitalisation. therapy started on average 1.92 days after admission from −2 to 17 days; one patient had already started treatment at home two days before admission. of the 31 patients, 5 (16.12%) were already on anticoagulant therapy for previous pathologies, while 12/31 (38.7%) received the treatment upon hospital admission. of the 31 patients, 13 (41.9%) were on antiplatelet therapy prior to admission. in 25/31 cases (80.65%) the treatment of haematomas was conservative, while 6/31 patients (19.35%) underwent endovascular embolisation at the hub hospital; 2/6 (33.3%) later demised. the haematomas were not surgically evacuated in any of the cases. a significant direct correlation was found between embolisation and active contrast extravasation (p = 0.002; r = 0.54) and with the evidence of multifocal contrast blushes on ct (p = 0.001; r = 0.59). outcome during the review period, 1396 patients affected by covid-19 were admitted to the authors’ centre (241/1396 [17.26%] in the icu) of whom 25.14% (351/1396) died, (77/241 [31.95%] in the icu). among patients with spontaneous bleeding, there were 4/31 deaths (12.90%) from any cause. this equated to 1.13% (4/351) of all deaths of patients affected by covid-19 and 5.2% (4/77) of icu deaths. all four deceased patients had multiple comorbidities, were hospitalised in the icu and had developed major bleeding. these patients, two males and two females, with a mean age of 75.75 years (75 years, males; 76.5 years, females), who died at an average of 19.75 days after admission (range: 18–24), had received the ct diagnosis of haematoma on an average of 14.5 days after admission. pulmonary embolism also occurred in one case and septic shock in another. the mean volume of haematomas in deceased patients was 953.2 ml; in 3/4 cases (75%), the bleeding involved only one anatomical site; and in 3/4 cases (75%), the bleeding was active (in two cases with multifocal contrast blush). a significant inverse correlation was found between death and haemoglobin values on the day of admission (p = 0.024; r = −0.40): haemoglobin at admission was significantly lower in patients who later died. the 27/31 surviving patients (87.1%, mean age 70.4 years) were discharged after an average hospital stay of 40.22 days (30.5 if hospitalised in the ward, 47.93 if in the icu); 21/27 (77.8%) suffered major bleeding (4/21 treated with embolisation) and developed haematomas with a mean volume of 634.26 ml, diagnosed on average 17 days after admission. the main imaging and population characteristics are summarised in table 1 and table 2. discussion role of anticoagulation in covid-19 therapy and risk factors for haematomas anticoagulant treatment is recognised as a possible cause of muscle haematomas in adult patients unaffected by covid-19.5,6 during the covid-19 pandemic, in addition to the pulmonary and neurological manifestations, the alteration of the coagulation pathway soon appeared significant, which represented the rationale for the use of heparin.5,7,8,9,10,11,12,13,14,15,16 this alteration resulted both in the form of hypercoagulability11,14,17 with expressions of a thromboembolic nature (e.g. pte, dvt), whose mechanism is still necessary to investigate,13 and in the form of haemorrhagic diathesis with depletion of coagulation factors, thrombocytopenia and hyperfibrinolysis.14,18 among the risk factors for the development of bleeding in covid-19 patients, contributing causes have been proposed, such as pronation manoeuvres, anticoagulant treatment, obesity, increased vascular fragility determined by the pro-inflammatory state, barotrauma from ventilation by c-pap and cough with consequent increase in intra-abdominal pressure and arterial rupture.17,19 many of these risk factors coincide with those that have been documented in this article. godier and colleagues observed that bleeding occurred in the hyperinflammation reduction phase typical of these patients, as evidenced by the reduction of fibrinogen and d-dimer.20 the biphasic coagulative alterations proposed by them, firstly pro-thrombotic and subsequently haemorrhagic in the phase of resolution of the inflammation, could be useful in explaining the average 16.7 days which elapsed from hospitalisation to diagnosis in our population. other authors have also highlighted the development of the complication at about two weeks.21,22 as proposed by kessler et al., it could therefore be reasonable to reduce anticoagulant treatment after 10–14 days in patients with favourable clinical progress.23 epidemiology qiu et al. reported that covid-19 itself represents a risk factor for bleeding by detecting bleeding in 35% of a cohort of these patients versus 10% in a cohort of patients with community-acquired pneumonia.24 a frequency of bleeding complications ranging from 4.8% to 8% with 3.5% major bleeding has been reported in patients with covid-19.9,25,26 however, these frequencies are widely variable. fraissé et al. reported a bleeding rate of 21% in their critically ill patients, 84% after anticoagulation at therapeutic doses.27 in two different papers, al-samkari et al. reported an overall bleeding rate of 4.8% with 2.3% major bleeding9 while in critically ill patients they reported a 2.8% rate of major bleeding approximately two weeks after admission to the hospital icu.28 demelo-rodriguez et al. found less frequent bleeding in patients admitted to the non-intensive ward compared with those in intensive care.29 in our case study 61.29% of bleeding (19/31) occurred in icu patients compared with 38.71% (12/31) in patients in other wards, although this difference did not show significance. lucatelli et al.1 reported a predominance of this complication in males (68.00% vs 74.20% in this study) and multifocal bleeding in 68.40% of cases, which is higher than the 29.03% in this study. in the authors’ icu, the incidence of complication was 7.88% (19/241) with 7.46% (18/241) major bleeding, compared with an overall incidence of 2.22% (31/1396) with 2.07% (29/1396) major bleeding; the data are substantially comparable to that reported by other authors.30,31 symptoms and imaging muscular haematomas are blood spills in a muscle group that can remain contained by the fascial plane or spread to adjacent spaces (e.g. peritoneum) and are spontaneous if not associated with trauma.32 symptoms of muscle haematomas are of variable magnitude: local (e.g. skin hypersensitivity, peritoneal signs in the abdominal wall or retroperitoneal haematomas) and general (e.g. tachycardia, hypotension, pallor), while complications include compartment syndrome, superinfections, compressive neuropathies and diffusion in adjacent spaces (e.g. haemoperitoneum).32,33 ct imaging with contrast medium is the gold standard for diagnosis and allows for defining the topography and size of the bleeding, highlighting compression complications, showing active contrast extravasation, providing useful indications to the interventionist on the bleeding vessel, as well as evaluating the possible coexistence of thromboembolic or ischaemic manifestations.8,13,26,32,34 dohan and colleagues argued that the presence of active bleeding is related to a greater severity of the clinical picture.32 in 75% (3/4) of our deceased patients, ct imaging detected active bleeding versus 40.7% (11/27) in the surviving patients, although this difference did not have statistical significance. the most commonly represented bleeding site in our case study was the retroperitoneum. in their case report, nakamura et al. recalled the lenk triad (haemodynamic shock, palpable mass, severe pain) as a possible manifestation of these haematomas26 while some authors have shown that retroperitoneal haematomas are associated with high mortality and can manifest themselves with haemorrhagic shock and are often underdiagnosed, especially in sedated and intubated patients.11,34,35 vergori et al. highlighted a higher incidence of retroperitoneal haemorrhages in covid-19 patients with 7.6 cases/1000 hospitalisations (12.18 cases/1000 hospitalisations in this series) versus 3.8 cases/1000 reported in critically ill non-covid-19 patients.11,36 as in some cases in our study, benazzi et al. reported pulmonary embolism in one of their two cases,17 dennison et al. reported the case of a patient with splenic ischaemia, abdominal wall haemorrhage and mesenteric vessel infarction,13 while concomitance of dvt and haemorrhage has been reported by other authors.19,37 laboratory shah et al. observed that prothrombin time is a poor predictor of bleeding,25 dohan et al. found international normalized ratio (inr) values in the therapeutic range in many cases32 while sottilotta et al. reported that there are no specific laboratory predictors for the onset of haematomas.38 lucatelli and colleagues highlighted the role of covid-19-induced thrombocytopenia as a cause for an increased risk of major bleeding during treatment with therapeutic dose heparin.1 in the work of al-samkari et al., the d-dimer value at hospitalisation was considered predictive of the risk of bleeding, thrombosis, clinical severity and death while the prolongation of the prothrombin time was associated with a reduction in survival and a worse clinical picture.9 in this case study, although the mean inr, aptt and blood platelet count values were normal at the time of haematoma diagnosis, more active bleeding was observed in patients with lower aptt values at admission and multiple bleeding in patients with lower blood platelet count values at diagnosis. the mean d-dimer value was high both at admission and at diagnosis, although this was not statistically significant. patients with a poor outcome had lower haemoglobin on admission. treatment as there are no guidelines for the treatment of the complication, treatment must be multidisciplinary and ‘tailored’ to the individual patient.11,13,39 however, lucatelli et al. supported the endovascular approach compared to conservative management.18 riu and colleagues highlighted some severity criteria such as active blood extravasation, retroperitoneal site, conspicuous size, haematoma wall rupture, reduction in haemoglobin greater than 2 g/dl or 3 g/dl, need for repeated transfusions and presence of thromboembolic complications with difficulty in interrupting anticoagulation.39 dohan and colleagues proposed the surgical option in cases of nerve compression or cutaneous ischaemia, however, highlighting frequent relapse with this approach. they underlined that small intrafascial haematomas can self-resolve, suggesting an endovascular approach for voluminous active haematomas.32 interestingly, while highlighting how heparin-induced bleeding tends to self-resolve upon discontinuation of anticoagulant treatment, lucatelli et al. decided not to discontinue this therapy, considering it necessary in patients with covid-19, given its association with an increase in survival in critically ill patients.1,40,41,42 in this case study, 80.65% of patients (25/31) were managed conservatively. among the six embolised patients, two died (33.33%) versus two (8.00%) patients who died among the 25 patients managed conservatively; however, this difference was not statistically significant. outcome mattioli et al. believed that the risk of haemorrhagic events could be underestimated as the focus appears more on the pro-thrombotic side of the alterations in the coagulative cascade, possibly also because of the lower lethality of the haemorrhagic complications.14,35 al-samkari et al. observed a 28-day mortality rate of 62.2% among critically ill patients with bleeding complications compared with 38.2% among patients with venous thromboembolic complications; however, noting a frequency of bleeding complications of approximately half than that of venous thromboembolic complications.28 the overall mortality among patients admitted for covid-19 at the authors’ centre was 25.14% (351/1396) and 31.95% (77/241) among those admitted into the icu, substantially in line with the overall mortality in icu patients of 31.6% reported by shah et al.,25 in our cohort of bleeding patients, mortality was 12.90% (4/31) representing only 1.13% of all deaths among patients with covid-19 (4/351). furthermore, unlike godier et al. who reported a mortality of 50.00% among critically ill patients with bleeding complications (vs 37.00% in patients without bleeding),20 this case study found lower mortality among patients bleeding in the icu (21.05%, 4/19) versus 32.88% (73/222) critically ill non-bleeding patients; this difference was not statistically significant. conclusion although some authors have expressed doubts about anticoagulant treatment in patients with covid-19,43,44,45 the bleeding complication in this study did not significantly affect the outcome. bleeding, major in most cases, occurred in anticoagulated patients, especially males with multiple comorbidities (e.g. obesity and heart disease), aged between 60 and 79 years and mainly appeared in a single anatomical region (especially retroperitoneal), with the most voluminous in the chest wall. the complication was diagnosed on average 16.7 days after admission and occurred predominantly in critically ill patients undergoing invasive ventilation and pronation-supination cycles. in just under half of the cases, the haematomas were active and mainly with single contrast extravasation. in addition, taking into account the start of anticoagulation, haematomas with active bleeding had an earlier onset than those without contrast blush. major bleeding was also experienced earlier in the presence of multiple morbidity and the vast majority of patients were treated conservatively and survived. at covid-19 hospital centres, it is advisable that there is knowledge of such a complication for which ct imaging is essential for proper management. limitations and bias the study is retrospective in nature and in the absence of a control group it is difficult to state the real impact of the complication on the outcome. anticoagulant treatment is another bias; moreover the authors did not stratify the population based on the dose of anticoagulant administered. in patients who developed multiple haematomas, we only reported the date of the first diagnostic ct scan and only bleeding diagnosed by ct was recorded. the history of non-iatrogenic trauma found in two patients could be a confounding factor. acknowledgements the authors would like to thank the following for their kind collaboration: hospital medical management district 4, aulss 9 scaligera, verona, italy; doctress antonella scandola unit for clinical research palazzo della sanità – verona; ms. manuela deotto it service, aulss 9 scaligera villafranca di verona, italy; ms. gabriella facincani and ms. daniela benassuti clinical records office, aulss 9 scaligera, “m. magalini” hospital, villafranca di verona, italy. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.t. (corresponding author) was involved in conception, literature, protocol drafting, ethics committee, data collection, text, revision, data interpretation, conclusions and coordination. p.c. was responsible for conception, text, clinical support and data collection. g.l. was responsible for statistics, tables and data interpretation. f.b.b. was involved in image selection and post-processing and wrote figure captions. e.r. was involved in revision of the manuscript. s.v. and j.h. were involved in literature and revision. l.l. performed data interpretation and revision. g.v. was responsible for support and revision. r.c. was involved in support, revisions and supervision. all the authors have approved the final article. ethical considerations the positive opinion of the institutional review board and the local ethical committee verona-rovigo (italy) was obtained (resolution no. 684 of 16/09/2021). patients’ data were processed according to the helsinki protocols and all data were managed in compliance with current privacy italian legislation and in accordance with the 2016 general data protection regulation (gdpr). anonymity was guaranteed to each patient, and no one received compensation. with reference to the acquisition of the informed consent of the patients involved, the authors referred to the ‘general authorisation for the processing of personal data carried out for scientific research purposes – 01 march 2012’ (published in the italian official gazette no. 72 from 26 march 2012) as well as what is stated in article in the epidemiology section, ‘derogations from consent’ of the document ‘ethics during the research of the covid-19 pandemic: observational and in particular epidemiological studies – iss bioethics covid-19 working group’ (version 29 may 2020). funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing is not applicable to this article. 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massive acute deep vein thrombosis as initial presentation of covid-19. cureus. 2020;12(8):e9772. https://doi.org/10.7759/cureus.9772 sottilotta g, mangano c, basile r, et al. iliopsoas hematoma in patients with covid-19 on low-molecular-weight heparin treatment. sage open med case rep. 2021;9. https://doi.org/10.1177/2050313x211016991 riu p, albarello f, di stefano f, et al. management of spontaneous bleeding in covid-19 inpatients: is embolization always needed? j clin med. 2021;10(18):4119. https://doi.org/10.3390/jcm10184119 paranjpe i, fuster v, lala a, et al. association of treatment dose anticoagulation with in-hospital survival among hospitalized patients with covid-19. j am coll cardiol. 2020;76(1):122–124. https://doi.org/10.1016/j.jacc.2020.05.001 musoke n, lo kb, albano j, et al. anticoagulation and bleeding risk in patients with covid-19. thromb res. 2020;196:227–230. https://doi.org/10.1016/j.thromres.2020.08.035 nadkarni gn, lala a, bagiella e, et al. anticoagulation, bleeding, mortality, and pathology in hospitalized patients with covid-19. j am coll cardiol. 2020;76(16):1815–1826. https://doi.org/10.1016/j.jacc.2020.08.041 chan nc, weitz ji. covid-19 coagulopathy, thrombosis, and bleeding. blood. 2020;136(4):381–383. https://doi.org/10.1182/blood.2020007335 santoro f, núñez-gil ij, viana-llamas mc, et al. anticoagulation therapy in patients with coronavirus disease 2019: results from a multicenter international prospective registry (health outcome predictive evaluation for corona virus disease 2019 [hope-covid19]). crit care med. 2021;49(6):e624–e633. https://doi.org/10.1097/ccm.0000000000005010 pesavento r, ceccato d, pasquetto g, et al. the hazard of (sub)therapeutic doses of anticoagulants in non-critically ill patients with covid-19: the padua province experience. j thromb haemost. 2020;18(10):2629–2635. https://doi.org/10.1111/jth.15022 cpd questionnaire 80 sajr june 2013 vol. 17 no. 2 a maximum of 5 ceus will be awarded per correctly answered and completed test. concerning the article entitled ‘the tale of two embolisations’: 1. in the vast majority of patients, massive haemoptysis originates from the bronchial circulation more so than the pulmonary circulation in the vast majority of patients. 2. bronchial artery embolisation has been used as preferential treatment for recurrent and massive haemoptysis since 1973. 3. rasmussen aneurysm is a common cause of recurrent and sometimes massive haemoptysis in patients with cavitatory pulmonary tuberculosis. concerning the article entitled ‘an unusual case of intrahepatic portosystemic venous shunt’: 4. intrahepatic shunts are more common than extrahepatic, and occur between intrahepatic portal veins and systemic veins. 5. pathogenesis of intrahepatic, non-tumorous portosystemic shunts may be due to portal hypertension. concerning the article entitled ‘pseudoachondroplasia: report on a south african family’: 6. affected individuals are born with normal facies and abnormal length. 7. false achondroplasia is an autosomal recessive skeletal dysplasia that results in micromelic short stature, severe brachydactyly with markedly lax small joints and malalignment of lower limbs due to laxity of large joints. 8. pseudoachondroplasia is the most common of the group of disorders under the term spondylo-epi-metaphyseal dysplasia. 9. mutations of the comp gene, encoding the cartilage oligomeric mineral protein, cause pseudoachondroplasia. concerning the article entitled ‘the pattern and prevalence of vertebral artery injury in patients with cervical spine fractures’: 10. risk factors for vertebral artery injury include facet joint dislocations and fractures of the vertebral bodies of the 1st 3rd cervical vertebrae. 11. fractures through/involving the transverse foramina of the cervical vertebrae have up to 78% incidence of vertebral artery injury. 12. a grade iv injury of the vertebral artery according to the blunt carotid and vertebral artery injuries (bcvi) grading system includes transection and total occlusion of the vessel. 13. grade iv injuries of the vertebral arteries are associated with a 22% risk of stroke and a 44% risk of mortality. concerning the article entitled ‘primary extradural meningioma arising from the calvarium’: 14. primary edm represents a meningioma that arises in any tissue, without direct extension from an intracranial tumour. 15. these tumours have previously been variously named as extracranial, ectopic, extradural, extraneuraxial, cutaneous, calvarial or intraosseous meningiomas. 16. the most common mri appearance is that of a hyperintense t1w and hypointense t2w bone lesion that shows intense homogeneous contrast enhancement following intravenous gadolinium administration. 17. on ct examination, the part of the skull that is involved usually has a hyperdense osteolytic appearance and demonstrates no intense contrast enhancement. concerning the article entitled ‘urachal remnant carcinoma – a rare entity’: 18. in early fetal development, the ventral cloaca (precursor of the urinary bladder) is connected to the allantois via the urachus, which undergoes progressive involution, resulting in an obliterated, fibrous cord by 32 weeks’ gestation. 19. patients with urachal remnant carcinoma present early with haematuria, dysuria, abdominal pain, umbilical mass or bloody mucoid discharge. 20. ct is pivotal in tumour staging, demonstrating local extent of disease, pelvic lymphadenopathy and systemic spread with perilesional fat stranding highly specific for malignancy. instructions: 1. cpd questionnaires must be completed online by registering with www.cpdjournals.co.za. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your cpd certificate(s). 4. please contact the online manager (021 681 7200 or publishing@hmpg.co.za) in the event of queries. accreditation number: mdb001/012/01/2013 (clinical) cpd questionnaire mark each numbered statement as true (a) or false (b). http://www.cpdjournals.co.za mailto:publishing@hmpg.co.za abstract introduction patient presentation discussion conclusion acknowledgements references about the author(s) luke d. metelo-liquito department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa thandi e. buthelezi department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation metelo-liquito ld, buthelezi te. sellar spine: a rare bony variant of the sella turcica. s afr j rad. 2022;26(1), a2371. https://doi.org/10.4102/sajr.v26i1.2371 case report sellar spine: a rare bony variant of the sella turcica luke d. metelo-liquito, thandi e. buthelezi received: 12 dec. 2021; accepted: 16 feb. 2022; published: 28 apr. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a sellar spine is a rare osseous projection from the dorsum sellae, resulting in variable compression of sellar and suprasellar structures and varied clinical presentations. ct is the diagnostic modality of choice, while variable signal intensity on mri may mimic a pituitary microadenoma. a patient presented with hypoprolactinaemia and puerperal alactogenesis due to a sellar spine diagnosed on ct brain. neurosurgical and endocrine review and pituitary mri were recommended with subsequent loss to follow-up. keywords: sellar spine; pituitary fossa; sella turcica; bony variant; hypoprolactinaemia. introduction a sellar spine is an osseous spur projecting from the dorsum sellae and is a rare variant of the pituitary fossa. this reported case of a sellar spine is unique for two reasons. to our knowledge, this is the first reported sellar spine that arises from the mid-ventral aspect of the dorsum sellae, with most of the previously described cases in the literature arising from the inferior ventral aspect of the dorsum sellae and two arising from the superior aspect of the dorsum sellae.1,2,3,4,5,6,7,8,9,10 secondly, the history of puerpural alactogenesis and mild hypoprolactinaemia has not yet been described in any of the known reported cases in the literature. patient presentation a 37-year-old woman with no known co-morbidities presented with a single episode of menorrhagia (1-month history of menstrual bleeding), severe constant headaches for one year, and a history of puerperal alactogenesis in all four of her previous pregnancies. physical examination was unremarkable. hormone levels: thyroid-stimulating hormone (tsh) and prolactin were mildly decreased. follicle-stimulating hormone (fsh) and luteinizing hormone (lh) were elevated (tsh: 0.33 miu/l (normal range 0.35–5.50 miu/l), thyroxine (free t4): 17.5 pmol/l (normal reference range 11.5–22.7 pmol/l), prolactin: 4.7 µg/l (normal range 4.8–23.3 µg/l), fsh: 31 iu/l, lh: 7.7 iu/l, oestradiol: < 19 pmol/l, progesterone: < 0.2 nmol/l). pelvic ultrasound was unremarkable. she was referred to the radiology department for ct brain to exclude any pituitary pathology. ct brain demonstrated a bony spur, consisting of a narrow stalk with a mildly distended tip, arising from the mid-anterior aspect of the dorsum sellae in the midline, projecting anterosuperiorly into the pituitary fossa. the spur measured 5.5 mm in length and compressed the posterior pituitary and the distal posterior aspect of the pituitary stalk (figures 1 and 2). no other intracranial pathology was noted. figure 1: ct of the pituitary fossa. (a) bone window in the sagittal plane in the midline demonstrating the sellar spine (arrow) protruding into the pituitary fossa producing a ‘figure of 3’ sign of the dorsum sellae. (b) soft tissue window in the sagittal plane in the midline demonstrating compression of the pituitary and distal pituitary stalk by the sellar spine (arrow). (c) bone window in the axial plane demonstrating the midline position of the sellar spine (arrow). figure 2: volume rendered ct of the sella turcica, (a) oblique view and (b) superior view, demonstrating the sellar spine (arrow) protruding into the pituitary fossa. non-urgent neurosurgical review, repeat endocrine profile and mri of the pituitary gland with dynamic contrast enhancement were recommended; however, the patient was lost to follow-up. discussion a sellar spine is a rare midline osseous spur, which arises from the dorsum sellae and projects into the pituitary fossa.1 in 1977, lang et al. described the first case in an article describing atypical ossifications of the sella turcica.11 it is a rare entity with an estimated incidence of 1 in 5000–8000.1,12 the leading hypothesis for its development is that it is due to the failure of regression of the most cephalic aspect of the notochord through the clivus into the vertebral column, resulting in a remnant of a notochordal rest in the fetal sella; this remnant then ossifies.1 other proposed hypotheses by dietemann et al. include ossification of a dural fold and an ossified vascular channel.1 in all the described cases, the sellar spine was located in the midline in keeping with the foremost theory that it is an ossified remnant of the notochord.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16 the most consistent imaging morphology of the bony spur among the literature was that of a narrow cylindrical bony stalk with a mildly distended tip and a flattened triangular base in continuity with the dorsum sellae.1,2,3,9,11,12,13 in most cases, the tip had a smooth contour; however, in one of the cases, it was irregular.1,2,3,7,11,12 the maximum described length was 9.0 mm.2 for the remainder of the reported cases, the length of the sellar spine ranged between 3.8 mm and 5.0 mm, making this case the second longest reported case at 5.5 mm.3,4.5,11,12,14 in most of the cases, the sellar spine arose from the inferior aspect of the anterior dorsum sellae with only two cases reported to be arising from the superior aspect.1,2,3,4,5,6,7,8,9,10 to our knowledge, this is the first case, reported, where the sellar spine arises from the mid-anterior aspect giving a ‘figure of 3’ sign of the dorsum sellae in the sagittal plane (figure 1). the spine most commonly projects in an anterosuperior orientation, with one case observed to be in a more horizontal orientation and one case in an anteroinferior orientation.2 the most commonly compressed structure is the posterior pituitary, in keeping with the anteroinferior origin from the dorsum sellae.8 in the two cases where there was an anterosuperior origin from the dorsum sellae, compression of the pituitary stalk as well as the optic chiasm was observed.5,6 our case compresses the junction of the stalk and posterior pituitary due to its mid-anterior origin. the age at presentation is varied and ranges from 8 to 53 years, with most of the cases reported between the ages of 13 and 29 years.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16 a possible explanation for this distribution is the slow progressive growth of the sellar spine over time, as well as normal progressive enlargement of the pituitary gland. this combination increases the probability of compression of the pituitary gland and thus the development of symptoms. this theory is supported by the findings of hosokawa et al. who demonstrated interval growth of the sellar spine in a patient for whom serial images were obtained over time.14 on the contrary, chivukula et al. demonstrated no significant growth on serial images obtained from their patient.8 another possible explanation for the development of symptoms in our case is the normal growth of the pituitary gland in pregnancy, as postulated by chivukula et al.8 the spectrum of described clinical presentations is varied, with most cases being asymptomatic.7 the most common presenting complaint among the reviewed literature was headache.4,6,7,8,13,15 the other common neurological manifestation was bitemporal hemianopia due to optic chiasm involvement.8,9,15 of the endocrine manifestations, there were varying degrees of hypopituitarism, with diabetes insipidus being the most explicable of these findings.2,9,15 few of the cases demonstrated pituitary hyperfunction, including hyperprolactinaemia and cushing’s syndrome; the pathophysiological mechanism for this is not understood.3,8,12 our case describes the first presentation with puerperal alactogenesis and mild hypoprolactinaemia. other endocrine disturbances in our case included elevated fsh and lh levels and decreased tsh levels; this combination of findings has not been previously described and may be attributed to the combination of pituitary and pituitary stalk compression or laboratory error. a repeat hormonal profile would have been of great benefit had the patient not been lost to follow-up. ct is the gold standard imaging modality to assess for a sellar spine as it appears as a well-ossified structure in continuity with the dorsum sellae.7 on mri, sellar spines have variable signal intensity depending on the marrow content.3,4,5,6,7,8,10,13,14,15,16 in the absence of marrow, they are hypointense on t1and t2-weighted images due to densely packed cortical bone and hyperintense on t1 and t2-weighted images if bone marrow is present; in addition, they are nonenhancing.3,4,5,6,7,8,10,13,14,15,16 a sellar spine is most commonly seen as a t1 hypointensity in the posterior pituitary and can thus be easily misdiagnosed as a pituitary microadenoma.7 the pituitary bright spot may be lost, and there may be deformation of the pituitary gland as adjunctive findings.15 chivukula et al. described transsphenoidal resection of the sellar spine in their patient with panhypopituitarism.8 there was a reported complete resolution of symptoms and hormonal imbalance following the surgical resection of the sellar spine in their case.8 an important differential for an intrasellar bony projection is a post-traumatic base of skull fracture with a projection of a bony fragment into the pituitary fossa such as in the case described by parizel et al.17 conclusion although a sellar spine is a rare entity, it should be considered in patients being referred for diagnostic imaging for potential pituitary pathology as they can present with variable symptoms and endocrine disturbances. ct is the imaging modality of choice because of its accurate visualisation of osseous pathology, while, caution should be practised when using mri, as sellar spines can have variable signal intensity depending on the marrow content and can therefore mimic pituitary microadenomas. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions l.d.m.-l. and t.e.b. were involved in the reporting of the initial ct scan for the case described in the case report. l.d.m.-l. wrote the case report and t.e.b. supervised this process and edited the final case report. ethical considerations ethical approval for the study was received from the human research ethics committee of the university of the witwatersrand (m210986, 14/10/2021). funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability the findings of the study are supported by data that can be found in the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references dietemann jl, lang j, francke jp, bonneville jf, clarisse j, wackenheim a. anatomy and radiology of the sellar spine. neuroradiology. 1981;21(1):5–7. https://doi.org/10.1007/bf00518787 abs r, van breusegem l, verhaert g, smet h, parizel pm. intrasellar bony spine, a possible cause of hypopituitarism. eur j endocrinol. 1995;132(1):82–85. https://doi.org/10.1530/eje.0.1320082 hyo jae l, lee y, baek b, yoon w, kim s. incidentally detected sellar spine in a patient with cushing’s syndrome: a case report. j int med res. 2020;48:030006052094015. https://doi.org/10.1177/0300060520940159 johnston pc, ellis pk, mccance dr. sellar spine: a rare cause of t1 signal hyperintensity and apparent pituitary enlargement. qjm. 2014;107(4):323–323. https://doi.org/10.1093/qjmed/hct147 matsumoto k, uchino a, kato a, kudo s, kuno t. ct and mri of sellar spine with upward extension of the pituitary gland: case report. eur radiol. 1997;7(2):287–288. https://doi.org/10.1007/s003300050152 carpenzano m, marini e, valenti re, ambrosetto p. upward oriented sellar spine. mri findings: a case report. neuroradiol j. 2010;23(4):426–428. https://doi.org/10.1007/s003300050152 demir mk, toktaş zo, kılıc t. sellar spine: a rare osseous anomaly. acta neurol belg. 2020;121:571–572. https://doi.org/10.1007/s13760-020-01457-5 chivukula s, everson r, linetsky m, et al. challenging diagnosis and surgical management of a symptomatic sellar spine. world neurosurg. 2016;91:669.e7–669.e10. https://doi.org/10.1016/j.wneu.2016.03.046 jacinto vm, andrade sd, martins s, et al. sellar spine associated with endocrine and neuro-ophthalmological manifestations. neuro-ophthalmology. 1985;5(1):57–60. https://doi.org/10.3109/01658108509071461 fujisawa i, asato r, togashi k, hayakawa k, nakano y, konishi j. mr imaging of the sellar spine. j comput assist tomogr. 1988;12(4):644–645. https://doi.org/10.1097/00004728-198807000-00022 lang j. structure and postnatal organization of heretofore uninvestigated and infrequent ossifications of the sella turcica region. acta anatomica. 1977;99(2):121–139. https://doi.org/10.1159/000144840 lamasters dl, boggan je, wilson cb. computerized tomography of a sellar spine: case report. j neurosurg. 1982;57(3):407–409. https://doi.org/10.3171/jns.1982.57.3.0407 ambrosetto p, frank g, brayda g, busacca m. ct and mr of the sellar spine. neuroradiology (berl, print). 1991;33(5):465. https://doi.org/10.1007/bf00598632 hosokawa t, yamada y, sato y, tanami y, kurihara j, oguma e. postnatal sellar spine growth. medicine (baltimore) [serial online]. 2016 [cited 2020 nov 13];95(33). available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5370814/ orr a, braunreiter c, keefe c, christy m, betz bw. pituitary sellar spine in a pediatric patient with diabetes insipidus. clin imaging. 2021;69:145–147. https://doi.org/10.1016/j.clinimag.2020.07.002 eguchi k, uozumi t, arita k, kurisu k, sumida m, nakahara t. sellar spine and pituitary adenoma: mr and ct appearance. j comput assist tomogr. 1994;18(6):994. https://doi.org/10.1097/00004728-199411000-00031 parizel p, brussaard c, moor j, schepper a. posttraumatic pituitary dysfunction and intrasellar bony spur. fortschr röntgenstr. 1990;153(10):487–488. https://doi.org/10.1055/s-2008-1033423 abstract introduction case report discussion conclusion acknowledgements references about the author(s) farhana e. suleman department of radiology, faculty of health sciences, university of pretoria, pretoria, south africa moipone n. vilakazi department of radiology, faculty of health sciences, university of pretoria, pretoria, south africa meshack bida department of anatomical pathology, faculty of health sciences, university of pretoria, pretoria, south africa richard edwards department of radiology, faculty of health sciences, university of pretoria, pretoria, south africa citation suleman fe, vilakazi mn, bida m, edwards r. primary giant cell tumour of the breast with recurrence: a rare case report. s afr j rad. 2022;26(1), a2393. https://doi.org/10.4102/sajr.v26i1.2393 case report primary giant cell tumour of the breast with recurrence: a rare case report farhana e. suleman, moipone n. vilakazi, meshack bida, richard edwards received: 06 jan. 2022; accepted: 18 feb. 2022; published: 20 apr. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract giant cell tumour (gct) arising from the soft tissues of the breast is a rare disease with only eight cases previously reported in the literature. we present a case of histologically proven gct of the breast, which demonstrated recurrence a few months after resection. keywords: giant cell tumour; breast tumour; gct-st; breast imaging. introduction microscopically, giant cell tumours (gcts) are diagnosed when an even distribution of multinucleated osteoclast-like giant cells (ogcs) are noted surrounded by oval and spindle mononuclear cells.1 they usually occur in the epiphysis of skeletally mature long bones and are called gct of the soft tissues (gct-st) when they occur in the soft tissue instead of bone.1 giant cell tumours of the soft tissues are usually found in the superficial and deep soft tissues of the extremities but have been described in the pancreas, lung, thyroid gland, urothelial tract, skin, larynx, heart and very rarely, in the breast.1,2 breast carcinomas containing ogcs compromise less than 2% of all breast cancer cases.3 however, primary gct of the breast resembling the one found in bone, and not related to underlying breast carcinoma is extremely rare with only eight other cases found, described in the literature between 1981 and 2020.1,2,4,5,6,7,8,9 this report focuses on a 58-year-old woman with histologically proven primary ogc-st of the breast, with a discussion on the radiological and histological findings, and a review of the available literature. case report a 58-year-old woman was referred with a self-detected mass in the left breast. she had no past or family history of breast disease and no underlying comorbidities. clinically on palpation, a firm, non-tender, well-defined left-sided breast mass measuring approximately 210 mm × 160 mm was noted extending into the axilla. ipsilateral axillary lymphadenopathy was palpated with no contralateral, supraclavicular or infraclavicular lymphadenopathy present. the clinical diagnosis of a phyllodes tumour was made, and the patient underwent a core biopsy of the mass and ipsilateral axillary lymph node by the surgeon prior to imaging. she was then referred to the radiology department for a mammogram and a breast ultrasound. the left mammogram demonstrated a 126 mm × 110 mm, circumscribed, round mass within the upper outer quadrant. the mass was homogenous with mass effect on the adjacent glandular tissue as displayed in figures 1a and 1b. ultrasound of the left breast demonstrated a large anechoic mass with septations and an irregular inner thickened wall with debris as displayed in figures 2a and 2b. the right mammogram and ultrasound were within normal limits. the mass was classified as a breast imaging-reporting and data systems (bi-rads) 4a lesion and the patient was referred back to the surgeons. an image-guided biopsy was not performed at this stage because the patient was awaiting histology results for the biopsy performed by the surgeon. subsequent biopsy results of the mass and lymph node showed features compatible with organising fat necrosis with a reactive lymph node. this was thought to be incompatible with the clinical imaging findings and therefore not representative of the pathology. unfortunately, because of the long waiting times for mri and the size of the lesion, the decision was made to take the patient for surgery. the patient then underwent a left-sided mastectomy; her tumour node metastases (tnm) staging prior to surgery was t3n0mx. figure 1: cranio-caudal view of the left breast on initial mammogram (a) and mediolateral oblique view (b) demonstrating a well-defined, hyper-dense mass within the supero-lateral aspect of the breast. figure 2: axial/transverse view (a) and sagittal/ longitudinal view (b) of the left breast on initial ultrasound, demonstrating a large anechoic mass with multiple septations and irregular walls with debris. histology of the mastectomy specimen revealed a large well-encapsulated tumour with necrotic debris. the tumour was multinodular and consisted of sheet-like arrangements of neoplastic mononuclear cells with evenly interspersed multinucleated ogcs. these mononuclear cells appeared plump, resembling histiocytic cells, admixed with oval to spindle-shaped cells, resembling myofibroblasts as demonstrated in figures 3a and 3b. there was no carcinomatous component present in all the sections examined. figure 3: histology of the surgical specimen. the tumour was composed mainly of oval and spindle mononuclear histiocyte-like cells and multinucleated giant cells; hematoxylin and eosin stain, × 4 (a) × 20 (b). immunohistochemistry of the tumour. oval and spindle mononuclear histiocyte – like cells and multinucleated giant cells stain positively for cd68 (c) and negatively for ae1/3 and mnf – 116 (d). nuclear atypia, characterised by nuclear enlargement, hyperchromasia and pleomorphism, was noted with as many as four mitotic figures per 10 high power field in some areas. in addition, aneurysmal bone cyst-like spaces were focally seen, containing red blood cells, but not lined by endothelium. cd68 stained the ogcs as well as some of the intervening histiocytic cells. mnf-116 and ae1/3 were negatively immunoreactive (figures 3c, 3d). the results were in keeping with a gct arising from the soft tissues of the breast. the patient then defaulted on her follow-up appointments including an appointment for a staging ct scan. five months after the mastectomy, she was referred for a repeat mammogram and ultrasound for multiple large lesions at the left mastectomy site. the mammogram of the left scar demonstrated a 50 mm × 60 mm hyper-dense mass within the axillary tail as displayed in figure 4. ultrasound of the left mastectomy site demonstrated round hypoechoic lesions at the scar as demonstrated in figures 5a and 5b. the largest measured 20 mm × 11 mm, situated at the inferior-lateral aspect of the scar and not separable from the underlying pectoralis muscle. large axillary masses consisting of fluid with areas in keeping with soft tissue densities were demonstrated; the largest measured 56 mm × 38 mm. the lesion was classified as bi-rads 4c. ultrasound-guided core biopsy of the largest lesion demonstrated a poorly differentiated malignancy with ogcs – features in keeping with recurrence. the patient underwent a single cycle of radiotherapy and was then referred to oncology where she was treated with adriamycin and continues follow-up. figure 4: post-surgical, medio-lateral oblique view of the left mastectomy scar demonstrating a hyper-dense mass within the axillary tail. figure 5: post-surgical, axial (a) and sagittal (b) views of the left breast on ultrasound demonstrating the largest hypoechoic lesions at the inferior-lateral aspect of the scar. this lesion was not separable from the underlying pectoralis muscle. discussion commonly gct-st is found in the superficial and deep soft tissues of the extremities but has been described in the pancreas, lung, thyroid gland, urothelial tract, skin, larynx, heart and very rarely in the breast.1,2 osteoclast-like giant cell tumour of the soft tissues is histologically and immunophenotypically similar to gct arising in the epiphysis of long bones with a diffuse distribution of ogcs, but it is important to evaluate the background component of mononuclear cells to make the diagnosis.5 osteoclast-like giant cell tumour of the soft tissues of the breast is a rarely diagnosed primary tumour of the breast with only eight cases previously reported in the literature.1,2,4,5,6,7,8,9 the prognosis is therefore still unknown. although it is usually considered a benign tumour, it may recur locally but seldom metastasizes.5 there are reports, however, describing osteoclast-like giant cell tumour of the soft tissue (ogct-st) as a biologically heterogeneous group of tumours ranging from benign to highly malignant.1 because it is so rare the prognosis is uncertain and standard therapy has not yet been established.8 this case is the only ogt-st of the breast to report local recurrence with aggressive behaviour. pulmonary metastases and death were reported in another case of ogct of the breast.5 no associated breast carcinoma was noted in either case. clinically the majority of these patients have presented with large masses, with the current case being the second to be clinically assessed as a phyllodes tumour.6 one reported case was associated with an intraductal papilloma7 and another had an adjacent separate tumour, histologically in keeping with ductal carcinoma in situ.9 on imaging, the majority of the cases reported well circumscribed tumours on mammogram, and all had hypoechoic cystic regions with solid tumour on ultrasound. all the gross specimens reported necrosis. the differential diagnosis to be considered in this case would include a multitude of other carcinomas, including breast cancer with ogcs and other tumours presenting with abundant giant cells such as leiomyosarcoma, osteosarcoma, malignant fibrous histiocytomas and metastatic gct of bone.5,7 underlying carcinoma of the breast with ogc’s is also uncommon and occurs in less than 2% of breast carcinoma cases.3 while these tumours are most commonly moderately or poorly differentiated invasive ductal carcinoma,10 a rare subtype of metaplastic carcinoma with osteoclast-like giant cells, comprising 11% of metaplastic carcinoma,11 should be differentiated from primary gct of the soft tissues of the breast.12 a lack of epithelial component, marked cellular atypia, and pleomorphism differentiates gct from these tumours. pathological assessment of the surgical specimen from the patient presented, demonstrated a relatively homogeneous and bland-appearing feature and only mild degree of nuclear pleomorphism throughout the tumour, which excluded breast cancer with ogcs, leiomyosarcoma, osteosarcoma, and malignant fibrous histiocytoma. metastatic gct of the bone was excluded by the absence of a history of gct of the bone. conclusion giant cell tumour of the soft tissues of the breast is an extremely rare tumour with the potential to recur locally and to metastasize. long-term prognosis is therefore uncertain and the importance of long-term clinical and radiological follow-up after resection is emphasised in order to detect any form of possible recurrence early and ensure swift, concise treatment options. acknowledgements the authors would like to gratefully acknowledge dr j.c. linden and dr c. campaini from the pathology department at the tshwane academic laboratory for assistance with the histological diagnosis of this tumour and recurrence. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions f.e.s. conducted the literature review, wrote the article and prepared radiological images. m.n.v. conceptualised the article and edited the final draft. m.b. contributed to the histology findings and images and edited the final draft. r.e. assisted with literature review and clinical information. ethical considerations ethical clearance to conduct this study was obtained from the university of pretoria, faculty of health sciences research ethics committee (number: 400/2021). funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article, as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references sawa a, tatsuhiko i, emika i, et al. preoperative diagnosis of a giant cell tumor of the soft tissue arising from the breast by ultrasound-guided core needle biopsy. j med ultrason. 2019;46:257–261. https://doi.org/10.1007/s10396-018-0891-0 romics l, mallon ea, reid r, cordiner cm, doughty jc. osteoclast-like giant cell tumor arising in the soft tissue of the breast: report of a case. surg today. 2009;39:48–51. https://doi.org/10.1007/s00595-008-3774-y albawardi as, awwad aa, almarzooqi ss. mammary carcinoma with osteoclast-like giant cells: a case report. int j clin exp pathol. 2014;7(12):9038–9043. lucas jg, sharma hm, o’toole rv. unusual giant cell tumor arising in a male breast. hum pathol. 1981;12(9):840–844. https://doi.org/10.1016/s0046-8177(81)80088-3 may sa, deavers mt, resetkova e, johnson d, albarracin ct. giant cell tumor of soft tissue arising in breast. ann diagn pathol. 2007;11:345–349. https://doi.org/10.1016/j.anndiagpath.2006.03.013 gaspar bl, sharma s, singh r, vasishta rk. primary giant cell tumor of the female breast: a diagnostic red herring with therapeutic implications. j pathol microbiol immunol. 2016;125(s1):32–37. https://doi.org/10.1111/apm.12634 fukunaga m. giant cell tumor of breast. virchows arch. 2002;441:93–95. https://doi.org/10.1007/s00428-002-0630-0 terada m, gondo n, sawaki m, et al. a case of giant cell tumor of the breast, clinically suspected as malignant breast tumor. surg case rep. 2019;5:77. https://doi.org/10.1186/s40792-019-0635-4 luangxay t, osako t, yonekura r, et al. giant cell tumor of soft tissue of the breast: case report with h3f3a mutation analysis and review of the literature. pathol res pract. 2020;216(2):152750. https://doi.org/10.1016/j.prp.2019.152750 syed h, edi b, frederick k, paul r. carcinoma with metaplasia and low-grade adenosquamous carcinoma. rosen’s breast pathology. 4th ed. the netherlands: wolters kluwer; 2014. wargotz es, norris hj. metaplastic carcinomas of the breast: v. metaplastic carcinoma with osteoclastic giant cells. hum pathol. 1990;21(11):1142–1150. https://doi.org/10.1016/0046-8177(90)90151-t jadhav ds, bagate an, swami sy, sonwane br. metaplastic carcinoma of breast-giant cell rich variant. indian j cancer. 2010;47(1):88–89. https://doi.org/10.4103/0019-509x.58876 32 sa journal of radiology • february 2012 review roentgenographic diagnosis of mucopolysaccharidosis with particular reference to morquio syndrome umesh parashari, mb bs, md (radiodiagnosis) sachin khanduri, mb bs, md (radiodiagnosis) samarjit bhadury, mb bs, md (radiology) sugandha rawat, mb bs, dmrd (std) department of radiodiagnosis, era’s lucknow medical college, lucknow, uttar pradesh, india corresponding author: u parashari (drumesh.rd@gmail.com) introduction mucopolysaccharidosis (mps) is a rare inherited biochemical disorder characterised by the accumulation of mucopolysaccharides (glycosaminoglycans) in various body tissues owing to insufficient amounts of the enzyme galactosamine sulphate (type a) and galactosidase (type b) to break them down. a deficiency of either enzyme leads to the accumulation of mucopolysaccharides in the body, abnormal skeletal development and additional symptoms. the symptoms are variable, with types a and b being clinically indistinguishable. the incidence of mps iv (morquio-brailsford syndrome, more commonly known as morquio syndrome) varies with geographic location – about 1 in every 75 000 births in northern ireland for morquio syndrome type a, for example. symptoms are usually noticed between ages 1 and 3 years. a family history of the syndrome raises the risk for the condition. it was first described, simultaneously and independently, in 1929, by luis morquio in montevideo, uruguay, and james brailsford in birmingham, england.1,2 they both recognised the occurrence of corneal clouding, aortic valve disease and urinary excretion of keratan sulphate. morquio observed the disorder in 4 siblings in a family of swedish extraction. patients with morquio syndrome usually can be clinically distinguished from patients with other forms of mps in that their intelligence is unimpaired, in contrast with other forms of mps. husler coined the term dysostosis multiplex to describe the skeletal findings. the radiological features in our patient were consistent with dysostosis multiplex. radiographic features include oval vertebral bodies with anterior beaking and unossified femoral heads with proximal femoral valgus deformities and broad, flat (wine-glass shape) ilia. case report a boy presented with complaints of short stature, limping and spinal deformity. physical examination showed pectus carinatum, short neck, knock knees, kyphosis, projecting jaw, broad mouth and flat feet. hypermobility of all the joints was noted. the limbs were normal in length. there was marked hepatosplenomegaly with coarse facies and abnormal gait. intelligence and development was appropriate for age. his slit-lamp examination, ecg and audiometry were completely normal .after radiological evaluation, he was confirmed as a case of morquio syndrome. x-ray of the skull showed frontal bossing with j-shaped sella (figs 1b and 1c). there was odontoid hypoplasia (one of the most critical feature of morquio syndrome) along with atlantoaxial subluxation in radiographs of the cervical spine performed in flexion and extension views (figs 1c and 1d). there were vertebra plana, or flattened vertebral bodies, with kyphoscoliosis and central beaking (figs 1 and 2). this can be distinguished from the ovoid vertebral bodies of hurler’s syndrome and other mucopolysaccharidoses. the central anterior beaking of morquio’s syndrome also differs from the anteroinferior beaking of hurler’s syndrome and other mucopolysaccharidoses. broadening of the anterior portion of the ribs (tongue shaped) was observed (fig. 2). ap radiography of both hands with wrist revealed conical (bullet-shaped) proximal bases of 2 5 metacarpals with normal construction of metacarpal shafts. the ossified carpal bones were small and reduced in number for the patient age. the planes of both the distal ulnar and radial growth plates were slanted towards each other (fig. 3). the pelvic film showed flared ilium laterally with inferior constriction (wine-glass shape) (fig. 4). frontal view of the femurs revealed enlarged acetabular cavities with rough margins, and poorly formed femoral epiphyses and widened femoral necks with coxa valga (fig. 4). x-rays of both knees in ap view and legs with feet in ap and lateral views showed genu valgus, metaphyseal expansion of long bones, and tapering of the proximal phalanges respectively (fig. 5). all these typical radiological features with specific laboratory findings confirmed this case as the rare metabolic syndrome of morquio syndrome. abstract mucopolysaccharidosis (mps) comprises a group of conditions associated with an abnormality in glycoprotein or mucopolysaccharides metabolism. types of mps identified are mps i-h (hurler’s syndrome, gargoylism), mps ii (hunter’s syndrome), mps iii (sanfilippo’s syndrome), mps iv (morquio-brailsford syndrome), mps i-s (scheie’s syndrome) and mps vi (maroteauxlamy syndrome). the hunter type is inherited as an x-linked recessive; the others are autosomal recessive. patients with mps iv can usually be clinically distinguished from patients with other forms of mps; their intelligence is unimpaired, in contrast with other forms of mps. husler coined the term dysostosis multiplex to describe the skeletal findings. sa journal of radiology • february 2012 33 review discussion morquio’s syndrome is a genetic disorder caused by the lack of the enzyme responsible for the breakdown of the mucopolysaccharide keratin sulphate. the resulting build-up of keratin sulphate causes a specific pattern of abnormalities. affected children have normal intelligence and usually survive well into adulthood. two forms are recognised: type a, a deficiency of the enzyme galactosamine-6 sulphatase; and type b, a deficiency of the enzyme beta-galactosidase. a genetic defect has been identified in the n-acetyl-galactosamine-6sulphate sulphatase (galns gene) in morquio’s syndrome type iva or beta-galactosidase (glb1 gene) in morquio’s syndrome type ivb. the catabolism of chondroitin 6-sulphate is also affected by the galns gene defect.3 the metabolism of heparan and dermatan sulphate is normal in morquio syndrome, which is why patients with morquio syndrome do not have mental retardation. patients with morquio’s syndrome appear healthy at birth. marked dwarfism, abnormal curvature of the spine (kyphoscoliosis), and decreased tone and weakness are prominent early childhood presentations. also seen are coarse facies, short nose, fig. 1. x-ray of skull; ap and lateral view (1a and 1b) and cervical spine in flexion and extension position (1c and 1d) showing frontal bossing and a j-shaped sella. atlanto-axial subluxation is seen in the cervical spine, and multi-level vertebra plana (flattened vertebrae). fig. 2. x-ray of dorso-lumbar spine in ap and lateral view (2a and 2b) showing kyphosis with multi-level vertebra plana with central anterior beaking. ribs show broadening of the anterior portion (tongue shape). fig. 3. x-ray of hands and wrists in ap view showng metaphyseal expansion of long bones with cortical thinning, conical (bullet-shaped) proximal bases of 2 5 metacarpals with normal construction of metacarpal shafts and tapering of the proximal phalanges. the ossified carpal bones are small and reduced in number for the patient’s age. the planes of both the distal ulnar and radial growth plates are slanted towards each other. fig. 4. x-ray of the pelvis and both femurs in ap view shows flared iliac bones laterally with inferior constriction (wine-glass shape). enlargement of both acetabular cavities is seen with rough margins, and poorly formed femoral epiphyses and widened femoral necks with coxa valga. 34 sa journal of radiology • february 2012 review broad mouth, and widely spaced teeth with thinned enamel. the patient may have a waddling gait. pectus carinatum (horizontal and protuberant sternum) and a shortened neck with clouding of the cornea, ligamentous laxity and joint stiffness are also seen. mental capacity is generally unimpaired. examination and testing may reveal short stature (flat vertebrae cause a short trunk), short neck, kyphosis or scoliosis with pectus carinatum (pigeon chest) and, at the cervical spine, odontoid hypoplasia; atlantoaxial instability may be associated with myelopathy with gradual loss of walking ability.4 laxity of joints, dysostosis multiplex, dysplastic hips, unstable knees, large elbows and wrists, and flat feet are other skeletal features. there may be cardiac abnormalities with enlarged liver and spleen. investigations include urine spot tests which are readily available to screen for mucopolysaccharides but are associated with false-positive and false-negative results. heparan, keratan and dermatan sulphate can be distinguished by electrophoresis techniques to differentiate between the mucopolysaccharidoses. the diagnosis is confirmed by direct enzyme assay of leucocytes, or fibroblast enzyme activity can be measured in amniocytes or chorionic villi. roentgenographic findings have been reviewed by langer and carry.5 compared with other forms of mps, morquio syndrome tends to have greater skeletal manifestations and spine involvement such as scoliosis, kyphosis, hyperlordosis , severe gibbus, flaring of the lower ribs as well as platyspondyly, pectus carinatum metacarpals, and small carpal bones (often with some absent). characteristic findings included hypoplasia of odontoid peg, universal platyspondyly gibbus, and kyphosis of the dorsal region with widening of disc spaces. also characteristic are a long pelvis with narrowing at the acetabulae, pubic symphysis widening and flaring of the ilia. there may be shortening of the metacarpals, and inclination of the distal portions of the radius and ulna toward each other can also be seen (as in our case). complications develop later and include breathing problems, cardiac problems, spinal cord damage leading to possible paralysis, vision problems, walking problems related to abnormal curvature of the spine, and other bony problems. most patients survive into their third or fourth decades. treatment is currently only palliative. possible future treatments include enzyme replacement, gene therapy and allogenic bone marrow transplantation.6 1. morquio l. surune forme de dystrophie osseuse familiale. bull soc pediatr (paris) 1929;27:145-152. 2. brailsford jf. chondro-osteo-dystrophy: roentgenographic and clinical features of child with dislocation of vertebrae. am j surg 1929;7:404-410. 3. fukuda s, tomatsu s, masue m, et al.: mucopolysaccharidosis type iva. n-acetylgalactosamine-6-sulfate sulfatase exonic point mutations in classical morquio and mild cases. j clin invest 1992;90:1049-1053. 4. montano am, tomatsu s, gottesman gs, smith m, orii t. international morquio a registry: clinical manifestation and natural course of morquio a disease. j inherit meta dis 2007;30(2):165-174. 5. langer lo, carey ls. the roentgenographic features of the ks mucopolysaccharidosis of morquio. am j roentgenol 1966:97:1-20. 6. tomatsu s, montano am, ohashi a, et al. enzyme replacement therapy in a murine model of morquio a syndrome. hum mol genet 2008;17(6):815-824. fig. 5. x-ray of both knees in ap view (5a) and leg with foot in ap (5b) and lateral view (5c) showing genu valgus, metaphyseal expansion of long bones, and tapering of the proximal phalanges respectively. 6 sa journal of radiology • march 2011 case report introduction scapuloiliac dysostosis, also known as pelvis-shoulder dysplasia and kosenow syndrome, is a rare skeletal dysplasia described first by kosenow et al. in 1970.1 the main components of the syndrome are varying degrees of bilateral iliac and scapular hypoplasia. various other skeletal abnormalities including exaggerated lumbar lordosis, and clavicular, vertebral, rib and long bone anomalies and extra-skeletal abnormalities, most commonly those of eye and ear, have also been reported.2 we report the plain radiography, ct and mri findings of an interesting case of the syndrome. case report a 4-year-old boy, the second born of non-consanguinous marriage, presented with abnormal gait; he had a normal neurological examination except for the waddling gait. the elder sibling was normal. plain radiography of the pelvis showed complete bilateral absence of the ilium, with normal well-formed ischium, the superior and inferior pubic rami, as well as the femoral heads bilaterally. frontal chest radiograph revealed severe hypoplasia of the body of scapulae bilaterally while the acromion, coracoid and glenoid were well formed. the shoulder joint was normally aligned. ct scan of the pelvis confirmed the radiographic findings. band-like soft-tissue density areas were seen in the normal location of the ilium, and the femoral heads were seen lying within the soft tissues. sacral spina bifida was also noted. mri was performed and showed absence of osseous or cartilaginous tissue in the normal location of the ilium. instead there was a soft-tissue structure, hypo-intense in all sequences, suggestive of fibrous tissue imaging features of a rare case of scapuloiliac dysostosis (kosenow syndrome) in an ambulatory child fig. 1. frontal radiograph of chest and abdomen shows bilateral absence of ilium and severe hypoplasia of the body of scapulae. the coracoid and acromion are normal bilaterally. fig. 2. axial ct section of pelvis in soft-tissue window setting shows bilateral absence of bony ilia replaced by band-shaped soft-tissue density structures. john joseph, mb bs harish narayanan, mb bs, dmrd jacob varghese, mb bs, md harish babu, mb bs, dmrd a praveen, mb bs department of radiodiagnosis, trivandrum medical college, kerala, india sa journal of radiology • march 2011 7 case report which, along with the surrounding skeletal muscles, seemed to be supporting the well-formed femoral heads. discussion scapulo-iliac dysostosis (pelvis-shoulder dysplasia, kosenow syndrome) is an uncommon hereditary skeletal dysplasia. it is classified as autosomal dominant owing to one of the original families, though both dominant and recessive inheritances are described.3 the chief components of the syndrome are varying degrees of bilateral hypoplasia of the ilium and scapulae, usually severe. the sacrum, ischium and pubis are normal while the acetabulum is markedly dysplastic with severe hip instability. the acromion and coracoid process of the scapula are usually preserved despite severe hypoplasia of the body. milder phenotypical variants may have involvement limited to the pelvis. several other skeletal and extraskeletal anomalies have also been described; these include hypoplastic or abnormally elongated clavicles, lumbar hyperlordosis, rounded appearance of the vertebral bodies, rib anomalies and overconstriction of the femora and tibiae.2,3 the common soft-tissue associations involve the eye and ear e.g. micro-ophthalmia, coloboma of the lids, low-set ears and deafness.4 a unique feature of the case under discussion is the well-formed femoral heads and ambulation with a fully functional though abnormal gait, despite the complete bilateral iliac agenesis. to the author’s knowledge, only one case of this syndrome with complete iliac agenesis and complete ambulation has been reported whereas the others had severe hip instability and were bedridden.5 the support for the femoral head, in the absence of the ilium, seems to be provided by soft tissues such as the surrounding muscles and the fibrous tissue replacing the ilium, as shown by mri. this seems to be the first report of mri findings of this syndrome. the case further supports the theory that the dysplastic changes in the femoral head in congenital dislocation of the hip are a result of its abnormal contact with the ilium or false acetabulum, and that the femoral head will grow normally even if dislocated, in the absence of this abnormal contact.5 this case report is believed to be unique in terms of rarity as well as the complete multi-modality radiological evaluation of the syndrome. in addition, the surprising degree of ambulation and well-formed femoral heads despite complete iliac agenesis provide insights into the development of the hip and femoral head. 1. kosenow w, niederle j, sinios a. becken-schulter dysplasie. fortschr geb rontgenstr nuklearmed 1970;113:36-48. 2. taybi h, lachman r. radiology of syndromes, metabolic disorders, and skeletal dysplasias, 4th ed. st louis: mosby year book, 1996: 444, 773, 789. 3. elliot am, roeder er, witt dr, et al. scapuloiliac dysostosis (kosenow syndrome, pelvis-shoulder dysplasia) spectrum: three additional cases. am j med genet 2000;95:496-506. 4. blane ce, holt jf, vine ak. scapuloiliac dysostosis. br j radiol 1984;57:526-528. 5. mac-thiong jm, leduc s, labelle h. complete bilateral agenesis of the ilium in a 7-year-old ambulatory girl. spine 2005;30:e420-e423 fig.3. coronal t1 pelvic mri reveals iliac agenesis with the femoral heads normal and supported by surrounding muscles and fibrous tissue. cpd questionnaire 104 sa journal of radiology • september 2011 1. regarding cardiac magnetic resonance imaging (cmr), which of the following statements is false? a. a huge research interest led to an enormous number of publications resulting in a clear understanding of its absolute value, especially when assessing myocardial perfusion, viability and function in ischaemic heart disease. b. cmr is also very valuable in the diagnosis of the cardiomyopathies, arrhythmogenic conditions and tumours. c. there is unfortunately a growing trend for publications to be authored solely by cardiologists. in the usa, 37.7% of the studies are reported by cardiologists, according to a survey published in the journal of the american college of radiology (jacr) in 2006, indicating a decreasing involvement by the radiology community. d. in view of significant technical advances over the past 20 years and growing research interest, infinitely more cardiac mri studies are performed by radiologists compared with competing and often inferior tests. 2. which of the following statements is false? a. aged x-ray equipment coupled with poor or no maintenance can have significant effects on radiographic image quality. b. the use of high-speed film/screen contributes minimally to compliance with internationally acceptable drls (diagnostic reference levels). c. good equipment selection, an effective qa programme, and dosimeters can ensure patient radiation protection. d. there is a need to use anatomical image quality assessment such as the ec image quality criteria during the adoption of a new imaging technique. 3. which of the following statements is false? a. pseudomyxoma peritonei (pmp) is a rare complication of mucinous tumours of appendiceal or ovarian origin which results in peritoneal and omental implants. b. therapeutic paracentesis is consistently effective because of the nature of the mucin. c. clinical morbidity and mortality arise from the fact that copious amounts of extracellular and peritoneal mucin result in distortion and loss of function of visceral organs. d. currently, new techniques are being used to attempt to debulk the mucin volume; none, however, has lead to superior outcome. 4. which of the following is true? a. ct characteristics of pmp include: multiple complex cystic masses of high attenuation in the peritoneum, which consistently have rims of calcifications. b. scalloping of the liver (and occasionally splenic) margins are seldom visualised. c. computed tomography is the modality of choice as it allows relatively accurate localisation and quantification of pmp. d. ultrasound often reveals gross, mobile ascites without septations and decreased echogenicity. 5. which of the following statements is false? a. the literature describes two distinct clinical forms of histoplasmosis that have different geographical distributions worldwide. b. african histoplasmosis is attributed to h. duboisii infection which most commonly occurs between the sahara and kalahari deserts. c. the most common site of infection is bone, but it can also involve skin. d. the femur is the most frequently affected skeletal site, with diaphyseal involvement in young children and juxtametaphyseal involvement in older children and adults. 6. identify the false statement in the following choices. a. three types of clinical disease may occur in patients with histoplasmosis. the most common presentation is acute pulmonary histoplasmosis. b. patients typically present with pulmonary symptoms that run a self-limiting course. chest radiographs may show hilar lymphadenopathy and upper lobe predominant nodules. c. chronic pulmonary histoplasmosis resembles tuberculosis. d. some patients may go on to disseminated infection with widespread disease. in this setting, pleural effusion and skeletal involvement is always present. 7. the following statements about arvd are true, except: a. arrythmogenic right ventricular dysplasia/cardiomyopathy (arvd) is a familial cardiomyopathy characterised clinically by right ventricular (rv) dysfunction as well as ventricular tachycardia. b. it is histopathologically characterised by fibro-fatty replacement of the myocardium. c. left ventricular (lv) involvement never occurs. d. cardiovascular magnetic resonance (cmr) findings are now included in the list of major and minor criteria and currently play an important role in establishing the diagnosis of arvd. 8. identify the false statement among the following. a. vascular abnormalities associated with neurofibromatosis type 1 (nf1) are well described. b. spinal arterio-venous fistula (avf) is a rare finding in nf1. c. management of spinal avfs can be endovascular or surgical. d. the large amount of shunting of arterial blood into the venous system also steals blood from the spinal cord, but never leads to myelopathy. 9. identify the single false statement below. a. primary fallopian tube carcinoma is a rare tumour, comprising less than 2% of female genital tract malignancies. b. the incidence peaks between the fourth and sixth decades of life, with a median age of 55. c. clinical features include vaginal bleeding, abdominal pain, a pelvic mass and ascites. imaging (most commonly ultrasound) may demonstrate a tubal mass. d. tubal carcinoma spreads mainly via the lymphatic system. 10. identify one false statement among the following. a. intramural stratification with deposition of fat in the submucosal layer of the bowel wall, visualised on computed tomographic (ct) scans of the abdomen, is known as the fat halo sign. b. due to the infiltration of the submucosa by fat, the inner layer mucosa is separated from the outer layer of muscularis propria/serosa (both being of soft tissue density) by a layer of fat (of low attenuation) measuring between -18 to -64 hounsfield units. c. historically, the fat halo sign has been associated with patients suffering from chronic inflammatory bowel disease. d. the fat halo sign is now known to occur only in patients whose mass exceeds 120 kg. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/010/01/2011 give one correct answer for each question. sajr 721 the sandwich sign n mahomed, mb bch, fcrad (d) h moodley, mb chb department of radiology, university of the witwatersrand, johannesburg   corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) the sandwich sign refers to the sandwiching of mesenteric vessels and fat by enlarged mesenteric nodes on cross-sectional imaging, commonly occurring in lymphoma, but not specific to lymphoma. the sign is radiologically indistinguishable from post-transplant lymphoproliferative disorders. the radiological significance of the sandwich sign is in suggesting the diagnosis of lymphoma so that appropriate treatment may be initiated early as the tumour has a rapid growth pattern.  s afr j rad 2012;16(3):114-115. doi:10.7196/sajr.721 the sandwich sign is demonstrated on cross-sectional imaging, commonly on ct or ultrasound. it refers to homogeneous soft-tissue masses representing mesenteric lymphadenopathy as the two halves of a sandwich bun, encasing the mesenteric fat and tubular mesenteric vessels that constitute the ‘sandwich filling’ (figs 1 and 2).1 , 2 as the mesenteric lymphadenopathy enlarges, it may compress the mesenteric vessels, partially obstructing venous return, resulting in engorgement of the enhanced mesenteric veins and making them more prominent within the sandwich filling.1 oral and intravenous contrast on abdominal ct scans make the sandwich filling more conspicuous, whereas colour doppler of the mesenteric vessels highlights the sandwich filling on abdominal ultrasound.1 fig. 1. axial ct image with intravenous contrast in a 3-year-old diagnosed with non-hodgkin’s lymphoma shows 2 large mesenteric lymphomatous masses (arrows), which represent the halves of the sandwich bun, enveloping mesenteric fat and enhanced vessels. there is also extensive retroperitoneal lymphadenopathy present. fig. 2. axial ct image with intravenous contrast in a 2-year-old girl diagnosed with burkitt’s lymphoma demonstrates the sandwich sign (filled arrows). note the diffuse lymphomatous infiltration of the stomach (open arrow) and ascites. according to the literature, the sandwich sign was previously accepted as specific for lymphomatous mesenteric involvement, with most mesenteric lymphomas being non-hodgkins lymphoma, but also including post-transplant lymphoproliferative disorders. non-hodgkin’s lymphoma cannot be distinguished from post-transplant lymphoproliferative disorders on morphological grounds, as both conditions are caused by the epstein-barr virus.1 , 3 it was generally held that – unlike the myriad other causes of mesenteric lymphadenopathy including metastatic carcinoma, sarcoma, carcinoid, aids-related lymphadenopathy, whipple’s disease and tb – only mesenteric lymphoma results in bulky lymphadenopathy that produces the sandwich sign.1 this was postulated on the basis of lymphoma’s rapid growth without producing clinical symptoms, and the lack of early bowel invasion, perforation or haemorrhage, as frequently seen in some of the above-mentioned tumours.1 inflammatory and infectious aetiologies do not commonly produce such large nodal masses and usually have the appearance of necrosis or rim enhancement, as typically seen in tb.1 this theory was refuted by a single study in 2008 by lien et al. which documents biopsy-proven non-lymphomatous causes of the sandwich sign.4 the authors reported that in addition to lymphoma being the most common cause of the sandwich sign, other malignancies such as desmoid tumour, metastatic carcinoma, mycobacterium avium complex (mac) and tb also demonstrate this sign.4 non-hodgkin’s lymphoma was seen in 50% and metastatic carcinomas in 41% of cases.4 the classic sandwich sign has evolved to encompass other regions and pathology. kunimasa et al. have coined a ‘thoracic sandwich sign’ in reference to anterior-mediastinal lymphadenopathy encompassing the brachiocephalic vein on chest ct in a patient with t-cell lymphoblastic lymphoma.5 the sandwich sign has also been used in the description of traumatic herniation of the stomach on ct, where two semi-circular contrast-filled loops of stomach were separated by a soft-tissue band, indicating that the stomach had folded on itself owing to herniation through a diaphragmatic defect.6 in conclusion: the sandwich sign refers to the sandwiching of mesenteric vessels and fat by enlarged mesenteric nodes on cross-sectional imaging, commonly occurring in lymphoma, but not specific to lymphoma. the sign is radiologically indistinguishable from post-transplant lymphoproliferative disorders. the radiological significance of the sandwich sign is in suggesting the diagnosis of lymphoma so that appropriate treatment may be initiated early, as the tumour has a rapid growth pattern.   1. hardy sm. signs in imaging. radiology 2003;226:651-652. 1. hardy sm. signs in imaging. radiology 2003;226:651-652. 2. toma p, granata c, rossio a, et al. multimodality imaging of hodgkin disease and non-hodgkin lymphoma in children. radiographics 2007;27:1335-1354. 2. toma p, granata c, rossio a, et al. multimodality imaging of hodgkin disease and non-hodgkin lymphoma in children. radiographics 2007;27:1335-1354. 3. ferry ja. burkitt’s lymphoma: clinicopathologic features and differential diagnosis. oncologist2006;11:375-383. 3. ferry ja. burkitt’s lymphoma: clinicopathologic features and differential diagnosis. oncologist2006;11:375-383. 4. lien w, huang s, liu k, et al. the sandwich sign of non lymphomatous origin. j clin ultrasound 2008;37:212-214. 4. lien w, huang s, liu k, et al. the sandwich sign of non lymphomatous origin. j clin ultrasound 2008;37:212-214. 5. kunimasa k, jo t, takaiwa t, ishida t. thoracic sandwich sign. intern med 2011;50:2865. 5. kunimasa k, jo t, takaiwa t, ishida t. thoracic sandwich sign. intern med 2011;50:2865. 6. caceres j, mata jm, castaner e, villanueva a. ct recognition of traumatic herniation of stomach: the sandwich sign. j thorac imaging 1995;10:150-152. 6. caceres j, mata jm, castaner e, villanueva a. ct recognition of traumatic herniation of stomach: the sandwich sign. j thorac imaging 1995;10:150-152. sajr 772 the pattern and prevalence of vertebral artery injury in patients with cervical spine fractures f ismail,1 fcrad (d) sa, mmed rad (d); s motsitsi,2 mmed (orth), fcs; n khan,3 mb bs, fc rad; i fabris-rotelli,4 bsc (hons), msc, phd 1 department of radiology, university of pretoria, pretoria, south africa 2 department of orthopaedic surgery, kalafong hospital, pretoria, south africa 3 department of radiology, kalafong hospital, pretoria, south africa 4 department of statistics, university of pretoria, pretoria, south africa corresponding author: f ismail (drfismail@yahoo.com) aim. it is not uncommon for vertebral artery injury to occur when there are fractures through the transverse foraminae of the first to the sixth vertebral bodies. other important risk factors for vertebral artery injury include facet joint dislocations and fractures of the first to the third cervical vertebral bodies. the aim of this study was to determine the pattern and prevalence of vertebral artery injury on ct angiography (cta) in patients with cervical spine fractures. method. a retrospective review of patients who had undergone cta of the vertebral arteries was undertaken. reports were reviewed to determine which patients met the inclusion criteria of having had both cervical spine fractures and cta of the vertebral arteries. images of patients who met the inclusion criteria were analysed by a radiologist. results. the prevalence of vertebral artery injury was 33%. four out of the 11 patients who had vertebral artery injury had post-traumatic spasm of the artery, with associated thrombosis or occlusion of the vessel. in terms of blunt carotid vertebral injury (bcvi) grading, most of the patients sustained grade iv injuries. four patients who had vertebral artery injury had fractures of the upper cervical vertebrae, i.e. c1 c3. fifteen transverse process fractures were associated with vertebral artery injury. no vertebral artery injury was detected in patients who had facet joint subluxations. conclusion. patients with transverse process fractures of the cervical spine and upper cervical vertebral body fractures should undergo cta to exclude vertebral artery injury. s afr j rad 2013;17(2):52-55. doi:10.7196/sajr.772 vertebral artery injuries are rare, with an incidence of 0.1 1.0%, if all patients admitted with blunt head trauma are considered.1 it is not unusual for vertebral artery injury to occur when there are fractures through the transverse foraminae of the first to the sixth vertebrae. woodring et al.2 found the incidence of vertebral artery injury to be 78% in patients who had fractures through the transverse foraminae. other important risk factors for vertebral artery injury include facet joint dislocations and fractures of the first to the third cervical vertebrae.3 , 4 injury to the vertebral arteries can result in permanent brain injury via ischaemia to the posterior circulation territory of the brain. vertebral-basilar insufficiency may occur if either both vertebral arteries or the dominant vertebral artery is injured. other sequelae include downstream embolisation of a thrombus, anterior spinal artery compromise causing spinal cord ischaemia, and occlusion of blood flow to the posterior inferior cerebellar artery (pica), causing lateral medullary syndrome.5 computed tomography angiography (cta) is becoming the study of choice (rather than digital subtraction angiography (dsa)) for imaging the vertebral arteries in trauma. cta is easily accessible, has no risk associated with an interventional procedure, and is more quickly and easily obtained in centres where both cta and dsa are available. in addition to visualisation of the vertebral arteries, cta also allows visualisation of the carotid arteries. at kalafong hospital in pretoria, cta is routinely used as a screening tool to exclude vertebral artery injury in all patients who have fractures involving the transverse foraminae of the cervical spine, those with facet joint dislocations, and those with fractures involving the first to the third cervical vertebrae. the aim of this study was to determine the pattern and prevalence of vertebral artery injury using cta in patients with cervical spine fractures, and to compare these findings with those from the international literature. methods a retrospective review of data from patients who had undergone cta of the vertebral arteries was undertaken at kalafong hospital, a secondary hospital in western tshwane in gauteng province. ethical clearance for the study was obtained from the main ethics committee of the university of pretoria. cta was performed on a philips multi-detector ct scanner (brilliance 16, netherlands; serial number 5067). routine cta protocols of the neck are titled ‘ct neck angiogram’, ‘ct cervical spine angiogram’ and ‘ct carotid angiogram’. the ct scan database was searched according to these protocol titles. the ct database also has a list of all patients who have been scanned, as well as the type of scan that was performed. reports were reviewed to determine which patients met the inclusion criteria of having had cervical spine fractures and/or subluxations, as well as cta of the vertebral arteries. all ct scans and reports were checked by a consultant radiologist. images of all patients are archived on erasable optical discs (eods). images of patients who met the inclusion criteria were accessed from the eods and analysed by a radiologist. the standardised method of performing cta of the vertebral arteries uses a bolus tracking technique with the region of interest (roi) placed in the aortic arch. one hundred ml of iodinated contrast medium (omnipaque 350 mg i/ml, ge health), was administered at a flow rate of 3 4 ml/s, followed by a normal saline bolus of 50 ml. the scan parameters were 360 ma/s per slice, 120 kv, a slice thickness of 0.8 mm with slice increments of 0.4 mm, a field of view (fov) of 220 mm, and pitch of 0.438. scans extended from the aortic arch to the posterior fossa of the brain. multiplanar reconstruction in coronal and sagittal planes in bone window (using a window of 2 000 hounsfield units (hu) and centre level of 800 hu) was used to assess for fractures. maximal intensity projection (mip) reconstructions in axial, coronal and sagittal planes, at a slice thickness of 3 4 mm (varied between the scans), window level of approximately 745 hu and centre of 228 hu were used to assess the vertebral arteries. the age, gender, mechanism of injury, fracture level of the transverse processes, and description of the vertebral artery injuries were documented. fractures of the vertebral bodies and the presence of subluxations were also documented. transverse processes included the transverse foraminae and anterior and posterior tubercles. transverse process fractures were numbered c1 c7 and separated right from left, and the level of vertebral artery injury was marked v1 v7, corresponding to the level of cervical spine vertebrae. the blunt carotid and vertebral artery injuries (bcvi) grading system was used to grade the extent of vertebral artery injuries.6 the bcvi grading system defines vessel injury as follows: grade i is the presence of luminal irregularity or dissection with an intra-luminal haematoma occluding less than 25% of the lumen. grade ii is similar to grade i, except that 25% or more of the vessel lumen is occluded. grade iii lesions are due to pseudo-aneurysms, grade iv lesions are due to total occlusion of the vessel and transection of the vessel are grade v injuries. post-traumatic spasm and congenital hypoplasia both have a similar imaging appearance, which is diffuse narrowing of the affected vertebral artery. the distinction between post-traumatic spasm of the vertebral artery and congenital hypoplasia is determined by comparing the anterior-posterior (ap) diameter of the transverse foramina on the right and the left. the level that was chosen for measurement was individualised for each patient, at a point where there was no injury to the vessel and no vertebral fracture. when the neural foraminae were of similar size and the vessel calibre was disproportionately smaller, the affected vessel was considered to be in spasm. stenosis of the vessel lumen was defined as a local or general decrease in calibre owing to the presence of an intraluminal thrombus. the degree of stenosis was calculated by measuring the narrowest diameter of the flow channel and expressing this as a percentage of the diameter of the vessel, including the thrombus, on axial maximum intensity projection (mip) images (corrected for vessel tortuosity). all available patient data were used. data were captured on a paper data collection sheet and later transferred to a microsoft excel spreadsheet. only descriptive analysis of the data was undertaken, owing to small patient numbers. results forty-two patients met the inclusion criteria. nine patients were excluded from the initial database, as the ct images were not accessible from the eods because of errors in saving the data at the time of performing the scan. the final patient sample size was 33. demographic data and the mechanism of injury for each patient are summarised in table 1. twenty-three (70%) patients were male, and 10 (30%) patients were female. the median age was 35 years. regarding the mechanism of injury, 29 (88%) patients were involved in a motor vehicle accident, 2 (6%) were assaulted, 1 (3%) was involved in a pedestrian-vehicle accident, and 1 (6%) patient fell off a bicycle. sixty-six segmental fractures of the transverse processes were detected: 44 on the right side and 22 on the left. twenty-six (39%) fractures were located in the upper cervical vertebrae, i.e. c1 c3. three patients had bilateral facet joint subluxations. two of these were located at c5 c6 and 1 was at c2 c3. twenty-five (76%) patients had unilateral transverse process fractures, and 8 (24%) patients had bilateral fractures. fifteen (23%) transverse process fractures were associated with vertebral artery injury. eleven (33%) patients sustained a vertebral artery injury. five of the 11 patients had fractures of c1 c3 vertebral bodies. five of the 11 had diffuse spasm and, of these, 4 had associated thrombosis or occlusion of the vessel; this is described in table 2. six patients sustained bcvi grade iv injury. four patients sustained bcvi grade ii injury. four patients who had a vertebral artery injury had fractures of the upper cervical vertebrae, i.e. c1 c3. no vertebral artery injury was detected in patients who had facet joint subluxations. discussion in this study, the prevalence of vertebral artery injury in the trauma setting was found to be 33%. in a systematic review by inamasu and guiot,3 an average prevalence rate of 37.8% for vertebral artery injury was found from similar studies carried out between 1999 and 2004. therefore our prevalence is similar to previous international studies (pubmed and medline search).3 vertebral artery diameter is normally between 3 mm and 5 mm. a hypoplastic vertebral artery is defined as having a diameter ≤2 mm and that makes little contribution to the basilar artery. the left vertebral artery is dominant in 50% of the population, the right in 25%, and the arteries demonstrate equal calibre in 25% of the population.7 when cta is interpreted, the distinction between a hypoplastic vertebral artery and a vertebral artery that is diffusely smaller in size, owing to post-traumatic spasm, is extremely important. to help distinguish the 2 possibilities, we compared the ap diameters of the right transverse foramina with the left transverse foramina on an axial ct slice, and compared this with the size of the vertebral artery at the same level. when the transverse foraminae were of a similar size and the vessel calibre was disproportionately smaller, the affected vessel was considered to be in spasm (fig. 1). in this study, 4 out of the 5 patients who had diffuse spasm of the vertebral artery had associated thrombosis (1 patient at c7) or occlusion (3 patients at levels c3 c6, c2 c3 and at c2) (fig. 2). fig. 1. axial cta of the vertebral arteries. in (a) the ap diameter of the transverse foraminae is equal. the left vertebral artery is much smaller than the right due to post-traumatic spasm. in (b) the ap diameter of the left transverse foramen is much smaller than the right. the left vertebral artery is proportionately smaller. this indicates a hypoplastic left vertebral artery. fig. 2. coronal mip of a cta of the vertebral arteries. the fracture involves the left transverse process of c3. there is diffuse spasm of the left vertebral artery with associated complete occlusion of the artery at c7 and at c3 c4 on the left (arrows). the method of measuring the ap diameter of the transverse foraminae to correlate vertebral artery size has not been proven in the literature, but was adopted for this study and proved to be a useful clue to alert the radiologist that a more sinister injury may be present. limitations of this study included (i) the loss of data, which affected the sample size; and (ii) the lack of current literature describing the method implemented to differentiate vertebral artery stenosis from congenital hypoplasia. although the latter was found to be useful in this study, further research is required. in terms of bcvi grading, 6 of the 11 patients sustained grade iv injuries, which is associated with a 44% risk of stroke and a 22% risk of mortality.6 four of the 11 patients sustained grade ii injuries, which is associated with an 11% risk of stroke and an 11% risk of mortality. some studies describe a higher prevalence of grade i and ii injuries, while others describe a higher prevalence of grade iv injuries.8 , 9 in 1 patient, the vertebral artery injury occurred at c7 but the fracture was at c5. it is important to evaluate all vertebral levels for fractures that may occur distant to the level of vertebral artery injury. conclusion patients with transverse process fractures of the cervical spine and upper cervical vertebral body fractures should have cta to exclude vertebral artery injury. acknowledgements. the authors thank mrs johanna masango for her outstanding assistance in image retrieval 1. hoit da, schirmer cm, weller sj, lisbon a, edlow ja, malek am. angiographic detection of carotid and vertebral arterial injury in the high-energy blunt trauma patient. j spinal disord tech 2008;21:259-266. [http://dx.doi.org/10.1097/bsd.0b013e318141fce8] 1. hoit da, schirmer cm, weller sj, lisbon a, edlow ja, malek am. angiographic detection of carotid and vertebral arterial injury in the high-energy blunt trauma patient. j spinal disord tech 2008;21:259-266. [http://dx.doi.org/10.1097/bsd.0b013e318141fce8] 2. woodring jh, lee c, duncan v. transverse process fractures of the cervical vertebrae: are they insignificant? j trauma 1993;34:797-802. [http://dx.doi.org/10.1097/00005373-199306000-00008] 2. woodring jh, lee c, duncan v. transverse process fractures of the cervical vertebrae: are they insignificant? j trauma 1993;34:797-802. [http://dx.doi.org/10.1097/00005373-199306000-00008] 3. inamasu j, guiot bh. vertebral artery injury after blunt cervical trauma: an update. surg neurol 2006;65:238-246. [http://dx.doi.org/10.1016/j.surneu.2005.06.043] 3. inamasu j, guiot bh. vertebral artery injury after blunt cervical trauma: an update. surg neurol 2006;65:238-246. [http://dx.doi.org/10.1016/j.surneu.2005.06.043] 4. cothren cc, moore ee, biffl wl. cervical spine fracture patterns predictive of blunt vertebral artery injury. j trauma 2003;55:811-813. [http://dx.doi.org/10.1097/01.ta.0000092700.92587.32] 4. cothren cc, moore ee, biffl wl. cervical spine fracture patterns predictive of blunt vertebral artery injury. j trauma 2003;55:811-813. [http://dx.doi.org/10.1097/01.ta.0000092700.92587.32] 5. fassett dr, dailey at, vaccaro ar. vertebral artery injuries associated with spinal injuries: a review of the literature. j spinal disord tech 2008;21:252258. [http://dx.doi.org/10.1097/bsd.0b013e3180cab162] 5. fassett dr, dailey at, vaccaro ar. vertebral artery injuries associated with spinal injuries: a review of the literature. j spinal disord tech 2008;21:252258. [http://dx.doi.org/10.1097/bsd.0b013e3180cab162] 6. biffl wl, moore ee, offner pj, brega ke, franciose rj, burch jm. blunt carotid arterial injuries: implications of a new grading scale. j trauma 1999;47:845-853. [http://dx.doi.org/10.1097/00005373-199911000-00004] 6. biffl wl, moore ee, offner pj, brega ke, franciose rj, burch jm. blunt carotid arterial injuries: implications of a new grading scale. j trauma 1999;47:845-853. [http://dx.doi.org/10.1097/00005373-199911000-00004] 7. cloud gc, markus hs. diagnosis and management of vertebral artery stenosis. q j med 2003;96:27-34. [http://dx.doi.org/10.1093/qjmed/hcg003] 7. cloud gc, markus hs. diagnosis and management of vertebral artery stenosis. q j med 2003;96:27-34. [http://dx.doi.org/10.1093/qjmed/hcg003] 8. mckinney a, ott f, short j, mckinney z, truwit c. angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector ct. eur j radiol 2007;62:385-393. [http://dx.doi.org/10.1016/j.ejrad.2007.01.008] 8. mckinney a, ott f, short j, mckinney z, truwit c. angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector ct. eur j radiol 2007;62:385-393. [http://dx.doi.org/10.1016/j.ejrad.2007.01.008] 9. biffl wl, egglin t, benedetto b, gibbs f, cioffi wg. sixteen-slice computed tomographic angiography is a reliable non-invasive test for clinically significant blunt cerebrovascular injuries. j trauma, injury, infection and critical care 2006;60:745-752. [http://dx.doi.org/10.1097/01.ta.0000204034.94034.c4] 9. biffl wl, egglin t, benedetto b, gibbs f, cioffi wg. sixteen-slice computed tomographic angiography is a reliable non-invasive test for clinically significant blunt cerebrovascular injuries. j trauma, injury, infection and critical care 2006;60:745-752. [http://dx.doi.org/10.1097/01.ta.0000204034.94034.c4] sajr 655 usefulness of lateral radiographs for detecting tuberculous lymphadenopathy in children – confirmation using sagittal ct reconstruction with multiplanar cross-referencing savvas andronikou, mb chb, fcrad, frcr (lond), phd department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg   dirk johannes van der merwe, mb chb department of radiology, stellenbosch university   pierre goussard, mmed (pae d) robert p gie, fcp department of paediatrics and child health, stellenbosch university   nicolette tomazos, ba commerce faculty, department of management studies, university of cape town   corresponding author: s andronikou ( docsav@mweb.co.za) background. diagnosis of pulmonary tuberculosis (ptb) in children remains difficult. lateral chest radiographs are frequently used to facilitate diagnosis, but interpretation is variable. in this study, lateral chest radiographs (cxrs) are evaluated against sagittal ct reconstructions for the detection of mediastinal lymphadenopathy. aim. to correlate suspected lymphadenopathy on lateral cxr with sagittal ct reconstructions and determine which anatomical group of lymph nodes contributes to each lateral cxr location. methods and materials. thirty tb-positive children’s lateral cxrs were retrospectively reviewed for presence of mediastinal lymphadenopathy in 3 pre-determined locations in relation to the carina: retrocarinal, subcarinal and precarinal. findings of the ct sagittal reconstructions were then correlated with the cxrs for the presence of lymphadenopathy in the same 3 pre-determined areas across the width of the mediastinum. axial and coronal ct cross-referencing confirmed the position of the lymphadenopathy. results. the most frequent locations for lymphadenopathy were the subcarinal (28) and right hilar (25). sensitivity and specificity values of the cxrs were moderate, with the precarinal region having the best sensitivity and specificity for presence of lymphadenopathy. contribution to each zonal group on lateral cxr were from multiple anatomical lymph node sites. conclusion. the precarinal zone on cxr had the best specificity and sensitivity, and represented mainly subcarinal and right hilar lymph node groups. attention should be paid to this area on lateral cxrs for detecting lymphadenopathy in children with suspected ptb.   s afr j rad 2012;16(3):87-92. doi:10.7196/sajr.655 diagnosis of pulmonary tuberculosis (ptb) in children remains a difficult problem,1 , 2 and radiography is frequently used for elucidation.1-3 interpretation of chest radiographs (cxrs), however, is variable when measured against computed tomography (ct), which is considered the gold standard.4 , 5 in the present study, the lateral cxr – a readily available and inexpensive diagnostic tool – is evaluated against sagittal ct reconstructions for the detection of mediastinal and hilar lymphadenopathy. densities suspected of representing lymphadenopathy on lateral cxr have not been confirmed using ct previously, and the contribution of different lymph node groups to the lateral cxr locations remain unproven. sagittal ct reconstructions were used for comparison with lateral radiographs for determining the position of suspected tb lymphadenopathy. multiplanar cross-referencing was used to confirm the presence and location of lymphadenopathy. the sensitivity and specificity of lateral cxr locations for the presence of lymphadenopathy was determined against the ct gold standard. aim we set out to compare detection of tuberculous lymphadenopathy on lateral cxrs with sagittal ct reconstructions and determine which anatomical group of lymph nodes contributes to locations on lateral cxr by using multiplanar cross-referencing. methods and materials a retrospective descriptive study was undertaken. children <13 years of age were included when a diagnosis of tb was made by positive culture of bronchoscopic washings or gastric aspirates and when cxrs (pa and lateral) as well as a chest ct were available (ct scans were performed for the indication of airway compression, as not all children with tb undergo ct routinely). thirty children meeting the criteria were included, working retrospectively and consecutively from the start date. patients were excluded when there was severe airspace disease (i.e. whiteout) and very poor-quality radiographs. where a case failed to meet the study criteria, the next sequential case was selected. the chest cts were retrieved from our electronic database, and multiplanar reconstructions (mprs) were performed retrospectively using voxar 3d 4.2 (barco, belgium). lateral cxrs were read from hard copy. reading of plain radiographs and ct was performed by a paediatric radiologist (sa) with a special interest in tb. plain radiographs were read first; cts were read at a different sitting with the reader blinded to patient details, history and previous radiological findings. lateral cxrs were read for presence of lymphadenopathy in 3 predetermined locations as ‘negative’ or ‘positive’. location positions were determined by extending lines from the anterior and posterior walls of the trachea beyond the carina and drawing another line horizontally (perpendicularly) to these below the level of the right upper lobe bronchus. the horizontal line was drawn at this level to exclude densities representing the major vascular structures around the upper regions of the hila (right and left main pulmonary arteries and aortic arch which are indistinguishable from lymph node soft tissue densities). three areas were thus viewed in relation to the carina: retrocarinal (posterior to the lines drawn), subcarinal (between the lines drawn) and precarinal (anterior to the lines drawn) to represent actual lymph node group locations (fig. 1). lymphadenopathy in the 3 zones was reported when conglomerate oval densities were noted. densities were reported to be vascular if these were linear and diverging from the central point. airspace disease was reported when confluent densities containing air bronchograms were present. fig. 1. lines were drawn along the anterior and posterior tracheal margins as well as a horizontal (perpendicular) line below the right upper lobe bronchus (asterisk). three zones were thus created below the horizontal line: precarinal, subcarinal and retrocarinal. density can be seen in all three zones in this example, suggesting lymphadenopathy. sagittal mprs were then read for the presence of lymphadenopathy. the same 3 lines that were drawn on the lateral cxr were digitally superimposed on the midand para-sagittal ct reconstructions. the sagittal mpr scan was then read for the presence of lymphadenopathy in the same 3 predetermined areas as a surrogate for lateral cxr, in the midline and every para-sagittal position across the mediastinum. position of adenopathy was confirmed on axial and coronal plane ct using the cross-referencing cross-hair (fig. 2). no size dimension for pathological mediastinal nodes was used and the presence of any lymph nodes was recorded as abnormal. fig. 2. the same three lines were digitally imposed on the sagittal mpr ct (top right image). the cross-hair in the coronal and axial planes indicates the subcarinal zone, and the soft-tissue density corresponds to a large subcarinal lymph node group. zonal findings on lateral cxr and sagittal mpr were then correlated. sensitivity, specificity, positive predictive value and negative predictive value were determined overall and for each of the predetermined positions using the ct images as the gold standard. ethical approval for this study was obtained from the local ethics board; the study was conducted in conformance with the guiding principles of the declaration of helsinki. results the 30 children in this study (15 male and 15 female) ranged from 0 7 years, with a mean age of 2 years. table 1 shows how lymphadenopathy was distributed as seen in the predetermined zones on lateral cxr and sagittal mpr. anatomical locations for all lymph nodes seen on (axial and mpr) ct were in descending order of frequency: subcarinal (28), right hilar (25), right para-tracheal and azygo-oesophageal (22), pre-carinal (21) and left hilar (15). table 1. positive findings of lymphadenopathy on lateral cxr and sagittal ct reconstruction according to zone in 30 children with ptb positive for adenopathy lateral cxr sagittal ct difference retrocarinal 22 25 3 subcarinal 22 28 6 precarinal 20 26 6 mismatches in diagnosis of the presence or absence of lymph nodes are summarised in table 2. sensitivity and specificity values of cxr (taking ct as the gold standard) were moderate, with the precarinal region having the best sensitivity and specificity for the presence of lymphadenopathy. positive predictive values were high at all zones, as was the incidence of lymphadenopathy in the chosen population; table 3 provides a summary. table 2. correlation of lateral cxr and sagittal ct reconstruction according to zone in 30 children with ptb zone positive on cxr and ct negative on cxr and ct mismatch retrocarinal 19 2 9 subcarinal 21 1 8 precarinal 19 3 8 table 3. sensitivity, specificity, ppv and npv of lateral cxr for presence of lymphadenopathy when compared with sagittal ct reconstructions by zone   retrocarinal subcarinal precarinal overall sensitivity 76% 75% 73% 75% specificity 40% 50% 75% 55% ppv 86% 95% 95% 92% npv 25% 12.5% 30% 23% ppv = positive predictive value; npv = negative predictive value.   contributions of the different lymph node groups to each of the zonal groups on the lateral cxr (taking only true positives into account) show a predominant contribution to the retrocarinal zone from azygo-oesophageal nodes, subcarinal zone from subcarinal nodes, and the precarinal zone from right hilar and subcarinal nodes. a more detailed summary of this correlation is in table 4. table 4. contribution of lymph node groups to defined zones on sagittal ct (and by inference on lateral cxr) using only true positives (see table 3) zone positive on sagittal ct and lateral cxr right hilar left hilar subcarinal precarinal azygo-oesophageal retrocarinal 19 8 7 9 0 15 subcarinal 21 17 7 21 0 10 precarinal 19 16 8 15 12 3 discussion tb remains a significant cause of mortality and morbidity in south africa and worldwide. the western cape in south africa had an incidence of 468 cases per 100 000 people in 1998, which is among the highest in the world.6 hiv has further increased the incidence of tb. diagnosing the disease in children is a challenge, as 56 65% of children are asymptomatic at the time of diagnosis. the mantoux test reaction lags behind radiological findings.1-3 , 7 sputum is frequently unavailable, and gastric washings are positive in only 30 40% of cases.3 because of all these factors, mycobacterium tuberculosis is isolated in less than 50% of paediatric cases. the diagnosis of ptb therefore often relies on imaging findings. children from birth to 3 years have a high prevalence of lymphadenopathy (92 96%) and a lower prevalence of parenchymal abnormalities, and this is the radiological hallmark of primary tb.2 , 3 , 6 in almost half of early childhood cases, lymphadenopathy is the sole radiological manifestation.3 because of these factors, strong reliance is placed on cxr in aiding the diagnosis through detection of mediastinal adenopathy. as the who’s proposed criteria for ptb include a suggestive appearance on cxr,8 children diagnosed with ptb through radiography are treated with a full course of anti-tuberculous drugs.9 the lateral cxr is still frequently used in south africa, as it is thought to assist with the detection of hilar and mediastinal lymph nodes.10 it demonstrates lymphadenopathy as lobulated densities appearing in the lower half of a doughnut configuration around the carina. the upper half of the doughnut is made up of the aortic arch and the main pulmonary arteries,11 , 12 which is the reason why we have defined the region below the right upper lobe bronchus for evaluation in our methodology. worldwide use of the lateral cxr is still a contentious issue. some feel that it adds value to frontal projections, which are frequently confusing owing to overlapping anatomical structures.13 in the presence of other pathology (e.g. infiltrates and miliary tb), the lateral projection was found to be more accurate in detecting hilar lymphadenopathy by smuts et al. their study confirmed the value of the lateral cxr in paediatric ptb but found difficulty in differentiating left and right hilar lympadenopathy on frontal cxr, as the heart obscures the left hilum.14 swingler et al. found low accuracy among expert observers in detecting adenopathy on plain film. their study found that the lateral cxr adds little extra value, but that diagnostic accuracy could be improved by refining radiological criteria for lymphadenopathy.9 such criteria have not yet been determined. tb lymphadenopathy occurs predominantly in the subcarinal and right hilar areas.3 , 4 , 15 hila are affected more often than the paratracheal region since lymph drainage occurs from the hilum to paratracheal nodes.14 glazer et al. found the largest mediastinal lymph nodes in normal individuals also occur in the subcarinal and right tracheobronchial areas.16 these features are useful when trying to determine diagnostic criteria on radiographs. ct is considered the gold standard for the detection of lymphadenopathy, while cxr has been shown to be insensitive for lymphadenopathy detection.4 , 5 however, in many areas of south africa and the developing world, ct is not readily available. cost constraints and the high radiation dose of ct limit routine use of this modality in diagnosing ptb. it is therefore best to use ct to define more sensitive and specific cxr criteria. the size of pathological lymph nodes in ptb on ct is also not well determined.17 some studies adopt the notion that any visible mediastinal and hilar lymph nodes on ct are abnormal in children. newer scanners, however, detect smaller nodes, which creates high sensitivity but lower specificity as some visualised nodes may only reflect reactive changes.6 diagnosing nodes of tb specifically may be more accurate on ct owing to the typical post-contrast enhancement patterns.6 , 15 , 18 , 19 calcification helps in lymph node detection (fig. 3) but is present in only 15 21% of children with ptb, and not before 6 months of age.6 a b figs 3a and b. lateral cxr (a) in this 2-year-old boy demonstrates densities in all 3 predetermined zones (arrows). the mpr ct (b) confirms the lateral cxr findings, and the cross hair position demonstrates that a calcified right hilar node is contributing to density seen in the subcarinal zone. a previous study done hammersley et al. showed high correlation between subcarinal density on pa films and subcarinal lymphadenopathy on ct.20 no studies to date correlating findings of lymphadenopathy on lateral cxr with those on ct could be found. in our study, we chose a group with a (pre-selection bias) high incidence of lymphadenopathy, as the goal was not to demonstrate an incidence of lymphadenopathy but rather to confirm the true site of origin of suspected lymphadenopathy on lateral cxr. numerous locations of nodes are a common finding in primary tb, and multiple groups contributed to each positive zone on lateral cxr. predominant groups in certain zones follow the anatomical distribution of nodes. examples are the azygo-oesophageal nodes in the retrocarinal zone. however logical this may seem, it has not been proven to date for lateral cxr imaging. even though there was a high incidence of nodes, there was still significant mismatch between lateral cxr and mpr. sensitivity in all zones was only moderately high, considering the high incidence and multiple sites of lymph nodes involved. specificity for most zones was poor. overall, the most frequent sites for lymphadenopathy in this study were subcarinal and right hilar and these two lymph node groups presented predominantly in the subcarinal and precarinal zones of the lateral cxr. the precarinal location on lateral cxr (fig. 4) was the only group with high sensitivity and specificity for detecting lymph nodes when correlated with mpr. a b figs 4a and b. in this 1-year-old girl, the lateral cxr (a) demonstrates oval density in the precarinal and subcarinal zones (arrows). the mpr ct (b) cross-hair position confirms that there is a left hilar node that is contributing to density in the precarinal zone. (the mpr in this patient also revealed adenopathy in the retrocarinal zone that was missed on lateral cxr.) note how the lines drawn along the trachea are projected into the parasagittal position to reflect the corresponding lateral cxr zones. limitations the population chosen had a very high incidence of lymph nodes. no normal control cases were used. therefore, ppv and npv might not reflect the situation in a regular population group. however, ethical considerations relating to high radiation exposure of chest ct in children prevent us from generating a control group. use of ct scans for pathology other than tb as controls is also unwise in our population, as tb is endemic with the highest per capita incidence in the world. conclusion this study proves only moderate correlation between findings of lymphadenopathy on lateral cxr and ct. the precarinal zone on cxr had the best specificity and sensitivity. in addition, this zone was contributed to by all the lymph node groups, and in particular by the subcarinal and right hilar groups, which are most frequently involved in primary tb. most attention should be paid to the area anterior to a line extended from the anterior tracheal wall and below the right upper lobe bronchus when assessing the cxr for lymphadenopathy in children with suspected ptb. the lateral cxr is still used in south africa and many other parts of the world in assessing lympadenopathy in ptb in children, and research should aim to assist clinicians to focus on the areas of lateral cxr that have higher yield for the presence of lymphadenopathy.   1. starke jr, taylor-watts kt. tuberculosis in the pediatric population of houston, texas. pediatrics 1989;84:28-35. 1. starke jr, taylor-watts kt. tuberculosis in the pediatric population of houston, texas. pediatrics 1989;84:28-35. 2. weber al, bird kt, janower ml. primary tuberculosis in childhood with particular emphasis on changes affecting the tracheobronchial tree. am j roentgenol 1968;103:123-132. 2. weber al, bird kt, janower ml. primary tuberculosis in childhood with particular emphasis on changes affecting the tracheobronchial tree. am j roentgenol 1968;103:123-132. 3. leung an, muller nl, pineda pr, fitzgerald jm. primary tuberculosis in childhood: radiographic manifestations. radiology 1992;182:87-91. 3. leung an, muller nl, pineda pr, fitzgerald jm. primary tuberculosis in childhood: radiographic manifestations. radiology 1992;182:87-91. 4. andronikou s, brauer b, galpin j, et al. interobserver variability in the detection of mediastinal and hilar nodes on ct in children with suspected pulmonary tuberculosis. pediatr radiol 2005;35:425-428. 4. andronikou s, brauer b, galpin j, et al. interobserver variability in the detection of mediastinal and hilar nodes on ct in children with suspected pulmonary tuberculosis. pediatr radiol 2005;35:425-428. 5. delacourt c, mani tm, bonnerot v, et al. computed tomography with a normal chest radiograph in tuberculous infection. arch dis child 1993;69:430-432. 5. delacourt c, mani tm, bonnerot v, et al. computed tomography with a normal chest radiograph in tuberculous infection. arch dis child 1993;69:430-432. 6. andronikou s, joseph e, lucas s, et al. ct scanning for the detection of tuberculous mediastinal and hilar lymphadenopathy in children. pediatr radiol 2004;34:232-236. 6. andronikou s, joseph e, lucas s, et al. ct scanning for the detection of tuberculous mediastinal and hilar lymphadenopathy in children. pediatr radiol 2004;34:232-236. 7. salazar ge, schmitz tl, cama r, et al. pulmonary tuberculosis in children in a developing country. pediartics 2001;108:448-453. 7. salazar ge, schmitz tl, cama r, et al. pulmonary tuberculosis in children in a developing country. pediartics 2001;108:448-453. 8. world health organization. the worldwide magnitude of protein-energy malnutrition: an overview from the who. provisional guidelines for the diagnosis and classification of the epi target diseases for primary health care, surveillance and special studies, epi/gen/83/4. geneva: world health organization, 1983. 8. world health organization. the worldwide magnitude of protein-energy malnutrition: an overview from the who. provisional guidelines for the diagnosis and classification of the epi target diseases for primary health care, surveillance and special studies, epi/gen/83/4. geneva: world health organization, 1983. 9. swingler gh, du toit g, andronikou s, van der merwe l, zar hj. diagnostic accuracy of chest radiography in detecting mediastinal lymphadenopathy in suspected pulmonary tuberculosis. arch dis child 2005;90:1153-1156. 9. swingler gh, du toit g, andronikou s, van der merwe l, zar hj. diagnostic accuracy of chest radiography in detecting mediastinal lymphadenopathy in suspected pulmonary tuberculosis. arch dis child 2005;90:1153-1156. 10. cremin bj, jamieson dh. childhood tuberculosis: modern imaging and clinical concepts. berlin, new york: springer verlag, 1995. 10. cremin bj, jamieson dh. childhood tuberculosis: modern imaging and clinical concepts. berlin, new york: springer verlag, 1995. 11. kuhn jp, slovis tl, silverman fn, et al. mediastinum. in: silverman fn, kuhn jp, eds. caffey’s pediatric x-ray diagnosis, 9th ed. st. louis: mosby; 1993:666-671. 11. kuhn jp, slovis tl, silverman fn, et al. mediastinum. in: silverman fn, kuhn jp, eds. caffey’s pediatric x-ray diagnosis, 9th ed. st. louis: mosby; 1993:666-671. 12. andronikou s, wieselthaler n. modern imaging of tuberculosis in children: thoracic, central nervous system and abdominal tuberculosis. pediatr radiol 2004;34:861-875. 12. andronikou s, wieselthaler n. modern imaging of tuberculosis in children: thoracic, central nervous system and abdominal tuberculosis. pediatr radiol 2004;34:861-875. 13. caffey j. pediatric x-ray diagnosis. chicago: year book, 1978:479-480. 13. caffey j. pediatric x-ray diagnosis. chicago: year book, 1978:479-480. 14. smuts na, beyers n, gie r p, et al. value of the lateral chest radiograph in tuberculosis in children. pediatr radiol 1994;24:478-480. 14. smuts na, beyers n, gie r p, et al. value of the lateral chest radiograph in tuberculosis in children. pediatr radiol 1994;24:478-480. 15. kim ws, choi j, cheon j, et al. pulmonary tuberculosis in infants:radiographic and ct findings. am j roentgenol 2006;187:1024-1033. 15. kim ws, choi j, cheon j, et al. pulmonary tuberculosis in infants:radiographic and ct findings. am j roentgenol 2006;187:1024-1033. 16. glazer gm, gross bh, quint le, et al. normal mediastinal lymph nodes: number and size according to american thoracic society mapping. am j roentgenol 1985;144:261-265. 16. glazer gm, gross bh, quint le, et al. normal mediastinal lymph nodes: number and size according to american thoracic society mapping. am j roentgenol 1985;144:261-265. 17. andronikou s. pathological correlation of ct-detected mediastinal lymphadenopathy in children: the lack of size threshold criteria for abnormality. pediatr radiol 2002;32:912. 17. andronikou s. pathological correlation of ct-detected mediastinal lymphadenopathy in children: the lack of size threshold criteria for abnormality. pediatr radiol 2002;32:912. 18. kim ws, moon wk, kim i, et al. pulmonary tuberculosis in children: evaluation with ct. am j roentgenol 1997;168:1005-1009. 18. kim ws, moon wk, kim i, et al. pulmonary tuberculosis in children: evaluation with ct. am j roentgenol 1997;168:1005-1009. 19. moon wk, im j, yeon km, han mc. mediastinal tuberculous lymphadenitis:ct findings of active and inactive disease. am j roentgenol 1998;170:715-718. 19. moon wk, im j, yeon km, han mc. mediastinal tuberculous lymphadenitis:ct findings of active and inactive disease. am j roentgenol 1998;170:715-718. 20. hammersley jr, grum cm, green ra. the correlation of subcarinal density visualized on plain chest roentgenograms with computed tomographic scans. chest 1990;97:869-872. 20. hammersley jr, grum cm, green ra. the correlation of subcarinal density visualized on plain chest roentgenograms with computed tomographic scans. chest 1990;97:869-872. pictorial interlude pictorial interludepictorial interlude diffusion-weighted imaging (dwi) and corresponding apparent diffusion coefficient (adc) maps have become routine magnetic resonance imaging (mri) sequences. in children one of the major uses of dwi is in neonates with perinatal hypoxic ischaemic injury.1 premature patients with hypoxic events, however, are also susceptible to intracranial haemorrhage. it is useful to be aware of the signal changes of the different stages of haemorrhage on dwi. our patient was born post term via caesarian section because of fetal heart rate abnormalities. he had a low birth weight and meconium at delivery. initially he was hypertonic with hypotonia in the subsequent stages after birth. mri was performed at 9 days. there was a haematoma adjacent to the left trigone which was hyperintense on t1 (fig. 1), hypointense on t2 (fig. 2). it showed ‘blackout’ (hypointense) on dwi (fig. 3) and adc map (fig. 4). periventricular white matter showed high signal on t2, which showed restricted diffusion with high signal on dwi (fig. 3) and low signal on adc map (fig. 4). this is consistent with a global hypoxic injury. hyperacute haematomas are hyperintense on t2-weighted imaging and dwi because of the t2 shine-through phenomenon.2 a less well-known phenomenon is termed ‘t2blackout’ which occurs in the acute and early subacute stage when haematomas are hypointense on t2-weighted imaging. these haematomas are equally hypointense on dwi and adc map: t2-blackout.3 1. oksuzler yf, cakmakci h, kurul s, oksuzler m, dirik e. diagnostic value of diffusion-weighted magnetic resonance imaging in pediatric cerebral diseases. pediatr neurol 2005; 32: 325-333. 2. moritani t, ekholm s, westesson pl. pitfalls and artifacts of dwi imaging. in: diffusion weighted mr imaging of the brain. heidelberg: springer, 2005: 12-17. 3. silvera s, oppenheim c, touze e, et al. spontaneous intracerebral hematoma on diffusion-weighted images: influence of t2-shine-through and t2-blackout effects. ajnr 2005; 26: 236-241. intracranial haemorrhage and the phenomenon of ‘t2-blackout’ 1dj van der merwe, mb chb 1s andronikou, mb bch, fcrad, frcr, phd 2s mcgurck, frcr 1s hlongwane, mb chb 1a brandt, mb chb 1department of radiology, stellenbosch university, tygerberg 2royal hospital for sick children, edinburgh, uk fig 1. there is a haematoma adjacent to the left trigone that is hyperintense on t1. blood is also present within the lateral ventricle. fig. 2. the haematoma is hypointense on t2. also note the hyperintense periventricular white matter representing hypoxic injury. 108 sa journal of radiology • december 2007 pg108-109.indd 108 12/11/07 2:21:56 pm pictorial interludepictorial interlude 109 sa journal of radiology • december 2007 fig. 3. dwi (b 1000). there is high signal in the periventricular white matter and thalami consistent with hypoxic injury. the haematoma and intraventricular blood on the left is hypointense: ‘blackout’ fig. 4. there is a hypointense area on adc map in the area of the haematoma (‘blackout’). also note the low density in the periventricular white matter consistent with restricted diffusion. fig. 3. as the same patient ages, the lesion is seen in the diaphysis, having moved away from the growth plate. this is typical for simple bone cysts. fig. 2. in addition to the visualised pathological fracture, a ‘fallen fragment’ is demonstrated which is almost pathognomonic of a simple bone cyst. erratum in the case report 'radiological features of simple (unicameral) bone cysts' in the september 2007 issue of the sa journal of radiology (p. 63) figs. 2 and 3 were placed incorrectly. please see corrected figures below. pg108-109.indd 109 12/11/07 2:21:59 pm a rare.html a rare cause of coffee-ground vomiting: retrograde jejunogastric intussusception kiran gangadhar, md department of radiodiagnosis and imaging, institute of medical sciences, banaras hindu university, varanasi, india corresponding author: k gangadhar (kirang.585@googlemail.com) retrograde jejunogastric intussusception is a well-recognised, rare, but potentially fatal long-term complication of gastrojejunostomy or billroth ii reconstruction. only about 200 cases have been reported in the literature to date. diagnosis of this condition is difficult in most cases. to avoid mortality, earlydiagnosis and prompt surgical intervention is mandatory. since gastrojejunostomies with vagotomy are on a declining trend, it is extremely rare to come across such a complication. we report on such a patient who presented with haematemesis. s afr j rad 2012;16(2):72-73. case history a 60-year-old man was admitted, complaining of abdominal pain after 4 days of coffee-ground vomiting. he had undergone gastric surgery for peptic ulcer disease 25 years earlier, but details of his surgery were not available at the time of admission. the patient underwent a gastrograffin swallow and computed tomographic (ct) examination for further evaluation. we considered whether the diagnosis might have been possible by the gastrograffin examination alone. discussion retrograde jejunogastric intussusception (jgi) is a rare but serious complication following gastric surgery, where small bowel loops become incarcerated and strangulated inside the stomach.1 , 2 the condition was first described by bozzi in a patient who had undergone gastroenterostomy.3 eight years later, the complication was also reported in a patient with billroth ii resection. subsequently, around 200 isolated cases and small series have been published.1 jgi seems therefore to be a rare complication after gastrojejunostomy or billroth ii gastrectomy. it also has been described as a complication following previously placed gastrostomy tube, total gastrectomy, billroth i operation1 and roux-en-y gastric bypass. the widely accepted anatomical classification proposed by shackman5 distinguishes 3 categories of jgi: type i – afferent loop intussusception (antegrade); type ii – efferent loop intussusception (retrograde); and type iii – combined form. type ii, or retrograde efferent loop intussusception (fig. 1), is the most common (80%), with the 2 other types accounting for 10%.1 in the case presented here, the type ii jgi was documented. the causes of jgi are poorly understood. various factors have been implicated, such as hyperacidity, long afferent loop, jejunal spasm with abnormal motility, increased intra-abdominal pressure, retrograde peristalsis, etc. retrograde peristalsis, which can occur in normal people prior to gastric surgery, seems to be accepted as the cause of type ii jgi. if not suspected, the clinical picture can be quite non-specific and the possibility of intussusception may not even be considered. the dominant symptom is pain, occasionally associated with nausea and vomiting. patients may present with high intestinal obstruction or severe haematemesis from secondary ulceration.6 a firm mass may be palpable in the epigastrium. a water-soluble upper gi contrast study may reveal a ‘coiled spring’ appearance within the stomach. upper gi endoscopic examination is often diagnostic and may visualise the jejunal segments as they migrate in and out of the stomach. when a patient presents with haematemesis and has a mobile upper abdominal mass with visible peristalsis, and bears an upper midline or paramedian scar, one should suspect this complication first.6 the treatment for jgi is surgical intervention as soon as possible. surgical options include reduction, resection and revision of the anastomosis, depending on the conditions found during the operation. the best way to prevent recurrence, if any, has not been identified yet. conclusion retrograde jgi is a very serious life-threatening complication of gastric surgery. there is a wide variation in the lapse time between the gastric surgery and occurrence of jgi, as seen in the present case. when a patient who has had history of gastric operation presents with epigastric pain, vomiting and haematemesis, the possibility of jgi should be considered along with more common diagnoses such as a recurrent stomach ulcer. because this condition is life-threatening, awareness of this rare complication is essential to save lives by operational intervention. 1. archimandritis aj, hatzopoulos n, hatzinikolaou p, et al. jejunogastric intussusception presented with haematemesis: a case presentation and review of literature. bmc gastroenterol 2001;1:1-4. 1. archimandritis aj, hatzopoulos n, hatzinikolaou p, et al. jejunogastric intussusception presented with haematemesis: a case presentation and review of literature. bmc gastroenterol 2001;1:1-4. 2. bapaye m, kolte s, pai k, et al. jejunogastric intussusception presenting with outlet obstruction. indian j gastroenterol 2008;22:31-32. 2. bapaye m, kolte s, pai k, et al. jejunogastric intussusception presenting with outlet obstruction. indian j gastroenterol 2008;22:31-32. 3. bozzi e. annotation. bull acad med 1914;122:3-4. 3. bozzi e. annotation. bull acad med 1914;122:3-4. 4. hasan m, mahamud mm, khan sa, rahman m. jejunogastric intussusception. mymensingh med j 2009;18(2):255-259. 4. hasan m, mahamud mm, khan sa, rahman m. jejunogastric intussusception. mymensingh med j 2009;18(2):255-259. 5. shackman r. jejunogastric intussusception. br j surg 1940;27:475. 5. shackman r. jejunogastric intussusception. br j surg 1940;27:475. 6. menezes lt, d’cruz a. retrograde jejunogastric intussusception following gastric surgery. j indian med assoc 1986;84:310-311. 6. menezes lt, d’cruz a. retrograde jejunogastric intussusception following gastric surgery. j indian med assoc 1986;84:310-311. fig. 1. axial cect of the patient showing retrograde intussusception of the jejunal loops within the stomach, the black arrow pointing towards the gastrojejunostomy stoma and its size shown by the broken line. a small intramural air density was noted in the intussuscepted bowel (white arrow). efferent loop of the gastrojejunostomy site involved is diagnostic of type ii variety. fig. 2. coronal cect of the patient showing retrograde intussusception of the jejunal efferent loops (white arrow) within the stomach, and a central hypodense (black arrow) area is seen giving a fat density, suggestive of mesenteric fat with mesenteric vessels that had intussuscepted along with the loops. pictorial interlude 37 sa journal of radiology • june 2010 we report on a male neonate born at 37 weeks’ gestation with severe respiratory distress immediately after birth. the child was cyanosed, requiring high oxygen pressures and continuous positive airway pressure. the pulmonary pattern on the earliest radiographs was difficult to definitively diagnose but, with serial radiographs, it became clear that the radiographic pattern was that of pulmonary venous congestion (pulmonary oedema). however, at no stage during serial radiographs over 8 days was the cardiothoracic ratio (ctr) greater than 60%. this suggested a likely specific diagnosis – infra-cardiac totally anomalous pulmonary venous drainage (tapvd) with obstruction. an echocardiogram confirmed an atrial septal defect (asd) and suggested anomalous pulmonary venous drainage, but the pulmonary veins were incompletely visualised owing to acoustic window limitations. multidetector computed tomography (ct) of the thorax confirmed infra-cardiac tapvd with common venous channel obstruction at the oesophageal hiatus. ct was used instead of mri because of the unstable clinical condition of the patient, enabling rapid diagnosis and minimising time out of the intensive care unit. after the definitive diagnosis was made, surgical correction was attempted. unfortunately, the patient died of respiratory failure shortly after surgery. discussion the radiologist usually suspects congenital heart disease in the face of an increased ctr (cardiomegaly). assessment of the ctr is a routine basic component of evaluation of the paediatric chest radiograph. before the age of 2 years, the ctr should not exceed 60%; after 4 years it should not exceed 50%, and between 2 4 years of age it should range between 60 50%. the great majority of congenital cardiac lesions will manifest with cardiomegaly. to enable a differential diagnosis, further evaluation is made in assessing the state of the pulmonary vasculature (i.e. oligaemia or plethora) and determining whether the patient is clinically cyanosed or not. the presented case demonstrates a rare but important exception to the algorithm outlined above. recognising pulmonary oedema (severe pulmonary venous congestion) with normal cardiac size is a difficult diagnosis. in the neonatal period, pulmonary oedema is often mistaken for primary pulmonary pathology such as surfactant deficiency syndrome (hyaline membrane disease), transient tachypnea of the newborn or infection on chest radiographs. recognition of septal lines (usually central kerley a lines rather than kerley b lines) is key to the diagnosis.1 the differential diagnosis of infantile pulmonary oedema is limited (table i). if the heart is not enlarged, the differential is further limited and the most likely diagnosis would be infra-cardiac tapvd. only the very rare entities of cor triatrium and congenital mitral stenosis could mimic the radiographic pattern but, in reality, these diagnoses can usually be diffentiated by recognising atrial enlargement. with infra-cardiac tapvd, the common pulmonary venous channel is almost invariably obstructed at the diaphragmatic hiatus, as in this case (figs 1 and 2); this leads to severe pulmonary congestion. the point of obstruction is too far removed from the heart (from a haemodynamic point of view) to result in chamber enlargement. tapvd usually results in severe cyanosis. there is a mandatory cardiac shunt (usually asd or patent infra-cardiac totally anomalous pulmonary venous drainage v dahya, mb bch, fcrad (sa) tuft and partners radiology, and department of radiology, groote schuur hospital, cape town table i. causes of neonatal pulmonary oedema • infantile coarctation • congenital aortic stenosis • hypoplastic left heart syndrome • congenital mitral stenosis • cor triatrium • obstructed tapvr fig. 1. chest radiograph of the patient showing evidence of severe pulmonary venous congestion with a normal cardiothoracic ratio. pictorial interlude pictorial interlude 38 sa journal of radiology • june 2010 ductus arteriosis (pda)) in patients with tapvd, the absence of which is a fatal condition. infra-cardiac tapvd represents approximately 10% of congenital tapvd. the other variations are supracardiac, intracardiac and mixed, with the former two not usually being obstructed and radiographically classically manifesting as pulmonary plethora. partially anomalous pulmonary venous return (papvd) is in contrast usually a minor congenital abnormality, often first detected in adulthood. papvd is often associated with an asd or pulmonary lobar hypogenesis (e.g. scimitar syndrome).2 conclusion the role of the general radiologist is vital in suspecting the diagnosis of infra-cardiac tapvd based on the plain radiograph. recognising pulmonary venous congestion without cardiac enlargement is a difficult radiological assessment but, when recognised, the diagnosis of infracardiac tapvd can be strongly suggested. 1. grainer r. congenital heart disease: general principles. in: grainger rg, allison d. diagnostic radiology: a textbook of medical imaging. 3rd ed. new york: churchill livingston, 1997: 657-675. 2. dahya v, mayosi bm. assessing scimitar syndrome-use of mri and mra. s afr med j 2007; 97(4): 248249. fig. 2b. mip reconstruction showing the common pulmonary venous channel (straight arrow) descending through the diaphragm to drain into the portal venous system. note the narrowing of the common venous channel at the oesophageal hiatus (curved arrow), the position confirmed by the nasogastric tube. fig. 2c. volume-rendered image of the ct angiogram showing the narrowing of the common venous channel (arrow) at the oesophageal hiatus. fig. 2a. mip reconstruction of the ct angiogram showing the four pulmonary veins converging to form a common channel (arrow) rather than entering the left atrium. estimation.html estimation of annual occupational effective doses from external ionising radiation at medical institutions in kenya g k korir, bsc, msc (nuclear science), phd (radiological science) department of physics and applied physics, university of massachusetts lowell, lowell, massachusetts, usa j s wambani, mb chb, m med (rad), pediatric (rad) radiology department, kenyatta national hospital, nairobi, kenya i k korir, bsc, msc (nuclear science), phd (nuclear physics) national nuclear regulator, centurion, pretoria corresponding author: g korir (chumo2009@gmail.com) abstract this study details the distribution and trends of doses from occupational radiation exposure among radiation workers from participating medical institutions in kenya, where monthly dose measurements were collected for a period of one year (january to december 2007) using thermoluminescent dosimeters. a total of 367 medical radiation workers were monitored, comprising 27% radiologists, 2% oncologists, 4% dentists, 5% physicists, 45% technologists, 4% nurses, 3% film processor technicians, 4% auxiliary staff, and 5% radiology office staff. the average annual effective dose for all subjects ranged from 1.19 to 2.52 msv. among these workers, technologists received the largest annual effective dose. the study forms the initiation stage of wider, comprehensive and more frequent monitoring of occupational radiation exposures and long-term investigations into its accumulation patterns, which could form the basis of future records on the detrimental effects of radiation, characteristic of workers in the medical sector, and other co-factors in a developing country such as kenya. introduction the discovery of x-rays in 1895 by wilhelm conrad röntgen (for which he won the nobel prize in physics in 1901) wrought a revolution in medicine and medical care. diagnostic and experimental radiation exposures in the early 1900s revealed the deterministic effects of radiation such as skin erythema and radiation burns. owing to this recognised harmful effect of radiation on patients and experimental subjects, significant modifications took place in the design of x-ray machines and patient positioning. other researchers who used radiation also suffered deterministic effects. in 1905, guidelines on the safety of workers handling patients for diagnostic x-ray were introduced for the first time.1 x-ray equipment was first installed in kenya in 1936 at the current grounds of the kenya medical training college within the kenyatta national hospital grounds. it was housed in a wooden structure; radiation safety and protection was not considered at that time. kenya is a developing nation, with about 1 000 radiation-producing facilities country-wide of which 80% are for medical applications. there are around 500 large x-ray machines for diagnostic radiology, 150 for dental imaging, 27 for ct scans, 18 for mammography and bone densitometer units, 3 cobalt radiotherapy units, 3 linac accelerators for radiotherapy, over 100 fluoroscopy units, 5 interventional units, 2 brachytherapy units, and 3 gamma cameras. there are less than 10 airport security cargo scanners, and a few dozen radioactive sources are estimated to be used in agriculture, as well as in industrial gamma radiography. a few sources with low activities are found at the in vitro biomedical research and teaching institutions. medical use accounts for the largest proportion of ionising radiation use in kenya. it is on this basis that the present study focused on occupational exposure in the medical sector. the legal framework for radiation protection in kenya is based on laws governing radiation protection;2 subsequent regulations are being revised to ensure compliance with current international practices and safety standards.3 the regulations that govern the radiation protection of persons working in radiation areas is covered internationally under the prescribed dose limits derived from quantitative estimates of human studies on the effects of acute high doses, such as the hiroshima and nagasaki nuclear bomb survivors, who have demonstrated increased deaths from circulatory, respiratory and digestive diseases associated with radiation exposure.4 however, current regulations in kenya do not classify radiation workers according to recognised occupational dose limits criteria. the type a radiation worker conditions allow the possibility of receiving in excess of 30% of the annual effective dose limit, and require a mandatory medical examination each year as well as individual monitoring of exposure levels. type b radiation workers are highly unlikely to receive more than 30% of the annual effective dose limit and therefore do not undergo mandatory medical examination or have individual exposure monitoring requirements.5 , 6 personnel radiation monitoring in the usa is required for workers who are likely to receive more than 10% of the occupational dose limits.7 overall, the kenyan regulatory requirements subject all radiation workers to the same medical examination, and require occupationally exposed persons to incorporate the sum of external and, where relevant, internal radiation exposures into the dose limitation criteria. however, assessment of internal radiation exposures is not yet well established in kenya. there are indications from epidemiological studies that radiologists and other medical x-ray workers may experience increased mortality from cancer and leukaemia.8 cytogenetic studies of hospital workers occupationally exposed to low doses of ionising radiation have revealed enhanced baseline levels of chromosomal aberrations, compared with the control populations.9 cytogenetic monitoring of persons who accidentally had large exposures is of special value in biodosimetry, and the measurement technique may be extended to personnel in hospitals as well as workers in the nuclear and radiopharmaceutical industries. without proper calibration references for personal dosimeters, individual monitoring of radiation exposure may result in underestimation of the actual occupational exposure. thermoluminescence dosemeters (tlds) are easy to calibrate and give reliable dose measurements, and have been the basis of many important studies, including national dose surveys in sweden10 and the uk.11 a radiation safety programme should lend support to all radiation users by promoting radiation safety at the equipment performance level and a safe working environment. the programme objectives require accurate and reliable monitoring of radiation workers to effectively manage radiation protection and quality assurance. the use of tlds in dose measurements offers several advantages in radiation protection monitoring programmes. tlds are small, robust dosimeters, allowing accurate positioning and reasonable spatial detail in dose measurement, and they are suitable for wide ranges of dose and dose rate values. some tld materials, especially li2b407, have nearly the same effective atomic numbers as soft tissue, and their energy responses to absorbed radiation show little variation over wide ranges of photon energy. the energy stored in tld crystals following exposure can be retained over long periods of time before read-out. tld cards can be re-used after suitable thermal treatment, making them cost-effective and viable in the long term. in kenya, there is no recorded evidence in the literature of studies on occupational radiation exposure, and personnel monitoring programmes are not yet fully established, except during this study. the aim of the study was to evaluate the dose delivered to the various groups of radiation workers as a result of external exposure to ionising radiation and to compare the results with dose limits stated by international safety standards.5 , 6 materials and methods this study was carried out over one year by monitoring occupationally exposed individuals working at medical institutions that agreed to participate in the international atomic energy agency (iaea) project raf/9/033 on medical exposure control.12 a list of medical radiation workers indicating job group and age was submitted by each participating hospital. each worker was assigned 2 pairs of individual tlds (tld-100) with a facility and a personal identification number (pin) for traceability. via hospital management, radiation safety officers were provided with dosimeter user instructions that included strict adherence to wearing of tld badges on the upper torso, between the neck and waist, and outside protective gear when undertaking exposure-related activities. hospital management assigned one person to deliver the dosimeters for monthly reading and collection of newly annealed tld badges. natural background radiation levels from control tld samples were used to correct for the actual individual dose received by each worker. the tld-100 is fabricated from lithium fluoride elements assembled in bar-coded cards encapsulated in teflon (harshaw model 0110); units were provided with the harshaw model 8814 card holder to each radiologist, oncologist, dentist, physicist, technologist, nurse, film processor, auxillary staff (cleaners in the department) and radiology office staff in participating medical institutions. a tld reader (harshaw model 4500 operating under winrems software) was used to process the tld signals. the tld-100 has a radiation dose measurement range of 0.05 msv 10 sv. the calibration factor rcf used was 0.024 nc/µsv for the radiation to which workers in the medical sector were exposed, as determined using the manufacturer’s instruction manual and recommendations in the iaea standard.12 dosimeter read-outs were done at the national radiation protection laboratories on the kenyatta national hospital grounds. accumulated dose from tld cards not submitted on time for reading was excluded and an appropriate value of the individual measured monthly mean dose was assigned instead. for penetrating external ionising radiation, personal deep dose equivalent (which is scientifically recommended for operational deep dose quantity) was adopted in this study. the measured dose and details of the data collected were entered into an excel spreadsheet for analysis. the collective effective dose was estimated from the number of persons multiplied by the average effective dose. an analysis of the average annual effective doses received for medical radiation workers according to gender was also determined. results table i indicates the distribution of age and annual occupational dose for different groups of medical radiation workers in kenya in 2007. the measured natural radiation background was 0.10 msv, and the measurement range for annual absorbed dose was 0.32 msv to 6.78 msv. the largest to the smallest radiation exposure was observed in the following worker groups respectively: technologists, physicists, radiologists, dentists, nurses, oncologists, film processors, auxillary staff, and radiology office staff. the annual collective effective dose from occupational exposure in the medical sector was estimated as 0.8 person-sv. fig. 1 indicates the trends over time for the individual worker groups. the monthly percentage range was 1 4%, with an average of 2%. the spread was less than 5% for each worker group. a standard deviation of 34% indicates the variation in exposure among the different groups of workers involved in the medical sector. fig. 2 indicates the distribution of occupational dose among the 29% female and 71% male radiation workers. the female mean annual dose was 2.16 msv, the male 2.14 msv. the level of mean annual dose for female radiation workers was higher than the fetal dose limit of 1 msv per year, and a study is therefore necessary to ensure that the working environment is safe for pregnant workers. fig. 3 indicates the distribution of annual personal dose; 17% were below 1 msv and 81% between 1 msv and 5 msv. for all the subjects monitored, the doses were well below the internationally recommended limit of 20 msv per year.5 , 6 in all the individual doses received by the radiation workers, none of the workers qualified to be classified as type a. only 4% of the workers received more than 10% (5 msv) of the annual occupational dose limits. discussion annual average occupational dose values in kenya are higher than those reported among south korean medical radiation workers.13 the former country’s average annual effective dose was found to be 2.15 msv, which was larger than the average annual dose of 0.80 msv for equivalent radiation workers in south korea for 2006. the korean means also were smaller than those of 3.6 msv, 4.7 msv and 7.7 msv reported for radiation workers in nigeria for 1999, 2000 and 2001, respectively.14 the distribution of annual dose, however, was similar to that reported for portugal (1986 1988), which showed that 97.8% of the personnel monitored received doses below 5 msv.15 the average dose to all radiation workers, corrected for the natural radiation exposure, was 4 times larger than the 2000 2002 estimated value of 0.5 msv.16 the technologist group exhibited the larger amount of radiation exposure owing to increased patient workload as well as the lack of physical or engineering radiation safety measures in the working environment. the technologist sample size produced consistent dose trends and the least spread among the group studied. the results of this study will consequently form the baseline for optimisation of radiation protection. the monthly dose trend indicates a reduction of average dose over the study period. the personal monitoring effort therefore made radiation workers more aware, and led to improvement, of some of their radiation protection practices. the study showed that providing each worker with the measured monthly dose can have a positive influence on improving radiation safety measures. radiation workers who, like physicists, have fundamental understanding and knowledge of radiation safety, can derive the most benefit from these studies because their measured monthly dose showed the largest spread in distribution. the trend also indicates that working behaviour changed when radiation workers realised that they would be subjected to detailed analysis of their monthly exposure. the level of mean annual dose to female radiation workers exceeded the fetal dose limit of 1 msv per year; the working environment therefore did not comply with regulations for pregnant radiation workers. additional radiation safety measures were necessary for this category of worker. seventeen per cent of radiation workers (comprising radiologists and technologists) worked in 2 medical facilities and consequently received twice-larger doses than the annual average doses for the respective groups. about 17% of the workers monitored (mainly radiology office staff) had doses within the permissible limits. however, some of the occupational doses for this group were above the third quartile value obtained in the study, which emphasises the importance of radiation safety training for all workers in medical irradiating facilities. conclusion a representative sample of occupationally exposed workers was surveyed in an effort to determine levels of radiation exposure in the medical industry in kenya. the study found that annual exposure levels ranged from 0.32 6.98 msv with a skewed annual distribution showing a median value of 1.5 msv. technologists were in the upper quartile in this radiation exposure distribution, therefore being the largest exposed group in the medical sector. the study also found shortcomings in various regulations governing radiation exposure of workers, wherein additional safety measures for pregnant radiation workers was lacking. lastly, this study will form the basis for a national database of exposures for radiation workers that can be used to assess potential adverse radiation effects. acknowledgements. we thank the ministry of health, the management and radiology staff of all the private and public facilities who agreed to participate in the iaea project (raf/9/033 – strengthening radiological protection of patient and medical exposure control), the national council for science and technology, and the iaea for their support. 1. calder j. the history of radiology in scotland 1896-2000. edinburgh: dunedin academic press, 2001. 2. the radiation protection act, chapter 243, laws of kenya. the radiation protection (standards) regulations, legal notice no. 54. nairobi: government printers, 1986. 3. international atomic energy agency. iaea safety standards. http://www-ns.iaea.org/standards (accessed 22 november 2010). 4. shimizu y, pierce da, preston dl, mabuchi k. studies of the mortality of atomic bomb survivors. report 12, part ii. noncancer mortality: 1950 1990. radiat res 1999;152:374-389. 5. international commission on radiation protection. individual monitoring for internal exposure of workers: replacement of icrp publication 54. icrp publication 78. ann icrp 1998;27:3-4. 6. international atomic energy agency. international basic safety standards for protection against ionizing radiation and for safety of radiation sources. safety series no. 115. vienna: iaea, 1996. 7. nuclear regulatory commission. standards for protection against radiation. 10 code of federal regulations, part 20. washington, dc: nrc, 1988. 8. aoyama t. radiations risk of japanese and chinese low dose repeatedly irradiated population. j uni occup environ health 1989;11:432-442. 9. bengtsson g, blomgren pg, bergman k, aberg l. patient exposures and radiations risks in swedish diagnostic radiology. acta radiol oncol 1978;17:81-105. 10. wall bf, fisher es, shrimpton pc, rae s. current levels of gonadal irradiation from a selection of routine diagnostic x-ray examinations in great britain. nrpb – r105. london: hmso, 1980. 11. international atomic energy agency. radiation protection of patients. http://rpop.iaea.org/rpop/rpop/content/informationfor/memberstates/1_regionalprojects/task5patientdose901.htm (accessed 20 november 2010). 12. international atomic energy agency. calibration of radiation protection monitoring instruments. safety reports series no. 16. vienna: iaea, 2000. 13. lee wj, cha es, ha m et al. occupational radiation doses among diagnostic radiation workers in south korea, 1996–2006. radiat prot dosimetry 2009;136(1):50-55. 14. ogundare fo, balogun fa. whole body doses of occupationally exposed female workers in nigeria (1999-2001). j radiol prot 2003;23:201-208. 15. careiro jv, avelar r. occupational exposure in medical and paramedical professions in portugal. radiat prot dosimetry 1991;36:233-236. 16. united nations scientific committee on the effects of atomic radiation. sources and effects of ionizing radiation. new york: unscear, 2008. table i. annual radiation exposure dose measured with tlds worn by occupationally exposed personnel in the medical sector quartile dose msv occupational classification age range q1 q2 q3 max. annual dose (msv) annual average dose (msv) number monitored ( n ) person-sv 1. radiologists 37 70 1.15 2.01 2.73 5.9 2.18 99 0.22 2. oncologists 40 68 1.58 1.63 2.00 2.1 1.55 6 0.01 3. dentists 30 71 1.88 2.27 2.54 3.6 2.04 16 0.03 4. physicist 26 -55 1.63 2.00 2.63 6.8 2.33 20 0.05 5. technologists 22 59 1.37 2.28 3.21 7.4 2.52 166 0.42 6. nurses 24 53 0.95 1.76 2.27 3.4 1.77 14 0.02 7. film processors 4554 1.13 1.29 1.73 1.9 1.26 10 0.01 8. auxillary 28 50 0.62 1.19 1.69 2.2 1.19 16 0.02 9. radiology office staff 28 55 0.92 1.08 1.25 2.3 1.21 20 0.02 fig. 1. distribution of monthly average dose according to work group. fig. 2. percentage distribution of radiation workers by gender in relation to quartile dose in msv. fig. 3. distribution of annual dose among medical radiation workers by dose range. upper.html upper abdominal visceral injury resulting from blunt trauma to the pelvis: a specific variant of shockwave injury? d j emby, mb bch, ffrad (d) sa anglogold ashanti health, western deep levels hospital, carletonville corresponding author: d emby (demby@anglogoldashanti.com) case histories and imaging findings patient 1 while working underground in a goldmine, a 35-year-old man was struck on the right side of his upper pelvis by a large rock during a rock-fall. owing to delays in the extraction process (he remained buried from the waist down for approximately 4 hours), the patient reached casualty approximately 7 hours following the acute injury. on arrival he was fully conscious and orientated, but had a low blood pressure of 84/56 and a pulse rate of 101. he complained of pain over the right ilium; external bruising and swelling was visible in the region. a pelvic radiograph demonstrated a comminuted but undisplaced fracture of the anterior portion of the body of the right ilium (fig. 1). there was also a comminuted fracture of the left medial tibial plateau and evidence of a compartment syndrome involving the left calf. in addition, there was marked tenderness over the entire abdomen and intraperitoneal haemorrhage was suspected. the chest x-ray was clear and no rib fractures were shown. the patient was taken to theatre where a laparotomy revealed extensive intraperitoneal haemorrhage from a ruptured spleen. (in addition to the laparotomy, internal fixation of the left medial tibial plateau was performed; together with a medial fasciotomy of the left calf). patient 2 a 23-year-old man was struck on the right side of the pelvis by a large boulder following an underground rock-fall. he was haemodynamically stable on arrival in casualty. on physical examination, the right side of the pelvis was found to be unstable and a pelvic radiograph showed disruption of the right sacro-iliac joint and diastasis of the pubic symphysis (fig. 2). as with patient 1, the chest x-ray was clear and no rib fractures were shown. the upper abdomen was non-tender. blood was found to be dripping from the penile meatus. a diagnosis of a ruptured (or possibly severed) urethra was made and a sonar examination was requested to examine the bladder for evidence of rupture and for localisation for the insertion of a supra-pubic catheter. on examination, the bladder was mildly distended with no visible injury to the bladder wall and no peri-vesical free fluid. following examination of the pelvis, a full abdominal ultrasound examination was performed. a large fluid collection (slightly echogenic, consistent with haematoma) was shown surrounding the spleen (fig. 3). although there was no visible splenic injury, a presumptive diagnosis of splenic rupture was made and the patient underwent immediate laparotomy. this revealed a rupture of the pancreas with extensive retroperitoneal and also intraperitoneal haemorrhage. the spleen was found to be intact. discussion tissue injury owing to the propagation of a shockwave is well described in ballistic injuries where the energy transfer from the missile to the tissue is responsible for the increased severity of the wound.1 the relationship between kinetic energy and the projectile can be derived from the following formula: kinetic energy (ke) = 0.5 x mass x (velocity)2 in the case of bullet wounds where the mass of the projectile is relatively small, the extent of the damage to the surrounding tissues is largely determined by the bullet velocity. shockwave damage to body tissues has been described in association with blast injuries.² in addition, shockwave injury to adjacent tissue is a well-recognised complication of extracorporeal shockwave lithotripsy.3 in the patients described above, the falling rock – although non-penetrating – can be equated to a missile. in both these cases, the large (estimated to be between 50 and100 kg) mass, despite its relatively low velocity, had sufficient kinetic energy to cause bony pelvic injury. in the first patient, the pelvic injury was relatively superficial and the splenic rupture could be explained by the propagation of a shockwave across the abdomen from the impact site inferiorly on the right to the left upper quadrant. in the second patient, as the pelvic injury was predominantly retroperitoneal, it is postulated that the resulting shockwave might have propagated predominantly through the retroperitoneal tissues, resulting in the rupture of a retroperitoneal organ, i.e. the pancreas. conclusion a syndromic pattern of injury is described where a direct blow to the pelvis resulted in rupture of a distant, upper abdominal viscus. shockwave propagation across the abdomen is the likely explanation for this phenomenon.4 the possibility of injury to an upper abdominal organ should be considered in all cases where there is a severe, direct blow to the pelvis. 1. 1. cooper gj, ryan jm. interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management. br j surg 1990;77:606-610. 1. 1. cooper gj, ryan jm. interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management. br j surg 1990;77:606-610. 2. 2. stapley sa, canon lb. an overview of the pathophysiology of gunshot and blast injury with resuscitation guidelines. current orthopaedics 2006; 20:322-332. 2. 2. stapley sa, canon lb. an overview of the pathophysiology of gunshot and blast injury with resuscitation guidelines. current orthopaedics 2006; 20:322-332. 3. 3. ilnyckyj a, hosking dh, pettigrew nm, bernstein cn. extracorporeal shock wave lithotripsy causing colonic injury. dig dis sci 1999;44(12):2485-2487. 3. 3. ilnyckyj a, hosking dh, pettigrew nm, bernstein cn. extracorporeal shock wave lithotripsy causing colonic injury. dig dis sci 1999;44(12):2485-2487. 4. 4. salomone ja, salomone jp. abdominal trauma, blunt. http://emedicine.medscape.com/article/821995-print (accessed 9 november 2010). 4. 4. salomone ja, salomone jp. abdominal trauma, blunt. http://emedicine.medscape.com/article/821995-print (accessed 9 november 2010). summary two patients who sustained severe blunt injury to the pelvis without external injury to the upper abdomen or lower chest, yet who were found to have a ruptured solid upper abdominal viscus, are reported. the first patient on delayed arrival revealed clinical features suggestive of intra-abdominal bleeding and was found to have a grade 3 ruptured spleen. with the second patient, upper abdominal injury (in this instance, a pancreatic laceration) was not initially suspected owing to the absence of clinical evidence of injury to the abdomen. it is postulated that both the splenic and pancreatic injuries were the result of a shockwave propagated through the abdomen following the severe external impact to the pelvis. fig. 1. x-ray of the pelvis showing fracture (arrows) of the right ilium in patient 1. fig. 2. pelvic x-ray showing disrupted right sacro-iliac joint (arrow heads) and diastasis (arrows) of the pubic symphysis in patient 2. fig. 3. sonar image showing haematoma (arrow) around spleen. about the author(s) maya patel department of radiology, school of medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africanational radiology services inc, johannesburg, south africa citation patel m. the culture of radiology: learning, teaching and curiosity. s afr j rad. 2020;24(1), a2045. https://doi.org/10.4102/sajr.v24i1.2045 editorial the culture of radiology: learning, teaching and curiosity maya patel copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. radiology is a world interposed between macroscopy and microscopy, capturing images that afford clinicians and surgeons with an in-depth analysis of the interior of the human body. it is a core instrument in their armamentarium for medical practice, analogous to the body’s heart, lungs, brain and spine. revolutionary technological advances are ensuring rapid enrichment in the discipline of radiology from image enhancement and resolution to faster acquisitions, improved patient comfort and artificial intelligence (ai). the relentless strive to raise the bar from competing technicians and engineers is creating a speciality that is becoming a challenge to foster and maintain academically, particularly when access to these newer strategies is limited by cost and availability. staying on par with these advances means that with each passing year, new learning paradigms are necessary. within our environment, this includes sub-specialisation, incorporation of ai and different teaching techniques and research. sub-specialisation focuses expertise in one area of radiology, providing clinicians with well-informed opinions and interpretations and ultimately a better outcome for the patient. whilst this is well established in the medical and surgical fields, radiology is trailing behind, particularly in developing countries with limited resources and lack of established protocols for specialisation. although certain areas in radiology have already dichotomised, such as paediatric radiology, musculoskeletal radiology and mammography, on the whole, radiology in south africa is still dominated by general radiologists. given the wide range of health service delivery needs from rural to urban areas and the high burden of trauma surgery and emergency medicine, the role of the general radiologist is pivotal to our healthcare system. we must rise to meet this public health need, but at the same time, not ignore the equally demanding need to join our subspecialist colleagues and ascend the steep learning curve. thankfully, international courses, fellowships, webinars and online resources are plentiful, and the path towards fixating on a niche is now more accessible. given the lack of established registered local university programmes currently, the onus lies with the radiologist to pursue such avenues. our next call is to embrace ai in radiology. welcome or not, ai is steadily permeating its way into our lives. the promise of ease of use, objective results, saving time, reproducibility and digital twins is far too alluring for both the clinician and the patient. although it is more likely to become embedded into daily practice in resource-rich, high expenditure countries because of cost, this amalgamated form of practice in radiology will probably be more useful in high disease burden regions such as ours. we need to ensure constant growth in information technology infrastructure and accessibility to these inventions. the role of ai should remain supportive, and it is up to the radiologist to ensure this. a lesson from the coronavirus pandemic includes exploring different ways of interacting with others in a ‘safer’ manner and ai offers such an opportunity. a further test of our performance is related to research in the field of radiology. we need to awaken our curiosity and ask more questions, given that we are in a country that offers a wealth of opportunity with the disease burden we face. research is the third category in the field of learning, together with an expert faculty of teachers and written learning material, the model upon which most medical schools and universities are developed. whilst germination has begun, radiological research in south africa still requires a fair amount of incentive, cultivation and grooming. here again, a local structured model is lacking and there is a hiatus for new prospects, which we need to embrace. this duty rests not only with the higher educational institutions but with all of us who can contribute to sharing new knowledge and expanding our field with what we have to offer. the universal future for radiology involves life-long training, growth and adaptability. in particular, the south african radiologist needs to foster a culture of learning, teaching and curiosity. by working together, this will ensure that we expand our intellectual environment, provide the best opinions for our patients and practice safe radiology. the future is in our hands – are you prepared? ‘never stop learning because life never stops teaching’ … anonymous dr maya patel sajr 725 + 710 perinatal lethal osteogenesis imperfecta s moosa division of human genetics, national health laboratory service and university of the witwatersrand, johannesburg s moosa, mb bch, dch (sa) corresponding author: s moosa (shahidamoosa@gmail.com) osteogenesis imperfecta (oi) is a heterogeneous group of genetic bone disorders that are characterised by decreased bone mass, increased bone fragility and susceptibility to fractures. the severe, perinatal lethal form (type ii) (omim 166210) is characterised by bone fragility, with perinatal fractures, severe bowing of long bones, undermineralisation, and death in the perinatal period owing to respiratory insufficiency. the overall prevalence of oi type ii is unknown. there are three subtypes of oi type ii (a, b and c) that are characterised by different radiological features, and may be caused by different genetic faults. two fetuses with oi type iia are presented.  s afr j rad 2012;16(4):141-142. doi:10.7196/sajr.710 osteogenesis imperfecta (oi) is a heterogeneous group of genetic bone disorders that are characterised by decreased bone mass, increased bone fragility and susceptibility to fractures. the severe, perinatal lethal form (type ii) (omim 166210) is characterised by bone fragility, with perinatal fractures, severe bowing of long bones, undermineralisation, and death in the perinatal period owing to respiratory insufficiency. the overall prevalence of oi type ii is unknown. there are three subtypes of oi type ii (a, b and c) that are characterised by different radiological features, and may be caused by different genetic faults.1 two fetuses with oi type iia are presented. as there is no molecular genetic testing currently available in south africa, the diagnosis of oi type iia relies on the accurate recognition of typical clinical and radiographic features. parents can be reassured that the recurrence risk for future pregnancies is low, as most affected individuals have de novo mutations. clinical findings the clinical findings in patient 1 are seen in fig. 1. patient 2 was a male fetus, noted to have a small chest, short bowed long bones, and multiple fractures on antenatal ultrasound. the parents opted to interrupt the pregnancy, based on the diagnosis of a lethal skeletal dysplasia and the associated poor prognosis. the fetus was delivered at 25 weeks’ gestation. dysmorphic features included: soft skull, prominent eyes with peri-orbital fullness, blue sclerae, micro-retrognathia and short extremities. fig. 1. a female fetus was stillborn at 34 weeks’ gestation, with a birth length less than the 3rd centile and an upper:lower segment ratio of 2.25 (increased). the following dysmorphic features were noted: soft skull, blue sclera, prominent beaked nose, small mouth, short upper limbs (both rhizomelic and mesomelic segments) and bowed lower limbs. radiological findings major radiological features of oi type iia may include severe retardation of calvarial bone formation (fig. 2a), generalised undermineralisation with multiple fractures and callus formation, wavy accordion-like appearance of the femora as well as short, thick crumpled shafts of long bones (figs 2a and 3) and short, thickened ribs with continuous beading (fig. 3).2 fig. 2(a). babygram x-ray of patient 1 demonstrating generalised undermineralisation. the skull bones are poorly ossified and facial bones poorly mineralised. the ribs are broad with continuous beading. all long bones are short and broad with crumpled shafts. fig. 2(b). the spine of patient 1 shows generalised mild platyspondyly, with irregularly shaped vertebral bodies. fig. 3. babygram x-ray of patient 2 demonstrating generalised undermineralisation and evidence of multiple fractures. the skull is poorly ossified. the ribs show continuous beading. all long bones are short and broad with crumpled shafts. discussion oi type iia is an autosomal dominant condition caused by mutations in the collagen 1 alpha-1 chain (col1a1) and collagen 1 alpha-2 chain (col1a2) genes. they encode the two chains pro α1(i) and pro α2(i), respectively, of type i procollagen. as molecular genetic testing for oi type 2 is not currently available in south africa, it is important to recognise the clinical and x-ray findings. an assessment by a medical geneticist is recommended to confirm the diagnosis. an accurate clinico-radiological diagnosis is important, as it has direct implications for the family concerned. firstly, the poor prognosis can be explained to the family, as oi type iia is invariably lethal. secondly, it is well known that virtually all individuals with oi type iia have de novo mutations. although the recurrence risk is never zero, owing to possible germline mosaicism in an unaffected parent, families can be reassured that the risk for future pregnancies is very low. consequently, we would advise that all parents be referred for genetic counselling, for explaining the condition and reinforcing the expected low risks for future pregnancies.   ethics approval was obtained from university of the witwatersrand human research ethics committee (medical): certificate m120152. written consent from the parents was obtained for use of the images. 1. online mendelian inheritance in man, omim. johns hopkins university, baltimore, md. mim number: 166210: 06/10/2011. http://omim.org (accessed 1 september 2012). 1. online mendelian inheritance in man, omim. johns hopkins university, baltimore, md. mim number: 166210: 06/10/2011. http://omim.org (accessed 1 september 2012). 2. spranger jw, brill pw, poznanski a. bone dysplasias: an atlas of genetic disorders of skeletal development. 2nd ed. oxford: oxford university press, 2002. 2. spranger jw, brill pw, poznanski a. bone dysplasias: an atlas of genetic disorders of skeletal development. 2nd ed. oxford: oxford university press, 2002. imaging.html imaging findings in an infant with congenital pulmonary venolobar syndrome (scimitar syndrome) t westgarth-taylor, mb chb, fc rad diag (sa) department of radiology, groote schuur hospital, cape town t kilborn, mb chb, frcr department of radiology, red cross war memorial children’s hospital, cape town corresponding author: t westgarth-taylor (twestgarthtaylor@gmail.com) abstract congenital venolobar syndrome (cvls) is a rare complex malformation that includes hypoplasia of the lung, partial anomalous pulmonary venous drainage and, in a quarter of patients, associated cardiac anomalies. we present the chest radiograph and multidetector ct findings in a case of congenital venolobar syndrome in an infant, and describe the history of the condition. introduction congenital venolobar syndrome (cvls) is a unique and rare form of lobar hypoplasia associated with other anomalies of the pulmonary vessels.1 the reported incidence is 0.4 0.7% of all congenital lung anomalies.3 the syndrome’s variable components include: lung hypoplasia (right more commonly affected than left), partial anomalous pulmonary venous drainage (to right atrium, coronary sinus, inferior vena cava (ivc), or hepatic circulation), absent or small pulmonary artery, systemic arterial supply to the lung, cardiac anomalies (atrial septal defect (asd), ventricular septal defect (vsd), patent ductus arteriosus (pda), tetralogy of fallot, coarctation, hypoplastic left heart or endocardial cushion defects), diaphragmatic hernia, and anomalies of the bony thorax or thoracic soft tissues.2 , 4 embryologically ,it is thought to represent a primary developmental anomaly of the right lung with secondary anomalous venous drainage.4 george cooper and raoul chassinat are credited with the earliest description of the anomaly in the medical literature. in 1836, they individually described single cases of a rare congenital malformation that included venous drainage from the lung beneath the diaphragm.5 , 6 the first authors to use the term ‘scimitar’ were halasz et al. in 1956.7 they referred to a vertical curvilinear vein resembling a scimitar, draining all or a portion of the right lung to the right atrium or more commonly to the ivc. the first detailed radiographic description of the ‘scimitar sign’ (the presence of a scimitar vein on a chest radiograph) was by dotter et al. in 1949; they were also the first to use angiography and cardiac catheterisation to document the anomaly.8 the term ‘scimitar syndrome’ first appears in the 1960 article by neill et al., referring to the combination of anomalous venous drainage of all or most of the right lung to the right atrium or ivc together with hypoplasia of the right lung and associated with systemic arterial collaterals.9 the name of the syndrome has subsequently been refined, and the preferred term ‘congenital pulmonary venolobar syndrome’ was coined by dr ben felson in 2003.3 the clinical presentation of cvls is variable. patients may be completely asymptomatic or symptomatic early in life; it depends on the associated cardiac abnormalities and degree of shunting.3 , 4 surgery is considered in patients who are symptomatic, and requires detailed and accurate preoperative imaging. case report our patient presented at 7 weeks of age with a 2-day history of cough and fever, and was initially diagnosed with right-sided pneumonia. at the time of presentation, a murmur was documented. chest radiography showed volume loss of the right lung with mediastinal shift to the right and opacification of the right hemithorax. the right lung was therefore difficult to assess and the heart size could not be accurately measured. the left lung showed air trapping and pulmonary plethora (fig. 1). in view of the clinical and radiographic findings, an echocardiogram was performed which revealed multiple cardiac anomalies including a large asd, small vsd, and dilated right atrium, ventricle and main pulmonary artery. the right and left pulmonary arteries were not well defined. this explained some of the clinical findings; however, the volume loss of the right lung remained a concern, and a chest ct was performed to further define the anatomy. the chest ct was done in the arterial phase and showed a hypoplastic right upper lobe bronchus and consequently also a hypoplastic right lung – this explained the mediastinal shift to the right (fig. 2). the right pulmonary artery was small, with normal main and left pulmonary arteries (fig. 3). assessment of the venous drainage revealed an anomalous right pulmonary vein entering the ivc at the junction with the right atrium – a so-called ‘scimitar vein’ (fig. 4). the left pulmonary veins showed normal drainage into the left atrium. the heart was enlarged and the pulmonary vasculature prominent, in keeping with the echo findings of a left to right shunt (asd and vsd). the study also documented coarctation of the aorta at the level of a pda, neither of which had been shown on echocardiography (fig. 5). discussion congenital venolobar syndrome refers to a wide spectrum of pulmonary developmental anomalies, which may occur singly or in combination.3 our case highlights the main components of cvls i.e. hypoplastic right lung with a small right pulmonary artery and anomalous pulmonary venous drainage of the right lung. in 25% of cases there is an associated cardiac abnormality, most commonly septal defects, as in our case.3 , 4 coarctation of the aorta is associated with cvls, but is uncommon and the actual incidence unknown. our patient did not exhibit co-existent diaphragmatic or soft-tissue abnormalities. the present case also demonstrates the diagnostic difficulties that may be encountered with cvls. it is a rare disorder, not often diagnosed at initial presentation. mediastinal shift and dextroposition of the heart on plain film are indicators of pulmonary hypoplasia, which warrants further investigation. this is particularly important if there is a co-existing cardiac anomaly or a suspicion of the scimitar sign on the radiograph. in these patients, the venous drainage and arterial supply of the lung need to be defined in order to direct management.4 echocardiography is the initial additional imaging method used in suspected cardiac anomalies. however, in the case of infants, small or absent pulmonary arteries and anomalous venous drainage can be very difficult to define.10 angiography has traditionally been used as an adjunct to echocardiography in the investigation of suspected pulmonary arterial and venous anomalies but is time-consuming, invasive, uses radiation, requires general anaesthetic and can have complications related to arterial access. more recently, mdct has been shown to be useful in accurately identifying both the pulmonary arteries and anomalous pulmonary venous return in cvls.4 , 10 , 11 as well as the source images, 3d reconstructed images are particularly helpful in depicting the entire course of the anomalous scimitar vein and its point of drainage as well as any systemic arterial supply to the lung.4 mdct also eloquently defines the tracheo-bronchial tree and associated lung abnormalities, as well as the cardiac and other non-vascular anomalies.1 , 4 , 10 mdct has the advantages of not requiring an anaesthetic or arterial access and is a fast, non-invasive investigation that has assumed a pivotal role in evaluating patients with congenital lung anomalies. the radiation dose delivered at mdct should be modified by using dose reduction techniques and paediatric protocols. magnetic resonance angiography using contrast-enhanced 3d mri has also been shown to have a good correlation with surgical findings and does not share the radiation burden of ct and angiography.12 however, it does require expertise that is not readily available at most institutions – ours included. cvls in isolation is compatible with life; symptoms in these patients are usually due to the associated cardiac abnormalities, and the severity thereof determines prognosis.5 , 6 when patients are symptomatic, surgical correction of the cardiac abnormality along with scimitar vein ligation or embolisation may be considered. our patient underwent aortic coarctation, and asd and vsd repair at age 14 weeks. at follow-up echocardiogram at age 7 months, the coarctation had recurred and required balloon dilation. no other complications were present. conclusion in patients with mediastinal shift on chest radiograph due to suspected lung hypoplasia, mdct is a non-invasive and appropriate investigation aiding in the diagnosis of congenital pulmonary venolobar syndrome and possible associated cardiac defects. 1. armstrong p, wilson ag, dee p, hansell dm. imaging of diseases of the chest. 3rd ed. philadelphia, usa: mosby, 2004. 1. armstrong p, wilson ag, dee p, hansell dm. imaging of diseases of the chest. 3rd ed. philadelphia, usa: mosby, 2004. 2. kirks dr, griscom nt. practical pediatric imaging. 3rd ed. philadelphia, usa: lippincott williams and wilkins, 2006. 2. kirks dr, griscom nt. practical pediatric imaging. 3rd ed. philadelphia, usa: lippincott williams and wilkins, 2006. 3. konen e, raviv-zilka l, cohen ra, et al. congenital pulmonary venolobar syndrome: spectrum of helical ct findings with emphasis on computerized reformatting. radiographics 2003;23:1175-1184. 3. konen e, raviv-zilka l, cohen ra, et al. congenital pulmonary venolobar syndrome: spectrum of helical ct findings with emphasis on computerized reformatting. radiographics 2003;23:1175-1184. 4. lee ey, boiselle pm, cleveland rh. multidetector ct evaluation of congenital lung anomalies. radiology 2008;247(3):632-648. 4. lee ey, boiselle pm, cleveland rh. multidetector ct evaluation of congenital lung anomalies. radiology 2008;247(3):632-648. 5. cooper g. case of malformation of the thoracic viscera: consisting of imperfect development of the right lung and transposition of the heart. london med gazette1836;18:600-601. 5. cooper g. case of malformation of the thoracic viscera: consisting of imperfect development of the right lung and transposition of the heart. london med gazette1836;18:600-601. 6. chassinat r. observation d’anomalies anatomiques remarquables de l’appareil circulatoire, avec hepatocele congenial, n’ayant donne lieu pendant la vie a aucun symptom particulier. arch gen med 1836;11:80-84. 6. chassinat r. observation d’anomalies anatomiques remarquables de l’appareil circulatoire, avec hepatocele congenial, n’ayant donne lieu pendant la vie a aucun symptom particulier. arch gen med 1836;11:80-84. 7. halasz na, halloran kh, liebow aa. bronchial and arterial anomalies with drainage of the right lung into the inferior vena cava. circulation 1956;14:826-846. 7. halasz na, halloran kh, liebow aa. bronchial and arterial anomalies with drainage of the right lung into the inferior vena cava. circulation 1956;14:826-846. 8. dotter ct, hardisty nm, steinberg i. anomalous right pulmonary vein entering the inferior vena cava: two cases diagnosed during life by angiography and cardiac catheterization. am j med sci 1949;218:31-36. 8. dotter ct, hardisty nm, steinberg i. anomalous right pulmonary vein entering the inferior vena cava: two cases diagnosed during life by angiography and cardiac catheterization. am j med sci 1949;218:31-36. 9. neill ca, ferencz c, sabiston dc, sheldon h. the familial occurrence of hypoplastic right lung with systemic arterial supply and venous drainage “scimitar syndrome”. bull j hop hosp 1960;107:1-15. 9. neill ca, ferencz c, sabiston dc, sheldon h. the familial occurrence of hypoplastic right lung with systemic arterial supply and venous drainage “scimitar syndrome”. bull j hop hosp 1960;107:1-15. 10. dillman jr, yarram sg, hernandez rj. imaging of pulmonary venous developmental anomalies. am j roentgenol 2009; 192:1272-1285. 10. dillman jr, yarram sg, hernandez rj. imaging of pulmonary venous developmental anomalies. am j roentgenol 2009; 192:1272-1285. 11. lucaya j, strife jl, baert al. pediatric chest imaging. 2nd ed. berlin: springer, 2007. 11. lucaya j, strife jl, baert al. pediatric chest imaging. 2nd ed. berlin: springer, 2007. 12. kauczor hu. mri of the lung. berlin: springer, 2009. 12. kauczor hu. mri of the lung. berlin: springer, 2009.   fig. 1. frontal chest radiograph showing opacified right hemithorax with mediastinal shift to the right and small right lung when compared with the left. the left lung is hyperinflated and plethoric.   fig. 2. coronal minimum intensity projection (minip) showing the hypoplastic right upper lobe bronchus and right lung. fig. 3. axial maximum intensity projection (mip) showing the small right pulmonary artery (arrow). fig. 4. coronal mip showing the scimitar vein (arrow) and its point of insertion into the ivc. note the plethoric left lung. fig. 5. oblique sagittal mip image showing the aortic coarctation (arrow). case series case series 54 sa journal of radiology • september 2007 case series abstract fat necrosis is a common benign condition. it is associated with iatrogenic, penetrating or blunt trauma. in a number of cases, there is no history of injury. mammographic presentation is either a typical lipid cyst or a spiculated lesion, mimicking malignancy. ultrasonographic appearance is that of either a cyst, or solid mass, or an area of increased echogenicity. calcifications may be present and are usually coarse or ring-like. introduction fat necrosis (fn) is a benign condition, occurring as a result of trauma. it has a variety of clinical, mammographic and ultrasonographic appearances. we present three illustrative cases, one after previous lumpectomy, one after breast augmentation and one with no history of trauma or surgery. cases case 1 (figs 1 & 2) a week previously a 56-year-old woman discovered a hard lump in her right breast. a palpable mass 3 x 4 cm in the lower/medial quadrant of the right breast was found. it was movable with no skin thickening. an area of increased density with architectural distortion was seen on mammography (mg). there were no microcalcifications (fig. 1). on ultrasonography (us), there was a well-outlined area of increased echogenicity (fig. 2). no increased flow was seen on duplex doppler examination. she had no history of surgery or trauma. core biopsy was done and reported as fat necrosis. the patient was given reassurance. no further treatment was necessary. case 2 (figs 3 & 4) a 48-year-old woman had had a benign lump removed from her left breast 6 years previously. she had a tender, palpable mass at the site of previous surgery. mg demonstrated a dense, spiculated lesion in the lower lateral quadrant of the left breast (fig. 3), corresponding to the region of the scar. there were no calcifications and no translucent centre. on us, the lesion was seen as a circumscribed area of decreased echogenicity, measuring 20 x 8 mm, orientated with the long axis parallel to the skin (fig. 4). core biopsy was reported as post-traumatic fat necrosis. case 3 (fig. 5) this 55-year-old woman was referred for mg (in 1991) for a hard mass in each breast. mg demonstrated a well-outlined, calcified mass in each breast. it measured about 5 cm in diameter. the mass on the right had fat necrosis of the breast – report of three cases peter evan, mudr (prague), dip rad candy pather, mb chb, fc rad (diag) department of radiology, netcare park lane clinic, parktown, johannesburg fig. 1. mg. area of increased density in the lower medial quadrant of the right breast near the areola. distortion of the glandular architecture. fig. 2. us. well-outlined area of increased echogenicity. no spiculae. no calcifications. no increased flow on colour doppler. pg54-56.indd 54 9/17/07 8:53:41 am case seriescase series 55 sa journal of radiology • september 2007 a calcified rim. in addition, multiple small, cyst-like calcifications were noted throughout both breasts. she had had breast augmentation 23 years previously. fat taken from her own buttocks was used instead of a prosthesis. she was asymptomatic and happy with the results. the diagnosis of fn was obvious and biopsy was not done. discussion fn was first described in 1920 by lee and munzer (quoted by hogge et al.1). history of trauma was noted in 40% of cases. it was thought to occur in the superficial breast tissue and sub-areolar region in obese patients with pendulous breasts.2 however, men can also be affected.3 causes are listed as iatrogenic and non-iatrogenic. iatrogenic causes these include biopsy, aspiration, lumpectomy and any other breast surgery. reconstructive surgery such as transverse rectus abdominis musculocutaneous (tram) flap, autogenous myocutaneous flap and breast reduction has an incidence of fn in up to 25% of cases.4 radiation therapy1,3,5 is also implicated. salhab et al.6 reported fn after injection of methylene blue dye for sentinel node biopsy. patent blue v should be used instead. fn can be the result of anticoagulation therapy7 with both unfractioned and low-molecular-weight heparin. non-iatrogenic causes fn is seen after either penetrating trauma, such as stab wounds, gun shots, dog bite and other accidents,3 or blunt trauma due to a direct hit to the anterior chest wall. in motor-car accidents, the impact of the steering wheel may cause fn. seat-belt injuries to the breast have been described by dipiro et al.8 on mg and us they present in two forms: (i) band-like areas of increased density compatible with haematoma and/or contusion; and (ii) nodular parenchyma. with time, these signs decrease in prominence. linear distribution of thin-walled oil cysts is typical and was seen in all patients. the cysts either resolve or calcify. the location of the injury correlates well with the position of the seat belt. we can expect to see more cases of fn in young women, as they participate in contact sports such as rugby, soccer and boxing. a large number of patients have no history of trauma and may have had a minor accident that was long forgotten. clinical presentation the patient is often asymptomatic1,3,9,10 and fn is discovered as an incifig. 3. mg. spiculated mass in the lower lateral quadrant left breast (arrow). no translucent centre. no calcifications. fig. 5. symmetrical mass in each breast with calcified centre and calcified rim. multiple small round calcifications with translucent centre, typical of oil cysts (arrows). fig. 4. us. circumscribed mass 20 x 8 mm. long axis parallel to the skin. no calcifications. no spiculae. no increased flow. pg54-56.indd 55 9/17/07 8:53:42 am case series 56 sa journal of radiology • september 2007 dental finding during screening mg, or at post-surgery follow-up. the most common symptom is a palpable mass, which may be irregular or fixed. there is often pain and tenderness. multiple smooth nodules are occasionally seen. skin thickening, induration, ecchymosis and occasionally lymphadenopathy are present. as the fn is often situated near the areola, retraction of the nipple and/or areola may be found. the incidence of fn was 2% in 536 breast biopsies reported by hogge et al.1 the incidence is higher in patients after surgery. dershaw et al.11 report on 28 women with suspected recurrence after lumpectomy for malignancy. twenty-nine biopsies were performed. three patients had microcalcifications. of the 26 palpable masses, 10 masses were malignant, 3 of them not demonstrated on mg. of the 16 benign masses, 7 were not visible on mg. the histological findings included fibrosis in 8, fn in 7 and granuloma in 1 case. the palpable mass may enlarge slowly over a few weeks and may or may not undergo spontaneous regression. diligent clinical examination is important, as a palpable mass was not demonstrated on mg in 9.5% and on us in 10%.1 mammographic findings lipid (oil) cyst. presents as a round or oval, lucent mass with smooth borders.1 the rim of the cyst may calcify. the appearance is benign in most cases. early calcification or collapse of the fibrous rim may produce indeterminate appearance requiring biopsy.1 focal mass. a common finding is a dense focal mass with or without calcifications (fig.1). distortion of the glandular architecture is often seen. this is a subtle sign and must be searched for. the mass may be totally or partially calcified (fig. 5). spiculated area of increased density. this occurs when fibrosis predominates (figs 1 & 3) and produces desmoplastic reaction mimicking scirrhous carcinoma.1 microcalcifications. focally clustered pleomorphic calcifications are rare. they may have rod-like or angular configuration13 and are indistinguishable from those of carcinoma. coarse and homogenous calcifications are common and are indicative of a benign lesion (fig. 5). ultrasound features there is a large variety of us appearances. most commonly a solid mass, usually well circumscribed and of low echogenicity, is seen (fig.4). it may have either posterior acoustic shadowing or enhancement or neither. when cystic, the cyst may be septated, complex or with a mural nodule. the cysts may contain oil-fluid levels.12 often, the only us sign is an area of increased echogenicity in the subcutaneous region (fig. 2). pathology fn is a benign, non-suppurative inflammatory process.9 it is the result of aseptic saponification of the fat by blood and tissue lipase. it contains anuclear fat cells, surrounded by giant histiocytes and aggregates of foamy phagocytic histiocytes. fibrotic connective tissue is seen at the periphery of the necrotic debris. the extent of fibrotic reaction correlates well with mg finding of a dense, spiculated lesion. conclusion fn is a benign condition, usually the result of trauma, most commonly iatrogenic. the appearances are either typical, in which case no further evaluation is needed, or may mimic malignancy which would require biopsy to distinguish them from recurring carcinoma. 1. hogge jp, robinsom re, magnant cm, zuurbier ra. the mammographic spectrum of fat necrosis of the breast. radiographics 1995: 15; 1347-1356. 2. haagensen cd. disease of the breast, 3rd ed. philadelphia: saunders, 1986: 369-378. 3. jackson vp, fu kl, fu ys. benign breast lesions. in: bassett lw, jackson vp, fu kl, fu ys, ed. diagnosis of diseases of the breast. 2nd ed. philadelphia: elsevier saunders, 2005: 409-419. 4. hogge jp, zuurbier ra, de paredes es. mammography of autologous myocutaneous flaps. radiographics 1999; 19: s63-s72. 5. kim sm, park jm. mammographic and ultrasonographgic features after autogenous myocutaneous flap reconstruction mammoplasty. j ultrasound med 2004; 23: 275-282. 6. salhab m, al sarakbi w, mokbel k. skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer. semin surg oncol 2005; 2: 26. 7. das ak. low molecular-weight heparin-associated fat necrosis of the breast. age ageing 2005; 34: 193194. 8. dipiro pj, meyer je, frenna th, denison cm. seat belt injuries of the breast. ajr 1995; 164: 317-320. 9. bassett lw, gold rh, cove hc. mammographic spectrum of traumatic fat necrosis: the fallibility of “pathognomonic” signs of carcinoma. ajr 1978; 130: 119-122. 10. bilgen ig, ustun ee, memis a. fat necrosis of the breast: clinical, mammographic and sonographic features. eur j radiol 2001: 39: 92-99. 11. dershaw dd, mccormick b, cox l, osborne mp. differentiation of benign and malignant tumor recurrence after lumpectomy. ajr 1990; 155: 35-38. 12. kim hs, cha es, kim hh, yoo jy. spectrum of sonographic findings in superficial breast masses. j ultrasound med 2005; 24: 663-680. 13. bassett lw, gold rh, mirra jm. nonneoplastic breast calcifications in lipid cysts: development after excision and primary irradiation. ajr 1982: 138: 335-338. pg54-56.indd 56 9/17/07 8:53:42 am 96 sa journal of radiology • september 2011 signs the fat halo sign t sewchuran, mb bch n mahomed, mb bch, fcrad (d) department of radiology, university of the witwatersrand, johannesburg corresponding author: t sewchuran (tanusha.sewchuran@yahoo.co.uk) intramural stratification with deposition of fat in the submucosal layer of the bowel wall, visualised on computed tomographic (ct) scans of the abdomen, is known as the fat halo sign.1 owing to infiltration of the submucosa by fat, the inner layer mucosa are separated from the outer layer of muscularis propria/serosa (both being of soft tissue density) by a layer of fat (of low attenuation) measuring between -18 to -64 hounsfield units.1-3 historically, the fat halo sign has been associated with patients suffering from chronic inflammatory bowel disease.1-3 less commonly, it has also been associated with cytoreductive therapy, graft-v.-host disease and renal calculi.1-3 when seen in both the small and large bowel, the fat halo sign has been considered pathognomonic of crohn’s disease.1,2 harisinghani et al. conducted a study in 2003 evaluating the presence and frequency of the fat halo sign in patients undergoing abdominal ct for clinical indications unrelated to the gastrointestinal tract.1 they concluded that 21% of the study population were positive for the fat halo sign, of whom 6 (28%) had renal stone disease and 15 (72%) did not have renal stone disease.1 the intestinal distribution of the fat halo sign in these patients was the terminal ileum (4%), ascending colon (28%), transverse colon (34%), descending colon (36%), sigmoid colon (14%) and rectum (10%).1 none of the patients in whom the fat halo sign was demonstrated had previous or current gastro-intestinal symptoms suggestive of inflammatory bowel disease or a history of gastro-intestinal disease.1-3 this argues the fat halo sign as being a normal variant seen in a certain portion of the population.1,2 a statistical relationship between the fat halo sign and obesity has also been established.1 fig. 1a. axial post contrast ct abdomen at the level of the rectum demonstrating the fat halo sign, i.e. the central fatty submucosal layer of low attenuation surrounded by higher attenuation inner and outer layers grossly corresponding to the mucosa and muscularis propria/serosa of the rectum respectively. fig. 1c. axial post contrast ct abdomen of the same patient with oral contrast demonstrates a low-attenuation fat layer in the wall of the caecum and terminal ileum. fig. 1b. coronal post contrast ct abdomen of the same patient with oral contrast demonstrates a low-attenuation fat layer in the wall of the caecum, ascending colon and terminal ileum. the patient did not have clinical or radiological features of inflammatory bowel disease, and the fat halo sign was a normal variant. sa journal of radiology • september 2011 97 signs pitfalls associated with interpretation of the fat halo sign specifically involve intestinal distension. the sign has a tendency to disappear or become less apparent when the bowel lumen is more distended.1 it is thought that distension of the bowel lumen causes obscuring of the thin fat layer.1 therefore, the fat halo sign is best appreciated when the lumen is partially collapsed.1 other factors advocating a positive fat halo sign are prone position of the patient, and not using a contrast agent.1 the constellation of 4 signs that strongly suggests the fat halo sign representing a normal variant, as opposed to inflammatory bowel disease, includes increased prevalence in the collapsed state, decreased prevalence with distension of the bowel lumen either by gravity or gas, disappearance of the fat halo sign with additional distension, and a thin calibre of the fatty layer.1 the presence of a normal haustral pattern also supports the sign being a normal variant.1 more commonly, a normal intramural fat layer is seen in the terminal ileum and descending colon.3 it is generally much thinner than the fat layer seen in inflammatory bowel diseases.3 in conclusion: the presence of the fat halo sign may in the absence of clinical and radiological features of inflammatory bowel disease represent a normal finding that may also be related to obesity. 1. harisinghani mg, wittenberg j, lee w, chen s, gutierrez al, mueller pr. bowel wall fat halo sign in patients without intestinal disease. ajr 2003;181:781-784. 2. ahualli j. the fat halo sign. radiology 2007;242:945-946. 3. wittenberg j, harisinghani mg, jhaveri k, varghese j, mueller pr. algorithmic approach to ct diagnosis of the abnormal bowel wall. radiographics 2002;22:1093-1109. the hyperdense mca sign and the mca dot sign n mahomed, mb bch, fcrad (d) department of radiology, university of the witwatersrand, johannesburg corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) the hyperdense middle cerebral artery sign (hmca), first described in 1983, refers to the hyperattenuation of the middle cerebral artery (mca) m1 segment on non-enhanced computed tomography (ct).1,2 the sign is due to a thromboembolus of the m1 segment of the mca. because the sign is a marker of vascular occlusion rather than a direct image of the resulting parenchymal changes, the hmca sign can be considered an indirect indicator of subsequent infarction and is one of the earliest signs of ischaemic stroke.3 the mca dot sign is a punctate focus of hyperattenuation located in the sylvian fissure on non-enhanced ct, and is a recently described variant of the hmca sign.3 the sign represents a thromboembolus within a segmental branch of the mca, m2 or m3 segment, located within the sylvian fissure.3 as the m2 and m3 segmental vessels tend not to course in the transverse plane of imaging, the occluded vessel is seen in cross section, appearing as a hyperattenuating dot within the sylvian fissure.3 while the hmca sign and mca dot sign are similar in that they both depict thromboembolus at different levels of the mca, there are important clinical and prognostic distinctions. the hmca sign suggests that a major cerebral vessel is occluded, suggesting a larger territory at risk for hypoperfusion compared with the more distal vessel occlusion of the mca dot sign. therefore, the mca dot sign in the absence of the hmca sign is associated with improved short-term clinical outcome.3 these signs have a high specificity of almost 100 % with a high positive predictive value but a low sensitivity of approximately 38 40% for thromboembolic occlusion of the mca.1-3 mimics of the hmca sign, the pseudo hyperdense mca sign, include vascular calcification, raised haematocrit, intravenous contrast and partial volume averaging.1 another important cause of a pseudo fig. 1. hmca sign. non-enhanced axial ct brain (at the level of the suprasellar cistern) in a patient with sudden onset left hemiparesis demonstrates hyperattenuation (measuring 82 hu) of the right middle cerebral artery, which is suggestive of occlusion of this artery and is an indirect sign. there is also diffuse hypodensity of the right temporal lobe, a direct sign of ischaemic stroke. 34 sa journal of radiology • june 2011 editorial no one in the practice of medicine today can deny the incredible advances and impact that computed tomography has had on how we display anatomy and visualise pathology. we entered the 21st century with over 60 million ct studies a year in the usa – and that number climbing. spiral or helical technology meant greater coverage in less time, and multiple scans related to contrast administration became standard. increasing availability of ct scanners allowed increasing utilisation. the annual increase of approximately 10% in ct studies has occurred with only a 1% population increase. of the 377 million diagnostic and interventional studies performed in the usa in 2006, 67 million were ct scans – yet these ct scans contributed 49% of all medical radiation dose. ct studies alone deliver an annual 1.47 msv per capita to the usa population (the annual background of 3 msv is without this additional medical radiation). these figures are from published literature, and i am not aware of any similar published figures from south africa, but i strongly suspect that very similar trends in ct usage have occurred anywhere that ct scanners are available and can be afforded. for all the advantages that ct has generated, there has been a significant hidden cost – radiation. a ct study has a high individual radiation burden but, collectively, the increased exposure to the population at large may well be a larger future concern. some basic radiation values to guide us are: frontal cxr 0.01 msv lung ct 3 msv abdominal ct 10 msv annual background radiation 3 msv radiation effects can be deterministic, requiring a threshold dose to manifest. examples are cataract formation and skin injury, both requiring large exposure, above 2 000 msv. knowing these thresholds easily allows setting limits and removing the risk. of more concern are the stochastic or random biological effects of radiation on dna. they do not have known thresholds, and the beir vii reports indicate a linear related response from very low exposure to radiation. ionisation can occur directly with electrons of dna molecules but, more commonly, radiation interaction with water molecules creates hydroxyl radicals, which then interact with dna. single-chain damage is usually quickly repaired but double-chain damage may be difficult to repair. the consequence may be radiation-induced carcinogenesis in the exposed individual but, also, this ‘radiation-induced genomic instability’ can be transmitted to future generations! much has been learnt of these stochastic radiation effects from the intensive epidemiological study of nuclear bomb survivors from nagasaki and hiroshima in 1945. longterm and robust data have shown increased cancers in survivors exposed to radiation doses equivalent to a modern ct study. the cancers include leukaemia, breast, digestive organs, colon, thyroid and lung. of particular concern is the age-related effect of radiation. the younger the subject, the higher the radiation-induced effects. children are deemed more radiosensitive as they have a larger proportion of actively dividing cells, and they have a longer latent period in which a radiation-induced cancer has the opportunity to manifest. young females are also noted to be more radiosensitive than males. at my paediatric institution, we estimate the lifetime risk of a future cancer as a result of a paediatric ct to be about 1:1000. this is an approximation. it is, however, clear that it has become our duty as physicians and radiologists to utilise ct scanning in children wisely and appropriately. action how many paediatric ct scans have you reported in the last year that had uncertain indications or would not clearly influence patient management and diagnosis? reports in the literature from 2002 and 2005 indicate that 30 40% of paediatric ct scans are not justified by medical need! given what we know today about the effects of radiation in children, this excess of ct imaging must be curtailed. improved screening of ct requests is, i believe, fairly and squarely the responsibility of the radiologist performing or interpreting the resultant examination. if ct is the best and most appropriate imaging required, then paediatric-appropriate protocols and techniques are mandatory. size and weight-related reduction in kvp and mas, appropriate collimation and table speed can substantially reduce the radiation dose. reducing irradiating of children: whose responsibility? n engl j med 2007;357:2277-2284. after completing his diagnostic radiology training at tygerberg hospital (university of stellenbosch) in 1991, dr jamieson started his paediatric radiology career under the guidance of professor bryan cremin at red cross war memorial children’s hospital in cape town. his paediatric fellowship training was at the hospital for sick children in toronto, canada. since 1996, he has been a paediatric radiologist at bc children’s hospital in vancouver and an associate professor in the department of radiology at the university of british columbia. mountaineering, skiing, river running and sea kayaking remain avid interests outside of paediatric radiology. 36 sa journal of radiology • june 2011 editorial anatomical coverage to the relevant area and excluding multiphase acquisitions, unless a clear advantage is to be gained, should become normal practice. claiming ignorance and lack of knowledge for not instituting change at any facility imaging children is no longer acceptable. there is an excellent source of information with paediatric-specific guidelines, and protocols are freely available on the internet. i strongly encourage every radiologist imaging children to visit and explore the society for pediatric radiology’s web-based initiative: image gently – the alliance for radiation safely in pediatric imaging (google ‘image gently’ or access the website at http://www.pedrad.org/associations/5364/ig/). it is also pertinent to note that this excellent web site not only provides the radiologist with information on paediatric-specific protocols and how to implement them in one’s practice, but it is also readily available to one’s patients and their parents to learn about the risks and benefits of diagnostic imaging. we should always ask if there are alternatives to radiation in the diagnostic imaging of children. ultrasound. in neonates and small children, the spatial resolution of high-resolution linear probes cannot be matched by ct or mr! ultrasound is a very good tool for the evaluation of appendicitis in paediatrics. ct may perform slightly better (certainly an advantage in the obese patient), but does this mean that anyone with right iliac fossa (rif) pain in the er needs a ct abdomen before they see a surgeon? surely a good clinical evaluation with us as a primary imaging tool is an appropriate balance between diagnosis and radiation burden. no one would question the role for ct in equivocal or diagnostic dilemma situations. magnetic resonance. its increased use in paediatrics is limited largely by availability and cost. hardware and technical improvement have made ‘breath hold imaging’ routine. where available, mr has replaced neonatal brain imaging. mr imaging of musculoskeletal pathology is established, and mr has gained a large component of abdominal imaging including solid organ tumour evaluation, the biliary tree and bowel diseases such as ibd. conclusion ct is a great tool and has revolutionised diagnostic imaging, but it should be used wisely, especially in paediatric patients where the radiation burden has the most impact and consequence. there are alternatives to consider, in particular us and mr. do not allow your patient to become better informed about radiation than you might be; visit the image gently web site for information. it is our responsibility as radiologists to monitor, utilise and advise on the use of diagnostic radiation, especially in children. education of referring clinicians regarding appropriate use of diagnostic imaging is a challenge that we should meet with dialogue, collaboration, information, and compliance with the principle that all doctors should identify with: primum non nocere (above all, do no harm.). douglas h jamieson paediatric radiologist bc children’s hospital vancouver, canada; and associate professor department of radiology faculty of medicine university of british columbia djamieson@cw.bc.ca recommended reading brenner dj, hall ej. computed tomography – an increasing source of radiation exposure. n eng j med 2007;357:2277-2284. donnelly lf. reducing radiation dose associated with pediatric ct by decreasing unnecessary examinations. ajr 2005;184:655-657. donnelly lf, emery kh, brody as. minimizing radiation dose for pediatric body applications of singledetector helical ct: strategies at a large children’s hospital. ajr 2001;176:303-306. hall ej. lessons we have learned from our children: cancer risks from diagnostic radiology. the 2002 neuhauser lecture. pediatr radiol 2002;32:700-706. mettler fa, bhargavan m, faulkner k, et al. radiological and nuclear medicine studies in the united states and worldwide: frequency, radiation dose, and comparison with other radiation sources 1950 2007. radiol 2009;253:520-531. national research council of the national academies. beir vii: health risks from exposure to low levels of ionizing radiation. national academies press, washington dc: 2005. pierce da, preston dl. radiation-related cancer risks at low doses among atomic bomb survivors. radiat res 2000;154:178-186. slovis t. ct and computed radiography: the pictures are great, but is the radiation dose greater than required? ajr 2002;179:39-41. 28 sa journal of radiology • march 2011 quiz case musculoskeletal diagnosis s k misser, mb chb, fcrad (d) p mercouris, mb bch, ff rad lake smit and partners, durban please refer to page 125 of the december 2010 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/view/541/412) for the presentation details. we congratulate dr himal gajjar (schnetler, corbett and partners, cape town) for a precise and detailed diagnosis, for which he receives an award of r1 000 from the rssa. drs misser and mercouris elaborate below on the condition and its radiological signs. presentation and diagnosis the patient, an active hockey player, presented with vague discomfort in the left hip after a hockey game. on questioning, she revealed that she had had a mountain-biking accident a month earlier when she landed on the contralateral hip. after that incident, she had encountered transient hip pain, as though ‘she had pulled a muscle’. on examination, minimal clinical abnormality was detected, and the initial orthopaedic impression was that of a labral tear. plain film and ultrasound examinations were normal. (due to space constraints, the images referred to below appear only in the online march 2011 sajr at www.sajr.org.za.) mri demonstrated a chondrolabral tear of the superior labrum (arrow, fig. 1c) and diffuse thickening and hyperintensity of the ligamentum teres (arrow in fig. 1a and fig. 2a) involving both the anterior and posterior bundles. there were no mri features of bone bruising, femoro-acetabular impingement or femoral head subluxation. attempted mr arthrography, with resultant extra-articular contrast extravasation, accounts for the increased signal within the left iliopsoas muscle as seen on the axial images (arrow in fig. 2b). arthroscopy was performed, confirming the presence of a chondrolabral tear (fig. 3) and markedly swollen ligamentum teres (grade 2 tear) with extension to involve the foveal attachment site of the ligamentum teres (fig. 4a). the patient made an excellent return to normal sporting activity 3 months after arthroscopy. discussion the ligamentum teres, previously described as an unimportant remnant, has recently been found to be an increasingly common abnormal finding at arthroscopy accounting for intractable hip pain in many athletes. the ligament, which is pyramidal in shape, may consist of multiple bundles, and blends with the transverse acetabular ligament. it plays a minor role in (i) maintaining hip stability by reducing excessive movement, (ii) nociception via type iva somatosensory fibres and (iii) minimal femoral head perfusion.1 byrd et al.2 reported that ligamentum teres tear (ltt) was the third most common finding at arthroscopy in their series of hip arthroscopy in athletes. contrary to previous suggestions that ltt was unlikely in the absence of hip dislocation, it has been found to occur in up to three-quarters of cases without associated dislocation. partial ltt has been described in large arthroscopic series, as a source of disabling pain.3 ltt with concomitant labral tear has also been reported.4 in this instance, as in the patient reported, the ligamentum teres serves as a secondary stabiliser. when displaced, the disrupted ligamentum teres can result in impingement, especially during hip flexion. gray and villar5 classified ltt as follows: (from bardakos nv, villar rn. the ligamentum teres of the adult hip. j bone joint surgery 2009;91-b:8-15.) impoved arthroscopic techniques and flexible probe development has allowed the surgeon to overcome the difficulty of femoral head sphericity.4 combined with early detection at mri, arthroscopic access to and debridement of the torn ligament of the femoral head is now much easier, with generally good outcome. 1. bardakos nv, villar rn. the ligamentum teres of the adult hip. j bone joint surgery 2009;91-b:8-15. 2. byrd jwt, jones ks. hip arthroscopy in athletes. clin sports med 2001;20:749-762. 3. rao j, zhou yx, villar rn. injury to the ligamentum teres. mechanism, findings, and results of treatment. clin sports med 2001;20(4):791-799. 4. bharam s. labral tears, extra-articular injuries, and hip arthroscopy in the athlete. clin sports med 2006;25(2):279-292. 5. gray aj, villar rn. the ligamentum teres of the hip: an arthroscopic classification of its pathology. arthroscopy 1997;13:575-578. type pathology mechanism of injury symptoms associated pathology i complete rupture major trauma gross instability; inability to bear weight fractures, labral tears, chondral damage are common ii partial rupture minor trauma occult instability; pain on strenuous activity occasional labral/chondral damage; reactive synovitis iii degenerate rupture (complete or partial) chronic attrition pain after prolonged walking commonly osteoarthritis case report 63 sa journal of radiology • september 2007 when encountering a radiologically benign lucent bone lesion in a child, a simple bone cyst is a reasonable diagnostic consideration. simple or unicameral bone cysts are expansile, serous-fluid-containing defects, that are not true neoplasms. peak age ranges between 3 and 14 years in 80% of cases. the incidence is estimated at 3% of all bone lesions, with a male to female ratio of 2:1.1 the aetiology of these lesions is poorly understood. various hypotheses have included dysplastic processes, synovial cysts, and abnormalities in the local circulation. the majority (94%) of these cysts occur in the proximal humerus and femur.2 less frequent sites include the calcaneus (2%), ilium (2%), talus, tibia and fibula.3 most often a single bone is affected.4 the most common complication, a non-displaced pathological fracture (66% of cases), is often the presenting complaint. the radiological features on plain radiographs include a centrally (medullary) located, expansile lesion of the metaphysis (fig. 1). cortical thinning without disruption is seen.2 as a result of the fracture and the fact that this is a hollow/fluid-filled unicameral lesion, a ‘fallen fragment/leaf ’ may be visualised (fig. 2). the ‘fallen leaf ’ sign is virtually pathognomonic of a multiloculated bone cyst.5 this distinguishes it from other low-density lesions such as an aneurysmal bone cyst, which is more septated or contains a more solid matrix. follow-up x-rays demonstrate that the growth plate moves away from the cyst as the child grows (fig. 3). this explains why two-thirds of these lesions are not in contact with the growth plate when discovered in children older than 10 years.6 ct can be useful to evaluate the extent of the cyst, especially if pelvic bones are affected. hounsfield units will help to differentiate lipomas from fluid-filled cysts.7 typically mri will demonstrate a lowsignal intensity on t1-weighted images and high-signal intensity on t2weighted images in the typical simple bone cyst.7 double-density fluid radiological features of simple (unicameral) bone cysts jaco du plessis, mb chb savvas andronikou, mb bch, fcrad, frcr (lond), phd murray hayes, mb chb ayanda mapukata, mb chb department of radiology, tygerberg hospital, stellenbosch university, tygerberg fig. 1. an expansile medullary, radiolucent lesion in the proximal humeral metaphysis extending to the growth plate is seen. this is the appearance of a simple bone cyst. a common complication is a pathological fracture which is seen to disrupt the cortex laterally in this patient. fig. 2. in addition to the visualised pathological fracture, a ‘fallen fragment’ is demonstrated which is almost pathognomonic of a simple bone cyst. pg63-64.indd 63 9/17/07 8:56:56 am case report case report 64 sa journal of radiology • september 2007 levels, septation and high-signal intensity (t1and t2-weighted) of the upper fluid layer, indicative of serous fluid or extracellular methaemoglobin, strongly suggest the bone cyst in question is an aneurysmal bone cyst, rather than a unicameral bone cyst.8 1. boseker eh, bickel wh, dahlin dc. a clinicopathological study of simple unicameral bone cysts. surg gynecol obstet 1968; 127:550-560 2. campanacci m, campanna r, picci p. unicameral and aneurysmal bone cysts. clin orthop 1986; 204: 25-36. 3. abdelwahab if, hermann g, norton ki, et al. simple bone cysts of the pelvis in adolescents. a report of four cases . j bone joint surg am 1991; 73: 1090-1094. 4. norman a, schiffman m. simple bone cysts: factors of age dependency. radiology 1977; 124: 779-782. 5. struhl a, pritzer h, seiman lp, et al. solitary (unicameral) bone cyst. the fallen fragment sign revisited. skeletal radiol 1989; 18: 261-265. 6. neer cs, francis kc, johnston ad, et al. current concepts on the treatment of solitary unicameral bone cyst. clin orthop 1973; 97: 40-51. 7. baig r, eady jl. unicameral (simple) bone cysts. south med j 2006; 99(9): 966-976. 8. sullivan rj, meyer js, dormans jp, et al. diagnosing aneurysmal and unicameral bone cysts with magnetic resonance imaging. clin orthop 1999; 366: 186-190. fig. 3. as the same patient ages, the lesion is seen in the diaphysis, having moved away from the growth plate. this is typical for simple bone cysts. case report the president of the radiological society of south africa (rssa), dr. clive sperryn, is pleased to announce the: rssa cpd trust travel award in order to stimulate contributions to the south african academic congress programme by junior radiologists, in south africa, the rssa has established a r20,000.00 prize for the best lecture given at the rssa biennial congress being held in conjunction with the isrrt world (radiographer) congress at durban in april 2008, by a radiology registrar or radiologist, qualified for no more than 5 years. the award is funded by the rssa/cpd education trust. the prize money is to be used to attend an overseas congress of the winner’s choice within 12 months. the winner will be required to submit a short, adequately detailed report of the congress attended to the rssa, within 14 days of attending the congress. the report will be published on the rssa website www.rssa.co.za the winner will be decided by a panel of judges appointed by the rssa congress chairman and review of evaluation forms completed by the audience. information on the durban congress is available on www.rssa.co.za interested persons must submit the topic and outline of the proposed lecture, names of all contributing co-workers if applicable, affiliation and a letter of academic status. if the lecture is co-authored, a letter signed by all co-workers that the presenter has made the major contribution will be required. by submitting an entry, the applicant accepts the conditions attached to the award. the closing date for submissions is 30 november 2007. entries must be submitted electronically to: radsoc@iafrica.com, for the attention of prof. leon janse van rensburg. pg63-64.indd 64 9/17/07 8:56:57 am abstract introduction discussion conclusion acknowledgements references about the author(s) rishi p. mathew department of radiology, faculty of radiology, rajagiri hospital, aluva, india sreekutty sarasamma department of radiology, faculty of radiology, rajagiri hospital, aluva, india merin jose department of radiology, faculty of radiology, rajagiri hospital, aluva, india ajith toms department of radiology, faculty of radiology, rajagiri hospital, aluva, india vinayak jayaram department of radiology, faculty of radiology, rajagiri hospital, aluva, india vimal patel department of radiology & diagnostic imaging, faculty of medicine and dentistry, university of alberta hospital, edmonton, canada gavin low department of radiology & diagnostic imaging, faculty of medicine and dentistry, university of alberta hospital, edmonton, canada citation mathew rp, sarasamma s, jose m, et al. clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the adult population: part 1. s afr j rad. 2021;25(1), a2022. https://doi.org/10.4102/sajr.v25i1.2022 pictorial review clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the adult population: part 1 rishi p. mathew, sreekutty sarasamma, merin jose, ajith toms, vinayak jayaram, vimal patel, gavin low received: 22 oct. 2020; accepted: 14 dec. 2020; published: 23 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract in the adult population, foreign bodies may be accidentally or intentionally ingested or even inserted into a body cavity. the majority of accidentally ingested foreign bodies pass through the alimentary tract without any complications and rarely require intervention. accidentally ingested foreign bodies are usually fish bones, bones of other animals, and dentures. oesophageal food impaction is the commonest cause of oesophageal foreign bodies in the western hemisphere. intentionally ingested foreign bodies may be organic or inorganic, and often require intervention; these patients have either underlying psychological or mental disease or are involved in illegal activities such as body packing, which involves trafficking narcotics. imaging plays a crucial role in not only identifying the type, number and location of the foreign body but also in excluding any complications. in this comprehensive pictorial review, we provide an overview of the spectrum of foreign bodies ingested in adults, emphasising the role of various imaging modalities, their limitations and common foreign body mimickers on imaging. keywords: foreign body; fish bone; dentures; food bolus; bezoar; body packing. introduction foreign body ingestion is a common clinical presentation with approximately 80% – 90% of all ingested foreign bodies passing through the digestive tract without need for intervention. only about 10% – 20% require endoscopic removal and hardly 1% need surgery. however, the statistics change when it comes to intentionally ingested foreign bodies, with nearly 76% of the cases requiring non-surgical intervention and 28% needing surgery.1 clinical symptoms may be acute, including epigastric pain, vomiting, dysphagia, pharyngeal discomfort and chest pain. interestingly, 30% of the patients may be asymptomatic, even for years.1 the intention of this article is to inform readers of the risk factors, the common locations where foreign bodies become lodged in the aerodigestive tract, useful imaging modalities and how to protocol them to aid in the diagnosis, how to identify the complications when present and the common foreign body mimickers on imaging. discussion foreign bodies may be ingested, inserted intentionally into a body cavity or accidentally deposited by trauma or iatrogenic injury. most ingested foreign bodies pass naturally, with nearly 80% having a benign course. approximately 1500 people die annually in the united states from foreign body ingestion.1,2 four broad categories of patients can present with foreign body ingestion or insertion, namely: (1) children, (2) mentally challenged persons, (3) adults with unusual sexual behaviours and (4) adults or children with pre-existing factors or injurious situational conditions (e.g. drug and/or alcohol abuse, extreme sports, criminal offenders, and those prone to child or spousal abuse). mentally challenged individuals are repeat offenders, presenting multiple times with foreign body insertion or ingestion. foreign body impaction in adults generally results from predisposing conditions such as strictures (37%), malignancy (10%), oesophageal rings (6%) and achalasia (2%).3,4 accidentally ingested foreign bodies as per published data, the foreign bodies most commonly swallowed by adults are fish bones (9% – 45%), bones of other animals (8% – 40%) and dentures (4% – 18%).4,5 fish bone ingestion accidental fish bone ingestion is a commonly encountered problem in the emergency department, especially across asia and the mediterranean where ingestion of unfilleted fish occurs regularly.6,7,8 because of the higher consumption of fish in asian countries, fish bones can account for as high as 60% of all accidentally ingested foreign bodies in that part of the world.9 the most common predisposing or risk factor for accidental fish bone ingestion is the use of dentures. dentures impair the natural feedback of the palatal sensory nerves that are required to identify sharp and hard textured contents in a food bolus. other less common factors are rapid eating, talking whilst eating, alcoholism and mental retardation.10 once swallowed, fish bones usually become lodged in the oral cavity or pharynx (figure 1a–d), especially in the tonsils, at the tongue base, vallecula or pyriform fossa, with the other less common sites of impaction being the oesophagus, stomach, small bowel and colon.9,10,11 uncomplicated cases of impaction in the oropharynx can be easily visualised by an ear nose throat (ent) surgeon and removed using a scope.11 within the oesophagus, the most common site of fish bone impaction is in the cervical portion, in the cricopharyngeus muscle at the c5–c6 level (figure 2a, b), followed by the thoracic portion at the level of the aortic arch; uncommon sites are the left subclavian artery origin or at the origin of an aberrant right retroesophageal artery.10,11 figure 1: impacted fish bone in a 45-year-old male. frontal and lateral radiographs of the neck (a and b) show no radio-opaque foreign body. sagittal (c) and coronal (d) reformatted computed tomography images demonstrate the fish bone (arrows) impacted in the left lateral pharyngeal wall. figure 2: axial (a) and sagittal reformatted (b) computed tomography images showing a 4 cm × 1 cm fish bone (thin arrows) impacted in the posterior cricopharyngeal wall with perforation resulting in a retropharyngeal abscess (thick arrow). foreign body aspiration into the tracheo-bronchial tree is rare in adults, and when present the fish bone may be seen in the right bronchial tree because of the anatomical, near parallel orientation of the right main bronchus with the trachea. these patients may be asymptomatic or can present with a cough.11 the value of symptoms (e.g. foreign body sensation, dysphagia, odynophagia, vomiting, blood-stained saliva, retrosternal pain, etc.) in locating the fish bone site remains controversial. foreign body sensation is the only symptom found to correlate with the site of lodgement, with a high success of retrieval in the proximal oesophagus (59%) in comparison to the lower oesophagus (11%). laterality of symptoms may also indicate an ipsilateral location of the foreign body, as reported by klein et al.12 conventional neck radiography (lateral view), being inexpensive and widely available, is often the first imaging modality used for evaluating patients who have accidentally ingested a fish bone. however, its diagnostic utility in identifying fish bones remains questionable and controversial with a reported false negative rate of 47%12 and a very low sensitivity of 25.3%.12,13 factors that affect the detection of foreign bodies on the lateral view neck radiograph are location of impaction, orientation and the density of the foreign body. a fish bone may be impacted anywhere in the aerodigestive tract, and the surrounding normal soft tissue density may hinder its detection, especially at the level of the cricopharyngeus muscle. in terms of orientation, a foreign body oriented orthogonal to the radiograph is much easier to identify than one that is oriented horizontally. the optical density of the bones of various fish species differ, making it difficult to identify at radiography.13 in addition, normal anatomical structures can often mimic an ingested foreign body on the lateral neck radiograph and these include partial ossification of the superior cornu of the thyroid cartilage, arytenoid cartilage, posterior lamina of the cricoid cartilage, the stylohyoid and thyrohyoid ligaments, the styloid processes and vascular calcifications. knowledge of the clinical history, typical anatomical landmarks on the neck radiograph and the lack of ancillary findings such as prevertebral soft tissue swelling or cervical emphysema can help differentiate these common mimickers from an impacted foreign body.13 multidetector computed tomography (mdct) is highly sensitive and specific for identifying foreign bodies, with the overall reported sensitivity and specificity being in the range of 90% – 100% and 93.7% – 100%, respectively.13 potential pitfalls on mdct include tonsilloliths (that appear as tiny, rounded structures with well-defined margins, unlike foreign bodies that are usually linear or irregular in shape), the hyoid bone (figure 3a, b), cricoid calcifications, swallowing motion artefacts (that appear streaky in density) and artefacts from radiodense materials, for example, barium or silver nitrate, or even faecal material in the bowel11,13 and slice thickness.14 a major limitation for the detection of foreign bodies on computed tomography (ct) is the lack of observer awareness.14 the use of contrast (oral or intravenous [i.v.]) can hamper the identification of fish bones on mdct. oral contrast can conceal fish bones in the intestinal lumen, whilst extraluminal fish bones can mimic blood vessels on i.v. contrast studies.14 if there is a strong clinical suspicion for accidental fish bone ingestion and if the initial study is an i.v. contrast examination that was negative, then the study needs to be repeated without contrast. factors that can improve detection on mdct include the use of thinner reconstructions (3 mm/1.5 mm) and using multiplanar reformatted images for evaluation.10,14 figure 3: (a–c) computed tomography images of a 65-year-old woman with a foreign body sensation in the right neck following a meal: (a) axial image shows suspicious hyperdense material near the base of the tongue (arrow) on the right side, mimicking a foreign body. however, (b) sagittal reformatted and (c) 3d multiplanar reformation (mpr) images confirmed it to be the greater cornu or horn of the hyoid bone. complications associated with accidentally ingested fish bones are uncommon and when present are usually laceration and penetration or perforation of the pharyngoesophageal wall.6,15 pharyngeal fish bone impaction can cause infection of the deep neck space, neck abscess and retropharyngeal haematoma or abscess formation. migrated soft tissue fish bones can cause a retropharyngeal abscess, oesophageal dissection, penetration of the facial artery or even the parotid duct. in severe cases it can even damage the cardiovascular system, causing complications such as pericarditis, cardiac tamponade, infectious endocarditis, systemic air embolism, pseudoaneurysm (figure 4a, e) or aorto-oesophageal fistula.12,16 perforations below the level of cricopharyngeus are uncommon,10,17 and when present the common sites of perforation are usually the lesser curvature of the stomach18 and the less mobile portions or regions with acute angulations in the bowel, such as the ileum and the rectosigmoid junction.11,19 pneumoperitoneum is rare with fish bone impaction, as bowel perforation occurs by slow erosion through the wall, which is spontaneously sealed by fibrin and omentum.11,19 figure 4: computed tomography (ct) images of a 61-year-old man with a pseudoaneurysm of a hypertrophied bronchial artery following impaction of a retro-oesophageal fish bone (fb). reformatted coronal ct images indicate the (a) underlying bronchiectasis (b) impacted retroesophageal fb and collection (thin arrow). (c) post contrast 3d-multiplanar reformation (mpr) coronal image shows the hypertrophied bronchial artery (thick arrow). (d) post contrast 3d ct axial image shows the impacted fb (thin arrow) causing a pseudoaneurysm of the hypertrophied bronchial artery (thick arrow). (e) post embolisation of the bronchial artery pseudoaneurysm; the fb was removed. chicken bone and other bone fragments when compared with fish, the bones of other animals (e.g. chicken, beef, etc.) tend to be more radio dense. a lateral neck radiograph can often localise an impacted chicken bone in the neck (figure 5a). the ability of a radiograph to satisfactorily demonstrate an ingested chicken bone depends on the radio-opacity of the bone and image quality of the radiograph. however, a ct will be necessary to assess for complications such as perforation and abscess formation (figure 5b).20 figure 5: (a) lateral radiograph of the neck shows a ‘y’ shaped chicken bone (thin arrow) impacted in the posterior wall of the cricopharynx, along with prevertebral soft tissue thickening demonstrating multiple air locules (thick arrow). (b) computed tomography sagittal reformatted image confirmed the chicken bone (thin arrow) location and the retropharyngeal abscess. dentures dentures are medical prosthetic devices used for improving aesthetics, mastication, articulation and self-esteem. ingestion of dentures is rare amongst the young and healthy population and is more common amongst the elderly, in alcohol or drug abusers and patients with psychoneurologic deficit. an additional risk factor is the dislodgment or loosening of removable or fixed dentures. the most common site for denture impaction is in the oesophagus (70%). small bowel impaction is rare, and when present, is usually in the terminal ileum. complications associated with denture impaction include perforation (most common), necrosis, penetration to adjacent organs, haemorrhage and bowel obstruction.21 soft tissue lateral radiographs of the neck are routinely performed in patients who have ingested dentures. however, its clinical value in these cases is questionable as the dental plates are radiolucent (unlike natural teeth, which can be visualised on plain radiographs).21,22 this has been the case since the 1940s when radio-opaque vulcanite was replaced by radiolucent acrylic materials in dentures. a normal lateral radiograph of the neck, therefore, does not exclude pathology, and an urgent ent consultation is required in the presence of dysphagia, pain or discomfort in the throat and pooling or excessive production of saliva. metal components in the dentures such as connectors, clasps, wire retainers or a metal core may allow the denture to be localised on a radiograph.21,22 acrylic dentures are visualised on ct (figure 6a, b) and on magnetic resonance imaging (mri); however, limitations to mri access in an emergency room (er) setting poses a challenge.22 a barium contrast study is not recommended and is rarely helpful, as it will coat all sides of a radiolucent object in addition to hampering endoluminal visualisation on subsequent endoscopy.23 figure 6: (a) lateral radiograph of the neck revealing a swallowed denture (thin arrow) at the level of the cricopharynx. (b) axial computed tomography image confirms the location of the denture (thick arrow), which appears as a curvilinear hyperdense structure. oesophageal food bolus impaction unlike in asia, oesophageal food impaction is the commonest cause of oesophageal foreign bodies in the western hemisphere,6 with an estimated annual incidence rate of 13 per 100 000.6,24 steakhouse syndrome is the clinical condition resulting from oesophageal food impaction after eating a piece of food (usually a meat bolus) because of inadequate chewing.25 previous studies have shown that 88% – 97% of oesophageal food bolus impaction cases have underlying oesophageal pathologies. common causes include oesophageal stenosis due to schatzki rings or peptic strictures, oesophageal webs, extrinsic compression, surgical anastomosis, oesophagitis and achalasia. eosinophilic oesophagitis is recognised as an emerging cause of food bolus impaction in younger patients. if the food gets impacted at the upper oesophageal sphincter, it can be readily localised by the patient; however, symptoms occur when the food becomes lodged in the distal oesophagus. symptoms include neck/chest pain or pressure, dysphagia, odynophagia, a sense of choking, retching and vomiting. patients with high grade food bolus impaction can present with hypersalivation and inability to swallow any liquids, including their own saliva. respiratory symptoms develop when there is aspiration of saliva or food from compression of the trachea or complete airway occlusion. on presentation at the er, clinical examination should assess the patient’s stability and assess for any complications. initial examination should assess ventilation, airway compromise and the risk for aspiration. signs of oesophageal perforation are fever, tachycardia, subcutaneous crepitus and neck or chest swelling. oesophageal perforation requires urgent surgical intervention without any delay.26 radiographic evaluation can be useful to identify any complications such as pneumomediastinum. food boluses are radiolucent (figure 7a–c) and are, therefore, not seen on conventional radiographs. due to the risk of aspiration, an oral contrast examination should not be performed. most cases of oesophageal food impaction are treated by flexible endoscopy, which should not be delayed by more than 24 h after presentation because of the risk of complications.26 figure 7: food bolus (meat) impaction in a 70-year-old male. (a) lateral radiograph of the neck was unremarkable. computed tomography (b) axial and (c) sagittal reformatted images shows the impacted bolus of food (black arrow) in the hypopharynx at the c6–c7 level. intentionally ingested foreign bodies patients who intentionally ingest foreign bodies can be challenging to treat, as the history provided is often confusing or incomplete, making it difficult for the endoscopist to plan the procedure and the type of anaesthesia to be administered. self-injurious behaviour is common amongst patients with post-traumatic stress disorder (ptsd), psychotic and personality disorders. often these patients have an underlying history of childhood deprivation, physical and/or sexual abuse (figure 8a–f). figure 8: serial chest and abdominal radiographs of a 25-year-old young woman taken over a period of one year with a history of physical and sexual abuse. the images demonstrate various intentionally ingested foreign bodies that included (a) a fork and spoon, (b) a table knife, and (c) a serrated knife, as well as various intentionally ingested foreign bodies that included (d) multiple glass pieces (thin arrows), (e) a cigarette lighter (arrowhead), and (f) a nail and a razor blade (thick arrow). the pattern of self-injury in these patients is usually non-suicidal and tends to be parasuicidal in nature. it is believed that the self-injurious harm is a form of expression of rage or punishment towards oneself and/or towards their caregivers, or a way to persuade others to provide attention or care. it is believed that these patients feel a sense of empowerment by being able to exasperate or infuriate and challenge the treating physician or surgeon and hence feel motivated to indulge in further ingestions.27 intentional ingestion of foreign bodies can also be seen in munchausen syndrome or in prison inmates as an act of malingering.28 in a study conducted by huang et al.29 involving 305 cases of intentionally ingested foreign bodies, it was found that the average time period from ingestion to presentation was more than 48 h. the most common items ingested were pens, batteries, knives, razor blades, pencils, toothbrushes, spoons, coins and metallic objects, and the overall success rate of endoscopic removal was 90%. bezoar the term ‘bezoar’ is derived from the arabic word ‘bedzehr’ or the persian word ‘padzhar’, meaning ‘protection against a poison’, as in the past bezoars from animal guts were used as antidotes to poisons and still form part of traditional chinese medicines.30 bezoar refers to a conglomerate mass composed of foreign bodies which, undigested by gastric acid, accumulates within the alimentary canal, most commonly in the stomach (figure 9a, b). the majority of gastric bezoars result as a complication of gastric surgery. however, gastric bezoars can also occur in the normal stomach from ingestion of various objects that do not easily pass through the gastric pylorus such as hair, prune, plastic, paper, cotton, et cetera. figure 9: (a and b) coronal reformatted computed tomography images of a 19-year-old female with a history of repeatedly chewing her ‘dupatta’ (a shawl-like scarf traditionally worn by women of the indian subcontinent) showing a short segment of bowel wall thickening in the proximal descending colon (arrows). the ‘faecal like’ material within the lumen of the affected descending colon was identified at laparoscopy as textile bezoar. phytobezoars and trichobezoars are the commonest forms of bezoars,31,32 with the former accounting for nearly 40% of all cases.32 it is made up of poorly digested fruits (e.g. oranges, persimmons, etc.) and/or vegetable fibres. a trichobezoar forms the second most common group and is composed of hair, either from the patient, other humans or animals. it is an occupational hazard amongst brush makers, blanket weavers and wool workers. it is most commonly seen in young women and usually located in the stomach; it may rarely migrate into the small bowel.31,32,33 the condition is most commonly associated with psychiatric conditions such as trichotillomania (an urge to pull one’s own hair) and trichophagia (an urge to eat one’s own hair).34 trichotillomania may also be seen in some neurodevelopmental disorders such as lesch–nyhan syndrome, which can be associated with other body-focused repetitive behaviours such as skin picking, scratching, nail, hand or finger biting, head banging, self-hitting, et cetera.35 a rapunzel syndrome is a rare form of gastric trichobezoar with a long tail extending beyond the stomach along the duodenum into the small intestine.30,32,34,36 small bowel obstruction is the most common clinical complication of a bezoar (figure 10a, b); however, it is responsible for only 0.4% – 4% of all intestinal obstructions. figure 10: (a) axial and (b) coronal reformatted computed tomography images of a 64-year-old woman with a history of crohn’s disease. computed tomography showed two intraluminal masses (arrows) with peripheral calcifications located within a dilated loop of distal jejunum. there was associated upstream small bowel obstruction. the patient underwent small bowel resection with primary anastomosis, and pathological evaluation of the excised specimen confirmed the intraluminal masses as bezoars. until recently, bezoars were rarely diagnosed prior to surgery, as the patient’s symptoms and radiographic findings appeared similar to small bowel obstruction attributable to other causes. however, recent studies have shown that ultrasound or ct can help diagnose a bezoar prior to surgery. conventional radiographs can help identify complications such as small bowel obstruction. a bezoar is rarely detected by abdominal radiography and can be mistaken for an abscess or the presence of faeces in the colon. ultrasound may have limitations in those cases of small bowel obstruction where the bezoar is far from the abdominal surface, cases with multiple bezoars, and in patients with gastric bezoars. gastric bezoars need to be differentiated from ingested food; however, on ultrasound a gastric bezoar causes diffuse posterior acoustic shadowing with an echogenic band that helps to differentiate it from the ‘dirty’ shadowing caused by ingested gas and food within the stomach.37 sonographic features of a bezoar include the presence of an intraluminal bowel mass with an echogenic arch-like surface and profuse acoustic shadowing. the presence of twinkling artefacts within the arch-like surface on colour doppler may also help to increase the diagnostic confidence. this artefact is because of a narrow band of intrinsic noise within the doppler circuitry of the ultrasound machine, called phase jitter. major differentials for a small bowel bezoar on ultrasound are gall stone ileus, small bowel tumours with calcifications and faecal material.37,38 it is not common for faecal material to present on ultrasound with a rough surface demonstrating twinkling artefacts and posterior shadowing. however, unlike bezoars, faecal material has a relatively soft consistency and is mobile with dynamic ultrasound imaging.39 at ct imaging, a bezoar appears as a well-defined oval intraluminal mass containing air bubbles within the interstices, along with dilated proximal small bowel loops and normal or collapsed distal bowel. an inconsistency between ct and the surgical location of a bezoar is usually because of migration of the bezoar during the interval between the imaging study and surgery. computed tomography may help to differentiate a small gastric bezoar from food contents, as the former is often round or oval in shape, tends to float on the water–air surface surrounded by gastric contents and is of lower density than food particles; large bezoars tend to occupy all of the lumen, demonstrating diffuse air bubbles throughout the mass. gastric bezoars may be missed on standard abdominal soft tissue window settings (level 40, width 350 hounsfield units [hu]), and the sensitivity may be increased by reducing the window level to approximately -100 hu.37,39 on a ct study, small bowel faeces can mimic a bezoar. the former tends to be located proximal to the site of obstruction, unlike bezoars which are located at the site of obstruction. also, small bowel faeces tend to be more tubular in shape, whilst the latter is often round or oval. one study pointed out that the length of the faeces-like material in the dilated small bowel proximal to the transition zone is a key imaging feature to differentiate small bowel faeces from a bezoar.40 treatment strategies for gastric phytobezoars include chemical dissolution by coca-cola®, endoscopic removal, laparotomy and laparoscopic surgery. however, phytobezoars caused by persimmon are resistant to chemical dissolution because of their hard consistency and are usually removed by endoscopy or surgery. intestinal bezoars are commonly removed by surgery as these patients generally present with intestinal obstruction and ileus. trichobezoars, because of their high intrinsic density, tend to be resistant to enzymatic degradation, pharmacotherapy and endoscopic fragmentation, often requiring laparotomy or laparoscopic surgery.41 body packing body packing was first reported in the literature in 1973 by canadian doctors, deitel and syed, who presented a case of ileus secondary to ingestion of a condom filled with hashish.42 the term ‘body packing’ refers to ingesting a large amount of narcotic material (usually cocaine, heroin or cannabis products) wrapped in a number of packages so that it can be concealed in the alimentary tract and transported to the target destination (usually across international borders) without being caught by security officials. the individuals involved in this act are called body packers; other names include drug mules, swallowers, intestinal carriers or couriers. the term ‘body stuffer’ or ‘mini packer’ refers to an individual who swallows small amounts of loosely wrapped illicit drugs, plastic pouches or small pellets on an unexpected encounter with law enforcement officials for fear of being arrested. the term ‘body pusher’ refers to individuals who insert narcotic packages into their rectum or vagina.43 as a result of the limitation of this article, we will not be discussing the latter group. the packing materials used for these illicit drugs may be handmade or manufactured. commonly used synthetic materials include condoms, plastic wraps or bags, latex glove fingers, balloons, aluminium foil, cellophane and glassine. these packages are also known as bolitas. in the majority of the cases, the narcotics are usually solid drugs; however, recently a novel method of smuggling has emerged where the body packers ingest packages stuffed with liquid cocaine.43,44 the various imaging modalities available for identifying body packing are plain abdominal radiography, ultrasound, ct and mri. of these, the first two are the most commonly used screening tools, with plain abdominal radiography being the most widely used test because of its lower cost and ease of availability. the reported sensitivity for plain abdominal radiography in body packing is between 40% and 90%.43,44 the presence of one or more well-defined opacities in the stomach, small or large intestine, that are not suggestive of gastrointestinal contents, should raise suspicion for body packing. other ancillary imaging findings or signs that have been described are: (1) the ‘double condom sign’ – the presence of radiolucent air crescent trapped between multiple layers of packing surrounding each packet; (2) the ‘tic-tac’ or ‘bag of eggs’ sign – refers to the presence of several homogeneous radiodense oval or round shaped structures with sharp margins and clear air-substance interface (figure 11a); (3) the ‘parallelism sign’ – firm narcotic packs aligning parallel to each other in the intestinal lumen; (4) the ‘rosette sign’ – refers to air trapped in the knot of the drug packet; (5) the ‘halo sign’ – a complete rim of blurred lucency surrounding the drug packet43,44; (6) the ‘black crescent sign’ – a crescent of air around the drug packet; and (7) the ‘lucent triangle sign’ – representing air in the interface between drug packets or with the bowel wall. the ‘double condom’ and ‘halo’ signs that have traditionally been used for detecting packets containing solid drugs, are also effective in detecting liquid cocaine. in addition, packets with liquid narcotics tend to be irregular, with ill-defined borders and show variable density unlike solid drugs that are often opaque to faeces (figure 11b).44 common mimickers for drug packets on conventional radiography include hardened faeces (faecaloma or scybala), intestinal air, calcifications and other foreign materials.43,44,45 figure 11: (a and b) abdominal radiographs of packages containing narcotic materials in a 45-year-old woman. on ultrasound, packages containing solid drugs appear as multiple, ovoid, immobile, smooth contoured echogenic masses within the bowel lumen, demonstrating strong posterior acoustic shadowing. moreover, reverberation artefacts may be seen behind the packets secondary to trapped air in the sheaths. however, ultrasound has limitations in differentiating packets containing liquid narcotics from intestinal gas and faeces.45 unenhanced ct remains the most valued imaging modality in body packing, and is often used for confirmation when radiography or ultrasound is negative but a strong suspicion remains. computed tomography allows not only confirmation, but also determines the size, number and localisation of the packages, in addition to any complications related to drug leaks (figure 12a, b).45 the reported sensitivity and specificity of ct is between 96% – 100% and 94% – 100%, respectively, and the most widely accepted protocol is non-contrast ct without oral or rectal contrast, as these may hamper the intraluminal visualisation of the packets, which have similar density to contrast material. computed tomography images should be assessed on both abdominal and lung windows, as trapped air in the packages is better seen with the lung window. on ct, packets containing solid drugs appear as multiple, oval-shaped, sharply margined structures of variable density in the bowel lumen with attenuation values ranging from -520 hu to 700 hu.45 liquid narcotic containing packets tend to appear as homogeneously hyperdense structures with irregular shapes, taking the shape of the intestinal lumen, with attenuation values ranging from 155 hu to 310 hu. low attenuating bands caused by air trapped between the package sheath and packages may be seen and are specific. in addition, a ‘jigsaw’ pattern has been reported resulting from packages interlocking with each other. figure 12: a 25-year-old male body packer and body pusher. (a) sagittal computed tomography imaging of the intestinal loop lumens without contrast material revealed multiple hyperdense drug-filled capsules along with two bigger sized packages in the lumen of the rectum. (b) three-dimensional volume-rendering technique images distinguish the capsules more easily. a total amount of 1093 g of 60 cocaine capsules were obtained from this case. although mri may be used for evaluating suspected cases of body packing, its role is often regarded impractical because of cost, limited availability and longer examination time when compared with the other imaging modalities. also, magnetic resonance (mr) artefacts secondary to motion can be intentionally introduced by a suspect, rendering the images suboptimal. additionally, mri can also be harmful to the body packer if the material used for packing the drugs contains ferromagnetic materials.45 some of the fatal complications reported in the literature related to body packing include oesophageal, gastric or bowel obstruction or perforation, gastric ulceration and even respiratory arrest from aspiration of the package contents. the role of the radiologist does not stop with identifying and confirming the presence of concealed narcotics, but also extends to identifying the number, location of the packages and any signs of complications that can result from the rupture of these drug packets.45 foreign body aspiration foreign body aspiration is a rare entity in adults and is more commonly reported in children. sehgal et al.46 conducted a systematic review of the literature on the subject of adult foreign body aspiration managed by flexible endoscopy. they reviewed the bronchoscopy database in pubmed for all studies in english from 1979 to 2014. a total of 25 998 flexible bronchoscopies were performed during this period, of which only 65 subjects (0.25%) had undergone bronchoscopy for foreign body aspiration. imaging abnormalities were seen in 86.2% of the patients (n = 56) on chest radiography (cxr) or ct at the time of presentation and included non-resolving opacities, segmental atelectasis or lobar collapse, bronchiectasis or hyperinflation. the cxr was diagnostic in 16 patients (24.6%). metallic foreign bodies (e.g. pins, whistles, etc.), followed by organic ones (e.g. betel nuts, peanuts, peas, rice, etc.), where the most common types of foreign bodies identified during bronchoscopy (figure 13a, b). the right lower lobe bronchus (30.6%) was the usual site for foreign body aspiration. unlike in children, who require rigid bronchoscopy for foreign body extraction, 90% of the aspirated foreign bodies in adults are managed by flexible bronchoscopy. rigid bronchoscopy may be required in adults in certain circumstances such as failed flexible bronchoscopy attempt(s) to retrieve a foreign body, foreign bodies that are impacted in extensive granulation tissue or excessive tissue scarring, a large foreign body that cannot be gripped with flexible forceps, asphyxiating foreign bodies, foreign bodies with a smooth margin and sharp foreign bodies.46 figure 13: (a) chest radiograph and (b) coronal reformatted chest computed tomography images of a 59-year-old lady who accidentally aspirated a hair pin (arrows) into the right lower lobe bronchus. conclusion imaging with plain radiography and mdct, in particular, play a crucial role in the diagnosis and management of foreign bodies lodged in the aerodigestive tract. familiarity with the common locations for impaction of these foreign bodies and their characteristic appearance on imaging combined with a cautious interpretational approach using multiplanar reformatted images and the knowledge to differentiate the common mimickers on imaging can aid in early and accurate diagnosis. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this pictorial review. authors’ contributions r.p.m. and s.s. were involved in conceptualising, visualising and writing the original draft of the article. m.j. assisted in data curation and resources. a.t. was responsible for project administration and supervision. v.j. 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[rapunzel syndrome removed with enteroscopy in a child]. korean j gastroenterol. 2019 jul 25;74(1):42–45. https://doi.org/10.4166/kjg.2019.74.1.42 ripollés t, garcía-aguayo j, martínez mj, gil p. gastrointestinal bezoars: sonographic and ct characteristics. ajr am j roentgenol. 2001 jul;177(1):65–69. https://doi.org/10.2214/ajr.177.1.1770065 kim hc, yang dm, kim sw, park sj, ryu jk. color doppler twinkling artifacts in small-bowel bezoars. j ultrasound med. 2012;31(5):793–797. https://doi.org/10.7863/jum.2012.31.5.793 lee kh, han hy, kim hj, kim hk, lee ms. ultrasonographic differentiation of bezoar from feces in small bowel obstruction. ultrasonography. 2015 jul;34(3):211–216. https://doi.org/10.14366/usg.14070 altintoprak f, degirmenci b, dikicier e, et al. ct findings of patients with small bowel obstruction due to bezoar: a descriptive study. scientific world journal. 2013;2013:298392. https://doi.org/10.1155/2013/298392 iwamuro m, okada h, matsueda k, et al. review of the diagnosis and management of gastrointestinal bezoars. world j gastrointest endosc. 2015;7(4):336–345. https://doi.org/10.4253/wjge.v7.i4.336 deitel m, syed ak. intestinal obstruction by an unusual foreign body. can med assoc j. 1973;109(3):211–212. pinto a, reginelli a, pinto f, et al. radiological and practical aspects of body packing. br j radiol. 2014;87(1036):20130500. https://doi.org/10.1259/bjr.20130500 tsang hkp, wong ckk, wong of, chan wlw, ma hm, lit cha. radiological features of body packers: an experience from a regional accident and emergency department in close proximity to the hong kong international airport. hong kong j emerg med. 2018;25(4):202–210. https://doi.org/10.1177/1024907918770083 bulakci m, cengel f. the role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools. br j radiol. 2016;89(1060):20150888. https://doi.org/10.1259/bjr.20150888 sehgal is, dhooria s, ram b, et al. foreign body inhalation in the adult population: experience of 25,998 bronchoscopies and systematic review of the literature. respir care. 2015 oct;60(10):1438–1448. https://doi.org/10.4187/respcare.03976 sajr 889 paediatric neuro-imaging: diagnosis s k misser , mb chb, fcrad (d) sa lake smit and partners, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) we congratulate professor savvas andronikou of the department of radiology, university of pretoria, for his spot-on diagnosis, for which he receives the award of r1 000 from the rssa. dr misser elaborates below on the images and findings. please refer to page 45 of the march 2013 issue of the sajr (http://dx.doi.org/10.7196/sajr.843) for the investigative images. diagnosis imaging and findings a 2-year-old boy presented with microcephaly and developmental delay. the mri images referred to above, were obtained. the sagittal t1 (fig. 1) sequence shows an abnormal appearance of the corpus callosum. the entire body of the corpus callosum is remarkably thin. only the splenium and part of the genu is relatively spared. along with the posterior frontal and parietal lobe cerebral fusion, note the absence of the septum pellucidum and fused frontal horns of the lateral ventricles (figs 2 4). the sylvian fissures appear continuous across the hemispheres. mra of the intracranial vessels (fig. 5) demonstrates an azygous anterior cerebral artery. the combination of features is compatible with a syntelencephaly subtype of holoprosencephaly. discussion holoprosencephaly (hpe) is perhaps one of the more complex and captivating congenital brain malformations, with its striking imaging phenotype abnormalities and complex neurological impairment. it is characterised by failure of cleavage of the prosencephalon, a process that usually occurs between the 18th and 28th days of gestation. the overall incidence is much higher than expected, with up to 1 in 250 conceptions affected. with the immense improvement in neuro-imaging, particularly in magnetic resonance imaging, we are now able to delineate the specific areas of involvement including cerebral frontal and parietal lobes, basal ganglia, thalami, orbits and facial structures. there are four subtypes of this malformation. the spectrum includes the classic hpe subtypes in the de myer classification (viz. alobar, semilobar and lobar hpe), in addition to the fourth subtype known as the middle interhemispheric variant of holoprosencephaly (mih) or syntelencephaly (table 1). solitary median maxillary central incisor is one of several microforms of autosomal dominant hpe not usually included in the classification. mih is a relatively milder clinical form of holoprosencephaly, first described in 1993 by barkovich et al.1 although akin to other forms of holoprosencephaly, mih is thought to develop on a somewhat different pattern of midline non-cleavage. the classic subtypes of hpe all involve induction of the embryonic floor plate, and shh is the primary gene abnormality described among several others. in contrast, in the pathogenesis of mih it is the embryonic roof plate that is involved. mutations of the zic2 gene on chromosome 13, which plays a critical role in differentiation of the roof plate of the developing embryo, have been implicated in mih.2 the affected children present with a variety of deficits including spasticity, dystonia and oromotor dysfunction affecting feeding and speech. seizures as well as mild cognitive and visual impairment are noted in these children. endocrinopathy is not a common feature owing to sparing of the hypothalamus and basal forebrain. when compared with other forms of hpe, the overall functional levels including mobility, hand/arm function and speech are better in patients with mih. on mr imaging, mih is characterised by abnormal fusion of the posterior frontal and parietal regions of the cerebral hemispheres. the anterior portions of the frontal lobes, olfactory tracts and the occipital lobes are usually normal. there is frequent incomplete cleavage of the heads of the caudate nuclei and thalami, but the hypothalamus and lentiform nuclei are well-separated. almost all patients with mih have a single or azygous anterior cerebral artery. there is a coronal configuration of the sylvian fissures which are continuous across the cerebral vertex. frequent association with heterotopias and malformations of cortical development have been reported.3 in the presence of typical mri features, a reasonably confident diagnosis of syntelencephaly may be made even antenatally.4 this radiological diagnosis may serve as a valuable tool in prognostication and in the counselling of parents. 1. barkovich aj, quint dj. middle interhemispheric fusion: an unusual variant of holoprosencephaly. ajnr 1993;14:431-440. 1. barkovich aj, quint dj. middle interhemispheric fusion: an unusual variant of holoprosencephaly. ajnr 1993;14:431-440. 2. brown l, odent s, david v, et al. holoprosencephaly due to mutations in zic2: alanine tract expansion mutations may be caused by parental somatic recombination. hum mol genet 2001;10:791-796. 2. brown l, odent s, david v, et al. holoprosencephaly due to mutations in zic2: alanine tract expansion mutations may be caused by parental somatic recombination. hum mol genet 2001;10:791-796. 3. fujimoto s, togari h, banno t, wada y. syntelencephaly associated with connected transhemispheric cleft of focal cortical dysplasia. pediatr neurol 1999;20:397-389. 3. fujimoto s, togari h, banno t, wada y. syntelencephaly associated with connected transhemispheric cleft of focal cortical dysplasia. pediatr neurol 1999;20:397-389. 4. pulitzer sb, simon em, crombleholme tm, golden ja. prenatal mr findings of the middle interhemispheric variant of holoprosencephaly. ajnr 2004;25:1034-1036. 4. pulitzer sb, simon em, crombleholme tm, golden ja. prenatal mr findings of the middle interhemispheric variant of holoprosencephaly. ajnr 2004;25:1034-1036. 5. kanekar s, shively a, kaneda h. malformations of ventral induction. semin ultrasound ct mri 2011 32(3):200-210. 5. kanekar s, shively a, kaneda h. malformations of ventral induction. semin ultrasound ct mri 2011 32(3):200-210. s afr j rad 2013;17(2):72-73. doi:10.7196/sajr.889 8 sa journal of radiology • march 2011 pictorial interlude images of a case of unilateral choanal atresia diagnosed in a 35-yearold woman are presented. this is an uncommon diagnosis in an adult patient, and a less frequently encountered form of the condition. in more than 90% of cases of choanal atresia, the abnormality is partly or completely osseous; pure membranous atresia is rare.1 it is unilateral in 50 60% of cases, and more than 75% are associated with syndromes and systemic anomalies. unilateral choanal atresia may go unrecognised until adulthood, as in our patient, when she presented with rhinorrhea and unilateral recurrent nasal obstruction. failure of perforation of the buccopharyngeal membrane during midface development in the developing fetus produces membranous choanal atresia.2 the imaging modality of choice for suspected choanal anomalies is computed tomography (ct). image reconstruction with a bone algorithm is required to clearly depict partially ossified/unossified structures. careful suctioning prior to the scan may be helpful in some patients. the purpose of ct scanning is to: • confirm the diagnosis, determine if it is uni/bilateral, and assess if it is bony/membranous or mixed • determine if it is a stenosis or atresia, and assess vomer bone width and choanal airspace distance in atresia. normal choanal orifices measure >0.37 cm in children <2 years.2 • exclude other possible sites of obstruction. ct virtual endoscopy is a post-processing tool that can aid in depicting disorders of the airways and may assist in preoperative planning. in choanal atresia, the posterior view provides a look at the abnormality and surrounding anatomical relationships.3 membranous choanal atresia is usually treated with endoscopic perforation. osseous atresia may require choanal reconstruction or transpalatine resection of the thick vomer. 1. valencia mp, castillo m. congenital and acquired lesions of the nasal septum: a practical guide for differential diagnosis. radiographics 2008;28:205-223. 2. castillo m. congenital abnormality of the nose: ct and mr findings. ajr 1994;162:1211-1217. 3. thomas bp, strother mk, donnelly ef, worrell ja. ct virtual endoscopy in the evaluation of large airway disease: review. ajr 2009;192:s20-230. unilateral membranous choanal atresia fig. 1. axial ct image demonstrates thin membrane occluding the right choanal lumen. no ossification is seen. fig. 2. posterior nasopharynx ct virtual endoscopic view. roof of nasopharynx above and soft palate below. right-sided membranous atresia shown. aadil ahmed, mb bch, fcrad (diag) visser, erasmus, vawda and partners, port elizabeth http://www.sajr.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the sa journal of radiology, we ask that you take a moment to update your electronic portfolio on https:// sajr.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajr. org.za 2. in your ‘user home’ [https://sajr.org.za/index. php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the sa journal of radiology. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this volume of the sa journal of radiology. we appreciate the time taken to perform your review(s) successfully. aadil a. ahmed abdu h. dambatta abubakar farate ahmed o.a. krim ajit k. reddy akhilanand chaurasia alexander doruyter amandeep singh amaresh ranchod anil bhaya arshed h. parry aruna patil ashesh ranchod atish vanmali aziza g. icksan bukunmi m. idowu chantal stewart cornelis van der merwe dahiru m. yunsa dale k. creamer damiano caruso diteboho khalema donovan feeney fekade a. gebremariam farhana e. suleman franck girard frank a. imarhiagbe gaurav sundar gilbert s. octavius hafsa essop hamid o. osman heena rajani heleen hanekom ilonka warnich jacobus a. pienaar jacqueline s. smilg jacques janse van rensburg jagidesa moodley jayaranjeetham jayabalan jinho jung john r. ouma jurgen h. runge kenneth b. beviss-challinor khairil a. sayuti khaled a. matrawy linda t. hlabangana mariam q. said-hartley mariska botha marthinus b. van rooyen mike m. sathekge miranda durand mridula m. muthe nausheen khan nompumelelo e. mlambo nondumiso n. dlamini ntombizakhona mthalane orapeleng seboco pankaj nepal peter mercouris philippe lefere pieter janse van rensburg rajiv kapur richard d. pitcher richard l. ehman rishi philip mathew ruchika meel salome n. ezeofor saurabh maheshwari shalendra k. misser sheree c. gray shirley lipschitz shivesh maharaj shuchi bhatt sithembiso m. langa siviwe s. mpateni stefan przybojewski susan w. karanja sushil g. kachewar t. gregory walker tanusha sewchuran thokozani sibanda tim cain tracy l. westgarth-taylor ukamaka d. itanyi vikram patil viresh bhagwandas werner s. harmse zarina i. lockhat http://www.sajr.org.za� https://sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za https://sajr.org.za/index.php/sajr/user https://sajr.org.za/index.php/sajr/user mailto:publishing@aosis.co.za sajr 866 quality management systems in radiology g k korir,1 bsc, msc, phd; j s wambani,2 mb chb, mmed (rad), pediatric (rad); i k korir,3 bsc, msc, phd; m tries,1 bs (physics), ms, phd; b mulama,2 mb chb, mmed (diagnostic rad) 1 department of physics and applied physics, university of massachusetts lowell, lowell, massachusetts, usa 2 radiology department, kenyatta national hospital, nairobi, kenya 3 national nuclear regulator, centurion, south africa corresponding author: g k korir (ggkk382@yahoo.com) background. the use of x-ray imaging is ever increasing in proportion to the need for radiological services and the latest technology. quality management of patient radiation dose monitoring is fundamental to safety and quality improvement of radiological services. objective. to assess the level of quality management systems in medical x-ray facilities in kenya. methods. quality management inspection, quality control performance tests and patient radiation exposure were assessed in 54 representative x-ray medical facilities. additionally, a survey of x-ray examination frequency was conducted in 140 hospitals across the country. results. the overall findings placed the country’s x-ray imaging quality management systems at 61±3% out of a possible 100%. the most and the least quality assurance performance indicators were general radiography x-ray equipment quality control tests at 88±4%, and the interventional cardiology adult examinations below diagnostic reference level at 25±1%, respectively. conclusions. the study used a systematic evidence-based approach for assessing national quality management systems in radiological practice in clinical application, technical conduct of the procedure, image quality criteria, and patient characteristics as part of the quality management programme. s afr j rad 2013;17(3):84-88. doi:10.7196/sajr.886 rapid advances in medical imaging evince a consequent need for timely and high-quality anatomical information of the subject’s body. high disease prevalence and the population explosion are additional compounding factors that increase the workload upon an insufficient number of skilled medical personnel, especially in developing countries.1 , 2 the performance and financial circumstances of radiology departments in the healthcare systems of level four (hcl iv) countries3 may be compromising the quality of patient care because of a low appreciation of quality management in operational efficiency, image quality and patient radiation dose. there is therefore a need to benchmark the level of quality management systems to provide evidence-based records aimed at improving safety and ensuring quality healthcare. in kenya, few studies on quality management in radiology have been reported,4 despite the need for in-depth studies to develop effective, efficient and sustainable programmes commensurate with the socio-economic status of the country. the broad legal requirements for quality assurance (qa) and quality control (qc) of medical imaging equipment and ancillary equipment exist in most developed countries.5-9 developing countries have yet to fully establish adequate guidelines to match those in developed countries, especially for x-ray equipment performance and image quality criteria, inter alia.10 , 11 in addition, a shortage of data from developing countries means that information is absent about radiology qa procedures, the organisational framework for the performance of qc tests, evaluation and institution of corrective measures. the present study was therefore initiated to benchmark the national quality management system (qms) and compare the results with established international safety standards from the international atomic energy agency (iaea), the international commission on radiological protection (icrp), the health protection agency (hpa) in the uk, the commission of european communities (cec), and the american college of radiology (acr).12-16 methods quality management in radiology radiology practice this study did not involve patients directly; it was approved by the kenyatta national hospital ethics and research committee. a total of 269 (90% coverage) radiology departments and private clinics in the country were sent letters via the administrator in charge of each institution, requesting them to participate and also to complete a qa questionnaire. the level of quality management per radiological facility was determined by scoring the quality indicators grouped into the following 3 main categories: human resource control, physical asset control, and safety of the work environment. the presence or absence of the quality factors mentioned in the questionnaire response provided by the facilities, or during the author’s inspection, led to the award of a score of 1 (pass) or 0 (fail), respectively. qa administration the overall performance evaluated as qa (16 points) constituted the summation of scores from: • category one (human resource control). seven points: patient records, workers’ licences, patient shielding, professional association, patient dosimetry, qa manual and in-service training. • category two (physical asset control). four points: qc programme, equipment service reports, qc results, and equipment licence. • category three (safety of work environment). five points: public safety, workers’ safety, personnel monitoring, radiation warning signs and appointed radiation safety officer. the facility qa administration rating was calculated as a percentage: the number of scores passed divided by the total 16 metrics considered. patient dose was calculated the same way, from the total of scores of one point if the measured dose were below the available diagnostic reference levels (drls), or zero if it were above the drls. national quality management level and index the 15 qa indicators listed in table 1 were as follows: qa administration per­formance, x-ray qc test performance (general radiography (gr), mammography, computed tomography (ct)), image quality (iq) performance (mammography, gr), and children and adult patient dose below drls (gr, mammography adults only, general fluoroscopy (gf), interventional radiology (ir) adults only, interventional cardiology (ic) adults only, ct). each quality indicator was scored and an average score calculated. the maximum score was 100% for each indicator, bringing the total maximum sum of percentage scores to 1 500. the national qa level was calculated as an average of the percentage scores from the 15 qa indicators. performance ratings were awarded as follow: an average score ≥75% was excellent, 50 74% was good, 26 49% was fair, and ≤25% was poor. the national quality management index (qmi), which has a maximum score of 1, was calculated by dividing the percentage score from each qa indicator by the sum of all percentage points scored in the qa indicators. for the qmi, a score ≥0.082 was rated as excellent, 0.054 0.081 as good, 0.027 0.053 as fair, and ≤0.026 as poor. results radiology practice comparison with rest of world the survey response was provided by 140 representative x-ray facilities, equivalent to 47% of the total number of operating facilities in kenya. a total of 54 (20%) representative x-ray facilities were visited to make qa presentations, qc measurements, in-person observations of radiological examinations, to interact with hospital staff, and to encourage participation in the survey. this was a large-scale study with the overall sample size of both patients and radiation facilities meeting the 95% confidence level and 5% confidence interval. the frequency of the number of x-ray procedures in the year 2011 was 82/1 000 of the general kenyan population. these statistics, when combined with the data in table 2, indicate that each radiologist was responsible for approximately 325 000 examinations/year in kenya. when general medical practitioners were included, each medical practitioner was responsible for approximately 8 100 x-ray examinations/year. the radiographer-patient workload was 189 300 examinations/year. the average annual case workload/x-ray machine was as follows: gr 4 000; mammography 700; gf 2 000; interventional procedures (ips) 300; and ct 3 500 patients. the number of qualified medical physicists responsible for monitoring equipment performance, image quality and estimating patient dose was largely inadequate. qa administration human resource control the 38% overall quality performance in this category based on operator qualification and practice was fair. all workers at the facilities considered were recognised by their respective professional body; 32% were authorised by the national regulatory authority to administer ionising radiation for medical purposes. no facility possessed a written qa manual that took into consideration radiation safety issues concerning patients, workers and the public. there were inadequate thyroid, eye and gonad shields in the facilities that used high-radiation modalities such as ct and the ips. none of the facilities used protective shielding on body regions not scanned during ct scan examination. similar results were noted for the need to document patient preparation procedures in the institutional qa manual. all the radiological facilities kept patient records that included name, weight, age, type of procedure and date of examination. however, there was only one facility that recorded ct and mammography doses; the rest did not, despite the fact that x-ray machines, like ct scanners, display patient dose per examination. physical asset control the 24% overall performance in this category was poor. only 22% of the facilities had reports of semi-annual preventive maintenance consisting of only the qc tests. only 68% of the x-ray facilities had received an equipment operating licence in 2011. the availability of qc programs scored lowest among the facilities that participated in the study, followed by the availability of qc records. safety of work environment the 57% overall performance in this category was good. a total of 72% of the facilities had radiation warning signs posted in conspicuous places. the requirements of monitoring radiation workers monthly for radiation dose and facility safety inspections were adhered to by 61% of the facilities. only 22% of the facilities had an appointed radiation safety officer, of whom 30% reported having been sponsored for refresher courses. individual facility performance figures indicated that 39% were good, 28% were fair, and 33% were poor, resulting in the overall national rating of 38% in the radiology qa administration section. patient dose assessment patient dose assessment was estimated according to the details obtained from over 10 000 x-ray examinations collected from over 54 facilities.10 , 18-20 the patient composition was: 4 514 (45%) children and 5 522 (55%) adults. the patient dose data were distributed according to imaging modalities as follows: gr 4 803 patients (48%); mammography 1 252 patients (12%); gf 493 patients (5%); ips 310 patients (3%); and ct scan 3 178 patients (32%). national qm level table 1 provides the overall qa performance for medical radiological facilities in kenya. the overall level of qa was determined to be 60%. for the various categories, the gr x-ray efficiency performance achieved the level of excellence at 84%, adult patient dose (68%) and image quality (61%) were good, and the qa administration (37%) and patient dose in adults were fair. none of the general quality indicators was rated as poor. discussion national quality management level the competent authority in kenya responsible for radiation safety is the radiation protection board, which was established in 1986 through the radiation protection act, cap 243 of the laws of kenya.21 the radiation protection board via legislation authorises the use of radioactive materials and radiation-producing devices at established or new facilities, establishes dose limits, and may conduct inspections and apply enforcement. regulations have been set up that cover notification and authorisation, dose limits, and control of medical exposure. the current radiation protection act, cap 243, is being revised as the radiation safety bill; it addresses additional regulatory requirements, but the acquisition, safety culture and proper use of modern radiological equipment is still dependent on the expertise of diagnostic imaging professionals within the facility. the situation poses a challenge to hospitals on how to establish a comprehensive qa programme for medical exposure with the participation of a limited number of qualified experts in radiation physics, as well as taking quality management principles, established locally and/or internationally, into account. effective use of medical equipment at the hospital level may be limited by cost, technical expertise and the level of co-ordination among personnel. the medical practitioners and dentist board (mpdb) has a well-established and critical role in regulating the health sector in kenya. however, there has been no reported co-ordination and development of radiological guidelines or any quality management studies conducted for diagnostic or therapeutic procedures in the country. moreover, the protocols for developing standards and guidelines in radiology are yet to be established. the radiation protection act generally requires irradiating devices in use in the country to comply with international safety standards.13 , 14 to compensate for the regulatory deficiencies, diagnostic imaging professionals within the country have indicated that standards for x-ray equipment performance tests, as well as referral guidelines, need to be established and mandated in a hospital qa manual, in terms of regulations and/or by licence conditions. the regulatory authority practice of outsourcing radiation protection services to board-certified service providers without a national guideline on x-ray equipment performance does not adequately address the country’s radiology quality management needs. the board certifications for dosimetry service providers must involve the diagnostic imaging community to establish guidelines that are being initiated through this study. the dosimetry service provision guidelines will not be limited to the standards for calibration and verification of radiation measuring instruments, but will also include monitoring, evaluations and corrective measures for the dosimetry service provider and the hospital diagnostic radiology departments. the radiation safety assessment within a qa manual should include a comprehensive account of x-ray equipment, staff qualifications, occupational radiation exposure monitoring, health status and integrity of structural shielding for the actual use of personal protective devices for staff and comforters, and the use of radiation protection devices for patients, among others. all these radiation protection parameters require regular checks, status confirmation, and the keeping of records. total qa can be promoted through dynamic departmental organisation structure, standard operating procedures, and the application of locally or internationally recognised standards.22 , 23 these practices will facilitate organisation, integration and the assigning of responsibilities to specific departmental professionals. the level of qa/qc roles and responsibilities will therefore be inextricably linked to a professional contribution to quality improvement of clinical practice through evidence-based audits and reviews, as well as follow-up of corrective measures. the radiologists or medical practitioners in charge should oversee the establishment of local quality systems guided by local practice as well as international standards that are currently available in most developed countries. the process of establishing local quality management systems may offer an opportunity to local radiology departments and hospitals to collaborate with established radiological institutions in developed countries. in addition to comprehensive qa systems, there should be effective qa committees, professional certification, quantitative measurements, equipment standards, imaging guidelines, technical capacity building, and continuous professional development.24 incident and accident investigation procedures as well as reporting procedures should also be established at both the hospital and the national level. the diagnostic imaging professionals indicated being affiliated with the mpdb, the kenya association of radiologists, the east african association for radiation protection, and the society of radiographers in kenya. the majority of radiological facilities involved in this study did not appreciate the critical role of patient dosimetry as contributing to a qa programme. the use of protective gear to cover body areas outside the region of interest while performing ct procedures was low. there was a general assumption that the protective gear was meant for radiation workers and those who assist unco-operative or incapacitated patients. this view resulted in low adherence to the use of basic protective gear, including the absence of a breast garment of thinly layered bismuth impregnated with radio-protective latex for covering the irradiated region not imaged.25 , 26 a critical evaluation of the data provided by the hospitals revealed divergent perspectives on the contents and details of a written qa manual in radiology. there was a need for a standard format in preparing a qa manual, and documenting patient preparation, the nature of radiological examinations, patient details, and potential risks and benefits, all in a consistent database format. according to ncrp report 99, proficient performance by imaging personnel can be enhanced by monitoring activities, and the establishment of policies and controlled record keeping systems that provide objective evidence of personnel performance.27 record keeping of equipment performance and maintenance was poor. most facilities kept equipment assessment technical reports after maintenance and repair work on the radiological devices, but these were brief and appropriate only for billing purposes. the engineers’ service and maintenance reports are similar in format and content to medical physicists’ equipment qc test reports that include proper equipment identification, documentation of performance tests results, and comments. there is a need to train imaging professionals and engineers in the initiation of regular performance verification, including the use of consistency and reproducibility checks to ensure that systematic errors are promptly detected and corrected. the resultant low performance level was attributed to the lack of medical physicists in the country and hence the absence of qa/qc programmes and compliance audits. radiology departments should institute an effective qa programme and train qc technologists. large hospitals, such as the teaching and referral or specialised centres, should consider the establishment of a qa committee whose primary function would be to maintain effective quality management systems among all groups associated with medical x-ray imaging. the low number of workers’ x-ray equipment operating licences reported in most facilities was associated with delayed inspections, delayed application to the issuing authority, and slow processing of licences by the regulator, or stringent requirements for licensing. the performance level in the occupational radiation protection measures and the posting of radiation warning signs was found to be in good standing. radiation safety officers were encouraged to scrutinise all relevant qa reports including monthly personnel radiation dose measurements, so that the best practices are identified and adopted for routine use. the superior performance in x-ray equipment quality control over qa administration in this study supports a central theme of medical imaging based on accomplishing diagnosis within a reasonable time, with minimum equipment variables, and improved patient dose management. in contrast, the qa administration components constitute the quality elements that are dependent on cost, awareness and co-ordination of health administrators, imaging professionals, regulatory authorities and x-ray equipment vendors. imaging professionals should therefore assert their roles and responsibilities in qa because they are inextricably linked to the quality of their product and service in the supply chain. whereas the shared mission of quality patient care is noted, the results from this study also indicate that the low interdependence of qa and iq can be improved if radiologists oversee the establishment of comprehensive qm systems, including effective qm committees, professional certification, quantitative measurements, equipment standards, imaging guidelines, technical capacity, and continuous professional development guided by the application of recognised international standards. the patient dose being generally above the published drls from developed countries emphasises that the drls, which are a quality assurance tool, should be specific to a particular medical imaging task for a group of patients in a specified region or local state of practice. in this study, the inclusion of radiation exposure to patients emphasises the importance of the national optimisation process in x-ray imaging practice as well as ensuring staff safety. in setting an optimisation strategy for a country, it is important that the choice of examinations be based on collective dose contribution and the frequency of the examinations, to maximise the overall benefit to the population. analysis of patient dose, and review of drls, should be performed at least twice a year. local diagnostic reference levels (ldrls) are dynamic and always changing with respect to current hospital equipment and the examinations performed within a specific facility. the qmi is derived from the scores accumulated from quality indicators that quantify performance in a step-by-step evaluation process. qmi is relevant to employees, managers, patients, equipment manufacturers, health authorities and regulatory authorities. qmi can enhance problem identification and teamwork within an institution. conclusion the present study has set out the status/level of the scientific and technical knowledge available towards integrating quality management and instituting effective radiological protection of patients in clinical practice. the study shows how to merge the role of hospital administrators, use of equipment performance tests and patient dose measurements without compromising clinical images, while achieving radiological protection. the information presented provides for a systematic evidence-based approach for the development of radiological practice guidelines that specify clinical purpose, technical conduct of the procedure, image quality criteria, unique patient characteristics, and other appropriate factors including the radiological protection of patients as part of a qa programme. we determined in this study that qa compliance in kenyan medical imaging facilities is good, but with room for improvement. at the end of the study period, each participating facility received an evaluation report and recommendations. seminar presentations were prepared for imaging professionals, equipment suppliers, and hospital administrators. the study thus provides baseline information that supports the urgent need for comprehensive qa via training, adequate regulations, professional certifications, clinical image quality guidelines, and accreditation of medical imaging facilities. the qmi is a unique performance assessment tool, suitable for hcl iv countries such as kenya, for regularly measuring, monitoring and benchmarking the national quality improvement in radiology. acknowledgements. we sincerely thank the management and radiology staff of the hospitals that participated in the iaea project (raf/9/033: strengthening radiological protection of patient and medical exposure control), and the iaea for their support. 1. wambani js, korir gk, onditi eg, korir ik. a survey of computed tomography imaging techniques and patient dose in kenya. east afr med 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js, korir ik. establishing quality management baseline in the use of computed tomography machines in kenya. j appl clin med phys 2012;13(1):187-196. [http://dx.doi.org/10.1120/jacmp.v13i1.3457] 4. korir gk,wambani js, korir ik. establishing quality management baseline in the use of computed tomography machines in kenya. j appl clin med phys 2012;13(1):187-196. [http://dx.doi.org/10.1120/jacmp.v13i1.3457] 5. environment protection authority. registration requirements & industry best practice for ionizing radiation apparatus used in diagnostic imaging, radiation guidelines; test protocols for parts 2 5. sydney: new south wales environment protection authority, 2000. 5. environment protection authority. registration requirements & industry best practice for ionizing radiation apparatus used in diagnostic imaging, radiation guidelines; test protocols for parts 2 5. sydney: new south wales environment protection authority, 2000. 6. international atomic energy agency. dosimetry in diagnostic radiology: an international quality assurance manual, technical report series no. 457. vienna: iaea, 2007. 6. international atomic energy agency. dosimetry in diagnostic radiology: an international quality assurance manual, technical report series no. 457. vienna: iaea, 2007. 7. national council on radiation protection and measurements. quality assurance for diagnostic imaging, ncrp report no.99. bethesda: ncrp, 1988. 7. national council on radiation protection and measurements. quality assurance for diagnostic imaging, ncrp report no.99. bethesda: ncrp, 1988. 8. american association of medical physicists. quality control of diagnostic radiology, aamp report no. 74. new york: aapm, 2002. 8. american association of medical physicists. quality control of diagnostic radiology, aamp report no. 74. new york: aapm, 2002. 9. institute of physical sciences in medicine (ipsm). dosimetry working party of the institute of physical sciences in medicine. national protocol for patient dose measurements in diagnostic radiology. chilton: nrpb, 1992. 9. institute of physical sciences in medicine (ipsm). dosimetry working party of the institute of physical sciences in medicine. national protocol for patient dose measurements in diagnostic radiology. chilton: nrpb, 1992. 10. korir gk, wambani js, korir ik. patient doses using multidetector computed tomography scanners in kenya. radiat prot dosimetry 2012;151(2):267-271. [http://dx.doi.org/10.1093/rpd/ncr484] 10. korir gk, wambani js, korir ik. patient doses using multidetector computed tomography scanners in kenya. radiat prot dosimetry 2012;151(2):267-271. [http://dx.doi.org/10.1093/rpd/ncr484] 11. muhogora we, ahmed na, almosabihi a, et al. patient doses in radiographic examinations in 12 countries in asia, africa, and eastern europe: initial results from iaea projects. am j roentgenol 2008;190(6):1453-1461. 11. muhogora we, ahmed na, almosabihi a, et al. patient doses in radiographic examinations in 12 countries in asia, africa, and eastern europe: initial results from iaea projects. am j roentgenol 2008;190(6):1453-1461. 12. international atomic energy agency. international basic safety standards for protection against ionizing radiation and for the safety of radiation sources, safety series no. 115. vienna: iaea, 1996. 12. international atomic energy agency. international basic safety standards for protection against ionizing radiation and for the safety of radiation sources, safety series no. 115. vienna: iaea, 1996. 13. international commission on radiological protection. the 2007 recommendations of the international commission on radiological protection. annals of the icrp publication 103. oxford: pergamon press, 2007. 13. international commission on radiological protection. the 2007 recommendations of the international commission on radiological protection. annals of the icrp publication 103. oxford: pergamon press, 2007. 14. international commission on radiological protection. recommendations of the international commission on radiological protection. annals of the icrp publication 60. oxford: pergamon press, 1991. 14. international commission on radiological protection. recommendations of the international commission on radiological protection. annals of the icrp publication 60. oxford: pergamon press, 1991. 15. european commission. european guidelines on quality criteria for diagnostic radiographic images, european commission report 16260. luxembourg: european commission, 1996. 15. european commission. european guidelines on quality criteria for diagnostic radiographic images, european commission report 16260. luxembourg: european commission, 1996. 16. american college of radiology. technical standard for medical physics performance monitoring of radiographic and fluoroscopic equipment. reston: american college of radiology, 2001:729-732. 16. american college of radiology. technical standard for medical physics performance monitoring of radiographic and fluoroscopic equipment. reston: american college of radiology, 2001:729-732. 17. contento g, malisan mr, padovani r, maccia c, wall bf, shrimpton pc. a comparison of diagnostic radiology practice and patient exposure in britain, france and italy. br j radiol 1988;61(722):143-152. 17. contento g, malisan mr, padovani r, maccia c, wall bf, shrimpton pc. a comparison of diagnostic radiology practice and patient exposure in britain, france and italy. br j radiol 1988;61(722):143-152. 18. wambani js, korir gk, bwonya smn, korir ik. assessment of patient doses during mammography practice at kenyatta national hospital. east afr med j 2011;88:368-378. 18. wambani js, korir gk, bwonya smn, korir ik. assessment of patient doses during mammography practice at kenyatta national hospital. east afr med j 2011;88:368-378. 19. wambani js, korir gk, korir ik, kilaha s. establishment of local diagnostic reference levels in paediatric screen-film radiography at a children’s hospital. radiat prot dosimetry 2013;154:465-476. 19. wambani js, korir gk, korir ik, kilaha s. establishment of local diagnostic reference levels in paediatric screen-film radiography at a children’s hospital. radiat prot dosimetry 2013;154:465-476. 20. korir gk. quality assurance and radiation protection for medical x-ray procedures in kenya. phd dissertation. lowell: university of massachusetts lowell, 2013. 20. korir gk. quality assurance and radiation protection for medical x-ray procedures in kenya. phd dissertation. lowell: university of massachusetts lowell, 2013. 21. the radiation protection act, chapter 243 laws of kenya. the radiation protection (standards) regulations, legal notice no. 54. nairobi: government printers, 1986. 21. the radiation protection act, chapter 243 laws of kenya. the radiation protection (standards) regulations, legal notice no. 54. nairobi: government printers, 1986. 22. american association of physicists in medicine. managing the use of fluoroscopy in medical institutions, aapm report no. 58. new york: aapm, 1998. 22. american association of physicists in medicine. managing the use of fluoroscopy in medical institutions, aapm report no. 58. new york: aapm, 1998. 23. international electrotechnical commission. evaluation and routine testing in medical imaging departments: part 2 6 constancy tests x-ray equipment for computed tomography iec 1223-2-6. geneva: international electrotechnical commission, 1994. 23. international electrotechnical commission. evaluation and routine testing in medical imaging departments: part 2 6 constancy tests x-ray equipment for computed tomography iec 1223-2-6. geneva: international electrotechnical commission, 1994. 24. korir gk, wambani js, korir ik. a pilot study on quality assurance performance in computed tomography facilities in kenya, proceedings of the xiv convención de ingeniería eléctrica, presentación si-10. las villas: 2011; cd isbn 978-959-250-685-5. 24. korir gk, wambani js, korir ik. a pilot study on quality assurance performance in computed tomography facilities in kenya, proceedings of the xiv convención de ingeniería eléctrica, presentación si-10. las villas: 2011; cd isbn 978-959-250-685-5. 25. beaconsfield t, nicholson r, tornton a, al-kutoubi a. would thyroid and breast shielding be beneficial in ct of the head. eur radiol 1998;8:664-667. 25. beaconsfield t, nicholson r, tornton a, al-kutoubi a. would thyroid and breast shielding be beneficial in ct of the head. eur radiol 1998;8:664-667. 26. hopper kd, king sh, lobell me, tenttore tr, weaver js. the breast: in-plane x-ray protection during diagnostic thoracic ct-shielding with bismuth radioprotective garments. radiology 1997;205:853-858. 26. hopper kd, king sh, lobell me, tenttore tr, weaver js. the breast: in-plane x-ray protection during diagnostic thoracic ct-shielding with bismuth radioprotective garments. radiology 1997;205:853-858. 27. national council on radiation protection and measurements. quality assurance for diagnostic imaging, ncrp report no.99. bethesda: ncrp, 1988. 27. national council on radiation protection and measurements. quality assurance for diagnostic imaging, ncrp report no.99. bethesda: ncrp, 1988. abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) mousam panigrahi department of radiodiagnosis, all india institute of medical sciences, raipur, india narendra k. bodhey department of radiodiagnosis, all india institute of medical sciences, raipur, india saroj k. pati department of radiodiagnosis, all india institute of medical sciences, raipur, india nighat hussain department of pathology and laboratory medicine, all india institute of medical sciences, raipur, india anil k. sharma department of neurosurgery, all india institute of medical sciences, raipur, india arvind k. shukla department of community and family medicine, all india institute of medical sciences, raipur, india citation panigrahi m, bodhey n.k, pati sk, et al. differentiation between various types and subtypes of intracranial meningiomas with advanced mri. s afr j rad. 2022;26(1), a2480. https://doi.org/10.4102/sajr.v26i1.2480 original research differentiation between various types and subtypes of intracranial meningiomas with advanced mri mousam panigrahi, narendra k. bodhey, saroj k. pati, nighat hussain, anil k. sharma, arvind k. shukla received: 15 may 2022; accepted: 24 aug. 2022; published: 26 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: meningiomas are the most prevalent of all intracranial tumours. although they are mostly benign, about 20% of meningiomas are atypical or malignant. knowledge of their histologic grade can be clinically useful while planning surgery. objectives: to differentiate between various grades and subtypes of meningiomas with advanced mr parameters. method: we assessed the advanced mr imaging characteristics of 27 histopathologically confirmed meningiomas on a 3t mri, of which 23 were grade i meningiomas (2 fibroblastic, 9 meningothelial, 9 transitional, 3 unspecified) and 4 were grade ii/iii meningiomas (2 atypical, 1 papillary, 1 anaplastic). analysis of the adc, fa, λ1, λ2, λ3 and mean diffusivity was performed using standard post-processing software. results: the mean size of atypical meningiomas (5.9 cm ± 0.7 cm) was significantly higher (p = 0.038, 95% confidence interval [ci]) than that of typical meningiomas (4.6 cm ± 1.6 cm) with a cut-off value of 6.05 cm (75% sensitivity and 87% specificity). the mean cerebral blood flow (cbf) (asl) of atypical meningiomas (286.70 ± 8.06) was significantly higher (p = 0.0000141, 95% ci) than that of typical meningiomas (161.09 ± 87.04) with a cut-off value of 276.75 (66.7% sensitivity and 75% specificity). among the typical meningiomas, transitional subtypes had the lowest adc. high fa and planar coefficient (cp) values and low λ3 and spherical coefficient (cs) values were seen in fibroblastic meningiomas. fibroblastic meningiomas also showed the lowest vascularity among typical meningiomas. conclusion: tumour size and asl perfusion are two parameters that could differentiate between typical and atypical meningiomas while adc, fa, λ3, cp, cs, rcbf and rcbv may be helpful in distinguishing different subtypes of typical meningiomas. keywords: meningioma; asl; t1 perfusion; adc; dti. introduction meningiomas are the most prevalent of all intracranial tumours, constituting 30% of all primary intracranial neoplasms.1 they appear in middle-aged individuals and are derived from arachnoid cap cells.2,3 although they are mostly benign, up to 20% of meningiomas are atypical or malignant and are more aggressive with higher recurrence rates.4,5 initial tumour resection extent and histologic grade are important predictors for tumour recurrence.6 therefore, knowledge of histologic grade can be clinically useful while planning surgery and adjunctive radiation therapy. because of intricate microstructural barriers in brain tissue, such as white matter tracts, cell membranes and capillary vessels, water molecules prefer to diffuse with direction (anisotropic diffusion) rather than uniformly in all directions (isotropic diffusion).7 diffusion tensor imaging (dti) offers data on the magnitude and directionality of water diffusion.8 when compared with classic or typical meningiomas, atypical meningiomas show higher diffusion anisotropy (fractional anisotropy values).7 in their literature review, the authors were unable to document any manuscripts comparing meningioma characteristics based on the combination of dwi (diffusion-weighted imaging), dti and perfusion, along with histopathological correlation. this research therefore sought to distinguish between the various grades and subtypes of meningiomas using advanced mr parameters. materials and methods this prospective, observational institution-based study was conducted over 22 months from 03 march 2019 to 31 december 2020. a total of 47 patients with a clinico-radiological diagnosis of meningiomas underwent mri with conventional and advanced mr sequences. of these, 12 patients did not undergo surgery for various reasons and no histopathological confirmation was available. of the remaining 35 patients, eight underwent surgery but were not meningiomas on hpe (histopathological examination). hence these eight were also excluded from the analysis. thus, we assessed the mr imaging characteristics of 27 histopathologically confirmed cases of meningiomas. brain mr image acquisition images were acquired on a discovery mr750w gem – 70 cm – 3.0 t mri scanner, ge, chicago, illinois, united states using a 16-channel bird cage coil. the standardised brain mr protocol included axial t1, axial t2, axial flair, coronal t2, sagittal t1, sagittal spgr, axial dwi (b0 and b2500 s/mm2), axial swi, axial dti, axial 3d arterial spin labelling (asl). this was followed by injection of intravenous contrast (0.1 ml/kg of gadopentetate dimeglumine [magnevist], schering, berlin, germany) with immediate dynamic susceptibility contrast (dsc) mr perfusion imaging, post-contrast t1 in the axial, coronal and sagittal planes. mr spectroscopy was also performed. post-processing standard post-processing software (ready view) was used for image analysis. circular regions of interest (rois) with areas ranging from 25 mm2 to 50 mm2 were placed centrally within the solid-enhancing area of all meningiomas and peritumoural area if oedema was present. regions of interest were then automatically transferred to the apparent diffusion coefficient (adc), fractional anisotropy (fa), mean diffusivity (md), eigen values in 3 orthogonal directions (λ1, λ2 & λ3), relative cerebral blood flow (rcbf), relative cerebral blood volume (rcbv), mean transit time (mtt) and cerebral blood flow (cbf) using arterial spin labelling (asl) maps. regions of interest were copied onto the corresponding contralateral normal-appearing white matter (nawm) in each patient to obtain the adc, fa, md, λ1, λ2 & λ3, rcbf, rcbv, mtt and cbf (asl) values for the purpose of normalisation. linear coefficient (cl), planar coefficient (cp) and spherical coefficient (cs) values were calculated using the following algorithms: mr spectroscopy was interpreted using the ready view software and the metabolite peaks in different areas were recorded. statistical analysis the largest dimension of each meningioma was recorded. mean adc, fa, md, λ1, λ2 & λ3, rcbf, rcbv, mtt and cbf (asl) values were recorded in the lesion, peritumoural oedema and in the contralateral nawm. comparisons between solid-enhancing areas of typical and atypical meningiomas and corresponding contralateral nawm were performed with use of paired t tests. mean absolute values of adc, fa, md, λ1, λ2 & λ3, rcbf, rcbv, mtt and cbf (asl) of solid-enhancing areas and peritumoural oedema, as well as the distribution of tensor shapes of the solid-enhancing areas for the two tumour types were compared with the independent sample t test (two-tailed; unequal variance). microsoft excel and ibm statistical package for social sciences (spss) statistics version 26 software were used for statistical analysis, and p-values less than 0.05 were considered to indicate statistically significant differences. cut-off values were estimated using roc (receiver operator characteristic) curve analysis, where the differences were statistically significant. ethical considerations an application for full ethical approval was made to the institute ethics committee and ethics consent was received on 02 march 2019. the ethics approval number is aiimsrpr/iec/2019/246. all procedures performed in the study were in accordance with the ethical standards of the institutional ethics committee and with the 1964 helsinki declaration and its later amendments. written informed consent was requested from subjects who were willing to participate in the study. results of the 27 cases, 23 (85.2%) were typical meningiomas (grade i) and four (14.8%) were atypical meningiomas (grades ii or iii). among the 23 typical meningiomas, two were fibroblastic, nine were meningothelial, nine were transitional and three were unspecified types. among the atypical group, one was anaplastic, one was papillary and two were atypical meningiomas. the representative cases are demonstrated in figure 1, figure 2, figure 3 and figure 4. figure 1: images of a 40-year-old female who presented with headache. axial t2wi (a) demonstrates the typical hypointense appearance of a fibroblastic meningioma. the lesion reveals a high fractional anisotropy value (b), and lower relative cerebral blood volume (c) value. the patient underwent surgery and histopathological photomicrograph (d) indicated tumour comprised of sheets of spindle cells with indistinct cell boundaries (hematoxylin and eosin staining, ×10) confirming a fibroblastic meningioma. figure 2: images of a 42-year-old female who presented with headache. a well-defined globular extra-axial lesion is noted in the anterior right parafalcine location. the lesion shows homogeneous avid post-contrast enhancement (a), which is a typical feature of meningothelial meningioma. an enhancing dural tail is also demonstrated. the lesion appears homogeneously hyperintense on axial t2wi (b). adjacent brain oedema is seen appearing hyperintense on t2wi. the lesion shows high relative cerebral blood volume values (c). the patient underwent surgery and histopathological photomicrograph (d) illustrated tumour comprised of syncytia of epithelial cells with indistinct cell boundaries (hematoxylin and eosin staining, ×10) confirming the meningothelial subtype of meningioma. figure 3: images of a 20-year-old female who presented with bilateral hearing loss. a well-defined lobulated extra-axial lesion is seen in the left cerebellopontine angle region. the lesion is heterogeneously hyperintense on axial t2wi (a). it is causing mass effect on the 4th ventricle with resultant upstream dilatation of ventricular system. the dilated temporal horn of left lateral ventricle is seen on axial t2wi (a). the lesion shows heterogeneous post-contrast enhancement (b) which is a typical feature of transitional meningioma. low apparent diffusion coefficient values (c) are seen. the patient underwent surgery and histopathological photomicrograph (d) illustrated tumour comprised of syncytia of epithelial cells with prominent psammoma bodies confirming the transitional subtype of meningioma (hematoxylin and eosin staining, ×10). figure 4: images of a 62-year-old female who presented with dysphasia and difficulty in walking. a relatively well-defined lobulated extra-axial lesion was seen along the left temporal lobe. it revealed heterogeneous post-contrast enhancement (a). brain-tumour interface was indistinct at a few sites. the lesion demonstrated diffusion restriction on axial diffusion-weighted imaging apparent diffusion coefficient (adc) not included (b) and a high cerebral blood flow value on arterial spin labelling (c). after surgery, histopathological photomicrograph (d) revealed tumour comprised of syncytia of epithelial cells with brain invasion (hematoxylin and eosin staining, ×10) confirming the diagnosis of atypical meningioma. typical versus atypical meningiomas comparison between typical and atypical meningiomas based on various parameters is displayed in table 1. table 1: typical versus atypical meningiomas. tumour size and cbf (asl) were the two parameters that showed significant differences between the two groups. the longest dimension of each meningioma was recorded for analysis of their sizes. typical meningiomas had sizes ranging from 2.2 cm to 8.7 cm with a mean of 4.6 cm. atypical meningiomas had sizes between 5.2 cm and 12.7 cm with a mean size of 5.9 cm. the mean size of atypical meningiomas was significantly higher than that of typical meningiomas (p = 0.038, 95% confidence interval [ci]). using roc curve analysis, a size cut-off of 6.05 cm was determined to differentiate between the two entities with 75.0% sensitivity and 87% specificity. the differences in the mean cbf values of typical and atypical meningiomas were also statistically significant (p ≤ 0.05). receiver operator characteristic curve analysis yielded a cut-off value of 276.75, which could differentiate between typical and atypical meningiomas with 66.7% sensitivity and 75.0% specificity. there were no discernible differences between the two groups for any of the other criteria included in table 1. subtypes of typical meningiomas comparison between the different subtypes of typical meningiomas based on various parameters is displayed in table 2, and their group wise comparison for p-values and cut-off values is displayed in table 3. table 2: subtypes of typical meningiomas. table 3: comparison between different subtypes of typical meningiomas. mr spectroscopy of the 27 patients, mr spectroscopy yielded analysable results in 22 patients. among these 22 patients, 20 were typical meningiomas and two were atypical meningiomas. nineteen of the 20 typical meningiomas and both atypical meningiomas showed elevated choline. all the 22 cases demonstrated an alanine peak and another peak resonating at 3.8 ppm (possibly glutamate–glutathione complex). lipid was elevated in four cases (three typical and one atypical meningiomas). discussion several studies have attempted to differentiate meningioma grades and subtypes based on different mr parameters. however, none have compared the combination of dwi, dti and perfusion findings with histopathology. typical versus atypical meningiomas the average size of meningiomas in this study was 5.0 cm ± 2.2 cm compared with magill et al.’s report of 3.8 cm ± 1.8 cm.9 the mean size of atypical meningiomas (5.9 cm ± 0.7 cm) in this study was higher than that of typical meningiomas (4.6 cm ± 1.6 cm), and it was statistically significant (p = 0.038) with a cut-off value of 6.05 cm. one meningioma of the atypical type was 12.7 cm, which was considered as outlier for the statistical calculation of significance. this was histopathologically proven to be an anaplastic meningioma (world health organization [who] grade iii), which has a propensity for rapid growth as pointed out before in literature.9,10 ressel et al. also reported significantly larger sizes of atypical meningiomas compared to typical ones.10 magill et al. identified the size of 3.2 cm as a cut-off point for the risk of being an atypical meningioma.9 the difference of the cut-off size in our study from that reported by magill could be attributed to the limited number of cases. however, there is a difference in the mean size of the lesions of this study itself in comparison with that of magill et al. this could be attributed to the timing of presentation and reflects the impact of socio-economic backgrounds on the results of various studies. patients with milder symptoms may harbour lesions for a longer time and present with larger lesions, while patients reporting symptoms earlier may have smaller lesions. similarly, lesions located near eloquent areas of brain will manifest symptoms early. typical versus atypical meningiomas – advanced mri parameters the various advanced mri parameters that were used for assessment in this study were adc values, fa, md, λ1, λ2, λ3, cl, cp, cs, rcbf, rcbv, mtt and cbf (asl). the mean adc values of typical and atypical meningiomas in previous studies and this study are listed in table 4. table 4: a comparison between the mean and standard deviations of apparent diffusion coefficient values of typical and atypical meningiomas in previous studies and this study. in all the mentioned studies, the mean adc of atypical meningiomas is lower than that of typical meningiomas. this could be explained based on high cellularity, tumour matrices, fibrous or gliotic tissues, or a combination of these factors in atypical meningiomas. the ratio of intracellular to extracellular space determines the degree of water diffusion in biologic tissue and higher cellularity in atypical meningiomas may decrease the fraction of extracellular space, hence reducing net water diffusion.12 increased mitotic activity, prominent nuclei, small cells with an increased amount of intracellular complex protein molecules, high nucleus-to-cytoplasm ratio and necrosis in atypical and malignant meningiomas contribute to reduced free diffusion of water.17 however, a statistically significant difference could not be established in our study, contrary to the previously documented statistical differences.11,12,13,14,15,16 this could be due to small number of atypical/malignant meningiomas in this study. moreover, the adc values of meningiomas in this study was much lower than previous studies. one possible explanation could be that 9 of the 23 typical meningiomas were of the transitional subtype, which show lower adc values and hence, the lower mean adc.18 another possible reason could be the higher b-value (2500 s/mm2) used in this study. all other previous studies were performed at b-values of 1000 s/mm2. bano et al.16 also reported lower adc values at a higher b-value (2000 s/mm2). the mean fa values of typical and atypical meningiomas in previous studies and this study are listed in table 5. the mean fa value of typical meningiomas in this study was in line with those of toh et al.,7 jolapara et al.19 and aslan et al.20 the mean fa value of atypical meningiomas was similar to that of aslan et al.20 however, the differences were not statistically significant. table 5: a comparison between the mean fractional anisotropy values of typical and atypical meningiomas in previous studies and this study. except for wang et al.,21 all other studies (including this study) showed higher fa values in atypical meningiomas. microscopic analysis of typical meningiomas has shown that they consist of oval or spindle-shaped neoplastic cells that form whorls, fascicles, cords or nodules. these microstructural elements in typical meningiomas act as physical barriers and stop water molecules from flowing linearly. on the other hand, atypical meningiomas show patternless or sheetlike growths. hence, the water molecules travel more directionally in atypical meningiomas due to the absence of the physical barriers which are seen in typical meningiomas.7,20 the lack of a statistically significant difference between the two groups in this study may be due to the small number of cases in the atypical group. another possible explanation may be due to differences in the number of various subtypes of typical meningiomas. lower fa values in atypical meningiomas, as reported by wang et al.,21 could be explained by the increased number of fibroblastic meningiomas in their study. fibroblastic meningiomas have higher fa values,22 and hence, their mean fa value for typical meningiomas was higher relative to atypical meningiomas. the lack of statistically significant differences in this study is in line with the previously reported study by lin et al.11 however, toh et al.7, jolapara et al.19 and aslan et al.20 reported significant differences in fa values between the two groups. few previous studies had tried to differentiate typical and atypical meningiomas based on perfusion (only rcbv). in this study, in addition to rcbv, we have also assessed rcbf and mtt for comparison. the means of perfusion parameters of typical and atypical meningiomas in previous studies and this study are listed in table 6. table 6: a comparison between the mean perfusion parameters of typical and atypical meningiomas in previous studies and this study. in this study, we found higher rcbv values in typical meningiomas compared to atypical meningiomas. similar results were found by zhang et al.23 however, yang et al. found completely contrasting results showing higher rcbv values in atypical meningiomas.24 the intravascular indicator dilution theory of zierler forms the basis of the dsc perfusion mr imaging technique. it states that ‘in the absence of recirculation and contrast material leakage, cbv is proportional to the area under the contrast agent concentration–time curve’.23 extravasation of contrast agent following administration of gadolinium leads to t1 effects, which might corrupt the evaluation of first-pass enhancement during perfusion imaging. a normal blood–brain barrier is fairly impermeable to gadolinium chelates because of the larger size of the molecule. as extra-axial lesions are present outside the blood-brain barrier, they are subjected to a substantial blood pool phase.25 further, the tortuous and immature intratumoural vessels may increase the amount of contrast material that leaks from vessels into the extravascular space.23 this results in t1 effects due to the pooling of contrast material. kimura et al. suggested: ‘another problem associated with dsc perfusion is artificially lowered cbf values due to the delay and dispersion of tracer bolus during passage from the large vessel to brain parenchyma’.26 hence, contrast perfusion techniques may not be accurate in extra-axial lesions.25 asl uses a diffusible intrinsic tracer (electromagnetically labelled arterial blood water) to yield measurements of cbf, whereas dsc perfusion uses intravascular non-diffusible contrast media to yield measurements of cbv. due to the constant exchange of water between tissue and capillary blood, asl alters the net magnetisation in the tissue, which depends on the amount of perfusion.26 this could explain the discrepancy between the assessment of cbf by dsc perfusion and asl. to the best of the authors’ knowledge, only two studies26,27 published in the english language have mentioned the use of asl for comparing different grades of meningiomas. the mean cbfs of typical and atypical meningiomas were 161.09 ± 87.04 and 286.70 ± 8.06, respectively, and the difference between the two was statistically significant (p = 0.0000141). receiver operator characteristic curve analysis suggested a cut-off value of 276.75 to differentiate between typical and atypical meningiomas with 66.7% sensitivity and 75.0% specificity. higher cbf in atypical meningiomas could be explained based on their higher metabolic activity. perfusion mri detects the vascularity within a tissue and indirectly measures the tissue metabolic activity, since vasculature controls perfusion to fulfil metabolic demands of tissues.28 of the 27 patients, mr spectroscopy yielded proper results in 22 patients. twenty of these 22 cases, showed elevated choline and reduced naa. this was similar to the results of kinoshita et al.29 all the 22 cases revealed an alanine peak, which is considered the spectroscopic signature for meningiomas.30,31,32 another distinct chemical compound resonating at 3.8 ppm peak was seen in each of the 22 cases. kousi et al.33 reported that ‘this chemical substance observed at 3.8 ppm in short te, might represent a glx-a peak or glx together with glutathione’. tugnoli et al.34 identified in their ex vivo study that ‘the peak at 3.8 ppm receives contribution from phosphoethanolamine (pe) and amino acids, such as leucine, alanine, glutamate, glutamine, glutathione, lysine, arginine and serine’. thus, in this study the peak at 3.8 ppm seen in all the cases could represent this glutamate–gluthathione complex. no significant difference was found in the perilesional oedema associated with the two groups in this study. this suggests that brain oedema associated with meningiomas is possibly vasogenic in origin rather than due to tumour infiltration. however, zikou et al.28 and zhang et al.23 had found significantly higher mean rcbvs in the peritumoural oedema of atypical rather than benign meningiomas. these studies suggest a possibility of tumour infiltration into the perilesional oedema and/or higher peritumoural vascularity in higher grade meningiomas. differentiating between subtypes of typical meningiomas among the 23 typical meningiomas, two were fibroblastic, nine were meningothelial and 9 were transitional type. three were unspecified. most (seven out of nine) of the meningothelial meningiomas were homogeneous in appearance, which is the usual appearance.17 one of the fibroblastic meningiomas was hypointense on t2-weighted imaging, which is characteristic of fibroblastic meningiomas.35 of the transitional meningiomas 77.8% (seven out of nine) showed heterogeneous post contrast enhancement, a classic feature of transitional meningioma.35 though diffusion restriction has been considered a feature of atypical meningiomas,35 we found 88.9% (8 out of 9) transitional meningiomas showing diffusion restriction in this study. it was also seen in 66.7% (6 out of 9) meningothelial meningiomas. hence, diffusion restriction may not be used as a criterion to differentiate typical and atypical meningiomas. the mean adc values of subtypes of typical meningiomas in a study by hakyemez et al. were fibroblastic: 1.29 ± 0.28; meningothelial: 1.09 ± 0.20; transitional: 1.19 ± 0.07, whereas in this study, they were 0.76 ± 0.15, 0.73 ± 0.09 and 0.66 ± 0.07, respectively. in this study, lower adc values were seen in transitional meningiomas as compared to meningothelial meningiomas. transitional meningiomas have a combination of fibrous and meningothelial tissue.35 the fibrous component of transitional meningioma can reduce the fraction of extracellular space and hence result in diffusion restriction or reduced adc values. the mean fa values of subtypes of typical meningiomas in a previous study by tropine et al.22 were fibroblastic: 0.396 ± 0.070; meningothelial: 0.196 ± 0.056; transitional: 0.296 ± 0.036, whereas in this study, they were 0.30 ± 0.02, 0.20 ± 0.07 and 0.22 ± 0.07, respectively. mean fa value of fibroblastic meningiomas in a study by jolapara et al. was 0.471 ± 0.03. all these studies showed higher fa values in fibroblastic meningiomas. this higher anisotropy can be credited to the regular cellular organisation within these tumours, thus allowing water molecules to travel more directionally. whereas in meningothelial and transitional meningioma, the haphazard arrangement of cells contribute to isotropic diffusion and hence the relatively lower fa values.7,22 the mean rcbf and rcbv of fibroblastic meningiomas in this study were significantly lower than those of meningothelial meningiomas (p < 0.05). this is similar to the results of zhang et al.36 and kimura et al.26 this suggests that, among the subtypes of typical meningiomas, fibroblastic meningiomas have the lowest vascularity. in this study, the mean rcbv and cbf (asl) values of perilesional oedema associated with transitional meningiomas were significantly higher than those associated with meningothelial meningiomas. also, a higher incidence of perilesional oedema was seen with transitional meningioma. it was also observed that extensive brain oedema was associated with typical meningiomas with higher cbfs, most of which were transitional meningioma. based on this, a possible correlation between cbf and perilesional oedema could be suggested. surgical excision is the treatment for meningiomas. knowing the consistency of the tumour preoperatively can help in planning the surgery better.1 consistency of meningioma depends on tumour cellularity, water content and fibrous content, which in turn depends on the meningioma subtype.37,38 hyperintensity on t2wi correlates well with soft tumours, which may be attributed to higher water content and increased vascularity while the lower signal on t2wi for hard tumours might be due to less water, higher cellularity and more collagen and calcium.1,37,38 hard lesions show lower adc values and higher fa values. fibroblastic meningiomas are typically hard in consistency and appear hypointense on t2wi.37 they are associated with increased risk of postoperative cranial nerve deficits.38 chromosome 22q abnormalities are also more common in transitional and fibrous meningiomas.28 meningothelial, angioblastic or atypical meningiomas are hyperintense on t2wi.38 the meningothelial variant is associated with an activating e17k mutation in the akt1 gene, which can act as therapeutic targets of akt inhibitors, thus holding prognostic and future therapeutic implications.28 in case of a high-grade atypical meningioma, alterations in the planned size, shape and extent of a craniotomy can ensure clean margins by achieving complete resection.24 hence, preoperative diagnosis of meningioma grade and subtype can help in better risk–benefit assessment, predict length of operating time, expectations regarding the extent of resection and the likelihood of need for adjuvant therapy, all of which can be very helpful in patient counselling regarding surgical outcome. limitations of the study the patients included were by purposive sampling in a hospital setting. therefore, the data are limited to patients with impairing/disabling symptoms and might not be totally representative of the findings in the patients with early stage lesions who do not report to the hospital. moreover, the sample size of 27 is small for an accurate depiction of such a wide variety of meningiomas and larger studies are needed for more definitive results. the number of high-grade meningiomas was very small, which may render these findings as less conclusive. less common subtypes of who grade i meningiomas such as angiomatous, microcystic, secretory and metaplastic meningiomas and other who grade ii meningiomas (i.e. chordoid and clear cell meningiomas) were not seen during this study period. conclusion advanced mri brain sequences proved to be useful in differentiating typical and atypical/anaplastic meningiomas as well as in the subtyping of typical meningiomas. the tumour size and asl perfusion were the two parameters, which could differentiate between typical and atypical meningiomas. atypical meningiomas have higher size and cbf values as compared to typical meningiomas. adc, fa, rcbf and rcbv are crucial in distinguishing different subtypes of typical meningiomas. transitional meningiomas have lower adc values while fibroblastic meningiomas have higher fa values and lower vascularity (rcbf and rcbv). considering the wide variety of meningiomas, studies with a larger sample size can be conducted to elucidate their individual characteristics further. since, the incidence of higher-grade meningiomas is less frequent, multicentric studies may be conducted to collate an adequate sample of higher-grade meningiomas for a more definitive conclusion. identifying the grade and subtype non-invasively can help in proper planning of treatment and improve clinical outcomes. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions all the authors have contributed to the study. m.p. collected the radiological data, analysed the findings as a part of his dissertation and contributed in manuscript preparation; n.k.b. contributed towards conceptualisation of the study, interpretation and analysis of the findings and the result, manuscript preparation and editing; s.k.p. contributed towards the interpretation of radiological data and manuscript editing; n.h. contributed towards interpretation of the histopathological data and manuscript editing; a.k. sharma contributed towards the collection of operative data and its interpretation and manuscript editing; a.k. shukla contributed towards the overall statistical analysis of the data of the study and manuscript editing. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data supporting the findings of this study are available from the corresponding author, n.k.b. disclaimer the views expressed in this article are of the author’s own and not an official position of the institution or funder. references alyamany m, alshardan m, jamea a, elbakry n, soualmi l, orz y. meningioma consistency: correlation between magnetic resonance imaging characteristics, operative findings, and histopathological features. asian j neurosurg. 2018;13(2):324. https://doi.org/10.4103/1793-5482.228515 claus 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shrivastava rk. can mri predict meningioma consistency?: a correlation with tumor pathology and systematic review. neurosurg rev. 2018;41(3):745–753. https://doi.org/10.1007/s10143-016-0801-0 today's two signs today's two signs 68 sa journal of radiology • september 2007 today's two signs the ‘fat’ c2 refers to the apparent increase in the distance between the anterior and the posterior margins of the c2 vertebra when compared with the similar two margins of the c3 vertebrae (fig. 1) on a lateral cervical spine x-ray in a trauma setting.1 this is caused by an obliquely oriented fracture which may be obscured on anteroposterior or lateral film as the fracture lines are not perpendicular to the plane of the radiograph (fig. 2). the applied traumatic forces may cause the interruption of the anterior (with primarily hyperflexion injury) and posterior (with primarily hyperextension injury) or both (combined injury) margins with apparent enlargement of the c2.2 the recognition of fat c2 sign is important as these fractures are unstable with ligamentous disruption.2 delay in diagnosis may be devastating to the patient. 1. smoker wrk, dolan kd. the ‘fat’ c2: a sign of fracture. ajr 1987; 148: 609-614. 2. harris jh, mirvis se. injuries of diverse or poorly understood mechanisms. in: the radiology of acute cervical spine trauma. 3rd ed. baltimore, md: williams & wilkins, 1996; 421-472. the ‘fat’ c2 sign amarjit kaur bajwa, mb bs, fcrad (diag) sa anthony briede, mb bch, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg flowing blood causes a ghosting artifact in the phase-encoding direction. gradient recalled echo (gre) sequences are much more susceptible to flow artifacts than spin echo (se) sequences are.1 the use of saturation bands can decrease these artifacts. these can also be minimised using flow compensation or gradient moment nulling.1 however, this artifact can be used to diagnostic advantage. pseudoaneurysm or avascular lesion can be missed on magnetic resonance (mr) imaging even with iv contrast. surrounding haematoma of different stages can complicate the matter even further (fig. 1a). however the recognition of ghosting artifact in the phase-encoding direction in line with the lesion along with signal void on the standard se sequences are important clues to the diagnosis (figs 1b and 2). thus pulsation artifact can be used as a diagnostic clue, especially in musculoskeletal imaging where it is normally not that marked. 1. zhuo j, gullapalli rao p. mr artifacts, safety and quality control. radiographics 2006; 26: 275-297. fig. 1. the lateral cervical spine radiograph shows that the anteroposterior diameter measured between anterior and posterior margins of c2 is more than the same distance at c3 (there is no significant soft-tissue swelling present). fig. 2. axial computed tomographic (ct) scan of the same patient shows the oblique fracture not well appreciated on lateral film. the pulsation sign amarjit kaur bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg pg68-69.indd 68 9/17/07 8:56:12 am today's two signs today's two signs 69 sa journal of radiology • september 2007 fig. 1a. patient with a few months’ history of an enlarging mass in the right thigh. sagittal t1 shows a complex cystic mass with a central signal void (arrow). fig. 1b. post contrast axial t1 shows central minimal enhancement (arrow) and the pulsation artifact in the phase-encoding direction (ap) indicating the vascular origin of the lesion (thick arrows). fig. 2. ct angiography with sagittal multiplanar reconstruction confirms a pseudoaneurysm of the profunda artery (arrow). pg68-69.indd 69 9/17/07 8:56:12 am abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) lene merbold department of oral and maxillofacial pathology, faculty of health sciences, university of pretoria, pretoria, south africa chané smit department of oral and maxillofacial pathology, faculty of health sciences, university of pretoria, pretoria, south africa jason ker-fox private statistician, cape town, south africa andre uys department of anatomy, faculty of health sciences, university of pretoria, pretoria, south africa citation merbold l, smit c, ker-fox j, uys a. the radiologic progression of ameloblastomas. s afr j rad. 2023;27(1), a2668. https://doi.org/10.4102/sajr.v27i1.2668 original research the radiologic progression of ameloblastomas lene merbold, chané smit, jason ker-fox, andre uys received: 22 feb. 2023; accepted: 20 apr. 2023; published: 31 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: in developing countries, many diagnosed cases of ameloblastoma (ab) have a significant delay in receiving treatment because of patient factors and healthcare facility constraints. objectives: the radiologic progression of abs with delayed treatment was analysed using panoramic radiographs and cone-beam computed tomography imaging. method: histopathologically confirmed cases of ab with follow-up radiographs indicating no treatment were retrospectively reviewed over a study period of 10 years. fifty-seven cases with 57 initial and 107 follow-up radiographs were included. each follow-up radiograph was analysed for changes in borders, locularity, effects on surrounding structures and lesion size. results: there was a general increase in poorly-demarcated lesions, with seven cases transforming from an initial unilocular to a multilocular appearance. at follow-up, there was an increase in cortical thinning and cortical destruction. ameloblastomas presented with a three-fold increase in average size from the initial to follow-up visits. regression analysis showed a statistically significant relationship between lesion duration and length (p = 0.001). a statistically significant relationship existed between duration and overall lesion dimensions when only the first and last observations per patient were used (p = 0.044). conclusion: considering the aggressive nature and unlimited growth potential, abs with delayed treatment may show extensive growth, complicating their eventual management. contribution: this study aimed to raise awareness of the importance of the timeous management of patients with ab by highlighting the detrimental effects of delayed treatment. keywords: ameloblastoma; delayed treatment; neoplasm; maxillofacial radiology; benign odontogenic neoplasm; progression. introduction ameloblastoma (ab) is a benign odontogenic neoplasm arising from epithelial remnants of the dental lamina.1 the aetiopathogenesis of abs has not yet been fully elucidated, but mutations in the genes involved in the mitogen-activated protein kinase (mapk) pathway have been implicated in 90% of abs.2 clinically abs present as slow-growing, painless, expansile masses that can exhibit accelerated growth.1 facial swelling and asymmetry may arise because of tumour enlargement over time. intra-orally, malocclusion, ill-fitting dentures and teeth mobility may occur,3 with advanced cases showing restricted mouth opening, difficulty with mastication and airway obstruction.1 although infrequent, pain, paraesthesia and pathologic fractures may be accompanying signs and symptoms.4 because of the asymptomatic nature, patients often only seek medical care when a facial deformity is noticeable.5 the treatment of ab is controversial. there are two main surgical approaches, namely conservative and radical. the former involves enucleation, curettage or cryosurgery of the bony cavity,5 while radical surgery includes surgical resection with 1 cm – 2 cm clear bony margins. the margin marked for resection is defined as the distance from the radiologic margin predicted to be disease free.6 this is recommended because of the bony infiltration of neoplastic cells beyond the radiologic margins.6,7 patients who receive conservative treatment have a higher propensity for recurrence (90%) than those who receive radical treatment (5%).8,9 post-operative follow-up for all ab cases is critical as over 50% of recurrences can occur 5 years post-treatment, with some presenting as early as 2 years after surgical intervention.5 because of high recurrence rates and the possibility of malignant transformation,8 the current treatment of choice is radical wide surgical excision.8,10,11 exceptions to this treatment approach are the luminal and intraluminal variants of unicystic abs, which may be managed with conservative treatment.6 radical surgery is frequently performed in a single-stage procedure to restore normal function, aesthetics and to decrease hospital inpatient stay.12 in developing countries, patients with abs often present with lesions reaching a considerable size before seeking care.13 considering the unlimited growth potential, delayed treatment of abs may show extensive and progressive growth, complicating their management.9 ultimately, if abs are delayed in treatment, they can continue to enlarge, leading to encroachment of anatomical structures, decreased function, closure of the airway, metabolic abnormalities and can, in rare instances, be fatal.6 the aim of the study was to analyse the radiological progression of abs, analysed on follow-up panoramic radiographs (prs) and cone-beam computed tomography (cbct) imaging. this study aimed to raise awareness of the importance of the timeous management of patients with ab by highlighting the detrimental effects of delayed treatment. research methods and design all histopathologically confirmed cases of ab with follow-up radiographs consisting of prs and/or cbct images were retrospectively reviewed over a 10-year period (2012 to 2021). accordingly, diagnosed cases from the department of oral and maxillofacial pathology were searched on the radiographic database within the section of diagnostic imaging. for the purpose of this study, abs with delayed treatment included cases with follow-up radiographs showing no radiologic signs of treatment for the tumour. teeth lost because of extraction, mobility or tumour expansion was not considered as treatment. during the 10-year study period, a total of 781 cases of ab were histologically diagnosed within the department of oral and maxillofacial pathology. external referral cases were excluded from the current study because the radiographs were not on the hospital’s digital radiographic database. in other instances, no follow-up radiograph could be detected, and the patient was therefore deemed lost to follow-up. cases with significant positioning errors on the prs were excluded. lastly, cases that only had an initial and post-operative radiograph were excluded. a total of 724 cases were excluded, with 57 cases included in the final sample. the demographic information of included cases was collected from the patient’s hospital records. the radiologic features were analysed by two clinicians with experience in the field of maxillofacial radiology, with any disagreements resolved by consensus. panoramic radiograph examinations were analysed with cliniview© software for radiographs performed on the instrumentarium dental unit (orthopantomograph®/orthoceph® op200d/oc200d, finland) and sidexis© software for radiographs performed using sirona dental systems, orthophos xg, germany. these radiographs were performed using the manufacturer’s instructions for recommended exposure for adults and children. all pr measurements were corrected for magnification. all cbct images were performed on planmeca promax 3d (helsinki, finland) and were evaluated by the principal investigator using romexis software (romexis version 6.0.1.812). the exposure setting for each cbct scan differed based on the field of view and patient parameters. cone-beam computed tomography examinations do not exhibit magnification because of the isotropic reconstruction of the volumetric data. all images were viewed in a dimly lit room on a radiology reporting monitor (barco diagnostic monitor with two-megapixel resolution). each image was optimised for assessment by adjusting the sharpness, density and contrast. a standardised patient positioning and procedure is maintained for all prs at the institution. panoramic radiographs with significant positioning errors and dimensional aberrations were excluded from the evaluations. for the cbct measurements, the patient’s orientation could be standardised after acquisition. the medio-lateral head tilt was orientated in the coronal slice of the scan by aligning an imaginary line running from the crista galli to the midsagittal suture of the maxilla, parallel to the sagittal orientation line. the superior-inferior head tilt was orientated in the midsagittal slice by placing the imaginary line from the anterior to the posterior nasal spine parallel to the axial orientation line. a pr was reconstructed from the volumetric data based on this positioning. this was done by manually drawing the focal trough running from the condylar head on the right, following the central points corresponding to the curve of the mandible, to the contralateral condylar head. the focal trough’s widest setting was used, equating to 19.9 mm. for the radiologic analysis, lesions were classified as anterior (canine to canine region) or posterior (distal to the first premolar). the borders, locularity, density and effects on surrounding structures were analysed for each initial and all follow-up radiographs. lastly, the size was calculated by measuring the anterior-posterior, superior-inferior and medial-lateral dimensions. the anterior-posterior dimension was defined as the longest dimension of the lesion measured by a line running parallel to the inferior border of the mandible in millimetres (mm) on pr. on cbct imaging, this was measured at the greatest dimension on the axial slice. in cases where the lesion followed a curvilinear pattern in the mandible when both the anterior and posterior regions were involved, this measurement was done on the reconstructed pr. the superior-inferior dimension was defined as the highest dimension of the lesion measured by a line perpendicular to the inferior border of the mandible in millimetres (figure 1). on cbct imaging, this was measured at the widest dimension on the coronal view. the medial-lateral dimension was only assessed on cbct images and was defined as the widest dimension of the lesion measured by a line running perpendicular to the length as measured on the axial view (figure 2). calibration for the magnification of prs was performed for both software systems to have measurements comparable to the cbct unit. figure 1: size measurement of an ameloblastoma on panoramic radiograph at initial presentation (a) and after 17 months (b). the yellow line represents the inferior border of the mandible. the blue line represents the anterior-posterior dimension and the green line the superior-inferior dimension. figure 2: size measurement of an ameloblastoma on cone-beam computed tomography at initial presentation (a, b) and after 11 months (c, d). the blue line represents the anterior-posterior dimension, the green line the superior-inferior dimension, and the orange line the medial-lateral dimension. the data analysis was done in the form of descriptive analysis and confirmatory data analysis. a univariate frequency table was constructed for each categorical variable, showing the percentage breakdown and distribution of the cases according to the variable parameters. additionally, multivariate tables were constructed to highlight the interaction of categorical variables prior to determining the statistical significance thereof. the association between time (continuous variable) and the various radiologic features of abs (categorical variable[s]) was evaluated using the wilcoxon rank-sum test, along with the two-sample t-test being used as a reasonability check. correlations with a two-sided asymptotic significance (p-value) of less than 0.05 were deemed statistically significant. a linear regression analysis was done to determine the change in lesion dimensions over time. these tests aimed to assess whether there was any relationship between change in time and growth measured using the radiologic dimensions. the interand intra-examiner reliability for measurements was evaluated using the interclass correlation coefficient (icc) as the data consisted of continuous variables. to assess the reliability of evaluations, the principal investigator re-evaluated 25 cases with their follow-up radiographs after 1 month to assess the intra-examiner reliability. additionally, 15 randomly selected cases with their follow-up radiographs were evaluated by a second calibrated investigator in order to determine the inter-examiner reliability. ethical considerations the study was conducted following approval by the faculty of health sciences research ethics committee, university of pretoria (571 of 2021). all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. results table 1 summarises the main demographic features. the mean age of patients at initial presentation was 34 years (range: 7–79), with a peak incidence in the third and fourth decades of life. the sample included 26 males and 31 females showing a slight female predilection of 1:1.2. table 1: demographic features and location of the 57 untreated cases of ameloblastoma diagnosed over the 10-year study period. the location of included cases of ab showed that maxillary lesions (5.3%) were a rare finding. ameloblastomas had a mandibular predilection (94.7%), with 89.5% of all cases involving the posterior mandible. all available radiographs of the included cases were analysed and assessed per follow-up appointment (table 2). radiographic images available for assessment included 101 pr and 63 cbct examinations, of which 57 were initial radiographs, and 107 were follow-up radiographs. in total, approximately 1.9 follow-up radiographs were performed per patient. table 2: radiologic features of 57 untreated cases of ameloblastoma at initial presentation and follow-up. of the 57 patients in the study, none received treatment at the first follow-up, 19 received treatment after two follow-ups, nine after three follow-ups and four after four and/or more follow-ups. thus, 25 patients had not received treatment at the current institution during the study period. radiologically, baseline imaging (initial visit) revealed that most lesions had well-demarcated borders, followed by a focal loss in demarcation. during follow-up examinations, there was a general decrease in the percentage of well-demarcated lesions and an increase in poorly-demarcated lesions or lesions exhibiting a loss of demarcation. nine cases presented as well-demarcated lesions at baseline imaging with a subsequent change to poorly-demarcated lesions or lesions with a loss in demarcation at follow-up. most cases of ab presented with multilocular margins at baseline imaging. the internal density of abs was radiolucent in the majority of cases. during follow-up visits, the frequency of multilocular lesions increased. seven cases transformed from an initial unilocular lesion to an eventual multilocular appearance (figure 3). figure 3: (a) well-defined unilocular ameloblastoma with scalloped margins causing root resorption and tooth displacement at initial visit. (b) the same lesion after 41 months presenting with a multilocular appearance, an increase in size and more severe root resorption. the average size using the calculated volume was 85 024 mm3 at initial presentation and increased to 250 044 mm3 at the final follow-up visit. an increase in mean length, height and width from the initial to final visit was seen in most cases (figure 4). only five cases showed a slight decrease in size in certain follow-up appointments. figure 4: radiologic size measurement between baseline or initial imaging and subsequent follow-up appointments. the overall dimensions (volume) increased at each follow-up visit. the most common effects on surrounding teeth at baseline imaging were root resorption, tooth displacement and teeth loss. at follow-up visits, the associated loss of teeth in the vicinity of the lesion increased (figure 5). the most common bone effects at baseline imaging included cortical thinning, bony expansion and cortical destruction. a general trend was noted at follow-up visits, with an increase in all reported bone effects. additionally, inferior alveolar nerve, maxillary sinus and nasal cavity involvement increased at follow-up visits. cone-beam computed tomography imaging revealed an additional tooth and bone effect in 10% and 20% of cases, respectively, compared to pr alone. figure 5: ameloblastoma at initial presentation (a), 21 months follow-up (b) and 84 months follow-up (c). the lesion showed significant increase in size with loss of associated teeth. a regression analysis was performed to determine the change in lesion dimensions over time. although the physical measurements showed a definite increase in the lesion’s dimensions over time, no significant correlation existed between the change in time and the total radiologic dimensions (p = 0.7). there was also no statistically significant relationship for clinical predictors, such as age or gender in the change in abs’ radiologic features or dimensions. further regression analysis also showed no statistically significant correlation in length (p = 0.158) or height (p = 0.393) over time. however, the lower p-value found for length shows that length had a stronger correlation to duration compared to ‘overall dimensions’ and ‘height’. this implies abs with delayed treatment are also more likely to increase in length than height over time. regression analysis was also performed to determine the change in measurements between the initial and last visits. the height showed no statistically significant correlation (p = 0.1). there was a statistically significant correlation between duration and length (p = 0.001). the r-square value (0.26) showed that 26% of the variance in the dependent variable could be attributed to the independent variable. based on these findings, a predictive equation for change in length over time could be established for abs (change in length over time [mm] = 10.327 + 0.438 × duration [months]). finally, a statistically significant correlation existed between duration and overall lesion dimensions (volume) when using only the first and last observations per patient (p = 0.044). both interand intra-examiner reliability tests were carried out on the size measurements, with an icc (r) of > 0.8 for all metrics. this shows a strong correlation and a high degree of reliability for both the interand intra-examiner reliability tests. to quantify this further, the intra-observer mean difference was also computed as a percentage of the average. this test showed that the average variance was never more than 1%. discussion ameloblastoma is the most common benign odontogenic tumour in africa, with a prevalence of 0.5 per million patients.2,6,13 at the current institution, 12 130 head and neck lesions have been diagnosed over the study period, of which 781 were abs. this translates into a prevalence of 6.4% of all head and neck lesions. only 57 cases met the inclusion criteria and were included in the final analyses. for this study, ‘delayed treatment’ referred to cases not receiving conservative or radical surgical treatment for the tumour. most patients received treatment after the second follow-up appointment, after a mean duration of 21 months. at the time of study completion, 32 of the 57 patients had received treatment, two patients who formed part of the study population were still not treated, and 23 were lost to follow-up. the reasons for these cases having delayed treatment were likely multifactorial. firstly, constraints in healthcare facilities in a developing country mean that malignant cases get preference, with benign lesions only receiving treatment later. secondly, the other possibility may be patient constraints, including financial problems, transport difficulties, education or language barriers or inadequate knowledge regarding health issues.14 however, the current data indicates that this occurs in a minority of cases. ameloblastoma usually presents during the third to fifth decades of life with a mean age of 36 years (range: 10–90 years).3,4,9 ameloblastomas is rarely diagnosed in the first two decades, accounting for only 10% – 15% of all reported cases.3,5,15 these findings were mirrored in the current study, with 17.5% of cases seen in the first two decades of life. ameloblastoma shows a slight male predilection with a male-to-female ratio of 1.3:1.4 in the current study, a slight female predilection was found. females presented at a lower median age compared to males. this could be related to the opinion that females present earlier for treatment, as they are more health conscious.16 over 80% of abs are found in the mandible, with 70% of cases arising in the molar-ramus region, followed by the anterior mandible and posterior maxilla.3,5 involvement of the anterior maxilla is a rare finding.4,5 these presentations were mirrored in the current study. radiologically, ab has characteristic features, although not entirely pathognomonic.4 the most common presentation includes a well-demarcated, multilocular lesion with a honeycomb or soap-bubble appearance.5,17 unilocular presentations are less commonly found. in the mandible, margins are usually well-demarcated, corticated and occasionally scalloped. in contrast, abs in the maxilla exhibit poorly-demarcated margins, as the lesion tends to grow within, rather than expand the bone. the internal structure of the lesion is radiolucent, with radiopaque bony septa creating internal compartments. radiologically, there was a general decrease in the percentage of well-demarcated lesions and an increase in cases with loss of demarcation of lesion borders and poorly-demarcated lesions between follow-up examinations. this finding can be explained by abs’ aggressive nature and persistent growth, where cortical destruction becomes more common over time.18 the bony borders lose their demarcation as lesions show increased cortical destruction and soft tissue invasion. the more prolonged the treatment of abs is delayed, the more tissue infiltration is seen. of the four cases involving the maxilla, one was well-demarcated at initial presentation but changed to a loss in demarcation at follow-up. the other three cases all showed poorly-demarcated borders or a loss in demarcation. the current study showed a general decrease in unilocular lesions, with more lesions changing to an eventual multilocular appearance. this finding was also mirrored in other literature. a study by mariz et al. found that the lesions changed from a unilocular to a multilocular appearance in 10 of the 12 patients they examined (83%).19 ameloblastomas commonly cause root resorption, tooth displacement or impaction.3 these findings were mirrored in the current study. the current study found that root resorption, tooth displacement and the number of impacted teeth decreased over time. this could be explained by the increased number of teeth lost in the tumour area. the authors speculate that more teeth were removed near the lesion as time progressed. this could be linked to root resorption resulting in tooth mobility or displacement leading to malocclusion. bucco-lingual expansion with cortical perforation is a common finding in most abs.3,4,20 effects on the dentition include root resorption, tooth displacement or tooth impaction.3 ameloblastomas located in the posterior maxilla can result in encroachment of the maxillary sinuses and, in some instances, intracranial extension.20 the current study confirmed this effect with the most common bone effects at baseline imaging, including cortical thinning (98%), bony expansion (91%) and cortical destruction (81%). during follow-up imaging appointments, these effects all increased. bony margins are significant in treating abs6, with cases with cortical destruction complicating the attainment of tumour-free margins. cortical destruction also implies soft tissue infiltration, further complicating the treatment and reconstruction. in the mandible, displacement of the inferior alveolar canal by the tumour is a common finding. maxillary abs may cause displacement of the sinus membrane.4 this study also confirmed these findings, with increased inferior alveolar canal displacement (61% to 67%) and maxillary sinus or nasal cavity (4% to 17%) involvement in follow-up imaging visits. this implies that as time progresses, the involvement of critical anatomical structures increases, further complicating management. ideally, abs should be treated at the initial presentation, but this is not always the reality in developing countries with financial or economic constraints. only isolated studies offer any information about the growth of abs. ameloblastoma exhibits an aggressive growth pattern18 that is initially slow but accelerates later.21 because of this, it is challenging to determine the growth characteristics of ab. factors associated with a more rapid growth rate and poorer prognosis include maxillary abs, conventional abs, mural unicystic ab subtypes, older patients and suboptimal treatment.21 the current study found no clinical predictors, such as age or gender, for the change in the radiologic features or dimensions of abs. one study found that abs have an average annual growth rate of 40.4%. this was a much lower growth rate than other studies (88% per year) because these studies only predicted the growth rate by relying on patient information about when the lesions started.21 the average size using the calculated volume increased from the initial presentation to the final available follow-up radiograph. at each follow-up visit, there was a significant increase in the overall dimensions of the lesion. there was, however, no significant linear correlation between the change in dimensions or mass between individual follow-up visits. this implies that one cannot predict how an ab will grow or change between follow-up appointments and that abs do not grow linearly. ameloblastoma has been described as a benign tumour with intermittent growth.20 however, when the lesion dimensions were analysed from the first to the last visit, a statistically significant relationship was found over duration or time. the growth in length had the strongest significant correlation over time with a prediction of change in length over the duration. the overall dimensions or volume of lesions also showed statistically significant and predictive growth over time. there were exceptions in five cases that slightly decreased in size between certain follow-up appointments. this could be attributed to central necrosis in large tumours or compression of cystic spaces after extractions. limitations of the current study included the different imaging modalities used to compare the lesion size (prs and cbct images). in addition, because of the study’s retrospective nature, not all patients could be included in the study owing to lost information or inadequate radiographic examinations. limitations in the evaluation process were lesions with a loss in demarcation, which made accurate measurements difficult. an additional shortcoming was the follow-up periods of patients not being standardised. not all patients came for follow-up after the same period, meaning that the growth rate of these lesions was challenging to assess. lesion size estimation on prs is problematic because of unequal magnification in cases with positioning errors.22 using the teeth as references to assess variable magnifications between the left and right side in cases of ab should be considered unreliable, as the tumour may displace teeth in buccal or lingual dimensions depending on the growth pattern. stramotas et al.23 showed that linear measurements on pr are affected more when the occlusal plane is titled in a superior-inferior dimension. nonetheless, considering this limitation, the margin of error was still minimal, within 1 mm. this finding was also mirrored in a study by nikneshan et al.24 with the advent and routine utilisation of more modern imaging modalities, the usefulness of pr should not be disregarded as they help estimate invasion and root resorption at a relatively low radiation dose. in addition, ab size estimation has previously been assessed on pr to indicate ab growth.19,21 two-dimensional limitations of radiographs, such as distortion and superimposition, are negated using a superior three-dimensional imaging projection. cone-beam computed tomography scans are mandatory for three-dimensional lesion demarcation, including accurate assessment of relationships with skull structures.25,26 other tooth and bone effects were identified in 10% and 20% of cases, respectively, because of cbct imaging. this highlights the importance of cbct as an imaging modality in cases of ab. the lesion dimensions of cbct images may also be an inaccurate reflection if the head tilt is altered or not standardised between scans. therefore, the results of all imaging modalities should be interpreted with a background understanding of the physics and the limitations of the imaging modalities used. irrespective of these limitations, the other findings of the current study related to the changes in borders, cortication and locularity are insightful. conclusion this study is the first to report on the radiological progression of abs with delayed treatment within a large sample size. overall, the lesions increased in size with increased effects on the teeth, bone and surrounding structures. this may complicate the management of these patients as more extensive surgical and reconstructive procedures are necessary. these findings may assist clinicians in emphasising the need for early diagnosis and management of these patients because of the growth potential of these tumours. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions all the authors (l.m., c.s., j.k.-f. and a.u) have made substantive contributions to the article and assume full responsibility for its content; have made substantive contributions to the article; gave final approval of the version to be published; agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. funding information this research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. data availability the data supporting the findings in this study is available from the corresponding author, c.s., upon request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references el-naggar ak, chan jkc, grandis jr, takata t, slootweg pj. world health organization classification of head 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questionnaire 40 sa journal of radiology • february 2012 1. regarding the agger nassi cells, which is the incorrect statement? a. these are the most anterior ethmoid cells. b. they are extramural cells (not confined within the ethmoid bone) and extend anteriorly into the lacrimal bone. c. they are anterior to the anterior attachment of the middle turbinate to the skull base. d. in the sagittal plane, they are located posterior and inferior to the frontal recess. 2. which one of the following statements is false? a. bulla ethmoidalis is a prominent anterior ethmoid air cell. b. its presence always leads to obstruction of the osteomeatal complex. c. the degree of pneumatisation may vary, and failure to pneumatise is termed torus ethmoidalis. d. haller cells are located below the bulla ethmoidalis and extend beneath the floor of the orbit. 3. which one of the following statements is false? a. the syndrome known as treacher collins, or franceschetti-zwahlen-klein, syndrome is a rare genetic disorder with an autosomal-dominant pattern of inheritance. b. the features are not noticeable at birth. c. this developmental disorder has an estimated prevalence of between 1 in 40 000 and 1 in 70 000 live births. d. there are various dysmorphic features and signs affecting the face, skull, ears, eyes, nose, mouth, throat and mental status. 4. which one of the following statements is false? a. in treacher collins syndrome, there are various dysmorphic features. among others, these include hypoplastic zygomas, downward sloping palpebral fissures, deficient mandibular rami and a cleft palate. b. auricular anomalies include malformed pinnae, abnormalities of the external auditory canal (stenosis or atresia), maldevelopment of the ossicles and absence of middle ear and tympanic spaces. c. the inner ears are usually grossly abnormal with neural hearing loss. d. although persons with mandibulofacial dysostosis usually have normal intelligence, developmental delay may occur if the hearing loss is not diagnosed. 5. which one of the following is true? a. acute acalculous cholecystitis (aac) is recognised to occur only in patients with serious comorbid illnesses such as after major surgery, severe trauma, burns, multiorgan failure, systemic sepsis and prolonged intravenous hyperalimentation. b. the development of aac in outpatients with none of the traditional risk factors,appears to be increasing, but only in japan. c. acute acalculous cholecystitis (aac) is acute inflammation of the gallbladder in the absence of gallstones. d. there have been several reports from south africa regarding the incidence of a spontaneous form of aac locally. 6. identify the one false statement among the following choices. a. spontaneous or primary cerebrospinal fluid (csf) fistula is a rare cause of csf rhinorrhoea. b. magnetic resonance imaging with high-resolution highly t2-weighted images is valuable in preoperative localisation and characterisation of the defect, particularly if a transnasal endoscopic approach is planned. c. the presence of csf rhinorrhoea often indicates the existence of an abnormal communication between the intracranial csf spaces and the nasal cavity or via the eustachian tube from a temporal bone fracture. d. the least common cause of csf rhinorrhoea is post-traumatic as a complication of a skull base fracture. 7. the following statements are true, except for: a. non-traumatic causes of csf rhinorrhoea make up only 3 4% of cases. b. spontaneous, or primary, csf fistula is a separate entity with no underlying cause for the csf leak. c. spontaneous leaks are more common in emaciated middle-aged men. d. the pathogenesis of lateral sphenoid cerebrospinal fluid fistula is thought to be due to a combination of embryological and acquired factors. 8. identify the false statement among the following. a. diffuse, severe beaten-copper pattern is an indicator of chronic elevated intracranial pressure, which is more common in patients with craniosynostosis. b. additional findings associated with a chronic increase in intracranial pressure include macrocrania, splitting of the sutures, skull demineralisation and erosion or enlargement of the sella turcica. c. the appearance is more frequent in children with complex, rather than simple, craniosynostosis. d. in children younger than 18 months, the presence of a diffuse copper beaten pattern on skull radiography, together with narrowing of the basal cisterns and obliteration of the anterior sulci, significantly decreases the likelihood of raised intracranial pressure. 9. identify the single false statement. a. prenatal ultrasound is the investigation of choice when screening for foetal abnormalities. b. in the third trimester, the sensitivity of ultrasound is maximal despite the ossification of the cranium and the relative size of the fetus compared with the volume of liquor. c. when an intracranial abnormality is detected on ultrasound specifically within the posterior fossa, a fetal mri is the next investigation of choice, to accurately characterise and diagnose the abnormality. d. disadvantages of mri include limitations due to fetal motion, poorer spatial resolution than ultrasound, cost, availability and lack of expertise. 10. identify the one false statement. a. the college of radiologists has been well positioned to take on the role of an independent examining body hosting a national ‘single-exit’ examination and has been awarded this responsibility. b. the college councils and examiner boards are made up of heads of department and examiners who hail predominantly from universities around the country. c. the strategic step of making a research component a prerequisite for registering as a specialist with the hpcsa lays to rest the argument of qualifying for government subsidies. d. the universities can now provide the infrastructure to produce mmed research that qualifies for an mmed degree, but not the government subsidy. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact ayesha charles on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/027/10/2011 give one correct answer for each question. sajr 656 mri diagnosis of alexander disease c g muralidharan, mb bs, md, dip nb (radiodiagnosis) r p s tomar, mb bs, md (paediatrics) m h jalandhar hospital, jalandhar, punjab, india   r aggarwal, mb bs, md (radiodiagnosis) a f hospital, halwara, punjab   corresponding author: c muralidharan (murali.cg@rediffmail.com) alexander disease (fibrinoid leucodystrophy; originally described by alexander in 1949) is a rare, fatal, nonfamilial leucoencephalopathy caused by astrocyte dysfunction characterised by missense mutation in the genes coding for glial fibrillary acidic protein (gfap). it typically presents with frontal preponderance of white matter abnormalities and macroencephaly. we report a case of leucoencephalopathy with macroencephaly that shows characteristic mri features of alexander disease. s afr j rad 2012;16(3):116-117. doi:10.7196/sajr.656 a 10-month-old term boy, firstborn of a non-consanguinous relationship, presented with a history of prolonged crying and seizures. no significant antenatal history was given, and the child had attained normal milestones until the age of 5 months, after which his development deteriorated. on examination, the head size was 55 cm (more than the 97th percentile for age of the patient). there were no signs or symptoms of raised intracranial tension such as vomiting, papilloedema etc. there was no normal eye contact, and global spasticity was noted. multiplanar imaging was done using t1 flair, t2 flair, and t2w fse sequences, and post-contrast sequences on a 1.5t high-definition magnetic resonance (hdmr) imaging system (ge signa excite 1.5t hd, usa). the mr study revealed bilaterally symmetrical confluent white matter hyperintensities on t2w images with frontal preponderance and involvement of the bilateral temporal and parietal lobes (fig. 1). the subcortical u fibres were involved. symmetrical bilateral hyperintensities on t2w images were also seen in external capsule, internal capsule, fornix, extreme capsule, corpus callosum and head of caudate nucleus. white matter expansion with resultant widened gyri was noted in the affected regions. all these regions were hypo-intense on t1w and t2 flair. a periventricular rim, t2 hyper, t1 hypointense, was seen along the lateral ventricles (figs 2a and 2b). the frontal lobes showed symmetrical areas of cavitation in the periventricular region (fig. 3). patchy symmetrical enhancement was noted in the periventricular rim and deep white matter of the frontal lobes (figs 4a and 4b). mr spectroscopy did not reveal raised n-acetylaspartate (naa) or myoinositol peak. based on these mr findings, a diagnosis of alexander disease was made. fig. 1. t2w image shows bilaterally symmetrical white matter hyperintensities with frontal predominance and involvement of heads of the caudate nuclei. fig. 2. t1w image (left) and t2w image (right) show a periventricular rim, hyperintense on t1w and hypointense on t2w, with cystic cavitation in the frontal periventricular region. fig. 3. t2w image shows bilaterally symmetrical cystic cavitation in the deep frontal and periventricular white matter. fig. 4. post-contrast t1w images show symmetrical enhancement of the periventricular rim, deep frontal white matter and heads of the caudate nuclei. discussion alexander disease (fibrinoid leucodystrophy), originally described by alexander in 1949,1 is a rare, fatal, nonfamilial leucoencephalopathy caused by astrocyte dysfunction characterised by missense mutation in the genes coding for glial fibrillary acidic protein(gfap).2 the disease is classified into 3 types: • cerebral alexanders (type 1), which primarily has an infantile onset with the presence of seizures, psychomotor developmental retardation, macrocephaly and abnormalities in the superior frontal cerebral white matter observed in a brain mri • bulbospinal alexanders (type 2), which primarily has an adult onset with the presence of muscle weakness, hyperreflexia, bulbar or pseudobulbar symptoms, signal abnormalities and atrophy observed in an mri of the medulla oblongata and upper cervical spinal cord • intermediate form (type 3) which has the characteristics of both the preceding.3 the mr imaging patterns of alexander disease have been described to be quite specific, dissimilar from patients observed in other white matter abnormalities either of known4 or unknown origin. five criteria were described by van der knaap et al;4 our patient met 4 of them, with the additional finding of rarely described periventricular cavitation/cysts.6 various differential diagnoses that were considered included canavan disease, which is characterised by a combination of macroencephaly, extensive cerebral white matter changes (without frontal preponderance) and basal ganglia abnormalities.5 however, contrast enhancement does not occur in canavan disease, and the typical raised n-acetyl aspartate (naa) peak on mr spectroscopy was absent in our patient. traditionally, biopsy was necessary to diagnose the disease, but diagnosis can now be made by mr imaging, using the criteria defined by van der knaap et al.4 additional confirmation can be obtained via genetic testing of a blood sample for missense mutation in the gene encoding for gfap.   1. alexander ws. progressive fibrinoid degeneration of fibrillary astrocytes associated with mental retardation in a hydrocephalic child. brain1949;72:373-381. 1. alexander ws. progressive fibrinoid degeneration of fibrillary astrocytes associated with mental retardation in a hydrocephalic child. brain1949;72:373-381. 2. quinlan ra, brenner m, goldman je, messing a. gfap and its role in alexander disease. exp cell res 2007;313:2077-2087. 2. quinlan ra, brenner m, goldman je, messing a. gfap and its role in alexander disease. exp cell res 2007;313:2077-2087. 3. yoshida t, nakagawa m. clinical aspects and pathology of alexander disease, and morphological and functional alteration of astrocytes induced by gfap mutation. neuropathology 2011; nov 28:1440-1789. [epub ahead of print] 3. yoshida t, nakagawa m. clinical aspects and pathology of alexander disease, and morphological and functional alteration of astrocytes induced by gfap mutation. neuropathology 2011; nov 28:1440-1789. [epub ahead of print] 4. van der knaap ms, naidu s, breiter sn, et al. alexander disease: diagnosis with mr imaging. am j neuroradiol 2001;22:541-552. 4. van der knaap ms, naidu s, breiter sn, et al. alexander disease: diagnosis with mr imaging. am j neuroradiol 2001;22:541-552. 5. ball ws, egelhoff jc, jones bv, et al. metabolic, congenital, neurodegenerative and toxic disorders. in:clinical magnetic resonance imaging, 3rd ed. edelman rr, hesselink jr, eds. philadelphia, usa: saunders, 2006:1656-1704. 5. ball ws, egelhoff jc, jones bv, et al. metabolic, congenital, neurodegenerative and toxic disorders. in:clinical magnetic resonance imaging, 3rd ed. edelman rr, hesselink jr, eds. philadelphia, usa: saunders, 2006:1656-1704. 6. klein ea, anzil ap. prominent white matter cavitation in an infant with alexander’s disease. clin neuropathol 1994;13:31-38. 6. klein ea, anzil ap. prominent white matter cavitation in an infant with alexander’s disease. clin neuropathol 1994;13:31-38. sajr 761 an unusual case of intrahepatic portosystemic venous shunt p naidoo, mb bch, fcrad diag (sa); n maharaj, mb chb, fcrad diag (sa); v naidu, mb chb, fcrad diag (sa); j maharajh, mb chb, ffrad (d) sa, mmed rad (d) department of diagnostic radiology, nelson r mandela school of medicine, university of kwazulu-natal and king edward viii hospital, durban, south africa corresponding author: p naidoo (pumersh@hotmail.com) intrahepatic portosystemic venous shunts are rare vascular anomalies that may be detected in asymptomatic patients, given the recent advances in radiological imaging techniques. accurate shunt evaluation and classification can be performed with ultrasound and multi-detector computed tomography. we report an unusual case of an intrahepatic portosystemic venous shunt with an incidental finding of neurofibromata. s afr j rad 2013;17(2):57-58. doi:10.7196/sajr.761 a 29-year-old woman with known hypertension and schizophrenia presented with vague abdominal pain. biochemistry revealed increased gamma-glutamyl transferase (ggt) and alkaline phosphatase (alp) levels. ultrasound detected a plexus of vascular, serpiginous structures in the porta hepatis anterior to the portal vein, and a provisional diagnosis of hepatic vascular malformation was considered. computed tomography (ct) demonstrated a conglomerate of dilated vessels in the region of the porta hepatis with an intrahepatic portosystemic venous shunt, also known as a portal hepatic venous shunt, between the right portal vein and the middle hepatic vein (figs 1a and 1b). in addition, numerous well-defined low-density non-enhancing soft-tissue masses were noted in the pelvis. enlarged, scalloped anterior sacral foramina were observed consistent with neurofibromata (fig. 1c). fig. 1. (a) axial post contrast ct image demonstrating intrahepatic portosystemic venous shunt between the right portal vein and middle hepatic vein. (b) coronal post contrast ct image demonstrating communication between the right portal vein and the middle hepatic vein. (c) axial ct image showing several non-enhancing hypodense lesions in the pelvis with enlarged, scalloped anterior sacral foramina consistent with neurofibromas. discussion portal to systemic venous communications are classified as intrahepatic or extrahepatic.1 intrahepatic shunts are less common and occur between intrahepatic portal veins and systemic veins.2 extrahepatic communications may be present in patients with portal hypertension due to cirrhosis and other causes, with the shunt through collateral vessels. the pathogenesis of intrahepatic non-tumorous portosystemic shunts is controversial.1 some authors believe that the cause is congenital, owing to persistent vitelline veins and the sinus venosus.1-3 others believe them to be post-traumatic, iatrogenic or as a result of portal hypertension with varices caused by liver disease or infections.1 intrahepatic portosystemic shunts are usually discovered incidentally, or on presentation of complications such as hepatic encephalopathy. other complications include liver failure, cirrhosis, pulmonary arterial hypertension and metabolic abnormalities such as hypergalactosaemia and hyperammonaemia.2 , 4 park and other workers1 , 2 have characterised intra-hepatic portosystemic shunts into 4 morphological types: • single large shunt that connects the right portal vein to the inferior vena cava (ivc) (most common) • localised peripheral shunt in which one or more communications are found in a single hepatic segment • portosystemic shunt through a portal vein ‘aneurysm’ • diffuse and multiple communications between peripheral portal and hepatic veins in several segments. ultrasound of the abdomen usually reveals abnormal cystic or tubular, anechoic, serpiginous vascular structures communicating between portal venous structures and the systemic circulation.2 doppler ultrasound can confirm the vascular nature of the structures and calculate a shunt ratio (total blood flow volume in the shunt divided by the blood flow in the portal vein). it is thought that a shunt ratio greater than 60% should be corrected owing to the risk of complications.2 on contrast-enhanced ct, a rounded mass with strong homogenous enhancement is demonstrated, with abnormal communication between a portal vein branch and hepatic vein or ivc.1 mri would provide a similar appearance to ct, with the added advantage of mr venography. nuclear medicine can also be used to calculate the shunt ratio by portal scintigraphy following submucosal rectal injection of iodine-123 iodo-amphetamine.2 minimally symptomatic patients, as in our case report, may reasonably be followed up to detect hepatic encephalopathy and hepatocellular carcinoma.4 treatment may be necessary in symptomatic patients.1 options include transcatheter embolisation or surgical correction with liver transplantation as a last resort.2 neurofibromatosis type 1 (nf1) has a well-known association with vascular anomalies such as stenoses and aneurysms. oktenli et al. recorded a specific association between nf1 and intrahepatic portosystemic shunts.5 conclusion intrahepatic portosystemic shunts are rare vascular abnormalities that may incidentally be detected in asymptomatic patients. accurate evaluation of the shunt can be performed with modern advanced radiological imaging techniques. considering the many documented vascular anomalies associated with nf1, this case report supports the association between nf1 and congenital intrahepatic portosystemic venous shunts.5 1. tsitouridis i, sotiriadis c, michaelides m, et al. intrahepatic portosystemic venous shunts: radiological evaluation. diagnostic and interventional radiology 2009;15:182-187. 1. tsitouridis i, sotiriadis c, michaelides m, et al. intrahepatic portosystemic venous shunts: radiological evaluation. diagnostic and interventional radiology 2009;15:182-187. 2. gallego c, miralles m, marin c, et al. congenital hepatic shunts. radiographics 2004;24:755-772. [http://dx.doi.org/10.1148/rg.243035046] 2. gallego c, miralles m, marin c, et al. congenital hepatic shunts. radiographics 2004;24:755-772. [http://dx.doi.org/10.1148/rg.243035046] 3. lane mj, jeffrey rb, katz ds. spontaneous intrahepatic vascular shunts. ajr 2000;174(1):125-131. 3. lane mj, jeffrey rb, katz ds. spontaneous intrahepatic vascular shunts. ajr 2000;174(1):125-131. 4. konstas aa, digumarthy sr, avery ll, et al. congenital portosystemic shunts: imaging findings and clinical presentations in 11 patients. ejr 2011;80(2):175-181. [http://dx.doi.org/10.1016/j.ejrad.2009.12.031] 4. konstas aa, digumarthy sr, avery ll, et al. congenital portosystemic shunts: imaging findings and clinical presentations in 11 patients. ejr 2011;80(2):175-181. [http://dx.doi.org/10.1016/j.ejrad.2009.12.031] 5. oktenli co, gul d, deveci ms, et al. unusual features in a patient with neurofibromatosis type 1: multiple subcutaneous lipomas, a juvenile polyp in ascending colon, congenital intrahepatic portosystemic venous shunt, and horseshoe kidney. am j med genet 2004;127a:298-301. [http://dx.doi.org/10.1002/ajmg.a.30008] 5. oktenli co, gul d, deveci ms, et al. unusual features in a patient with neurofibromatosis type 1: multiple subcutaneous lipomas, a juvenile polyp in ascending colon, congenital intrahepatic portosystemic venous shunt, and horseshoe kidney. am j med genet 2004;127a:298-301. [http://dx.doi.org/10.1002/ajmg.a.30008] abstract introduction materials and methods results discussion limitations conclusion acknowledgements references about the author(s) polite tshalibe department of radiology, faculty of health sciences, rahima moosa mother and child hospital, university of the witwatersrand, johannesburg, south africa jacinta adrigwe department of radiology, faculty of health sciences, highveld hospital, university of the witwatersrand, johannesburg, south africa susan lucas department of radiology, faculty of health sciences, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa citation tshalibe p, adrigwe j, lucas s. clinicians’ perspective of picture archiving and communication systems at charlotte maxeke johannesburg academic hospital. s afr j rad. 2023;27(1), a2578. https://doi.org/10.4102/sajr.v27i1.2578 original research clinicians’ perspective of picture archiving and communication systems at charlotte maxeke johannesburg academic hospital polite tshalibe, jacinta adrigwe, susan lucas received: 29 oct. 2022; accepted: 15 mar. 2023; published: 10 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: picture archiving and communication systems (pacs) are now an established means of capturing, storing, distribution and viewing of all radiology images. the study was conducted in a quaternary hospital, charlotte maxeke johannesburg academic hospital (cmjah), part of the university of the witwatersrand teaching circuit, in south africa. objectives: to measure the clinicians’ perceived benefits and challenges of pacs. to document perceived views on how the current pacs can be improved. method: this was a cross-sectional observational study over a period of 5 months from september 2021 to january 2022 carried out at cmjah. questionnaires were distributed to referring clinicians with pacs experience. descriptive statistics was conducted. categorical variables were presented as frequency and percentages. the continuous variables were presented as means ± standard deviation. results: a survey with a response rate of 54% found the benefits most reported by clinicians were improved patient care, less time needed to review an exam, improved image comparison and consultation efficiency. with respect to perceived challenges, the unavailability of images at the bedside, problems with access and the lack of advanced image manipulating software were noted. the most frequent recommendations on improvements focused on the aforementioned challenges. conclusion: hospital-wide pacs was viewed beneficial by most clinicians. nonetheless, there are a few aspects that deserve attention to improve the functionality and access of the system. contribution: the findings will assist in future hospital or provincial-wide pacs deployment projects. keywords: picture archiving and communication systems (pacs); physicians; cross sectional studies; surveys and questionnaires; south africa; referral and consultation; clinician satisfaction. introduction picture archiving and communication systems (pacs) are now an established, recognised and appropriate means of digital image acquisition, archiving, distribution and viewing.1 the technology is unique in that it delivers the radiology diagnostic images and reports to the clinicians at the point of care.2 picture archiving and communication systems present an opportunity to eliminate film-based imaging.2,3 in the past, the means for capturing, storing and viewing medical images was the hard copy film. the last few years have seen a tremendous increase in the adoption of pacs in most radiology departments in south africa.4 the implementation of pacs began primarily in the private sector, with the public sector implementation of pacs significantly lagging behind because of lack of funding.4 currently, most public sector hospitals in south africa have a mini pacs limited to the radiology department. a hospital-wide pacs was first installed in 2016 at the charlotte maxeke johannesburg academic hospital (cmjah). the onsite-pacs network was set up by phillips architects, who configured the system connecting all the radiology imaging hardware, radiology and clinician workstations, using a software called isite. it has been well documented in the literature that hospital staff do not easily accept new technology unless they understand and embrace it fully.5 the focus of the present study was to evaluate the benefits and challenges clinicians perceived from the pacs at cmjah, 6 years post-implementation of the system. in addition, their views on how the system could be improved were documented. materials and methods study design a cross-sectional, observational, descriptive study design based on a questionnaire survey was followed. a pre-tested questionnaire used by jorweker et al.1 was adopted and modified to suit our local environment. a four-point likert scale and a categorical approach were used to elicit responses for the majority of statements. responses to statements ranged from 1 to 5: 1 (strongly disagree) to 4 (strongly agree) and 5 (neutral). some opportunities for open-ended questions were included. study setting the study population included referring doctors from different specialities who routinely referred patients to the radiology department for imaging. interns, medical officers, registrars and consultants were among them. further included were the registrars who had rotated through cmjah from other university circuit hospitals. radiologists and radiology registrars were excluded. the hospital is a quaternary government hospital situated in johannesburg, in the gauteng province of south africa. data collection data collection was performed over a 5-month period from 01 september 2021 to 31 january 2022. a sample size of 375 was calculated with the open source epidemiologic statistics calculator for public health6 using a power of 80% at 0.05 alpha with a 95% confidence interval. convenience sampling of the referring clinicians with pacs experience at the academic hospital resulted in the distribution of 682 questionnaires. the clinicians that responded were 372. the calculated response rate was 54.5%. two complementary methods of administering the questionnaire were employed: an online survey was used and hard-copy questionnaires were distributed at the time of academic meetings. for the online survey, a link was created and distributed to participants via e-mail. in both cases, participant information and consent sheets were distributed along with the survey questionnaires. data analysis for the online survey, data were collected on microsoft forms. data from the data collection sheets were entered into a microsoft excel spreadsheet. these data were imported into stata® version 15 (stata corp) for further analysis. descriptive statistics were conducted. data were grouped into categorical and continuous groups. categorical variables were presented as frequency and percentages. the continuous variables such as the years of using pacs were presented as means ± standard deviation (s.d.) or medians and interquartile range (if not normally distributed). as part of quality assurance, data cleaning processes included checking for duplicates, missing values, recoding and categorising variables. correlations between categorical data were assessed using the pearson’s chi-square or fisher exact test. pearson’s correlation was done and cronbach’s alpha was used to check the reliability and validity of the questions. the open-ended questions were analysed using a method of content analysis that determines the number of times certain qualities appear in a written text. in the context of this study, two coding units were used: words and themes. statistical analysis graphs of the results were generated. all statistical analyses were two-sided and p-values < 0.05 were statistically significant. for the purpose of using the 2 × 2 chi-square, the four-point likert scale was collapsed into two categories: disagree included strongly disagree and moderately disagree and agree included strongly agree and moderately agree. the degree of level of agreement was further categorised as follows: strong agreement: 75% – 100% moderate agreement: 50% – 74% minimal agreement: 25% – 49% little agreement: 0% – 24% results demographics the highest number of respondents were registrars, 194 out of 372 (52%). distribution of participants by speciality and position held are presented in figure 1 and figure 2. figure 1: distribution of clinicians by specialty (n = 372). figure 2: participants’ distribution according to position held and specialty. overall, the mean (s.d.) for using pacs by position held was 2.5 (1.03) years. consultant mean was 3.38 (0.93) years and interns had the lowest mean of 1.42 (0.75) years. when categorised to the nearest number, the majority had used pacs for 3 years composing 39% of the respondents, and only 3% had used pacs for 5 years. the distribution of participants by years of pacs experience is presented in figure 3. figure 3: chart of participants’ years of picture archiving and communications systems experience. the results showed that the majority of respondents accessed pacs for both reports and examinations. twenty-eight of the 54 (51.9%) interns accessed reports only, while 26 out of 54 (48.2%) accessed both reports and examinations. the majority of consultants 52 out of 53 (98%), medical officers 67 out of 69 (97%) and registrars 183 out of 194 (94%) accessed both reports and examinations. this was statistically significant with p-value = 0.001. the vast majority of the respondents accessed pacs from a hospital pc workstation 370 out of 372 (99.5%). survey results the reliability of the questionnaire was measured using cronbach’s alpha. the data is presented in table 1 and table 2. table 1: perceived benefits statement reliability tests. table 2: perceived challenges statement reliability test. perceived benefits most clinicians strongly agreed that pacs has reduced the length of patients’ stay at the hospital (83%), improved the ability for decision making regarding patient care (98%), enhanced patient care and service delivery (88%), reduced time taken to review an exam (98%), increased access to more exams than with film (99%), improved teaching of medical students and registrars (98%), improved consultation with other clinicians and radiologists (99%), and reduced the number of repeat examinations (97%). there was moderate agreement that pacs had improved clinicians’ efficiency (65%) (table 3). table 3: picture archiving and communication system survey results. of the nine benefit measures asked to clinicians with respect to their position held, there were no significant differences in terms of level of agreement with respect to: time taken to review an exam (p = 0.272), exams being accessed more frequently with pacs than with film (p = 0.114), impact of pacs on improved consultation with other clinicians and/or radiologists (p = 0.311), improved ability to make decision making regarding patient care (p = 0.343), reduced number of repeat exams (p = 0.075), enhanced patient care and service delivery (p = 0.075), improved teaching of medical students and registrars (p = 0.132), reduced length of patients’ stay at the hospital (p = 0.604). there was significant difference among respondents in the percentage agreement with respect to the impact of pacs on improved efficiency (p = 0.02) (table 4). table 4: perceived benefits survey results. perceived challenges the majority of clinicians strongly agreed that there was inadequate access to pacs workstations (80%) and mentioned inability to view images at the bedside using portable devices (96%). there was minimal agreement that there was inadequate workstation performance speed (25%), higher than acceptable downtime (26%), and the lack of system support availability (37%). there was little agreement that pacs had resulted in inadequate image quality (2%), that they had received inadequate pacs training (19%), that they had difficulty finding images in pacs when needed (1%), or that they had difficulty logging onto the pacs (8%) (table 3). of the nine indicators for measuring perceived challenges, only three indicators were perceived to be significantly different among clinicians with respect to position held. half of the interns (50%) agreed they received insufficient training, while only 19% of registrars, 7% of consultants, and 4% of medical officers felt this was the case (p = 0.001). the lack of availability of system support was identified by 50% of the interns, 44% of registrars, 22% of consultants and 21% of medical officers (p = 0.001). downtime being higher than acceptable was identified by 26% of consultants, 30% of medical officers, 29% of registrars and 9% of interns (p = 0.001) (table 5). table 5: perceived challenges survey results. open ended questions a total of 66 out of 371 (17.8%) clinicians responded to the open-ended question on additional comments on benefits and challenges. the total number of views expressed were 93. positive comments were 46, negative comments were 41, and non-relevant were 6. of the total number of views expressed (n = 93), 48% were focused on benefits, whereas 46% mentioned challenges. table 6 presents a summary of the comments expressed by respondents. taking into consideration that some respondents passed more than one comment in their response, the researcher determined if the views expressed were either negative or positive, and documented them as either a benefit or a challenge. table 6: summary of open-ended question comments (n = 93). access to pacs, whether in the clinic environment or in wards, was noted as a major challenge among 17.2% of respondents. this was followed by the lack of advanced image viewing software 9.7%, power outage related downtime 8.6%, and the lack of bedside access to pacs 5.4%. an open-ended question yielded respondents’ recommendations for improvements on the current system. a total number of 230 out of 372 (61%) responses were received from respondents (table 7). after subjective categorisation, the total number of views identified as recommended improvements was 466. the most frequent recommendations were: increase pacs access in wards, clinics and bedside with 157 out of 466 (37%), enable pacs access via portable devices with 143 out of 466 (31%), install advanced image viewing software 36 out of 466 (8%), introduce an online booking system integrated with pacs (7%), integrate systems with other hospital pacs or set up a provincial pacs system (5%), increase the number of pacs training workshops and technical support (5%), and offsite access to pacs (4%). table 7: proposed recommendations for picture archiving and communication systems improvement (n = 466). discussion patient care and service delivery the strong agreement response on improved patient care and service delivery compares with the high level of agreement observed in other studies. lenhart7 conducted a study on ‘pacs: acceptance by orthopaedic surgeons’ wherein she recorded 64% agreement that pacs improved patient care. there are no specific studies in the literature that specifically focus on the impact of pacs on improving patient care. it is difficult to come up with an objective measure for patient care. watkins8 concluded that there was no clearly discernible influence of pacs on clinical decision making; however, prompt access to images could have some beneficial impact. this is particularly the case in icu and the emergency department where immediate access to images is thought to be more critical in influencing further patient management. reduced hospital length of stay it can be hypothesised that prompt access to radiology reports and exams via pacs may result in prompt decision making and initiation of treatment, thereby reducing the patient’s length of stay. in a study conducted in saudi arabia evaluating pacs at three ministry hospitals by alalawi et al.,9 79% of the participants agreed with this statement. however, in another study evaluating the benefits of pacs, bryan et al.10 concluded there was no convincing evidence that pacs reduced the length of inpatient stay. this was further supported by a study conducted by macdonald et al.3 who concluded that the length of stay was not significantly impacted by pacs. they pointed out many external influencing factors to pacs such as clinician practice, hospital type and policy, and patient comorbidities. although our local clinicians communicated a reduced hospital stay with pacs, examples of some external factors include the following: charlotte maxeke johannesburg academic hospital is overburdened by many emergency cases resulting in a lack of availability of high care or intensive care unit (icu) beds which further delays scheduling of some major elective cases that require post-operative admission to these units. some of the equipment required for surgical procedures is outsourced from private companies, for example, the equipment for neuro-monitoring and neuro-navigation; however, if these companies are completely booked, there may be a delay in the scheduling of neurosurgical procedures, increasing the hospital length of stay. consultation with other clinicians and impact on efficiency the authors expected pacs to reduce the interaction between clinicians and radiologists due to the availability of images and reports at multiple sites within the hospital. this study’s results strongly supported this argument: 98% of clinicians agreed that pacs had facilitated consultation among clinicians, and clinicians with radiologists. a limitation of the study is that consultations among clinicians themselves, and consultations between clinicians and radiologists were not separated. this question should have been split into two to specify the type of consultation. macdonald et al.3 documented reduced in-site consultations with radiologists, and increased offsite consultations between radiology and clinicians in a provincial pacs-based system study. there was moderate agreement of 66.4% that pacs had increased offsite consultations. redfern et al.11 supported the notion that the availability of pacs stations at clinical areas would lead to decreased consultations with radiology. most clinicians suggested they saved time by no longer consulting with the radiology department to view images and/or reports. the radiology exams were readily available at multiple clinician workstations immediately after the images were acquired. treatment planning could commence prior to the patient’s return from the radiology department. this benefit was particularly observed in the emergency medicine and trauma units. impact on academic teaching regarding the impact of pacs on the teaching of medical students and registrars, there was moderate agreement of 67% that there was an improvement. these results correlate with the study by jorwerkar et al.1 where 51% of the respondents were in agreement. picture archiving and communication systems are valuable for teaching due to the ease with which images can be compared, the convenience with which exams can be archived for use in teaching, and the ease with which image quality may be manipulated. perceived challenges the challenges most often cited were the inability to view the images at the bedside, the lack of portable device access, and few available viewing stations. while this limitation could be a gap in the implementation plan, it must be analysed within the context of what is practical in the hospital setting of interest. it would be costly to set up workstations at every bedside and in a public sector hospital in a lowto middle-income country, logistically near impossible. theft of equipment was highlighted as a challenge by the pacs administrators. one practical solution would be for clinicians to access pacs from their portable devices (tablets, laptops and mobile phones). this would reduce the capital cost of deploying more workstations. image quality and performance (speed) although image quality assessment is subjective and dependent on the viewing platform, the majority of the respondents were satisfied with the image quality. only 2% of respondents stated that pacs produces inadequate image quality. although entry level clinician workstation monitors are not held to the strict quality control standards of dedicated diagnostic display units used for formal radiology reporting, recent technological advances yield these monitors sufficient for general hospital-wide image review. mobile device technology has certainly matured significantly for use by radiologists in the on-call, hospital offsite setting and by doctors at the bedside or in the operating theatre.12 slow image retrieval can be attributed to network speed which is more of an information technology (it) support issue, although no formal assessment of this factor was done. furthermore, the recent electricity supply challenges faced by the country affected the network connectivity and speed. system support and training insufficient pacs training was reported by 24% of responding clinicians, and 36% agreed that they experienced a lack of system support from pacs administrators. although 20% – 40% of the respondents did not constitute a majority, this nonetheless suggests there are training and support issues to be addressed. picture archiving and communication systems administrators conduct two training workshops every year, however, the turnout of clinicians during these pacs training workshops is usually low. this could in part explain why some clinicians felt that they did not receive adequate training. a limitation of the study is the fact that the roles of it support and pacs administrators were not distinguished when it came to system support. improvements the most frequent recommendations 320 out of 466 (68%) were related to pacs access. very few clinicians were aware that pacs can be accessed via portable devices (personal tablets, laptops and cell phones) from within the hospital. the hospital pacs is wired through a local area network (lan) and is web-based. the hospital already has the infrastructure to facilitate wireless connectivity to this network. devices to be connected to this network will need to be configured by the it department. some doctors opined that they were able to access laboratory results from their portable devices through internet connection; hence, the same technology could be availed for pacs access. one respondent commented that the network is very slow on portable devices. offsite access will be beneficial to clinicians who are on call as they will be able to view images in the comfort of their homes or call rooms. furthermore, this will benefit those who would want to access images for teaching purposes on virtual platforms. this will require an upgrade to a private cloud-based pacs which is more cost-effective, reliable and secure.13 off-site access to pacs is a challenge for onsite pacs systems due to security and privacy requirements; therefore, onsite pacs solutions have trouble transmitting secure data outside of their immediate area.14 contrarily, cloud pacs is designed for offsite access and providers follow stringent security and privacy guidelines.14 budget constraints, funding, current pacs vendor’s contractual obligations and government decisions may influence the hospitals’ decisions on which pacs system to upgrade to. few comments recommended the deployment of a provincial pacs (24 out of 466, 5%). this will significantly reduce the number of repeat exams, as well as the number of unnecessary patient transfers as a result of prior image review and consultations. the referring hospitals connected to cmjah pacs include berta gxowa, far east rand, sizwe and pholosong hospitals. at the time of writing, efforts were being made to connect leratong, helen joseph and yusuf dadoo hospitals. the downside of this connectivity is that it is one way, with only cmjah being able to access studies done from the connected hospitals. clinicians from referring hospitals are unable to access the cmjah pacs. the isite archive could not be integrated into the other hospital archives as they use different running software. these have different repository archives, architectures and data registry. charlotte maxeke johannesburg academic hospital has computers installed with software compatible with the referring hospitals, allowing it to access studies done at these hospitals. most clinician pacs workstations are equipped with basic image manipulating tools, which include zoom, panning, measure, window and level function. some clinicians highlighted the need to have more advanced hanging protocols and image manipulation tools similar to those found in the radiology pacs workstations. these include 3-d reconstruction, multiplanar reformation (mpr), virtual bronchoscopy, virtual colonoscopy and angiography post processing techniques for planning endovascular aneurysm repair. it is impractical to equip every clinician pacs station with advanced image viewing software due to the cost involved. the solution would be to customise the image viewing software according to speciality requirements. only 7% of comments referred to an online booking system for radiology exams. this recommendation came mainly from interns, medical officers and registrars. most of these respondents suggested this will increase their efficiency as they will spend less time going to the radiology department. from a radiology department perspective, physical bookings have the advantage of planning a patient’s imaging in consultation with the requesting clinician, which will aid coming up with the best modality suitable for the clinical question and ultimately reduce unnecessary bookings. telephonic discussions and online booking systems are compelling options to consider in the post-coronavirus disease 2019 (covid-19) milieu, where everything has moved to digital platforms and remote access. in this study, issues raised regarding downtime were specifically related to power cuts rather than routine scheduled maintenance. at the time of writing, south africa was experiencing severe power outages; this crisis is predicted to continue into the near future. connecting the entire pacs infrastructure to an uninterrupted power supply (ups) system was suggested as an option to mitigate downtime. the radiology department prints hard copy films for clinicians during pacs downtime. uninterrupted power supply (ups) connectivity will help minimise film printing costs. limitations the study was limited to a post-pacs implementation evaluation. to fully assess the impact of pacs on clinical practice, a study that involved the preand post-implementation would have been ideal. however, this was not feasible as there were few respondents from the pre-implementation era. despite a reasonable sample size, the response rate was low at 54%. at the time of writing, the hospital was only partially open due to ongoing renovations after a fire incident which forced the entire hospital to close in 2021. some departments were still not fully functional with their staff deployed to satellite hospitals. this could have contributed to the low response rate. only clinicians referring patients to the radiology department were included. the study excluded radiologists. hence, there is a need for further research to validate research findings by comparing outcomes of pacs users working in different environments. during data analysis, detailed information could have been lost by collapsing the four-point likert scale to two categories, which were ‘disagree’ and ‘agree’. conclusion the findings of this study provide overwhelming evidence that referring clinicians support the implementation of a hospital-wide pacs. the benefits of pacs, in particular reduction of repeat imaging, ease of comparison with previous imaging, image and report availability at multiple sites at any time and eliminating the scenario of lost films were seen as compelling rationale for the implementation of a hospital-wide pacs system. the main challenges raised regarded pacs access both at inpatient and outpatient environments, downtime and the lack of advanced image manipulating tools at clinician workstations. these issues were cited as major areas that need improvements for clinicians to fully realise the benefits of pacs. the case for switching to a cloud-based pacs system is strong given the acknowledged desire from clinicians for offsite access and the difficulties faced by cmjah with regard to equipment theft, few pacs access stations and frequent power outages. this study will serve as a benchmark for future hospital and provincial-wide pacs deployment projects in public hospitals. acknowledgements a special thanks to the cmjah pacs administrators for providing background information on pacs implementation. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions p.t. was the principal investigator responsible for the literature review, data collection and preparation of the manuscript. s.l. and j.a. were responsible for the research conception and supervision. ethical considerations ethical approval to conduct the study was obtained from the human research ethics committee (medical) of the university of the witwatersrand (approval number: m200606). informed consent was obtained from all individual participants involved in the study. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, p.t., upon request. disclaimer the views contained in this article are that of the authors and not of the institutions they are affiliated with. references jorwekar gj, dandekar kn, baviskar pk. picture archiving and communication system (pacs): clinician’s perspective about filmless imaging. indian j surg. 2015;77(suppl 3):774–777. https://doi.org/10.1007/s12262-013-0998-x hains im, georgiou a, westbrook ji. the impact of pacs on clinician work practices in the intensive care unit: a systematic review of the literature. j am med inform assoc. 2012;19(4):506–513. https://doi.org/10.1136/amiajnl-2011-000422 macdonald d, neville d, alaghehbandan r. referring physicians’ perceived benefits of pacs: a regional survey preand post-pacs implementation. radiol manage. 2011;33(4):46–54. moodley i, moodley s. a comparative cost analysis of picture archiving and communications systems (pacs) versus conventional radiology in the private sector. s afr j rad. 2015;19(1):7. https://doi.org/10.4102/sajr.v19i1.634 ahmadi m, mehrabi n, sheikhtaheri a, et al. acceptability of picture archiving and communication system (pacs) among hospital healthcare personnel based on a unified theory of acceptance and use of technology. electron physician. 2017;9(9):5325–5330. https://doi.org/10.19082/5325 dean a, sullivan k, soe m. openepi: open source epidemiologic statistics for public health, version. 2013. lenhart m, haueis a, schneider h, et al. [pacs: acceptance by orthopedic surgeons]. orthopade. 2010;39(10):994–1002. https://doi.org/10.1007/s00132-010-1616-2 watkins jr, bryan s, muris nm, et al. examining the influence of picture archiving communication systems and other factors upon the length of stay for patients with total hip and total knee replacements. int j technol assess health care. 1999;15(3):497–505. https://doi.org/10.1017/s0266462399015354 alalawi zm, eid mm, albarrak ai. assessment of picture archiving and communication system (pacs) at three of ministry of health hospitals in riyadh region – content analysis. j infect public health. 2016;9(6):713–724. https://doi.org/10.1016/j.jiph.2016.09.004 bryan s, buxton m, brenna e. estimating the impact of a diffuse technology on the running costs of a hospital. a case study of a picture archiving and communication system. int j technol assess health care. 2000;16(3):787–798. https://doi.org/10.1017/s0266462300102065 redfern ro, langlotz cp, abbuhl sb, et al. the effect of pacs on the time required for technologists to produce radiographic images in the emergency department radiology suite. j digit imaging. 2002;15(3):153–160. https://doi.org/10.1007/s10278-002-0024-5 o’connell tw, patlas mn. mobile devices and their prospective future role in emergency radiology. br j radiol. 2016;89(1061):20150820. https://doi.org/10.1259/bjr.20150820 koch p. benefits of cloud computing for pacs and archiving. radiol manage. 2012;34(2):16–19; quiz 21–22. intelerad. cloud pacs vs onsite pacs. which is best for your medical imaging solution? [homepage on the internet]. 2022 [cited 2022 oct 28]. available from: https://www.intelerad.com/en/2022/09/19/cloud-pacs-vs-on-premise-pacs/ abstract introduction case history discussion conclusion acknowledgements references about the author(s) monish g. karthikeyan department of radiodiagnosis, mahatma gandhi medical college and research institute, pondicherry, india poojitha ronda department of radiodiagnosis, mahatma gandhi medical college and research institute, pondicherry, india prabhu c. sugumaran department of radiodiagnosis, mahatma gandhi medical college and research institute, pondicherry, india citation karthikeyan mg, ronda p, sugumaran pc. factor xiii deficiency in a neonate presenting as subpial haemorrhage. s afr j rad. 2022;26(1), a2344. https://doi.org/10.4102/sajr.v26i1.2344 project research registration: project number: 23549 case report factor xiii deficiency in a neonate presenting as subpial haemorrhage monish g. karthikeyan, poojitha ronda, prabhu c. sugumaran received: 08 nov. 2021; accepted: 26 feb. 2022; published: 20 may 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract subpial haemorrhage is a rare cause of seizures in term neonates. a 3-day-old male infant, born at term with no history of perinatal hypoxia, presented with seizures and unremarkable physical examination in the interictal state. imaging demonstrated left temporal subpial haemorrhage with the classic ‘yin-yang sign’ on mri. the patient was subsequently diagnosed with factor xiii deficiency. follow-up at 6 months and 12 months revealed encephalomalacia in the previous haemorrhagic areas with normal developmental milestones. keywords: intracranial haemorrhage; subpial haemorrhage; term neonate; yin-yang sign factor xiii; ct; mri. introduction haemorrhagic stroke in neonates typically results in mild-to-severe long-term neurological disabilities.1,2 the commonly occurring haemorrhages are usually intraparenchymal and involve the region of the germinal matrix in preterms.1 extraparenchymal haemorrhages are rare and usually occur as a result of trauma but can also be non-traumatic, secondary to asphyxia, blood dyscrasias or vascular abnormalities and may even be spontaneous.3 few cases of subpial haemorrhage have been described in the literature due to their relative rarity, which is estimated at approximately 4% according to pathological reports.4,5,6,7 consequently, there is a relative paucity of knowledge regarding its aetiology, associated clinical manifestations and outcomes. the risk factors and pathophysiology of this entity are unique compared with other forms of extra-axial haemorrhage. this case report describes subpial haemorrhage in the left temporal region and the typical ‘yin-yang sign’ described in the recent literature in a term neonate presenting with seizures. there was also intraparenchymal and intraventricular extension at presentation. encephalomalacia of the previous haemorrhagic areas was evident at follow-up imaging six months later, but no breakthrough seizures or motor developmental delay was reported on follow-up after one year. case history a 3-day-old term male infant presented with seizures and lip-smacking. there was no fever nor any signs of recent trauma. the perinatal history was unremarkable, and the baby was delivered via spontaneous vaginal delivery. his older brother was 12 years old with no relevant medical history. there were two prior abortions – one spontaneously at the third month of gestation and another that was induced with mifepristone after the 45th day of amenorrhea. no identifiable cause was found for the prior spontaneous abortions. routine blood investigations revealed no significant abnormality with normal prothrombin time (pt), activated partial thromboplastin time (aptt) and international normalized ratio (inr), normal sepsis screen and negative cerebrospinal fluid (csf) culture. imaging was requested to determine the cause of the seizures. an initial ct scan indicated a large hyperdense localised extra-axial haematoma in the left temporal region with intraparenchymal and intraventricular extension and mild hydrocephalus. the underlying cortex was hypodense, likely reflecting ischaemic changes (figure 1). the mri performed later that day confirmed the findings with the subpial haemorrhage appearing hypointense and contrasting with the underlying hyperintense cortex on t2-weighted (t2w) and diffusion-weighted imaging (dwi), resembling the ‘yin-yang sign’ (figure 2a and b). the intraparenchymal and intraventricular extension demonstrated significant blooming on the gradient recalled echo (gre) sequence (figure 2c). there was also mass effect with mild midline shift to the right. magnetic resonance venography (mrv) was unremarkable. figure 1: axial ct brain. localised extra-axial hyperdensity in the left temporal region (red arrowhead) and left temporal lobe parenchymal hyperdensity (red star) representing subpial haemorrhage with intraparenchymal extension. the cortical hypodensity (white arrow) represents ischaemia. blood products also identified in the ventricular system (red curved arrow) with hydrocephalus and transependymal oedema (white curved arrow). figure 2: axial mri sequences. t2-weighted (a), diffusion-weighted imaging (dwi) (b), gradient recalled echo (gre) (c) and t1 weighted (d) reveal left temporal t2 hypointense subpial haemorrhage with blooming on gre. left temporal lobe intraparenchymal extension (star), intraventricular extension and hydrocephalus noted (curved arrow). the t2-weighted and dwi sequences demonstrate the classic ‘yin-yang sign’ of subpial hypointensity and underlying cortical hyperintensity (circled in red). the patient was diagnosed with subpial haemorrhage, and therapy with oral phenobarbitone was commenced. electroencephalogram (eeg) revealed spikes suggestive of generalised seizure activity. the baby improved symptomatically and was discharged after a week of observation with the recommendation for detailed clotting factor profile assays to exclude coagulopathies. results of the clotting profile revealed factor xiii deficiency. on follow-up examination at six months of age, microcephaly was observed with the head circumference two standard deviations below normal. however, there was no significant motor neurological deficit for this age nor any breakthrough seizures. mr imaging revealed extra-axial cystic changes in the left temporal region with no new haemorrhage (figure 3a and c). the underlying cortex demonstrated t1 hyperintensity with blooming on gre, suggesting cortical laminar necrosis (figure 3c and d). therapy with oral phenobarbitone was continued, as repeat eeg showed occasional seizure-like spikes of activity. figure 3: follow-up axial mri brain at 6 months of age. t2-weighted (a), diffusion-weighted imaging (dwi) (b), gradient recalled echo (gre) (c) and t1 weighted (d) demonstrate resolution of the subpial haemorrhage with cystic encepahalomalacia and haemosiderin staining (arrowhead). associated underlying temporal lobe volume loss (curved arrow). gyriform t1 hyperintensity and blooming on gre suggested left temporal cortical laminar necrosis with haemosiderin deposition (arrow). at the age of one year, the child had started walking with support and was able to articulate words expected for his age. there were no seizures nor any evidence of motor delay. the child continues follow-up and remains seizure free. discussion extra-axial haemorrhages are typically classified according to their location as subdural, subarachnoid or extra-dural. subpial haemorrhage is a rare entity and can be radiologically confused with subarachnoid haemorrhage. the pia mater is the innermost, highly vascular layer of the meninges covering the entire brain and the spinal cord. it invests both the brain and spinal cord until the conus medullaris, following which it tapers and forms the bulk of the filum terminale.8 the pial sheath in the perivascular spaces around the intracerebral arteries is in direct continuity with them in their subarachnoid course as well.9 a strong trabecular meshwork is present along the vessels in the subarachnoid space but is absent in the subpial space, which may result in increased fragility of the subpial vessels.4 subpial haemorrhage has been uncommonly documented and is usually ascribed to trauma or as part of child abuse – the ‘shaken baby syndrome’.10 the first cases of subpial haemorrhage were described in neuropathology specimens by friede in 1975 wherein he described them as dissecting underneath the pia mater without dissecting into the subarachnoid space or the neuroparenchyma. he thought it to be a variant manifestation of respiratory distress syndrome and assumed that it began with an injury to the superficial glial cells in the molecular layer of the cortex.7 the same has also been described independently as ‘superficial cortical tears’ by lindenberg in 1969, six years before friede’s seminal work.11 these subcortical clefts or tears are now attributed to being a part of the secondary cascade due to impaired venous drainage and not necessarily related to traumatic events.12 the mechanisms by which haemorrhage occurs in the subpial space have not been definitively discovered but current theories regarding venous thrombosis have the most validity. okudera et al. detailed the venous anatomy of the cerebral hemisphere using roentgenograms of pathological brain specimens in 1999 and described the subcortical and superficial medullary veins that run superficially and penetrate the cortex to join the pial vessels.13 likely, this anatomy, combined with the absence of the trabecular mesh in the pial space, produces a potential pathomechanism by which venous injury can decompress superficial haemorrhage into the subpial space without haemorrhage in the subarachnoid space.14 a case report in 2015 also described subpial haematoma in the sylvian fissure in an adult and attributed it to bleeding from small vessels in the subpial space.15 this may also provide the mechanism for the intraparenchymal extension that was observed in the presented case. subpial haemorrhages typically appear as a well-circumscribed extra-axial haemorrhage, usually seen adjacent to a gyrus. they may be bilateral, depending on the underlying pathology (such as coagulopathy), and are usually located adjacent to the cerebellum or temporal regions.16 their well-localised nature and ‘yin-yang sign’ (representing the hypointense haemorrhage and hyperintense underlying cortex on t2 and diffusion-weighted mr sequences) are characteristic differentiators from other extra-axial counterparts. additional major differentiating features are the presence of localised mass effect from the haemorrhage and ischaemic changes of the underlying cortex, which are not seen with subarachnoid or subdural haemorrhages.17 roth et al. described non-traumatic subpial haemorrhage in a population of 10 patients with ages ranging from 53 years to 80 years, and observed that most of their patients recovered completely, suggesting an excellent prognosis.4 a cohort study of 17 patients by cain et al. noted medullary venous congestion or thrombosis adjacent to the areas of subpial haemorrhage and suggested a venous pattern of ischaemia as the cause rather than birth trauma.6 dabrowski et al. conducted the largest retrospective cohort study, to date, including 31 neonates with subpial haemorrhage. the majority were term babies (55%) with the subpial haemorrhages being commonly multifocal and if isolated, located in the temporal lobe. about 77% of cases had other haemorrhages, the most common being intraparenchymal haemorrhage. the majority of cases had no intervention but were followed up clinically and with imaging; most had some form of developmental delay on follow-up after at least 1 year.18 however, this was not evident in the current case study. conclusion subpial haemorrhage is a relatively uncommon finding in clinical practice. knowledge of its appearance, together with the recently described ‘yin-yang sign’ on mri, will prevent misdiagnosis and exclude other extra-axial haemorrhages that might have different prognoses. the diagnosis of subpial haemorrhage should also initiate a search for background coagulopathies, which may be the underlying cause as in this case. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report. author’s contributions m.g.k., p.r. and p.c.s. equally contributed to the design and implementation of the research, to the analysis of the results and to the writing of the case report. ethical considerations this case report followed all ethical standards for research. funding information this case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references dunbar m, kirton a. perinatal stroke. semin pediatr neurol. 2019;32:100767. https://doi.org/10.1016/j.spen.2019.08.003 dunbar m, kirton a. perinatal stroke: mechanisms, management, and outcomes of early cerebrovascular brain injury. lancet child adolesc health. 2018;2(9):666–676. https://doi.org/10.1016/s2352-4642(18)30173-1 huang ah, robertson rl. spontaneous superficial parenchymal and leptomeningeal hemorrhage in term neonates. ajnr am j neuroradiol. 2004;25(3):469–475. ajnr am j neuroradiol. 2004;35(4):666. roth p, happold c, eisele g, nägele t, weller m, luft ar. a series of patients with subpial hemorrhage: clinical manifestation, neuroradiological presentation and therapeutic implications. j neurol. 2008;255(7):1018–1022. https://doi.org/10.1007/s00415-008-0824-8 assis z, kirton a, pauranik a, sherriff m, wei x-c. idiopathic neonatal subpial hemorrhage with underlying cerebral infarct: imaging features and clinical outcome. ajnr am j neuroradiol. 2021;42(1):185–193. https://doi.org/10.3174/ajnr.a6872 cain dw, dingman al, armstrong j, stence nv, jensen am, mirsky dm. subpial hemorrhage of the neonate. stroke. 2020;51(1):315–318. https://doi.org/10.3174/ajnr.a6872 reinhard l, friede md. subpial hemorrhage in infants. j neuropath exp neurol. 31(3):548–556. https://doi.org/10.1097/00005072-197207000-00012 adeeb n, mortazavi mm, deep a, et al. the pia mater: a comprehensive review of literature. childs nerv syst. 2013;29(10):1803–1810. https://doi.org/10.1007/s00381-013-2044-5 zhang et, inman cb, weller ro. interrelationships of the pia mater and the perivascular (virchow-robin) spaces in the human cerebrum. j anat. 1990;170:111–123. squier w. the ‘shaken baby’ syndrome: pathology and mechanisms. acta neuropathol. 2011;122(5):519–542. https://doi.org/10.1007/s00401-011-0875-2 lindenberg r, freytag e. morphology of brain lesions from blunt trauma in early infancy. arch pathol. 1969;87(3):298–305. larsen kb, barber z, squier w. the pathology and aetiology of subcortical clefts in infants. forensic sci int. 2019;296:115–122. https://doi.org/10.1016/j.forsciint.2019.01.011 okudera t, huang yp, fukusumi a, nakamura y, hatazawa j, uemura k. micro-angiographical studies of the medullary venous system of the cerebral hemisphere. neuropathology. 1999;19(1):93–111. https://doi.org/10.1046/j.1440-1789.1999.00215.x gunda d, cornwell bo, dahmoush hm, jazbeh s, alleman am. pediatric central nervous system imaging of nonaccidental trauma: beyond subdural hematomas. radiographics. 2019;39(1):213–228. https://doi.org/10.1148/rg.2019180084 suzuki k, matsuoka g, abe k, okada y, sakai s. subpial hematoma and extravasation in the interhemispheric fissure with subarachnoid hemorrhage. neuroradiol j. 2015;28(3):337–340. https://doi.org/10.1177/1971400915576664 orman g, kralik sf, meoded a, desai n, risen s, huisman tagm. mri findings in pediatric abusive head trauma: a review. j. neuroimaging. 2020;30(1):15–27. https://doi.org/10.1111/jon.12670 barreto arf, carrasco m, dabrowski ak, sun lr, tekes a. subpial hemorrhage in neonates: what radiologists need to know. ajr am j roentgenol. 2021;216(4):1056–1065. https://doi.org/10.2214/ajr.20.22999 dabrowski ak, carrasco m, gatti jr, et al. neonatal subpial hemorrhage: clinical factors, neuroimaging, and outcomes in a quaternary care children’s center. ped. neurology. 2021;120:52–58. https://doi.org/10.1016/j.pediatrneurol.2021.04.011 image quality.html image quality dependence on image processing software in computed radiography lourens j strauss, bmedsc (hons) (medical physics) william i d rae, mb bch, phd (medical physics) department of medical physics, university of the free state, bloemfontein corresponding author: l strauss (lourens.strauss@gmail.com) background. image post-processing gives computed radiography (cr) a considerable advantage over film-screen systems. after digitisation of information from cr plates, data are routinely processed using manufacturer-specific software. agfa cr readers use musica software, and an upgrade with significantly different image appearance was recently released: musica2 . aim. this study quantitatively compares the image quality of images acquired without post-processing (flatfield) with images processed using these two software packages. methods. four aspects of image quality were evaluated. an aluminium step-wedge was imaged using constant ma at tube voltages varying from 40 to 117 kv. signal-to-noise ratios (snrs) and contrast-to-noise ratios (cnrs) were calculated from all steps. contrast variation with object size was evaluated with visual assessment of images of a perspex contrast-detail phantom, and an image quality figure (iqf) was calculated. resolution was assessed using modulation transfer functions (mtfs). results. snrs for musica2 were generally higher than the other two methods. the cnrs were comparable between the two software versions, although musica2 had slightly higher values at lower kv. the flatfield cnr values were better than those for the processed images. all images showed a decrease in cnrs with tube voltage. the contrast-detail measurements showed that both musica programmes improved the contrast of smaller objects. musica2 was found to give the lowest (best) iqf; mtf measurements confirmed this, with values at 3.5 lp/mm of 10% for musica2 , 8% for musica and 5% for flatfield. conclusion. both musica software packages produced images with better contrast resolution than unprocessed images. musica2 has slightly improved image quality than musica. s afr j rad 2012;16(2):44-48. introduction in radiology, image quality is a measure of the effectiveness with which clinical diagnoses may be made. it is usually evaluated on the basis of three measures of imaging performance, namely: spatial resolution, contrast, and noise.1 other factors considered are the effect of patient dose on the image quality, as well as the occurrence of artefacts. since the introduction of digital technology to radiology, many additional benefits have been realised. probably the most important of these has been the ability to post-process and manipulate images. to readily obtain the most information from an image, manufacturers have developed optimised software algorithms to prepare images for soft copy display and reporting. the software has specific settings and filters which are used to achieve optimal images in an attempt to make the most accurate diagnosis. these settings are applied as appropriate for the specific views and anatomy being imaged, and include edge enhancement, contrast enhancement, excess contrast reduction, noise reduction, etc. making accurate and efficient diagnoses from radiological images requires good image contrast and sufficient spatial resolution at acceptable noise levels, which is what manufacturers are striving to achieve.2 the software package developed by agfa and used in agfa cr readers is called musica; an upgrade was recently released: musica2 .3 , 4 the acronym stands for multi scale image contrast amplification, and the algorithm is essentially a multi-scale transform of the image data into a stack of detail layers. this is done in musica using a laplacian pyramid decomposition.5 contrast can then be improved in each sub-band of spatial frequencies. another important function of the processing software is to extract the appropriate signal sub-range through a process of signal normalisation. the unprocessed data captured by the cr plates, which are typically in the range of 211 gray levels, are reduced to only 28 gray levels for the observer to see most of the relevant image features at the same time. a detailed discussion of the image processing involved is presented by vuylsteke et al. 5 image quality evaluation studies of cr systems typically use metrics such as contrast-to-noise ratios (cnrs), limiting spatial resolution, the modulation transfer function (mtf), noise power spectrum (nps) and detective quantum efficiency (dqe). however, when evaluating only a part of the imaging chain (e.g. assessing the processing software), these metrics are not all relevant. aspects which can be readily evaluated are signal-to-noise ratios (snrs), contrast-to-noise ratios (cnrs), object visibility with decreasing size and contrast, and spatial resolution response using mtfs. the signal-to-noise ratio within a specified region of interest (roi) is defined by the following equation:1 (1) where n is the average pixel value and σ the standard deviation (noise) over the pixel values within the roi. likewise, for the specified roi, the contrast-to-noise ratio is given by equation 2: (2) where a and b are the average pixel values within the rois on adjacent steps on the image of the aluminium step wedge. object visibility with decreasing size and contrast can be evaluated qualitatively and/or using an image quality figure (iqf) score (visually assessed) specific for the in-house manufactured phantom. this is given by equation 3:6 (3) where d i,min the threshold diameter in the i’th contrast column for columns, and c i is the depth of the hole generating the contrast in that column. therefore, a low iqf represents better image quality. the modulation transfer function of a system gives a very thorough description of its resolving capabilities, showing the fraction of an object’s contrast recorded by the system as a function of the object’s size (spatial frequency).1 it is calculated mathematically from the fourier transform of the line spread function (lsf), which is the receptor’s response to a thin, high contrast line. the fourier transform of this lsf shows the system’s effectiveness in transferring the different frequency components in an object into the image of that object. the aim of this study was to quantitatively compare the image quality of images acquired without post-processing (flatfield) with images processed with agfa’s musica and musica2 software packages. materials and method data processing was done on images in dicom format, using matlab.7 all imaging was done on a standard x-ray machine at a fixed ssd of 100 cm. owing to the number of images acquired using low kv settings, the cr plates were placed on the bed to prevent the appearance of the ion chambers on the images. no scatter grid was present during imaging. each image was repeated on three separate cr-plates of 24 x 30 cm and read out on an agfa cr 85-x digitiser using the three different post-processing software algorithms. an aluminium step-wedge placed on top of a 2.5 cm perspex sheet was imaged at tube voltages of 40, 55, 70, 85, 102 and 117 kv. the ma for each kv setting was determined using the automatic exposure control (aec) of the x-ray unit. these exposure parameters were recorded and used as the standard while acquiring images for all three processing algorithms. the snrs were calculated for all of the steps using equation 1. the value for n and σ were obtained from a region-of-interest (roi) of 100x40 pixels on each step. the roi covered 50% of the area of a step, and was drawn in appropriate areas of approximately uniform signal strength in which artefacts were not noted. the cnrs were calculated for all contrast steps, in the same rois as for the snr calculation, from equation 2. the value of σ in this case was obtained from the thicker step, which is the step with lowest signal strength (b in equation 2). object visibility with decreasing size and decreasing contrast was evaluated with visual assessment of images of a perspex contrast-detail phantom placed on a 2.5 cm thick perspex sheet. the phantom was made in-house by drilling a square array of small holes into the surface of a perspex block. the holes varied in depth (creating variable low contrast spots) in the one direction, and in diameter in the other. each contrast row had a centre and randomly positioned off-centre hole of each size. the contrast steps are produced by varying hole depths from 0.70 to 2.5 mm (±0.05 mm), and the hole diameters ranged from 0.40 to 2.30 mm (±0.05 mm) (verified with a micro meter gauge). the phantom was imaged at 40 kv using the small focal spot size. the images were scored on the 3 megapixel screen used for clinical evaluation. the number of centre circles of which the off-centre circle was also visible in each contrast row (i.e. the smallest object still visible for a certain contrast) was determined by three different observers. observers were allowed to adjust the window level, window width and zoom settings for best object visibility. the average score from the three observers were used to calculate iqfs for each processing algorithm using equation 3. resolution was assessed using mtfs, calculated from images acquired at 40 kv using the small focal spot size. an apg phantom was used8 that had small metal plates, rotated 1°, specifically for this purpose (fig. 1). several profiles were drawn across the edge of an mtf plate, each 1 pixel wide. the number of profiles needed for a 1 pixel shift in the edge owing to the angulation was determined from pixel values. a method to generate additional data points across the plate edge was used by the designers of the apg phantom,9 and is explained in the exaggerated illustration in fig. 4. each profile drawn provides a point on the edge with a slightly different pixel value. the displacement needed to align the pixel values with the real edge location was calculated using basic trigonometry, and the data sets for each profile were then shifted by this displacement. the equation is as follows: (4) where α is the tilt angle of the plates (1°). this provides multiple data points across the edge profile. the resulting curve is called the edge spread function (esf), which is then smoothed and differentiated to obtain the line spread function (lsf), and the fourier transform of the lsf was taken to obtain the mtf. results the snrs on every step for all three processing methods at all energies were calculated, and are fairly similar. the results for energy of 70 kv are shown in fig. 2. the average cnrs between steps 1 and 4 were calculated and are shown in fig. 3. average cnrs were used to reduce errors introduced by artefacts (dust, cr defects). the specific steps used are the only steps clearly separable at all kvs. the contrast-detail images were scored by the three observers, and the results show that both musicas allow better visualisation of small objects for all contrast conditions. the scoring of the observers was very similar. to quantify overall contrast-detail capabilities, a hyperbolic fit of the form as shown in equation 5 was used. a fit parameter (h, x’, y’) fit was done on the data using the solver add-in in excel: (5) the fitted curves are shown in fig. 4. the iqfs calculated for the three processing algorithms are given in table 1. profiles were drawn across the edge of the centre bottom mtf plate, and the positional displacements calculated using equation 4. a smoothing function in matlab (curve fitting tool; loess, span=0.2) was applied to obtain the esf, which was differentiated to get the lsf and the fourier transform applied to calculate the mtf. the mtfs were calculated for the same mtf plate in all three images in the xand y-axes. the x-axis is perpendicular to the cathode-anode direction of the x-ray tube. the mtfs calculated for the three algorithms are shown in fig. 5. discussion a number of observations were made from the snr graphs. firstly, the flattening off of the curve over the thick part of the wedge (step 20) is where the photons cannot penetrate the wedge, and therefore this effect diminishes at higher kv. secondly, some outliers are seen (e.g. fig. 2, step 1 mi), which are probably caused by artefacts (scratches on cr plate) in the image causing the average signal to be lower than it really is, and the standard deviation to be higher. consequently, the ratio is reduced. the overall assessment over all energies shows musica2 to be somewhat better than the other two methods regarding the snr. the cnrs are lower for the processed images than the flatfield, mainly owing to increased noise during the processing. there is also a downward trend as the energy increases, which is thought to be mainly due to the decrease in contrast caused by increasing the kv, as photons become more penetrating. the noise also increases slightly, but the contrast has a bigger influence. for the higher energies, the cnrs are fairly constant, and the unprocessed images again show a higher cnr than the processed images, possibly owing to the noise increase in the processed images. musica2 shows slightly higher cnr at lower kv, while at higher kv no significant difference is seen between the methods. the benefit of post-processing in visualising small objects over all contrast levels can be seen clearly from the contrast-detail graph (fig. 4). the iqfs as shown in table 1 indicate that musica2 has slightly better image quality. both processing methods show an improved ability to see low-contrast objects compared with the unprocessed image. quantitatively this translates to objects of a size 10% smaller than with flatfield imaging being visible at all contrast levels using either of the musicas. this is not an improvement in the spatial resolution capabilities of the system, but simply better visualisation of small objects owing to manipulation of the pixel values to enhance the contrast between the edges of small objects and their surrounding pixels. in other words, the transfer of frequencies is changed, as shown in the mtfs section. this is effectively selective signal amplification. both processing software packages show an increased transfer at almost all frequencies, the images therefore appearing visually sharper and overall resolution is improved (at sufficient contrast). the ability to see small objects better can be expected since the transfer of higher frequency information is better than for the flatfield image. the deviation from the trend in the y-axis of musica2 at high frequencies is thought to be due to some high-frequency noise still present in the lsf, which gives a false impression of having higher mtf values. the image shown in fig. 6 shows a problem faced in automated software. this uniform black artefact area was created by the post-processing software after encountering a perfectly straight edge throughout the length of the image. an artefact commonly seen with post-processing is edge enhancement. this can be seen clearly in fig. 7 (over-enhanced by window level/width adjustment), the square on the right illustrating how the area away from any edge is smoothed out while the edge is sharpened and so becomes noisier. conclusion both musica software packages produced images with better contrast resolution than unprocessed images. the quantitative measurements indicate that musica2 delivers marginally improved image quality over musica. both musica packages show improved spatial resolution, which is the result of better visualisation of small objects owing to software manipulation of the pixel values. the mtf calculation might also include some noise, which does not represent real increased transfer of frequencies, and illustrates one of the complications faced in calculating mtfs. musica2 has also shown slightly improved snrs and cnrs at lower kv; however, the images still appear more noisy. it is also important to keep in mind that this study aimed at quantitative analysis of image quality differences between the software packages to provide an unambiguous comparison. to evaluate the system clinically, further investigation is necessary into all factors, including clinical image assessment by radiology experts, practical application aspects for the radiographers, cost, etc. 1. bushberg j, seibert j, leidholt e, boone j. the essential physics of medical imaging, 2nd ed. philadelphia: lippincott williams & wilkins, 2002;255-287. 1. bushberg j, seibert j, leidholt e, boone j. the essential physics of medical imaging, 2nd ed. philadelphia: lippincott williams & wilkins, 2002;255-287. 2. international atomic energy agency (iaea). radiation protection in diagnostic and interventional radiology. http://www.iaea.org (accessed 3 december 2010). 2. international atomic energy agency (iaea). radiation protection in diagnostic and interventional radiology. http://www.iaea.org (accessed 3 december 2010). 3. vuylsteke p, schoeters e. multiscale image contrast amplification (musica). proc spie 1994;167:551-560. 3. vuylsteke p, schoeters e. multiscale image contrast amplification (musica). proc spie 1994;167:551-560. 4. schaetzing r. agfa’s musica2, taking image processing to the next level. mortsel, belgium: agfa healthcare, 2007. 4. schaetzing r. agfa’s musica2, taking image processing to the next level. mortsel, belgium: agfa healthcare, 2007. 5. vuylsteke p, schoeters e. image processing in computed radiography. 1999. paper 16, dgzfp proceedings, bb 67-cd, germany. 5. vuylsteke p, schoeters e. image processing in computed radiography. 1999. paper 16, dgzfp proceedings, bb 67-cd, germany. 6. aichinger h, dierker j, joite-barfuss s, sabel m. radiation exposure and image quality in x-ray diagnostic radiology. heidelberg, germany: springer verlag, 2004:78-79. 6. aichinger h, dierker j, joite-barfuss s, sabel m. radiation exposure and image quality in x-ray diagnostic radiology. heidelberg, germany: springer verlag, 2004:78-79. 7. matlab – the language of technical computing. v7. natick ma, usa: mathworks, 2004. 7. matlab – the language of technical computing. v7. natick ma, usa: mathworks, 2004. 8. hamza a, alport mj, rae wid. the design and fabrication of a full field quantitative mammographic phantom. journal of science and technology 2009;10(3):141-158. 8. hamza a, alport mj, rae wid. the design and fabrication of a full field quantitative mammographic phantom. journal of science and technology 2009;10(3):141-158. 9. hamza a, alport mj, rae wid. qualitative and quantitative evaluation of the apg phantom. journal of science and technology 2009;10(3):168-187. 9. hamza a, alport mj, rae wid. qualitative and quantitative evaluation of the apg phantom. journal of science and technology 2009;10(3):168-187. fig. 1. the apg phantom used for mtf evaluation. the enlarged area shows an mtf plate. fig. 2. signal-to-noise ratios for all steps imaged at 70 kv. readout artefacts can cause outliers as seen at step 1 (musica). fig. 3. average contrast-to-noise ratios calculated from steps 1 to 4 of the step wedge at all energies. fig. 4. graph showing contrast with decreasing object size for the different algorithms. fig. 5. modulation transfer functions in both xand y-axes as calculated on the same mtf plate for all three algorithms. the post-processed images have higher mtf values over all useful frequencies. fig. 6. image of artefact encountered due to post-processing. fig. 7. the result of edge enhancement during software processing. table 1. image quality figures for the three different algorithms iqf flatfield 30.25 musica 24.75 musica2 23.75 the dural.html the dural tail sign n mahomed, mb bch, fcrad (d) y seedat, mb bch department of radiology, university of the witwatersrand, johannesburg corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) the dural tail sign was first described by wilms in 1989, as a post-contrast linear thickening of the meninges that resembles a tail extending from a mass on t1-weighted mr imaging.1 the sign consists of a tapering rim ranging from 0.5 to 3.0 cm in length with an inner surface that is either smooth or slightly nodular.2 in 1990, goldsher and colleagues devised a subset of radiologic criteria to reliably establish the absence or presence of the dural tail sign. the criteria adopted included (i) the tail must have an enhancement greater than that of the tumor itself, (ii) the tail should taper smoothly away from the tumour, and (iii) the tail should be identified on 2 successive sections through the tumour.2 based on these criteria, they concluded that the dural tail sign was a ‘highly specific feature of meningioma’.2 the dural tail sign is thought to have a 60 72% specificity for the diagnosis of meningioma.3 it was initially proposed that dural tails resulted from direct tumour invasion, but investigators have not been able to demonstrate direct tumour involvement. it was therefore proposed that dural tails represented reactive changes to the dura mater, adjacent to but not in contiguity with the tumour.4 hypervascular meningiomas result in additional adjacent reactive changes such as hyperostosis to adjacent bone. it is reasonable that both mechanisms (tumour invasion and hypervascular reaction) may be responsible for the dural tail sign.4 the dural tail sign is also infrequently reported in a variety of other intra-axial as well as extra-axial lesions including neuromas, chloromas, metastases, lymphoma, glioma, pituitary diseases and granulomatous disorders affecting the cns.5 despite its non-specificity, it remains a useful sign in assessing the morphology, enhancement pattern and centricity of a lesion. we thank professor s andronikou for reviewing this article. 1. wilms g, lammens m, marchal g, et al. thickening of dura surrounding meningiomas: mr features. j comput assist tomogr 1989;13:763-768. 1. wilms g, lammens m, marchal g, et al. thickening of dura surrounding meningiomas: mr features. j comput assist tomogr 1989;13:763-768. 2. goldsher d, litt aw, pinto rs, bannon kr, kricheff ii. dural “tail” associated with meningiomas on gd-dtpa-enhanced mr images: characteristics, differential diagnostic value, and possible implications for treatment. radiology 1990;176:447-450. 2. goldsher d, litt aw, pinto rs, bannon kr, kricheff ii. dural “tail” associated with meningiomas on gd-dtpa-enhanced mr images: characteristics, differential diagnostic value, and possible implications for treatment. radiology 1990;176:447-450. 3. aoki s, sasaki y, machida t, tanioka h. contrast-enhanced mr images in patients with meningioma: importance of enhancement of the dura adjacent to the tumor. am j neuroradiol 1990;11:935-938. 3. aoki s, sasaki y, machida t, tanioka h. contrast-enhanced mr images in patients with meningioma: importance of enhancement of the dura adjacent to the tumor. am j neuroradiol 1990;11:935-938. 4. wallace ew. the dural tail sign. radiology 2004;233:56-57. 4. wallace ew. the dural tail sign. radiology 2004;233:56-57. 5. guermazi a, lafitte f, miaux y, adem c, bonneville jf, chiras j. the dural tail sign beyond meningioma: journal of clinical radiology 2005;60:171-188. 5. guermazi a, lafitte f, miaux y, adem c, bonneville jf, chiras j. the dural tail sign beyond meningioma: journal of clinical radiology 2005;60:171-188. fig. 1. axial t1-weighted spin-echo mr image of the brain with intravenous gadolinium demonsrates the dural tail (arrow) i.e. linear thickening and enhancement of the meninges appearing as a tail, attached to a meningioma in the right anterior temporal lobe. fig. 2. saggital t1-weighted spin-echo mr image of the brain with intravenous gadolinium of the same patient demonsrates the dural tails (arrows) of the meningioma and the hyperostosis of the adjacent bone. fig. 3. saggital t1-weighted spin-echo mr image of the upper thoracic spine demonstrates a dural tail (arrow) associated with a spinal meningioma. sajr 870 extramedullary haematopoiesis: an uncommon posterior mediastinal mass e marchiori, md, phd; m m barreto, md, phd; b hochhegger, md, phd; g zanetti, md, phd department of radiology, rio de janeiro federal university, rio de janeiro, brazil corresponding author: e marchiori (edmarchiori@gmail.com) a 59-year-old man presented with anaemia and complaints of abdominal pain, weight loss, fatigue and dizziness. computed tomography (ct) scans of the chest revealed bilateral paravertebral masses. the ct features were typical of extramedullary haematopoiesis (emh). emh should be strongly considered in a patient with bilateral, well-marginated, paravertebral thoracic masses and a history of chronic, severe anaemia. s afr j rad 2013;17(3):114-115. doi:10.7196/sajr.870 a 59-year-old man presented with anaemia and complaints of abdominal pain, weight loss, fatigue and dizziness. he had undergone a cholecystectomy due to cholelithiasis 3 years previously, and had a history of sickle-cell disease since the age of 10 years. chest radiography depicted bilateral posterior mediastinal masses (fig. 1). chest computed tomography (ct) scans revealed well-marginated and lobulated bilateral paravertebral masses in the lower half of the thorax, with heterogeneous density owing to areas of fat and soft-tissue attenuation, suggesting long-standing disease (fig. 2). the lung parenchyma showed no abnormality. the ct features were typical of extramedullary haematopoiesis (emh), defined as the development and growth of haematopoietic tissue outside the bone marrow. fig. 1. chest x-rays in frontal (a) and lateral (b) views revealed bilateral posterior lobulated retrocardiac masses. pulmonary parenchyma and bone structures were normal. fig. 2. computed tomography scans with lung window (a) and mediastinal window (b) settings show bilateral masses in the inferior paravertebral thoracic regions. the masses were heterogeneous, with low-density areas suggesting a fatty component. discussion emh is seen in a variety of haematological disorders, including severe haemolytic anaemias (thalassaemia, sickle-cell anaemia, spherocytosis), leukaemia, lymphoma, myelodysplasia and myelofibrosis. extensive replacement of normal bone marrow occurs when production is insufficient to meet the body’s demands.1-3 the most common sites of emh are the liver, spleen and lymph nodes, although it can occur in any organ. thoracic involvement is less frequent, usually manifesting as bilateral lobulated masses in the lower paravertebral areas.3 , 4 the destruction of adjacent ribs and vertebrae is not seen in emh. the erythropoietic masses are usually asymptomatic, although the presence of emh within the spinal canal may be associated with spinal cord compression and neurological deficit related to the level of involvement.2 laceration of the mass may result in spontaneous rupture and massive haemothorax.1 , 3 another uncommon thoracic complication is involvement of the pulmonary interstitium that can cause acute and rapidly fatal respiratory failure,5 , 6 and the formation of pleural masses that usually are asymptomatic but, rarely, develop haemothorax.6 , 7 the radiographic manifestations of thoracic emh are unilateral or bilateral, sharply circumscribed, often lobulated, paraspinal soft-tissue masses. ct usually shows well-defined, lobulated, soft-tissue masses in the distal thoracic paraspinal region, which may or may not enhance after intravenous contrast administration.3 ct can be helpful in detecting areas of fat attenuation within these lesions and in depicting bony changes related to haematological disorders, such as thalassaemia and sickle-cell anaemia.4 ct can also demonstrate splenic infarcts with focal calcifications or a small and dense calcified spleen (autosplenectomy), which can aid the differential diagnosis.1 mri may show intermediate signal intensity on both tland t2-weighted images. the masses are moderately enhancing on a postcontrast t1-weighted image. inactive lesions show high signal intensity on both tland t2-weighted mr images owing to fatty infiltration or low signal intensity on both t1and t2-weighted mr images owing to iron deposition.8 bone marrow scintigraphy with tc-99m-labelled colloid usually reveals uptake in the paravertebral masses.8 the diagnosis of emh can be established with reasonable certainty on the basis of characteristic radiological findings in a patient with a predisposing haematological condition.4 invasive diagnostic procedures are potentially hazardous because of the highly vascular nature of the thoracic masses and the haemorrhagic potential of the condition.3 microscopic examination shows well-formed haematopoietic tissue.1 main considerations in the differential diagnosis of emh are tumours of the posterior mediastinum, including neurogenic masses, lymphoma, paravertebral abscesses, extrapleural cysts, lateral meningoceles, mediastinal lymph node hyperplasia, and primary and metastatic malignant neoplasms.1 in conclusion: emh should be strongly considered in a patient with bilateral, well-marginated, paravertebral thoracic masses and a history of chronic severe anaemia. 1. marchiori e, escuissato dl, irion kl, et al. extramedullary hematopoiesis: findings on computed tomography scans of the chest in 6 patients. j bras pneumol 2008;34(10):812-816. 1. marchiori e, escuissato dl, irion kl, et al. extramedullary hematopoiesis: findings on computed tomography scans of the chest in 6 patients. j bras pneumol 2008;34(10):812-816. 2. chiam ql, lau kk. extramedullary haematopoiesis in thalassaemia major causing spinal cord compression. australas radiol 2007;51(2):168-171. [http://dx.doi.org/10.1111/j.1440-1673.2007.01689.x] 2. chiam ql, lau kk. extramedullary haematopoiesis in thalassaemia major causing spinal cord compression. australas radiol 2007;51(2):168-171. [http://dx.doi.org/10.1111/j.1440-1673.2007.01689.x] 3. pornsuriyasak p, suwatanapongched t, wangsuppasawad n, ngodngamthaweesuk m, angchaisuksiri p. massive hemothorax in a beta-thalassemic patient due to spontaneous rupture of extramedullary hematopoietic masses: diagnosis and successful treatment. respir care 2006;51(3):272-276. 3. pornsuriyasak p, suwatanapongched t, wangsuppasawad n, ngodngamthaweesuk m, angchaisuksiri p. massive hemothorax in a beta-thalassemic patient due to spontaneous rupture of extramedullary hematopoietic masses: diagnosis and successful treatment. respir care 2006;51(3):272-276. 4. fielding jr, owens m, naimark a. intrathoracic extramedullary hematopoiesis secondary to b12 and folate deficiency: ct appearance. j comput assist tomogr 1991;15(2):308-310. [http://dx.doi.org/10.1097/00004728-199103000-00023] 4. fielding jr, owens m, naimark a. intrathoracic extramedullary hematopoiesis secondary to b12 and folate deficiency: ct appearance. j comput assist tomogr 1991;15(2):308-310. [http://dx.doi.org/10.1097/00004728-199103000-00023] 5. weinschenker p, kutner jm, salvajoli jv, et al. whole-pulmonary low-dose radiation therapy in agnogenic myeloid metaplasia with diffuse lung involvement. am j hematol 2002;69(4):277-280. [http://dx.doi.org/10.1002/ajh.10075] 5. weinschenker p, kutner jm, salvajoli jv, et al. whole-pulmonary low-dose radiation therapy in agnogenic myeloid metaplasia with diffuse lung involvement. am j hematol 2002;69(4):277-280. [http://dx.doi.org/10.1002/ajh.10075] 6. yusen rd, kollef mh. acute respiratory failure due to extramedullary hematopoiesis. chest 1995;108(4):1170-1172. [http://dx.doi.org/10.1378/chest.108.4.1170] 6. yusen rd, kollef mh. acute respiratory failure due to extramedullary hematopoiesis. chest 1995;108(4):1170-1172. [http://dx.doi.org/10.1378/chest.108.4.1170] 7. kupferschmid jp, shahian dm, villanueva ag. massive hemothorax associated with intrathoracic extramedullary hematopoiesis involving the pleura. chest 1993;103(3):974-975. [http://dx.doi.org/10.1378/chest.103.3.974] 7. kupferschmid jp, shahian dm, villanueva ag. massive hemothorax associated with intrathoracic extramedullary hematopoiesis involving the pleura. chest 1993;103(3):974-975. [http://dx.doi.org/10.1378/chest.103.3.974] 8. kakite s, tanabe y, kinoshita f, harada h, ogawa t. clinical usefulness of in-111 chloride and tc-99m sn colloid scintigraphy in the diagnosis of intrathoracic extramedullary hematopoiesis. ann nucl med 2005;19(4):317-320. [http://dx.doi.org/10.1007/bf02984625] 8. kakite s, tanabe y, kinoshita f, harada h, ogawa t. clinical usefulness of in-111 chloride and tc-99m sn colloid scintigraphy in the diagnosis of intrathoracic extramedullary hematopoiesis. ann nucl med 2005;19(4):317-320. [http://dx.doi.org/10.1007/bf02984625] abstract introduction case presentation discussion acknowledgements references about the author(s) tineke van zyl department of maxillofacial radiology, faculty of dentistry, university of the western cape, cape town, south africa leon janse van rensburg department of maxillofacial radiology, faculty of dentistry, university of the western cape, cape town, south africa department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa komeela naidoo department of radiation oncology, faculty of medical imaging and clinical oncology, stellenbosch university, cape town, south africa marc merven department of ear, nose and throat, faculty of medicine, stellenbosch university, cape town, south africa johan f. opperman department of oral and maxillofacial pathology, faculty of dentistry, university of the western cape, cape town, south africa department of oral and maxillofacial pathology, national health laboratory service, cape town, south africa citation van zyl t, janse van rensburg l, naidoo k, merven m, opperman jf. correlative imaging and histopathology of a complicated sinonasal teratocarcinosarcoma. s afr j rad. 2023;27(1), a2548. https://doi.org/10.4102/sajr.v27i1.2548 case report correlative imaging and histopathology of a complicated sinonasal teratocarcinosarcoma tineke van zyl, leon janse van rensburg, komeela naidoo, marc merven, johan f. opperman received: 31 aug. 2022; accepted: 17 nov. 2022; published: 30 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract sinonasal teratocarcinosarcoma (sntcs) is a highly malignant and rare tumour characterised by a complex admixture of teratomatous and carcinosarcomatous components. in the head and neck area, it almost exclusively occurs in the sinonasal cavities; however, rare instances of nasopharyngeal and oral cavity involvement have been reported, with fewer than 100 cases reported in the literature. contribution: the contributed case involves the correlative ct, mri and histopathology of a sinonasal teratocarcinosarcoma with intracranial involvement. keywords: sinonasal teratocarcinosarcoma; histopathology; computerised tomography; magnetic resonance imaging; intracranial; diffusion-weighted imaging. introduction sinonasal teratocarcinosarcoma (sntcs) is a rare tumour characterised by the presence of benign and malignant epithelial, mesenchymal and neural components.1 in view of its complex histological architecture, sntcs has also previously been classified as malignant teratoma, blastoma or mixed mesodermal tumour.2 it was first described by shanmugaratnam et al. in 1983, but only appropriately termed teratocarcinosarcoma by heffner and hyams in 1984.2 male patients are affected more than female patients, with the head and neck area, nasal cavity and paranasal sinuses most commonly involved.3,4 frequent symptoms include nasal obstruction with epistaxis, atypical facial pain, exophthalmos, headaches, epiphora and anosmia.4,5 a mean survival rate of 1.7 years is reported with a 60% mortality rate within three years.6 intracranial extension and intracranial involvement are rarely observed. a series of 86 cases of sntcs reviewed by misra et al. reported 20.9% of cases demonstrating intracranial, cribriform plate and anterior cranial fossa involvement.7 because of its anatomical location, an accurate pre-operative diagnosis is essential, especially to demonstrate intracranial extension, which may be occult on ct; mri is, however, superior to ct for detecting intracranial extension. owing to its heterogeneous histological appearance, adequate sampling and recognition of all the components of this type of tumour are needed for its correct diagnosis. inadequate sampling may lead to erroneous diagnoses of olfactory neuroblastoma, squamous cell carcinoma, undifferentiated carcinoma, adenocarcinoma, malignant salivary gland–type tumours and adenosquamous carcinoma.5,8 this article describes the ct and mri findings as well as the histopathology of a rare case of a sntcs, with the epicentre in the left nasal cavity involving the left maxillary sinus, with intracranial extension. to the authors’ knowledge, this is the first case described in south africa. case presentation a 44-year-old man presented with a 3-month history of a rapidly growing left-sided nasal mass. he complained of recurrent epistaxis, blocked nose and generalised headaches, concentrated mostly on the left side of his face; however, there were no visual or olfactory disturbances. his medical history included hypertension and previous pulmonary tuberculosis. nasal endoscopic examination revealed a distended left nostril with a protruding, friable, haemorrhagic, exophytic, foul-smelling mass. the rest of the clinical examination was unremarkable. brush cytology of the lesion showed atypical malignant epithelial cells morphologically suggestive of a carcinomatous lesion. based on the cytological features and radiological imaging, a provisional diagnosis of a schneiderian papilloma with malignant transformation, sinonasal neuroendocrine carcinoma (snec), sinonasal undifferentiated carcinoma (snuc), sinonasal adenocarcinoma or a malignant salivary gland neoplasm was considered. following demonstration of an intracranial component on mri, a decision was made to treat surgically with a combined rhinology and neurosurgery approach. the intracranial tumour was removed first, followed by a transnasal endoscopic procedure. histology revealed a sntcs. postoperatively, the patient developed a brain abscess with associated seizures and convulsions. the brain abscess was drained, but the patient subsequently demised as a result of rapid disease progression. radiological imaging a ct scan revealed a soft tissue mass with its epicentre in the left nasal cavity, measuring approximately 89 mm × 30 mm × 46 mm in diameter (anteroposterior × transverse × craniocaudal). anteriorly, the mass projected through the nostril and posteriorly extended to the posterior choana. superiorly, the mass extended to the cribriform plate with bony demineralisation. bulging and demineralisation of the medial wall of the left orbit was present, but no intra-orbital involvement was evident (figure 1). figure 1: (a) coronal ct bone window shows an expansile, polypoid mass in the left nasal cavity. superiorly, the cribriform plate, olfactory recess and fovea ethmoidalis are eroded and widened (blue arrow). the nasal septum is deviated to the right. the left anterior ethmoid and frontal sinus air cells are opacified. there is convex bulging of the lamina papyracea, which is eroded (orange arrow). the infundibulum and middle meatus are eroded and widened. the left maxillary is opacified. the hard palate is eroded. (b) coronal ct soft tissue contrast-enhanced image shows a uniformly contrast-enhancing polypoid tumour in the left nasal cavity, extending to the cribriform plate, olfactory recess and ethmoid sinus. no demonstrable intracranial extension. the left maxillary sinus outflow tract is widened and obstructed by a tumour extending into the infundibulum and middle meatus with a resultant effusion (yellow arrow). the mri showed a t2 hyperintense, t1 isointense and post–contrast enhancing mass in the left nasal cavity. the nasal septum was deviated to the right, with obstruction of the maxillary sinus. superiorly, the mass extended into the left anterior cranial fossa and frontal lobe with mild mass effect but no peritumoural oedema (figures 2 and 3). the lateral ventricles, basal cisterns, cerebellum and brainstem were normal. figure 2: (a) coronal t2 turbo spin echo (tse) with fat saturation (fs) mri. there is an expansile t2 solid hyperintense polypoid mass extending intracranially into the anterior cranial fossa with mild mass effect on the inferior left frontal lobe (red arrow). the maxillary sinus is obstructed with a resultant effusion. (b) sagittal t2 turbo spin echo (tse) with fat saturation (fs) mri image shows the antero-posterior extent of the mass, the extradural intracranial component (orange arrow) and obstructed frontal and sphenoid sinuses. figure 3: (a) t1 turbo spin echo (tse) sagittal mr image shows a homogeneously mass, iso-intense to grey matter and muscle (red arrow). (b) sagittal t1 turbo spin echo (tse) with fat saturation (fs) with gadolinium-enhanced mr image shows a diffusely heterogeneous enhancing tumour in the left nasal cavity that transgresses the cribriform plate extending intracranially (orange arrow). at dwi b-1000/mm, the mass showed increased signal. there were areas of susceptibility artefact anteriorly and at the posterior skull base (figure 4). the axial adc map showed a lobulated left nasal mass with restricted diffusion and small foci of t2 shine-through, ascribed to small foci of intratumoural cysts or necrosis (figure 4). figure 4: (a) diffusion-weighted imaging b-1000/mm. the mass shows restricted diffusion (red arrow). there is an area of susceptibility artefact anteriorly and at the posterior skull base. (b) axial adc map mri image shows a lobulated left nasal mass with restricted diffusion and small foci of t2 shine-through, ascribed to small foci of intratumoural cysts or necrosis (red arrow). histopathology the surgically resected specimen showed a necrotic, friable haemorrhagic tissue mass. microscopic examination revealed fragments of inflamed sinonasal mucosa with foci of atypical glandular structures, composed of pleomorphic cuboidal to columnar epithelium, demonstrating irregular hyperchromatic nuclei and abundant cytoplasm (figure 5a). adjacent to the malignant glands, islands of primitive-appearing round-to-oval immature-appearing cells were noted, morphologically reminiscent of olfactory neuroblastoma, representing the neuroepithelial component (figure 5b). mitotic figures and rosette-like structures were present, admixed with numerous islands comprising ‘foetal’ clear squamous cells (figure 5c). osseous and cartilaginous differentiation was absent, but sarcomatous areas were evident, composed of fascicles of pleomorphic spindle cells (figure 5d). figure 5: pathological examination showed (a) adenocarcinomatous glands; (b) adjacent primitive neuroepithelium with rosette-like structures; and (c) islands of ‘foetal’ clear-cell squamous cells. (d) shows a malignant spindled smooth muscle component with numerous atypical mitotic figures. (e) proliferation index (ki67) > 70%. (f and g) immunoreactivity of neuroepithelium with s100 and cd56, respectively, and (h) desmin positivity demonstrating smooth muscle differentiation. immunohistochemical staining revealed a high proliferation index in the atypical glands and primitive round cells. the adenocarcinoma component showed immunoreactivity with cytokeratin ae1 and ae3 (not shown). the primitive neuroepithelium was positive with s100, cd56 and neuron-specific enolase (nse) (figure 5f and g), as well as with neuroendocrine markers, synaptophysin and chromogranin (not shown), while the clear-cell squamous cells were immunoreactive to cd99 (not shown). the spindle cell sarcomatous component was positive for smooth muscle markers, desmin and α-smooth muscle actin, representing a leiomyosarcoma (figure 5d and 5h). the immunohistochemical staining pattern and histomorphological features were consistent with the diagnosis of a sntcs. discussion sinonasal teratocarcinosarcoma is a rare and aggressive tumour showing combined histological features of a carcinosarcoma and a teratoma.2 the histogenesis of sntcs is debatable. the presence of neural tissue in these neoplasms raises the possibility that the origin may be in some way related to the olfactory membrane, or alternatively to the sinonasal membrane, as it also develops from the olfactory membranes. other theories propose germ cell origin or pluripotential progenitor cell with multidirectional differentiation.9,10 in contradiction to malignant gonadal teratomas, which are frequently found in patients at a younger age, sntcs does not contain histological evidence of embryonal carcinoma, choriocarcinoma or germinomas (seminomas), making germ cell origin for sntcs unlikely.9,10,11 these tumours are more common in adults in the fourth to fifth decade and occur mostly in male patients, with only five cases reported in children.10 in a series reported by smith et al., a total of 9 out of 10 tumours occurred in the nasal cavity with extension to the maxillary sinus, the ethmoid sinus and sphenoid sinus.12 a review of the literature revealed 15 cases of sntcs with intracranial extension between 1998 and 2020.13,14,15 the first case of a primary thyroid teratocarcinosarcoma in a 17-year-old male patient was reported by abayie et al., implying that teratocarcinosarcomas can occur in primary tissues other than the sinonasal tract.16 sinonasal tumours usually lack specific ct and mri features, and the imaging is similar to common malignant sinus tumours such as olfactory neuroblastomas, small cell carcinomas, immature teratomas, carcinosarcomas and adenocarcinomas. ct findings of a mass widening the olfactory recess and extending to the cribriform plate should alert to the possibility of intracranial extension, and mri is indicated.17 nguyen reported that f-18 fluorodeoxyglucose (fdg) uptake by normal brain parenchyma may be a pitfall of not detecting intracranial invasion on f18-fdg-positron emission tomography (pet)/ct. an advantage of fdg-pet/ct, however, is that regional and distant metastases can be detected.17 the infrequency, complex phenotypic composition and radiological similarities with other malignant sinonasal tumours often lead to misdiagnoses and management difficulties. these tumours may therefore be mistaken for olfactory neuroblastoma because of their neuroectodermal histological component and transgression of the cribriform plate on radiology. histological features that may aid in the recognition of these tumours are the presence of immature neural tissue and foetal clear-cell epithelial structures admixed with various malignant and mesenchymal elements. a panel of immunohistochemical antibodies – monoclonal and polyclonal – can be utilised to assist in the diagnosis of sntcs. the glandular and/or epithelial structures show positive immuno-expression with epithelial membrane antigen (ema) and keratins (ck); the mesenchymal components express various antibodies, for example, vimentin, desmin and alpha smooth muscle actin (α-sma), the latter two indicating smooth muscle differentiation. neurofilament (nf), glial fibrillary acid protein (gfap), neuron-specific enolase (nse) and s100 protein show the presence of primitive neural elements. cd99 expression is noted in the foetal clear-cell epithelial component while beta human chorionic gonadotropin (β-hcg) and alpha foetoprotein (afp) are typically negative, highlighting the absence of germ cell elements. in summary, sntcs is an aggressive tumour, exhibiting a highly invasive behaviour and a propensity for recurrence and dissemination. both ct and mri can detect the tumour and determine the local extent; mri is, however, more sensitive for detection of intracranial extension. total excision of the tumour and aggressive sampling for histopathological examination is necessary to avoid an erroneous diagnosis. treatment usually involves multimodal surgical resection, with or without adjuvant treatments comprising radiation and chemotherapy.14,18,19 aggressive tumour spread, intracranial extension and high recurrence rate may negatively impact the survival rate.14,15 despite aggressive surgical resection and adjuvant radiation therapy, the prognosis is still poor, as half of the patients with sntcs succumb to their disease within three years of diagnosis.15 acknowledgements the authors would like to acknowledge drs amir afrogheh and abraham van wyk for assisting in the histological diagnosis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions t.v.z, j.o and l.j.v.r made substantial contributions to the conception, drafting and revision of the manuscript, l.j.v.r. to the radiological content and approval of the report. m.m., g.d.b. and k.n. contributed to the acquisition of data, drafting and revision of the report. all authors read and approved the final manuscript. ethical considerations this material is the authors’ own original work, which has not been previously published elsewhere. written consent was obtained from the patient and is available. funding information the research received no specific grant from any funding agency in the public, commercial or non-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references pai sa, naresh kn, masih k, et al. teratocarcinosarcoma of the paranasal sinuses: a clinicopathological and immunohistochemical study. hum pathol. 1998;29(7):718–722. https://doi.org/10.1016/s0046-8177(98)90281-7 heffner dk, hyams vj. teratocarcinosarcoma (malignant teratoma?) of the nasal cavity and paranasal sinuses: a clinicopathological study of 20 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chb, mfammed, ccfp department of diagnostic radiology, tygerberg academic hospital, tygerberg savvas andronikou, mb chb, fcrad, frcr (lond), phd department of radiology, university of the witwatersrand, johannesburg presentation a 39-year-old man was referred from a rural hospital. on examination, he had a new onset left hemiplegia, left gaze palsy and decreased level of consciousness. prior to the acute deterioration, he had shown progressive decline in his cognitive functioning. he was known to be hiv-positive with a cd4 count of 19. he was not on anti-retroviral therapy (art) at the time of admission. two years earlier, he had been diagnosed with pulmonary tuberculosis and had completed his prescribed treatment. what is the most likely diagnosis according to the imaging? select the diagnosis from one of the following options, and provide a justification. • hiv encephalitis (hive) • toxoplasma encephalitis • progressive multifocal leucoencephalopathy (pml) • primary central nervous system lymphoma (pcnsl). please submit your response to els.hein@gmail.com or docsav@mweb.co.za by 29 april 2011. the winning respondent will receive a r1 000 prize from the rssa. a detailed diagnosis and discussion will appear in the next issue of the sajr. fig.1a. unenhanced ct image reveals a focal white matter hypodensity involving the right frontoparietal area and right basal ganglia. a smaller left-sided lesion was noted in the anterior capsula externa. fig. 1b. no enhancement was demonstrated on post-contrast imaging. fig. 2. t2wi shows hyperintense signal in white matter right parietal lobe with involvement of the subcortical u-fibres and mild mass effect. the right basal ganglia and left anterior capsula externa lesions are again demonstrated. fig. 3. follow-up ct 2 months later demonstrates significant progression of the disease. sajr 678 glioblastoma multiforme has many faces p van rensburg, mb chb department of radiology, steve biko academic hospital and university of pretoria   m van rensburg, frcr, franzcr neuroradiologist in private practice, life wilgers hospital, pretoria   corresponding author: p van rensburg (pjvanr@gmail.com) gliomas are central nervous system (cns) neoplasms with specific histological characteristics that comprise almost 60% of all cns malignancies.1 they are subdivided into astrocytomas and oligodendrogliomas.1 the most common form of gliomas are the astrocytomas, and the most aggressive type of astrocytoma is glioblastoma multiforme (gbm).1 surgery, chemotherapy and radiation therapy achieve little success in the management of glioblastoma. despite intensive research into treatment options, the median life expectancy for patients with glioblastoma remains unchanged at 12 months. only 5% of patients will be alive 5 years after diagnosis. the behaviour of malignant glioma is unusual. systemic metastases occur but are rare, and most tumours recur within 2 cm of their original tumour margin. they are so aggressive and invasive that they have been referred to as a ‘whole cns’ disease.2 glioblastoma multiforme demonstrates a high degree of heterogeneity in both its pathological and radiological appearance.3 we present a series of 5 patients with histologically proven glioblastoma multiforme with atypical mri findings. case 1: gliosarcoma a 64-year-old man was initially admitted for pneumonia. on further inquiry, relatives reported that he had suffered from mild confusion, forgetfulness and inappropriate behaviour for a few weeks prior to admission. the clinical examination was unremarkable. mri demonstrated a left frontal mass with surrounding oedema and pressure effects including midline shift. the mass had low to intermediate signal on t1wi and high signal on t2 and flair. peripheral enhancement and central necrosis were noted (figs 1a, b).the mass was resected and, after histological examination, found to be a gliosarcoma. fig. 1a. t1 axial post-contrast view shows marked peripheral contrast enhancement and central breakdown. fig. 1b. flair axial view shows surrounding oedema and associated pressure effects. case 2: meningeal involvement a 31-year-old man presented with seizures and subsequent diplopia. initial imaging revealed a space-occupying, non-enhancing lesion in the optic chiasm. an excision biopsy showed a grade ii astrocytoma. subsequent radiotherapy localised to the lesion and base of the brain was completed. at the 18-month follow-up, he complained of recurrent headaches, and was found to have dural thickening on imaging. a biopsy of the dura over the vertex was non-contributory. a ventriculo-peritoneal shunt for hydrocephalus was placed following the negative biopsy, and repeat biopsy at this time was still inconclusive. mri following clinical deterioration 6 months after the shunt placement showed marked enhancement of the meninges, especially of the pia mater, extending around the midbrain, into the cerebral gyri and cerebellar folia (fig. 2). a biopsy was then taken from the meninges in the left sylvian fissure, which confirmed gbm. fig. 2. t1 axial post-contrast images show marked meningeal enhancement extending into the cerebellar folia, around the midbrain and along the left sylvian fissure. case 3: early-stage glioblastoma multiforme a 62-year-old man presented with generalised tonic-clonic seizures. the eeg and mri at this time were reported as normal. he was treated with anticonvulsants and had no further seizures. five months later, he had an episode of confusion with receptive and expressive aphasia, lasting a few minutes, but no associated seizure. he also complained of feeling blunted, with mild memory impairment, but ascribed this to the medication.no imaging was performed. a further 3 months later, he again experienced expressive aphasia and memory loss. at this stage, a second mri was performed. a large, heterogenous, left temporal rim-enhancing lesion was seen on the follow-up images (fig. 3a). fig. 3a. t1 coronal post-contrast view shows a large, centrally necrotic, peripherally enhancing tumour. fig. 3b. t2 coronal view shows small hyperintense foci in the left superior temporal gyrus. review of the initial non-contrast mri revealed 2 high-signal foci in the left superior temporal gyrus on the t2 images, confirmed on the coronal flair (fig. 3b). the lesion was found to be a gbm on histological examination. case 4: early-stage glioblastoma multiforme a 66-year-old woman presented with status epilepticus. the initial mri (fig. 4a) showed 2 adjacent areas in the left frontal lobe with high signal on t2wi and flair. these showed high signal on diffusion weighted imaging (dwi) and low apparent diffusion coefficient (adc) values, with subtle enhancement following contrast administration. polymerase chain reaction (pcr) testing for herpes simplex was positive, and the patient was managed medically. seven weeks later, she was re-admitted, clinically better and the status had resolved, but there was mild personality change with blunted affect. follow-up images (fig. 4b) demonstrated a large lesion in the left frontal lobe with central breakdown, peripheral enhancement and surrounding oedema. repeat mri led to a biopsy, and the lesion was histologically confirmed to be a gbm. fig. 4a. flair axial view shows 2 high-signal foci in the left frontal lobe. fig. 4b. follow-up flair axial view shows a large lesion with mass effect and surrounding oedema. case 5: subependymal spread of glioblastoma multiforme a 60-year-old man was admitted for left-sided abdominal pain of approximately 3 weeks. a chest radiograph showed nodules in the base of the right lung. during his admission, he had episodes of confusion and experienced nausea and vomiting. mri a week after admission demonstrated subependymal infiltration of tumour in the fourth, third and lateral ventricles. associated oedema was seen surrounding the frontal horn of the right lateral ventricle. areas of breakdown are seen within the tumour, notably surrounding the occipital and temporal horns of the right lateral ventricle (fig. 5). the histology report was that of a gbm. fig. 5. flair axial post-contrast view shows extensive subependymal infiltration of tumour. discussion gbms normally arise in white matter and are typically solitary, relatively large, irregularly shaped masses with associated necrosis and neovascularity, leading to intra-tumoral arteriovenous shunting.3 infiltration occurs along white matter tracts and perivascular spaces, leading to distant spread despite minimal underlying architectural distortion.3 pathology typical histopathological features include cellular polymorphism, increased mitotic activity, atypical nuclei, vascular thrombosis and microvascular proliferation as well as necrosis.4 gbm frequently arises de novo, but may develop from diffuse or anaplastic astrocytomas that undergo de-differentiation.4 glioblastoma is the most common brain tumour, accounting for 12 15% of intracranial neoplasms and 50 60% of astrocytic tumours.4 imaging mr imaging is crucial in lesion characterisation. lesions are typically hypo-intense on t1wi and hyperintense on t2wi and flair. following intravenous contrast administration, findings include nodular and irregular rim enhancement with central hypo-intensity interpreted as necrosis. ill-defined margins and surrounding oedema are typical. it is important to note that non-enhancing regions may also include tumour as noted on histological analysis.3 metabolic information may be acquired using mr spectroscopy where there is typically a reduction in naa (n-acetylaspartate) corresponding to a decreased density of neuronal cells and increased choline as a result of higher cell membrane turnover.3 as complete resection is rare, radiotherapy is used to treat residual disease. mri is useful in monitoring disease progression and in treatment planning.3 computerised tomography, catheter angiography, spect and pet play a lesser role in imaging.3 gliosarcoma is a glioblastoma variant with different areas displaying glial and mesenchymal differentiation.4 the tumour contains a portion that satisfies the histological criteria for gbm, and a mesenchymal component that may display a variety of morphologies with origins from fibroblastic, cartilaginous, osseous, smooth muscle, striated muscle or adipose cell lineage. there are 2 distinct types of gliosarcoma: one that is similar to a gbm, and one that macroscopically mimics a meningioma that is more amenable to resection and, as such, has a more favourable prognosis.5 multifocal glioblastomas the presence of true multiple, independent lesions outside of inherited syndromes remains controversial as, even on careful post mortem studies, the connection between lesions may be difficult to confirm owing to the fact that the infiltrating cells are often small, undifferentiated and polar.4 diffusion abnormalities in a subset of patients with glioblastoma, development of a new focus of restricted diffusion during treatment may precede the development of new enhancing tumour.6 spread via cerebrospinal fluid risk factors for cerebrospinal fluid (csf) dissemination include direct invasion of the ependyma, fissuring of the ependyma secondary to hydrocephalus, fragmentation of tumour in contact with csf, and surgical intervention.7 conclusion while the classic appearance of gbm is one of the more recognisable diagnoses in radiology, it is important to bear in mind that many variations occur. seemingly innocuous foci of signal abnormality, meningeal pathology and multicentric lesions may represent or progress to gbm.   1. chengkai d, holland e. astrocyte differentiation states and glioma formation. cancer j 2003;9(2):72-81. 1. chengkai d, holland e. astrocyte differentiation states and glioma formation. cancer j 2003;9(2):72-81. 2. market j. glioblastoma multiforme: introduction. cancer j 2003;9(2):71. 2. market j. glioblastoma multiforme: introduction. cancer j 2003;9(2):71. 3. nelson sj, cha s. imaging glioblastoma multiforme. cancer j 2003;9(2):134-145. 3. nelson sj, cha s. imaging glioblastoma multiforme. cancer j 2003;9(2):134-145. 4. louis dn, ohgaki h, wiestler od, et al. classification of tumors of the nervous system. geneva: world health organization, 2007. 4. louis dn, ohgaki h, wiestler od, et al. classification of tumors of the nervous system. geneva: world health organization, 2007. 5. han sj, yang i, ahn bj, et al. clinical characteristics and outcomes for a modern series of primary gliosarcoma patients. cancer 2010;116(5):1358-1366. 5. han sj, yang i, ahn bj, et al. clinical characteristics and outcomes for a modern series of primary gliosarcoma patients. cancer 2010;116(5):1358-1366. 6. gupta a, young rj, karimi s, et al. isolated diffusion restriction precedes the development of enhancing tumor in a subset of patients with glioblastoma. am j neuroradiol 2011;32(7):1-6. 6. gupta a, young rj, karimi s, et al. isolated diffusion restriction precedes the development of enhancing tumor in a subset of patients with glioblastoma. am j neuroradiol 2011;32(7):1-6. 7. alatakis s, malhamand m, thien c. spinal leptomeningeal metastasis from cerebral glioblastoma multiforme presenting with radicular pain. surg neurol 2001;56:33-38. 7. alatakis s, malhamand m, thien c. spinal leptomeningeal metastasis from cerebral glioblastoma multiforme presenting with radicular pain. surg neurol 2001;56:33-38. glioblastoma multiforme (gbm) is a class of devastating, highly aggressive central nervous system tumours. while the classical appearance is easily recognisable, several variations occur. we present 6 cases of confirmed gbm that illustrate the unusual findings in histological subtypes, early presentation and spread on mri imaging. s afr j rad 2012;16(3):94-99. doi:10.7196/sajr.678 sajr 708 is anomalous origin of the left vertebral artery indeed a rare finding? braham van der merwe, christelle ackermann, shaun scheepers, sulaiman moosa   department of diagnostic radiology, stellenbosch university and tygerberg academic hospital, tygerberg, western cape braham van der merwe, mb chb , da (sa) christelle ackermann, mb chb, mrcs (eng), mmed (diagr) shaun scheepers, mb chb   department of diagnostic radiology, 2 military hospital, wynberg, cape town sulaiman moosa, mb chb, mphil, bsc hons, ffrad diag (sa) corresponding author : b van der merwe (attiemalan@mweb.co.za ) we present a pictorial review of anomalous origin of the left vertebral artery observed in 5 patients imaged in our after-hours trauma radiology unit within a period of 7 days. we raise the question of whether the incidence of anomalous origin of the left vertebral artery quoted in the radiology literature as 5% is really that low, and suggest that the current increased frequency of cross-sectional imaging could elevate the observed incidence of this anomaly in practice. we discuss the implications of vertebral artery anomalies in the endovascular treatment of aortic arch injuries. s afr j rad 2012;16(4):144-146. doi:10.7196/sajr.708 the incidence of anomalous origin of the left vertebral artery from the aortic arch ranges between 1% and 5.8%.1 , 2 this anomaly has important implications for thoracic surgery and interventional procedures. the left vertebral artery may originate from: • the left common carotid artery • the root of the left subclavian artery close to the aortic arch, or • directly from the aortic arch. in addition, there may also be doubling of the vertebral arteries.1 there are complications associated with anomalous vertebral artery origin; these include: • atherosclerosis at the anomalous vertebral artery origin • increased likelihood of dissection • absence of the left inferior thyroid artery • abnormal haemodynamics with intracranial complications.2 during a one-week period, we observed 5 patients with an anomalous origin of the left vertebral artery. they were all imaged in our after-hours radiology unit. four patients had ct angiography for penetrating neck trauma, and 1 patient had ct angiography of the chest for blunt trauma. figs 1 4 demonstrate the anomalous vertebral arteries and some of the complications encountered. fig. 1. (a) ct angiogram (b) and 3d reconstruction. the left vertebral artery (white arrows) with anomalous origin from the aortic arch distal to the left subclavian artery was demonstrated in one patient. fig. 2. (a) ct angiogram and (b) 3d reconstruction. left vertebral artery (white arrows) arising from the aortic arch between the left carotid and the left subclavian arteries was demonstrated in 4 patients. fig. 3. ct angiography of the chest demonstrating a contained false aneurysm at the aortic isthmus (black arrows) in the (a) sagittal and (b) axial planes. fig. 4. (a) digital subtraction angiography demonstrating a covered endovascular stent within the aortic arch which covers the left subclavian artery origin (black arrow). (b) follow-up ct angiography in the same patient demonstrating a hypodense thrombus (large white arrow) at the left subclavian artery origin. the left subclavian artery is perfused from the left vertebral artery (small white arrow), i.e. the subclavian steal phenomenon. discussion the cluster of cases observed in our unit within such a short period raised the following questions: • was this cluster of cases entirely random and incidental? • is the incidence of anomalous origin of the left vertebral artery possibly higher than the reported 5%? • could the current increased frequency of cross-sectional imaging play a role in the suspected (but yet unconfirmed) increased radiological observation of this anomaly? we consider prospective reporting of anomalous origin of the left vertebral artery to be important as the anomaly has significant clinical and surgical implications during endovascular treatment of aortic arch injuries and during angioplasty and stent procedures in conditions such as aortic coarctation. stent coverage of the left subclavian origin in such procedures results in perfusion of the left subclavian artery by way of the subclavian steal phenomenon from a normally positioned left vertebral artery, as demonstrated in fig. 4b. however, when a patient who has an anomalous left vertebral artery (i.e. vertebral artery origin from the aortic arch) requires endovascular treatment, stent coverage can occlude the left vertebral artery origin. this will preclude the subclavian steal phenomenon from occurring so as to perfuse the left subclavian artery; consequently, surgical re-implantation of the left subclavian artery to the left carotid artery would be mandatory. conclusion and teaching point anomalous origin of the left vertebral artery could be more prevalent than reported in the literature, but a larger cohort is required to confirm this suspicion. we are of the view that the accurate prospective radiological reporting of this anomaly is important, especially in the context of endovascular stent procedures of aortic arch lesions, as the left subclavian artery perfusion would in such cases depend on the subclavian steal phenomenon from a normal left vertebral artery. the presence of an anomalous left vertebral artery kwould require left subclavian re-implantation in such patients.   1. kubikova e, osvaldova m, mizerakova p, el falougy h, benuska j. a variable origin of the vertebral artery. bratislavske lekarske listy 2008;109(1):28-30. 1. kubikova e, osvaldova m, mizerakova p, el falougy h, benuska j. a variable origin of the vertebral artery. bratislavske lekarske listy 2008;109(1):28-30. 2. panicker hk, tarnekar a, dhawane v, ghosh sk. anomalous origin of left vertebral artery — embryological basis and applied aspects. journal of the anatomical society of india 2002;51(2):234-235. 2. panicker hk, tarnekar a, dhawane v, ghosh sk. anomalous origin of left vertebral artery — embryological basis and applied aspects. journal of the anatomical society of india 2002;51(2):234-235. pycnodysostosis.html pycnodysostosis with the focus on clinical and radiographic findings ben barnard, mb chb department of radiology, kimberley hospital complex, kimberley wim hiddema, mb chb department of orthopaedics, pelonomi hospital, university of the free state corresponding author: b barnard (benwbarnard@gmail.com) pycnodyostosis is a rare autosomal recessive disorder that manifests as generalised osteosclerosis of the skeleton as a result of decreased bone turnover. patients tend to suffer from numerous fractures owing to dense, abnormally brittle bones. the syndrome has a number of characteristic clinical and radiographic signs that differentiate it from other osteosclerotic conditions. this report is of a young man with a history of long bone fractures. s afr j rad 2012;16(2):74-76. pycnodyostosis is a rare genetic osteosclerotic disorder first described by maroteaux and lamy in 1962.1 it is an autosomal recessive illness1 that manifests as generalised osteosclerosis of the skeleton as a result of decreased bone turnover.2 patients present with multiple fractures owing to dense, abnormally brittle bones. pycnodysostosis has a number of characteristic clinical and radiographic signs that differentiate it from other osteosclerotic conditions. recognition of these signs is important in order to make the diagnosis and prevent possible complications. case report our patient was a 21-year-old man who presented to the orthopaedic outpatient department with the complaint of a painful left lower leg following a minor fall 2 weeks prior to presentation. he also provided a history of multiple previous long bone fractures over the course of the previous 4 years, including bilateral femur fractures, bilateral tibia fractures and a right humerus fracture. all fractures were preceded by only minimally traumatic events and had been treated conservatively, with the exception of the femur fractures which were surgically managed with open reduction and internal fixatation. the rest of his past medical history was unremarkable. on clinical examination, the patient demonstrated dysmorphic features with short stature and proportionately short limbs. he had a large head, with a small facial structure and jaw. dental examination revealed a narrow palate, crooked teeth with overcrowding, as well as multiple caries. his lower limbs demonstrated angular deformities in keeping with the history of previous fractures. extremities had short digits with dysplastic nails. bloodwork was normal, including serum calcium, magnesium and phosphate. no elevation of the alkaline phosphatase level was found. the patient was sent for a plain film x-ray survey of his axial skeleton and limbs, including extremities. a subacute fracture of the midshaft of the left tibia was noted, with mild angulation and early callous formation. the rest of the long bones demonstrated clear osteosclerosis, with poorly formed but open medullary spaces. evidence of previous fractures of both femurs as well as both tibias was noted. the previous tibia fractures had healed with anterior angular deformities. skull films showed a large cranial vault with persistent open fontanelles and wide sutures, as well as wormian bones. the maxilla was hypoplastic with non-pneumatisation of the frontal sinuses. the mandible was underdeveloped with an obtuse jaw angle. the left acromion was underdeveloped, with a large acromio-clavicular joint space. spool-shaped thoracic and lumbar vertebral bodies were seen, with prominent anterior defects. a spondylolisthesis of l5 on s1 was also noted. films of the hands showed aplastic terminal phalanges in keeping with acro-osteolysis. the characteristic clinical and radiological features exhibited by the patient led to a diagnosis of pycnodysostosis. discussion pycnodysostosis is a rare inherited disorder, with an incidence estimated to be 1.7 per million births.1 , 2 it was first described in 1962 by maroteaux and lamy as a form of dwarfism with craniofacial malformations similar to cleidocranial dysostosis.2 other authors have labeled it the toulouse-lautrec syndrome, as the french painter henri de toulouse-lautrec is claimed to have suffered from the disorder.2 pycnodysostosis is an autosomal recessive disease1 characterised by systemic osteosclerosis owing to decreased bone turnover. during the 1990s, the genetic defect was located on chromosome 1q21 which led to specific genetic testing and accurate diagnosis.1 , 2 a mutation in the gene that codes for the enzyme cathepsin k inhibits the normal functioning of osteoclasts. cathepsin k is a lysosomal cystine protease expressed in osteoclasts that is primarily responsible for degrading collagen type 1 (which forms 95% of the organic bone matrix).1 , 2 , 5 defective osteoclasts cause impaired bone resorbtion and remodelling, which is essential for normal bone maintenance, both during growth and healing. bones in affected individuals are therefore abnormally dense and brittle and easily fracture.1 sparing of the medullary cavity within the long bones is characteristic of the disorder, resulting in normal haematopoietic function.1 , 2 , 4 , 5 the disorder is normally diagnosed at a young age owing to the characteristic phenotypical appearance with proportionate dwarfism and dysmorphic facies.2 it is, however (as in our case), sometimes diagnosed late, as a result of inclination to fractures and infections resulting from increased bone density and impaired bone vascularity.2 cognitive functioning and life expectancy for pycnodysostosis sufferers is normal. several bone diseases should be considered in the differential diagnosis of pycnodysostosis, most importantly cleidocranial dysostosis, osteogenesis imperfecta and osteopetrosis.1 , 2 cleidocranial dysostosis presents similarly to pycnodysostosis, with persistent open fontanelles and cranial sutures; however, it always involves the clavicle (a bone only rarely affected in pycnodysostosis)1 and does not result in overall increased bone density.2 osteogenesis imperfecta patients present with multiple fractures; however, these are more severe than in pycnodysostosis, and have associated features such as choanal atresia and blue sclera.1 osteopetrosis also causes generalised osteosclerosis and increased bone density; however, the medullary cavities in the long bones are obliterated, and patients present with anaemia. increased density of the skull base causes attenuation of foraminae, with resultant compression symptoms of the cranial nerves.2 characteristic clinical and radiographic features of pycnodysostosis are summarized in table 1.1 the diagnosis is primarily based on the aforementioned clinical and radiographic features. however, a cathepsin k gene mutation analysis1 , 2 remains the gold standard confirmatory test. no specific treatment options exist, so treatment is supportive, with fracture prevention and management constituting the most important aspects of clinical care. dental hygiene and regular checkups are also helpful in preventing complications.1 conclusion pycnodysostosis is a rare condition that is diagnosed primarily on its clinical and radiographic features. the importance of recognition of these features in the diagnosis and prevention of future complications is stressed in this case report. 1. mujawar q, naganoor r, patil h, thobbi an, ukkali s, malagi n. pycnodysostosis with unusual findings: a case report. cases journal 2009;2:6544. 1. mujawar q, naganoor r, patil h, thobbi an, ukkali s, malagi n. pycnodysostosis with unusual findings: a case report. cases journal 2009;2:6544. 2. hernandez-alfaro f, arenaz-bua j, serra serrat m, mareque bueno j. orthognathic surgery in pycnodysostosis: a case report. int j oral maxillofac surg 2011;40:106-123. 2. hernandez-alfaro f, arenaz-bua j, serra serrat m, mareque bueno j. orthognathic surgery in pycnodysostosis: a case report. int j oral maxillofac surg 2011;40:106-123. 3. stark z, savarirayan r. review osteopetrosis. orphanet journal of rare diseases 2009;4:5. 3. stark z, savarirayan r. review osteopetrosis. orphanet journal of rare diseases 2009;4:5. 4. sutton d. textbook of radiology and imaging. 7th ed. kidlington, oxford, uk: churchill livingstone, 2003:1123-1124. 4. sutton d. textbook of radiology and imaging. 7th ed. kidlington, oxford, uk: churchill livingstone, 2003:1123-1124. 5. ihde ll, forrester dm, gottsegen cj, et al. sclerosing bone dysplasias: review and differentiation from other causes of osteosclerosis. radiographics 2011;31:1865-1882. 5. ihde ll, forrester dm, gottsegen cj, et al. sclerosing bone dysplasias: review and differentiation from other causes of osteosclerosis. radiographics 2011;31:1865-1882. 6. ferreira costa al, de castro lopes sl, de almeida sm, steiner ce. pycnodysostosis: an early case report with emphasis on the radiographic findings. internet journal of dental science 2006;3:2. 6. ferreira costa al, de castro lopes sl, de almeida sm, steiner ce. pycnodysostosis: an early case report with emphasis on the radiographic findings. internet journal of dental science 2006;3:2. fig. 1. ap and lateral skull x-rays reveal a large cranial vault with persistent open sutures and fontanelles as well as wormian bones. hypoplastic facial bones with non-pneumatisation of the frontal sinuses and an underdeveloped mandible with an obtuse jaw angle are also demonstrated. fig. 2. ap x-ray of both hands demonstrate short stubby fingers with dysplastic nails and acro-osteolysis. table 1. characteristic clinical and radiographic features of pycnodysostosis clinical features radiographic findings general short stature with proportionate dwarfism generalised osteosclerosis multiple fractures multiple fractures of varying ages sparing of the medullary cavities of long bones head and neck large head with frontal and parietal bossing sclerotic calvarium and skull base hypoplastic facial bones with dysmorphic features hypoplastic facial bones, including mandible incomplete pneumatisation of the paranasal sinuses persistent open anterior fontanelle persistent open anterior fontanelle persistent open cranial sutures with wormian bones obtuse mandibular angle obtuse mandibular angle micrognathia micrognathia dental abnormalities dental abnormalities snoring and stridorous breathing thorax narrow chest aplastic acromion and/or distal clavicles pectus excavatum spine and pelvis kyphoscoliosis kyphoscoliosis increased lumbar lordosis increased lumbar lordosis dense vertebral bodies with sparing of the transverse processes failure of complete segmentation of the atlas, axis and lower lumbar vertebrae spool-shaped vertebral bodies limbs joint hypermobility widening of the distal femur coxa valga extremities broad hands and feet abnormal radio-ulnar articulation short fingers acro-osteolysis (aplastic terminal phalanges with loss of ungual tufts) dysplastic nails abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) monica van wijk division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, south africa michelle m. barnard sub-directorate medical imaging services, directorate: health technology, western cape department of health, cape town, south africa amanda fernandez sub-directorate medical imaging services, directorate: health technology, western cape department of health, cape town, south africa keith cloete sub-directorate medical imaging services, directorate: health technology, western cape department of health, cape town, south africa matodzi mukosi tygerberg hospital, department of health, western cape government, cape town, south africa richard d. pitcher division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, south africa citation van wijk m, barnard mm, fernandez a, cloete k, mukosi m, pitcher rd. trends in public sector radiological usage in the western cape province, south africa: 2009–2019. s afr j rad. 2021;25(1), a2251. https://doi.org/10.4102/sajr.v25i1.2251 original research trends in public sector radiological usage in the western cape province, south africa: 2009–2019 monica van wijk, michelle m. barnard, amanda fernandez, keith cloete, matodzi mukosi, richard d. pitcher received: 23 july 2021; accepted: 23 aug. 2021; published: 30 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: although global use of medical imaging has increased significantly, little is known about utilisation trends in lowand middle-income countries (lmics). objectives: to evaluate changes over a decade in public sector diagnostic imaging utilisation at provincial level in a middle-income country. method: a retrospective analysis of medical imaging utilisation in the western cape province of south africa in 2009 and 2019. use of conventional radiography, ultrasonography (us), fluoroscopy, ct, mri, digital subtraction angiography (dsa) and whole-body digital radiography was assessed by total studies and studies/103 people, for the whole province, the rural and metropolitan areas. mammography utilisation was calculated for every 103 females aged 40–70 years. results: the provincial population and total imaging investigations increased by 25% and 32%, respectively, whilst studies/103 people increased by 5.5% (256 vs 270/103), with marked variation by modality. provincial us, ct and mri utilisation/103 people increased by 111% (20 vs 43/103), 78% (10 vs 18/103) and 32% (1.9 vs 2.5/103) respectively, whilst use of fluoroscopy (3.6 vs 3.7/103) and mammography (14.2 vs 15.9/103 women aged 40–70 years) was steady and plain radiography decreased by 20% (216 vs 196/103). for ct, mammography and fluoroscopy, percentage utilisation increases/103 people were higher in the rural than metropolitan areas. conclusion: population growth is the main driver of overall imaging utilisation in our setting. the relatively constant imaging workload per 1000 people, albeit with increasing ultrasound, ct and mr utilisation, and decreasing use of plain radiography, reflects improved provincial imaging infrastructure, and appropriate use of available resources. keywords: radiology; trends; utilisation; middle-income country; healthcare; public sector. introduction there have been remarkable advances in diagnostic imaging since the discovery of x-rays just over 120 years ago, with the evolution of fluoroscopy, angiography, mammography and ct. additionally, in the last 60 years, modalities that do not utilise ionising radiation, namely ultrasound (us) and magnetic resonance (mr), have emerged, whilst progress in information technology in the last three decades has yielded picture archiving and communication systems (pacs), radiology information systems (ris), fully digital, paperless radiology departments and teleradiology. these developments have entrenched diagnostic imaging as a pivotal clinical service.1,2,3,4 between 1988 and 2016, annual global imaging investigations increased by 161% from 1.38 to 3.6 billion studies, representing an average annual increase of approximately 6%.5,6 however, the growing global demand for imaging is a challenge, since radiological services are capital and labour intensive, demand high levels of technical expertise and may involve the hazards of ionising radiation.4,5,6,7 despite medical imaging currently accounting for approximately 10% of the total per capita healthcare expenditure in well-resourced environments, radiological needs are perceived to remain unmet.8,9,10 increased utilisation is predominantly in the more sophisticated modalities.3,4,11 in the united kingdom, from 2012 to 2020, the average annual ct, mr, us and x-ray utilisation increased by 10%, 9%, 5% and 1%, respectively.12 between 2003 and 2019, mr utilisation in canada and the united states showed an average annual increase of 10% and 5%, respectively, whilst the corresponding average annual ct usage increased by 7% and 5%, respectively.13 advances in imaging technology have the potential to compound inequity in global access to services. well-resourced environments, with an aging population and a high prevalence of non-communicable diseases tend to have a ready supply of trained imaging personnel and state-of-the-art equipment, but are confronted by over-utilisation, unsustainable imaging consumption and an escalating population exposure to ionising radiation.5,14,15,16 conversely, many lowand middle-income countries (lmics) have a disease burden largely related to poverty and lack of access to basic medical imaging, particularly in the rural areas.17,18,19 of note, organisation for economic cooperation and development (oecd) countries average 14 mri and 25 ct units per million people, compared to an average of 0.1 mri and 0.6 ct units per million people in southern and east african countries.20,21,22 increased imaging resources are associated with increased utilisation of radiological services. in the last decade, an estimated 1245 imaging investigations per 1000 people were performed in the united states, of which 949 made use of ionising radiation, including 149 ct scans; european commission countries averaged 505 ionising radiation investigations per 1000 people, including 79 ct scans; oecd countries averaged 144 ct scans per 1000 people.4,13,23 by contrast, an analysis of imaging utilisation in the public healthcare sector of south africa’s (sa) western cape province (wcp) in 2017 documented 262 radiological examinations per 1000 people, 218 utilising ionising radiation, including 16 ct scans.24 however, little is known about temporal trends in lmic public-sector imaging utilisation. it is acknowledged that analyses of registered diagnostic imaging equipment in resource-constrained environments provide useful insights into healthcare access and equity.25,26 trends in imaging utilisation allow appreciation of advances in lmic healthcare infrastructure, assist in defining population-based norms, guide healthcare planning and policy and potentially serve as a yardstick for sustainable imaging practice. such knowledge is also pivotal for the assessment of population radiation exposure, a focus of ongoing analysis by the united nations educational, scientific and cultural organisation.5 south africa is one of just five upper middle-income countries in sub-saharan africa. public sector healthcare is delivered by the district health system (dhs) and administered at provincial level.27 the wcp is the most southern of sa’s nine provinces and comprises six managerial districts. the cape town metropolitan district, with more than 60% of the provincial population, but just 2% of the land area, is surrounded by five rural districts.27,28,29 accordingly, the metropolitan population density exceeds the rural population density by a factor of almost 90 (1682 vs 19 people/km2; 89:1).24 western cape province health services are based on mirrored, tiered referral pathways for the metropolitan and rural areas.30 initial imaging access is typically at community centres with subsequent referral to district, regional and central hospitals with progressive access to more specialised imaging modalities. the central hospitals are university-affiliated tertiary-level teaching institutions. the wcp public sector healthcare infrastructure was considered ideal for the analysis of diagnostic imaging utilisation patterns. there is a digital imaging platform across the wcp, with pacs-integration of services at the various levels of care. this eliminates unnecessary duplication of services by facilitating access to imaging by the various healthcare facilities across the platform. the medical imaging services sub-directorate (missd) within the directorate of health technology (doht) in the wcp department of health (doh) is tasked with collation of all data pertaining to the utilisation of provincial diagnostic imaging services. the aim of this study was to analyse changes over a decade in the utilisation of public sector diagnostic imaging services at the provincial level in a middle-income country. materials and methods this was a retrospective audit of the utilisation of public sector radiological services in the wcp of sa in 2009 and 2019. imaging utilisation data for 2009 and 2019 were extracted from the database of the missd and stratified by imaging modality (plain radiographs, us, fluoroscopy, mammography, angiography, ct, mr) and by geographic location (rural/metropolitan). population statistics for 2009 and 2019 were obtained from the district development model documentation of the department of cooperative governance and traditional affairs and supplied by information handling services (ihs) markit (personal communication, j boshoff). approximately 75% of the wcp population is dependent on public healthcare.31 imaging studies performed per 1000 people reliant on the public healthcare sector were calculated by modality for 2009 and 2019, for the whole province, and for the metropolitan and rural areas.29,31 the ratio of metropolitan: rural studies performed across the modalities was compared for 2009 and 2019. magnetic resonance, digital angiography and lodox whole-body scanning were considered shared/central services. for the analysis, plain radiographs were evaluated in total, as well as by chest x-rays and general x-rays, the latter being all plain radiographs other than chest x-rays. workload was analysed by an absolute number of investigations and investigations per 1000 people. for breast imaging, analysis was by mammograms per 1000 women aged 40–70 years, the screening age recommended by the radiological society of south africa as well as the breast imaging society of south africa.27,32,33 ethical considerations the study was approved by the health research ethics committee of the faculty of medicine and health sciences at stellenbosch university, and by the health research committee of the wcp, under the auspices of the national health research database (project reference 1703; hrec reference: n17/10/098). it was undertaken with the full support of the head of health of the western cape government (wcg) and the imaging task team of the wcg doh. results provincial analysis population between 2009 and 2019, the wcp population grew by 25% (n = 1.36 million people; 5.45 million vs 6.81 million). overall imaging utilisation in the same period, the annual provincial imaging workload increased by 32% (n = 333 807; 1.05 million vs 138 million), with increments across all modalities. ultrasound showed the highest numerical (n = 135 570) and percentage (164%) growth, whilst ct, mr and mammography utilisation grew by 123%, 62% and 59%, respectively. plain x-rays were the most common investigation throughout the review period (884 981 vs 1 005 545) but showed the lowest percentage growth (14%). in 2009, plain x-rays represented 83% of all imaging investigations, compared to 73% in 2019. by contrast, us increased from 8% to 16% of all provincial imaging investigations. imaging utilisation per 1000 people between 2009 and 2019, the number of imaging investigations/103 people increased from 256 to 270, representing 5% of overall growth, or an average annual increment of just 1.4 studies/103 people. utilisation trends varied across modalities. (see tables 1 and 2). table 1: overall utilisation. table 2: utilisation per 1000 people. ultrasounds/103 people more than doubled (20 vs 43; 111%) whilst ct utilisation increased almost 80% (10 vs 18; 78%) and that of mr by nearly one third (1.9 vs 2.5; 32%). the use of fluoroscopy (3.6 studies/103 people) and mammography (14.2 vs 15.9 studies/103 women aged 40–70 years) was steady, whilst that of general radiography declined 14%, from 216 to 196 studies/103 people. metropolitan versus rural analysis population the city of cape town population growth of 26% (n = 913 000; 3.48 million vs 4.39 million) was slightly higher than the 23% (n = 444 630; 1.97 million vs 2.42 million) recorded in the rural districts. in 2009, 63.8% of the wcp population lived in the city of cape town, compared to 64.5% in 2019. overall imaging utilisation the rural districts recorded higher percentage increases in the more sophisticated imaging modalities such as ct, fluoroscopy and mammography. this was particularly true for ct, where rural workload increased 144–fold (n = 14 066; 98 vs 14 164). imaging utilisation per 1000 people metropolitan use of the more sophisticated imaging modalities was higher than the rural use throughout the review period, although differences were smaller in 2019. for example, ct utilisation per 103 people was 240 times higher in the metropole in 2009, compared to 3-times higher in 2019. there was substantial and comparable growth in us usage in the metropolitan and rural districts, whilst chest radiography declined in similar measure in both metropolitan and rural districts. discussion to our knowledge, this is the most detailed analysis of utilisation trends for public sector radiological services in either a lowor a middle-income country. it, therefore, represents a key reference, contributing to crucial discussions on equitable access to healthcare and appropriate and sustainable utilisation of diagnostic imaging in less resourced environments. it can serve as a benchmark and stimulate similar work in this domain. there are five key findings. firstly, whilst the provincial population expanded 25% and the overall radiological workload increased 32%, the corresponding increment in investigations per 1000 people was just 5%, suggesting that population growth is the main driver of overall imaging utilisation in our setting. secondly, whilst there was relatively little change in the number of studies per 1000 people, there was marked variation in utilisation by modality, broadly characterised as increased use of us, ct and mr, and decreased recourse to plain radiography. thirdly, the work provides key health system planning data for population growth, showing that for every 1000 people, healthcare infrastructure is required for approximately 260 imaging investigations per annum, if overall provincial access to radiological services is to be maintained. fourthly, the study highlights the importance of invoking dual analyses when assessing healthcare utilisation trends. both the absolute number of patient interactions and the number of patient interactions per 1000 people are key utilisation indicators. fifthly, in our setting, and across all modalities, utilisation of imaging services per 1000 people remains substantially lower than that documented in well-resourced environments. the wcp population expansion of 25% in the review period was higher than the south african national average of 19% and was impacted by migration and improved health indicators.27,32 between 2006 and 2021, the wcp had south africa’s second-highest provincial in-migration (after gauteng), gaining almost 900 000 inhabitants through interprovincial or international relocation.27 additionally, key health indicators improved in the review period, with 5.8% and 7.5% increased life expectancy for females (67.2 vs 71.1 years) and males (61.1 vs 65.7 years), respectively, 75% reduction in mother-to-child hiv-transmission (11.8% in 2008 vs 3.4% in 2018), 38% reduction in mortality amongst children aged 1–59 months and 29% decrease in neonatal deaths.27,34 the finding that radiological workload tends to be diverted from plain radiography, with increasing availability of newer modalities such as us, ct and mri, is intuitive. for many years, observers have noted that the number of providers of a given medical service is closely related to the rate at which the service is used.35,36 however, to date, this trend has not been formally documented or quantified for diagnostic imaging. the demonstration that the number of radiological investigations per 1000 people remains relatively constant, despite the increasing availability of newer modalities is of particular interest. this suggests prudent use of wcp radiological resources. it is in line with smith-bindman’s contention that newer imaging tests should replace, not supplement, older, less accurate modalities, in the interest of cost containment.3 trends in wcp imaging utilisation by modality reflect the expansion of provincial radiological infrastructure in the review period. key developments included the introduction of three new rural and four new metropolitan ct services, the commissioning of a new rural mammography service and a 50% increase in the operating hours of one provincial mr facility. additional us services were introduced at seven sites between 2015 and 2019 (49 vs 56 centres) and basic medical imaging services were introduced in five healthcare centres. for each new service, appropriate additional radiologist, radiographer and sonographer resources were recruited.37,38 this study also provides novel insights into the utilisation of wcp radiological services, compared to high-income countries (figures 1). western cape province plain radiograph utilisation (216 vs 196 studies/103 people in 2009 and 2019, respectively) was less than one third of the united states (722/103 people) in 2010 and approximately half of european usage (410/103 people) in 2008.4,23 local us workload (20 vs 40 studies/103 people) from 2009 through 2019 was consistently 8–9 fold less than the united states (177 vs 347/103 people) and canada (188 vs 386/103 people) between 2000 and 2016.39 western cape province ct studies in 2009 and 2019 (10 vs 18.2/103; 78% increase) were approximately one sixteenth and one tenth of average figures for the united states (252 vs 278/103; 10% increase), canada (123 vs 156/103; 27% increase) and australia (93 vs 141/103; 52% increase) in the same years, respectively.13 similarly, wcp mri workload during the review period (1.9 vs 2.5 studies/103 people; 32% increase) remained, on an average, 26 times lower than the corresponding annual figures for the united states (96 vs 128/103 people; 33% increase), canada (43 vs 55/103 people; 28% increase) and australia (21 vs 51/103 people; 143% increase).13 local mammography utilisation (15 studies/103 women) in the eligible population is approximately 45-times lower than in the united kingdom.40 figure 1: comparison of western cape province imaging trends with published international trends, 2009–2019. (a) comparison of computed tomography utilisation, (b) comparison of magnetic resonance imaging utilisation. a major strength of this study is the consistent and meticulous collation of imaging utilisation data by a central provincial body constituted for a specific purpose. the reported data are unique in the south african context, and to our knowledge, across all lmics. a weakness is the absence of detail regarding the clinical indication for imaging, specifics of imaging protocols, particularly the anatomical region of studies and demographic particulars of the imaged population. going forward, consideration should be given to collating these additional data, which could enhance the understanding of the complex relationship between burden of disease and imaging utilisation. a further limitation is the absence of detailed corresponding data on provincial equipment and personnel resources through the review period. data pertaining to the radiological workforce are available from the register of the health professions council of south africa (hpcsa). in the wcp, between 2011 and 2019, registered sonographers increased by 135% (46 vs 108), registered radiographers increased by 57% (795 vs 1247) and registered radiologists increased by 26% (186 vs 234). however, these numbers include both the public and private sectors and reflect the address at the time of hpcsa registration, rather than on-going employment in the wcp.37 further detailed data would have contributed to a more insightful analysis of the impact of improved imaging infrastructure on utilisation of resources. of note, since 2014, detailed data on provincial equipment and personnel have been collated and can be correlated with utilisation trends in future analyses. an additional limitation is the potential under-reporting of us studies. such investigations are increasingly performed by medical practitioners outside the domain of diagnostic imaging and are not reported in this analysis. a final limitation was the inability to accurately stratify the female population aged 40–70 years by geographical region (metropolitan/rural). accordingly, the analysis of mammography utilisation was for the province as a whole. it is hoped that this work will serve as a yardstick for analyses of imaging utilisation in resource-limited settings and will stimulate further work in this domain, particularly in other south african provinces. conclusion from 2009 to 2019, imaging use in the public healthcare sector of the wcp increased in total, with the greatest increase in the advanced modalities, which have correspondingly become more accessible to rural populations. imaging utilisation rate per 1000 was maintained at approximately 260 studies, indicating that population growth was the main driver of the increase in imaging. this number provides an important yardstick for sustainable imaging practice and overall access needs of an lmic. total and population-based frequency of imaging is substantially lower than that of well-resourced settings. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions the concept was conceived by r.d.p., k.c. and m.m. r.d.p. and m.v.w. prepared the protocol. m.b. and a.f. collected and collated the data. data analyses were conducted by m.v.w. and r.d.p. the manuscript was prepared by m.v.w. and refined by r.d.p. m.m.b., a.f., k.c. and m.m. provided critical review and contributed to the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article as tables. raw data were generated at the missd and are available from the corresponding author, m.v.w. disclaimer all views expressed in this 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https://digital.nhs.uk/data-and-information/publications/statistical/breast-screening-programme/england---provisional-statistics-2018-19 abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) sabelo h. mabaso department of radiology, faculty of health sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg, south africa deepa bhana-nathoo department of radiology, faculty of health sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg, south africa susan lucas department of radiology, faculty of health sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg, south africa citation mabaso sh, bhana-nathoo d, lucas s. an audit of ct brain findings in adults with new-onset seizures in a resource restricted setting in south africa. s afr j rad. 2022;26(1), a2294. https://doi.org/10.4102/sajr.v26i1.2294 original research an audit of ct brain findings in adults with new-onset seizures in a resource restricted setting in south africa sabelo h. mabaso, deepa bhana-nathoo, susan lucas received: 05 sept. 2021; accepted: 02 nov. 2021; published: 20 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: globally, adults presenting with seizures account for 1% – 2% of visits to emergency departments (eds), of which 25% are new-onset seizures. neuroimaging is essential as part of the initial workup. multiple studies have demonstrated abnormal ct brain (ctb) findings in these patients. objectives: to review the ctb findings in adults presenting with new-onset seizures in a resource restricted setting. method: a retrospective review of 531 ctbs was conducted at a tertiary hospital in gauteng on adults presenting to the ed with new-onset seizures. results: the mean age of the patients was 45.6 ± 17.1 years, and the male to female ratio was 1.2:1. generalised and focal seizure types were almost equally represented. of the total 531 patients, 168 (31.6%) were hiv positive. the ctb findings were abnormal in 257 (48.4%) patients, albeit vascular pathology accounted for 21.9%. infective pathology accounted for 14.1% with a statistically significant association with hiv (p = 0.003). trauma related pathology was 2.4%, whilst neoplastic pathology was seen in 3.0%. other causes included congenital pathology, calcifications, atrophy and gliosis. clinical factors associated with abnormal ctb findings were age ≥ 40 years, hiv infection, hypertension, focal seizures, low glasgow coma scale (gcs), raised cerebrospinal fluid (csf) protein and presence of lymphocytes. conclusion: a high yield of abnormal ctb findings was noted in adult patients who presented with new-onset seizures, supporting the use of urgent ctb in patients with certain clinical risk factors. patients without these risk factors can be scanned within 24–48 h in a resource restricted setting. keywords: new-onset; first-onset; adult-onset; seizure; ct findings. introduction globally, adults presenting with seizures account for up to 2% of visits to medical emergency departments (eds)1,2,3,4 and of these, 25% are new-onset seizures.1,5 it is estimated that 5% – 10% of the population will experience a seizure in their lifetime.3,6,7 according to gavvala and schuele,5 seizures represent ‘a transient occurrence of signs and symptoms due to excessive neuronal activity in the brain’. they may be classified simply as focal (affecting a single cerebral hemisphere), generalised (affecting both hemispheres) or unknown1,5 in a clinical setting, seizures are defined in a specific manner. gavvala and scheule5 described them as follows: unprovoked seizure, occurring without precipitating factors; acute asymptomatic seizure, occurring in close temporal relationship with a transient brain insult; focal seizure, affecting one part of cerebral hemisphere; generalised seizure, distributed in both cerebral hemispheres; and epilepsy, an enduring predisposition to generate seizures. the estimated incidence rate of adult-onset seizures is 81.7 per 100 000 per year in developing countries compared to 45.0 per 100 000 per year in developed countries, as reported by ba-diop et al.8 the incidence rate of new-onset adult seizures is higher in hiv positive populations.9 another study noted that the majority of patients that were severely immunosuppressed had an underlying, identifiable intracranial abnormality,10 confirming the predisposition of patients with advanced hiv to opportunistic infections as a cause of new-onset seizures. patients with new-onset seizures require imaging as part of their clinical workup.1 multiple international studies have demonstrated varying degrees of abnormal ct brain (ctb) findings,3,5,7 however, the urgency or optimal timing of imaging has not yet been determined. computed tomography is the initial imaging of choice, being the most practical, especially in the emergency setting and for those requiring follow-up imaging to monitor disease progression.6,7 magnetic resonance imaging (mri) may be utilised as supplementary imaging, where ctb findings are inconclusive or for further characterisation.3,5 the purpose of this study was to determine the underlying ctb findings in adults with new-onset seizures and to identify specific risk factors, if any, that may contribute to the urgency or timing of imaging. research methods and design a retrospective cross-sectional study of 531 adult patients was conducted, reviewing the ctb findings in cases with new-onset seizures at a tertiary hospital in gauteng, south africa, between 01 january 2016 and 31 december 2018. patients with missing data, illegible reports, those presenting with acute trauma, repeat scans for patients with a known diagnosis and ctb findings not reviewed by a consultant radiologist were excluded from the study. clinical information including patient age, sex, type of seizure (generalised, focal or status epilepticus) and co-morbidities (including hiv status) were accessed and recorded from the hospital picture archiving and communication system (pacs). relevant laboratory results were accessed from the national health laboratory services (nhls) and relevant clinical data were recorded and tabulated using an anonymous data collection sheet. categorical variables were expressed as numbers and percentages and compared with the chi-square test. continuous variables with a normal distribution were expressed as means and standard deviation (s.d.). the median and interquartile ranges (iqr) were used for continuous variables with a non-normal distribution. the one-way analysis of variance (anova) was used to compare normally distributed continuous variables and the kruskal-wallis rank test was used to compare medians for non-normal data. differences between groups were considered statistically significant at p < 0.05. all analyses were conducted using stata mp version 13.0 (statacorp, texas). ethical considerations the study was approved by human research ethics committee of the university of the witwatersrand, certificate number m190609. participant consent was not required as this was a retrospective record review and to maintain strict anonymity, no personally identifiable information was recorded. results of the included 531 patients, 285 (53.7%) were male. the ages ranged from 18 to 95 years with a mean age of 45.6 years (s.d.: ± 17.1) and a median age of 44 years (iqr: 32–59 years). demographic data and major abnormal findings are presented in table 1. table 1: demographic data of patients presenting with new-onset seizures. clinical and laboratory data there were 94 (17.7%) focal seizures, 95 (17.9%) generalised seizures and 14 (2.6%) cases of status epilepticus; 328 (61.8%) were undocumented. the glascow coma scale (gcs) was documented in 104 patients with a median gcs of 13 (iqr: 9–14). the gcs was < 8 in 16 (15.4%) patients, between 9 and 12 in 29 (27.9%) patients and between 13 and 15 in 59 (56.7%) patients. abnormal ctb findings were more frequent in patients with a gcs ≤ 12 (p = 0.175). a total of 168 (31.6%) patients were hiv positive, while 225 (42.4%) had undocumented hiv statuses. there was a significantly high prevalence of hiv in the 30–49 years age group (p < 0.001). the cd4 count was documented in 124 hiv positive patients with a median cd4 count of 229 cells/μl (iqr: 52 cells/μl – 430 cells/μl); 48.4% were below 200 cells/μl. hypertension was present in 78 (14.7%) patients. there was a statistically significant prevalence of hypertension above the age of 49 years (p < 0.001). diabetes mellitus was documented in 23 (4.3%) patients and was significantly prevalent above the age of 59 years (p = 0.001). there were 16 (3.0%) patients with chronic kidney disease and 42 (7.9%) with other co-morbidities including 18 (3.3%) cases of tuberculosis, 11 (2.1%) cases of known primary malignancy, 4 (0. 8%) cases of eclampsia, 6 (1.1%) cases of systemic lupus erythematosus and 3 (0.6%) cases of liver disease. laboratory data included renal function, full blood count and cerebrospinal fluid (csf) analysis. a high prevalence of abnormal ctb findings was seen in patients with a white cell count above 10.0 × 109/l (p = 0.011). abnormal ctb findings were also more prevalent in patients with a csf protein above 0.45 g/l (p = 0.033); csf lymphocytosis was significantly associated with abnormal ctb findings (p = 0.004). ct brain findings the ctb findings were abnormal in 48.4% of the cases. the aetiologies of the abnormal ctb findings are presented in table 2. of the 116 vascular cases, 60 (51.7%) had infarcts, 12 (10.3%) intracerebral haemorrhages and 3 (2.6%) vascular malformations. there were 41 (35.4%) cases of vascular pathologies related to white matter changes, of which most were suggestive of chronic small vessel ischemic disease and posterior reversible encephalopathy syndrome. selected images of vascular related pathology are demonstrated in figure 1. table 2: proportions of abnormal ctb findings and cause categories in patients with new-onset seizures. figure 1: vascular pathology as a cause of adult-onset seizures. (a and b) hypertensive intraparenchymal haemorrhage in a 56-year-old male with newly diagnosed hypertension. axial non-enhanced ct (nect): left thalamic haemorrhage with minimal surrounding oedema. associated intraventricular blood. (c and d) chronic right middle cerebral artery territory infarction in an adult patient with index episode of seizures. axial and coronal nect: right mca territory wedge-shaped hypodensity with mild right lateral ventricular ex vacuo dilatation. (e) right occipital lobe arteriovenous malformation in a 53-year-old female with no background medical history. axial contrast enhanced ct (cect): ‘bag of worms’ appearance of draining and feeding vessels in the right occipital lobe. seven (9.3%) of the 75 infective cases had features suggestive of meningitis, 6 (8.0%) pyogenic abscesses, 14 (18.7%) neurocysticercosis and 3 (4.0%) toxoplasmosis. the other cases were attributable to tuberculosis, cryptococcosis and miscellaneous infective white matter disease disorders. of the tuberculosis cases, 7 (9.3%) had tuberculous meningitis, whilst 12 (16.0%) were attributable to tuberculomas and tuberculous abscesses. there were 26 (34.7%) cases of white matter changes related to infection, of which herpes encephalitis was seen in 6 (8.0%) patients, cerebritis in 5 (6.7%) cases, suspected hiv encephalopathy in 9 (12%) cases and progressive multifocal leukoencephalopathy in 6 (8.0%) cases. selected images of infective pathology are shown in figure 2. figure 2: infective pathology as a cause of adult-onset seizures. (a and b) herpes simplex (hsv) encephalitis in a young immunocompromised female patient. axial nect: bilateral anterior temporal lobe oedema with hyperdense foci in keeping with microhaemorrhages. (c and d) neurocysticercosis in a 47-year-old male with newly diagnosed hiv. axial contrast enhanced ct (cect): multiple bilateral non-enhancing round csf density cystic intra-axial lesions of varying sizes with central hyperdense scolices (dot sign). (e and f) hiv positive patient on tuberculosis treatment. coronal and axial cect: large right frontal lobe ring-enhancing lesion adjacent to the right lateral ventricle. surrounding vasogenic oedema with associated mass effect. a differential diagnosis of a pyogenic or a tuberculous abscess was given. (g and h) a 53-year-old hiv positive male patient. cd4 = 26 cells/μl. axial cect: multiple ring-enhancing lesions with vasogenic oedema in the cerebellum and corticomedullary junction of cerebrum. a differential of toxoplasmosis and tuberculomas was given. neoplastic pathologies were seen in 16 (3.0%) of the patients, of which 9 were primary central nervous system (cns) neoplasms whilst 7 were secondary cns neoplasms. selected images of neoplastic pathology are shown in figure 3. the ct findings in neoplastic or infective cases were diagnosed largely on clinical and imaging work up and treated accordingly. not all cases had histological or microbiological confirmation at the time of the study. figure 3: neoplastic pathology as a cause of adult-onset seizures. (a and b) meningioma in a 64-year-old female with worsening of left arm weakness and new-onset seizures. sagittal contrast enhanced ct (cect). (brain and bone window): large right frontal avidly enhancing extra-axial mass with associated hyperostosis of the adjacent skull inner table as well as mass effect and oedema of the adjacent parenchyma. (c and d) left frontal lobe mass in a 59-year-old female who presented with new-onset seizures. axial and coronal non-contrast ct (ncct): large left frontal lobe solid round intra-axial heterogeneously hyperdense mass with surrounding vasogenic oedema and mass effect on the frontal horn of the left lateral ventricle. a differential diagnosis of metastases or lymphoma was given. e: metastasis from endometroid adenocarcinoma of the endometrium. 69-year-old female with endometroid adenocarcinoma of the endometrium who presented with first onset seizures. axial cect: large ring-enhancing solid-cystic intra-axial mass in the left temporal lobe corticomedullary junction with surrounding oedema. a total of 13 (2.4%) traumatic pathologies were recorded. these were subdural hematoma and old depressed fractures with underlying encephalomalacia. selected images of trauma related pathology are shown in figure 4. figure 4: trauma related pathology as a cause of adult-onset seizures. (a and b) bilateral rectus gyri gliosis in a 49-year-old male with new-onset seizures. sagittal and coronal contrast enhanced ct (cect): hypodensities of bilateral rectus gyri consistent with gliosis. (c and d) left acute subdural hematoma in a 72-year-old male with new-onset seizures and confusion. axial and coronal non-enhanced ct (nect): large left mixed density subdural hematoma with a haematocrit level. associated subfalcine and uncal herniation with right lateral ventricle entrapment hydrocephalus. of the 5 (0.9%) cases with congenital pathology, frontoethmoidal encephalocele accounted for 2 cases, with the other 3 cases being arachnoid cyst, schizencephaly and dandy-walker malformation. a total of 32 (6.0%) unclassified abnormal ctb findings were recorded, 5 cases of calcifications, 5 of atrophy and 22 of gliosis. associations with various ctb abnormalities cerebral oedema was present in 40 cases, midline shift in 26 cases, hydrocephalus in 32 cases and herniation in 10 cases. extra-axial collections were seen in 8 cases associated with infective pathologies. venous sinus thrombosis was noted in 2 cases associated with infection. infarction was present in 12 cases associated with infective pathology. there was higher parietal lobe involvement with vascular and infective pathologies. the basal ganglia were more involved with vascular pathology, whilst extra-axial involvement was seen more in infective and traumatic pathologies. this data is presented in table 3. table 3: ctb abnormality in patients with new-onset seizures characterised by site of involvement. the mean age for vascular pathology was 59.6 years and for infective causes, 41.0 years (table 1). patients with focal seizures had a high prevalence of abnormal ctb findings (p = 0.560). of the patients with neoplastic pathologies that had a recorded seizure type, 50% had focal seizures. the relationship between various pathology categories and seizure type is shown in table 4. table 4: relationship between seizure type and abnormal ctb categories. a large proportion of hiv positive patients had a higher prevalence of infective causes on abnormal ctb imaging (p = 0.003). there were more infarcts, intracerebral haemorrhages, chronic small vessel ischemic white matter disease and posterior reversible encephalopathy syndrome in patients with hypertension. discussion relating to demographics, this study demonstrated a gender distribution that was similar to other studies with a male to female ratio of 1.2:1. a study by zarmehri et al. also consisted of more males, accounting for 62% of their study population.11 in contrast, in a retrospective study performed in south africa by smith et al, their study sample consisted of more females, accounting for 61.2%.7 another study by kaur et al. had 65% male subjects.12 the mean age for abnormal ct brain findings in this study was 51.3 years. in the study by smith et al.,7 the common age of presentation of new-onset seizures was between 31 and 40 years. in another study by zarmehri et al., their study population had a mean age of 39.78 ± 17 years.11 additionally, this study revealed that elderly patients had more abnormal ctb findings. more vascular pathologies were seen in older patients and more infective pathologies in younger and hiv infected patients. kaur et al. showed that 68.1% of patients aged below 40 years had idiopathic seizures.12 this observation suggests that older patients require ctb imaging more urgently than hiv negative younger patients. clinically, smith et al. found that generalised seizures were the commonest seizure type, representing 86.7% of their patients.7 a high prevalence of generalised seizures were also reported by kaur et al. at 59%.12 in contrast, this study showed that focal and generalised seizures were almost equally represented when the seizure type was documented. there was a high prevalence of abnormal ctb scans in patients with focal seizures, but this was not statistically significant (p = 0.560). yang et al. demonstrated similar findings in children, but no comparable study was found in adults.13 the gcs value was recorded in 104 (19.6%) patients. although there was a high number of abnormal ctb scans seen in patients with gcs ≤ 12 (29/45 [64.4%]), this number was not statistically significant (p = 0.175). despite the lack of statistical significance, this observation is similar to international literature. wang et al. demonstrated that altered level of consciousness is a strong predictor of abnormal ctb findings.14 in another study by moolla et al. that looked at adult-onset seizures in hiv positive patients, gcs less than 15 was found to predict space occupying lesions and cerebral oedema.9 the lack of statistical significance in this study may be attributable to the low proportion of recorded levels of consciousness. the hiv prevalence of 31.6% in this study was higher than the 2018 statistics south africa report, which estimated the prevalence of hiv at 13.1%. the age group commonly affected by hiv in our study was similar to the 2018 statistics south africa report which states that 15–49-year-old patients are predominantly affected.15 there was a statistically significant relationship between hiv and infective pathology accounting for abnormal ctb findings (p = 0.003), owing to vulnerability to opportunistic intracranial infections in this group. in a study by sinha et al., the majority of hiv infected patients had opportunistic central nervous system infections, ranging from tuberculosis, cryptococcosis, toxoplasmosis and hiv encephalitis.16 the infections demonstrated in this study included pyogenic abscesses, neurocysticercosis, toxoplasmosis, tuberculosis and cryptococcosis. the other common comorbidities included diabetes mellitus, hypertension and chronic kidney disease, all of which were common in older patients. however, only hypertension showed a statistically significant relationship with abnormal ctb findings (p = 0.012), including infarcts, intracerebral haemorrhages, chronic small vessel ischemic white matter disease and posterior encephalopathy syndrome. this could be explained by an increased risk of stroke and other intracranial complications associated with hypertension. hesdorffer et al.17 found that severe uncontrolled hypertension increased the risk of unprovoked seizures and they postulated the mechanism to be that of epileptogenic white matter changes caused by hypertension. hypertension related central nervous system complications such as intracerebral haemorrhage, subarachnoid haemorrhage and posterior reversible syndrome increase the likelihood of abnormal ctb findings.18 there was a significant association between a high white cell count (above 10.0 × 109/l) and abnormal ctb findings (p = 0.011). this may be related to infective pathologies but we found no supporting literature in this regard. a study by khalili et al. found that a raised white cell count has a low positive predictive value and low specificity for bacterial meningitis.19 elevated csf protein (above 0.45 g/l) was significantly associated with abnormal ctb findings (p = 0.033) in this study, although this is a retrospective association since lumbar puncture is usually performed after ctb imaging. zisimopoulou et al. found a correlation between abnormal csf protein and unprovoked first episodes of seizure, thought to be related to disruption of the blood brain barrier.20 no studies have looked at the direct correlation between abnormal csf protein and ctb findings. the presence of high csf lymphocytes showed a statistically significant correlation with abnormal ctb findings (p = 0.004). this is supported by the findings in the study by zisimopoulou et al., where a high csf cell count correlated with abnormal ctb findings in 71 patients.20 there were 48.4% abnormal ctb findings in this study. according to the literature, abnormal ctb findings range from 10% to 68.9%,5,6,21 most likely underlined by the demographic differences in patients studied as suggested by adams et al.2 additionally, this study did not differentiate between ctbs performed with or without intravenous iodinated contrast as no significant impact was anticipated. studied literature indicated that administration of intravenous contrast does little to change the sensitivity of ctb findings.1,22,23,24 vascular pathology accounted for 21.9% of abnormal ctb findings. these results are similar to a south african study by smith et al., where vascular pathology contributed a larger proportion of ctb abnormalities, with infarcts accounting for 25% and intracerebral haemorrhage 12.5%.7 similarly, kaur et al. showed that stroke was the most common cause of abnormal ctb findings in india, accounting for 23%.12 vascular causes of abnormal ctb were more likely in the patients over 60 years and included ischemic infarction, chronic small vessel white matter disease and intracerebral haemorrhage. this finding confirms that age is a major risk factor for cerebral vascular disease. yousufuddin and young noted that ‘aging is the most robust non-modifiable risk factor for stroke, which doubles every 10 years after age 55 years’.25 similarly, kaur et al., demonstrated that 95.6% of seizures above the age of 40 years were secondary to stroke.12 this study also showed a high occurrence of vascular pathology in the parietal lobe, which is likely due to a higher incidence of stroke in the mca distribution. this finding is supported by ng et al., who found that mca territory infarcts accounted for 50.8% of all ischemic strokes.26 infective pathology constituted 14.1% of abnormal ctb findings and was seen in younger patients and the hiv infected. in the literature, the range of infective pathology ranged between 5.2% and 11.5%.7,12 there was a high frequency of infective pathology in the parietal lobe, likely due to a higher incidence of haematogenous sources of cerebral infection, which is also likely to involve the middle cerebral arterial territory. a review article by patel et al. reported that hematogenous spread accounted for 9% – 43% of cerebral abscesses.27 neoplastic pathology contributed 3.0% to the abnormal ctb findings, occurring in older patients with a mean age of 57.6 years. this is slightly different from the international literature, where neoplastic pathology contributed 8% – 14.8% of abnormal ctb findings.11,12 focal seizures were seen in 50% of cases with neoplastic pathology but there was poor documentation of seizure type and statistical significance was not reached. the fourth common cause of abnormal ctb finding was trauma related pathology, contributing 2.4%. these were largely subdural hematomas and old depressed fractures with underlying encephalomalacia. there was a high frequency of traumatic pathology in the frontal lobe. frontal lobe pathology is more likely to present with seizures, behavioural and personality changes, whilst other areas of brain involvement will have additional focal neurological deficits.28 congenital pathology as abnormal ctb finding in this study was an unexpected finding in patients over the age of 18 years who were unlikely to have their first seizure as adults. it is possible that patients may have been unconscious around the time of the seizure event and were unable to provide a history of previous seizures or there was a lack of thorough history taking. on the other hand, this may be due to loss to follow-up or caregivers seeking alternative opinion in a different health centre. the case of an arachnoid cyst in this study was likely an incidental finding and not the cause of the seizure, as arachnoid cysts are usually asymptomatic.29 cerebral oedema, midline shift and hydrocephalus were the associated findings predominantly seen with infective and neoplastic pathologies. these findings guide the need for urgent medical or neurosurgical intervention. ctb is an ideal imaging modality for the emergent identification of these associated findings due to its ease of access and relatively low cost.30 this study did not investigate the follow-up management of the patients with these associated ctb findings. study limitations this retrospective study was limited by poor documentation of seizure type by the referring clinicians. as a result, p-values were calculated on smaller sample sizes and likely underestimate the power of our findings and the ability to investigate for predictors of abnormal ctb findings. conclusion a high yield of ctb imaging in adult new-onset seizures was demonstrated, with vascular and infective pathologies being the most common. age ≥ 40 years, hiv infection, hypertension, focal seizures, low gcs, raised csf protein and lymphocytes were identified as predictors of an abnormal ctb, and patients with these risk factors should be scanned urgently for prompt detection of medical and neurosurgical emergencies. other patients without these risk factors, can be imaged as soon as possible within 24–48 h in resource restricted settings. acknowledgements a special thanks to the staff in the radiology department at chris hani baragwanath academic hospital and the university of the witwatersrand post-graduate office in the health sciences faculty for their support. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution s.h.m. was the principal investigator responsible for literature review, data collection and preparation of the manuscript. s.l. and d.b-n. were responsible for the research conception and supervisory roles. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, s.m. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references tranvinh e, lanzman b, provenzale j, et al. imaging evaluation of 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https://doi.org/10.1177/1941874414540684 webster j, taylor a, balchin r. traumatic brain injury, the hidden pandemic: a focused response to family and patient experiences and needs. s afr med j. 2015;105(3):195–198. https://doi.org/10.7196/samj.9014 mustansir f, bashir s, darbar a. management of arachnoid cysts: a comprehensive review. cureus. 2018;10(4):e2458. https://doi.org/10.7759/cureus.2458 kuzniecky ri. neuroimaging of epilepsy: therapeutic implications. neurorx. 2005;2(2):384–393. https://doi.org/10.1602/neurorx.2.2.384 sa journal of radiology • september 2011 97 signs pitfalls associated with interpretation of the fat halo sign specifically involve intestinal distension. the sign has a tendency to disappear or become less apparent when the bowel lumen is more distended.1 it is thought that distension of the bowel lumen causes obscuring of the thin fat layer.1 therefore, the fat halo sign is best appreciated when the lumen is partially collapsed.1 other factors advocating a positive fat halo sign are prone position of the patient, and not using a contrast agent.1 the constellation of 4 signs that strongly suggests the fat halo sign representing a normal variant, as opposed to inflammatory bowel disease, includes increased prevalence in the collapsed state, decreased prevalence with distension of the bowel lumen either by gravity or gas, disappearance of the fat halo sign with additional distension, and a thin calibre of the fatty layer.1 the presence of a normal haustral pattern also supports the sign being a normal variant.1 more commonly, a normal intramural fat layer is seen in the terminal ileum and descending colon.3 it is generally much thinner than the fat layer seen in inflammatory bowel diseases.3 in conclusion: the presence of the fat halo sign may in the absence of clinical and radiological features of inflammatory bowel disease represent a normal finding that may also be related to obesity. 1. harisinghani mg, wittenberg j, lee w, chen s, gutierrez al, mueller pr. bowel wall fat halo sign in patients without intestinal disease. ajr 2003;181:781-784. 2. ahualli j. the fat halo sign. radiology 2007;242:945-946. 3. wittenberg j, harisinghani mg, jhaveri k, varghese j, mueller pr. algorithmic approach to ct diagnosis of the abnormal bowel wall. radiographics 2002;22:1093-1109. the hyperdense mca sign and the mca dot sign n mahomed, mb bch, fcrad (d) department of radiology, university of the witwatersrand, johannesburg corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) the hyperdense middle cerebral artery sign (hmca), first described in 1983, refers to the hyperattenuation of the middle cerebral artery (mca) m1 segment on non-enhanced computed tomography (ct).1,2 the sign is due to a thromboembolus of the m1 segment of the mca. because the sign is a marker of vascular occlusion rather than a direct image of the resulting parenchymal changes, the hmca sign can be considered an indirect indicator of subsequent infarction and is one of the earliest signs of ischaemic stroke.3 the mca dot sign is a punctate focus of hyperattenuation located in the sylvian fissure on non-enhanced ct, and is a recently described variant of the hmca sign.3 the sign represents a thromboembolus within a segmental branch of the mca, m2 or m3 segment, located within the sylvian fissure.3 as the m2 and m3 segmental vessels tend not to course in the transverse plane of imaging, the occluded vessel is seen in cross section, appearing as a hyperattenuating dot within the sylvian fissure.3 while the hmca sign and mca dot sign are similar in that they both depict thromboembolus at different levels of the mca, there are important clinical and prognostic distinctions. the hmca sign suggests that a major cerebral vessel is occluded, suggesting a larger territory at risk for hypoperfusion compared with the more distal vessel occlusion of the mca dot sign. therefore, the mca dot sign in the absence of the hmca sign is associated with improved short-term clinical outcome.3 these signs have a high specificity of almost 100 % with a high positive predictive value but a low sensitivity of approximately 38 40% for thromboembolic occlusion of the mca.1-3 mimics of the hmca sign, the pseudo hyperdense mca sign, include vascular calcification, raised haematocrit, intravenous contrast and partial volume averaging.1 another important cause of a pseudo fig. 1. hmca sign. non-enhanced axial ct brain (at the level of the suprasellar cistern) in a patient with sudden onset left hemiparesis demonstrates hyperattenuation (measuring 82 hu) of the right middle cerebral artery, which is suggestive of occlusion of this artery and is an indirect sign. there is also diffuse hypodensity of the right temporal lobe, a direct sign of ischaemic stroke. signs 98 sa journal of radiology • september 2011 hyperdense mca sign is a normal density mca appearing hyperdense owing to adjacent abnormal brain parenchymal hypodensity. this may appear in the setting of infection, tumour or contusion.1 in a study by koo et al. to establish the objective criteria for the hmca sign, the authors concluded that an absolute attenuation value of 43 hounsfield units (hu) of the abnormal mca and a ratio of more than 1.2 between the abnormal mca attenuation compared with the normal contralateral mca attenuation, identified all the hyperdense mcas associated with acute ischaemic stroke.4 non-enhanced ct of the brain is usually the first diagnostic study performed for the investigation of acute neurologic symptoms and signs as it is sensitive for haemorrhage and less expensive than mr. early non-enhanced ct scans can be an invaluable tool in detecting these indirect signs of acute infarction and are helpful for accurate and prompt management of these patients.3 1. jha b, kothari m. pearls & oysters: hyperdense or pseudohyperdense mca sign: a damocles sword? neurology 2009;72:e116-e117. 2. chavhan gb, shroff mm. twenty classic signs in neuroradilogy: a pictorial essay. indian j radiol imaging 2009;19:135-145. 3. shetty sk. the mca dot sign. radiology 2006;241:315-318. 4. koo ck, teasdale e, muir kw. what constitutes a true hyperdense middle cerebral artery sign. cerebrovasc disease 2000;10:419-423. fig. 2. non-enhanced axial ct brain of the same patient (at the level of the sylvian fissures) demonstrates a hyperattenuating dot (arrow) in the partially attenuated right sylvian fissure, which is more opaque (measuring 70 hu) than any structure in the ipsilateral or contralateral sylvian fissure — the mca dot sign. fig. 3. enhanced axial ct brain done 5 days later (at the level of the suprasellar cistern) demonstrates evolution of the complete right mca ischaemic stroke with significant mass effect and features of luxury perfusion. case report case report 46 sa journal of radiology • june 2010 case report first rssa short course on current ethical issues in radiology: 23 january 2010 (continued from page 36) arrangements that create a potential or real conflict of interest in the maintenance of professional autonomy and independence can be considered as a perverse incentive. any conflicts of interest, incentives or forms of inducement that threaten such autonomy, independence or commitment to the appropriate professional and ethical rules and policies or that do not accord first priority to the clinical needs of patients, are unacceptable. it is unethical for a health care practitioner to: • refer patients to a facility or for a procedure in which he/she has a financial interest (excepting private hospitals) • share fees with any person who has not taken a commensurate part in the service provided • allow a person (natural or juristic) who does not otherwise qualify as a partner or shareholder to share in the profits or income of a professional practice. the rssa will continue to discourage any form of perverse incentives and kick-backs by its members, and will report any cases where sufficient evidence is available. cases and actions taken by the rssa in instances of suspected kick-backs and perverse incentives were discussed by ms esme prins-van den berg, attorney at law and director of benguela health. what might have commenced as an effort to keep cpd ethics points updated, developed into an interesting meeting which exceeded the audience’s expectations, the vast majority of whom initially saw it as a necessary sacrifice of a beautiful saturday! there has been wide, very positive feedback. the course will be repeated in johannesburg later this year. details may be found at http://www.rssa2010ethics.co.za. congratulations to professor leon janse van rensburg who once again arranged an excellent course; to nelda rousseau and mari horn from consultus for the organisation, to covidien for an educational grant, and to discovery health for administering the cpd certificates. another ‘first’ is the rssa/sgr (society of gastrointestinal radiologists) gastrointestinal radiology course to be held on 7 9 august 2010 at the spier estate a few kilometres outside stellenbosch in the western cape. the long weekend of 7 9 august was chosen to allow more delegates the opportunity to attend. after more than 18 months of review and planning by members of both societies, the 2010 git radiology course was established to meet the important challenges of advancing git imaging. the course offers an extremely well-balanced and full programme, presented by an international faculty of 8 leading and acclaimed academics. they will address a wide variety of topics important to daily practice as well as the basics of techniques such as double contrast radiography and molecular imaging advances. central to the course is the role and application of multi-detector computed tomography (mdct). a course of this nature is essential and long overdue for all south african and african radiologists and should not be missed. international colleagues and clinical specialists as well as diagnostic radiographers will also attend.the course is designed for the general radiologist as well as those with a special interest in git and abdominal radiology. details are on the website www.rssa.co.za. rssa/stoller sports medicine: cape town the exclusive rssa/stoller update sports medicine was held at the bmw pavilion in the v&a waterfront, cape town last march. professor leon janse van rensburg achieved the near-incredible: firstly, in getting dr david stoller (md, facr), the internationally renowned san francisco musculoskeletal radiologist, to agree to lecture outside the usa, and secondly, in actually getting dr stoller to cape town despite high drama and acute stress initiated by the british airways strike – the start had to be rescheduled to accommodate the arrival of the ba flight. vip rapid transit from the aircraft to the venue was arranged with assistance from acsa, and professor janse van rensburg and dr stoller arrived with 30 seconds to spare. dr stoller is an impressive musculoskeletal radiologist and excellent teacher and, despite the demanding programme, was able to infuse the audience with his infectious enthusiasm for musculoskeletal imaging and impress with his detailed structured technique for evaluating mri scans of the joints. the entire first day was dominated by the shoulder and knee, with emphasis on the correct imaging technique and his checklist approach to assessing relevant structures in each of the planes. this is a unique approach that significantly improves musculoskeletal mri interpretation. as the only speaker, dr stoller was able to modify his presentation to ensure that all the material was covered and that audience requests for a recap of several areas could be met. easy switching between more didactic slides and demonstration of analyses of actual workstation cases enhanced the learning experience. dr graeme thompson was the volunteer who found himself on stage at the laptop, analysing a full shoulder case in front of an audience of 300 with dr stoller looking over his shoulder. all credit to graeme for acquitting radioactive news radioactive news from left to right: professor leon janse van rensburg (rssa), dr david stoller (san francisco) and mr graham maritz (ceo, siemens). (photo: dr hein els, tbh) case reportcase report 47 sa journal of radiology • june 2010 himself exceptionally well and keeping the local flag flying high. the remainder of the second day was devoted to the elbow, wrist, hip and ankle. fears that the tough schedule and jetlag might take their toll were unfounded, and dr stoller showed a relaxed side, treating the audience to his sense of humour, a glimpse of philosophy, and an unexpected clip of the young jack nicholson doing things his way! after less than 36 hours in the country, dr stoller flew home, no doubt exhausted and relieved that two gruelling days were over. certainly, the audience appreciated the opportunity to have been enlightened by this leading expert and hoped that, should he venture to south africa again, it would be a more relaxed visit with time to see something of the country. thanks to siemens and bayer healthcare for their generosity in making the event possible, to christelle snyman and the consultus team for the seamless organisation, and the bmw pavilion management for their contribution. the timing of this congress with south africa about to host the world cup and the venue in close proximity to the stadium were appropriate. the south african musculoskeletal imaging group (samsig) is hosting a musculoskeletal congress in botswana from 4 8 october 2010 (http://www.samsig.co.za). the site can also be accessed via a link in the rssa website. rssa/leuven ear imaging course: stellenbosch dr judy ross attended the rssa/leuven ear imaging course conducted by internationally renowned belgium and dutch radiologists on 16 18 april at spier estate, stellenbosch, and commented as follows: i would like to commend the organisers for a brilliant conference which achieved the highest academic standards, focusing on the temporal bone and ear. the lectures were excellent and the interactive teaching sessions with reviews of clinical cases were outstanding. all congress attendants were provided with their own computer for the duration of the congress, with the ability to view and reformat all case-related images, and direct feedback was provided by the relevant clinicians. the programme schedule was strictly adhered to but there was otherwise a wonderfully relaxed atmosphere in beautiful surroundings with all the frills but no fuss. a special commendation must go to the convener professor leon janse van rensburg. i have attended many overseas conferences but none can actually equate with this event. radioactive news professor zarina lockhat and dr david stoller (photo: dr hein els, tbh) professor zarina lockhat of pretoria welcomes dr stoller. (photo: dr hein els, tbh) interactive teaching workshop with faculty members assisting delegates. (photo: dr hein els, tbh) from left to right: dr herve tanghe(rotterdam), dr marc lemmerling(ghent), professor robert hermans (leuven), professor leon j van rensburg( rssa), dr berit verbist( leiden). (photo: dr hein els, tbh) case series 39 sa journal of radiology • june 2010 introduction macrodystrophia lipomatosa (mdl) is described as a rare, non-hereditary, congenital condition presenting with localised macrodactyly and a proliferation of mesenchymal elements. there is in particular a marked increase in fibroadipose tissue.1 we describe 2 young patients presenting to our department in a 6-month period, with a history of disproportionately large limbs since birth. while our first case demonstrated all the typical features of mdl, our second case failed to demonstrate osseous gigantism, but all other features of mdl were present. an extensive search of the literature failed to yield any cases described without osseus gigantism; but at the same time, the other radiological features failed to fit in with any other causes of focal gigantism, and the most appropriate diagnosis appears to be mdl. we therefore concluded that this may be a case of a rare, atypical mdl that was arrested or frustrated and so failed to demonstrate full expression of the syndrome. case 1 a 33-month-old boy was referred by a paediatric surgeon for radiographs of the left arm. according to the history, he was born with the left arm disproportionately larger than the rest of the body. clinically, there was marked increase in the soft-tissue bulk of the entire left arm with focal gigantism involving the thumb and second finger. good functionality of the arm was maintained. radiographs revealed lucent soft-tissue thickening of the affected arm, suggesting the presence of fat (fig. 1). focal gigantism involving the metacarpals and phalanges of the thumb and second finger were noted. the rest of the bony elements were normal. ultrasound (us) examination demonstrated an extensive increase in subcutaneous tissue with poor visualisation of muscles and nerves. normal vascularity was noted on doppler us. us of the abdomen was normal. mri studies showed diffuse proliferation of fatty tissue throughout the arm, with fat infiltration of the muscles (figs 2 4). the nerves imaging of a rare disorder: macrodystrophia lipomatosa farhana ebrahim suleman, mb chb, fcrad (d) sa, mmed rad (d) department of radiology, university of limpopo, medunsa campus, garankuwa margaret kisansa, mb chb, mmed rad (d) department of radiology, george mukhari hospital, garankuwa fig. 1. radiograph of the left upper extremity demonstrates diffuse soft-tissue swelling involving the entire upper limb. soft tissues are lucent, suggestive of fat. multiple skin folds are evident. marked osseous gigantism of the 1st and 2nd fingers noted. humerus, radius ulnar and bony elements of the 3rd, 4th and 5th fingers are within normal limits. fig. 2. axial t1wi through the forearm. there is proliferation of subcutaneous fat that is not encapsulated. the muscles are markedly infiltrated by fat, and the nerve cannot be identified. case series case series 40 sa journal of radiology • june 2010 case series could not be identified on mri, probably owing to infiltration by fat. histological analysis of the tissue revealed adipose tissue only, which was in keeping with a diagnosis of mdl. case 2 an 11-month-old girl was referred by a plastic surgeon for mri to exclude lymphoedema of the right lower limb. according to the history, she was born with the right lower limb disproportionately bigger than the rest of the body. clinically, there was marked increase in soft tissue of the entire right lower limb. good function of the limb was maintained, and the child was otherwise normal. radiographs revealed increased soft tissue throughout the limb, and the underlying bones were normal (fig. 5). us was not performed. mri showed diffuse increase of fat in the soft tissues, as well as scattered cystic lesions of varying signal intensity (figs 6 8). this feature has not been described in the literature reports of other cases of mdl, and was thought to be due to either fat necrosis or old haematomas secondary to trauma. there was no fat infiltration of the muscles, and the neurovascular bundles were intact. once again, histological analysis revealed proliferation of adipose tissue in keeping with a diagnosis of mdl. literature review mdl is a rare congenital disorder of focal gigantism affecting the extremities – more commonly, the second and third digits of the foot, but it may also affect the hand.2,3 it is characterised by the proliferation of all mesenchymal elements but especially of fibroadipose tissue.2,4,5 it is typically described in a particular nerve distribution; usually the medial plantar nerve or median nerve.3 radiological investigations include plain film radiographs, us and mri, where findings may be typical. plain films show lucent soft-tissue overgrowth as well as hypertrophy of osseous structures in the distribution of the median and plantar nerves.1 in our cases, only one patient demonstrated the osseous overgrowth. in the second case, the bony elefig. 3. coronal proton density image of the left upper limb showing osseous gigantism of the 1st finger and diffuse increase of subcutaneous fat with very little muscle bulk. fig. 4. fat-suppressed images of the left upper limb.there is marked suppression of the signal from the subcutaneous fat, confirming the diagnosis of mdl. fig. 5. frontal radiograph of the lower limbs. there is diffuse soft-tissue swelling involving the subcutaneous fat of the right lower extremity more marked in the distal lower leg and foot. soft-tissue skin folds are evident. there is no discrepancy in the bony elements in comparison with the left side. case seriescase series 41 sa journal of radiology • june 2010 ments were within normal limits. in older patients, secondary osteoarthritis changes may also be seen. us reveals large amounts of subcutaneous tissue, infiltration of the muscle and thickening of the affected nerves. doppler studies reveal an absence of any increased vascularity. mri findings are most useful in confining the differential diagnosis.4 mri investigations reveal overgrowth of unencapsulated fatty tissue that demonstrates high signal on t1wi and t2wi, with suppression of the signal on short inversion time inversion recovery (stir) sequences, as demonstrated by our patients. thickened nerves may, or may not, be demonstrated. lack of flow voids and calcifications helps to differentiate the condition from vascular malformations of klippel-trenauney-weber syndrome. lymphangiomas and neurofibromas may be hyperintense to fat on t2wi,4 distinguishing mdl from these conditions. proteus syndrome may be similar but has other associated features such as skull anomalies, lung cysts and pigmented naevi.1 some authors suggest that mdl is a localised form of proteus syndrome.1 fibrolipomatous harmatoma of the nerve displays features similar to mdl;1 however, fat deposition is within the nerve, giving a speckled appearance on mri. two subtypes of the condition are described in the literature: the static and progressive types. in the static type, the enlarged digits grow at the same rate as the other digits. in the more rare progressive type, the growth of the enlarged digits is more rapid. our patients were thought to have the static type clinically. conclusion numerous aetiologies of focal gigantism exist. while clinically the distinction may be difficult, radiological investigation is very useful in confining the differential diagnosis. mri in particular shows characteristic findings of mdl, and radiologists therefore play an important role in the diagnosis of these conditions. 1. sone m, ehara s, tamakwa y, nishida j, honjoh s. macrodystrophia lipomatosa: ct and mr findings. radiat med 2000; 18(2): 129-132. 2. singla v, virmani v, singh p, khandelwal n. case report: macrodystrophia lipomatosa – illustration of two cases. indian j radiol imaging 2008; 18(4): 298-301. 3. turkington jra, grey ac. mr imaging of macrodystrophia lipomatosa. ulster med j 2005; 74(1): 47-50. 4. blacksin m, barnes fj, lyons mm. mr diagnosis of macrodystrophia lipomatosa. am j radiol 1992; 158: 1295-1297. 5. balakrishna bv, prasad srh. macrodystrophia lipomatosa – a rare congenital disorder. indian j radiol imaging 2005; 15: 349-352.w fig. 6. t1wi of the right lower limb shows marked thickening of subcutaneous fat with associated well-circumscribed lesions of low signal intensity. fig. 7. t2wi of the right lower limb confirms fat signal in the thickened soft tissue. the well-circumscribed lesions demonstrate varying signal intensities. case series case series 42 sa journal of radiology • june 2010 straight talking on ct scanning bradley m tipler, md dr tipler is a private-practice radiologist in waynesboro, va, usa. we are indebted to him and to the website diagnosticimaging.com for this viewpoint. for the past 10 years i have been lecturing on america's radiation phobia. obviously, i am not doing a good job, because it is growing. what i find particularly distressing is the problem's growth among radiologists. recently, phobic radiologists have been publishing and lecturing like rabbits on viagra. i have always endorsed and applied alara. i heartily endorse the image lightly campaign. if there is any risk from medical radiation, it is to children. but i raise cattle on my farm, and i occasionally step in the stuff being printed and propagated by a lot of radiologists now. while reports on biological effects of ionising radiation (beir) and the alphabet soup that formulates radiation standards for the usa are monumental works of statistics, they are not facts. historically, they were developed to help us to formulate national and international policy on radiation safety and work out radiation regulations. still today, they are based in large part on data gathered from survivors of hiroshima and nagasaki. the american public's exposure to radiation from medical imaging has nothing in common with that of japanese atom bomb survivors. the figures are great for developing radiation regulation guidelines, but they are not appropriate for determining the risk/benefit ratio for an acutely ill patient in an emergency room. what us radiologist in his or her right mind uses japanese statistics for gastric cancer when reading an upper gi? every one of the data now being headlined by the lay press is based on the linear no-threshold (lnt) theory. is there a radiologist who actually believes that the effects of low-dose radiation over a lifetime are the same as those of one massive dose? the lnt made sense in the early development of radiation safety guidelines. rule-makers need to err on the side of safety. we all know ct is being overused. and we all know there is one primary reason: money. clinicians with their own scanners want to produce income for themselves, and good docs who don't own a machine want to avoid generating income for plaintiffs' lawyers. radiation regulations are to clinical decision-making what highway construction regulations are to nascar. you don't see speed limit signs on nascar tracks because that would be dumb. it is just as dumb to put theoretical numbers on the risk of a ct scan for an individual patient. if the patient needs the test, the theoretical radiation risk is immaterial. if the patient doesn't need the test – duh, don't do the test. if you are not sure, the american trial lawyers association would love to review your decision later. as i say in my lectures, this is the classic american approach to risks. we love scary movies, but we want mother hen to eliminate all real risk from our lives. we can save thousands of lives by lowering the speed limits, but we want to drive fast. when we wreck, we hire a lawyer and sue anyone who didn't make our fast driving safer. we need to emphasize .dam (dot dam = don't order the test if it doesn't alter management) and make sure we use the lowest possible dose for a given exam. recent literature has shown we are lousy at the latter. we do not need to complicate the ordering process, especially with biased statistics that were never intended to be applied on an individual basis. i think putting a note on a ct order form about the theoretical risk of cancer from a single ct means the radiologist is clueless about the conflicts facing the ordering doctor. the radiologist looks like, and probably is, a fool. americans like to compare ct doses to our background level of 3 msv per year. background radiation on the coast of brazil exceeds 150 msv a year. have you seen those poor, over-irradiated brazilian beach babes? and they live longer than us. fig. 8. fat-suppressed image of the right lower limb. there is loss of signal in the thickened soft tissue. the muscles and osseous elements appear normal in all sequences. paediatric.html paediatric vascular imaging: diagnosis s k misser, mb chb, fcrad (d) sa lake smit and partners, durban j n narsai, mb chb, fc paed sa crompton hospital, durban corresponding author: s misser (misser@lakesmit.co.za) please refer to page 151 of the december 2011 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/view/662/477) for the presentation details. no precise diagnosis was received from the readership. dr misser elaborates below on the condition and its imaging. presentation and diagnosis (due to space constraints, the images referred to below are not all reproduced here, but are in the online december 2011 sajr at the above url.) the computed tomography angiogram (cta) confirms presence of a vascular ring (fig. 1) compressing the trachea at the level of the thoracic inlet. on the volume-rendered reformatted images, the ring conforms to a double aortic arch with stenosis of the right aortic arch component. this may be due to an atretic segment or coarctation and is unusual for this aortic morphology. there is post-stenotic aneurysmal dilatation of the left arch component at the origin of the left subclavian artery, suppposedly an aortic diverticulum (also unusual for double aortic arch). a small aneurysm is also noted from the right aortic arch component just distal to the origin of the right carotid artery. the compressive effect on the trachea is well-demonstrated on the 3-d maximum intensity projection (mip) virtual bronchoscopy image with remarkable attenuation of the lumen over a long segment, up to just above the carina. the abdominal aorta shown on the abdominal cta coronal image is of very small calibre. this is probably due to an underlying vasculopathy. agenesis of the left kidney is also noted incidentally; this should raise suspicion for associations of the vater syndrome, which are known to occur with double aortic arch anomaly. discussion the radiological approach to neonatal stridor is broadly based on vascular or non-vascular aetiology. vascular tracheo-bronchial compression may result from anomalies such as double aortic arch, anomalous left pulmonary artery or aberrant subclavian artery, among others. clinically, hyperextension of the neck is usually observed as this position affords some relief. stridor resulting from tracheal compression is often aggravated by feeding. the diagnosis is usually suggested by this neonatal clinical presentation. the first description of a vascular ring (a double aortic arch) was by hommel in 1737. vascular rings result from the abnormal or incomplete regression of one of the 6 embryonic branchial arches. contrast swallow studies have been used to classify the vascular causes of tracheal compression based on the indentations on the oesophagus. baker and berdon1 reviewed klinkhamer’s2 20 patterns and formulated 4 typical patterns on oesophagography (table 1). contrast studies may, however, not be possible in some instances where the child is intubated and ventilated. current trends in ct evolution and magnetic resonance angiography (mra) have made a multimodality imaging approach possible in the assessment and treatment of these complex vascular anomalies. mra has the added benefit of no ionising radiation, which is useful in children where follow-up studies are usually necessary. conventional digital subtraction angiography (dsa), although diagnostic in its demonstration of the vascular anomalies, has largely been replaced by cta and mra. schlesinger et al.3 described imaging appearances of 10 patients with similar arch anomaly to that presented in this quiz case. it is a rare variant, and it is imperative for the radiologist to identify the vascular abnormality and describe the ring in detail, as the surgical approach is highly dependent on the imaging. in addition, such complex vascular anomalies must be managed at an institution where multislice ct, mri and high-level paediatric surgical service are available. 1. berdon we. rings, slings, and other things: vascular compression of the infant trachea. updated from the midcentury to the millennium – the legacy of robert e. gross and edward b. d. neuhauser. radiology 2000;216:624-632. 1. berdon we. rings, slings, and other things: vascular compression of the infant trachea. updated from the midcentury to the millennium – the legacy of robert e. gross and edward b. d. neuhauser. radiology 2000;216:624-632. 2. klinkhamer ac. esophagography in anomalies of the aortic arch system. baltimore, md: williams & wilkins, 1969. 2. klinkhamer ac. esophagography in anomalies of the aortic arch system. baltimore, md: williams & wilkins, 1969. 3. schlesinger ae, krishnamurthy r, sena lm, et al. incomplete double aortic arch with atresia of the distal left arch: distinctive imaging appearance. ajr 2005;184:1634-1639. 3. schlesinger ae, krishnamurthy r, sena lm, et al. incomplete double aortic arch with atresia of the distal left arch: distinctive imaging appearance. ajr 2005;184:1634-1639. 4. shuford wh, sybers rg, edwards fk. the three types of right aortic arch. ajr 1970;109:67-74. 4. shuford wh, sybers rg, edwards fk. the three types of right aortic arch. ajr 1970;109:67-74. 5. banka p, geva t, powell aj, geggel r, lahiri t, valente am. right aortic arch with aberrant left innominate artery. a rare vascular ring. circulation 2009;120:264-265. 5. banka p, geva t, powell aj, geggel r, lahiri t, valente am. right aortic arch with aberrant left innominate artery. a rare vascular ring. circulation 2009;120:264-265. table 1. features of complete vascular rings especially with right arch present vascular anomaly embryology oesophagography other findings double aortic arch persistence of 4th branchial arches on both sides bilateral impressions on sides of oesophagus on frontal and posterior impression on lateral view most common vascular ring anomaly. rarely associated with cardiac defects right aortic arch with aberrant origin of left subclavian artery, with ligamentum arteriosum and aortic diverticulum4 interruption of left aortic arch between left carotid and subclavian arteries posterior impression on trachea and barium-filled oesophagus heart normal in size aorta descends on right associated cardiac defects in 5 10% esp. tetralogy, asd, vsd, coarctation right aortic arch with mirror image branching4 symmetrical great vessel branching pattern no posterior impression on trachea or barium-filled oesophagus heart is abnormal in size/shape owing to associated congenital cardiac defect(>95%) esp. tetralogy, asd, vsd, coarctation. aorta descends on right right aortic arch with aberrant left innominate artery5 aberrant innominate artery may arise from diverticulum posterior compression defect on the barium-filled oesophagus rare vascular ring with right arch. not usually associated with other cardiac defects fig. 1. note the vascular ring (arrowed). quiz case abstract introduction case report discussion conclusion acknowledgements references about the author(s) zahra qaiyumi frank h. netter md school of medicine, quinnipiac university, north haven, ct, the united states of america pankaj nepal department of radiology, st. vincent’s medical center, bridgeport, ct, the united states of america christopher iannuzzi department of radiation oncology, st. vincent’s medical center, bridgeport, ct, the united states of america joshua sapire department of radiology, st. vincent’s medical center, bridgeport, ct, the united states of america citation qaiyumi z, nepal p, iannuzzi c, sapire j. primary squamous cell carcinoma of the urinary bladder presenting as an inguinal mass. s afr j rad. 2021;25(1), a2048. https://doi.org/10.4102/sajr.v25i1.2048 case report primary squamous cell carcinoma of the urinary bladder presenting as an inguinal mass zahra qaiyumi, pankaj nepal, christopher iannuzzi, joshua sapire received: 08 nov. 2020; accepted: 16 jan. 2021; published: 29 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this report involves a rare case of a 74-year-old man who presented with a progressively increasing swelling in the right groin, which represented a squamous cell bladder carcinoma herniating into the right inguinal canal. the manuscript discusses the role of multimodality imaging in bladder carcinoma presenting as an inguinoscrotal hernia. the patient subsequently underwent treatment with a chemotherapy regimen consisting of 5-fluorouracil and mitomycin, which was extrapolated from squamous cell carcinoma of the anal canal, and responded well. keywords: urinary bladder hernia; squamous cell carcinoma; imaging; ct; pet-ct. introduction urinary bladder hernia is uncommon, comprising less than 4% cases of all inguinal hernias.1 the urinary bladder may herniate into the inguinal canal (most common), scrotum or femoral canal; isolated cases of urinary bladder herniation into the obturator foramen, ischiorectal fossa, as well as through the abdominal/pelvic wall have been reported. the most common risk factor is bladder outlet obstruction with chronic bladder distention and its contact with the inguinal canal. risk is increased with advanced age, usually occurring after the fifth decade of life, probably related to decreased tone of the bladder wall; it tends to occur in obese men.2 urinary bladder malignancy within the inguinal hernia is extremely rare, with a few cases reported in the literature.3 to the best of our knowledge, the available current literature does not mention squamous cell carcinoma (scc) of the urinary bladder arising from the bladder hernia. in this article, we describe a rare case of an scc of the urinary bladder presenting as an inguinoscrotal hernia. case report a 74-year-old male, non-smoker with a past medical history of hypertension, benign prostate hypertrophy (bph) and remote post-traumatic exploratory laparotomy presented to the emergency department with progressively increasing right groin pain and swelling. these symptoms had been present for 2 years, relieved by analgesic use, but had been exacerbated over the last 2 months. the patient had accompanying macroscopic haematuria and weight loss. examination revealed a non-reducible, large painful mass palpable in the right groin. computed tomography (ct) scan of the abdomen and pelvis demonstrated a 6.5 cm × 5.4 cm × 6.4 cm enhancing soft tissue mass in the right inguinal canal, inseparable from the anterolateral aspect of the urinary bladder with an accompanying hydrocoele (figure 1). additionally, a few enlarged lymph nodes were noted in the pelvis (bilateral obturator and iliac groups) and retroperitoneum (left para-aortic). the largest enlarged lymph node in the pelvis was the right obturator lymph node measuring 1.2 cm × 1 cm, and the left para-aortic lymph node measuring 1.1 cm × 0.9 cm. figure 1: computed tomography (ct) scan of the pelvis with intravenous contrast: (a) axial ct image of the pelvis acquired during the portal venous phase demonstrates irregular thickening of the right anterolateral urinary bladder wall (red arrow) and an enlarged prostate bulging into the bladder base (white arrow). (b) axial and (c) sagittal ct images of the inguinal region reveal a heterogeneous, enhancing soft tissue mass in the right inguinal canal, inseparable from the right anterolateral aspect of the urinary bladder wall (red arrow). there is a moderately sized hydrocoele in the right scrotum (yellow arrow). a cystoscopy was performed; however, the inguinal mass was not approachable. a trans-urethral biopsy of the enlarged prostate demonstrated moderately differentiated keratinising scc with necrosis. a 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with ct (18f-fdg positron emission tomography [pet]/ct) scan demonstrated a hypermetabolic mass in the right inguinal region, with continuous extension into the urinary bladder lumen (figure 2). however, accurate tumour differentiation was not possible because of background normal tracer excretion into the bladder. multiple enlarged bilateral obturator, iliac and left para-aortic group of lymph nodes seen on diagnostic ct also demonstrated increased tracer activity. a few bilateral hypermetabolic pulmonary nodules were noted in keeping with metastases. ultrasound-guided biopsy of the inguinal mass was consistent with scc (figure 3). figure 2: (a) coronal 18-fluoro-d-glucose positron emission tomography/computed tomography (pet/ct) fusion image shows intense hypermetabolic activity (standardised uptake value [suv] max 28) in the right inguinal mass (yellow arrow). a few metabolically active nodules were present in both lungs, of which one is shown in the same picture (white arrow). (b) axial pet/ct fusion image demonstrating multiple metabolically active lymph nodes in the pelvis (white arrows) with suv max of 10. figure 3: histopathological diagnosis of primary squamous cell carcinoma of the urinary bladder (a) hematoxylin and eosin stain; 400 × magnification indicating well differentiated squamous cells (red arrow). (b) the ck-7 stain is positive (yellow arrow). (c) the p40 stain is also positive in the tumour cells (white arrow). the histopathology confirms the diagnosis of primary squamous cell carcinoma of the urinary bladder. trans-urethral resection of the prostate demonstrated scc that was unusual, but suggested submucosal infiltration of the primary bladder carcinoma. a modified treatment protocol extrapolated from treatment of scc of the anal canal was utilised. the patient received radiation therapy and a chemotherapy regimen consisting of 5-fluorouricil and mitomycin. discussion most often, the urinary bladder herniates into the inguinal canal. the second most frequent location is through the femoral triangle, followed by less common sites including the obturator, perineal and umbilical regions.4 three types of inguinal hernias of the urinary bladder have been described with regard to their relation to the peritoneum: (1) paraperitoneal hernia, in which the bladder remains extraperitoneal and medial to the peritoneal reflection, (2) intraperitoneal hernia, in which the bladder is completely covered by the peritoneum, and (3) extraperitoneal hernia, in which the peritoneum remains in the abdomen and the bladder alone herniates.5 risk factors for inguinal bladder hernia include male gender, advanced age, chronic urinary obstruction and obesity.2 as with other hernias, bladder hernia occurs as a result of increased intra-abdominal pressure coupled with a loss of mechanical integrity of the muscles, tendons and other soft tissue structures. the majority of patients with inguinal bladder hernia remain asymptomatic, thus making clinical diagnosis challenging, and dependent upon imaging findings. symptomatic patients may present with swelling in the inguinal region, dysuria, haematuria and urinary obstruction.2 although inconsistent, the classic mery’s sign may be elicited, which is a two-step urination facilitated by applying pressure on the hernia, and disappearance of the hernia after voiding.4 potential complications of bladder hernia are obstructive uropathy, incarceration, strangulation, bladder infarction secondary to incarceration and iatrogenic injury damage during hernia repair.2 benign prostatic hyperplasia, hydronephrosis, vesicoureteric reflux and scrotal abscesses may be associated with bladder hernia.2 squamous cell carcinoma accounts for 3% – 5% of bladder malignancies in western countries. our index patient demonstrated a rare case of scc within a herniated bladder that also infiltrated the prostate gland.6 predisposing factors include those that cause urothelial injury, such as indwelling catheters, chronic inflammation, calculi, smoking and urinary tract infections.2 squamous cell carcinoma of the urinary bladder is also more common in countries where schistosoma haematobium is endemic. in such endemic regions, patients with scc of the bladder are 10–20 years younger at presentation than patients with transitional cell carcinoma.7 additionally, scc related to schistosomiasis is usually well differentiated, presenting as an exophytic, nodular and fungating mass with relatively low propensity for lymph nodal and distant metastases compared to scc not related to schistosomiasis.7 this is believed to be caused by lymphatic and capillary fibrosis due to chronic parasite infection. accurate staging of bladder cancer is crucial to optimise and prognosticate the individual patient. treatment of the bladder cancer depends on the presence or absence of muscle invasion, carcinoma in situ and metastases.8 when a trans-urethral resection of a bladder tumour (turbt) is feasible, complete resection of the tumour is attempted, whereas radical cystectomy is the standard curative treatment for patients with muscle invasion.8 patients with metastatic bladder cancer or unresectable muscle invasive tumours are treated with chemotherapy.8 because of the paucity of specific symptoms, clinical diagnosis of bladder hernia is challenging. imaging is important to diagnose a bladder hernia and its associated pathologies. it is important to diagnose the contents pre-operatively to avoid the risk of injury during surgical repair. inguinoscrotal bladder hernias are associated with emergency complications such as obstructive uropathy and bladder infarction because of an incarcerated hernia that requires subtotal cystectomy.9 computed tomography is the most common imaging modality performed for the detection and staging of bladder tumours.10 computed tomography urography provides information about the anatomy, as well as physiological function, and is usually performed as a three-phase examination. three phases of acquisition include non-contrast, nephrographic and excretory phases after intravenous administration of iodinated contrast material. the non-contrast phase can detect high-attenuation blood clots, calcifications and calculi. acquisition of the urinary bladder in the nephrographic phase allows visualisation of an enhancing bladder tumour, which is better delineated against low-attenuation urine. at the delayed excretory phase, the tumour appears as a filling defect and the tumour may be a polypoidal, plaque-like, infiltrative or diffuse lesion.10 delayed excretory phase scans are superior in delineating the inguinal bladder hernia, which is continuous with the urinary bladder lumen. alternatively, a direct ct cystogram can be performed; however, it is invasive and requires catheterisation. magnetic resonance imaging provides superior contrast resolution compared to ct, making it possible to delineate the tumour from the normal detrusor muscle of the bladder wall. the detrusor muscle layer is seen as a hypointense band against hyperintense urine and perivesical fat on t2-weighted images.11 muscular invasion is seen as interruption of the normal hypointense band of the detrusor muscle by an intermediate to high signal tumour on t2-weighted images. magnetic resonance imaging has a 91% sensitivity and 96% specificity in differentiating ≤ t1 tumours (non-muscle invasive) from ≥ t2 tumours (muscle invasive) prior to surgery.10,11 newer functional mri techniques, such as diffusion-weighted imaging (dwi) and dynamic contrast-enhanced (dce) imaging, increase the accuracy of local staging. both ct and mri have low sensitivity in detecting abdominal or pelvic lymph node metastasis. pelvic nodes greater than 8 mm and abdominal nodes greater than 10 mm should be regarded as pathologically enlarged.10,11 staging of pulmonary, liver and lymph nodal metastasis is usually performed with ct. detection of the primary bladder tumour on 18f-fdg pet/ct is often difficult because of the intense accumulation of excreted fdg tracer in the urine.12 similar problems exist when evaluating tumour developing within a bladder diverticulum or bladder hernia. a careful inspection of the non-diagnostic ct images may detect extravesical extension of the tumour, which indicates t3b disease.12 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with ct is most useful in the evaluation of lymph node or distant metastasis, and recurrence. increased fdg tracer activity within the adjacent organs, such as the prostate, vagina, cervix, uterus and rectum, may help in establishing t4a disease. computed tomography and mri are also useful tools in monitoring the effects of treatment.12,13 in our index patient, a biopsy during cystoscopy was not amenable because of the size and position of the hernia. instead, a trans-urethral resection of the prostate with a biopsy was performed, revealing metastases from the scc of the bladder. conclusion to the best of our knowledge, scc of the urinary bladder hernia has not been previously reported. imaging plays a vital role in diagnosis and management of such unusual presentations. the role of multimodality imaging techniques, as well as imaging features, has been described in this article. acknowledgements the authors acknowledge the patient as a great source of learning. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions z.q., p.n., c.i. and j.s. contributed equally to this article. ethical considerations the institutional review committee board waived the consent for publication of the case report. funding information this case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references branchu b, renard y, larre s, leon p. diagnosis and treatment of inguinal hernia of the bladder: a systematic review of the past 10 years. turk j urol. 2018;44(5):384–388. https://doi.org/10.5152/tud.2018.46417 elkbuli a, narvel ri, mckenney m, boneva d. inguinal bladder hernia: a case report and literature review. int j surg case rep. 2018;58:208–211. https://doi.org/10.1016/j.ijscr.2019.04.040 katsourakis a, noussios g, svoronos c, alatsakis m, chatzitheoklitos e. direct inguinal hernia containing bladder carcinoma: a case report and review of the literature. int j surg case rep. 2014;5(4):180–182. https://doi.org/10.1016/j.ijscr.2014.01.007 peiró f, zaragozá c, castano s, olavarrieta l, garcıa-aguado r, vivó m. giant inguino-scrotal bladder hernia: report of a case. ambul surg. 2001;9(1):23–24. https://doi.org/10.1016/s0966-6532(00)00068-8 becker ja. a hernia of the urinary bladder. radiology. 1965;84(2):270–273. https://doi.org/10.1148/84.2.270 dahm p, gschwend je. malignant non-urothelial neoplasms of the urinary bladder: a review. eur urol. 2003;44(6):672–681. https://doi.org/10.1016/s0302-2838(03)00416-0 wong jt, wasserman nf, padurean am. bladder squamous cell carcinoma. radiographics. 2004;24(3):855–860. https://doi.org/10.1148/rg.243035153 matsumoto h, shiraishi k, azuma h, et al. clinical practice guidelines for bladder cancer 2019 update by the japanese urological association: summary of the revision. int j urol. 2020;27(9):702–709. https://doi.org/10.1111/iju.14281 nepal p, ojili v, sapire jm, katkar a, baxi a, nagar a. imaging of non-traumatic urinary bladder emergencies. emerg radiol. 2019;26(6):675–682. https://doi.org/10.1007/s10140-019-01703-1 lee ch, tan ch, faria sc, kundra v. role of imaging in the local staging of urothelial carcinoma of the bladder. ajr am j roentgenol. 2017;208(6):1193–1205. https://doi.org/10.2214/ajr.16.17114 witjes ja, bruins hm, cathomas r, et al. european association of urology guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2020 guidelines. eur urol. 2021;79(1):82–104. https://doi.org/10.1016/j.eururo.2020.03.055 patil vv, wang zj, sollitto ra, et al. 18f-fdg pet/ct of transitional cell carcinoma. ajr am j roentgenol. 2009;193(6):w497–w504. https://doi.org/10.2214/ajr.08.1945 songmen s, nepal p, fang d, lewis e, yagan n. rectovaginal septum primary squamous cell cancer: extremely rare entity. radiol case rep. 2020;15(4):326–329. https://doi.org/10.1016/j.radcr.2019.12.022 uterine.html uterine and tubal anatomical abnormalities in infertile women: diagnosis with routine hysterosalpingography prior to selective laparoscopy m heis, md, frcr, ffrrcsi, cst z amarin, md, frcog, ffph a y ibrahim, md n obeidat, md b obeidat, md, frcog m omari, md jordan university of science and technology, irbid, jordan corresponding author: z amarin (zoamarin@hotmail.com) abstract objective. to assess the findings and usefulness of hysterosalpingography (hsg) as a routine investigation in the fertility workup prior to selective laparoscopy. design. descriptive retrospective study. setting. a university hospital in the north of jordan. subjects. all patients who underwent hysterosalpingography in the period 1 january 31 december 2008. outcome measures. detection of uterine and fallopian tube abnormalities and their correlation with laparoscopic findings. results. during the study period, 281 infertile women underwent hsg with no post-procedural complications. the mean (sd) age was 31.5 (5.9) years. mean (sd) duration of infertility was 4 (3.4) years. infertility was reported as primary and secondary in 119 (42.3%) and 162 (57.6%), respectively. altogether, 281 patients and 562 tubes were examined. of those, 402 were patent and 160 occluded. in only one woman were peritubal adhesions diagnosed. because of hysterosalpingographically diagnosed tubal occlusion, 46 women (16.4%) were referred for laparoscopy. eight (17.3%) of them were treated with unilateral salpingectomy, and 28 (60.8%) with bilateral salpingectomy. salpingolysis was performed on 7 (15.2%) women; 3 (6.7%) women had untreatable adhesions. the concordance was 71.7%. the sensitivity of hsg was 80%, the specificity 50%, the negative predictive value 61%, and the positive predictive value 71%. of the total of 281 women, 30 (10.7%) conceived within 1 11 months after hsg. conclusion. the very high abnormal predictive value of hsg in the diagnosis of tubal occlusion suggests that this procedure could be performed as a screening examination. introduction infertility affects about 15% of the population, with at least 1 in 6 couples needing specialist help at some time in their lives because of infertility.1 after history taking, physical examination, semen analysis and ovulation studies, assessment of tubal patency is the next standard test. a universally agreed upon test for fallopian tube patency has not been established. a variety of investigation modalities are available that include hysterosalpingography (hsg), laparoscopic dye hydrotubation, hysterosalpingo contrast sonography (hycosy), selective salpingography, mr hysterosalpingography with an angiographic time-resolved 3d pulse sequence, radiography/mri, 2d hycosy with contrast-tuned imaging, and falloposcopy.2 traditionally, hsg and laparoscopy with dye have been used in the diagnosis of tubal pathology. however, non-invasive methods are associated with false-positive results where occlusion is related to tubal spasm. laparoscopy with dye is still considered to be the gold standard if tubal pathology is suspected, but it requires general anaesthesia and operating theatre facilities. despite advanced technology and experience, complications during laparoscopy remain a major cause of significant morbidity and very seldom reveal any pathological conditions.6 furthermore, infertility healthcare costs are difficult to calculate. there are few published data that determine the actual medical costs of adding an infertility evaluation test.7 without such data, it is difficult to determine if a certain investigation would obviate the need to use other more invasive or more financially onerous tests. the aim of this study was to assess the findings and define the role of hsg as a routine investigation in the fertility workup, prior to selective laparoscopy, in a tertiary referral institute in jordan. materials and methods between 1 january and 31 december 2008, 281 pragmatic hsg studies were performed at the jordan university of science and technology to investigate anatomical causes for subfertility on an outpatient basis during the proliferative phase of the menstrual cycle, prior to selective laparoscopy. all procedures were monitored fluoroscopically and interpreted by a radiologist. a water-soluble contrast medium (omnipaque 33) was used. one photograph was taken when the cavity and fallopian tubes were filled, and one after overflow into the peritoneal cavity or when there was maximal filling without spillage. a late film was taken to detect contrast depots. findings of tubal pathology were classified as normal, unilateral abnormality, bilateral abnormality, and findings suggestive of peritubal adhesions on the basis of loculation of contrast medium around the fallopian tube and restriction of flow away from the distal end. proximal tubal occlusion was diagnosed by the absence of contrast medium beyond the isthmus, while the distal tubal occlusion was diagnosed on the basis of contrast medium within the ampulla but not passing through to the peritoneal cavity. results the study population comprised 281 infertile women. overall, the mean age (sd) was 31.5 (5.9) years, with a range of 18 46 years. mean (sd) duration of infertility was 4 (3.4) years, range 1 21 years. infertility was reported as primary and secondary by 119 (42.3 %) and 162 (57.6 %), respectively. altogether, 281 patients and 562 tubes were examined. none of the women had only one tube. of the investigated tubes, 402 were patent and 116 occluded. table i shows tubal pathology, and tables ii and iii show the congenital uterine anomalies and uterine pathology, respectively, as estimated by hsg. in all the 281 hsg investigations in this study, the procedure was tolerated well, with no post-procedural complications to warrant termination of the procedure, and no febrile morbidity was noted. because of hysterosalpingographically diagnosed tubal occlusion, 46 women (16.4%) were referred for laparoscopy. laparoscopy confirmed the findings shown on hsg. eight (17.3%) subjects underwent unilateral salpingectomy and 27 (58.6%) bilateral salpingectomy. salpingolysis was performed on 7 (15.2%) women;4 (8.6%) women had untreatable adhesions. the concordance was 71.7%. the sensitivity of hsg was 80%, specificity 50%, negative predictive value 61%, and positive predictive value 71% (see table iv). the remaining 34 women were either lost to follow-up or were referred for in vitro fertilisation. of the total of 281 women, 30 (10.7%) conceived within 1 11 months after hsg. discussion the issue of a gold standard is important. laparoscopy and dye test is commonly used in most clinical studies on tubal factor subfertility as the reference standard. some studies questioned the choice of laparoscopy and dye test as a gold standard procedure. meta-analyses comparing results of hsg and laparoscopy and dye test for the diagnosis of tubal pathology demonstrated that over one-third of the tubes found to be occluded at laparoscopy and dye test showed patency at hsg.8 therefore, it could be said that the diagnosis of tubal occlusion can not be made with absolute certainty unless it is checked and probably confirmed by hsg, unless it is argued that the actual procedure of one or the other procedure was instrumental in affecting tubal patency, owing to the actual hydrostatic pressure exerted on the tubes during the procedure. in the current study, all 46 women (16.4%) with hysterosalpingographically diagnosed tubal occlusion were confirmed by laparoscopy, confirming the value of hsg for intra-tubal pathology. in contrast, laparoscopy and dye test as a primary procedure has not proved to be a gold standard test, as some patients diagnosed with bilateral tubal occlusion by this technique were reported to have a 3-year cumulative pregnancy of 2%.9 fertiloscopy has been recently advocated as the procedure of choice for evaluation of tubal status, but further evaluation of its merits is necessary.10 the routine use of hsg in the fertility workup should be undertaken against the background of the possibility of faulty technique and artifacts. hofmann et al.11 found that 17% of the films were technically inadequate. artifacts include faulty insertion of the cannula, vaginal reflux, different tubal muscle tone and cornual spasm.12 , 13 although hsg has traditionally been used as a first-line technique for the diagnosis of tubal pathology, it is associated with false-positive results related to tubal spasm. in addition, the diagnostic accuracy of hsg could be influenced by lack of reproducibility. the interpretation of hsg results could be biased owing to variability within and between observers, especially regarding the interpretation of the possibility of adhesions.14 furthermore, it has been estimated that clinicians were more reliable in diagnosing hydrosalpinx and tubal obstruction, while radiologists were more reliable in the detection of salpingitis isthmica nodosa and uterine adhesions.15 some studies advocate a 3to 6-month interval to allow for the so-called positive perturbation effect after normal hsg. only patients who did not conceive during this interval were referred for laparoscopy with dye.16 , 17 in our study, of the total of 281 women, 30 (10.7%) conceived within 1 11 months after hsg. we conclude that the very high abnormal predictive value of hsg in the diagnosis of tubal pathology suggests that this procedure could be performed as a screening examination, whereas diagnostic laparoscopy could be used as a second-line technique. 1. hull mg, glazener cm, kelly nj, et al. population study of causes, treatment, and outcome of infertility. bmj 1985;291:1693-1697. 1. hull mg, glazener cm, kelly nj, et al. population study of causes, treatment, and outcome of infertility. bmj 1985;291:1693-1697. 2. ahinko-hakamaa km, huhtala h, tinkanen h. confirmation of tubal patency in hysterosalpingo-contrast sonography by transvaginal hydrolaparoscopy. acta obstet gynecol scand 2009;88(3):286-290. 2. ahinko-hakamaa km, huhtala h, tinkanen h. confirmation of tubal patency in hysterosalpingo-contrast sonography by transvaginal hydrolaparoscopy. acta obstet gynecol scand 2009;88(3):286-290. 3. sadowski ea, ochsner je, riherd jm, et al. mr hysterosalpingography with an angiographic time-resolved 3d pulse sequence: assessment of tubal patency. am j roentgenol 2008;191(5):1381-1385. 3. sadowski ea, ochsner je, riherd jm, et al. mr hysterosalpingography with an angiographic time-resolved 3d pulse sequence: assessment of tubal patency. am j roentgenol 2008;191(5):1381-1385. 4. freeman-walsh cb, fahrig r, ganguly a, rieke v, daniel bl. a hybrid radiography/mri system for combining hysterosalpingography and mri in infertility patients: initial experience. am j roentgenol 2008;190(2):w157-160. 4. freeman-walsh cb, fahrig r, ganguly a, rieke v, daniel bl. a hybrid radiography/mri system for combining hysterosalpingography and mri in infertility patients: initial experience. am j roentgenol 2008;190(2):w157-160. 5. lanzani c, savasi v, leone fp, ratti m, ferrazzi e. two-dimensional hycosy with contrast tuned imaging technology and a second-generation contrast media for the assessment of tubal patency in an infertility program. fertil steril 2008; 29 sep [epub ahead of print]. 5. lanzani c, savasi v, leone fp, ratti m, ferrazzi e. two-dimensional hycosy with contrast tuned imaging technology and a second-generation contrast media for the assessment of tubal patency in an infertility program. fertil steril 2008; 29 sep [epub ahead of print]. 6. tarik a, fehmi c. complications of gynaecological laparoscopy: a retrospective analysis of 3572 cases from a single institute. j obstet gynaecol 2004;24:813-816. 6. tarik a, fehmi c. complications of gynaecological laparoscopy: a retrospective analysis of 3572 cases from a single institute. j obstet gynaecol 2004;24:813-816. 7. stovall dw, allen bd, sparks ae, syrop ch, saunders rg, vanvoorhis bj. the cost of infertility evaluation and therapy: findings of a self-insured university healthcare plan. fertil steril 1999;72(5):778-784. 7. stovall dw, allen bd, sparks ae, syrop ch, saunders rg, vanvoorhis bj. the cost of infertility evaluation and therapy: findings of a self-insured university healthcare plan. fertil steril 1999;72(5):778-784. 8. swart p, mol bw, van der veen f, van beurden m, redekop wk, bossuyt pm. the accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. fertil steril 1995;64(3):486-491. 8. swart p, mol bw, van der veen f, van beurden m, redekop wk, bossuyt pm. the accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. fertil steril 1995;64(3):486-491. 9. mol bw, collins ja, burrows ea, van der veen f, bossuyt pm. comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. hum reprod 1999;14(5):1237-1242. 9. mol bw, collins ja, burrows ea, van der veen f, bossuyt pm. comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. hum reprod 1999;14(5):1237-1242. 10. watrelot a, nisolle m, chelli h, hocke c, rongieres c, racinet c. is laparoscopy still the gold standard in infertility assessment? a comparison of fertiloscopy versus laparoscopy in infertility. results of an international multicentre prospective trial: the 'fly' (fertiloscopy-laparoscopy) study. hum reprod 2003;18(4):834-839. 10. watrelot a, nisolle m, chelli h, hocke c, rongieres c, racinet c. is laparoscopy still the gold standard in infertility assessment? a comparison of fertiloscopy versus laparoscopy in infertility. results of an international multicentre prospective trial: the 'fly' (fertiloscopy-laparoscopy) study. hum reprod 2003;18(4):834-839. 11. hofmann ge, scott rt, rosenwaks z. common technical errors in hysterosalpingography. int j fertil 1992;37(1):41-43. 11. hofmann ge, scott rt, rosenwaks z. common technical errors in hysterosalpingography. int j fertil 1992;37(1):41-43. 12. shah sm, towobola oa, masihleho m. diagnosis of fallopian tube patency. east afr med j 2005;82(9):457-462. 12. shah sm, towobola oa, masihleho m. diagnosis of fallopian tube patency. east afr med j 2005;82(9):457-462. 13. cheong yc, li tc. evidence-based management of tubal disease and infertility. current obstetrics & gynaecology 2005;15(5):306-313. 13. cheong yc, li tc. evidence-based management of tubal disease and infertility. current obstetrics & gynaecology 2005;15(5):306-313. 14. glatstein iz, sleeper la, lavy y, et al. observer variability in the diagnosis and management of the hysterosalpingogram. fertil steril 1997;67(2):233-237. 14. glatstein iz, sleeper la, lavy y, et al. observer variability in the diagnosis and management of the hysterosalpingogram. fertil steril 1997;67(2):233-237. 15. renbaum l, ufberg d, sammel m, zhou l, jabara s, barnhart k. reliability of clinicians versus radiologists for detecting abnormalities on hysterosalpingogram films. fertil steril 2002;78(3):614-618. 15. renbaum l, ufberg d, sammel m, zhou l, jabara s, barnhart k. reliability of clinicians versus radiologists for detecting abnormalities on hysterosalpingogram films. fertil steril 2002;78(3):614-618. 16. perquin da, beersma mf, de craen aj, helmerhorst fm. the value of chlamydia trachomatis-specific igg antibody testing and hysterosalpingography for predicting tubal pathology and occurrence of pregnancy. fertil steril 2007;88(1):224-226. 16. perquin da, beersma mf, de craen aj, helmerhorst fm. the value of chlamydia trachomatis-specific igg antibody testing and hysterosalpingography for predicting tubal pathology and occurrence of pregnancy. fertil steril 2007;88(1):224-226. 17. evers jl, land ja, mol bw. evidence-based medicine for diagnostic questions. semin reprod med 2003;21(1):9-15. 17. evers jl, land ja, mol bw. evidence-based medicine for diagnostic questions. semin reprod med 2003;21(1):9-15. table i. tubal pathology identified by hysterosalpingography bilateral hydrosalpinx 27 unilateral hydrosalpinx 19 bilateral distal occlusion 5 unilateral distal occlusion 27 bilateral proximal occlusion 11 unilateral proximal occlusion 16 bilateral combined proximal/distal occlusion 6 unilateral combined proximal/distal occlusion 5 periadnexal adhesions 1 table ii. congenital uterine anomalies identified by hysterosalpingography attribute frequency % no congenital anomalies 258 91.8 bicornuate unicollis uterus 9 3.2 arcuate uterus 11 3.9 uterine septum 1 0.4 hypoplastic uterine cavity 2 0.7 total 281 100 table iii. uterine pathology identified by hysterosalpingography attribute frequency % normal opacification 216 76.8 congenital uterine anomalies 23 8.1 retroverted uterus with normal opacification 14 5,.0 uterine fibroid 15 5.3 poor opacification with irregular outline 4 1.4 caesarean section scar 4 1.4 adhesions 1 0.4 irregular outline of uterine cavity 4 1.4 total 281 100 table iv. tubal pathology identified by hysterosalpingography and findings at laparoscopy tubal pathology identified by hysterosalpingography findings at laparoscopy type of pathology n normal one-sided tubal occlusion two-sided tubal occlusion peri-adnexal adhesions bilateral hydrosalpinx 12 1 1 9 1 unilateral hydrosalpinx 8 0 6 0 2 bilateral distal occlusion 2 0 0 2 0 unilateral distal occlusion 9 1 6 0 2 bilateral proximal occlusion 3 0 0 3 0 unilateral proximal occlusion 6 4 2 0 0 bilateral combined proximal/distal occlusion 2 0 0 2 0 unilateral combined proximal/distal occlusion 3 0 2 0 1 periadnexal adhesions 1 0 0 0 1 total 46 6 17 16 7 abstracts oral presentations (in alphabetical order according to presenting author’s surname) white matter signal abnormalities in children with hiv-related brain disease c ackermann (tygerberg academic hospital, stellenbosch university), s andronikou (university of the witwatersrand), b laughton, m cotton (children’s infectious diseases research unit, stellenbosch university; and tygerberg children’s hospital) background. children vertically infected with hiv may develop encephalopathy. although encephalopathy has often been severe in the past, the natural history and manifestations have been ameliorated by effective antiretroviral therapy. incidence and characteristics of white matter abnormalities have not been documented or correlated with neurodevelopmental assessments, which is the aim of this study. methods. hiv-positive children <10 years old presenting with hiv-related neurodevelopmental delay or neurological abnormalities who underwent mri were included. a neuroradiologist reviewed the mris for white matter abnormalities; although a brief synopsis of presenting complaints was given, the neuroradiologist was blinded to neurodevelopmental data. results. forty-four children (22 boys) between 7 months and 4.1 years old were included. multifocal high-signal intensity lesions on t2 and fluidattenuated inversion recovery (flair) were documented in 22 patients (50%), predominantly in the frontal (45%) and parietal (39%) subcortical and deep white matter. seven patients demonstrated asymmetrical confluent peritrigonal white matter signal abnormality not consistent with terminal zones of myelination. no significant differences were found in any of the neurodevelopmental scores when comparing the group of children with and without white matter signal abnormality (wmsa). lesion load also showed no statistically significant correlation with developmental quotients. conclusion. our results demonstrate that half of children diagnosed clinically with hiv-related brain disease have wmsa on t2/flair mri, involving mainly the frontal and parietal lobes both superficially and in the deep white matter. the lesion load as assessed by the number of regions involved did not correlate with the neorodevelopmental scores and neither did distribution of white matter signal abnormalities. the diagnostic accuracy of mr and fluoroscopic mucous fistulography in the pre-operative evaluation of infants with anorectal malformation: a pilot study j alves (division of radiodiagnosis, department of medical imaging and clinical oncology, tygerberg academic hospital and stellenbosch university) background. anorectal malformation (arm) is often associated with rectal pouch fistulae. surgical correction of arms requires accurate evaluation of the presence and position of such fistulae. fluoroscopy is currently the chosen modality for arm-related fistula evaluation. the role of mri in this context has not been defined. aim. to compare the diagnostic accuracy of mri and fluoroscopic fistulography in the pre-operative evaluation of infants with arm. materials and methods. a pilot study of infants requiring defunctioning colostomy for initial management of arm. dynamic sagittal truefisp mri images of the pelvis were acquired during introduction of saline into the mucous fistula. mri findings were compared with fluoroscopic fistulography and surgical findings. results. eight patients (n=8; 8 males) were included. there was 100% correlation between the mri and fluoroscopic fistulography and surgical findings. conclusion. the findings of this pilot study suggest that mri fistulography is an accurate investigation in the pre-operative evaluation of patients with arm and justify a larger prospective study to better define the role of mr fistulography in this clinical setting. radiological diagnosis of h-type fistula b banieghbal aim. there are 4 commonly quoted anatomical sub-categories in oesophageal atresia complex. h-type fistula without oesophageal atresia is considered to be the rarest of these; its diagnosis is based on the patient’s symptoms and a radiological demonstration of the fistula on an upper gi contrast study at the lower cervical area. the standard description is to insert a feeding catheter in the mid-oesophagus and slowly inject a water-soluble contrast as the catheter is withdrawn. this should be done with the patient in the supine position. constant fluoroscopy is considered to be the key to diagnosis of h-fistula. methods. over a year, 3 patients (2 neonates and 1 infant) with a barium upper gi contrast study suggestive of h-fistula were seen by a paediatric surgeon. barium study was requested by the paediatrician due to difficult feeding, persistent vomiting and coughing during feeds. one case was not diagnosed by the attending radiologist but was detected by the surgeon during routine review of the x-rays. diagnostic bronchoscopy confirmed the presence of h-fistula in the upper trachea. a right neck exploration was carried out and the fistula divided. an interposing strap muscle was used to reduce the risk of a recurrence. results. all procedures were performed without any major perior postoperative complications. the infant in this series had had prior cardiac surgery and underwent a simultaneous tracheostomy due to several prior extubation failures. rssa/saspi paediatric imaging congress sandton sun hotel conference centre, johannesburg, 9 11 november 2012 __________________________________ abstracts conclusion. h-type fistula can be diagnosed on a standard upper gi contrast study without any specific methodology. radiologist should be cognisant of this anomaly in all neonates and infants who undergo ‘routine’ barium swallow or meals. radioembolisation with yttrium-90 micro-spheres for treatment of liver malignancy: first reported series in south africa a chacko, n nyakale, s ahmad, m sathekge (university of pretoria) radioembolisation is a technique used to administer radiotherapy internally (selective internal radiation therapy (sirt)) to non-resectable primary or secondary hepatic malignancies. the technique involves the injection of resin or glass micro-spheres that contain yttrium-90 (y90) into the arterial supply of the liver tumour. sirt is becoming widely recognised as a new modality for selectively treating non-resectable liver tumours. sirt irradiates malignant liver lesions using microscopic beads. it provides micro-embolisation coupled with high-dose interstitial radiotherapy, where conventional external beam radiotherapy is not feasible due to potential damage to normal tissue within the beam path, and where liver lesions are not amenable to surgical removal. the technique used in our hospital is relatively new in south africa, with no previously reported series in south africa in the literature. the procedure is performed in two stages and requires a multi-disciplinary approach and planning for success. both stages require active participation of all departments, with the first stage being the planning and workup phase, and the second stage the actual radio-embolisation procedure. we describe the technique, indications, preparation and procedure involved in y90 radio-embolisation of liver tumours. we specifically describe a series of four patients who had the procedure at our institution, with special emphasis on the experience and the associated technical issues. presentation of preliminary follow-up results of treatment is also made in this paper. the accuracy of after-hour registrar computed tomography (ct) reporting in a tertiary south african teaching hospital j de witt (division of radiodiagnosis, tygerberg academic hospital) introduction. the division of radiodiagnosis at tygerberg academic hospital, a 1 060-bed tertiary training institution in cape town, provides a comprehensive 24-hour clinical radiology service, and has a duty registrar on site at all times. the demand for ct imaging is increasing and plays a pivotal role in patient management. aim. the purpose of this study was to determine the accuracy of after-hour registrar ct reporting and identify possible factors that may affect the error rate. results. the overall discrepancy rate was 8% (18 of 225) and overall accuracy rate was 92% (207 of 225). the major error rate was 4% (9 of 225) and the minor error rate was also 4% (9 of 225). conclusion. we observed that the accuracy of after-hour ct reporting by senior registrars at the division of radiodiagnosis at tygerberg hospital was on a par with international standards. we investigated three factors which might have affected discrepancy rates, and only found one (time of day) to be significant. steps can be taken to create awareness of this fact among registrars, which hopefully would result in improved patient care and management. adequacy of paediatric renal tract ultrasound requests and reports in a general radiology department n govender, s andronikou, m goodier (university of the witwatersrand) background. according to current guidelines, ultrasound (us) is the most important modality for imaging urinary tract infections (utis) in children. objectives. (i) to assess the adequacy of paediatric renal us requests and reports in a general radiology department, and correlate the request adequacy and the performing radiologist’s experience with report adequacy; and (ii) to determine the yield of abnormal findings. materials and methods. retrospective review of renal us requests. the information was scored: requests 0 3 (3 as highest adequacy) and reports 0 21 (21 as highest adequacy, based on the rsna reporting guidelines). correlation tests used included spearman’s correlation, kruskal-wallis test, chi-square test of independence and fisher exact test. results. mean report adequacy score was 6.67/21. trainees did 87% of all scans and performed better (score 6.76) than the staff radiologists (score 6.08). hydronephrosis was the most common abnormality. there was no correlation between request or reporter rank and reporting adequacy. conclusion. renal us requests and reports are inadequate. to improve reporting standards for trainees and specialists, a renal ultrasound reporting template was designed for use. introduction of a pictorial poster of radiographic errors for improving the quality of paediatric chest radiographs in an unsupervised unit l hlabangana (department of radiology, faculty of health sciences, university of the witwatersrand) background. chest radiography is the most commonly performed diagnostic x-ray examination. the radiation dose to the patient for this examination is relatively low but, because of its frequent use, the contribution to the collective dose is considerable. optimised image quality not only allows more accurate diagnosis but also supports radiation protection and should be targeted, particularly in children because of the radio-sensitivity of immature organs. aim. the aim of this study was to determine whether the introduction of a poster of technical errors in paediatric radiography accompanied by a ‘crash course’ on common errors could sustainably decrease the number and rate of these in an unsupervised unit of a general hospital. method. a retrospective study was performed at the charlotte maxeke johannesburg academic hospital. technical errors in frontal chest radiographs performed in one unsupervised paediatric radiology unit were assessed by qa analysis using a customised qa ticksheet. the qa review was performed before and after an ‘intervention’ which involved a ‘crash course’ of 30 mins and a poster display in the department. comparisons were made of the technical errors made before and after the ‘intervention’. results. there was statistically significant improvement (p<0.0083) between the radiographs performed immediately after the ‘intervention’. there was statistically significant decline (p<0.0083) in the quality of radiographs performed in the review periods that were ≥2 months from the intervention. abstracts conclusion. good radiographic technique is the most important factor in improving quality without the cost of increased dosage. regular qa is critical as a means of ensuring superior image quality. simple, regular interventions such as lectures and posters highlighting common errors show improvement in image quality. optimised image quality therefore supports radiation protection in paediatric imaging units and should be targeted through repeated qa interventions, particularly in unsupervised departments. accuracy of ‘red-dot’ after-hour trauma-radiograph triage by radiographers in a south african regional hospital s hlongwane, r pitcher (stellenbosch university) introduction. the global demand for diagnostic imaging exceeds the supply of radiologists and is of particular significance in poorly resourced healthcare environments, where many x-rays are unreported. delayed or absent reporting may negatively affect patient management. in well-resourced countries, it is recognised that extending the role of radiographers to radiological reporting tasks helps to meet service demands. aim. to determine the accuracy of acute fracture detection by south african radiographers working in an after-hour setting. method. a retrospective study of radiographers at a western cape regional hospital during 2 months in 2011. the sensitivity and specificity of radiographer fracture detection were compared with that of a consultant radiologist. differences were evaluated using the mcnemar chi-square test, with p<0.05 achieving significance. results. three hundred and sixty-nine radiographs were analysed. overall radiographer reporting accuracy was 93.7%, with 74.4% sensitivity for fracture detection. experienced radiographers performed better than inexperienced ones; adult fractures were more consistently identified than paediatric fractures, and appendicular fractures better visualised than axial fractures. there was significant difference in all instances between radiologists and radiographers. experienced radiographers evaluating appendicular fractures in adults achieved the highest sensitivity (89.9%), which was not significantly different from a consultant radiologist (p=0.88). conclusion. the performance of experienced radiographers in our study is comparable to that of experienced radiographers internationally, who have no specific training in trauma radiograph reporting. however, additional training is required if role extension is to be considered. uterine artery embolisation for uterine leiomyomata: a multicentre study in south africa a lawson, s dyer, j olarogun, s beningfield, m patel (groote schuur hospital), d legge, c cluver (tygerberg hospital) aim. to introduce uterine artery embolisation (uae) as an effective and safe treatment option in patients with symptomatic fibroids in the western cape provincial service. method and materials. prospective observational multi-centre study at groote schuur and tygerberg hospital, western cape province. 36 women (average age 37 years, range 30 47) with symptomatic fibroids were treated with uae between november 2009 and february 2012. pre-procedure mri followed by a 6-month follow-up mri or ultrasound was performed. embolisation was achieved using boston hi-flow renegade microcatheters as the particle delivery system and polyvinyl alcohol (pva) particles 300 500 mm as embolic agents. results. the presenting symptoms were menorrhagia, dysmenorrhoea, pressure symptoms and intermenstrual bleeding. three were treated for primary infertility. the average uterine volume was 1 576 cm3 (range 473 5 506) pre-embolisation. 5.5% (2/36) had concomitant adenomyosis. uterine artery sub-selection and embolisation was successful in all patients. 14% (5/36) had additional arterial fibroid supply from the ovarian arteries that were not embolised. 8% (3/36) had low-grade pyrexia during their hospital stay. 3% (1/36) were re-admitted after 2 weeks with a low-grade pyrexia. mean clinical follow-up was 15 months (range 7 32). 81% (29/36) were satisfied that their symptoms had been treated effectively. 8% (3/36) did not respond to embolisation. the average reduction in uterine volume at 6 months was 45%. conclusion. uterine artery embolisation is associated with a high clinical success rate. provisional results suggest that uae should be offered as an attractive alternative to surgery in our practice. chest x-ray findings in hiv-infected children starting haart at a tertiary institution in south africa n mahomed, s andronikou, j naidoo, m mbakaza (university of the witwatersrand), h moultrie, a van rie, s sawry (wits reproductive health and hiv institute) introduction. respiratory infections are common in hiv-infected children. there is limited information on the radiographic presentation of children eligible to start haart in resource-limited settings. aim. to determine the radiographic patterns on pre-haart chest x-rays (cxrs) in children and assess the inter-observer variability between 3 paediatric radiologists. methods. children (0 8 years) participating in a cohort study of tb and bcg-iris who had an acceptable routine pre-haart cxr were included. cxrs were independently assessed by 3 radiologists, blinded from clinical data, using a standardised assessment form. all 3 readings were used to create a majority consensus finding. results. among 161 children, the median age was 2.3 years (41/161 <1 year), 54% (87/161) were on tb treatment and 62% (100/161) were immunesuppressed (cd4% <25% or cd4 count <350). the majority (71%) had an abnormal cxr finding, predominantly air space disease (42%) and parenchymal interstitial disease (20%). of the 112 (70%) cxrs that could also be assessed for lymphadenopathy (i.e. evaluable airways), 74 (66%) had lymphadenopathy. among the 112 children with a cxr that could be fully evaluated, 67% (75/112) had ≥1 abnormalities suggestive of tb (74 lymphadenopathy, 2 cavities, 18 milliary infiltration). the inter-observer variability was fair (κ=0.22) for airspace disease, moderate (κ=0.54) for parenchymal interstitial disease and slight (κ=0.051) for lymphadenopathy. conclusions. among children eligible to start haart, most (71%) presented with abnormal cxr findings, and the majority (67%) had ≥1 cxr signs suggestive of tb. of concern was the high proportion of cxrs that were of insufficient quality to be assessed for lymphadenopathy and the relatively poor inter-reader agreement for radiological features of tb. abstracts diagnostic quality of neonatal radiograph images after 50% radiation dose reduction on a computed radiography system f naude (university of the free state) aim. a prospective study to reduce the radiation burden to neonatal intensive care patients by reducing mas. background. greater emphasis is placed on the image gently approach, with the object of radiation dose reduction and safety in children. most radiology departments use radiation dose settings as per the old screen film systems, with 3.2 3.6 mas and 55 60 kv. it is possible with the newer computed digital film screen radiography systems to reduce radiation exposure, without losing significant image quality. method. in this study, mas was reduced to 1.6 (approximately 50% reduction) without changing kv (kept at 55). the images were compared with those at higher mas setting. ethics approval and parents’ consent were obtained for neonatal icu patients at universitas hospital to lower mas of the second x-ray film of the day. consultants of the radiology department and neonatal icu department compared 60 pairs of lower and higher dose x-ray films, on a philips isite pacs system. reviewers were blinded to the radiation dose, time of acquisition and patient name. each consultant had to complete a questionnaire where they had to choose the film with the best image quality. additional questions concerned quality of lung parenchyma, mediastinum, diaphragm borders, and visibility of lines and tubes. if a difference was observed, indication was given whether it was of diagnostic significance. conclusion. radiation dose can be reduced in the neonatal icu by approximately 50%, without losing diagnostic image quality. even if the lower dose is used only for x-rays requested for line and tube position, the radiation burden to neonatal patients will decrease significantly. assessment of mri accuracy in predicting operability and tumour stage in wilms’ tumours (nephroblastomas) when correlated with surgical findings and histopathology t pillay, t kilborn, s cox, k pillay (red cross war memorial children’s hospital) pre-operative imaging of wilms’ tumours is critical in determining the timing of surgery, by providing detailed anatomical information to decide on operability and aid in planning a surgical approach. staging of the tumour can be predicted by imaging but is primarily based on findings at the time of surgical exploration and final tumour histology. traditionally, ct scanning has been the main cross-sectional imaging modality used, as it is readily available and quick to perform in small children. however, concerns over the radiation burden in the long-term risk of radiation-induced malignancy have made it a less attractive option. mri has therefore taken on a greater role in the imaging of childhood tumours; it is now the preferred imaging modality. the sensitivity of mri for identification of nephroblastomatosis and volumetric response of the tumour to chemotherapy has been well documented, but its ability to predict operability, tumour stage and potential tumour rupture is less clear. this study is a retrospective review of the preoperative mris of 38 patients with wilms’ tumours treated at our institution between 2008 and 2012. the scans were assessed for tumour multifocality and bilaterality, volume, presence of necrosis and haemorrhage, rupture, capsular integrity, infiltration into adjacent structures, vascular extension, nodes, ascites and liver metastases. based on this information, the pre-operative imaging stage was documented. the results were compared with the findings at surgery as well as the final histology. the accuracy of mri in predicting operability and tumour stage is presented. persistent chest radiographic abnormalities in hiv-infected south african children r pitcher (division of radiodiagnosis, faculty of medicine and health sciences, stellenbosch university), carl lombard (biostatistics unit, medical research council), mark cotton, h zar (department of paediatrics and child health, faculty of medicine and health sciences, stellenbosch university), s beningfield (division of radiology, faculty of health sciences, university of cape town) introduction. there are limited data on persistent chest x-ray (cxr) abnormalities in hiv-infected children in lowand middle-income countries (lmics) and on the impact of antiretroviral therapy (art) on such abnormalities. aim. to document the incidence, radiographic features and natural history of persistent cxr abnormalities in hiv-infected south african children, with emphasis on the impact of art. methods. a 24-month prospective longitudinal study of 330 hiv-infected children, documenting clinical, immunological, nutritional and cxr parameters. cxrs were systematically reported and findings stratified as normal, minor abnormality or severe abnormality. a first-order transition model assessed the association of baseline parameters and time-dependent variables with severity of radiological findings. results. two hundred and twenty-eight patients (69.0%; median age 28.2 months) had comprehensive follow-up. at baseline, 205 (89.9%) had moderate/advanced clinical hiv disease, the median cd4+% was 21.0% (iqr 15.4 37.8), 118 (51.7%) showed severe cxr abnormality and 49 (21.5%) were on art. almost half (n=113; 49.5%) commenced art during the study. by conclusion, the cohort had demonstrated overall immunological and radiological improvement; the median cd4+ was 28%, and less than a third had severe radiological abnormality (n=74; 32.5%). during follow-up, 211 (92.5%) showed persistent cxr abnormalities that were severe in most cases (n=131; 57.4%) and persisted for an average of 44% of follow-up. severe cxr abnormality was positively associated with (i) severe abnormality on the preceding cxr (55%; p=0.000) and (ii) multifocal or diffuse cxr abnormality at enrolment (7%; p=0.008) and negatively associated with (i) art usage (13%; p=0.000) and (ii) time since enrolment (8%; p=0.000). conclusion. there is a high incidence of persistent, severe cxr abnormality in hiv-infected children from lmics. early initiation of art is recommended for prevention of persistent cxr abnormalities. fluoroscopy guided dilatation of benign oesophageal strictures in children – a 12-year experience m van wyk, a reinders (department of radiology, university of the free state) benign oesophageal strictures (bes) are a debilitating health concern in the paediatric populations of developing countries, leading to impaired weight gain, second only to malnutrition. causes include oesophageal atresia (ea), abstracts caustic ingestion (ci), achalasia and gastro-oesophageal reflux (ger). a retrospective review of the procedure and clinical notes as well as swallow reports of procedures performed during january 2001 june 2012 was made. all patients aged 12 years and younger who underwent oesophageal dilatation in the unit of interventional radiology, universitas hospital, were included. over 12 years, 432 dilatations in 63 patients (57% male; aged 21 days 142 months) were performed. the most common indication for dilation was ea (59%), followed by ci (20%), ger (9%), post-surgical strictures other than atresia repair (9%), and foreign bodies (3%). exclusive balloon dilatation was used in the majority (71%) of patients, bougienage in 19%, and a combination in 10% of cases. the success rate, and the ability to pass and dilate the stricture, was 99%. no perforations occurred. atresia secondary to tracheo-oesophageal fistula repair was the most common indication for dilatation. although balloon dilatation was used in most cases, neither the combined nor the exclusive use of savary-gilliard bougienage resulted in complications. in our centre, the use of over-thewire, fluoroscopy-assisted, exclusive or combined balloon or savary-gilliard oesophageal dilatation is a safe and successful treatment modality for benign oesophageal strictures. poster presentations (in alphabetical order according to presenting author’s surname) spinal segmental dysplasia v. caudal regression syndrome n abdurahman, n mahomed, g firth, j naidoo (faculty of health sciences, university of the witwatersrand) spinal segmental dysplasia (ssd) and caudal regression syndrome (crs) represent two faces of a single spectrum of segmental malformations of the spine and spinal cord that differ embryologically. the presence of a cord segment within the caudal spinal canal is a unique feature of ssd. however, when the lumbosacral spine is involved, the level of the segmental anomaly may be too caudal for a cord segment to develop below the level; in such cases, the imaging features are indistinguishable from crs. ssd is a congenital spinal anomaly characterised by localised dysgenesis of the thoracolumbar spine. the x-ray features include a kyphosis; vertebral anomalies demonstrated at different levels; and a spinal stenosis. mri features are variable but the presence of a distal cord segment is a unique feature. four types of caudal vertebral dysgenesis characterise crs. the common imaging findings include a sacrococcygeal defect and a blunt distal cord or wedge-shaped cord terminus, as well as an association with currarino triad. clinically, the two disorders may be indistinguishable, with neural tube defects, anorectal and urogenital malformations, and lower limb anomalies. the radiological characteristics may be the only distinguishing features. it is important to separate these two syndromes to assist in the surgical approach; ssd is less likely to benefit from untethering procedures. our poster aims to compare and contrast the two entities by using annotated diagnostic images of both conditions alongside each other. the paranasal sinuses in children a ahmed (visser, erasmus, vawda and partners) the air-filled spaces of the facial and skull bones are dynamic and evolving structures in children. there are a number of normal variations related to the sinuses that are well demonstrated with imaging. the importance of these variations increases with the increasing surgery and imaging being performed on children. the paranasal sinuses are affected by a wide spectrum of conditions including congenital abnormalities and inflammatory, traumatic and neoplastic diseases. the purpose of this review is to highlight some salient features regarding the anatomy and development of the sinuses in children. a spectrum of pathologies affecting the paediatric paranasal sinuses is also covered. this is primarily a pictorial review with emphasis on imaging features. mention is also made of suggested imaging guidelines for sinus imaging in vulnerable paediatric patients. the diagnostic algorithm is developing and needs to be continuously adapted for the paediatric population. where’s the line/tube? a ahmed (visser, erasmus, vawda and partners) this pictorial review outlines correct and suggested positioning of commonly used vascular lines and tubes in the paediatric patient, including incorrect positions and positions related to anatomical anomalies and congenital abnormalities. common complications related to placement and positioning of these catheters is also outlined. neonatal anatomy can provide challenges in interpreting locations of catheters, and variations are seen, in particular with the commonly used umbilical venous and arterial lines. issues relating to gastro-intestinal tubes, ventriculo-peritoneal shunts and other vascular lines are also outlined. radiologists are confronted with a spectrum of catheters placed in various locations in routine paediatric radiology practice and have to be familiar with the different catheters, their uses and acceptable positioning for suggested safe practice. the unusual suspects: making the case for spinal mr imaging b barnard, b van der merwe, j de witt (department of radiodiagnosis, tygerberg hospital) the spectrum of spinal disease is broad and complex; patients often present with non-specific signs and symptoms. we present an assortment of unusual cases of spinal pathology of varying aetiology, from metabolic to idiopathic, in both the paediatric and adult population. we emphasise the importance of the role of appropriate and accurate mr imaging in the resolution of diagnostic dilemmas. how to mend a broken heart: the tygerberg diagnostic approach f bezuidenhout (stellenbosch university) the correct interpretation of chest radiographic findings in congenital heart disease is difficult. in most instances, a definitive diagnosis is not possible. however, utilisation of a few key radiographic signs facilitates narrowing of the differential diagnoses. this poster highlights a simplified diagnostic approach based on the appearance of the pulmonary arteries, which has been shown to be effective and accurate in its application. supratentorial lobulated bubbly tumour g blignaut (university of the free state) introduction. astroblastomas are rare cns tumours and represent 0.4 2.8% of all glial tumours, with 40 cases reported in the literature since 1930. astroblastomas are seldom seen in practice and can easily be misdiagnosed. they share a common radiological and histopathological appearance with other glial neoplasms. history. a 42-month-old girl from lesotho presented to us with a 4-day history of right-sided hemiparesis, associated with nausea and vomiting. abstracts imaging findings. mri of the brain revealed a large left frontoparietal multicystic lobulated mass with a solid component that had a bubbly appearance and was iso-intense to gray matter on t2-weighted imaging. the mass caused raised intracranial pressure. little peritumoural oedema was present. outcome. the patient was referred to neurosurgery. she received a biopsy and complete surgical resection of the tumour. the histopathological differential diagnosis included: astroblastoma, papillary meningioma and ependymoma. the pathology specimen was also sent to a neuropathologist in cape town who confirmed the diagnosis of a low-grade astroblastoma. a rare entity: macrodystrophia lipomatosa involving the entire foot n browning, s jeetoo, v du plessis (department of radiology, pietermaritzburg metropolitan hospital complex) introduction. macrodystrophia lipomatosa (mdl) is a rare congenital cause of local gigantism, diagnosed by exclusion of other causes of macrodactyly, that refers to hypertrophy of all mesenchymal elements, particularly fibroadipose tissue. discussion. we describe a case of a 1-year-old girl who presented with progressive swelling of the left midand fore-foot noted from the age of 1 month. there was no history of trauma or family history of congenital disorders. we systematically excluded differentials for macrodactyly. radiological findings. on x-ray, there was enlargement of the metatarsals and to a lesser extent the phalanges of the left foot; no periosteal reaction, enchondromas or calcifications; soft-tissue swelling of the left midand forefoot on the dorsal and plantar aspect. on mri, there was excessive fat tissue involving the dorsal and plantar aspects, predominantly the tendon sheaths. no haemangiomas, neurofibromas, enchondromas, haemosiderin deposition, and vascular or neural sheath anomalies. the fat was not encapsulated. these findings helped us to differentiate from other causes of local gigantism. conclusion. mdl is a rare entity that can only be diagnosed on the basis of exclusion of other causes of local gigantism. our case is believed to be unique in that there is diffuse involvement as opposed to the more common involvement of the 2nd and 3rd digits of the limb. acetabular column sizes specific to percutaneous fixation of acetabular fractures a chacko, p mostert, c snyckers, f ismail (university of pretoria) acetabular fractures can be difficult to treat surgically owing to high operative risks and complications of open approaches. percutaneous fixation of these fractures is a novel technique with reduced complications and better outcomes. the procedure and technique requires an experienced surgeon and meticulous planning as well as specialised intra-operative views with appropriately sized screws used in actual fixation of the fracture. there is, however, a paucity of studies on what is a safe screw diameter to use, especially in the south african population. we therefore describe the measurements obtained of the lengths and diameters of the anterior and posterior acetabular columns using computed tomography (ct) threedimensional (3d) volume reconstructions of the normal pelvis, specific to the south african population. we check correlation with previous similar international studies and make recommendations for selecting percutaneous fixation screws to treat fractures of the acetabular columns. a retrospective study using data obtained from ct of adult patients was used. 3d volume reconstructions of the pelvis were used to take the measurements of the anterior and posterior acetabular columns in 500 patients (250 male; 250 female) with exclusion criteria being previous trauma to and fractures of the pelvis; congenital abnormalities; and tumours involving the bony pelvis. we present the preliminary results of a pilot feasibility study performed using 108 patients (62 male; 46 female) and provide recommendations regarding the safe sizes for the south african population as well techniques to accurately and safely measure the columns for individual outliers. imaging of disease progression in a case of idiopathic moyamoya a chacko, j smal, e lubbe, n adroos (university of pretoria) moyamoya is a rare cerebrovascular disease characterised by progressive stenosis of the terminal portion of the internal carotid artery and its main branches. we present a pictorial poster of disease progression in a 3-yearold boy confirmed to have idiopathic moyamoya disease, over 6 years, using serial mri with mr angiography. comparison is also made with conventional angiography at the last visit. characteristic imaging appearances of asymmetric narrowing of the internal carotid arteries (especially the supra-clinoid portion) with multiple collateral vessels around the brainstem especially within the ambient and quadrigeminal plate cisterns are demonstrated with progression. imaging of interesting lumps and swellings of the head and neck, trunk and extremities in children with pathological correlation r dixon, v tang (royal manchester children’s hospital, uk) lumps and swellings in the head, neck, trunk and extremities in children from infants to teenagers are common. there is a wide variety of pathologies including congenital, infection and neoplastic, often requiring several imaging modalities including ultrasound, mri and ct, given their nonspecific imaging findings. we present a variety of unusual pathologies with histological correlation to demonstrate the imaging findings, and to highlight the malignant potential of swellings, even though they may, clinically and radiologically, appear to be benign. vertebral body shapes – a clue to the underlying diagnosis r dixon, m kaleem (royal manchester children’s hospital, uk) vertebral body shape anomalies can occur as part of congenital or acquired conditions. recognition of anomalies of vertebral body shapes can help in radiographic identification of the underlying disease/condition. 3d ct reconstructions are invaluable for assessing the anomalies. we present radiographs and ct findings of various known underlying conditions with vertebral body anomalies. we include examples from our centre of congenital anomalies such as block vertebra and dysplasia, as well as acquired deformities due to such conditions as sickle cell and metabolic conditions. accuracy of radiology voice recognition reports at a tertiary south african hospital j du toit (stellenbosch university) introduction. voice recognition (vr) technology (the process whereby spoken words are converted to digital text) has been used in radiology reporting since 1981. vr has the potential to dominate radiology abstracts reporting, with the latest software claiming up to 99% accuracy, reduced report turnaround times and significant cost savings. however, to date these expectations have not been realised. vr reports have been shown to contain significantly higher levels of inaccuracy than traditional dictation transcription (dt) reports, to require thorough proofreading and editing, and to have greater aggregate costs when radiologists’ time is incorporated. the radiology department of the tygerberg academic hospital (tah) introduced limited use of english language vr software in january 2010. aim. to compare the accuracy of vr and dt reports at tah, and to establish the clinical significance of any errors. method. the first 300 vr reports and the first 300 dt reports generated at tah during march 2010 were retrieved from the hospital’s picture archive and communication system (pacs), and reviewed by a single observer. text errors were identified and recorded on a study data sheet, and then classified as either clinically significant or insignificant, based on the potential effect on patient management. ethics approval was obtained from the health research ethics committee of stellenbosch university. results. of the 300 vr reports analysed, 77 (25.6%) contained errors, of which 29 (9.6%) were clinically significant. only 28 (9.3%) dt reports contained errors, with 7 (2.3%) being potentially clinically significant. this vr error rate was significantly greater than the dt error rate (p = 0.00000). the difference in clinically significant errors between the two groups (9.6% v. 2.3%) was also statistically significant (p = 0.00016). conclusion. vr technology significantly increases the clinically significant inaccuracies found in radiology reports. individual thigh muscle volume quantification: 3d slicer-based modeldraw semi-automated segmentation technique h gongxeka (pretoria university and steve biko academic hospital) objective. there is a need to develop, validate and implement a semiautomated modeldraw 3d slicer image segmentation technique for quick, accurate determination of individual muscle volume from mri series. method. axial mri slices from thigh muscles of 16 healthy human subjects (age 21 61 years; mean 32) were acquired using a 1.5 tesla machine, q-body coil and proton density weighted spin echo pulse imaging sequence. a manual and a semi-automated 3d slicer software were used by two blinded observers to segment each of the selected mri thigh muscles, build their modeldraw and quantify the volume of each modeldraw. results. one-way anova statistical assessments of the degree of interobserver variability of the acquired modeldraw volumes between the two observers showed a good one-on-one correlation as noted on the manual (g=1.05 x 19970, r²=0.99 and p<0.0001) and the semi-automated (g=1.045 x -18143, r²=0.99 and p<0.0001) muscle segmentation methods respectively. the semi-automated analysis of the four muscles of each subject with a reduced set of slices (an average of 17) took about 45 minutes, as opposed to 3 hours when using all the slices during the manual segmentation. conclusion. 3d slicer is an open source-based and a multi-platform computer software program. the inter-observer correlations observed higher precision point with the semi-automated tool regarding g values (5%) than the 10% obtained for manual segmentation. future work related to this effort includes application to non-healthy subjects, to quantify the specific outcomes of medical interventions that may counteract the negative regulators of muscle physiology. the use of positron emission tomography/computed tomography in characterising the lymph nodes in patients infected with mycobacterium tuberculosis and mycobacterium avium intracellulare infection h gongxeka (pretoria university and steve biko academic hospital) aim. to compare the characteristics of the chest lymph nodes in the positron emission tomography computed tomographic (pet/ct) study of mycobacterium tuberculosis (mtb) infection and mycobacterium avium intracellulare (mai) infection in patients with human immunodeficiency virus type 1 (hiv) infection. methods. a retrospective review of the chest lymph node pet/ct findings of 61 patients with hiv and proven mtb (n=20) or mai (n= 41) infection was conducted. images were reviewed by a radiologist and nuclear physician blinded to the diagnosis, and the radiological findings involving the lymph nodes in the axilla and mediastinal regions were characterised and compared. preliminary results. mtb lymph node appearances range from normal to abnormal morphological and metabolic features. mai lymph nodes were not significant. preliminary summary. mai appears to predominantly affect the lung parenchyma and interstitial elements more than the lymph nodes. reducing radiological error rates m govind, r hift (university of kwazulu-natal) formulating a radiology report is complex and fraught with many potential mishaps. radiological error rates have changed little over the last 50 years, and research into the aetiology and impact of intervention is gaining momentum. the persistence of such a high error rate despite medical and technological advances is surprising, until one appreciates that the most common reason for error is cognitive perception. perception is an individual skill, not correctable by departmental policies. the debate around inherent and trained perceptual capabilities still rages, but it is evident that changes occur in the functioning of the brain early (within the first 18 months) in training and are a good predictor for eventual radiological ability. reliable and reproducible formative assessment of trainees is difficult as the course work is not structured and is opportunistically encountered in daily work. those trainees who do not show these changes may benefit from intervention that is tailored to hone perceptual skill and ability. experience and an expanding knowledge base play a great role in ability later in training and are assessed on summative assessments appropriately. in the early training period, a tool is needed to assess evolving capabilities and to identify those trainees who need assistance. we discuss these issues in the context of a study we are about to commence to investigate the perceptual and psychological factors and processes that underlie the development of radiological accuracy and avoidance of error during the training of radiologists. abstracts the impact of hiv infection when superimposed on pulmonary tuberculosis on the success of bronchial artery embolisation m govind (university of kwazulu-natal) introduction. pulmonary tuberculosis (ptb) is often associated with hiv co-infection in south africa. bronchial artery embolisation (bae) is a specialised, expensive and risky procedure. aim. to investigate the effect of co-infection with hiv and ptb on the success of bae. method. a retrospective cross-sectional study of sequential bae procedures during 2006 and 2007 was performed. rates of procedural and clinical outcome, reasons for procedural failures and the effect of cd4 levels on procedural and clinical failure was investigated. cases were included if they presented with massive or life-threatening haemoptysis with a diagnosis of previous or active ptb in whom hiv status was known, for the first 2 attempts at bae only. results. the study population comprised 74 hiv-positive and 33 hivnegative cases. the median cd4 level was 176 cells/μl. statistically, procedural success did not imply clinically successful outcome. hiv status and cd4 level did not correlate significantly with procedural success. statistically, no technical reason influenced the success of the procedure when correlated with hiv status. the detection of lymphadenopathy was noted in 19.1% of hivpositive cases and 42.4% of hiv-negative cases, and was the only feature of significance. conclusion. co-infection with hiv does not affect the success of bae in patients with active or sequelae ptb who present with massive or lifethreatening haemoptysis. technical success does not imply clinical success regardless of hiv status. improvement in technique locally may produce better results. mapping the lungs – iodine mapping in pulmonary emboli w harmse (university of the free state) background. ct pulmonary angiography is the current preferred imaging for the diagnosis of pulmonary emboli. sensitivity, however, decreases in the peripheral smaller vessels for which nuclear medicine perfusion studies are often needed. dual energy ct pulmonary angiography (dectpa) allows creation of iodine maps of the lung fields, simulating perfusion scans which can be used to identify perfusion defects. this is done by material decomposition which separates two different elements or compounds on the basis of their attenuation co-efficients at different energy levels. aim and methods. we present 3 patients who received dectpa at universitas hospital for possible pulmonary emboli. the pulmonary arteries were initially evaluated for filling defects as per routine single-energy ctpa, after which iodine maps were created to detect perfusion defects. results. patients a and b had multiple large and smaller emboli in virtually all the segmental bronchi. this correlated well with all the perfusion defects seen on the iodine maps. in patient c, no large emboli were seen, with only small partial occlusions in 3 sub-segmental bronchi. after review of the iodine maps, several other segmental perfusion defects were seen. retrospectively, thrombi were seen in 4th and 5th generation pulmonary arteries of 10 further segments, which correlated with the perfusion defects. the mean iodine content of all lung segments was measured and was 3.85 mg/ml (n=11) in those with no thrombi, 2.06 mg/ml (n=44) in those with partial occlusion, and 0.43 mg/ml (n=5)in those with complete occlusion. conclusion. ct pulmonary angiography employing a dual energy technique provides a single, quick examination from which to evaluate the pulmonary arteries, lung parenchyma, and indirectly the pulmonary perfusion — all with a high spatial resolution, and a higher sensitivity in diagnosing pulmonary emboli than single energy scanning alone. assessing a broken heart l huang, z lockhat, f ismail (department of radiology, steve biko academic hospital and university of pretoria), l mitchell (department of paediatric cardiology, steve biko academic hospital and university of pretoria) the term ‘single ventricle heart’ includes a heterogeneous group of complex congenital cardiac malformations characterised by a univentricular atrioventricular connection; i.e. both atria are completely or predominantly connected to a single ventricle. this ventricle has to maintain both the pulmonary and systemic circulations, and inevitably its function will deteriorate. surgical cavopulmonary shunts reduce the workload of this sole ventricle, increasing its longevity. timeous assessment of morphology on echocardiography and physiology at cardiac catheterisation is essential in planning the surgical management of such patients to optimise their life expectancy. this is especially true of our case series in south africa, where end-stage cardiac transplantation is not readily available. systematic radiological assessment is a guide to prompt surgical intervention and thus to optimising the patient’s outcome. chest radiographs assess the cardiac silhouette, cardiac size, pulmonary vasculature and great arteries. twodimensional echocardiography remains the mainstay for the sequential segmental analysis of these complex lesions and associated abnormalities. diagnostic cardiac catheterisation evaluates the haemodynamics with calculation of the pulmonary bloodflow (qp), mean pulmonary pressure and pulmonary vascular resistance (pvr) as well as demonstrating venous return to assess suitability for cavopulmonary shunts. cardiac mri, if available, is also effective. in this case series, we demonstrate the anatomical variants found in the spectrum of univentricular or ‘single’ ventricle hearts and describe the imaging modalities needed to accurately delineate the features of these complex cardiac defects to ensure the best outcome for such patients. walking the tightrope: when to intervene in rheumatic heart disease l huang, z lockhat, f ismail (department of radiology, steve biko academic hospital and university of pretoria), l mitchell (department of paediatric cardiology, steve biko academic hospital and university of pretoria) rheumatic fever is a disease of poverty. poor socio-economic circumstances including overcrowding, malnutrition and limited access to primary healthcare contribute to this epidemic in sub-saharan africa and other third-world economies. in our series, children as young as 6 years have established, severe rheumatic heart disease necessitating prosthetic valve replacement. however, owing to their small annular size, placing a prosthesis that will be adequate for future growth is impossible, and serial valve replacements will be needed, which contributes significantly to their morbidity and mortality. delaying surgery until the child is older is also not the answer as the progressive dilation of the left ventricle (lv) inevitably leads to its dysfunction. vigilant monitoring of the valvular pathology and lv size and function is therefore needed for abstracts timeous surgical intervention. the role of radiological imaging in rheumatic heart disease is to systematically evaluate the severity of valvular pathology and its impact on lv function, and to ascertain when surgical intervention is needed to preserve ventricular function. chest radiography monitors cardiac size, chamber enlargement and pulmonary congestion. rheumatic valvular pathology has classic echocardiographic features. the resultant severity of valvular incompetence and/or stenosis can be graded and its effect on the lv size in systole and diastole and the ejection fraction can be assessed. serial echocardiography in the child with rheumatic heart disease is therefore invaluable for ascertaining the ideal time for surgical intervention. this is the left, right? l huang, z lockhat, f ismail (department of radiology, steve biko academic hospital and university of pretoria), l mitchell (department of paediatric cardiology, steve biko academic hospital and university of pretoria) heterotaxy is a complex of malformations involving abnormal right-left axis determination with an incidence of 1 in 10 000 births. thoraco-abdominal visceral laterality is deranged, often accompanied by midline defects of the face and brain. studies suggest that heterotaxy represents a spectrum of laterality defects with variable expression. syndromes of left or right atrial isomerism have been well-described. patients may present incidentally when chest x-ray shows dextrocardia or an inverted stomach bubble, or with symptoms associated with cardiac defects, intestinal obstruction or immune deficiencies. radiological studies such as echocardiography define the cardiac orientation and any associated cardiac defects. abdominal ultrasound identifies the liver, gallbladder and spleen, and the position of the aorta and ivc. upper gastro-intestinal contrast procedures are recommended to evaluate intestinal malrotations. if anatomical uncertainty persists, further investigation with ct, mri or angiography may be necessary for surgical planning. for our case series, we describe the classification of heterotaxy syndromes with their associated spectrum of anatomical abnormalities. understanding the situs abnormalities facilitates a logical, systematic imaging approach. thorough radiological examination of every organ system is needed to delineate all rotational abnormalities and their associated complications to plan optimal management. laryngotracheal papillomatosis complicated by squamous cell carcinoma f ismail, z lockhat, f suleman (university of pretoria) laryngotracheal papillomatosis is a condition caused by human papilloma virus infection of the larynx, the trachea and occasionally the bronchi and alveoli.the virus enters the tracheo-bronchial tree of the neonate at childbirth, during passage past an infected cervix.the granulomas are a common cause of a benign mass lesion of the larynx and trachea in children. some granulomas undergo cavitation, which may be visible on chest radiographs. patients usually present with stridor, wheezing and recurrent infections. the condition does not usually complicate. very rarely (2 3% of cases), the granulomas undergo malignant transformation to squamous cell carcinoma, which has a poor prognosis. we present a case report of a child with recurrent laryngotracheal papillomatosis (rltp), complicated by squamous cell carcinoma,where imaging played a significant role in diagnosis and detecting malignant transformation. the mystical foot with pink mushrooms: imaging findings in maduromycosis – a rarity in southern africa g jackson (kalafong and steve biko academic hospitals, and university of pretoria) maduromycosis is an insidious, debilitating granulomatous infection of the subcutis. infrequently encountered by physicians in countries outside an endemic global belt, it is often misdiagnosed as a neoplasm or other aggressive lesion, with the diagnosis of maduromycosis often not even considered. the diagnosis relies on direct examination of the grains formed by the organisms and isolation of the aetiological agents. imaging studies are useful not only for defining the extent of the infection, but also to act as a guide for the clinician as to the correct pathology. we present a case of advanced, recurrent maduromycosis in a teenager (an uncommon age for the disease to occur), in a non-endemic region, but having typical radiological features that are considered hallmarks of the disease. biloma and traumatic haemobilia: two distinct complications of blunt hepatic injury in a patient, successfully treated with a combination of radiological and endoscopic interventions s jeetoo, d reitz (department of radiology, pietermaritzburg metropolitan hospital complex), g laing (department of surgery, pietermaritzburg metropolitan hospital complex) introduction. the conservative management of blunt hepatic trauma is well established. nevertheless, complications such as the development of bilomas and traumatic pseudo-aneurysms can arise following a conservative management course. we describe the case of a 25-year-old man who presented 10 days after blunt abdominal trauma. ct of the abdomen showed a biloma with no features of arterial injury. this was managed by an ultrasound-guided drain initially and an ercp with papillotomy following a persistent biliary leak. subsequently, the patient had a significant episode of haemobilia. a conventional angiogram demonstrated a pseudo-aneurysm of a segmental branch of the right hepatic artery. selective angio-embolisation resolved this complication. discussion. non-operative management of blunt liver trauma in the haemodynamically stable patient without peritoneal signs has become the standard of care. complications are related to either ongoing biliary leakage or ongoing haemorrhage. most bilomas can be drained percutaneously using radiological guidance. if there is a persistent biliary leak, an ercp with papillotomy can be performed. traumatic haemobilia is a rare complication with a prevalence of less than 3% of liver injuries. angio-embolisation is the intervention of choice in the management of this complication. our patient developed both complications, which were successfully treated using minimally invasive techniques. conclusion. bilomas and haemobilia are two known complications arising from the conservative management of blunt liver injury. both can be successfully treated by a combination of minimally invasive techniques, as depicted in our case. classic tetralogy of fallot and three odd-balls c liebenberg, g jackson, n makhanya, j joshi, s andronikou (university of pretoria) classic tetralogy of fallot (tof) is described as a tetrad of cardiac malformations, i.e. ventricular septal defect (vsd), and right ventricular outflow tract obstruction (rvoto) with right ventricular hypertrophy (rvh) and an aorta overriding the ventricular septum. we present a case series of the rarer imaging spectra of tof, namely tof with a combination of absent pulmonary valve and absent left pulmonary artery, tof with abstracts pulmonary atresia and associated aorto-pulmonary shunt, and tof with absent left pulmonary artery. breathtaking africa: proposed pathogenesis of lymphobronchial tb s lucas, s andronikou (university of the witwatersrand), pierre goussard, robert gie (stellenbosch university) lymphobronchial tuberculosis (lbtb) describes lymphadenopathy affecting the airways, which is particularly common in children because of their small, compressible airways. lung complications distal to an airway narrowing are believed to develop progressively if untreated. this poster is a pictorial representation of a proposed pathogenesis. recognition of lbtb and its complications is important to help identify those patients with potentially reversible pathology and to guide intervention aimed at salvaging residual vital lung parenchyma. an approach to a pancreatic mass in a child – the red herring! n mahomed, k mahango, t westgarth-taylor (university of the witwatersrand) pancreatic tumours are a rare and unusual entity in paediatric patients, accounting for less than 0.2% of cancer-related paediatric deaths; their prognosis and histological spectrum differs from those of adults. pancreatoblastoma is the most common primary pancreatic tumour of childhood. these tumours are often large, typically compress and displace adjacent structures rather than invade them, and may cause distant metastases. dilatation of the biliary tree is uncommon. nonepithelial primary pancreatic tumours include lymphoma, sarcoma, pnet, lymphangioma and haemangioendothelioma. haemangioendotheliomas are rare benign tumours of vascular origin. the pancreas is a rare primary site of occurrence, with only 9 children with a pancreatic haemangioma/ haemangioendothelioma reported in the english literature. kaposiform haemandioendothelioma is a tumour that contains common features to both karposi sarcoma and haemangioma, and has been characterised as a vascular tumour of intermediate malignancy by the who because of its local infiltrative growth pattern and low-grade histomorphological features. we present a case of primary pancreatic kaposiform haemandioendothelioma in an 8-month-old boy who presented with obstructive jaundice and kasabachmerritt syndrome. the aim of this poster is to provide a practical approach to pancreatic masses, which encompasses both common and rare causes. lipoid proteinosis – radiological and dermatological manifestations i matela (university of pretoria) we present a rare case of lipoid proteinosis. it is a rare autosomal recessive disorder, characterised radiologically by comma-shaped calcifications in the hippocampus bilaterally on plain radiographs and computed tomography (ct). clinical features include skin scarring, beaded eyelid papules, and laryngeal infiltrations leading to hoarseness of the voice. the latter is usually present at birth or in early infancy, as the first manifestation. moreover, the infiltrates in the tongue and its frenulum decrease lingual movement, resulting in speech difficulties. on histology lipoid proteinosis is characterised by infiltration of periodic acid schiff-positive hyaline material in the skin, upper aerodigestive tract and other internal organs. we present a young girl who presented to the ear, nose and throat department with hoarseness of the voice and was subsequently referred to dermatology where the diagnosis of lipoid proteinosis was made. ct and skull radiographs confirmed the diagnosis. she has a sister with a similar clinical picture. eyes wide shut: recognising optic radiation involvement in optic glioma in nf1 h moodley, n mahomed, s andronikou (faculty of health sciences, university of the witwatersrand) neurofibromatosis type i is a common phakomatosis with characteristic bilateral optic nerve gliomas. involvement of the optic radiations, however, is rare. it should be recognised because it may carry a worse prognosis, and to obviate biopsy. this pictorial essay documents the mri findings of optic radiation involvement in a 7-year-old boy with nf1. biopsy in the region of the optic tract and thalamus yielded a histological grade ii astrocytoma. there are only a few case reports of optic radiation involvement in nf1, while some large series have no documented cases. the significance of optic radiation involvement in terms of contiguous tumour spread v. peritumoural oedema is contentious. our biopsy result is significant in supporting the hypothesis that this represents true tumour spread. inflammatory myofibroblastic tumour – a pictorial essay on diverse imaging findings c morkel (university of cape town) inflammatory myofibroblastic tumour (imt) is a rare benign neoplasm of mesenchymal origin that can affect individuals of any age, but has a predilection for children and young adults. the aetiology and pathogenesis remain unknown. it commonly involves the lung and abdomen in children but has been found in almost every site in the body. the presenting symptoms of these lesions vary widely according to the site of the tumour, and range from fever, malaise, abdominal pain, iron deficiency anaemia, cough and nonspecific respiratory symptoms to asymptomatic patients or patients with a palpable mass. the imaging characteristics of imts vary according to their site of origin and underlying histology (varying amounts of fibrosis and cellular infiltration). some lesions demonstrate calcification, and can be single or numerous, wellor ill-defined and show variable contrast enhancement. the ultrasound and ct features are often non-specific. mri may point towards the diagnosis, showing low signal on t1 and t2, reflecting the fibrotic nature of the lesions. definite radiological differentiation between a malignant lesion and imt may be impossible; as a result, the diagnosis is often only reached after exploratory laparotomy with open biopsy or surgical resection. in this pictorial essay, we present 3 cases (involving lung, stomach and liver) of imt that presented at our institution, focusing on the diverse imaging features correlated with the histology. we discuss the potential differential diagnoses and offer a review of the literature. a case of job buckley (hyper ige) syndrome c nkabinde (pretoria university) a 12-year-old black boy presented to witbank accident and emergency with: cough productive of copious purulent sputum and haemoptysis; pyrexia; severe tachycardia; and respiratory distress. detailed history revealed longstanding illness with numerous consultations at various health centres. on examination, the patient had finger clubbing, pallor, primary and secondary teeth, and mouth sores. crackles, rhonchi and amphoric breathing were heard in the chest, but no wheezes. chest radiograph showed a loss of volume on the left side. pneumatocoeles, bronchiectasis and abscesses were noted bilaterally. ct showed extensively destroyed lungs, more so on the left. there were features of end-stage lung disease. differential diagnoses of cystic fibrosis, tb or asthma complicated by fungal infection were considered. after noting negative tb and hiv, but positive staphylococcus on sputum culture, abstracts high ige, eosinophilia and abnormal dentition, a diagnosis of job buckley (hyper ige) syndrome was made. walker-warburg syndrome j otto, w harmse, g van der westhuizen (university of the free state) walker-warburg syndrome is a rare autosomal recessive congenital muscular dystrophy with multisystem involvement, including brain and ocular abnormalities. it is the most severe form of a small group of ‘muscle-eyebrain’ syndromes that include fukuyama congenital muscular dystrophy (fcmd) and muscle-eye-brain disease (meb). the condition is also known as cerebro-ocular dysgenesis (cod), hydrocephalus-agyria-retinal dystrophy (hard) and chemke syndrome. we discuss the case of a 5-month-old boy who presented with seizures, hypotonia, dysphagia and dysmorphic features. the serum creatine kinase level was severely raised. the imaging findings included cobblestone lissencephaly, hydrocephalus, brainstem and cerebellum abnormalities, agenesis of the corpus callosum and ocular defects. these findings are in keeping with walker-warburg syndrome. our discussion elaborates on the aetio-pathogenesis and genetic aspects of this disorder. walker-warburg syndrome is a rare and fatal multisystem condition with an average life expectancy of 3 years. recognising this condition is important in terms of prognosis and genetic counselling. the role of mri in the management of post-traumatic pancreatic pseudocysts in children t pillay, t kilborn, s cox (red cross war memorial children’s hospital) pancreatic damage occurs in 3 12% of children with blunt abdominal trauma. the most important complication is the development of pseudocysts owing to duct injury. the clinical course is unpredictable, with spontaneous resolution in 30 50%; however, rupture, haemorrhage, infection and maturation occur in up to 70%. management of high-grade injuries is controversial in paediatric patients. some centres recommend early aggressive surgical management with ercp, stenting and in some cases distal pancreatectomy. conservative management with octreotide acetate and total parenteral nutrition to decrease pancreatic exocrine functions for all duct injuries is more commonly practised in children. non-resolving pseudocysts are then treated by drainage procedures – usually pseudocystgastrostomy or pseudocystjejunostomy either done sonographically, endoscopically or as an open procedure, depending on resources available. imaging of pancreatic trauma at initial presentation is done by ct. ultrasound is unreliable in the acute phase but is accurate in the detection and follow-up of peri-pancreatic fluid collections and pseudocysts. mri with mrcp has proved to be an accurate way of detecting pancreatic injuries in adults; there are limited data available discussing the routine use of mri in children. six cases of highgrade pancreatic injury that developed pseudocysts have been seen at our institution since 2008. all patients were managed conservatively and had mri scans between 2.5 and 6 weeks post-injury to assess suitability for drainage. this study assesses the use of mri in predicting the need for drainage, the role of mrcp in defining the ductal injury, and the optimal sequences to define pseudocyst boundaries. white out of the lung – not so black and white t pillay, n wieselthaler (red cross war memorial children’s hospital) white-out of the lung on chest x-ray is most commonly caused by either a pleural effusion or consolidation. in a patient with a non-resolving whiteout of the lung, other causes need to be considered. ultrasound is a good first-line investigation; however, most complicated cases will go on to have further imaging. we highlight 4 patients who presented with white-out of the lung and were found to have unusual pathologies. cryptococcal meningo-encephalitis in an immune-competent 7-monthold infant – an unusual radiologic presentation s vedajallam, a chacko, j smal, e lubbe (university of pretoria) cryptococcal meningitis and meningo-encephalitis is an opportunistic fungal infection and usually a disease of immune-compromised (aids) patients. it is an especially rare condition in immune-competent persons. the radiological features of cryptococcal meningo-encephalitis can include normal computed tomography or show meningeal enhancement, single or multiple nodules (cryptococcomas), cerebral oedema or hydrocephalus. mri is more sensitive for numerous enhancing nodules within brain parenchyma, meninges, basal ganglia and midbrain. we present the unusual radiological findings in an immune-competent 7-month-old girl who presented with a left hemiplegia and no evidence of fulminant infection/sepsis. meconium pseudocyst secondary to intra-uterine bowel perforation s vlok (department of radiology, grey’s hospital) introduction. intra-uterine bowel perforation with consequent intra-peritoneal meconium extravasation causes a sterile chemical inflammatory response known as meconium peritonitis. peritoneal inflammation caused by the extravasated meconium may lead to peritoneal calcification as early as 12 hours after perforation. association of meconium peritonitis with cmv and parvovirus b19 infections is well known. discussion we present the case of a 25-year-old rvd-positive woman, g3p2, in her third trimester of pregnancy, in whom antenatal ultrasound investigation at 32 weeks revealed a large, cystic intra-abdominal mass with an irregularly calcified rim and internal echoes within the fetus, as well as polyhydramnios and an oedematous placenta. the diagnosis of a large meconium pseudocyst secondary to intra-uterine bowel perforation was made. this was retrospectively associated with cmv infection, for which the neonate tested positive post partum. an abdominal ct performed for surgical planning on the day of birth again confirmed the diagnosis. a quiz with a cheeky answer! t westgarth-taylor, n mahomed, s andronikou, c westgarth-taylor (university of the witwatersrand) we present a rare case of a unilateral parotid mass in a child. this poster, through a pictorial review and quiz, illustrates the differential diagnosis for parotid masses in children, providing both the clinical and radiological findings for each diagnosis. through an interactive process, the rare diagnosis in our case (muco-epidermoid carcinoma) is revealed and discussed. the intra-operative, histological and radiological findings are also displayed. finally, the important learning points demonstrated by this case are provided. doi:10.7196/sajr.787 case report 57 sa journal of radiology • september 2007 abstract gas in the wall of the stomach is a rare condition and may be caused by gastric pneumatosis (also known as gastric emphysema) or emphysematous gastritis. we present the case of a 27-year-old white female patient with a history of thoracic and abdominal surgery who presented with intractable vomiting, clinically suspected to be as a result of gastric outlet obstruction. intramural gastric air was subsequently demonstrated on plain abdominal x-rays, fluoroscopy (water-soluble contrast meal), and on an abdominal ct scan. introduction gastric pneumatosis (also known as gastric emphysema) and emphysematous gastritis are terms describing air in the wall of the stomach. intramural gastric air is a rare clinical condition. it was first described by chamberlain in 1947.1 cases in the literature have described radiological, endoscopic, histological and trans-abdominal ultrasound findings in adult and paediatric populations. case report a female patient, aged 27 years, presented with intractable vomiting, clinically diagnosed as gastric outlet obstruction. at this point, the patient was afebrile and abdominal pain was not present. plain abdominal radiographs (fig. 1) and a water-soluble contrast meal (fig. 2) demonstrated linear streaks of gas in the gastric wall. there were no gas loculi present and there was no thickening of the gastric rugae. a ct scan of the abdomen confirmed the presence of intramural gastric air (fig. 3). four months prior to this episode, the patient delivered a healthy full-term infant via a normal vaginal delivery. there had been no prenatal complications. ten days following delivery she presented with dyspnoea. a chest x-ray demonstrated a large mass adjacent to the right hemi-diaphragm. a thoracotomy was performed, the mass was excised and the differential diagnosis on histology was a pleomorphic rhabdomyosarcoma or a liposarcoma. one month following the thoracotomy, the patient developed a low small-bowel obstruction. surgery was undertaken and perforations of the ileum and urinary bladder were found. an ileostomy was consequently performed. during her hospital stay, two further laparotomies and abdominal wash-outs were performed, as well as an ultrasoundguided percutaneous drainage of a left anterior sub-phrenic abscess. intramural gastric air – gastric pneumatosis or emphysematous gastritis? werner harmse, mb chb vicci smith, mb chb, da (sa) aisne stoker, mb chb, dmrd, frcr department of radiology, pietermaritzburg hospital complex, nelson r mandela school of medicine, university of kwazulu-natal fig. 1. plain film demonstrating linear intramural gastric air (arrows) and the left anterior subphrenic percutaneous drain (arrowhead). fig. 2. water-soluble contrast meal demonstrating intramural gastric air (arrows) and the left anterior subphrenic percutaneous drain (arrowhead). pg57-58.indd 57 9/17/07 8:55:57 am case report case report 58 sa journal of radiology • september 2007 two weeks after the percutaneous drainage she developed intractable vomiting and the water-soluble contrast meal was performed, demonstrating the intramural gastric air. the patient was treated empirically with broad-spectrum iv antibiotics and total parenteral nutrition (tpn) for 7 days. at that stage she was able to tolerate food, and subsequently recovered and was discharged 3 weeks later. discussion gas in the wall of the stomach is a rare radiological finding, which can be caused by gastric pneumatosis or emphysematous gastritis. these two conditions can be distinguished on the bases of pathogenesis, clinical picture and radiological appearance, although they may mimic each other. gastric pneumatosis or gastric emphysema describes the presence of gas within the stomach wall. this is caused by a disruption in gastric mucosa leading to the dissection of air into the wall. there are various causes for this phenomenon: (i) conditions causing raised intragastric pressure, i.e. gastric outlet obstruction; (ii) post-gastroscopy (air insufflation and other instrumentation may cause mucosal damage); (iii) severe vomiting, which causes mucosal damage; (iv) dissection of air from the mediastinum (e.g. ruptured bullae or pneumothorax).2,3 these patients are usually asymptomatic or complain of mild dysphagia and/or epigastric discomfort. plain radiographs characteristically demonstrate a linear lucency conforming to the contour of a thin-walled, often distended, stomach, and enveloping any intraluminal gas and fluid content.2,3 the clinical course is usually benign, with spontaneous resolution after the cause is removed. in these cases, gas is not produced within the stomach wall but enters it from elsewhere.2 this should be the main criterion in making the diagnosis of gastric pneumatosis/emphysema. in comparison, emphysematous gastritis occurs when there is diffuse infiltration of the stomach wall by pathogenic gas-forming bacteria. thus the gas is formed within the stomach wall. in these cases, an earlier gastric mucosal injury allows gas-forming organisms to gain access to deeper tissue layers. causes of this condition include: (i) ingestion of toxic or corrosive substances; (ii) alcohol ingestion; (iii) trauma; (iv) gastric infarction; (v) ulcer disease; (vi) necrotising enterocolitis.5 the most common organisms involved include haemolytic streptococci, clostridia welchi, escherichia coli and staphylococcus aureus. these patients present with severe, acute epigastric pain, fever, shock, toxaemia, nausea, often haematemesis and a leucocytosis. radiologically, the stomach is often contracted with numerous frothy or mottled radiolucencies (gas bubbles) in the gastric wall.2,4 these lucencies silhouette the stomach outline and remain constant with positional change. other features may include gas in the portal venous system and thickened rugal folds. contrast studies may demonstrate a cobblestone appearance of the mucosa due to submucosal blebs, and occasionally intramural penetration of contrast may be seen. abdominal ct may further distinguish this from gastric pneumatosis/emphysema by detecting small amounts of intramural gas as well as gastric wall thickening. emphysematous gastritis has a uniformly poor prognosis with a mortality of 60 – 80%.2,5 treatment is usually conservative with broad-spectrum antibiotics, intravenous fluids and nutritional support being the mainstay. if the patient survives, cicatricial stenosis may occur, which requires surgery. in the case we present, the patient was not toxically ill at the time of demonstration of intramural gastric air. the radiographs showed a streaky intramural gas pattern. we therefore diagnosed this case as gastric pneumatosis/emphysema and hypothesised that her condition was as a result of her previous surgical interventions. her uneventful recovery and subsequent discharge from hospital further substantiates our diagnosis. conclusion intramural gastric air is a rare but important sign to recognise and diagnose as it may represent either one of two conditions, which differ vastly in terms of clinical and radiographic presentation, management plan and prognosis. patients with gastric pneumatosis are clinically asymptomatic, and a streaky or linear air pattern is demonstrated radiographically. the prognosis is excellent. in contrast, patients with emphysematous gastritis are usually severely ill and the gas pattern has a mottled or bubbly radiographical appearance. the prognosis is uniformly poor. 1. chamberlain dt. pneumoperitoneum following gastroscopy apparently without perforation: report of a case. new engl j medicine 1947; 237: 843-845. 2. fidvi sa, klein sa. clinical quiz. appl radiol 2002; 31(3): 33-36. 3. soon m, yen h, soon a, lin o. endoscopic ultrasonographic appearance of gastric emphysema. world j gastroenterol 2005; 11(11): 1719-1721. 4. tuck js, boobis lh. case report: interstitial emphysema of the stomach due to perforated appendicitis. clin radiol 1987; 38: 315-317. 5. herring w. gastric emphysema. http://www.learningradiology.com/notes/ginotes/gastricemphysemapage. htm (last accessed 4 april 2007). fig. 3. ct of the abdomen demonstrating linear intramural gastric air (arrows). pg57-58.indd 58 9/17/07 8:55:58 am sajr 1008 radiology in the research environment clinicians and epidemiologists at mcmaster university in canada coined the term ‘evidence-based medicine’ in 1988.1 the scottish physician dr archibald leman cochrane (1909 1988) was a pioneer of evidence-based medicine; the cochrane library database of systemic reviews was named after him. knowledge exchange occurs between researchers and the users of research, whereby research is used to change policy and planning or practice and systems. the translation of best evidence integrated with healthcare practices conduces to saving money and lives. translational research is viewed as a solution to the disparity between evidence-based medicine2 , 3 in the growing field of basic biomedical research and its application in creating sustainable health solutions (‘from bench to bedside’). more recently, it has been viewed as a two-way exchange whereby clinical data and human trials inspire biomedical insights (‘from bedside to bench’).4 there are now several journals dedicated to translational research, including the american journal of translational research and translational research. in imaging research, the process would include the development of more sensitive and specific imaging techniques; assessment of their performance in clinical practice; and investigation of their implementation at an epidemiological level in changing the standard of care in imaging.3 the translation of research in imaging technology to its application in clinical medicine is a perfect illustration of a successful translational pathway that has had a huge impact on diagnostic and interventional medicine. magnetic resonance and computed tomography imaging, balloon angioplasty and mammography5 were ranked among physicians as 3 of the top 5 medical innovations in the last 30 years. to facilitate collaborations between stakeholders in clinical and translational research, institutions such as john hopkins have established dedicated support structures for translational research. the world health report 2013 6 argues that health coverage cannot be achieved without the evidence provided by scientific research. the volume of research on health issues in resource-limited settings has increased, but investigators beyond africa’s borders tend to determine the research agenda.7 , 8 it follows that the development and implementation of radiology protocols specific to the type of pathology and trauma encountered in south africa would have a greater impact on local health priorities. developing skills to deliver health research is necessary for every country’s development. incorporating these skills at the undergraduate and postgraduate training level is therefore essential. radiology incorporated into research performed by other specialties can result in radiologists falling behind competing specialties where high-quality research is performed. the lack of research initiated by the radiologist stems from a lack of funding and dedicated research time, as a result of ever-increasing workloads in clinically demanding environments. in conclusion, then, i wish to emphasise that radiologists assu­ming a key role in multidisciplinary research communities would be in a position to have a direct and beneficial impact on radiology practices. razaan davis editor 1. donald a. evidence-based medicine: key concepts. medscape general medicine 2002;4(2). http://www.medscape.com/viewarticle/430709_3 (accessed 20 october 2013). 1. donald a. evidence-based medicine: key concepts. medscape general medicine 2002;4(2). http://www.medscape.com/viewarticle/430709_3 (accessed 20 october 2013). 2. lean me, mann ji, hoek ja, et al. translational research. br med j 2008;337:a863. [http://dx.doi.org/10.1136/bmj.a863] 2. lean me, mann ji, hoek ja, et al. translational research. br med j 2008;337:a863. [http://dx.doi.org/10.1136/bmj.a863] 3. petrou m, foerster br, reich ds. translational research in radiology: challenges and roles in a patient-based practice. acad radiol 2009;16(5):593-596. [http://dx.doi.org/10.1016/j.acra.2009.01.017] 3. petrou m, foerster br, reich ds. translational research in radiology: challenges and roles in a patient-based practice. acad radiol 2009;16(5):593-596. [http://dx.doi.org/10.1016/j.acra.2009.01.017] 4. ledford, h. translational research, the full cycle. nature 2008;453:843-845. [http://dx.doi.org/10.1038/453843a] 4. ledford, h. translational research, the full cycle. nature 2008;453:843-845. [http://dx.doi.org/10.1038/453843a] 5. fuchs vr, sox hc jr. physicians’ views of the relative importance of thirty medical innovations. health aff (millwood) 2001;20(5):30-42. 5. fuchs vr, sox hc jr. physicians’ views of the relative importance of thirty medical innovations. health aff (millwood) 2001;20(5):30-42. 6. world health organization. world health report 2013: research for universal health coverage. http://www.who.int/whr/en/ (accessed 13 october 2013). 6. world health organization. world health report 2013: research for universal health coverage. http://www.who.int/whr/en/ (accessed 13 october 2013). 7. gretchen lb, wiysonge cs, mills ej, et al. global health: the importance of evidence-based medicine. bmc medicine 2013;11:223. [http://dx.doi.org/10.1186/1741-7015-11-223] 7. gretchen lb, wiysonge cs, mills ej, et al. global health: the importance of evidence-based medicine. bmc medicine 2013;11:223. [http://dx.doi.org/10.1186/1741-7015-11-223] 8. ijsselmuiden c, marais dl, becerra-posada f, ghannem h. africa’s neglected area of human resources for health research – the way forward. s afr med j 2012;102(4):228-233. 8. ijsselmuiden c, marais dl, becerra-posada f, ghannem h. africa’s neglected area of human resources for health research – the way forward. s afr med j 2012;102(4):228-233. about the author(s) efosa p. iyawe college of medicine, university of ibadan, ibadan, oyo state, nigeria bukunmi m. idowu department of radiology, union diagnostics and clinical services plc, yaba, lagos state, nigeria olasubomi j. omoleye department of general medicine, louismed hospital and fertility centre, lekki phase 1, lagos state, nigeria citation iyawe ep, idowu bm, omoleye oj. corrigendum: radiology subspecialisation in africa: a review of the current status. s afr j rad. 2022;26(1), a2347. https://doi.org/10.4102/sajr.v26i1.2347 note: doi of original article published: https://doi.org/10.4102/sajr.v25i1.2168 correction corrigendum: radiology subspecialisation in africa: a review of the current status efosa p. iyawe, bukunmi m. idowu, olasubomi j. omoleye published: 30 june 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the published article, iyawe ep, idowu bm, omoleye oj. radiology subspecialisation in africa: a review of the current status. s afr j rad. 2021;25(1):a2168. https://doi.org/10.4102/sajr.v25i1.2168, on page 4 the following paragraph is updated as it was incorrectly formulated: the original incorrect wording: the tanzanian ir project was midwifed by the rad-aid international ir programme in collaboration with academic institutions in the united states and europe. the revised and updated wording: the tanzanian ir project was midwifed by the radiological society of north america (rsna) and an organisation called road2ir (www.road2ir.org). the authors apologise for this error. the correction does not change the significance of study’s findings or overall interpretation of its results or the scientific conclusions in any way. sajr 853 imaging of disease progression in a case of idiopathic moyamoya a chacko,1 mb bch; j smal, 1 mb chb, mmed (rad d); e lubbe,2 mb chb, fcpaed (sa), cert paediatric neurology (cmsa); n adroos,1 mb chb, mmed (rad diag) 1 department of radiology, steve biko academic hospital and university of pretoria, pretoria, south africa 2 department of paediatrics, steve biko academic hospital and university of pretoria, pretoria, south africa corresponding author: a chacko anithchacko@gmail.com moyamoya is a rare cerebrovascular disease characterised by progressive stenosis of the terminal portion of the internal carotid artery and its main branches. we report on the progression of the disease in a 3-year-old boy, confirmed to have idiopathic moyamoya disease, over 6 ensuing years, using serial magnetic resonance imaging with mr angiography. comparison is also made with conventional angiography at the last visit. characteristic imaging appearances of asymmetric narrowing of the internal carotid arteries (especially the supraclinoid portion) with numerous collateral vessels around the brainstem, especially within the ambient and quadrigeminal plate cisterns, are demonstrated with progression. s afr j rad 2013;17(3):88-90. doi:10.7196/sajr.853 moyamoya is a rare cerebrovascular arteriopathy characterised by progressive stenosis of the terminal portion of the internal carotid artery (ica) and its main branches, and is associated with cerebral ischaemia. the moyamoya vessels are the fragile collaterals formed in compensation for this progressive stenosis of the ica at the base of the brain (at the level of the circle of willis). these collaterals of the thalamostriate and lenticulostriate arteries give the characteristic appearances on mr or conventional angiography. aetiology can be varied, and numerous causes can result in secondary moyamoya-like collateralisation. idiopathic or primary moyamoya is rare; diagnosis is usually made with mri and after exclusion of all possible secondary causes. we present progressive imaging of a 3-year-old boy confirmed to have idiopathic moyamoya disease, over 6 years using serial mri with mr angiography, and compare with conventional angiography at the last visit. case report a 3-year-old boy presented initially in 2006, with alternating and resolving hemiplegias, seizures and headaches. mr images (figs 1a c) demonstrated numerous collateral vessels around the brainstem, especially within the ambient and quadrigeminal plate cisterns. also demonstrated was asymmetry and narrowing of the supraand infraclinoid portions of the internal carotid arteries (icas) with significant stenosis of the supraclinoid portion (figs 1d and 1e). a diagnosis of moyamoya disease was made after clinical and laboratory exclusion of secondary causes and with the use of imaging. fig. 1. mri and mra imaging diagnosis of moyamoya at the initial presentation of a 3-year-old boy: t2w axial images (a c) of the brain, at the level of the circle of willis, show numerous collateral vessels, seen as multiple flow voids (black arrows), around the brainstem, especially within the ambient and quadrigeminal plate cisterns. mra images with sagittal (d) and coronal (e) views show asymmetrical narrowing of the supraand infraclinoid internal carotid arteries (white arrows) as well as the collateral vessel formation (dashed white arrows). over the next 6 years (2006 to 2012), the patient was followed up regularly as an outpatient, utilising serial routine mri studies to monitor progression of the disease. documented deterioration of cognitive function as well as significant learning difficulties was maintained. progression of the disease from 2006 2012 was demonstrated over serial mr examinations, which clearly demonstrated progressive collateral vessel formation around the brainstem as well as progressive narrowing of the icas bilaterally. no dilatation of the anterior or middle cerebral arteries was ever demonstrated; in fact, these vessels appeared smaller than on initial presentation. in 2012, owing to worsening cognitive function and learning difficulties, repeat mr imaging (fig. 2) was performed as well as conventional angiography (fig. 3) to plan for possible surgical intervention. the characteristic ‘puff/spiral of smoke’ appearance of the collateral vessels at the level of the circle of willis was noted on conventional angiography. marked narrowing of the infraclinoid portion of the icas bilaterally as well as complete stenosis of the supraclinoid portions of the icas bilaterally was also noted. currently, the patient is stable and awaiting neurosurgical intervention in the form of a pial synangiosis. fig. 2. follow-up mri and mra imaging of the patient in fig. 1 after a 6-year period: t2w axial images (a c) show the markedly increased number of collateral vessels around the brainstem at the level of the circle of willis (black arrows). mra on sagittal (d) and coronal (e) views shows increased stenosis of the supraand infraclinoid portion of both internal carotid arteries (white arrows) and more numerous collateral vessels (dashed white arrows) compared with fig. 1. fig. 3. conventional angiogram images with lateral views of the cerebral arteries. note the characteristic ‘puff/spiral of smoke’ appearance of the collateral vessels at the level of the circle of willis (white arrows). also noted is the marked narrowing and stenosis of the supraclinoid portion of bilateral internal carotid arteries (dashed white arrows). a = left internal carotid artery; b = right internal carotid artery; c = left vertebral artery; d = right vertebral artery. discussion moyamoya syndrome is a cerebral arteriopathy characterised by bilateral progressive stenosis of the terminal portions of the icas.1 collateral vessels (most commonly the lenticulostriate and thalamoperforator arteries) hypertrophy to compensate for the stenosis. the angiographic appearance of these collaterals gave rise to the term moyamoya and refers to ‘hazy like a puff of smoke drifting in the air’.2 many disorders are associated with the moyamoya syndrome, and almost any slowly progressive intracranial vascular occlusion results in a similar appearance. for this reason, moyamoya syndrome is seen by many to be a radiographic syndrome rather than a specific disease. the term moyamoya disease or primary moyamoya, however, is reserved for cases where no underlying or secondary cause can be identified, as in our patient.3 an inherited form has been described in japanese patients, where 10% of cases are familial.4 disorders associated with secondary moyamoya include down syndrome, neurofibromatosis type 1, tuberous sclerosis and sickle cell disease. an underlying cause is more likely when the occlusive changes are unilateral, and can usually be identified.3 causes of moyamoya must be actively and rigorously investigated for. most patients present during childhood with varying neurological signs and symptoms, as in our patient. approximately 70% of reported cases occur in patients <20 years of age, and 50% occur in children <10 years. children usually have recurrent transient ischaemic attacks (tias) with progressive neurological impairment, while adult patients more often present with intracranial haemorrhage.4 our patient was noted to have alternating resolving hemiplegias (tias), seizures and headaches. ct and mr are useful for detecting regions of cerebral infarction or ischaemia owing to the vasculopathy. mr is more sensitive than ct for detecting the enlarged moyamoya collaterals, which are seen as signal voids in the basal ganglia. mra also demonstrates narrowing of affected intracranial vessels, as in our patient (figs 1 and 2). if intravenous contrast is administered, intense enhancement of the basal nuclei can occur – either owing to infarction and breakdown of the blood-brain barrier or from visualisation of the collateral vessels coursing through them. curvilinear enhancement may be seen coursing radially through the centrum semiovale from the lateral ventricles to the cortex, probably representing dilated deep medullary veins. branching, pial enhancement may also be seen, probably representing dilated capillaries. perfusion imaging (spect or mr) is useful for identifying regions of relative ischaemia at risk for infarction.5 conventional angiographic evaluation is nearly always included to define the extent of the disease and adequacy of collateral flow. the typical angiographic appearance is narrowing of the supraclinoid ica, proximal anterior cerebral artery and proximal middle cerebral artery. the posterior circulation is rarely involved until late in the course of the disease. lenticulostriate and thalamoperforator arterial hypertrophy is well appreciated on angiography. evaluation of associated vascular abnormalities, such as saccular aneurysms, dissecting aneurysm and arteriovenous malformations is necessary at angiography.6 none of these complications were noted in our case (fig. 4). if left untreated, intellectual function and motor deficits worsen over time. indirect bypassing procedures are preferred for good outcome and relative simplicity v. direct bypassing procedures. pial synangiosis (placing a branch of the external carotid artery in apposition to the pia-arachnoid) is an example of an indirect bypassing procedure that can be used.7 the pial synangiosis procedure is planned for our patient to try to improve blood flow to the cerebral parenchyma. conclusion moyamoya is a rare cerebral arteriopathy, especially in its idiopathic form. secondary causes, with a moyamoya-like appearance, are more common. ct, mri and conventional angiography can all be used to image the disease and its progression, and to assist planning for the various bypass treatment procedures that are possible. 1. hoffman hj. moyamoya disease and syndrome. clin neurol nerosurg 1997;99 suppl 2: s39-s44. 1. hoffman hj. moyamoya disease and syndrome. clin neurol nerosurg 1997;99 suppl 2: s39-s44. 2. kudo t. spontaneous occlusion of the circle of willis. a disease apparently confined to japanese. neurology 1968;18(5):485-496. 2. kudo t. spontaneous occlusion of the circle of willis. a disease apparently confined to japanese. neurology 1968;18(5):485-496. 3. scott rm, smith er. moyamoya disease and moyamoya syndrome. n engl j med 2009;360:1226-1237. 3. scott rm, smith er. moyamoya disease and moyamoya syndrome. n engl j med 2009;360:1226-1237. 4. smith er, scott rm. moyamoya: epidemiology, presentation, and diagnosis. neurosurg clin n am 2010;21(3):543-551. [http://dx.doi.org/10.1016/j.nec.2010.03.007] 4. smith er, scott rm. moyamoya: epidemiology, presentation, and diagnosis. neurosurg clin n am 2010;21(3):543-551. [http://dx.doi.org/10.1016/j.nec.2010.03.007] 5. jayakumar pn, vasudev mk, srikanth sg. radiological findings in moyamoya disease. ind pediatrics. 1994;32(4):461-467. 5. jayakumar pn, vasudev mk, srikanth sg. radiological findings in moyamoya disease. ind pediatrics. 1994;32(4):461-467. 6. maas k, barkovich aj, dong l, et al. selected indications for and applications of magnetic resonance angiography in children. pediatr neurosurg 1994;20(2):113-125. 6. maas k, barkovich aj, dong l, et al. selected indications for and applications of magnetic resonance angiography in children. pediatr neurosurg 1994;20(2):113-125. 7. scott rm, smith jl, robertson rl, et al. long-term outcome in children with moyamoya syndrome after cranial revascularization by pial synangiosis. j neurosurg 2004;100(2 suppl pediatrics):142-149. 7. scott rm, smith jl, robertson rl, et al. long-term outcome in children with moyamoya syndrome after cranial revascularization by pial synangiosis. j neurosurg 2004;100(2 suppl pediatrics):142-149. sajr 934 neonatal imaging s k misser,1 mb chb, fc rad (d) sa; t a mitha,2 bsc, mb chb, fcp (sa) paed; a s shaik,3 mb chb, fcs (sa), cert (paed surg) sa 1 lake smit and partners, durban, south africa 2 specialist paediatrician, parklands hospital, durban, south africa 3 paediatric surgeon, parklands hospital, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) a neonatal first set of radiographs of a baby girl appear below. describe the relevant findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 23 september 2013. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. s afr j rad 2013;17(3):116. doi:10.7196/sajr.934 fig. 1. portable supine abdominal radiograph. fig. 2. portable shoot-through lateral abdominal radiograph. fig. 3. portable babygram radiograph. fig. 4. portable occipito-frontal radiograph. sajr 769 chest imaging by high-resolution computed tomography (hrct): diagnosis s k misser, mb chb, fcrad (d) sa lake smit and partners, durban   i a abdullah, mb chb, fcp (sa), fccp st augustine’s hospital, durban   corresponding author: s misser (misser@lakesmit.co.za) we congratulate dr qonita said-hartley, consultant radiologist at new somerset hospital, cape town, for a most detailed diagnosis for which she receives an award of r1 000 from the rssa. the two runners-up – dr kamila padia and dr marc jordaan – warrant honourable mention. dr misser elaborates below on the condition and its imaging. please refer to page 79 of the june 2012 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/view/729/566) for the presentation details (a 39-year-old man with subacute dyspnoea and intermittent cough) and images. the previously published and two new images appear below diagnosis the plain radiograph demonstrates multi-segment bilateral lung opacities with associated fine nodular infiltration. the chemotherapy port in situ relates to prior treatment for colonic cancer. cardiomediastinal silhouette and pulmonary vascularity are normal. serial level hrct images reveal diffuse centrilobular nodular infiltrates and ground glass opacification (ggo) in both lung fields. patchy areas of involvement with adjacent normal-appearing lung segments are noted. this is in keeping with a mosaic pattern of attenuation. no air trapping was detected on expiration. pulmonary vessels are of uniform calibre throughout the lung. the areas of ggo are therefore the abnormal finding, and the low attenuation areas are normal intervening lung segments. in the absence of marked superimposed reticulation, the pathology suspected is parenchymal lung disease rather than predominant interstitial or lymphatic process. fig. 1. plain pa chest radiograph. fig. 2. axial hrct at pulmonary artery level. fig. 3. axial hrct at aortic root level. figs 4a and 4b. coronal reformatted ct images before and after steroid therapy. figs 5a and 5b. axial ct images before and after steroid therapy. further questioning revealed that the patient was a pigeon breeder with more than 100 birds in his aviary. the chemotherapy port was a red herring. the possibility of post-chemotherapy (infective or immunologic) related lung disease was thought a less likely differential diagnosis. a diagnosis of subacute hypersensitivity (bird fancier’s) pneumonitis was made. he was treated with a short course of steroids and advised to reduce exposure to birds. follow-up study showed complete resolution of the allergic alveolitis changes – see figs 4 and 5 above, demonstrating beforeand after-treatment images. hypersensitivity pneumonitis (hp), originally known as extrinsic allergic alveolitis, is an allergic lung disease caused by the inhalation of organic or inorganic particles that trigger a cascade of immune-complex and cell-mediated reactions. bird fancier’s lung is one of the most common forms of hp.1 it is a unique form of hp in that the offending antigen is a protein, rather than a micro-organism, and is contained in the feathers, serum and guano of birds.2 imaging usually undertaken in the subacute phase of the disease reveals ill-defined small centrilobular nodules and a mosaic pattern (table 1). treatment is usually supportive and antigen avoidance in the acute/subacute phase is generally all that is needed. table 1. subacute hp hrct findings 1 , 3 • small centrilobular nodular opacities • isolated or diffuse ggo • superimposition of first two findings • lobular areas of decreased/mosaic attenuation • lobular areas of air-trapping approach to mosaic pattern of attenuation ground-glass opacity (ggo) is defined as a hazy increase in lung density with preservation of airway and vessel margins. a mosaic pattern refers to the presence of patchy areas of ggo interspersed with adjacent darker areas. the radiologist has to determine if the area of increased lung opacity is abnormal or if the darker areas are abnormal. a key step is the assessment of the calibre of the pulmonary vessels in the areas of inhomogeneous lung opacity. (see diagnostic algorithm below.) when the pulmonary vessels are uniform in size, this is probably due to parenchymal lung disease (table 2). decreased size of the pulmonary vessels is cause to suspect mosaic perfusion. the pattern may be due to vascular causes (e.g. chronic pulmonary thrombo-embolism) or airway obstruction with redistribution of blood to the normal hyper-attenuated areas (e.g. bronchiolitis obliterans). an expiratory ct scan assists in dividing these patterns further. those with air trapping demonstrate further relative darkening of the low attenuation areas. table 2. peripheral/patchy ggo 3 • hypersensitivity pneumonitis • interstitial pneumonia (uip, nsip, dip) • alveolar proteinosis • eosinophilic pneumonia • sarcoidosis • organising pneumonia 1. silva ci, churg a, müller nl. hypersensitivity pneumonitis: spectrum of high-resolution ct and pathologic findings. ajr 2007;188(2):224-244. 1. silva ci, churg a, müller nl. hypersensitivity pneumonitis: spectrum of high-resolution ct and pathologic findings. ajr 2007;188(2):224-244. 2. chan al, juarez mm, leslie ko, ismail ha, albertson te. bird fancier’s lung: a state of the art review. clin rev allergy immunol 2012;43(1-2):69-83. 2. chan al, juarez mm, leslie ko, ismail ha, albertson te. bird fancier’s lung: a state of the art review. clin rev allergy immunol 2012;43(1-2):69-83. 3. webb wr, muller nl, naidich dp. high-resolution ct of the lung. 4th ed. philadelphia, usa: lippincott williams & wilkins, 2008. 3. webb wr, muller nl, naidich dp. high-resolution ct of the lung. 4th ed. philadelphia, usa: lippincott williams & wilkins, 2008. s afr j rad 2012;16(3):118-119. doi:10.7196/sajr.769 case report 101 sa journal of radiology • december 2007 abstract objectives: this is a good example with interesting imaging of a condition which rarely presents in adulthood. methodology: case was described and a review and short summary of the literature was done. conclusions: the complete resection of choledochal cysts is mandatory because of risk of malignant transformation. choledochal cysts occur in approximately 1:10 000 to 1:150 000.1 of these only 20-30% are diagnosed in adults,2 with 80% of cases diagnosed reported as being of the type i variety. complete surgical excision with biliary reconstruction is considered the treatment of choice rather than biliary enteric bypass procedures. this minimises the known risk of malignancy and the development of recurrent cholangitis or pancreatitis that may occur with these cystic lesions.1-3 the diagnosis, surgical findings and treatment of an adult patient who presented to us with a type i choledochal cyst are described and the epidemiology, diagnosis, treatment and cancer risk of choledochal cysts are discussed. case report a 33-year-old female presented with complaints of a right upper quadrant mass increasing in size over a 6-month period. she gave no history of melaena or haematemesis and had no gastrointestinal complaints but had noticed her eyes becoming progressively yellow. on examination she was found to be jaundiced with a large mass occupying the right side of her abdomen, thought to be separate from the liver. she had a palpable spleen, no ascites and all other systems were found to be normal. liver enzymes were all marginally raised, hepatitis studies, echinococcus and amoebiasis serology were all negative. ultrasound showed a large cystic mass thought of be part of the biliary tree and a computed tomography (ct) scan was requested which confirmed a cystic mass (hu 5) at the porta hepatic (figs 1 & 2). differential diagnosis included enteric duplication cyst, lymphoma and especially in an african setting, hydatid cyst and amoebic abscess. on surgical exploration a large bile-containing cyst was found, arising from the proximal aspect of the common bile duct, compatable with a type i choledochal cyst. complete excision of the cyst was performed and a choledochoduodenostomy was done. choledochal cysts – an unusual cause of jaundice in adults anne-marie du plessis, mb chb ellie georgiou, mb chb savvas andronikou, mb bch, fcrad, frcr, phd departments of radiology and surgery, stellenbosch university, tygerberg hospital, tygerberg fig. 1. coronal reconstruction of multislice ct abdomen demonstrates a massive cystic lesion (curved arrow) at the right inferior border of the liver, choledochal cyst, with associated intrahepatic biliary dilatation (black arrow). fig. 2. axial ct abdomen demonstrates the choledochal cyst located in the right hemi-abdomen (curved arrow) the gall bladder is indicated with a straight arrow. pg101-102.indd 101 12/11/07 2:22:55 pm case report case report 102 sa journal of radiology • december 2007 discussion choledochal cysts are classified according to the todani modification of the original alonso-ley classification.1,2 six groups are identified. type i is a fusiform dilatation of the extra hepatic bile duct, as was found in our patient. type ii is a single extrahepatic diverticulum. type iii is a dilatation of the intraduodenal portion of the bile duct. type iv consists of two subtypes: iva which is combined intraand extrahepatic dilatation and ivb which is multiple extrahepatic cysts only. type v is also known as caroli’s disease and consists of cystic dilatation of the intrahepatic biliary system. it is also associated with hepatic fibrosis.2-4 the aetiology of choledochal cysts remains unproven but an anomalous pancreaticobiliary junction has been reported in choledochal cyst disease. babbit3 proposed a theory that suggests a high insertion of the bile duct into the pancreatic duct allowing pancreatic enzymes to reflux into the bile duct. this causes inflammation, weakening and fibrosis of the bile duct and the distal obstruction leads to progressive dilatation of the biliary tree.2,3 children present with the classic triad of abdominal mass, abdominal pain and jaundice. adults however present mainly with pain2,3 and complications of longstanding cysts such as recurrent cholangitis, pancreatitis and malignancies.4 a palpable mass is rare as a presenting feature in adults. laboratory tests have not been proven to be useful in establishing a diagnosis and it has been shown that hepatic transaminase, bilirubin and white cell count were normal in up to 50% of patients at time of diagnosis.2 imaging however is essential in making a diagnosis. ultrasound and ct are useful for detecting cysts, but differentiation from other fluid collections and confirmation of the biliary origin of the cyst can sometimes be difficult. direct contrast cholangiography is used to define extent of involvement and visualise the remaining biliary tree.2,4,5 contrast cholangiography is invasive though, and magnetic resonance cholangiography (mrcp) is a non-invasive technique, shown by govil et al.6 to be as accurate in confirming the diagnosis of choledochal cysts and defining extent of involvement pre-operatively. there is an increased risk of malignancy in choledochal cysts and the occurrence of cancer is most marked in adults. type i has the highest predominance of cancer, followed by the type iv cyst. the type iii cyst is the least common type harbouring cancer. most of the tumours found are adenocarcinomas, although squamous and anaplastic cell carcinomas are occasionally discovered. the most common site of occurrence is the posterior cyst wall. prognosis is poor and most patients die within 2 years of diagnosis.1 early surgical intervention protocols consisted of drainage and enterostomy.2,3 complications occurring with this approach included anastomotic strictures, calculi associated with stasis, recurrent cholangitis and most importantly, malignant disease. currently total excision with reconstuction of the biliary tree by means of hepaticojejenostomy is considered to be the treatment of choice although type iii cysts have been shown to respond adequately when managed with endoscopic sphincterotomy.3 this approach reduces the risk of malignant disease by 60-70%.3 conclusion in conclusion, choledochal cysts in adults are rare and usually present with complications of longstanding cysts. diagnosis is made by ultrasound, ct contrast cholangiography and mrcp. total cyst excision is performed to minimise malignant transformation and prevent complications of pancreatitis and recurrent cholangitis. 1. weyant mj, maluccio ma, bertagnolli mm, et al. choledochal cysts in adults: a report of two cases and review of the literature. am j gastroenterol 1998; 93: 2580-2583. 2. lopez rr, pinson cw, campell jr, et al. variation in management based on type of choledochal cyst. am j surg 1991; 161: 612-615. 3. scudamore ch, hemming aw, teare jp, et al. surgical management of choledochal cysts. am j surg 1994; 167: 479-500. 4. jesudason srb, govil s, mathai v, et al. choledochal cysts in adults. ann r coll surg engl 1997; 79; 410413. 5. lipsett pa, pitt ha, colombani pm, et al. choledochal cyst disease: a changing pattern of presentation. ann surg 1994; 220: 644-652. 6. govil s, justus a, korah i, et al. choledochal cysts: evaluation with mr cholangiography. abdom imaging 1998; 23:616-619. pg101-102.indd 102 12/11/07 2:22:55 pm 38 sa journal of radiology • june 2011 original article introduction although the implementation of fully digitised hospital imaging archiving systems is still in its infancy in the south african (and african) setting, advances in the expansion, assessment and refinement of digitised archiving systems in developed countries are at the forefront of current radiological and information technology research. pacs: do clinical users benefit from it as a training adjunct? jolandi van heerden, mb chb zarina lockhat, mb chb, fcrad (sa) donovan bam, mb chb department of radiology, university of pretoria lizelle fletcher, bcomm (econometrics), bsc (hons), msc (mathematical statistics), phd (statistics) jaqui sommerville, msc (botany) department of statistics, university of pretoria corresponding author: j van heerden (jolandivh@hotmail.com) abstract background. over the past four years, steve biko academic hospital has been in the process of implementing and refining the use of a picture archiving and communications system (pacs). as part of a post-implementation refining process, it was necessary to evaluate user-perceptions in order to improve on good system qualities and correct flaws. aim. the aim of this study was to assess whether medical clinicians perceived pacs as a positive adjunct to training and teaching opportunities – specifically those opportunities related to radiological image viewing and interpretation as part of patient case discussions. method. standardised questionnaires with ‘free text’ and ‘option selection’ questions were distributed to clinicians who, as part of their training, rotated at steve biko academic hospital (where a pacs is in place) as well as other teaching hospitals without a pacs. between february 2009 and may 2009, approximately 400 questionnaires were distributed. as a result of constant academic rotations, leave schedules of medical staff and posts vacated, questionnaires could not be distributed to the entire target population that was estimated to be in the region of 550 medical clinicians (comprising senior medical students, interns, medical officers, registrars and consultants). of the 400 questionnaires distributed, 189 completed questionnaires were returned. completion of the questionnaires was voluntary and anonymous. results and conclusion. although a pacs relates specifically to the archiving and retrieval of radiological images and reports, it became clear from the feedback received from medical clinicians (who are ward-based, theatre-based or clinic-based users of a digital system) that many other factors, such as lack of adequate hardware and sub-optimal personal it proficiency, contributed to some of the negative pacs-related perceptions and ‘lost teaching opportunities’ reported. negative comments specifically related to pacs as a training adjunct included the frustrations associated with pacs downtime (especially during the period in 2009 when many electrical power cuts were experienced nationwide, resulting in network interruptions) and slow image retrieval during peak work-flow times. the advantages of pacs as a positive training adjunct were highlighted in the areas of multi-site viewing and consultation, the possibility of image manipulation and measurement tools, and better overall image quality. clinicians felt that their training experience was also enhanced because of better patient follow-up made possible by access to all previous radiological imaging of a particular patient. of the clinicians who completed the questionnaires, 63.5% felt that the pacs at steve biko academic hospital contributed positively to their training by creating more overall learning opportunities than other training environments without a pacs. fig. 1. a schematic representation of the events following implementation of a pacs. sa journal of radiology • june 2011 39 original article steve biko academic hospital (sbah) is a government-funded academic hospital with a fully digitised imaging archiving system in place. over the past four years at sbah, the process of implementation, integration and refinement of the pacs has been an on-going project co-ordinated by the department of radiology, the department of information technology, the vendor involved, and the key roleplayers at hospital administration level. the african status quo currently lags about 10 years behind our firstworld counterparts. this is clear from early american and european post-pacs implementation quality assessment literature published from 1999 to 2002.1-6 subsequently, as the development and refinement of those pacs systems proceeded, literature pertaining to the ‘added value’ aspects of pacs came to the forefront from around 2005 to 2007.7-10 despite this time lag, our current experiences echo theirs. a process of planning, implementation, use, evaluation and improvement is clearly reflected. the process of change from a hardcopy imaging system to an integrated, digitised archiving system follows a certain natural course – see fig. 1. predicted pre-implementation advantages and disadvantages have previously been described in south african literature.11 at sbah, we are now entering our fourth post-pacs implementation year. on reaching this milestone, it has become necessary to objectively assess the advantages and disadvantages of the implemented pacs as perceived by users. we aim to use our findings to improve on perceived advantages and to act to correct flaws. for medical and surgical clinicians training at an academic hospital, each step of patient interaction contributes to the overall learning experience. this includes viewing of radiological imaging studies and reading the attached radiology reports during ward rounds, clinic days, theatre procedures and formal patient case discussions. the function of a pacs pertains particularly to the storage, archiving and retrieval of radiological images and reports. the system is linked to, and forms the back-bone of, both the hospital information system (his) and the radiology information system (ris). because training medical and surgical clinicians and students come into contact with both of these information systems (his used in clinics, wards and theatres, and ris for interface exposure during inter-departmental case discussions hosted by the department of radiology), this study aimed at evaluating the perceptions regarding the core application of digital image and report archiving and retrieval, regardless of the system interface used. for this reason, the study focuses particularly on pacs as a training adjunct to medical and surgical clinicians and students who are rotating at both a teaching hospital with a pacs as well as teaching hospitals without a pacs. as the process of improvement and re-assessment continues, more optimal use of the ‘value added’ aspects of pacs (that we have only recently started to delve into) will be further developed; these include the use of tele-radiology (possibly linked to other tertiary institutions) and the development of a comprehensive digital image library for training. materials and methods an analytical cross-sectional survey was conducted between february 2009 and may 2009 to evaluate the effects that the integrated pacs had on training opportunities as perceived by clinicians rotating at sbah during their training. standardised questionnaires with free text questions as well as ‘option selection’ questions were distributed to clinicians training and teaching at sbah. these clinicians included consultants, registrars, medical officers, interns and senior medical students working in general surgery, orthopaedic surgery, paediatric surgery, cardio-thoracic surgery, neurosurgery, ophthalmology, ent, urology, dermatology, internal medicine, cardiology, neurology, pulmonology, rheumatology, gastro-enterology, paediatrics, obstetrics and gynaecology, as well as trauma medicine. the questionnaires gave the clinicians the opportunity to state their perceptions and suggestions regarding the pacs as a positive or negative contributor to training opportunities created at sbah, compared with their experiences at other training hospitals where they rotate during their training and do not have imaging archiving systems. although the entire target population was estimated to be in the region of 550 medical and surgical clinicians and students, only about 400 questionnaires were distributed as a result of clinicians’ academic rotations, leave schedules and unforeseen post vacations. of the questionnaires distributed, 189 completed questionnaires were returned. clinicians completed the questionnaires voluntarily and anonymously. results demographics the post descriptions and age range of clinicians who completed the questionnaires demonstrated a demographic distribution similar to the overall demographics in a training hospital – a larger numbers of students and junior doctors than the number of senior specialist consultants (figs 2 and 3). fig. 2. post descriptions of clinicians participating in the study. fig. 3. age distribution of the study population. 40 sa journal of radiology • june 2011 original article due to the fact that this study aims to assess the perceived efficiency of the pacs at sbah as a training adjunct (as perceived particularly by medical and surgical clinicians and students in training), the demographic distribution of the survey respondents is appropriate – the largest proportion of recipients being clinicians and students in training. duration of pacs usage (bearing in mind that total pacs implementation time is currently entering its fourth year) feedback from the study population indicated that 35% had been working with the pacs for more than 2 years, and 63% indicated that they had been working with the pacs for less than 2 years. of the group that had been working with the pacs for less than 2 years, 13% had been working with the pacs for 6 months. general pre-existing computer proficiency of clinical users the majority (45%) of clinicians felt that their pre-existing computer proficiency was good (fig. 4). when asked to comment on their perceived use of the pacs, 43.4% of clinicians experienced the digitised archiving system as easy to negotiate from the start; 51.3% of clinicians experienced the archiving system as difficult to negotiate initially, becoming easier with continued use; and 3.7% of clinicians experienced the system as difficult to navigate, despite continued use. amount of clinicians who had frequent image viewing and associated learning opportunities clinicians were asked to mark whether or not the existing image filming and archiving infrastructure allowed frequent image viewing opportunities during various academic case discussions for the period of their rotations at either sbah or at the other training hospitals without a pacs. frequency was described as ‘more than half of the time’ and ‘less than half of the time’. fig. 5 demonstrates the percentage of clinicians who had image viewing opportunities more than half of the available teaching time at the various institutions (the balance of clinicians viewed images less than half the time). from fig. 5, it is clear that, in most of the academic teaching scenarios, a larger percentage of clinicians reported image viewing opportunities at sbah (using the pacs) than at other training institutions without a pacs. the largest discrepancy in image viewing opportunities was noted regarding formal inter-departmental case presentations. sixty-four per cent of the respondents reported that they viewed images during formal presentations more than half the time at sbah, while 43% indicated that they had similar frequency of image viewing opportunities during formal case presentations when working at other teaching hospitals without a pacs. a smaller discrepancy was demonstrated with informal discussions, where 40% of clinicians felt that they frequently had image viewing opportunities during informal discussions at sbah, and 37% felt that they had frequent image viewing opportunities during informal discussions at other teaching hospitals without a pacs. image viewing opportunities during ward rounds at sbah v. other teaching hospitals without a pacs, differed by only one per cent. the reason for this low figure is directly related to a lack of available appropriate hardware for optimal ward-based image viewing – as outlined by the free-text comments received (see table i below). additional perceptions regarding pacs as a training adjunct other feedback was that 94.7% of clinicians felt that the multi-site viewing of images on the pacs make inter-departmental consultations much easier. also, 94.2% of clinicians felt that digital picture archiving made patient follow-up more efficient by having all the previous imaging studies available for immediate display. the majority of clinicians (97.4%) found the display tools (image manipulations and measurements) helpful when studying images, and 75.1% of clinicians felt that digital images had better resolution than hard copy images. fig. 6 shows positive responses received by the majority of respondents regarding pacs as an overall positive adjunct to medical education by creating more training opportunities. fig. 5. percentage of clinicians who had the opportunity to view images more than half the available teaching time at institutions without and with a pacs. fig. 6. the effects of a pacs on various training opportunities as perceived by respondents. fig. 4. pre-existing computer proficiency as perceived by individual clinicians. perceived pre-existing computer proficiency poor average good advanced 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 6% 29% 45% 20% sa journal of radiology • june 2011 41 original article conclusion in the setting of a teaching hospital such as sbah, every aspect of patient contact contributes to the medical or surgical clinicians’ and students’ training – from patient history taking and examination to the optimal evaluation and appreciation of radiological images and reports. to this end, a well-administrated pacs plays a pivotal role in the amount and quality of medical education offered and learning opportunities created. from this study, the value and potential of a pacs as a training adjunct is highlighted. this is reflected in the fact that the majority of respondents felt that there are aspects of a pacs that contribute positively to the level and amount of training opportunities created, particularly during patient consultations, informal case discussions and formal inter-departmental case-based conferences. however, this post-implementation qualitative survey also clearly outlines that the implementation and use of a pacs is a dynamic process. as imaging, display and digital technology advances, user needs (and therefore system needs) concomitantly change. this demands a continuum of planning, implementation, use, evaluation and improvement that necessitates input from all pacs administrators, vendors and, most importantly, end-users. we gratefully acknowledge the assistance of drs f ismail and l huang. 1. bryan gc, weatherburn jr, buxton mj. the benefits of hospital-wide picture archiving and communication systems: a survey of clinical users of radiology services. brit j radiol 1999;72(857):469478. 2. gouin s, patel h, bergeron s, amre d, guerin r. the effect of picture archiving and communications systems on the accuracy of diagnostic interpretation of pediatric emergency physicians. acad emerg med 2006;13(2):186-190. 3. hruby w. digital (r)evolution in radiology. bridging the future of health care. 2nd ed. new york: springer wien, 2001. 4. strickland nh. pacs (picture archiving and communication systems): filmless radiology. arch dis child 2000;83(1):82-86. 5. weatherburn g, bryan s, nicholas a, cocks r. the effect of a picture archiving and communications system (pacs) on diagnostic performance in the accident and emergency department. j accid emerg med 2000;17(3):180-184. 6. yallop kg, makin e. difficulties with the picture archive and communication system for the transferred patient. arch dis child 2007;92: 79. 7. blunt d, o’regan d. using pacs as a teaching resource. brit j radiol 2005;78(930):483-484. 8. devolder p, pynoo b, voet t, adang l, vercruysse j, duyck p. optimizing physicians’ instruction of pacs through e-learning: cognitive load theory applied. j digit imaging 2009;22(1):25-33. 9. wiggins rh, davidson hc, dilda p, harnsgerger hr, katzman gl. the evolution of filmless radiology teaching. j digit imaging 2001;14(2 suppl 1): 236-237. 10. wilkinson le, gledhill sr. an integrated approach to a teaching file linked to pacs. j digit imaging 2007;20(4):402-410. 11. schulze oc, ackermann c, greyling j, viljoen h, andronikou s. talking pacs: part 2 – why should we change to pacs? south african journal of radiology 2007;11(4):86-90. table i. summary of ‘free text’ comments received positive attributes negative attributes easy image viewing slow image retrieval during peak workflow times. easy image retrieval pacs down-time (especially at times of power supply interruptions and system upgrade difficulties). conveniently accessible images difficulties encountered during ward rounds and student examinations due to absence of a bedside mobile image viewing solution e.g. computers on wheels (cows). images can be viewed at several sites simultaneously some clinicians reported that it was difficult for large groups attending ward rounds to appreciate pathology on the wardbased viewing stations due to small screen size and sub-optimal screen resolution (especially for more specialised investigations such as high-resolution ct chest scans). better time management some clinicians expressed frustration about broken/stolen hardware. access to all previous imaging studies of a particular patient frustrations also expressed about theatre viewing screens that were not fully functional. the benefit of large image-viewing during formal interdepartmental conferences better image quality resulting in better appreciation of pathology during formal inter-departmental conferences the digital nature of the images makes it possible to use them for powerpoint presentations 56 sa journal of radiology • june 2011 radioactive news nominations and election of rssa council and exco office bearers further to the request to members for nominations for the 2011 2013 period, the rssa advises that nominations were received for all the applicable office bearer positions. all nominations were for the existing office bearers, and no opposing nominations were received, therefore nullifying the need for an election. the existing office bearers consequently remain in office for a further 2-year term following the 2011 agm to be held later in the year. the office bearers for 2011 2013 are: president clive sperryn vice-president sheldon godino secretary mark velleman treasurer thami mngoma congress chair leon janse van rensburg member without portfolio ashesh ranchod we thank all members who participated in the nomination process. mark velleman secretary sorsa-rssa 2011 imaging congress: durban 4 6 march 2011 clinical course in mammography mri richard tuft the international society of magnetic resonance in medicine (ismrm) global outreach programme-sponsored faculty comprised gillian newstead, rola shaheen, sughra raza, robyn birdwell and shihchang wang. the strength of a faculty depends on the quality of its speakers, their experience and preparation, and the co-ordination of the subject matter to avoid repetition and give an overview of the subject. they excelled in all these aspects. progressing through mammography and ultrasound to mri, we were treated to a course that was equally appropriate for a radiologist in training, an occasional breast imager or a breast-imaging superspecialist. the speakers came from the usa, canada and australia, and all spoke a language only used by a minority of south african radiologists: bi-rads (breast imaging reporting and data system). owing to its standard lexicon and uniform reporting, all radiologists in south africa should adopt it. the key message was that mri is now an essential and integral part of breast imaging for screening, problem solving and the staging of breast cancer. functional mri of physiological processes leon j van rensburg (rssa congress chair) dr bruce spottiswoode, head of the cape universities brain imaging centre (cubic), must be congratulated on the functional mri of physiological processes workshop held on 5 march 2011 in durban. it was the first of its kind in south africa, not only because the majority of the material presented was new to the audience, but also because the synergy between radiologists and mr physicists has not been well established in south africa. it was run as a parallel session at the 2011 annual imaging congress of the radiological society of south africa (rssa) and society of radiographers of south africa (sorsa), held in durban from 4 6 march 2011. over 600 delegates attended the congress. the workshop was sponsored by the ismrm global outreach programme and a sa/germany grant from a collaboration between the south african national research foundation (nrf), the german federal ministry of education and research (bmbf) and the university of freiburg, germany. six international and 2 local faculty members conducted the workshop. the faculty members were: professor david saloner (university of california, san francisco); professor oliver wieben (university of wisconsin, madison); professor ernesta meintjes (university of cape town); drs michael markl, bernd jung, matthias weigel and daniela foell (university of freiburg, germany); and dr bruce spottiswoode (cubic). the workshop covered the basic principles, clinical applications and new frontiers of a variety of mri techniques aimed at assessing function and physiological processes in the human body. topics included functional cardiac imaging, flow and motion imaging, functional neuro (bold) imaging and diffusion imaging. the workshop was structured to accommodate interactive question-and-answer sessions, and time was allocated for attendees to meet the speakers. the afternoon session consisted of free papers in the categories clinical mri of physiological processes, and new mri techniques. feedback following the workshop was overwhelmingly positive, and there is certainly interest to hold further similar workshops. (l to r) drs gillian newstad and robyn birdwell (usa), professor shih-chang wang (australia), drs sughra raza and rola shaheen (usa), and professor leon j van rensburg (rssa). (l to r) daniela foell, bruce spottiswoode, ernesta meintjes, bernd jung, matthias weigel, michael markl, leon janse van rensburg, oliver wieben* and david saloner.* *ismrm-sponsored faculty sa journal of radiology • june 2011 57 radioactive news rssa/sgr (american society of gastrointestinal radiologists) 2011 award andrew lawson (uct; rssa travel award winner 2010) the first rssa/sgr gastrointestinal imaging course took place at spier estate together with the first combined rssa/sgr abdominal imaging congress in august 2010. the rssa funded the r40 000 travel award to attend the annual sgr meeting, hosted at the park aviara hyatt hotel in carlsbad, san diego, southern california in march 2011. i was privileged to be the sgr beneficiary for the 2011 congress and to present a paper (effectiveness of percutaneously placed self-expanding metal stents for palliation of malignant biliary obstruction) at the scientific forum. i wish to thank the president of the rssa, dr clive sperryn, and the president of the sgr, professor jay p heiken, for the opportunity to take part. over 600 specialists attended the meeting. the 6-day congress kicked off on sunday, 20 march 2011 at 7 a.m. with 5 hours of scientific oral presentations. each presentation was exactly 7 minutes, followed by a 2-minute question-and-answer session from the floor. the congress programme then continued in earnest on the monday morning with lectures starting again at 7 a.m. each topic was given a 20-minute slot for the speaker to succinctly summate the traditional imaging approaches to specific disease and discuss the latest and greatest advances in that particular field. the majority of speakers not only held abdominal imaging fellowships, but had also further subspecialised in certain branches of abdominal imaging, so facilitating exposure to leaders in the respective fields of modern imaging. several sessions were interactive plenary sessions on a case-by-case shout-thediagnosis forum – particularly appealing to a final-year resident! the congress presented an opportunity to meet experts working at the coal-face of modern imaging. it facilitated an opportunity to share ideas, open doors to potential collaborative research work and establish both social and professional relationships that i look forward to nurturing. european society of radiology (esr) congress, vienna 2011 – report back andrew lawson the annual european society of radiology (esr) congress took place in vienna from 3 7 march 2011, drawing over 20 000 delegates from around the globe. it is the largest radiological society in the world, with over 50 000 members. i presented two papers (‘imaging the rex recessus vein preoperatively using wedged hepatic venous portography and the role of post-operative doppler ultrasound in rex shunt surveillance’; and ‘imaging displacement and strain in the medial gastrocnemius muscle during ankle-joint motion using 2d ciné dense mri’) and a poster (‘effectiveness of percutaneously placed self-expanding metal stents for palliation of malignant biliary obstruction’) as part of the scientific sessions, and was generously supported by the radiological society of south africa (rssa) towards the journey to europe. i am extremely grateful for the support that our society offers young researchers, and wish to encourage junior researchers to reach out for this support! i also thank the university of cape town for their financial support. the congress is on a scale so different to our south african experience that it is almost overwhelming. there are 10 15 daily parallel sessions ranging from refresher courses to new horizon lectures, covering the spectrum of radiology. interactive on-line programme planners allow you to select the courses that specifically interest you! a major attraction for me was the emphasis on encouraging residents to attend congresses and produce research. residents are referred to as the ‘rising stars’. there is in fact an entire lounge on the 2nd floor of the centre for residents only, to facilitate social networking, and a night club in fact is booked out for the friday night exclusively for the rising stars party! i had the opportunity again to meet, debate and make wonderful contacts with a worldwide spectrum of radiologists and residents. the third rssa short course on current ethical issues in radiology: 6 march 2011 leon j van rensburg (rssa congress chair) following the success of the first two short courses in cape town and johannesburg during 2010, a third was held at the sorsa-rssa imaging congress in durban on 6 march. it was very well received, with a packed auditorium. the previously discussed topics were updated and thoroughly re-visited: • ethical considerations in cochlear implant patients, presented by dr derrick wagenfeld. he drew attention to a new emerging ethical dilemma, viz. funderdriven pressure upon implant surgeons to use untested generically manufactured implant devices. • self-referral – a moral hazard, by dr clive sperryn. • paediatric imaging: the ethics of radiation exposure, by professor savvas andronikou. • patient confidentiality in clinical practice: is hiv status still relevant? by professor keymanthri moodley. the important message was that patient confidentiality is sacrosanct in patient-doctor and inter-discipline referrals. • dr susan otto, a consultant radiologist with a llb degree, gave important lectures on the basics and essence of professionalism and negligence. • dr richard tuft presented a very lucid, comprehensive and practical overview of mistakes that can lead to litigation. • ms esme prins, a practicing attorney, highlighted and simplified the important aspects and implications of the new consumer protection act for health providers. many attendees participated in lively debate at the end of each lecture. congratulations to the faculty, and thanks to the consultus team for the organising and to covidien for sponsorship. dr derrick wagenfeld stresses a point. 58 sa journal of radiology • june 2011 radioactive news rssa-cme book donation clive sperryn (rssa president) to quote leon janse van rensburg (rssa congress chair), ‘the rssa cme association will support and provide a sustainable, affordable, appropriate, visionar y and constantly expanding programme of education, teaching and training with support for academic research.’ this year, each department was invited to submit their wish-list of books to the value of approximately r25 000. i recently had the privilege of visiting five of our radiology institutions to officially present the books on behalf of the rssa cme association. i was warmly received in all the departments and had an opportunity to experience first-hand the feel of each and gain some sense of the conditions prevailing and some of the very real constraints on the efficient running of these departments. unfilled consultant posts at medunsa and in mthatha contrast with frozen consultant posts elsewhere. in general, i was impressed with the equipment installed; at medunsa, the active installation of new equipment was in progress. i was particularly pleased to see the close co-operative working relationship between radiology departments at pretoria and medunsa. at wits, i joined a meeting and witnessed some focussed questioning of senior registrars preparing for their exams. unfortunately, in gauteng, failure of the payment system to compensate the equipment vendors for repairs and maintenance seems a significant limitation on the optimisation of the use of existing equipment. at the nelson mandela academic hospital in mthatha, an impressive towering statue of madiba stands outside the entrance. the absence of an mri will soon be addressed and will save patients the long trip to albert luthuli in durban. the mri together with the recently installed mammography machine with stereotactic facility will complete the suite of equipment to complement the spotlessly clean hospital building, helpful staff and excellent resource centre. the most remarkable feature of the department in durban is the rapid turnaround from the bleak prospects a few years ago to a vibrant department that produced the recent gold medallists. the new curriculum will bring new challenges for registrars, and i hope that the various benefits of rssa membership, including the sajr, the opportunities available through associated membership of the esr and the isr, and the reduced congress fees for members and various rssa awards will prove to be of value to all registrars. the rssa looks forward to further strengthening of all the academic departments. neuroradiology subgroup a small group of rssa members are wanting to form a neuroradiology subgroup. would any members with neuroradiological fellowships, special interests or expertise contact the rssa secretariat (jako@xray. co.za) as soon as possible, if they are interested in participating. rssa academic prizes for 2011 the following 2011 rssa travel award and poster prizes will be awarded at the rssa essentials in mdct/cta course, to be held from 26 28 august 2011 in sandton, johannesburg. 1. the rssa travel award this r 40 000 prize is for the best paper presented by a registrar or junior radiologist not qualified for more than 5 years. the winner must use the prize money to attend an overseas course or congress of own choice within a year, and submit a report that will be published in the sajr. 2. poster awards • rssa first prize of r15 000 • discovery second prize of r10 000 • rssa third prize of r5 000 the topics for submission are unrestricted. go to http://www. rssa2011ctcourse.co.za for further details. the deadline for submission is 30 june 2011. leon j van rensburg rssa congress chair professor irena targonska and her department at nelson mandela academic hospital in mthatha. dr sperryn with professor zarina lockhat and professor james ker (deputy dean, faculty of health sciences, university of pretoria) at pretoria academic. professor margaret kisansa and her department at the book handover at medunsa. sa journal of radiology • june 2011 59 radioactive news international advisory board for sajr jan lotz to attain – and then maintain – the highest international standards in our reporting, i have sought to establish an international panel of foremost imaging authorities who will provide critical commentary of the sajr. the members are joshua farber, jonathan kruskal, walter kucharczyk and pia sundgren, and i am delighted and honoured to introduce them to you. walter kucharczyk (md, frcpc) is a professor in the departments of medical imaging and surgery at the university of toronto, and director of magnetic resonance imaging and spectroscopy at the university health network and mount sinai hospital in toronto. he was the chair of the department of medical imaging at the university of toronto from 1991 2007, and a past president of the international society of magnetic resonance in medicine (ismrm) in 2004/2005. on completing his term as department chair in 2007, he was awarded a hans fischer senior fellowship in the institute of advanced studies at the technical university of munich, where he did a 9-month sabbatical in 2007/2008. pia c maly sundgren (md, phd) is professor of radiology and head of the department of diagnostic radiology, clinical sciences lund, lund university in lund, sweden, and also affiliated to the center for medical imaging and physiology, skåne university hospital. her scientific activities focus on neuro-imaging with an emphasis on advanced mr imaging. she has co-authored almost 90 original papers in peer-reviewed journals, another 20 papers (mainly reviews), and co-author of 2 books and several book chapters. professor sundgren serves as a reviewer for a number of journals such as jmri, ajnr, ajr, european radiology and neuroradiology. she is presently the publication editor for the european society of neuroradiology, and is a member of the ecr program planning commitee, and the board of trustees of the ismrm. jonathan kruskal (md, phd) received his mb chb from the university of cape town in 1982 and, after an internship at groote schuur hospital, joined the south african liver research center at uct medical school, where he received a phd in 1987 under the mentorship of ralph kirsch. in 1994, he completed his radiology residency training at new england deaconess hospital/har vard medical school in boston. currently, he is professor of radiology at harvard medical school, chairman of the department of radiology at beth israel deaconess medical center, boston, and chairman of the radiology executive committee at harvard university. a former rsna scholar, he is the recipient of numerous research and teaching awards, is an internationally-recognised lecturer and teacher, and serves on numerous society committees, including chairing the instructional and categorical course committee, and participates on the international relations standing committee, the corporate relations committee, and the executive council of the american roentgen ray society, is chairman of the quality improvement committee of the rsna, and is deputy editor of the journal, radiographics. dr. kruskal has authored more than 150 scholarly publications and has been in the forefront of both molecular imaging and quality improvement initiatives in radiology. he and his wife, pamela, have two children, and live in newton, ma. dr joshua m farber (md) received his md from the university of pennsylvania in 1988. he completed a residency in radiology from nyu in 1994. subsequently, he completed two formal fellowships, one in musculoskeletal imaging from nyu and one in mri from duke. dr farber has served on the scientific and educational program committees for the ismrm and rsna, and he reviews for 6 journals. past research interests and publications have dealt with optimising the protocols for musculoskeletal imaging for mri and mdct, especially in the postoperative setting. currently, dr farber is collaborating on research in quantitative analysis with qmetrics, a quantitative firm based in rochester, ny. he also practices musculoskeletal radiology with a group in cincinnati, ohio. sajr 781 radioactive news rssa mip ultrasound mini conference highly successful zarina lockhat university of pretoria the rssa’s medical imaging partnership (mip) visiting international professors programme for winter 2012 took the form of a mini-conference on ultrasound hosted by the department of diagnostic radiology and imaging at the university of limpopo’s medunsa campus, in conjunction with the rssa’s cme association, on 6 and 7 august 2012. professor harriet paltiel, paediatric radiologist at the children’s hospital, boston, and of harvard medical school, graciously accepted the rssa’s invitation to be the visiting lecturer. the conference was exceptionally well attended, and the number of delegates had to be limited. while larger conferences with internationally renowned speakers play a fundamental role in continuing medical education, an intimate focused workshop plays an important role in developing and promoting sub-specialty interest and in clarifying difficult and complex subjects. this was particularly highlighted at the conference, where professor paltiel patiently and in great detail discussed complex paediatric ultrasound topics. the focus of her talks was on the major aspects of paediatric radiology and, although the essential mode was ultrasound, the topics were comprehensively discussed, covering all major paediatric subjects, and correlated with other relevant imaging modalities. professor paltiel showcased exquisitely detailed images and videos, supplementing each condition with clinical, pathological and imaging findings that summarised and enhanced the most important teaching points for different conditions. the presentations were in depth and covered the spectrum related to each topic, and professor paltiel very effectively conveyed complex and difficult subjects and imaging concepts in an easy-to-understand format, which was the hallmark of how she lectured and discussed each topic. the presentations were extremely valuable to specialist radiologists, specialist radiologists-in-training, ultrasonographers and sonologists. numerous disciplines attended the sessions. professor paltiel mentioned a free-source website for paediatric radiology self-assessment and curriculum guideline: www.cchs.net/onlinelearning/cometvs10/pedrad, powered by comet – centre for online medical education and training. professor margaret kisansa, head of the department of radiology at the university of limpopo’s medunsa campus, and her colleagues are commended for the phenomenal success of the event.the auditorium was packed to capacity and there were no vacant seats throughout the sessions, even when snow fell on 7 august! professor paltiel was particularly touched by the warmth and hospitality she received, and made many acquaintances and friends in south africa. thanks too to professors naseema ebrahim, acting chair of the school of medicine, medunsa campus; darius tsatsi, head of the department of radiology, limpopo campus; and victor mngomezulu, head of the department of radiology, university of the witwatersrand, for their participation; and leon janse van rensburg and the rssa for arranging this highly successful conference. first international day of radiology – 8 november 2012 on 8 november this year, the rssa, the european society of radiology (esr), the radiological society of north america (rsna) and the american college of radiology (acr), together with other international radiological societies, joined in celebrating the first international day of radiology (idor 2012). the initiative was established with the aim of building greater awareness of the value that radiology contributes to healthcare and to improved understanding of the vital role that radiologists play. as a rssa member, you are invited and encouraged to promote the idor within your practice and radiology community. key information about the idor, including booklets about oncologic imaging and the history of radiology, appears on the day’s official website at http://internationaldayofradiology.com. in addition, on the rssa website, one can download the beautifully compiled booklet the story of radiology (volume i) which  has been published by the esr in co-operation with ishrad (international society for the history of radiology – deutsches röntgen museum). please visit http://rssa.co.za/alerts/international-day-of-radiology-8th-november-2012.html for more info. you can also keep up to date with the latest news by liking the international day of radiology facebook page, and show your support by joining the official facebook event page. honorary rssa membership awarded to professor dr robert hermans clive sperryn rssa president robert hermans became a medical doctor with distinction in 1987 and a certified radiologist in 1991. he obtained a phd in 1998 and is professor of radiology at katholieke universiteit leuven. he was president of the international cancer imaging society (icis) and is an executive member of the european society of head and neck radiology (eshnr). he has published over 150 articles and is regularly invited to lecture at national and international meetings. a member of the icis satellite faculty visiting south africa for the first rssa/icis cancer imaging course in 2009, he was back the next year to conduct the internationally renowned interactive leuven ear imaging course for the first time outside europe, and recently returned for the 2012 interactive head and neck cancer imaging course held at spier, near stellenbosch. south african radiologists have derived significant benefit from these courses held outside europe, and we greatly appreciate that he has made 3 long-distance visits to south africa. moreover, he paid his own way, and the savings to the rssa cme fund have thus been used for the benefit of registrars. at the spier meeting, i was privileged to present robert hermans with honorary membership of the rssa in recognition of his selfless commitment to teaching in south africa. dr mngoma presented him with a kruger rand on behalf of the rssa cme fund. thank you to professor leon janse van rensburg (congress chairman) for the vision and dedication which has made all this possible. the rssa cme programme in south africa is without equal, and the groundwork done over the past few years has been and will be of significant benefit to south african radiology for years to come as the programme continues. (l r) drs clive sperryn (rssa president) and sally candy (sasni chair), professor dr robert hermans (leuven), dr zimele mngoma (rssa cme association trustee) and professor leon janse van rensburg (rssa congress chair). rssa/leuven head and neck cancer imaging course, spier estate, 21 23 september 2012 sally candy chair, sa society of neuroradiology imaging (sasni) the privilege of attending the oversubscribed rssa/leuven head and neck cancer imaging workshop more than made up for the disappointing weather! the course was led by a stellar team of experts in the field, comprising vincent chong of the national university of singapore, robert hermans from ku leuven, frank pameijer of utrecht university, ilona schmalfuss of the university of florida, and harriet thöny of the university of bern. working methodically from skull base to thyroid gland and using the requirements of the surgeon and oncologist as reference points, the lectures revised the complex anatomy and the range of neoplasia on both ct and mri. in a memorable 30 minutes that should be compulsory course material for all radiologists, robert hermans unravelled the mysteries of the pterygopalatine fossa. theoretical lectures were followed by a hands-on session where each delegate had the opportunity to apply the theory to a series of illustrative cases. these sessions were conducted under the careful scrutiny of all lecturers. attention to detail, a thorough knowledge of anatomy, and familiarity with the normal fat planes and fascial compartments of the neck are crucial. although the presenters were equally divided in their preference for ct v. mri, they agreed that mri has the upper hand in the demonstration of perineural spread of tumour. common to all head and neck tumours including skin cancers, nerve sheath spread via the endoneurium, perineurium or perineural lymphatics requires meticulous attention to the paths of the vth and viith nerves and their branches. in particular, involvement of the auriculotemporal and inferior alveolar nerves in the spread of skin cancers and parotid tumours was emphasised. features of smooth thickening, nerve enhancement, expansion of the involved foramina, involvement of the cavernous sinus, and denervation atrophy of the muscles of mastication are elegantly demonstrated if you know where to look! lymph node counting is not my favourite pastime but the argument for a good working knowledge of nodal levels and patterns of expected lymphatic drainage in cancer and lymphoma grading and post treatment follow-up was persuasive. the improvement in the preand post-course test results confirmed the subjective consensus that this superbly constructed and executed form of teaching is effective. thank you to the rssa cme association and the leuven team! [the following report on the same course was submitted by dr pieter henning, registrar, university of pretoria.] on 21 september 2012, some of the leading lights in current radiology gathered at spier wine estate in a typical cape storm for the rssa head and neck cancer imaging course. registrars from various medical fraternities also attended. i was one of those privileged to attend, in the hope of demystifying some of the intimidating nature of head and neck cancer reporting, which has earned it a notorious reputation and tendency to move to the tail end of a work list. following the congress, i can attest that this objective has been achieved. the rssa, under the guidance of professor leon janse van rensburg, provided us with the world’s leading experts on the subject matter – proff dr robert hermans and vincent chong, and drs harriet thöny, ilona schmalfuss and frank pameijer. special mention has to be made of robert hermans who was the driving force of this initiative; our society’s appreciation for his great contribution was demonstrated by awarding him with the second honorary membership of the rssa. this was indeed a special occasion and the deserved recognition of an individual who has made a priceless contribution to the teaching and development of radiology in south africa and abroad. the practical application and valuable knowledge gained from this congress cannot be translated into words. i believe that an event of this calibre cannot be considered an adjunct to radiological training, but an absolute necessity. there is simply no equal to having first-hand insight into the methodology and interpretation of difficult subject matter by the foremost experts in that field. i personally thank proff robert hermans and leon janse van rensburg for the opportunity and financial assistance that made it possible to attend this course. i am convinced that the future of radiology in south africa, and maintaining its high standard, will be defined by our ability to continually host and attend international events such as this, which exemplify the words of didacus and newton when they remarked that great intellectual pursuits can only be achieved by ‘standing on the shoulders of giants’.  (l r) proff leon janse van rensburg (rssa), harriet thöny (switzerland), frank pameijer (netherlands), robert hermans (belgium), ilona schmalfuss (usa) and vincent chong (singapore). the course in progress. mip hold seminar at grey’s nicola browning department of radiology, grey’s hospital it was a great privilege for grey’s hospital in pietermaritzburg to host the recent rssa-mip ultrasound workshop and seminar held from 1 3 october 2012. the programme was initiated by the rssa cme association’s chair (professor leon janse van rensburg) and the medical imaging partnership (mip), chair of the board of trustees, professor vikram dogra (university of rochester, ny, usa). we were further fortunate to have two very accomplished professors (dr deborah rubens (university of rochester) and dr leslie scoutt (yale university)) to share their expertise and knowledge with us. the workshop and seminar were attended by radiologists, colleagues and aspiring radiologists from pietermaritzburg and afar. topics covered included vascular, abdominal, pelvic and antenatal imaging. professors rubens and scoutt offered invaluable hands-on training after each session. arrays of classic and atypical case presentations, accumulated by the professors themselves, were shared with the audience. their vast experience was imparted in a manner that encouraged participation and was a delight for all. it was an incredible opportunity for our local doctors to engage with proff scoutt and rubens, who practise with unwavering meticulousness. a highlight of the congress was the rssa online webinar session presented on monday evening. professor rubens began with an insightful presentation on carotid doppler pitfalls. professor scoutt followed this with a most practical discussion on pelvic pain. our heartfelt gratitude is extended to all those who were instrumental in making this amazing learning experience possible – in particular, dr aisne stoker. ‘if you have knowledge, let others light their candles with it.’ [winston churchill] (l r) proff deborah rubens (usa), leon janse van rensburg (rssa) and leslie scoutt (usa). original article original article 16 sa journal of radiology • march 2010 original article abstract neurofibromatosis (or von recklinghausen disease) is a hereditary condition due to mesodermal and neuroectodermal dysplasia, eponymously named after the researcher who reported it in 1882. the disorder is transmitted as an autosomal dominant condition, but 50% of cases arise as spontaneous mutations. the incidence falls within the range 1:2 000 1:4 000, and has no gender bias. we present a series of images produced by different modalities that show lesions and pathologies that are characteristic of the disease. introduction despite being named after von recklinghausen, who documented the disorder in 1882, the classical signs of neurofibromatosis were first reported by smith in dublin in 1849.a1 neurofibromatosis represents a form of disseminated phakomatosis.1 the term ‘phakoma’ (from the greek phakos – lentil) is used for a lentil-shaped object such as a mark on the skin or the retina.2 the disorder is transmitted as an autosomal dominant condition, but 50% of cases arise as spontaneous mutations. there is no gender predilection.3 neurofibromatosis is not a single entity but actually a group of heterogeneous diseases. although several variants of neurofibromatosis have been proposed, only 2 distinct types have been defined to date. neurofibromatosis type 1(nf1) is also termed peripheral neurofibromatosis, and neurofibromatosis type 2 (nf2) as central neurofibromatosis, due to their more peripheral and central involvement, respectively. because nf1 often has central lesions and nf2 can occasionally have peripheral manifestations, the terms central and peripheral have been discarded.4 segmental neurofibromatosis (nf5) is a rare form of neurofibromatosis in which the cutaneous and neural changes are confined to one region of the body. pain and pruritis (due to the large number of mast cells in the neurofibromas) are the presenting symptoms in most afflicted patients. the genetics and the relationship of segmental neurofibromatosis to von recklinghausen disease is undetermined.4 the classic clinical signs include cutaneous pigmentation (café au lait) spots, multiple soft tissue tumours (molluscum fibrosum) and palpable neurofibromas of the peripheral nerves.3 neurofibromatosis type 1 (nf1) nf1 is the most common of the phakomatoses. it is an autosomal dominant condition with high penetrance and abnormalities localised to the pericentrometric region of chromosome 17, with 50% having spontaneous mutants with variable expressivity. the incidence is 1:2 000 4 000 with a male:female ratio of 1:1. mental retardation is present in 10% of cases. diagnostic criteria4,5 diagnosis of nf1 is established when 2 or more of the following are present: • 6 or more café au lait spots ≥5 mm • 1 plexiform neurofibroma or more neurofibromas of any type • ≥2 pigmented iris hamartomas (lisch nodules) • freckling in the axillary or inguinal regions • optic nerve glioma • first-degree relative with nf • presence of a characteristic bone lesion (e.g. dysplasia of greater wing of sphenoid, pseudoarthrosis). mr imaging findings have not at present been incorporated into the diagnostic criteria. radiological presentation skull, meningeal and osseous lesions the most common abnormality of the skull includes macrocrania, hypoplasia of the greater wing of the sphenoid (harlequin appearance of the orbit) (fig. 1) with temporal lobe herniation into the orbit (buphthalmos), calvarial defects (lambdoid and, uncommonly, coronal suture) (fig. 2a d), and dural ectasia.4 enlargement of the internal auditory canal in nf1 that is sometimes seen, is usually the result of dural ectasia and is not due to acoustic neuromas.4 orbits and brain optic nerve gliomas (ongs) are seen in 5 15% of cases, can involve one or both optic nerves and commonly extend posteriorly to involve the chiasma (fig. 3a c). posterior involvement of the optic tracts and radiation and lateral geniculate body is less commonly seen. study by kornreich et al. concluded that the most common site of involvement was the orbital nerve (66%), followed by the chiasma (62%). in patients who do not have nf, the chiasma is the most common site of involvement (92%).5 most ongs are benign, but 20% of chiasmatic gliomas in neurofibromatosis revisited: a pictorial review nausheen khan, mb bs, fcrad (d) sa irma van de werke, mb bch, dmrd, frcr department of radiology, kalafong hospital, university of pretoria farzanah ismail, mb bch department of radiology, steve biko academic hospital, university of pretoria because of the large number of images accompanying this review, and the cost of including them in the printed version of the journal, only the text has been published in print while the full review with all images appears on the open-access sajr website http://www. sajr.org.za. go to the site, click on current, then on the image of ths issue’s front cover, and then on the title of this review on the contents page. original articleoriginal article 17 sa journal of radiology • march 2010 children may behave aggressively.4 imaging is best determined by magnetic resonance imaging (mri). most tumours are isoto hypo-intense to brain on ti (fig. 3b) and show increased signal on t2 (fig. 3c). there is variable post-intravenous contrast enhancement. imes et al. have reviewed the mri findings in 4 patients with ong and have found that double-intensity tubular thickening characteristic of perineural arachnoidal gliomatosis, elongation of the nerves and downward kinking of the nerves in the mid-orbit are typical imaging findings on mri.6 non-optic gliomas have an increased frequency of occurrence in nf1. most are low-grade benign astrocytomas of the brain stem, tectum and periacqueductal region.4 plexiform neurofibromas are a hallmark of nf1 and are diagnostic of von recklinghausen nf (fig. 4). they are found in about a third of patients with nf1. plexiform neurofibromas are poorly delineated diffusely infiltrating multiple tortuous worm-like masses (fig. 5a) that arise along the axis of the major nerves. the first division (orbital) of the trigeminal nerve (fig. 5b) is commonly involved and often associated with sphenoid wing dysplasia and middle cranial fossa arachnoid cyst or prominent subarachnoid space.4 a computed tomography (ct) scan shows a poorly defined mass in the infratemporal fossa (fig. 4). on mr imaging, plexiform neurofibromas are isointense to muscle on t1 and enhance moderately to intensely on post-contrast images. sarcomatous change is reported in 5 15% of cases. benign brain parenchymal abnormalities are observed in nearly 80% of patients with nf1. multiple lesions in the basal ganglia, optic radiation, brain stem and cerebral peduncles are common. on ct scan, they are seen as relatively well-defined unilateral or bilateral hypodense lesions with no appreciable mass effect or contrast enhancement (fig. 6a). on mri, they appear as focal areas of signal intensity (fasi) in white matter and deep grey matter.7 the lesions are of variable intensity on t1-weighted images and are hyperintense on t2-weighted images, with sharp or hazy margins. pathologically, these lesions are foci of hyperplastic or dysplastic glial proliferation, and not neoplastic, and do not show mass effect or contrast enhancement (fig. 6b d). these whitematter changes usually diminish with age.4 lesion progression in a child >10 years of age warrants close follow-up to rule out neoplasm.8 spine (spinal cord and nerve roots) the incidence of spinal involvement in nf1 is approximately 60%. in a study of patients with nf1 by thakkar et al., 6% of patients had intramedullary tumours, 57% had intraforaminal tumours (dumbbell), and 33% had extradural tumours.9 common abnormalities include enlargement of ≥1 neural foramina secondary to the exiting neurofibroma along the nerve root (dumbbell tumour – fig. 7).rarely, it may be caused by dural ectasia (figs 8a c), arachnoid cysts or lateral thoracic meningocoeles. posterior scalloping of the vertebral bodies is only due to dural dysplasia (fig. 8a).4 other abnormalities include kyphoscoliosis (fig. 9) which may be due either to vertebral anomalies or to large meningocoeles or neurofibromas distorting and eroding the adjacent spine and ribs (fig. 9b). meningocoeles can be lateral or anterior thoracic or anterior sacral in localisation.4,10 intramedullary tumours are typically low-grade astrocytomas. hamartomatous lesions similar to those seen in the paraventricular white matter are noted with the same mri signal characteristics.4 chest numerous well-defined subcutaneous neurofibromas may be seen projected over the chest wall (fig. 10a). twisted ribbon ribs (fig. 10b) is a frequently noted feature in nf1, due to mesodermal bone dysplasia. progressive interstitial fibrosis in the lower zones, and large thin-walled bullae in the upper lung zones, may be seen on chest radiography and high resolution computed tomography (hrct) of the lungs (figs 11a and b). other findings include lateral or anterior thoracic meningocoeles presenting as mediastinal masses (figs 12a and b), paraspinal neurofibromas or neurogenic tumours. pedunculated intercostal neurofibromas may be confused with lung nodules.11 musculoskeletal system the commonly noted abnormalities include marked anterolateral bowing of the tibia/fibula; pseudoarthrosis (fig. 13a); and atrophic, thinned (fig. 13b) or absent fibulas, radius and ulna. subperiosteal haemorrhage with easy detachment of the periosteum from the bone and endosteal sclerosis (fig. 14a) may also be seen. intramedullary longitudinal streaks of increased density, multiple non-ossifying fibromas, intraosseous neurofibromas (fig. 14b), and single or multiple bone cysts (deossification/ nonossification) may also be seen. focal gigantism in the form of a digit or an entire limb is often observed (figs 15a and b), and also, at times, bone erosion from an adjacent neurofibroma can be observed (fig. 15c). plexiform neurofibroma of the skin may cause focal enlargement of an area called a pachydermatocoele1 (figs 16a and b). large soft-tissue skin neurofibromas can at times cause pressure erosion of the adjacent bone (figs 16c and d) or may also erode the terminal tufts, mimicking acreosteolysis due to other conditions (fig. 17). gastrointestinal tract solitary neurofibroma, neuroma, ganglioneuroma and schwannoma may present as submucosal or subserosal filling defects, with mass effect on adjacent bowel loops with signs of obstruction. multiple leiomyomas have also been noted.10 genitourinary system plexiform neurofibromas may compress the renal arteries causing stenosis and secondary hypertension. a urinary bladder mass arising from vesicoprostatic or urethrovaginal plexus may also be seen.10 vascular lesions10 vascular abnoirmalities in nf1 include progressive cerebral artery occlusions, aneurysms, vascular ectasia , arterio-venous fistulas and malformations, renal artery stenosis and a high incidence of coarctation of the aorta endocrine abnormalities10 nf1 patients also present with visceral and endocrine tumours such as phaeochromocytomas and thyroid cancers. associations original article original article 18 sa journal of radiology • march 2010 original article the following are associated with nf1: • multiple endocrine abnormalities (mea) type ii b • congenital heart disease (chd), pulmonary valve stenosis, atrial septal defect (asd), ventricular septal defect (vsd) and idiopathic hypertrophic subaortic stenosis (ihss). • associated congenital abnormalities, failure of vertebral segmentation (fig. 7a), spina bifida, congenital dislocation of the hip, and osteomalacia due to disturbance of renal function. complications malignant transformation to neurofibrosarcomas (figs 18 a and b) and malignant schwannomas is extremely rare. in general, imaging cannot distinguish between benign and malignant nerve sheath tumours with certainty; 67ga scintigraphy has been shown by levine et al.12 to be a promising screening technique to identify lesions with malignant degeneration. neurofibromatosis type 2 (nf2) nf2 is an autosomal dominant condition affecting 1:50 000 people, with the mutation occurring on chromosome 22; cutaneous manifestations are rare as it affects schwann cells and meninges. the diagnostic criteria are: • bilateral acoustic neuromas • first-degree relative with nf2 • single 8th nerve mass or any 2 of the following: schwannoma, neurofibroma, meningioma (often multiple – figs 19a c), glioma or juvenile posterior subcapsular lenticular opacity.4 discussion nf2 is associated with tumours of the schwann cells and meninges. bilateral acoustic neuromas and multiple schwannomas of other cranial nerves are highly suggestive of nf2. meningiomas are usually multiple4 (figs 19a c). the acronym misme characterises nf2 and describes multiple intracranial schwannomas, meningiomas and ependymomas5 (figs 20a c). other findings include non-neoplastic intracranial calcifications of the choroid plexus,4 cerebellar and cerebral cortex and occasionally on the surface of the cerebral cortex, spinal cord ependymomas, multiplelevel bulky schwannomas of exiting roots, secondary changes in the spine (expansion, erosions secondary to cord/root tumours) and rarely endobronchial neurofibromas that can cause obstructive bronchiectasis.13 in the spine, the presence of multiple tumours of various histological types is highly suggestive of nf2. conclusion neurofibromatosis, with its multi-faceted presentation, is an entity that has long intrigued and fascinated radiologists, and continues to do so. it is always a diagnostic possibility that should be borne in mind in unusual and rare clinical and radiological presentations. acknowledgements we thank dr z ebrahim for his contribution of the mris of the plexiform neurofibroma of the foot and dumbbell tumour of the spine, and professor zi lockhat for her valued input. 1. murray ro, jacobson hg, stoker dj. the radiology of skeletal disorders. 3rd ed. philadelphia, usa: churchill livingstone,1990:784. 2. sutton d. a textbook of radiology and imaging. 7th ed. philadelphia, usa: churchill livingstone, 2003. 3. klatte ec, edmund a, franken md, smith ja. the radiographic spectrum of neurofibromatosis. semin roentgenol 1976; xi(1): 17-33. 4. osborn ag. diagnostic neuroradiology. 1st ed. philadelphia, usa: mosby, 1994: 430. 5. kornreich l, blaser s, shuper a, et al. optic pathway glioma: correlation of imaging findings with the presence of neurofibromatosis. am j neuroradiol 2001; 22: 1963-1969. 6. imes rk, hiyt wf. magnetic resonance imaging signs of optic nerve gliomas in neurofibromatosis 1. am j ophthalmol 1991; 111: 729-734. 7. osborn ag. diagnostic imaging: brain. 1st ed. salt lake city, usa: amirsys, 2007: 78-82. 8. sevick rj, barkovich aj, edwards ms, koch t, berg b, lempert t. evolution of white matter lesions in neurofibromatosis type 1: mr findings. am j roentgenol 1992; 159: 171-175. 9. thakkar sd, feigen u, mautner v-f. spinal tumors in neurofibromatosis type 1: a study of frequency, multiplicity and variety. neuroradiol 1999; 41: 625-629. 10. dähnert w. radiology review manual. 5th ed. philadelphia, usa: lippincott williams and wilkins, 2003: 309-312. 11. hansell dm, armstrong p, lynch da, page mcadams h. imaging of diseases of the chest. 4th ed. philadelphia, usa: mosby, 2005: 679. 12. levine e, huntrakoon m, wetzel lh. malignant nerve sheath neoplasms in neurofibromatosis: distinction from benign tumours by using imaging techniques. am j roentgenol 1987; 149: 1059-1064. 13. mautner vf, tatagiba m, lindenau m, et al. spinal tumours in patients in neurofibromatosis type 2: mr imaging study of frequency, multiplicity and variety. am j roentgenol 1995; 165: 951-955. 14. kritzinger hg. neurofibromatosis type 2 – a case study. south african journal of radiology 2002; 6(2): 37-40. 15. sher bj, duncan ic. neurofibromatosis type 1 – some cranial and spinal manifestations. south african journal of radiology 2004; 8(3): 32-35. 16. grobbelaar m, george r, theron sh, mapukata a, andronikou s. neurofibromatosis 1 (nf1): features on mri. south african journal of radiology 2006; 10(4): 33-36. original articleoriginal article 18a sa journal of radiology • march 2010 fig. 1. frontal x-ray of the skull showing harlequin appearance of the left orbit owing to hypoplasia of the greater wing of the sphenoid bone. fig. 2a. lateral skull x-ray demonstrates defect in the lambdoid suture. fig. 2b. contrast-enhanced axial brain ct with right lambdoid suture defect with an overlying plexiform neurofibroma. fig. 2c. another patient with a large parietal defect. → → → → original article original articleoriginal article 18b sa journal of radiology • march 2010 fig. 2d. coronal sutural defect – less commonly seen. fig. 3a. axial non-enhanced brain ct showing bilateral gliomas at the level of the optic nerve extending into the chiasm. fig. 3b. coronal t1-weighted mri demonstrates chiasmatic glioma in a patient with nf1. fig. 3c. coronal t2-weighted mri demonstrates chiasmatic glioma in a patient with nf1. high signal is also visualised in the left basal ganglia. → →→ → → original articleoriginal article 18c sa journal of radiology • march 2010 fig. 4. axial ct scan of the skull base showing a large plexiform neurofibroma on the right – note the characteristic poorly delineated diffusely infiltrating mass. fig. 5a. coronal t1-weighted image of the distal lower limb showing poorly delineated multiple tortuous worm-like masses typical of a plexiform neurofibroma (courtesy of dr z ebrahim). fig. 5b. axial non-enhanced brain ct showing plexiform neurofibroma of the right trigeminal nerve, optic glioma and partial hypoplasia of the greater wing of the sphenoid bone. fig. 6a. axial non-enhanced brain ct demonstrating bilateral low-density lesions in the basal ganglia with no appreciable mass effect. → → →→ → → original article original articleoriginal article 18d sa journal of radiology • march 2010 fig. 6b. axial flair sequence of the same patient as above shows bilateral hamartomatous high signal changes in the basal ganglia (fasi) with no appreciable mass effect. fig. 6c. coronal t2-weighted mri of the same patient. note that these lesions are hyperintense with fairly well-defined margins and no mass effect. fig. 6d. axial flair mri sequence demonstrating bilateral optic nerve gliomas and fasi changes in the brainstem. fig 7a. → → → → → → → → original articleoriginal article 18e sa journal of radiology • march 2010 fig 7b. fig. 7c. axial t1-weighted mri of the lumbar spine showing exiting neurofibroma along the nerve root at the level of the sacral nerve (courtesy of dr z ebrahim). fig. 8a. lateral x-ray of the thoracic spine showing enlargement of the neural foramina at multiple levels and posterior vertebral scalloping gibbus owing to multiple dumbbell tumours and dural ectasia. fig. 8b. myelogram of the lumbar spine in a different patient showing multilevel vertebral anomalies and dural ectasia. → → → → → → → → original article original articleoriginal article 18f sa journal of radiology • march 2010 fig. 8c. ct myelogram of the same patient as in 8b with dural ectasia. fig. 9a. lateral and frontal x-rays of the thoracic spine demonstrating kyphoscoliosis, which may be due either to vertebral anomalies or to large meningoceles or neurofibromas. fig. 9b. frontal chest x-ray demonstrates dextroscoliosis of the lower thoracic spine associated with large soft-tissue left para-vertebral mass, erosion and thinning of the 10th, 11th and 12th ribs on the left, and left lateral vertebral body scalloping. → → → → → → → original articleoriginal article 18g sa journal of radiology • march 2010 fig. 10. ct scan of the preceding patient showing a large plexiform neurofibroma on the left side, causing spine and rib changes. fig. 10a. frontal chest x-ray showing bilateral cutaneous neurofibromas of the areola projecting over the lung fields. fig. 10b. chest x-ray showing twisted ribbon ribs. fig. 11a. frontal chest x-ray with interstitial fibrosis of nf1 complicated by spontaneous pneumothorax on the right. → → → → → → original article original articleoriginal article 18h sa journal of radiology • march 2010 fig. 11b. axial hrct of the same patient showing interstitial fibrosis and cystic changes. fig. 12a. frontal chest x-ray showing multiple cutaneous neurofibromas projecting over the lung fields and a posterior mediastinal mass on the left. fig. 12b. ct myelogram in the same patient demonstrating postero-lateral meningocoele. → → → → → original articleoriginal article 18i sa journal of radiology • march 2010 fig. 13a. patient with nf1 presenting with radial fractures. note also pseudoarthrosis of the ulna. fig. 13b. anteroposterior x-ray of the forearm with thinned atrophic distal radius. → → original article original articleoriginal article 18j sa journal of radiology • march 2010 fig. 14a. anteroposterior x-ray of the proximal tibia and fibula demonstrating endosteal sclerosis of the tibia and an intraosseous neurofibroma of the fibula with associated soft-tissue mass. fig. 14b. anteroposterior radiograph of the knee with intraosseous neurofibroma of the proximal tibia. → → → original articleoriginal article 18k sa journal of radiology • march 2010 fig. 15a. fig. 15b. frontal and lateral radiographs of the right foot showing macrodactyly (focal gigantism) of the 4th and 5th toes. fig. 15c. posteroanterior x-ray of the chest with bilateral soft-tissue neurofibromas eroding the lateral ends of the clavicle. fig. 16a. frontal x-ray of the hands showing large plexiform neurofibroma causing focal enlargement, elongation, thinning of the metacarpals and pressure changes (scalloping) of the bases of the metacarpals and carpal bones, also called a pachydermatocoele. → → → → → → → original article original articleoriginal article 18l sa journal of radiology • march 2010 fig. 16b. ct scan of a different patient with a large right plexiform neurofibroma causing distortion of the abdominal wall. fig. 16c. anteroposterior x-ray of the knee with soft-tissue neurofibroma of the knee with extensive pressure changes. fig. 16d. lateral view of the cervical spine with a large anterior soft-tissue neurofibroma causing pressure erosion of the anterior margin of c3. fig. 17. frontal x-ray of the terminal tufts with acreosteolysis owing to an overlying neurofibroma. → → → → → original articleoriginal article 18m sa journal of radiology • march 2010 fig. 18a. figs 18a and b. posteroanterior and lateral x-rays of the chest with sarcomatous change in the right posterior mediastinal neurofibroma with rib erosions. note surgical clips (arrowed) in the neck from previous surgery. fig. 19a. fig. 19b. → → → → original article original article 18n sa journal of radiology • march 2010 fig. 19c. axial contrast-enhanced brain ct at multiple levels with multiple meningiomas and bilateral acoustic neuromas. fig. 20a. fig. 20b. fig. 20c. axial contrast-enhanced ct scans at different levels showing multiple intracranial schwannomas (acoustic), meningiomas, and ependymomas of the lateral ventricles (misme). note also in fig. 20a an abnormally tortuous optic nerve on the right. → → → → → → → → → → the copper.html the copper-beaten skull n mahomed, mb bch, fcrad (d) t sewchuran, mb bch z mahomed, mb bch department of radiology, university of the witwatersrand, johannesburg corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) abstract variations and abnormalities of skull appearance and shape are generally related to a primary maldevelopment of the brain. the copper-beaten skull appearance is typically associated with craniosynostosis, where premature fusion of the cranial bone sutures results in the growing brain exerting pressure on the malleable cranium, producing a pattern known as the copper-beaten skull appearance. a 6-year-old girl with known craniosynostosis graphically demonstrates the copper-beaten skull on plain radiography (fig. 1). variations and abnormalities of skull appearance and shape are often related to a primary maldevelopment of the brain.1 the copper-beaten skull appearance is typically associated with craniosynostosis, which is the premature fusion of the cranial bone sutures (fig. 2).2 severe craniosynostosis and reduced cranial growth in our patient caused brain volume to exceed the cranium size, resulting in raised intracranial pressure.2 consequently, the growing brain exerts a continuous pulsatile pressure on the malleable cranium, producing a gyral pattern evidenced on plain skull x-rays most commonly known as the copper-beaten skull appearance.3 this is the least common manifestation of craniosynostosis on the developing skull.1 convolutional markings are inner table indentations that conform to the cerebral surface of the growing brain in infants.1 the pattern was initially assumed to have resulted from chronically elevated intracranial pressure but currently it is widely considered to be a reflection of normal brain growth, without pathological significance.4 the markings are most prominent during periods of rapid brain growth, between age 2 3 years and 5 7 years. they become less prominent after approximately 8 years of age.1 diffuse, severe beaten-copper pattern is an indicator of chronic elevated intracranial pressure, which is more common in patients with craniosynostosis.4 additional findings associated with a chronic increase in intracranial pressure include macrocrania, splitting of the sutures, skull demineralisation and erosion, or enlargement of the sella turcica.1 the appearance is more frequent in children with complex, rather than simple, craniosynostosis.2 in children <18 months, the presence of a diffuse copper-beaten pattern on skull radiography, together with narrowing of the basal cisterns and obliteration of the anterior sulci, increases the likelihood of raised intracranial pressure.2 , 4 of interest, van der meulen et al. concluded that the presence of the copper-beaten skull pattern did not significantly affect long-term intelligence levels.2 however, there appeared to be a negative influence on more subtle areas of development, such as reading, spelling and behaviour.2 these convolutional markings should be differentiated from lückenschädel (lacunar skull), which is due to mesenchymal dysplasia of calvarial ossification. it is characterised by numerous oval lucencies (a honeycomb appearance about 2 cm in diameter) of the inner table and diploic space.1 , 4 these are usually present at birth and are associated with meningocoele/myelomeningocoele/encephalocoele, spina bifida, cleft palate and arnold chiari ii malformation.1 it is most prominent in the parietal and occipital bones. occasionally these findings are normal and disappear by 6 months of age.1 craniosynostosis is more adequately evaluated for surgical planning with computer tomography (ct) and 3d reconstructions (fig. 3), and has the advantage of concurrently demonstrating the intracranial complications. the associated interpretation of plain-film skull radiography is an incidental contribution. acknowledgements. we thank professor s. andronikou for reviewing this article. 1. glass bjr, fernbach sk, norton ki, choi sp, naidich tp. the infant skull : a vault of information. radiographics 2004;24:507-522. 1. glass bjr, fernbach sk, norton ki, choi sp, naidich tp. the infant skull : a vault of information. radiographics 2004;24:507-522. 2. van der meulen j, van der vlugt j, okkerse j, hoffman b. early beaten-copper pattern: its long term effect on intelligence quotients in 95 children with craniosynostosis. j neurosurgery: paediatrics 2008;1:25-30. 2. van der meulen j, van der vlugt j, okkerse j, hoffman b. early beaten-copper pattern: its long term effect on intelligence quotients in 95 children with craniosynostosis. j neurosurgery: paediatrics 2008;1:25-30. 3. agrawal d, steinbok p, cochrane dd. significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis. childs nerv syst 2007;23:1467-1470. 3. agrawal d, steinbok p, cochrane dd. significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis. childs nerv syst 2007;23:1467-1470. 4. el khasab m, nejat f, yazdani s, baradaran n. aquired craniomeningocele in an infant with craniosynostosis : a case report. journal of medical case reports 2010;4:104-106. 4. el khasab m, nejat f, yazdani s, baradaran n. aquired craniomeningocele in an infant with craniosynostosis : a case report. journal of medical case reports 2010;4:104-106. fig. 1. pa and lateral skull x-rays demonstrating impressive convolutional markings (copper-beaten skull appearance) in a 6-year-old girl with known craniosynostosis. note associated fusion of the saggital, coronal and lamdoid sutures. fig. 2. axial ct of brain bony windows, demonstrating the convolutional markings of the inner table of the skull that conform to the cerebral surface of the growing brain associated with fusion of the coronal and lamdoid sutures. fig. 3. ct 3d saggital reconstruction demonstrating the prominent convolutional markings of the inner table of the skull. there is no obvious expansion or erosion of the sellar turcica. sa journal of radiology • march 2011 31 radioactive news mdct/cta essentials course leon janse van rensburg (rssa congress chairman) i take great pleasure in announcing and welcoming you to another ‘first’ in the rssa cme programme: the first rssa essentials in mdct/ cta course, presented by an international faculty of four highly distinguished and acclaimed radiologists. the course is co-ordinated by professor elliot fishman of john hopkins university school of medicine, baltimore, usa. owing to rapid advances in technology, radiologists and radiographers often require comprehensive review of recent advances in computed body tomography. the course will focus on 64-slice multi-detector computed tomography (mdct) and newer systems including dualsource ct scanners. the programme consists of a series of 40-minute lectures that will concentrate on specific topics in depth, including state-of-the-art technology and software. participants will have the opportunity to expand their knowledge of the latest concepts and principles of spiral/helical ct, thoracic ct, cardiac ct and computed tomography angiography (cta), the uses of ct in the gi tract, including the liver, spleen and kidneys, as well as virtual colonoscopy and imaging the oncologic patient. the course runs from 26 28 august 2011 at the sandton convention centre, johannesburg; details are on the conference website http://www. rssa2011ctcourse.co.za. the scientific paper session for the 2011 rssa travel award of r40 000 will take place at the same time, and there will also be a poster exhibition with substantial prizes. i take this opportunity to thank the scientific committee (professors victor mngomezulu (chairperson) and zarina lockhat, and dr christelle ackermann). the rssa gratefully acknowledges the support of all our sponsors. without educational grants, events like these cannot be hosted, and their commitment to radiology, training and teaching is appreciated and indispensable. thank you very much. i extend a special word of gratitude and a warm south african welcome to the faculty members: professors elliot fishman, jill jacobs, karen horten and david p naidich. i believe that this event will be mutually beneficial. esor musculoskeletal visiting scholarship report hanief moosa (dr moosa was awarded the first european school of radiology (esor) visiting msk scholarship for south africa, and spent 3 months at the university hospital of strasbourg from 15 september 15 december 2010.) working in a state-of-the-art centre of excellence has certainly been among the best 3 months of my life and has helped me to grow professionally and personally. as i had only read about, and not performed, any of the msk interventional procedures prior to my stay in strasbourg, professor afshin gangi and his team went out of their way to teach me all that they could, theoretically and practically, up to the point where i am confident of performing the procedures independently. the department is a dedicated non-vascular interventional radiology suite with an open-bore mri, 128-slice ct and fluoroscopy units. eighty per cent of the cases were msk (predominantly spinal intervention); the balance comprised body oncology management (rf and cryoablation) and drainages. the department was very busy, with full lists booked every day from 8 a.m. 8 p.m., monday to friday. in general, about 6 long cases were booked in the morning and about 10 12 short cases for the afternoon. a large number of diagnostic scans relating to the procedures to be done were also done in the afternoon/evening each day. the long cases involved mainly vertebroplasty, radiofrequency ablation and cryoablation of various tumours (hepatic, renal, pulmonary, prostatic, paraveterbral), laser ablation of osteoid osteomas, and pulmonary, bone and intervertebral disc biopsies. the shorter cases involved epidural and foraminal steroid infiltrations, facet joint steroid infiltrations, discography, nucleotomy, gastrostomies and drainages. as the bulk of the work was interventional and a small component diagnostic and predominantly spine imaging, professor gangi arranged in the second month for me to spend 2 days a week at the sister hospital in hautpierre, under the tutelage of dr jean-claude dosch, an esteemed msk radiologist with over 30 years’ experience in the field. from 8 9 a.m. we reviewed and reported on all the plain radiographs from the trauma unit’s calls the night before. the rest of the morning to midday was spent performing and interpreting ct arthrograms of various joints, with the afternoons spent in the mri unit interpreting about 17 cases of a variety of msk pathologies. furthermore, i was introduced to the basics of msk ultrasound. i was also fortunate to attend the esor advanced galen msk cross-sectional imaging course in madrid, which was most beneficial. the lecturers and their workshops were engaging, informative and of a very high standard. i moreover met radiologists and residents from the rest of europe; networking and learning how things are done in various countries around the world made the course even more enjoyable. professor gangi’s ability to enjoyably motivate staff and patients, while providing healthcare par excellence and innovating and designing new techniques and equipment for improved patient care, has been truly inspiring and has taught me much about leadership in the radiology workplace as well. i am deeply indebted and most grateful to him and his team, notably dr xavier buy and dr julien garnon (senior consultant and fellow respectively), for their guidance and tutelage; their patience and desire to teach is commendable. i’m extremely grateful to dr jean-claude dosch for his passionate interest and striving to pass on his vast experience and knowledge, despite him not being the most fluent in english. i also take this opportunity to thank my head of department, professor victor mngomezulu, and the department of diagnostic radiology at the university of the witwatersrand, and notably my fellow registrars, for their support and sacrifice during my time away. it has been an honour for me to represent the university in this regard. special thanks to the radiological society of south africa too, for their encouragement and facilitating this opportunity through their association with esor. the everlasting friendships made along the way, the chance to learn some french and the intercultural experience has been most memorable. musculoskeletal radiology is a massive field; while i have grown tremendously, both diagnostically and interventionally, i still have much to learn. the visiting scholarship has achieved its objective and has sparked a strong personal desire to sub-specialise in this field. i thank esor and bracco imaging s.p.a. for affording me this opportunity to fulfil a dream. i look forward to sharing and implementing my newlylearnt skills for the benefit of the south african population. cpd questionnaire give one correct answer for each question. 48 sa journal of radiology • june 2010 a. reviews suggest a considerable number of abnormal ct scans following a depressed skull fracture with no focal clinical neurological deficit. b. although most injuries are minor and possibly do not require intervention, ct of the brain is still warranted retrospectively on the basis of the intracranial pathology. c. ct scans could provide a baseline for comparison of subsequent pathology related to injury in the event of later complications and patient follow-ups. d. a depressed skull fracture is seldom associated with intracranial pathology as observed on ct. 1. in patients with clinically suspected depressed skull fracture and no focal neurological deficit, which of the following statements is incorrect? 2. which one of the following statements is true? a. a patient with normal ct of the brain always has an abnormal mri. b. an abnormal ct does not predict neurological outcome. c. previous studies have shown that patients with minor brain injury requiring no surgery or medical intervention had an average stay of 5 days in hospital. d. patients with minor ct abnormalities and normal mental status have a moderate risk of deterioration. 3. which one of the following statements is false? a. hepatic vascular lesions are not an uncommon finding in children, and represent the most common benign liver tumours to present in infancy. b. based on their biological and clinical behaviour, vascular anomalies can be broadly divided into two groups: vascular tumours and vascular malformations. c. congenital haemangiomas stain positive for glucose transporter-1 protein (glut-1), a marker of haemangioma of infancy. d. vascular malformations are congenital lesions of vascular dysmorphogenesis, are always present at birth and enlarge in proportion to the growth of the child. 5. the most likely cause of severe pulmonary congestion and a normal heart is: a. mitral stenosis b. persistent fetal pulmonary circulation c. large vsd d. tapvr. 6. which one of the following is not characteristic of macrodystrophia lipomatosa (mdl)? a. a rare, non-hereditary, congenital condition b. presenting with localised macrodactyly and a proliferation of mesenchymal elements c. there is in particular a marked increase in adipose tissue with only strands of fibrous tissue around margins. d. disproportionately large limbs since birth may be a feature. 7. which one of the following statements is false? a. macrodystrophia lipomatosa is a rare congenital disorder of focal gigantism affecting the extremities, more commonly the second and third digits of the foot, but it may also affect the hand. b. it is typically described in a particular nerve distribution; usually the medial plantar nerve or median nerve. c. plain films show lucent soft-tissue overgrowth as well as hypertrophy of osseous structures in the distribution of the median and plantar nerves. d. mri findings are relatively inconsistent in confining the differential diagnosis. 8. in mdl, which one of the following statements is incorrect? a. doppler studies reveal extensive increase in vascularity. b. in older patients, secondary osteoarthritis changes may be seen. c. mri shows overgrowth of unencapsulated fatty tissue that demonstrates high signal on t1wi and t2wi. d. suppression of the signal on short inversion time inversion recovery (stir) sequences. 10. a registrar post recently advertised at one of our radiology departments attracted how many applications? a. 1 b. 28 c. 35 d. 67 tip: the answer is in the next issue; but a clue is that radiology has become the most sought-after specialty at south african medical schools. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals. org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/007/01/20104. causes of neonatal pulmonary oedema include all of the following, except: a. infantile coarctation b. congenital aortic stenosis c. acquired mitral stenosis d. obstructed tapvr. 9. regarding mdl, identify one incorrect answer: a. lack of flow voids and calcifications helps to differentiate the condition from vascular malformations of klippel-trenauney-weber syndrome. b. fibrolipomatous hamartoma of the nerve displays features similar to mdl; however, fat deposition surrounds the nerve, giving a solid hyperacoustic appearance on ultrasound and a continuous, linear fat signal on t1 mri. c. lymphangiomas and neurofibromas may be hyperintense to fat on t2wi, distinguishing mdl from these conditions. d. proteus syndrome may be similar but has other associated features such as skull anomalies, lung cysts and pigmented naevi. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) riaan potgieter department of diagnostic radiology, faculty of health sciences, university of pretoria, pretoria, south africa piet becker department of statistics, faculty of health sciences, university of pretoria, pretoria, south africa farhana suleman department of diagnostic radiology, faculty of health sciences, university of pretoria, pretoria, south africa citation potgieter r, becker p, suleman f. the effectiveness of the pregnancy adapted years algorithm to safely identify patients for ct pulmonary angiogram in pregnant and puerperal patients suspected of having pulmonary embolism. s afr j rad. 2022;26(1), a2454. https://doi.org/10.4102/sajr.v26i1.2454 original research the effectiveness of the pregnancy adapted years algorithm to safely identify patients for ct pulmonary angiogram in pregnant and puerperal patients suspected of having pulmonary embolism riaan potgieter, piet becker, farhana suleman received: 15 apr. 2022; accepted: 31 may 2022; published: 29 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: pulmonary thromboembolism is one of the leading causes of maternal death worldwide. globally there has been increasing physician reliance on ct pulmonary angiogram for definitive diagnoses and exclusion of pulmonary thromboembolism. the problem, however, arises when considering the high radiation penalty from performing these investigations, highlighted by the low diagnostic yield. of recent, the pregnancy-adapted years algorithm has shown promise in international studies as a possible alternative for stratifying risk of pulmonary thromboembolism during the pregnancy and puerperal period. objectives: to determine the effectiveness of the pregnancy adapted years algorithm to safely minimise the number of true negative ct pulmonary angiograms for patients suspected of having pulmonary embolism in our clinical setting. method: a cross-sectional study was performed in a tertiary hospital in gauteng on puerperal and pregnant patients suspected of having pulmonary embolism. we retrospectively applied the pregnancy adapted years algorithm and reviewed the various outcomes. results: the pregnancy adapted years algorithm proved effective in safely identifying patients for ct pulmonary angiography. by retrospectively applying the algorithm, there could have been a 25.7% scan reduction, whilst maintaining a negative predictive value of 100.0%. conclusion: as physician reliance on radiological investigations increases, we must remain cognisant of the added radiation exposure and the long-term adverse effects of ionising radiation. the pregnancy-adapted years algorithm provides a safe, reproducible alternative to aid our bid going forward. keywords: pulmonary embolism; ct pulmonary angiogram; pregnancy-adapted years algorithm; radiation safety; pregnancy; puerperium; persistent tachycardia; breast cancer. introduction pulmonary thromboembolism is a well-known complication during the pregnancy and puerperal periods.1 in the 2017 saving mothers report, as well as in previous iterations, it is listed as one of the leading causes of maternal mortality in south africa, causing roughly 30–40 maternal deaths per year.2 the physiological changes that take place during pregnancy render women especially vulnerable to this complication during their pregnancy and puerperal periods, with an estimated 5-fold increased risk when compared to age-related control groups.3 in addition, given the rising pandemic of obesity and increasing caesarean section rates in south africa, both of which have been identified as independent risk factors, pulmonary thromboembolism in the south african context is a disease entity of justified concern.2,4,5 the clinical diagnosis of pulmonary thromboembolism is known to be challenging, given the fact that normal physiological changes that take place during pregnancy can mimic disease. lower limb swelling, shortness of breath, and an increase in heart rate are all symptoms that can be experienced during the normal pregnancy and puerperal periods. furthermore, established clinical criteria outside of pregnancy such as the wells score, has to a large extent not been proven valid during the pregnancy and puerperal periods.6,7 given this fact, there has been an increasing trend of clinicians relying on radiological methods to assist in diagnosing and/or excluding pulmonary thromboembolism and in the context of pregnancy, clinicians are over investigating suspected cases, with an exceptionally low diagnostic yield of 5% versus 15% – 20% in non-pregnant patients.8,9 ct pulmonary angiography is the investigation of choice in many institutions, including our own, for diagnosing pulmonary thromboembolism. it relies on contrasted imaging of the chest to opacify the pulmonary vasculature. in doing so, filling defects in the pulmonary arteries and associated complications of pulmonary thromboembolism can be detected. in addition, other unrelated pathologies (such as pneumonia or heart failure) that might explain the patient’s presenting symptoms can be diagnosed.10 there is however a trade-off in the form of radiation exposure to the patient. foetal radiation exposure during ct imaging limited to the maternal chest is negligible, regardless of the use of radiation shielding.11 uncertainty regarding the in-utero effects of iodinated contrast on the foetal thyroid gland has also not been correlated with significant postpartum side-effects.12 a factor for concern however is radiation exposure to gravid breast tissue, where it is estimated that a single ct pulmonary angiogram study increases a woman’s lifetime risk of developing breast cancer by 13.6%.1,11 this is a distressing figure given the fact that breast cancer is the most common cancer in women, with an increasing incidence worldwide.13 the use of bismuth breast shields and limited radiological techniques has been proven effective in lowering radiation dose to the female breast, although not a common practise in our institution.14 ventilation/perfusion (v/q) scans offer a more than 10 fold reduction in breast radiation dose in addition to mitigating the risk of adverse reactions from iodinated intravenous contrast.11 unfortunately v/q scans are underutilised at our institution given its unavailability in the after-hours setting. from the aforementioned information, it is evident that there is a need for a diagnostic protocol that balances the urgency of the disease with the potential adverse effects of radiation exposure. it should also consider the physiological changes and disease mimics in pregnancy. the years study was conducted in 2015-2016, and is currently under scrutiny by the international community as a proposed alternative algorithm for risk stratification in cases where pulmonary thromboembolism is suspected. it relies on disease-specific signs and symptoms, case-specific d-dimer levels and the utilisation of lower limb doppler ultrasound to prioritise patients that need further imaging workup with ct pulmonary angiogram. the study resulted in the safe exclusion of pulmonary emboli, with a 14% reduction in required ct pulmonary angiogram studies.15 the years algorithm has also been adapted for use in pregnancy, with one study showing a 39% reduction in ct pulmonary angiogram utilisation with the safe exclusion of pulmonary thromboembolism.16 methods this was a cross-sectional study performed at kalafong provincial tertiary hospital department of radiology. in-patients presenting with suspected pulmonary embolism in the pregnancy and puerperal periods who underwent ct pulmonary angiogram at kalafong provincial tertiary hospital radiology department from 1 june 2017 to 1 june 2020 were considered for the study. a list of patients who underwent ct pulmonary angiograms in the stipulated time frame was compiled from the phillips intellispace portal (isp) study list. corresponding electronic reports were available from march 2019 onwards on the isp. studies performed prior to this were accessed from the printed and filed reports at the kalafong department of radiology and were physically reviewed in the department. the study list was then abbreviated to include only patients during the pregnancy and puerperal periods who met the inclusion criteria. patient files were reviewed on site and d-dimer results were retrieved from the national health laboratory service (nhls) online portal using the patient’s demographic information available from the patient study list. the pregnancy-adapted years algorithm used to aid clinical decision making is detailed in figure 1. the pregnancy-adapted years algorithm uses a step wise approach based on clinical findings, d-dimer values and compression ultrasonography to guide clinicians as to whether further radiological workup with ct pulmonary angiogram is necessary. figure 1: pregnancy-adapted years algorithm. a retrospective comparison was made with regard to the ctpa outcome and the pregnancy-adapted years algorithm criteria. patient demographic and clinical information was tabulated, in addition to the outcome of their ct pulmonary angiogram and d-dimer levels during hospital stay using google sheets. clinical information required included: are there clinical signs of deep vein thrombosis? does the patient have haemoptysis? is pulmonary embolism the most likely diagnosis? for quantitative measurement, ct report findings were assigned boolean values: ct pulmonary angiogram (ctpa) positive for pulmonary embolism. normal ctpa study – including incidental and non-pathological findings, that is, negative study. ctpa negative for pulmonary embolism but positive for other pathology likely accountable for patient’s presenting symptoms. patients were further categorised according to the pregnancy-adapted years algorithm as either: ctpa was indicated. ctpa was not-indicated. ethical considerations the research was approved by the ethics review panel of the university of pretoria (rec #377/2021) prior to data collection. permission was also granted by the medical manager of kalafong provincial tertiary hospital to access patient records and radiological investigations. results this descriptive study reports the findings as frequency and percentage, and most importantly, documents the sensitivity of the pregnancy-adapted years algorithm. ct pulmonary angiograms were performed on a total of 131 patients during the study period. in 30 patients, the clinical information required to retrospectively compile the pregnancy-adapted years algorithm was missing and these patients were excluded from the study. missing information was attributable to d-dimer results not being performed during patient hospital stay and files missing from patient records during data collection. a total of 101 female patients during the pregnancy and puerperal periods met the inclusion criteria and were included in the study. patient timing of pregnancy and method of delivery is presented in figure 2. figure 2: method of delivery and timing of pregnancy (n = 101). of the 101 patients who underwent ct pulmonary angiogram, six patients (5.9%) were diagnosed with pulmonary embolism. sixty-four studies were negative for pulmonary embolism and did not reveal any contributory findings to the patient’s diagnosis (63.4%).) (figure 3). in 34 instances, ct pulmonary angiogram provided additional diagnostic information (33.7%). in addition, three of these studies demonstrated the presence of pulmonary embolism as well. additional diagnostic findings yielded included puerperal sepsis (n = 20; 19.8%), cardiovascular disease, including dilated cardiomyopathy and heart failure (n = 10; 9.9%), and complications pertaining to hellp syndrome (n = 2; 2.0%). in one instance, ct revealed diffuse pulmonary cystic change consistent with lymphangiomatosis (1.0%). one patient was also diagnosed with a mucous plug resulting in segmental atelectasis (1.0%). with regard to pregnancy timing, all six patients (100.0%) diagnosed with pulmonary embolism were in the puerperal period. three patients (50.0%) delivered via caesarean section, one (16.7%) delivered via normal vaginal delivery and two suffered early pregnancy loss (33.3%), of which one (16.7%) had a miscarriage and one (16.7%) had a laparotomy for a ruptured tubal ectopic pregnancy. figure 3: ct pulmonary angiogram outcome. when we retrospectively applied the pregnancy-adapted years algorithm, it was revealed that in 26 cases (25.7%) a ct pulmonary angiogram was not indicated. of these 26 cases, none (n = 0; 0.0%) of the patients were diagnosed with pulmonary embolism. the pregnancy adapted years algorithm thus had a 100.0% sensitivity for identifying true negatives (100.0%; 95% ci: 54–100) figure 4. figure 4: agreement of years algorithm with ctpa outcome. the primary indication for referral was persistent tachycardia (n = 86; 85.1%). in four cases (4.0%), the diagnoses of pulmonary embolism were made (figure 5). referral indication for the other two cases included dyspnoea and chest pain, which were the second and third most common reasons for referral, respectively. in one instance patient referral was based on persistent tachycardia in addition to acute respiratory distress. figure 5: agreement of persistent tachycardia with pulmonary embolism. in our study population, the most common disease entities, and final clinical diagnoses attributable to the patient presentation included puerperal sepsis in 53 instances, anaemia in 26 instances and 6 were diagnosed with having pulmonary embolism. discussion this study demonstrated the effectiveness of the pregnancy adapted years algorithm to safely identify patients for ct pulmonary angiogram in pregnant and puerperal patients suspected of having pulmonary embolism. applying the pregnancy-adapted years algorithm for risk stratification before deciding on further radiological workup, would have reduced the number of ct pulmonary angiograms performed at our institution by 25.7%, without missing any true positives. this is in line with what international studies have demonstrated.15,16,18 the current study also highlighted the underutilisation of compression ultrasonography, which could have further reduced the number of ctpas performed. only two patients had lower limb ultrasound performed prior to ctpa. furthermore, none of the patients diagnosed with pulmonary embolism had compression ultrasonography prior to ctpa. since ultrasonography is not reliant on ionising radiation, its value as a special investigation appears undervalued in our bid to mitigate unnecessary radiation exposure to our patients. persistent tachycardia appears to be an unreliable indicator of pulmonary embolism specifically. this study revealed a positive predictive value of merely 4.6%, which is not unexpected as there are numerous other causes for tachycardia in the pregnancy and puerperal periods, whether it be physiological or pathological. this reiterates the validity of the pregnancy-adapted years algorithm, as it is not reliant on maternal heart rate for risk stratification. in total, 86 patients presented with persistent tachycardia. in this subset of patients, puerperal sepsis, anaemia and cardiovascular disease were the most common underlying conditions. here, the utilisation of other imaging techniques, including abdominal ultrasonography and x-ray, could also have potentially mitigated the need for ct pulmonary angiogram by assisting the diagnosis, and in so doing, greatly reduce patient radiation exposure. these imaging investigations remain invaluable given their availability and comparative low cost. patients in the puerperal period appear to be at an increased risk for developing pulmonary thromboembolism than during pregnancy. the six patients (100.0%) who were diagnosed with pulmonary embolism were all in the puerperal period. furthermore, patients undergoing operative management, which included three patients who underwent caesarean section (50.0%) and one who had a laparotomy for a ruptured tubal ectopic pregnancy (16.7%), incorporated most of the patients diagnosed with pulmonary embolism (66.7%), suggesting that patients in the puerperal period requiring operative obstetric management are at an increased risk of developing pulmonary embolism. both findings are in line with international studies.3,17 the major limitation of our study was our small sample size, which consisted of only 101 patients. given that the study was performed in only one institution, our patient population was limited. furthermore, our patient population was abbreviated given missing clinical information needed to retrospectively apply the pregnancy-adapted years criteria in many instances, and misplaced patient files. this study has however replicated the findings of similar, larger studies and has arrived at the same conclusion, which further validates their findings.15,16,18 conclusion as physician reliance on radiological investigations increases, we should remain cognisant of the added radiation exposure and the long-term adverse effects of ionising radiation. of particular concern in pregnant and post-partum patients undergoing ct pulmonary angiogram for suspected pulmonary embolism is radiation exposure to gravid breast tissue. breast cancer, being the most prevalent female cancer with rising incidence, is a disease entity of justified concern. we, therefore, need to put evidence-based measures in place to mitigate any additional risk that can further increase the prevalence of female breast cancer. the pregnancy-adapted years algorithm provides a safe, reproducible alternative to aid our bid going forward. acknowledgements the authors would like to thank kalafong hospital for granting access to patient files and radiological reports, and ms. elné potgieter for her assistance in the data visualisation done in figures 1–5. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.p. was the lead investigator and author in the study concept, design and data collection, as well as data interpretation, manuscript writing and final editing for submission. p.b. was co-author and statistical advisor involved in the final manuscript editing and review. f.s. was the study supervisor involved in the study design, data interpretation, manuscript review and final editing. funding information the study was self-funded by the principal investigator. data availability the data supporting the findings of this study are available from r.p. and will be made available upon request. disclaimer the results and recommendations of this study does not necessarily represent the views of the institution in which the study was performed, nor any professional bodies affiliated to them. references simcox le, ormesher l, tower c, greer ia. pulmonary thrombo-embolism in pregnancy: diagnosis and management. breathe. 2015;11(4):282–289. https://doi.org/10.1183/20734735.008815 republic of south africa department of health. saving mothers 2017: annual report on confidential enquiries into maternal death in south africa. south africa: department of health; 2017. romp er, lenselink am, rosendaal fr, doggen cjm. pregnancy, the postpartum period and prothrombotic effects: risk of venous thrombosis in the mega study. j thromb haemost. 2008;6(4):632–637. https://doi.org/10.1111/j.1538-7836.2008.02921.x health systems trust. district health barometer 2015/2016. 2016. cois a, day c. obesity trends and risk factors in the south african adult population. bmc obes. 2015;2(1):42. https://doi.org/10.1186/s40608-015-0072-2 ramsay r, byrd l, tower c, james j, prescott m, thachii j. the problem of pulmonary embolism diagnosis in pregnancy. brit j haem. 2015;170(5):727–728. https://doi.org/10.1111/bjh.13322 van der pol lm, mairhuhu ata, tromeur c, couturaud f, huisman vm, klok fa. use of clinical prediction rules and d-dimer tests in the diagnostic management of pregnant patients with suspected acute pulmonary embolism. blood rev. 2017;31(2):31–36. https://doi.org/10.1016/j.blre.2016.09.003 kline ja, garret js, sarmiento ej, strachan cc, courtney dm. over-testing for pulmonary embolism in american emergency departments. circoutcomes. 2020;13(1):e005753. https://doi.org/10.1161/circoutcomes.119.005753 kline ja, richardson dm, than mp, penaloza a, roy p. systemic review and meta-analysis of pregnant patients investigated for suspected pulmonary embolism in the emergency department. acad emerg med. 2014;21(9):949–959. https://doi.org/10.1111/acem.12471 herring w. learning radiology: recognising the basics. philadelphia, pa: elsevier; 2007, p. 107–108. schembri gp, miller ae, smart r. radiation dosimetry and safety issues in the investigation of pulmonary embolism. semin nucl med. 2010;40(6):442–454. https://doi.org/10.1053/j.semnuclmed.2010.07.007 bourjeily g, chalhoub m, phornphutkul c, alleyne tc, woodfield ca, chen kk. neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero. radiology. 2010;256(3):744–750. https://doi.org/10.1148/radiol.10100163 tao z, shi a, lu c, song t, zhang z, zhao j. breast cancer: epidemiology and etiology. cell biochem biophys. 2015;72(2):333–338. https://doi.org/10.1007/s12013-014-0459-6 hurwitz lm, yoshizumi tt, goodman pc, et al. radiation dose savings for adult pulmonary embolus 64-mdct using bismuth breast shields, lower peak kilovoltage, and automatic tube current modulation. ajr am j roentgenol. 2009;192(1):244–253. https://doi.org/10.2214/ajr.08.1066 van der hulle t, cheung wy, kooij s, et al. simplified diagnostic management of suspected pulmonary embolism (the years study): a prospective, multicentre, cohort study. lancet. 2017;390(10091):289–297. https://doi.org/10.1016/s0140-6736(17)30885-1 van der pol lm, tromeur c, bistervels im, et al. pregnancy-adapted years algorithm for diagnosis of suspected pulmonary embolism. n engl j med. 2019;380(12):1139–1149. https://doi.org/10.1056/nejmoa1813865 bokan a, matijasevic j, trobok jv. pregnancy-adapted years algorithm: can years do more for pregnant woman? breathe. 2020;16(1):190307. https://doi.org/10.1183/20734735.0307-2019 heit ja, kobbervig ce, james ah, petterson tm, bailey kr, melton lj iii. trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. ann intern med. 2005;143(10):697–706. https://doi.org/10.7326/0003-4819-143-10-200511150-00006 sa journal of radiology • september 2011 99 radioactive news 2011 essr award to dr peter mercouris dr peter mercouris, who is a partner with drs lake, smit and partners in durban, is a member of the essr (european society of musculoskeletal radiology) and is in the process of successfully completing the essr diploma programme. one of the requirements of the diploma is the submission of a scientific presentation or exhibit (poster) at the essr congress held annually in europe. the 2011 congress took place in crete, greece, and his article entitled ‘mri of slap lesions: a pictorial review of imaging and anatomy with arthroscopic correlation’ received one of the three poster prize awards (magna cum laude). he is seen here holding his poster prize certificate. rssa travel award winner attends ecr 2011 in vienna dr shaun scheepers, a radiology registrar at the university of stellenbosch and tygerberg hospital, was one of the 2010 rssa travel award winners; he used his prize to attend the european congress of radiology from 3 8 march 2011 in vienna, austria, and has written the following report. the ecr is the largest radiology congress in europe and second only to the rsna. nothing can prepare one for the magnitude of such an event. nearly 23 000 delegates attended the congress over 5 days. the city of vienna and the austria conference centre are ideally equipped to host such a prestigious event. the wide variety of sessions included scientific presentations, refresher courses, interactive teaching sessions and special focus sessions. every year, the ecr invites a number of their radiology counterparts from outside europe who, together with the host nation, present ‘ecr meets’ sessions. over the 5 days, we heard about chest imaging from brazil, interventional radiology from iran, and imaging in neurosciences from france. with up to 7 concurrent sessions at a time, careful planning is needed to optimise one’s experience of the ecr. highlights included an excellent session on breast imaging and what the radiologist should report on. the ever-increasing role of breast mri was emphasised, with a careful reminder of the potential pitfalls. a third of patients with breast carcinoma on mammography and/or ultrasound are found to have additional lesions on mri. mri also changes the surgical management correctly in 11% of patients. for the radiologist to make the correct diagnosis, accurately determine the extent of disease and effectively guide its management, a multi-modality approach utilising mammography, ultrasonography and mri in combination is essential. in a session entitled ‘sports injuries: us or mri?’, it was concluded that us can be as good as mri in sports imaging, but only when performed by experienced msk radiologists, with the added advantages of mobility and availability next to the sports field. during lunch breaks, satellite symposia were hosted by leading manufacturers. the general focus was on new developments in imaging technology, especially dose reduction techniques. techniques mentioned included care dose, current modulation, care kv, and second-generation iterative reconstruction. the latter is especially promising, as it enables extra-low dose imaging with minimal loss in image quality. immediate implications include renal stone imaging, and imaging for patients requiring frequent follow-up, with excellent efficacy demonstrated among patients with crohn’s disease. the ultimate goal is to perform a standard ct abdomen at the same dose as an abdominal x-ray, so enabling ct to replace the abdominal x-ray. another exciting development is flash ct. it utilises dual-source technology to increase acquisition speed, thereby avoiding the need for breath holding as well as reducing the need for sedation in paediatric patients. it can provide high-quality cardiac scans for patients with high or irregular heart rates, while being able to achieve sub-msv doses. the concept of contrast-induced nephropathy (cin) was also raised again. it was emphasized that cin is a laboratory parameter and not a clinical syndrome. the largest studies on cin were performed on data collected from patients receiving intra-arterial contrast, while undergoing coronary angiography. therefore, some authors propose the term ‘catheter effect’ instead of cin. currently, trials are underway to investigate the safety of intravenously administered, low osmolar, non-ionic contrast agents. hopefully, we shall all have clarity on this contentious issue in the near future. in the rapidly developing world of radiology, the expanding role of the radiologist in therapeutic management and functional imaging was also discussed. with the aid of mr-guided high-intensity focused ultrasound (mrghifu), the radiologist can now deliver a chemotherapy agent directly to the area of interest, so increasing bio-availability and effectivity, while minimising adverse effects on other organ systems. by inducing local hyperthermia and thereby increasing tissue oxygenation, mrghifu can sensitise target tissue to irradiation. mrghifu can also be used for tumour ablation, with the ultrasound delivering tissue heating and the mri simultaneously being implemented for planning of the intervention, and continuous monitoring of the delivery site and the response to intervention. functional imaging is rapidly expanding with the advent of molecular imaging. exciting developments such as optical imaging, by utilising near-infrared fluorescence, enable the radiologist to demonstrate neoplastic tissue with the naked eye or with the assistance of an infrared camera. this is of particular importance in breast imaging, as the surgeon can now be guided as to the exact number and location of tumour foci as well as lymph nodes to which tumour cells have spread. other functional imaging techniques include ultrasound-targeted microbubbles and mri nanoparticle imaging such as ultra-small superparamagnetic iron oxide (uspio)-enhanced mri. myocardial stress perfusing imaging using mri is being utilised more extensively in evaluating patients with coronary artery disease. stress is either induced physically or mentally (by giving patients complex mathematics to perform). innovative software now enables the radiologist to perform virtual surgery on mri images obtained from patients with congenital heart disease. this helps surgeons to optimise the surgical technique, as well as alerting them to potential complications. post-surgical flow dynamics can also be determined. i extend my sincere thanks to the rssa for the generous prize which afforded me this wonderful opportunity of attending a world-class international congress. cubital.html cubital tunnel syndrome: a report of two cases f e suleman, mb chb, fcrad(d)(sa), mmedrad(d) department of radiology, university of pretoria m velleman, mb chb, fcrad(d)(sa), mmedrad(d) radiology department, little company of mary medical centre, pretoria corresponding author: f suleman (fesuleman@gmail.com) cubital tunnel syndrome is the second most common peripheral neuropathy of the upper limb. this is due to the anatomy of the tunnel, the physiological changes that the nerve undergoes during elbow flexion, as well as pathological conditions that occur within the tunnel. we present two cases of ulnar neuropathy occurring at the level of the cubital tunnel, demonstrating that this entity may occur owing to an identifiable cause or may show only signal alteration without a visible cause on mri. s afr j rad 2012;16(2):77-78. introduction cubital tunnel syndrome occurs as a result of compression of the ulnar nerve between the medial epicondyle, the olecranon and the roof of the tunnel that is formed by the retinaculum which is also known as osborne’s band or the arcuate ligament.1 , 2 physiological compression occurs during elbow flexion, but compression may also be the result of masses in the tunnel, including ganglions and bursae or synovitis or osteophytes.3 rarely, compression has been attributed to the presence of an accessory muscle – the anconeus epitrochlearis.2 , 3 the ulnar nerve is also the most commonly injured nerve, owing to the relatively unprotected location of the nerve within the tunnel at the elbow.3 case report two unrelated men aged 40 and 42 years, respectively, were referred for magnetic resonance imaging (mri) on separate occasions, with elbow pain and suspected cubital tunnel syndrome. there was no history of work-related causality or injury in either case. mri was requested to rule out any underlying mass lesion or anatomic variants that might have contributed to the development of an ulnar neuropathy at the level of the cubital tunnel. patient 1 a 40-year-old man revealed high signal on t2w (t2 weighted) mri in a thickened ulnar nerve with no evidence of mass lesions or osteodegenerative changes. a normal cubital tunnel retinaculum was seen and no anatomic variants were noted. the rest of the joint was within normal limits (fig. 1). a diagnosis of cubital tunnel syndrome of unknown aetiology was made. patient 2 a 42-year-old man demonstrated the presence of an olecranon spur as well as an anconeus epitrochlearis muscle on mri scanning. tendinosis of the triceps muscle was also present. t2wi also demonstrated high signal in the thickened ulnar nerve (fig. 2). a diagnosis of cubital tunnel syndrome was made, with both the olecranon spur and the anconeus epitrochlearis muscle being implicated in the aetiology. discussion physiological compression of the ulnar nerve within the cubital tunnel occurs without neuropathy. pathological compression gives rise to cubital tunnel syndrome. possible causes include overuse, subluxation of the nerve, trauma including fractures around the elbow joint, osteophyte formation, soft-tissue masses and a thickened retinaculum. the presence of the anconeus epitrochlearis muscle is rarely implicated. the incidence is also reported to be higher in certain occupations especially those involving repetitive actions, prolonged flexion of the elbow and the use of vibrating tools. diabetes and obesity are also predisposing factors.4 patients may present with pain in the medial elbow but more commonly complain of sensory loss in the ulnar nerve distribution. clinically, in long-standing cases, marked wasting of the small muscles of the hand on the ulnar side may be seen.4 the diagnosis is usually based on clinical findings and nerve conduction tests. imaging is indicated only to exclude possible underlying causes of nerve entrapment. radiographs of the elbow joint may show evidence of osteoarthritis or previous trauma, and ultrasound can be used to image the nerve itself but mri is excellent for visualising changes in the signal of the nerve as well as changes in the nerve diameter while excluding any underlying masses or anatomical variants that may result in ulnar neuropathy. in a study of cadavers, o’driscoll et al.5 classified the variants of the retinaculum into the following types: type 0: absence of the retinaculum that predisposed to subluxation of the ulnar nerve type 1a: normal thin retinaculum that did not compress the nerve even in flexion type 1b: thickened retinaculum that was thought to predispose to chronic nerve compression type 3: replacement of the retinaculum by the anconeus epitrochealaris muscle. mri changes should be interpreted with caution, however, and the clinical picture should always be taken into consideration during the interpretation of images. in a study of the elbows of 60 asymptomatic patients, husarik et al.3 found that 60% of subjects had increased signal in the ulnar nerve on fluid-sensitive mr images, and 23% of patients had the presence of an anconeus epitrochlearis muscle. the retinaculum was also found to be thickened in 8% of asymptomatic subjects. the increasing use of technology is also being implicated in the development of entrapment neuropathies of the upper limb. ruess et al.1 reported on a study within their radiology department where a third of their radiologists sought medical attention during a 3-month period for symptoms in the upper limbs. all were found to be suffering from cubital tunnel syndrome, with one having carpal tunnel syndrome in addition. this implicated prolonged periods spent at the computer with widespread implementation of pacs, as well as administrative and teaching duties that involved computer use, as increasing the risk of development of entrapment syndromes. prolonged elbow flexion involved in the use of hand-held dictation microphones and telephone receivers or mobile phones could also be contributing factors. poor ergonomics of workstations were also thought to be a problem. they strongly recommended that radiology departments obtain professional advice from ergonomic experts and implement their recommendations for workstation designs. conclusion mri is well suited for demonstrating signal abnormality of the ulnar nerve in patients with cubital tunnel syndrome and also has the advantage of demonstrating causes such as osteophytes, soft-tissue masses, a thickened retinaculum and presence of an anconeus epitrochlearis muscle. many factors relating to modern living, such as prolonged use of a computer mouse, telephone and, in certain occupations, dictation devices, could cause this syndrome, resulting in signal abnormality in the nerve without an obvious cause on mri. 1. ruess l, o’connor sc, cho kh, hussein fh, slaughter rc, hedge a. carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists. ajr 2003;181:37-41. 1. ruess l, o’connor sc, cho kh, hussein fh, slaughter rc, hedge a. carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists. ajr 2003;181:37-41. 2. andreisek g, crook dw, burg d, marincek b, weishaupt d. peripheral neuropathies of the median, radial and ulnar nerves: mr imaging features. radiographics 2006;26:1267-1287. 2. andreisek g, crook dw, burg d, marincek b, weishaupt d. peripheral neuropathies of the median, radial and ulnar nerves: mr imaging features. radiographics 2006;26:1267-1287. 3. husarik db, saupe n, pfirmann cwa, jost b, hodler j, zanetti m. elbow nerves: mr findings in 60 asymptomatic subjects – normal anatomy, variants and pitfalls. radiology 2009;252:148-156. 3. husarik db, saupe n, pfirmann cwa, jost b, hodler j, zanetti m. elbow nerves: mr findings in 60 asymptomatic subjects – normal anatomy, variants and pitfalls. radiology 2009;252:148-156. 4. cutts s. cubital tunnel syndrome. postgrad med journal 2007;83:28-31. 4. cutts s. cubital tunnel syndrome. postgrad med journal 2007;83:28-31. 5. o driscoll sw, horii e, carmichael sw, morrey bf. the cubital tunnel and ulnar neuropathy. j bone joint surg br 1991;73:613-617. 5. o driscoll sw, horii e, carmichael sw, morrey bf. the cubital tunnel and ulnar neuropathy. j bone joint surg br 1991;73:613-617. fig. 1. axial and coronal fat-suppressed mr images of the left elbow demonstrating increased signal in the thickened ulnar nerve (arrows). note the normal retinaculum (arrowhead). fig. 2. axial fat-suppressed mr image of the right elbow in patient 2, demonstrating the presence of the anconeus epitrochlearis muscle (arrowhead) and high signal in the thickened ulnar nerve (arrow). 110 sa journal of radiology • december 2007 by: jacob ekins at the point-of-care (poc), a good imaging reference system improves the speed and accuracy of the interpretation of imaging studies. reference books continue to serve as a staple to radiologists worldwide. the web has not entirely replaced the utility of paper-based libraries, but with the appropriate internet connectivity, access to the web usually offers improved searchability, a virtually unlimited capacity for information and images, and the ability to interrelate relevant knowledge with hyperlinks. how do we select the textbooks or websites from which we draw supplemental insight? this decision is often driven by the relative weaknesses that can commonly occur: uncertain credibility of the material, a lack of breadth or depth of coverage, or difficulty in searching and navigating the information. to some degree or another, every legitimate resource strives to overcome these. statdx™, a product of amirsys inc., is a new on-line diagnostic decision support system that boasts a serious response to the aforementioned issues and then takes the concept of an on-line poc imaging reference a step further (fig. 1). credibility within the database, the body is conceptually divided into relevant medical categories (brain, abdomen, obstetrics, paediatrics, and so forth). an acknowledged expert in the field pertaining to that aspect of medical imaging leads each section. these individuals drive a collaborative effort among scores of other experts in the task of authoring diagnoses and cases within each diagnosis. once authored, each diagnosis or case passes a quality control review before being published on-line. with names like anne osborn and ric harnsberger driving database content, end users — in a sense — draw from the collective expertise of hundreds of imaging subspecialists — hence the tag line ‘names you know. content you trust.®’ breadth and depth the breadth of modern imaging can place any radiologist — whether general or specialised — in unfamiliar territory in any number of clinical scenarios. cataloging the gamut of natural variation in typical and atypical presentations of disease in a book is often impractical. this often requires the selection of a subset of cases from the complete spectrum of disease. in this way, printed resources can demonstrate the classic findings for a disease and may even offer images of an atypical presentation of that disease but often must stop there. the web becomes an intuitive outlet for limitations in breadth and depth of coverage. as a well-reputed representative of on-line references, statdx™ is managed in a way that allows it to offer a nearly unabridged and continually growing wealth of cases and diagnoses. each diagnosis can house any number of typical and variant case presentations for the given diagnosis with multiple images and descriptive text within each case (fig. 2). to date, the diagnostic database contains over 3 000 separate diagnoses, 11 000 image-rich cases, and nearly 100 000 images. ease of use bestselling american author john naisbitt argued that ‘uncontrolled and unorganized what is statdx™? fig. 1. statdx™ logo. fig. 2. diagnosis page for ependymoma fig. 3. search results by category and relevance for the hepatobiliary and pancreas anatomical search. pg110-111.indd 110 12/11/07 2:23:35 pm 111 sa journal of radiology • december 2007 information is no longer a resource in an information society, instead it becomes the enemy.’ as internet resources provide larger and larger reservoirs of knowledge, the task of creating intuitive order requires considerable design. ideal search mechanisms allow users to find a subject quickly and easily and, once found, the subject’s organisation should lend itself to orderly discovery. users of statdx™ can approach the initial search with a simple keyword search or take an anatomical approach by navigating an expandable menu. these searches return lists of diagnoses in terms of relevance and category (fig. 3). in addition to the numerous typical and variant example cases within each diagnosis, users find an annotated set of classic images of the diagnosis (including gross and microscopic pathology and colour graphic illustrations). there is also a consistent treatment of each of the following topics: key facts, terminology, imaging findings, differential diagnosis, pathology, clinical issues, diagnostic checklist, and selected references (fig. 4). unlike many on-line and on-the-shelf resources, statdx™ is relatively unique in how each diagnosis contains links to relevant anatomy tutorials (fig. 5). beginning later this year, a feature called ‘expert differential diagnosis’ will allow even more refined searches. users will be able to query over 500 differentials based on anatomical or subanatomical location (e.g. ‘suprasellar mass’ or ‘thick infundibular stalk’), generic imaging findings (e.g. ‘ringenhancing mass’), modality-specific findings (e.g. ‘multifocal hypointensities or “black dots” in the brain on t2* or swi’), and clinical indications (e.g. ‘pulsatile tinnitus’). and beyond... statdx™ is a new animal in the world of publication. not only does an on-line database reference provide for more rapid updates but its contents are naturally poised antecedents to printed publications. the well known diagnostic imaging, diagnostic and surgical imaging anatomy, and pocket radiologist series produced by amirsys, are all derivatives of the database that populates statdx™ on-line. another unique feature is the progressive attitude taken by amirsys toward copyright issues. the copyright of authored cases and images is left in the hands of the independent contributors. this mentality has further bolstered the inherently collaborative efforts that have produced statdx™. the collaborative mindset behind statdx™ is also being mixed with outreach efforts in india, egypt, and south africa. in conjunction with the university of utah (usa), amirsys is providing 3 years of access to statdx™ to seth gordhandas sunderdas medical college in mumbai, india, the university of alexandria in alexandria, egypt, and the university of cape town and stellenbosch university in cape town, south africa. in exchange, these institutions will provide interesting cases of diseases prevalent in their region which will be added to the database. statdx™ also took a step into the future of radiology as it was recently integrated into a number of pacs systems (ge, sectra, etc.) as well as speech recognition software (powerscribe 4.8). this provides radiologists with the ability to seamlessly interact with statdx™ while reporting studies by mouse click or by voice. these features make it possible for the radiologist to benefit from the strengths offered by statdx™ in terms of credibility, breadth and depth of coverage, ease of use, and then take radiology a step beyond. an animated tour of statdx™ is available from the ‘tour’ button at https://my.statdx. com. fig. 4. each diagnosis contains information on each of these topics. fig. 5. each diagnosis provides access to anatomy modules relevant to the diagnosis. pg110-111.indd 111 12/11/07 2:23:35 pm sajr 773 trauma imaging of the cranio-cervical junction s k misser, mb chb, fc rad (d) sa t z mngoma, mba, mb chb, ffrad (sa) lake smit and partners, durban   m roux, mb chb, fcs (sa) entabeni hospital, durban   corresponding author: s misser (misser@lakesmit.co.za) presentation a 5-year-old boy presented to a&e after a motor vehicle accident in which he was an unrestrained passenger. he was found to have quadriparesis, with the following images of the cranio-cervical junction (ccj) obtained on admission. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 11 november 2012. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr.   s afr j rad 2012;16(3):111-113. doi:10.7196/sajr.773 fig. 1. axial ct scan at the level of the pons. fig. 2. axial ct scan at the level of the foramen magnum. fig. 3. sagittal ct reformat of the ccj.    fig. 4. axial t2-weighted mri at the ccj. fig 5. midline sagittal t1-weighted mri at the ccj. fig. 6. midline sagittal t2-weighted mri at the ccj. abstract introduction materials and methods discussion conclusion acknowledgements references about the author(s) amy j. spies human variation and identification research unit (hviru), school of anatomical sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of basic medical sciences, university of arizona college of medicine, phoenix, arizona, united states of america maryna steyn human variation and identification research unit (hviru), school of anatomical sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa desiré brits human variation and identification research unit (hviru), school of anatomical sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa daniel n. prince department of diagnostic radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa department of radiology, wits donald gordon medical centre, johannesburg, south africa citation spies aj, steyn m, brits d, prince dn. case discussions of missed traumatic fractures on computed tomography scans. s afr j rad. 2022;26(1), a2516. https://doi.org/10.4102/sajr.v26i1.2516 case series case discussions of missed traumatic fractures on computed tomography scans amy j. spies, maryna steyn, desiré brits, daniel n. prince received: 19 july 2022; accepted: 05 oct. 2022; published: 30 nov. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract radiological diagnostic errors are common and may have severe consequences. understanding these errors and their possible causes is crucial for optimising patient care and improving radiological training. recent postmortem studies using an animal model highlighted the difficulties associated with accurate fracture diagnosis using radiological imaging. the present study aimed to highlight the fact that certain fractures are easily missed on ct scans in a clinical setting and that caution is advised. a few such cases were discussed to raise the level of suspicion to prevent similar diagnostic errors in future cases. records of adult patients from the radiological department at an academic hospital in south africa were retrospectively reviewed. case studies were selected by identifying records of patients between january and june 2021 where traumatic fractures were missed during initial imaging interpretation but later detected during secondary analysis or on follow-up scans. seven cases were identified, and the possible causes of the diagnostic errors were evaluated by reviewing the history of each case, level of experience of each reporting radiologist, scan quality and time of day that initial imaging interpretation of each scan was performed. the causes were multifactorial, potentially including a lack of experience, fatigue, heavy workloads or inadequate training of the initial reporting radiologist. identifying these causes, openly discussing them and providing additional training for radiologists may aid in reducing these errors. contribution: this article aimed to use case examples of missed injuries on ct scanning of patients in a south african emergency trauma setting in order to highlight and provide insight into common errors in scan interpretation, their causes and possible means of mitigating them. keywords: radiology; diagnostic errors; fracture misdiagnoses; traumatic fractures; emergency department. introduction traumatic fractures are frequently encountered in both postmortem and clinical settings.1,2 investigating these cases and providing appropriate patient care and management rely on correctly diagnosing these fractures.3,4 recent studies5,6,7,8,9 using an animal model have found that in postmortem radiological assessments of blunt and sharp force trauma, ct, although more sensitive than x-ray and low-dose full-body x-ray (lodox), fails to detect between 16.0% and 79.0% of bone lesions, with all modalities commonly missing skull and vertebral lesions (figure 1). it was recommended that in postmortem cases, osteological examinations of these regions be performed if trauma is suspected, rather than simply relying on radiological imaging.5,6,7,8,9 the potential reasons for these missed lesions in the postmortem context range from superimposition of structures on radiographs to a lack of observer experience and training.5,6,7,8,9 figure 1: comparison of percentage of blunt (bft) and sharp force (sft) lesions detected by ct, x-ray and lodox in various body regions in a postmortem context using a pig model. piglets (black bars) were included to simulate cases of child abuse. (a) skull, (b) ribs, (c) vertebrae, (d) forelimbs, (e) hindlimbs. percentages taken from spies et al.5,6,7,8 while the radiological analysis in postmortem and clinical settings may differ, the potential reasons for failing to detect traumatic fractures may largely be the same. in a clinical setting, major detection errors may result in inadequate patient care and management and could have life-threatening results.3,4 however, radiology is between the sixth and eighth most frequent recipient of malpractice claims, with up to 60.0% of claims citing failure to diagnose either soft tissue or skeletal abnormalities.10,11,12,13 the risk of failing to detect fractures needs to be limited as much as possible, which can be achieved by recognising fractures commonly missed during initial radiological assessments, and potential reasons for these errors.3,4,10 while the potential reasons for missing skeletal lesions radiologically in a postmortem context have been explored,5,6,7,8,9 this study aims to evaluate this in a clinical context. the purpose of this study was to retrospectively review patient records at an emergency radiological department in south africa and analyse specific cases to demonstrate the errors with regard to the radiological interpretation of traumatic fractures. materials and methods records of adult patients (18–99 years) who presented to the radiological department at an academic hospital in south africa, over a 6-month period between january 2021 and june 2021, were retrospectively reviewed by the senior author (d.n.p.). in this department, initial imaging interpretation is performed by the trainee radiologist (registrar) on call, and these initial reports are checked by a consultant radiologist during the following shift. junior and senior registrars typically have less than and more than two years of experience prequalification, respectively. junior and senior consultants, respectively, typically have less than and more than five years of training post qualification. fractures detected during both the initial and secondary imaging interpretations are recorded. case studies were selected from patient records that showed fractures not diagnosed upon initial interpretation but identified during secondary analysis of the initial scan or upon analysis of a follow-up scan. patient age, sex, case history, time of day initial imaging was performed, and the level of experience of the registrars and consultants were recorded. no patient identifying information was recorded, and patient anonymity was ensured throughout the study. case reports seven cases with fractures not diagnosed at the initial interpretation of the radiological images, but identified during secondary analysis, were selected. these cases may not represent all of those where fractures were not diagnosed but were selected as they each had specific teaching points that could be used to highlight learning opportunities. they all also demonstrate specific potential pitfalls in detection and interpretation. case 1 a 57-year-old man presented to the emergency department (ed) following a motor vehicle accident (mva) and had been stabilised with a cervical collar. the patient experienced a loss of consciousness, headache and cervical spine tenderness. a head and cervical spine ct was performed at 03:23 on a saturday. initial interpretation by a junior registrar failed to detect any fractures and the cervical collar was removed. soon thereafter, the patient developed ‘unexplained quadriplegia’. a subsequent ct pan-scan was performed at 10:00 the same day to search for any thoracolumbar spine fractures to explain the symptoms. a junior consultant identified a fracture of the c4 vertebra on the ct pan-scan, which, in retrospect, was visible on the initial ct (figure 2a–d). had the findings been detected upon initial interpretation and relayed to the referring clinicians, the cervical spine collar would not have been removed and this outcome may have been avoided. figure 2: axial (a and b) and coronal (c) reconstructions of the cervical spine ct showing comminuted fractures of the left superior and inferior facets of c4 (black arrow) and left lamina of c4 (white arrow). sagittal (d) reconstruction shows a small avulsion fracture of the anterosuperior margin of the c4 vertebral body (black arrow). these fractures represent an unstable cervical spine injury. case 2 a 60-year-old man presented to the ed following a mva. the patient had an altered level of consciousness, headache, cervical spine tenderness and was unable to move his legs. a head and cervical spine ct was performed at 17:56 on a monday. the junior registrar noted severe degenerative changes in the cervical spine but no fractures. upon review, the senior consultant detected a missed c4 spinous process fracture – a stable injury – but no other abnormalities (figure 3a). a follow-up ct pan-scan was requested to confirm that there were no thoracolumbar spine fractures that could have explained the patient’s worsening neurological symptoms, and a different consultant radiologist detected retrolisthesis of c4 on c5 (figure 3b–d). secondary interpretation of the initial ct was performed by this same consultant, who noted an anterior teardrop fracture of the c4 vertebra (figure 3b–d), making the cervical spine injury unstable. figure 3: sagittal reconstruction of the initial ct of the cervical spine (a) showing the c4 spinous process fracture (black arrow). the follow-up ct (b) shows worsened retrolisthesis of the c4 on c5 vertebra with an anterior teardrop fracture of the c4 vertebra (white arrow). this fracture is visible in (a) but was called a ‘fractured osteophyte’ (white arrowhead). the axial (c) and coronal (d) reconstructions of the scan show how the degenerative cervical spine changes may make diagnosing fractures challenging – the teardrop fracture is pointed out by the white arrow in (c) and may have been misinterpreted as an osteophyte (white arrowhead). the black arrowhead in (c) demonstrates a right lamina fracture, and the black arrow again points out the spinous process fracture. case 3 a 34-year-old man involved in a mva, presented to the ed with loss of consciousness, a large head wound, cervical spine tenderness, a fractured left femur and rib fractures. a ct pan-scan was performed at 17:47 on a saturday. a senior registrar performed the initial interpretation, reporting the cervical spine ct as normal. a junior consultant then reviewed the ct and noted several vertebral fractures that were missed initially (figure 4a–d). associated prevertebral soft tissue swelling was also noted (figure 4a–d). figure 4: paramidline sagittal (a and b) reconstructions of a cervical spine ct showing a fracture of the right inferior facet of the c6 vertebra (black arrow), a fracture of the right superior facet of the c7 vertebra (white arrow) and a fracture of the anterosuperior margin of the body of c7 (black arrowhead). a midline sagittal reconstruction (c) demonstrates reversed cervical spine lordosis but no listhesis. associated prevertebral soft tissue swelling is present (white asterisk). note that the patient was ‘scanned skew’ (d). case 4 a 29-year-old man sustained blunt trauma to the head and a ct on the day of injury demonstrated a large, depressed skull fracture which was treated conservatively. ten days later, a high-resolution temporal bone ct was performed at 12:27 on a wednesday after the patient complained of a 1-day history of right facial nerve fallout. initial interpretation by a junior registrar noted the depressed squamous temporal fracture (figure 5a) but failed to notice that it extended into the petrous and mastoid regions to involve the facial nerve canal within the otic capsule, known as an ‘otic capsule-violating’ fracture (figure 5b–e). figure 5: axial ct of the head (a) demonstrating the depressed right squamous temporal bone fracture (black arrow) detected on initial interpretation. an oblique reconstruction of the right temporal bone (b) shows that the fracture (white arrow) extends into the facial nerve canal (highlighted here by the white dots). specifically, it involves the tympanic segment of the canal. the fracture line extending into the mastoid part of the temporal bone is pointed out by the black arrowhead in the axial image (c) – note the fluid in the mastoid air cells and compare it to the well-aerated left mastoid air cell; a secondary sign of temporal bone fracture. the fracture line (white arrowhead) is much more conspicuous on the axial cut of the bone reconstruction algorithm (d) than the soft tissue algorithm (e), despite both being set to a standard ‘bone window’. case 5 a 65-year-old man with an unknown mechanism of trauma presented with a right pneumothorax and extensive subcutaneous emphysema. a ct pan-scan (figure 6a–f) was performed at 12:48 on the tuesday of presentation and was initially reported as normal by a junior registrar. however, on secondary analysis by a consultant, several missed fractures were detected, including an otic capsule–sparing right temporal fracture (figure 6c–d) and multiple nondisplaced right rib fractures (figure 6e–f). figure 6: a ct pan-scan showing extensive subcutaneous emphysema of both the head (a) and chest (b). when viewed without straightening the scan using multiplanar reconstruction (c), the right temporal bone otic capsule–sparing fracture is not easy to detect even utilising the bone reconstruction algorithm (black arrow) and nearly invisible (white arrow) on the soft tissue reconstruction algorithm (d). the bone window (e) demonstrates an initially overlooked nondisplaced right 9th rib fracture (black arrowhead). note the right haemothorax (black star) and pneumothorax (white star) seen on the lung window of the chest ct (f). also note that the patient was ‘scanned skew’. case 6 an adult man of unknown age, involved in a mva, presented to the ed on a sunday. the patient had a head injury and a fractured tibia and fibula confirmed at radiography. a ct pan-scan was performed at 12:42, and initial interpretation by a junior registrar failed to diagnose subtle fractures of the right 10th, 11th and 12th ribs with associated lung contusions (figure 7a–b). these were identified by a junior consultant during secondary interpretation. no pneumothorax was associated with these fractures. figure 7: axial bone reconstruction of a ct (a and b) of the chest demonstrating subtle buckle-type fractures of the 10th and 11th ribs (black arrows) associated with a small lung contusion (white arrow). case 7 a 30-year-old man involved in a mva had a loss of consciousness with an open midshaft fracture of the tibia and fibula confirmed on plain radiographs. a junior registrar performed the initial interpretation of the ct pan-scan at 02:05 on a monday, reporting no additional fractures. secondary analysis by a junior consultant, however, revealed a nondisplaced fracture of the right second rib and a buckle-type fracture of the right third rib (figure 8). while small lung contusions and a laceration were associated with these fractures, there was no pneumothorax (figure 8). figure 8: axial bone reconstruction ct of a the chest demonstrating a minimally displaced second rib fracture (black arrow) associated with a small lung laceration and contusion (white arrow). as with cases 5 and 6, lung injuries such as contusions or lacerations should prompt careful search for associated rib fractures in the trauma patient. discussion a growing body of literature shows that there are many radiological misdiagnoses of fractures of the ribs, vertebrae and cranial region, both in clinical and postmortem contexts,5,6,7,8,9,12,13,14 and these diagnostic errors could have severe consequences. a review of trauma patients who had undergone ct scanning at an academic hospital in south africa similarly revealed that many of the fractures not detected on initial ct imaging interpretations are those of the vertebrae, temporal bone and ribs. these diagnostic errors resulted in a range of consequences, from pain and discomfort due to undiagnosed subtle rib fractures (cases 5, 6 and 7) to spinal cord pathology due to undiagnosed cervical spine fractures (cases 1 and 2). had these fractures been diagnosed initially, surgical plans and patient management strategies would likely have been altered. while some of the fractures missed in the present study are subtle (cases 5, 6 and 7), others are very evident on the initial scans (cases 1, 2 and 4). that these fractures were not detected or were misinterpreted as other abnormalities are likely due to a combination of factors termed ‘observer errors’ or other extenuating circumstances. it could even suggest inadequate radiology training and/or inadequate image interpretation techniques.3,4,10,15,16 three types of observer error have been described.3,4,16 scanning error occurs when the observer fails to fixate on the region where the fracture is present. recognition error occurs when the observer fixates on the correct region where the fracture is present but fails to identify it. decision-making error occurs when the observer correctly detects the abnormality but misinterprets it as something else. in a postmortem setting, missed fractures were shown to be partially due to a lack of radiological experience and training.9 similarly, in a clinical setting, all three types of observer error may occur as a result of the level of experience and training of the reporting radiologist.3,4 all but one of the initial imaging interpretations of the cases were performed by junior registrars with less than two years of training. this lack of experience may result in junior registrars failing to identify fractures and secondary signs thereof. for example, in cases 5, 6 and 7, a pneumothorax (case 5) and small lung contusions and a soft tissue laceration (cases 6 and 7) were associated with undiagnosed rib fractures. moreover, the presence of subcutaneous emphysema adjacent to the temporal bone and fluid within the mastoid air cells (case 5) or the presence of prevertebral soft tissue swelling in the cervical region (case 3) should have prompted the initial reader to look carefully for fractures in these regions. this was also found to be the case in postmortem examinations of sharp force trauma, where the presence of soft tissue lesions enabled forensic anthropologists to detect underlying osseous trauma.8 adequate training and experience would likely result in the radiologist identifying these ‘secondary signs’ of fractures and then actively searching for and detecting any associated osteological trauma. lack of experience with and knowledge of normal skeletal anatomy and skeletal growth, development and degeneration may result in misdiagnosing fractures as normal anatomical variants or other pathological conditions.3,17 in case 2, recognition and decision-making errors were made as cervical spine fractures were mistaken for degenerative changes. increased osteological experience and knowledge would potentially reduce errors, as recollection of previously encountered pathologies and anatomical variants, as well as a knowledge of those not yet encountered, could improve recognition rates.3 however, diagnostic errors are also commonly made by more experienced radiologists. the cervical spine fractures in case 2 were also initially misdiagnosed by a consultant as a stable injury, having only detected the spinous process fracture and missing the unstable teardrop fracture (recognition error). one potential reason for this could be that as experience level increases, the speed with which the observer interprets images increases, and as a result, so does the number of detection errors.3,4,18 errors of speed may also occur due to increased workloads and a reduction in the time available for radiological reporting.3,10,18 the number of radiological examinations performed has increased exponentially over the years, which reduces the amount of time a radiologist can dedicate both to interpreting these images and to continued education and training.10,18 additionally, error rates may be related to the level of alertness of the radiologist.3,19 only two scans (cases 4 and 5) were performed during the institution’s ‘normal business hours’, while initial imaging of cases 1 and 7 were performed during overnight shifts (at 03:23 and 02:05, respectively), when it is likely that the radiologist on call is tired, resulting in a reduced level of alertness and consequently an increased error rate.3,19 initial interpretations of the remaining three cases (2, 3 and 6) were performed after-hours during weekends and in the early evening. busy days with high workloads may also result in fatigue and, as a result, higher error rates.3,19 another type of diagnostic error is a satisfaction of search error, which is the result of one abnormality causing the attention of the radiologist to be diverted away from another, such as a fracture, resulting in this abnormality being overlooked.3,4,16 in case 5, the extensive surgical emphysema may have distracted the reporting registrar, diverting their attention away from the more subtle rib fractures. the senior consultant reviewing case 2 may have also fallen into this trap in that they diagnosed the spinous process fracture and thereafter was ‘satisfied’ that an abnormality was detected to explain the patient’s symptoms and simply moved on to another search area. in cases of polytrauma, ct pan-scans are often requested and include noncontrast head, cervical spine, contrast-enhanced chest and multiphase abdomen and pelvis imaging. occasionally, these scans will also include peripheral or cervical ct angiograms, if clinically indicated. trauma patients, for various reasons, are sometimes placed on the ct table in ways that result in the scans not being true axial cuts such as in cases 3 and 5. the resultant asymmetry when the patient is ‘scanned skew’ can make fractures of the skull and spine difficult to detect (cases 3 and 5). this was also noted in the postmortem studies using pig models, where some of the x-ray and lodox images were ‘skew’, and some scans were not true-lateral or true-frontal images.5,6,7,8,9 viewing the scan of each body region in multiple planes and in three-dimensional volumetric reconstructions is therefore essential. however, this adds drastically to the number of images to be reported. furthermore, different image reconstruction algorithms – that is, soft tissue and bone reconstructions, which, if reviewed with special care, may have resulted in the temporal bone fractures in cases 4 and 5 being detected more easily – essentially double the number of images per body region. all of these image acquisition and postprocessing techniques result in a very large dataset to read and interpret. it is therefore not sufficient to simply view the images as the patient is being scanned but is crucial that radiologists carefully and systematically view all body regions in different planes to ensure that all injuries are diagnosed. as in the postmortem contexts,5,6,7,9 there are many potential reasons for radiologists failing to detect fractures in a clinical setting, and these often exist in combination.17,19 diagnostic errors can potentially be limited by improvements in knowledge, training and experience, as well as double reporting and improved communication between radiologists and clinicians.3,4,10,12,13,16 in addition, having open discussions about errors and their causes could aid in reducing errors.3,4 one way of addressing this, which was trialled by the senior author (d.n.p.), is to institute ‘radiology morbidity and mortality meetings’ (‘m&ms’) where cases such as those discussed in this study are presented monthly. these were conducted as non-confrontational, non-accusatory tutorial sessions in which potential causes for the misdiagnoses were hypothesised and learning points from each case were emphasised. this was met with positive feedback from the registrars and could be a powerful training tool if routine ‘m&ms’ are held in academic radiology departments. cases in these ‘m&ms’ were anonymised, and the interpreting radiologists were never named so as not to place blame or judgement but to create learning opportunities in order to reduce diagnostic errors and improve patient care and management.3,4,16 conclusion like the imaging of trauma in postmortem contexts, the causes of diagnostic errors in detecting traumatic fractures in a radiology department are multifactorial and may include lack of radiologist training, knowledge and experience; fatigue and heavy workloads; and inadequate image interpretation techniques. understanding these errors and their root causes is crucial to improving the efficacy of radiological departments. additional training and open discussions of these errors and their causes, treating them as learning opportunities, can aid in reducing the prevalence of reporting errors. in particular, a high index of suspicion is important, especially when injuries to the chest and skull are concerned, as these are the most commonly misdiagnosed regions. acknowledgements we acknowledge the chief executive officer (ceo) and head of the department of radiology at the academic hospital in south africa for allowing access to and analysis of patient radiological records. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed to the study’s conception and design. data collection was performed by d.n.p. the first draft of the manuscript was written by a.j.s. with support from d.n.p. all authors commented on all subsequent versions of the manuscript, read and approved the final manuscript. ethical considerations permission was obtained from the human research ethics committee (medical) at the university of the witwatersrand (ref. no. m220114), and permission to access patient records was obtained from both the ceo and the head of the department of radiology at the academic hospital in south africa. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available on request from the corresponding author, a.j.s., subject to ethical clearance. the data are not publicly available due to ethical considerations. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references nicol a, knowlton lm, schuurman n, et al. trauma surveillance in cape town, south africa: an analysis of 9236 consecutive trauma center admissions. jama surg. 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patients with carcinoma of the oesophagus using radio-opaque contrast is a standard step in treatment planning prior to delivering radiation therapy. various contrast mediums such as barium, gastrograffin and hexabrix have been used for simulation at different centres. objective. the purpose of the study was to compare barium and gastrograffin as a useful and cost-effective contrast medium in simulation for delineation of site and length of the lesion. materials and methods. fifteen patients accepted for radiation therapy underwent simulation using oral barium and gastrograffin swallows prior to treatment. the amount of contrast material used was recorded for both the procedures. the x-rays were taken with both contrast agents keeping the same exposure factors. results. the mean amount of barium used was 14 ml (range 10 20 ml) as compared to 27.66 ml of gastrograffin (range 10 70 ml). the mean cost per patient was r4.40 for barium as against r70.80 for gastrograffin. no aspiration of contrast was noted in any patient. the opacification and delineation of the lesion on the x-ray films was much better with barium. conclusion. barium is a better contrast medium in simulation for delineation of lesion length and treatment planning compared with gastrograffin. it is also cost effective. this comparison has changed the practice in our department, and it is recommended that it be evaluated by other centres. introduction patients with carcinoma of the oesophagus are commonly treated with radiation therapy with or without chemotherapy (curative treatment), and with external beam radiation (palliative treatment).1 intraluminal radiation is used for palliation as well as in combination with external beam radiation for radical treatments.2,3 patients are planned for treatment on a simulator using radio-opaque contrast to delineate the exact site and length of the lesion for accurate field placement during external beam radiation, as well as to delineate the placement of brachytherapy comparison of barium and gastrograffin swallow for radiation therapy planning in carcinoma of the oesophagus v sharma, md, phd d n gumbi, dip (rd), b tech (rt) m mbhele, ndip (rd), ndip (rt) b donde, mmed rad (t) department of radiation oncology, johannesburg hospital and university of the witwatersrand, johannesburg fig. 1a. simulator film with barium as a contrast. fig. 1b. simulator film with gastrograffin as a contrast. pg14-16.indd 14 6/13/07 9:24:15 am original articleoriginal article 15 sa journal of radiology • june 2007 sources during intraluminal radiation therapy.4 this forms an essential part of the treatment planning so that high dose can be delivered to the tumour and the critical surrounding structures can be spared. approximately 150 175 patients with carcinoma of the oesophagus receive radiation therapy in our department every year. the standard contrast medium used in our department for the simulation procedure is gastrograffin. the purpose of this prospective study was to compare barium sulphate and gastrograffin as two contrast mediums in simulation for delineation of exact site and length of lesion and to analyse the cost of the materials used. materials and methods fifteen patients with carcinoma of the oesophagus accepted for radiation therapy at the department of radiation oncology, johannesburg hospital were included in this study. the radiographer explained the procedure to the patients prior to the simulation, and informed consent was obtained. barium sulphate is available in powder and liquid forms, and gastrograffin is available as a solution. their constituents and characteristics are shown in table i. a solution of the barium sulphate was reconstituted at the time of the procedure by mixing the powder with water. gastrograffin was used in the available solution form. patients were given gastrograffin to swallow, and if on screening the physician was unable to delineate the lesion accurately, more contrast was given. once satisfied, an x-ray was taken. this procedure was then repeated with barium. the exposure factors of kv (kilovoltage) and mas (milliamperes) were kept similar for both the barium and gastrograffin contrast (figs 1a and b, figs 2a and b) to limit bias due to different exposure factors. the amount of contrast medium used was recorded by the radiographer. results the mean amounts of barium and gastrograffin used were 14 ml (10 20 ml) and 27.66 ml (10 70 ml) respectively. the paired sample t-test done showed a significant difference in favour of barium (p = 0.00). ten of the 15 patients (67%) needed more gastrograffin, with the amount ranging from 10 ml to 55 ml. the cost per patient was r4.40 for barium versus r70.80 for gastrograffin as per the cost of the available packs (340 g barium powder container for r108, and 100 ml bottle of gastrograffin for r256). the projected cost calculated for 150 patients was r667 for barium and r1 0623 for gastrograffin for 1 year, leading to a cost saving of r9 956. barium was more accurate in evaluating lesion length and site, demonstrating filling defects and greater opacification in 7 patients (47%) whereas results were similar to gastrograffin in 8 patients. discussion patients with carcinoma of the oesophagus receive radiation therapy either with external beam or with intra-luminal brachytherapy.2,3 the treatment planning with simulation using contrast forms an essential component of the radiation therapy treatment. gastrograffin has been used for diagnosis of dissecting intramural haematoma in patients with carcinoma of the oesophagus following chemotherapy5 as well as to rule out the leaks following surgery.6 levine et al.7 reported 96% accuracy in diagnosing or suspecting a diagnosis of carcinoma of the oesophagus using barium as contrast medium. ginsberg and fleischer8 suggest that barium is the preferred con fig. 2a. simulator film with barium as a contrast. table i. comparison of characteristics of contrast agents used contrast barium gastrograffin composition 100 g contains 98 g barium sulphate mixture of sodium and megulamine amidotrizoate 100 ml contains 76 g contrast iodine content: 37 g/100 ml action insoluble, eliminated unchanged only 3% absorbed, eliminated mainly via kidneys indications double contrast radiography of git visualisation of git fistulae/tumour prior to endoscopy side-effects granuloma formation or pneumonitis pulmonary oedema cost r108 for 340 g r256 for 100 ml pg14-16.indd 15 6/13/07 9:24:16 am original article original article 16 sa journal of radiology • june 2007 trast agent for carcinoma of the oesophagus as opposed to gastrograffin which may cause pulmonary inflammation or oedema if it enters the airway via aspiration or a fistula. the main complication of barium aspiration is granuloma formation. in the present study, barium was more accurate in evaluating lesion length and site, demonstrating filling defects as well as greater opacification in 7 patients (47%) whereas results were similar in 8 patients. this was measured by comparing the contrast on the x-ray films. it was not possible to outline the lesion in 1 patient with gastrograffin, and a longer length was used in 1 patient for treatment due to poor opacification by the treating physician. more gastrograffin was required compared with barium, probably because the liquid passes more quickly through the oesophagus during fluoroscopy and x-rays. frequently additional films need to be taken when using gastrograffin. in addition gastrograffin is less radio-opaque, making accurate definition of the lesion more difficult. there was no evidence of aspiration in any patient with either contrast agent. it was not possible to find any articles analysing the cost effectiveness of the contrast materials such as barium and gastrograffin during the review of the literature. this study indicates that barium was a more cost-effective contrast medium than gastrograffin for the evaluation of carcinoma of the oesophagus. conclusion compared with gastrograffin, barium proved to be a useful and costeffective contrast in treatment planning for carcinoma of the oesophagus patients prior to radiation therapy. 1. cooper sj, guo dm, herskovic a, et al. chemo-radiotherapy of locally advanced esophageal cancer – long-term follow-up of a prospective randomized trial (rtog 85-01). jama 1999; 281:1623-1627. 2. sharma v, agarwal jp, dinshaw ka, et al. late oesophageal toxicity using a combination of external beam radiation, intraluminal brachytherapy and 5-fluorouracil infusion in carcinoma of the oesophagus. dis esophagus 2000; 13: 219-225. 3. sharma v, mahantshetty u, dinshaw ka, et al. palliation of advanced / recurrent oesophageal carcinoma with high dose rate brachytherapy. int j radiat oncol biol phys 2002; 52: 310-315. 4. sharma v, donde b, mohiuddin m, et al. vertebral height as measurement for lesion length in carcinoma of the oesophagus – is it accurate? south african journal of radiology 2004; 8(1): 31-33. 5. george r, govindraj r, das sk, et al. dissecting intramural haematoma in oesophageal carcinoma. indian j gastroenterol 2004; 23: 221-222. 6. nishihira t, watanabe t, ohm n, et al. long term evaluation of patients treated by radical operation for carcinoma of thoracic oesophagus. world j surg 1984; 8:778-785. 7. levine ms, chu p, furth ee, et al. carcinoma of the oesophagus and esophago-gastric junction – sensitivity of radiographic diagnosis. am j roentgenol 1997; 168:1423-1426. 8. ginsberg gg, fleischer de. tumours of the oesophagus: in: feldman m, friedman land brandt l, eds. gastrointestinal and liver disease. vol 1. philadelphia: elsevier, saunders: 2006: 949-978. fig. 2b. simulator film with gastrograffin as a contrast. pg14-16.indd 16 6/13/07 9:24:16 am sa journal of radiology • december 2010 113 case report presentation a 41-year-old woman presented with a lump above the right areola. she also complained of a burning and heavy sensation of the right breast of recent onset. on further history, the patient was an insulin-dependent diabetic of 35 years’ duration. she had no family history of breast disease. on examination, a palpable thickening above the right areola was detected. bilateral mammography revealed dense fibro-glandular tissue, denser in the right retro-areolar region than the left, with right peri-areolar skin thickening. there was no discrete mass nor suspicious microcalcifications or axillary adenopathy. ultrasound (us) demonstrated an ill-defined peri-areolar region of decreased echogenicity and posterior shadowing. diagnosis core biopsy under us guidance showed abundant thick collagen bands containing epitheloid fibroblasts and a stroma with small capillarysized and larger muscularised blood vessls, some of which contained peri-vascular lymphocytic inflammatory cells. small ductal elements and an occasional lobule showed a peri-ductal and a periand intralobular lymhocytic and plasma cell infiltrate. these features were in keeping with sclerosing lymphocytic mastitis, known also as diabetic mastopathy. discussion diabetic mastopathy is an uncommon benign fibro-inflamatory breast disease.1 it may mimic cancer and as such poses a diagnostic challenge.2 raising awareness of this condition is essential to avoid unnecessary surgical intervention and patient anxiety.3 diabetic mastopathy accounts for less than 1% of benign breast lesions. up to 13% of long-standing insulin-dependent diabetics are affected by diabetic mastopathy.4 the disease is not exclusive to females.6 it was first reported by soler and khardori in 1984. three years later, the term ‘diabetic mastopathy’ was given to this entity.6 the pathogenesis is not completely understood. three dominant mechanisms are: • exogenous insulin may result in an inflammatory or immunologic reaction to the insulin, the vehicle or a contaminant in the vehicle6,7 • the effects of hyperglycaemia have been postulated. hyperglycaemia results in abnormal extracellular matrix accumulation. the abnormal matrix and advanced glycosylated end products create a neoantigen that triggers a secondary auto-immune reaction and b-cell proliferation and auto-antibody formation6,7 • the role of auto-immunity must be considered. there is a link between diabetes, thyroid disease and connective tissue diseases. the inflamed lobules are reminiscent of the lympho-epithelial lesions seen in other auto-immune diseases e.g. hashimoto’s thyroiditis and sjörgen’s syndrome.6 patients are diabetic, predominantly type 1, on exogenous insulin. many have complications of diabetes including retinopathy and microvascular disease.3 other co-existing endocrine diseases may be present, especially thyroid disease.8 most commonly, the patient presents with palpable change/s in the breast. the lumps may be multiple (67% of patients)4 and bilateral (63% of patients).3,4 the masses tend to be very firm, irregular, discrete and plaque-like3 but remain mobile. they may undergo rapid growth.4 the size of the mass ranges from 5 60 mm. the clinical findings raise suspicion for breast carcinoma and patients are therefore referred for imaging. mammography generally does not demonstrate a distinct mass, spiculation or microcalcification.7 most mammograms are reported as ‘dense breast parenchyma’, ‘dense glandular tissue’, ‘asymmetric densities’ and ‘parenchymal deformity’.3 us shows marked posterior acoustic shadowing from an irregular, hypo-echoic density.3 a small study demonstrated absence of doppler signal on colour flow us9 (malignancies tend to show increased vascularity). us cannot distinguish this entity from malignancy. us should be used to guide core biopsy and to follow up these patients. scintimammography using tc-99 sestamibi has been shown to be of use in palpable breast lesions. a few cases of diabetic mastopathy have demonstrated no radiotracer uptake with scintimammography;4 this requires further evaluation. mri is useful in assessing dense breast tissue and may be of use in evaluating suspected breast cancer in patients with diabetic mastopathy.2 dynamic contrast mri and mr spectroscopy may help support a diagnosis of diabetic mastopathy. there are few studies, however, in this regard;3 further studies are required to determine the role of mri in this setting. us-guided core biopsy is the preferred method to diagnose the condition. fine needle aspiration yields insufficient cellular material in 50% of cases with diabetic mastopathy.3,10 the histological features are those of keloidal fibrosis and variable periductal, perilobular or perivascular lymphocytic infiltrate that consists predominantly of b-cells. epitheliod fibroblasts have also been described.1,3,7 diabetic mastopathy: a clinical and radiological challenge debra ardath meerkotter, mb bch, fcrad (d) sa regional imaging, st vincents hospital, launceston, tasmania, australia grace rubin, mb bch, da (sa), fcrad (diag) (sa) department of radiology, helen joseph hospital, johannesburg 114 sa journal of radiology • december 2010 case report the natural history of this disease is that 60% of the masses tend to be bilateral, recurrent or both – this reflects what appears to be a multicentric field effect of diabetes on mammary tissue. surgery appears to exacerbate the condition.7,8 with the marked b-cell infiltrates and the presence of lympho-epithelial lesions, there has been concern that this disease carries a risk for lymphoma. however, all the studies concur that these patients are not at increased risk for lymphoma.1 once this benign condition is diagnosed, the patient should perform routine breast self-examination and have regular clinical breast examinations. us and even mri are recommended for follow-up. the minimum follow-up period is annual.7 if any changes are detected, core biopsy should be performed.3 fig. 2. right craniocaudal mammogram. fig. 3. left mediolateral oblique view mammogram. fig. 1. left craniocaudal mammogram. fig. 4. right mediolateral oblique view mammogram. sa journal of radiology • december 2010 115 case report conclusion diabetic mastopathy is an uncommon but important entity. core biopsy under us guidance is essential. surgery should be avoided where possible, as it may unnecessarily exacerbate this benign condition. 1. valdez r, thorson j, william gf, et al. lymphocytic mastitis and diabetic mastopathy: a molecular, immunophenotypic, and clinicopathological evaluation of 11 cases. mod pathol 2003; 16(3): 223-228. 2. gabriel h, feng c, mendelson eb, benjamin s. breast mri for cancer detection in a patient with diabetic mastopathy. ajr 2004; 182: 1081-1083. 3. thorncroft k, forsyth l, desmond s, audisio r.the diagnosis and management of diabetic mastopathy. breast j 2007; 13(6): 607-613. 4. shaffrey j, frederic ba, gatewood o, brem r. diabetic fibrous mastopathy: case reports and radiologicpathologic correlation. breast j 2008; 6(6): 414-417. 5. tuncbilek n, muammer karakas h, okten o. diabetic fibrous mastopathy: dynamic contrast-enhanced magnetic resonance imaging findings. breast j 2004; 10(4): 359-362. 6. ely k, tse g, simpson j, clarfeld r, page dl. diabetic mastopathy, a clinicopathological review. am j clin pathol 2000; 113: 541-545. 7. camuto p, zetrenne e, ponn t. diabetic mastopathy. a report of 5 cases and a review of the literature. arch surg 2000; 135: 1190-1193. 8. mak cw, chou ck, chen sy, lee ps, chang jm. diabetic mastopathy. bjr 2003; 76: 192-194. 9. wong kt, tse gmk, yang wt. ultrasound and mr imaging of diabetic mastopathy. clin radiol 2002; 57(8): 730-735. 10. andrews-tang d, diamond ab, rogers l, butler d. diabetic mastopathy: adjunctive use of ultrasound and utility of core biopsy in. breast j 2001; 6(3): 183-188. fig. 5. ultrasound image of the right breast. 126 sa journal of radiology • december 2010 radioactive news molecular imaging at the rssa/sgr meeting last august at spier, we were treated to a fascinating presentation by an ex-capetonian, professor jonathan kruskal (harvard), that included an in vivo video of liver tumour deposition and angiogenesis in a rat model. as we watched tumours grow from a single cell and observed the angiogenesis, we were reminded that the future of imaging lies not in the anatomical depiction of tumours already containing millions of cells but in molecular imaging techniques. medical imaging has been through revolutions before. the discovery and harnessing of x-rays allowed images of the inside of the living human body for the first time, and there seemed to be no limit to the body spaces into which radiologists could introduce positive or negative contrast agents to better delineate anatomy. cormack (ex uct) and hounsfield shared a nobel prize for the mathematics which facilitated the development of ct. the subsequent refinements, which lead to modern multidetector ct scanners, have revolutionised this technology so that we are able to acquire 3-d submillimetre isometric datasets which can be sliced, diced and modelled, cut away, rotated and viewed. software can now take us on virtual journeys through bronchi, colons and vessels. images can be enhanced by the administration of contrast agents and temporal changes in contrast density be mapped, but the images remain anatomical maps of the body according to the attenuation of radiation. mri has allowed us to map the density and behaviour of perturbed precessing protons in bodies placed in a magnetic field. imaging sequences continue to be modified to produce exquisitely detailed anatomical images.we are able to interrogate chemical composition and metabolism with mr spectroscopy and functional imaging techniques. advances in nanoand microparticle contrast have potential to expand clinical molecular imaging beyond the current techniques of spect and pet. ultrasound allows real-time imaging, but molecularly targeted microbubbles represent a new strategy. targeted contrast agents will pave the way for targeted therapeutic delivery. non-ionising techniques such as mri/mrs, optical imaging, ultrasound and hybrid technologies are suited to early disease detection and screening. the new frontier is molecular imaging (mi), and a revolutionary new chapter in the history of medical imaging is about to be written. at the end of it, we will all wonder how we ever practiced medicine without mi as the new technology ushers in more personalised treatments. will radiologists be at the forefront of developments in mi and, more specifically, are there young south african radiologists who will embrace the challenge of new technology and enter this exciting field? there are those who make things happen, those who watch things happen, and those who wonder what happened! good luck. clive sperryn president, rssa samsig seeks growth dr mark velleman samsig (the south african musculoskeletal imaging group) was established in october 2005, with the aim of promoting musculoskeletal radiology among radiologists and interested disciplines in south africa; it is an official subgroup of the rssa. the majority of members come from the rssa, but membership is open to all clinicians with an interest in imaging. the current committee comprises dr richard de villiers (chairman), dr mark velleman (vice-chairman), dr ralph posner (treasurer), dr graeme thompson (secretary), dr john zietkiewicz (it), and regional contacts dr peter mercouris (kzn/central region), dr andrew van den heever (western cape) and dr mark velleman (northern region). the group holds yearly meetings to run concurrently with the south african sports medicine association congress, where possible. the most recent meeting took place from 4 8 october 2010 at chobe, botswana, in the form of a well-filled 3-day conference devoted to high-level msk imaging with interactive case presentations by delegates from around the country as well as australia and the usa. attendance was fully subscribed. interaction between presenters and delegates was encouraged and proved to be very successful. case studies were also shown by delegates for further discussion, and were equally popular. feedback on the lectures was most positive, and all the delegates were keen to return for the next meeting in two years’ time. the social programme included morning game drives, fishing trips and sunset river cruises, and a visit to the local school which was well received by the locals. most of the delegates came with their children and spouses who took part in the social activities and could enjoy day trips too. during the concluding dinner, some of the children spontaneously joined the traditional dancers on stage, epitomising the success of the event. all look forward to the 2012 samsig meeting, the idea being to again host it in a safari-like setting; the venue has yet to be finalised. further information is on the website www.samsig.co.za. sa journal of radiology • december 2010 127 radioactive news report-back by 2009 rssa travel award winner pieter janse van rensburg i used the 2009 rssa travel award to attend the 8th interventional mri symposium held on 24 25 september 2010 in leipzig, germany. the scope of the symposium was quite wide, with the main topics being intraoperative mri; thermometry; laser, rf and cryoablation therapy; cellular therapies and targeted drug delivery; mr-guided high-intensity focused ultrasound (hifu); biopsy and vascular applications. it was clear to me that many of the percutaneous interventions performed commonly under ultrasound or ct guidance, can quite easily be adapted to mri-guided procedures. an open mri is ideally suited for many of the more complex procedures, but there were many presentations where interventions were guided by short-bore conventional closed magnets. therefore, mr-guided interventions are well within reach of radiologists who perform percutaneous biopsies under ultrasound or ct guidance in south africa, and the transition to performing such a procedure should be relatively straightforward, given the availability of the correct mr-compatible needles and related equipment. another interesting aspect was the application of intraoperative mri, currently mostly used during neurosurgical procedures such as tumour resections and deep brain stimulator implantations. one of the common reasons for incomplete tumour resection is that the brain shifts during surgery. an intra-operative mr system therefore allows the radiologist to identify residual tumour while the patient is still within the operating room under general anaesthetic and guide the surgeon accordingly. these fused or shared mr and neurosurgical suites are going to be mainstream in the first world very soon, and south africa is sure to follow this trend. mr-guided hifu is probably the most revolutionary technology that i witnessed at the symposium. the basic concept involves a special ultrasound transducer that is embedded into an mr table. the ultrasound beam is then focused analogously to a magnifying glass focusing the sun’s rays to a point. the intense heat generated by the focused ultrasound causes protein denaturation, irreversible cell damage and coagulative necrosis at specific target locations. it is used thus to ablate neoplasms within the body. mr is the ideal modality to guide and monitor the hifu ablation of tumours because not only does it provide high-detail anatomical data on the target, but it also provides accurate thermometry to measure the local temperature at the target and so allows safe execution of the procedure. hifu is used to ablate tumours without any physical transgression of the patient’s skin, so it is a non-invasive therapy that radiologists will perform. current and quite established applications are the ablation of uterine fibroids and small breast carcinomas, as an alternative to lumpectomy. other potential applications are the ablation of liver tumours, prostate carcinoma and bone lesions. it is my opinion that mr-guided hifu is a groundbreaking technology that radiologists should embrace. the role that mr will play in molecular imaging was also discussed, and it is very promising. alginate-poly-l-lysine-alginate (apa) microcapsules can be used to encapsulate stem cells that contain a gene that expresses luciferase, which can be used for bioluminescence imaging. however, the gene can also express truncated thymidine kinase for pet imaging. the same apa microcapsules can also be used to encapsulate perfluorobromide (pfob-apa), which is useful because the fluorine is visible on 19f mri and the bromide is visible on x-ray. consequently, x-ray, mr, pet and bioluminescence imaging can all play a role in visualising these apa capsules and therefore will be helpful in confirming whether a certain gene or stem cell therapy has been successful or not. leipzig has a rich heritage and a beautiful old inner city which is a joy to explore by foot or bicycle. famous residents include johan sebastian bach, gottfried leibniz, felix mendelssohn and felix bloch. i thank the rssa for this opportunity and their continued support. abstract introduction case presentation management and outcome discussion conclusion acknowledgements references about the author(s) humphrey mapuranga department of radiodiagnosis, faculty of medicine and health sciences, stellenbosch university, cape town, south africa siseko silolo department of urology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa abraham c. van wyk division of anatomical pathology, faculty of medicine and health sciences, national health laboratory service, stellenbosch university, cape town, south africa sucari s.c. vlok department of radiodiagnosis, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation mapuranga h, silolo s, van wyk ac, vlok ssc. a rare case of small-cell neuroendocrine tumour of the lung metastasising to the urinary bladder. s afr j rad. 2023;27(1), a2556. https://doi.org/10.4102/sajr.v27i1.2556 case report a rare case of small-cell neuroendocrine tumour of the lung metastasising to the urinary bladder humphrey mapuranga, siseko silolo, abraham c. van wyk, sucari s.c. vlok received: 15 sept. 2022; accepted: 03 mar. 2023; published: 26 apr. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a 77-year-old woman with suspected lung carcinoma had multiple bladder masses and lymphadenopathy outside the normal urinary bladder drainage area. fine needle aspiration and immunocytochemistry of the cervical lymph node complex and transurethral biopsy of the bladder masses confirmed metastatic small-cell neuroendocrine carcinoma. contribution: clinical correlation, imaging findings, tumour markers and immunohistochemistry are necessary for metastatic bladder tumour work-up. keywords: small-cell neuroendocrine carcinoma; metastases; cystoscopy; immunohistochemistry; biopsy. introduction urinary bladder metastases are rare, accounting for 4.5% of all bladder neoplasms. secondary bladder neoplasms can arise from direct extension from another pelvic malignancy or from distant organs as part of a more extensive disease.1 primary malignancies with distant spread to the urinary bladder include the stomach, skin, lung and breast.2 bladder metastases from a proven primary lung neoplasm are extremely rare with a paucity of literature on this specific entity. owing to the uncommon occurrence of distant bladder metastases from a non-contiguous primary source and the morphologic diversity of urothelial carcinoma of the bladder, accurate diagnosis can be challenging. case presentation a 77-year-old woman known with hypertension, chronic obstructive pulmonary disease and a strong smoking history of 20 pack years, presented with a 4-month history of dysphagia, odynophagia and dysphonia. she reported chronic loss of appetite and tolerated only fluid feeds with hesitancy for solids. she had significant weight loss of approximately 20 kg over a 3-month period. at the time of presentation, she had no haematuria, flank pain, dysuria or any accompanying genitourinary symptoms. she had a previous hysterectomy and a surgical procedure for perforated peptic ulcer disease. on physical examination, she was frail and cachectic with poor performance status: eastern cooperative oncology group grade 4 (ecog-4). on clinical examination, a 3 cm firm, fixed and tender right cervical lymph node complex was palpated. chest and breast examinations were normal. review of other systems was unremarkable. gastroscopy demonstrated extrinsic oesophageal compression at 30 cm. right neck ultrasound revealed a cluster of large, lobulated, hypoechoic lymph nodes with loss of fatty hila (figure 1a & b). a lymph node fine needle aspiration biopsy proved metastatic carcinoma with morphological features suggestive of small-cell carcinoma (figure 2a & b). synaptophysin, chromogranin a and cd56 immunocytochemical stains were positive on the cell block, confirming neuroendocrine differentiation. figure 1: right cervical pathological lymphadenopathy (a) longitudinal and (b) transverse ultrasound images demonstrated loss of the fatty hila (solid white arrow), lobulated contours (solid white arrow heads) and increased short axis diameter of 1.69 cm. figure 2: fine needle aspiration biopsy of the cervical lymph node showed poorly cohesive malignant cells with a high nuclear-cytoplasmic ratio, scant cytoplasm, ‘salt-and-pepper’ chromatin and inconspicuous nucleoli similar to the cells seen in the urinary bladder. papanicolaou stain, original magnification 400x (a) and diff quik stain, original magnification 400x (b). a posteroanterior chest radiograph performed at presentation revealed a left hilar mass with attenuation of the left main-stem bronchus and accompanying contralateral mediastinal shift (figure 3). post-contrast staging chest ct (figure 4) showed an infiltrative, central, trans-spatial mediastinal mass encasing the left main-stem bronchus, left and right main pulmonary arteries and descending aorta. abdomino-pelvic ct revealed multiple enhancing soft tissue mural lesions in the urinary bladder – consistent with metastases – the largest was located at the bladder base, with a similar lesion located anteriorly – in the space of retzius – (figure 5a), and complicated by right-sided hydro-uretero-nephrosis because of infiltration of the right vesico-ureteric junction (vuj) by the largest deposit (figure 5b & c). there was no abdominopelvic nodal or solid organ metastatic disease. no enhancing nodules were present in the right renal pelvis. the axial and appendicular skeletal elements were clear of metastases. figure 3: (a) pa cxr: left hilar soft tissue mass with attenuation of the left main-stem bronchus and right tracheal shift (white arrow). lateral cxr (b) shows hilar and mediastinal adenopathy (white arrow heads). figure 4: (a) ct chest axial: confirms extensive hilar and mediastinal mass-nodal complex with necrosis (white arrow heads). the mass encases and narrows the left mainstem bronchus (solid white arrow), main pulmonary trunk (grey arrow), and (b) coronal reconstruction shows trans-spatial extent of the mass. figure 5: abdomino-pelvic ct (a) multiple urinary bladder enhancing exophytic mural mass lesions (white arrows) (b) lesion (white arrow) located in the posterior bladder wall infiltrates the right vesico-ureteric junction (white arrow head), causing upstream obstructive uropathy (c) dilatation of the right renal pelvis (white arrow) secondary to tumour infiltrating the right vesico-ureteric junction. at this point, the patient was discussed at a multidisciplinary meeting and the diagnosis of central bronchus carcinoma (small-cell) with possible metastases to the urinary bladder was made. the cancer was staged radiologically as t4n3m1c. the patient was referred to the urology team for further workup of the bladder lesions and management of the right-sided hydro-uretero-nephrosis. cystoscopy revealed several solid broad-based masses, of which the mass along the right posterior bladder wall was biopsied. histology of the biopsy specimen revealed a small round blue cell tumour in the lamina propria with normal overlying urothelium and accompanying lymphoid aggregates. immunohistochemical stains for broad-spectrum cytokeratin (mnf116), synaptophysin, chromogranin a and ttf-1 were all positive, confirming the diagnosis of metastatic small-cell neuroendocrine carcinoma (figure 6a, b, c & d). figure 6: histological and immunohistochemical findings in the bladder biopsy. (a) malignant cells are present in the lamina propria (left lower quadrant) with overlying normal urothelium and a lymphocytic aggregate to the right (haematoxylin and eosin, original magnification 200x). the tumour cells and urothelium express cytokeratins (mnf116) (b). synaptophysin is expressed in the cytoplasm of the tumour cells (c) and thyroid transcription factor 1 is strongly expressed in the tumour cell nuclei (d). correlating the clinical, radiological and pathological findings, a final diagnosis of small-cell neuroendocrine carcinoma of the lung with metastases to the urinary bladder was made. management and outcome given the patient’s extensive disease burden, metastatic spread and poor performance status (ecog-4), the decision was taken by the family in conjunction with the oncology team to place the patient on palliative care. the patient was discharged and hospice care was arranged. the patient unfortunately succumbed 6 months after the initial presentation. discussion neuroendocrine tumours consist of a large heterogeneous group of malignancies derived from embryonic neural crest tissue found in various organ systems. four major types of lung neuroendocrine tumours are described in the 2004 world health organization classification: typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma and small-cell lung cancer. neuroendocrine tumours make up 25% of primary lung carcinomas with the most common of these being small-cell carcinoma. more than 95% of small-cell carcinomas arise from the lung, implying that a primary lung lesion should be sought for if a lesion, which is histologically confirmed as small-cell carcinoma is found within any other organ system.3 small-cell neuroendocrine carcinomas (snecs) of the lung are high-grade, poorly differentiated malignancies, known to be highly aggressive. they tend to arise near the bronchial region in the majority of cases. these tumours carry a poor prognosis and once diagnosed, local or distant metastases from the primary site are usually present. the mean age at presentation is 65 years, and a strong association with heavy cigarette smoking is well known.4 although neuroendocrine tumours of the urinary bladder are much less common compared with lung neuroendocrine tumours, it is essential to consider this differential diagnosis in uropathology as this is central in guiding drug development and patient management. bladder neuroendocrine tumours are less common than the other conventional histological genitourinary variants, namely urothelial carcinoma, adenocarcinoma and squamous cell carcinoma, constituting only 0.7% – 1% of malignant bladder cancers.5,6 they can present with haematuria and pelvic pain. secondary neoplasms to the urinary bladder have been known to be extremely rare. in one series of 11 cases with bladder metastases, it was noticed that the most common primary tumour was the breast. interestingly, in the same series, none of the patients had lung carcinoma as a primary site. of the patients in this series, 51% demised within 1 year after the diagnosis of bladder metastases.7 the radiological features of secondary bladder tumours have not been extensively described in the relevant literature. the imaging features of secondary bladder tumours closely resemble primary bladder cancers. differentiation on imaging alone is nearly impossible with tissue sampling, immunohistochemistry and clinical history often being necessary.8 the diagnosis of snec is confirmed when chromogranin, synaptophysin or cd56 are positive. in the presented case, the lymph node biopsy was also positive for all these markers. it is interesting to note that small-cell carcinoma of the urinary bladder is histologically indistinguishable from small-cell carcinoma of the lung. this has led to the proposal that a shared pathogenesis in these entities exists. a research study, however, concluded that small-cell cancers of the bladder and lung share a convergent but distinct pathogenesis and in fact the former actually arises from a cell of origin shared with urothelial bladder cancer.9 patients with primary small-cell carcinoma of the urinary bladder require aggressive combination therapy, such as combined chemotherapy and radical cystectomy or chemotherapy and radiation therapy, to achieve cure. those with secondary small-cell bladder cancer are usually treated with palliative chemotherapy. a cisplatin-based chemotherapy regimen is the preferred initial therapy for patients with metastatic urothelial cancer of the bladder and urinary tract, but cisplatin-related toxicity is a major drawback to this regimen, especially in patients with diminished renal function and poor performance status.10 conclusion while metastatic bladder cancers are rare and typically arise from contiguous sites, non-contiguous primary cancers can metastasise to the urinary bladder, although very few have been described in the literature. in particular, small-cell lung neuroendocrine cancer is extremely rare. in the workup of patients with bladder masses in the presence of a known primary, immunohistochemistry, histology and cross-sectional imaging are important in differentiating metastases to the bladder from a synchronous carcinoma and for assessing tumour genotype. acknowledgements the authors would like to acknowledge prof richard pitcher, stellenbosch university radiology head of department for overall guidance and support in article submission to the health research ethics committee (hrec). they would like to express their special thanks to elvira rohland who was very instrumental in ensuring the article meets the required minimum standard for ethical approval with the health research ethics committee (hrec). competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.m. conceptualised and drafted the original article. s.s.c.v. created the legends, completed final editing, article supervision and oversight. radiological images were selected by h.m. and approved by s.s.c.v. s.s. contributed patient management details while a.c.v.w. supplied histological findings and the respective images. ethical considerations approval to conduct the study was received from the hrec, stellenbosch university, faculty of medicine and health sciences (reference hrec: c22/07/017). funding information the article received no specific grant from any funding agency in the public, commercial or not-or-profit sectors. data availability no new data were created and hence no data sharing is required for this article. disclaimer the professional views and opinions expressed in this article reflect those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references el-taji o, al-mitwalli a, malik f, et al. secondary neoplasms of the urinary bladder-clinical management and oncological outcomes. transl androl urol. 2021;10(6):2427–2434. https://doi.org/10.21037/tau-20-955 sheehan ee, greenberg sd, scott r jr. metastatic neoplasms of the bladder. j urol. 1963;90:281–284. https://doi.org/10.1016/s0022-5347(17)64406-9 rekhtman n. neuroendocrine tumors of the lung: an update. arch pathol lab med. 2010;134(11):1628–1638. https://doi.org/10.5858/2009-0583-rar.1 demarinis a, malik f, matin t, rahmany z, putnam t, nfonoyim j. a rare case of metastatic small cell neuroendocrine carcinoma of the lung presenting as isolated thrombocytopenia. j community hosp intern med perspect. 2019;9(4):327–329. https://doi.org/10.1080/20009666.2019.1644916 bayrak by. the clinical and uropathological aspects of neuroendocrine tumours of the bladder. j urol surg 2021;8(1):1–7. https://doi.org/10.4274/jus.galenos.2020.3986 qayoom s, chakrabarti d, khan f, goel mm. primary small cell carcinoma of the urinary bladder. bmj case rep. 2019;12(9):e230185. https://doi.org/10.1136/bcr-2019-230185 xiao g-q, chow j, unger pd. metastatic tumors to the urinary bladder: clinicopathologic study of 11 cases. int j surg pathol. 2012;20(4):342–348. https://doi.org/10.1177/1066896911428736 karaosmanoglu ad, onur mr, karcaaltincaba m, akata d, ozmen mn. secondary tumors of the urinary system: an imaging conundrum. korean j radiol. 2018;19(4):742–751. https://doi.org/10.3348/kjr.2018.19.4.742 chang mt, penson a, desai nb, et al. small-cell carcinomas of the bladder and lung are characterized by a convergent but distinct pathogenesis. clin cancer res. 2018;24(8):1965–1973. https://doi.org/10.1158/1078-0432.ccr-17-2655 griffiths tr. action on bladder cancer. current perspectives in bladder cancer management. int j clin pract. 2013;67(5):435–448. https://doi.org/10.1111/ijcp.12075 experiences.html experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection p c pretorius, fcrad (diag) sa drs visser, erasmus, vawda & partners, port elizabeth corresponding author: p pretorius (ppret@telkomsa.net) introduction i was alerted to an article in radiology vol. 255 no. 2 (may 2010)1 by a colleague. the article, entitled ‘kidney and urinary tract imaging: triple-bolus multidetector ct urography as a one-stop shop – protocol design, opacification, and image quality analysis’, clearly describes the technique, while the quotation below, from the article, summarises the findings: ‘we have shown that triple-bolus multidetector ct urography allowed visualization of renal parenchymal, excretory, and vascular contrast-enhancement phases in a single dose-efficient acquisition and provided sufficient opacification of the uut, with simultaneous and adequate image quality of renal parenchyma and vascular anatomy.’ the main emphasis on this technique is to reduce the number of unnecessary ct scans when assessing the urinary tract. our previous protocol for scanning the urinary tract for pathology included four phases: a pre-contrast, corticomedullary, nephrographic and delay excretory phase. this new split-bolus technique, with one ‘post-contrast’ scan, including all three of the above post-contrast phases, was preferentially initiated in our radiology practice to scan the urinary tracts of patients from our referring urologists (this technique was not used for dedicated renal artery scans or for uncontrasted surveys for renal colic). this technique was tested on a few cases and we then consulted with our referring urologists. we pointed out the benefits and they were happy for us to scan their patients in this way – in fact, some of them were enthusiastic! we have now scanned over 100 cases in this manner throughout our practice. it requires the radiologist to shift his/her comfort zone, to rely on a single post-contrast scan replacing the traditional three-phase post-contrast scan. i have included a pictorial representation of numerous different pathologies that we picked up while using the newer technique, to share our experiences over a wide range of pathologies, to assist our colleagues in making this shift of technique with more confidence, and to attempt to address some of the queries that could be raised. injection plan we modified the original recommended protocol. fig. 1 is a summary of our technique, which is as follows: 1. the patient is hydrated with 3 glasses of oral water 30 minutes prior to examination. this was not always possible as many of the patients were booked for retrograde studies in theatre, by the urologists, on the same day after the ct scan was performed. many of the scans were performed without this pre-hydration. 1. the patient is hydrated with 3 glasses of oral water 30 minutes prior to examination. this was not always possible as many of the patients were booked for retrograde studies in theatre, by the urologists, on the same day after the ct scan was performed. many of the scans were performed without this pre-hydration. 2. the patient is positioned on the ct table, an iv canula inserted, and a pre-contrast scan from above the diaphragm to below the symphysis is made. we were not meticulous about doing ‘low radiation’ precontrast scans as suggested in the article. 2. the patient is positioned on the ct table, an iv canula inserted, and a pre-contrast scan from above the diaphragm to below the symphysis is made. we were not meticulous about doing ‘low radiation’ precontrast scans as suggested in the article. 3. 30 ml of iv contrast is then injected through the canula, usually by hand injection. no scan is made at this time. the contrast is excreted and will contribute to the ‘delayed excretory phase’ on the later scan. 3. 30 ml of iv contrast is then injected through the canula, usually by hand injection. no scan is made at this time. the contrast is excreted and will contribute to the ‘delayed excretory phase’ on the later scan. 4. the contrast pump’s 2 syringes are then set up with loaded doses of 120 ml contrast and 50 ml saline separately. 4. the contrast pump’s 2 syringes are then set up with loaded doses of 120 ml contrast and 50 ml saline separately. 5. after about 10 minutes, the patient is rolled once or twice to mix the contrast in the bladder (this normally layers in the dependent portion after lying flat for prolonged periods). 5. after about 10 minutes, the patient is rolled once or twice to mix the contrast in the bladder (this normally layers in the dependent portion after lying flat for prolonged periods). 6. a repeat scoutview is taken, a new scan planned, and the next 2 phases of contrast are set up to inject via the automated pump, and injected as follows: 6. a repeat scoutview is taken, a new scan planned, and the next 2 phases of contrast are set up to inject via the automated pump, and injected as follows: 6.1 60 ml contrast at 1.5 ml/sec (40 sec) (contributes to nephrographic phase of the scan), followed by: 6.1 60 ml contrast at 1.5 ml/sec (40 sec) (contributes to nephrographic phase of the scan), followed by: 6.2 20 ml saline at 1.5 ml/sec (13 sec), followed by: 6.2 20 ml saline at 1.5 ml/sec (13 sec), followed by: 6.3 a delay after the saline injection (17 sec), followed by: 6.3 a delay after the saline injection (17 sec), followed by: 6.4 60 ml contrast at 3.0 ml/sec (20 sec) (contributes to the corticomedullary phase of the scan), followed by: 6.4 60 ml contrast at 3.0 ml/sec (20 sec) (contributes to the corticomedullary phase of the scan), followed by: 6.5 start the scan at this point, followed by: 6.5 start the scan at this point, followed by: 6.7 30 ml saline at 3.0 ml/sec (chases the last dose of contrast) 6.7 30 ml saline at 3.0 ml/sec (chases the last dose of contrast) 7. the scan time on our 64-slice mdct was 10 12 sec, and on the 16-slice mdct scanners 16 20 sec. 7. the scan time on our 64-slice mdct was 10 12 sec, and on the 16-slice mdct scanners 16 20 sec. note that, on some of our scanners, the iv pump could not deliver saline injection as well as contrast, and therefore the single saline injection was only delivered after the late corticomedullary-arterial phase injection. in summary, then, the timing of starting the single post-contrast scan incorporates the following stages: • excretory phase – about 10 min after the first 30 ml injection • nephrographic phase – 90 sec after start of the second injection • corticomedullary/arterial phase – 20 sec after start of third injection. will a renal carcinoma be hidden? the following points are noted from comparing these two cases: • renal carcinoma surgery is often done through keyhole surgery. the renal anatomy and the mass relative to the renal artery and vein and the collecting system are all shown on one scan. this allows the urologist to plan surgery and review anatomy more easily, without having to scroll back and forwards between different series. • careful evaluation of arterial and vein anatomy is required as there is overlap of these structures. when reviewing the classic 4-phase study above (fig. 2), one will note that this is a problem with that method as well. • the contrast concentration in veins and arteries was dense enough to make mip and 3d reconstructions, for easier interpretation for the referring clinicians. • the mass was easily seen, and there is no real decrease in clarity of the mass when comparing with the ‘classical 4-phase’ scan technique above in fig. 2. • one is advised to be meticulous about changing window width and levels during the reviewing of the kidneys (and the rest of the urinary tract). this should be standard protocol when reviewing any ct scans, whatever the method of scanning and region of scanning; however, it is unfortunately not always practiced meticulously by radiologists. • the question about whether hepatic metastases may be missed or hidden by this technique has not been addressed. however, when comparing experiences of radiologists in our large radiological practice, which includes a dedicated oncology practice, most had difficulty in remembering when they last saw renal carcinoma metastases to the liver despite the fact that the 4-phase contrast scan technique has been the standard protocol for many years. will neoplasms of the uro-epithelium in the urinary tract be obscured? when there is a history of haematuria, it is imperative to not only look for pathology in the kidneys, but also to carefully evaluate the ureters and the bladder. below are three cases of bladder cancer that highlight different facts (fig. 4). a second case of bladder carcinoma is shown below (fig. 5). a third case of bladder carcinoma is shown below (fig. 6). these three cases of bladder carcinoma highlight different points about the bladder and ureters: • although the concentration of contrast in the bladder is not dense and there is often layering of contrast (despite rolling the patient), there is no compromise in identifying the bladder wall mass. in fact, it is probably preferable for contrast not to be less dense than normally seen on the classical 4-phase scans, so not obscuring polypoid masses protruding into the lumen. • measurement of enhancement of the bladder mass comparing preand post-contrast studies was easy and consistent (examples not included here). • enhancement of all the vascular structures, ureters and bladder on one series made identification of lymph nodes and perivesical infiltration easier. one needed to follow contrast-filled tubular structures proximally to differentiate ureters from blood vessels; this was an easy and consistently reproducible task. • obstructive hydronephroses and hydro-ureters were also easily identified and the ureters followed to the site of obstruction by the mass. will ureteric masses and other pathology be missed? numerous instances of ureteric wall thickening associated with inflammatory and obstructive uropathies were demonstrated. it is assumed that ureteric and pyelocalyceal masses will also be easily identified. what about other renal masses? interestingly, the above scan was made using the same technique, but on a single-slice entry-level ct scanner, acquired in 1998 and still in service. this scanner has a limited heat capacity, and scan series have to be spaced to allow tube cooling, with a limited scan time of 40 sec per series. this proved to be the ideal technique to gain a comprehensive study with all contrast phases on 1 series, which demonstrated the robustness of the technique. this technique also allowed us to use a 5 mm-thick spiral cut on a single post-contrast scan – rather than the 8 mm-thick cuts necessary if both a corticomedullary and nephrographic series have to be run back to back (less cuts with less time required and less tube heating from each series). the resolution is thus significantly increased. we modified the protocol for a single-slice scanner (see addendum at end). what about renal cyst analysis? will the interpretation of subtle changes in renal cyst walls and lumens be compromised? the calcification within the cyst, the cyst walls and density are clearly seen on both scan series (white arrows), and the contrast within a calyx is seen abutting the cyst margin (black arrowhead in fig. 9b). small and large renal cysts were easily identified and analysed, and their relationship to contrast-filled vessels and pelvicalyceal structures all on one scan made the interpretation easier. is this useful in trauma of the urinary tract? provided that the patient is clinically stable and can be left in the department for the required time, i believe that this technique can be used. below is a case of a subcapsular renal haematoma. i believe that injury to vascular structures as well as the urinary organs will be identifiable. the purist may argue that a dedicated vascular series is required. it may be that this series might only be useful in the more chronic post-injury cases for follow-up, as was this case. what about renal calculi and more chronic mechanical obstructions? the above two cases of a chronic calculus obstruction in a ureter and an acute obstruction are included to highlight the following points of the technique: • highlights non-functioning hydronephrosis, with its cause: calculus in ureter • highlights calculus in bladder – seen pre-contrast and not hidden by contrast • shows calculus within contrast-filled ureter, causing a partial obstruction – need to change windows to view • see ureteric jets into bladder, confirming obstruction on the right is only partial in fig. 13. ileal bladder this series shows the function kidneys, ureters and bladder. this case was included to highlight the use of this scan technique in the unusual situation of assessing the urinary tract after diversion surgery. discussion • in this radiologist’s opinion, it was far easier and more efficient to read pathology of the urinary tract with all the relevant information on one series, without having to skip backwards and forwards between three post-contrast series to try to correlate findings, particularly with complex pathology situations. • referring clinicians are not usually as skilled as radiologists when viewing ct scans on work stations or their computers. this simplifies the number of series they have to view to gain all the information they require when reviewing the images. • a range of urinary tract pathologies has been included to highlight the robustness and reliability of this technique. very few delayed scans were required for better visualisation of the contrast-filled collecting systems and bladder; in my experience, this did not compromise the demonstration of any pathology. there were no cases where i regretted not performing the classic 4-phase series. • many of the cases did not get their pre-injection oral water load and, at some of the scanners, the injection pump could not be programmed for dual saline flushes after the two later contrast injections; this did not seem to compromise the quality of resulting images. • the cases presented above were a fair representation of the quality of scans acquired. these cases were not ‘hand-picked’ because of quality – they were chosen purely for demonstration of pathology. • there is a strong drive and emphasis by the radiological fraternity towards reducing radiation doses to patients. this technique effectively halves the radiation dose. • there is a reduction of wear and tear on expensive ct scanners, by reducing scanning time. • the number of images requiring either printing on film or taking up storage space on digital archives is halved. • medical insurers are reluctant to compensate for the full series of scans required for good diagnostic care in radiology. this technique allows one to gain all the information required within the ‘limited fee’ that the medical insurers insist on when dictating how many post-contrast series they feel is adequate. if patients foot the bill privately, it also helps to contain costs to them. • this technique is not recommended for dedicated renal arterial angiography. • experience with renal carcinoma, hepatic metastases and pyelonephritis has not yet been gained; however, i am convinced that this technique will be as reliable in visualising the pathology as the classical 4-phase technique. • there is debate as to whether small renal cell carcinoma masses may be missed, and this aspect may need further studies. however, i feel that meticulous variation in windowing the kidneys during viewing will prevent this potential problem; in fact, it may prove to be even more accurate – as i feel is the case with bladder masses. addendum single-slice scanner protocol • 30 ml iv by hand • 55 ml iv at 1.5 ml/sec (36 sec) • 37 sec delay • 70 ml iv at 2.5 ml/sec (28 sec) • no saline pump to ‘chase’ the contrast is available at this facility. the sum of the times during the active phase of the injection are as follows: 36+37+28 sec=101 sec. the scan is started at 90 sec from beginning the nephrographic contributing phase of injection. therefore it starts 18 sec into the corticomedullary contributing phase of the injection, and a further 11 sec of contrast injection at the arm venous level follows the start of the scan (101 sec minus 90 sec=11sec). acknowledgement. i thank dr andy dutoit for alerting me to this article and technique. 1. kekelidze m, dwarkasing rs, dijkshoorn ml, sikorska k, verhagen pcms, krestin gp. kidney and urinary tract imaging: triple-bolus multidetector ct urography as a one-stop shop – protocol design, opacification, and image quality analysis. radiology 2010;255(2):508-516. 1. kekelidze m, dwarkasing rs, dijkshoorn ml, sikorska k, verhagen pcms, krestin gp. kidney and urinary tract imaging: triple-bolus multidetector ct urography as a one-stop shop – protocol design, opacification, and image quality analysis. radiology 2010;255(2):508-516. fig. 1. injection and scan technique. 2a 2b 2c 2d fig. 2. a traditional renal cell carcinoma scan series with 4 separate post-contrast scans: 2a – pre contrast, 2b – corticomedullary phase, 2c – nephrographic phase, 2d – delay excretory phase. 3a. pre-contrast. 3b. post triphasic contrast. 3c. renal artery. 3d. renal vein. 3e. 3d reconstruction. 3f. mip reconstruction. fig. 3. renal cell carcinoma scanned with a single post-contrast series after the triphasic contrast injection. the mass shows up clearly against the background renal tissue. the relation of the mass to the contrast-filled collecting system is shown (b), seen medial to the mass. the renal arteries’ (e) and veins’ (f) anatomy relative to the kidneys is seen. the lumen of the renal vein is clear and any arterial or venous anomalies are easily seen. 4a. bladder. 4b. single kidney. 4c. perivesical infiltration. 4d. perivesical lymphadenopathy. fig. 4. there is a carcinoma mass arising from the bladder wall, protruding into the bladder lumen, outlined by the contrast (4a). perivesical fat infiltration (4c) and adjacent lymphadenopathy (4d) is demonstrated (white arrows). the patient had a unilateral kidney only, with good demonstration of renal anatomy with relevant vessels and collecting system (4b). 5a. bladder. 5b. kidneys. 5c. ureters. 5d. coronal mpr. fig. 5. bladder carcinoma in left posterior wall of bladder (5a), causing obstruction and hydronephrosis of left kidney (5b and 5d) and left hydro-ureter (5c) with no contrast concentrating in the left collecting system and ureter. 6a. bladder 6b. coronal mpr of kidneys. 6c.ureters at varying levels. fig. 6. bladder carcinoma arising from posterior right bladder wall (6a) causing partial obstruction and dilatation of right collecting system and ureter (6b and 6c). fig. 6c shows contrast-filled dilated proximal ureters bilaterally, with layering of contrast and urine in dilated, more distal right ureter and no contrast in the dilated right lower ureter. fig 7. this is an image from the same case as fig. 13 below – a calculus impacted in the distal right ureter. note the proximal ureteric wall thickening clearly demonstrated around contrast in the lumen. 8a 8b fig. 8a. axial post-contrast scan with (8b) coronal mpr showing inhomogenous, predominantly fatty renal mass in left kidney – a known angiomyolipoma for follow-up. fig. 9a. pre-contrast. fig. 9b. post-contrast. fig. 10. parapelvic renal simple cyst showing relationship to adjacent renal vein and adjacent contrast-filled calyx. fig. 11a. post-contrast axial view. fig. 11b. coronal mpr. fig. 11. the large subcapsular haematoma is noted compressing and distorting the kidney. the subtle increased density of the retracting clot within the larger seromatous fluid collection can be differentiated; this was also noted on the precontrast series, with no change in density after contrast, confirming this was not contrast leakage. fig. 12a. coronal mpr fig. 12b. coronal mip of the of the urinary tract. renal arteries. fig. 12c. axial view of the ureters. fig. 12d. axial view of the bladder. fig 12. shows a calculus impacted in the distal left ureter causing chronic obstruction a) with hydronephrotic non functioning left kidney and ureter. atrophy of the left renal artery b). the non contrast filling of the left ureter (compared with the contrast filled right) is clearly shown on the axial view c). there is also a bladder calculus d) which was not obscured by the contrast (this was also seen on the precontrast series – image not included) fig. 13a. axial post-contrast view. 13b. same as 13a, with wide windows. 13c. pre-contrast.  13d. post-contrast. 13e. sagittal mpr of right ureter. 13f. wide window. 13g. coronal mip.  13h. coronal 3d. fig. 13 shows a case of a small calculus impacted in the distal end of the right ureter, causing partial obstruction in the right ureter. 14a. axial renal.  14b. contrast in ileal bladder. 14c. sagittal mpr 14d. sagittal view of right ureter. bladder. fig 14. views of an ileal bladder (arrows in 14b, 14c and 14d), with the kidneys and right ureter (arrowhead in 14c). 70 sa journal of radiology • september 2011 original article establishing a quality assurance baseline for radiological protection of patients undergoing diagnostic radiology g k korir, bsc, msc (nuclear science), phd (radiological science) department of physics and applied physics, university of massachusetts lowell, lowell, massachusetts, usa j s wambani, mb chb, m med (rad), pediatric (rad) radiology department, kenyatta national hospital, nairobi, kenya i k korir, bsc, msc (nuclear science), phd (nuclear physics) national nuclear regulator, centurion, pretoria corresponding author: g korir (ggkk382@yahoo.com) introduction the high rate of poverty, illiteracy and disease in most developing countries results in high demands for effective healthcare. expensive diagnostic equipment compounded by a poor economy, low technical resource capabilities, inadequate policies, and costly control systems have hindered the implementation of quality assurance. additionally, the international commission of radiological protection (icrp) has in their publication 60 recommended the need to adopt elaborate quantitative analysis of quality control tests as well as optimisation of radiological examinations.1 this recommendation poses a challenge to the majority of diagnostic x-ray departments which are slowly replacing standard speed with high-speed film/screen combination, and rarely with computed or digital radiography. the widespread use of x-rays in diagnosis and management of patients has led to increased exposure to this man-made radiation. although the clinical use of x-rays is governed by optimisation, justification and the as-low-as-reasonably-achievable (alara) principle, more aggressive methods have been proposed. according to hart et al., the 97/43/ euratom council directive which promoted establishment and use of diagnostic reference levels (drls), also motivated legislative status.2 essentially, the use of drls should form the core part of good imaging practice. imaging professionals should develop clearly defined guidelines that promote quality assurance in accordance with the latest technical knowledge of the equipment concerned. this professional approach will promote the due process of developing technical specifications, standards, and quality management. according to the american college of radiology (acr), the use of drls assists imaging professionals in managing radiation exposure by exercising good practice based on current knowledge, obtainable resources, and the specific needs of patients, in a safe and cost-effective medical care environment.3 this system falls within the recommendations of the united nations scientific committee on the effects of atomic radiation (unscear)4 and the international commission on radiological protection,5 and as so far revealed by research conducted by the international atomic energy agency.6 at the departmental level, local drls support quality assurance by specifying investigation levels for unusually high radiation exposure.7 the measurement of these dose quantities can be achieved by direct measurements using thermoluminescent dosimeters (tlds), indirect measurement of physical test phantoms8 and kerma area product (kap) meters. european commission (ec) report 16262 recommends the use of widely accepted simple methods of measurement that clearly define diagnostic reference levels, expressed as dose quantities with meaningful indications of patient exposure and considering the clinical imaging technique.7 our study was undertaken to establish the baseline data for radiographic image processes and image quality to optimise radiological protection for patients. materials and methods the study was done over 1 month in 1 representative x-ray room using a 400-speed film/screen system at 4 hospitals in kenya. the examination abstract background. the wide use of ionising radiation in medical care has resulted in the largest man-made cause of radiation exposure. in recent years, diagnostic departments in kenya have adapted the high-speed film/screen combination without well-established quality control, objective image quality criteria, and assessment of patient dose. the safety of patients in terms of justification and the as-lowas-reasonably-achievable (alara) principle is inadequate without quality assurance measures. aim. this study assessed the level of film rejects, device performance, image quality and patient dose in 4 representative hospitals using high-speed film/screen combination. results. the x-ray equipment quality control tests performance range was 67% to 90%, and 63% of the radiographs were of good diagnostic value. the measured prevalent chest examination entrance surface dose (esd) showed levels above the international diagnostic reference levels (drls), while lumbar spine and pelvis examination was the largest source of radiation exposure to patients. conclusion. the optimisation of patient protection can be achieved with optimally performing x-ray equipment, the application of good radiographic technique, and continuous assessment of radiographic image quality. original article 72 sa journal of radiology • september 2011 frequencies were obtained from patient records at each hospital. the film processors shown in table i were assessed for performance according to base plus fog, speed index and contrast index. the optical density was measured using an x-rite model 341c densitometer (x-rite inc., usa) on an aluminium 11-step wedge image produced using adult chest pa exposure factors. during the study period, film rejects from each room were collected, counted and grouped according to size, type and cause of rejection by a senior imaging technologist. a calibration validation was done on the harshaw 4500 tld system (erlangen, germany) used to read the tld cards for patient dose. four sets of 10 dosimeters each and 3 control dosimeters were sent to the secondary standards dosimetry laboratory (ssdl) in arusha, tanzania, for exposure to a known dose. the tld sets and 3 control dosimeters were read using the tld system and results provided to the ssdl for comparison. the validated system was used to read the tld cards for measuring entrance skin dose (esd) on patients. throughout the study, 2 non-irradiated tlds were included in the batch to evaluate the contribution of background radiation. while measuring doses on adult patients, the following parameters were recorded: exposure factors, focus to film distance, and the patient’s age, weight and thickness. an open tld card was placed on the central position of the beam on the patient’s skin using tape. the measured esd was then compared with diagnostic reference levels (drls), and appropriate dose reduction measures issued to each participating x-ray facility. the image quality of the radiograph was assessed by radiologists who awarded grade a, b or c based on the ec quality criteria.7 grade a meant features detected and fully reproduced, details visible and clearly defined; b meant features just visible, details just visible but not clearly defined; and c meant features invisible, and details invisible and undefined. at the end of the study period, quality control tests were performed using standard methods on each x-ray machine. the tests performed included kvp accuracy, reproducibility of exposure, timer accuracy, ma and exposure time linearity, radiation output, light/radiation beam alignment and total filtration (mm al). the tests were considered ‘passed’ or ‘failed’ according to the new south wales environment protection authority methods and standards.9 results examination frequencies fig. 1 indicates the percentage distribution of annual examination frequencies. in this study, the other examinations performed included postnasal space (pns), skull, thoracic, thoracic lumbar, cervical spine, abdomen and intravenous urogram (ivu). rejects analysis fig. 2 indicates trends and causes of film rejects. the leading causes were related to equipment (21%), positioning (7%), human error (3%), and other causes (8%). in this study, rejects owing to image blur, processor failures, film storage and cassette clips were all grouped as other causes. processor performance the sensitometry results in fig. 3 indicate the performance level at each hospital. only hospital 4 had good darkroom conditions, as indicated in the good fog plus base test results. tld reader system validation at the ssdl, the 4 sets of 10 dosimeters each were exposed to a cs-137 source with the following specific known doses: 0.2 mgy, 0.5 mgy, 1.0 mgy and 2.0 mgy. the results obtained from reading the tld cards are shown in table ii. there was an evenly increasing deviation from the lowest absorbed dose reading of 8% for 0.12 mgy to 15% for 2 mgy. these results validated the performance of the tld system to be credible; therefore, esd results reported in this study are accurate and representative of patient dose. table i. type of x-ray equipment and film processor at each hospital names x-ray unit installation year processor installation year hospital 1 philips ro 1230 rotarix 1992 kodak x-omat m6b 2002 hospital 2 shimadzu rad/flo circlex 1986 kodak x-omat 5000 ra 2007 hospital 3 siemens 0946004g444g 1982 fujifilm fpm3800ad 2004 hospital 4 shimadzu radiotex 2005 kodak x-omat 000 ra 2007 fig. 1. frequency of x-ray examinations. fig. 2. causes of film rejects per hospital. 74 sa journal of radiology • september 2011 original article x-ray equipment performance the results of the quality control assessment of the x-ray equipment are presented in table iii. analysis of the measured quality control results indicated that x-ray equipment performance in the 4 hospitals can be ranked as follows: hospital 4 – 90%, hospital 1 – 80%, hospital 2 – 70%, and hospital 3 – 67%. radiographic technique and patient dose table iv indicates the exposure factors and patient parameters used at each hospital. there was a general tendency in most hospitals not to use high kvp radiographic techniques. table v shows the mean esd for the examinations considered. the minimum and maximum esd ranges measured in the study were: 0.26 2.20 mgy (chest posterior anterior), 2.96 16.65 mgy (lumbar spine anterior posterior), 4.96 34.00 mgy (lumbar spine lateral) and 1.2 3.90 mgy (pelvis anterior posterior). image quality assessment image quality assessment results for the radiographs for which doses were measured are shown in fig. 4. fig. 3. mean values of the quality control tests for each film processor. table ii. results of intercomparison dose measurements of the tld system sets mean calculated dose (mgy) std dev. of sets ref. dose (mgy) avg % dev. corrected measured values (mgy) set 1 0.18 0.04 0.20 8 0.20 set 2 0.43 0.04 0.50 13 0.50 set 3 0.86 0.03 1.00 14 1.00 set 4 1.7 0.05 2.00 15 2.00 table iii. quality control test results quality control tests kvp accuracy (5%) reproduci bility of exposure (2%) timer accuracy (5%) ma and exposure time linearity (10%) radiation output (5%) hvl (mm al) light/radiation beam alignment (1% sid) performance (%)top bottom anode side cathode side hospital 1 result 4 0.53 1 1 1 3.2 -3 -1 -0.1 0.5 comment pass pass pass pass pass pass fail fail pass pass 80 hospital 2 result 1 0.85 1 4 4 2.9 2.5 2.5 0.5 1.75 comment pass pass pass pass pass pass fail fail pass fail 70 hospital 3 result 1 1.32 * 3 1 2.7 2.3 -2.5 -0.1 0.5 comment fail pass — pass pass pass fail fail pass pass 67 hospital 4 result 1 1.16 1 5 2 3.4 0.1 -3 0.1 0.1 comment pass pass pass pass pass pass pass fail pass pass 90 *=test not done; —=no comment; hvl measurements done at 80 kvp. fig. 4. image quality performance per hospital. original article 76 sa journal of radiology • september 2011 discussion the annual average number of patients for hospitals 1, 2, 3 and 4 was 72 000, 9 600, 12 000, and 14 400 patients respectively. hospital 1 comprised 5 times more patients than the other participating hospitals. the examination frequency distribution in fig. 1 did not exhibit notable variations between the hospitals. the high rate of lumbar spine examination was noted at hospital 1, which is a referral hospital. the unscear 1993 report did not find significant gender difference except for pelvis and hip examinations.10 the results in this study found a distribution of 43% male and 57% female, of whom 18% were children. the film reject rate per hospital was correlated with age of equipment age and state of maintenance (tables i and iii). the highest rejects came from hospital 2 (13%); hospitals 1 and 3 produced 11%, and hospital 4 was 6%. the largest proportion of rejects due to positioning came from hospital 3 and 4. training should reduce film reject rates. although the number of film rejects was comparable with iaea reported values,10 there is adequate scope for dose reduction that would tend to improved image quality, patient dose and use of resources. the annual estimate of film rejects in these 4 hospitals implied that 15 048 radiographic films were wasted and the same number of persons exposed unnecessarily to radiation. the amount of rejects could be reduced through proper choice of film processor, standard radiographic techniques, qc tests, and appropriate education and training of imaging staff. the film processors passed the speed index and developer temperature tests. however, there were deviations from the expected contrast index values. hospital 4 deviated by 32% lower, while the other 3 hospitals deviated by more than 30%. the overall sensitometry performance per hospital in descending order was hospital 4, hospital 1, hospital 3 and hospital 2, respectively. performance correlated with equipment age, film processor maintenance and level of qc in the hospital. hospital 1 used an established processor maintenance programme but showed a low level of qc test performance, as did the other participating hospitals. the film processor in hospital 2 was a refurbished unit that was not given any qc tests. in this study, contrast index was the most sensitive film processor test; the routine performance and daily plotting of the values obtained would be a good processor performance table iv. the range of radiographic exposure factors, patient parameters, and ec-recommended radiographic technique mean values of radiographic technique and patient parameters at each hospital ec-recommended radiographic technique parameters examination hospital kvp mas time (ms) ffd (cm) weight (kg) age (yrs) kvp time in ms ffd (cm) cxr pa hospital 1 66 4 10 150 67 43 100 150 <20 140 200 hospital 2 70 24 100 180 72 34 hospital 3 72 19 231 133 85 48 hospital 4 66 18 76 157 77 50 mean 69 16 104 155 75 44 lumbar hospital 1 78 24 120 99 70 44 70 90 <400 100 150 spine ap hospital 2 77 40 200 114 70 46 hospital 3 77 57 — 106 80 38 hospital 4 77 60 82 107 68 41 mean 77 45 101 106 72 42 lumbar hospital 1 84 24 60 90 71 39 90 100 <100 100 150 spine lat hospital 2 92 40 200 114 73 43 hospital 3 91 72 — 107 80 38 hospital 4 78 103 180 106 64 34 mean 86 60 120 104 72 38 pelvis ap hospital 1 72 10 28 105 72 40 70 90 <400 100 150 hospital 2 85 40 200 110 70 54 mean 78 25 28 108 71 47 —= measurement not performed. table v. results of esd survey in mgy: mean esd per hospital (ratio of mean esd/drl in parentheses) examinations names cxr pa lumbar spine ap lumbar spine lat pelvis ap hospital 1 0.41 (1.03) 7.07 (0.71) 8.54 (0.28) 1.55 (0.16) hospital 2 0.7 (1.75) 3.55 (0.36) 6.01 (0.20) 3.68 (0.37) hospital 3 1.6 (4.00) 14.7 (1.47) 28.6 (0.95) — hospital 4 0.8 (2.00) 4.7 (0.47) 14.8 (0.49) — drl 0.4 10 30 10 —=measurement not performed. indicator. in addition, there was a need to expand qc to cover storage, retrieval, and change of films. the accuracy of exposure factors was essential for consistently highquality diagnostic clinical images. the device performance results in table iii, based on 10 equally weighted quality control tests, showed a correlation with equipment age. the best performing equipment was at hospital 4 (2 years old), and the worst at hospital 3 (25 years old). the kvp accuracy and consistency test indicated good generator performance in most hospitals, except hospital 3. timer accuracy for the same number of x-ray machines was good except in hospital 3, which used fixed ma or falling load operation that made it difficult to assess exposure time. the overall x-ray equipment qc results obtained in this study indicated proper functioning of the tube voltage, tube voltage ripple, tube current and total filtration.6,12 beam quality results were also consistent with the american association of physicists in medicine (aapm) 2002 recommendation of beam quality for all tube settings on any focal spot size and kvp.13 the average performance in collimator tests for all the x-ray machines showed shifts of mirror position, or collimator position in the tube head. there was therefore a possibility of scatter radiation affecting image contrast. x-ray equipment performance can be improved by training, establishing a qa programme and not relying on qc tests performed by service and maintenance engineers alone. the tld reader must perform within permissible limits to ensure accurate and reliable results. the esd range in this study was 0.41 mgy 28.6 mgy, with an associated corresponding error limit of 0.04% and 1.5% respectively (see table ii). although the minimum detectable dose of <0.05 mgy was not achieved for the tld reader used, the results were comparable with iaea (2004) dosimetry system requirement of 5% standard deviation per tld batch and <30% for dose measurements at 0.1 mgy.6 chest examination was the least compliant with international drls. the non-compliance was attributed to imaging technique and poor equipment performance. the lumbar spine and pelvis examinations were compliant with international drls but they constituted the highest proportion of patient dose. this reveals a new perspective of optimisation that can be exploited. the use of high kvp radiographic technique and standard focus-to-film distance can help to attain optimum imaging range at all the hospitals concerned. this optimisation process can be enhanced by maintaining optimal device performance, promoting the use of local drls, continuous image quality assessment, and sound selection of the x-ray equipment during procurement. to facilitate such an optimisation process, documentation and analysis of patient data and technical factors (as shown in table iv) are necessary. the average estimated body depths of 22 cm for chest pa, 23 cm for lumbar spine ap, and 25 cm for lumbar spine lat did not have a significant effect on patient dose. however, the average body weight of 70 kg at hospitals 1 and 4, 71 kg at hospital 2, and 82 kg at hospital 3 had an effect on patient dose measurements. the method employed to measure patient dose was therefore fundamental in developing standard imaging techniques. it was necessary to extensively collect and analyse exposure and patient parameters to develop a quality management system commensurate with a specific radiological facility. this process would facilitate a comparison between diagnostic facilities nationally and internationally including the ec radiographic technical factors.7 it might be hampered by the absence of integrated kap meters in the x-ray equipment; inbuilt dosimeters would allow the setting of dose action levels, drls and validation of optimum image quality. the relationship between radiation exposure and image quality is essential for radiologists to institute corrective optimisation measures without any loss of clinical information. the results in fig. 4 show that, out of 542 radiographs, the scores were as follows: 63% grade a, 31% grade b and 6% grade c. the radiologists noted the additional work owing to detailed quality criteria for clinical images, and observed the variation owing to radiographic and processing techniques. sensitisation of the imaging technologist on radiological image quality factors is essential and could be adopted by hospitals as part of the quality improvement process. a nationwide study could provide results that could be adopted by imaging professionals for accrediting diagnostic departments. conclusions and recommendations the magnitude of patient dose due to rejects, poor equipment performance, poor radiographic techniques and equipment age can be significant. high film rejects results in unnecessary cost that can be avoided if effective quality assurance measures are in place. quality improvement processes within radiological facilities could be enhanced through accreditation of diagnostic facilities, audits and surveillance programmes. the results from the present study showed that aged x-ray equipment coupled with poor or no maintenance can have significant effects on radiographic image quality. good equipment selection, an effective qa programme, and dosimeters can ensure patient radiation protection. the use of high-speed film/screen contributes to compliance with internationally acceptable drls without compromising the diagnostic value of images. there is a need to use anatomical image quality assessment such as the ec image quality criteria during the adoption of a new imaging technique. radiological protection of patients should be an integral part of a radiological facility’s qa programme. x-ray equipment should therefore be installed with kap meters to facilitate routine patient dose measurements. developing countries such as kenya, with a minimal number of radiology experts, can achieve quality assurance through collaboration between regional hospitals and a national referral hospital where the radiology experts are based. the imaging professionals can then perform the necessary qc tests, assess the level of quality improvement, and do acceptance tests on imaging equipment. acknowledgements we sincerely thank the ministry of health, management and radiology staff of all the private and public facilities who agreed to participate in the iaea project (raf/9/033 – strengthening radiological protection of patient and medical exposure control), the national council for science and technology and the international atomic energy agency for their support. 1. international commission on radiological protection. data for protection against ionizing radiation from external sources. bethesda, usa: icrp report 21, publication 60, 1990. 2. hart d, hillier mc, wall bf. commentary: national reference doses for common radiographic, fluoroscopic and dental x-ray examinations in the uk. bjr 2009;82:1-12. 3. american college of radiology standards. reston: acr, 2002:413-416. 4. united nations report of the united nations scientific committee on the effects of atomic radiation, to the general assembly. new york, usa: unscear 2000, volume i. 5. international commission on radiological protection, radiological protection and safety in medicine. icrp publication 73. oxford: pergamon press, 1996. 6. international atomic energy agency. optimization of the radiological protection of patients undergoing radiotherapy, fluoroscopy and computed tomography. vienna: iaea, 2004. 7. european commission. european guidelines on quality criteria for diagnostic radiographic images. ec report 16260. luxembourg: ec, 1996. 8. diagnostic x-ray imaging committee; aapm task group no. 8. standardized methods for measuring 78 sa journal of radiology • september 2011 original article diagnostic x-ray exposures: aapm report 31. college park, md: american association of physicists in medicine, 1990. 9. environment protection authority. registration requirements and industry best practice for ionizing radiation apparatus used in diagnostic imaging. radiation guidelines; test protocols for parts 2 5. sydney: epa, 2000. 10. united nations report of the united nations scientific committee on the effects of atomic radiation, to the general assembly; volume i. new york: unscear, 1993. 11. muhogora we, ahmed na, almosabihi a, et al. patient doses in radiographic examinations in 12 countries in asia, africa, and eastern europe: initial results from iaea projects. ajr 2008;190:1453-1461. 12. international atomic energy agency. radiation doses in diagnostic radiology and methods for dose reduction. tecdoc 796. vienna: iaea, 1995. 12. diagnostic x-ray imaging committee; aapm task group no. 12. quality control of diagnostic radiology. no. 74. college park, md: american association of physicists in medicine, 2002. sa journal of radiology • september 2011 79 review article pseudomyxoma peritonei (pmp) – a rare entity zaeem i ebrahim, mb bch zarina i lockhat, ffrad (d) (sa) farzanah ismail, fcrad (d) (sa) department of radiology, university of pretoria corresponding author: z ebrahim (zaeem@iafrica.com) pseudomyxoma peritonei (pmp) is a rare complication of mucinous tumours of appendiceal or ovarian origin that results in peritoneal and omental implants. in addition to the appendix and the ovary, other rare sites of apparent origin of pmp have been reported. these include the colon, stomach, gallbladder, pancreas, urachus, urinary bladder, uterine corpus, fallopian tube, breast and lung.1-3 pmp is also known as ‘jelly belly’ or ‘gelatinous ascites’.2 clinical findings and complications while the exact pathogenesis of pmp is controversial, clinical morbidity and mortality results from the fact that copious amounts of extracellular and peritoneal mucin cause distortion and loss of function of visceral organs.3 subsequent unrelieved compression can lead to adhesions and further morbidity, including small-bowel obstruction, renal or caval obstruction, and death. because of the viscous, gelatinous and septated nature of the mucus, it cannot be drained by paracentesis. impending bowel obstruction, renal compromise and discomfort may be relieved by repeated laparotomy for debridement of the mucin and subsequent decompression of the viscera. ronnett et al. first described a widely accepted and useful definition of pmp into three pathological subtypes with different pathological characteristics and different prognoses: disseminated peritoneal adenomucinosis (dpam) which remains potentially non-invasive and abstract pseudomyxoma peritonei (pmp) is a rare complication of mucinous tumours of appendiceal or ovarian origin that results in peritoneal and omental implants. clinical morbidity and mortality arise from the fact that copious amounts of extracellular and peritoneal mucin result in distortion and loss of function of visceral organs. therapeutic paracentesis is not possible because of the nature of the mucin. currently, new techniques are being used to attempt to debulk the mucin volume; none, however, has lead to superior outcome. 1a 1b fig. 1. multiple complex cystic masses of fat density in the peritoneum (1a), and characteristic scalloping of the liver and spleen margins (1b). sajr 26-1_2022_contents.indd http://www.sajr.org.za open access table of contents original research paediatric minor head injury applied to paediatric emergency care applied research network ct recommendations:  an audit jacques du plessis, sharadini k. gounden, carolyn lewis south african journal of radiology | vol 26, no 1 | a2289 | 14 april 2022 original research diagnostic accuracy and inter-reader reliability of the mri liver  imaging reporting and data system (version 2018) risk stratification  and management system ranjit singh, mitchell p. wilson, florin manolea, bilal ahmed, christopher fung, darryn receveur, gavin low south african journal of radiology | vol 26, no 1 | a2386 | 19 may 2022 original research appropriateness of imaging modality choice by doctors at the  kenyatta national hospital’s accident and emergency  department salman s. ahmed, callen k. onyambu, eunice omamo, alfred odhiambo south african journal of radiology | vol 26, no 1 | a2367 | 29 june 2022 original research a 6-year audit of public-sector mr utilisation in the western cape  province of south africa yusuf parak, razaan davis, michelle barnard, amanda fernandez, keith cloete, matodzi mukosi, richard d. pitcher south african journal of radiology | vol 26, no 1 | a2464 | 22 july 2022 original research the effectiveness of the pregnancy adapted years algorithm to  safely identify patients for ct pulmonary angiogram in pregnant  and puerperal patients suspected of having pulmonary  embolism riaan potgieter, piet becker, farhana suleman south african journal of radiology | vol 26, no 1 | a2454 | 29 july 2022 original research stereotactic breast biopsies: radiological-pathological  concordance in a south african referral unit natasha alexander, ilana viljoen, susan lucas south african journal of radiology | vol 26, no 1 | a2463 | 26 august 2022 original research temporal trends in ultrasound utilisation in the radiology  department of a tertiary hospital nwabisa siyeka, michelle da silva, richard d. pitcher south african journal of radiology | vol 26, no 1 | a2449 | 29 august 2022 original research diagnostic yield and accuracy of paediatric image-guided fine  needle aspiration biopsy of deep organ tumours tichayedza bondera, pawel schubert, anel van zyl, richard pitcher, asif bagadia south african journal of radiology | vol 26, no 1 | a2485 | 28 september 2022 51 58 64 68 74 80 89 96 page i of iii table of contents editorial ‘techtorial’: changing paradigms maya patel south african journal of radiology | vol 26, no 1 | a2571 | 19 december 2022 original research chest radiography evaluation in patients admitted with confirmed  covid-19 infection, in a resource limited south african isolation hospital sereesh moodley, tanusha sewchuran south african journal of radiology | vol 26, no 1 | a2262 | 17 january 2022 original research an audit of ct brain findings in adults with new-onset seizures in  a resource restricted setting in south africa sabelo h. mabaso, deepa bhana-nathoo, susan lucas south african journal of radiology | vol 26, no 1 | a2294 | 20 january 2022 original research ct pulmonary angiography findings in hiv-infected patients  referred for suspected pulmonary thrombo-embolic disease diane wiese, leisha rajkumar, susan lucas, david clopton, jacob benfield, jason deberry south african journal of radiology | vol 26, no 1 | a2273 | 31 january 2022 original research fatal non-accidental injury in south africa: a gauteng hospital’s  perspective on the incidence and fracture types in post-mortem  skeletal surveys robyn m. wessels, halvani moodley south african journal of radiology | vol 26, no 1 | a2311 | 22 february 2022 original research a retrospective review of ct pulmonary angiogram confirmed  pulmonary emboli in covid-19 patients admitted to groote  schuur hospital, cape town petri ahlers, mariam q. said-hartley south african journal of radiology | vol 26, no 1 | a2280 | 28 february 2022 original research concurrent cranial and cervical spine injuries by associated injury  mechanisms in traumatic brain injury patients pilasande hlwatika, timothy c. hardcastle south african journal of radiology | vol 26, no 1 | a2321 | 24 march 2022 original research an audit of the adequacy of contrast enhancement in ct pulmonary angiograms in a south african tertiary academic hospital setting derik j. basson, halvani moodley south african journal of radiology | vol 26, no 1 | a2350 | 24 march 2022 original research a digital audit of emergency upper gastrointestinal fluoroscopy  workflow in children with bilious vomiting bradley c. messiahs, richard d. pitcher south african journal of radiology | vol 26, no 1 | a2300 | 30 march 2022 1 2 9 16 22 29 34 39 45 vol 26, no 1 (2022) issn: 1027-202x (print)  |  issn: 2078-6778 (online)south african journal of radiology http://www.sajr.org.za open access table of contents original research radiation induced cataracts in interventionalists occupationally  exposed to ionising radiation andré rose, william i.d. rae, margaret a. sweetlove, lumko ngetu, mohamed a. benadjaoud, wayne marais south african journal of radiology | vol 26, no 1 | a2495 | 30 september 2022 original research differentiation between various types and subtypes of intracranial  meningiomas with advanced mri mousam panigrahi, narendra k. bodhey, saroj k. pati, nighat hussain, anil k. sharma, arvind k. shukla south african journal of radiology | vol 26, no 1 | a2480 | 26 october 2022 original research spontaneous bleeding in covid-19: a retrospective experience of an  italian covid-19 hospital mirko trentadue, plinio calligaro, gianluigi lazzarini, fabio bonomi boseggia, elena residori, jennifer hu, silvana vanti, linda lillo, giovanna varischi, roberto cerini south african journal of radiology | vol 26, no 1 | a2509 | 31 october 2022 review article a review of teleradiology in africa – towards mobile teleradiology  in nigeria mohammed y. tahir, maurice mars, richard e. scott south african journal of radiology | vol 26, no 1 | a2257 | 11 january 2022 case report spinal chloroma – herald of blast crisis in a patient with chronic  myeloid leukaemia: a case report stuti chandola, m. sarthak swarup, radhika batra, alpana manchanda south african journal of radiology | vol 26, no 1 | a2286 | 27 january 2022 case report a case of carotid web: cause of stroke in healthy and  young patients sanjay m. khaladkar, darshana dilip, rahul arkar, vijetha chanabasanavar, purnachandra lamghare south african journal of radiology | vol 26, no 1 | a2291 | 28 january 2022 case report otosyphilis: a rare cause of acute bilateral sensorineural  hearing loss in a hiv-negative patient johan sothmann, shaun adam, gideon van tonder, razaan davis, leon janse van rensburg south african journal of radiology | vol 26, no 1 | a2351 | 29 march 2022 case report primary giant cell tumour of the breast with recurrence:  a rare case report farhana e. suleman, moipone n. vilakazi, meshack bida, richard edwards south african journal of radiology | vol 26, no 1 | a2393 | 20 april 2022 case report sellar spine: a rare bony variant of the sella turcica luke d. metelo-liquito, thandi e. buthelezi south african journal of radiology | vol 26, no 1 | a2371 | 28 april 2022 105 112 121 130 139 144 148 153 157 case report diagnosing rare intraductal biliary neoplasms – intraductal  papillary neoplasm of the bile duct: a case report with  typical imaging findings saumya pandey, nitin agarwal, vidushi gupta, ashok sharma, anil aggarwal, sunita gupta, ram krishan south african journal of radiology | vol 26, no 1 | a2387 | 29 april 2022 case report cervical extension of pancreatic pseudocyst: an unusual cause  of neck stiffness and dysphagia sneha harish c, rashmi dixit, sapna singh, anjali prakash south african journal of radiology | vol 26, no 1 | a2385 | 09 may 2022 case report factor xiii deficiency in a neonate presenting as subpial  haemorrhage monish g. karthikeyan, poojitha ronda, prabhu c. sugumaran south african journal of radiology | vol 26, no 1 | a2344 | 20 may 2022 case report a rare case of tuberous sclerosis complex-associated renal  cell carcinoma humphrey mapuranga, bianca douglas-jones, danelo du plessis, camilla e. le roux, christel du buisson, shahida moosa south african journal of radiology | vol 26, no 1 | a2406 | 20 may 2022 case report a case report of multinodular hepatic steatosis mimicking  pseudotumors of the liver pavel burko, nitin juggath, ruslan iliasov, mariya fedorova, natalia nazarova south african journal of radiology | vol 26, no 1 | a2410 | 27 june 2022 case report a lumpy bumpy stomach: the more the murkier binit sureka, siddhi chawla, sudeep khera, ashish agarwal, chhagan l. birda, sandeep bairwa south african journal of radiology | vol 26, no 1 | a2437 | 28 june 2022 case report a case of leiomyosarcoma of the ovarian vein with obstructive  uropathy and hepatic metastasis sanjay m. khaladkar, tejvir singh, karthik mohanan, rajesh kuber, satvik dhirawani south african journal of radiology | vol 26, no 1 | a2501 | 28 october 2022 case series revisiting the forgotten remnant: imaging spectrum of meckel’s  diverticulum manish kumar, priya singh, priti kumari, rohit kaushik south african journal of radiology | vol 26, no 1 | a2431 | 19 july 2022 case series scar endometriosis: looking beyond the diagnosis -  a case series stuti chandola, anju garg south african journal of radiology | vol 26, no 1 | a2493 | 29 november 2022 160 165 169 173 178 183 187 191 197 page ii of iii http://www.sajr.org.za open access table of contents case series imaging of the neurological manifestations of dengue:  a case series varsha rangankar, divyajat kumar, rajesh kuber, tushar kalekar south african journal of radiology | vol 26, no 1 | a2528 | 29 november 2022 case series case discussions of missed traumatic fractures on computed  tomography scans amy j. spies, maryna steyn, desiré brits, daniel n. prince south african journal of radiology | vol 26, no 1 | a2516 | 30 november 2022 204 214 correction corrigendum: radiology subspecialisation in africa: a review of  the current status efosa p. iyawe, bukunmi m. idowu, olasubomi j. omoleye south african journal of radiology | vol 26, no 1 | a2347 | 30 june 2022 reviewer acknowledgement south african journal of radiology | vol 26, no 1 | a2575 | 20 december 2022 221 222 page iii of iii editorial � sa journal of radiology • june 2007 health sciences is leading the way with its plans to improve the registrar success rates in the mmed. apart from the research techniques course offered within the department of radiology, the faculty is planning two comprehensive courses on protocol preparation, ethics, research methodology, data analysis, report writing and editing. the courses will be held at chris hani baragwanath hospital and the faculty and should start in about august. they will be offered as a set or as individual courses. radiology registrars should keep an eye open for the notices! during november we host our annual health graduates re-union and the seminar this year (saturday 10 november 2007) is on imaging. seems radiology is becoming a leader in research in this faculty! the sajr is improving its profile and horizons all the time as we want to be indexed so that we can be available online, i.e. on pubmed, and we will therefore have an impact factor (if). the if is an american invention, started in the 1950s by the institute of scientific information (isi) of philadelphia, pennsylvania.1,2 the if is often used to assess the quality of a journal or article. the if of a journal is determined by the number of times a particular journal is cited over a given period – usually a 3-year period.2 although the if has created controversy in many circles, one has to bear in mind that in some countries it is used to evaluate grant applications, staff promotions, job applications, and bonuses.3,4 the controversies are largely based on inherent biases in the system which include english language preference; review articles (being more citable than case reports, so if a journal does not publish case reports it automatically becomes more citable, e.g. the american journal of radiology); free journals – for obvious reasons; longer articles; and of course the poor yield of citations from regional journals with highly specialised topics, for example antarctic science.1,5 basic science journals usually carry a high impact factor (nature has an if of 27.0740), whereas the clinical journals less so. at present the if of radiology is 3.899, the ajnr 1.556, paediatric radiology 0.8, and the samj 0.794.5 once a journal applies to be included in the isi database, there are a few criteria that are scrutinised. these include: (i) regularity of publication; (ii) profile of the editorial team; (iii) whether the journal is peer-reviewed; and (iv) the relevance and topicality of the contents.1 so by applying to be indexed we do leave ourselves vulnerable to a flawed system – but a system that is used relatively often, and that has international recognition. it is important that the if does not become all-consuming, and that the if of a journal or the if of an individual’s research be approached with caution, and not be the sole criterion in assessing the quality of a journal or a researcher. this issue of the sajr includes an original article from dr steven braude and the lambert group of the mrc/uct research unit for exercise science and sports medicine, who have concluded that plain radiographs alone are not ideal or accurate enough to identify age cheats in sport. dr vicci du plessis, a radiology registrar from petermaritzburg, together with professor savvas andronikou, has just completed a pilot study investigating criteria used when selecting radiology registrars for the teaching circuit. their preliminary findings are that academic credentials and work experience are key criteria for the selection of radiology registrars in south africa, and that a marked racial misrepresentation still prevails (this should silence the ever-sceptic critics – and not only in sydney!). professor vinay sharma of the johannesburg hospital radiation oncology unit compared barium and gastrograffin swallows for use in radiation therapy planning in patients with carcinoma of the oesophagus, and found barium to be more cost effective. dr humza carim, a first-year radiology registrar from johannesburg, together with the chris hani baragwanath hospital interventional radiology department, has described our experiences with bronchial artery embolisation for massive haemoptysis. there is also a case report with a review of the literature from professor sheldon wiebe, a paediatric radiologist from saskatoon university, saskatchewan, canada. he describes the radiographic and prenatal ultrasound features of perinatal lethal hypophosphatasia and its differentiation from osteogenesis imperfecta type ii. this broad spectrum of submissions, as well as international submissions, bodes very well for the future of the sajr. we have a second guest editor for this issue, professor merryll vorster, the previous head of psychiatry, with extensive legal and ethics experience, and who is now the vice dean of the faculty of health sciences, university of the witwatersrand. thank you kindly! 1. nayak bk. the enigma of impact factor. indian j ophthalmol 2006; 54:225-226. 2. impact factor of journals in alphabetical order. www.bioscience.org/services/impact15.htm-64k (last accessed 1 may 2007). 3. martyn c. the malign influence of impact factors. j r soc med 2005; 98:556. 4. ha tc, tan sb, soo kc. the journal impact factor: too much of an impact? ann acad med singapore 2006; 35: 911-916. 5. journal impact factors. www.sciencegateway.org/impact/-5k (last accessed 1 may 2007). the future impact of the sajr mala modi, mb chb, fcrad (sa), mmed division of radiology, department of radiation sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg mala modi guest editor hello from the faculty of health sciences, wits! professor merryll vorster, vice-dean faculty of health sciences, university of the witwatersrand, johannesburg do not let sleeping dogs lie!! pg2.indd 2 6/13/07 9:18:29 am case report case report 96 sa journal of radiology • december 2007 case report abstract the term superficial siderosis is used to describe the haemosiderin deposition on the surface of the brain, spinal cord, brainstem and cranial nerve leptomeninges following recurrent subarachnoid haemorrhage. the concern is the cytotoxic nature of the haemosiderin on the underlying tissue causing slow but progressive and irreversible neurological dysfunction. removal of the source of bleeding has little effect on the progression of clinical deterioration but halting the chronic subarachoid haemorrhage will reduce the iron load in the csf and hence the cytotoxic risk. we present a case of superficial siderosis presenting with hearing loss and cerebellar signs highlighting the imaging findings. introduction superficial siderosis describes the hemosiderin deposition on the surface of the brain, brainstem, cranial nerves and spinal cord following recurrent subarachnoid haemorrhage. the diagnosis can be made on mri. the gradient echo sequence (gre) best demonstrates the haemosiderin deposition on the surface of the brain1 and should prompt one to search for the cause of haemorrhage in order to prevent the irreversible neurotoxic effects on the underlying cortex. case report this 44-year-old patient presented with a history of night sweats and malaise. he was observed to be inco-ordinate, had weakness of the left leg and changes in speech. of significance is a history of two episodes of sudden loss of consciousness 6 months previously. he complained of hearing loss in his left ear. on examination, he had upper limb cerebellar signs of intention tremor and disdiadocokinesis. he was also ataxic, demonstrated heel to shin ataxia, broad-based gait and was unable to tandem walk. the rhomberg test was negative. the hearing loss was determined to be of the sensorineural type. superficial siderosis of the central nervous system mayuri govind, mb chb, fcrad diag (sa) department of radiology, inkosi albert luthuli central hospital, durban j maharajh, mb chb, fc rad diag (sa), mmed department of radiology, nelson r mandela school of medicine, and university of kwazulu-natal, durban figs 1 and 2. mri t2w axial images demonstrating hypointense lining along the pial surface of the cerebellum indicative of haemosiderin deposition and brainstem. pg96-98.indd 96 12/13/07 12:46:45 pm case reportcase report laboratory investigations were normal including full blood count, iron studies, clotting profile, thyroid function test and erythrocyte sedimentation rate. his cerebrospinal fluid (csf) was xanthochromic and contained abundant red blood cells. the mri scans are diagnostic of superficial siderosis of the brain and spinal cord (figs 1-5). there is ‘staining’ or lining of the meningeal surface of predominantly the cerebellum, brainstem and cord, but this may also include the sylvian fissures more superiorly. this is seen on t1, t2 and gradient echo sequences. magnetic resonant angiography (mra) and magnetic resonant venography (mrv) were normal. no intraparenchymal haemorrhage was noted. discussion the term superficial siderosis is used to describe the haemosiderin deposition on the surface of the brain, spinal cord, brainstem and cranial nerve leptomeninges1 following recurrent subarachnoid haemorrhage. patients present with a triad of progressive bilateral sensorineural hearing loss (95%), cytotoxic consequences on the cerebellum of limb and gait ataxia and myelopathy.2 all three occur in only 39% of patients with the sensorineural hearing loss most commonly manifested.3 it leaves the patient almost totally deaf. later, severe dementia, anosmia, bladder disturbance (26%) and hyperreflexia (24%) occur. our patient presented with cerebellar dysfunction and hearing loss. as with all acute subarachnoid haemorrhage (sah), the csf demonstrates increased protein (100%) and is xanthochromic (75%) but can be normal as chronic subarachnoid haemorrhage can occur intermittently.3 the eighth cranial nerve is commonly affected as it has a long segment exposed to csf4 and is particularly well lined by myelin that is supported by haemosiderin-sensitive microglial cells. in addition, the eighth cranial nerve lies in the pontine cistern which is a large pool of csf subjected to greater csf flow. the result is greater axonal damage. the same theory applies to the susceptibility of the olfactory nerves to increased iron load. the second cranial nerve is entirely within the cns and is thus spared from the damaging effects of this process. this occurs three times more commonly in males and has a broad age range (14-77 years) of presentation. the cause of the recurrent sah is determined on imaging in only 50% of cases3 and includes dural pathology, postsurgical csf cavity with neovascularity, bleeding central nervous system (cns) tumours (ependymoma, oligodendroglioma and astrocytoma), vascular malformations (arteriovenous malformations and cavernous malformation near the brain’s surface), aneurysms, and in the spinal cord – tumours, arteriovenous malformations and traumatic nerve root avulsion.2 pathologically there is brown discoloration of the leptomeninges of the cerebellum (especially the vermis), basal frontal lobe, olfactory bulb, temporal cortex, brainstem, cranial nerves, spinal cord, nerve roots, ependyma and subpial tissue of < 3 mm deep.1 the vermis of the cerebellum is particularly susceptible due to its close anatomical relation to the roof of the fourth ventricle and the compartmentalisation of csf, therefore resulting in consistent increased exposure to csf contents. mri can be used to make the diagnosis of superficial siderosis. the mri gre is the most sensitive,1 and demonstrates thick dark signal lining the nervous system surfaces as a susceptibility artifact due to haemosiderin. this shows no enhancement. because of the paramagnetic nature of haemosiderin, t1and t2-weighted sequences demonstrate a blackened surface.5 the seventh and eighth cranial nerves appear darker and thicker than normal. fluid attenuated inversion recovery (flair) imaging suggests the diagnosis as the darker surface of the cns and should prompt one to perform the gre sequence.3 once the diagnosis is made a search for the cause is indicated and includes contrast administration, mra if an aneurysm is suspected and whole spine mri. the role of mri is in the diagnosis of superficial siderosis, in terms of the easy detection of blood degradation products by gre compared with computed tomography (ct), detecting a potentially treatable condition and avoiding unnecessary searches for other causes of hearing loss and ataxia. ct scan is relatively insensitive to the haemosiderin and may be suggested by a slightly hyperdense rim over the brain surface 97 sa journal of radiology • december 2007 figs 3 and 4. mri gre axial sequence confirms the blood degradation products seen as hypointensity along the pial surface of the sylvian fissures bilaterally. `blooming´ of the hypo-intense lining of the brainstem is present when compared to the t2 images. pg96-98.indd 97 12/13/07 12:46:45 pm case report case report 98 sa journal of radiology • december 2007 if the iron load is heavy.3 it may demonstrate vermian atrophy and the underlying bleeding source. the differential diagnosis includes: mri sequence artifact seen on some but not all sequences, normal or abnormal surface veins, neurocutaneous melanosis or meningioangiomatosis.1 neurocutaneous melanosis is a congenital syndrome consisting of benign pigmented cell tumour of the leptomeninges. it is suggested by the presence of a large congenital melanocytic nevus. meningoangiomatosis is a rare benign focal lesion of the cerebellum and underlying cortex. the locality of the lesion, mixed signal characteristics and occasional contrast enhancement differentiates it from the diffuse nature of superficial siderosis. treatment is to treat the source of bleeding. there has been little success with iron or copper chelators as sole therapy.4 conclusion the imaging findings of superficial siderosis are a reflection of the recurrent subarachnoid haemorrhage. careful inspection of the brain surface on t2 and flair should prompt one to further imaging with gre, contrast administration and mra. 1. osborn ag, blaser si, salzman kl, et al. diagnostic imaging: brain. manitoba: amirsys, 2004. 2. feamley jm, stevens jm, rudge p. superficial siderosis of the central nervous system. brain 1995; 118: 1051-1066. 3. levy m, turtzo c, llinas rh. superficial siderosis: a case report and review of the literature. nature clinical practice neurology 2007; 3: 54-58. 4. ushio m, lwasaki s, sugasawa k, et al. superficial siderosis causing retrolabyrinthine involvement in both cochlear and vestibular branches of the 8th cranial nerve. acta oto-laryngologica 126; 9: 997-1000. 5. messori a, di bella p, herber n, et al. the importance of suspecting superficial siderosis of the central nervous system in clinical practice. j neurol neurosurg psychiatry 2004; 75: 188-190. fig. 5. mri sagittal t2w image demonstrating hypointensity on the pial surface of the spinal cord indicative of haemosiderin deposition. pg96-98.indd 98 12/13/07 12:46:46 pm case report 66 sa journal of radiology • september 2010 abstract we were recently intrigued by a baby born at kalafong hospital with fused lower extremities resembling a mermaid, which caused us to search for the background and origin of this entity called sirenomelia. case report a 40-year-old woman delivered a baby at 36 weeks with fused lower limbs. there was no maternal history of ingestion of teratogenic agents or diabetes mellitus. initial x-rays (figs 1 and 2) showed fused feet, lower limbs with 2 tibiae, 2 femurs and a single fibula. there was a single femoral head and incomplete development of the pelvis with absent acetabulum, ischium and pubic bones. the neonate did not survive this lethal abnormality and died a few hours after birth. the parents declined a postmortem examination. discussion mermaids or sirens have been part of the cultural tradition of sailors since the earliest maritime expeditions in the western world. the siren myth was recorded for the first time by homer, who described in the odyssey alluring singing creatures that lured sailors to their deaths.1 the etymology of the word ‘siren’ is unclear; it may derive from the greek seirios (hot, weak), seira (rope) or seirazein (to bind – because sirens ‘bind’ sailors to them).1 the origin in latin and other languages centres on serene, from the word ‘serenus’ (without cloud, clear), implying the peaceful sea on which sirens usually appeared.1 historical texts of around 2 500 bc found in several european countries include references to female hybrids.1 it can be assumed that these creatures were probably individuals affected by sirenomelia, which is a rare and lethal congenital anomaly characterised by rotation and fusion of the lower extremity with medial position, fusion or absence of the fibulas, and abnormalities of the lumbar and sacral spines.1-3 other abnormalities include imperforate anus, renal agenesis or dysgenesis, internal genital organ agenesis except for the gonads, absent or hypoplastic renal arteries, oligohydramnios and presence of aberrant vasculature. there are 3 known variants of the different degrees of lower extremities fusion: mermaid baby n khan, mb bs, fcrad (d) f ismail, mb bch, fcrad (d) i van de werke, mb bch, dmrd, frcr h j m gongxeka, mb chb department of radiology, kalafong hospital and university of pretoria fig. 1. photo’s of a siren with fused lower limbs. case report 68 sa journal of radiology • september 2010 1. symelia apus: no feet are present and the limbs are completely fused into a single limb; one femur and one tibia are present. 2. symelia unipus: one foot is present (a partial fusion of both feet), 2 femurs, 2 tibiae and 2 fibulae.1 our case partially fits into this category. 3. symelia dipus: two feet are present giving the appearance of fins, hence the term ‘mermaid fetus’ for this condition. the fusion of the limbs extends only as far as the ankles. the embryological and pathological causes of the condition occur before the 4th week to the structures derived from the caudal mesodermal axis of the embryo, extended to various cranio-caudal levels.1,4-6 various teratogenic agents, maternal diabetes, caudal regression syndrome and nutritional deficit have been suggested as possible aetiological factors.1,2 it was previously thought that caudal regression syndrome and sirenomelia were manifestations of the same syndrome, but it seems that syrenomelia is the result of vascular steal phenomenon that causes severe ischaemia of the caudal portion of the fetus.1,2 prenatal diagnosis is possible in the first trimester with the important role of colour and power doppler to estimate vascular abnormalities including aberrant ileal vessels, abnormal small abdominal aorta, and two-vessel umbilical cord.1-3 in rare cases of surviving neonates, angiography, ct and mri can also be used to document anatomical findings. although syrenomelia has been described as a rare lethal pattern of congenital anomalies, 9 mermaid cases surviving after reconstructive surgery have been reported.1 the most important characteristic that seems to allow survival of the affected individuals is the presence of a functional kidney. our patient only survived for a few hours after birth, implying possible other severe anomalies of the internal organs. 1. romano s, esposito v, fonda c, russo a, grassi r. beyond the myth: the mermaid syndrome from homeus to andersen a tribute to hans christian anderson’s bicentennial of birth. eur j radiol 2006;58:252-259. 2. akabyir o, gunorduk k, gulkilik a, ark c. first trimester diagnosis of sirenomelia: a case report and review of literature. arch gynecol obstet 2008;278:589-592. 3. ladure h, d’herve d, loget p, poulain p. prenatal diagnosis of sirenomelia. j gynecol obstet biol reprod 2006;35:181-185. 4. taghavi mm, jafari n, shariati m, morteza zf. sirenomelia (mermaid syndrome): an infant from parents who used a special form of snuff. pakistan journal of biological science 2009;12:722-725. 5. langer b, stoli c, nicolau r, gasser b, schlaeder g. sirenomelia and situs inversus: case report and review of literature. fetal diagn ther 1996;11:79-84. 6. sivridis e, giatromanolaki a, androulakis i, hatzmichael a, anastasiadis p. sirenomelia in uneventful pregnancy. clin exp obstet gynecol 2002;29:140-142. fig. 2. antero-posterior radiographs of the upper chest and abdomen and the lower extremities show complete fusion of the lower limbs and feet with 2 femurs, 2 tibiae and a single fibula. there is fusion of both feet, which partially concurs with symelia limbus. note also the dysgenesis of the pubic and ischial bones and agenesis of the sacrum. sajr 652 a semi-automated method for measuring thickness and white matter integrity of the corpus callosum s andronikou, b s spottiswoode, n tomazos   department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg s andronikou, mb bch, fcrad, frcr, phd   mrc/uct medical imaging research unit, department of human biology, university of cape town; and department of radiology, stellenbosch university b s spottiswoode, phd   faculty of commerce, department of management studies, university of cape town n tomazos, ba corresponding author: s andronikou (docsav@mweb.co.za) aim. diseases affecting cerebral white matter may lead to left-right asymmetries and atrophy of interhemispheric connections, i.e. the corpus callosum (cc). our aim was to describe and test a semi-automated system that divides the midline cc into a number of segments and determines thickness at each, then performs fibre tracking from these segments. methods. six normal female volunteers (average age 25.8 ± 6.7 years) and a female patient with diagnosed multiple sclerosis (age 26 years) were scanned on a 3t mri. we performed diffusion-weighted imaging in 12 directions, and calculated diffusion tensors and fractional anisotropy (fa) maps from this pre-processed data. fibre tracking from a region-of-interest encompassing the entire cc was done. this fibre data, together with fa maps and the unweighted diffusion tensor imaging (dti) image (b = 0 s/mm2), were imported into a custom tool written in matlab. the midline sagittal position was carefully defined by selecting multiple midline points in coronal and axial views and rotating the image volume and fibre co-ordinates accordingly. using the customised tool, dorsal and ventral cc contours were manually drawn on the mid-sagittal fa image, initiating automated calculation of a contour midway between these manually drawn lines. the programme was designed to then divide the midline contour into a pre-selected number of segments; from each segment border, perpendicular spokes were projected until they intersected with the dorsal and ventral contours. this technique divided the cc into a pre-set amount of segments, the number of which was limited by the spatial resolution. it was decided to set the number at 40 to ensure that each segment depicted a contiguous strip of voxels across the cc from the dorsal to the ventral contour. the system allows these segments to then be used as seeds for separate fibre tracking in each cerebral hemisphere, and various parameters are automatically plotted as a function of distance along the midline contour. the following parameters are measurable: midline cc thickness; midline fa; fibre volume for each hemisphere (represented as a left/right ratio centred on zero) and mean fibre fa for each hemisphere (also represented as a left/right ratio centred on zero). results. the tool proved successful in measuring and plotting cc midline thickness and fa, but was not sensitive for peripheral white matter lesions. conclusions. the technique successfully determined values of cc midline thickness, fa and interhemispheric differences. future research will determine normal values for age and compare cc thickness with peripheral white matter volume loss in large groups of patients, using the semi-automated technique.  s afr j rad 2012;16(4):130-133. doi:10.7196.sajr.652 many diseases affect human brain white matter, multifocally or diffusely, in adults and children. these may be metabolic (e.g. leigh’s disease), toxic (e.g. carbon monoxide poisoning), hypoxic (e.g. hypoxic ischaemic injury), infective (e.g. hiv or syphilis), inflammatory (e.g. multiple sclerosis) or vascular (e.g. microvascular dementia). two important conditions that result in significant loss of global white matter volume in affected children are hypoxic ischaemic injury and hiv encephalopathy. these diseases result in the thinning of associated fibre bundles and may be reflected by atrophy of inter-hemispheric connections – most importantly the corpus callosum (cc) (fig. 1). a b c d fig. 1(a and b). a child with a normal volume of peri-ventricular white matter on (a) axial t2-weighted imaging and (b) the corresponding corpus callosum thickness expected on the sagittal image. fig. 1(c and d) demonstrates a child with a previous global hypoxic insult affecting the brain and resulting in marked white matter volume loss. this is best appreciated on the axial t2-weighted image (c) by the depth of the sulci, which abut the ventricular edge. the corresponding sagittal image (d) shows easily identifiable thinning of the corpus callosum in response to this extreme white matter volume loss. a simple automated method of determining normal values of the cc according to age is desirable. a tool which is also applicable for diagnosing white matter disorders and offering prognosis in children with global white matter insults will have a wide clinical application. this article describes a semi-automated system that divides the midline cc into a number of segments, determines thickness at each, and performs fibre tracking from these segments. methodology six normal female volunteers (average age 25.8 ± 6.7 years) and a 26-year-old female patient with diagnosed multiple sclerosis (ms) were scanned on a 3t mri system (magnetom allegra, siemens, erlangen). informed consent was obtained and protocols were approved by the stellenbosch university ethics committee. diffusion-weighted imaging was performed in 12 directions with a b-value of 1 000 sec/mm2, and one volume was acquired with b = 0 sec/mm2. other parameters included: • field of view (fov) = 240 mm • spatial resolution = 1.9 x 1.9 mm2 • slice thickness = 1.9 mm • matrix size = 128 x 128 pixels • slices = 75 • tr = 10 400 ms • te = 86 ms. five identical acquisitions were taken, and were averaged after eddy correction and outlier rejection. co-registration was then performed across the 5 averages using affine transformations, with the unweighted image of the first average as a reference. diffusion tensors and fractional anisotropy (fa) maps were then calculated from these pre-processed data. from a region-of-interest encompassing the entire cc, fibre tracking was done using fibre assignment by continuous tracking (fact) in dtistudio (jiang and mori, johns hopkins university, 2007). the fa tract initiation and termination threshold was 0.2, and the principle eigenvector angle stopping criterion was 70°. extraneous fibres, such as those projecting down into the spinal cord, were removed. this fibre data, together with fa and the unweighted diffusion tensor imaging (dti) image (b = 0 s/mm2), were imported into a custom tool written in matlab (the mathworks inc, natick, ma). the midline sagittal position was carefully defined by selecting multiple midline points in coronal and axial views, and rotating the image volume and fibre co-ordinates accordingly. using the customised tool, dorsal and ventral cc contours were manually drawn on the mid-sagittal fa image. this initiated the automated calculation of a contour midway between the manually drawn lines. the programme was designed to then divide the midline contour into a pre-selected number of segments, from the borders of which perpendicular spokes were projected until they intersected with the dorsal and ventral contours. this in turn divided the cc into a pre-set number of segments (fig. 2). the number of segments was limited by the spatial resolution, and it was decided that having 40 segments would ensure that each one still contained a contiguous strip of voxels across the cc from the dorsal to the ventral contour. fig. 2. semi-automated division of the corpus callosum into multiple intervals along a midline contour. the corpus callosum superior (red) and inferior (blue) contours were drawn manually by the user on the sagittal dti image. the midline contour (green) was calculated automatically using the software, and lines perpendicular to the midline were extended (again automatically) until they intersected with the manual contours. these perpendiculars offer the measures of corpus callosum thickness at several locations and also serve as seeds for fibre tracking. with this system, the segments can be measured (representing the cc thickness at several locations) and used as seeds for fibre tracking separately in each cerebral hemisphere (fig. 3). the various parameters are automatically plotted as a function of distance along the midline contour. the following parameters are measurable: • midline cc thickness • midline fa • fibre volume for each hemisphere (represented as a left/right ratio centred on zero) • mean fibre fa for each hemisphere (also represented as a left/right ratio centred on zero). a b fig. 3. fibre tracking can be performed for all the regions simultaneously and is colour-coded by distance along the midline contour (a) or for isolated regions as selected by the user (b). results fig. 4 shows the various parameters successfully determined from the ms patient, plotted as a function of normalised distance along the cc midline, with the splenium to the left and the genu to the right. the dotted lines provide a normal range (defined as the mean ± 1 standard deviation of the corresponding parameters) successfully determined from the 6 normal subjects. to simplify interpretation but still preserve the trend details, these normal bounds have been smoothed using a 6th order polynomial. fig. 4. the result of the semi-automated system is a battery of automatically generated graphs, plotting patient parameters as a function of the normalised distance along the corpus callosum midline (demonstrated here for the patient with multiple sclerosis). (a) corpus callosum thickness; (b) fibre volume (left/right-1); (c) mean fibre fa (left/right-1); and (d) midline fa. the dotted lines in (a) indicate corresponding mean ± 1 standard deviation values for the 6 normal subjects’ corpus callosum thickness. discussion the cc is the main inter-hemispheric commissure of the brain. it plays a role in unifying sensory fields, organising bimanual motor output, aiding memory storage and retrieval, allocating attention and arousal, facilitating language and auditory functions, and in consciousness itself.1 for pathologists and radiologists alike, however, the ability to evaluate the volume and integrity of white matter has been notoriously elusive. now, dti fibre tracking, and dti-derived metrics such as fa, provide a means for measuring and demonstrating white matter features.2 dti fibre tracking can be used to associate known anatomical landmarks (such as the cc) with regions where localisation may be ambiguous (such as off-midline, or peripheral, hemispheric white matter).3 the midline sagittal view of the cc has been parcellated in a variety of ways according to both structural geometry and function.4-8 dti fibre tracking has already been used in this context to segment the cc into bands corresponding to structural and functional units.9-11 cc thickness in the sagittal plane has been shown to be associated with a variety of factors including better motor performance12 and with verbal iq and fluency.13 the cc thickness may be secondarily affected by fibre loss,12 as seen in children after severe hypoxic ischaemic injury, hiv encephalopathy or large infarcts. the semi-automated system that we designed (as described above) was tested successfully and allowed measurement of midline cc, midline fa, mean fibre fa for each hemisphere and fibre volume for each hemisphere for all 7 adults. these were plotted by the system as graphs demonstrating the ability to determine ranges of normal values. this would be suitable for use in children, to determine age-related differences in myelin maturation and volume. the technique can now also be used to compare cc thickness with hemispheric brain volume in both normal children and those with cerebral atrophy, such as seen with hypoxic ischaemic injury and hiv encephalopathy. observations can then be correlated with functional scores and used for predicting outcome and function. in addition, cases in which patients with hiv are receiving antiretroviral therapy can be followed up to determine if the patients regain white matter volume and cc thickness. for the patient with ms, we anticipated a thinning of the cc or decrease in midline fa. a previous study by dorion et al. 14 shows the total size of the cc in females to be unrelated to hemispheric asymmetry. in our patient, differences in cc thickness (fig. 4a) were too large to be accounted for by differences in midline contour length. although regional decreases in fa in normal-appearing white matter have been shown in the cc of ms patients15 , there is no clear indication thereof in fig. 4b. on a macro-scale, a healthy brain is largely symmetrical across the mid-sagittal plane.16 however, the ratio of grey to white matter is smaller in the right hemisphere than in the left,17 and numerous regional interhemispheric asymmetries have also been identified.17-21 of these inter-hemispheric differences, regions that the cc fibres are likely to cross include frontal areas (where the right volume is greater than the left) and occipital areas (where the left volume is greater than the right). even with rough estimations of the location of the frontal and occipital regions, these differences are not apparent in the normal ratios in fig. 4c. fig. 4d shows a more consistent hemispheric bias, suggesting that the left hemispheric cc fibres have a consistently greater fa than the corresponding fibres in the right hemisphere. this is compatible with the theory that the left hemisphere is focally organised, whereas the right is more diffusely organised.22 a voxel-based asymmetry analysis, using fa images, also identified several regions in the cc where fa was greater in the left hemisphere than in the right.23 the fa provides a convenient measure of macro-axonal organisation and its integrity, and there is histological evidence suggesting that regional axonal loss in the cc correlates with peripheral white matter lesion volume and distribution.24 conclusions our study aims to provide a semi-automated means of evaluating peripheral white matter volume and integrity using inter-hemispheric tract symmetry and features measured at the midline cc as a surrogate marker. the technique has been tested on an ms patient and 6 normal, healthy volunteers. the tool has proven that it can be used to determine normal values including the thickness and fa of the cc, as well as differential hemispheric white matter fibre volume at several locations. the tool shows good promise for measuring the cc thickness and plotting abnormal patients against a calculated normal range. future work planned will compare cc thickness, measured using this technique, with brain volume (segmented into white matter and grey matter) in an attempt to use cc thickness as an indicator of white matter volume loss in children with hiv and hypoxic ischaemic injury. acknowledgements. we thank siemens medical solutions south africa and all the staff at the cape universities brain imaging centre. 1. giedd jn, rumsey jm, castellanos fx, et al. a quantitative mri study of the corpus callosum in children and adolescents. de brain res 1996;91(2):274-280. 1. giedd jn, rumsey jm, castellanos fx, et al. a quantitative mri study of the corpus callosum in children and adolescents. de brain res 1996;91(2):274-280. 2. beaulieu c. the basis of anisotropic water diffusion in the nervous system – a technical review. nmr biomed 2002;15:435-455. 2. beaulieu c. the basis of anisotropic water diffusion in the nervous system – a technical review. nmr biomed 2002;15:435-455. 3. berman ji, mukherjee p, partridge sc, et al. quantitative diffusion tensor mri fibre tractography of sensorimotor white matter development in premature infants. neuroimage 2005;27(4):862-871. 3. berman ji, mukherjee p, partridge sc, et al. quantitative diffusion tensor mri fibre tractography of sensorimotor white matter development in premature infants. neuroimage 2005;27(4):862-871. 4. witelson sf. hand and sex differences in the isthmus and genu of the human corpus callosum. brain 1989;112:799-835. 4. witelson sf. hand and sex differences in the isthmus and genu of the human corpus callosum. brain 1989;112:799-835. 5. hynd gw, semrud-clikeman m, lorys ar, et al. corpus callosum morphology in attention deficit-hyperactivity disorder: morphometric analysis of mri. j learn disab 1991;24:141-146. 5. hynd gw, semrud-clikeman m, lorys ar, et al. corpus callosum morphology in attention deficit-hyperactivity disorder: morphometric analysis of mri. j learn disab 1991;24:141-146. 6. rajapakse jc, gieff jn, rumsey jm, et al. regional mri measurements of the corpus callosum: a methodological and developmental study. brain dev 1996;18:379-388. [http://dx.doi.org/10.1016/0387-7604(96)00034-4] 6. rajapakse jc, gieff jn, rumsey jm, et al. regional mri measurements of the corpus callosum: a methodological and developmental study. brain dev 1996;18:379-388. [http://dx.doi.org/10.1016/0387-7604(96)00034-4] 7. denenberg vh, kertesz a, cowell pe. a factor analysis of the human’s corpus callosum. brain res 1991;548(1-2):126-132. 7. denenberg vh, kertesz a, cowell pe. a factor analysis of the human’s corpus callosum. brain res 1991;548(1-2):126-132. 8. peters m, oeltze s, seminowicz d, et al. division of the corpus callosum into subregions. brain cogn 2002;50:62-72. 8. peters m, oeltze s, seminowicz d, et al. division of the corpus callosum into subregions. brain cogn 2002;50:62-72. 9. dougherty rf, ben-shachar m, deutsch g, et al. occipital-callosal pathways in children: validation and atlas development. ann ny acad sci 2005;1064:98-112. 9. dougherty rf, ben-shachar m, deutsch g, et al. occipital-callosal pathways in children: validation and atlas development. ann ny acad sci 2005;1064:98-112. 10. hofer s, frahm j. topography of the human corpus callosum revisited – comprehensive fibre tractography using diffusion tensor magnetic resonance imaging. neuroimage 2006;32(3):989-994. 10. hofer s, frahm j. topography of the human corpus callosum revisited – comprehensive fibre tractography using diffusion tensor magnetic resonance imaging. neuroimage 2006;32(3):989-994. 11. hasan km, kamali a, iftikhar a, et al. diffusion tensor tractography quantification of the human corpus callosum fibre pathways across the lifespan. brain res 2009;1249:91-100. 11. hasan km, kamali a, iftikhar a, et al. diffusion tensor tractography quantification of the human corpus callosum fibre pathways across the lifespan. brain res 2009;1249:91-100. 12. skranes j, vangberg tr, kulseng s, et al. clinical findings and white matter abnormalities seen on diffusion tensor imaging in adolescents with very low birthweight. brain 2007;130:654-666. [http://dx.doi.org/10.1093/brain/awm001] 12. skranes j, vangberg tr, kulseng s, et al. clinical findings and white matter abnormalities seen on diffusion tensor imaging in adolescents with very low birthweight. brain 2007;130:654-666. [http://dx.doi.org/10.1093/brain/awm001] 13. yung a, poon g, qiu dq, et al. white matter volume and anisotropy in preterm children: a pilot study of neurocognitive correlates. pediatr res 13. yung a, poon g, qiu dq, et al. white matter volume and anisotropy in preterm children: a pilot study of neurocognitive correlates. pediatr res 14. dorion aa, chantôme m, hasboun d, et al. hemispheric asymmetry and corpus callosum morphometry: a magnetic resonance imaging study. neurosci res 2000;36(1):9-13. 14. dorion aa, chantôme m, hasboun d, et al. hemispheric asymmetry and corpus callosum morphometry: a magnetic resonance imaging study. neurosci res 2000;36(1):9-13. 15. hasan km, gupta rk, santos rm, wolinsky js, narayana pa. diffusion tensor fractional anisotropy of the normal-appearing seven segments of the corpus callosum in healthy adults and relapsing remitting multiple sclerosis patients. j magn reson imaging 2005;21(6):735-743. 15. hasan km, gupta rk, santos rm, wolinsky js, narayana pa. diffusion tensor fractional anisotropy of the normal-appearing seven segments of the corpus callosum in healthy adults and relapsing remitting multiple sclerosis patients. j magn reson imaging 2005;21(6):735-743. 16. joshi s, lorenzen p, gerig g, bullitt e. structural and radiometric asymmetry in brain images. med image anal 2003;7:155-170. [http://dx.doi.org/10.1016/s1361-8415(03)00002-1] 16. joshi s, lorenzen p, gerig g, bullitt e. structural and radiometric asymmetry in brain images. med image anal 2003;7:155-170. [http://dx.doi.org/10.1016/s1361-8415(03)00002-1] 17. petty rg. structural asymmetries of the human brain and their disturbance in schizophrenia. schizophr bull 1999;25:121-139. 17. petty rg. structural asymmetries of the human brain and their disturbance in schizophrenia. schizophr bull 1999;25:121-139. 18. galaburda am, lemay m, kemper tl, geschwind n. right-left asymmetries in the brain. science 1978;199:852-856. 18. galaburda am, lemay m, kemper tl, geschwind n. right-left asymmetries in the brain. science 1978;199:852-856. 19. shapiro r, galloway sj, shapiro md. minimal asymmetry of the brain: a normal variant. am j roentgenol 1986;147(4):753-756. 19. shapiro r, galloway sj, shapiro md. minimal asymmetry of the brain: a normal variant. am j roentgenol 1986;147(4):753-756. 20. iwasaki s, nakagawa h, fukusumi a, et al. left-right asymmetry of the temporal and parietal regions in children: based on the medullary pattern of cerebral white matter. surg radiol anat 1990;12:209-214. 20. iwasaki s, nakagawa h, fukusumi a, et al. left-right asymmetry of the temporal and parietal regions in children: based on the medullary pattern of cerebral white matter. surg radiol anat 1990;12:209-214. 21. watkins ke, paus t, lerch jp, et al. structural asymmetries in the human brain: a voxel-based statistics analysis of 142 mri scans. cereb cortex 2001;11(9):868-877. 21. watkins ke, paus t, lerch jp, et al. structural asymmetries in the human brain: a voxel-based statistics analysis of 142 mri scans. cereb cortex 2001;11(9):868-877. 22. semmes j. hemispheric specialisation: a possible clue to mechanism. neuropsychologia 1968;6:11-26. [http://dx.doi.org/10.1016/0028-3932(68)90035-3] 22. semmes j. hemispheric specialisation: a possible clue to mechanism. neuropsychologia 1968;6:11-26. [http://dx.doi.org/10.1016/0028-3932(68)90035-3] 23. park h, westin c, kubicki m, et al. white matter hemisphere asymmetries in healthy subjects and in schizophrenia: a diffusion tensor mri study. neuroimage 2004;23(1):213-223. 23. park h, westin c, kubicki m, et al. white matter hemisphere asymmetries in healthy subjects and in schizophrenia: a diffusion tensor mri study. neuroimage 2004;23(1):213-223. 24. evangelou n, konz d, esiri mm, et al. regional axonal loss in the corpus callosum correlates with cerebral white matter lesion volume and distribution in multiple sclerosis. brain 2000;123:1845-1849. 24. evangelou n, konz d, esiri mm, et al. regional axonal loss in the corpus callosum correlates with cerebral white matter lesion volume and distribution in multiple sclerosis. brain 2000;123:1845-1849. 18 sa journal of radiology • march 2011 pictorial interlude gorlin syndrome – an incidental radiographic detection introduction gorlin-goltz syndrome (also known as nevoid basal cell carcinoma syndrome) was first reported in 1894, but described by gorlin and goltz in 1960 as a distinct entity consisting of ectodermal and mesodermal abnormalities.1 it is an hereditary autosomal dominant disease with a prevalence estimated in various studies to be between 1/57 000 and 1/256 000, and a male:female ratio of 1:1.2 we describe in brief the important radiological features of an accidentally detected case of gorlin syndrome in the form of a pictorial interlude. case report a 28-year-old abnormally tall man with forwardly displaced teeth presented to us. as part of pre-treatment evaluation, a panoramic radiograph was made. well-defined cyst-like radiolucent areas which were associated with impacted third molars were observed in all quadrants of the jaw (fig. 1). evoking suspicion of a syndrome, a thorough general examination was performed. the patient had long, slender, fused fingers and toes, and multiple naevi measuring 2 3 mm over the skin. a chest radiograph revealed t1 splitting fusion and forking of the 3rd and 4th right ribs (figs 2 and 3). a hand-wrist radiograph showed localised gigantism of the 2nd and 3rd digits with flexion deformity at the proximal metacarpo-phalangeal joints and soft fig. 1. panoramic view showing cyst-like radiolucencies in all quadrants of the jaws. note also impacted 3rd molars associated with the radiolucencies. fig. 2. cropped section of chest radiograph showing abnormal rib splitting. fig. 3. cropped section of chest radiograph showing forking of the 4th thoracic rib. shishir ram shetty, mds department of oral medicine and radiology, ab shetty memorial institute of dental sciences, mangalore, india k m veena, mds laxmikanth chatra, mds prashanth shenai, mds prasanna kumar rao, mds department of oral medicine and radiology, yenepoya dental college, deralakatte, mangalore jagadish chandra, mds department of oral and maxillofacial surgery, yenepoya dental college sa journal of radiology • march 2011 19 pictorial interlude tissue syndactyly of the 4th and 5th fingers, with fusion of the terminal phalanges. alignment deformity of the distal interphalangeal joints of the 2nd and 3rd fingers was also observed (fig. 4). radiography of the feet revealed soft-tissue syndactyly of the 2nd and 3rd toes bilaterally and a bone island on the proximal phalanx of the big toe (fig. 5). based on these clinical and radiological findings, a diagnosis of gorlin syndrome was made. no evidence of calcification of falx cerebri was detected during the ct scan. surgical excisions of the cysts were performed under general anaesthesia. histopathological examination of the excised specimens revealed features of odontogenic keratocyst. the patient did not agree to surgical correction of the finger and toe deformities. unfortunately, he could be followed up for only 6 months, during which time no relapse was observed. discussion gorlin syndrome (also known as gorlin-goltz syndrome) is a condition characterised by multiple odontogenic keratocysts, basal cell carcinoma, congenital skeletal abnormalities, cleft lip and/or palate, and eye anomalies. various low-frequency neoplasms, such as meningiomas and ovarian and cardiac fibromas, have been also reported.3 our patient presented with features of multiple keratocysts in all quadrants of the jaw, skin and skeletal abnormalities, so fulfilling 2 major and 1 minor criteria.4 keratocysts are present in 90% of cases of gorlin syndrome, and are most commonly seen in the molar-ramus areas.5 similar areas were involved in our case. rib and finger abnormalities are noticed in 30 40% of cases.6 similar findings were detected in our case. our case highlights the key radiological features in the form of a pictorial interlude. 1. gorlin rj, goltz rw. multiple nevoid basal-cell epithelioma, jaw cysts and bifid rib: a syndrome. n engl j med 1960;262:908-912. 2. lo muzio l. nevoid basal cell carcinoma syndrome (gorlin syndrome). orphanet j rare dis 2008;25(3):32. 3. evans dg, ladusans ej, rimmer s, et al. complications of the naevoid basal cell carcinoma syndrome: results of a population based study. j med genet 1993;30:460-464. 4. kimonis ve, mehta sg, digiovanna jj, et al. radiological features in 82 patients with nevoid basal cell carcinoma (nbcc or gorlin) syndrome. genet med 2004;6(6):495-502. 5. muzio l, nocini p, bucci p, et al. early diagnosis of nevoid basal cell carcinoma. j am dent assoc 1999;130(5):669-674. 6. muzio l, nocini p, bucci p, et al. nevoid basal cell carcinoma syndrome. clinical findings in 37 italian affected individuals. clin genet 1999;55(1):34-40. fig. 4. hand-wrist radiograph showing bony fusion of the terminal 4th and 5th terminal phalanges. fig. 5. radiograph showing soft-tissue fusion of 2nd and 3rd toes. note too bone island on the big toe. sajr 936 oncology imaging: diagnosis s k misser,1 mb chb, fc rad (d) sa; d d royston,1 mb bch, ff rad (sa); l v heslop,2 mb chb, ffrad t (sa) 1 lake smit and partners, durban, south africa 2 oncologist, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) we congratulate drs vanesha naidu of king edward viii hospital, durban, and ayesha mitha of inkosi albert luthuli central hospital, durban, for their excellent diagnoses, for which they share the award of r1 000 from the rssa. drs misser et al. elaborate below on the images and findings. please refer to pages 74 76 of the june 2013 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/view/890/724) for the presenting details (recent onset personality change, depression and cognitive impairment) and the investigative images. diagnosis imaging and findings the current imaging undertaken for new-onset neurological symptoms is superimposed on a background of long-standing neoplastic disease. the clinical context in this patient is therefore of great importance to the diagnosis. the brain mr images (figs 1 3) demonstrate abnormal increased t2-weighted and flair hyperintensity in the medial temporal lobes, particularly on the left side, including the hippocampal formation and amygdala. there is corresponding subtle t1-weighted shortening in the left limbic structures but no significant post-gadolinium enhancement (fig. 4), which favours an inflammatory/encephalitic process over neoplastic/metastatic disease. his prior imaging studies (figs 5 13) show extensive intra-abdominal lymphadenopathy, predominantly involving retroperitoneal (para-aortic, interaortocaval, paracaval) and juxtarenal groups. all nodal masses demonstrate restricted diffusion on the diffusion b1000 study (fig. 10) and corresponding adc shortening (fig. 11). there is evidence for metastatic disease including: • right lung base nodular parenchymal deposit (fig. 8) • left pleural effusion and sub-pleural nodular metastasis (fig. 12) • bony metastases to the thoracolumbar vertebral bodies d11, l1 and l2 (figs 5 7) • hepatic parenchymal lesions in both lobes (figs 9 13). hepatocyte-specific contrast mri shows the metastatic lesions as hypo-intense non-enhancing foci on a background of homogenously enhancing liver parenchyma. most of them demonstrate restricted diffusion as well. note the low signal ovoid focus within the lumen of the contrast opacified ivc (fig. 13) owing to intracaval tumour invasion. the combination of distant haematogenous and regional nodal metastases, also seen on the sagittal lumbar spine mri (figs 5 7), in a young male patient is most probably due to a testicular germ cell tumour. lymphoma is a plausible differential diagnosis. the current neurological presentation is due to paraneoplastic limbic encephalitis. the patient was treated with salvage chemotherapy and, on follow-up imaging, the nodal masses were noted to be much smaller, the hepatic metastases had cleared completely, the limbic encephalitis changes had resolved, and there was normalisation of tumour markers. at relook laparotomy, the remaining para-aortic nodes were noted to be irresectable. his future management will depend on monitoring of the tumour markers. if there is a rapid elevation in levels, then chemotherapy will be re-introduced. if there is a gradual increase, localised small fields of radiotherapy will be applied to the residual metastatic nodes. discussion paraneoplastic syndromes are rarely encountered in clinical practice. the relationship between tumours and distant organ symptomatology not attributable to direct tumour effect or metastasis has been described over a century ago. these syndromes represent a distant manifestation of neoplasia on an auto-immune basis. the paramalignant syndromes are divided into paraneoplastic neurological syndromes (pns) and non-neurological syndromes. here we will focus on pns as it is relevant to the patient presented. the pathophysiology of pns is complex (fig. 1 in this diagnosis). during early neoplasm development, apoptotic cells become phagocytosed by dendritic cells and are transported to lymph node stations. there, the dendritic cells induce a cascade of humoral and cell-mediated responses including the activation of t-lymphocytes and b-cells. the b-cells mature into plasma cells and produce antibodies against a tumour-specific antigen in an attempt to destroy it. there are, however, instances where the cytotoxic t-lymphocytes and antibodies produced by the body cross-react with normal tissues and destroy them. depending on the auto-antibody formed, immune cross-reactivity occurs with destruction of normal tissue, and symptoms relevant to that organ system will manifest. in pns, one of the components of the nervous system (table 1) will be involved owing to immune cross-reactivity by the produced onco-neural antibodies. fig. 1 describes the combined auto-immune response resulting in destruction of neuromuscular junction in the lambert-eaton myaesthenic syndrome. the same principle applies to the other pns subtypes. fig. 1. pathophysiology of pns with activated cd-8 lymphocyte and plasma cell induced cell-mediated and humoral immune reaction to neural tissue resulting in target organ damage. (reproduced with kind permission of dr j b posner.) an increasing number of onconeural antibodies have been identified in patients with pns, including anti-hu, anti-cv2, anti-ma and anti-ta (ma2), among several others.1 anti-ta (ma2) typically occurs in young men with testicular germ cell tumours (including extragonadal sites). paraneoplastic limbic encephalitis (pnle) was first described by corsellis et al.2 in 1968. patients with pnle may present with subacute personality change, major depression, irritability, amnesia and convulsions. some patients can progress to dementia. the diagnosis of pnle depends on several related criteria, as outlined in table 2. radiological imaging by mri has become an integral component in making this profound clinical diagnosis. on flair and t2-weighted imaging, abnormal shortening resulting in hyperintensity is usually documented in the temporobasal regions, especially the limbic structures including the hippocampus and amygdala. the main differential diagnosis for these mri changes is herpes simplex encephalitis, the presentation of which is more acute. in many instances, the flair sequence may be the only contributory sequence depicting the medial temporal lobe abnormality. gultekin et al.3 showed absence of t2-weighted abnormalities in 43% of their series of patients. corresponding t1-weighted low signal may be seen and post-gadolinium enhancement is generally absent. isolated cases demonstrating post-contrast t1-weighted enhancement of the limbic structures have been documented. in clinical practice, the radiologist is usually the first to raise the alarm that a paraneoplastic phenomenon is suspected, and correlation with other criteria for pnle follows. generally, these patients respond well to immunotherapy and treatment of the underlying malignancy.1 follow-up imaging to document clearing of the medial temporal lobe abnormality is recommended. the radiologist therefore plays a pivotal role in the diagnosis and follow-up of these patients. 1. darnell rb, posner jb. paraneoplastic syndromes involving the nervous system. new engl j med 2003;349:1543-1554. [http://dx.doi.org/10.1056/nejmra023009] 1. darnell rb, posner jb. paraneoplastic syndromes involving the nervous system. new engl j med 2003;349:1543-1554. [http://dx.doi.org/10.1056/nejmra023009] 2. corsellis ja, goldberg gj, norton ar. “limbic encephalitis” and its association with carcinoma. brain 1968;91(3):481-496. [http://dx.doi.org/10.1093/brain/91.3.481] 2. corsellis ja, goldberg gj, norton ar. “limbic encephalitis” and its association with carcinoma. brain 1968;91(3):481-496. [http://dx.doi.org/10.1093/brain/91.3.481] 3. gultekin sh, rosenfeld mr, voltz r, eichen j, posner jb, damau j. paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumour association in 50 patients. brain 2000;123:1481-1494. [http://dx.doi.org/10.1093/brain/123.7.1481] 3. gultekin sh, rosenfeld mr, voltz r, eichen j, posner jb, damau j. paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumour association in 50 patients. brain 2000;123:1481-1494. [http://dx.doi.org/10.1093/brain/123.7.1481] s afr j rad 2013;17(3):117-118. doi:10.7196/sajr.936 156 sajr december 2012 vol. 16 no. 4 cpd questionnaire regarding the semi-automated method for measuring thickness and white matter integrity of the corpus callosum: 1. diseases affecting cerebral white matter may lead to left-right asymmetries and atrophy of interhemispheric connections, i.e. the corpus callosum. 2. the technique successfully determined values of corpus callosum midline thickness and interhemispheric differences. 3. future research is not likely to determine normal values for age, but will be able to compare corpus callosum thickness with peripheral white matter volume loss in large groups of patients, using the semiautomated technique. regarding sialoblastomas: 4. sialoblastomas are rare salivary gland neoplasms that present congenitally or during early infancy, with significant variability in histological range and clinical course. 5. the term ‘sialoblastoma’ was coined by taylor to describe these lesions because it conveyed the dysontogenetic character and the site of the tumour. 6. these tumours uncommonly originate in the parotid gland. 7. they may arise in the submandibular or minor salivary gland. with regard to varicose veins: 8. varicose veins is one of the most common diseases in the world. 9. routine surgical intervention is no longer the principal definitive management for large, unsightly varicose veins. 10. a sub-group of patients develop recurrent varicose veins post surgery or atypical varicose veins. 11. conventional venography is no longer considered the gold standard of venous imaging. rice body formation: 12. is a common complication of rheumatoid arthritis. 13. rice body formation can also occur without any underlying systemic disorder. 14. ct is the modality of choice for discriminating this pathology from synovial chondromatosis. osteogenesis imperfecta: 15. is a heterogeneous group of genetic bone disorders. 16. is characterised by decreased bone mass, increased bone fragility and susceptibility to fractures. 17. the severe, perinatal lethal form (type ii) (omim 166210) is characterised by bone fragility, with perinatal fractures, severe bowing of long bones, undermineralisation, and death in the perinatal period due to renal failure. regarding free intraperitoneal air: 18. rigler’s sign was first described in 1941 by l g rigler as a new radiological sign for recognising free air in the peritoneal cavity on supine radiograph. 19. the presence of pneumoperitoneum allows free intra-peritoneal air to be contrasted with intraluminal gas, accentuating the wall of gascontaining viscera. 20. the football sign was first described by frik du preez in 1965. mark each numbered statement as true or false. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/027/10/2011 we are pleased to announce that effective from this issue, the number of ceus per test has been increased to 5. radiation protection.html radiation protection and the safe use of x-ray equipment: laws, regulations and responsibilities charles p herbst, phd department of medical physics, university of the free state, bloemfontein gerhard h fick, dcl department of private law, university of the free state corresponding author: c herbst (gnbich@ufs.ac.za) background. south africa’s regulatory framework for electromagnetic medical devices has come under considerable criticism. here it is reviewed in terms of how it has given form to protective measures against ionising radiation. the hazardous substances act provides for effective protection against radiation, but has been undermined by poor administration and uncertainty about regulations and licensing conditions. the legal weight of enforcing licensing conditions through a website without proper consultation with all parties concerned is questionable and ineffective. effective and legal radiation control is possible by activating the national advisory committee on electronic products, provided for in regulation r326 published in 1979, but this has never been implemented. the possible impact of annual quality assurance tests currently enforced through licensing conditions on radiation dosage to the population is not cost-effective, as new training and accreditation structures have to be created. conclusions. that more than 80% of overexposures are generally caused by human error is a clear indication that training of the regular users of x-ray equipment should be emphasised, and not the training and accreditation of the technicians responsible for a single quality assurance test per year. constructive engagement with the professional bodies involved in the medical use of x-rays through a national advisory committee on electronic products may be a cost-effective solution for lowering radiation dosage to the population. s afr j rad 2012;16(2):50-54. author’s note: since completion of this article, the licencing conditions have been changed again and, moreover, been removed from the website of the department of health, and are now on an independent website at http://sites.google.com/site/radiationcontroldoh. revising the article in its current form to take these developments into account will lengthen it and delay its publication; but its principle message – an appeal for implementing an advisory body, as statutorily provided for – is yet further strengthened. introduction it has been recognised since early studies on x-rays that exposure to high levels of radiation may cause tissue damage, and that chronic exposure to lower levels of radiation may result in cancer. however, the use of x-rays is part and parcel of the fight against disease and plays an indispensable role in clinical management of patients. the annual worldwide number of x-ray procedures has been rapidly increasing, from 1.9 billion in 2000 to 3.1 billion in 2008.1 over the same period, the annual collective dose to the world’s population increased from 2.4 msv to 4 msv. today, electromagnetic radiation from medical procedures constitutes the single largest manmade means by which people encounter radiation exposure.2 protection against the medical use of radiation is therefore even more important than protection against any other source of radiation. the innovative use of radiation, and specifically x-rays, imposes risks if inadequately controlled by suppliers, users and government. concerns about the possible effects of exposure to radiation on the human body were raised to a high level during the 1980s and 1990s, culminating in several international studies3 that proposed basic safety standards to control and limit exposure to such radiation.4 the department of health (doh) in south africa has, through its directorate: radiation control (drc), adopted these standards and applied excerpts as legal requirements and guidelines. in addition, the minister of health, and specifically the director-general: national health and population development (dg), are mandated to administer the hazardous substances act of 1973 by granting, suspending or revoking licences to importers, manufacturers and users of electromedical products (x-rays).5 the licence is issued if the product and usage comply with legislative and international requirements for safety and performance. however, in november 2010, the doh briefed the parliamentary health portfolio committee that the administration of south africa’s regulatory framework for electromagnetic medical devices was under considerable pressure as its technical and managerial competence was impugned by inadequate and insufficiently qualified personnel6 – fewer even than in botswana. accordingly, it is the aim of this review to determine whether south africa has in place a sound legislative framework and effective regulatory infrastructure for guaranteeing the safe application of radiation and radioactive substances. this will be done by firstly looking at how the legislature has given form to protective measures against ionising radiation and, secondly, discussing the application in practice of group iii hazardous substance control and the shortcomings of the regulatory infrastructure. lastly, recommendations and a possible future path are set out. the legal framework for radiation control in south africa: an historical and critical appraisal south africa is considered to have had a relatively ‘good’ system of electro-medical device regulation in place, which started in 1971. the legislative control of electronic products was for the first time introduced by the public health amendment act of 19717 that added section 133a to the public health act of 1919, allowing the minister of health to make regulations mandating the secretary of health to grant, suspend and revoke licences in respect of electronic products and prescribe conditions and requirements for the categories of electronic products, premises and persons in control of the equipment. comprehensive regulations (regulation r1332) concerning the use of x-ray equipment in terms of the 1971 amendment act were made in 1973.8 these regulations pertaining to group iii hazardous substances are still in force, although some uncertainty prevailed after the whole of section 133a along with the amendment act of 1971 (and by implication also regulation r1332) were specifically repealed by section 32(1) of the hazardous substances act, 1973. superficially viewed, the uncertainty was reinforced when almost all of the public health act of 1919 and the whole of the public health amendment act of 1971 were for a second time repealed, this time by section 63(1) of the health act of 1977,9 which in turn was abrogated partially by the national health act of 2003,10 omitting any reference to radiation control whatsoever. however, section 32(2) of the hazardous substances act revived regulation r1332 indirectly, deeming the latter to have been made under its own reserved capacity. hazardous substances act and regulations the hazardous substances act (1973)11 prohibits and controls the importation, manufacture, sale, use, operation, application, modification, disposal or dumping of substances and (electronic) products that may hurt or kill human beings by reason of their detrimental direct or side effects. the act classifies such substances and products in groups according to the degree of danger. the minister of health, by one of only two ruling regulations issued in terms of section 29 of the hazardous substances act, listed electronic products (x-rays) to be a group iii hazardous substance.12 the act empowers the dg to grant, refuse, amend, suspend or revoke a licence for the use of x-ray equipment.13 these powers may be delegated in writing to ‘any officer of the department of health’.14 current practice is that these powers are executed by the directorate of radiation control (drc), but no such authority has been bestowed (by any statutory stipulation) on the drc. in fact, the drc is not a juristic person and has no locus standi or legal capacity to take decisions, issue licences, determine conditions or function on its own. the common idea that the drc is the ‘regulatory authority’ is not only wrong, but also without legal foundation. section 3(1)c of the act prohibits anybody to ‘… install or keep installed any group iii hazardous substance on any premises … otherwise than subject to the conditions prescribed or determined [author’s emphasis] by the director-general.’15 the definition of ‘prescribed’ in section 1 of the act stipulates that ‘prescribed’ means prescribed by regulations. it is only fair and transparent if conditions are subject to a process of regulatory consultation. such a procedure allows public and interest group scrutiny before the final notification is published in the government gazette. if the dg (or delegate) should ‘determine’ the conditions without a consultation processes, it may create uncertainty and reinforce the idea of unfair coercion. there is, however, a time-consuming and probably less effective legislative escape for the licence holder. if a person is aggrieved by the decision or condition imposed by the dg, such person may appeal to the minister.16 notwithstanding that there are no regulatory prescripts regarding inspections, inspectors are appointed and have powers prescribed by sections 8 and 9 of the hazardous substances act. in an effort to overcome the insufficient number of inspectors (12 posts in south africa for more than 6 500 licence holders and 16 000 x-ray machines!),17 the drc granted permission to inspection bodies (ibs) to perform the required acceptance and annual quality assurance tests of equipment. although the intention was that only south african national accreditation system (sanas)-accredited companies would be approved as an ib, no official reference to this policy could be found. in general, the control and sale of listed electronic products are satisfactorily regulated in south africa by regulations r690 of 1989 and r1302 of 1991. as mentioned above, the use of listed electronic products is regulated by die-hard regulation r1332 as well as additional restrictions imposed by licencing conditions. licensing conditions for medical x-ray equipment users current practice of the drc when a licence is issued is to attach licensing conditions as an annexure to the licence, which usually refers to only two conditions directly but to more conditions indirectly. the annexure does not contain the licencing conditions, but refers the licence holder to documents containing the licensing conditions on the doh website. these web-based documents therefore possess legal authority as licence requirements, but may change without further notice to the licence holder. the first licensing condition, namely the code of practice for users of medical x-ray equipment 18 (hereinafter code of practice) (note that the url on the document is wrong as it has changed since the last revision), is based on recommendations of the australian radiation protection and nuclear safety agency, recommendations (1991, 1996, 2000) of the international commission on radiological protection (icrp), and the code of the national radiation laboratory of the new zealand ministry of health. whether the code of practice was first of all subject (if at all) to comment from the medical radiation community, followed by formal public consultation and finally approved or adopted by the dg (or delegate), is unclear. what is clear, however, is that the drc has no legal status to devise new requirements or conditions, and the fact that they had been incorporated in the code of practice would be of no consequence. furthermore, within the code of practice it is stated that ‘this code must be read in conjunction with doh guideline documents as listed in annexure a of this code.’ the guidelines annexed to the code of practice are also published on the website and consequently also form part of the licensing conditions. the second licensing condition usually attached to a licence enforces annual quality assurance according to a prescribed list, and is also listed on the website under the guidelines. weaknesses in the current legal framework and enforcement of the act poor management, insufficient staffing levels, high vacancies, outdated data for radiation sources and installations, lack of financial resources and deficient human regulatory capacity, undermine a sound radiation protection infrastructure and put the health and safety of south africans at risk. the practice of publishing licensing conditions on a website as an annexure to an annexure of the licence without a proper consultation process is questionable, and leads to ambiguities and inconsistencies in the radiation protection legislature and license requirements. potential areas of conflict include the repeal of regulations and paragraphs from regulation r 1332 (published after a consultation process) by the code of practice (published without consultation). besides the questionable legal basis of the code of practice, unpredictable and ad hoc requirements/conditions are added randomly, making license compliance uncertain and may be against basic human rights enshrined in the constitution, namely academic freedom,19 the freedom to pursue economic activities,20 and access to healthcare services. furthermore, the legal standing of the inspection body is unclear, as neither the act nor any regulations make provision for such a body. this fact may have severe consequences in cases where the results via an ib differ from those of the company responsible for maintenance of the equipment. legal pathway to the future is it fair to say that south africa has failed in almost every aspect of the iaea’s safety standards for radiation safety and infrastructure, apart from the relatively ‘good regulations’ that are in place? the constitutional dispensation the state has the obligation to take steps to acknowledge the socio-economic rights of all individuals so that they may be pursued to the optimum. these steps include legislative frameworks within which individuals can exercise their rights. the constitution specifically makes provision for the right of access to healthcare services,21 in which area the state has been extremely active.22 since 1994, more than 40 pieces of legislation have been promulgated under the auspices of the minister of health23 – yet we still rely on the outdated regulation r1332 of 1971 to protect users and patients against the serious risk of radiation effects. the revival or creation of a regulatory authority – currently and in the future in view of the inability of the doh, its division (the drc) and the dg to administer the provisions of the hazardous substances act (and regulations) effectively, it remains to be answered how the situation can be speedily turned around. the hazardous substances act provides adequate measures for ensuring public safety; but the administration of the act leaves much to be desired. the uncertainty about regulation r1332, lack of proper regulations, and discrepancies between existing regulations and licensing conditions may be addressed within a framework that has already been created, but not put into operation. the national advisory committee in terms of the hazardous substances act regulation r326 of 1979, published under this act, provides for a statutory legal entity, known as the national advisory committee on electronic products,24 but nothing has been realised. the committee was to function as, firstly, an advisory body to the dg and, secondly, as a research facility to engage with international institutions in an effort to combat the dangers associated with electronic products.25 by not instituting an informed, independent and statutory body, the valuable opportunity was lost to promote safety standards and proactive management performance. the creation of the committee, though, is still latent and remains captured in the 1979 regulation for urgent implementation. this national advisory committee on electronic products could and should play a pivotal role in all future radiation control requirements. the contemplated south african health products regulatory authority in terms of the medicines and related substances amendment act, 2008 after a relatively long, shaky and controversial beginning, the medicines and related substances amendment act of 2008 was assented to on 19 april 2009.26 although the act has yet to come into operation, the new regulator (the south african health products regulatory authority (sahpra))was expected to have started functioning in april 2012 and is destined to replace the medicines control council (mcc).27 the main aim of the act (2008) is to register medicines, products, medical devices, certain foodstuffs and cosmetics. although the definition of ‘product’28 in the 2008 act is too narrow to involve radiation equipment and sources, the definition of ‘medical device’,29 however, is broad enough to do so. in this way, the sahpra may become the regulatory authority for x-ray equipment and radioactive substances as well. recent indications are that this is precisely what is contemplated as a panacea. the radiation inspectorate is bound for absorption in some way or another into the designated sahpra under the medicines and related substances act of 1965 (as amended in 200830 ). this possible accommodation will involve a second act without any current regulations controlling the use of x-ray equipment. in view of the administrative inability of the drc to function under a single act, it is hard to foresee that the new amendment will relieve any of the problems encountered, inter alia lack of regulations, lack of a consultative process, and lack of a management system referred to above. the solution may very well lie on another level. responsible use of radiation equipment the strong enforcement of licensing conditions that were set without public consultation, and the lack of communication between the ‘regulator’ and users of radiation equipment, have created a confrontational culture. the strong enforcement of conditions may also lead to a false sense of security on the side of users, as enforcement of the restrictions of the licensing conditions is regarded as sufficient radiation control. this is counter-productive as the unfortunate reality is that approximately 80% of overexposures in radiology are caused by human error.11 , 31 the 20% of overexposures caused by faulty equipment are mostly caused by intermittent aec failure or breakdown of equipment during complex radiological procedures. if we are really concerned about exposure levels to staff, patients and the public, the problem should be addressed at source, i.e. human incompetency. the use of medical x-ray equipment should be restricted by regulation (not licensing conditions) to professionals registered with the hpcsa and appropriately trained in those aspects of imaging or therapy and safety relevant to their clinical role in order to limit overexposures caused by human error. this will bring us in line with other countries (e.g. australia,32 canada,33 the european community34 ) as well as recent recommendations by the radiological community of the united states35 that acknowledge the importance of human competency in radiation protection and where each user of a machine must be certified to do so. constructive engagement with the hpcsa and professional bodies may set the required standards and ensure that current and potential future users (surgeons, cardiologists, urologists etc.) will have the necessary skills and knowledge to perform their duties with minimal risk to patients, the public and personnel. by engaging with the professional bodies, high-risk areas can be identified. in 2008, for example, ct examinations accounted for 80% of the total norwegian population’s medical radiation exposure.36 similar trends were observed in the usa.37 by concentrating on high-risk areas, manpower can be utilised more effectively (and no increase in cost) with a marked impact on the population’s cumulative radiation dosage. the unwillingness to engage with existing professional bodies about including radiation protection as a prerequisite for registration/certification is in sharp contrast to the very active engagement with sanas for setting standards and creating a previously non-existing accreditation body that will accredit ibs. an irony is that the impact of the financial burden concentrating on quality assurance of equipment once per year may be insignificant to the radiation dose of the population at large, as equipment-related over-exposures will not be prevented nor reduced by the annual quality assurance imposed by the licensing conditions. conclusion as pointed out above, the hazardous substances act provides adequately for regulatory measures to ensure public safety, but the administration of the act leaves much to be desired. the national advisory committee on electronic products committee should be constituted by the minister as soon as possible to investigate and rectify the uncertainties and discrepancies pointed out above. the committee should include radiologists,medical physicists, radiation biologists, radiographers, the hpcsa and equipment suppliers. the constructive engagement between the drc, the hpcsa, the radiological community of south africa and other roleplayers will ensure appropriate regulations with correct terminology and unambiguous interpretation that will conform to legal requirements. by the appropriate sharing of the responsibility for radiation protection with professionals registered with the hpcsa, the burden on the understaffed directorate will also be alleviated by concentrating on high-risk areas identified and agreed upon within a properly constituted national advisory committee on radiation equipment. until that time, the danger will remain that the current situation may be legally challenged by an affected party. one might summarise the situation by saying that inadequate personnel (in numbers as well as competency) are using obsolete legislation and control measures to protect the public against the most important source of radiation. the situation will be rectified by actively engaging the trained professionals primarily and routinely responsible for radiation, under the auspices of the hpcsa, and to use their professional expertise within a national advisory committee on radiation equipment to identify the highest risk areas to be addressed by appropriate legislation and other measures. 1. united nations. unscear report 2008 (1), paragraph 41. 1. united nations. unscear report 2008 (1), paragraph 41. 2. united nations. unscear report 2008 (1), paragraph 46. 2. united nations. unscear report 2008 (1), paragraph 46. 3. the international commission on radiological protection. annals of the icrp, publication 103, 2007. 3. the international commission on radiological protection. annals of the icrp, publication 103, 2007. 4. international atomic energy agency. international basic safety standards for protection against ionizing radiation and for the safety of radiation sources. vienna: iaea, 1996. 4. international atomic energy agency. international basic safety standards for protection against ionizing radiation and for the safety of radiation sources. vienna: iaea, 1996. 5. sa government. act no 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). sections 3,4,7,8 and 24. 5. sa government. act no 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). sections 3,4,7,8 and 24. 6. pc health: briefing by directorate of radiation control on staff shortages, backlog in inspections part 1: parliamentary monitoring group. http://www.pmg.org.za/node/24306 (accessed 24 november 2011). 6. pc health: briefing by directorate of radiation control on staff shortages, backlog in inspections part 1: parliamentary monitoring group. http://www.pmg.org.za/node/24306 (accessed 24 november 2011). 7. sa government. act no 42: public health amendment act. (gn 888 in government gazette 3119 of 26/5/1971). 7. sa government. act no 42: public health amendment act. (gn 888 in government gazette 3119 of 26/5/1971). 8. sa government. regulation r1332: regulations concerning the control of electronic products. (gn r1332 in government gazette 3991 of 3 august 1973). 8. sa government. regulation r1332: regulations concerning the control of electronic products. (gn r1332 in government gazette 3991 of 3 august 1973). 9. sa government. act no 63: health act. (gn 915 in government gazette 5558 of 26/5/1977). 9. sa government. act no 63: health act. (gn 915 in government gazette 5558 of 26/5/1977). 10. sa government. act 61: national health act. (gn 869 in government gazette 26595 of 23/7/2004), section 93(1). 10. sa government. act 61: national health act. (gn 869 in government gazette 26595 of 23/7/2004), section 93(1). 11. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). 11. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). 12. sa government. regulation r1302: declaration of group iii hazardous substances (gn r1302 in government gazette 13299 of 14/6/1991). 12. sa government. regulation r1302: declaration of group iii hazardous substances (gn r1302 in government gazette 13299 of 14/6/1991). 13. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 4(1)(b), 4(5) and s 7. 13. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 4(1)(b), 4(5) and s 7. 14. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973), section 26. 14. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973), section 26. 15. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 3(1)(b) (c) and 4(1)(b). 15. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 3(1)(b) (c) and 4(1)(b). 16. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 6. 16. sa government. act 15: hazardous substances act. (gn 550 in government gazette 3834 of 4/4/1973). section 6. 17. department of health’s radiation control unit presentation. parliamentary monitoring group. http://www.pmg.org.za/files/docs/101110radiation_0.ppt (accessed 29 november 2011). 17. department of health’s radiation control unit presentation. parliamentary monitoring group. http://www.pmg.org.za/files/docs/101110radiation_0.ppt (accessed 29 november 2011). 18. code of practice for users of medical x-ray equipment. directorate radiation control. http://www.doh.gov.za/docs/forms/2010/code2.pdf (accessed 29 november 2011). 18. code of practice for users of medical x-ray equipment. directorate radiation control. http://www.doh.gov.za/docs/forms/2010/code2.pdf (accessed 29 november 2011). 19. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 16(1)(d) (accessed 30 november 2011). 19. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 16(1)(d) (accessed 30 november 2011). 20. constitution of the republic of south africa, 1996. south afican government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 22 (accessed 30 november 2011). 20. constitution of the republic of south africa, 1996. south afican government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 22 (accessed 30 november 2011). 21. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 27(1) (accessed 30 november 2011). 21. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 27(1) (accessed 30 november 2011). 22. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 27(2) (accessed 30 november 2011). 22. constitution of the republic of south africa, 1996. south african government. http://www.info.gov.za/documents/constitution/1996/96cons2.htm#16. section 27(2) (accessed 30 november 2011). 23. carstens p, pearmain d. foundational principles of south african medical law. durban: lexisnexis, 2007:229. 23. carstens p, pearmain d. foundational principles of south african medical law. durban: lexisnexis, 2007:229. 24. sa government. regulation r326: regulations to provide for the institution of a national advisory committee on electronic products. (gn r326 in government gazette 6309 vol. 164 of 23/2/1979). 24. sa government. regulation r326: regulations to provide for the institution of a national advisory committee on electronic products. (gn r326 in government gazette 6309 vol. 164 of 23/2/1979). 25. sa government. regulation r326: regulations to provide for the institution of a national advisory committee on electronic products. (gn r326 in government gazette 6309 vol. 164 of 23/2/1979). section 3.1, 3.2. 25. sa government. regulation r326: regulations to provide for the institution of a national advisory committee on electronic products. (gn r326 in government gazette 6309 vol. 164 of 23/2/1979). section 3.1, 3.2. 26. sa government. medicines and related substances amendment act (gn 434 in government gazette 32148 of 21/4/2009). 26. sa government. medicines and related substances amendment act (gn 434 in government gazette 32148 of 21/4/2009). 27. medical device registration in south africa. azary group: medical device consultants. http://arazygroup.com/medicaldeviceregistrationinsouthafrica (accessed 19 september 2011). 27. medical device registration in south africa. azary group: medical device consultants. http://arazygroup.com/medicaldeviceregistrationinsouthafrica (accessed 19 september 2011). 28. sa government. act 72: medicines and related substances amendment act. gn 434 in government gazette 32148 of 21/4/2009) section 1j. 28. sa government. act 72: medicines and related substances amendment act. gn 434 in government gazette 32148 of 21/4/2009) section 1j. 29. sa government. act 72: medicines and related substances amendment act. gn 434 in government gazette 32148 of 21/4/2009) section 1g. 29. sa government. act 72: medicines and related substances amendment act. gn 434 in government gazette 32148 of 21/4/2009) section 1g. 30. directorate of radiation control unit & south african medical association briefings. parliamentary monitoring group. http://www.pmg.org.za/print/24392 (accessed 29 november 2011). 30. directorate of radiation control unit & south african medical association briefings. parliamentary monitoring group. http://www.pmg.org.za/print/24392 (accessed 29 november 2011). 31. martin cj. a survey of incidents in radiology and nuclear medicine in the west of scotland. br j radiol 2005;78(934):913-921. 31. martin cj. a survey of incidents in radiology and nuclear medicine in the west of scotland. br j radiol 2005;78(934):913-921. 32. radiation legislation: environmental health. state government of victoria, australia. http://www.health.vic.gov.au/environment/radiation/legislation.htm (accessed 29 november 2011). 32. radiation legislation: environmental health. state government of victoria, australia. http://www.health.vic.gov.au/environment/radiation/legislation.htm (accessed 29 november 2011). 33. public health act. the government of prince edward island, canada. http://www.gov.pe.ca/law/regulations/pdf/p&30-06.pdf (accessed 29 november 2011). 33. public health act. the government of prince edward island, canada. http://www.gov.pe.ca/law/regulations/pdf/p&30-06.pdf (accessed 29 november 2011). 34. european communities (medical ionising radiation) regulations 2002. brussels: european union, 2002. 34. european communities (medical ionising radiation) regulations 2002. brussels: european union, 2002. 35. amis es, butler pf, applegate ke, et al. american college of radiology white paper on radiation dose in medicine, j am coll radiol 2007;4:272-284. 35. amis es, butler pf, applegate ke, et al. american college of radiology white paper on radiation dose in medicine, j am coll radiol 2007;4:272-284. 36. martinsen act, saether hk. qa and optimisation in diagnostic radiology – a multi-disciplinary task: how to build a regional service to implement alara. european alara newsletter october 2011. 36. martinsen act, saether hk. qa and optimisation in diagnostic radiology – a multi-disciplinary task: how to build a regional service to implement alara. european alara newsletter october 2011. 37. national council on radiation protection and measurements. ionizing radiation exposure of the population of the united states (report 160). bethesda, md: national council on radiation protection and measurements, 2009. 37. national council on radiation protection and measurements. ionizing radiation exposure of the population of the united states (report 160). bethesda, md: national council on radiation protection and measurements, 2009. 42 sa journal of radiology • june 2011 case report clinical presentation a 19-year-old woman (para 1, gravida 1) delivered a baby girl at 36 weeks’ gestational age. antenatal blood test results showed that the mother was rhesus positive, the rapid plasma reagin (rpr) for syphilis was negative, and she was hiv-positive (she was receiving treatment). there were no other significant findings in the maternal history. there was no record of antenatal ultrasound findings. the baby was delivered by normal vaginal delivery, with a birth weight of 2 670 g and apgar scores of 5/10 at 1 minute and 7/10 at 5 minutes. the baby had an initial heart rate of 86 beats per minute, was pale and cyanosed (respiratory rate of 50 breaths per minute), with oxygen saturation levels of 88 92%. the baby was resuscitated, after which her pulse and saturation improved. examination revealed cardiomegaly with the apex in the sixth intercostal space in the anterior axillary line. a pansystolic murmur and a palpable second heart sound (p2) was present on auscultation. chest radiographs demonstrated significant cardiac enlargement with signs of congestive cardiac failure (fig. 1). this prompted cardiac ultrasound which demonstrated right atrial dilatation, an inter-atrial septal aneurysm (fig. 2) with a right to left shunt. there was pulmonary hypertension with a large tricuspid incompetence and a dilated right ventricle. a patent ductus arteriosus (pda) with right to left shunt was also visualised. the degree of right to left shunt suggested a possible ‘steal phenomenon’ owing to an arterio-venous malformation (avm). in the search for a high-volume extra-cardiac shunt, cerebral ultrasound revealed a vein of galen malformation (vgm) with massive hydrocephalus with no normal brain parenchyma (fig. 3). contrastenhanced computed tomography confirmed the ultrasound findings, showing dilated, tortuous contrast enhancing vessels, a dilated vgm and massive hydrocephalus with no visualised brain parenchyma (fig. 4). the baby died 2 days later and underwent postmortem. the findings confirmed the presence of a large vgm, massive hydrocephalus and no normal brain tissue identified macroscopically. there was hypertrophy of the left atrium (la) and right myocardium, and right heart failure a severe case of astrogliosis and encephalomalacia in a neonate with a massive vein of galen malformation (vgm) f ismail, fc rad (d) n khan, fc rad (d) i van de werke, frcr r ahmed, mb chb department of radiology, kalafong hospital and university of pretoria corresponding author: f ismail (drfismail@yahoo.com) fig. 1. frontal radiograph of the patient’s chest shows massive global cardiomegaly. fig. 2. four-chamber cardiac ultrasound demonstrates enlargement of the ra with aneurysm of the asd. doppler studies (not shown) showed right to left shunting of blood. aneurysm of the asd la ra abstract vein of galen malformations (vgms) are rare anomalies of intracranial circulation that constitute 1% of all intracranial vascular malformations. we describe a case of severe encephalomalacia associated with a vgm, which has not been previously described. sa journal of radiology • june 2011 43 case report owing to the right to left shunt. an atrial septal defect (asd) and pda were also noted. no other anomalies were found. discussion vgms are rare anomalies of intracranial circulation that constitute 1% of all intracranial vascular malformations.1 they represent 30% of vascular malformations in the paediatric age group.1 the first description of a possible vgm was reported by steinhel in 1895.2 raybaud and co-workers were the first to recognise the ectatic venous structure that is characteristically seen in these lesions representing the median prosencephalic vein (mpv) and not the vein of galen itself.1 the mpv is responsible for drainage of the choroid plexus prior to the development fig. 3. coronal cranial ultrasound demonstrates enlarged central vein of galen with increased blood flow on doppler study (left) and massive hydrocephalus with no brain parenchyma. vgm hydrocephalus fig. 4. axial non-enhanced and enhanced computed tomography of the brain demonstrates dilated, tortuous vessels draining into a large vein of galen with secondary hydrocephalus and astrogliosis with no brain parenchyma. 44 sa journal of radiology • june 2011 case report of the internal cerebral veins, during embryogenesis, prior to the 11th week of gestation.1 vgms form during the late somite stages of the 4th week of embryonic life. the malformation consists of persistent primitive connections between the arteries and veins that develop from the sinusoidal vascular network of the telencephalon.3 absence of capillaries results in a lowresistance shunt, which results in rapid arterio-venous shunt within the malformation.3 this results in blood flow away from the parenchyma, resulting in hypoperfusion, with consequent astrogliosis and atrophy.3 high pressure and shear stresses from turbulent flow may result in the formation of arterial aneurysms, stenosis or occlusion in the draining veins, particularly where the vein enters a dural sinus.3 more recently, anatomical and embryological evidence has allowed vgms to be categorised as specific choroidal type or mural type.4,5 there is a relationship between the choroidal type of malformation and heart failure in neonates, and it is more severe in presentation than the mural type, as was the case with our patient.4-6 the mural type is characterised by fewer (1 4) large-calibre connections that drain into the wall of the mpv.5,6 there is also a distinction between the vgm and the vein of galen aneurysmal dilation (vgad) which are avms localised in the subpial space, which drain into a tributary of the vein of galen, resulting in overload and dilatation.4,5 the vein of galen varix refers to a varicose dilation of the vein of galen without an underlying arterio-venous shunt.4 increased venous return to the right heart promotes shunting of blood through a patent foramen ovale and ductus venosis. this leads to cyanosis and often refractory congestive cardiac failure.1,7 neurological manifestations occur as a direct result of cerebral venous hypertension that prevents drainage of cerebrospinal fluid (csf) via the medullary veins. transependymal drainage of csf, followed by medullary venous drainage, supervenes as arachnoid granulations are not fully matured in the neonate.1,4 this in turn causes chronic hypoxia, ischaemia, hydrocephalus and cerebral oedema.1 chronic hypoxia results in progressive cerebral parenchymal damage.1 cerebral damage can be severe, as cases of hydranencephaly with arterial and venous malformations have been reported.7 this was the case in our patient, who developed severe leucomalacia and astrogliosis owing to chronic intra-uterine hypoxia. conclusion vgms are rare anomalies that may cause secondary neurological abnormalities. the degree of hypoxic damage and hydrocephalus, as seen in our case, has not been previously documented. 1. gupta ak, varma dr. vein of galen malformations: review. neurology india 2004;52:43-53. 2. lasjaunias pl, chng sm, sachet m, alvarez h, rodesch g, garcia-monaco r. the management of vein of galen aneurysmal malformations. neurosurgery 2006;59(5):184-194. 3. barkovich aj. paediatric neuroimaging. 4th ed. baltimore, usa: lippincott williams and wilkins, 2005:873-878. 4. alvarez h, garcia monaco r, rodesch g, sachet m, krings t, lasjaunias p. vein of galen aneurysmal malformations. neuroimaging clin n am 2007;17:189-206. 5. du toit j, bam ja. mngomezulu v. endovascular treatment of vein of galen aneurysmal malformation. south african journal of radiology 2009;13:12-17. 6. osborn a, blaser si, salzman kl, et al. diagnostic imaging: brain. salt lake city, usa: amirsys, 2007:12-14. 7. stevenson da, hart bl, clericuzio cl. hydranencephaly in an infant with vascular malformations. am j med genet 2001;104:295-298. case series 39 sa journal of radiology • june 2010 introduction macrodystrophia lipomatosa (mdl) is described as a rare, non-hereditary, congenital condition presenting with localised macrodactyly and a proliferation of mesenchymal elements. there is in particular a marked increase in fibroadipose tissue.1 we describe 2 young patients presenting to our department in a 6-month period, with a history of disproportionately large limbs since birth. while our first case demonstrated all the typical features of mdl, our second case failed to demonstrate osseous gigantism, but all other features of mdl were present. an extensive search of the literature failed to yield any cases described without osseus gigantism; but at the same time, the other radiological features failed to fit in with any other causes of focal gigantism, and the most appropriate diagnosis appears to be mdl. we therefore concluded that this may be a case of a rare, atypical mdl that was arrested or frustrated and so failed to demonstrate full expression of the syndrome. case 1 a 33-month-old boy was referred by a paediatric surgeon for radiographs of the left arm. according to the history, he was born with the left arm disproportionately larger than the rest of the body. clinically, there was marked increase in the soft-tissue bulk of the entire left arm with focal gigantism involving the thumb and second finger. good functionality of the arm was maintained. radiographs revealed lucent soft-tissue thickening of the affected arm, suggesting the presence of fat (fig. 1). focal gigantism involving the metacarpals and phalanges of the thumb and second finger were noted. the rest of the bony elements were normal. ultrasound (us) examination demonstrated an extensive increase in subcutaneous tissue with poor visualisation of muscles and nerves. normal vascularity was noted on doppler us. us of the abdomen was normal. mri studies showed diffuse proliferation of fatty tissue throughout the arm, with fat infiltration of the muscles (figs 2 4). the nerves imaging of a rare disorder: macrodystrophia lipomatosa farhana ebrahim suleman, mb chb, fcrad (d) sa, mmed rad (d) department of radiology, university of limpopo, medunsa campus, garankuwa margaret kisansa, mb chb, mmed rad (d) department of radiology, george mukhari hospital, garankuwa fig. 1. radiograph of the left upper extremity demonstrates diffuse soft-tissue swelling involving the entire upper limb. soft tissues are lucent, suggestive of fat. multiple skin folds are evident. marked osseous gigantism of the 1st and 2nd fingers noted. humerus, radius ulnar and bony elements of the 3rd, 4th and 5th fingers are within normal limits. fig. 2. axial t1wi through the forearm. there is proliferation of subcutaneous fat that is not encapsulated. the muscles are markedly infiltrated by fat, and the nerve cannot be identified. case series case series 40 sa journal of radiology • june 2010 case series could not be identified on mri, probably owing to infiltration by fat. histological analysis of the tissue revealed adipose tissue only, which was in keeping with a diagnosis of mdl. case 2 an 11-month-old girl was referred by a plastic surgeon for mri to exclude lymphoedema of the right lower limb. according to the history, she was born with the right lower limb disproportionately bigger than the rest of the body. clinically, there was marked increase in soft tissue of the entire right lower limb. good function of the limb was maintained, and the child was otherwise normal. radiographs revealed increased soft tissue throughout the limb, and the underlying bones were normal (fig. 5). us was not performed. mri showed diffuse increase of fat in the soft tissues, as well as scattered cystic lesions of varying signal intensity (figs 6 8). this feature has not been described in the literature reports of other cases of mdl, and was thought to be due to either fat necrosis or old haematomas secondary to trauma. there was no fat infiltration of the muscles, and the neurovascular bundles were intact. once again, histological analysis revealed proliferation of adipose tissue in keeping with a diagnosis of mdl. literature review mdl is a rare congenital disorder of focal gigantism affecting the extremities – more commonly, the second and third digits of the foot, but it may also affect the hand.2,3 it is characterised by the proliferation of all mesenchymal elements but especially of fibroadipose tissue.2,4,5 it is typically described in a particular nerve distribution; usually the medial plantar nerve or median nerve.3 radiological investigations include plain film radiographs, us and mri, where findings may be typical. plain films show lucent soft-tissue overgrowth as well as hypertrophy of osseous structures in the distribution of the median and plantar nerves.1 in our cases, only one patient demonstrated the osseous overgrowth. in the second case, the bony elefig. 3. coronal proton density image of the left upper limb showing osseous gigantism of the 1st finger and diffuse increase of subcutaneous fat with very little muscle bulk. fig. 4. fat-suppressed images of the left upper limb.there is marked suppression of the signal from the subcutaneous fat, confirming the diagnosis of mdl. fig. 5. frontal radiograph of the lower limbs. there is diffuse soft-tissue swelling involving the subcutaneous fat of the right lower extremity more marked in the distal lower leg and foot. soft-tissue skin folds are evident. there is no discrepancy in the bony elements in comparison with the left side. case seriescase series 41 sa journal of radiology • june 2010 ments were within normal limits. in older patients, secondary osteoarthritis changes may also be seen. us reveals large amounts of subcutaneous tissue, infiltration of the muscle and thickening of the affected nerves. doppler studies reveal an absence of any increased vascularity. mri findings are most useful in confining the differential diagnosis.4 mri investigations reveal overgrowth of unencapsulated fatty tissue that demonstrates high signal on t1wi and t2wi, with suppression of the signal on short inversion time inversion recovery (stir) sequences, as demonstrated by our patients. thickened nerves may, or may not, be demonstrated. lack of flow voids and calcifications helps to differentiate the condition from vascular malformations of klippel-trenauney-weber syndrome. lymphangiomas and neurofibromas may be hyperintense to fat on t2wi,4 distinguishing mdl from these conditions. proteus syndrome may be similar but has other associated features such as skull anomalies, lung cysts and pigmented naevi.1 some authors suggest that mdl is a localised form of proteus syndrome.1 fibrolipomatous harmatoma of the nerve displays features similar to mdl;1 however, fat deposition is within the nerve, giving a speckled appearance on mri. two subtypes of the condition are described in the literature: the static and progressive types. in the static type, the enlarged digits grow at the same rate as the other digits. in the more rare progressive type, the growth of the enlarged digits is more rapid. our patients were thought to have the static type clinically. conclusion numerous aetiologies of focal gigantism exist. while clinically the distinction may be difficult, radiological investigation is very useful in confining the differential diagnosis. mri in particular shows characteristic findings of mdl, and radiologists therefore play an important role in the diagnosis of these conditions. 1. sone m, ehara s, tamakwa y, nishida j, honjoh s. macrodystrophia lipomatosa: ct and mr findings. radiat med 2000; 18(2): 129-132. 2. singla v, virmani v, singh p, khandelwal n. case report: macrodystrophia lipomatosa – illustration of two cases. indian j radiol imaging 2008; 18(4): 298-301. 3. turkington jra, grey ac. mr imaging of macrodystrophia lipomatosa. ulster med j 2005; 74(1): 47-50. 4. blacksin m, barnes fj, lyons mm. mr diagnosis of macrodystrophia lipomatosa. am j radiol 1992; 158: 1295-1297. 5. balakrishna bv, prasad srh. macrodystrophia lipomatosa – a rare congenital disorder. indian j radiol imaging 2005; 15: 349-352.w fig. 6. t1wi of the right lower limb shows marked thickening of subcutaneous fat with associated well-circumscribed lesions of low signal intensity. fig. 7. t2wi of the right lower limb confirms fat signal in the thickened soft tissue. the well-circumscribed lesions demonstrate varying signal intensities. case series case series 42 sa journal of radiology • june 2010 straight talking on ct scanning bradley m tipler, md dr tipler is a private-practice radiologist in waynesboro, va, usa. we are indebted to him and to the website diagnosticimaging.com for this viewpoint. for the past 10 years i have been lecturing on america's radiation phobia. obviously, i am not doing a good job, because it is growing. what i find particularly distressing is the problem's growth among radiologists. recently, phobic radiologists have been publishing and lecturing like rabbits on viagra. i have always endorsed and applied alara. i heartily endorse the image lightly campaign. if there is any risk from medical radiation, it is to children. but i raise cattle on my farm, and i occasionally step in the stuff being printed and propagated by a lot of radiologists now. while reports on biological effects of ionising radiation (beir) and the alphabet soup that formulates radiation standards for the usa are monumental works of statistics, they are not facts. historically, they were developed to help us to formulate national and international policy on radiation safety and work out radiation regulations. still today, they are based in large part on data gathered from survivors of hiroshima and nagasaki. the american public's exposure to radiation from medical imaging has nothing in common with that of japanese atom bomb survivors. the figures are great for developing radiation regulation guidelines, but they are not appropriate for determining the risk/benefit ratio for an acutely ill patient in an emergency room. what us radiologist in his or her right mind uses japanese statistics for gastric cancer when reading an upper gi? every one of the data now being headlined by the lay press is based on the linear no-threshold (lnt) theory. is there a radiologist who actually believes that the effects of low-dose radiation over a lifetime are the same as those of one massive dose? the lnt made sense in the early development of radiation safety guidelines. rule-makers need to err on the side of safety. we all know ct is being overused. and we all know there is one primary reason: money. clinicians with their own scanners want to produce income for themselves, and good docs who don't own a machine want to avoid generating income for plaintiffs' lawyers. radiation regulations are to clinical decision-making what highway construction regulations are to nascar. you don't see speed limit signs on nascar tracks because that would be dumb. it is just as dumb to put theoretical numbers on the risk of a ct scan for an individual patient. if the patient needs the test, the theoretical radiation risk is immaterial. if the patient doesn't need the test – duh, don't do the test. if you are not sure, the american trial lawyers association would love to review your decision later. as i say in my lectures, this is the classic american approach to risks. we love scary movies, but we want mother hen to eliminate all real risk from our lives. we can save thousands of lives by lowering the speed limits, but we want to drive fast. when we wreck, we hire a lawyer and sue anyone who didn't make our fast driving safer. we need to emphasize .dam (dot dam = don't order the test if it doesn't alter management) and make sure we use the lowest possible dose for a given exam. recent literature has shown we are lousy at the latter. we do not need to complicate the ordering process, especially with biased statistics that were never intended to be applied on an individual basis. i think putting a note on a ct order form about the theoretical risk of cancer from a single ct means the radiologist is clueless about the conflicts facing the ordering doctor. the radiologist looks like, and probably is, a fool. americans like to compare ct doses to our background level of 3 msv per year. background radiation on the coast of brazil exceeds 150 msv a year. have you seen those poor, over-irradiated brazilian beach babes? and they live longer than us. fig. 8. fat-suppressed image of the right lower limb. there is loss of signal in the thickened soft tissue. the muscles and osseous elements appear normal in all sequences. pictorial essay a 45-year-old malagasy man, with a 2-month medical history of chronic pericarditis, presented to the department of cardiology at joseph raseta hospital with cardiac tamponade. pericardiocentesis was performed, with improvement in the patient’s clinical condition, following aspiration of 400 cc of serofibrinous fluid. the control chest x-ray revealed a hydropneumopericardium (figs 1a and 1b). following evaluation of the fluid, tuberculosis treatment was started with an adjunctive corticosteroid régimen and resultant complete resolution of all cardiac symptoms. the diagnosis of hydropneumopericardium requires the application of shackelford criteria which include (i) high-pitched tympanic percussion note, (ii) loud metallic splashing sound synchronous with heart sounds, and (iii) characteristic chest x-ray with an air-fluid level in the pericardial cavity.1 traumatic origins of hydropneumopericardium are more common than non-traumatic causes. non-traumatic causes of hydropneumopericardium include asthma, gastro-pericardic fistula complicating gastric pathology, and infectious disease from illnesses such as pericarditis and pneumonia. traumatic causes are many and varied, including chest trauma (11%) and iatrogenic causes (74%), particularly those arising after mechanical ventilation, cardiac surgery, and pace-maker implantation.2 pericardiocentesis is the cornerstone of the management of cardiac tamponade. kabukcu has performed 50 such procedures safely.3 there are few reports of pneumopericardium linked to pericardic drainage.4 cardiac tamponade is encountered in 37.7% of pneumopericardium cases.2 although its occurrence is not dependent upon the quantity of air in the pericardic cavity, spontaneous remission has been documented in the case of a small pneumopericardium.5 1. shackelford rt. hydropneumopericardium. jama 1931; 96: 187-191. 2. wu m, he x, yang g. spontaneous tension hydropneumopericardium complicating serofibrinous pericarditis. eur j cardiothorac surg 2006; 29: 422-424. 3. kabukcu m, demircioglu f, yanik e, basarici i, ersel f. pericardial tamponade and large pericardial effusion: causal and efficacy of percutaneous catheter drainage in 50 patients. heart inst j 2004; 31: 398-403. 4. gan h, simpson jm. pneumopericardium presenting as reduced ecg voltages. heart 2005; 91: 298. 5. levin s, maldonado i, rehm c, ross s, weiss r. cardiac tamponade without pericardial effusion after blunt chest trauma. am heart j 1996; 131: 198-200. large uncomplicated hydropneumopericardium r a rakotoarivelo, md s h razafimahefa, md p ramanalimanana, md d ranoharison, md a d johnson, md s rakotoarimanana, phd department of cardiology, joseph raseta hospital, university hospital center of antananarivo, antananarivo, madagascar fig. 1a and b. chest x-ray after pericardiocentesis. hydropneumopericardium showing air/fluid level: frontal view (a) and side view (b). 19 sa journal of radiology • march 2010 large uncomplicated.indd 19 2/26/10 9:49:03 am 60 sa journal of radiology • june 2011 quiz case please refer to page 30 of the march 2011 issue of the sajr (http://www. sajr.org.za/index.php/sajr/article/view/450/425) for the presentation details and radiographic images. we congratulate dr himal gajjar (schnetler, corbett and partners, cape town) for the precise diagnosis, for which he receives an award of r1 000 from the rssa. professor andronikou and dr els elaborate below on the condition and its radiological signs. diagnosis and discussion t h e p a t i e n t w a s f o u n d t o h a v e p r o g r e s s i v e m u l t i f o c a l leucoencephalopathy (pml) – a progressive demyelinating disorder caused by the john cunningham virus (jcv), which is a dna papovavirus. it was discovered in 1971 and named after a patient with pml from whom the virus was first isolated.1 epidemiologically, the majority of cases are currently seen in association with aids.2 the original patient profile was that of chronic disease with immune suppression caused by diseases such as lymphoma, leukaemia, carcinomatosis, sarcoidosis and tuberculosis.3,4 invasion of myelin-producing oligodendrocytes by the jcv causes foci of demyelination. these foci can vary from millimetres to centimetres in size and can occur anywhere, but are frequently found in the cerebral hemispheres and, less commonly, in the cerebellum, brain stem and spinal cord. pml has an insidious onset of neurological symptoms including impairment of mental state, and disturbance of speech and vision. the disease progresses rapidly and results in end-stage disease characterised by severe disability with dementia, hemiparesis and cortical blindness,5 with eventual coma and death. histological and virological isolation of the jcv from brain tissue will confirm the diagnosis. proof of jcv antibodies in serum and/or cerebrospinal fluid (csf) in isolation does not confirm the diagnosis, but the absence thereof makes the diagnosis of pml highly unlikely. computed tomography (ct) findings are described as single or multiple confluent hypodense lesions without mass effect, most commonly in the parieto-occipital white matter.6 fig. 1a demonstrates a right fronto-parietal, right basal ganglia and left anterior capsula externa hypodense lesions without significant mass effect and no contrast enhancement (fig. 1b). magnetic resonance imaging (mri) is the preferred method of imaging. the lesions are located in the white matter and are widespread and asymmetrical. they are hypo-intense on t1-weighted imaging (wi) and hyperintense on t2wi and flair. characteristically, there is involvement of the subcortical u-fibres. this feature is best appreciated at mri and results in the overlying cortex being sharply contrasted with the lesion.7 following ct, our patient underwent an mri (fig. 2), which demonstrated t2 hyperintensity in the right parietal lobe, right basal ganglia and left anterior capsula externa with mild mass effect but no contrast enhancement. only rarely do such lesions cause mass effect. pml can be differentiated from many other demyelinating diseases by the absence of perivenous inflammation and therefore a lack of enhancement on imaging. inflammatory pml and hiv-associated pml in the setting of immune recovery following art may, however, show contrast enhancement. a fluctuant course and interval improvement may occur with pml.8 in patients with aids, atypical presentations are common, and there may be co-existent central nervous system (cns) pathologies that will make interpretation of studies more difficult.6 because there is no effective treatment for pml, the prognosis is very poor, resulting in death within 2 5 months. our patient was diagnosed with pml and commenced on art. the diagnosis was based on the clinical presentation, imaging findings and polymerase chain reaction (pcr) of cerebrospinal fluid testing positive for jcv. despite being on art, the patient presented 2 months later with new neurological symptoms, and a follow-up ct demonstrated significant progression of the lesions (fig. 3). differential diagnoses hive hiv encephalopathy (hive) is the most frequent neurological manifestation due to a neurotrophic virus causing direct infection of the cns. clinically, patients present with cognitive impairment and motor abnormalities. ct may be normal or show atrophy with or without white matter (wm) lesions. wm lesions are usually bilateral, symmetric, varied in size and manifest as hypodensities. they are seen in the periventricular regions, centrum semiovale, basal ganglia, brainstem and cerebellum. the subcortical wm is spared. mr is the imaging modality of choice, demonstrating lesions of high signal intensity on t2wi and iso-intensity on t1wi. there is no enhancement after contrast administration and no mass effect.9 toxoplasmosis the obligate intracellular protozoal parasite toxoplasma gondii (reser voirs in faeces of the domestic cat) is the most common opportunistic cns infection in patients with aids.7 patients present hein els, mb chb, mfammed, ccfp department of diagnostic radiology, tygerberg academic hospital, tygerberg savvas andronikou, mb bch, fcrad, frcr (lond), phd department of diagnostic radiology and imaging, university of limpopo, medunsa campus, garankuwa corresponding author: h els (els.hein@gmail.com) cognitive decline and depressed level of consciousness in aids: diagnosis sa journal of radiology • june 2011 61 quiz case with fatigue, headache, fever and chills. confusion and drowsiness may follow with seizures, hemiparesis and coma if not treated. toxoplasma has a predilection for the gray-white matter junction and basal ganglia. ct demonstrates single or multiple hypodense lesions with surrounding oedema and mass effect. on t1wi, the lesions are hypointense and hyperintense on t2wi. on both ct and mri, lesions may show focal, nodular or rim enhancement.6,8 this is an important feature in distinguishing lesions from pml. occasionally the lesions may haemorrhage, which will aid in differentiating the condition from untreated lymphoma.7 lymphoma usually does not haemorrhage prior to treatment. often the condition is indistinguishable from pcnsl, and the lack of ependymal spread and additional imaging with single photon emission computed tomography (spect) and positron emission tomography (pet) can be helpful. toxoplasma will be negative at these modalities with lymphoma (typically lager than 2cm) being positive. mr spectroscopy will typically show elevated lactate and lipid.7 primary central nervous system lymphoma (pcnsl) hiv-associated lymphoma may present with symptoms such as headache, lethargy and confusion, often with an insidious onset. any part of the cns may be affected, but lesions are found most frequently in the periventricular region, often with subependymal and subarachnoid spread, and can be single or multiple. multiple lesions favour toxoplasmosis as opposed to lymphoma, while callosal involvement favours lymphoma. the lesions may show oedema and exert mass effect. ct may demonstrate hyperdense or isodense lesions. on mri, signal is isoor hypo-intense to gray matter on t2wi and isoor hypo-intense on t1wi. on both ct and mri, lesions may show enhancement which may be rim, dense homogenous or nodular in pattern. untreated lesions typically do not show signs of haemorrhage. at mr spectroscopy, the lesions will show decreased n-acetyl aspartate (naa) and elevated choline. elevated lactate and lipid may also appear if the voxel is placed in the necrotic area.7 we offer the following simplified flow diagram to use when faced with a similar scenario: 1. padgett, bl, walker dl, zu rhein gm, eckroade rj. cultivation of papova-like virus from human brain with progressive multifocal leucoencephalopathy. lancet 1971;1:1257-1260. 2. berger jr, kaaszovitz b, post jd, dickinson g. progressive multifocal leucoencephalopathy associated with human immunodeficiency virus infection. ann intern med 1984;107:78-87. 3. richardson ep jr. progressive multifocal leucoencephalopathy. n eng j med 1961;265;815-823. 4. astrom ke, walker dl. progressive multifocal leucoencephalopathy: a hitherto unrecognized complication of chronic lymphatic leukemia and hodgkin’s disease. brain 1958;81:93-111. 5. sweeney bj, miller rf, harrison mjg. progressive multifocal leucoencephalopathy. br j hosp med 1993;50:187-192. 6. mark as, atlas sw. progressive multifocal leucoencephalopathy in patients with aids: appearance on mr images. radiology 1989;173:517-520. table i. comparing select features of pml and the differential diagnoses pml hive toxoplasmosis pcnsl (immunocompromised) causative agent jcv hiv toxoplasma gondii immunodeficiency predisposes; epstein-barr virus plays a role location frontal, parietooccipital; characteristic involvement of the subcortical u-fibres wm bilateral periventricular and centrum semiovale, basal ganglia, brainstem, cerebellum. subcortical wm spared. basal ganglia, thalamus, cerebral hemispheres characteristically the greywhite interface frontal and parietal (most common), deep gray nuclei, cluster around ventricles and extend along ependymal surfaces, callosal multiplicity often bilateral and asymmetric bilateral symmetrical often multiple often solitary, may be multiple ct hypodense ± atrophy hypodense isoor hypodense hyperdense, may be isodense t1wi isoand later hypointense iso-intense hypo-intense isoor hypo-intense t2wi hyperintense hyperintense: focal or diffuse hyperintense; also isoor hypo-intense or target lesion isoor hypo-intense flair hyperintense same as t2, but more conspicuous hyperintense isoor hypo-intense, may be hyperintense enhancement rarely; may enhance, especially following art no enhancement focal, nodular or rim nodular, rim or homogenous mass effect + + quiz case 62 sa journal of radiology • june 2011 7. smith ab, smirniotopoulos jg, rushing ej. from the archives of the afip: central nervous system infections associated with human immunodeficiency virus infection: radiologic-pathologic correlation. radiographics 2008; 28:2033-2058. 8. garrels k, kucharczyk w, wortzman g, shandling m. progressive multifocal leucoencephalopathy:clinical and mr response to treatment. am j neuroradiol 1996;17:597-600. 9. osborne ag, salzman kl, harnsberger hr, et al. diagnostic imaging: brain. 2nd ed. utah, usa: amirsys, 2009. normal.html normal variance in renal size in relation to body habitus werner s harmse, mb chb department of diagnostic radiology, faculty of health sciences, university of the free state, bloemfontein corresponding author: w harmse (wsharmse@mweb.co.za) abstract objective. renal length determination is common in everyday radiology practice. however, a normal range of kidney sizes may not apply to people of all body habitus. this study investigates this relationship in order to determine normal ranges in relation to body habitus. a secondary aim was to evaluate the relationship of renal size to gender and race. methods. kidney lengths were measured on oblique coronal reformatted ct images of 514 patients who received routine abdominal ct scans for conditions unrelated to renal pathology. the patients had normal serum creatinine levels, no history of renal disease, no renal masses, and normal-appearing kidneys on ct. weight, height, race and gender of the patients were recorded. results. the mean renal length was 108 mm with a standard deviation of 9.82 mm. statistical analysis demonstrated a relationship between kidney size and body weight and height, both individually and collectively. the most accurate prediction model was ‘kidney size = 49.18 + 0.21 x weight + 0.27 x height’, with a r2-value of 0.32. additionally, kidneys were generally larger in the white population than in the black, and also in males than females. conclusion. normal renal size varies according to patients’ body habitus. this variation can be expressed as a function of body weight and height, which can be represented by a nomogram and used as an easy reference in clinical practice. renal size is an important parameter for clinical assessment of patients with diabetes, renal artery stenosis or chronic renal failure, and for assessment of kidney transplant candidates. renal sizes facilitate differentiation between chronic and acute renal failure, and when a decision has to be made on whether to take renal biopsies or not. it is therefore imperative to have accurate data regarding normal renal sizes. numerous studies have established normal renal lengths for the average adult population, which is approximately 11 cm ± 1 cm,1 with only slight variation among different authors. however, limited research has been done on the variation of normal renal size in relationship to body habitus, as well as gender and race. in a study performed in 1991 with a volunteer danish population in copenhagen,4 a definite association in adults between renal size and body habitus was found. however, no specific model was developed, as this was not the primary aim of the investigation. this study was also on a single racial group.4 fernandes et al.5 found differences in measurements between different population groups in a study performed in brazil. most previous studies also used sonography or intravenous urography to measure renal dimensions. in 2007, kang et al.6 evaluated different radiological methods of estimating renal size, and concluded that coronal ct scans were the most accurate radiological method for doing so. a clinical dilemma facing radiologists and clinicians may arise in deciding whether larger kidney sizes may be acceptable for a big patient or, conversely, if a small kidney can be accepted as normal for a smaller adult patient. the aim of this study was (i) to evaluate the relationship between renal length and different body habitus indices, including weight, height, body mass index (bmi) and body surface area (bsa) by using ct images; (ii) to determine whether a relationship exists and, if so, to establish a normal range for renal lengths in relation to body habitus; and (iii) to establish a possible relationship between renal size and age, gender and/or race. ethical approval to conduct the investigation was granted by the ethics committee of the faculty of health sciences, university of the free state. methods an analytical cross-sectional study was performed on patients attending the diagnostic radiology department at the national district hospital, bloemfontein. all patients receiving routine ct scans of the abdomen from july 2009 to june 2010 were evaluated for inclusion in the study. these patients were scanned on a ge (general electric) 8-slice brightspeed ct scanner at a section thickness of 2.5 mm. patients were limited to adults between 18 and 70 years of age. the patients were from central south africa and represented different racial groups, including black, white, coloured and asian. patients with diseases or pathology that might influence renal size were excluded from the study. exclusion criteria applied to the patients on arrival were (i) known chronic renal disease, (ii) previous renal surgery, (iii) patient too ill to allow weighing and measuring, and (iv) elevated serum creatinine >100 µmol/l (upper limit of normal at the local laboratory). patients included in the study were weighed and measured, and their age, gender and race recorded. after receiving their scans, their images were evaluated and a further 4 exclusion criteria were applied, namely (i) incidental finding of renal masses on ct scan, including a solitary cyst >4 cm, multiple cysts (>4), polycystic renal disease,4 (ii) hydronephrosis, (iii) a single kidney, and (iv) congenital abnormalities including ectopic and fused kidneys. both the left and right kidneys of the remaining patients were measured, which was done by using multiplanar reformations on philips isite advanced visualisation software. oblique coronal planes were used to measure the maximum diameter of the kidneys. standard coronal reformatted images were individually tilted along the longitudinal axes for both left and right kidneys, using a reference line on sagittal images. the maximum length of the kidneys was then measured on these oblique coronal images (see fig. 1). results a total of 677 patients from july 2009 to june 2010 with no known renal disease, no previous renal surgery and a serum creatinine level <100 µmol/l received abdominal ct scans at national hospital in bloemfontein. one hundred and sixty-three of these patients were excluded owing to hydronephrosis, visible renal atrophy, renal masses, multiple cysts or congenital renal variants, giving a remainder of 514 patients who were included in the study. on average, the left kidney was 2.06 mm (p <0.001) larger than the right kidney, with differences ranging from 23 mm larger to 17 mm smaller. for each patient, the mean kidney size between left and right was determined and used for further analysis, being referred to as ‘kidney size’ unless stated otherwise. kidney sizes varied from 80 mm to 134 mm, with a mean size of 108 mm. as illustrated in fig. 2, the kidney sizes showed a symmetric distribution with a standard deviation of 9.82 mm. firstly the relationship between kidney size and weight was explored. the regression model (see fig. 3) was indicative of a significant relationship between kidney size and weight, with a unit increase in the patient’s weight being associated with an increase of 0.2562 units in kidney size. the r2 of the regression model is 0.2464, indicating that weight can explain 24.64% of the variation in kidney size. the relationship between kidney size and the patient’s height is shown in fig. 4 with the estimates of a regression model. the regression model indicates a significant relationship between kidney size and length, with a unit increase in length being associated with an increase of 0.39868 units in kidney size. the r2 of the model is 0.1801. fig. 5 illustrates the relationship between kidney size and the patient’s body mass index (bmi = weight in kg divided by height in meters squared) with the estimates of a linear regression model. bmi is significant in the regression model, with one unit increase in bmi being associated with an increase in kidney size of 0.42180 units. however, the r2 of the model is only 0.08708, indicating that bmi can explain only 8.7% of the variation in kidney sizes. the relationship between kidney size and the patient’s body surface area (bsa) is shown in fig. 6 with the estimates of a linear regression model. bsa was calculated using the mosteller formula,7 being bsa (m²) = ([height (cm) x weight (kg)]/3600)½. bsa is significant in the regression model, with one unit increase in bsa being associated with an increase in kidney size of 20.359 units. the r2 of the model is 0.2975. regarding these variables (weight, height, bmi and bsa), bsa best explains the variance in kidney size. however, a model was also fitted with both weight and length, and both these parameters were significant in the model. the estimated model is: kidney size (mm) = 49.18109 + 0.20605 x weight (kg) + 0.27360 x height (cm) (standard error = 8.1 mm) when comparing this model with the model using only bsa, we see that ‘weight + height’ has an adjusted r2 of 0.3191, while the model with only bsa has an adjusted r2 of 0.2962. this difference indicates that ‘weight + length’ is a better model than using only bsa. for further discussion, ‘0.20605 x weight (kg) + 0.27360 x height (cm)’ is referred to as the ‘body habitus constant’. further analyses of data were done regarding differences in renal size related to age, gender and race. no clear relationship between age and kidney size was found (see fig. 7). table i illustrates the gender and racial distribution, with the average renal sizes, as well as body habitus constants for each group. owing to the coloured and asian groups being too small to make a meaningful contribution to the findings, their results were excluded from specific race group analyses. kidney sizes were generally larger in males than females (3.2 mm, p <0.05) and also in whites than blacks (9.1 mm, p <0.05). body habitus may be regarded as a confounding factor in interpreting these results when considering our initial analysis. the mean body habitus constant of males was 61.0, and 57.7 in females, which is similar to the findings on gender-related differences in renal sizes. this finding suggests that the difference in renal sizes between gender groups is most likely due to the difference in body habitus between male and female, rather than a true difference due to gender. when correcting for this difference in body habitus, a much smaller difference in renal sizes of only 0.1 mm (p=0.6) is found between male and female patients, which is not clinically significant. similar results were found comparing the renal sizes and body habitus constants of blacks and whites. blacks had on average smaller renal sizes (9.1 mm), but also smaller body habitus constants than whites. this finding therefore suggests that the difference in renal sizes found between different racial groups may also be due to the difference in body habitus, rather than a true racial difference. when correcting renal sizes for the differences in body habitus, a difference of only 3.2 mm (p <0.05) is observed, which is substantially smaller than the 9.1 mm and, although statistically significant, unlikely to be clinically significant. the differences in body habitus may be attributed to a number of different genetic, cultural and socio-economic factors. discussion kidney sizes are important in the evaluation of renal disease for both radiologists and clinicians. coronal reformatted ct scans were used for measurement purposes as this approach was previously proven to be the most accurate way of measuring kidney sizes on imaging studies.6 furthermore, ct scans are more reproducible and less operatorand patient-dependent than ultrasound. in clinical practice, however, ultrasound is more readily available and free of radiation, and will most likely remain the preferred method for evaluating renal sizes. the mean renal size is 110 mm (±10 mm),1 with only minimal variation reported by different authors. in our study population, mean renal sizes were fairly similar, with a mean size of 108.2 mm and a standard deviation of 9.82 mm. a clinical dilemma might arise in patients with a kidney size bigger or smaller than this; one then needs to decide whether this can be accepted as normal for the particular patient owing to his/her body habitus. as expected, i found a relationship between renal sizes and body habitus, which supports the findings of emamian et al.,4 who demonstrated a correlation between renal sizes and bsa and height. from a physiological perspective, this finding would make sense, as patients with a bigger body habitus will have a larger blood volume requiring larger kidneys for filtration. glodny et al.8 also demonstrated a relationship between body height and renal length. they, however, found a strong relationship between renal length and bmi, which differed from my results where the relationship with bmi was the weakest of all the factors studied. they also did not study the influence of body weight, bsa or other combinations of weight and height.8 the most accurate model proposed by the author for predicting renal sizes is ‘kidney size (mm) = 49.18109 + 0.20605 x weight (kg) + 0.27360 x height (cm)’. this model had a standard error of 8.1 mm. it is a cumbersome formula to use in daily practice, and i consequently constructed a nomogram (fig. 8) to allow easy reference in the clinical situation. when a patient’s weight and height is known, a straight line can be drawn between these values on the scales representing weight (left) and height (right). this line will intersect the central scale indicating the approximate kidney size expected for this patient. no relationship between age and renal size was found, although variation between different genders and races was observed. the variation in kidney sizes, however, was similar to the differences in body habitus, and more likely due to body habitus rather than inherent differences. it could further be argued that the differences in body habitus are in all probability the result of numerous socio-economic and cultural factors. a few limitations were experienced during this study and need to be noted. the measurements were made by a single observer, which was mostly because of lack of personnel. reformations were also done on 2.5 mm slices which were the limit on routine abdominal scans on the available equipment. these factors limited the accuracy of the results, leading to a larger variation of normal values. the standard error of estimation of our model was 8.1 mm. by increasing sample size and improving the accuracy of the measurements, it should be possible to decrease this error. nevertheless, the results were regarded as valid, especially since normal renal sizes do have a range of values spanning approximately 20 mm in variation, rather than a single specific value. conclusion normal renal sizes vary according to patients’ body habitus, and can be expressed as a function of body weight and height. this function can be represented by a nomogram that can be used as an easy reference in clinical practice. no relationship was found between renal sizes and age. variations were found in renal sizes of different genders and races, although these appeared to be related to differences in body habitus and not true inherent differences. acknowledgements. professor gina joubert, department of biostatistics, university of the free state, and christiaan marais are thanked for the statistical analysis of data, and daleen struwig, medical writer, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript for publication. 1. brandt td, neiman hl, dragowski mj, bulawa w, claycamp g. ultrasound assessment of normal renal dimensions. j ultrasound med 1982;1:49-52. 2. kabala j, roobottom c. the urogenital tract: anatomy and investgations. in: sutton d, ed. textbook of diagnostic radiology and imaging. 7th ed. london: churchill livingstone, 2003:828-885. 3. dahnert w, ed. radiology review manual. 6th ed. philadelphia: lippincott williams & wilkins, 2007. 4. emamian sa, nielsen mb, pedersen jf, ytte l. kidney dimensions at sonography: correlation with age, sex, and habitus in 665 adult volunteers. am j roentgenol 1993;160:83-86. 5. fernandes mmr, lemos ccs, lopes gs, et al. normal renal dimensions in a specific population. int braz j urol 2002;28:510-515. 6. kang k, lee yj, park sc, et al. a comparative study of methods of estimating kidney length in kidney transplantation donors. nephrol dial transplant 2007;22:2322-2327. 7. mosteller rd. simplified calculation of body-surface area (letter). n engl j med 1987;317:1098. 8. glodny b, unterholzner v, taferner b, et al. normal kidney size and its influencing factors – a 64-slicemdct study of 1.040 asymptomatic patients. bmc urology 2009;9:19-31. fig. 1. oblique coronal images used to measure maximum renal length. fig. 2. distribution of kidney sizes. fig. 3. kidney size in relation to body weight. fig. 4. kidney size in relation to body height. fig. 5. kidney size in relation to body mass index. fig. 6. kidney size in relation to body surface area. fig. 7. kidney size in relation to age. fig. 8. renal size nomogram in relation to weight and height. table i. mean renal size and body habitus constant related to gender and race. number of participants mean renal size (mm) body habitus constant total 514 108.2 59.01 gender female 306 106.9 57.7 male 208 110.1 61.0 race african 342 105.5 57.4 caucasian 146 114.6 63.2 coloured 25 108 56.5 asian 1 107.5 58.8 abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) tichayedza bondera division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa pawel schubert division of anatomical pathology, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa anel van zyl department of paediatrics and child health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa richard pitcher division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa asif bagadia division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation bondera t, schubert p, van zyl a, pitcher r, bagadia a. diagnostic yield and accuracy of paediatric image-guided fine needle aspiration biopsy of deep organ tumours. s afr j rad. 2022;26(1), a2485. https://doi.org/10.4102/sajr.v26i1.2485 original research diagnostic yield and accuracy of paediatric image-guided fine needle aspiration biopsy of deep organ tumours tichayedza bondera, pawel schubert, anel van zyl, richard pitcher, asif bagadia received: 19 may 2022; accepted: 23 june 2022; published: 28 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: paediatric tumour cytological diagnosis by image-guided fine needle aspiration biopsy (fnab) with rapid on-site evaluation (rose) has not gained wide acceptance despite increasing publications advocating the procedure. objective: the primary aim was an audit of the diagnostic yield and accuracy of paediatric image-guided fnab with rose at a single institution. evaluation of safety was a secondary aim. method: details of consecutive cases of paediatric image-guided fnab with rose for suspected non-benign deep-seated lesions performed from 01 january 2014 to 30 april 2020 were retrieved from the institutional radiology and laboratory databases. diagnostic yield and accuracy were evaluated using clinico-pathological-radiological correlation and/or subsequent histological specimen diagnosis correlation. complications and the frequency of key radiological features potentially affecting yield and accuracy were described. results: of 65 cases retrieved, cytology showed malignancy in 52, benign features in five and one indeterminate diagnosis; seven samples were insufficient for cytological assessment. of the 65 cases, 58 had subsequent formal histological diagnosis. the overall diagnostic yield was 98.5%, with 94.5% sensitivity, 100.0% specificity, 100.0% positive predictive value, 75.0% negative predictive value and 95.3% diagnostic accuracy. all cases (n = 26) demonstrating restricted diffusion on mri yielded adequate samples and cyto-histopathological correlation. conclusion: paediatric image-guided fnab with rose has a relatively high diagnostic yield, sensitivity, specificity, positive predictive value and accuracy in the diagnosis of deep-seated tumours. the relatively low negative predictive value may reflect insufficient samples obtained from cystic and/or benign lesions. sampling from areas of restricted mri diffusion may enhance diagnostic yield. keywords: paediatric; image-guided fine needle aspiration and biopsy (fnab); rapid on-site evaluation (rose); diagnostic yield; diagnostic accuracy; deep organ tumours. introduction image-guided percutaneous biopsy is frequently performed in interventional radiology departments by way of core needle biopsy (cnb) or fine needle aspiration biopsy (fnab).1 these techniques utilise available imaging technology to improve the safety of needle insertion into deep visceral organs and tissues for biopsies that would otherwise require open or laparoscopic surgery. of note, some patients with advanced disease or certain comorbidities may be unfit for surgery. furthermore, theatre time is limited in resource-constrained environments. various image-guidance modalities are available, including ultrasonography (us), ct, mri, fluoroscopy and newer commercially available navigation systems.1 the preferred modality is dependent on the interventional radiologist’s experience, available imaging equipment and the site of the lesion. the success of these minimally invasive procedures rests on their safety, high diagnostic yield and rapid recovery time.1 they facilitate pathological tissue diagnosis and assessment of tumour biomarkers with a lower risk of severe complications than open surgical biopsies (< 1% versus 2% – 10%).2 in addition, as imaging techniques have advanced, the ability to detect and target smaller lesions has improved, allowing earlier diagnosis and treatment.3 adult data suggest that image-guided biopsies are faster and less invasive, and thus safer and cheaper than open surgical incisional biopsy.4 although open biopsy has historically provided better diagnostic yield, fnab and cnb have generally become the first-line procedures without sacrificing diagnostic outcome.4 although cnb yields more tissue for evaluation, it is generally performed with a larger-bore needle (14to 20-gauge; outer diameter 2.1 mm – 0.91 mm) whereas fnab is typically defined by the use of a ≥ 22 gauge needle (outer diameter ≤ 0.72 mm).5 larger needles have the potential for greater tissue disruption and hence increased risk of tumour tract seeding, haemorrhage, pain and need for more formal anaesthesia.6 furthermore, compared to fnab, there is less provision for on-site evaluation of cnb sample adequacy and the cost is higher.6 fine needle aspiration biopsy advantages include rapidity of diagnosis, cost-effectiveness, multiple sampling (including primary and metastatic sites) and the inclusion of small lesions such as lymph nodes. the capacity for numerous ancillary investigations, namely immunocytochemical stains and molecular investigations has enabled fnab to achieve high sensitivity and specificity.7 rapid on-site evaluation (rose) is a cytopathologic diagnostic adequacy assessment of individual biopsy passes performed during a biopsy procedure in order to optimise the procedure itself and inform subsequent patient management.8 it improves diagnostic yield while minimising the risk of multiple needle passes.1 furthermore, therapeutic aspiration is also possible in cases with cysts, which is not possible with cnb.6 while certain studies have documented higher fnab sensitivity compared to cnb,9,10 others have shown the converse.11,12 these discrepant reports highlight the challenge of accurately determining relative performance due to the interplay of multiple objective and subjective parameters.6,7 these include operator factors (radiologist and cytopathologist experience), the availability of cytopathology rose, lesional features (palpability, size, overt malignancy) and imaging equipment performance.6,7 primary paediatric tumour cytological diagnosis by image-guided fnab with rose has not gained wide acceptance despite increasing publications in support of the procedure.13 this procedure has the potential to shorten the time to definitive diagnosis thereby facilitating an earlier start to treatment, particularly in institutions where paediatric surgery theatre time is limited. in this study at a tertiary south african academic centre, we retrospectively audited consecutive paediatric image-guided fnab with rose to evaluate the procedure’s diagnostic yield and accuracy. these parameters were assessed by clinico-pathological-radiological correlation with treatment response and follow-up where needed and/or subsequent histological specimen diagnosis. research methods and design this was a five-year, retrospective, descriptive, non-experimental, cross-sectional study conducted from 01 january 2014 through 30 april 2020 at tygerberg hospital, cape town, south africa. all consecutive image-guided fnab procedures with rose for deep organ tumours in children 0–17 years were included. cases without histological confirmation or adequate clinico-pathological-radiological correlation were excluded. the anonymised data collection form included demographic and clinical data, the anatomical site, radiological characteristics of the lesion, procedural complications, fnab and ancillary pathological test results and the histopathological diagnosis. clinical information was obtained from patient records, radiology images and results were obtained from the picture archiving and communication system (pacs) electronic radiology platform and pathology laboratory results from the national health laboratory services electronic platform. the majority of the paediatric fnab procedures were synchronised with the imaging studies. most lesions were located in the abdomen, and thus typically required staging mri abdomen and ct chest studies. at our institution these studies are performed sequentially, most commonly under general anaesthesia or conscious sedation. this provides an opportunity for synchronised sampling while the patient is still on the ct machine table, that is, immediately after the staging ct chest study, and takes advantage of the same anaesthesia. in our experience, this results in increased operational efficacy, without sacrificing patient safety standards. alternatively, for the remainder of cases or where patients already had the required imaging studies done at peripheral centres, the patients were booked on a dedicated elective paediatric interventional radiology list done once a week under general anaesthesia. post-procedure, the patients were monitored overnight for complications in the paediatric oncology unit and discharged the following day if continued admission was not required. all fnab cases in this cohort were performed with ultrasound guidance utilising a 22-gauge needle. biopsies were conducted by the interventional radiology team, with rose evaluation by the attending cytopathologist. histology where available, as well as relevant clinical and laboratory correlation were used as the control for the measurement of the study question. cases with no clinical, laboratory and histology correlation were excluded. statistical analysis for statistical computation purposes, both the cytological and surgical diagnoses were categorised into four groups: benign, atypical/indeterminate, malignant, and insufficient for diagnosis (table 1). ‘atypical’ and ‘suspicious for malignancy’ were considered and categorised as ‘positive for tumour’ for statistical computation purposes. each of these lesions was assigned to a specific diagnostic category (true positive, true negative, false positive, false negative or excluded). table 1: summarised results and diagnostic categories. the sensitivity, specificity, diagnostic yield, accuracy, negative and positive predictive values were calculated as a proportion of the total cases. basic descriptive statistics were used to describe demographic data, tumour type, site and size. ethical considerations the study was approved by the stellenbosch university health research ethics committee (hrec1-2021-13195). a waiver of informed consent was obtained as the risk to participants for participating in this retrospective study was minimal. data was anonymised by the allocation of a unique study number. results sixty-five cases met the inclusion criteria, with only one case excluded from the calculation of the study question due to patient demise prior to both histological confirmation and adequate clinico-pathological-radiological correlation. in this study cohort (male:female = 1.0:2.5), the mean age was 47.5 months, median age 34 months, range of five days to 17 years and interquartile range q1 = 15; q3 = 65. the diagnosis in five fnab cases was benign (one normal liver; four non-neoplastic acute or chronic inflammation), one was classified as atypical/suspicious/indeterminate, 52 were malignant and seven samples were insufficient for diagnosis. table 1 summarises the diagnostic categories outlined. the majority of lesions were in the abdomen (54/65; 83.1%), followed by pelvis (4/65; 6.1%), chest (2/65; 3.1%), neck (2/65; 3.1%) and miscellaneous sites (3/65; 4.6%) (table 2). the kidney (20/65; 30.7%) was the commonest organ biopsied or site of primary tumour. table 2: anatomical location. table 3 illustrates histologically confirmed tumour types, age distribution and average tumour size at the time of sampling. nephroblastoma (23/65; 35.4%) was the most common diagnosis, followed by neuroblastoma (8/65; 12.3%), hepatoblastoma (8/65; 12.3%), lymphoma (4/65; 6.2%) and other (10/65; 15.4%). rhabdomyosarcoma (118 × 100 × 146mm) had the largest average size, followed by nephroblastoma (110.12 × 98.2 × 105.83mm) and hepatoblastoma (99.25 × 108.38 × 136.25mm). from the eight cases of neuroblastoma, two were n-myc amplified, one showed n-myc gain and four were negative. assessment of n-myc gene amplification was performed using the fluorescent in situ hybridization technique (fish), with four samples each documented as fnab cell blocks and bone marrow aspirates respectively. of the four fnab cellblock samples, three samples yielded sufficient n-myc classification (n-myc negative = 2 cases; n-myc gain = 1) with unsuccessful analysis in one case. table 3: histologically confirmed malignant tumours. the average turnaround time for a final fnab result publication on lab trak was 4.7 days, whereas the average turnaround time for a formal histology result was 11.5 days. provisional/verbal fnab with rose results are, however, typically provided at the time of sampling. there was only one case of a minor peri-procedural complication (1.5%), that is, a small haematoma which resolved on manual compression and required no further intervention. diagnostic yield and accuracy of the 65 fnab cases, seven cases (10.7%) were inadequate (no cells or too few cells) for diagnosis to be confirmed with fnab (figure 1). of the remaining 58 cases, 52 (89.7%) were diagnosed as malignancies and 51 (98%) of those had a corresponding histological specimen. the one case that did not have a corresponding histological specimen was diagnosed as nephroblastoma on clinico-radiological grounds and fnab, however this patient died of sepsis prior to surgical resection, therefore the diagnosis was not confirmed. this case was excluded for the statistical measurement of diagnostic yield and accuracy, as there was no histology available. figure 1: breakdown of fnab with rose results. the six cases (10.3%) that were not confirmed malignancies by fnab included one case which was diagnosed as a cyst of indeterminate origin (atypical) with a differential diagnosis of cystic nephroma, cystic partially differentiated nephroblastoma and cystic nephroblastoma. this case was subsequently confirmed to be a cystic nephroblastoma on resection specimen histology. the other five cases were diagnosed as either an inflammatory or infective lesion or normal tissue (table 1). these cases had no histological follow-up specimen; however, the diagnoses were accepted based on clinico-microbiological-radiological correlation. of the seven cases where a diagnosis could not be made with fnab, one case had no histological follow-up, but was diagnosed as a breast cyst on subsequent ultrasound with complete resolution on short-term follow-up. three cases turned out to be benign (arteriovenous malformation, fibrous tissue and a benign teratoma). the remaining three cases were confirmed as malignancies on histology, namely cystic nephroblastoma, desmoid fibromatosis and medullary thyroid carcinoma. of the 58 cases that had a corresponding histological diagnosis as stated above, 46 cases (79.3 %) had congruent fnab and histology results for a specific tumour diagnosis, while one case (1.7%) had an incongruent specific diagnosis: the fnab diagnosis was neuroblastoma whereas the histological diagnosis was nephroblastoma. in 10 of the 58 cases (17.2%), a malignant diagnosis was confirmed via fnab, but the specific tumour type could not be determined. the one remaining case (1.7%) had a fnab diagnosis of a paucicellular cyst comprising bland epithelial cells with a cytological differential diagnosis of mesoblastic nephroma, dysplastic kidney or cystic nephroblastoma. the final histological diagnosis was cystic nephroblastoma. as described above, one case was diagnosed on fnab as neuroblastoma but after histological review of the resection specimen, the diagnosis was changed to nephroblastoma. this error is thought to have been caused by under sampling, as only the neuroepithelium that was present in the nephroblastoma was aspirated and based on this feature a diagnosis of neuroblastoma was issued. the neuroblastic epithelium was confirmed by immunocytochemical stains on the cell block but the nephroblastoma tissue was not represented on the cytology specimen. of the 10 cases diagnosed as malignant on fnab but where a specific diagnosis could not be determined, non-specific malignant cells were identified in six cases and small round blue cell tumour cells in four cases. the ‘undifferentiated malignant cells’ cases had the following corresponding histological diagnoses: angiosarcoma (n = 1); desmoplastic small round blue cell tumour (dsrct) (n = 1), rhabdomyosarcoma (n = 1), myoepithelial carcinoma (n = 1), kaposiform haemangioendothelioma (n = 1) and non-hodgkin’s anaplastic large t-cell lymphoma (n = 4). for the angiosarcoma, dsrct and rhabdomyosarcoma cases, the cell block contained no cells and hence no immunocytochemical stains could be performed. for the myoepithelial carcinoma, kaposiform haemangioendothelioma and lymphoma cases, the cell block contained cells and immunocytochemical stains were performed but a specific diagnosis could not be reached. of the four cases described as small round blue cell tumour on fnab, three were histologically confirmed as nephroblastoma, while the remaining one case was confirmed as a neuroblastoma. the overall diagnostic yield was 98.5%, with a sensitivity of 94.5% and specificity of 100.0%. the diagnostic fnab accuracy was 95.3%, with a positive predictive value of 100.0% (i.e., there were no false positive diagnoses on fnab in this series), and a negative predictive value of 75.0%. the low negative predictive value is attributable to the insufficient samples on fnab. the specific entity diagnostic rate was 72.0%. imaging observations fifty-six of the 65 cases (86.2%) were predominantly solid lesions, with six (9.2%) being solid-cystic (complex) lesions and three (4.6%) predominantly cystic lesions. of note, inadequate samples accounted for 7.1% (four cases out of 56), 16.7% (one case out of six) and 66.7% (two cases out of three) of these categories, respectively. restricted diffusion restricted diffusion on mri (low apparent diffusion coefficient (adc) and high diffusion-weighted imaging (dwi) signal at high b values) was reported in 26 cases (40.0%) of which 11 cases were nephroblastoma (42.3%); eight cases hepatoblastoma (30.8%); four cases neuroblastoma (15.4%); and one case each of lymphoma, rhabdomyosarcoma, and dsrct. of note, all 26 cases (100%) that demonstrated restricted diffusion had a cytologically adequate specimen and were confirmed malignant on both cytology and histology, suggesting that highly cellular tumours may be more amenable to a correct fnab diagnosis as a first line, with both a high diagnostic yield (100%) and accuracy (100%) respectively in this cohort. nephroblastoma as mentioned, the most common malignancy was nephroblastoma (23/65; 35.4%) with an average three-dimension orthogonal tumour size of 110.12 × 98.20 × 105.83 mm at the time of imaging (second largest). of the 24 confirmed primary renal tumours (23 nephroblastoma; one renal rhabdoid tumour), 20 (83.33%) representing the vast majority had an identifiable claw sign on mri (figure 2). of these 20 cases, the primary radiological diagnosis was nephroblastoma in 18 cases (90.0%), with two cystic lesions diagnosed as multilocular cystic nephroma. of the 18 radiologically diagnosed nephroblastoma cases demonstrating a claw sign, seventeen (94.4%) were subsequently confirmed as nephroblastoma (16 on both fnab and histology; one on fnab alone as no resection was performed due to death), with one misdiagnosed case which was subsequently confirmed to be a renal rhabdoid tumour. figure 2: (a) axial t2w and (b) coronal t2w images demonstrate a large heterogeneously hyperintense mass with sharp angles (red arrows) on either side of the surrounding normal renal parenchyma described as the ‘claw sign’, in keeping with renal origin. (c) shows cytological image of blastema cells dispersed with tubule formation (red arrow). the tubules are more rigid and seem to form a tubular structure (papanicolaou stain 20×). (d) higher magnification shows a tubule with surrounding basement membrane material (greenish in colour) (papanicolaou stain 40×). one of the four remaining confirmed renal cases without a claw sign present was the case that was misdiagnosed as neuroblastoma, both radiologically and on fnab, and for which the resection histology confirmed a diagnosis of nephroblastoma. this misdiagnosis was attributed to the massive nature of the lesion, however when the images were reviewed again, a claw sign was identified on the t2w coronal sequence (figure 3). figure 3: (a) axial t2w image demonstrated a massive heterogeneous intra-abdominal mass (white arrow), which appeared to arise from the retroperitoneum, and crossed the midline to the contralateral side. exit foramina were, however, intact. (b) coronal t2w image of the same patient, demonstrated a left renal claw sign (white arrows), in keeping with renal origin. this claw sign was initially missed which resulted in an incorrect primary radiological diagnosis of neuroblastoma instead of nephroblastoma. (c & d) cytology shows small blue cells with round-oval nuclei with a pinpoint nucleolus lying associated with a green fibrillar matrix (red arrow) which is neuropil. this was interpreted as neuroblastoma as the only component present on the fnab (papanicolaou stain, 40×). neuroblastoma and hepatoblastoma the second most common tumours were neuroblastoma (figure 4 and figure 5) and hepatoblastoma (figure 6) with eight cases each (12.3%). figure 4: (a) t1w and (b) t2w axial slices demonstrate a large left retroperitoneal mass (blue arrows) with t1w heterogeneously hypointense signal, and areas of increased signal likely representing subacute to chronic haemorrhage; t2w heterogeneously hyperintense signal. the mass anteriorly crosses the midline, displacing and encasing vessels and posterolaterally abuts and displaces the left kidney (white arrow). no claw sign is present. findings are consistent with a neuroblastoma. (c) shows a papanicolaou stain confirming a neuroblastoma with neuroblasts lying pink fibrillary stroma (neuropil) (green arrow) (20×). (d) shows a giemsa stain with metachromatic, fibrillary neuropil with small blue neuroblasts (40×). figure 5: (a) t1w and (b) t2w axial images demonstrate a large lobulated left sided heterogeneous intra-abdominal mass (red arrow heads), t1w hypointense, t2w moderately hyperintense with restricted diffusion (high signal on [c] diffusion-weighted imaging with corresponding low signal on [d] apparent diffusion coefficient white arrow head). the mass encases and displaces vessels (red arrow), crossing the midline to the contralateral side. no infiltration of neural foramina on limited axial slices. (e) cytology image showing small primitive hepatocytes in a small, cohesive, tissue fragment. the cells are small with minimal cytoplasm, round nuclei with nucleoli (papanicolaou stain, 40×). (f) a larger tissue fragment showing hepatoblasts growing in sheets and semi-trabeculae. in one area sinusoidal cells line the edge of the trabeculae (sinusoidal rapping) (white arrow) (papanicolaou stain, 40×). figure 6: (a & b)t1w and t2w axial images illustrate a large heterogenous t1w hypointense, t2w hyperintense round hepatic mass (blue arrows) replacing the left liver lobe. the mass demonstrates areas of mild restricted diffusion on dwi and adc sequences (c & d). pseudo tumour lesions two pseudo tumour lesions were identified, both with an initial radiological diagnosis of rhabdomyosarcoma, which were subsequently confirmed as benign fibro-connective tissue and an abscess on fnab, respectively (figure 7 and figure 8). figure 7: t1w and t2w axial images illustrated a right paraspinal muscle lesion (red arrows), t1w markedly hypointense, and t2w iso to hypointense suspected radiologically to be a mass, subsequently confirmed as benign fibro-connective tissue. figure 8: (a) mri images: t2w coronal image illustrated a heterogenous left flank abdominal wall lesion (white arrow), with a central area of hyperintense signal. the lesion demonstrated restricted diffusion on (b) diffusion-weighted imaging and (d) apparent diffusion coefficient. this lesion, initially suspected to be a mass, was subsequently confirmed to be an abscess on fine needle aspiration biopsy, with an aspirate of pus. (d) shows a giemsa stain showing acute and chronic inflammatory cells with numerous bacterial cocci in the background (white arrow) (giemsa stain, 40×). discussion in this study, fnab performed under ultrasound-guidance was quick and relatively easy with only one minor complication observed. the procedure is mostly performed post mri and ct scan imaging under the same anaesthesia/sedation which in our experience results in increased operational efficiency. the overall diagnostic fnab yield was 98.0%, with a 72.0% diagnostic accuracy for a specific lesion diagnosis (overall diagnostic accuracy 95.3%) which is comparable to similar other studies.14,15,16,17,18 a treatment plan could be initiated in most cases based on a specific diagnosis confirmed via fnab. in a resource-limited setting, with a high pressure on theatre facilities, image-guided fnab with rose is a valuable and accurate diagnostic modality as a first line investigative tool. though cnb is viewed as diagnostically superior and able to provide more tissue for ancillary investigations, fnab offers a viable alternative with fewer side effects and less risk for tumour spillage19,20. additionally, not all lesions are malignant or lend themselves to cnb, either due to their location and/or vascularity, size, or a poor patient health status. surgical biopsy performed in theatre is available, but in our setting, there is a trade-off with either a prolonged waiting time for surgery on an emergency theatre list (often days) or postponing the surgical management of another patient already on a routine surgical list to make space for the new patient with a suspected tumour. hence image-guided biopsies in the radiology department are preferable for expedited diagnosis and initiation of management. the international society of paediatric oncology (siop) treatment protocol for renal tumours does not require a tissue diagnosis for initiation of pre-operative chemotherapy.21 we found that performing a fnab at the time of diagnostic imaging was of value to the paediatric oncology team as it confirmed malignancy in all 22 solid renal lesions, with 21 of the 22 (95.5%) lesions diagnosed correctly. one renal rhabdoid tumour was diagnosed on fnab while radiologically being suspected as a nephroblastoma. this early correct diagnosis allowed the paediatric oncology team to schedule additional staging investigations required for this malignancy and assisted in providing more accurate information regarding prognosis and the treatment plan, which could be shared with the patient’s parents. in addition, the imaging claw sign is sensitive in accurate identification of an intra-renal mass, however this has a low specificity, particularly for the larger tumour sizes at presentation seen in developing countries.22 this study, however, found that multicystic renal lesions do not lend themselves to fnab, as sampling is inadequate. two such lesions were confirmed as cystic partially differentiated nephroblastoma and cystic nephroblastoma on histopathology. we suspect that the yield of cnb would not be significantly better in this scenario. in the age of personalised medicine, fnab is not always viewed as adequate for a complete diagnosis given a large number of available molecular diagnostics including genetic tests, biomarker tests, and companion diagnostics.23 however, in a resource-limited setting, the use of large numbers of tumour biomarkers is not available. preparation of fnab cell blocks allows the identification of some biomarkers, making the use of fnab even more compelling and a very viable alternative. neuroblastomas are a good example of such a situation. seven cases were diagnosed correctly with one case being misdiagnosed as a neuroblastoma on fnab and which turned out to be a nephroblastoma on resection histology. as mentioned, this misdiagnosis was due to under sampling of the tumour with only the neuroepithelial component being sampled. this case was further complicated with a conflicting radiological differential diagnosis and some uncertainty whether it primarily arose in the kidney or affected it secondarily. the authors propose that if there is conflicting radiological-pathological diagnosis that a formal biopsy be performed for a definitive diagnosis. the weakness of fnab is that it is unable to identify a specific subtype diagnosis and perform the mitotic-karyorrhectic index that is needed for neuroblastoma histological subclassification. however, as most of our neuroblastoma cases are metastatic at presentation often with more than one image-defined risk factor, the fnab weakness can be mitigated as an international neuroblastoma pathology classification (the shimada system) is not absolutely required for diagnosis in such cases.24,25,26 fnab yielded valuable information about the n-myc status in three of our cases. of the eight hepatoblastomas in this cohort, fnab managed to diagnose all correctly. two cases were children less than six months old, three were between six months and three years and the remaining three cases were older than three years. histology is usually needed prior to commencement of chemotherapy in children younger than six months, older than three years or if a normal serum alpha fetoprotein (afp) is present.27,28,29 as the majority of our hepatoblastoma cases occurred in these age groups (5/8; 62.5%), fnab assisted in providing a rapid diagnosis after which treatment could be initiated. soft tissue sarcomas can be diagnosed on fnab; however, this may be challenging and the reasons are threefold: (1) reactive cellular / pseudo malignant changes in aspirated surrounding tissues; (2) poor yield or technically inferior smears and more commonly (3) misinterpretation of the aspirated cells due to numerous subtypes and morphological heterogeneity.30 one of the dsrct cases was diagnosed accurately including the ewing sarcoma breakpoint (ewsr) translocation. in the second case there was no material on the cell block for ancillary investigations. this also held true for the cases of angiosarcoma and rhabdomyosarcoma. in the cases of myoepithelial carcinoma and anaplastic large t-cell lymphoma, the immunostains could not confirm the true nature of these cells and a diagnosis of kaposiform haemangioendothelioma is deemed extremely difficult as it is a rare tumour. key radiological descriptors of tumours include the presence of restricted diffusion, which suggests highly cellular lesions or cellular swelling.31 all cases which demonstrated restricted diffusion on imaging, had adequate samples and appropriate diagnoses on fnab with rose, suggesting that high cellularity increases diagnostic yield. although fnab is not the preferred modality of diagnosis in many centres, particularly where there is a need to determine multiple tumour biomarkers; it does, however, offer a viable alternative to other modes of biopsy and is an excellent companion to a cnb. our cohort shows that fnab can provide a diagnosis that is adequate for initiation of therapy in many cases. as ancillary techniques evolve and become easier and more affordable, we are certain that fnab with cell block material will be able to play a larger and more important role in tumour diagnosis and management. study strengths and limitations the multidisciplinary involvement of pathology, radiology and oncology divisions in this study will potentially result in optimised practices and ultimately improved patient experience and diagnosis. in addition, the retrospective nature of the study reduces the risk of interpreter bias, however on the same note the retrospective nature may not be representative due to the possibility of missed / lost data. future recommendations an important next step would be to further evaluate the role of imaging findings, in particular the presence of restricted diffusion to guide patient selection for paediatric imaged-guided fnab with rose. it would also be important to explore the impact of the use of fnab with rose on clinical outcomes. conclusion paediatric imaged-guided fnab with rose has a relatively high diagnostic yield, sensitivity, specificity, positive predictive value and accuracy in the diagnosis of suspected malignancy. it offers a fast, viable and safe alternative diagnostic modality to diagnose such tumours, particularly when correlated with imaging findings. the relatively low negative predictive value in this study was attributed to a number of insufficient samples, particularly from cystic and benign lesions. acknowledgements the research team wishes to thank the health research and ethics committee (hrec), the departments of radiology, anatomical pathology, oncology, paediatrics and child health at stellenbosch university, tygerberg hospital. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions t.b. was responsible for radiological and laboratory data collection, literature research and manuscript preparation. p.s. and a.v.z. were responsible for cytological and clinical data review. t.b., p.s., a.b., a.v.z. and r.p. were responsible for literature review, study concepts, analytical data review and manuscript editing. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability raw data mined using tygerberg hospital records. data analysis findings are available from the corresponding author t.b. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references lipnik aj, brown db. image-guided percutaneous abdominal mass biopsy. technical and clinical considerations. radiol clin north am. 2015;53(5):1049–1059. https://doi.org/10.1016/j.rcl.2015.05.007 bruening w, 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[cited 2022 apr 17]. available from: https://cisncancer.org/personalized_medicine/molecular_diagnostics_types.html tanaka y, kawashima h, mori m, et al. contraindications and image-defined risk factors in laparoscopic resection of abdominal neuroblastoma. pediatr surg int. 2016;32(9):845–850. https://doi.org/10.1007/s00383-016-3932-z shimada h, ambros im, dehner lp, et al. the international neuroblastoma pathology classification (the shimada system). cancer. 1999 jul 15;86(2):364–72. https://doi.org/10.1002/(sici)1097-0142(19990715)86:2<364::aid-cncr21>3.0.co;2-7 parikh ns, howard sc, chantada g, et al. siop-podc adapted risk stratification and treatment guidelines: recommendations for neuroblastoma in lowand middle-income settings. pediatr blood cancer. 2015;62(8):1305–1316. https://doi.org/10.1002/pbc.25501 maibach r, roebuck d, brugieres l, et al. prognostic stratification for children with hepatoblastoma: the siopel experience. eur j cancer. 2012;48(10):1543–1549. https://doi.org/10.1016/j.ejca.2011.12.011 zhou s, malvar j, chi yy, et al. independent assessment of the children’s hepatic tumors international collaboration risk stratification for hepatoblastoma and the association of tumor histological characteristics with prognosis. jama netw open. 2022;5(2). https://doi.org/10.1001/jamanetworkopen.2021.48013 de ioris m, brugieres l, zimmermann a, et al. hepatoblastoma with a low serum alpha-fetoprotein level at diagnosis: the siopel group experience. eur j cancer. 2008;44(4):545–550. https://doi.org/10.1016/j.ejca.2007.11.022 akerman m, domanski ha. the cytology of soft tissue tumours. 2003;16. https://doi.org/10.1159/isbn.978-3-318-00986-6 bashir u, baba y. diffusion-weighted imaging. radiopaedia. 2012:1–5. https://doi.org/10.53347/rid-16718 abstract introduction patient presentation testing, management and outcome discussion conclusion acknowledgements references about the author(s) humphrey mapuranga department of radio-diagnosis, faculty of medical imaging and clinical oncology, tygerberg hospital, stellenbosch university, cape town, south africa bianca douglas-jones department of medical genetics, division of molecular biology and human genetics, tygerberg hospital, stellenbosch university, cape town, south africa danelo du plessis department of surgery, division of urology, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa camilla e. le roux department of radio-diagnosis, faculty of medical imaging and clinical oncology, tygerberg hospital, stellenbosch university, cape town, south africa christel du buisson department of paediatrics and child health, paediatric nephrology, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa shahida moosa department of medical genetics, division of molecular biology and human genetics, tygerberg hospital, stellenbosch university, cape town, south africa citation mapuranga h, douglas-jones b, du plessis d, le roux ce, du buisson c, moosa s. a rare case of tuberous sclerosis complex-associated renal cell carcinoma. s afr j rad. 2022;26(1), a2406. https://doi.org/10.4102/sajr.v26i1.2406 project research registration: project number: 23549 case report a rare case of tuberous sclerosis complex-associated renal cell carcinoma humphrey mapuranga, bianca douglas-jones, danelo du plessis, camilla e. le roux, christel du buisson, shahida moosa received: 23 jan. 2022; accepted: 23 mar. 2022; published: 20 may 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract renal cell carcinoma is rarely described in paediatric patients with tuberous sclerosis complex. this report describes a case of an 11-year-old male with tuberous sclerosis-associated renal cell carcinoma. keywords: tuberous sclerosis complex; renal cell carcinoma; paediatric; neuro-cutaneous; hamartomas. introduction tuberous sclerosis complex (tsc) is one of a large heterogeneous group of neurocutaneous syndromes with characteristic involvement of structures derived from embryologic neuro-ectoderm, and a prevalence of 1 in 6000–10 000 persons. the disease is characterised by slow-growing hamartomas with multisystem involvement being typical. tuberous sclerosis complex is an autosomal-dominant disorder, caused by heterozygous variants in one of the two genes: tsc1, which encodes for hamartin (located on chromosome 9q34), or tsc2, which encodes for tuberin (located on chromosome 16p13.3). hamartin and tuberin act together as tumour suppressors and are components of the mammalian target of rapamycin (mtor) signalling pathway.1,2 a clinical diagnosis of tsc is established if the individual has (1) two major clinical criteria, (2) one major and two or more minor criteria, or (3) the identification of a pathogenic variant in either tsc1 or tsc2 on genetic testing. major criteria include multiple angiofibroma (≥ 3), cardiac rhabdomyoma, cortical dysplasias including tubers and white matter migration lines, hypomelanotic macules (≥ 3 mm of > 5 mm in diameter), lymphangioleiomyomatosis, retinal nodular hamartomas, shagreen patches, subependymal giant cell astrocytomas, subependymal nodules and ungual fibromas. minor features include ‘confetti’ lesions on the skin, dental enamel pits, intraoral fibromas, multiple renal cysts, non-renal hamartomas and retinal achromic patches. angiomyolipomas (amls) are the most common renal lesions associated with tsc and are present in 75% – 80% of patients. renal cell carcinomas (rccs) are very rare in patients with tsc (1% – 4%) (2). moreover, the average age of diagnosis of rcc in patients with tsc is 30 years, with the youngest tsc-associated rcc reported in a 6-month-old girl.3 the clear cell, papillary and chromophobe rcc subtypes have been described in association with tsc.1,4 renal cysts and oncocytomas may also occur.1,4 this report describes a unique case of an 11-year-old boy with confirmed tsc-associated rcc and highlight his management. patient presentation an 11-year-old boy was referred to paediatric nephrology at tygerberg hospital with a clinical concern of hypertension following a seizure at his local hospital. he had a history of generalized tonic-clonic seizures from the age of three years. the seizure episodes were managed and controlled with sodium valproate. at presentation, he was fully awake and alert but persistently hypertensive with a blood pressure higher than the 95th percentile for his height, age and gender. the patient was examined by a medical geneticist, and the clinical diagnosis of tsc was made, based on fulfillment of two major criteria: (1) > 3 hypomelanotic macules of > 5 mm in diameter, and (2) facial angiofibromas, in addition to further tsc-related features, like multiple ‘confetti’ skin lesions on his neck and chest and the clinical suspicion of multiple renal cysts. based on the cystic kidneys, a contiguous gene deletion involving both tsc2 and pkd1 on chromosome 16p13.3 was considered as part of the differential molecular diagnosis, in addition to variants in tsc1 or tsc2. initial imaging evaluation at our institution included renal ultrasound, which demonstrated multiple bilateral mild to markedly hypoechoic cortical masses (figure 1a and b). magnetic resonance imaging (mri) of the brain and abdomen was subsequently performed. figure 1: (a) eleven-year-old male. longitudinal greyscale ultrasound right kidney. multiple markedly hypoechoic parenchymal masses were demonstrated (white arrows). (b) longitudinal greyscale ultrasound left kidney. large midpole mildly hypoechoic mass (white arrow). brain imaging demonstrated t2-weighted hypointense subependymal nodules (figure 2a and b) with a subependymal giant cell astrocytoma (figure 2a to d). fluid-attenuated inversion recovery (flair) demonstrated multiple hyperintense cortical tubers (figure 2c) and hyperintense white matter radial bands (figure 2e). no retinal hamartomas were identified. figure 2: (a) eleven-year-old male. t2w axial demonstrates numerous hypointense subependymal nodules (white arrows). (b) t2w axial demonstrated large subependymal giant cell astrocytoma (sega), with hypointense signal (white arrow). additional subependymal nodule (black arrow). (c) fluid inversion axial demonstrates hyperintense tubers (white arrows). (d) axial t1-weighted precontrast image. iso-intense subependymal nodule (white arrow). subependymal giant cell astrocytoma (black arrow). (e) axial fluid-attenuation inversion recovery (flair) hyperintense white matter radial bands (white arrows). abdominal mri demonstrated numerous bilateral renal cortical t2-weighted hypo to hyperintense (figures 3a and b), t1-weighted hypointense mass lesions (figure 4a). fat suppression failed to demonstrate fat content (not shown). post-contrast enhancement of bilateral renal mass lesions was seen. (figure 4b and c). time of flight mri imaging of the abdominal aorta and renal arteries excluded renal artery stenosis (not shown). a radiological guided biopsy of the left midpole lesion was performed and confirmed tuberous sclerosis-associated rcc of the left kidney. figure 3: (a) prior to treatment. t2-weighted coronal. enlarged left kidney with multiple bilateral hyperintense (white arrows) and more hypointense masses (black arrows). (b) t2-weighted trufi coronal post-sirolimus and radiofrequency ablation of the left midpole renal cell carcinoma, with size reduction of left upper pole (white arrow) and midpole renal cell carcinoma ( black arrow). figure 4: (a) t1-weighted axial abdomen demonstrates bilateral iso-intense renal mass lesions (white arrows). (b) t1-weighted axial abdomen post-contrast demonstrated enhancement of the bilateral renal mass lesions (black arrows). (c) t1-weighted coronal abdomen post-contrast demonstrates enhancement of bilateral renal mass lesions (white arrows). no concrete evidence of cardiac abnormalities, specifically rhabdomyomas, was found on echocardiogram. testing, management and outcome genetic testing was performed in a stepwise manner. first, a chromosomal microarray was done and excluded the presence of a contiguous gene deletion on chromosome 16p13.3. the next step in testing was a tsc gene panel (invitae, united states [us]), which included sequencing and deletion/duplication analysis of tsc1 and tsc2. this showed a pathogenic variant in tsc2 (c.5238_5255del; p.his1746_arg1751del), which is a known pathogenic variant and definitively confirms the diagnosis. the patient was started on sirolimus (a oral mtor inhibitor) to treat his central nervous system (cns) lesions. due to the absence of demonstrable fat on mri, a renal biopsy of the left midpole lesion was performed, which confirmed the diagnosis of tuberous sclerosis-associated rcc of the granular eosinophilic and macrocystic subtype. the renal nephrometry score of the left midpole lesions was 11p, indicating a high complexity. given the complexity and number of lesions, nephron sparing surgery was deemed too high a risk. we performed percutaneous ultrasound-guided microwave ablation (emprint ablation system, medtronic) to treat the lesions in the left kidney, average wattage of 50 w and ablation time 6 min 30 s per lesion. technical success was confirmed at post-ablation mri (figure 3b). interval microwave ablation of the right renal lesions will be performed. the patient did not experience any post-ablation complications. discussion this patient had obvious features of tsc including, seizures due to underlying brain abnormalities, typical skin lesions, and hypertension as the presenting sign of underlying renal anomalies. with the identification of a pathogenic variant in tsc2, his condition was molecularly confirmed and enabled accurate genetic counselling. up to two-third of patients with tsc have the condition due to a de novo (new) mutation. the risk to his offspring of inheriting the tsc2 variant is 50%. renal lesions occur in 50% – 80% of patients with tsc, with amls being the most common (75% – 80%). angiomyolipomas may be classified according to fat content into lipid rich, lipid poor and lipid absent.5 renal cysts may also be identified in patients with tsc.4 while most rccs occur sporadically, 3% – 5% are associated with hereditary syndromes, like von-hippel lindau (vhl) disease, hereditary papillary rcc, and birt–hogg–dubé (bhd) syndrome which is the most common. renal cell carcinoma is very rare in tsc (< 3% of patients) and even rarer in the paediatric population (average age is 30 years).4 treatment principles for these patients are cancer control, rather than cure, while preserving renal function. rcc develops metastatic potential as the size increases, and if individual tumour size can be kept below 3 cm – 7 cm in maximal diameter, the risk of metastases is estimated at less than 4%. treatment should be nephron sparing, either surgical or using ablative therapy.6,7 everolimus, an oral mtor inhibitor, is effective in treating tsc-associated lesions, not only in the kidney, but also in the cns; however, it is not recommended for the treatment of non-metastatic rcc.8,9 renal cysts or polycystic kidney disease can develop in patients with tsc. as opposed to renal amls, renal cysts occur in younger children. although renal cysts are generally asymptomatic, they can more frequently cause subsequent hypertension with rapid progression to end-stage renal failure.10,12 thus, screening and treating hypertension and proteinuria, as well as preserving renal tissue, with the use of mtor inhibitors, and sparing of renal tissue are advocated.11,13 conclusion microwave ablasion of selected cases of tsc-associated rcc, in conjunction with everolimus, is a cornerstone of treatment for renal and central nervous system lesions in tsc. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.m. was the primary author; c.e.l.r and s.m. provided overall guidance in article preparation and write up. c.d.b. and d.d.p contributed equally to the case, providing clinical input and patient management details. s.m. and b.d.-j. assessed the patient, made the clinical diagnosis and interpreted the genetic test results. ethical considerations ethical clearance to conduct this study was obtained from stellenbosch university health research ethics committee (number c21/11/039). consent for case publication was obtained from the guardian, the patient’s mother. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references yang p, cornejo km, sadow pm, et al. renal cell carcinoma in tuberous sclerosis complex. am j surg pathol. 2014;38(7):895–909. https://doi.org/10.1097/pas.0000000000000237 verine j, pluvinage a, bousquet g, et al. hereditary renal cancer syndromes: an update of a systematic review. eur urol. 2010;58:701–710. https://doi.org/10.1016/j.eururo.2010.08.031 breysem l, nijs e, proesmans w, smet mh. tuberous sclerosis with cystic renal disease and multifocal renal cell carcinoma in a baby girl. pediatr radiol. 2002;32(9):677–680. https://doi.org/10.1007/s00247-002-0765-9 northtup h, krueger da, international tuberous sclerosis complex consensus group. tuberous sclerosis complex diagnostic criteria update: recommendations of the 2012 international tuberous sclerosis complex consensus conference. paediatr neurol. 2013;49(4):243–254. song s, park bk, park jj. new radiologic classification of renal angiomyolipomas. eur j radiol. 2016;85(10):1835–1842. https://doi.org/10.1016/j.ejrad.2016.08.012 pavlovich cp, schmidt ls. searching for the hereditary causes of renal-cell carcinoma. nat rev cancer. 2004;4:381–393. https://doi.org/10.1038/nrc1364 gupta gn, peterson j, daryanani ka, et al. oncologic outcomes of partial nephrectomy for multifocal renal cell carcinoma with tumors greater than 4 cm. j urol. 2010;184:59–63. lechuga l, franz dn. everolimus as adjunctive therapy for tuberous sclerosis complex-associated partial-onset seizures. expert rev neurother. 2019;19(10):913–925. https://doi.org/10.1080/14737175.2019.1635457 alsidawi s, kasi pm. exceptional response to everolimus in a novel tuberous sclerosis complex-2 mutation-associated metastatic renal-cell carcinoma. cold spring harb mol case stud 2018;4:1–7. https://doi.org/10.1101/mcs.a002220 nair n, chakraborty r, mahajan z, sharma a, sethi sk, raina r. renal manifestations of tuberous sclerosis complex. j kidney cancer vhl. 2020;7(3):5–19. https://doi.org/10.15586/jkcvhl.2020.131 rakowski sk, winterkorn eb, paul e, steele dj, halpern ef, thiele ea. renal manifestations of tuberous sclerosis complex: incidence, prognosis, and predictive factors. kidney int. 2006;70(10):1777–1782. crino pb. the tuberous sclerosis complex. n engl j med. 2006;355:345–356. https://doi.org/10.1056/nejmra055323 janssens p, van hoeve k, de waele l, et al. renal progression factors in young patients with tuberous sclerosis complex: a retrospective cohort study. pediatric nephrol. 2018;33(11):2085–2093. https://doi.org/10.1007/s00467-018-4003-6 editorial this editorial addresses a trend, that has become apparent over the past few years, concerning the highest healthcare professional body in the land: the health professions council (hpcsa) of south africa. a current process serves as a perfect example of how this body chooses to conduct its business. the methodology and potential outcome of the process need to be placed in the public arena, as the consequences concern all south africans. a unilateral process has been instituted by the hpcsa to embark on opening the diagnostic use of ionising radiation to all medical disciplines (specialist and non-specialist). this initiative has progressed to the point of being a fait accompli – but it has all happened without consultation and without the contribution of expert opinion in the field of radiation medicine. international academic literature – especially over the past 5 years – has emphasised the established association between radiation exposure from computed tomography (a primary concern), as well as other sources of diagnostic x-rays, that leads to a significant increase in the risk for fatal cancer over a child’s lifetime. the reviews aim to heighten awareness and spearhead efforts to reduce unnecessary radiation, and especially computed tomography (ct) scans, in children and young adults. the use of ct in these target age groups continues to grow; more than 60 million ct scans are estimated to be performed annually in the usa, of which 7 million are on children.1 education and advocacy directed to referring clinicians reinforce these principles. radiation exposure may be further reduced by developing clinical pathways that limit ct scanning and instead encourage alternative, non-radiation imaging modalities such as ultrasound and magnetic resonance imaging. we view with alarm the actions of the hpcsa against the background of the growing concerns of an alerted world towards a radiation health issue that has two disconcerting components: (i) the startling increase in radiation-induced cancers in the young, and (ii) the effect and final outcome of accumulated dose on the human genetic pool. and so, while countries with a genuine concern for the effects of medical radiation are tightening the controls, we in south africa have a council that seems recklessly intent on opening the radiation floodgates to all medical and medically-related fields (specialist and non-specialist). it is difficult to identify a rationale, as this country has an academically sound, morally strong and scientifically reliable programme for the use of ionising radiation in the diagnostic process. the specialty of diagnostic radiology, assisted by a radiation control board and several departments of medical physics, as well as other experts in the field, stand central in this process. properly trained specialists in imaging diagnosis, radiation protection and the process of weighing the potential hazards of ionising radiation against diagnostic gain, constantly ensure our international rating. so what are the motives for wanting to destroy a well-established system in good working order? some form of political expediency comes to mind. why else do we witness decisions not based on scientific fact or academic foundation, without scientific survey or consultation with professional experts, and a refusal to grasp the consequences of a radiation carte blanche to all and sundry? jan lotz editor-in-chief 1. alara: is there a cause for alarm? reducing radiation risks from computed tomography scanning in children. shah nb, platt sl. curr opin pediatr 2008; 20: 243-247. radiation free-for-all is imminent editorial 2 sa journal of radiology • march 2010 editorial.indd 2 2/26/10 9:48:43 am radioactive news radioactive news rssa cme grant report nishentha govender department of radiology, university of the witwatersrand my attendance at the 49th annual meeting of the european society of paediatric radiology, held in athens, greece, from 28 may to 1 june 2012, was made possible by the generosity of the radiological society of south africa cme association grant. this meeting provided me with an opportunity for continued learning by sharing in the experiences of international paediatric radiologists. the 2-day comprehensive junior european society of paediatric radiology (jesper) course, covering important and relevant paediatric topics, was the highlight of my trip. i was privileged to have been given the opportunity to deliver an oral presentation and to have also had the opportunity to meet the authors whom i had referenced in my research. the questions to the presenters at the meeting were as relevant and thought-provoking as the researched presentations. it was an incredible opportunity to engage with individuals who practice with such determination to deliver the best quality of care to children within their disciplines. dr nasreen mahomed of chbh also attended the meeting, and made 3 poster presentations (as reported in the last sajr), and professor andronikou delivered the jesper honorary lecture, entitled tuberculosis from a ω. information gathered at this meeting, and the people who imparted their knowledge and research, has made a huge impression on me and my understanding of the manner in which the international community practice radiology. my sincere thanks to the trustees of the rssa cme association for affording me this opportunity to attend. (from left to right) dr m riccabona, the chair of the espr uroradiology task force and esur paediatric uroradiology working group, with dr n govender and professor s andronikou, both from the university of the witwatersrand, and dr p rao, a paediatric subspecialist from the royal children’s hospital in australia. today's two signs today's two signs 68 sa journal of radiology • september 2007 today's two signs the ‘fat’ c2 refers to the apparent increase in the distance between the anterior and the posterior margins of the c2 vertebra when compared with the similar two margins of the c3 vertebrae (fig. 1) on a lateral cervical spine x-ray in a trauma setting.1 this is caused by an obliquely oriented fracture which may be obscured on anteroposterior or lateral film as the fracture lines are not perpendicular to the plane of the radiograph (fig. 2). the applied traumatic forces may cause the interruption of the anterior (with primarily hyperflexion injury) and posterior (with primarily hyperextension injury) or both (combined injury) margins with apparent enlargement of the c2.2 the recognition of fat c2 sign is important as these fractures are unstable with ligamentous disruption.2 delay in diagnosis may be devastating to the patient. 1. smoker wrk, dolan kd. the ‘fat’ c2: a sign of fracture. ajr 1987; 148: 609-614. 2. harris jh, mirvis se. injuries of diverse or poorly understood mechanisms. in: the radiology of acute cervical spine trauma. 3rd ed. baltimore, md: williams & wilkins, 1996; 421-472. the ‘fat’ c2 sign amarjit kaur bajwa, mb bs, fcrad (diag) sa anthony briede, mb bch, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg flowing blood causes a ghosting artifact in the phase-encoding direction. gradient recalled echo (gre) sequences are much more susceptible to flow artifacts than spin echo (se) sequences are.1 the use of saturation bands can decrease these artifacts. these can also be minimised using flow compensation or gradient moment nulling.1 however, this artifact can be used to diagnostic advantage. pseudoaneurysm or avascular lesion can be missed on magnetic resonance (mr) imaging even with iv contrast. surrounding haematoma of different stages can complicate the matter even further (fig. 1a). however the recognition of ghosting artifact in the phase-encoding direction in line with the lesion along with signal void on the standard se sequences are important clues to the diagnosis (figs 1b and 2). thus pulsation artifact can be used as a diagnostic clue, especially in musculoskeletal imaging where it is normally not that marked. 1. zhuo j, gullapalli rao p. mr artifacts, safety and quality control. radiographics 2006; 26: 275-297. fig. 1. the lateral cervical spine radiograph shows that the anteroposterior diameter measured between anterior and posterior margins of c2 is more than the same distance at c3 (there is no significant soft-tissue swelling present). fig. 2. axial computed tomographic (ct) scan of the same patient shows the oblique fracture not well appreciated on lateral film. the pulsation sign amarjit kaur bajwa, mb bs, fcrad (diag) sa department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg pg68-69.indd 68 9/17/07 8:56:12 am today's two signs today's two signs 69 sa journal of radiology • september 2007 fig. 1a. patient with a few months’ history of an enlarging mass in the right thigh. sagittal t1 shows a complex cystic mass with a central signal void (arrow). fig. 1b. post contrast axial t1 shows central minimal enhancement (arrow) and the pulsation artifact in the phase-encoding direction (ap) indicating the vascular origin of the lesion (thick arrows). fig. 2. ct angiography with sagittal multiplanar reconstruction confirms a pseudoaneurysm of the profunda artery (arrow). pg68-69.indd 69 9/17/07 8:56:12 am sajr 890 oncology imaging s k misser,1 mb chb, fc rad (d) sa; d d royston,1 mb bch, ff rad (sa); l v heslop,2 mb chb, ffrad t (sa) 1 lake smit and partners, durban, south africa 2 oncologist, durban, south africa corresponding author: s k misser (misser@lakesmit.co.za) a 27-year-old man presented with recent onset personality change, depression and cognitive impairment. his pacs folders revealed several prior and recent imaging studies. describe the relevant findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 11 july 2013. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr . s afr j rad 2013;17(2):74-76. doi:10.7196/sajr.890 figs 1 (left) and 2 (right). coronal flair mr images at the level of the temporal lobes. fig. 3. axial t2-weighted mr image at the level of the temporal lobes. fig. 4. coronal post-gadolinium t1-weighted mr image at the level of the temporal lobes. fig. 5. sagittal t2-weighted mri image of the lumbar spine. fig. 6. sagittal stir-mr image of the lumbar spine.   fig. 7. sagittal t1-weighted post-gadolinium mr image of the lumbar spine. fig. 8. axial ct scan image at the lung base level. fig. 9. axial t2-weighted mr image at l1 vertebral level, adjacent to the renal hilar and segment 6 of the liver. fig. 10. axial diffusion-weighted mr image at similar level as the above. fig. 11. axial adc map mr image at a slightly inferior level. fig. 12. coronal t2-weighted mri image at the epigastric region including costophrenic angles. fig. 13. axial post-primovist t1-weighted mr image at the level of segment 6 of the liver. cpd questionnaire give one correct answer for each question. a. dural sac endings range from the lower third of l5 to the lower third of s3. b. the dural sac most commonly terminates at the middle third of the s2 vertebra. c. there is no association between age and the level of dural sac termination. d. there is a significant statistical difference in the dural sac termination between male and female subjects. 1. which of the following statements is false? 2. which of the following statements is false? a. the position of the dural sac ending is of great consequence for craniospinal irradiation. b. most oncology centres extend the craniospinal irradiation field to the lower border of s2. this is adequate as fewer than 1% of dural sacs extend below this level. c. during craniospinal irradiation, the entire neuro-axis should be covered by ensuring that the dural sac is included in the spinal field. d. certain patients would remain undertreated if the lower border of the craniospinal irradiation field were placed at the inferior border of s2. 3. which of the following statements is false? a. ct detects mediastinal, airway and lung abnormalities with high accuracy, sensitivity and specificity. b. in patients with airway compression, the advantage of ct over bronchoscopy is limited. c. the introduction of mdct scanners has made it possible to acquire high-resolution images of the upper, central and segmental airways within a short acquisition time. d. chest ct is an indispensable tool for identifying airway stenoses caused by tb lymphadenopathy. 5. which of the following statements is false? a. measurements taken in lung windows consistently measure the diameter of stenoses of the central airways less than soft tissue (1.4 mm on average). b. the wide window and low-level setting of lung window should make it the desired setting for evaluating the airfilled airways. it is therefore more likely that soft tissue underestimates stenoses. c. currently, a coarse parameter of 20% luminal obstruction of a main stem or lobar bronchus is considered a significant clinical indicator for management of children with airway obstruction. d. the degree of central airway stenoses is accurately assessed on axial images, obviating the need to perform mpr to obtain a true axial diameter of the airways in children. 6. identify the false statement among the following. a. sjögrens syndrome is an auto-immune disease affecting the lacrimal and all salivary glands, but predominantly the parotid glands. b. initial periductal lymphocyte aggregates extend into, and finally destroy, salivary acinar parenchyma, which leads to small cystic spaces beginning peripherally in the gland. c. as acinar destruction progresses, salivary production decreases and ascending infections develop, eventually leading to sialectasis developing in the gland, enlargement of the microcysts and fatty replacement of the destroyed acinar within the salivary gland parenchyma. d. xerostomia (dryness of the mouth) is an infrequent oral symptom. 7. the following are true, except for: a. mr sialography is an excellent example of the technique of mr hydrography, using extremely long tr and te times to highlight fluid and suppress other surrounding tissue signals. b. hydrography is more commonly applied in other areas of the body, such as creating mr myelograms in the cervical and lumbar spine, mr cholangiopancreatograms of the biliary system, and mr renograms of the urinary tract. c. a t2w fat-suppression sequence should have the te increased from the usual 60 ms to 100 120 ms. d. in the case of parotid glands, cystic structures may not stand out clearly from the normal parenchyma, which itself is fluid-rich. a more t2-weighted series is required to highlight the cystic changes in the gland. 8. identify the false statement among the following. a. thalassaemia (the greek etymon literally means ‘anaemia of the sea’) occurs in a broad geographical band from the mediterranean through to asia. b. the cause is an inherited defect in the synthesis of one of the alpha or beta globin chains. homozygous (major) or heterozygous (minor) forms of the condition exist. c. defective globin chains lead to excessive haemolysis and compensatory haematopoeisis within bone marrow, which in turn leads to enlargement of the medullary cavities and thinning of cortices. d. in the spine, extramedullary haematopoeis is most commonly located in the lower thoracic and upper lumbar regions. 10. identify the false statement among the following. a. mermaids or sirens have been part of the cultural tradition of sailors since the earliest maritime expeditions in the western world. b. the siren myth was recorded for the first time by homer, who described in the odyssey alluring singing creatures that lured sailors to their death. c. historical texts of around 2 500 bc found in several european countries include references to female hybrids. it can be assumed that these creatures were probably individuals affected by sirenomelia, which is a rare and mostly lethal congenital anomaly characterised by rotation and fusion of the lower extremity with medial position, fusion or absence of the fibulas, and abnormalities of the lumbar and sacral spines. d. most ancient mariners preferred maidmers over mermaids (fish and female anatomy inversely proportional). cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg. co.za in the event of queries. accreditation number: mdb 001/007/01/2010 4. which of the following statements is true? a. only axial ct images are accurate in detecting airway stenoses. b. there is a significant statistical difference between axial measurements and measurements taken after mpr. c. although axial ct images are sufficient for evaluating most airway abnormalities, there are inherent limitations of axial sections for assessing the airways: • limited ability to detect subtle airway stenoses • underestimation of the craniocaudal extent of the disease • difficulty in displaying the complex 3-d relationships of the airway to adjacent mediastinal structures • inadequate representation of airways oriented obliquely to the axial plane • difficulty in assessing the interfaces and surfaces of airways that lie parallel to the axial plane. d. central airway stenoses are difficult to detect and are significantly overestimated. 9. regarding syrenomelia , identify a single false statement. a. the embryological and pathological causes of the condition occur before the 4th week to the structures derived from the caudal mesodermal axis of the embryo, extended to various cranio-caudal levels. b. although syrenomelia has been described as a rare lethal pattern of congenital anomalies, 9 mermaid cases surviving after reconstructive surgery have been reported. the most important characteristic that seems to allow survival of the affected individuals is the presence of a functional bladder. c. various teratogenic agents, maternal diabetes, caudal regression syndrome and nutritional deficit have been suggested as possible aetiological factors. d. it was previously thought that caudal regression syndrome and sirenomelia were manifestations of the same syndrome, but it seems that syrenomelia is the result of vascular steal phenomenon that causes severe ischaemia of the caudal portion of the fetus. 80 sa journal of radiology • september 2010 105 sa journal of radiology • june 2009 presentation a 50-year-old woman, known to have been recently diagnosed with advanced colonic carcinoma, and on palliative therapy, presented with an acute confusional state and associated seizures. the following mri images were obtained. cranial mri diagnosis quiz case 105 sa journal of radiology • december 2009 s k misser, mb chb, fcrad (d) lake smit and partners, durban fig. 2a. uncontrasted axial t1-weighted image. fig. 2b. axial post-gadolinium t1-weighted sequence. fig. 2c. coronal post-gadolinium t1-weighted sequence. figs 1a and 1b. axial t2-weighted sequence. fig. 1c. coronal flair sequence. a b we invite readers to describe the mri findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@ hotmail.com. an award of r1 000 will be made for the best interpretation. a detailed diagnosis will be presented in the next sajr. quiz case.indd 105 11/18/09 9:06:20 am sajr 633 alcapa: the al capone of coronary artery anomalies farzanah ismail, fcrad (d) sa, mmed rad (d) department of radiology, steve biko academic hospital and university of pretoria   corresponding author: f ismail (drfismail@yahoo.com) anomalous left coronary artery originating from the pulmonary artery (alcapa) is a rare coronary artery anomaly that presents with myocardial ischaemia or infarction and/or cardiac failure in infants. it is associated with a mortality rate of 90% within the first year of life. surgical correction to re-establish a two-coronary artery perfusion system is the treatment of choice, once patients are medically stable. s afr j rad 2012;16(3):100-101. doi:10.7196/sajr.633 clinical presentation a 12-month-old infant presented with tachycardia and respiratory distress. on clinical evaluation, the child was in cardiac failure. there were no clinical features of infection. haematological studies were normal. the electrocardiogram (ecg) demonstrated septal ischaemic changes. the chest radiograph (fig. 1) demonstrated gross cardiomegaly involving mainly the ventricles and right atrium. there was peri-hilar alveolar opacification and a left pleural effusion. there was a positive silhouette sign at the right cardiac border, indicating right middle lobe consolidation. these findings were due to pulmonary oedema or infection. the differential diagnosis at this stage was dilated cardiomyopathy, viral myocarditis, mitral valve disease or anomalous left coronary artery originating from the pulmonary artery (alcapa). echocardiography excluded cardiomyopathy and mitral valve disease. coronary angiography confirmed alcapa (figs 2 and 3). the patient was evaluated for surgery. fig. 1. antero-posterior radiograph of the chest demonstrates massive cardiomegaly, involving mainly the ventricles and right atrium. peri-hilar alveolar opacification and left pleural effusion as well as right middle lobe consolidation are present. fig. 2. antero-posterior aortic angiogram with catheter in the ascending aorta. only the right coronary artery fills with contrast. the left coronary artery is not visualised. cardiomegaly is present. feint contrast within the pulmonary arteries is also visible. fig. 3. selective catheterisation of the right coronary artery. multiple collateral vessels are present (smallest white arrow) which drain into the left coronary artery (arrow to the left of catheter) and into the main pulmonary artery (largest white arrow). discussion anomalous left coronary artery originating from the pulmonary artery (alcapa) is a rare coronary artery anomaly that affects 1 in 300 000 live births.1 it was first described in 1886, but bland, garland and white described in 1933 the landmark case describing the clinical features linked with alcapa; hence it is also known as bland-white-garland syndrome.2 , 3 there are two types of alcapa syndrome: the adult and the infant type. the infant type presents with myocardial ischaemia or infarction and/or cardiac failure, and has a mortality rate of 90% within the first year of life.1 infants may also present with paroxysms of irritability which correlate with episodes of angina.4 alcapa can occur in isolation or in conjunction with other lesions such as atrial septal defect and ventricular septal defect.4 embryologically, the anomaly arises from either abnormal septation of the aorta and the pulmonary artery, or from persistence of aortic buds that form the coronary arteries.2 in the neonatal period, the baby is asymptomatic as there is anterograde flow of desaturated blood from the pulmonary artery to the left coronary artery. as pulmonary arterial pressure drops, the combination of low flow and desaturated blood causes myocardial ischaemia, especially during exertion. collateral vessels develop between the right and left coronary arteries. further decreases in pulmonary arterial pressure result in reversal of flow, as the left coronary artery drains from the right coronary artery, through collaterals, into the pulmonary artery. this is known as myocardial steal; hence the nickname of al capone of coronary vessels.2 , 4 the steal phenomenon causes ischaemia or infarction of the antero-lateral lv wall. the electrocardiogram findings include a qr pattern followed by inverted t waves seen on leads i and avl. the left ventricular surface leads (v5 v6) may also show deep q waves and exhibit elevated st segments and inverted t waves.2 patients who survive to adulthood have a good collateral network with large-calibre left and right coronary arteries. they may present with dysrrythmias or sudden death. chest radiography may demonstrate left ventricular hypertrophy and dilation secondary to chronic myocardial ischaemia.1 the main differential diagnosis at this stage is cardiomyopathy, which is excluded on echocardiography. echocardiography may also demonstrate the anomalous left coronary artery with doppler flow confirming the reversal of flow.2 coronary artery angiography will additionally demonstrate dilated tortuous vessels and reversal of flow into the pulmonary artery on delayed images. ct coronary angiography has the benefit of being non-invasive and will also demonstrate the origin of the left coronary artery from the pulmonary artery. anomalous origin of the other coronary vessels may also be identified. the retrograde flow from the lca to the pulmonary artery is well depicted on mri and is seen as a jet of blood flowing into the pulmonary artery.1 medical management involves treatment of cardiac failure.2 surgical correction to re-establish a two-coronary artery perfusion system is the treatment of choice, once patients are medically stable. the surgery is performed preferably in the neonatal period as it is in this age group that there is some improvement of left ventricular function.1 conclusion the steal phenomenon caused by alcapa causes significant left ventricular myocardial compromise and is associated with a high morbidity in infants. an infant who presents with lv enlargement, ischaemic ecg changes and/or features of cardiac failure should be considered to have alcapa until proven otherwise.   1. pena e, nguyen et, merchant n, dennie c. alcapa syndrome: not just a pediatric disease. radiographics 2009;29:553-565. 1. pena e, nguyen et, merchant n, dennie c. alcapa syndrome: not just a pediatric disease. radiographics 2009;29:553-565. 2. lardhi aa. anomalous origin of left coronary artery from pulmonary artery: a rare cause of myocardial infarction in children. journal of family community medicine 2010;17:113-116. 2. lardhi aa. anomalous origin of left coronary artery from pulmonary artery: a rare cause of myocardial infarction in children. journal of family community medicine 2010;17:113-116. 3. cowles ra, berdon we. bland-white-garland syndrome of anomalous left coronary artery arising from the pulmonary artery: a historical review. pediatr radiol 2007;37:890-895. 3. cowles ra, berdon we. bland-white-garland syndrome of anomalous left coronary artery arising from the pulmonary artery: a historical review. pediatr radiol 2007;37:890-895. 4. brotherton h, phillip rk. anomalous left coronary artery from pulmonary artery (alcapa) in infants: a 5 year review in a defined birth cohort. eur j pediatr 2008;167:43-46. 4. brotherton h, phillip rk. anomalous left coronary artery from pulmonary artery (alcapa) in infants: a 5 year review in a defined birth cohort. eur j pediatr 2008;167:43-46. sajr 820a   tracheal bronchus and pulmonary, hepatic and renal vascular congenital abnormalities – a case report s vedajallam,1 fc rad (d) sa; f ismail,1 fcrad (d) sa, mmed rad (d); j a joshi,2 fcpaed (sa); a chacko,1 mb bch; z i lockhat,1 ffrad (d) (sa); s andronikou,1 mb bch, fcrad, frcr, phd  1 department of radiology, steve biko academic hospital and university of pretoria, pretoria, south africa 2 department of paediatric cardiology, steve biko academic hospital and university of pretoria, pretoria, south africa   corresponding author: f ismail (drfismail@yahoo.com) tracheal bronchus, also referred to as bronchus suis or pig’s bronchus, is a rare tracheobronchial anomaly in which an ectopic bronchus arises from the lateral wall of the trachea above the carina and supplies the entire upper lobe or a segment of the upper lobe. it affects 0.5 2% of the population and may be detected incidentally, or in patients who present with bronchospasm, persistent cough, recurrent upper lobe infections and haemoptysis. surgical resection is reserved for patients with severe or persistent symptoms that are resistant to treatment. we present a case of a symptomatic 5-month-old baby who had a type ii right-sided tracheal bronchus on bronchography and ct.   s afr j rad 2013;17(2):59-61. doi:10.7196/sajr.820 we present a case of a symptomatic 5-month-old girl who had a type ii right-sided tracheal bronchus on computed tomography (ct), which was later confirmed on bronchography. tracheal bronchus is a rare tracheobronchial anomaly where an ectopic bronchus arises from the lateral wall of the trachea. case report a 5-month-old girl presented with a clinical picture of bronchiolitis and showed minimal improvement on medical treatment. the chest radiograph revealed a hypoplastic right lung-associated mediastinal shift to the right and cardiac dextroposition (fig. 1). fig. 1. antero-posterior radiograph of the chest demonstrates cardiac dextroposition and a hypoplastic right lung. the left subclavian central line is in situ. a ct angiogram of the chest was performed to further evaluate the persistent right upper lobe consolidation and to exclude an endobronchial lesion. this demonstrated a right-sided tracheal bronchus arising more than 2 cm above the carina and supplying the posterior segment of the right upper lobe. there was severe stenosis of the right bronchus intermedius and proximal left main stem bronchus and a hypoplastic right lung (fig. 2). other anomalies present were a pulmonary sling with an anomalous left pulmonary artery originating from the right pulmonary artery (fig. 3), azygos continuation of the ivc (not shown) and a circumaortic renal vein (fig. 4). the hepatic veins drained directly into the right atrium. fig. 2. axial ct of the chest – lung window demonstrates the tracheal bronchus (arrow) on the right, which supplies the posterior segment of the right upper lobe. this segment demonstrates ground-glass opacification and is possibly dysplastic. the image on the right is lower down, at the level of the carina, and demonstrates that the trachea distal to the tracheal bronchus is narrowed and the carina is low (at t5/t6 level). fig. 3. axial contrast-enhanced ct demonstrates the left pulmonary sling (arrow) and circumaortic left renal vein (arrows fig. 4. frontal and lateral radiographs of the bronchogram study demonstrating the right tracheal bronchus that supplies the posterior segment of the right upper lobe. the patient was treated successfully with medical therapy and was discharged from hospital after 2 weeks. at 7 months of age, cardiac catheterisation was performed electively to fully delineate other possible cardiac anomalies, whereat the anomalous origin of the left pulmonary artery was confirmed. this was the only positive finding and an otherwise normal anatomy was demonstrated. at 10 months of age, bronchoscopy and bronchography were performed. the decision to perform bronchoscopy was made to avoid further radiation from a repeat ct and to fully evaluate the endobronchial anatomy. the bronchogram confirmed a right tracheal bronchus (fig. 4) supplying the posterior segment of the right upper lobe. the patient was discharged from hospital after responding well to medical treatment for bronchospasm, and is being followed up as an outpatient at the paediatric pulmonology department. discussion tracheal bronchus is also referred to as bronchus suis or pig’s bronchus (as it is a normal finding in pigs and some ruminant animals). it has been described in the literature as a rare tracheobronchial anomaly, where an ectopic bronchus arises from the lateral wall of the trachea above the carina and can supply the entire upper lobe or a segment of the upper lobe. the prevalence of the right tracheal bronchus is 0.1 2%, and prevalence of the left tracheal bronchus is 0.3 1%. both the right and left tracheal bronchi have a high association with cardiovascular and costovertebral defects.1 tracheal bronchus is subdivided into supernumerary and displaced types. the ectopic bronchus is supernumerary if the right upper lobe bronchus has a normal trifurcation into apical, posterior and anterior segments. the displaced type arises from the lateral wall of the trachea and supplies one or more segments of the upper lobe, most commonly the apical segment, as in our patient. in most cases, the tracheal bronchus originates less than 2 cm from the carina. however, it has been described up to 6 cm from the carina.2 there are various classifications,3 but conacher4 has presented a simpler one that describes the anatomical relationship between the tracheal bronchus and the carina. type i is more than 2 cm above the carina with narrowing of the distal trachea. type ii is more than 2 cm above the carina with a normal diameter of distal trachea, and type iii is less than 2 cm above the level of the carina. in the past, tracheal bronchus was diagnosed using bronchoscopy or bronchography. more recently, multidetector computed tomography (mdct) with 3d volume reconstruction has replaced these more invasive techniques. mdct has the advantage of improved temporal, spatial and contrast resolution, decreased scanning time and reduced sedation requirements.5 in our patient, mdct initially diagnosed, and bronchography later confirmed, the presence of the tracheal bronchus and evaluated the associated endobronchial pulmonary anatomy. patients with tracheal bronchi are often asymptomatic, and the finding is incidental. however, several articles have been published describing symptomatic cases where patients presented with bronchospasm, persistent cough, recurrent upper lobe infections and haemoptysis. co-existing bronchiectasis, focal emphysema and cystic lung formations have also been reported.3 tracheal bronchus is also associated with cardiovascular abnormalities. mclaughlin et al. conclude that the presence of a clinically significant tracheal bronchus should be considered in every child with recurrent right upper lobe pneumonia, especially in those with down’s syndrome or rib abnormalities.6 a higher occurrence of tracheal bronchus has been found in patients with congenital heart diseases, with other vascular abnormalities also described.7 however, no direct association has been made between the presence of tracheal bronchus and congenital vascular abnormalities. therefore, careful evaluation and a high index of suspicion is necessary when evaluating such patients, so as to recognise and diagnose any associated vascular abnormalities, as was the case in our patient. in most cases, expectant management is preferred, while surgical resection is reserved for patients with severe or persistent symptoms that are resistant to treatment. our patient had a displaced type ii right-sided tracheal bronchus, with multiple associated pulmonary, hepatic and renal vascular anomalies. conclusion paediatric patients presenting with non-resolving respiratory symptoms should be investigated to exclude congenital anomalies of the trachea-bronchial tree. if a tracheal bronchus is detected, it is important to exclude other cardiovascular and pulmonary abnormalities.   1. srivastava a, warrier g, trehan m, radha as. tracheal bronchus: a cause of unexplained prolonged hypoxemia during ventilation. paedtr cardiol 2010;31(8):1229-1231. [http://dx.doi.org/10.1007/s00246-010-9759-9] 1. srivastava a, warrier g, trehan m, radha as. tracheal bronchus: a cause of unexplained prolonged hypoxemia during ventilation. paedtr cardiol 2010;31(8):1229-1231. [http://dx.doi.org/10.1007/s00246-010-9759-9] 2. wiser sh, hartigan pm. challenging lung isolation secondary to aberrant tracheobronchial anatomy. anesth analg 2011;112(3):688-692. [http://dx.doi.org/10.1213/ane.0b013e318206917a] 2. wiser sh, hartigan pm. challenging lung isolation secondary to aberrant tracheobronchial anatomy. anesth analg 2011;112(3):688-692. [http://dx.doi.org/10.1213/ane.0b013e318206917a] 3. ghaye b, szapiro d, fanchamps jm, dondelinger rf. congenital bronchial abnormalities revisited. radiographics 2001;21(1):105-119. 3. ghaye b, szapiro d, fanchamps jm, dondelinger rf. congenital bronchial abnormalities revisited. radiographics 2001;21(1):105-119. 4. conacher id. implications of a tracheal bronchus for adult anaesthetic practice. br j anaesth 2001;86:155-156. 4. conacher id. implications of a tracheal bronchus for adult anaesthetic practice. br j anaesth 2001;86:155-156. 5. lee ey, boiselle pm, shamberger rc. multidetector computed tomography and 3-dimensional imaging: preoperative evaluation of thoracic and tracheobronchial anomalies and abnormalities in pediatric patients. j paedtr surg 2010;45(4):811-821. [http://dx.doi.org/10.1016/j.jpedsurg.2009.12.013] 5. lee ey, boiselle pm, shamberger rc. multidetector computed tomography and 3-dimensional imaging: preoperative evaluation of thoracic and tracheobronchial anomalies and abnormalities in pediatric patients. j paedtr surg 2010;45(4):811-821. [http://dx.doi.org/10.1016/j.jpedsurg.2009.12.013] 6. mclaughlin fj, strieder dj, harris gb, vawter gp, eraklis aj. tracheal bronchus: associations with respiratory morbidity in childhood. j paedtr 1985;106(5):751-755. [http://dx.doi.org/10.1016/s0022-3476(85)80348-6] 6. mclaughlin fj, strieder dj, harris gb, vawter gp, eraklis aj. tracheal bronchus: associations with respiratory morbidity in childhood. j paedtr 1985;106(5):751-755. [http://dx.doi.org/10.1016/s0022-3476(85)80348-6] 7. suzuki m, matsui o, kawashima h, et al. radioanatomical study of a true tracheal bronchus using multidetector computed tomography. jpn j radiol 2010;28(3):188-192. [http://dx.doi.org/10.1007/s11604-009-0405-5] 7. suzuki m, matsui o, kawashima h, et al. radioanatomical study of a true tracheal bronchus using multidetector computed tomography. jpn j radiol 2010;28(3):188-192. [http://dx.doi.org/10.1007/s11604-009-0405-5]   116 sa journal of radiology • december 2010 case report abstract echinococcosis is caused by the larva of the tapeworm, echinococcus granulosus or echinococcus multiloccularis and is endemic in many rural areas of southern africa. echinococcosis of the bone is an unusual manifestation of echinococcal disease and a rare cause of a lytic lesion of bone. this report describes a 30-year-old woman who presented with an echinococcal cyst of the right radius complicated by a pathological fracture. case presentation a 30-year-old woman presented to the casualty department of helen joseph hospital complaining of right forearm pain after a minor trauma. although currently residing in johannesburg, she had spent most of her life on a farm near polokwane. anteroposterior (ap) and lateral radiographs of the right radius and ulna (fig. 1) revealed a pathological transverse fracture of the mid-shaft of the radius. there was an underlying multiloculated lytic lesion with a narrow zone of transition. there was endosteal scalloping with thinning of the cortex but no bony expansion. there was no associated periosteal reaction or soft-tissue mass. the patient was taken to theatre where the lesion was curetted, the defect filled with bone chips from an iliac autograft, and internal fixation performed. at operation, partial cortical erosion was noted and the cyst was found to contain gritty, gelatinous material with a thick white membrane. the microbiology report indicated the presence of hydatid hooklets. this was confirmed on histology which demonstrated the presence of the laminated and germinative layers of a hydatid cyst (fig. 2). the indirect haemagglutination assay (iha) for hydatid disease was negative. chest x-ray, ultrasound of the abdomen and radiographs of the other long bones were normal. postoperatively, the patient was placed on albendazole 400 mg bd. discussion echinococcosis is caused by the larva of the tapeworm echinococcus granulosus or echinococcus multiloccularis and is endemic in many matthew goodier, mb chb grace rubin, mb bch, da (sa), fcrad( diag) sa department of radiology,university of the witwatersrand, johannesburg echinococcal disease of the bone: an unusual cause of a pathological fracture fig.1. plain radiographs demonstrate a multilocular lucent lesion in the midshaft of the right radius, complicated by pathological fracture. fig. 2. histological slide indicating the presence of a hydatid hooklet (arrow) (figure by courtesy of the division of anatomical pathology/nhls, university of the witwatersrand). sa journal of radiology • december 2010 117 case report rural areas of southern africa. the disease is acquired when man becomes the intermediate host of the parasite by ingestion of ova either through contact with dogs (the definitive host) or environmental contamination.1 echinococcal cysts usually involve the liver or lung; involvement of the bone is rare, accounting for 0.5 4% of all cases of echinococcosis.1 when the bone is involved, the most common site is the spine, followed by the pelvis, femur, tibia, ribs, skull, scapula, humerus and fibula.2 involvement of the radius, as in our case, appears to be especially rare, although isolated cases have been reported.3 the disease is usually clinically silent until a complication occurs. in lesions of the long bones, pathological fracture is the most common presentation.2 uncommonly, the cyst may become secondarily infected, resulting in osteomyelitis with formation of an abscess and draining sinus to the overlying skin. the diagnosis is usually suggested by a combination of radiological and serological findings, and then confirmed intraoperatively. as expected, the iha serological test in our patient was negative. this is because cysts in the bone seldom induce detectable levels of host antibody.4 radiographs usually show a lytic lesion which may be unilocular or more commonly multilocular. this is because, in echinococcal cysts of the bone, the pericyst layer, which usually forms a connective tissue barrier to spread of the disease, does not form.1 the margins may be well or ill-defined. the most common site is the metaphysis. involvement of the epiphysis and articular surface of the bone is uncommon. periosteal reaction usually indicates the presence of a pathological fracture. if the disease extends through the cortex, an associated soft-tissue mass may be seen. if the cyst remains intraosseous, internal calcifications are uncommon.2 abdominal ultrasonography and chest radiography are routinely performed to detect liver and lung cysts, which may co-exist with bone cysts in up to 45% of patients.5 both mri and ct help to define the exact extent of the lesion, with ct defining internal calcifications and mri allowing better depiction of any extra-osseous soft-tissue extension and nerve involvement. differential diagnosis includes expansile lytic lesions of bone, such as aneurysmal bone cyst, simple bone cyst, enchondroma and fibrous dysplasia, as well as giant cell tumour if the lesion is situated in the epiphysis. surgery is the treatment of choice. because of the high recurrence rate following curettage, radical resection of the involved segment with bone grafting is preferred.6 if the diagnosis is suspected preoperatively, adjuvant medical therapy with imidazole derivatives (e.g. albendazole) may be initiated preoperatively and continued postoperatively to control systemic spread and prevent local recurrence. conclusion echinococcal cyst of bone is a rare manifestation of echinococcal disease, with involvement of long bones, such as the radius, especially rare. nevertheless, the diagnosis should always be considered in the radiological differential of a lytic lesion of the bone, especially in a patient who has spent time in an endemic area. making the diagnosis preoperatively by means of radiological and serological methods is important as this allows initiation of preoperative imidazole therapy as well as suggesting the most appropriate form of surgical management. 1. pedrosa i, saíz a, arrazola j, ferreirós j pedrosa cs. echinococcosis disease: radiographic and pathologic features and complications. radiographics 2000;20:795-817. 2. polat p, kantarci m, alper f, suma s, koruyucu mb, okur a. echinococcosis disease from head to toe. radiographics 2003; 23:475-494. 3. ammari f, khasawneh z, salem m, mesmar m, omari h, masa’deh r. hydatid disease of the musculoskeletal system. surgery 1998;124:934-937. 4. eckhert j, deplazes p. biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. clin microbiol rev 2004;17:107-135. 5. herrera a, martinez aa, rodriguez j. spinal hydatidosis. spine 2005;30:2439-2444. 6. sayek i, tirnaksiz mb, dogan r. cystic echinococcosis disease: current trends in diagnosis and management. surg today 2004;34:987-996. 32 sa journal of radiology • march 2011 cpd questionnaire give one correct answer for each question. 1. regarding the rare condition of idiopathic granulomatous mastitis (igm), the following are correct, except for: a. it mimics breast carcinoma. b. it has characteristic ultrasound features. c. diagnosis is made by core biopsy and histology. d. surgical excision is the treatment of choice in all cases. 2. which one of the following statements is true? a. ruptured ovarian artery aneurysms are extremely common. b. they occur during the peripartum or early postpartum periods. c. the most common symptom of rupture of an ovarian artery aneurysm is vaginal bleeding. d. ultrasound is an excellent imaging technique for rapid and safe evaluation, and may be the examination of choice for such patients. 3. regarding kosenow syndrome, which one of the following statements is false? a. the main components of the syndrome are varying degrees of bilateral iliac and scapular hypoplasia. b. it is an autosomal dominant condition. c. the acromion and coracoid process of the scapula are usually preserved despite severe hypoplasia of the body d. a unique feature is the well-formed femoral heads and ambulation with a fully functional though abnormal gait. 4. identify the one false statement below. a. renal biopsy plays a pivotal role in determining the diagnosis in patients with impaired renal function and with other renal diseases. b. the pathology and pathogenesis of glomerular disease have become far better understood since the introduction of ultrasound (us)-guided renal biopsies. c. horseshoe kidney is not considered a major contra-indication. d. biopsies are specifically necessary in cases of: • unexplained renal failure • nephrotic syndrome • unexplained failure of a transplanted kidney • progressively worsening renal function. 5. which one of the following statements is false? relative contraindications for renal biopsy include: a. bleeding diathesis b. solitary kidney c. severe hypertension conclusively documented d. end-stage or near end-stage renal disease with bilaterally small kidneys. 6. identify the one incorrect statement among the following choices. a. in total anomalous pulmonary venous return (tapvr), the pulmonary veins make an abnormal connection to the right atrium, with coronary sinus or systemic veins resulting physiologically in an extracardiac right-to-left shunt. this anomaly is accompanied by an intracardiac left-to-right shunt through a patent foramen ovale or an atrial septal defect. b. tapvr is a rare congenital cardiac defect that may present with cyanosis, cardiac failure and failure to thrive in infancy. c. tapvr type 1 has a typical radiographic appearance of the heart termed the snowman. d. children with chronic diseases are at greater risk of non-accidental injury. 7. regarding camurati-engelmann disease, all the following are correct, except for: a. camurati-engelmann disease, or progressive diaphyseal dysplasia, is a rare sclerosing dysplasia. b. radiologically, the hallmark of the disorder is bilateral, symmetrical cortical thickening of the metaphyses of the long bones. c. the disease affects one in a million people and is autosomal dominant with variable penetrance. d. the onset of the disease is usually during childhood. patients usually present by puberty and definitely before age 30. 8. identify the one false statement among the following. in gorlin syndrome, various low-frequency neoplasms have been recorded. these include: a. meningioma b. ovarian fibroma c. cardiac fibroma d. gist tumour. 9. regarding gorlin syndrome, identify a single false statement from those below. a. gorlin-goltz syndrome (also known as nevoid basal cell carcinoma syndrome) was first reported in 1894. b. it was described by gorlin and goltz in 1960 as a distinct entity consisting of ectodermal and mesodermal abnormalities. c. it is an hereditary autosomal recessive disease with a prevalence estimated in various studies to be between 1/57 000 and 1/256 000, and a male: female ratio of 1:3. d. it is a condition characterised by multiple odontogenic keratocysts, basal cell carcinoma, congenital skeletal abnormalities, cleft lip and/or palate, and eye anomalies. 10. you are presently reading the south african journal of radiology that includes the following except for: a. a new front cover design. b. a new layout style. c. at least 4 extra pages sponsored by philips sa. d. a centrefold mri of shakira that was inadvertently omitted by the printers. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/010/01/2011 42 sa journal of radiology • june 2012 editorial in memoriam bryan joseph cremin bryan cremin was a great friend and a phenomenal teacher. i could easily write a series of articles about a trip to the okavango delta with bryan and richard hewlett – an experience that i’d never wish to repeat, but that i wouldn’t want to have missed for all the money in the world. kindly allow me to dedicate this issue of the sajr to an exceptional man and a great radiologist. the following is a tribute from one irishman to another. let others recall his academic achievements, but here let us listen to sean conway on bryan cremin, the man. jan lotz editor-in-chief tribute to bryan cremin by sean conway bryan joseph cremin was born in london on 2 september 1929 to a limerick gp father and a kerry mother, both of the province of munster, ireland. he was the baby of the family, with 2 elder sisters and an older brother, desmond, who is 92. having an eye for detail, he noted that he was conceived in ireland though born in england (‘of irish insertion but english extraction’, in his own words) as his family had emigrated to london during this period. by his admission, his father’s one failing was a penchant for gambling on the horses, which contributed to bryan’s fairly shrewd financial sense in life. he went to prep school in london – possibly the oratory – and i recall a photograph he had of himself in his house in school uniform with lopsided school cap and a cheeky, somewhat pugnacious grin. he attended guy’s hospital for his medical training and represented the hospital in both boxing and rugby football, at which he excelled; he also had a run with london irish and a rugby trial for ireland. on qualification, he underwent his national service in the royal army medical corps of the british army and was posted to malaya, where i first came across him when i was about 4 years old, around the time of the coronation (june 1953), while he was doing his national service as captain cremin in the 16th field ambulance in kuala lumpur, whose then co was my father, lieutenant-colonel steve conway. my first unknowing encounter with him was being thrown into the deep end of the swimming pool at the selangore club in kl on the instructions of my father – the order having been given for me to sink or swim; i’ve been doggy paddling ever since. during his time with the field ambulance, my father had him pegged as a most competent and ambitious officer with great charm, and both my parents became very fond of him; there were many hilarious and enjoyable sessions in the officers’ mess and elsewhere. he also tried his hand at ear piercing and charmed his way into my mother’s ear lobes which, apparently, was not immediately successful as the first attempt became slightly septic but with no lasting ill-effect. he was of adventurous spirit and, for the latter half of his national service, was attached to the sas as a medical officer. during this time my father, not lacking in spirit himself, underwent parachute training in the jungle. on one of these jumps, cremin and the others landed safely on the jungle floor, but my father was trapped and suspended up high from the branch of a tree. although uninjured, my father called out, ‘cremin [kreeman], have you appointment of deputy editor we extend a hearty welcome to dr razaan davis who joins the editorial board of the sajr as deputy editor. razaan became a fellow of the college of diagnostic radiologists of south africa in october 2009, qualifying as a master of medicine, specialising in radiology, at the university of cape town. she commenced duties as a senior consultant in the division of diagnostic radiology at tygerberg hospital in august 2010. she is an excellent teacher and competent administrator, and also at present a moderator for the stellenbosch university modular course in diagnostic radiology. at the time of assuming the sajr editorship with volume 12, issue 1 in 2008, i alluded to the necessity of always being aware of the need to bring in new blood, and am delighted at razaan’s appointment accordingly. at the time, i drew on a line from the aeneid by virgil (70 19 bc): vires acquirit eundo [gathering strength as it goes.]. i wish to reconfirm this, and we look forward to ongoing gathering of strength as we proceed into the next half-decade. jan lotz editor-in-chief sa journal of radiology • june 2012 43 editorial got the medicinal brandy? pass it along now, if you please.’ – which bryan managed to achieve by means of a jungle vine. it took another 40 minutes to extricate my dad from the tree, but everyone was most relaxed and stress free – i’m told. an interesting sequela of the parachute jumps was the first article written by bryan: on the medical aspects of parachuting into the jungle from very low height – a technique pioneered in malaya at the time. it was the only article entirely written by cremin himself – but in which he appeared as second author, my father achieving first author status merely by virtue of army rank: (1). lt. col. s.m.p. conway, mc, ramc; (2). capt. b.j. cremin, ramc. following his national service, our family lost contact with bryan for many years. during this time he held a number of positions including gp work in the uk and an extended sojourn as ship’s surgeon on the p & o line. during one of these trips, he had a liaison with his nursing staff sister, which resulted in the birth of his daughter – although he was not aware of these details until much later in life when contact was made with him by her in the midto late-1990s. then and since, he made every effort to erase the time lost. he then underwent radiology training in london and further postgraduate radiology in australia. around 1967 he went to rhodesia, to mpilo hospital in bulawayo, where by chance i myself went in 1972 to do my internship followed by paediatrics, but i was unaware of his movements. he moved to south africa in 1968 to the red cross war memorial children’s hospital as a senior radiologist, and it was there that he made his mark as a paediatric radiologist of world renown. it was purely by chance that i ended up as a trainee radiologist at groote schuur hospital in june 1976, having finished my own national service in rhodesia and having started radiology in harare hospital, salisbury. at the time, bryan had established a worldwide reputation in paediatric radiology. he was honoured with the position of the chair of radiology at uct/groote schuur concurrent with his position as head of radiology at red cross hospital. as already said, he was ambitious but he deserved to be as this drive was backed up by enormous talent, hard work, academia and excellent organisation. groote schuur and red cross were staffed at the time by very talented and bright radiologists – i refer to the consultant staff specifically. these consultants were attracted from elsewhere largely on the reputation that bryan had established in international radiology. he was the author and co-author of literally hundreds of articles in the radiological literature. a criticism was that some of the co-authored articles were penned by his more junior staff, but he was indeed the sole author of many articles and a number of specialised paediatric textbooks and the genuine co-author of others including, with professor jannie louw, on neonatal paediatric git, and with aaronson on paediatric urology, among others. in the early 1980s he relinquished his position as professor of radiology at uct and returned to his first love of paediatric radiology at red cross hospital, maintaining his position as head of department. he continued to be an innovator and to attract doctors from all corners to the hospital. he had a special soft spot for the underdog and so-called ‘outsiders’ – he had not a trace of academic xenophobia and welcomed the fresh air that others could introduce into his department, and he went to great lengths to welcome, be hospitable to, and to discourse with, them at his house. he was still penning articles when he retired from red cross in 1995. he had a reputation as a lady’s man and was the master of well-chosen phrases; women seemed to treat him well. his companion in the most ambitious period of his life was sybil, whom i met only once or twice, and she passed on in the mid-1980s. but the love and stalwart of his life was edwina, whom i first met in 1988 shortly after they got together. at this time my parents had come to live in south africa and renewed their friendship. they saw quite a lot of bryan and edwina and always thoroughly enjoyed their company. after retiring from red cross, bryan and edwina maintained their adventurous spirit and lifestyle, travelling locally and abroad in a camper van. bryan also volunteered to do occasional unpaid saturday morning locums in our practice, which he did (and we paid him). he had a talent for occasionally saying or doing the somewhat outlandish, which antagonised some but which those of us who knew him learnt to take in our stride. i think edwina’s family had some initial reservations about him but soon welcomed him into their hearts. he was always most kind to me but never shy to state his mind. he stepped into the breach on several occasions: • he gave a best-man-type speech at 2 minutes’ notice at my chaotic garden wedding many years ago. • he kept a watching brief over me during the short and somewhat peculiar divorce period. • he gave an oration at my former wife’s funeral. • he also accepted gracefully when i hijacked him to be godfather to giselle. he was gentle and kind to giselle and was never short of a packet of jelly tots – she describes him as having an eccentric sense of humour and a kind fondness in his eyes. she always had a familiar and special feeling when stepping over the threshold of conor close to visit bryan and edwina and to play with the tabby cat and tortoise in the garden – a feature for many years. bryan maintained a beautiful garden and took delight in nurturing and seeing things grow and develop. he had the same attitude in life: never stopping still, erudite, eloquent, inquisitive, and questioning the why and the whereto. he had great humanity, was a brilliant orator, and entertaining company at all times. in recent years, when his mobility was reduced and he was losing some of his faculties, particularly memory, he was very lucky to have edwina who nurtured and looked after him with tremendous personal effort but, even as these faculties dwindled, he would always pop up out of the blue with an appreciative gesture or meaningful statement of his love and gratitude to her. i was not present at his passing in april, but edwina tells me he still mustered all his dignity as he died in her arms. he was succinct and direct to the last. this ends my somewhat personal contribution to the life of bryan – bryan joseph cremin – with apologies where indicated. we shall miss his indomitable nature, but his generous spirit lives on. 126 sa journal of radiology • december 2010 radioactive news molecular imaging at the rssa/sgr meeting last august at spier, we were treated to a fascinating presentation by an ex-capetonian, professor jonathan kruskal (harvard), that included an in vivo video of liver tumour deposition and angiogenesis in a rat model. as we watched tumours grow from a single cell and observed the angiogenesis, we were reminded that the future of imaging lies not in the anatomical depiction of tumours already containing millions of cells but in molecular imaging techniques. medical imaging has been through revolutions before. the discovery and harnessing of x-rays allowed images of the inside of the living human body for the first time, and there seemed to be no limit to the body spaces into which radiologists could introduce positive or negative contrast agents to better delineate anatomy. cormack (ex uct) and hounsfield shared a nobel prize for the mathematics which facilitated the development of ct. the subsequent refinements, which lead to modern multidetector ct scanners, have revolutionised this technology so that we are able to acquire 3-d submillimetre isometric datasets which can be sliced, diced and modelled, cut away, rotated and viewed. software can now take us on virtual journeys through bronchi, colons and vessels. images can be enhanced by the administration of contrast agents and temporal changes in contrast density be mapped, but the images remain anatomical maps of the body according to the attenuation of radiation. mri has allowed us to map the density and behaviour of perturbed precessing protons in bodies placed in a magnetic field. imaging sequences continue to be modified to produce exquisitely detailed anatomical images.we are able to interrogate chemical composition and metabolism with mr spectroscopy and functional imaging techniques. advances in nanoand microparticle contrast have potential to expand clinical molecular imaging beyond the current techniques of spect and pet. ultrasound allows real-time imaging, but molecularly targeted microbubbles represent a new strategy. targeted contrast agents will pave the way for targeted therapeutic delivery. non-ionising techniques such as mri/mrs, optical imaging, ultrasound and hybrid technologies are suited to early disease detection and screening. the new frontier is molecular imaging (mi), and a revolutionary new chapter in the history of medical imaging is about to be written. at the end of it, we will all wonder how we ever practiced medicine without mi as the new technology ushers in more personalised treatments. will radiologists be at the forefront of developments in mi and, more specifically, are there young south african radiologists who will embrace the challenge of new technology and enter this exciting field? there are those who make things happen, those who watch things happen, and those who wonder what happened! good luck. clive sperryn president, rssa samsig seeks growth dr mark velleman samsig (the south african musculoskeletal imaging group) was established in october 2005, with the aim of promoting musculoskeletal radiology among radiologists and interested disciplines in south africa; it is an official subgroup of the rssa. the majority of members come from the rssa, but membership is open to all clinicians with an interest in imaging. the current committee comprises dr richard de villiers (chairman), dr mark velleman (vice-chairman), dr ralph posner (treasurer), dr graeme thompson (secretary), dr john zietkiewicz (it), and regional contacts dr peter mercouris (kzn/central region), dr andrew van den heever (western cape) and dr mark velleman (northern region). the group holds yearly meetings to run concurrently with the south african sports medicine association congress, where possible. the most recent meeting took place from 4 8 october 2010 at chobe, botswana, in the form of a well-filled 3-day conference devoted to high-level msk imaging with interactive case presentations by delegates from around the country as well as australia and the usa. attendance was fully subscribed. interaction between presenters and delegates was encouraged and proved to be very successful. case studies were also shown by delegates for further discussion, and were equally popular. feedback on the lectures was most positive, and all the delegates were keen to return for the next meeting in two years’ time. the social programme included morning game drives, fishing trips and sunset river cruises, and a visit to the local school which was well received by the locals. most of the delegates came with their children and spouses who took part in the social activities and could enjoy day trips too. during the concluding dinner, some of the children spontaneously joined the traditional dancers on stage, epitomising the success of the event. all look forward to the 2012 samsig meeting, the idea being to again host it in a safari-like setting; the venue has yet to be finalised. further information is on the website www.samsig.co.za. sa journal of radiology • december 2010 127 radioactive news report-back by 2009 rssa travel award winner pieter janse van rensburg i used the 2009 rssa travel award to attend the 8th interventional mri symposium held on 24 25 september 2010 in leipzig, germany. the scope of the symposium was quite wide, with the main topics being intraoperative mri; thermometry; laser, rf and cryoablation therapy; cellular therapies and targeted drug delivery; mr-guided high-intensity focused ultrasound (hifu); biopsy and vascular applications. it was clear to me that many of the percutaneous interventions performed commonly under ultrasound or ct guidance, can quite easily be adapted to mri-guided procedures. an open mri is ideally suited for many of the more complex procedures, but there were many presentations where interventions were guided by short-bore conventional closed magnets. therefore, mr-guided interventions are well within reach of radiologists who perform percutaneous biopsies under ultrasound or ct guidance in south africa, and the transition to performing such a procedure should be relatively straightforward, given the availability of the correct mr-compatible needles and related equipment. another interesting aspect was the application of intraoperative mri, currently mostly used during neurosurgical procedures such as tumour resections and deep brain stimulator implantations. one of the common reasons for incomplete tumour resection is that the brain shifts during surgery. an intra-operative mr system therefore allows the radiologist to identify residual tumour while the patient is still within the operating room under general anaesthetic and guide the surgeon accordingly. these fused or shared mr and neurosurgical suites are going to be mainstream in the first world very soon, and south africa is sure to follow this trend. mr-guided hifu is probably the most revolutionary technology that i witnessed at the symposium. the basic concept involves a special ultrasound transducer that is embedded into an mr table. the ultrasound beam is then focused analogously to a magnifying glass focusing the sun’s rays to a point. the intense heat generated by the focused ultrasound causes protein denaturation, irreversible cell damage and coagulative necrosis at specific target locations. it is used thus to ablate neoplasms within the body. mr is the ideal modality to guide and monitor the hifu ablation of tumours because not only does it provide high-detail anatomical data on the target, but it also provides accurate thermometry to measure the local temperature at the target and so allows safe execution of the procedure. hifu is used to ablate tumours without any physical transgression of the patient’s skin, so it is a non-invasive therapy that radiologists will perform. current and quite established applications are the ablation of uterine fibroids and small breast carcinomas, as an alternative to lumpectomy. other potential applications are the ablation of liver tumours, prostate carcinoma and bone lesions. it is my opinion that mr-guided hifu is a groundbreaking technology that radiologists should embrace. the role that mr will play in molecular imaging was also discussed, and it is very promising. alginate-poly-l-lysine-alginate (apa) microcapsules can be used to encapsulate stem cells that contain a gene that expresses luciferase, which can be used for bioluminescence imaging. however, the gene can also express truncated thymidine kinase for pet imaging. the same apa microcapsules can also be used to encapsulate perfluorobromide (pfob-apa), which is useful because the fluorine is visible on 19f mri and the bromide is visible on x-ray. consequently, x-ray, mr, pet and bioluminescence imaging can all play a role in visualising these apa capsules and therefore will be helpful in confirming whether a certain gene or stem cell therapy has been successful or not. leipzig has a rich heritage and a beautiful old inner city which is a joy to explore by foot or bicycle. famous residents include johan sebastian bach, gottfried leibniz, felix mendelssohn and felix bloch. i thank the rssa for this opportunity and their continued support. diagnostic x-ray exposures: aapm report 31. college park, md: american association of physicists in medicine, 1990. 9. environment protection authority. registration requirements and industry best practice for ionizing radiation apparatus used in diagnostic imaging. radiation guidelines; test protocols for parts 2 5. sydney: epa, 2000. 10. united nations report of the united nations scientific committee on the effects of atomic radiation, to the general assembly; volume i. new york: unscear, 1993. 11. muhogora we, ahmed na, almosabihi a, et al. patient doses in radiographic examinations in 12 countries in asia, africa, and eastern europe: initial results from iaea projects. ajr 2008;190:1453-1461. 12. international atomic energy agency. radiation doses in diagnostic radiology and methods for dose reduction. tecdoc 796. vienna: iaea, 1995. 12. diagnostic x-ray imaging committee; aapm task group no. 12. quality control of diagnostic radiology. no. 74. college park, md: american association of physicists in medicine, 2002. sa journal of radiology • september 2011 79 review article pseudomyxoma peritonei (pmp) – a rare entity zaeem i ebrahim, mb bch zarina i lockhat, ffrad (d) (sa) farzanah ismail, fcrad (d) (sa) department of radiology, university of pretoria corresponding author: z ebrahim (zaeem@iafrica.com) pseudomyxoma peritonei (pmp) is a rare complication of mucinous tumours of appendiceal or ovarian origin that results in peritoneal and omental implants. in addition to the appendix and the ovary, other rare sites of apparent origin of pmp have been reported. these include the colon, stomach, gallbladder, pancreas, urachus, urinary bladder, uterine corpus, fallopian tube, breast and lung.1-3 pmp is also known as ‘jelly belly’ or ‘gelatinous ascites’.2 clinical findings and complications while the exact pathogenesis of pmp is controversial, clinical morbidity and mortality results from the fact that copious amounts of extracellular and peritoneal mucin cause distortion and loss of function of visceral organs.3 subsequent unrelieved compression can lead to adhesions and further morbidity, including small-bowel obstruction, renal or caval obstruction, and death. because of the viscous, gelatinous and septated nature of the mucus, it cannot be drained by paracentesis. impending bowel obstruction, renal compromise and discomfort may be relieved by repeated laparotomy for debridement of the mucin and subsequent decompression of the viscera. ronnett et al. first described a widely accepted and useful definition of pmp into three pathological subtypes with different pathological characteristics and different prognoses: disseminated peritoneal adenomucinosis (dpam) which remains potentially non-invasive and abstract pseudomyxoma peritonei (pmp) is a rare complication of mucinous tumours of appendiceal or ovarian origin that results in peritoneal and omental implants. clinical morbidity and mortality arise from the fact that copious amounts of extracellular and peritoneal mucin result in distortion and loss of function of visceral organs. therapeutic paracentesis is not possible because of the nature of the mucin. currently, new techniques are being used to attempt to debulk the mucin volume; none, however, has lead to superior outcome. 1a 1b fig. 1. multiple complex cystic masses of fat density in the peritoneum (1a), and characteristic scalloping of the liver and spleen margins (1b). review article 80 sa journal of radiology • september 2011 stays localised to the abdomen; peritoneal mucinous carcinomatosis (pmca) which has a metastatic potential; and an intermediate subtype (pmca-i) which has invasive and metastatic potential with the possibilities of liver, lung and lymph node metastases.4 recent research indicates that the pmp clinical symptoms may be caused by an overwhelming production in mucin 2 protein (muc2) secreting cells, as well as the fact that the excessively produced mucin has no place to drain; this raises the possibility of muc2-targeted therapy.5 imaging findings computed tomography (ct) is the modality of choice as it allows relatively accurate localisation and quantification of pmp.6 ct characteristics of pmp include: multiple complex cystic masses of low attenuation in the peritoneum, which may have rims of calcifications; characteristic scalloping of the liver (and occasionally splenic) margins; omental thickening, omental ‘cake’ and peritoneal implants; septated ‘pseudo’ ascites and varying degrees of compression of the visceral organs and structures (figs 1 3).3-9 ultrasound often reveals gross, non-mobile ascites with septations and echogenicity. when correlated clinically, these radiologic features are highly specific for pmp. in patients with incidental findings of pmp, plain films of the abdomen may reveal abdominal calcific plaques, ascites and poorly-defined soft-tissue masses. these plain-film findings should be followed by ct studies.6 ct can also be used to follow-up and re-evaluate patients. 2a 2b figs 2 a and 2b. compression of varying degrees of the visceral organs and structures. 3a 3b figs 3a and 3b. omental thickening (arrow), omental (omental cake) and peritoneal implants (arrow head), and septated ‘pseudo’ ascites. review article sa journal of radiology • september 2011 81 treatment although therapeutic paracentesis is not possible because of the nature of the mucin, enough material can be removed by ultrasound guidance for diagnostic evaluation, if the diagnosis is not certain. this is rarely required as the history, examination, and imaging studies often lead to the diagnosis.1 currently, cytoreductive surgery combined with peri-operative intraperitoneal chemotherapy is the standard treatment for patients with peritoneal spread of primary appendiceal tumours. this is achieved by combining peritonectomy procedures with peri-operative intraperitoneal chemotherapy.8 pmp of ovarian origin is usually treated surgically by hysterectomy, bilateral salpingo-oophorectomy, prophylactic appendectomy, and general debulking of the mucin.3 differential diagnosis the differential diagnosis includes primary or secondary peritoneal tumours, which may also present with scalloped liver margins and septated ascites.10 pancreatitis with ascites and pancreatic pseudocysts may also form part of the differential diagnosis, although the presence of pancreatic abnormalities may allude to this diagnosis. infective causes such as pyogenic peritonitis, widespread echinococcal disease and tb peritonitis, may be considered but the clinical presentation of these patients as well as the presence of other imaging findings such as liver abscesses or micro-abscesses (in the case of tb) may also be present. 1. devang, b, allen c, sean c. pseudomyxoma peritonei. app radiol 2005;34:6-8. 2. dahnert wf. radiology review manual, 5th ed. philadelphia: lippincott williams and wilkins, 2007. 3. harshen r, jyothirmayi r, mithal n. pseudomyxoma peritonei. clin oncol 2003;15:73-77. 4. chen cf, huang cj, kang wy, hsieh js.experience with adjuvant chemotherapy for pseudomyxoma peritonei secondary to mucinous adenocarcinoma of the appendix with oxaliplatin/fluorouracil/leucovorin (folfox4) world journal of surgical oncology 2008;6:118. 5. o’connell jt, tomlinson js, roberts aa, mcgonigle kf, barsky sh. pseudomyxoma peritonei is a disease of muc2-expressing goblet cells. am j pathol 2002;161:551-564. 6. lee h, agha f, weatherbee l, boland c.pseudomyxoma peritonei. radiologic features. j clin gastroenterol 1986;8:312-316. 7. pickhardt pj, levy ad, rohrmann ca jr, kende ai. primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation. radiographics 2003;23:645-662. 8. sugarbaker p. cytoreductive surgery and peri-operative intraperitoneal chemotherapy as a curative approach to pseudomyxoma peritonei syndrome. eur j surg oncol 2001;27:239-243. 9. weissleder r, wittenberg j, mukesh gh, john wc. primer of diagnostic imaging. philadelphia: mosby elsevier, 2007. 10. gupta s, gupta rk, gujral rb, saxena dar, tandon p. peritoneal mesothelioma simulating pseudomyxoma peritonei on ct. gastrointestinal radiology 1992;17:129-131. sonographygastrointest radiol 17:129-131 (19 sa journal of radiology • june 2011 63 quiz case presentation a chronically ill 49-year-old woman presented to the trauma unit with acute on chronic right arm pain after a syncopal episode. the following radiographic images were obtained (figs 1 3). at subsequent follow-up, plain radiography and an ultrasound scan were performed. figs 4a and 4b are plain abdominal radiographs, and fig. 5 is a gallbladder sonar image. findings describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@hotmail.com before 29 july 2011. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will appear in the next issue of the sajr. arm pain after syncope s k misser, mb chb, fcrad (d) lake smit and partners, durban corresponding author: s misser (shalendramisser@hotmail.com) fig. 1. lateral chest radiograph. fig. 2. antero-posterior view of the right shoulder. fig. 3. antero-posterior view of the right tibia. fig. 4a fig. 4b fig. 5 case report case report 72 sa journal of radiology • august 2009 case report introduction mammography is an established screening tool for breast cancer.1 early detection of breast cancer has a significant impact on morbidity and mortality.1 correct interpretation of mammograms can avoid false negatives and unnecessary biopsies in respect of benign changes. however, interpretation of mammograms can be challenging.2 the medial aspect of the breast is a ‘blind spot’ on the medio-lateral oblique view. as mammographic techniques improve, more attention is being given to imaging the medial breast, and the sternalis muscle will be revealed with increasing frequency.2 a case of the mammographic findings of the sternalis muscle is presented. features of this normal mammogram variant are described. in addition, the computed tomography findings are described and presented. case report a 37-year-old woman presented with bilateral ‘lumpy’ breast parenchyma on palpation. there was no family history of breast cancer and she had not undergone any previous breast surgery. all of her three children had been breastfed. she was not taking any form of hormonal manipulation. a mammogram and ultrasound were performed to further assess the palpable changes. the mammogram revealed bilateral, moderately dense breast parenchyma. normal skin and nipple contours were present. no clustered microcalcifications or architectural distortion were noted. however, in the cranio-caudal view of the right breast, a triangular opacity was noted in the postero-medial aspect of the breast. the medio-lateral oblique view did not contribute to the assessment of this density. ultrasound did not conclusively identify the density seen on mammogram in this patient. a limited computed tomography (ct) scan of the chest wall was performed to gain clarity of the mammographic findings (figs 1a, 1b and 2). the ct scan demonstrated a flattened band of muscle density lying anterior to the medial margin of the pectoralis muscle. this structure was separated from the underlying pectoralis muscle by a thin band of fat (fig. 3). the finding on mammography, which was further elucidated by ct scanning, was the sternalis muscle (fig.4). mammographic normal variant: the sternalis muscle debra meerkotter, mb bch, fcrad (d) sa regional imaging, st vincents hospital, launceston, tasmania, australia fig. 1a. right cranio-caudal view. fig. 1b. left cranio-caudal view. mammographic.indd 72 8/17/09 3:05:05 pm case reportcase report discussion the sternalis muscle is an uncommon normal variant that may present a diagnostic dilemma as it requires differentiation from pathology.2 the sternalis muscle may be unilateral or bilateral. cadaveric studies demonstrate its incidence in 8% of the male and female population. it is found in all population groups.3 it is twice as often unilateral as bilateral.3 the function of this muscle is uncertain, with various proposed interpretations regarding it. many surveyed surgeons are unaware of this muscle,1 and many anatomy textbooks do not include it.2 this narrow muscle bundle runs parallel to the sternum, with fibres running at 90 degrees to the pectoralis major muscle. it extends infraclavicularly to the inferior aspect of the sternum. the pectoral nerves provide innervation to the sternalis muscle. it is anatomically distinct from the pectoralis muscle and the abdominal musculature. the origin of this muscle is uncertain, with pectoralis major, rectus abdominus and sternomastoid all being proposed. mammographic techniques are continually improving, and for this reason we will encounter this muscle with increasing frequency. when the cranio-caudal view is properly performed, 30 40 % of mammograms will reveal the pectoralis muscle.4 it is seen as a smooth, convex density along the posterior edge of the image; distinct from this, the sternalis muscle may be visualised as a focal density on the medial aspect of the breast. mammographically, a single focal soft-tissue density will be seen in the medial aspect of the breast only on the cranio-caudal view. the density may be flame-shaped or triangular, it may have an irregular margin, and it is generally surrounded by fat. the maximum dimension of the density is 1 2 cm. the density is not seen on the medio-lateral oblique view as the medial breast is a ‘blind spot’ on this view.2 73 sa journal of radiology • august 2009 fig. 2. right medio-lateral oblique view. fig. 3. sternalis muscle coronal ct image. fig. 4. sternalis muscle sagittal ct image. mammographic.indd 73 8/17/09 3:05:06 pm case report case report 74 sa journal of radiology • august 2009 what are the guidelines in differentiating this feature from pathology? the location on the cranio-caudal view and the normal medio-lateral oblique view are useful guides. in addition, good clinical examination is essential in assessing the breast. the differential diagnosis is that of a mass (benign or malignant) or variable attachment of the pectoralis muscle (this is a slip of pectoralis muscle abutting the sternum and is imaged on both cranio-caudal and medio-lateral oblique views). if doubt still exists, a ct scan or magnetic resonance imaging (mri) can confirm the presence of the sternalis muscle. unnecessary biopsy of this normal variant can be avoided if one is aware of the entity. on ct scanning, the longitudinal course of the muscle can be defined. it lies parallel to the sternum and superficial to, and on the medial aspect of, the pectoralis muscle. often, the sternalis is separated from the pectoralis muscle by fat. ct scanning in the decubitus position encourages the muscle to bulge forward, providing improved visualisation of the muscle.2 mri scanning will provide superior soft-tissue resolution and will define the muscle clearly. mri scanning can be optimised by placing the patient prone, which utilises gravity to pull the muscle away from the chest wall by dependent breast tissue.1 conclusion the sternalis muscle is an unusual normal variant which is seen on occasion on the cranio-caudal view of a mammogram. the main differential is that of significant pathology. there are certain features that will guide the radiologist in the interpretation of the mammogram, so avoiding unnecessary biopsy. if there is any doubt in interpreting the mammogram, further correlation with ct or mri will enable a conclusive diagnosis of this normal variant. 1. berg wa, birdwell rl. diagnostic imaging: breast, 1st ed. manitoba, canada: amirysis, 2006. 2. bradley fm, hoover hc, hulka ca, et al. the sternalis muscle: an unusual normal finding seen on mammogram. am j roentgenol 1996; 166: 33-36. 3. jeng h, shuen-jing s. the sternalis muscle: an uncommon anatomical variant among taiwanese. j anat 1998; 193: 287-288. 4. ramirez-escobarr ma, salmeron ir. what is this breast mass? br j radiol 1998; 71: 573-574. mammographic.indd 74 8/17/09 3:05:06 pm editorial � sa journal of radiology • june 2007 health sciences is leading the way with its plans to improve the registrar success rates in the mmed. apart from the research techniques course offered within the department of radiology, the faculty is planning two comprehensive courses on protocol preparation, ethics, research methodology, data analysis, report writing and editing. the courses will be held at chris hani baragwanath hospital and the faculty and should start in about august. they will be offered as a set or as individual courses. radiology registrars should keep an eye open for the notices! during november we host our annual health graduates re-union and the seminar this year (saturday 10 november 2007) is on imaging. seems radiology is becoming a leader in research in this faculty! the sajr is improving its profile and horizons all the time as we want to be indexed so that we can be available online, i.e. on pubmed, and we will therefore have an impact factor (if). the if is an american invention, started in the 1950s by the institute of scientific information (isi) of philadelphia, pennsylvania.1,2 the if is often used to assess the quality of a journal or article. the if of a journal is determined by the number of times a particular journal is cited over a given period – usually a 3-year period.2 although the if has created controversy in many circles, one has to bear in mind that in some countries it is used to evaluate grant applications, staff promotions, job applications, and bonuses.3,4 the controversies are largely based on inherent biases in the system which include english language preference; review articles (being more citable than case reports, so if a journal does not publish case reports it automatically becomes more citable, e.g. the american journal of radiology); free journals – for obvious reasons; longer articles; and of course the poor yield of citations from regional journals with highly specialised topics, for example antarctic science.1,5 basic science journals usually carry a high impact factor (nature has an if of 27.0740), whereas the clinical journals less so. at present the if of radiology is 3.899, the ajnr 1.556, paediatric radiology 0.8, and the samj 0.794.5 once a journal applies to be included in the isi database, there are a few criteria that are scrutinised. these include: (i) regularity of publication; (ii) profile of the editorial team; (iii) whether the journal is peer-reviewed; and (iv) the relevance and topicality of the contents.1 so by applying to be indexed we do leave ourselves vulnerable to a flawed system – but a system that is used relatively often, and that has international recognition. it is important that the if does not become all-consuming, and that the if of a journal or the if of an individual’s research be approached with caution, and not be the sole criterion in assessing the quality of a journal or a researcher. this issue of the sajr includes an original article from dr steven braude and the lambert group of the mrc/uct research unit for exercise science and sports medicine, who have concluded that plain radiographs alone are not ideal or accurate enough to identify age cheats in sport. dr vicci du plessis, a radiology registrar from petermaritzburg, together with professor savvas andronikou, has just completed a pilot study investigating criteria used when selecting radiology registrars for the teaching circuit. their preliminary findings are that academic credentials and work experience are key criteria for the selection of radiology registrars in south africa, and that a marked racial misrepresentation still prevails (this should silence the ever-sceptic critics – and not only in sydney!). professor vinay sharma of the johannesburg hospital radiation oncology unit compared barium and gastrograffin swallows for use in radiation therapy planning in patients with carcinoma of the oesophagus, and found barium to be more cost effective. dr humza carim, a first-year radiology registrar from johannesburg, together with the chris hani baragwanath hospital interventional radiology department, has described our experiences with bronchial artery embolisation for massive haemoptysis. there is also a case report with a review of the literature from professor sheldon wiebe, a paediatric radiologist from saskatoon university, saskatchewan, canada. he describes the radiographic and prenatal ultrasound features of perinatal lethal hypophosphatasia and its differentiation from osteogenesis imperfecta type ii. this broad spectrum of submissions, as well as international submissions, bodes very well for the future of the sajr. we have a second guest editor for this issue, professor merryll vorster, the previous head of psychiatry, with extensive legal and ethics experience, and who is now the vice dean of the faculty of health sciences, university of the witwatersrand. thank you kindly! 1. nayak bk. the enigma of impact factor. indian j ophthalmol 2006; 54:225-226. 2. impact factor of journals in alphabetical order. www.bioscience.org/services/impact15.htm-64k (last accessed 1 may 2007). 3. martyn c. the malign influence of impact factors. j r soc med 2005; 98:556. 4. ha tc, tan sb, soo kc. the journal impact factor: too much of an impact? ann acad med singapore 2006; 35: 911-916. 5. journal impact factors. www.sciencegateway.org/impact/-5k (last accessed 1 may 2007). the future impact of the sajr mala modi, mb chb, fcrad (sa), mmed division of radiology, department of radiation sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg mala modi guest editor hello from the faculty of health sciences, wits! professor merryll vorster, vice-dean faculty of health sciences, university of the witwatersrand, johannesburg do not let sleeping dogs lie!! pg2.indd 2 6/13/07 9:18:29 am 46 sa journal of radiology • june 2011 case report introduction diffuse infiltrative lymphocytosis syndrome (dils) is an entity found in patients infected with the human immune deficiency virus (hiv) with a persistent cd8+ lymphocytosis and diffuse lymphocytic infiltration of various organs.1 the aetiology is unknown, but it is postulated that the possible cause is a ‘hyper-immune’ lung response to hiv or epstein-barr virus that results in infiltration of organs by the cd8+ lymphocyte.2 typically, patients present with asymptomatic salivary gland enlargement. however, in our setting (third-world), patients may not necessarily present in this way. other features include sicca or sjogrenslike syndrome and associated cervical and generalised lymphadenopathy.1 unilateral parotid gland enlargement in an hiv-positive patient should alert the clinician to suspected dils.3 radiological manifestations of this disease should be first sought in the lungs, which is the most common extra-glandular site of infection. other manifestations of this entity include a severe form of peripheral neuropathy, hepatitis, myositis and nephritis.3 lymphocytic interstitial pneumonitis (lip) is part of the dils spectrum.2 lip is a rare disease which is more common in children and the radiological presentation of dils in adults is similar to lip in children. imaging findings the lung is the most commonly affected extra-glandular site of dils. the disease may mimic pneumocystis jirovecii pneumonia with bilateral f ismail, fcrad(d) irma van de werke, frcr nausheen khan, fcrad (d) department of radiology, kalafong hospital, pretoria p f levay, msc, mb chb, mmed (int) department of internal medicine, kalafong hospital g h davel, mmed (anat path) department of anatomical pathology, kalafong hospital corresponding author: f ismail (drfismail@yahoo.com) radiological chest manifestations in diffuse infiltrative lymphocytosis syndrome (dils) fig. 1. frontal and lateral chest radiographs in an adult female patient demonstrate bilateral basal reticulo-nodular infiltrate with areas of coalescence in both lower lobes, and lingula resulting in areas of subsegmental consolidation. hilar adenopathy is present. fig. 2. frontal and lateral radiographs of an adult female patient demonstrate predominantly nodular infiltrate distributed in the basal lung zones with hilar adenopathy and left pleural effusion. fig. 3. frontal and lateral chest radiographs demonstrate coarse reticular and nodular infiltrate in the mid and lower lung zones, with associated hilar adenopathy and left basal consolidation. abstract this report focuses on the radiological manifestations of diffuse interstitial lymphocytosis syndrome (dils) in the chest. awareness of this entity and early diagnosis by radiologists will enable timeous intervention by clinicians. sa journal of radiology • june 2011 47 case report ground-glass opacification and reticulonodular infiltrate. it may also be confused with miliary tb as demonstrated on chest radiograph (figs 1 3) and high-resolution computed tomography images (fig. 4). as bilateral hilar adenopathy and basal kerley b lines are also a feature, lymphangitis carcinomatosis and lymphoma of the lung are also possible differential diagnoses to consider. the diagnosis is confirmed histologically (fig. 5) by demonstrating diffuse lymphocytic infiltration of the lung. treatment involves the use of anti-retrovirals and steroids. recommendation radiologists should consider dils as part of the differential diagnosis in hiv-positive patients who present with enlarged parotid glands and a basal miliary infiltrate with hilar adenopathy, and should timeously alert the clinician of this entity. 1. levay pf, botes me. diffuse infiltrative lymphocytosis syndrome. sa fam pract 2008;50(2):23-27. 2. jeanes ac, owens dm. imaging of hiv disease in children. imaging 2002;14:8-23. 3. franco-paredes c, robolledo p, folch e, hernandez i, del rio c. diagnosis of diffuse cd8+ lymphocytosis syndrome in hiv infected patients. aids reader 2002;12(9):410-411. figs 4a and b. axial high resolution computed tomography (hrct ) of the chest demonstrates lymphatic distribution of a nodular infiltrate with interlobular septal thickening. 4a 4b figs 5a and b. histological stains of lung biopsy demonstrate thickening of the interalveolar septae with focal peribronchiolar collections of lymphocyte infiltration in keeping with interstitial lung disease. 5a 5b 43 sa journal of radiology • june 2010 radiologists and radiographers must remain the custodians of diagnostic radiation to the editor: the editorial in the march 2010 issue of the sajr by professor lotz1 draws attention to ‘a unilateral process instituted by the hpcsa to embark on opening the diagnostic use of ionising radiation to all medical disciplines’. this is a reckless and alarming prospect. as i write, the medical imaging industry throughout the usa, and the world at large, awaits the outcome of 2 days of hearings held on 30 and 31 march by the us food and drug administration (fda) regarding widespread concerns over rising medical radiation dose. these hearings were prompted by a rising tide of articles in the medical literature drawing attention to the danger posed by the increasing use of ionising radiation in medical diagnostic imaging, mainly a result of an explosive increase in the number of ct scans that are performed annually. the editorial quotes that more than 60 million ct scans are estimated to be performed annually in the usa. a further source2 (quoted in an article reviewing the hazards of ionising radiation)3 adds the perspective that in the 24-year period between 1981 and 2005, the number of ct examinations increased more than twentyfold, from 3 million in 1981 to 63 million in 2005. in raising the alarm against what appears to be an unbelievably irresponsible move by the hpcsa (which appears bent on removing all control over diagnostic radiation in south africa) at a time when the rest of the world is tightening control, the editorial surely speaks not only for the radiological society but for the entire radiological fraternity in south africa. we, as the custodians of the appropriate use of ionising radiation for medical imaging, must make ready for battle. d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com 1. lotz j. editorial: radiation free-for-all is imminent. south african journal of radiology 2010; 14(1): 2. 2. the delicate balance between radiation exposure and imaging efficiency. leading article: inpractice; quarterly publication of the american roentgen ray society. summer 2007: 5-7. 3. emby dj. radiation: friend and foe. occ health southern africa 2008; 14(5): 9-13. the hpcsa and radiology to the editor: your editorial1 decrying the role of the hpcsa in allegedly encouraging a ‘radiation free-for-all’ nearly hit the mark (is it better to nearly hit or nearly miss?). allow me as a member of the maligned committee to make a few points. the committee originated from a concern by the radiation control division of the department of health about unregulated radiological practices by practitioners, particularly in rural areas. not only was radiation control often inadequate but the quality of the examinations was also often sub-standard. the issue was how to ensure the safety of the public while not depriving them of a service not otherwise available. from the outset, the radiological society was aware of this initiative and provided helpful documentation. the committee noted that there were practitioners other than general practitioners (such as cardiologists etc.) who also used imaging in their practices. the general principle of the hpcsa in allowing practitioners to apply techniques for which they were adequately trained was considered to be appropriate also in these circumstances i.e. where specialists (such as cardiologists) demonstrably received adequate training, including the use of x-rays, they should be free to use this in subsequent practice. however, general practitioners were not considered to have had sufficient training in radiological services, and the committee resolved that an appropriate training programme should be developed and completed by those who wished to provide a radiological service. the provision of such training for all users of imaging equipment is a well placed function of the rssa. there is general agreement that adequate radiation control is essential. but in my opinion there are more important issues that were not in the remit of the committee, namely the proliferation of many diagnostic and therapeutic interventions that are reliant on expensive equipment. such equipment is often acquired because of its potential revenue generation, and that often results in self-referral – a sure way of driving up medical costs through unnecessary procedures. jp van niekerk health & medical publishing group rondebosch jpvann@hmpg.co.za 1. lotz j. radiation free-for-all is imminent. south african journal of radiology 2010; 14: 2. letters tips for the radiologist 69 sa journal of radiology • september 2010 background imaging can be helpful when investigating salivary gland pain and swelling. typically in such cases, an ultrasound (us) or conventional sialogram would be requested in seeking obstructed or dilated ducts, a ductal calculus or an abscess within the gland. occasionally a computed tomography (ct) scan is requested. magnetic resonance imaging (mri) is usually reserved for investigating clinically palpable masses in the glands. in acute non-obstructive parotitis, the differential diagnosis includes acute non-suppurative parotitis (as found in mumps), early sjögren’s syndrome, or suppurative parotitis as seen following duct obstruction. sometimes there is strong insistence on retrograde contrast sialography; however, this may exacerbate the pre-existing inflammatory process.1 the imaging of a young patient expands on these observations. findings and diagnosis a young girl presented with only a non-specific history of recurrent painful swelling of both parotid glands over the preceding few months. an us scan showed numerous small, discrete hypoechoic foci throughout both parotid glands. an mri was recommended and performed using standard sequences including thin-slice axial and coronal t1 and t2 (fat-suppressed) sequences. in view of the pathological changes seen on us, fat-suppressed t1 series were also obtained, as were preand post-contrast axial and coronal series. an mr sialogram was acquired through each parotid gland in an oblique sagittal orientation, which proved to be the most useful diagnostic sequence (fig. 1). the images from these sequences showed both parotid glands to be diffusely swollen with numerous microcysts within the gland parenchyma. this was felt to be typical of sjögrens disease, stage i or ii (depending on the size of the cysts). discussion sjögrens syndrome is an auto-immune disease affecting the lacrimal and all salivary glands, but predominantly the parotid glands. initial periductal lymphocyte aggregates extend into, and finally destroy, salivary acinar parenchyma, which leads to small cystic spaces beginning peripherally in the gland.1 as acinar destruction progresses, salivary production decreases and ascending infections develop, eventually leading to sialectasis developing in the gland, enlargement of the microcysts and fatty replacement of the destroyed acinar within the salivary gland parenchyma. xerostomia (dryness of the mouth) is the most common oral symptom.1 literature over the last 2 decades has described the use of mr imaging to diagnose and stage the severity of sjögrens syndrome involving the parotid glands.1,2 mr sialography can now be used to replace conventional sialography in diagnosing and staging parotid gland involvement in this condition.1,2 mr sialography approaches 95% sensitivity and specificity.1,2 although not histologically proven, the clinical diagnosis of sjögrens syndrome in this case is considered almost certain. the case highlights two important mri techniques: mr sialography and t2w fat-suppression sequence. mr sialography mr sialography is an excellent example of the technique of mr hydrography, using extremely long tr and te times to highlight fluid and suppress other surrounding tissue signals. hydrography is more commonly applied in other areas of the body, such as creating mr myelograms in the cervical and lumbar spine, mr cholangiopancreatograms of the biliary system, and mr renograms of the urinary tract. most modern mr scanners often have pre-programmed ‘myelogram’ sequences in the list of cervical spine protocols. these can be modified use of mr sialography and t2w fat-suppressed mr in parotitis phil pretorius, ffrad (diag) sa drs visser, vawda, erasmus and partners, greenacres hospital, port elizabeth fig. 1. mr sialogram (tr 8 000 msec, te 1 000 msec, fov 150 mm, spir fat suppression, slice thickness 40 mm, scan time 8 sec on 3t scanner). numerous microcysts in parotid gland (arrow) without associated duct dilatation. these changes were identical in the other parotid gland. a few small microcysts were also noted in the submandibular gland (arrowhead), with the ducts also visible. tips for the radiologist 70 sa journal of radiology • september 2010 to create a ‘sialogram’ sequence by performing single sagittal oblique slices over each gland. these should be planned on the axial series and angled obliquely along the ap axis of the individual glands. this scan sequence is typically a 30 40 mm-thick single shot, turbo spin echo, with long tr (8 000 msec) and long te (1 000 msec) and spectral presaturation inversion recovery (spir) fat suppression. each slice takes approximately 8 seconds to acquire (depending on the strength of the magnet). a standard head coil is usually adequate; however, a receiver surface coil can also be used, placed directly over the parotid gland to increase the signal-to-noise ratio and hence the quality of the scan, if necessary. the scan sequence effectively suppresses signal from any tissues without water content, while fluid-filled structures stand out as bright objects against an almost black background. the sequence will therefore clearly show any cysts or dilated ducts (sialectasis) within the relevant glands, and provides a non-invasive alternative to retrograde contrast sialography. as with mrcps and mr myelograms, mr sialograms should enjoy clinical support as a good alternative to conventional sialography when investigating inflammatory conditions of the parotid glands. t2w fat-suppression sequence this useful sequence is used extensively in musculoskeletal, abdominal and head and neck imaging. typically for msk imaging, the t2w fat-suppressed sequence should have the te reduced from the usual 100 120 msec down to approximately 60 msec; this significantly reduces the time required to obtain the images, increases signal-to-noise ratio and permits good visualisation and separation of pathology from surrounding tissues. unfortunately, in the case of parotid glands, cystic structures may not stand out clearly from the normal parenchyma, which itself is fluidrich (fig. 2). a more t2-weighted series is required to highlight the cystic changes in the gland (fig. 3). as for other fluid-filled structures in the body, mr hydrography is useful in imaging the salivary glands. it is a valuable complement to conventional mr imaging, and avoids the need to inject contrast material. from the author’s personal experience, mr sialography can reasonably be considered the radiological investigation of choice for suspected sjögrens syndrome and acute acalculous parotiditis. as opposed to the usual practice of reducing te to improve the signal in t2w fat-suppressed series, standard or even prolonged tes (100 150 msec) are required to better demonstrate fluid-filled structures in highfluid-content backgrounds such as the salivary glands. 1. yukinori t, sumia m, sumia t, ichikawaa y, nakamura t. mr microscopy of the parotid glands in patients with sjogrens syndrome: quantitative mr diagnostic criteria. am j neuroradiol 2005;26:1207-1214. 2. ohbayashi n, yamada i, yoshino n, sasaki t. sjogren syndrome: comparison of assessments with mri sialography and conventional sialography. radiology 1998;209:683-688. 3. harnsberger hr, wiggins iii rh, hudgins pa, davidson hc. diagnostic imaging: head and neck. philadelphia, usa: amirysys, part iii, section 7:12-15. fig. 2. axial t2w fat-suppressed image (te 60 ms, tr 3 000 ms) acquired with standard 4 mm-thick t2 fat-suppressed protocols for deep face and salivary gland. microcysts are not differentiated from the glandular tissues. fig. 3. axial t2w fat-suppressed image with te 110 ms, tr 5 200 ms. note improved visibility of microcysts (arrow). abstract introduction case report discussion conclusion acknowledgements references about the author(s) pokhraj p. suthar department of diagnostic radiology and nuclear medicine, rush university medical center, chicago, illinois, united states of america kathryn hughes department of diagnostic radiology and nuclear medicine, rush university medical center, chicago, illinois, united states of america geetanjalee kadam department of diagnostic radiology and nuclear medicine, rush university medical center, chicago, illinois, united states of america miral jhaveri department of diagnostic radiology and nuclear medicine, rush university medical center, chicago, illinois, united states of america santhosh gaddikeri department of diagnostic radiology and nuclear medicine, rush university medical center, chicago, illinois, united states of america citation suthar pp, hughes k, kadam g, jhaveri m, gaddikeri s. human parechovirus meningoencephalitis. s afr j rad. 2023;27(1), a2589. https://doi.org/10.4102/sajr.v27i1.2589 case report human parechovirus meningoencephalitis pokhraj p. suthar, kathryn hughes, geetanjalee kadam, miral jhaveri, santhosh gaddikeri received: 10 nov. 2022; accepted: 10 jan. 2023; published: 23 feb. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract human parechovirus-3 (hpev-3) infection is one of the differential diagnoses of neonatal meningoencephalitis. a 13-day-old full-term female neonate presented with a seizure. brain mri showed classic imaging findings of the meningoencephalitis which was confirmed on cerebrospinal fluid analysis. contribution: the hpev-3 is an emerging pathogen for neonatal meningoencephalitis. the case in this study is unique with classic imaging findings, which are not routinely encountered in day-to-day practice. this case raises reader awareness. keywords: meningoencephalits; human parechovirus; neonate; mri; csf. introduction the differential diagnosis of neonatal meningoencephalitis or sepsis is broad. human parechovirus-3 (hpev-3) is one of the differential diagnoses of neonatal meningoencephalitis or sepsis. it is an emerging pathogen that has been increasingly recognised as a causative agent in recent years. the human parechoviruses are a family of viruses closely related to enteroviruses. characteristically, young infants present with fever, irritability and on occasions, a diffuse rash. severe disease can manifest as meningoencephalitis, seizures or sepsis-like presentations, including septic shock. while mri findings overlap in many of the bacterial and viral aetiologies, the presented case of human parechovirus infection in this report increases radiologists’ awareness of the characteristic mr brain imaging findings, providing a unique opportunity to be able to make a definitive diagnosis in clinically suspected cases of neonatal meningoencephalitis. case report a 13-day-old full-term female neonate presented with a seizure. at presentation, seizure semiology included rhythmic twitching of both upper and lower extremities with eye deviation. the neonate was feeding less but passing urine normally. on examination, the neonate was lethargic, with decreased tone in both upper extremities, weak grasp and head lag. the neonate had hypoglycaemia (neonatal heel prick glucose 24 mg/dl; normal reference range 46 mg/dl – 120 mg/dl) which was corrected with a glucose infusion. continuous electroencephalogram (ceeg) monitoring revealed electrographic right centrotemporal seizures. the baby was born at 37 weeks and 2 days to a 32-year-old g5p2 mother with apgar scores of 8 and 9 at 1 min and 5 min, respectively. the antepartum and intrapartum course was unremarkable except for artificial rupture of the membranes for 2 h. neonatal laboratory screening and blood culture were negative. basic metabolic profile, magnesium and c-reactive protein were within normal limits. serum procalcitonin was elevated. lumbar puncture was performed, and cerebrospinal fluid (csf) analysis demonstrated a decrease in csf protein, normal glucose and no csf pleocytosis. ultrasound of the head was unremarkable (images not displayed). multiplanar multi-sequence mri of the brain was performed for further evaluation, revealing areas of restricted diffusion and t2 fluid-attenuated inversion recovery (flair) signal abnormality involving the entire corpus callosum and bilateral supratentorial white matter, predominantly in the frontal regions with sparing of the thalami (figure 1, figure 2 and figure 3). there were areas of t1 and t2 shortening in the distribution of the deep medullary veins (figure 4). t1-weighted contrast-enhanced mri indicated faint minimal leptomeningeal contrast enhancement without parenchymal contrast enhancement (figure 5). based on the imaging findings, the diagnosis of an infectious process such as meningoencephalits was considered. the csf meningitis encephalitis panel was positive for human parechovirus. figure 1: (a, b, c) axial diffusion-weighted mri of the brain (repetition time msec/echo time msec, 8500/100; flip angle, 90°; b-value = 1000 sec/mm2) and (d, e, f) corresponding axial apparent diffusion coefficient maps (8500/100; flip angle, 90°; b-value = 1000 sec/mm2) at the level of the high frontal lobes (a, d), basal ganglia (b, e) and peritrigonal white matter (c, f). areas of restricted diffusion involving the bilateral supratentorial white matter, predominantly bilateral frontal lobes (solid white arrows on all images), corpus callosum (dashed white arrows on images [b]) and [e]) and bilateral peritrigonal periventiruclar white matter (solid white arrow heads on images [b], [c], [e] and [f]). figure 2: axial t2-weighted mri of the brain (repetition time msec/echo time msec, 3680/90, 3-mm section thickness) at the level of the high frontal lobes (a), basal ganglia (b) and peritrigonal white matter (c). the images show areas of t2 signal abnormality involving the corpus callosum and the bilateral supratentorial white matter, predominantly the bilateral frontal regions (solid white arrows on all images) with sparing of the thalami. figure 3: axial fluid-attenuated inversion recovery mri of the brain (inversion time 2500, repetition time msec/echo time msec, 9000/112, 3-mm section thickness) at the level of the high frontal lobes (a), basal ganglia (b) and peritrigonal white matter (c). images demonstrate areas of flair signal abnormality involving the corpus callosum and the bilateral supratentorial white matter, predominantly the bilateral frontal regions (solid white arrows on all images) with sparing of the thalami. figure 4: axial unenhanced t1-weighted mri of the brain (repetition time msec/echo time msec, 300/2.52, 3-mm section thickness) at the level of centrum semiovale and corona radiata (a, b, c) with corresponding axial t2-weighted mri of the brain (repetition time msec/echo time msec, 3680/90, 3-mm section thickness) (d, e, f). there were areas of t1 and t2 shortening following the distribution of deep medullary veins (solid white arrows on all images), more evident on the t1-weighted images. figure 5: axial t1-weighted mri of the brain at the level of centrum semiovale (repetition time msec/echo time msec, 300/2.52, 3-mm section thickness), unenhanced (a) and contrast-enhanced (b) after intravenous injection of 1 ml of gadoteridol (prohance; bracco). there were areas of non-enhancing signal abnormality in the bilateral supratentorial frontal white matter (solid white arrow heads on images [a] and [b]), corresponding to the restricted diffusion. subtle leptomeningeal contrast enhancement seen (solid white arrows on image b). discussion closely related to enteroviruses, human parechoviruses comprise a genus within the picornaviridae family.1,2,3 up to 19 different parechovirus genotypes have been identified with varying clinical presentations.3,4 transmission is predominantly via the oral-faecal route.1 although other genotypes are often associated with mild symptoms, hpev-3 is an emerging pathogen that has been increasingly recognized as a causative agent of neonatal meningoencephalitis and sepsis.1,2 the pathophysiology of the hpev-3 is not clearly understood.4 human parechovirus-3 most commonly infects children less than 3 months of age, with infections uncommon among patients older than 10 years.1,2 clinically, patients with hpev-3 infection may present with mild gastrointestinal or respiratory symptoms, rash or severe disease such as sepsis and central nervous system (cns) infection.1,2,5 risk factors for severe disease may include prematurity and age less than 28 days.2 in this study, a 13-day old patient was at risk of severe hpev-3 disease and presented with signs of cns infection. treatment of hpev-3 is supportive, although patients often empirically receive antibiotics and acyclovir because of overlapping presentations with bacterial and herpes simplex virus (hsv) infection.5 human parechovirus-3 infection may be confirmed via reverse transcriptase real-time polymerase chain reaction (rt-pcr) using stool, blood, respiratory samples or csf, while characteristic imaging plays a supportive role in diagnosis.1,3 cranial ultrasound findings are non-specific and can be insensitive early in the disease course.2 parechovirus meningoencephalitis is best evaluated with mri.2 characteristic imaging findings include bilateral supratentorial white matter abnormalities with corresponding restricted diffusion.4,6,7 involvement along the deep medullary veins, thalamus and entire corpus callosum with sparing of the basal ganglia and posterior fossa have also been reported.4 the preference for supratentorial white matter suggests supratentorial white matter neuroaxonal trophism. signal abnormality along the course of the deep medullary vein suggests perivenular invasion or venous ischemia. the presented case demonstrates these classic imaging findings of t2-flair hyperintensity and corresponding restricted diffusion involving the subcortical white matter and entire corpus callosum, with some lesions along the deep medullary veins. the basal ganglia and posterior fossa were spared. head ultrasound, in this study, was normal. differential diagnoses include hypoxic-ischemic encephalopathy (hie), molybdenum cofactor deficiency (mcd) and isolated sulfite oxide deficiency (isod). a major cause of neonatal morbidity and mortality, hie typically involves one of two main imaging patterns on mri, which are strong predictors of neurodevelopmental outcome: cortical watershed and deep grey matter.8,9 in contrast to parechovirus encephalitis, which predominantly involves the subcortical white matter, the watershed pattern of hie involves the cortex along the borders of the major arterial vascular territories.9 in addition, the deep grey matter pattern of hie affects the basal ganglia and thalamus, whereas hpev-3 encephalitis often spares the basal ganglia.4,9 molybdenum cofactor deficiency is a rare autosomal recessive disease, which can mimic hie on mri.10 it results from decreased production of molybdenum, a cofactor for three important enzymes: sulfite oxidase, xanthine dehydrogenase and aldehyde oxidase.11 the resultant toxicity from elevated neuronal levels of sulfite in mcd causes progressive, fatal neurological decline, with a median survival of 36 months.11 similar to hie, the mri findings of mcd include diffuse cerebral oedema with involvement of the deep grey matter, followed by cerebral and cerebellar atrophy and ventriculomegaly.11 in contrast, the characteristic hpev-3 imaging findings involving the supratentorial white matter with sparing of the basal ganglia and posterior fossa, can thus help to differentiate mcd from hpev-3 encephalitis. like mcd, isod is a rare, fatal autosomal recessive disorder that often presents with seizures and progressive neurological decline.11 sulfite oxidase utilizes molybdenum as a cofactor, and thus mcd and isod may have similar clinical and imaging features, with laboratory confirmation distinguishing between the two conditions.11 on mri, isod may indicate signal abnormalities involving the cortex, subcortical white matter, thalami and basal ganglia, with marked cerebral volume loss and cystic encephalomalacia over time.11 the condition can thus be differentiated from hpev-3 by the striking cystic changes and involvement of the basal ganglia with isod, compared with the supratentorial white matter predominance and sparing of the basal ganglia seen with hpev-3. conclusion severe infection with hpev-3 can manifest as meningoencephalitis, seizures or sepsis-like presentations, including septic shock. while mr brain imaging findings overlap in bacterial and viral aetiologies of meningitis, human parechovirus infection displays characteristic findings which can support a definitive diagnosis in clinically suspected cases. as only a few cases are documented in the literature and cases are infrequently encountered in day-to-day practice, radiologists should familiarize themselves with the mr imaging findings in this condition. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions g.k. and s.g. diagnosed and assisted p.p.s. and k.h. in writing, drafting and finalising the article. p.p.s. and k.h. drafted and wrote the article. g.k., s.g. and m.j. critically revised the article with important conceptual and editorial inputs. ethical considerations this article followed all ethical standards for research. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references esposito s, rahamat-langendoen j, ascolese b, senatore l, castellazzi l, niesters hg. pediatric parechovirus infections. j clin virol. 2014;60(2):84–89. https://doi.org/10.1016/j.jcv.2014.03.003 britton pn, jones ca, macartney k, cheng ac. parechovirus: an important emerging infection in young infants. med j aust. 2018;208(8):365–369. https://doi.org/10.5694/mja18.00149 leow jy, gupta r, sohal ap. human parechovirus central nervous system infection: a rare cause of neonatal encephalitis. j paediatr child health. 2015;51(12):1244. https://doi.org/10.1111/jpc.13025 sarma a, hanzlik e, krishnasarma r, pagano l, pruthi s. human parechovirus meningoencephalitis: neuroimaging in the era of polymerase chain reaction-based testing. ajnr am j neuroradiol. 2019;40(8):1418–1421. https://doi.org/10.3174/ajnr.a6118 khatami a, mcmullan bj, webber m, et al. sepsis-like disease in infants due to human parechovirus type 3 during an outbreak in australia. clin infect dis. 2015;60(2):228–236. https://doi.org/10.1093/cid/ciu784 britton pn, dale rc, nissen md, et al. parechovirus encephalitis and neurodevelopmental outcomes. pediatrics. 2016;137(2):e20152848. https://doi.org/10.1542/peds.2015-2848 belcastro v, bini p, barachetti r, barbarini m. teaching neuroimages: neonatal parechovirus encephalitis: typical mri findings. neurology. 2014;82(3):e23. https://doi.org/10.1212/wnl.0000000000000040 trivedi sb, vesoulis za, rao r, et al. a validated clinical mri injury scoring system in neonatal hypoxic-ischemic encephalopathy. pediatr radiol. 2017;47(11):1491–1499. https://doi.org/10.1007/s00247-017-3893-y sorokan st, jefferies al, miller sp. imaging the term neonatal brain. paediatr child health. 2018;23(5):322–328. https://doi.org/10.1093/pch/pxx161 durmaz ms, özbakır b. molybdenum cofactor deficiency: neuroimaging findings. radiol case rep. 2018;13(3):592–595. https://doi.org/10.1016/j.radcr.2018.02.025 dublin ab, hald jk, wootton-gorges sl. isolated sulfite oxidase deficiency: mr imaging features. am j neuroradiol. 2002;23(3):484–485. metastatic.html metastatic melanoma to the small bowel complicated by fistula formation nausheen khan, mb bs, fc rad irma van de werke, mb chb, frcr department of radiology, kalafong hospital, pretoria zaeem i ebrahim, mb bch, fc rad farzanah ismail, mb bch, fc rad department of radiology, steve biko academic hospital and university of pretoria corresponding author: z ebrahim (zaeem@iafrica.com) introduction malignant melanoma (mm) is an unpredictable tumour that can metastasise to any organ, and is well known for its widespread dissemination. the incidence of metastases to the gastro-intestinal (gi) tract is well documented; this, however, is a late manifestation of the disease with an overall poor prognosis. most gi metastases are asymptomatic and are only discovered on postmortem, with the majority in the small bowel. the presenting symptoms are usually of obstruction or intussusception; gi bleeding is also common. fistula formation with the small bowel is rare; ours is believed to be the second case documented.1 , 2 case history a 59-year-old man presented with a 2-month history of change in bowel habits. there was no significant history of illness in the past and no known primary lesion. clinically, his abdomen was distended with a palpable right iliac fossa mass extending to the supra-pubic area. there were no signs of guarding or tenderness. blood tests showed that he was anaemic, with haemoglobin of 9.4g/dl, leucocytosis and raised c-reactive protein (crp). radiological findings ultrasound ultrasound showed a para-caecal mass associated with para-aortic and para-pancreatic lymphadenopathy. computed tomography (ct) scans (figs 1 3) revealed a large intraperitoneal, predominantly mesenteric, mass in the right lower abdomen crossing to the contra-lateral side, with a large central ulceration and fistula formation with the distal small bowel i.e. ileum with an air contrast level within the tumour. there was also para-aortic and peri-pancreatic lymphadenopathy.the rest of the small bowel was displaced anteriorly, and the sigmoid pushed postero-laterally. discussion mm is one of the most common malignancies to metastasise to the gi tract.2 it does so via lymphatic channels to parenchymal organs. symptomatic metastasis to the gi tract is seen only in 2% of patients.3 metastases may present at the time of primary diagnosis or decades later as the first sign of recurrence. mm that involves the gi tract may be either primary or metastatic.2 symptoms include abdominal pain, dysphagia, small bowel obstruction, haematemesis and melena. symptoms are usually identical to those caused by primary gi tumours.4 , 6 primary gi melanoma can arise in various gi mucosal sites, including the oral cavity, oesophagus, small bowel, rectum and anus, in the absence of prior cutaneous melanoma. primary melanoma of the gi tract is rarely diagnosed at an early stage. distinguishing between a primary gi mucosal melanoma and melanoma metastases to the gi tract from an unknown or regressed cutaneous primary may be difficult.2 , 4 the most common sites of metastases are lymph nodes (73%) and lung (71%), followed by the liver, brain, bone and adrenal glands; gi metastasis stands at 43%. superficial spreading melanoma is the most common subtype to metastasise to the gi tract.2 diagnosis of mm is generally made by radiographic contrast studies, including ct, ultrasound and barium studies, as well as endoscopic evaluation. most recently, positron emission tomography computed tomography (pet/ct) has been used to identify sites of metastatic melanoma. ct sensitivity is between 60 and 70%.2 , 5 metastatic lesions may be intraluminal masses, ulcerating lesions (as in our case), diffusely infiltrating lesions or mesenteric implants. conclusion mm in the gi tract is a late manifestation of the disease, with overall poor prognosis.6 in a patient presenting with a gi tract mass, initial differentials should include primary gi tract tumours as well as lymphoma; however, a high index of suspicion for metastatic melanoma should be maintained if the patient presents with seemingly unrelated symptoms or history of treated melanoma in the past. 1. casanova f, lizazo j, shezi s, oliver f. right inguinal bowel fistula on the course of melanoma disease. internet journal of oncology. 2009;6(2). 1. casanova f, lizazo j, shezi s, oliver f. right inguinal bowel fistula on the course of melanoma disease. internet journal of oncology. 2009;6(2). 2. liang kv, sanderson so, nowakowski gs, arora as. metastatic malignant melanoma of the gastrointestinal tract. mayo clinic college of medicine. mayo clinic proceedings 2006;81(4): 511-516. 2. liang kv, sanderson so, nowakowski gs, arora as. metastatic malignant melanoma of the gastrointestinal tract. mayo clinic college of medicine. mayo clinic proceedings 2006;81(4): 511-516. 3. tsilimparis n, menenakos c, rogalla p, braumann c, hartmann j. malignant melanoma metastasis as a cause of small bowel perforation. onkologie 2009;32(6):356-358. 3. tsilimparis n, menenakos c, rogalla p, braumann c, hartmann j. malignant melanoma metastasis as a cause of small bowel perforation. onkologie 2009;32(6):356-358. 4. capizzi pj, donohue jh. metastatic melanoma of the gastrointestinal tract: a review of the literature. compr ther 1994;20:20-23. 4. capizzi pj, donohue jh. metastatic melanoma of the gastrointestinal tract: a review of the literature. compr ther 1994;20:20-23. 5. serin g, doğanavşargil b, calişkan c, akalin t, sezak m, tunçyürek m. colonic malignant melanoma, primary or metastatic? case report. turk j gastroenterol 2010;21(1):45-49. 5. serin g, doğanavşargil b, calişkan c, akalin t, sezak m, tunçyürek m. colonic malignant melanoma, primary or metastatic? case report. turk j gastroenterol 2010;21(1):45-49. 6. marks ja, rao as, loren d, witkiewicz a, mastrangelo mj, berger ac. malignant melanoma presenting as obstructive jaundice secondary to metastasis to the ampulla of vater. j pancreas online 2010;11(2):173-175. 6. marks ja, rao as, loren d, witkiewicz a, mastrangelo mj, berger ac. malignant melanoma presenting as obstructive jaundice secondary to metastasis to the ampulla of vater. j pancreas online 2010;11(2):173-175. 1a 1b fig. 1. axial post-contrast ct, venous phase at the level of the pelvis, showing a large mass with central ulceration as well as contrast collection (1a) and an air fluid level (1b).2b 2a 2b fig. 2. axial (2a) and coronal (2b) post-contrast ct, venous phase, showing communication between contrast-containing mass and terminal ileum. fig. 3. axial post-contrast ct scan, venous phase at the level of the kidneys, showing large para-pancreatic lymph nodes with central low density. 84 sa journal of radiology • december 2010 original article abstract aim. the aim of the study was to determine the ultrasonic gallbladder wall thickness in normal adult nigerians so as to create standards for defining gallbladder abnormalities in nigerians. method. four hundred adults comprising 228 (57%) women and 172 (43%) men aged 16 78 years, who had normal clinical history and physical findings, were recruited. the gallbladder wall thickness was obtained in the supine, prone and right anterior oblique positions. differences in gallbladder wall thickness were determined using the chisquare test, while the relationship between the ultrasound-measured gallbladder wall thickness and the subjects’ age, sex, height and weight were analysed using the pearson product moment correlation. normal ranges and related statistics were estimated and tabulated according to age group and sex. results. the mean age of the subjects was 32±13.2 years. the mean gallbladder wall thickness range was 1.8 2.8 mm±0.5mm. the thickness range for females was 1.7 2.7 mm±0.5 mm, and that for males was 1.9 2.9 mm±0.5 mm. there was a statistically significant difference (p<0.05) in the mean wall thickness between males and females. the mean body parameters (height, weight) of males were significantly greater than those of females (p<0.047, p<0.000 respectively). there was no correlation between gallbladder wall thickness and age and height of subjects (r=0.34, p<0.09). conclusion. our study was able to establish population-specific ultrasonic values for gallbladder wall thickness in normal adults that can be reliably used as standards to define gallbladder abnormalities in nigerians. introduction thickening of the gallbladder wall is a relatively frequent finding in diagnostic imaging studies.1,2 historically, a thick-walled gallbladder has been regarded as proof of primary gallbladder disease, and it is a well-known hallmark feature of acute cholecystitis.3,4 the finding itself, however, is non-specific and can be found in a wide range of gallbladder diseases and extracholecystic pathological conditions.1,3,5 ultrasound (us), computed tomography (ct) and magnetic resonance imaging (mri) all allow direct visualisation of the normal and thickened gallbladder wall.5 traditionally, us is used as the initial imaging technique for evaluating patients with suspected gallbladder disease, because of its high sensitivity in the detection of gallbladder dimensions, real-time character, speed and portability.6,7 to establish our own standards and to contribute to the literature on this subject, we sought to evaluate normal gallbladder wall thickness in healthy adults by means of us. materials and methods this was a prospective cross-sectional study that spanned a 2-year period from june 2005 to may 2007, involving 400 adults aged 16 78 years, carried out at the university of maiduguri teaching hospital (umth) at maiduguri, borno state, which is in north-eastern nigeria. the city has a population of slightly over 1.1 million.8 the study concerned the clinically normal gallbladder in consenting adults aged ≥16 years. subjects were recruited consecutively from the neighboring school of nursing and high schools and within the hospital. excluded from the study were: pregnant women (confirmed by additional pelvic scan because of physiological distension of the gallbladder), volunteers with a past history of gallbladder and liver diseases or chronic alcohol consumption, those who could not fast (such as diabetics and sickle cell patients), and those who were <16 years old. at inclusion, a full history was obtained from each subject, with particular emphasis on demographic characteristics, history of previous jaundice, right hypochondrial pain, and history of upper abdominal surgery or chronic alcohol consumption. all volunteers gave informed consent but, in addition, a review and authorisation of the study protocols was done by the ethical committee of the university of maiduguri teaching hospital. the study subjects were informed of the safety of us. the healthy subjects who voluntarily submitted themselves for routine abdominal us were instructed to fast for 6 8 hours prior to the procedure to ensure gallbladder distension and to reduce the amount of gastric and intestinal gas. subjects were, however, recruited mainly in the afternoon during the muslim ramadan period, which assisted in compliance with fasting. the clinical parameters, which included age, sex, height in metres and weight in kilograms, were also recorded for each subject prior to examination. the examination was performed using a high-resolution real-time doppler us scanner (aloka, ssd-3500) equipped with 3.5 mhz and 5.0 mhz curved linear array transducers. a 3.5 mhz curved linear array transducer generally provides optimum resolution while maintaining sonographic gallbladder wall thickness in normal adult population in nigeria s mohammed, mb bs, fwacs, fmcr a tahir, mb bs, fwacs, fmcr a ahidjo, mb bs, fwacs, fmcr z mustapha, mb bs, fwacs o franza, msc department of radiology, university of maiduguri teaching hospital, maiduguri, borno state, nigeria i okoye, mb bs, fmcr department of radiation medicine, university of nigeria teaching hospital, ozalla, enugu state, nigeria a shugaba, mb bs, msc, phd department of anatomy, university of jos, jos, plateau state, nigeria sa journal of radiology • december 2010 85 original article adequate depth penetration, and is suitable for obese subjects. a 5.0 mhz curved linear array transducer provides greater resolution for slender subjects. subjects were scanned in the supine, prone and right anterior oblique positions. the transducer was placed in the right hypochondrial area, in the mid clavicular line and cephalad angled in both longitudinal and transverse planes, to obtain a full view of the gallbladder. scanning in the prone position was also adopted as the gallbladder was difficult to visualise otherwise in some of the subjects. for prone scanning, the subjects were placed in the prone position, and then the gallbladder was scanned intercostally or subcostally with the subject positioned prone oblique and right side elevated sufficiently to allow transducer contact at about the midclavicular line. scanning continued as the subject was rolled slowly into a left lateral decubitus position and then laid supine again. in each separate position, the fluid-filled gallbladder was assessed in the longitudinal scans and sometimes zoomed, to obtain maximum gallbladder wall thickness in millimetres (fig. 1). data from the structured data collection sheet were entered into a computer to generate a data base for subsequent analysis. for all the observed measurements, the data were initially summarised into frequency distribution tables. from these tables, the percentages of age, sex distributions and mean height and weights were calculated. results were expressed as the mean±standard deviation (sd). categorical differences were analysed using the chi-square test of independence. an independent student’s t-test was done to study the group difference for continuous variables. chi-square and student’s t-tests were applied for univariate analysis. multivariate regression analysis with logistic regression using the spss 11.0 package (spss inc., chicago, il, usa) was applied to evaluate the effect of the various factors on gallbladder wall thickness; a p-value <0.05 was considered to be significant. results the sample population comprised 400 healthy subjects made up of 228 (57%) females and 172 (43%) males (ratio of 1.3:1). their ages ranged from 16 78 years, with mean age and sd of 32±13.2 years. one hundred and forty-eight subjects in the sample population were in the age group 16 25 years, representing 37% of the population. the age group of 66 75 years was the smallest (1.5%) of the population, and had equal numbers of men and women at 3 (0.75%) each (table i). the highest mean weight (72.14 kg) in the study population was in the age group 46 55 years, which correspondingly reflected the highest body mass index (bmi). the lowest body parameters (height 1.60 m, weight 49.13 kg and bmi 19.13) were in the 76 85 years age group. women showed lower mean body parameters than men in the study (p<0.05). however, the mean total bmi was higher for women (23.66) than men (22.99). gallbladder wall thickness fond in the study ranged from 1.7 mm 2.7 mm. there was no correlation between gallbladder wall thickness and subject’s age and height (p<0.05) (table ii), although the highest mean wall thickness (2.57±0.41 mm) was observed in the 66 75 years age group. however, there was a strong positive correlation between gallbladder wall thickness and bmi (r=0.153, p<0.002)(table ii). the average gallbladder wall thickness was significantly higher in men than in women (p<0.000), and the differences in body parameter were statistically significant in both sexes (p<0.047) (table iii). discussion the study group comprised 228 (57%) women and 172 (43%) men. the female dominance in our study population was probably due to the greater willingness of women to be recruited and, secondly, that most of the volunteers came from a nursing school and therefore were predominanatly female. the study population’s age ranged from 16 78 years, with a mean age and sd of 32±13.2 years. the age parameter was unevenly distributed → → fig. 1. longitudinal us image showing site of measurement of gallbladder wall thickness (arrows). table i. age distribution of mean gallbladder wall thickness in the study population age group wall thickness (mm) (years) (n) mean range std 16 25 (148) 2.20 1.0 3.3 0.56 26 35 (142) 2.36 1.0 4.0 0.51 36 45 (58) 2.37 1.1 3.4 0.52 46 55 (22) 2.29 1.6 2.9 0.38 56 65 (16) 2.28 1.7 3.0 0.44 66 75 (6) 2.57 1.9 2.9 0.41 76 85 (8) 2.15 1.0 3.0 0.71 400 table ii. correlation between mean gallbladder wall thickness and body parameters of the population age (years) height (m) weight (kg) mi wall thickness (mm) 0.048 0.042 0.168† 0.153† p value 0.341 0.405 0.001 0.002 †correlations were significant at the 0.01 level (2-tailed) bmi=body mass index 86 sa journal of radiology • december 2010 original article with many (37%) of the volunteers fallingin the age group of 16 25 years, and 35% in the 26 35 years group (table i). the age groups of 66 75 years and 76 85 years had the least representation (1.5 2.0%). the unevenness of our population was a result of the randomised selection process, which unfortunately might affect the accuracy of the age influence on our measurement parameters. we observed in the study that most of the gallbladder wall thicknesses measured were greater in men than in women. there was also a statistically significant difference between the mean gallbladder wall thickness of women and of men at p<0.001 (table iii), which is in line with the fact that organ sizes in men are generally larger than those in women. this finding is in agreement with caroli-bosc et al.6 there have been few studies of normal gallbladders in adults, and the resulting dearth of information regarding standard reference measurements can make decisions about the presence or absence of gallbladder disease difficult. in our study, the average gallbladder wall thickness ranged from 1.7 2.7 mm, which is lower than figures reported by wolson et al. 7 and cooperberg et al.,9 who reported in separate studies that gallbladder wall thickness measured 2 – 3 mm and ≤3 mm respectively, though it is known that greater gallbladder wall thickness may be a non-specific finding.10,11 however, in adults as well as in children, an increase in thickness may result from a large spectrum of pathological conditions. in our study, gallbladder wall thickness showed no significant correlation with subjects’ age and height (table ii), unlike the observations reported by mcgahan et al.12 in a similar study on children. graphing gallbladder wall thickness against age showed a sinusoidal incremental pattern with plateau and peak levels at 26 35, 36 45 and 66 75 years (fig. 2), which cannot be explained by this study. however, the peak value of gallbladder wall thickness noted in the 66 75 years age group could represent the age at which the organ thickness is highest before involution begins to occur. our study also showed a strong positive correlation between gallbladder wall thickness and bmi of subjects (table ii). the definition of abnormal gallbladder wall thickness measurements of adult subjects has received very little attention. indeed, the fairly uniform agreement to use 3 mm as the upper limit for normal gallbladder wall thickness also applies to children.13,14 we would say that normal gallbladder wall thickness for most adults is ≤3 mm. occasionally, even in normal subjects, the wall cannot be adequately measured, which may simply be due to the superficially located gallbladder being out of the focal zone of the transducer, but this can be corrected by adjusting the focal zone and gain. conclusion us can be used to reliably measure the thickness of the gallbladder wall, as was attested to by this study. in addition, this study enabled the establishing of a population-based us gallbladder wall thickness so that a gallbladder wall >3 mm thick will suggest an abnormality in most patients, whereas a thickness <3 mm will suggest normalcy but cannot be used to rule out gallbladder diseases. statistically significant differences between gallbladder wall thickness and height and weight of each sex have been established by the study. the established normogram can be used as both a complementary modality in clinical evaluation as well as a more sensitive means of evaluating patients for gallbladder disorder. 1. middleton wd, kurtz ab. ultrasound. the requisites. 2nd ed. st louis, usa: mosby, 1996. 2. cooperberg pl, burhenne hj. real-time ultrasonography. a diagnostic technique of choice in calculus gallbladder disease. n engl j med 1980; 302: 277-279. 3. warwick r, williams pl. pancreas and liver. in: warwick r, williams pl, eds. gray’s anatomy. 35th ed. philadelphia: wb saunders, 1973: 1299-1310. 4. sanders rc. the significance of sonographic gallbladder wall thickening. j clin ultrasound 1980; 8: 143146. 5. fleischer ac, james ae jr, norwalk ct, eds. real-time sonography. appleton: century-crofts, 1984. table iii. comparison of the mean gallbladder wall thickness and body parameters in the different sexes sex (n) wall thickness (mm) height (m) weight (kg) f (228) mean 2.196 1.61 60.93 std ±0.504 ±0.07 ±14.50 m (172) mean 2.432 1.72 67.70 std ±0.524 ±0.08 ±12.36 p value: 0.000* 0.047* 0.000* total mean 2.298 1.654 63.84 std ±0.525 ±0.925 ±14.01 *significant at p<0.05 fig. 2. graph of gallbladder wall thickness versus age group. m e a n w a ll th ic kn e ss i n m m group age sa journal of radiology • december 2010 87 original article 6. caroli-bosc fx, pugliese p, peten ep, et al. gallbladder volume in adults and its relationship to age, sex, body mass index, body surface area and gallstones. an epidemiologic study in a non selected population in france. int j gastroenterol 1999; 60(4): 344-348. 7. wolson ah. ultrasound measurements of the gall bladder. in: goldberg bb, kurtz ab, eds. atlas of ultrasound measurements. chicago: year book medical publishers, 1990: 108-109. 8. wikipedia. list of cities proper by population. http://en.wikipedia.org/wiki/nigeria (accessed 6 april 2009). 9. cooperberg pl, gibney rg. imaging of the gallbladder. radiology 1987; 163: 605-613. 10. callen pw, filly ra. ultrasonographic localization of gallbladder. radiology 1979; 133: 687-691. 11. rall pw, quinn mf, juttner hu. gallbladder wall thickening: patients without intrinsic gallbladder disease. am j roentgenol 1981; 13: 65-68. 12. mcgahan jp, phillips he, cox kl. sonography of the normal pediatric gallbladder and biliary tree. radiology 1982; 144: 873-875. 13. jeong hy, hyun jk, myung jl. sonogr aphic measurements of normal gallbladder sizes in children. j clin ultrasound 2003; 31: 80-84. 14. zins m, boulay ci, molinie v, et al. imaging of a thickened-wall gallbladder. j radiol 2006; 87: 479-493. uraemic tumoral calcinosis in patients on haemodialysis in the renal unit at dr george mukhari hospital, pretoria abstract objective. uraemic tumoral calcinosis refers to metastatic calcifications that occur rarely on the extensor surfaces of joints in patients undergoing long-term haemodialysis. the aim of the study was to assess the incidence of uraemic tumoral calcinosis in participants undergoing haemodialysis and to investigate any relationship that might exist between the development of uraemic tumoral calcinosis and the length of time on dialysis. design. twenty-four of the 25 patients on haemodialysis at the time of the study underwent radiographs of their shoulders and hips to look for calcinosis, which were then read by the researcher and two independent readers to assess for calcinosis. study setting. dr george mukhari hospital, pretoria. results. eight per cent (n=2) of participants were found to have asymptomatic calcinosis of the hips. no relationship to length of time on dialysis was found. conclusions. the study was constrained by a small sample size but the presence of calcinosis in 8% of the participants indicates that an extensive study of a larger sample could prove to be useful in determining the true incidence of uraemic tumoral calcinosis in the region. long-term follow-up could provide more information on the development of calcinosis and length of time on dialysis. introduction tumoral calcinosis may be defined as metastatic peri-articular calcifications that can be found in a wide variety of conditions such as primary hyperthyroidism and connective tissue diseases, as well as an idiopathic form.1 uraemic tumoral calcinosis is an uncommon occurrence in patients with chronic renal failure who are on long-term haemodialysis therapy, and falls within the broad definition of tumoral calcinosis.1 the disease is usually asymptomatic but can present with complications such as impairment of mobility, nerve compression, ulceration of the overlying skin and bony erosion.1 if the radiologist is unfamiliar with the radiological patterns of tumoral calcinosis or disease processes that mimic the condition, then diagnosis and treatment might be delayed or the patient may be subjected to unwarranted invasive procedures.2 literature review metastatic calcifications may have benign or malignant causes.3 uraemic tumoral calcinosis is known to occur in patients with chronic renal failure undergoing haemodialysis and is the most common cause of metastatic peri-articular calcifications.3 the aetiology is multifactorial and awareness is important since the condition is progressive.1 the disease is uncommon and current prevalence is not well known but a frequency range of 0.5 3% has been reported.4 the pathogenesis is not fully understood but significant disturbances of calcium and phosphate homoeostasis can result from chronic renal disease. among these disturbances are decreased phosphate excretion, f e suleman, mb chb, fc rad (diag), m med rad (diag) department of diagnostic radiology and imaging, dr george mukhari hospital, pretoria v mngomezulu, mb bch, fc rad (diag) sa, mba division of diagnostic radiology, faculty of health sciences, university of witwatersrand and charlotte maxeke johannesburg academic hospital, johannesburg n ebrahim, nat dip radiography (diag), fetc, msc radiography (diag), pg dip int ethics department of radiography, university of limpopo( medunsa campus), pretoria editorial 20 sa journal of radiology • march 2010 mri findings and diagnosis cranial mri: findings and diagnosis quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban please refer to page 105 of the december 2009 issue of the sajr (http:// www.sajr.org.za/index.php/sajr/article/view/395/310) for the clinical details and images. we congratulate dr n maharaj, who is a radiology registrar at king edward viii hospital, durban, for the precise and winning diagnosis, for which she receives an award of r1 000 from the rssa. dr misser elaborates below on the causative condition. diagnosis t2-weighted (figs 1a and 1b) and flair (fig. 1c) sequences demonstrate bilateral paramedian thalamic and parieto-occipital subcortical hyper-intensity. bilateral superior parietal gyral swelling is shown on the t1-weighted axial image (fig. 2a). nodular lepto-meningeal and perivascular post-gadolinium enhancement is seen in figs 2b and 2c. in a patient with known colonic carcinoma, on chemotherapy, the most likely cause for abnormalities in such a distribution is chemotherapy-related posterior reversible encephalopathy syndrome (pres). pres, as described in 1996 by hinchey et al.,1 is a clinico-radiological syndrome characterised by reversible symmetrical subcortical vasogenic oedema with a predilection for posterior cerebral arterial territories and watershed zones. in addition to the parietal lobes, the basal ganglia, thalami, brain-stem and cerebellum may be involved.1 there is classically absence of restricted diffusion in these affected areas, and patchy nodular pial enhancement is occasionally seen (as in the patient reported). causes include hypertensive encephalopathy, eclampsia, combination chemotherapy, renal failure and septic shock. despite several theories, the pathogenesis of vasogenic oedema in pres is not clear.2 relative paucity of sympathetic innervation of the vertebrobasilar circulation when compared with the internal carotid territories has been suggested as an explanation for the distribution frequently observed. chemotherapeutic and immunosuppressive agents are known to increase porosity of the blood-brain barrier as well as to elevate intravascular pressure. p-glycoprotein expression in the blood-brain barrier is also affected in patients with brain metastases. hypomagnesaemia, a consequence of some platinum-containing chemotherapeutic agents and eclampsia, has also been implicated in increasing blood-brain barrier permeability. 1. hinchey j, chaves c, appignani b, et al. a reversible posterior leukoencephalopathy syndrome. n engl j med 1996; 334: 494-500. 2. bartynski ws. posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. am j neuroradiol 2008; 29: 1043-1049. quiz case.indd 20 2/26/10 9:50:03 am sajr 704 a tale of two embolisations m van wyk, mb chb, fcraddiag (sa); e loggenberg , mb chb, mmed radd unit of interventional radiology, department of radiology, university of the free state, bloemfontein, south africa corresponding author: m van wyk (matthysvw@gmail.com) chronic pulmonary tuberculosis may present as massive haemoptysis. haemoptysis usually originates from the bronchial artery but the pulmonary artery might be the culprit vessel in recurrent haemoptysis. we present a case where bronchial artery embolisation had to be augmented by pulmonary artery coil embolisation for a rasmussen’s aneurysm after recurrent haemoptysis. in cases where recurrent haemorrhage occurs, sources other than the bronchial artery should be considered. s afr j rad 2013;17(3):68-69. doi:10.7196/sajr.704 massive haemoptysis, defined as the expectoration of 300 600 ml of blood per day, is a frequent complication of acute and chronic pulmonary tuberculosis (ptb) (caused by mycobacterium tuberculosis). owing to epidemic hiv/aids in the south african population, ptb has flourished. invariably, owing to their limited pulmonary reserve, such patients are poor surgical candidates.1 systemic arterial embolisation by particles or metallic coils is therefore the core management in many of these patients.1 the haemoptysis usually originates from the bronchial arteries but rupture of an underlying rasmussen aneurysm might cause recurrent haemoptysis, sometimes with fatal consequences.2 case report a 49-year-old man presented with a week-long history of haemoptysis, haematemesis and melena stools. he complained about loss of weight, a chronic cough and night sweats. the patient was known, with sputum-proven ptb and on the continuation phase of ptb treatment. he was clinically anaemic with a haemoglobin level of 6.3 g/dl, hypotensive with a blood pressure of 100/60 mmhg, and tachycardic with a pulse rate of 100 bpm. the hb was restored after transfusion of packed cells. chest x-ray revealed active pulmonary tb with destruction and cavitation of the right lung. once the patient was optimally resuscitated, selective bronchial arteriography revealed abnormal contrast extravasation from the right bronchial artery. this was successfully embolised with 300 µm polyvinyl alcohol (pva) particles (cook, bloomington, usa). the haemoptysis ceased and the patient improved clinically. one week later, the patient returned with a recurrent episode of massive haemoptysis. his hb dropped to 3.3 g/dl. ct angiography of the chest revealed a 2 cm oval aneurysm of the right upper lobe posterior segment pulmonary artery. selective embolisation of the rasmussen aneurysm pedicle with one 3 mm x 5 cm and two 3 mm x 4 cm helical coils (cook, bloomington, usa) via a 5 fr catheter achieved complete exclusion of the aneurysm. the patient’s haemoptysis resolved over the next day. discussion massive haemoptysis usually originates from the bronchial circulation (95%) rather than the pulmonary circulation (5%).2 conservative management of massive haemoptysis has a 50 100% mortality rate.2 , 3 published mortality rates for elective surgery performed for massive haemoptysis are less than 20%.4 the mortality rate for emergency surgical control, however, escalates to about 40%.4 pulmonary tuberculosis can affect the pulmonary arteries and veins, leading to vasculitis and thrombosis.5 the bronchial arteries may enlarge and hypertrophy.5 rasmussen aneurysm is a rare complication (in 5% of autopsied patients with cavitatory tuberculosis6 ) caused by pulmonary artery wall weakening owing to the adjacent cavitatory tuberculosis.5 granulation tissue replaces the adventitia and media, leading to gradual weakening of the arterial wall.5 the granulation tissue is replaced by fibrin, leading to thinning, pseudoaneurysm formation and eventual rupture.6 in a study by sanyika et al., 38% of patients who re-bled after successful bronchial artery embolisations for haemoptysis had rasmussen aneurysms.1 haemoptysis is usually the presenting symptom and may be fatal when substantial.6 since 1973, the use of bronchial artery embolisation (bae) has become customary management for recurrent and massive haemoptysis.2 recurrent haemoptysis occurs in approximately 20% of patients.1 , 7 multidetector computed tomography (mdct) has established itself as a very useful tool in identifying the precise location of the source of bleeding.8 additionally, it may assist in identifying signs suggesting that the pulmonary artery is the source of bleeding, such as the presence of a proximal cavity, visualisation of a pulmonary artery bordering a cavity and a rasmussen aneurysm.8 the present case serves to emphasise the fact that, in cases of recurrent haemoptysis, complicating pulmonary tb, a ct angiogram of the pulmonary vessels should be considered, to exclude aneurysms that might lead to catastrophic haemoptysis. it furthermore illustrates the complementary role that particle and coil embolisation has to play in management of massive haemoptysis. fig. 1. chest radiograph demonstrating cavitary pulmonary tuberculosis with marked destruction of the right lung. fig. 2. (a) selective right bronchial angiogram (arrow) demonstrates a large, hypervascular lesion in the right upper lobe (arrow heads). (b) post-particle embolisation angiogram reveals complete obliteration of the hypervascular region. fig. 3. (a) axial contrast enhanced ct demonstrates filling of the rasmussen aneurysm (arrow). the hyperdense ovoid structure in the oesophagus is a medicine tablet; (b) coronal reformation illustration of the aneurysm (arrow); (c) pulmonary angiogram demonstrates a rasmussen aneurysm (arrow) in the right upper lobe posterior segment pulmonary artery; (d) post-embolisation pulmonary angiogram with occlusion of the vascular pedicle and exclusion of the rasmussen aneurysm. the coils are indicated by the arrowheads. 1. kim hy, song k-s, goo jm, lee js, lee ks, lim t-h. thoracic sequelae and complications of tuberculosis. radiographics 2001;21:839-860. 1. kim hy, song k-s, goo jm, lee js, lee ks, lim t-h. thoracic sequelae and complications of tuberculosis. radiographics 2001;21:839-860. 2. santelli ed, katz ds, goldschmidt am, thomas ha. embolization of multiple rasmussen aneurysms as a treatment of hemoptysis. radiology 1994;193:396-398. 2. santelli ed, katz ds, goldschmidt am, thomas ha. embolization of multiple rasmussen aneurysms as a treatment of hemoptysis. radiology 1994;193:396-398. 3. najarian e, morris cs. arterial embolization in the chest. j thorac imaging 1998;13:93-104. [http://dx.doi.org/10.1097/00005382-199804000-00004] 3. najarian e, morris cs. arterial embolization in the chest. j thorac imaging 1998;13:93-104. [http://dx.doi.org/10.1097/00005382-199804000-00004] 4. fernando hc, stein m, benfield jr, link dp. role of bronchial artery embolization in the management of hemoptysis. arch surg 1998;133:862-866. [http://dx.doi.org/10.1001/archsurg.133.8.862] 4. fernando hc, stein m, benfield jr, link dp. role of bronchial artery embolization in the management of hemoptysis. arch surg 1998;133:862-866. [http://dx.doi.org/10.1001/archsurg.133.8.862] 5. yoon w, kim jk, kim yh, chung tw, kang hk. bronchial and nonbronchial systemic artery embolization for life threatening hemoptysis: a comprehensive review. radiographics 2002;22:139-1409. [http://dx.doi.org/10.1148/rg.226015180] 5. yoon w, kim jk, kim yh, chung tw, kang hk. bronchial and nonbronchial systemic artery embolization for life threatening hemoptysis: a comprehensive review. radiographics 2002;22:139-1409. [http://dx.doi.org/10.1148/rg.226015180] 6. sanyika c, corr p, royston d, blyth df. pulmonary angiography and embolization for severe hemoptysis due to cavitatory pulmonary tuberculosis. cardiovasc intervent radiol 1999;22:457-460. [http://dx.doi.org/10.1007/s002709900432] 6. sanyika c, corr p, royston d, blyth df. pulmonary angiography and embolization for severe hemoptysis due to cavitatory pulmonary tuberculosis. cardiovasc intervent radiol 1999;22:457-460. [http://dx.doi.org/10.1007/s002709900432] 7. remy j, lemaitre l, lafitte jj, vilian mo, saint michel j, steenhouwer f. massive hemoptysis of pulmonary origin: diagnosis and treatment. ajr 1984;143:963-969. [http://dx.doi.org/10.2214/ajr.143.5.963] 7. remy j, lemaitre l, lafitte jj, vilian mo, saint michel j, steenhouwer f. massive hemoptysis of pulmonary origin: diagnosis and treatment. ajr 1984;143:963-969. [http://dx.doi.org/10.2214/ajr.143.5.963] 8. khalil a, fartoukh m, tassart m, parrot a, marsault c, carette m-f. role of mdct in identification of the bleeding site and the vessels causing hemoptysis. ajr 2007;188:w117-w125. 8. khalil a, fartoukh m, tassart m, parrot a, marsault c, carette m-f. role of mdct in identification of the bleeding site and the vessels causing hemoptysis. ajr 2007;188:w117-w125. abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) herchel clarke department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa trevor nefale department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa victor mngomezulu department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation clarke h, nefale t, mngomezulu v. endovascular management of intracranial aneurysms at chris hani baragwanath academic hospital. s afr j rad. 2023;27(1), a2634. https://doi.org/10.4102/sajr.v27i1.2634 original research endovascular management of intracranial aneurysms at chris hani baragwanath academic hospital herchel clarke, trevor nefale, victor mngomezulu received: 02 feb. 2023; accepted: 11 apr. 2023; published: 26 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: worldwide, intracranial aneurysms are associated with a high mortality rate. while endovascular management has proven to be the choice of treatment in selected patients, patient demographics and aneurysm characteristics differ between study populations. objectives: this study aimed to investigate the profile of patients with intracranial aneurysms who underwent endovascular management in the interventional neuroradiology unit at chris hani baragwanath academic hospital. patient demographics, risk factors, indications, aneurysm characteristics and intra-operative complications were studied. method: this was a 3-year retrospective study of all adult patients between 01 january 2018 and 31 january 2021. the chi-square test was used to compare categorical variables. results: a total of 77 patients were included in this study. the mean age of the patients was 47 ± 11.6 with a male-to-female ratio of 1:1.8. hypertension was the most reported risk factor in 27% of patients. there was no statistical correlation between the gender groups according to presentation, multiplicity, aneurysmal size dimensions and locations. according to the presentation, there was statistical significance in ruptured intracranial aneurysms (p = 0.020), neck size dimensions less than 4 mm (p = 0.010), and aneurysms located in the internal cerebral artery (ica) circulation (p = 0.001). conclusion: the study findings support known parameters including females and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. interestingly, intracranial aneurysms presented with rupture at smaller size dimensions. contribution: this study provides valuable insights into intracranial aneurysm characteristics and endovascular management efficacy in a resource-limited setting. keywords: endovascular management; intracranial aneurysms; cerebral aneurysms; interventional neuroradiology; cerebral angiography. introduction intracranial aneurysms are a common condition affecting nearly 3.2% of the adult (mean age of 50 years) population globally.1,2 unruptured aneurysms constitute 2% – 5% of the general population.3 ruptured intracranial aneurysms with subarachnoid haemorrhage (sah) have a significantly poor outcome with a mortality rate as high as 20% – 45% and a morbidity rate of approximately 30% – 40%.4,5 according to the international study of unruptured intracranial aneurysms (isuia) trial, unruptured aneurysms reportedly rupture at a minimal annual rate of approximately 0.8%.6 according to the world health organization (who), non-communicable diseases (ncds) are the leading cause of death globally, with lowand middle-income countries carrying the highest burden,7,8,9 thus harbouring the risk factors for developing intracranial aneurysms. several risk factors have been linked to the development of intracranial aneurysms such as female predilection, hypertension, smoking, high alcohol consumption, familial or genetic syndromes and certain aneurysmal morphological features.1,2,4 these risk factors are not universal as there remains variation in the literature across demographics. intracranial aneurysms in pregnancy are reported to occur in approximately 1.8% of women, with rupture occurring in the range of 1–10 per 100 000 pregnancies.10,11 furthermore, human immunodeficiency virus (hiv) infection remains a leading cause of mortality and morbidity in south africa.8 in a local study, hiv-associated intracranial aneurysms were shown to occur in patients at a younger age and often with complex morphological features.12 the prevalence of multiple intracranial aneurysms is 17% – 33.4% in patients suffering from subarachnoid haemorrhage.13 multiple aneurysms as a risk factor are, however, not yet well understood. a south african audit found that patients with multiple aneurysms had a predominance for patients older than 40 years.14 intracranial aneurysm rupture depends on certain characteristics such as size, location and shape.15 intracranial aneurysms are reported to have an 85% anterior circulation predominance.5 in an african study, variations in the location of aneurysms differed in population groups.16 aneurysm size categorisation into small, medium and large differs in the literature and is also controversial in the decision to treat; several references refer to an aneurysm size of 7 mm as one of the criteria for treatment.1,17,18,19 international literature recommends intervention only for aneurysms greater than 7 mm or aneurysms in the posterior circulation; however, in a south african study, it was found that ruptured aneurysms occurred with aneurysm sizes less than 7 mm.18 the mean aneurysm size dimensions also appeared to rupture at smaller sizes in the hiv-infected population.12 endovascular management of intracranial aneurysms is an evolving field with new technological advancements.20 endovascular coiling of intracranial aneurysms has been shown to significantly improve outcomes compared with surgical clipping.15,17,19,21,22 in a recent meta-analysis, surgical clipping attracted a poorer outcome compared with endovascular management; no significant difference was observed in mortality and re-bleeding.23 although endovascular management is becoming more widely adopted as the first-line management of ruptured and unruptured aneurysms, the scope and implementation in africa are still considered suboptimal.24,25 in a south african-based study, a 16% reduction in mortality and major morbidity was achieved through endovascular management.26 endovascular coiling was also shown to be a more durable treatment method compared with surgical clipping in terms of patients’ long-term outcomes.27 thrombo-embolic events and intra-operative rupture are the most common complications experienced with endovascular coiling of intracranial aneurysms.24,28 in a recent multicentre cohort, thrombo-embolic events occurred more frequently, with a female and middle cerebral artery (mca) predominance. in addition, it was found that aneurysms that are small and located in the anterior cerebral and communicating arteries were more frequently associated with intraoperative rupture.24,28 this study aimed at assessing the profile of patients with intracranial aneurysms who underwent endovascular management at chris hani baragwanath academic hospital (chbah) in soweto, south africa, investigating the patient demographics, risk factors, aneurysm characteristics and intraoperative complications. materials and methods this was a retrospective study of patients who underwent endovascular management of ruptured and unruptured intracranial aneurysms in the interventional neuroradiology unit at chbah over a period of 3 years, from 01 january 2018 to 31 january 2021. the data were recorded on an electronic data recording sheet, and included patient demographics (age and gender), risk factors (hypertension, hypercholestrolaemia, smoking, family history, genetics and pregnancy), presentation on admission (ruptured or unruptured), aneurysm location (anterior cerebral artery [aca], anterior communicating artery [acoma], posterior cerebral artery [pca], posterior communicating artery [pcoma], middle cerebral artery [mca], internal cerebral artery [ica] and basilar tip [bt]), aneurysm size (neck and maximum diameter dimensions), aneurysm multiplicity (single or multiple), and intraoperative complications (aneurysm perforation and thromboembolic event). aneurysm size definitions were adopted from pierot et al. where maximum diameter (dome width) was dichotomised into < 5 mm and ≥ 5 mm and a neck size ≥ 4 mm was defined as a wide-neck aneurysm, rendering a narrow-neck aneurysm as < 4 mm. all patients 19 years of age or older who underwent endovascular management for index ruptured or unruptured intracranial aneurysms with complete records (images and angiogram reports) were included. angiogram reports and accompanying images were obtained from the picture archiving and communication system (pacs) in the radiology department at chbah. the principal investigator was primarily responsible for data collection and data analysis supported by a biostatistician. a p-value < 0.05 was used to determine statistical significance by utilising the chi-square test. ethical considerations the study was approved by the human research ethics committee of the university of the witwatersrand (certificate number m211038). participants’ consent was not sought as this was a retrospective record review and to maintain strict anonymity, no personally identifiable information was recorded. results a final sample of 77 patients who underwent endovascular management for intracranial aneurysms were included. a total of 49 were female and 28 were male patients (1:1.8 male:female ratio) with a mean age of 47 years (p = 0.217). the angiogram reports yielded 21 (27%) patients with documented hypertension, one patient with hypercholesterolaemia (1%), and two (4%) patients from the female group who presented with ruptured intracranial aneurysms during pregnancy. sixty six patients (87%) presented with ruptured intracranial aneurysms. one patient’s mode of presentation was unspecified on the angiogram report and there was no supporting imaging on pacs as the patient was referred from a regional hospital; therefore, the patient was excluded from the statistical analysis according to presentation. a total of 89 aneurysms were detected among the 77 patients. the majority of patients had a single aneurysm (88%), while nine (12%) presented with multiple aneurysms. most intracranial aneurysms were narrow neck aneurysms (83%). similarly, the maximum diameter dimensions were less than 5 mm in 83%. there was no statistical significance in presentation, multiplicity, neck and maximum diameter dimensions regardless of gender (table 1). table 1: intracranial aneurysm characteristics according to gender. there was no statistical significance in presentation regardless of aneurysm multiplicity and maximum diameter dimensions. narrow neck aneurysms (< 4 mm) constituted a significant proportion (83%) of aneurysms on presentation (p = 0.01) (table 2). table 2: characteristics of treated intracranial aneurysms. in total, acoma (22%) aneurysms were the most common. basilar tip aneurysms (2%) accounted for the least common location. males were mostly affected by ica (26%) and acoma (24%) aneurysms. anterior cerebral artery (22%) and acoma (22%) aneurysm locations were equally distributed among females. no statistical significance was demonstrated in intracranial aneurysm location according to gender (table 3). table 3: location of intracranial aneurysms according to gender. in total, 88% of the study population presented with ruptured intracranial aneurysms (p = 0.02) and of these, acoma aneurysms were the most common (23%). all patients who underwent intervention for acoma aneurysms were ruptured on presentation; however, there was no statistical significance according to location (p = 0.064). the ica aneurysms demonstrated statistical significance (p = 0.001) according to location (table 4). table 4: location of intracranial aneurysms according to presentation. referring to table 5, there were three patients who developed intraoperative complications from the total of 82 aneurysms managed endovascularly, yielding a complication rate of approximately 4%. in all three instances, the complications were immediately identified and managed. two patients presented with no immediate postoperative neurology. the third patient had no records available regarding the immediate neurological status of the patient in the postoperative angiogram report. table 5: intraoperative complication, patient demographics and aneurysmal characteristics. discussion consistent with local and international studies, this south african-based population study of patients who underwent endovascular management for intracranial aneurysms demonstrated a female predominance with a male: female ratio of 1:1.8.2,11,14,16,18,21,25 there was poor yield of patient risk factors in the angiogram reports. hypertension was the most reported risk factor consistent with the literature.2,4,15 intracranial aneurysms in pregnancy are rare and it is postulated that normal haemodynamic changes during pregnancy may play a role in the risk for complications in patients harbouring intracranial aneurysms.11 although not included in this study as a risk factor, hiv-associated aneurysms have been shown to present in younger patients and at smaller sizes.12 there is a high population variance regarding intracranial aneurysm location in the literature, some with a posterior circulation predominance and some with an anterior predominance.14,15,16,23,26 this study population demonstrated an acoma predominance, regardless of gender or presentation. internal cerebral artery aneurysms demonstrated significance according to presentation and had a near equal distribution between the ruptured and unruptured groups. patients with ruptured aneurysms often present with subarachnoid haemorrhage on initial diagnostic imaging.2 a patient presenting with an unruptured aneurysm may be asymptomatic or present with isolated cranial nerve palsies or with non-specific symptoms such as headaches. there was a statistical difference between patients presenting with ruptured intracranial aneurysms on presentation in this study. this is consistent with the literature where it has been shown in a systematic review and meta-analysis that the prevalence of unruptured intracranial aneurysms ranged between 0% and 41.8% with an overall mean prevalence of 2.8% between studies.29 according to the literature, larger aneurysms are an independent risk factor for the risk to rupture. although the literature is not clear as to the exact dimensions, some studies have reported maximum aneurysm diameters of 6 mm – 7 mm as a guide for the decision to treat.1,17,18,19 this study demonstrated that most intracranial aneurysms presenting with rupture were less than 4 mm and less than 5 mm for aneurysmal neck and maximum diameter size dimensions, respectively. although there are known independent risk factors increasing the risk of developing intracranial aneurysms, because of the poor reporting yield in angiogram reports in this study, comparisons could not be sought. endovascular neuro-intervention has been shown to reduce morbidity and, in some studies mortality, compared to surgical clipping.19,21,23,24 the two most common complications in endovascular neuro-intervention are perioperative intracranial aneurysm perforation and acute thromboembolic phenomenon. this study population had a 4% complication rate that correlates with the literature documenting 2% – 8%, while surgical clipping complications can range between 15% and 50%.28 in this study, endovascular intervention for intracranial aneurysms showed a low complication risk and was managed actively to minimise postoperative long-term complications. limitations this was a retrospective, single institutional study with a small sample size limiting comparison of the location, aneurysm morphology and larger-sized aneurysm subcategories. in addition, angiogram reports did not include comprehensive documentation of patient risk factors and were primarily dependent on information provided on the patient’s request forms for endovascular management. finally, this study did not investigate long-term clinical outcomes on subsequent follow-up cerebral angiography. conclusion overall, this study supports known parameters including a female and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. interestingly, intracranial aneurysms presented with rupture at smaller size dimensions. multi-institutional prospective studies are recommended to further investigate aneurysm morphology and risk factor stratification. the findings may influence the decision threshold to treat smaller-sized intracranial aneurysm dimensions and anterior circulation aneurysms in our population. acknowledgements the authors would like to acknowledge dr z. zingoni for her review and support in the data analysis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.c. was the principal investigator responsible for the literature review, data collection, and preparation of the manuscript. t.n. and v.m. were responsible for the research conception and supervisory roles. funding information this research received no grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data supporting this study’s findings are available from the corresponding author, h.c. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references thompson bg, brown rd, amin-hanjani s, et al. guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the american heart association/american stroke association. stroke. 2015;46(8):2368–2400. 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department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa nasreen mahomed department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation slave o, mahomed n. an audit of patient radiation doses in interventional radiology at a south african hospital. s afr j rad. 2023;27(1), a2559. https://doi.org/10.4102/sajr.v27i1.2559 original research an audit of patient radiation doses in interventional radiology at a south african hospital oneile slave, nasreen mahomed received: 21 sept. 2022; accepted: 11 nov. 2022; published: 19 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: interventional radiology (ir) is becoming more relevant in patient care and is associated with increased patient radiation exposure and radiation-induced adverse effects. diagnostic reference levels (drls) are crucial for radiation control. there is a paucity of published drls for ir in south africa and sub-saharan africa. objectives: this study aimed to determine local drls for fluoroscopically-guided ir procedures and compare the achieved drls with published local and international drls. method: retrospective, descriptive, single-centre study. kerma air product (kap), reference point air kerma (ka,r) and fluoroscopy time (ft) were collected for patients (12 years and older) who underwent ir procedures at a university hospital from 01 january 2019 to 31 december 2019. the 75th percentile of the distribution of each dose parameter (kap, ka,r and ft) per procedure was calculated and taken as the local diagnostic reference levels (ldrl). the established ldrls were compared to published drls. results: a total of 564 cases were evaluated. the 13 most frequent procedures (with 15 or more cases) represented 86.1% (487/564). percutaneous transhepatic biliary drainage was the most common procedure (n = 146, 25.9%). diagnostic cerebral angiogram drls exceeded the published drl data ranges for all parameters (drl 209.3), and interventional cerebral angiogram exceeded published ranges (drl 275). uterine artery embolisation (uae) exceeded these ranges for kap and ka,r. (kap-954.9 gy/cm2, ka,r-2640.8 mgy). conclusion: the ldrls for diagnostic cerebral angiogram, interventional cerebral angiogram and uae exceeded published international drl ranges. these procedures require radiation optimisation as recommended by the international commission on radiological protection (icrp). contribution: in addition to informing radiation protection practices at the level of the institution, the established ldrls contribute towards regional and national drls. keywords: interventional radiology; diagnostic reference level; kerma air product; reference point air kerma; fluoroscopy time. introduction use of interventional radiology (ir) in patient care is increasing,1,2 and in some countries, it is doubling every 2–4 years.3 this calls for effective radiation control. radiation exposure can lead to deterministic (radiation-induced tissue injuries) or stochastic effects. the linear-no-threshold (lnt) model, derived in part from epidemiological studies,4 is used to estimate the risk of stochastic effects. because there is no threshold, all radiation doses are afforded the same scrutiny. there are measures to minimise patient radiation dose in ir.5 limited knowledge and awareness of patient radiation exposure amongst non-radiology doctors6,7 and radiologists8,9 contributes to suboptimal patient radiation protection in south africa. this leads to significant underestimation of dose and the risk of adverse events. radiation control is achieved through optimisation, justification and dose limitation without compromising image quality.10 for optimisation, the international commission on radiological protection (icrp) recommends the use of diagnostic reference levels (drls). a drl value is set at the 75th percentile of the distribution of a radiation parameter observed in a facility (typical drls), a few facilities (local drls) or multiple facilities throughout a country (national drls).10 the drls are not set as radiation limits, nor are they meant for individual patients; instead, the median values (from multiple patients undergoing a procedure) of a drl parameter are compared with typical, local, national or regional values. if the obtained drl value exceeds these values, an investigation should be undertaken and corrective measures implemented without undue delay. the icrp acknowledges that establishing drls for ir procedures is more complex because of variation in patients (patient anatomy and clinical factors) and the lesions (pathology) being treated.10 to account for this, some studies use a complexity factor to normalise drl values. this requires substantial clinical data that is not always available. diagnostic reference levels obtained without factoring complexity are of substantial use. there is limited published data on drls in south africa and sub-saharan africa. this is true for lowand middle-income countries (lmics) in comparison to high-income countries. in 2015, less than one-quarter of the 135 lmics had any form of published drl data.11 there has, however, been a trend towards an increasing number of publications: 5 in 1997–2006, 18 in 2007–2011 and 30 in 2012–2015.11 very few articles have been published on south african drls for diagnostic radiology and even fewer for ir fluoroscopically guided procedures. a 2021 review of south african drl data12 showed that there were only drl data from three of the nine provinces (a requirement for national drls is that data should be from all provinces) and that there were no drls established for mammography and dental procedures (not all the five major imaging modalities). as far as the authors are aware, there are only two articles establishing drls for ir in sub-saharan africa. the most recent study is from south africa by malan et al.13 at stellenbosch university. it was published in 2020 and sought to determine the local diagnostic reference levels (ldrls) for common fluoroscopically-guided procedures in the south african context and to compare those to published international data. the other study was from kenya, conducted in 2013 by korir et al.14 to quantify ionising radiation exposure to patients during interventional procedures and establish national diagnostic reference levels (ndrls) for clinical radiation exposure management. this study sought to address the paucity of drl data for ir procedures in south africa. the aim was to establish local drls for fluoroscopically-guided ir procedures and compare the achieved drl to published local and international drls. research methods and design the study was designed as a retrospective, descriptive, single-centre study. the study population included consecutive patients (adolescents over the age of 11 years and adults) who underwent fluoroscopically-guided ir procedures (diagnostic or therapeutic) at chris hani baragwanath academic hospital (chbah) from 01 january 2019 to 31 december 2019. the period was chosen to reflect pre-coronavirus disease 2019 (covid-19) figures. chris hani baragwanath academic hospital is located in soweto in gauteng, south africa. it is a tertiary-level 3400-bed (the third largest in the world) hospital and is the main teaching hospital for the university of the witwatersrand medical school. data collection the kerma air product (kap), reference point air kerma (ka,r) and fluoroscopy time (ft) were automatically generated by the fluoroscopy unit at the conclusion of each procedure. radiographers recorded this data in logbooks, from which the researchers acquired it. the department at the time of the study used two fluoroscopy units, the philips allura xper fd20/20 (biplane) and the philips allura xper fd20 (monoplane), which were both installed in 2010. dosimetry the dose area product (dap) – indirect dose parameters – was provided by built-in software for the biplane system. the kap is the integral of air kerma (the energy extracted from an x-ray beam per unit mass of air in a small irradiated air volume; for diagnostic x-rays, the dose delivered to that volume of air) across the entire x-ray beam emitted from the x-ray tube.15 air kerma at the patient reference point (ka,r), also known as cumulative dose or reference dose, is the air kerma accumulated at a specific point in space (the patient entrance reference point) relative to the fluoroscopic gantry.15 fluoroscopy time refers to all the time spent using fluoroscopy. this correlates poorly with other dose indicators.16 data analysis the distribution of ir procedures in this sample was tabled using the frequency function on microsoft excel. the most frequent procedures were identified (15 or more cases) and included in the analysis. conversely, procedures with fewer than 15 cases were excluded from the analysis. the kap, ka,r and ft for the included procedures were captured. the mean, median (50th percentile) and 75th percentile of the distribution of each radiation exposure parameter were determined for each procedure. the 75th percentile of data distribution for the dap and ka,r of each ir procedure was taken as the ldrl. the ldrls were compared with published local and international drls. ethical considerations ethical approval to conduct this study was obtained from the university of the witwatersrand human research ethics committee (ref. no. m220320). results frequency of interventional radiology procedures the total number of ir cases performed during the study period was 564. the 13 most frequent procedures (each with 15 or more cases) represented 86.1% (n = 487) of all cases, as reflected in figure 1. procedures that had 14 or fewer procedures included transthoracic needle lung biopsy (n = 6), transjugular liver biopsy (n = 5) and transjugular intrahepatic portosystemic shunt (tips) (n = 1). the most frequently performed procedure was percutaneous transhepatic biliary drainage (ptbd) (n = 146). the biplane angiography unit was nonfunctional for four months (april 2019 – july 2019). during this period, no neuro-interventional cases were conducted, affecting the total number of cases. figure 1: the total number of interventional radiology cases performed during the study period was 564. the 13 most frequent procedures (each with 15 or more cases) representing 86.1 % (n = 487) of all cases are reflected. radiation exposure parameters table 1 represents the per procedure median, interquartile range, 75th percentile and 75th:50th ratio for kap, ka,r and ft. the highest radiation dose was recorded for uterine artery embolisation (uae) (kap = 954.9 gy/cm2, ka,r = 2640.8 mgy). the longest ft ldrl was recorded for interventional cerebral angiogram (34.1 min). peripherally inserted central catheter (picc) insertion had the lowest ldrl for both kap (2 gy/cm2) and ka,r (5 mgy). the shortest ft ldrl was for percutaneous transhepatic cholangiogram (ptc) (0.7 min). table 1: dosimetry data for chris hani baragwanath academic hospital. the ratio of the 75th to 50th centile is used as a measure of the variation with a dose parameter (table 1). the procedures with the narrowest variation in dose for each parameter were diagnostic cerebral angiogram (1.3) for kap, interventional cerebral angiogram (1.2) for ka,r and ptbd internalisation (1.2) for ft. procedures with the widest variation in dose were unilateral nephrostomy (5) for kap, uae (3) for ka,r and picc (2.3) for ft. comparison with published diagnostic reference levels tables 2a–c represent chbah ldrls in comparison to published local and international drls. there were comprehensive comparable drls for 6/13 procedures, namely ptbd, bronchial artery embolisation (bae), diagnostic cerebral angiogram, interventional cerebral angiogram and uae. diagnostic cerebral angiogram drls exceeded the published drl data ranges for all parameters. interventional cerebral angiogram exceeded published ranges for ft only. uterine artery embolisation exceeded these ranges for kap and ka,r. the 7/13 procedures with no or incomplete published drls to date for comparison are pigtail catheter insertion, bilateral nephrostomy, selective abdominal vessel angiogram, picc insertion, ptbd internalisation, unilateral antegrade ureteric stent and ptc. table 2a: comparison with published data on kerma air product and diagnostic reference levels. table 2b: comparison with published data on reference point air kerma and diagnostic reference levels. table 2c: comparison with published data on fluoroscopy time and diagnostic reference levels. the procedure type with the most drl published data were ptbd with published drls from 9/10 studies reviewed. dose parameter with the most published data was kap with 34 drls across all procedures. regarding published drls, the highest recorded across all parameters was for interventional cerebral angiogram (kap-233.5 gy/cm2, ka,r–2993.5 mgy and ft-62.9 min). the lowest was for picc insertion (kap-1.2 gy/cm2, ka,r–1 mgy and ft-1). discussion the study identified the current scope of ir procedures carried out at a single institution while simultaneously determining procedures not performed or those performed with low frequency. hepatobiliary (liver and pancreas) ir has room for growth through adding procedures such as tips, portal vein embolisation, transarterial chemo-embolisation (tace), radio-embolisation with radioactive microspheres and radiofrequency ablation, a similar outcome to what another local study13 at a public sector hospital found. this reflects the limited ir expertise in public sector hospitals and should improve with time as more radiologists and registrars are trained in ir. uterine artery embolisation recorded the highest dap doses (selective abdominal vessel interventional angiogram was the second highest), in keeping with findings from other studies. based on published literature, abdominal and pelvic angiographic interventions13,17 typically have the highest recorded dap. this study showed a relationship between kap and ka,r. generally, high kap corresponds to high ka,r. the relationship between kap and ft is not as strong. this is consistent with findings from local13 and international17,18 studies and emphasises that no dose parameters can be extrapolated to infer radiation exposure; instead, as many parameters as possible should be evaluated when optimising radiation exposure. this is echoed in the recommendations by the icrp.10 unilateral percutaneous nephrostomy (pcn) had the widest variation in kap (75th:50th percentile ratio of 5) and wide, although not the widest, variation in ka,r (1.8) and ft (2.1). this is consistent with findings from other published studies.13 as with the other institutions, nephrostomies are entry-level procedures performed by mostly junior registrars, and the wide variation in dose is most likely attributable to the inconsistency in skill level. the effect of operator experience level on radiation dose has been studied extensively.19,20 regarding neurological procedures, there was no consistency in the degree of dose variation. diagnostic cerebral angiogram had the narrowest variation in kap and ka,r, whereas interventional cerebral angiogram had the second widest variation in dose. both these procedures were performed by two highly experienced specialist radiologists. this shows that dose variation is a factor of more than just skill level but rather several factors, including but not limited to patient factors and lesion or pathology factors. many studies have assessed the effect of the degree of lesion complexity on patient radiation.18,21,22,23 this study could not incorporate lesion complexity because it was a retrospective study and such information was neither recorded, nor was there a standardised way of assessing complexity for the procedures. diagnostic reference level data from studies that did not include lesion complexity are still of great value.24 this study did not use patient weight as a dose parameter. the link between body mass index (bmi) and patient radiation dose has long been established for digital radiography and fluoroscopically-guided injections.23,25 regarding ir, some studies found that stratification by weight had no statistically significant effect on third quartile values (drls) for head procedures but had significant effect on body procedures.22,24 diagnostic cerebral angiogram (all parameters), interventional cerebral angiogram (ft) and uae (kap and ka,r) exceeded published local and international drl ranges. as such, these procedure types need to be reviewed and optimised in accordance with the recommendations of the icrp so that they are aligned with published drls.10 this study is a step towards establishing national ir drls, adding to the work by malan et al.13 limitations as a retrospective study, a limited number of parameters that impact dose were evaluated. parameters such as patient weight (body mass index [bmi]) and lesion complexity could not be included, as this information was not available. going forward, such information should be recorded to improve the quality of future studies. although the number of cases for calculating drls with a reasonable 95% confidence interval as suggested by miller et al.24 is 30, the icrp recommends anything above 15, which is what was applied in this study. recommendations there is a need for standardisation of the terminology used for ir procedures. as with malan et al.,13 this study stratified nephrostomy into unilateral and bilateral, whereas most other studies did not. in addition, this study also recognises antegrade ureteric stents because it is a procedure that can be performed post nephrostomy. the same principle applies to ptbd internalisation. standardisation will enable more accurate comparison of dose. pertaining to the institution, drls should be evaluated annually to keep up with factors such as operator expertise, changing procedure profile and machines. conclusion this study is in line with international radiation protection initiatives. at an institution level, it contributes to patient radiation optimisation and nationally to establishing national interventional radiology drls. the ldrls for diagnostic cerebral angiogram, interventional cerebral angiogram and uae exceeded international ranges in this study. these procedures must be reviewed for radiation optimisation. a suggestion is to include patient weight and complexity of lesions as input parameters. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions o.s was the principal investigator and n.m. was the supervisor of the study. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data supporting the findings of this study are available from the corresponding author, n.m., on request. the authors confirm that the data supporting the findings of this study are available within the article (figure 1; tables 1, 2). disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references sardanelli f. trends in radiology and experimental research. eur radiol exp. 2017 dec;1(1):1. https://doi.org/10.1186/s41747-017-0006–5 smith-bindman r, miglioretti dl, johnson e, et al. use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010. jama. 2012 jun 13;307(22):2400–2409. https://doi.org/10.1001/jama.2012.5960 hamada n, fujimichi y. classification of radiation effects for dose limitation purposes: history, current situation and future prospects. j radiat res. 2014 jul;55(4):629–640. https://doi.org/10.1093/jrr/rru019 brenner dj. what we know and what we don’t know about cancer risks associated with radiation doses 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review of 2011 in a year characterised by international political turmoil and economic uncertainty, there are numerous issues which are of simmering concern to south african radiologists, as political initiatives may dramatically change healthcare economics. there are also significant changes imminent in how we become radiologists and aspects of how we practice. congratulations to professor savvas andronikou on again being elected president of the college of radiology, and thanks to professor coert de vries for the time he has served. in recognition of the need for time to cover the syllabus, some institutions are using the primary exam as an entrance examination to the registrar programme, while others are looking to a 5-year curriculum. the unification of the curricula and the unified examination with dissertation are becoming a reality. the sajr continues to strengthen; it is a vehicle for publication of dissertations, and the collaboration through the isr with professor eric stern’s go rad initiative is a welcome enhancement to the international profile of our journal. congratulations and thanks to professor jan lotz and all those involved for the work being done. the cme fund, now formally constituted with trustees dr thami ngoma, professors zarina lockhat and leon janse van rensburg, and dr johan basson, is fully functional and has healthy finances. during this year, funds were made available to the academic institutions for the purchase of books for departmental libraries. i was able to visit many of these and was impressed by the enthusiasm on the ground; it is our hope that, through the cme fund, we will be able to pursue initiatives that can further strengthen radiology training and academic radiology within south africa. the active congress programme organised by professor leon janse van rensburg is anticipated to cover major areas of the syllabus over a 4 5-year cycle, giving all radiologists, and particularly those in training, the opportunity to continually update knowledge with renowned international speakers visiting south africa. the hands-on ct workshops have proved popular and are excellent learning experience, but the nature of these meetings is that spaces are limited. the sorsa-rssa meeting in durban is part of an ongoing collaboration with radiographers, and panel discussions on contrast injection by radiographer, and radiographer role extension, were a specific focus this year. the clinical mammography and mri course was popular. there were two key messages: bi-rads should become the standard reporting format, and breast mri is assuming an increasingly important role. an important parallel session was the functional mri of physiological processes workshop. the rssa short course on current ethical issues in radiology has now been presented in cape town, johannesburg and durban. at the rssa mdct congress in sandton this year, our prizes for poster and paper presentations were awarded (see report in this section of the journal). the international judges were impressed by the high quality of both the paper presentations and the posters, and all who participated are to be commended. of the subgroups, samsig (musculoskeletal) continues to be active, and the formal formation of sasni (neuroradiology) and saspi (paediatric radiology) was completed this year. it is hoped that the red cross paediatric fellowship will be reinstated, and we anticipate new fellowships in neuro-imaging and musculoskeletal imaging in which the expertise within these subgroups will play a major role. and it is anticipated that a breast imaging sub-group will take shape this year! the rssa has been invited to participate in the ‘esr meets south africa’ programme at ecr 2013, and we look forward to the opportunity to show work that has been done in south africa, particularly in hiv and tb. the esr continues to extend the hand of friendship to those beyond the borders of the eu, and visiting fellowships and other educational opportunities are available via rssa affiliation with the esr. the links are on the website. if you are a member of the rssa, please ensure that your details are up to date so that we can keep you informed of upcoming events; and if you are not, please join. for those not in private practice, the fees are low and members enjoy the free journal and cheaper rates at our congresses. contact patricia trietsch, radiological society of south africa, email radsoc@iafrica.com, and website www.rssa.co.za, tel. 011 794 4395 and fax 011 794 4313. for those in private practice, the reference price list as promoted by the department of health on a cost-based methodology is at an advanced stage of development and, in anticipation of nhi, will provide a defensible transparent tariff structure. it has become clear, however, that the hpsca will not be in a position to publish tariff lists for 2012; no other body has authority to do so. other statutory bodies, such as the law society and that for architects, have published tariff guidelines for many years without any intervention from the competition commissioner, and it is hoped that healthcare will eventually have a robust published tariff structure. co-payments remain contentious. co-payments are permissible as a percentage of the fee for an examination and were designed to ensure that patients, by assuming responsibility for a part of the fee for an examination, would not undertake these examinations lightly. however, funders are increasingly using fixed high co-payments as a tool to avoid payment for examinations that fall below the co-payment value. this is contrary to what was originally envisaged and, on an ethical basis, highly questionable as it amounts to the removal of benefits by stealth. the patient does not have sufficient knowledge to be involved in the choice of examination, and co-payment considerations can lead to inappropriate choice of modality. the society accepts the principal of co-payment as a percentage of the examination fee. however, we cannot countenance the use of co-payments by funders to, in effect, withdraw benefits from patients. as co-payments increase, the number of examinations not actually covered increases. national health insurance, with the publication of the green paper, is starting to assume a more concrete form. however, there is still little detail. risk-adjusted capitation at the primary level is suggested, with global budgets at the hospital level. currently, whether the patient or the funder is responsible for payment may depend on the patient status as an inpatient or outpatient. for radiology, this makes little sense. radiology occupies a unique space at the cusp serving the needs of inpatients and outpatients, and many of our investigations determine who will be admitted and who can be safely sent home. image-guided, minimally invasive procedures performed on outpatients may prevent costly admissions altogether. there does not yet seem to be any indication as to how radiology will be funded in a future nhi environment or how to ensure a level playing field. we have an opportunity to comment on the contents before the end of december this year, and i would encourage all radiologists to read the document and submit comment to the society to ensure that all radiologist concerns are adequately addressed in our formal submission on the green paper. universal coverage is a noble ideal that has broad support. problems in the public sector should be addressed as a priority. it is encouraging that the minister of health recognises a role for the private sector, and acknowledges that correcting problems in one sector should not destroy the other. expertise, infrastructure and capacity in the private system should be used to extend quality health care. there are future opportunities for radiologists to contribute to training in our own speciality, to service delivery particularly using electronic image transfer, and by providing a quality service to a population currently underserved. radiology is a referred-to specialty, and it is appropriate that the clinician requesting the examination does not stand to benefit from the performance of the examination. our aim should be to practice appropriate evidence-based radiology. bad referrer habits and funding considerations may work against this ideal. the rssa has succeeded in securing the right to use the acr guidelines, which will be of use to referrers, radiologists and funders whether private or public. the attenuation of the road accident fund has lead to significant increased activity of lawyers touting for business in the media, with the main focus of the business being medical litigation. the medical protection society has experienced a dramatic increase in medico-legal cases in both the private and public sectors, and this is a trend of major concern. this problem has previously developed in other jurisdictions in which the mps operate, and they have advised that we need to be proactive in two aspects: firstly, at the level of the legislative framework in which we operate, it is important to note that legal contingency fees are a contributing factor not only to the increased number of cases but also to the size of the settlement demanded and, if we are to avoid malpractice insurance becoming unaffordable, it is essential that the underlying causes are addressed. it is inherently repugnant that, where a patient has suffered and is justly deserving of a high settlement, the lawyer involved is entitled to disproportionately high remuneration that is at the expense of the remainder of the health budget, in the case of the public sector or those contributing to malpractice insurance in the private setting. it is hoped that the mps engagement with the relevant ministries will be successful. secondly, we need to re-examine the way in which we practice and ensure that we do so in such a way that opportunities for medical litigation are limited. poor communication, or failure of communication, is a factor in at least 70% of litigation cases. it is essential that, as radiologists, we ensure that communication with our clinical colleagues is above reproach and, in particular, to ensure that urgent or important results are communicated effectively to the referring clinician. the continued roll-out of ris pacs systems brings renewed problems, with a conflict between considerations of patient confidentiality and the ability of clinicians to easily view the images from other clinicians, institutions and systems. image distribution systems are critical, particularly as doctors in theatres may be using images on the systems, and they need to be able to function even when the supply of power may be unreliable. proper communication is sufficiently important in respect of medical malpractice that the mps has arranged a series of free workshops which carry ethics cpd points, and radiologists are actively encouraged to attend these workshops. at a meeting with the mps that i recently attended, a representative from the hpcsa was present, and it is possible that attendance at mps workshops may become part of the ethics requirement. i thank all those within the rssa who have the ability or aptitude to contribute in some way and have done so by teaching of registrars, supporting academic departments, volunteering to become examiners or reviewers, and contributing to the journal or participating in subgroups. finally; the recent liquidation in radiology is a sober reminder to hospitals, vendors, investors who may have burnt their fingers, and funders that, in an industry with high fixed costs, viability can be precarious. may i close by wishing all rssa members, in private and public settings, success in 2012. clive sperryn president, rssa visit by rssa president to stellen-bosch university dr clive sperryn, president of the radiological society of south africa, was the guest of the division of radiodiagnosis at tygerberg academic hospital on 1 august 2011. dr sperryn joined the division for lunch and was an invited speaker at the weekly modular academic programme, during which he made a donation of selected textbooks to the value of r25 000 to the division’s imaging reference library. this formed part of the rssa’s broader donation of textbooks to university radiology departments nationwide. in thanking dr sperryn for the very generous donation, professor richard pitcher, head of the division, acknowledged the rssa’s sustained support of academic radiology in south africa. professor pitcher made particular mention of the significant growth, over the last five years, of the society’s official mouthpiece, the south african journal of radiology, under the editorship of professor jan lotz. he also cited the society’s highly successful conference programme convened by professor leon janse van rensburg, which had culminated in the formation of the rssa’s cme fund, from which the national library donations had been made. in addition, over the past years, a number of stellenbosch university registrars had been able to attend international congresses as recipients of cme fund travel awards, made for prize-winning oral and poster presentations at the society’s annual national congress. leuven lung imaging the first of the rssa/leuven hrct lung imaging courses will take place on 17 19 february 2012 at the sandton sun hotel in johannesburg, and on 24 26 february 2012 at the spier estate near stellenbosch in the western cape. this hands-on, interactive teaching course on high resolution computed tomography (hrct) of the lung is internationally acclaimed and recognised as the lung course to do, and is in extremely high demand. the course is conducted by internationally renowned and leading belgian radiologists professors dr johny verschakelen and walter de wever, of the department of radiology, university hospitals, catholic university of leuven, (k.u. leuven), belgium. this is the first time that two back-to-back courses will be conducted and, on behalf of the rssa, i extend our most sincere appreciation and gratitude to professors dr verschakelen and de wever. a cost-effective, pragmatic and comprehensive hrct imaging approach to patients with lung disease is of particular importance to all radiologists providing a service to these patients, as well as the clinicians and therapists caring for them. the human and social impact, and financial implications, of lung disease are far-reaching, especially in developing countries. the aim of the course is to train and update radiologists and teach those in training in state-of-the-art hrct imaging of the lung. on completion of the course, participant should be able to recognise the different basic disease patterns that can be seen on hrct of the lungs, and to make a diagnosis or suggest a differential diagnosis. the indications and limitations of hrct in different lung diseases will be emphasised. starting with an overview of lung disease and applied radiological anatomy, the course will focus upon the hrct appearance of common and uncommon lung diseases and the interpretation of findings. apart from lectures, practical teaching will be done during workshops where participants will have the opportunity to test and expand their knowledge by reviewing clinical cases, with direct tutoring and feedback from the teachers. the course will be held at the modern, impressive and conveniently situated sandton sun hotel in johannesburg and again at the historic, beautiful and tranquil spier estate, surrounded by the verdant mountains and vineyards of the stellenbosch area owing to the technical and logistical requirements in presenting such a course, and to ensure interactivity with the teachers, enrolment is limited to 80 rssa member participants per course. please go to http://www.rssa2012lungcourse.co.za/registration for course and registration details. the organization of such an event is challenging and no small feat. i extend my sincere appreciation to the rssa congress event organiser, consultus and the audio-visual team presentation staging, for making this possible. i take great pleasure and pride in welcoming professors dr johny verschakelen and walter de wever to south africa, and wish them an enjoyable visit. leon janse van rensburg rssa congress chair rssa mdct course – august 2011 the first rssa essentials in mdct/cta course was held at the sandton convention centre from 26 28 august 2011. the central location, easy access from the airport via the gautrain, and the international faculty of four exceptional international radiologists contributed to a record attendance of 340 of whom 270 were radiologists. congratulations to professor leon janse van rensburg who was able to persuade distinguished professor elliot fishman of john hopkins university school of medicine, usa, to co-ordinate the course. the course focussed on 64-slice mdct and newer systems including dual-source ct scanners. the programme consisted of a series of 40-minute lectures that concentrated on specific topics in depth, including state-of-the-art technology and software. participants had the opportunity to expand their knowledge of the latest concepts and principles of spiral/helical ct, with professor fishman emphasising the importance of studying the volumes and interacting with the datasets to optimise image interpretation. professor david naidich elucidated hrct and provided a fascinating insight into imaging of the sub-solid nodule. professor jill jacobs highlighted the intricacies of cardiac ct and cta. professor karen horton emphasised the complementary 2d and 3d techniques in ct colonography and imaging of small-bowel neoplasms. the use of ct in the gi tract, including the liver, spleen and kidneys, were all extensively covered. there were anxious moments for the visiting faculty who had their return travel arrangements disrupted by hurricane irene on the east coast of the usa. our thanks to them all for making the trip to south africa, and we hope that they will return. congratulations to all those who participated in the poster and paper presentations. our esteemed international judges were extremely impressed, and confirmed that these presentations were of an international standard. the prizes were awarded as follows: 2011 rssa travel award: r40 000. to dr lizelle clark: the role of multi-detector ct angiography as an adjunctive tool in the evaluation of paediatric cardiac disease in an african setting. 2011 rssa travel award: r20 000. to dr braham van der merwe: how we eyeball the small bowel: newly introduced ct enteroclysis at tygerberg hospital. 2011 rssa best poster prize r15 000. to dr vicci du plessis: baseline chest radiograph appearances of hiv-infected children eligible for anti retroviral therapy. 2011 rssa poster prize r10 000. to dr werner steyn: vanishing white matter disease, mri imaging over four years. 2011 rssa poster prize r5 000. to dr nishentha govender: adequacy of paediatric renal tract ultrasound. thanks to the scientific committee of professor victor mngomezulu (chairperson), professor zarina lockhat and dr christelle ackermann; to sune van rooyen and the consultus team for seamless organisation; and to all our sponsors for their support. we greatly appreciate their commitment to radiology training and teaching. clive sperryn president, rssa dr clive sperryn, president of the radiological society of south africa (centre), with members of the division of radiodiagnosis at stellenbosch university, surveying the society’s recent book donation. (from left to right) professors leon janse van rensburg, jill jacobs (usa), margaret kinsana (univ. limpopo), david naidich (usa), zarina lockhat (univ. pretoria) and elliott fishman (usa). case report case report � sa journal of radiology • march 2009 case report abstract echinococcosis is an infection caused in humans by the larval stage of the echinococcus parasite. multi-organ involvement is common, and cysts may develop in various organs. radiological imaging modalities play an important role in the diagnosis, management and follow-up of echinococcosis. we present a case of multi-organ echinococcosis with extensive pulmonary involvement. introduction echinococcosis (hydatid disease) is a potentially fatal disease that can affect animals and humans. patients usually become symptomatic when larval cysts elicit space-occupying effects. by this stage, extensive multiorgan involvement may be present, as was demonstrated in this case. case report the 3-year-old patient presented with acute-onset respiratory distress and temperature spikes. the patient had had a chronic cough for 3 months prior to this point. auscultation of the lungs revealed bilateral coarse crackles, while the rest of the physical examination was unremarkable. a chest x-ray (cxr) showed bilateral well-defined rounded opacities involving all the lung zones (fig. 1). a ct (computed tomography) scan of the chest revealed the cystic nature of these pulmonary lesions, while a ct scan of the abdomen demonstrated further cystic lesions in the spleen and the liver (figs 2 and 3). the indirect haemagglutination (iha) serological test was positive for hydatid disease. the multi-organ echinococcosis in a paediatric patient juruan de witt, mb chb department of radiology, edendale hospital, pietermaritzburg af stoker, mb chb department of radiology, grey’s hospital, pietermaritzburg fig. 1. chest x-ray demonstrating multiple well-rounded opacities in both lung fields. fig. 2. axial ct scan of the chest. the cystic nature of the pulmonary lesions can be appreciated. fig. 3. coronal ct scan of the abdomen. three cysts noted in the spleen, as well as a solitary cyst in the inferior region of the liver. multi-organ.indd 6 3/16/09 2:25:12 pm case reportcase report patient was commenced on albendazole, prednisone and berotec, and responded well. a follow-up cxr after 3 months’ treatment showed marked improvement of the lesions (fig. 4). discussion echinococcosis is an infection caused in humans by the larval stage of echinococcus granulosis, e. multilocularis, or e. vogeli. e. granulosis produces unilocular cysts and is most prevalent in areas where livestock is raised in association with dogs.1 humans are accidental hosts and are infected by the ingestion of ova from fomites or contaminated water, and by direct contact with dogs. after ingestion, embryos escape from the ova, penetrate the intestinal mucosa and enter the portal system, from where they are carried to various organs, most commonly the liver and the lungs. here they develop into mature larval cysts.2 unless these slowly enlarging cysts elicit spaceoccupying effects on specific organs, an infected patient would usually remain asymptomatic. pulmonary symptoms include cough, chest pain and haemoptysis, while hepatic involvement may cause fever, right upper quadrant pain, pruritis, urticaria, or eosinophilia. other presentations may include anaphylaxis, pathological fractures, neurological deficit, pericarditis, arrhythmias and pelvic masses.2 radiographic imaging studies are important in detecting and evaluating echinococcal cysts. plain films will reveal unruptured pulmonary cysts as rounded masses of uniform density, while ruptured cysts result in complex cavitary lesions with variable radiographic features, which include an air-fluid level, a floating membrane (water-lily sign), a double wall, an essentially dry cyst with crumpled membranes (serpent sign, rising sun sign) or an empty cyst.2,3 plain films may also be helpful in detecting cysts in other organs, e.g. calcified cysts in the liver. ultrasound, ct and mri may all reveal well-defined cysts with thick or thin walls. on ct, it is occasionally possible to demonstrate daughter cysts within a larger cyst; this has the characteristic appearance of eggshell or mural calcification and is virtually pathognomonic of e. granulosis infection, which is helpful when distinguishing echinococcus cysts from carcinomas, abscesses or haemangiomas.1 the indirect haemagglutination serological test is one of the most sensitive serological tests for the diagnosis of echinococcosis. treatment modalities include medical therapy with albendazole, percutaneous aspiration, infusion of scolicidal agents and re-aspiration of cyst content (pair) and surgical resection. treatment is based on considerations of the size, location and manifestations of the cysts, as well as the overall health of the patient. the condition can be prevented by treating and vaccinating animals as well as encouraging basic human hygienic practices. conclusion although echinococcosis is mainly prevalent in rural areas, patients present at all levels of health care owing to complications of the disease or the lack of a definitive diagnosis. various radiological modalities � sa journal of radiology • march 2009 fig. 4. follow-up cxr after 3 months, demonstrating improvement of the pulmonary cysts. fig. 5. the life cycle of e. granulosis.4 fig. 6. histological diagram of a hydatid cyst.5 multi-organ.indd 7 3/16/09 2:25:13 pm case report case report � sa journal of radiology • march 2009 are used in the diagnosis, treatment and follow-up of echinococcosis. prompt recognition of the radiological features may prevent serious lifethreatening complications, which makes the radiologist an important role-player in the management of these patients. 1. kasper dl, braunwald e, fauci as, hauser sl, longo dl, jameson jl. harrison's principles of internal medicine. 16th ed. new york: mcgraw-hill, 2005: 1275. 2. grainger rg, allison d, adam a, dixon ak. diagnostic radiology. 4th ed. new york: churchill livingstone, 2001: 400-401. 3. dahnert w. radiology review manual. 6th ed. philadelphia: lippincott williams & wilkins, 2007: 500501. 4. palmer pes, reeder mm. the imaging of tropical diseases: with epidemiological, pathological and clinical correlation. 2nd ed. heidelberg, 2001: 206-222. 5. pedrosa i, saiz a, arrazola j, ferreirós j, pedrosa cs. hydatid disease: radiologic and pathologic features and complications. radiographics 2000; 20: 795-817. rssa neuroradiology and body imaging advances congress 28 – 30 august 2009 sandton convention centre join us at the first joint meeting between: • the radiological society of south africa (rssa) • the radiological society of north america international visiting professors programme (rsna) • the international society for magnetic resonance in medicine (ismrm) global outreach programme f o r p r o g r a m m e i n f o r m a t i o n a n d t o r e g i s t e r o n l i n e , p l e a s e v i s i t o u r w e b s i t e a t w w w . r s s a n e u r o r a d 2 0 0 9 . c o . z a multi-organ.indd 8 3/16/09 2:25:14 pm cpd questionnaire give one correct answer for each question. 108 sa journal of radiology • december 2009 a. ionising radiation is potentially harmful to humans, with a tendency to induce malignancy. b. routine chest radiography is the most frequent radiological examination performed worldwide, in both adults and children, accounting for a significant proportion of ionising radiation attributable to diagnostic imaging. c. a reduction in the radiation dose of a chest radiograph would have significant advantages for both public health and individual radiation risk. d. radiation dose reduction is less important in paediatric practice as the increased risk of radiation-induced malignancy in children is independent of dose. 1. regarding radiation due to chest x-ray, which of the following statements is false? 2. which of the following statements is true? a. purchasing a pacs & ris solution is as simple as purchasing a new modality. b. pacs & ris is not a modality; it is an information system requiring integration into the business processes of the institution. c. patient administrative information systems are used widely across south africa and should not be set up to extend to the clinical environment. d. the difference in the benefits gained from a pacs & ris installation does not necessarily correlate with the number of resources allocated to this process. 3. which of the following statements is false? a. the statscan has limitations in erect chest radiography in terms of movement artefacts, exposure fluctuations, and poor definition of lung markings. b. supine chest images obtained with the statscan also show these movement and exposure artefacts. c. it is clear that statscan chest images, both in the supine and erect positions, allow better visualisation of the major airways, equivalent to a ‘high kv’ film at a fraction of the radiation dose. d. therefore, statscan chest images have the potential to play a role in the diagnosis of tuberculosis in children, especially in high-prevalence countries, and also in the imaging of cases where airway narrowing or compression are suspected but not clearly seen on the cr images. 5. factors contributing to the occurrence of chilaiditi syndrome are all the following except: a. absence of normal suspensory ligaments of the transverse colon. b. abnormality or absence of the falciform ligament. c. redundant colon as might be seen in patients with chronic constipation. d. eventration of the right hemidiaphragm but only when associated with chronic lung disease, cirrhosis and ascites. 6. chilaiditi syndrome may present with all of the following except: a. abdominal pain. b. nausea, vomiting and constipation. c. chest pain and dysphagia. d. ultrasonography will always fail to show a loop of intestine between the liver and diaphragm. 7. regarding radiation dose in mammography, all the following are false except: a. exposure time is not decreased by immobilisation. b. the main method of achieving increased image quality and reduced radiation dose is by compression. c. decreasing breast thickness does not necessarily reduce radiation dose. d. theoretically, an increase in breast compression gives a reduction in thickness, resulting in a change in density. 8. identify the one false statement among the following. a. reduction of the breast dose is important, as the risk of carcinogenesis in the breast is cumulative and directly related to the absorbed breast dose. b. improvement of image quality gives better visualisation of small lesions and therefore leads to earlier malignancy detection. c. there exists a point beyond which an increase in compression of the breast does not give spreading of the tissues but rather a change in breast density. d. compression beyond the point in c (above) is essential to identify small calcifications. 9. regarding intimomedial mucoid degeneration, identify a single false statement. a. intimomedial mucoid degeneration is a rare vascular condition that predominantly affects the abdominal aorta. b. the condition can also involve other large arteries including the superior mesenteric artery, and carotid, subclavian and iliac arteries. c. extra-aortic involvement only occurs in the presence of aortic disease. d. the aneurysmal morphological characteristics may be fusiform, saccular or both. 10. x-ray diagnosis was first utilised in: a. the crimean war. b. the first world war. c. the anglo-boer war. d. the franco-prussian war. see previous page for cpd instructions. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www. cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg. co.za in the event of queries. accreditation number: mdb 015/180/04/2009 4. regarding chilaiditi syndrome, all the following statements are correct except: a. chilaiditi’s sign is a radiographic term that is used when the hepatic flexure of the colon is seen interposed between the liver and right hemidiaphragm. b. this syndrome is a rare condition and most often an asymptomatic anomaly that is typically an incidental finding. c. it is seen in 0.1 0.25% of chest x-rays, most frequently in females and almost always adolescent. d. it is usually asymptomatic. cpd decemeber 2009.indd 108 11/18/09 12:04:33 pm editorial going digital has been one of the great experiences of my professional life in radiology. a properly functioning picture archiving and communications system (pacs) has brought new interaction between the radiology department and our clinical colleagues. the centralisation and control of the department make it a pleasure to advise and train registrars. all the images are stored and available for comparison, and it is possible to alert certain departments on radiation control. the other day i made a call on behalf of a 16-day-old infant who had been irradiated 28 times during his short lifetime. ‘the future’s so bright, you gotta wear shades.’ (with acknowledgement to timbuk3); but only if we plan correctly. we need to look at interactive systems within and outside our national borders. hence the request to otto schulze to introduce the first african pacs and ris edu-conference, supported by the radiological society of south africa. now is the time to lay the solid foundation of an integrated continental system. the next generation will thank us for that. jan lotz editor-in-chief first african pacs & ris edu-conference: a practical approach to pacs & ris within africa picture archiving and communications systems and radiology information systems (pacs & ris) is not a new technology, either internationally or in south africa. most private practices as well as academic training institutions have some form of digitising imaging equipment in operation. unfortunately, not all institutions are obtaining the same results from their pacs & ris installations; and this is the issue that will be addressed in the edu-conference. the focus of the conference is not to set out why one should purchase a pacs & ris or which system to buy – the pacs & ris vendors are best suited to do this and to explain their benefits and special features. the purpose of the conference is to provide guidance on how to purchase, implement and maintain a pacs & ris to ensure that you will receive the benefits that are promised in the brochures. purchasing a pacs & ris is not as simple as purchasing a modality; it is not a modality but an information system requiring integration into the business processes of the institution. although patient administrative information systems are widespread across south africa, their use has remained administrative, and very few have made the transition to the clinical environment. moving into the clinical environment is the distinguishing factor of pacs & ris. for the first time, we need to define clinical business processes and start regarding ourselves as elements in a factory making a product – the product being patient care, with the variables of quality of patient care and speed of patient care. by comparison, the implementation in a factory of, for example, an sap system (an information system that manages and facilitates business processes, which is comparable with ris at a basic level) requires considerable resources for successful implementation, maintenance and optimisation. the differences in the benefits derived from the installation depend on the resources allocated to the process; this is why some practices realise the benefits from pacs & ris as promised in the vendor’s glossy brochures, whilst others regard it as a financial and productivity burden. successful implementation requires the active involvement of all members of the practice during implementation, and also their ongoing involvement in workflow evaluation, identifying bottlenecks and optimising the workflow. furthermore, the system has to be maintained, and the errors that invariably arise must be attended to before they have disruptive consequences. the job of the pacs & ris administrator, which is a new position within the radiology environment, is to attend to the database management and guide workflow optimisation. information and communications technology (ict) support of sufficient capacity and knowledge is crucial to supporting the clinical it environment of 24/7 service. effective change management procedures must be in place to ensure that upgrades do not cause service delivery problems. agreement on, and managing of, the service level agreement with the vendor is the final touch that can make the solution fly or fail. all these issues will be discussed during the edu-conference, with emphasis on examples from the african environment. the programme includes: case presentations from two practices in south africa, focusing on the lessons learned during implementation; a walk-about through tygerberg hospital to demonstrate certain concepts; a demonstration of the concepts, with reference to integration and working within a low bandwidth environment; and an open-panel discussion to address questions that delegates experience in their own practices. the nearly 300 delegates cover a wide spectrum – radiologists, clinicians, radiographers, clinical engineers, hospital managers and several vendors of not only pacs & ris products but also ict support and solutions – and come from across the country as well as other african states. networking opportunities with colleagues and vendors alike will abound during tea breaks and lunches, the welcoming function and social dinner. vendors will display their products in the exhibition hall. by the end of the edu-conference, three questions are intended to have been resolved: (i) is there a need to create a body to serve as a forum for individuals involved with pacs & ris, for gathering and sharing information and advice? (ii) is there a need for creating a pacs & ris administrator course? and (iii) is there a need to hold more such information sessions, and in what format? otto schulze a digital thumbs-up for pacs & ris editorial 78 sa journal of radiology • december 2009 editorial.indd 78 11/18/09 9:06:40 am 10 sa journal of radiology • march 2011 opinion piece introduction the field of radiography in south africa is complex and presents a multitude of ethical issues. the discipline is often regarded as a supporting function in the healthcare chain, and a stepping-stone in the diagnostic process. this status of the discipline seems to have left many radiographers in a position of substantial confusion. in the course of numerous bioethics presentations for radiographers in south africa, several ethical and legal issues have recurrently come to my attention. this article aims to address some of these issues and to offer ethically and legally acceptable solutions. the proposed solutions are not absolute – they are based on personal discussions and experiences – and their practicability needs to be scrutinised. consequently, this article should be seen as a starting point only. radiography at present in south africa, radiography forms an integral part of the healthcare process. a patient who has presented at a healthcare facility will be referred to the radiology department for necessary scans and screening which will be undertaken by a radiographer. it is generally beyond the purview of the radiographer to disclose scan results to patients.1 rather, the process entails that a radiologist writes a report on the scans and sends this to the referring doctor, who will communicate the results to the patient.2 although this system is laudable in terms of promoting patient-centred care and ensuring that the margin for misdiagnosis is minimised, it does not afford radiographers much professional autonomy in their working environment. it means that radiographers have very little leeway in terms of performing repeat views or extra views, and the restrictions on communications with patients put radiographers in a precarious position when patients ask difficult questions. informed consent according to the national health act no. 61 of 2003, medical procedures may not be extended to patients in south africa without their informed consent.3 informed consent involves familiarising patients with their health condition, explaining procedural options available, and also elaborating on the possible consequences of any given option. this would require a discussion about anticipated risks and benefits of procedures and the consequences – both social and psychological – thereof. the probable costs of procedures also warrant discussion. for an informed consent to be valid, it is important that the patient is of consenting age (the age of consent for different healthcare procedures varies in south africa according to different pieces of legislation.) and that the patient is able to critically engage with the information presented. the patient should then make a voluntary decision about the proposed treatment plan. dissemination of information should account for the patient’s language preferences and level of literacy.3 it is apparent that, as a field which constitutes a building block in a larger process, there is some confusion among radiographers about informed consent. questions arise such as: ‘who is responsible for getting consent?’, and ‘how much can a radiographer tell the patient when obligated to act in accordance with instructions from a radiologist?’ radiographers, legislation and informed consent this section considers the legal and professional status of the radiographer, examining informed consent requirements for practising radiographers in south africa. legally speaking, the situation is as follows: the health professions act no. 56 of 1974 stipulates who is considered a healthcare professional. rethinking responsibility in radiography: some ethical issues in south africa harriet etheredge, mscmed steve biko centre for bioethics, school of clinical medicine, university of the witwatersrand, johannesburg fig. 1. the diagram depicts the interaction of south african legislation that pertains to informed consent and radiographers. it shows how certain legislative documents link together to ultimately confer a legal duty to obtain informed consent on radiographers (as well as all other healthcare professionals). sa journal of radiology • march 2011 11 opinion piece in terms of the act, a healthcare professional is a person who practises a profession which requires registration with the health professions council of south africa (hpcsa). registration is determined by whether or not there is a professional board of the hpcsa which regulates the profession in question.4 radiography is regulated by the professional board for radiography and clinical technology.1 therefore, radiographers are considered healthcare professionals in terms of the health professions act. the national health act no. 61 of 2003 outlines the legal and professional duties of ‘health care providers’. stipulated is the requirement for ‘consent of user’ which is detailed in chapter 2, section 7. the section emphasises that ‘a healthcare provider must take all reasonable steps to obtain the user’s (patient’s) informed consent.’3 but are radiographers healthcare providers? and does the legal duty to obtain informed consent fall to radiographers? a healthcare provider is defined as any person registered in terms of a particular piece of regulatory legislation.3 one such piece is the health professions act. as noted above, radiographers are registered with the council in terms of the health professions act. we can therefore draw the conclusion that a radiographer is a ‘health care provider’ in terms of the national health act no. 61 of 2003 (fig. 1). consequently, radiographers are legally responsible for obtaining informed consent from their patients for any procedure which the patients might require. defining responsibilities and informed consent an issue which came to my attention during the course of my presentations is that radiographers do not have clearly defined responsibilities in the chain of treatment. frequently, they are unsure whether they should be getting consent, or whether this is the responsibility of the referring doctor or radiologist. from the legal deduction above, it is quite clear that the informed consent is the responsibility of the radiographer (as well as all other healthcare professionals/providers). it would be advisable, then, for medical teams to brainstorm informed consent issues within their respective institutions and develop protocols to ensure that informed consent is appropriate and valid. informed consent and problems with interpreters this legal justification for the radiographer to ensure that informed consent is obtained poses another, perhaps more challenging, question: ‘how does one get informed consent from a patient in an institution where there is a shortage (or complete absence) of translators and the radiographer cannot speak the language of the patient?’ to answer this question, we have to consider the context in which we practise in south africa. severe resource constraints – whether owing to a certifiable lack of financial means, mismanagement of funds or high-level corruption – characterise almost every aspect of service delivery (and non-delivery) in the public sector. within these resource constraints, the government is obliged ‘to take reasonable legislative and other measures ... to achieve the progressive realisation of ...’ our human rights to health care, food, water and social security.5 this means that government must prioritise certain aspects of healthcare provision over others that it deems less important. from a legislative perspective, it appears that informed consent is an important right of the patient in the south african healthcare system. informed consent is mentioned in the constitution, the national health act no. 61 of 2003 and in the hpcsa ethical rules and regulations.6 from a practical perspective, however, it is evident that many radiographers practising in state hospitals do not have access to interpretive resources some (or most) of the time. access to these resources is necessary to ensure the ethical and legal validity of informed consent, taking into account the language requirements inherent therein. so what should a radiographer practising under such circumstances do, given the legal obligation to obtain informed consent? although there is no easy answer, there are alternative options. • a family member accompanying the patient could act as an interpreter. however, the patient would need to consent to the disclosure of medical information to the interpreter; if the radiographer cannot speak the patient’s language, this might be problematic. • a hospital staff member or patient advocate could translate. again, this solution poses some confidentiality problems, and possible breaches of confidentiality should be weighed against acting in the best interests of the patient before such decisions are made. • the use of other communication methods (e.g. drawing and gesturing) can aid patient understanding. the development of a generic patient information sheet, translated into the official languages, should help. once again, this solution is contingent on the fact that the patient can read, posing yet another challenge. in short, this is a complex situation in which the person at the coal face (the radiographer, in this case) sometimes faces a dilemma: provide a service to patients without their informed consent in order to practise in the best interests of the patient, allowing speedy diagnosis and initiation onto treatment; or do not provide the service, as doing so without informed consent is illegal, even though it may be in the best interests of the patient. it would be advisable for radiographers in such a case to weigh up the situation as it applies to the individual patient, ask superiors for advice, and ensure that any action which is taken can be legally and ethically justified. addressing a problem with a superior or referring colleague another, more sensitive, issue which has come up frequently during discussions is the relationship between radiographers and their superiors. it appears that radiographers find themselves near the bottom of the food chain and are ill-equipped or too apprehensive to confront and address issues such as perceived over-servicing, and pointing out to radiologists that they have missed an important abnormality on the scan that should be factored into the report and diagnosis. radiographers often find themselves on the receiving end of a great deal of wrath and contempt when they do this. i shall address these issues separately. overservicing in their booklet entitled guidelines on overservicing, perverse incentives and related matters, the hpcsa expressly states that overservicing is a common problem in modern medicine, often exemplified by ‘ordering or providing more tests, procedures or care than is strictly necessary.’ healthcare providers – radiographers and radiologists included – shall not perform (or direct to be performed) any procedure on a patient which is not indicated.7 it has come to the attention of radiographers with whom i have 12 sa journal of radiology • march 2011 opinion piece interacted that some doctors refer patients for scans on a routine basis. these scans would not generally be indicated owing to patient age or current state of health. radiographers have questioned how they should proceed in such a situation, given the inherent professional complexities which include fears that, if they report overservicing, they may experience unpleasant treatment from their superiors. radiographers also feared reporting overservicing by those radiologists who pay their salaries. although the guidelines on overservicing, perverse incentives and related matters do not expressly dictate a course of action in matters such as these, ethical and legal considerations suggest that medical practitioners who perpetuate overservicing should be reported to the relevant authority. the hpcsa guidelines which prohibit overservicing have legal standing – violation of these guidelines is considered an offence. from the perspective of a radiographer, it is advisable neither to be party to such matters, nor to be complacent about them. therefore, reporting issues is the most sensible option. ethically, all healthcare professionals have an obligation to act in the best interests of their patients. there are many arguments as to why performing non-indicated scans is not ethically acceptable. scans can cause emotional distress, and it is not in the best interest of the patient to go through this unnecessarily. scans are expensive, and it is unethical to expect patients to pay for superfluous services (in the private sector) or to expect the taxpayer to do likewise (in the public sector). the author recognises that the process of reporting is a sensitive issue as it may be interpreted as impugning the reputation of superiors. i propose that the best way to go about it is to report the problem to one’s immediate senior. if no support is forthcoming from that person, it would be advisable to report to the next senior person. another school of thought suggests that the most appropriate course of action is to speak to the person at issue in private and tell them very politely that one considers something to be amiss in the situation. in practise, many radiographers with whom i have spoken consider this option to be unfeasible, as the cost of victimisation that comes with it outweighs the benefit of reporting a superior. a third school of thought suggests that the most appropriate course of action would be to report the offending party to the ombudsman of the hpcsa. this is a feasible option that helps to protect the whistle-blower by providing a degree of confidentiality, and it is important for radiographers to be aware of this function of the hpcsa. challenging the diagnosis of a superior although radiologists are legally mandated to read, interpret and report on scans, the author has been made aware of numerous cases where the radiographer believes that the radiologist has made a mistake or missed important pathology when reading scans. although analysing scans and writing reports is not necessarily within the scope of practise of a radiographer, these aspects are covered in their training. (indeed, it seems a wanton waste of teaching resources that radiographers are not encouraged to practise these skills on a daily basis.) common thought is that two minds are better than one, and team work characterised by open communication and debate is in the best interests of the patient. therefore i would argue in this case that, firstly, radiographers need to be more proactive in challenging their superiors and, secondly, that the scope of practise of radiographers needs to be extended. ethically speaking, it is important to remember once again that the obligation of the healthcare professional is to act in the best interests of the patient. the multidisciplinary approach is, it is argued, also in the best interest of the patient. therefore, challenging a superior on this basis is ethically acceptable, and indeed imperative. of course, this is easier said than done (owing in large part to the issues raised in the previous section). once again, it may be a good idea to approach a direct superior for aid and advice on this issue if one is fearful of the consequences. this is an issue that ought to be brought out into the open and that warrants continued discussion and debate. in my experience, it is not only radiographers who experience problems with their medical colleagues. i submit that a good way to ensure the efficiency and efficacy of multidisciplinary teamwork is to address the issues which appear to be hindering it. unqualified persons performing mammograms and ultrasound another issue which has come to my attention is that of mammographers performing ultrasounds, sonographers performing mammograms, and other such happenings. radiographers have queried the ethical and legal ramifications of such practise. according to both the ethical tenets and the legal standpoint, this kind of behaviour is unacceptable. i shall discuss each issue in turn. ethical issues in this era of patient-centred medicine, patients and their healthcare providers have certain reciprocal rights and obligations towards each other. healthcare providers have an obligation to act in the best interests of their patients, while patients are obliged to be truthful about their condition to ensure that the most appropriate treatment option is chosen. an unqualified healthcare practitioner who performs a procedure on a patient is not acting in the best interests of the patient. it is important to remember that the process of diagnostic scanning can be a traumatic experience for the patient. it is vital that unnecessary mistakes are not made. films taken by an unqualified person may be unreadable or show apparent abnormalities that are not in fact present, which could lead to patients being treated for a non-existent condition, or remaining untreated for a condition. this would constitute a waste of resources and would not be in the best interests of the patient. therefore, radiographers performing aspects of radiography for which they are not qualified is unethical, and such behaviour should not be condoned. legal issues legally, the field of radiography is separated into different categories i.e. diagnostic radiography, therapeutic radiography, nuclear medicine and ultrasound.8 within each category are subsections that require particular competencies. according to the hpcsa’s rules of conduct pertaining specifically to the profession of radiography and clinical technology, radiographers ‘shall not in [their] practise exceed the limits of the category or categories in which [they are] registered.’1 given that the hpcsa has quasi-legal standing in south africa (owing to the fact that the hpcsa is mandated by the national health act and, because of its legislative status, the council is considered a legal body and has disciplinary powers), rules such as this must be adhered to if one wishes to practise within the scope of the law. sa journal of radiology • march 2011 13 opinion piece reporting deviational behaviour as considered beforehand, health professionals who become aware of illegal and unethical practises are obliged to report them. the questions of possible victimisation, the most appropriate recipient of the report, and the consequences of reporting still remain, and unfortunately are not easy to answer. given, however, that the healthcare professional has an overriding ethical (and legal) obligation to act in the best interests of patients, reporting of such unethical and illegal behaviours should be undertaken to avoid foreseeable harm to patients. conclusion whereas this article has attempted to highlight some day-to-day issues being faced by radiographers ‘on the ground’, there is no question that the advice and guidance provided is not definitive and needs to be debated. most importantly, radiographers themselves need to start discussing these issues and developing sustainable solutions that meet both the ethical and legal requirements of practise. development of protocols and procedures should take place at a departmental and institutional level. once again, this is easier said than done. under-resourcing means that the workload of radiographers (as with most other healthcare practitioners) is unfeasibly high, which leaves little time for brainstorming meetings and the development of protocols. this is only the beginning of the debate, and it must be taken further. 1. health professions council of south africa. annexure 10: professional board for radiography and clinical technology – rules of conduct pertaining specifically to the profession of radiography and clinical technology. pretoria: health professions council of south africa. http://files.ithuta.net/sorsa/ cpd%20rules.pdf (updated february 2009; accessed 21 september 2010). 2. radiological society of south africa. the radiological society of south africa code of conduct – referrals. johannesburg: the radiological society of south africa http://rssa.co.za/code-of-conduct?start=6. (updated january 2002; accessed 4 november 2010). 3. the south african government. national health act no. 61 of 2003. cape town: government gazette. http://www.info.gov.za/view/downloadfileaction?id=68039. (updated 23 july 2004; accessed 20 september 2010). 4. the south african government. health professions act no. 56 of 1974. pretoria: government gazette. http://www.hpcsa.co.za/downloads/health_act/health_act_56_1974.pdf. (accessed 21 september 2010). 5. the south african government. chapter 2: bill of rights of the south african constitution. pretoria: government gazette. http://www.info.gov.za/documents/constitution/1996/96cons2.htm. (updated 26 march 2009; accessed 4 november 2010). 6. the health professions council of south africa. guidelines for good practise in the healthcare professions – seeking patients’ informed consent: the ethical considerations. pretoria: the health professions council of south africa http://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ ethical_rules/booklet_9_informed_consent.pdf. (updated may 2008; accessed 21 september 2010). 7. the health professions council of south africa. guidelines for good practise in the healthcare professions – guidelines on overservicing, perverse incentives and related matters. pretoria: the health professions council of south africa. http://www.hpcsa.co.za/downloads/conduct_ethics/rules/ generic_ethical_rules/booklet_5_perverse_incentives.pdf. (updated may 2008; accessed 21 september 2010). 8. the south african medical and dental council. regulations defining the scope of the profession of radiography. pretoria: the health professions council of south africa http://www.hpcsa.co.za/downloads/rules_reg_constitution/scope_of_rct_r2326_dr_03_01.pdf. (updated 1 august 1997; accessed 21 september 2010). prostate mri course the first esur teaching course on prostate mri will be held from 3 5 june 2011 in ghent, belgium. a teaching course on mr spectroscopy (with hands-on sessions) takes place on friday the 3rd at ghent university hospital, followed by the prostate mri course, which includes plenary sessions and interactive discussions. the main topics are: • overview of the normal and diseased prostate • interpretation of mri techniques (t2w, dwi, mrsi, dce-mri) • mri in the diagnosis and staging of prostate cancer • mri-guided biopsy and therapy monitoring • recommendations and esur guidelines. the objectives of the course are to provide practical information for radiologists who are willing to start or promote prostate mri at their own institution. it will include formal state-of-the-art lectures presented by experts in the field, and practical case studies and ample time for open discussions among participants and experts. the teaching course will be preceded by a comprehensive 1-day specialfocus course on prostate mr spectroscopy, integrating educational lectures, practical demonstrations and hands-on sessions. the official language used is english. for further details, go to www.prostatemricourse.com. the contact person is g villeirs (department of genitourinary radiology, ghent university hospital) on email prostatemricourse@gmail.com. let us take heart in the wisdom of the ovambo proverb: kwa kukuta, oko ku nonkenya. (the hard thing has a seed in it.)4 perseverance prevails! richard pitcher faculty of health sciences stellenbosch university 1. subcommittee for postgraduate education and training (medical). new requirements for the registration of specialists in south africa. pretoria: health professions council of south africa, 2010. 2. subcommittee for postgraduate education and training (medical). guideline on the minimum conditions of service, education and training of registrars and subspecialist trainees in south africa. pretoria: health professions council of south africa, 20 january 2010. 3. subcommittee for postgraduate education and training (medical). trainer:trainee ratios for specialist and subspecialist training. pretoria: health professions council of south africa, 20 january 2010. 4. stewart d, swanson c. wisdom from africa: a collection of proverbs. cape town: struik, 2005. the dissertation generation (continued from page 2) sa journal of radiology • june 2012 79 quiz case musculoskeletal imaging of a painful knee: diagnosis s k misser, mb chb, fcrad (d) lake smit and partners, durban corresponding author: s misser (shalendramisser@hotmail.com) we congratulate dr dirk van der merwe of drs schnetler, corbett and partners, cape town, for a detailed diagnosis for which he receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its imaging. please refer to page 39 of the february 2012 issue of the sajr (http://www.sajr.org.za/index.php/sajr/article/ view/691/549) for the presentation details. in addition, delayed congratulations to dr rory tayler, who is a consultant in the department of radiology at ch baragwanath hospital, for submitting a precise diagnosis of the december 2011 quiz case, for which he also receives a r1000 award from the rssa. his submission fell within the stipulated cut-off date but missed publication because of the earlier-than-usual printing of the sajr. dr misser elaborated on this case in the february 2012 issue of the journal. presentation and diagnosis (the images referred to below are not reproduced here but are in the online february 2012 sajr at the above url.) the plain radiographs (figs 1 and 2) demonstrate moderate background osteopaenia and osteoarthritic change involving both compartments of the femoro-tibial joint. fig. 2 (performed at time of admission) reveals microfracture of the medial tibial plateaux with collapsed subchondral bony plate. mr images (figs 3 6) show a degenerative medial meniscus tear with joint fluid and established osteoarthritic change. articular surface hyperintensity of both femoral condyles and the medial tibial condyle with subchondral fracture at the latter is noted. the combination of features is in keeping with subchondral insufficiency microfracture or previously described spontaneous osteonecrosis of the knee (sonk). first described in 1968 by ahlbach et al.,1 this entity has become a distinct form of osteonecrosis with typical clinical and radiological patterns. generally, elderly female patients, with no preceding steroid or ethanol use, present with acute knee pain along the joint line. the differentiation from secondary osteonecrosis may be difficult on imaging alone and predisposing factors, patient profile and areas of joints involved are useful distinguishing features (see box below).2 sonk has been categorised into 5 radiographic stages.3 in the immediate phase, plain radiographs are usually normal (stage 1). in stage 2, flattening of the weight-bearing surface of the femoral condyle is noted. follow-up radiographs may demonstrate some progressive articular surface change with lucent subchondral focus (stage 3). the focus of osteonecrosis enlarges and becomes surrounded by a sclerotic halo in stage 4. development of secondary osteoarthritic changes including osteophytes, erosions, sclerosis and joint space narrowing, as well as later tibial articular surface involvement, marks stage 5 disease.3 fat-suppressed mri studies, with long tr sequences (t2and pd-weighted) characteristically demonstrate high signal intensity in the condyles with a central subchondral low signal area.2 this is classically described as the bone marrow oedema pattern with central focal lowintensity necrotic zone. technetium-labelled isotope bone scan demonstrates focal increased tracer uptake at the affected condyle. scintigraphy was used by ahlbäck1 in the landmark description of sonk by showing increased tracer uptake localised to one side of the joint after excluding other predisposing factors. more recently, with histopathological correlation, the primary event leading to sonk was found to be a subchondral insufficiency fracture, and the resultant osteonecrosis was due to the microfracture.2 this has led to the new descriptive terminology for this entity with improved reference to both the aetiology and variability of the outcome in patients with sonk. the importance of detection of this process on imaging studies lies in the fact that, owing to its subchondral location, the lesion may not be detectable at arthroscopy. the radiologist is therefore instrumental in making this diagnosis, which may be occult to the orthopaedic surgeon’s arthroscope. 1. ahlbäck s, bauer gc, bohne wh. spontaneous osteonecrosis of the knee. arthrit rheumat 1968;11:705733. 2. yamamoto t, bullough pg. spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. j bone joint surg 2000;82:858-866. 3. stoller dw. magnetic resonance imaging in orthopaedics and sports medicine. 3rd ed. vol 1. philadelphia: lippincott williams and wilkins, 2007:685-692. sonk atraumatic osteonecrosis synonyms primary necrosis, osteonecrosis secondary, idiopathic osteonecrosis age group older patients, usually >55 years younger patients, usually <55 years patient profile elderly female, with moderate oa young active presentation acute pain/acute-on-chronic pain insidious onset and slow progression risk factors none steroid/ethanol use, renal disease joints involved weight-bearing, usually unilateral non-weight-bearing, commonly bilateral location of bone involvement epiphyseal to subchondral surface diaphyseal, metaphyseal, epiphyseal t2-weighted mri increased signal at margin, decreased signal at centre of lesion decreased signal at margin with increased signal of inner border – double-line sign experiences.html experiences of using a single post-contrast ct scan of the chest after biphasic contrast injection p c pretorius, fcrad (diag) sa drs visser, erasmus, vawda & partners, port elizabeth corresponding author: p pretorius (ppret@telkomsa.net) computed tomographic (ct) chest investigations can be enhanced; in many cases, the arterial phase of a post-contrast arterial and delay (60 seconds) study can be omitted when planning the contrast injection and scanning technique carefully. a biphasic contrast injection was used before starting a single 60-second post-contrast scan. s afr j rad 2012;16(2):56-60. introduction while experimenting with single post-contrast computed tomographic (ct) scans of the urinary tract after a triphasic contrast injection,1 i considered whether a similar technique could be used to cut down on unnecessary scan series in our patients referred for chest ct scans. a precontrast scan and then a biphasic contrast injection followed by a single scan of the thorax was therefore considered and implemented to test the reliability and quality of this technique. protocols for chest ct surveys for mediastinal pathology, lung masses and ‘rule out pathology’ chest scans traditionally dictate a post-contrast scan beginning 60 s after initiating an intravenous contrast injection. in numerous practices, 100 120 cc of contrast is traditionally used. this process usually results in adequate contrast throughout the vascular structures in the mediastinum and lungs and enhancement of pathologic masses or lymph nodes. when there are clinical indications of vascular pathology (i.e. aortic or pulmonary arteries and their respective branch vessels), it is imperative to add a dedicated arterial phase scan before the 60 s scan series. if there are no clinical indications to include an arterial phase, a single 60 s post-contrast scan only should be performed. unfortunately, clinical information from referring physicians is not always clear and, even when clear, many radiologists feel insecure without including an arterial series. we felt that this biphasic injection followed by a single post-contrast scan technique improved the diagnostic information and also alleviated the insecurity of excluding the arterial series when performing chest ct scans for non-vascular indications. after scanning a few test cases using a single post-contrast series after a biphasic contrast injection, we were pleasantly surprised with the results, and we have now introduced this technique in most of our practice, when a ‘general rule out’ or ‘mass lesion characterisation’ scan is requested. this requires radiologists to shift their comfort zones, to rely on a single post-contrast scan replacing either a post-contrast arterial, 60 s, or both arterial and 60 s scans. i have included a pictorial representation of a variety of pathologies while using the newer technique, to share our experiences over a wide range of pathologies, which will assist our colleagues in making this shift of technique with more confidence, and will hopefully address some of the queries that may be raised. injection plan 1. 80 cc contrast @ 3 cc/s (27 s) – contributes to ‘venous phase’ of the scan 2. 20 cc saline @ 3 cc/s (7 s) – pushes contrast into system. 3. delay (11 s) 4. 40 cc contrast @ 2.5 cc/s (16 s) – contributes to the ‘arterial phase’ of the scan 5. followed by 20 cc saline @ 2.5 cc/s 6. the scan is started at 60 s, which is 15 s into the arterial phase of the injection, 1 s before the end of the injection. most scanners require a 4 5 s delay from the time the scan is initiated until the first ‘cuts’ are taken – see comments in the discussion below. case studies normal arterial phase scan (fig. 2) arterial phase-contrast scans of the chest show good contrast enhancement of pulmonary arteries and veins, heart chambers, the aorta and its branch vessels. there is good differentiation of contrast between the central venous and arterial structures (dense enhancement v. no enhancement). the returning systemic veins contralateral to the side injected, from the head and neck, from infradiaphragmatic veins (especially the azygos vein) and any mediastinal and hilar masses and lymph nodes and lung pathology are not enhanced at this early post-contrast phase. consequently, there is often difficulty in differentiating the unenhanced dilated or anomalous venous structures from the unenhanced lymph nodes and masses in the chest. normal 60 s post-contrast scan (fig. 3) the contrast enhancement of the vascular structures, mass lesions and lymph nodes within the chest is usually adequate, but differentiation between central arterial and venous structures and returning systemic venous structures relies on anatomical identification, as the contrast density of these structures is usually very similar. the contrast in the pulmonary arteries and branches is often mediocre, and incidental pulmonary arterial emboli may not be well seen. post biphasic contrast injection scan (fig. 4) after a biphasic contrast injection, there is dense enhancement of central pulmonary arteries and veins and the aorta and its branches. returning systemic veins also show enhancement, but less dense than the central vessels, allowing further clarity to confirm the anatomical differentiation. lung and mediastinal masses and lymph nodes will also enhance, usually to a lesser degree than systemic veins, and will show their enhancement patterns. lung carcinoma after biphasic contrast injection (fig. 5) despite the scan beginning at 60 s, there is dense enhancement of the pulmonary arteries, veins and aorta, without compromising enhancement and characterisation of the lung mass and lymph nodes. mycetoma after biphasic contrast injection (fig. 6) it is interesting to compare this case with the preceding lung carcinoma case (fig. 5), where there was enhancement of the mass and the typical peripheral enhancement of infiltrated lymph nodes, unlike the non-enhancement of this mass and the uniform node enhancement. lymphoma after biphasic contrast injection (fig. 7) having dense contrast in all the vascular structures, with enhancement of the mass, all on one post-contrast series, helped to ‘unpack’ all the pathological processes going on in this case, which initially appeared quite complex because of the gross changes. goitre after biphasic contrast injection (fig. 8) although not a particularly challenging diagnosis to make, following the enhanced thyroid from the neck, into the mediastinum, and differentiation from adjacent vascular structures all on one post-contrast series was made easier in this case. sarcoid after biphasic contrast injection (fig. 9) there is clear differentiation of the enhancing lymph nodes from the adjacent, more densely enhancing vascular structures. again, this is not a particularly challenging call to make – but compare with the next case below (fig. 10). interstitial lung disease after biphasic contrast injection (fig. 10) the lymphadenpathy was more subtle than the sarcoid case above, but can be confidently called because of the adjacent azygos vein and aortic enhancement. opportunistic infection after biphasic contrast injection (fig. 11) the pulmonary arterial emboli might not have been as clearly seen on a single standard post-contrast 60 s scan, and the splenic micro-abscesses might also have been missed on a standard post-arterial scan. these were all seen on the single post-contrast series. atelectasis after biphasic contrast injection (fig. 12) the collapsed lung is enhanced, with dense enhancement of vascular structures. discussion the contrast load traditionally used for a survey chest ct is 100 120 cc, to gain adequate contrast density in vascular structures in the chest. a ‘rule of thumb’ is that, from the time the contrast injection into an antecubital vein begins, it takes 9 s to reach the heart, by 12 s it is through the lungs back to the heart, and by 15 s has reached the descending thoracic aorta. contrast injection rates vary between 2 5 cc/s, depending on the sequence chosen. a contrast injection of 100 cc at 4 cc/s. will ensure a 25 s bolus of contrast. since modern multislice scanners can scan the whole thorax in 10 16 s and the resolution is so high, it is conceivable that, if one could get the timing perfect in every patient, one could theoretically perform a good arterial phase diagnostic scan of the chest with only 16 s x 2.5 cc/s = 40 cc of contrast. naturally, there are numerous variable factors in patients such as body morphology, cardiac function, degree of valsalva with breath hold, etc. ‘perfect timing’ of the scan in every case is consequently not feasible but, as can be seen from the above description, a theoretical 60 80 cc of contrast (100 120 cc minus 40 cc) is non-contributory to the diagnostic information, if one were looking purely at the arterial filling of vessels. this ‘extra’ contrast can be used to enhance the contrast appearances in the other vessels by splitting the bolus delivery. using the above logic, we designed an injection sequence to try to maximise the benefit of this ‘non-contributory’ portion of contrast that we inject. the logic is as follows: • the initial 80 cc starting 60 s before the scan allows adequate contrast filling of the returning systemic veins, particularly the brachiocephalic and azygos veins. the injection rate is kept similar to that of a ‘traditional’ chest survey ct scan. this contrast is ‘pushed’ by a saline chaser injection at the same rate, followed by a calculated delay. • a second contrast injection begins 15 s before the ct scan starts. this will enhance the pulmonary arterial and pulmonary venous vessels and the aortic vessels in the chest. this timing allows the end of the second phase bolus of contrast to densely enhance the central vessels (pulmonary veins and arteries), while the lead portion of this second bolus will have reached the descending aorta in almost all patients. • in fit patients, this timing is invariably adequate. • in patients with known poor cardiac function, the contrast passage may be a bit slower. in these cases, one may start the scan a little later – possibly at 65 s this is still usually adequate as the contrast bolus tends to ‘stretch out’ i.e. a tight bolus injected into a peripheral vein over 15 s. will have spread out to possibly over 20 s by the time it has gone through the heart, lungs and heart again, before entering the aorta. • the 60 s initiation of the scan after the beginning of the contrast injection, means that the scan effectively starts at 64 s, because of the built-in delay for a scan to initiate. this is 3 s after completion of the contrast injection in the arm. i have found that this timing is adequate (as the contrast bolus still has to travel up the arm and through the heart and lungs and into the aorta) and the dense arterial phase of contrast in the vessels from the superior vena cava, through the heart, pulmonary arteries and veins and aorta is captured regularly with this timing. • a final saline chaser injection pushes the contrast towards the chest. this routine gave the following advantages: • adequate enhancement of returning systemic veins, to help differentiate them from mediastinal and hilar masses and lymph nodes • relatively dense contrast enhancement of pulmonary arteries, veins and thoracic aorta and its branches, which allowed clear differentiation between systemic returning veins and mediastinal and hilar masses and lymph nodes • enhancement of masses and lymph nodes allowed their characterisation • all the post-contrast information was seen on one set of images, negating the need to run both an arterial and a 60 s post-contrast series (2 series). this made interpretation quicker and in many cases easier (see case of lymphoma above – fig. 7). in my opinion, the information gained is increased when compared with a single 60 s post-contrast scan. radiation exposure is reduced by omitting the arterial phase scan in practices where both an arterial and 60 s post-contrast are run for those cases where the arterial series is not indicated, but is added for the radiologist’s comfort. other advantages from reducing unnecessary series of post-contrast ct scans have been discussed in a previous article using a single post-contrast ct scan of the urinary tract after triphasic contrast injection.1 these advantages include: • more efficient reading of the scans owing to more information presented on a single post-contrast series • ease of viewing of a single scan post-contrast series for the referring clinician • reduction in radiation to the patient from unnecessary extra scan series • reduced wear and tear on scanner hardware • reduction in the number of images needing electronic archiving. it must again be emphasised that this technique is used to replace chest ct scans where the clinical information dictates a pre-contrast and a single post-contrast scan at 60 s and should not to be used when a dedicated arterial series is indicated. 1. pretorius pc. experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection. sa journal of radiology 2011;15(4):140-145. 1. pretorius pc. experiences of using a single post-contrast ct scan of the urinary tract after triphasic contrast injection. sa journal of radiology 2011;15(4):140-145. fig. 1. injection plan. 2a 2b fig. 2a. white arrows point to unenhanced left brachiocephalic vein anteriorly and unenhanced lymph nodes posteriorly. in fig. 2b, the white arrow indicates the unenhanced azygos vein. 3a   3b  3c 3d fig. 3. scan of the chest 60 s after contrast injection. arrows in 3a and 3b point to the left brachiocephalic vein and azygos vein, respectively. 4a 4b 4c 4d fig. 4. biphasic contrast injection single post-contrast injection series. the white arrow in 4a and 4b shows contrast-enhanced left brachiocephalic and azygos veins. the white arrow in figs 4c and 4d show an enhancing ectopic thyroid nodule, with calcification, abutting on the enhanced left brachiocephalic vein. 7e 7f fig. 7. mass in right chest with superior medistinal syndrome clinically. the mass seen on precontrast (7a) shows vague enhancement (20hu) on the 60 s scan (7b and 7c). there is tumour infiltration causing partial obstruction of svc (7e), the ivc (7f) and the left internal jugular vein (7d) (white arrows). 5a 5b 5c 5d fig. 5. there is a carcinoma mass in the right lung (arrows in precontrast 5a and post-contrast 5b scans) with peripheral enhancement of the mass. infiltrated lymph nodes show typical peripheral enhancement on the post-contrast series (arrowheads in 5b, 5c and 5d). 6a 6b 6c 6d fig. 6. a lung mass showing increased density of 52hu on the precontrast scan (6b) with no significant enhancement on the 60 s post-contrast scan (6c). there are inflammatory uniformly enhancing lymph nodes in the adjacent mediastinum – arrow in 6d. 7a 7b 7c 7d 7e 7f fig. 7. mass in right chest with superior medistinal syndrome clincally. the mass seen on precontrast (7a) shows vague enhancement (20hu) on the 60 s scan (7b and 7 c). there is tumour infiltration causing partial obstruction of svc (7e), the ivc(7f) and the left internal jugular vein (7d) (white arrows). 8a 8b 8c fig. 8. retrosternal extension of a goitre (arrow), with cystic change in left lobe. clear separation and differentiation from adjacent aortic arch branches bilaterally and the enhanced left brachiocephalic vein anteriorly noted in 8b. 9a  9b  9c 9d fig. 9. sarcoid infiltration of lung (arrow in 9a), with enlarged uniformly enhancing mediastinal and hilar lymph nodes (arrows in 9b d). 10a 10b fig. 10. interstitial changes in the right lung. there is mediastinal lymphadenopathy (arrow in 10b) differentiated from the adjacent enhanced azygos vein (arrowhead in 10b). 11a 11b 11c 11d fig. 11. opportunistic nodular lung infection in immunocompromised patient. unsuspected pulmonary arterial emboli noted on the right (arrow in 11b and arrowhead in 11c). lymph node enlargement noted (arrow in 11c). micro-abscesses also identified in spleen (arrows in 11d) at the inferior range of the scan. 12a  12b fig. 12. right pneumothorax (arrow in 12a) with atelectasis of underlying lung (arrow in 12b) and pleural fluid. 118 sa journal of radiology • december 2010 case report acute pituitary apoplexy complicating a pituitary macroadenoma abstract pituitary apoplexy is a rare but potentially life-threatening condition caused by either haemorrhage or infarction of the pituitary gland. in most cases, a pre-existing pituitary macroadenoma is present. patients present with the clinical syndrome of headache, visual defects or ophthalmoplegia, altered state of consciousness and variable endocrine deficits. case history a 49-year-old man presented to the emergency department with headaches, visual disturbances and severe hypotension. on examination, a left temporal hemianopia was found. his gcs was 15/15 and there were no other cranial nerve deficits. laboratory investigations revealed decreased cortisol, thyroid stimulating hormone, prolactin, testosterone and adreno-cortico-thyrotropic hormone levels. he was also hyponatraemic. a clinical diagnosis of pituitary apoplexy with severe hypopituitarism was made, and the patient had immediate fluid and electrolyte replacement, hydrocortisone and t4 replacement. the patient was reluctant to undergo surgery and was initially managed with medical therapy. imaging findings on mr investigation, a sella and supra-sella mass showing mixed signal intensity was found (figs 1 3). subsequent imaging to plan for transsphenoidal surgery included a ct scan of the skull base and brain, done 3 months after the initial diagnosis, and it was then discovered that the sella mass had decreased in size. further mr imaging a week after the ct scan and again 2 months later (figs 4 6) revealed a febin joseph, mb chb zarina i lockhat, ffrad (d) (sa) malan janse van rensburg, mb chb, mmed rad (d), frcr, franzcr janet smal, mb chb, mmed rad (d) department of radiology, university of pretoria and steve biko academic hospital, pretoria tshepo peter moja, mb chb, fcs (sa) neurosurg department of neurosurgery, university of pretoria and steve biko academic hospital fig. 1. axial t2w and t2 flair images demonstrate a mass of heterogeneous signal intensity within the pituitary fossa. sa journal of radiology • december 2010 119 case report further reduction in tumour volume. a final diagnosis of acute pituitary apoplexy complicating a pituitary macro-adenoma was made. discussion the first case of a pituitary tumour associated with haemorrhage was described by bailey in 1898.1 the signs and symptoms of pituitary tumour infarction or haemorrhage are collectively termed ‘pituitary apoplexy’, which term was first used by brougham et al.2 verrees et al. further expanded this term to ‘pituitary tumour apoplexy’ because of the overwhelming number of cases associated with pituitary adenoma and only isolated instances of apoplexy in healthy glands.3 pituitary apoplexy occurs in approximately 1% of macro-adenomas; in 65 95% of cases, a pre-existing macro-adenoma is present.4 commonly, the episode of apoplexy occurs spontaneously; however, several risk factors have been implicated in the development of apoplexy. these include anticoagulation, dynamic pituitary function tests, radiation, bromocriptine therapy for existing macro-adenoma, trauma, surgery, perior post-partum state, elevated oestrogen levels and diabetes.4 up to 20% of pituitary apoplexy cases may be sub-clinical, but with radiological and pathological evidence of a haemorrhagic infarction. the clinical signs and symptoms are a result of the expanding pituitary mass secondary to haemorrhage or non-haemorrhagic infarction, fig.2. coronal tiw images, preand post-gadolinium, demonstrate expansion of the pituitary mass with resultant displacement and compression of the optic chiasm superiorly and displacement of the internal carotid arteries and cavernous sinuses laterally. inhomogeneous contrast enhancement is evident. fig. 3. sagittal tiw images, preand post-gadolinium, show expansion of the pituitary fossa by the pituitary mass. the suprasellar cistern is obliterated. inhomogeneous contrast enhancement of the mass is also evident. fig. 4. axial t2 flair image shows reduction in tumour volume 120 sa journal of radiology • december 2010 case report with resultant compression of the adjacent structures, viz. cavernous sinus and neuro-vascular bundle (hence cranial nerve palsies and ophthalmoplegia).5 headache occurs secondary to meningeal irritation owing to blood entering the basal cisterns or from dural stretching. blood in the supra-sellar cistern may provoke chemical meningitis, as has been reported by wen-yi et al.6 restricted visual fields are the result of distension of the optic nerves and chiasm, specifically bitemporal hemi-anopia. lateral haemorrhage and necrosis leads to deficits in the 3rd, 4th, 5th (1st and 2nd branches) and 6th cranial nerves. a decreased level of consciousness may be the result of endocrine abnormalities associated with the hypopituitarism or pressure transmitted to the brainstem or owing to hypothalamic compression.3 a life-threatening pituitary insufficiency or an acute adrenal crisis may occur.4 most of the patients who present with apoplexy have a hypopituitarism with decreased levels of all or several pituitary hormones. three causes for this have been postulated that include elevated intra-sellar pressure compressing the pituitary, pre-existing deficits from the adenoma itself, and destruction of the pituitary gland.3 diabetes insipidus is rarely a fig. 5. coronal t1w images pre and post gadolinium show a smaller pituitary mass. the mass effect that was previously exerted on the optic chiasm and cavernous sinuses is no longer evident. fig.6. sagittal t1w images pre and post gadolinium, now demonstrating a smaller mass.the suprasellar cistern is now visible. sa journal of radiology • december 2010 121 case report feature because the posterior lobe is usually not part of the adenoma. the imaging findings on contrast-enhanced ct reveal a pituitary mass with peripheral enhancement, with or without haemorrhage. patchy or confluent hyperdensity may be seen on non-enhanced ct. an associated sub-arachnoid haemorrhage can sometimes be present. on t1w mr imaging, in the early acute stage, an enlarged gland that is isoor hypointense to brain can be seen, while in the late acute or sub-acute stage, a hyperintense gland is seen. acute compression of the hypothalamus and optic chiasm may cause hyperintensity along the optic tracts on t2w mr images. in the chronic stage, a hyperintense ‘empty’ sella filled with csf can be demonstrated on t2w images. restricted diffusion within an adenoma may be an early sign of apoplexy. contrast administration often reveals rim-enhancement. the differential diagnoses to consider include a non-haemorrhagic pituitary macro-adenoma, a craniopharyngioma, a rathke cleft cyst, a pituitary abscess, primary intra-pituitary haemorrhage, or a giant thrombosed intra-sellar aneurysm. pituitary apoplexy is a neurosurgical emergency that requires urgent surgical decompression to prevent permanent visual loss and possible death from local pressure on the hypothalamus and brainstem. the pituitary gland remains capable of secreting adequate amounts of hormones when as little as 10% of residual tissue remains.3 prompt diagnosis allows the initiation of steroid, fluid and electrolyte replacement; definitive treatment by surgical decompression is then required.3,4 conclusion pituitary apoplexy should be considered in a patient who presents with a sudden onset of headache, visual field abnormalities and ocular muscle paresis. mri is the most sensitive diagnostic imaging modality, and prompt diagnosis expedites immediate treatment. 1. bailey p. pathological report of a case of acromegaly, with especial reference to the hypophysis cerebri and in the thyroid gland; and a case of haemorhage into the pituitary. philadelphia med j 1898;1:789. 2. brougham m, heusner ap, adams rd. acute degenerative changes in adenomas of the pituitary body with special reference to pituitary apoplexy. j neurosurg 1950;7:421. 3. verrees m, arafah bm, selman wr. pituitary tumour apoplexy: characteristics, treatment, and outcomes. neurosurgical focus 2004. http://www.medscape.com/viewarticle/474903_6 (accessed 3 august 2009). 4. osborn ag. diagnostic imaging: brain, sella and pituitary, 1st ed. salt lake city, usa: amirsys, 2004:ii2:28-30. 5. goel v, debnath uk, singh j, brydon h. pituitary apoplexy after joint arthroplasty. j arthroplasty 2009; 24(5):826.e7-826.e10. 6. wen-yi h, chien y, wu c, et al. pituitary adenoma apoplexy with initial presentation mimicking bacterial meningoencephalitis: a case report. am j emerg med 2009;27: 517.e1-517.e4. 100 sa journal of radiology • september 2011 quiz case arm pain after syncope: diagnosis s k misser, mb chb, fcrad (d) lake smit and partners, durban corresponding author: s misser (shalendramisser@hotmail.com) please refer to page 63 of the june 2011 issue of the sajr (http://www. sajr.org.za/index.php/sajr/article/view/579/443) for the presentation details. we congratulate dr himal gajjar (schnetler, corbett and partners, cape town) for a precise and detailed diagnosis, for which he receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its imaging. presentation and diagnosis (due to space constraints, the images referred to below are not reproduced here but are in the online june 2011 sajr at the above url.) the patient presented with arm pain after a syncopal episode. she had encountered numerous episodes of dizziness and falls that were attributed to her long-standing renal failure. however, the patient reported that, despite routine dialysis, she had felt a difference with generalised weakness and fatigue becoming progressively worse. the initial series of plain radiographs performed on presentation demonstrate (in fig. 1) the dialysis catheter in position and ‘rugger jersey’ appearance of the dorsal spine. fig. 2 shows focal medial humeral neck sub-periosteal resorption with an undisplaced fracture. there are also lucent foci of varying sizes with endosteal scalloping owing to multiple brown tumours. a remodelled right fifth rib probably is a healed fracture. fig. 3 reveals marked endosteal and trabecular resorption of tibia and fibula as well as distal third fibular periostitis change. prompted by these radiographic features of renal osteodystrophy and secondary hyperparathyroidism, a series of blood tests were performed. these confirmed low serum calcium, hyperphosphataemia and markedly raised parathormone (1 617 pg/ml). abdominal radiographs (fig. 4) taken 6 weeks later show that a new catheter has been placed via the left femoral vein, with its tip in the ivc. bony changes with demineralisation, brown cysts and vertebral end plate sclerosis are noted. fig. 5 demonstrates a solitary uncomplicated gallbladder calculus, a not uncommon finding in hyperparathyroidism. this case is another example where the radiologist may offer a definitive diagnosis (renal osteodystrophy with secondary hyperparathyroidism) based on diagnostic radiographic features aiding further clinical management. discussion of all endocrine organs, the parathyroid gland is unique, being the only one not under the control of the hypothalamic-pituitary axis. the parathyroid gland secretes parathormone (pth) on the basis of serum calcium and phosphate levels. in renal failure, phosphorus retention stimulates increased pth production and vitamin d is not converted to its active form. both occur due to a complex cascade involving fgf-23 with reduction in phosphaturia and inhibition of 1-α hydroxylase. clinically, hyperparathyroidism presents with ‘bones, stones, groans and moans’, i.e. manifesting by bone pain, kidney/gallstones, gastrointestinal symptoms and lethargy/weakness respectively. there are numerous radiographic features of hyperparathyroidism (see table i). a sine qua non for hyperparathyroidism is subperiosteal resorption along the radial side of middle phalanges.1 vertebral end plate osteosclerosis is particularly specific for secondary hyperparathyroidism.2 renal osteodystrophy, as in the patient presented here, is the term used to describe the combination of renal dysfunction coupled with hyperparathyroidism and the associated soft tissue and skeletal changes.3 1. helms, ca. fundamentals of skeletal radiology, 3rd ed. philadelphia, usa: saunders, 2005:145-147. 2. lenchik l, mitchell k. hyperparathyroidism and renal osteodystrophy. in: el-khoury g, ed. essentials of musculoskeletal imaging. philadelphia, usa: churchill livingstone, 2003:295-301. 3. resnick d. chapter 52: parathyroid disorders and renal osteodystrophy. in: diagnosis of bone and joint disorders, 4th ed. philadelphia, usa: saunders, 2002:2043-2111. erratum the award winner of the new quiz case in the march 2011 issue of the sajr was incorrectly announced as dr himal gajjar of schnetler, corbett and partners, cape town. in fact, the winner is dr m omar, a radiology consultant at chris hani baragwanath hospital. however, as it turns out, dr gajjar is the winner of the quiz case in the june 2011 issue. we congratulate both winners, and apologise for the error. table i. radiographic features of hyperparathyroidism and common sites at which they occur radiographic feature common sites 1. bone resorption (osteopaenia) • sub-periosteal • intracortical • endosteal • trabecular • sub-ligamentous • sub-chondral 2. bone sclerosis 3. brown tumours 4. periostitis 5. stones radial aspect of middle phalanges, medial side of humerus, tibia terminal tufts(acro-osteolysis) hands and long bones skull (salt and pepper appearance) trochanters, calcaneus, ischial/humeral tuberosities, lateral clavicle acromioclavicular, sacro-iliac and sternoclavicular joints rugger jersey spine, cranio-facial bony hypertrophy with leonine facies mandible, clavicle, ribs, pelvis, long bones and hands long bones, esp. tibia, fibula, femur gallstones, kidney stones or nephrocalcinosis 128 sa journal of radiology • december 2010 cpd questionnaire give one correct answer for each question. a. it is a relatively frequent finding at diagnostic imaging. b. it is a well-known hallmark feature of acute cholecystitis. c. the finding itself is non-specific and can be found in a wide range of gallbladder diseases and extracholecystic pathological conditions. d. sonography is not sufficient as the initial imaging technique for evaluating patients with suspected gallbladder disease, because of its moderate sensitivity in the detection of gallbladder dimensions. 1. regarding thickening of the gallbladder wall, which of the following statements is false? 2. which of the following statements is false? a. tumoral calcinosis may be defined as metastatic periarticular calcification that can be found in a wide variety of conditions such as primary hyperthyroidism and connective tissue diseases, as well as an idiopathic form. b. uraemic calcinosis occurs commonly in patients with chronic renal failure on long-term haemodialysis therapy and does not fall within the broad definition of tumoral calcinosis. c. the disease is usually asymptomatic but can present with complications such as impairment of mobility, nerve compression, ulceration of the overlying skin or bony erosion. d. if the radiologist is unfamiliar with the radiological patterns of tumoral calcinosis or disease processes that mimic the condition, then diagnosis and treatment can be delayed or the patient may be subjected to unwarranted invasive procedures. 3. which of the following statements regarding cardiac magnetic resonance (cmr) is false? a. various image sequences can be used, either rendering ‘dark blood imaging’ where the blood pool is darker than the myocardium, or ‘bright blood imaging’ where the myocardium is darker than the blood pool. b. cardiac imaging planes (short axis, long axis and fourchamber orientations) are traditionally used. standard imaging planes (axial, coronal and sagittal) have no value in assessment of the heart or extra-cardiac structures. c. cmr is used to excellent effect in patients with suspected cardiomyopathies, myocardial inflammation, tumours and infiltration. d. myocardial iron deposits associated with transfusiondependent anaemias can be quantified using t2* mapping. 5. which of the following statements is false? a. a bifid rib or sternum bifidum is a congenital abnormality of the anterior chest wall, with the sternal end of the rib cloven into two. b. the condition occurs in approximately 1.2% of the population and is usually unilateral. c. congenital anomalies of the anterior chest wall are uncommon. d. bifid rib may be associated with gorlin-goltz basal cell nevus syndrome, a rare autosomal dominant condition characterised by multiple nevoid basal cell carcinomas, jaw cysts and bifid ribs. further features include other rib anomalies, deficiency of the lateral clavicle, mandibular hypoplasia, macrocephaly and mental retardation. 6. identify the false statement among the following. a. macrodystrophia lipomatosa (mdl) results from progressive overgrowth of all the mesenchymal elements with a disproportionate increase in the fibro-adipose tissues. b. this congenital abnormality occurs most frequently in the distribution of the median nerve in the upper and medial plantar nerve in the lower extremity. c. excess of unencapsulated fibro-fatty tissue on magnetic resonance imaging (mri) is virtually diagnostic and can differentiate this entity from other diseases with similar presentation. d. involvement of the ulnar aspect of the hand, though rare, has been described; however, involvement of the lateral aspect of the foot is a well-recognised and constant finding. 7. the following are true about gout, except for: a. gout is the most common form of microcrystal arthropathy bilaterally. b. gout results from the deposition of uric acid crystals in and around the joints and soft tissues. c. plain radiographs remain the imaging modality of choice in the diagnosis of gouty arthritis. a characteristic feature is the loss of bone mineral density in the early stages of the disease. d. the most common cause is decreased uric acid clearance by the kidneys. 8. identify the false statement among the following. a. diabetic mastopathy is an uncommon benign fibroinflamatory breast disease. b. it may mimic cancer and as such poses a diagnostic challenge. raising awareness of this condition is essential to avoid unnecessary surgical intervention and patient anxiety. c. up to 13% of long-standing insulin-dependent diabetics are affected by diabetic mastopathy. d. the disease is exclusive to females. 10. identify one false statement: a. the hilum overlay sign is present on a frontal chest radiograph when normal hilar structures can be visualised through a mass, which implies that the mass is either anterior or posterior to the hilum. b. the presence or disruption of mediastinal lines may further aid in the localisation of the mass. the absence of the paraspinal and azygo-oesophageal lines suggests that a mass is located in the posterior mediastinum. c. the sign enables the observer to distinguish a mediastinal mass from a prominent cardiac silhouette. d. a typical posterior mediastinal mass displaying the hilum overlay sign is vertebral in origin in the majority (88%) of cases. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals. org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/007/01/2010 4. which of the following is true regarding digital teaching files (dtf)? a. the selected images may be submitted to the teaching archive in any digital form. b. once submitted, no further editing of the case is necessary. c. the creation of a dtf requires several steps; firstly, a suitable case has to be chosen and appropriate selected images identified. d. once the case has been completed, it should be made available for usage/review. a target group need not be identified. 9. identify the false statement: a. echinococcal cyst of the bone is a rare manifestation of echinococcal disease, with involvement of long bones, such as the radius, especially rare. b. the disease is acquired when man becomes the definitive host of the parasite by ingestion of ova. c. echinococcosis is caused by the larva of the tapeworm echinococcus granulosus or echinococcus multiloccularis and is endemic in many rural areas of southern africa. d. echinococcal cysts usually involve the liver or lung, with involvement of bone rare and accounting for 0.5 4% of all cases. case report 59 sa journal of radiology • september 2007 abstract paranasal sinus mucoceles are extremely rare in children. we report a case of a 5-year-old boy with no evidence of cystic fibrosis who underwent endoscopic marsupilisation of an ethmoid mucocele. case report a previously well 5-year-old boy presented to our department with a 3-week history of a swollen, teary left eye. he did not have any systemic complaints, and no specific ear, nose or throat symptoms. on examination he was apyrexial and appeared systemically well. examination of his eyes revealed left-sided proptosis, but his visual acuity and eye movements were normal. his oral cavity and oropharynx appeared normal and anterior rhinoscopy revealed no abnormality. endoscopic nasal examination revealed a smooth-surfaced mass protruding from the upper part of the middle meatus on the left side. the rest of the examination was noncontributory. laboratory investigations including a full blood count and electrolytes were normal and he had a normal chest x-ray. a sweat test performed was negative for cystic fibrosis. computed tomography (ct) (figs. 1 3) of his orbits and sinuses was performed and revealed a mixed-density soft-tissue expansile mass arising in the left ethmoid sinus, causing thinning and bowing of the medial wall of the left orbit. there was minimal rim enhancement of the mass. the mass caused minimal lateral displacement of the left optic nerve and mild left proptosis, but resulted in obstruction of the left maxillary antrum. the patient underwent endoscopic marsupilisation of the mucocele. biopsies of the cyst wall showed strips of mucoperiosteum with fragments of reactive bone. the mucosa was lined by respiratory epithelium with subepithelial chronic inflammatory cell infiltrate. there was no evidence of malignancy. a repeat ct scan was done 4 weeks post surgery and showed no residual mass. at 6-month follow-up, endoscopic nasal examination showed no recurrence. ethmoid mucocele in a 5-year-old patient without cystic fibrosis wakisa mulwafu, mb chb division of otolaryngology, university of cape town gisella furlan, mb bch, fcrad (d) sa department of radiology, red cross children’s hospital and university of cape town nico jonas, mb chb, frcs (glas), fcorl (sa) division of otolaryngology, university of cape town fig. 1. axial ct scan (soft-tissue window post contrast) shows a mixeddensity soft-tissue expansile mass arising in the left ethmoid sinus, causing thinning and bowing of the medial wall of the left orbit. fig. 2. coronal ct scan (soft-tissue window) shows minimal rim enhancement of the left ethmoid mucocele, with no enhancement of its content — central high-density foci (within the mucocele) are due to inspissated mucus. there is minimal displacement of the left optic nerve and mild left proptosis. there is associated obstruction and opacification of the left maxillary antrum. pg59-60.indd 59 9/17/07 8:54:20 am case report case report 60 sa journal of radiology • september 2007 discussion a mucocele is an epithelial-lined mucus-containing sac that fills a paranasal sinus and is capable of expansion by bone resorption and new bone formation.1 they are extremely rare in children and their presence warrants thorough investigation to rule out aetiological entities such as cystic fibrosis.2 paediatric mucoceles were previously thought to occur predominantly in patients with cystic fibrosis but some authors have recently reported mucoceles occurring in patients who do not have cystic fibrosis.3,4 ethmoid sinus mucoceles often appear with painless orbital swellings.2 they may also produce frontal headaches and proptosis.2 differential diagnoses of ethmoid sinus mucoceles in the paediatric population include meningocele, rhabdomyosarcoma, haemangioma, neuroblastoma and bony lesions such as fibrous dysplasia and osteomas.5 mucoceles of the frontal sinus can often be diagnosed on plain x-ray films. because of overlapping bone structures, mucoceles of the maxillary, sphenoid and ethmoid sinuses may not be apparent on x-ray. for this reason ct scan is the primary imaging method of choice.6 on ct, a mucocele appears as a non-enhancing, low-density expansile mass filling the sinus, with remodelling and/or thinning of the bony sinus walls.7 mucoceles have variable densities on ct depending on protein content, inspissation and superinfection.8 following intravenous contrast administration the lining of the mucocele may be enhanced.4 magnetic resonance imaging (mri) is only indicated if uncertainty persists following a ct scan.4 mri can provide information about tissue composition, therefore enabling differentiation between different lesions which may be of similar density on ct.9 mucoceles are managed surgically and most authors advocate marsupilisation rather than complete excision.4,10 endoscopic management of paediatric ethmoid mucoceles is recommended as this enables exceptional visualisation of the surrounding anatomy and identification of vital structures which allows for a safe and minimally invasive treatment option. the endoscopic approach avoids an incision and subsequent facial scarring. in conclusion, ethmoid mucoceles in the paediatric population are rare but can occur in the absence of cystic fibrosis. ct scan is the primary imaging method of choice and endoscopic marsupilisation is recommended. 1. lund vj, milroy cm. fronto-ethmoidal mucoceles: a histopathological analysis. j laryngol otol 1991; 105: 921-923. 2. alvarez rj, liu nj, isaacson g. pediatric ethmoid mucoceles in cystic fibrosis: long term follow-up of reported cases. ear nose throat j 1997; 76: 538-539, 543-546. 3. zrada se, isaacson gc. endoscopic treatment of pediatric paranasal ethmoid mucoceles. am j otolaryngol 1996; 17: 197-201. 4. hartley be, lund vj. endoscopic drainage of pediatric paranasal sinus mucoceles. int j pediatr otorhinolaryongol 1999; 50: 109-111. 5. nicollas r, facon f, sudre-levillain i, forman c, roman s, triglia jm. pediatric paranasal sinus mucoceles: etiologic factors, management and outcome. int j pediatr otorhinolaryngol 2006; 70: 905-908. 6. lloyd g, lund vj, savy l, howard d. optimum imaging for mucoceles. j laryngol otol 2000; 114: 233236. 7. harnsberger hr , wiggins rh, hudgins pa, et al. mucocele, sinonasal. in: diagnostic imaging: head and neck. salt lake city: amirsys 2004, 56-58. 8. kosling s, hintner m, brandt s, schulz t, blonching m. mucoceles of the sphenoid sinus. eur j radiol 2004; 51: 1-5. 9. ishibashi t, kikuchi s. mucocele-like lesions of the sphenoid sinus with hypointense foci of t2-weighted magnetic resonance imaging. neuroradiology 2001; 43: 1108-1111. 10. sciarretta v, pasquini e, farneti g, ceroni ar. endoscopic treatment of paranasal sinus mucoceles in children. int j pediatr otorhinolaryngol 2004; 68: 955-960. case report fig. 3. axial ct scan (bone window). there is evidence of thinning and remodelling of the walls of the expanded left ethmoid sinus. there is no evidence of bony destruction. pg59-60.indd 60 9/17/07 8:54:21 am 82 sa journal of radiology • september 2011 case report multiple skeletal lesions and pleural effusion owing to histoplasma capsulatum infection in an immunocompetent patient from a nonendemic region f e suleman, mb chb, fcrad (diag) sa, m med rad (diag) department of imaging and diagnostic radiology, university of limpopo (medunsa campus), pretoria p a scheepers, mb chb, fcrad (diag) sa, m med rad (diag) department of imaging and diagnostic radiology, university of limpopo (medunsa campus); consultant radiologist in private practice corresponding author: f suleman (tar@absamail.co.za) case report a 16-year-old girl from venda presented with a 3-month history of gradual onset of weakness involving both legs as well as bilateral knee pain. she was otherwise well. on clinical examination, she was not acutely ill, but had paraparesis and loss of sphincter control. no skin lesions were noted. blood test results showed an esr of 70 mm/hr and a mildly raised wcc. hiv tests were not performed because the patient was a minor and the guardians were not available for consent. however, the cd4 count was found to be >900 cells/mm3. radiographs of the spine, chest and both knees were obtained. these showed a pleural effusion (fig. 1) and multiple lytic lesions within the metadiaphyses of the long bones around the knees (fig. 2) as well as within the fourth thoracic vertebral body. an urgent mri of the spine showed abnormal t1 hypoand t2 hyperintensity within the body and posterior elements of t4. abnormal enhancement was demonstrated with post-contrast administration (figs 3 5). an associated extradural soft-tissue mass caused compression of the spinal cord. nuclear medicine studies (mdp bone scan) demonstrated increased uptake in all lesions and in addition showed abnormal uptake in both proximal humeri (fig. 6). the involved vertebra and surrounding soft-tissue mass were surgically removed and spinal fusion was performed. the excised tissue was sent for histological investigation, which revealed a chronic inflammatory infiltrate composed of lymphocytes, plasma cells and numerous foam cells (fig. 7). special staining techniques (periodic acid schiff and silver stain) showed the presence of multiple yeast cells both within and outside the foamy histiocytes (figs 8 and 9). some yeast cells demonstrated budding. morphologically, the fungus was consistent with histoplasma capsulatum. accordingly, a diagnosis of disseminated h. capsulatum infection was made. discussion the literature describes two distinct clinical forms of histoplasmosis that have different geographical distributions worldwide. african histoplasmosis is attributed to h. duboisii infection which most commonly occurs between the sahara and kalahari deserts. the most common site of infection is the skin but it can also involve bone, with skeletal manifestations occurring in up to two-thirds of patients with disseminated infection.1 the femur is the most frequently affected skeletal site, with diaphyseal involvement in young children and juxtametaphyseal involvement in older children and adults.1,2 skeletal lesions are usually multiple, and spinal involvement resulting in paraplegia has been reported.3 h. capsulatum infection is responsible for american or classical histoplasmosis infection. it has a worldwide distribution but is most commonly found in certain parts of north and central america. the reasons for this endemic distribution are unknown but are thought to include climate, humidity and soil characteristics. growth of the organism is enhanced by bird and bat excrement in the soil, so a typical exposure history would be that of cave exploration.4 our patient gave no history of entering caves. however, further enquiry abstract we describe a rare case of multiple skeletal lesions and a pleural effusion owing to histoplasma capsulatum infection in a 16-year-old immunocompetent girl residing in a non-endemic region. of note is that she had a lesion within a thoracic vertebra. following an extensive literature search, we found that vertebral involvement by h. capsulatum had not been previously described. pleural effusion and skeletal lesions are both rare manifestations of h. capsulatum infection. fig. 1. supine chest radiograph of the patient, with a large pleural effusion on the left (arrow). case report revealed that she resides in a rural area surrounded by caves inhabited by bats. three types of clinical disease may occur in patients with histoplasmosis. the most common presentation is acute pulmonary histoplasmosis.5 patients typically present with pulmonary symptoms that run a self-limiting course. chest radiographs may show hilar lymphadenopathy and upper lobe predominant nodules. chronic pulmonary histoplasmosis resembles tuberculosis.4 some patients may go on to disseminated infection with widespread disease, which can be fatal in the absence of therapy. even in this setting, pleural effusion and skeletal involvement is extremely rare.4 the distal femoral lesions found in our patient resemble those frequently seen in h. duboisii infection, which typically show juxtametaphyseal destruction of bony trabeculae. owing to the presence of multiple bone lesions, a provisional diagnosis of chronic multifocal osteomyelitis was considered, but histological analysis revealed the presence of multiple yeast cells both within and outside foamy histiocytes that morphologically resembled h. capsulatum. we could find only 8 cases of bony lesions due to h. capsulatum in the literature; to the best of our knowledge, the present one would be the first reported case of a patient with vertebral body involvement.6 fig. 2. lateral (2a, 2b) and antero-posterior (2c, 2d) x-rays of both knees show permeative lesions of the metadiaphyses of both distal femurs, with a solid smooth periosteal reaction on the left femur,. b a c d fig.3. t1-weighted mri shows low intensity changes of the t4 vertebra (arrow) and involvement of the inferior endplate of the vertebral body of t3. sa journal of radiology • september 2011 83 case report 84 sa journal of radiology • september 2011 conclusion this is an unusual case of chronic disseminated h. capsulatum infection, having occurred outside an endemic region and with the patient immunocompetent. she presented with two unusual clinical manifestations, i.e. multiple bone lesions, including a vertebral body lesion, as well as a left-sided pleural effusion. none of the radiographic findings raised any suspicion of h. capsulatum infection, and it was thanks to the astute histopathologist that the diagnosis was made. as a result, the patient went on to receive appropriate treatment. 1. thompson em, ellert j, peters llw, adjukiewicz a, mabey d. histoplasma duboisii infection of bone. br j radiol 1981;54:518-521. 2. onwuasoigwe o, gugnani hc. african histoplasmosis: osteomyelitis of the radius. mycoses 1998;41:105107. 3. cockshott wp, lucas ao. radiological findings in histoplasmosis duboisii infections. br j radiol 1964;37:653-660. 4. aziz r, khan n, qayum i, khan ar. histoplasmosis – case report. j ayub med coll abbottabad 2002;14(4):42-44. 5. kapotsis ge, daniil z, malagari k, et al. a young male with chest pain, cough and fever. eur respir j 2004;24:506-509. 6. jones rc, goodwin jr ra. histoplasmosis of bone. am j med 1981;70:864-866. fig. 6. mdp bone scan shows uptake in the proximal humeri, distal femurs and the t3 and t4 vertebral bodies. fig 7. haematoxylin and eosin stain showing mixed chronic inflammation with foam cells (arrow). fig 8. periodic acid schiff ’s stain showing intracytoplasmic yeast cells (arrow). fig 9. silver stain demonstrating yeast cells with faint halo (arrow). fig. 5. t2-weighted mri shows high signal intensity changes of the t4 (arrow) vertebra. the adjacent disc spaces are narrowed and show loss of the normal signal intensity. there is high signal change within the cord, and the outline is irregular and ill-defined. there are high signal changes in the posterior elements and surrounding soft tissue. fig. 4. post contrast t1-weighted mri shows slight enhancement of t4 (arrow) and the t3-t4 disc. a. medical ionising radiation sources give a moderate contribution to the population dose from man-made sources. b. most of this radiation contribution comes from sources other than diagnostic x-rays. c. there is a stabilised concern about the use of ionising radiation in diagnostic radiology. d. south africa is a healthcare level ii country according to the unscear definition based on physician densities. this healthcare level classification broadly translates to 150 x-ray examinations per 1 000 inhabitants. 2. which one of the following statements is true? cpd questionnaire give one correct answer for each question. 44 sa journal of radiology • june 2009 1. regarding ionising radiation, identify one correct answer: a. irradiation for medical purposes differs from most other types of radiation exposure in that the benefit is normally limited to the person receiving the dose, and it is assumed that the benefit does not necessarily outweigh associated hazards. b. in line with the alara principle, the directorate of radiation control (drc) in the department of health, south africa, has mandated all facilities having fixed fluoroscopy x-ray units to have a dosearea-product (dap) meter installed on their units. c. the preceding legal requirement was communicated as an annexure separate to the licensing document for all fixed fluoroscopy units. d. in comparison with stochastic effects, deterministic effects are a greater cause of concern in diagnostic radiology as they occur above a certain threshold dose. 3. which one of the following statements is false? a. spinal segmental dysgenesis is a rare congenital spinal abnormality seen in neonates and infants. b. the condition is segmental in nature, but with abnormal vertebrae also above and below the malformation. c. it is a condition in which a segment of the spine and spinal cord fails to develop normally. d. it is commonly associated with various abnormalities that affect the heart and genitourinary, gastrointestinal tract and skeletal systems. 5. with regard to trans-abdominal ultrasonic findings correlated with cd4+ counts in adult hivinfected patients, which one of the following statements is false? a. the degree of immunodeficiency is related to the level of the cd4+ count and, as such, the cd4+ count is a good index for monitoring the disease’s progression. b. splenic hyperechogenicity was found to increase in proportion as the cd4+ count decreased. c. gallbladder wall thickening and cholelithiasis both correlate with cd4+ count. d. patients with diffuse hypoechoic pancreatic parenchyma have associated pancreatic enlargement. 6. identify the one false statement among the following. a. most sonographic abnormalities correlate with cd4+ counts, indicating that there is a strong direct association between the infection stage, the cd4+ count and ultrasound findings. b. a myriad of sonographic abnormalities can appear in the abdomens of hiv/aids patients. c. splenomegaly, hepatomegaly, increased renal cortical echogenicity, lymphadenopathy, thickened bowel walls and fluid-filled bowels correlate with cd4+ counts. d. ultrasound scans should be used as a routine baseline investigation as well as in the follow-up of hiv-infected patients. 7. regarding ionising radiation, all the following are true except: a. fluoroscopy examinations can lead to various radiation effects, e.g. transient erythema, epilation, erythema, pericarditis, dermal necrosis, symptomatic skin reactions, non-symptomatic skin reactions and skin cancer, depending on the duration of the beam on time. b. should the procedure be prolonged unexpectedly, the radiologist should consider enlarging the x-ray field size or altering the x-ray beam collimation. c. to prevent skin injuries, the entrance surface doses should be monitored from direct dose measurements or from observing the change in the patient’s skin colour. d. the international commission on radiological protection (icrp) has recommended the use of diagnostic reference levels (drls) as a first step in the optimisation of diagnostic radiography. 8. identify the one false statement below: a. drls are defined as dose levels in medical radio-diagnostic practices or, in the case of radiopharmaceuticals, levels of activity, for typical examinations of groups of standardsized patients or standard phantoms for broadly defined types of equipment. b. a drl is not a dose limit and does not apply to a single individual; it must be established for typical examinations, for groups of standard-sized patients or standard phantoms, and for broadly defined types of equipment. c. drls are expected not to be exceeded for standard procedures when good and normal practice regarding diagnostic and technical performance is applied. d. there is a narrow spread in the radiation doses registered for any one type of examination. 9. identify the one false statement below: a. the large variability in delivered radiation dose proves that the studied fluoroscopic examinations stand to gain from dose optimisation. b. the great potential usefulness of dap meters in radiology for dose optimisation is in line with efforts to optimise diagnostic radiography. c. there is strong recommendation for the establishment of drls in south africa for the most frequent examinations in general radiography, fluoroscopy, mammography and computed tomography. d. a common protocol is of no value in determining patient doses for the purposes of establishing drls. 10. bates alheit is: a. the lead singer in a cape town band. b. secretary-general of nehawu. c. the minister of public works and foreign affairs. d. executive director of the rssa. 4. which one of the following radiological signs is not associated with spinal segmental dysgenesis? see previous page for cpd instructions. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www. cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg. co.za in the event of queries. accreditation number: mdb 015/180/04/2009 a. lumbar or thoraco-lumbar spinal dysgenesis or agensis causing kyphosis of one or more vertebrae. b. focal spinal cord narrowing with absent exiting nerve roots. c. bony defects that include dysmorphic, hypoplastic or absent vertebrae; focal spinal canal stenosis; and atrophy of the spinal cord. d. congenital paraplegia and congenital lower limb deformity. cpd june 2009.indd 44 6/10/09 10:23:19 am abstract introduction neurosurgical techniques and imaging appearances post-operative findings and complications conclusion acknowledgements references about the author(s) varsha rangankar department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, dr. d. y. patil vidyapeeth, pune, india anmol singh department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, dr. d. y. patil vidyapeeth, pune, india sanjay khaladkar department of radiodiagnosis, dr. d. y. patil medical college, hospital and research centre, dr. d. y. patil vidyapeeth, pune, india citation rangankar v, singh a, khaladkar s. pictorial review of the post-operative cranium s afr j rad. 2023;27(1), a2684. https://doi.org/10.4102/sajr.v27i1.2684 pictorial review pictorial review of the post-operative cranium varsha rangankar, anmol singh, sanjay khaladkar received: 29 mar. 2023; accepted: 06 june 2023; published: 21 july 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract imaging evaluation of the brain and cranium after cranial surgery is a routine and significant part of the workflow of a radiology department. various normal expected findings and early and late complications are associated with the post-operative cranium. in this pictorial review, the authors describe the typical imaging features of the spectrum of various conditions associated with cranial surgery with illustrative cases. contribution: a good knowledge and understanding of the spectrum of imaging appearances in the post-operative cranium is vital for the radiologist to accurately diagnose potential complications and distinguish them from normal post-operative findings, improving patient outcomes and guiding further treatment. keywords: cranium; craniotomy; craniectomy; complications; post-operative; trephine syndrome; tension pneumocephalus; paradoxical herniation. introduction surgical procedures like burr holes, craniotomy and cranioplasty are commonly performed for various neurosurgical indications such as intra-axial and extra-axial haemorrhages and collections, tumours, and infections.1 imaging, especially ct, is often performed in the post-operative follow-up of these patients. when interpreting these scans, it is imperative to be aware of the operative procedure performed and the expected post-operative findings, such as pneumocephalus, routine post-operative inflammatory changes and haemorrhages. at the same time, radiologists need to be vigilant of the abnormal imaging findings and be able to identify the various associated post-operative complications such as infections, tension pneumocephalus, sinking flap and herniation. ct is the first-line modality for these cases, because of short scan times and accessibility, and is routinely used for post-surgical follow-up. while mri is better than ct for certain conditions such as infection, intracranial collections and ischemia, it is often limited by incompatibility or artifact related to surgical material and implants. this article discusses the surgical techniques with expected imaging findings and describes the important post-operative complications. neurosurgical techniques and imaging appearances burr holes burr holes are small holes that are made in the skull bones using a surgical drill. the usual indications include insertion of a device such as a ventricular drain, endoscope or a deep brain stimulator electrode, drainage of a subdural haematoma and provision of access for stereotactic brain biopsy.1 on ct, a burr hole appears as a focal well-defined defect in the calvarium (figure 1). in the acute setting, associated subgaleal or extradural fluid collections and tiny air foci may be seen.2 figure 1: axial soft tissue (a) and bone window (b) ct head images showing burr holes, seen as rounded well defined defects in the skull bones in the left frontal and right parietal regions (long white arrows). note the small postoperative pneumocephalus in the left frontal region (a, short white arrow). craniotomy craniotomy is the surgical removal of a segment of the calvarium to achieve neurosurgical exposure (figure 2a). the calvarial segment is replaced at the end of the procedure. the various types of craniotomies include fronto-spheno-temporal, sub-temporal, anterior or posterior parasagittal, median suboccipital and lateral suboccipital.3 the margins of the bone flap are sharp and well defined, with a tram track appearance on ct images in the early post-operative period. later on, the edges become smooth and rounded as the flap undergoes resorption and remodelling.4 figure 2: axial bone window ct brain image (a) demonstrates a left parietal craniotomy (short white arrows) in a patient who underwent surgery for a left parietal space occupying lesion. note the post-operative pneumocephalus in the left frontal and parietal regions (thick white arrows). axial soft tissue window ct brain image (b) reveals bifrontal craniectomy with a normal meningogaleal complex seen as a slightly hyperdense linear structure separating the subcutaneous layer and the subarachnoid space (white arrows). axial bone window ct image in another patient (c) indicating a right parietal craniectomy with chronic calcifications of the meningogaleal complex (dashed arrows). craniectomy in contrast with craniotomy, the surgically removed segment of skull bone is not replaced at the end of the procedure in craniectomy (figure 2). usual indications are decompression of intracranial contents and removal of an infected bone flap.5 the bone flap is usually stored in an abdominal subcutaneous pocket for subsequent cranioplasty. post-craniectomy, the subgaleal space is usually obliterated, with formation of a meningogaleal complex, which consists of the galea aponeurotica, connective and fibrous tissue, and the duramater (figure 2b). on ct, this meningogaleal complex manifests as a thin, smooth, slightly hyperattenuating layer that enhances mildly on post-contrast images.6 in the chronic phase, calcifications of the meningogaleal complex are commonly seen (figure 2c). cranioplasty cranioplasty is a surgical procedure performed to reconstruct a patient’s skull, usually following a previous surgical intervention; or less commonly, in the setting of a congenital defect or after trauma.7 the goal of the procedure is to protect the brain from mechanical damage and improve cosmesis. ideally, the cranioplasty implant should be biocompatible, strong and durable to resist deformation, radiolucent to allow clean visualisation of the underlying brain tissue on ct and also mri compatible.7 commonly used materials for cranioplasty include autologous bone grafts and synthetic materials such as polymethyl methacrylate, titanium (figure 3), or ceramics. figure 3: (a, b) ct scanogram and axial bone window ct image demonstrating a right fronto-parietal craniectomy with a titanium cranioplasty implant (long white arrows). post-operative findings and complications post-operative haemorrhages small scalp and extradural haemorrhages are relatively common and benign findings in the post-operative period. only about 1% of post-craniotomy intracranial haemorrhages require surgical intervention.8 the most common post-operative haematomas are intraparenchymal (43%) (figure 4), extradural haematoma (33%), subdural haematoma (5%) and mixed (8%) (figure 5).8 figure 4: axial soft tissue window ct brain image (a) in a patient with left decompressive fronto-parietal craniotomy reveals subgaleal hemorrhage (thick short white arrow) with postoperative pneumocephalus and multiple hyperdense intraparenchymal hemorrhages in the left fronto-parietal region with surrounding oedema (long white arrows). post-operative drain tube is noted at the craniectomy site on image b, bone window ct image (arrowhead). also note the small lentiform epidural haemorrhage and intraparenchymal hematoma on the right side (a, white dashed arrows) associated with a fracture of the right parietal bone (b, short thick arrow). figure 5: axial soft tissue window ct image (a) in a patient with a right fronto-parietal craniotomy demonstrates a lentiform hyperdense extra-axial hematoma (thick white arrow) in the right fronto-parietal region with mass effect causing effacement of the right lateral ventricle and midline shift toward left side. axial soft tissue window ct image (b) in another patient with a left parietal craniectomy reveals a lentiform mixed attenuation epidural hematoma (long arrows) and subgaleal hematoma (short arrows) at the craniectomy site, causing mass effect and resultant effacement of the left cerebral sulci and lateral ventricle with midline shift to right side. extradural haematomas are situated between the dura and the inner table of the skull. the majority of the post-operative extradural hematomas are regional, in the location related to the surgical site.9 further subtypes are adjacent haematomas that occur at the margins of the craniotomy site and remote extradural haematomas, located distant from the craniotomy site.10 the majority of intraparenchymal haemorrhages are small (less than 3 cm in size) and do not cause much neurological compromise. large haematomas are associated with poorer outcomes.1 causes of large intraparenchymal haemorrhages include poor haemostasis, excessive brain retraction, hypertension in the post-operative period and bleeding disorders. infections post-craniotomy infections are a relatively uncommon complication, with an incidence of less than 1% described in the literature, and usually present as extradural abscesses, meningitis (figure 6), subdural empyema and parenchymal abscesses.11,12 the infection usually begins in the subcutaneous plane at the surgical site and extends to the deeper tissues. contrast imaging plays an important role in diagnosing involvement of the bone flap, extra-axial cerebrospinal fluid (csf) spaces, meninges and brain parenchyma. figure 6: meningitis. axial post-contrast soft tissue window ct image in a patient with a right occipital craniectomy (a, thick white arrow) indicates extensive leptomeningeal enhancement (b, thin white arrows). herniation of the cerebellar parenchyma is also seen at the occipital craniectomy site. bone flap infections account for nearly half of all post-craniotomy infections12 and usually present 1–2 weeks after surgery. risk factors include intra-operative breach of the paranasal sinuses, presence of an active infective focus during the surgery, surgery performed for traumatic injuries, longer surgical duration, re-operation, immunodeficient status and post-procedure csf leakage.13 detached bone flaps are also more likely to get infected as they lack a vascular supply. on ct, the bone flap may show an irregular outline with multiple lytic areas or sclerosis of the bone flap (figure 7). presence of superficial skin thickening, fat stranding and subgaleal and extradural fluid collections in the presence of bony changes increases the specificity for the diagnosis (figure 8). on mri, the marrow of the involved bone appears hypointense on t1 weighted images and hyperintense on t2 weighted images, with diffusion restriction. figure 7: bone flap infection. axial bone window ct image in a patient with a right parietal craniotomy demonstrates a mildly sclerosed bone flap with multiple well defined lytic areas (a, long white arrows) and a small adjacent soft tissue component (b, short white arrows). extradural abscesses present as biconvex fluid collections, usually adjacent to the craniotomy site, with thickened enhancing dura on contrast enhanced images (figure 8 and figure 9).14 subdural empyemas present as extra-axial crescentic fluid collections along the cerebral convexity.14 figure 8: cranioplasty flap infection. axial bone window (a) and contrast-enhanced soft tissue window ct images (b, c) in a patient with a left frontoparietal craniectomy reveals an acrylic cranioplasty implant with small air foci (a, b, long arrows). adjacent epidural (b, c, thick arrow) and subgaleal (c, asterisk) fluid collections along with thickening and enhancement of the meningogaleal complex is seen. figure 9: axial t1 (a), coronal t2 (b) and axial contrast enhanced t1 fat saturated (c) images reveal a left fronto-parietal craniectomy with a t1 hypointense and t2 hyperintense extradural infected collection (long arrows) with thickened, enhancing dura on the post contrast image. a small subgaleal collection (b, c, short arrows) with peripheral enhancement can also be seen. large subdural empyemas may be associated with subfalcine herniation, significant effacement of the ventricles and sulci and cerebral oedema. these collections are hypointense on t1 weighted images, hyperintense on t2 weighted images and mildly hyperintense to csf on fluid attenuated inversion recovery (flair) images. they may show diffusion restriction and peripheral rim enhancement (figures 10a–f). rarely, the collection can extend into the brain parenchyma and intraparenchymal abscesses can rupture into the ventricle leading to ventriculitis (figures 10g and h).15 figure 10: axial t2 (a) and t1 (b) images show a subdural collection with diffusion restriction (c) in the right fronto-parietal region with parenchymal extension. post contrast axial (d, e) and coronal (f, g) t1 images show thick, peripheral rim enhancement and extension into the right lateral ventricle (thin white arrows). axial diffusion weighted image (h) reveals restricted diffusion in the dependent debris within the occipital horns of the lateral ventricles (short white arrows). apparent diffusion coefficient (adc) maps not included. extracranial herniation in cases of raised intracranial pressure from any aetiology, such as cerebral oedema or haemorrhage; the oedematous brain parenchyma herniates via the craniectomy defect (figure 11, figure 12 and figure 13). this leads to compression and contusions in the parenchyma at the bony margins of the craniectomy and compression of the superficial cortical veins leading to infarction.16 figure 11: axial soft tissue window ct image in a patient with a left fronto-parietal decompressive craniectomy indicates herniation of the brain parenchyma through the craniectomy defect (thick white arrows). extensive encephalomalacia (asterisks) in the left fronto-parietal region along with ex vacuo dilatation of the left lateral ventricle is also seen (white arrows). figure 12: axial soft tissue (a) and bone window (b) ct brain images in a patient with a right fronto-parietal decompressive craniotomy (a, thick white arrows) demonstrate extracranial herniation of brain tissue (a, asterisks) with thinning and remodeling of the bone flap (b, thin arrows). figure 13: axial post-contrast t1 weighted mr image in a patient with a left fronto-parietal decompressive craniectomy demonstrates herniation of the brain parenchyma through the craniectomy site along with a thickened enhancing meningogaleal complex (white arrows). tension pneumocephalus unlike post-operative pneumocephalus, which is an expected finding in the post-operative cranium, tension pneumocephalus is a rare and life-threatening entity. there is build up subdural air that causes compression of the brain parenchyma (figure 14). it most commonly results from a ball-valve mechanism that causes entry of air into the subdural space.17 figure 14: axial soft tissue window ct image (a) shows tension pneumocephalus in both frontal regions (asterisks) causing mass effect on the underlying brain parenchyma with a heaped-up appearance of the anterior tips of the bilateral frontal lobes (mount fuji sign). axial soft tissue window ct image (b) in a different patient shows asymmetric tension pneumocephalus (thick white arrows) in both frontal regions (left > right), causing mass effect on the underlying brain parenchyma and subfalcine herniation towards right side. there is an associated subdural hemorrhagic collection (thin white arrow) present on the left side and postoperative air in the left lateral ventricle (arrowhead). the diagnosis of tension pneumocephalus is made on ct in the presence of subdural air with the ‘peaking’ sign and the ‘mount fuji’ sign (figure 14a). ‘peaking’ sign refers to mass effect on the frontal lobes because of the presence of subdural air and the ‘mount fuji’ sign refers to separation of the frontal lobes from the falx.18 subdural and subgaleal hygromas subdural and subgaleal hygromas are early complications that usually occur as a result of altered csf circulation dynamics in the post-operative period leading to csf accumulation in the subdural or the subgaleal region, most commonly on the side of the surgery.16 rarely, however, they can also be seen on the opposite side or in the interhemispheric region.19 the fluid collections accumulate in the first few days following the surgery and resolve spontaneously over weeks or months. they follow csf attenuation and signal intensity on ct (figure 15) and mri (figure 16) images, respectively and generally do not cause any significant neurological compromise. figure 15: axial soft tissue window ct image (a) in a patient with a right temporal decompressive craniectomy reveals a subgaleal hypodense fluid collection in the right temporal region (white arrow), suggestive of a subgaleal hygroma. axial soft tissue window ct image (b) in another patient with a right fronto-parietal decompressive craniectomy demonstrates an extra-axial hypodense fluid collection in the subdural region along the cerebral convexity (white arrow), consistent with subdural hygroma. axial soft tissue window ct image (c) with a right parietal craniotomy indicating subdural (thick white arrow) and subgaleal (thin white arrow) hygromas. figure 16: subgaleal and subdural hygromas. coronal t2 weighted mri in a patient with a left parietal craniectomy shows a hyperintense fluid collection in the left subgaleal region, extending beyond the margins of the craniectomy to the left temporal region (thin white arrows). an extra-axial subdural collection is also noted in the right frontoparietal region (thick white arrow). external brain tamponade external brain tamponade is a rare, life-threatening condition. it is characterised by excessive subgaleal fluid accumulation that exerts pressure on the underlying brain parenchyma. clinically, the patient presents with neurological deterioration and a tense craniectomy flap. imaging shows a subgaleal fluid collection producing mass effect on the brain (figure 17). midline shift and sub-falcine herniation may be seen in severe cases. drainage of the subgaleal fluid usually leads to neurological improvement.20 figure 17: external brain tamponade. axial (a) and reformatted coronal soft tissue window (b) ct images in a patient with a left fronto-parietal craniotomy demonstrate a large hypodense subgaleal fluid collection causing compression of the underlying left frontoparietal brain parenchyma (long arrows). sinking skin flap syndrome sinking skin flap syndrome, or trephine syndrome, is an intermediate to late post-operative complication in patients who undergo craniectomy. there is a sunken appearance of the skin flap and concave appearance of the underlying parenchyma due to chronic exposure of the brain to atmospheric pressure causing deformity of the underlying parenchyma (figure 18).21 unlike paradoxical herniation, there is no midline shift, subfalcine or uncal herniation. the patients usually present with vague complaints such as headache, dizziness, mood changes and fatiguability.21 figure 18: trephine syndrome. axial soft tissue window ct brain image reveals a right fronto-parieto-temporal craniectomy with a sunken skin flap (white arrows) and mild deformation of the underlying brain parenchyma without midline shift. paradoxical herniation paradoxical herniation is a rare, late complication in the post-craniectomy patient. it is characterised by a sunken skin flap and contralateral displacement and herniation of brain, with resultant mass effect, midline shift and effacement of csf spaces (figure 19 and figure 20).20 the mechanism is usually a decrease in intracranial pressure because of lumbar puncture, ventricular drainage or ventriculoperitoneal shunting, which leads to an imbalance in the intracranial pressure and the atmospheric pressure. it is a potentially life-threatening condition, usually treated by clamping any shunts or drains, putting the patient in the trendelenberg position, administering fluids and performing an early cranioplasty.22 figure 19: paradoxical herniation. axial soft tissue window ct brain images (a, b) reveal a left fronto-temporo-parietal craniectomy with a sunken skin flap (arrows), deformation of the underlying brain parenchyma, midline shift of 9.1 mm (b) and subfalcine herniation to the right side. associated meningogaleal complex calcifications are also seen. figure 20: axial soft tissue window ct image reveals bilateral fronto-parietal craniectomies with sinking of the skin flaps on both sides (left > right) (white arrows) and midline shift towards the right side. conclusion imaging plays a crucial role in the assessment of the post-operative cranium, providing valuable information about potential complications and helps in optimising treatment. radiologists should be familiar with the different early and late complications to provide accurate and timely diagnoses. with proper imaging interpretation, clinicians can make informed decisions regarding patient management, ultimately leading to better post-surgical outcomes and improved patient care. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.r. conceptualised this article. a.s. collected the relevant data and references and prepared the primary article draft. v.r. and s.k. reviewed and edited the final draft of the manuscript and selected the images. ethical considerations this article followed all ethical standards for research. written consent was obtained from the patients for publication of the radiological images. all the images were anonymised to protect the identity of the patients. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability original images and any required information are available on request from the corresponding author, a.s. disclaimer the views and opinions expressed in this article are those of the authors and not an official position of the institution. references sinclair ag, scoffings 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https://doi.org/10.1007/s00701-008-0145-9 reasoner dk, todd mm, scamman fl, warner ds. the incidence of pneumocephalus after supratentorial craniotomy. observations on the disappearance of intracranial air. anesthesiology. 1994;80(5):1008–1012. https://doi.org/10.1097/00000542-199405000-00009 michel sj. the mount fuji sign. radiology. 2004;232(2):449–450. https://doi.org/10.1148/radiol.2322021556 yang xf, wen l, li g, zhan ry, ma l, liu wg. contralateral subdural effusion secondary to decompressive craniectomy performed in patients with severe traumatic brain injury: incidence, clinical presentations, treatment and outcome. med princ pract. 2009;18(1):16–20. https://doi.org/10.1159/000163040 akins pt, guppy kh. sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. neurocrit care. 2008;9(2):269–276. https://doi.org/10.1007/s12028-007-9033-z dujovny m, agner c, aviles a. syndrome of the trephined: theory and facts. crit rev neurosurg. 1999;9(5):271–278. https://doi.org/10.1007/s003290050143 seinfeld j, sawyer m, rabb ch. successful treatment of paradoxical cerebral herniation by lumbar epidural blood patch placement: technical case report. neurosurgery. 2007;61(3):suppl:e175; discussion e175. https://doi.org/10.1227/01.neu.0000289731.27706.af editorial 26 sa journal of radiology • june 2010 the south african journal of radiology reports below a south african ‘first’: the award of the frank doyle medal to dr pieter janse van rensburg by the royal college of radiologists for being the highestscoring candidate in the autumn 2009 part a final examination. i asked around cape town about who frank doyle was. the only response came from dr david legge, an irishman (who stresses his strong south african roots) presently in charge of our interventional theatre. he told me that doyle had in fact examined him. ‘he examined me in the final (then) ffr. apart from standing behind me when showing films, he came across as a very fair, sympathetic and good-humoured examiner.’ after some emailing, we discovered that doyle had been a physicist before doing medicine, where he put his skills as a physicist to good use; this included designing the ct head scanner with houndsfield and pioneering the use of yttrium implants for pituitary tumours. his clinical interests lay in the musculoskeletal and endocrine areas. doyle pioneered retroperitoneal air insufflation for adrenal tumours , the accurate recognition of osteoporosis, and measurement of osteoblastic response to new therapies. he had a hidden talent for classical piano playing which was privy to a select few. personality-wise, he was described as a humorous, kind, self-effacing, generous and wonderful man. he had a severe stroke in the mid-1970s and took several years to rehabilitate. we could not confirm whether doyle had to return to medical school to refresh his knowledge; however, he returned to radiology and took a special interest in mri scanning. and so is frank doyle, the man behind the medal, commemorated. i thought that this may also be an opportune time to pause to look at the state of academic radiology in south africa. all major academic departments now have full-time academic heads. steve benningfield (cape town) and coert de vries (bloemfontein) are old stalwarts. a younger generation – zarina lockhat (pretoria) victor mngomezulu (wits) and richard pitcher (stellenbosch) – has emerged. aisne stoker is standing strong in natal, and we all believe that it is just a matter of time before durban will return to its former days of glory. as we go to press, i’m awaiting news from medunsa and mthatha. the faculty of radiology of the college of medicine is vibrant and active under the presidency of savvas andronikou. we are seeing talented young radiologists from academic departments and the private sector being drawn in as examiners, and a unitary examination policy has at last become a reality. continuing radiology education (cre) is on an unequalled level. leon janse van rensburg has achieved a perfect balance with the programme, and south african radiologists, both academic and private, have been exposed to practical, hands-on tuition by international experts. i take pride on this late autumn day here in cape town in declaring south african radiology to be alive and in vibrant good health. the frank doyle medal is a personal achievement, but i believe that it also represents the state of excellence of radiology in south africa. jan lotz editor-in-chief frank doyle medal award the royal college of radiologists has awarded the frank doyle medal to dr pieter janse van rensburg who was the highest-scoring candidate to pass all six modules of the final frcr part a august 2009 examination. two hundred and forty-eight international candidates passed the examination, which comprises six modules: cardiothoracic and vascular, musculoskeletal and trauma, gastrointestinal, genito-urinary, adrenal, obstetrics and gynaecology and breast, pediatrics, and central nervous system – head and neck. each module is tested separately during an examination each of two hours. the award is a ‘first’ for south africa. it is a much sought-after prize in the uk, with foremost universities and hospitals in hot contention. dr janse van rensburg’s achievement is equally a great achievement for south african radiology. the state of academic radiology in south africa in 2010 editorial sajr 778 imaging of the paediatric paranasal sinuses a ahmed, mb bch, fcrad (diag) visser, erasmus, vawda & partners, port elizabeth, south africa corresponding author: a ahmed (docaadil@gmail.com) sinus development is a dynamic process in children, and appropriate imaging is necessary to adequately demonstrate pathology in our vulnerable paediatric population. the paediatric paranasal sinuses are affected by a wide spectrum of conditions including congenital abnormalities and inflammatory, traumatic and neoplastic diseases. the purpose of this review is to illustrate the normal pattern of development and the complex anatomy of the sinuses, which should guide imaging protocols. common anatomical variations and their clinical relevance are described. the paper also describes the various conditions affecting the paediatric paranasal sinuses, with emphasis on imaging features. the diagnostic algorithm for sinus disease continues to evolve along with advances in imaging modalities, and this review discusses suggested imaging guidelines for sinus imaging in children. s afr j rad 2013;17(3):91-97. doi:10.7196/sajr.778 figs 1 16 are available as online supplementary material at http://dx.doi.org/10.7196/sajr.778 anatomy and development the development of the paranasal sinuses begins as evaginations of the nasal mucous membranes during the second and fourth months of pregnancy. further development takes place after birth. the process of development is completed after puberty. as sinus development progresses, asymmetry in size and shape is common, and opacification or mucous membrane thickening continues to be physiologic until approximately age 6 years.1 the maxillary sinus is the first paranasal sinus to develop from the ethmoid sinuses. these sinuses show a biphasic growth pattern until the adult form at about the age of 12 years. they are rudimentary at birth and expand by pneumatisation into the developing alveolar process. their growth rate matches that of the maxilla and development of the dentition. inferior growth usually reaches the hard palate by age 9, although the timing of these various stages of development is highly variable (fig. 1a).2 the maxillary sinus resembles a four-sided pyramid. the base lies vertically on the medial surface and forms the lateral nasal wall. the apex extends laterally into the zygomatic process of the maxilla. the roof of the sinus is also the floor of the orbit. the posterior wall extends the length of the maxilla. the nasolacrimal duct drains the lacrimal sac and runs from the lacrimal fossa down the posterior aspect of the maxillary vertical buttress and empties into the inferior meatus. the duct lies very close to the maxillary ostium.3 the ethmoid air cells are present at birth and continue to grow until late puberty or until they reach compact bone (fig. 1b). the ethmoid sinuses are divided into groups of cells by bony basal lamellae of the middle turbinate, which separate the ethmoid into anterior and posterior groups with different drainage patterns. pneumatisation progresses in a posterior direction. the final phase includes medial and inferior air cell extension. as a result, the ethmoid air cells are rarely limited to the lateral ethmoid masses; they often extend into the turbinates, crista galli and the neighbouring frontal, maxillary, sphenoid and palate bones.4 this extension into the adjacent structures creates the commonly encountered normal variants. inferomedial extension into the middle turbinate creates the concha bullosa variant, best seen on computed tomography (ct) scans (fig. 2a). anteroinferior extension results in formation of the agger nasi cells. the agger nasi cells serve as the anterior floor of the frontal sinus (fig. 2b). haller’s cells are created when pneumatisation progresses inferolaterally into an infraorbital location.2 haller’s cells can be clinically significant because of their location along the course of the infundibulum. at birth, the sphenoid sinus is undeveloped, with the sphenoid bone containing erythropoietic marrow. usually at about age 3 years, aeration begins anteriorly and progresses in an inferior posterolateral direction. the sinus attains its mature size by the age of 14 years.1 the degree of pneumatisation is highly variable. aplasia is extremely rare. pneumatisation can extend into the greater wing of sphenoid, creating lateral recesses. other variants include aeration of the medial pterygoid process (44%), anterior clinoid process (13%) and posterior orbital wall (fig. 2c). sphenoethmoidal/onodi cells represent contiguous extension of the posterior ethmoid air cells laterally and superiorly to the sphenoid sinus, and are closely associated with the optic nerve. in the presence of this anatomical variation, there is an increased risk of optic nerve damage during sphenoid surgery (fig. 2d). the last paranasal sinus to develop between the inner and outer table of the frontal bone is the frontal sinus. the frontal sinus is formed by pneumatisation of the frontal recess into the frontal bone. the earliest pneumatisation occurs at, or shortly after, 2 years of age. by 4, the cranial extent reaches half the height of the orbit.2 usually at about 6 years of age, the cranial extent of the frontal sinus is at the superior orbital rim. growth continues throughout childhood, and full size is reached after puberty.4 the frontal sinuses are exceedingly variable in extent and form. not infrequently, one sinus is entirely lacking. aplasia or overly pneumatised frontal sinuses may occur. the formation of additional cells in the frontal recess and the frontal infundibulum, apart from the agger nasi cells, is very individual. they are described according to their anatomic orientation. a cell that pneumatises into the frontal bone is named a frontal cell of the anterior ethmoid or bulla frontalis, and lies above the ethmoid bulla. a supraorbital cell is a variant that develops as an extension, from the posterior aspect of the frontal or suprabullar cells.5 other variants include a pneumatised crista galli or cells of the interfrontal septum. sinus drainage sinus drainage involves complex anatomical structures and pathways. the ostiomeatal complex (omc) is a functional entity of the anterior ethmoid complex that represents the final common pathway for drainage and ventilation of the frontal, maxillary and anterior ethmoid cells.5 the maxillary sinus ostium drains into the infundibulum, which joins the hiatus semilunaris and drains into the middle meatus. the uncinate process is a thin bony leaflet that resembles a hook. it is orientated almost sagitally and runs from anterosuperior to posteroinferior and forms the medial border of the ethmoid infundibulum. the lateral border of the infundibulum is the lamina papyracea (fig. 3a).5 the anterior omc comprises the frontal sinus ostium, frontal sinus drainage pathway, maxillary sinus ostium, infundibulum and middle meatus. these structures connect the frontal, anterior ethmoid and maxillary sinuses. a second possible route of drainage from the maxillary sinus is via an accessory ostium along the medial maxillary wall, into the middle meatus. an accessory ostium exists in 15 30% of individuals (fig. 3b). accessory ostia are over-reported in the literature owing to incorrect window settings on ct. the infundibulum frontale is a funnel-shaped narrowing at the inferior aspect of the frontal sinus, extending toward the floor of the frontal sinus ostium. both frontal sinuses have their ostia at the most dependent portion of the cavity (posteromedial).6 in the sagittal section, the frontal recess, when taken together with the infundibulum frontale, resembles an hourglass, with the constricted portion being at the level of the natural ostium (fig. 3c). this drainage system ends in the middle meatus. anatomical obstruction to this pathway can result when the frontal recess is narrowed posteriorly by an ethmoid bulla. anterior obstruction occurs when an enlarged agger nasi cell attenuates the infundibulum frontale.5 the anterior ethmoid drains into the hiatus semilunaris and middle meatus. posterior ethmoid drainage is into the sphenoethmoidal recess and superior meatus. the sphenoid sinus drains via the ostium into the sphenoethmoidal recess, which opens into the nasal cavity inferiorly.3 any of the surrounding cells, recesses and ostia, with their dependent sinuses, may become diseased, thereby contributing to the symptoms and pathophysiology of sinusitis. anatomical variations can affect normal drainage, efficiency of mucocilliary clearance and the morphology of the sinuses, predisposing the patient to sinus disease. this is particularly possible if occuring at the level of the frontal recess and the omc.7 this relationship between anatomical variations and the development of chronic sinusitis is less significant in children than in adults.8 at the level of the omc, there can be variations to the intrinsic structures, such as an abnormal uncinate process orientation or a large ethmoid bulla.9 the ethmoid bulla is one of the largest anterior ethmoid cells and, if enlarged, can encroach on the omc (fig. 3a).10 common variants of the uncinate process include pneumatisation, or an uncinate bulla. the uncinate process can have variations in its insertion. the uncinate process may deviate medially and fuse with the middle turbinate, affecting the middle meatus, or deviate laterally and attach to the lamina papyracea; this will obstruct the hiatus semilunaris and/or infundibulum. the uncinate process tip may fuse with the orbital floor or the inferior portion of the lamina papyracea, which is known as an atelectatic uncinate process. this variation is usually associated with a hypoplastic maxillary sinus.11 this variant is important to note for surgical planning because the ipsilateral orbit will be low-lying.12 extrinsic variations that could result in obstruction are a large concha bullosa, haller’s cells or a paradoxical middle turbinate. congenital abnormalities aplasia or hypoplasia are uncommon conditions, but are occasionally encountered. in the paediatric population, maxillary hypoplasia may be misdiagnosed as chronic sinusitis.13 the maxillary sinus is most frequently affected. there are other nonheritable congenital bony conditions that arise from the sinuses or affect them as a result of their anatomic location. fibrous dysplasia is a developmental disease of bone typically seen in childhood and adolescence. the maxilla is the most frequent facial bone affected.14 the medullary cavity is filled by abnormal fibrous tissue, resulting in progressive swelling and expansion of the affected bone (fig. 4). the adjacent sinuses are thus secondarily involved. sequelae include obstruction to the drainage pathway or sinuses of small volume. the sphenoid and frontal bones are also involved. fibrous dysplasia can be monostotic or polyostotic. most cases of monostotic fibrous dysplasia are incidental findings on a cranial ct exam.12 characteristic radiological features described include overgrowth of the bone with outward expansion of the outer table, and a ‘ground-glass’ texture to the involved bone. this is well demonstrated on ct.12 the craniofacial form of fibrous dysplasia has been named leontiasis ossea. an additional variant with autosomal dominant inheritance is familial fibrous dysplasia or cherubism.15 the eventual size of the sinuses is influenced by brain growth. owing to impaired brain growth in sturge-weber syndrome, there is enlargement of the ipsilateral sinuses.15 in other malformation syndromes (e.g. neurofibromatosis type 1 and gardener syndrome), there may be a sinus abnormality secondary to local bony malformation.1 in beta thalassaemia, there may be osseous abnormalities caused by marrow hyperplasia. this can result in delayed pneumatisation and expansion of the maxilla.12 , 16 cystic fibrosis (cf) is a heritable systemic condition where patients have chronic sinus disease owing to an abnormality of the mucus-producing exocrine glands. the paranasal sinuses are ultimately involved in almost all patients. the abnormal viscous secretions result in chronic pan-sinusitis, often with associated polyposis (fig. 5).17 nasal polyposis is otherwise rare in children without cf. kartagener’s syndrome is another uncommon familial disorder in which patients have polyposis and chronic sinusitis secondary to abnormal mucocilliary function. inflammatory conditions the spectrum of inflammatory conditions affecting the paranasal sinuses, collectively represent the most frequently encountered paranasal sinus diseases in both the adult and paediatric patients. sinusitis may be secondary to infection, allergy, altered immunity or a combination of these factors. pathogens implicated include bacteria (more commonly) and a variety of fungi. sinusitis may be classified as acute, subacute, and chronic. the american academy of pediatrics (aap) defines acute bacterial sinusitis as infection lasting less than 30 days. subacute sinusitis is infection lasting between 30 and 90 days, and inflammation of the sinuses lasting more than 90 days as chronic.18 the imaging findings are nonspecific, more so in children, and should be correlated clinically and with age. the radiographic hallmark of acute sinusitis is sinus opacification. however, an opacified sinus in childhood does not equate to sinusitis unless there is clinical corroborative evidence. air-fluid levels in a sinus usually correlate with acute sinusitis (fig. 6). chronic sinusitis usually results from repeated episodes of sinusitis. mucosal thickening is not uncommonly interpreted as chronic sinusitis. the degree of mucosal thickening is important, as up to 2 3 mm may be seen normally as part of the nasal cycle. the degree of mucosal thickening can be described as mild (<5 mm), moderate (5 10 mm), or severe (>10 mm), and the location is important to mention.19 mucosal thickening is, however, a non-specific finding. other important ct findings in chronic sinusitis are a small-volume maxillary sinus, sclerosis, and thickening of the bone surrounding the affected sinus.14 allergic sinusitis is a local manifestation of an allergic reaction in the respiratory tract resulting in oedema and increased secretions. infection may co-exist and radiological differentiation is usually impossible. in the majority of patients, the turbinates are thickened and nasal and/or sinus polyps can co-exist.1 fungal sinusitis occurs in a variety of forms depending on the patients’ immune system, and can be divided into non-invasive and invasive subgroups. the non-invasive group can be further divided into allergic fungal sinusitis and fungal balls (mycetomas). the allergic form may mimic sinonasal polyposis radiographically and is more commonly seen in children. the pathogenesis is similar to allergic bronchopulmonary aspergillosis. aspergillus is the most commonly encountered fungal pathogen. there is usually involvement of several sinuses, and the disease tends to be bilateral.20 mycetomas are also usually encountered in immune-competent people. a differentiating radiological feature of fungal sinusitis that is commonly demonstrated is foci of high attenuation in the centre of the affected sinus. punctate calcifications can be seen on ct, particularly within mycetomas (fig. 7a).20 on t2-weighted (t2w) mri, there may be significant signal loss, particularly centrally within the involved sinus. this is thought to be secondary to the high fungal mycelial iron, magnesium and manganese content (fig. 7b). on t1w sequences, the signal is usually elevated in allergic fungal sinusitis.15 , 20 invasive fungal sinusitis can be classified as acute, chronic and chronic granulomatous, and tends to be encountered more in the immune-compromised population, particularly the acute form, which is rapidly progressive and may demonstrate bone erosion, vascular invasion and intracranial extension. whereas ct is better for assessing bony changes, mri is superior in evaluating intraorbital and intracranial extension. in the invasive form of fungal sinusitis, the t1w signal can be decreased, unlike in the allergic form.12 chronic invasive fungal sinusitis usually affects immune-competent individuals, but those with diabetes mellitus or a low level of immune compromise are also susceptible. on uncontrasted ct, mass-like hyperattenuated soft-tissue collections may mimic malignancy. there can also be invasion of adjacent structures. differentiation between the chronic invasive form and malignancy may not be possible on imaging.20 mucormycosis is a rare fungal opportunistic infection that usually affects the sinuses and brain. the infection can be very aggressive, with high mortality rates, and commonly affects individuals with diabetes and those in immune-compromised states. dental-related pathology owing to the close relationship with the dentition, dental disease can extend into the maxillary sinus or cause maxillary infection. cysts of dental origin arising from the maxilla may result in bone remodelling and extension into the maxillary sinus. apical or radicular cysts are by far the most common; they are located at the apex of the root of a carious tooth. the lamina dura in this region is usually absorbed (fig. 8). a dentigerous cyst is related to the crown of an unerupted tooth. this is the most common type of noninflammatory odontogenic cyst and is primarily found in adolescents and young adults.16 it is important to determine if the sinus pathology is odontogenic in origin, as this may influence the surgical management. complications of sinusitis there are local changes that occur secondary to chronic inflammation, and complications that arise from contiguous extension of infection/inflammation. these can affect the orbits and bones, as well as cause potentially life-threatening intracranial complications. these are best assessed with cross-sectional imaging. other complications, including pulmonary abscess and sepsis, may also occur infrequently: 1. mucous retention cysts are asymptomatic and result from obstruction of the seromucinous glands. they can form after a sinus infection and are commonly found at the inferior aspect of the maxillary antrum. radiologically, they are seen as dome-shaped structures, and cannot be differentiated from a solitary polyp on imaging (fig. 9a).14 , 19 2. polyps . polyposis is an inflammatory condition of the mucosa of the nose and paranasal sinuses that assumes a characteristic polypoid appearance. sinonasal polyposis is encountered in all sinuses, but commonly in the maxillary antrum. polyps form secondary to folding and hypertrophy of the mucosa, with accumulation of fluid in the submucosal space. they frequently have an allergic association, but are also seen following inflammation, infection and vasomotor rhinitis. polyposis is more common in adults. in children, predisposing conditions such as cystic fibrosis and kartagener’s syndrome may need to be considered. imaging features include polypoid nasal and sinus masses, and expansion of the nasal fossa, sinus and ostium. partial or complete pansinus opacification can also be seen frequently. occasionally, polyps may cause bone thinning that mimics carcinoma (fig. 5). the polyps may show high density centrally and have a peripheral rim of low attenuation on ct. a ct finding that allows differentiation from tumours is the presence of a thin low-attenuation zone of mucoid material between the polypoid sinus masses.12 mr imaging demonstrates these polyps (polyps can have mixed signal intensities, depending on their composition), mucosal hypertrophy and/or sinonasal secretions.17 , 19 an antrochoanal polyp refers to a solitary lesion that arises in the maxillary antrum of a non-atopic person, increases in size to widen the sinus ostium, and then extends into the nasal cavity. it may eventually extend into the nasopharynx (fig. 9b).1 3. mucoceles are expansile mucosa-lined sinus cysts that form secondary to an obstructed paranasal sinus ostium. they are most commonly post inflammatory, but any other cause of ostial obstruction could result in their formation. the frontal sinuses are most frequently involved (60%). on imaging, an expanded sinus cavity is seen. ct reveals a low attenuation mass. there may be bone thinning and remodelling secondary to pressure, but no destruction (fig. 9c). in severe cases, there may be encroachment on adjacent structures, as seen with expansion into the subarachnoid space, resulting in a csf leak. the signal intensity on mri depends on the state of hydration, protein content and viscosity of the mucoceles. they characteristically demonstrate a regular, peripheral rim of enhancement.15 this feature, together with the lack of bony destruction, is helpful in differentiating mucoceles from neoplasms. if infection is superimposed, a pyocele results. 4. orbital complications. the most common complication of acute sinusitis in young children is extension of the infection into the periorbital region. the majority of cases are unilateral, but bilateral orbital cellulitis may occur. when confined to the eyelids, the condition is termed preseptal cellulitis. imaging features include eyelid swelling, thickening of the preseptal tissues, and posterolateral extension of the inflammation into the temporal fossa.21 the process may extend postseptally, resulting in intra-orbital cellulitis, orbital abscess, subperiosteal abscess and cavernous sinus thrombosis.1 postseptal complications of sinusitis mandate a ct scan to differentiate abscess from orbital cellulitis. postseptal disease is treated with intravenous antibiotics, with surgery necessary in selected cases.22 the ethmoid sinuses are the most frequent source of infection. the infection can spread directly through the thin lamina papyracea into the orbits. infection may also extend through the neurovascular foramina or ethmoidal veins.19 retrobulbar infection is most commonly confined to the extraconal space, with the subperiosteal space on the medial wall the most frequent location. this may progress to a frank subperiosteal abscess with pus that will require surgical drainage. this is the most common intraorbital complication in the paediatric population.23 ct and mri demonstrate this subperiosteal fluid collection that may be rim-enhancing, with displacement of the adjacent fat and extraocular muscles (fig. 10a). orbital cellulitis or abscess may lead to thrombosis of the superior ophthalmic vein, which may lead to cavernous sinus thrombosis. the clinical signs of opthalmoplegia and proptosis may be present in orbital infection without cavernous sinus thrombosis. the presence of cranial nerve palsy in the setting of an orbital or sinus infection should raise the suspicion of cavernous sinus thrombosis.23 contrast-enhanced ct imaging will show a non-enhancing ‘filling’ defect within the thrombosed cavernous sinus. the enhancing cavernous carotid artery will stand out in this enlarged cavernous sinus. mri will show loss of the normal low-signal intensity flow void owing to the thrombosis (fig. 10b). an engorged superior ophthalmic vein is also seen on both ct and mri. 5. intracranial complications of sinusitis are the most feared, and include meningitis, epidural empyema, subdural empyema and cerebral abscess formation. brain infarction and mycotic aneurysm formation are rare complications of sinusitis and can have devastating consequences. these occur most often after frontal sinusitis, with sphenoid sinusitis being next in frequency. sphenoid sinusitis has a relatively high rate of associated neural and ophthalmic complications.22 mri is superior to ct in the detection of intracranial complications of sinusitis.19 , 23 the first site of infection following direct extension is the epidural space. once there is penetration of the dura, a subdural collection can form. on imaging, it may be difficult to differentiate a subdural from an epidural empyema. an epidural empyema should not cross suture lines. multiplanar contrast enhanced imaging is essential in imaging intracranial complications of sinusitis. these infected extra-axial fluid collections usually have enhancing rims and may show mass effect. meningitis is often seen in conjunction with empyema, and is more frequently associated with sphenoid or ethmoid sinusitis. meningeal enhancement is seen with contrast enhanced imaging (fig. 10b). intracerebral abscesses are an uncommon complication of sinusitis. when they do occur, they usually involve the frontal and frontoparietal lobes. ct and mri demonstrate surrounding vasogenic oedema, mass effect and ring enhancement of the abscess. spectroscopy may be helpful in differentiating abscess from cystic tumour. the morbidity and mortality for a brain abscess remain high, despite treatment advances.23 , 24 6. osteomyelitis can affect the bony wall of any sinus, but most often involves the frontal sinus. pott’s puffy tumour is an entity that occurs predominantly in the paediatric and adolescent population. this is a subperiosteal abscess of the frontal bone where the precipitating infection originates in the frontal sinus and causes a progressive osteomyelitis of the bone. in the absence of osteomyelitis, it is thought that the frontal sinus infection spreads by transvenous spread through the frontal bone. if this is suspected, contrast-enhanced ct or mri should be performed to look for frontal sinusitis, signs of osteomyelitis and any intracranial complications (fig. 11).1 , 24 neoplastic lesions paranasal sinus neoplasms are uncommonly encountered in the paediatric patient. a variety of benign and malignant tumours affect the sinuses (table 1). neoplasms may clinically present as chronic or recurrent sinusitis. unilateral involvement of a sinus with extensive opacification or extension into the omc, with or without bony changes, should always raise the question of a tumour. a large number in fact do not arise from the sinuses but from adjacent structures, and secondarily affect the sinuses. the diagnosis of a soft-tissue tumour within the sinus cavities can be challenging on imaging. on ct imaging, bone involvement and changes are important clues. the presence of bone destruction would indicate an aggressive malignancy with rhabdomyosarcoma the most common in the paediatric patient. benign tumours and inflammatory processes tend to remodel bone and cause thinning.12 fungal infections and wegener’s granulomatosis can, however, also present with an aggressive appearance. t2w mr imaging can also occasionally provide a clue. benign tumours as well as inflammatory diseases can have increased t2w signal owing to the high water content. sinonasal tumours are highly cellular and most have an intermediate t2w signal.12 the enhancement characteristics of tumours also help to differentiate tumours from other entities. the enhancement patterns of some tumours are mentioned below. benign tumours 1. osteoma is the most common benign tumour of the paranasal sinuses. it is a well-defined, bone-forming tumour arising from the wall of the sinus that extends into the sinus lumen.25 it may become large, deforming and obstruct the sinus cavity. this tumour is usually an incidental finding and most commonly arises from the frontal sinus.1 multiple osteomas are associated with gardner’s syndrome. ct and plain radiography show these tumours as well delineated sclerotic lesions with smooth borders (fig. 12). 2. juvenile angiofibroma. typically, this benign, vascular, locally invasive neoplasm occurs in pubescent males, presenting with nasal obstruction and epistaxis. juvenile angiofibromae are the most common benign nasopharyngeal tumour, and can grow to enormous size.15 this neoplasm predominantly comprises angiomatous tissue, which accounts for the increased vascularity and intense enhancement seen on contrast enhanced ct and mri. biopsy of these masses is contraindicated. the mass is usually centred in the posterior nasal cavity, originating at the sphenopalatine foramen, extending into the pterygopalatine fossa (in 90% of cases). the mass can extend into the sinuses, orbits and middle cranial fossa.15 , 25 intracranial extension occurs uncommonly in about 5 20% of cases. superior orbital fissure widening is seen as an indication of intracranial extension.21 embolisation of the tumour prior to surgery decreases intraoperative blood loss. 3. haemangioma. these benign lesions uncommonly arise from the sinonasal cavity. they are divided into two types: capillary (seen in infancy) and cavernous (childhood or adolescence). most nasal haemangiomas arise from the nasal septum or vestibule and are of the capillary type.26 these tumours are usually small and non-aggressive. they are best imaged with contrast-enhanced multiplanar imaging and appear as a well-defined, lobular, diffusely enhancing mass. there may be adjacent bone changes in chronic tumours or due to increasing size of the mass.25 , 26 4. ossifying fibroma is an uncommon, benign fibro-osseous tumour that can occasionally arise from a sinus. the mass is well demarcated and expansile, generally asymptomatic, but may be found if there is obstruction to a sinus drainage pathway or owing to facial deformity.25 ct demonstrates a mass of central low attenuation and a peripheral ossified rim. on imaging, it may be impossible to differentiate from fibrous dysplasia. it is usually unilateral and monostotic.15 5. inverted papilloma. this benign nasal tumour is usually seen in older males, but can occur in children and adolescents. this epithelial tumour is almost always unilateral and characteristically arises from the lateral nasal wall. it can extend into the ethmoid and maxillary sinuses.19 the homogenous enhancement seen with ct and mri can help to differentiate it from an antrochoanal polyp, with which it can be confused. although histologically benign, it can be locally aggressive, and a small percentage can either degenerate into, or co-exist with, squamous cell carcinoma.15 , 25 malignant tumours 1. rhabdomyosarcoma (rms). also called parameningeal rms, this is the most common soft tissue tumour in children. up to 40% arise in the head and neck region. sites include the orbit, nasopharynx, paranasal sinuses and the middle ear. rms occurs primarily in patients from age 2 5 years of age. embryonal rms is the most common histological subtype, particularly in the head and neck region, and is considered the most treatable form of the disease.15 , 27 the risk of childhood rms increases with certain inherited diseases, e.g. li-fraumeni syndrome, neurofibromatosis type 1 and beckwith-wiedemann syndrome.4 , 15 rms is an aggressive malignancy, with intracranial extension not uncommon and distant metastases also seen. multiplanar imaging with contrast is essential. mri is the modality of choice, particularly for demonstrating the presence of intracranial and perineural spread. ct displays the extent of bony destruction (fig. 13). cross-sectional imaging and serial scans should be done to objectively monitor tumour regression or residual and recurrent disease. 2. lymphoma is a common neoplasm of childhood, accounting for approximately 50% of all head and neck malignancies.27 lymphomas arising primarily in the nose and paranasal sinuses are of the non-hodgkin’s type, but are uncommon. non-hodgkin’s lymphoma presenting with extranodal disease in the head and neck region most frequently involves waldeyer’s ring. on ct and mri, lymphoma of the sinonasal cavity may mimic the more common entities of chronic sinusitis, polyposis, granulomatous diseases and other neoplasms. mri with contrast is the best imaging tool. the imaging features are non-specific, demonstrating a bulky, locally destructive soft tissue mass. enlarged regional lymph nodes may assist in the diagnosis.19 3. olfactory neuroblastoma. also known as esthesioneuroblastoma, this neuroendocrine malignancy arises from the olfactory epithelium of the superior nasal cavity.16 it may present in the adolescent patient with nasal blockage and mild epistaxis. the tumour demonstrates avid enhancement on both ct and mri.19 occasionally, the classical imaging appearance of a dumb-bell shaped mass with an intracranial portion and a portion within the nasal cavity is seen. long-term follow-up is recommended as they have a tendency to recur late.25 trauma the patterns of facial injury in children differ from adults because of anatomical and physiological differences, as well the extent of pneumatisation of the sinuses. the diagnosis is more difficult in children, and paediatric plain x-ray reporting is more challenging than in adults. ct is necessary to confirm the diagnosis, and for detailed evaluation. the overall frequency of paranasal sinus fractures is much lower than in adults. the radiologist should always bear in mind the possibility of child abuse. nasal fractures are the most common, followed by mandibular fractures.28 the maxillary sinus is the sinus most frequently injured in direct trauma. the ‘blow-out’ fracture of the orbital floor is the most common fracture involving the paranasal sinuses in childhood. the frequency of such fractures increases with increasing pneumatisation of the maxillary sinus. there may be orbital injury, enophthalmos as well as opacification of the maxillary sinus. peri-orbital fat and/or the inferior rectus muscle can become entrapped on the maxillary sinus side of the orbital floor (fig. 14). medial wall fractures also result from direct trauma. fracture of the lamina papyracea is usually best demonstrated on ct. this fracture is usually clinically insignificant and heals spontaneously.1 , 28 complex mid-facial fractures result from severe trauma and are the least common facial fractures in children. the le fort classification is generally used to describe these complex fractures. there are three types, all having certain common features: (i) all bilateral; (ii) in all, some part of the face is mobile; and (iii) all involve the pterygoid processes.1 miscellaneous 1. foreign bodies. a variety of foreign bodies (organic and inorganic) have been reported in the sinus cavities. they are more frequently seen in the paediatric patient, and more commonly within the nasal cavity. if the foreign body is present for a long time, it may act as a nidus for infection and may also calcify.12 complications related to foreign bodies include sinusitis, nasal perforation, cellulitis and meningitis. ct may localise a radio-opaque foreign body and identify related complications. 2. wegener’s granulomatosis is typically a disease of adults but rarely can affect the paediatric population. wegener’s is an aseptic, necrotising vasculitis that usually involves the kidneys and respiratory tracts. within the upper respiratory tract, most start in the nasal cavity as soft tissue masses with, or without, septal and bone destruction. there may be an associated, chronic, non-specific pan-sinusitis.16 , 24 ct is recommended to assess extent of disease and degree of bone destruction. 3. langerhans cell histiocytosis is an idiopathic group of disorders, characterised by abnormal clonal proliferation of the langerhans cell, that can manifest as local or systemic disease.15 the mildest expression of histiocytosis is eosinophillic granuloma with predominantly bony lesions. the skull is involved in a quarter of cases. in approximately two-thirds of patients, the lesions are solitary. the radiographic differential diagnosis in these cases may be extremely difficult, and ranges from osteomyelitis to fibrous dysplasia.25 isolated bony involvement is associated with the best prognosis. rarely, the bones of the sinus cavities are involved and there may be a soft tissue mass overlying the lytic bony lesion (fig. 15). imaging recommendations when considering imaging in a child with sinus disease, important factors that need to be considered are age, radiation exposure and the possibility of an underlying clinical condition. most of the sinuses are rudimentary with very small volumes until age 5 or 6 years. this normal process of pneumatisation has to be considered when planning imaging of the sinuses. in developing countries, availability and cost-effectiveness of imaging protocols are other important factors. in view of this, the aap and american college of radiology recommend that the diagnosis of a sinus infection in a child be made clinically. it would not be necessary to get a sinus x-ray, especially in children <6 years old.29 although controversial, imaging studies may be necessary to confirm a diagnosis of acute bacterial sinusitis in children >6 years old.18 a suggested guide to imaging the sinuses is given in fig. 16. plain x-ray interpretation of the findings in the paranasal sinuses is less accurate in infants and children than in adults. in the former, the cavities are smaller and the margins of normal sinuses are often indistinct. the sinus cavities are commonly cloudy and opaque when the infant is in good health. this physiologic cloudiness is caused by the relatively redundant normal mucous membranes of early infancy.4 they can also become opacified during and after crying. sinus opacification does not equate to sinus disease in young children (fig. 17). the diagnostic algorithm for sinus disease continues to evolve along with advances in imaging modalities. plain radiographs were once the mainstay in the diagnosis of sinus disease; however, ct has become a major diagnostic tool in both children and adults for the adequate evaluation and diagnosis of sinus disease. standard radiography lacks sensitivity and specificity, and radiography-based evaluations alone can either overor underestimate soft tissue changes in the paranasal cavities.30 plain radiographs are not adequate in evaluating the osteomeatal complex or the sphenoid and ethmoid sinuses because of overlapping anatomic structures. thickening of the extra sinus soft tissues superimposed on the paranasal air spaces also causes haziness. an example is facial cellulitis, which may be associated with maxillary and/or ethmoid sinusitis. asymmetric bone wall thickening of one of the paired sinuses may also cause it to appear more opaque.4 lateral sinus radiographs in children <3 years old have been found to be of little value. submentovertex projections also contribute little diagnostic information in patients with sinus disease.31 ct is an important diagnostic tool in children when used in the appropriate clinical setting. the issue of increased radiation dose always needs to be remembered with ct. children are more sensitive to radiation than are adults by a factor of 10, and girls are more sensitive than boys.18 , 30 however, when ct is properly performed for appropriate indications, the benefits far exceed this very small individual risk; this is the basis of the alara (as low as reasonably achievable) principle in paediatric ct. the use of radiography v. ct for imaging of sinusitis in children continues to be controversial, owing to the radiation dose and costs involved. such precautions are needed because there seems to be an increased lifetime cancer mortality risk for children exposed to ct radiation.32 the aap recommends that ct scans of the paranasal sinuses be reserved for patients in whom surgery is being considered as a management strategy. this policy includes children who present with complications of acute bacterial sinus infection or those who have very persistent or recurrent infections that are not responsive to medical management.18 the improved anatomical detail seen with ct is important for assessing the omc in patients with recurrent sinusitis and for assessing complications of sinus inflammatory disease. the goal of ct in chronic sinusitis is to provide objective information to support diagnosis and detailed anatomy for surgery, and to predict which patients will benefit from surgery.33 ct scanning of the sinuses involves imaging of tissues with three markedly different densities: air, bone and soft tissue. this results in an inherent high image contrast and allows the possibility of using low-dose ct of adequate diagnostic quality in children. with the widespread introduction of multidetector ct technology, the use of low-dose ct has become the method of choice, delivering images of good quality.30 improved multiplanar reconstructions are also obtained, affording optimal visualisation and assessment of the complex anatomy and pathological conditions affecting the sinuses. ct is also used in assessing sinonasal tumours; however, in this regard, mri is superior to ct for mapping the extent of the tumour. its advantages include multiplanar capability, superior soft tissue contrast, absence of ionising radiation, and the potential to differentiate neoplasms from adjacent inflammation.1 a more recent development in ct technology is a miniaturised ct scanner called a cone beam ct (cbct), providing sufficient resolution to outline the facial bony architecture. the spectrum of its clinical usage remains to be determined. some advantages include decreased cost and radiation exposure; however, an important disadvantage is the poor soft tissue contrast resolution. there are many other factors that may limit its widespread clinical use.34 there have been studies evaluating the clinical use of ultrasound in the evaluation of maxillary sinusitis. studies of ultrasound in paediatric maxillary sinusitis revealed conflicting results, with wide variations in sensitivity and specificity. ultrasound may come to represent an accessible, non-invasive imaging alternative to assess the presence of fluid in the maxillary sinus in children.35 conclusion the air-filled spaces of the facial and skull bones are dynamic and evolving structures in growing children. normal variations are well demonstrated with imaging. the importance of these normal variants increases with increasing numbers of children undergoing imaging and endoscopic surgery. this review has covered a spectrum of conditions affecting the paranasal sinuses in the paediatric patient. salient features regarding their imaging appearances have been mentioned. cross-sectional imaging has become the mainstay in imaging of the sinuses, and provides exceptional detail of the anatomy and variations seen in the paranasal sinuses. it is also an essential tool for assessing disease extent, and assists in determining diagnosis and planning surgery. the diagnostic algorithm is developing and needs to be continuously and individually adapted in the paediatric population. acknowledgements. i thank professors martin mack and savvas andronikou for their help and advice in preparing this review. 1. towbin r, dunbar js. the paranasal sinuses in childhood. radiographics 1982;2:253-279. 1. towbin r, dunbar js. the paranasal sinuses in childhood. radiographics 1982;2:253-279. 2. scuderi aj, harnsberger hr, boyer rs. pneumatisation of the paranasal sinuses: normal features of importance to the accurate interpretation of ct scans and mr images. am j roentgenol 1993;160:1101-1104. [http://dx.doi.org/10.2214/ajr.160.5.8470585] 2. scuderi aj, harnsberger hr, boyer rs. pneumatisation of the paranasal sinuses: normal features of importance to the accurate interpretation of ct scans and mr images. am j roentgenol 1993;160:1101-1104. 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[http://dx.doi.org/10.1016/s0033-8389(05)70069-5] 20. aribandi m, mccoy va, bazan c. imaging features of invasive and noninvasive fungal sinusitis: a review. radiographics 2007;27:1283-1296. 20. aribandi m, mccoy va, bazan c. imaging features of invasive and noninvasive fungal sinusitis: a review. radiographics 2007;27:1283-1296. 21. reid jr. complications of pediatric paranasal sinusitis. pediatr radiol 2004;34:933-942. [http://dx.doi.org/10.1007/s00247-004-1252-2] 21. reid jr. complications of pediatric paranasal sinusitis. pediatr radiol 2004;34:933-942. [http://dx.doi.org/10.1007/s00247-004-1252-2] 22. sobol se, marchand j, tewfik tl, et al. orbital complications of sinusitis in children. j otolaryngol 2002;31:131-136. [http://dx.doi.org/10.2310/7070.2002.10979] 22. sobol se, marchand j, tewfik tl, et al. orbital complications of sinusitis in children. j otolaryngol 2002;31:131-136. [http://dx.doi.org/10.2310/7070.2002.10979] 23. zeifer b. pediatric sinonasal imaging. neuroimaging clin north am 2000;10:137-159. 23. zeifer b. pediatric sinonasal imaging. neuroimaging clin north am 2000;10:137-159. 24. anand vk. intracranial complications of sinusitis: a 15-year review of 39 cases. ear nose throat j 2002, the free library. http://www.thefreelibrary.com (accessed 12 april 2011). 24. anand vk. intracranial complications of sinusitis: a 15-year review of 39 cases. ear nose throat j 2002, the free library. http://www.thefreelibrary.com (accessed 12 april 2011). 25. harnsberger hr, davidson hc, wiggins, et al. diagnostic imaging: head and neck, 1st ed. salt lake city: amirsys, 2004:2:60-90. 25. harnsberger hr, davidson hc, wiggins, et al. diagnostic imaging: head and neck, 1st ed. salt lake city: amirsys, 2004:2:60-90. 26. hyung-jin kim, jung hee kim, jae hyoung kim, et al. bone erosion caused by sinonasal cavernous hemangioma: ct findings in two patients. ajnr 1995;16:1176-1178. 26. hyung-jin kim, jung hee kim, jae hyoung kim, et al. bone erosion caused by sinonasal cavernous hemangioma: ct findings in two patients. ajnr 1995;16:1176-1178. 27. donnelly lf, kraus sj, jones bv, et al. diagnostic imaging: pediatrics, 1st ed. salt lake city: amirsys, 2005:206-209. 27. donnelly lf, kraus sj, jones bv, et al. diagnostic imaging: pediatrics, 1st ed. salt lake city: amirsys, 2005:206-209. 28. alcala-galiano a, arribas-garcia ij, martin-perez ma, et al. pediatric facial fractures: children are not just small adults. radiographics 2008;28:441-461. [http://dx.doi.org/10.1148/rg.282075060] 28. alcala-galiano a, arribas-garcia ij, martin-perez ma, et al. pediatric facial fractures: children are not just small adults. radiographics 2008;28:441-461. [http://dx.doi.org/10.1148/rg.282075060] 29. karmazyn bk, gunderman r, coley bd, et al. acr appropriateness criteria − sinusitis child. american college of radiology (acr), 2009. http://www.acr.org/ac (accessed 22 march 2011). 29. karmazyn bk, gunderman r, coley bd, et al. acr appropriateness criteria − sinusitis child. american college of radiology (acr), 2009. http://www.acr.org/ac (accessed 22 march 2011). 30. mulkens th, broers c, fieuws s, et al. comparison of effective doses for low-dose mdct and radiographic examination of sinuses in children. am j roentgenol 2005;184:1611-1618. [http://dx.doi.org/10.2214/ajr.184.5.01841611] 30. mulkens th, broers c, fieuws s, et al. comparison of effective doses for low-dose mdct and radiographic examination of sinuses in children. am j roentgenol 2005;184:1611-1618. [http://dx.doi.org/10.2214/ajr.184.5.01841611] 31. mcalister wh, lusk r, muntz hr. comparison of plain radiographs and coronal ct scans in infants and children with recurrent sinusitis. am j roentgenol 1989;153:1259-1264. [http://dx.doi.org/10.2214/ajr.153.6.1259] 31. mcalister wh, lusk r, muntz hr. comparison of plain radiographs and coronal ct scans in infants and children with recurrent sinusitis. am j roentgenol 1989;153:1259-1264. [http://dx.doi.org/10.2214/ajr.153.6.1259] 32. brenner dj, elliston cd, hall ej, et al. estimated risks of radiation induced fatal cancer from pediatric ct. am j roentgenol 2001;176:289-296. [http://dx.doi.org/10.2214/ajr.176.2.1760289] 32. brenner dj, elliston cd, hall ej, et al. estimated risks of radiation induced fatal cancer from pediatric ct. am j roentgenol 2001;176:289-296. [http://dx.doi.org/10.2214/ajr.176.2.1760289] 33. medina ls, blackmore cc, applegate ke. evidence-based imaging: improving the quality of imaging in patient care. revised ed. berlin: springer, 2011:16:277-293. 33. medina ls, blackmore cc, applegate ke. evidence-based imaging: improving the quality of imaging in patient care. revised ed. berlin: springer, 2011:16:277-293. 34. campbell pd, zinreich sj, aygun n. imaging of the paranasal sinuses and in-office ct. otolaryngol clin north am 2009;42:753-764. [http://dx.doi.org/10.1016/j.otc.2009.08.015] 34. campbell pd, zinreich sj, aygun n. imaging of the paranasal sinuses and in-office ct. otolaryngol clin north am 2009;42:753-764. [http://dx.doi.org/10.1016/j.otc.2009.08.015] 35. fufezan o, asavoaie c, panta pc, et al. the role of ultrasonography in the evaluation of maxillary sinusitis in pediatrics. med ultrason 2010;12:4-11. 35. fufezan o, asavoaie c, panta pc, et al. the role of ultrasonography in the evaluation of maxillary sinusitis in pediatrics. med ultrason 2010;12:4-11. 43 sa journal of radiology • june 2010 radiologists and radiographers must remain the custodians of diagnostic radiation to the editor: the editorial in the march 2010 issue of the sajr by professor lotz1 draws attention to ‘a unilateral process instituted by the hpcsa to embark on opening the diagnostic use of ionising radiation to all medical disciplines’. this is a reckless and alarming prospect. as i write, the medical imaging industry throughout the usa, and the world at large, awaits the outcome of 2 days of hearings held on 30 and 31 march by the us food and drug administration (fda) regarding widespread concerns over rising medical radiation dose. these hearings were prompted by a rising tide of articles in the medical literature drawing attention to the danger posed by the increasing use of ionising radiation in medical diagnostic imaging, mainly a result of an explosive increase in the number of ct scans that are performed annually. the editorial quotes that more than 60 million ct scans are estimated to be performed annually in the usa. a further source2 (quoted in an article reviewing the hazards of ionising radiation)3 adds the perspective that in the 24-year period between 1981 and 2005, the number of ct examinations increased more than twentyfold, from 3 million in 1981 to 63 million in 2005. in raising the alarm against what appears to be an unbelievably irresponsible move by the hpcsa (which appears bent on removing all control over diagnostic radiation in south africa) at a time when the rest of the world is tightening control, the editorial surely speaks not only for the radiological society but for the entire radiological fraternity in south africa. we, as the custodians of the appropriate use of ionising radiation for medical imaging, must make ready for battle. d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com 1. lotz j. editorial: radiation free-for-all is imminent. south african journal of radiology 2010; 14(1): 2. 2. the delicate balance between radiation exposure and imaging efficiency. leading article: inpractice; quarterly publication of the american roentgen ray society. summer 2007: 5-7. 3. emby dj. radiation: friend and foe. occ health southern africa 2008; 14(5): 9-13. the hpcsa and radiology to the editor: your editorial1 decrying the role of the hpcsa in allegedly encouraging a ‘radiation free-for-all’ nearly hit the mark (is it better to nearly hit or nearly miss?). allow me as a member of the maligned committee to make a few points. the committee originated from a concern by the radiation control division of the department of health about unregulated radiological practices by practitioners, particularly in rural areas. not only was radiation control often inadequate but the quality of the examinations was also often sub-standard. the issue was how to ensure the safety of the public while not depriving them of a service not otherwise available. from the outset, the radiological society was aware of this initiative and provided helpful documentation. the committee noted that there were practitioners other than general practitioners (such as cardiologists etc.) who also used imaging in their practices. the general principle of the hpcsa in allowing practitioners to apply techniques for which they were adequately trained was considered to be appropriate also in these circumstances i.e. where specialists (such as cardiologists) demonstrably received adequate training, including the use of x-rays, they should be free to use this in subsequent practice. however, general practitioners were not considered to have had sufficient training in radiological services, and the committee resolved that an appropriate training programme should be developed and completed by those who wished to provide a radiological service. the provision of such training for all users of imaging equipment is a well placed function of the rssa. there is general agreement that adequate radiation control is essential. but in my opinion there are more important issues that were not in the remit of the committee, namely the proliferation of many diagnostic and therapeutic interventions that are reliant on expensive equipment. such equipment is often acquired because of its potential revenue generation, and that often results in self-referral – a sure way of driving up medical costs through unnecessary procedures. jp van niekerk health & medical publishing group rondebosch jpvann@hmpg.co.za 1. lotz j. radiation free-for-all is imminent. south african journal of radiology 2010; 14: 2. letters sajr 669 ventricular perforation as a complication of percutaneous valve replacement cornelis de jager, bsc college of medicine, university of saskatchewan, saskatoon, canada   ivan l norval, mb chb jennifer r tynan, md, frcp (c) department of medical imaging, royal university hospital, university of saskatchewan   corresponding author: c de jager (cod204@mail.usask.ca) aortic stenosis (as) is the most commonly encountered valvular disease in developed countries. once symptomatic, this disease carries a dismal prognosis. patients unfit for surgical valve replacement may require transcatheter aortic valve implantations (tavi). we present a complication of this novel approach where a prosthetic valve is delivered through the femoral artery by means of a retroflex delivery system developed by edwards lifesciences. s afr j rad 2012;16(3):102-103. doi:10.7196/sajr.669 an 81-year-old woman was admitted to hospital for symptomatic aortic stenosis (as) in july 2010, with a history of moderate as, mild-moderate aortic regurgitation, moderate mitral regurgitation, paroxysmal atrial fibrillation and pacemaker implantation for a 2:1 atrioventricular heart block. according to the new york heart association (nyha) classification, she had class 4 symptoms despite a preserved ejection fraction of 65 70%. owing to prior bilateral mastectomies, she was considered high risk for conventional surgery, with concern about wound complications of her sternum. it was felt that a transcatheter valve would be a safer option, and she underwent the transcatheter aortic valve implantation (tavi) procedure in april 2011. she received an aortic 23 mm edward sapien xt (9300 tfx) prosthesis in what was described as a successful procedure at the time. three days later, computed tomographic angiography (cta) of the chest revealed a small left pleural effusion and a 5 mm rounded area of contrast in the epicardial space. owing to the stable condition of the patient, the peri-procedural complication was deemed to be of uncertain significance. two days after discharge, she was re-admitted with signs and symptoms of hypovolaemia. echocardiogram and computed tomography (ct) confirmed cardiac tamponade. an associated defect in the left ventricular free wall was visualised on ct, consistent with left ventricular perforation (fig. 1). the patient developed bilateral pleural effusions over the interval, thought to be related to congestive heart failure (fig. 3). after treatment with diuretics and thoracocentesis, the patient was discharged, only to be re-admitted a week later for worsening bilateral pleural effusions. an echocardiogram showed self-sealing of the left ventricular free wall rupture and disappearance of tamponade physiology. at the 2-month follow-up, the patient was still being treated in hospital for pleural effusions by means of diuretics, thoracocentesis and supportive treatment. fig. 1. axial ct showing a thin tract of contrast extending into the myocardium and leading up to a small pseudoaneurysm in the posterolateral aspect of the left ventricular free wall. fig. 2. sagittal ct reconstruction of the thorax showing the implanted aortic valve. the left ventricle free wall defect with small pseudoaneurysm is also again noted. fig. 3. ap radiograph showing valve prosthesis in situ. discussion as most often arises from age-related degenerative calcified changes to the valve, and is defined as the obstruction of blood flow through the aortic valve during left ventricular ejection.3 a transvalvular gradient is established when the valve orifice is reduced by more than 50% of its normal size.3 significant elevation in left ventricular pressure is then needed to drive blood into the aorta.2 at first, the heart can compensate through concentric hypertrophy but, due to disease progression, becomes overwhelmed, causing a drop in the systolic left ventricular ejection fraction.3 severe as is graded as an orifice area <1.0 cm2 (0.6 cm2/m2), mean gradient >40 mmhg or peak jet velocity >4m/s.1 , 3 the current gold standard of treatment is surgical valve replacement. many patients do not meet inclusion criteria or have overwhelming co-morbidities which make them unfit for surgery.5 this is unfortunate as 1-year mortality with medical management for inoperable as exceeds 50%.6 balloon valvulopasty has been used for symptomatic relief in inoperable patients until recently when tavi was introduced as a new treatment option for patients who have inoperable as.6 the first human valve implant was performed in 2002, and techniques and equipment have steadily improved since.4 while there are several new generations of valves in clinical trials, there are only 2 prosthetic valves currently in commercial use, known as the metronic corevalve and edwards sapien xt. according to the recently reported placement of aortic transcatheter valve trial (partner) study, tavi dramatically reduces mortality at 1 year by an absolute 20% and improves quality of life.1 , 6 this means that only 5 patients have to undergo tavi to save one life at 1 year. a multidisciplinary team usually performs the tavi procedure in a cardiac catheter lab or hybrid operating room equipped with high-quality imaging.6 conscious sedation with transthoracic echocardiography is an option although general anaesthesia may facilitate trans-oesophageal echocardiography and increase patient safety and comfort. vascular access most commonly includes femoral and trans-apical (through anterolateral thoracotomy), although utilising subclavian access is becoming increasingly popular, especially with corevalve implantation.6 complications associated with tavi most frequently include vascular events owing to large-calibre catheters, and used to range from 2 18%.5 , 6 this number is falling due to improved techniques, screening, and the development and use of smaller catheters.6 pericardial tamponade has been documented with the corevalve to occur between 0 and 7%, and is usually due to guidewire or manoeuvring thrusts to bring the prosthesis into the left ventricle that can potentially cause peforations.3 clinical stroke reportedly complicates from 0 10% of tavi procedures.5 , 6 other complications include coronary occlusion, atrioventricular block (3 10% of sapien valves) and acute renal injury.5 , 6 trace to mild aortic regurgitation post implantation is reported in up to 70% of cases. moderate regurgitation is less common at 5 15%, and severe regurgitation occurs in approximately 2%.6 conclusion tavi is becoming an increasingly popular treatment for symptomatic aortic stenosis in patients unfit for conventional surgery. although the procedure is less invasive than surgical valve replacement, significant risks are still involved with this form of treatment. it is of the utmost importance that radiologists are aware of possible complications and are able to identify them promptly, as early treatment could have a significant effect on patient outcomes.   1. leon m, smith c, mack m, et al. transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. n engl j med 2010;363:1597-1607. 1. leon m, smith c, mack m, et al. transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. n engl j med 2010;363:1597-1607. 2. lilly l. pathophysiology of heart disease. 5th ed. philadelphia: lippincot williams & wilkins, 2011:202-204. 2. lilly l. pathophysiology of heart disease. 5th ed. philadelphia: lippincot williams & wilkins, 2011:202-204. 3. spaccarotella c, mongiardo a, indolfi c. pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation. circ j 2011;75:11-19. 3. spaccarotella c, mongiardo a, indolfi c. pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation. circ j 2011;75:11-19. 4. thomas, m. the global experience with percutaneous aortic valve replacement. jacc: cardiovascular interventions 2010;3(11):1103-1109. 4. thomas, m. the global experience with percutaneous aortic valve replacement. jacc: cardiovascular interventions 2010;3(11):1103-1109. 5. webb j, cribier a. percutaneous transarterial aortic valve implantation: what do we know? eur heart j 2011;32(2):140-147. 5. webb j, cribier a. percutaneous transarterial aortic valve implantation: what do we know? eur heart j 2011;32(2):140-147. 6. willson a, webb j. transcatheter treatment approaches for aortic valve disease. int j cardiovasc imaging 2011;27(8):1123-1132. 6. willson a, webb j. transcatheter treatment approaches for aortic valve disease. int j cardiovasc imaging 2011;27(8):1123-1132. 21 sa journal of radiology • march 2010 presentation abdominal imaging diagnosis quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban a 53-year-old woman, of otherwise excellent health, presented with acute abdominal pain, severe cramping and vomiting. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@hotmail.com before the end of april. the winner will receive r1 000. a diagnosis will appear in the next issue of the sajr. fig. 1a. erect abdominal x-ray. fig. 1b. pa chest x-ray. fig. 1c. us of right iliac fossa. figs 2a and 2b. axial post-iv contrast ct of abdomen. 2c. coronal ct reformat. 2a 2b quiz case february 2010.indd 21 2/26/10 9:49:47 am original article original article � sa journal of radiology • march 2010 original article abstract aim.the purpose of this study was to examine the outcome of patients with skeletal metastases from well-differentiated thyroid carcinoma and analyse the effect of variables that influence the prognosis of this disease. method. we retrospectively reviewed 352 patients treated and followedup at the charlotte maxeke johannesburg academic hospital’s thyroid cancer clinic from 1982 1999. findings. skeletal metastases were diagnosed in 24 (6.8%), 17 at presentation to the thyroid clinic, and 7 at follow-up. patients’ ages ranged from 30 77 years (mean 53.9 years) and the female:male ratio was 3.8:1. based on the original pathology reports from resected tumours, 9 were papillary and 15 were follicular cancers. twenty-three of the 24 patients underwent thyroid surgery as the initial management – total thyroidectomy in 18, subtotal thyroidectomy in 3, and lobectomy plus neck dissection in one. the diagnosis of thyroid cancer was based on lobectomy in a single subject. radioactive iodine (rai) was used as part of the original treatment; external radiation therapy (xrt) was mainly used to alleviate severe symptoms. twenty-one patients (87.5%) were treated with rai; 11 (45.8%) received radiotherapy. seven patients died – 4 from neurological disease directly associated with bone metastases. of the 17 surviving patients, 2 appeared to be disease-free, 8 were asymptomatic despite overt bony disease, and 7 had persistent symptoms which much improved in 5. bone metastases were uncommon, and follicular cancer predominated in this survey. conclusion. rai therapy improves quality of life in most patients. there is a place for xrt. introduction thyroid cancer is a rare disease, and the controversy surrounding the treatment of well-differentiated types continues.1 one can readily note this position in the optimal extent of primary thyroid resection in most patients with papillary thyroid carcinoma, who are at lower or minimal risk of mortality. it is necessary to follow a large number of patients for a long time to assess the effectiveness of a particular therapeutic modality. the presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival of patients by 50% (from 80 90% down to 40%). the methods used more than 15 years ago for diagnosis and treatment differ from present-day management.2 more recent studies show that survival drops to 13 21% when bone metastases are present.3-5 bone metastases represent a frequent complication, especially of follicular thyroid cancer, and severely reduce quality of life, causing pain, fractures and spinal cord compression. the objective of this study was to look retrospectively at the outcomes of patients with skeletal metastases from well-differentiated thyroid carcinoma and to consider the impact of several variables influencing the prognosis of this illness. materials and methods our study was based on the analysis of treatment of 352 patients treated and followed-up from 1982 1999 at the johannesburg hospital thyroid cancer clinic, university of the witwatersrand. patients’ information was available from records kept by the thyroid cancer clinic, which is part of the division of nuclear medicine. twentyradioiodine therapy in skeletal metastases from well-differentiated thyroid cancer: a johannesburg experience nalini sindy perumal, mb bch, fcnp mboyo-di-tamba heben willy vangu, md, mmed, msc division of nuclear medicine, charlotte maxeke johannesburg academic hospital and university of the witwatersrand, johannesburg table i. clinical characteristics of the 24 patients with skeletal metastases patient no. sex age (years) histology type capsule involvement followup (months) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 f f m f f f f m f f f f f f m f m f f f m f f f 59 30 48 69 65 32 52 66 37 77 51 57 47 58 55 70 54 69 37 65 59 66 31 40 fo pa pa fo fo pa fo fo pa fo fo fo pa pa fo fo fo pa fo fo pa fo pa fo yes no yes yes yes no yes yes no yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 27 132 41 39 84 74 75 66 148 103 2 4 170 51 4 15 18 30 2 46 43 3 25 60 fo = follicular; pa = papillary radioiodine.indd 4 3/1/10 9:27:55 am original articleoriginal article four patients (6.8%) had skeletal metastases that were diagnosed on iodine scans and one or more other modalities. the median follow-up of this group of patients with bony metastases was 39 months (range 2 170 months). the patients’ ages ranged from 30 77 years (mean 53.9). patients were categorised into papillary and follicular types, depending on histological reports. only the original reports of pathology tests at the time of initial referral were used, and the papillary cancer included both purely papillary and mixed papillary-follicular tumours. follicular cancer therefore had no papillary elements. radioiodine was used as part of the original treatment, whereas external radiation therapy was used to control symptoms, principally at presentation. results clinical characteristics of this group of patients are summarised in table i. eighteen of these patients were female. follicular carcinoma was diagnosed in 15 patients, and the balance had papillary carcinoma of the thyroid. all but one patient underwent surgery for the primary disease. eighteen had total thyroidectomy, 2 had sub-total thyroidectomy, 1 had a total lobectomy plus a contralateral sub-total lobectomy, and 1 had a total lobectomy plus neck dissection. therapeutic modalities used in our group of patients are shown in table ii. twenty-one patients were treated with radioactive iodine (rai); of these, 13 were given rai to ablate the residual thyroid gland tissue following surgery, and 8 patients received it for ablation of the residual thyroid gland tissue and treatment of metastatic cancer disease at the same time. in the former group, 9 patients showed abnormal uptake compatible with metastatic disease on the ablative scans. the amount of rai received by these patients ranged from 30 300mci depending on thyroid stimulating hormone (tsh) level and visual appearance of the residual thyroid gland tissue, and/or with the association of metastatic uptake. the median therapeutic dose of rai for all patients was 80mci in the weeks following surgery. in the presence of residual thyroid gland tissue and metastases (clinical and/or indentified with a 10mci diagnostic scan), doses of rai varied from 100 200mci (mean ±sd 167.5±43.5). the treatment doses for persistent metastatic disease ranged from 100 300mci (mean±sd 183.5±44.26) in a total of 41 therapies, with the majority of patients receiving >2 therapeutic doses. of the 13 patients who received rai alone, bone uptake was eliminated with undetectable serum thyroglobulin in 2; 10 had persistent bone uptake but were either asymptomatic or had persistent symptoms; and 1 died 30 months after diagnosis. external beam radiation therapy was used in 11 patients, and in 3 of them as sole treatment. these 3 patients, along with 2 other patients, were treated with external radia� sa journal of radiology • march 2010 table ii. different treatment modalities patient no. type of surgery iodine therapy other treatments 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22* 23 24 tt tt ltl + rst tt tt tt rtl tt tt tt tt tt tt tt tt tt tt tt tt stt tt rtl+dissec. stt + + + + + + + + + + + + + + + + + + + + + xrt, thyroxine thyroxine xrt, thyroxine xrt, thyroxine xrt, thyroxine thyroxine xrt, thyroxine thyroxine thyroxine xrt, thyroxine xrt, thyroxine xrt, thyroxine thyroxine thyroxine thyroxine thyroxine thyroxine thyroxine thyroxine xrt, thyroxine thyroxine xrt, thyroxine thyroxine xrt, thyroxine *did not have surgery. tt = total thyroidectomy; stt = subtotal thyroidectomy; rtl = right total lobectomy; ltl = left total thyroidectomy; rst = right subtotal thyroidectomy; dissec = dissection; xrt = external radiation therapy; + = given; = not given. radioiodine.indd 5 3/1/10 9:27:55 am original article original article � sa journal of radiology • march 2010 original article tion therapy (xrt) at presentation; the remaining 6 patients received xrt later in the course of their disease for symptom control. of these 11, 4 had clinically improved symptoms, 2 had persistent bony pain, and 5 died. two patients treated with both of these therapeutic modalities showed transient bone marrow hypocellularity. in table iii, details of the sites of bone and other metastases, modalities used to demonstrate bony metastases, complications of disease, and patients, progress are shown. bone metastases were present on diagnostic (rai) scans in 17 patients. the other 7 patients developed metastases at a mean of 22 months after diagnosis. the majority of bone metastases were seen in the skull (9 patients), followed by spinal regions (9 patients), and the pelvis (8 patients). three patients with spinal lesions were paraplegic, and the pelvic lesions constituted the most extensive bony disease. ten patients had other metastases in the lungs, and 2 of them also had brain metastases. one patient with skull lesions experienced recurrence with symptoms of increased intracranial pressure, and another one was admitted via the emergency unit with proptosis and unilateral vision loss. seven patients died, 4 from neurological disease directly associated with bone metastases; of the 17 surviving patients, 2 appeared to be disease-free (patients 11 and 12), 8 were asymptomatic despite overt bony diseases for 35 months (range 18 148), and 7 had persistent symptoms that were much improved in 5 after 27 months’ follow up (range 3 60). discussion in our study, bone metastases were uncommon and showed a lower rate of incidence (6.8%) compared with the estimated published incidence (19 50%).1,6 seventeen of 24 patients in our group had skeletal metastases at presentation, but these became evident only when clinically visible or when diagnosed by an imaging modality as a result of symptomatology expressed by the patients. this observation explains the phenomenon related to the significant statistical correlation between bone pain and the presence of metastases in oncology patients.7,8 we found that those who died were elderly female patients with mainly follicular-type carcinoma. however, several studies have found that gender was not indicative of survival.9-12 those patients who died also had extensive metastatic diseases beyond the skeletal lesions, with the lung being the most common site, followed by the brain. these findings are similar to those of dimeen et al.13 the predominance of follicular carcinoma in this study correlates with the work of kalk et al.,14 who analysed the incidences of papillary and follicular cancers of the thyroid as a function of iodine intake in the south african population. the female/male ratio in our group echoes the general perception of the disease: our female/male ratio was 3.8:1, which is close to the findings of others.10,15-18 all but one patient with papillary cancer were still alive at the time of analysis of these data. all but one of the patients who died had follicular cancer. these findings support views that papillary table iii. metastatic sites, diagnostic modalities and course of disease patient no. site of bone metastases diagnostic modalities other metastases/complications progression of disease 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 l&s spine pelvis skull, ribs, pelvis pelvis skull skull skull, pelvis, c spine ribs skull skull, pelvis, sternum l spine l&s spine femur sacrum, hip skull skull, ribs, t&l spine pelvis, femur tspine skull skull, ribs, t&l spine skull pelvis, tspine sternum skull, pelvis x-ray, ct, is bs, is bs, x-ray, is bs, x-ray, is mri, is bs, is bs,ct, is bs, x-ray, is bs, x-ray, is bs, x-ray, is x-ray, ct bs, x-ray, is bs, x-ray, is bs, x-ray, is, ct bs, x-ray, is bs, x-ray, is bs, x-ray, is ct, is bs, x-ray, is bs, x-ray, is, ct bs, x-ray, is bs, x-ray, fna x-ray, is bs, x-ray, ct, is tbmh tbmh lung, brain increased icp lung lung, brain paraplegic paraplegic lung lung lung paraplegic proptosis, vision loss lung unable to walk lung lung s a s s us a us a a us s s ac s us a a us ac us s us a a c, l, t, s spine = cervical, lumbar, thoracic and sacral spine; y = done; n = not done; bs = bone scan; ct = computed tomography; fna = fine needle aspiration; mri = magnetic resonance imaging; tbmh = transient bone marrow hypocellularity; a = asymptomatic; s = symptomatic but stable; us = unstable; icp = intra cranial pressure; ac = appear cured; is = iodine scan. radioiodine.indd 6 3/1/10 9:27:56 am original articleoriginal article � sa journal of radiology • march 2010 carcinoma has the better prognosis.1 except for 2 patients ( patients 11 and 12 ), all the surviving patients still showed iodine uptake within their bony metastases after more than 2 therapeutic doses of rai, regardless of current clinical improvement. this fact has been described by other investigators.19-21 the data from our study also show the role of xrt together with rai or as the sole treatment in improving quality of life in patients with bone lesions, which may suggest the need for iodine therapy for all patients showing thyroid uptake on scans following surgery for the primary disease. for large lesions and in patients debilitated by pain, external radiation therapy should be considered to ease and stabilise symptoms. conclusion bony metastases were uncommon but, when seen, they tended to manifest at presentation. follicular cancer predominated in patients in this survey. in most patients with skeletal metastases, rai improves the quality of life, and treatment with rai should be recommended in patients with a positive scan following surgery. rai alone may occasionally eliminate bone metastases, but longer follow-up is needed to verify this approach. there is a definite role for xrt, especially to control bone pain in patients with large bony masses. 1. samaan na, schultz pn, hickey rc, et al. the results of various modalities of treatment of well differentiated thyroid carcinoma: a retrospective review of 1599 patients. j clin endocrinol metab 1992; 75: 714-720. 2. muresan mm, olivier p, leclre j, et al. bone metastases from differentiated thyroid carcinoma. endocr relat cancer 2008; 15: 37-49. 3. durante c, haddy n, leboulleux s, et al. long term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy. j clin endocrinol metab 2006; 91: 2892-2899. 4. schlumberger m, tubiana m, de vathaire f, et al. long term results of treatment of 283 patients with lung and bone metastases from differentiated thyroid carcinoma. j clin endocrinol metab 1986; 63: 960-967. 5. marcocci c, pacini f, elisei r, et al. clinical and biologic behaviour of bone metastases from differentiated thyroid carcinoma. surgery 1989; 106: 960-966. 6. tenebaum f, schlumberga m, bonnin f, et al: usefulness of technetium-99m hydroxy methylene diphosphonate scans in localizing bone metastases of differentiated thyroid carcinoma. eur j nucl med 1993; 20: 1168-1174. 7. palmer e, henrikson k, mc kusick k, strauss hw, hochberg f. pain as an indicator of metastases. acta radiol 1988; 29: 445-449. 8. schutte he, park wm. the diagnostic value of bone scintigraphy in patients with a low back pain. skeletal radiol 1983; 10: 1-4. 9. wanebo hj, andrew w, kaiser dl. thyroid cancer: some basic considerations. am j surg 1981; 142: 474479. 10. mazzaferri el, young rl. papillary thyroid carcinoma: a 10-year follow-up report of the impact of therapy in 576 patient. am j med 1981; 70: 511-518. 11. franssila ko. is the differentiation between papillary and follicular thyroid carcinoma valid? cancer 1973; 32: 853-864. 12. tscholl-ducommun j, hedinger ce. papillary thyroid carcinomas: morphology and prognosis. virchows arch 1982; 396: 19-39. 13. dimeen sf, valinaki mj, bergstralh ej, goellner jr, gorman ca, hay id. distant metastases in papillary thyroid carcinoma : 100 cases observed at one institution during 5 decades. j clin endocrinol metab 1995; 80: 2041-2045. 14. kalk wj, sitas f, patterson ac. thyroid cancer in south africa – an indicator of regional iodine deficiency. s afr med j 1997; 87: 731-733. 15. mc conahey wm, hay id, woolner lb, van heerden ja, taylor wf. papillary thyroid cancer treated at the mayo clinic, 1946 through 1970: initial manifestations, pathologic findings, therapy, and outcome. mayo clinic proc 1986; 61: 978-996. 16. meissner wa, adler a. papillary carcinoma of the thyroid: a study of the pathology of two hundred and twenty-six cases. arch pathol lab med 1958; 66: 518-525. 17. jensen mh, davis rk, derrick l. thyroid cancer: a computer assisted review of 5287 cases. otolaryngol head neck surg 1990; 102: 51-65. 18. young rl, mazzaferri el, rahe aj, dorfman sg. pure follicular thyroid carcinoma: impact of therapy in 214 patients. j nucl med 1980; 21: 733-737. 19. brown ap, greening wp, mccready vr, shaw hj, harmer cl. radioiodine treatment of metastatic thyroid carcinoma: the royal marsden hospital experience. br j radiol 1984; 57: 323. 20. maheshwari yk, hill cs jr, haynie tp iii, hickey rc, samaan na. 131-i therapy in differentiated thyroid carcinoma: md anderson hospital experience. cancer 1981; 47: 664. 21. beierwaltes wh, nishiyama rh, thompson nw, copp je, kubo a. survival time and “cure” in papillary and follicular thyroid carcinoma with distant metastases: statistics following university of michigan therapy. j nucl med 1982; 23: 561. radioiodine.indd 7 3/1/10 9:27:56 am 64 sa journal of radiology • june 2011 cpd questionnaire 1. regarding the role of ct in the radiation burden of mankind, all the following are true, except: a. presently, over 60 million ct studies are performed annually in the usa. b. spiral or helical technology means greater coverage in less time, and multiple scans related to contrast administration become standard. c. the approximate annual increase of 10% in ct studies in the usa has occurred with only a 1% population increase. d. ct studies alone deliver an annual 0.47 msv per capita to the usa population. 2. which one of the following statements is true? some basic radiation values are: a. frontal cxr 0.11 msv b. abdominal ct 10 msv c. lung ct 1.33 msv d. annual background radiation 0.3 msv 3. which one of the following statements is false? a. the younger the subject, the higher the radiation-induced effects. b. children have a shorter latent period in which a radiation-induced cancer has the opportunity to manifest. c. children are deemed more radiosensitive as they have a larger proportion of actively dividing cells. d. young females are more radiosensitive than males. 4. regarding digital imaging, identify the one false statement. a. pacs relates specifically to the archiving and retrieval of radiological images and reports. b. the system is linked to, and forms the backbone of, both the hospital information system (his) and the radiology information system (ris). c. only 42% of clinicians feel that digital picture archiving makes patient followup more efficient. d. in a survey published in this journal, the majority of respondents felt that there were aspects of a pacs that contribute positively to the level and amount of training opportunities created. 5. which one of the following statements is false? a. vein of galen malformations are rare anomalies of intracranial circulation that constitute 1% of all intracranial vascular malformations. b. vein of galen malformations represent 30% of vascular malformations in the paediatric age group. c. vein of galen malformations form during the late somite stages of the 7th week of embryonic life. d. there is a relationship between the choroidal type of vein of galen malformation and heart failure in neonates. 6. identify the one correct statement among the following. a. diffuse infiltrative lymphocytosis syndrome (dils) is an entity found in patients infected with the human immune deficiency virus (hiv). b. patients present with an intermittent cd8+. c. patients present with lymphocytosis and diffuse lymphocytic infiltration limited to the lung interstitium. d. the aetiology is known, and is due to a ‘hypo-immune’ lung response to hiv or epstein-barr virus that results in infiltration of organs by the cd8+ lymphocyte. 7. regarding the use of fabric for haemostasis, all the following are true except: a. oxidised regenerated cellulose (surgicel) fibrillar is the preferred absorbable material for fast haemostasis. b. the absorbable haemostatic materials and (non-absorbable) teflon felt are macroscopically similar in appearance. teflon is as efficient for haemostasis as the above-mentioned. c. textile implants are not biocompatible. d. textile implants elicit a foreign body response. 8. identify the one false statement among the following: a. in their review of pregnancy-related ruptured arterial aneurysms, barret et al. list in decreasing order of frequency those of intracranial, aortic, splenic, renal and ovarian artery origin. b. of the above, the ovarian artery location is by far the least frequent, with only 11 cases recorded in the english-language literature. c. concerning hormonal factors, barret et al. noted the results of both animal and human studies suggesting that the pregnancy-related alterations in steroid hormones may cause a variety of arterial changes. d. the most common symptom of rupture of ovarian artery aneurysm is sudden haematuria. 9. regarding radiation effects, identify a single false statement. a. radiation effects can be deterministic, requiring a threshold dose to manifest. b. stochastic effects do not have known thresholds, and the beir vii reports indicate a linear related response from very low exposure to radiation. c. ionisation can occur directly with electrons of dna molecules, but more commonly radiation interaction with water molecules creates hydroxyl radicals that then interact with dna. d. single-chain damage is repaired with difficulty, but double-chain damage is easily removed by replication. the consequence may be radiation-induced carcinogenesis in the exposed individual, but also this ‘radiation-induced genomic instability’ can be transmitted to future generations. 10. identify the single false statement. douglas jamieson: a. completed diagnostic radiology training at tygerberg hospital and university of stellenbosch in 1991. b. started his paediatric radiology career under the guidance of professor bryan cremin at red cross war memorial children’s hospital in cape town. c. completed a paediatric fellowship training at the hospital for sick children in toronto, canada. d. is a bafana bafana loose forward. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www. cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/010/01/2011 give one correct answer for each question. 48 sa journal of radiology • june 2011 case report introduction we report on 2 patients with surgical site infections following the inadvertent use of teflon felt for haemostasis in elective and emergency surgery. ct scanning was superior to plain radiography in demonstrating the foreign bodies to enable planning of further surgical treatment. case 1 a 30-year-old woman presented to casualty in februar y 2008 complaining of pain in her left ear and a discharging wound. she had previously had a left tympano-mastoidectomy for chronic suppurative otitis media in december 2007. on clinical examination, marked swelling of the soft tissues of the left temporal region and a chronically discharging sinus over her left mastoid were noted. she was otherwise well. a staphylococcus aureus was cultured from the wound discharge. no abnormality was visible on plain film radiographs of the skull (fig. 1a). a ct scan of the brain, however, demonstrated a large, folded, radio-dense foreign body within the soft tissues of the scalp in the left tempero-parietal region (fig. 1b). at surgical exploration under general anaesthetic, two felt-like foreign bodies were removed with difficulty from ingrowing tissue. these were subsequently identified as teflon felt. the wound was irrigated and closed. the patient received cloxacillin intravenously post-operatively for 2 days, then orally for 5 days. complete healing was subsequently documented. case 2 a 45-year-old man was admitted to casualty in december 2007 with a gunshot injury. on examination, wounds to his right femoral triangle and the right side of his scrotum were noted. he was in type 3 haemorrhagic shock from a haemorrhaging right femoral artery. the patient was urgently transferred to theatre where the right femoral artery was repaired, a right thigh fasciotomy performed, and the right-sided scrotal wound debrided. he required transfusion of 8 units of packed cells. he was discharged approximately 3 weeks later in mid-january 2008. the patient was re-admitted in march 2008 for drainage of a right thigh abscess. he subsequently developed chronic wound sepsis. radiographs of his thigh showed no visible abnormality (fig. 2a). wound swabs grew proteus mirabilis, methicillin-resistant staphylococcus aureus and methicillin-resistant s. epidermedis. the wound sepsis settled with delayed post-surgical sepsis from teflon felt: the diagnostic value of ct scanning, and a reminder for theatre staff donald emby, mb bch, ffrad (d) sa andrew lancaster, mb chb anglogold ashanti health, western deep levels hospital, carletonville corresponding author: d emby (demby@anglogoldashanti.com) fig. 1a. lateral skull radiograph. teflon felt is not visible fig. 1b. ct image showing teflon felt in soft tissues of scalp. sa journal of radiology • june 2011 49 case report dressings. he was re-admitted in january 2010 with recurrence of the wound sepsis, with skin ulceration and a discharging sinus. a radiograph of the pelvis including the upper thighs was obtained. this showed faint linear lucencies within the soft tissues of the medial thigh on the right (fig. 2b). no radio-dense foreign body was visible. a ct scan of the right inguinal region and thigh was then performed and this showed a folded, radio-dense foreign body, extending over a long segment of the upper thigh (fig. 2c). at surgical exploration under general anaesthetic, a 6 x 4 cm piece of teflon felt intimately associated with the old femoral artery repair was removed and the wound closed. the patient subsequently made a full recovery and returned to work. discussion in both patients, non-absorbable ptfe (tef lon) felt had been inadvertently used for haemostasis in place of an absorbable haemostatic material, at the initial operation. oxidised regenerated cellulose (surgicel) fibrillar is the preferred absorbable material that is routinely used at this institution for fast haemostasis of bleeding tissue with irregular surface. absorbable haemostatic gelatine sponge (spongostan) (both from johnson and johnson wound management) is regarded as an acceptable alternative. the absorbable haemostatic materials and (non-absorbable) teflon felt are macroscopically similar in appearance and can be easily confused if theatre staff are inexperienced or are not aware of the important differences in their biological properties. in both cases, the inadvertent use of teflon felt resulted in a foreign body response that became infected. textile implants are not biocompatible. these implants elicit a foreign body response that will either break down a non-stable polymer through enzymatic attack or hydrolysis, or will encapsulate a stable polymer with native tissue to isolate it. the foreign body response is what allows textile implants to become incorporated into tissue.1 incorporation is facilitated if an implant is in the form of a mesh. biocompatibility in terms of such implants really denotes that the implants are non-toxic.1 if the operative field is potentially infected (as in case 1), or potentially contaminated (as in case 2), the implantation of non-absorbable teflon felt into the soft tissues results in a foreign body reaction that is prone to secondary infection. non-absorbable teflon felt is intended for use in cardiac surgery, most commonly as a patch where there is a tissue defect but also as a buttress for sutures, using small pledgets for vessel repair. it can be used as a material for replacement of segments of ventricular myocardium after resection.2 its use in the repair of left ventricular rupture has been well described.3 of particular interest is that the teflon felt was not visible on plainfilm radiographs but was prominently radio-dense on ct scan. this once again highlights the very much greater sensitivity of ct scanning compared with standard radiographs in the detection of low-density objects within tissues. recognised examples of low-density objects that fig. 2a. right thigh with circular metallic skin-marker; teflon felt not visible. fig. 2b. teflon felt not visible in pelvic x-ray; note air lucencies in right medial thigh (arrows). fig. 2c. ct scan image through upper thighs shows teflon felt in base of ulcer. ulcer crater contains air; this accounts for the fine linear lucencies visible within the soft tissues of the right medial thigh on the pelvic radiograph. 50 sa journal of radiology • june 2011 case report are not visible on standard radiographs but are clearly shown on ct scan include faintly calcified ureteric calculi and low-density foreign bodies such as certain types of glass4 and also fish bones.4 the two cases described clearly show that ct scanning is the modality of choice for demonstrating teflon felt when this has been used as an implant. following these incidents, a case can be made to lobby the manufacturers of teflon felt to investigate colouring the felt in such a way that it is readily macroscopically distinguishable from other implantable materials. 1. textiles in medicine. http://surgicalmesh.com/sldindex_files/slide0001.htm (accessed 18 march 2010). 2. bard ptfe felt. http://www.bardpv.com/_vascular/product.php?p=30 (accessed 17 march 2010. 3. de la fuente a, augudo o, sanchez r, fernandez jl, moriones i. repair of left ventricular rupture after mitral valve replacement: use of teflon patch and glue. ann thoral surg 1999;67:1082-1083. 4. emby dj. retained glass fragments in body tissues. s afr med j 2009;99(12):858-859. introduction ruptured ovarian artery aneurysms are extremely rare, occurring during the peripartum or early postpartum periods. only 11 cases have been reported in the english literature; the following represents the 12th. case report a 30-year-old woman presented at the casualty department 12 days after having given birth to a healthy baby via normal vaginal delivery. she complained of increasing pain and a mass in her right flank. there were no complaints of nausea, vomiting, dysuria or abnormal bowel habits. on examination, the patient was acutely distressed, in severe pain and anaemic with an hb of 5 g/dl. her blood pressure was 151/71 mmhg and her pulse 125/minute. physical examination revealed a severely distended abdomen with features of peritonitis. abdominal ultrasound revealed a large abdominal fluid collection; a ct scan was therefore requested. a contrast-enhanced ct scan demonstrated a large homogenous retroperitoneal fluid collection in the right flank, with a 25mm rounded, intensely enhancing focus located close to the inferior border of the collection (fig. 1). the collection displaced the bowel to the left and inferiorly, and the liver superiorly. the differential diagnosis included a ruptured ovarian artery aneurysm. as soon as the patient was stable, she was taken for ovarian rupture of an ovarian artery aneurysm following normal vaginal delivery francois van schouwenburg, mb chb hassan lameen, mb chb, md, fcrad (diag) sa department of radiology, grey’s hospital, pietermaritzburg corresponding author: h lameen (h.alameen1@yahoo.com) figs 1a and b. axial and coronal contrast-enhanced ct image of the abdomen demonstrating large right retroperitoneal abdominal and pelvic haematoma (stars) with right-sided focal area of contrast extravasation at the expected location of the right ovarian artery (arrow). ascites also present. a b * → * sajr 751 congenital sialoblastoma of the accessory parotid gland p parag   department of radiology, inkosi albert luthuli central hospital, durban p parag, mb chb, fcrad (d) sa corresponding author: p parag (priyashinipar@ialch.co.za) sialoblastomas are rare, locally aggressive, perinatal or congenital salivary gland tumours that mostly originate in the parotid gland. significant variability in histological range and clinical course exists. this report is of a case of congenital sialoblastoma of the accessory parotid gland. s afr j rad 2012;16(4):134-135. doi:10.7196/sajr.751 sialoblastomas are rare salivary gland neoplasms that present congenitally or during early infancy, with significant variability in histological range and clinical course.1 in 1966, 2 cases were reported and referred to as embryomas.2 in 1988, the term sialoblastoma was coined by taylor to describe these lesions because it conveyed the dysontogenetic character and the site of the tumour.3 these tumours generally originate in the parotid gland but may arise in the submandibular or minor salivary gland. this report presents a case of congenital sialoblastoma of the accessory parotid gland. case report a 3-day-old male neonate was referred with a large left facial mass with a provisional diagnosis of a teratoma. the baby was born at 35 weeks per normal vaginal delivery. clinical examination revealed a 7 x 8 cm solid mass over the left cheek with central ulceration. dilated superficial blood vessels and facial distortion were noted. the mass was non-pulsatile. the rest of the physical examination was unremarkable. mri of the face with contrast was performed. a lobulated soft-tissue mass of the face was noted on the left with internal septations and foci of t1 hyperintensity. the mass extended to the inferior margin of the left orbit and laterally to the infratemporal fossa. deviation of the nose to the left, absence of serpiginous flow voids and intense enhancement were noted. the parotid glands were normal. a diagnosis of haemangioma or sarcoma was considered. subsequently, a biopsy was undertaken. the histological diagnosis was that of a sialoblastoma, placed in the who malignant category.pre-operative chemotherapy was commenced and tumour shrinkage was observed over a 3-month period. a follow-up mri was performed to aid surgical planning. the mass was significantly smaller and noted in close proximity to the superficial lobe of the left parotid gland. a diagnosis of congenital sialoblastoma of the accessory parotid gland was then made (figs 1 3). fig. 1. t1w sagittal mri image depicting the lobulated facial mass. fig. 2. t2w coronal fat-saturated mri image showing the left facial mass with internal septations. fig. 3. t1w fat-saturated post-contrast axial image depicting intense enhancement of the mass. complete excision of the tumour was performed and clear margins were confirmed on histology. the postoperative course was unremarkable and the baby was discharged after a week and closely followed up with no evidence of tumour recurrence. a 1-year surveillance mri is being considered. discussion less than 3% of salivary gland tumours occur in children.4 the most common salivary gland lesion in childhood is a haemangioma.3 sialoblastomas are rare, locally aggressive perinatal or congenital salivary gland tumours that occur predominantly in the parotid gland3 and were initially classified as benign.1 , 3 the biological behaviour of this lesion is incompletely defined because of its rarity, and early surgery is recommended.3 in the literature, only 4 cases with lung metastases and 1 case with nodal neck metastases have been reported.5 surgical resection with negative margins is the mainstay of treatment, with some centres using neoadjuvant chemotherapy.5 histologically, sialoblastomas appear as organoblasts in the primitive stage of salivary gland development.6 typically, the tumours are iso-intense to muscle on t1, iso-intense to fat on t2, and enhance sparsely.3 , 4 , 6 in this case, the imaging characteristics and intense enhancement is atypical. congenital haemangioma or fibrosarcoma are reasonable differential diagnoses in this case.4   1. brandwein m, al-naeif ns, manwani d, et al. sialoblastoma: clinicopathological/immunohistochemical study. am j surg pathol 1999;23:342-348. 1. brandwein m, al-naeif ns, manwani d, et al. sialoblastoma: clinicopathological/immunohistochemical study. am j surg pathol 1999;23:342-348. 2. farooqi km, kessel r, brandwein-gensler m, granowetter l, manwani d. sialoblastoma — long-term follow-up and remission for a rare salivary malignancy. rare tumors 2011;3(2):39-40. 2. farooqi km, kessel r, brandwein-gensler m, granowetter l, manwani d. sialoblastoma — long-term follow-up and remission for a rare salivary malignancy. rare tumors 2011;3(2):39-40. 3. cristofaro m, giudice a, amentea m, giudice m. diagnostic and therapeutic approach to sialoblastoma of submandibular gland: a case report. j oral maxillofac surg 2008;66(1):123-126. 3. cristofaro m, giudice a, amentea m, giudice m. diagnostic and therapeutic approach to sialoblastoma of submandibular gland: a case report. j oral maxillofac surg 2008;66(1):123-126. 4. fuchsmann c, viremouneix l, collardeau-frachon s, bouvier r, guibaud l, froehlich p. management and treatment of a sialoblastoma of the submandibular gland in a neonate: report of one case. int j pediatr otorhinolaryngol 2011;6(4):168-171. [http://dx.doi.org/10.1016/j.pedex.2010.07.001] 4. fuchsmann c, viremouneix l, collardeau-frachon s, bouvier r, guibaud l, froehlich p. management and treatment of a sialoblastoma of the submandibular gland in a neonate: report of one case. int j pediatr otorhinolaryngol 2011;6(4):168-171. [http://dx.doi.org/10.1016/j.pedex.2010.07.001] 5. xiao-feng s, zhi-gang c, jian-guo z, jie z, yan g, guang-yan y. management of sialoblastoma with surgery and brachytherapy. pediatr blood cancer 2010;55:1427-1430. 5. xiao-feng s, zhi-gang c, jian-guo z, jie z, yan g, guang-yan y. management of sialoblastoma with surgery and brachytherapy. pediatr blood cancer 2010;55:1427-1430. 6. som pm, brandwein m, silvers ar, rothschild ma. sialoblastoma (embryoma): mr findings of a rare pediatric salivary gland tumor. ajnr 1997;18(may):847-850. 6. som pm, brandwein m, silvers ar, rothschild ma. sialoblastoma (embryoma): mr findings of a rare pediatric salivary gland tumor. ajnr 1997;18(may):847-850. 75 sa journal of radiology • august 2009 spinal segmental dysgenesis to the editor: i read with interest the article by mahomed and naidoo in the august 2009 issue of sajr1 of two exceptional cases of spinal segmental dysgenesis. however, i believe that a normal corpus callosum has been misinterpreted as a developmental abnormality. fig. 2(c) is furnished as proof of ‘partial agenesis of the corpus callosum’ in the first patient and that there is absence of the rostrum, genu and body whereas this image demonstrates a normal corpus callosum for a 2-week-old child. the terminology of the suggested condition is better termed ‘hypogenesis of the corpus callosum’.2 in hypogenesis the anterior portion (posterior genu and body) should be present (fig. 1). in addition, whenever there is hypogenesis or agenesis, there is failure of inversion of the cingulate gyrus. the normal cingulate gyrus follows a curved horizontal course similar to that of the corpus callosum. in absence of the corpus callosum the cingulate is not visualised on the sagittal image and gyri and sulci radiate at right angles to the csf space (‘sunburst appearance’) (fig. 1).3 this feature is used in neonates and in preterm children as an indication of the presence of the corpus callosum, because in early life the corpus callosum is very thin, isointense to cortex and therefore difficult to visualise. as children develop, more myelin is laid down, increasing the thickness of the corpus callosum and its signal on t1 (fig. 2 a-c). absence of the anterior portion of the corpus callosum with presence of the posterior portion only result from dysgenesis associated with holoprosencephaly and when there is a focal cortical infarct with fibres that cross through the anterior corpus callosum (local atrophy). other unanswered questions from the article are: • peripheral nerves exit the neural foramina below the reported termination of the cord on the sagital image in case 1. is this expected considering a criterion for diagnosis should be ‘absent exiting nerve roots’? • what are the unusual structures demonstrated on the axial t2 surrounded by fat? is one of the structures a visible spinal cord? the cord is reported to terminate at t6 but the image is at the level of the isthmus of the horseshoe kidney which appears to be lower than t10 on the sagittal views. reports of rare abnormalities are necessary and the authors are commended for publishing these. however, expert opinion should be obtained prior to publication of complex abnormalities to avoid misdiagnosing normal anatomy as pathology. normal paediatric brain developmental anatomy knowledge is critical before attempting to interpret complex abnormalities such a segmental spinal dysgenesis. the legends should read: • fig. 1. there is hypogenesis of the corpus callosum. the components that are present are part of the genu and body. note the partially inverterted cingulate gyrus anteriorly while posteriorly the vertically oriented gyri and sulci radiate from the csf space. • fig. 2 (a c). normal development of the corpus callosum in infancy. (a) a 2-day-old neonate demonstrates a very thin but present corpus callosum. this is confirmed by the everted cingulated gyrus lying horizontally separating the vertically oriented gyri from the csf space. (b) at 2 months of age the corpus callosum itself becomes more distinct. (c) at 4 months of age the corpus callosum develops a thickness and high signal due to laying down of myelin. dr s andronikou docsav@mweb.co.za 1. mahomed n, naidoo j. spinal segmental dysgenesis. south african journal of radiology 2009; 6: 29-32. 2. przybojewski s, andronikou s. corpus callosum hypogenesis vs. dysgenesis. south african journal of radiology 2006; 6: 24. 3. barkovich aj. pediatric neuroimaging. 3rd ed. philadelphia: lipincott williams &wilkins, 2000: 254-255, 323-327. the authors of the ssd case report reply: we apologise for the incorrect terminology used, as the corpus callosum is in fact an immature corpus callosum. this observation was incidental and the article did not suggest that it was a feature of ssd. in response to dr andronikou’s second question, the dysgenetic segment in fig 2a is between t12 to l5, but we acknowledge that the words ‘terminating at thoracic level 6’, as in the article, might have caused this confusion. it seems that our article has created much interest, and we would like to take this opportunity to elaborate further on this rare malformation, particularly to clarify its relationship with caudal regression syndrome (crs). ssd and crs probably represent two faces of a single spectrum of segmental malformations of the spine and spinal cord. they differ from an embryological point of view, in the segmental location of the derangement along the longitudinal axis of the embryo. in ssd, the intermediate segment is involved as opposed to the caudal segment in crs. it is important to distinguish ssd from crs and other spinal malformations as ssd is unlikely to benefit from untethering procedure, since the neurological disturbance is related to the congenital hypoplasia or absence of roots or segment of the spinal cord, rather than from cord tethering.1 1. tortori-donati p, fondelli mp, rossi a, raybaud ca, cama a, capra v. segmental spinal dysgenesis: neuroradiologic findings with clinical and embryologic correlation. am j neuroradiol 1999; 20: 445456. letter to the editor letter 75 sa journal of radiology • august 2009 mystery.html mystery of bilateral breast masses nausheen khan, fc rad zaeem i ebrahim, fc rad irma van de werke, frcr department of radiology, kalafong hospital and university of pretoria corresponding author: z ebrahim (zaeem@iafrica.com) introduction leiomyosarcoma (lms) is an uncommon malignant tumour of smooth muscle origin. it arises in the gastro-intestinal tract, retroperitoneum, urinary bladder, uterus and soft tissue. peritoneal leiomyosarcomatosis (pl) is defined as a peritoneal dissemination of a primary sarcoma. we present a case of leiomyosarcomatosis with widespread dissemination including involvement of both breasts. case report a 38-year-old woman, retrovirus negative, presented at the outpatient department of kalafong hospital, with a 3-month history of weight loss and enlarging bilateral breast masses. on examination there were numerous large, hard, nodular fixed masses in both breasts and axillae. the preliminary diagnosis at this stage was lymphoma, bilateral breast carcinoma, or unknown primary malignancy with metastasis to the axillae and breasts. on further examination, masses were felt in the anterior abdominal wall and in the back and thigh. several soft tissue core biopsies were done of the axillary masses. a cervical smear showed no malignant cells. computed tomography (ct) of the chest and abdomen demonstrated a large complex mass arising from the uterus with both cystic and solid components (fig. 1). another mass lesion was noted in the right kidney with extension into the inferior vena cava with complete occlusion (fig. 2). there were several soft-tissue enhancing masses in both breasts and axillae (fig. 3); a mass in the anterior abdominal wall (fig. 4); and a mass in the pericardium (fig. 5) and the posterior compartment of the left thigh (fig. 6). all the masses had similar soft-tissue features. the diagnosis on ct was disseminated leiomyosarcomatosis. histological examination of the tissue submitted showed several cores of tumour comprising pleomorphic spindle-shaped cells. tumour giant cells were also noted and several mitoses were present including atypical mitosis. there were areas of myxoid degeneration. immunohistochemical staining of the tissue was diffusely and strongly positive for actin, negative for desmin, and negative for cluster of differentiation (cd) of 117. the histological and immunohistochemical features were most in keeping with the diagnosis of a leiomyosarcoma. further evaluation of the uterine mass was recommended and discussed with the patient and her prognosis explained. she refused further intervention. she was sent home with the clinical diagnosis of disseminated leiomyosarcomatosis. discussion leiomyosarcoma is a relatively uncommon malignant mesenchymal tumour that exhibits smooth muscle differentiation.1 , 2 it is a tumour of adult life seen more commonly in women than men, and generally has a poor prognosis with a high percentage of recurrence. leiomyosarcomatosis is defined as dissemination of leimyosarcoma from a primary in the gastro-intestinal tract to the peritoneum or omentum; or haematogenous spread to distant sites including the head and neck, skin and soft tissue.2 diffuse peritoneal and omental seeding are well-known forms of dissemination of metastatic carcinoma either via direct invasion through the serosa, or haematogenous or embolic spread.2 , 3 breast metastasis from extramammary malignancy is rare, constituting 2% of breast tumours.4 conforming to virchow’s concept, the breast has resistance to metastasis from extra-mammary malignancy because the breast has large areas of fibrous tissue, with a relatively poor blood supply.4 , 5 breast metastasis with multiple lesions from uterine leiomyosarcoma and especially with bilateral involvement as seen in our case, is less common, however. primary leiomyosarcoma of the breast is rarer;4 , 6 it is usually low-grade and should be distinguished from leiomyoma.6 the average interval for occurrence of non-breast tumour metastasis to the breast is approximately 2 years.5 , 6 our patient presented primarily with metastatic breast masses rather than with a primary tumour in the uterus. in 85% of patients, metastatic leiomyosarcoma presents as a solitary breast lump and only 15% as bilateral or multiple lumps as in our case. leiomyomas and leiomyosarcomas arise from the spindle cells of the muscular coat of the gastro-intestinal tract and less commonly from the muscularis mucosa.7 ct examination in leiomyosarcomatosis usually demonstrates multiple dumbbell or oval tumours of soft-tissue density that enhance homogenously on intravenous contrast administration. tumours more than 5 cm may show central hypodensity owing to necrosis. calcifications are uncommon.7 conclusion metastases to the breasts from primary sites are unusual and bilateral involvement even rarer. so far there have only been a few cases reported of leiomyosarcoma to the breast. these metastases to the breast are seen on an average interval of approximately 2 years after the detection of the primary site. in our case, the patient presented primarily with metastasis. the diagnosis becomes a formidable issue when the breast metastasis represents the first event in the patient’s work-up. the presence of metastatic tumour in the breast carries a poor prognosis, and radical procedures are unnecessary and can be avoided. 1. akata d, aralasmak a, ozmen mn, et al. us and ct findings of multicentric leiomyosarcomatosis. eur radiol1999;9:711-714. 1. akata d, aralasmak a, ozmen mn, et al. us and ct findings of multicentric leiomyosarcomatosis. eur radiol1999;9:711-714. 2. choi bni, lee wj, chi jg, han jk. ct manifestations of peritoneal leiomyosarcomatosis. ajr 1990;10(155): 799-801. 2. choi bni, lee wj, chi jg, han jk. ct manifestations of peritoneal leiomyosarcomatosis. ajr 1990;10(155): 799-801. 3. rha su, ha hk, kim ay, et al. peritoneal leiomyosarcomatosis originating from gastrointestinal leiomyosarcomas: ct features. radiology 2003;227:385-390. 3. rha su, ha hk, kim ay, et al. peritoneal leiomyosarcomatosis originating from gastrointestinal leiomyosarcomas: ct features. radiology 2003;227:385-390. 4. tulasi nr, kurian s, mathew g, viswanathan fr, roul rk. breast metastases from primary leiomyosarcoma. aust nz j surg 1997;67:71-72. 4. tulasi nr, kurian s, mathew g, viswanathan fr, roul rk. breast metastases from primary leiomyosarcoma. aust nz j surg 1997;67:71-72. 5. lin ch, yeh cn, chen mf. breast metastasis from uterine leiomyosarcoma: a case report. arch gynecol obstet 2003;267:233-235. 5. lin ch, yeh cn, chen mf. breast metastasis from uterine leiomyosarcoma: a case report. arch gynecol obstet 2003;267:233-235. 6. omeroglu g, erssahin c, potkul rk, booth cn. fna diagnosis of retroperitoneal leiomyosarcoma metastasizing to the breast. diagn cytopathol 2007;35(8):508-511. 6. omeroglu g, erssahin c, potkul rk, booth cn. fna diagnosis of retroperitoneal leiomyosarcoma metastasizing to the breast. diagn cytopathol 2007;35(8):508-511. 7. korman u, ersavasti g, kurugoglu s,uygun nt, akman c. radiologic evaluation of gastrointestinal leiomyosarcomatosis. eur radiol 1997;7:1332-1334. 7. korman u, ersavasti g, kurugoglu s,uygun nt, akman c. radiologic evaluation of gastrointestinal leiomyosarcomatosis. eur radiol 1997;7:1332-1334. fig. 1. sagittal post-contrast ct through the pelvis demonstrates a large hetrogenous mass with areas of low densities representing necrosis (asterisks) arising from the anterior superior aspect of the uterus. arrow points to the uterus. fig. 2. axial ct post-contrast through the upper abdomen. there is a large mass in the right kidney (open arrow) with complete occlusion of the ivc (black arrow). there is also a soft-tissue mass in the right paraspinal mass (asterisk). fig. 3. axial ct post-contrast through the chest at the level of the breasts. there are bilateral breast masses and a mass in the right axilla. fig. 4. solitary mass in the anterior abdominal wall. note a markedly dilated ivc (asterisk). fig. 5. mass in the pericardium (arrow) and left axilla. fig. 6. similar soft tissue mass in the posterior compartment of the left thigh. 71 sa journal of radiology • september 2010 the fallacy of comparing diagnostic radiation with background radiation; and the need to learn from past mistakes to the editor: the subject of radiation exposure for diagnostic purposes is currently a ‘hot’ topic, and it is appropriate that the debate around this issue is given exposure in the pages of the sajr. i would like to comment on a few of the points raised by dr tipler in his article that appeared in the june 2010 sajr.¹ the advent of ct scanning has revolutionised the practice of medicine. no one in their right mind would argue that, when a ct scan is performed correctly and for an established indication, the benefit of the examination outweighs the risk (in terms of radiation exposure) many times over. dr tipler, however, states: ‘we all know ct is being overused.’ this goes to the heart of the matter and in particular to the danger posed by self-referral by specialists outside of radiology, should such specialists obtain a licence to operate a ct scanner. dr tipler mentions the issue of background radiation. he also makes the statement that background radiation on the coast of brazil exceeds 150 msv a year. these issues require some clarification. with regard to the comments about brazil, it is true that some, but by no means all, beaches contain radioactive monazite deposits. these deposits give the sand a characteristic black colour – unlike the golden sand of the beaches of rio de janeiro. if one camped out specifically on one of the monazite-containing beaches for a prolonged period, it would be possible to receive external radiation exceeding 150 msv a year. besides brazil, monazite deposits are also found in india and china. the dose of radiation to people living in these areas is on average 5 6 msv per year. individual doses up to 32 msv per year have, however, been reported. of note is that in areas of high background radiation, an increased frequency of chromosome aberrations has been noted repeatedly.² more research is needed to quantify the effects of the high background radiation levels in these areas. regarding the red herring of background radiation as argued by the radiation dissidents, i would quote the following: ‘a criticism of a conservative approach in the use of ionising radiation is that we are all daily exposed to background radiation and have evolved cellular mechanisms capable of repairing damage caused by ionising radiation. the counter-argument is: “sola dosis facit venenum.” (it is only the dose which makes the poison.) ‘the average individual dose received from background radiation is approximately 3.6 msv, delivered over the period of a year. a ct scan of the abdomen and pelvis delivers 10 msv, approximately 3 times this dose, in a few minutes. this is not what our repair mechanisms have evolved to cope with. an analogy might be the cellular mechanisms evolved to metabolise alcohol. a 750 ml bottle of brandy drunk over a period of a few minutes is likely to have a fatal outcome. the same volume of brandy, if taken over a year, equates to marginally more than 2 ml per day; an amount unlikely to pose a challenge to the cellular metabolic systems.’³ in conclusion, dr tipler alludes to the linear no-threshold theory and the information gleaned from the japanese atomic bomb survivors, on which much of the beir 7 report is based. although easy to criticise, these are not the only sources of information with regard to the risks of radiation. i quote again: ‘many of the early pioneers of the science of radiation and radiology were exposed to high doses of radiation and succumbed to its carcinogenic effects. in addition, from the 1930s to the early 1960s, ionising radiation was used to treat many benign conditions. these included sacro-ileitis, and postpartum mastitis. numerous children received x-ray screening and radiation treatment for “enlargement” of the thymus gland and many have subsequently died from radiation-induced malignancy. these treatments were terminated when the association with the subsequent development of cancer became clear.’ further evidence for harm from injudicious medical use of ionising radiation has come from the large radiation doses given by bi-weekly fluoroscopic (non-image intensified) screenings to determine whether an iatrogenic pneumothorax, performed for the treatment of tuberculosis, was still present. fifteen and more years later, the incidence of breast cancer on the side subjected to fluoroscopy was doubled. unfortunately, we have short memories. to paraphrase george santayana: ‘those who do not learn from the mistakes of history are destined to repeat them.’ samuel taylor coleridge put this more philosophically: ‘if men could learn from history, what lessons it might teach us! but passion and party blind our eyes and the light which experience gives is a lantern at the stern, which shines only on the waves behind us!’³ d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com 1. tipler m. letter: straight talking on ct scanning. south african journal of radiology 2010;14(2):42. 2. idaho state university, radiation information network's. radioactivity in nature. www.physics.isu.edu/ radinf/natural.htm (accessed 9 september 2008). 3. emby d j. radiation: friend and foe. occ health southern africa 2008;14(5):9-13. the hpcsa and radiology to the editor: i find the letter by professor van niekerk1 which was published in the june 2010 edition of the south african journal of radiology most interesting. he stated that it was acceptable for specialists such as cardiologists to use ionising radiation for imaging in their practices, but went on to mention ‘the proliferation of many diagnostic and therapeutic interventions that are reliant on expensive equipment’. have you looked up the price of a cardiac angiogram lately? or the placing of a drug-eluting stent in a carotid artery? the decision to perform these procedures on patients is taken by the cardiologist alone, who, as things have it, performs the procedures too. i know the training a cardiologist receives in radiation, and it is minuscule compared to that which a radiologist receives (a full first year – as a registrar – of instruction in radiation physics, with an entire part of a two-part examination devoted to the subject). what about the cardiologists in the western cape who bought their own multislice ct scanner (talk about expensive equipment), enabling them to do non-catheter angiograms as well? they received no training in ct physics at all (and employ a radiographer to operate the machine and make impressive images). letters 72 sa journal of radiology • september 2010 letters radiologists never have the opportunity to self-refer. we are sent patients by our medical colleagues, requesting a specific examination or procedure. the request form has to be forwarded to the medical aids as proof that no additional examinations were performed other than directly requested, in writing. i know of gps in my part of the world who routinely perform their own x-rays and ultrasound examinations. you are correct; besides all the safety issues, such as lead shielding, the quality is nondiagnostic in most cases; patients are told they have gallstones, when they clearly don't, and so the abuse goes on. i know this, because eventually the unwell patients find their way to our practice, and i get to see the x-ray films and listen to the misdiagnosis. so, let's see if this committee actually has any teeth, or is it all just another useless talk-shop, a typical case of the dogs bark, but the caravan moves on. this letter will be forwarded, possibly in altered form, to the hpcsa and rssa. mark richardson drs nisbet, govender and associates the bay hospital richards bay markrich@netactive.co.za 1. van niekerk jp. the hpcsa and radiology. south african journal of radiology 2010;14(2):43. professor van niekerk replies: thank you for your response. the hpcsa policy is that doctors may practise in fields in which they have had adequate training. if training is perceived to be inadequate, it is up to the person(s)/group believing it to be so to persuade those who are responsible for regulation and for education to address this. it was in response to the inadequacy of the training of general practitioners who owned x-ray equipment that the committee was established. i share your concern that self-referral is open to considerable abuse. apart from the dangers of ionising radiation, we should also be concerned about the financial implications of the proliferation of 'safe' imaging modalities, especially ultrasound. fee-for-service and third-party payment have been shown to be the key drivers of escalating health care costs, and this debate is virtually nonexistent in the public sector. public rural facilities that have poor radiological facilities and services at least have the possibility of an arm,s-length supervision and for ensuring their correction. jp van niekerk health & medical publishing group rondebosch jpvann@hmpg.co.za cpd notice in the june 2010 edition of the sajr, the questionnaire unfortunately contained errors relating to two questions. the question in both cases should have read which of the following statements is incorrect? (and not ‘correct’, as stated). i use a template in compiling the quiz and, of all potential mishaps, the ‘in’ was omitted. all readers (with the exception of two) recognised the mistake and answered accordingly. nevertheless, it was decided to credit all participants with their points irrespective of how they read the questions. the questionnaire will be triple-checked, and i do not foresee a repeat occurrence. recent audits of some colleagues by the health professionals council of south africa have indicated a chronic shortage of cpd ethics points, and we considered posting one ethics question per edition. after discussion with professor jp van niekerk, we decided to follow an alternative route: please note that members of the south african medical association (sama) and/or the radiological society of south africa (rssa) may acquire cpd ethics points by completing the cpd questionnaire in the south african journal of bioethics and law (sajbl) which is available in online format only at www.sajbl.org.za. the journal is published biannually, in june and december. jan lotz paediatric neuropatho.html paediatric neuropathology: diagnosis s k misser, mb chb, fcrad (d) lake smit and partners, durban j f roos, mb chb, mmed (paed) parklands hospital, durban corresponding author: s misser (shalendramisser@hotmail.com) please refer to page 101 of the september 2011 issue of the sajr (also available online at http://www.sajr.org.za/index.php/sajr/article/view/610/459) for the presentation details. we congratulate dr s moosa (department of radiology, 2 military hospital, wynberg, cape town) for a well-researched and comprehensive diagnosis, for which he receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its imaging. presentation and diagnosis (because of space constraints, the images referred to below are not reproduced here but are in the september 2011 issue of the sajr and online at the above url.) the patient presented here was a 10-month-old girl, delivered pre-term by caesarean section, with a birthweight of 2.4 kg and good apgar scores. in her first year, she was treated for gastro-oesophageal reflux and had one life-threatening episode of reflux-associated apnoea with aspiration pneumonia. fundoplication surgery was succesfully performed. in the late neonatal period, progressive loss of neurological milestones was observed. baseline and preliminary special investigations(including chromosomal analysis, lacate and pyruvate) were non-contributory. on visual testing, cortical blindness was suspected. hearing was normal. the paediatric neurologist noted marked irritability and exaggerated response to basic stimuli, prompting further testing. mri scan showed marked generalised cerebral atrophy and proportional ventriculomegaly. t2-weighted high signal was noted extensively in the white matter, thalami and basal ganglia, with relative sparing of the u-fibres. inversion recovery sequence showed reduced ventral pontine signal, sparing the transverse pontine fibres. after gadolinium administration, symmetrical cranial nerve enhancement was demonstrated of the optic, oculomotor and trigeminal nerves. questionable focal enhancement was noted at the left brachium pontis (fig. 4b). serum galactocerebrosidase levels were found to be very low, confirming suspected krabbe leucodystrophy. discussion white matter disease in childhood is broadly classified as demyelinating or dysmyelinating. the dysmyelinating diseases, or leukodystrophies, result in abnormal production and breakdown of myelin. these are usually caused by an enzyme deficiency and are best sub-divided based on the cellular organelle involved.1 see table i. krabbe disease, or globoid cell leukodystrophy, is a neurodegenerative illness of infancy, with 4 clinical subtypes, distinguished by age of onset viz. infantile, late infantile, juvenile and adult. it is an autosomal recessive disorder, with the gene fault mapped to chromosome 14, resulting in deficiency of galactocerebroside-β-galactosidase. this enzyme degrades cerebrosides, a normal constituent of myelin. accumulation of cerebrosides in the lysosmes of macrophages results in formation of globoid cells, typical of this disease. clinically, the infantile subtype is the most common, manifesting with irritability, progressive spasticity, blindness, dysphagia, mental deterioration and milestone regression. mri has been shown to play a fundamental role in diagnosis and follow-up imaging of children with krabbe’s disease. provenzale et al.2 showed good correlation of mri findings (using loes scores3 ) with clinical scoring systems. centrum ovale, basal ganglia, thalami, internal capsule, cerebellum and brainstem are all areas that demostrate t2 and flair sequence hyperintensity. thalamic involvement is a useful sign to differentiate from metachromatic leukodystrophy.4 optic nerve hypertrophy and/or enhancement , as well as enhancement of other cranial nerves, is a feature of the disease.5 severe progressive atrophy, involvement of u-fibres, cortical blindness and seizures are usually late phenomena. diagnosis is made by detecting enzyme deficiency in leukocytes or cultured skin fibroblasts. treatment includes bone marrow transplantation, supportive therapy and physiotherapy. 1. cheon j, kim io, hwang ys, et al. leukodystrophy in children: a pictorial review of mr imaging features. radiographics 2002;22:461-476. 1. cheon j, kim io, hwang ys, et al. leukodystrophy in children: a pictorial review of mr imaging features. radiographics 2002;22:461-476. 2. provenzale jm. correlation of neurodevelopmental features and mri findings in infantile krabbe’s disease. ajr 2009;192:59-65. 2. provenzale jm. correlation of neurodevelopmental features and mri findings in infantile krabbe’s disease. ajr 2009;192:59-65. 3. loes dj, hite s, moser h, et al. adrenoleukodystrophy: a scoring method for brain mr observations. ajnr 1994;15:1761-1766. 3. loes dj, hite s, moser h, et al. adrenoleukodystrophy: a scoring method for brain mr observations. ajnr 1994;15:1761-1766. 4. candy s. an approach to white and grey matter disease in children. in: baby steps into paediatric neuroradiology. andronikou s, wieselthaler n, kader e (eds). 1st ed. pretoria: sama press, 2004. 4. candy s. an approach to white and grey matter disease in children. in: baby steps into paediatric neuroradiology. andronikou s, wieselthaler n, kader e (eds). 1st ed. pretoria: sama press, 2004. 5. jones bv, barron tf, towfighi j. optic nerve enlargement in krabbe’s disease. ajnr 1999;20:1228-1231. 5. jones bv, barron tf, towfighi j. optic nerve enlargement in krabbe’s disease. ajnr 1999;20:1228-1231. table i. white matter diseases according to cellular organelle involved lysosomal storage diseases with white matter involvement peroxisomal disorders mitochondrial dysfunction with leukoencephalopathy other white matter dysmyelinating disorders metchromatic leukodystrophy zellweger syndrome leigh disease canavan disease krabbe disease x-linked adrenoleukodystrophy melas alexander disease niemann-pick disease neonatal adrenoleukodystrophy (ald) merrf congenital muscular dystrophy (fukuyama) fabry disease pseudoneonatal ald gm1 and gm2 gangliosidosis classic refsum disease pelizaeus-merzbacher disease mucopolysaccharidosis fucosidosis mucolipidosis wolman disease ceroid lipofuscinosis abstract introduction patient presentation discussion acknowledgements references about the author(s) siviwe s. mpateni department of radiodiagnosis, faculty of health sciences, stellenbosch university, cape town, south africa jacques bence department of radiodiagnosis, faculty of health sciences, stellenbosch university, cape town, south africa richard d. pitcher department of radiodiagnosis, faculty of health sciences, stellenbosch university, cape town, south africa michelle da silva department of radiodiagnosis, faculty of health sciences, stellenbosch university, cape town, south africa citation mpateni ss, bence j, pitcher rd, da silva m. terminal quadrifurcation of the aorta: a case report. s afr j rad. 2023;27(1), a2564. https://doi.org/10.4102/sajr.v27i1.2564 case report terminal quadrifurcation of the aorta: a case report siviwe s. mpateni, jacques bence, richard d. pitcher, michelle da silva received: 23 sept. 2022; accepted: 07 dec. 2022; published: 30 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract congenital anatomical variations of the terminal aorta are rare. given the increasing number of endovascular and laparoscopic procedures, such variations are likely to assume greater clinical significance. a 15-year-old male sustained a pelvic vascular injury following a stab to the left gluteus. computed tomographic angiography and digital subtraction angiography demonstrated a left superior gluteal artery pseudoaneurysm and absence of the common iliac arteries consistent with congenital quadrifurcation of the terminal aorta. the patient was subsequently treated with endovascular coil embolisation with a good angiographic and clinical outcome. contribution: terminal aortic variants are rare and given the increasing number of interventional endovascular procedures performed in the aorta, an awareness of the potential anatomical configurations of the distal aortic branches is of increasing relevance. the authors describe the imaging findings of one such anatomical variant. keywords: interventional radiology; vascular anatomy; trauma; aorta; angiography. introduction the normal distal aorta bifurcates into the left and right common iliac arteries at the lower border of the l4 vertebral body.1 the two common iliac arteries then course anterior and slightly to the left of the l5 vertebral body before bifurcating into the internal and external iliac arteries at the level of the pelvic inlet.1,2 congenital anomalies of the iliac arteries are exceedingly rare, with a reported incidence of only six cases in angiography studies of 8000 patients.2,3 terminal aortic quadrifurcation results from congenital absence of the common iliac arteries likely due to formation of an abnormal communication between the 5th lumbar intersegmental, dorsolateral, and descending umbilical arteries of the dorsal aorta.2 this anatomical variation is asymptomatic; however, awareness of this anomalous configuration is important in the planning of endovascular procedures, obstetric surgery and organ transplantation.4,5,6 patient presentation a 15-year-old male was referred to the tertiary emergency centre with active haemorrhage after a left gluteal stab. bleeding was controlled with two inflated wound-track foley’s catheters and urgent pelvic ct angiography was performed. this demonstrated a traumatic pseudoaneurysm of the left superior gluteal artery and incidental absence of the common iliac arteries with the abdominal aorta terminating as bilateral internal and external iliac arteries at the superior margin of the l5 vertebral body (figure 1). figure 1: a 3d computed tomography angiogram of the pelvis depicting quadrifurcation of the terminal aorta. the patient was then referred for endovascular coiling of the pseudoaneurysm by our trauma surgery team. arterial access was obtained in the right common femoral artery under sonographic guidance. subsequent digital subtraction angiogram of the distal abdominal aorta was performed to guide selective catheterisation of the left internal iliac artery. super-selective catheterisation of the posterior division of the left internal iliac artery demonstrated a superior gluteal artery pseudoaneurysm, which was successfully embolised using three pushable coils (one 4 mm × 14 cm and two 4 mm × 5 cm). there was good preservation of the remaining left internal iliac branches (figures 2 a–c). figure 2: (a) digital subtraction angiogram of the terminal aorta demonstrates bilateral absence of the common iliac arteries. (b) digital subtraction angiogram of the posterior division of the left internal iliac artery demonstrating the traumatic pseudoaneurysm of the superior gluteal artery. (c) digital subtraction angiogram of the left internal iliac artery demonstrated successful post-embolisation exclusion of the pseudoaneurysm. the wound-track foley’s catheters were deflated in the angiography suite and there was no further haemorrhage. the patient was discharged from hospital by our trauma team 2 days later. discussion the embryological development of foetal vascularisation begins in the 3rd week by a process of vasculogenesis and angiogenesis.2 the abdominal aorta forms by the fusion of the paired dorsal aorta in the 4th week.1,2 subsequently, four paired dorsal segmental arteries originate from the abdominal aorta to form the upper lumbar arteries and the fifth lumbar artery gives rise to the bilateral common iliac arteries.2 at 3 months gestation definitive vascularisation is achieved.1 the normal distal aorta bifurcates into the left and right common iliac arteries at the lower border of the l4 vertebral body in most individuals.1,5 the two common iliac arteries then course anterior and slightly to the left of the l5 vertebral body before bifurcating into the internal and external iliac arteries at the level of the pelvic inlet.1 variations to the configuration of the terminal aorta and iliac arteries are far rarer than the thoracic aorta and complete failure of bilateral common iliac arteries formation is extremely rare.5,7 the incidence of distal aortic and iliac anomalies is unknown, however, a study of 8000 patients performed by grebe and colleagues revealed only six cases with iliofemoral anomalies.8,9 this rare anatomical variation is often found incidentally but carries clinical implications in several open and endovascular interventions, such as the selection of distal stent landing zone in endovascular aortic aneurysm repair,6 emergent surgical ligation of the internal iliac arteries to arrest intra-operative haemorrhage5 and selection of pelvic host vessels in renal transplantation. pham et al. describe a novel endovascular approach to preserve internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of the common iliac arteries by using an iliac branched aortic graft device to repair the aneurysm. they describe selective preservation of a single internal iliac branch to perfuse the pelvis and embolisation of the contralateral internal iliac branch prior to graft deployment.10 with the increasing number of endovascular and laparoscopic pelvic procedures performed, such variations are likely to be encountered with greater frequency and interventionists should be prepared to tailor their procedural approach to accommodate such anomalies. this is to the best of our knowledge the first case report demonstrating the diagnostic imaging features of this anatomical variation on the african continent. reporting of this finding when encountered is encouraged. conclusion consideration of this rare anomaly in the planning and execution of open surgical and endovascular arterial procedures is recommended. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.s.m., j.b., r.d.p. and m.d.s contributed equally to this work. ethical considerations verbal and written consent for the use of these radiological images was obtained from the patient and the patient’s mother. ethical committee approval was obtained from stellenbosch university health research ethics committee (reference number c22/04/011). funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references de boo d, koukounaras j. vascular anatomy of the abdominal aorta and the inferior vena cava. in: mauro ma, murphy kp, thomson kr, venbrux ac, morgan ra, editors. image-guided interventions. 3rd ed. philadelphia: saunders (imprint), 2020; p. 337–351.e1. https://doi.org/10.1016/b978-0-323-61204-3.00019-1 abdul-hameed a, ibrahim am. terminal aortic quadrifurcation: a rare congenital anomaly (tria 100144). transl res anat. 202125:100144. https://doi.org/10.1016/j.tria.2021.100144 hager e, isenberg g, gonsalves c, moudgill n, dong s, dimuzio p. a new anatomic variant of the aorta: a case report. j vasc surg. 2008;48(1):213–215. https://doi.org/10.1016/j.jvs.2008.02.026 dabydeen da, shabashov a, shaffer k. congenital absence of the right common iliac artery. radiol case rep. 2008;3(1):47. https://doi.org/10.2484/rcr.v3i1.47 el-agwany as. bilateral absence of common iliac artery: abnormal anatomical variation of the internal iliac artery during ligation in conservative surgical management of placenta previa accreta. indian j gynecol oncol. 2016;14(2). https://doi.org/10.1007/s40944-016-0053-5 george jm, ilonzo n, choinski kn, grossi rj. congenital absence of bilateral common iliac arteries. j vasc surg cases innov tech. 2021;7(2):266. https://doi.org/10.1016/j.jvscit.2021.01.003 ho a, slagle j, vellody r, meagher e, sharma k, yadav b. aortic quadfurcation with persistent left sciatic artery: an extremely rare anatomic variant in a 3-year-old boy. j vasc surg cases innov tech. 2021;7(2):262–265. https://doi.org/10.1016/j.jvscit.2020.12.018 greebe j. congenital anomalies of the iliofemoral artery. j cardiovasc surg (torino). 18(3):317–323. green cs, helmy ma. novel, congenital iliac arterial anatomy: absent common iliac arteries and left internal iliac artery. radiol case rep. 2014;9(3):978. https://doi.org/10.2484/rcr.v9i3.978 pham ma, le tp. preservation of internal iliac artery flow during endovascular aortic aneurysm repair in a patient with bilateral absence of common iliac artery. j vasc surg cases innov tech. 2021;7(1):108–112. https://doi.org/10.1016/j.jvscit.2020.12.012 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) yeshkhir naidoo department of radiology, faculty of diagnostic radiology, university of kwazulu-natal, durban, south africa rohen harrichandparsad department of neurosurgery, faculty of neurosurgery, university of kwazulu-natal, durban, south africa khatija amod department of radiology, inkosi albert luthuli central hospital, university of kwazulu-natal, durban, south africa citation naidoo y, harrichandparsad r, amod k. why swi? the sensitivity of susceptibility weighted imaging in aneurysmal subarachnoid haemorrhage in the chronic phase. s afr j rad. 2023;27(1), a2520. https://doi.org/10.4102/sajr.v27i1.2520 original research why swi? the sensitivity of susceptibility weighted imaging in aneurysmal subarachnoid haemorrhage in the chronic phase yeshkhir naidoo, rohen harrichandparsad, khatija amod received: 24 july 2022; accepted: 30 jan. 2023; published: 31 mar. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: incidentally detected unruptured intracranial aneurysms have a prevalence of 3% with some predisposed to rupture and others remaining static. diagnostic knowledge of previous aneurysmal subarachnoid haemorrhage (asah) in the chronic phase could identify patients requiring treatment. objectives: to assess the sensitivity of susceptibility weighted imaging (swi) in the detection of asah at 3 months post ictus and determine any influencing effects. method: a retrospective chart analysis of 46 patients with asah who underwent post-embolisation swi imaging at 3 months. the swi and available initial ct brain scans or ct reports were evaluated and correlated with patient demographics and clinical severity. results: susceptibility weighted imaging indicated a sensitivity of 95.7% in the detection of asah at 3 months. increased number of haemosiderin zones on swi correlated with older patient age (p = 0.0003). clinical severity (world federation neurosurgical societies score) showed a tendency towards a statistically relevant relationship (p = 0.07). no statistically significant relationship was identified between the number of haemosiderin zones and initial ct modified fisher score (p = 0.34) or the causative aneurysm location (p = 0.37). conclusion: susceptibility weighted imaging is sensitive in the detection of asah at 3 months, increasing in sensitivity with patient age and higher initial clinical severity. contribution: in patients presenting in the subacute to chronic phase with a clinically suspicious history of previous aneurysm rupture but without convincing ct or spectrophotometry evidence, swi can detect previous rupture. this can identify patients who could benefit from endovascular treatment and those who can safely undergo follow-up imaging. keywords: aneurysmal subarachnoid haemorrhage (asah); susceptibility weighted imaging (swi); chronic aneurysmal subarachnoid haemorrhage; endovascular coiling; haemosiderosis; intracranial aneurysm. introduction patients presenting in the subacute to chronic phase with a clinically suspicious history of previous aneurysm rupture, but without convincing radiological or spectrophotometry evidence, present a clinical conundrum to patient management. the natural history of intracranial aneurysms varies with some inherently being predisposed to rupture (5 year risk of 3.4%), while most others remain unruptured and without complications.1,2 the treatment of ruptured aneurysms is well established because of the increased risk of re-rupture and associated high patient mortality and morbidity.3 preventative repair is not without risks (risk of 6% – 10% of poor neurological outcome) and should be weighed against any potential benefit.4 it is therefore important to differentiate a previously ruptured from an unruptured intracranial aneurysm. in the acute phase, non-enhanced ct is the modality of choice for aneurysmal subarachnoid haemorrhage (asah) with sensitivities initially at 98%, reducing to 50% at 1 week and 0% after 3 weeks.5 the decreasing sensitivity over time is attributable to csf flow dynamics clearing the initial haemorrhagic load and thereby reducing its conspicuity on ct. however, ct plays no role in the detection of subacute and chronic asah and other investigations such as lumbar puncture csf spectrophotometry and mri are helpful. lumbar puncture csf spectrophotometry detects bilirubin, indicative of previous subarachnoid haemorrhage, which remains positive up to 14 days following asah with a subsequent rapid decrease in sensitivity.6 these factors limit the usefulness of csf analysis for the detection of asah in the subacute to chronic phase. pathophysiologically, after the onset of subarachnoid haemorrhage, a clot forms at the rupture site while the remaining free erythrocytes are either absorbed by the arachnoid villi and re-enter the vascular system or undergo lysis, resulting in free haeme deposition on subpial surfaces and conversion to intracellular haemosiderin.7,8,9 the initial haematoma surrounding the rupture is eventually washed away or phagocytosed by macrophages and converted to haemosiderin, accounting for greater volume of haemosiderin staining at the site of aneurysmal rupture, which is resistant to the effects of csf flow and can be detected well into the chronic period as demonstrated by autopsy studies.10 in the subacute phase of asah, fluid-attenuated inversion recovery (flair), t2*, double inversion recovery and swi are all useful. these sequences detect deoxyhaemoglobin which is paramagnetic and takes up to 90 days to clear. any residual blood products are converted to haemosiderin.10 studies have even shown that after 3 months, haemosiderin remains unchanged for up to 16 years on t2* imaging.11,12 haemosiderin staining along the superficial central nervous system is defined as superficial siderosis and has traditionally been because of repeated chronic subarachnoid haemorrhages of any cause. recent studies with pathology specimens confirm that superficial siderosis can occur in nearly all patients after a single episode of asah.12 imaging options for asah in the chronic phase have been limited with a few studies demonstrating the utility of t2*, with sensitivities ranging between 54.2% and 89.9%.13,14,15,16 apart from the wide variation in sensitivity, t2* is limited because of its inability to differentiate between haemosiderin and calcification.10,12,13 susceptibility weighted imaging utilises inherent susceptibility variations such as t2* but has the improved benefit of high resolution and allows differentiation between haemosiderin and calcification.10,12,13 in addition, swi has improved sensitivity of four times that of t2* in the detection of intraparenchymal haemorrhage because of its use of phase imaging.15 susceptibility weighted imaging has not been compared with t2* in the assessment of extra-axial haemorrhage and it can only be presumed to exceed t2* sensitivity. to our knowledge, no published study has investigated swi’s utility in detecting haemosiderin in the chronic phase of asah (after a single haemorrhagic event as assessed clinically). the aim of this study was to determine the ability of swi to detect asah at 3 months post ictus, investigate factors influencing the amount of haemosiderin staining and ascertain if haemosiderin staining identified on swi could correlate with the initial aneurysm location. methods study population this was a retrospective, analytic, descriptive study of patients with asah managed at inkosi albert luthuli hospital, kwazulu-natal, between 01 june 2015 and 30 june 2019. the neurosurgical department offers services for both endovascular and microsurgical clipping of asah. patients who underwent confirmatory initial ct brain imaging shortly after asah at their base hospitals and subsequent endovascular repair of the causative aneurysm were considered. of these, all patients who underwent the same routine mri brain sequences (including swi) at 3 months post endovascular repair were included (figure 1). patients who had previous intracranial surgery, haemorrhage, trauma or malignancy prior to the initial asah or between the repair of the causative aneurysm and the acquisition of the swi study were excluded. figure 1: flow chart of patient selection. data collection patient demographics and clinical information were obtained using the hospital information system. patient charts were reviewed for date of ictus, initial ct report, modified fisher score, age, gender, date of ct and swi, world federation neurosurgical societies score (wfns), date of endovascular surgery, location of aneurysms on digitally subtracted angiograms and any clinical information, which precluded involvement in the study. the radiology information system and picture archive and communication system were used to analyse the available ct scans from base hospitals (n = 15) and all mri swi scans performed at our institution (n = 46) with a 3t siemens machine, using the axial 5 mm and 3 mm slices, respectively. all confirmatory nect were performed at the patients’ referral hospitals where the diagnoses were made. where these ct scans were available, those images were evaluated in the study. the ct and swi images were analysed by a senior radiologist with over 25 years of experience and an interest in neuroradiology as well as by a senior radiology registrar. the ct and mri images were interpreted in separate settings individually and performed as blind reads. available ct and mri images were read by the two readers independently with a combined reading performed together for discussion and conformity. the subarachnoid space was divided into 13 zones (adapted from prior studies that analysed acute phase asah with swi7,8) – six were peripheral zones: frontoparietal, temporooccipital and sylvian fissure (divided into a right and left side), five were central zones: inter-hemispheric and ventricular system (right and left lateral, 3rd and 4th ventricles) and the remaining two zones were in the perimesencephalic and posterior cranial fossa (defined as the prepontine, superior cerebellar and cisterna magna). haemosiderin staining was defined as blooming with corresponding aliasing on phase images, whenever identified in the specified sulcal/ventricular surfaces. if a localised maximum site of haemosiderin staining was identified, with the greatest amplitude of blooming, its location was recorded. modified fisher scores were graded on the available initial nect scans and where not available, were calculated from the radiology ct report findings and compared with the neurosurgical recorded modified fisher scores. statistical analysis statistical analyses were performed using the statistical package for social science (spss) version 26.0 to obtain the means, frequencies and perform a univariate analysis. level of statistical relevance used was p < 0.05. ethical considerations ethics approval received from higher research committee at inkosi albert luthuli central hospital (clearance number: brec/00001655/2020). results the final study cohort included 46 patients with asah who were managed at inkosi albert luthuli hospital with endovascular aneurysmal repair and who underwent swi imaging at 3 months post ictus. haemosiderin zones swi detected haemosiderin in 44/46 (95.7%) patients with asah. of the two patients who had no haemosiderin staining on swi at 3 months, the first patient had a right posterior communicating aneurysm, modified fisher score 1, wfns grade 2, and was 57 years old. the second patient had an anterior communicating aneurysm, modified fisher score 1, wfns grade 1 and was 28 years old. a total of 14 (30.4%) patients had multiple intracranial aneurysms. demographic data relating to haemosiderin zones are presented in table 1. females represented 63% (n = 29) of patients. the median age was 49 years (range 17–69 years). a statistically significant correlation was identified between increasing number of haemosiderin zones and increasing age (p = 0.003). no relationship was found between gender and the number of haemosiderin zones. table 1: correlation of demographic, clinical and radiological factors affecting the extent of haemosiderin zones. there was a tendency towards a higher number of haemosiderin zones having higher initial clinical severity, wfns; however, not reaching statistical significance (p = 0.07). five patients had a modified fisher score < 3 and 34 patients had modified fisher scores of 3–4. no statistical significance was found between the number of haemosiderin zones and the type of circulation aneurysm (p = 0.37) or the modified fisher score (p = 0.34). ct versus mri in those patients with both swi and available initial nect images (15 patients), 390 zones were analysed (195 ct and 195 swi zones). of the total 195 zones on ct, 86 positive haemorrhage zones were identified. of the total 195 zones on swi, 108 positive haemorrhage zones were detected (table 2). overall, swi (108 regions) detected more regions than ct (86 regions) with a global sensitivity of 61% and specificity 51% per location (table 3). table 2: correlation between areas of subarachnoid haemorrhage by modality. table 3: location-based sensitivity and specificity of swi. localisation of aneurysm maximum haemosiderin staining localised to one zone was found in 73.9% (n = 34) while the remainder demonstrated either generalised haemosiderin staining (n = 10) or no haemosiderin staining (n = 2). localisation for each of the zones were as follows: sylvian cistern 47.1% (n = 16), interhemispheric fissure 41.2% (n = 14), perimesencephalic 5.9% (n = 2) and posterior cranial fossa cisterns 5.9% (n = 2). maximum haemosiderin staining within the sylvian cistern was because of five aneurysms of the middle cerebral (100% of all middle cerebral artery (mca) aneurysms; ppv = 31.25%), eight of the posterior communicating (61.53% of all posterior communicating artery aneurysms; ppv = 50%) and three of the distal internal carotid arteries (100% of all distal internal artery aneurysms; ppv = 18.75%). maximum haemosiderin staining in the interhemispheric fissure was isolated to 12 aneurysms of the anterior communicating (70.59% of all anterior communicating artery aneurysms; ppv = 85.71%) and two of the pericallosal arteries (100% of all pericallosal aneurysms; ppv = 14.29%). maximum haemosiderin staining in the perimesencepahlic cistern was limited to two aneurysms of the posterior communicating arteries (15.38% of all posterior communicating artery aneurysms; ppv = 100%). maximum haemosiderin staining in the posterior cranial fossa cistern was isolated to one aneurysm of the posterior communicating (7.69% of all posterior communicating artery aneurysms; ppv = 50%) and one posterior inferior cerebellar artery aneurysm (100% of all posterior inferior cerebellar artery aneurysms; ppv = 50%). discussion this study demonstrated the ability of swi to detect asah in the chronic phase (> 3 months) after a single aneurysmal haemorrhage: 95.7% (44/46) as depicted in figure 2. these findings exceeded previous studies utilising t2* in the same setting with rates of only 54.2% – 89.9%.13,14,15,16 this is likely attributable to swi employing phase differences, which may not necessarily correspond to noticeable t2* effects, as shown in intraparenchymal haematomas demonstrating increased sensitivity of up to 4× in swi.15 figure 2: the nect at presentation (a–d) and swi at 3 months (e–h) in a patient with a ruptured anterior communicating aneurysm. the nect demonstrates localised haematoma within the lamina terminalis (a) and frontoparietal convexities (d). the swi at 3 months demonstrates diffuse blooming (haemosiderin) remote to the initial haemorrhagic load now along the cerebral convexities (white arrows), interhemispheric fissure (double white arrows), intraventricular (curved white arrow) and posterior cranial fossa cisterns (dashed white arrows) (e). of the two patients who were negative for haemosiderin staining on swi, a low modified fisher score of 1 and low wfns of 1–2 were mutual findings. it is postulated that smaller initial haemorrhagic loads may be less likely to have haemosiderin staining detectable on swi in the chronic phase. this corresponds with prior studies conducted by lummel et al. and falter et al. in patients with chronic asah and t2* who similarly showed absent haemosiderin staining in patients with lower modified fisher scores.12,14 impact of location on swi detection of aneurysmal subarachnoid haemorrhage convexity overall, swi detected more regions of haemorrhage than the initial ct (as depicted in figure 2) with a location-based sensitivity of 56% and specificity of 50%. a previous study by mulé with t2* showed a similar sensitivity of 64% with an improved specificity of 82%.16 the marked difference in specificity was unanticipated and thought to be because of csf flow dynamics causing haemorrhage to be washed to more regions remote from the site of rupture and hence detected on imaging in the chronic phase.12,13,16 basal cisterns this study showed a sensitivity of 50% in the perimesencephalic cistern, exceeding that of previous studies with t2* of 8%.16 the poor sensitivity in this region was because of regional artefact from the base of skull and high csf flow displacing any haemorrhage as depicted in figure 3.12,13,16,17,18 figure 3: the nect and swi in patient with a ruptured anterior communicating aneurysm. subarachnoid haematoma (a. white arrow) in the suprasellar cistern is not appreciated on the 3 month swi because of adjacent susceptibly artefact from the base of skull (b. white dashed arrow). ventricular system previous t2* studies in chronic asah showed poor sensitivities in the detection of haemorrhage in the ventricular system. mulé et al. demonstrated a sensitivity of 10%.16 this was thought to be related to high csf flow velocities in these locations, preventing adequate time for haemosiderosis.12,13,16 the current study contradicted this with increased sensitivity of 62.5% for haemosiderin, even exceeding regions seen on the initial nect as depicted in figure 4. these areas of haemosiderin identified on swi were located in the dependent regions of the ventricular system (occipital horns of the lateral ventricles and dependent lateral recesses of the 4th ventricle). figure 4: susceptibility weighted imaging in a patient with a ruptured anterior communicating aneurysm. haemosiderin staining the ependymal surface of the ventricles (white arrows), predominantly involving the dependent occipital horns (dashed white arrow). two postulated reasons were thought to account for this. firstly, the inherent increased sensitivity and high-resolution imaging of swi compared with t2* resulted in a greater sensitivity. secondly, over time there is reflux of haemorrhage from the cisterns into the ventricular system in patients with subarachnoid haemorrhage as shown in previous studies.8,19 this process is thought to occur to equalise csf pressures and may show haemosiderin in the ventricular system in patients who initially did not have intraventricular haemorrhage. infratentorial studies by falter et al. and mulé et al. showed t2* detection rates of haemosiderin in chronic asah in the infratentorial cisterns approaching 70% – 90%.12,16 despite this, lummel et al. and mulé et al. demonstrated poor sensitivity of haemosiderin on t2* in the infratentorial compartment 10% – 21.9%.14 susceptibility artefact in these sequences is related to the strength of the mri magnetic field and previous surgical washout. however, lummel et al. utilised a 3t machine similar to the other studies and the majority of patients underwent endovascular repair. a reason to account for the discrepancy in these studies is unknown. in comparison, the current study showed high haemosiderin detection, with a sensitivity of 86% in the infratentorial compartment, exceeding that of the initially detected haemorrhage on nect (swi 11; ct 7) as depicted in figure 5. this is most likely because of csf flow as described by koeppen et al., who showed in csf flow studies that the brainstem and cerebellar convexities initially receive preferential csf flow and serve as a site of haemosiderin deposition, albeit remote to the site of rupture. this has been described in patients with recurrent subarachnoid haemorrhage causing superficial haemosiderosis. figure 5: the nect (a) and swi (b) in a ruptured right mca aneurysm. swi at 3 months demonstrates haemosiderin staining (white arrows) on the pial surface, not seen on initial nect. factors contributing to haemosiderin detection on swi secondary objectives of the study were to evaluate for any correlations between the number of haemosiderin-stained zones with patient demographics, location of the causative aneurysm, initial clinical (wfns) or radiological severity (modified fisher score). demographics studies performed by imaizumi et al. and falter et al. showed no statistical significance between age and haemosiderin extent on t2* imaging. however, previous researchers have shown that age had a statistically significant relationship with the presence of haemosiderin on t2* ge imaging (p = 0.02).12,13,14 like previous studies it is hypothesised that with ageing and subsequent cerebral atrophy there are larger subarachnoid spaces, which allow for larger areas of haemorrhage aggregation and hence haemosiderin deposition.12 the current study concurred with lummel et al. indicating a statistically significant correlation with increasing numbers of haemosiderin deposition zones and increasing patient age (p = 0.003). aneurysmal subarachnoid haemorrhage has a 50% increased incidence in the female population. previous studies utilising t2* by imaizumi et al. and falter et al. demonstrated no statistically significant correlation between gender and the extent of haemosiderin staining. similar findings were found in this study with females representing 63% of the study population and no statistical correlation with the number of haemosiderin zones (p = 0.9). clinical severity world federation neurosurgical societies score falter et al. identified a statistically significant relationship between initial wfns and the extent of haemosiderin staining on t2* imaging (p = 0.0008).12 this study showed an approaching tendency (p = 0.07) between the number of haemosiderin zones and wfns, but was not statistically significant. the clinical applications imply that haemosiderin detection on swi in the chronic phase may infer a more clinically severe initial asah (clinical wfns grade). radiological severity (modified fisher score) modified fisher scale on initial nect has been proven to correlate with vasospasm risk. the mechanism is related to the direct effect of haemorrhage on the vessels in the subarachnoid space.20 imaizumi et al. divided the cerebral convexities into 10 zones and imaged asah in the chronic phase. their findings showed that ≥ 4 haemosiderin zones correlated with an initial modified fisher score of ≥ 3 (p = 0.0005). falter et al. and lummel et al. showed that t2* had corresponding statistically significant findings where a modified fisher score ≥ 3 correlated with the presence of haemosiderin (p = 0.0004 and p = 0.03, respectively).12,14 the mechanism is postulated to be related to the larger initial haemorrhage load resulting in greater haemosiderin staining and hence detection on imaging in the chronic phase. the current study showed no statistically significant correlation (p = 0.34). this could be because of swi’s increased sensitivity to detect small amounts of haemosiderin and thus haemosiderin remotely located from the initial rupture, even in small initial haemorrhage loads (lower modified fisher scores). as a result of the inherent limitations of this study with a bias of patients with higher modified fisher scores ≥ 3 (n = 35) and underrepresentation of lower modified fisher scores < 3 (n = 5), a true statistical analysis is limited. location aneurysmal subarachnoid haemorrhage in patients with multiple intracranial aneurysms can cause difficulty in identifying the causative ruptured aneurysm and direction of treatment. ruptured aneurysm localisation rates on nect and digitally subtracted angiograms vary from 52% to 80%, with studies reporting high sensitivities in localising anterior communicating, anterior cerebral and middle cerebral artery aneurysms.21,22,23,24 in these studies, performed in the acute phase, the haemorrhage pattern was identified and causative aneurysm prediction was performed. as the current study was performed in the chronic phase of asah, swi was able to detect haemosiderin distal to the areas of the initial haemorrhage load, thus creating complexity in the localisation of the maximum site of haemosiderin. maximum haemosiderin staining in the sylvian cisterns was seen with ipsilateral middle cerebral (ppv = 31.25%), posterior communicating (ppv = 50%) and distal internal carotid arteries aneurysms (ppv = 18.75%) and hence was not specific for ruptured mca aneurysms as observed in previous studies in the acute phase.21,22,23,24 this is thought to be related to csf flow dynamics and deposition of haemosiderin. figure 6 demonstrates an example of localised haemosiderin and haematoma related to the sylvian fissure. figure 6: the nect (a, c) and swi (b, d) in ruptured left mca aneurysm. subarachnoid haemorrhage in the left sylvian cistern (a) and left frontoparietal convexities (c) and swi at 3 months demonstrates corresponding blooming in the respective zones (b, d). of note the maximum haemorrhage load and haemosiderin zone localises to the left sylvian cistern. maximum haemosiderin staining in the interhemispheric fissure was limited to anterior communicating (ppv = 85.71%) and pericallosal aneurysms (ppv = 14.29), correlating with previous studies in the acute phase and hence proves useful in the determination of the causative ruptured aneurysm. maximum haemosiderin staining in the perimesencephalic cistern was limited to posterior communicating aneurysms (ppv = 100%); however, the known poor sensitivity on swi in this region because of the base of skull artefact limits its usefulness. similarly, maximum haemosiderin staining in the posterior cranial fossa cisterns was limited to posterior communicating (ppv = 50%) and posterior inferior cerebellar artery aneurysms (ppv = 50%). this knowledge may be of use in identifying the site of causative ruptured aneurysm in patients with multiple intracranial aneurysms and help direct appropriate treatment. study limitations the small sample size, single centre, retrospective nature of the study and bias with the majority of patients having severe asah (modified fisher ≥ 3) are limitations in this study. not all initial ct images were available for re-evaluation and information from radiology reports and neurosurgical documentation was relied upon. imaging clinically unruptured intracranial aneurysms for occult rupture by assessing for haemosiderin on swi may be performed in the future to help identify patients requiring treatment. conclusion susceptibility weighted imaging is sensitive (95.7%) for the detection of asah at 3 months after a single aneurysmal rupture episode and exceeds previous study sensitivities utilising t2* imaging. sensitivity along the convexity, interhemipsheric fissure, sylvian cisterns and within the ventricles was better than in the perimesencephic cisterns. factors such as age and higher initial clinical severity (wfns) showed an increased number of haemosiderin zones, while radiologic severity (modified fisher), site of aneurysmal rupture and gender showed no predictive value in the determination of number of haemosiderin zones. swi was useful in localisation of the causative ruptured aneurysm, particularly for anterior communicating and pericallosal aneurysms, with haemosiderin in the interhemispheric fissure. this study proposes that in the clinical scenario of a patient with clinically suspected asah without confirmatory imaging in the chronic phase, swi can be performed to identify previous haemorrhage and possibly identify patients who would benefit from aneurysm treatment. acknowledgements the principal author (y.n.) would like to express his gratitude to his supervisor r.h., for his constant supervision, knowledge and patience. he also expresses his deepest gratitude to k.a. for all her time and expertise in image interpretation, without which this study would not have been a reality. the author expresses his gratitude to mrs cathy connoly for her assistance with data analysis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions y.n. was the primary researcher, r.h. was the primary co-supervisor and k.a. was the secondary co-supervisor in this study. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data pertaining to this study can be requested from the corresponding author, y.n. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ishibashi t, murayama y, urashima m, saguchi t, ebara m, 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measurements. chicago: year book medical publishers, 1990: 108-109. 8. wikipedia. list of cities proper by population. http://en.wikipedia.org/wiki/nigeria (accessed 6 april 2009). 9. cooperberg pl, gibney rg. imaging of the gallbladder. radiology 1987; 163: 605-613. 10. callen pw, filly ra. ultrasonographic localization of gallbladder. radiology 1979; 133: 687-691. 11. rall pw, quinn mf, juttner hu. gallbladder wall thickening: patients without intrinsic gallbladder disease. am j roentgenol 1981; 13: 65-68. 12. mcgahan jp, phillips he, cox kl. sonography of the normal pediatric gallbladder and biliary tree. radiology 1982; 144: 873-875. 13. jeong hy, hyun jk, myung jl. sonogr aphic measurements of normal gallbladder sizes in children. j clin ultrasound 2003; 31: 80-84. 14. zins m, boulay ci, molinie v, et al. imaging of a thickened-wall gallbladder. j radiol 2006; 87: 479-493. uraemic tumoral calcinosis in patients on haemodialysis in the renal unit at dr george mukhari hospital, pretoria abstract objective. uraemic tumoral calcinosis refers to metastatic calcifications that occur rarely on the extensor surfaces of joints in patients undergoing long-term haemodialysis. the aim of the study was to assess the incidence of uraemic tumoral calcinosis in participants undergoing haemodialysis and to investigate any relationship that might exist between the development of uraemic tumoral calcinosis and the length of time on dialysis. design. twenty-four of the 25 patients on haemodialysis at the time of the study underwent radiographs of their shoulders and hips to look for calcinosis, which were then read by the researcher and two independent readers to assess for calcinosis. study setting. dr george mukhari hospital, pretoria. results. eight per cent (n=2) of participants were found to have asymptomatic calcinosis of the hips. no relationship to length of time on dialysis was found. conclusions. the study was constrained by a small sample size but the presence of calcinosis in 8% of the participants indicates that an extensive study of a larger sample could prove to be useful in determining the true incidence of uraemic tumoral calcinosis in the region. long-term follow-up could provide more information on the development of calcinosis and length of time on dialysis. introduction tumoral calcinosis may be defined as metastatic peri-articular calcifications that can be found in a wide variety of conditions such as primary hyperthyroidism and connective tissue diseases, as well as an idiopathic form.1 uraemic tumoral calcinosis is an uncommon occurrence in patients with chronic renal failure who are on long-term haemodialysis therapy, and falls within the broad definition of tumoral calcinosis.1 the disease is usually asymptomatic but can present with complications such as impairment of mobility, nerve compression, ulceration of the overlying skin and bony erosion.1 if the radiologist is unfamiliar with the radiological patterns of tumoral calcinosis or disease processes that mimic the condition, then diagnosis and treatment might be delayed or the patient may be subjected to unwarranted invasive procedures.2 literature review metastatic calcifications may have benign or malignant causes.3 uraemic tumoral calcinosis is known to occur in patients with chronic renal failure undergoing haemodialysis and is the most common cause of metastatic peri-articular calcifications.3 the aetiology is multifactorial and awareness is important since the condition is progressive.1 the disease is uncommon and current prevalence is not well known but a frequency range of 0.5 3% has been reported.4 the pathogenesis is not fully understood but significant disturbances of calcium and phosphate homoeostasis can result from chronic renal disease. among these disturbances are decreased phosphate excretion, f e suleman, mb chb, fc rad (diag), m med rad (diag) department of diagnostic radiology and imaging, dr george mukhari hospital, pretoria v mngomezulu, mb bch, fc rad (diag) sa, mba division of diagnostic radiology, faculty of health sciences, university of witwatersrand and charlotte maxeke johannesburg academic hospital, johannesburg n ebrahim, nat dip radiography (diag), fetc, msc radiography (diag), pg dip int ethics department of radiography, university of limpopo( medunsa campus), pretoria 88 sa journal of radiology • december 2010 original article which leads to decreased calcitriol synthesis and hyperparathyroidism.5 decreased calcitriol leads to decreased intestinal absorption of calcium, which further stimulates hyperparathyroidism, eventually leading to autonomous hyperparathyroidism that results in hypercalcaemia.6 hyperphosphataemia and ca×po4 product greater than 60 75 and hyperparathyroidism are thought to be strong risk factors.3,4 high dialysate calcium concentrations are also implicated.1,4 studies also suggest that uraemic tumoral calcinosis occurs more commonly in patients on haemodialysis for more than 3 years.8 patients with uraemic tumoral calcinosis may be asymptomatic or present with joint mobility impairment.9 nerve compression can occur with large ‘tumours’ and, less commonly, ulceration of the overlying skin with discharge of milky white fluid.1 uraemic tumoral calcinosis may induce a systemic inflammatory response presenting as a pyrexia of unknown origin.7 the extensor surfaces of joints are usually involved, with the hip, shoulder and elbow (in order of decreasing frequency) commonly affected.8 radiologically, multiple large lobulated homogenous calcifications are noted in the soft tissue around the joint, with the joint spaces preserved.1 lesions may vary in size from 2 10 mm.8 no bone, muscle or visceral invasion is usually noted,1 but some cases report a degree of bone erosion in extensive calcinosis.8 the differential diagnosis for soft tissue calcifications should include idiopathic tumoral calcinosis, collagen vascular diseases (scleroderma, rheumatoid arthritis, systemic lupus erythematosis and dermatomyositis), myositis ossificans, metabolic causes (hyperparathyroidism) and neoplasms (osteosarcoma and chondrosarcoma).1,4 these diseases can usually be differentiated radiologically from uraemic tumoral calcinosis and a biopsy is rarely warranted. treatment options used in patients with uraemic tumoral calcinosis are usually aimed at correcting the underlying cause. relief may be achieved by surgical resection in patients presenting with symptoms, but excision is usually incomplete and recurrence is common.4,8 total or subtotal parathyroidectomy has also been shown to be effective in some patients, emphasising the important role of secondary hyperparathyroidism in patients on haemodialysis.10 this treatment option remains controversial, with other authors arguing that it has not been shown to be effective in the majority of patients and, in some cases, progression of calcinosis was noted following this method of treatment.11 medical interventions are aimed at correction of ca×po4 product. induction of a negative ca balance by increasing the number and duration of haemodialysis sessions with a low dialysate ca concentration has been reported to bring about a reduction of the masses.6 sodium thiosulphate may improve solubility and mobilisation of calcified masses but needs further investigation. tumoral calcinosis often resolves after successful renal transplantation, which is the definitive therapy for this condition.6 the disease is progressive. it is therefore vital that the prevalence of uraemic tumoral calcinosis in the renal haemodialysis unit of dr george mukhari hospital be assessed so that appropriate measures can be taken for its prevention, such as decreasing the calcium concentration in dialysis solutions or increasing duration of haemodialysis. aim the study was a preliminary investigation of the incidence of uraemic tumoral calcinosis in a sample of 25 patients known to be on renal haemodialysis at the dr george mukhari hospital (gmh) so as to determine any relationship that might exist between the development of uraemic tumoral calcinosis and the length of time on dialysis, and to suggest interventional and preventative methods to reduce development and progression of the condition in any of the patients found to be affected. methodology a prospective study was conducted on 25 patients on the haemodialysis programme at the time. one patient subsequently refused radiography. twenty-four participants had radiographs taken of their hips and shoulders. one participant, with clinically palpable nodules of both wrists, had radiographs of both wrists in addition to hips and shoulders. the radiographs were then assessed by the researcher and 2 consultant table i. percentage of patients in each period of dialysis period of dialysis n (%) 0 12 months 5 (20) 13 24 months 6 (24) 25 36 months 6 (24) 37 48 months 5 (20) 49 60 months 1 (4) 61 72 months 0 (0) 73 84 months 1 (4) missing 1 (4) total 25 (100) fig. 1. calcifications on the extensor surface of both hips in a patient on haemodialysis for 12 months. → sa journal of radiology • december 2010 89 original article radiologists in the radiology department at gmh, for the presence of calcinosis. bias all patients on haemodialysis were included in the study, except for one who subsequently refused to be radiographed. all radiographs were read by the researcher and 2 independent readers to avoid introduction of any form of bias. a discrepancy arose between the readers regarding findings on the radiographs of one participant, for which case only a third reader was involved. validity validity can be defined as the degree to which a test measures what it is supposed to measure.12 radiographs are the best method of detecting, localising and diagnosing soft-tissue calcifications in patients.8 all participants had radiographs taken of their shoulders and hips (the most common sites for uraemic tumoral calcifications) to look for soft-tissue calcifications. reliability the reliability of a research instrument concerns the extent to which the instrument yields the same results on repeated trials.12 as radiological images were used to assess the radiological patterns of tumoral calcinosis, the researcher used a reliable and validated instrument of measurement. results data were assessed using the chi square test statistical package for the social sciences (spss) version 15 and statistical analysis system (sas) version 9.2. a sample of 25 patients on haemodialysis in the renal unit at gmh were assessed for the study. one patient did not present himself for radiographs and was excluded from the analysis. of the 24 participants comprising the sample, 60% were male and 40% female. the range of the dialysis periods for the 25 patients is shown in table i. two participants were found to have radiological evidence of calcinosis. of these, one participant was on dialysis between 0 12 months (fig. 1) while the other participant was on dialysis for 13 24 months (fig. 2). only one participant (4% of the sample) was found to have nodules which were detected in both wrists. the other 96% had normal clinical examinations of the joints. assessment of calcinosis is illustrated in table ii (24 participants). only one participant had radiographs of both wrists because nodules were found on them during clinical examination, but no calcinosis was found radiologically. a discrepancy was found between reader 1 and reader 2 regarding the presence of calcinosis in one patient. a third reader was then asked to assess the relevant radiograph to improve the validity of the study, and she concurred with reader 1. chi-square analyses indicated that there were no significant differences between the variables: • gender and length of period of time on dialysis (p>0.78) • presence/absence of nodules and period of time on dialysis (p>0.68) • presence of calcinosis and length of period of dialysis (p>0.92). discussion the small sample size means that the results of the study may not be statistically significant. however, since this study was the first at gmh, it allows for ancillary treatment of participants who were found to have uraemic tumoral calcinosis, and it allows for further research. the findings reflect that the prevalence of uraemic tumoral calcinosis in the population of patients attending haemodialysis at the renal unit of gmh during december 2007 was 8%, with the literature reporting the range to be 0.5 3%.4 no correlation was found between the length of time on dialysis and the incidence of calcinosis in this research setting. the literature suggests that uraemic tumoral calcinosis occurs more commonly in patients on haemodialysis for more than 3 years.8 interestingly, both participants found to have calcinosis in our study had been on haemodialysis ≤24 months while none of the patients on haemodialysis ≥36 months were found to have been affected. none of the studies referred to the correlation between uraemic tumoral calcinosis and length of time of renal failure. males and females were equally affected by calcinosis, so no gender predilection appears to exist. fig. 2. small area of calcification on the extensor surface of the left hip in keeping with calcinosis in a patient on haemodialysis for 15 months. table ii. assessment of calcinosis in hips, shoulders and wrists by each reader and researcher reader calcinosis hips shoulders wrists yes no yes no yes no researcher 8% 88% 96% 100% reader 1 8% 88% 96% 100% reader 2 4% 92% 96% 100% n=24 90 sa journal of radiology • december 2010 original article the clinical presence of nodules did not correlate with the presence of calcinosis either, as the one participant with nodules did not have calcinosis. the nodules in this patient represented soft-tissue swellings, probably related to previous catherisation of vessels in the wrists. both patients with calcinosis did not have any palpable nodules and were found to have involvement of the hips, which is the most common site of involvement noted in the review of the literature.8 the results of this study were forwarded to the renal unit at gmh so that appropriate interventions could be instituted, i.e. increased duration and frequency of dialysis and changes in dialysis solution, to benefit those participants affected by calcinosis. conclusions and recommendations the study was the first of its kind conducted at our institution. the small sample size implies that the study might not be statistically significant, but it opens the door to further research in this field. among the questions raised by the study are the following: • will a larger sample size involving participants from other hospitals in the region provide a better reflection of the incidence of uraemic tumoral calcinosis in our region? • will long-term follow-up of our participants provide a better understanding of the relationship between development of calcinosis and length of time on dialysis? • what is the underlying cause of uraemic tumoral calcinosis in our participants and what measures should be implemented to treat them? the results of the study have been presented to the head of the renal unit, and the following recommendations for implementation were made: • assessment of the affected participants ca×po4 product • assessment of parathyroid hormone levels • intervention aimed at correcting the above factors • regular radiographic follow-up to assess progression/regression of calcinosis • regular monitoring clinically and radiographically of patients on longterm haemodialysis to allow early detection of calcinosis. we gratefully acknowledge the assistance of dr me kisansa, dr ma mabiletsa, mr d sebola, sister nancy pooe and the staff of the renal unit at gmh. 1. cofan f, garcia s, combalia a, campistol j, oppenheimer f, ramon r. uraemic tumoral calcinosis in patients receiving long-term hemodialysis therapy. j rheumatol 1999;26:379-385. 2. olsen km, chew. tumoral calcinosis, pearls, polemics and alternative possibilities. radiographics 2006;26:871-875. 3. jason m, udaya bsp, ricardo eb. a 57-year-old man with end-stage renal disease and chronic cough. chest 2008;133:1021-1024. 4. hamada j, tamai k, ono w, saotome k. uraemic tumoral calcinosis in haemodialysis patients : clinicopathological findings and identification of calcific deposits. j rheumatol 2006;33:119-126. 5. hamdy nat. calcium and bone metabolism preand post-kidney transplantation. endocrinol metab clin north am 2007;36:923-935. 6. phanish mk, kallarackel g, ravanan r, lawson tm, baboolal k. tumoral calcinosis associated with pyrexia and systemic inflammatory response in hemodialysis patient: successful treatment using intravenous pamidronate. nephrol dial transplant 2000;15:1691-1693. 7. binnani p, aggarwal v, bahadur mm, fulara n. tumoral calcinosis (teutschlander disease) in a dialysis patient. ind j nephrol 2008;18:122-124. 8. huang y, chen c, yang c, yao m, chan wp. tumoral calcinosis-like metastatic calcifications in a patient on renal dialysis. j clin imaging 2006;30:66-68. 9. alusik s, neradova m, galianova a, zdimera a. tumoral calcinosis in a dialysis patient. med sci monit 1998;4:874-876. 10. eisenberg b, tzamaloukas ah, hartshorne mf, listrom mb, arrington er, sherrard dj. periarticular tumoral calcinosis and hypercalcaemia in a haemodialysis patient without hyperparathyroidism: a case report. j nucl med 1990;31:1099-1103. 11. zins b, zingraff j, basile c. tumoral calcifications in haemodialysis patients: possible role of aluminium intoxication. nephron 1992;60:260-267. 12. last jm. a dictionary of epidemiology. 3rd ed. new york: oxford university press, 1995:15,171. quiz case sa journal of radiology • september 2011 101 paediatric neuropathology s k misser, mb chb, fcrad (d) lake smit and partners, durban j f roos, mb chb, mmed (paed) parklands hospital, durban corresponding author: s misser (shalendramisser@hotmail.com) presentation a 10-month-old child presented with spasticity, regression of milestones and irritability. the following images were obtained (figs 1 5). nonspecific eeg abnormality was also documented. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@ hotmail.com not later than 1 november 2011. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. 1 2 3 fig. 3 is an axial inversion recovery sequence. 4a 4b figs 4a and 4b are axial preand post-gadolinium sequences respectively. 5a 5b figs 5a and 5b are axial preand post-gadolinium sequences respectively. figs 1 and 2 are axial t2-w mri sequences. original article original article 14 sa journal of radiology • march 2007 original article abstract background. current practice at our institution for routine abdominal ct includes coverage from the diaphragm to the symphysis pubis and therefore includes pelvic organs. limited upper abdominal imaging exists in other modalities, and tailoring the examination to pathology will result in higher positive yield. objective. to determine if the pelvic component of a routine abdominal ct scan contributes to the final diagnosis in organ-specific upperabdominal pathology. methods. this was a retrospective study spanning a 14-month consecutive period; all abdominal cts for organ-specific upper-abdominal pathology were included. there were no age or gender limitations. patients with multi-organ involvement such as lymphoma and tb were excluded. the consultant radiologists’ reports were evaluated for the indication, preceding investigations, presence of pelvic pathology and final ct diagnosis. results. of 133 ct studies done, 116 did not show any abnormality in the pelvis. in 3 cases there were pelvic abnormalities that contributed to making the final diagnosis. independent review of these cases by 4 consultant radiologists with masking of the pelvic cuts did not influence the final outcome. in 5 cases free fluid was noted and in 9 cases there were incidental findings with no impact on the final diagnosis. conclusions. it is not essential to include the pelvis in the field of radiation in scanning specific upper-abdominal pathology, with the exclusion of staging a known renal mass and imaging renal calculi. introduction current practice at our institution for routine abdominal ct includes coverage from the diaphragm to the symphysis pubis and therefore includes pelvic organs. this study aimed to determine whether the pelvic component of a routine abdominal ct for upper-abdominal pathology contributes to the final diagnosis, and if not to exclude it from the protocol and reduce ionizing radiation to the pelvis as well as improve patient throughput (both beneficial to the patient). the most common indications for abdominal ct at our institution include: obstructive jaundice, pancreatitis, complicated renal cysts and liver lesions all upper-abdominal pathology. the question arises whether the pelvis receives unnecessary radiation in many patients.1 limited upper-abdominal imaging is common practice and is used in other modalities such as us and mri.2,3 many protocols for specific upper-abdominal pathology exist4 and wide variations of these are in use.5 federle and blachar6 believe that a standard abdominal ct does not exist and that all investigations should be tailored to the pathology. it has also been found that abdominal ct performed for generalised abdominal pain with poor clinical examination and laboratory results has a very low positive yield.7 it is mainly in oncology and staging examinations that the pelvis is included as a routine part of the study. objective the aim of the study was to determine if the pelvic component of a routine abdominal ct contributes to the final diagnosis in organ-specific upper-abdominal pathology. methods a retrospective study was done spanning a consecutive 14-month period; all abdominal cts for organ-specific upper-abdominal pathology (hepatobilliary, pancreatic, splenic, adrenal and renal abnormalities) were included. the mean age was 51.6 years. the oldest patient was 91 and the youngest patient 2 years of age. abdominal cts where multi-organ involvement was suspected, i.e. lymphoma, abdominal tb and trauma, were excluded. the request forms and consultant radiologist’s reports were evaluated for: (i) indications and presenting symptoms; (ii) preceding investigations, specifically abdominal us; (iii) findings of us investigation with specific reference to findings in the pelvis; (iv) the presence or absence of pelvic pathology on ct; and (v) the final ct diagnosis by the radiologist. results one hundred and thirty-three ct studies met the inclusion criteria. of these, 116 did not show any abnormality in the pelvis. in 3 cases pelvic abnormalities contributed to making the final diagnosis. the first patient had chronic pancreatitis and was scanned for evaluation of a possible pancreatic mass. matted bowel loops were found in the pelvis. complicated pancreatitis or possible underlying malignancy of the pancreas was suggested as a diagnosis. the second patient had hepatocellular carcinoma. no pathology was noted in the pelvis, but the right iliac wing and l5 vertebral body demonstrated metastases. the third patient had diabetes mellitus and a mass in the right kidney on us. hydroureteronephrosis was present, with multiple renal abscesses. a level of obstruction was identified on ct due to an enlarged uterus compressing the right ureter. to evaluate the ability to make the correct diagnosis in the above 3 cases without the pelvic images, 4 independent consultant radiologists reported the cases with masking of the pelvic cuts. the results are presented in table i, and indicate that in all 3 cases the individual reports contained the same conclusion, and were able to confirm the diagnosis as reported on the initial study. 14 sa journal of radiology • march 2007 ct for upper abdominal pathology is imaging of the pelvis necessary? c ackermann, mb chb, mmed rad (d), mrcs (uk) s andronikou, mb bch, fcrad (d), frcr, phd a erlank, mb chb j j parsons, mb chb, mmed rad (d) g cilliers, mb chb, mmed rad (d) department of radiology, university of stellenbosch and tygerberg hospital pg14-18.indd 14 2/26/07 1:55:19 pm original articleoriginal article 15 sa journal of radiology • march 200715 sa journal of radiology • march 2007 table i. results of independent radiologist review patient radiologist 1 radiologist 2 radiologist 3 radiologist 4 1 1) lymphoma 1) pancreatitis 1) exudative pancreatitis 1) pancreas head ca 2) pancreas head ca 2) pancreas head ca 2) pancreatitis 3) focal pancreatitis 2 1) liver and bony metastases 1) hepatocellular ca 1) hepatocellular ca 1) hepatocellular ca 2) hepatocellular ca 2) liver metastases 2) liver metastases 3 1) pyonephrosis, hydro1) pyonephrosis, hydro1) pyonephrosis, hydro1) renal abscess, hydro ureteronephrosis ureteronephrosis ureteronephrosis ureteronephrosis the differential diagnoses are presented in most likely order where applicable. final diagnosis: 1. complicated pancreatitis. 2. hepatocellular carcinoma. 3. pyonephrosis, hydroureteronephrosis. table ii. indications for ct scanning symptoms / organ related organ-specific indications number (%) liver hepatocellular carcinoma 4 (3) hepatoblastoma 4 (3) liver mass 3 (2.2) metastases 2 (1.5) liver abscess 1 (0.7) liver cirrhosis 1 (0.7) hepatospenomegaly 3 (2.2) portal hypertension 1 (0.7) spleen splenomegaly 1 (0.7) pancreas pancreatitis (acute/chronic) 9 (6.8) pancreas head carcinoma 4 (3) adrenals adrenal mass 2 (1.5) kidneys renal cell carcinoma 25 (18.7) cysts 4 (3) abscess/pyonephroses 3 (2.2) renal calculi 2 (1.5) angiomyolipoma 1 (0.7) stomach stomach outlet obstruction 2 (1.5) stomach carcinoma 2 (1.5) gallbladder/bileducts gallbladder carcinoma 2 (1.5) cholangiocarcinoma 1 (0.7) cholangitis 1 (0.7) obstructive jaundice 25 (18.7) right hypochondrial pain 9 (6.8) left hypochondrial pain 1 (0.7) right flank mass 3 (2.2) right flank pain 4 (3) epigastric pain 5 (3.7) epigastric mass 7 (5.2) gastrointestinal haemorrhage 1 (0.7) pg14-18.indd 15 2/26/07 1:55:19 pm original article original article 16 sa journal of radiology • march 2007 original article in 5 cases (3.7%), free fluid was noted in the pelvis which did not influence the final diagnosis, but contributed to a complete evaluation. in 9 cases (6.8%), incidental findings were noted on ct with no impact on the final diagnosis. these were ovarian cysts (n = 4), prostate calcifications (n = 2), uterine myomas (n = 2), and fluid in the uterus (n = 1). prior to ct investigation, 89 patients had us examinations (67%); of these only 59 could be retrieved. in 56 cases no pelvic pathology was reported, 2 cases demonstrated enlarged prostates and in 1 case free fluid was noted in the pelvis. the commonest requests for ct scanning were evaluation for obstructive jaundice (n = 25, 18.8%) and complicated renal cysts/exclusion of renal cell carcinoma (n = 25, 18.8%). liver pathology as a group also ranked high on the request list (table ii). the final diagnoses are listed in table iii, of which the most common were pancreas head carcinoma (n = 14, 10.5%), pancreatitis (n = 13, 9.8%), renal cell carcinoma (n = 12, 9%) and cholangiocarcinoma (n = 11, 8.2%). the indeterminate or non-specific findings comprised 33% of the group (n = 44), and there was a total of 12 normal studies (9%). discussion with the technical advances in ct scanning, the quality of imaging has improved dramatically, especially with regard to: decrease in scanning time, elimination of respiratory misregistration artifacts, imaging during optimal parenchymal as well as vascular contrast enhancement,8 and reconstructing images retrospectively.5 it is also generally accepted that previous poor visualisation of the liver and pancreas can be ascribed to the use of a general standard abdominal ct protocol for upper-abdominal pathology.6 in this study most of the requests for abdominal ct were aimed at resolving specific problems. in these cases the patients had several investigations prior to scanning to identify the pathology more accurately and to limit the list of differential diagnoses. this supports the findings of previous studies looking at the positive yield of abdominal ct scans.7,9 in the light of this it can be concluded that when faced with a specific request / problem, the radiologist’s approach must be tailored to address this and plan the ct scan accordingly.5 recently, it was noted that up to 40% of all ct examinations in children have questionable indications. clinical information will help guide the radiologists’ choices of imaging modalities (e.g. sonography or mr imaging replacing ct) and protocols or techniques.10 for this reason, we wanted to evaluate preceding us examinations and establish the correlation of pathology noted in the pelvis on us with abnormalities on ct, and whether us can be used as a good sorting tool.11,12 eighty-nine patients had us prior to scanning. in the 56 retrieved studies no pathology was demonstrated in the pelvis, which correlated well with the ct scan. an incidental finding of an enlarged prostate in 1 case was not reported on the ct scan. in 5 cases pelvic pathology noted on ct was not reported on the us, namely incidental prostate calcifications (n = 2), ovarian cyst (n = 1), and free fluid (n = 2). it is accepted that us is both sensitive and specific for detecting free fluid in the abdomen and pelvis.13,14 free fluid was missed in the pelvis of 2 patients. possible reasons for the discrepancy could be a time difference between us and ct scan, operator dependence and poor evaluation of the pelvis as directed by a request for upper-abdominal pathology. the most common requests for ct scan at our institution were evaluation of obstructive jaundice and complicated renal cysts. the most common diagnoses made were adenocarcinoma of the pancreas, pancreatitis, renal cell carcinoma and cholangiocarcinoma. the literature quoted deals mainly with common imaging findings in specific upper-abdominal pathology and some advice on scanning protocols. one article10 pertinently discusses the issue of inclusion of the pelvis in the field of imaging, mainly relating to paediatric patients. frush10 states that the ct scan can be designed to answer a specific question and this means that pelvic scanning is not always necessary with an abdominal scan, and that follow-up ct examinations do not necessarily need to be full abdomen or chest examinations. he also makes the point that ct likely accounts for the single largest radiation exposure after background. this data precedes the newest mdct, and it is likely that the increasing use will continue to accelerate.10 review of the literature states that the most common pancreatic table iii. most common diagnoses made in this study diagnosis n % pancreas head carcinoma 14 10.5 pancreatitis 13 9.8 renal cell carcinoma 12 9 cholangiocarcinoma 11 8.3 hepatocellular carcinoma 9 6.8 simple renal cysts 8 6 autosomal-dominant polycystic kidney disease and hepatoblastoma 5 3.7 renal abscess, echinococcus cysts, liver metastases and stomach carcinoma 3 2.2 liver abscess, adrenal adenoma and gallbladder carcinoma 2 1.5 other 44 33 normal 12 9 pg14-18.indd 16 2/26/07 1:55:19 pm original articleoriginal article 17 sa journal of radiology • march 2007 pathology demonstrated on ct is pancreatitis and pancreatic adenocarcinoma.15 adenocarcinoma is the most common malignant pancreatic tumour, affecting the head of the pancreas in 60 70% of cases.16 today, ct is the most commonly used imaging method in the assessment of pancreatic tumours.17 on imaging the primary tumour is a hypoattenuating mass, usually well visualised on the pancreatic phase (a circulation phase corresponding in timing to the late arterial/portal vein inflow phase, when the pancreatic parenchyma is enhanced more than hepatic parenchyma)15 (figs. 1a and b). cephalocaudate coverage for the pancreatic phase, as used by w dennis foley, is from the diaphragm to the inferior margin of the pancreas, and is usually less in extent than for a hepatic mdct study. imaging is used to assess resectability, extrapancreatic spread and metastases. nonresectable tumours invade the peripancreatic tissue planes to encase the celiac axis and superior mesenteric artery, the superior mesenteric vein and portal vein confluence, as well as the hepatoduodenal ligament and hepatic hilum. other signs of nonresectability include peripancreatic lymphadenopathy, hepatic metastases, and peritoneal carcinomatosis, the latter usually associated with either infiltration of the root of the mesentery or the transverse mesocolon.15 none of the above important findings relate to possible abnormalities in the pelvis. we confirmed this in our study, with no significant pathology noted in the pelvis of all the patients finally diagnosed with adenocarcinoma of the pancreas. in one patient with pelvic abnormality on ct (matted bowel loops), free fluid was documented on the preceding us and could have alerted the radiologist to pathology in the pelvis and subsequent alteration of scanning method if deemed necessary. masking of the pelvic cuts did not alter the outcome of the final ct report. in acute pancreatitis, the major imaging findings are pancreatic necrosis, peripancreatic effusion and pseudocyst, and the possible complications of peripancreatic venous thrombosis and gastrointestinal fistulisation. a double pass pancreatic technique is advised consisting of a pancreatic and hepatic phase, with coverage as described above for adenocarcinoma of the pancreas.15 malignant biliary obstruction is usually secondary to pancreatic adenocarcinoma or is due to cholangiocarcinoma of the common bile, or common hepatic duct (including the bifurcation, collectively called hilar), or the intrahepatic bile ducts (peripheral). cholangiocarcinoma is an adenocarcinoma that arises from the bile duct epithelium and is the second most common primary hepatobiliary cancer, after hepatocellular cancer, accounting for 5 – 30% of all primary hepatic malignant tumours.18,19 frequently these patients will have had sonography, ercp or mrcp, with the level of obstruction having been identified and the figs 1a and b. adenocarcinoma of the uncinate/head of pancreas. fig. 1a. abdominal ct in the late arterial phase demonstrating a dilated pancreatic duct as well as common bile duct. the body and tail of the pancreas appear atrophic. fig. 1b. an ill-defined low-density mass is present in the head/uncinate process of the pancreas. note clear separation from the sma and smv, but close approximation to the duodenum. no regional lymphadenopathy is present. fig. 2. abdominal ct in the portovenous phase demonstrating a distended gallbladder, severe intra/extra hepatic bile duct dilatation and a lobulated, enhancing mass in the distal common bile duct in keeping with a cholangiocarcinoma. pg14-18.indd 17 2/26/07 1:55:19 pm original article original article 18 sa journal of radiology • march 2007 likely diagnosis of pancreatic adenocarcinoma or cholangiocarcinoma established.15 cholangiocarcinomas may be limited to the bile duct and adjacent periductal tissues, being either infiltrating or polypoid in configuration (fig. 2). alternatively, the tumour may present as a mass lesion at the hepatic hilum and be associated with perihepatic adenopathy.15 the major issue of imaging this tumour is to determine whether the tumour is resectable,20 and with local infiltration they have a dismal prognosis if left untreated, with a mean survival of approximately 3 months after the initial presentation.21 information needed is therefore concentrated on the liver, with imaging of the pelvis becoming superfluous. wd foley believes the average cephalocaudate distance of the liver, approximately 16 cm, allows the cephalocaudate hepatic span, in the majority of patients to be accomplished in 20 cm of scan coverage. in addition the hepatic phase is extended to include the whole abdomen, and possibly pelvis, to evaluate for extrahepatic disease.15 in one of our patients diagnosed with hepatocellular carcinoma pelvic bone and lumbar vertebral metastases (l5), would not have been diagnosed had the pelvis not been included. these findings were missed by 3 of the observing radiologists when reporting the masked ct scans, but one radiologist observed the l5 metastases. known ct protocols for the evaluation of possible liver mass/ hepatocellular carcinoma do not include the pelvis routinely.22 renal cell carcinoma (rcc) is the most common cancer of the kidney, accounting for approximately 2 3% of adult malignancies.23 radical cancer surgery remains the only curative treatment in localised and advanced rcc. therefore, preoperative imaging is most important for planning of the surgical approach and strategy. the aim of preoperative imaging in rcc is to differentiate benign from malignant lesions, to adequately assess tumour size, localisation and organ confinement, to identify lymph node and/or visceral metastases, and to reliably predict the presence and extent of any thrombus of the vena cava.24 rcc can appear iso-, hyper-, or hypodense on uncontrasted ct scans, and usually demonstrates a significant contrast enhancement of about 115 hu and intratumoural areas of necrosis. the detection of visceral metastases appears to be crucial since it has been shown that even patients with metastatic disease might benefit from radical nephrectomy followed by immunotherapy. involvement of the renal vein and inferior vena cava with tumour thrombus will change surgical strategy.24 this is important in all known cases of rcc. although comprehensive renal mass evaluation protocol provides a more thorough patient evaluation, only a small fraction of indeterminate renal masses seen on us are malignant and a targeted renal ct imaging protocol is suggested for evaluation of indeterminate renal masses incidentally discovered on us.25 in one of our patients hydronephrosis was present but a possible level of obstruction not identified. the radiologist however would notice the hydonephrosis and suggest lower cuts to identify the collecting system (especially in view of an us indicating hydronephrosis). in standard renal imaging, the pelvis is only included in cases of possible renal calculi and staging of known renal masses (not suspected renal lesions).4, 26-29 conclusion in this study only 3 of 133 cases demonstrated significant pelvic abnormalities on ct scans done for specific upper-abdominal pathology. masking of the pelvis did not influence the outcome of the final diagnosis, and therefore it can be concluded that it is not essential to include the pelvis in the field of radiation in these cases. the literature however recommends the inclusion of the pelvis in the following scenarios: 1. staging of a known renal mass. the collecting system must be imaged in the event of a possible transitional carcinoma. 2. imaging of renal calculi. 3. some authors include the pelvis with assessment of liver metastases. the value of us investigation as a sifting tool may be underestimated and its value needs to be evaluated formally. 1. cohnen m, poll lj, puettmann c, ewen k, saleh a, modder u. effective doses in standard protocols for multi-slice ct scanning. eur radiol 2003; 13: 1148-1153. 2. oh ky, gilfeather m, kennedy a, et al. limited abdominal mri in the evaluation of acute right upper quadrant pain. abdom imaging 2003; 28: 643-651. 3. ramsay dw, markham dh, morgan b, rodgers pm, liddicoat aj. the use of dilute calogen as a fat density oral contrast medium in upper abdominal computed tomography, compared with the use of water and positive oral contrast media. clin radiol 2001; 56: 670-673. 4. tomiak mm, foley wd, jacobson dr. variable-mode helical ct: imaging protocols. am j roentgenol 1995; 164: 1525-1531. 5. o’malley me, halpern e, mueller pr, gazelle gs. helical ct protocols for the abdomen and pelvis: a survey. am j roentgenol 2000; 175: 109-113. 6. federle mp, blachar a. ct evaluation of the liver: principles and techniques. semin liver dis 2001; 21: 135-145. 7. benson m, bree rl, schwab re, ouimette m. computed tomographic studies of the painful abdomen. radiology 1985; 155:443-444. 8. foley wd, mallisee ta, hohenwalter md, wilson cr, quiroz fa, taylor aj. multiphase hepatic ct with a multirow detector ct scanner. am j roentgenol 2000; 175:679-685. 9. ward m. upper abdominal pain-management issues. aust fam physician 1994; 23:331-336. 10. frush dp. review of radiation issues for computed tomography. semin ultrasound ct mr 2004; 25(1): 17-24. 11. niu l, hao y, zhou c, dai j. diagnostic significance of ultrasonography and ct for large upper abdominal mass. chin med j (engl) 2002; 115: 1358-1362. 12. ditchfield mr, de campo jf, waters kd, nolan tm. wilms’ tumour: a rational use of preoperative imaging. med pediatr oncol 1995; 24:93-96. 13. poletti pa, kinkel k, vermeulen b, irmay f, unger pf, terrier f. blunt abdominal trauma: should us be used to detect both free fluid and organ injuries? radiology 2003; 227(1): 95-103. 14. lentz ka, mckenney mg, nunez db jr, martin l. evaluating blunt abdominal trauma: role for ultrasonography. j ultrasound med 1996; 15: 447-451. 15. foley wd, kerimoglu ulku. abdominal mdct: liver, pancreas and biliary tract. semin ultrasound ct mr 2004; 25: 122-144. 16. schima w, ba-ssalamah a, kolblinger c, kulinna-cosentini c, puespoek a, gotzinger p. pancreatic adenocarcinoma. eur radiol 2006, epub ahead of publication. 17. gritzmann n, macheiner p, hollerweger a, hubner e. ct in the differentiation of pancreatic neoplasms – progress report. dig dis 2004; 22(1): 6-17. 18. slattery jm, sahani dv. what is the current state-of-the-art imaging for detection and staging of cholangiocarcinoma? oncologist 2006; 11: 913-922. 19. soyer p, bluemke da, reichle r,et al. imaging of intrahepatic cholangiocarcinoma: 1.peripheral cholangiocarcinoma. am j roentgenol 1995; 165: 1427-1431. 20. soyer p, bluemke da, reichle r, et al. imaging of intrahepatic cholangiocarcinoma: 2.hilar cholangiocarcinoma. am j roentgenol 1995; 165: 1433-1436. 21. byun jh. radiological staging of hilar cholangiocarcinoma. korean j gastroenterol 2005; 46(1): 7-15. 22. spiral ct protocols. http//www.ctisus.org. 23. kim j. imaging findings of renal cell carcinoma. expert rev anticancer ther 2006; 6: 895-904. 24. heidenreich a, ravery v, european society of oncological urology. world j urol 2004; 22:307-315. 25. prasad sr, saini s, stewart s, hahn pf, halpern ef. ct characterization of ‘indeterminate’ renal masses: targeted or comprehensive scanning? j comput assist tomogr 2002; 26:725-727. 26. bosniak ma. the small (< 3.0 cm) renal parenchymal tumour; detection, diagnosis, and controversies. radiology 1991; 179:307-317. 27. davidson aj, hartman ds, choyke pl, wagner b. radiologic assessment of renal masses; implications for patient care. radiology 1997; 202:297-305. 28. mcnicholas mm, raptopoulos vd, schwartz rk, et al. excretory phase ct urography for opacification of the urinary collecting system. am j roentgenol 1998; 170:1261-1267. 29. kassouf w, aprikian ag, laplante m, tanguay s. natural history of renal masses followed expectantly. j urol 2004; 171(1): 111-113. pg14-18.indd 18 2/26/07 1:55:20 pm case report case report 42 sa journal of radiology • july 2008 case report introduction meconium peritonitis results from intrauterine gastrointestinal perforation, and can occur as early as the second trimester.1 meconium extrudes into the peritoneal cavity, inciting an intense fibroplastic reaction that results in intra-abdominal calcifications.2 it is a rare condition occurring in 1 in 35 000 pregnant women.3 the clinical and radiological manifestations depend on whether the bowel perforation seals off in utero in the neonatal period or remains patent.3 accordingly, the radiological spectra range from the incidental demonstration of diffuse intra-abdominal calcifications to meconium ascites (free meconium in the peritoneal cavity), meconium pseudocysts (walled-off meconium concentrations), and meconium hydrocoeles. meconium has also been reported in the thoracic cavity (via diaphragmatic hernias) and in the pelvic soft tissues.4 antenatal ultrasound allows early detection of the condition, demonstrating free fluid, hydrocoeles and echogenic foci representing intraperitoneal calcifications.5 in the newborn, plain abdominal radiographs demonstrating calcifications and/or ascites are sufficient for diagnosis.1 postnatal ultrasound is reserved for atypical presentations and can exclude intra-abdominal masses.1 although computed tomography (ct) was used as an ancillary tool in the case report described below, it is unnecessary, thus negating the need for radiation exposure and expenditure of time. the imaging findings in a newborn with an ongoing bowel perforation, resulting in gross meconium ascites, is presented below. this case report serves also to describe the pathogenesis, radiological spectra, role of imaging and causes of meconium peritonitis. case report a newborn presented with increased abdominal girth and a clinical suspicion of ascites. the mother had been a late booking at the antenatal clinic and was sent to the ultrasound department for an estimation of gestational dates. the fetus’ measurements were estimated at 31 weeks and an incidental finding of a ‘hydrocoele’ was noted. unfortunately, for reasons unknown to us, the hydrocoele was not investigated further and the next presentation was at delivery. a 3 kg boy was born at 37 weeks’ gestation following an uncomplicated delivery with good apgar scores. on examination, the newborn had a markedly distended abdomen and scrotum with an abdominal girth of 40 cm. the abdomen was described as ‘shiny’ with poor bowel sounds. diaphragmatic motion appeared restricted as a result of the increased abdominal pressure, resulting in mild respiratory distress. an abdominal radiograph, ultrasound and ct scan were performed by the on-call registrar and were reviewed by the consultant with the suggested diagnosis of meconium peritonitis. the abdominal radiograph (fig. 1) revealed a massively enlarged abdomen with elevated hemidiaphragms, resulting in small lung capacities. the central floating bowel loops, bulging flanks and loss of soft tisimaging findings of meconium peritonitis logeshini naidoo, mb chb, fcrad (diag) sa helen joseph and coronation hospitals, johannesburg fig. 1. supine abdominal x-ray revealing a massively distended abdomen with poor lung capacities. the bulging flanks and central floating bowel loops indicate ascites. note the intra-abdominal calcifications. fig. 2. transverse section cut on abdominal ultrasound depicting echogenic material with a ‘snowstorm’ appearance. imaging findings.indd 42 8/1/08 10:06:32 am case reportcase report sue planes and properitoneal lines were indicative of ascites. there were intraperitoneal calcifications that appeared to be irregular and scattered through the abdomen. no free air was visualised. ultrasound (figs 2 and 3) demonstrated complex fluid. this highly echogenic material spread throughout the abdomen to produce a ‘snowstorm’ appearance. clumped echogenic foci depicting the intraperitoneal calcifications were scattered around bowel loops. dense calcifications with shadowing were demonstrated in the scrotum. a ct scan (fig. 4) confirmed the complex fluid extending into the scrotum. calcifications were seen at the periphery of the fluid and interspersed among posteriorly displaced bowel loops. bowel loops appeared dilated. central free air (not visualised on plain films) was demonstrated on ct. air usually enters the small bowel within 3 hours of birth.1 as ct was the last investigation performed, free air penetrated the ongoing perforation and was visible on ct but not on the plain abdominal radiograph which was done immediately after birth. the final diagnosis was meconium ascites with an ongoing perforation. at exploratory laparotomy, an ileal perforation was demonstrated. copious amounts of meconium were removed. a portion of necrotic bowel was removed at ileostomy. no identifiable causes were found. discussion meconium peritonitis results from prenatal intestinal perforation nearly always involving the small bowel.5 meconium and digestive enzymes are extruded into the peritoneal cavity, inciting an intense chemical peritonitis and secondary inflammatory response.5 within days, giant cells and histiocytes surround the meconium, resulting in foreign body granulomas.5 these often calcify, resulting in the characteristic intraperitoneal deposits identified prior to birth via antenatal ultrasound and after birth with plain radiography.5 the calcifications appear amorphous and irregular on plain radiographs.1 antenatal and postnatal ultrasound depicts these calcifications as highly echogenic linear or clumped foci exhibiting posterior acoustic shadowing.5 ancillary features on antenatal sonar include polyhydramnios, fetal ascites and bowel dilatation.5 calcific plaques may be the only finding on incidental radiographs and antenatal ultrasound when perforations are small and seal off in utero.3 eventually, most of these disappear; it is rare to encounter an older child with residual calcifications.1 hydrocoeles may also occur in cases of spontaneous perforation closure in utero. they result when meconium migrates into the fetal scrotum via a patent processus vaginalis. meconium interacts with the tunica vaginalis to incite an intense inflammatory reaction resulting in local calcifications.1 meconium pseudocysts may also present in this category. they present as walled-off concentrations that display a mass effect mimicking abdominal tumours.1 meconium ascites and pseudocysts result from perforations that seal off/remain patent after birth. meconium peritonitis, as in our case, features bulging flanks and central bowel loops on plain radiographs. ante/postnatal sonar demonstrates highly echogenic material spreading through the abdomen and around bowel loops.2 this results in multiple speckled echoes and has been described as a ‘snowstorm’ appearance.2 pseudocysts may feature heterogenous collections as a result of debris and calcifications.2 ongoing perforations display free air or encysted air pockets. the radiological categorisation mentioned above is essential for management. surgical intervention, for example, is required to eliminate obstructing meconium, for respiratory compromise, and ongoing perforations. prior to delivery, meconium is sterile; however, bacterial contamination can occur after delivery, and severe meconium ascites should therefore be cleared. the causes of meconium peritonitis include bowel obstruction from strictures, small bowel atresia, volvulus, intussusception, and meconium ileus from cystic fibrosis (cf).2 the cause is sometimes idiopathic, as in this case.2 43 sa journal of radiology • july 2008 fig. 3. high-resolution abdominal sonar showing echogenic foci in keeping with calcifications at the periphery of organs. fig. 4. axial ct revealing anterior intraperitoneal free air. the meconium ascites causes posterior displacement of bowel loops. note the peripheral calcifications. imaging findings.indd 43 8/1/08 10:06:33 am case report case report 44 sa journal of radiology • july 2008 foster et al.5 found that meconium peritonitis diagnosed in utero was associated with causes other than cf. interestingly, this study also found that the presence of abdominal calcifications was associated with causes of meconium peritonitis other than cf. there are different proposals to explain this: some feel that pancreatic enzymes that are deficient in 80% of patients with cf may be necessary for calcifications to occur; others speculate that the abnormal, thick and tenacious meconium that is characteristic of cf cannot spill freely into the peritoneal cavity, resulting in a poor inflammatory response, and hence poor calcifications. most babies with meconium peritonitis do well. at one time, this condition carried a poor prognosis, but this has changed with advances in surgical techniques and postoperative care, with recent literature indicating a 100% survival.7 conclusion the division of meconium peritonitis into groups depending on whether the perforation occurred in utero or neonatally is necessary for determining the type of management. surgical management is essential in conditions of respiratory compromise, meconium ascites, and ongoing perforation. improvements in antenatal clinics in south africa are leading to earlier detection by antenatal ultrasound. earlier detection will alert the neonatologist, obstetrician and paediatric surgeon to possible complications such as dystocia, respiratory distress, bacterial peritonitis, acidbase disturbances and septic shock.6 in the postnatal period, plain radiographs are usually sufficient for diagnosis.1 ultrasound is indicated for atypical presentations and to exclude other causes. the use of ct, while adhering to alara principles of paediatric radiology, is not indicated, though it proved useful in demonstrating free air in this case. it is also useful for the radiologist and sonographer to know that most antenatally diagnosed cases of meconium peritonitis are unrelated to cf, and that patients with cf rarely present with intraperitoneal calcifications.5 1. hekmatnia a, mchugh k. meconium ileus. emedicine [updated 21 july 2005] http://www.emedicine. com/radio/topic 427.htm (accessed 22 december 2007). 2. berrocal t, lamas m, gutierrez j, et al. congenital anomalies of the small intestine, colon and rectum. radiographics 1999; 19: 1219-1236. 3. catanzarite v, wozniak p, maida c, et al. meconium peritonitis. thefetus.net [updated 1993-08-22-12] http://www.thefetus.net/page.php?id=252 (accessed 22 december 2007). 4. salman a, karaoglanoglu n, suma s. abdominal, scrotal, and thoracic calcifications owing to healed meconium peritonitis. j pediatr surg 1999; 34: 1415-1416. 5. foster m, nyberg d, mahony b, et al. meconium peritonitis: prenatal sonographic findings and their clinical significance. radiology 1987; 165: 661-665. 6. mcgahan j, hanson f. meconium peritonitis with accompanying pseudocyst: prenatal sonographic diagnosis. radiology 1983; 148: 125-126. 7. reynolds e, douglass b, bleacher j. meconium peritonitis. j perinatol 2000; 3: 193-195. imaging findings.indd 44 8/1/08 10:06:34 am editorial.html the south african journal of radiology goes go rad! the sajr took a major step towards international recognition when eric stern, editor of go rad, extended an invitation to the editorial board to join a 2-year-old consortium of 30 continental/multinational/national society journals. eric stern is a professor of radiology at the university of washington, usa, and specialises in thoracic imaging. go rad (global outreach-radiology  – www.isradiology.org/gorad) is a global outreach programme of the international society of radiology. their aim is greater global exchange of radiological knowledge and a positive influence on healthcare, by providing a vehicle for worldwide dissemination of appropriate peer-reviewed published educational and scientific content for radiologists and related healthcare providers. with articles chosen as those most appropriate to developing nations and medically underserved areas, go rad helps to increase the visi-bility and global outreach of co-operating journals and the authors of selected articles, as well as to bring together senior editors of the sponsoring organisations. partnering society journals agree to provide select open access immediately on publication to appropriate content (e.g. one article per issue). the mechanics are that go rad simply places hyperlinks from the selected go rad articles back to the respective home journal. since the sajr is a quarterly open-access journal, it is easy to link the content. an example from sajr vol. 15 no. 3 is: pseudomyxoma peritonei (pmp) a rare entity http://www.sajr.org.za/index.php/sajr/article/view/344   eric stern states the following in his invitation: ‘in summary, although your journal is open access, we warmly welcome you and your publisher to be active participants and stake-holders in go rad, helping us to create a more valuable and coordinated global outreach effort.’   access the go rad newsletter and announcement of the latest issue at http://isradiology.org/gorad/news/2011/2011_7.html. here you will find freely available links to timely and topical articles from many of the world's leading radiology journals. in the latest issue, there are many new open-access articles on a variety of interesting topics, e.g. ‘incidence and significance of inconclusive results in ultrasound for appendicitis in children and teenagers’, ‘normal mediastinal and hilar lymph nodes in children on multi-detector row chest computed tomography’, ‘multidetector computed tomography of spinal trauma: a pictorial review’ and ‘spectrum of medication-induced complications in the abdomen: role of cross-sectional imaging’. help us to spread the word about this valuable international radiology educational resource – tell your colleagues and friends! please send feedback to professor stern at: editor.gorad@gmail.com. dissertation development it has come to the notice of the editorial board that publication of an mmed dissertation as an original article in the south african journal of radiology is accepted as an alternative and reciprocal document for the mmed degree by a number of academic institutions. the editorial board welcomes this development and intends facilitating the process by expediting dissertation material for early publication. a number of issues remain unresolved, however, and i ask for assistance from registrars, heads of academic departments, the rssa executive, college office bearers and the health & medical publishing group publication team. manuscripts must be clearly marked and uploaded on the webpage as a university dissertation. all dissertations presently in the pipeline need to be identified to expedite publication. a review team consisting of south african academics needs to be constituted. presently, the most difficult and time-consuming aspect of the publication process is finding a reasonably qualified person as a reviewer in the field of expertise. clearly, dissertations constitute a different exercise, to be evaluated at a different academic level. if we intend using the journal as a vehicle for publication of university research material, then the process of validation and peer review has to be transparent and beyond reproach. suggestions, opinions and constructive criticism are needed. this is part of an evolutionary process towards a single-exit examination in radiology. at the same time, there is a natural stimulus for research and a constant flow of quality original research material to our journal. we need to plan correctly to ensure academic and ethical excellence at all times. jan lotz editor-in-chief editorial 44 sa journal of radiology • june 2010 abdominal imaging diagnosis quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban findings and diagnosis please refer to page 21 of the march 2010 issue of the sajr (http:// www.sajr.org.za/index.php/sajr/article/viewfile/422/354) for the clinical details and images. we congratulate dr richard de villiers of drs van wageningen and partners in somerset west for his precise diagnosis, for which he receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its radiological signs. diagnosis the plain radiographs are useful in clarifying the relevant negative findings. of note is the absence of intestinal obstruction on the abdominal radiograph (fig. 1a) and no free subphrenic air on the chest radiograph (fig. 1b). there is questionable mass effect in the central and right paramedian major pelvis on the abdominal radiograph. sonar (fig. 1c) revealed a right lower quadrant inflammatory mass with posterior acoustic shadowing and surrounding loculated fluid collection. the postcontrast ct scans (figs 2a-c) better define the central dense enhancing focus at the epicentre of the inflammatory process with surrounding wall thickening, fat stranding and fluid collection. mass effect on adjacent bowel loops and pelvic viscera is evident. at exploratory laporotomy, the inflammatory mass was identified, with omental wrapping preventing diffuse peritonitis. histopathology revealed an acutely inflamed meckel’s diverticulum with ectopic gastric tissue and haemorrhagic peptic ulceration, confirming the suggestion of meckel’s diverticulitis in our ct report. meckel’s diverticulum (md) is the most common congenital abnormality of the small bowel, estimated to occur in 2% of the population.1 although usually an innocuous anomaly, complications (including diverticulitis, haemorrhage and obstruction) bring up to 4%2 of these patients to accident and emergency centres (a&e centres) world-wide. of these, only a small proportion are found to be due to the presence of ectopic gastric tissue with haemorrhage. imaging studies are useful, but pre-operative diagnosis is rare. plain radiographs are largely used to identify intestinal obstruction or pneumoperitoneum. sonography may show the typical ‘gut signature’3 of the wall of the md in the inflammatory mass. angiography is used in patients with occult gastro-intestinal bleeding and suspected md. tc-99m pertechnetate (meckel scan) scintigraphy has an overall diagnostic accuracy of 90% in md with ectopic gastric mucosa,1 but has been less utilised with multi-slice ct advances prompting improved detection on ct scan. a high index of suspicion meckel’s diverticulitis must be maintained by the reporting radiologist in the presence of a loculated, central, or right central, lower abdomino-pelvic blind-ending bowel mass on ct scan. the diverticulum may contain fluid, air, faecal matter, enteroliths or any combination thereof.1,3 central mucosal enhancement and surrounding mesenteric inflammation is commonly noted. the principle differential consideration of appendicitis may be excluded with certainty when a separate normal appendix is visualised on ct. other differential diagnoses include inflammatory bowel disease, colitis, typhlitis, carcinoid or other bowel tumour, and pelvic inflammatory disease in females. 1. bennet gl, birnbaum ba, balthasar ej. ct of meckel’s diverticulitis in 11 patients. am j roentgenol 2004; 182: 625-629. 2. leijonarck ce, bonman-sandelin k, frisell j. meckel’s diverticulum in the adult. br j surg 1986; 73: 146–149. 3. levy ad, hobbs cm. from the archives of the afip. meckel diverticulum: radiologic features with pathologic correlation. radiographics 2004; 24: 565-587. case report 93 sa journal of radiology • december 2008 introduction diffuse signal changes in the liver on magnetic resonance imaging (mri) often represent a depositional process with a decreased signal when iron or copper is deposited or an increased signal with fatty deposition.1 such findings are often incidental when imaging is done to identify a cause for other symptoms or to assess for complications of primary pathology. case report a 68-year-old man presented to our hospital with myelodysplasia, a pre-leukaemic haematological disorder characterised by bone marrow malfunction, which leads to cytopenia of one or more cell lines. due to his recurrent anaemia, he had been transfused with 20 units of blood over a 4-month period. he was referred to radiology for mri of his liver to rule out malignant lesions. at the time of the scan, he had a ferritin level of 951 ng/ml (normal 20 100 ng/ml). mri signal changes in the liver following multiple transfusions m durand, mb chb department of radiology, grey's hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg j c abrahams, mb chb, fcrad diag (sa) kauffman and partners, pietermaritzburg fig. 2. unenhanced ct scan of the liver showing a hyperdense liver with an hu of 103 (normal value 54 601), with normal density of the spleen. fig. 1a. axial t1w images demonstrating decreased signal in the liver and spleen. fig. 1b. axial t2w image demonstrating t2 shortening in the liver and spleen. mri signal.indd 93 12/5/08 11:33:40 am case report case report 94 sa journal of radiology • december 2008 discussion in patients who receive multiple blood transfusions, the excess iron is initially deposited in the reticuloendothelial system of the liver, spleen and bone marrow as well as in the heart and endocrine system.2 this may eventually lead to complications such as transfusion haemosiderosis of the liver, cardiac failure, diabetes and inadequate hypothalamic-pituitary adrenal reserve. the iron that accumulates in the liver is paramagnetic and interacts with adjacent hydrogen nuclei to cause susceptibilityinduced relaxation owing to shortened proton relaxation times.3 this leads to decreased signal intensity of the liver on t1w, t2w and stir images4 (as shown in figs 1a and 1b). the increase in the 1/t2 relaxation rate of the liver is linearly related to the amount of blood transfused up to a level of 60 units, after which no significant increase is seen.5 the t2 relaxation rate of the spleen also changes after blood transfusion but is not related to the number of blood transfusions.4 bone marrow may show hypo-intensity secondary to iron deposition after transfusion. no relationship has been demonstrated between bone marrow t2 relaxation rates and serum ferritin levels, or between liver and spleen 1/t2 relaxation.6 iron deposition may be seen as increased density in the liver and spleen on ct, but is less readily quantifiable (fig. 2). conclusion multiple transfusions result in iron deposits in the reticuloendothelial system, heart and endocrine system. awareness of the signal changes when incidentally identifying this will avoid misdiagnoses. in addition, t2w mri can be used as a prognostic tool to quantitatively determine true iron levels in the liver. 1. grainger rg. grainger & allison’s diagnostic radiology: a textbook of medical imaging. 4th ed. london: churchill livingstone, 2001: 1242. 2. schafer ai, cheron rg, dluhy r, et al. clinical consequences of acquired transfusional iron overload in adults. n engl j med 1981; 304(6): 319-324. 3. brittenham gm, badman dg. noninvasive measurement of iron: report of an niddk workshop. blood 2003; 101(1): 15-19. 4. bondestam s, lamminen a, anttila vj, ruutu t, ruutu p. magnetic resonance imaging of transfusional hepatic iron overload. br j radiol 1994; 67(796): 339-341. 5. salo s, alanen a, leino r, bondestam s, komu m. the effect of haemosiderosis and blood transfusions on the t2 relaxation time and 1/t2 relaxation rate of liver tissue. br j radiol 2002; 75(889): 24-27. 6. johnston dl, rice l, vick gw 3rd, hedrick td, rokey r. assessment of tissue iron overload by nuclear magnetic resonance imaging. am j med 1989; 87(1): 40-47. @ radiology positions.indd 1 10/2/08 9:49:05 am mri signal.indd 94 12/5/08 11:33:41 am abstract introduction case series discussion conclusion acknowledgements references about the author(s) stuti chandola department of radiodiagnosis, maulana azad medical college, new delhi, india anju garg department of radiodiagnosis, maulana azad medical college, new delhi, india citation chandola s, garg a. scar endometriosis: looking beyond the diagnosis a case series. s afr j rad. 2022;26(1), a2493. https://doi.org/10.4102/sajr.v26i1.2493 case series scar endometriosis: looking beyond the diagnosis a case series stuti chandola, anju garg received: 31 may 2022; accepted: 13 sept. 2022; published: 29 nov. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract scar endometriosis usually affects the abdominal wall or the perineum. virtually all cases are linked with some form of surgical manipulation. although the clinical diagnosis of scar endometriosis may be straightforward with classical symptomology, imaging with ultrasound and mri are important for the determination of its extent, which is imperative for adequate preoperative planning. in addition, assessment of perineal scar endometriosis also requires the identification of anal sphincter complex involvement, which can significantly impact the surgical approach. radiology plays a vital role in its diagnosis in atypical clinical scenarios. contribution: this series of four cases describes the morphology and highlights the importance of imaging in the surgical management of scar endometriosis; three with abdominal wall involvement and one with the involvement of perineum. keywords: scar endometriosis; perineal scar endometriosis; abdominal wall endometriosis. introduction endometriosis is a multifocal and polymorphic disease in the reproductive age group with a prevalence of 10% – 15%1; however, implantation of endometriotic tissue into scar sites remains an infrequent entity to date. possible sites include the abdominal wall and perineum with involvement of the skin, subcutaneous tissue and underlying musculature. surgery remains a sine qua non inciting factor for this condition and consequently, cesarean section (cs) scars in the anterior abdominal wall constitute the most common site, with an estimated incidence of approximately 0.03% – 0.4%.2,3 scar endometriosis has also been reported in post-hysterotomy scars, perineal episiotomies, post-bartholin’s gland excisions, in laparoscopic trocar tracts and even in amniocentesis needle tracts.3 involvement of the scar in the uterus is an even more rare entity, with limited case reports described in literature.4 with the aim of highlighting the importance of imaging in the assessment of scar endometriosis, four patients are presented, all of whom were provisionally diagnosed with scar endometriosis through a combination of clinical and radiological features with subsequent pathological confirmation. besides suggesting the diagnosis, imaging plays an unequivocal role in evaluating the depth of infiltration by these lesions, which is imperative for preoperative planning and management. case series four patients from the outpatient department were included in the series. three patients had anterior abdominal wall involvement and one patient had involvement of perineum at the episiotomy site. informed consent was obtained and relevant clinical details including surgical history were recorded in each case. the radiological assessment in all patients involved a multimodality imaging approach with ultrasound (transabdominal or transperineal), including colour doppler, followed by mri on a 3t scanner. ultrasound scanning especially involved the use of a high frequency transducer (7 mhz to 10 mhz) as the lesions were not readily apparent on examination with the routine 3 mhz – 5 mhz transducer. when planning the mri, it was ensured that the anterior saturation bands were cautiously placed to avoid concealing lesions. conventional mr sequences were then acquired, which included t1w, t2w and fat saturated t1w sequences in the sagittal and axial planes. this was followed by acquisition of diffusion weighted images (b–values = 0 mm2/s, 400 mm2/s, 800 mm2/s; with corresponding adc maps) and post-contrast imaging sequences in the axial and sagittal planes following administration of intravenous gadolinium at a dose of 0.1 mmol/kg. case 1 a 36-year-old lady presented with complaints of progressively increasing periodic pain and swelling near her abdominal scar coinciding with her menstrual cycles for a period of 3-years. she had undergone sling surgery (cervicopexy) for uterine prolapse five years previously. clinical examination demonstrated a well-approximated and healed pfannenstiel incision scar with no evidence of erythema or drainage. a firm tender palpable mass, 2 cm × 1.5 cm was situated superior and lateral to the scar region on the left. on ultrasound, an infiltrative hypoechoic lesion with two associated internal echogenic foci and extensive posterior acoustic shadowing was appreciated in the subcutaneous plane (figure 1a). minimal vascularity was appreciated on power doppler (figure 1b). the mr examination showed a similar sized spiculated mass, which appeared hypointense on t1w and t2w images with internal hyperintense foci on t1w fat supressed images suggestive of haemorrhage (figures 2a, b and figure 3a). the mass demonstrated restricted diffusion on dwi and heterogeneous enhancement on post-contrast images (figures 2c, d and figure 3a–b). it mainly involved the subcutaneous plane in left lower anterior abdominal wall and revealed poorly defined fat planes with the underlying rectus muscle, which, however, appeared normal in signal intensity. figure 1: scar endometriosis in a 36-year-old lady with previous history of sling surgery with current complains of painful swelling at the incisional site. grey scale ultrasound image in the region of swelling (a) demonstrates an ill-defined hypoechoic area (labelled e, rectus muscle [rm]) with two internal echogenic foci and extensive posterior shadowing in the subcutaneous plane. minimal vascularity was seen on power doppler (b). figure 2: sagittal t2w (a) and axial t1 w (b) mr images show a spiculated hypointense mass (arrow) in the subcutaneous plane in left lower anterior abdominal wall with loss of fat planes with the underlying rectus muscle, which shows normal signal. diffusion weighted image (c) with corresponding adc map (d) shows diffusion restriction within the lesion. figure 3: axial pre-contrast fat suppressed t1 w image (a) shows a hyperintense area of haemorrhage (arrow) within the lesion (a) with heterogeneous enhancement on the post contrast image (b). post-resection surgical specimen (c) shows endometriotic scar tissue (e) with surrounding adipose tissue (a). the patient underwent wide local excision of the mass, which was removed with clear margins. the lesion was found to be adherent to the underlying rectus sheath (which was not infiltrated), measured 3 cm × 3 cm × 2.5 cm in size and showed scar tissue centrally with surrounding adipose tissue (figure 3c). microscopic analysis with haematoxylin and eosin (h&e) stain showed endometriotic glands and stroma with associated blood and adjacent adipose tissue, confirming scar endometriosis. the patient was followed up on an out-patient basis and continues to remain asymptomatic. case 2 a 32-year-old female complained of a 2-year history of debilitating lower abdominal pain in the region of her abdominal scar, which worsened during menstruation. she had a prior history of two lower segment caesarean sections (lscs), followed by a hysterotomy (at 6 months of gestation, for intrauterine foetal death). on examination, a healthy approximated transverse lscs scar was seen and a tender nodule, approximately 2 cm × 2 cm in size, was palpated superiorly, 3 cm from the scar. superficial anterior abdominal wall ultrasound revealed an ill-defined hypoechoic lesion with multiple internal anechoic areas and extensive edge shadowing (figure 4a). moderate vascular flow was observed on colour doppler (figure 4b). on mri, an ill-defined mass was seen, the bulk of which appeared hypointense on t1w and t2w images and showed few t2w hyperintense foci within (figure 5a, b). the lesion involved the subcutaneous and intramuscular planes (medial aspect of right rectus) (figure 5c, d). figure 4: (a, b) ultrasound image (a) in 32-year-old female with prior lscs and hysterotomy with current complaints of cyclical scar site pain reveals an irregular hypoechoic lesion within the subcutaneous plane of the lower anterior abdominal wall showing multiple anechoic areas (arrow, a) and edge shadowing. moderate intralesional flow was seen on doppler (b) (rectus muscle [rm]). figure 5: (a–e) sagittal (a) and axial (b) t2 w images show an ill-defined hypointense mass (arrows) in the subcutaneous tissue and underlying right rectus muscle with a few t2w hyperintense foci. the fundus of the uterus (u) was also adherent to this site. sagittal (c) and axial (d) post contrast images show avid enhancement of the lesion and the underlying rectus muscle (yellow arrow). photomicrograph specimen (magnification-40 ×) with haematoxylin and eosin-stain (e) shows endometrial glands (arrow) with surrounding fibrous stroma (asterisks), confirming endometriosis. the patient consented for surgical excision of the lesion and a haemorrhagic nodule measuring 3 cm × 3.5 cm × 4 cm, which was partly infiltrating the right rectus muscle, was excised with clear margins. histopathological analysis of the mass demonstrated the endometriotic nodule with adjacent adipose tissue, thus confirming scar endometriosis (figure 5e). the patient remained asymptomatic at follow up after three months. case 3 a 24-year-old lady complained of continuous debilitating lower abdominal pain with no periodicity for one year prior to presentation. she had a past history of a lscs two years back. local examination revealed a healthy pfannenstiel incision scar with surrounding tenderness; however, no obvious swelling was palpable. suspicion of scar endometriosis was first raised on sonography when evaluation (at the site of maximum tenderness) revealed an oval hypoechoic lesion, which showed irregular, infiltrating margins with internal vascularity on doppler evaluation (figure 6a, b). it involved the right rectus muscle with resultant contoural bulge and was situated about 5 cm above the scar. mri confirmed the sonographic findings and showed an avidly enhancing oval mass. it was predominantly within the right rectus muscle, which showed bulging contours on conventional t1 and t2w images; however, no obvious signal change was appreciated (figure 6c). this inconspicuous nature could be explained by the similar signal intensity of lesion to the rectus muscle. avid enhancement on the post-contrast images helped in its delineation (figure 6d). figure 6: (a–d) involvement of rectus abdominis by scar endometriosis in a 24-year-old lady who complained of continuous debilitating lower abdominal pain. ultrasound image (a) shows an oval hypoechoic lesion within the right rectus muscle (rm), which appears to be displaced around it (arrow). it shows irregular, infiltrating margins and significant internal vascularity on colour doppler (b). on axial t2 w mri (c), bulging contours of the right rm were appreciated with no obvious signal change. axial post-contrast t1 w image (d) shows avid enhancement, which allowed better delineation of the lesion. at surgery, the mass was seen within the rectus muscle with extension into the subcutaneous plane. it was excised with clear margins and measured 3.5 cm × 2 cm × 2.5 cm in size. microscopic examination showed features consistent with scar endometriosis. the patient continues to remain asymptomatic on routine outpatient follow up. case 4 a 33-year-old female presented with cyclical pain and swelling in the right vulval region over two years. she had a normal vaginal delivery with a right-sided episiotomy seven years previously. on examination, a small tender nodule was felt on deep palpation in the perineal region at the 7 o’clock position. on b-mode ultrasonography, a stellate hypoechoic mass with internal vascularity was observed in the subcutaneous plane in the right vulval region (at the site of the palpable nodule) (figure 7a, b). on mri, the mass demonstrated spiculated margins and appeared hypointense on t1w and t2w images. a few hyperintense foci were observed on the t1w fat supressed images, suggestive of haemorrhages. the mass also showed diffusion restriction on dwi/adc and heterogeneous enhancement on post-contrast images. the lesion involved the subcutaneous plane and was abutting the external anal sphincter on the right side with maintained intervening fat planes (figure 7c, d and figure 8a–c). figure 7: (a–d) perineal scar endometriosis at the episiotomy site in a 33-year-old female with cyclical pain and swelling in the right vulval region. the ultrasound image (a) shows a stellate hypoechoic mass with internal vascularity (b) in the subcutaneous plane at the right vulva. axial (c) and coronal (d) t2 w mr images show a predominantly t2 hypointense lesion (white arrows) abutting the external anal sphincter (external anal sphincter [eas] – yellow arrow) posterosuperiorly with maintained fat planes. figure 8: (a–d) pre-contrast fat suppressed t1w image (a), shows hyperintense areas of haemorrhage (arrow). serial axial (b and c) post-contrast fat suppressed t1w images demonstrate heterogeneous enhancement (arrow). fnab specimen of the lesion (d, 600× magnification) reveals clusters of cells having well-formed acini (white arrow) mixed with stromal cells (yellow arrow) and surrounding adipocytes (asterisk) confirming endometriosis. ultrasound guided fine needle aspiration biopsy (fnab) of the mass was performed, revealing epithelial cells, hemosiderin laden macrophages and spindle cells with fibroadipose tissue, which suggested scar endometriosis (figure 8d). however, the patient refused surgery and was subsequently lost to follow up. none of the patients in the series had concomitant endometriosis at any other site on imaging. discussion as defined by the presence of functional endometrial tissue (consisting of glands and stroma) outside the uterus,5 endometriosis is a polymorphic condition that can manifest as superficial implants on the peritoneal surface, ovarian cysts called endometriomas and deep lesions that infiltrate the peritoneal surfaces, known as deep infiltrative endometriosis (die). the common sites of involvement include the ovaries (most common), uterosacral ligaments, serosal surfaces, pouch of douglas, fallopian tubes, rectosigmoid and urinary bladder. however, any tissue can potentially be involved by these endometriotic implants including the liver, small bowel, appendix, lung, brain, abdominal wall and perineum. abdominal or pelvic wall endometriosis consists of ectopic endometrial tissue embedded within the subcutaneous adipose layers and the muscles of the abdominal wall6 and is usually associated with scar tissue from a previous surgical procedure, most commonly a cs, with an estimated incidence of approximately 0.03% – 0.4%.2,7,8 perineal scar endometriosis is a rare condition with an incidence of 0.03% – 0.15%9; however, it can cause severe morbidity because of close proximity to and hence higher potential for involvement of the anal sphincter. the exact pathogenesis of scar endometriosis still remains to be elucidated; however, it is known that surgery remains a sine qua non inciting factor for this condition. uterine manipulation during surgeries can potentially lead to dissemination and implantation of ectopic endometrium at surgical sites, which is known as the theory of metastatic implantation. it is further supported by the fact that many patients with scar endometriosis (including the cases in this series) do not have symptoms or signs of endometriosis because of dissemination of endometrial cells into the wound at the time of surgery. the metaplastic theory is an alternative theory which proposes the differentiation of coelomic stem cells into endometriotic tissue within the scar and hence may explain the presence of endometriosis at other sites. however, the metastatic theory is currently more favoured as a plausible cause for scar endometriosis.3,10 even after complete excision, occasionally this condition can be recurrent, with a recurrence rate of nearly 15% for abdominal and 14% for perineal endometriosis, as shown in a recent study.11 continuous recurrence following excision should raise the suspicion of malignant transformation, typically to endometrioid or clear cell carcinoma, which has a documented incidence of approximately 1%.12 the diagnosis of scar endometriosis is mostly made in women of reproductive age following instrumentation of the uterus.13 a presumptive clinical diagnosis may be made on the basis of a triad of clinical features, which include a history of surgery, cyclical pain at or near the scar site progressively increasing with menstrual cycles and a palpable, painful abdominal mass (as present in three patients of our series). however, as seen in case 3, a significant proportion of patients may present with continuous lower abdominal pain, dysmenorrhoea or may show no symptoms at all, with the findings being discovered incidentally. a variable latent period is also observed before the symptom onset which, in a recent study, was found to have a possible correlation with the depth of involvement.6 on histopathology, scar endometriosis consists of endometrial glands and stroma with intervening focal areas of chronic inflammation, fibrous tissue, smooth muscle hyperplasia and hemosiderin deposition. the presence of hemosiderin-filled macrophages is a peculiar feature seen in endometriosis.3 it should be realised that because the ectopic endometrial tissue remains responsive to hormonal stimulation, the appearance of scar endometriosis on imaging may vary depending upon the phase of the patient’s menstrual cycle, with maximum growth of the tissue in the late secretory and menstrual phase. this often also coincides with the severity of symptoms experienced by the patient. hence, imaging should be scheduled either just prior to or during the menstrual phase with due consideration of the patient’s symptomology, which helps in correct assessment of the size and extent of the lesion.14 irrespective of the site and modality, scar endometriosis is characteristically seen as an irregular nodule with spiculated infiltrative margins because of associated extensive fibrosis and chronic inflammation. sonography remains the first line for imaging of these lesions with emphasis on the use of high frequency transducers as they may be missed on examination by routine 3 mhz – 5 mhz transducers. while appearances are varied, ranging from solid, mixed solid-cystic or multicystic lesions, the most common appearance is of a solid inhomogeneous infiltrative hypoechoic mass with echogenic foci, spiculated margins and thick echogenic strands.1,3,15 as a result of the associated infiltration of the adjacent soft tissues, the lesions are often not clearly delineated from surrounding tissues, thus limiting the accuracy in assessing the lesion size and infiltration depth.14 internal cystic changes may also be seen representing haemorrhagic foci or dilated ectopic glands. contrary to endometriomas in the ovary, scar endometriosis often shows internal vascularity on colour doppler with a single vascular pedicle or dilated feeding vessels at the periphery or centre of the mass.2 mri is a non-invasive modality which allows good tissue characterisation and offers the advantage of multiplanar evaluation of the lesions.3,16 it provides an accurate assessment of the extent including depth of involvement (i.e. whether limited to the subcutaneous plane, intramuscular plane, peritoneal involvement etc.) by the endometriotic lesions and has high sensitivity for detection of blood products. as evident in cases 1 and 2 in our series, mri demonstrated greater precision of depth assessment and showed better concordance with surgical findings. in addition, it can also identify endometriosis in other locations and hence mri plays a crucial role in preoperative planning in order to achieve complete resection of the lesions, thereby minimising recurrence.3 as a result of its fibrotic nature and the presence of blood products of different ages, the bulk of the lesion appears heterogeneously hypointense on t1w and t2w images with some small t1 and t2 hyperintense foci within, representing areas of subacute haemorrhage, as seen in cases 1 and 4. use of fat suppressed t1w images improves the conspicuity of such haemorrhagic foci leading to a significant increase in accuracy for lesion detection. isolated t2 hyperintense foci, as observed in case 2 may also be seen, which represent ectopic glandular elements.16,17 diffusion characteristics may vary depending on the predominant tissue within the lesion. on post-contrast images, the lesions invariably demonstrate intense enhancement (evident in all four cases) with an occasional feeding vessel sign, which has been attributed to the associated extensive inflammation.3 hence contrast-enhanced-mri forms an integral part for imaging of such lesions. in perineal scar endometriosis, preoperative mr imaging plays an indispensable role by identifying the involvement of the anal sphincter complex, which can significantly impact the surgical management.9 an excisional biopsy is the gold standard for diagnosis of this condition. however, in cases where fnab or incisional biopsy are performed (as in case 4), excision of the needle tract is required at the time of surgical excision in order to prevent recurrence. the ultimate curative treatment for these lesions is a wide excision with at least 1 cm clear margins to prevent recurrence and possible future malignant transformation.3,14 deeper lesions often require skin flaps or wire mesh for covering the resultant fascial defects in abdominal wall endometriosis. anal sphincter involvement in perineal scar endometriosis may require sphincter reconstruction. careful manipulation of tissue is essential as mishandling during surgery can potentially lead to dissemination of implants and future recurrence. post-surgery, patients may be treated with hormonal-based therapies such as gonadotropin releasing hormone (gnrh) and progesterone analogues, which cause suppression of the potentially retained microscopic implants thereby preventing recurrence. although very rare, potential malignant transformation of the lesion needs consideration when dealing with continued recurrence.14 radiologists should be aware of this entity especially in women of reproductive age with classical clinical and imaging findings. other differential diagnoses that may be seen in the context of previous surgery and hence merit consideration are tabulated in table 1. table 1: differential diagnoses of surgical scar endometriosis. conclusion in a female of reproductive age with previous pelvic surgery complaining of cyclical abdominal pain with swelling at or near the surgical site, a diagnosis of scar endometriosis is of prime concern. radiology plays an important role in its accurate detection and also excludes the various differential diagnoses. besides confirming the diagnosis, imaging, especially mri, evaluates the extent of tissue involvement by the endometriotic lesion and helps the surgeon in devising an appropriate patient centred management strategy. acknowledgements the authors would like to acknowledge the departments of obstetrics and gynaecology, lok nayak hospital for providing clinical inputs and department of pathology, lok nayak hospital, new delhi for providing histopathological images. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.t. and a.g. contributed significantly and equally to this work. ethical considerations this article followed all ethical standards for this research. consent was obtained from the patients for their data and for publication. funding information this case series received no specific grant from any funding agency in the public, commercial and not for profit sectors. data availability data sharing does not apply to this article, as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references choudhary s, fasih n, papadatos d, et al. unusual imaging appearances of endometriosis. am j roentgenol. 2009;192(6):1632–1644. https://doi.org/10.2214/ajr.08.1560 francica g, scarano f, scotti l, et al. endometriomas in the region of a scar from cesarean section: sonographic appearance and clinical presentation vary with the size of the lesion. j clin ultrasound. 2009;37(4):215–220. https://doi.org/10.1002/jcu.20569 gidwaney r, badler rl, yam bl, et al. endometriosis of abdominal and pelvic wall scars: multimodality imaging findings, pathologic correlation, and radiologic mimics. radiographics. 2012;32(7):2031–2043. https://doi.org/10.1148/rg.327125024 lahiri ak, sharma k, busiri n. endometriosis of the uterine cesarean section scar: a case report. indian j radiol imaging. 2008;18(1):66. lo gm, wenger jm, petignat p, et al. role of imaging in endometriosis. cleve clin j med. 2014;81(6):361–366. https://doi.org/10.3949/ccjm.81a.13032 zhang p, sun y, zhang c, et al. cesarean scar endometriosis: presentation of 198 cases and literature review. bmc womens health. 2019;19(1):1–6. https://doi.org/10.1186/s12905-019-0711-8 wicherek l, klimek m, skret-magierlo j, et al. the obstetrical history in patients with pfannenstiel scar endometriomas – an analysis of 81 patients. gynecol obstet invest. 2007;63(2):107–113. https://doi.org/10.1159/000096083 nominato ns, prates lf, lauar i, et al. caesarean section greatly increases risk of scar endometriosis. eur j obstet gynecol reprod biol. 2010;152(1):83–85. https://doi.org/10.1016/j.ejogrb.2010.05.001 jayanthan ss, shashikala g, arathi n. perineal scar endometriosis. indian j radiol imaging. 2019;29(4):457. https://doi.org/10.4103/ijri.ijri_366_19 steck wd, helwig eb. cutaneous endometriosis. clin obstet gynecol. 1966;9(2):373–383. https://doi.org/10.1097/00003081-196606000-00007 matalliotakis m, matalliotaki c, zervou mi, et al. abdominal and perineal scar endometriosis: retrospective study on 40 cases. eur j obstet gynecol reprod biol. 2020;252:225–227. https://doi.org/10.1016/j.ejogrb.2020.06.054 hoyos lr, benacerraf b, puscheck ee. imaging in endometriosis and adenomyosis. clin obstet gynecol. 2017;60(1):27–37. https://doi.org/10.1097/grf.0000000000000265 horton jd, dezee kj, ahnfeldt ep, et al. abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. am j surg. 2008;196(2):207–212. https://doi.org/10.1016/j.amjsurg.2007.07.035 kocher m, hardie a, schaefer a, et al. cesarean-section scar endometrioma: a case report and review of the literature. j radiol case rep. 2017;11(12):16. https://doi.org/10.3941/jrcr.v11i12.3178 francica g. reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar. world j radiol. 2012;4(4):135. https://doi.org/10.4329/wjr.v4.i4.135 rezvani m, shaaban am, kennedy am. the role of multimodality imaging after cesarean delivery. ultrasound q. 2015;31(1):5–18. https://doi.org/10.1097/ruq.0000000000000075 balleyguier c, chapron c, chopin n, et al. abdominal wall and surgical scar endometriosis: results of magnetic resonance imaging. gynecol obstet invest. 2003;55(4):220–224. https://doi.org/10.1159/000072078 a. this narrow bundle runs parallel to the sternum. b. the pectoral nerves provide its innervation. c. its origin is from the masseter muscle. d. it is anatomically distinct from the pectoralis muscle. 2. which one of the following statements is true? cpd questionnaire give one correct answer for each question. 76 sa journal of radiology • august 2009 1. regarding the sternalis muscle, identify one incorrect answer: a. the sternalis muscle is common, occurring in 80% of people. b. the sternalis muscle is only found unilaterally. c. the sternalis muscle is only found in chinese people. d. the function of the sternalis muscle is uncertain. 3. which one of the following statements is false? a. interpretation of mammograms can be challenging. b. the sternalis muscle is seen as an irregular calcified mass on mammography. c. the sternalis muscle is seen on occasion on the cranio-caudal view of the mammogram. d. the sternalis muscle is found in all population groups. 5. with regard to mammography, which one of the following statements is incorrect? a. subtle signs of breast cancer can be missed by radiologists. b. computer-aided diagnosis (cad) was developed to draw the radiologists attention to suspicious regions in a mammogram. c. commercial cad systems are designed to be consulted before the radiologist has made an initial assessment. d. one aspect of the cad system is to detect suspicious features. 6. which one of the following statements is incorrect? a. excision biopsy is the most common method of detecting breast cancer in the early stages. b. breast cancer is the most common cancer among women worldwide. c. breast cancer is second to cervical cancer among south african women. d. mammography is the most common method of detecting breast cancer in the early stages. 7. with regard to patent ductus arteriosis (pda) which statement below is false? a. pda comprises 5 10% of all congenital cardiac lesions. b. most children with pda are asymptomatic. c. the defect always persists permanently if present at birth. d. the male-female ratio is 1:2. 8. identify one false statement below: a. 50% of patients with t large pda will develop pulmonary hypertension. b. patients with a large pda left patent may develop eisenmenger’s syndrome. c. eisenmenger’s syndrome is an irreversible condition where there is a reversal of flow of a congenital systemic to pulmonary shunt that occurs in untreated congenital heart defects. d. untreated eisenmenger’s syndrome in turn can develop into the classic hippocratic syndrome. 9. concerning chest radiographs most suggestive of pda, which one of the statements below is incorrect? a. filling in of the aorto-pulmonary window and enlargement of the pulmonary arteries. b. pruning of pulmonary arteries peripherally. c. calcification of the left ventricle. d. calcification of the pda in elderly patients. 10. which one of the following is correct? a. in detecting pda trans-thoracic echocardiogram is superior to trans-oesophageal echocardiogram. b. trans-oesophageal echocardiograms are used much more commonly in diagnosing pdas. c. ct angiography and magnetic resonance angiography have largely replaced formal angiography in the investigation of pdas. d. pdas complicated by eisenmenger’s syndrome are very easy to detect on transthoracic echocardiography. 4. identify one correct statement among the following. jan lotz is: see previous page for cpd instructions. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www. cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg. co.za in the event of queries. accreditation number: mdb 015/180/04/2009 a. a famous rugby lock forward. b. a model for ferrari cars. c. the editor of the sajr. d. a well-known draft beer. cpd aug 2009.indd 76 8/17/09 3:06:55 pm case report case reportcase report abstract conjoined twins are rare variants of monozygotic twins. there are many types of conjoined twins, usually classified according to the site of fusion. the most common type of renal fusion anomaly is the horseshoe kidney, comprising two distinct functioning kidneys on either side of the midline, which are more likely to be connected at the lower poles. we report on a 30-year-old woman who presented to the antenatal clinic at chris hani baragwanath hospital, soweto. fetal magnetic resonance imaging revealed thoraco-omphalopagus conjoined twins with complex thoracic and abdominal structures, including a horseshoe kidney that was confirmed on postnatal computed tomography screening. our patient was classified as a thoraco-omphalopagus type, with fusion of the thorax and the mid-trunk. introduction conjoined twins are rare variants of monozygotic twins. they result from incomplete division of the embryonic disk.1 the incidence is estimated at about 1 in 250 000 live births, with a strong female predominance.2 there are many types of conjoined twins, usually classified according to the site of fusion. the more common types of conjoined twins include the thoracopagus type where the fusion is anterior, at the chest, and involves the heart (35%); the omphalopagus type where the fusion is at the mid-trunk (30%); the pygopagus type where there is a posterior union involving the rump (19%); the parapagus type, with a lateral fusion of the lower half of the body extending upwards (5%); and combination types. our patient was classified as a thoraco-omphalopagus type, with fusion of the thorax and the mid-trunk.3 the most commonly described type of renal fusion anomaly is the horseshoe kidney. it consists of two distinct functioning kidneys on either side of the midline, which are more likely to be connected at the lower poles by an isthmus of functioning renal parenchyma or fibrous tissue that crosses the midline of the body.4 the reported frequency of horseshoe kidney ranges from 1 in 400 live births to 1 in 800 live births, and is twice as common in males as in females. there is no known genetic determinant, although it has been reported in siblings and in identical twins in the same family.4 case report a 30-year-old woman presented to the antenatal clinic at chris hani baragwanath hospital, soweto, at >34 weeks’ gestation. she had been referred from a peripheral hospital. an ultrasound examination revealed probable thoraco-omphalopagus conjoined twins and polyhydramnios. however, the exact details of the fusion were not fully elucidated. fetal magnetic resonance imaging (fmri) was performed on a general electric 1.5 tesla mr scanner using a phased-array pelvic coil. t1-weighted and t2-weighted images were obtained in 2 orthogonal conjoined twins with a horseshoe kidney m modi, mb bch, fcrad (sa), mmed l kramer, mb bch, fcrad (sa) department of radiology, chris hani baragwanath hospital, university of the witwatersrand, johannesburg fig.1. coronal t2-weighted mri. a: brain of twin a demonstrating mature grey-white matter differentiation b: twin b on the right in a sagital position looking at twin a c: the complex multi-chambered heart d: stomach of twin a e: horseshoe kidney f: high signal in the pelvis due to a single full bladder. fig 2. day 2 post delivery photograph showing the larger twin a on the left, smaller twin b on the right, 2 heads, 2 necks, extra-large conjoined thorax, 2 sets of upper limbs, single female genitalia, and single set of lower limbs 10 sa journal of radiology • march 2009 conjoined twins.indd 10 3/12/09 2:06:35 pm case reportcase report planes only, as the mother was uncomfortable. the fmri demonstrated a larger dominant ‘twin a’ and a smaller ‘twin b’. two heads, 2 sets of upper limbs, 2 complete spines, a single complex multi-chambered heart, a conjoined liver, a single gallbladder, 2 stomachs, a long horizontally positioned centrally fused shared kidney, an additional single kidney in twin b, a single urinary bladder, a single bony pelvis, and a single set of lower limbs were seen. twin b also had a hyploplastic right lung, and an aplastic left lung (fig. 1). the mother was counselled about the poor prognosis for conjoined thoraco-omphalopagus twins; however, she opted not to have the pregnancy terminated and the twins were delivered by caesarean section 3 days later (fig. 2). after delivery, on day 2, a whole-body contrast-volume computed tomography (ct) scan was performed using a toshiba 4-slice multidetector ct scanner to further assess the anatomy of the twins, and to evaluate them for viability and separability. the scan confirmed a centrally positioned horseshoe kidney in twin a, and a single kidney in twin b, where the renal hilum was posterolateral because of the abnormal renal axis (fig. 3). the twins died on day 3. conclusion to our knowledge, this is the first reported case of a shared horseshoe kidney in thoraco-omphalopagus twins. 1. khanna pc, pungavkar sa, patkar dp. ultrafast magnetic resonance imaging of cephalothoracopagus janiceps disymmetros. j postgrad med 2005; 51: 228-229. 2. mchugh k, kiely em, spitz l. imaging of conjoined twins. pediatr radiol 2006; 36(9): 899-910. 3. types of conjoined twins. http://zygote.swarthmore.edu/cleave4a.html (accessed 15 july 2006). 4. allen rc. horseshoe kidney. http://emedicine.medscape.com/article/441510-overview (accessed 16 february 2009). 11 sa journal of radiology • march 2009 fig 3. axial post-contrast ct of the abdomen. a. twin b single kidney with abnormal renal axis. b. twin a central horseshoe kidney with a ventral collecting system. twin atwin b a → b → conjoined twins.indd 11 3/12/09 2:06:36 pm digital sajr: the web and more the switch of sajr to a fully online journal has been most successfully managed by jan lotz, editor of the journal. in his editorial of april 2008 he explained the process of readers, authors and others accessing the sajr in this format via www.sajr.org.za he promised that cpd would also be available for members. how has this shaped up some 18 months later? firstly the printed version of the journal caters for a few hundred readers, almost all who are in south africa. however at the time of writing a check on the use of the website showed that in the past month there had been 1190 visits from 62 countries and growing! the top users were south africa (637), usa (182), uk (66), india (42), australia (34), and canada (31). another advantage of the online process is that back issues can be accessed and items therein easily ‘searched’. the pages per visit and time on site also indicate that the sajr is actively read online, not merely searched and dropped. the sajr cpd programme has joined the other journals and the south african medicines formulary in the health and medical publishing group (hmpg) stable offering cpd via www.cpdjournals.org.za. members can also meet their cpd requirements in ‘ethics’ via the online journal south african journal of bioethics and law accessed via www.sajbl.org.za the cpd site now attracts over 3000 active users per month. as with the other journals in the stable the licensing agreement has been standardised allowing anyone to use material published in sajr freely provided they attribute the origin and do not use it for commercial purposes. all of these developments will add to the stature of the journal and to its authors. keeping up the quality and continuity of the journal is important to enable proceeding with the next step of getting local and international accreditation. in this issue the paper on mammographic computeraided diagnosis by padayachee, alport (department of physics, university of kwazulu-natal) and rae (department of medical physics, university of the free state) is a reminder that radiology was founded by wilhelm conrad roentgen, himself a physicist. most of the major technical discoveries of radiology were made in the first few years after roentgen’s discovery of x-rays until computerisation enabled the development of ct, mri and modern ultrasound. apart from the few major technical discoveries most changes have come from incremental improvements such as promised by this paper. a report on a patient with subclincal patent ductus arteriosis by reddy and colleagues provides a useful update on the investigations of this condition. from australia debra meerkotter describes the importance of the sternalis muscle which is a normal anatomical variant seen in mammography. jp van niekerk md, frcr hmpg managing editor 14 sa journal of radiology • march 2011 review article complications, disease profile and histological yield from percutaneous renal biopsy under real-time us guidance: a retrospective analysis introduction renal biopsies play a pivotal role in determining the diagnosis in patients with impaired renal function and with other renal diseases. the outcome of histological diagnosis after percutaneous renal biopsy can be utilised in not only making a diagnosis, but also planning treatment of the specific illness.1 the pathology and pathogenesis of glomerular disease have become far better understood since the introduction of ultrasound (us)-guided renal biopsies; this technique has transformed the diagnosis, treatment and long-term outcome of glomerular disease. biopsies are specifically necessary in cases of: • unexplained renal failure • nephrotic syndrome • unexplained failure of a transplanted kidney • progressively worsening renal function.2 other indications for percutaneous renal biopsy include: • suspected primary involvement of the kidneys by localised disease (such as with microscopic haematuria, unexplained macroscopic haematuria, proteinuria, impaired renal function and hypertension) • renal involvement by systemic disease (including multiple myeloma, monoclonal gammopathy of uncertain significance, systemic lupus erythematosis, antiphospholipid syndrome, diabetes, systemic vasculitis and scleroderma) • cardiac or liver transplantation with renal impairment (such as in long-term treatment with calcinereum inhibitors (e.g. cyclosporine) for autoimmune conditions).1 an absolute contraindication for this procedure is the inability of the patient to co-operate (e.g. when controlling breathing and lying in the prone position); children are therefore usually sedated for the biopsy. a horseshoe kidney is considered a major contraindication owing to the anomalous and unpredictable location of internal renal structures and because horseshoe kidneys often straddle the aorta. relative contraindications include: • bleeding diathesis • solitary kidney • end-stage or near end-stage renal disease with bilaterally small kidneys • although severe hypertension is universally listed as a contraindication to renal biopsy owingdue to risk of haemorrhage, no clinical studies are available to support this view.3 the difference in the diagnostic yield and complications of coaxial versus non-coaxial biopsy methods is a further consideration, but so far there is no evidence of any difference between the two methods in different studies.4 by international standards, over 99% of percutaneous renal biopsies are diagnostic. in a study of more than 1 000 patients by hergesell et al., only 1.2 % of biopsy specimens contained no glomeruli or renal tissue; the median number of glomeruli per specimen was 9.5 renal biopsy is a relatively safe procedure, with life-threatening complications occurring in less than 0.1% of biopsies. standard care post-biopsy includes bedrest and close observation for 24 hours. owing to the safety profile of the procedure, the international ongoing need m kruger, mb chb e loggenberg, mb chb, mmed (diag rad) department of diagnostic radiology, faculty of health sciences, university of the free state, bloemfontein abstract objective. the objective of the study was to evaluate (i) the technique used at universitas hospital in comparison with other international centres also performing renal biopsies, (ii) the disease profile in patients undergoing renal biopsies, (iii) the complications experienced during and/or after the procedure, and (iv) the histological yield of the biopsies (amount of nephrons per biopsy taken) using this technique. design. a retrospective descriptive analysis of all patients who underwent percutaneous renal biopsy under ultrasound (us) guidance at the interventional radiology unit, universitas hospital, bloemfontein, was undertaken for the period 1 january 2003 31 december 2008. data obtained from the patients’ files and histology reports were statistically analysed. results. a total of 112 patients qualified for inclusion in the study, all of whom had proof of renal failure and then had percutaneous renal biopsy performed under us guidance. the histology was diagnostic in 111 (99.1%) of the cases, with more than 5 nephrons present in 105 (93.5%) of the cases. minor complications were found in 29 (25.8%) of the patients, but no major complications were noted. primary renal disease was found in 67 (59.8%) of patients, and the renal pathology and failure in 45 (40.2%) of the patients were shown histologically to be owing to systemic disease. conclusion. the technique utilised for performing percutaneous renal biopsy under us guidance at the interventional radiology unit was shown to be safe, with a diagnostic histological yield comparable with international standards. a small majority or patients suffered primary renal disease in comparison with renal failure owing to systemic illness. sa journal of radiology • march 2011 15 review article for cost containment and the inherent safety of the procedure, renal biopsies are performed as outpatient procedures, with the patient being discharged after 6 8 hours of observation. this applies to stable patients biopsied by experienced interventional radiologists or nephrologists.6 stiles et al. found that where major complications occurred, these were detected in 46% of patients in <4 hours, in 79% of patients in <8 hours, and in 100% of patients in ≤12 hours. they proposed that a 12-hour observation period would therefore be sufficient in comparison with the 24-hour observation period previously recommended.3 shina et al. showed that there was no difference in the rate of detection of complications after 6 hours instead of 24 hours in sedated or fully anaesthetised pediatric patients.7 the relevance of anti-platelet agents, including aspirin, and whether these should be stopped pre-biopsy was addressed by mackinnon et al.8 who found that minor complications were reduced when anti-platelet agents were stopped 5 days beforehand. these minor complications include macroscopic haematuria and perinephric haematoma that need no further intervention. haemoglobin levels were also used to quantify the amount of blood loss, using a drop of more than 1g/dl without need for transfusion or intervention as a criterion. however, no difference was found in the rate of major complications. major complications result in the need for intervention, such as a transfusion of blood products or more invasive procedures (radiological or surgical) as well as complications such as acute renal obstruction, renal failure, septicaemia or death.6,8 one of the most feared complications is the creation of arteriovenous fistulae (avfs) or false aneurysms. stiles et al. found avfs in 10.8% of patients, by colour doppler sonography. a significant disparity was shown in this complication between native kidney biopsies (4.4%) and transplanted kidney biopsies (16.9%). according to reports, 95% of avfs resolve spontaneously within 2 years, although haematuria, pain and urinary tract obstruction from blood clots had been reported, in rare cases up to 30 years after the biopsy. routine screening for avfs is, however, not recommended as clinically significant avfs are uncommon.3 the cost implications and medico-legal aspects related to this procedure are also of specific interest in south africa.5 methodology a retrospective descriptive analysis was conducted at the interventional radiology unit, universitas hospital, bloemfontein. data were collected from 112 consecutive patients from 1 january 2003 31 december 2008. all patients included in the study had clinically relevant renal failure (indicated by elevated serum urea and creatinine levels and/or reduced 24 hour urinary creatinine-clearance). other indicators for biopsy were proteinuria, haematuria or active urinary sediment (casts). patients’ ages ranged from 13 months to 72 years (average 41.5 years) and race was included in the analysis. information was collected from clinical notes, and histology results were obtained from hospital records. data were captured on a data form and transferred to a microsoft excel spreadsheet for statistical analysis. approval to conduct the investigation was granted by the ethics committee of the faculty of health sciences, university of the free state. technique of us-guided percutaneous renal biopsy the biopsies were all performed in the interventional radiology theatre by a consultant radiologist with experience in performing vascular and interventional radiological procedures. a dedicated histologist was present at all biopsies to confirm that an adequate number of glomeruli were present in the biopsy specimen. children were given general anaesthesia, while adults had an infiltration of 10 ml of 2% lignocaine as local anaesthetic. all patients were prone with a pillow under the abdomen to obliterate the normal lumbar lordosis. a second pillow was then placed under the chest to ensure adequate ventilation. after sterile preparation of the patient and biopsy site, a toshiba echo c us machine with a 3.75 mhz curvilinear probe and biopsy guide for adult patients was used. a 3.75 mhz narrow curvilinear (footprint) probe without a biopsy guide was used for paediatric patients. a sterile transparent plastic sleeve was used to cover the probe and cable. standard adult biopsies were performed using a promag ultra automatic biopsy instrument with a throw (advancement) of 25 mm. a 10 cm-long 16-gauge promag biopsy needle was used for paediatric renal biopsies and for transplant kidney biopsies. in adult native kidney renal biopsies, a 16-gauge, 16 cm-long promag biopsy needle was used. table i. patient gender (n=112) male 55 (49.1%) female 57 (50.9%) table ii. patient age in years (n=112) 0 10 8 (7.1%) 11 20 31 (27.7%) 21 30 24 (21.4%) 31 40 16 (14.3%) 41 50 19 (17.0%) 51 60 7 (6.3%) 61 70 5 (4.5%) >70 2 (1.8%) table iii. complications (n=112) none 83 (74.1%) microscopic haematuria 27 (24.1%) macroscopic haematuria 2 (1.8%) table iv. glomeruli found in the histological specimen (n=112) 0 1 (0.9%) 1 4 6 (5.4%) 5 9 48 (42.8%) >9 57(50.9%) table v. diagnosis after percutaneous renal biopsy (n=112) primary renal pathology 67 (59.8%) systemic disease 45 (40.2%) 16 sa journal of radiology • march 2011 review article the lower pole of the left kidney was selected for biopsy, unless interpositioned bowel was present. a biopsy of the cortex was taken with the needle tip placed against the renal capsule before firing the biopsy instrument. results data were collected from the records of 112 patients during the study period. their sex and age distribution are shown in tables i and ii. no routine follow-up us was performed after biopsy. urinary dipstick evaluation was performed prior to and after biopsy to exclude haematuria. patients were monitored in the nephrology ward for 24 hours after the biopsy. the number of patients developing haematuria is shown in table iii. no severe complications, including post-biopsy avfs, need for blood transfusion, septicaemia or death were encountered. histological yield of glomeruli is shown in table iv. only 1 (representing 0.9%) of the 112 patients who were biopsied had no glomeruli present. the number of glomuli per specimen exceeded 5 in 105 (93.5%) patients. the histological diagnosis, either as primary renal pathology or as renal disease as part of a systemic illness, is shown in table v. primary renal diseases include diseases such as nephrotic syndrome and glomerulonephritis. systemic illness include systemic lupus erythematosis, diabetes and scleroderma. discussion this retrospective descriptive analysis has the weakness that complications occurring after discharge might not have been captured, and the results might have underestimated the occurrence of minor complications. furthermore, small perinephric haematomas would not have been documented as no routine us follow-up was done. only haematuria would prompt post-biopsy us evaluation. the analysis nonetheless provides data concerning the general safety of this procedure at our institution, as well as the diagnostic yield. although the international trend is to discharge the patient after 12 hours in uncomplicated cases,3,6,7 the routine 24-hour inpatient followup is still used at our institution. with the pressures of cost containment within the public hospital system in free state province, one could argue that the possibility of discharging patients after 12 hours should be further investigated. deficiencies in transport systems and large travelling distances raise concerns, however. the technique employed was shown to be generally safe with a good diagnostic yield. the 0.9% of specimens that did not show glomeruli is in keeping with international results.4,5 the yield of ≥5 glomeruli in the biopsy specimens in 93.5% of specimens also compares favourably. the non-coaxial method employed at our institution is diagnostic in over 99% of biopsies. the direct, real-time evaluation of the renal tissue being sampled, as well the ability to verify correct needle positioning and depth, is important in obtaining a high percentage of diagnostic specimens.2-5 the size of the needle and correct patient positioning technique are also felt to be beneficial in the containment of complications and ensuring high diagnostic yields of glomeruli. the experience of the radiologist performing the biopsy is also important. renal biopsy in this setting is safe and has high diagnostic yield. the majority (59.8%) of patients undergoing percutaneous renal biopsy suffered from primary renal disease. 1. tompson crv. indications for renal biopsy in chronic kidney disease. clinical medicine 2003;3:513-516. 2. alexoupoulos e. how important is renal biopsy in the management of patients with glomerular disease? nephrol dial transplant 2001;16:83-85. 3. stiles kp, yaun cm, chung em, lyon rd, lane jd, abbott kc. renal biopsy in high-risk patients with medical diseases of the kidney. am j kidney dis 2000;36:419-433. 4. hatfield mk, beres ra, sane ss, zaleski gx. percutaneous imaging-guided solid organ core needle biopsy: coaxial versus non-coaxial method. am j radiol 2008;190:413-417. 5. hergesell o, felten h, andrassy k, köhn k, ritz e. safety of ultrasound-guided percutaneous renal biopsy– retrospective analysis of 1090 consecutive cases. nephrol dial transplant 1998;13:975-977. 6. whittier wl, korbet sm. timing of complications in percutaneous renal biopsy. j am soc nephrol 2004;15:142-147. 7. sinha md, lewis ma, bradbury mg, webb nja. percutaneous real-time ultrasound-guided renal biopsy by automated biopsy gun in children: safety and complications. j nephrol 2006;19:41-44. 8. mackinnon b, fraser e, simpson, fox jg, geddes c. is it necessary to stop anti-platelet agents before a native renal biopsy? nephrol dial transplant 2008;23(11):3566-3570. paediatric vascular.html paediatric vascular imaging s k misser, mb chb, fcrad (d) sa lake smit and partners, durban j n narsai, mb chb, fc paed sa crompton hospital, durban corresponding author: s misser (misser@lakesmit.co.za) presentation an early neonate presented with stridor, and the following images were obtained. figs 1 and 2 are axial post-contrast ct angiogram images at the level of the aortic arch. note a nasogastric tube in situ . figs 3 and 4 are volume-rendered 3d reconstructions of the ct angiogram from the level of the aortic root to the great vessels. fig. 5 is a coronal reformatted image through the abdomen. fig. 6 is a virtual bronchoscopy image of the tracheobronchial tree. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response by email to dr misser at misser@lakesmit.co.za not later than 1 february 2012. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis and discussion will be presented in the next sajr . fig. 1. fig. 2. fig. 3. fig. 4. fig. 5. fig. 6. article information author: andrew j. van den heever1 affiliation: 1tuft and partners incorporated radiologists, cape town, south africa correspondence to: andrew van den heever email: andrew.vdh@tuft.co.za postal address: po box 461, plumstead 7801, south africa dates: received: 09 june 2014 accepted: 06 nov. 2014 published: 11 dec. 2014 how to cite this article: van den heever, a. juxta-articular myxoma of the wrist. s afr j rad. 2014;18(2); art. #668, 5 pages. http://dx.doi.org/10.4102/sajr.v18i2.668 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. juxta-articular myxoma of the wrist in this case report... open access • abstract • introduction • case presentation    • imaging findings    • surgical findings    • histopathology    • clinical course    • follow-up mri findings • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ this case report describes a juxta-articular myxoma (jam) in an uncommon location, demonstrating an unusually aggressive local growth pattern. introduction top ↑ myxomas are benign mesenchymal tumours characterised by the production of mucinous material in a scant spindle cell matrix.1 juxta-articular myxoma (jam) is a rare form of myxoma in the vicinity of a joint.2 jam has an association with trauma or joint arthrosis. it is may be locally aggressive and commonly recurs after surgical excision.3 case presentation top ↑ a 78-year-old man, with a history of colon carcinoma and gout, presented with a large mass in the thenar eminence and bilateral carpal tunnel syndrome. on clinical examination, the mass was fixed and had no inflammatory or infective features. magnetic resonance imaging (mri) was requested to assess the nature of the mass and exclude a neoplastic lesion. imaging findings an extensive, multiseptated cystic mass was noted in the thenar eminence with infiltration around the flexor pollicis longis (fpl) and abductor pollicis brevis (apb) tendons. the mass had uniform fluid signal on proton density (pd) fat-saturated images (figure 1 and figure 2). post-contrast images demonstrated enhancement of the septations with central fluid signal. similar cystic infiltration was noted in and deep to the pronator quadratus (figures 3b, 4, 5a and 5b). figure 1: axial pd fat-saturated image shows a cystic mass in the thenar eminence extending into the pronator quadratus and the radial epiphysis (white arrows). there is widespread flexor and extensor tenosynovitis (red arrow). figure 2: coronal pd-weighted fat-saturated image shows a large, well-circumscribed cystic mass in the thenar eminence with extensive infiltration into the adjacent carpal bones, distal radius and pronator musculature (white arrows). figure 3: sagittal t1 fast spin echo (fse)-weighted images precontrast (a) and post contrast (b) demonstrate the pronator quadratus component and the intraosseous erosions in the radius, carpal bones and bases of the metacarpal bones. there is peripheral enhancement of the pronator mass, and intense solid and peripheral enhancement of the osseous erosions (white arrows). figure 4: axial t1-weighted fat-saturated image post intravenous gadolinium shows intense, predominantly peripheral, enhancement with central low t1 signal in the thenar mass (white arrow) and the radial erosion. figure 5: coronal t1-weighted post intravenous gadolinium images (a and b). intense, predominantly peripheral enhancement of the thenar mass and osseous erosions (red arrows). multiple osseous erosions involving the distal radius, the carpal bones and the metacarpal bases were observed. prominent osseous erosion of the capitate and scaphoid was present with almost total destruction of the normal trabecular marrow. the erosions were pd hyperintense (figure 1 and figure 2), t1w hypointense (figures 3a and figure 6) and enhanced peripherally with almost uniform central fluid signal (figures 3b, 4, 5a and 5b). the erosions were sharply marginated and corticated and there was no associated bone marrow oedema. figure 6: coronal t1 fse-weighted image shows an isointense lobulated mass in the thenar eminence with contiguous spread into the pronator quadratus, the radius, the carpal bones and the bases of the metacarpal bones (white arrows). tenosynovitis was noted, involving all of the extensor and flexor compartments. the median nerve, compressed in the carpal tunnel, was oedematous and swollen proximal to the carpal tunnel (figures 3b, 4, 5a and 5b). prominent radiocarpal and intercarpal synovitis was present. moderate arthrosis of the radiocarpal, first carpometocarpal (cmc) and scaphotrapeziotrapezoid (stt) joints. periarticular fluid collections, synovitis and enhancing erosions were noted in relation to the metacarpophalangeal (mcp) joints. a diagnosis of probable gout was made, with a differential diagnosis of polyarticular inflammatory arthritis. metastatic disease was thought unlikely. surgical findings at surgery, a complex, infiltrating, locally aggressive cystic mass was confirmed (figure 7). the thenar mass was debulked, the carpal tunnel was released and a biopsy of the synovium of the radiocarpal joint was done. figure 7: at surgery, a complex, infiltrating, locally aggressive cystic mass was confirmed. histopathology histology and immunohistological staining revealed a mucin-producing mass with scant spindle cells expressing smooth muscle actin and vimentin. no features of autoimmune synovitis were present and no crystals were found. s100 and desmin staining was negative. a pathological diagnosis of jam was made. clinical course the postoperative course was initially unremarkable; however, the patient returned four months later complaining of an increase in the size of the lesion, with decreasing left hand function. a repeat mri was performed prior to further surgery, as dramatic clinical deterioration suggested a possible infectious or malignant diagnosis. follow-up mri findings the mri showed recurrence of the thenar eminence jam, marked progression of the erosive intraosseous components, prominent flexor and extensor tenosynovitis, and radiocarpal and intercarpal synovitis (figure 8). figure 8: coronal (a) and axial (b) pd fat-saturated images with marked flexor and extensor compartment tenosynovitis (red arrows) and large hyperintense erosions in the radius, carpal and metacarpal bones (white arrows). discussion top ↑ jam is most commonly associated with large joints, with a male preponderance. it is mostly found in the lower limbs, and is very unusual in the hand and wrist.5 jam involves periarticular tissues including subcutaneous fat, joint capsule, tendons and rarely skeletal muscle. the aetiology of the lesion is uncertain; however, there is an association with previous trauma and osteoarthrosis of the underlying joint.1, 6 the lesion itself is usually painless, but it may cause local mechanical symptoms. jams do not metastasise; however, as in this case, they can be very locally aggressive. postoperative recurrence is seen in approximately 30% of jams within five years of excision.3, 4 other types of myxoma are intramuscular, cutaneous aggressive angiomyxoma, and myxoma of the nerve sheath (neurothekeoma).3 intramuscular myxoma is the most commonly encountered myxoma in clinical practice, occurring in the thigh, upper arm and buttock.5 the lesion is characteristically a well-circumscribed oval mass that is cystic in appearance. intramuscular myxomas are usually solitary but may be multiple and, in this scenario, are usually associated with monostotic or polyostotic fibrous dysplasia, which is known as mazabraud's syndrome.5 on ultrasound, the lesion may appear as a complex cystic mass (hypoor anechoic with increased through-transmission and posterior acoustic enhancement) or may even appear solid. it is hypovascular.1 computed tomography (ct) typically shows a lesion denser than water but less dense than muscle.8 the lesion on mri is isoto hypointense on precontrast t1w, inhomogeneously hyperintense on t2w, and demonstrates mild to moderate diffuse or peripheral contrast enhancement.8 typical mri findings also include mild perilesional oedema, owing to an incomplete fibrous capsule, and a split-fat sign as a result of adjacent muscle atrophy.8 jam and intramuscular myxoma share the same histological characteristics, but are differentiated by lesion location and the high recurrence rate of jam. the differential diagnosis of a lesion with imaging findings of a soft-tissue mass that mimics a cyst includes synovial cyst, bursa, ganglion, neurogenic neoplasms, myxoid liposarcomas and myxoid malignant fibrous histiocytoma (mfh).5, 7 conclusion top ↑ jam is a benign mesenchymal soft-tissue tumour that is a variant of myxoma, associated with large joints and joint degeneration. the present case demonstrates a histologically proven case of jam in an unusual location, with an unusually aggressive growth pattern and prominent local tissue infiltration. acknowledgements top ↑ competing interests the author declares that they he has no financial or personal relationships that he might have inappropriately influenced him in writing this article. references top ↑ meis jm, enzinger fm. juxta-articular myxoma: a clinical and pathologic study of 65 cases. hum pathol. 1992;23(6):639–646. http://dx.doi.org/10.1016/0046-8177(92)90319-x allen pw. myxoma is not a single entity: a review of the concept of myxoma. ann diagn pathol. 2000;4(2):99–123. http://dx.doi.org/10.1016/s1092-9134(00)90019-4 fletcher jw, watson hk, weinzweig j. recurrent myxoma of the hand. j hand surg am. 2000;25(4):772–775. http://dx.doi.org/10.1053/jhsu.2000.9412 haluk oa, merter ozenski e, inanc g, serdar t. juxta-articular myxoma of the wrist: a case report. j hand surg am. 2005;30(1):165–167. http://dx.doi.org/10.1016/j.jhsa.2004.09.009 murphey md, mcrae ga, fanburg-smith jc, temple ht, levine am, abouilafia aj. imaging of soft-tissue myxoma with emphasis on ct and mri and comparison of radiologic and pathologic findings. rad. 2002;225(1):215–224. http://dx.doi.org/10.1148/radiol.2251011627 korver rjp, theunissen ph, van de kreeke wt, van der linde mj, heyligers ic. juxta-articular myxoma in a 5-year-old boy: a case report and review of the literature. eur radiol. 2010;20(3):764–768. http://dx.doi.org/10.1007/s00330-00901490-7 al-qattan mm. myxoma of the hand. j hand surg br. 1996;21(5):690–692. http://dx.doi.org/10.1016/s0266-7681(96)80163-x petscavage-thomas jm, walker ea, logie ci, clarke le, duryea dm, murphey md. soft-tissue myxomatous lesions: review of salient imaging features with pathologic comparison. radiograph. 2014;34(4):964–980. http://dx.doi.org/10.1148/rg.344130110 case report case report � sa journal of radiology • march 2010 background retention of a foreign body in the heart or great vessels may be due to direct penetrating injury or embolism. in a series by jiang chun-li,1 retained foreign bodies were usually the result of penetrating cardiovascular injuries secondary to gunshot or stab wounds. the clinical manifestations of such patients vary from asymptomatic to haemodynamic instability. case history the patient had a history of penetrating abdominal trauma; 6 years before, a metal projectile (a piece of wire) entered his pelvis during a farming accident. x-rays on 6 may 2003 confirmed a metal fragment in the pelvis. six years later, on 4 april 2009, the patient was again involved in a farming accident and sustained facial bone fractures, contusion of the right lung, a right pneumothorax, as well as sacral and pelvic fractures. x-rays taken on 4 april 2009 revealed the same metal object as a metal foreign body pulmonary embolism c j joubert, mb chb, mmed rad d worcester radiology, worcester, w cape fig. 1. x-ray of 2003 shows a metal foreign body in the pelvis. fig. 2. x-ray of april 2009 shows no foreign body in the pelvis. fig. 3. the same metal object that was visible previously in the pelvis can now be seen in the left lower lung region. figs 4a and 4b. uncontrasted (coronal and sagittal reconstructions) ct scans of the chest demonstrate the metal foreign object in a pulmonary artery branch to the left lower lobe. a b a metal foreign.indd 8 2/26/10 9:47:08 am case report case report 10 sa journal of radiology • march 2010 seen before, but this time located in the left lung. a ct scan of the chest confirmed a piece of metal in a pulmonary artery to the left lower lobe. discussion the foreign body in the pelvis of our patient most probably migrated from the pelvis to the inferior vena cava and from there to the right atrium and right ventricle, from where it entered the left pulmonary artery to the pulmonary circulation loop. this could have happened in the 6 years between the x-rays or possibly during the trauma. foreign bodies can usually be diagnosed with conventional radiology, but a clinical history is also of value. conventional x-rays are sufficient to make a correct diagnosis of a metal foreign body, but a multislice ct scan is indicated for precise location. management options include surgical or conservative therapy (dr theo franken, personal communication, 22 may 2009), and should be individualised after the risk evaluation of removal of the foreign body. conclusion this rare case demonstrates migration of a metal missile from the pelvis to the left pulmonary artery after a penetrating abdominal injury. 1. jiang chun-li, gu tian-xiang, wang chun. surgical treatment of post traumatic foreign bodies in the heart and great vessels. chin med j 2006; 119(23): 2018-2020. 2. vagvolgyi a, vadasz p, heiler z, cseko a. delayed pulmonary embolism caused by a wandering bullet after abdominal shooting injury – case report. presented at the 17th european conference on general thoracic surgery, 31 may 3 june 2009, krakow, poland. 10 sa journal of radiology • march 2010 a metal foreign.indd 10 2/26/10 9:47:08 am case report case reportcase report abstract we present a case of a 43-year-old man who attended the ent clinic complaining of bilateral hearing loss. he had multiple bony swellings in both ear canals that mimicked exostoses. an audiogram showed bilateral symmetrical mixed hearing loss. excision was carried out to facilitate the use of a hearing aid. intraoperatively, the swellings were confluent, extending down to the annulus. the blood tests and skull x-ray were suggestive of osteopetrosis. following surgery, the patient was referred to the medical team. introduction patients with systemic bone disease presenting to the ent department are rare. we report an interesting case of a patient who presented with gradual onset of deafness and external auditory canal swellings, mistaken initially for multiple simple exostoses of both ear canals, in combination with mild background sensorineural hearing loss. case report the patient was a 43-year-old man who was referred to the ent department complaining of gradual deterioration in hearing in both ears. he had a history of being an avid swimmer. there were no other otological symptoms. on examination, he had multiple bony swellings in both ear canals. the tympanic membranes were normal. a pure tone audiogram showed bilateral symmetrical mixed hearing loss. a provisional diagnosis of exostoses with sensorineural hearing loss was made. the patient was initially prescribed a hearing aid. unfortunately, the hearing aid did not function well due to the poor fitting of ear moulds in the narrow ear canal. excision of the osteomas and canaloplasty was therefore undertaken on the narrowest canal to facilitate hearing aid effectiveness. intra-operatively, these bony swellings were found to be a solid bony mass under the meatal skin, extending down to the level of the annulus. the ossicles appeared normal and mobile. the excess bone was drilled out and a temporalis fascia graft was used to close a small iatrogenic perforation of the posterior tympanic membrane. the appearance of these thickened bony swellings was not typical of exostoses. in retrospect, the patient was observed to have an enlarged cranium. further tests were conducted to investigate metabolic or dysplastic bone disease. it also transpired, on direct questioning, that the patient had a maternal history of osteopetrosis. the liver function tests showed raised serum alkaline phosphatase; however, serum calcium, full blood count, urea and electrolytes were all normal. imaging studies of the skull (fig. 1) and lumbar and thoracic spine radiography showed generalised thickening and bony sclerosis in keeping with the diagnosis of osteopetrosis. a temporal bone computed tomography (ct) scan revealed narrowing in both internal auditory canals and constriction of the contents of both otic capsules. all these features were suggestive of osteopetrosis (fig. 2), with the exception of the raised alkaline phosphate which is more typical of paget’s disease than of osteopetrosis. however, the patient was reviewed by the endocrinology team who thought that the elevated alkaline phosphate was attributed to high alcohol consumption and obesity. therefore, the final diagnosis of osteopetrosis was made on the clinical and imaging features. no treatment was recommended apart dysplastic bone disease mimicking exostoses of the ear canal a shayah, mrcs, dohns c gadepalli, mrcs d loke, frcs l c knight, mphil, frcs department of otolaryngology – head and neck surgery, leeds general infirmary, leeds, uk fig. 1. axial ct scan showing generalised thickening of the cranial vault. fig. 2. temporal bone ct scan showing narrowing in both internal auditory canals and constriction of the contents of both otic capsules. � sa journal of radiology • april 2008 pg 4-5.indd 4 4/16/08 9:49:57 am case reportcase report from lifestyle changes and reducing his alcohol intake. further genetic study was planned in view of his family history. discussion various metabolic and dysplastic diseases can involve the temporal bone but rarely present initially to the ent clinic. we report the case of a man who presented with bilateral hearing impairment thought to be related to ear canal exostosis. family history and imaging studies guided the diagnosis toward osteopetrosis, a sclerotic dysplastic disorder of bone. osteopetrosis is a heterogeneous disorder characterised by the failure of osteoclasts to resorb bone. as a consequence, bone modelling and remodelling are impaired. osteopetrosis was first described by a german radiologist, albers-schönberg, in 1904.1 the estimated global incidence is up to 1:500 000.2 the defect in bone turnover characteristically results in skeletal fragility despite increased bone mass, and it may also cause haematopoietic insufficiency, disturbed tooth eruption, nerve entrapment syndromes, and growth impairment. deafness is usually conductive, secondary to anomalous bone formation3 or tubal blockade.4 sensorineural hearing loss secondary to nerve compression in the internal auditory meatus has been reported.3 there are three clinical types of osteopetrosis: ‘malignant’ (infantile), ‘benign’ (adult) and intermediate. the so-called ‘malignant’ form is an autosomal recessive disease and presents in infants and children as anaemia and neutropenia, neuropathy secondary to direct compression of nerve or resulting from vascular infarction, severe sensorineural hearing loss, mental retardation, hydrocephalus, multiple fractures and hypocalcaemia. this form has a very poor prognosis.5 the ‘benign’ form is autosomal dominant, is also called albersschönberg disease, and affects adults. this form can be asymptomatic or present with macrocephaly, widening of the mandible, proptosis, conductive hearing loss and sensorineural hearing loss. narrowing of the internal and external acoustic meatus (sensorineural loss) and sclerosis of the skull may occur.5 the intermediate autosomal recessive form appears during the first decade of life and has features in common with the benign form.6 two genes have been shown to be associated with osteopetrosis: atp6a3 (tcirg1) associated with type 1 (autosomal recessive) and clcn7 associated with type 2 (autosomal dominant). however, the genetic basis of type 3 (intermediate) is unknown.7 treatment of the benign form is entirely symptomatic, aimed at correcting facial deformity or recurrent fractures. surgery may also be indicated to treat neuropathy related to nerve compression.8 however, in the infantile malignant form, studies have shown that a bone marrow transplant is the only curative treatment.8 other methods of treatment for the malignant disease have included gamma interferon and calcitrol (1,25-dihydroxy vitamin d).8 skull thickening can be encountered in various other conditions. chronic phenytoin therapy has shown to provoke osteoblast proliferation, causing skull thickening which can develop in 34% of patients with seizure disorders on long-term phenytoin therapy. the consequences of skull thickening are mainly cosmetic, giving the features of acromegaly with normal size of hands and feet.9 similar features can also present in van buchem disease, which was first described in 1955 as an autosomal recessive bone dysplasia linked to a genetic locus on chromosome 17q12–21. this disease is characterised by asymmetrically increased thickness of bones (mostly jawbone) but can also present in skull, ribs, long bones as well as hands and feet, resulting in increased cortical bone density. this may lead to facial nerve palsy causing hearing loss, visual problems, neurological pain and, very rarely, blindness as a consequence of optic atrophy. bone anomalies appear in the first decade of life and become more prominent among the elderly.10 other causes of bilateral hyperostosis of the skull vault are marrow hyperplasia, hyperparathyroidism and acromegaly. none of these conditions was evident in the in the above case. 1. waguespack sg, hui sl, white ke, buckwalter ka, econs mj. measurement of tartrate-resistant acid phosphatase and the brain isoenzyme of creatine kinase accurately diagnoses type ii autosomal dominant osteopetrosis but does not identify gene carriers. j clin endocrinol metab 2002; 87(5): 2212-2217. 2. beighton p, hamersma h, cremin bj. osteopetrosis in south africa. the benign, lethal and intermediate forms. s afr med j 1979; 55(17): 659-665. 3. milroy cm, michaels l. temporal bone pathology of adult-type osteopetrosis. arch otolaryngol head neck surg 1990; 116(1): 79-84. 4. magliulo g, celebrini a, cuiuli g, parotto d. osteopetrosis of temporal bone with blockage of the eustachian tube. a case report. an otorrinolaringol ibero am 2004; 31(1): 51-58. 5. antunes ml, testa jr, frazatto r, barberi ja, silva rf. rare osteodysplasia of the temporal bone. rev bras otorrinolaringol 2005; 71(2): 228-232. 6. frederic s. osteopetrosis: current clinical considerations. clin orthop 1993; 294: 34-44. 7. frattini a, pangrazio a, susani l, et al. chloride channel clcn7 mutations are responsible for severe recessive, dominant, and intermediate osteopetrosis. j bone miner res 2003; 18(10): 1740-1747. 8. carolino j, perez ja, popa a. osteopetrosis. am fam physician 1998; 57(6): 1293-1296. 9. chow km, szeto cc. cerebral atrophy and skull thickening due to chronic phenytoin therapy. cmaj 2007; 176(3): 321-323. 10. wergedal je, veskovic k, hellan m, et al. patients with van buchem disease, an osteosclerotic genetic disease, have elevated bone formation markers, higher bone density, and greater derived polar moment of inertia than normal. j clin endocrinol metab 2003; 12: 5778-5783. � sa journal of radiology • april 2008 pg 4-5.indd 5 4/16/08 9:49:57 am sajr 927 obstetric ultrasound − its risks and the cost of addressing them g r howarth, 1 mb chb, mmed (o&g), mphil (bioethics); s bown, 2 llb (hons), mrcp, drcog, ffflm 1 medicolegal advisor and head of medical services − africa, medical protection society, london, united kingdom 2 director of policy and communications, medical protection society, london, united kingdom corresponding author: g r howarth (graham.howarth@mps.org.uk) until recently, obstetric claims (which are invariably high-value) used to be clustered around problems related to labour. however, a second group of high-value claims is emerging: those related to missed abnormaltities. the value of claims is now so high that a single individual is unable to compensate a claimant adequately, and indemnity is therefore essential. although such claims are relatively rare, indemnity costs are high as the claims are large. the high value of obstetric claims, including those for missed abnormalities, is reflected in the cost of indemnity for obstetricians and those performing antenatal ultrasound. s afr j rad 2013;17(3):98-99. doi:10.7196/sajr.927 children born following obstetric misadventure are usually severely compromised and require specialised care and sophisticated treatment that allows them to live longer and more fulfilling lives. owing to costly care and longer life expectancy, raising such children is expensive; therefore, understandably, the cost of obstetric claims is high, and settlements can easily reach eight-figure sums. accordingly, indemnity costs for obstetricians are far higher than most other specialties; with few exceptions, obstetricians’ indemnity costs are multiples of those of other specialities, and may threaten private obstetric care in south africa by the end of the decade.1 , 2 until fairly recently, most high-value obstetric claims concerned intrapartum problems – mainly cerebral palsy related to mismanaged intrapartum care. however, a second group of high-value claims is now emerging: those related to missed abnormalities.3 the gist of the allegations in these claims is that structural abnormalities were missed during an antenatal ultrasound examination. had the parents been aware of the severity of the abnormality that was missed, they claim that they would have elected to terminate the pregnancy. alternatively, if the parents felt that they would have decided against terminating the pregnancy, they allege that intra-uterine diagnosis and alternative management of the pregnancy or delivery would have alleviated complications and some of the costs for caring for the child. the latter is a classic claim in medical negligence not dissimilar to any claim for the financial consequences of a delayed or missed diagnosis. the former is a claim by the parents for wrongful birth, holding the defendant responsible for the extra costs of raising the compromised child.4 south african law does not allow a child to sue for wrongful life.5 , 6 with modern ultrasound equipment, it is possible for the trained observer to diagnose the majority of major structural abnormalities antenataly.7 the converse is also true; if abnormalities can be seen, they can also be missed. as most major abnormalities can and will be seen on ultrasound, it follows that when missed, successful defence of a case may be difficult as the claimant will argue that ‘on the balance of probabilities’, the abnormality should have been seen. defending a case may also be made more difficult by reviewing images of an ultrasound, given to the patient as a keepsake, that clearly demonstrate the abnormality. to date, all that was needed to perform ultrasound in pregnancy was appropriate equipment, an operator and a willing pregnant patient.8 each time an obstetric ultrasound is performed, there is a risk that an abnormality may be missed. while the chance of missing an abnormality in a particular scan is low, the risk among a cohort of scans is not; abnormalities, including major structural abnormalities, are missed, even by experts. the issue is compounded by the magnitude of a claim for a missed abnormality. unfortunately, such claims tend to be high, and can also easily run into millions of rand. while an individual’s risk of having a claim made may be relatively low, the magnitude of a missed abnormality claim’s value is so high that a single individual could not afford to compensate a deserving claimant.1 , 9 what can individuals do to negate that risk? they can avoid the risk by no longer performing obstetric ultrasound or they can try to decrease the risk of missing a structural abnormality by increasing their knowledge and expertise. while the former action is a solution, the second merely decreases but does not remove the risk; even experts miss structural abnormalities. while improving operator knowledge and skill may be helpful, the only way of performing obstetric ultrasound and avoiding the financial risk of a missed abnormality is by transferring that risk to either an insurer or a not-for-profit indemnifier. now one has to add appropriate indemnity to the requirements for performing obstetric ultrasound! while large insurers or indemnifiers will have the capacity to meet high claims costs, they, like the individuals confronted by the risk, need to decide whether or not they will accept the risk. if they wish to avoid the risk of claims for missed structural abnormalities, they can either decline to accept the risk or make their product unaffordable – risk avoidance. if they decide to accept the risk, they may wish to decrease it, one approach being to insist that those performing these specialised scans have predetermined training, knowledge or expertise. most importantly, indemnifiers accepting the financial risks of claims for missed structural abnormalities need to ensure they have sufficient reserves to meet future administrative and claims costs. to do this, they perform actuarial risk assessments to determine the reserves needed to meet the financial risk of missed structural abnormalities, given the chance of an abnormality being missed and the magnitude of claims anticipated. once the magnitude of the financial risk for missed structural abnormalities has been calculated, it has to be decided who should pay for the risk. there can only be one equitable answer: if you contribute to the financial risk, you must contribute to covering it. only one question remains: how much should individuals contribute? again, there is only one equitable answer: each individual who contributes to the risk has to contribute to the covering of the risk. the person who performs the ultrasound is the individual who may be sued for missing an abnormality, and it is important that that individual is appropriately indemnified. if the individual is an employee, it is important that the employer either requires that their employees make their own arrangements for appropriate indemnity, or the employer pays for the indemnity arrangements for the employee. although the chances of missing a major structural abnormality on a single scan are low, claims are likely to be very high, and indemnifying the risk will be correspondingly expensive. making those who take the financial risk of missing a structural abnormality pay to cover their own risk will have consequences. given that the fee for an individual antenatal scan is low, some will be unable to absorb the cost by performing a few extra scans. many may feel that they cannot afford the cost increase and, unable to bear the financial risk themselves, may have to give up obstetric ultrasound. rather than precluding the performing of ultrasound in pregnancy, is there an alternative? are there scans that can be performed that are lower-risk and require less expertise, for which indemnity therefore costs less? there are; first trimester scans confirming pregnancy, its location and gestational age are of lower risk and can be performed by those with less expertise who are exposed to less financial risk. it is important to note the distinction between these restricted first trimester scans and the higher risk first trimester scans evaluating intracranial and/or nuchal translucency; clearly these scans also require specialist expertise. those performing the simpler scans need to ensure that patients understand the limits of the restricted scan, and that the pregnancy is not being screened for genetic or structural abnormalities. to reinforce the message, patients need to be informed of the prudence of having a fetal evaluation scan performed by someone else who has the appropriate expertise and indemnity. the conversation with the patient needs to be contemporaneously documented and the documentation retained. neither the nuchal nor the intracranial translucency should be evaluated or measured, and no image should be given to the patient that shows either. some professionals who are trained and competent to perform obstetric scans later in pregnancy may be discouraged by high indemnity costs but are concerned about where this leaves their professional obligations in certain circumstances. ‘what if’ arguments arise, a classic one being: what if you decline to perform a second or third trimester scan, despite having the equipment and a degree of expertise, because you do not have the appropriate indemnity? are you not vulnerable to criticism from the health professions council of south africa (hpcsa) for failing to act in the patient’s best interests? to be vulnerable to criticism from the hpcsa, the individual would have to unreasonably decline to perform a scan in a true emergency situation with nobody else appropriate available. it is important to remember that few obstetric ultrasound scans are true emergencies; additionally, in the vast majority of private patients, an earlier scan will be available that is of assistance. while an urgent scan may be reassuring or helpful, it may not be clinically essential. a few true emergencies do spring to mind, however; e.g. placental localisation in a pregnant patient who is bleeding painlessly near term and does not have a previous ultrasound; or evaluation of fetal heart activity in a patient with a viable fetus and a clinical diagnosis of probable placental abruption. confirmation of fetal heart activity may allow for a life-saving caesarean section, while the absence of fetal heart activity would save the mother an unnecessary and dangerous caesarean section. were an abnormality missed in these life-threatening emergency situations where action and time are of the essence, it is unlikely that, under the circumstances, an individual would be found negligent of missing a structural abnormality. additionally, it is unlikely that there would be any liability as delivery would be imminent, and it is unlikely that there would be time or opportunity to modify the outcome. in such cases, the litigation risks are very low and could be carried by the individual probably at little financial risk to themselves. if sued, however, and the individual was indemnified by a discretionary organisation, the individual could always approach the organisation to exercise their discretion positively. a claim following a missed structural or chromosomal abnormality is rare but expensive to settle, leading to increased indemnity costs. those wishing to perform obstetric ultrasound need to ensure that they are appropriately and adequately indemnified, giving them and their patients peace of mind. 1. howarth gr. the threat of litigation: private obstetric care – quo vadis? south african journal of bioethics and law 2011;4(2):85-88. 1. howarth gr. the threat of litigation: private obstetric care – quo vadis? south african journal of bioethics and law 2011;4(2):85-88. 2. howarth gr. obstetric risk avoidance: will anyone be performing private obstetrics by the end of the decade? s afr med j 2013;103(8):513-514. [http://dx.doi.org/10.7196/samj.7233] 2. howarth gr. obstetric risk avoidance: will anyone be performing private obstetrics by the end of the decade? s afr med j 2013;103(8):513-514. [http://dx.doi.org/10.7196/samj.7233] 3. nhs litigation authority. ten years of maternity claims. an analysis of nhs litigation authority data. london: nhs litigation authority, 2012. 3. nhs litigation authority. ten years of maternity claims. an analysis of nhs litigation authority data. london: nhs litigation authority, 2012. 4. friedman v glicksman 1996 1 sa 1134 (w). 4. friedman v glicksman 1996 1 sa 1134 (w). 5. stewart v botha (340/2007) [2008] zasca 84 (3 june 2008). 5. stewart v botha (340/2007) [2008] zasca 84 (3 june 2008). 6. sithole s. liability of medical practitioners to children born with congenital defects – a discussion of stewart v. botha. south african journal of bioethics and law 2009;2(2):41-42. 6. sithole s. liability of medical practitioners to children born with congenital defects – a discussion of stewart v. botha. south african journal of bioethics and law 2009;2(2):41-42. 7. chaoui r, nicolaides kh. from nuchal translucency to intracranial translucency: toward the early detection of spina bifida. ultrasound obstet gynecol 2010;35:133-138. [http://dx.doi.org/10.1002/uog.7552] 7. chaoui r, nicolaides kh. from nuchal translucency to intracranial translucency: toward the early detection of spina bifida. ultrasound obstet gynecol 2010;35:133-138. [http://dx.doi.org/10.1002/uog.7552] 8. geerts l. ultrasound services in our rainbow nation – many shades of grey? south african journal of obstetrics and gynaecology 2010;18(2):34-35. 8. geerts l. ultrasound services in our rainbow nation – many shades of grey? south african journal of obstetrics and gynaecology 2010;18(2):34-35. 9. howarth gr, bown s, whitehouse s. the importance of comprehensive protection in today’s healthcare environment. s afr med j 2013;103(7):453-454. [http://dx.doi.org/10.7196/samj.7106] 9. howarth gr, bown s, whitehouse s. the importance of comprehensive protection in today’s healthcare environment. s afr med j 2013;103(7):453-454. [http://dx.doi.org/10.7196/samj.7106] editorial 50 sa journal of radiology • september 2010 editorial in her 2009 presidential address, rsna president theresa mcloud1 focused on trends in radiological training: national and international implications. she said: ‘we need to embrace the change that globalization is bringing and actively join in the discussion as we seek ways to adapt ourselves and our training programs to it.’ the editorial in the june 2010 issue of this journal focused positively on the state of academic radiology in south africa and also drew attention to the continuing medical education (cme) programme of the radiological society of south africa (rssa). the rssa is a professional society whose purpose is to improve the health of patients through maximising the value of radiology and radiologists by: • advancing the science of radiology • improving radiological service to patients • studying the socio-economic aspects of the practice of radiology • providing and supporting continuing education for radiologists and related professional fields. the rssa also supports its members as they adapt to a rapidly changing healthcare environment. the challenges for the rssa are complex because the needs of patients are diverse. to best represent and fulfill the cme requirements, the rssa congress portfolio must relate to many different organisations and entities. the rssa had for decades before the introduction by the hpcsa in 2007 of the obligatory continuing professional development (cpd) programme, organised national and international congresses and courses. i pay tribute to dr paul schneider, peter reichman, professor brian cremin, professor jan lotz, dr jan labuschagne and others who contributed to the congress programme over many years. i vividly recall lectures by internationally renowned radiologists such as drs margulis, levine, laufer, husband, modick, maffee, resnick, osborn, bradey, harnsberger, heiken, kucharczyk and many other great names. despite such events, there are most likely very few private radiologists who have not regularly travelled overseas to attend congresses and courses at great expense. against the background of optimism regarding the state of academic radiology in south africa, most teaching departments are sub-optimally staffed, and no single department can boast a full complement of sub/super-specialists or fellowship-trained faculty staff. few full-time staff or registrars can afford to regularly travel abroad to attend congresses and courses, unless they participate academically, which is not always possible. however, i believe that if all resources are pooled and effectively managed, and the wide spectrum of local expertise accessed, the rssa can significantly contribute to the training and cme needs of the profession. against this background, i accepted the nomination of rssa congress chair. the vision was to establish an active, integrated, affordable and sustainable state-of-the-art cme programme that will address and complement the academic needs (shortfall) of registrars in training, as well as the ongoing cme requirements of academic and private radiologists. the programme was launched with the full support of the rssa exco and many other role players. from february 2008 to august 2010, there have been 10 courses including 2 short courses on current ethical issues in radiology. in addition, there were separate workshops by samsig, the rssa-affiliated musculo-skeletal sub-group, the paediatric imaging society (pisa) and a rssa-endorsed pacs course. more than 40 international speakers have participated so far. all this was achieved by forming partnerships and securing rssa participation in the satellite and outreach educational programmes of international societies such as the international cancer imaging society (icis), international society for magnetic resonance and medicine (ismrm) global outreach program, radiological society of north america (rsna), visiting international professors program(vip), the society of gastro-intestinal radiology (sgr), international education conference (iec), the university of leuven and leading international radiologists. on an international intersociety level, rssa members have free corresponding membership of the ecr, and registrars and junior radiologists qualify for participation in the european school of radiology visiting fellowship programmes.the international society of radiology (isr) allows free access by rssa members, academic institutions and registrars to an online virtual journal project, gorad, which gives online access to 17 selected major journals for free. course topics are chosen and integrated to cover the major organ system and imaging modalities over a 4-year period. ideally, all the academic departments in the country should have a similar integrated modular curriculum, and the cme congress/course programme should be an integral part of the curriculum. it is anticipated that registrars should be exposed to the leading teachers in radiology during their training and that practicing radiologists would have completed the ‘essentials for board certification review’. all courses are available on cd for participants. every effort is made to promote faculty participation and chair opportunities for south african radiologists, and to create the opportunity to participate and gain experience at an international level. great care is taken to keep the courses affordable and registration fees market-related, compared with similar courses overseas. registrars and full-time academic staff are cross-subsidised by private radiologists. it is, however, important to establish a culture of investing in oneself among young colleagues. the cme programme can only be sustained over time if it runs at a profit. the financial support of the major vendors and pharmaceutical companies is indispensible for the programme’s success, and is highly appreciated. long-term partnerships with international radiological societies and commercial vendors must be continuously fostered and maintained. new and innovative approaches to industry and corporate sponsorships and education grants will have to be formulated and agreed upon by all stakeholders, to pool the limited and available financial resources for the benefit of all. it is important to take cognisance of the ‘winds of change’ about international rules and trends in corporate continuing medical education in radiology in south africa continued on page 78 the radiological.html the radiological appearance of metastatic cystic lesions p barnardt, mb chb, dip oncol j du toit, mb chb department of medical imaging and clinical oncology, tygerberg hospital, parow corresponding author: p barnardt (pieterb@sun.ac.za) abstract introduction. cystic and cavitatory pulmonary lesions are abnormalities encountered on chest computed tomography (ct). malignant lesions, including metastases, rarely present as cystic lesions; we report on two such cases: a man with advanced carcinoma of the left testis, and a woman with epithelioid trophoblastic tumour. discussion. the lungs are the most common site for metastases from non-pulmonary neoplasms. the appearance of cystic lesions in the lung in malignancy is rare and predisposes to spontaneous pneumothoraces. multiple cystic lesions occur commonly in bronchus carcinoma and also sarcoma, bladder cancer and, less commonly, lymphoma and metastasis. both chemotherapy and immune suppression can induce cavitation in malignant lesions. tumour necrosis and tumour infiltration of air-containing spaces with a check-valve mechanism are postulated for causing these cystic lesions. spontaneous resolution is the rule. close follow-up is recommended as these spaces may become infected. conclusion. ct is the mainstay of diagnostic imaging in cancer patients. cystic lung lesions are caused by a diverse array of pathological processes, and are rare in metastatic disease. introduction cystic and cavitatory pulmonary lesions are abnormalities frequently encountered on chest radiography and computed tomography (ct). a cyst is defined as any round circumscribed space that is surrounded by an epithelioid or fibrous wall of variable thickness. the underlying nature of these lesions may be apparent, as in the case of bullae associated with emphysema, but may pose a diagnostic challenge. generally, malignant lesions including metastases rarely present as cystic lesions.1 high-resolution ct of the chest helps to define morphological features that may serve as clues regarding the nature of cystic and cavitatory lung lesions. a well-established differential list for consideration exists for these radiological phenomena (table i).1 , 2 we report two cases of metastatic malignant tumors with cystic pulmonary lesions post-chemotherapy on radiological imaging: a man with advanced non-seminomatous germ cell tumour (nsgct) and a woman with epithelioid trophoblastic tumour (ett). prior written informed consent and local ethics committee approval was obtained. case 1 a 22-year-old man presented at the tygerberg hospital oncology unit post-orchidectomy for a large left testicular mass. clinical examination revealed a palpable para-umbilical mass of 10 x 15 cm. the post-operative blood examinations showed raised hormonal markers of alpha fetoprotein (afp) of 15 167 µg/l (0.0 9.0 µg/l), β-human chorionic gonadotropin (hcg) 6104 iu/l (<5 iu/l) and a lactate dehydrogenase (ldh) value of 313 u/l (100 190 u/l). staging examinations included a chest x-ray (cxr), which showed multiple bilateral lung nodules, and thoracic and abdomino-pelvic ct that confirmed multiple diffuse nodules in both right and left lungs in keeping with metastases (fig. 1a). significant left para-aortic and porta-hepatic lymphadenopathy was also demonstrated. these features were suggestive of metastatic testicular cancer. a brain ct was normal, with no evidence of metastatic disease. microscopic examination revealed tumour cells displaying a trabecular pattern with papillary and pseudoglandular structures, as well as solid areas. extensive necrosis and haemorrhage were also seen. these changes were consistent with embryonal carcinoma and yolk sac elements, and the histological features confirmed a non-seminomatous germ cell tumour (nsgct) of the left testis. the patient was staged according to the european germ cell cancer consensus group as a pt2 n3 m1a s2 (stage iiia), intermediate risk nsgct. he was offered systemic chemotherapy with the standard bep regime (bleomycin 30 iu iv day 1, 8, 15; cisplatinum 20 mg/m2 iv day 1 5 and etoposide 100 mg/m2 iv day 1 5 every 21 days) and completed 6 cycles. his hormonal markers decreased with each consecutive cycle and normalised after cycle 4. restaging cxr, chest ct and abdomino-pelvic ct were compared with baseline investigations. in both lungs, the majority of the previously demonstrated pulmonary lesions showed cystic degeneration and a reduction in size (fig. 1b). individual small solid lesions were still noted peripherally. the para-aortic lymph nodes were still present but appeared smaller, demonstrating a partial response to therapy. owing to marker normalisation, the patient was referred to a urology-oncology surgeon for a retroperitoneal lymph node dissection. case 2 a 35-year-old woman presented with a history of secondary infertility, persistent vaginal bleeding, raised β-hcg and an ultrasonic appearance of a molar pregnancy. her staging examinations include a cxr revealing numerous small bilateral lung lesions and an abdominal ct that confirmed a single liver metastasis. a brain ct was normal, with no signs of metastatic disease. microscopic sections of the tumour showed haemorrhage, necrosis and numerous fragments of malignant trophoblastic tissue of intermediate origin. the cells were epithelioid in shape with hyperchromatic nuclei. syncytotrophoblastic giant cells were few. in view of the morphology and the intense positivity of p63 and k167 immunohistochemistry, the features were in keeping with an epithelioid trophoblastic tumour (ett). according to the revised international federation of gynecology and obstetrics (figo) classification for gestational neoplastic disease (gnd), she had stage iv disease. chemotherapy consisted of etoposide 100 mg/m2 iv day 1 5 and cisplatinum 20 mg/m2 iv day 1 5 every 21 days. she completed 6 cycles with a slow decline in β-hcg. restaging examinations included a chest and abdominal ct. numerous cystic metastatic lesions were detected bilaterally throughout both lung fields secondary to systemic treatment. bilateral pneumothoraces were present (fig. 2). a single hypodensity was detected in the periphery of the right lobe of the liver but was, however, too small to characterise and could represent either a benign cyst or a cystic metastasis. the remainder of the abdomen was clear. currently, the patient continues with second-line multi-agent chemotherapy on a weekly basis. discussion the appearance of cystic lesions in the lung in malignancy is rare and best described radiologically by chest ct. cysts appear radiologically as rounded parenchymal lucencies or as low-attenuating areas with a well-defined interface of normal lung, and are usually thin-walled (<2 mm). cysts in the lung usually contain air but can also contain fluid or solid material.1 , 3 important parameters in evaluating cystic and cavitatory lesions are (i) the tempo of disease (acute versus chronic) and (ii) the clinical context. a chronic process is more likely, owing to neoplastic disease, long-standing inflammatory or fibrotic disorders, and congenital lesions. the presence of cysts and cavities in the lung predisposes to the occurrence of spontaneous pneumothoraces.1 , 5 the lungs are the most common site for metastases from non-pulmonary neoplasms. these are typically round and well-defined; however, they may present radiologically with a spectrum of unusual appearances including cavitation, calcification or surrounding ill-defined haemorrhage. numerous cystic and cavitatory lesions occur frequently in bronchus carcinoma (10% 15%) and are usually associated more with squamous cell carcinoma than other cell types. however, they also occur with sarcoma, transitional cell carcinoma of the bladder and, less commonly, with lymphoma and metastasis.4 , 5 the frequency of cavitation in pulmonary metastases is approximately 4%, as opposed to 9% in primary bronchogenic carcinoma.5 both chemotherapy and immune suppression are known to induce cavitation in malignant lesions. several mechanisms are postulated: tumour necrosis secondary to rapid tumour kill in chemosensitive tumors, and tumour infiltration of air-containing structures with a check-valve mechanism are some.5 there is a suggestion that ett may not be as chemosensitive as other gestational trophoblastic diseases, but testis cancer is a highly chemosensitive tumour. both our patients presented post-chemotherapy with cystic pulmonary lesions and, in the case of the ett patient, bilateral pneumothoraces appeared as a result of ruptured cavitations. spontaneous resolution is the rule. close follow-up in immune-suppressed patients is recommended as these spaces may become infected.1 conclusion ct is the mainstay of diagnostic imaging in cancer patients as it is non-invasive, highly sensitive, and specific for a range of diseases. cystic and cavitatory lung lesions are caused by a diverse array of pathological processes and are rare in metastatic disease. we have described two cases of cystic pulmonary metastases post-chemotherapy, with the aim of highlighting to both clinicians and radiologists the atypical appearances of malignant disease and the associated diagnostic possibilities. 1. ryu hj, swensen sj. cystic and cavitary lung diseases: focal and diffuse. mayo clin proc 2003;744-752. 1. ryu hj, swensen sj. cystic and cavitary lung diseases: focal and diffuse. mayo clin proc 2003;744-752. 2. cantin l, bankier aa, eisenberg rl. multiple cystic-like lung lesions in the adult. ajr 2010;194(1):1-11. 2. cantin l, bankier aa, eisenberg rl. multiple cystic-like lung lesions in the adult. ajr 2010;194(1):1-11. 3. hansell dm, bankier aa, macmahon h, et al. glossary of terms for thoracic imaging. radiology 2008;246(3):697-722. 3. hansell dm, bankier aa, macmahon h, et al. glossary of terms for thoracic imaging. radiology 2008;246(3):697-722. 4. godwin jd, webb wr, savoca cj, et al. multiple, thin-walled cystic lesions of the lung. ajr 1980;135:593-604. 4. godwin jd, webb wr, savoca cj, et al. multiple, thin-walled cystic lesions of the lung. ajr 1980;135:593-604. 5. topal nb, oruc e, gokalp g, topal u. atypical pulmonary metastases: radiologic appearances. indian j radiol imaging 2007;17:181-185. 5. topal nb, oruc e, gokalp g, topal u. atypical pulmonary metastases: radiologic appearances. indian j radiol imaging 2007;17:181-185. table i. differential considerations for multiple cystic lung lesions pulmonary langerhans cell histiocytosis pulmonary lymphangioleiomyomatosis lymphocytic interstitial pneumonia pneumatoceles neurofibromatosis type 1 tracheobronchial papillomatosis metastases (rare) fig. 1. chest computed tomography of metastatic testicular cancer. (a) pre-treatment: note bilateral lung nodules and masses. (b) post-treatment: note thin-walled cystic lesions. fig. 2. chest x-ray of metastatic liver cancer. (a) pre-treatment: note numerous bilateral solid nodules, and (b) post-treatment: note numerous bilateral pulmonary nodules that have decreased in size and density with associated cystic degeneration owing to chemotherapy. fig. 3. lung ct of a patient with metastatic epithelioid trophoblastic tumour (ett). note the irregular thin-walled cystic structures with ruptured subpleural lesions, resulting in bilateral pneumothoraces. case report 22 sa journal of radiology • march 2010 magnetic resonance imaging of miliary tuberculosis of the central nervous system in children with tuberculous meningitis pieter janse van rensburg, savvas andronikou, ronald van toorn, manana pienaar stellenbosch university background. tuberculous meningitis (tbm) is closely associated with miliary tuberculosis, and a pathogenetic relationship is suspected, although it has been proposed that the two processes are unrelated. objective. to describe miliary tuberculosis of the central nervous system (cns) on mri in children with tbm. materials and methods. a retrospective descriptive study of 32 paediatric tbm patients referred for mri. the presence of miliary nodules in the cns was recorded. lesions were categorizsd according to their distribution, enhancement pattern, size and signal characteristics. results. a miliary distribution of nodules was present in 88% of patients. all patients with a miliary distribution had leptomeningeal nodules, and 18% of these patients had deep parenchymal nodules in addition. at least one tuberculoma with central t2 hypointensity was identified in 39% of patients. conclusion. the high prevalence of miliary leptomeningeal nodules in the cns of children with tbm is significant because it points to a pathogenetic relationship that has long been suspected on epidemiological grounds. our findings challenge the concept that miliary tuberculosis is only an incidental finding in tbm patients, and suggest that it plays an integral part in the pathogenesis. determination and comparison of the termination of the dural sac tip in a south african population: clinical significance in craniospinal irradiation d h schulenburg, a cilliers, j janse van rensburg university of the free state objectives. to determine, using mri, the level of termination of the dural sac in the south african population, comparing our results with findings from international studies. methods. we retrospectively reviewed the lumbosacral mris of 309 patients, including black and white males and females with ages ranging from 18 to 83, in each case identifying the tip of the dural sac and establishing the level of termination. this level was recorded in relation to the adjacent vertebral body i.e. upper-, middleand lower third and adjacent intervertebral disc. results. the dural sac tip level ranged from the lower third of l5 to the lower third of s3. the overall mean of the dural sac position was at the middle third of s2. a notable percentage (13.9%) of patients had a dural sac level lower than the lower third of s2, and 15.2% patients had a dural sac level higher than the s1-s2 intervertebral disc. no significant difference in dural sac level was seen between black and white patients, neither was any significant difference observed between male and female patients. no relation was found between age and the level of the dural sac. conclusion. the study failed to demonstrate a difference in the dural sac termination level, as found in the south african population, compared with levels reported in various international studies; nor is there a statistical difference between gender, race and age. our study shows that routine placement of the spinal field at the lower border of s2 adequately treats the majority of csi patients. using spinal mri to establish the lower border of the csi spinal field will, however, benefit patients by ensuring adequate coverage of the entire neuroaxis as well as minimising late gonadal toxicity. neuroradiological features of the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome paul scholtz, sally candy department of radiology, university of cape town suzaan marais infectious diseases unit, gf jooste hospital; institute of infectious diseases and molecular medicine, university of cape town dominique j pepper, graeme meintjes infectious diseases unit, gf jooste hospital; institute of infectious diseases and molecular medicine, university of cape town; department of medicine, university of cape town robert j wilkinson infectious diseases unit, gf jooste hospital; institute of infectious diseases and molecular medicine, university of cape town; department of medicine, university of cape town; division of medicine, wright fleming institute, imperial college london; national institute for medical research, mill hill, london objective. paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (tb-iris) is an important complication in hiv-1-infected tuberculosis patients who start combination antiretroviral therapy (art). neurological manifestations occur in more than 10% of tb-iris cases. apart from a few case reports, the radiological features of neurological tb-iris have not previously been described. our objective was to describe the radiological features of paradoxical neurological tb-iris. methods. we reviewed neuroradiological imaging of 16 patients with neurological manifestations of paradoxical tb-iris. computer tomography (ct) (n=13) and magnetic resonance imaging (mri) (n=3) were reported by 2 neuro-radiologists, blinded to clinical presentation. results. neurological tb-iris manifestations included: meningitis (4), intracranial space occupying lesions (sols, presumed tuberculoma) (5), both meningitis and sols (5), radiculomyelitis (1) and spondylitis (1). in 10 patients with tuberculoma iris, we observed a high prevalence of (i) low-density lesions on non-contrast enhanced ct radioactive news abstracts of oral presentations at the rssa neuroradiology and body imaging advances congress, sandton, 28 30 august 2009 radioactive news radioactive news.indd 22 2/26/10 9:50:24 am 23 sa journal of radiology • march 200723 sa journal of radiology • march 2010 (all lesions), (ii) multiplicity of lesions (in 5 of 10 patients), (iii) perilesional oedema (17/22 lesions) and (iv) contrast enhancement of the lesion/s (20/22 lesions). in 9 patients with meningitis, meningeal enhancement (n=2) and hydrocephalus (n=1) were infrequently observed. conclusions. this is the first substantial series to describe the radiological features of paradoxical neurological tb-iris. compared with published radiological findings of tuberculomas in hiv-1infected patients (not receiving art), an increased inflammatory response is evident in tuberculoma iris. however, in patients with tb meningitis iris, we found no evidence of more frequent leptomeningeal enhancement, compared with what is described in hiv-1 infected patients with tb meningitis not on art. loeffler’s endocarditis with cardiac and neurological features: a case report johann steyn, ernesta meintjes medical imaging research unit, department of biomedical engineering, university of cape town sulaiman moosa, sally candy department of radiology, groote schuur hospital and university of cape town niel hendricks, adrzej okreglicki, bongani m mayosi division of cardiology, department of medicine, groote schuur hospital and university of cape town hypereosinophilic syndrome is a rare disorder characterised by a persistent eosinophilia of 1 500/µl for at least 6 months; it can be primary or secondary. widespread end organ damage occurs in the heart and brain, among others. the neurological presentations include sensory polyneuropathy and encephalopathy. thromboembolism is the most significant mechanism of neurological injury. the typical neuroimaging findings include multiple high signal lesions on t2w or flair images. as these are infarcts, they are distributed in the watershed/ border zones, and may increase in size if left untreated. reduction in peripheral eosinophilic count often leads to regression of neurological symptoms and signs. knowledge of the association between cardiac and neurological symptoms and signs in the setting of hypereosinophilia might prevent an unnecessary delay in diagnosis. we describe a 37-year-old woman who presented with palpitations and worsening dyspnoea. in addition, a neurological examination revealed dysarthric speech, right arm pronator drift with mild extensor weakness, and reflex asymmetry. the right-sided weakness resolved within 24 hours. an uncontrasted ct scan of the brain preceded an mri. axial flair, sagittal t1w preand sagittal mprage post gadolinium images were acquired on a 1,5t siemens mri. gyral cortical high signal intensity lesions were present on t1w images in the cortex and subcortical areas of the frontal and occipital lobes and cerebellum. multiple high-signal lesions were seen on t2w flair images in watershed territories, confirming the ct diagnosis of borderzone infarcts. low-signal lesions seen centrally in highsignal lesions represented lacunar infarcts. cardiac echography and mri revealed obliteration of both apices of ventricles by thrombus and delayed enhancement in keeping with the classic appearance of loeffler’s endocarditis. low platelets and an eosinophilic count of 3.08 (normal 0 0.45 x109/l) were found. the patient’s diagnosis of loeffler’s endocarditis was confirmed histologically post cardiac transplant. ethical issues in radiology the first of a series of short courses entitled current ethical issues in radiology was presented on 23 january at the tygerberg campus of stellenbosch university by the radiological society of south africa (rssa). the workshop was established in response to many requests by rssa members, as well as the rapidly changing professional, social, technical and political environment, to meet the challenges facing radiologists and other important roleplayers. a national faculty of leading radiologists, a clinician and an academic addressed wideranging topics pertinent to the daily practice of radiology, some of which were ethical considerations in cochlear implant patients, paediatric imaging and radiation exposure, and kickbacks and perverse incentives. covidien, a leading pharmaceutical company, made an unrestricted educational grant to the rssa for hosting the event, adding impetus to the initiative. it is envisaged that the course will be repeated in gauteng during the second half of 2010. participants will receive 8 cpd ethical points. we remind readers that a further cpd-accredited ethics resource is the online journal south african journal of bioethics and law, available at http://www.sajbl.org.za/index.php/sajbl. rssa/stoller sports medicine and rssa/ leuven ear imaging courses a last-minute reminder that the first and exclusive rssa/stoller update in sports medicine course will be presented by dr david stoller (md, facr), the internationally renowned orthopaedic and musculoskeletal radiologist of san francisco, usa, on 19 and 20 march 2010 at the bmw pavilion in cape town’s v&a waterfront. registration details are on the website www. stollercapetownupdate2010.co.za. for enquiries regarding registration, advertisements and exhibitions as well as scientific, general and social programmes, please contact christelle snyman, rssa/stoller 2010 update, po box 19063, tygerberg 7505, south africa, tel. +27 21 938 9245 or email csnyman@sun.ac.za. and a not-quite-last-minute reminder that the rssa/leuven ear imaging course will take place on 16 18 april 2010 at the historic and scenic spier estate near stellenbosch in the western cape. this hands-on interactive teaching course on temporal bone imaging is currently in its fourth european cycle. the course is conducted by internationally renowned belgium and dutch radiologists, under the leadership of professor dr robert hermans of the department of radiology, university hospitals, k.u. leuven, belgium. enrolment is limited to 90 participants and exclusively rssa members. course and registration details are online at www. rssa2010earcourse.co.za. radioactive news radioactive news.indd 23 2/26/10 9:50:25 am 71 sa journal of radiology • september 2010 the fallacy of comparing diagnostic radiation with background radiation; and the need to learn from past mistakes to the editor: the subject of radiation exposure for diagnostic purposes is currently a ‘hot’ topic, and it is appropriate that the debate around this issue is given exposure in the pages of the sajr. i would like to comment on a few of the points raised by dr tipler in his article that appeared in the june 2010 sajr.¹ the advent of ct scanning has revolutionised the practice of medicine. no one in their right mind would argue that, when a ct scan is performed correctly and for an established indication, the benefit of the examination outweighs the risk (in terms of radiation exposure) many times over. dr tipler, however, states: ‘we all know ct is being overused.’ this goes to the heart of the matter and in particular to the danger posed by self-referral by specialists outside of radiology, should such specialists obtain a licence to operate a ct scanner. dr tipler mentions the issue of background radiation. he also makes the statement that background radiation on the coast of brazil exceeds 150 msv a year. these issues require some clarification. with regard to the comments about brazil, it is true that some, but by no means all, beaches contain radioactive monazite deposits. these deposits give the sand a characteristic black colour – unlike the golden sand of the beaches of rio de janeiro. if one camped out specifically on one of the monazite-containing beaches for a prolonged period, it would be possible to receive external radiation exceeding 150 msv a year. besides brazil, monazite deposits are also found in india and china. the dose of radiation to people living in these areas is on average 5 6 msv per year. individual doses up to 32 msv per year have, however, been reported. of note is that in areas of high background radiation, an increased frequency of chromosome aberrations has been noted repeatedly.² more research is needed to quantify the effects of the high background radiation levels in these areas. regarding the red herring of background radiation as argued by the radiation dissidents, i would quote the following: ‘a criticism of a conservative approach in the use of ionising radiation is that we are all daily exposed to background radiation and have evolved cellular mechanisms capable of repairing damage caused by ionising radiation. the counter-argument is: “sola dosis facit venenum.” (it is only the dose which makes the poison.) ‘the average individual dose received from background radiation is approximately 3.6 msv, delivered over the period of a year. a ct scan of the abdomen and pelvis delivers 10 msv, approximately 3 times this dose, in a few minutes. this is not what our repair mechanisms have evolved to cope with. an analogy might be the cellular mechanisms evolved to metabolise alcohol. a 750 ml bottle of brandy drunk over a period of a few minutes is likely to have a fatal outcome. the same volume of brandy, if taken over a year, equates to marginally more than 2 ml per day; an amount unlikely to pose a challenge to the cellular metabolic systems.’³ in conclusion, dr tipler alludes to the linear no-threshold theory and the information gleaned from the japanese atomic bomb survivors, on which much of the beir 7 report is based. although easy to criticise, these are not the only sources of information with regard to the risks of radiation. i quote again: ‘many of the early pioneers of the science of radiation and radiology were exposed to high doses of radiation and succumbed to its carcinogenic effects. in addition, from the 1930s to the early 1960s, ionising radiation was used to treat many benign conditions. these included sacro-ileitis, and postpartum mastitis. numerous children received x-ray screening and radiation treatment for “enlargement” of the thymus gland and many have subsequently died from radiation-induced malignancy. these treatments were terminated when the association with the subsequent development of cancer became clear.’ further evidence for harm from injudicious medical use of ionising radiation has come from the large radiation doses given by bi-weekly fluoroscopic (non-image intensified) screenings to determine whether an iatrogenic pneumothorax, performed for the treatment of tuberculosis, was still present. fifteen and more years later, the incidence of breast cancer on the side subjected to fluoroscopy was doubled. unfortunately, we have short memories. to paraphrase george santayana: ‘those who do not learn from the mistakes of history are destined to repeat them.’ samuel taylor coleridge put this more philosophically: ‘if men could learn from history, what lessons it might teach us! but passion and party blind our eyes and the light which experience gives is a lantern at the stern, which shines only on the waves behind us!’³ d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com 1. tipler m. letter: straight talking on ct scanning. south african journal of radiology 2010;14(2):42. 2. idaho state university, radiation information network's. radioactivity in nature. www.physics.isu.edu/ radinf/natural.htm (accessed 9 september 2008). 3. emby d j. radiation: friend and foe. occ health southern africa 2008;14(5):9-13. the hpcsa and radiology to the editor: i find the letter by professor van niekerk1 which was published in the june 2010 edition of the south african journal of radiology most interesting. he stated that it was acceptable for specialists such as cardiologists to use ionising radiation for imaging in their practices, but went on to mention ‘the proliferation of many diagnostic and therapeutic interventions that are reliant on expensive equipment’. have you looked up the price of a cardiac angiogram lately? or the placing of a drug-eluting stent in a carotid artery? the decision to perform these procedures on patients is taken by the cardiologist alone, who, as things have it, performs the procedures too. i know the training a cardiologist receives in radiation, and it is minuscule compared to that which a radiologist receives (a full first year – as a registrar – of instruction in radiation physics, with an entire part of a two-part examination devoted to the subject). what about the cardiologists in the western cape who bought their own multislice ct scanner (talk about expensive equipment), enabling them to do non-catheter angiograms as well? they received no training in ct physics at all (and employ a radiographer to operate the machine and make impressive images). letters 72 sa journal of radiology • september 2010 letters radiologists never have the opportunity to self-refer. we are sent patients by our medical colleagues, requesting a specific examination or procedure. the request form has to be forwarded to the medical aids as proof that no additional examinations were performed other than directly requested, in writing. i know of gps in my part of the world who routinely perform their own x-rays and ultrasound examinations. you are correct; besides all the safety issues, such as lead shielding, the quality is nondiagnostic in most cases; patients are told they have gallstones, when they clearly don't, and so the abuse goes on. i know this, because eventually the unwell patients find their way to our practice, and i get to see the x-ray films and listen to the misdiagnosis. so, let's see if this committee actually has any teeth, or is it all just another useless talk-shop, a typical case of the dogs bark, but the caravan moves on. this letter will be forwarded, possibly in altered form, to the hpcsa and rssa. mark richardson drs nisbet, govender and associates the bay hospital richards bay markrich@netactive.co.za 1. van niekerk jp. the hpcsa and radiology. south african journal of radiology 2010;14(2):43. professor van niekerk replies: thank you for your response. the hpcsa policy is that doctors may practise in fields in which they have had adequate training. if training is perceived to be inadequate, it is up to the person(s)/group believing it to be so to persuade those who are responsible for regulation and for education to address this. it was in response to the inadequacy of the training of general practitioners who owned x-ray equipment that the committee was established. i share your concern that self-referral is open to considerable abuse. apart from the dangers of ionising radiation, we should also be concerned about the financial implications of the proliferation of 'safe' imaging modalities, especially ultrasound. fee-for-service and third-party payment have been shown to be the key drivers of escalating health care costs, and this debate is virtually nonexistent in the public sector. public rural facilities that have poor radiological facilities and services at least have the possibility of an arm,s-length supervision and for ensuring their correction. jp van niekerk health & medical publishing group rondebosch jpvann@hmpg.co.za cpd notice in the june 2010 edition of the sajr, the questionnaire unfortunately contained errors relating to two questions. the question in both cases should have read which of the following statements is incorrect? (and not ‘correct’, as stated). i use a template in compiling the quiz and, of all potential mishaps, the ‘in’ was omitted. all readers (with the exception of two) recognised the mistake and answered accordingly. nevertheless, it was decided to credit all participants with their points irrespective of how they read the questions. the questionnaire will be triple-checked, and i do not foresee a repeat occurrence. recent audits of some colleagues by the health professionals council of south africa have indicated a chronic shortage of cpd ethics points, and we considered posting one ethics question per edition. after discussion with professor jp van niekerk, we decided to follow an alternative route: please note that members of the south african medical association (sama) and/or the radiological society of south africa (rssa) may acquire cpd ethics points by completing the cpd questionnaire in the south african journal of bioethics and law (sajbl) which is available in online format only at www.sajbl.org.za. the journal is published biannually, in june and december. jan lotz magnetic resonance.html magnetic resonance imaging of the breast: a clinical perspective j edge, mb bs, frcs (edin), bsc, mmed i boeddinghaus, mb chb, mrcp (lond), md (lond) christiaan barnard memorial hospital, cape town corresponding author: j edge (jmedge@mweb.co.za) the role of magnetic resonance imaging (mri) in screening for breast cancer and its use after the diagnosis of breast cancer is discussed. the topic is enormous, with over 5 000 papers published in the last 10 years. in this précis, we focused on articles that examine its clinical relevance. we did not look at economic factors. s afr j rad 2012;16(2):61-64. mri and breast cancer screening in 2004, an article was published in the nejm looking at the use of mri screening in 1 909 high-risk dutch women.1 the screening process included clinical examination, mammogram and mri. the mean age of the women was 40; 18.7% had a known mutation. the sensitivity and specificity for the 3 screening modalities in this young cohort are shown in table 1. the authors concluded that mri screening could detect breast cancer at an early stage in high-risk women. the results are in keeping with other studies.2 , 3 the findings have consistently shown that high-risk young women (whose disease tends to be missed with mammography) benefit from the addition of an mri. the american cancer society has combined the findings to give clear recommendations (table 2).4 it is our opinion that south africa should accept the recommendations where possible. two points highlighted in the american cancer society guidelines that are often glossed over, bear repetition. the first is that, within the context of high-risk breast screening, mri should be used as an adjunct to, and not as a replacement for, mammography, given the lack of sensitivity of mri for ductal carcinoma in situ (dcis), and the tendency of the different modalities to diagnose cancers missed on the other. the second refers to the low positive predictive value (ppv) of mri (20 40%), leading to a high rate of biopsies and further investigations – acceptable in women with a high risk of breast cancer, but potentially harmful to women in lower-risk categories. it is our opinion that women who present with an unknown primary (e.g. with malignant axillary nodes) should have an mri, in addition to conventional radiology, as this investigation has demonstrated high sensitivity for the detection of an ipsilateral breast cancer primary.5 mri in women with a proven breast cancer while it is clear that a small group of women will benefit from a screening mri, its use in patients with a diagnosed breast cancer is less clear. undoubtedly, the lesion is seen more clearly. breast mri post diagnosis has become a common pre-operative investigation, and the questions that need to be considered are whether its increased use is translating into clearer margins at the time of the initial surgery, decreased recurrence and, as a consequence, improved patient survival. are patients benefitting or are they just having more radical surgery? the comparative effectiveness of mri in breast cancer (comice) trial was a multicentre trial based in the uk.6 forty-five breast centres took part in a prospective randomised study. over 1 600 women who had been diagnosed with breast cancer and selected for breast conservation therapy (bct) were enrolled. they were randomised into 2 groups: half received an mri pre-operatively, and half did not. the outcomes measured were the percentage of patients who underwent re-excision or mastectomy within 6 months of their initial surgery and also the number of patients who had an avoidable mastectomy. the surgical margins had to be clear after their initial surgery. the investigators did not consider the question of survival. the patients were well matched pathologically and demographically. the results are shown in table 3. as can be seen, there was no difference in re-excision rate, and pre-operative mri resulted in a statistically non-significant decrease in the number of completion mastectomies. as a result of a pre-operative mri, 7% of patients were advised to have a mastectomy rather than bct. in retrospect, 30% of these mastectomies were unnecessary (the mri over-estimated the size of the tumour (see case 1) or there was no pathological evidence of multicentricity as indicated by the scan). one patient had an undetected lung metastasis. two per cent had contra-lateral procedures following the mri, and 4% had biopsies. based on the trial’s findings, the ppv of an mri scan was calculated to be 62%, and the negative predictive value of 84% (case 2) illustrates the problem of a low ppv. the number of lobular cancers in the study group was considered to be too low to allow any definitive guidelines. the conclusions from the comice trial were that (i) the rate of reoperation for bct was unchanged by pre-operative mri, and (ii) that all mri lesions seen must be biopsied. other centres have noted an increase in the mastectomy rate for early breast cancer.7 this is a reversal of the trends seen in the 1990s. in 1990, the nih recommended bct as the preferred treatment for early breast cancer.8 in 1989, 35% of women with early breast cancer in the usa were treated with bct. this figure rose to 60% in 1995.9 numerous studies have shown that the outcome in the two groups was equivocal and that the patients who had bct did better from a psychosocial perspective.10 the incidence of local recurrence has decreased over the last 20 years. the incidence of 8% local recurrence for stage 1 disease seen in the nsbap trial has reduced to as little as 1.8% in some centres with the improvement of adjuvant therapy.11 mri studies have quoted the change in surgical management based on mri findings for between 8 and 30% of all patients.6 , 12 local recurrence data show that most of these patients would not have needed their mastectomy in retrospect. radiotherapy, together with the added benefit of improved systemic adjuvant treatment, has proved to be very effective in dealing with small residual areas of disease within the breast. few papers have looked at whether the outcome of patients with breast cancer has improved since mri usage became more commonplace. a retrospective study by solin et al. reviewed 756 women who were treated with bct13 where 215 had an mri scan pre-operatively and 541 did not. the study was not randomised but the groups were treated concurrently. the timing of the mri was variable (27% before the core biopsy, 23% after the core biopsy, 37% after the initial excision and 6% after re-excision). although the mri group had slightly better pathological features, their outcome at 8 years was no different in terms of overall survival, cause-specific survival, distant metastases, local failure and the occurrence of contralateral breast cancer. this paper demonstrates the very real difficulties of detecting a breast cancer specific outcome in unselected patients, in an era where recurrence rates are low. the usage of mri scanning has also increased the rate of contralateral prophylactic mastectomy (cpm). a retrospective study by king et al. 14 noted that there was an increase in cpm in the usa of 150% since 1998. in his paper, he noted that whilst the number of very high-risk patients (e.g. brca positive, mantle radiotherapy) remained constant, the general incidence of contralateral breast cancer had decreased. this is in part attributable to improved systemic therapies, where 5 years of adjuvant hormone therapy decreases cbc by 50 55%, and chemotherapy by approximately 20%.15 the recent surveillance, epidemiology and end results (seer) data from 1992 to 2004 estimate an annual risk of 0.1% in women aged <50 years. king found the decision for a cpm was based on race, brca mutations, past history of mantle radiotherapy, the surgeon, mri usage and non-invasive histology. the pre-operative usage of mri in patients diagnosed with breast cancer increased from 1.3% to 36.3% over the same period. forty-three per cent of patients choosing to have a cpm had had a pre-operative mri as opposed to 16% in the patients choosing unilateral surgery. the relationship between mri usage and cpm can be seen graphically in fig. 1. in their single-institution study, at a median follow-up of 4.4 years for patients undergoing cpm and 6.8 years for patients not undergoing cpm, multivariate cox regression demonstrated no difference in subsequent breast cancer event rates between the groups (p=0.23), and that prognosis was determined by the index lesions. in conclusion, mri scanning has a clearly defined role in breast screening. it is reasonable to adopt the american cancer society guidelines to guide us in south africa. its routine use for patients with a newly diagnosed breast cancer cannot be justified. there is no evidence that it decreases the re-excision or the recurrence rate following bct, and it increases the number of mastectomies being performed. the available data suggest that the change in management of patients following an mri will not increase their survival. case 1 a 40-year-old woman presented with a mass in her left breast. clinically the mass was consistent with a benign process. her mammogram was unhelpful and her sonar showed 3 discreet similar-looking masses; the largest was noted to be 11 mm. tru-cut of the palpable lesion confirmed the diagnosis of lobular carcinoma. fna of the other lesions was not diagnostic. mri scan showed a single large lesion 87 x 44 mm. on the basis of the mri findings, the patient had a mastectomy. her final histology showed 3 discreet lesions, which corresponded to those seen on ultrasound: 12 mm, 8 mm and 10 mm lobular carcinoma (fig. 2). case 2 a 49-year-old woman was diagnosed with breast cancer in august 2010. her mammogram showed a single malignant-looking lesion. ultrasound noted 2 malignant-looking lesions and a further benign-looking lesion in the upper outer quadrant of her right breast. tru-cut biopsy of one (malignant-looking) lesion confirmed the diagnosis of an infiltrating ductal carcinoma. fna of the second malignant-looking lesion showed atypia. the third (benign-looking) lesion showed features in keeping with a benign proliferative mass. the patient did not want a mastectomy, so had a wide local excision of the 2 adjacent cancers and biopsy of the third lesion (ultrasound guided). the 2 breast cancers (3 mm and 4 mm) were completely excised. the third lesion was noted to be a fibroadenoma. the patient had postoperative radiotherapy and hormone therapy. in august 2011 the patient presented with a palpable mass in the upper outer quadrant of her right breast. clinically the mass was suspicious. fna of the mass was consistent with an intramammary lymph node. her mammogram was normal, sonar showed a separate area of fat necrosis (aspirated) and the patient had an mri that showed a suspicious lesion (birads 4) in keeping with a new primary (fig. 3). it was not clear whether this corresponded to the palpable lesion or sonographic lesion. the patient was happy with her cosmetic result (fig. 4) so did not want to consider mastectomy. a clip was placed and the area was removed surgically. the lesion was shown to be a benign intramammary lymph node. 1. kriege m, brekelsmans ct, boetes c, et al. efficacy of mri and mammography for breast cancer screening in women with a familial or genetic disposition. n engl j med 2004;351:427-437. 1. kriege m, brekelsmans ct, boetes c, et al. efficacy of mri and mammography for breast cancer screening in women with a familial or genetic disposition. n engl j med 2004;351:427-437. 2. leach mo, boggis cr, dixon ak, et al. screening with magnetic resonance imaging and mammography of a uk population at high familial risk of breast cancer: a prospective multicentre cohort study (maribs). lancet 2005;365:1769-1778. 2. leach mo, boggis cr, dixon ak, et al. screening with magnetic resonance imaging and mammography of a uk population at high familial risk of breast cancer: a prospective multicentre cohort study (maribs). lancet 2005;365:1769-1778. 3. warner e, plewes db, hill ka, et al. surveillance of brca1 and brca2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. jama 2004;292:1317-1325. 3. warner e, plewes db, hill ka, et al. surveillance of brca1 and brca2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. jama 2004;292:1317-1325. 4. saslow d, boetes c, burke w, et al. american cancer society guidelines for breast cancer screening with mri as an adjunct to mammography. ca cancer j clin 2007;57:75-89. 4. saslow d, boetes c, burke w, et al. american cancer society guidelines for breast cancer screening with mri as an adjunct to mammography. ca cancer j clin 2007;57:75-89. 5. orel s. who should have breast magnetic resonance imaging evaluation? jco 2008;26:703-711. 5. orel s. who should have breast magnetic resonance imaging evaluation? jco 2008;26:703-711. 6. turnbill l, brown s, harvey i, et al. comparative effectiveness of mri in breast cancer (comice) trial: a randomized controlled trial. lancet 2010;375:528-530. 6. turnbill l, brown s, harvey i, et al. comparative effectiveness of mri in breast cancer (comice) trial: a randomized controlled trial. lancet 2010;375:528-530. 7. katipamula r, degnim a, hoskin t, et al. trends in mastectomy rates at the mayo clinic rochester: effect of surgical year and preoperative magnetic resonance imaging. jco 2009;27:4082-4088. 7. katipamula r, degnim a, hoskin t, et al. trends in mastectomy rates at the mayo clinic rochester: effect of surgical year and preoperative magnetic resonance imaging. jco 2009;27:4082-4088. 8. nih consensus conference: treatment of early-stage breast cancer. jama 1991;265:391-395. 8. nih consensus conference: treatment of early-stage breast cancer. jama 1991;265:391-395. 9. lazovich d, solomon cc, thomas db, et al. breast conservation therapy in the united states following the 1990 national institutes of health consensus development conference on the treatment of patients with early stage invasive breast cancer. cancer 1999;86: 628-637. 9. lazovich d, solomon cc, thomas db, et al. breast conservation therapy in the united states following the 1990 national institutes of health consensus development conference on the treatment of patients with early stage invasive breast cancer. cancer 1999;86: 628-637. 10. wapnir il, anderson sj, mamounas ep, et al. prognosis after ipsilateral breast cancer recurrence and locoregional recurrences in five national surgical adjuvant breast and bowel project node-positive adjuvant breast cancer trials. j clin oncol 2006;24:2028-2037. 10. wapnir il, anderson sj, mamounas ep, et al. prognosis after ipsilateral breast cancer recurrence and locoregional recurrences in five national surgical adjuvant breast and bowel project node-positive adjuvant breast cancer trials. j clin oncol 2006;24:2028-2037. 11. nauven pl, taghian ag, katz ms, et al. breast cancer subtype approximated by oestrogen receptor, progesterone receptor and her2 is associated with local and distant recurrence after breast-conserving surgery. j clin oncol 2008;26:2373-2378. 11. nauven pl, taghian ag, katz ms, et al. breast cancer subtype approximated by oestrogen receptor, progesterone receptor and her2 is associated with local and distant recurrence after breast-conserving surgery. j clin oncol 2008;26:2373-2378. 12. pettit k, swatske m, gao f, et al. the impact of breast mri on surgical decision-making: are patients at risk for mastectomy? j surg oncol 2009;100:553-558. 12. pettit k, swatske m, gao f, et al. the impact of breast mri on surgical decision-making: are patients at risk for mastectomy? j surg oncol 2009;100:553-558. 13. solin l, orel s, hwang w, et al. relationship of breast magnetic resonance imaging to outcome after breast-conservation treatment with radiation for women with early-stage invasive breast cancer or ductal carcinoma in situ. jco 2008;26:386-391. 13. solin l, orel s, hwang w, et al. relationship of breast magnetic resonance imaging to outcome after breast-conservation treatment with radiation for women with early-stage invasive breast cancer or ductal carcinoma in situ. jco 2008;26:386-391. 14. king t, saktr r, patil s, et al. clinical management factors contribute to the decision for contralateral prophylactic mastectomy. jco 2011;29:2158-2164. 14. king t, saktr r, patil s, et al. clinical management factors contribute to the decision for contralateral prophylactic mastectomy. jco 2011;29:2158-2164. 15. early breast cancer trialists’ collaborative group (ebctcg). effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. lancet 2005;365:1687-1717. 15. early breast cancer trialists’ collaborative group (ebctcg). effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. lancet 2005;365:1687-1717. table 1. adapted from data in the nejm 1 clinical examination (%) mammography (%) mri (%) sensitivity (invasive ca and dcis) 17.8 40.0 71.1 specificity (invasive ca) 98.1 95.0 90.0 table 2. american cancer society guidelines for breast screening with mri as an adjunct to mammography, 2007 recommend annual mri screening as an adjunct to mammography (based on evidence) brca mutation first degree relative of brca carrier but untested life risk >20 25% as defined by model dependent on family history recommend annual mri screening as an adjunct to mammography (based on expert consensus opinion) radiation to chest age 10 30 li-fraumeni (p53 gene mutation) syndrome and 1st-degree relatives cowden and bannayan-riley-ruvalcaba (pten gene mutation) syndromes and 1st-degree relatives insufficient evidence to recommend for or against mri screening lifetime risk 15 20% % as defined by model dependent on family history lcis* or atypical lobular hyperplasia atypical ductal hyperplasia extremely dense breasts on mammography women with a personal history of breast cancer including dcis recommend against mri screening women <15% lifetime risk *lcis = lobular carcinoma in situ. table 3. outcome from the comice trial: results adapted mri no mri time to surgery (days) 14 13 bct (%) 92 95 mastectomy (%) 7 1 (patient choice) re-excision (%) 10 11 completion mastectomy (%) 6 8 pathologically avoidable mastectomy (%) 2 <1 fig. 1. the relationship between mri usage and cpm rates and use of mri at diagnosis by year of surgery (based on data from king et al.)14 fig. 2. the mri over-estimated the size of the lesions. the patient had appropriate surgery. fig. 3. the mri scan overcalled a benign-looking lesion. fig. 4. the patient’s cosmetic result. article information authors: gerrit blignaut1 eugene loggenberg1 coert de vries1 affiliations: 1department of clinical imaging sciences, university of the free state, south africa correspondence to: gerrit blignaut postal address: department of clinical imaging sciences (g61), faculty of health sciences, university of the free state, 205 nelson mandela drive, bloemfontein 9300, south africa dates: received: 27 aug. 2013 accepted: 29 nov. 2013 published: 04 apr. 2014 how to cite this article: blignaut g, loggenberg e, de vries c. the radiological appearance of intracranial aneurysms in adults infected with the human immunodeficiency virus (hiv). s afr j rad. 2014;18(1); art. #586, 4 pages. http://dx.doi/org.10.4102/ sajr.v18i1.586 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the radiological appearance of intracranial aneurysms in adults infected with the human immunodeficiency virus (hiv) in this original research... open access • abstract • introduction • method • results • ethical considerations • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: the global prevalence of intracranial aneurysms is estimated at 2.3%. limited literature is available on intracranial aneurysms in hiv-infected patients.objectives: to describe the radiological appearance of intracranial aneurysms in hiv-positive adults. method: in this retrospective analysis of data, 23 hiv-positive patients, of which 15 (65.2%) were female, with a total of 41 aneurysms were included. the mean age was 38 years, and their median cd4 count was 305 x 106/l. inclusion criteria comprised subarachnoid haemorrhage and confirmed intracranial aneurysms on four-vessel angiography. results: fifteen (65.2%) patients had a single aneurysm, of which 12 (80.0%) had a saccular appearance. seven (46.7%) of the single aneurysms had a neck width larger than 50% of the transverse aneurysm sac size. the mean longitudinal diameter of the aneurysm sac was 4.9 mm and the transverse diameter 4.4 mm. more than half of these aneurysms occurred at the anterior communicating artery. the median cd4 count of single-aneurysm patients was 319 x 106/l. eight patients (34.8%) had multiple aneurysms, with a total of 26 aneurysms (range 2–6 aneurysms per patient), of which 13 (50.0%) had a complex appearance. twenty-four (92.3%) of the multiple aneurysms had a neck width larger than 50% of the transverse aneurysm sac size. the mean longitudinal diameter of the aneurysm sac was 4.0 mm and the transverse diameter 3.9 mm. the multiple aneurysms occurred more commonly in the internal carotid artery. these patients had a median cd4 count of 294 x 106/l. conclusion: hiv-associated intracranial aneurysms occur at a younger age, appear to be saccular and complex in shape, with a wide neck, and might rupture at small sizes. introduction top ↑ it is estimated that the global prevalence of intracranial aneurysms is approximately 2.3% in the general population.1 human immunodeficiency virus (hiv)-associated aneurysmal vasculopathy has been described in young adults and affects predominantly the extracranial blood vessels.2 intracranial aneurysms in hiv-positive adults are described infrequently. about 22 case reports of hiv-infected adult patients who presented with intracranial aneurysms could be located in the literature. isolated saccular as well as fusiform aneurysms have been described in these cases.3,4,5south africa has a high prevalence of hiv and aids, with the prevalence in the free state province being above the national average.6 the aim of our study was to describe the radiological appearance of intracranial aneurysms in hiv-positive adults who presented with subarachnoid haemorrhage (sah) and were referred for further evaluation to the departments of clinical imaging sciences and neurosurgery at the universitas academic hospital complex in bloemfontein. method top ↑ a retrospective analysis of data was done on all hiv-positive adult patients with sah who had confirmed intracranial aneurysms on four-vessel angiography between 01 january 2008 and 31 december 2012. twenty-three hiv-positive patients with intracranial aneurysms, of which 15 (65.2%) were female, were included in the study. the mean age was 38 years (range 24–51 years). the median cd4 count was 305 x 106/l (range 62–1120 x 106/l) and 16 (69.6%) of the patients had a cd4 count of less than 350 x 106/l.digital subtraction angiography was performed on a fluoroscopic unit (philips allura xper fd 20/20, philips electronics, netherlands, or siemens axiom artis, siemens ag, germany). patient data and angiography reports were obtained from the interventional radiology register and the hospital information system. the hiv status and cd4 count of each patient were obtained from the hospital information system. the cd4 counts of these patients were used to determine any possible relationship between aneurysm morphology and immune status. only the initial examination was analysed in patients who had more than one examination. aneurysms were counted separately in patients who had more than one aneurysm. each aneurysm was evaluated for (1) its position, (2) number, (3) type, (4) neck size – whether larger than 50% of the transverse aneurysm diameter – and (5) longitudinal and transverse lumen diameter of the aneurysm sac. the largest diameter of each aneurysm, whether longitudinal or transverse, was used to determine the mean maximum aneurysm sac size. these assessments were done by an interventional radiology consultant. measurements were obtained on imaging views where the aneurysm was seen best in profile. the longitudinal measurement was taken from the midpoint of the aneurysm neck to the midpoint of the aneurysm dome. the transverse diameter was the maximum transverse diameter of the aneurysm sac. the neck size was measured as close as possible to the lumen of the artery from which the aneurysm originated. these measurements are important in the decision regarding further aneurysm management. the following standard views were used: anteroposterior, left anterior oblique 20°, right anterior oblique 20° and lateral for the carotid arteries, as well as townes and lateral projections for the vertebral arteries. additional views were obtained in some cases to get the aneurysms in profile. the statistical analysis of data was done by the department of biostatistics, faculty of health sciences, university of the free state (ufs) in bloemfontein, south africa. results top ↑ the 23 patients had a total of 41 aneurysms. fifteen (65.2%) of the patients had a single aneurysm. the remaining eight patients had multiple aneurysms (n = 26), with a range of two to six aneurysms per patient.nine female patients and six male patients had a single aneurysm. the mean age of patients with a single aneurysm was 39 years. the median cd4 count was 319 x 106/l. twelve (80.0%) of the aneurysms had a saccular appearance. one patient had a fusiform aneurysm. seven aneurysms had a neck width larger than 50% of the transverse aneurysm sac size. the aneurysm sac size had a mean longitudinal diameter of 4.9 mm (range 1.8 mm – 8.6 mm) and transverse diameter of 4.4 mm (range 1.6 mm – 13.0 mm). the mean maximum aneurysm sac size was 5.0 mm (range 1.8 mm – 13.0 mm) (see table 1). more than half of the single aneurysms involved the anterior communicating artery (acoa) (see figure 1). table 1: summary of data regarding intracranial aneurysms in hiv-positive patients (n = 23). figure 1: location of aneurysms in different vascular segments. six female patients and two male patients had multiple aneurysms. their mean age was 37 years. the median cd4 count was 294 x 106/l. twenty-four (92.3%) aneurysms had a neck width larger than 50% of the transverse aneurysm sac size. the mean longitudinal diameter of the aneurysm sac size was 4.0 mm (range 1.4 mm – 11.8 mm) and the transverse diameter 3.9 mm (range 1.1 mm – 9.0 mm). the mean maximum aneurysm sac size was 4.1 mm (range 1.8 mm – 11.8 mm) (see table 1). a slight predominance for internal carotid artery (ica) aneurysms was observed in patients who had multiple aneurysms (see figure 1).twenty-two (53.7%) of all the aneurysms were saccular and only one (2.4%) was fusiform in shape. as shown in table 1, saccular aneurysms were more common in patients with a single aneurysm (n = 12; 80.0%), whilst both complex (n = 13; 50.0%) and saccular (n = 10; 38.5%) aneurysms occurred more frequently in patients with multiple aneurysms. with regard to specific location, as shown in figure 1, 53.3% of the single aneurysms occurred in the anterior communicating artery (acoa) distribution, whilst 30.8% of the multiple aneurysms occurred in the internal carotid artery (ica). ethical considerations top ↑ approval to conduct the investigation was obtained from the ethics committee of the faculty of health sciences, university of the free state, south africa (number: etovs 162/2011). discussion top ↑ previous studies have shown that ruptured intracranial aneurysms occur more between the ages of 40 and 60 years.7,8 the peak age group for ruptured aneurysms in this study was between 35 and 45 years. therefore, in our study, we observed that aneurysm rupture occurred at a younger age in patients with hiv infection than in the general public.previous studies in non-hiv-infected populations showed that single aneurysms had a higher incidence in the anterior circulation as well as acoa,8 which was also evident in our study amongst patients with single aneurysms. the location of multiple aneurysms in the ica and its branches, as well as the middle cerebral artery (mca), was similar to previously reported cases. it appears that there is no difference between the location of multiple aneurysms in hiv-positive patients and the general population. multiple aneurysms have been proposed as a typical feature of hiv-associated aneurysms.9 multiple aneurysms were seen in more than a third (34.8%) of our patients, of which 75% were female. these findings were also observed in other studies, which showed that multiple aneurysms occur more frequently in patients older than 40 years. however, no comment was made on the hiv-status of these patients.10,11 the mean age of our patients with multiple aneurysms was 37 years, which is considerably younger than those in the general population with multiple aneurysms (see figure 2). figure 2: right ica contrast injection demonstrates multiple aneurysms situated at the ica bifurcation, mca and aca (a), with longitudinal and transverse measurements for the ica bifurcation and mca aneurysms (b), and aca aneurysm (c). half of the multiple aneurysms in our study had a complex configuration that included multilobar, daughter and multi-vessel take-off configurations. the majority (92.3%) of the multiple aneurysms had a neck width larger than 50% of the transverse aneurysm diameter. with morphological findings such as these, endovascular treatment becomes a challenge (see figure 3). figure 3: a saccular acoa aneurysm filling from the left ica is demonstrated, with blood supply to both aca vascular territories. no contrast filling of the right aca occurred during contrast injection in the right ica; therefore, endovascular coiling of the aneurysm was not suitable. note the vasospasm in both a2 territories. similar to our findings, saccular aneurysms are the most common type of intracranial aneurysm described in the non-hiv-infected population. modi, ranchod, modi and mochan2 reported three hiv-positive patients with fusiform type aneurysms and suggested that the characteristics of these aneurysms are distinctive of hiv-related aneurysms.the international study for unruptured intracranial aneurysms (isuia trial)12 reported that the risk for sah is very low in aneurysms with a maximum aneurysm sac diameter of less than 7 mm. delgado almandoz, feasse, crandall, et al.13 studied 1681 intracranial aneurysms and reported that the mean maximum aneurysm sac size for ruptured aneurysms was 6.5 mm. in our study, the mean maximum aneurysm sac size was smaller, with a mean diameter of 5.0 mm for single aneurysms and 4.1 mm for multiple aneurysms. from our findings, it appears that ruptured hiv-associated intracranial aneurysms are substantially smaller than those in the general population. however, this observation should be confirmed with larger comparative studies. the mechanism is not clear, but a possible explanation could be that the aneurysm wall is prone to rupture because of a weaker structure resulting of a defective immune system. the imaging morphology of intracranial aneurysms in our study may be explained by the proposed role of hiv in aneurysm formation. previous studies have shown that the vessel walls have intimal hyperplasia with destruction of the internal elastic lamina, medial fibrosis and loss of the muscularis layer.14 hiv viral proteins have been associated with vascular pathology. a possible link between vascular pathology and the protease inhibitor ritonavir was also identified.15 there is also the possibility that bacterial infection of the vessel wall, secondary to immune suppression, could lead to the development of aneurysms, as previously suggested with extracranial aneurysms in hiv-positive patients.16 hiv binds on the surface of cd4 cells and deactivates these cells. we could not establish a relationship between aneurysm morphology and immune status. the median cd4 count for single aneurysms was 319 x 106/l and for multiple aneurysms 294 x 106/l, although this difference was not statistical significant. sixteen (69.6%) of our patients had a cd4 count below 350 x 106/l. when interpreting these results, it must be taken into account that our study population was relatively small, and that we were not able to establish if these patients were on anti-retroviral therapy, what their viral load was, or if any co-existent infections were present, as this information was not available in the patient files. conclusion top ↑ hiv-associated intracranial aneurysms in adult patients appear to be mostly saccular and complex in shape with a wide neck. they apparently rupture at a smaller size than those in the general population, although larger comparative studies are necessary to confirm this. these findings indicate that the strength of the vessel wall is, at least in part, a function of the immune status of a person. acknowledgements top ↑ the authors wish to thank dr daleen struwig, medical writer, faculty of health sciences, ufs, for assistance with the technical and editorial preparation of the manuscript, and mr cornel van rooyen, department of biostatistics, faculty of health sciences, ufs, for statistical analysis of the data. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions g.b. (university of the free state) was responsible for the literature search, conception and design of the study, data acquisition, analysis and interpretation of data, and drafting of the manuscript. e.l. (university of the free state) was the study leader and revised the manuscript critically for important intellectual content. c.d.v. (university of the free state) also revised the manuscript critically for important intellectual content. all three authors approved of the final version of the manuscript to be published. references top ↑ 1. rinkel g, djibuti m, algra a, van gijn j. prevalence and risk of intracranial aneurysms: a systematic review. stroke. 1998;29:251–256. http://dx.doi.org/10.1161/01.str.29.1.2512. modi g, ranchod k, modi m, mochan a. human immunodeficiency virus associated intracranial aneurysms: report of three adult patients with an overview of the literature. j neurol neurosurg psychiatry. 2008;79:44–46. http://dx.doi.org/10.1136/jnnp.2006.108878 3. kossorotoff m, touzé e, godon-hardy s, et al. cerebral vasculopathy with aneurysm formation in hiv-infected young adults. neurology. 2006;66:1121–1122. http://dx.doi.org/10.1212/01.wnl.0000204188.85402.0c 4. tipping b, de villiers l, candy s, wainwright h. stroke caused by human immunodeficiency virus-associated intracranial large-vessel aneurysmal vasculopathy. arch neurol. 2006;63:1640–1642. http://dx.doi.org/10.1001/archneur.63.11.1640 5. taylor a, lefeuvre d, levy a, candy s. arterial dissection and subarachnoid haemorrhage in human immunodeficiency virus-infected patients. a report of three cases. interv neuroradiol. 2004;10:137–143. pmcid pmc3464403 6. human sciences research council (hsrc). south african national hiv prevalence, incidence, behaviour and communication survey [document on the internet]. c2009 [cited 2013 march 7]. available from http://www.mrc.ac.za/pressrelease/2009/sanat.pdf 7. wilson fm, jaspan t, holland im. multiple cerebral aneurysms – a reappraisal. neuroradiology. 1989;31:232–236. http://dx.doi.org/10.1007/bf00344349 8. keedy a. an overview of intracranial aneurysms. mcgill j med. 2006;9:141–146. pmid 18523626 9. nair r, robbs jv, naidoo ng, woolgar j. clinical profile of hiv-related aneurysms. eur j vasc endovasc surg. 2000;20:235–240. http://dx.doi.org/10.1053/ejvs.2000.1169 10. louw dj, de vries cs, joubert g. cerebral aneurysms – an audit. s afr j radiol. 2004;8:28–30. 11. ogeng’o ja, obimbo mm, olabu bo, sinkeet sr. pattern of aneurysms among young black kenyans. indian j thorac cardiovasc surg. 2001;27(2):70–75. http://dx.doi.org/10.1007/s12055-011-0088-2 12. wiebers do, whisnant jp, huston j iii, et al. unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. lancet. 2003;362:103–110. http://dx.doi.org/10.1016/s0140-6736(03)13860-3 13. delgado almandoz j, feasse j, crandall b, et al. size and location of ruptured intracranial aneurysms in a consecutive series of 588 patients with first-time acute subarachnoid hemorrhage treated endovascularly at a tertiary referral medical center over a 16-year time period. oral abstract o-008. abstracts of the snis (society of neurointerventional surgery) 9th annual meeting. july 23–26 2012. san diego, usa. j neurointerv surg. 2012;4(suppl 1):a4–a5. http://dx.doi.org/10.1136/neurointsurg-2012-010455a.8 14. shah ss, zimmerman ra, rorke lb, et al. cerebrovascular complications of hiv in children. am j neuroradiol. 1996;17:1913–1917. pmid:8933877 15. zhong ds, lu xh, conklin bs, et al. hiv protease inhibitor ritonavir induces cytotoxicity of human endothelial cells. arterioscler thromb vasc biol. 2002;22:1560–1566. http://dx.doi.org/10.1161/01.atv.0000034707.40046.02 16. bulsara k, ali r, owen j. hiv and cerebral aneurysms. neurosurg rev. 2005;28:92–95. http://dx.doi.org/10.1007/s10143-004-0371-4 case report sa journal of radiology • september 2011 85 arrythmogenic right ventricular dysplasia/ cardiomyopathy l scholtz, mmed (radd) drs scholtz radiologists, pretoria r van tonder, mmed (int) montana private hospital, pretoria corresponding author: l scholtz (scholtzleonie@gmail.com) introduction arrythmogenic right ventricular dysplasia/cardiomyopathy (arvd) is a familial cardiomyopathy characterised clinically by right ventricular (rv) dysfunction as well as ventricular tachycardia1-4 and histopathologically by fibro-fatty replacement of the myocardium.5 left ventricular (lv) involvement can occur and appears to correlate with increased disease severity.3,4 owing to the complexity of the disease, task force criteria for diagnosis of arvd were drawn up in 1994 and revised in 2010.6,7 cardiovascular magnetic resonance (cmr) findings are now included in the list of major and minor criteria and currently play an important role in establishing the diagnosis of arvd (see table i). cmr is extremely valuable for delineation of right ventricular (rv) anatomy and function as well as for characterising the composition of the rv wall, especially regarding the presence of fatty and/or fibrous tissue. case report a 60-year-old woman with metabolic syndrome was referred to us with a history of chest pain, syncopy and palpitations. her ecg revealed rv strain pattern and inverted t waves in leads v1, v2 and v3. echocardiographically, her rv wall was thickened and echo-dense and measured 15 mm at the free wall. no definite family history of any specific cardiac abnormality was present. she was referred for a cmr scan to confirm the possible diagnosis of arvd. the cmr examination was performed with a 1.5-t mr imager (philips medical systems) using a dedicated cardiac phased array coil. bright blood cine imaging in the short axis, right ventricular outflow tract (rvot) and 4 chamber planes were obtained. black blood images were acquired in short axis and 4 chamber planes with and without fat suppression. gadolinium was administered at a dose of 1 ml/10 kg (24 ml omniscan, ge healthcare) and perfusion sequences performed as well as late enhancement views (le) in the short axis and 4 chamber planes. functional analysis was done utilising the short axis bright blood images. global decreased contractility of the rv was recorded with the rv ejection fraction measuring 40%. diffuse fatty infiltration of the rv wall was clearly visible. the fatty infiltration mainly involved the sub-epicardium of the free wall of the rv (figs 1-4). fatty infiltration was also visible in the right atrial free wall as well as the inter-atrial septum (fig. 5). the lv wall morphology and function was normal. no obvious late enhancement was noted. fig. 1. short axis bright blood btfe image. tr=3.4, te=1.7, flip=60. fig. 2. short axis dark blood t1 fat sat spir tse tr=612, te=10. 86 sa journal of radiology • september 2011 case report cardiac catheterisation was undertaken, during which coronary angiography as well as endomyocardial biopsy were performed. three specimens were taken from the rv free wall. all the coronary vessels appeared normal. very mild elevated pulmonary arterial pressure was noted (34 mmhg/10 mmhg). histological investigation revealed the presence of mature fatty tissue as well as fibrous tissue in the rv free wall biopsy specimens. the confirmed presence of fibrous tissue in addition to the marked fatty infiltration on histology suggested the possible diagnosis of arvd. discussion the term arrhythmogenic right ventricular dysplasia was first used by frank et al. in 1978.8 marcus et al. were the first to note a familial occurrence of arvd.1 there are several genetic defects described that lead to an arvd phenotype, but the exact pathogenesis is still under discussion. hereditary occurrence in 30% of cases requires the assessment of relatives. the wide spectrum of clinical presentations includes palpitations, tachy-arrhythmias, cardiac failure and sudden death. the condition is characterised by structural and functional abnormalities of the rv eventually leading to ventricular arrhythmias and progressive rv failure. ventricular arrhythmias probably occur via the fibromuscular bundles being isolated from each other by fatty tissue, leading to re-entry phenomena. the rv sub-epicardial wall is initially replaced by fibro-fatty tissue often starting in the areas known as the ‘triangle of dysplasia’,1 i.e. the inferior tricuspid region, the rv outflow tract and the rv apical region. the fibro-fatty changes eventually progress to involve the whole rv wall trans-murally and globally. although lv involvement may be found, the lv myocardium is usually spared. until recently, the only accurate way to confirm the presence of fibrofatty changes involved endomyocardial biopsy. to lower potential risk, endomyocardial biopsies are usually obtained from the septum region (an area uncommonly affected), so resulting in a lowered sensitivity. (owing to the marked thickening of the rv wall, the biopsies in our patient could be taken from the free wall, without substantial risk). the diagnosis of arvd at its early stages remains a clinical challenge. no single test can be used to establish or exclude arvd. cmr can assist substantially in the diagnosis of anatomical abnormalities and functional disturbances, as well as detecting the presence of fat or fibrous tissue once they occur. cmr is superior to 2-d echocardiography in determination of rv mass and volume. cmr allows the acquisition of true short-axis images encompassing the entire rv with high spatial and temporal resolution, so providing highly accurate qualitative rv mass and functional data. functional abnormalities can be detected on the bright blood cine sequences, and include global or regional hypokinesia resulting in reduced ejection fraction (ef) as well as increased rv volumes. fig. 3. short axis dark blood t1 tse. fig. 4. rvot bright blood cine btfe tr=3.4, te=1.7, flip=60. fig. 5. four chamber bright blood cine image. btfe tr=3.4, te=1.7, flip=60. case report sa journal of radiology • september 2011 87 table i. task force criteria 2010 revised task force criteria for the diagnosis of arvc/d¹ definite diagnosis: 2 major and 2 minor criteria or 4 minor from different categories borderline: 1 major and 1 minor or 3 minor criteria from different categories possible: 1 major or 2 minor criteria from different categories i. global and/or regional dysfunction and structural alterations* major (by 2d echo) • regional rv akinesia, dyskinesia, or aneurysm • and one of the following (end diastole): plax rvot≥32 mm (corrected for body size [plax/ bsa]≥19 mm/m²) psax rvot≥36mm (corrected for body size [psax/ bsa]≥21 mm/m² • or fac≤33% minor (by 2d echo) • regional rv akinesia or dyskinesia • and one of the following (end diastole): plax rvot≥29 to <32 mm (corrected for body size[plax/bsa] ≥16 to <19 mm/m²) psax rvot ≥32 to <36mm (corrected for body size [psax/ bsa]≥18 to <21 mm/m²) or fac>33% to ≤40% major (by mri) • regional rv akinesia or dyskinesia or dyssynchronous rv contraction • and one of the following: ratio of rvedv to bsa (rvedv/bsa)≥100 ml/m² (female) or rvef ≤40% minor (by mri) • regional rv akinesia or dyskinesia or dyssynchronous rv contraction • and one of the following: ratio of rvedv to bsa (rvedv/bsa)≥100 to <110 ml/m² (male) or ≥90 to <100 ml/m² (female) or rvef >40% to ≤ 45% major (by rv angiography) • regional rv akinesia, dyskinesia or aneurysm ii. tissue characterisation of wall major • residual myocytes <60% by morphometric analysis, (or <50% if estimated), with fibrous replacement of the rv free wall myocardium in ≥1 sample, with or without fatty replacement of tissue on endomyocardial biopsy minor • residual myocytes 60% to 75% by morphometric analysis, (or 50%, to 65% if estimated), with fibrous replacement of the rv free wall myocardium in ≥1 sample, with or without fatty replacement of tissue on endomyocardial biopsy iii. repolarisation abnormalities major • inverted t waves in right precordial leads (v1, v2, and v3) or beyond in individuals >14 years of age (in the absence of complete rbbb qrs ≥120 ms) minor • inverted t waves in leads v1 and v2 in individuals>14 years of age (in the absence of complete rbbb) or in v4, v5, or v6 • inverted t waves in leads v1, v2, v3 and v4 in individuals >14 years of age in the presence of complete rbbb iv. depolarisation/conduction abnormalities major • epsilon wave (reproducible low-amplitude signals between end of qrs complex to onset of the t wave) in the right precordial leads (v1 to v3) minor • late potentials by saecg in ≥1 of 3 parameters in the absence of a qrs duration of ≥110 ms on the standard ecg • filtered qrs duration (fqrs)≥114 ms • duration of terminal qrs <40µv (low-ampplitude signal duration) ≥38ms • root-mean-square voltage of terminal 40 ms ≤20µv • terminal activation duration of qrs ≥55ms measured from the nadir of the s wave to the end of the qrs, including r’, in v1, v2, or v3, in the absence of complete rbbb v. arrythmias major • nonsustained or sustained vt of lbbb† morphology with superior axis (negative or indeterminate qrs in leads ii, iii, avf and positive in lead avl) minor • nonsustained or sustained vt or rv outflow configuration, lbbb morphology with inferior axis (positive qrs in leads ii, iii, and a vf and negative in lead avl) or of unknown axis • >500 ventricular extrasystoles per 24 hours (holter) vi. family history major • arvc/d confirmed in a first-degree relative who meets current task force criteria • arvd/d confirmed pathologically at autopsy or surgery in a first-degree relative • identification of a pathogenic mutation‡ categorised as associated or probably associated with arvc/d in the patient under evaluation minor • history of arvc/d in a first-degree relative in whom it is not possible or practical to determine whether the family member meets current task force criteria • premature sudden death (<35 years of age) due to suspected arvc/d in a first-degree relative • arvd/d confirmed pathologically or by current task force criteria in second-degree relative *hypokinesis is not included in this or subsequent definitions of rv regional wall motion abnormalities for the proposed modified criteria. †the orginal document says ‘left bundle-branch’ or lbb. dr frank marcus has confirmed this should read ‘left bundle-branch block’ or lbbb. case report case report 88 sa journal of radiology • september 2011 the structural abnormalities occurring in arvd include rv dilatation (localised or global bulging), right ventricular outflow tract (rvot) enlargement, thinning of the rv wall (segmental or global) and aneurysm formation. fatty infiltration can be detected on the black blood t1-weighted images as well as the cine bright blood images. fat visualisation on mri has not been found to be specific for arvd, however,9,10 and there is poor inter-reader agreement on reporting of its presence and severity.11 recently, the first observations of delayed enhancement of fibrotic tissue in patients with arvd have been reported on.12 only two-thirds of the patients with arvd showed delayed enhancement. the reason for the lack of delayed enhancement in the remainder may be the presence of a pure fatty form of arvd or may simply reflect the insensitivity of current mri techniques to detect a small amount of fibrosis in early disease. the emergence of techniques enabling us to quantify and refine the detection of localised or diffuse fibrosis will certainly help to improve the sensitivity.13 although the presence of fatty or fibrous tissue in the rv wall is not specific, it confirms the diagnosis in the presence of other criteria including a positive family history and specific ecg abnormalities. three of the major diagnostic criteria for arvd according to the new task force criteria were present in our patient, i.e. inverted t waves in v1-v3 on ecg, global hypokinesia of the rv (with increased rv volumes) and histologically proven fibro-fatty changes in the rv wall. the extensive amount of fatty infiltration and thickening of the rv wall in this patient are rare, however, and can possibly be attributed to her additional underlying metabolic abnormality and body habitus (the right atrial wall was also involved, underscoring this). there was a large amount of mediastinal and pericardial fat visible as well. although all the necessary criteria for the diagnosis of arvd were present in our patient, her existing metabolic disorder probably contributed to the severity of the fatty infiltration visible in the rv wall. arvd remains a difficult disorder to diagnose, but cmr has evolved to become a very valuable adjunctive diagnostic tool. 1. marcus fi, fontaine gh, guiraudon g, et al. right ventricular dysplasia: a report of 24 adult cases. circulation 1982;65:384-398. 2. marcus fi, fontaine gh. arrhythmogenic right ventricular dysplasia/cardiomyopathy: a review. pacing clin electrophysiol 1995;18:1298-1314. 3. hulot js, jouven x, empana jp, et al. natural history and risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy. circulation 2004;110:1879-1884. 4. dalal d, nasir k, bomma c, et al. arrhythmogenic right ventricular dysplasia: a united states experience. circulation 2005;112:3823-3832. 5. thiene g, nava a, corrdo d, et al. right ventricular cardiomyopathyand sudden death in young people. n eng j med 1988;318:129-133 6. mckenna wj, thiene g, nava a, et al. diagnosis of arrythmogenic right ventricular dysplasia/cardiomyopathy. task force of working group myocardial and pericardial disease of the european society of cardiology and of the scientific council on cardiomyopathies of the international society and federation of cardiology. br heart j 1994;71:215-218. 7. marcus fi, mckenna wj, sherill d, et al. diagnosis of right ventricular cardiomyopathy/dysplasia (arvc/d); proposed modifications of the task force criteria. circulation 2010;121:1533-1541. 8. frank r, fontaine g, vedel j, et al. electrocardiologie de quatre cas de dysplasie ventriculaire droite arythmogene. arch mal cœur vaiss 1978;71:963-972. 9. fontaliran f, fontaine g, fillette f, et al. nosologic frontiers of arrythmogenicdysplasia. quantitative variations of normal adipose tissue of the right ventricle. arch mal coeur vaiss 1991;84:33-38. 10. globits s, kreiner g, frank h, et al. significance of morphological abnormalities detected by mri in patients undergoing successful ablation of right ventricular outflow tract tachycardia. circulation 1997;96:2633-2640. 11. bluembe da, krupnski ea, ovitt t, et al. mr imaging of arrythmogenic right ventricular cardiomyopathy: morphologic findings and interobserver reliability. cardiology 2003;99:153-162. 12. tandri h, saranathan m, rodriguez er, et al. noninvasive detection of myocardial fibrosis in arrhythmogenic right ventricular cardiomyopathy using delayed enhancement magnetic resonance imaging. j am coll cardiol 2005;45:98-103. 13. mewton n, liu cy, croisille p, et al. assessment of myocardial fibrosis with cardiovascular magnetic resonance. j am coll cardiol 2011;57:891-903. ‡a pathogenic mutation is a dna alteration associated with arvc/d that alters or is expected to alter the encoded protein, is unobserved or rare in a large non-arvc/d control population, and either alters or is predicted to alter the structure or function of the protein or has demonstrated linkage to the disease phenotype in a conclusive pedigree. acronyms avf: augmented voltage unipolar left foot lead avl: augmented voltage unipolar left arm lead bsa: body surface area ecg: electrocardiogram fac: fractional area change lbbb: left bundle-branch block plax: parasternal long axis view psax: parasternal short axis view rbbb: right bundle-branch block rv: right ventricular rvedv: right ventricular end diastolic volume rvef: right ventricular ejection fraction rvot: right ventricular outflow tract saecg: signal averaged electrocardiogram vt: ventricular tachycardia ‘modifications of the orginal criteria have been proposed to facilitate clinical diagnosis in first-degree relatives who often have incomplete expression of the disease. according to these recommendations, in the context of proven arvc/d in a first-degree relative, the diagnosis of familial arvc/d is based on the documentation of one of the following in a family member: 1. t-wave inversion in right precordial leads v1, v2, and v3 in individuals over the age of 14 years. 2. late potentials by signal-averaged ecg (saecg). 3. ventricular tachycardia of left bundle-branch block morphology on ecg, holter monitor, or during exercise testing or >200 premature ventricular contractions in 24 hours. 4. either mild global dilatation or reduction in rv ejection fraction with normal lv or mild segmental dilatation of the rv or regional tv hypokinesis.’¹ 1. marcus fi, mckenna wj, sherrill d, et al. special report: diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. circulation 2010;121:1533-1541. imaging plays a vital role in the staging and restaging of breast cancer. traditionally, chest x-ray, bone scintigraphy and liver ultrasound or computed tomography are used.1 fluorine-18 fluorodeoxyglucose (f-18 fdg) positron emission tomography/computed tomography (pet/ct) has great potential for whole-body staging with a single procedure. the greatest utility of pet/ct lies in distant or m-staging, whereas its role in locoregional staging is generally considered to be complementary to other modalities.2,3 we present details of a 48-year-old woman with breast carcinoma, clinically staged as a t3n2 lesion. initial ultrasonography showed a liver lesion with an equivocal appearance. a f-18 fdg pet/ct scan was then performed. it showed a left breast mass with two pathological axillary lymph nodes. the breast tumour and lymph nodes were associated with intense fdg-activity. a hypodense liver lesion with absent fdg activity was noted, consistent with a haemangioma (not shown). with the pelvic images, a myomatous uterus was seen with a small mass right posterolateral to the uterus. the mass measured 19 mm x 14 mm, with a density of 80 hounsfield units and increased metabolic activity. after review, the differential diagnosis was finally proposed as follows: primary ovarian lesion, pedunculated uterine myoma with sarcomatous degeneration and an ovarian metastasis. a hysterectomy with bilateral salpingo-oophorectomy was performed. metastatic breast carcinoma was seen in the ovary with staging of breast cancer with pet/ct j s möller, fcnp (sa) w h pieterse, m med (rad d) p d du toit, m med sc free state pet/ct centre, bloemfontein s bonnet, m med (rad t) a diedericks, fcog (sa) w brummer, m med (anat path) bloemfontein medi-clinic 75 sa journal of radiology • october 2008 pictorial essay fig. 1. transaxial pet/ct images of the primary breast tumour. fig. 2. axillary lymphadenopathy, with abnormal metabolic activity. fig. 3. small, metabolically active mass postero-lateral to the uterus. staging of.indd 75 10/15/08 11:38:03 am pictorial essay 76 sa journal of radiology • october 2008 micrometastases in the contralateral ovary. it is known that pet may miss micrometastases.4 the patient was upstaged to m1 with a subsequent change in management. following chemotherapy, a toilet mastectomy and axillary clearance were performed. histology confirmed an infiltrating ductal carcinoma with metastatic carcinoma in 5 of the 10 axillary lymph nodes. post-surgical radiotherapy was not indicated in view of the m1 status. the patient is currently on hormonal therapy and in remission 12 months later. these findings illustrate the utility of f-18 fdg pet/ct in the staging of breast carcinoma, by clarifying an equivocal liver lesion and demonstrating an occult ovarian metastasis. however, this report also shows that the sensitivity of pet/ct regarding micrometastases is limited. 1. buscombe jr, holloway b, roche n, et al. position of nuclear medicine imaging modalities in the diagnostic work-up of breast cancer. q j nucl med mol imaging 2004; 48: 109-118. 2. eubank wb, mankoff da. current and future uses of positron emission tomography in breast cancer imaging. semin nucl med 2004; 34: 224-240. 3. lind p, igerc i, beyer t, et al. advantages and limitations of fdg pet in the follow-up of breast cancer. eur j nucl med mol imaging 2004; 31: s125-134. 4. chung a, liou d, karlan s, et al. pre-operative fdg pet for axillary metastases in patients with breast cancer. arch surg 2006; 141: 783-789. ayanda mbanga communications (cape) 15778 u n i v e r s i t e i t s t e l l e n b o s c h u n i v e r s i t y j o u k e n n i s v e n n o o t y o u r k n o w l e d g e p a r t n e r medical imaging & clinical oncology radiodiagnosis professor (ref. 09tgb324) duties: teaching and guiding undergraduate and postgraduate students requirements: of research. recommendation: a doctorate. commencement of duties: 1 december 2008 or as soon as possible thereafter closing date: 31 october 2008 enquiries: appointment is made on the joint personnel of stellenbosch university and the provincial government of the western cape. the university will consider all applications in terms of its employment equity plan, which acknowledges the need to diversify the demographic composition of the staff corps, especially with regard to the appointment of suitable candidates from the designated groups. the university reserves the right not to make an appointment. 021 938 9128. obtain the prescribed application form on our homepage at http://www.sun.ac.za/applicationforms ldavids@sun.ac.za or contacting 021 808 2369. ldavids@sun.ac.za or to the manager: personnel provisioning & planning, stellenbosch university, private bag x1, matieland 7602 or fax 021 808 2484. applicants should request their referees to forward confidential reports by the closing date direct to the same address. staging of.indd 76 10/15/08 11:38:03 am original article original article 28 sa journal of radiology • june 2010 original article abstract objective. the objective of the study was to determine whether computed tomography (ct) of the brain is necessary in all head trauma patients with clinically suspected depressed skull fractures, glasgow coma scale (gcs) scores of 13 and above, and no focal neurological deficits. design. a retrospective descriptive analysis was undertaken of patients of all ages who presented at the trauma unit of the pelonomi hospital complex in bloemfontein with gcs of 13 to 15, depressed skull fracture, no clinical focal neurological deficit, and who also underwent ct of the brain. data were obtained from patients' files, and radiological reports and were analysed by the department of statistics, university of the free state. results. one hundred and thirty-one patients were included in the study, of whom 56 (42.7%) were found to have substantial intracranial pathology as determined by ct. twenty-four (18.3%) of these patients had a gcs of 13, of whom 6 (25%) had normal ct scans and 18 (75%) intracranial pathology. twenty-eight (21.37%) of the 56 patients with intracranial pathology had a gcs of 14, of whom 11 (39.3%) had normal ct scans and 17 (60.7%) intracranial pathology. a gcs of 15 was determined in 79 (60.3%) of the 131 patients, of whom 58 (73.4%) had normal ct scans and 21 (26.6%) intracranial pathology. conclusion. based on our findings, ct imaging of the brain in patients with a clinically suspected depressed skull fracture despite any clinical neurological deficit and a gcs of 13 or more is warranted in our setting. the likelihood of injury on ct correlated inversely with the gcs. introduction the glasgow coma scale (gcs), introduced by teasdale and jenner in 1974, was devised to provide a uniform approach to the clinical assessment of patients with acute head trauma. the scale measures levels of arousal and awareness and attempts to assign numeric values (1 to 5 ) to eye opening, the best motor response and the best verbal response. as a predictor of outcome, scores of 13 to 15 are considered to correspond with mild injury, 9 to 12 with moderate injury and 8 or lower with severe injury.1-3 since the advent of computed tomography (ct) scans in the early 1970s, the demand from emergency room physicians for ct scans for minor head injury patients is a routine practice, although most of these investigations are normal and fewer than 1% of patients require neurosurgery.4,5 it is not known how many ct scans are done in south africa but, according to one estimate in the usa, even a 10% reduction in the number of ct scans in patients with minor head injuries would save more than $20 million per year.6 over the past decade, numerous studies have investigated and attempted to regulate the utility of head ct in patients with minor head injury, such as the new orleans criteria, the canadian ct head rule and the national institute for health and clinical excellence (nice) head injury guidelines. these studies use lists of clinical findings, any of which call for ct after minor head injury,7 and have given rise to a good deal of controversy.8 the aim of our study was to carry out a retrospective analysis of ct scans performed in the radiology department at pelonomi hospital in bloemfontein. only patients with clinically diagnosed depressed skull fracture with a gcs of 13 15 were included in this study and where the presence of brain pathology on ct, if any, was documented. the diagnosis of a depressed skull fracture was made by clinical examination of the patient's head and a skull x-ray to confirm the clinical observation. by undertaking this study, we hoped to provide more reliable guidelines permitting general practitioners, specialists and radiologists to be more selective in using ct scans, without compromising the care of patients with minor head injuries. methods a retrospective descriptive analysis was conducted at the pelonomi hospital complex and trauma unit in bloemfontein. data from 1 january 2008 1 january 2009 were collected. the trauma protocol at our institution requires all patients with depressed skull fractures to undergo an acute ct brain scan, irrespective of their gcs scores. a ct examination of the brain without intravenous iodinated contrast was required for the study. all patients with a history of head trauma and depressed skull fracture on clinical examination, a gcs score of 13 15/15 and no focal neurological signs referred to the department of radiology for an acute ct of the brain, were eligible for the study. the ct scans of patients of all age and racial groups who fulfilled the inclusion criteria were assessed. all ct scans were performed on a ge high-speed zxt single-slice helical ct scanner. two radiology registrars evaluated the scans; results were verified by a specialist radiologist. information was also collected from patient records, and all intracranial pathology was noted. data were captured on a form and transferred to a microsoft excel spreadsheet for statistical analysis of normal and abnormal findings. approval to conduct the investigation was granted by the ethics committee of the faculty of health sciences, university of the free state. is computed tomography of the brain necessary in patients with clinically suspected depressed skull fracture and no focal neurological deficit? j a rabie, mb chb s otto, mb chb, mmed (diagnost radiol) a j le roux, mb chb department of diagnostic radiology, faculty of health sciences, university of the free state, bloemfontein original articleoriginal article 29 sa journal of radiology • june 2010 results data were collected from 131 patients' records during the study period. all these patients had a clinically diagnosed depressed skull fracture and no focal neurological deficit. the gcs of the patients varied between 13/15 and 15/15. a ct brain scan was performed on all the patients as requested at the time of presentation. one hundred and fourteen (87.0%) of the patients were male. patients' ages ranged from 1 76 years. fifty-six (42.7%) of the ct brain scans showed abnormalities. the distribution of patients with regard to gcs score and the number of abnormalities found per gcs level are shown in table i. seven different groups of intracranial pathology were encountered. a number was allocated to each pathology group for statistical analysis, as shown in table ii. three types of pathology predominated, i.e. intracerebral contusion/haemorrhage, brain oedema and pneumocranium, which were observed in more than 15% of patients overall. the other pathologies (subarachnoid, subdural and extradural haemorrhage, and base of skull fractures) occurred at a remarkably lower rate. twenty-four (42.9%) of the abnormal ct scans revealed a single pathology, while multiple pathologies were observed in the remainder. discussion similar to previously published reports,9-11 a considerable number of abnormal ct scans following a depressed skull fracture with no clinical focal neurological deficit were found. although most of the injuries were minor and possibly did not require any intervention, a ct of the brain was still warranted on the basis of the intracranial pathology retrospectively identified in these patients. furthermore, these ct scans could provide a baseline for comparison of subsequent pathology related to the initial injury in the event of later complications and patient follow-ups. a depressed skull fracture was significantly associated with intracranial pathology, as observed by the presence of ct scan abnormality in 42.3% of patients. as shown in table i, a clear association between incidence of intracranial pathology and gcs score was revealed, showing an increase in the rate of pathology as the gcs score decreases. seventy-five percent of patients with a gcs score of 13 had abnormal ct scans, as opposed to 26.6% of those patients with a gcs score of 15. however, despite a gcs of 15/15, intracranial pathology was nonetheless demonstrated. the majority (19.8%) of these were intracerebral contusions and haemorrhages. as this study was a retrospective assessment of ct scans performed on patients fulfilling the inclusion criteria, further management of these patients with regard to observation, treatment and/or surgical intervention was beyond the scope of this investigation. some clinicians believe that it is necessary to identify patients with minor brain injuries. however, several problems with this approach exist. firstly, a patient with a normal ct of the brain may have abnormal mri scans.12,13 secondly, an abnormal ct does not predict neurological outcome.14-16 previous studies have shown that patients with minor brain injury requiring no surgery or medical intervention had an average stay of 1.7 days in hospital, which questions the necessity for admission.17 some physicians16 also warn of the risk of early epidural haematomas. however, only 17 (12.9%) of our patients presented with epidural haematomas. in a paediatric study, one-third of patients were diagnosed with epidural hematomas within 24 48 hours after sustaining head injury. all of these patients presented with normal mental status.17 patients with minor ct abnormalities and normal mental status were found to have a very low risk for deterioration.17 as a result, some centres now have a non-operative approach to asymptomatic haematomas.16,17 regarding the results presented in tables i and ii, we are convinced that ct of the brain in patients with depressed skull fractures, gcs of 13 15 and no focal neurological signs, is indeed necessary, owing to the high percentage of abnormalities found in this study group. the rate of abnormal ct findings for patients with a gcs score of 13/15, clinical depressed skull fracture and no focal neurological signs was much higher than expected. owing to intracranial pathology observed in 42.7% of ct scans performed on patients with minor head injuries, it can be concluded that ct of the brain will be required in our table ii. pathology groups observed on ct scan no. pathology no. of patients (%) (n=131) 1 cerebral oedema 23 (17.6) 2 subarachnoid haemorrhage 8 (6.1) 3 subdural haemorrhage 9 (6.9) 4 pneumocranium 22 (16.8) 5 intracerebral contusion/ haemorrhage 26 (19.8) 6 base of skull fracture 1 (0.8) 7 extradural haemorrhage 7 (5.3) table i. number of patients and abnormal ct scan findings per gcs level gcs score no. of patients (%) (n=131) ct scan findings normal no. of patients (%) abnormal no. of patients (%) 13 24 (18.3) 6 (25.0) 18 (75.0) 14 28 (21.4) 11 (39.3) 17 (60.7) 15 79 (60.3) 58 (73.4) 21 (26.6) total 131 (100) 75 (57.3) 56 (42.7) original article original article 30 sa journal of radiology • june 2010 setting for all patients with depressed skull fractures and gcs scores of 13 15/15 without clinical neurological deficit. acknowledgements we thank daleen struwig (medical writer, faculty of health sciences, ufs) for technical and editorial preparation of the manuscript for publication, and professor gina joubert, department of biostatistics, faculty of health sciences, ufs, for statistical analysis of the data. 1. grossmann ri, yousem dm. neuroradiology: the requisites. 2nd ed. philadelphia: mosby, 2003: 243-245. 2. herndon rm. handbook of neurologic rating scales. new york: demos vermande, 1997: 187-208. 3. haydel mj, preston ca, mills tj, luber s, blaudeau e, de blieux pm. indication for computer tomography in patients with minor head injury. new engl j med 2000; 343: 100-105. 4. peters mc. does every minor head injury need a ct scan? emergency medicine news 2003; 25: 28-30. 5. smits m, dippel dw, de haan gg, et al. minor head injury: guidelines for the use of ct – a multicentre validation study. radiology 2007; 245: 831-838. 6. saboori m, ahmadi j, farajzadegan z. indications for brain ct scan in patients with minor head injury. clin neurol neurosurg 2007; 109: 399-405. 7. steill ig, clement cm, rowe bh, et al. comparison of the canadian ct head rule and the new orleans criteria in patients with minor head injury. jama 2005; 294: 1511-1518. 8. holmes jf, baier me, derlet rw. failure of the miller criteria to predict significant intracranial injury in patients with a glasgow coma scale score of 14 after minor head trauma. acad emerg med 1997; 4: 788792. 9. stein sc, ross se. mild head injury: a plea for routine early ct scanning. j trauma 1992; 33; 11-13. 10. harad ft, kerstein md. inadequacy of bedside clinical indicators in identifying significant intracranial injury in trauma patients. j trauma 1992; 32: 359-363. 11. shackford sr, wald sl, ross se, et al. the clinical utility of computed tomography scanning and neurologic examination in the management of patients with minor head injuries. j trauma 1992; 33: 385394. 12. levin hs, williams dh, eisenberg hm, high wm jr, guinto fc jr. serial mri and neurobehavioural findings after mild to moderate closed head injury. j neurol neurosurg psychiatr 1992; 55: 255-262. 13. eide pk, tysnes ob. early and late outcome in head injury patients with radiological evidence of brain damage. acta neurol scand 1992; 86: 194-198. 14. lee st, lui tn. early seizures after mild closed head injury. j neurosurg 1992; 76: 435-439. 15. mendelow ad, teasdale g, jennett b, bryden j, hessett c, murray g. risks of intracranial haematoma in head injured adults. bmj 1983; 287: 1173-1176. 16. miller ec, derlet rw, kinser d. minor head trauma: is computed tomography always necessary? ann emerg med 1996; 27: 290-294. 17. knuckey nw, gelbard s, epstein mh. the management of "asymptomatic" epidural hematomas. j neurosurg 1989; 70: 392-396. guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agents musculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines. the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn 978-1-875098-43-9978-1-875098-43-9 s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition 9 ninth edition produced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f the essential reference for ever y healthcare professional! the carefully and thoroughly updated 9th edition of the south african medicines formulary (samf) can now be ordered. it is your essential reference to rational, safe and cost-efficient use of medicines. that is why you should not prescribe without it. the newly published samf provides easy access to the latest, most scientifically accurate information – including full drug profiles, clinical notes and special prescriberʼs points. the convenient pocket-size design enables you to fit it comfortably into your bag or hospital coat pocket – always at hand for ready reference. w h y yo u s h o u l d n ’ t b e w i t h o u t t h e s a m f 9 t h e d i t i o n the new 9th edition of samf provides expanded information on key issues facing south african healthcare professionals today, including antiretrovirals, tb treatment guidelines, management guidelines for asthma and chronic heart failure, other common chronic conditions and prescribing in sport. • it presents practical, new approaches to the management of venomous bites and stings. • it outlines extensively the acute adverse reactions to drugs of abuse, and their management. • it features new as well as existing drugs, indexed by both trade and generic names. • it offers fresh insights into informed prescribing and carries cautionary guidelines on drug interactions and a range of special risk patients and conditions. and, as always, you can rely on... • the professional compilation and editing by a team from the division of clinical pharmacology, uct • an independent and unbiased guide on prescribing in south africa today • the indication of agents included in the sa and who essential drug lists • support of the sa national drug policy • guidance for prescribing during pregnancy and lactation, and in patients with porphyria, liver disease and renal impairment (including tables with drug dosage adjustments); and • indexed and page tabs for quick and easy access to each section. y o u r s a t i s f a c t i o n i s g u a r a n t e e d 3 e a s y o r d e r o p t i o n s : 1. phone edward or byron 021 6817000 2. fax the completed samf order form to 0866006218 3. email: edwardm@hmpg.co.za or byronm@hmpg.co.za guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agentsmusculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines.the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn 978-1-875098-43-9 978-1-875098-43-9 s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition 9 ninth editionproduced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f original article original article 80 sa journal of radiology • december 2009 original article abstract background. chest radiography accounts for a significant proportion of ionising radiation in children. the radiation dose of radiographs performed on the lodox statscan system has been shown to be lower than that of a computed radiography (cr) system. the role of the lodox statscan (subsequently referred to as the statscan) in routine erect chest radiography in children has not been evaluated. objective. to evaluate the image quality and diagnostic accuracy of erect paediatric chest radiographs obtained with the statscan and to compare these with conventional erect chest images obtained with a cr system. materials and methods. thirty-three children with suspected chest pathology were enrolled randomly over a period of 3 months. erect chest radiographs were obtained with the statscan and a shimadzu r-20j x-ray machine coupled with a fuji fcr 5000 cr system. image quality and diagnostic accuracy and diagnostic capability of the two modalities were evaluated and compared. results. the erect statscan allowed superior visualisation of the 3 major airways. statscan images, however, demonstrated exposure and movement artifacts, with hemidiaphragms and ribs most prone to movement. bronchovascular clarity was also considered unsatisfactory on statscan images. conclusion. the statscan has limitations in erect chest radiography in terms of movement artefacts, exposure fluctuations, and poor definition of lung markings. despite this, the statscan allows better visualisation of the major airways, equivalent to a ‘high kv’ film, at a fraction of the radiation dose, which supports the finding of an earlier study evaluating statscan images in trauma cases, where the images were taken supine. the statscan has great potential in assisting in the diagnosis of childhood tuberculosis where airway narrowing occurs as a result of nodal compression. introduction ionising radiation is potentially harmful to humans, with a tendency to induce malignancy in tissue.1,2 routine chest radiography is the most frequent radiological examination performed worldwide on both adults and children,3 accounting for a significant proportion of ionising radiation attributable to diagnostic imaging.1,4 a reduction in the radiation dose of a chest radiograph would therefore have significant advantages for both public health and individual radiation risk;5 this is particularly true in paediatric practice, given the increased risk of radiation-induced malignancy in children.1,2 a study conducted at red cross war memorial children’s hospital (rch) showed that the radiation dose of a paediatric chest radiograph performed on the statscan digital radiography unit (lodox systems pty ltd, sandton, south africa) is lower than that of conventional x-ray equipment coupled with a computed radiography (cr) system.6 the statscan has been shown to provide lower doses than cr for other anatomical areas in paediatric patients,6 and than conventional radiography systems for adult patients.7 the utility of the statscan in the trauma setting has been demonstrated.8-10 in a study on triage evaluation of polytrauma patients, the statscan afforded superior visualisation of the paediatric trachea and main bronchi on ap supine chest radiographs, compared with cr.11 however, the former’s role in routine erect chest radiography in children has not been evaluated. as routine chest radiographs are performed erect, a pilot study was conducted to assess the image quality and diagnostic accuracy and capabilities of erect paediatric chest radiographs obtained with the statscan, compared with erect chest radiographs obtained with conventional x-ray equipment combined with a cr system. a pilot study evaluating erect chest imaging in children, using the lodox statscan digital x-ray machine rupesh baloo daya, mb bch maurice a kibel, frcp (edin), dch (rcp&s, lond) school of child and adolescent health, institute of infectious diseases and molecular medicine, university of cape town richard denys pitcher, mb chb, fcrad (d) sa department of paediatric radiology, school of child and adolescent health, red cross war memorial children's hospital, and university of cape town lesley workman, rn south african tuberculosis vaccine initiative, institute of infectious diseases and molecular medicine, university of cape town tania s douglas, phd virginia sanders, msc medical imaging research unit, department of human biology, university of cape town fig.1. the statscan machine and its main components. a pilot.indd 80 11/19/09 2:26:01 pm original articleoriginal article 81 sa journal of radiology • december 2009 materials lodox statscan the statscan machine, approved by the food and drug administration (fda) in the united states, uses linear slot scanning technology. it comprises a slotted tungsten plate over the x-ray tube, providing collimated fan-beam radiation, aligned on a c-arm opposite a detector array of 5 800 60-micron scintillator elements which are optically linked to charge-coupled devices (ccds).6,11,12 when the statscan is used for polytrauma imaging (for which it was designed), the patient is supine on a horizontal custom-built trolley that ‘docks’ onto the c-arm (fig. 1). scanning is in a cranio-caudal direction, producing an adult ap bodygram in approximately 13 seconds. for erect chest radiography, the carm is rotated 90 degrees anti-clockwise and a custom-built chair positioned at the foot of the x-ray table, thus facilitating erect projections of the paediatric chest. scanning is from right to left for the ap study, and anterior-to-posterior for the lateral view. scan times were approximately 3 4 seconds, depending on the size of the child. exposure factors were similar to those previously documented for statscan radiation dose measurements.6 conventional x-ray machine coupled with a cr system a shimadzu r-20j x-ray machine (shimadzu corporation, chiyoda-ku, japan), coupled with a fuji fcr 5000 cr system (fuji photo film co. ltd, tokyo, japan) was used, employing standard paediatric exposure factors.6 methods after obtaining consent from departmental and institutional ethics committees, a pilot study was conducted over 3 months on a random cohort of 33 patients presenting with signs of chest pathology to the emergency unit of the rch. erect ap and lateral chest radiographs on both cr and statscan systems were obtained for all participants, after obtaining informed consent from parents or legal guardians. the mean age of the children enrolled was 46.3 months (range 0.9 125.2). twenty-four boys and 9 girls were included in the study. each pair of radiographs was assigned a random study number and printed on standard analog x-ray film after removal of patient details. image pairs were independently evaluated for image quality, diagnostic accuracy and diagnostic capability by a paediatric radiologist and a paediatrician experienced in chest radiology. evaluators were blinded to clinical details and the modality that had generated the image pair. table i. airway visualisation grading grade length of airway clarity of margins 0 no portion of airway seen. airway not visualised. 1 not seen in entire length. no portions showing well defined margins. 2 seen in entire length segments showing well defined margins. 3 entire length of airway has well defined margin. fig. 2. image showing the chevron artefact consisting of alternating dark and light bands, indicated by the white arrows. fig. 3. image showing the movement artefact involving the hemidiaphragm, indicated by the arrows. a pilot.indd 81 11/19/09 2:26:02 pm original article original article 82 sa journal of radiology • december 2009 original article the following technical aspects were evaluated: • rotation. scored as: present – 2, absent – 0, uncertain – 1. • exposure. scored as: satisfactory – 2, unsatisfactory – 0, uncertain – 1. • inspiratory excursion. scored as: satisfactory – 2, unsatisfactory – 0, uncertain – 1. general image quality was assessed by evaluating each of the following for movement artefacts and resolution: vertebral column, clavicles, ribs, hemidiaphragms, trachea, main bronchi, heart, mediastinum and bronchovascular markings. movement artefact was scored as: present – 2, absent – 0, uncertain – 1, while resolution was scored as: satisfactory – 2, unsatisfactory – 0, uncertain – 1. proximal airway visualisation was evaluated according to the ‘airways index’ (0 5), i.e. the sum of the scores for length of airway visualised (0 2) and the clarity of margins (0 3),11 as shown in table i. the trachea and main bronchi were assessed. diagnostic capability was assessed by the ability of the two modalities to demonstrate the following pleural, mediastinal or pulmonary pathologies: (i) pneumothorax, (ii) pleural effusion, (iii) mediastinal adenopathy, (iv) consolidation, (v) atelectasis, (vi) bronchial wall table ii. assessment of agreement between observers and modalities for visualisation of the airways, as judged by the airways index airways index agreement (%) expected agreement (%) kw p score mean range right main bronchus observer 1 on statscan and cr 76.0 75.1 0.0380 0.2717 observer 1 statscan 4.8 0 5 observer 2 statscan 3.8 2 5 observer 2 on statscan and cr 60.9 61.9 -0.0256 0.6710 observer 1 cr 3.8 0 5 observer 2 cr 2.3 0 4 left main bronchus observer 1 on statscan and cr 70.9 67.6 0.0998 0.0698 observer 1 statscan 4.7 0 5 observer 2 statscan 3.5 2 5 observer 2 on statscan and cr 73.1 71.6 0.0523 0.1865 observer 1 cr 3.5 0 5 observer 2 cr 2.2 0 4 trachea (antero-posterior) observer 1 on statscan and cr 76.2 74.1 0.0799 0.0562 observer 1 statscan 4.9 3 5 observer 2 statscan 4.0 2 5 observer 2 on statscan and cr 71.1 69.7 0.0452 0.2964 observer 1 cr 4.2 2 5 observer 2 cr 3.1 0 5 trachea (lateral) observer 1 on statscan and cr 88.0 88.9 -0.0766 0.7400 observer 1 statscan 4.92 4 5 observer 2 statscan 3.68 2 5 observer 2 on statscan and cr 73.3 67.0 0.1909 0.0783 observer 1 cr 4.68 1 5 observer 2 cr 3.44 2 5 a pilot.indd 82 11/19/09 2:26:02 pm original articleoriginal article 83 sa journal of radiology • december 2009 thickening, (vii) peribronchial infiltrates, (viii) pulmonary air cysts, (ix) pulmonary nodules, and (x) an interstitial pulmonary pattern. these were recorded as present (2), absent (0) or uncertain (1). agreement between radiographic methods was assessed with the aid of cohen’s weighted kappa statistic (kw).13 kw accounts for both percentage agreement and percentage agreement expected by chance, and weights disagreement according to its magnitude, making it suitable for ordinal data. absolute error weights were used. the null hypothesis that agreement is due to chance was tested for kw using the p value at the 95% significance level. kw is interpreted as follows: below 20% is regarded as poor; 21 40% fair; 41 60% moderate; 61 80% good; and >80% as very good.13 results technical evaluation longitudinal rotation there was no difference in the clinically significant rotation on ap projection between the statscan and cr images. on the lateral statscan images, longitudinal rotation was considered clinically significant in one instance (3%). the lateral cr images showed clinically significant longitudinal rotation in 2 cases (6%). horizontal rotation there was no clinically significant horizontal rotation on the statscan images. in 2 (6%) of the cr images, horizontal rotation was considered clinically significant. exposure factors nine (27%) of the statscan images demonstrated exposure artefacts, manifesting as longitudinally orientated, alternating light and dark bands, extending across the image (fig. 2). on 2 (6%) images, the artefact involved only the ap projection. on 3 (9%), it was manifest on the lateral projection alone, while in 4 (12%), both ap and lateral projections were degraded. this was termed the ‘chevron exposure artefact’. none of the cr images showed exposure artefacts. inspiratory excursion the average and range of the number of posterior ribs visualised were similar on cr and statscan, and for the different observers. more anterior ribs were visible on cr than on statscan. in 18 cases, hyperinflation was diagnosed or suspected on the statscan images, compared with 21 cases on the cr. of note on the ap statscan images was the potential for different degrees of inspiratory excursion to be demonstrated in the hemithoraces of the same patient (fig. 3). the discussion elaborates on this point. cardiothoracic ratio (ctr) ctr was measurable in 23 (69.6 %) of image pairs. in the remainder, chest pathology obscured the heart border. the mean ctr on the statscan was 50.3 mm (range 40 58), compared with 50.0 mm (range 38 60) for cr. image quality movement the hemidiaphragms and ribs were the structures most prone to movement on the statscan images. in 4 (12%) images, the ap projection showed such artefact involving either the left or right hemidiaphragm (r – 3; l – 1), while this was seen on 5 (15%) of the lateral projections. the ribs showed movement on 2 (6%) of the ap and 1 (3%) of the lateral statscan projections. no movement artefacts were seen on cr images. resolution bronchovascular clarity was considered unsatisfactory on 9 (27%) of the statscan images, involving the ap projection in 5 (15%) cases, the lateral projection in 7 (21%), and both views in 3 (9%) cases. exposure or movement artefact could be implicated in all instances. in a further 6 (18%), there was uncertainty about bronchovascular clarity. visualisation of the major airways the statscan allowed superior visualisation of the 3 major airways (table ii). the left main bronchus (lmb) was least welland the trachea best-visualised. the statscan afforded better visualisation of the right main bronchus (rmb) by an average of 1.8 points and the lmb by an average of 1.25 points. the disparity in image quality was not as great for tracheal visualisation, where the statscan scored an average of 0.8 points better than cr on the ap projection and 0.24 points better on the lateral projection. diagnostic capability the spectrum of chest pathology, with inter-modality diagnostic agreement, is shown in table iii. in 19 cases (58%), there was diagnostic agreement between the modalities. this agreement was highest for mediastinal pathology (100%) and least for diffuse interstitial pulmonary disease (0%). in 14 cases (42%), the statscan images had diagnostic limitations, with false negative findings in 12 (86%) and false positive findings in 2 (14%) cases. in the 12 false negative cases, the following technical factable iii. percentage agreement for diagnostic capabilities between the two modalities pathology cr statscan % agreement normal 3 2 66 hyperinflated but clear lungs 3 2 66 hyperinflated lungs with peribronchial infiltrate 9 6 66 consolidation 14 7 50 mediastinal adenopathy 2 2 100 interstitial pattern (reticulo-nodular) 2 0 0 total 33 19 58 a pilot.indd 83 11/19/09 2:26:03 pm original article original article 84 sa journal of radiology • december 2009 original article tors were implicated: (i) chevron exposure artefact in 9 (64%) of cases, occurring alone in 7 cases (50%) and in combination with movement of the hemidiaphragms in 2 instances (14%), (ii) movement artefact in 2 (14%) of cases, and (iii) clinically significant vertical rotation in one (7%) case. discussion the protocol for chest radiography at our institution includes both ap/pa and lateral projections, bearing in mind the high prevalence of pulmonary tuberculosis (ptb) in south africa and the increased sensitivity of the lateral projection for diagnosis of ptb.14,15 the erect statscan images were taken in the ap plane, as the design of the machine makes it impractical to obtain a pa image. to be consistent, all cr images for this study were also taken in the ap plane. for the purposes of this study, cr was considered the ‘gold standard’ for technical quality.16 in terms of technical factors, rotation evaluation was similar for both modalities, while the erect statscan images were prone to exposure artefacts in the form of the chevron exposure artefact mentioned earlier. the erect statscan was also prone to movement artefacts affecting the diaphragm. the exposure artefacts were the result of rotating the c-arm of the statscan to obtain an erect chest image. the 90-degree anti-clockwise rotation of the c-arm used for erect views redistributes the weight of the x-ray tube, changing the centre of gravity and limiting the efficiency of the scanning motion. this results in subtle fluctuations in the scanning speed that are reflected as variations in exposure and account for the chevron exposure artefact. the longitudinally orientated dark lines represented areas of relative over-exposure corresponding to periods of slightly slower c-arm movement, while for the lighter lines, the converse applies. lodox systems have indicated that they have subsequently resolved this problem. the movement artefacts were the result of the direction of scanning for the erect chest images. in the erect ap projection, scanning is from left to right (sagittal plane) whereas, for the lateral view, it is from anterior to posterior (coronal plane). in both instances, the scanning direction is perpendicular to the direction of respiratory movement of the hemidiaphragms and ribs, making the images more susceptible to changes in inspiratory or expiratory movement of the diaphragm and ribs as a result of breathing. in our study, movement and exposure artefacts were seen in 40% and 27% of statscan image pairs respectively. as a result, image quality was adversely affected, which influenced the diagnostic accuracy of the statscan. these technical aspects of the statscan erect chest views therefore compromise image quality and diagnostic accuracy and together were implicated in 93% of diagnostic errors encountered on the statscan images. evaluation of the major airways revealed that the trachea and left and right main bronchi were visualised better on the statscan than the cr images. visualisation of the airways with the statscan would be advantageous in developing countries with a high prevalence of pulmonary tuberculosis, given that the hallmark of paediatric ptb is enlargement of mediastinal lymph nodes, with potential for distortion of the pliable paediatric tracheo-bronchial tree. the statscan offers a much lower radiation exposure dose compared with a ‘high kv’ film that is generally used to delineate tracheo-bronchial narrowing. the statscan could also be used as a screening tool in this regard if the cost is reduced. the diagnostic capabilities for chest pathology, other than that involving the airways, appeared to be poor on the statscan images, except for mediastinal pathology, for which statscan and cr showed equivalent performance. further work is required to define the clinical role of the statscan chest radiograph in diagnosis of proximal airway and mediastinal pathology, especially in children <5 years old suspected of having ptb. it is important to note here that, in an earlier study assessing the supine statscan ap chest projections on polytrauma patients, no movement or exposure artefacts were seen.11 for the statscan supine ap projections, the fan-beam of ionising radiation is orientated in the axial (transverse) plane. scanning is in a cranio-caudal direction and therefore in the same direction as respiratory movement of the hemidiaphragms and ribs, so eliminating movement artefacts. regarding the ‘chevron exposure’ artefacts observed on the erect statscan images, the most important differences between the supine and erect views appear to be due to repositioning of the c-arm. for the supine images, the c-arm is in the original position with a balanced weight distribution, optimising scanning speeds. a supine chest image obtained with the statscan moving in the cranio-caudal direction offers better image quality than erect chest images obtained with the statscan. both statscan configurations, however, provide better visualisation of the airways than cr does. conclusion the statscan has limitations in erect chest radiography in terms of movement artefacts, exposure fluctuations, and poor definition of lung markings. supine chest images obtained with the statscan, however, do not show these movement and exposure artefacts. it is clear that statscan chest images, both in the supine and erect positions, allow better visualisation of the major airways, equivalent to a ‘high kv’ film at a fraction of the radiation dose. statscan chest images therefore have the potential to play a role in the diagnosis of tuberculosis in children, especially in high-prevalence countries, and also in the imaging of cases where airway narrowing or compression are suspected but not clearly seen on cr images. our hope is that the statscan will evolve as a screening tool in suspected cases of tuberculosis. the lodox statscan digital radiography machine was loaned to rch for the duration of this study. none of the clinical participants or investigators has any financial interest in the company. ethics approval from the local irb was obtained. 1. roebuck dj: risk and benefit in paediatric radiology. pediatr radiol 1999; 29: 637-640. 2. mettler fa jr, upton ac (eds). medical effects of ionizing radiation, 2nd ed. philadelphia: wb saunders, 1995. 3. legmann p. imaging and lung disease. tuber lung dis 1993 74(3): 147-158. 4. kiljunen t, jarvinen h, savolainen s. diagnostic reference levels for thorax x-ray examinations of paediatric patients. br j radiol 2007; 80: 452-459. 5. icrp. recommendations of international commission on radiological protection, 60 – 1990. ann icrp 21: 1-201. 6. maree gj, irving bj, hering er. paediatric dose measurement in a full-body digital radiography unit. pediatr radiol 2007; 37(10): 990-997. 7. irving bj, maree gj, hering e, douglas ts. radiation dose from a linear slit scanning x-ray machine with full body imaging capabilities. radiat prot dosimetry 2008; 130(4): 482-489. 8. douglas ts, sanders v, pitcher r, van as ab. early detection of fractures with low-dose digital x-ray images in a pediatric trauma unit. j trauma 2008; 65(1): e4-7. a pilot.indd 84 11/19/09 2:26:03 pm original articleoriginal article 85 sa journal of radiology • december 2009 9. van as ab, douglas ts, kilborn t, pitcher r, rode h. multiple injuries diagnosed using full-body digital x-ray. j pediatr surg 2006; 41(7): e25-28. 10. koning l, douglas ts, pitcher r, van as ab. short emergency department length of stay attributed to full-body digital radiography – a review of 3 paediatric cases. s afr med j 2006; 96(7): 613-614. 11. pitcher rd, van as ab, sanders v, et al. a pilot study evaluating the statscan digital x-ray machine in paediatric polytrauma. emerg radiol 2008; 15: 35-42. 12. boffard kd, goosen j, plani f, degiannis e, potgieter h. the use of low dosage x-ray (lodox/statscan) in major trauma: comparison between low dose x-ray and conventional x-ray techniques. j trauma 2006; 60(6): 1175-1181. 13. jakobsson u, westergreen a. statistical methods for assessing agreement for ordinal data. scand j caring sci 2005; 19(4): 427-431. 14. provincial department of health. annual performance plan 2006/2007. cape town: provincial department of health, western cape, 2007: 47, fig. 2. 15. smuts na, beyers n, gie r, s, et al. value of the lateral chest radiograph in tuberculosis in children. pediatr radiol 1994; 24: 478-480. 16. ishigaki t, endo t, ikeda m, et al. subtle pulmonary disease: detection with computed radiography versus conventional chest radiography. radiology 1996; 201(1): 51-60. erratum notice the incorrect image was used in the printed version of the previous (august 2009, vol. 13 no. 3, page 53, fig. 4) issue of the sa journal of radiology. the online version was corrected shortly after its publication. the correct image is below. we apologise for the error. fig. 4. sample images: (a) reference image, (b) search image, (c) groundtruth map, (d) distance map, (e) tm similarity map, (f) mi similarity map, (g i) mi similarity map thresholded at grey-levels of 1, 64 and 128. the thresholded maps are compared with the ground-truth map in (c) to determine the tpfand fpf-values that were used to generate an roc curve. a pilot.indd 85 11/19/09 2:26:04 pm untitled review article 4 sa journal of radiology • december 2005 abstract actinomycosis is a chronic infection caused by gram-positive anaerobic bacteria which is found worldwide. common features of actinomycosis infections include abscess formation, granulation, dense fibrous tissue formation, and the classical cutaneous sinuses with yellow/sulphur granular discharge. however some of the features may be nonspecific and the absence of classical features may delay the diagnosis. since actinomycosis responds well to various antibiotic treatments, with or without surgical intervention it is worthwhile including actinomycosis infection in the differential diagnosis. we present radiological findings for 4 patients presenting with different forms of thoracic and abdominopelvic actinomycosis infection, and a short review of the documented literature findings. introduction actinomycosis is a chronic infection caused by gram-positive anaerobic bacteria, with the usual pathogen in man being actinomycosis israelii, accounting for 85% of human infections.1,2 actinomycosis is found worldwide and may affect any age group.1,3,4 this pathogen is normally found in the oral cavity and gastrointestinal tract (git) of healthy individuals. when the protective barriers are broken, opportunistic infection develops by direct extension, for example after dental manipulation. infection may also develop by aspiration of oropharyngeal contents or gastrointestinal secretions causing respiratory tract infection, or may develop in association with foreign bodies such as intrauterine contraceptive devices (iucds) causing abdominopelvic acinomycosis.1,2,5 haematogenous dissemination from a preexisting focus is rare, but may occur from thoracic disease.1,2,4 the chronic progressive suppurative infection caused by actinomycosis organisms has shown three major sites of predilection being cervicofacial (55% mean frequency),3 abdominopelvic (25%), and thoracic (15%).5 common features of actinomycosis infections include abscess formation, granulation, dense fibrous tissue formation, and the classical cutaneous sinuses with ‘yellow sulphur’ granular discharge. cavitations may be noted in lung involvement which may develop sinuses to the skin. fistula formations are seen in git infections, and permeative bone destruction is seen with osseous involvement. however some of the features may be nonspecific and the absence of classical features may delay the diagnosis.1 actinomycosis infection responds well to antibiotic treatment, traditionally intravenous penicillin g for 4 6 weeks being the treatment of choice, followed by oral penicillin for 6 12 months.1 however erythromycin, tetracycline, cephalosporins and other antibiotics, alone or in combination, may also be used successfully.1,2,4,5 the duration of treatment may need to be tailored to the individual. a combined medical-surgical approach may be required. surgical intervention assists in recovery but is not usually curative on its own.2 we present the radiological findings for 4 patients presenting with different forms of actinomycosis infection and give a short review of the relevant literature. thoracic actinomycosis case 1 a 63-year-old woman presented with chronic cough and chest pain. a small sinus was found on the skin adjacent to the sternum on the left which was not draining at the time of examination. chest x-ray demonstrated an illdefined mass adjacent to the aorta on the left, associated with left upper lobe fibrosis. an area of sub-segmental atelectasis was seen in the right lower lobe. this was thought not to be significant (fig. 1). a post-contrast ct scan of the chest demonstrated an irregular inhomogeneous soft-tissue mass in the left upper lobe adjacent to the aorta extending to the anterior thoracic wall lateral to the left edge of the sternum. the degree of contrast enhancement was negligible (figs 2a and b). the differential diagnosis included tuberculosis, neoplasm, or actinomycosis. an open lung biopsy was performed and the histology demonstrated sclerotic lung changes with interstitial fibrosis, and a filamentous bacterium, namely actinomycosis, was isolated. case 2 an adult male patient presented with swollen painful knees and a history of chronic cough. chest x-ray demonstrated an irregular right upper lobe mass associatthoracic and abdominopelvic actinomycosis k spiegel mb bch, fcrad (diag) e joseph mb bch, ffrad (diag) helen joseph hospital auckland park johannesburg fig. 1. erect chest x-ray demonstrating opacification in the left upper lobe adjacent to the mediastinum (arrow). 7 11/25/05 1:49 pm page 4 ed with right upper-lobe volume loss and elevation of the right hilum as well as right parattracheal fullness (figs 3a and b). contrast-enhanced ct scan of the chest confirmed the presence of the irregular right upper lobe posterior segment inhomogeneous lobulated mass with associated pleural reaction but no rib erosion. extension into the mediastinum was demonstrated with a hypodense mass seen in the right paratracheal region which was splaying and displacing the major vessels. no significant contrast enhancement was demonstrated (figs 4a and b). plain x-ray of the knees demonstrated bilateral distal femoral and proximal tibial and fibular periosteal reactions bilaterally which were diagnosed as hypertrophic osteoarthropathy (fig. 5). the differential diagnosis in this case included right upper lobe neoplasm with mediastinal lymph node involvement, or a chronic infection with involvement of mediastinal lymph nodes, such as thoracic actinomycosis. sputum analysis confirmed the diagnosis of actinomycosis. abdominopelvic actinomycosis case 3 a 42-year-old man presented with a palpable lesion in the right hypocondrium. chest x-ray demonstrated an elevation of the right hemi-diaphragm. there were no focal lung parenchymal lesions (fig. 6). contrast-enhanced ct scan of the chest demonstrated a subcutaneous abscess with communication to the pericapsular region of the liver extending through the anterior lower right chest wall. the lesion showed contrast rim enhancement. no focal pathology was demonstrated in the liver (figs 7a and b ). this infection was pathologically proven to be actinomycosis and the patient duly responded to iv penicillin treatment. review article 5 sa journal of radiology • december 2005 figs 2a and b. axial post-contrast ct scan of the chest demonstrating a left para-aortic mass extending to the anterior thoracic wall (arrow). 2a 2b figs 3a and b. pa erect and lordotic (apical view) chest x-ray demonstrating the right upper lobe opacity in the right paratracheal region (arrow). 3a 3b figs 4a and b. axial non-enhanced ct scan of the chest demonstrating a lesion in the right upper lobe posterior segment (arrow) and an inhomogeneous hypodense lesion (arrow head) in the upper mediastinum. 4a 4b fig. 5. ap x-ray of the knees demonstrating bilateral periostial reactions involving the femora, tibiae and fibulae. fig. 6. erect pa chest x-ray demonstrating an apparent elevation of the right hemidiaphragm. 7 11/25/05 1:49 pm page 5 case 4 a 39-year-old woman presented with a pelvic mass. she had had an iucd in situ for several years. a contrast-enhanced ct scan of the abdomen demonstrated an inhomogeneous irregular pelvic mass involving the uterus with infiltration of the surrounding mesentery and multiple associated abscesses. extension to the right anterior lower abdominal wall with abscess formation through the lower abdominal wall was shown, but with no breakthrough to the skin. the adjacent bowel wall was thickened (figs 8a-d). this was confirmed as actinomycosis and the patient responded well to treatment with penicillin. discussion thoracic actinomycosis thoracic actinomycosis is a rare disease that may mimic other pathology such as tuberculosis and primary or metastatic lung cancer.1,4 actinomycosis may also coexist with these pathologies.2-4 infection of the lung, pleura, mediastinum or chest wall may be caused by direct extension from cervicofacial infection, an oesophageal tear, by inhalation or aspiration and rarely by haematogenous spread from a distant focus.2 the radiological features include localised ill-defined lung infiltrate, air space consolidation, or a mass lesion, with or without associated cavitation.2,4 a pulmonary infiltrate with a basal predominance and involvement of adjacent lobes through interlobar fissures is said to be suggestive of thoracic actinomycosis.1,4 the pathology may extend to the mediastinum, pericardium, myocardium, and prevertebral space with vertebral body involvement. extension to the skin surface with sinus tract formation may also be present,2 as demonstrated in case 1 (figs 1 and 2). pleural involvement includes both pleural thickening and pleural effusion.1,6 the presence of a chronic pleural effusion with underlying lung changes and periosteal rib involvement is usually accepted as a diagnostic triad. unfortunately sumoza et al.4 found this to be the exception rather then the rule. table i lists the common and less common features of thoracic actinomycosis. not all features may be demonstrated by actinomycosis infection and in the absence of the classic cutaneous fistulas with yellow granular discharge the diagnosis may be delayed.1 hypertrophic osteoarthropathy hypertrophic osteoarthropathy (hoa) is characterised by periostosis of the tubular bones and digital clubbing. in the primary form no underlying cause is found, but when an underlying disease is present this syndrome is referred to as secondary 6 sa journal of radiology • december 2005 figs 7a and b. axial post-contrast ct scan of the upper abdomen demonstrating a right upper-quadrant rim-enhancing collection over the right lobe of the liver anteriorly. extension to the subcutaneous tissue in a collar stud appearance is demonstrated in fig. 7a.(arrow). 7a 7`b 8a 8c 8b 8d figs 8a-d. axial post-contrast ct scan of the pelvis demonstrating an inhomogeneously enhancing central pelvic mass iinvolving the uterus, with solid and liquid components representing multiple abscesses (small arrows) as well as infiltration of the surrounding mesentery and adjacent bowel wall thickening. figs c-d also demonstrate involvement of the right anterior lower abdominal wall with abscess formation (large arrows). table i. radiological features of thoracic actinomycosis 1. infiltrative changes suggestive of aspiration pneumonitis or consolidation extending across interlobar fissures. 2. fibronodular or cavitary parenchymal disease . 3. an intraparenchymal mass. 4. pleural effusion or empyema (rare). 5. involvement of chest wall soft tissue and destruction of adjacent bone with formation of sinus tracts to the skin. 6. involvement of the mediastinum, pericardium, myocardium. rarely, superior vena caval obstruction and oesophageal fistula formation. 7. thoracic vertebral destruction with preservation of disk space height. 8. hypertrophic osteoarthropathy. review article 7 11/25/05 1:49 pm page 6 hoa. many underlying pathologies may be associated with hoa such as intrathoracic malignancy or infection, pleural pathology, cyanotic cardiac pathology, intestinal pathology, and more. the association of digital clubbing and hoa with chronic pulmonary disease was recognised in the late 1800s.7,8 in a review of the literature no reports of hoa with actinomycosis was found. since thoracic actinomycosis is considered a chronic infection associated with cavitation, fibrosis and pleural involvement it falls under chronic pulmonary disease and therefore, as in our second case (case 2), it is assumed that it may be associated with hoa on this basis. abdominopelvic actinomycosis abdominal actinomycosis usually occurs following penetrating trauma, perforation of a hollow viscus (e.g. appendix) or surgical manipulation 9,10 there is a predilection for the ileocaecal region where it may be confused with caecal tuberculosis, amoeboma, chronic appendicitis, and carcinoma of the caecum.2,3 primary pelvic actinomycosis may occur in association with iucd colonisation and infection and is more likely with prolonged use of an iucd, as demonstrated in case 4.3,11 pelvic actinomycosis is also known to occur in association with septic abortion, retained sutures from previous surgery, or spread from an intra-abdominal focus. abdominopelvic actinomycosis may present as an aggressive-looking mass.3,5 bowel-wall thickening with multiple abscesses, abundant granulation, dense fibrous tissue, as seen in case 4 (fig 8a-d), chronic fistulas and draining sinuses to the surface are the characteristic features.3,9,10 these features are not specific to actinomycosis and may mimic neoplasm, or other infective processes such as tuberculosis, or chronic appendicitis.2,10,12 the sinuses draining to the surface with yellow sulphur granules are also not unique to actinomycosis, and may occur in nocardiasis, chromomycosis and other fungal infections of the body.2 the aggressive infiltrative pattern of abdominopelvic actinomycosis has been described as an important radiological feature of this infection.3,5,13 table ii lists some of the imaging features of abdominopelvic actinomycosis. conclusion in the absence of classical features of cutaneous sinuses with yellow sulphur granular discharge, the common imaging findings in abdominopelvic and thoracic actinomycosis may be nonspecific. actinomycosis responds well to various antibiotic treatments, with or without surgical intervention. for this reason it is worthwhile including actinomycosis infection in the differential diagnosis, particularly where clinical findings do not support the diagnosis of other processes such as tuberculosis or neoplasm. actinomycosis should also be considered in situations where there is prolonged iucd use, previous pelvic or abdominal surgery or in appendicular infection. references 1. ossorio ma, fields cl, byrd rp, roy tm. thoracic actinomycosis and human immunodeficiency virus infection. south med j 1997; 90: 11361138. 2. smego ra jun., foglia g. actinomycosis. clin infect dis 1998; 26: 1255-1263. 3. lee i, ha hk, park cm, et al. abdominopelvic actinomycosis involving the gastrointestinal tract: ct features. radiology 2001; 220: 76-80. 4. sumoza d, raad i, douglas e. differentiating thoracic actinomycosis from lung cancer. infect ions in medicine 2000; 17: 695-698. 5. ko sf, ng sh, lee ty, lo cw. retroperitoneal actinomycosis with intraperitoneal spread: stellate pattern on ct. clin imaging 1996; 20: 133-136. 6. cheon je, lm jg, kim my, lee js, choi gm, yeon km. thoracic actinomycosis: ct findings (abstract). radiology 1998; 209: 229-233. 7. menard ha hypertrophic osteoarthropathy. emedicine-hypertrophic osteoarthropathy . http://www.emedicine.com/med/topic2929.htm april 2003. 8. burton md, mark ej. case 46-1994a 35 year-old smoker with an air fluid level in the upper lobe bulla. n engl j med 1994; 31: 1761-1767. 9. goldwag s, abbitt pl, watts b. case report: percutaneous drainage of periappendiceal actinomycosis (abstract). clin radiol 1991; 44: 422-424. 10. kaliaras v, mylaria s, lyra s, tasonidou d, thanos l. ileo-caecal actinomycosis 2002 dec 27 {online} url: http://www.eurorad.org/ case. cfm?uid=2091luxembourg,euromultimedia 11. yeguez jf, mortinez sa, sanda lp, hellinger md. pelvic actinomycosis presenting as malignant large bowel obstruction: a case report and a review of the literature (abstract). am surg 2000; 66(1): 8590. 12. chaudhuri s, billings pj. intra-abdominal actinomycosis presenting as complex abdominopelvic mass. j indian med assoc 2002; 100: 463-464. 13. ha hk, lee hj, kim h, et al. abdominal actinomycosis: ct findings in 10 patients (abstract). am j roentgenol 1993; 161: 791-794. 7 sa journal of radiology • december 2005 table ii. radiological features of abdominopelvic actinomycosis 1. git mucosal fold thickening and ulceration (may resemble crohn’s disease).3 2. abdominal/pelvic infiltrative mass (often with multiple compartments involved). 3. post-contrast ct may demonstrate homogeneous or inhomogeneous enhancement.3,5 4. rupture of hollow viscus with free intra-abdominal air. 5. chronic fistula and draining sinuses. 6. retroperitoneal, psoas muscle or liver abscess formation. 7. minimal or absent ascites.3 8. stellate infiltrates from mass lesion with mesenteric involvement.5 review article 7 11/25/05 1:49 pm page 7 article information authors: anand moodley1 william i.d. rae2 yarish brijmohan3 miranda durand4 catherine connolly5 andrew michowicz6 ahmed bhigjee7 affiliations: 1department of neurology, grey's hospital, university of kwazulu-natal, south africa 2department of medical physics, university of the free state, south africa 3department of electrical, electronic and computer engineering, university of kwazulu-natal, south africa 4department of radiology, grey's hospital, south africa 5biostatistics unit, medical research council, south africa 6department of medicine, edendale hospital, south africa 7department of neurology, university of kwazulu-natal, south africa correspondence to: anand moodley email: anand.moodley1@gmail.com postal address: po box 13833, cascades 3202, south africa dates: received: 05 mar. 2014 accepted: 30 jul. 2014 published: 15 dec. 2014 how to cite this article: moodley, a, rae, wid, brijmohan y, et al. the impact of optic nerve movement on optic nerve magnetic resonance diffusion parameters. s afr j rad. 2014;18(1); art. #596, 6 pages. http://dx.doi.org/10.4102/sajr.v18i1.596 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the impact of optic nerve movement on optic nerve magnetic resonance diffusion parameters in this original research... open access • abstract • introduction • method • statistics • results • discussion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: optic nerve diffusion imaging is a useful investigational tool of optic nerve microstructure, but is limited by eye-movement-induced optic nerve movement and artifacts from surrounding cerebrospinal fluid, fat, bone and air. attempts at improving patient cooperation, thus voluntarily limiting eye movement during a standard diffusion imaging sequence, are usually futile. the aim of this study was to establish the impact of optic nerve movement on clinical diffusion parameters of the optic nerve. method: twenty-nine healthy volunteers with intact vision and intact conjugate gaze were recruited and subjected to magnetic resonance diffusion-weighted imaging (dwi) and diffusion-tensor imaging (dti) of the optic nerves. twenty right eyes had nerve tracking done using single-shot echo-planar imaging at 20 time points over 3 minutes. optic nerve movement measurements were correlated with diffusion parameters of apparent diffusion coefficient (adc), mean diffusivity (md), fractional anisotropy (fa) and anisotropic index (ai) using spearman's rank correlation. results: no significant correlations were noted between optic nerve movement parameters and adc in the axial plane and md of the optic nerve. low to moderate negative correlations were noted between optic nerve movement parameters and ai and fa and positive correlation with adc in the radial plane. conclusion: optic nerve movement documented during the timespan of standard diffusion sequences (dwi and dti) has a negative effect on the anisotropic diffusion parameters of the optic nerve. with greater eye movement, optic nerve diffusion appears less anisotropic owing to greater radial diffusion. introduction top ↑ optic nerve (on) diffusion imaging has gained prominence as a useful investigational tool for optic nerve microstructure and pathology.1,2,3 whilst initially developed to demonstrate the effects of chronic optic neuritis on on structure, its use in recent studies has revealed early changes in acute optic neuritis, too.4 the anticipated benefit of detecting these early changes is better understanding of the pathophysiology of processes affecting the optic nerve and possibly the development of better strategies to prevent and reverse such damage. on diffusion imaging has also been used both qualitatively and quantitatively for ischaemic optic neuropathy, glaucoma and cryptococcus-induced visual loss.5,6,7 different pulse sequences and imaging protocols for on diffusion imaging have been used (table 1). the lack of standardisation of imaging parameters has had apparently little effect on the quantitative assessment of on diffusion parameters. good consistency for such parameters has been determined using the different techniques of iwasawa's intravoxel incoherent motion (ivim),8 wheeler-kingshott's zonal oblique multislice echo planar imaging (zoom epi),9 chabert's non-carr-purcell-meiboom-gill fast spin echo (non-cpmg fse)10 and our coronal oblique method.7 each method, unfortunately, has its own limitation. the on is surrounded firstly by cerebrospinal fluid (csf) within the optic nerve sheath, and then by fat within a bony orbit which is bordered by paranasal sinuses containing air. in most of the on diffusion techniques, fluid-attenuated inversion recovery (flair) and fat saturation are utilised to minimise the csf and fat artifact surrounding the nerve, respectively. we used fat saturation (spectral presaturation with inversion recovery [spir]) to suppress the fat signal and a high, but clinically widely used, diffusion gradient (b = 1000 s/mm2) instead of flair, to reduce the csf artifact.7 the benefit of this method was improved identification of the on on b = 0 s/mm2 images. on coronal oblique imaging, the nerve appears centrally hypo-intense and is surrounded by hyper-intense csf in the peri-optic space. susceptibility artifact from the bone and air are minimised by using sensitivity encoding (sense), averaging and rayleigh noise reduction.9 on motion, however, cannot be entirely eradicated, but merely decreased by asking the subject to be calm, listen to relaxing music, and focus on a target placed in his central field of view. we asked subjects to focus on an orange sticker placed overhead on the mri machine. nevertheless, eye movement (voluntary and/or involuntary) and therefore on movement continues, and it is not uncommon with single-shot epi to image an apparent ‘double nerve’ as a result of movement. the effect of this movement on on diffusion parameters has not been previously investigated. table 1: summary of demographic data (where available), diffusion sequences and parameters of the optic nerve. to investigate the pathophysiology of various on disorders, including those which derange the csf flow dynamics of the nerve and surrounding csf, it would be useful to have some quantitative measure of the flow within the csf and on, and therefore it is necessary to look at factors, such as movement, that influence the accuracy of quantitation. all research done so far on on diffusion has not factored in the influence of on movement on the diffusion parameters. diffusion in the radial plane is more likely to be affected by on movement than diffusion in the axial direction, since displacement of the nerve occurs predominantly in the radial plane. consequently, the ratio of axial to radial diffusion (i.e. the anisotropic index [ai]) will be affected by the degree of movement. anxious and encephalopathic patients are more likely to have more eye movement and scanning movements than lucid patients, which may affect the ai and perhaps other diffusion parameters. the first aim of this study was to determine the amount of movement of the on that occurs during the timespan of a standard diffusion imaging study when attempts were made to reduce movement. the second aim was to determine the effect of this movement on the diffusion parameters, namely apparent diffusion coefficient (adc), mean diffusivity (md), fractional anisotropy (fa) and ai of the on. method top ↑ full ethical approval for the study was obtained from the grey's hospital ethics committee and the university of kwazulu-natal ethics department. informed consent was obtained from healthy volunteers with intact visual acuity and ocular motor function demonstrating preserved conjugate eye movements in the horizontal and vertical axes. each volunteer underwent full neuro-ophthalmological examination, to ensure normality of visual function, and an mri scan of the orbits and brain. a 1.5t philips gyroscan was used for magnetic resonance (mr) diffusion-weighted imaging (dwi) and diffusion-tensor imaging (dti) of the brain and ons using the coronal oblique technique for each nerve as previously reported.7 a clinically relevant diffusion gradient of b = 1000 s/mm2 was selected for the orthogonal three-axis dwi acquisitions, and fat-saturated (spir) single-shot epi using sense without cardiac gating was used. epi was acquired using echo time (te) = 93 ms, repetition time (tr) = 3000 ms, 180 mm field of view (fov), matrix = 112 x 128 and 4 mm slice thickness. dti was obtained in 15 directions and longitudinal, axial and mean diffusivity values were selected for analysis. twenty-nine volunteers were recruited who demonstrated bilateral visual acuity of 6/6 or better, full range of extra-ocular movement and preserved conjugate eye movements. on tracking using single-shot epi followed immediately after dwi and dti of the on. an mri-compatible eye-tracking device was not available for this study. we therefore opted for mr epi optic nerve tracking, which is limited in that the nerve tracking could not be performed at the same time as diffusion acquisition. however, subjects were made to lie on the table for at least 25 minutes prior to the acquisition of dwi and dti of the ons, when standard brain imaging of flair, t1w, t2w and dwi were acquired. this period prior to diffusion imaging of the ons and epi tracking of the ons allowed the subjects to settle down and acclimatise to the mri milieu. we therefore postulated that when on diffusion and epi tracking were acquired, the subjects’ emotional state and level of anxiety were generally stable and equivalent, hence resulting in a similar amount of eye movement during both acquisitions. conjugate eye movements were essential as only the tracking of the right on was done. on movement measurements so obtained could therefore be correlated to diffusion parameters from the right and left eyes. twenty snapshots of the on were done in 3 minutes, which was the equivalent duration of the standard on diffusion study. images were spaced at 9-second intervals from each other. during both studies, the subjects, while relaxing and listening to light music, was asked to fixate on an orange sticker placed in their field of view on the inner anterior surface of the mri scanner. ons selected for analysis were those that were easily identified on the b = 0 s/mm2 coronal oblique diffusion images. on tracking was done on the image series acquired for 20/29 volunteers using the 20 images obtained for each subject over the 3-minute period. the 20 images were acquired in a plane perpendicular to the long axis of the nerve, and positioned to include the orbital segment of the nerve midway between the optic canal and the globe where minimal artifact from surrounding bone and paranasal sinus air was present. a target of 1 pixel size (1.6 mm x 1.6 mm) was placed in the centre of the on in the coronal oblique image (figure 1) for all 20 images. the position of the on in image 1 was labelled as the reference point (x1,y1) with which all subsequent 19 images were compared. the on movement parameters (viz. total distance moved from the reference point, total area of displacement and displacement in the x and y axes) were recorded. figures 2a–2c show displacement of the on in the x axis, y axis and the x-y plane. all simulations were performed in matlab r2009b. the total distance (sum of all the 19 distances recorded on the images from the starting point) from the reference point was calculated using the formula: distance (x20,y20; x19,y19) + distance (x19,y19;x18,y18) +… distance (x2,y2;x1,y1), where distance (a,b;c,d) = ([a−c]2 + [b−d]2)½ and is expressed in mm. figure 1: echo-planar imaging snapshot of coronal oblique view of the right optic nerve. a pixel-size target (white dot) was placed on the centre of the optic nerve and movement recorded over 3 minutes with 20 snapshots; (a), optic nerve; (b), peri-optic cerebrospinal fluid space. figure 2: sample displacement of the optic nerve in 20 snapshots in the x and y axes and the x-y plane from one subject; (a), x-axis; (b), y-axis; (c), x-y plane. the displacement in the x and y axes was calculated in reference to the starting points x1 and y1 respectively. the x displacement of d(x) = xi – x1 and y displacement of d(y) = yi – y1 for i = 1–20. area of displacement was calculated as (max x – min x) × (max y – min y) and was expressed in mm2. the on slice approximately midway through the orbital segment of the nerve was used for diffusion analysis to match the segment chosen for movement analysis. it is the segment of the on that is least susceptible to surrounding bone and air artifact, and is best visualised on diffusion imaging. a 2 x 2 pixel, square region of interest (roi) was placed on the centre of the nerve from which diffusion parameters were obtained. the diffusion parameters (viz. adc, md, fa and ai) were obtained by imaging the ons separately in the coronal oblique plane on dwi and dti. adc and ai were obtained from dwi whereas md and fa were obtained from dti. dwi acquisition was repeated in three orthogonal axes in order to obtain adcs for each direction. the radial diffusion was the average of the two adcs in the radial plane and compared with the axial diffusion when calculating the ai. hence ai was calculated using the formula ai = 2λ1/(λ2 + λ3), where λ1 = axial diffusion and λ2, λ3 = radial diffusion in the other two orthogonal axes (table 2). table 2: optic nerve movement parameters and effect on diffusion parameters in 20 patients. statistics top ↑ spearman's rank correlation was used to assess the association between movement and diffusion parameters owing to the small sample size, and the t-test to test for significance. significance level was set at p < 0.05. statistical analysis was done in stata, version 12. results top ↑ from the 29 healthy volunteers recruited, 26 right eyes and 26 left eyes were analysed for diffusion parameters owing to poor nerve visualisation in those excluded. table 1 shows the demographic profile of the volunteers and the diffusion parameters recorded. comparison is made with other reported diffusion sequences. of the 29 volunteers, 20 had right optic nerve tracking recorded by the single-shot epi method. the average total distance moved by the optic nerve during the 3 minutes’ recording was 11.8 mm (range 5.7 – 23.7) despite requesting the patient to fixate on the orange sticker placed overhead on the mri scanner (table 2). eye movement was perhaps a combination of voluntary and involuntary saccadic movement. spearman's rank correlation showed low to moderate negative correlations between on movement parameters and ai and fa of the on (table 2). whilst the t-test did not reach significance levels, a trend towards this negative correlation was evident, especially in relation to on displacement in the x-axis and ai (table 2). no significant correlations were noted between any of the on movement parameters and adc in the axial plane and md of the on (table 2). table 1 shows fairly similar diffusion parameters with and without csf suppression, and the current values fall within the range of values that have been reported. discussion top ↑ on diffusion as an investigational tool for on microstructure in normal and pathological conditions is gaining in popularity.2,5,6,11,12 objective, reproducible and verifiable mr sequences for diffusion is paramount in maintaining this impetus. the influence of eye movement, however, remains a problem. intuitively, one might tend to consider that on movement affects the brownian motion of water molecules within the nerve and consequently on on diffusion imaging. the range of movement between the immediate retrobulbar portion of the intra-orbital on is far more than the pre-canalicular portion which is fixed.9 on diffusion studies usually examine the mid-portion of the orbital on which is relatively free from the susceptible artifacts of surrounding bone and air.1,4,13. the amount of movement by this portion of the nerve is therefore of relevance to the diffusion parameters measured in that region. obsessive attempts to limit this movement invariably result in frustrated and less co-operative subjects. wheeler-kingshott et al. have shown that asking the subject to fixate on a point for 5 minutes or more does not significantly reduce eye movement.14 on movement distorts diffusion imaging of the nerve. six eyes had to be excluded from analysis owing to poor visualisation as a result of eye movement. where analysis was possible, table 1 shows that the results obtained were reliable. the adc, md, fa and ai of the on obtained in the present study are comparable to those of wheeler-kingshott et al., iwasawa et al. and chabert et al. (table 1). despite attempts to limit on movement, both voluntary and involuntary saccadic movements are unavoidable during a dwi or dti recording of between 3 and 5 minutes. macroscopically, the on moves appreciably during a 3-minute recording. we recorded a mean total distance of 11.8 mm (range 5.7 – 23.7) over a mean area of 5.2 mm2 (range 0.6 – 22.1). no significant correlation was noted between on movement parameters and adc in the axial plane and md. however, low to moderate negative correlations were noted between on movement parameters and fa and ai. the t-test showed a trend towards significance even though significance levels were not reached, which may be the result of the small sample size. movement of the nerve, which physiologically occurs in the radial plane (x and y displacement), did not significantly affect adc in the axial plane and md, but moderately increased adc in the radial plane, resulting in less anisotropy of the nerve and subsequently a lower ai. increased radial diffusion with on movement also moderately lowered the fa even though significance levels were not reached. the moderate correlations of on displacement in the x direction and adc in the radial direction did not reach statistical significance (p = 0.17), but this too may be the result of the small sample size. surprisingly, not suppressing the peri-optic csf had no significant effect on on diffusion parameters from dwi and dti in our series when compared with those where csf suppression was done. the advantage of not suppressing the csf signal is better identification of the nerve on b = 0 s/mm2 images. an additional benefit is recording of peri-optic csf diffusion parameters that can potentially be applied to disorders that involve the peri-optic csf space, such as papilloedema. a limitation of the present study was the inability to track movement of ons during the actual performance of dwi and dti of the on. nevertheless, we feel that the amount of on movement was a good reflection of the mental and physical state of the subject as no time was wasted between imaging sequences. both studies were done about 25 minutes into the entire mr imaging, when the subject was more settled. the concern of co-registration of diffusion volumes from the on and surrounding csf was addressed by the short scanning time with snapshots of the on taken within 9 seconds. with the mean displacement of the on during the entire 180 seconds being 2.1 mm ± 0.97 mm in the x-axis and 2.2 mm ± 1.61 mm in the y-axis, one could predict that with each image acquisition over a 9-second interval, the on would have spent most of the time close to or within the reference point (table 2). the standard deviations given are of the order of 1 pixel in size. the on is normally 4 mm – 6 mm in diameter, therefore manual placement of the 2 x 2 pixel roi within the nerve also avoided co-registration of diffusion volumes between the on and surrounding csf. our study provides reasonable evidence that macroscopic on movement has an effect on radial diffusion obtained from the mid-portion of the orbital segment of the on. the result is lowering of the ai and fa. consequently, future studies that evaluate anisotropic diffusion of the on need to take into account the effect of on movement and motion correction methods or software devised to reduce the errors. md, as expected, is unaffected by this movement as it is a scalar average of the diffusion tensor. furthermore, recording of on movement as obtained with rapid sequential single-shot epi is valid and a reasonable reflection of the amount of eye movement during standard mr sequences. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions a.m. (university of kwazulu-natal), w.r. (university of the free state), a.b. (university of kwazulu-natal) and y.b. (university of kwazulu-natal) were responsible for the study conception and design. a.m., a.m. (edendale hospital) and y.b. did acquisition of data. a.m., y.b., w.r., a.b., m.d. (grey's hospital) and c.c. (medical research council) did the analysis and interpretation of the data. a.m. and w.r. drafted the manuscript, and w.r., a.b. and m.d. did the critical revision. references top ↑ xu j, sun sw, naismith rt, snyder az, cross ah, song sk. assessing optic nerve pathology with diffusion mri: from mouse to human. nmr biomed. 2008;21(9):928–940. http://dx.doi.org/10.1002/nbm.1307 trip sa, wheeler-kingshott c, jones sj, et al. optic nerve diffusion tensor imaging in optic neuritis. neuroimage. 2006;30(2):498–505. http://dx.doi.org/10.1016/j.neuroimage.2005.09.024 zhang y, wan sh, wu gj, zhang xl. magnetic resonance diffusion tensor imaging and diffusion tensor tractography of human visual pathway. int j ophthalmol. 2012;5(4):452–458. fatima z, motosugi u, muhi a, hori m, ishigame k, araki t. diffusion-weighted imaging in optic neuritis. can assoc radiol j. 2013;64(1):51–55. http://dx.doi.org/10.1016/j.carj.2011.08.006 cauquil c, souillard-scemama r, labetoulle m, adams d, ducreux d, denier c. diffusion mri and tensor tractography in ischemic optic neuropathy. acta neurol belg. 2012;112(2):209–211. http://dx.doi.org/10.1007/s13760-012-0013-5 chen z, lin f, wang j, et al. diffusion tensor mri reveals visual pathway damage that correlates with clinical severity in glaucoma. clin experiment ophthalmol. 2013;41(1):43–49. http://dx.doi.org/10.1111/j.1442-9071.2012.02832.x moodley a, rae w, bhigjee a, loubser n, michowicz a. new insights into the pathogenesis of cryptocococcal induced visual loss using diffusion-weighted imaging of the optic nerve. neuro-ophthalmology. 2012;36(5):186–192. http://dx.doi.org/10.3109/01658107.2012.715716 iwasawa t, matoba h, ogi a, et al. diffusion-weighted imaging of the human optic nerve: a new approach to evaluate optic neuritis in multiple sclerosis. magn reson med. 1997;38(3):484–491. http://dx.doi.org/10.1002/mrm.1910380317 wheeler-kingshott ca, parker gj, symms mr, et al. adc mapping of the human optic nerve: increased resolution, coverage, and reliability with csf-suppressed zoom-epi. magn reson med. 2002;47(1):24–31. http://dx.doi.org/10.1002/mrm.10016 chabert s, molko n, cointepas y, le roux p, le bihan d. diffusion tensor imaging of the human optic nerve using a non-cpmg fast spin echo sequence. j magn reson imaging. 2005;22(2):307–310. http://dx.doi.org/10.1002/jmri.20383 hickman sj, wheeler-kingshott ca, jones sj, et al. optic nerve diffusion measurement from diffusion-weighted imaging in optic neuritis. ajnr am j neuroradiol. 2005;26(4):951–956. kolbe s, chapman c, nguyen t, et al. optic nerve diffusion changes and atrophy jointly predict visual dysfunction after optic neuritis. neuroimage. 2009;45(3):679–686. http://dx.doi.org/10.1016/j.neuroimage.2008.12.047 naismith rt, xu j, tutlam nt, trinkaus k, cross ah, song sk. radial diffusivity in remote optic neuritis discriminates visual outcomes. neurology 2010;74(21):1702–1710. http://dx.doi.org/10.1212/wnl.0b013e3181e0434d wheeler-kingshott ca, trip sa, symms mr, parker gj, barker gj, miller dh. in vivo diffusion tensor imaging of the human optic nerve: pilot study in normal controls. magn reson med. 2006;56(2):446–451. http://dx.doi.org/10.1002/mrm.20964 pictorial interlude 37 sa journal of radiology • june 2007 bilateral symmetrical calcification of the basal ganglia is a frequently encountered incidental finding on ct scan. the aetiology of adult basal ganglia calcification ranges from a physiological type secondary to aging, which may be regarded as a normal variant, to the less typical pathological causes. physiological basal ganglia calcification is usually punctate, localised in the globus pallidus and of no clinical significance. if accompanied by other calcification one should then consider an underlying pathological condition. endocrine diosorders, e.g. hypoparathyroidism, pseudohypoparathyroidism and hyperparathyroidism are the more commonly recognised pathological causes of basal ganglia calcification.1,2 the calcification may be dense and its distribution frequently involves the caudate and lentiform nuclei, thalami, dentate nuclei of the cerebellum and subcortical regions (figs 1 and 2). the above non-contrast axial ct in a 60-year-old patient with known pseudohypoparathyroidism demonstrates an example thereof. 1. oliveira jr, spiteri e, sobrido mj, et al. genetic heterogeneity in familial idiopathic basal ganglia calcification (fahr disease). neurology 2004; 63: 2165-2167. 2. verulashvili iv, glonti lsh, maniia mn, et al. basal ganglia calcification: clinical manifestations and diagnostic evaluation. georgian med news 2006; 140: 39-43. pathological basal ganglia calcification in a patient with pseudohypoparathyroidism l sweidan, mb chb division of radiology, department of radiation sciences, university of the witwatersrand, johannesburg fig. 1. dense calcification of the dentate nuclei bilaterally. fig. 2. dense calcification of the basal ganglia, thalami, nuclei and subcortical white matter. pg37.indd 37 6/13/07 9:23:11 am 102 sa journal of radiology • september 2011 rssa mdct essentials course 2011 sandton convention centre, johannesburg, 26 28 august 2011 oral presentations (alphabetical order according to presenting author (bold font)) the role of multi-detector ct angiography as an adjunctive tool in the evaluation of paediatric cardiac disease in an african setting – experiences at red cross war memorial children’s hospital (rxh) lizelle clark (department of radiology,university of cape town), tracy kilborn, nicky wieselthaler (rxh) paediatric cardiac imaging is a complex, challenging and highly specialised field that has been revolutionised by newer imaging techniques in the form of multidetector computed tomography angiography(mdcta)and magnetic resonance (mr) cardiac imaging. these modalities have emerged to play dominant roles in the assessment of congenital heart disease, challenging conventional forms of imaging. it is clear from the literature that the roles of these newer imaging modalities have been established in developed countries; however, their roles in the developing world remain limited owing to lack of infrastructure and resources. at present, our institution does not offer a cardiac mr imaging service. echocardiography remains the primary modality for the diagnosis of cardiac disease, predicting the need for surgery in the majority of cases. cardiac catheterisation and cardiac cta are reserved for a subset of patients. in this retrospective study, we evaluate our initial experiences using a 64-slice phillips mdct to answer specific questions raised by inconclusive echocardiography and cardiac catheterisation findings. from december 2009 to april 2011, a total of 35 children underwent cardiac ctas. all patients had echocardiography imaging. fifty-four per cent of patients underwent conventional cardiac angiography. in our case series, cta proved to be effective in the evaluation of structural abnormalities not adequately defined – particularly with regard to the pulmonary arteries, major aorto-pulmonary collateral arteries, extra-cardiac anatomy and patency of shunts. cardiac cta in our setting is feasible, accurate, reproducible and objective, and we recommend synergistic use of echocardiography and cta in selected cardiac patients. free fluid on 64-mdct after blunt abdominal injury in a trauma referral centre in kwazulu-natal: a profile of incidence and outcome damon surjit jeetoo, frederik buitendag (department of radiology, pietermaritzburg metropolitan hospitals complex), damian clarke,thomas walker (department of surgery, pietermaritzburg metropolitan hospitals complex introduction and background. free fluid seen in the absence of solid organ or hollow viscus injury poses a diagnostic dilemma for both radiologists and trauma surgeons. we looked at the incidence of isolated free fluid in the context of a busy south african trauma referral centre (edendale hospital) in kwazulu-natal. we identified and followed retrospectively and prospectively 121 patients with blunt abdominal injury who had a ct of the abdomen and pelvis upon first presentation, within a period of 20 months from september 2009 to april 2011. results. there were 36 cases of free fluid in the abdomen and pelvis on ct. of these, 21 included solid organ injuries. there were 7 cases with hollow viscus injuries and 8 cases with isolated free fluid. of the latter group, 3 had negative laparotomies, 4 were managed conservatively, and 1 was lost to follow-up. conclusion.the studied patients who sustained blunt abdominal trauma and were diagnosed with isolated free fluid in the abdomen or pelvis on a 64-mdct did not require laparotomy and could have been managed conservatively. multi-detector computed tomography venography (mdctv) as a diagnostic tool in the management of patients with atypical, complicated and/or recurrent varicose veins andrew lawson (university of cape town, groote schuur hospital), paul rischbieter (general practice), tushar peedikayil, jeannine owen, steve beningfield (groote schuur hospital) purpose. to evaluate the role of mdctv as a diagnostic tool in the management of patients with atypical, complicated and/or recurrent varicose veins when compared with conventional venography. materials and methods. a retrospective review of 21 patients who had undergone both mdctv and conventional transfemoral or transpopliteal venography between january 2008 and april 2011 for the management of recurrent varicose veins and/or chronic venous ulcers. mdctv was performed using a siemens emotion somatom 16-slice ct scanner. spiral acquisition was commenced 180 seconds after intravenous injection of 150 ml of 350 mmol/l iodinated contrast medium. a reconstruction interval of 1.5 mm was used. conventional venography was performed by the resident vascular surgeon and was followed by stenting or coiling where appropriate. results. mdctv and venography were compared in 21 patients (6 males, 15 females; average age 55 years, range 33 78 years); 8 also underwent endovascular iliac vein stenting. the area under the receiver operator curve (roc) curve for percentage iliac vein stenosis determined on mdctv v. venography was 0.75. four false-positive (19%) iliac vein stenoses were reported on mdctv. ten patients underwent gonadal vein coil embolisation. gonadal vein size >5.2 mm (range 1 – 11 mm) on mdctv predicted significant venographic reflux requiring coil embolisation. three (30%) patients who underwent embolisation did not have gonadal vein enlargement on mdctv. conclusion. mdctv plays an important adjunctive role in the diagnostic workup of patients with complex venous disease. the findings at mdctv correlate well with conventional venography. the prevalence of missed pathology on normal non-contrast-enhanced cranial computed tomography cornelia minne (university of limpopo), farhana e suleman, nonjabulo z makhanya, margaret e kisansa, nazema ebrahim (university of pretoria) objective. to determine the prevalence of missed pathology on normal noncontrast-enhanced cranial computed tomography. method. cranial computed tomography scans over a 12-month period were retrospectively reviewed by 3 readers. the non-enhanced ct (nect) and contrast-enhanced ct (cect) scans were read at separate occasions and readers blinded to the history, each other’s interpretation and their own interpretation of the nect. interpretation discrepancies between readers were resolved during a meeting where consensus was reached. cases with missed pathology on the nect were also evaluated retrospectively at a joint meeting between the 3 readers to determine whether the pathology was visible on the nect. results. in this study, 3.28% of cases had pathology missed by 3 readers on the nect. re-evaluation by the panel reduced this to 1.42%, indicating a reading error of 1.85%. conclusion. patients with a normal nect, no neurological clinical signs, no history of tuberculosis, and no known tumours or risk factors for venous thrombosis have a very small chance of missed pathology when using only nect. omitting unnecessary cect will in turn reduce the risk of intravenous iodinated contrast and radiation exposure to the patient and running cost, as well as increase the throughput of patients. the alternative of doing only nect will reduce radiation exposure and the risk of missing pathology. how we eyeball the small bowel: newly introduced ct enteroclysis at tygerberg hospital braham van der merwe (university of stellenbosch and department of radiology, tygerberg hospital), b van der merwe, h els, a maydell, s scheepers (division of radiodiagnosis, tygerberg hospital)) the imaging and diagnosis of small bowel disease is a complex issue. the previous gold standard of fluoroscopy utilising barium as positive contrast medium has numerous limitations and is increasingly being replaced with cross-sectional imaging. both computed tomography enteroclysis (cte) and magnetic resonance enterography (mre) offer the advantage of imaging the bowel lumen as well as extraluminal tissues. the latter is not achievable with conventional fluoroscopic examinations and has important management abstracts sa journal of radiology • september 2011 103 implications, especially for conditions such as crohn’s disease. cte is relatively available, but the technique described in the literature proposes utilising methyl cellulose via infusion pumps as enteral negative contrast. this enteral agent is not available in south africa and the technique is quite costly, which is a further hindrance in our resource-constrained setting. we have solved these problems with a creative and unique technique not previously described. it is an inexpensive solution using equipment already at our disposal and available in most hospital settings. the bowel distension is adequate for diagnostic purposes, and we believe the image quality to be on a par with that published in the literature. we present a number of diverse cases demonstrating various small bowel pathologies to this end. findings on ct brain scans of patients referred with an index psychotic episode matthys van wyk (university of the witwatersrand) introduction. psychosis is the inability to separate subjectivity and reality and can be functional or organic. organic psychoses are attributed to physical brain conditions, excluded by imaging. ct scanning requires evaluation regarding the detection of organic pathology in south africa, with its high tb and hiv prevalence and resource limitations. aim. to determine the prevalence of structural brain abnormalities detected on ct in patients referred with a first-episode psychosis in a south african population. materials and methods. ct scans of the brain in patients referred after a first-episode psychosis (as per protocol, at one institution) were reviewed retrospectively over a 2-year period. demographic data, hiv status, spaceoccupying lesions (sol), ventricle size, abnormal calcifications and features of raised intra-cranial pressure were recorded. results. of 112 scans reviewed (51.79% males; mean age 37 yrs; range 16 67 yrs), 11.61% tested hiv-positive. a total of 21 (18.75%) patients had abnormalities on ct, 2 (1.78%) of which were significant requiring further investigations. no sols were detected. only 4 (3.57%) patients had enlarged but not hydrocephalic ventricles. nine (8.03%) patients had ageinappropriate involutional changes. seven (6.25%) patients had old calcified granulomata. no scans showed features of raised intra-cranial pressure. conclusion. the yield of abnormalities in ct brain scans in patients referred with a first-episode psychosis at our institution is high. however, only a small percentage of these are significant, and can be attributed to the psychosis or affect management. poster presentations (alphabetical order according to presenting author (bold font)) paraduodenal hernias exposed ernst boshoff, matthew goodier (university of the witwatersrand) baseline chest radiograph appearances of hiv-infected children eligible for anti-retroviral therapy vicci du plessis, aisne stoker (grey’s hospital), savvas andronikou (university of the witwatersrand), gabriel struck (stony brook university school of medicine), neil mckerrow (pietermaritzburg metropolitan hospitals) an atypical appearance of pulmonary metastases jacqueline du toit (stellenbosch university radiology department, tygerberg hospital), pieter barnardt (clinical oncology, tygerberg hospital) adequacy of paediatric renal tract ultrasound nishentha govender (university of the witwatersrand) severe coarctation of the aorta v. interrupted aortic arch: a case of severe aortic obstruction in a 24-year-old woman with refractory hypertension damon jeetoo, vicci du plessis (department of radiology, pietermaritzburg metropolitan hospitals complex) the many faces of lymphobronchial tb susan lucas, savvas andronikou (university of the witwatersrand), pierre goussard, robert gie (university stellenbosch) the many faces of hydatid in south africa nasreen mahomed, matthew goodier, michelle wong, grace rubin (university of the witwatersrand) disseminated rhabdomyosarcoma with spinal metastases nasreen mahomed, sugeshnee pather (university of the witwatersrand) unusual suprasellar presentation of an atypical teratoid/rhabdoid tumour in a child nasreen mahomed, s dlangamandla, s pather (university of the witwatersrand) non-accidental injury – a south african experience nasreen mahomed, matthew goodier (university of the witwatersrand) brain computed tomography perfusion imaging for acute stroke: university of the free state’s experience frans naude, werner harmse (university of the free state) the role of multidetector computed tomographic angiography (mdcta) in pre-endovascular interventional decision making tushar peedikayil, andrew lawson, stephen beningfield (groote schuur hospital/uct) supracardiac total anomalous pulmonary venous connection tanyia pillay, firoza motara (rahima moosa hospital) can you diagnose the different congenital cardiac anomalies? tanyia pillay (rahima moosa hospital) name this vessel – a rare primitive carotid-basilar anastomosis amaresh ranchod (department of radiology, university of the witwatersrand, chris hani baragwanath hospital), ronel swartz, savvas andronikou, victor mngomezulu (department of radiology, university of the witwatersrand), shaheed gora (department of neurology, university of the witwatersrand) a case of complete androgen insensitivity syndrome – clinical and imaging findings shirley sadler, ronald james urry, fazleh mahomed (grey’s hospital, pietermaritzburg) hydatid disease: here, there and everywhere shaun scheepers, hein els, arthur maydell, braham van der merwe (stellenbosch university) impending aortic rupture: four signs to keep you out of trouble shaun scheepers, hein els, arthur maydell, braham van der merwe (stellenbosch university) vanishing white matter disease, mri imaging over 4 years werner steyn (university of the witwatersrand) ovarian vein thrombosis: common ct findings of an uncommon entity braham van der merwe (stellenbosch university, tygerberg radiology) radiology of the cutting edge braham van der merwe (stellenbosch university, tygerberg radiology) abstracts case report case report 20 sa journal of radiology • march 2007 case report abstract multicentric epitheloid haemangioendothelioma (ehe) of bone is a rare primary bone tumour which may present at any age. the diagnosis is suspected on radiographs and the differential diagnosis includes metastatic disease, epitheloid angiosarcoma and ehe. confirmation is only by means of biopsy and histological examination. multiple lesions and metastases are confirmed or excluded by further imaging such as radiographs, whole-body nuclear bone scan and ct scan of the chest. when positive, these findings change the prognosis and approach to treatment. in our case an elderly man presented with a pathological fracture of the right tibia as a complication of ehe. diagnosis was suspected on radiographs and confirmed on histology. whole-body bone scintigraphy and ct scan of the chest were performed, which confirmed multiple bone lesions and metastases to the lungs. introduction haemangioendothelioma is the term used to describe vascular neoplasms presenting with histological features and clinical behaviour intermediate between benign well-differentiated haemangiomas and anaplastic angiosarcomas.1 they can occur in the liver, skin, soft tissue, heart, central nervous system and many other locations.1-3 less frequently they are found in the bone, accounting for less than 0.5 1% of all primary bone neoplasms.1,2 the tumour is mainly located in the long tubular bones of the lower extremity and the pelvis, less frequently in the vertebral column, upper extremity, and flat bones.2 cases have also been described involving the skull.1 all age/sex groups can be affected by the tumour, but there is predilection for the 4th 6th decade.1,2 case report a male patient, age 79 years, presented with a pathological fracture of the right tibia. radiographs showed multiple lytic lesions of the right femur and tibia. the lesions were well circumscribed with no associated sclerosis or soft tissue mass (figs. 1a c). pelvic, lumbosacral and chest x-rays revealed additional lytic bone lesions in the pelvis (fig. 1d). an open reduction and internal fixation together with open biopsy were performed. the initial diagnosis was that of metastatic disease. histological analysis demonstrated epitheloid haemangioendothelioma (ehe) and no features of angiosarcoma. the patient was referred to a tertiary hospital for further management. a ct scan of the lung revealed lung metastases and diffuse alveolar airspace disease in keeping with infection (fig. 2a). on bone windows a lytic lesion was detected in the third lumbar vertebra. whole-body scintigraphy using tcmdp 905 mbq demonstrated osteoblastic lesions in both femurs and the third lumbar vertebra (fig. 2b). the patient unfortunately died due to gram-negative sepsis. 20 sa journal of radiology • march 2007 multicentric epitheloid haemangioendothelioma of bone s t hlongwane, mb chb h b louw, mb chb, mfammed g dekker, mb chb, mfammed k m naidu, mb chb, mmedrad m pienaar, bsc, mb chb s andronikou, mb bch, fcrad, frcr, phd department of radiology, stellenbosch university and tygerberg hospital figs. 1a d. conventional x-rays of the right knee, femur and pelvis. multiple lytic lesions, some well circumscribed and others permeative, in the right tibia, femur and pelvis. case report pg20-22.indd 20 2/26/07 1:55:42 pm case reportcase report 21 sa journal of radiology • march 2007 discussion there are two forms of haemangioendothelioma, viz. epitheloid type and spindle-cell type.1 the epitheloid type is a well-differentiated endothelial vascular neoplasm, with an epitheloid appearance to the endothelial cells and a tendency to be multifocal. the spindle cell type is a rare tumour of the endothelial cells that resembles cavernous haemangioma. ehe of bone is a low-grade malignant vascular tumour with a relatively benign course in contrast to the poorly differentiated angiosarcoma. there is varying opinion about its malignant potential, prognosis, and clinical course.2,4 for some authors 1,2 the most important indicator is the histological grade of the tumour. the tumor is graded i iii according to the amount of cellular atypia present, with grade iii being the most malignant. with occurrence of metastases or lesions in other organs the prognosis is poor.1,2 metastatic disease occurs most often to the lung.1 in up to 55% of cases the disease is multicentric and often multicompartmental.1,2 multicentric appearance is either metachronous or synchronous.2 the rarity of this tumour and the uncharacteristic clinical symptoms of pain and sometimes swelling may make its clinical detection difficult. plain film radiography is the best diagnostic procedure for the initial imaging of the tumour.2,3 as in our patient, the findings on plain film radiography are multiple small osteolytic lesions which may have a more permeative character.2 sclerosis and calcification is rare.1,4 the radiological appearance correlates closely with the histological grade. high-grade tumours have indistinct and irregular margins while low-grade tumours have sharp case report fig. 1b. fig. 1c. pg20-22.indd 21 2/26/07 1:55:42 pm case report case report 22 sa journal of radiology • march 2007 demarcated edges.1 cortical destruction often occurs, but periosteal reaction is uncommon.2 it is essential to do a complete skeletal survey with plain films, mri or scintigraphy. mri can demonstrate occult lesions. there is intermediate signal intensity on t1w and high signal intensity on t2w images. tumour enhances after ivi gadolinium injection.2 ct can be used for assessment of cortical destruction and soft tissue penetration.2 bone scintigraphy shows 'doughnut' lesions with increased uptake in the periphery and photopaenic zone in the central region of the tumour.2 preoperative angiography may show unseen lesions on ct and mri. in some cases pre-operative tumour embolisation can be performed, which can reduce bleeding at the time of operation.2 the radiological differential diagnosis includes epitheloid haemangioma,4 metastases, angiosarcoma,1,2 fibrous dysplasia2 and melanoma.1 definitive diagnosis requires histopathological examination. treatment is determined by the grade, location and spread of the tumour. the ultimate goal remains that of cure. wide resection of the tumour is recommended.1,2 limb-saving procedures should be done when possible. radiation therapy is indicated for a widespread or irresectable tumour in an attempt to stop local tumour progression. radiotherapy is not recommended as an alternative to surgical treatment. the role of chemotherapy has not been adequately assessed because of infrequent application.2 conclusion keep this tumour in mind as a diagnostic possibility when multiple lucent bone lesions resembling metastases are seen on radiographs. 1. cansiz h, yener m, dervisoglu s, kalekoglu n. hemangioendothelioma of the frontal bone in a child. journal of craniofacial surgery 2003; 14: 724 – 728. 2. gosheger g, hardes j, ozaki t, horst e, burger h, winkelmann w. the multicentric epitheloid hemangioendothelioma of bone: a case example and review of the literature. j cancer res clin oncol 2002; 128: 11 – 18. 3. palsson b. epitheloid hemangioendothelioma. acta oncologica 1999; 38: 659 – 661. 4. lewis vo, montag ag, simon ma. epitheloid hemangiomas of bone. clin orthop 2003; 407: 167 – 172. fig. 1d. fig. 2a. ct of the chest – lung windows. multiple, fairly poorly circumscribed, subpleural nodules on a background of alveolar airspace disease and pleural effusions. this constitutes most probably metastatic disease on a background of infective changes within the lung parenchyma. fig. 2b. whole-body bone scintigraphy and tomography. osteoblastic lesions in both femurs and third lumbar vertebra. pg20-22.indd 22 2/26/07 1:55:43 pm article information authors: chris van zyl1 razaan davis2 delmé hurter1 gerhard van der westhuizen3 affiliations: 1kimberley hospital complex, department of clinical imagining science, university of the free state, south africa 2department of radiology, tygerberg hospital, stellenbosch university, tygerberg, south africa 3department of anatomical pathology, universitas hospital, south africa correspondence to: chris van zyl email: chrisjvanzyl@gmail.com postal address: tembuku 11, paddy goodrick street, bloemfontein 9301, south africa dates: received: 31 aug. 2014 accepted: 20 nov. 2014 published: 27 mar. 2015 how to cite this article: van zyl, c, davis, r, hurter, d, van der westhuizen, g. giant peritoneal loose bodies. s afr j rad. 2015;19(1); art. #730, 3 pages. http://dx.doi.org/10.4102/sajr.v19i1.730 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. giant peritoneal loose bodies in this case report... open access • abstract • introduction • case presentation • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ giant peritoneal loose bodies are rare lesions, originating from auto-amputated appendices epiploicae. they may cause urinary or gastrointestinal obstruction and, should the radiologist not be familiar with the entity, can potentially be confused with malignant or parasitic lesions. familiarity with their characteristic computed tomographic features is essential to prevent unnecessary surgery in the asymptomatic patient. we present a case of a 70-year-old man diagnosed with two giant peritoneal loose bodies. introduction top ↑ giant peritoneal loose bodies, also known as peritoneal mice,1,2 are rare lesions with only a few reported cases in the literature. the recognition of these lesions is essential, as familiarity with their characteristic computed tomography (ct) features will assist with an accurate diagnosis, preventing unnecessary surgical intervention in an asymptomatic patient.3,4 it is important to differentiate giant peritoneal loose bodies from lesions such as gastrointestinal stromal tumour (gist), fibroma, desmoid tumour, teratoma, mesenteric calcification, leomyoma, a retained surgical sponge and urinary, gallbladder and appendix stones.2,3,4,5,6,7 case presentation top ↑ a 70-year-old man, with known hypertension, presented with a longstanding history of a tender enlarging abdominal mass in the left lower quadrant. his vital signs were normal and laboratory results were non-contributory. abdominal radiographs revealed well-circumscribed calcifications in the left upper and right lower quadrants. subsequent abdominal ultrasound revealed what appeared to be aperistaltic thickened bowel loops containing large calcifications. two well-circumscribed soft-tissue masses were identified on abdominal ct, one just deep to the anterior abdominal wall at the level of the umbilicus, and the second in the left upper quadrant anterior to the left kidney. a tissue plane was clearly visible between these masses and the surrounding intra-abdominal structures. each lesion had distinct alternating layers of density, namely an outer non-enhancing rim; a concentric layer of soft-tissue density; a hyperdense layer arranged in the form of petals; and, in the centre, a coarse lobulated calcification (figure 1). a diagnosis of echinococcus multilocularis was entertained, but the radiological findings were not typical and hydatid serology was negative. figure 1: preand post-contrast axial computed tomography (ct) images demonstrate the peritoneal ‘mice’ with alternating layers of density. note the movement of the anterior mass between non-contrast-enhanced ct (a) and contrast-enhanced ct (b) acquisitions. during exploratory laparotomy, two mobile solid masses, measuring 65 × 50 × 35 mm and 95 × 75 × 55 mm respectively, were found adherent to the retroperitoneum and anterior abdominal wall. macroscopically, both lesions were ovoid and very firm (figure 2), matching the ‘boiled egg’ appearance described by sewkani et al.;1 the cut surface revealed the alternating layers identified on ct. figure 2: the two giant peritoneal loose bodies removed after laparotomy (a). note the boiled egg appearance as described by sewkani et al.1 a section (b) through one of the peritoneal loose bodies demonstrates the calcified centres (black arrow) with laminated fibrous connective tissue arranged concentrically around them (white arrow). microscopic examination demonstrated dense acellular to paucicellular hyalinised connective tissue with a concentric arrangement around the central calcified areas (figure 3). the hyalinised connective tissue demonstrated scattered small pinpoint calcifications, variable in size. there was no evidence of fat necrosis, dysplasia or malignancy. the central calcified areas were not examined histologically. figure 3: concentric arrangement of hyalinised connective tissue (a). punctate calcification (black arrow) in the paucicellular hyalinised fibrous connective tissue rings (white arrow) (b). discussion top ↑ peritoneal loose bodies, also known as peritoneal mice, are mostly found as incidentalomas during laparotomy or autopsy.1,2,4 when small (5 mm – 25 mm), these peritoneal loose bodies are asymptomatic; however, when they reach a diameter of 50 mm – 100 mm (‘giant’ peritoneal loose bodies or ‘mice’),1,2 they may present with urinary retention and bowel obstruction,1,2 necessitating surgical removal. although the pathophysiology is still poorly understood, the current hypothesis, even as early as 1956,8 is that appendices epiploicae undergo chronic torsion, leading to saponification, calcification, fibrosis and, ultimately, auto amputation. once free within the peritoneal cavity, exudative serum accumulates on the surface, leading to further growth.1,2,3,4,5,6,7,8 peritoneal mice are usually found free within the peritoneal cavity but can re-attach (as with our patient), when they are known as parasitised peritoneal bodies.1 microscopically, these lesions consist of many layers of laminated fibrous tissue with a paucity of cellular elements, necrotic saponified fat, central calcification and peripheral proteinaceous material.1,2,6,7 the differential diagnoses for loose peritoneal bodies include gastrointestinal stromal tumour (gist), fibroma, desmoid tumour, teratoma, mesenteric calcification, leiomyoma and urinary, gallbladder and appendix stones. a retained sponge with a radio-opaque marker can also be mistaken for a loose peritoneal body;2,6,8 however, a retained surgical sponge is not likely to change position when the patient is rescanned in the prone position. the ct features, including a well-defined, round or oval-shaped mass with central calcification, surrounded by non-enhancing peripheral soft tissue, are usually characteristic.3,4 a tissue plane between the lesion and surrounding structures is usually seen. variability in position also helps to confirm the diagnosis.2,3 conclusion top ↑ the present case emphasises the importance of recognising the typical radiological appearance of this rare benign lesion, so preventing erroneous diagnosis of malignant or parasitic lesions and unnecessary surgery in an asymptomatic patient. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship that may have inappropriately influenced them in writing this article. authors’ contributions c.v.z. (university of the free state) was the main author, with r.d. (stellenbosch university) helping with the literature review and write-up. d.h. (university of the free state) also contributed to the initial write-up. g.v.d.w. (universitas hospital) was responsible for the histopatho-logical evaluation. references top ↑ sewkani a, jain a, maudar k, et al. ‘boiled egg’ in the peritoneal cavity – a giant peritoneal loose body in a 64-year-old man: a case report. j med case rep. 2011;5:297. http://dx.doi.org/10.1186/1752-1947-5-297 gayer g, petrovitch i, jeffrey rb. foreign objects encountered in the abdominal cavity at ct. radiographics. 2011;31:409–428. http://dx.doi.org/10.1148/rg.312105123 gayer g, petrovitch i. ct diagnosis of a large peritoneal loose body: a case report and review of the literature. br j radiol. 2011;84:e83–e85. http://dx.doi.org/10.1259/bjr/98708052 takayama s, skamoto m, takeyama h. clinical challenges and images in gi. image 1: huge peritoneal loose body in the pelvic cavity. gastroenterology. 2009;136:404. http://dx.doi.org/10.1053/j.gastro.2008.04.014 takada a, moriya y, muramatsu y, et al. a case of giant peritoneal loose bodies mimicking calcified leiomyoma originating from the rectum. jpn j clin oncol. 1998;28:441–442. http://dx.doi.org/10.1093/jjco/28.7.441 takabe k, greenberg ji, blair sl. giant peritoneal loose bodies. j gastrointest surg. 2006;10:465–468. http://dx.doi.org/10.1016/j.gassur.2005.05.003 nomura h, hata f, yasoshima t, et al. giant peritoneal loose body in the pelvic cavity: report of a case. surg today. 2003;33:791–793. http://dx.doi.org/10.1007/s00595-003-2573-8 southwood wf. loose body in the peritoneal cavity. lancet. 1956;271:1079. http://dx.doi.org/10.1016/s0140-6736(56)90211-2 case report 95 sa journal of radiology • december 2008 abstract we report the case of a 31-year-old man with chronic pancreatitis and haematemesis secondary to a gastroduodenal artery pseudoaneurysm. no evidence-based guidelines exist regarding the optimal treatment modality for this condition. in referring to this case, we emphasise the value of coeliac arteriography for confirmation and transcatheter embolisation. introduction gastroduodenal artery pseudoaneurysms are rare. they mainly develop secondary to pancreatitis. they are reported to occur in 10% of chronic pancreatitis cases, with a high mortality rate after rupture. the optimal treatment of arterial pseudoaneurysms following pancreatitis is controversial, with operative and interventional methods as options. case report a 31-year-old man with a history of alcohol abuse was admitted to our hospital with recurrent episodes of epigastric pain, haematemesis and melena. he reported a weight loss of 13 kg during the preceding month. on admission, mild anaemia (haemoglobin 9.3 g/dl), slight hyperglycaemia and mild cholestasis were found. during hospitalisation, the patient was haemodynamically stable but experienced a further drop in haemoglobin level to 7.6 g/dl. to clarify the cause of his upper gastrointestinal bleeding, an oesophagogastroduodenoscopy was performed, which showed normal endoscopic findings. a plain and contrast-enhanced abdominal computed tomography (ct) scan revealed multiple pancreatic body calcifications and a dilated biliary tree. in the region of the pancreatic head, a 6 cm pseudoaneurysm with contained contrast enhancement was identified (fig. 1). management of haemorrhage secondary to a pseudoaneurysm of the gastroduodenal artery affes nejmeddine, mb chb guirat ahmed, mb chb ben salah khalil, mb chb beyrouti issam, mb chb, fcp department of surgery, habib bourguiba hospital, sfax, tunisia ketata henda, mb chb department of radiology, habib bourguiba hospital, sfax, tunisia fig. 1. axial scan ct of upper abdomen demonstrating expansive mass in the pancreatic head (arrows) and extensive calcifications in pancreatic body and tail. → fig. 2. common hepatic artery angiography showing gastroduodenal artery pseudoaneurysm (arrow). → fig. 3. ct scan performed 2 weeks after embolisation, revealing complete exclusion of the pseudoaneurysm (arrow). → management of.indd 95 12/5/08 11:24:12 am case report case report 96 sa journal of radiology • december 2007 these ct findings supported the possibility of secondary haemorrhage into a pancreatic head pseudocyst. diagnostic angiography with selective common hepatic artery and superselective gastroduodenal artery angiograms showed extravasation of contrast medium into a 4 5 cm pseudoaneurysm arising from the proximal third of the gastroduodenal artery, approximately 4 cm from the origin. a catheter was placed deep into the gastroduodenal artery inferior to the point of extravasation, and embolisation with microspheres followed by gianturco coils was performed. a post-embolisation angiogram confirmed successful complete occlusion of the gastroduodenal artery and absence of blood flow in the pseudoaneurysm (fig. 2). the immediate post-embolisation period passed without any complications. the pain subsided and the patient was discharged the following day. a ct scan performed 2 weeks post-embolisation revealed complete occlusion of the pseudoaneurysm with a significant decrease of biliary tree dilatation (fig. 3). over the following 6 months, the patient was re-admitted twice with recurrence of pain secondary to chronic pancreatitis, but no further haemorrhage. discussion peri-pancreatic pseudoaneurysms in patients with chronic pancreatitis are an uncommon but serious complication. mortality rates can reach 40%, depending on the clinical status, site and characteristics of the bleeding lesion, and the surgical management.1 arterial lesions related to pancreatitis are predominantly localised in the splenic artery, the pancreaticoduodenal arteries and the gastroduodenal artery. although gastroduodenal artery pseudoaneurysms develop mainly secondarily to pancreatitis, other rare causes such as atherosclerosis, trauma, iatrogenic lesions, tuberculous inflammation and connective tissue diseases have been reported. the pathogenesis of pseudoaneurysms in pancreatitis results from the proteolytic action of the pancreatic enzymes in the pseudocyst (mainly the elastase) in direct contact with the visceral artery, thereby converting the pseudocyst into a large pseudoaneurysm. the symptoms of such post-pancreatitis pseudoaneurysms may be masked by the clinical features of chronic pancreatitis, until they rupture into the gastrointestinal tract, biliary tree, peritoneal cavity or retroperitoneum, manifesting with the dramatic clinical symptoms of haemorrhagic shock and consequently high mortality rates.2 in chronic pancreatitis, several factors may increase the risk of acute bleeding, such as duration of disease, proximity of the vessel to a pseudocyst, communication with the biliary or pancreatic ducts, and splenic vein occlusion due to thrombosis. in the diagnostic workup, non-invasive diagnostic procedures are the priority: ultrasonography with colour doppler, endoscopic ultrasonography and contrast-enhanced ct, including ct angiography. the pseudoaneurysm size, presence of thrombus, and pseudoaneurysm topography can often be well defined. catheter angiography remains important in the visualisation and measuring of the exact gastroduodenal artery pathology and artery width, and presence of arteriovenous fistula. it is an invasive procedure, but can also allow treatment of the pseudoaneurysm at the same time.2 in cases of haemodynamic instability, patients have in the past undergone urgent surgery. the optimal treatment of pseudoaneurysms in chronic pancreatitis with haemodynamic stability remains controversial, and there are as yet no evidence-based guidelines, owing to limited data. in our opinion, the risks and difficulties of major surgical intervention made embolisation preferable. recent studies have confirmed the effectiveness of arteriographic embolisation or ultrasound-guided thrombin injection3 for temporary and definitive control of bleeding from pseudoaneurysms associated with chronic pancreatitis.3 however, some authors consider surgery as the treatment of choice for bleeding pseudoaneurysms in patients with chronic pancreatitis, arguing that embolisation does not cure the diseased pancreas and that subsequent surgery is always indicated, anyway. also, jun-te hsu4 found in his study that embolisation had a high overall treatment failure rate of 20% and a mortality rate of 20%. as chronic pancreatitis is an ongoing inflammatory process, it is accepted that embolisation may be only a temporary measure, followed by operative intervention as required. embolisation failure is an indication for operative treatment, although there is debate about the best surgical procedure. some authors suggest that proximal and transcystic ligation of bleeding vessels with internal or external cyst drainage is superior to pancreatic resection in the acute situation, although resection is acknowledged to prevent bleeding recurrence in chronic pancreatitis and should be employed when possible. 1. balachandra s, siriwardena ak. systemic appraisal of the management of the major vascular complications of pancreatitis. am j surg 2005; 190: 489-495. 2. parildar m, oran i, memis a. embolization of visceral pseudoaneurysms with platinum coils and n-butyl cyanoacrylate. abdom imaging 2003; 28: 36-40. 3. bergert h, hinterseher i, kersting s, leonhardt j, bloomenthal a, saeger hd. management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. surgery 2005; 137: 323-328. 4. jun-te hsu, chun-nan yeh, chien-fu hung, et al. management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis. bmc gastroenterol 2006; 6: 3. 96 sa journal of radiology • december 2008 management of.indd 96 12/5/08 11:24:12 am contents tib abstract breast mr imaging is the most accurate imaging investigation to detect breast prosthesis rupture. rupture is common in older prostheses (> 10 years post implantation) and is often asymptomatic. the radiological signs of rupture are due to collapse of the elastomer shell which is eneveloped by silicone gel and when the silicone gel separates the elastomer shell from the surrounding fibrous breast capsule. introduction breast implantation using prostheses is becoming a common plastic surgical procedure in this country. in the usa between 1 and 2 million women have had breast implantation procedures.1 the main reasons for implantation are breast reconstruction following breast cancer surgery or augmentation for cosmetic reasons. however complications following implantation of prostheses are common, occurring in 24% of patients in a series of 749 patients treated at the mayo clinic.1 complications are difficult to detect by palpation, or even with ultrasound or mammographic examinations.2-4 they include rupture or leaking of silicone gel from the prosthesis and the development of silicone granulomas. ruptured prostheses occur in 23 65% of patients and are usually silent.5 breast mr is both sensitive and specific in detecting complications following prosthesis insertion. in this review we illustrate the utility of breast mr imaging in detecting these complications. breast prostheses prostheses consist of a silicone-elastomer bag filled with saline, or previously with silicone gel. currently in the usa only saline is used to fill the prostheses because of the complications associated with silicone gel rupture.1 the new generation of prostheses are manufactured with stronger and thinner capsules, so preventing rupture. complications associated with breast implantation complications can be classified into those associated with the surgical procedure and those associated with the prosthesis itself. wound complications include the development of a haematoma, seroma, wound infection, and wound dehiscence.6 implant complications include rupture or leakage and capsular contraction by the surrounding scar fibrosis resulting in loss of the normal breast shape and consistency.6 implant rupture or valve/port failure appears to be a function of the age of the prosthesis.1 in a large community-based prospective study of 344 patients in the usa, 55% of patients had mr evidence of rupture with silicone gel, evident outside the elastomer shell in 21% of patients.7 rupture is very common 10 years after implantation.7 the prosthesis must be removed once the diagnosis of rupture is made. capsular contraction results from a scar forming around the shell and requires re-operation in 5 20% of all patients implanted. capsular contraction is the commonest cause of patient dissatisfaction and the commonest cause of replacement of the prosthesis. older prostheses contained silicone gel. rupture of these prostheses, although asymptomatic in most patients, has been associated with collagen vascular disorders and chronic fatigue syndrome. however more current data disputes any of these associations. currently there is debate on whether all the migrated silicone gel requires removal or not. detection of rupture is inaccurate with mammography and ultrasound examination. the prosthesis contents usually obscure the surrounding breast parenchyma making detection of a leak extremely difficult. mr imaging of the breast using a phased array local breast coil has been demonstrated to be the most sensitive and specific investigation to detect rupture. in large series7,8 sensitivity for ruptured prostheses was from 74% to 94%, with a specificity of 85 98%. breast mr imaging signs of rupture breast mr technique consists of both t1 and t2-weighted spin echo transverse and sagittal images, a t1-weighted transverse image with fat saturation, a t2weighted stir sequence, and a turbo inversion recovery t1 transverse (tirm) sequence with fluid suppression to detect silicone migration. the tirm sequence suppresses fluid so making displaced silicone gel more visible. a phased array local breast coil is essential. there are essentially two signs of rupture detectable with breast mr. the first sign is when the elastomer shell collapses and is enveloped by the silicone gel and this is detected as collapsed low-intensity lines internal to the high-intensity gel (figs 1 and 2). the second sign is when silicone gel separates the elastometer shell from the fibrous capsule of breast tissue or the gel is found outside the shell within the breast tissue (fig. 3). various radiological descriptions are associated with these two signs, 7 sa journal of radiology • october 2005 review article magnetic resonance imaging of breast prostheses p corr ffrad (d) sa p seolall nat dip rad (d) h booth nat dip rad (d) department of radiology nelson mandela school of medicine and inkosi albert luthuli hospital durban pg7-8 9/28/05 1:22 pm page 7 such as the linguine sign, double wavy sign, key hole sign, noose sign, and inverted tear drop sign.7 conclusions breast mr imaging is a reliable and accurate investigation to detect the complication of breast prosthesis implantation. rupture of implants is common and often asymptomatic and appears to be dependent on the age of the prosthesis. references 1. gabriel se, woods je, o'fallon wm, beard cm, kurland lt, melton lj. complications leading to surgery after breast implantation n engl j med 1997; 336: 677-682. 2. ahn cy, debruhl nd, gorczyca dp, shaw ww, bassett lw. comparative silicone breast implant evaluation using mammography, sonography, and magnetic resonance imaging: experience with 59 implants. plast reconstr surg 1994; 94: 620 -627. 3. reynolds he, buckwalter ka, jackson vp, siwy bk, alexander sg. comparison of mammography, sonography and mr imaging in the detection of silicon implant rupture. ann plast surg 1994; 33: 247-257. 4. everson li, parantainen h, detlie t, et al. diagnosis of breast implant rupture: imaging findings and relative efficacies of imaging techniques. am j roentgenol 1994; 163: 57 -60. 5. brown sl, silverman bg, berg wa. rupture of silicone gel breast implants: causes, sequelae, and diagnosis. lancet 1997; 350: 1531 -1537. 6. mathes sj. breast implantation the quest for quality and safety. n engl j med 1997; 336: 718719. 7. brown sl, middleton ms, berg wa, soo ms, pennello g. prevalence of rupture of silicone gel breast implants revealed on mr imaging in a population of women in birmingham, alabama am j roentgenol 2000; 175: 1057-1064. 8. soo ms, kornguth pj, walsh r, et al. intracapsular implant rupture: mr findings of incomplete shell collapse. j magn reson imaging 1997; 4: 724 -730. 8 sa journal of radiology • october 2005 fig.1 t1-weighted transverse scan of a patient with implanted prostheses demonstrating early rupture of the right prosthesis with a rupture of the posterior wall of the right prosthesis ('wavy' line or 'linguine' sign) (arrow), with fluid escaping posteriorly between the elastomer shell and the breast capsule (arrowhead). fig. 2.t2 sagittal scan demonstrates rupture of the elastomer shell superiorly (arrow) with escape of prosthesis contents between the elastomer shell and capsule (arrowhead). fig.3. t2 inversion recovery magnitude or tirm scan of a patient with a ruptured left breast prosthesis in the transverse plane. note the prosthesis fluid collecting anterior to the breast capsule (arrows) with a rupture anteriorly of the elastomer shell. review article pg7-8 tib 10/8/05 10:46 am page 8 92 sa journal of radiology • december 2010 review article cardiovascular magnetic resonance imaging – a pictorial review introduction cardiovascular magnetic resonance imaging (cmr) is a powerful problem-solving tool and arguably offers the most comprehensive assessment of cardiac morphology and function, as well as the opportunity of rebuilding the bridge between cardiologists and radiologists. the role of cmr-trained imaging physicists is also valuable, and many cmr centres harmoniously incorporate these three sub-specialty fields. this paper comprises an overview of several cmr techniques, outlining both the strengths and limitations of the modality. cardiovascular magnetic resonance imaging the combinations of cardiac and respiratory motion make the heart a challenging organ to image. electrocardiogram (ecg) gating is done almost without exception, and patients are often asked to hold their breath for each scanning sequence to minimise respiratory motion artefacts. in prospective gating, the acquisition is triggered by the qrs complex, and usually only 90% of the cardiac cycle is acquired. in retrospective gating, data are acquired continuously while the ecg trace is recorded, and processing is done retrospectively to provide images throughout the cardiac cycle. mri is a relatively slow modality, and samples need to be taken from a number of heartbeats. image acquisition is made more time-efficient by capturing interleaved samples or slices during each heartbeat. the resulting samples from different phases of the cardiac cycle can be represented as a multi-slice collection of images, or interleaved into a cinematographical series of images. where patients are unable to hold their breath, respiratory gating can also be incorporated, either using a belt around the abdomen or vijay dahya, mb bch, fcrad (sa) tuft and partners inc., and department of radiology, university of cape town bruce s spottiswoode, phd (med) mrc/uct medical imaging research unit, department of human biology, university of cape town; and department of radiological sciences and oncology, stellenbosch university fig. 1a. four-chamber t2-weighted image showing evidence of active inflammation (arrow) in a patient with myocarditis. (1b.) four-chamber bright-blood image showing a mediastinal neoplasm, post-operatively confirmed to be a benign thymoma (block arrow) impressing the right atrium (arrow) but not invading the heart. (1c.) short axis post-contrast t1 image showing diffuse rv infiltration, confirmed on catheter directed myocardial biopsy to represent primary cardiac lymphoma, bulging into and severely narrowing the rv outflow tract (arrow). a b c fig. 2a. bright-blood image showing thrombus (arrow) in a typical site with the left atrium. (2b.) dark-blood image in the same patient as in (a) confirming thrombus (arrow) within the left atrium. cmr was used in this case following equivocal echocardiography for confirmation of thrombus and to differentiate this from an atrial myxoma. (2c.) extensive mural thrombus (arrows) is shown in a patient with previous infero-septal myocardial infarction with aneurysm formation. a b c sa journal of radiology • december 2010 93 review article monitoring the liver-lung interface using navigator echoes, which are incorporated in some mri pulse sequences. a number of fast imaging techniques have been developed, including steady state free precession (ssfp) and echo planar imaging (epi). details of these sequences can be found in many mri texts.1 a specialised phased-array radiofrequency chest coil is used for cardiac imaging to maximise the mri signal. if multiple phased-array coils are used, parallel imaging2,3 can be applied to significantly reduce the scan time, with only a marginal trade-off in signal. techniques and clinical applications morphology various image sequences can be used, either rendering ‘dark blood imaging’ where the blood pool is darker than the myocardium, or ‘bright blood imaging’ where the myocardium is darker than the blood pool. cardiac imaging planes (short axis, long axis and four-chamber orientations) are traditionally used. standard imaging planes (axial, coronal and sagittal) are usually also employed to ensure that the extracardiac structures are assessed. cmr is used with excellent effect in patients with suspected cardiomyopathies, myocardial inflammation, tumours and infiltration (fig. 1). both the right ventricle (rv) and left ventricle (lv) can be viewed in their entirety. intracardiac thrombus can also definitively be identified and differentiated from neoplasms (e.g. atrial myxoma) with cmr as a problem-solving tool following equivocal echocardiography (fig. 2). myocardial iron deposits associated with transfusion-dependent anaemias can be quantified using t2* mapping. this allows pre-clinical monitoring of iron deposition with immense therapeutic implication (iron deposition can be reversed), as the first clinical manifestation is often intractable heart failure.4 cmr also offers the most complete evaluation of the pericardium. this allows the distinction between constrictive pericarditis and restrictive cardiomyopathy, which can both be clinically and haemodymically indistinguishable (fig. 3). general chamber orientation and morphology can be evaluated as well as abnormal communications (atrial septal defect, ventricular septal defect and patent ductus arteriosus), often applied to congenital cardiac disease. function both the right and left ventricular parameters can be evaluated with excellent reproducibility. a series of semi-automatically defined contours are used to obtain estimates of ventricular volume and myocardial mass. evaluation of rv function is important in patients with suspected arrhythmogenic right ventricular cardiomyopathy (arvc) and in therapeutic follow-up of patients after repair of certain congenital heart diseases, and cannot be reliably measured on any other non-invasive modality. stress tests can be performed where controlled doses of dobutamine can be administered to investigate wall motion abnormalities under fig. 3. constrictive pericarditis. (3a.) dark blood t1-weighted image clearly depicting the thickened pericardium (arrows) which is nodular in parts (long arrow). (3b.) bright blood four-chamber image in the same patient showing bi-atrial enlargement (stars), a feature common to constrictive pericarditis and restrictive cardiomyopathy. a b fig. 4. gradient echo bright blood image in the plane of the left ventricular outflow showing prominent low signal (spin dephasing) owing to turbulent flow from aortic regurgitation (arrow), leading to early closure of the mitral valve anterior leaflet. 94 sa journal of radiology • december 2010 review article stress conditions. this is, however, less accurate than perfusion stress cmr (see perfusion below). gradient echo cine images are also useful for valvular imaging and have a niche application since slow moving or turbulent blood results in low signal intensity (fig. 4). these can be quantified with phase contrast (pc) velocity encoding, which provides an instantaneous measure of fluid velocity, and can be used to provide velocity-time and flow-time curves through the valves and the great vessels, thus allowing calculation of pressure gradients. flow can also be measured in structures not easily or accurately assessed by echocardiography e.g. post-valvar pulmonary stenosis and aortic coarctation (fig. 5). this technique can also be applied to the myocardium, yielding regional measures of velocity and strain rate.5,6 three-dimensional (3d) phase contrast velocity encoding is also being used as an emerging technique for creating high-resolution angiograms without the need for contrast agents.7,8 mr angiography 3-d contrast angiography can be performed in conjunction with cmr to fully evaluate the great vessels, and is particularly useful in patients fig. 5. a patent post aortic coarctation repair for evaluation of a residual stenosis at the repair site. (5a.) regions of interest depicting the ascending and descending aorta on the axially orientated magnitude image with resultant in-laid velocity-time curves measured in the ascending and descending aorta respectively. (5b.) region of interest through the repaired segment on the sagitally orientated magnitude image with in-laid resultant velocity-time curve through the repaired segment confirming no significant step-up in velocity and therefore no pressure gradient, consistent with successful repair. a b fig. 7. delayed enhancement images showing examples of infarction. (7a.) subendocardial anteroseptal and apical lv infarction (arrows) on four-chamber orientation. (7b.) acute transmural septal infarct (arrows) in short-axis orientation. the low signal intensity, subendocardial region within the infarct (block arrow) indicates ‘no reflow’ infarction (microvascular obstruction) associated with a poorer prognosis and increased chance of myocardial rupture in the acute setting and aneurysm formation in the chronic setting. note the simple pericardial effusion (star). (7c.) septal transmural infarct with aneurysm formation (arrow) on four-chamber orientation. a b c fig. 6. contrast-enhanced mr angiogram of a patient with scimitar syndrome. note the anomalous drainage of the right inferior pulmonary vein into the supra-hepatic ivc via the scimitar vein (block arrow). sa journal of radiology • december 2010 95 review article with congenital heart disease where intracardiac and extra-cardiac abnormalities often co-exist (e.g. tetralogy of fallot with associated post-valvar pulmonary stenosis and aortic coarctation with associated vsd). fig. 6 shows a post-contrast mr angiogram maximum intensity projection (mip) image of a patient with scimitar syndrome. viability and delayed enhancement imaging mri viability imaging is unparalleled by any other techniques. gadolinium contrast agents settle in oedematous areas and take longer to be washed out of scar tissue. delayed-enhancement mri involves imaging the heart 10 minutes after administering the intravenous contrast using inversion recovery sequences that null normal myocardial tissue. scar tissue appears unmistakeably bright in these images. this technique can map the severity and extent of myocardial infarction, with obvious prognostic implications (fig. 7). this technique is also increasingly being used to differentiate ischaemic from non-ischaemic cardiomyopathy. typical patterns of delayed enhancement have been described for various non-ischaemic cardiomyopathies,9 allowing non-invasive diagnosis and prognostication (fig. 8). perfusion myocardial perfusion can be quantified by rapidly measuring the uptake of gadolinium. a cine image series with manually introduced contours is fig. 9. myocardial motion trajectories for a mid-ventricular short-axis view of a healthy volunteer. the septum is centred at 9 o’clock in the image. a b fig. 8. delayed enhancement cmr in non-ischaemic cardiomyopathies. (8a.) four-chamber orientation showing multifocal enhancement (arrows) in a patient with cardiac sarcoidosis. (8b.) short-axis orientation in cardiac sarcoidosis. the distribution of enhancement (subepicardial (block arrow) and at the lv-rv junction (arrow)) is typical. (8c.) short axis image in cardiac amyloidosis. note the inhomogeneous lv nulling indicating diffuse infiltration with typical distribution (subendocardial not limited to vascular territories) enhancement (arrows). c fig. 10a. mid-ventricular short-axis map of end-systolic tangential strain of a patient with a right bundle branch block (rbbb) and an anteroseptal infarct (arrows), and (10b) corresponding strain versus time curves. a b 96 sa journal of radiology • december 2010 review article post-processed to yield regional measures of tissue perfusion. in contrast with the longer-term gadolinium uptake, ischaemic myocardium appears darker than normal myocardium in the first images owing to reduced perfusion. this can be incorporated into a stress test but requires the use of adenosine, which is unfortunately not currently licensed for this application in south africa. coronary angiography although mr coronary angiography has been steadily improving, this arguably remains the one shortcoming of cmr. resolution lags behind multidetector ct, and techniques such as volume imaging with respiratory navigator tagging are not as robust. myocardial tagging and dense in mri tagging, the myocardium is modulated by a series of saturated dark bands or tags. these are a material property of the tissue and can be seen to deform as the heart moves. tagged images provide insight into contractility and myocardial mechanics, and can be processed to yield meaningful measures of myocardial strain.10 displacement encoding with stimulated echoes (dense) is a more recent technique that provides more accurate measures of displacement and hence myocardial strain.11,12 both myocardial tagging and dense allow a user to track discrete portions of tissue as they traverse the cardiac cycle. fig. 9 shows an example of this technique, where a number of points in the left ventricle are tracked through the cardiac cycle. myocardial dyssynchrony can be mapped by using tagging or dense regional strain-time curves. dyssynchronous but healthy segments of myocardium can be identified using a variety of metrics such as the time to onset of strain or the time to peak strain. this technique can be used in combination with delayed-contrast mri to improve the planning of cardiac resynchronisation therapy. fig. 10 presents a patient with a right bundle branch block and an anteroseptal myocardial infarct. fig. 10a is an end-systolic displacement and strain map obtained using cine dense imaging. the black lines represent motion relative to end-diastole, and the underlying colour represents tissue deformation corresponding to circumferential shortening. the infarct is clearly apparent as a region of zero or slightly positive strain. the positive strain occurs when infarcted tissue is stretched by the adjacent healthy tissue. further information can be obtained by looking at regional strain as a function of time. the plots in fig. 10b show strain for the anterior septum and regions in the right and left ventricular free walls. a delay in onset to contraction is clearly apparent in the rv segment, but the peak strain is normal; this implies that pacing the rv free wall would benefit this patient but pacing the anterior septum would yield no benefit. conclusion just as mri has made and continues to make a major impact on neuroscience, sports medicine, orthopaedics and various other fields, it is currently also making a major impact in cardiology. cmr is established as the gold standard imaging technique for assessing myocardial and pericardial pathology. it is the most accurate and reproducible non-invasive investigation for ventricular function and viability assessment. cmr is also a valuable problem-solving adjunct to echocardiography in congenital and valvular heart disease. inability to depict detailed coronary artery anatomy is the major shortcoming of cmr, but physicists continue to develop new and faster methods of imaging to overcome this factor and further improve established applications. 1. haacke wm, brown rw, thompson mr, venkatesan r. magnetic resonance imaging: physical principles and sequence design. new york: john wiley and sons, 1999. 2. blaimer m, breuer f, mueller m, heidemann rm, griswold ma, jakob pm. smash, sense, pils, grappa: how to choose the optimal method. top magn reson imaging 2004;15:223-236. 3. heidemann rm, ozsarlak o, parizel pm, et al. a brief review of parallel magnetic resonance imaging. eur radiol 2003;13:2323-2337. 4. deborah cs, geukes-foppan m, barry k, et al. practical implications of liver and heart iron load assessment by t2*-mri in children and adults with transfusion dependent anaemias. am j hematol 2008; 83(10):781-783. 5. petersen se, jung ba, wiesmann f, et al. myocardial tissue phase mapping with cine phase-contrast mr imaging: regional wall motion analysis in healthy volunteers. radiology 2006;238(3):816-826. 6. jung b, föll d, böttler p, petersen s, hennig j, markl m. detailed analysis of myocardial motion in volunteers and patients using high-temporal-resolution mr tissue phase mapping. j magn reson imaging 2006;24:1033-1039. 7. bock j, wieben o, johnson km, hennig j, markl m. optimal processing to derive static pc-mra from time-resolved 3d pc-mri data. proc intl soc mag reson med 2008;16:3053. 8. anderson ag, johnson km, bock j, markl m, wieben o. comparison of image reconstruction algorithms for the depiction of vessel anatomy in pc vipr datasets. proc intl soc mag reson med 2008;16:934. 9. cummings kw, bhalla s, javidan-nejad c, bierhals aj. a pattern-based approach to non-ischaemic cardiomyopathy at mr imaging. radiographics 2009;1:89-103. 10. axel l, montillo a, kim d. tagged magnetic resonance imaging of the heart: a survey. med image anal 2005;9:376-393. 11. aletras ah, ding s, balaban rs, wen h. dense: displacement encoding with stimulated echoes in cardiac functional mri. j magn reson 1999;137:247-252. 12. kim d, gilson wd, kramer cm, epstein fh. myocardial tissue tracking with two-dimensional cine displacement-encoded mr imaging: development and initial evaluation. radiology 2004;230:862-871. case report case reportcase report introduction vein of galen aneurysmal malformation (vgam) accounts for up to 30% of paediatric vascular malformations.1 as the internal cerebral veins develop, the anterior portion of the median prosencephalic vein of markowski (mpm) regresses, and the posterior portion remains to form the vein of galen. it is believed that the vgam is the result of an arteriovenous connection between the primitive choroidal arteries and the mpm.2 the abnormal flow in these connections inhibits the involution of the mpm.3 case report an 11-month-old boy presented with a progressively increasing head circumference. he had normal milestone development up to the date of admission, with no cardiac abnormalities. the patient underwent computed tomography (ct) scan of the head, which showed obstructive hydrocephalus and an aneurysmally dilated vein of galen, a stenotic straight sinus, and a distended torcular herophili. prominence of the sulci and gyri were also evident (fig.1a). these findings were confirmed on magnetic resonance imaging (mri), angiography (mra) and magnetic resonance venography (mrv) (figs 1b, 3a, 3b.) digital substraction angiography (dsa) confirmed a mural type of vgam supplied by the left posterior medial choroidal artery. dsa also demonstrated the classical ‘jet phenomenon’ as contrast flowed into the vgam through the left medial posterior choroidal artery (fig. 2). endovascular treatment of vein of galen aneurysmal malformation j du toit, mb chb j a bam, mb chb v mngomezulu, mb bch, fcrad (d) (sa), mba department of radiology, dr george mukhari hospital, university of limpopo (medunsa campus), ga-rankuwa fig. 1b. three-dimensional mrv confirming the findings of the postcontrast ct. fig. 2. lateral vertebral dsa demonstrates the ‘jet phenomenon’ (black arrow). the vgam is supplied by the left posterior medial choroidal artery (white arrow). ↓↓ 12 sa journal of radiology • march 2009 fig. 1a. mid-saggital reconstruction of post-contrast ct demonstrating the dilated median prosencephalic vein of markowski (white arrow) characteristic of vgam. there is a stenotic straight sinus (open arrow) and a prominent torcular herophilli (curved arrow). note also the congested scalp veins (black arrow). ↓ ↓ endovascular.indd 12 3/12/09 2:06:58 pm case reportcase report method the foregoing procedures were followed by transarterial embolisation. a micro-catheter was advanced into the posterior medial choroidal artery approximately 1.5 cm from the fistula leading to the vgam. a solution of 96% histo-acryl glue in lipiodol with tantalum powder was injected through the micro-catheter. there was very good obliteration of the fistula, with the subsequent control runs showing only small vessels still supplying the aneurysm from the more proximal part of the posterior medial choriodal artery. these smaller vessels were then embolised using a 20% solution of hysto-acryl glue in lipiodol. no further significant filling of the aneurysm was seen. a follow-up mri was obtained (fig.4.) discussion vgam is divided into choroidal and mural types, based on the arterial supply.1,3,4 the choroidal type is supplied by all the choroidal arteries with an interposed network opening into a midline venous pouch.5 the arterial feeders are usually bilateral in the choroidal type, and this type is associated with cardiac failure in the neonate.1,4-6 in the mural type, direct av fistulae open on the wall of the mpm, as seen in our case.3-5 vgams drain via the straight sinus to the torcula but, in the absence of the sinus, drainage is via a persistent falcine sinus to the post third of the superior sagittal sinus.3,5 although this pathway has been challenged by several authors,3 the deep venous system is said not to communicate with the vgam.2,5 associated venous anomalies include anomalous dural sinuses and sinus stenoses. it is postulated that stenosis is the response of the venous endothelium to the rapid and turbulent flow caused by the arteriovenous shunt.3 stenosis of the outflow may beneficially reduce cardiac venous return, preventing congestive cardiac failure. it may, however, also contribute to enlargement of the vein of galen, with consequent aqueductal compression.6 vgam must be distinguished from vein of galen aneurysmal dilatation (vgad). a dural fistula or avm draining into a true vein of galen is characteristic of vgad.2 these lesions may present with haemorrhage.4 presentation of vgam depends on the age of the patient. neonates, unlike older infants and children, often present with high-output cardiac failure.1,3-5 high-output cardiac failure is the result of a steep increase in the cardiac preload owing to the steal phenomenon.7 when presenting in older infants, it is usually milder and more responsive to treatment. hydrocephalus, megalencephaly, developmental delay and seizures are common presentations in older infants and children. 1,2,5 hydrocephalus can result from direct aqueductal compression, increased production of csf owing to increased choroidal blood flow or reduced absorption of csf because of venous hypertension.6 cerebral hypoperfusion secondary to the steal phenomenon may result in brain infarcts and 13 sa journal of radiology • march 2009 fig. 3a. on the mid-saggital t1-weighted mri (pre-contrast) before embolisation, the vgam is seen as a flow void (white arrow). note also the flow artifacts (black arrow) at the level of the vgam. ↓↓ fig. 3b. mid-saggital post-embolisation t1-weighted mri demonstrating thrombosis of the vgam as evidenced by a peripheral high-intensity (white arrow) and central iso-intensity (black arrow) within the vgam. ↓↓ fig. 4. the vgam thrombus (white arrow) is seen on coronal postembolisation t2-weighted mri as a central high-signal intensity (due to methaemoglobin) and a low-signal intensity rim (black arrow) of haemosiderin. ↓↓ endovascular.indd 13 3/12/09 2:07:00 pm case report leucomalacia.7,8 congenital cardiac abnormalities may also be present.2 spontaneous thrombosis of vgam is a rare phenomenon.5 when children are referred late, they commonly present with seizures and mental retardation. imaging may reveal calcification and subependymal, cortical or subcortical atrophy.5 after 30 weeks’ gestation, vgam can be detected sonographically as a midline supratentorial cystic mass posterior to the third ventricle demonstrating high-velocity turbulent flow on colour doppler.8 progressive cardiac dysfunction indicates a high flow lesion that may be unresponsive to treatment.3 fetal mri can be performed to confirm the antenatal diagnosis. mri and mra can aid in diagnosis, as well as in identifying the major arterial supply and venous anatomy. mri plays an important role in evaluating the brain parenchyma and ventricles, especially after intervention.4 computed tomography (ct) is generally used for screening and evaluating the vgam. ct angiography can aid in planning embolisation. before endovascular treatment, the infant must be evaluated for the development of macrocrania. if there is evidence of preclinical mri intraventricular hyper-pressure or the head circumference is increasing too rapidly, or there is significant developmental delay, urgent embolisation should be carried out.5 shunting of hydrocephalus before endovascular treatment is generally accepted as the worst option.3,4 shunting is associated with haemorrhage from the dilated superficial veins in vgam. progressive hydrocephalus in the post-embolisation period may nonetheless necessitate shunting.3 it is generally accepted that a multidisciplinary team approach should be used to manage this condition.4 aggressive medical treatment is needed in the neonate presenting with congestive cardiac failure (ccf). if the ccf continues to worsen, evaluation of the brain, heart, kidney and liver is crucial to determine if endovascular treatment can be offered.9 transarterial embolisation with a liquid acrylic polmer, n-butylcyanoacrylate (or ‘glue’) is the treatment of choice.5 a staged approach is advisable. in experienced hands, embolisation can be carried out rapidly and the degree of devascularisation can be controlled.2,3 transvenous treatment by packing the venous pouch with coils, balloons and nylon has also been described.5 access for venous occlusion is usually obtained via the femoral or jugular veins, although a transtorcular approach can also be used. transvenous embolisation is technically less demanding but is reserved for situations where the transarterial method is not feasible.2 the venous method has an increased risk of venous infarction and haemorrhage.5 the transarterial approach gives a more lasting reversal of ccf compared with the venous approach.9 conclusion vgam is associated with a high morbidity and mortality but, with prompt recognition and appropriate treatment, a good clinical outcome can be achieved. acknowledgement we thank professor p a fourie and dr p a scheepers for the transarterial embolisation. 1. meyers pm, halbach vv, phatouros cp, et al. hemorrhagic complications in vein of galen malformation. ann neurol 2000; 47(6): 748-755. 2. gailloud p, o’raidan dp, burger i, lehmann cu. confirmation of communication between deep venous drainage and the vein of galen after treatment of a vein of galen aneurysmal malformation in an infant presenting with severe pulmonary hypertension. am j neuroradiol 2006; 27: 317-320. 3. jones bv, ball ws, tomsick ta, millard j, crone kr. vein of galen aneurysmal malformation: diagnosis and treatment of 13 children with extended clinical follow-up. am j neuroradiol 2002; 23: 1717-1724. 4. mitchell pj, rosenfeld jv, dargaville p, et al. endovascular management of vein of galen aneurysmal malformations presenting in neonatal period. am j neuroradiol 2001; 22: 1403-1409. 5. lasjaunias pl, chng sm, sachet m, alvarez h, rodesch g, garcia-monaco r. the management of vein of galen aneurysmal malformations. neurosurgery 2006; 59(5): 184-194. 6. tomsick ta, ernst rj, tew jm, brott tg, breneman jc. adult choroidal vein of galen malformation. am j neuroradiol 1995; 16: 861-865. 7. lee th, shih jc, peng ssf, lee cn, shyu mk, hsieh fj. prenatal depiction of angioarchitecture of an aneurysm of the vein of galen with three-dimensional color power angiography. ultrasound obstet gynecol 2000; 15: 337-340. 8. white bd, kostaki gb, cacciarelli aa, madrazo bl. ultrasound case of the day. radiographics 1992; 12(2): 396-400. 9. terbrugge kg. vein of galen management in neonatal period. am j neuroradiol 2001; 22: 1236. 14 sa journal of radiology • march 2009 endovascular.indd 14 3/12/09 2:07:01 pm article information authors: hendrik r. van den berg1 suzanne o’hagan2 delme hurter3 affiliations: 1registrar in radiology, university of the free state, bloemfontein, south africa 2medical officer in radiology, kimberley provincial hospital, south africa 3department of radiology, kimberley provincial hospital, south africa correspondence to: hendrik van den berg email: rynovandenberg@hotmail.com postal address: po box 11828, universitas 9321, south africa dates: received: 03 aug. 2014 accepted: 06 feb. 2015 published: 29 apr. 2015 how to cite this article: van den berg, h.r., o’hagan, s, hurter, d. s afr j rad. 2015;19(1); art. #707, 8 pages. http://dx.doi.org/10.4102/sajr.v19i1.707 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. percutaneous placement of peritoneal dialysis catheters in resource-limited developing countries as an alternative to conventional placement methods in this original articles... open access • abstract • introduction • research method and design • technique    • preoperative evaluation    • procedure • results    • patient demographics and clinical characteristics    • complications • discussion    • limitations of the study • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: the percutaneous placement of peritoneal dialysis (pd) catheters using conscious sedation with ultrasound and fluoroscopic guidance is underutilised and has several advantages over the open surgical and laparoscopic placement methods, especially in the resource-limited developing world. objectives: to describe our patients’ demographics and clinical characteristics, our method of pd catheter placement within the radiology department at kimberley provincial hospital, compare our early complication types and frequencies, overall peritonitis rate and one-year catheter survival rate with findings in the international literature and, by demonstrating comparable outcomes, propose that percutaneous placement be considered as a feasible alternative to conventional placement techniques. method: we conducted a retrospective study on 25 patients who had their pd catheters inserted between january 2009 and may 2013. medical records were reviewed for demographic and clinical information as well as type and frequency of early (within 30 days) and late (between 30 days and one-year) complications related to the pd catheter. early complication types and frequencies were then compared with similar internationally published data. the overall peritonitis rate, in terms of episodes per patient-year, was calculated and compared with international recommendations, and our one-year catheter survival rate was calculated using the kaplan meier method and compared with similarly calculated international studies. results: the study group comprised 16 male and 9 female patients with a median age of 44 years. hypertension was the primary cause of end-stage renal disease (esrd), and was found in 10 (40%) patients. our early exit site infection rate of 12% was slightly higher than that found in the literature. literature varies on the overall infection rates; however, our overall peritonitis rate of 0.75 episodes per patient-year was higher than that recommended by the international society of peritoneal dialysis. this finding might be attributed to the lower socio-economic grouping of our patients and the small number in the study group. all but two peritonitis cases were successfully treated with antibiotics, and we had no major procedure-related complications. our early peritonitis rate of 8%, as well as the other early complication types and rates, and our one-year catheter survival rate of 84%, compared favourably with international studies. conclusion: percutaneous pd catheter placement under conscious sedation with the aid of ultrasound and fluoroscopy is a sound alternative to conventional methods in the resource-limited developing world. introduction top ↑ end-stage renal disease (esrd) is at least 3–4 times more common in africa than in developed countries.1 in africa, esrd affects mainly adults aged 20 – 50 years, and predominantly results from hypertension and/or glomerular disease. in developed countries, esrd occurs more commonly in the older age group, where it mainly stems from hypertension and/or diabetes. the burden of managing this condition places additional financial and economic pressure on an already impoverished continent.1 renal transplantation as a treatment modality requires medical and surgical expertise, financial resources and a donor system. according to the south african renal registry annual report 2012, less than 20% of patients on renal replacement therapy for esrd receive renal transplantation. this figure includes public and private sector patients.2 renal dialysis is therefore the mainstay of esrd treatment, but is underutilised, mainly owing to financial constraints. two well-established methods of dialysis are haemodialysis (hd) and peritoneal dialysis (pd). pd is a most effective renal replacement therapy that offers several advantages over hd. these include: better patient mobility and quality of life more flexible scheduling encourages employment and independence ease of use lower cost if the dialysate fluid is produced locally preferable in certain comorbidities, such as cardiovascular disease, liver disease, diabetes and patients with electrolyte disturbances preservation of residual renal function lower mortality during the first year after initiating therapy.3,4,5 the advantages of pd make it a viable treatment option for esrd in resource-limited developing countries where a chronic dialysis programme can be sustained. the major disadvantages of pd compared with hd include: risk of infection, especially peritonitis the requirement for daily dialysis. in comparison, hd patients are usually dialysed three times per week. pd patients have less contact with medical personnel and other patients than hd patients pd patients need to store all of their dialysate fluid at home.3,4,5 the major disadvantages of hd include: need for vascular access, with infection risk more stringent diet, including strict fluid restrictions post dialysis physical symptoms, such as headache and lethargy.3,4,5 pd catheters (tenckhoff catheters) are usually placed using open surgical, laparoscopic and percutaneous (seldinger) techniques.3,4 various international studies have been conducted comparing the techniques by assessing patient outcomes, costs and related complications of these different placement techniques. disadvantages of the laparoscopic and open surgical techniques, compared with the percutaneous method, are: the need for a willing and experienced surgeon operating room time need for general anaesthesia and associated expertise specialised equipment more invasive procedure longer hospital stay and higher costs waiting times for placement are longer, with the risk of interim patient deterioration.4,5,6,7 advantages of the percutaneous method are: more expedient placement no need for specialised surgical skills no operating room time, as the procedure can be performed in the fluoroscopy suite bypassing the risks associated with general anaesthesia placement in patients unable to tolerate general anaesthesia faster recovery time less costly, with a shorter hospital stay similar or lower complication rates, depending on patient selection ultrasound and fluoroscopy facilities are available in most hospitals.4,8,9,10,11 we place pd catheters via the percutaneous method with the assistance of ultrasound and fluoroscopy under conscious sedation within the radiology department at kimberley provincial hospital. this report describes our method and is a retrospective analysis of patient outcomes. research method and design top ↑ approval was obtained from kimberley hospital’s clinical manager and the research and ethics committee of the university of the free state. we retrospectively analysed the hospital records of 25 patients who had their pd catheters inserted between january 2009 and may 2013. these records are kept at the hospital’s dialysis unit. we collected data using a pro forma, recording early (within the first 30 days) and late (>30 days up to 1 year) complications and their frequencies, patient demographics (age and gender), causes of renal failure, comorbidities and the referring physician’s reasons for choosing this placement method. the type and frequency of predetermined catheter-related complications were documented within the two time intervals mentioned above. we also noted whether the catheter was removed, how long after the insertion date it was removed, and the reason for removal. non-surviving patients were included. patients were excluded if they defaulted their follow-up within the first year after placement or if their hospital records were incomplete or missing. outcome assessment was based on: comparing our early catheter-related complication types and frequencies to those in similar international studies. determining our one-year catheter survival rate (calculated as the percentage of normally functioning catheters after one-year from the insertion date, using the kaplan meier method) and comparing it with similarly calculated international studies. determining our overall peritonitis rate (calculated as number of infections, divided by time at risk and expressed as episodes per patient-year) and comparing it with international recommendations. data were analysed with the aid of the biostatistics department of the university of the free state. technique top ↑ preoperative evaluation we excluded patients with previous abdominal or pelvic surgery, previous peritonitis, previous penetrating abdominal injury and abdominal hernia because of the risk of adhesions increasing the complication rate. patients were discussed with the radiologist prior to performing the procedure. patients required an hb > 8g/dl, with a normal clotting profile (inr <1.4). patients were kept nil per mouth from 22h00 on the night preceding the procedure. the patients’ abdomens were washed with hibiscrub on the preceding day and the morning of the procedure. bowel preparation was administered with two doses of colo-prep the day before the procedure and patients were only allowed fluids orally. they were given paracetamol 1 g orally two hours prior to the procedure for pain relief, and vancomycin 1 g and amikacin 500 mg iv one hour prophylactically prior to the procedure. procedure after confirming suitable blood results, excluding contra-indications including allergies, the procedure was explained and the patient asked to empty their bladder before being taken into the fluoroscopy suite. because the catheter was subcutaneously tunnelled from the infra-umbilical entrance site to the catheter exit site, the exit site was marked prior to starting the procedure. with the patient standing erect, the exit site is just lateral to the midclavicular line and just superior to the patient’s belt line (figure 1). figure 1: marked catheter exit site is on the right, just lateral to the midclavicular line above the patient’s belt line. the patient then lay supine on the fluoroscopy table and a screening abdominal ultrasound was done to confirm an empty bladder and to check for any unsuspected intra-abdominal pathology. patient monitoring was set in place (pulse oximeter, ecg and blood pressure cuff) and intravenous access was obtained. an anaesthetist performed conscious sedation, according to own drug preference. the radiologist and assistant scrubbed up and cleaned the anterior abdominal wall, which was then draped using the standard sterile technique. the catheter insertion site was identified on the midline, just infra-umbilically, and infiltrated with 2% lignocaine without adrenaline (figure 2). figure 2: the entrance site is within the midline, just infra-umbilically. a vertical incision of 2 cm – 3 cm was made at the insertion site with blunt dissection through the subcutaneous tissue up to the rectus sheath. a 20 ml syringe was filled with saline and directly connected to a 16-gauge iv needle/cannula assembly that was slowly advanced inferiorly through the rectus sheath, whilst the rectus sheath was lifted anteriorly using an artery forceps. gentle pressure was simultaneously applied to the plunger until resistance was lost, confirming the intra-peritoneal position. the cannula was then advanced whilst the syringe and needle were removed (figure 3). figure 3: syringe filled with saline attached to iv needle/cannula being advanced through the rectus sheath. the rigid guidewire supplied with the kit (medionics international, ontario, canada) was advanced through the cannula and directed towards the pelvis under fluoroscopic guidance (figure 4 and figure 5). figure 4: guidewire being advanced through the cannula into the pelvis, whilst the rectus sheath is slightly lifted. figure 5: correct position of the guidewire intra-peritoneally within the pelvis. the cannula was removed and the entrance site was sequentially dilated over the guidewire with 10 – 16 f dilators, with the provided peel-away sheath covering the final 18 f dilator. the dilator tip position within the pelvis was confirmed fluoroscopically (figure 6). figure 6: final dilator and peel-away sheath, with guidewire positioned intra-peritoneally within the pelvis. the dilator was removed and the 62 cm coiled, double-cuff pd catheter (medionics international, ontario, canada) introduced over the guidewire and through the peel-away sheath into the peritoneal cavity with its coiled tip within the pelvis. the catheter’s inner cuff was advanced up to the rectus sheath whilst the peel-away sheath was removed. the position within the pelvis was again confirmed fluoroscopically. a 0.5 cm vertical incision was then made at the previously marked exit site and the catheter was tunnelled subcutaneously through the exit site, leaving the outer cuff buried within the subcutaneous tissue (figure 7). it is important not to have any acute turns, twists or tension on the catheter. figure 7: peritoneal dialysis catheter tunnelled subcutaneously from the entrance site to the exit site. functionality was tested by infusing 500 ml of pd fluid through the catheter. it should flow freely, without any pericatheter leaks. the fluid was then drained again and monitored for evidence of acute haemorrhage or bowel content. the bag was disconnected and replaced by the locking adaptor (baxter healthcare corporation, deerfield, usa) (figure 8). figure 8: peritoneal dialysis catheter with locking adaptor. functionality was tested, and there was no evidence of acute complications. the entrance skin incision was approximated using the interrupted horizontal mattress suturing technique with nylon 3/0 and covered with a sterile dressing. the catheter exit site was covered with sterile gauze and an opsite dressing specifically not applied to the catheter (to prevent difficulty in subsequent removal). the exit site was not sutured to avoid seroma and potential infection (figure 9). figure 9: peritoneal dialysis catheter after being covered with dressings. a control pelvic radiograph was taken to document and confirm the correct position of the catheter (figure 10). figure 10: control pelvic radiograph showing the peritoneal dialysis catheter correctly positioned within the pelvis. results top ↑ patient demographics and clinical characteristics table 1 shows the demographic data and clinical characteristics of the group of 25 patients with 16 men (64%) and nine women (36%). ages ranged from 18–60 years, with a median of 44 years. table 1: patient demographics and clinical characteristics. hypertension was the primary cause of esrd in 10 patients (40%), followed by diabetes mellitus in 5 patients (20%). these data appear to be more in line with causes found in the developed world as opposed to literature stating hypertension and glomerular disease as being the main causes of esrd in africa.1 nine patients (36%) had two comorbidities and eight patients (32%) had one comorbidity. hypertension was present in 12 patients (48%); cardiovascular disease was the next most prevalent comorbidity, found in 10 patients (40%). at our institution, all the patients were started on hd, because they needed urgent acute dialysis owing to their poor clinical condition and were selected for pd, based on patient preference, an acceptable social and psychological evaluation, and absence of contra-indications. our method of catheter insertion, as well as the open surgical technique under general anaesthesia in theatre by the general surgeon, were available options. there were two classes of reasons for choosing to insert the catheters percutaneously under conscious sedation within the radiology department, instead of under general anaesthesia in theatre. in 23 cases, this was because of lack of theatre time and/or unavailability of a surgeon, and in two cases because of the high risk of general anaesthesia. our study confirms the utility of the percutaneous placement method as an alternative, especially with limited resources. complications table 2 shows catheter-related complications encountered within the first 30 days. two patients had minor bleeding at the infra-umbilical entrance site immediately after catheter placement. the bleeding was controlled prior to the patient leaving the fluoroscopy room, one by manual compression and the other by cauterisation. table 2: complications within 30 days. of the three patients who developed acute exit site infection, one progressed to intractable peritonitis, and his catheter was removed after 10 days. this was also the only hiv-positive patient. a second patient who developed peritonitis was successfully treated with antibiotics. table 3 shows catheter-related complications encountered between 30 days and one year after catheter placement. one patient’s catheter migrated out of the pelvis and was removed after 47 days owing to irremediable outflow dysfunction. another patient’s catheter kinked and was removed after 33 days. a further patient developed exit site infection and seven patients developed peritonitis. of these seven, the catheter was removed in only one case owing to intractable peritonitis; the remainder were treated successfully with antibiotics with no recurrent related infections during the one-year follow-up. table 3: complications from >30 days – 1 year. in total, nine patients developed peritonitis over the one-year follow-up period, which gave us an overall peritonitis rate of 0.75 episodes per patient-year. the 3 patients who died before the one-year follow-up had normally functioning catheters at the time of death. only four catheters were removed during the one-year follow-up period. using the kaplan meier method, this gave a one-year catheter survival rate of 84%. discussion top ↑ table 4 shows the comparisons in early complication rates between our study and similar internationally published studies. we had two cases (8%) of minor intra-operative bleeding at the infra-umbilical entrance site. maya described his technique using ultrasound guidance to gain access into the peritoneal cavity and colour doppler flow to identify and avoid vasculature. he reported no bleeding complications in his 32-patient study population.12 table 4: comparison of our early complications with similar published studies. our early exit site infection rate of 12% is slightly higher than that found in the literature, which ranges from 0 – 8.2%.9,10,11,12,13,14,15 the increased infection rate might be attributable to the lower socio-economic status of the patient population or the small study group. our early peritonitis rate of 8% is comparable to that cited, which ranges from 0 – 1 5%.9,10,11,12,13,14,15 our patients had no bowel or bladder perforations, pericatheter leaks or early catheter dysfunction, comparing favourably with other studies, where these events ranged from 0 – 4.4%, 0 – 6.6% and 0 – 20% respectively.9,10,11,12,13,14,15 the overall quoted infection rates vary; our peritonitis rate of 0.75 episodes per patient-year is, however, higher than that recommended by the international society of peritoneal dialysis 2010 update. they recommend aiming for less than 0.67 episodes per patient-year. this difference could be related to our patient’s socio-economic circumstances.16 however, of our nine peritonitis cases, all but two patients were successfully treated with antibiotics, and we had no recurrent episodes within the one-year follow-up period. our one-year catheter survival rate of 84% is comparable to the findings of vaux et al., savader et al. and zaman et al. who recorded one-year catheter survival rates of 77%, 81% and 89%, respectively.10,13,14 limitations of the study the study was retrospectively performed, with relatively small patient numbers. certain patients were excluded from the procedure in the preoperative evaluation, but some who were unfit for general anaesthesia were included. conclusion top ↑ there is good evidence that percutaneous placement of pd catheters under conscious sedation has advantages over the open surgical and laparoscopic placement techniques. the procedure is relatively easy and can be performed in any hospital with ultrasound and fluoroscopy facilities. there were no major complications in our series and, except for a slightly elevated infection rate, outcomes were on a par with comparable international data regarding complications and catheter survival. percutaneous pd catheter placement under conscious sedation with the aid of ultrasound and fluoroscopy is therefore a sound alternative to conventional methods in the resource-limited developing world. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions h.r.v.d.b. (university of the free state), was project leader, wrote the study protocol, obtained ethical approval, collected data, analysed the data and wrote the article. s.o’h. (kimberley hospital), collected data, reviewed and gave input on the final article. d.h. (kimberley hospital), was the supervisor and gave input on the final article. references top ↑ naicker, s. end-stage renal disease in sub-saharan africa. ethn dis.2009; 9: 13–15. davids mr, marais n, jacobs, jc. south african renal registry annual report 2012. south african renal society 2014. c2014 [cited 25 october 2014]. available from: http://sa-renalsociety.org ellsworth pi, kim ed. peritoneal dialysis catheter insertion. medscape, september 2012. c2012 [cited 01 january 2013]. available from: http://emedicine.medscape.com/article/1829737overview yip t, lui sl, lo wk. review article: the choice of peritoneal dialysis catheter implantation technique by nephrologists. international journal of nephrology. 2013; article id 940106. http://dx.doi.org/10.1155/2013/940106 peppelenbosch a, van kuijk whm, bouvy nd, van der sande fm, tordoir jhm. peritoneal dialysis catheter placement technique and complications. ndt plus. 2008;1 (suppl 4):iv23–iv28. http://dx.doi.org/10.1093/ndtplus/sfn120 brunier g, hiller ja, drayton s, pugash ra, tobe sw. a change to radiological peritoneal dialysis catheter insertion: three-month outcomes. peritoneal dialysis international. 2010; 30:528–533. http://dx.doi.org/10.3747/pdi.2009.00114 mellotte gj, ho ca, morgan sh, bending mr, eisinger aj. peritoneal dialysis catheters: a comparison between percutaneous and conventional surgical placement techniques. nephrol dial transplant. 1993;8:626–630. voss d, hawkins s, poole g, marshall m. radiological versus surgical implantation of first catheter for peritoneal dialysis: a randomized non-inferiority trail. nephrol dial transplant. 2012; 27:4196–4204. http://dx.doi.org/10.1093/ndt/gfs305 reddy c, dybbro pe, guest s. fluoroscopically guided percutaneous peritoneal dialysis catheter placement: single centre experience and review of literature. renal failure. 2010; 2:294–299. http://dx.doi.org/10.3109/08860220903548932 savader sj, geschwind jf, lund gb, scheel pj. percutaneous radiological placement of peritoneal dialysis catheters: long-term results. j vasc interv radiol. 2000; 1:965–970. http://dx.doi.org/10.1016/s1051-0443(07)61323-2 georgiades cs, geschwind jf. percutaneous peritoneal dialysis catheter placement for the management of end-stage renal disease: technique and comparison with the surgical approach. techn vasc interv radiol. 2002; 5:103–107. http://dx.doi.org/10.1053/tvir.2002.36054 maya id. ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters. semin dial. 2007;20:611–615. http://dx.doi.org/10.1111/j.1525-139x.2007.00371.x vaux e, torrie p, barker l, naik r, gibson m. percutaneous fluoroscopically guided placement of peritoneal dialysis catheters – 10 year experience. semin dial. 2008;21:459–465. http://dx.doi.org/10.1111/j.1525-139x.2008.00463.x zaman f, pervez a, atray n, murphy s, work j, abreo k. fluoroscopy-assisted placement of peritoneal dialysis catheters by nephrologists. semin dial. 2005;18:247–251. http://dx.doi.org/10.1111/j.1525-139x.2005.18321.x jacobs ig, gray rr, elliott ds, grosman h. radiolologic placement of peritoneal dialysis catheters: preliminary experience. radiology. 1992;182:251–255. http://dx.doi.org/10.1148/radiology.182.1.1727292 li pkt, szeto cc, piraino b, et al. peritoneal dialysis-related infections recommendations: 2010 update. perit dial int. 2010;30:393–423. http://dx.doi.org/10.3747/pdi.2010.00049 cpd questionnaire 152 sa journal of radiology • december 2011 give one correct answer for each question. 1. which one of the following statements is false? a. peer-reviewed literature demonstrates increasing support for the use of focused abdominal sonography in trauma (fast) in the setting of blunt trauma. b. indications are that, compared with abdominal ct, the sensitivity and specificity of fast for the detection of free fluid is 0.64 0.98 and 0.86 1.00, respectively. c. utilising ultrasound in trauma triage increases efficiency, cost-effectiveness and reduces reliance on ct compared with using ct alone. d. there is overwhelming evidence to support reliance solely on a negative fast and physical exams for patient management. 2. which one of the following statements is false? a. a representative sample of occupationally exposed workers surveyed in kenya found that the annual exposure levels range from 0.32 to 6.98 msv. b. there is a skewed annual distribution showing a median value of 2.5 msv. c. the technologists were in the upper quartile in this radiation exposure distribution, thus being the largest exposed group in the medical sector. d. in kenya, there exist shortcomings governing radiation exposure of workers whereby additional safety measures for pregnant radiation workers is lacking. 3. which one of the following statements is false? a. malignant melanoma is one of the most common malignancies to metastasise to the gi tract. b. symptomatic metastasis to the gi tract is seen in 20% of patients. c. it metastasises via lymphatic channels to parenchymal organs. d. metastases may present at the time of primary diagnosis or decades later as the first sign of recurrence. 4. which one of the following is true? a. the ‘dural tail sign’ was first described by wilms in 1889, as a post-contrast linear thickening of the meninges that resembles a tail extending from a mass on t1-weighted mr imaging. b. in 1990, goldsher and colleagues devised a subset of radiologic criteria that proved to be of no value in identifying the absence or presence of the dural tail sign sign. c. this sign consists of a tapering rim ranging from 0.5 to 3.0 cm in length with an inner surface that is either smooth or slightly nodular. d. due to its high specificity, it remains the only sign in assessing the morphology, enhancement pattern and centricity of a meningeal lesion. 5. which one of the following statements is false? a. cystic and cavitatory pulmonary lesions are abnormalities commonly encountered on chest radiography and computed tomography (ct). b. a cyst is defined as any round circumscribed space that is surrounded by an epitheloid or fibrous wall of variable thickness. c. malignant lesions including metastases often present as cystic lesions. d. high-resolution ct of the chest helps to define morphological features that may serve as clues regarding the nature of cystic and cavitatory lung lesions. 6. identify the one false statement among the following choices. a. oculodentodigital dysplasia (oddd), also known as ‘oculodentoosseous dysplasia’, is an extremely rare autosomal dominant disorder with high penetrance, intraand interfamilial phenotypic variability, and advanced paternal age in sporadic cases. b. oddd is caused by mutations in the connexin 43 (cx43) or gap junction protein alpha-1 (gja1) gene. c. the actual incidence of this disease is not known, but only 243 cases have been reported in the scientific literature, suggesting an incidence of the order of one affected person in ten million people. d. it is marked mainly by eye abnormalities, craniofacial dysmorphism, dental anomalies, hand and foot malformations, various skeletal defects, and markedly delayed mental development. 7. the following are true, except for: a. tissue injury due to the propagation of a shockwave is well described with ballistic injuries where the energy transfer from the missile to the tissue is responsible for the severity of the wound. b. the relationship between the kinetic energy and the projectile can be derived from the formula: kinetic energy (ke) = 0.5 x mass x (velocity)². c. shockwave injury to adjacent tissue is a rare complication of extracorporeal shock wave lithotripsy. d. in the case of bullet wounds where the mass of the projectile is relatively small, the extent of damage to surrounding tissues is largely determined by the velocity. 8. identify the one false statement among the following. a. investigators have not been able to demonstrate direct tumour involvement of the dural tail. b. dural tails represent reactive changes to the dura mater, adjacent to but not in contiguity with the tumour. c. the dural tail sign is also reported in a variety of other intra-axial as well as extra-axial lesions including neuromas, chloromas, metastases, lymphoma, glioma, pituitary diseases and granulomatous disorders. d. the dural tail sign is a highly specific feature of meningioma. 9. regarding the following, identify a single false statement. a. primary gi melanoma can arise in various gi mucosal sites, including the oral cavity, oesophagus, small bowel, rectum and anus. b. primary melanoma of the gi tract is rarely diagnosed at an early stage. c. distinguishing between a primary gi mucosal melanoma and melanoma metastases to the gi tract from unknown or regressed cutaneous primary may be difficult. d. gi metastasis is the most common manifestation of the disease. 10. identify the one false statement below. a. go rad is a 2-year-old consortium of 30 continental/multinational/national society journals. b. go rad (global outreach-radiology – www.isradiology.org/gorad) is a global outreach programme of the international society of radiology. c. partnering society journals agree to provide select open access immediately on publication to appropriate content (e.g. one article per issue). the mechanics are that go rad simply places hyperlinks from the selected go rad articles back to the respective home journal. since the sajr is a quarterly open-access journal, it is easy to link the content. an example from sajr vol. 15 no. 3 is: pseudomyxoma peritonei (pmp) a rare entity http://www.sajr.org.za/index.php/sajr/article/view/344 d. at go rad you will find freely available links to barack obama, george bush and gerry springer. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals.co.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/010/01/2011 73 sa journal of radiology • september 2010 musculoskeletal diagnosis quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban findings please refer to page 45 of the june 2010 issue of the sajr (http://www. sajr.org.za/index.php/sajr/article/view/460/370) for the clinical details and images. we congratulate dr hanief moosa (3rd-year radiology registrar at the university of the witwatersrand) for his near spot-on diagnosis, for which he receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its radiological signs. diagnosis a single modality is depicted with preand post-gadolinium mri sequences. the medullary cone biconvex mass is iso-intense to subcutaneous fat on all sequences. near-complete fat saturation (fig. 3) of the lesion indicates predominant fatty content. t2-weighted intermediateand low-signal components (figs 1b and 2b), some of which are strand-like centrally and more solid at the inferior aspect of the mass, suggest encasement of nerve roots and partly fibrous content respectively. the cord is secondarily tethered, the filum terminale is thickened (>2 mm) and there is evidence of previous wide laminectomies at l2/3. minimal post-gadolinium enhancement (fig. 3b) is noted of the lesion periphery and the meninges, probably related to post-surgical granulation. no syringohydromyelia, neurenteric cyst or meningocoele could be demonstrated. incidental note was made of the l2/l3 disc herniation with mild thecal sac impression. radiological diagnosis of intradural lipoma and differential diagnosis of dermoid tumour, teratoma or complex mucinous myxopapillary ependymoma was offered. intra-operatively, the mass was shown to be almost completely fatty in content with intratumoral nerve root incorporation and solid fibrotic component documented. no teeth or calcification could be shown at histology. final diagnosis of intradural fibrolipoma located at the conus with tight filum terminale and cord tethering was made. discussion spinal lipomas, including intradural lipomas and lipomyelocoeles, result from premature separation of the neuro-ectoderm from the cutaneous ectoderm, allowing mesenchymal fat-forming cells to enter the spinal canal. fibrolipomas of the filum terminale are usually more caudally located and generally much smaller. associated incomplete retrogressive differentiation results in tethered cord syndrome. isolated fibrolipomas of the filum terminale are usually asymptomatic. fibrolipomas of the conus medullaris in adult patients with tight filum and associated cord tethering have been previously reported.1 these patients present later with progressive lower limb weakness, muscle atrophy and spasticity. incontinence is a late phenomenon.2 in adults, a precipitating factor can lead to increased pressure on the already tethered cord, resulting in them presenting with worsening symptomatology.3 in the index patient, disc herniation at l2/l3 may be implicated. the imaging of these fat-containing tumours is enhanced by using the appropriate sequences to demonstrate the true content of the mass. fat saturation sequences using stir or saturation bands enables a narrowing down of the differential diagnosis. mri also allows the radiologist to advise the neurosurgeon on the extent of the mass, presence of fibrous content (which may be adherent to cord, cauda equina or meninges), cystic component, occult dysraphism or neurenteric communication. therefore, here we illustrate that a single radiological modality, by the use of varied sequences, allows the radiologist to arrive at a clinically accurate differential diagnosis. 1. freund m, thale a, hutzelmann a. radiologic and histopathologic findings in a rare case of complex occult spinal dysraphism with association of a lumbar fibrolipoma, neurenteric cyst and tethered cord syndrome. eur radiol 1998;8:624-627. 2. raghavan n, barkovich aj, edwards m, norman d. mr imaging in the tethered cord syndrome. ajr 1989;152:843-852. 3. gupta sk, khosla vk, sharma bs, mathuriya sn, pathak a, tewari mk. tethered cord syndrome in adults. surgical neurology 1999;52(4):362-369. article information author: joel h. bortz1 affiliation: 1lsg imaging, santa monica, united states of america correspondence to: joel bortz postal address: 13031 villosa place, apartment 141, playa vista, california 90094, united states of america dates: received: 13 mar. 2014 accepted: 17 aug. 2014 published: 01 dec. 2014 how to cite this article: bortz, jh. an approach for performing a successful computed tomography colonography examination. s afr j rad. 2014;18(1); art. #607, 11 pages. http://dx.doi/org/10.4102/ sajr.v18i1.607 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. an approach for performing a successful computed tomography colonography examination in this review article... open access • abstract • introduction • ctc protocol • colonic preparation • positioning and introduction of co2 • do spasmolytics have a role in ctc? • role of tagging • should 40% w/v barium be used in ctc? • ctc protocol: radiation dose considerations • diagnostic ctc following incomplete oc • extracolonic findings • interpretation • concluding remarks • acknowledgements    • competing interests • references abstract top ↑ computed tomography colonography (ctc) is a minimally invasive, fast, safe and accurate screening examination for colorectal cancer. it also allows evaluation of structures outside the colon. a successful ctc examination requires good bowel preparation, adequate patient hydration, tagging agents, the use of automated carbon dioxide insufflation, and correct positioning for two view and additional view scans. knowledge of polyp morphology and measurement of polyps are important when interpreting 2d or 3d scans. introduction top ↑ colorectal carcinoma (crc) is the third most common cancer in the united states of america (usa), and the second most common cause of death from cancer. the latest crc statistics for new cases in the usa is expected to decrease to 136 830 from the previous estimate of more than 143 000 cases in 2012.1,2,3 the number of deaths in 2014 is expected to decrease to 50 310 from the previous figure of more than 52 000 deaths per year.1,2,3 most colon cancers, apart from inherited genetic disorders, such as hereditary non-polyposis colorectal cancer, arise from a pre-existing polyp which develops over a period of 10–15 years into a cancer.4 colon cancer screening is recommended every five years from the age of 50,2 but colorectal examinations are a contested terrain of diagnostic imaging versus optical colonoscopy (oc). this contested terrain has shifted since the introduction of newer imaging technologies, such as computed tomography colonography (ctc),2,5,6 which is widely recognised as a highly sensitive and specific test for identifying polyps and cancer in the colon.2,5 to the best of the author’s knowledge, no article on how to perform a ctc has been published to date in south africa. ctc was not included as a screening test for crc in a 2011 survey of a privately insured population for a single insurer across all nine south african provinces.7 crc was the fourth leading cancer in south africa in 2004;8 more recent crc statistics are not available. although double-contrast barium enema (dcbe) is not as effective as ctc, and is rapidly becoming an obsolete technique,9 it remains widely practised in south africa and elsewhere in the world. fairly recent studies show the sensitivity of dcbe at approximately 50% for polyps >10 mm10 whereas for ctc it is 97% for polyps >10 mm.11 an important advantage of ctc over oc is the former’s ability to visualise the intra-abdominal and pelvic organs. the majority of findings will ultimately prove to be of little or no clinical significance.12,13 however, in approximately 10% of cases, significant pathology may be identified, such as early cancers of the kidney and ovary as well as abdominal or pelvic lymphadenopathy in underlying lymphoma. abdominal aortic aneurysms >5 cm in transverse diameter may be detected incidentally.12,13 visualisation of such pathology is not possible with oc or dcbe. ctc is less invasive, with minimal complications.14 oc holds inherent risks related to sedation and potential bowel perforation.15 ctc is a much safer form of study than oc as no sedation is required and the risk of perforation is significantly less, with only sporadic cases of perforation recorded.16 perforation is higher in diagnostic studies than with screening procedures, particularly when stenosing lesions are present. certain precautions are recommended to maintain a low perforation rate, namely (1) the use of a soft rubber catheter as opposed to the large plastic barium enema tube; (2) constant infusion of carbon dioxide (co2) under monitored pressure; and (3) not performing the study after a recent full thickness biopsy.16 the aim of the present paper is to present an approach for a successful ctc examination, ensuring the performance of a high-quality study that allows accurate interpretation by a general diagnostic radiologist.17 the author has performed more than 5200 ctcs in the usa over the past 10 years. bowel cleansing in ctc for screening patients is highlighted. in addition, ctc following an incomplete oc is discussed. interpretation of images is also briefly discussed. ctc protocol top ↑ there are two critical components to achieving a successful ctc: an adequately cleansed bowel and good distension of the colon with co2. there are many ways to perform ctc, but it is advisable to choose a method from an institution that has published evidence of consistently producing outstanding results, and to then follow the published recommendations. the author has adopted the technique used by drs pickhardt and kim from the university of wisconsin (usa),18 who have shown the importance of: bowel preparation; the use of co2 instead of room air; 3d visualisation using approved software; and a multiple detector computed tomography (mdct) scanner. a deficiency in any of these factors can cause a poor ctc result. the following points are embedded in the ct protocol used by the author: adherence to ctc indications (table 1); informed consent; adequate patient hydration; cathartic and tagging agents; and the use of co2 (table 2). table 1: indications and contra-indications for ctc. table 2: room air versus co2. colonic preparation top ↑ bowel preparation is controversial in terms of patients’ compliance.19,20 there are a variety of bowel preparations available, including magnesium citrate, a cathartic bowel preparation. in addition, tagging agents, such as 250 ml of 2.1% w/v readi-cat and 60 ml diatrizoate (gastrografin), are used. the barium tags the stool and the gastrografin tags the residual fluid (table 3). table 3: patient preparation. for a successful examination, bowel preparation should comprise a well-established ctc standard protocol.6 bowel preparation commences the day before the scheduled examination; a 24-hour liquid diet is required (table 3 presents a list of permitted liquids), with nil per mouth from midnight. if the patient has had breakfast in error, another ctc appointment must be arranged. it is important for the patient to be fully briefed on all requirements when a ctc is booked. an appropriately trained person must carefully explain to the patient the importance of adhering to a liquid diet and taking the bowel preparation medication at the correct times (steps 1 and 2 in table 3). the times to take the medication in these steps, and the tagging agents, must be included on the labels on the bottles. the patient must be informed that onset of bowel action is variable: it may occur after 30 minutes or for up to 4 hours. tagging is an integral part of the colonic preparation (steps 3 and 4 in table 3). the patient should be warned of the unpleasant taste of gastrografin; dilution in a flavoured drink lessens the unpleasant taste. notably, barium does not adhere to the colonic wall, but rather coats the surface of polyps, making them more conspicuous and easier to diagnose.6,17 this effect may reduce the false-positive rate on ctc. gastrografin has a dual action: (1) it stains the residual fluid white, aiding in 2d evaluation of submerged polyps; and (2) it emulsifies the stool adherent to the bowel wall, causing a secondary catharsis.6 it is sensible to shift to polyethylene glycol solution (peg: klean-prep) for the extremely small percentage of patients who are in poor health owing to cardiac or renal disease, or hypertensive patients taking angiotensin-converting-enzyme (ace) inhibitors to avoid fluid or electrolyte shift. klean-prep has an unpleasant taste, and consumption of a large volume is necessary; consequently, patients do not usually adhere strictly to its correct use. positioning and introduction of co2 top ↑ before commencing a ctc examination, the patient is sent to the restroom as the rectum must be emptied of any residual fluid. figure 1 is a synopsis of the ctc technique described below. the patient is positioned feet first in a left lateral position in the scanner. a disposable soft rubber rectal catheter is then gently inserted into the rectum and the balloon is insufflated with 20 cc of air employing a 3-way connection (figure 2). the hard plastic tube previously used for dcbe is employed only in rare cases. use of a soft rubber catheter reduces risk of perforation. figure 1: schematic presentation of computed tomography colonography (ctc) technique. figure 2: three-way connection. rectal drainage (black arrow). rectal drainage bag (white arrow). it is essential to check that there is sufficient co2 in the cylinder before commencing a ctc. the co2 insufflator (protoco2l – bracco) is switched on and the pressure set to 15 mmhg to enable the co2 to gently flow at low pressure into the descending colon until one litre of co2 has been introduced (figure 3). at this point, turn the patient onto the right side to fill the proximal transverse and ascending colon. the pressure at this stage may be increased to 20 mmhg to distend the colon. when the volume reaches two litres, return the patient to the supine position and commence scanning. for all scans, instruct the patient to inhale, then exhale, and suspend breathing during scanning. scanning is performed in exhalation as this elevates the diaphragm and allows the colon and flexures to expand. the first breath hold (5 seconds) allows acquisition of the scout film. once this film is reviewed, inform the patient that the full supine scan of the abdomen will commence. figure 3: the co2 insufflator. figure 4: large internal haemorrhoids (arrows) visualised when the balloon is deflated. next, the co2 insufflator is switched off whilst the patient is turned prone. this is done because elderly and obese patients may have trouble turning prone and the intracolonic pressure rises rapidly, often above 60 mmhg, thereby triggering the machine alarm. some radiologists use the deflation manoeuvre after completion of the supine scan by emptying the rectum of air and then re-inflating for the prone scan; this reduces the incidence of pain.21 from time to time, it may not be possible for some patients to turn into the prone position, and a decubitus view will be required instead. ensure that, when scanning in the prone position, a pillow placed under the patient’s chest does not impinge on the abdomen. with the patient in the prone position, (1) the balloon is deflated to visualise internal haemorrhoids, if present (figure 4); and (2) the co2 insufflator is switched on and the patient positioned for scanning. a scout film is taken on exhalation and breath hold. the scan usually takes 12 seconds. when the prone scan is completed, the insufflator is switched off and the clip of the rectal bag is opened to empty the rectum. this manoeuvre gives immense relief to the patient, who is turned into the right lateral decubitus (rld) position while the images are examined by the radiologist. on average, the acquisition and assessment of a two-view ctc study takes no more than five minutes. ctc requires on average between 15 to 20 minutes’ room time. should areas of poor distension be identified, in particular the sigmoid colon in cases of diverticular disease, the patient is ready to be scanned in the rld position. the insufflator is switched on again, introducing a litre of co2, as the rectum was previously emptied when the bag was unclamped. after the co2 has been introduced, scanning on breath hold can recommence. whilst waiting for the images to be processed, the co2 is switched off. in the rare case where the rld is unable to distend the appropriate area, the patient is turned into the left lateral decubitus (lld) position. the co2 is switched on and the patient re-scanned. it is important to appreciate the benefits of using an insufflator. the intracolonic pressure is constantly monitored, as indicated on the second dial on the co2 insufflator. the maximum pressure is 25 mmhg, which prevents the risk of perforation. by comparison, a standard handheld air-bulb insufflator cannot determine the intracolonic pressure or the volume of gas introduced. according to sosna and colleagues,22 each puff of the handheld device will introduce approximately 40 cc of air; at least 50 puffs will be required to introduce two litres of air. of importance is that the pressure at which the air is introduced is unknown. the danger of perforating the bowel under these circumstances far exceeds that of the gentle measured pressure and volume attained with a co2 insufflator. carbon dioxide is rapidly resorbed compared with room air, which results in reduced abdominal distension and pain.23,24 it may, however, cause bloating for a short period. if a patient does complain of pain early on in the procedure, it is important to immediately check the inguinal regions for possible bowel herniation (figure 5a and figure 5b). if this is negative, the most likely cause is underlying diverticular disease. adequate distension does not imply complete distension of all segments in all cases. cases of established diverticulosis tend to cause areas of non-distension. additional views are frequently required to open the sigmoid area satisfactorily. figure 5: (a) herniation of sigmoid colon in left inguinal region (arrow). (b) small bowel in right inguinal region (arrow). figure 6: air in stomach (arrow). do spasmolytics have a role in ctc? top ↑ glucagon is rarely used as a spasmolytic in the usa because of cost and the side-effects of nausea and vomiting. buscopan (hyoscine butylbromide) is not available because it has not been approved by the usa’s fda (food and drug administration).6 in europe and south africa, buscopan is often used to relax the bowel for good distension. however, it may relax the ileo-caecal valve and result in the small bowel filling with air. occasionally the valve may be incompetent without the use of a spasmolytic. carbon dioxide refluxes into the small bowel and it may rapidly reach the stomach (figure 6). when this occurs, the patient complains of nausea and usually breaks into a sweat. it is essential to instruct the patient to burp, causing immediate relief. role of tagging top ↑ apart from tagging stool, barium also lightly covers a polyp, thereby making it more conspicuous on 2d viewing. a useful tip is to scroll carefully through the polyp to assess whether there is soft-tissue thickening underlying the barium. a recent paper6 underscores that contrast coating of a flat polyp can act as a marker for detection (figure 7). figure 7: barium covering flat polyp (black arrow). figure 8: air in stool (arrows). figure 9: stool moved to the opposite wall in the prone position. figure 10: (a) pedunculated polyp on long stalk in supine position (green arrow = head and black arrow =stalk). (b) pedunculated polyp on medial wall (arrow). there are clues that allow differentiation between a polypoidal lesion and stool: 2d and 3d views are complementary. the former is the most useful method for making the distinction. stool may be covered by barium and frequently contains small bubbles of air, giving it a heterogeneous appearance (figure 8). air within stool is not identified on 3d viewing. most typically, stool will move to the opposing wall when the patient is turned from the supine to the prone position (figure 9). a sessile polyp does not move with postural change. however, beware of the pedunculated polyp on a long stalk which may move with postural change (figure 10). should 40% w/v barium be used in ctc? top ↑ use of the relatively high-density barium has several disadvantages and is therefore not recommended for use in ctc examinations. if 40% w/v barium is used for a ctc study, this does not include a cathartic bowel cleansing so it is not possible to perform a same-day oc.17 electronic cleansing is not routinely performed because it may cause a large number of artifacts that could make interpretation difficult. part of the surface mucosa may be electronically removed and could result in missed lesions. ctc protocol: radiation dose considerations top ↑ it is feasible to perform ctc using a 4-slice and above scanners.25 currently, 16-slice scanners and above are recommended. such scanners allow for a short breath hold during scanning but image quality is not improved. sub-millimetre collimation is neither recommended nor used. slice collimation is set at 1.25 mm with a 1 mm reconstruction interval. tube potential is set for 120 kvp which is raised to 140 kvp for large patients. reducing tube current (ma) reduces dose to the patient, in keeping with alara (as low as [is] reasonably achievable) principles.26 ct manufacturers have taken heed of increasing concerns about radiation dose, and have developed radiation reduction tools such as automated tube current modulation, automated tube potential and iterative reconstruction, in the latest generation scanners.27 with the introduction of tube current modulation, protocols can now concentrate on setting an appropriate noise level to minimise dose. a tube current modulation system is used (smart ma, ge healthcare) whereby the noise level is set at 30 for the supine study and 50 for the prone study, and the tube current range at 30 ma–300 ma. this has yielded a 40% reduction of dose in the prone position with minimal degradation of 3d and 2d images. for mdct scanners not equipped with a tube current modulation system, a technique with a tube current-time product in the range of 50 mas–75 mas usually suffices.28 a tube current-time is set between 50 mas–75 mas for those machines not equipped with a tube current modulation system. these protocols result in a median effective dose of 4.5 msv for both supine and prone studies: ctc is a low-dose examination.29 diagnostic ctc following incomplete oc top ↑ reasons for a failed oc might include older patients, female gender, colon length, number of acute angle bends and flexures, advanced diverticular disease, prior abdominal surgery, occlusive cancers, benign strictures, colon containing hernias, intestinal malrotation and poor bowel preparation. from a ctc perspective, this latter group of patients is the most challenging. they have predominantly been prepared for an oc using a ‘wet’ preparation, such as peg, and not a ‘dry’ one as is favoured for ctc. in addition, these patients were not given preprocedural contrast or fluid tagging, making it more challenging to exclude false-positives, such as stool adherent to the wall. it is imperative to first exclude the possibility of an oc-caused colonic perforation before commencing with ctc. there have been rare reports of colonic perforation at ctc, especially in patients with obstructive lesions.16 approximately 50% of patients with colonic perforations do not have symptoms. to avoid possible medico-legal implications, a pre-procedure low-dose ct scan should be done prior to rectal catheter insertion. the technique used by the author comprises a 10 mm slice thickness at 10 mm intervals.30 the subsequent images are viewed by the radiologist and, if extra-luminal air is present, a ctc is not performed. the referring clinician is informed of this ct finding. hough et al.30 reported a total effective dose of 0.9 msv for men and 1.2 msv for women in low-dose abdomino-pelvic ct to exclude perforation. alternative techniques may be used, such as a slice through the upper, middle and lower abdomen. these increased gaps may be a trade-off for sensitivity. professor p. pickhardt (personal communication, may 2014) stated that low-dose ct is preferred to erect plain-film radiographs. according to professor pickhardt, the latter only excludes free air whereas most perforations have contained extra-luminal gas, retroperitoneally or intramural. before proceeding with a ctc, the radiologist must know whether a recent polypectomy or biopsy (superficial or deep) has been performed. occasionally, with superficial biopsies, the co2 may track sub-mucosally and result in pneumatosis coli. if a deep biopsy or polypectomy has recently been performed, it is advisable to wait at least four weeks before proceeding with the ctc to allow the mucosa to heal (see table 1). patients would prefer a same-day ctc after a failed oc to eliminate the need for two separate bowel preparations. from a ctc standpoint, the examination tends to be sub-optimal as tagging has not been performed. to overcome this limitation, 30 ml of gastrografin is administered when the patient is fully awake and able to swallow. the patient is then turned onto the right side and kept in this position for two hours to empty the stomach. gastrografin usually takes a minimum of two hours to travel through the colon. the patient is then scanned. this ctc technique results in moderate success because there is excess luminal fluid or streak artifacts from the dense residual contrast in the stomach, which degrades the quality of the study. unfortunately, 30 ml of gastrografin does not effectively tag residual faecal matter. an option that is seldom adopted is to keep the patient on a liquid diet for a second day. then 250 ml of 2.1% w/v readi-cat is taken at approximately 17h00, followed by 60 ml gastrografin three hours later (at 20h00). no further laxatives are required, and the patient is scanned the following morning. in view of ctc’s efficacy, barium enema following incomplete oc should no longer be performed.31 extracolonic findings top ↑ ctc screening is usually performed in healthy asymptomatic individuals. the protocol also includes performing non-contrast scans of the pelvis and abdomen. an automatic retrospective reconstruction of the supine series of all patients is performed for evaluation of extracolonic findings. this consists of 5 mm sections at 3 mm intervals. it is important to remember that, when performing the prone series, there is often more coverage and certain lesions, such as those from lung cancer, may only be detected on prone imaging. a classification of extracolonic findings has been devised (table 4).18,32,33 the overall detection rate of unsuspected cancer is approximately one per 200 asymptomatic adults undergoing routine screening ctc, including about one invasive crc per 500 cases, and one extracolonic cancer per 300 cases.34 table 4: extracolonic classifications†. interpretation top ↑ a successful ctc is not difficult to perform if the bowel is clean and the colon is well distended. there are two methods available to read the scans: 2d and 3d. some proponents prefer using 2d as a primary approach with 3d reserved for problem-solving, whereas others prefer 3d as the primary method.2,35 there is consensus that readers need to be skilled in both interpretation methods. for 2d polyp detection, the window setting should be at a window width of 1500 and centred at 0 to -200.18 sessile polyps have a round or ovoid morphology and are of soft-tissue density. these should be visualised in both prone and supine scans as their position is not affected by postural change. stool, on the other hand, does move as previously discussed. air is often visible in the stool, giving it a heterogeneous appearance (figure 8). as stated previously, one must beware the pedunculated polyp on a long stalk in terms of postural change (see figure 10). pickhardt et al. maintain that primary 3d evaluation is preferable; they advocate the use of 2d for evaluation of polyp/stool differentiation.35 they maintain that this approach is easy, quick and extremely accurate. they conducted research on the accuracy of readers when using 2d compared with 3d.35 according to these authors, primary 2d ctc is less sensitive than primary 3d ctc for polyp detection in low-prevalence screening cohorts. all current systems allow improved 3d fly-through. the author’s preference is a primary 3d system, such as the viatronix 3d system, but there are other options. the author’s standard protocol is to perform supine and prone scans; additional views in the rld and lld may be required (figure 1). changing a patient’s position by 180⁰ allows shifting of pooled liquid as well as movement of stool from one wall to the opposite wall. the field of view (fov) is set at 120⁰ to provide good visualisation of the mucosa and folds. the folds in the left colon (anal verge to splenic flexure) are usually circular; in the right colon (caecum to splenic flexure) they become triangular (figure 11 and figure 12). a centreline is automatically generated and continues in a retrograde fashion to the caecum and ileo-caecal valve. an icon is then clicked which reverses the fly-through from the caecum to the rectum. it takes less than two minutes to perform this bidirectional flight. the same is done in the prone study. the software used by the author allows exceptional visualisation of the bowel lumen for every case by clicking on the ‘paint’ icon to spray the bowel green. areas that may not have been visualised (i.e. missed regions) are visualised as pink. to remedy this requires clicking the icon area by area until 100% visualisation has been achieved. note that unidirectional fly-through results in only about 90% coverage of the colon. figure 11: left colon has circular folds (anal verge to splenic flexure). figure 12: triangular folds in the right colon (caecum to splenic flexure). a colour-density map is used to assess the density of any protrusions suggestive of polyps or stool that are encountered on the way. polyps appear as red, barium appears white, and lipomas display as green colouration. the anterior surface of a colon fold faces the rectum and anus; the posterior surface of the fold faces the caecum and ileo-caecal valve (figure 13). the anterior folds are seen on a retrograde fly-through from the rectum; the posterior ones are seen on the reverse fly-through from the caecum. a ‘bookmark’ or red dot can be placed on the colon outline to indicate the site of a polyp or carcinoma. the bookmark is useful if a subsequent oc needs to be done. the red dot indicates the site of the lesion as well as the distance from the anal verge (figure 14). the green line indicates the automated centerline. figure 13: sessile polyp on the posterior haustral fold (white arrow). there is a smaller sessile polyp on the anterior haustral fold (black arrow). figure 14: red dot (next to black arrow) indicates lesion site on 3d. how to manage polyps is important. radiologists need to have a working knowledge of polyp morphology and how to measure polyps,36 as well as recommendations to make when polyps are present. it is advisable to include the following disclaimer in all ctc reports: ’ctc is not intended for detection of diminutive polyps (≤5 mm), the presence or absence of which will not change the clinical management of the patient’. the head of a pedunculated polyp is measured; the length of its stalk is not measured. polyps of 6 mm–9 mm are termed small. a study is considered positive when a lesion ≥6 mm is detected. if there are more than 3 polyps in the 6mm–9mm range, oc is recommended. if the polyp burden is lower, an option is oc on the same day (table 3); this will require the study to be read soon after completion of the ctc. a further option is for the patient to be put in a surveillance programme and followed up in three years. if after three years there is an increase in polyp size, the patient can be referred for an oc. most polyps, however, tend to regress in size. polyps ≥10 mm are routinely removed. the chance of malignancy is <1% in an asymptomatic low-risk individual.37 a summary of classifications of colonic pathology is presented in table 5. the characteristics of advanced adenomas should be known by radiologists.18,37 there are three components to this pathology (table 6). table 5: colonic classifications†. table 6: advanced adenomas†. more recently, computer-aided diagnosis (cad) systems have become available.38,39 they are of value as either a primary or secondary reader depending on a radiologist’s experience. cad has demonstrated excellent performance for polyp detection in a large screening population undergoing ct colonography with cathartic preparation and oral contrast agent tagging. the combination of high sensitivity for relevant polyps and an acceptable number of falsepositive results is very important if cad is to be implemented clinically.38 given the ongoing technological advances in imaging, new ctc display techniques are also available, such as the ‘filet’ view where the colon is opened up to view for polyps, or the band view.40 these new techniques speed up interpretation time but there is distortion of the mucosal folds, making polyp visualisation difficult. concluding remarks top ↑ in a panel discussion in 2006, it was suggested that, within the subsequent five years, ctc would make oc obsolete as the primary colon cancer screening test.41 unfortunately, this prediction has not come to fruition. ctc is a minimally invasive, fast, safe and accurate screening examination for colorectal cancer,1 yet 99% of screening colonoscopies are done via the optical route. in this contested terrain, the referral rate for low-cost screening ctc is dismal. when all the benefits of ctc are presented,2,5,21,42,43 patients should be given a choice of deciding to either undergo ctc as the primary screening procedure or therapeutic oc.44 a screening ctc study should be undertaken every five years.1,2 regardless of oc’s predominance, radiologists need to embrace the new technology, and be prepared and fully trained in all aspects of ctc. this will require making a small investment in a co2 insufflator as the benefits of co2 are clearly evident.23 what constitutes an adequate number of studies performed before being competent varies and should be contextualised.25,45 in countries where ctc is a developing modality, such as in south africa, the role-players should collectively agree on the number of studies that should be performed in order to be competent. ctc is a relatively new procedure that has been validated in the literature.2,6,29,33,36,46 it should be part of routine imaging and not a super-specialist examination. there are two aspects to ctc competency: performing the study and interpreting the images. to address both aspects, cme courses could be developed to meet local needs.25,45 acknowledgements top ↑ professor perry pickhardt and professor david kim, of the department of radiology, university of wisconsin medical school, are thanked for their support and sharing their knowledge with me. i am indebted to both of them for advice and guidance for many years as well as always being available for ‘second opinions’. competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1. american cancer society. cancer facts and figures 2014. 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[cited 2014 march 01]. available from: http://www.acr.org/~/media/acr/documents/pgts/guidelines/ct_colonography.pdf 26. talati rk, dunkin j, parikh s, moore wh. current methods of monitoring radiation exposure from ct. j am coll radiol. 2013;10(9):702–707. http://dx.doi.org/10.1016/j.jacr.2013.03.002 27. raman sp, johnson pt, deshmukh s, mahesh m, grant kl, fishman ek. ct dose reduction applications: available tools on the latest generation of ct scanners. j am col radiol. 2013;10(1):37–41. http://dx.doi.org/10.1016/j.jacr.2012.06.025 28. brenner dj, georgsson ma. mass screening with ct colonography: should radiation exposure be of concern? gastroenterology. 2005;129(1):328–337. http://dx.doi.org/10.1053/j.gastro.2005.05.021 29. levin b, lieberman da, mcfarland b, et al. screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the american cancer society, the us multi-society task force on colorectal cancer, and the american college of radiology. ca cancer j clin. 2008;58(3):130–160. http://dx.doi.org/10.3322/ca.2007.0018 30. hough dm, kuntz ma, fidler jl, et al. detection of occult colonic perforation before ct colonography after incomplete colonoscopy: perforation rate and use of a low-dose diagnostic scan before co2 insufflation. ajr. 2008;191(4):1077–1081. http://dx.doi.org/10.2214/ajr.07.2746 31. copel l, sosna j, kruskal jb, raptopoulos v, fareell rj, morrin mm. ct colonography in 546 patients with incomplete colonoscopy. radiology. 2007;244(2):471–478. 32. zalis me, barish ma, choi jr, et al. ct colonography reporting and data system: a consensus proposal. radiology. 2005;236(1):3–9. http://dx.doi.org/10.1148/radiol.2361041926 33. pickhardt pj, taylor aj. extracolonic findings identified in asymptomatic adults at screening ct colonography. ajr. 2006;186(3):718–728. http://dx.doi.org/10.2214/ajr.04.1748 34. pickhardt pj, kim dh, meiners rj, et al. colorectal and extracolonic cancers detected at screening ct colonography in 10286 asymptomatic adults. radiology. 2010;255(1):83–88. http://dx.doi.org/10.1148/radiol.09090939 35. pickhardt pj, lee ad, taylor aj, et al. primary 2d versus primary 3d polyp detection at screening ct colonography. ajr. 2007;189(6):1451–1456. http://dx.doi.org/10.2214/ajr.07.2291 36. pickhardt pj, kim dh. colorectal cancer screening with ct colonography: key concepts regarding polyp prevalence, size, histology, morphology, and natural history. ajr. 2009;193(1):40–46. http://dx.doi.org/10.2214/ajr.08.1709 37. johnson cd, chen m, toledano ay, et al. accuracy of ct colonography for detection of large adenomas and cancers. n engl j med. 2008;359(12):1207–1217. http://dx.doi.org/nejmoa0800996 38. lawrence em, pickhardt pj, kim dh, robbins jb. colorectal polyps: stand-alone performance of computer-aided detection in a large asymptomatic screening population. radiology. 2010;256(3): 791–798. http://dx.doi.org/10.1148/radiol.10092292 39. halligan s, mallett s, altman dg, et al. incremental benefit of computer-aided detection when used as a second and concurrent reader of ct colonographic data: multiobserver study. radiology. 2011;258(2):469–476. http://dx.doi.org/10.1148/radiol.10100354 40. lee ss, park sh, kim jk, et al. panoramic endoluminal display with minimal image distortion using circumferential radial ray-casting for primary three-dimensional interpretation of ct colonography. eur radiol. 2009;19(8):1951–1959. http://dx.doi.org/10.1007/s00330-009-1362-1 41. yoshida h, svoboda ac. within the next five years ct colonography will make conventional colonoscopy obsolete for colon cancer screening. in: orton cg, hendee wr, editors. controversies in medical physics: a compendium of point/counterpoint debates. maryland: american association of physicists in medicine [cited 2008]. available from: http://149.28.118.16/pubs/books/pointcounterpointcompedium.pdf#page=245 42. perisinakis k, seimenis i, tzedakis a, papadakis a, kourinou k, damilakis j. screening computed tomography colonography with 256-slice scanning: should patient radiation burden and associated cancer risk constitute a major concern? invest radiol. 2012;47(8):451–456. http://dx.doi.org/10.1097/rli.0b013e318250a58c 43. gonzalez am, kim kp, yee j. ct colonography: perforation rates and potential radiation risks. gastrointest endosc clin n am. 2010;20(2):279–291. http://dx.doi.org/10.1016/j.giec.2010.02.003 44. kim dh, pickhardt pj, taylor aj, et al. ct colonography versus colonoscopy for the detection of advanced neoplasia. n engl j med. 2007;357(14):1403–1412. http://dx.doi.org/10.1056/nejmoa070543 45. fletcher jg, chen m, herman ba, et al. can radiologist training and testing ensure high performance in ct colonography? lessons from the national ct colonography trial. ajr. 2010;195(1):117–125. http://dx.doi.org/10.2214/ajr.09.3659 46. yee j, keysor kj, kim dh. the time has arrived for national reimbursement of screening ct colonography. ajr. 2013;201(1):73–79. http://dx.doi.org/ajr.13.10656 cpd questionnaire give one correct answer for each question. 24 sa journal of radiology • march 2010 a. is a relatively frequent finding in diagnostic imaging studies. b. is a well-known hallmark feature of acute cholecystitis. c. the finding itself is non-specific and can be found in a wide range of gallbladder diseases and extracholecystic pathological conditions. d. traditionally, sonography has been used as the initial imaging technique for evaluating patients with suspected gallbladder disease. other imaging modalities are now preferred because of the questionable sensitivity of ultrasound. 1. thickening of the gallbladder wall: 2. which one of the following statements is true? a. thyroid cancer is a common disease. b. the presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival of patients by 50% (from 80 90% down to 40%). c. the methods used more than 15 years ago for diagnosis and treatment are similar to present-day management. d. bone metastases represent a rare complication. 3. regarding the case report of a migrating foreign body, which one of the following statements is false? a. the foreign body in this patient most probably migrated from the pelvis to the inferior vena cava and from there to the right atrium and right ventricle, from where it entered the left pulmonary artery to the pulmonary circulation loop. b. this could have happened in the 6 years between the xrays or it could have occurred during the trauma. c. conventional x-rays are sufficient to make a correct diagnosis of a metal foreign body. metal artifact rules out precise location on multislice ct. d. management options include surgical or conservative therapy and should be individualised after the risk evaluation of removal of foreign bodies. 5. with respect to hydropneumopericardium, which one of the following is incorrect? a. traumatic causes of hydropneumopericardium are more frequent than non-traumatic causes. b. non-traumatic causes of hydropneumopericardium include asthma and gastro-pericardic fistula complicating gastric pathology. c. pericardiocentesis is the cornerstone in the management of cardiac tamponade. d. spontaneous remission has not been documented. 6. which one of the following is not associated with isolated reversible splenial lesions? a. epilepsy. b. anti-convulsant therapy. c. tuberculous gumma. d. mild encephalitis. 7. which one of the following statements is false? differential considerations which usually lead to persistent splenial abnormalities include: a. diffuse axonal injury. b. multiple sclerosis. c. marchiafava-bignami disease. d. anterior communicating artery aneurysm. 8. identify the one incorrect statement in the following choices regarding lesions of the splenium of the corpus callosum. a. lesions in epileptic patients are poorly-circumscribed, round or ovoid. b. lesions in epileptic patients are well-circumscribed, round or ovoid. c. those patients without history of seizures or anti-convulsant therapy are more likely to develop lesions that may irregularly extend into the lateral aspect of the scc. d. adem is a cause of reversible lesions. 9. regarding periventricular nodular heterotopias, identify the one wrong statement. a. pnh is a neuronal migration disorder characterised by nodules of ectopic neurons adjacent to the lateral ventricles, due to failed migration of neurons from the germinal zone towards the cortical plate. b. hypoplasia of the cerebellar vermis is commonly associated, but no valvular heart disease is ever seen. c. classical bilateral pnh is the commonest type. d. most affected females develop seizures with variable age of onset and type. 10. identify the one false statement among the following. a. the use of paediatric ct continues to grow despite evidence on known risks of ct-related radiation and induction of fatal cancers in children. b. more than 60 million ct scans are estimated to be performed annually in the usa, with 7 million on children. c. paediatric radiologists apply the practice of alara (‘as low as reasonably achievable’) to reduce radiation exposure. d. education and advocacy directed to referring clinicians is strongly adhered to, and it remains a famously easy task to convince paediatricians not to use ct if another modality could provide the same answer. see previous page for cpd cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www.cpdjournals. org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg.co.za in the event of queries. accreditation number: mdb 001/007/01/2010 4. regarding neurofibromatosis, which one of the following is incorrect? a. nf1 is the most common of the phakomatoses. b. it is an autosomal dominant condition with high penetrance. c. abnormalities are localised to the pericentrometric region of chromosome 18, with 50% having spontaneous mutants with variable expressivity. d. the incidence is 1:2 000 – 4 000, with m:f ratio of 1:1. cpd.indd 24 2/26/10 9:48:26 am sajr 899 molar tooth sign − looking beyond the obvious n mahomed,1 mb bch, fcrad (sa), s p prabhu,2 mb bs, frcr 1 department of radiology, university of the witwatersrand, johannesburg, south africa 2 department of radiology, boston children’s hospital, harvard medical school, boston, ma, usa corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) the molar tooth sign was initially identified in joubert syndrome, named after marie joubert who first described it in 1968 as a rare autosomal recessive disorder characterised by the neuroradiological hallmark of the molar tooth sign caused by cerebellar vermian hypoplasia. subsequently, it emerged that the molar tooth sign encompasses many syndromes that are now grouped together and termed joubert syndrome and related disorders (jsrds). knowledge of the newer classification system and the subtypes is important and helps to direct and interpret imaging studies based on clinical signs so as to avoid delay in diagnosis of the hepatic, oculorenal and renal subtypes of jsrds in patients in whom the molar tooth sign is identified on brain mri. s afr j rad 2013;17(3):102-103. doi:10.7196/sajr.899 the molar tooth sign refers to the characteristic appearance on axial ct or mri of enlarged and horizontally directed columnar structures on each side of the midline flanking a deep interpeduncular fossa.1 this appearance is a result of absence or hypoplasia of the cerebellar vermis, lack of normal dorsal decussation and consequent enlargement of the superior cerebellar peduncles which follow a more horizontal course as they extend perpendicularly to the brainstem between the midbrain and the cerebellum.1 , 2 the absence of decussation of the superior cerebellar peduncular fibre tracts causes decreased anteroposterior diameter of the midbrain and a deep interpeduncular fossa.1 the ‘roots’ of the molar tooth are represented by thick, perpendicular, non-decussated superior cerebellar peduncles, while the ‘body’ of the molar tooth is formed by the cerebral peduncles of the brainstem with a deep interpeduncular fossa (fig. 1a).3 fig. 1a. axial t2 mri at the level of the midbrain demonstrating the molar tooth sign (i.e. thickened superior cerebellar peduncles (arrow indicates left-side peduncle) with a deep interpeduncular fossa) in an 8-year-old patient diagnosed with joubert syndrome in combination with clinical and imaging findings. this appearance is characteristic of non-decussation of the superior cerebellar peduncles. there is marked vermian hypoplasia. diffusion tensor tractography confirms the failure of superior cerebellar peduncle decussation.2 colour-coded functional anisotropic maps evaluate for the presence of a focal red dot anterior to the mesencephalon, adjacent to the interpeduncular fossa, which represents the decussation of these fibre tracts (fig. 1b). absence of the focal red dot demonstrates failure of decussation of the fibre tracts within the superior cerebellar peduncles and laterally located deep cerebellar nuclei (fig. 1c).4 fig.  1b. mri 2d tractography in a normal child. colour-coded functional anisotropic maps demonstrate the presence of a focal red dot anterior to the mesencephalon, adjacent to the interpeduncular fossa which represents the decussation of these fibre tracts. fig. 1c. mri 2d tractography in a patient with jsrd demonstrates lack of superior cerebellar peduncle decussation, i.e. the absent focal red dot. the molar tooth sign was initially identified in joubert syndrome. marie joubert first described this syndrome in 1968 as a rare autosomal recessive disorder characterised by the neuroradiological hallmark of the molar tooth sign caused by cerebellar vermian hypoplasia.4 , 5 subsequently, it has become clear that the molar tooth sign is a radiological hallmark that encompasses many syndromes that are now grouped together and termed joubert syndrome and related disorders (jsrds).2 the genetic basis of jsrds is complex and heterogenous owing to the resultant mutations of genes encoding ciliary proteins important in brain and ocular development and renal function.2 according to the most recent classification, jsrds are classified into 6 phenotypic subgroups: pure js (fig. 1a); js with ocular defect; js with oculorenal defects; js with hepatic defect (fig. 2); js with renal defect (figs 3a and 3b); and js with orofaciodigital defects.6 with the identification of various genetic mutations in each of these subtypes, subsequent classifications will need to incorporate this information.6 it is important for the radiologist to look for associated findings in the central nervous system and other organs, such as the orbits, liver and kidney, associated with jsrds.2 fig. 2. joubert syndrome demonstrating the molar tooth sign on axial t2 mri in a 10-year-old boy with chronic liver disease being treated for wilson disease with chelation therapy. in view of oculomotor apraxia and presence of the molar tooth sign on his brain mri, jsrd was diagnosed. genetic evaluation revealed two mutations for joubert syndrome and, based on the presence of liver disease, diagnosis of the hepatic variant of jsrd was made. fig. 3a. fetal mri, axial t2, at 29 weeks’ gestation demonstrating the molar tooth sign, which was confirmed on postnatal mri and genetic evaluation. fig. 3b. fetal mri, coronal t2, in the same fetus, demonstrating enlarged echogenic kidneys. this finding in conjunction with the molar tooth sign is consistent with a diagnosis of the jsrd renal subtype. once the molar tooth sign is identified, the brain mri scan should be reviewed for other associated abnormalities including abnormal configuration and malrotation of the hippocampi, callosal dysgenesis, malformations of cortical development and cephaloceles, which have been described in a sizeable number of patients with jsrds.7 knowledge of the newer classification system and the subtypes is important as it helps to direct and interpret imaging studies based on clinical signs to avoid delay in diagnosis of the hepatic, oculorenal and renal subtypes of jsrds in patients in whom the molar tooth sign is identified on brain mri. 1. mcgraw p. the molar tooth sign. radiology 2003;229:671-672. [http://dx.doi.org/10.1148/radiol.2293020764] 1. mcgraw p. the molar tooth sign. radiology 2003;229:671-672. [http://dx.doi.org/10.1148/radiol.2293020764] 2. barkovich aj, raybaud c. pediatric neuroimaging, 5th ed. philadelphia, usa: lippincott williams and wilkins, 2012:481-483. 2. barkovich aj, raybaud c. pediatric neuroimaging, 5th ed. philadelphia, usa: lippincott williams and wilkins, 2012:481-483. 3. alorany i, sabir s, seidahmed z, farooqu h, salih m. brainstem and cerebellar findings in joubert syndrome. j comput assist tomogr 2006;30(1):116-121. 3. alorany i, sabir s, seidahmed z, farooqu h, salih m. brainstem and cerebellar findings in joubert syndrome. j comput assist tomogr 2006;30(1):116-121. 4. poretti a, boltshauser e, loenneker t, et al. diffusion tensor imaging in joubert syndrome. am j neuroradiol 2007;28(10):1929-1933. 4. poretti a, boltshauser e, loenneker t, et al. diffusion tensor imaging in joubert syndrome. am j neuroradiol 2007;28(10):1929-1933. 5. sarikaya b, akpinar e, karli-ogus k, cil b. joubert syndrome mri findings. neuroanatomy 2004;1:330-331. 5. sarikaya b, akpinar e, karli-ogus k, cil b. joubert syndrome mri findings. neuroanatomy 2004;1:330-331. 6. brancati f, dallapiccola b, valente em. joubert syndrome and related disorders. orphanet journal of rare diseases 2010;5:20. [http://dx.doi.org/10.1186/1750-1172-5-20] 6. brancati f, dallapiccola b, valente em. joubert syndrome and related disorders. orphanet journal of rare diseases 2010;5:20. [http://dx.doi.org/10.1186/1750-1172-5-20] 7. şenocak eu, oğuz kk, haliloğlu g, topçu m, cila a. structural abnormalities of the brain other than molar tooth sign in joubert syndrome-related disorders. diagn interv radiol 2010;16(1):3-6. [http://dx.doi.org/10.4261/1305-3825.dir.2673-09.1] 7. şenocak eu, oğuz kk, haliloğlu g, topçu m, cila a. structural abnormalities of the brain other than molar tooth sign in joubert syndrome-related disorders. diagn interv radiol 2010;16(1):3-6. [http://dx.doi.org/10.4261/1305-3825.dir.2673-09.1] case report sa journal of radiology • september 2011 89 case history a 34-year-old woman pres ented with a histor y of a pre vious laparoscopic cholecystectomy, followed within a few days by a formal laparotomy for a suspected bile duct injury. approximately one week after the laparotomy, she developed a sinus on the anterior abdominal wall that was draining bile. she was then referred to our institution for further management. the earlier surgery was done at another hospital, and these details were not clear. a ct scan, including a ct sinogram, was performed. the sinogram was done by inserting a catheter into the sinus and running in diluted contrast under gravity. ct images showed the sinus tract communicating with a collection in the gallbladder fossa, as well as contrast opacification of the segment 6 and 7 bile ducts. (figs 1 and 2). a week later, an endoscopic retrograde cholangiopancreatography (ercp) examination was performed. this showed no filling of the right posterior sectoral ducts but normal opacification of the other ducts (figs 3a and b). these findings led to the diagnosis of an aberrant right posterior sectoral bile duct that was not identified prior to surgery and that was damaged at the time of laparoscopic cholecystectomy. this duct now drained into the gallbladder fossa, causing the collection and draining sinus. iatrogenic injury of an aberrant right posterior sectoral bile duct fig. 1. reconstructed ct sinogram demonstrates contrast filling the sinus tract, gallbladder fossa and the right posterior sectoral ducts. fig. 2. reconstructed ct sinogram with contrast in the gallbladder fossa and right posterior sectoral ducts (note surgical clips in the gallbladder fossa). john cantrell, mb bch, fcrad (diag) sa donald gordon medical centre, university of the witwatersrand, johannesburg corresponding author: j cantrell (cantrell_j@hotmail.com) figs 3a, b. ercp shows normal left ducts and normal right anterior sectoral ducts, but non-filling of the right posterior sectoral ducts. a b case report 90 sa journal of radiology • september 2011 discussion pericholecystic biliary anomalies that are often overlooked at the time of laparoscopic cholecystectomy include both aberrant ducts and accessory ducts such as luschka’s duct anomaly (a meshwork of small ducts that extend from the right lobe of the liver in the gallbladder fossa to the right hepatic or common hepatic duct).1 the non-visualisation of the right posterior sectoral duct at ercp supports the diagnosis of an aberrant duct as opposed to an accessory duct. bile duct injuries as a result of laparoscopic cholecystectomy are estimated to occur in 0.5% of cases and continue to exceed the rate at open cholecystectomy. undiagnosed aberrant bile ducts are a common cause of bile duct injury.2 the incidence of aberrant biliary anatomy is approximately 13 25%, with anomalies of the right ducts being the most frequent.2-4 aberrant right sectoral ducts usually drain into the common hepatic or cystic duct (fig. 4). between 4.8 and 8.4% of the population have an aberrant right posterior sectoral duct draining segments 6 and 7.2 injuries to these ducts may be symptomatic as in our case, but are often asymptomatic, with atrophy of the affected segments over time. 1. hirao k, miyazaki a, fujimoto t, isomoto i, hayashi k. evaluation of aberrant bile ducts before laparoscopic cholecystectomy. ajr 2000; 175:713-720. 2. babel n, sakpal sv, paragi p, wellen j, feldman s, chamberlain rs. iatrogenic bile duct injury associated with anomalies of the right hepatic sectoral ducts: a misunderstood and underappreciated problem. hpb surg 2009; 2009: 153269. 3. dahnert w. radiology review manual. 6th ed. philadelphia: lippincott williams and wilkins, 2007: 687. 4. la berge jm, venbrux ac. biliary interventions. 1st ed. fairfax, va, usa: society of cardiovascular and interventional radiology, 1995: 42-43. rasd rpsd cd rhd lhd chd cbd 1. 2. 3. 4. schematic diagrams demonstrating aberrant anatomy of the right posterior sectoral duct (rspd) (shown in red). 1.) normal anatomy. 2.) insertion of the rpsd into the common hepatic duct. 3.) insertion of the rpsd into the cystic duct. 4.) insertion of the rpsd into the left hepatic duct. cbd=common bile duct, cd=cystic duct, chd=common hepatic duct, rhd=right hepatic duct, lhd=left hepatic duct, rasd=right anterior sectoral duct, rpsd=right posterior sectoral duct. fig. 4. anatomical variations of the right posterior sectoral bile duct. case report case reportcase report in patients with a neck injury, the recommendation that positive findings on standard radiographs, or negative findings but a strong clinical suspicion of injury, are indications for computed tomographic (ct) scan, remains current.1 although ct scanning is invaluable for defining bony injury, its inability to satisfactorily demonstrate the spinal soft-tissue structures, particularly the ligaments, makes it an unsuitable modality for excluding instability,2 as the following case illustrates. the patient, an underground mine worker, sustained an injury to his neck in a rock fall accident. cervical spine radiographs and a ct scan demonstrate bilateral fractures which have resulted in disruption of the bony ring of c2. this constitutes a hangman’s fracture (figs 1 and 2). the hangman’s fracture (traumatic spondylolisthesis of the axis) represents fractures of the neural arch of c2 that are produced by a hyper-extension force. although due to a rock fall in this case, it is an injury that is more commonly seen when the head or face hits the windshield or steering wheel in a motor car accident. the forced hyperextension results in bilateral fractures of the c2 neural arch. this is the same fracture as caused by judicial hanging, whence it derives its name.3 neurological consequences of the hangman’s fracture are often less severe than may be anticipated, for two reasons. firstly, the cervical cord occupies only approximately one-third of the antero-posterior diameter of the spinal canal at this level. secondly, bilateral fractures of the posterior arch of c2 produce a decompression of the canal. these combine to spare the upper cervical cord.3 our patient, who was neurologically intact, was treated with skull traction by means of cones calipers for 6 weeks and was then cautiously mobilised (out of bed) in a rigid neck brace. a repeat ct scan 6 months later demonstrates solid bony union at both the right and left c2 ring fracture sites (fig. 3). the important question that should then be asked is: does the demonstration of bony union mean that the injury is now stable? lateral views in flexion and extension are the recommended examination for assessing stability in the cervical spine and should be obtained in all patients in whom the need to exclude instability is clinically indicated. (they are not indicated in patients with clinically or radiographically unstable injuries.) the neck movements by the patient must be voluntary, and under no circumstances should an operator assist the patient with flexion or extension. the examination is also best carried out under the supervision of a radiologist or the attending doctor. figures 4a and 4b show the cervical spine in extension and in flexion respectively. in extension, the gap between the anterior margin of the odontoid peg and the posterior margin of the anterior arch of c1 measures 1 mm. however, in flexion the gap increases to 5 mm. in a normal adult, this gap should not exceed 2 mm. the increased separation between the anterior arch of c1 and the odontoid peg in flexion indicates that there is residual hypermobility/instability present; by implication, this is due to (an additional) injury to the transverse ligament. the answer to the question is therefore that the demonstration of bony union on ct scan does not necessarily indicate that a spinal injury is stable. one should remember that although ct scan demonstrates the bony structures in superb detail, it does not adequately assess the soft-tissue structures, particularly the ligaments. it is in fact possible to have a completely unstable spinal injury as a result of ligamentous injury, without any visible bony injury on plain film radiographs or ct scan.2 1. lau l, ed. imaging guidelines. 3rd ed. melbourne: royal australasian college of radiologists, 1997: 156 (adopted by the radiological society of south africa in 1999). 2. harrison jl, ostlere st. diagnosing purely ligamentous injuries of the cervical spine in the unconscious trauma patient. bjr 2004; 77: 276-278. 3. grainger rg, allison d, eds. grainger & allison’s diagnostic radiology: a textbook of medical imaging. 3rd ed., vol. 2. new york: churchill livingstone, 1997: 1614-1615. assessing cervical stability: a reminder donald emby, mb bch, ff rad (d) sa andrew lancaster, mb chb anglogold ashanti health, western deep levels hospital, carletonville health professionals international is a retained search company!specialising in the placement of medical professionals throughout new zealand and australia. we are currently searching for radiologists to join private radiology groups, with excellent working conditions & generous salary packages, throughout australia. locations such as sydney nsw, central coast nsw, and gold coast qld. assistance will be given with relocation, registration and immigration procedures, if required. australia radiologists needed f o r m o r e i n f o r m a t i o n , c o n t a c t d a r r y l c o o k s l e y d a r r y l @ n y h e a d h u n t e r. c o m p h : ( + 6 4 ) 2 1 9 1 7 5 7 7 w w w . n y h e a d h u n t e r. c o m � sa journal of radiology • april 2008 pg 6-7.indd 6 4/16/08 9:50:35 am case reportcase report fig. 1. lateral shoot-through of the cervical spine. a broad vertical linear lucency (big arrows), which is consistent with posterior fracture of the c2 ring, is demonstrated. a more anterior fracture of the c2 ring is also faintly visible (small arrows). fig. 2. ct scan through the body and dorsal ring of c2, showing fractures of the right lamina and left pedicle (arrows). (the classic hangman’s fracture consists of fractures through the base of the posterior ring of c2 on both sides. as the fracture on the right side in this patient is more posteriorly situated, this could technically be described as a ‘variant hangman’s fracture’.) fig. 3. ct scan through the body and dorsal ring of c2 at same level as in fig. 2, but 6 months later. both fractures are shown to have healed. fig. 4a. lateral upper cervical spine in extension. the anterior cortical margin of the odontoid peg and the posterior cortical margin of the anterior tubercle of c1 have been highlighted and are indicated by the arrow. the gap between the odontoid peg and anterior tubercle of c1 measures approximately 1 mm. fig. 4b. lateral upper cervical spine in flexion. the gap between the odontoid peg and the anterior tubercle of c1 has increased significantly and now measures approximately 5 mm. this indicates abnormally increased mobility (i.e. instability) of c1 on c2. � sa journal of radiology • april 2008 pg 6-7.indd 7 4/16/08 9:50:38 am original article original article 18 sa journal of radiology • june 2007 original article abstract a current trend towards specialisation exists amongst medical graduates worldwide. available registrar positions are therefore limited and there is often strong competition for posts. south africa has a unique political history, and as a result there are government directives promoting equal opportunities in order to correct the inequalities of the past. in other countries, race is considered to be an unimportant factor in residency selection, and registrars are chosen predominantly on merit. in this context, an anonymous survey was conducted amongst registrars in radiology to determine whether selection for a registrar post in south africa is defined by a preconceived social profile or whether candidates are selected on academic credentials and work experience. our results showed that academic credentials and work experience are key criteria for the selection of registrars in south africa. gender equality is achieved in medical specialist training departments, but a marked racial misrepresentation exists despite current employment policies. the explanation for this finding warrants further study. introduction a current trend towards specialisation exists amongst medical graduates worldwide. in the united kingdom, a 2002 survey concluded that ‘a total of 22.7% of the medical graduates (28.1% of women, 14.5% of men) expressed a preference for a long-term career in general practice.’1 similar statistics are reflected in united states data, which showed ‘a decrease in medical student interest in primary care careers (from 35.6% in 1999 to 21.5% in 2002)’.2 the popularity of medical specialisation can be attributed to the potential of acquiring certain rewards, such as: prestige; academic exposure, involvement and/or prowess; a higher income; and better working hours or a more ‘controllable’ lifestyle. radiology has become an increasingly popular career choice specialty for medical graduates over the past decade. in south africa there are presently limited training posts and competition is strong. to quote the information letter for registrar applicants currently provided by the department of radiology at groote schuur hospital, ‘we usually have 2 5 posts available in february each year, and about ten times as many applicants’. in most countries, registrars are chosen predominantly on merit. a united states survey, which aimed to determine the most important criteria for selecting candidates for diagnostic radiology residency, found that class rank and medical school grades have the highest rating of importance.3 on average, 60 candidates are invited to interview for approximately 5 available positions (comparable to the trend in south africa). however, the south african political history is unique and the african national congress has developed labour policies in an attempt to rectify the inequalities of the past. as a result, white male applicants (the minority population group) theoretically experience the most difficulty in obtaining registrar posts in south africa, not only in radiology, but in all medical specialties. in this study we hoped to establish whether there is a certain predetermined social (racial and gender) profile for the selection of registrars in south africa and to what degree they are selected on merit (academic performance and work history). objective to determine whether radiology registrars fit a social ‘profile’ or whether they fulfil criteria considered to represent academic credentials, work experience and personal effort or tenacity. hypothesis that selection of registrars in radiology in south africa is based on social criteria (such as gender and race) rather than academic credentials (such as school results, undergraduate results and research publications), work experience (such as years of clinical experience and previous radiology experience), and personal effort and tenacity (such as perseverance and contacting the head of department). method a survey was designed to include 16 questions based on social, academic, work, and personal effort criteria thought to affect selection onto the radiology registrar circuits at 8 accredited institutions in south africa. these were not categorised on the questionnaire (table i). the survey was conducted during the 3rd annual pre-exam course of the college of radiologists (the only dedicated radiology registrar meeting in south africa) in september 2006. questionnaires were completed anonymously and collected immediately. the results were categorised and analysed by an applicant for registrar selection and supervised by a radiology consultant. results there were 45 respondents: 35.5% from the university of stellenbosch, 26% from the university of the witwatersrand, 15.5% from the university of cape town, 8.8% from the university of pretoria, 6.6% from the is selection for a registrar post in south africa defined by a preconceived social profile or are candidates selected on academic credentials and work experience? v du plessis, mb chb, da (sa) department of radiology, greys hospital, pietermaritzburg hospital complex, nelson r mandela school of medicine, university of kwazulu-natal s andronikou, mb bch, fcrad (d), frcr (lond), phd department of radiology, tygerberg hospital, stellenbosch university pg18-23.indd 18 6/13/07 9:21:20 am original articleoriginal article 19 sa journal of radiology • june 2007 ta bl e i. su rv ey (s ep te m be r 2 00 6) – c ur re nt s ou th a fr ic an re gi st ra rs in r ad io lo gy * a ge ☐ < 2 5 ye ar s ☐ 2 530 y ea rs ☐ 3 040 y ea rs ☐ > 4 0 ye ar s g en de r ☐ m al e ☐ f em al e r ac e ☐ b la ck ☐ c ol ou re d ☐ in di an ☐ w hi te ☐ a sia n po st gr ad ua te u ni ve rs ity ☐ u ni ve rs ity o f c ap e to w n ☐ u ni ve rs ity o f s te lle nb os ch ☐ u ni ve rs ity o f w itw at er sr an d ☐ u ni ve rs ity o f p re to ri a ☐ u ni ve rs ity o f k w az ul un at al ☐ u ni ve rs ity o f f re e st at e ☐ m ed ic al u ni ve rs ity o f s ou th a fr ic a ☐ w al te r s isu lu u ni ve rs ity u nd er gr ad ua te u ni ve rs ity ☐ u ni ve rs ity o f c ap e to w n ☐ u ni ve rs ity o f s te lle nb os ch ☐ u ni ve rs ity o f w itw at er sr an d ☐ u ni ve rs ity o f p re to ri a ☐ u ni ve rs ity o f k w az ul un at al ☐ u ni ve rs ity o f f re e st at e ☐ m ed ic al u ni ve rs ity o f s ou th a fr ic a ☐ w al te r s isu lu u ni ve rs ity ☐ o th er (e .g . f or ei gn ) pl ea se sp ec ify c ur re nt y ea r o f r eg ist ra rs hi p ☐ 1 st y ea r ☐ 2 nd y ea r ☐ 3 rd y ea r ☐ 4 th y ea r ☐ 5 th y ea r u nd er gr ad ua te re su lts (a gg re ga te ) ☐ 9 0 – 10 0 % ☐ 8 0 – 90 % ☐ 7 5 – 80 % ☐ 7 0 – 75 % ☐ 6 0 – 70 % ☐ 5 0 – 60 % sc ho ol re su lts ☐ a a gg re ga te ☐ b a gg re ga te ☐ c a gg re ga te ☐ d a gg re ga te o th er q ua lif ic at io ns o bt ai ne d pr ere gi st ra rs hi p ☐ a t ls ☐ a c ls ☐ a pl s/ pa ls ☐ d ip lo m a pl ea se sp ec ify __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ☐ o th er (e .g . p rim ar y m m ed /c ol le ge e xa m ) pl ea se sp ec ify _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ r es ea rc h/ pu bl ic at io ns p re -r eg ist ra rs hi p ☐ y es ☐ n o if “y es ”, pl ea se sp ec ify ty pe o f r es ea rc h/ pu bl ic at io n _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ po st gr ad ua te cl in ic al ex pe ri en ce be fo re r eg is tr ar ap po in tm en t (in cl ud in g in te rn sh ip ) n o of y ea rs _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ m ed ic al o ffi ce r i n r ad io lo gy b ef or e r eg ist ra r? ☐ y es ☐ n o if “y es ”, nu m be r o f y ea rs in m o p os t_ __ __ __ __ __ __ __ __ __ __ __ _ r ad io lo gy fa cu lti es a pp lie d to fo r p os tg ra du at e st ud y ☐ u ni ve rs ity o f c ap e to w n ☐ u ni ve rs ity o f s te lle nb os ch ☐ u ni ve rs ity o f w itw at er sr an d ☐ u ni ve rs ity o f p re to ri a ☐ u ni ve rs ity o f k w az ul un at al ☐ u ni ve rs ity o f f re e st at e ☐ m ed ic al u ni ve rs ity o f s ou th a fr ic a ☐ w al te r s isu lu u ni ve rs ity ti m e be tw ee n ap pl ic at io n an d ap po in tm en t a s r eg ist ra r ☐ < 6 m on th s ☐ 6 m on th s – 1 y ea r ☐ 1 – 2 y ea rs ☐ > 2 y ea rs c on ta ct w ith h ea d of r ad io lo gy d ep t b ef or e in te rv ie w ☐ p er so na l ☐ e -m ai l ☐ t el ep ho ni c ☐ w rit te n co rr es po nd en ce ☐ n on e a va ila bi lit y fo r r eg ist ra r p os t a t t im e of a pp lic at io n ☐ im m ed ia te ☐ < 1 m on th n ot ic e ☐ > 1 m on th n ot ic e c om m en ts (i f p os sib le , i nc lu de in di vi du al c rit er ia w hi ch y ou b el ie ve le d to y ou r s el ec tio n as a r ad io lo gy re gi st ra r) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ t ha nk y ou fo r y ou r t im e an d co -o pe ra tio n in c om pl et in g th is su rv ey *t he p ur po se o f t hi s s ur ve y is to d et er m in e th e cu rr en t s el ec tio n cr ite ri a fo r r ad io lo gy re gi st ra rs to tr ai n at s ou th a fr ic an fa cu lti es . t hi s i s a c om pl et el y an on ym ou s s ur ve y an d w ill b e us ed fo r s ta tis tic al p ur po se s. pg18-23.indd 19 6/13/07 9:21:21 am original article original article 20 sa journal of radiology • june 2007 original article university of kwazulu-natal, and 6.6% from the medical university of south africa. the 3rd-year registrars comprised 40% of the respondents, the 4th-year’s 22.2%, the 2nd-year’s 20%, and the 1st-year’s 15.5%. social profile gender. there was an almost equal incidence of males and females (51% female). race. the majority were white (55.5%) followed by indian (24.4%), black (13.3%) and coloured (2.2%) (2 non-respondents). age. the majority (67%) fell between and 30 and 39 years of age (fig. 1). academic profile undergraduate results. the majority (51.1%) fell into the 60 70% aggregate category, and 24.4% fell into the >75% aggregate category (fig. 2). school results. the majority (68.9%) had an a-aggregate (fig. 3). research/publications. the minority had published or done research (26.6%) (fig. 4). (these included case reports and articles in the south african journal of radiology, posters, a primary health article, audits – 1 in radiology, 1 in neonatal medicine and 1 unspecified, an unspecified chapter within a book, and unspecified theses). fig. 6. time between application and appointment as a registrar. time between application and appointment as registrar time between application and appointment as registrar 16 15 8 5 1 0 2 4 6 8 10 12 14 16 18 <6 months 6 months 1 year 1-2 years >2 years (blank) n o o f r e g is tr a rs fig. 6. time between application and appointment as a registrar . fig. 1. registrars attending the college course according to age. age of registrars registrars attending the college course according to age 0 5 10 15 20 25 30 35 25 29 years 30-39 years > 40 years n o o f r e g is tr a rs 24% 67% 9% fig. 1. registrars attending the college course according to age. fig. 2. registrars attending the college course according to undergraduate results. registrars attending the college course according to undergraduate results 1 23 9 8 3 0 5 10 15 20 25 50-59% 60-69% 70-74% 75-79% 90-100% n o o f r e g is tr a rs undergraduate results fig. 2. registrars attending the college course according to undergraduate results. fig. 3. registered attending the college course according to school results. registrars attending the college course according to school results 69% 27% 4% school results 31 12 2 0 5 10 15 20 25 30 35 a aggregate b aggregate c aggregate n o o f r e g is tr a rs fig. 3. registrars attending the college course according to school results. fig. 4. percentage of registrars involved in research / publication pre-registrarship. percentage of registrars involved in research/publication pre-registrarship 33 12 0 5 10 15 20 25 30 35 no yes involvemen t n o o f r e g is tr a rs 73% 27% not involved involved t fig. 4. percentage of registrars involved in research/publicatioin pre-registrarship. fig. 5. years of postgraduate experience (including internship) before registrars appointment. years of postgraduate experience (including internship) years of postgraduate experience (including internship) before registrar appointment 1 5 1 2 10 1 9 1 3 1 2 1 2 2 1 3 0 2 4 6 8 10 12 1.5 2 2.5 3 4 4.5 5 5.5 6 7 8 9 12 13 16 (blank) n o o f r e g is tr a rs fig. 5. years of postgraduate experience (including internship) before registrar appointment. a aggregate b aggregate c aggregate time between application and appointment as registrar age of registrars pg18-23.indd 20 6/13/07 9:21:23 am original articleoriginal article 21 sa journal of radiology • june 2007 work experience postgraduate clinical experience (pre-registrarship) – 80% had 4 years or more (48.8% had 5 years or more) (fig. 5) experience as medical officer in radiology – 18%. persistence and tenacity time from first application to appointment – 69% less than 1 year, 11% more than 2 years (fig. 6). contact with head of department – 58%. availability to start job – 47% in less than 1 month. bias there are various limitations to this study. volunteer bias is inherent to every survey; in this survey 57 questionnaires were distributed and there were 45 respondents.4 secondly, the information provided by the participants may not be accurate enough to generalise and produce conclusions. thirdly, only 27.3% of the national group of 165 radiology registrars were represented by the survey. the conference was attended mostly by the more senior registrars as the juniors remained at their various departments to carry the workload. there was a large proportion of registrars from the universities of cape town and stellenbosch (based on location of the course in the western cape), and by the university of the witwatersrand (the largest number of registrars in training). therefore the distribution of the sample may under or over-estimate the data. discussion rationale for the popularity of radiology as a specialty the shortage of registrar posts in south africa can be justified, in part, by the increased demand for posts by medical graduates wanting to specialise. the popularity of radiology as a specialty choice can be explained by addressing the rewards of specialisation and discussing their specific relevance to radiology. 1. academic as a registrar in a training institution, one has the opportunity to gain valuable knowledge from well-regarded academic consultants and to become involved in funded research projects. radiology is a rapidly advancing field of medicine, and specialisation in this discipline allows direct exposure to the latest innovative technology. academic performance. in the united states, the selection process for registrars usually includes a pre-selection review of medical school performance and an interview phase.4 several studies to identify which selection criteria best predict in-training performance of radiology residents have consistently found a lack of correlation between academic performance during medical school or pre-clinical training and later performance during residency training, suggesting that the assessment of non-cognitive abilities is essential for successful recruitment.4 however, evidence is controversial because some studies have reported the opposite.4,5 the usmle (united states medical licensing examination) score remains the most important criterion in selecting applicants for an interview.4,6 the academic profiles of our survey participants show that the radiology registrars generally achieved good school and undergraduate results. most of them (68.9%) achieved an a-aggregate at school and the majority (71.1%) achieved between 60% and 75% aggregate at medical school (24.4% achieved more than 75%). academic research and publications. we found that 26.6% of the registrars were involved in research before their registrarship. whether or not previous involvement in research is predictive of publication potential during radiology residency, remains controversial: a 1992 canadian study7 reported that ‘academic radiologists were more likely to have performed research, published and presented the results of their research activities, and taught before undertaking the residency program in radiology’, while a 2002 american study8 suggests that ‘there was no difference in publication potential between those residents who were academically productive in the past and those who were not’. work experience. the majority of the registrars (80%) had more than 4 years of postgraduate clinical experience before commencing their registrarship (48.8% had more than 5 years). the minority (18%) spent time in a medical officer post in radiology before being selected as a registrar. previous experience in radiology is therefore presumably not a decisive factor in the registrar selection process, but work experience seems to be important. our results thus suggest that a registrar applicant’s academic and work experience profile is an important criterion in the selection process in south africa, implying that, as in other countries, merit is considered to be of great significance. 2. financial radiology is amongst the top-earning state-employed medical specialties in the united states.9 in 1998, the human sciences research council of south africa published the remumeration update, extracted from the graduate employment survey that was conducted in 1997. radiology was one of the 10 top-earning occupations for 1997. (four of 1997s ten highest-paid occupations were in the medical field, all in the private sector).10 medical specialists who are self-employed or in private practice earn a higher income, on average, when compared with academic or state-employed specialists. this is demonstrated by a survey studying the factors that influence radiologists’ career choices, which showed that ‘an exodus from academic radiology to private practice is evident among graduates … with greater financial reward being the primary motivation’.11 3. desirable working hours / lifestyle several surveys conducted with medical students in the united states from 1996 to 2004 have addressed the changing influence of lifestyle and income on career choice.12-14 ‘students’ perceptions of specialties existed on a continuum of lifestyle-friendly (e.g. radiology) to lifestyleunfriendly (e.g. obstetrics-gynaecology).’12 the authors concluded that perception of ‘controllable’ lifestyle (determined by income, work hours and years of graduate medical education required), accounts for most of the variability in recent changing patterns in the specialty choices of graduating united states medical students.13 changing trends are occurring equally for male and female medical students.14 pg18-23.indd 21 6/13/07 9:21:23 am original article original article 22 sa journal of radiology • june 2007 original article 4. medico-legal risk private radiologists in south africa fall under the ‘private specialists – medium risk’ category as ranked by the medical protection society. their risk of medico-legal action and thus their annual mps rates are at the lower end of the scale for medical specialists. selection criteria for registrars in most countries, registrars are chosen predominantly on merit. a united states survey,3 which aimed to determine the most important criteria for selecting candidates for diagnostic radiology residency, found that class rank and medical school grades have the highest rating of importance. a similar study added that research participation, gender and race were the three least important attributes.15 internationally, selection of residents is by application, pre-interview screening and interview. standardised interviews are used in the united states where 60% of the residency programs use a checklist and 55.4% compile score sheets during interviews. many american program directors believe that a ‘gut feeling’ or the ‘right fit’ of candidates in the program was the single most important factor that determines admission.4 at present, the minimum requirements for registrar selection in south africa are: (i) a tertiary qualification (mb chb) or equivalent; (ii) full current registration with the health professions council for independent practice; and (iii) completion of community service at the time of taking up appointment. the department of health must also comply with the employment equity act, no. 55 of 1998, which states that ‘every designated employer must, in order to achieve employment equity, implement affirmative action measures for people from designated groups’, where ‘employment equity’ means ‘equal opportunity and fair treatment in the workplace’, ‘affirmative action’ means ‘a policy of correcting past inequalities, for example, hiring people from previously disadvantaged backgrounds in order to create a representative workforce’, and ‘designated groups’ means black people (‘a generic term which means africans, coloureds and indians’), women and people with disabilities.16 the white paper for the transformation of the health system in south africa states that ‘the personnel profile of the health system should reflect broadly the composition of the relevant labour market at all organisational levels’ and that ‘the admission of students to training and educational institutions should reflect national demography’.17 according to statistics south africa, the 2006 mid-year population estimates show that of a population of approximately 47.4 million, 51% (24.1 million) are female. population group demographics are represented in table ii.18 thus, for a true representation of national demography, the registrar posts in a training department should be represented equally by men and women, 90.8% of the posts should be occupied by black registrars (i.e. african, coloured or indian, as per definition in the employment equity act), and 9.2% by white registrars. otherwise stated, in a department of 10 registrars, there should be 9 black and 1 white, and equal numbers of males and females. consequently, it stands to reason that if there is adherence to these employment policies, an applicant’s chance of success will vary according to the existing representation of national demography within a department. such policies theoretically make it less likely for an applicant from a minority population group (e.g. a white male who constitutes a mere 4.6% of national demography) to be selected. the results of our survey show an equal distribution of gender groups amongst radiology registrars. however, the group was non-representative of national demography in terms of race 55.5% of the registrars were white and only 39.9% black as per definition in the employment equity act (24.4% indian, 13.3% african, 2.2% coloured). this racial misrepresentation in the setting of more than 10 years of democracy in south africa is a matter of concern, and the rationale behind it warrants further study. conclusion the popularity of medical specialisation is on the increase internationally and available registrar posts are limited. south africa’s political situation is unique, but despite government directives to represent national demographics in medical specialty training departments, the results of this survey have shown that a marked racial misrepresentation prevails. this is a surprising finding following more than 10 years of democracy and 8 years of employment equity in south africa, and the explanation warrants further study. consequently, our results have disproved our hypothesis. it appears that the selection of radiology registrars in south africa is, in fact, based primarily on academic credentials, work experience and personal effort and tenacity, rather than on a preconceived social profile. the authors view this survey as a pilot study. we intend to distribute this survey to more registrars during 2007, thus broadening our sample and attaining more accurate results. table ii. mid-year estimates for south africa by population group and sex, 2006 male female total number % of total number % of total number % of total population group population population population african 18 558 500 79.65 19 104 400 79.4 37 662 900 79.5 coloured 2 060 000 8.8 2 138 800 8.9 4 198 800 8.9 indian/asian 570 200 2.4 593 700 2.5 1 163 900 2.5 white 2 138 900 9.2 2 226 400 9.3 4 365 300 9.2 total 23 327 600 100 24 063 300 100 47 390 900 100 pg18-23.indd 22 6/13/07 9:21:24 am original articleoriginal article 23 sa journal of radiology • june 2007 1. lambert tw, goldacre mj, turner g. career choices of united kingdom medical graduates of 2002: questionnaire survey. med educ 2006; 40: 514-521. 2. newton da, grayson ms. trends in career choice by us medical school graduates. jama 2003; 290: 1179-1182. 3. grantham jr. radiology resident selection: results of a survey. invest radiol 1993 28(1): 99-101. 4. otero hj, erturk sm, ondategui-parra s, ros pr. key criteria for selection of radiology residents: results of a national survey. acad radiol 2006; 13: 1155-1164. 5. boyse td, patterson sk, cohan rh, et al. does medical school performance predict radiology resident performance? acad radiol 2002; 9: 437-445. 6. gunderman rb, jackson vp. are nbme examination scores useful in selecting radiology resident candidates? acad radiol 2000; 7:603-606. 7. bilbey jh, fache js, burhenne hj. are there predictors for future academic radiologists? a canadian survey. can assoc radiol j 1992; 43: 369-373. 8. patterson sk, fitzgerald jt, boyse td, cohan rh. is past academic productivity predictive of radiology resident academic productivity? acad radiol 2002; 9: 211-216. 9. top earning specialties in the us. http://www.mgma.com/workarea/showcontent.aspx?id=5498 (last accessed 25 october 2006) 10. top earners in south africa 1998. http://www.hsrc.ac.za/media/1998/4/19980422.html (last accessed 25 october 2006) 11. feng l, ruzal-shapiro c. factors that influence radiologists’ career choices. acad radiol 2003; 10(1): 45-51. 12. newton da, grayson ms, thompson lf. the variable influence of lifestyle and income on medical students’ career specialty choices: data from two u.s. medical schools, 1998-2004. acad med 2005; 80: 809-814. 13. dorsev er, jarjoura d, rutecki gw. influence of controllable lifestyle on recent trends in specialty choice by us medical students. jama 2003; 290: 1173-1178. 14. dorsev er, jarjoura d, rutecki gw. the influence of controllable lifestyle and sex on the specialty choices of graduating u.s. medical students, 1996-2003. acad med 2005; 80: 791-796. 15. bajaj g, carmichael kd. what attributes are necessary to be selected for an orthopaedic residency position: perceptions of faculty and residents. south med j 2004; 97: 1179-1185. 16. employment equity act, no. 55 of 1998. http://www.labour.gov.za/download/8276/act%20%20employment%20equity.pdf (last accessed 25 october 2006) 17. white paper for the transformation of the health system in south africa. http://www.doh.gov.za/docs/ policy/white_paper/healthsys97_01.html (last accessed 25 october 2006). 18. mid-year estimates for south africa by population group and sex, 2006. http://www.statssa.gov.za/publications/p0302/p03022006.pdf (last accessed 25 october 2006). learning radiology: recognizing the basics with student consult online access by william herring isbn 0323043178 / 9780323043175 ä paperback ä 320 pages ä 510 illustrations mosby ä forthcoming title (june 2007) health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 086 695 0461 e-mail: claudec@hmpg.co.za / brents@hmpg.co.za ease your exam anxiety...and sharpen your clinical skills! written by william herring, md a seasoned radiology instructor and creator of an award-winning radiology teaching web site learning radiology efficiently presents just the radiology knowledge you need to know to get through clinical rotations and usmles. and, bonus online access via student consult where you will find the complete text of the book, selfassessment quizzes, and more -, makes this an even more effective learning tool! pg18-23.indd 23 6/13/07 9:21:24 am article information author: a. fourie bezuidenhout1 affiliation: 1 department of radiodiagnosis, stellenbosch university, south africa correspondence to: fourie bezuidenhout postal address: po box 19179, tygerberg 7505, south africa dates: received: 07 jan. 2014 accepted: 16 feb. 2014 published: 20 june 2014 how to cite this article: bezuidenhout af. persistent hyperplastic primary vitreous – the martini glass sign. s afr j rad. 2014;18(1); art. #597, 1 page. http://dx.doi.org/10.4102/ sajr.v18i1.597 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. persistent hyperplastic primary vitreous – the martini glass sign in this signs... open access • content • acknowledgements    • competing interests • references content top ↑ persistent hyperplastic primary vitreous (phpv) is a congenital lesion due to incomplete regression of the embryonic ocular blood supply (hyaloid vasculature).1 it represents 28% of childhood presentations of leukocoria and is almost always accompanied by poor vision, micropthalmia and often retinal detachment.1 , 2 , 3 the absence of ocular calcifications helps distinguish phpv from the more common retinoblastoma.4 the appearance of phpv has been likened to that of a martini glass. the martini glass is represented by triangular retrolental fibrovascular tissue and a central tissue stalk of hyaloid remnant extending to the optic disc in cloquet’s canal (see figure 1a).5 the retrolental fibrovascular tissue and stalk-like hyaloid remnant are hypointense to isointense on t1and t2-weighted images and show enhancement post contrast administration. the globe may be hyperintense on t1-weighted images; this may represent either subhyaloid or subretinal fluid with blood degradation products (methaemoglobin) or high protein content (see figure 1b).11 figure 1: axial t2-weighted (a) and axial t1-weighted (b) images show the triangular retrolental fibrovascular tissue (arrow 1) and a central tissue stalk of hyaloid remnant in cloquet's canal (arrow 2) representing the 'martini glass' sign; (b) micropthalmia and hyperintense vitreous (arrow) on t1-weighted image due to accumulation of blood degradation products or high protein content compared to normal right globe. acknowledgements top ↑ competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1.smirniotopoulos jg, bargallo n, mafee mf. differential diagnosis of leukokoria: radiologic-pathologic correlation. radiographics. 1994;14(5):1059–1079. pmid: 7991814. http://dx.doi.org/10.1148/radiographics.14.5.7991814 2.küker w, ramaekers v. persistent hyperplastic primary vitreous: mri. neuroradiology. 1999;41(7):520–522. pmid: 10450848. http://dx.doi.org/10.1007/s002340050796 3.sun mh, kao ly, kuo yh. persistent hyperplastic primary vitreous: magnetic resonance imaging and clinical findings. chang gung med j. 2003 apr;26(4):269–276. pmid: 12846526. 4.edward dp, mafee mf, garcia-valenzuela e, weiss ra. coats’ disease and persistent hyperplastic primary vitreous. role of mr imaging and ct. radiol clin north am. 1998;36(6):1119–1131, x. pmid: 9884692. 5.kaste sc, jenkins jj, meyer d, fontanesi j, pratt cb. persistent hyperplastic primary vitreous of the eye: imaging findings with pathologic correlation. am j roentgenol. 1994;162(2):437–440. pmid: 8310942. http://dx.doi.org/10.2214/ajr.162.2.8310942 case series 11 sa journal of radiology • march 2010 abstract focal reversible lesions of the splenium of the corpus callosum have been described in a number of clinical paradigms. epilepsy and related conditions are the most commonly reported underlying clinical association. sudden anti-epileptic therapy withdrawal or seizure activity may be presumed to be the predisposing cause. however, an individual susceptibility must also be considered. although the exact mechanism producing this syndrome is not known, the mri appearance and course in each of these clinically distinct causative entities is similar. the complete reversibility of the abnormality on follow-up studies is common to all, and many authors suggest that a conservative watchful approach is all that is required. we present here the findings in two patients with similar, completely reversible, splenial lesions. case 1 a 28-year-old female it engineer with a background 4-year history of migraine presented with an atypical constant headache that had been progressing over the previous 2 weeks. no previous seizures, anticonvulsant therapy or recreational drug use was noted. she had been using an appetite suppressant containing pseudo-ephedrine. her neurological examination was normal. initial magnetic resonance imaging (mri) study revealed swelling of the splenium of the corpus callosum (scc) with t1 and t2 prolongation (fig. 1) and associated restricted diffusion (fig. 2) within the area of concern. there was no enhancement after intravenous gadolinium administration. computerised tomographic (ct) angiography of the the enigma of reversible splenial lesions shalendra kumar misser, mb chb, fcrad (diag) sa duncan royston, mb bch, ffrad (sa), msc lake smit and partners, st augustine’s hospital, durban farhana motala, mb chb, fcp (sa) (neurol) st augustine’s hospital, durban christo coetzee, mb chb, mmed (neuro) entabeni hospital, durban fig. 1. cranial mr images demonstrate a focal non-enhancing corpus callosum splenial lesion (arrow). (a) sagittal t1-weighted image shows swelling of splenium of the corpus callosum with t1 prolongation. (b) lesion in the splenium is hyperintense on axial t2-weighted turbo spin echo. (c) hyperintense on the coronal flair image. fig. 2. diffusion-weighted mri sequences reveal a focal lesion with restricted diffusion. (a) adc map demonstrates reduced signal within the splenial lesion (arrow). (b) corresponding hyperintensity on the b1000 image confirms restricted diffusion (~~>). fig. 3. follow-up mri study demonstrates complete resolution of the splenial lesion with no residual abnormal signal on any sequence. (a) adc map; (b) b-1000 diffusion-weighted image; (c) the coronal flair sequence. the enigma.indd 11 2/26/10 9:51:01 am case series case series 12 sa journal of radiology • march 2010 intracranial vessels was normal. cerebrospinal fluid analysis and blood tests including search for typical cns infections were non-contributory. a follow-up mri study (fig. 3) showed complete resolution of the previously demonstrated scc lesion. case 2 a 22-year-old woman, known to have been epileptic for the past 6 years, presented with increased seizure frequency while on an overseas holiday. electro-encephalogram showed bifrontal sharp waves and wave bursts with hyperventilation, but no temporal lobe focus could be identified. subsequent to these seizures of mixed phenomenology (including generalised tonic-clonic, absence and myoclonic seizures), marked expressive dysphasia was noted. her medication had been changed from valproic acid to phenytoin and lamotrigine while on holiday in europe. initial brain mri scan performed at an overseas facility was reportedly normal. a repeat mri scan was performed 3 months later at our institution owing to persistent seizures. a focal scc lesion, identical to that demonstrated in patient 1, was apparent, including t2 signal hyperintensity, low apparent diffusion coefficient (adc) and absence of contrast uptake. her treatment regimen was again modified to levitiracetum 250 mg twice daily, with only mild improvement to her expressive dysphasia and decreased seizure frequency. a follow-up mri 5 months later showed complete resolution of the scc lesion. discussion isolated lesions of the scc have been documented in a variety of clinical entities. these include epilepsy, anticonvulsant therapy, mild encephalitis, ischaemia and acute disseminated encephalomyelitis (adem) as the more common aetiologies causing reversible lesions. differential considerations, which usually lead to persistent abnormalities, are diffuse axonal injury, multiple sclerosis, lymphoma and – more rarely – extra-pontine myelinolysis, marchiafava-bignami disease and posterior reversible encephalopathy syndrome (pres).1,2 the pathogenesis of the changes in the scc is unknown. the scc is generally not an epileptogenic focus, but rather a pathway for seizure propagation. whether the scc contributes to secondary generalisation is a controversial hypothesis equally supported and refuted by various authors.3,4 anticonvulsant therapies have also been shown to be a possible cause leading to scc lesion development.5 the rapid change of dose of anticonvulsant drugs influences the arginine-vasopressin fluid homeostasis systems and may be a contributory factor to the development of vasogenic oedema by disequilibrium owing to a syndrome of inappropriate antidiuresis. reversibility of these scc foci was attributed to reduction of anti-epileptic drug dose or complete withdrawal.6 studies have shown that the fibre composition within the scc is no different from the rest of the corpus callosum.7 curiously, however, the splenium is the only portion of the corpus callosum where the vertebrobasilar system provides some vascular supply by the terminal branches of the posterior cerebral arteries.8 the corpus callosum is otherwise primarily supplied by the internal carotid system, via the anterior cerebral arteries. the role of the autonomic nervous system innervation of the intracranial vessels and its impact on scc lesions is uncertain. malnutrition, including vitamin deficiencies, has been postulated as a predisposing cause of scc lesions.2,3 folate and vitamin b12 deficiency are the principal considerations for nutritional causes. patient 1, as reported here, was on an appetite suppressant, and diet restriction in this instance may not be disregarded as a possible predisposing cause. in clinically diagnosed encephalitis, scc lesions have been documented.1,9-12 these foci may be related to the underlying viral aetiology or the sequelae of encephalitis. patho-physiological processes proposed in the case of the latter include inflammatory cell infiltrate (especially with interleukin-6)10 and intramyelinic cytotoxic oedema. such cellular swelling is responsible for the high b-1000 diffusion-weighted signal, reduced adc values and corresponding t1 and t2 prolongation on mri. thomas et al.13 suggested that the cytotoxic oedema described by restricted diffusion on mri scanning was in fact due to excitotoxicity. the final common pathway, however, described by polster et al.3 is that of transient white-matter oedema with or without demyelination. the morphology of the scc lesions was recently analysed10 in 15 patients with encephalitis and compared with prior studies3-6 where lesions in epileptic patients were shown to be well circumscribed, round or ovoid (as in the patients reported here). it was found that those patients without history of seizures or anticonvulsant therapy were more likely to develop lesions that may irregularly extend into the lateral aspect of the scc. this is, however, a descriptive feature on a limited sample population. with increasing use of mri scanning in patients with epilepsy, encephalitis or other causes of encephalopathy, increasing numbers of reversible scc lesions have been described. despite the various possible aetiologies, the benign course that these lesions seem to follow is well documented, and for this reason, as in the two patients presented, a conservative approach is recommended. unnecessary additional investigations or therapies should be avoided; a limited follow-up mri study to demonstrate resolution is reassuring to patient and clinician alike. 1. yeh ib, tan lcs, sitoh yy. reversible splenial lesion in clinically mild encephalitis. singapore med j 2005; 46(12): 726. 2. kosugi t, isoda h, imai m, sakahara h. reversible focal splenial lesion of the corpus callosum on mr images in a patient with malnutrition. magn reson med sci 2004; 3(4): 211-214. 3. polster t, hoppe m, ebner a. transient lesion in the splenium of the corpus callosum: three further cases in epileptic patients and a pathophysiological hypothesis. j neurol neurosurg psychiatry 2001; 70: 459-463. 4. chason dp, fleckenstein jl, ginsburg mi. transient splenial edema in epilepsy: mr imaging evaluation. proceedings of the 34th annual meeting of the american society of neuroradiology; june 21-27. 1996, seattle, wa, usa. chicago: old smith printers, 1996. 5. kim ss, chang k, kim st. focal lesion in the splenium of the corpus callosum in epileptic patients: antiepileptic drug toxicity? ajnr 1999; 20: 125-129. 6. mirsattari sm, lee dh, jones mw, blume wt. transient lesion in the splenium of the corpus callosum in an epileptic patient. neurology 2003; 60: 1838-1841. 7. aboitiz f, scheibel ab, fisher rs, zaidel e. fiber composition of the human corpus callosum. brain res 1992; 598(1-2): 143-153. 8. kakou m, velut s, destrieux c. vascularisation artérielle et veineuse du corps calleux. neurochirurgie 1998; 4(suppl1): 31-37. 9. takanashi j, barkovich aj, yamaguchi k, kohno y. influenza-associated encephalitis/ encephalopathy with a reversible lesion in the splenium of the corpus callosum: a case report and literature review. ajnr 2004; 25: 798-802. 10. tada h, takanashi j, barkovich aj, et al. clinically mild encephalitis/encephalopathy with a reversible splenial lesion. neurology 2004; 63: 1854-1858. 11. takanashi j, barkovich aj, shiihara t, et al.widening spectrum of a reversible splenial lesion with transiently reduced diffusion. ajnr 2006; 27: 836-838. 12. kato z, kozawa r, teramoto t, hashimoto k, shinoda s, kondo n. transient lesion in the splenium of the corpus callosum in acute cerebellitis. j child neurol 2003; 18: 291-292. 13. thomas b, kesavadas c. focal splenial hyperintensity in epilepsy. j neurol neurosurg psychiatry 2006; 77: 202. the enigma.indd 12 2/26/10 9:51:01 am original article � sa journal of radiology • june 2007 abstract background. cheating often occurs in sports that are defined by age when older participants compete by falsifying their true age. in some cases administrators have responded by implementing a programme that attempts to establish true age by measuring the skeletal age of competitors. however, because the technique has not been validated in this context there is a risk that competitors who are the correct age may have been unfairly excluded from competition based on these tests. objective. to determine whether this technique has sufficient precision to be used effectively to identify ‘age cheats’. methods. twenty-three males (14 18 years) volunteered for the study. their skeletal age was determined by means of an x-ray assessment of the hand and wrist undertaken by nine experienced radiologists. results. the coefficient of variation of skeletal age for each subject predicted by the different radiologists ranged from 0% to 3.8%. the average difference between the chronological and skeletal ages was -0.5 years (95% confidence interval: -0.9 -0.1 years), with a maximum underprediction of 2.4 years and maximum over-prediction of 0.9 years. the magnitude of the error in the prediction did not seem to be related to either the mass or stature percentile of the subjects. conclusion. the technique of assessing skeletal age in an attempt to identify sports participants who are older than the prescribed age limit lacks the necessary precision. until such time as an objective biological method is available to predict age more accurately, sport administrators should rather develop structures that can verify the accuracy of birth certificates. introduction the incidence of age cheating in sport has increased and has caused a problem comparable to athletes taking illegal substances.1,2 for example, it has been alleged that the captain of the south african under-14 national soccer squad was a 17-year-old student playing under a false name.3,4 furthermore, more than half of this team that won the international four nations tournament for underprivileged children in 1998 were over the age limit.5 identity documents or birth certificates cannot be used with confidence to identify age, particularly in developing countries. in south africa, soccer administrators responded to the age cheating by introducing skeletal age determinations at some of the major age-group tournaments6 in an attempt to identify players older than the prescribed age limit. they assessed the skeletal maturity of the players as they were under the impression that this technique was definitive and without error. several players were excluded from tournaments for ostensibly being over-age, causing a reaction from many of the parents of these players who claimed that their children had been disqualified unfairly. skeletal maturity or bone age describes the degree of biological maturation.7 the most common method of skeletal maturity assessment uses a radiograph of the left hand and wrist to determine the different stages in bone maturation.8 there are two different techniques, namely the tanner and whitehouse ii (tw2)9 and greulich and pyle10 methods. both techniques have similar reproducibility8 and are used to predict either the adult height of a child or to evaluate advanced or delayed growth. the greulich and pyle method is faster and easier to score and it is often the preferred method for a clinical application.8 however there are no data on the precision of this technique in predicting age, particularly in a sporting context. objective the aim of this study was to establish the reliability of determining chronological age in adolescent boys via hand and wrist x-rays using the greulich and pyle method.10 the goal was to determine whether this technique has a practical application in verifying chronological age of boys competing in specified age groups. methods twenty-three subjects between the ages of 14 and 18 years volunteered for the study. written consent was provided by the parents after the study was explained. the study was approved by the university of cape town research and ethics committee. all subjects had their age verified by official identity documents which were derived from original birth certificates. the stature and mass of each subject was measured to the nearest cm and 0.5 kg respectively. each subject then reported to the same radiology practice and had an x-ray taken of their left hand and wrist measured in the anterior-posterior position. the x-rays were distributed to 9 independent, experienced radiologists who assessed the skeletal maturity and predicated chronological age from this x-ray using the greulich and pyle method.10 the radiologists were blinded to the identity and age of each subject. the stature and mass of each subject was compared with normative data derived from a similar population of boys (n = 2 167) (sports science institute of south africa unpublished data). the percentiles for stature and mass were calculated for these data for the ages of the subjects in this study. accuracy of bone assessments for verifying age in adolescents – application in sport s c braude, l m henning, m i lambert, mrc/uct research unit for exercise science and sports medicine, department of human biology, university of cape town original article pg!!!4-7.indd 4 6/18/07 4:16:31 pm � sa journal of radiology • june 2007 statistics data are expressed as mean ± standard deviation (sd) or as 95% confidence intervals (cis) where appropriate. the repeatability of the age predictions was determined using an analysis of variance with repeated measures. the coefficient of variation ((mean/standard deviation) x 100) of the age assessments by the 9 different radiologists was calculated for each subject. a pearson’s moment correlation coefficient was calculated to determine the relationship between chronological and skeletal age. the limits of agreement between these variables were calculated using the bland-altman test.11 statistical significance was accepted as p < 0.05. results general characteristics of all 23 subjects are shown in table i. the average body mass was 64.6 ± 14.4 kg, with a range from 39.9 to 96.4 kg. the mass percentile ranged from 9% to 97%. stature varied from 150.0 cm to 186.0 cm, with an average of 173.6 ± 8.9 cm. the stature percentiles ranged from 5% to 99%. the chronological ages of the subjects ranged from 14.1 to 17.9 years (15.7 ± 1.2 years). the skeletal age of each subject determined from the scores of 9 independent radiologists are shown in table i with their 95% cis. the coefficient of variation of skeletal age for each subject predicted by the 9 different radiologists ranged from 0% to 3.8 % (mean ± sd 2.1 ± 1.0%). the average difference between the chronological and skeletal ages was -0.5 years (95% ci: -0.9 to -0.1 years) with a maximum underprediction of 2.4 years and maximum overprediction of 0.9 years. the relationship between the chronological age and skeletal age (average of the 9 scores) was r = 0.71 (p < 0.0001). the mean difference between chronological and skeletal age for each subject is plotted against mass percentile (a) and stature percentile (b) (fig. 1). negative deviations show an underestimation of the chronological age whereas a positive deviation shows an overestimation. the limits of agreement between chronological age and skeletal age were -2.4 1.4 years. there was no obvious systematic bias in predicting skeletal age related to either mass or stature percentiles (fig. 2). discussion our main finding showed that the coefficient of variation of skeletal age for each subject predicted by the 9 different radiologists ranged from 0% to 3.8 %. this was not dependent on either the mass or the stature percentile of the subject. the mean difference between chronological and skeletal age for all the subjects was -0.5 years (95% ci: -0.9 -0.1 years) which defines the precision with which this type of test can be interpreted. in 1 subject the difference between the chronological age was underestimated by 2.4 years (fig. 1). clearly the method lacks the level of precision required for the purpose of screening players at agegroup tournaments where a player 1 day older than the defined age is regarded as ‘too old’ for the competition. in a similar study on dutch children (n = 572) the chronological age preceded skeletal age by 1.7 months in girls and 3.3 months in boys.12 in that study only 2 assessors were used, which may have contributed to the increased precision of their data compared with the data in our study where 9 assessors were used. the greulich and pyle method10 was developed on white children from england and should be used with reservation for children of different ethnicities.13 for example, prepubertal american children of european descent have significantly delayed skeletal maturation when compared with those of african descent, and postpubertal american children of european descent have significantly advanced skeletal maturation when compared with postpubertal children of african descent.14 another factor affecting the accuracy of the assessment of skeletal age is the experience of the assessors.15 in that study 4 radiologists (2 experienced paediatric radiologists and 2 radiology residents) measured the skeletal age of 47 children (2 months fig. 1. relationship between the deviations between chronological age and skeletal age and percentiles for body mass (a) and stature (b). a negative value means that chronological age has been underestimated by skeletal age. each data point represents the mean difference for each subject ( n = 23) with the standard deviations for the predictions of the 9 radiologists. fig. 2. the bland-altman plot11 for chronological and skeletal age. the limits of agreement were -2.4 to 1.4 years (negative differences mean that chronological age was underestimated). d e v ia ti o n i n c h ro n o lo g ic a l a g e ( y e a rs ) d if fe re n c e b e tw e e n c h ro n o lo g ic a l a n d s k e le ta l a g e ( y e a rs ) original article pg!!!4-7.indd 5 6/18/07 4:16:47 pm � sa journal of radiology • june 2007 19 years). although it was not significant, the difference between the chronological age and the measured bone age was -1.5 ± 7.6 months for the experienced readers and 2.7 ± 10.3 months for the radiology residents.15 in our study all the radiologists were experienced and therefore the variation in the results cannot be attributed to this. while determination of the skeletal age has important implications for forensic studies related to age determination in living people associated with crime, this is usually a part of a battery of tests including a general physical examination, x-rays of the skull, long bones and shoulder as well as an examination of the teeth by a dentist.16 indeed, a combination of skeletal and orthodontic age variables provide a more accurate prediction of the chronological age than either method alone.17 in summary, verifying the age of participants in competitive sport defined by age groups is important. however, predicting skeletal age via hand and wrist x-ray using the greulich and pyle method in an attempt to verify chronological age lacks the precision needed and will result in many false-positive tests (i.e. saying someone is over-age when in fact they are not) or false-negative tests (i.e. failing to detect an over-age participant). until accurate objective biological methods are available the authorities should rather implement structures that confirm the validity of birth certificates. table i. general characteristics of subjects (n = 23). subject mass mass percentile stature stature percentile bmi chronological skeletal age 95% (kg) (%) (cm) (%) (kg/m2) age (years) confidence intervals* 1 82.0 91 181.0 65 25.0 17.4 16.9 17.2 2 96.4 96 175.0 69 31.5 17.2 17.6 18.1 3 77.4 95 182.0 99 23.4 16.0 16.7 17.1 4 47.2 15 164.0 30 17.5 16.2 14.2 14.9 5 49.8 9 166.0 29 18.1 17.2 16.9 17.2 6 66.4 53 169.0 13 23.2 16.7 16.9 17.2 7 59.5 52 172.0 38 20.1 15.6 13.8 14.4 8 51.1 32 161.0 29 19.7 15.4 14.9 15.2 9 70.5 67 178.5 54 22.1 16.9 16.0 16.0 10 79.3 89 178.0 47 25.0 17.9 15.2 15.8 11 58.2 25 165.8 5 21.2 16.6 15.1 15.5 12 86.7 97 186.0 82 25.1 15.9 15.9 16.8 13 46.5 69 164.0 81 17.3 14.7 12.8 13.6 14 62.1 87 176.5 99 19.9 14.6 15.8 16.4 15 65.6 84 185.0 95 19.2 14.5 14.7 15.4 16 74.3 94 177.5 85 23.6 14.9 15.3 15.8 17 71.2 92 177.0 83 22.7 14.3 14.1 14.7 18 48.8 22 172.0 89 16.5 15.5 13.0 13.5 19 55.0 69 173.0 89 18.4 14.6 13.9 14.7 20 68.1 81 185.0 93 19.9 15.8 14.8 15.2 21 56.5 62 171.0 70 19.3 16.1 15.1 15.5 22 39.9 11 150.0 7 17.7 14.1 12.3 12.7 23 74.3 94 183.0 93 22.2 14.7 15.1 15.5 mean 64.6 64.6 173.6 62.8 21.2 15.7 15.1 15.6 ± sd ± 14.4 ± 31.0 ± 8.9 ± 31.5 ± 3.5 ± 1.2 * the confidence intervals are determined for the scores of 9 independent radiologists. original articleoriginal article pg!!!4-7.indd 6 6/18/07 4:16:47 pm � sa journal of radiology • june 2007 conclusions age cheats in sport are a reality, and strategies need to be implemented to identify players who are older than the prescribed age, and officials and parents who condone this behaviour. whilst predicting age by measuring skeletal development has an important role to play in forensic and general medicine, the techniques do not have sufficient precision to be used in a sporting context where the accuracy has to be refined. at this stage, until a more accurate objective age-assessment technique is developed, it is recommended that officials implement strategies to verify birth certificates for the purpose of determining true age. acknowledgements thanks to dr michael cooper and his team of radiologists who participated in assessing the skeletal age. discovery health, the medical research council of south africa and the nellie atkinson and harry crossley research funds of the university of cape town provided funding for the study. 1. kwenaite t. little cheats: who to blame? the star, 26 august 1998. 2. mokone t. poverty no excuse for cheating. news24.com 2004 july 27. 3. kwenaite t. south africa national under-14. the star, 29 august 1998. 4. kwenaite t. safa to probe amajita age cheats claims. independent news online, 28 february 2001 (www. iol.co.za). 5. kwenaite t. sa’s world champs’ cheated’ in france. the star, 22 august 1998. 6. motjuwadi h. x-rays expose soccer parents who cheat. sunday times, 4 october 1998. 7. beunen gp, malina rm, lefevre j, et al. skeletal maturation, somatic growth and physical fitness in girls 6-16 years of age. int j sports med 1997; 18:413-419. 8. king dg, steventon dm, o’sullivan mp, et al. reproducibility of bone ages when performed by radiology registrars: an audit of tanner and whitehouse ii versus greulich and pyle methods. br j radiol 1994; 67: 848-851. 9. tanner jm, whitehouse rh, cameron n, marshall wa, healy mjr, goldstein h. assessment of skeletal maturity and prediction of adult height (tw2 method). 2nd ed. london: academic press, 1983. 10. greulich ww, pyle si. radiographic atlas of skeletal development of the hand and wrist. 2nd ed. stanford: stanford university press, 1959. 11. bland jm, altman dg. statistical methods for assessing agreement between two methods of clinical measurement. lancet 1986; 1:307-310. 12. van rijn rr, lequin mh, robben sg, hop wc, van kuijk c. is the greulich and pyle atlas still valid for dutch caucasian children today? pediatr radiol 2001; 31:748-752. 13. ontell fk, ivanovic m, ablin ds, barlow tw. bone age in children of diverse ethnicity. am j roentgenol 1996; 167:1395-1398. 14. mora s, boechat mi, pietka e, huang hk, gilsanz v. skeletal age determinations in children of european and african descent: applicability of the greulich and pyle standards. pediatr res 2001; 50:624-628. 15. groell r, lindbichler f, riepl t, gherra l, roposch a, fotter r. the reliability of bone age determination in central european children using the greulich and pyle method. br j radiol 1999; 72:461-464. 16. schmeling a, olze a, reisinger w, rosing fw, geserick g. forensic age diagnostics of living individuals in criminal proceedings. homo 2003; 54:162-169. 17. garamendi pm, landa mi, ballesteros j, solano ma. reliability of the methods applied to assess age minority in living subjects around 18 years old. a survey on a moroccan origin population. forensic sci int 2005; 154(1): 3-12. original article pg!!!4-7.indd 7 6/18/07 4:16:48 pm case series case series 24 sa journal of radiology • june 2007 case series abstract the ectopic posterior pituitary (epp) refers to the anomalous position of the distinctly bright posterior pituitary gland. defective neural migration during embryogenesis is believed to be the cause of the epp. this hypothesis is supported by the co-existence of other midline structural malformations where anterior pituitary hypoplasia and epp are the end products. the epp often occurs in patients with growth hormone deficiency (ghd), and is a marker of ghd. the epp should alert the radiologist to perform a precise mri study as it is an important marker of anterior pituitary structure and function. the hyperintense posterior pituitary is due to its phospholipid content. introduction the anterior and the posterior pituitary are composed of tissues that are embryologically and histologically different, as the normal pituitary development results from the upward growth of rathke’s pouch (ectoderm) fusing with the downward growth of the neuroectoderm of the diencephalon.1 therefore defective neural migration during embryogenesis is believed to be the cause of the ectopic posterior pituitary (epp). this may be partial or complete, possibly explaining why the epp can be located at different sites of the stalk.2 this abnormal embryonic development hypothesis is supported by the co-existence of other midline structural malformations where anterior pituitary hypoplasia and epp are the end products.2,3 the associated described midline anomalies include septo-optic dysplasia, grey matter hetrotopia, scizencephaly, corpus callosal dysgenesis, and anopthalmia.3 another (less popular) hypothesis postulated for the epp is transection of the cord possibly on the basis of prenatal or perinatal trauma.1 the pituitary functions as an endocrine gland under the control of the hypothalamus via the infundibular stalk.1 the epp often occurs in patients with growth hormone deficiency (ghd), and is a marker of ghd.3 the cause of ghd maybe ‘idiopathic’ or can occur secondary to surgery, tumour or radiation.1 idiopathic ghd may occur in isolation or in association with multiple anterior pituitary hormone deficiencies (mphd).1 mphd is defined as ghd associated with at least one other abnormality of the anterior pituitary hormones (including thyroid-stimulating hormone (tsh), adrenocorticotrophic hormone (acth), and prolactin).2 previous studies have demonstrated that patients with a low growth hormone (gh) level (< 3 g/l) are more likely to have an epp.1 magnetic resonance imaging (mri) is the cornerstone for evaluating the hypothalamic-pituitary axis in children.4 it was instrumental in identifying the hyperintense epp on t1 imaging, and has been found to be a significant contributing factor to the diagnosis of ‘idiopathic’ and permanent ghd.5 the distinctly hyperintense posterior pituitary is due to its phospholipid content. imaging of the pituitary varies with age, and the adenohypophysis also demonstrates a high signal in the first 2 months of life.4 the pituitary gland height decreases during the first year of life, then increases to achieve its plateau after puberty.4 the magnetisation transfer ratio (mtr) has been noted to increase in males and females up to the age of 30.4 dynamic contrast-enhanced studies have demonstrated simultaneous enhancement of the posterior pituitary lobe and the straight sinus, with the adenohypophysis enhancing slightly later – but all within 30 seconds.4 although mri provides excellent definition of the hypothalamicpituitary axis, gadolinium is necessary for better description of the stalk – especially if the stalk is thin.2 adequate visualisation of the stalk is very important as it has a bearing on the adenohypophysis structure. chen et al.2 demonstrated that when the pituitary stalk was present, the adenohypophysis was only hypoplastic in 50% of cases, however when the pituitary stalk was ‘absent’ the adenohypophysis was hypoplastic in the vast majority of cases. this observation is very pertinent as it has therapeutic and prognostic implications. the visible pituitary stalk may be a sensitive marker for idiopathic ghd in epp, whereas its absence constitutes a predictive factor for mphd.2 moreover, major technical strides achieved in dna technology have assisted in shedding new light on the genetic causes of hypopituitarism and the epp.3,5 two gene abnormalities associated with hypopituitarism have been identified, gh-n encoding for gh and the ghrh receptor (ghrh-r); and thus far only the hesx1 gene appears to be linked to the epp.3,5 patients and methods we scanned 3 patients with epp glands at the chris hani baragwanath hospital mr department over a period of 3 months. the mr scans were done on a 1.5 tesla general electric (ge) signa excite machine. dynamic contrast injection was used in patients 2 and 3. a hand injection was used in patient 1 due to his tender age. patient 1 the patient was 5 weeks old, and was being investigated for mphd. the sagittal t1-weighted mri scan demonstrated the high signal intensity posterior pituitary lobe outside the confines of the sella, and a hypoplastic adenohypophysis. the stalk was not visualised pre or post intravenous contrast (fig. 1). patient 2 the patient was 3 years old, and was a known patient with hypopituitarism on replacement therapy. the sagittal t1-weighted mri scan demonstrated the high signal intensity posterior pituitary lobe outside the the ectopic posterior pituitary – a short case series m modi, mb bch, fcrad (d), mmed division of radiology, department of radiation sciences, chris hani baragwanath hospital, university of the witwatersrand, johannesburg pg24-26.indd 24 6/13/07 9:21:46 am case seriescase series 25 sa journal of radiology • june 2007 confines of the sella, a hypoplastic adenohypophysis, and again the stalk was not visualised pre or post intravenous contrast (fig. 2). patient 3 the patient was a fully functional woman of 25 years (she worked as a cashier at the local supermarket). she appeared to be of shorter than average stature, was well spoken, and did not suffer from any seizure disorder. she was referred for a pituitary mri as her prolactin level was found to be high. the mri scan demonstrated an epp, a hypoplastic adenohypophysis, non-visualisation of the pituitary stalk, corpus callosal agenesis, absent septum pellucidum, small calibre optic nerves, and periventricular grey matter heterotopia. the co-existence of an epp, periventricular grey matter heterotopia, corpus callosal agenesis and septo-optic dysplasia has been previously fig. 1. a sagittal t1w post-contrast mri scan demonstrating the hyperintense posterior pituitary gland outside the sella and along the pathway of the stalk. the pituitary stalk is not visualised. the adenohypophsis is hypoplastic. fig. 2. a sagittal t1w mri scan demonstrating the hyperintense posterior pituitary gland outside the sella, and adjacent to the optic chiasm. the pituitary stalk is not visualised. the adenohypophsis is hypoplastic. note the small cyst in the pineal gland. fig. 3a. a sagittal t1w mri scan demonstrating the not very hyperintense posterior pituitary gland outside the sella and along the pathway of the stalk, non-visualisation of the adenohypophsis, an absent corpus callosum, prominence of the anterior commisure, and a tiny cyst in the pineal. fig. 3b. a coronal t1w mri scan demonstrating the hyperintense central ectopic posterior pituitary, and the absent septum pellucidum. the pituitary stalk was not visualised. pg24-26.indd 25 6/13/07 9:21:46 am case series 26 sa journal of radiology • june 2007 documented.3 the patient had not undergone any previous mr imaging (figs 3 a d). conclusion the epp should alert the radiologist to perform a precise mri study as it is an important marker of anterior pituitary structure and function. a sagittal t1-weighted sequence is imperative, while zoomed thin slice preand post dynamic contrast scans of the hypothalamic-pituitary axis are necessary to fully assess the anatomy, to plan further investigations and for future management. coronal imaging is helpful, as seen above, for evaluation of the optic nerves and septum pellucidum. a coronal stir or t1 flair assists in delineating the grey matter heterotopia better. the use of contrast is often necessary to identify and characterise the stalk and adenohypophysis.2 the following associations need to be looked for when assessing patients with an epp. an ectopic posterior lobe of the pituitary with a hypoplastic or absent pituitary stalk may be observed in patients with hypopituitarism, and is a specific marker of permanent gh defiency.4,5 an epp may be part of the spectrum associated with septo-optic dysplasia. this is possibly related to the fact that some cases of septooptic dysplasia are caused by mutations of the hesx1 gene linked to epp.3 the co-existence of an epp and periventricular grey matter heterotopia has also been linked to the hesx1 gene.3 it is also necessary to differentiate a stalk lipoma from an epp. rarely, a normal pituitary mr study may be encountered in subjects with severe gh deficiency where there is a genetic origin for the disease.2,5 acknowledgements thanks to dr aadil ahmed, chris hani baragwanath hospital. 1. patkar d, patankar t, krishnan a, prasad s, shah j, limdi j. mr imaging in children with ectopic pituitary gland and anterior hypopituitarism. j postgrad med 1999; 45: 81-83. 2. chen s, leger j, garel c, hassan m, czernichow p. growth hormone deficiency with ectopic neurohypophysis: anatomical variations and relationship between the visibility of the pituitary stalk asserted by magnetic resonance imaging and anterior pituitary function. j clin endocrinol metab 1999; 84: 2408-2413. 3. mitchell la, thomas pq, zacharin mr, scheffer ie. ectopic posterior pituitary lobe and periventricular heterotopia: cerebral malformations with the same underlying mechanism? am j neuroradiol 2002; 23: 1475-1481. 4. argyropoulou mi, kiortsis dn. mri of the hypothalamic-pituitary axis in children. pediatr radiol 2005; 35:1045-1055. 5. maghnie m, ghirardello s, genovese e. magnetic resonance imaging of the hypothalamic-pituitary unit in children suspected of hypopituitarism: who, how and when to investigate. j endocrinol invest 2004; 27: 496-509. fig. 3d. a coronal stir inverted image demonstrating the clump-like periventricular grey matter heterotopia. fig. 3c. a coronal post-contrast zoomed t1w mri scan demonstrating the hypoplastic optic nerves. the pituitary stalk was not visualised. pg24-26.indd 26 6/13/07 9:21:47 am a. arthrographic mri of the shoulder is known to increase diagnostic accuracy compared with conventional mri. b. mri arthrography is the most sensitive technique in the detection of shoulder joint abnormalities. c. mri arthrography changes conventional mri into a minimally invasive examination. d. by using real-time ultrasound, the procedure is not only quicker but, unlike the case of fluoroscopicallyguided arthrography, there is no ionising radiation. administration of radio-opaque contrast medium is recommended. 2. which of the following statements associated with mri arthrography is false? cpd questionnaire give one correct answer for each question. 80 sa journal of radiology • october 2008 instructions: 1. cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission, you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. 2. read the articles in the journal to find the answers to the questions. 3. go to www.cpdjournals.org.za to answer the questions. 1. regarding mri arthrography, choose one false answer. a. the technique of arthroscopy generally follows the posterior route. b. the path lies between the infraspinatus muscle and the teres minor muscle, with the point of entry 1 cm inferior and 2 cm medial to the posterior angle of the acromion. c. a potential risk is contact with the suprascapular nerve and the circumflex scapular vessels. d. if an entry point inferior to the teres minor muscle (through the quadrangular space) is used, other potential risks are contact with the axillary nerve and the posterior humeral circumflex artery. 3. which of the following statements is false? a. hyperparathyroidism is a term used to describe the consequences of excessive secretion of parathyroid hormone (pth), due to either primary disease of the parathyroid gland or secondary to renal disease. b. primary hyperparathyroidism is usually due to a single parathyroid adenoma. occasionally there may be multiple adenomas. malignant transformation does not occur. c. parathyroid glands are usually 4 in number, each measuring 5 mm in diameter. the 2 superior glands tend to be posterior, and the 2 inferior ones, anterior. d. the inferior glands are supplied by the inferior thyroidal artery and the superior glands by the superior thyroidal artery. 5. which of the following statements is false? a. benign strictures are said to occur in up to 11% of ulcerative colitis cases. b. long-standing uc does not only affect the mucosa. in the chronic phase, wall thickening, marked loss of haustration and colonic shortening can also occur. c. fibrosis is dominant and accounts for most cases of stricturing. d. stricturing is mostly the result of hypertrophy and thickening of the muscularis mucosa. 6. identify the correct statement from the following choices. the associated mri features of schizencephaly include all the following, except: a. absent cavum septum pellucidum (80 90 %) b. focally thin or absent corpus callosum c. polymicrogyria and hetertopias d. tenting of the ventricle, pointing away from the defect. 7. the following is true about pet/ ct except: a. the introduction of f-18 fdg pet/ ct renders information on both morphology and metabolism. b. size criteria to classify lymph nodes as normal or pathological remains acceptable in clinical practice. c. pet-ct expected to provide the clinician with accurate information for response assessment in lymphoma, possibly leading to major changes in the treatment and prognosis. d. the physical principle in pet/ct relates directly to einstein’s formula e=mc2. 8. identify the false statement among the following: a. positron emission tomography (pet) uses the glucose analogue f-18 fdg. b. pet/ct was first introduced in the late 1970s. c. international sentiments express the ‘unparalleled contribution of f-18 fdg pet to medicine over 3 decades’. d. potential users of pet/ct in south africa have established an ideal working relationship to ensure financial viability and access to all. 9. regarding pet/ct, identify a single false statement: a. pet has the ability to demonstrate abnormal metabolic activity (at the molecular level) in organs that as yet do not show an abnormal appearance based on morphologic criteria. b. precisely co-registered functional and anatomical images are obtained by performing a pet study and a ct study on the same scanner without moving the patient. c. fdg is a radiopharmaceutical analogue of glucose that is taken up metabolically by active tumour cells using facilitated transport unlike those used by glucose. d. like glucose, it undergoes phosphorylation to form fdg-6phosphate; however, unlike glucose, it does not undergo further metabolism, thereby becoming trapped in metabolically active cells. 10. the approximate price of a pet/ct scan is: a. 10 000 000 000 000 000 000 000 0000 00000 zim dollars b. when (if) wall street opens tomorrow: $us100 000 c. icelandic krona: ∞ [currency effectively no longer exists] d. r12 000 in south africa 4. which of the following ultrasound findings signs is not associated with parathyroid adenoma? a. an abnormal gland as it enlarges appears as a hypo-echoic, often anechoic, lesion, often posterior in location to the thyroid. b. as the gland enlarges, it can develop lobularity and foci of echogenicity. c. parathyroid glands of at least 1 cm have vascularity by colour doppler or power doppler characterised by high resistance waveforms on spectral analysis. d. an extrathyroidal artery that feeds the parathyroid adenoma is commonly noted by sonography with both colour and power doppler, and its visualisation helps in the parathyroid delineation. cpd.indd 80 10/15/08 11:38:56 am contents tib introduction vertebral haemangioma is the most common benign tumour of the spine.1 the prevalence of spinal haemangiomas varies from 10% to 12% from postmortem and radiographic studies.1,2 sixty per cent of patients with haemangiomas are asymptomatic and are discovered as incidental findings on imaging.3 twenty per cent of patients present with pain, which is usually not related to the spinal haemangioma.3 however approximately 20% of patients become symptomatic with increasing pain related to the haemangioma, or less commonly with progressive neurological signs with or without signs of spinal cord compression.3,4 we present 4 cases to demonstrate the clinical spectrum and imaging findings of spinal haemangiomas. case 1 a 32-year-old man presented with a long history of backache. clinical examination was unremarkable. focal sclerosis in the t6 vertebral body was detected on the thoracic spine radiographs (fig 1a). mr demonstrated replacement of the t6 body by a heterogeneous hyperdense lesion with vertical hypodense striations on both t1 and t2-weighted images (figs 1b,c). a smaller identical focal lesion was detected in the t5 body. a diagnosis of multiple spinal haemangiomas was made. the patient responded well to analgesics. case 2 a 52-year-old man complained of localised severe upper lumbar backache and episodes of rectal bleeding. clinical examination was normal. a barium enema demonstrated sigmoid diverticular disease. the thoracic spine radiographs were unremarkable. a technetium 99m pyrophosphate bone scan demonstrated a focus of increased activity in the left pedicle of the l1 vertebra and solitary metastasis was suspected. a mr scan demonstrated a focal lesion in the left body, pedicle and transverse process of l1. the lesion was hyperintense on both t1 and t2-weighted images with a heterogeneous speckled appearance on both axial and sagittal images (figs 2a-c). these features were considered typical of spinal haemangioma. the patient’s pain settled on analgesics and physiotherapy. a repeat study 8 weeks later demonstrated no interval change in the appearance of the haemangioma. case series 22 sa journal of radiology • october 2005 imaging of vertebral haemangiomas contribution of mr imaging p corr ffrad (d)sa md f lockhat fcrad (d) sa department of radiology inkosi albert luthuli hospital and nelson mandela medical school durban fig.1a. in case 1 lateral thoracic radiograph demonstrates typical vertical sclerotic striated pattern of a haemangioma. fig. 1c. fig. 1b,c. in case 1 on t1 and t2-weighted sagittal scans there are hyperdense striated lesions in the body of t5 and t6 typical of haemangiomas. figs 2a-c. in case 2 on t1 and t2-weighted mr scans the heterogeneous hyperdense haemangioma is noted replacing the left side of the l1 body, pedicle and transverse process. this is best visualised on the transverse image on fig.2c. pg22-24 tib 10/9/05 9:50 am page 22 case series 23 sa journal of radiology • october 2005 case 3 a 36-year-old painter fell off a step ladder, injuring his back. he complained of severe upper lumbar back pain with difficulty walking. clinically he had severe localised spinal tenderness over l1 with decreased power (2/5) and reflexes in both legs. spine radiographs demonstrated an ill-defined sclerotic lesion in the body of l1. mr imaging demonstrated a hyperintense lesion replacing the whole of the l1 body, with vertical hypointense striations on t1 and t2-weighted images. there was an extradural haematoma causing thecal sac and conus compression (figs 3a-c). a diagnosis of a pathological fracture of a vertebral haemangioma was made. this patient underwent a laminectomy and spinal fusion. case 4 a 25-year-old man presented with gradual onset of paraparesis. clinical examination confirmed weakness in the lower limbs. subcutaneous telangectasia were noted over the chest. t1 and t2weighted mr images of the spine (figs 4a and b) demonstrated a low signal intensity lesion in the c6 vertebral body on t1 and a high intensity signal on t2. the lesion had the classic celery-stalk appearance on the axial t2-weighted image (figs 4a-d) with contrast enhancement following gadolinium enhancement (fig. 4d). there was a focal intramedullary lesion at t1 with a heterogeneous appearance on t2 in keeping with a spinal cord haemangioma. fig. 2c. fig. 2b. fig. 3c. figs 3a-c. in case 3 on t1 and t2 images a pathological fracture of the l1 body haemangioma is noted with intraosseus and extradural haematoma (arrows) causing thecal compression. figs 4a-d. in case 4 on t1 and t2 images an ‘aggressive haemangioma’ with low intensity on t1 and high intensity on t2 is demonstrated at the c6 level with an associated spinal cord haemagioma at t1. fig. 4b. fig. 3b. pg22-24 tib 10/8/05 11:41 am page 23 discussion the importance of making a radiological diagnosis of spinal haemangioma is that the majority of lesions, as in cases 1 and 2, require no further investigation or any form of treatment. the mr findings are characteristic with a heterogeneous hyperdense appearance on both t1 and t2weighted scans.5 there is often vertical hypodense striations on sagittal mr and a celery-stalk appearance on axial images which are characteristic. these represent thickened vertical bony trabeculae within the haemangioma.6 spinal metastases are the main differential diagnosis, however they usually extend into the pedicles unlike haemangiomas, and are hypodense on t1weighted images while asymptomatic haemangiomas are usually hyperdense on t1weighted images. focal fatty marrow may be round and conspicuous on mr imaging and could be confused with haemangiomas, however there are no vertical lowdensity striations within the fatty marrow and they normally become very hypointense on a fat saturation sequence. on histological examination most spinal haemangiomas are cavernous but can also be capillary or venous in origin.6 they are usually thin-walled endotheliumlined sinuses interspersed with bony trabeculae and fat. they are most common in the thoracic spine involving the whole or part of a vertebral body while posterior element or pedicle involvement is uncommon (10 15%).6 multiple involvement is common in the thoracic spine, occurring in 25 30% of patients.7 symptomatic or ‘aggressive’ spinal haemangiomas present with intense localised pain, myelopathy and/or radiculopathy from osseous expansion, pathological fracture or extradural haematoma. symptoms are often acute with sudden haemorrhage and mass effect. these tumours usually contain less fat and more vascular stroma than asymptomatic haemangiomas. they tend to be more hypodense on t1-weighted and hyperdense on t2-weighted images due to the presence of interstitial oedema.5 this pattern is demonstrated in case 4. treatment options for symptomatic haemangiomas include: surgical decompression, radiotherapy, endovascular embolisation using particles, direct ctguided alcohol injection and vertebroplasty.3,8-10 surgical decompression is necessary when there is compression of the spinal cord although embolisation is usually required to reduce intra-operative blood loss. in the largest series of 86 patients,8 there was a 6% mortality due to haemorrhage. vertebroplasty using methyl methacrylate glue has been used with some success although no large series are available at this time.10 haemangiomas are the commonest benign tumour of the spine that are often confused with spinal metastases. uncommonly they may bleed or cause a pathological fracture resulting in spinal cord compression. imaging with mr, although an expensive investigation, will usually give the correct diagnosis and prevent the patient from undergoing unnecessary further investigations including spinal biopsy. references 1. yocum tr, lile rl, schultz gd. acquired spinal stenosis secondary to an expanding thoracic vertebral hemangioma. spine 1993; 18: 299-305. 2. hemmy dc. vertebral hemangiomas. in: wilkins rh, rengachary ss, eds. neurosurgery. new york: mcgraw hill, 1996: 1827-1829. 3. fox mw, onofrio bm. the natural history and management of symptomatic and asymptomatic vertebral hemangiomas. j neurosurg 1993; 78: 3645. 4. nguyen jp, djindjian m, gaston a. vertebral hemangiomas presenting with neurologic symptoms. surg neurol 1987; 27: 391-397. 5. baudrez v, galant c, van de berg bc. benign vertebral hemangioma: mr-histological correlation. skeletal radiol 2001; 30: 442-446. 6. osborn ag. tumors, cysts and tumor like lesions of the spine and spinal cord. in: osborn ag, ed. diagnostic neuroradiology. st louis: mosby, 1994: 876-918. 7. djindjian m, nguyen jp, gaston a multiple vertebral hemangiomas with neurologic signs. j neurosurg 1992; 76: 1025-1028. 8. pastushyn ai, slin’ko el, mirzoyeva gm. vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. surg neurol 1998; 50: 535-547. 9. smith tp, koci t, mehringer cm, et al. transarterial embolization of vertebral hemangioma. j vasc interv radiol 1993; 4: 681-685. 10. ide c, gangi a, rimmelin a, et al. vertebral hemangiomas with spinal compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate. neuroradiology 1996; 38: 585-589. case series 24 sa journal of radiology • october 2005 fig. 4c. fig. 4d. pg22-24 tib 10/8/05 11:50 am page 24 article information authors: shailender n. singh1 gaurav sundar1 hanuman satishchandra1 affiliations: 1bangalore medical college and research institute, karnataka, india correspondence to: gaurav sundar email: gauravsundar@gmail.com postal address: b105 sriramsrishti apartments, anandnagar, bangalore 560032, india dates: received: 05 mar. 2014 accepted: 05 mar. 2014 published: 08 dec. 2014 how to cite this article: singh sn, sundar g, satishchandra h. an unusual case of bilateral renal lymphangiectasia. s afr j rad. 2014;18(1); art. #587, 4 pages. http://dx.doi/org/10.4102/sajr.v18i1.587 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. an unusual case of bilateral renal lymphangiectasia in this case report... open access • abstract • introduction • ethical considerations • case presentation • discussion • management and outcome • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ renal lymphangiectasia is a very rare benign disorder characterised by dilatation of the perirenal and peripelvic lymphatics. the condition is commonly misdiagnosed for other cystic lesions of the kidney such as polycystic kidneys. the diagnosis can be made with near-certainty if classical imaging findings are recognised. we report a case of bilateral renal lymphangiectasia, diagnosed on ultrasonography and computed tomography based on the typical imaging findings and the laboratory analysis of aspirated fluid. the patient was managed conservatively. introduction top ↑ renal lymphangiectasia is a rare benign disorder of the kidneys with dilated perirenal lymphatics caused by non-communication of the perirenal and peripelvic lymphatics with the main lymphatics.1 the condition in itself is benign, but is commonly misdiagnosed as other cystic renal diseases and hydronephrosis.2 knowledge of this condition and its typical imaging appearances will assist radiologists to arrive at the correct diagnosis and permit appropriate management of the patient. we present a case of bilateral renal lymphangiectasia associated with a right-sided retrocaval ureter with typical ultrasonography (us) and computed tomography (ct) findings. to the best of our knowledge, this is the first reported association of bilateral renal lymphangiectasia with a retrocaval ureter. ethical considerations top ↑ ethical clearance was obtained from the institutional review board. case presentation top ↑ a 24-year-old male presented with complaints of abdominal pain and distension, which he had experienced for two years. he had an episode of haematuria one week prior to presentation. he had no history of fever, diabetes mellitus or any previous abdominal surgeries. on clinical examination he was hypertensive with a blood pressure of 150/110 mmhg and had abdominal ascites. routine laboratory investigations revealed his haemoglobin, total leucocyte count and differential leucocyte counts to be within normal limits. his blood urea nitrogen level was 7.14 mmol/l (normal range: 8.0–16.4 mmol/l), serum creatinine 79.56 µmol/l (normal range: 50–110 µmol/l) and blood urea nitrogen to creatinine ratio 22.2 (normal value: < 10:1), indicating prerenal azotaemia. his urine examination was normal. the patient subsequently underwent imaging to assess the abdominal pain and distention. ultrasonography examination of the abdomen using a 2–5 mhz curvilinear transducer (philips iu-22, eindhoven, netherlands) demonstrated bilaterally enlarged and echogenic kidneys with loss of corticomedullary differentiation. there were large, clear, multi-septated fluid collections in the perinephric spaces bilaterally, which were indenting the surface of the kidney, and mild hydronephrosis on the right side (figure 1). there was mild to moderate ascites. no cysts or masses were identified in other organs. figure 1: sagittal us image of the kidneys. bilateral multiseptated perinephric collection is noted (arrowheads). corticomedullary differentiation is lost (solid black arrow). a contrast enhanced ct of the abdomen was performed on a six-slice helical scanner (siemens somatom emotion 6, munich, germany) to investigate the extent and relation of the fluid collection to adjacent structures. this revealed enlarged kidneys with preserved reniform shape as well as septated perinephric collections (figure 2). the two fluid collections were communicating with each other across the midline, anterior to the inferior vena cava and aorta (figure 3). the density of the fluid collection ranged from 3–10 hounsfield units. no soft tissue or fat density masses were present within the fluid collections. both ureters were delineated throughout their course and a retrocaval ureter was noted on the right side coursing medially, posterior to the inferior vena cava at the level of the renal hilum and coursing back laterally (distally). on the right side, there was hydronephrosis and blunting of the calyces secondary to the retrocaval ureter (figure 2). figure 2: reformatted (a) coronal contrast enhanced ct scan in the corticomedullary phase. bilateral enlarged kidneys with perinephric collection (arrowheads). reformatted (b) maximum intensity projection ct urography. medial deviation of the proximal right ureter posterior to the ivc, swinging back to the normal course distally, consistent with retrocaval ureter (arrow). figure 3: axial contrast-enhanced ct scan. bilateral low density perinephric collections (black arrows) with normal enhancement of the renal parenchyma and communication of collections with each other across the midline (arrowheads). there was no hydronephrosis on the left side. renal arteries and veins were normal on both sides. both kidneys showed normal contrast enhancement and excretion. the perirenal fluid, aspirated under ultrasound guidance, was found to be clear and straw coloured. laboratory analysis of the aspirated fluid revealed urea level of 5.24 mmol/l, total protein of 0.77 g/dl, absence of triglycerides and the presence of a few lymphocytes. on protein electrophoresis there was a selective protein band in the albumin region. both gram and acid-fast stain revealed no organisms and culture was negative. the laboratory analysis was in favour of lymphatic fluid. the diagnosis, based on the typical imaging findings and the laboratory analysis of the fluid, was bilateral renal lymphangiectasia with a retrocaval right ureter. following conservative management with antihypertensives and diuretics, his renal function improved and blood pressure returned to normal. discussion top ↑ bilateral renal lymphangiectasia is a rare benign condition that is often mistaken for other forms of cystic disease of the kidney.2 it is synonymous with renal lymphangiomatosis, hygroma renale and polycystic disease of the renal sinus.1, 3, 4 the exact pathogenesis of this condition is not known but is thought to be due to failure of the perinephric lymphatics to communicate with the main lymphatic system.5 there is no particular age or sex predilection for this condition but familial association has been reported in a few cases.1 the clinical course of this condition is variable. most commonly, is asymptomatic and is diagnosed incidentally. however, there can be sudden appearance and rapid growth or cessation of growth and even spontaneous regression of symptoms.5 when symptomatic, abdominal pain, haematuria, hypertension and renal failure are usually the presenting features.4 exacerbation during pregnancy has also been reported.1 in this case report the patient presented with abdominal pain and distention with hypertension and features of prerenal azotaemia. imaging appearances, when typical, can be striking, and often help make the diagnosis. on plain radiography, there is usually a large homogenous soft-tissue mass in the renal fossa displacing the adjacent structures. excretory urography may demonstrate hydronephrosis and distortion of the pelvicalyceal system, which may be due to compression of the pelvi-ureteric junction by the collections or associated conditions such as retrocaval ureter, as in our case.6 us examination demonstrates multiseptated, thin-walled fluid collections, localised to the perinephric and peripelvic space with normal renal parenchyma.7 the kidneys may be of normal size or enlarged and may have increased cortical echogenicity with loss of corticomedullary differentiation due to increased through transmission of us by the collections, as was seen in our case.6 it may also appear as a solid mass when the smaller intrarenal lymphatics are blocked.8 ascites may also be present. ct examination may show the presence of low-density fluid collections (0 to 10 hu) in the perinephric space but the septations may not be delineated as clearly as in us.3 there will be no invasion of the adjacent structures or evidence of cysts in other organs.9 the differential diagnoses in this condition are polycystic kidney disease, multilocular cystic nephroma, urinoma, abscess and bilateral perirenal liposarcomas.6, 7 the cysts in polycystic kidney disease and multilocular cystic nephroma are parenchymal. perirenal liposarcomas show the presence of macroscopic fat.7 apart from the typical clinical history, laboratory analysis of the fluid is helpful to differentiate lymphangiectasia from urinoma and abscess as the former will demonstrate low proteins and fat levels, and a sparse number of lymphocytes.3 management and outcome top ↑ haematuria, ascites, hypertension and deterioration of the renal function are the known complications of this condition. however, hypertension and renal failure, which is usually mild, will improve following conservative treatment, as in our case.3, 9 most asymptomatic patients do not require treatment. in symptomatic patients, especially with large collections, the treatment options available are marsupialisation or nephrostomy.3 antihypertensives and diuretics can be used to reduce blood pressure and fluid secretion.6 nephrectomy is reserved for complicated cases, including page kidney.6 conclusion top ↑ our case is of interest as renal lymphangiectasia is a rare benign condition which imaging can differentiate from other cystic diseases of the kidneys and perinephric space. to the best of our knowledge, an association of this condition with retrocaval ureter has not yet been mentioned in the literature. knowledge of this condition will be helpful in the work-up of cystic diseases of the kidney and in arriving at the correct diagnosis. the diagnosis can be made with near-certainty if typical imaging findings as described here are recognised on us and ct. in difficult cases, an imaging-guided fluid aspiration and laboratory analysis can help to establish the diagnosis and avoid unnecessary surgical procedures and their associated risks. most patients can be managed conservatively and their cases have an uneventful course once the diagnosis is correctly established. acknowledgements top ↑ the authors would like to thank mrs ranjana for her assistance in english language and grammar in writing the manuscript. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions g.s. (bangalore medical college and research institute, india) performed the imaging. s.n.s. (bangalore medical college and research institute, india) and h.s. (bangalore medical college and research institute, india) interpreted the imaging studies and wrote the manuscript. references top ↑ meredith wt, levine e, ahlstrom ng, grantham jj. exacerbation of familial renal lymphangiomatosis during pregnancy. ajr am j roentgenol. 1988;151:965–6. http://dx.doi.org/10.2214/ajr.151.5.965 lindsey jr. lymphangiectasia simulating polycystic disease. j urol 1970;104:658–662. schwarz a, lenz t, klaen r, et al. hygroma renale: pararenal lymphatic cysts associated with rennin-dependent hypertension (page kidney). case report on bilateral cysts and successful therapy by marsupialization. j urol 1993;150:953–957. davidson aj, hartman ds. lymphangioma of the retroperitoneum: ct and sonographic characteristics. rad 1990;175:507–510. http://dx.doi.org/10.1148/radiology.175.2.2183287 leonidas jc, brill pw, bhan i, et al. cystic retroperitoneal lymphangioma in infants and children. rad 1978;127:203–208. http://dx.doi.org/10.1148/127.1.203 ashraf k, raza ss, ashraf o, memon w, memon a, zubari ta. renal lymphangiectasia. british journal of radiology 2007;80:e117-118. http://dx.doi.org/10.1259/bjr/16931054 varela jr, bargiela a, requejo i, fernandez r, darriba m, pombo f. bilateral renal lymphangiomatosis: us and ct findings. eur radiol 1998;8:230–231. http://dx.doi.org/10.1007/s003300050368 kim jk, ahn hj, kim kr, cho ks. renal lymphangioma manifested as a solid mass on ultrasonography and computed tomography. j ultrasound med 2002;21:203–206. ramseyer lt. renal lymphangiectasia. rad 2001;219:442–444. http://dx.doi.org/10.1148/radiology.219.2.r01ma17442 article information authors: shalendra k. misser1 thami z. mngoma1 affiliation: 1lake smit and partners inc, durban, south africa correspondence to: shalendra misser email: misser@lakesmit.co.za postal address: private bag x08, overport 4067, durban, south africa how to cite this article: misser, sk, mngoma, tz. neuro imaging. s afr j rad. 2015;19(1); art. #815, 3 pages. http://dx.doi.org/10.4102/sajr.v19i1.815 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. neuro imaging in this quiz case... open access • presentation presentation top ↑ a 50 year-old gentleman of otherwise excellent health presents with recent onset of left upper limb weakness and left facial nerve palsy. these are selected mr images. figure 1: axial flair mr image. figure 2: axial swi mr image. figure 3: coronal t2-weighted mr image. figure 4: coronal post contrast t1-weighted mr image. figure 5: axial post contrast t1-weighted mr image figure 6: axial rcbv mr perfusion image. figure 7: mr spectroscopy image obtained at te 135ms. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 30 september 2015. the winning respondent will receive a r1000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. radiographic.html radiographic diagnosis of a rare case of oculodentodigital dysplasia umesh chandra parashari, m.d. sachin khanduri, m.d. samarjit bhadury, m.d. fareena akbar qayyum, m.b.b.s. department of radiodiagnosis, lucknow medical college, lucknow, uttar pradesh, india corresponding author: u parashari (drumesh.rd@gmail.com) abstract oculodentodigital dysplasia (oddd), also known as oculodento-osseous dysplasia, is an extremely rare autosomal dominant disorder with high penetrance, intra and interfamilial phenotypic variability, and advanced paternal age in sporadic cases. the incidence of this disease is not precisely known, with only 243 cases reported in the scientific literature, suggesting an incidence of around 1 in 10 million people. it is marked mainly by eye abnormalities, craniofacial dysmorphism, dental anomalies, hand and foot malformations, various skeletal defects, and mildly delayed mental development. neurological changes may appear earlier in each subsequent generation. this case report describes a radiological diagnosis of oddd based on physical appearance, clinical features and radiographic findings in a 16-year-old girl. introduction oculodentodigital dysplasia (oddd) is a condition that affects many parts of the body, particularly the eyes, teeth and fingers, as the term indicates. mutations in the connexin 43 gene or gap junction protein alpha-1 gene (gja1) located on chromosome 6q22-q24 lead to disruption of cx43-mediated cell-to-cell communication, resulting in disrupted morphological patterning during development and altered functioning of cells in mature tissue. most cases of oddd are inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder. less commonly, oddd can be inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. the condition is also known as oculodento-osseous syndrome or meyer-schwickerath syndrome. craniofacial abnormalities include a thin nose with hypoplastic alae nasi, small anteverted nares, prominent columnella, and microcephaly. brittle nails and hair abnormalities of hypotrichosis and slow growth are also prominent. common ocular features with this condition are microphthalmia, microcornea, fine porous spongy iris abnormalities, cataracts, glaucoma, optic atrophy and other eye abnormalities that can lead to vision loss. abnormalities seen in the orodental region are small or missing teeth, weak enamel, multiple cavities and early tooth loss. other common features of this condition include a thin nose and webbing of the skin (syndactyly) between the fourth and fifth fingers. there is also evidence of camptodactyly and clinodactyly owing to hypoplasia or aplasia of the middle phalanges.siobhcranial hyperostosis and broad tubular bones may be present. case report a 16-year-old girl presented to the hospital with complaints of weakness in her lower limbs, abnormal dentition and bladder incontinence. on general examination, her gait was ataxic with moderate spasticity in both legs. she had dry and scaly skin and brittle nails. hair growth was sparse and showed characteristics of hypotrichosis and pili annulati. examination of the face revealed small and narrow eyes with thin and sparse eyebrows. she also had a thin nose with prominent columella and wide lower jawbone. on skeletal examination, her hands revealed underdeveloped fingers and toes with camptodactyly of the 5th (little) fingers on both sides, and syndyctaly of the thumbs and 2nd, 3rd and 4th fingers.the feet revealed syndyctaly of the 2nd to 5th toes and clinodactyly of the great toes. oral cavity examination revealed localised arrested tooth development that mainly involved the anterior teeth on one side of the midline, mainly the maxillary central and lateral incisors. radiographically, the teeth had a ghost-like appearance. calcification and bits of prismatic enamel were found in the pulp, and the enamel was thin and absent in parts. various x-rays of both the limbs were taken, revealing broad tubular bones and marked hypoplasia of the middle phalanges in the 5th fingers and in all toes. the cranial bones were hyperostotic, and the long bones as well as the ribs and clavicles showed widening. on ct of the face, the rami of the mandible appeared bulky and showed features of mandibular retrognathism. ct of the head also revealed bilateral basal ganglia calcification. the patient did not have any features of mental retardation. on ophthalmic examination, she was diagnosed with cataract, diminished visual acuity and reduced tear secretion. she also had small corneas and eccentric pupils. otoscopy revealed conductive hearing loss in the right ear. after summing up all the clinical features, various clinical examinations and radiological evaluations, the diagnosis of oddd was made. discussion oddd is a rare autosomal dominant congenital disorder mainly affecting the development of the face, eyes, skeletal system, heart and dentition. oddd has been mapped to chromosome 6q22-q24 and germline mutations have been identified in the connexin 43 gene, gja1. to date, over 70 reports in the literature describe the clinical features of oddd in more than 240 patients, the majority of whom were white. typical craniofacial anomalies include a thin nose with hypoplastic alae nasi, small anteverted nares, prominent columnella, and microcephaly. brittle nails and hair abnormalities of hypotrichosis and slow growth are present.1 some cases have dysplastic ears and conductive hearing loss. ophthalmic findings include microphthalmia, microcornea, fine porous spongy iris abnormalities, cataracts, glaucoma and optic atrophy. anomalies observed in the oral region are mandibular overgrowth and cleft palate. the majority of cases have abnormal primary and permanent dentition with microdontia, partial anodontia, enamel hypoplasia, numerous caries, and early tooth loss. hand and foot abnormalities in oddd include syndactyly involving the 3rd, 4th and 5th fingers and 2nd to 4th toes, camptodactyly, and clinodactyly owing to hypoplasia or aplasia of the middle phalanges.2 other skeletal abnormalities are cranial hyperostosis, mandible with wide alveolar ridge, and broad tubular bones. neurological symptoms are inconsistent but frequent, and include dysarthria, neurogenic bladder disturbances, spastic paraparesis, ataxia, anterior tibial muscle weakness, and seizures.3 some patients have dysplastic ears and conductive hearing loss. oddd is caused by heterozygous mutations in the gja1 gene (6q22-q23), which encodes the gap junction protein connexin 43 (cx43). over 40 causative mutations have been identified. in most cases, oddd is inherited in an autosomal dominant manner with high penetrance and variable expression.4 advanced paternal age has been noted in sporadic oddd cases. diagnosis is based on clinical findings and can be confirmed by molecular studies. differential diagnoses include a wide number of syndromes that present with skeletal, ocular, dental and neurological manifestations. genetic counseling should be offered to all oddd patients.1 there are many conditions mentioned in the literature with overlapping features as in oddd.these include: eec syndrome, hallermann-streiff syndrome, orofacial digital syndrome type ii, kid syndrome etc. the eec syndrome is characterised by ectrodactyly or lobsterclaw deformity, ectodermal dysplasia, and cleft lip and palate. it is a rare disorder with autosomal dominant inheritance, variable expression and, in some families, lack of penetrance. cleft lip/palate is present in most patients; in those without cleft lip/palate, the philtrum or uvula or both are often abnormal. the cleft lip/palate was not present in our patient, while significant eye changes and facial features favouring oddd were present.5 hallermann-streiff syndrome (hss) is a rare disorder characterised primarily by head and face abnormalities, with dental abnormalities also present. the digital changes, such as syndactyly or camptodactyly, as in oddd, are not present in the former syndrome.6 mohr-claussen syndrome, or oro-facial-digital syndrome type ii (ofd-ii), is transmitted as an autosomal recessive disorder, and is characterised by malformation of the face, oral cavity and digits. cleft upper lip and cleft palate, lobulated tongue and digital features include clinodactyly, syndactyly, brachydactyly and duplication of the first toe. there are usually no eye manifestations and skin changes as seen in oddd.7 keratitis-ichthyosis-deafness (kid) syndrome is the most severe cutaneous connexin disorder because of the involvement of several epithelia of ectodermal origin, including skin, appendages, nails, teeth, inner ear and cornea. most sufferers develop symmetrical, well-circumscribed hyperkeratotic plaques with underlying erythema on the extremities and face (erythrokeratoderma). chronic cheilitis and perléche are common, whereas hair and nail dystrophy, scarring alopecia, dental anomalies and heat intolerance are less frequent. differential diagnoses for bilateral symmetrical enlargement of the mandibular rami and anterior symphyseal lesions include ameloblastic fibro-odontoma, cherubism, torus, osteosarcoma and chronic osteomyelitis, but associated syndactyly is absent.8 bilateral basal ganglia calcification is also present in fahr syndrome, but it occurs between the age of 30 and 35 years of age. important differential diagnoses of basal ganglia calcification of familial nature are fahr’s syndrome (familial idiopathic symmetrical basal ganglia calcification), cockayne’s syndrome, tubero sclerosis, and familial degenerative disorders. aicardi-goutières syndrome is an autosomal recessive encephalopathy that causes developmental arrest, basal ganglia calcification and white matter disease in the presence of chronic cerebrospinal fluid lymphocytosis, and a raised level of cerebrospinal fluid interferon-alpha. management is multidisciplinary. regular follow-up should include complete eye examination and neurological, hearing and dental evaluation. as blindness owing to glaucoma can occur, patients at risk should receive anti-glaucoma treatment. plastic or orthopaedic surgery is indicated for severe limb malformations. early recognition of the syndrome is of crucial importance in prevention and treatment of the wide variety of clinical manifestations. 1. kjaer kw, hansen l, eiberg h, leicht p, opitz jm, tommerup n. novel connexin 43 (gja1) mutation causes oculo-dento-digital dysplasia with curly hair. am j med genet 2004;127a:152-157. 1. kjaer kw, hansen l, eiberg h, leicht p, opitz jm, tommerup n. novel connexin 43 (gja1) mutation causes oculo-dento-digital dysplasia with curly hair. am j med genet 2004;127a:152-157. 2. vitiello c, d’adamo p, gentile f, vingolo em, gasparini p, banfi s. a novel gja1 mutation causes oculodentodigital dysplasia without syndactyly. am j med genet 2005; 133:58-60. 2. vitiello c, d’adamo p, gentile f, vingolo em, gasparini p, banfi s. a novel gja1 mutation causes oculodentodigital dysplasia without syndactyly. am j med genet 2005; 133:58-60. 3. loddenkemper t, grote k, evers s, oelerich m, stogbauer f. neurological manifestations of the oculodentodigital dysplasia syndrome. j neurol 2002;249:584-595. 3. loddenkemper t, grote k, evers s, oelerich m, stogbauer f. neurological manifestations of the oculodentodigital dysplasia syndrome. j neurol 2002;249:584-595. 4. paznekas wa, boyadjiev sa, shapiro re, et al. connexin 43 (gja1) mutations cause the pleiotropic phenotype of oculodentodigital dysplasia. am j hum genet 2003;72:408-418. 4. paznekas wa, boyadjiev sa, shapiro re, et al. connexin 43 (gja1) mutations cause the pleiotropic phenotype of oculodentodigital dysplasia. am j hum genet 2003;72:408-418. 5. mc nab aa, potts mj, welham ran. the eec syndrome and its ocular manifestations. br j ophthalmol 1989;73:261-264. 5. mc nab aa, potts mj, welham ran. the eec syndrome and its ocular manifestations. br j ophthalmol 1989;73:261-264. 6. kirzioglu z, ceyhan d. hallermann-streiff syndrome: a case report from turkey. med oral patol oral cir bucal 2009;14 (5):236-238. 6. kirzioglu z, ceyhan d. hallermann-streiff syndrome: a case report from turkey. med oral patol oral cir bucal 2009;14 (5):236-238. 7. biswas a, ghosh jk, sinha mkr, basu k, chatterjee s. mohr-claussen syndrome or orofacial-digital syndrome (ofds) type-ii. j pak med assoc 2009;59(7):484-486. 7. biswas a, ghosh jk, sinha mkr, basu k, chatterjee s. mohr-claussen syndrome or orofacial-digital syndrome (ofds) type-ii. j pak med assoc 2009;59(7):484-486. 8. neyaz z, gadodia a, gamanagatti s, mukhopadhyay s. radiographical approach to jaw lesions. singapore med j 2008;49(2):165. 8. neyaz z, gadodia a, gamanagatti s, mukhopadhyay s. radiographical approach to jaw lesions. singapore med j 2008;49(2):165. fig. 1. photograph of the patient at age one year (1a) and 16 years (1b and 1c) showing hypotrichosis and pili annulati. the face is small with narrow eyes, thin nose, prominent columella and wide mandible. the fingers are underdeveloped and deformed. fig. 2. ap x-ray of the skull (2a) and lateral (2b) view show a ghost-like appearance (‘alien look’) with cranial hyperostosis (black arrowheads). focal bilateral symmetrical intracranial calcification is seen (black arrows). thinned out and focally absent enamel with missing teeth and cavities are seen (thin white arrows) with broadened mandible (thick white arrow). fig. 3. ct of the face (3a and 3b) show bulky rami of the mandible with mandibular retrognathism (thick white arrows). microdontia, partial anodontia, enamel hypoplasia, multiple caries and early tooth loss are seen (thin white arrows). fig. 4. non-contrast ct of the head shows dense bilateral basal ganglia calcification (black arrows). fig. 5. x-rays of both hands with ap view (5a) and ankles with lower leg lateral view (5b) reveal broad tubular bones and marked hypoplasia of the middle phalanges in the fifth fingers (white arrowheads) with camptodactyly. case report case report 32 sa journal of radiology • june 2010 introduction hepatic vascular lesions are not an uncommon finding in children, and represent the most common benign liver tumours to present in infancy. we present a case of a complex vascular malformation with an intrahepatic component suggestive of a venous/arteriovenous malformation as well as a large extrahepatic lesion. the extrahepatic mass was present in both suband supra-diaphragmatic locations, with features of a congenital haemangioma. in view of the clinical presentation and different imaging appearances, this case was felt to be interesting in its radiological workup, management and eventual unusual pathology. case report a term neonate presented a few days after birth with worsening respiratory distress that required ventilation. a left-sided pleural effusion had been treated in utero by means of a pleuro-amniotic shunt at 27 weeks’ gestation. the ultrasound and chest x-ray done shortly after birth showed a left pleural effusion and a lobulated, moderately vascular thoraco-abdominal mass displacing the spleen and kidney inferiorly (fig. 1). the patient did not have any cardiovascular compromise, and echocardiography demonstrated normal anatomy and function. subsequent computed tomography (ct), magnetic resonance imaging (mri) and magnetic resonance angiography (mra) studies further demonstrated the extent, hepatic involvement, appearance and vascularity of the lesion. a well defined, predominantly solid, lobulated mass exhibiting diffuse early vascular enhancement was seen, which on delayed imaging remained dense with increased centripetal opacification. the mid portion of the left hemidiaphragm was not clearly defined (fig. 2). the multiple feeding arteries were best demonstrated on the contrast-enhanced mra, showing a large artery arising from the abdominal aorta, adjacent to the coeliac axis (fig. 3). there was also significant supply seen from a branch of the left hepatic artery, as well as intercostal arteries and the left internal mammary artery. venous drainage was directly into the ivc via a large aberrant vein running parallel to the left hepatic vein, as well as into the left renal vein (fig. 4). in addition, multiple serpentine vessels were seen surrounding the lesion, with some noted to drain into the spinal epidural venous plexus, as well as left subclavian vein. the possibility of this being an extralobar pulmonary sequestration was considered at this stage. an angiogram was thereafter performed to further characterise the vascularity, as well as allow embolisation of the lesion prior to surgery (fig. 5). multimodality imaging and interventional management of a complex congenital vascular malformation aadil ahmed, mb bch, fcrad (diag) visser, erasmus, vawda and partners, port elizabeth fig. 1b. colour doppler ultrasound shows vascular malformation (arrow) displacing spleen inferiorly. → fig. 1a. cxr demonstrates left subphrenic mass (arrow) displacing nasogastric tube in stomach inferiorly. left-sided effusion present (arrowhead). → → case report case report 34 sa journal of radiology • june 2010 case report branches arising from the left hepatic artery supplying the vascular malformation were successfully occluded using onyx (micro therapeutics inc.). the anomalous, tortuous vessel arising from the aorta was seen to supply the solid component related to the left hemidiaphragm. some of the former’s branches were embolised using hepasphere embospheres (biosphere medical) and n-butyl cyanoacrylate. at surgery the following day, the supraand sub-diaphragmatic vascular mass was excised, and a partial left hepatectomy was performed. histological analysis confirmed the hepatic lesion to be a mixed vascular malformation. the diaphragmatic mass probably represented a vascular malformation with a predominantly capillary component; however, some features suggestive of a congenital haemangioma were present. glucose transporter-1(glut-1) stains were negative in all lesions. the patient made an uneventful recovery and, at the time of this report (4 months later), is symptom-free, with the follow-up mri showing no residual mass or vascular abnormality (fig. 6). fig. 2a. coronal ct image: enhancing, lobulated mass (arrow), displacing intra-abdominal viscera and reactive left pleural effusion. → fig. 2b. hyperintense mass on sagittal t2 fat suppression sequence. prominent vascular flow voids seen (arrows). the diaphragm is poorly outlined. → → fig. 3. coronal mip image from contrast-enhanced mra study. the dominant arterial supply from the abdominal aorta and left hepatic artery are shown (arrows). → → fig. 4. coronal mip image. delayed phase of contrast-enhanced mra. venous drainage to the ivc is shown (arrow). → case reportcase report 35 sa journal of radiology • june 2010 discussion based on their biological and clinical behaviour, vascular anomalies can be broadly divided into two groups: vascular tumours and vascular malformations. histologically identified lesions belonging to both these groups were present in our patient. the extrahepatic mass was confirmed to be a congenital haemangioma, a clinical entity distinct from the more common haemangioma of infancy. these congenital tumours bear some resemblance to haemangiomas of infancy but, unlike these, are fully developed and do not undergo any post-natal enlargement. congenital haemangiomas also stain negative for glucose transporter-1 protein (glut-1), a marker of haemangioma of infancy. there is a further differentiation of congenital haemangiomas into rapidly involuting congenital haemangiomas (rich) and non-involuting congenital haemangiomas (nich).1 the haemangioma in our patient probably falls within the nich category in view of the lack of significant regression in size although, admittedly, intervention occurred very early in the patient’s life, and might have affected the natural history. vascular malformations are congenital lesions of vascular dysmorphogenesis, are always present at birth, and enlarge in proportion to the growth of the child. vascular malformations can be divided on the basis of vascular channel type (capillary, lymphatic, venous, arterial or combined) or by flow (slow or fast).2 on angiography, reasonably fast flow and shunting was demonstrated in the intrahepatic malformation. histological inspection showed arterial components, which would also support this lesion being a high-flow malformation. multiple modalities can be used to examine vascular lesions, with mri and ultrasound being the most useful non-invasive tools, providing important information on disease extent and involvement of vital structures. imaging also helps to characterise lesions and, with mra, the vascular supply and drainage can specifically be assessed. gadoliniumenhanced images have been advocated in differentiating between lowflow vascular malformations and venous malformations. doppler characteristics of vascular malformations are also helpful in differentiating lowfrom high-flow vascular malformations.3 embolisation is an important component in the treatment of arteriovenous malformations, and is considered the most effective treatment/ palliation of arteriovenous malformations.4 in our patient, owing to the complexity of the lesion, it was accepted that embolisation alone would not achieve definitive treatment. the goals of the embolisation here were to diminish hepatic arterial and collateral flow as best as possible to facilitate subsequent surgical resection. fig. 5a. flush aortogram demonstrating extensive arterial supply, including branches from intercostal arteries (arrows). → → fig. 5b. arteriogram done during the embolisation. onyx is seen in branches arising from the left hepatic artery (arrow). an embolisation coil was also used to occlude one of the feeder vessels. dense contrast blush is seen in the solid component of the malformation (arrowhead). → fig. 6. coronal mri image, four months after intervention and surgery, demonstrating no residual malformation and near-normal anatomy. case report case report 36 sa journal of radiology • june 2010 in this regard, the procedure was considered successful as it significantly decreased vascularity. this multidisciplinary approach to the assessment and treatment of haemangiomas and vascular malformations is vital for the effective management and care of such patients. 1. powell j. update on haemangiomas and vascular malformations. curr opin pediatr 1999; 11: 457-463. 2. ashcraft kw, holcomb gw, murphy jp. pediatric surgery, 4th ed. philadelphia: elsevier saunders, 2005: 1038-1039. 3. donnelly lf, adams dm, bisset gs. vascular malformations and haemangiomas: a practical approach in a multidisciplinary clinic. am j roentgenol 2000; 174: 597-608. 4. yakes wf, rossi p, odink h. arteriovenous malformation management. cardiovasc intervent radiol 1996; 19: 65-71.w first rssa short course on current ethical issues in radiology: 23 january 2010 as a result of many requests from rssa members as well as the rapidly changing professional, social, technical and political environment, this workshop was established to meet the important challenges facing radiologists and other significant role players. topics pertinent to the daily practice of radiology were presented. ethical considerations in cochlear implant patients dr derrick wagenfeld (head of the tygerberg and stellenbosch university cochlear implant unit gave a fascinating insight into the technology, the cost implications, the vociferous opposition to the procedure (paradoxically from the deaf themselves), and the significant challenges facing those tasked with deciding who should be considered for the procedure. the role of the radiologist in the critical decision process was presented, and dr wagenfeld’s eloquent delivery left the audience in no doubt why he was recognised as the best debater in his matric year at the age of 16. this presentation inspired several immediate registrations for the forthcoming first rssa/leuven ear imaging course to be held at the spier estate. self referral – a moral hazard dr clive sperryn (president of the rssa) presented an address on the moral hazard of self-referral which is prevalent in the fee-for-service environment. despite the arguments in favour of self-referral advanced by lobby groups, research by independent neutral organisations confirms that self-referral leads not only to increased utilisation (by 1.7 7.7 times) but also to higher imaging costs (5 104%) and more expensive treatment. increased cost of care, where the cost of care outstrips the ability of a population to afford it, has lead directly to the current healthcare cost crisis in the usa. self-referral has undesirable consequences that have been well documented in the usa, where $16 billion per year is spent on unnecessary self-referred non-invasive diagnostic imaging. utilisation is the way that insurance companies determine their premiums and, if utilisation is artificially inflated by self-referrals, insurance is pushed even further out of the reach of many people across the country. radiologists are a referred-to speciality but are not immune from this moral hazard. radiologists are prevented, as far as possible, from generating their own referrals; however, it is incumbent on every radiologist to avoid becoming a facilitator of self-referral by others and to refrain from overuse of contrast studies, inappropriate or unnecessary imaging or up-coding. any inappropriate administration of ionising radiation, whether owing to kickbacks, perverse incentives, ignorance, defensive medicine, overservicing or self referral, contributes to unnecessary radiation exposure. paediatric imaging: the ethics of radiation exposure dr savvas andronikou (president of the college of radiologists of south africa) delivered an enthusiastic address in his unique, highly entertaining and inimitable style, challenging the audience as a serious message was delivered. radiologists were reminded of the significantly increased radiation risks to the vulnerable paediatric population and implored to seriously consider whether each exposure was necessary and whether an alternate form of imaging such as ultrasound, mri or nuclear medicine might not be more appropriate. radiologists were also challenged to consider whether they were competent to perform studies on children using the lowest possible dose, whether the equipment used was up to the task in terms of dose reduction techniques such as pulsed fluoroscopy, and whether the settings had actually been modified for the paediatric examination. do radiologists use screen capture techniques to record studies rather than full exposures? how often do radiologists contact the referring clinician to advise against an inappropriate examination and recommend an alternative investigation? patient confidentiality in clinical practice: is hiv status still relevant? professor keymanthri moodley is head of the bioethics unit at tygerberg and has served on the research ethics committee for the past 10 years. it was a privilege to be addressed by a professional ethicist and to be guided through the minefield of patient confidentiality in the context of responsibilities both to the individual patient and society. the issue of hiv confidentiality was placed in an historical perspective, and aids exceptionalism highlighted. the presentation generated passionate discussion on hiv confidentiality, particularly in the context of healthworker safety and needle-stick injuries, with strong opinions from the floor and clear professional responses from professor moodley. kick-backs and perverse incentives dr bates alheit, the rssa medical director, reviewed the definitions of kick-backs and perverse incentives: any actions or business continued on page 46 article information author: richard de villiers1 affiliation: 1drs van wageningen and partners, somerset west, south africa correspondence to: richard de villiers email: rmldev@mweb.co.za postal address: po box 317, somerset west 7129, south africa dates: received: 05 may 2014 accepted: 04 nov. 2014 published: 12 dec. 2014 how to cite this article: de villiers, r. thoracic cage injury imaging in rugby players. s afr j rad. 2014;18(2); art. #630, 5 pages. http://dx.doi.org/10.4102/sajr.v18i2.630 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. thoracic cage injury imaging in rugby players in this pictorial essay... open access • abstract • introduction • imaging approach • anatomy    • sternum, manubriosternal joint and xiphisternal joint • sternoclavicular joint • ribs and associated joints • muscle injury • conclusion • acknowledgements    • competing interests • references abstract top ↑ rugby players often sustain high-impact collisions and are therefore at risk of significant traumatic thoracic injuries. injury to the thoracic cage may be associated with potentially life-threatening sequelae. player management is often based on the accuracy of the imaging report. the author suggests a combination of computed tomography and magnetic resonance imaging to optimally evaluate the full spectrum of these potentially serious injuries. introduction top ↑ rugby players often sustain high-impact collisions and are therefore at risk of significant traumatic thoracic injuries. furthermore, minimal gear is worn to protect the thoracic cage. in my experience, there have been significant changes in the physique of the modern-day rugby union player who, as a consequence of advanced fitness and nutritional programmes, is of superior strength, size and agility. this physique has resulted in an increase in the frequency of injuries as well as changes in the types of injury that we (drs van wageningen and partners) often encounter in our practice. the thoracic cage protects the heart, lungs, trachea and large mediastinal vessels from injury. injury to the thoracic cage may be associated with potentially life-threatening sequelae. computed tomography (ct) and magnetic resonance imaging (mri) are vital in the imaging of these potential injuries, especially as conventional radiography can often be falsely negative. since the advent of professional sport, the roles of ct and mri have been particularly relevant because decisions regarding player management are often based on the accuracy of the imaging report. this pictorial essay highlights (1) an imaging approach and (2) the relevant anatomy of the thoracic cage. imaging approach top ↑ plain radiography is often not sufficient for the diagnostic assessment of thoracic cage injuries. high-resolution ultrasound (us) can assist in the diagnosis, but is limited by operator dependence and is also restricted to the visualisation of superficial structures.1 a combined ct/mri protocol was developed at the author's institution – a private practice with a large sports injury referral base – in response to the low accuracy of conventional radiography and us in detecting thoracic cage injuries. the author's experience of thoracic cage injuries is in excess of 50 patients. the patient is scanned in the prone position to decrease respiratory motion artifact. a single breath-hold acquisition or respiratory-gated acquisition is utilised for ct, where possible, to minimise motion artifact arising from the patient's respiration.2 patients should otherwise be advised to breathe gently following diaphragmatic excursions.3 for mri, the patient is asked to breathe gently. a standard large flex surface coil is used for mri. an mri-visible marker (vitamin e capsule) is placed at the position of maximal tenderness. axial t1 and short tau inversion recovery (stir) sequences as well as coronal oblique t1 and stir images (figure 1) are obtained. figure 1: coronal short tau inversion recovery (stir) magnetic resonance imaging (mri) of the chest wall demonstrates two undisplaced fractures (arrows) of the costochondral cartilage with surrounding soft-tissue oedema. a non-contrast ct scan is performed and multiplanar reconstructions (mpr) and volume rendering technique (vrt) lead to optimal demonstration of the relevant pathology in most cases (figure 2). adjustment of ct window settings may be necessary (figure 3). figure 2: computed tomography (ct) scan with volume rendering technique (vrt) view of the chest wall. two minimally displaced costochondral fractures are demonstrated (arrow). figure 3: axial computed tomography (ct) scan of the chest wall demonstrating a displaced fracture of the costochondral cartilage – an example of ‘cartilage overlap’ sign (arrow). anatomy top ↑ sternum, manubriosternal joint and xiphisternal joint the sternum comprises the body, manubrium and xiphoid process. it articulates with the clavicles and the cartilaginous portion of the first to seventh ribs, providing attachment sites for the sternocleidomastoid and pectoralis major muscles. sternal fractures are rare owing to the elastic recoil of the ribs, which suspend the sternum.4 a frontal impact may lead to sternal contusion, fracture and manubriosternal joint subluxation or dislocation (figure 4). there may be an associated retrosternal haematoma (figure 5). associated cardiac injury is rare.5 figure 4: coronal short tau inversion recovery (stir) magnetic resonance imaging (mri) of the sternum. there is a linear hyperintense signal in the manubriosternal joint in keeping with disruption of the manubriosternal synchondrosis (arrow). note the intact sternocostal joints and costochondral cartilage. figure 5: sagittal short tau inversion recovery (stir) magnetic resonance imaging (mri) of the sternum showing hyperintense fluid posterior to the sternum in keeping with retrosternal haematoma. note the associated stripping of the posterior periosteum (arrow). sternoclavicular joint top ↑ the sternoclavicular joint (scj) is a synovial joint that represents the only skeletal articulation between the axial skeleton and the upper limbs (figure 6).6 figure 6: schematic illustration of the sternoclavicular joint. the right joint is depicted as a coronal section through the clavicle, manubrium and first costal cartilage, whilst the left shows the intact joint. trauma to the sternoclavicular joint may cause a subluxation, dislocation and/or fracture of the medial clavicle or a fracture of the first costochondral cartilage (figure 7).7 posterior dislocations of the sternoclavicular joint are less common than anterior dislocations, with a reported incidence ranging between 5% and 27% of all scj dislocations.8 posterior dislocation of the clavicle can cause potentially highly hazardous injuries owing to proximity to mediastinal vascular structures, the trachea and oesophagus (figure 8).9 figure 7: coronal short tau inversion recovery (stir) magnetic resonance imaging (mri) of the manubriosternal joint demonstrates disruption of the sternoclavicular cartilage (larger two arrows) with surrounding haematoma (smaller arrow). figure 8: axial short tau inversion recovery (stir) sequence magnetic resonance imaging (mri) of the sternocostal joint demonstrates fracture of the first sternocostal junction with posterior rib subluxation and surrounding haematoma (arrow). ribs and associated joints top ↑ the first to seventh ribs articulate with the sternum via the costal cartilages. the cartilages of the first to tenth ribs join the superjacent costal cartilage, whereas the eleventh and twelfth ribs have a free anterior end. the sixth to ninth costal cartilages articulate via a synovial joint with a fibrous capsule. these interchondral joints are strengthened by interchondral ligaments. costal cartilages are connected to the ribs via the costochondral joints. posteriorly, the head of the ribs articulate with the corresponding vertebral body to form the costovertebral joints.10 rib fractures are often identified following a compressive force to the thorax. the typical site of fracture is at the weakest point, namely the angle of the rib. costochondral injuries are often the result of direct trauma and usually involve the middle and lower ribs.11 these injuries may be missed or misdiagnosed and therefore us, ct and mri play an important role in their diagnosis (figure 9a, figure 9b and figure 10).12 figure 9: axial computed tomography (ct) scan of the chest (a) shows a subtle costochondral cartilage fracture (arrow). axial short tau inversion recovery (stir) magnetic resonance imaging (mri) (b) shows the fracture with surrounding haematoma (arrow). this type of injury can easily be missed and emphasises the need to perform both mri and ct scans. figure 10: computed tomography (ct) scan of the chest wall shows a minimally displaced posterior rib fracture (arrow). ct-guided injections to the costovertebral and thoracic facet joints are administered to expedite return to activity (figure 11). figure 11: computed tomography (ct) scan of the costovertebral joint demonstrating osteoarthrosis of the right costovertebral joint. there is subchondral sclerosis and osteophyte formation. a ct-guided intra-articular injection of the right costovertebral joint was performed, which gave instant pain relief. muscle injury top ↑ the most common muscle injuries encountered at our institution involve the pectoralis major, rectus abdominus, transversus abdominus and oblique muscle groups. pectoralis major muscle tears are observed at the sternal and/or clavicular heads, intramuscularly (figure 12) at the musculotendinous junction (figure 13), or may be at or near the humeral insertion.13 figure 12: axial t2 fs magnetic resonance imaging (mri) of the pectoralis major muscle demonstrating a tear of the muscle, with tendon retraction and surrounding hyperintense haematoma (arrow). figure 13: coronal oblique short tau inversion recovery (stir) magnetic resonance imaging (mri) of the pectoralis major muscle. a tear of the pectoralis major tendon is noted with retraction (arrow) and surrounding haematoma. conclusion top ↑ imaging plays a vital role in the prompt and accurate diagnosis of thoracic cage injuries. the author suggests a combination of ct and mri to optimally evaluate the full spectrum of various injuries. a thorough knowledge of the relevant anatomy and pathology is essential in developing an approach to the imaging of potential thoracic cage injuries in the professional athlete. acknowledgements top ↑ drs daichi hayashi and frank roemer are thanked for their contributions towards this article. competing interests the author declares that he has no financial or personal relationships that might have inappropriately influenced him in writing this article. references top ↑ westcott j, davis s, fleishon h, et al. rib fractures. radiology. 2000;215:suppl.637–639. aslam m, rajesh a, entwisle j, et al. pictorial review: mri of the sternum and sternoclavicular joints. br j radiol. 2002;75(895):627–634. http://dx.doi.org/10.1259/bjr.75.895.750627 hopper ma, tirman p, robinson p. muscle injury of the chest wall and upper extremity. semin musculoskelet radiol. 2010;14(2):122–130. http://dx.doi.org/10.1055/s-0030-1253156 fowler aw. flexion-compression injury of the sternum. j bone joint surg br. 1957;39b:487–497. crestanello ja, samuels le. sternal fracture with mediastinal haematoma: delayed cardiopulmonary sequelae. j trauma. 1999;47(1):161–164. http://dx.doi.org/10.1097/00005373-199907000-00034 johnson d. section 6, pectoral girdle and upper limb. in: standring s, editor. gray's anatomy: the anatomical basis of clinical practice. 40th edn. london: elsevier; 2008:800–801. hayashi d, roemer fw, kohler r, guermazi a, gebers c, de villiers r. thoracic injuries in professional rugby players: mechanisms of injury and imaging characteristics. br j sports med. 2013. http://dx.doi.org/10.1136/bjsports-2013-092681 gilot gj, wirth ma, rockwood ca jr. injuries to the sternoclavicular joint. in: bucholz rw, heckman jd, court-brown c, editors. rockwood and green's fractures in adults. 6th edn. lippincott williams & wilkins, 2006; p. 1365–1397. thomas dp, davies a, hoddinott hc. posterior sternoclavicular dislocations—a diagnosis easily missed. ann r coll surg engl. 1999;81(3):201–204. gatzoulis ma. section 7, thorax. in: standring s, editor gray's anatomy: the anatomical basis of clinical practice. 40th edn. london: elsevier, 2008; p. 917–926. lopez v jr, ma r, li x, steele j, allen aa. costal cartilage fractures and disruptions in a rugby football player. clin j sport med. 2013;23(3):232–234. http://dx.doi.org/10.1097/jsm.0b013e31825b55ed kemp sp, targett sg. injury to the first rib synchondrosis in a rugby footballer. br j sports med. 1999;33(2):131–132. http://dx.doi.org/10.1136/bjsm.33.2.131 connell da, potter hg, sherman mf, wickiewicz tl. injuries of the pectoralis major muscle: evaluation with mr imaging. radiology. 1999;210(3):785–791. http://dx.doi.org/10.1148/radiology.210.3.r99fe43785 article information authors: pumersha naidoo1 bhugwan singh2 affiliations: 1department of radiology, nelson r. mandela school of medicine, university of kwazulu-natal, south africa 2department of surgery, nelson r. mandela school of medicine, university of kwazulu-natal, south africa correspondence to: pumersha naidoo email: pumershanaidoo@gmail.com postal address: 25 the curl, sunningdale, durban 4051, south africa dates: received: 18 july 2014 accepted: 14 sept. 2014 published: 05 dec. 2014 how to cite this article: naidoo p, singh b. current radiological strategies for the assessment of right lower quadrant abdominal pain. s afr j rad. 2014;18(1); art. #695, 15 pages. http://dx.doi/org.10.4102/sajr.v18i1.695 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. current radiological strategies for the assessment of right lower quadrant abdominal pain in this review article... open access • abstract • introduction • inflammatory and infective conditions    • acute appendicitis    • crohn's disease    • diverticulitis    • tuberculous enterocolitis    • epiploic appendagitis • right lower quadrant pain associated with immunosuppression    • neutropaenic colitis (typhilitis) • right lower quadrant pain associated with neoplastic conditions    • lymphoma    • colonic carcinoma • right lower quadrant pain associated with gynaecological diseases    • pelvic inflammatory disease    • endometriosis    • ectopic pregnancy • right lower quadrant pain associated with miscellaneous causes    • intussusception    • caecal volvulus • diagnostic algorithm • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ right lower quadrant abdominal pain is a common clinical entity. imaging and the radiologist play an integral role in achieving a diagnosis, so guiding prompt management of patients. this review discusses the spectrum of pathology and imaging findings, and highlights and contrasts the preferred imaging modalities in different subsets of patients. introduction top ↑ right lower quadrant abdominal pain is a common clinical occurrence, with a wide spectrum of aetiologies that can present a diagnostic challenge for clinicians. appendicitis is invariably the first differential diagnosis and most common cause of right lower quadrant pain. however, other considerations include infective, inflammatory and malignant conditions involving the ileo-caecal region, right colon, mesentery and surrounding anatomical structures. 1 hiv has affected the spectrum of pathology afflicting the right lower quadrant and altered the traditional diagnostic challenges presented by this anatomical region. the attendant clinician must be alert to this influence. imaging is currently at the forefront in assessing and diagnosing patients with right lower quadrant pain, thus guiding appropriate clinical management. ultrasound (us) is the preferred imaging modality in children, pregnant women, and generally young patients, owing to the absence of ionising radiation. advances in computed tomography (ct) with multiplanar reformations and 3d reconstruction have led to some clinicians considering multi-detector ct (mdct) as the modality of choice when evaluating patients with right lower quadrant pain. ct is considered to be the first line imaging investigation for diffuse or peritonitic clinical pictures, and in elderly patients. 1, 2 magnetic resonance imaging (mri) has an emerging imaging role in female patients being assessed for gynaecological diseases – during pregnancy for non-obstetric conditions – and in patients where iodinated contrast is contraindicated, as well as for the evaluation of crohn's disease. 1, 3, 4 mri offers short imaging protocols of approximately 10 minutes, and high contrast resolution, without the use of intravenous contrast or radiation burden. mri and ct yield high sensitivities and specificities, without being user dependent. 5 in this review, we consider the spectrum and typical imaging findings of common pathologies affecting the right lower quadrant. we highlight the preferred imaging modalities in accordance with the alara (as low as reasonably achievable) principle and diagnostic yield. 1 inflammatory and infective conditions top ↑ acute appendicitis acute appendicitis is the most common non-traumatic abdominal emergency. however, only one-half of patients have a classical presentation (leucocytosis, fever and right lower quadrant pain), and the exact cause may be multifactorial. currently, plain film radiography has a limited role, and has been superseded by us and ct. 4 mri is beneficial in those patients for whom a ct scan is not warranted and for whom ultrasound is inconclusive. 5 using high-frequency us with mild compression, an inflamed appendix is typically dilated – more than 6 mm in diameter. an appendicular wall thickness of more than 3 mm may be present with peri-appendicular or pericaecal hyperechogenicity – in keeping with fat infiltration from the inflammatory process (figure 1). 2 figure 1: acute uncomplicated appendicitis in a 24-year-old man. longitudinal (a) and transverse (b) ultrasound images demonstrate a thickened inflamed appendix that has increased in diameter (solid arrow). there is peri-appendiceal hyperechogenicity in keeping with surrounding inflammation (open arrow). typical ct features of an inflamed appendix, using multi-planar reconstruction (mpr), manifest as enlargement of the appendix (diameter > 7 mm), mural thickening and enhancement, and peri-appendiceal fat stranding (figure 2). figure 2: axial (a) and coronal (b) ct images of a young adult showing acute appendicitis with appendicular wall enhancement and thickening (open arrow) with surrounding fat stranding and fluid (solid arrow). secondary signs include the presence of an appendicolith, focal wall thickening of the terminal ileum or caecum, and lack of gas and oral contrast within the appendix. focal caecal wall thickening results in funnelling of oral contrast, termed the arrowhead sign. the complications associated with acute appendicitis include perforation, a peri-appendiceal abscess, pericaecal phlegmon, an extraluminal appendicolith, and small bowel obstruction (figure 3). 6, 7, 8 figure 3: axial (a) and coronal (b) ct scan images of a 26-year-old woman demonstrate complicated appendicitis with caecal wall thickening (white solid arrows), peri-appendiceal phlegmon and extraluminal air (yellow arrows). distal appendicitis is diagnosed when a normal proximal appendix is visualised with an inflamed distal portion. a transition point is visualised with distal luminal narrowing and wall thickening or enlargement. surrounding inflammatory changes are usually present; however, there is no caecal apical thickening or the arrowhead sign, as these are contiguous inflammatory changes. the normal appearance of the proximal appendix can lead to a missed diagnosis of distal appendicitis; therefore it is important to trace the appendix in its entirety. 5, 9 stump appendicitis is a rare complication of appendicectomy that can occur from 2 months to 50 years post-surgery. it occurs when the appendiceal remnant becomes inflamed. the imaging features are similar to acute appendicitis. the increased incidence of stump appendicitis is thought to be directly related to the length of the stump (longer stumps are more prone to infection) and the growing number of laparoscopic appendicectomies. it is important to remember that a past history of appendicectomy does not exclude appendicitis. 10, 11 an appendicular mass or lump may be individualised; there can be adhesion of adjacent viscera (ileum, bladder, greater omentum) to the infectious location (figure 4). 2 figure 4: ct images of a 30-year-old man with acute appendicitis. coronal (a) and axial (b) images demonstrate an appendicolith (white arrows) within an inflamed, enlarged appendix complicated by an appendicular mass and small bowel obstruction (yellow arrows). factors that complicate the diagnosis of appendicitis when using ct include lack of intra-abdominal fat or an unusual location of the caecum or appendix. intra-abdominal fat acts as a natural contrast agent, allowing easy visualisation of an inflamed appendix. therefore, in thin patients, the appendix may be difficult to visualise, leading to a false negative diagnosis of appendicitis. since the caecum is a highly mobile structure and variable in position, locating the ileocaecal valve and accordingly then the appendix, may be beneficial. multiplanar reconstruction (mpr) images are useful in visualising a retrocaecal, pelvic or transmesocolic appendix. 6 two recent studies assessed the value of a non-visualised appendix in patients with clinically suspected appendicitis. they reported that the absence of a visualised appendix on ct almost excludes acute appendicitis (negative predictive value 98%). 12, 13 acute appendicitis is the most common gastrointestinal emergency requiring surgery in pregnant patients. the clinical manifestations in pregnancy are nonspecific and the caecum is displaced anteriorly and out of the pelvis, which makes visualisation of the appendix difficult. there is superior migration and rotation of the appendix as the pregnancy progresses, with the appendix frequently being found in the right upper quadrant. there is a longstanding dilemma when considering the use of diagnostic imaging for evaluating pregnant patients with non-obstetric conditions such as acute appendicitis. imaging modalities that do not make use of ionising radiation (such as us and mri) are preferred as first options. if ionising radiation is to be used, a low radiation dose ct scan must be performed. 3 the american college of radiology (acr) criteria for evaluating pregnant patients for this clinical challenge include the use of targeted right lower quadrant us with graded compression as the first-line imaging modality, with mri as second option, and followed by abdominal ct scan. 3, 14 with targeted compression us, the appendix is better visualised in the first two trimesters. in the third trimester, detection can be improved by placing the patient in the left lateral decubitus position; however, this reduces sensitivity. the sonographic features are similar to a non-gravid patient. if us evaluation is indeterminate and further imaging is clinically indicated, mri may be undertaken. 3 mri allows cross-sectional imaging with identification of appendicitis, and with no exposure to ionising radiation. with excellent soft-tissue contrast resolution, additional structures may be viewed, thereby excluding other sources of abdominal pain. on mri, the imaging features of appendicitis include an appendiceal diameter > 7 mm, wall thickness > 2 mm, t2 high signal intensity in the wall and t2 hyperintensity in the peri-appendiceal fat stranding and surrounding fluid. 4 in the non-pregnant patient, contrast-enhanced and diffusion-weighted imaging may be of value – especially in patients who have equivocal wall thickness and no peri-appendiceal fat stranding. strong contrast enhancement or restricted diffusion is indicative of appendicitis. in general, the major drawbacks of mri are high cost, long imaging times and limited availability. 5, 15 appendicitis in pregnant patients is associated with premature labour, foetal mortality and a higher rate of perforation than in the general population. there should be no delay in the diagnosis. if mri cannot be performed, ct of the abdomen and pelvis should be used as a second-line imaging modality. however, clinicians and radiologists must be aware of the theoretical risk of radiation-induced childhood cancer (approximately one cancer per 500 foetuses exposed to 30 mgy). intravenous and oral contrast agents are preferred in some centres to improve visualisation of the appendix in pregnant patients. 3, 15 crohn's disease crohn's disease is a chronic relapsing auto-immune disorder. whilst predominantly affecting young patients (between 15 and 30 years), it may occur in older patients up to 65 years of age. the disorder can manifest anywhere in the gastrointestinal tract. the ileocaecal region is the most affected and often mimics acute appendicitis. a ct scan excellently depicts the extent and severity of crohn's disease. typical ct scan findings include bowel wall thickening (generally > 1 cm), mucosal hyperenhancement, pericolonic fat stranding, and mural stratification owing to intramural oedema. segmental involvement of the bowel with skipped normal areas are helpful in distinguishing crohn's disease from ulcerative colitis. further findings, such as engorgement of the vasa recta that penetrate the bowel wall (the comb sign), are an important feature of active disease (figure 5). figure 5: ct images of a patient with crohn's disease. axial images (a, b) show a markedly thickened wall of the terminal ileum (open arrows) with interloop fluid (solid white arrow) and comb sign (yellow arrow). sclerolipomatous or fibrofatty proliferation along the mesenteric border of the affected bowel (the creeping fat sign) may be visualised. mesenteric lymph nodes may also be present. associated complications include fistulae, abscesses and small bowel strictures. with the aid of ct mpr, these complications are easily characterised (figure 6). figure 6: ct images of a known crohn's disease patient. coronal (a) and sagittal (b) images demonstrate bowel wall thickening of the caecum and terminal ileum with mucosal hyperenhancement (solid arrows) complicated by an abscess extending into the anterior abdominal wall (open arrow). positive oral contrast agents may allow better depiction of fistulous tracts; however, this may obscure bowel wall hyperenhancement. mri and mr enterography demonstrate similar bowel-related imaging findings noted on ct scan. owing to the young patient population affected by crohn's disease and its chronicity, mri is considered as the first-line imaging option in some centres, to reduce the radiation burden. 1, 2, 16 ct enterography and small bowel follow-through studies also have high appropriateness ratings in the diagnosis and monitoring of crohn's disease. 17 mri short tau inversion recovery (stir) and t2-weighted sequences allow correct localisation of the inflammatory process and the extent of disease. contrast-enhanced sequences can estimate the severity of the episode and also depict complications such as perforation and abscesses (figure 7). figure 7: thirty-three-year-old patient with known crohn's disease. axial (a) and coronal (b) post-contrast fat suppression t1-weighted mri demonstrates marked wall thickening of the terminal ileum with hyperenhancement (white arrows). the use of diffusion-weighted imaging (dwi) appears to be promising, with restricted diffusion believed to be strongly correlated with severity and complications. 5 a recent study assessed the capability of mri to quantitatively assess the response to therapy in crohn's disease. 18 the results clearly showed the distinction between normal and pathological bowel wall, and depicted significant variation in bowel wall thickness and enhancement, so reflecting any favourable response to treatment. diverticulitis diverticulitis is a common cause of abdominal pain. when encountered in the right lower quadrant, it may be caused by diverticulitis in a loop of the sigmoid colon located in the right iliac fossa or, less commonly, the caecum or ascending colon. typical features on ct include extensive pericolonic fat stranding (maximal at the site of the diverticulae), mesenteric fluid and bowel wall thickening with enhancement. it is important to differentiate diverticulitis from acute appendicitis; the key finding is visualisation of a normal appendix. right-sided diverticulae are less common and frequently associated with a stercolith. furthermore, ileal diverticulae are less frequent than colonic diverticulae; ileal diverticulae are located on the mesenteric border and are usually asymptomatic. when ileal diverticulae are inflamed, these must also be distinguished from appendicitis. complications of diverticulitis include fistulae, abscesses, free perforation and bowel obstruction (figure 8). 1, 2, 16 figure 8: complicated diverticulitis. axial (a) and coronal (b) ct images show a rim-enhancing hypodense abscess (open arrows) in a patient with caecal diverticulae. ct is an effective imaging modality that enables prompt diagnosis. using coronal stir mri sequences, the area of inflammation can also be readily identified. guided by this, bowel wall thickening, diverticulae and a narrowed lumen can be visualised. the inflamed areas will enhance on the post-contrast images and complications can be readily detected. 5 tuberculous enterocolitis tuberculosis (tb) is endemic in the south african population, with a marked increase resulting from the aids epidemic. tb involvement of the gastrointestinal tract is well recognised, with the ileocaecal region most commonly affected (figure 9). figure 9: an interesting case of a patient with proven appendicular tuberculosis. coronal ct image shows mucosal hyperenhancement and wall thickening of the appendix (solid arrow), with low-density ileocaecal lymphadenopathy (long open arrows) and numerous splenic granulomas (short open arrow). with barium studies, an early manifestation is spasm and hypermobility, with oedema of the ileocaecal valve leading to its incompetence (figure 10). figure 10: spot film (ap supine) in a barium enema series of a patient with tuberculosis demonstrating a marked thickened caecum (solid arrow), ileocaceal valve (open arrow) and terminal ileum (arrowheads). there is reflux of contrast into the ileum consistent with an incompetent ileocaecal valve. the caecum and terminal ileum are usually both affected; the ct features are concentric mural thickening and enhancement, which may cause luminal narrowing leading to proximal bowel dilatation and obstruction (figure 11). figure 11: ct images of a 29-year-old woman with abdominal tuberculosis. coronal image (a) reveals significant ileal wall thickening causing luminal attenuation (open arrow). there are several ileo-caecal lymph nodes of low-density (small solid arrow). axial image (b) demonstrates the ‘target’ or ‘halo’ appearance of tuberculosis (open arrow). advanced gastrointestinal tb characteristically appears as napkin ring stenosis, with a conically shaped, shrunken caecum retracted out of the right iliac fossa. 19 it can be a radiological and clinical challenge to differentiate tb from crohn's disease, considering the overlap in clinical presentation and imaging features (table 1). this is important as it has significant therapeutic implications. 20 table 1: contrast fluoroscopy and ct findings in tb and crohn's disease. epiploic appendagitis first described by lynn et al. in the mid-1950s, epiploic appendagitis is a well-recognised cause of pain in the right lower quadrant. 2, 21 it is thought to be caused by inflammatory and ischaemic changes secondary to torsion or venous thrombosis of the epiploic appendages. the diagnosis is usually established with ct, allowing early recognition and conservative management. the ct appearance is that of an oval lesion of fat density with a hyperattenuating rim. pericolonic fat attenuation and wall thickening of the adjacent colon may also be present (figure 12). 1, 17, 21 figure 12: example of classic epiploic appendagitis. axial (a), coronal (b) and sagittal (c) ct images show an inflamed epiploic appendage (open arrow) with the typical appearance of a pericolic oval lesion of fat attenuation with an enhancing rim and surrounding fat stranding. right lower quadrant pain associated with immunosuppression top ↑ neutropaenic colitis (typhilitis) neutropaenic colitis usually occurs in patients receiving chemotherapy for malignancies such as leukaemia, and for other immunosuppressive states. clinically, it manifests with right lower quadrant pain, fever, diarrhoea and sometimes peritonitis. ct is considered the study of choice, and the features include caecal dilatation, circumferential wall thickening, intramural air and pericaecal fat stranding and fluid (figure 13). figure 13: ct images of a known leukaemic patient on treatment. axial image (a) shows significant mural thickening and mucosa enhancement of the caecum (solid arrow). coronal image (b) shows significant mural thickening of the caecum and terminal ileum (open arrow) with enlarged lymphadenopathy (open arrowheads). the presence of pneumoperitoneum, pneumatosis, gastrointestinal bleeding and fluid collections may require urgent surgical care. in an immunocompromised patient with symmetrical and circumferential caecal wall thickening, neutropaenic colitis should be suggested first. 1, 2, 16 right lower quadrant pain associated with neoplastic conditions top ↑ lymphoma ileocaecal lymphoma is not uncommon. the four forms of ileocaecal lymphoma are the circumferential, polypoid, ulcerative and aneurysmal varieties. ileocaecal lymphoma usually manifests as areas of bowel wall thickening with uniform attenuation and poor enhancement. long segments of bowel involvement may be demonstrated. signs of bowel obstruction are uncommon. the polypoidal variety can act as lead point for intussusception. the ulcerative form can develop fistulous tracts with adjacent structures. the aneurysmal form may demonstrate dilatation of the lumen of the bowel or cavity of the lymphoid mass. enlarged mesenteric and retroperitoneal lymph nodes are common (figure 14). 1 figure 14: a 23-year-old patient newly diagnosed with lymphoma. axial mdct image (a) shows significant mural thickening of the terminal ileum (open white arrows). coronal image (b) demonstrates enlarged mesenteric lymph nodes (short solid yellow arrow) and significant mural thickening of the terminal ileum (long open yellow arrow). note that there is no evidence of small bowel obstruction. colonic carcinoma most colorectal carcinomas are adenocarcinomas. in comparison with the left colon, and owing to the larger calibre of the right colon, tumours in the latter location can grow to a large size without causing bowel obstruction (figure 15). figure 15: axial (a), coronal (b) and sagittal (c) reformatted ct images of a 63-year-old patient with a caecal carcinoma, showing a large concentric heterogeneously enhancing mass causing marked distortion of the caecum (solid arrows). patients may present with rectal bleeding, anaemia or a palpable mass. 1, 16 ct scanning (mdct and ct colonography) can be used for screening of colon carcinoma for the staging of the disease, for assessing and staging of recurrent disease, and also for detection of distant metastases. 22 carcinomas may demonstrate variable appearances, and perforation can occur, leading to peritonitis or intraperitoneal abscess formation (figure 16). figure 16: ct images of a 56-year-old patient presenting with features of small bowel obstruction. axial (a) and coronal (b) images demonstrate a concentric enhancing mass causing stricturing in the proximal ascending colon (solid arrows), with subsequent small bowel obstruction (open arrows). abscess formation and peritonitis may simulate an inflammatory process rather than a malignancy (figure 17). 1 figure 17: an interesting case of a 37-year-old patient presenting with alteration in bowel habit associated with right iliac fossa pain. this supine radiograph in a barium enema series demonstrates marked thickening with luminal narrowing of the caecum, ascending colon and terminal ileum including the ileocaecal valve. a differential diagnosis of chrohn's disease or lymphoma was given. interestingly, this was proven to be adenocarcinoma on histological testing. right lower quadrant pain associated with gynaecological diseases top ↑ pelvic inflammatory disease pelvic inflammatory disease (pid) is seen in sexually active female patients and manifests as lower abdominal pain. the source of infection is usually an ascending lower genital tract infection. pid encompasses endometritis, salpingitis and tubo-ovarian abscesses. neisseria gonorrhoea and chlamydia trachomatis are the most common pathogens. 23 us may demonstrate loss of normal tissue planes and an ill-defined uterus. thickening of the endometrium may be present, but is nonspecific. fluid may also be seen in the endometrial cavity. salpingitis may progress to hydroor pyosalphinx, and is usually visualised as complex fluid with echogenic debris distending the fallopian tubes. at a later stage, a tubo-ovarian abscess may form. 23 on ct, a complex hypodense fluid collection with thickened and irregular walls of a tubo-ovarian complex, is seen within the pelvis (figure 18). 23 figure 18: ultrasound and ct images of a 22-year-old woman presenting with right iliac fossa pain. transabdominal sonographic image (a) demonstrates a complicated hypoechoic cystic mass with low-level internal septations in the right adnexa (solid arrow). coronal (b) and axial (c) contrast-enhanced ct confirmed the tubular-appearing, rim-enhancing hypodense fluid collection in keeping with a tubo-ovarian abscess (solid arrows). axial ct (c) shows a smaller lesion on the left (small open arrow). mri stir and t2-weighted images may demonstrate a cystic enlarged ovary. on t2-weighted images, signal hyperintensity can be localised within the parametrial tissues. a tubo-ovarian abscess appears with mild t1 hyperintensity and high signal intensity on t2-weighted images. post-contrast mr images demonstrate a thick, enhancing wall of the abscess – with or without an adjacent hydrosalpinx. 5, 17 endometriosis endometriosis is a chronic gynaecological disorder characterised by growth of endometrial tissue outside the endometrial cavity – primarily in the pelvis, peritoneum and ovaries. 24 this ectopic mucosa undergoes cyclical hormonal changes and also bleeds, forming haemorrhagic cysts (figure 19). figure 19: axial ct image in a young female patient with endometriosis demonstrates a heterogeneously enhancing lesion in the caecum that was found to be an endometriotic deposit at surgery (solid arrow). although us can visualise these lesions, ct and mri are better for evaluating and characterising them. mri has a greater sensitivity owing to the detection of blood and blood products. these appear as t1 hyperintensities, also known as the light bulb appearance on fat suppression sequence, which results from the intracellular methaemoglobin. on t2-weighted images, endometriomas appear hypointense. this hypointense signal can also be described as shading that completely occupies the cyst or is seen as a dependent layer. it is thought to be the result of high concentrations of protein and iron from recurrent haemorrhages. 17 minimal enhancement is demonstrated on post-contrast scans (figure 20). 24 figure 20: magnetic resonance images of a young female patient with endometriosis. axial (a) and sagittal (b) t2-weighted images without fat saturation show two endometriotic cysts within the pelvis (solid arrows), with dependent fluid levels (open arrows) of low signal intensity blood products. shading is visualised in both the cysts. axial post-contrast t1 image with fat saturation (c) shows minimal enhancement, with fluid levels still noted (solid arrows). endometriomas are demonstrated on non-contrast ct scan as areas of hyperattenuation with solid and cystic heterogenous adnexal masses and fluid-fluid levels within the cysts. cysts often rupture, leading to haemoperitoneum. the sonographic appearance of endometrioma demonstrates a uniform, low-level echogenicity or a ground glass appearance. the rupture of endometriomas may simulate complex masses, which can make diagnosis challenging. 17, 23 ectopic pregnancy when patients present with features suggestive of an ectopic pregnancy, hormonal (β-hcg) levels and pelvic us should be performed. transvaginal us is the preferred method of evaluation, although abdominal us can demonstrate ectopic pregnancies when β-hcg levels exceed 6 500 miu/ml. 25 tubal pregnancies are the most common ectopic location. on mri, a tubal pregnancy is described as a sac-like, cystic tubal structure with a t2 hyperintense thick wall. the cystic sac may demonstrate t1 hyperintense to intermediate signal intensity, depending on the haemorrhagic component. it is thought that intravenous contrast may help to confidently diagnose an ectopic pregnancy, but contrast is rarely administered in pregnant patients. t2 hyperintensity or t1 hyperintensity may represent free fluid or haemoperitoneum within the abdomen. 26 approximately 35% of ectopic pregnancies may not demonstrate any adnexal abnormalities (figure 21). 25 figure 21: transabdominal ultrasound images (a, b, c) of a young pregnant female patient with right iliac fossa pain. longitudinal scan (a) demonstrates a thick-walled cystic lesion in the right adnexa with a yolk sac and fetus within (open arrow), demonstrating a ring of fire appearance, with colour uptake (solid arrow). tranverse images (b, c) show the tubal ring sign – a hyperechoic rim surrounding the extra-uterine sac (open arrow), the ectopic pregnancy (solid arrow) and an empty uterine cavity with a pseudo-gestational sac appearance (yellow arrow). it is crucial to differentiate normal pregnancy from ectopic pregnancies with the use of us (table 2). table 2: comparison of sonographic features in normal intrauterine and ectopic pregnancies. right lower quadrant pain associated with miscellaneous causes top ↑ intussusception intussusception is not common in adults; it presents as vague abdominal pain, and occurs when a proximal segment of bowel (intussusceptum) telescopes into an adjacent distal segment (intussuscipiens) (figure 22). figure 22: axial ct image of a young patient showing an ileocaecal intussusception with an intussusceptum (open arrow) and an intussuscipens (solid arrow). in adults, there is often an underlying lead point such as benign or malignant neoplasms (e.g. lipoma, polyps, lymphoma, carcinoma, metastases and leiomyomas). in contrast with children, operative treatment is usually necessary in adults. 1, 16, 27 gayer et al. report an increased incidence of intussusception in patients with aids; compare the association of aids with numerous infectious and neoplastic conditions (infectious enteritis, kaposi's sarcoma, non-hodgkin's lymphoma). intussusception should be considered in aids patients with prolonged abdominal pain. 27 although diagnosis can be made using other imaging modalities (including barium enema, us and gastrointestinal series), ct is considered the modality of choice. not only can the diagnosis be made accurately, but the cause and complications – such as bowel obstruction – can be assessed (figure 23). the three typical characteristics are the reniform appearance, sausage appearance and target-shaped bowel-within-bowel appearance. 1, 16, 27 figure 23: a 19-year-old patient presented with vomiting. axial (a) and coronal (b) ct images show an ileocolic intussusception with a lipoma as a lead point (open arrows); this caused subsequent small bowel obstruction (solid arrows). caecal volvulus caecal volvulus is seen in patients with an abnormally mobile caecum; this allows twisting along the long axis, leading to bowel obstruction. three types of caecal volvulus have been described: type 1: the caecum twists in the axial plane, rotating along its long axis type 2: the distended caecum twists and inverts type 3: caecal bascule – the distended caecum folds anteriorly, without torsion. the diagnosis of caecal volvulus and its complications (ischaemia and obstruction) can be readily made using mdct. a distended caecum and swirl of mesenteric vessels is demonstrated in types 1 and 2 caecal volvulus. concentric wall thickening, mesenteric fat stranding, and pneumatosis intestinalis are all signs related to complications. 1 in addition to the causes of right lower quadrant pain enumerated and discussed above, six other causes are listed, together with their respective imaging findings, in table 3. table 3: causes of right lower quadrant pain and their associated imaging findings – not listed or discussed in the text. diagnostic algorithm top ↑ there is a wide spectrum of conditions affecting the right lower quadrant, some with disease-specific investigations and imaging modalities. therefore it is vital that a structured guideline be used. the department of health in western australia has devised several diagnostic imaging pathways as a guide for their practitioners. these pathways are reviewed and updated periodically. the imaging pathway for right iliac fossa pain is particularly pertinent for use in the south african medical setting as it is practical and takes into consideration local availability and imaging constraints (figure 24). figure 24: diagnostic imaging pathway of right iliac fossa pain. conclusion top ↑ right lower quadrant pain is a common clinical situation. when considering imaging, age and sex of the patient are essential factors, as the differential diagnoses may differ. 2 acr criteria still rate us and ct as the primary imaging modalities for evaluating acute abdominal and pelvic conditions such as appendicitis, diverticulitis, pid and ectopic pregnancy. 5 us is clearly preferred in young and pregnant patients, whilst ct is considered first-line imaging for the elderly and those with peritonism. 2 mri is not the modality of choice in all patients, but is a method with high accuracy and may be beneficial in a subset of patients for whom ct is not warranted. 5 all these imaging modalities are of value under certain circumstances, and must not oppose each other but rather have complementary functions, which will allow precise diagnosis and prompt management of patients presenting with right lower quadrant pain. 1, 2 acknowledgements top ↑ we thank dr j. maharajh and dr a. mitha for their help in compiling the images. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions both authors have contributed in various degrees to the article produced. p.n. (university of kwazulu-natal) was responsible for the study conception and design, acquisition and analysis of data and drafting of manuscript. b.s. 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http://dx.doi.org/10.1148/rg.325115153 gayer g, zissin r, apter s, et al. adult intussusception – a ct diagnosis. br j radiol. 2002;75(890):185–190. http://dx.doi.org/10.1259/bjr.75.890.750185 angelelli g, scardapane a, memeo m, et al. acute bowel ischemia: ct findings. eur j radiol. 2004;50(1):37–47. http://dx.doi.org/10.1016/j.ejrad.2003.11.013 brandt lj, feuerstadt p, blaszka mc. anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology. am j gastroenterol. 2010;105(10):2245–2252. http://dx.doi.org/10.1038/ajg.2010.217 romano s, romano l, grassi r. mulidetector row computed tomography findings from ischemia to infarction of the large bowel. eur j radiol. 2007;61(3):433–441. http://dx.doi.org/10.1016/j.ejrad.2006.11.002 stark je, siegel mj. ovarian torsion in prepubertal and pubertal girls: sonographic findings. ajr. 1994;63:1479–1482. http://dx.doi.org/10.2214/ajr.163.6.7992751 vijayaraghavan sb. sonographic whirlpool sign in ovarian torsion. j ultrasound med. 2004;23:1643–1649. o'conner oj, maher mm. imaging of cholecystitis. ajr. 2011;196(4):w367–w374. http://dx.doi.org/10.2214/ajr.10.4340 kambadakone ar, eisner bh, catalano a, et al. new and evolving concepts in the imaging and management of urolithiasis: urologists’ perspective. radiographics. 2010;30:603–623. http://dx.doi.org/10.1148/rg.303095146 takahashi n, vrtiska tj, kawashima a, et al. detectability of urinary stones on virtual non-enhanced images generated at pyelographic-phase dual-energy ct. radiology. 2010;256(1):184–190. http://dx.doi.org/10.1148/radiol.10091411 macari m, hines j, balthazar e, et al. mesenteric adenitis: ct diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. ajr. 2002;178:853–858. http://dx.doi.org/10.2214/ajr.178.4.1780853 lucey bc, stuhlfaut jw, soto fa. mesenteric lymph nodes seen at imaging: causes and significance. radiographics. 2005;25:351–365. http://dx.doi.org/10.1148/rg.252045108 puylaert jbcm. right-sided segmental infarction of the omentum: clinical, us, and ct findings. radiology. 1992;185:169–172. pereira jm, sirlin cb, pinto ps, et al. disproportionate fat stranding: a helpful ct sign in patients with acute abdominal pain. radiographics. 2004;24:703–715. http://dx.doi.org/10.1148/rg.243035084 department of health western australia. diagnostic imaging pathways [homepage on the internet]. available from http://imagingpathways.health.wa.gov.au abstract introduction methods results discussion conclusion acknowledgements references about the author(s) andré rose center for health systems research and development, faculty of humanities, university of the free state, bloemfontein, south africa william i.d. rae prince of wales hospital, faculty of medical imaging, university of sydney, sydney, australia margaret a. sweetlove department of medical physics, faculty of health sciences, university of the free state, bloemfontein, south africa lumko ngetu department of ophthalmology, faculty of health, university of the free state, bloemfontein, south africa mohamed a. benadjaoud institute for radiological protection and nuclear safety (irsn), fontenay-aux-roses, france department of radiobiology and regenerative medicine (seramed), fontenay-aux-roses, france wayne marais department of ophthalmology, faculty of health, university of the free state, bloemfontein, south africa citation rose a, rae wid, sweetlove ma, ngetu l, benadjaoud ma, marais w. radiation induced cataracts in interventionalists occupationally exposed to ionising radiation. s afr j rad. 2022;26(1), a2495. https://doi.org/10.4102/sajr.v26i1.2495 original research radiation induced cataracts in interventionalists occupationally exposed to ionising radiation andré rose, william i.d. rae, margaret a. sweetlove, lumko ngetu, mohamed a. benadjaoud, wayne marais received: 07 june 2022; accepted: 06 july 2022; published: 30 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational exposure to ionising radiation may have detrimental health effects. longer and more complex fluoroscopic procedures have placed interventionalists at increased occupational health risks especially for developing cataracts in the radiosensitive lenses of the eyes. objectives: this study aimed to determine the prevalence of occupational related cataracts and describe the risk factors for cataracts in occupationally exposed interventionalists compared with unexposed doctors. method: a cross-sectional study using multiple methods. a survey was conducted. the radiation workload was determined based on a self-administered questionnaire and dose area product values determined in previous studies. both groups had slit lamp examinations. the data were analysed analytically using r software version 9.3. results: the study included 98 interventionalists. the combined prevalence of posterior sub-capsular (psc) and cortical cataracts was 18.8% in the exposed and 13.9% in the unexposed group. the prevalence of psc cataracts in the exposed group was 5.9% and 2.8% in the unexposed group, with an odds ratio (or) of 2.2 (95% confidence interval [ci]: 0.58; 8.61). posterior sub-capsular cataracts were more common in the left eye. the increase in cataracts was not statistically significant in the exposed group but is of clinical significance. conclusion: the findings are important as they highlight the need for greater vigilance for protecting the radiation healthcare workforce in a developing country setting. contribution: the research is the first of its kind in south africa and africa and contributes to determining the prevalence in this highly skilled and occupationally vulnerable group. keywords: interventionalists; interventional radiology; ionising radiation; radiation cataracts; radiation protection. introduction ionising radiation (ir) is integral and essential in modern medical diagnostic, prognostic and interventional procedures.1 the number of procedures has dramatically increased globally over the past few decades.1 the technology has improved and lower radiation doses are delivered to patients. interventionalists are, however, performing more complex procedures, which are lengthier and they are thus occupationally exposed to ir for a longer duration and their eyes are at particular risk of developing cataracts in the long term.2 interventional clinicians such as interventional radiologists, interventional cardiologists and radiation healthcare workers (hcws) are at high risk of radiation exposure in the catheterisation laboratory.3 when compared with other interventional procedures, cardiac catheterisation procedures expose operators to radiation doses 2–3 orders of magnitude greater.4 interventional radiologists and interventional cardiologists receive similar radiation doses in the catheterisation laboratory (even though the procedures are in some ways quite different) and therefore should be similarly trained and protected to mitigate the risk.2 the effects of ir on interventionalists include stochastic effects such as cancer and chromosomal aberrations.5 it was previously thought that the relationship between ir exposure and cataractogenesis was deterministic, but increasingly there is uncertainty about a threshold level and evidence is mounting that the effects may be evident even at low doses.6,7,8 the additive effect of low dose radiation on other cataract risk factors also remains to be answered.7 low dose exposure to ir places radiation hcws at increased risk of developing cataracts if they are not adequately protected.9 the lenses of the eyes are highly radiosensitive and there is a strong correlation between occupational radiation exposure and cataracts.8 cataracts related to occupational radiation exposure are frequently reported to occur in the posterior sub-capsular (psc) region of the lens of the eye but recent data suggest that it may also occur in the cortical region.10 radiation-induced cataracts also occur more commonly in the left eye compared with the right eye, and this is related to the position in which the interventional cardiologist is working with respect to the x-ray beam.10 in a french study conducted between 2009 and 2011, it was shown that cardiologists with a mean age of 51 ± 7.3 had a prevalence of psc cataracts of 17% (n = 109; confidence interval [ci]: 10% – 24%; odds ratio [or]: 3.8 [1.3–11.4]).11 in another study conducted in malaysia in 2009 the prevalence of psc cataracts was reported as 54% (n = 56; ci: 35–73; relative risk of 5.7 [ci: 1.5–22]). in this cohort there were 56 interventional cardiologists with a mean age of 43 ± 7 years (31–64).12 in contrast, separate greek and finnish studies showed that there was no statistically significant difference between cataract findings in interventionalists occupationally exposed to ir and a group of doctors not occupationally exposed to ir.13,14 in the greek study, thrapsanioti, et al. (2017), included 44 interventional cardiologists.13 in the finnish study by auvinen, et al. (2015) psc cataracts were detected in 3/21 exposed participants compared with 1/15 unexposed participants (the prevalence ratio was 2.29 [ci: 0.29–19.97] for the exposed group) and the mean age was 54.14 it is, however, difficult to compare studies on the prevalence of occupational radiation-induced cataracts as these studies used different grading systems, different assessments of risk factors and there are concerns about dosimetry because of dose uncertainties.6 however, these discrepancies do not negate the clinical significance of these studies and the importance of protecting the eyes of doctors (and other radiation hcws) in this occupational setting. this is particularly important given the mounting evidence of the detrimental biological effects of low dose radiation to the eyes, which has resulted in the international commission on radiological protection (icrp) revising its exposure limit recommendations from 150 msv per year to 20 msv per year, averaged over five years, with no one year exceeding 50 msv.15 a survey done in the united kingdom by public health england in 2012/2013 found that compliance with these recommendations would be possible in the united kingdom.16 these recommendations, however, have potentially major implications for resource constrained environments such as south africa (and africa). in such settings the implementation, control and monitoring of regulatory structures would be a challenge, making it difficult to comply with icrp recommendations to reduce the dose as mentioned here.17 south africa (and other lowto middle-income countries) has a paucity of highly trained doctors such as interventionalists, which is compounded by an escalating burden of non-communicable diseases that requires these skills for its management.18 it is thus important that this human resource is protected and that safety in the workplace is optimised. this can be achieved through several initiatives such as measuring and monitoring ir exposure in the workplace,19 enforcing personal dosimetry utilisation and feedback, promoting informed decision making when using imaging in clinical practice,20 appropriate use of imaging equipment,20 encouraging consistent and appropriate use of personal protective equipment (ppe),21 formalised training and continued medical education on radiation safety,22 and engaging hospital management structures to support all aspects of promoting radiation safety in the workplace.23 underpinning these initiatives is the creation of a culture of radiation protection (crp).23 this crp is the cornerstone of the norms, values and standards within an organisation.24 the aim of this study was to determine the prevalence of occupational related cataracts and describe the risk factors for cataracts in this study population of occupationally exposed interventionalists compared with an occupationally unexposed group of doctors in south africa. methods study design this was a prospective cross-sectional study that formed part of a larger multiple methods study.25 study population figure 1 illustrates the participants who were recruited for the study. the inclusion criteria for the occupationally exposed participants were interventional radiologists and interventional cardiologists. the occupationally unexposed participants had to be a doctor who was not routinely occupationally exposed to ir. all participants had to have completed the survey and had a slit lamp examination. participants were excluded because they did not meet the inclusion criteria, because the survey was not fully completed or the data provided were not useable or they did not have a bio-microscopy slit lamp examination. the participants not occupationally exposed to ir included family physicians, specialists physicians, psychiatrists and pathologists. the occupationally exposed participants included 25 interventional radiologists, 42 adult cardiologists and 31 paediatric cardiologists. the two groups were comparable to each other in terms of socio-demographics and levels of education. figure 1: illustration of the study population that were screened and completed the survey. data collection data were collected at conferences and workshops across south africa between may 2015 and march 2017. the survey was conducted using a paper-based system and an electronic format. the questionnaire collected demographic data, medical risk factors, non-occupational exposure, occupational workload, personal protective equipment utilisation, dosimetry practice and radiation safety training.25 ophthalmological examination all participants had a bio-microscopy slit lamp examination by the same trained ophthalmologist using the same slit lamp. the clinician was not blinded to the participants because screening was conducted at radiology or cardiology conferences. the participants’ eyes were dilated and a bio-microscopy slit lamp examination was conducted.25 cataracts were classified according to the world health organization simplified cataracts grading score (whoscgs).26 the cataracts were graded as cortical, nuclear or psc.26 visual acuity was measured using a modified snellen chart. workload estimation workload was calculated from self-administered questionnaires completed by interventionalists who indicated the type of procedure, the number of procedures per week and the number of years worked with fluoroscopy guided interventional procedures. average dose area product (dap) values per procedure were obtained from previous work performed both in the same institution as this study and more widely in south africa.27,28 as dap reflects not only the dose within the radiation field but also the area of tissue irradiated, it is a better indication of scattered radiation, which is the source of radiation to the eye. the dap was an average for a specific procedure. this average would have changed with time for the specific procedure and it is a limitation that we did not consider in the calculations. three categories of modifiers were considered: (1) an attenuation modifier accounting for attenuation afforded by the use of ceiling suspended screens and the frequency of use of these screens; (2) a similar modifier for the use of lead glasses and the frequency of use of these glasses; and (3) an escalating modifier for radial (as opposed to femoral) approach and its frequency of use. the maximum modifying factors were taken from published data.29 the modification factor for the ceiling suspended screen and the lead glasses was 0.1 and 2.0 for radial access, which was applied to the calculated lifetime dap of the participants.30 statistical analysis statistical analyses were performed using r software version 9.3 (r: a language and environment for statistical computing. r foundation for statistical computing, vienna, austria, url https://www.r-project.org). the comparison of demographics between the participants occupationally exposed to ir and those not occupationally exposed was conducted using the mann–whitney u-test and chi-squared test according to the nature of the covariates (continuous and categorical, respectively). ordinary logistic regression, adjusted for age, was conducted to analyse and compare the cataracts in the left and right eyes in the two population groups. in order to identify the risk factors associated with cortical and psc cataracts using the left and right eye scoring within each participant, a mixed effect logistic regression was performed generating ors and 95% cis (r-package lme4). ethical considerations the study was approved by the health sciences ethics committee of the university of the free state (ecufs44/2015). all participants consented to completing the survey and to having a bio-microscopy slit lamp examination. results table 1 illustrates the basic demographic data and the risk factors for cataracts in the participants. there were 243 participants in total and 98 were routinely occupationally exposed to ir. we included only participants who both completed the survey and had the bio-microscopy slit lamp examination. table 1: demographics and risk factors with percentages for categorical variables and mean ± standard error for continuous variables. the p-values are for comparison of exposed and unexposed groups. there was no statistical difference in demographics and risk factors between the exposed and unexposed groups (except for hypertension), which meant that the two groups were comparable in all respects including age, gender and risk factors. in the analysis, years worked for the exposed group refers to how many years they worked performing fluoroscopy procedures and thus is a measure of their duration of occupational exposure to ir. years worked in the unexposed group refer to how long they have worked as doctors. this may explain the p-value (0.004) in the analysis. there were 11 (10.2%) participants who reported using lead glasses consistently, 66 (61.1%) reported never using lead glasses and 21 (19.4%) never used ceiling suspended screens. this is consistent with low use of protective lead eyewear in other settings.31 table 2 illustrates that there were no risk factors that were statistically significantly associated with any risk factor for cortical or psc cataracts for all the participants. table 2: the univariate analysis for cortical and posterior sub-capsular cataracts risk factors in all participants. in table 3, the combined prevalence of psc and cortical cataracts was 18.8% in the exposed and 13.9% in the unexposed group. the prevalence of psc cataracts in the exposed group was 5.9% and 2.8% in the unexposed group, giving an or of 2.2 (95% ci: 0.58; 8.61). although the difference between the exposed and unexposed groups for psc was not statistically significant, it was based on very small numbers of cases and the increase was restricted to the left (and most exposed) eye. the 2.2-fold increase in the exposed group may therefore be of clinical significance. table 3: description of cataracts after exclusion of participants less than 35 years and less than 5 years’ experience. in table 4, we would have expected a pattern showing an increase in risk with age and occupational exposure to ir. even if significant risk of psc and cortical cataracts was found amongst the exposed practitioners with career duration less than five years and between 11 and 20 years, respectively, a global risk trend was not demonstrated. the correlation between years exposed to ir and cataract was not demonstrated. on the other hand, the age was confirmed as a major risk factor in both types of cataracts increasing the odds by 6% – 7% for each additional age year. table 4: posterior sub-capsular and cortical cataracts according to career after excluding participants < 35 years of age and years of occupational exposure to ionising radiation. table 5 demonstrates the years worked with fluoroscopy and the lifetime workload exposure when lead suspended ceiling screens, lead glasses and radial access are considered. the lifetime workload exposure is the cumulative ionising dose that interventionalists were exposed to during their career. table 5: estimated radiation workload exposure in gy.cm2 for each category of worker without ppe protection and with the different ppe used. discussion the exposed and unexposed groups were both doctors and thus comparable to each other occupationally and socio-economically. in previous studies the control groups were often support staff such as nurses. the comparability of the two groups was further reaffirmed when adjusting for confounders which did not change the results. the bio-microscopy slit lamp examination was carried out by the same ophthalmologist (l.n.). the advantage of using a single ophthalmologist is that it does not introduce inter-observer bias. the grading was carried out according to the whoscgs grading system.26 this is a standardised system cataract grading system, which is freely available. this, however, does make it difficult to compare the findings to studies that used a different scoring system. there was no statistically significant difference between the prevalence of cortical and psc cataracts in the interventionalists occupationally exposed to ir compared with the occupationally unexposed group although 2.2and 1.4-fold increases were observed, based on the small numbers of cases. this is in contrast to previous studies that mostly demonstrated an increase of 3–5-fold compared with an unexposed group.11,12,32 our findings, however, corroborate those of two other studies that showed a lower prevalence of radiation associated cataracts compared with the preceding studies cited.13,14 the combined prevalence of cataracts for both psc and cortical was 18.8%. there is evidence to suggest that cortical cataracts may also be associated with radiation.10 although there was no statistical difference in the prevalence of psc cataracts between the occupationally exposed group compared with the unexposed group, psc cataracts were 2.2 times more likely than in the unexposed group (or: 2.2; ci: 0.578; 8.611; p = 0.244). this is clinically significant and therefore occupationally significant. this study findings further showed an increase in cataracts in the left eye compared with the right eye. this finding is congruent with current literature which reports that radiation-induced cataracts are more common in the sub-capsular region in the left eye of interventionalists occupationally exposed to ir.11 south african interventionalists spend 2–3 days per week in the catheterisation laboratory and thus may have less accumulated occupational exposure to ir than in countries where interventionalists may spend more time in the catheterisation laboratory. we postulate that this may be a reason that the prevalence of psc cataracts is not as high as reported in previous studies. another possible reason could have been that the interventionalists were consistently using lead glasses. however, our study showed that only 10.2% of participants consistently used lead glasses and therefore, there must be other factors that could explain the difference between our findings and studies which showed a higher prevalence. we did not directly measure the radiation dose to the eye and this is a limitation of this study. future studies should measure the radiation dose to the eye in the south african context. the workload estimates calculated are limited by the many confounders that could affect the radiation workload estimate. the calculations, however, consider those main factors that could have influenced the workload dose estimates. the workload exposures were a lifetime dose exposure estimate, which were extrapolated from a self-completed questionnaire and may have been affected by recall error. the recall error may have affected the reliability of the findings. the strength of this study is that it is the first to determine the prevalence of cataracts in interventionalists occupationally exposed to ir in a resource constrained african setting. africa is rapidly acquiring advanced radiological technologies and it is crucial to protect the health workforce that will be operating these machines. the results do not negate previous findings of a higher prevalence of radiation-induced cataracts. it, however, does support the need for greater vigilance in radiation protection measures for the eye and the need to develop a crp in the catheterisation laboratory in order to prevent radiation damage to the eyes. a south african study showed an underdeveloped crp within the south african context especially amongst south african cardiologists.23 the use of personal protective eyewear is imperative for protecting the eyes of interventionalists and should be part of a radiation safety culture.33 education and training is key to developing a crp.34 the training programme for interventionalists and especially cardiologists in south africa requires urgent and decisive intervention to aid developing an entrenched crp.22,35 conclusion although there was no statistical difference between exposed and unexposed groups, possibly because of the relatively small numbers of subjects included in the study, psc cataracts were more likely to occur in interventionalists occupationally exposed to ir. radiation safety measures should be implemented, encouraged and enforced in interventionalists occupationally exposed to ir to mitigate for ir damage to the eyes. although this study was conducted in south africa, the recommendations may be transferable to other resource constrained settings in africa and other lowand middle-income countries. acknowledgements we thank prof elisabeth cardis (radiation programme, isglobal, center for research in environmental epidemiology, barcelona, spain) for input to the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions w.i.d.r., a.r. and w.j.m. conceptualised the study. a.r., m.a.s. and l.n. collected the data. l.n. did the bio-microscopy slit lamp screening and l.n. and w.j.m. assisted with interpretation of the ophthalmological findings. m.a.s. and w.i.d.r. did the calculations for the workload exposure. m.a.b. assisted with the statistical analysis. a.r. wrote the first draft of the manuscript. all authors gave input to the article. all authors read and approved the final manuscript. funding information the phd from which this study emanated was funded by the medical research council of south africa under the south african medical research council (samrc) clinician researcher programme. a.r. received the discovery foundation scholarship, which funded the data collection of this project. the south african heart (sa heart) (free state branch) partially funded data collection of this project. w.i.d.r. is a recipient of a national 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https://doi.org/10.1093/rpd/ncw356 auvinen a, kivelä t, heinävaara s, mrena s. eye lens opacities among physicians occupationally exposed to ionizing radiation. ann occup hyg. 2015;59(7):945–948. https://doi.org/10.1093/annhyg/mev022 bouffler s, ainsbury e, gilvin p, harrison j. radiation-induced cataracts: the health protection agency’s response to the icrp statement on tissue reactions and recommendation on the dose limit for the eye lens. j radiol prot. 2012;32(4):479–488. https://doi.org/10.1088/0952-4746/32/4/479 ainsbury ea, bouffler s, cocker m, et al. public health england survey of eye lens doses in the uk medical sector. j radiol prot 2014;34(1):15–29. https://doi.org/10.1088/0952-4746/34/1/15 barnard sg, ainsbury ea, quinlan ra, bouffler sd. radiation protection of the eye lens in medical workers-basis and impact of the icrp recommendations. br j radiol. 2016;89(1060):20151034. https://doi.org/10.1259/bjr.20151034 sliwa k, zühlke l, kleinloog r, et al. cardiology-cardiothoracic subspeciality training in south africa: a position paper of the south africa heart association. cardiovasc j afr. 2016;27(3):188–193. https://doi.org/10.5830/cvja-2016-063 durán a, hian sk, miller dl, le heron j, padovani r, vano e. recommendations for occupational radiation protection in interventional cardiology. catheter cardiovasc interv. 2013;82(1):29–42. https://doi.org/10.1002/ccd.24694 fazel r, gerber tc, balter s, et al. approaches to enhancing radiation safety in cardiovascular imaging. circulation. 2014;130(19):1730–1748. https://doi.org/10.1161/cir.0000000000000048 könig am, etzel r, thomas rp, mahnken a. personal radiation protection and corresponding dosimetry in interventional radiology: an overview and future developments. fortschr röntgenstr. 2019;191(06):512–521. https://doi.org/10.1055/a-0800-0113 rose a, rae w. perceptions of radiation safety training among interventionalists in south africa. cardiovasc j afr. 2017;28(3):196–200. https://doi.org/10.5830/cvja-2017-028 rose a, uebel ke, rae wid. interventionalists’ perceptions on a culture of radiation protection. s afr j rad. 2018;22(1):a1285. https://doi.org/10.4102/sajr.v22i1.1285 fridell k, ekberg j. making the invisible visible: a qualitative study of the values, attitudes and norms of radiologists relating to radiation safety. j radiol prot. 2016;36:200–214. https://doi.org/10.1088/0952-4746/36/2/200 rose a, rae w, chikobvu p, marais w. a multiple methods approach: radiation associated cataracts and occupational radiation safety practices in interventionalists in south africa. j radiol prot. 2017;37(2):329–339. https://doi.org/10.1088/1361-6498/aa5eee thylefors b, chylack jr l, konyama k, et al. a simplified cataract grading system. ophthalmic epidemiol. 2002;9(2):83–96. https://doi.org/10.1076/opep.9.2.83.1523 muller h. patient radiation dose ranges for procedures in universitas hospital vascular laboratories. bloemfontein: central university of technology; 2014. de vos hj. radiation dose optimization in interventional radiology and cardiology using diagnostic reference levels. cape town: university of cape town; 2015. vañó e, gonzalez l, fernández jm, haskal zj. eye lens exposure to radiation in interventional suites: caution is warranted. radiology. 2008;248(3):945–953. https://doi.org/10.1148/radiol.2482071800 lange hw, von boetticher h. randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach. catheter cardiovasc interv. 2006;67(1):12–16. https://doi.org/10.1002/ccd.20451 valuckiene z, jurenas m, cibulskaite i. ionizing radiation exposure in interventional cardiology: current radiation protection practice of invasive cardiology operators in lithuania. j radiol prot. 2016;36(3):695–708. https://doi.org/10.1088/0952-4746/36/3/695 bitarafan rajabi a, noohi f, hashemi h, et al. ionizing radiation-induced cataract in cardiology staff. res cardiovasc med. 2015;4(1):e25148. https://doi.org/10.5812/cardiovascmed.25148 klein lw, miller dl, balter s, et al. occupational health hazards in the interventional laboratory: time for a safer environment. j vasc interv radiol. 2009;20(2):147–153. https://doi.org/10.1016/j.jvir.2008.10.015 georges j, livarek b, gibault-genty g, et al. reduction of radiation delivered to patients undergoing invasive coronary procedures: effect of a programme for dose reduction based on radiation-protection training. arch cardiovasc dis. 2009;102(12):821–827. https://doi.org/10.1016/j.acvd.2009.09.007 brown s. radiation safety: time to act. cardiovasc j afr. 2017;28(3):139–140. editorial 74 sa journal of radiology • june 201074 sa journal of radiology • september 2010 cardiac case quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban presentation a 26-year-old woman with a background history of cardiac surgery in childhood, presented with worsening atypical chest pain and dyspnoea. the following images were obtained. we invite readers to describe the findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@hotmail.com before 28 october 2010. the winning respondent will receive a r1 000 award from the rssa. a detailed diagnosis will appear in the next issue of the sajr. fig 1. erect pa chest x-ray. fig. 2. pre-contrast axial chest ct. fig. 3. post-contrast dynamic axial chest ct, at levels of the aortic arch, pulmonary trunk and left atrium. fig. 4. post-contrast axial ct abdomen. fig. 5. post-contrast coronal and sagittal ct chest reformat. 38 sa journal of radiology • june 2006 as a radiologist with a special interest in magnetic resonance (mr) imaging and teaching, i have spent years looking for a computer solution to archive teaching cases electronically. at last i have found something way beyond my expectations. i have been digitising films for many years, initially for specific lectures using a film scanner. recently, i have used a digital camera selecting images on the ‘run’ during a busy working day for use in general teaching. although the image quality is good, i have ended up with enormous files of digital images, many unopened, which often have incomplete demographics and an uncertain diagnosis. consequently, preparing a presentation which requires searching through and transferring poorly catalogued jpeg (joint photographic experts group) images into a powerpoint (microsoft office, microsoft corporation, redmond, usa) presentation is very time consuming. how much better to have all the images already organised into electronic teaching files! teaching library programs available off the internet, have been reviewed.1 many of these are very good but it is still a laborious task to enter jpeg images with history and findings into these databases, and on top of that the retrieval of ct or mr teaching cases from workstations via cd or ‘memory sticks’ is rather cumbersome. over the last few years many dicom (digital imaging and communications in medicine standard) software viewers have become available off the internet.2,3 scanner vendors will also supply a very basic dicom viewer when exporting images to cd, which is of little use. my electronic teaching ‘project’ remained in a shambles until a year ago. at that time i had become thoroughly frustrated by ‘windoze’ (term of endearment for the operating system on pcs) and when my laptop screen expired, i decided to switch computer system and bought an apple laptop computer, ‘macbookpro’ (apple computers inc., cupertino, ca, usa). i will avoid going into the difficult comparison of two such different packages as an apple computer with its integrated software and the microsoft windows software which has to be able to run on a variety of different quality machines. suffice to say, the mac operating system does not need antivirus programs, and rarely if a program does ‘hang’, you can force it to quit without the computer crashing. while showing off my new mac, i got to hear about a visiting uk radiologist who was teaching, using his mac laptop as a workstation! i tracked him down quickly for more details. the program is called osirix, open source software (oss) downloadable free off the internet at http://homepage.mac.com/rossetantoine/osirix, but it only runs on the apple platform (operating system x – os x) for the moment.4,5 this is truly an amazing dicom and pacs program. osirix will accept dicom cds from all vendors, and if it doesn’t ‘see’ the dicom folder automatically, exploring the cd's hidden directories is simple. this is not possible on our workstations, which run on a windows platform, but do not allow access to the windows programs, presumably for ‘security’ reasons. this restriction of access i find very frustrating, especially considering the hefty price of these workstations. it would be much more efficient to run the viewing software in open integration with powerpoint, web browser for quick internet searches, and e-mail for sending selected images to colleagues or referring physicians. this is however possible with osirix. fortunately, i have a connection point for our ethernet at my desk linking scanners and workstations. sending cases straight to my laptop via ethernet was fairly easy with the help of the mr technicians, who needed to set up the correct addresses of my laptop on the mr console and later ct workstation as well. these technicalities are described on a congress poster which can be downloaded from the web.6 it was not long before i was reporting mr studies off my laptop, increasing my efficiency considerably compared with my previous film reading. picture quality is superb and image handling fast. in osirix the images are available instantly; it can view multiple sequences in flexible windows and relates them automatically to each other, i.e. while scrolling through an axial stack, the current slice is indicated by a line on the sagittal and coronal views, and if one double clicks on a lesion its position is immediately indicated on the other open sequences of the study. old and new ct studies can be compared in both the axial and coronal projections which is not possible on our conventional workstation. one can subtract and fuse images easily with ‘drag and drop’, for example fusing an mr angio sequence with a flair sequence not only slice by slice, but also in 3d. calculating organ or lesion volume is simple and when drawing rois (region of interest) osirix has an amazing ‘repulsor tool’ for pushing the line into position. of course the usual data manipulations are available, such as mpr (multi-planar reconstructions), and mip (maximum intensity projections), but also more complex processes such as volume and surface rendering, which are facilitated by various cutting and seeding tools as well as clut (colour lookup table) editors. the osirix team, led by a radiologist and software developer antoine rosset, are developing and improving the program constantly, getting feedback from the user group, which now numbers over 10 000 worldwide. joining this group will give you access to a regular stream of e-mails (questions and answers, requests and announcements of new downloadable upgrades) from all over the world, and quite entertaining sometimes. the use of oss is new to radiology, but judging from the quality of osirix and the enthusiasm, it is here to stay (for more detail and history on oss, search www.wikipedia.org, which also has a manual on osirix). for clinicians, osirix represents a cost-effective solution, enabling them to have access and the ability to manipulate their imaging studies for better patient management. the dicom viewers distributed with the patients’ cds are very basic without any facility to manipulate the dataset in detail. for radiologists, osirix represents a very attractive, economical solution, enabling them to have an extra or personal workstation, which will integrate with a pre-existing pacs or just your workstations. my personal portable pacs station by: mark haagensen 38 sa journal of radiology • june 2007 background eureka! the personal pacs gets underway the osirix user group changing systems who can benefit from osirix pg38-39.indd 38 6/13/07 9:23:32 am 39 sa journal of radiology • june 2006 osirix is particularly useful when conducting academic meetings, e.g. for our weekly neuroradiological combined meeting, the co-ordinator receives cases for discussion the day before on cd in dicom format. videoprojection of osirix is in real-time and interactive and best done by somebody with a little experience of the program. the large image display promotes audience participation and learning. osirix runs smoothly on the laptop with no restrictions making it very convenient. however additional ram up to 2 gigabytes is generally recommended. video projection of osirix is also very useful in tutorials for radiology registrars. simulating the work situation with a pacs station and giving the candidate the original dataset to examine, seems the proper way to go. using an oss program(s) would be inexpensive and fairer to exam candidates by not favouring a particular vendor’s workstation, and osirix is easy to use for general manipulations. although osirix only runs on the apple os at the moment, the new apple computers can also run microsoft windows for an alternative viewer to osirix, making apple mac the more flexible solution. in the case of formal lecture presentations, osirix again comes to the rescue. you can view your entire teaching case on the one hand, while making your presentation on the other, and the dicom image you want to use can be ‘dragged and dropped’ into the ‘slide’, where it is automatically converted to a jpeg format. it does the same for any 3d or fusion images. if you need a cine, you export the series from osirix in quicktime format (apple computers inc.) to ‘desktop’ and drop it into your slide. briefly, osirix has many other features such as a dicom print function to laser printer, query and retrieve function from other nodes on the pacs, export in dicom either to file or back to the pacs server of secondary generated images, report function including dicom structured report with plans for word recognition as a plug-in in the future. however, i haven’t had the opportunity or necessity to check out all the complex pacs features. lastly, one of the most impressive and powerful functions is the 4d player. this involves 3d plus the added dimension of time; for example i tested a new super-fast contrast-enhanced mr angiogram sequence supplied by a vendor, consisting of 40 slices in 3 seconds as a volume repeated over 9 dynamics. using the 4d player you can view the cine run as a mip, and simultaneously rotate it as a 3d volume! osirix can also do 5d, which is the further addition of a functional parameter, such as positron emission tomography (pet). there is a cine of a 5d study downloadable from the osirix website (http://homepage.mac.com/rossetantoine/ osirix). after all that – yes i did find my little teaching database as well. a subgroup of the osirix team has made a small oss program called xphile modelled on the itunes program, which can be downloaded free from http://homepage.mac.com/d2p/xphile. it integrates with osirix making data capture easier. the need for a teaching file seems less urgent after osirix, which has ‘albums’ and search functions plus report facility enough for a dicom teaching library for the moment. as mentioned, i have not explored osirix to its fullest as yet, and other appealing features are teleradiology, teleconferencing and connectivity to ipod (apple computers inc).7 osirix is a very powerful and fast pacs and dicom program freely available off the internet. it is an open source program without any guarantees, but where one relies on support from a large user group of similarminded people with a large pool of experience. support companies are emerging that sell support and hardware for a pacs entirely based on osirix, which in their hands has been fda-approved. osirix has made great impact on my teaching and efficiency as a radiologist. it only runs on apple computers, but ‘switching’ is highly recommended as well. 1. scarsbrook af, foley pt, perriss rw, graham rnj. radiological digital teaching file development: an overview. clin radiol 2005; 60: 831–837. 2. escott ej, rubinstein d. free dicom image viewing and processing software for your desktop computer: what’s available and what it can do for you. radiographics 2003; 23: 1341-1357. 3. escott ej, rubinstein d. free dicom image viewing and processing software for the macintosh computer: what’s available and what it can do for you. radiographics 2004; 24:1763-1777. 4. ratib o, rosset a. open-source software in medical imaging: development of osirix. international journal of computer assisted radiology and surgery 2006; 1:187-196. 5. rosset a, spadola l, ratib o. osirix. an open-source software for navigating in multidimensional dicom images. j digit imaging 2004; 17: 205-216. 6. rosset a, ratib o, heuberger j, tao w. how to integrate your personal computer in a pacs environment. http://homepage. mac.com/rossetantoine/osirix/posterrsna2005.jpg 7. rosset c, rosset a, ratib o. general consumer communication tools for improved image management and communication in medicine. j digit imaging 2005; 18: 270-279. congrats and best wishes to my friends and colleagues, dr ashwin hurribance who is the new president of the college of radiology of south africa, and professors savvas andronikou and victor mngomezulu who are now at the helm of the university of stellenbosch and medunsa respectively. it would be remiss of me not to point out that all of them hailed from wits university. a further congrats to savvas on being awarded the derek harwood scholarship. this is just one of two scholarships awarded by the rsna on an annual basis. the scholarship is worth 10 000 dollars, and enables savvas to study at an american institution of his choice. he is presently at the columbia university medical centre in the fmri centre and the children’s hospital neuroimaging centre. he is learning fmri under the supervision of joy hirsch and bill millar, and he is also busy assisting in the set-up of the dti (diffusion tensor imaging) services there. he will also be visiting cornell to learn more detailed dti, and is an invited speaker at salt lake city, utah to talk on tb in children. well deserved and best wishes! paediatric mini-conference savvas will share his experiences and research findings with us next year (march 2008) when professor sheldon wiebe, a paediatric radiologist from saskatoon, canada, will be in south africa. we will be hosting a joint paediatric mini-conference in johannesburg, and possibly other centres. details will be forwarded to all via the college of radiology and the rssa who will be approached for financial and organisational assistance. neuroradiology mini-conference a big thank you to professor jonathan kleefield of the neuroradiology department of harvard medical school. jonathan was the sole, tireless, and impressive speaker at the neuroradiology mini-conference that was held at johannesburg hospital in march this year. thank you to robert makhubedu of toshiba and mike botha of bracco for assisting with this endeavour. it is good to see the public sector receiving some of the goodwill from our trade partners. 39 sa journal of radiology • june 2007 congrats by: mala modi conference news by: mala modi osirix has more conclusion pg38-39.indd 39 6/13/07 9:23:33 am original article original article 48 sa journal of radiology • august 2009 original article abstract background. radiologists analyse both standard mammographic views of a breast to confirm the presence of abnormalities and reduce false-positives. however, at present, no computer-aided diagnosis system uses ipsilateral mammograms to confirm the presence of suspicious features. aim. the aim of this study was to develop image-processing algorithms that can be used to match a suspicious feature from one mammographic view to the same feature in another mammographic view of the same breast. this algorithm can be incorporated into a computer-aided diagnosis package to confirm the presence of suspicious features. method. the algorithms were applied to 68 matched pairs of craniocaudal and mediolateral-oblique mammograms. the results of this pilot study take the form of maps of similarity. a novel method of evaluating the similarity maps is presented, using the area under the receiver operating characteristic curve (auc) and the contrast (c) between the area of the matched region and the background of the similarity map. results and conclusions. the first matching algorithm (using texture measures extracted from a grey-level co-occurrence matrix (glcm) and a euclidean distance similarity metric) achieved an average auc of 0.80±0.17 with an average c of 0.46±0.26. the second algorithm (using glcms and a mutual information similarity metric) achieved an average auc of 0.77±0.25 with an average c of 0.50±0.42. the latter algorithm also performed remarkably well with the matching of malignant masses and achieved an average auc of 0.96±0.05 with an average c of 0.90±0.21. in conclusion, texture analysis methods used with suitable similarity metrics allow a suspicious feature from one mammographic view to be matched with the same suspicious feature in other mammographic views of the same breast. introduction according to the cancer association of south africa, breast cancer is currently the most common cancer among women worldwide, and is second to cervical cancer among south african women. while sometimes fatal, breast cancer can be successfully treated, provided that it is detected early. the most common method of detecting breast cancer in its early stages is mammography. unfortunately, mammography suffers from the problem that radiologists, in their visual interpretation of the resulting mammograms, can sometimes miss the subtle signs of breast cancer.1 computer-aided diagnosis (cad) was developed to consistently draw the radiologist's attention to suspicious regions in a mammogram that could be missed. commercial cad systems are designed to be consulted after the radiologist has made an initial assessment of the mammogram, and it has been shown that prompting by a cad system improves radiologists' detection performance.2 the basic algorithm in a cad system is (i) the detection of suspicious features, (ii) the reduction of false-positives, and (iii) the classification of suspicious features as malignant or benign. while current cad methods can achieve sensitivities of up to 100% in identifying microcalcification clusters, masses are detected with a lower sensitivity because of their variable appearance and similarity to normal tissue. mass detection cad algorithms also have high false-positive rates, which are not very practical because the radiologist would waste time examining the false-positive marks. the minimum requirements of a cad system should be to completely emulate the actions of a radiologist, who uses many methods to analyse a set of mammograms. these methods are summarised in fig. 1. most methods generally used by a radiologist in mammographic cad: correlation of regions in ipsilateral views – a pilot study jayanethie padayachee, phd michael j alport, phd department of physics, university of kwazulu-natal, durban william i d rae, mb bch, phd department of medical physics, university of the free state, bloemfontein fig. 1. methods used by a radiologist to analyse a set of mammograms. most methods have been implemented in a cad system, but the examination of ipsilateral views has not. original articleoriginal article 49 sa journal of radiology • august 2009 interpreting mammograms (e.g. examination of single views, bilateral comparison, temporal comparison) have been implemented in cad systems, mostly for the detection of abnormalities. in practice, radiologists also consider the distance from the nipple to the centroid of a suspicious feature in one mammographic view, and then search an annular region in another mammographic view at about the same radial distance from the nipple corresponding to the suspicious feature. this technique is known as the arc method and is used under certain circumstances to confirm a true-positive feature or to eliminate a false-positive feature. while there have been a few studies indicating the usefulness of using two standard mammographic views for false-positive reduction,3-6 these algorithms have not been incorporated into cad systems. most importantly in these dual-view algorithms, the suspicious features are identified in both standard mammographic views and information is correlated between pairs of suspicious features to identify matches and thereby reduce the number of false-positives. all these methods also rely on some form of training (e.g. linear discriminant analysis, artificial neural networks) and therefore only perform as well as the data set that was used for the training. any algorithms based on training generally perform very poorly when applied to situations outside the scope of the training data. this paper presents an algorithm that finds a suspicious feature in one standard mammographic view and then uses the position and characteristics of the feature to find it in another standard mammographic view. two image-processing matching algorithms were developed that perform an exhaustive search of a reduced breast tissue region to match a suspicious feature identified in one mammographic view with the same feature in another mammographic view of the same breast. the algorithms developed have the advantage of not requiring any training and can be slotted into existing cad systems as a method of providing further information to reduce false-positives. materials and methods the general matching algorithm was based on three assumptions:4 (i) at least two mammographic views of the breast are available, (ii) a mass is visible in at least two mammographic views, and (iii) a mass has similar image textural characteristics in all mammographic views. a schematic of the image-processing matching algorithm is shown in fig. 2. the steps in the matching algorithm were: 1. identification: a radiologist identified a region of interest (roi) in the reference image, as there was no access to a cad system. the radiologist manually drew borders around suspicious features in both standard mammographic views. 2. pre-processing: the mammogram background7 and pectoral muscle8 were removed to reduce the area of the search image that was analysed. the arc method was used to further reduce the area analysed and is detailed in fig. 3. variations on the arc method have been used by paquerault et al.4, zheng et al.5 and van engeland et al.6 to reduce the search region in their cad algorithms. 3. quantification of image texture: textural characteristics of the roi were quantified using haralick’s texture measures9 and grey-level co-occurrence matrices (glcms). texture measures extracted from glcms have been applied to the texture analysis of mammograms on numerous occasions.3,10 fig. 2. schematic (not to scale) of the matching algorithm. the location of the reference roi was used to reduce the search region in the search image. textural characteristics of the reference roi are compared with textural characteristics of equivalently sized sub-images in the search image. the comparison process results in a similarity map. the brighter the regions on the similarity map, the greater the similarity. the similarity map is generally smaller than the search image because the sampling windows are >1 pixel and the windows are stepped in increments >1 pixel. fig. 3. geometry of the arc method used to reduce the search region in the search image with the cc view as the reference view and the mlo view as the search view. the position of the nipple and the position of the centroid of the roi in the reference view were used to define the arc distance a. the maximum extent of the roi border from the centroid in the reference view was also determined. then the nipple in the search view was used as an origin to draw two arcs (of radii ) that were bounded by the breast border. the region enclosed between the arcs and the breast border defined the reduced search region in the search view. the method is independent of which view was used as a reference. the positions of the nipple in both standard mammographic views and the centroid of the selected roi in one view were used to extract that portion of the breast in the other view where the roi could possibly lie. the value of was based on the size of the roi in the reference view, which meant that the area of the annular region depended on the size of the selected roi. [ ]mm yx , [ ]rr nynx , aa δ± 2 aδ aδ original article original article 50 sa journal of radiology • august 2009 4. similarity: the similarity between the roi and the reduced search image was quantified with a euclidean distance metric and mutual information. this comparison process resulted in a similarity map where maxima corresponded to positions of greatest similarity between the roi and the search image. glcms and texture measures extracted from the glcms form the basis of the textural analysis in this study. glcms have the advantage of including information about the distributions of the relative locations of pixels and their grey levels.9 the glcms were computed at four angles ( ) and then averaged to remove any directional effects that may be introduced by the change in orientation of the breast tissue between mammographic views. texture measures were calculated from the averaged glcm.9 similarity metrics were used to quantify how similar the reference roi was to the search roi. the euclidean distance and mutual information similarity metrics were used in this study. • euclidean distance metric, de: the euclidean distance metric is the most commonly used metric to calculate distance. for two points and in n-dimensions, de is defined as: (1) • mutual information, mi: mutual information has been shown to be a robust similarity metric in image registration problems,11 but has also been applied to template matching,12 feature selection and segmentation problems. mutual information can be interpreted as a measure of the information that two quantities have in common and is defined as:13 (2) mutual information is an acceptable similarity metric because mi>0 unless the two quantities are completely independent, then mi=0. also, mi increases as the dependency between both quantities increases and is independent of the actual value of the probability.13 in the first matching algorithm, referred to as texture measure matching or tm-matching, the image texture was quantified by 13 texture measures calculated from averaged glcms: maximum probability, entropy, energy, inertia, inverse difference moment, correlation, sum average, sum entropy, difference entropy, sum variance, difference average, difference variance, information measure of correlation. a 13-dimensional texture measure vector was calculated for each position of the sampling window and was then compared with the texture measures of the reference roi using euclidean distance as a measure of similarity. the result was a 2-dimensional map of distance values. in the second matching algorithm, referred to as mutual information matching or mi-matching, glcms were used to quantify the image texture. mutual information was used to quantify the similarity between the reference and search glcms. this study uses the full glcm as an estimate of the probability density function that incorporates spatial information. the only application of the full glcm that used mutual information was for image registration,14 but the full glcm has not been applied to template-matching problems or to any problem in mammographic cad. for the calculation of mutual information, individual glcms of the reference and search images as well as a joint glcm between the reference and search images were calculated. the results of the tmand mi-matching algorithms are maps of similarity, defined to have the optimal match at maximum similarity map values. the accuracy of each matching algorithm was evaluated by comparing the similarity maps to ground-truth maps. groundtruth maps were generated from the rois manually marked by a radiologist. matching accuracy is defined as a combination of two quantities: the area under the receiver operating characteristic curve and contrast between the matched region and its background. receiver operating characteristic (roc) analysis is a standard method of evaluating and ranking medical diagnostic tests.15 to perform any evaluation, the ‘truth’ must be known so that it can be compared with the output of the test. the evaluation and ranking of cad algorithms is analogous to that of a standard medical diagnostic test and is therefore perfectly suited to the use of roc analysis. the basis of roc analysis is the roc curve, which is a plot of the true-positive fraction (tpf) v. the false-positive fraction (fpf). for the evaluation of the results from the matching algorithms, the similarity maps were thresholded at grey-level values between 0 and 255 (8 bits of information). the thresholded maps (fig 4g i) were compared with the ground truth data (fig. 4c) to compute values of the tpf and the fpf at each threshold. the tpf and fpf values were used to generate the roc curve. the area under the roc curve, auc, (computed using the trapezoidal rule) is used as an indication of what proportion of the matched region was actually matched and . contrast is used as a measure of how well the matched roi stands out from its surroundings in the similarity map. contrast refers to a local change in brightness and is defined as the ratio of the average brightness of an object to the average brightness of the background.16 (3) f is the average grey level of the foreground, b is the average grey level of the background and . negative values arise when the foreground is darker than the background, and positive values arise when the foreground is brighter than the background. a contrast of 0 means that the object cannot be distinguished from its background. the ground-truth data were used to define regions in the similarity map used to calculate f and b. ideally, the matched regions should be the brightest objects in the similarity map. by definition, the best match should have the highest matching accuracy. the selection of the best combination of auc and c values is facilitated by the novel use of a combined auc-c value referred to as matching accuracy, κ, and calculated as follows: [ ]110 −= nyyyy ,,, k [ ]°°°°= 13590450 ,,,θ ( )∑ − = −= 1 0 2 n i iie yxd ( ) ( ) ( ) ( )∑∑ − = − = ⋅ ⋅ ⋅=⋅ 1 0 1 0 log)( n i n j ji ji ji ypxp yxp yxpyxmi 10 ≤≤ auc f b f + b c = 11 ≤≤− c original article original article 52 sa journal of radiology • august 2009 original article (4) 11 ≤≤− κ because 10 ≤≤ auc and 11 ≤≤− c . acceptable matches should have auc>0.5 as this indicates that the matching is better than random, and c should be positive as this indicates that the matched region is brighter than the background in the similarity map. a pc with an amd athlon xp 2.4ghz processor and 512 mb of ram, running microsoft windows 2000, was used for the software development. all algorithms were implemented in idl 6.1, a programming environment providing mathematical functionality with a graphic interface. the algorithms were applied to 34 pairs of cranial-caudal (cc) and medio-lateral oblique (mlo) mammograms. the mammograms were arbitrarily selected from the patient archives at the inkosi albert luthuli central hospital, durban, to represent a range of breast densities, mass sizes and patient ages. the images were acquired on a siemens mammomat 3000 nova mammography unit, with a focal spot size of 0.3 mm, a molybdenum anode and a 30 µm molybdenum filter. the image reader was a digiscan m (fuji photo film co. ltd). the computed radiography images were exported in the digital imaging and communications in medicine (dicom) format from the hospital data archives, at a bit-depth of 10 bits and 0.05 mm per pixel. for processing, images were resampled to 0.254 mm per pixel (100 dpi). since the matching results are independent of which view is used as a reference, each cc and mlo view was used separately as a reference image and a search image, resulting in the matching algorithms being applied to 68 pairs of mammograms. the 68 individual mammograms were divided into four categories based on the pathology of the suspicious roi or overall diagnosis of the mammogram: 28 benign, 18 malignant, 10 normal and 12 indeterminate. most patients are referred to the inkosi albert luthuli central hospital for diagnostic tests, so not all the mammograms had a full pathological history, since not all referring physicians recommended a biopsy. in these cases, the radiologist's report was used as a basis for the diagnosis of the mammogram. the ‘benign', ’indeterminate' and ‘malignant' diagnoses refer to masses, while the ‘normal' diagnosis refers to a suspicious-looking region in a normal mammogram. masses were categorised as ‘indeterminate' if the biopsy was inconclusive or the radiologist was unable to render a diagnosis based on the mammographic appearance. a radiologist marked the borders of the suspicious rois in magicview, the software interface used to view standard digital imaging and communications in medicine (dicom) medical images. the borders were saved as dicom images and were automatically extracted in idl, for use as ground truth data, which eliminated the need to register the ground truth data with the mammograms. the areas of the regions enclosed by the radiologist-drawn borders were automatically computed in magicview. the average area of the rois together with the average visibility of the rois is shown in table i. visibility was automatically determined from the original mammograms (at 0.254 mm per pixel) before pre-processing. visibility was defined to be the contrast of the roi compared with the surrounding tissue and was computed from eq. 3. visibility ranges between 0 for a very subtle roi and 1 for a very obvious roi. there is a wide range of roi sizes, and some of these are very subtle while others are more visible. results examples of similarity maps for tm-matching and mi-matching are shown in figs 4e and 4f respectively. while both maps show the roi as the brightest feature, both maps also have other features that have been matched. these false-positive detections lower the auc value and c value, and therefore lower the overall matching accuracy. for example, the tm similarity map (fig. 4e) has auc=0.94, c=0.44 and κ=0.39, while the mi similarity map (fig. 4f ) has auc=0.92, c=0.36 and κ=0.30. the map for tm-matching has a bright band around the interface between the breast and the segmented background. however, the bright region does not lower the overall accuracy of the match, because the evaluation focuses on the feature of interest and its immediate surroundings. the mi map does not display any artefacts at the interface between the breast and the segmented background. the averages of the best matching results for tm-matching are listed in table ii. results show that the malignant masses were matched with the highest matching accuracy compared with the other mammogram classifications. results for the benign and indeterminate masses and the normal mammograms were scattered across a range of auc and c values, and there were 5 rois (2 benign, 1 indeterminate, 2 normal) that were not matched with tm-matching. the average of the best matching accuracies for mi-matching are listed in table iii. the malignant masses were matched with the highest accuracy. the matching accuracy for the malignant masses was statistically different (p<0.002) from the matching accuracies for the other mammogram categories. all malignant masses were well matched, with the results generally clustered around auc=1 and c=1. mammograms classified as non-malignant were poorly matched in both methods. possible factors that contributed to the poor matching results were the roi area and the roi visibility. most of the rois on mammograms classified as benign, indeterminate and normal were either very small (<0.5 cm2) or had a low visibility, while the rois on mammograms classified as malignant were generally larger and more visible. matching accuracy was generally well ( ) ( )⎩ ⎨ ⎧ − ≤≤−− = otherwise5.02 0 and 5.0 if5.02 cauc cauccauc κ table i. average area and visibility of rois for the 68 mammograms used type number average area (cm2) average visibility benign 28 1.54±2.50 0.18±0.08 indeterminate 12 2.23±2.05 0.23±0.01 malignant 18 11.0±12.8 0.40±0.19 normal 10 1.46±2.26 0.14±0.04 original articleoriginal article 53 sa journal of radiology • august 2009 correlated with roi visibility (71% correlation), and the rois with low visibilities had very poor matching accuracies. matching accuracy is spread over a wide range for the small, low-visibility rois, while the large, high-visibility rois generally have high matching accuracies. regarding tm-matching, matching accuracy was correlated with roi visibility (62% correlation). there were 12 image pairs (8 benign, 2 indeterminate, 2 normal) that were not matched with mi-matching. areas of the non-matched rois ranged from 0.16 cm2 to 1.21 cm2 and all had low visibilities. discussion fig. 5 shows the best matching results for each of the 68 pairs of mammograms, for each matching algorithm. the auc and c values are generally quite scattered for both. some results have auc<0.5 and c<0, indicating that the match was unsuccessful. matching accuracies are, however, generally quite high for both methods; this is confirmed by examining the average of the best matching accuracies (tables ii and iii). the results of performing a paired t-test analysis on the distribution of the best κ values for tm-matching and mi-matching yielded a t value of -1.40 and a p value of 0.16. for a significance level of 0.05, the average values of κ for tm-matching compared with mi-matching are not statistically different. overall, both tm-matching and mi-matching show potential as matching schemes, as both methods yielded quite accurate matches on the small data set. results at a significance level of 0.05 show that the average results for matching the benign and indeterminate masses and normal rois are similar for each method (p=0.78, p=0.46, p=0.97, respectively), but that the results of matching malignant masses are statistically different (p<0.01), with the mi-matching results better than the tm-matching results. mi-matching required less computational time and was more accurate at matching malignant masses, but there were fewer unmatched pairs of mammograms for tm-matching (5 out of 68 compared with 12 out of 68 for mi-matching). therefore, a hybridtable iii. average of the best matching results for mimatching diagnosis average auc average c average κ benign 0.68±0.26 0.29±0.36 0.21±0.30 indeterminate 0.75±0.28 0.59±0.40 0.44±0.34 malignant 0.96±0.05 0.90±0.21 0.84±0.23 normal 0.71±0.24 0.26±0.29 0.17±0.23 all 0.77±0.25 0.50±0.42 0.41±0.39 table ii. average of the best matching results for tmmatching diagnosis average auc average c average κ benign 0.75±0.17 0.37±0.21 0.22±0.16 indeterminate 0.80±0.15 0.50±0.26 0.34±0.27 malignant 0.93±0.05 0.67±0.21 0.58±0.21 normal 0.68±0.19 0.29±0.26 0.18±0.19 all 0.80±0.17 0.46±0.26 0.33±0.25 fig. 4. sample images: (a) reference image, (b) search image, (c) groundtruth map, (d) distance map, (e) tm similarity map, (f) mi similarity map (g i) mi similarity map thresholded at grey levels of 1, 64 and 128. the thresholded maps are compared with the ground-truth map in (c) to determine the tpfand fpf-values that were used to generate an roc curve. fig. 5. scatter plot of auc v. c with the best matching accuracies for each mammogram pair for (a) tm-matching and (b) mi-matching. original article original article 54 sa journal of radiology • august 2009 matching scheme using the results of both methods could yield better matching results. both matching algorithms showed great potential for use in a cad scheme. the average best matching accuracy for mi-matching was κ=0.41±0.39, which corresponds with average best auc and c values of 0.77±0.25 and 0.50±0.42, respectively. the average best matching accuracy for tm-matching was κ=0.33±0.25, which corresponds with average best auc and c values of 0.80±0.17 and 0.46±0.26, respectively. the average best results for these two methods were not statistically different (p>0.05) mi-matching showed the best matching accuracy for matching malignant masses (κ=0.84±0.23 corresponding to auc=0.96±0.05 and c=0.90±0.21), while the results for the other types of roi (benign, indeterminate, normal) were similar for both methods. the tmand mi-matching algorithms show potential for providing more information for use in a false-positive reduction scheme in a cad system. the ideal solution would be to incorporate mutual information ideas into the texture measure method. if the suspicious object is present in both mammographic views, only one view needs to be analysed to detect the object, while the second view is analysed with information extracted from the object in the first view, for confirmation of a true object. one advantage of using a distance similarity metric and mutual information for matching is that no training is required, which is quite important for a mammographic cad system since breast tissue varies considerably from patient to patient. the tmand mimatching algorithms can be applied to any image-matching problem. unfortunately, the current algorithms are very time-consuming and will have to be optimised for implementation in a cad system. two shortcomings of this study are the quality of the ground truth data and the small data set. only one radiologist marked the borders of the rois in each mammogram, and there was no method of confirming the accuracy of the identified borders. also, results will be strengthened if the algorithms are tested on a larger database of mammograms. conclusion texture analysis methods used with suitable similarity metrics allow a suspicious feature from one mammographic view to be matched with the same suspicious feature in other mammographic views of the same breast. the matching algorithms (using grey-level cooccurrence matrices, distance similarity metrics and mutual information) perform especially well in matching malignant masses. this dual-view analysis method can most probably be used to provide complementary information to a false-positive reduction scheme in a mammographic cad system. we gratefully acknowledge the funding received from the university of kwazulu-natal, department of labour and the medical research council of south africa, and also thank ms p baxter, dr s chick, dr f malan, dr l marishane, ms l moodley, dr i j movson, dr j sarawan and dr j zietkiewicz (of the addington and the inkosi albert luthuli central hospitals) for their assistance. 1. huynh p, jarolimek a, daye s. the false-negative mammogram. radiographics 1998; 18: 1137-1154. 2. freer t, ulissey m. screening mammography with computer-aided detection: prospective study of 12 860 patients in a community breast center. radiol 2001; 220: 781-786. 3. chang y, good w, sumkin j, do b, gur d. computerized localization of breast lesions from two views: an experimental comparison of two methods. invest radiol 1999; 34: 585-588. 4. paquerault s, petrick n, chan h, sahiner b, helvie m. improvement of computerized mass detection on mammograms: fusion of two-view information. med phys 2002; 29: 238-247. 5. zheng b, leader j, abrams g, et al. multiview-based computer-aided detection scheme for breast masses. med phys 2006; 9: 3135-3143. 6. van engeland s, timp s, karssemeijer n. finding corresponding regions of interest in mediolateral oblique and craniocaudal mammographic views. med phys 2006; 9: 3202-3212. 7. padayachee j, rae w, alport m. identification of the breast edge using areas enclosed by iso-intensity contours. comput med imaging graph 2007; 31: 390-400. 8. karssemeijer n. automated classification of parenchymal patterns in mammograms. phys med biol 1998; 43: 365-378. 9. haralick r, shanmugam k, dinstein i. texture features for image classification. ieee t syst man cyb 1973; 3: 610-621. 10. sahiner b, chan h, petrick n, helvie m, hadjiiski l. improvement of mammographic mass characterization using spiculation measures and morphological features. med phys 2001; 28: 1455-1465. 11. pluim jw, maintz ja, viergever m. mutual-information-based registration of medical images: a survey. ieee trans med imaging 2003; 22: 986-1004. 12. tourassi g, vargas-voracek r, catarious d, floyd ce. computer-assisted detection of mammographic masses: a template matching scheme based on mutual information. med phys 2003; 30: 2123-2130. 13. abramson n. information theory and coding. new york: mcgraw-hill, 1963. 14. hseu h, bhalerao a, wilson r. image matching based on the co-occurrence matrix. tech. rep. cs-rr-358. department of computer science, university of warwick, coventry, uk, 1999. http://citeseer.ist.psu. edu/hseu99image.html (accessed 2003). 15. van erkel a, pattynama pt. receiver operating characteristic (roc) analysis: basic principles and applications in radiology. eur j radiol 1998; 27: 88-94. 16. sonka m, hlavac v, boyle r. image processing, analysis and machine vision. florence, kentucky, usa: thomson-engineering, 1999. 45 sa journal of radiology • june 2010 musculoskeletal diagnosis quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban presentation a 46-year-old woman presented with progressive back pain and lower limb weakness. the following mri images were obtained. we invite readers to describe the findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@hotmail.com before 2 august 2010.the winning respondent will receive a r1000 award from the rssa. a detailed diagnosis will appear in the next issue of the sajr. fig. 1. unenhanced sagittal mri with t1-weighted (fig. 1a), t2-weighted (fig.1b) and t2-weighted (fig. 1c) sequences. fig. 2. unenhanced axial mri images with t1-weighted (fig. 2a) and t2-weighted (fig. 2b) sequences. 1a 1b 1c fig. 3. sagittal fat-suppressed t1-weighted mri sequences; pre-gadolinium (fig. 3a) and post-gadolinium (fig. 3b). 2a 2b 3a 3b article information author: pieter j. oberholzer1 affiliation: 1department of radiology, university of pretoria, south africa correspondence to: pieter oberholzer postal address: private bag x24270, gezina 0031, south africa dates: received: 04 aug. 2014 accepted: 29 oct. 2014 published: 05 dec. 2014 how to cite this article: oberholzer pj. humeral avulsion of the glenohumeral ligament: the j sign. s afr j rad. 2014;18(2); art. #709, 2 pages. http://dx.doi/org/10.4102/ sajr.v18i2.709 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. humeral avulsion of the glenohumeral ligament: the j sign in this case reports... open access • abstract • introduction • case report • discussion    • hagl and anterior instability • teaching point • conclusion • acknowledgements    • competing interests • references abstract top ↑ the lesion resulting from humeral avulsion of the glenohumeral ligament (hagl) is an important cause of anterior glenohumeral instability and can be seen in isolation or combination with an antero-inferior labral complex lesion. a conclusive magnetic resonance imaging diagnosis is aided when either a joint effusion is present or a contrast arthrography of the shoulder is performed.it is important to be familiar with the j sign as it represents contrast leaking through the defect in the lateral attachment of the joint capsule. introduction top ↑ the musculotendinous structures of the rotator cuff and almost all the shoulder muscles maintain the stability of the glenohumeral joint.1 humeral avulsion of the glenohumeral ligament (hagl) is a less frequent cause of anterior instability than the classic bankart lesion. the hagl lesion may appear in patients with anterior stability, with or without association of an anterior labral tear. magnetic resonance imaging (mri) is essential in preoperative detection of a hagl lesion. the 15° oblique radiograph view in the anterior plane of the shoulder (garth view) demonstrates only the variant bony hagl lesion.2 intra-articular fluid (joint effusion) or the introduction of contrast medium (arthrography) is necessary to identify a hagl lesion on mri. case report top ↑ a 16-year-old rugby player, with a four-month history of injury to his right shoulder, presented with anterior glenohumeral instability. mri was requested to assess the labrum and anterior capsule. the mri arthrogram demonstrated an antero-inferior labral tear with adjacent avulsion of the cortical rim of the glenoid (figure 1). a coronal t2w fat-saturation sequence showed the typical j sign caused by contrast leaking between the humerus and the displaced ligament (figure 2). the findings were confirmed on arthroscopy (figure 3). the inferior glenohumeral ligament (ighl) in the patient was retracted and very tight at arthroscopic examination. he underwent open surgical repair, where part of the subscapularis muscle was used to close the defect. figure 1: axial magnetic resonance imaging (mri): 3d water-selective cartilage scan (wats) sequence demonstrating antero-inferior labral tear with adjacent avulsion of the cortex rim (arrow). figure 2: coronal magnetic resonance imaging (mri) t2 fat-saturation sequence demonstrating the j sign (arrows) with contrast leak between the humerus and displaced ligament. figure 3: arthroscopy images confirming the pathology; (a): antero-inferior labral tear with probe in the defect; (b): humeral avulsion of the glenohumeral ligament (hagl) defect; (c): probe in the hagl defect exposes the subscapularis muscle. discussion top ↑ hagl and anterior instability the ighl consists of an anterior and a posterior band with the axillary pouch interposed. the medial attachment, at the antero-inferior and postero-inferior glenoid margin, forms part of the labral complex, which is the main anterior stabiliser of the shoulder. the ighl has a u-shaped appearance with the lateral attachment at the anatomic neck of the humerus. intra-articular fluid or contrast medium is necessary for evaluation of the ighl-labral complex. when detachment of the ligament from the humerus (infero-medially) occurs, fluid leaks between the humerus and the torn ligament or capsule, and the u-shaped capsule develops a j-shaped appearance. tears of the ighl can also involve the midportion of the ligament or the glenoid attachment. this involvement, with or without associated labral tears, leads to anterior instability and predisposes to recurrent subluxation and dislocation. teaching point top ↑ look for the j sign (hagl lesion) on coronal mri sequence when there is a history of anterior shoulder instability. conclusion top ↑ the humeral attachment of the joint capsule and ighl are important stabilisers of the antero-inferior glenohumeral joint. this area is an important checkpoint when there is a history of anterior shoulder instability. it is important to be familiar with the j sign as it suggests an ighl humeral attachment tear. acknowledgements top ↑ i thank drs s.a. peach, m.d. velleman and s. miller, and m. robbertse and d. coetzee, for their contributions. competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1. stoller dw. magnetic resonance imaging in orthopaedics and sports medicine, volume 2. 3rd edn. philadelphia: lippincott williams & wilkens, 2007; p. 1324–1352. 2. carlson cl. the ‘j’ sign. radiology. 2004;232(3):725–726. http://dx.doi.org/10.1148/radiol.2323021239 i was hoping to publish an editorial by a renowned overseas expert in the field of pet-ct; this has not been possible but i hope it will appear in the next issue of the sajr. developments around pet-ct are of critical importance to state-ofthe-art medicine in this country. i experience a feeling of déjà vu when i hear that south africa cannot afford technology of this nature. ten years ago, i had to counter such arguments against magnetic resonance – and today there is universal agreement that mri is probably the most efficient and cost-saving modality in medicine. gone are the days of extended hospitalisation for diagnostic ‘tests’. non-acute patients are diagnosed on an outpatient basis, and it may be an interesting calculation to identify the effect that this has had on the budgets of medical aids and state hospitals. we are now hearing that pet-ct is finding it difficult to survive. there are even prognostications that pet centres may have to close down and that the modality may disappear from the diagnostic scene in this country – regressing us to past times when a 1cm node spells malignant and a 9 mm node is debatable. i intend to continue this issue in the next edition of the sajr, when we can weigh the consequences against the perspective of an objective editorial of international authority in the field of cancer therapy. but at this point, it’s enough to state that if this modality disappears from the south african scene, it will probably not return for a decade or more. i believe that this would be disastrous for everyone in the field of cancer diagnosis and therapy. thanks to savvas andronikou for conceptualising and compiling radioactive news. this is a news forum for south african radiology, and i welcome contributions from the society, college and all our university departments. pet-ct meltdown is looming jan lotz editor-in-chief editorial 26 sa journal of radiology • july 2008 pet.indd 26 8/1/08 2:35:30 pm case report case reportcase report introduction short stature is a frequent presenting problem in the paediatric population. various causes including endocrinopathies, skeletal dysplasias, dysmorphic syndromes and malabsorption have been implicated. in girls with short stature, turner syndrome is frequently considered in the differential diagnosis and can easily be ruled out with chromosome analysis. however, it is not uncommon for a child to have no identifiable cause of their short stature. advances in the field of genetics have estimated that about 2% of idiopathic short stature is related to haplo-insufficiency of the short stature homeobox (shox) gene, which is found on the short arm of the x and y chromosomes in the pseudo-autosomal region. heterozygous carriers of shox mutations may be minimally affected or may present with disproportionately short stature, madelung deformity and other radiographic findings, as in leri-weill dyschondrosteosis (lwd). in this report, we discuss a 14-year-old girl with mesomelic short stature and bilateral madelung deformities caused by lwd and describe the radiographic findings. case report the subject was born at term following an unremarkable pregnancy. birth parameters were: length 54 cm (90th centile), weight 3 985 g (80th centile) and head circumference 36.5 cm (70th centile). the newborn period was unremarkable and the patient was discharged on day 2. developmental milestones were met appropriately. she was an aboveaverage student at school. leri-weill dyschondrosteosis: an underrecognised cause of short stature edmond g lemire, md, phd, frcpc, fccmg, facmg division of medical genetics, department of pediatrics, royal university hospital and university of saskatchewan, saskatoon, canada sheldon wiebe, md, frcpc, faap department of medical imaging, royal university hospital and university of saskatchewan figs. 1a and 1b. antero-posterior and lateral radiographs of the right forearm demonstrating the typical features of madelung deformity: bowing and shortening of the distal radius, widening of the distal radial-ulnar joint, and triangulation of the distal radial epiphysis, producing an ulnar slant to the articular surface. 1b1a 16 sa journal of radiology • march 2009 leri-weill.indd 16 3/12/09 2:07:25 pm case reportcase report she had always been one of the shortest students in her class. menarche occurred at age 10 years, preceded by a growth spurt when, for a brief period, she reportedly was of average height among her peers until they also entered puberty. her sister, three years her junior, is now taller than her. past medical history was remarkable for surgical excision of a congenital cholesteatoma and insertion of transtympanic tubes to correct a conductive hearing loss. the family history was unremarkable, and her parents were both approximately 170 cm tall. a number of investigations were performed: she was found to have an advanced bone age on x-ray; somatomedin c and tsh levels were normal; and chromosome studies revealed a normal female karyotype – 46xx. she was referred to the medical genetics division for further assessment. on physical examination at age 14 years and 7 months, the patient presented with disproportionately short stature and relative macrocephaly. clinically, she appeared to have mesomelic limb shortening with bilateral madelung deformities, which was confirmed by measurements. her growth parameters were as follows: height 151 cm (5th centile), weight 54 kg (60th centile) and head circumference 56.25 cm (90th centile). other measurements included a reduced arm span (148 cm) to height ratio (normal >1.0 and <1.05 for age) and an increased upper segment (83 cm) to lower segment (68 cm) ratio of 1.22 (normal ~1.0 for age).1 a diagnosis of lwd was advanced clinically, and additional x-rays were requested to confirm the diagnosis radiographically. radiographs supported the clinical diagnosis (fig. 1). the prominent madelung deformity (shortening and bowing of the radii and triangulation of the distal radial epiphysis producing an ulnar slant to the articular surface) of the distal radius and ulna is a well-described feature of dyschondrosteosis (leri-weill disease). the lunate carpal bone wedges between the deformed distal radial ulnar joint are slightly subluxed.2 the patient and her family declined genetic testing. discussion shox-related haplo-insufficiency disorders are estimated to have a prevalence of 1/4 000 and are known to account for a not insignificant proportion of cases of idiopathic short stature.3 the shox gene is located on the pseudo-autosomal regions of the short arms of the x and y chromosomes. consequently, transmission appears to be autosomal dominant because recombination occurs, but it is more correctly termed pseudo-autosomal dominant. the majority of shox gene mutations are deletions, but point mutations are also known to occur. most affected individuals have inherited the mutation from one of their parents, but rarely it can be caused by a de novo mutation. penetrance is known to be incomplete, meaning that some carriers of a shox mutation may appear to be normal or minimally affected. homozygosity or compound heterozygosity for shox mutations leads to a more severe skeletal dysplasia – langer mesomelic dysplasia. the clinical spectrum of shox mutation carriers is quite variable, ranging from normal to the mesomelic short stature of lwd. mesomelia leads to a reduction in the arm span and an increase in the upper-tolower segment ratio. disproportionately short stature was observed in our patient, which led us to suspect lwd. the radiographic finding of the madelung deformity supported the clinical diagnosis. the differential diagnosis includes turner syndrome, growth hormone deficiency and idiopathic short stature. the diagnosis of turner syndrome was excluded in our patient by karyotype analysis. interestingly, the short stature seen in turner syndrome is in part related to shox haplo-insufficiency caused by the missing x chromosome. madelung deformity is also an occasional feature of turner syndrome but is not commonly associated with isolated growth hormone deficiency or idiopathic short stature. 1. hall jg, allanson je, gripp kw, slavotinek am. handbook of physical measurements. 2nd ed. new york: oxford university press, 2007: 196, 243-244. 2. taybi h, lachman rs. radiology of syndromes, metabolic disorders, and skeletal dysplasias. 4th ed. st louis, usa: mosby, 1996. 3. munns c, glass i. shox-related haploinsufficiency disorders (updated 1 february 2008). genereviews at genetests: medical genetics information resource, university of washington. http://www.genetests.org (accessed 2 february 2009). 17 sa journal of radiology • march 2009 leri-weill.indd 17 3/12/09 2:07:25 pm pictorial interlude 13 sa journal of radiology • march 2010 a female neonate was delivered at 30 weeks’ gestation to a mother with suspected bilateral periventricular nodular heterotopia (pnh) on computed tomography brain scan. antenatal ultrasound (us) performed at 28 weeks’ gestation showed mild lateral cerebral ventricle dilatation, but no other fetal anomalies. clinical examination revealed mild dysmorphic features: facial and skull asymmetry, square-shaped ears, and long tapering fingers. chromosomal analysis showed a 46xx karyotype. cerebral us revealed asymmetry and irregular dilatation of the lateral ventricles (figs 1 and 2). these findings are nonspecific and can be associated with post-infectious, post-ischaemic and/or post-haemorrhagic periventricular infarction.1 however, a scan through the extreme lateral margin of the lateral ventricle revealed multiple large nodules covering the lateral aspects of the frontal horn and body of the lateral ventricles (fig. 3). the nodules were better demonstrated by rotating the us probe to focus predominantly on the lateral and inferior aspects of the frontal horn (fig. 4). pnh is a neuronal migration disorder characterised by nodules of ectopic neurons adjacent to the lateral ventricles, owing to failed migration of neurons from the germinal zone towards the cortical plate.2 classical bilateral pnh is the most common type and, in more bilateral periventricular nodular heterotopia – neonatal cranial ultrasound a r horn, mb chb, dch (sa), mrcp (uk), fcpaed (sa), cert neon (sa) neonatal medicine, school of child and adolescent health, university of cape town a nel, mb chb, dch (sa), mmed paed department of paediatrics and child health, school of medicine, university of the free state, bloemfontein m f urban, mb bch, mrcp (uk), fcpaed (sa), cert med genet (sa) division of human genetics, university of cape town fig. 1. parasagittal us scan through the body of the left lateral ventricle. fig. 2. coronal us scan through the body of the lateral ventricles. fig. 3. parasagittal us scan through the lateral aspect of the left lateral ventricle. bilateral.indd 13 2/26/10 9:47:47 am pictorial interlude pictorial interlude 14 sa journal of radiology • march 2010 than 50% of cases, is due to mutations of the x-linked filamin a gene.2 most affected females develop seizures, with variable age of onset and type. dyslexia is common but intellect is usually normal to borderline. hypoplasia of the cerebellar vermis and valvular heart disease are commonly associated, but neither were present in this neonate.3 pnh is usually diagnosed on magnetic resonance imaging but the us scans obtained in this patient demonstrate nodules that are typical of bilateral pnh.1 previously published ultrasound images of neonates with this condition4 have not clearly demonstrated the distribution and size of the nodules as shown in this neonate. we thank professor linda de vries for comments on the manuscript and images. 1. de vries ls, groenendaal f. neuroimaging in the preterm infant. ment retard dev disabl res rev 2002; 8: 273-280. 2. spalice a, parisi p, nicita f, pizzardi g, del balzo f, iannetti p. neuronal migration disorders: clinical, neuroradiologic and genetics aspects. acta paediatr 2009; 98: 421-433. 3. parrini e, ramazzotti a, dobyns wb, et al. periventricular heterotopia: phenotypic heterogeneity and correlation with filamin a mutations. brain 2006; 129: 1892-1906. 4. pellicer a, cabañas f, pérez-higueras a, garcía-alix a, quero j. neural migration disorders studied by cerebral ultraosund and colour doppler flow imaging. arch dis child fetal neonatal ed 1995; 73: f55-61. fig. 4. parasagittal us scan through the outer aspect of the left lateral ventricle with probe rotated to show more detail in the frontal horn. bilateral.indd 14 2/26/10 9:47:48 am untitled 21 sa journal of radiology • december 2005 introduction a higher proportion of paediatric interstitial lung diseases can be diagnosed with high-resolution computed tomography (hrct) scan than plain radiography, with the diagnosis being made with more confidence and higher accuracy.1 hrct is probably easier to interpret in the child than in the adult. there is less pressure to reach a definitive diagnosis from the hrct alone, because many entities resulting in diffuse lung disease are rare in childhood and do not require consideration. in addition, endstage fibrosis, which has nonspecific appearances, is rare. lastly, infection is the most likely cause of most positive studies. when to perform a hrct (indications are similar to those in adults)2,3 (i) when the patient is symptomatic but the chest x-ray (cxr) is normal; (ii) to confirm an interstitial pattern seen on cxr; (iii) to determine the severity of disease; (iv) to look for bronchiectasis; (v) to look for predisposing factors; (vi) to identify the main abnormality and possibly come close to a diagnosis; (vii) to look for sequelae of infection; and (viii) to show a site for biopsy. how to approach hrct4 look for the following: aaiirrwwaayy ddiisseeaassee:: nodules, mosaic pattern, bronchiectasis, bronchial wall thickening, and air trapping. aaiirrssppaaccee ddiisseeaassee:: nodules, ground glass, mosaic pattern, and consolidation. iinntteerrssttiittiiaall ddiisseeaassee:: nodules, ground glass, mosaic pattern, septal thickening, parenchymal bands, air-filled cysts, honeycombing, and architectural distortion. features on hrct nodules nodules are focal oval densities of a variety of sizes that can be ‘well defined’ or ‘ill defined’ and are interpreted according to their predominant distribution and size (table i). a good example of ‘fluffy’ or ill-defined pictorial essay paediatric hrct of the chest – help for the general radiologist s andronikou mb bch, fcrad (d) (sa), frcr department of radiology tygerberg hospital and university of stellenbosch; n wieselthaler mb bch, fcrad (d) (sa) j bertelsmann diploma in radiology department of radiology red cross children’s hospital and university of cape town table i. causes of pulmonary nodules in children3,4 small ill-defined clos small soft-tissue nodules larger masses halo sign bronchogenic tb* miliary tb tb tb aspiration* fungi fungi pulmonary aspergillosis bronchiectasis* metastases metastases lymphoproliferative asthma* langerhans cell histiocytosis septic emboli wegener’s granulomatosis cystic fibrosis* pulmonary haemosiderosis lymphoma pulmonary haemorrhage infective bronchiolitis* avm osteosarcoma metastases lip* lch lch papillomatosis hypersensitivity pneumonitis vasculitis pulmonary capillary haemoangiomatosis boop/cop pulmonary haemosiderosis pulmonary arterial aneurysm follicular bronchiolitis bleomycin bo lipoid granuloma (tpn) congenital lymphangiectasia immotile cilia *common causes. lip = lymphoid interstitial pneumonitis; lch = langerhans cell histiocytosis; bo = bronchiolitis obliterans; avm = arteriovenous malformation; boop/ cop = bronchiolitis obliterans organising pneumonia / cryptogenic organising pneumonia; tpn = total parenteral nutrition article andronikou 11/30/05 10:46 am page 21 22 sa journal of radiology • december 2005 nodules is in pulmonary oedema where they tend to coalesce and form areas of consolidation. true interstitial nodules are ‘well-defined’ and are well represented by military tuberculosis (tb) (fig. 1a and b). even though there are innumerable nodules, they remain discreet and ‘can be picked off the page individually with tweezers’. nodules of varying sizes, which are randomly distributed, especially in the periphery and usually affect both lungs, are characteristic of metastatic disease (fig. 2a). a special type of nodule is the centrilobular opacity (clo). these are about 5 mm in size and are seen within the secondary lobule as nodules, branching ‘y’ structures or ‘trees in bud’ (fig. 2b). they represent material within the central bronchiole of the secondary lobule. 3,4 ground glass opacification (gg) and consolidation gg is an increased density of the lung where the vascular and bronchial markings are still visible. there may be air bronchograms. causes include filling of air spaces, thickening of the interstitium, partial collapse of alveoli, expiration in a normal individual or increased capillary volume. gg is seen regularly with infections and is an important but nonspecific hrct feature of the chronic diffuse interstitial pneumonitides (table ii) (fig. 3). gg surrounding a nodule results in the ‘halo sign’, often seen in fungal disease (fig. 4a and b).4 consolidation is caused by filling of the alveoli with fluid or cells or both and differs from gg in that the increased density obscures vascular markings and is usually accompanied by air bronchograms (figs 5 and 6). pictorial essay fig.1a. miliary tb. fig.1b. miliary tb. fig. 2a. metastases. fig. 2b. centrilobar opacity (clo). table ii. ground glass / consolidation 3,4 oedema* pneumonia* respiratory distress syndrome* leukaemia* contusion* pulmonary haemorrhage* alveolar proteinosis drug toxicity extrinsic allergic alveolitis transplant rejection sarcoid collagen vascular disease post lavage idiopathic interstitial pneumonitides (nsip) idiopathic pulmonary fibrosis *common causes. nsip = nonspecific interstitial pneumonitis. fig. 3. ground glass (gg). fig. 4a. halo sign. fig. 4b. zoomed ‘halo sign’. fig. 5. lobar airspace opacification. article andronikou 11/30/05 10:46 am page 22 23 sa journal of radiology • december 2005 tip: focal gg is usually due to air space disease or a vasculitis and diffuse gg is usually representative of an interstitial process.2-4 tip: gg can cause a ‘mosaic pattern’ on hrct and requires an expiratory scan to distinguish it from air-trapping.2-4 mosaic pattern and air-trapping (table iii) ‘mosaic pattern’ is a geographic pattern of varying lung density. it reflects either focal areas of air-trapping (a sign of small airways disease) (fig. 7a) but is also associated with focal areas of gg (fig. 7b). the two entities can be differentiated by an expiratory hrct in which the low-density areas become more exaggerated and vessel calibre decreases if the mosaic pattern is due to air-trapping. mosaic perfusion is seen with bronchiolitis obliterans and bronchiectasis. generalised air-trapping may be due to partial or complete airway obstruction or local abnormality in pulmonary compliance. measuring the hounsfield density of the lung can assess this. normal lung measures -600 to -750 hu while air-trapping results in density measurements of -900 hu. it can also be assessed with an expiratory view, which in small children is obtained by a decubitus view of the ‘sidedown’ hemithorax (fig. 8).3,4 septal lines this is abnormal widening of the interlobular septa and can either be seen as linear densities perpendicular to and touching the pleura (equivalent to kerley b lines) or as a polygonal pattern outlining the secondary lobule more centrally (fig. 9a and b).4 these are often seen with lymphatic involvement in diseases such as lymphangiomatosis and lymphangitic spread of malignancy.5 the polygonal pattern of linear densities on a background of gg results in the ‘crazy paving’ pattern best known to occur in alveolar proteinosis.4 lines may be smooth or irregular helping to differentiate some of the causes of this feature (table iv). parenchymal bands / architectural distortion / honeycombing these findings all represent some form of chronic involvement and scarring / fibrosis of the lung. parenchymal bands are longer than septal lines measuring between 2 and 5 cm (fig. 10) and are often associated with a pleural ‘tag’. they can occur with fibrosis and scarring or atelectasis associated with fibrosis and are most often seen in children with bronchopulmonary dysplasia (chronic lung disease). architectural distortion indicates displaced bronchi, vessels and or fissures and is usually associated with decreased vascularity and bronchial abnormalities (fig. 11a). honeycombing is rare in children and represents destroyed lung that becomes cystic and fibrotic (fig. 11b). hrct shows air-filled cysts that tend to occur in a subpleural distribution over several layers and are unaffected by expiration. this is seen in children with chronic diffuse idiopathic pneumonitides and connective tissue diseases. pictorial essay fig. 6. patchy airspace opacification. table iii. air-trapping 3,4 bronchiolitis obliterans cystic fibrosis bronchiectasis asthma viral left to right follicular bronchial hyperplasia fig. 7a. mosaic pattern due to air-trapping. fig. 7b. mosaic pattern due to focal areas gg. fig. 8. air-trapping in ‘side down’ lung. fig. 9a. septal lines. fig. 9b. septal lines. article andronikou 11/30/05 10:46 am page 23 bronchiectasis bronchiectasis can either be a diagnosis or a feature of another disease. it indicates irreversible dilation of a bronchus and the signature feature is the ‘signet ring sign’ (fig. 12 a and b). this represents a thickwalled bronchus, which is larger than the adjacent pulmonary artery.4,6 other indicators of bronchiectasis include non-tapering of a bronchus, bronchial wall thickening (fig. 12b) (more than a fine ‘pencil-thin’ line) and visualisation of a bronchus within 1 cm of the periphery (including the fissures).7 associated with bronchiectasis are atelectasis, mosaic pattern and clos.8 airfluid levels may also be present within dilated bronchi. the causes of bronchiectasis are many but are most commonly associated with previous, current or recurrent infection, cystic fibrosis and aspiration (table v). pictorial essay 24 sa journal of radiology • december 2005 table iv. septal lines 3,4 smooth nodular / irregular crazy paving pulmonary oedema* lymphoma alveolar proteinosis infection* sarcoma / neuroblastoma lipoid pneumonia bpd* sarcoid ards pulmonary alveolar proteinosis fibrosis aip neoplasms drug-induced pneumonia pulmonary lymphangiectasia lymphangiomatosis pulmonary capillary haemangiomatosis gaucher / nieman piek sarcoid pulmonary alveolar microlithiasis pulmonary haemosiderosis tuberous sclerosis collagen vascular diseases fibrosis bpd = bronchopulmonary dysplasia; ards = acute respiratory distress syndrome; aip = acute interstitial pneumonitis. fig. 10. parenchymal bands. fig. 11a. architectural distortion fig. 11b. honeycombing. table v. causes of bronchiectasis 3,6,8 infection tb aids adenovirus immunodeficiency aspiration recurrent infection sequelae of infection obstruction foreign body neoplasm lymphadenopathy cystic fibrosis (most common cause in children) allergic bronchopulmonary aspergillosis ciliary dyskinesia fibrosis williams-campbell syndrome fig.12a. bronchiectasis. fig.12b. bronchial wall thickening and ‘signet ring sign’. article andronikou 11/30/05 10:46 am page 24 air-filled cysts these are usually thin-walled and contain air. they may be oval with smooth walls as in tuberous sclerosis or have irregular margins as in langerhans cell histiocytosis (fig. 13). the causes of air-filled cysts in children are listed in table vi. specific diseases seen in children on hrct the range of diseases in children differs from adults (table vii)1,5 and the reported accuracy for a confident first choice diagnosis on hrct varies from 56% to 61%.2,5 the diseases diagnosed with the highest degree of confidence in children include alveolar proteinosis, pulmonary lymphangiectasia and idiopathic pulmonary haemosiderosis.1,2 we will describe the hrct appearances of the acute infective causes of diffuse lung diseases and diseases affecting the airways that involve the interstitium, because these occur most commonly in our practice. we will also review the appearances of those conditions characterised by nodules and septa that are seen less often in paediatric practice. infections infection tuberculosis miliary nodules are common but not always present, measure 2 3 mm and remain discreet (figs 1a and b, and 14). bronchogenic spread of tb may result in larger nodules that may confluence. both gg and consolidation are regular features of primary tb. clos, bronchiectasis and air trapping also occur. in addition, the important characteristic association is hilar and mediastinal lymphadenopathy which are the fingerprint of primary tb.9 infection aids: lip (lymphoid interstitial pneumonitis) lip is an aids-defining feature in children < 13 years of age. between 30% and 40% of children with aids have lip. hrct features involve septal lines and nodules (clos and subpleural) (fig. 15). gg, cysts and bronchiectasis are common associations. hilar lymphadenopathy and thymic cysts may or may not be present. effusions are not a feature.3 infection aids: pneumocystis carinii this begins as a patchy airspace or gg appearance and progresses to a more homogeneous gg or airspace process that involves both lungs. in addition there are septa and cysts. effusions are not a feature and there is a notable absence of nodules and lymphadenopathy.3 infection invasive aspergillosis this occurs in immunocompromised patients. the most characteristic features are nodules with a ‘halo’ sign that may cavitate (50%) (figs 4 and 16) and result in the ‘air crescent’ sign as air collects between normal and infected lung. more widespread gg or airspace disease is also noted.3 bone marrow transplant children may require a hrct to exclude this disease process. airways (table viii) airways cystic fibrosis hrct is performed to document the presence and extent of disease. the hallmark is widespread bronchiectasis involving the upper zones (fig. 12b). associated features such as peribronchial thickening, clos, larger mucoid impactions and mosaic pattern are common.3,6,8 airways immotile cilia syndrome half of these patients have kartagener’s pictorial essay 25 sa journal of radiology • december 2005 fig.13. air-filled cysts in lagerhans cell histiocytosis. table vi. air-filled cysts4 pneumatoceles* (infective, trauma, toxins) pneumonia* septic emboli* congenital* tuberous sclerosis* lch* papillomatosis pseudocysts (barotrauma) wegener’s granulomatosis ehlers-danlos syndrome marfan’s syndrome williams-campbell syndrome *common causes. lch = langerhans cell histiocytosis. fig.14. miliary tb. fig.15. lymphoid interstitial pneuomonitis. fig.16. fungi. article andronikou 11/30/05 10:46 am page 25 syndrome (situs inversus, sinusistis and bronchiectasis). features cannot be differentiated from cystic fibrosis but there is a predilection for the right middle lobe.8 airways allergic bronchopulmonary aspergillosis this is a hypersensitivity reaction to endobronchial growth of aspergillus fumigatus and results in asthma. the main feature is central bronchiectasis, which in a patient with asthma, clinches the diagnosis.8 airways swyer-james / macleod’s syndrome this is a post-infectious bronchiolitis and signs include a unilateral lucent lung with air-trapping. in reality on hrct 50% of these patients have bilateral disease with the most affected lung showing low density, mosaic pattern and bronchiectasis, and the less affected lung showing patchy air-trapping.3,8 airways bronchiolitis obliterans / constrictive bronchiolitis as expected for diseases of the airways the predominant hrct findings are bronchial wall thickening and bronchiectasis with the associated mucoid impaction and clos and resultant mosaic pattern of air-trapping.3,4,8 the causes of bronchiolitis obliterans are listed below (table ix). bronchocentric granulomatosis has the above features but also shows septal thickening.3 airways boop (bronchiolitis obliterans organising pneumonia) and cop (cryptogenic organising pneumonia) this is rare in children but is characterised by patchy consolidation or a gg pattern (fig. 17a and b). bronchial wall thickening and bronchiectasis are also features (fig. 17c). nodules and septa may be seen. small effusions may also be present.6,8 the causes of boop are listed in table ix. pictorial essay 26 sa journal of radiology • december 2005 table vii. diffuse lung diseases in children 2,3,8 common seen in practice rare infant-specific infection lch extrinsic allergic alveolitis persistent tachypnoea of infancy tb pulmonary lymphangiectasia sarcoid bpd pneumocystis pulmonary haemorrhage intersitial pneumonitides cellular interstitial pneumonia viral alveolar proteinosis collagen vascular diseases infantile pulmonary haemosiderosis mycoplasma collagen vascular disease vasculitides chronic pneumonitis of infancy aspergillosis neurocutaneous syndromes lymphangiomatosis surfactant protein b deficiency chronic/recurrent ` alveolar microlithiasis familial dip lip (aids-related) gauchers / nieman piek idiopathic pulmonary fibrosis infancy bpd pulmonary infiltrates with eosinophilia aspiration lymphangitis carcinomatosa lip = lymphoid interstitial pneumonitis; bpd = bronchopulmonary dysplasia; dip = desquamative interstitial pneumonitis; lch=langerhans cell histiocytosis. table viii. airway diseases in children 1-4,8 infection sequelae of infection bronchiectasis cystic fibrosis allergic bronchopulmonary aspergillosis and asthma aspiration foreign body swyer james / macleod’s syndrome bronchiolitis obliterans / boop/ follicular bonchiolitis immotile cilia boop = bronchiolitis obliterans organising pneumonia. table ix. causes of bronchiolitis obliterans and bronchiolitis obliterans with organising pneumonia 3,8 idiopathic infection viral (adenovirus, influenza, measles) bacteria mycoplasma transplant (heart/lung 50% and bone marrow 10%) collagen vascular diseases toxic fumes stevens-johnson syndrome post chemotherapy fig.17a. bronchiolitis obliterans. article andronikou 11/30/05 10:46 am page 26 interstitial disease: nodules and lines nodules and lines bronchopulmonary dysplasia / chronic lung disease this occurs as a result of the treatment of premature lungs. early appearances are characterised by septa, parenchymal bands and cystic spaces forming a ‘cobblestone’ pattern. later in life a mosaic pattern and architectural distortion are present and even later there is associated bronchiolitis obliterans and traction bronchiectasis. nodules and lines langerhans cell histiocytosis the predominant features are nodules that cavitate and become cysts. these then become thin-walled and fuse. this results in an irregular cystic appearance and is often complicated by a pneumothorax (fig. 18). early on in the disease, the costophrenic angles are spared.2,3,5 the other causes of air-filled cysts in the lungs are listed below (table vi). nodules and lines alveolar proteinosis this is characterised by septa on a background of gg resulting in an easily recognisable geographic ‘crazy paving’ sign (fig. 19a and b).2,3 nodules and lines lymphangiectasia (noonan’s) / lymphangiomatosis here hrct shows septal thickening and gg often associated with effusions (fig. 20a and b).2,3,5 nodules and lines lymphangitis carcinomatosa this is a rare finding in children but can occur with lymphoma, neuroblastoma, sarcomas and thyroid malignancy. the main feature is septa accompanied by fissural and bronchovascular bundle thickening (fig. 21a and b). it differs from sarcoid where the fissures are beaded with nodules.3 pictorial essay 27 sa journal of radiology • december 2005 fig.17b. bronchiolitis obliterans. fig.17c. brochiolitis obliterans. fig. 18. langerhans cell histiocytosis with bilateral pneumothoraces. fig. 19a. alveolar proteinosis. fig. 19b. alveolar proteinosis ‘crazy paving’. fig. 20a. noonan’s. fig. 20b. noonan’s fig. 21a. lymphangitis carcinomatosa. fig. 21b. lymphangitis carcinomatosa. article andronikou 11/30/05 10:46 am page 27 nodules and lines extrinsic allergic alveolitis / hypersensitivity pneumonitis patchy or diffuse gg, mosaic pattern and clos are the prominent hrct features.2,3,5 nodules and lines pulmonary haemorrhage / idiopathic pulmonary haemosiderosis acute haemorrhage appears either as gg or denser consolidation and is usually bilateral on hrct (fig. 22 a c).3,10 more chronic haemorrhage results in nodules (clos and other) and septa.2,10 the causes of pulmonary haemorrhage in children are listed below (table x). nodules and lines sarcoid the nodules in sarcoid are described as ‘beeding’ the fissures, bronchovascular bundles and pleura (fig. 23). larger dense nodules may represent confluent areas of gg or consolidation, which may cavitate. lymphadenopathy is a major feature.3 nodules and lines systemic sclerosis (vasculitis) even though vasculitides are rare in children, systemic sclerosis may result in lung changes on hrct in childhood. the hrct features are a gg pattern with subpleural nodules that may progress to supleural cysts and honeycombing. septa are not a feature.2,3 drug-related toxicity and injury chemotherapy and other insults to the lung may result in airspace and interstitial disease, which may range from gg to septal lines and nodules to endstage fibrosis (fig. 24). endobronchial papillomatosis endobronchial papillomas cause obstruction with bronchial wall thickening and dilation (fig. 25). idiopathic / chronic interstitial pneumonitides and idiopathic pulmonary fibrosis these diseases are rare in children and are distinguished only after biopsy. hrct is less accurate in the diagnosis.1 they are predominated on hrct by gg (fig. 26) that progresses to pulmonary fibrosis (ipf). in children the diagnoses of dip (desquamative interstitial pneumonitits) and uip (usual interstitial pneumonitis) should not be listed in the differential diagpictorial essay 28 sa journal of radiology • december 2005 table x. causes of diffuse pulmonary haemorrhage in children10 idiopathic pulmonary haemorrhage heiner’s syndrome stacybotrys atra diffuse alveolar haemorrhage with glomerulonephritis wegener’s granulomatosis systemic necrotic vasculitis goodpasture’s syndrome systemic lupus erythematosis henoch-schonlein purpura idiopathic glomerulonephritis and alveolar haemorrhage cardiovascular causes pulmonary venous hypertension mitral stenosis eisenmenger’s congenital pulmonary vein stenosis congenital pulmonary artery stenosis pulmonary capillary haemangiomas fig. 22a. idiopathic pulmonary haemosiderosis. fig. 22b. idiopathic pulmonary haemosiderosis. fig. 22c. idiopathic pulmonary haemosiderosis. fig. 23. sarcoid with ‘beeding’. fig. 24. drug toxicity. fig. 25. papillomatosis. article andronikou 11/30/05 10:46 am page 28 noses. instead nsip (non-specific interstitial pneumonitis) and aip (acute interstitial pneumonitis) may be added to a differential diagnosis.2,3,8 the end result of these is pulmonary fibrosis that is characterised on hrct by cysts, honeycombing, parenchymal bands and traction bronchiectasis. recommended techniques for hrct in children2,3,5 the aim is to produce images of high spatial resolution with no motion artefact using the least amount of radiation possible. diffuse disease allows for large interslice imaging. current multi-detector ct allows the acquisition of a volume of contiguous data and allows reconstruction of this data on a high-frequency algorithm in fine slices, thereby yielding both contiguous thicker-slice ct scans and high-resolution ct scans in one event. mmaass:: 40 80 (tip: reduces radiation by up to 80%) kkvv:: 120 (tip: an increase from 120 to 140 kv increases the dose by 40%) slice thickness: 12 mm (multidetector = 1.25) (tip: thicker slice = less motion artefact) sslliiccee ssppaacciinngg:: > 10 years = 10 mm, 2 10 years = 7 mm, < 2 years = 5 mm (irrelevant for mdct) ffoovv:: small as possible, < 25cm (tip: small fov = higher resolution) ssccaann ttiimmee:: shortest possible, e.g. 12 s (tip: shorter time = less motion) rreeccoonnssttrruuccttiioonn:: high frequency, e.g. bone or lung (tip: increases edge and detail) iinnssppiirraattoorryy:: quiet respiration represents inspiration in children eexxppiirraattoorryy:: use decubitus side down (tip: flat, half or sliver moon trachea = expiration) ppoossiittiioonn:: only rarely require prone position in children vviieewwiinngg:: lung window, width 1 500 hu and level -500 hu references 1. copley sj, coren m, nicholson ag, rubens mb, bush a, hansell dm. diagnsotic accuracy of thinsection ct and chest radiography of pediatric interstitial lung disease. am j roentgenol 2000; 174: 549-554. 2. koh dm, hansell dm. computed tomography of diffuse interstitial lung disease in children. clin radiol 2000; 55: 659-667 3. kuhn jp, brody as. high resolution ct of pediatric lung disease. radiol clin north am 2000; 40(1): 89-110. 4. lucaya j, le pointe hd. hrct features of lung disease. in: baert al, sartor k, eds. pediatric chest imaging. 1st ed. berlin: springer-verlag, 2002: 64 73. 5. lynch da, hay t, newell jd, divgi vd, fan ll. pediatric diffuse lung disease: diagnosis and classification using high resolution ct. am j roentgenol 1999; 173: 713-718. 6. evans ed, kramer ss, kravitz rm. pediatric diseases of the lower airways. semin roentgenol 1998; 33: 136-150. 7. kim js, muller nl, park cs. cylindrical bronchiectasis: diagnostic findings on thin-section ct. am j roentgenol 1997; 168: 751-754. 8. lucaya j, le pointe hd. hrct features in diagnosis of airway disease (4.7). hrct features in specific lung disease (4.8). in: baert al, sartor k, eds. pediatric chest imaging. 1st ed. berlin: springerverlag, 2002: 74 87. 9. andronikou s, wieselthaler n. modern imaging of tuberculosis in children: thoracic, central nervous system and abdominal tuberculosis. pediatr radiol 2004; 34: 861-875. 10. states lj, fields jm. pulmonary haemorrhage in children. semin roentgenol 1998; 33: 174-186. pictorial essay 29 sa journal of radiology • december 2005 fig. 26. fibrosing alveolitis. price: r399.00 to order contact: the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za article andronikou 11/30/05 10:46 am page 29 article information author: mark velleman1 affiliation: 1department of radiology, university of pretoria, south africa correspondence to: mark velleman email: mdvelleman@gmail.com postal address: po box 11315, silver lakes 0054, south africa dates: received: 04 sept. 2014 accepted: 04 nov. 2014 published: 12 dec. 2014 how to cite this article: velleman, m. magnetic resonance imaging of the forefoot: a concise, practical overview. s afr j rad. 2014;18(2); art. #732, 5 pages. http://dx.doi.org/10.4102/sajr.v18i2.732 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. magnetic resonance imaging of the forefoot: a concise, practical overview in this pictorial essay... open access • abstract • introduction • anatomy • magnetic resonance imaging technique    • supine versus prone examination position    • imaging planes • anatomical planes for forefoot imaging • sequences    • additional sequences • mr short axis anatomy • biomechanics • pathology • teaching points • conclusion • acknowledgements    • competing interests • references abstract top ↑ the forefoot may be affected by a wide variety of pathologies that require imaging. magnetic resonance imaging is the modality of choice for soft-tissue pathologies and occult bone lesions. correct imaging protocols and an awareness of anatomy are essential for accurate diagnosis. introduction top ↑ a sound knowledge of forefoot anatomy, a basic understanding of applicable biomechanics, and a structured differential diagnosis, are essential when performing imaging of the forefoot. anatomy top ↑ the foot is divided into the hind foot, mid foot and forefoot. the hind foot comprises the talus and calcaneus; the mid foot comprises the navicular, cuboid, medial, intermediate and lateral cuneiforms; and the forefoot comprises the metatarsal bones and phalanges. magnetic resonance imaging (mri) examinations are usually divided into the (1) ankle and hind foot; (2) mid foot; and (3) forefoot examinations. a dedicated examination technique and protocol is essential for each region. magnetic resonance imaging technique top ↑ high-resolution images of the forefoot should be obtained in three anatomical planes. if the region of suspected pathology is uncertain, a large field of view (fov) short tau inversion recovery (stir) examination of the ankle and foot (200 mm – 270 mm) may be obtained, to identify a specific region of interest (roi). dedicated forefoot, mid foot or ankle examinations may then be performed. the use of dedicated foot and ankle coils is advised but, if these are not available, knee, head or flexible coils can be used as a substitute. imaging of the feet should be obtained separately, as large fov examinations of both the foot and ankle in one coil does not yield adequate imaging quality.1 a vitamin e tablet can be used as a skin marker to identify the region of discomfort (figure 1).2, 3 figure 1: sagittal t2 fs mr image demonstrating a vitamin e capsule (arrow) used to indicate the region of discomfort. supine versus prone examination position a supine position is more comfortable for the patient, but the prone position has been advocated for cases with suspected morton's neuroma, 2 as biomechanical action in the prone position aids in visualising this condition. imaging planes imaging planes are prescribed from the scout views. 3 initially, three-axis short scout views are obtained (acquisition time 40 seconds), followed by slightly high resolution scout views in the short and long axis (acquisition time 50 seconds), after which the first sagittal diagnostic sequence is prescribed (figure 2). figure 2: scout views used to plan imaging planes. (a) sagittal plane, (b) long axis plane and (c) short axis plane. anatomical planes for forefoot imaging top ↑ the sagittal plane is usually prescribed in the long axis of the second metatarsal, but may be adjusted according to the roi. the short axis is prescribed in the axis of the second or third metatarsal perpendicular to the sagittal and long axis planes. the long axis is prescribed in the axis of the second or third metatarsal on sagittal views.2 it is important to avoid confusion when identifying the imaging planes. we prefer to use short and long axis terminology, rather than coronal and axial descriptions, to avoid confusion because positioning (prone versus supine) can influence the relative plane in relation to the long axis of the body.3 sequences top ↑ a combination of non-fat-saturated (proton density (pd)/t1) and fluid-sensitive fat-saturated (pd fs/t2 fs) image sequences are obtained, with all sequences preferably in three imaging planes. typical echo times for fluid-sensitive sequences are 30 ms – 60 ms but are adjusted to vendor variations and magnetic field strength. the field of view is 120 mm– 220 mm and slice thickness is 2.5 mm – 3 mm, with a small slice gap (10% – 20%). additional sequences a stir sequence is obtained if adequate fat saturation is not obtained, or when dealing with metal or other artefacts. gradient echo sequences are added when searching for foreign bodies, blood products or calcifications. t1 fs with or without intravenous gadolinium is reserved for special cases such as mass lesions and infections. routine use of contrast when evaluating morton's neuroma is debatable. mr short axis anatomy top ↑ compartmental anatomy is crucial when evaluating forefoot pathology and is best imaged in the short axis plane. the deep transverse metatarsal ligament divides the forefoot into the dorsal and plantar compartments. the dorsal compartment contains the metatarsals and intermetatarsal spaces including the intermetatarsal bursae. the plantar compartment contains the important neurovascular bundles, specifically important when imaging for a possible morton's neuroma (figure 3). the first metatarsophalangeal and sesamoid complex anatomy is also visualised in the short axis plane (figure 4). figure 3: schematic diagram of forefoot anatomy in the short axis view. figure 4: schematic diagram of the anatomy of the first metatarsophalangeal sesamoid complex in the short axis view. biomechanics top ↑ human bipedalism has evolved over a period of approximately 4 million years. during this process, the first tarso-metatarsal joint has not evolved into an adequately rigid joint, with the medial longitudinal arch also not sufficiently rigid to absorb continuous high-stress loads. when the medial longitudinal arch starts to sag, usually owing to old age or underlying foot pathology such as rheumatoid arthritis or other joint-centred pathology, secondary load transference occurs to the second digit and lateral arch, with also a relatively rigid second tarso-metatarsal joint. stress-load transference may lead to tibialis posterior dysfunction, and stress changes in the second metatarsal with secondary pressure changes in the second metatarsal head and peripheral soft-tissue pressure point or plantar plate. a short first metatarsal index (greek/morton's foot) also contributes to an increased risk and earlier occurrence of this cascade of events.4, 5 pathology top ↑ the following are differential diagnoses for forefoot pain:6 morton's neuroma v. true neuroma (rare neurofibroma/schwannoma) (figure 5) intermetatarsal bursitis (figure 6) stress fractures (figure 7) stress reaction freiberg's disease/metatarsal osteochondritis (figure 8) sesamoiditis/fracture/osteonecrosis (figure 9) rheumatoid nodules (figure 10) giant cell tumour of the tendon sheath (figure 11) miscellaneous: synovial cyst, chondroma of soft tissue, foreign-body granuloma, plantar fibromatosis, bony lesions (figure 12) trauma to bone and soft tissue. figure 5: schematic diagram illustrating the location of (a) morton's neuroma occurring in the webspace between the 3rd and 4th toes; and (b) the region of peripheral nerve where excision should occur to prevent the formation of a stump neuroma. figure 6: short axis t2 fs mr image of the foot demonstrating an intermetatarsal bursitis. figure 7: long axis stir mr image of the foot demonstrating oedema in the 4th metatarsal owing to a stress fracture. figure 8: long axis t2 fs mr image of the foot demonstrating oedema in the 2nd metatarsal head owing to freiberg's disease. figure 9: short axis t2 fs mr image of the foot demonstrating oedema in the medial sesamoid (arrow) owing to sesamoid stress changes. figure 10: long axis t2 fs mr image of the foot demonstrating synovitis, erosions and bone oedema in a patient with rheumatoid arthritis. figure 11: short axis t1 fs mr image of the foot demonstrating a giant cell tumour in the tendon sheath of the 3rd toe. figure 12: sagittal gradient recalled echo (gre) mr image of the foot demonstrating a foreign body (arrow) in the plantar aspect of the foot. teaching points top ↑ high-resolution true plane anatomical imaging is important for accurately diagnosing forefoot pathology and abnormalities. a basic understanding of forefoot biomechanics is valuable when assessing forefoot pain. a sound knowledge of the differential diagnoses of forefoot pathology, as well as a list of the most likely causes of forefoot pain, is important. conclusion top ↑ a sound knowledge of normal anatomy, biomechanics, differential pathology and the most common causes of forefoot pain is essential when imaging the forefoot. high-resolution anatomical imaging in three planes should be obtained with sequences specifically tailored for the forefoot. fat-saturated fluid-sensitive as well as non-fat-saturated pd or t1 sequences should be included. in specific instances, stir, gradient echo or post-contrast image sequences may be added. if there is uncertainty about the specific region of pathology, a large fov stir study may be obtained to identify the region of pathology. acknowledgements top ↑ i thank dr marinel gericke for her assistance with the illustrations. competing interests the author declares that they he has no financial or personal relationships that he might have inappropriately influenced him in writing this article. references top ↑ erickson sj, rosengarten jl. mr imaging of the forefoot: normal anatomical findings. ajr 1993;160(3):565–571. http://dx.doi.org/10.2214/ajr.160.3.8430554 needell s. guide to mr imaging of the foot & ankle. boca radiology group [homepage on the internet]. [cited january 2014]. available from: http://www.bocaradiology.com/foot/index.html arnold g, saifuddin v, marcantonio d, shashin d. normal magnetic resonance imaging anatomy of the ankle and foot. magn reson imaging clin n am. 2011;19(3):655–679. http://dx.doi.org/10.1016/j.mric.2011.05.010 rothbart ba. an explanation of morton's foot aka morton's toe and greek foot. curing chronic pain. [homepage on the internet]. [cited january 2014]. available from: http://curingchronicpain.com/an-explanation-of-mortons-foot-aka-mortons-toe-and-greek-foot wikipedia. morton's toe. [homepage on the internet]. [cited january 2014]. available from: http://en.wikipedia.org/wiki/morton's_toe zanetti m, weishaupt d. mr imaging of the forefoot: morton neuroma and differential diagnosis. semin musculoskelet radiol. 2005;9(3):175–186. http://dx.doi.org/10.1055/s-2005-921938 case report case report 46 sa journal of radiology • july 2008 case report abstract temporal bone fractures and their acute complications have been well described in radiology and ent journals; this is in contrast to the delayed and rare complication of implantation cholesteatomas. we present the computed tomographic (ct) findings of two cases of infiltrating cholesteatomas that developed many years after temporal bone trauma. introduction post-traumatic cholesteatomas are well recognised albeit rare late complications of temporal bone injuries. they were first described in german literature by doctors reviewing world war i blast victims,1 with the first definitive series by eckel in 1966.2 he described three cases of post-traumatic cholesteatomas and made postulations on their origin. since then, there have been sporadic reports describing mainly cholesteatomas in the middle ear and mastoid,3 although external ear lesions have also been mentioned.4 ct plays an invaluable role in the evaluation of this condition owing to its ability to delineate bony anatomy. preoperative ct establishes the type of surgical procedure as it determines the extent of the cholesteatoma, ocular chain involvement, facial canal integrity, and tegmen tympani and dural plate involvement.5 we report two cases of post-traumatic cholesteatomas that caused extensive middle ear destruction that developed many years following trauma. case 1 a 13-year-old boy presented with a 10-month history of a foul discharge from his left ear. he had sustained a gunshot wound to the left side of his face at the age of 3 that had resulted in temporal bone injury and subsequent hearing loss. the exact extent of the injury was not known. otological examination was unhelpful due to severe external auditory canal stenosis. case 2 a 30-year-old man presented with a longstanding offensive left-ear discharge and non-pulsatile tinnitus. he had sustained a gunshot injury with temporal bone injury 10 years before. a protruding mass was noted extending into the distal external auditory meatus on otological examination. in both cases, temporal bone ct scans were performed prior to surgery. case 1 revealed a non-enhancing soft-tissue mass (fig. 1) that had engulfed the epitympanum with extrusion through the aditus ad antrum into the mastoid air cells. ossicles were medially displaced with erosion of the malleus and incus body (fig. 2). vestibular and semi-circular canal erosions were noted (figs 3 and 4). tegmen tympani, jugular foramen as well as condylar fossa and lateral semi-circular wall dehiscence were noted. a longitudinal fracture through the external auditory canal, middle ear and mastoid bone was present. post-traumatic cholesteatoma … a rare occurrence logeshini naidoo, fc rad (diag) sa a nanan, fcs (orl) sa helen joseph and coronation hospitals, johannesburg fig. 1. coronal ct using soft-tissue windowing, depicting a non-enhancing soft-tissue mass (arrow). post-traumatic.indd 46 8/1/08 10:49:15 am case reportcase report case 2 displayed a similar mass with marked middle ear extension. artifact from a bullet lodged in the mastoid was present (fig. 5). the lesion, although extensive, also seemed to arise from the epitympanum. tegmen tympani and lateral semi-circular wall dehiscence were also visible (fig. 6). ossicles were not visible. a transverse fracture through the external ear and mastoid air cells was present. surgery was consistent with ct findings. in both cases, radical mastoidectomies with cholesteatoma excision were performed. discussion cholesteatomas are non-neoplastic but destructive lesions consisting of desquamating keratin epithelium.5 the keratin is shed continu47 sa journal of radiology • july 2008 fig. 2. coronal ct with bony windows showing the invasive cholesteatoma eroding and displacing the incudo-malleolar complex (arrow). fig. 3. coronal ct displaying erosions adjacent to the vestibule (arrow). fig. 4. coronal ct with semi-circular erosions (arrow). post-traumatic.indd 47 8/1/08 10:49:16 am case report case report 48 sa journal of radiology • july 2008 case report ally by an envelope surrounding the cholesteatoma called the matrix.5 they occur mainly in the middle ear cleft but have also been reported intracranially and in the external auditory canal.6 there are two types of cholesteatomas: congenital and acquired. congenital cholesteatomas develop behind an intact tympanic membrane; acquired cholesteatomas are associated with defects in the tympanic membrane.6 acquired cholesteatomas are more common and may develop by various mechanisms, including trauma.6 eckel recognised that traumatic cholesteatomas occurred as a complication of different types of injury to the temporal bone.2 he suggested central tympanic membrane rupture, external meatal fractures with marginal tympanic membrane injury, soft-tissue and bony defects of the mastoid and, lastly, meatal stenosis as causes of cholesteatomas. he postulated that central tympanic membrane rupture allowed foreign body implantation in the middle ear, resulting in localised chronic inflammatory reactions and squamous metaplasia; and hence cholesteatomas. external meatal fractures and soft-tissue and bony fragment displacement predispose to soft tissue and blood organising in fracture lines, thus providing a good substrate for bacterial growth.1,2 in traumatic meatal stenosis, the medial canal skin continues to grow, casting off sheets of desquamation, and ultimately leads to cholesteatomas. the question arises as to why post-traumatic cholesteatomas are rare. it appears that straightforward, uncomplicated fractures as seen in the majority of patients, generally heal with callus formation that forms a strong barrier against epithelial migration and thus implantation cholesteatomas. in our series, both patients displayed extensive tympanic membrane rupture and external and mastoid bone fractures. patient 1 also had meatal stenosis. these findings are consistent with eckel's theory of post-traumatic cholesteatoma development. the time interval between injury and diagnosis of post-traumatic cholesteatoma is very variable and may range from 1 to 25 years.1,2 in most of the cases reported, time to presentation was more than 10 years.2 in our series, the latent interval averaged 10 years. growth rates depend on numerous factors, including vascular status, age and site.2 rates seem faster in children and with concurrent infection.2 high-resolution temporal bone ct depicts cholesteatomas as nonenhancing, soft-tissue masses.7 bony erosion adjacent to the soft-tissue mass, with/without intramural bony fragments, forms the mainstay of the diagnosis, and distinguishing the lesion from granulation tissue and fluid and pus.7 bony erosions may be smooth or irregular, secondary to necrotic bone.7 other ct findings include: erosions of scuta, destruction and displacement of the ossicular chain, labyrinthine fistulas, facial canal erosions, tegmen tympani dehiscence, and destruction of the mastoid.5 it is important to evaluate for extension into mastoid air cells, tegmen tympani integrity and facial nerve canal delineation, as these features may change the surgical management. pre-operative knowledge is helpful in planning the surgical approach. ct is the preferred investigation owing to its superior imaging of bony anatomy.5 the role of mri is limited to differentiating cholesteatomas from granulation tissue and scar tissue, which display enhancement post-contrast.5 mri may also show intracranial extensions, and be used for intraand extratemporal complications as well as post-surgical follow-up.5 fig. 5. axial ct displaying a bullet lodged in the mastoid secondary to the old trauma. note the cholesteatoma extending into the mastoid (arrow). fig. 6. coronal ct showing the infiltrating cholesteatoma, extending into the middle ear with tegmen tympani dehiscence (arrow). post-traumatic.indd 48 8/1/08 10:49:17 am case reportcase report 49 sa journal of radiology • july 2008 conclusion post-traumatic cholesteatomas are rare entities and tend to develop after severe temporal bone trauma. ct displays a non-enhancing soft-tissue mass in the background of previous trauma and delineates the anatomy and variants, which is essential for pre-surgical planning. 1. brookes g. post-traumatic cholesteatoma. clin otolaryngol 1983; 8: 31-38. 2. eckel w. traumatic cholesteatoma of the hearing organ. z laryngol rhinol 1966; 45: 265. 3. wallwork b, black b. middle cranial fossa cholesteatoma following temporal bone trauma. aust j otolaryngol 2002; 5: 128-130. 4. tsuyoshi k, yoshiro y, norikuni k, et al. post-traumatic cholesteatoma of the external auditory meatus: 2 case reports. practica otologica 2000; 93: 201-205. 5. waizel s, grandvallet j, vargas a, et al. temporal bone acquired cholesteatomas. http://www.emedicine. com/radio/topic[updated 1 may 2007] (accessed 30 may 2008). 6. persaud r, hajioff d, trinidade a, et al. evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma. j laryngol otol 2007; 121(11): 1013-1019. 7. heilburn m, salzman k, glastonbury c, et al. external auditory canal cholesteatoma: clinical and imaging spectrum. am j neuroradiol 2003; 24: 751-756. radiology secrets, 2nd edition with student consult online access by e. scott pretorius and jeffrey a. solomon isbn 0323034055 / 9780323034050 ä paperback ä 656 pages ä 679 illustrations mosby ä published november 2005 health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za the smart way to study! elsevier titles with student consult will help you master difficult concepts and study more efficiently in print and online! perform rapid searches. integrate bonus content from other disciplines. download text to your handheld device. and a lot more. each student consult title comes with full text online, a unique image library, case studies, usmle style questions, and online note-taking to enhance your learning experience. features  uses bulleted lists, tables, short answers, and a highly detailed index to expedite reference.  features pearls, tips, memory aids, and � secrets� from the experts.  covers all of today� s most common conditions and their treatment. post-traumatic.indd 49 8/1/08 10:49:18 am article information author: charles s. wiysonge1 affiliation: 1centre for evidence-based health care and division of community health, faculty of medicine and health sciences, stellenbosch university, south africa postal address: centre for evidence-based health care, room 5014, teaching block, faculty of medicine and health sciences, stellenbosch university, po box 19063, tygerberg 7505, south africa how to cite this article: wiysonge cs. the importance of systematic reviews in radiology. s afr j rad. 2014;18(1); art. #609, 2 pages. http://dx.doi.org/10.4102/ sajr.v18i1.609 note: professor charles s. wiysonge is a specialist in systematic reviews, knowledge translation, and vaccinology, and holds an md from the university of yaoundé i (cameroon), an mphil from the university of cambridge (uk), and a phd from the university of cape town (south africa). he is the deputy director of the centre for evidence-based health care, and full professor in the division of community health, at stellenbosch university. professor wiysonge serves on the world health organization (who) african task force on immunisation, the independent review committee of the global alliance for vaccines and immunisation (gavi), the who african advisory committee on health research and development, the executive committee of the great network (guideline‐driven, research priorities, evidence synthesis, application of evidence, and transfer of knowledge), and other advisory committees. copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the importance of systematic reviews in radiology in this editorial... open access • introduction • acknowledgements • references introduction top ↑ mindful of the dangers of making healthcare decisions without reference to trustworthy evidence, a new approach to healthcare delivery was introduced in the late 1970s.1 this approach, referred to as evidence-based medicine or more broadly as evidence-based health care, is defined as ‘the conscientious, explicit, and judicious use of current best evidence’ in making healthcare decisions. 2 evidence-based health care integrates individual healthcare expertise, patient values and preferences, and the best available research evidence from systematic reviews. see boxes 1 and 2 for key definitions and resources for evidence-based health care respectively. systematic reviews provide a complete picture of the totality of evidence on a given topic.3 in practice, a summary of evidence is considered to be a systematic review if (at a minimum) the authors conducted a literature search that was comprehensive enough to avoid publication, language and indexing biases; report the criteria used for deciding which studies to include in the review; undertook duplicate study selection and data extraction; and combined data from included studies using reliable methods.4 there are numerous examples where failure to prepare timely systematic reviews of existing research evidence resulted in untold and preventable suffering.5,6 in a recent methodological study, ochodo and colleagues estimated the frequency of over-interpretation or ‘spin’, defined as: reporting that distorts study results to make interventions look favourable e.g. an overly optimistic abstract, stronger conclusion in abstract, selective reporting of results in abstract, study conclusions based on selected subgroups, and discrepancy between aim and conclusion.7 the authors searched and identified 126 eligible primary diagnostic accuracy studies published between january and june 2010 in pubmed-indexed journals with an impact factor of at least 4. of these studies, 53 focused on radiological imaging. an analysis of the latter revealed that one-third of the studies contained forms of actual over-interpretation and all contained forms of potential over-interpretation of the diagnostic accuracy of imaging. in line with this methodological study, i will use two examples to illustrate the importance of systematic reviews in radiology. the first review was conducted by brealey and colleagues to determine the accuracy of radiographer plain radiograph reporting in clinical practice.8 the authors conducted a comprehensive search of numerous peer-reviewed and grey literature sources for studies conducted between 1971 and october 2002. twelve studies were included in this review, which revealed that the sensitivity and specificity of radiographers’ reports of plain radiographs were 93% and 98% respectively, against a reference standard. the subgroup of studies that focused on accident and emergency settings found no evidence of a difference in reporting accuracy between selectively trained radiographers and radiologists of varying seniority, compared to a reference standard. the authors concluded that flexible teamwork between different professions as to who reports plain radiographs should be promoted. the second example is a comprehensive review of the effectiveness of several radiological techniques in diagnosing occult inguinal hernias, published in 2013.9 the authors included 23 studies published since 1950, and found that herniography has a sensitivity of 91% and a specificity of 83%, ultrasound a sensitivity of 86% and a specificity of 77%, and computed tomography a sensitivity of 80% and a specificity of 65% in detecting occult inguinal hernias. the implications of this review for clinical practice, in settings where all three techniques are available, are that herniography should be the initial investigation for occult inguinal hernia. in settings where herniography is not available, ultrasound of the groin should be used, with consideration of computed tomography only in the presence of persistent diagnostic uncertainty. box 1: key definitions in evidence-based health care. box 2: resources for evidence-based health care. as illustrated by these systematic reviews, professional good intentions and plausible theories are inadequate criteria for selecting interventions to promote, restore, maintain, protect or monitor the health of human populations. as iain chalmers said: humility and uncertainty are preconditions for unbiased assessments of the effects of the prescriptions and proscriptions of policy makers and practitioners for other people. we will serve the public more responsibly and ethically when research designed to reduce the likelihood that we will be misled by bias and the play of chance has become an expected element of professional and policymaking practice, not an optional add-on.10 universal adoption of systematic reviews in radiology and other healthcare disciplines will ensure that patients benefit from health research and that healthcare resources are used efficiently. systematic reviews provide a means for decision makers (including policy makers, programme managers and clinicians) to access all available evidence on key questions in a judicious manner11 as well as identify areas where there are knowledge gaps, thus assisting researchers and research funders in setting priorities for new studies12. systematic reviews help to increase value and reduce waste in research priority-setting. therefore: research funders and regulators should demand that proposals for additional primary research are justified by systematic reviews showing what is already known, and increase funding for the required syntheses of existing evidence.13 however, an investigation of the current research landscape paints a dismal picture of how limited research resources continue to be wasted on unnecessary research and needless confusion continues to persist from failure to set new studies in the context of systematic reviews.13,14 but, every cloud has a silver lining. this could be a golden opportunity for radiologists in south africa to provide leadership in increasing value and decreasing waste in health research, through routine use of systematic reviews when making healthcare decisions and designing new studies. the ball is in your court – shall you make or mar? acknowledgements top ↑ the author acknowledges prof. taryn young for critical comments on an earlier version of this manuscript. references top ↑ 1. chalmers i, hedges lv, cooper h. a brief history of research synthesis. eval health prof. 2002; 25:12–37. http://dx.doi.org/10.1177/01632787020250010032. sackett dl, rosenberg wm, gray ja, haynes rb, richardson ws. evidence based medicine: what it is and what it isn’t. bmj. 1996;312:71–72. http://dx.doi.org/10.1136/bmj.312.7023.71 3. moher d, cook dj, eastwood s, olkin i, rennie d, stroup df. improving the quality of reports of meta-analyses of randomised controlled trials: the quorom statement. quality of reporting of meta-analyses. lancet. 1999;354:1896–900. http://dx.doi.org/10.1016/s0140-6736(99)04149-5 4. shea bj, grimshaw jm, wells ga, et al. development of amstar: a measurement tool to assess the methodological quality of systematic reviews. bmc med res methodol. 2007;7:10. http://dx.doi.org/10.1186/1471-2288-7-10 5. murphy c, hahn s, volmink j. reduced osmolarity oral rehydration solution for treating cholera. cochrane database syst rev. 2004;(4):cd003754. 6. wiysonge cs, bradley h, mayosi bm, et al. beta-blockers for hypertension. cochrane database syst rev. 2007;(1):cd002003. 7. ochodo ea, de haan mc, reitsma jb, hooft l, bossuyt pm, leeflang mm. overinterpretation and misreporting of diagnostic accuracy studies: evidence of ‘spin’. radiology. 2013;267:581–588. http://dx.doi.org/10.1148/radiol.12120527 8. brealey s, scally a, hahn s, thomas n, godfrey c, coomarasamy a. accuracy of radiographer plain radiograph reporting in clinical practice: a meta‐analysis. clin radiol. 2005;60:232–241. http://dx.doi.org/10.1016/j.crad.2004.07.012 9. robinson a, light d, kasim a, nice c. a systematic review and meta‐analysis of the role of radiology in the diagnosis of occult inguinal hernia. surg endosc. 2013;27:11–18. http://dx.doi.org/10.1007/s00464-012-2412-3 10. chalmers i. trying to do more good than harm in policy and practice: the role of rigorous, transparent, up-to-date evaluations. ann am acad polit soc sci. 2003;589:22–40. http://dx.doi.org/10.1177/0002716203254762 11. wiysonge cs, volmink j. strengthening research capacity. lancet. 2002;359:713. http://dx.doi.org/10.1016/s0140-6736(02)07798-x 12. wiysonge cs, lavis jn, volmink j. make the money work for health in sub-saharan africa. lancet 2009;373:1174. http://dx.doi.org/10.1016/s0140-6736(09)60685-1 13. chalmers i, bracken mb, djulbegovic b, et al. how to increase value and reduce waste when research priorities are set. lancet. 2014;383:156–165. http://dx.doi.org/10.1016/s0140-6736(13)62229-1 14. robinson ka, goodman sn. a systematic examination of the citation of prior research in reports of randomized, controlled trials. ann intern med. 2011;154:50–55. http://dx.doi.org/10.7326/0003-4819-154-1-201101040-00007 82 sa journal of radiology • december 2010 editorial bob bury, the editor of clinical radiology, has kindly written an accompanying editorial for this issue of the south african journal of radiology. to place his piece in context, one has to at least have paged through the special june 2010 edition of clinical radiology on molecular imaging (mi).1 the introductory article explains the role of small molecules in the form of peptides or antibodies that are linked to an imaging label and are destined to attach to a tumour antigen. in the case of pet and spect, the labels are radioactive substances. rssa president clive sperryn’s thoughts on mi appear in this sajr’s radioactive news section. new in the field is optical mi. fluorescent dyes are important, but the recent introduction of quantum dots, carbon nanotubes and gold nanoshells defines the scale of magnitude being referred to. acoustic mi has seen the introduction of microor nanoparticles in the form of microbubbles, perfluorocarbon nanodroplets and liposomes. mri labels include paramagnetic iron oxide and manganese oxide. where does the radiologist stand relative to all this? i do not know, and feel like moses of old ‘on the outside, looking in’. what i do know is that we need to define our role and define it fast. we need to ask many questions. for one: are we properly prepared for these changes that loom on our doorstep? this is probably the most pertinent question needing a response. i believe that our primary examinations fall short, with a lack of knowledge of physiological and patho-physiological principles seeming to represent the most significant hiatus. i echo bob bury’s words as a clarion call to south african radiology: ‘… if we want to continue to attract the brightest and best of our young doctors into the specialty, we need to pick up the new techniques and run with them. if we don’t do it, and do it well, someone else will.’ jan lotz editor-in-chief 1. clin radiol 2010; 65:499-582. a clarion call to south african radiology i was delighted and flattered when jan lotz invited me to contribute to the south african journal of radiology; although, if you were aware of how little i know about molecular imaging (mi – yet another acronym to confuse with mr), you might reasonably be wondering why on earth he approached me. well, i edit clinical radiology, the journal of the royal college of radiologists, and we recently published a special issue1 on this hot topic. i wrote a brief editorial introducing the issue, then sat back to marvel as the contributions from around the world came in, and jan asked if i would write a similar piece for the sajr. i’ll resist the temptation to reference each paper in our special issue in a blatant attempt to boost the journal’s impact factor, but hopefully most of you will have electronic access to it through your institutions or possibly as fellows of the college. when you are as close to retirement as i am, it can get a bit depressing to find your hard-won skills becoming obsolete (remember lymphangiography, anyone?), and to see your juniors effortlessly overtaking you in the application of new imaging technology. the great thing about mi is that most radiologists – even those irritatingly bright young ones – are nearly as ignorant of the subject as me. in fact, of course, it transpires that most of us have practised some aspects of mi, often without realising it. my sub-specialty is nuclear medicine, or radionuclide imaging (rni) as we are now required to call it, in the uk at least. rni practitioners have always boasted, quite rightly, that it is a functional imaging technique, so it is not surprising that many of the early developments in mi have come in this field, in particular those utilising positron emission tomography (pet). similarly, anyone who has bought an mr machine recently will no doubt have tentatively pressed the dwi button to see what it does, and functional mr is already an accepted imaging technique in the fields of neurology and cardiology. however, mi is much more than an extra option on the mr console, or a sexed-up version of the bone scan. mi has been defined as the ability to visualise and quantitatively measure the function of biological and cellular processes in vivo.2 whereas 20 years ago that definition would probably, with few exceptions, only have applied to rni techniques, it now encompasses all imaging modalities except plain film, and includes some, such as optical imaging, that are completely unfamiliar to most of us. even ultrasound, that most anatomical of techniques, is now utilising molecularly targeted micro-bubbles to take diagnosis to the cellular level, and similar bubbles can be used to deliver tailored therapy agents to tumour tissue by using the ultrasound beam to disrupt them in situ. computed tomography also has some mi applicability, with dynamic contrast enhancement techniques being used to look at processes such as tumour angiogenesis and tissue hypoxia. and, of course, the development of new molecular targets for novel pet agents is a wellestablished growth area in mi research. and there’s still more: i could molecular imaging sa journal of radiology • december 2010 83 editorial go on to talk, at least superficially, about optical and photo-acoustic imaging and raman spectroscopy/microscopy, but i probably wouldn’t be able to fool you for very long. so, it is likely that all radiologists will need to learn new applications for their imaging modalities of choice, in addition to mastering a number of completely new techniques. in addition to these obvious imaging aspects, the other issue i want to mention in relation to mi is the political/service delivery dimension. i don’t know how much of a problem so-called turf wars have been in south african medicine, but in the uk we have always thought of these battles for the possession of areas of practice (and income) as a feature of the north american, insurance-funded, medical scene. lately, though, we have realised that the state-funded nhs is not immune. for example, we have already lost much of cardiac imaging to the cardiologists – not just the invasive coronary angiography and intervention, but also a lot of the cardiac mr work; and in mainland europe, the usurpation of imaging techniques by clinicians has been even more widespread. mi is a new and exciting field, with applications in therapy as well as diagnosis, and there’s no doubt that some clinicians will want to get what they see as their share of the action. i suppose it doesn’t matter to the patient which specialist undertakes their investigation, as long as they do it well, but in the main these are imaging investigations we are talking about, and radiologists are the imaging experts. i also believe that if we want to continue to attract the brightest and best of our young doctors into the specialty, we need to pick up the new techniques and run with them. if we don’t do it, and do it well, someone else will. when you read a paper in a journal of clinical radiology which includes a section headed ‘molecular imaging of the metabolome: hypoxia-inducible factor (hif) and the warburg effect’,3 you realise that times are changing, and that we have moved beyond the demonstration of gross anatomy (although that’s clearly still important) into a world where we can reveal cellular physiology and pathophysiology on a scale that is several orders of magnitude smaller than anything we have been used to. in fact, now that i think about it, this exciting new direction for radiology is almost enough to make me wish i wasn’t retiring at the end of the year ... almost. and that’s it, really. it’s all very well me exhorting you to take on this new area of practice – i’m at the end of my career, and won’t need to do any of the work myself. however, i am about to become a net consumer of healthcare for the first time in my adult life, so i may soon have a very direct vested interest in the competence and skill set of the next generation of radiologists! i should also say at this point that, having visited your wonderful country for the first time a couple of years ago and fallen in love with it, i shall be available from the end of 2010 for expenses-paid lecturing tours of the wine-producing areas of sa, preferably during your summer months. just don’t ask me to lecture on mi. 1. clin radiol 2010;65:499-582. 2. mankoff da. a definition of molecular imaging, j nucl med 2007;48(6):18n-21n. 3. gillies rj, anderson ar, gatenby ar, morse dl. the biology underlying molecular imaging in oncology: from genome to anatome and back again. clin radiol 2010; 65:517-521. bob bury editor-in-chief clinical radiology sajr bigger and quicker the south african journal of radiology has, under the excellent leadership of jan lotz, exceeded all expectations and is growing exponentially, with the development of a backlog of accepted manuscripts awaiting publication. we are pleased to announce that, through generous sponsorship by philips medical systems via an ongoing commitment to the rssa cpd programme, the size of the journal has been increased. the increase in page count will facilitate a reduction in the waiting time to publication. the increased capacity of the sajr assumes additional significance in the light of new requirements for the registration of specialists in south africa. the most significant point is the appointment of the colleges of medicine of south africa (cmsa) as the executor of a single exit exam for all registrars entering from 1 january 2011 and the requirement of completion of a research component for registration as specialists. the rssa’s contribution through the sajr to produce a number of bumper issues will allow increased mmed publications. clive sperryn president, rssa original article original article 86 sa journal of radiology • december 2009 original article abstract background. mammography aims to obtain mammograms of the best possible image quality with the least possible radiation dose. theoretically, an increase in breast compression gives a reduction in thickness without changing the density, resulting in improved image quality and reduced radiation dose. aim. this study investigates the relationship between compression force, phantom thickness, image quality and radiation dose. the existence of a compression point beyond which increased compression gives a change in density rather than thickness is also considered. method. image quality is assessed with a contrast-detail phantom within superflab phantom on a computed radiography (cr) mammography unit using automatic exposure control (aec). image quality is determined by visual inspection and image quality figure (iqf) scoring. the effect of compression and lesion depth on image quality is determined. entrance and exit doses are calculated. the relationship between entrance dose, compression and thickness is investigated, as is the existence of a compression point beyond which a change in phantom density occurs. the average glandular dose (agd) is calculated from the scanning average level (sal) and logarithmic mean (lgm) and compared with the allowable limit. results. the geometry effect was not observed. an improvement in image quality with increased compression was found. entrance dose decreased with increased compression. this trend was not observed with exit dose as aec was used and exit dose was calculated from sal values. the ‘change-in-density’ point of compression was determined. both lgm and sal could be used successfully for agd calculation. introduction the main method of achieving increased image quality and reduced radiation dose is by compression, which spreads out overlapping tissues,1 gives immobilisation of the breast and decreases exposure time, thus reducing movement. it also decreases breast thickness, whereby the breast dose is reduced. reduction of the breast dose is important, as the risk of carcinogenesis in the breast is cumulative and directly related to the absorbed breast dose.2 improvement of image quality gives better visualisation of small lesions and therefore leads to earlier malignancy detection. according to poulos et al.,3,4 there exists a point beyond which an increase in compression of the breast does not give spreading of the tissues but rather a change in breast density. compression beyond this point holds no diagnostic advantage and only contributes to patient discomfort. the existence of this point is investigated using the superflab phantom to a maximum compression of 18 decanewtons (dan) by using equation 1, where io is the entrance dose, i is the exit dose, µ is the attenuation coefficient and t is the thickness. (1) if the natural logarithm of is plotted against thickness t, the slope of the graph is µ and thus a change in the slope of the graph implies a change in µ, which is indicative of a change in density. with the contrast-detail phantom, image quality is investigated both visually and by image quality figure (iqf) scoring. contrast is determined in terms of object diameter by detecting pairs of low-contrast objects. the scoring is done according to equation 2.5 (2) where iqf is the image quality figure, ci is the radiation contrast for the ith column and di,min is the threshold diameter in the i th contrast column. according to koen et al.,6 the average glandular dose (agd) can be calculated from the scanning average level (sal) and logarithmic mean (lgm) using equations 3 and 4. (3) (4) the agd must be less than 3 mgy per exposure, according to the american college of radiology (acr) manual.7 material and method a ge senographe unit was used. quality assurance of the unit was done according to the specifications in the acr manual before the study was conducted. breast dose was affected by the tube voltage (kvp) and the currenttime product (mas).5 these factors were selected by using automatic exposure control (aec) as this was most commonly used in the facility. a phantom of superflab with uncompressed thickness of 60 mm and a minimum thickness of 44 mm was used. this thickness and matethe relationship between compression force, image quality and radiation dose in mammography a korf, bmedsc (hons) c p herbst, phd w i d rae, mb chb, phd department of medical physics, university of the free state, bloemfontein the relationship between.indd 86 11/19/09 2:26:24 pm original articleoriginal article 87 sa journal of radiology • december 2009 rial was selected, as it was comparable to the average compressed and uncompressed thickness of a moderately sized breast. compressing the superflab to 0, 5, 10, 15 and 18 dan and noting the displayed thickness on the mammography unit and actual thickness measured with a ruler, tested the accuracy and reproducibility of the thickness of the superflab at different compressions. measurements were made 3 times at each compression force. a graph of kv versus mr/mas was plotted for the calculation of entrance dose from exposure parameters. for this, the kv was varied from 30 40 kv and the mas was set to 20 mas. a nero max detectable i. superflab thickness accuracy and reproducibility at different compression forces applied compression force (dan) 0 5 10 15 18 displayed thickness (mm) 60 59 60 50 49 50 48 47 47 46 45 45 45 45 44 actual thickness (mm) 58 57 58 49 48 49 48 48 48 47 46 46 43 44 44 average displayed thickness (mm) 60 50 47 45 45 average actual thickness (mm) 58 49 48 46 44 displayed thickness standard deviation (mm) 0.6 0.6 0.6 0.6 0.6 actual thickness standard deviation (mm) 0.6 0.6 0.0 0.6 0.6 difference between displayed and actual averages (mm) 2.0 1.0 0.7 1.0 1.0 standard deviation in difference (mm) 0.8 0.8 0.6 0.8 0.8 t-test result for displayed and actual thickness 0.01 0.10 0.18 0.10 0.10 table ii. entrance and exit dose calculation parameters entrance dose parameters kv mas mr mr/mas target/filter 30 20 1342 67.1 rh/rh 31 20 1471 73.6 rh/rh 32 20 1589 79.5 rh/rh 33 20 1729 86.5 rh/rh 34 20 1870 93.5 rh/rh 35 20 2012 100.6 rh/rh 36 20 2153 107.7 rh/rh 37 20 2297 114.9 rh/rh 38 20 2443 122.2 rh/rh 39 20 2594 129.7 rh/rh 40 20 2747 137.4 rh/rh exit dose parameters kv mas mr exit dose (mgy) sal (arb. unit) target/filter 31 12.5 0.1 7.0e-04 436 rh/rh 31 14.0 0.1 8.0e-04 458 rh/rh 31 16.0 0.1 9.0e-04 489 rh/rh 31 18.0 0.1 1.1e-03 523 rh/rh 31 20.0 0.1 1.1e-03 548 rh/rh 31 22.5 0.1 1.3e-03 578 rh/rh 31 25.0 0.2 1.4e-03 607 rh/rh 31 28.0 0.2 1.7e-03 651 rh/rh 31 32.0 0.2 1.8e-03 688 rh/rh 31 36.0 0.2 2.1e-03 743 rh/rh 31 40.0 0.3 2.3e-03 774 rh/rh 31 45.0 0.3 2.6e-03 821 rh/rh the relationship between.indd 87 11/19/09 2:26:25 pm original article original article 88 sa journal of radiology • december 2009 original article tor was used for the measurements on the bucky, i.e. at breast level. the mr/mas was found to be linear over the range of 5 320 mas. the exit dose was determined by obtaining the scanning average level (sal) values of images at different mas settings, from 12.5 45 mas, at 31 kv, with a 5 cm perspex attenuator in the beam. dose measurements were done with a fluke biomedical 451 victoreen ionisation chamber survey meter. a perspex thickness of 5 cm was selected as this was almost equivalent to an average 6 cm-thick breast, taking density into account. the 5 cm of perspex reduced the amount of radiation incident on the detector in order to achieve a linear relationship between sal and exit dose. exit dose was then determined from the sal of an image using this relationship. with the contrast-detail phantom at a depth of 6 cm (i.e. the theoretically best geometrical location), aec exposures for entrance and exit dose calculations were made at compressions of 3 18 dan. the relationship between the calculated entrance dose and phantom thickness, and that between compression force and phantom thickness, were graphically investigated for the superflab phantom. the existence of a compression force point beyond which an increase in compression gave a change in density was examined using equation 1. an artinis contrast detail mammography (cdmam)-phantom type 3.4 was used for image quality assessment. the phantom was placed at 0, 2, 4 and 6 cm uncompressed depth in the superflab for determination of the influence of object depth on image quality, i.e. the geometry effect. at each depth, aec was used for exposure parameter selection, and different compression forces (3, 10 and 14 dan) were applied. geometry effect assessment was done by image quality figure (iqf) scoring of the images at different phantom depths and a constant compression force of 14 dan. scoring the images obtained at a depth of 6 cm at different compressions assessed the relationship between image quality and compression force. scoring was done according to equation 2, and results were compared with theory. fig. 1a (above). entrance dose calculation from kv, mas and entrance exposure. fig. 1b (below). exit dose calculation from sal. table iii. contrast-detail phantom imaging parameters image number imaging parameters exposure parameters lgm (arb. units) sal (arb. units) phantom depth (cm) compression force (dan) phantom thickness (mm) kv mas target/filter 1 0 3 54 32 238 rh/rh 2.14 1165 2 0 10 50 32 220 rh/rh 2.17 1202 3 0 14 47 32 211 rh/rh 2.16 1181 4 2 3 54 32 241 rh/rh 2.16 1151 5 2 10 49 32 222 rh/rh 2.14 1164 6 2 14 47 32 213 rh/rh 2.15 1160 7 4 3 53 32 236 rh/rh 2.17 1180 8 4 10 49 32 223 rh/rh 2.16 1164 9 4 14 47 32 218 rh/rh 2.16 1154 10 6 3 55 32 242 rh/rh 2.16 1149 11 6 10 49 32 222 rh/rh 2.19 1191 12 6 14 47 32 209 rh/rh 2.16 1152 average 2.16 1168 standard deviation 0.01 16.34 the relationship between.indd 88 11/19/09 2:26:26 pm original articleoriginal article 89 sa journal of radiology • december 2009 image quality was visually inspected for the 12 films of the superflab phantom. the images were ranked from best to worst. the results obtained were compared with the iqf results and with what was expected from theory. the images obtained on the agfa cr mm3.0 mammo cr plates were read with an agfa cr 85-x reader, and the sal was obtained in a 10x10 cm2 region of interest positioned 4 cm from the chest wall edge and centred laterally. the lgm was automatically calculated for each exposure. the sal and lgm were used to calculate the agd according to equations 3 and 4. the results were compared with the adg limit of 3 mgy per exposure.7 with each exposure, the kvp, mas, target/filter combination, sal, lgm, compression force and displayed phantom thickness were noted. results the accuracy and reproducibility of the thickness of the superflab at different compressions was investigated and the results noted in table i. the results for entrance and exit dose calculation are shown in table ii. fig. 1a was plotted from the entrance dose data in table ii, and fig. 1b shows the relationship between exit dose and sal. the contrast-detail phantom was imaged in the superflab at different depths and compressions, and the results tabulated in table iii. an example of the images that were obtained is shown in fig. 2. the 12 films of the superflab phantom were ranked visually. image 1 was the theoretically best image, i.e. the image obtained with the contrast-detail phantom at 6 cm depth and a 14 dan compression force. image 12 was the theoretically worst image, i.e. with the phantom at 0 cm depth and 3 dan compression. the theoretical classification of the images, the visual ranking positions and the iqf scoring results appear in table iv. the stability of the lgm and sal values of the different images was investigated statistically and the results shown in table iii. the geometry effect was assessed by looking at the image quality at a certain compression force (14 dan) at different phantom depths, i.e. 0, 2, 4 and 6 cm. the relationship between image quality and compression force was investigated by considering image quality at a certain depth, i.e. 6 cm, for different compression forces, i.e. 3, 10 and 14 dan. this is shown in fig. 3 in terms of the iqf of the different images. for the dosimetry analysis, the exposure parameters and results were recorded in table v. here, the equation of the quadratic fit on fig. 1a and the aec kv and mas were used to calculate the entrance exposures in mr, which was converted to entrance dose. the agd values calculated with equations 3 and 4 were compared statistically. the comparison is included in table v. the relationship between entrance dose and phantom thickness, and the correlation between compression force and phantom thickness, are shown in fig. 4. a graph of the natural logarithm of the quotient of the exit dose by the entrance dose against the thickness of the phantom (see fig. 5a) was used to determine the ‘change-in-density’ point where an increase in compression resulted in changed density. fig. 5b shows a plot of the slope (i.e. µ) of fig. 5a. the agd values calculated with equations 3 and 4 were compared statistically. the results are set out in table v. fig. 2. cdmam superflab phantom image. fig. 3. iqf scoring demonstrating the geometry effect, compression force and image quality relationship. fig. 4. entrance dose and compression force. the relationship between.indd 89 11/19/09 2:26:28 pm original article original article 90 sa journal of radiology • december 2009 original article discussion table i indicates that the thickness of the superflab, as displayed on the unit and measured with a ruler, was accurate and reproducible. standard deviations were very small. there was no significant difference between the actual and displayed thickness values. the t-test results showed that the null hypothesis (i.e. that the actual and displayed thickness values were the same) could not be rejected with authority. the displayed thickness was therefore used for the rest of the study. theoretically, the sal and lgm values should remain similar for different exposures when aec is used. we found that the values were tightly grouped around the mean values, i.e. the standard deviations were small, as shown in table iii. table iv. different superflab phantom image classifications imaging parameters theoretical classification position visual inspection classification position iqf scoring positionimage number compression force (dan) phantom depth (cm) 12 14 6 1 2 1 11 10 6 2 6 8 10 3 6 3 10 12 9 14 4 4 4 3 8 10 4 5 8 5 7 3 4 6 12 9 6 14 2 7 1 4 5 10 2 8 5 10 4 3 2 9 9 11 3 14 0 10 3 2 2 10 0 11 7 7 1 3 0 12 11 6 table v. dosimetry analysis results compression force (dan) kv mas phantom thickness (mm) calculated mr/mas calculated entrance exposure (mr) calculated entrance dose, io (mgy) calculated exit dose, i (mgy) ln (i/io) (arb. units) lgm from image sal from image ln(i/io)/ phantom thickness (arb. units) agd (mgy) from lgm agd (mgy) from sal 3 32 247 57 79.9 19736.3 179.8 3.26e-03 10.9 2.15 952 0.19 1.8 1.3 4 32 240 56 79.9 19177.0 174.7 3.16e-03 10.9 2.13 932 0.20 1.7 1.2 5 32 236 55 79.9 18857.4 171.8 3.16e-03 10.9 2.12 932 0.20 1.7 1.2 6 32 235 54 79.9 18777.5 171.1 3.18e-03 10.9 2.12 935 0.20 1.7 1.2 7 32 232 53 79.9 18537.8 168.9 3.22e-03 10.9 2.12 944 0.21 1.7 1.3 8 32 223 52 79.9 17818.6 162.3 3.16e-03 10.8 2.11 932 0.21 1.6 1.2 9 32 222 51 79.9 17738.7 161.6 3.21e-03 10.8 2.11 942 0.21 1.6 1.3 10 32 221 51 79.9 17658.8 160.9 3.16e-03 10.8 2.11 931 0.21 1.6 1.2 11 32 221 50 79.9 17658.8 160.9 3.29e-03 10.8 2.12 957 0.22 1.7 1.3 12 32 215 50 79.9 17179.4 156.5 3.25e-03 10.8 2.11 950 0.22 1.6 1.3 13 32 213 50 79.9 17019.6 155.0 3.14e-03 10.8 2.10 928 0.22 1.6 1.2 14 32 211 49 79.9 16859.8 153.6 3.25e-03 10.8 2.12 949 0.22 1.7 1.3 15 32 205 49 79.9 16380.4 149.2 3.18e-03 10.8 2.10 936 0.22 1.6 1.3 16 32 204 48 79.9 16300.5 148.5 3.25e-03 10.7 2.11 950 0.22 1.6 1.3 17 32 207 48 79.9 16540.2 150.7 3.28e-03 10.7 2.12 955 0.22 1.7 1.3 18 32 202 47 79.9 16140.6 147.0 3.25e-03 10.7 2.12 969 0.23 1.7 1.3 average 1.7 1.3 standard deviation 0.05 0.03 t-test result for agd 3.8e-21 the relationship between.indd 90 11/19/09 2:26:29 pm original articleoriginal article 91 sa journal of radiology • december 2009 table iv demonstrates that visual classification of the images yielded no well-defined pattern. the images were not ranked according to what was expected from theory, which meant that distinct variations in image quality between the 12 images were not seen, and implied that increased compression and lesion depth did not influence visual image quality to a great extent. one would expect that image quality should improve as the contrast-detail phantom was placed closer to the image receptor, owing to the geometry effect. the quality should also be better with greater compression force. when the iqf of the superflab phantom was considered, fig. 3 indicated that the compression force did affect image quality considerably. on the figure, groups of images were distinguished, i.e. images 1 3, 4 6, 7 9 and 10 12, as obtained with the contrast-detail phantom at a depth of 0, 2, 4 and 6 cm respectively. within a group, the images were acquired at 3, 10 and 14 dan compression. for all the image groups, the iqf of the images became smaller as the compression force was increased; thus, the image quality improved. however, when the images obtained at a certain compression force at different depths of the contrast-detail phantom were compared, such a trend was not observed. the geometry effect was thus not shown. this result was in accordance with that of poulos et al. who showed that if minimisation of breast thickness were not done, image quality would be compromised and the potential to miss small lesions would increase.4 the quadratic relationship between kv and mr/mas (or dose) of fig. 1a was used to calculate the entrance exposure mr at a certain kv and mas. a roentgen-to-rad conversion factor of 0.911, as recommended by khan,8 was used. the peak energy of the beam was 31kev, therefore the average energy was approximately a third, i.e. 10kev. according to khan, one roentgen equalled 0.911 rad in water at this average energy. this answer was multiplied by 10 to convert to mgy. the correspondence between exit dose in mgy and the sal of an image was obtained from the fig. 1b equation. fig. 4 demonstrates that entrance dose decreased as phantom thickness decreased, i.e. as compression force was increased, which was a main argument in increasing compression as much as possible. increased compression gave reduced phantom thickness; however, continuous spreading of phantom tissue was not achieved and density was changed. this was further indicated in fig. 5. the point of compression beyond which the density of the phantom was changed, with decreased tissue spreading, can be determined from fig. 5. from the equation of a straight-line graph, µ was the gradient, and it should have remained constant if continuous spreading of tissues and reduction in phantom thickness was achieved without changing the density. this implied that fig. 5a should have been a linear graph and fig. 5b a horizontal line graph. it was therefore clear that a ‘change-indensity’ compression point did exist and that the density of the superflab changed with increased compression. poulos et al.3 advised that compression should only be applied until the minimum breast thickness was achieved and not beyond that point, and that a large number of women did not have a change in breast thickness with reduced compression; this implied no benefit with increased discomfort. we made the same finding in this study. the calculated agd values in table v were relatively stable for each method of calculation, but the results of the two calculation methods differed somewhat. however, the t-test proved that the null hypothesis that the agd calculated with the sal and lgm were the same could not be rejected with confidence. the agd values were also closely grouped around the mean value, showing that the dose with aec stayed repeatedly constant. all the calculated agd values were less than the limit of 3 mgy. with the superflab phantom, visual arrangement and iqf scoring of images obtained at different compression forces did not rank the images according to theoretical predictions. lesion detection would be improved with increased compression for a lesion situated at a certain depth. we found that lesions or calcifications situated closer to the image receptor did not have a better chance of being detected owing to the geometry effect. the aim in mammography should be minimisation of breast thickness rather than maximisation of breast compression.6 in our study, it was shown that minimisation of phantom thickness resulted in improved image quality, increased chance of detection of small lesions, and reduced radiation dose. increasing compression gave reduced phantom thickness up to a point after which no image quality benefits were achieved, entrance dose still decreased, and patient discomfort fig. 5. determining compression ‘change-in-density’ point. fig. 5a (above): phantom thickness versus ln (i/io) with µ the slope of the graph. fig. 5b (below): line graph of µ. the relationship between.indd 91 11/19/09 2:26:31 pm original article original article 92 sa journal of radiology • december 2009 increased. this was an important finding because discomfort and pain discourage women from having regular mammograms. by not overcompressing a breast beyond the ‘change-in-density’ point, pain could be reduced without much reduction in image quality. in response to the aim of our study, we found that a trade-off existed between increased compression force, reduced phantom thickness, improved image quality, reduced radiation dose, and increased patient discomfort. early lesion detection remained the primary objective; therefore, from the results of this study, it is recommended that breast compression is done up to the point of maximum displacement of breast tissue, but not beyond. we also concluded that less compression was acceptable, without a significant reduction in visual image quality, if the woman was uncomfortable or experienced pain. the primary goal of compression is reduction in breast thickness, which leads to reduced scatter and in turn better image quality. reduced radiation dose is a secondary benefit. with the superflab phantom, we found that entrance dose continued to decrease although image quality was not improved when the density of the phantom was changed. if reduced dose were the primary objective of compression, maximisation of compression would have been the aim, but image quality was the main aim and therefore minimisation of breast thickness is recommended. we thank the personnel of the mammography division of the diagnostic radiology department at universitas hospital, bloemfontein, for accommodating our study. 1. saunders rs, samei e. the effect of breast compression on mass conspicuity in digital mammography. med phys 2008; 35(10): 4464-4473. 2. brnić z, hebrang a. breast compression and radiation dose in two different mammographic oblique projections: 45 and 60 o . eur j radiol 2001; 40(1): 10-15. 3. poulos a, mclean d, rickard m, heard r. breast compression in mammography: how much is enough? australas radiol 2003; 47: 121-126. 4. poulos a, mclean d. the application of breast compression in mammography: a new perspective. radiography 2004; 10(2): 131-137. 5. thijssen mao, bijkerk kr, van der burght rjm. manual contrast-detail phantom artinis cdmam type 3.4. zetten, the netherlands: artinis medical systems b.v., 2007. 6. koen l, herbst cp, rae wid. computed radiography exposure indices in mammography. south african journal of radiology 2008; 28-31. 7. mammography quality control manual, revised ed. reston, usa: american college of radiology, 1994. 8. khan fm. the physics of radiation therapy. baltimore: lippincott williams and wilkens, 1984: 110-112. the relationship between.indd 92 11/19/09 2:26:31 pm case series 97 sa journal of radiology • december 2008 abstract the early detection of carcinoma is the high point of mammography. we present 2 patients with pathological diagnoses of dcis with unusual mammographic findings for which one needs to have a higher index of suspicion. the first patient presented with multifocal disease requiring biopsy of all visible lesions, and the second patient (a young woman) presented with segmental distribution of calcifications, which might have been missed had a single-view baseline mammogram not been done. introduction one of the main objectives of mammography and breast ultrasound is the early detection of cancer and the correct, individualised management of the disease thereafter. therefore, it is important to bear in mind that ductal carcinoma in situ (dcis) may present with multifocal or multicentric disease (as demonstrated in our first case), which implies that all visible lesions should be biopsied and that it is necessary to consider doing a single-view baseline mammogram in young patients with breast disease so that abnormal calcification patterns are not missed (highlighted in our second case). case 1 a 51-year-old woman was referred to us by the surgery department with a history of a right-breast mass since november 2006. she was referred for a mammogram and biopsy of the lesion. previous biopsies of the mass had been attempted but were unsuccessful. she had had 3 children and breast-fed each of them. she was currently on occasional anti-inflammatory medication for back pain and was perimenopausal. there was neither a previous history of cancer nor family history of cancer. on examination, her vital signs, and general, cardiovascular and respiratory functions were normal. she had no thyroid enlargement. examination of her breasts revealed a small mass in the right outer, lower quadrant. the mass was firm but mobile and approximately 1.5 × 1.5 cm in size. imaging the mammogram (fig. 1) demonstrated 3 distinct lesions in the right upper, outer quadrant of the right breast. lesion a is the most lateral lesion and demonstrates a cluster of calcifications of heterogeneous shape and density and an associated moderately dense mass with an irregular margin and some architectural distortion. the lesion was not clinically palpable, and was suspect for malignancy. lesion b demonstrated scattered, well-circumscribed round-to-oval calcifications and a region with similar calcifications clumped together. these calcifications had a similar density and regular margins but varied in size. there were associated moderate densities which were well circumscribed with minimal architectural distortion. this lesion was not clinically palpable. lesion c demonstrated a heterogeneously dense lesion with irregular margins and mild architectural distortion. there were 4 calcifications of different sizes, with regular margins associated with the mass. this lesion was clinically palpable. biopsies were taken of each lesion. the histological analyses confirmed dcis in all 3 lesions. solid, micropapillary and comedo types were present in all 3 biopsies. there were small foci of invasive cancer in specimens a and c. case 2 a 27-year-old woman presented with a 2-week history of a right nipple discharge which was intermittently bloody but mostly cream in colour. also, a mass was present in the 3 o’clock position, which had first been noticed 2 weeks prior to the onset of the discharge. she had no children, no significant medical or surgical history and no history of cancer or family history of cancer. she had a normal menstrual cycle and was on an injectable contraceptive. on examination, her vital signs, and unusual mammography findings in patients with ductal carcinoma in situ (dcis) of the breast f ismail, mb bch j höll, mb chb, ffrad (d) z lockhat, fcrad (d) sa department of radiology, pretoria academic hospital, university of pretoria h j akande, mb bs, fmcr (nigeria) department of radiology, university of ilorin, nigeria fig. 1. three lesions in the right outer, upper quadrant of the right breast (labelled a, b, c). c b a unusual.indd 97 12/5/08 11:59:22 am case series case series 98 sa journal of radiology • december 2007 case series 98 sa journal of radiology • december 2008 general, cardiovascular and respiratory functions were normal. she had no thyroid enlargement. a mass was not palpable, but a change in the consistency of the breast was noted in the 3 o’clock position. an ultrasound scan was performed which did not demonstrate any mass but a change in the breast architecture. a single discharging duct appeared to be present. the discharge was sent for cytological evaluation. a ductogram showed obstruction of the duct. a single-view baseline mammogram was done (fig. 2) that showed segmental diffuse increased density of the glandular breast tissue and segmental diffuse calcifications of heterogeneous size, shape and density. there were areas of clustering of the calcifications, and the pattern was highly suggestive of malignancy. cytological examination of the nipple discharge demonstrated atypical cells. a stereotactic biopsy was then performed. histological analysis of the specimen demonstrated extensive dcis (comedo type). discussion our first case highlights two important points about dcis. the first is that non-palpable lesions may exist concurrently with palpable lesions; mammography is an important tool in this regard and has huge implications for further management of the patient, i.e. mastectomy, wide-excision breast-conserving surgery (bcs) plus radiotherapy or bcs alone. it is also important that, as radiologists, we have a high index of suspicion for multicentric and multifocal disease and therefore need to perform a biopsy on every visible lesion. multifocal lesions are defined as multiple lesions occurring in the same quadrant. multicentric lesions occur in different quadrants of the same breast. bilateral cancers are synchronous when diagnosed at the same time or within 6 months of each other, and metachronous when they occur bilaterally at different times, i.e. more than 6 months apart.1 the incidence of multicentric disease varies but may be as high as 33 50%.1 in patients under the age of 40, ultrasound is more beneficial than mammography owing to the increased density of breast tissue. in young patients, especially those without a breast mass, abnormal calcification patterns may be missed on ultrasound. we therefore advocate a singleview baseline mammogram to exclude this presentation. in our second case, had this not been done, we might not have elected to perform a biopsy. the most common mammographic finding of dcis is calcifications that are characteristically rod-shaped and branching with a ductal distribution.1 the next most common is a spiculated or lobulated mass or architectural distortion. patients may also present with a palpable mass or spontaneous nipple discharge. features that are important when evaluating calcifications are:1 1. form, i.e. are they round, oval or linear in shape, or do they have no specific shape (amorphic) or do they change shape (pleomorphic)? 2. sizes of the microcalcifications, i.e. are they large calcifications or small punctuate calcifications and do they demonstrate homogenous or heterogeneous size? 3. distribution, i.e. are they clustered together or sporadic, or are they distributed in a particular pattern, e.g. in a breast segment or along a duct? 4. density of the calcifications, i.e. are they homogenous or heterogeneous in density, and is the density high or low? 5. margin – calcifications with irregular margins are more likely to be malignant. some studies have also propounded the number of calcifications within a cluster as an important tool in determining the potential of malignancy. one study showed that a cluster with ≥35 calcifications had a positive predictive value of 83% for malignancy.2 other authors did not find that the number of calcifications in a cluster was helpful in their studies.2 a study by yunus et al. showed that the number of microcalcifications (mcs) per cm2 of a cluster was nonspecific, as malignancy could not be excluded even if there were <10 mc/cm2. they also suggested that other nonspecific criteria for malignancy were the total number of mcs and the heterogeneity of the mcs. factors that were more specific for malignancy included the linear, branched and vermicular shape of mcs (le gal type 5) and irregularity in size and density of mcs.3 diffuse, randomly distributed calcifications are usually associated with benign breast disease. however, if the calcifications are wild, profuse and chaotic and have irregular, heterogenic shape, then diffuse breast cancer should be considered.3 this is probably secondary to dcis, comedo type, which usually presents in older patients. this was the presentation of the second patient; however, she was only 27 years old. the presence of calcifications on ultrasound, which is then correlated with mammography, has also been shown to be useful in determining malignancy in calcifications that are not sonographically benign (bi-rads 2).4 fig. 2. a left medio-lateral oblique view demonstrating segmental diffuse increased density of the breast tissue and segmental diffuse pleomorphic calcifications of heterogeneous size, shape and density. unusual.indd 98 12/5/08 11:59:24 am case seriescase series 99 sa journal of radiology • december 200799 sa journal of radiology • december 2008 conclusion as dcis may present with multicentric or multifocal disease, biopsies of all presenting lesions should be undertaken as this will influence further management of the patient, i.e. mastectomy, wide-excision bcs plus radiotherapy or bcs alone. in patients under the age of 40, ultrasound is still the investigation of choice, but a single baseline medio-lateral oblique mammogram view of the affected breast should be performed to exclude any abnormal calcification patterns as these may be missed on ultrasound. this is especially important if no clinical mass is present and also because the incidence of breast cancer in younger females is increasing. 1. cardenosa g. breast imaging, the core curriculum. philadelphia, usa: lippincott, williams & wilkins, 2004: 239-280. 2. fondrinier e, lorimer g, guerin-boblet v, bertrand a-f, mayras c, dauver n. breast microcalcifications; multivariate analysis of radiological and clinical factors for carcinoma. world j surg 2002; 26: 290 -296. 3. yunus m, ahmad n, masroor i, yaqoob j. mammographic criteria for determining value of microcalcifications in the detection of early breast cancer. j pak med assoc 2004; 54(1): 24-29. 4. hashimoto be. sonographic assessment of breast calcifications. curr probl diagn radiol 2006; 35: 213-218. sama member price: r325.00 sama price: r375.00 p l e a s e c o n t a c t e d w a r d m a c d o n a l d : te l : 0 2 1 6 5 7 8 2 0 0 f a x : 0 8 6 6 0 0 6 2 1 8 e m a i l : e d w a r d m @ h m p g . c o . z a guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agentsmusculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines.the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. university of cape town the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn ����������������� ����������������� samf south african medic ines fo rmular y produc ed by t he divi sion of clinica l pharm acolog y, faculty of hea lth scie nces, u niversit y of ca pe tow n. publish ed by t he hea lth and medic al publ ishing g roup of the s outh af rican m edical a ssociat ion. 8 s a m f s o u th a fric a n m e d ic in e s f o rm u la ry samf advert 2008.indd 1 4/11/08 12:29:34 pm 681 7225 unusual.indd 99 12/5/08 11:59:25 am 122 sa journal of radiology • december 2010 signs case history a 9-month-old girl presented with a 1-month history of coughing. a chest x-ray (cxr) was performed, and the antero-posterior view demonstrated the hilum overlay sign. furthermore, there was absence of the azygo-oesophageal line and bilateral paraspinal lines. the lateral cxr revealed a posterior mediastinal mass. subsequently, a computed tomogram of the chest confirmed a posterior mediastinal mass, with calcifications and intraspinal extension consistent with neuroblastoma. histological analysis confirmed this mass as a neuroblastoma. the sign felson described the hilum overlay sign as the visualisation, on a frontal x-ray, of the first bifurcation of either the left or right pulmonary artery more than 1 cm medial to the lateral edge of the cardiac shadow. this is highly suggestive of a mediastinal mass.1,2 the hilum overlay sign is present on a frontal chest radiograph when normal hilar structures can be visualised through a mass, which implies that the mass is either anterior or posterior to the hilum.3 the presence or disruption of mediastinal lines may further aid in the localisation of the hilum overlay sign in a child m j van wyk, mb chb n mahomed, mb bch, fcrad (diag) (sa) department of diagnostic radiology, chris hani baragwanath hospital and university of the witwatersrand, johannesburg fig. 1. ap cxr demonstrates the hilar overlay sign, with normal hilar structures visualised through the mass, and the absence of the azygooesophageal and bilateral paraspinal lines. fig. 2. lateral cxr confirms a posterior mediastinal mass. fig. 3. post-contrast axial chest ct at the level of the mediastinum demonstrates a poorly enhancing, predominantly right sided, posterior mediastinal mass with calcification and right neural foramen extension. sa journal of radiology • december 2010 123 signs the mass. the absence of the paraspinal and azygo-oesophageal lines suggests that a mass is located in the posterior mediastinum. the sign also enables us to distinguish a mediastinal mass from a prominent cardiac silhouette.4 a typical posterior mediastinal mass displaying the hilum overlay sign is neurogenic in origin in the majority (88%) of cases.5 when there is calcification or adjacent bony erosion on a radiograph, it is highly suggestive of neuroblastoma.5,6 it may displace and invade adjacent structures and may even cross the midline.6 most (70 90%) neuroblastomas usually occur in the first 5 years of life.5,6 1. felson b. the mediastinum. semin roentgenol 1969;4:41-58. 2. felson b. more chest roentgen signs and how to teach them. annual oration in memory of l henry garland, m.d., 1903-1966. radiology 1968;90:429-441. 3. whitten cr, khan s, munneke gj, grubnic s. a diagnostic approach to mediastinal abnormalities. radiographics 2007;27:657-671. 4. lesslie m, chasen mh, munden rf. imaging of the mediastinum in oncology. applied radiology 2007;36(1): 8-19. 5. merten df. diagnostic imaging of mediastinal masses in children. ajr 1992;158:825-832. 6. strollo dc, rosado-de-christenson ml, jett jr. primary mediastinal tumors part ii: tumors of the middle and posterior mediastinum. chest 1997;112:1344-1357. guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agents musculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines. the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn ���������������������������������� s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition � ninth edition produced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f the essential reference for ever y healthcare professional! the carefully and thoroughly updated 9th edition of the south african medicines formulary (samf) can now be ordered. it is your essential reference to rational, safe and cost-efficient use of medicines. that is why you should not prescribe without it. the newly published samf provides easy access to the latest, most scientifically accurate information – including full drug profiles, clinical notes and special prescriber’s points. the convenient pocket-size design enables you to fit it comfortably into your bag or hospital coat pocket – always at hand for ready reference. w h y yo u s h o u l d n ’ t b e w i t h o u t t h e s a m f 9 t h e d i t i o n the new 9th edition of samf provides expanded information on key issues facing south african healthcare professionals today, including antiretrovirals, tb treatment guidelines, management guidelines for asthma and chronic heart failure, other common chronic conditions and prescribing in sport. • it presents practical, new approaches to the management of venomous bites and stings. • it outlines extensively the acute adverse reactions to drugs of abuse, and their management. • it features new as well as existing drugs, indexed by both trade and generic names. • it offers fresh insights into informed prescribing and carries cautionary guidelines on drug interactions and a range of special risk patients and conditions. and, as always, you can rely on... • the professional compilation and editing by a team from the division of clinical pharmacology, uct • an independent and unbiased guide on prescribing in south africa today • the indication of agents included in the sa and who essential drug lists • support of the sa national drug policy • guidance for prescribing during pregnancy and lactation, and in patients with porphyria, liver disease and renal impairment (including tables with drug dosage adjustments); and • indexed and page tabs for quick and easy access to each section. y o u r s a t i s f a c t i o n i s g u a r a n t e e d 3 e a s y o r d e r o p t i o n s : 1. phone edward or byron 021 6817000 2. fax the completed samf order form to 0866006218 3. email: edwardm@hmpg.co.za or byronm@hmpg.co.za guidance on prescribing alimentary tract and metabolism blood and blood-forming organs cardiovascular system dermatologicals genitourinary system and sex hormones systemic hormonal preparations general anti-infectives for systemic use antineoplastic and immunomodulating agentsmusculoskeletal system central nervous system antiparasitic products respiratory system sensory organs contrast media treatment of poisoning published by the south african medical association, the formulary is aimed at doctors, pharmacists, nurses, dentists and others concerned with the safe and cost-effective prescribing of medicines.the south african medicines formulary is researched and written by members of the division of clinical pharmacology of the university of cape town, in collaboration with health care professionals. the south african medical association, health and medical publishing group, private bag x1, pinelands 7430 isbn ����������������� ����������������� s o u th a fric a n m e d ic in e s f o rm u la ry ninth edition � ninth editionproduced by the division of clinical pharmacology, faculty of health sciences, university of cape town. published by the health and medical publishing group of the south african medical association. south african medicines formulary samf sam f untitled the patient, a 44-year-old woman from chris hani baragwanath hospital, was a para 5 gravida 5 post-menopausal woman, who had breastfed her children for 2 years in total. she was not on hormone replacement therapy. the patient was being treated for a pseudotumour of the right orbit as the computed tomography (ct) scan demonstrated a large right retrobulbar mass, as well as meningeal thickening. to ascertain a primary cause for the above picture, a mammogram (mmg) was done. the mmg demonstrated extensive bilateral patchy spiculated densities with associated amorphous microcalcifications, and axillary nodes (figs 1 and 2). ultrasound (us) demonstrated illdefined hypoechoic areas with scattered microcalcifications (fig 3). the patient had bilateral core biopsies done. the histological finding was that of bilateral invasive lobular carcinoma. 34 sa journal of radiology • december 2005 pictorial interlude lobular carcinoma of the breast – an unusual presentation m modi mb bch, fcrad(sa), mmed department of radiology chris hani baragwanath hospital university of the witwatersrand johannesburg fig. 2b. mammogram showing patchy spiculated densities. fig. 2a. mammogram showing microcalcifications. fig. 1a. mammogram showing amorphous microcalcifications. fig. 1b. mammogram showing nodes, microcalcifications and patchy spiculated densities. fig. 3. ultrasound scan transverse image of the right breast showing illdefined hypoechoic lesion and microcalcifications. case report-modi 11/25/05 12:32 pm page 34 case report case reportcase report abstract we report on a 12-year-old boy with a rare form of pulmonary valve atresia with a ventricular septal defect (vsd) and anomalous origin of the left pulmonary artery arising from the aortic arch. he also has an absent right pulmonary artery, the right lung being supplied by small major aorto-pulmonary collaterals (mapcas).1 he has decreased pulmonary blood flow to his right lung and increased pulmonary blood flow with irreversible pulmonary hypertension (pht) on the left. due to the late presentation, he was deemed inoperable due to the severe pht of the left lung.2 introduction pulmonary valve atresia with a vsd is an extreme form of tetralogy of fallot (tof).3 it usually presents in the neonatal period as a ductaldependent lesion and can be fatal without early surgical palliation.2 anomalous origin of either pulmonary artery branch from the aorta has been reported. the association of pulmonary atresia (pa) with anomalous origin of the left pulmonary artery and an absent right pulmonary artery is, however, a very rare occurrence.3-5 the best estimates of the relative frequency of pa-vsd are 2.5 3.4% of all congenital cardiac malformations.3,5-7 pa-vsd is slightly more prevalent in males than in females.3 case report we report on a 12-year-old boy who was referred to our cardiology service for evaluation due to his decreased effort tolerance, palpitations and coughing up of blood-stained sputum. clinical examination revealed an appropriately grown boy with no dysmorphic features. mild central cyanosis with oxygen saturation of 85% and digital clubbing were evident. his pulse rate was 90 beats/min. all his pulses were equally palpable but bounding in character. a wide pulse pressure with a blood pressure of 110/50 mmhg was present. there was cardiomegaly with the apex beat in the 5th left intercostal space, lateral to the mid-clavicular line. a loud, single second heart sound was audible and no murmur was present. there were no signs of congestive cardiac failure. chest radiography (fig. 1) revealed cardiomegaly (boot-shaped), with a cardiothoracic index (cti) >60%, and an absent pulmonary bay. there was differential perfusion with increased pulmonary blood flow to the left lung relative to the right, and volume loss of the right lung, with associated oligaemia and hyperinflation of the left lung with increased pulmonary vasculature. electrocardiography showed left atrial enlargement and left ventricular hypertrophy. echocardiography demonstrated pulmonary valve atresia with a large vsd. no main pulmonary artery segment could be visualised. the left pulmonary artery (lpa) branch arose directly from the aortic arch. unusual case of pulmonary valve atresia f j s steyn, mb chb n bellew, mb bch, da (sa) department of radiology, pretoria academic hospital and university of pretoria f takawira, mb chb, fc (paed), mmed (paed) department of paediatric cardiology, pretoria academic hospital and university of pretoria fig. 1. chest radiograph. � sa journal of radiology • april 2008 fig. 2. ct angiogram demonstrates the left ( ) as well as the hypoplastic right pulmonary artery ( ) originating from the aortic arch. note the overriding arterial trunk ( ) as well as the aberrant right pulmonary artery ( ). pg 8-9.indd 8 4/16/08 9:38:51 am case reportcase report no right pulmonary artery (rpa) branch could be visualised, and there were indications of multiple collateral arteries supplying the lungs. conventional pulmonary angiography confirmed an lpa arising from the aortic arch, with no lpa stenosis and presumed to be at systemic aortic pressure, supplying the left lung. there was a blind-ending stump of the rpa arising from the descending aorta, giving rise to a few small mapcas supplying the right upper lobe. the right lower lung was perfused by an additional collateral from the abdominal aorta. a pulmonary computed tomographic angiogram demonstrated a prominent overriding aortic outflow tract with a vsd and no pulmonary trunk. a large-calibre left pulmonary artery arose from the aortic arch. there was a hypoplastic right pulmonary artery arising from the proximal descending aorta, supplying the right upper lung zone. a hypoplastic right lung with a compensatory hyperinflated left lung was noted. an aberrant right pulmonary artery arising from the abdominal aorta at the origin of the superior mesenteric artery (sma) supplying the right lower lung zone was also demonstrated. discussion pa-vsd is a cyanotic congenital heart disease characterised by underdevelopment of the right ventricular (rv) outflow tract (i.e. subpulmonary infundibulum) with atresia of the pulmonary valve, a large vsd, and overriding of the aorta. in the past, this anomaly was termed pseudotruncus or truncus arteriosus type 4.1,5,8 pa-vsd demonstrates a wide spectrum of severity, depending on the degree of pulmonary artery development.2 pathologically, pa-vsd is frequently considered the most severe end of the spectrum of tof, but controversy exists as to whether pa-vsd and tof should be treated as two distinct entities.4-7 unlike pa-vsd, patients with the standard type of tof with pulmonary atresia have pulmonary arteries that are usually normal in size with normal peripheral pulmonary arborisation. in addition, systemic-to-pulmonary collateral vessels are not as well developed in patients with tof with pulmonary atresia as they are in patients with pa-vsd.4,6 our patient has a congenital cyanotic heart defect which is characterised by the rare combination of increased pulmonary blood flow to the left lung, with development of unilateral pulmonary hypertension, and decreased blood flow to the right lung, with under-perfusion of that lung.1,3,4 because of his late presentation, he already had significant pulmonary hypertension; therefore, surgical palliation was no longer feasible or advisable.2 this patient presented with an overriding aortic arch, vsd, pulmonary valve atresia, absent main pulmonary artery (mpa), and an lpa and a hypoplastic rpa arising from the aorta. the left lung was hyperinflated with increased pulmonary vasculature, and the right lung was hypoplastic with aberrant supply from the abdominal aorta. according to the classification of collett and edwards, this condition was classified as a type iv truncus arteriosus (pseudotruncus). it has been reclassified as pulmonary valve atresia with a vsd and mapcas by van praagh.5 the above-mentioned congenital heart disease represents less than 0.1% of all congenital heart diseases.3 congenital obstruction of the right ventricular outflow tract leads to hypoplasia of the pulmonary arteries and persistence or hypertrophy of the primitive arterial connections to the lungs. patients present with progressive dyspnoea and irreversible pulmonary hypertension. 1. allanby kd, brinton wd, campbell m, garnder f. pulmonary atresia and the collateral circulation to the lungs. guys hosp rep 1950; 99(2-3): 110-152. 2. bharati s, paul mh, idriss fs, et al. the surgical anatomy of pulmonary atresia with ventricular septal defect: pseudotruncus. j thorac cardiovasc surg 1975; 69(5): 713-721. 3. beauchesne lm, warnes ca, connolly hm, et al. prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies. j am coll cardiol 2005; 45(4): 595-598. 4. calder l, van praagh r, van praagh s, et al. truncus arteriosus communis. clinical, angiocardiographic, and pathologic findings in 100 patients. am heart j 1976; 92(1): 23-38. 5. van praagh r. editorial: classification of truncus arteriosus communis (tac). am heart j 1976; 92(2): 129-132. 6. mair dd, julsrud pr. diagnostic evaluation of pulmonary atresia and ventricular septal defect: cardiac catheterization and angiography. prog pediatr cardiol 1992; 1(1): 23-36. 7. somerville j. management of pulmonary atresia. br heart j 1970; 32(5): 641-651. 8. d'udekem y, alphonso n, norgaard ma, et al. pulmonary atresia with ventricular septal defects and major aortopulmonary collateral arteries: unifocalization brings no long-term benefits. j thorac cardiovasc surg 2005; 130(6): 1496-1502. � sa journal of radiology • april 2008 pg 8-9.indd 9 4/16/08 9:38:51 am contents tib abstract hydatid disease is endemic to south africa. radiological findings may help establish the diagnosis and aid preoperative preparation. unusual locations and atypical imaging appearances may complicate the differential diagnosis. a case of isolated hydatid disease mimicking choledochal cyst is presented. primary hydatid disease of the pancreas in the paediatric population is rare and this is only the sixth case reported in the english literature. this article highlights the importance of always considering hydatid disease in our patient population whenever a cystic mass of the pancreas is identified. introduction hydatid disease is a parasitic infection caused by the larval stage of the tapeworm echinococcus. human infection is endemic in sheep-raising areas of the world, including south africa. pancreatic involvement in adults occurs with a reported prevalence of 0.25%.1 primary pancreatic hydatid disease in childhood with no other associated visceral involvement is extremely rare, and only 5 cases have been reported to date.2-6 nonetheless, hydatid disease should always be included in the differential diagnosis when a cystic lesion is identified in a patient from an endemic area. case report an 11-year-old girl was admitted with symptoms of epigastric pain and vomiting. examination revealed a palpable epigastric mass and jaundice. the latter was confirmed biochemically. the serum amylase was normal. abdominal ultrasound (fig. 1a and b) and computed tomography (ct) scan (fig. 2a and b) of the abdomen were obtained. the differential diagnosis considered included choledochal cyst, congenital cyst, pseudocyst, cystadenoma and hydatid disease. in view of the symptoms, the patient was operated on and the cyst removed. histopathological examination revealed flimsy translucent membranous material confirmed on microscopy to be consistent with echinococcal disease. discussion pancreatic cysts are uncommon in children.7 cysts may be congenital (i.e. developmental) or acquired. the latter includes pseudocysts, retention cysts, duplication cysts, neoplastic cysts and parasitic cysts.7 choledochal cysts, although not arising from the pancreas, are intimately related and may sometimes be difficult to distinguish from pancreatic cysts on imaging studies. hydatid disease in humans begins with ingestion of eggs, followed by penetration of the gut wall by the embryo and entrance 34 sa journal of radiology • october 2005 case report pancreatic hydatid cyst mimicking a choledochal cyst m r h bayat mb chb, dip pec (sa) s mahomedy mb bch s k misser mb chb p corr mb chb, ffrad (d) sa, md department of radiology nelson r mandela school of medicine, university of kwazulu-natal durban fig.1a. coronal ultrasound through the liver and common bile duct. the dilated bile duct (curved arrow) appears to communicate with a large anechoic cystic collection in the pancreatic head. fig.1b. coronal ultrasound through the liver and common bile duct. the wall separating the two structures (arrow) is now visualised but is thin and almost imperceptible leading to diagnostic confusion. fig.2b. coronal reconstructions confirm the well-marginated pancreatic cyst separated from the dilated common duct (arrow) and gallbladder (star). fig. 2a. axial enhanced ct demonstrates a 4 × 2 cm type 1 hyatid cyst in the pancreas (arrow). the dilated debris-filled stomach and compressed second part of the duodenum are also seen. pg34-35 tib 10/8/05 12:26 pm page 34 into the portal circulation. this explains the high frequency of liver and lung involvement. the liver is involved in approximately 75% of cases, with lung involvement in 15%.8 it is postulated that possible sources of infestation in isolated pancreas involvement include hematogenous dissemination, local spread via the pancreatobiliary ducts, and peripancreatic lymphatic invasion.3 several classification schemes have been proposed based on the cyst appearance.8 lewall9 proposed a four-stage pathology-based classification scheme. the initial stage or type i cyst is a fluid-filled cystic structure with 3 layers: the outermost pericyst composed of modified host cells and fibrous tissue, the middle laminated membrane and the thin inner germinal membrane. a type ii cyst has daughter cysts and/or matrix. when the hydatid fluid is replaced by formed elements the lesion dies and eventually becomes calcified and biologically inert, forming a type iii lesion. complications of hydatid disease including rupture and secondary infection are classified as type iv cysts. three subtypes of rupture are described, viz. contained rupture, communicating rupture and direct rupture with peritoneal spill.10 on ultrasound, the appearance of visceral hydatid disease varies according to the stage.11 the cyst wall may be a thin welldefined echogenic rim but in certain cases double echogenic lines separated by a central hypoechoic layer have been described.8 internal architecture is also variable. in this case a unilocular anechoic lesion was seen but internal septa, floating membranes, daughter cysts and echogenic hydatid sand have also been described.11 the latter creates a snowstorm appearance when the patient is turned over and scanned immediately.10,11 multilocular cysts may manifest with a cyst within a cyst appearance12 or a honeycomb pattern with multiple septa, each septum representing the wall of the daughter cyst. curvilinear cyst wall and internal calcification is also seen as a hyperechoic contour with acoustic shadowing.11 ct may display the same findings as ultrasound. the cyst fluid is usually of water attenuation unless complicated by super-added infection. the cyst wall is usually well defined except in super-added infection, with variable nonspecific contrast enhancement.8 the classic ‘wheel spoke’ appearance described on ultrasound is also seen on ct scanning (fig. 3).11 review of the 5 previously described paediatric pancreatic hydatid cysts, confirmed unilocular cysts with no specific distinguishing features in 3 instances.2,3,6 the other 2 cases had more characteristic type ii features.4,5 in conclusion, the appearance of a cystic mass with an undulating membrane, as with contained rupture,10 or of multiple degenerating daughter cysts within the mother cyst9,12 may alert the clinician to the possibility of pancreatic hydatid disease. on the other hand, radiologic examinations alone may not be sufficient to diagnose primary pancreatic hydatid disease and serological tests may be necessary. in our case, both us and ct were useful in diagnosing the cystic mass in the head of the pancreas, but were unhelpful in lesion characterisation. the radiologist should always strive to make the diagnosis of hydatid disease as direct rupture has great clinical significance, including anaphylaxis, hydatid dissemination and secondary bacterial infection.10 references 1. kattan yb. hydatid cysts in the pancreas. bmj 1975; 44:: 729-730. 2. barrera mc, villanua j, barrena jf, et al. pancreatic hydatid disease. pediatr radiol 1995; 2255:: 169-170. 3. brown ra, millar ajw, krige jej, et al. hydatid cyst of the pancreas a case report in a child. eur j pediatr surg 1995; 55:: 121-124. 4. hicsonmez a. hydatid cysts in childhood: analysis of 208 cases. progress in pediatric surgery 1982; 1155:: 87-94. 5. ismail k, haluk gi, necati o. surgical treatment of hydatid cysts of the pancreas. int surg 1991; 7766:: 185-188. 6. arikan a, sayan a, erikci vs. hydatid cyst of the pancreas: a case report with 5 years’ follow-up. pediatr surg int 1999; 1155:: 579-581. 7. rowe mi, o’neill ja, grosfeld jl, et al. essentials of pediatric surgery. st. louis: mosby year book, 1995: 668. 8. pedrosa i, saiz a, azzarzalo j, ferreiros j, pedrosa cs. hydatid disease: radiological and pathologic features and complications. radiographics 2000; 2200:: 795-817. 9. lewall db. hydatid disease: biology, pathology, imaging and classification. clin radiol 1998; 5533:: 863-874. 10. dahniya mh, hanna rm, ashebu s, et al. pictorial review the imaging appearances of hydatid disease at some unusual sites. br j radiol 2001; 7744:: 283289. 11. polat p, kanarci m, alper f, suma s, koruyucu mb, okur a. hydatid disease from head to toe. radiographics 2003; 2233:: 475-494. 12. morton pcg, terblanche jt, bornman pc, tyrrell jch. obstructive jaundice caused by intrapancreatic hydatid cyst. br j surg 1981; 6688:: 474-476. case report 35 sa journal of radiology • october 2005 fig.3. enhanced ct scan of the abdomen in a different patient showing the typical ‘wheel spoke’ appearance of a type ii cyst in the right kidney. the daughter cysts (curved arrow) are of lower attenuation than the mother cyst and are arranged along the periphery. the mother cyst has a matrix with a density of 35 hu (arrow). pg34-35 9/28/05 3:03 pm page 35 case report sa journal of radiology • september 2011 91 endovascular embolisation of a cervical spinal avf in a patient with nf1 n mahomed, mb bch, fcrad (d) p malatji, mb bch, fcrad (d) i a nagdee, mb bch, fcrad (d) s andronikou, mb bch, fcrad (d), frcr, phd m modi, mb bch, fcrad (d) department of diagnostic and interventional radiology, chris hani baragwanath hospital, soweto corresponding author: n mahomed (nasreen.mahomed@wits.ac.za) history a 38-year-old woman with known nf1 presented with right-sided 12th cranial nerve palsy. on examination, she also had a continuous bruit over the right carotid space. imaging findings magnetic resonance imaging (mri) demonstrated a right-sided occipital plexiform neurofibroma in keeping with nf1 (fig. 1). mri of the cervical spine demonstrated a large signal void in keeping with an extradural spinal avf. there was a significant intra-spinal component causing a compressive myelopathy of the cervical spine (fig. 2), including the medulla at the level of the right 12th cranial nerve, accounting for the clinical presentation. magnetic resonance angiography (mra) demonstrated the large right-sided cervicle spinal avf fed by the right vertebral artery and draining into the epidural veins and the right jugular veins (fig. 3). digital subtraction angiography (dsa) confirmed the cervical spinal avf, demonstrating the shunting through an intricate web of communications between the right vertebral artery and drainage into the right epidural and right internal and external jugular veins (figs 4a and 4b). treatment treatment was initially via endovascular means. owing to the complex anatomy of the spinal avf, the fistula orifice was not identified. abstract vascular abnormalities associated with neurofibromatosis type 1 (nf1) are well described. spinal arterio-venous fistula (avf) is a rare finding in nf1 and may present with neurological symptoms that require treatment. management of spinal avfs can be endovascular or surgical. we present a patient with known nf1 and neurological symptoms due to a spinal avf demonstrated by imaging, who required a combination of endovascular and surgical management. fig. 1. axial t2-weighted image of the brain demonstrating the right occipital plexiform neurofibroma (white arrow). fig. 2. axial t2-weighted gradient echo image of the neck demonstrating the large serpiginous signal void (arrow head) of the avf with an intra-thecal component (filled arrow) causing mass effect on the cervical spinal cord (open arrow). 92 sa journal of radiology • september 2011 case report therefore, 2 imwce 35-6-6 coils were inserted into the avf from the ipsilateral vertebral artery. as this was unsuccessful in treating the fistula, an amplatzer vascular plug was placed into the proximal right vertebral artery. however, selective micro-catheterisation of the left vertebral artery demonstrated persistence of the spinal avf that was now fed by the contralateral vertebral artery (fig. 5). selective microcatheterisation of the left vertebral artery to occlude the distal aspect of the right vertebral artery was attempted but not successful. therefore, surgical clipping of the distal right vertebral artery at the level of the foramen magnum was performed. discussion nf1 is one of the most common autosomal-dominant inherited genetic disorders, with an incidence of approximately 1:3 500.1 patients with nf 1 may present with a spectrum of vascular lesions affecting the central nervous system, including occlusions, hypoplasia of intracranial arteries, ‘moyamoya’ vessels and aneurysms.1 cutaneous neurofibromata, as were present in our patient, are pathognomonic for nf1 and can also be associated with an abnormal vascular supply that may cause increased bleeding during surgical resection.1 spontaneous spinal avfs associated with nf1 are an uncommon association.1,2 the combination of skeletal abnormalities of the spine with abnormal vessel fragility in nf1 may predispose patients to the development of spontaneous high-flow spinal avfs.1 ninety-seven per cent of spontaneous spinal avfs associated with nf1 occur in the cervical spine and arise from the vertebral artery.1 these fistulae usually drain into the vertebral venous plexus, or intrathecally via the epidural venous plexus.2 the clinical presentations of spinal avfs include radiculomyelopathy (78%), bruit (50%) , tinnitus (10%), cranial neuropathy (3%) or a pulsatile neck mass (3%).1 a cranial neuropathy and bruit were described in our patient. a direct connection between an extradural spinal/radiculomedullary artery and adjacent vein lead to the development of a high-flow fistula with engorgement of the epidural venous system and potential compression of the spinal cord, resulting in progressive myelopathy (fig. 2).3 the high venous pressure in the epidural venous system can also lead to intradural venous hypertension by increasing the overall resistance to outflow. the large amount of shunting of arterial blood into the venous system can also steal blood from the spinal cord, leading to a myelopathy.3 figs 4a and 4b. dsa of the right vertebral artery, confirming the cervical spinal avf (open arrow), demonstrating the intricate web of communications between the dysplastic right vertebral artery (filled arrow) and the right internal (smaller arrow head) and external jugular (larger arrowhead) veins. a b fig. 3. mra demonstrating the cervical spinal avf fed by the right vertebral artery (arrow head). note the engorged epidural vein (open arrow) and the right internal jugular vein (filled arrow). case report sa journal of radiology • september 2011 93 confusion of spinal avfs with spinal neurofibromata may occur on mri because of the vascularity of some neurofibromas, as well as the similar appearances of neurofibromata and distended vessels as dumbbell-shaped masses associated with vertebral scalloping. however, a distinct flow-related signal void usually indicates a spinal avf.1 the classification of complex vascular lesions associated with nf1 is controversial. some authors consider the lesions as spinal arteriovenous malformations (avms), while other authors describe them as spinal avfs.1 on evaluation of our patient on mri, mra and dsa, the characteristic single vertebral artery that feeds this spinal av lesion would cause the lesion to be classified as a spinal avf.1,3 however, a confounding factor in this classification is the number of engorged and tortuous collaterals and draining vessels that can simulate the multiple feeders of an avm. super selective angiography is a valuable investigation in this differentiation.1 the goal in managing spinal avfs in nf1 is complete occlusion of the fistula, i.e. occlusion of the vertebral-epidural anastomosis.1,2 extradural spinal avfs rarely require open surgery as they can be usually be treated effectively by endovascular procedures, which should therefore be first-line management.1-3 endovascular occlusion has a lower risk of bleeding compared with open resection.1 the endovascular approach involves occlusion of the vertebral artery first distal to the fistula via the ipsilateral vertebral artery, then fistula occlusion and proximal embolisation.1 owing to the complex anatomy as described in our patient, the fistula orifice was not identified and the ipsilateral vertebral artery distal to the fistula could not be occluded. proximal occlusion of the right vertebral artery using the amplatzer device was successful. use of a detachable balloon would have been better suited in this case, owing to the tortuosity of the dysplastic right vertebral artery allowing better passage of the delivery system; however, detachable balloons were not available at our institution at the time of this procedure. using a contra-lateral approach to occlude the fistula distally may be difficult and risky, and in our patient was not successful. a further treatment option is the use of a covered stent to occlude the fistula orifice, while preserving the vessel.1 the fragility or tortuosity of the vessels in nf1 can further complicate endovascular procedures, and delayed recanalisation may be a problem.1,2 for large fistulae with multiple collateral feeders, as described in our patient, embolisation alone may be difficult or unsuccessful. surgery is generally reserved for incomplete endovascular cure and to relieve compression of the dura and spinal cord.2,3 conclusion this case highlights the importance of mra as a sensitive and noninvasive modality in the imaging of nf1 and the diagnosis of cervical spinal avfs. spontaneous spinal avfs from the vertebral artery may simulate a cervical spinal avm owing to multiple collateral arterial feeders arising from the vertebral artery in nf1. endovascular techniques is the first-line management for cervical spinal avfs, but may need to be performed in combination with surgery for large fistulae with multiple collateral feeders, as described in this patient. 1. hauck ef, nauta hjw. spontaneous spinal epidural arterio-venous fistulae in neurofibromatosis type 1. surg neurol 2006;66:215221. 2. paolini s, colonnese c, galasso v, et al. extradural arteriovenous fistulas involving the vertebral artery in neurofibromatosis type 1. j neurosurg spine 2008;8:181-185. 3. spetzler rf, detwiler pw, riina ha, porter rw. modified classification of spinal cord vascular lesions. j neurosurg 2002;96:145-156. fig. 5. dsa post embolisation with the catheter tip in left (contra-lateral) vertebral artery (open arrow) demonstrates persistence of the spinal avf, which is fed by the contra-lateral vertebral artery. note the amplatzer vascular plug in the proximal right vertebral artery (filled arrows) and the 2 imwce 35-6-6 coils (arrowhead) within the spinal avf. case report article information authors: maria kaloianova1 jaishree naidoo1 heather thomson2 louisa bhengu3 affiliations: 1department of radiology, charlotte maxeke johannesburg academic hospital and university of the witwatersrand, south africa 2department of paediatrics charlotte maxeke johannesburg academic hospital and university of the witwatersrand, south africa 3department of human genetics national health laboratory services, school of pathology and university of witwatersrand, south africa correspondence to: maria kaloianova email: mkaloianova@gmail.com postal address: po box 785085, sandton 2146, south africa dates: received: 07 june 2015 accepted: 14 aug. 2015 published: 30 oct. 2015 how to cite this article: kaloianova m, naidoo j, thomson h, bhengu l. krabbe disease – an unusual presentation of optic nerve enlargement. s afr j rad. 2015;19(2); art. #887, 4 pages. http://dx.doi.org/10.4102/sajr.v19i2.887 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. krabbe disease – an unusual presentation of optic nerve enlargement in this case report... open access • abstract • introduction    • case 1    • case 2 • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ krabbe disease is an autosomal recessive leukodystrophy that presents clinically with regression of milestones, excessive irritability and inconsolable crying. the pathologic basis of the disease is abnormal myelin metabolism resulting from a deficiency in the galactocerebrosidase enzyme with subsequent white matter destruction. although optic atrophy is a classic presentation of krabbe disease, we report on two patients who are biological brothers presenting with optic nerve enlargement in addition to other typical magnetic resonance imaging features of krabbe disease, thereby confounding the initial diagnosis. introduction top ↑ krabbe disease, also known as globoid cell leukodystrophy, is a lysosomal function disorder that ultimately results in demyelination and dysmyelination of white matter. the worldwide incidence of krabbe disease has been shown to be 1 in 100 000–200 000, with 1 in 150 000 live births reported in europe.1,2 the incidence in the south african population has not been well established. case 1 patient 1 presented in february 2012 to the neurodevelopmental clinic at 7 months of age with excessive inconsolable crying, regression of milestones, numerous café au lait macules and large eyes. birth history was non-contributory. magnetic resonance imaging (mri) of the brain demonstrated hypertrophy of the optic nerves and several other cranial nerves bilaterally (figure 1). high signal intensities were noted within the white matter of the brachium pontis, cerebellar dentate nuclei and corona radiata with a significant background of cortical and white matter atrophy (figure 2). the patient died at 1 year of age with a provisional diagnosis of neurofibromatosis i (nfi). no specific tests for krabbe disease were performed prior to his death. figure 1: t2 flair image of patient 1. bilateral pre-chiasmatic optic nerve enlargement (arrows) as well as thickening of both cranial nerves iv (arrowheads). figure 2: t2 coronal image of patient 1. white matter hyperintensities of the corona radiata (arrows) and cerebellar dentate nuclei (arrowheads), with background cerebral atrophy. case 2 patient 2 presented in november 2014 at 5 months of age with regression of milestones, excessive crying that was difficult to soothe, numerous café au lait macules, large eyes and a relative macrocephaly. birth history was non-contributory and the child developed normally up until 3 months of age. blood tests for amino acids and organic acids, as well as liver and renal functions were normal. cerebrospinal fluid lactate and glycine levels were also normal. specific enzyme testing for krabbe disease was performed for patient 2 in philadelphia, usa. the results revealed the galactocerebrosidase enzyme value to be very low (0.07); this figure is in the range of patients affected with krabbe disease. mri brain imaging of patient 2 demonstrated markedly hypertrophied optic nerves (figure 3and figure 4). increased t2 and t2 flair signal intensities of the white matter of the brachium pontis and the cerebellar dentate nuclei (figure 5) were visualised. the midbrain, pons and cerebellum also demonstrated increased t2 and t2 flair signal intensities with a significant background of cortical and white matter atrophy (figure 6). figure 3: sagittal oblique t2 image of patient 2. pre-chiasmatic enlargement of the right optic nerve (arrow). figure 4: t2 flair axial image of patient 2. enlargement of the pre-chiasmatic optic nerves bilaterally (arrows). figure 5: t2 axial image of patient 2. increased signal intensities in the cerebellar dentate nuclei bilaterally (arrows). figure 6: t2 axial image of patient 2. increased signal intensities in the periventricular white matter (arrowheads) and internal capsules (arrows) bilaterally. there is associated diffuse cortical atrophy. discussion top ↑ krabbe disease is classified as a progressive leukodystrophy with an autosomal recessive inheritance pattern. it is caused by a mutation of the galactocerebroside beta-galactosidase gene located on chromosome 14q31.2,3 presentation is usually between 3 and 6 months of age, with death commonly occurring before the age of 2 years. the presenting features most often encountered are regression of milestones, inconsolable irritability, and agitation and feeding problems, with an inevitable need for enteric feeding in the terminal stages of the disease.2,3,4,5 the pathophysiology of krabbe disease results from a deficiency in the production of the enzyme galactocerebrosidase, a lysosomal enzyme that forms a key component of the myelin metabolism pathway.3 this deficiency results in progressive demyelination and dysmyelination of both the peripheral and central nervous systems.4,6 the impaired galactocerebrosidase production results in accumulation of lethal levels of galactocerebroside and psychosine within macrophages, with resultant globoid cell formation.4,7 psychosine in particular has been shown to be toxic to oligodendroglial cells, neurons and schwann cells.1,3 the microscopic features of krabbe disease typically include severe neuronal destruction in the white matter of the thalami, cerebellar peduncles, corona radiata and corpus callosum.3 computed tomography (ct) usually shows hyperdensities in the thalami, caudate nuclei, cerebellar dentate nuclei and corona radiata during the early stages of the disease.3 as the disease progresses, associated white matter atrophy manifests, making it indistinguishable from other dysmyelinating conditions in the terminal stage.3,6 in very young patients, t1-weighted mri demonstrates abnormally high signal in the thalami, with a delay in the appearance of the normal high signal in the internal capsules. high t1 signal intensities are also observed in the caudate nuclei, corona radiata, dentate nuclei of the cerebellum and also within the cerebral and cerebellar white matter. in the early stages of the disease, the subcortical white matter is spared.3,6 the cerebellar dentate nuclei maintain their high signal on t2-weighted imaging. in addition, there are also abnormally high t2 signal intensities within the corticospinal tracts of the internal capsules, cerebral white matter and the medial medullary pyramids. these findings are highly indicative of the disease.3 beyond the first year of the disease, white matter high t2 signal intensities are noted to involve the splenium of the corpus callosum and the deep cerebral white matter, notably in the posterior frontal and anterior parietal lobes.3 diffusion weighted imaging (dwi) demonstrates proportionally increased diffusion with disease progression, noted uniformly throughout the white matter. mr spectroscopy, although non-specific, may show an increased lactate and decreased n-acetylaspartate (naa).3 optic nerve as well as other cranial nerve enlargement, however, is seldom described in association with krabbe disease. when present, it is thought to be as a result of globoid cell accumulation within the optic and other cranial nerves in combination with an inflammatory response related to myelin breakdown.3,4,5,6,8 jones et al. proved the presence of globoid cells within the optic nerves on histological review of one of their analysed cases.6 in the presence of optic nerve enlargement, the differential diagnosis will include optic nerve glioma in patients with nf-i, optic dural ectasia, granulomatous or histiocytic infiltration of the optic nerves, post-viral optic neuritis and optic nerve medulloepithelioma.6,7 making the distinction on clinical grounds is of great importance. conclusion top ↑ optic atrophy is one of the clinical presenting features of krabbe disease. however, in rare cases as we report here, optic nerve enlargement may be an association. considering the higher prevalence of nf-i, one can easily be misled by these imaging features into making the latter diagnosis. early awareness of neuroimaging findings in krabbe disease together with a suggestive clinical presentation will allow timely management and genetic counseling to parents. acknowledgements top ↑ we thank professor l.b. jacklin and dr j. epstein of the neurodevelopmental unit, department of paediatrics, charlotte maxeke johannesburg academic hospital and university of the witwatersrand, johannesburg, who were the clinicians involved in the care of the above patients. in addition, we thank dr d.a. wenger, director, lysosomal diseases testing laboratory, sidney kimmel medical college, thomas jefferson university, philadelphia, usa, for assisting us in confirming the diagnosis. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.k. (university of the witwatersrand) and j.n. (university of the witwatersrand) contributed towards the imaging and literature review. h.t. (university of the witwatersrand) and l.b. (university of the witwatersrand) contributed towards the clinical information and confirmation of the diagnosis. references top ↑ nagar va, ursekar ma, krishnan p, jankharia bg. krabbe disease: unusual findings. pediatr radiol. 2006;36:61–64. pmid: 16247616. http://dx.doi.org/10.1007/s00247-005-0008-y korn-lubetzki i, dor-wollman t, soffer d, raas-rothschild a, hurvitz h, nevo y. early peripheral nervous system manifestations of infantile krabbe disease. pediatr neurol. 2003;28:115–118. pmid: 12699861, http://dx.doi.org/10.1016/s0887-8994(02)00489-7 barkovich aj, raybaud c. pediatric neuroimaging. 5th edn. philadelphia: lippincott williams and wilkins, 2012; p. 92–93. beslow la, schwartz es, bönnemann cg. thickening and enhancement of multiple cranial nerves in conjunction with cystic white matter lesions in early infantile krabbe disease. pediatr radiol. 2008;38:694–696. pmid: 18265968, http://dx.doi.org/10.1007/s00247-008-0763-7 patel b, gimi b, vachha b, agadi s, koral k. optic nerve and chiasm enlargement in a case of infantile krabbe disease: quantitative comparison with 26 age-matched controls. pediatr radiol. 2008;38:697–699. pmid: 18438656, http://dx.doi.org/10.1007/s00247-008-0849-2 jones bv, barron tf, towfighi j. optic nerve enlargement in krabbe’s disease. ajnr am j neuroradiol. 1999;20:1228–1231. pmid: 10472976. hussain sa, zimmerman hh, abdul-rahman oa, hussaini sm, parker cc, khan m. optic nerve enlargement in krabbe disease: a pathophysiologic and clinical perspective. j child neurol. 2011;26:642–664. pmid: 21285037, http://dx.doi.org/10.1177/0883073810387929 shah s, freeman e, wolf v, murthy s, lotze t. teaching neuroimages: intracranial optic nerve enlargement in infantile krabbe disease. neurology. 2012;78:e126. pmid: 22585439, http://dx.doi.org/10.1212/wnl.0b013e3182563bad article information authors: ryno schoeman1 nicky mostert-phipps1 affiliations: 1department of information technology, nelson mandela metropolitan university, south africa correspondence to: nicky mostert-phipps email: nicky.mostert@nmmu.ac.za postal address: po box 77000, port elizabeth 6031, south africa dates: received: 06 feb. 2015 accepted: 14 may 2015 published: 20 nov. 2015 how to cite this article: schoeman, r. & mostert-phipps, n. referring physician perceptions of picture archive and communication systems. s afr j rad. 2015;19(1); art. #790, 5 pages. http://dx.doi.org/10.4102/sajr.v19i1.790 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. referring physician perceptions of picture archive and communication systems in this original research... open access • abstract • introduction • research method and design    • instrument design    • setting    • data collection    • data analysis       • ethical considerations • results and discussion • communication benefits • access benefits • response time benefits    • diagnostic benefits    • drawbacks    • study limitations • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ the picture archive and communication system (pacs) is a digital radiographic system that is steadily replacing the older film-based radiographic records. despite the various benefits associated with pacs implementation, it is not yet clear what referring physicians think of such systems. this article reviews their thoughts and perceptions, which were obtained via surveys that were completed by referring physicians with practices at private hospitals in port elizabeth. a critical analysis of the data collected indicated that most referring physicians perceive pacs to be beneficial. introduction top ↑ a picture archive and communication system (pacs) is an information system that manages the storage, distribution and viewing of digital radiography images.1 amongst the many benefits associated with pacs is an improved image-management process via an enhanced system. the benefits of this system are:2 better administration of imaging examination requests enhanced performance of imaging examinations enhanced distribution of images and reports improved archiving of imaging examinations more secure archiving of results easier retrieval of previous examinations and results. pacs increases the productivity of radiologists and technologists, and holds many benefits for referring physicians.3 the perceptions of referring physicians regarding pacs is important in order to improve acceptance rates when introducing pacs.4 little research has been devoted to the perceptions of south african referring physicians of pacs implementation. the primary objective of this article is to investigate the perceptions of referring physicians regarding pacs. research method and design top ↑ instrument design the study was designed as an observational study to determine a cross-sectional view of referring physician perceptions regarding the benefits and drawbacks associated with pacs. a survey was selected as the appropriate data collection instrument to investigate such perceptions. a literature review was conducted to identify the benefits, as well as any drawbacks, associated with pacs. these benefits and drawbacks were developed into statements, and the participants were asked to indicate their level of agreement with these statements. the participants were able to indicate their level of agreement as: strongly agree, agree, neutral, disagree, or strongly disagree. the statements in the survey can be categorised as they relate to communication, access, speed and the diagnostically related benefits, as well as the drawbacks associated with pacs. the survey also included open-ended questions regarding participant introduction to pacs; the training they had received in its use; and their views on pacs versus traditional film based radiological systems. setting convenience sampling of those referring physicians who have consultation rooms at three private hospitals in port elizabeth (eastern cape province, south africa) yielded a sample of 96 referring physicians. data collection survey forms were delivered to the receptionists of the 96 identified referring physicians, with a request to hand the surveys to the physicians to complete. eighty-eight forms were accepted, while eight receptionists indicated that the physician would not be willing to participate in the study, or was not available. a covering letter included information related to the purpose of the study, as well as contact details of the research team. the surveys were left at each practice for approximately three weeks, to allow physicians sufficient time to complete them. the data was collected during august 2014. data analysis data from completed surveys was captured in a spreadsheet for analysis. the response from each participant was placed in a row, together with the results of each closed-ended question placed in a separate column. the percentages of the level of agreement for each statement were then calculated. ethical considerations participation was voluntary and anonymous. no information was gathered to identify the individual referring physicians. the mere completion of the survey indicated an informed consent to participate in the study. the necessary institutional ethical clearance was obtained from the nelson mandela metropolitan university before distributing the surveys. results and discussion top ↑ of the 88 surveys handed out, 37 completed surveys were returned, yielding a response rate of 42%. figures 1–2 indicate the area of speciality and age distributions of the participants. figure 1: participant speciality. figure 2: participant age range. figure 3 indicates the comfort levels of participants in using technology such as pcs, laptops and tablets, as well as how easily they were able to navigate the internet. participants were asked to indicate their response to these questions on a rating scale from 0 to 5, with 5 indicating that they were extremely comfortable and 0 indicating that they were not at all comfortable. figure 3: participant comfort levels in the use of technology. table 1 indicates the results as they relate to referring physicians perceptions of pacs table 1: survey results. when reference to specific statements is made refer to table 1. communication benefits top ↑ 89.2% of the participants strongly agree to agree that communication with other physicians is improved (statement 1); while 59.4% of participants indicated that they strongly agree to agree that communication with the radiology department is considerably improved with pacs (statement 2). the greatest improvement in communication relates to communication with other physicians; this is improved by the ease of multi-site viewing (statement 1) which allows any physician to view any image on the system – provided they can access the web.5 a total of 62.2% strongly agreed, while 27% agreed, that this is a benefit. access benefits top ↑ this includes easier access to patients’ current and previous images, the ease of retrieving them, and accessibility. pacs can be accessed at a diagnostic workstation or remotely via a webpage.3 from the survey results, the access benefit that participants found the most useful seems to relate to the availability of previous imaging studies, which makes patient follow-up more efficient (statement 3). all participants agreed with this statement (73% strongly agreed and 27% agreed). this may be because, prior to pacs, film had to be stored in a storage room and, because of the large number of images made per day, the quantity of film in storage became large and caused numerous problems such as loss of information, cost of storage, and delayed clinical decision-making.2 some participants commented in the open-ended questions that they disliked the storage of x-rays (film), and that housing the envelopes became problematic. the survey results also indicate that there was an improvement in access to current and historical patients’ records (statements 6–7). response time benefits top ↑ most referring physicians agreed that, when using pacs, the benefits include faster retrieval of patient data and images, and faster clinical decision-making. the response rate overall is much faster than film-based systems, as demonstrated by various studies.3,6 consequently, examination and waiting times for patients are reduced, as indicated by the responses to statements 12–13. waiting time is decreased because examination results are available for interpretation much sooner than with traditional film-based systems. this finding is confirmed by the responses to statement 11. diagnostic benefits before pacs, film images were used for diagnosing many patients’ conditions. no specialised tools such as magnification, panning or zooming were available. on occasion, patients had to be sent back for re-examination. as seen in the results relating to diagnostic benefits in table 1, participants agreed that pacs plays a major role in improving the diagnosis of patients. the image can be manipulated using different sets of specialised tools, thus allowing more accurate decisions. common tools include window width/level, tools that control the range of image pixel values displayed on the monitor; measurement tools that allow measurements to be made on the image; magnifying, panning and zooming.7 the number of participants who disagreed with, or who indicated a neutral response to, statement 15 which relates to the tools used in diagnoses, may relate to a lack of training on how to use the pacs system. in one of the open-ended questions in the survey related to training, 14 (37.8%) of the 37 participants indicated that they had received insufficient training, and that learning more about the various features offered by the pacs system would be beneficial to them. drawbacks to investigate the level of agreement of the referring physicians on drawbacks associated with pacs, the participants were asked in statement 22 if they felt that the adoption of pacs was too complicated. only 2.7% agreed with this statement, while 13.5% were neutral. the rest disagreed and strongly disagreed with this statement; for the majority, therefore, it may be confidently said that complication was not a drawback with pacs. the results for other drawbacks are shown in table 1. with all the mentioned benefits related to access, there were unfortunately two major drawbacks concerning image access; many physicians commented on this issue. the first was the absence of bedside mobile imaging in the ward (statement 19). previously, film-based images could easily be shown to a patient and to other members of the care team in the ward. as many as 21.6% of participants strongly agreed, and 37.8% agreed, that the absence of bedside mobile image viewing in the ward introduced difficulties. many of the physicians also commented that this was a big problem in one of the open-ended questions. the other disadvantage raised by two doctors in the openended section of the questionnaire was confidentiality of patients’ data and images. they were concerned that any physicians who could access the pacs system could view any patients’ data. it may be seen that most of the physicians agreed with the drawbacks of pacs but felt that the benefits outweighed the drawbacks. accordingly, 32 of the 37 referring physicians responded that they preferred pacs in one of the open-ended questions of the survey. study limitations the generalisability of the results of the present study is limited, as the study was conducted in a specific geographical region. despite the good response rate, the sample size was relatively small. conclusion top ↑ the aim of the study was to investigate referring physicians’ perceptions of pacs, as well as the related benefits and drawbacks. from the survey results, it became clear that while numerous benefits are realised via pacs, some issues still require attention. acknowledgements top ↑ the financial assistance of the south african national research foundation (nrf) in this research is hereby acknowledged. the opinions expressed and the conclusions drawn are those of the authors, and are not necessarily attributable to the nrf. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions r.s. (nelson mandela metropolitan university) contributed to the study design, data collection and analysis, writing and planning of the article draft and final version. n.m. (nelson mandela metropolitan university) contributed to the study design, study coordination, review of the article draft and final version. references top ↑ schulze oc, greyling j, heys m, andronikou s. talking pacs: part 1 – what is pacs? s afr j radiol. 2007;11:50–53. schulze oc, ackermann c, greyling j, viljoen h, andronikou s. talking pacs: part 2 – why should we change to pacs? s afr j rad. 2007;11:86–90. http://dx.doi.org/10.4102/sajr.v11i4.19 honeyman-buck j. pacs adoption. semin roentgenol. 2003;38:256–269. http://dx.doi.org/10.1016/s0037-198x(03)00045-2 pynoo b, devolder p, duyck w, sijnave b, duyck p. do hospitals physicians’ attitudes change during pacs implementation? int j med inf. 2012;81:88–97. http://dx.doi.org/10.1016/j.ijmedinf.2011.10.007 benjamin m, aradi y, shreiber r. from shared data to sharing workflow: merging pacs and teleradiology. eur j radiol. 2010;73:3–9. http://dx.doi.org/10.1016/j.ejrad.2009.10.014 mariani c, tronchi a, oncini l, pirani o, murri r. analysis of the x-ray work flow in two diagnostic imaging departments with and without a ris/pacs system. j digit imaging. 2006;19:18–28. http://dx.doi.org/10.1007/s10278-006-0858-3 kerr c, turner j. pacs workstation software [homepage on the internet]. [cited 2015 apr 2]. available from http://www.ninestepstougly.com/pacsnet.org.uk/presentations&posters/workstawork_web.pdf article information authors: raksha ramlakhan1 nicky wieselthaler2 affiliations: 1division of radiology, groote schuur hospital, south africa 2division of radiology, red cross war memorial children's hospital, south africa correspondence to: raksha ramlakhan email: docrakshar@gmail.com postal address: private bag, observatory, cape town 7937, south africa dates: received: 27 may 2015 accepted: 11 aug. 2015 published: 03 nov. 2015 how to cite this article: ramlakhan r, wieselthaler n. pearls in paediatric trauma neuroimaging reporting – what not to miss. s afr j rad. 2015;19(2); art. #852, 6 pages. http://dx.doi.org/10.4102/sajr.v19i2.852 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. pearls in paediatric trauma neuroimaging reporting – what not to miss in this pictorial essay... open access • abstract • introduction • the pursuit of fractures • use of the 3d reconstruction algorithm    • for fracture detection    • for suture assessment • additional clues to finding fractures    • use of coronal reconstruction for mandibular fracture detection    • carotid canal fractures and carotid artery dissection • hunting high and low    • bridging vein thrombosis    • retroclival haematoma • do not stop looking for lesions • conclusion • acknowledgement    • competing interests    • authors’ contributions • references abstract top ↑ the features of paediatric head trauma are well described. this article aims to highlight review areas and ‘do not miss’ lesions over and above the known and easily recognised injuries often sought when analysing computed tomography (ct) brains for head injury. particular attention is paid to fractures and three-dimensional (3d) imaging. emphasis is also placed on bridging vein thrombosis, retroclival hematomas and corpus callosum injuries. introduction top ↑ paediatric head trauma is a major cause of mortality and morbidity. a review of the red cross children's hospital 2013 trauma statistics showed that of the approximately 1570 patients seen for a ‘head injury’, more than half of these were due to a fall. the other half were attributed to motor vehicle or pedestrian vehicle accidents (either high or low impact) or miscellaneous causes. approximately 4% of head injuries were due to assault. approximately 1000 ct scans for head trauma are performed per year, indicating that about two-thirds of patients who present with head trauma have at least one head ct. a large proportion of these scans are normal. however, in the case of the abnormal scans, it is the radiologist's role to accurately recognise all injuries in order to allow the clinician to determine an appropriate management protocol. extensive articles have been written on paediatric head trauma, but over the years we have encountered some areas that require special review. we would like to highlight some ‘do not miss lesions’, as well as give some ‘tips’ as to which ‘lesions’ to image or investigate further, because missing them may be detrimental to the paediatric patient. the pursuit of fractures top ↑ skull fractures are a marker of severity of injury to a child's cranium. fractures provide clues to localising the site of impact of an injury and assist in predicting and understanding the associated intracranial consequences. calvarial fractures are a sign of primary brain injury in both accidental and non-accidental trauma. the presence of fractures in both clinical settings therefore has a significant impact on further and future aspects of management.1 use of the 3d reconstruction algorithm top ↑ for fracture detection the availability of 3d reconstructions for ct makes this an invaluable problem-solving, post-processing tool. the 3d reconstructions are particularly useful in resolving fractures that are not easily identifiable in the axial imaging plane on ct (figure 1a and figure 1b).1 where there is confusion, or poor knowledge of suture anatomy, it is useful to use the other side for comparison (figure 1c). figure 1: (a) an 8 month old infant fell off the bed and presented with left sided scalp swelling. axial ct bony algorithm demonstrated left parietal scalp swelling (white arrow). no distinct fracture was visualised in this plane; (b) 3d reconstruction demonstrated a linear left parietal fracture (white arrow); (c) 3d reconstruction of the non-fractured side revealed normal sutures. the 3d application must be a routine and perhaps an initial step when evaluating a ct head scan, irrespective of whether the scan is performed for a ‘medical’ indication or in the setting of trauma. non-accidental injury (nai) is commonly seen at our institution, and the radiologist is often the first and initial clinician to detect these cases, especially when the history of abusive trauma is absent. ct head scans performed for seizure investigation, without an accompanying history of trauma or abuse, have often led to the findings of skull fractures when the 3d setting is used. this point is emphasised by a patient who was recently referred for an urgent ct to investigate seizures. the ct scan showed a large subacute left temporal intracerebral haematoma and a left occipito-parietal subdural haematoma (figure 2a). figure 2: (a) a 2 month old male infant was referred with a history of focal seizures and suspected blindness. axial ct brain demonstrated a large left temporal intracerebral haematoma (left white arrow). in addition there was a small acute left parieto-occipital subdural haematoma (black arrow) and blood in the posterior interhemispheric fissure (right white arrow). (b) 3d reconstruction demonstrated a contralateral parietal linear fracture (white arrow). upon evaluation of the bones on the 3d setting, it was immediately evident that there was a skull fracture on the opposite side involving the right parietal bone (figure 2b). the referring clinician was then immediately informed and alerted to nai as the aetiology for the haemorrhage. for suture assessment a knowledge of normal suture anatomy and appearance is important to the radiologist interpreting head ct. normal sutures have a zig-zag appearance, and sclerotic borders.1 the use of 3d reconstruction provides a quick-and-easy tool with which to assess sutures, and especially asymmetry, when evaluating sutural diastasis (figure 3). according to bhatt et al., ‘the presence of diastasis is the most common of paediatric skull fractures’.1 but in our population group, linear and depressed skull fractures were found to be more common. figure 3: a 7 year old pedestrian was hit by a vehicle. 3d reconstruction demonstrated right lambdoid suture diastasis. additional clues to finding fractures top ↑ calvarial fractures almost always occur with associated overlying soft tissue swelling. in the absence of soft tissue swelling, however, the presence of gas locules or fluid within an aerated space such as the paranasal sinuses and the mastoid air cells is a clue to the presence of localised fractures.1 mastoid air cells are important review areas that help the radiologist not to miss the base-of-skull fractures (figure 4). figure 4: a 6 year old boy presented with a closed head injury and right otorrhea, following a fall from a moving vehicle. axial ct bony algorithm demonstrated partially opacified right mastoid air cells. a subtle linear fracture was seen traversing the right mastoid temporal bone (white arrow). use of coronal reconstruction for mandibular fracture detection mandibular fractures are common in children and are the second most common type of facial bone fracture, following the nasal bones.2 the importance of reviewing the mandibular condyles has previously been highlighted in this journal.2 mandibular condyle fractures can be subtle, and easily overlooked in the axial imaging plane. it is thus imperative to review thoroughly the temporomandibular joints and the upper mandible in the coronal plane (figure 5a and figure 5b). figure 5: (a) a 6 year old female sustained a head injury of unknown mechanism and presented with vomiting. coronal mpr view of the bony algorithm demonstrated a linear fracture of the left mandibular condyle (white arrow). the corresponding axial views are far more subtle; (b) axial ct bony algorithm for the above patient, showing lucency of the left mandibular condyle (white arrow). carotid canal fractures and carotid artery dissection post-traumatic carotid artery dissection (ptcad) in children results from rapid deceleration-type injuries to the head and neck. it is a common cause of paediatric acute arterial ischaemic stroke (ais).3 neurological sequelae can be variable, even devastating, depending on the degree and extent of injury. ptcad most commonly involves the distal cervical segment of the internal carotid artery before its entry into the carotid canal at the skull base.3 non-contrasted ct head is useful for identifying base-of-skull fractures, which are associated with ptcad. the presence of base-of-skull fractures must prompt the radiologist to review the carotid canals for fractures. air extending along the carotid canal, in combination with base-of-skull fractures, should prompt a careful examination of the internal carotid arteries (figure 6a).3 in the absence of air but in the presence of a carotid canal fracture, we recommend proceeding to mra swiftly in order to exclude carotid artery dissection. in order to avert additional radiation, mra is preferable to cta (figure 6b). figure 6: (a) a 5 year old boy presented with epistaxis, vomiting and a gcs of 12, following blunt trauma. axial ct bony algorithm demonstrated a right base-of-skull fracture, with air tracking along the right carotid canal (white arrow); (b) axial t1 post contrast mri of the brain shows a filling defect in the right petrous segment of the ica (white arrow), in keeping with subacute thrombus secondary to dissection. hunting high and low top ↑ bridging vein thrombosis in known or suspected abusive head trauma/shaken baby syndrome (sbs) it is imperative to look for multifocal or subdural haematomas in different stages of breakdown, either with or without cerebral injury. we would, however, stress the need to carefully screen the vertex (hunt high) to look for bridging vein thrombosis, particularly when associated with an acute subdural haematoma. the features of sbs are exhaustively described in the literature but little mention is made of bridging vein thrombosis, which is an important finding and of high diagnostic value for sbs.4 these veins lie within the subarachnoid space and constitute a short, non-tortuous, perpendicular pipeline between the arachnoid and the dura.4 they are especially vulnerable to rupture during movement in the antero-posterior direction (violent shaking). thrombosis occurs within a few hours.4 a case in point was a five-month-old child who was referred with failure to thrive and seizures. a chest radiograph showed multiple rib fractures. this prompted an emergency ct head, which demonstrated bridging vein thrombosis and an acute subdural hematoma, which assisted in confirming the diagnosis of non-accidental injury (figures 7a–7c). figure 7: (a) a 5month old infant presented with failure to thrive, and new onset seizures. axial ct brain demonstrated an acute right frontal subdural haematoma (white arrow); (b) tubular hyperdensity in the right high parietal lobe, consistent with a cortical vein thrombosis (black arrow). the acute right frontal subdural haematoma (white arrow) is also demonstrated on this slice; (c) coronal mpr ct brain confirms the high /vertex location of the bridging vein thrombosis (black arrow). retroclival haematoma retroclival haematoma is a paediatric entity that occurs with trauma. this lesion may easily be missed if not specifically looked for (hunt low) as this haematoma may be either a sliver, along the clivus, or large, resulting in brainstem or cord compression. reportedly 20% of patients with atlanto-occipital injuries may initially present with intact neurology. another important point to remember is that the cervical spine plain film or bony sagittal cervical spine reconstruction may be normal without any prevertebral swelling or bony injury. the haematoma may be either epidural or subdural5 and has even been described as subarachnoid.6 the distinction may not be relevant, but suffice to say the epidural haematoma is below the tectorial ligament, which may or may not be intact, whereas the subdural haematoma lies on top of an intact tectorial membrane. screening of the cervical spine with mri is necessary after identifying such a lesion to assess for associated ligamentous rupture (around the cranio-cervical junction) or associated cord injury, as these associations will determine the patient's management. the trick is to have the pre-pontine (retroclival) space as a review area and always to review the brain in sagittal on the brain window algorithm so as not to miss this injury (figures 8a–8c). figure 8: (a) a 6yr male involved in a high velocity mva presented with decreased level of consciousness, hypertonia, decorticate posturing, and severe respiratory distress requiring intubation. axial ct brain demonstrated a retroclival haematoma (white arrow); (b) sagittal mpr ct brain confirms the retroclival location of the haematoma and extent (white arrow); (c) sagittal t2 mri brain confirmed a retroclival haematoma with tectorial ligament and probable apical ligament disruption (white arrow), with a normal proximal cord. do not stop looking for lesions top ↑ severe head trauma, particularly that due to rotational acceleration and deceleration injury or shearing injury, can result in diffuse axonal injury (dai).1 the history and mechanism of injury as well as poor clinical status will point to the diagnosis of dai. ideally, all patients should have an mri for the purposes of prognosis, but in a resource-poor setting this is not always feasible. often ct does not appreciate all the lesions, particularly those affecting the corpus callosum, which are often missed on ct. over the years we have noticed a trend in requests for ‘hemiplegia’ or ‘not moving a limb’ in these severe head injury patients. mri spine requests are often made in the face of severe head trauma in order to look for a cord injury. if there are no time constraints and an anaesthetist is readily available; then a complete brain and spine mri is ideal. however; where time is an issue; we have found that a large field of view t2 sagittal of the cervical spine and including the corpus callosum is extremely useful. often patients with suspected cervical spine injuries have corpus callosum shearing injuries and a normal cervical cord (figures 9a–9c). this can thus limit the investigation to a ‘brain only’ scan. figure 9: (a) a 9 year old girl presented with a head injury (gcs 8t), and suspected cervical spine injury. sagittal t2 weighted mri (large open field view) showed a corpus callosum shearing injury, with high signal in the body and extending to the splenium (white arrow). the cervical spine was normal; (b) axial flair mri confirmed the high signal in the body of the corpus callosum (white arrow); (c) review of axial ct brain on admission showed no features of callosal injury. conclusion top ↑ radiologists play a vital role in the interpretation of images related to paediatric head trauma. it is important to remember to review areas so as not to miss pathology that may affect the outcome and management of paediatric patients. acknowledgement top ↑ thank you to lyle eyssen for assistance with reproducing the images. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions r.r. (groote schuur hospital) and n.w. (red cross war memorial children's hospital) contributed equally to the writing of this manuscript. references top ↑ bhatt aa, hunsaker j, kalina p. pearls and pitfalls of pediatric head trauma imaging. appl radiol. 2014 [cited 2015 apr 17]. available from: http://www.appliedradiology.com peedikayil t, wieselthaler n. coronal views of the paediatric mandibular condyle on computerised tomography brain (ctb) studies: an important review area. s afr j rad. 2013;17(1):38–39. http://dx.doi.org/10.4102/sajr.v17i1.211 orman g, tekes a, poretti a, robertson c, huisman ta. posttraumatic carotid artery dissection in children: not to be missed! j neuroimaging. 2014;24(5):467–472. pmid: 24251954, http://dx.doi.org/10.1111/jon.12071 adamsbaum c, rambaud c. abusive head trauma: don’t overlook bridging vein thrombosis. pediatr radiol. 2012;42(11):1298–1300. pmid: 22885602, http://dx.doi.org/10.1007/s00247-012-2434-y silvera vm, danehy ar, newton aw, et al. retroclival collections associated with abusive head trauma in children. pediatr radiol. 2014;44(suppl. 4):s621–631. pmid: 25501734, http://dx.doi.org/10.1007/s00247-014-3170-2 koshy j, scheurkogel mm, clough l, huisman ta, poretti a, bosemani t. neuroimaging findings of retroclival hemorrhage in children: a diagnostic conundrum. childs nerv syst. 2014;30(5):835–839. pmid: 24469948, http://dx.doi.org/10.1007/s00381-014-2369-8 article information authors: enrico arkink1,2 j. frijns3 berit verbist1,4 affiliations: 1department of radiology, leiden university medical center, the netherlands 2department of radiology, medical center haaglanden, the netherlands 3department of otorhinolaryngology, leiden university medical center, the netherlands 4department of radiology, radboud university nijmegen medical center, the netherlands correspondence to: enrico arkink email: e.b.arkink@lumc.nl postal address: po box 9600, 2300 rc leiden, the netherlands dates: received: 26 aug. 2015 accepted: 28 aug. 2015 published: 21 oct. 2015 how to cite this article: arkink e, frijns j, verbist b. answer to quiz case: temporal bone imaging. s afr j rad. 2015;19(1): art. #929, 4 pages. http://dx.doi.org/10.4102/sajr.v19i1.929 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. answer to quiz case: temporal bone imaging in this quiz case... open access • abstract • introduction • background • diagnosis • discussion    • competing interests    • authors’ contributions • references abstract top ↑ computed tomographic scanning of the petrous bone and magnetic resonance imaging sequences of the inner ear and cerebellopontine angle of a deaf patient were performed to find an explanation for his deafness, and to establish whether he would be a good candidate for cochlear implantation. the imaging features were considered pathognomonic for incomplete partition type iii (ip type iii). further management and discussion of this deafness subtype are detailed. introduction top ↑ the best responses received for this temporal bone imaging quiz case were from dr t.e. buthelezi and dr herman van vuuren. congratulations to them. background top ↑ computed tomographic (ct) scanning of the petrous bone and magnetic resonance imaging (mri) sequences of the inner ear and cerebellopontine angle of a deaf patient were performed to find an explanation for his deafness, and to establish whether he would be a good candidate for cochlear implantation. diagnosis top ↑ the ct images of the temporal bone showed a normal aspect of the mastoid, tympanic membrane middle ear cavity and ossicular chain bilaterally (not shown in detail in figure 1). the abnormalities can be seen in the inner ear structures (figure 1). the images show bilateral bulbous dilatation of the internal auditory canal (iac). the bone plates at the fundus of the iac, which separate them from the cochlear basal turn, are absent. the modiolus is deficient, with a present interscalar septum, giving the dysplastic cochleas a corkscrew appearance. this corkscrew appearance is also apparent on 3d t2 mr-imaging (figure 2). also visible is the minor dilatation of the labyrinthine segment of the facial canal on the right, and of the tympanic segment of the facial canal on the left (figure 1). these specific imaging features are considered pathognomonic for incomplete partition type iii (ip type iii). figure 1: axial images through the right (a, c, e and g) and left (b, d, f and h) petrous bone. images show bilateral bulbous dilatation of the internal auditory canal (long thin arrows), absent modioli (short thick arrows) and dilatation of the labyrinthine segment of the facial canal on the right (curved arrow, g) and of the tympanic segment of the facial canal on the left (curved arrow, h). figure 2: axial 3d t2 of the cerebellopontine angle, showing the typical corkscrew appearance of the anomalous cochlea. the cochlear nerve is present. the patient underwent cochlear implantation on the right side. insertion of the electrode of the cochlear implant was troublesome but complete. upon cochleostomy, expected perilymph gushing owing to a fistulous connection between the iac and the cochlea occurred. the gushing was controlled and properly sealed. perioperative impedance measurements of the electrodes and brainstem responses showed good measurements for apical and basal electrode contacts, but not for those in between. postoperative imaging confirmed an unusual position of the electrode, with parts of it bulging into the iac (figure 3). apparently, the tip of the electrode had been blocked in the upper basal turn during insertion, causing part of the middle portion of the array to bulge into the internal auditory meatus, when the surgeon tried to achieve full insertion. despite this unfavourable electrode position, the patient recovered well from surgery and, with an adequate fitting, postoperative performance of this prelingually deaf adult was acceptable (up to 55% of phonemes correct on a monosyllabic word test on a cd in quiet), with the patient able to hear sufficiently to participate normally in conversation. figure 3: preoperative (upper and middle images) and postoperative (bottom image) axial ct images of the right temporal bone, with abnormal positioning of the inserted cochlear implant electrode (volume rendering superimposed on the preoperative image, middle image), partially positioned in the internal auditory canal (bottom image). discussion top ↑ the combination of clinical and imaging findings in this patient are characteristic of ip type-iii, which is often also referred to as x-linked deafness type 2 (dfnx2).1,2,3,4,5,6,7,8,9 this inner ear anomaly is a rare congenital cause of progressive mixed (conductive and sensorineural) hearing loss. it is the rarest form of incomplete partitioning, representing about 2% of all inner ear malformations.10 the simultaneous occurrence of bilateral bulbous dilatation of the iac, absence of the lamina cribrosa separating the iac from the cochlear basal turn, absent modioli and dilatation of the first two segments of the facial canal should make one aware of the diagnosis of ip type-iii. glasscock, using coronal section polytomography,11 recognised the dilatation of the iac already in the early 1970s. with improving technology, more detailed descriptions were published,12,13 with dilatation of the facial canal noted for the first time in the 1980s.14 in a few dfnx2 patients, medialisation of the origin of the vestibular aqueduct and slight dilatation of this structure have also been described.5 the modiolus is completely absent, but interscalar septa are present.15 the cochlea is positioned at the lateral end of the iac instead of the usual anterolateral position, resulting in the corkscrew appearance10 but, contradictory to the initial reports using polytomography,4 is considered to have normal external diameters.16 the slight dilatation of the first two segments of the intratemporal facial nerve may be accompanied by an abnormal, superior position of the labyrinthine segment in relation to the cochlea. in addition, enlargement of superior vestibular nerve canals has been reported in some patients with ip type-iii.9 the round window may be small and artretic.9 the absence of the bony partition between the iac and cochlea allows a direct fistulous connection between the subarachnoid space and the perilymph in the labyrinth. intracranial pressure is transmitted to the perilymphatic spaces (scala vestibuli and scala tympani), leading to an increased pressure impinging on the cochlear duct17; this may cause progressive inner ear dysfunction, eventually leading to sensorineural hearing loss. patients may also show impaired vestibular function, as demonstrated in the current patient.18 dfnx2 is also associated with fixation of the (thickened) stapedial footplate, leading to the alternative term ‘conductive deafness with stapes fixation’ (dfn3). the increased pressure in the perilymphatic compartment, in particular within the vestibule, interferes with normal movement of the stapedial footplate, resulting in immobilisation.17 in this respect, the audiogram can be misleading, and suggest a false diagnosis of otosclerosis. stapedectomy, in an attempt to improve the conductive portion of the hearing loss, is, contraindicated in affected individuals, however. removal of the immobilised stapedial footplate results in a perilymphatic gusher owing to the fistulous connection between the internal auditory canal and the cochlea.19 because of attempted stapedectomy with resulting leakage in the past, the anomaly is sometimes referred to as ’x-linked stapes gusher’. dfnx2 is caused by a mutation in or around the pou3f4 gene on chromosome xq21.20 it is one of at least five loci implicated in congenital deafness.21,22 it is found in approximately 50% of families with x-linked hearing loss.23 most of the other types of x-linked hearing loss, such as x-linked deafness type 3 (dfnx3, dfn4), show no evidence of radiographic abnormalities of the temporal bone. however, the x-linked congenital deafness that was ascribed to a mutation on the type iv collagen gene col4a6 recently showed ct findings remarkably similar to dfnx2,21 which questions whether the terms ip type iii and dfnx2 should be used interchangeably. because of the x-linked recessive inheritance pattern, affected individuals with this type of mixed hearing loss are mostly male. these male patients typically present with profound hearing loss at birth, rapidly progressing to severe deafness within the first decade of life.23 although similar ct findings have been observed in affected female patients,24 female carriers tend to have milder forms of the same anomaly,4,18 resulting in normal hearing or only mild, moderate or delayed-onset hearing loss.1,9 however, ct imaging should be obtained in female patients with suspected family history who present with clinical features of the disease.24 despite the absence of a family history, as in our patient, a radiologist should suggest the diagnosis of dfnx2 when typical inner ear abnormalities are seen on ct. mri with a 3d constructive interference in steady state (ciss) should be obtained to confirm the presence of cochleovestibular nerves in the event that cochlear implantation is considered. preferably, an experienced neuroradiologist should interpret the imaging studies.9 a correct imaging diagnosis before surgical intervention might avoid a perilymphatic gusher and consequent complications, such as increased hearing loss or (recurrent) meningitis, in the patient, or even in other family members with hearing loss. recurrent meningitis may also occur spontaneously.8 in the patient presented here, neither genetic testing nor screening of relatives was performed. with normal outer diameters, but disorganised internal architecture of the cochlea, ip type iii can be treated successfully with cochlear implantation when sensorineural hearing loss is profound.9 apart from regular complications of cochlear implants, such as facial nerve stimulation or device failure, two major problems may occur peroperatively in ip type iii: perilymphatic gusher when the cochlea is opened (cochleostomy), and misplacement of the cochlear implant electrode in the iac. because of this possibility of electrode malpositioning, cochlear implantation in ip type iii was initially not advised.25 to prevent electrode misplacement, the surgeon should carefully consider the type of electrode to be used.9,10 in summary: ip type iii is a rare cause of mixed conductive and sensorineural hearing loss, but the radiologist may play a crucial role in both diagnosis and treatment of the disorder. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions e.b.a. (leiden university medical center; medical center haaglanden) drafted the manuscript. j.f. (leiden university medical center) and b.v. (leiden university medical center; radboud university nijmegen medical center) critically revised it for important intellectual content. references top ↑ altay h, savas r, ogut f, kirazli t, alper h. ct and mri findings in x-linked progressive deafness. diagn interv radiol. 2008;14:117–119. pmid: 18814129. gong wx, gong rz, zhao b. hrct and mri findings in x-linked non-syndromic deafness patients with a pou3f4 mutation. int j pediatr otorhinolaryngol. 2014;78: 1756–1762. pmid: 25175280, http://dx.doi.org/10.1016/j.ijporl.2014.08.013 kumar g, castillo m, buchman ca. x-linked stapes gusher: ct findings in one patient. ajnr am j neuroradiol. 2003;24:1130–1132. pmid: 12812938. phelps pd, reardon w, pembrey m, bellman s, luxom l. x-linked deafness, stapes gushers and a distinctive defect of the inner ear. neuroradiology. 1991;33:326–330. pmid: 1922747, http://dx.doi.org/10.1007/bf00587816 talbot jm, wilson df. computed tomographic diagnosis of x-linked congenital mixed deafness, fixation of the stapedial footplate, and perilymphatic gusher. am j otol. 1994;15:177–182. pmid: 8172298. tang a, parnes ls. x-linked progressive mixed hearing loss: computed tomography findings. ann otol rhinol laryngol. 1994;103:655–657. pmid: 8060062, http://dx.doi.org/10.1177/000348949410300814 chee nw, suhailee s, goh j. clinics in diagnostic imaging (111): x-linked congenital mixed deafness syndrome. singapore med j. 2006;47:822–824. pmid: 16924369. alizadeh h, nasri f, mehdizadeh m, jamsa s. computed tomography findings of a patient with severe dysplasia of the inner ear and recurrent meningitis: a case report of gusher ear in a five-year old boy. iran j radiol. 2014;11:e4168. pmid: 25763081, http://dx.doi.org/10.5812/iranjradiol.4168 incesulu a, adapinar b, kecik c. cochlear implantation in cases with incomplete partition type iii (x-linked anomaly). eur arch otorhinolaryngol. 2008;265:1425–1430. pmid: 18305951, http://dx.doi.org/10.1007/s00405-008-0614-z naito y. pediatric ear diseases. basel: karger; 2013. glasscock me, iii. the stapes gusher. arch otolaryngol. 1973;98:82–91. pmid: 4723769, http://dx.doi.org/10.1001/archotol.1973.00780020088004 bento rf, miniti a. x-linked mixed hearing loss: four case studies. laryngoscope. 1985;95:462–468. pmid: 4039021, http://dx.doi.org/10.1288/00005537-198504000-00017 jensen j, terkildsen k, thomsen ka. inner ear malformations with oto-liquorrhea. tomographic findings in three cases with a mixed hearing impairment. arch otorhinolaryngol. 1977;214:271–282. pmid: 576408, http://dx.doi.org/10.1007/bf00458322 cremers cw, hombergen gc, wentges rt. perilymphatic gusher and stapes surgery. a predictable complication? clin otolaryngol allied sci. 1983;8:235–240. pmid: 6652936, http://dx.doi.org/10.1111/j.1365-2273.1983.tb01434.x sennaroglu l. cochlear implantation in inner ear malformations–a review article. cochlear implants int. 2010;11:4–41. pmid: 19358145, http://dx.doi.org/10.1002/cii.416 sennaroglu l, sarac s, ergin t. surgical results of cochlear implantation in malformed cochlea. otol neurotol. 2006;27:615–623. pmid: 16788416, http://dx.doi.org/10.1097/01.mao.0000224090.94882.b4 swartz jd, loevner la. imaging of the temporal bone. new york: thieme; 2009. van de water t, staecker h. otolaryngology: basic science and review. new york: thieme; 2006. nance we, setleff r, mcleod a, sweeney a, cooper c, mcconnell f. x-linked mixed deafness with congenital fixation of the stapedial footplate and perilymphatic gusher. birth defects orig artic ser. 1971;7:64–69. pmid: 5173351. de kok yj, van der maarel sm, bitner-glindzicz m, et al. association between x-linked mixed deafness and mutations in the pou domain gene pou3f4. science. 1995;267:685–688. pmid: 7839145, http://dx.doi.org/10.1126/science.7839145 rost s, bach e, neuner c, et al. novel form of x-linked nonsyndromic hearing loss with cochlear malformation caused by a mutation in the type iv collagen gene col4a6. eur j hum genet. 2014;22:208–215. pmid: 23714752, http://dx.doi.org/10.1038/ejhg.2013.108 song mh, lee ky, choi jy, bok j, kim uk. nonsyndromic x-linked hearing loss. front biosci (elite ed). 2012;4:924–933. pmid: 22201925. petersen mb, wang q, willems pj. sex-linked deafness. clin genet. 2008;73: 14–23. pmid: 18005182. papadaki e, prassopoulos p, bizakis j, karampekios s, papadakis h, gourtsoyiannis n. x-linked deafness with stapes gusher in females. eur j radiol. 1998;29:71–75. pmid: 9934561, http://dx.doi.org/10.1016/s0720-048x(98)00027-8 phelps pd. cochlear implants for congenital deformities. j laryngol otol. 1992;106: 967–970. pmid: 1479272, http://dx.doi.org/10.1017/s0022215100121486 contents tib introduction the pregnancy-related syndromes of pre-eclampsia, eclampsia, the haemolysis, elevated liver enzymes and low platelets or hellp syndrome, and the thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome (ttp/hus) are a group of disorders sharing various clinical and pathogenetic features, principally related to endothelial damage and development of thrombotic microangiopathy triggered by pregnancy. the clinical abnormalities of these disorders include neurological disturbances, acute renal failure, hypertension, haemolysis, deranged liver enzymes, and thrombocytopenia. this review looks at the similarities and differences between these various pregnancy-related syndromes as well as some of the relevant imaging features that may sometimes be encountered by radiologists. definitions gestational hypertension is defined as blood pressure (bp) elevation of 140/90 mmhg or higher in a woman previously normotensive before 20 weeks’ gestation, without proteinuria. this is seen in about 6% of all pregnancies.1,2 pre-eclampsia is defined as gestational hypertension (bp ± 140/90 mmhg) with proteinuria > 0.3 g /24 hours. pre-eclampsia is seen in about 3 8% of all pregnancies.1,2 severe pre-eclampsia is defined as occurring when the bp is higher than 160 180/110 mmhg and/or evidence of systemic involvement or end-organ dysfunction.1,2 eclampsia is defined as the occurrence of seizures without any apparent neurological aetiology in a woman who has or who develops pre-eclampsia. about 2% of women with pre-eclampsia will develop seizures.1,2 the hellp syndrome is defined as the presence of haemolysis, elevated liver enzymes and thrombocytopenia. although often referred to as being severe pre-eclampsia with the additional features mentioned above, hypertension does not have to be severe or even present at all in the hellp syndrome. hellp syndrome occurs to some degree in about 4 39% of women with pre-eclampsia. when the platelet count is < 50 000/µl the syndrome is considered severe.1-3 ttp/hus is characterised by the presence of thrombocytopenia, haemolysis, neurological abnormalities and oliguric renal failure. most pregnancy-related cases occur in the last trimester or postpartum period, and many have associated preeclampsia. however, only 13% of cases in women with ttp/hus are pregnancyrelated.1,2 pathology the aetiology of these syndromes remains largely unclear, with several proposed theories including abnormalities of the placento-maternal unit, auto-immune disorders, endothelial cell damage and further genetic and dietary influences.1,4 the basic underlying process involves vascular endothelial cell damage. this, in turn, may be initiated by circulating factors released by the placenta secondary to ischaemic damage within the placenta itself. substances released by the damaged endothelium such as ultra-large multimers of von willebrand factor (vwf) and thromboxane a2 cause platelet activation and aggregation, further activating other clotting factors and fibrin. these plateletfibrin microaggregates then lodge in the microvessels (arterioles) either blocking them completely leading to reduced tissue perfusion, or partly leading to damage of erythrocytes as they are forced through the narrowed channels. this, in turn, leads to haemolysis and is therefore termed microangiopathic haemolytic anaemia or maha. the endothelial cell damage also results in an abnormal pressor response to both circulating vasopressor agents (e.g. angiotensin ii) and local endothelial ones (e.g. thromboxane a2, nitric oxide). this results in a generalised increase in vascular tone with resulting hypertension and vasospasm further contributing to endorgan hypoperfusion and damage. finally the endothelial damage leads to capillary leakage with the development of tissue oedema, reduced circulating volume and haemoconcentration. these are the basic common pathomechanisms behind the pregnancy-related thrombotic microangiopathies. the various clinical syndromes are largely differentiated by the degree of severity and specificity of the end-organ damage, although the common pathomechanisms permit an explanation for the considerable degree of clinical and pathogenetic overlap between them. clinical features these are largely related to the presence of vasomotor abnormalities and reduced tissue perfusion, as well as the effects of thrombocytopenia, haemolysis and anaemia, and mainly include neurological manifestations, hepatic and renal dysfunction, and coagulapathies. although preeclampsia is diagnosed on the basis of the elevated bp and proteinuria (minimal diagnostic criteria), there are a number of other associated abnormalities that when present make the diagnosis of pre-eclampsia more certain. these include mild thrombocytopenia with a platelet count of < 100 000/ml, haemolysis with an abnormal blood smear and increased lactate dehydrogenase (ldh) levels, elevated liver function review article 9 sa journal of radiology • october 2005 pre-eclampsia, eclampsia and the thrombotic microangiopathic syndromes of pregnancy i c duncan ffrad(d) sa unitas interventional unit centurion pg9-12 9/28/05 1:17 pm page 9 tests (alt, ast), epigastric pain and nausea due to liver distension, and neurological disturbances such as persistent headache or visual disturbances. whereas mild thrombocytopenia is common in women with pre-eclampsia (15 29% of cases), haemolytic anaemia is not and occurs in only about 2% of pre-eclamptic women. haemolysis, if significant enough, is more likely to be part of hellp or ttp/hus. hellp is characterised by low platelets (< 100 000/ml), haemolysis and elevated liver enzymes with associated swelling of the liver producing epigastric or right upper quadrant pain, nausea and vomiting. in rare cases spontaneous hepatic rupture may occur due to massive liver swelling. hypertension may or may not be present with hellp, and cerebral manifestations are rare.3 on the other hand, renal and cerebral complications are more frequently encountered in patients with ttp/hus,2,5,6 whereas liver function disturbances are not, although these patients may still develop abdominal pain, nausea and vomiting. the neurological features associated with ttp/hus include generalised mental status abnormalities (such as confusion, stupor or coma), focal neurological abnormalities (such as visual disturbances, aphasia, dysarthria, hemiparesis) and seizures. hypertension is not a feature of ttp/hus unless there is associated pre-eclampsia.2 put simplistically, pre-eclampsia/severe pre-eclampsia may have some or all of the abovementioned clinical features plus hypertension, whereas hellp mainly affects the liver and ttp/hus preferentially involves the kidneys and central nervous system. many cases of antepartum pre-eclampsia, hellp or ttp/hus will resolve spontaneously. some may persist, worsen or even change following delivery, e.g. from pre-eclampsia to hellp or ttp/hus. some cases develop de novo in the postpartum period. eclampsia developing within 48 hours after delivery occurs in approximately 25% of all eclamptics. late postpartum eclampsia (beyond 48 hours after delivery) is very rare and can occur up to 23 days after delivery.7,8 mortality due to eclampsia can occur in up to 13% of cases, while in the hellp syndrome mortality ranges from 2% to 24%.4 between 50% and 65% of maternal deaths due to eclampsia occur as a result of cerebral haemorrhage, with other causes including hypertensive encephalopathy, cardiac arrhythmias, congestive heart failure and disseminated intravascular coagulapathy. other complications that can occur in eclamptics include pulmonary oedema and retinal detachment.4 obstetric complications related to these syndromes include placental abruption and foetal distress and death. more about ttp/hus ttp was first described in 1925, being characterised by fever, fluctuating neurological manifestations, renal dysfunction, thrombocytopenia and haemolytic anaemia. hus was first described in 1955, being described primarily as a disease of childhood and also being characterised by fever, oliguric renal failure, thrombocytopenia and haemolytic anaemia. hus occurs mainly in young children due to infection by shiga-toxin producing enterohaemorrhagic strains of escherichia coli. these children invariably do well clinically with supportive therapy only.2,5,6more recently both ttp and hus have been recognised as being different clinical presentations of a common pathological spectrum of thrombotic microangiopathy, and are now referred to jointly as ttp/hus. there are idiopathic and familial forms of ttp/hus, with other cases of ttp/hus occurring secondary to cancer and chemotherapy, transplantation and immunosuppressive therapy, systemic infection, autoimmune disease, drug reactions and pregnancy. sixty-six per cent of all patients with ttp/hus are female. of these cases only 13% are pregnancy related, meaning that unlike hellp which is totally pregnancy-induced, only 8.5% of all ttp/hus cases are pregnancy related. some patients with ttp/hus have been found to be severely deficient in the activity of the metalloprotease adamts-13 (< 5% normal activity).9,10 adamts-13 cleaves ultra-large multimeric molecules of von willebrand factor (vwf) released by the endothelium. vwf is a potent activator of platelet activation and aggregation. therefore a severe deficiency of adamts13 allows uncontrolled platelet aggregation resulting in microvascular occlusion, thrombocytopenia and consumption coagulopathy. as not all patients with ttp/hus have adamts-13 deficiency there are clearly other pathogenetic factors involved that have yet to be elucidated. pregnancy has been shown to provoke acute ttp/hus in women with familial adamts-13 deficiency,2,5 particularly in homozygotes. without treatment ttp is fatal in 90% of patients. the only effective treatment is plasma exchange, thought to work by removing autoantibodies or other circulating pathogenetic trigger factors, as well as by replenishing absent levels of adamts-13. it is therefore important to differentiate cases with ttp/hus from those with severe pre-eclampsia and hellp as plasma exchange is of no benefit in the treatment of the latter pathologies.2,5,9 imaging features these are generally related to the neurological manifestations of these pathologies. cerebral vasospasm has been demonstrated in eclampsia and severe preeclampsia using a variety of imaging methods including transcranial doppler (tcd), magnetic resonance angiography and conventional catheter angiography (figs 1a, b).7,11-16 the true incidence of cerebral vasospasm in eclamptics and severe preeclamptics is unknown. similar findings have also been reported in patients with hellp,3,8 and we have seen a single case of cerebral vasospasm associated with postpartum ttp/hus. in addition to the abnormal pressor response of blood vessels relating to endothelial cell damage, the develop of cerebral vasospasm may also result in part due to high circulating levels of oxyhaemoglobin following breakdown of red blood cells due to the maha, with irritation of the vessels by the free oxyhaemoglobin itself.3 this spasm can affect intracranial vessels in an interrupted or continuous manner, and affects both large and medium-sized vessels. it mimics cerebral vasculitis angiographically.12,16,17 as review article 10 sa journal of radiology • october 2005 pg9-12 9/28/05 1:17 pm page 10 with the clinical symptoms the angiographic findings can spontaneously resolve within weeks of presentation.17,18 although most cases are eventually reversible, some can develop associated cerebral infarction or haemorrhage.13,18 the other major radiological abnormality seen in these cases is cerebral oedema. hypodense areas are seen on ct scans and hyperintense areas are seen on t2-weighted and flair mr images in such cases. these areas tend to be subcortical but can include the cortex, basal gangha and brainstem. associated infarction and haemorrhage are uncommon.19 two key differentiating features of cerebral oedema related to the pregnancy syndromes are firstly that the changes are commoner in the occipital and parietal lobes, and secondly that they are reversible.7,14,15,19,20 these features have led to coining of the term ‘posterior reversible encephalopathy syndrome’ (pres). pres is, however, not unique to pregnant patients, and has also been described in cases receiving immunosuppressive and chemotherapeutic drugs, after transplantation, in patients with hyperintensive encephalopathy, and in patients with ttp/hus due to causes other than pregnancy.10,21-23 despite a predilection for the posterior circulation territories, the deep structures and anterior circulation territories are also frequently involved (figs 2a-c). the density/signal changes are said review article 11 sa journal of radiology • october 2005 fig. 1a. 36-year-old woman with last trimester pre-eclampsia with severe postpartum hypertension and intracerebral haemorrhage 11 days after delivery. note the generalised spastic appearence of the central cerebral arteries at arteriography. fig. 1b. mirror oblique projection, left internal carotid artery showing diffuse vasospasm on this side as well. fig. 2a. 30-year-old woman who developed hellp syndrome and eclampsia shortly after delivery at 39 weeks. this flair mr image shows areas of increased signal in the cerebellum and pons. fig. 2b. similar areas of increased signal are seen in the occipital lobes and midbrain. fig. 2c. this image shows further involvement of the deep cerebral structures. there is relative sparing of the frontal and anterior parietal and temporal regions. the mr appearance is compatible with pres, predominantly affecting the posterior brain structures. fig. 2d. a gradient-echo sequence shows subtle early haemorrhage in both hemicerebellar hemispheres. this suggests the development of true infarctions with early haemorrhagic transformation, which is uncommonly seen in pres.there is also severe thrombocytopenia present at this stage. fig. 2e. a ct scan obtained 2 days later after further neurological deterioration now shows further haemorrhagic transformation of the cerebellar lesions, leading to greater brain swelling and eventual fatal outcome. pg9-12 10/8/05 11:16 am page 11 review article 12 sa journal of radiology • october 2005 to be due to vasogenic oedema, showing up on t2 and flair images but with negative diffusion scans. where present diffusion abnormalities suggest progression from vasogenic to cytotoxic oedema with cell death and infarction and thus poorer clinical outcome. subclinical haemorrhages may be seen using the appropriate gradient-echo or other blood/iron sensitive sequences (figs 2d,e). the pathophysiology of these reversible changes is incompletely understood and is felt to be due to a failure in cerebral autoregulation, possibly secondary to endothelial damage coupled with hypertension, vasospasm and micro circulatory ischaemic damage.21-23 the differential diagnosis for cerebral oedema and/or haemorrhage in pregnancy must include central venous/ dural sinus thrombosis and venous infarction, haemorrhage from a vascular malformation or aneurysm, arterial infarction and trauma.1,24 treatment the mainstay of prevention of eclampsia remains administration of magnesium sulphate. nimodipine has been shown to be less effective in this regard.25,26 supportive therapy such as platelet and blood transfusions, antihypertensive agents, dialysis and early delivery may all be of benefit in severe pre-eclampsia. highdose intravenous corticosteroid therapy is useful in hellp syndrome.27 there is a single documented case28 of percutaneous angioplasty used to treat eclampsia-related vasospasm with good angiographic and clinical results. conclusion in conclusion, the role of the radiologist in the diagnosis and management of these conditions is somewhat limited, but it is useful to have at least some understanding of their pathogenesis and in particular of the potential neurological complications and cause and recognition thereof. references 1. sloan ma, stern bj. cerebrovascular disease in pregnancy. current treatment options in neurology 2003; 5: 391-407. 2. mcminn jr, george jn. evaluation of women with clinically suspected thrombotic thrombocytopoenic purpura hemolytic uremic syndrome. j clin apheresis 2001; 16: 202-209. 3. knopp u, kehler u, rickmann h, arnold h, gilemroth j. cerebral haemodynamic pathologies in hellp syndrome. clin neurol neurosurg 2003; 105: 256-261. 4. lipstein h, lee cc, crupi rs. a current concept of eclampsia. am j emerg med 2003; 21: 223-226. 5. george jn. the association of pregnancy with thrombotic thrombocytopoeinic purpura hemolytic uremic syndrome. curr opin hematol 2003; 10: 339-344. 6. kakishita e. pathophysiology and treatment of thrombotic thrombocytopoenic purpura/ hemolytic uremic syndrome (ttp/hus). int j hematol 2000; 71: 320-327. 7. bartynski ws, sanghaui a. neuroimaging of delayed eclampsia. j comput assist tomogr 2003; 27: 699-713. 8. gilemroth j, knopp u, kehler u, felberbaum r, nowak g. hellp syndrome with hemoglobin vasospasm. j clin neurosci 2000; 7: 58-62. 9. vesely sk, george jn, lemmie b, et al. adamts13 activity in thrombotic thrombocytopoenic purpura haemolytic uraemic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. blood 2003; 102: 60-68. 10. lattuada a, rossi e, calzarossa c, candolfi r, marinucci pm. mild to moderate reduction of von willebrand factor cleaving protease (adamts13) in pregnant women with hellp microangiopathic syndrome. haematologica 2003; 88: 10291034. 11. qureshi bl, frankel mr, ottenlips jr, stern bj. cerebral vasospasm and eclampsia. stroke 1988; 19: 326-329. 12. trommer bl, homer d, mikhael ma. cerebral vasospasm and eclampsia. stroke 1988; 19: 326329. 13. geraghty jj, hoch db, robert me, vinters hv. fatal puerperal cerebral vasospasm and stroke in a young woman. neurology 1991; 41: 1145-1147. 14. sengar ar, gupta rk, dhanuka ak, das k. mr imaging, mr angiography and mr spectroscopy of the brain in eclampsia. am j neuroradiol 1997; 18: 1485-1490. 15. lewis lk, hinshow db, will ad, hasso an, thompson jr. ct and angiographic correlation of severe neurological disease in toxemia of pregnancy. neuroradiology 1988; 30: 59-64. 16. ito t, sakai t, inagawa s, utsu m, bun t. mr angiography of cerebral vasospasm in pre-eclampsia. am j neuroradiol 1995; 16: 1344-1346. 17. garner bf, burns p, bunning rd, laureno r. acute blood pressure elevation can mimic arteriographic appearance of cerebral vasculitis. j rheumatol 1990; 17: 93-97. 18. ursell mr, marras cl, farb r, rowed dw, black se, perry jr. recurrent intracranial hemorrhage due to postpartum cerebral angiopathy. stroke 1998; 29: 1995-1998. 19. dahmus ma, barton jr, sibai bm. cerebral imaging in eclampsia: magnetic resonance imaging versus computed tomography. am j obstet gynecol 1992; 157: 935-941. 20. raroque hg, orrison ww, rosenberg ga. neurologic involvement in toxemia of pregnancy: reversible mri lesions. neurology 1990; 40: 167169. 21. hinchey j, chaves c, appignani b, et al. a reversible posterior leukoecephalopathy syndrome. n engl j med 1996; 334: 494-500. 22. provenzale jm, petrella jr, cruz lch, wong jc, engelter s, barboriak dp. quantitative assessment of diffusion abnormalities in posterior reversible encephalopathy syndrome. am j neuroradiol 2002; 23: 1038-1048. 23. covarrubias dj, luetmer ph, campeau ng. posterior reversible encephalopathy syndrome: prognostic utility of quantitative diffusion-weighted mr images. am j neuroradiol 2002; 23: 10381048. 24. mantello mt, schwartz rb, jones km, ahn ss, tice hm. imaging of neurologic complications associated with pregnancy. am j roentgenol 1993; 150: 843-847. 25. naidu s, payne aj, moodley j, hoffmann m, gouws e. randomised study assessing the effect of phenyton and magnesium sulphate on maternal cerbebral circulation in eclampsia using transcranial doppler ultrasound. br j obstet gynaecol 1996; 103: 111-116. 26. belfort ma, anthony j, saade gr, allen jc. a comparison of magnesium sulfate and nimodepine for the prevention of eclampsia. n engl j med 2003; 348: 304-311. 27. martin jn jun., thigpen bd, rose ch, cushman j, moore a, may wl. maternal benefit of high-dose intravenous corticosteroid therapy for hellp syndrome. am j obstet gynecol 2003; 189: 830-834. 28. ringer aj, quereshi ai, kim s, fessler rd, guterman lr, hopkins ln. angioplasty for cerebral vasospasm from eclampsia. surg neurol 2001; 56: 373-379. pg9-12 9/28/05 1:17 pm page 12 98 sa journal of radiology • december 2010 review article introduction radiologists have always collected copies of model examples and interesting cases encountered in daily practice to use for teaching purposes.1,2 a collection of teaching files is an important resource for medical education and the dissemination of knowledge in radiology. furthermore, the presence of a radiological teaching file is also a requirement at several universities and tertiary institutions in south africa and abroad, where radiology postgraduate training is conducted.2 the advent of digital radiology and the more widespread use of picture archiving and communication systems (pacs) have led to a unique opportunity to change the way that radiology teaching cases are collected, stored and managed. traditional teaching file systems are rapidly becoming obsolete and incompatible with the digital environment of modern radiology departments.3,4 traditional v. digital teaching files the traditional way in which radiology teaching cases were collected comprised mostly film-based teaching file systems that were compiled and stored in a store room or filing cabinet. the cases would typically be stored or archived according to anatomical site or pathological process, often using the american college of radiology (acr) anatomical or pathological codes as indices. with the advent of digital radiology, radiological images are acquired in an inherent digital format, which lends itself to the unique position of digital teaching files (dtf). with a dtf, the selected images and appropriate information are stored electronically and then recalled for review on a personal computer. shortcomings of traditional teaching files compilation of film-based teaching cases was cumbersome, with several steps needed to create a teaching case: • identify an appropriate case • request copies of the selected radiographs • write clinical and radiological information on the film packet • code according to the filing system • file in store room or cabinet. managing and storing traditional teaching file cases can also be problematic, especially if the library consists of hundreds or thousands of cases. not only is accurate archiving of the cases time-consuming but physical storage space can also be a problem. the additional issue of film degradation, when film is kept over long periods (especially if not under optimum conditions), can also be problematic. radiograph envelope degradation is also of concern. cases can only be viewed at one location at a specific time – this may therefore limit the availability of cases if there are multiple viewers at different locations. duplication of traditional teaching cases to share them among different sites is possible although less than ideal – radiographs need to be duplicated, with resultant loss in image quality. characteristics of the ideal dtf the creation of a dtf requires several steps. first, a suitable case has to be selected and appropriate selected images identified. the selected images should then be submitted in the appropriate format to the teaching archive. the case should then be edited to include annotations, relevant clinical history, teaching notes or tips, and references (if available) to optimise its teaching potential. once the case has been completed, it should be made available for use or review by the targeted users.1 the ideal dtf system should therefore possess the following characteristics to maximise its usefulness: • versatility. the system should be able to support the whole process of case preparation from image acquisition through image editing and case annotation, to structured organisation of cases, comprehensive search and cross-referencing functionality (on multiple parameters), and secure image storage.1 • accessibility. dtf cases should be easily accessible either within the hospital computer network or internet (if desired). selective access rights may also be implemented to prevent unauthorised access or inappropriate use. the ideal system should employ some form of copyright protection to prevent unauthorised duplication. • ease of use. the system should be user-friendly, quick to use and intuitive. where possible, integration into the daily workflow of the pacs system is very important to minimise the impact on clinical workflow.1 • compatibility. dtf system software and hardware should be compatible with a variety of image formats and should also seamlessly interface with departmental hardware (and software/pacs) to allow direct transfer of images and dtf case creation.1 compatibility should be pacs vendor-independent and ideally the interface should be built on the ihe tce (integrating the healthcare enterprise teaching file and clinical trial export) protocol. • flexibility. the case database should be easily viewed either as unknowns or by user-defined searches.1 this would enable the system to be used as a reference library or for exam preparation if unknown cases are to be reviewed. digital teaching files – a useful teaching tool for the modern radiologist andré tertius du plessis, mb chb, mmed rad diag, fc rad diag (sa) department of radiology, steve biko academic hospital, pretoria (current affiliations: scholtz and partners, and department of radiology, university of pretoria) sa journal of radiology • december 2010 99 review article • installation. installation should be uncomplicated, with the minimum amount of software installation needed. web interface software is ideal in this situation, minimising software installation on the user pc. advantages of dtf v. traditional image libraries several advantages of dtf systems are apparent;3 the most prominent are: • cost-effectiveness. this important advantage should not be overlooked. while the initial set-up costs of dtf systems may be higher compared with the traditional system (owing to the cost of expensive hardware), the everyday maintenance and cost per case produced is less with a dtf system. the current cost of radiographic film (approximately r5 r30 per film depending on size and type of film) adds an additional cost to each traditional teaching case, whereas dtf systems utilise electronic storage, which is significantly cheaper on a per-case basis.5 the initial cost outset may also be lessened by the fact that dtf system hardware may be utilised for different tasks. • simultaneous access. owing to the digital format of dtf cases, a specific case from the dtf library can be reviewed at multiple separate locations. • data duplication. the ability to duplicate dtf cases very easily without any loss of image quality is also a major advantage. therefore, potential library duplication or shared libraries between several institutions are real and viable options. • transfer of dtf. transfer of a digital collection is extremely easy compared with a traditional system. this can be achieved either via network transfer or via portable storage media (e.g. dvd or portable hard disk).6 • interactivity. with a digital system, it is possible to add interactive elements to dtf cases (i.e. self-evaluation tests or quizzes).7 • searchability. searches across multi-level parameters are possible (i.e. not only searching for a specific anatomical site or pathological process, but also combining anatomical site, pathological process, image modality, patient parameters and more). • facilitation of case creation. a digital system greatly facilitates the process of case creation compared with the traditional system. as mentioned earlier, the process of creating a traditional teaching case is cumbersome. creating a dtf case simplifies these cumbersome steps into easier and more streamlined case creation – the selected images are transferred directly from the pacs8 to the dtf system, the user then adds information and annotations as needed via the dtf software, and the case is immediately available on the dtf library.9 current problems with dtf systems with the great technical advances in digital radiology and pacs, it is unfortunate that dtf systems have not received the same great level of advancement. it would seem that most pacs vendors initially underestimated the value of a comprehensive incorporated dtf system as most of the pacs software lacks incorporated dtf functionality as required. some pacss do, however, offer limited dtf capability, albeit with limited functionality.1,2,10-12 another disadvantage of such systems is the limitation of only being able to access such cases via a pacs workstation (as such cases remain on the pacs). additionally, this may incur separate costs, depending on the licensing model of the pacs or ris vendor. this drawback has led to many institutions now relying on thirdparty applications or even custom-developed dtf systems.3 the use of third-party applications has its own set of problems. firstly, considerable effort, financial commitment and expertise are needed to implement such a dtf system, especially at larger institutions.1 secondly, the different types of dtf solutions unfortunately do not all demonstrate inter-compatibility and functionality – this is problematic where sharing or duplication of dtf libraries is planned. this lack of inter-compatibility is also a problem when planning to move from one dtf system to another – the older dtf cases may not be compatible with the new system, leading to extra time, effort and cost to convert older cases. even though some dtf systems comply with most of the required functionality, integration into the normal workflow is still problematic with most systems. this unfortunately leads to under-utilisation of the dtf system, as creating cases is too time-consuming and disruptive to normal daily workflow – in such instances, case creation (and therefore educational opportunities) will take a back seat to the pressures of clinical workflow.2 some dtf systems, on the other hand, offer the required functionality and versatility but lack the user-friendliness and ease-of-use, which unfortunately will not encourage individuals (especially those who are not computer literate) to both contribute cases and also to choose to use the teaching file system as part of their preferred learning resource. a system understandable only by computer scientists is likely to be quietly ignored. current different types of dtf system there are several different third-party applications available to use as dtf system solutions. broadly, these applications can be categorised as institution-based technology or internet-based image libraries (although there are some applications that span both groups). institution-based technology the easiest and most cost-effective way to establishing a dtf system is to use a system incorporated into the pacs. although many commercially available pacss allow for creation of a teaching folder, these folders unfortunately often lack the desired functionality and versatility.2,10-12 there are multiple teaching file authoring packages available which have been specifically developed for radiologists.13-15 these packages are designed for rendering teaching file creation on a local network or intranet. examples of such packages include mypacs.net custom (vivalog technologies, www.mypacs.net) and casimage (pubimage. hcuge.ch). casimage is a database system developed at the digital imaging unit of geneva university hospital, switzerland. images can be sent directly from pacs to the dtf server and can either be converted to a joint photographic expert group (jpeg) file at the workstation or sent in digital imaging and communications in medicine (dicom) form to the server, where they are automatically converted. unfortunately, all these solutions come at a considerable cost: casimage software currently 100 sa journal of radiology • december 2010 review article sells for about us$8 000 and mypacs.net for a similar amount. mypacs was originally developed to be an internet-based system but may now be purchased to use as a stand-alone institution-based system. several other innovative ways have been described to create dtf systems. one such system uses advantage windows workstations (general electric medical systems, milwaukee, usa) – a tagged image file format (tiff) file is created from the relevant images and then stored on another computer connected to the local network which supports file transfer protocol (ftp), after which such files are manually entered into a database. this is a reasonable approach but requires programming expertise.11 another way is to export images from workstations to other computers using inexpensive, commercially available ‘screen-grab’ software. products such as snag it (tech-smit, east lansing, mi, usa, www.snagit.com) allow images to be sent directly to a remote server. although simple in essence, this solution still requires an authoring and database system for the images to be sent to.11 an alternative way of transmitting images via email has been described: images and some text are sent via email to the teaching file database. the images and text are automatically extracted from the email message and captured into the database, with only the need to add finishing touches to the case at a later stage. internet-based technology internet-based teaching files in essence require dtf cases to be stored on an internet-based server, which then allows access to these table i. quick reference table internet based: mypacs.net hybrid: mirc hybrid: mypacs.net institutional: vendor based institutional: casimage easy integration with workflow no requires programming, unless vendor uses ihe tce requires programming yes requires programming adding dicom images to dtf yes yes yes yes yes adding other image formats to dtf yes yes yes no yes adding relevant clinical info to dtf excellent excellent excellent no excellent dtf as reference library – user-defined searches excellent excellent excellent limited excellent dtf as exam preparation – 'unknowns' excellent excellent excellent limited excellent personal use limited excellent excellent excellent excellent institutional/ practice use limited excellent excellent limited excellent multi-institutional use excellent excellent excellent limited no vendor-independent yes yes yes no yes software web interface web interface web interface pacs/ris interface web interface hardware client pcs server and client pcs server and client pcs client pcs server and client pcs cost us$8 000 free, software must run on a server us$8 000 server software and hardware included in pacs, free of charge. client usage may be license bound and at additional cost. us$8 000 sa journal of radiology • december 2010 101 review article cases from remote locations. this has the obvious advantage of being accessible from remote, non-work network-related locations (such as from home). however, this raises several issues of concern. firstly, there is the issue of privacy, with the anonymity of images being essential (especially if accessible over the internet by nearly anyone). the second issue of concern is copyright, with the question of whether the creator of the dtf case or the software developer company holds the copyright.1 thirdly, to utilise such a system, internet connectivity is required; this may not always be possible, depending on bandwidth availability (developing countries) as well as it regulations of the practice or institution. online teaching files fall into two categories: static websites, where cases are stored in hypertext mark-up language (html) documents indexed by a list of hyperlinks and, secondly, dynamic (database-driven) web applications. for static websites, each case is created as an html document that contains images and text, with a labelled hyperlink from the collection index page. there are numerous static websites available on the web, a prime example being eurorad (www.eurorad.org). several dynamic database internet-based dtf authoring packages are available for use in developing image libraries. one such is mypacs (www.mypacs.net), which allows radiologists to create their own teaching files cases from any web browser to add to the large growing collection of cases.16 the software supports over 60 file formats and automatically converts such files into the appropriate format used in mypacs cases. access to dtf cases can be restricted to the authoring radiologist or, alternatively, be made freely available to all users. medpix is another free database of images accessible from the internet (rad.usuhs.mil/medpix).14 radiologists can submit cases, but they have to be peer-reviewed by the editorial committee before being accepted. brighamrad (brighamrad.harvard.edu/), the online teaching file of brigham and women’s hospital in boston, usa, is another online database-driven system. this dtf database is available to external users over the internet, but individuals or institutions not affiliated to brigham and women’s hospital may not contribute cases.17 hybrid systems these systems were originally developed as intuition-based technologies with the option of connecting to other similar systems via the internet or over a wide area network (wan). this group has the added advantage of locally based content that can be augmented by content from similar systems not in the same location. these systems then are the ideal configuration where multiple sites require their own dtf library but still want the functionality to connect to other similar sites to broaden their content. examples of hybrid systems are mirc (medical image resource centre) (mirc, www.mirc.rsna.org) and mypacs.net (www. mypac.net). mirc is an ambitious attempt by the radiological society of north america (rsna) to link online teaching files and construct a global library of digital images and supporting content. mirc is available as a free program from the rsna mirc site. the ultimate aim is to facilitate content searching where a user would only need to log onto one site that searches all available resources, instead of the user needing to search each site individually. this aim will be made possible because every participating image repository files its index card with mirc. it is however also possible to restrict access to certain files, if needed. mirc makes use of the extendible mark-up language (xml), a so-called metalanguage that can be used to pass information between different computer systems that would otherwise be unable to communicate. any mirc site functions as both a query service and a storage service. in its query service role, it provides access to the entire mirc (if connected via the internet, or only to the local cases if not) by presenting a query form to the user, distributing the search criteria to all selected storage services, collating the responses and presenting them back to the user. in its storage service role, it responds to the query received from the query service, searches its index for documents meeting the search criteria, and returns abstracts and links to those documents to the query service.1,2,18 several add-ons for the mirc software have been developed, aiding with mirc integration in pacs systems among others. requirements of dtf at a tertiary institution in south africa very little information is available on the specific requirements of a dtf system at tertiary institutions in south africa. searches on pubmed (www.pubmed.com), medline and google (www.google.com) on this subject yielded no suitable literature on the specific subject of requirements at tertiary institutions in south africa. requirements set in this regard at the pretoria academic hospital in south africa during implementation of the current dtf system related to ease of use, the ability to host multiple users, the option of dtf case confirmation before publishing, and cost of implementating such a system. another requirement – that of compatibility with other systems in the possibility of a national dtf archive – is currently in the planning stage (initiated as a joint effort between pretoria academic hospital and tygerberg hospital). the road forward in the recent past, radiology as a whole has been transformed with the advent of digital systems. there have been significant changes, not only in the digital acquisition of images but also in the digitisation of image review, image manipulation, image reporting and distribution of reports to the referring clinicians. the advent of digital radiology with the implementation of ris/pacs systems has changed radiology forever. case libraries for teaching unfortunately did not receive the same jolt in advancement. however, dtfs will become the standard method of creating, archiving and displaying relevant cases for teaching purposes as the radiological field gradually progresses into digital radiology. on a general scale, implementation of dtf library systems in the ris/pacs environment should be actively pursued by vendors, with the focus on implementing an integrated solution. if possible, these solutions should be cross-vendor compatible to facilitate dtf library duplication or joint dtf library ventures between institutions operating software from different vendors. the logical choice in this instance would be to build on the existing ihe tce protocol and to ensure that vendor solutions conform to and are fully compliant with the ihe tce protocol. if third-party software is utilised, this should also conform to and be compliant with the ihe tce protocol. 102 sa journal of radiology • december 2010 review article on a national scale in south africa, the focus should be on developing local dtf libraries at the major academic and tertiary institutions. once these are implemented, a national dtf library should be the goal, either by local dtf library duplication and exchange with other institutions, or possibly even a centralised dtf library accessible from all sites. this can, however, only be achieved if there is compatibility between the systems implemented at the different institutions. another recently proposed application of the dtf library software or other form of electronic format is the use of such cases during examinations for postgraduate degree purposes. however, this brings with it some challenges, including (but not limited to) logistical problems, ensuring proper image quality during display (especially if projected), and the introduction of a new medium in established examinations. this form of examination of postgraduate candidates will most likely require some further research and development before it will become standard practice. conclusion radiology teaching files are an important and fundamental aspect of radiology training. the advent of digital radiology, ris/pacs and the resulting transformation of modern radiology departments into a digital environment have led to the traditional teaching file system rapidly becoming obsolete. with these changes, the dtf system has stepped to the forefront and will most likely be the manner in which teaching file cases will be submitted, organised and archived. implementation of a dtf system, especially in radiology departments equipped with a ris/pacs system, is essential. unfortunately, development of vendor-specific dtf solutions has lagged behind the advances seen in the other fields of digital radiology. there are several different types of dtf solutions, including thirdparty applications, each with its own advantages and disadvantages. these should be carefully reviewed before implementation. academic and tertiary institutions, especially in south africa, will require specific needs for a dtf system which will be different from international first-world institutions or private sector practices (whether national or international). the cost of system implementation, among other factors, is a major consideration in the south african context. 1. scarsbrook af, foley pt, perris rw, et al. radiological digital teaching file development: an overview. clinical radiology 2005;60:831-837. 2. monkolwat p, bhalodia p, makori a, et al. integrating mirc-compliant semi-automated teaching files into pacs work flow. radiographics 2005;25:543-548. 3. rosset a, ratib o, geissbuhler a, et al. integration of a multi-media teaching and reference database in a pacs environment. radiographics 2002;22:1567-1577. 4. wiggins rh, davidson h, dilda p, et al. the evolution of filmless radiology teaching. j digit imaging 2001;14:236-237. 5. tran th, roach na, o’kane pl, thune m. creating a digital radiographic teaching file and database using a pc and common software. am j roentgenol 2000;175:325-327. 6. wangel m, niemitukia l, katia t, et al. www: an effective way of teaching radiology. comput methods programs biomed 2001;66:91-98. 7. maleck m, fischer m, kammer b, et al. do computers teach better? a media comparison study for casebased teaching in radiology. radiographics 2001;21:1025-1032. 8. goldberg d, demarco jk, parikh t. internet based interactive teaching file for neuroradiology. am j roentgenol 2000;175:1371-1373. 9. mehta a, dreyer kj, montgomery m, et al. a world wide web internet engine for collaborative entry and peer review of radiologic teaching files. am j roentgenol 1999;172:893-896. 10. henderson b, camorlinga s, degagne jc. a cost-effective web-based teaching file system. j digit imaging 2004;17:87-91. 11. maldjian ja, listerud j. automated teaching file and slide database for digital images. am j roentgenol 2000;175:1249-1251. 12. halsted mj, moskovitz j, johnson n, et al. a simple method of capturing pacs and other radiographic images for digital teaching files or other image repositories. am j roentgenol 2002;178:817-819. 13. jakobovits r. mypacs teaching file management system. http://www.mypacs.net (accessed 1 march 2008). 14. smirniotopoulos jg. medpix™ medical image database. http://rad.usuhs.mil/medpix (accessed 1 march 2008). 15. rosset a. casim@ge teaching file database. http://pubimage.hcuge.ch (accessed 1 march 2008). 16. weinberger e, jakobovits r, halsted m. mypacs.net: a webbased teaching file authoring tool. am j roentgenol 2002;179:579-582. 17. holman bl, mammone gl, greenes ra, et al. brighamrad: an approach to education, decision support, information dissemination, and collaboration via the world wide web. http://ej.rsna.org/ej_0_96/001096/0010-96.sit/title_page.html rsna ej 1996 (accessed 1 march 2008). 18. medical imaging resource center. mircwiki.rsna.org. (accessed 1 march 2008). original article 52 sa journal of radiology • september 2010 original article abstract knowledge of the approximate caudal termination of the dural sac (ds) is important, especially when placing the portal fields during lower craniospinal irradiation (csi) and performing caudal anaesthesia. the purpose of this investigation was to determine the level of termination of the ds in relation to the spine in a group of south african patients by using magnetic resonance imaging (mri). we retrospectively reviewed the lumbosacral mr imaging of 309 patients, in each case identifying the tip of the ds. this level was recorded in relation to the adjacent lumbosacral vertebral body i.e. upper-, middleand lower-third and adjacent intervertebral disc. the overall mean of the ds position was at the middle third of s2. although the caudal ds tip was at the level of s2 in the majority of patients, a notable percentage (13.9%) had a ds tip level lower than the lower third of s2, and 15.2% had levels higher than the s1-s2 intervertebral disc. this study failed to demonstrate a difference in the ds termination level, compared with the levels reported in various international studies; nor is there a statistical difference between gender, race and age. our study shows that routine placement of the portal field at the lower border of s2 adequately treats the majority of csi patients. however, some patients (13.9%) will be undertreated and some patients (15.2%) will be overradiated. using spinal mri to establish the lower border of the csi portal field will, however, benefit patients by ensuring adequate coverage of the entire neuroaxis as well as minimising late gonadal toxicity owing to overradiation. introduction the spinal cord ends at the level of the l1-l2 disk space, with the nerve roots extending caudally in an enclosed sac known as the dural sac (ds). the ds protects the dangling nerve roots and is made up of two distinct but tightly bound layers called the dura mater and arachnoid mater. generally, the mean level of termination of the ds, which has been described in the standard textbook and some cadaveric studies, is located at the second sacral vertebral level.1-3 however, cadaveric dissection is subject to distortion, and measurements may alter after skeletonisation of the cadaver.4 variations in the level of the ds termination were shown in previous studies where the ds extended caudally to the s2 level.3,5 in defining and/or placing the distal portal fields for csi in the treatment of cerebrospinal fluid (csf) seeding or leptomeningeal metastasis, the radiotherapist needs to know the level of the ds ending to ensure complete coverage of the entire subarachnoid space. in patients where the ds tip ends very low, the distal part of the spinal column might be excluded from the radiation field, whereas patients with a ds ending higher than expected will receive unnecessary irradiation to their pelvic organs. a caudal approach to the extradural space (caudal block) is used for intraand postoperative analgesia in a variety of operations, as well as the management of chronic pain. a detailed understanding of the anatomy of the caudal region of the extradural space is therefore desirable for clinicians using this technique. the ds ending is most relevant to clinical practice as the length of the needle used to perform the caudal block should be carefully chosen to avoid puncturing the dura.6 the development of mri has greatly enhanced our understanding of the living human anatomy. with the help of mri, it is possible to determine the vertebral level of termination of the ds in the living individual.7 the level of the caudal ds tip in the adult population, as determined by mri, has been described in various studies.5,6,8,9 these studies were, however, all limited in the number of cases reviewed. knowing the caudal termination of the ds in the south african population is important, especially for more precise performance of the distal spinal part of a csi, and also for caudal anaesthetic blocks. the purpose of this investigation was to determine by using mri the level of termination of the ds in relation to the spine in a group of south african patients, and to compare this position among age groups, gender, and black and white racial groups. material and methods t1 and t2 sagittal spin-echo mr images made between october 2007 and november 2008 of the lumbar-sacral spine of 526 patients were retrospectively reviewed in the department of diagnostic radiology, universitas hospital, bloemfontein. of this number, 217 (41.3%) of these examinations were excluded from our study owing to previous spinal surgery, presence of congenital anomalies such as scoliosis, severe degenerative changes and malignancies in the lumbosacral area, and in patients where identification of the ds was difficult. data from 309 (58.7%) patient records were included in the statistical analysis. the study group consisted of patients who were referred to the mr scanner for assessment of possible causes of lower back pain and mri determination of the vertebral termination of the dural sac tip in a south african population: clinical significance during spinal irradiation and caudal anaesthesia a cilliers, mb chb, da(sa) d h schulenburg, mmedsc, mb chb j janse van rensburg, mb chb, mmed (diagn rad), dip gen intervent radiol department of diagnostic radiology, faculty of health sciences, university of the free state, bloemfontein original article 53 sa journal of radiology • september 2010 radiculopathy. mr scans were reported as either normal or with minor age-related degenerative changes. fig. 1 shows an mr image of the lumbosacral spine to demonstrate our method for determining the position of the caudal tip of the ds. mri of the spine was performed on a signa 1.5t (ge medical systems, milwaukee, usa) using a phased array spine coil, with the patient supine. sagittal images were acquired using a slice thickness of 4.0 mm and a 1 mm interslice gap. although both t1and t2-weighted sagittal images were available, the relevant anatomy was better demonstrated by the latter imaging protocol. each patient's age, sex, race and location of the lower limit of the ds were recorded. the most caudal level of the ds was determined in relation to the adjacent vertebra and disc space. this was done by extending a line, perpendicular to the long axis of the dura, across to the adjacent vertebrae and disc space. in accordance with the method of saifuddin et al,10 each vertebra was divided into 3 equal portions (upper, middle and lower thirds respectively) and the intervertebral disc was defined as a separate region (see fig. 1.) the image that showed the most inferior convergence point of the ds was used for measurement. for statistical evaluation, each lumbosacral vertebral regional level of the caudal ds tip was assigned a number; for example, the upper third of l5 = 1 and the upper third of s4 = 17. results were summarised by the department of biostatistics according to frequencies and percentages (categorical variables) and means, standard deviation or percentiles (numerical variables). subgroups (race, gender and age groups) were compared for differences between percentages. the study was approved by the ethics committee of the faculty of health sciences of the university of the free state. fig. 1. a midline, sagittal, t2-weighted, spin-echo mr image of the lumbosacral spine demonstrating our method for determining the position of the tip of the dural sac. fig. 2. distribution of different levels of the dural sac tip as determined by means of a t2-weighted mri of the lumbar spine. table i. comparison of ds tip levels by race level of ds tip no. of patients (%) p-value black (n=118) white (n=191) l5 low 0 (0) 1 (0.5) 1.000 l5-s1 disc space 1 (0.9) 1 (0.5) 1.000 s1 high 2 (1.7) 5 (2.6) 0.712 s1 middle 6 (5.1) 8 (4.2) 0.781 s1 low 11 (9.3) 12 (6.3) 0.323 s1-s2 disc space 19 (16.1) 26 (13.6) 0.547 s2 high 20 (16.9) 36 (18.8) 0.674 s2 middle 27 (22.9) 48 (25.1) 0.654 s2 low 13 (11.0) 30 (15.7) 0.247 s2-s3 disc space 13 (11.0) 9 (4.7) 0.036 s3 high 5 (4.2) 14 (7.3) 0.272 s3 middle 0 (0) 1 (0.5) 1.000 s3 low 1 (0.9) 0 (0) 0.382 table ii. comparison of ds tip levels by gender level of ds tip no. of patients (%) p-value male (n=133) female (n=176) l5 low 1 (0.8) 0 (0) 0.4304 l5-s1 disc space 0 (0) 2 (1.1) 0.5081 s1 high 1 (0.8) 6 (3.4) 0.2456 s1 middle 8 (6.0) 6 (3.4) 0.2856 s1 low 11 (8.3) 12 (6.8) 0.6659 s1-s2 disc space 23 (17.3) 22 (12.5) 0.2750 s2 high 19 (14.3) 37 (21.0) 0.1383 s2 middle 34 (25.6) 41 (23.3) 0.6885 s2 low 16 (12.0) 27 (15.3) 0.5071 s2-s3 disc space 10 (7.5) 12 (6.8) 0.8266 s3 high 9 (6.8) 10 (5.7) 0.8120 s3 middle 0 (0) 1 (0.6) 1.0000 s3 low 1 (0.8) 0 (0) 0.4304 original article 54 sa journal of radiology • september 2010 original article results images from 309 patients were assessed for the study. the group included 191 (61.8%) white and 118 (38.2%) black patients. one hundred and seventy-six (57%) patients were female and 133 (43%) male, with ages ranging from 18 83 years. a spectrum of ds endings was seen extending from the lower third of l5 to the lower third of s3. the distribution frequency of levels of termination of the ds in all patients on mr images demonstrated that the median ending of the ds was located at the middle third of s2, as observed in 75 (24.3%) patients (fig. 2). in 15.2% of patients, the ds terminated at levels above the s1-s2 intervertebral disc space, while 13.9% had ds levels below the lower border of s2 (fig. 2). the caudal ds tip was located between the level of the s1-s2 interspace and the lower third of s2 in 70.9% of the study population. regarding racial distribution, the study group consisted of 118 (38.2%) black and 191 (61.8%) white patients. the mean ds tip levels of the black and white patients (22.9% and 25.1%, respectively) were at the middle third of s2 (table i). no statistical differences in the mean level of the ds tip were observed between black and white patients. the study group was divided into the following age groups; the number of patients in each group is in brackets: 18 29 years (35), 30 39 years (63), 40 49 years (91), 50 59 years (64), 60 69 years (46) and 70 83 years (10). this was done to determine any notable difference in the position of the ds tip with increasing age. the mean ds levels in the age groups 18 29, 40 49, 50 59 and 70 83 years were at the middle third of s2, while patients in the age groups 30 39 and 60 69 years showed a mean level in the upper third of s2. no statistically significant differences in ds levels were seen with increasing age. a comparison of male and female patients was also performed to determine any gender-related differences in the caudal vertebral position of the ds tip. results are shown in table ii. the mean levels for the male (25.6%) and female (23.3%) patients were both at the middle third of s2, with no statistical differences noted between the two genders. discussion the supposition that the lower border of the ds tip was situated at the inferior edge of s2 had been widely accepted for many years, based mainly on published findings from autopsies performed on adults.11,12 larsen et al.13 performed a radio-anatomical study of the ds in patients subjected to myelography. they reported that the tip of the ds ended at the s1-s2 intervertebral disc space in the majority of cases, and further described a range of ds tip endings extending from the l5-s1 to s4-s5 intervertebral disc spaces. previous studies of the lumbar spine utilising mr imaging to visualise the ds demonstrated a mean level of termination at the middle third of s2,5,6,14 similar to the level found in our study. in contrast to our findings, macdonald et al.5 found minor gender differences in the level of ds termination, with the level ranging from the upper third of s1 to the upper third of s4, which is slightly lower than the spectrum found in our study. the findings reported here are of particular importance as far as caudal block, csi and spine surgery are concerned. routine setting of the radiation field with csi is at the inferior border of the s2 vertebra. this recommendation has largely been based on myelography and autopsy studies performed in adults.2,11,12 some of the limitations imposed on cadaveric studies are based on a predominantly aged group of subjects and include unselected subjects plus time-dependent shrinkage of the specimens. in a living population, mri appears to be a reasonable alternative for determining the level of the ds and anatomy of the lumbosacral region. the advantages of mri are (i) it identifies possible disorders in live healthy subjects, (ii) the spinal column is in the supine position, and (iii) the age range is wider when a living population is investigated compared with cadaveric studies. our study demonstrated a spectrum of ds endings ranging from the lower third of l5 to the lower third of s3, similar to the published findings from previous studies.8,15 we determined that, across the various groups included in this study, the ds most commonly terminated at the middle third of the s2 vertebra, which is consistent with the findings of macdonald et al.,5 although it differs from previous studies where the ds termination was reported at the upper third of s2.8,15 binokay et al.8 attributed this difference from other studies to racial differences and techniques used in the study groups. as with other studies,14-16 we were unable to demonstrate a statistical difference between the level at which the ds terminated in black or white patients, and could find no association between age and the level of ds termination. we were also in agreement with others3,15 who could find no statistical difference between male and female patients. the study by macdonald et al.5 did, however, report a difference in the ds termination level between males and females. the findings reported here are also of great consequence for csi. the entire neuroaxis should be covered by ensuring that the ds is included in the spinal field.15,17 at our oncology centre, the routine placement of the csi field is at the lower border of s2. according to our results, 13.9% of patients showed a ds termination below the lower border of s2, which is consistent with data published by nazmy et al.16 who determined that the inferior border of the ds was lower than the inferior border of s2 in 31% of patients. dunbar et al.17 found that 14.7% of patients showed a ds termination below the s2-s3 junction, while scharf et al.15 reported similar findings, with 8.7% of patients having a ds lower than the s2-s3 junction. consequently, these patients would be undertreated if the lower border of the csi spinal field were placed at the inferior border of s2. this may lead to considerable geographical miss, probably with negative effects on local control of the disease. in 15.2% of the patients included in our investigation, the inferior border of the ds was situated above the s1-s2 intervertebral space. dunbar et al.17 showed that in 16.6% of patients, the inferior border of the ds was at mid-s1, whereas data reported by scharf et al.15 showed that 17.4% of patients had a ds termination at this level. on the basis of the above information, these patients would therefore receive unnecessary irradiation to critical structures if the lower border of the csi spinal field was placed at the lower border of s2. although the extent of this difference is minor, its effects – especially on the dose to the ovaries in female patients – would be considerable. the wide variation in the level of the inferior border of the ds and the failure to find any other tool to indicate its level accurately, make individualised treatment using mri data of the spine a crucial element in the planning process. original article 55 sa journal of radiology • september 2010 our findings are also relevant to the performance of safe caudal block procedures, which are used for intraand postoperative analgesia and the management of chronic pain. crighton et al.6 suggested that,to increase the chances of performing a successful caudal block with minimal risk of dural puncture, the most frequent termination level of the ds should be known. they found a mean termination level of the ds at the middle third of s2 which compares favourably with our study. in the former study, the authors reported a mean distance between the sacrococcygeal membrane (scm) and the ds of 60.5 mm, with a range of 34 80 mm. the distance of 34 mm is of substantial importance in clinical practice because the use of a 21 gauge 40 mm ‘green’ needle to perform a caudal block has the additional risk of puncturing the dura in some patients. the results of the present study failed to demonstrate a difference in the dural sac termination level found in the south african population in comparison with the levels reported in various international studies; nor is there a statistical difference between gender, race and age groups. we did, however, determine that the routine placement of the portal field at the lower border of s2 adequately treats the majority of csi patients. nevertheless, we propose using spinal mri to set the lower border of the csi spinal field as this will benefit the patient in ensuring adequate coverage of the entire neuroaxis as well as minimising late gonadal toxicity. as mri investigations are usually part of the workup for medulloblastoma and other neuroaxis seeding brain tumours, no additional costs need be incurred. radiologists can and should make a note of the ds termination during these examinations to set a level for possible csi spinal field. acknowledgements we thank professor gina joubert of the department of biostatistics, faculty of health sciences, ufs, for assisting with the statistical analysis, and daleen struwig (medical writer, faculty of health sciences, ufs) for technical and editorial preparation of the manuscript. 1. moore kl. clinically orientated anatomy. 2nd ed. baltimore: williams & wilkins, 1985:606-618. 2. berry m, bannister lh, standring sm. gray's anatomy. 38th ed. new york: churchill livingstone, 1995: 1212. 3. hansasuta a, tubbs rs, oakes wj. filum terminale fusion and dural sac termination: study in 27 cadavers. pediatr neurosurg 1999;30:176-179. 4. lanier vs, mcknight he, trotterm. caudal analgesia: an experimental and anatomical study. am j obstet gynecol 1944;47:633-641. 5. macdonald a, chatrath p, spector t, ellis h. level of termination of the spinal cord and the dural sac: a magnetic resonance study. clin anat 1999;12:149-152. 6. crighton im, barry bp, hobbs gj. a study of the anatomy of the caudal space using magnetic resonance imaging. br j anaesth 1997;78:391-395. 7. ruggieri pm. a practical approach to magnetic resonance physics in spinal imaging. in: modic mt, masaryk tj, eds. magnetic resonance of the spine. 2nd ed. philadelphia: mosby, 1994:1-35. 8. binokay f, akgul e, bicakci k, soyupak s, aksungur e, sertdemir y. determining the level of the dural sac tip: magnetic resonance imaging in an adult population. acta radiol 2006; 47:397-400. 9. phongkitkarum s, jaovisidha s, dhanachai m. determination of the thecal sac ending using magnetic resonance imaging: clinical applications in craniospinal irradiation. j med assoc thai 2004;87:1368-1373. 10. saifuddin a, burnett sj, white j. the variation of position of the conus medullaris in an adult population. a magnetic resonance imaging study. spine 1998; 23:1452-1456. 11. mccotter r. regarding the length and extent of the human medulla spinalis. anat rec 1915;10:559-574. 12. needles j. the caudal levels of termination of the spinal cord in american whites and american negroes. anat rec 1935;63:417-424. 13. larsen jl, olsen ko. radiographic anatomy of the distal dural sac. a myelographic investigation of dimensions and termination. acta radiol 1991;32:214-219. 14. kim jt, bahk jh, sung j. influence of age and sex on the position of the conus medullaris and tuffier's line in adults. anaesthesiol 2003;99:1359-1363. 15. scharf cb, paulino ac, goldberg kn. determination of the inferior border of the thecal sac using magnetic resonance imaging: implications on radiation therapy treatment planning. int j radiat oncol biol phys 1998;41:621-624. 16. nazmy ms, attalla em, refeat a. effect of magnetic resonance myelography on the target volume in craniospinal irradiation in children. clin oncol 2009;21:14-18. 17. dunbar sf, barnes pd, tarbell nj. radiologic determination of the caudal border of the spinal field in cranial spinal irradiation. int j radiat oncol biol phys 1993;26:669-673. fellowship announcement the following newly qualified radiologists and registrars have been elected for subspecialty fellowships. from the university of pretoria: dr scott davies passed fc rad (diag) in2009. taking up a neuroradiology fellowship at royal perth hospital/sir charles gairdner hospital, australia, at the end of 2010. from the university of the witwatersrand’s radiology department: dr hanief moosa, registrar, has been awarded the first esor visiting msk scholarship for south africa for 2010. he will spend 3 months at the university hospital of strasbourg, france, from september november 2010. from the university of kwazulu-natal, greys hospital, pietermaritzburg: dr ruan visagie passed fc rad (diag) in may 2010. he started a fellowship in musculoskeletal imaging on 1 july 2010 at mcmaster university, hamilton, ontario, canada. dr miranda durand passed fc rad (diag) in october 2009 and started a fellowship in cardiac imaging on 1 july 2010 at the university of toronto, canada. from the university of cape town/groote schuur hospital: dr nuraan abdurahman passed fc rad (diag) sa in 2009 and starts a fellowship in paediatric imaging in melbourne, australia, in july 2011. from tygerberg hospital/ university of stellenbosch: dr dirk van der merwe passed fc rad (diag) in may 2010. starts an msk fellowship at the university of calgary, canada, in october 2010. dr arthur maydell, registrar, starts a neuroradiology fellowship at rush university, chicago, in july 2011. dr pieter janse van rensburg passed mmed (rad d) in 2009 and frcr in 2010, starts a 2-year neuroradiology fellowship at the university of utah, salt lake city, usa, on 1 july 2011. the rssa congratulates them – and hopes to see them all back in south africa. answer and discussion discussion references about the author(s) shalendra misser lake smit and partners inc., durban, south africa thamsanqa mngoma lake smit and partners inc., durban, south africa citation misser s., mngoma t. answer to neuroimaging quiz case. s afr j rad. 2016;20(1):a957. http://dx.doi.org/10.4102/sajr.v20i1.957 quiz case answer to neuroimaging quiz case shalendra misser, thamsanqa mngoma received: 22 nov. 2015; accepted: 01 dec. 2015; published: 05 apr. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a 50-year-old man of otherwise excellent health presented with recent onset of left upper limb weakness and left facial nerve palsy. figures 1–7 are selected magnetic resonance (mr) images. we congratulate dr thato sefanyetso for his submission of the correct findings and diagnosis of this quiz case. answer and discussion the patient’s acute presentation with left arm monoparesis and upper motor neuron facial nerve palsy, in an otherwise healthy individual, was confounding. he had no risk factors for vasculopathy, hypertension or diabetes mellitus. preliminary imaging performed elsewhere by conventional mr imaging suggested that the lesions seen were neoplastic, probably a primary glioma. our initial review of the imaging, on request of the neurologist, raised some doubt and we proceeded to repeat the mri study with specific functional imaging sequences. an axial flair (figure 1) sequence reveals a triangular focus of hyperintensity at the right subrolandic frontal white matter in the centrum semiovale. this lesion, for its size, is not associated with any significant mass effect and there is no disruption of the grey-white matter interface. incidentally, a few left frontal subcortical hyperintensities are also observed, probably microangiopathic in origin. figure 1: axial flair mr image. the axial swi (figure 2) sequence demonstrates a very useful and highly specific sign. through the central and lateral aspect of the hyperintense focal lesion, a flow void is noted in keeping with a medullary vein branch ramifying through the white matter lesion. this central vascular flow void surrounded by a hyperintense lesion raises suspicion for a demyelinating process that favours perivenular white matter in the first instance. in addition, no peripheral signal voids or central calcification can be noted on the susceptibility weighted imaging sequence. figure 2: axial swi mr image. the location of the lesion is well shown on the coronal t2-weighted image (figure 3) as well as the extent of the lesion from the juxta-ventricular margin up to the subcortical white matter. figure 3: coronal t2-weighted mr image. coronal (figure 4) and axial (figure 5) post-gadolinium t1-weighted sequences demonstrate the patchy enhancement of the major portion of the lesion except for the focal areas of necrosis centrally within the lesion bed. the enhancing vessel is well demonstrated, extending from the pial surface through the centre of the lesion. subtle brush-like vascular enhancement is also seen in the contralateral centrum semiovale white matter. figure 4: coronal post-contrast t1-weighted mr image. figure 5: axial post-contrast t1-weighted mr image. perfusion-weighted rcbv map imaging (figure 6) shows normal perfusion of the right hemisphere in the area of concern. the central vessel is noted as a linear focus of hyperperfusion surrounded by normal perfusion of the rest of the lesion bed. figure 6: axial rcbv mr perfusion image. a mr spectroscopy image (figure 7) performed at te = 135 ms demonstrates a prominent choline peak with suppression of n-acetyl aspartate (naa) and presence of a small lactate peak at 1.3ppm. a choline-to-naa ratio greater than 2:1 is noted. this pattern is non-specific and can be seen in primary or metastatic tumours as well as in tumefactive demyelinating lesions. figure 7: mr spectroscopy image obtained at te 135 ms. we concluded that the combination of imaging findings as well as the relatively acute presentation favoured a demyelinating process and we suggested a diagnosis of a clinically isolated syndrome associated with a tumefactive demyelinating lesion, much to the contrary of the referring clinician’s expectation. we advised correlation with cerebrospinal fluid testing for oligoclonal band analysis. this was undertaken and confirmed a demyelinating process. discussion tumefactive demyelinating lesions (tdls) are intriguing entities to neuroradiologists and neurologists alike. they prove to be a challenge primarily in their distinction from primary or metastatic brain tumours, inflammatory lesions (such as cerebral abscesses) and lymphoma. tdls are a small subgroup of a large spectrum of central nervous system disorders collectively known as idiopathic inflammatory-demyelinating disorders (iidds). the clinical course, neuroimaging, laboratory findings and prognosis varies considerably for each of the subgoups of iidds.1 conventionally, the diagnosis of demyelinating disease (e.g. owing to multiple sclerosis) is a simple one to make in the presence of multiple periventricular, corpus callosal, posterior fossa or cord lesions. on the contrary, in the instance of a solitary large focus of cerebral demyelination with an appearance that mimics a tumour mass, the diagnosis may be much more difficult to suggest and the neurologist more difficult to convince. clinically, tdl may present with features attributable to an intracranial neoplastic mass lesion. mri is by far the best modality for the assessment of demyelinating lesions of the central nervous system. generally, tdls are greater than 2 cm in diameter and exhibit minimal surrounding white matter hyperintensity, oedema or mass effect.2 this is a useful distinguishing feature as neoplastic lesions of this size are known to assert significant mass effect at similar dimensions. the lesions are predominantly located in the supratentorial white matter and favour frontal and parietal lobes, with cortical involvement rarely seen. when identified in the posterior fossa, demyelinating lesions tend to have a predilection for the middle cerebellar peduncles (boxes 1–2). box 1: imaging features suggestive of tumefactive demyelinating lesions. box 2: imaging features not specific for tumefactive demyelinating lesions. the post-gadolinium enhancement patterns associated with tdl may be ring-like, nodular, patchy, incomplete or open-ring types.3 in the case of the latter types, the open portion of the ring usually lies along the grey matter interface of the lesion. the enhancing portions of the lesion correlate with the leading edge of the demyelination and are therefore seen on the white matter side of the lesion.4 enhancing components of tdl are also well assessed on unenhanced ct scan. kim et al.5 have shown that using unenhanced ct in addition to conventional post-contrast mri studies increases the accuracy in diagnosing tdl over neoplastic aetiologies and lymphoma. the areas of enhancement seen on mri studies in tdl are indistinct, with reduced attenuation on ct scans. conversely, in gliomas there is variable attenuation of the enhancing portions, and in cases of lymphoma isoattenuation of the enhancing portions was described (table 1). table 1: differentiating tdl from glioma and lymphoma. there is considerable overlap of not only the imaging features, but also the histopathological findings in biopsied tdl and brain neoplasms. in fact, tdls have in the past been erroneously reported as gliomas on biopsy owing to the hypercellular nature of these lesions and the presence of creutzfeld cells which are giant glial cells with fragmented chromatin and abnormal mitoses. a critical difference between tdls and tumours is the absence of neoangiogenesis in the former. perivenular demyelination results in lesions having a venocentric appearance; a feature not seen in other leukodystrophies or neoplastic processes. these vessels in effect represent periventricular tributaries, radial veins or branch venules ramifying through the white matter. dynamic contrast-enhanced t2* or susceptibility-weighted mr imaging has become an effective additional sequence recently introduced in the characterisation of tdl and has proven to assist further in the delineation of these lesions from neoplastic entities.6 additionally, using perfusion-weighted mri, the rcbv values for tdls were much lower than for brain neoplasms. the difference between tdl and lymphoma was less marked but still significant in that lymphoma lesions had higher mean rcbv values as well.7 proton mr spectroscopy (mrs) is a powerful tool that is increasingly shown to be of value in molecular and metabolic neuroimaging. in tdl, elevated choline (cho) peak is thought to represent a combination of demyelination, reactive astrogliosis and perivenular inflammation. the reduction in n-acetyl aspartate (naa) seen in tdl represents cumulative axonal destruction and secondary neuronal mitochondrial dysfunction. the presence of lactate indicates a shift in cellular respiration from the oxidative metabolism of substrates to anaerobic glycolysis. this may be consequent on localised ischaemia, mitochondrial dysfunction and the inflammatory cascade. typically, mrs of tdl may therefore reveal a brain metabolite pattern quite similar to that of gliomas with elevated choline, suppressed naa, increased choline/creatine(cr) ratio and presence of lactate and lipid peaks. this non-specific pattern is frequently seen in low-grade gliomas and tdl. some authors8 have shown that, despite this considerable overlap in the patterns expressed by both entities, there is a difference in the naa/cr ratio, particularly centrally in tdl when compared with high-grade gliomas. tdl demonstrate a higher mean central naa/cr ratio owing to the lack of coagulative necrosis in the central aspect of tdl – a feature seen frequently in the centre of similar-sized gliomas. tdls continue to prove to be a challenge to neurologists, radiologists and neuropathologists. higher diagnostic accuracy is being reached through the use of advanced mri techniques in order to obviate unnecessary brain biopsy and in particular to avoid lethal treatment options for erroneously diagnosed neoplasms after biopsy. in combination, imaging features of incomplete rim/ring enhancement, lack of mass effect, absence of cortical involvement and reduced ct attenuation of lesions (relative to grey matter) correlate with a high sensitivity and accuracy for tdl. more specific advanced mri sequences such as reduced perfusion rcbv values, central vein sign, absence of restricted diffusion and central high naa/cr ratio are useful differentiating features. these tools are vital in the radiologists’ armamentarium as shown in the algorithm (figure 8) aiding the approach to an intracranial tumefactive lesion.9 figure 8: algorithm – approach to intracranial mass. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions s.m. (lake smit and partners inc.) created the quiz case, undertook the literature review and compiled the discussion on the topic presented. t.m. (lake smit and partners inc.) provided the case details and assisted with the literature review. references rovira cañellas a, gols ar, izquierdo jr, subirana mt, gairin xm. idiopatic inflammatory-demyelinating disease of central nervous system. neuroradiology. 2007;49:393–409. http://dx.doi.org/10.1007/s00234-007-0216-2 dagher ap, smirniotopoulos j. tumefactive demyelinating lesions. neuroradiology. 1996;38:560–565. http://dx.doi.org/10.1007/bf00626098 given ca ii, stevens bs, lee c. the mri appearance of tumefactive demyelinating lesions. am j roentgenol. 2004;182:195–199. http://dx.doi.org/10.2214/ajr.182.1.1820195 he j, grossman ri, ge y, mannon lj. enhancing patterns in multiple sclerosis: evolution and persistence. ajnr 2001;22:664–669. kim ds, na dg, kim kh, et al. distinguishing tumefactive demyelinating lesions from glioma or central nervous system lymphoma: added value of unenhanced ct compared with conventional contrast-enhanced mr imaging. radiology. 2009;251:467–475. http://dx.doi.org/10.1148/radiol.2512072071 cha s, pierce s, knopp ea, et al. dynamic contrast-enhanced t2*-weighted mr imaging of tumefactive demyelinating lesions. ajnr 2001;22:1109–1116. cha s, knopp ea, johnson g, wetzel sg, litt aw, zagzag d. intracranial mass lesions: dynamic contrast-enhanced susceptibility-weighted echoplanar perfusion mr imaging. radiology. 2002;223:11–29. http://dx.doi.org/10.1148/radiol.2231010594 saindane am, cha s, law m, xue x, knopp ea, zagzag d. proton mr spectroscopy of tumefactive demyelinating lesions. ajnr. 2002;23:1378–1386. al-okaili rn, krejza j, wang s, woo jh, melhem er. advanced mr imaging techniques in the diagnosis of intraaxial brain tumors in adults. radiographics 2006;26:s173–s189. http://dx.doi.org/10.1148/rg.26si065513 article information authors: christopher t. sikwila1 khatija amod2 brindley d. cupido3 ali sabri4 affiliations: 1department of radiology, nelson r. mandela school of medicine, university of kwazulu-natal, south africa2department of radiology, inkosi albert luthuli central hospital, south africa 3department of radiology, addington hospital, south africa 4department of radiology, cypress health region hospital, canada correspondence to: christopher sikwila postal address: po box 30904, lusaka 10101, zambia dates: received: 03 nov. 2013 accepted: 28 nov. 2013 published: 09 may 2014 how to cite this article: sikwila ct, amod k, cupido, bd, sabri a. multi-detector computed tomography radiation doses in the follow-up of paediatric neurosurgery patients in kwazulu-natal: a dosimetric audit. s afr j rad. 2014;18(1); art. #588, 4 pages. http://dx.doi.org/10.4102/ sajr.v18i1.588 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. multi-detector computed tomography radiation doses in the follow-up of paediatric neurosurgery patients in kwazulu-natal: a dosimetric audit in this original research... open access • abstract • introduction • methods and materials • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: multi-detector computed tomography (mdct) is the preferred modality for follow-up of paediatric neurosurgery patients. serial imaging, however, has the disadvantage of an ionising radiation burden, which may be mitigated using the ‘as low as reasonably achievable’ (alara) principle.objectives: the primary objectives were to determine the radiation dose exposure in paediatric patients subjected to mdct imaging following neurosurgery and to compare these values with references in current literature. our secondary objective was to assess the relationship between radiation dose and clinical scenario. method: retrospective descriptive data were collected from all paediatric postsurgical patients (n = 169) between the ages of 0 and 12 years who had their first followed-up scan in the year 2010 and were followed up for six months or less. dose-length product (dlp) and current-time product were collected from the picture archiving and communication system. demographic data including radiology reports were collected from the hospital information system. the effective doses (ed) were calculated from the corresponding dlp using age-adjusted conversion factors. for purposes of comparison with other studies, median dosimetric values were calculated and the children were grouped into three age ranges, namely younger than 3 years, 3–7 years and 8–12 years old. results: the highest median radiation doses were noted in patients being followed-up for intracranial abscesses (1183 mgy cm) in the 8–12 year age group, most of whom were female. the lowest radiation doses were for intracranial shunt follow-ups (447 mgy cm). median values for dlp, ed and current-time product (mas) were comparable to reference doses in all three age groups. however, our study showed a much broader distribution of values with higher upper limits relative to reference values. indications for follow-up included shunts (n = 110; 65%), intracranial abscess (n = 31; 18%), subdural haematoma (n = 13; 8%) and tumour (n = 6; 4%). head trauma only accounted for 5% of the cases. conclusion: the median radiation doses measured were comparable to values in literature and therefore deemed acceptable. the wider dose distributions of all three dosimetric parameters (dlp, ed and mas) were attributed to inappropriate use of scan length and reference effective mas. adherence to recommended scan length protocols should be encouraged. evaluation of the current use of reference effective mas is needed and will require a separate study to determine the smallest value that can be used without compromising image quality. further dose reductions could be achieved by omission of unenhanced scans in the follow-up of intracranial abscesses. it is recommended that diagnostic reference levels specific to south african clinical scenarios be developed to make local dosimetric audits more relevant. introduction top ↑ children treated for complex or chronic neurological disease such as hydrocephalus, tumours and intracranial abscess often undergo serial imaging studies with multi-detector computed tomography (mdct). the associated ionising radiation has raised concern as it is the dominant contributor to radiation dose from medical x-rays. the department of neurosurgery at inkosi albert luthuli central hospital (ialch) has a heavy case load as it serves the entire province of kwazulu-natal. current protocols permit neurosurgeons to order computed tomography (ct) scans without prior consultation with a radiologist in order to increase efficiency in light of human resource constraints. as a result, an increase in the number of serial scans in the follow-up of paediatric patients was noted, raising concerns over excessive radiation burden due to the long-term increased risk of developing malignancies such as leukaemia, thyroid carcinomas, breast cancer as well as damage to the lens of the eye. children and women in particular are more radiosensitive because of a higher rate of cell division in the former and radiosensitive organs being anatomically closer to the primary beam in the latter. however, there are no ‘normal limits’ with respect to radiation exposure to children in diagnostic imaging. radiologists and medical physicists depend on the ‘as low as reasonably achievable’ (alara) principle and diagnostic reference levels (drls)1,2 to minimise the radiation exposure. south africa has not yet developed drls with which we could compare our data; consequently comparisons were made with european drls/data sets predominantly derived from head trauma centres. the study was aimed at quantifying the radiation burden and comparing it to accepted values in literature. the outcomes would be beneficial in deciding whether to alter current paediatric protocols and establish benchmarks for future dosimetric audits. methods and materials top ↑ ethical approval was obtained from the biomedical research and ethics committee of the university of kwazulu-natal. retrospective descriptive data was collected from all paediatric postsurgical patients (n = 169) between the ages of 0 and 12 years who had their first follow-up scan in the year 2010 and were followed up for six months or less. the 16-slice and 128-slice ct scanners used were calibrated by independent inspection bodies and dose parameters were checked and verified for accuracy to within 15% of the baseline values. dose-length product (dlp) and current-time product are parameters recorded by the mdct machines used at the time of the scan and were thus collected from the picture archiving and communication system. demographic data including radiology reports were collected from the hospital information system. the effective doses (ed) were calculated from the corresponding dlp using age-adjusted conversion factors (see table 1) and the following equation: ed = edlp x dlp (msv), where: dlp (mgy cm) is the dose-length product, and edlp is the age-specific normalised ed per dlp (msv mgy-1 cm-1). [eqn 1] for purposes of comparison with other studies, median dosimetric values were calculated and the children were grouped into three age ranges, namely younger than 3 years, 3–7 years and 8–12 years old. results top ↑ the highest median radiation doses were noted in patients being followed-up for intracranial abscesses (1183 mgy cm) in the 8–12 year age group, most of whom were female. the lowest radiation doses were noted in intracranial shunt follow-ups (447 mgy cm). median values for dlp, ed and current-time product (mas) were comparable to reference doses in all three age groups. however, our study showed a much broader distribution of values with higher upper limits relative to reference values. seventy-nine (47%) of those scanned were male and 90 (53%) were female. median age was 2 years (range 1–12 years). the age distribution between the three age groups < 3, 3–7 and 8–12 years were 98 (58%), 34 (20%) and 37 (22%) respectively. the female distribution in the study was 51 (57%), 17 (19%) and 22 (24%) and male distribution 47 (59%), 17 (22%) and 15 (19%) children in the < 3, 3–7 and 8–12 year age groups respectively. indications for follow-up included: shunt (n = 110; 65%), intracranial abscess (n = 31; 18%), subdural haematoma or sdh (n = 13; 8%), trauma (n = 8; 5%), tumour (n = 6; 4%) and other (n = 1; < 1%) (see figure 1). no interval change between scans was reported by the radiologist in 65 (59%) of shunt, 13 (42%) of intracranial abscess, 7 (50%) of sdh, 3 (31%) of trauma and 4 (67%) of tumour follow-ups. with respect to radiation burden attracted by an examination indication, our study showed the median dlps (mgy cm) to be 447 (shunts), 1183 (intracranial abscess), 719 (sdh), 681 (trauma) and 591 (tumour). sixty-eight percent of two-phase scans (i.e. with and without contrast material) were done in the 8–12 year age group, 22% in the < 3 year age group and 47% in the 3–7 year age group. the median dlp (with range indicated in parenthesis) for the < 3, 3–7 and 8–12 year age groups were 463 (251–1461), 615 (360–1268) and 1134 (393–3111) mgy cm respectively. associated median effective doses were 3.1 (1.7–9.8), 2.5 (1.4–5.1) and 3.6 (1.3–10.0) msv respectively. the median current-time product for the same age groups were 122 (89–350), 137 (107–300) and 191 (123–360) mas respectively. discussion top ↑ children treated for complex or chronic neurological disease often undergo serial imaging studies with mdct. as mentioned, the associated ionising radiation has raised concern as it is the dominant contributor to radiation dose from medical x-rays. in this study, 141 (83%) of the cases were due to shunt or intracranial abscess follow-up – the latter carrying a large radiation burden due to the two-phase scans done in accordance with neurosurgery protocols. udayasankar et al.4 recommended the use of 80 kv/80 mas for shunt follow-up and 80 kv/90–140 mas for follow-up of abscesses and tumours as an alternative low-dose protocol. rybka, staniszewska and biegański5 showed that as much as 70% reduction in patient doses were achieved without compromising image quality and that a low-dose protocol was feasible. table 1: edlp values used in this study.3 figure 1: distribution of scan indications with age group. notwithstanding the use of the reference effective mas function on ct scanners, the upper limit of the mas in children younger than 7 years was higher than those noted by pages, buls and osteaux6 despite the median values being comparable (see table 2). we attributed the finding to the inappropriately high reference effective mas used on the 128-slice machine (see table 3). given that the mas is directly proportional to the radiation dose, yu, bruesewitz, thomas, fletcher, kofler and mccollough7 noted a 40% – 50% reduction in radiation dose with correct use of such aec (automatic exposure control) systems. radiologists have to be aware that these systems control radiation exposure relative to the required image quality (as determined by the reference effective mas), rather than decrease radiation dose directly.8,9 table 2: dose and current-time product distribution with age. table 3: scan parameters. the median values for dlp for the < 3 and 3–7 year age groups in our study were comparable to those obtained by buls, bosmans, mommaert, malchair, clapuyt and everarts8 and freiberg, almen, einarsson et al.11, most likely due to the fact that their studies, like ours, included mdct (rather than single-slice) machines as well as two-phase scans. the median dlp for the 8–12 year age group, however, was higher by a factor of 1.7–2.0. it is in this age group that we found the highest indication for intracranial abscess follow-up and consequently the most two-phase scans and greatest radiation dose burden (see figures 1–3). furthermore, given that 42% of the scan follow-ups for intracranial abscess had no interval change identified on follow-up and that 22 (59%) of the children in this age group were female, targeted application of a low-dose protocol and stringent assessment of the risk-benefit ratio for each ct request would have the greatest impact on dose reduction. the dlp distribution in all three age groups were much greater than drls of similar studies in literature (see table 2), attributable to the high variation in scan lengths used. buls, bosmans, mommaert, malchair, clapuyt and everarts8, using tube potential and pitch similar to that in this study, had upper limit values for dlp which were smaller by a factor of 2.7–7 for comparative age ranges. calculations based on figures supplied by buls, bosmans, mommaert, malchair, clapuyt and everarts8 for the radiation doses expected given similar technique parameters to our study (see table 3) suggest the scan lengths used at ialch were greater by a factor of approximately 2–5 compared to those recommended by shrimpton3. figure 2: frequency of single and two-phase scans. figure 3: radiation burden of different clinical scenarios. ed calculations from dlp values provide for a simple method for radiologists without access to medical physicists to obtain valuable information regarding the radiation exposure associated with their scanners or protocols.12 the median ed in our study were comparable to those of friberg, almen, einarsson et al.’s study for the < 3 and 3–7 year age groups; however, the 8–12 year age group had a higher dose by a factor of 1.6 due mainly to the large number of two-phase scans. the higher median ed noted in the < 3 age group compared to the 3–7 age group despite a lower dlp was also noted in the freiberg, almen, einarsson et al. study, in which they attributed it to scan length discrepancies. we believe, however, that this difference is more a reflection of the higher conversion coefficients used to calculate ed in this age group. study limitations include non-separation of the neonatal group from the < 3 year age grouping. the calculated effective doses were all done using the 1–3 age group conversion coefficient of 0.0063 instead of the higher 0.011 of the < 1 year age group. doses for the highly radiosensitive neonate were thus not captured and the calculated ed for the < 3 year age group in our study was therefore an underestimation of the true ed. the study represented a radiation burden from ct head scans only and is not representative of the total radiation exposure during the relevant six-month period, that is, from ct scans of other body parts or daily chest x-rays in icu. south africa has not developed drls with which we could compare our data; consequently comparisons were made with european data sets which were predominantly derived from head trauma centres. conclusion top ↑ our results show that radical changes to the existing paediatric protocols are not necessary given that the average dlp, ed and mas values used were within acceptable limits compared to current literature. the marked variations in dose distribution were of concern, however, and were attributed to the inappropriate selection of scan length and operator-dependent reference effective mas. corrective strategies should include strict adherence to recommended scan length protocols, application of the alara principle and evaluation of the current use of reference effective mas (which will require a separate study to determine the smallest value that can be used without compromising image quality). further dose reductions with respect to intracranial abscess follow-up may be achieved by omitting the pre-contrast scan. finally, future dosimetric audits would be greatly improved if national drls were developed which would reflect more common clinical scenarios such as intracranial sepsis. acknowledgements top ↑ we gratefully acknowledge dr william rae (associate professor, medical physics, university of the free state) for his invaluable insight into the development of the article. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions c.t.s. (university of kwazulu-natal) was the principal author, whilst k.a. (inkosi albert luthuli central hospital), b.d.c. (addington hospital) and a.s. (cypress health region hospital) made conceptual contributions. references top ↑ 1. icrp. recommendations of the international commission on radiological protection. icrp publication 103. ann icrp. 2007;37(2–4).2. icrp. radiological protection and safety in medicine. icrp publication 73. ann icrp 1996;26(2), 1–47. http://dx.doi.org/10.1016/s0146-6453(00)89195-2 3. shrimpton pc. assessment of patient dose in ct. nrpbpe/1/2004. chilton: national radiological protection board; 2004. 4. udayasankar uk, braithwaite k, arvaniti m, et al. low-dose non-enhanced head ct protocol for follow-up evaluation of children with ventriculoperitoneal shunt: reduction of radiation and effect on image quality. am j neuroradio. 2007;29:802–806. http://dx.doi.org/10.3174/ajnr.a0923 5. rybka k, staniszewska am, biegański t. low-dose protocol for head ct in monitoring hydrocephalus in children. med sci monit. 2007;13(suppl 1):147–151. pmid:17507900 6. pages j, buls n, osteaux m. ct doses in children: a multicenter study. br j radiol. 2003;76:803–811. http://dx.doi.org/10.1259/bjr/92706933 7. yu l, bruesewitz mr, thomas kb, fletcher jg, kofler jm, mccollough ch. optimal tube potential for radiation dose reduction in pediatric ct: principles, clinical implementations, and pitfalls. radiographics. 2011;31:835–848. http://dx.doi.org/10.1148/rg.313105079 8. buls n, bosmans h, mommaert c, malchair f, clapuyt p, everarts p. ct pediatric doses in belgium: a multi-centre study. brussels: brussels free universities; 2010. 9. lee ch, goo jm, lee hj, et al. radiation dose modulation techniques in the multidetector ct era: from basics to practice. radiographics 2008;28:1451–1459. http://dx.doi.org/10.1148/rg.285075075 10. shrimpton pc, hillier mc, lewis ma, dunn m. dose from computed tomography (ct) examination in the uk. br j radiol. 2006;79:968–980. http://dx.doi.org/10.1259/bjr/93277434 11. friberg eg, almen a, einarsson g, et al. doses from pediatric ct examinations and level of optimization of the scan protocols in the nordic countries. proceedings of the 15th nordic society for radiation protection (nsfs) conference; 2008 may 26–30; ålesund, norway. nsfs; 2008. p. 41–50. 12. thomas ke, wang b. age-specific effective dose for pediatric msct examinations at a large children’s hospital using dlp conversion coefficients: a simple estimation method. pediatr radiol. 2008;38:645–656. http://dx.doi.org/10.1007/s00247-008-0794-0 38 sa journal of radiology • june 2006 as a radiologist with a special interest in magnetic resonance (mr) imaging and teaching, i have spent years looking for a computer solution to archive teaching cases electronically. at last i have found something way beyond my expectations. i have been digitising films for many years, initially for specific lectures using a film scanner. recently, i have used a digital camera selecting images on the ‘run’ during a busy working day for use in general teaching. although the image quality is good, i have ended up with enormous files of digital images, many unopened, which often have incomplete demographics and an uncertain diagnosis. consequently, preparing a presentation which requires searching through and transferring poorly catalogued jpeg (joint photographic experts group) images into a powerpoint (microsoft office, microsoft corporation, redmond, usa) presentation is very time consuming. how much better to have all the images already organised into electronic teaching files! teaching library programs available off the internet, have been reviewed.1 many of these are very good but it is still a laborious task to enter jpeg images with history and findings into these databases, and on top of that the retrieval of ct or mr teaching cases from workstations via cd or ‘memory sticks’ is rather cumbersome. over the last few years many dicom (digital imaging and communications in medicine standard) software viewers have become available off the internet.2,3 scanner vendors will also supply a very basic dicom viewer when exporting images to cd, which is of little use. my electronic teaching ‘project’ remained in a shambles until a year ago. at that time i had become thoroughly frustrated by ‘windoze’ (term of endearment for the operating system on pcs) and when my laptop screen expired, i decided to switch computer system and bought an apple laptop computer, ‘macbookpro’ (apple computers inc., cupertino, ca, usa). i will avoid going into the difficult comparison of two such different packages as an apple computer with its integrated software and the microsoft windows software which has to be able to run on a variety of different quality machines. suffice to say, the mac operating system does not need antivirus programs, and rarely if a program does ‘hang’, you can force it to quit without the computer crashing. while showing off my new mac, i got to hear about a visiting uk radiologist who was teaching, using his mac laptop as a workstation! i tracked him down quickly for more details. the program is called osirix, open source software (oss) downloadable free off the internet at http://homepage.mac.com/rossetantoine/osirix, but it only runs on the apple platform (operating system x – os x) for the moment.4,5 this is truly an amazing dicom and pacs program. osirix will accept dicom cds from all vendors, and if it doesn’t ‘see’ the dicom folder automatically, exploring the cd's hidden directories is simple. this is not possible on our workstations, which run on a windows platform, but do not allow access to the windows programs, presumably for ‘security’ reasons. this restriction of access i find very frustrating, especially considering the hefty price of these workstations. it would be much more efficient to run the viewing software in open integration with powerpoint, web browser for quick internet searches, and e-mail for sending selected images to colleagues or referring physicians. this is however possible with osirix. fortunately, i have a connection point for our ethernet at my desk linking scanners and workstations. sending cases straight to my laptop via ethernet was fairly easy with the help of the mr technicians, who needed to set up the correct addresses of my laptop on the mr console and later ct workstation as well. these technicalities are described on a congress poster which can be downloaded from the web.6 it was not long before i was reporting mr studies off my laptop, increasing my efficiency considerably compared with my previous film reading. picture quality is superb and image handling fast. in osirix the images are available instantly; it can view multiple sequences in flexible windows and relates them automatically to each other, i.e. while scrolling through an axial stack, the current slice is indicated by a line on the sagittal and coronal views, and if one double clicks on a lesion its position is immediately indicated on the other open sequences of the study. old and new ct studies can be compared in both the axial and coronal projections which is not possible on our conventional workstation. one can subtract and fuse images easily with ‘drag and drop’, for example fusing an mr angio sequence with a flair sequence not only slice by slice, but also in 3d. calculating organ or lesion volume is simple and when drawing rois (region of interest) osirix has an amazing ‘repulsor tool’ for pushing the line into position. of course the usual data manipulations are available, such as mpr (multi-planar reconstructions), and mip (maximum intensity projections), but also more complex processes such as volume and surface rendering, which are facilitated by various cutting and seeding tools as well as clut (colour lookup table) editors. the osirix team, led by a radiologist and software developer antoine rosset, are developing and improving the program constantly, getting feedback from the user group, which now numbers over 10 000 worldwide. joining this group will give you access to a regular stream of e-mails (questions and answers, requests and announcements of new downloadable upgrades) from all over the world, and quite entertaining sometimes. the use of oss is new to radiology, but judging from the quality of osirix and the enthusiasm, it is here to stay (for more detail and history on oss, search www.wikipedia.org, which also has a manual on osirix). for clinicians, osirix represents a cost-effective solution, enabling them to have access and the ability to manipulate their imaging studies for better patient management. the dicom viewers distributed with the patients’ cds are very basic without any facility to manipulate the dataset in detail. for radiologists, osirix represents a very attractive, economical solution, enabling them to have an extra or personal workstation, which will integrate with a pre-existing pacs or just your workstations. my personal portable pacs station by: mark haagensen 38 sa journal of radiology • june 2007 background eureka! the personal pacs gets underway the osirix user group changing systems who can benefit from osirix pg38-39.indd 38 6/13/07 9:23:32 am 39 sa journal of radiology • june 2006 osirix is particularly useful when conducting academic meetings, e.g. for our weekly neuroradiological combined meeting, the co-ordinator receives cases for discussion the day before on cd in dicom format. videoprojection of osirix is in real-time and interactive and best done by somebody with a little experience of the program. the large image display promotes audience participation and learning. osirix runs smoothly on the laptop with no restrictions making it very convenient. however additional ram up to 2 gigabytes is generally recommended. video projection of osirix is also very useful in tutorials for radiology registrars. simulating the work situation with a pacs station and giving the candidate the original dataset to examine, seems the proper way to go. using an oss program(s) would be inexpensive and fairer to exam candidates by not favouring a particular vendor’s workstation, and osirix is easy to use for general manipulations. although osirix only runs on the apple os at the moment, the new apple computers can also run microsoft windows for an alternative viewer to osirix, making apple mac the more flexible solution. in the case of formal lecture presentations, osirix again comes to the rescue. you can view your entire teaching case on the one hand, while making your presentation on the other, and the dicom image you want to use can be ‘dragged and dropped’ into the ‘slide’, where it is automatically converted to a jpeg format. it does the same for any 3d or fusion images. if you need a cine, you export the series from osirix in quicktime format (apple computers inc.) to ‘desktop’ and drop it into your slide. briefly, osirix has many other features such as a dicom print function to laser printer, query and retrieve function from other nodes on the pacs, export in dicom either to file or back to the pacs server of secondary generated images, report function including dicom structured report with plans for word recognition as a plug-in in the future. however, i haven’t had the opportunity or necessity to check out all the complex pacs features. lastly, one of the most impressive and powerful functions is the 4d player. this involves 3d plus the added dimension of time; for example i tested a new super-fast contrast-enhanced mr angiogram sequence supplied by a vendor, consisting of 40 slices in 3 seconds as a volume repeated over 9 dynamics. using the 4d player you can view the cine run as a mip, and simultaneously rotate it as a 3d volume! osirix can also do 5d, which is the further addition of a functional parameter, such as positron emission tomography (pet). there is a cine of a 5d study downloadable from the osirix website (http://homepage.mac.com/rossetantoine/ osirix). after all that – yes i did find my little teaching database as well. a subgroup of the osirix team has made a small oss program called xphile modelled on the itunes program, which can be downloaded free from http://homepage.mac.com/d2p/xphile. it integrates with osirix making data capture easier. the need for a teaching file seems less urgent after osirix, which has ‘albums’ and search functions plus report facility enough for a dicom teaching library for the moment. as mentioned, i have not explored osirix to its fullest as yet, and other appealing features are teleradiology, teleconferencing and connectivity to ipod (apple computers inc).7 osirix is a very powerful and fast pacs and dicom program freely available off the internet. it is an open source program without any guarantees, but where one relies on support from a large user group of similarminded people with a large pool of experience. support companies are emerging that sell support and hardware for a pacs entirely based on osirix, which in their hands has been fda-approved. osirix has made great impact on my teaching and efficiency as a radiologist. it only runs on apple computers, but ‘switching’ is highly recommended as well. 1. scarsbrook af, foley pt, perriss rw, graham rnj. radiological digital teaching file development: an overview. clin radiol 2005; 60: 831–837. 2. escott ej, rubinstein d. free dicom image viewing and processing software for your desktop computer: what’s available and what it can do for you. radiographics 2003; 23: 1341-1357. 3. escott ej, rubinstein d. free dicom image viewing and processing software for the macintosh computer: what’s available and what it can do for you. radiographics 2004; 24:1763-1777. 4. ratib o, rosset a. open-source software in medical imaging: development of osirix. international journal of computer assisted radiology and surgery 2006; 1:187-196. 5. rosset a, spadola l, ratib o. osirix. an open-source software for navigating in multidimensional dicom images. j digit imaging 2004; 17: 205-216. 6. rosset a, ratib o, heuberger j, tao w. how to integrate your personal computer in a pacs environment. http://homepage. mac.com/rossetantoine/osirix/posterrsna2005.jpg 7. rosset c, rosset a, ratib o. general consumer communication tools for improved image management and communication in medicine. j digit imaging 2005; 18: 270-279. congrats and best wishes to my friends and colleagues, dr ashwin hurribance who is the new president of the college of radiology of south africa, and professors savvas andronikou and victor mngomezulu who are now at the helm of the university of stellenbosch and medunsa respectively. it would be remiss of me not to point out that all of them hailed from wits university. a further congrats to savvas on being awarded the derek harwood scholarship. this is just one of two scholarships awarded by the rsna on an annual basis. the scholarship is worth 10 000 dollars, and enables savvas to study at an american institution of his choice. he is presently at the columbia university medical centre in the fmri centre and the children’s hospital neuroimaging centre. he is learning fmri under the supervision of joy hirsch and bill millar, and he is also busy assisting in the set-up of the dti (diffusion tensor imaging) services there. he will also be visiting cornell to learn more detailed dti, and is an invited speaker at salt lake city, utah to talk on tb in children. well deserved and best wishes! paediatric mini-conference savvas will share his experiences and research findings with us next year (march 2008) when professor sheldon wiebe, a paediatric radiologist from saskatoon, canada, will be in south africa. we will be hosting a joint paediatric mini-conference in johannesburg, and possibly other centres. details will be forwarded to all via the college of radiology and the rssa who will be approached for financial and organisational assistance. neuroradiology mini-conference a big thank you to professor jonathan kleefield of the neuroradiology department of harvard medical school. jonathan was the sole, tireless, and impressive speaker at the neuroradiology mini-conference that was held at johannesburg hospital in march this year. thank you to robert makhubedu of toshiba and mike botha of bracco for assisting with this endeavour. it is good to see the public sector receiving some of the goodwill from our trade partners. 39 sa journal of radiology • june 2007 congrats by: mala modi conference news by: mala modi osirix has more conclusion pg38-39.indd 39 6/13/07 9:23:33 am radiology 35 sa journal of radiology • february 2005 re: the hyperdense middle cerebral artery sign in a polycythaemic child the letter by douis et al.1 (p. 34) concerning the hyperdense middle cerebral artery (hmca) sign brings to mind a case seen by myself several years ago. a 47-year-old man had developed an acute episode of jerking followed by paresis of his left arm and leg as well as facial numbness at approximately 14h00 one afternoon. after reaching the casualty department and following a neurological consultation he underwent an unenhanced ct scan of the brain at around 18h00. a mildly hyperdense appearance of the right internal carotid termination and adjacent proximal m1 segment of the right middle cerebral artery (mca) was noted, more so than seen in other adjacent vessels, but not strikingly so (fig. 1a). there was no evidence of parenchymal infarction or haemorrhage. in fact, his symptoms had largely resolved just prior to performing the ct scan. given this ct appearance together with the short history and symptoms fitting a possible right-sided cerebral ischaemic episode, we took the patient directly to angiography within the same hour. this was done with a view to both confirmation of the presence of a clot and possible intra-arterial thrombolysis. the arteriogram showed no abnormalities of the right anterior cerebral vasculature including no proximal or distal intraluminal thrombus (fig. 1b). one might have tended to ignore the initial ct picture except for the strongly correlative clinical signs. the fact that the symptoms had resolved in our patient could have meant collateral vessel recruitment or partial fragmentation of the clot with recanalisation, therefore warranting further investigation in our opinion. our patient was not polycythaemic and the cause of this transient neurological episode was never established. currently the initial investigation of choice for suspected acute intracranial arterial occlusion and/or infarction is mri scanning. many modern scanners allow rapid multisequence acquistions such as flair, diffusion (and perfusion) and mr angiography sequences all within 10 15 minutes, permitting rapid confirmation of diagnosis and assessment of the degree of probable temporary versus permanent parenchymal damage particularly with reference to the potential therapeutic use of thrombolytic agents. however, as mri facilities are not available at many centres throughout south africa, reliance on ct scanning in this situation is still commonplace, primarily to distinguish between haemorrhagic and non-haemorrhagic stroke. we have noted the ‘hyperdense’ appearance of intracranial vessels to be more pronounced with some makes of ct scanner than with others, with changes in window settings also contributing to the overall visual impression of hyperdense vessels. a similar mildly hyperdense appearance is often seen in the major venous sinuses on ct scans of the brain, which we have also seen mistakenly diagnosed as acute sinus thrombosis. when an intraluminal thrombus is present then the vessel is usually somewhat more hyperdense than in the example shown in fig. 1. we agree with rauch et al.2 that a hyperdense appearance to the mca is in itself not a reliable indicator of vessel occlusion or impending infarction and that such findings should be correlated carefully with the clinical presentation before venturing on to more expensive and invasive investigations. references 1. douis h, andronikou s, jadwat s. the hyperdense middle cerebral artery sign in a polycythaemic child south african journal of radiology 2005; 9: 34 (this issue). 2. rauch ra, bazon c 3rd, larsson em, jinkins jr. hyperdense middle cerebral arteries identified on ct as a false sign of vascular occlusion. am j neuroradiol 1993; 14: 669-673. letters fig .1a. axial unenhanced ct scan showing the hyperdense appearance of the terminal right ica and proximal mca. fig .1b. selective right internal carotid digital subtraction arteriogram shows normal patency of the distal right ica and adjacent mca. i c duncan unitas interventional unit centurion radiology 2/24/05 4:50 pm page 35 article information authors: indres moodley1 sivani moodley1 affiliation: 1health outcomes research unit, department of public heath medicine, university of kwazulu-natal, south africa correspondence to: indres moodley email: moodleyi15@ukzn.ac.za postal address: private bag x7, congella 4013, durban, south africa dates: received: 10 may 2014 accepted: 22 dec. 2014 published: 31 mar. 2015 how to cite this article: moodley, i, moodley, s. a comparative cost analysis of picture archiving and communications systems (pacs) versus conventional radiology in the private sector. s afr j rad. 2015;19(1); art. #634, 7 pages. http://dx.doi.org/10.4102/sajr.v19i1.634 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a comparative cost analysis of picture archiving and communications systems (pacs) versus conventional radiology in the private sector in this original article... open access • abstract • introduction • background • methods       • ethical considerations • results    • capital costs of pacs and conventional radiography    • productivity gains    • time and motion study for pacs vs. conventional radiology    • user satisfaction survey • discussion • acknowledgements    • competing interests • references abstract top ↑ background: radiology is rapidly advancing, with a global transition to digital imaging technology to improve productivity and enhance communication. the major challenge confronting radiology practices is to demonstrate cost savings and productivity gains when a picture archiving and communication system (pacs) is established. aim: to undertake an incremental cost analysis of pacs compared with conventional radiology to determine productivity gains, if any, at two private hospitals in durban. method: an incremental cost analysis for chest radiographs, computed tomography and magnetic resonance imaging brain scans with and without contrast were performed. the overall incremental cost for pacs in comparison with a conventional radiology site was determined. the net present value was also determined to evaluate the capital budgeting requirements for both systems. results: the incremental cost of both capital and the radiology information system for installing pacs shows an expected increase. the incremental pacs image cost shows a reduction. conclusion: the study provides a benchmark for the cost incurred when implementing pacs. it also provides a decision framework for radiology departments that plan to introduce pacs and helps to determine the feasibility of its introduction. introduction top ↑ radiology is rapidly advancing with the introduction of new technologies. globally, a transition to digital imaging technology and picture archiving and communication systems (pacs) is rapidly transforming radiology. until recently, conventional radiology based on screen-film technology dominated all radiology departments. however, many radiology departments have since introduced pacs, an electronic system that is used in radiology to transfer, archive, store and retrieve digital images and produce reports. pacs and digital radiography (dr) have the potential to bring about a major change in radiology workflow. patients benefit from reduced waiting times, whilst radiology practices benefit from increased productivity with a reduction in staffing costs. the purpose of the present study is to undertake a cost analysis of a pacs system in comparison with conventional radiology in two private sector radiology departments in durban. the study focuses on the incremental costs of introducing pacs with digital radiology versus conventional radiology. it is important that decision-makers have information regarding the financial impact of pacs, to allow appropriate budget planning for radiology departments in south african hospitals. the study will also assist in understanding the financial implications of pacs in terms of efficiency gains in human resource allocation and the potential subsequent reduction in overall health care costs. background top ↑ table 1 shows differences in systems and processes between hospital a and hospital b. hospital a removed the conventional film or screen radiography unit and replaced it with a conventional radiography and dr radiology unit. both sites had used a similar radiology information system (ris) which existed prior to the implementation. the only difference for hospital a was linking the digital imaging and communications in medicine (dicom) modality work list to the radiology modalities. the darkroom and processing unit was removed in hospital a to accommodate a server room. both hospitals retained their laser film processors. printing of the report and film for distribution for hospital b remained the same; however, hospital a had installed web access throughout the hospital as well as a compact disc (cd) burner for distribution of patient images. both hospital a and hospital b had one darkroom assistant at the time of implementation. the assistant from hospital a was transferred to another department within the radiology group and would not be replaced if she left. table 1: a comparison of systems and processes used to produce radiographs in a hospital using pacs (hospital a) and one using conventional radiography (hospital b). hospital a had been operating with a fully installed pacs for two years. pacs introduction involved training staff who still had to continue regular work, which created pressure for them during the training phase of the implementation. teething problems were experienced during this phase, such as incorrect scanning of referring documents, mismatch of images owing to incorrect accession numbers used by the radiographers, and cancelling of accounts. troubleshooting with the assistance of the pacs and application specialist was done as problems arose because many problems could not be anticipated before implementation. all major and minor workflow issues had been rectified at the time of the present study. paper printouts were given to patients on request for hard-copy images. the laser printer was kept on site for emergency purposes and for special requests. methods top ↑ the study was undertaken at two private hospitals in durban, kwazulu-natal province (hospital a and hospital b). hospital a has 400 beds and hospital b has 270. both hospitals have dedicated specialist wards. the study population comprised all walk-in patients attending the radiology department for chest radiographs, magnetic resonance imaging (mri) and computed tomography (ct) brain scans for a period of one month (august 2009) as well as all radiographers working in these departments. data for the cost analysis were obtained from the accounting departments of each hospital. costs attributable to radiology services were determined for personnel, equipment, consumables, and utility and maintenance costs. costs of procedures were obtained from the electronic billing system at both the hospitals. for the purposes of comparison, the costs of all procedures were determined using medical aid rates. the time taken for the different types of studies using either conventional radiology or pacs were obtained from radiographers by means of questionnaires. a pilot study consisting of 10 radiographers was conducted to ensure there was no ambiguity in the questionnaires before they were administered. waiting time sheets were self-administered by all walk-in patients for chest, ct and mri brain procedures. this information was cross-referenced to the data recorded on the ris at both sites. questionnaires were used to determine radiographers’ work experience, actual times for examination taken with pacs and conventional radiology methods, any problems experienced with pacs, and any suggestions that could assist in implementing pacs. data obtained from the time sheets were verified with those recorded on the ris. the total number of procedures was determined for the month of august (31 days). the cost per procedure (chest radiograph, ct and mri brain scans) was then determined. personnel salaries were weighted according to the time taken to undertake each step of the procedure. consumables and materials needed for each procedure were also added to make up the final cost. water, electricity, cleaning services, maintenance of the building and security were included in the monthly rental costs for both sites. costs for chest radiographs, ct and mri brain scans were extrapolated to annual costs, and the monthly cost for each procedure was then calculated. the maintenance of the building was included in the rental cost. the cost of equipment and furniture was calculated using replacement values as well as their lifespan. for computers and furniture, average lifespan is 3–5 years depending on usage. for all other equipment and mainframe computers, the south african revenue service's (sars) depreciation allowance of 5 years was used and 2 years for software depreciation.1 income after tax was calculated on the gross income after allowance for wear and tear. net income was calculated after deducting income tax at 28%. the net present value (npv) takes into account cash flows over a period of time, discount rates and the lifetime of the project. the npv for conventional radiology workflow methods was compared to that of pacs. productivity gains were added from the pacs npv values to show the npv with the total cost savings for chest radiographs and ct and mri brain scans. the formula for calculating npv is: where: npv = net present value cf t = the cash flow in period t r = discount rate n = number of periods. the npv calculation in the above formula can be described as the present value of an investment's expected cash inflows minus the costs of acquiring the investment. npv calculations are used to analyse acquisitions or future capital costs. ethical considerations ethical approval for the study was obtained from the biomedical research ethics committee of the nelson r. mandela school of medicine (reference number exp003/06). results top ↑ capital costs of pacs and conventional radiography the capital costs of pacs and conventional x-ray equipment are shown in table 2. the capital costs for pacs included software, computers, digital x-ray equipment, ct and mri scanners compatible with dicom, wide-screen monitors and 17-inch monitor screens for radiologists, computed radiography (cr) cassettes, cd printer, ups, single slot reader, operator consoles for radiographers and training costs. table 2: overall costs for chest radiographs and ct and mri brain scans using the pacs system. table 2 and table 3 show each cost item used for the calculation of the capital cost of pacs and conventional radiography for chest radiographs and ct and mri brain scans with and without contrast. an important aspect noted in the tables is that the implementation of pacs incurs greater capital cost for all three procedures than conventional radiography systems. table 3: overall costs for chest radiographs and ct and mri brain scans using the conventional radiography system. table 4 shows a detailed imaging cost for pacs. weighted labour costs required to produce a radiograph were included as well as the costs of each consumable to produce the radiograph. the labour costs for radiographers were used to calculate the minimum (one radiographer) and maximum (two radiographers) total costs. operating costs included maintenance (building and equipment), utilities and services excluding service level agreements. table 4: imaging costs for pacs. the imaging costs for producing images by conventional radiography methods are shown in table 5. radiographer labour costs were used to calculate the minimum and maximum total costs. operating costs included maintenance (building and equipment), utilities and services, excluding the service level agreement. table 5: imaging costs for conventional radiography. table 6 shows the overall incremental imaging costs for pacs v. conventional x-rays. a decrease in imaging cost for pacs compared with conventional radiology was observed. chest radiographs and mri brain scans with pacs showed a substantial cost saving on a single examination image cost. a moderate cost saving of 5% and 14.2% was seen for ct brain scans (with and without contrast, respectively). however, a more substantial cost saving of 27% was seen for chest radiographs whilst mri brain scans (with and without contrast) decreased by 22% and 15% respectively. table 6: overall incremental imaging cost of pacs v. conventional x-ray (net present value). the capital costs allocated for radiology equipment (conventional radiography (cassettes, cassette reader and x-ray unit), ct, mri), computer hardware (reception pcs, consoles for radiographer and radiologists, cd publisher, server, quality control pc, network costs) as well as ris and pacs were weighted according to the number of patients per examination procedure. income after tax was used in determining the npv. the individual npvs for both systems, though not significantly different, were positive, indicating that both systems were equally profitable. the overall npvs for pacs and conventional methods, including the difference between both systems, is shown in table 7. table 7: overall net present values for chest x-ray and ct and mri brain scans. productivity gains all salaries (radiographers, radiologists, pacs administrators and darkroom assistants) were weighted according to the number of chest radiographs and ct and mri brain scans undertaken. because private hospital salary scales were deemed to be confidential, the radiologist's salary was taken from the national department of health salary scales and is probably a conservative estimate. following the introduction of pacs, a decrease in the number of radiologists on site from five to three was noted, signifying productivity gains for the practice. the cost savings of two radiologists for a year was in the range of r1 833 000 to r3 665 000. there was no decrease in radiographer staff numbers at the time of the study. however, it was noted over a period of time that, when radiographers left, fewer were replaced. table 8 shows the npv values for chest radiographs’ and ct and mri brain scans’ productivity gains over a five-year forecast period. table 8: productivity gains after 5 years for chest x-rays and ct and mri brain scans. productivity gains were weighted for the time spent by a radiologist to diagnose and report a procedure. the npv for chest radiographs and ct and mri brain scans after five years was positive, showing a net productivity gain. in the present study, the project timeline was assumed to be five years. the timeline is based on the expected useful life of current hardware, software systems and procedure technologies. time and motion study for pacs vs. conventional radiology a time and motion study determined the time taken to capture patients’ details onto the ris until the report was produced; this provided the total waiting time for patients. pacs waiting times showed a reduction owing to reduced report waiting times for all three procedures (figures 1–3). figure 1: patient waiting times in minutes for chest radiographs at hospital a (pacs) (n = 255) and hospital b (conventional) (n = 255). figure 2: patient waiting times in minutes for ct brain scans at hospital a (pacs) (n = 21) and hospital b (conventional) (n = 20). figure 3: patient waiting times in minutes for mri brain scans at hospital a (pacs) (n = 52) and hospital b (conventional) (n = 18). the results shown in figures 1–3 reveal that both sites performed the same number of procedures for chest radiographs and ct brain scans, except for hospital a where more mri brain scans were performed. compared with conventional radiography, chest radiographs and ct and mri brain scans using the pacs site were completed in less time; this could provide added advantage to hospitals with pacs as the potential exists to increase patient throughput. user satisfaction survey a total of 16 radiographers from hospital a were given the opportunity to participate in the present study, with 81% of them returning their self-administered questionnaires. the results show that all the radiographers had a year or more pacs experience in a completely filmless and paperless environment. all (100%) staff who participated in the study preferred the new pacs system over the conventional system. further interrogation of their responses showed that a large proportion (46%) of the radiographers preferred pacs because they found the system to be fast and efficient. about 23% observed that time efficiencies were possible with pacs. a small proportion (8%) of the radiographers felt that pacs was easier to use than conventional radiology methods. discussion top ↑ the present study compared the cost of introducing pacs with conventional radiology. pacs is fast becoming the method of choice for both local and international radiologists. the recent application of digital technology to radiology has not only eliminated the need for producing x-ray film and paper-based reports but also improved patient workflow in radiology departments. referring doctors are now able to make a more rapid diagnosis owing to the quick and easy access to radiological images and reports via the electronic system. radiologists are able to increase diagnostic accuracy thanks to the accessibility via pacs of previous studies. pacs can increase the productivity of a radiology department and lead to positive financial outcomes, depending on various other factors such as the vendor used and location of the radiology department. however, careful financial consideration must be applied. the implementation of pacs requires a major capital investment initially, with a total cost that must include ris. where a radiology department has an existing ris and digital equipment, as is becoming the norm as equipment is replaced, the additional cost would then be only for the acquisition of pacs. the present study did not take into consideration the building modifications needed when implementing pacs. in this study, those aspects were minor: the server room and radiographer and radiologist workspace needed some modifications and requirements to be met. the findings presented here suggest that the incremental capital costs for implementing pacs are greatest when new digital x-ray equipment and pacs are purchased at the same time, as in the case of hospital a. this option may not apply to all radiology practices as x-ray equipment costs are often fully paid off before pacs is purchased. pratt et al.2 suggest that when a hospital is committed to implementing cr equipment regardless of implementing pacs, or if the cr equipment is already installed, it would result in a positive financial effect on the cost analysis because the implementation of cr can be regarded as a sunk cost. the implementation of cr or dr equipment before the introduction of pacs could prove to be a cost-effective method for radiology practices and reduce the need for a large capital outlay at one time. hospital a required hardware and software as well as labour costs for implementation and training. these initial costs account for the greater capital investment needed for pacs. with the introduction of pacs in hospital a, the radiographer and radiologists required client computers. for the radiologists, additional diagnostic monitors were also needed. these costs were not incurred in hospital b (conventional radiography) as the radiographer and radiologist made use of referral letters and printed radiographs. both hospital a and hospital b with ris required a local area network (lan) to be set up. however, the layout of the network in hospital a was more complicated as it involved linking reception, radiographer and radiologist. hospital a was able to reduce these costs by using the existing it department to configure and establish this network. the lan cost incurred in hospital a was far greater than that of hospital b owing to the increased need to network the entire radiology department in hospital a. the cost incurred for the hospital network was not included in the present study as the hospital had taken responsibility to configure and maintain this network for the referral doctors. although the initial capital outlay for pacs is high, there are other financial benefits in its use. the incremental image costs for chest radiographs and ct and mri brain scans are less than the incremental ris and capital costs. incremental image production costs in all the pacs radiology departments showed a cost saving for all three procedures. these findings are consistent with previous findings on pacs costings.2,3,4,5 the image cost savings and related consumable costs are one of the positive aspects to implementing pacs. while the npv for mri brain scans was negative, a positive npv value was found for chest radiographs and ct brain scans. the findings for mri brain scans were not similar to previous studies as a positive npv value for pacs was obtained.2,6,7,8 the reason for this difference could be the volume of patients seen at the practice, which offsets the costs; however, it could also indicate that different examination procedures yield different npv values.2,6,7,8 other major direct cost savings derived from pacs arose in staffing and operational costs, which showed a reduction in cost for chest radiographs and ct and mri brain scans. the predominant gain seen with pacs is the productivity gain. a reduction from five radiologists to three resulted in cost savings to hospital a owing to both pacs and the central work list. wide area network (wan) cost was not included as it was implemented after this study was completed. the radiology department was now able to decrease the need for additional radiologists as well as re-allocate radiologists for a newer venue and annual leave. this cost saving had a positive effect on the npv value for chest radiographs and ct brain scans. it was also observed that, over the period of the study, radiographers were not always replaced upon their departure, thus reducing the number of radiographers currently working in the department. the need for darkroom assistants was eliminated and, in hospital a, they were relocated to the distribution section of radiology. however, the additional cost of a pacs administrator was incurred in hospital a. the results presented in the present study show that, whilst pacs incurs a greater initial capital cost than conventional radiology methods, there are downstream cost savings in human resources and image production. to determine the true costing of pacs, both monetary and non-monetary benefits need to be considered. mweli9 points out an interesting aspect on non-monetary costs, in that, for patients, the benefit of implementing pacs is immediate, whilst the benefit to a radiology practice is in the long term. mweli9 also states that the benefits to patients are indirect and can only be seen downstream of the value process.3,8 radiologists are now able to immediately access the images, patient referring letter and history, thus reducing the time to clear their work lists. the workload on radiologists is eased via even distribution of work. consequently, reporting backlogs can be avoided and patients’ report turnaround time can be improved. at hospital a, it was later found that with the introduction of further workflow enhancements within pacs, a radiologist could work at any practice or venue and report a case anywhere with pacs facilities; for example, a central work list. there was also a moderate improvement in report waiting times for patients who opted to wait for their radiographs, as these can now be transmitted electronically to the requesting doctor. the productivity gains from pacs show that with the decrease in times, the potential exists to increase the number of patients, providing an increase in profitability. the referring doctor also benefits as patient images are available for viewing at the same time as their interpretation by the radiologist. referring doctors can now benefit through faster turnaround times for patient diagnosis as images are immediately accessible to them and treatment of patients can be expedited. the radiographers’ experience with pacs was shown to be positive owing to improvements in the working environment. radiographers who are the end users are important in making any system work successfully, especially in a pacs environment. radiographer productivity gains were not evaluated in the present study. however, in the self-administered questionnaire, they reported improved speed and efficiency of workflow with pacs. the new system made the working environment easier for some radiographers by eliminating slow and tedious processes used in conventional radiology. some of the initial disadvantages of using pacs are downtime owing to initial errors and computer glitches during the setup phase; however, these arise only in the first few months of implementation. once this phase is over, very few incidents occur, and onsite assistance is available at all times. in the present study, one of the radiology practices with pacs has seen productivity gains owing to the reduced need for an onsite radiologist, thus contributing to cost savings. however, both radiology departments have seen the opportunity to enhance workflow by introducing remote reporting, voice recognition and tele-radiology through the introduction of pacs technology. pacs could potentially be of benefit to the proposed national health insurance scheme by reducing the number of radiologists required and image processing costs, whilst containing costs, thereby eliminating compromise in the quality of patient care.10,11 costing a new investment such as pacs is a key factor in controlling the high spend on health care in south africa. however, radiology practices need to evaluate pacs technology in terms of both its monetary and non-monetary benefits before coming to an implementation decision. the present study could be used to inform other practices contemplating the introduction of pacs. it should be noted that a return of investment might not be seen in the short-term; further cost benefit studies would be required to evaluate this. however, the benefits to the practice, radiologists, referring physicians and patients in terms of time and efficiency are more immediate. acknowledgements top ↑ this article is an objective production by the authors. where applicable, the research work or material from various academic scholars and sources has been acknowledged and reported accurately. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. references top ↑ south african revenue services. wear and tear or depreciation allowance [homepage on the internet] c2010 [cited 10 january 2012]. available from: http://www.sars.gov.za/home.asp?pid=55888 pratt hm, langlotz cp, feingold er, schwartz js, kundel hl. incremental cost of department wide implementation of a picture archiving and communication system and computer radiography. radiology. 1998;206:245–252. http://dx.doi.org/10.1148/radiology.206.1.9423679 becker sh, arenson rl. costs and benefits of picture archiving and communication systems. j am med inform assoc. 1994;1:361–371. http://dx.doi.org/10.1136/jamia.1994.95153424 huda w, honeyman jc, frost mm, staab eva. cost analysis of computed radiography and picture archiving and communication systems in portable radiography. j digit imaging. 1996;9:39–44. http://dx.doi.org/10.1007/bf03168567 reddy as, loh s, kane ra. budget variance analysis of a department wide implementation of a pacs at a major academic medical center. j digit imaging. 2006;19:66–71. http://dx.doi.org/10.1007/s10278-006-0852-9 duerinchkx aj, kenagy jj, grant eg. cost analysis of pacs: fact or fiction. medical imaging. 1999;253. http://dx.doi.org/10.1117/12.352752 fang yc, yang m, hsueh ys. financial assessment of a picture archiving and communication system implemented all at once. j digit imaging. 2006;19:44–51. http://dx.doi.org/10.1007/s10278-006-0632-6 hilsenrath pe, smith wl, berbaum ks, franken ea, owen da. analysis of the cost effectiveness of pacs. ajr. 1991;156:177–180. http://dx.doi.org/10.2214/ajr.156.1.1898556 mweli, t. an exploratory business case for radiology information system (ris) – a south african firm level analysis [dissertation for master of business administration]. pretoria: university of south africa; 2010. economist intelligence unit. healthcare and pharmaceuticals report south africa – market data at a glance. [homepage on the internet] c2012 [cited 26 april 2012]. available from: http://store.eiu.com/article.aspx?.productid=1557096955 masombuka s. nhi plan now on a roll. the times. 23 march 2012. available from: http://www.timeslive.co.za/local/2012/03/23/nhi-plan-now-on-a-roll untitled 35 sa journal of radiology • december 2005 according to 1999 cancer association of south africa (cansa) statistics, breast cancer is the most common cancer in south africa among women and has overtaken the reported rates for cervical cancer. they report that the biggest increase has been in the indian community and among black women between the ages of 30 and 50 years.1 cansa statistics demonstrate that between 1973 and 1998 there was a 21% increase in the number of female breast cancers in south africa – women less than 35 years old account for 2% of this increase. from 1998 to 1999, 11 507 new cases of breast cancer were reported in south africa, comprising ± 19% of all cancers reported in the 2 years.1 however, the same source indicates that over the last 10 years there has been a 20% increase in survival primarily due to early diagnosis and improved treatments.1 the importance of early diagnosis cannot, therefore, be emphasised enough and since the early 1970s mammography has remained the mainstay of early detection of breast cancer. but as mammography is now over 3 decades old, the question in 2005 is whether mammography is still the best option as a screening modality. the alternatives are: 1. self examination – this involves regular self assessment by the patient and relies on the abnormality being palpable and the patient having the education to recognise what is abnormal. clinically this implies a size far bigger than is acceptable for screening purposes. it is hence only of use as an adjuvant to other investigations. 2. sonar – ultrasound imaging of the breast is done routinely as an adjuvant to mammography but is of little value as a stand-alone investigation. 3. magnetic resonance imaging (mri) – this modality was fda-approved in 1991 but only as a supplement to mammography. it lacks the spatial resolution available with mammography. however, it is an excellent problem-solving tool and may be useful for screening younger women at high risk for breast cancer, viz. those who are breast cancer genes 1 and 2 (brca 1 and 2) -positive. 4. ductal lavage – this modality relies on breast cells extracted from the milk ducts exhibiting pre-cancerous or cancerous qualities. the cells are examined microscopically for suspicious changes. the rate of false-positives is still too high and although lavage may play a role in the assessment of high-risk women, it is still only fda-approved as an adjuvant.2 5. electrical impedance scanning – this method uses electrical potential principles to measure the way electrical current passes through cancerous tissue versus its passage though normal tissue. it was fdaapproved as an adjuvant in 1999 but is limited by its availability.3,4 6. biofield diagnostic scanning – this modality is similar to the principle of electro-cardiogram (ecg). electrical bio potentials are measured across the breast and correlate with the proliferative activity of the tissue. its usefulness in screening has yet to be proven.3 7. thermography – this is a heat-sensitive processing system that captures heat radiating from the body. it was fdaapproved in 1982 as a supplement to mammography.5 according to the american college of radiologists it has not shown value as a screening, diagnostic or adjunctive imaging tool.3 a newer version known as computerised thermal imaging (cti) is now under investigation.5 8. scintimammography – this modality may be useful in selected cases following diagnostic mammography. the radioactive tracer 99mtc mibi has been shown to accumulate differently in cancerous versus non-cancerous tissue.6 9. position emission tomography (pet) – the isotope fluorodeoxyglucose (fdg) goes to places where cells are most active. pet scanning depends on changes in tissue metabolism. pet is being used to detect metastatic disease but is not currently being used for primary breast cancer detection because it does not reliably detect tumours smaller than 1 cm in diameter.6,7 10. dynamic optical breast imaging (dobi) – this uses differences in light transmission and absorption through normal and abnormal tissue. its value has not yet been proven.8 11. computer laser tomography – this uses a laser operating in the near-infra-red portion of the spectrum. normal and abnormal tissue show differential transmission and refraction.7 it is currently being investigated in trials but has not yet been approved by the fda for general use.7 over 30 years since its inception, mammography clearly remains the gold standard screening tool for breast cancer detection and is unlikely to be replaced by any other modality in the near future. the advent of digital mammography has changed the way images are recorded, viewed and stored but still relies on the same principles as film screen mammography to produce the image. references 1. mqoqi n, kellett p, jula m, sitas f. incidence of histologically diagnosed cancer in south africa 1998 1999, national cancer registry of south africa. johannesburg: national health laboratory service, 2004. 2. zielinski s. ductal lavage may not detect breast cancer. j natl cancer inst 2004; 96: 1487. 3. american college of radiology. breast imaging reporting and data system atlas. bi-rads atlas 2003. 4. malich a, boehm t, facius m, et al. differentiation of mammographically suspicious lesions, evaluation of breast ultrasound, mri, mammography and eis as adjunctive technologies in breast cancer detection. clin radiol 2001; 56: 278 283. 5. amalu w. a review of breast thermography. international academy of clinical thermology, 2003. 6. greener m. value of scintimammography in the diagnosis of breast cancer. cirugia espanola 2001; 69: 8-12. 7. gotzche pc, olsen o. is screening for breast cancer with mammography justifiable. lancet 2000; 355: 129 134. 8. grable r, pander s, gkanatsios n, et al. optical computed tomography for imaging the breast: first look. proceedings of spie 2000, 4082: 40 45. update mammography – any alternative imaging in 2005? j smilg mb bch, dip pec (sa), ffrad (d) (sa) department of radiology johannesburg hospital 10 11/25/05 2:20 pm page 35 article information authors: cornelia minné1 margaret e. kisansa1 nazeema ebrahim2 farhana e. suleman3 nonjabulo z. makhanya3 affiliations: 1department of diagnostic radiology, university of limpopo, south africa2department of radiography, university of limpopo, south africa 3department of radiology, university of pretoria, south africa correspondence to: cornelia minné postal address: po box 100143, moreletta plaza 0167, south africa dates: received: 08 may 2013 accepted: 18 jan. 2014 published: 01 aug. 2014 how to cite this article: minné c, kisansa me, ebrahim n, suleman fe, makhanya nz. the prevalence of undiagnosed abnormalities on non-contrast-enhanced computed tomography compared to contrast-enhanced computed tomography of the brain. s afr j rad. 2014;18(1); art. #598, 7 pages. http://dx.doi.org/10.4102/ sajr.v18i1.598 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the prevalence of undiagnosed abnormalities on non-contrast-enhanced computed tomography compared to contrast-enhanced computed tomography of the brain in this original research... open access • abstract • introduction • aim • method    • statistics • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: even though magnetic resonance imaging (mri) is the gold standard investigation for intracranial pathology, it is not widely available in developing countries and computed tomography (ct) of the brain remains the first-line investigation for patients with suspected intracranial pathology. it is generally accepted that certain intracranial pathology can be missed on non-contrast-enhanced ct (nect) of the brain if a contrast-enhanced ct (cect) is not done. we have to consider on the one hand the risk of delayed or missed diagnosis and on the other hand the cost, increased radiation exposure and contrast-induced reactions. advances in ct technology have also improved the resolution of ct scan images, making it easier to identify pathology on an nect of the brain. to date, no study comparing nect to cect of the brain, utilising 64-slice ct technology, has been published. objectives: to determine the prevalence of undiagnosed abnormalities on non-contrast-enhanced computed tomography (nect) scans of the brain reported as normal, on a 64-slice ct scanner. method: a descriptive retrospective study was undertaken of ct brain scans done during a 12-month period at a tertiary provincial hospital in the northern tshwane district of gauteng, south africa. the ct brain scans were evaluated by three reviewers (general radiologists). the nect and contrast-enhanced computed tomography (cect) scans of the brain were reviewed independently on separate occasions. reviewers were blinded to patient history, each other’s interpretation, and to their own interpretation of the nect when evaluating the cect and vice versa. discrepancies in interpretation were resolved during a consensus meeting between all three reviewers. the reviewers also re-evaluated the nect scans of the cases with undiagnosed abnormal findings during this session. a decision was made pertaining to the visibility of the abnormal findings on the nect scan. results: in this study, 3.28% of cases had abnormal findings undiagnosed by three reviewers on the nect scans. re-evaluation by the panel reduced this to 1.42%, indicating a reading error of 1.85%. conclusion: there is a small prevalence of missed abnormal findings on the nect scan when using only nect. omitting unnecessary cect will reduce the radiation exposure to the patient and reduce the risk of adverse events from the use of intravenous iodinated contrast. alternatively, doing only a cect scan would reduce the risk of missing abnormal findings and would also decrease the patient’s exposure to radiation. introduction top ↑ we live in a technologically advanced age, but not in an ideal world. magnetic resonance imaging (mri) is the gold standard investigation for intracranial pathology, but is not widely available in developing countries.1 within the public health sector of south africa, mri is limited to a few tertiary institutions. radiologists and clinicians in many centres must therefore rely on computed tomography (ct) of the brain as a first-line investigation for patients with suspected intracranial pathology. traditionally these patients would be investigated with non-contrast-enhanced ct (nect) followed by contrast-enhanced ct (cect) of the brain. most pathological processes result in alterations in the blood–brain barrier that lead to local oedema and contrast enhancement.1,2,3,4 imaging characteristics, including enhancement patterns, have been described for various pathological conditions.1,2,3,4,5 it is well recognised that vascular abnormalities and isodense lesions could be undiagnosed on nect and that cect may subsequently demonstrate these lesions.2 a cect can also confirm, change or shorten the differential diagnosis.1 , important factors to consider before subjecting patients to cect are: • the risk of adverse events after intravenous injection of iodinated contrast media • the cost and time implication of doing an nect and cect of the brain • the radiation dose to the patient. on the other hand, performing only an nect poses a risk of missing abnormal findings that a cect could detect. the omission of a cect may lead to misdiagnosis or delayed diagnosis in patients with possible intracranial pathology. existing policies for the use of cect were established in the 1970s based on experiences with early-generation ct scanners.3,6 barrington et al. regarded cect as unhelpful if the nect was normal.7 later studies by chishti et al.1 and huckman2 demonstrated that pathology undiagnosed on nect could subsequently be seen on cect. other authors suggested the use of contrast media in patients with normal nect scans if there were focal clinical signs,1,3,6 whilst some like butler et al. were of the opinion that a cect on its own was as accurate as an nect and a cect combined.8 we have to consider that improved ct scanners with better resolution may mean that increased pathology would be detected on the nect and could eliminate the need for performing a cect of the brain. to date, no study comparing nect to cect of the brain, utilising 64-slice ct technology, has been published. aim top ↑ the aim of this study was to determine the prevalence of occult abnormalities on an nect of the brain (done on a 64-slice ct scanner), if a cect was omitted. method top ↑ ethics approval was obtained from the medunsa campus research and ethics committee (mrec) of the university of limpopo. a descriptive retrospective study was undertaken of patients who presented for a ct of the brain to the diagnostic radiology department of dr george mukhari hospital, a tertiary provincial hospital in the northern tshwane district of gauteng province, south africa. patient confidentiality was maintained during the study. all patients underwent an nect directly followed by a cect of the brain. patients selected for the study were imaged during the period 01 october 2007 – 30 september 2008. ct brain scans of all patients suspected of having intracranial pathology, referred for brain imaging, were considered. patients were excluded if they had an acute head injury, an abnormal nect of the brain, an incomplete ct study, or if severe artefacts were present on the ct images.all brain ct scans were performed on a toshiba aquilion model tsx-101a, a 64 multislice ct scan system. ct scans were viewed on a 1600 x 1200 pixel monitor and a high-definition video-card workstation. ct scans were evaluated by three reviewers (general radiologists). none of the reviewers were neuroradiologists. all ct scans were interpreted by the reviewers in the radiology department during working hours, simulating normal working conditions. reviewers were blinded to their own interpretation of the nect when the cect was evaluated and vice versa. reviewers were also blinded to each other’s interpretation and to patient history. only intracranial structures were evaluated; bony abnormalities and abnormal findings outside the skull were disregarded. the nect and cect were evaluated independently on separate occasions and separate datasheets were completed and then captured as follows: if two or three reviewers interpreted the scan as abnormal it was entered as ‘abnormal’. if only one of the three reviewers interpreted a scan as abnormal, the scan was entered as ‘undetermined’. all three reviewers had to agree that a scan was normal before it was entered as ‘normal’. this process was done for both nect and cect. discrepancies in interpretation were then resolved during a consensus meeting between all three reviewers. at this meeting reviewers also re-evaluated the cases with abnormal findings on cect that were undiagnosed on the nect, and a decision was made as to the visibility of the abnormal findings on the nect. both the nect and cect were reviewed consecutively. the reviewers were blinded to the history of the patient during the consensus meeting. the data was then updated. the records of cases with an undiagnosed abnormal finding on nect were reviewed and summarised. statistics sample size was calculated assuming that a proportion of 0.4 brain nect would be normal scans and the prevalence of undiagnosed abnormalities on nect as compared to cect would be 0.05. a significance threshold of 0.05 was selected. a minimum sample of 521 ct scans was required. the number of normal, abnormal and undetermined outcomes were counted within each group, using the statistical analysis system (sas) (2010). a finding was regarded as undiagnosed if the consensus decision on the nect was normal and the cect abnormal. inter-rater agreement was assessed with kappa statistics using medcalc (2011). results top ↑ a total of 992 patients were initially selected by the lead researcher. cases with subtle abnormalities were included in the initial selection to reduce selection bias. subsequent evaluation by all three reviewers excluded patients with subtle abnormalities on nect, reducing the sample size to 726. the gender distribution was more or less equal. age categories are summarised in figure 1. the majority of patients were between the ages of 1 and 39, with the largest group 30–39 years (139), the second largest group 1–9 years (127) and the third largest group 20–29 years (120). figure 1: summary of age distribution. kappa statistics were performed between the reviewers on the cect dataset before consensus was reached (table 1). the inter-rater agreement between reviewer 1 and 3 was moderate but between reviewer 2 and other reviewers fair. table 1: summary of kappa statistics of the reviewers done on the cect dataset before consensus was reached to determine inter-rater agreement. after the three reviewers reached consensus, the data was updated. twenty-five cases were excluded as they were regarded to have an abnormal nect. the number of patients with normal nect was thus reduced to 701. of the 701 patients that had a normal nect, 23 (3.28%, ci 1.98–4.88%, p < 0.001) cases had abnormalities on the cect. the 23 cases with abnormal findings undiagnosed on the nect were re-evaluated by the three reviewers during the consensus meeting. thirteen (1.85%) of these cases had an identifiable abnormal finding on the nect in retrospect and 10 cases (1.42%) were still deemed normal on nect. abnormalities detected on cect that were not detected by the nect are summarised in table 2. patient hospital records of only 15 of the 23 cases with abnormal findings undiagnosed on nect were available from the hospital archives. nine of these 15 cases had a history or clinical finding that would alert the radiologist to proceed with a cect. two cases had recorded fever, three had focal signs, three had confusion, three had meningism, three had convulsions and one had a recorded history of dehydration that poses a risk for dural venous sinus thrombosis. table 2: summary of findings undiagnosed on nect. discussion top ↑ a cect contributed extra information in 3.28% (23 out of 701 cases) of normal nect of the brain. retrospectively only 1.42% (10 out of 701 cases) had abnormal findings on cect that were not visible on the nect scans. the difference between 3.28% and 1.42% constitutes a reader error of 1.85% (13 out of 701 cases). the abnormalities undiagnosed by the reviewers in this study (table 2) can be classified into four main groups: • infective: meningitis (figure 2), empyema (figure 3) • vascular: dural venous sinus thrombosis and vascular malformations (figure 4) • neoplasms: meningioma (figure 5), pituitary lesions • ischaemic events: lacunar infarcts. when records of cases with an undiagnosed finding were evaluated, it revealed that the majority of these patients had a history or clinical findings that would have guided the radiologist to perform a cect. in some cases, a reviewer reported the nect study as abnormal, but after the administration of contrast media reported it as normal. this demonstrates that in some cases contrast media will help to eliminate false positive reports and help to confirm a normal brain ct in an equivocal nect. chishti et al.1 also showed that a cect can help reduce false positive findings on an nect. figure 2: (a) nect and (b) cect of the cerebellum. multiple enhancing nodules seen in the cp angle and to the right of the fourth ventricle on the cect (b, arrows). these nodules are vaguely visible on the nect (a, arrows) but were missed by the reviewers. figure 3: (a) nect and (b) cect of the brain. the nect shows a vague parafalx hypodensity (arrow). this finding was undiagnosed during the first review and only identified on the cect, which shows a small empyema (arrow). figure 4: (a) nect and (b) cect of the brain. no abnormal finding is visible on the nect but the cect reveals a vascular abnormality left frontally (arrow). figure 5: (a) nect and (b) cect of the brain. the nect is apparently normal but the cect demonstrates a small well-defined enhancing lesion (arrow). meningioma was reported the most likely diagnosis. undiagnosed findings on nect may be attributed to several factors. these factors can be divided into imaging factors and reviewer factors. imaging factors include the quality of the ct images, the density and size of the abnormal findings and the presence or absence of secondary signs. pathology will not be visible on an nect when it is isodense to the surrounding parenchyma and when there are no secondary signs like oedema or mass effect. reviewer factors can be cognitive or perceptive errors. cognitive errors occur when the radiologist sees an abnormal finding but interprets it as a normal variant or a normal structure. perceptive reviewer errors occur when the abnormal finding is overlooked by the reviewer. perceptive errors are four times more common than cognitive errors.9,10 errors can also be classified into false positive and false negative errors.9,10 false negative errors occur five times more commonly than false positive errors. there are many other factors that influence the accuracy of a radiologist’s report. some of these factors are fatigue, interruptions, incomplete or inaccurate clinical history, unavailability of previous investigations for comparison, poor viewing conditions and poor quality examination.9,10 in this study, factors that could have affected the reviewers were: repeated interruptions, fatigue from reading multiple brain ct scans in short periods of time, long periods between reading sessions due to workload, shortage of staff and shortage of workstations. however, these factors are present in most departments and work environments in south africa. our selection criteria may have created a bias, as convenience sampling was done. no history was available to the reviewers as a clinical history would have created an interpretive bias. nect and cect were read at different times in order to reduce a possible bias being created by reading two similar ct scans directly after each other. this also prevented the reviewers from reviewing their first evaluation of the nect and making changes on the datasheet. ct technology has changed dramatically in the last few years. ct scanners offer increased resolution, decreased radiation, multiplanar imaging and post-reconstruction processing functions. the most recent study by chishti et al.1 investigating the usefulness of intravenous iodinated contrast media in cranial ct from 1997 to 2001 had a total of 547 adult patients with ct scans performed on a third-generation ct scanner. the patients were divided into three groups. the first group of 496 patients had a normal nect and no clinical indication for cect, for example lateralising signs. in this group, only one patient (0.2%) had an abnormal cect (a meningioma). in the second group of 16 patients with lateralising signs, only two patients (12.5%) had a normal nect and an abnormal cect (meningeal enhancement). in the third group of 35 patients (30 abnormal and 5 equivocal cranial nect), the cect changed the diagnosis in 12 cases and added to the differential diagnosis in 7 cases. overall, in this study, an abnormality was seen exclusively on the cect in 3 out of 547 cases (0.5%) and it changed the diagnosis in 15 cases (2.7%). the clinicians in this study had some limited access to an mri and patients with demyelinating diseases, cranial nerve pathology, sella pathology, infection, metastasis and neoplasm were excluded from ct. in our setting, these patients would all receive a cranial ct before a mri would be considered. this study suggests that taking the clinical history into consideration when deciding whether a cect is indicated can reduce the risk of missing abnormal findings, although the number of patients in the group with lateralising signs and normal nect was small. comparing the results from the study conducted by chishti et al.1 to the results from the study reported here, despite marked differences in the methodology, both showed a very small prevalence of abnormal findings undiagnosed on nect. both studies also suggest that the risk can be reduced if history is taken into account when the decision is made whether to do a cect or not. wood et al.11 evaluated the value of cect in the non-trauma patient in the emergency room. only 3 out of 240 cases (0.0125%) had abnormalities on the cect not initially evident on the nect. in their study, the additional information did not alter patient management. they concluded that in the acute setting if an nect is normal the cect is usually not necessary.11 the results of the study by wood et al.11 correlate with the study reported here although they reported fewer cases with additional findings on the cect. this could probably be attributed to the higher tuberculosis and hiv burden in the south african population. radiation exposure is an important risk factor to consider when performing a ct of the brain. ionising radiation has many documented adverse effects. the most serious is the induction of cancer. cancer is a complication of radiation and has no threshold dose, thus even a small dose will have a small risk. the ct dose from each ct is cumulative. a recently published retrospective cohort study by pearce et al. on radiation exposure from ct scans in childhood showed a positive association between the radiation dose from ct scans and the development of leukaemia and brain tumours.12 the study estimates an excess relative risk (err) of 0.036 per mgy (ci 0.005–0.120; p = 0.0097) for leukaemia and an err of 0.023 per mgy (ci 0.010–0.049; p < 0.0001) for brain tumours following childhood exposure. the estimated brain dose received from a brain ct in the study by pearce et al.12 ranged between 28 and 44 mgy and the estimated red marrow dose ranged between 2 and 9 mgy. in the study by pearce et al., cumulative doses of 50 mgy almost tripled the risk for leukaemia and cumulative doses of 60 mgy tripled the risk for brain tumours.12 the effective dose of a brain ct is approximately 4 msv, which is equivalent to 200 chest radiographs.13 a pre-contrast and post-contrast ct result in double the radiation dose and would therefore carry double the risk for development of cancer. radiologists must keep radiation exposure as low as reasonably achievable (the alara principle). this is another reason for re-evaluating ct protocol. an important consideration is the risk of adverse reactions related to intravenous contrast media used in cect. as with any drug, intravenous iodinated contrast media have a risk of adverse reactions. these can be divided into general and organ-specific reactions including nephro-, cardiovascular, pulmonary and neurotoxicity.14,15 general reactions can be subdivided into acute and delayed reactions, whilst acute reactions can be subdivided into mild, moderate and severe reactions. mild reactions (nausea, vomiting, limited urticaria, extremity pain) have a reported incidence of 3% when using non-ionic intravenous contrast media (nicm). moderate reactions (severe vomiting, extensive urticaria, dyspnoea, rigors and laryngeal oedema) have a reported incidence of 0.2% – 0.4% and severe reactions (pulmonary oedema, hypotension, loss of consciousness, cardiac arrest and arrhythmias) are seen in 0.04% of nicm.14,15 a review of 48 fatal reactions revealed renal failure (58%) as the most common cause of death followed by anaphylaxis and allergy (19%).16 cardiopulmonary arrest (10%), respiratory failure (8%), cerebrovascular incidents and hypoxia (4%) accounted for a quarter of deaths.16 contrast-induced nephropathy (cin), the acute decline in renal function within 72 hours of intravenous contrast injection, is the most common organ-specific adverse reaction. patients who develop cin have an increased risk of developing chronic renal disease.17 in the developing world, the cost of contrast media is always a factor that needs consideration. the cost of contrast media, the operational cost of the ct scanner and the number of ct scans performed per day. throughput of patients can be increased if either nect or cect were performed. this would in turn also reduce the cost involved to both patient and department. the cost reduction includes servicing and electricity, radiographer time and contrast media costs. conclusion top ↑ in many centres in south africa, ct remains the first-line diagnostic imaging investigation for suspected intracranial pathology. a diagnostically sound yet cost-effective approach to brain ct is required. the risk to the patient from iodinated intravenous contrast media and radiation exposure should be minimised but weighed against the risk of missing pathology.in this study, only 3.28% of nect scans had findings undiagnosed by three reviewers, with a reader error of 1.85%. it was noted retrospectively that 1.42% of cases had an abnormality only visible on cect. the radiation exposure and operational cost could be reduced and patient throughput increased by omitting either nect or cect. the risk of moderate and severe contrast-media-induced adverse events is only slightly smaller than the prevalence of missing abnormal findings on a normal nect. the possibility of missing occult findings could be reduced by assessing the history and evaluating the indications for a cect. patients with fever, meningism, confusion, focal signs and a history suggestive of vascular lesions or risk factors for dural venous sinus thrombosis should have a cect only. in patients with a normal nect and none of these indications there is a small risk of missing abnormal findings on nect, and cect could therefore be omitted. doing only an nect in carefully selected cases would reduce the total amount of iodinated intravenous contrast used in the department and thus reduce the cost with a small risk of missing occult pathology. the alternative of performing only a cect would reduce the risk of missing pathology and reduce the radiation burden. this study, however, did not evaluate the use of cect without performing nect. a further study evaluating the advantages and disadvantages of only a cect would be of value. acknowledgements top ↑ the authors wish to thank h.s. schoeman (university of limpopo) and d. van zyl (university of pretoria) for conducting the statistical analysis. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions c.m. (university of limpopo) was the lead researcher and was responsible for the concepts, design, literature review and preparation of the manuscript. c.m. (university of limpopo), f.e.s. (university of pretoria) and n.z.m. (university of pretoria) conducted the study. m.e.k. (university of limpopo) and n.e. (university of limpopo) made conceptual contributions and were involved with the manuscript editing. references top ↑ 1.chishti fa, al saeed om, al khawari h, shaikh m. contrast-enhanced cranial computed tomography in magnetic resonance imaging era. med princ pract. 2003;12:248–251. http://dx.doi.org/10.1159/0000722922.huckman ms. clinical experience with the intravenous infusion of iodinated contrast material as an adjunct to computed tomography. surg neurol. 1975;4:297–318. 3.cowan i, macdonald s. how useful is contrast enhancement after a normal unenhanced computed tomography brain scan? australas radiol. 1999;43: 448–450. http://dx.doi.org/10.1046/j.1440-1673.1999.00710.x 4.albertyn le. rationales for the use of intravenous contrast medium in computed tomography. australas radiol. 1989;33:29–33. http://dx.doi.org/ 10.1111/j.1440-1673.1989.tb03231.x 5.kramer ra, janetos gp, perlstein g. an approach to contrast enhancement in computed tomography of the brain. radiology. 1975;116:641–647. 6.bernard ms, hourihan md, adams h. computed tomography of the brain: does contrast enhancement really help? clin radiol. 1991;44:161–164. http://dx.doi.org/10.1016/s0009-9260(05)80860-8 7.barrington na, lewtas na. indications for contrast medium enhancement in computed tomography of the brain. clin radiol. 1977;28:535–537. http://dx.doi.org/10.1016/s0009-9260(77)80073-1 8.butler ar, kricheff ii. noncontrast ct scanning: limited value in suspected brain tumour. radiology. 1978;126:689–693. 9.european society of radiology [homepage on the internet]. risk management in radiology in europe iv. 2004 [cited 2011 january 09]. available from: http://www.myesr.org/html/img/pool/esr_2006_iv_riskmanagement_web.pdf 10.royal college of radiologists. risk management in clinical radiology. london: royal college of radiologists; 1995. 11.wood lp, parisi m, finch ij. value of contrast enhanced ct scanning in the non-trauma emergency room patient. neuroradiol j. 1990;32:261–264. http://dx.doi.org/10.1007/bf00593043 12.pearce ms, salotti ja, little mp, et al. radiation exposure from ct scans in childhood and subsequent risk of leukemia and brain tumours: a retrospective cohort study. lancet. 2012;380:499–505. http://dx.doi.org/10.1016/s0140-6736(12)60815-0 13.shah nb, platt sl. alara: is there a cause for alarm? reducing radiation risk from computed tomography scanning in children. curr opin pediatr. 2008;20:243–247. http://dx.doi.org/10.1097/mop.0b013e3282ffafd2 14.namasivayam s, kalra mk, torres we, et al. adverse reactions to intravenous iodinated contrast media: a primer for the radiologist. emerg radiol. 2006;12: 210–215. http://dx.doi.org/10.1007/s10140-006-0488-6 15.namasivayam s, kalra mk, torres we, et al. adverse reactions to intravenous iodinated contrast media: an update. curr probl diagn radiol. 2006;35:164–169. http://dx.doi.org/10.1067/j.cpradiol.2006.04.001 16.wysowski dk, nourjah p. deaths attributed to x-ray contrast media on us death certificates. am j roentgenol. 2006;186:613–615. http://dx.doi.org/10.2214/ajr.04.1790 17.cronin re. contrast-induced nephropathy: pathogenesis and prevention. pediatr nephrol. 2010;25:191–204. http://dx.doi.org/10.1007/s00467-009-1204-z radioactive news 18 sa journal of radiology • july 2008 rssa/icis cancer imaging course feedback from delegates to the groundbreaking satellite cancer imaging course, jointly presented by the radiological society of south africa (rssa) and the international cancer imaging society (icis), which took place last month at the beautiful spier estate near stellenbosch, has been that the course was ‘an overwhelming success’ and ‘met its objectives in every respect’. the venue compares favourably with the best in the world: an exquisite hotel in verdant surroundings, with a comfortable and modern conference centre and outstanding social amenities, encouraging relaxed intermingling and exchange between delegates and faculty. the course was arranged by the rssa and icis to discuss advancing imaging techniques in the multidisciplinary management of cancer patients by promoting continuous education in oncological imaging and stimulating research in human tumour behaviour. the faculty comprised 12 icis fellows (from the usa, uk, austria and singapore), a canadian neuro-radiologist, and a south african skull base surgeon. over 40 state-of-the-art lectures on imaging in a wide variety of cancers were presented to an audience of close to 250. the programme was well-balanced and appropriate for local practitioners. an exciting topic was the growth of diffusion mri as an alternative to the huge expense of pet-ct. all lectures were transcribed onto cd – an educational standard set for future meetings. positive feedback from the attentive and appreciative audience confirmed that this was a programme that met a local need. particularly gratifying was the number of young radiologists. all aspects of the organisation, under the enthusiastic direction of congress chairman professor leon janse van rensburg, were run with precision and efficiency and rated by the faculty as ideal. professor van rensburg is to be congratulated on initiating and organising this short but comprehensive conference. the icis was grateful to be given the opportunity of combining with the rssa, and hopes that it is the first of many future such ‘satellite’ ventures. rewards of the travel award dr salomine theron was the joint winner of the rssa travel award; she reports below on how she put it to good purpose. ‘i was privileged to attend the course entitled multimodality approach to the detection and diagnosis of occult breast cancer, conducted by professor lászló tabár, from 24 27 september 2008 in bologna, italy. the course was attended by 305 delegates from 40 countries, with most attendees, however, being italian. i was the only delegate from south africa. the same course was held in cape town a little over a year ago, and i had some proud moments when professor tabár showed numerous photo’s of cape 18 sa journal of radiology • march 2009 radioactive news some members of the international faculty. from left to right: leon janse van rensburg (rssa), hans kauczor (germany), wolfgang schima (austria and icis president), jay p heiken (usa), richard gore (usa), vincent chong (singapore). some members of the international faculty. from left to right: leon janse van rensburg (rssa), hans kauczor (germany), wolfgang schima (austria and icis president), jay p heiken (usa), richard gore (usa), vincent chong (singapore). all lectures were put onto cd, so that delegates were not distracted by note-taking. all lectures were put onto cd, so that delegates were not distracted by note-taking. australian opportunity are you…….. a qualified radiologist, sonographer or radiographer? looking for a change of scenery? skg radiology has the largest network of radiology locations in western australia, including community locations and major hospital sites. we continue to celebrate our success with over 25 years in radiology. perth has much to offer blending the best of the big city with the relaxed coastal lifestyle. the city is experiencing growth on the back of the resources boom which has added to the vibrancy and diversity of our city. opportunity skg offers state of the art equipment, supportive team environment and a friendly and enjoyable workplace. we can offer: permanent opportunities temporary opportunities qualifications relevant qualifications and eligibility to register with the applicable australian/wa authorities are essential. salary and benefits skg offers an attractive salary package, superior benefits and entitlements, excellent working conditions and the opportunity of continuing development in your field of specialty. we offer full or partial subsidies for relocation expenses to successful applicants. to find out more, contact lyn de wet, hr manager on +61 8 9320 1243 or email at lyn.dewet@skg.com.au or view our current vacancies on our website: www.skg.com.au excellence in diagnostic imaging tm p w p 0 5 0 9 2 8 radioactive news rssa-icis.indd 18 3/18/09 9:44:13 am town, calling it “one of the most beautiful places in the world”. the conference venue was the zan hotel in centregross, which is 8 km from the bologna city centre. ‘professor tabár’s enthusiasm for mammography is infectious! his systematic approach to the evaluation of a mammogram provides structure to a difficult topic. normal breast patterns, anatomical variances and various abnormalities/pathologies found on mammograms were discussed in depth, with emphasis on pitfalls. he was assisted by dr anthony stavros, a radiologist from greenwood, colorado, usa, who is a breast imaging specialist with a special interest in breast ultrasound, and professor vincenzo eusebi, a local pathologist from bologna. each mammography topic was followed by a short ultrasound lecture, correlating the findings. i found the course extremely useful for my everyday work. ‘i wish to express my gratitude to the radiological society of south africa for presenting me with the cpd award and giving me the opportunity to attend this course.’ dr salomine theron fellowship appointment we are pleased to announce that dr jaishree naidoo has accepted the harry crossley fellowship in paediatric radiology at the red cross war memorial children’s hospital, with effect from 1 march 2009. he writes: ‘i am currently a senior consultant at chris hani baragwanath hospital. i was offered a fellowship at the royal children’s hospital in melbourne, australia, but withdrew as i felt that, as my intention was to come back to south africa, the fellowship would be more suitable for me and also that it is more relevant to the african context. so i look foward to the year ahead and hope that more radiologists take an interest in subspeciality training’. australian opportunity are you…….. a qualified radiologist, sonographer or radiographer? looking for a change of scenery? skg radiology has the largest network of radiology locations in western australia, including community locations and major hospital sites. we continue to celebrate our success with over 25 years in radiology. perth has much to offer blending the best of the big city with the relaxed coastal lifestyle. the city is experiencing growth on the back of the resources boom which has added to the vibrancy and diversity of our city. opportunity skg offers state of the art equipment, supportive team environment and a friendly and enjoyable workplace. we can offer: permanent opportunities temporary opportunities qualifications relevant qualifications and eligibility to register with the applicable australian/wa authorities are essential. salary and benefits skg offers an attractive salary package, superior benefits and entitlements, excellent working conditions and the opportunity of continuing development in your field of specialty. we offer full or partial subsidies for relocation expenses to successful applicants. to find out more, contact lyn de wet, hr manager on +61 8 9320 1243 or email at lyn.dewet@skg.com.au or view our current vacancies on our website: www.skg.com.au excellence in diagnostic imaging tm p w p 0 5 0 9 2 8 radioactive news rssa-icis.indd 19 3/18/09 9:44:14 am case report case report 62 sa journal of radiology • august 2009 abstract two young, nonlactating, nulliparous women presented with acutely painful breast masses. sonographic features showed mixed echogenic masses. core biopsies were not diagnostic, and surgical excision revealed infarcted fibroadenomas in both cases. although fibroadenomas are common, they do not commonly infarct, and only rarely in non-lactating or non-pregnant females. these two cases highlight the clinical and imaging characteristics of an important differential diagnosis. introduction case 1 a 15-year-old girl had been aware of a left breast lump for several months. she presented acutely with severe pain in the mass. on examination, the left breast was erythematous, slightly warm and tender, particularly over the mass. the mass itself was firm but mobile. high-frequency linear ultrasound of the left breast demonstrated a solitary mass which was predominantly solid with an ill-defined area of decreased echogenicity within it and a linear area of anechogenicity within the latter. there was a capsule around the anechogenic area which was echogenic. no posterior acoustic shadowing was present, and it measured at least 30 x 40 x 45 mm in size (figs 1a and 1b). a reactive lymph node in the left axilla was noted. the right breast and axilla were within normal limits. a core biopsy of the mass revealed benign features with areas of extensive infarctoid necrosis, abscess formation and a cellular, necrotic proliferation. complete local excision was recommended due to the extensive necrosis, and a 50 x 40 x 30 mm mass weighing 34 grams was excised. histological examination showed the presence of an infarcted juvenile (cellular) fibroadenoma with extensive areas of unusual presentation and inconclusive biopsy render fibroadenoma in two young females a diagnostic dilemma debra meerkotter, mb bch, fcrad (d) sa regional imaging, st vincents hospital, launceston, tasmania, australia savvas andronikou, mb bch, fcrad, frcr, phd department of radiology, university of cape town fig. 1a. case 1: high-frequency linear ultrasound left breast mass – transverse section. fig. 1b. case 1: high-frequency linear ultrasound of left breast mass – longitudinal section. unusual presentation.indd 62 8/17/09 3:12:43 pm case report case report 64 sa journal of radiology • august 2009 case report infarctoid necrosis. viable areas showed no evidence of atypia or malignancy. areas of suppurative inflammation were also noted, suggesting superinfection within the infarcted areas. the diagnosis of an infarcted fibroadenoma was made. case 2 a 19-year-old woman presented with a lump in the right breast which had recently become painful. she was not pregnant or lactating. on examination, a palpable mass was noted in the right breast in the 12 o’ clock position. the overlying skin was not inflamed. on ultrasound examination, there was a rounded space-occupying lesion measuring 22 x 24 x 28 mm in size, just above the areola. it was of mixed echogenicity, and the superficial border was well defined by an echogenic capsule. the deep border was ill defined (figs 2a and 2b). the mass was solitary. a core biopsy revealed morphological features suggestive of an inflammatory lesion consistent with a resolving mastitis. a wide local excision of the lesion was performed and breast tissue measuring 40 x 25 x 25 mm in was excised. a poorly circumscribed lesion measuring 30 x 25 mm and weighing 21.5 g was found. histological analysis showed an infarcted benign fibroadenoma. the tumour was well circumscribed with a lobulated appearance. dense fibrous tissue was present with a large area of coagulative necrosis with areas of haemorrhage. no atypia or malignancy was noted. the lesion was completely excised. discussion the presence of fibroadenomas in female adolescents is well documented; these are generally observed over time without complications. fibroadenomas are known to infarct in approximately 0.5 1.5 % of cases. the rare case of spontaneous infarction generally occurs in three known settings. performing a fine-needle aspiration (fna) is a known predisposing factor in precipitating infarction.1 this type of infarction is not common but has been documented following fna of thyroid nodules, salivary glands, breast fibroadenomas, lymph nodes and renal cell carcinomas. the other predisposing factors are pregnancy and lactation.2 the increased metabolic demands of pregnancy and lactation are thought to result in a relative vascular ischaemia and infarction in these settings.3 a rare case of spontaneous infarction of a fibroadenoma in a postmenopausal woman has been documented.4 in our two patients, spontaneous infarction of a fibroadenoma had occurred. neither patient was pregnant nor lactating, and no previous fna had been performed. this process has previously been documented as a rare and unique occurrence3 in the absence of factors predisposing to infarction. on ultrasound, the masses were predominantly solid but contained mixed echogenicity within them. they no longer appeared to have the classic features of a fibroadenoma. sonographic distinction from a phyllodes tumour was not possible. in both patients, core biopsy results were not diagnostic of the condition, and full diagnosis was obtained only on surgical excision. this entity may be confused with mastitis, duct ectasia, tuberculosis of the breast, and carcinoma on cytology smears.5 a combination of clinical examination and ultrasound and histology findings are essential for the diagnosis, which can be aided by an awareness of this rare complication. conclusion although a rare complication, infarction of fibroadenomas should be considered in the acutely painful deterioration of a breast mass. 64 sa journal of radiology • august 2009 fig. 2a. case 2: high-frequency linear ultrasound of lesion in right breast – transverse section. fig. 2b. case 2: high-frequency linear ultrasound of lesion in right breast – longitudinal section. unusual presentation.indd 64 8/17/09 3:12:44 pm case reportcase report 65 sa journal of radiology • august 2009 the salient clinical features in our report were that both cases were young healthy females and that the masses had recently become painful. the sonographic features show nonspecific mixed echo patterns, which would reflect the process of infarction of a solid mass. 1. pinto rg, couto f, mandreker s. infarction after fine needle aspiration. a report of four cases. acta cytol 1996; 40(4): 739-741. 2. raju gc, naraynsingh v. infarction of fibroadenoma of the breast. j royal coll surg edinb 1985; 30: 162-163. 3. fowler cl. spontaneous infarction of fibroadenoma in an adolescent girl. pediatr radiol 2004; 34: 988990. 4. ichihara s, matsuyama t, kubo k, tamura z, aoyama h. infarction of breast fibroadenoma in a postmenopausal woman. pathol int 1994; 44(5): 398-400. 5. kamayani m. diagnostic difficulties in spontaneous infarction of a fibroadenoma in an adolescent: case report. diag cytopathol 2002; 26(1): 26-28. the essential reference for every healthcare professional! the carefully and thoroughly updated 9th edition of the south african medicines formulary (samf) can now be ordered. it is your essential reference to rational, safe and cost-efficient use of medicines. that is why you should not prescribe without it. the newly published samf provides easy access to the latest, most scientifically accurate information – including full drug profiles, clinical notes and special prescriber’s points. the convenient pocket-size design enables you to fit it comfortably into your bag or hospital coat pocket – always at hand for ready 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published: 11 dec. 2014 how to cite this article: mercouris, p. sports hernia: a pictorial review. s afr j rad. 2014;18(2); art. #670, 4 pages. http://dx.doi.org/10.4102/sajr.v18i2.670 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. sports hernia: a pictorial review in this pictorial reviews... open access • abstract • introduction • definition • clinical presentation • anatomy • biomechanics • imaging • conclusion • acknowledgements    • competing interests • references abstract top ↑ sports hernia represents a complex clinical and imaging entity. the purpose of the review is to provide a practical imaging approach to this condition. the review includes an overview of the anatomy and biomechanics of sports hernia by means of colour illustrations. the role of imaging, and particularly magnetic resonance imaging, is highlighted. introduction top ↑ athletic pubalgia is a general term to describe exertional pubic or groin pain.1 groin pain in elite athletes is common and accounts for approximately 5% – 18% of all athletic injuries and is especially prevalent in kicking sports.2 the differential diagnosis is broad but the most common causes are considered to be adductor longus injury, common adductor-rectus abdominis dysfunction, osteitis pubis and sports hernia.1 this review is of the imaging of sports hernia. definition top ↑ sports hernia represents an acquired deficiency of the inguinal wall and has been described by a myriad of names, such as gilmore's groin, groin disruption, pubalgia, sportsman's hernia, prehernia complex, incipient hernia, symphysis syndrome and inguinal canal disruption.2 practically, it is best appreciated as a deficiency that involves the anterior inguinal wall (external oblique muscle and aponeurosis), the posterior inguinal wall (transversus abdominis and internal oblique muscles), or both. anterior inguinal wall deficiency represents an injury of the external oblique muscle aponeurosis, whereas posterior inguinal wall deficiency represents an injury at the level of the transversus abdominis and internal oblique muscles and aponeuroses.2 clinical presentation top ↑ athletes give a history of an insidious onset of groin pain that is initially experienced at the end of a game, progressing to pain during play and eventually pain at rest. some may also experience pain at night.3 on physical examination, point tenderness may be elicited at or near the pubic symphysis, and there may be resistance or pain on ipsilateral hip adduction. classically, there is no palpable hernia on physical examination.4 anatomy top ↑ anatomically, the anterior aspect of the pubis acts as a common origin for important musculotendinous, aponeurotic and ligamentous structures around the symphysis pubis (figure 1). this prepubic soft-tissue complex is known as the prepubic aponeurotic complex (p-pac) (figure 2) and includes interconnections between the adductor tendons, rectus abdominis, inguinal musculoaponeurotic structures, articular disc and pubic ligaments of the symphysis pubis.1 laterally, the caudal rectus abdominis lies just posteromedial to the superficial inguinal ring, and probably plays a role in reinforcing the wall of the posteromedial superficial inguinal canal.5 figure 1: musculotendinous and aponeurotic attachments of the anterior pubis. ab, adductor brevis; al, adductor longus; eo, external oblique aponeurosis; g, gracilis; io, internal oblique; ra, rectus abdominis; ta, transversus abdominis. figure 2: prepubic aponeurotic complex (p-pac). biomechanics top ↑ the rectus abdominis and adductor longus are relative antagonists during core rotation and extension, with the result that the former elevates the anterior pelvis and the latter depresses it (figure 3).3 there is therefore a dynamic imbalance between the strong adductors and weak abdominal musculature, resulting in shearing forces across the inguinal wall musculoaponeurotic and symphyseal structures (figure 3). figure 3: vector and shearing forces across the prepubic aponeurotic complex (p-pac). white arrows: vector forces; black arrows: shearing forces. imaging top ↑ the fascial structures of the inguinal canal are not reliably imaged and sports hernia is therefore a clinical diagnosis and a radiological diagnosis of exclusion.2 imaging in affected athletes is usually normal but occasionally injury to the inguinal aponeurotic structures can be identified. imaging is, however, still important to exclude injury to the other musculoaponuerotic structures that constitute the prepubic aponeurotic complex. the imaging approach of athletic pubalgia and sports hernia includes primarily the use of radiography, ultrasound and magnetic resonance imaging (mri), with computed tomography (ct) and nuclear medicine imaging playing ancillary roles. obtaining a pelvic radiograph is still a good imaging principle to follow, although this is usually normal. a pelvic radiograph is useful in demonstrating symphyseal alignment and may indicate a potential osseous cause for the groin pain including hip, sacro-iliac, lower lumbar spine, and symphyseal (figure 4) and apophyseal pathology. figure 4: osteitis pubis. pelvic radiograph in a 21-year-old soccer player presenting with left groin pain demonstrating symphyseal cortical enthesiopathic changes on the left (white arrow). see figure 6 for correlative mri. there is also incidental cam-type femoro-acetabular impingement morphology. ultrasound, as with radiography, is also usually normal. ultrasound is accurate in evaluating true inguinal and femoral hernias but these are rare in athletes.3 there is perhaps a role for dynamic ultrasound in evaluating potential posterior inguinal wall deficiency. this application arose from a study amongst australian footballers in the late 1990s that documented the presence of abnormal ballooning of the posterior wall during straining. this sign was considered to be more specific if bilateral and in older athletes.6 current consensus appears to indicate that this sign is too nonspecific and nonsensitive for widespread practical use.3 the goal of imaging is to accurately evaluate the musculoaponeurotic structures of the groin and is best achieved by mri. mri is both sensitive (98%) and specific (89% – 100%) in patients with athletic pubalgia for injuries involving the rectus abdominis (figure 5d), the adductor tendon origin (figure 5), and the symphysis (figure 6) itself.7 mri is usually normal in sports hernia but an injury to the anterior (figure 7 and figure 8) or posterior wall (figure 9) can sometimes be identified (table 1). mri is also useful in evaluating the regional osseous structures, as stress fractures (figure 10) are common causes of groin pain beyond the inguinal and p-pac regions (table 1). figure 5: spectrum of adductor dysfunction: (a) adductor tendinosis. a 46-year-old professional tennis player with chronic groin pain on the right. axial fat-saturated proton density (pd) image demonstrates a thickened adductor longus tendon of intermediate signal (white arrow) surrounded by fluid (white arrowhead) on the right. note the normal adductor longus tendon on the left (black arrow); (b) adductor strain in a 17-year-old soccer player with acute left groin pain. axial fat-saturated pd image demonstrates fluid signal in relation to the adductor longus musculotendinous unit (white arrow); (c) adductor aponeurotic tear in a 27-year-old rugby player with subacute left groin pain. coronal fat-saturated pd image demonstrates adductor aponeurotic tear on the left (white arrow); (d) common adductor-rectus abdominis tear in a 30-year-old professional rugby player with left groin pain of 3 weeks’ duration. coronal fat-saturated t2 image demonstrates tear of adductor longus origin (white arrow). note the metallic artifact from prior bilateral hernia surgery (black arrows); (e) coronal fat-saturated t2 image (same patient/athlete as in figure 5d) demonstrates associated partial tear of rectus abdominis (white arrow). this injury pattern highlights the prepubic aponeurotic complex (p-pac) anatomic configuration. figure 6: osteitis pubis in a 21-year-old soccer player with left groin pain. axial fat-saturated proton density (pd) image demonstrates bilateral and asymmetric bone marrow oedema in the symphysis pubis (white arrows). the hallmark of osteitis pubis is that the bone marrow oedema extends through the entire sagittal dimension of the bone as seen on the left in this athlete. see figure 4 for correlative pelvic radiograph. figure 7: anterior inguinal wall deficiency. a 35-year-old professional male rugby player presenting with right-sided groin pain. axial fat-saturated proton density (pd) image demonstrates an external oblique aponeurosis tear on the right (black arrow) that was surgically confirmed. note the intact aponeurosis on the left (white arrow). figure 8: anterior inguinal wall deficiency. coronal t2-weighted fat-saturated image through the anterior abdominal wall of an elite 28-year-old male australian-rules football player shows area of increased hyperintensity of left external inguinal ring, consistent with traumatic disruption of most medial fibres of the external oblique aponeurosis (arrowhead) and therefore in keeping with acute disruption of anterior inguinal wall. (reprinted with permission from the american journal of roentgenology). figure 9: posterior inguinal wall deficiency. axial proton density-weighted image in a 26-year-old male recreational soccer player with left-sided groin pain shows anterior bulging of posterior inguinal wall on left side (arrow), consistent with posterior inguinal wall deficiency. this results in a more anteriorly positioned spermatic cord (s) when compared with right side. figure 10: stress fracture in a 38-year-old female runner with right groin pain. coronal fat-saturated pd image demonstrates bone marrow oedema of the right femoral neck with an associated fracture (white arrow). table 1: sports hernia – key concepts. conclusion top ↑ sports hernia represents an acquired deficiency of the inguinal wall. imaging is usually normal in affected athletes, and the entity remains a clinical diagnosis. acknowledgements top ↑ i thank neil northey for the medical illustrations. competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ macmahon pj, hogan ba, shelley mj, eustace sj, kavanagh ec. imaging of groin pain. magn reson imaging clin n am. 2009;17(4):655–666. http://dx.doi.org/10.1016/j.mric.2009.06.013 koulouris g. imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. am j roentgenol. 2008;191(4):962–972. http://dx.doi.org/10.2214/ajr.07.3410 robinson p, bhat v, english b. imaging in the assessment and management of athletic pubalgia. semin musculoskelet radiol. 2001;15(1):14–26. http://dx.doi.org/10.1055/s-0031-1271956 zajick dc, zoga ac, omar im, meyers wc. spectrum of mri findings in clinical athletic pubalgia. semin musculoskelet radiol. 2008;12(1):3–12. http://dx.doi.org/10.1055/s-2008-1067933 khan w, zoga ac, meyers wc. magnetic resonance imaging of athletic pubalgia and sports hernia. current understanding and practice. magn reson imaging clin n am. 2013;21(1):97–110. http://dx.doi.org/10.1016/j.mric.2012.09.008 orchard jw, read jw, neophyton j, garlick d. groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in australian rules footballers. br j sports med. 1998;32(2):134–139. zoga ac, kavanagh ec, omar im, et al. athletic pubalgia and the ‘sports hernia’: mr imaging findings. radiology. 2008;247(3):797–807. http://dx.doi.org/10.1148/radiol.2473070049 dwi definition: mri sequences made sensitive to the diffusion of molecules – usually water. dwi provides • measure of the cellular function by assessing the metabolic state of cells. • structural images representing the integrity and direction of white matter tracts.1 how diffusion gives the signal two gradient pulses: • the first labels the position of the water molecules. • the second ‘reads’ the final position of the molecules after they have had time to diffuse. if the molecules changed position the mri signal is not refocused properly by the second gradient pulse and image intensity is reduced. the basic sequences makes use of epi (echoplanar imaging). single echo-train is used to collect data from all lines of k-space during one tr. < 100 ms, i.e. 16. 5 mm slices in 6 s and therefore very sensitive to motion. either echoplanar se or a fast gre.2 parameters affecting the signal • ‘b’-value: the degree of diffusion sensitivity. • high b-values = high degree of diffusion sensitivity. by increasing either the gradient timing, time of separation between gradient pulses or gradient strength, we can increase diffusion weighting. • te and tr are generally long in dwi. dwi therefore inherently has some degree of t2weighting. • t2 changes will also change the appearance of dwi: t2 shine-through effect. how do i read the dwi what we get in practice (figs 1 a – e) • b0 t2-weighted images • b500 in 3 directions • b1000 in 3 directions • adc map b1000 and adc map read in conjunction to eliminate t2 shine-through effects. the 3 directions are denoted by ‘s’, ‘p’, or ‘r’, respectively indicating ‘slice encoding direction’, ‘phase encoding direction’ and ‘readout gradient direction’. getting rid of t2 shine-through and allowing diffusion to affect the signal • two sets of images with (b = 800/1000) and without (b = 0) are acquired. post processing subsequently calculates an image that reflects diffusion only, called the adc map. • adc is calculated from the signal intensities of images acquired with varying magnitudes of diffusion sensitivity (b-values) and represented as an image (figs 2 a c). when do i use it? routine: high speed acquisition sequence and can therefore be incorporated easily into routine mri protocol. specific: • cellular metabolism – infarcts. area of ischaemia ↑dwi and ↓adc map (fig. 3 a c). • discrimination of acute (↓adc map) versus chronic (↑dwi) lesions. • epidermoid (↓adc map) v. arachnoid cyst the dumbo guide to diffusion-weighted imaging (dwi) 33 sa journal of radiology • march 2007 fig. 1a. axial t2wi of the brain. fig. 1b. axial ‘dwi’ with b value = 0 which is in reality a t2wi, the initial series of a diffusion-weighted sequence. fig. 1c. dwi with b value = 500, in the ‘p’ direction – phase encoding gradient or y-axis. fig. 1d. dwi with b value = 1000, in the ‘r’ or read out direction – frequency encoding gradient, or x-axis. fig. 1e. corresponding calculated adc map. fig. 2 a. axial t2wi of a patient with a focal meningoencephalitis and associated vasogenic oedema l posterior parietal as t2 high signal. c ackermann, s andronikou pg33-34.indd 33 2/26/07 1:56:08 pm case report (no restricted diffusion) (fig. 4 a – c). • brain abscess (↑dwi,↓adc map) v. cystic tumours (usually no restricted diffusion). children • hie • monitoring development of wm tracts in neonates. • assessing wm damage as a result of an insult, i.e. infections, inherited metabolic diseases. other • ms – improves specificity of mr on characterising lesions and detects lesions on normal appearing t2wi (↑adc). • neurodegenerative diseases (i.e. alzheimer’s, huntington’s) ↑adc. • ischaemic leukoencephalopathy ↑adc. dti = diffusion tensor imaging • problem with dwi : dependence on the direction along which d is measured. if regions of anisotropic diffusion are present, dwi / adc maps can vary considerably depending on the direction of diffusion gradients. • anisotropic = d different in various directions. isotropic = d the same in various directions. • these anisotropic ‘artefacts’ can be eliminated by acquiring the diffusion tensor. • this basically means measuring diffusion along a large number of directions (> 6). • postprocessing of the dti images can result in both maps in which ischaemic lesions are better delineated trace adc maps and maps in which white matter tracts are highlightedfractional anisotropy maps. 1. beaulieu c, d’arceuil h, hedehus m, de crespigny a, kastrup a, moseley me. diffusion-weighted magnetic resonance imaging: theory and potential applications to child neurology. semin pediatr neurol 1999; 6:87-100. 2. bitar r, leung g, perng r, et al. mr pulse sequences: what every radiologist wants to know but is afraid to ask. radiographics fig. 4a. axial t2wi with a well-circumscribed, hyperintense mass lesion in the region of the l quadrigeminal plate cistern. fig. 4b and c. dwi (b = 1000) shows the same lesion to be hyperintense (b), the corresponding adc map indicates reduced adc values confirming the suspicion of an epidermoid. fig. 3a. axial t2wi with focal high signal right periventricular, in the sentrum semi-ovale representing an acute infarct in a patient with tbm. fig. 3b and c. corresponding dwi (b = 1000) the same lesion appears hyperintense (b), with restricted diffusion demonstrated on the adc map (black) (c). fig. 2b. dwi (b = 1000) demonstrates subtle high signal in the same region. fig. 2c. on the corresponding adc map there is no restricted diffusion (white) confirming the t2 shine-through effect. 34 sa journal of radiology • march 2007 pg33-34.indd 34 2/26/07 1:56:09 pm article information authors: christopher westgarth-taylor1 tracy westgarth-taylor2 richard wood3 marc levitt3 affiliations: 1chris hani baragwanath academic hospital, university of the witwatersrand, south africa 2parklane radiology department, netcare park lane hospital, south africa 3center for colorectal and pelvic reconstruction, nationwide children’s hospital, columbus, united states of america correspondence to: christopher westgarth-taylor email: drcwtaylor@gmail.com postal address: 30 lurgan road, parkview 2193, south africa dates: received: 30 june 2015 accepted: 07 oct. 2015 published: 11 dec. 2015 how to cite this article: westgarth-taylor c, westgarth-taylor t, wood rj, levitt ma. imaging in anorectal malformations: what does the surgeon need to know? s afr j rad. 2015;19(2); art. #903, 10 pages. http://dx.doi.org/10.4102/sajr.v19i2.903 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. imaging in anorectal malformations: what does the surgeon need to know? in this original research... open access • abstract • introduction • classification of arm • management • imaging approach • antenatal • newborn evaluation    • babygram    • ultrasound of the abdomen and pelvis    • spinal ultrasound    • prone cross table lateral x-ray    • perineal ultrasound    • micturating cystourethrogram (mcug)/voiding cystourethrogram    • echocardiogram • high-pressure distal colostogram • cloacal malformation • follow-up imaging • imaging of complications • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ imaging is essential in the diagnosis, management, surgical planning and eventual outcome in patients with anorectal malformation (arm). this article outlines the imaging that may be required and the information needed by the surgeon to attain the best possible surgical outcome. arm encompasses a wide spectrum of congenital malformations relating to the distal rectum and anus as well as the urinary and or gynaecological systems. the malformations range from a relatively simple perineal fistula with the potential for an excellent functional outcome, to complex cloacal malformation that requires specialist care and intervention. approximately half of these children will have associated abnormalies. in the first 24–48 hours of life, imaging is used to determine if any associated anomalies are severe enough to preclude an operation, and what operation will be required so that the child can grow as normally as possible. if a colostomy is done, pre-definitive repair imaging in the form of a high-pressure distal colostogram determines the surgical approach required to repair the malformation. in more complicated cases of cloacal malformation, advanced imaging in the form of mri or 3d fluoroscopy is valuable. in the south african setting, 2d fluoroscopy with the surgeon present is adequate to help in planning for the surgical management. communication between the radiologist and paediatric surgeon is essential to ensure that such patients have the best possible outcome. introduction top ↑ anorectal malformation (arm) encompasses a wide spectrum of congenital malformations relating to the distal rectum and anus as well as the urinary and or gynaecological systems. the malformations range from a relatively simple perineal fistula with the potential for an excellent functional outcome and a good anatomical reconstruction, to the complex cloacal malformation that requires specialist care and intervention.1 approximately half of the children so affected will have an associated abnormality. the reported incidence is variable, but genitourinary (40%–50%) is the most common, followed by cardiovascular (30%–35%), spinal cord (25%–30%), gastrointestinal (5%–10%), and vertebral defects, anal atresia, ca defects, tracheo-oesophageal fistula, renal anomalies and limb abnormalities (vacterl) (4%–9%).2 arm has a worldwide prevalence of approximately 1 in 5000 live births but, in the greater gauteng area, the prevalence is 1 in 4000 live births.3 classification of arm top ↑ the krickenbeck classification (2005) is descriptive and places emphasis on the preoperative identification and anatomic evaluation of the rectal pouch and fistula. this information is vital for the surgeon as it allows anticipation of the extent of mobilisation in relation to the urinary tract as well as the most appropriate surgical approach for each case4 (table 1). table 1: krickenbeck classification of arms. management top ↑ the aim of surgical intervention is to reconstruct the rectum/anus, genital tract and urinary tract. from a functional point of view, the goal is to be clean for stool and dry to urine. many of these patients may require several medical or surgical interventions. normal sexual function and the potential to bear children later in life are also very important long-term outcomes.5 additionally, the urinary tract needs to be functional in such a way as to prevent long-term renal damage. the early management of a newborn infant born with an arm is crucial, and two questions must be answered: are there life-threatening associated abnormalities? is the child eligible for a primary procedure with no protective stoma, or is a protective decompressing stoma with definitive repair in 3–6 months required? the decision is made on the basis of clinical features as well as radiological findings. patients with a perineal/vestibular fistula will be eligible for a primary posterior sagittal anorectal plasty (psarp); all other cases will require a defunctioning colostomy. exceptions may have to be made if the baby’s presentation is delayed and there is severe abdominal distension. in such cases, it is safer to decompress with a stoma than attempt a primary psarp. the decision as to which management pathway to follow can only be taken after 24–48 hours of life. this delay allows time for gas to descend to the rectum and cause enough distension to establish if there is a fistula or not. during this time, it is essential to collate all possible radiological information to facilitate the decision process. see figures 1 and 2 for the algorithm for neonatal management of male and female arm patients respectively. unfortunately, in the developing world, a significant number of these cases are missed at birth and they require a diverting colostomy regardless of the type of malformation, and therefore the algorithms do not apply in such cases. figure 1: male anorectal malformation.psarp, posterior sagittal anorectoplasty; us, ultrasound scan; eua, examination under anaesthetic; ng, nasogastric; rv, rectovaginal; cc, common channel figure 2: female anorectal malformation.psarp, posterior sagittal anorectoplasty; us, ultrasound scan; eua, examination under anaesthetic; ng, nasogastric; rv, rectovaginal; cc, common channel; tum, total urogenital mobilisation; vf,  vestibular fistula imaging approach top ↑ imaging of patients with arm can be divided into separate entities: antenatal diagnosis newborn evaluation high-pressure distal colostogram cloaca imaging follow-up imaging evaluation of complications. antenatal top ↑ the prenatal diagnosis of arm on ultrasound (us) is rarely made. there have been reports that it has been diagnosed at 12 weeks’ gestation, but the classical teaching is that it can be diagnosed at 22 weeks’ gestation on the screening ultrasound (us). the difficulty in diagnosis probably results from the changing physiological characteristics of the fetal gastrointestinal tract, in addition to the small size of fetal structures in early pregnancy.6 the reported antenatal diagnosis rate is 16%–21%.4,7 it is suggested that if anomalies associated with arms are identified on the scan, the examiner should intensify the search for an arm.7 oligohydramnios is present in 26% of arms. other common prenatal imaging findings include an abdominal or pelvic cystic mass (52%), fetal hydronephrosis (49%), fetal ascites (22%) and intestinal distension (18%). if a distended bladder is identified with the diagnosis of oligohydramnios, the diagnosis of arm should be considered. cloacal malformations should be suspected if several pelvic cystic structures are identified on a scan,4 in a female fetus. other associations include single kidney, absent radius and absent sacrum. if there are features of a possible arm on antenatal ultrasound, a fetal mri in the third trimester should be considered. urine normally has a signal intensity similar to that of simple fluid, with homogeneous hyperintensity on t2-weighted images and hypointensity on t1-weighted images, whereas normal meconium in the distal colon and rectum appears hyperintense on t1-weighted images and hypointense on t2-weighted images. in some fetuses with arm (mainly recto-urethral fistulas in the male and long common-channel cloacal anomalies in the female), there is mixing of urine and meconium, thus resulting in heterogenous t1 and t2 signal intensity in the bladder and rectum.4 having an antenatal diagnosis of an arm allows better parental counselling and can also guide the site of delivery, where appropriate surgical facilities are available8 (figure 3). figure 3: midline sagittal t1w fetal mri demonstrating a dilated rectum with some areas of t1w hypointensity in the central rectum representing mixing of meconium and urine. newborn evaluation top ↑ the purpose of imaging in the first 24–48 hours is to aid the surgeon’s clinical examination and to decide which baby needs a decompressing colostomy and which baby would benefit from a primary definitive procedure without a covering stoma. at the same time, it is important to diagnose any associated anomalies that may influence the surgical decision-making in order to prevent potential unnecessary morbidity or mortality. imaging required in the first 24–48 hours includes: babygram (thorax, spine, limbs and pelvis), abdominal us, echocardiogram and spinal us. additional imaging, but with much lower yield, may include a perineal us or a prone cross table lateral x-ray. babygram a babygram should include the thorax, spine and pelvis in an ap and lateral projection. these images should allow identification of cardiac, costal, spinal and sacral abnormalities (figure 4). if any sacral or vertebral anomalies are identified, this may be an indication for an mr spine in the future. the ap and lateral sacral views can identify anomalies such as a hemisacrum, sacral hemivertebrae, scimitar sacrum and sacral agenesis, and can also be used to identify the sacral ratio by measuring the distance between key bony structures. this is an important ratio that may help to predict future continence of the child (figure 5). figure 4: supine radiograph demonstrating bilateral radial aplasia and sacral abnormalities. figure 5: schematic diagram illustrating how the sacral ratio is measured. a sacral ratio of 0.77 is accepted to be normal. it would be very unusual to have a sacral ratio of less than 0.3 and obtain adequate bowel control.9 if the limbs are included in the x-ray series, limb abnormalities such as radial aplasia may also be noted. all this information assists in giving parents correct expectations regarding their child’s functional outcome. ultrasound of the abdomen and pelvis abdominal and pelvic us is used to detect any anomalies in the urogenital tract. urological abnormalities are the most common abnormalities associated with arms. they are usually performed with an 8 mhz transducer in both the prone and supine positions. owing to the relative physiological oliguria that occurs in the first 24–48 hours of life, imaging of the urinary tract can be misleading.4 it is important to repeat the us at 2 weeks if it was obtained in the first 24–48 hours. in the case of a cloacal malformation, it is also important to identify a distended vagina (hydrocolpos), which will require surgical intervention to drain it. the hydrocolpos has two potential problems: (1) it can cause ureteric obstruction by compressing the trigone of the bladder, with resultant hydroureter and hydronephrosis, resulting in obstructive uropathy; and (2) the second, much rarer, problem is that it can become infected and form a pyocolpos that can be potentially life threatening to a newborn baby if not urgently drained.5 pre-sacral masses also need to be identified especially if there are sacral abnormalities as they may indicate a currarino triad – an autosomal dominant condition consisting of an arm, presacral mass and bony defect of the sacrum. these masses are usually teratomas, but can also be meningocoeles or dermoid cysts. because of possible malignant transformation, these masses need to be removed at the time of surgery. spinal ultrasound controversy exists regarding the best form of spinal imaging in patients with arms. the teaching was that spinal us under the age of 3 months was a good screening tool to rule out spinal abnormalities such as spinal cord tethering, lipomas or spinal dysraphism.4 recent studies are refuting this view, owing to the high number of false negatives obtained when comparing us to mri. false negatives were found in 21% and 53% of cases when comparing ultrasound with mri in studies by kim et al. and scottoni et al. respectively.10,11 there are obvious limitations to each modality; but us is safe, inexpensive, non-invasive, does not require sedation and can be performed at the bedside. mri, on the other hand, is expensive, time consuming, may require sedation or anaesthetic, and is not available at all centres. it is probably safe to say that all children with an abnormality detected on us or x-ray require an mri spine. some centres do not perform spinal us but go straight to a spinal mri at 6 months of age. prone cross table lateral x-ray the cross table lateral x-ray can be used on rare occasions when the level of the fistula has not declared itself after 24 hours.12,13 the aim of the investigation is to try to determine if the lesion is ‘low’ and can therefore have a primary definitive procedure without a covering stoma. the position of the anus should be marked with a radio-opaque material, preferably barium paste or a ball bearing, and the distance from the skin to the rectal gas measured. if the distance is less than 1 cm, the patient is probably a candidate for a primary procedure; if greater than 1 cm, a decompressing stoma should be performed1 (figure 6). an arm patient without a fistula is extremely uncommon and is commonly associated with trisomy 21. figure 6: prone cross table lateral radiograph of a neonate at 24 hours of age demonstrating a dilated rectum (arrow) measuring >1 cm from the anal marker. perineal ultrasound perineal us has been used to measure the distance of the distal rectal pouch to the skin and to identify any recto-urogenital fistula. a 10–12 mhz high-frequency linear array transducer is normally used with the child in the supine position with pelvis and legs raised. a reference of 15 mm has been used to determine the difference between a ‘high’ and ‘low’ lesion. it must be cautioned that any straining or crying during the procedure can increase the intra-abdominal pressure and displace the rectal pouch into a falsely ’low’ position. another problem is the probe itself indenting the perineum and once again falsely reassuring the operator of a ’low’ lesion.4 many surgeons do not find this examination useful as it is very operator dependent and there are numerous factors involved that may alter the results. micturating cystourethrogram (mcug)/voiding cystourethrogram the mcug is an important study to do if abnormalities have been detected on the abdominal ultrasound or spinal us/mri. it enables the diagnosis of associated congenital urological problems, the most common being vesico-ureteric reflux (vur). mcug may also demonstrate the location of a recto-urinary fistula, but is not considered the best method of visualising the fistula.4 echocardiogram an echocardiogram is essential to obtain prior to any surgical intervention to rule out cardiovascular anomalies that could cause problems during anaesthesia. cardiovascular anomalies are the second most common association occurring in arm after urological anomalies, with the former occurring in about 30%–35% of patients. high-pressure distal colostogram top ↑ the high-pressure distal colostogram is the most accurate way of determining the anatomy of the distal rectal pouch and fistula in boys.12,13 the investigation is ideally done at 2–3 months of age in arm patients who have undergone a diverting colostomy; it should be done just prior to the definitive repair. the most common stoma done in patients with arm is a divided stoma with a skin bridge between the proximal and distal limb. the distal limb is made small and flush with the skin and will appear close to the midline in the lower abdomen (figure 7). sometimes the skin grows over the distal opening and it can appear quite small. the surgeon’s assistance may be necessary to find the ostia. figure 7: immediate postoperative image of the anterior abdomen showing the location of the divided stoma; arrow indicates the distal loop, which would be catheterised at colostogram. a foley catheter is then inserted into the distal fistula and 3 ml of saline is injected into the balloon. gentle traction is applied to the catheter to create a seal so that adequate pressure can be applied when injecting the contrast. a radio-opaque marker is placed where the anus should be. contrast medium (water soluble) is injected via the foley catheter with a 50 ml catheter tip syringe into the rectum under gentle but increasing pressure until the distal rectum and fistula are identified. the ap view is pivotal to see how much distal bowel is present, and the lateral view then defines the distal rectal anatomy as it relates to the urinary tract. fluoroscopy with spot filming with the child in ap and then lateral position is performed. sufficient pressure must be applied to distend the distal rectum adequately and identify the fistula. it is worth noting that too much pressure may cause bowel perforation or decrease the actual distance from distal rectum to skin, giving the impression of a falsely low pouch. however, too little pressure will give the false impression of a high rectum with no fistula; this will show up as a flattening of the distal rectum at the pubococcygeal line, and means more pressure is required for an accurate study. in most cases where there is not a fistula to the bladder, the study will be considered completed once contrast has reached the level below the pubococcygeal line, indicating that enough pressure has been applied. the sacrum, coccyx, perineum and bladder must all be visible during fluoroscopy. if a fistula is identified, it is suggested to continue injecting the contrast until the bladder fills and the baby spontaneously voids. if this is the case, valuable information regarding the urinary tract can be obtained. it is in essence a modified mcug14 (figures 8– 10). figure 8: lateral radiograph during high-pressure distal colostogram showing a recto-vesical fistula (arrow). figure 9: lateral radiograph during high-pressure distal colostogram showing a recto-prostatic fistula (arrow). figure 10: lateral radiograph during high-pressure distal colostogram showing a recto-bulbar fistula (arrow). the information that the surgeon would like to know is the precise location of the fistula in relation to the urinary tract, the length of bowel available for the pullthrough procedure, and the relationship between the sacrum, coccyx and rectum. all this information is vital to plan the type of operation required (psarp, laparotomy or laparoscopy).9 the usual surgical approach for a bulbar or low prostatic fistula would be psarp. for a vesical or high prostatic fistula, the approach would normally be laparotomy or laparoscopy for ligating the fistula and mobilising the bowel, then a limited psarp incision to bring it down to the cutaneous junction in the centre of the muscle complex. it must be emphasised, however, that not every patient fits this formula, and one may find a low prostatic fistula that has a long fistula with a rectal stump that is high. such a patient would do best with a laparotomy/laparoscopy first, followed by a limited psarp (figure 11). figure 11: lateral radiograph during high-pressure distal colostogram showing a recto-bulbar fistula with a high rectal pouch and long fistula (arrow). in lieu of doing colostograms, many centres do pelvic mr imaging to determine the position of the fistula, and are obtaining good results. mri avoids radiation, and increases detection of spinal dysraphism, tethered cord and pre-sacral masses; it can also show sphincter and pelvic floor musculature preoperatively. the disadvantages are that the procedure may require sedation/anaesthesia, is expensive and logistically demanding.15,16 our view is that mri is not yet able to replace the high-pressure distal colostogram for accurately demonstrating the anatomy required for preopertaive planning, but certainly plays a role in imaging patients who have previously been operated on. cloacal malformation top ↑ cloacal malformation is the most difficult technical challenge in the spectrum of arms. the defect involves fusion of the urethra, vagina and rectum to form a common channel. above the level of the common channel, the rectum and the vagina share a common wall, as do the urethra and vagina. the length of the common channel is vitally important to the surgeon, and a cut-off of a channel length of 3 cm is used to determine the surgical technique used to repair the malformation. with a channel length of less than 3 cm, theoretically a posterior sagittal procedure involving psarp and total urogenital mobilisation should suffice in the repair of these children. it is reproducible and can be done by most paediatric surgeons. with a common channel of greater than 3 cm, a combined abdomino-perineal approach is recommended. the repair of the rectum is similar to any other arm, but it is the repair of the vagina, urethra and associated urological problems that presents the main surgical challenge. such cases should be sent to a specialist centre with paediatric surgeons who have a special interest in these conditions and perform the operations regularly.5 all cloacal malformations should receive a primary stoma to decompress them prior to the definitive repair at 3–6 months. as previously mentioned, it is imperative that all patients with cloacal malformations receive an urgent abdominal and pelvic us to rule out hydrocolpos and its associated complications. if a hydrocolpos is present, it can be drained at the time of the colostomy creation. before any definitive surgical management is attempted, it is important to identify the anatomy of the malformation and its associated urogenital anomalies; this is done by endoscopy combined with a cloacagram. the endoscopy is done by the paediatric surgeon and involves cystoscopy and vaginoscopy. at this point, it is essential to measure the length of the common channel and insert catheters into the respective orifices so that a cloacagram can be performed in the radiology suite at a later time. a problem with 2d fluoroscopy is that it can be difficult to interpret overlapping structures.17 since it is a dynamic study, it would be appropriate to have the surgeon in the room during the study. it must be remembered that approximately 40% of patients have a double mullerian system consisting of 2 hemi-uteri and 2 hemi-vaginas; this can make interpretation very difficult. it can also be difficult to measure distance with 2d fluoroscopy, which is vital to know when planning a definitive repair (figure 12). figure 12: lateral radiograph during cloacogram. rotational fluoroscopy with 3d reconstruction is showing promise in negating the shortfalls of 2d fluoroscopy. vaginal anatomy and anomalies can be identified using 3d reconstruction. vaginal characteristics, such as location, size and presence of hemi-vaginas, are important to identify pre-operatively in order to determine the best approach to the repair of the genital component of the malformation.17 other key factors are common channel length, and length from urethra to bladder neck. because of magnification and foreshortening with conventional 2d screening, measuring the length of the common channel can be difficult. with rotational fluoroscopy, this is more accurate and the surgical approach can thus be determined accurately.17 the length of the distal colon and rectum can be more accurately measured, especially if there is redundancy in the loop, which can be missed in 2d fluoroscopy. this reassures the surgeon that there is sufficient length of distal rectum to pull through to the perineum. disadvantages of 3d fluoroscopy are that more radiation is required and a general anaesthetic is suggested to reduce movement artefact. the centres that use this technique have determined that the information obtained with this technique far outweighs the disadvantages because it supplies the surgeon with precise anatomical information to facilitate accurate surgical planning of a cloacal malformation and to define prognoses regarding long-term bowel, bladder and sexual function.17 other centres have taken 3d fluoroscopy to the next step and added low-osmolality iodinated contrast material mixed with a small amount of gadolinium. contrast material is used to distend the catheterised cavities and a high-resolution 3d mri of the pelvis is performed, which allows soft-tissue structures outside the lumens of the vagina, rectum and bladder to be well defined.18 not all centres have the luxury of being able to offer such advanced imaging techniques, but this can be overcome with a well-planned cloacagram (2d fluoroscopy), ideally with the operating surgeon in the radiology suite with the radiologist. follow-up imaging top ↑ after definitive repair of patients, it must be remembered that a large number might have associated renal abnormalities. the most common anatomical abnormalities observed are dysplastic kidneys or an absent kidney, followed by hydronephrosis. the most common functional defect is vur. surveillance of these anomalies is usually left to the discretion of the urologist and nephrologist. there is no doubt, however, that they will need follow-up by us, mcug and nuclear medicine. in patients with arm, their most significant morbidity is from their urological problems.9 imaging of complications top ↑ despite advances in surgical repair, complications are still common. these can be in the form of a persistent fistula, mislocated rectum, posterior urethral diverticulum, rectal stricture and a persistent urogenital sinus. mri seems to be the appropriate imaging technique in these patients to determine if reoperative surgery is required and to plan the surgical technique19 (figures 13 and 14). figure 13: sagittal t2w mri of the pelvis showing a posterior urethral diverticulum (arrow). figure 14: sagittal t1w mri of the pelvis showing the postoperative mislocated neo-anus anterior to the muscle complex (arrow). conclusion top ↑ imaging in patients with arm is vital in determining the correct surgical management. in the first 24–48 hours, imaging is used to determine if any associated anomalies are severe enough to preclude an operation, and what operation will be required. if a colostomy is done, the pre-definitive repair imaging in the form of a high-pressure distal colostogram determines the surgical approach required to repair the malformation. in more complicated cases such as persistent cloaca, advanced imaging in the form of mri or 3d fluoroscopy is valuable. although these advanced imaging modalities may add important information in planning surgery for these patients, 2d fluoroscopy images with the surgeon present is in most settings the most important radiological investigation by far to help planning for the surgical management. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions c.w.t. (university of the witwatersrand) wrote most of the manuscript. t.w.t. (parklane radiology), r.w. (center for colorectal and pelvic reconstruction) and m.l. (center for colorectal and pelvic reconstruction) contributed individually to the manuscript. images were provided by rw, ml and twt. references top ↑ levitt ma, peña a. anorectal malformations. orphanet j rare dis. 2007;2:33. pmid: 17651510, http://dx.doi.org/10.1186/1750-1172-2-33 gangopadhyay a, pandey v. anorectal malformations. j indian assoc pediatr surg. 2015;20:10. pmid: 25552824, http://dx.doi.org/10.4103/0971-9261.145438 theron a, loveland j. birth prevalence of anorectal malformation in the referral area for the university of the witwatersrand tertiary hospitals, south africa. eur j pediatr surg off. 2015;25:220–225. http://dx.doi.org/10.1055/s-0033-1360456 alamo l, meyrat bj, meuwly j-y, meuli ra, gudinchet f. anorectal malformations: finding the pathway out of the labyrinth. radiographics. 2013;33:491–512. pmid: 23479709, http://dx.doi.org/10.1148/rg.332125046 levitt ma, peña a. cloacal malformations: lessons learned from 490 cases. semin pediatr surg. 2010;19:128–138. 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http://dx.doi.org/10.1016/j.jpedsurg.2013.06.006 alves jcg, sidler d, lotz jw, pitcher rd. comparison of mr and fluoroscopic mucous fistulography in the pre-operative evaluation of infants with anorectal malformation: a pilot study. pediatr radiol. 2013;43:958–963. pmid: 23460374, http://dx.doi.org/10.1007/s00247-013-2653-x patel mn, racadio jm, levitt ma, bischoff a, racadio jm, peña a. complex cloacal malformations: use of rotational fluoroscopy and 3-d reconstruction in diagnosis and surgical planning. pediatr radiol. 2012;42:355–363. pmid: 22072072, http://dx.doi.org/10.1007/s00247-011-2282-1 jarboe md, teitelbaum dh, dillman jr. combined 3d rotational fluoroscopic-mri cloacagram procedure defines luminal and extraluminal pelvic anatomy prior to surgical reconstruction of cloacal and other complex pelvic malformations. pediatr surg int. 2012;28:757–763. http://dx.doi.org/10.1007/s00383-012-3122-6 podberesky dj, towbin aj, eltomey ma, levitt ma. magnetic resonance imaging of anorectal malformations. magn reson imaging clin n am. 2013;21:791–812. http://dx.doi.org/10.1016/j.mric.2013.04.010 contents tib abstract breast mr is a sensitive but nonspecific imaging investigation to detect breast cancer. mr imaging strengths lie in the accurate staging of the primary tumour, detecting recurrent cancer following lumpectomy and radiation therapy, problem solving in cases where there are equivocal mammographic findings, and screening for breast cancer in younger women with familial breast cancer. interpretation of mr images requires a meticulous imaging technique including the use of contrast enhancement and fat suppression mr sequences using a good breast coil. introduction the role of mr imaging in the diagnosis of breast cancer is not clearly defined, however this modality is becoming important in breast imaging to solve problematic cases where the mammogram is inconclusive.1 mr imaging is highly sensitive to the detection of focal breast masses, approaching 100%, but not very specific for cancer, varying from 37% to 70% in most series.1 this is the reason why breast mr imaging is relegated to a second-line imaging investigation. to interpret mr breast studies accurately it is important to understand the mr appearance of normal breast tissue, the enhancement pattern following gadolinium contrast injection and the specific mr techniques used to obtain these images. technique phased array surface breast coils are essential to improve the signal-to-noise ratio (fig. 1). we use spin echo (se) t1 and t2 stir sequences in the transverse planes. these are repeated following gadolinium enhancement using fat suppression in the transverse and sagittal planes. fat suppression is essential as both normal breast glandular tissue and breast cancer enhance following contrast injection and this enhancement is easily obscured by the high intensity of normal fat on t1-weighted images (fig. 2a-d). normal breast glandular tissue enhancement is minimal during days 7 20 of the menstrual cycle.2 this is the best period of time to image the breast in premenopausal women.2 in perimenopausal women focal enhancement of involuting breast parenchyma is a normal appearance.3 contrast enhancement gadolinium dtpa is injected intravenously as a bolus of 20 ml at 3 ml/sec (0.15 mmol/kg) and signal intensity is measured over 5 minutes. however breast cancer enhances within the first 120 seconds of a contrast injection while normal glandular tissue enhances later than 120 seconds (figs 2c, d). a mean curve function using regions of interest (roi) over the first 5 minutes post contrast injection is then generated automatically. although the shape of the curve, which measures contrast enhancement as a change of signal intensity over time, is useful in improving specificity of a focal lesion, the curve cannot be used to localise lesions for biopsy. the curve can be broken down into 2 components: the initial rise in contrast enhancement and the delayed phase. the initial rise can be slow, medium or fast. the delayed phase can be persistent, plateau or washout in character. breast cancer has a rapid initial rise in contrast enhancement due to tumour neovascularity (figs 2c,d, 3a-e), however in onethird of lobular cancers and in patients with ductal carcinoma in situ (dcis) there is a slow rise in enhancement. in the delayed phase there is persistent or plateau curve with breast cancer while normal glandular tissue shows a washout curve. 4 sa journal of radiology • october 2005 review article magnetic resonance imaging of invasive breast cancer p corr ffrad (d) sa s panday fcrad (d) p seolall nat dip rad (d) h booth nat dip rad (d) department of radiology nelson mandela school of medicine and inkosi albert luthuli hospital durban fig.1. breast coil used at inkosi albert luthuli hospital. both breasts can be imaged simultaneously in the prone position. fig 2a,b. patient with a breast cancer involving the medial aspect of the breast (arrow) is more conspicuous on the fat-saturated t1 stir postcontrast sequence. pg4-6 tib 10/8/05 11:10 am page 4 review article 5 sa journal of radiology • october 2005 morphological signs of breast masses focal mass as in film screen mammography, the presence of a mass is confirmed by its mass effect and architectural distortion. most malignant breast masses have a low intensity on t1 and t2-weighted scans. simple breast cysts, fat necrosis and intra-mammary lymph nodes have a high intensity on t1-weighted scans. myxoid fibroadenomas, fat necrosis and lymph nodes have a high intensity on t2-weighted scans. it is important to appreciate that focal contrast enhancement may not be due to a focal mass but it could rather represent normal glandular tissue in a perimenopausal patient, fibrocystic disease of the breast or localised dcis. this is called 'non mass' enhancement. shape and margins of the mass masses may be round, oval, lobular, figs 2c,d. t1 stir post gadolinium-enhanced image of the same patient as in fig.2a demonstrates focal enhancement of the cancer (region of interest 1) in fig. 2d, and the corresponding curve for this lesion (continuous line curve, arrow) shows the rapid initial wash in rise and the delayed washout typical of cancer. figs 3a,b. mammogram of the right breast of a 30-year-old woman who had a right lumpectomy for breast cancer demonstrates a dense parenchymal pattern with a suspicious mass in the outer lateral quadrant (arrow) on the magnified view, figs 3c,d. t1 and t1 fat-saturated contrast-enhanced transverse images of the right breast demonstrate the focal mass as a low-density spiculated lesion on t1 (arrow 3c) which enhances markedly after contrast injection (arrow 3d) which is suspicious for a new cancer. fig. 3e. dynamic contrast curve for region 1 over the suspicious lesion (arrow) demonstrates the typical curve for a cancer with a rapid initial rise and slow washout of contrast with time. pg4-6 tib 10/8/05 11:10 am page 5 irregular, smooth or spiculated as detected mammographically. however the most predictive sign of cancer on breast mr imaging is spiculation (positive predictive value of 80 91%) while the presence of a 'halo' of surrounding breast parenchyma, rim and central enhancement and ductal distribution of enhancement have a lower positive predictive value varying from 40% to 86%.4 mass architecture and contrast enhancement patterns contrast enhancement within the mass can be focal, diffuse or segmental in nature. segmental or branching enhancement represents ductal pathology and is commonly detected in dcis. focal clumped enhancement is also found in dcis. heterogeneous focal enhancement is seen in cancers and fibroadenomas. rim or edge enhancement is found in cancer. masses with internal septations are found in fibroadenomas. interpretation of mr images it is always good practice to assess a mass on its morphological appearances and use the contrast curves as secondary evidence. mr images must be read in conjunction with mammograms and ultrasound examinations.1 indications for breast mr imaging preoperative staging determination of the size of the cancer and the presence or absence of multifocal and multicentric cancers is critical in determining the type of surgical procedure or treatment offered. mr is superior to both mammography and ultrasound in determining the true extent of a cancer and is the most accurate imaging investigation when compared with the histological tumour extent following resection.5 postoperative assessment of residual cancer the detection of residual cancer following lumpectomy is important if breast conservation is to be considered. assessment of histological tumour margins and detection of residual malignant microcalcifications on postoperative mammograms are often inaccurate. mr imaging is more accurate with a sensitivity varying from 89% to 94%.6 specificity improves if the mr scan is performed at least 28 days following lumpectomy and at this time is 70%.7 mr has been found to be useful in differentiating scar from recurrent tumour in those patients who have had lumpectomies and/or radiotherapy treatment. however it is important to remember that surgical scars can enhance up to 6 months postoperatively and if radiotherapy is given then up to 18 months post treatment. lobular breast cancer mr is especially useful in detecting lobular cancer, which occurs in 10% of women with breast cancer. this cancer infiltrates along ducts without a desmoplastic response making it difficult to detect by mammography. lobular cancer is often bilateral and multicentric making this cancer more easily detected by mr imaging.1,8 cancer in mammographically dense breasts mr imaging detects more extensive tumour as well as multifocal and multicentric cancer in patients with newly diagnosed cancer than mammography. this is especially true in those patients with mammographically dense breasts.9 this has been demonstrated to change surgical management in up to 51% of patients.10 screening in familial breast cancer breast mr imaging has been demonstrated to be more sensitive than screening mammography in the detection of familial cancer which may be multifocal in patients who are brca1 or 2 positive or who have a strong family history of breast cancer.11 mr detects between 1% and 4% more cancers than mammography in these patients.1 conclusions breast mr imaging is a new advance in the diagnosis of breast cancer and in screening for cancer in high-risk women. attention to mr technique is essential for the correct interpretation of findings. as with all forms of breast imaging, there is a steep learning curve for the radiologist to take to become proficient in interpretation. references 1. lee c. problem solving mr imaging of the breast. radiol clin north am 2004; 42: 919-934. 2. muller-schimpfle m, ohmenhauser k, stoll p, dietz k, clauseen cd. menstrual cycle and age: influence on parenchymal contrast enhancement in mr imaging of the breast. radiology 1997; 203: 145-149. 3. kuhl c, bieling hb, gieseke j, kreft bp, sommer t, lutterbey g. healthy premenopausal breast parenchyma in dynamic contrast enhanced mr imaging of the breast: normal contrast medium enhancement and cyclical phase dependency. radiology 1997; 203: 137-144. 4. american college of radiology. breast imaging reporting and data system (bi-rads). reston, usa: acr, 2003. 5. boetes c, mus rd, holland r, barentsz j, strijk s, wobbs t. breast tumors: comparative accuracy of mr to mammography and ultrasound in determining extent. radiology 1995; 197: 743-747. 6. frei ka, kinkel k, bonel hm, lu y, esserman lj, hylton nm. mr imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and mr imaging. am j roentgenol 2000; 175: 1577-1584. 7. lee jm, orel sg, czerniecki bj, solin lj, schnall md mri before re-excision surgery in patients with breast cancer. am j roentgenol 2004; 182: 473480. 8. weinstein wp, orel sg, heller r, reynolds c, czerniecki b, solin l. mr imaging of the breast in patients with invasive lobular carcinoma. am j roentgenol 2001; 176: 399-406. 9. hlawatsch a, tiefke a, schmidt m, thelen m. preoperative assessment of breast cancer: sonography vs mr imaging. am j roentgenol 2002; 179: 1493-1501. 10. bedrosian i, mick r, orel sg, schnall m, reynolds c. changes in the surgical management of patients with breast carcinoma based on preoperative mr imaging. cancer 2003; 98: 468-473. 11. kuhl ck, schmutzler rk, leutner cc, kempe a, wardelman e, hocke a. breast mr imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene; preliminary results. radiology 2000; 215: 267-269. review article 6 sa journal of radiology • october 2005 pg4-6 9/28/05 2:31 pm page 6 124 sa journal of radiology • december 2010 quiz case s k misser, mb chb, fcrad (d) lake smit and partners, durban cardiological diagnosis findings please refer to page 74 of the september 2010 issue of the sajr (http:// www.sajr.org.za/index.php/sajr/article/view/497) for the clinical details and images. we congratulate dr nasreen mohamed (department of radiology, university of the witwatersrand) for her precise and detailed diagnosis, for which she receives an award of r1 000 from the rssa. dr misser elaborates below on the condition and its radiological signs. diagnosis the patient has a background history of childhood cardiac surgery, which is evident in fig. 2, by the dense calcification of the inter-atrial repair patch for an atrial septal defect. pulmonary arterial hypertension is indicated by the dilated pulmonary trunk and branches in figs 1 and 3. a stomach bubble is slightly displaced from the diaphragm outline owing to intervening bridging liver (fig. 1). the persistent leftsided svc (unopacified) and interruption of the ivc, with azygous continuation, is noted (fig. 3). there is levocardia but with situs anomaly of the subphrenic organs including central, left-dominant liver, and right-sided stomach and spleen (with polysplenia). there is no overt bowel malrotation, and the superior mesenteric vessels are normally positioned (fig. 4). on the coronal reformat in fig. 5, mild tricuspid regurgitation is seen, and there is suggestion of mild post-ductal aortic coarctation on the sagittal reformat. an additional abnormality is the dysplastic left kidney with only a small cystic remnant. diagnosis of heterotaxy syndrome (with polysplenia, azygous continuation of the ivc, repaired atrial septal defect and pulmonary arterial hypertension) was made, with incidental associated mild aortic coarctation and left renal dysplasia. discussion situs anomalies imply a disorder of the organ arrangement in the chest and abdomen, with abnormality of lateralisation. these are divided broadly into those which are complete (situs inversus totalis) or incomplete (heterotaxy syndromes). the embryologic periods of pregastrulation through gastrulation and somitogenesis have all been identified as possible timing of the failure of lateralisation, especially at the 20 30-day embryonic stage when cardiac and venous channel development occurs.1 mutations of 9 genes have been identified in humans, accounting for the genetic predisposition; however, a number of cases remain sporadic. autosomal dominant and recessive as well as x-linked recessive inheritance has been described.1 the heterotaxy syndromes are quite complex entities that require fairly extensive clinico-radiological evaluation including use of chest radiograph, echocardiography (congenital heart defects), abdominal ultrasound (position of major viscera, ivc, splenic abnormality) and ct/mri scanning. angiography, upper gi series and tc-labelled isotope scanning are less utilised owing to high sensitivity of ct scan. assessment of the following is mandatory: position of atria and cardiac apex, location of aorta, bior trilobed lungs, sub-diaphragmatic venous return, position of stomach and/or malrotation, liver/gallbladder position, and the spleen (present/absent, splenuncules).1,2 in patients with heterotaxy (with polysplenia), there is a high incidence of congenital cardiac disease3 and particularly atrial septal defects, atrio-ventricular canal defects or abnormal pulmonary venous return. pulmonary hypertension may be due to intracardiac shunt, viscero-vascular configuration anomaly or pulmonary microvascular obstructive disease. azygous continuation of the interrupted hepatic ivc, multiple splenuncules on the same side as the stomach4 and left-sided isomerism are classic features. there is, however, no single pathognomonic abnormality for this subtype.2 prognosis is slightly better in this group compared with asplenia, where the risk for infection is much higher owing to immune function failure. appelgate et al. revised the classification of heterotaxy and suggested an individualised approach, as used in the patient described. the simplified method includes all aspects of the anomaly in the individual patient stipulated in parentheses. this is a more universal language to describe the abnormality identified, rather than using the basic terminology of asplenia/polysplenia/ isomerism where the exact constellation of findings will not be communicated to the referring clinician or fellow radiologist. 1. appelgate ke, goske mj, pierce g, murphy d. situs revisited: imaging of the heterotaxy syndrome. radiographics 1999;19:837-852. 2. winer-muram ht, tonkin ild. the spectrum of heterotaxic syndromes. radiol clin north am 1989;27:1147-1170. 3. peoples wm, moller jh, edwards je. polysplenia: a review of 146 cases. pediatr cardiol 1983;4:129-137. 4. oleszczuk-raschke k, set pak, von lengerke hj, trojer j. abdominal sonography in the evaluation of heterotaxia in children. pediatr radiol 1995; 25(suppl 1): s150-s156. 82 sa journal of radiology • december 2010 editorial bob bury, the editor of clinical radiology, has kindly written an accompanying editorial for this issue of the south african journal of radiology. to place his piece in context, one has to at least have paged through the special june 2010 edition of clinical radiology on molecular imaging (mi).1 the introductory article explains the role of small molecules in the form of peptides or antibodies that are linked to an imaging label and are destined to attach to a tumour antigen. in the case of pet and spect, the labels are radioactive substances. rssa president clive sperryn’s thoughts on mi appear in this sajr’s radioactive news section. new in the field is optical mi. fluorescent dyes are important, but the recent introduction of quantum dots, carbon nanotubes and gold nanoshells defines the scale of magnitude being referred to. acoustic mi has seen the introduction of microor nanoparticles in the form of microbubbles, perfluorocarbon nanodroplets and liposomes. mri labels include paramagnetic iron oxide and manganese oxide. where does the radiologist stand relative to all this? i do not know, and feel like moses of old ‘on the outside, looking in’. what i do know is that we need to define our role and define it fast. we need to ask many questions. for one: are we properly prepared for these changes that loom on our doorstep? this is probably the most pertinent question needing a response. i believe that our primary examinations fall short, with a lack of knowledge of physiological and patho-physiological principles seeming to represent the most significant hiatus. i echo bob bury’s words as a clarion call to south african radiology: ‘… if we want to continue to attract the brightest and best of our young doctors into the specialty, we need to pick up the new techniques and run with them. if we don’t do it, and do it well, someone else will.’ jan lotz editor-in-chief 1. clin radiol 2010; 65:499-582. a clarion call to south african radiology i was delighted and flattered when jan lotz invited me to contribute to the south african journal of radiology; although, if you were aware of how little i know about molecular imaging (mi – yet another acronym to confuse with mr), you might reasonably be wondering why on earth he approached me. well, i edit clinical radiology, the journal of the royal college of radiologists, and we recently published a special issue1 on this hot topic. i wrote a brief editorial introducing the issue, then sat back to marvel as the contributions from around the world came in, and jan asked if i would write a similar piece for the sajr. i’ll resist the temptation to reference each paper in our special issue in a blatant attempt to boost the journal’s impact factor, but hopefully most of you will have electronic access to it through your institutions or possibly as fellows of the college. when you are as close to retirement as i am, it can get a bit depressing to find your hard-won skills becoming obsolete (remember lymphangiography, anyone?), and to see your juniors effortlessly overtaking you in the application of new imaging technology. the great thing about mi is that most radiologists – even those irritatingly bright young ones – are nearly as ignorant of the subject as me. in fact, of course, it transpires that most of us have practised some aspects of mi, often without realising it. my sub-specialty is nuclear medicine, or radionuclide imaging (rni) as we are now required to call it, in the uk at least. rni practitioners have always boasted, quite rightly, that it is a functional imaging technique, so it is not surprising that many of the early developments in mi have come in this field, in particular those utilising positron emission tomography (pet). similarly, anyone who has bought an mr machine recently will no doubt have tentatively pressed the dwi button to see what it does, and functional mr is already an accepted imaging technique in the fields of neurology and cardiology. however, mi is much more than an extra option on the mr console, or a sexed-up version of the bone scan. mi has been defined as the ability to visualise and quantitatively measure the function of biological and cellular processes in vivo.2 whereas 20 years ago that definition would probably, with few exceptions, only have applied to rni techniques, it now encompasses all imaging modalities except plain film, and includes some, such as optical imaging, that are completely unfamiliar to most of us. even ultrasound, that most anatomical of techniques, is now utilising molecularly targeted micro-bubbles to take diagnosis to the cellular level, and similar bubbles can be used to deliver tailored therapy agents to tumour tissue by using the ultrasound beam to disrupt them in situ. computed tomography also has some mi applicability, with dynamic contrast enhancement techniques being used to look at processes such as tumour angiogenesis and tissue hypoxia. and, of course, the development of new molecular targets for novel pet agents is a wellestablished growth area in mi research. and there’s still more: i could molecular imaging sa journal of radiology • december 2010 83 editorial go on to talk, at least superficially, about optical and photo-acoustic imaging and raman spectroscopy/microscopy, but i probably wouldn’t be able to fool you for very long. so, it is likely that all radiologists will need to learn new applications for their imaging modalities of choice, in addition to mastering a number of completely new techniques. in addition to these obvious imaging aspects, the other issue i want to mention in relation to mi is the political/service delivery dimension. i don’t know how much of a problem so-called turf wars have been in south african medicine, but in the uk we have always thought of these battles for the possession of areas of practice (and income) as a feature of the north american, insurance-funded, medical scene. lately, though, we have realised that the state-funded nhs is not immune. for example, we have already lost much of cardiac imaging to the cardiologists – not just the invasive coronary angiography and intervention, but also a lot of the cardiac mr work; and in mainland europe, the usurpation of imaging techniques by clinicians has been even more widespread. mi is a new and exciting field, with applications in therapy as well as diagnosis, and there’s no doubt that some clinicians will want to get what they see as their share of the action. i suppose it doesn’t matter to the patient which specialist undertakes their investigation, as long as they do it well, but in the main these are imaging investigations we are talking about, and radiologists are the imaging experts. i also believe that if we want to continue to attract the brightest and best of our young doctors into the specialty, we need to pick up the new techniques and run with them. if we don’t do it, and do it well, someone else will. when you read a paper in a journal of clinical radiology which includes a section headed ‘molecular imaging of the metabolome: hypoxia-inducible factor (hif) and the warburg effect’,3 you realise that times are changing, and that we have moved beyond the demonstration of gross anatomy (although that’s clearly still important) into a world where we can reveal cellular physiology and pathophysiology on a scale that is several orders of magnitude smaller than anything we have been used to. in fact, now that i think about it, this exciting new direction for radiology is almost enough to make me wish i wasn’t retiring at the end of the year ... almost. and that’s it, really. it’s all very well me exhorting you to take on this new area of practice – i’m at the end of my career, and won’t need to do any of the work myself. however, i am about to become a net consumer of healthcare for the first time in my adult life, so i may soon have a very direct vested interest in the competence and skill set of the next generation of radiologists! i should also say at this point that, having visited your wonderful country for the first time a couple of years ago and fallen in love with it, i shall be available from the end of 2010 for expenses-paid lecturing tours of the wine-producing areas of sa, preferably during your summer months. just don’t ask me to lecture on mi. 1. clin radiol 2010;65:499-582. 2. mankoff da. a definition of molecular imaging, j nucl med 2007;48(6):18n-21n. 3. gillies rj, anderson ar, gatenby ar, morse dl. the biology underlying molecular imaging in oncology: from genome to anatome and back again. clin radiol 2010; 65:517-521. bob bury editor-in-chief clinical radiology sajr bigger and quicker the south african journal of radiology has, under the excellent leadership of jan lotz, exceeded all expectations and is growing exponentially, with the development of a backlog of accepted manuscripts awaiting publication. we are pleased to announce that, through generous sponsorship by philips medical systems via an ongoing commitment to the rssa cpd programme, the size of the journal has been increased. the increase in page count will facilitate a reduction in the waiting time to publication. the increased capacity of the sajr assumes additional significance in the light of new requirements for the registration of specialists in south africa. the most significant point is the appointment of the colleges of medicine of south africa (cmsa) as the executor of a single exit exam for all registrars entering from 1 january 2011 and the requirement of completion of a research component for registration as specialists. the rssa’s contribution through the sajr to produce a number of bumper issues will allow increased mmed publications. clive sperryn president, rssa case report case report 94 sa journal of radiology • december 2009 case report introduction chilaiditi’s sign is a radiographic term that is used when the hepatic flexure of the colon is seen interposed between the liver and right hemidiaphragm.1 this syndrome is a rare condition and most often an asymptomatic anomaly that is typically an incidental finding.2 it is seen in 0.1 0.25% of chest x-rays, most frequently in males, and almost always in adults. factors contributing to its occurrence are thought to include absence of normal suspensory ligaments of the transverse colon, abnormality or absence of the falciform ligament, redundant colon as might be seen in patients with chronic constipation or in bedridden patients, paralysis or even eventration of the right hemidiaphragm, and patients with chronic lung disease, cirrhosis and ascites. the condition is usually asymptomatic3 but may present with abdominal pain, nausea, vomiting and constipation.1,2 chest pain and dysphagia have been described, therefore chilaiditi’s syndrome should be considered in the differential diagnosis of chest pain.3,4 chilaiditi’s syndrome may mimic pneumoperitoneum on chest x-ray. computed tomography (ct) scan usually shows the haustral folds consistent with air within the colon, while ultrasonography may clearly show a loop of intestine between the liver and diaphragm. we report here on an unusual and incidental finding of this syndrome using single photon emission computed tomography-ct (spect-ct) in a patient referred for a possible inflammatory process. gallium-67 citrate was the agent used in an attempt to localise a site of active disease. the use of this hybrid imaging modality prevented us from looking into the differential of a ‘photon-deficient’ area on gallium imaging of the abdomen. our case is the first in the literature to describe the finding of chilaiditi’s syndrome using this hybrid imaging modality. case report a 49-year-old woman was referred to us from the neurology general ward for gallium imaging. she was admitted for proximal body weakness possibly caused by myopathy. she gave a 4-year history of weakness that started with fatigue and progressed to the point that she could not walk. she did not offer any history of sensory complaints but occasional double vision (diplopia) was mentioned. physical examination revealed nothing abnormal on the vital signs or the cardiovascular and respiratory systems. the cns examination noted a clear decreased proximal power. the clinical diagnosis of myopathy was retained and she was sent to us for a gallium scan to rule out a granulomatous myositis. both planar imaging and spect-ct reconstructed images were done using a dual-head ge medical systems infinia hybrid system equipped with a medium-energy collimator. gallium-67 citrate 5 mci was injected intravenously 2 days before imaging. whole-body sweep chilaiditi’s syndrome demonstrated by spect-ct nalini s perumal, mb bch, fcnp mboyo-di-tamba h vangu, md, mmed (nuclear medicine) khushica purbhoo, mb chb shireen dhoodhat, mb bch division of nuclear medicine, university of the witwatersrand, johannesburg fig. 1. spect-reconstructed images of the gallium-67 scans showing a ‘cold’ area on the transverse plane. chilaiditti's.indd 94 11/19/09 2:27:04 pm case reportcase report (h-mode for anterior-posterior, feet first) was done for planar acquisition using a continuous mode with an exposure time per pixel of 300 seconds. spect recording of imaging was done on a step-and-shoot mode (40 seconds per projection and 10 mm slice step) using a 128 x 128 matrix. the ct tomography was acquired with a full ct/ac range using a current of 2.5 ma, 140 kv voltage and rotation velocity of 2.6 rpm. the planar images on gallium scintigraphy showed a large photondeficient area in the right lobe of the liver. the spect-reconstructed images confirmed the presence of this large photopenic area (fig. 1), and the ct scan shows evidence of air consistent with bowel filling the abovementioned photon-deficient area (fig. 2) as positively identified on the combined or fused images of spect-ct (fig. 3). a full diagnostic 16-slice ct scan with contrast was ordered for academic interest and confirmed all the above. discussion we report on a female patient with a clinical diagnosis of myopathy thought to be caused by granulomatous myositis. an incidental finding of chilaiditi’s syndrome was noted during imaging investigation by using spect-ct for gallium scanning. the use of spect-ct made the interpretation of our finding easier and prevented the search for differential diagnoses of decreased gallium uptake such as cysts, fibrosis, benign tumours, bile peritonitis, and liver replacement by non-ga-67-avid lesions, amoebic abscess or a necrotic liver metastasis. previous incidental finding of this syndrome on scintigraphic studies has been described in the literature but with clear contrast to our findings. a linear area of intensely increased gallium activity was seen along the superior and lateral margins of the right lobe of the liver during the search for a possible opportunistic infection or neoplastic disease in a male patient with aids who had fever and lymphadenopathy.6 this activity was caused by interposition of the colon as demonstrated on a concurrent chest radiograph that shows the gas-filled hepatic flexure of the colon between the right diaphragm and the liver. in another scintigraphic study on a male patient with ulcerative colitis that was not responding to treatment, chilaiditi’s syndrome was identified with tc-99m hexamethyl-propylene amine oxime-labelled leukocytes requested to evaluate the site, extent and severity of disease.7 a prominent increased uptake was seen in the right side of the colon, which was interposed between the liver and the diaphragm; this was a segment of active inflammatory bowel that was confirmed at surgery. in our case presentation, the use of ct as part of the hybrid imaging modality made it easier to suspect this syndrome in a patient without symptoms of either abdominal or chest pain. in fact, the increased number of studies with spect-ct in the current clinical practice of nuclear medicine clearly signals the need to accurately localise the site of functional abnormalities; this was also our motivation for using such a modality. the use of spect-ct for gallium-67 citrate by fuertes and colleagues was shown to improve the diagnostic yield of their study in providing better anatomical localisation of lesions.8 o’connor and kemp recently stated that the anatomical and functional information presented by spect-ct can aid in the decision-making process by enabling better localisation and definition of organs and lesions and thus improve the precision of sites for biopsies.9 finally, the most recent publication of the procedure guideline for spect-ct imaging to assist physicians in performing, interpreting, and reporting spect-ct images is an indication that the use of this integrating device containing both a ct scanner and a spect gamma camera will offer numerous advantages, the most important being the anatomic referencing.10 in conclusion: the use of the hybrid imaging technique that combines anatomical and functional information should be considered when it is available in cases where there is a need for accurate localisation of active disease. regardless of the nature of radioactive tracer on scintigraphy, increased or decreased within the interposed colon in the right hepatic 95 sa journal of radiology • december 2009 fig. 2. the ct scans for localisation on the same imaging machine (hybrid equipment) show air in the area of no gallium uptake, suggesting the clinical diagnosis of chilaiditi’s syndrome. fig. 3. fused anatomical and functional images confirming the findings on spect and ct of the abdomen. chilaiditti's.indd 95 11/19/09 2:27:10 pm case report case report 96 sa journal of radiology • december 2009 flexure, the ct component should confirm the presence of air in symptomatic or asymptomatic patients with chilaiditi’s syndrome. 1. widjaja a, walter b, bleck js, et al. diagnosis of chilaiditi’s syndrome with abdominal ultrasound. z gastroenterol 1999; 37:607-610. 2. kurt y, demirbas s, bilgin g, et al. colonic volvulus associated with chilaiditi’s syndrome: report of a case. surg today 2004; 34: 613-615. 3. haddad cj, lacle j. chilaiditi’s syndrome. a diagnostic challenge. postgrad med 1991; 89: 249-252. 4. naito m, funaki c, miura s, et al. three cases of chilaiditi’s syndrome -hepatodiaphragmatic interposition of colon. nippon ronen igakkai zasshi 1992; 29: 586-590. 5. sorrentino d, bazzocchi m, badano l, et al. heart-touching chilaiditi’s syndrome. world j gastroenterol 2005; 11: 4607-4609. 6. chandramouly b, shah r, nardi p. chilaiditi’s syndrome: incidental findings on ga-67 scintigraphy. clin nucl med 1997; 22: 575-576. 7. siraj qh, mcglone b. chilaiditi’s syndrome on tc-99m hexamethylpropylene amineoxime imaging. clin nucl med 1999; 24: 699-700. 8. fuertes mj, estorch cm, camacho mv, et al. spect-ct 67 ga studies in lymphoma disease. contribution to staging and follow-up. rev esp med nucl 2006; 25: 242-249. 9. o’connor mk, kemp bj. single-photon emission computed tomography/computed tomography: basic instrumentation and innovations. semin nucl med 2006; 36: 258-266. 10. delbeke d, colemen re, guiberteau mj, et al. procedure guideline for spect/ct imaging. j nucl med 2006; 47: 1227-1234. chilaiditti's.indd 96 11/19/09 2:27:10 pm pg93.pdf page 1 � sa journal of radiology • june 2007 abstract objectives. to report our experience with bronchial artery embolisation (bae) for the treatment of massive haemoptysis due to untreated or partially treated pulmonary tuberculosis. materials and methods. in february 2007 five male patients, between the ages of 40 and 51, presented to chris hani baragwanath hospital (chbh) with massive haemoptysis. bronchial arteriography and embolisation were performed using a 4 french c2 catheter and polyvinyl alcohol (pva) particles ranging from 300 to 900 micrometers. results. seven bronchial arteries in total were embolised (2 patients required embolisation of 2 arteries each). the haemoptysis was controlled during the first endovascular treatment session in all 5 patients. no serious complications developed in any of our patients as a result of the interventions. at the 1-month follow-up none of the patients had reported any episodes of haemoptysis. conclusion. massive haemoptysis due to pulmonary tuberculosis can be effectively treated with bae when in a controlled environment, with the proper patient selection and with the appropriate expertise. introduction percutaneous transcatheter embolisation is a safe and effective method of vascular occlusion that has been successfully applied in practically every vascular territory to arrest haemorrhage. it has become the therapeutic technique of choice in the treatment of many vascular abnormalities.1 bronchial artery embolisation (bae) is a safe and well-accepted procedure for the management of massive or recurrent haemoptysis.2 massive haemoptysis is defined as the expectoration of more than 300 ml of blood in a 24-hour period.2 the mortality rate from untreated massive haemoptysis can be as high as 50%.3 death, in most cases, is secondary to asphyxiation from aspiration rather than from the bleeding itself. surgical management during an acute episode of massive haemoptysis also has a high mortality rate, reported to be in the region of 30 40%.4 we report our experience with bae for the immediate treatment of massive haemoptysis due to untreated or partially treated pulmonary tuberculosis (ptb) at chris hani baragwanath hospital (chbh). chbh is a 3 200-bed public-sector urban hospital in johannesburg, south africa. it is affiliated to the university of the witwatersrand and services the 3 million-plus inhabitants of soweto. patients and methods in february 2007, five male patients between the ages of 40 and 51, presented to the respiratory unit with massive haemoptysis. they were then referred to our unit for bae. in all these patients the cause of the haemoptysis was determined to be untreated or partially treated ptb (table i). where available, the hiv status of the patients was also documented. for logistical reasons bronchoscopy was not performed before embolisation, therefore the decision to perform angiographic intervention was made on the basis of review of chest radiographs alone. these were evaluated for the site and extent of the pathology. in all the patients referred to us, chest radiographs demonstrated features of advanced, extensive and chronic disease, seen commonly with ptb (figs 1a and b). four of the 5 patients were stable after having received blood transfusions. the fifth patient was sent to our unit intubated and on ventilatory support. in all 5 patients, the right femoral artery was punctured using the seldinger technique. initially non-selective aortograms were performed using a 5 french pigtail catheter, followed by selective and super-selective bronchial artery catherisation using a 4 french cobra 2 catheter to accurately detect the site of haemorrhage. bronchial artery embolisation for the treatment of massive haemoptysis resulting from pulmonary tuberculosis i carim, mb bch, fcrad(d) h carim, mb bch, dch (sa) m modi, mb bch, mmed, fcrad(d) division of radiology, department of radiation sciences, chris hani baragwanath hospital and the university of the witwatersrand, johannesburg table i. ptb and hiv status pulmonary tuberculosis status retroviral status cd4 counts (cells/mm3) patient 1 partially treated ptb, bronchiectasis positive 194 patient 2 partially treated ptb, previous defaulter unknown patient 3 untreated ptb positive 376 patient 4 third episode of partially treated ptb positive 34 patient 5 untreated ptb unknown original articleoriginal article pg!!!!!!!!8-12.indd 8 6/18/07 4:22:08 pm � sa journal of radiology • june 2007 fig. 1b. chest radiograph of patient 4 demonstrating: bilateral dense perihilar and lower lobe consolidation with cavitation and underlying bronchiectasis, patchy consolidation in left upper lobe and a left-sided pleural effusion. fig. 1a. chest radiograph of patient 2 demonstrating: bilateral apical fibrosis with bronchovascular distortion and volume loss, a diffuse nodular infiltrate with confluence and consolidation in the right lower lobe, dense consolidation with underlying bronchiectasis in the left mid and lower zones and a left-sided pleural effusion. table ii. chest radiograph findings and sites of haemorrhage chest radiograph findings site of haemorrhage patient 1 • dense consolidation right lower lobe with underlying bronchiectasis • right lower lobe • fibrocavitatory changes left apex patient 2 • bilateral apical fibrosis • right lower lobe • dense consolidation with cavitation in the left mid and lower zones (underlying bronchiectasis) • left lower lobe • nodular infiltrate with confluence and consolidation in the right lower lobe • left-sided pleural effusion patient 3 • apical pleural thickening on the left • left upper lobe • fibrosis with traction bronchiectasis in the left upper lobe • bilateral hilar adenopathy patient 4 • patchy consolidation in the left upper lobe • left lower lobe • bilateral dense perihilar and lower lobe consolidation with cavitation (underlying bronchiectasis) • right lower lobe • left-sided pleural effusion patient 5 • bilateral apical fibrosis with underlying bronchiectasis • right upper lobe • bilateral hilar adenopathy original article pg!!!!!!!!8-12.indd 9 6/18/07 4:22:10 pm 10 sa journal of radiology • june 2007 the sites of haemorrhage varied from patient to patient (table ii). in 4 out of the 5 patients the same c2 catheter that was used to detect the site of haemorrhage was also used for the embolisation. in 1 case a 4 french sheppard hook catheter was used due to difficulty in accessing the bronchial arteries. micro-catheters, though routinely used in our centre for bae and definitely recommended and preferred, were unavailable at the time. hypervascularity was a common finding at the site of bleeding in all of the 7 arteries embolised (2 patients required embolisation of 2 arteries each). hypertrophy of the bronchial artery was seen in 4 cases and extravasation of contrast into the bronchial lumen was seen in 1 case (figs 2 and 3). in 1 patient we encountered a spinal artery being fed by a branch of the proximal bronchial artery. here a selective embolisation was performed with the catheter positioned distal to the origin of the feeding vessel. polyvinyl alcohol (pva) particles ranging from 300 500 micrometers up to 700 900 micrometers were used in all cases. these were gradually injected into the bronchial arteries with a dilute mixture of contrast using a 10 ml syringe. results seven bronchial arteries in total were embolised (2 patients required embolisation of 2 arteries each). embolisation was considered to be successful if less than 100 ml of blood was expectorated within 24 hours following the procedure. thereafter, occasional bloodstained sputum, or fig. 4. post embolisation bronchial arteriography demonstrating occlusion of abnormal vessels. fig. 2. bronchial arteriography demonstrating hypertrophy of the bronchial artery with hypervascularity. fig. 3. bronchial arteriography demonstrating abnormal vascularity with contrast extravasation. fig. 5. cessation of bleeding following embolisation.. original article original article pg!!!!!!!!8-12.indd 10 6/18/07 4:22:11 pm 11 sa journal of radiology • june 2007 none at all, was considered to indicate a successful outcome. the haemoptysis was controlled during the first endovascular treatment session in all 5 patients; 2 patients having minimal haemoptysis (< 100 ml in 24 hours) and 3 patients having no haemoptysis at all (figs 4 and 5). no serious complications developed in any of our patients as a result of the interventions, although 1 patient did complain of chest pain corresponding to the vascular territory embolised. the patient was treated with non-steroidal anti-inflammatory drugs and the pain subsided within 24 hours. at the 1-month follow-up none of the patients had reported any episodes of haemoptysis. discussion bronchial arteriography was first performed in the late 1950s and early 1960s using non-selective aortography, while the first selective bronchial angiogram was performed in 1963. the remy group performed the first bae for haemoptysis in 1973.5 since then many studies have documented the use of bae for the effective treatment of haemoptysis.6,7 the haemoptysis may result from various causes and differs greatly between the western and non-western world. in south africa ptb, particularly tuberculous bronchiectasis is the most common underlying cause of massive haemoptysis.8,9 although ptb is effectively treated with chemotherapy in the majority of patients, 10 20% will develop serious complications.6 this percentage is increased substantially in our population because of the complex socio-economic circumstances together with a lack of insight into the disease that often leads to incomplete or partial treatment in a large number of patients (fig. 6). the prevalence of tuberculosis in sub-saharan africa has also been on the increase due largely to the advent of the hiv epidemic.10 as a result we are now encountering more life-threatening complications of the disease, and post-tuberculous bronchiectasis is the major cause of massive haemoptysis in southern africa.9 small, single episodes of haemoptysis and chronic minor haemoptysis associated with ptb, though an important clinical problem, are generally managed well with anti-tb drugs. on the other hand, massive haemoptysis can be life threatening because of either volume depletion and circulatory collapse or, more often, aspiration and consequent asphyxiation. in this setting urgent intervention is required due to the high mortality rate (reportedly between 50% and 100%) associated with conservative management.11 surgery during an acute episode of massive haemoptysis is also associated with a high morbidity and mortality rate.8 bae is the preferred method of treatment for massive haemoptysis in patients who have diffuse lung disease or those who are not surgical candidates.12 bae should be considered early in the evolution of massive haemoptysis. bae for the short-term control of haemoptysis is effective in around 90% of cases. incomplete embolisation is usually the reason for early rebleeding. ten to twenty per cent of patients will develop late rebleeding within 1 year due to the proliferation of collateral vessels. repeated embolisation may be attempted for early or late rebleeding, however patients with localised lesions and adequate pulmonary function reserve should undergo surgical resection, as this is the most effective definitive therapy.12 in 90% of cases the source of haemoptysis is the bronchial circulation.13 thus familiarity with the vascular anatomy is important, especially since the anatomy of the bronchial arteries can be variable. the arteries usually arise directly from the proximal descending aorta. a useful landmark for accessing the arteries is in the region of the origin of the left main bronchus, most commonly between the levels of the t5 and t6 vertebrae. based on a study of 150 human cadavers in 1948 cauldwell et al.14 reported 4 classic bronchial artery branching patterns (fig. 7). it is important to note that in some cases branches of the bronchial artery supply the spinal artery. this makes it imperative to assess the bronchial circulation prior to embolisation in order to ensure that the spinal arteries are not inadvertently embolised. in these instances it is essential to perform the embolisation distal to the origin of the branches to the spinal artery. conclusion massive haemoptysis due to ptb can be effectively treated with bae when in a controlled environment, with the proper patient selection and with the appropriate expertise. it should not be considered definitive treatment in patients with lesions that are appropriate for surgical resection, as there is a significant recurrence rate associated with the procedure. 1. drooz at, lewis ca, allen te, et al. quality improvement guidelines for percutaneous transcatheter embolisation. j vasc interv radiol 2003; 14:s237-s242. 2. hayakawa k, tanaka f, torizuka t, et al. bronchial artery embolisation for haemoptysis: immediate and long-term results. cardiovasc intervent radiol 1992; 15:154-159. 3. jean-baptiste, e. clinical assessment and management of massive haemoptysis. crit care med 2000; 28:1642-1647. 4. knott-craig cj, oostuizen jg, rossouw g, et al. management and prognosis of massive haemoptysis. j thorac cardiovasc surg 1993; 105:394-397. 5. remy j, voisin c, dupuis c, et al. traitement des hemoptysies par embolization de la circulation systemfig. 7. diagrams illustrating the different types of bronchial arterial supply: type i, two bronchial arteries on the left and one on the right that manifests as an icbt (intercostal bronchial trunk); type ii, one on the left and one icbt on the right; type iii, two on the left and two on the right (one icbt and one bronchial artery); type iv, one on the left and two on the right (one icbt and one bronchial artery). fig. 6. treatment outcomes of ptb in africa compared with the rest of the world (world health organization, 2001). original article pg!!!!!!!!8-12.indd 11 6/18/07 4:22:11 pm original article 12 sa journal of radiology • june 2007 ique. ann radiol (paris) 1974; 17:5-16. 6. uflacker r, kaemmerer a, neves c, picon pd. management of massive haemoptysis by bronchial artery embolisation. radiology 1983; 146:627-637. 7. remy j, arnaud a, fardou h, et al. treatment of haemoptysis by embolisation of bronchial arteries. radiology 1977; 122:33-37. 8. conlan aa, hurwitz ss, krige l, et al. massive haemoptysis: review of 123 cases. j thorac cardiovasc surg 1983; 85(1): 120-124. 9. wong ml, szkup p, hopley mj. percutaneous embolotherapy for life-threatening haemoptysis. chest 2002; 121:95-102. 10. aaron l, saadoun d, calatroni i, et al. tuberculosis in hiv-infected patients: a comprehensive review. clin microbiol infect 2004; 10:388-398 11. najarian ke, morris cs. arterial embolization in the chest. j thorac imaging 1998; 13:93-104. 12. johnson lj. manifestations of haemoptysis. postgrad med 2002; 112: 101-113. 13. remy j, remy-jardin m, voisin c. endovascular management of bronchial bleeding. in: butler j, ed. the bronchial circulation. new york: dekker, 1992: 667-723. 14. cauldwell e, siekert r, lininger r, et al. the bronchial arteries: an anatomic study of 105 human cadavers. surg gynecol obstet 1948; 86:395-412. original article pg!!!!!!!!8-12.indd 12 6/18/07 4:22:11 pm case report 75 sa journal of radiology • september 2010 the second rssa short course on current ethical issues in radiology: 31 july 2010 dr clive sperryn following the success of the first short course in cape town in january, it was repeated in the investec auditorium in sandton. the workshop was well attended, with 210 delegates. the four topics (as in the january course) were: • ethical considerations in cochlear implant patients, presented by dr derrick wagenfeld • self-referral – a moral hazard, by dr clive sperryn • paediatric imaging: the ethics of radiation exposure, by professor savvas andronikou • patient confidentiality in clinical practice: is hiv status still relevant? by professor keymanthri moodley • kick-backs and perverse incentives, by dr bates alheit. this included a discussion of cases and actions taken by the rssa in such instances, by esme prins who also highlighted the new rules published by the hpcsa. these are accessible via the hpcsa website, which is included as a link on the rssa website. cpd ethics points were updated and very positive feedback received. many attendees experienced the convenience of the gautrain, and the venue will certainly be useful for future meetings in the area. congratulations to professor leon janse van rensburg, who again arranged an excellent course, and thanks to the consultus team for the organising, to covidien for sponsorship, and to investec for use of the auditorium and generous catering. the first rssa/sgr gastrointestinal radiology course: stellenbosch, 7 9 august 2010 professor steve beningfield this first combined meeting between the rssa and the society of gastrointestinal radiologists international education conference, held at the spier estate just outside stellenbosch, was a thoroughly wellorganised and enjoyable gathering, despite some chilly showers which doubled the flow of the adjacent eerste river overnight. proceedings were conducted under the guidance of some of the foremost international gi radiology experts – jay heiken, michael federle, sat somers (who originally hails from durban), kumar sandrasegaran, christine menias, (egyptian-born), erik paulson, jonathan kruskal (ex-uct, recently appointed chair at beth israel deaconess medical centre) and larry schwartz, who presented an update on the recist (response evaluation criteria in solid tumours) criteria. imaging in all the key abdominal regions, including the hollow muscular organs and solid viscera, was comprehensively covered in a refresher/update format, well-delivered for both the starters and experienced attendees. a wide range of pathological topics was covered, including blunt and penetrating trauma, benign disease and malignancy, inflammatory and infective entities, and surgical and iatrogenic issues. an excellent overview of the embryological basis of peritoneal anatomy clarified many of the confusing aspects of this complex area. logical walk-throughs of duplex doppler and ct techniques preceded some of the more detailed presentations. the techniques of grading splenic and liver injuries, and the preeminent role of conservative management, coupled with interventive radiology to deal with arterial injury, bile leaks and drainages, came through clearly. the value of the sentinel clot sign providing reliable evidence indicating the origin of the bleed (by virtue of the higher density clot in that area, versus the lesser density elsewhere) and haematocrit-sign of anticoagulation, were convincingly illustrated by case material. the role of imaging before and after liver transplantation was also presented, including split liver transplants and the attendant complexities, both surgical and radiological. liver masses, both benign and malignant, received attention, with the increasing value radioactive news the faculty, standing from left to right: professor steve benningfield (uct, scientific committee chair), dr christine menias (usa), professor jonathan kruskal (usa), professor erik paulsen (usa),professor sat somers (canada), dr clive sperryn (rssa president), professor mickael federle (usa), sitting: professor jay p heiken (sgr president) and professor leon j van rensburg (rssa congress chair). inset: dr kumar sandrasegaran (usa). welcome address by professor leon j van rensburg, rssa congress chair. case report 76 sa journal of radiology • september 2010 of hepatocyte-specific mri agents in focal nodular hyperplasia; increasing accumulation of this contrast implies biliary excretion and hence functional hepatocytes. disappointingly, well-differentiated hepatocellular carcinomas can behave in a similar fashion. a riveting presentation by jonathan kruskal, including in vivo video images of liver tumour deposition and angiogenesis in a rat model, highlighted some innovative research on the processes involved in tumour-seeding in the liver. in the rat, the hepatic veins are the site of tumour cell implantation. the evolution of angiogenesis in the subsequent expansion of the tumour implant was also graphically illustrated. another thought-provoking point was the fact that dna analysis of hcc recurrences in transplanted livers show that the cell lines are from the patient’s original tumour and not from the transplanted liver, implying that the cells remain elsewhere in the body until re-manifesting in the donor liver. the technically challenging realm of liver diffusion weighted imaging to analyse tumours and their response to therapy has a number of hurdles to overcome before becoming a mainstream clinical tool. biliary calculous disease (don’t forget the pre-contrast ct), imaging and intervention in iatrogenic laparoscopic cholecystectomy biliary injuries, and the benign and malignant spectrum of biliary disease, were presented, with particular emphasis on cholangiocarcinoma in its various forms (mass forming, periductal infiltrating and intraductal growing). also covered were some of the more important congenital biliary disorders such as caroli’s disease, as well as primary and other forms of sclerosing cholangitis. pancreatitis in both acute and chronic forms, with the new concept of ‘peripancreatic fat necrosis; (as distinct from a pseudocyst) was detailed. the expected appearances following pancreatic surgery were also shown in detail, this including imaging following a whipple's resection, frey’s procedure and other pancreatic drainages. the newly described entity of autoimmune pancreatitis was further clarified, reminding us to look for the loss of lobulation (giving rise to a sausage shape), a peri-pancreatic halo of tissue and other associated autoimmune conditions, with igg4 elevation. the subtypes of main-duct and side-branch intraductal pancreatic mucinous neoplasms (ipmns) with differing risks of malignancy give rise to management controversies. the imaging of the viscous gelatinous secretions was convincingly demonstrated. other cystic pancreatic lesions such as the serous and mucinous cystadenomas and the rarer solid papillary epithelial neoplasms were clarified. the major category of pancreatic adenocarcinoma was then tackled in a useful and pragmatic manner, emphasising the importance of carefully checking the portal and superior mesenteric veins (as well as the usual sma). a concentrated review of the art of localising pathology using ‘steam-powered’ barium imaging in the gut emphasised its continuing relevance, particularly given that the material was from the hallowed grounds of harvard university. small bowel imaging, inflammatory bowel disease, and refinements in the techniques of ct colonography all enjoyed separate presentations. unique looks at problems with enteral lines, swallowing pathology and pelvic floor imaging and defaecography provided expert advice on less common conditions. the looming roles of endoscopic ultrasound and capsule endoscopy were flagged. the important contribution of ct in the diagnosis of appendicitis was discussed, along with the problems and potential benefits of positive and negative contrast of the bowel in ct in general. hernia imaging by barium and ct techniques, as well as the imaging of small bowel obstruction, with particular attention being paid to closed loop configurations, was covered. the key observation here was of the tapering conjunction of two loops of bowel, indicating a twist or shared constriction. investigation of abdominal pain was tempered by increasing awareness of radiation risk. trauma in its blunt and penetrating forms, abdominal haemorrhage and mesenteric ischaemia were all addressed. the puzzling entity of non-occlusive mesenteric ischaemia (nomi) on the basis of mesenteric vasoconstriction, and the more mechanical causes of arterial or venous thrombosis, together with the less common vasculitides, were also covered. early detection of ruptured or threatening abdominal aortic aneursyms was mentioned by a few speakers, demystifying the highattenuating crescent and draped aorta signs, as well as the tangential radioactive news winners of the poster competition were (from left to right) dr arthur maydell (us, 3rd place), dr matthew goodier(on behalf of dr ernst boshoff) (wits, 1st place) and dr hein els (us, 2nd place). the rssa 2010 travel award winners were (from left to right) dr andrew lawson (uct, rssa award and sgr prize), and dr shaun scheepers (us, rssa award), with dr clive sperryn (rssa president). 77 sa journal of radiology • september 2010 calcification and calcium gap sign as early warnings of impending rupture included was an informative and well-illustrated local presentation on the local imaging of hiv and tb manifestations from marc mendelson and christelle ackerman. ‘boards’ cases tested the audience’s perceptions and lateral thinking, including the classic missing viscera, pointing us in the right direction e.g. no colon or testis or kidney. the number of posters from a good range of institutions was welcome, with three noteworthy oral presentations competing for the rssa award that was finally split, with andrew lawson also receiving the sgr award for his presentation on self-expanding metal stents. the turnout was excellent, particularly considering that the meeting was held over a long weekend. the scenic surroundings of spier with the excellent catering, conference planning and support by vendors added to the value of proceedings. this was yet another tribute to the organising skills and persuasive capabilities of our congress chairman, professor leon janse van rensberg. hats off to the rssa and sgr on this initiative, and welcome to the sgr in what will hopefully become a long-term relationship leading to the strengthening of our local abdominal imaging skills. abstracts of oral presentations at the first rssa/sgr gastrointestinal radiology course: stellenbosch, 7 9 august 2010 (presenting author first) imaging the rex recessus vein pre-operatively using wedged hepatic venous portography and the role of post-operative doppler ultrasound in rex shunts andrew lawson, groote schuur hospital paul rischbieter, themba hospital alp numanoglu, nicky wieselthaler, red cross war memorial children's hospital background. in children with extrahepatic portal vein obstruction (ehpvo), formation of a mesentericoportal bypass (rex shunt) restores hepatopedal flow, relieves portal hypertension and reduces variceal bleeding. the rex shunt is created by inserting a vein graft between the superior mesenteric vein and the umbilical segment of the left portal vein (rex vein). we report our experience with wedged hepatic venous portography (whvp) in the pre-operative evaluation of the rex vein and the post-operative ultrasound findings. methodology. a retrospective chart review was done in patients with ehpvo who had been considered for a mesoportal bypass between january 2001 and january 2010 at red cross war memorial children’s hospital. results. sixteen patients (13 boys, 3 girls, mean age 5, range 1 13 years) were considered for mesoportal bypass including 4 post reduced-size liver transplant patients. ten patients (62%) underwent whvp. the rex vein was clearly identified in 8 (80%) patients. a poorly canalised rex vein was reported in one of these cases yet found to be functionally viable at surgery. one rex vein was seen at surgery despite not being demonstrated at whvp. six mesoportal bypasses were performed without whvp of which 3 (50%) were successful. two of the patients who underwent whvp were post liver transplant patients; a patent rex vein was demonstrated in both. the average shunt sizes on the first post-operative day as documented using doppler ultrasonography was 7.8 mm with an average flow of 20.8 cm/s. the average flow rate increased to 27.1 cm/s after 1 month. all shunt occlusions (n=1) or partial thromboses (n=2) were detected by post-operative doppler ultrasound. conclusion. our series demonstrates the use of whvp as an effective tool with a sensitivity of 80% and specificity of 100% in the preoperative patency assessment of the rex vein. the sensitivity of whvp in patients who had undergone liver transplantation remains above 90%. doppler ultrasonography is useful for evaluating the size and flow rates in the post-operative shunt and is sensitive (100%) to the detection of early shunt thrombosis. abdominal lymphadenopathy in children with tuberculosis presenting with respiratory symptoms shaun scheepers, savvas andronikou, ayanda mapukata, peter donald, stellenbosch university and tygerberg hospital background. tuberculosis (tb) remains one of the leading causes of childhood morbidity and mortality. pulmonary tb (ptb) is the most common form; however, extrapulmonary tb is on the increase, with abdominal tb being most prevalent in the paediatric age group. the radiologic hallmark of primary tb in children is lymphadenopathy. ultrasound is a sensitive tool for detecting abdominal lymphadenopathy and may have an important role in the primary investigation of suspected tb in children. objectives. to determine the prevalence of abdominal lymphadenopathy in children with culture-positive ptb, presenting with respiratory symptoms; to determine whether the presence of abdominal tb could predict the presence of thoracic (hilar and mediastinal) lymphadenopathy, given the predictable course of lymphatic spread; and to define the role of ultrasound in the primary investigation of suspected tb in children. materials and methods. chest radiographs and abdominal ultrasound reports of 47 children, with culture-positive ptb and respiratory symptoms, were reviewed. the prevalence of abdominal lymphadenopathy and thoracic lymphadenopathy was determined. the relative effectiveness of ultrasound for predicting thoracic lymphadenopathy was determined using 2 x 2 tables. results. the prevalence of abdominal lymphadenopathy was 19% (n=9) as demonstrated on ultrasound. thoracic lymphadenopathy was reported in 70% of our study participants. abdominal ultrasonography had a sensitivity of 18% and a specificity of 79% for predicting thoracic lymphadenopathy when chest radiography was used as the radiological reference standard. abdominal ultrasound did, however, identify one additional case of lymphadenopathy that was not detected on chest radiography. thanks to dr hein els (tygerberg hospital) for the photo's. radioactive news radioactive news 78 sa journal of radiology • september 2010 conclusion. since patients were selected on the basis of having respiratory tb, the fact that 19% had abdominal lymphadenopathy is noteworthy. owing to its poor sensitivity and overall accuracy, ultrasound cannot be used in isolation for the prediction of thoracic lymphadenopathy. it is therefore suggested that ultrasound remains a valuable supplementary tool for diagnosing tb in children, due to its safety, portability and affordability. effectiveness of percutaneously placed self-expanding metal stents for palliation of malignant biliary obstruction andrew lawson (principle investigator), s burmeister, j krige, groote schuur hospital p rischbieter, themba hospital background. percutaneously placed self-expanding metal stents (sems) have been widely used for palliation of malignant biliary obstruction as an alternative to major bypass surgery or when endoscopic drainage is not technically feasible. we report our experience in the placement of sems at groote schuur hospital. methods. a retrospective chart review was done of patients who had percutaneously placed sems for obstructing biliary malignancy between may 2008 and february 2010. data included demographic information, level of biliary obstruction, efficacy and complications of sems insertion. boston scientific 6f, 69 mm*10 mm, wallstent sems were used. results. forty patients (23 men, 17 women, mean age 61, range 48 74 years) underwent percutaneous sems. stent insertion was successful in all patients. ten patients had obstruction at the level of the hilum, 5 in the mid common bile duct, and 25 in the low common bile duct. in 15 (37.5%) patients, sems were placed during the first attempt at biliary decompression. five (12.5%) patients required bilateral sems insertion. the mean serum bilirubin decreased from 313 µmol/l to 127 µmol/l (60% decrease) 5 days post stent insertion. mean hospital stay post stent insertion was 5.1 days. nine patients (22.5%) developed complications unrelated to sems insertion that included gastric outlet obstruction requiring endoscopic stenting (n=6), myocardial ischaemic events (n=2) and pneumonia (n=1). eight patients (20%) developed a procedure-related complication that included cholangitis after stent insertion (n=3), cholangitic liver abscess (n=1), subphrenic liver collection (n=1), bile leakage (n=1) and cholecystitis (n=2). stent occlusion occurred in 4 patients (10%) within a week as a result of tumour ingrowth (n=3) or biliary sludge (n=1). two (5%) stents occluded between 7 days and one month. three (7.5%) patients died during hospital admission owing to pre-existing cholangitic sepsis (n=2) and pneumonia (n=1). six patients (15%) survived less than one month, 10(25%) survived between 1 and 3 months, 8 (20%) survived between 3 and 6 months, and 9 (22.5%) survived beyond 6 months. seven (17.5%) patients from distant referral institutes were not seen after discharge. conclusion. these data demonstrate that percutaneously placed sems achieve satisfactory palliation with a low complication rate in a highrisk patient group with advanced malignant biliary obstruction. governance and cme sponsorships/educational grants at both corporate and individual levels. i am delighted to report that the rssa cpd fund that was established in 1999 will formally be constituted as the official rssa cme fund (an association not for gain) and will become the custodian of the rssa cme in south africa, namibia and botswana. the rssa cme fund currently supports the rssa travel award of r40 000 for the best paper by a registrar or junior radiologist, as well as the best poster prizes of r15 000 and r5 000 respectively. the r1 000 quiz case prize in the sajr is rssa-sponsored, and various ad hoc allocations have been made. there are other initiatives, such as financial support for departmental libraries and increasing the capacity of the sajr, under consideration. a major project under consideration is the establishment of a local rssa visiting professor programme whereby local experts conduct courses and visit departments for short periods. the current ethical issues courses are the prototype of such an initiative. i have a personal vision that the rssa cme fund will in the medium term be strong enough to fund one or more rssa chairs in radiology (the benefit to radiology of the privately sponsored chair of professor lotz at stellenbosch is widely acknowledged), and this concept should be expanded to support other full-time faculty, fellowship or research posts. during the presidential address, professor mcloud1 reminded radiologists that they found themselves in a ‘24/7’ environment in imaging, and that we face new demands from both patients and referring clinicians. global tele-medicine and tele-radiology are realities. they continue to grow as our profession evolves. the future of radiology hinges on the decisions we make today about how we educate and train in this new global environment. if we are to guarantee our specialty’s future, we must be viewed as representing the highest level of specialty and sub-specialty care. in conclusion: the new rssa cme programme aims to instill a new co-operative attitude among all radiologists, academic institutions and industry stakeholders in southern africa, with reliable and prestigious international partners. most importantly, the rssa cme fund must be financially strong enough to keep the programme affordable, sustainable and enjoyable, with contented members, all contributing to maintain radiology as a vibrant, growing and relevant specialty. leon janse van rensburg rssa congress chair 1. mcloud tc. trends in radiologic training: national and international implications. radiology http://radiology.rsna.org/content/256/2/343.full (accessed 26 july 2010). continuing medical education in radiology in south africa (continued from page 50) sajr 917 ct-guided biopsy of suspected malignancy: a potential pitfall s henderson,1 mb chb; w elsaify,2 mb chb, msc, frcsi, frcs (glasgow), frcs (general surgery) 1 department of radiology, victoria infirmary, glasgow, uk 2 department of endocrine surgery, james cook university hospital, middlesbrough, uk corresponding author: s henderson (steven.henderson.04@aberdeen.ac.uk) paragangliomas are rare catecholamine-secreting neuro-endocrine tumours that can arise from sympathetic or parasympathetic tissue. any manipulation of these tumours, without appropriate medical therapy, can result in excess catecholamine release leading to a catecholamine crisis. neuro-endocrine tumours must be considered prior to interventional biopsy of an unknown soft-tissue mass, and appropriate biochemical investigations should be performed in suspected cases to prevent catastrophic complications. s afr j rad 2013;17(4):139-140. doi:10.7196/sajr.917 a 70-year-old woman was referred for computed tomography (ct)-guided biopsy of an incidentally detected partially necrotic 35 mm para-aortic mass in the left infrarenal area (figs 1 and 2). immediately post procedure, she developed severe central chest pain. anterolateral myocardial infarction was confirmed on ecg and serum biochemistry, and the patient underwent percutaneous coronary intervention. the lesion was histologically identified as a paraganglioma. subsequent 24-hour urine collection showed markedly raised urinary adrenaline and noradrenaline as well as raised plasma normetadrenaline. the patient subsequently underwent laparotomy under appropriate medical therapy and the lesion was successfully excised. discussion background a phaeochromocytoma is a rare neuro-endocrine tumour of the paraganglionic chromaffin cells affecting 2 8 persons per million per year.1-6 although usually benign, around 10% are found to be malignant.1 , 2 , 7 they can arise in the adrenal medulla and also, in around 10% of cases, in the extra-adrenal paraganglionic cells.1 , 3-5 these extra-adrenal tumours are known as paragangliomas. paragangliomas can be classified as either sympathetic or parasympathetic, depending on the nature of the tissue from which they arise. parasympathetic paragangliomas arise principally in the thorax, head and neck and, in around 95% of cases, are not hormone secretors.4-6 sympathetic paragangliomas, on the other hand, can arise from anywhere along the sympathetic nervous system from the skull base to the prostate gland. most commonly, in around 75% of cases, they originate in the para-aortic region of the abdomen. they are frequently seen in the organ of zuckerkandl, near the inferior mesenteric artery origin.4 typically, these sympathetic tumours secrete catecholamines. it should be noted that phaeochromocytomas, arising from the adrenal medulla, are, by definition, sympathetic and therefore also always secrete catecholamines.2 , 4 , 6-9 clinical presentation and investigations the majority of paragangliomas present in the third to fifth decades.4 paragangliomas can cause symptoms as a result of direct pressure4 or because of hormone secretion. tumours secreting catecholamines often present nonspecifically with headache, palpitations and often paroxysmal hypertension.1 , 3 , 4 , 6 , 7 , 10 notably, however, it is a rare cause of hypertension with less than 0.1% of hypertensives being found to have a secreting tumour.1 , 10 in severe cases, arrhythmias, stroke, heart failure, pulmonary oedema, raynaud’s phenomenon and metabolic acidosis may be present.2-4 , 7 in up to 40% of cases, however, these tumours are asymptomatic and discovered incidentally during the course of investigation for an unrelated condition.2-4 , 6 if clinically suspected, diagnosis can be made with 24-hour urine collection demonstrating raised urinary catecholamines and metanephrines, which has a sensitivity of 87 90% and specificity >99%.6 serum catecholamines are also found to be raised on serum analysis although this is of less diagnostic benefit in modern practice owing to a high false positive rate.1 , 3 , 4 , 7 , 10 radiological investigation radiologically, ct, mri, metaidbenzylguanidine scan and pet imaging are all used in locating the primary lesion and the detection of metastatic disease.4-6 on cross-sectional imaging, the lesions are usually visible although they usually appear as a non-specific soft-tissue mass.10 ct-guided biopsy is generally contra-indicated in suspected cases of paraganglioma. such procedures can cause a surged release of catecholamines into the systemic circulation, which can lead to features of a catecholamine crisis − headache, sweating, elevated blood pressure, lesion haemorrhage, haemodynamic compromise, and limb and cardiac ischaemia.3 , 6 , 7 , 10 cases of death precipitated by catecholamine release following ct-guided biopsy of adrenal phaeochromocytomas have been reported.3 fig. 1. coronal ct slice through abdomen showing mass indicated by arrow. fig. 2. axial ct slice through abdomen showing mass indicated by arrow. conclusion thirteen per cent of patients with a catecholamine-secreting tumour will not be hypertensive and 8% will be completely asymptomatic. 3 these figures, coupled with the nonspecific imaging features, make it imperative that, prior to performing biopsy, paraganglioma is considered and, if considered a realistic possibility, excluded biochemically. this can be done with 24-hour urine collection as described above. there should be a low threshold for screening any extra-adrenal mass planned for intervention. certainly, all patients who undergo biopsy of an adrenal mass must be screened for phaeochromocytoma.10 in the case of a positive screening result, biopsy is unlikely to influence the diagnosis and would be actively contra-indicated. 1. rangaswamy m, kumar sp, asha m, manjunath gv. ct-guided fine needle aspiration cytology diagnosis of extra-adrenal phaeochromocytoma. j cytol 2010; 27(1):26-28. 1. rangaswamy m, kumar sp, asha m, manjunath gv. ct-guided fine needle aspiration cytology diagnosis of extra-adrenal phaeochromocytoma. j cytol 2010; 27(1):26-28. 2. welander j, soderkvist p, gimm o. genetics and clinical characteristics of hereditary phaeochromocytomas and paragangliomas. endocr relat cancer 2011;18:r253-r276. [http://dx.doi.org/10.1530/erc-11-0170] 2. welander j, soderkvist p, gimm o. genetics and clinical characteristics of hereditary phaeochromocytomas and paragangliomas. endocr relat cancer 2011;18:r253-r276. [http://dx.doi.org/10.1530/erc-11-0170] 3. sood sk, balasubramanian sp, harrison bj. percutaneous biopsy of adrenal and extra-adrenal retroperitoneal lesions: beware of catecholamine secreting tumours! the surgeon 2007;5(5):279-281. 3. sood sk, balasubramanian sp, harrison bj. percutaneous biopsy of adrenal and extra-adrenal retroperitoneal lesions: beware of catecholamine secreting tumours! the surgeon 2007;5(5):279-281. 4. lee ja, duh q. sporadic paraganglioma. world j surg 2008;32:683-687. [http://dx.doi.org/10.1007/s00268-007-9360-4] 4. lee ja, duh q. sporadic paraganglioma. world j surg 2008;32:683-687. [http://dx.doi.org/10.1007/s00268-007-9360-4] 5. havekes b, king k, lai ew, et al. new imaging approaches to pheochromocytomas and paragangliomas. clin endocrinol 2010;72(2):137-145. [http://dx.doi.org/10.1111/j.1365-2265.2009.03648.x] 5. havekes b, king k, lai ew, et al. new imaging approaches to pheochromocytomas and paragangliomas. clin endocrinol 2010;72(2):137-145. [http://dx.doi.org/10.1111/j.1365-2265.2009.03648.x] 6. gimm o, demicco c, perren a, et al. malignant pheochromocytomas and paragangliomas: a diagnostic challenge. arch surg 2012;397:155-177. [http://dx.doi.org/10.1007/s00423-011-0880-x] 6. gimm o, demicco c, perren a, et al. malignant pheochromocytomas and paragangliomas: a diagnostic challenge. arch surg 2012;397:155-177. [http://dx.doi.org/10.1007/s00423-011-0880-x] 7. bajwa sjs, bajwa sk. implications and considerations during pheochromocytoma resection: a challenge to the anaesthesiologist. indian j endocrinol metab 2011;15(suppl4):s337-s344. [http://dx.doi.org/10.4103/2230-8210.86977] 7. bajwa sjs, bajwa sk. implications and considerations during pheochromocytoma resection: a challenge to the anaesthesiologist. indian j endocrinol metab 2011;15(suppl4):s337-s344. [http://dx.doi.org/10.4103/2230-8210.86977] 8. pacek k. pheochromocytoma: a catecholamine and oxidative stress disorder. endocr regul 2011;45(2):65-90. 8. pacek k. pheochromocytoma: a catecholamine and oxidative stress disorder. endocr regul 2011;45(2):65-90. 9. levy mt, braun jt, pennant m, thompson ldr. primary paraganglioma of the parathyroid: a case report and clinopathologic review. head neck pathol 2010;4(1):37-43. [http://dx.doi.org/10.1007/s12105-009-0157-7] 9. levy mt, braun jt, pennant m, thompson ldr. primary paraganglioma of the parathyroid: a case report and clinopathologic review. head neck pathol 2010;4(1):37-43. [http://dx.doi.org/10.1007/s12105-009-0157-7] 10. paulsen sd, nghiem hv, korobkin m, caoili em, higgins ej. changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies. ajr 2004;182(4):1033-1037. 10. paulsen sd, nghiem hv, korobkin m, caoili em, higgins ej. changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies. ajr 2004;182(4):1033-1037. 104 sa journal of radiology • december 2010 pictorial interlude a 4-year-old girl was referred to tygerberg academic hospital with a long-standing history of an asymptomatic anterior chest wall ‘lump’. on physical examination, a bony mass was palpated in relation to the anterior aspect of the left 4th rib. plain radiography demonstrated anterior widening of the left 4th rib (fig. 1). fearing a sinister cause, a multidetector computed tomography (mdct) examination of the chest, with 3d reconstruction and volume rendering, was performed (fig. 2). a congenital bifid left 4th rib was demonstrated. discussion a bifid rib, or sternum bifidum, is a congenital abnormality of the anterior chest wall, with the sternal end of the rib cleft into two. it occurs in approximately 1.2% of the population and is usually unilateral. bifid ribs are frequently asymptomatic. a single bifid rib is most commonly a normal incidental finding discovered on chest radiography.1 it may be associated with gorlin-goltz basal cell nevus syndrome, a rare autosomal dominant condition characterised by multiple nevoid basal cell carcinomas, jaw cysts and bifid ribs. further features include other rib anomalies, deficiency of the lateral clavicle, mandibular hypoplasia, macrocephaly and mental retardation.1 a large number of disease processes frequently affect the chest wall in children, including congenital anomalies, inflammatory and infectious processes and neoplasms, both benign and malignant. congenital anomalies of the anterior chest wall are common. studies by donnelly et al.2 and wong et al.3 demonstrated a prevalence of 33% and 36% respectively for anatomical variations of the chest wall. in another study, donnelly et al. demonstrated that all patients who presented with asymptomatic lesions of the chest wall had benign conditions, most commonly a congenital anomaly.2 apart from congenital anomalies, other benign primary bony lesions include fibrous dysplasia, aneurysmal bone cyst and osteochondromata.4 infectious causes such as osteomyelitis, tuberculosis and fungal infection could also be considered, although these lesions are often more aggressive and rarely asymptomatic.2 the literature highlights the fact that malignant lesions of the chest wall are commonly aggressive and are often associated with symptoms such as pain, dyspnoea and local tenderness. plain radiography often reveals bony and pleural involvement in addition to chest deformities.2 it can be concluded for small, non-tender lesions isolated to the anterior chest wall that demonstrate no history of interval growth, that clinical examination and chest radiography may suffice, with ultrasound as backup.5 1. glass r, norton k, mitre s, kang e. pediatric ribs: a spectrum of abnormalities. radiographics 2002;22:87-104. 2. donnelly l, frush d, foss j, o’hara s, bisset iii g. anterior chest wall: frequency of anatomic variations in children. radiology 1999;212:837-840. 3. wong k, hung i, wang c, lien r. thoracic wall lesions in children. ped pulm 2004;37:257-263. 4. donnelly l, frush d. abnormalities of the chest wall in pediatric patients. ajr 1999;173:1595-1601. 5. donnelly l, taylor c, emery k, brody a. asymptomatic, palpable, anterior chest wall lesions in children: is cross-sectional imaging necessary? radiology 1997;202:829-831. beware the bifid rib! shaun scheepers, mb bch department of radiology, tygerberg hospital, w cape savvas andronikou, mb bch, fcrad, frcr, phd department of radiology, university of the witwatersrand, johannesburg fig 1. plain radiograph of the chest demonstrating a bifid 4th rib on the left. fig 2. a 3d mdct reconstruction, with volume rendering, confirming the presence of a left 4th bifid rib. radiological tips radiological tips 50 sa journal of radiology • july 2008 abstract magnetic resonance imaging (mri) is widely used as a non-invasive imaging modality for a wide variety of diseases and disorders. a patient placed in the mr machine for scanning is subjected to a powerful static magnetic field, rapidly varying gradient magnetic field, and radiofrequency field – in addition to the risk factors associated with gadolinium-based mr contrast agents. at present, there is no conclusive evidence for adverse biological effects in patients undergoing mri. however, a clear understanding of the various bioeffects associated with mri diagnostics is necessary to ensure the safety of patients as well as to justify its clinical use. introduction magnetic resonance imaging was introduced as a clinical imaging modality by lauterbur in 1972.1 since then, more than a hundred million diagnostic procedures have been completed worldwide, with relatively few major incidents or side-effects.2 a potential health hazard of mri is the influence of static, gradient and radiofrequency fields. although guidelines have been laid for maximum permissible limits for each of these fields, they have been regarded as ‘ … interim and somewhat arbitrary in nature’.3 numerous research studies conducted to date have failed to demonstrate any significant or unexpected hazards at currently used field strengths in clinical mri; however, the data are not comprehensive enough to assume absolute safety. bioeffects due to static magnetic field extensive studies on the bioeffects of the static magnetic field in mri diagnostics have been conducted over the past 30 years. most of these studies concluded that exposure to static magnetic fields produces no significant bioeffects. although there have been reports of harmful effects on isolated cells by static magnetic fields, no effect has been clearly verified as a scientific fact. the only well-established observation is the augmentation of t-wave amplitude and other nonspecific waveform changes on an electrocardiogram (ecg); these have been observed at static magnetic field strengths as low as 0.1 tesla.4 the increase in twave amplitude is proportional to the intensity of the static magnetic field. once the patient is removed from the magnetic field, these ecg abnormalities revert to normal. as no circulatory alterations appear in association with these ecg changes, no biological risks are believed to be connected with magneto-hydrodynamic effects in static magnetic field strengths up to 2 tesla.4 according to the latest guidelines from the usa’s food and drug administration (fda), clinical mr systems using static magnetic fields up to 8.0 tesla are considered ‘a non-significant risk’ for patients above the age of 1 month.5 bioeffects due to time-varying gradient magnetic fields during mr procedures, gradient magnetic fields may stimulate nerves or muscles by means of induction. at sufficient exposure levels, peripheral nerve stimulation is perceptible as ‘tingling’ or ‘tapping’ sensations. at gradient magnetic field exposure levels of 50 100% above perception threshold, patients may experience pain. at extremely high levels, cardiac stimulation may occur. however, the induction of cardiac stimulation requires exceedingly large gradient fields of a magnitude greater than those used for commercially available mr systems. studies performed on human subjects indicated that anatomical sites of peripheral nerve stimulation vary depending on the activation of a specific gradient (i.e. x-, yor z-gradient).6 stimulation sites for xgradients included the bridge of the nose, left side of thorax, iliac crest, left thigh, and lower back. stimulation sites for y-gradients included the scapula, upper arms, shoulders, right side of thorax, iliac crest and upper back. stimulation sites for z-gradients included the scapula, thorax, xyphoid, abdomen, iliac crest, and upper and lower back.6 typically, peripheral nerve stimulation sites were at bony prominences. according to schaefer et al.,6 since bone is less conductive than the surrounding tissue, it may increase current densities in narrow regions of tissue between the bone and the skin, resulting in lower nerve stimulation thresholds than expected. bioeffects due to radiofrequency fields the majority of radiofrequency (rf) power transmitted for mr imaging is transformed into heat within the patient's tissue as a result of resistive losses.7 the bioeffects associated with exposure to rf radiation are thus mainly related to the thermogenic effects. many investigations have been conducted to characterise the thermal effects of mr-related heating. investigators have quantified exposure to rf radiation by means of determining the specific absorption rate (sar). the sar is the massnormalised rate at which rf power is coupled with biological tissue and is typically indicated in units of watts per kilogram (w/kg).8 the relative amount of rf radiation that an individual encounters during an mr procedure is usually characterised with respect to the wholebody averaged and peak sar levels. the sar produced during an mr procedure is a complex function of numerous variables – frequency, the type of rf pulse used (e.g. 90° v. 180° pulse), the type of rf coil used, is mri as safe as we think? s wahab,1 md r a khan,2 ms, mch e ullah,1 md a wahab,3 md department of radiodiagnosis1/department of medicine,3 jawaharlal nehru medical college hospital, aligarh muslim university, aligarh, india department of paediatric surgery,2 postgraduate institute of medical education and research, chandigarh, india radiological reflections.indd 50 8/1/08 10:49:32 am radiological tips radiological tips 52 sa journal of radiology • july 2008 radiological tips 52 sa journal of radiology • july 2008 repetition time, the volume of tissue contained within the coil, and other factors.8 with regard to rf fields, the fda currently stipulates that mr procedures involving sar values above the following levels are a significant risk:8 • 4 w/kg averaged over the whole body for 15 minutes • 3 w/kg averaged over the head for 10 minutes • 8 w/kg averaged over the head or torso per gram of tissue for 5 minutes • 12 w/kg averaged over the extremities per gram of tissue for 5 minutes. response to mri-related heating depends on physical, physiological and environmental factors; these include duration of exposure, rate of energy transfer deposition, patient’s thermoregulatory system, the underlying health condition, and environmental conditions within the mr machine. certain human organs, such as the testis and the eye, are particularly sensitive to elevated temperatures owing to their reduced capability to dissipate heat. these are potential sites for harmful effects if rf radiation exposure during mri exceeds permissible limits.8 hazards associated with strong magnetic field one of the most significant potential hazards around a magnet is the ‘missile effect’. magnetic objects in close proximity to a magnet can be drawn towards it with sufficient velocity to cause injuries. a hazard also exists for patients with ferromagnetic implants or foreign bodies as a result of movement or dislodgement of the objects9 or their heating up as a result of current induction. hence, patients with cardiac pacemakers, cerebral aneurysm clips, implanted electrodes (e.g. cochlear implants, bone growth stimulators), shrapnel, bullets, etc. should be kept away from the electromagnetic field of an mr machine. safety considerations of mr contrast media mr contrast media are gadolinium-based compounds with paramagnetic properties; they develop a magnetic moment and thus alter the image of hydrogen atoms in a magnetic field. free gadolinium is toxic, so it is chelated with another compound that reduces its toxicity by altering its pharmacokinetics. various mr contrast agents are available on the market – gadodiamide (omniscan), gadopentetate (magnascan), gadoteridol (prohance), etc. – each with its own advantages and disadvantages. excretion of gadolinium is mainly by the kidneys and to some extent by the liver. according to the american college of radiology (acr) guidelines, no patient may be administered mr contrast agents without authorisation from a duly licensed physician. the overall incidence of adverse reactions for mr contrast agents ranges from approximately 2% to 4%;10 symptoms include nausea, emesis, urticaria, anaphylactoid reactions, hypotension, nonspecific ecg changes, injection site discomfort, localised oedema, taste change, etc. transient elevation of serum iron and bilirubin has been observed on laboratory investigations. mr contrast media should therefore not be administered to patients with known or suspected sickle cell anaemia, renal failure or hypersensitivity to gadolinium. it was recently noted that a few patients developed a very rare disease – nephrogenic systemic fibrosis (nsf) – that is seen only in patients with severely impaired renal function;11 it is associated with increased tissue deposition of collagen, resulting in fibrosis and thickening and tightening of the skin, usually involving the extremities but possibly also any part of the body. each of these patients had been administered a gadolinium-based mr contrast agent for mr imaging within a few weeks of the onset of the disease. accordingly, the fda recommends caution in administering gadolinium-based mr contrast agents to patients with moderate to end-stage renal disease, and also advises consideration of haemodialysis treatment immediately after administration of these agents to such patients. furthermore, there is no concrete information regarding the safety of these agents in pregnant women, lactating mothers or children up to 2 years of age. safety considerations for specific population subgroups as mentioned, certain population subgroups (such as infants, pregnant women, lactating mothers, and patients with cardiac and renal failure and anxiety and panic disorders) require special precautions. studies to date have not conclusively documented any deleterious effects of mr imaging on the developing fetus, but the evidence is not sufficient to presume absolute safety. as gadolinium-based mr contrast agents have been shown to cross the placenta, a decision to administer the contrast agent to pregnant patients should be accompanied by a well-documented and thorough risk/benefit analysis. lactating mothers are advised to express their breastmilk and not breastfeed for 36 48 hours after mr contrast administration, as these agents have been shown to be excreted in breastmilk in very low concentrations. infants and small children require sedation for mri, primarily because of their inability to remain motionless during the procedure. apart from the risks of sedation and anaesthesia, precautions are advised in administering mr contrast agents to infants <1 year old as their renal function is not completely developed. proper explanation of the procedure, improvements in mr design and relaxation methods can be helpful in psychological problems associated with mr procedures.8 miscellaneous safety considerations these include acoustic noise problems, asphyxiation and frostbite (an inadvertent system quench). during mr scanning, various acoustic noises are produced,12 the primary source of which is the gradient magnetic field activation during the mr procedure. problems associated with this noise include annoyance, heightened anxiety, and temporary and rarely permanent hearing loss.12 disposable ear plugs can be used to offer protection. in a case of system quench and release of helium and/or nitrogen gas all patients and health professionals should immediately evacuate the area. risk to mr workers from long-term exposure there are many reports in the literature that submit evidence of various adverse health effects associated with long-term exposure to electromagnetic fields, including elevated cancer risk and abortion rates. although these observations have not yet been supported by empirical proof, the perceived occupational risk requires exposure monitoring in mr imaging workers.13 conclusion mri, although a very useful clinical imaging modality, requires a clear radiological reflections.indd 52 8/1/08 10:49:33 am radiological tipsradiological tips knowledge and understanding of the various components of an mr system and its safety considerations, not only to ensure its prudent use for the benefit of patients but also to minimise the occupational risk to health care professionals and to provide efficient system operation. 1. lauterbur pc. image formation by induced local interactions: example employing nuclear magnetic resonance. nature 1973; 242: 190. 2. fornica d, silvestri s. biological effects of exposure to magnetic resonance imaging: an overview. http: // www. biomedical-engineering-online.com 2004, 3: 11 (accessed 14 august 2007). 3. magnetic resonance imaging. in: curry ts, dowdey je, murry rc, eds. christensen’s physics of diagnostic radiology. 4th ed. philadelphia, usa: lea & febiger, 1990: 470-504. 4. barnothy mf. biological effects of magnetic fields, vols 1 and 2. new york: plenum press, 1964 and 1969, respectively. 5. criteria for significant risk investigations of magnetic resonance diagnostic devices. rockville, md. center for devices and radiological health, 14 july 2003. 6. schaefer dj, bourland jd, nyenhuis ja. review of patient safety in time-varying gradient fields. j magn reson imaging 2000; 12: 20-29. 7. shellock fg. radiofrequency energy – induced heating during mr procedures: a review. j magn reson imaging 2000; 12: 30-36. 8. shellock fg, kanal e. bioeffects and safety. in: stark dd, bradley wg, eds. magnetic resonance imaging. 3rd ed. philadelphia, usa: mosby inc., 1999: 291-306. 9. kanal e, talagala l, shellock fg. safety considerations in mr imaging. radiology 1990; 176: 593. 10. harpur e, worah d, hals p, et al. preclinical safety assessment and pharmacokinetics of gadodiamide injection, a new magnetic resonance imaging contrast agent. invest radiol 1993; 28: 280. 11. grobner t. gadolinium: a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? nephrol dial transplant 2006; 21: 1104-1108; erratum in nephrol dial transplant 2006; 21: 1745. 12. mc jury m, shellock fg. acoustic noise and mr procedures: a review. j magn reson imaging 2000; 12: 37-45. 13. magnavita n, fileni a. occupational risk among magnetic resonance workers. analysis of literature. radiol med (torino) 1995; 89(5): 662-666. 53 sa journal of radiology • july 2008 interventional radiology secrets by david l. waldman; nikhil c. patel and wael e.a. saad isbn 1560536098 / 9781560536093 ä paperback hanley & belfus ä published september 2004 health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za noted expert steven d. waldman, md, jd, is the editor of this volume in the secrets series on one of the hottest topics in the field-interventional radiology. he provides clear, concise coverage of all of the basics as well as succinct, but thorough coverage of both vascular and nonvascular topics. the secrets popular question and answer format makes this title perfect for board review, as a clinical refresher, or as a quick-reference guide. features  hot topics include: gene therapy, noninvasive diagnosis and management of vascular disease, and cost-effective outpatient clinics.  offers guidance on all of interventional radiology� s most important concepts in the proven q&a format of the secrets seriesä.  features the author� s pearls, tips, memory aids, and � secrets� in the answer sections.  provides bulleted lists and algorithms for quick review.  presents a wealth of clear, crisp illustrations and images that bring the text to life. radiological reflections.indd 53 8/1/08 10:49:34 am case report case report 10 sa journal of radiology • april 2008 case report abstract we present a case of parameningeal embryonal rhabdomyosarcoma with the primary lesion arising in the middle and inner ear, with associated diffuse skeletal metastases and metastatic calcifications. introduction rhabdomyosarcoma is the third most common extracranial solid malignancy in children.1 parameningeal rhabdomyosarcoma arises in sites adjacent to the meninges. severe visceral metastatic calcification in this patient as a result of extensive bone metastases is described. case presentation a 5-year-old boy presented with a chronic non-productive cough and right hip pain. during the clinical work-up, he was found to have a left pre-auricular mass. his biochemistry test results showed corrected calmetastatic calcification as a result of extensive bone metastases in a paediatric patient with parameningeal embryonal rhabdomyosarcoma f ismail, mb bch z lockhat, ffrad (d) sa n khan, mb bs, fcrad (d) (sa) i van de werke, frcr narosha adroos, mb chb department of radiology, university of pretoria m sathekge, mb chb, mmed (nuclear medicine) department of nuclear medicine, university of pretoria m kruger, mmed paed, mphil, phd d reynders, mb chb, mrcpch fc (paed) department of paediatrics, university of pretoria figs 1a, 1b and 1c. axial computed tomography in soft tissue (a), in bony windows (b) and sagittal view (c) demonstrates the left temporal mass eroding the temporal bone, extending anterior to the pre-auricular region. there are lytic lesions involving the inner and outer table of the calvarium and a soft-tissue metastatic mass in the occiput. a c b pg 10-12.indd 10 4/16/08 9:40:16 am case reportcase report cium of 4.19 mmol/l and phosphate of 1.73 mmol/l, which were elevated in comparison with normal reference ranges. computed tomography (ct) (figs 1a, b and c) of the brain showed a large, destructive lesion in the left ear cavity, extending anterior to the pre-auricular region and posterior to the mastoid air cells. there was destruction of the left temporal bone and external ear canal. there were lytic lesions in the calvarium and a soft-tissue mass in the occiput. the radiological diagnosis considered at this stage was metastatic neuroblastoma. ct of the chest, abdomen and pelvis was suggested to locate the primary lesion. the scan demonstrated diffuse lytic bony metastases (fig. 2), involving all visible bones. the adrenal glands and para-aortic regions were normal, as were plain radiographs and ct of the lungs. a tc-99m-methylene diphosphonate (mdp) bone scan revealed diffuse metastatic visceral calcifications on the lungs, myocardium and stomach (figs 3a and b). these calcifications were not found on any of the other modalities. wedge biopsy of the pre-auricular lesion revealed a parameningeal embryonal rhabdomyosarcoma. the primary tumour mass was in the left middle and inner ear. the patient presented at a late stage with diffuse bone metastases. he died a few days after the ct scan. discussion rhabdomyosarcoma is the third most common extracranial solid malignancy in children. it is a tumour of primitive mesenchymal cells committed to skeletal muscle differentiation which can occur in a variety of organs. there are three main histological types, viz. embryonal, alveolar and botryoid.1 ‘parameningeal’ sites are those primary sites which are anatomically adjacent to the meninges. these sites include the middle ear, mastoid, ear canal, oral cavity, paranasal sinuses and infratemporal fossa.1,2 tumours originating in the middle ear and mastoid have a particularly bad prognosis. they are generally considered to be aggressive as they are in close proximity to vital structures, with a tendency to spread intracranially and the potential for meningeal involvement.2 primary lesions can lead to bone remodelling and destruction,2 as was the case with our patient. at presentation, 42% of cases have cervical adenopathy and 58% have distant metastases.3 metastatic calcification usually results from a deposition of calcified products in otherwise normal tissues as a result of hyperphosphataemia with or without hypercalcaemia. it may affect mainly the lungs, blood vessels, stomach, periarticular soft-tissue, kidneys and myocardium, and to a lesser extent skin and skeletal muscles of extremities.4 metastatic calcification affecting the myocardium and lungs is potentially lethal and is rarely detected before death, because of the absence of specific radiographic abnormalities.5 this lethal presentation was noted in our patient, as detected by tc-99m mdp bone scan, and indeed the patient died soon after diagnosis. 11 sa journal of radiology • april 2008 fig. 2. axial computed tomography scan in bone window at various levels demonstrating extensive lytic bone metastases. fig. 3a. tc-99m mdp whole body scan demonstrating diffuse visceral calcification in the lungs, myocardium and stomach, with no well-defined osteoblastic metastases noted. fig. 3b. tc-99m mdp spect-ct clearly localising the metastatic calcification in the lungs, myocardium and stomach. pg 10-12.indd 11 4/16/08 9:40:20 am case report case report 12 sa journal of radiology • april 2008 metastatic calcification may occur in patients with chronic renal failure, primary hyperparathyroidism, extensive bone malignancy, hypervitaminosis d, diffuse myelomatosis, and milk-alkali syndrome.4 metastatic calcification may occur in the presence or absence of hypercalcaemia and is therefore not a prerequisite. at autopsy, metastatic calcification is reported to be present in up to 60 80% of patients with chronic renal failure.6 however, calcification is rarely identified on conventional chest radiographs. mckay et al. recommend evaluation for bone metastases with tc99m mdp bone scan or plain skeletal radiographs, and measuring the serum levels of parathyroid hormone (pth) and pth-related peptide, as well as the levels of 25-(oh) vitamin d and 1,25-(oh) vitamin d as this will point to the common causes for hypercalcaemia of malignancy and help to rule out non-malignant causes of hypercalcaemia.7 the lung is one of the primary sites of metastatic calcification deposition and, although most patients are asymptomatic, respiratory failure may develop. the deposition of calcium may be diffuse, predominantly lobar, or predominantly apical. the choice of imaging techniques is important in making the diagnosis. a chest radiograph may not be effective in the detection of metastatic calcification.6 ct − in particular, high-resolution ct − may or may not detect metastatic calcification. when pulmonary abnormalities are present, they most commonly consist of parenchymal opacification or poorly defined infiltrates that may simulate pneumonia or pulmonary oedema. on ct scans, multiple pulmonary nodules with or without calcification and calcifications of the vessels of the chest wall may be seen, more frequently on high-resolution chest ct. other causes of pulmonary calcification include prior infections (tuberculosis, fungal or varicella), silicosis, sarcoidosis, metastatic tumour, rheumatic mitral valve disease, alveolar microlithiasis and idiopathic pulmonary ossification. however, these latter conditions do not usually display calcification of vessels of the chest wall.6 furthermore, on ct there is relative lack of interlobular septal thickening, since the predominant sites of calcium deposition seen on pathological examination are the alveolar septa and, to a lesser extent, the pulmonary arterioles and bronchioles. detecting pulmonary uptake of bone-seeking radiopharmaceuticals is a valuable adjunct to diagnosis, and it has been suggested that bone scanning be used to screen for occult pulmonary calcifications.8 the scintigriphic pattern of dense uptake in the lung, frequently associated with stomach and kidney uptake in general, correlates with the distribution of calcification found at autopsy.8 in conclusion, the case discussed revealed a parameningeal embryonal rhabdomyosarcoma with diffuse skeletal metastases and visceral metastatic calcifications, and highlights the fact that chest radiographs and ct findings may be nonspecific and that the use of tc-99m mdp scintigraphy is valuable to the diagnosis. in patients with hypercalcaemia, it is important to exclude other benign causes for hypercalcaemia, which are more easily treatable as hypercalcaemia of malignancy may be resistant to treatment. 1. wataru w, sutow md, lindberg md, et al. three year relapse-free survival rates in childhood rhabdomyosarcoma of the head and neck. report from the intergroup rhabdomyosarcoma study. cancer 1982; 49: 2217-2221. 2. greyling p, andronikou s, ackerman c, schulze oc, wieselthaler na. rhabdomyosarcoma – site matters. s afr j radiol 2006; 10: 8-13. 3. sutton d. a textbook of radiology and imaging. 7th ed. philadelphia: elsevier churchill livingstone, 2003: 1529. 4. centili a, miron sd, bellon em. nonosseous accumulation of bone-seeking radiopharmaceuticals. radiographics 1990; 10: 871-881. 5. casani f, villanueva-meyer j. myocardial and lung uptake of tc-99m-pyrophosphate using single photon emission computed tomography in a patient with end-stage renal disease and secondary hyperparathyroidism. int urol nephrol 1996; 28: 569-574. 6. hartman t, muller n, primack s, johkoh t, takeuchi n. metastatic pulmonary calcification in patients with hypercalcemia: findings on chest radiographs and ct scans. ajr 1994; 162: 799-802. 7. mckay c, furman wl. hypercalcemia complicating childhood malignancies. cancer 2006; 72: 256-260. 8. rosenthal d, chandler h, azizi f, schneider p. uptake of bone imaging agents by diffuse pulmonary metastatic calcification. ajr 1977; 129: 871-874. 9. wharam md. rhabdomyosarcoma of parameningeal sites. semin radiat oncol 1997; 7: 212-216. 10. daya h, chan hsl, sirkin w, forte v. pediatric rhabdomyosarcoma of the head and neck. is there a place for surgical management? arch otolaryngol head neck surg 2000; 126: 468-472. pg 10-12.indd 12 4/16/08 9:40:20 am article information authors: narosha adroos1 janet smal1 farhana e. suleman1 affiliations: 1department of radiology, university of pretoria, south africa correspondence to: farhana suleman email: fesuleman@gmail.com postal address: private bag x169, pretoria 0001, south africa dates: received: 28 nov. 2014 accepted: 11 apr. 2015 published: 14 aug. 2015 how to cite this article: adroos n, smal j, suleman fe. double trouble: bilateral cerebral involvement in sturge-weber syndrome. s afr j rad. 2015;19(1); art. #760, 4 pages. http://dx.doi.org/10.4102/sajr.v19i1.760 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. double trouble: bilateral cerebral involvement in sturge-weber syndrome in this pictorial interlude... open access • abstract • introduction • discussion • imaging findings • conclusion • competing interests • authors’ contributions • references abstract top ↑ sturge-weber syndrome, also known as encephalotrigeminal angiomatosis or meningofacial angiomatosis, is characterised in its classical form by a congenital, usually unilateral, ‘port-wine stain’ (capillary naevus) on the face, convulsions, typical intracranial calcification and some degree of mental retardation and hemiparesis. the clinical correlation of intractable seizures with the presence of bilateral intracranial disease has management and prognostic implications, thus making the presence of bilateral disease an important factor to all those involved in the management of the child with sturge-weber syndrome. introduction top ↑ sturge-weber syndrome (sws), an uncommon condition that forms part of the group of phakomatoses, is also known as encephalotrigeminal angiomatosis or meningofacial angiomatosis. it is characterised by a congenital, usually unilateral, ‘port-wine stain’ (capillary naevus) affecting the face, convulsions, typical intracranial gyral calcification and tram tracking (figure 1), some degree of mental retardation and hemiparesis.1,2 it is a progressive disorder, ultimately associated with profound neurological decline, the mechanism of which is incompletely understood. figure 1: axial nonenhanced computed tomography (nect) at two levels, (a) and (b), demonstrating the radiological hallmark of curvilinear calcification following a gyral pattern. bilateral disease may occur in up to 15% of patients diagnosed with sws; however, this probability is not mentioned in any of the widely used radiology, neurology or paediatrics textbooks.2 discussion top ↑ the aetiology of sws is thought to be the result of residual embryonal blood vessels and their secondary effects on surrounding brain tissue. a vascular plexus develops around the cephalic portion of the neural tube, under ectoderm destined to become facial skin. normally, this vascular plexus forms in the sixth week and regresses around the ninth week of gestation. failure of this normal regression results in residual vascular tissue, which forms the angiomata of the leptomeninges, face and ipsilateral eye. neurological dysfunction results from secondary effects on surrounding brain tissue, which include hypoxia, venous occlusion, thrombosis, infarction, or vasomotor phenomenon.1 patients with sws are particularly susceptible to brain injury as a consequence of status epilepticus and require optimal seizure control. bilateral cutaneous involvement is seen in 32.5% of cases as compared to bilateral intra-cranial involvement seen in only 7.5% of cases. patients with bilateral intracranial disease are usually more severely affected with intractable seizures; therefore the diagnosis of unexpected bilateral sws is clinically important as urther ischaemic injury reduces the cortex to a calcified non-functioning mantle.3 diagnosis of sws is usually made on clinical findings, and imaging is useful for confirming the diagnosis. in severe cases, the seizures become resistant to medical treatment and surgery may be considered, thus making diagnostic imaging essential to define the full extent of the disease. according to hoffman et al.,4 patients with seizures associated with sws who do not respond to medication can be candidates for surgery in the form of hemispherectomy to remove the seizure focus or less radical lobar surgery. sectioning of the corpus callosum has been described in an attempt to prevent extension of seizures into the normal hemisphere from the abnormal side.5 in such cases, imaging is very important, firstly to exclude or confirm the presence of bilateral sws, and secondly to determine the full extent of leptomeningeal and cortical disease that would facilitate less radical resection.6 imaging findings top ↑ magnetic resonance imaging (mri) post contrast enhancement is the most accurate imaging study to demonstrate the extent of the pial enhancement, as cortical calcifications usually mask the degree of enhancement on computed tomography (ct) scans. the choroid plexus is frequently enlarged with a positive correlation to the extent of the leptomeningeal angioma (figure 2). the underlying white matter typically shows accentuated t2 shortening.7 figure 2: coronal t1 post gadolinium image demonstrating enhancement of the left choroidal angioma, marked pial enhancement of the right cerebral hemisphere and intense enhancement and enlargement of the right choroid plexus, in keeping with active disease in the right hemisphere. no contrast enhancement is seen in the left hemisphere in the regions of the calcifications, in keeping with ‘burnt out’ disease on the left. unilateral cerebral hemisphere involvement eventually becomes atrophic, with dystrophic calcifications in most cases (figure 3). cranial asymmetry often results from the cerebral hemiatrophy. there is thickening of the ipsilateral calvarium and enlargement of the paranasal sinuses and mastoid air cells owing to the lack of brain growth on the affect side. figure 3: axial t1 inversion recovery (a) and axial t2 flair (b) images demonstrating atrophy of the left cerebral hemisphere and low signal in the left occipital lobe (arrow). about 30% of patients with sws have angiomas of the choroid and sclera (figure 4). the presence of choroidal angioma correlates with the presence of bilateral disease and the extent of facial involvement; it does not correlate with the size of the intracranial pial angioma. figure 4: axial nect (a) and corresponding axial t2wi (b) images demonstrating high density (grey arrow) and low signal (white arrow) respectively along the choroid of the left globe in keeping with a choroidal angioma. conclusion top ↑ bilateral intracranial calcification in sws has been described only occasionally, and is not commonly referred to in the widely used radiology, neurology or paediatric texts. the clinical correlation of intractable seizures with the presence of bilateral intracranial disease has management and prognostic implications, thus making the presence of bilateral disease an important factor to all those involved in the management of the child with sws. competing interests top ↑ the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions top ↑ n.a. (university of pretoria) wrote the original manuscript. j.s. (university of pretoria) identified the cases and contributed to the literature review. f.e.s. (university of pretoria) prepared the images and was responsible for final editing of the report. references top ↑ takeoka m, riviello jr jj. sturge-weber syndrome. medscape. 05 january 2010 [cited 2011 jan 11]. available from: http://www.emedicine.medscape.com/article/1177523-overview bolthauser e, wilson j, hoare rd. sturge-weber syndrome with bilateral intracranial calcification. j neurol neurosurg psychiatry. 1976;39:429–435. http://dx.doi.org/10.1136/jnnp.39.5.429 evans al, widjaja e, connolly dja, griffiths pd. cerebral perfusion abnormalities in children with sturge-weber syndrome shown by dynamic contrast bolus magnetic resonance perfusion imaging. pediatrics. 2006;117:2119–2125. http://dx.doi.org/10.1542/peds.2005-1815 hoffman hj, hendrik eb, dennis m, armstrong d. hemispherectomy for sturge-weber syndrome. childs brain.0 1979;5:233–248. http://dx.doi.org/10.1159/000119821 rappaport zh. corpus callosum section in the treatment of intractable seizures in the sturge-weber syndrome. childs nerv syst. 1988;4:231–232. http://dx.doi.org/10.1007/bf00270919 griffiths pd, boodram mb, blaser s, armstrong d, gilday dl, harwood-nash d. 99mtechnetium hmpao imaging in children with the sturge-weber syndrome: a study of nine cases with ct and mri correlation. neuroradiology. 1997;39: 219–224. http://dx.doi.org/10.1007/s002340050398 barkovich ja. pediatric neuroimaging. 4th ed. philadelphia: lippincott williams & wilkins, 2005; p. 476–481. review article review article 28 sa journal of radiology • july 2008 review article abstract background. studies indicate that computed radiography (cr) can lead to increased radiation dose to patients. it is therefore important to relate the exposure indicators provided by cr manufacturers to the radiation dose delivered so as to assess the radiation dose delivered to patients directly from the exposure indicators. aim. the aim of this study was to investigate the performance of an agfa cr system in order to characterise the dose indicators provided by the system. method. the imaging plate response was characterised in terms of entrance exposure to the plate and the digital signal indicators generated by the system (sal – scanning average level; and lgm – logarithmic median) for different beam qualities. several exposures were performed on a mammography unit, and the digital signal, expressed in terms of sal and lgm for each image, was correlated with the entrance exposure on a standard american college of radiology (acr) phantom. from this correlation, a relationship between the agfa dose indices (sal and lgm) and the average glandular dose (agd) in mammography could be established. an equation was derived to calculate the agd delivered to the patient as a function of the exposure indicator, lgm, and the kv. results. the results indicated that the measured agd at 28 kv for a standard breast thickness during routine calibration with the acr phantom was 1.58 mgy (lgm=1.99). this dose value lay within 1.5% of the value calculated using the derived equation for a standard perspex thickness of 4.2 cm using the automatic exposure control (aec) (1.56 mgy). the standard error in using this equation was calculated to be 8.3%. introduction in cr, the displayed image density is automatically adjusted by system image processing, independently of the applied dose. in fact, this is one of the key advantages of this technology; it helps to reduce the retake rate significantly, but at the same time this feature may obscure occasional or systematic underor over-exposure. while in conventional radiography the amount of exposure is directly related to the average optical density, in cr it determines the signal-to-noise ratio (snr), and not the image density. higher absorbed doses result in better snr. this is desired but, over the long term, there is a risk of a gradual drift to higher absorbed doses, as the higher exposed images tend to appear superior.1 current clinical practice dictates that absorbed doses in radiography be minimised, while simultaneously ensuring sufficient diagnostic information in the image, and reducing the need for repeat exposures.2 the cr plate does not accumulate information about the tube current and time, mas or tube potential, as kvp is used; it only stores energy proportional to the amount of radiation it receives. the amount of radiation that reaches the detector is influenced by the tube potential, filtration, patient thickness, exposure time, filament current and other factors.3 to quantify the response of the plate, two indices (sal and lgm) are defined by agfa and are derived from the pixel values in the histogram of the digital image.4 these exposure indices are useful if the relationship with the air kerma is understood. the number of pixels with the same exposure or signal level is segmented from the histogram of pixel gray-scale intensities by algorithms that remove the directly exposed area on the image and the scattered radiation to distinguish relevant from irrelevant data. the sal is calculated as the average signal level (grey-scale value) in the image region of interest (‘useful’ peak in the histogram) and has a square-root relationship to the signal or the entrance kerma on the imaging plate:5 where α0 is a proportionality factor that depends on the beam quality (i.e. the radiation spectrum),6 s represents the readout speed class, and s0 is the reference speed class equal to 200. the square root in both equations is due to the agfa-specific analogic filter applied to the photomultiplier output. lgm is the median of log (converted pixel values) in the image region of interest (roi) and is an indication of the dose level. it is directly related to sal. in the case of a flat-field image, the lgm is specified as: a change of 0.3 in the numerical value of lgm corresponds to a change in exposure by a factor of 2.6 photostimulable phosphor plates behave as energy-integrating detectors, and the output signal is proportional to the total deposited energy.5 to characterise the response of the plate for different exposure conditions, it is useful to correlate the output pixel value (sal) with the entrance surface dose (esd) and also the average glandular dose to the breast. however, the exposure level indicated by agfa is not directly related to patient esd, but to the light emitted during the plate read-out process. nevertheless, when similar patient thickness and x-ray beam quality are used, the dose indicators may be related to the esd.7 in work involving cr exposure indicators, the behaviour of the dose indicators of an agfa cr system as a function of delivered dose has been investigated. the imaging plate response was characterised in terms of exposure and in terms of the digital signal for different beam qualities applicable in mammography using a phantom with standard thickness. from the physical characterisation of the cr system, it was possible to establish a relationship between the agfa dose indicators and average glandular dose delivered to patients undergoing mammography examinations. an equation was derived to convert the exposure indicator lgm, to agd. this equation could provide users with a guide to the absorbed dose delivered as a function of the agfa indices and the tube kv. computed radiography exposure indices in mammography liebner koen, bmed (hons) charles herbst, phd william rae, mb bch, phd department of medical physics, university of the free state, bloemfontein 0 0 sal  kerma (1) s   s = ⋅ =  lg m 2 log(sal) 3.9478 (2)= × −  computed radiography.indd 28 8/1/08 11:30:56 am review article review article material and method the philips mammo diagnostic uc unit which we used contained a mo/mo target/filter combination and was calibrated using the procedure described in the acr manual before measurements.8 the standard acr mammographic phantom simulated an average patient with breast thickness of 4.2 cm and 50% adipose/50% glandular composition. an ionisation chamber and electrometer (nero 8000 max) calibrated at mammographic x-ray beam energies (with a calibration factor traceable to international standards) were used to measure the entrance exposure in roentgens. the ionisation chamber was positioned in the x-ray field, beside the phantom, with the centre of the chamber level with the top surface of the phantom (as described by the acr’s mammography quality control manual).8 therefore, the phantom was used to measure typical entrance exposures for an average patient and to calculate the associated average glandular dose. the characterisation was performed by doing entrance exposure measurements using the manual technique, fixing the kilovoltage and varying the mas, and then repeating the procedure for a series of kilovoltages: 23, 25, 26, 28, 30, 32 and 34 kvp. the digital phantom images were obtained by means of an agfa adc compact reader using a readout class of 50.1 for each image, the sal was evaluated as the average value of the pixels in a roi with a dimension of approximately 10×10 cm2 centred in the middle of the plate. for each kv, several exposures were performed, ranging from about 25 to 160 mas. conversion factors, depending on beam quality and filter/target combination,8 were used to convert entrance exposure to agd. beam quality in terms of half-value layers in mm of aluminium were measured using a standard procedure.8 subsequently, agd was plotted as a function of sal and lgm, with a minimum of 6 data points for each graph, respectively. the relationship between agd and sal was found to be quadratic; microsoft excel 2003 was used to determine this relation and optimise the fitted points. the relationship between agd and lgm was found to be exponential. in combining the fitted equations at different beam qualities and plotting the fitted parameters against kv, it was possible to obtain a unified equation for average glandular dose as a function of sal/lgm and kilovoltage. the standard error in the fitted parameters was calculated. results in table i, the conversion factors for converting entrance exposure to average glandular dose are shown for each kv and half-value layer, respectively. as indicated in the table, the voltage ranges from 23 kv to 34 kv, and the corresponding half-value layers varied between 0.27 and 0.36 mm of aluminium. this information was used to look up the average glandular dose conversion factors from the acr manual.8 in fig. 1, plots of average glandular dose versus sal for the kv range are displayed. the results show that sal, as expected from equation 1, has a quadratic relationship to the exposure on the imaging plate. the respective regression equations in fig. 1 can be expressed as a single equation: 29 sa journal of radiology • july 2008 table i. kilovoltage (kv) range and half-value layer (hvl) in millimetres of aluminium (al); information used to calculate average glandular dose from entrance exposure glandular dose conversation kv hvl (mm al) factor dgn (mrad/r)[5] 23 0.27 135 25 0.29 148 26 0.29 150 28 0.32 166 30 0.33 173 32 0.35 182 34 0.36 188 table ii. summary of equation coefficients from the regression equations obtained from regression fits shown in figs 1 and 2 sal equation coefficient igm equation igm equation kv a [mgy x 10-8] coefficient b coefficient c 23 2.48 0.021 2.32 25 2.12 0.019 2.30 26 1.89 0.016 2.35 28 1.82 0.016 2.31 30 1.67 0.013 2.38 32 1.42 0.012 2.33 34 1.26 0.011 2.31 fig. 1. agd v. sal on the plate at different kvp values. computed radiography.indd 29 8/1/08 11:30:57 am review article review article 30 sa journal of radiology • july 2008 review article where a is a parameter dependent on beam quality. the parameter values for different kilovoltages are given in table ii and are plotted in fig. 3. fig. 2 shows plots of average glandular dose versus lgm for different kilovoltages. the results show that lgm has an exponential relation to exposure on the imaging plate. from regression fits, the relationship between agd and lgm can be expressed as: where b is a parameter dependent on beam quality and c is effectively a constant. these parameters are given in table ii and also plotted in figs 4 and 5, respectively. the relationship between coefficient ‘a’ and kilovoltage is as follows (regression through data points in fig. 3): equation 5 can be substituted into equation 3 to calculate agd in terms of sal and kv: the standard error in equation 6 was calculated to be 5.1%. from fig. 4, the regression equation is as follows: when substituting this into equation 4, agd in terms of lgm can then be expressed as: the standard error in this equation was calculated to be 8.3%. one standard deviation is shown in the figure; therefore, one would expect 67% of the values to be within the standard error indicated by the lines shown. discussion the use of a standard breast phantom for entrance dose estimation does not reflect the true skin dose for larger or smaller breasts. however, this aspect does not influence the purpose of this study to investigate the relationship between average glandular dose and agfa dose indices. our experimental results demonstrate the dependence of exposure indices on the amount of energy deposited onto the receptor. we were forced to acquire data for individual kvps during separate sessions, as it was impossible to complete all the measurements in one day. in an effort to minimise systematic errors, the experimental setup was duplicated as reproducibly as possible. the results show that a well-defined square root relationship exists between sal and agd, and that this relationship is dependent on fig. 2. agd v. lgm on the plate at different kvp values. fig. 3. a plot of the sal equation coefficient ‘a’ as a function of kv, as indicated in equation 3 (correlation factor r2=0.9763). fig. 4. lgm equation coefficient ‘b’ (equation 4) as a function of kv (r2=0.944). fig. 5. lgm equation coefficient ‘c’ (equation 4) as a function of kv. average value=2.329. c lg magd(mgy) b e (4)×= ×  6 1.623a 395.71 10 kv (5)− −= × ×  6 1623 2agd(mgy) 395.71 10 kv (sal) (6)− −= × × ×  1.6865 2.329 lg magd(mgy) 4.1693 kv e (8)− ×= × ×  2agd(mgy) a sal (3)= ×  1.6865b 4.1693 kv (7)−= ×  computed radiography.indd 30 8/1/08 11:30:59 am review article review article 31 sa journal of radiology • july 2008 the kilovoltage used. the dependence on kilovoltage was investigated by doing measurements at 7 different clinically relevant kv settings. graphs in fig. 1 have excellent correlation coefficients with a mean r2 value of 0.9998±0.0003. similarly, lgm has an exponential relationship to agd. once again, correlation coefficients showed a mean value of 0.9997±0.0002 for all kvs. the unified equations allow estimation of agd for a standard breast thickness for any kv setting from the sal or lgm, thus providing users with guidelines for the average glandular dose delivered to patients during cr mammography. at our centre, agfa dose monitoring statistics1 indicated that the average lgm value for all the exposure types fluctuates around 2. from the measurements, an lgm value of 2 is equivalent to an average glandular dose of 2.48 mgy (23 kv); 1.89 mgy (25 kv); 1.58 mgy (28 kv); 1.45 mgy (30 kv); 1.29 mgy (32 kv); and 1.21 mgy (34 kv), respectively. in using equation 8, the agd for 28 kv is calculated to be 1.56 mgy for an lgm value of 2. this value is within 1.5% of the measured value (1.58 mgy). the standard error on the equation is 8.3%; therefore, estimation of dose could fluctuate around ±8.3% from the true average glandular dose delivered to the patient. this result is understandable and still useful, as it is important to recognise that the exposure indices are only an estimate of the incident exposure on the imaging plate, and are not an absolute value.6 furthermore, as the agd is doubled, e.g. from 1 mgy to 2 mgy (28 kv), the corresponding increase in lgm value is 0.3 (from lgm=1.79 to lgm=2.09), as mentioned by other authors.1,2 one should note that the agd is an indication of the dose to the glands measured in a phantom that is a breast equivalent and is only valid for specific kv and mas settings; it cannot be directly applied to the human breast. the equations derived in this paper relate agd to the sal value received from an image. the danger exists that users may be tempted to use the sal and the equation to calculate a particular patient dose. the change in histogram may change the sal value and therefore the relationship. we thank the department of radiology at universitas hospital, bloemfontein, for accommodating our study in the department. 1. agfa-gevaert: adc compact dose monitoring software user manual. mortsel, belgium: agfa-gevaert, 1998. 2. schaetzing r. management of pediatric radiation dose using agfa computed radiography. pediatr radiol 2004; oct. (suppl 1): s207-s214. 3. willis ec. computed radiography: a higher dose? pediatr radiol 2002; 32: 745-750. 4. adc application manual – general radiology, 2nd ed. mortsel, belgium: agfa-gevaert, 2005. 5. mazzocchi s, belli s, busoni c, et al. aec set-up optimization with computed radiography imaging. radiat prot dosimetry 2005; 117(1-3): 169-173. 6. samei e, seibert ja, willis ce, et al. acceptance testing and quality control of photostimulable phosphor imaging systems. report of the american association of physicists in medicine (aapm), task group 10 (1998). 7. sanchez jacob r, vano-galvan e, vano e, et al. optimizing the use of computed radiography in pediatric chest imaging. j digit imaging 2007; september: 1-10. 8. mammography quality control manual, revised ed. reston, usa: american college of radiology, 1994. radiology positions canada radiologist: sk radiology associates of regina is seeking radiologists to join 16 member sole practice in regina. rar serves two acute care hospitals, its two clinics as well as numerous outside clinics and rural hospitals. canadian royal college certification or eligibility to write exam preferred. locum positions are also available. regina has a booming economy, no traffic and an international airport. contact larry kliman, business manager tel: 306-529-3305 or e-mail larry@rarsk.com computed radiography.indd 31 8/1/08 11:30:59 am pictorial essay pictorial essaypictorial essay 100 sa journal of radiology • december 2008 introduction appendicitis is one of the most common causes of abdominal pain requiring surgery. early diagnosis and management are essential to reduce morbidity and mortality. imaging is valuable in the diagnosis of cases that are clinically atypical. imaging also allows evaluation of the complications of appendicitis, which include perforation, peri-appendiceal abscess formation and portal pyaemia. in certain circumstances, conservative treatment of complicated appendicitis with percutaneous drainage is appropriate. case 1 a 62-year-old man with no past medical history of note presented to a secondary level hospital with a 5-day history of severe abdominal pain more severe on the right, nausea, vomiting and diarrhoea. the patient consulted 2 general practitioners prior to presentation, and analgesia and antibiotics were prescribed. on examination, he was dehydrated with a tachycardia of 125 bpm and a temperature of 37.90c. the abdomen was distended and diffusely tender, with guarding on the right side. no rebound was elicited. dilated loops of small bowel were visible on the abdominal radiograph. white blood cell count was normal. renal failure was evident with urea = 28 mmol/l and creatinine = 342 µmol/l. the differential diagnosis included appendicitis, diverticulitis or perforated colonic neoplasia. the patient was initially treated with intravenous (iv) antibiotics and fluid, with some improvement in symptoms. imaging of appendicitis himal gajjar, mb chb anthony levy, mb chb, fcrad division of diagnostic radiology, groote schuur hospital, observatory, cape town fig. 1. ct scan of the abdomen. gas and fluid-containing collection (arrow) present posterior to the caecum (arrowhead). the appendix itself is not visualised separate to the collection. adjacent mesenteric stranding is evident. fig. 2. ct scan of the abdomen. retrocaecal collection (arrowhead) containing a high-density calculus consistent with an appendicolith. the caecum is indicated by the arrow. fig. 2. is superior to fig. 1. fig. 3. ultrasound of the abdomen. distended appendix containing appendicolith. adjacent low echogenicity fluid collection (arrow) and echogenic inflamed fat (arrowhead). although not indicated in the figure, the appendiceal diameter was 12 mm. imaging.indd 100 12/5/08 11:25:14 am pictorial essaypictorial essay an abdominal ultrasound performed 3 days later was considered normal. owing to lack of resolution of symptoms, a computed tomo graphy (ct) scan of the abdomen was performed with oral contrast. this revealed a retrocaecal gas and fluid collection (fig. 1) containing an appendicolith (fig. 2) which extended from the expected origin of the appendix to the subhepatic space. a diagnosis of peri-appendiceal abscess formation was made. the patient was treated with percutaneous drainage with a good result. case 2 a 60-year-old man with a background of type 2 diabetes mellitus presented to groote schuur hospital, complaining of a 1-week history of right iliac fossa pain and diarrhoea. four days prior to this presentation, he was assessed as having gastroenteritis and treated with intravenous rehydration. on examination he was apyrexial, with a tachycardia of 100 bpm. a tender mass was present in the right iliac fossa. laboratory investigations revealed a raised white cell count of 13.9 x 109/l. on ultrasound imaging, a distended non-compressible appendix was present, containing an appendicolith (fig. 3). an adjacent fluid collection was present with surrounding inflammatory fat stranding. a ct scan with oral and intravenous contrast was performed to delineate the extent of the collection. again, the appendicolith (fig. 4) was well seen, with the distended appendix present inferior to this (fig. 5). the patient was treated with percutaneous drainage with a good clinical result. a colonoscopy excluded a caecal neoplasm as a cause for appendiceal obstruction. discussion acute appendicitis is one of the most common surgical emergencies in both the adult and paediatric populations. it occurs when the appendiceal lumen is obstructed, resulting in accumulation of fluid and subsequent inflammation and infection. the inflammation can progress, with resultant appendiceal rupture.1 delayed diagnosis has serious consequences. these include appendiceal rupture, peri-appendiceal abscess formation, peritonitis and death.2 traditionally, the diagnosis has been based on clinical assessment, with a reported accuracy of 71 97%.3 owing to the dire consequences of appendiceal perforation, a negative laparotomy rate of 20% has been regarded as acceptable.4 imaging can assist in the diagnosis of appendicitis and is usually indicated when the clinical signs are atypical. the goal of imaging is to facilitate the diagnosis of appendicitis or suggest an alternative diagnosis without delaying management. imaging can also be used to evaluate complications of appendicitis and to guide percutaneous intervention. traditionally, plain film radiography and barium enema were the main imaging modalities used. however, owing to insensitivity and lack of specificity, these are no longer utilised specifically in the diagnosis of appendicitis. ultrasound evaluation of appendicitis was first described by puylaert in 1986.5 he described a technique termed ‘graded compression ultrasound’. this involved using a high-frequency linear probe for imaging which provides excellent resolution but poor penetration of tissues. the patient is initially asked to localise the site of maximal tenderness, allowing a more focused ultrasonic examination. gradual compression of the right iliac fossa both displaces overlying small-bowel loops which may obscure visualisation and brings the probe closer to the appendix. the compression is usually well tolerated. it is important to visualise the entire appendix as isolated appendicitis of the appendix tip is well described.2 a non-compressible appendix with a diameter >6 mm confirms appendicitis. echogenic inflamed surrounding mesenteric fat and the presence of an appendicolith strengthens diagnostic certainty. in a meta-analysis conducted between 1986 and 1994, orr et al. reported a sensitivity of 85% and a specificity of 92% among adult and paediatric populations.6 sonography has the advantage of being quick to perform, without any need for patient preparation. mobile examinations are possible. the most important advantage is the absence of ionising radiation in imaging, which has resulted in ultrasound being the initial imaging choice for appendicitis in many centres, especially in paediatric and pregnant patients. evaluation of pelvic structures can also be performed in females, as gynaecological pathology is an important differential in the diagnosis of appendicitis. unfortunately, ultrasound is highly operator-dependent and, even with good technique, the appendix may not be visualised. appendiceal perforation may also result in false-nega101 sa journal of radiology • december 2008 fig. 4. ct scan of the abdomen. the inflamed base of the caecum is seen (arrowhead) with an appendicolith present within the appendix (arrow). extensive periappendiceal inflammatory fat stranding and fluid are present. fig. 5. ct scan of the abdomen. a fluid collection containing a gas locule (arrow) is seen adjacent to the thick-walled distended appendix (arrowhead). fig. 5 is inferior to fig. 4. imaging.indd 101 12/5/08 11:25:16 am pictorial essay pictorial essay 102 sa journal of radiology • december 2008 tive diagnoses, with relief of appendiceal obstruction resulting in loss of luminal distention and incompressibility. ct scanning has emerged as a valuable resource in the imaging of appendicitis. this modality has the advantage of improved rates of visualisation of the appendix and surrounding structures, as well as more accurate evaluation of the rest of the abdomen. it allows more confident detection of a normal appendix, so excluding appendicitis as a cause of symptoms. reported sensitivities and specificities in the diagnosis of appendicitis are between 88 100% and 91 99% respectively.1 modern multidetector ct scanners allow rapid evaluation of the entire abdomen with excellent resolution both in the axial as well as sagittal and coronal planes. the biggest disadvantage is the high ionising radiation dose delivered, although techniques to reduce the dose have been developed. the technique of examination varies, as many options are available. the entire abdomen can be imaged or the examination can be focused onto the pelvis. a focused examination reduces dose, at the risk of missing pathology in the rest of the abdomen. the scan may be performed with or without intravenous contrast. withholding intravenous contrast reduces the risk of contrast media reactions and cost. however, intravenous contrast assists in evaluation of subtle cases and complications of appendicitis, such as portal pyaemia. oral contrast media predominantly opacify the small bowel and improve detection of intra-abdominal collections. unfortunately, oral contrast administration means delaying imaging to allow contrast media to transit the small bowel. rectal contrast is extremely useful in evaluation of appendicitis as caecal distention is a prerequisite for some of the radiological signs discussed below.1 the main diagnostic criteria for appendicitis on ct are based on the morphology of the appendix, the caecum and the periappendiceal structures. distention of the appendix to a diameter of ≥10 mm, wall thickening (>3 mm) and wall hyperenhancement are useful diagnostic signs. an appendiceal diameter of 7 10 mm is regarded as inconclusive. the diameter threshold is larger than on ultrasound, and this is related to the lack of compression during ct scanning. appendicoliths are not diagnostic of appendicitis but may have prognostic importance as a higher rate of perforation is found in their presence. caecal changes relate to inflammation at the appendiceal opening at the base of the caecum. the result is caecal thickening; a number of signs related to this have been described. peri-appendiceal inflammatory change manifests as fat stranding or a ‘misty’ appearance to the adjacent fat. the inflammatory change can also affect adjacent structures such as adjacent small bowel or the bladder.1 unfortunately, as with ultrasound, ct is not a sensitive modality in detecting perforation. the findings of free air and periappendiceal collections are highly specific but have poor sensitivity.7 various alternate diagnoses can be suggested by ct scanning; these include: mesenteric adenitis, epiploic appendagitis, diverticulitis, crohn’s disease and caecal carcinoma. the role of magnetic resonance imaging (mri) in the imaging of appendicitis is currently being evaluated. it has the advantages of not utilising ionising radiation, and of having superior soft-tissue contrast and acquiring in direct multiplanar imaging. unfortunately, mri is more expensive with reduced availability in comparison with either ct or ultrasound; it is also unsuitable for imaging unstable patients owing to long acquisition times and the necessity for mri-compatible monitoring equipment. it may have a role in the imaging of appendicitis in pregnant or paediatric patients in whom ultrasound is not conclusive.8,9 the radiology service can also provide a therapeutic option in specific situations. percutaneous catheter drainage has shown its value in intra-abdominal abscess drainage in a wide variety of situations. it is a safe technique with good clinical results if utilised appropriately. patients with localised, well-defined peri-appendiceal abscesses >3 cm without generalised peritonitis are good candidates for percutaneous drainage; this may be performed under ultrasound or ct guidance with local anaesthetic and conscious sedation. percutaneous drainage has been shown to reduce complications and hospital stay in comparison with open surgical drainage. fistulous connections from the caecum to the abscess cavity may be demonstrated in a significant proportion of patients; however, in the vast majority, this connection closes within 2 weeks. in the vast majority of patients, the abscess resolves and interval appendicectomy may be performed electively.10,11 conclusion imaging can provide assistance in the diagnosis of appendicitis and the complications thereof or suggest an alternative diagnosis. choosing the appropriate imaging modality should be done on an individual case basis in discussion with the radiology service. in selected patients, therapeutic intervention in the form of percutaneous catheter drainage is appropriate. 1. pinto leite n, pereira j, cunha r, pinto p, sirlin c. ct evaluation of appendicitis and its complications: imaging and key diagnostic findings. am j roentgenol 2005; 185: 406-407. 2. sivit c, siegel m, appelgate k, newman k. when appendicitis is suspected in children. radiographics 2001; 21: 247-262. 3. john h, neff u, kelemen m. appendicitis diagnosis today: clinical and ultrasonic deductions. world j surg 1993; 17: 243-249. 4. jones pf. suspected acute appendicitis: trends in management over 30 years. br j surg 2001; 88: 15701577. 5. puylaert j. acute appendicitis: us evaluation using graded compression. radiology 1986; 158: 355-360. 6. orr rk, porter d, hartman d. ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probablistic reasoning. acad emerg med 1995; 2: 644-650. 7. bixby s, lucey b, soto j, theysohn j, ozonoff a, varghese j. perforated versus nonperforated acute appendicitis: accuracy of multidetector ct detection. radiology 2006; 241(3): 780-786. 8. singh a, danrad r, hahn p, blake m, mueller p, novelline r. mr imaging of the acute abdomen and pelvis: acute appendicitis and beyond. radiographics 2007; 27: 1419-1431. 9. pedrosa i, levine d, eyvazzadeh a, slewart b, ngo l, rofsky n. mr imaging evaluation of acute appendicitis in pregnancy. radiology 2006; 238(3): 891-899. 10. brooke jr, ferderle m, tolentino c. periappendiceal inflammatory masses: ct directed management and clinical outcomes in 70 patients. radiology 1988; 167: 13-16. 11. van sonnenberg e, wittich g, casola g, et al. periappendiceal abscess percutaneous drainage. radiology 1987; 163: 23-26. imaging.indd 102 12/5/08 11:25:16 am untitled introduction intracranial tuberculosis is an important cause of morbidity and mortality in developing countries where tuberculosis is endemic.1 in the central nervous system tuberculosis manifests as cerebritis, cerebral abscess, tuberculoma, and tuberculous meningitis (tbm).1-5 tbm is thought to arise from cerebrospinal fluid (csf) seeding of a ruptured pial or subependymal granuloma.2-5 tuberculomata result from haematogenous dissemination and histologically are granulomas with central areas of caseous necrosis.2-5 tuberculomata may develop whilst patients are on treatment for tb.6 the co-occurrence of intracranial tuberculoma and tbm is well recognized.2-5 medical therapy is effective for both forms, with a high cure rate in tbm, and a regression in size of the lesion with improvement of neurological deficit in tuberculoma.1-6 deterioration in patients with tbm is caused by the development of obstructive hydrocephalus or cerebral infarction on the basis of endarteritis.1-7 deterioration in patients with tuberculoma may result from paradoxical expansion of the lesion, poor treatment compliance, and postulated haemorrhage into the tuberculoma.5,6 intracranial haemorrhage as a complication of tbm has been described, albeit rarely.8-16 there are a few case reports of patients with tbm complicated by intraventricular, intracerebral and subarachnoid haemorrhage on an aneurysmal or non-aneurysmal basis.8-16 we describe here a patient with tbm and an associated left cerebellar tuberculoma who suddenly deteriorated and died on treatment. a large haemorrhage involving the right cerebellum, with subarachnoid extension was demonstrated on computed tomography (ct) scan of the brain and at postmortem. these findings are discussed with respect to the possible mechanism/s of haemorrhage in intracranial tuberculosis. case report a 22-year-old black female patient presented with headache, drowsiness and disorientation. clinically she had marked neck stiffness, multiple cranial nerve palsies (right third and seventh, bilateral sixth), and bilateral pyramidal tract signs. fundoscopy was normal. the patient was hivnegative. csf analysis revealed a protein of 5 g/100 ml, 81 lymphocytes per ml, 3 neutrophils per ml, glucose of 1.9 mmol/l and a positive tb enzyme-linked immunosorbent assay (elisa). ct scan of the brain showed a left cerebellar ring-enhancing mass lesion abutting the adjacent brainstem, hydrocephalus with obstruction at the fourth ventricle, and increased basal meningeal enhancement (fig. 1a). a diagnosis of tbm with left cerebellar tuberculoma and obstructive hydrocephalus was made. oral antituberculous therapy (4-drug regimen) was commenced. gradual clinical improvement was noted with complete resolution of the sixth nerve palsies and partial resolution of the right third and seventh nerve palsies. serial fortnightly ct scans revealed diminishing diameter of the tuberculoma, and resolution of the hydrocephalus. approximately 9 weeks after commencing anti-tuberculous therapy, the patient developed a sudden severe generalised headache and became comatose. a ct scan of the brain revealed a large haemorrhage in the right cerebellar hemisphere with extension into the brainstem and the subarachnoid space (fig. 1b). the patient died shortly thereafter. case report 16 sa journal of radiology • july 2005 haemorrhage in intracranial tuberculosis m modi fcrad (sa), mmed department of radiation sciences university of the witwatersrand johannesburg a mochan fcp (sa) g modi phd (lond), fcp (sa), frcp (lond) department of neurosciences university of the witwatersrand johannesburg m j hale fcpath (sa) department of anatomical pathology university of the witwatersrand johannesburg 16-18pgs 9/28/05 9:21 am page 16 autopsy findings examination of the cranial contents revealed extensive subarachnoid haemorrhage overlying the brainstem on the right extending caudally to involve the right cerebellum and obscuring the circle of willis. a leptomeningitis was present. a 10 mm tuberculoma was found in the left cerebellar hemisphere. examination of the left vertebral artery showed several small white nodules (granulomas) on the adventitia running along its length. microscopically, the meninges showed a florid granulomatous inflammatory reaction with caseous necrosis, epitheloid histiocytes, and cuffing by lymphocytes and plasma cells. the left vertebral artery and many of the meningeal arteries and arterioles showed pronounced intimal proliferation and endarteritis obliterans associated with fibrin platelet thrombus and total vascular occlusion. a striking feature seen in some vessels was fragmentation and loss of the internal elastic lamina (fig. 2). this occurred in areas of the vessel wall where granulomatous inflammation (fig. 2, arrow) was present in the adventitia. a specific site of origin for the subarachnoid haemorrhage was not identified. the lesion in the left cerebellar hemisphere showed histopathological features of a tuberculoma and was surrounded by a moderate degree of perilesional oedema. discussion intracranial haemorrhages secondary to or in association with tbm have been ascribed to aneurysmal rupture following the formation of mycotic aneurysms, or to nonaneurysmal rupture as a consequence of weakening of the vessel wall by the granulomatous inflammation.8-16 in terms of the latter it has been proposed (but to date not pathologically proven as far as we are aware) that the granuloma produces disintegration of a vessel wall with resultant haemorrhage.13 tuberculoma in association with an a-v fistula causing haemorrhage has also been described.17 in our patient at autopsy we found numerous deficiencies in the internal elastic lamina of the meningeal blood vessels in addition to the expected intimal proliferation and endarteritis obliterans with fibrin platelet thrombus and vascular occlusion. the deficiencies or fragmentations of the internal elastic lamina were found in areas of the vessel wall where granulomatous inflammation was present, providing the pathological evidence for the proposed mechanism of nonaneurysmal haemorrhage in patients with tbm. the granuloma in the adventitia invades and gradually weakens the vessel wall leading to disintegration as represented by the fragmentation of the internal elastic lamina seen in our case, with or without mycotic aneurysm formation and consequent rupture. the pathological process described in the meningeal vessels is akin to that which occurs in the pulmonary circulation with pulmonary tuberculosis except that in the pulmonary vessels the chronic granulomatous infiltrate not only causes inflammatory disintegration of the wall but leads to aneurysm formation as described by rasmussen.18 rupture of the aneurysm results in pulmonary haemorrhage and haemoptysis. in the case report 17 sa journal of radiology • july 2005 fig. 1a. ct scan of the brain (post intravenous contrast) in a patient with tuberculous meningitis demonstrating a left cerebellar enhancing lesion abutting the adjacent brainstem (tuberculoma); increased basal meningeal enhancement and obstructive hydrocephalus with associated subependymal oedema. fig. 1b. ct scan of the brain (non-contrast) demonstrating a large right-sided cerebellar haemorrhage with extension into the adjacent brainstem and subarachnoid space. fig. 2. photomicrograph showing a mediumsized artery exhibiting fragmentation and loss of the internal elastic lamina accompanied by granulomatous inflammation in the adventitial tissue (arrow). (h&e – original magnification x 100). 16-18pgs 9/28/05 9:21 am page 17 brain we propose that this process results in haemorrhage in the intracerebral, intraventricular, and subarachnoid spaces. our case highlights intracranial haemorrhage as a potential additional cause of death in tbm. treatment would require search for an aneurysm if patients survive. this has been reported previously.15 the use of steroids in our patient to prevent or reduce the inflammatory response and the accompanying vasculitis is contentious. had the patient been treated with steroids from the outset, is it possible that the disintegration of the internal elastic lamina by the inflammatory process would not have occurred and the consequent rupture with haemorrhage could have been prevented. a cochrane database review concluded that adjunctive steroids might be of benefit in patients with tbm, but the evidence is inconclusive.19 references 1. karstaedt as, valtchanova s, barriere r, crewebrown hh. tuberculous meningitis in south african urban adults. qjm 1998; 91: 743-747. 2. gray f, nordmann p. bacterial infections. in: graham di, lantos pl, eds. greenfield’s neuropathology. 6th ed. vol 2. london: arnold, 1997: 130-132. 3. esiri mm, oppenheimer dr. diagnostic neuropathology. oxford: blackwell, 1989: 131133. 4. berger jr. tuberculous meningitis. curr opin neurol 1994; 7: 191-200. 5. campi de castro c, garcia de barros n, de sousa campos zm, cerri gg. ct scans of cranial tuberculosis. radiol clin north am 1995; 33: 753-769. 6. awada a, daif ak, pirani m, khan my, memish z, al rajeh s. evolution of brain tuberculomas under standard antituberculous treatment. j neurol sci 1998; 156: 47-52. 7. leiguarda r, berthier m, starkstein s, nogues m, lylyk p. ischaemic infarction in 25 children with tuberculous meningitis. stroke 1988; 19: 200 -204. 8. shuangshoti s, phisitbutr m. fatal haemorrhage in tuberculosis of the brain. j med assoc thai 1979; 62: 639-645. 9. modilevsky t, arlazoroff a, goldenberg e, marmor a. spontaneous subarachnoid bleeding and stroke syndrome in tuberculous meningoencephalitis. harefuah 1979; 97: 68-70. 10. xiao zx, haemorrhagic tuberculous meningitis: a report of 10 cases (authors translation). zhonghua jie he he hu xi xi ji bing za zhi 1981; 4: 172-173. 11. hu ch, tuberculous meningitis complicated by massive intracerebral haemorrhage. report of two cases. chug-hua shen ching ching shen ko tsa chih (chinese journal of neurology and psychiatry) 1986; 19: 119-121. 12. mohapatra ak, sharma sn, sethi pk, ahuja im. subarachnoid haemorrhage in tubercular meningitis. j assoc physicians india 1988; 36: 237. 13. roh j, kang d. a case of tuberculous meningitis complicated by intracerebral haemorrhage. eur neurol 1998; 40: 50-52. 14. nakayama y, tanaka a, nagasaka s, ikui h. intracerebral haemorrhage in a patient with moyamoya phenomenon caused by tuberculous arteritis: a case report. no shinkei geka 1999; 27: 751-755. 15. griffiths sj, sgouros s, james g, john p. intraventricular haemorrhage due to ruptured posterior inferior cerebellar artery aneurysm in tuberculous meningitis. childs nerv syst 2000; 16: 872-874. 16. yeh, st, lee w, lin h, chen c, te al, lin h. nonaneurysmal subarachnoid haemorrhage secondary to tuberculous meningitis: report of two cases. j emerg med 2003; 25: 265-270. 17. pathare av, patil rr chikhalikar aa, dalvi sg. association of tuberculoma with arteriovenous malformation (a case report). j postgrad med 1988; 34: 190-192. 18. corrin b. pathology of the lungs. edinburgh: churchill livingstone, 2001: 391. 19. prasad k, volmink j, menon gr. steroids for treating tuberculous meningitis. cochrane database syst rev 2000; 3: cd002244. case report 18 sa journal of radiology • july 2005 16-18pgs 9/28/05 9:21 am page 18 36 sa journal of radiology • june 2007 umbilical venous anomalies are not a common occurrence, and when encountered, they encompass a spectrum of variations. in the case presented, the possibility of an umbilical venous anomaly was raised on the abdominal x-ray done soon after birth. the neonate had a venous catheter inserted for vascular access. on the film done thereafter, the venous catheter was seen to deviate to the left of the midline (fig. 1). the child subsequently underwent a laparotomy. no falciform ligament was demonstrated, the ligamentum venosum was absent and the umbilical vein was seen to drain directly into the superior mesenteric vein (fig. 2). the umbilical veins are a pair of developmental vessels that carry oxygenated blood between the placenta and the heart. from the fifth week of gestation, part of the umbilical veins becomes incorporated into the region of the developing liver. they merge with the vitelline veins to form sinusoids. the right umbilical vein regresses along with the part of the left umbilical vein that is nearest to the heart. the distal part of the left umbilical vein is left to become the main channel through the liver. it forms an anastamosis with the right hepatocardiac channel. by 3 months the right hepatocardiac channel enlarges and is termed the ductus venosus.1 the ductus venosus connects the portal and umbilical veins with the inferior vena cava and acts as a sphincter to protect the fetus from placental overcirculation. the ductus venosus regresses at birth to form a fibrous cord, the ligamentum venosum. its absence may cause hydrops fetalis, and is associated with a high mortality rate, chromosomal anomalies and congenital malformations.2 in our patient there were a host of additional abnormalities. on the abdominal film (fig. 1) the nasogastric tube is curled in the proximal oesophageal pouch; this was confirmed to be the common type of oesophageal atresia with a fistula. in addition vertebral abnormalities of the upper dorsal spine are present. the poor abdominal gas pattern was in keeping with the clinical and surgical findings of an anorectal malformation, colonic atresia, malrotation and the incidental finding of a meckel’s diverticulum. at surgery a horseshoe kidney was observed. the infant also had left radial hypoplasia. the heart however was structurally normal. in view of the high incidence of congenital defects associated with umbilical vein variations and particularly an aberrant right umbilical vein, when these are detected it is suggested that the patient should be carefully investigated for other congenital abnormalities. 1. moore kl. the developing human. 7th ed. philadelphia: wb saunders, 2002: 262-280, 364-371. 2. perles z, nir a, nadjari m, et al. absent ductus venosus in the fetus: review of the literature and first report of direct umbilical venous drainage to the coronary sinus. fetal diagn ther 2003; 18:247-251. umbilical vein variation – case of an umbilical vein draining into the portal venous system a ahmed, mb bch, fcrad(d) division of radiology, department of radiation sciences, chris hani baragwanath hospital, johannesburg g pitcher, mb bch, fcs(sa) department of paediatric surgery, chris hani baragwanath hospital, johannesburg fig. 1. abdominal and chest x-ray demonstrating deviation of the umbilical venous line, curled up nasogastric tube in the oesophageal pouch and dorsal spine hemivertebrae. fig. 2. at surgery the umbilical vein is seen draining into the superior mesenteric vein. pictorial interlude pg36.indd 36 6/15/07 11:09:36 am article information author: aadil ahmed1 affiliation: 1rssa, radiologist at visser, erasmus, vawda & partners, port elizabeth, south africa correspondence to: aadil ahmed email: aadil.a@bayradiology.co.za postal address: po box 10517, linton grange 6015, port elizabeth, south africa dates: received: 06 june 2015 accepted: 11 aug. 2015 published: 27 nov. 2015 how to cite this article: ahmed a. where's the line/tube? s afr j rad. 2015;19(2): art. #888, 8 pages. http://dx.doi.org/10.4102/sajr.v19i2.888 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. where's the line/tube? in this pictorial essay... open access • abstract • introduction    • umbilical catheters       • umbilical venous catheter (uvc)       • anomalous positions       • complications       • umbilical arterial catheter (uac)       • complications       • endotracheal tube (ett)       • complications       • nasogastric tube (ngt)       • complications       • ventriculo-peritoneal shunt (vps)       • complications       • others • acknowledgements    • competing interests • references • appendix 1: self-test questions    • where is the line/tube? abstract top ↑ radiologists are confronted with a spectrum of catheters placed in various locations in routine radiology practice and have to be familiar with the different catheters, their uses and acceptable positioning for suggested safe practice. the commonly used vascular and non-vascular catheters are described and discussed in this brief guide. introduction top ↑ the chest radiograph (cxr) plays an important role in assessing patients in intensive care units (icu). it is the most common radiological investigation due to its value in diagnosing cardio-respiratory disease. an abdominal radiograph (axr) commonly accompanies the cxr in evaluating the neonate in icu. the cxr and axr are also extremely useful and important for evaluating the position of various lines and tubes. the american college of radiology (acr) recommends a cxr immediately following placement of indwelling tubes, catheters and other devices to check their positions and detect procedure-related complications.1 umbilical catheters umbilical venous catheter (uvc) uses: these are commonly used for vascular access during the neonatal period. the uvc allows for the infusion of hypertonic solutions, total parenteral nutrition and emergency access for fluids, drugs and blood products. it is directed into the umbilical vein. a developmental foetal remnant – the ductus venosus – connects the umbilical vein to the inferior vena cava (ivc). the portal sinus connects the umbilical vein to the portal vein. this connection allows for anomalous positioning of the uvc within the portal vein. the normal neonatal anatomy is demonstrated in figure 1. figure 1: schematic drawing demonstrating the umbilical vessels and their connections to the systemic circulation during the neonatal period. there is a higher incidence of congenital defects associated with umbilical vein variations. if such a variation is detected, the neonate should be investigated for other congenital abnormalities.2 the objective is to place the uvc above the diaphragm, at the entrance to the right atrium. despite their common use, uvcs are still frequently malpositioned. anomalous positions below the diaphragm: umbilical vein, portal vein, hepatic vein. above the diaphragm: through a patent foramen ovale or an atrial septal defect (asd) into the left atrium, pulmonary vein, superior vena cava (svc), internal jugular vein (figure 2 and figure 3).3 figure 2: umbilical venous catheter (uvc) (arrow) passing through a patent foramen ovale into the left atrium and ending in the left ventricle. umbilical arterial catheter (uac) (dotted arrow) in acceptable high position (t9). satisfactorily positioned endotracheal tube (ett) and nasogastric tube (ngt). figure 3: umbilical venous catheter (uvc) advanced beyond the right atrium (ra), passing into the superior vena cava (svc) and ending in the right internal jugular vein. good endotracheal tube (ett) (dotted arrow) position. complications below the diaphragm: perforation of intrahepatic vascular wall – the formation of hepatic haematoma, and even abscess formation (figure 4a and figure 4b). the uvc positioned within the portal venous system predisposes the patient to thrombus formation. figure 4: (a) umbilical venous catheter (uvc) (arrow) incorrectly positined within the right branch of the portal vein. motted gas shadows within the liver represent complicatins related to uvc infusate delivered into liver. this could represent liver parenchymal injury and/or liver abscess formatin. it should be diffrentited from bubbles of air that can be seen within the portal vein soon aftr catheris. (b) follow-up cxr of patint in image 4a. cxr done one month later shows rim calcifid lesion (arrows) within the liver. the infusate within the liver has become encysted and, together with hepati necrosis, has formed the calcifid lesion. above the diaphragm: perforating the atrial wall and entering the pericardial space may lead to cardiac tamponade.4 when the uvc passes through a patent foramen ovale or asd or through the tricuspid valve into the right ventricle, this can lead to cardiac arrhythmias. other complications include pulmonary infarction and thrombotic endocarditis.5 umbilical arterial catheter (uac) uses: a uac is used in blood sampling, arterial blood gas sampling, the administration of intravenous fluids and drugs, checking blood pressure, and in exchange transfusions. umbilical arteries are the direct continuation of the internal iliac arteries. the uac initially courses caudally, and then passes cranially into the aorta via the internal and common iliac arteries. it has a posterior course compared to the more anterior location of the uvc (figure 5). figure 5: lateral axr demonstrating the initial caudal course of the umbilical arterial catheter (uac). the uac also has a more posterior course within the iliac arteries and the aorta. the umbilical venous catheter (uvc) passes more anteriorly. the optimum position of the uac is either above or below the visceral branches of the aorta.3,6 it should not be in a branch of the aorta as it can block the vessel. high lines have their tips positioned between t6–10 and low lines have their tips between l3–5.3 the high position is favoured since it leads to fewer vascular complications. anomalous positions: occasionally, the uac can pass into the femoral or gluteal arteries. it can also pass into a branch of the aortic arch, for instance the common carotid artery or subclavian artery (figure 6). figure 6: the umbilical arterial catheter (uac) is positioned to the right of the umbilical venous catheter (uvc) in this x-ray. is there an anomaly? no, this finding is due to poor technique, as the patient is rotated to the left. on a correctly positioned ap view, the uvc should lie to the right of the uac, in keeping with the normal aorta–ivc relationship. complications complications include infection, thrombosis, air embolism, perforation and bleeding.3,6 endotracheal tube (ett) uses: the ett is inserted for ventilatory support and it also prevents aspiration. the ett should be placed halfway between the thoracic inlet and the carina or 1.5 vertebral bodies above the carina.6 figure 7: the umbilical arterial catheter (uac) has been advanced too far. its distal tip is in the left subclavian artery. the umbilical venous catheter (uvc) tip (dotted arrow) is located in the ra. the end of the nasogastric tube (ngt) is in the stomach. complications the most common complication is selective intubation of the bronchus (figure 8a and figure 8b). this results in collapse/atelectasis of the contralateral lung. if the patient is on a ventilator, the ipsilateral lung can become hyperinflated, leading to pneumothorax or tension pneumothorax. another serious complication is inadvertent oesophageal intubation (figure 9).1 this complication is mostly diagnosed clinically and can be detected radiographically by an air-filled esophagus, over distended stomach and no ett in the trachea. there are also other complications related to long-term intubation. figure 8: (a) the end of the endotracheal tube (ett) (arrow) is lying within the right main bronchus. there is resultant left-sided atelectasis and mediastinal shift to the left. (b) the endotracheal tube (ett) in figure 8a has been withdrawn, and there has been re-expansion of the left lung. the ngt is within the stomach. figure 9: the ett is positioned in the oesophagus. the trachea (white arrow) is visible to the right of the ett. secondary to oesophageal intubation there is dilatation of the stomach (dotted arrow) and distal oesophagus. nasogastric tube (ngt) uses: the ngt is inserted for the aspiration of gastric contents, gastric decompression or feeding the patient. the tip should lie within the stomach. complications the ngt can be misplaced in the tracheobronchial tree (figure 10). perforation of the oesophagus or stomach is extremely uncommon, but can occur, particularly in premature infants.7 a coiled ngt in a proximal oesophageal pouch is important to recognise in oesophageal atresia.2 in neonates with left-sided congenital diaphragmatic hernia, the ngt tip is most commonly positioned at the gastro-oesophageal junction or within the left hemithorax. an ngt deviating to the right is seen in a patient with heterotaxy syndrome and abdominal situs (figure 11). figure 10: the nasogastric tube (ngt) (arrow) has entered the tracheobronchial tree, with the end lying within a terminal bronchiole of the right lower lobe. the surrounding lung changes are secondary to inadvertent administration of feeds into this ngt. figure 11: the nasogastric tube (ngt) end is within a right-sided stomach in a patient with abdominal situs inversus. there is a right-sided central venous catheter in situ with its end in the superior vena cava (svc) (dotted arrow). a urinary catheter is in the bladder (black arrow). ventriculo-peritoneal shunt (vps) uses: vps's are used to relieve hydrocephalus. the peritoneum is commonly used because it is an efficient site of absorption.8 complications shunt malfunction/complications are common. the leading cause of shunt malfunction is mechanical failure. other complications include infections and overdrainage. causes of mechanical failure: these include obstruction, migration, leakage, disconnection, improper placement and cerebrospinal fluid pseudocysts. an obstructed vp shunt will lead to increasing ventricular size, as diagnosed on a ct/mri scan. ultrasonography (us) or ct may be helpful in the diagnosis of abdominal csf pseudocysts. occlusion accounted for about 50% of shunt complications in one paediatric series. it occurs more at the ventricular end than at the peritoneal end.8 disconnection/fracture is the second most common cause of mechanical shunt failure. the neck and scalp are common sites. an x-ray shunt series (skull ap and lateral, chest ap, abdomen ap views) can be done to determine the location of the break. shunts can be improperly positioned at the level of the ventricles or within the peritoneum (figure 12a and figure 12b); similarly, shunt migration can occur at both ends. within the abdomen, the viscera can also be perforated by the shunt. figure 12: (a) the abdominal end of the ventriculo-peritoneal shunt (vps) (arrow) is lying in an extraperitoneal location (between the anterior abdominal wall and the peritoneal cavity), unable to uncoil. adequate csf drainage was not possible and this resulted in raised intracranial pressure and neurogenic pulmonary oedema. (b) the ventriculo-peritoneal shunt (vps) (arrows) in figure 12a was repositioned and is now correctly positioned with the peritoneal cavity (freely lying). there has been a marked improvement in the pulmonary oedema changes as the raised intracranial pressure has been relieved. others intercostal drains: these are used for drainage of a pneumothorax or effusion. all the holes of the drain should be within the pleural space1 (figure 13). the tube should ideally be inserted in the midaxillary line via the 4th–6th intercostal spaces. it should be lying apico-anterior in patients with a pneumothorax. figure 13: patient with right-sided pneumothorax (arrow). the right icd is, however, not lying within the pleural space. it is lying instead in the soft tissues outside the thoracic cavity, and thus the pneumothorax remains. the peripherally inserted central catheter (picc) is inserted into peripheral limb veins, with the end lying in the distal svc or at the cavo-atrial junction. common complications are related to insertion and malpositioning (figure 14). correctly positioning it is important for the administration of certain intravenous medications. figure 14: the left upper limb peripherally inserted central catheter (picc) line (arrow) has been advanced too far and its end is within the right ventricle, close to the pulmonary outflow tract. other venous catheters include dialysis catheters and chemotherapy ports. these can be malpositioned or become occluded by thrombus and fibrin sheaths (chemotherapy ports). the transpyloric tube is similar to the ngt, except that it is longer and its end is sited distal to the pylorus (proximal to ligament of treitz). it is used for feeding. reploggel suction catheters are used in patients with oesophageal atresia to remove saliva from the blind ending oesophageal pouch. the markings of a reploggel tube form a dashed line, and help to differentiate it from the ett (figure 15). figure 15: reploggel tube with dashed line lying in the oesophageal pouch. et tube lying to the right. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. references top ↑ jain sn. a pictorial essay: radiology of lines and tubes in the intensive care unit. indian j radiol imaging. 2011;21(3):182–190. pmid: 22013292, http://dx.doi.org/10.4103/0971-3026.85365 ahmed a, pitcher g. umbilical vein variation – case of an umbilical vein draining into the portal venous system. s afr j radiol. 2007;11:4. http://dx.doi.org/10.4102/sajr.v11i2.49 narla ld, hom m, lofland gk, moskowitz wb. evaluation of umbilical catheter and tube placement in premature infants. radiographics. 1991;11:849–863. pmid: 1947320, http://dx.doi.org/10.1148/radiographics.11.5.1947320 van niekerk m, kalis nn, van der merwe pl. cardiac tamponade following umbilical vein catheterization in a neonate. s afr med j. 1998;88(suppl. 2):c87–90. pmid: 9595002. schlesinger ae, braverman rm, dipietro ma. neonates and umbilical venous catheters: normal appearance, anomalous positions, complications, and potential aid to diagnosis. am j roentgenol. 2003;180:1147–1153. pmid: 12646473, http://dx.doi.org/10.2214/ajr.180.4.1801147 engelbrecht mr, blickman jg. the acute pediatric chest. appl radiol. 2004;33:26. batra p. radiology of monitoring devices. in syllabus for thoracic imaging 2001, the annual meeting of the society of thoracic radiology. 2001; p. 202–204. goeser cd, mcleary ms, young lw. diagnostic imaging of ventriculoperitoneal shunt malfunctions and complications. radiographics. 1998;18:635–651. pmid: 9599388, http://dx.doi.org/10.1148/radiographics.18.3.9599388 appendix 1: self-test questions top ↑ where is the line/tube? answers self-test questions the ngt is coiled in the oesophageal pouch in a patient with oesophageal atresia and a tracheo-oesophageal fistula. there is an anomalous connection between the umbilical vein and the superior mesenteric vein (smv). surgery confirmed the absence of the ligamentum venosum. the uvc deviates to the left and is lying in the smv. there are also thoracic and sacral vertebral body abnormalities, 13 ribs on the right and 12 on the left. this child also had cardiac, anorectal and radial abnormalities in keeping with a vacterl association. a vps is passing into the right scrotal sac via the patent processus vaginalis. this dialysis catheter was inserted into the left subclavian vein. the patient has a persistent left svc which drains into the coronary sinus. the catheter has entered the right atrium via the coronary sinus. this was confirmed with an mri of the chest. article information author: pieter j. oberholzer1 affiliation: 1department of radiology, university of pretoria, south africa correspondence to: pieter oberholzer postal address: private bag x24270, gezina 0031, south africa dates: received: 04 aug. 2014 accepted: 29 oct. 2014 published: 05 dec. 2014 how to cite this article: oberholzer, pj. complete rupture of the long head of the biceps tendon and the distal biceps tendon. s afr j rad. 2014;18(2); art. #710, 3 pages. http://dx.doi/org/10.4102/ sajr.v18i2.710 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. complete rupture of the long head of the biceps tendon and the distal biceps tendon in this case reports... open access • abstract • introduction • case reports    • case 1    • case 2 • discussion • teaching point • conclusion • acknowledgements    • competing interests • references abstract top ↑ the most common injury to the biceps muscle is rupture of the long head of the biceps tendon. a tear can occur proximally, distally or at the musculotendinous junction. two cases are discussed, in both of which the patients felt a sudden sharp pain in the upper arm, at the shoulder and elbow respectively, and presented with a biceps muscle bump (popeye deformity). introduction top ↑ patients with a biceps tendon rupture may complain of a wide variety of symptoms. several report a sudden sharp pain in the anterior shoulder during activity, which may be accompanied by an audible ‘pop’ or a perceived snapping sensation.1 the patient may present with a popeye deformity, where the disruption of the normal biceps muscle attachment leads to its retraction distally in the arm. a traumatic biceps tear is more common in younger patients but can occur at any age. it can occasionally occur during heavy weightlifting, from actions that cause a sudden load on the arm, local trauma, rapid extension of the arm or falling on an outstretched arm during competitive sports. the long head of the biceps tendon can also be injured by repetitive motion.2 patients may still be able to use the biceps muscle, because of the intact short head of the biceps tendon which rarely tears.3 proximal biceps tears do not always need surgical repair (depending on the patient’s functionality), but distal tears need to be repaired. case reports top ↑ case 1 a 38-year-old man presented with a popeye deformity and a clinical diagnosis of ruptured long head of the biceps tendon. the injury occurred with the left arm in abduction and external rotation. a magnetic resonance image (mri) was acquired to evaluate the biceps tendon. an empty bicipital groove with an intact transverse ligament on the axial plane was diagnostic of a ruptured long head of the biceps tendon (figure 1). the distal position of the retracted tendon was demonstrated in the sagittal plane (figure 2). the biceps anchor was demonstrated in the coronal plane (figure 3). figure 1: magnetic resonance image (mri) pd tse fs in the axial plane, demonstrating an empty bicipital groove (arrow). figure 2: magnetic resonance image (mri) pd tse fs in the sagittal plane, demonstrating the retracted tendon in the upper arm (arrow). figure 3: magnetic resonance image (mri) pd tse fs in the coronal plane, demonstrating complete rupture of the biceps anchor (arrow). case 2 a 28-year-old professional rugby player sustained an injury to his arm and was referred for mri. a distal biceps tendon rupture with retraction was identified in the sagittal plane (figure 4). figure 4: magnetic resonance image (mri) t2 fs in the sagittal plane, demonstrating complete tear of the distal biceps tendon (arrow). discussion top ↑ biceps tendon ruptures tend to occur at the following sites:4 • proximal rupture at the superior aspect of the bicipital groove and rotator interval. this is the most common site and is usually part of the impingement spectrum. • distal rupture at the biceps anchor (radial tuberosity). • rupture at the musculotendinous junction is rare and is associated with violent trauma. an absent long head of the biceps tendon in its expected location in the bicipital groove (on axial or sagittal images) is diagnostic4 of a proximal biceps tendon rupture. some tears can be difficult to diagnose; for example, longitudinal and self-attaching tears. a longitudinal tear usually involves the superior part of the tendon, where a bifid tendon will extend inferior to the glenoid margin.4 a clinical diagnosis of a self-attaching long head of a biceps tendon rupture without retraction is challenging and is usually identified during a rotator cuff repair. mri is sensitive in diagnosing complete tears of the distal biceps tendon, but less sensitive for partial tears.5 the mri features of a partial tear include intratendinous fluid signal, oedema in the radial tuberosity and increased fluid signal intensity in the tendon sheath. determining the degree of retraction in partial tears may provide a diagnostic challenge on mri. diagnosis should therefore not rely on imaging studies alone; correlation with history and clinical findings is necessary.2 the correct classification of a biceps tendon rupture is important because the management of proximal and distal biceps tendon tears differs. the biceps muscle is a flexor of the elbow and a supinator of the forearm. repair of distal biceps tendon rupture is therefore generally always important.2 the biceps tendon is also a weak flexor and passive stabiliser of the shoulder. treatment of a proximal long head of the biceps tendon rupture consists of either a tenodesis, where the tendon is fixed in the bicipital groove, or a tenotomy (a release of the tendon).2 the latter often results in a permanent popeye deformity. teaching point top ↑ in the event of a complete tear of the long head of biceps: • identify the site of tear and the amount of retraction • evaluate the proximal stump of the tendon. in the event of a complete tear of the distal biceps tendon (elbow): • establish if the lacertus fibrosis is intact • the field of view should be sufficient to identify the retracted stump. conclusion top ↑ a complete tear of the biceps tendon is usually a clinical diagnosis. mri should be done to reveal the site, degree of tear, distance of retraction and trauma to surrounding soft tissue and bone. acknowledgements top ↑ i thank drs s. miller and m. velleman, and m. robbertse and d. coetzee, for their contributions. competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1. branch gl, wieting jm. biceps rupture. medscape. updated 28 february 2014. [homepage on the internet]. [cited 21 may 2014]. available from: http://emedicine.medscape.com/article/327119clinical 2. reznik am. the orthopaedic group. biceps tendonitis, partial biceps tears, biceps subluxation, biceps rupture and biceps tenodesis. revised 03 july 2011. [homepage on the internet]. [cited 21 may 2014]. available from: http://www.togct.com/downloads/reznik 3. orthoinfo. biceps tendon tear at the shoulder. updated may 2009. [homepage on the internet]. [cited july 2014]. rosemont: american academy of orthopedic surgeons. available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00031 4. stoller dw. magnetic resonance imaging in orthopaedics and sports medicine, vol. 2., 3rd edn. philadelphia: lippincott williams & wilkens, 2007; p. 1423–1424. 5. festa a, mulieri pj, newman js, spitz dj, leslie bm. effectiveness of mri in detecting partial and complete distal biceps tendon ruptures. j hand surg am. 2010;35(1):77–83. http://dx.doi.org/10.1016/j.jhsa.2009.08.016 case report 28 sa journal of radiology • march 2007 case report percutaneous drainages of intra-abdominal collections are routinely undertaken, commonly in the subphrenic area.1 however, there are a number of areas in the abdomen in which it may be difficult to directly reach fluid collections with a needle, especially if the collections are not large. one such area is the high right subphrenic space, as in this patient with a collection seen on ct and ultrasound (figs 1 and 2), thought to be on the basis of a ruptured liver abscess. it was found to be difficult to gain safe entry to the fluid using any of the standard approaches. the intercostal route is not generally recommended due to the risk of pneumothorax1 or subsequent pleural empyaema, which therefore means that with either a right subcostal or an epigastric approach is required. the angles from these entry sites may not permit direct entry, and the needle may not be long enough to traverse the liver to reach the target. the hepatic flexure and transverse colon can be interposed from the subcostal or epigastric routes. the costal cartilages can also interfere with an epigastric approach, meaning that the puncture entry point needs to be moved to the left and inferior to the xiphisternum. this requires a more oblique course, and again may mean that the standard needle is too short, and that the central portal structures may come into the intended line. longer needles are not always readily available, and may still be defeated by awkward angles and intervening portal structures. an alternative technique is to smoothly curve a fine-needle by using gentle pressure applied with the thumb and first two fingers to produce a constant radius curve along the entire length of the needle (fig. 3). alternative bending techniques have been described, using a partly open forceps, or the side of a syringe.2 care must be taken to obtain a constant radius curvature to facilitate low resistance passage through the tissues, and easier placement of the stilette. the inner stilette should remain within the needle during the curving process to moderate and spread the bending forces. there may be some resistance of stilette withdrawal and re-advancement, especially if the curve is not even. during placement and advancement of the needle, there may be an initial tendency for the needle to straighten somewhat and/or curve away from its intended target, but gentle pressure and torque generally overcome this. in theory, having the bevel of the needle facing to the outside of the arc should facilitate retention of the curve – this has also been suggested to allow determination of the curve direction from the hub orientation.2 varying degrees of gentle rotation accompanied by advancement or withdrawal can redirect and steer the needle tip. curved-needle approach to high right subphrenic collections s beningfield, mb chb, ffrad (d) department of radiology, university of cape town technical note fig. 1. longitudinal ultrasound of the right upper quadrant showing crescentic collection (arrow) in the right subphrenic space. dashed line showing approximate needle path. fig. 2. computed tomography scan showing right subphrenic collection (arrows). dashed line showing needle course. fig. 3. diagram of curved fine-needle path; needle bevel position as shown in circle. technical note pg28-29.indd 28 2/26/07 1:56:21 pm case reportcase report 29 sa journal of radiology • march 2007 careful visualisation of the advancement of the needle to ensure that the diaphragm is not traversed is also important, with intermittent fluoroscopy and ultrasound to confirm needle position in relation to the diaphragm. it is also helpful to place the ultrasound probe intercostally over the intended point of entry of the needle into the collection, where the visualisation of both the needle tip and collection are frequently superior. if ct or ct fluoroscopy are available, these are more accurate. once the collection is reached, the procedure is standard from there onward. discussion the curved needle technique has previously been described in a coaxial configuration for use in ct-guided biopsy.2 abscess drainage routing is less tolerant than fine needle biopsy is to passage through intervening structures. the curved needle technique can usefully expand the role of the radiologist in reaching and treating difficult-to-access collections. the transpleural route has associated risks of pneumothorax and delayed empyaema, and, although it has been used relatively safely in a series of post-splenectomy collections,3 should probably be reserved for when other options have been exhausted and after clear explanation of the possible risks to the patient and his/her doctor. the curved needle approach can sometimes overcome problems of length, angle and intervening structures. 1. mueller pr, simeone jf, butch rj, et al. percutaneous drainage of subphrenic abscess: a review of 62 patients. am j roentgenol 1986; 147: 1237-1240. 2. gupta s, ahrar k, morello fa jr., wallace mj, madoff dc, hicks me. using a coaxial technique with a curved inner needle for ct-guided fine-needle aspiration biopsy. am j roentgenol 2002; 179: 109-112. 3. mcnicholas mm, mueller pr, lee mj, et al. percutaneous drainage of subphrenic fluid collections that occur after splenectomy: efficacy and safety of transpleural versus extrapleural approach. am j roentgenol 1995; 165: 355-359. technical note radiology secrets, 2nd edition with student consult online access by e. scott pretorius and jeffrey a. solomon isbn 0323034055 / 9780323034050 ä paperback ä 656 pages ä 679 illustrations mosby ä published november 2005 health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za the smart way to study! elsevier titles with student consult will help you master difficult concepts and study more efficiently in print and online! perform rapid searches. integrate bonus content from other disciplines. download text to your handheld device. and a lot more. each student consult title comes with full text online, a unique image library, case studies, usmle style questions, and online note-taking to enhance your learning experience. features  uses bulleted lists, tables, short answers, and a highly detailed index to expedite reference.  features pearls, tips, memory aids, and � secrets� from the experts.  covers all of today� s most common conditions and their treatment. pg28-29.indd 29 2/26/07 1:56:22 pm case report abstract this report describes an intraventricular neurocysticercus cyst of the 4th ventricle with consequent hydrocephalus in an adult man. he was managed with anti-helminthic therapy and a 3rd ventriculostomy. initial imaging showed the cyst within the 4th ventricle. at follow-up imaging a cyst was present in the 3rd ventricle and the 4th ventricle had returned to normal. it is postulated that the cyst ‘migrated’ from the 4th to the 3rd ventricle. introduction neurocysticercosis (ncc) is more commonly seen to involve the brain parenchyma and uncommonly involves the ventricular system and subarachnoid spaces.1 whereas parenchymal cysticerci can be readily identified on ct and mri, most authors agree that it is difficult to identify lesions within the cerebrospinal fluid (csf) spaces.1 we present a case of ncc of the 4th ventricle which was well demonstrated on conventional mri sequences. on follow-up imaging the cyst appeared to have ‘migrated’ to the 3rd ventricle. we are not aware of any reports in the english literature describing ‘migrating’ intraventricular ncc cysts. case description a 24-year-old male patient presented with progressively worsening occipital headaches and diplopia over a 4-month period. routine observations were normal and neurological examination was unremarkable. specifically, there were no cerebellar signs, signs of meningism or papilloedema. a ct scan (fig. 1) showed hydrocephalus with a disproportionately enlarged 4th ventricle. in addition, multiple calcified punctate lesions were seen scattered throughout the brain parenchyma in keeping with old ncc lesions. there was no abnormal contrast enhancement. the patient was seen by the neurosurgeons who managed the patient as having hydrocephalus of uncertain origin. a 3rd ventriculostomy was performed and the patient responded well. mri (fig. 2) showed resolution of the hydrocephalus post 3rd ventriculostomy and a 4th ventricular cyst of csf signal intensity on t1 and t2-weighted sequences. the cyst wall was best demonstrated on the axial and sagittal flair sequences. furthermore, an eccentric flair hyperintense mural nodule was easily identified. this nodule represented the scolex and the diagnosis of intraventricular ncc was made. the patient was discharged on albendazole and prednisone. the patient was asymptomatic at follow up 3 months later and repeat mri (fig. 3) showed that the 4th ventricle had returned to its normal size and no longer contained the previously seen cyst. however, a cyst with an eccentric scolex was now present within the 3rd ventricle. it is postulated that the 4th ventricular cyst had ‘migrated’ to the 3rd ventricle. discussion ncc is an infestation by the larval form of taenia solium and is the most frequently encountered parasite of the cns.2 it is endemic in the developing world2 and contributes significantly to acquired epilepsy.1,3 the incidence is increasing in the developed world as a result of widespread international travel to endemic regions and immigration of infected individuals.1,3 upon ingestion of infected meat, viable eggs adhere to and penetrate the gastrointestinal mucosa to enter the circulation.1-3 ncc occurs when cysticercus larvae infect the central nervous system.1 the larvae normally land in the brain parenchyma and less commonly lodge in the ventricles and the csf cisterns.1,4 cysts can also be encountered in several locations at once.2,4,5 ncc can be asymptomatic or present with a variety of clinical manifestations including convulsions and signs and symptoms of raised intracranial pressure.1,2 presentation depends on several factors such as host response, stage of evolution, and number, size and location of cysticerci.1,2,5 patients with parenchymal cysts normally present with seizures, whereas patients with intraventricular cysts usually present with headaches, vomiting and visual disturbances as a result of hydrocephalus which is potentially fatal.1,2,5,6 the 4th ventricle is the most common intraventricular site2,5 probably because of gravity or direct entry via the choroid plexus.6 cysts can degenerate in the ventricular system causing an ependymal reaction identifiable on contrast-enhanced mri and can lead to permanent neurological complications.2 25 sa journal of radiology • march 2007 ‘migrating’ intraventricular neurocysticercus cyst s j przybojewski, mb chb, dip pec (sa), mmedrad (d), fcrad (d) s b griffith-richards, mb chb m strachan, mb chb, lmcc y vadachia, mb chb, mmed rad (d) d l kathan, mb chb, msc, mba department of radiology, stellenbosch university and tygerberg hospital fig. 1. uncontrasted ct scan of the brain showing marked hydrocephalus, a disproportionately enlarged 4th ventricle, loss of surface sulcal markings and compression of the basal cisterns. multiple punctate calcified parenchymal lesions are also present, consistent with old ncc. pg25-27.indd 25 2/26/07 1:53:26 pm case report case report 26 sa journal of radiology • march 2007 case report before the advent of mri, intraventricular cysts were difficult to diagnose noninvasively.2 previously used invasive procedures included contrast and ct ventriculography.2 mri is currently the most useful imaging tool for ncc4,5 and is superior to ct.2,5 it is especially useful for the assessment of intraventricular cystic lesions and is often diagnostic.2 however, unlike parenchymal ncc, it is often not possible to detect ncc cysts when they are present in the csf spaces1 using conventional mri sequences as they are obscured by the adjacent csf.2,3 despite this, neuroimaging remains one of the most important clinical tools for the diagnosis of ncc.4 t1-weighted sequences are reportedly more sensitive than t2-weighted sequences.2 proton density images may also better delineate cysts from surrounding csf.5 other sequences reported to be useful include three-dimensional (3d) spoiled gradient recalled echo (spgr)1 and 3d constructive interference in steady state (3d-ciss) which is a heavily t2-weighted high-resolution sequence.2 degenerating cysts can be detected on flair and contrast-enhanced t1-weighted sequences by their increased signal intensity.3 flair sequences proved to be the most useful in our patient. management of ncc depends on the area of brain involvement.3 many authors recommend surgical excision as the treatment of choice for intraventricular ncc before the cysts degenerate causing ventriculitis1,2,4,6 and irreversible hydrocephalus.1,4 other authors advocate a trial of anti-helminthic therapy4,7 and if hydrocephalus is present, shunt procedures or ventriculostomy should be performed,4 as was done in our patient. these patients should be monitored closely for recurrent hydrocephalus.2,4 26 sa journal of radiology • march 2007 figs. 2a and b. sagittal and axial flair mr images clearly demonstrating the 4th ventricular neurocysticercus cyst and the eccentric scolex. the hydrocephalus is markedly improved post-3rd ventriculostomy. figs. 3a and b. follow-up axial flair mr images showing a 3rd ventricular neurocysticercus cyst and scolex not present at initial mri. the previously abnormal 4th ventricle has returned to its normal configuration. pg25-27.indd 26 2/26/07 1:53:28 pm case reportcase report 27 sa journal of radiology • march 2007 1. robbani i, razdan s, pandita kk. diagnosis of intraventricular cysticercosis by magnetic resonance imaging: improved detection with three-dimensional spoiled gradient recalled echo sequences. australas radiol 2004; 48:237-239. 2. govindappa ss, narayanan jp, krishnamoorthy vm, et al. improved detection of intraventricular cysticercal cysts with the use of three-dimensional constructive interference in steady state mr sequences. am j neuroradiol 2000; 21: 679-684. 3. hauptman js, hinrichs c, mele c, et al. radiologic manifestations of intraventricular and subarachnoid racemose neurocysticercosis. emerg radiol 2005;11:153-157. 4. cuetter ac, garcia-bobadilla j, guerra lg, et al. neurocysticercosis: focus on intraventricular disease. clin infect dis 1997; 24:157-164. 5. ghosh d, dubey tn, prabhakar s. brain parenchymal, subarachnoid racemose, and intraventricular cysticercosis in an indian man. postgrad med j 1999;75:164-166. 6. madrazo i, garcia-renteria ja, sandoval m, et al. intraventricular cysticercosis. neurosurgery 1983; 12: 148-152. 7. allcut da, coulthard a. neurocysticercosis: regression of a fourth ventricular cyst with praziquantel. neurol neurosurg psychiatry 1991; 54:461-462. interventional radiology secrets by david l. waldman; nikhil c. patel and wael e.a. saad isbn 1560536098 / 9781560536093 ä paperback hanley & belfus ä published september 2004 health & medical publishing group private bag x1, pinelands, 7430 tel: 021 – 6578200 fax: 0216834509 e-mail: carmena@hmpg.co.za / brents@hmpg.co.za noted expert steven d. waldman, md, jd, is the editor of this volume in the secrets series on one of the hottest topics in the field-interventional radiology. he provides clear, concise coverage of all of the basics as well as succinct, but thorough coverage of both vascular and nonvascular topics. the secrets popular question and answer format makes this title perfect for board review, as a clinical refresher, or as a quick-reference guide. features  hot topics include: gene therapy, noninvasive diagnosis and management of vascular disease, and cost-effective outpatient clinics.  offers guidance on all of interventional radiology� s most important concepts in the proven q&a format of the secrets seriesä.  features the author� s pearls, tips, memory aids, and � secrets� in the answer sections.  provides bulleted lists and algorithms for quick review.  presents a wealth of clear, crisp illustrations and images that bring the text to life. pg25-27.indd 27 2/26/07 1:53:29 pm abstract introduction method results ethical considerations discussion limitations of the study conclusion acknowledgments references about the author(s) michael pieters department of clinical imaging sciences, university of the free state, south africa susan otto department of clinical imaging sciences, university of the free state, south africa gina joubert department of biostatistics, university of the free state, south africa citation pieters m, otto s, & joubert g. the histological underestimation of a 9-gauge stereotactic vacuum-assisted breast biopsy system compared with surgical excision at a tertiary hospital in south africa. s afr j rad. 2016;20(1); a818. http://dx.doi.org/10.4102/sajr.v20i1.818 original research histological underestimation of a 9-gauge stereotactic vacuum-assisted breast biopsy system compared with surgical excision at a tertiary hospital in south africa michael pieters, susan otto, gina joubert received: 13 april 2015; accepted: 30 nov. 2015; published: 09 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: breast cancer is a major cause of morbidity and mortality worldwide. certain lesions encountered on mammography require histological assessment of biopsy samples to identify benign versus malignant disease. stereotactic vacuum-assisted breast biopsy (svab) is a useful technique, especially for non-palpable microcalcific lesions, and was introduced at our institution in 2011. objectives: to determine whether the histological underestimation from 9-gauge svabs performed at our institution is within acceptable limits. method: in this cross-sectional study, 9-gauge stereotactic biopsy histology results and breast imaging and reporting data system (bi-rads) findings of 158 lesions (from 153 patients) were analysed and the histological findings compared with surgical excision histology results (54 lesions) to determine histological underestimation (upgrade rates). results: one out of eight cases of ductal carcinoma in situ (dcis) was underestimated, yielding a dcis underestimation rate of 12.5%. conclusion: the dcis underestimation obtained from the present study in our institution was on a par with other authors’ findings and was therefore within acceptable limits. atypical ductal hyperplasia underestimation could not be reliably obtained with the small study population. introduction the most common malignancy in women globally is breast cancer.1 screening mammography reduces breast cancer mortality, but numerous benign abnormalities that cannot be distinguished from malignancy2 are detected on mammography. histological evaluation is therefore required for these abnormalities.2 histologic underestimation occurs when a high-risk or malignant lesion which has been identified on percutaneous biopsy is incompletely characterised.3 examples include ductal carcinoma in situ (dcis) underestimation and atypical ductal hyperplasia (adh) underestimation. dcis underestimation occurs when a lesion characterised as dcis yields infiltrating carcinoma on surgical biopsy. adh underestimation occurs when a lesion characterised as adh on percutaneous biopsy yields carcinoma on subsequent surgery.3 a small sample of a dcis lesion may be interpreted as adh by the pathologist.3 histologic underestimation in lesions containing both adh and dcis as well as lesions containing both dcis and infiltrating ductal carcinoma may be attributed to sampling error.3 the diagnosis of adh or dcis on percutaneous biopsy is an indication for subsequent therapeutic surgical excision because of the risk of carcinoma and invasive carcinoma residing within these lesions.3 an in-depth study by parker et al. showed that percutaneous large-core breast biopsy is a reliable alternative to surgery.4 non-operative accurate diagnosis of benign and malignant disease reduces the number of operations necessary for appropriate staging and management of breast cancer,5 and this is where stereotactic vacuum-assisted biopsy has a role to play. patient selection for neo-adjuvant therapy requires that prognostic information be available from non-operative diagnostic tumour samples. assessment of histological grade on biopsy can aid in preoperative oncological planning and treatment decision-making, despite the limitations associated with the accuracy of grading core biopsies related to tumour sampling.6,7 it follows that the lower an institution’s histological underestimation rate from stereotactic biopsies, the better the patient’s pre-operative management will be. stereotactic vacuum-assisted breast biopsy (svab) yields larger volumes of tissue, allows sampling of lesions that are difficult to sample (microcalcifications, distortions), and allows several biopsies to be taken with a single pass.7 the vacuum-assisted biopsy device is powered by suction and utilises a rotational cutter to obtain several samples as the operator rotates the device through 360 degrees. the sample is suctioned into the specimen port for collection without removing the needle from the biopsy site.7 compared with conventional core-needle biopsy, svab affords less targeting errors and lower underestimation and re-biopsy rates, as well as high patient acceptance, minimal post-procedural complications and good cost-effectiveness.7,8 stereotactic localisation achieves accurate 3-dimensional lesion localisation (figure 1) by utilising 15-degree spatially opposed mammographic images, which forms the basis of svab.9 figure 1: post-fire 15-degree spatially opposed images taken during stereotactic vacuum-assisted breast biopsy. the tissue containing the pathological microcalcifications is suctioned into the open needle aperture before being automatically cut and suctioned into the specimen chamber. on pre-fire images, the needle should be slightly superficial and inferior to the lesion. on post-fire images (shown), the lesion should overlie the needle aperture. percutaneous core-needle biopsy has become the method of choice for the pathologic evaluation of clinically occult breast lesions.10 vacuum-assisted biopsy is currently preferred to core-needle biopsy, especially for subclinical lesions and lesions displaying microcalcifications.11 svab was introduced in 1995 and allows better characterisation of breast lesions than conventional core-needle biopsy by employing larger gauge needles, thus yielding larger tissue specimens12,13 with a sensitivity and a predictive negative value of more than 99%.12 utilisation of larger gauge needles yields more representative tissue samples (figure 2), so decreasing the likelihood of false-negative or false-positive findings.9 figure 2: stereotactic vacuum-assisted breast biopsy specimen view for documentation purposes and confirmation of intra-lesional microcalcifications. the use of a large-gauge needle (9-gauge) yields more representative tissue samples. svab has been offered by the department of clinical imaging sciences, universitas hospital, bloemfontein, south africa, since february 2011. svab is used for non-palpable lesions that are not visible on ultrasound in patients who have been screened by mammography at our institution. the bi-rads scoring system (breast imaging and reporting data system of the american college of radiology)14 is used in our department, and svab is performed on all patients with mammographically demonstrated lesions where lesions are not visible on ultrasound with a bi-rads score ≥ 4. bi-rads 3 lesions that are found in high-risk patients or that show progression on short-term follow-up are also stereotactically biopsied, provided that they are not demonstrable on ultrasound. method the study was conducted at universitas academic hospital, bloemfontein, at the faculty of health sciences of the university of the free state. the study was a cross-sectional study including all patients (totalling 158 mammograms and stereotactic biopsies for 153 patients with a total of 158 lesions) who presented for opportunistic screening mammography and underwent svab at our institution from 01 february 2011 – 01 june 2014. all suspicious lesions that were visible on mammography, but not visible on ultrasound, were selected for svab as per bi-rads guidelines and included in the study population. asymmetric densities and distortions were included in the biopsy criteria, but none was encountered as the sole finding, and consequently all lesions biopsied included microcalcifications. radiographic markers were left in situ after specimen retrieval to aid surgical localisation. all patients with adh, dcis or invasive ductal carcinoma (idc) on svab are routinely booked for surgical excision at our institution. five patients were encountered twice in the data set for biopsies of the contra-lateral breast or separate lesions. data for separate or contra-lateral lesions were incorporated into the dataset. all patients in the study were imaged with a selena dimensions (hologic, massachusetts, usa) unit for mammography, and stereotactic biopsies were performed on a multicare platinum prone table unit (hologic, massachusetts) with a 9-gauge atec breast biopsy and excision system (hologic, massachusetts) (figure 3). figure 3: the suros atec vacuum-assisted biopsy device. all the biopsies were performed by our institution’s breast imaging specialist radiologist. the histopathological data required for the study were retrieved from the universitas hospital’s national health laboratory service digital laboratory results system. our departmental digital radiology picture archiving and communications system (pacs) records were utilised for bi-rads and other information. histological findings at svab and open biopsy were classified into three groups: (1) the malignant category which included idc, tubular carcinoma, mucinous carcinoma and micropapillary carcinoma as well as intermediateor high-grade dcis; (2) intermediate category lesions comprising low-grade dcis, adh and flat epithelial atypia (fea); and (3) benign category lesions that included fibrocystic change, fibroadenoma, papilloma and other (e.g. apocrine metaplasia, sclerosing adenosis, granulomatous inflammation, fat necrosis and fibromatosis). dcis underestimation was defined as all lesions that were upgraded from dcis to idc on open biopsy. adh underestimation was defined as all lesions that were upgraded to carcinoma on open biopsy. the statistical analysis of data was done by the department of biostatistics, faculty of health sciences, university of the free state, bloemfontein. results were summarised by frequencies and percentages with 95% confidence intervals (cis) for underestimation rates. results svab yielded 101 (63.9%) benign category lesions, 7 (4.4%) intermediate category (low-grade dcis, adh and fea) and 45 (28.5%) malignant category lesions (idc and subtypes, intermediateand high-grade dcis), with 5 lesions (3.2%) being non-representative (table 1). of the idc lesions, 2 were reported as exhibiting a mucinous growth pattern and 4 exhibiting a tubular growth pattern. one case of idc was reported to display a micropapillary appearance, with the remainder reported as idc alone. of the 13 dcis lesions, 4 lesions were low-grade dcis, 2 lesions were intermediate-grade dcis, and 7 lesions were high-grade dcis on svab. of 158 lesions that underwent svab, 54 (34.2%) were followed on open biopsy. the average number of passes per biopsy was 6. the mean age of the patients followed on open biopsy was 57 years (range 30 – 77 years) and all were female. all of the 158 lesions that were excised by svab showed microcalcifications on their stereotactic biopsy specimen radiographs, thus yielding a calcification retrieval rate of 100%. table 1: summary of histological findings on svab (n = 158). of the 54 lesions that were followed on open biopsy, 12 yielded benign findings (22.2%), 8 yielded dcis (14.8%), and 34 yielded idc (62.9%). of the 13 dcis cases on svab, 5 were lost to follow-up. one case of dcis was upgraded to idc on open biopsy, yielding a dcis underestimation rate of 12.5% (95% ci 0.3% – 52.7%). two cases (1.3% of lesions) of adh were found on svab in our study population, of which one was upgraded to idc on subsequent open biopsy. a total of 5 (3.2%) svab samples were deemed inadequate for evaluation. of the 158 svabs included in the study, 3 (1.8%) cases had no bi-rads information on record, leaving 155 patients with bi-rads information. seven cases (4.5%) were representative of bi-rads 3, 123 (79.4%) of bi-rads 4, and 25 (16.1%) of bi-rads 5. no bi-rads 1 or bi-rads 2 lesions were encountered in the records for svab. ethical considerations approval to conduct the study was obtained from the ethics committee of the faculty of health sciences, university of the free state (number ecofs 24/2014). patient confidentiality was maintained throughout. discussion internationally, false-negative rates for svab range from 1.3% – 3.3%, with underestimation rates from 11.8% – 28.6%.7 siegmann et al. found in their study population of 166 stereotactic biopsies using a mammotome system (breast care, ethicon endo-surgery, norderstedt, germany) that the histology of a sufficient vacuum-assisted biopsy was underestimated in 15% of their study population when compared with histology at excision.15 salem et al. reported an overall underestimation rate of 9.6% for high-risk lesions and a dcis underestimation rate of 19.2% for a hand-held vacuum-assisted stereotactic biopsy device (vacora vacuum-assisted biopsy system, bard, tempe, usa) in a study population of 288 stereotactic biopsies.12 of the 13 cases of dcis on svab in our study, 8 were followed with surgical excision, of which 1 case was upgraded to idc on open biopsy, yielding a dcis underestimation rate of 12.5%. this figure compares favourably with the dcis underestimation rate of 12% found in a study by kettritz et al.,2 of 23% in a study by laurenco et al.,5 and of 0% – 19% quoted in the review article by liberman.3 two cases of adh were found on svab in our study population, of which one was upgraded to idc on subsequent open biopsy. a study by khor16 (991 patients) in 2010 investigated the histological underestimation rate of adh and showed an underestimation rate of 19.8%. a larger study population would probably have yielded more cases of adh, with better clarification of adh underestimation at our institution. furthermore, the lack of an official screening programme (our institution offers opportunistic screening only) with the resultant lower volume of mammographic examinations might have contributed to the low adh yield. of the total svab biopsy population with available bi-rads information in our study, 79.4% were bi-rads 4 lesions, 4.5% were bi-rads 3, and 16.1% were bi-rads 5. no bi-rads 1 or 2 lesions were biopsied stereotactically. seven bi-rads 3 lesions were found in high-risk patients, and these lesions were stereotactically biopsied. these figures are in keeping with current practice of obtaining histology through biopsy on all patients with bi-rads scores of 4 and 5, and short-term follow-up with possible biopsy for bi-rads 3 lesions. a factor that became evident from the present study is that many patients were not followed up with open biopsy. of a total of 158 svabs, 104 were not followed up with biopsy. the main reason for this is that most patients had benign lesions on svab that did not require open biopsy. twenty-one patients (20.2%) with non-benign lesions were also not followed up with biopsy. possible reasons for this include low socio-economic status, theatre backlogs, long-distance travel to the hospital, and the demise of patients. this finding needs to be further investigated. limitations of the study the largest limiting factor was the small study population. as our institution started performing svabs only in february 2011, the study population was not expected to be large, but most probably sufficient to gain a perspective on whether or not we were obtaining an acceptable histological yield. a second possible limiting factor is the fact that a single operator performed all the svabs, and hence the possible effect of a learning curve when initially using the stereotactic biopsy system. conclusion the dcis underestimation for our institution is on a par with other authors’ findings and is therefore within acceptable limits. a revisitation of biopsy techniques and equipment is accordingly not deemed necessary to improve histological yield at our institution, although our findings warrant further investigation in order to gain a more accurate perspective, as adh underestimation could not be reliably obtained with the small study population. acknowledgments competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.p. (ufs) was the main author, responsible for the protocol, data collection and analysis, and compilation of the manuscript. g.j. (ufs) did the biostatistical analysis and proofreading. s.o. (ufs) was the study leader, and did the conceptualisation and proofreading. references world health organization. the global burden of disease 2004 update. geneva: world health organization, 2004; p. 13. kettritz u, rotter k, schreer i, et al. stereotactic vacuum-assisted breast biopsy in 2874 patients: a multicenter study. cancer. 2004;100:245–251. http://dx.doi.org/10.1002/cncr.11887 liberman l. percutaneous imaging-guided core breast biopsy. am j roentgenol. 2000;174:1191–1199. http://dx.doi.org/10.2214/ajr.174.5.1741191 parker sh, burbank f, jackman rj, et al. percutaneous large-core breast biopsy: a multi-institutional study. radiology. 1994;193:359–364 http://dx.doi.org/10.1148/radiology.193.2.7972743 lourenco ap, mainiero mb, lazarus e, giri d, schepps b. stereotactic breast biopsy: comparison of histologic underestimation rates with 11and 9-gauge vacuum-assisted breast biopsy. am j roentgenol. 2007;189:275–279. http://dx.doi.org/10.2214/ajr.07.2165 rakha ea, reis-filho js, baehner f, et al. breast cancer prognostic classification in the molecular era : the role of histological grade. breast cancer res. 2010;12:207 http://dx.doi.org/10.1186/bcr2607 o’flynn eam, wilson arm, michell mj. image-guided breast biopsy: state-of-the-art. clin radiol. 2010;65:259–70. http://dx.doi.org/10.1016/j.crad.2010.01.008 lee ke, kim hh, shin hj, cha jh. stereotactic biopsy of the breast using a decubitus table: comparison of histologic underestimation rates between 11and 8-gauge vacuum-assisted breast biopsy. springerplus. 2013;2:551. http://dx.doi.org/10.1186/2193-1801-2-551 neal l, tortorelli cl, nassar a. clinician’s guide to imaging and pathologic findings in benign breast disease. mayo clin proc. 2010;85:274–279. http://dx.doi.org/10.4065/mcp.2009.0656 margenthaler ja, duke d, monsees bs, barton pt, clark c, dietz jr. correlation between core biopsy and excisional biopsy in breast high-risk lesions. am j surg. 2006;192:534–537. http://dx.doi.org/10.1016/j.amjsurg.2006.06.003 graesslin o, antoine m, chopier j, et al. histology after lumpectomy in women with epithelial atypia on stereotactic vacuum-assisted breast biopsy. eur j surg oncol. 2010;36:170–175. http://dx.doi.org/10.1016/j.ejso.2009.09.002 salem c, sakr r, chopier j, marsault c, uzan s, daraï e. accuracy of stereotactic vacuum-assisted breast biopsy with a 10-gauge hand-held system. the breast. 2009;18:178–182. http://dx.doi.org/10.1016/j.breast.2009.03.007 bianchi s, caini s, renne g, et al. positive predictive value for malignancy on surgical excision of breast lesions of uncertain malignant potential (b3) diagnosed by stereotactic vacuum-assisted needle core biopsy (vancb): a large multi-institutional study in italy. the breast. 2011;20:264–270. http://dx.doi.org/10.1016/j.breast.2010.12.003 d’orsi c, sickles e, mendelson e, morris e. acr bi-rads atlas, breast imaging reporting and data system. reston: american college of radiology; 2013. siegmann kc, wersebe a, fischmann a, et al. stereotactic vacuum-assisted breast biopsy – success, histologic accuracy, patient acceptance and optimizing the bi-rads-correlated indication. rofo. 2003;175:99–104. http://dx.doi.org/10.1055/s-2003-36600 kohr jr, eby pr, allison kh, et al. risk of upgrade of atypical ductal hyperplasia after stereotactic breast biopsy: effects of number of foci and complete removal of calcifications. radiology. 2010;255:723–730. http://dx.doi.org/10.1148/radiol.09091406 a. patients usually become symptomatic when larval cysts elicit space-occupying effects. by this time, extensive multi-organ involvement may be present, as was demonstrated in this case. b. by the time of the symptomatic stage, extensive multi-organ involvement may be present, as was demonstrated in this case. c. humans are accidental hosts and are infected by the ingestion of ova from fomites. d. after ingestion, embryos escape from the ova, penetrate the intestinal mucosa and enter the portal system from where they are carried to various organs, most commonly the liver and the brain. 2. which one of the following statements does not apply to echinococcus disease? cpd questionnaire give one correct answer for each question. 20 sa journal of radiology • march 2009 1. regarding echinococcus disease, choose one false answer. a. presentations may include anaphylaxis, pathological fractures, neurological deficit, pericarditis, arrhythmias and pelvic masses. b. treatment is based on considerations of the size, location and manifestations of the cysts, as well as the overall health of the patient; it should always be preceded by needle biopsy. c. radiographic imaging studies are important in detecting and evaluating echinococcal cysts. plain films will reveal unruptured pulmonary cysts as rounded masses of uniform density. d. ruptured cysts result in complex cavitary lesions with variable radiographic features, which include: an air-fluid level, a floating membrane (water-lily sign), a double wall, an essentially dry cyst with crumpled membranes (serpent sign, rising sun sign) or an empty cyst. 3. which one of the following statements is false? a. a hydatid cyst may be found in almost any part of the body; however, a primary chest wall cyst is rare. b. a possible mechanism of primary hydatid disease of the chest wall may be for the embryo to pass through the colonic wall into either the portal vein or thoracic duct. c. the natural course of costal echinococcosis starts when the larvae lodge in the rib and buds start vegetating out of the mother cyst to produce a multilocular cavity. d. the primary rib lesion is multiloculated and osteolytic and continues to grow slowly. 5. which one of the following statements is false? a. the most commonly described type of renal fusion anomaly is the horseshoe kidney. b. the horseshoe kidney consists of two distinct functioning kidneys on each side of the midline, and is more likely to be connected at the lower poles by an isthmus of functioning renal parenchyma or fibrous tissue that crosses the midline of the body. c. the reported frequency of horseshoe kidney ranges from 1 in 400 live births to 1 in 800 live births, and is twice as common in females as in males. d. no genetic determinant is known, although it has been reported in identical twins and in siblings within the same family. 6. identify the one correct statement among the following choices: a. as the internal cerebral veins develop, the anterior portion of the median prosencephalic vein of markowski regresses and the posterior portion remains to form the vein of galen. b. vein of galen aneurysmal malformation accounts for up to 50% of paediatric vascular malformations. c. it is believed that the vein of galen aneurysmal malformation is the result of an arteriovenous connection between the primitive perforating arteries and the prosencephalic vein of markowski. d. the abnormal flow in these connections allows the involution of the prosencephalic vein of markowski. 7. regarding vein of galen aneurysm, all the following are false except: a. vein of galen aneurysmal malformation is divided into choroidal and mural types, based on the venous drainage. b. the choroidal type is supplied by all the choroidal arteries, with an interposed network opening into a midline venous pouch. the arterial feeders are usually bilateral in the choroidal type, and this type is associated with cardiac failure in the neonate. c. in the mural type, direct av fistulae open on the wall of the internal cerebral vein. d. presentation of vein of galen aneurysm depends on the age of the patient. older infants and children often present with high-output cardiac failure. 8. identify the one false statement among the following: a. short stature is a frequent presenting problem in the paediatric population, and turner syndrome is frequently considered in the differential diagnosis in females. b. turner syndrome can easily be ruled out with chromosome analysis. c. advances in the field of genetics have estimated that about 2% of idiopathic short stature is related to haploinsufficiency of the short stature homeobox (shox) gene, which is found on the short arm of the x and y chromosomes in the pseudoautosomal region. d. madelung deformity is diagnostic of leriweill dyschondrosteosis. 9. regarding short stature, identify a single false statement from the following: a. shox-related haploinsufficiency disorders are estimated to have a prevalence of 1/4 000 and are known to account for a not insignificant proportion of cases of idiopathic short stature. b. shox mutations can lead to langer mesomelic dysplasia. c. bilateral madelung deformities exclude turner syndrome. d. the differential diagnosis of leri-weill disease includes turner syndrome, growth hormone deficiency and idiopathic short stature. 10. the optimum way of completing your quiz and generating your cpd certificate is via: a. �heat magazine. b. tattersall’s. c. the hpcsa has probably forgotten about this issue (maybe let’s also just forget about it). d. go to www.cpdjournals.org.za and do it digitally. a. conjoined twins are rare variants of monozygotic twins. b. conjoined twins result from incomplete division of the embryonic disk. c. the incidence is estimated to be about 1 in 250 000 live births, with a strong male predominance. d. there are many types of conjoined twins, and they are usually classified at the point at which they are fused. 4. which one of the following features is not associated with conjoined twins? see previous page for cpd instructions. cpd instructions: 1. cpd questionnaires must be completed online by going directly (not via google) to www. cpdjournals.org.za, and registering. you will then receive an email notifying you of your username and password for subsequent logging on. 2. read the articles in the journal to find the answers to the questions. 3. after completing the questionnaire, you can check the answers and print your own cpd certificate. questions may be answered up to 6 months after publication of the journal issue concerned. 4. please contact gertrude fani on 021 681 7200 or gertrude@hmpg. co.za in the event of queries. cpd.indd 20 3/12/09 2:08:17 pm article information authors: shalendra misser1 john zietkiewicz1 affiliation: 1lake smit and partners inc., durban, south africa correspondence to: shalendra misser email: misser@lakesmit.co.za postal address: unit 301, 7 poynton place, musgrave 4001, durban, south africa dates: received: 13 feb. 2015 accepted: 18 feb. 2015 published: 04 june 2015 how to cite this article: misser, s, zietkiewicz, j. answer to musculoskeletal imaging quiz case. s afr j rad. 2014;19(1); art. #792, 5 pages. http://dx.doi.org/10.4102/sajr.v19i1.792 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. answer to musculoskeletal imaging quiz case in this quiz case... open access • case findings and diagnosis • discussion • acknowledgements    • competing interests • references case findings and diagnosis top ↑ no correct answer was received for this musculoskeletal quiz case. the patient, a 34-year-old female runner, presented with a 6-week history of right hip pain that progressed slowly. she curtailed her physical activity, but was still able to continue with her other daily living activities. at the time of initial presentation, a plain radiograph (figure 1) was performed, demonstrating subtle lytic foci in the right supra-acetabular ileum and right lesser trochanter. no surrounding sclerotic rim or soft-tissue fat plane displacement was noted. preliminary radiographic differential diagnoses included multiple myeloma, osteolytic metastatic disease, eosinophilic granulomas or cystic angiomatosis. initial blood tests confirmed normal haemoglobin, serum calcium, liver function, urea and electrolytes. figure 1: plain radiograph of the right hip. source: authors own work figure 2 and figure 3 are axial t2-weighted and sagittal proton-density (pd)-weighted magnetic resonance images respectively of the right hip, showing the circumscribed hyperintense lesser trochanteric lesion with reactive surrounding soft-tissue hyperintensity including the iliopsoas tendon insertion. a computed tomography (ct) scan of the chest (figure 4) suggested borderline splenic enlargement with areas of low attenuation in the body of the spleen. the other organs were not involved. figure 5a and figure 5b are coronal t1 and pd images of the pelvic girdle demonstrating several focal lesions, with t1 shortening and corresponding hyperintensity on the pd sequence. the lesions, of varying size, measured up to a centimeter, with preserved margins, no significant periosteal reactions or adjacent soft-tissue masses. figure 2: axial t2-weighted mr image of the right hip. source: authors own work figure 3: sagittal proton-density mr image of the right hip. source: authors own work figure 4: coronal ct reformat of the chest and abdomen. source: authors own work figure 5: coronal t1-weighted mr image (a) of the pelvis, and coronal pd mr image (b) of the pelvis. source: authors own work a ct scan of the pelvis (figure 6a) was performed on follow-up to re-evaluate the lesser trochanter focus. this showed a little internal density within the trochanteric lesion and small lytic foci at both iliac bones. ct angiography (figure 6b) did not show any significant neovascularisation or prominent vasculature of aneurysmal bone cysts. we performed a ct-guided biopsy (figure 7) of the right lesser trochanteric lesion. histopathological analysis demonstrated cystic vascular spaces, lined by a single layer of endothelial cells, separated by thin intervening spindled stroma. immunochemistry showed cd34/cd31 positivity, and the histological conclusion was that of a vasoformative lesion with local bony destruction compatible with cystic angiomatosis. figure 6: coronal ct reformat image (a) of the right hip, and volume-rendered cta reformat (b) of the right hip. source: authors own work figure 7: axial ct image acquired in biopsy mode. source: authors own work as the patient had single visceral organ involvement, splenectomy was subsequently performed. she has since had close clinical and radiological follow-up. unfortunately, at recent follow-up the patient was found to have several angiomatous lesions of her liver and several further skeletal lesions, and she is currently unwell. figure 8a to figure 8c are selected images from recent magnetic resonance scanning – whole body screening, t2-weighted sequence. figure 8a demonstrates several rib lesions. figure 8b shows the presence of angiomas of the liver, and new bony lesions at the humeri and in the spine. figure 8c reveals the more confluent angiomatous infiltration of the right lobe of the liver anteriorly. ultrasound of the liver (figure 9) shows the infiltrative mixed, predominantly echogenic, lesions of the liver in keeping with multiple angiomas. her prognosis is now poor. figure 8: t2-weighted coronal sequence images (a, b and c) demonstrating rib lesions, hepatic angiomas and new skeletal foci. source: authors own work figure 9: ultrasound image of the liver demonstrating infiltrative angiomatous lesions in both liver lobes. source: authors own work discussion top ↑ cystic angiomatosis of bone (cab) is a rare pathologic entity characterised by several cysts of varying sizes involving the skeleton. first described in 1953 by jacobs and kimmelsteil,1 several synonyms have been used including haemangiomatosis, lymphangiomatosis and hamartomatous haemolymphangiomatosis. the reason for this overlap between haemangioma and lymphangioma is most apparent on histopathology where, even in an individual patient, there may be significant variability in the degree of expression. some areas of a cystic lesion may be filled with blood constituents whilst others may contain proteinaceous material akin to haemangiomas and lymphangiomas respectively.2,3,4,5 cab is usually a disease of younger patients affecting adolescents and young adults, and rarely occurring in older persons. there is no significant gender predilection; however, some authors indicate a slightly increased incidence in young men.3,4 patients with cab may be completely asymptomatic or may experience some bone pain even in the absence of any pathological fractures.2 the clinical course and severity depends largely on the presence of visceral and soft-tissue involvement, which has been reported in up to 60%–70% of affected individuals.2 the spleen is almost always involved in such instances. other organs that may be involved include the pleura, lung, peritoneum, liver, kidneys, mesentery and lymphatic tissue. in these patients, cab has been referred to as 'skeletal-extraskeletal angiomatosis’,6 with the disease more progressive, and it can result in early death.5 concepts regarding the aetiology of cab have varied in the last six decades. in 1972, boyle3 purported two possible pathomechanisms: (1) a true metastasising angioma or (2) a multicentric congenital malformation such as a vascular hamartoma. support has followed for the latter in more recent times.4 cab commonly affects the axial skeleton, particularly the pelvis, ribs, spine and skull. of the appendicular skeleton, the femur, humerus and scapula may also be frequently involved, but hands and feet are usually spared. roentgen features of cab (table 1) include well-circumscribed round or ovoid cysts, usually numerous, with some lesions that may show expansion and peripheral sclerosis. the sparing of the overlying cortex and absence of periosteal reactions are typical, but the converse may be true if a pathological fracture develops. a honeycomb or lattice-work pattern is also described, and resembles a solitary bony haemangioma radiographically.5 table 1: radiographic features of cystic angiomatosis of bone. on ct scans, lesions are lytic and well-circumscribed, sometimes demonstrating peripheral sclerosis. pathological fractures are better delineated on ct scanning, and multiplicity, which may be radiographically occult, becomes more obvious. mri signal characteristics of cab lesions include t1-weighted low-to-intermediate signal intensity depending on the internal fat content within the lesion. corresponding t2-weighted high-signal intensity is shown in cab lesions owing to vascular and cystic/fluid components.2 there is a wide differential diagnosis (table 2) for cab. eosinophilic granulomas typically occur in younger patients, before age 30, and can affect the skull up to five times more frequently than any other site.3 hepatosplenomegaly is a feature of letterer-siwe disease but this syndrome, associated with histiocytosis, largely occurs in very young children. furthermore, cortical destruction with coalescence of adjacent lesions is commonly seen in eosinophilic granulomas. table 2: differential diagnosis of cystic angiomatosis of bone. multiple myeloma is rare in persons under the age of 40 years. lytic lesions tend to be of similar size and, when present, relate to earlier disease progression. serum protein electrophoresis can identify a gammopathy, aiding diagnosis confirmation. sarcoidosis can affect bone with non-caseating granulomas resulting in solitary or multiple lytic lesions that may be expansile and tend to involve bony cortex in addition to the medullary cavity. visceral involvement in sarcoidosis and storage diseases such as gaucher's disease may lead to hepatosplenomegaly, making these mimickers of cab. one should look for additional features of erlenmeyer flask deformities of the femora or aseptic necrosis in patients with gaucher's disease. in hyperparathyroidism, the cystic bone lesions generally lack a surrounding rim of sclerosis, which may also be seen in cab. skull involvement is rare, and vertebral involvement owing to renal osteodystrophy may produce a ‘rugger jersey’ spine appearance. polyostotic fibrous dysplasia lesions are usually unilateral, and the bony lesions demonstrate an opalescent ground glass appearance. a skull base predilection is common and, conversely, visceral involvement is unusual in fibrous dysplasia. enchondromas are more commonly solitary and generally demonstrate intralesional calcification with matrix mineralisation, resulting in some internal t2-weighted low signal. gorham disease, which may be histologically indistinguishable from cab, is particularly destructive, with solitary osseous involvement being the rule. treatment for cab is largely symptomatic. analgesics suffice for bone pain and, when bony remodelling occurs, biphosphonates may be prescribed. occasionally, surgery is required for bony lesions including for the repair of displaced pathological fractures. local radiotherapy and chemotherapy have been used for skeletal lesions but these measures have not been shown to alter the outcome. if the spleen is the sole visceral organ involved, splenectomy may be performed.2,6 cab has radiographic features that are not specific and overlap considerably with other vascular or lytic lesions of bone. a radiologist's knowledge of this entity and its imaging characteristics is vital in guiding the clinical investigation and management of affected individuals. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. references top ↑ jacobs jf, kimmelstiel p. cystic angiomatosis skeletal system. j bone joint surg am. 1953;35-a:409–420. ballina-garcia fj, queiro-silva mr, molina-suarez r, fernandez-martinez j, rivela-vasquez m, rodriguez-perez a. multiple painful bone cysts in a young man. ann rheum dis. 1996;55:346–349. http://dx.doi.org/10.1136/ard.55.6.346 boyle wj. cystic angiomatosis of bone. a report of three cases and review of the literature. j bone joint surg br. 1972;54:626–636. lateur l, simeons cj, gryspeerdt s, samson i, mertens v, van damme b. skeletal cystic angiomatosis. skeletal radiol. 1996;25:92–95. http://dx.doi.org/10.1007/s002560050042 murphey md, fairbairn kj, parman lm, baxter kg, parsa mb, smith ws. from the archives of the afip. musculoskeletal angiomatous lesions: radiologic-pathologic correlation. radiographics. 1995;15:893–917. http://dx.doi.org/10.1148/radio­graphics.15.4.7569134 clayer m. skeletal angiomatosis in association with gastro-intestinal angiodysplasia and paraproteinemia: a case report. j orthop surg (hong kong). 2002;10:85–88. radiology 20 sa journal of radiology • february 2005 abstract hypertensive encephalopathy (he) is a clinical syndrome that occurs infrequently in children and is often underdiagnosed. we review four patients with he and describe their clinical presentation and radiological findings on computed tomography (ct). our cases demonstrate typical features on ct and correlate clinically with the syndrome of he. prompt recognition of the syndrome aids in earlier diagnosis and treatment, and hence proves beneficial to the patient. introduction hypertensive encephalopathy (he) is a clinical syndrome consisting of rapidly progressive symptoms and signs. it occurs in the setting of acute and/or prolonged systemic hypertension that disrupts cerebral autoregulation. recent studies involving the pathophysiologic mechanisms of he have postulated that cerebral vascular vasodilatation from high-pressure autoregulatory failure results in increased vascular permeability and cerebral oedema.1,2 the clinical features include headache, seizures, visual disturbances, altered mental state and focal neurological signs. delayed diagnosis can prove fatal for the patient, but with treatment there is usually full recovery. he is rare in paediatric patients and frequently presents in conjunction with a systemic disorder. the clinical presentation and ct findings of 4 recently identified paediatric cases with he as a complication of renal disease are reviewed. case 1 a 10-year-old boy presented with headaches, facial swelling, visual impairment, vomiting and a rightsided focal seizure which became generalised. his legs were covered with old impetiginous skin lesions, his antidnase b levels were raised at 480 (titre) (normal < 200) and he was diagnosed with acute post-streptococcal glomerulonephritis. renal function on presentation was fairly well preserved (urea 7.4 mmol/l and creatinine 61 umol/l), but the blood pressure (bp) at admission was raised at 140/91 mmhg (the 95th percentile for his height is 116/78 mmhg). ct demonstrated low density areas in the subcortical white matter of the cerebellar hemispheres and in the posterior parietal parafalcine regions bilaterally (fig. 1). case 2 a 10-year-old girl presented with acute renal failure and hypertension with a bp of 149/86 mmhg (95th percentile for her height – 118/78 case report hypertensive encephalopathy with ct confirmation in four children with acute renal disease s andronikou mb bch, fcrad (diag) (sa), frcr (lond) m patel mb chb, fcrad (diag) (sa) department of paediatric radiology red cross children’s hospital and university of cape town p sinclair mb chb, dch (sa), fcp paeds (sa) m mcculloch mb chb, dch (sa), dtm&h (lond), mrcpch (lond), fcp paeds (sa) department of paediatric nephrology red cross children’s hospital and university of cape town fig. 1. axial post-contrast ct scan of the brain shows bilateral parafalcine posterior parietal white matter low densities (arrows) without associated enhancement. radiology 2/24/05 4:50 pm page 20 mmhg). she subsequently developed seizures and became progressively obtunded. a history of recurrent pharyngitis was elicited. renal function on presentation was extremely deranged (urea 65 mmol/l and creatinine 1 095 umol/l). asot (antistreptolysin o titre) was > 2 560 iu (normal < 200) and antidnase b 1 960 (titre). renal biopsy showed rapidly progressive post-infective nephritis with crescents. peritoneal dialysis was required for 7 days and she responded well to steroids and cyclophosphamide. creatinine at discharge from hospital was 56 umol/l. in view of her seizures, a ct scan was performed. ct showed low-density changes within the white matter of the high occipital and posterior parietal regions on either side of the midline, with focal areas of peripheral enhancement (fig. 2). case 3 a 10-year-old boy presented with a 2-day history of generalised body swelling, dark urine, vomiting and headaches and also a past history of skin infections. clinically, there were widespread impetiginous lesions together with a scabies infestation. at presentation he had a generalised tonic-clonic seizure and was poorly responsive with a bp of 164/107 mmhg (95th percentile for his height – 113/74 mmhg). his renal function deteriorated rapidly and peaked at a urea of 14.5 mmol/l and a creatinine of 114 umol/l, but settled to a urea of 6.2 mmol/l and creatinine of 55 umol/l on discharge 5 days later. antidnaseb was greater than 2 560 (titre) and asot was 320 iu, and therefore a diagnosis of post-streptococcal glomerulonephritis was made. at ct there were symmetrical white matter hypodensities in the high parietal parasagittal regions (fig. 3). case 4 an 8-year-old boy with acute renal failure as the result of tumour lysis after chemotherapy for burkitt's lymphoma, presented with a seizure. the bp at the time was 133/102 mmhg (95th percentile for his height 113/76 mmhg). he also had pulmonary oedema and was clinically fluid overloaded. urea was 21 mmol/l, creatinine 205 umol/l, uric acid 0.61 mmol/l and lactate dehydrogenase (ldh) 1 300 u/l. he was placed on haemodialysis for a week and recovered his renal function (urea 2.4 mmol/l and creatinine 35 umol/l). ct scan showed bilateral, assymetrical cortical and subcortical hypodensities in the cerebellar hemispheres, as well as in the posterior parietal regions. no associated enhancement was noted (fig. 4). a repeat ct scan after 2 months demonstrated complete resolution. discussion although clinical hypertension occurs less frequently in children than in adults, it still has significant consequences. new data for normal bp ranges are available for children and adolescents, and depend on height case report 21 sa journal of radiology • february 2005 fig. 2. post-contrast ct scan of the brain demonstrates bilateral parafalcine areas of low density in the posterior parietal and occipital white matter (straight arrows). there is focal enhancement at the periphery (curved arrow). fig. 3. axial post-contrast ct scan of the brain shows subtle parasagittal white matter low densities in the high parietal regions (arrows). fig. 4. axial post-contrast ct scan of the brain demonstrates bilateral assymetrical hypodensities in the cortical and subcortical regions of the cerebellar hemispheres with no associated enhancement (arrows). radiology 2/24/05 4:50 pm page 21 22 sa journal of radiology • february 2005 percentiles, age and gender.3 each of the children in our cases was plotted on these charts and had elevated bps on presentation. clinically, they all had features of hypertensive encephalopathy, presenting with seizures. typically in he, cerebral imaging indicates oedema in the posterior temporal, parietal and occipital regions, predominantly in the paramedian subcortical white matter.4 the oedema appears hypodense on ct and may enhance post contrast. on t2-weighted magnetic resonance imaging (mri), these areas show increased signal intensity and on diffusion-weighted imaging, there are no features of ischaemia or infarction.1,2 abnormalities have also been reported in the parieto-occipital areas, frontal lobes, basal ganglia, brainstem and cerebellum, but occur less often.2 further confirmation of the diagnosis is obtained with resolution of the imaging abnormalities after normalisation of the blood pressure. if the bp is not normalised, irreversible cerebral ischaemia and infarction or haemorrhage may result. it is reasonable to assume that the precise range of cerebral blood flow autoregulation is lower in children than adults. children may develop he at a lower absolute bp than adults. although several paediatric cases of he have been reported, a limited number have been documented or illustrated with ct or mri findings.1,5-10 the 4 cases reviewed showed characteristic imaging abnormalities of he on ct. at follow-up all 4 patients were found to have neither neurological symptoms nor any clinical sequelae. however, confirmation was not obtained with a repeat radiological investigation in each case. in conclusion, he is often underdiagnosed in children and early recognition of characteristic radiographical findings on ct or mri allows for the implementation of appropriate antihypertensive therapy with the potential for complete neurological recovery. references 1. cooney mj, bradley wg, symko sc, et al. hypertensive encephalopathy: complications in children treated for myeloproliferative disorders — report of three cases. radiology 2000; 214: 711-716. 2. schwartz rb, mulkern rv, gudbjartsson h, jolesz f. diffusion-weighted mr imaging in hypertensive encephalopathy: clues to pathogenesis. am j neuroradiol 1998; 19: 859-862. 3. national high blood pressure education program working group on hypertension control in children and adolescents. update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from the national high blood pressure education program. pediatrics 1996; 98: 649-658. 4. schwartz rb, jones km, kalina p, et al. hypertensive encephalopathy: findings on ct, mr imaging, and spect imaging in 14 cases. am j roentgenol 1992; 159: 379 -383. 5. jones bv, egelhoff jc, patterson rj. hypertensive encephalopathy in children. am j neuroradiol 1997; 18: 101-106. 6. pavlakis sg, frank y, chusid r. hypertensive encephalopathy, reversible occipitoparietal encephalopathy, or reversible posterior leukoencephalopathy: three names for an old syndrome. j child neurol 1999; 14: 277-281. 7. kandt rs, caoili aq, lorentz wb, elster ad. hypertensive encephalopathy in children: neuroimaging and treatment. j child neurol 1995; 10: 236-239. 8. assadi fk, lansky ll, john eg, helgason cm, tan ws. acute hypertensive encephalopathy in minimal change nephrotic syndrome. child nephrol urol 1990; 10: 96-99. 9. shanley dj, sisler cl. mr demonstration of reversible cerebral lesions in a child with hypertensive encephalopathy caused by wilms' tumor. am j roentgenol 1992; 158: 1161-1162. 10. weingarten k, barbut d, filippi c, zimmerman rd. acute hypertensive encephalopathy: findings on spin-echo and gradientecho mr imaging. am j roentgenol 1994; 162: 665-670. case report australia radiologists attractive terms and conditions in sunny and secure melbourne an opportunity to work in a private, patient focussed environment, employing state of the art equipment including stereotaxis & mammatome in victoria. a complete spectrum of breast disease presents in this unit, which operates in close association with the multi-disciplinary breast unit @ mercy, affording a unique relationship with the breast surgeons. our migration agent will assist with visa and registration applications please forward your detailed c.v. via email: grace@austmigrate.com.au fax: 61 3 98527889 • tel: 61 3 98527095 radiology 2/24/05 4:50 pm page 22 sa journal of radiology • december 2010 125 quiz case presentation an active 43-year-old woman hockey player presented with subacute left hip pain after a mountain-biking accident. the following images were obtained. we invite you to describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to shalendramisser@hotmail.com by 10 february 2011. the winning respondent will receive a r1 000 prize from the rssa. a detailed diagnosis will appear in the next issue of the sajr. musculoskeletal case s k misser, mb chb, fcrad (d) p mercouris, mb bch, ff rad lake smit and partners, durban fig. 1 unenhanced coronal fat-suppressed proton density mri sequences. figs 1a c from anterior to posterior. fig. 2. serial axial fat-suppressed proton density mri sequences. 1a 1b 1c 2a 2b abstract introduction research method and design ethical considerations results discussion conclusion acknowledgements references about the author(s) richard j. cormack rca diagnostics, calgary, canada mollie c.m. ferris foothills medical centre, university of calgary, canada jason k. wong foothills medical centre, university of calgary, canada stefan przybojewski foothills medical centre, university of calgary, canada citation cormack rj, ferris mcm, wong jk, przybojewski s. splenic artery embolisation in the non-operative management of blunt splenic trauma in adults. s afr j rad. 2016;20(1), a1014. http://dx.doi.org/10.4102/sajr.v20i1.1014 original research splenic artery embolisation in the non-operative management of blunt splenic trauma in adults richard j. cormack, mollie c.m. ferris, jason k. wong, stefan przybojewski received: 11 apr. 2016; accepted: 25 aug. 2016; published: 23 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the purpose of this study was to evaluate the splenic salvage rate with angioembolisation in the non-operative management (nom) of blunt splenic injury. methods: we conducted a retrospective analysis of patients presenting to our level i trauma centre with computed tomography (ct)-confirmed splenic injury following blunt trauma and in whom angioembolisation was utilised in the algorithm of nom. data review included ct and angiography findings, embolisation technique and patient outcomes. results: between january 2005 and april 2010, 60 patients with splenic injury following blunt trauma underwent nom, which included splenic artery embolisation (sae). all patients included in the study required a preadmission. ct scan was used to document the american association for the surgery of trauma (aast) grade of splenic injury. the average injury grade was 3.0. the non-operative splenic salvage rate following sae was 96.7% with statistically similar salvage rates achieved for grades ii to iv injuries. the quantity of haemoperitoneum and the presence of a splenic vascular injury did not significantly affect the splenic salvage rate. the overall complication rate was 27%, of which 15% were minor and 13% were major. conclusion: sae is a safe and effective treatment strategy in the nom of blunt splenic injury. the quantity of haemoperitoneum, the presence of vascular injury and embolisation technique did not significantly affect the splenic salvage rate. introduction at our institution, haemodynamically stable patients with blunt splenic injury are managed non-operatively with the goal of preserving splenic function by avoiding splenectomy. in blunt splenic trauma, non-operative management (nom) generally includes bed rest, limited oral intake and close clinical and biochemical observation. however, high failure rates, necessitating splenectomy, have been reported for observational nom alone in patients with american association for the surgery of trauma (aast) grades iii to v splenic injuries and those demonstrated to have vascular injuries.1,2,3 splenic artery embolisation (sae) has increasingly been utilised as an adjunct to nom in order to improve splenic salvage rates.2,4,5,6,7 patients with suspected splenic trauma who are candidates for nom should have a contrast-enhanced computed tomography (ct) scan to evaluate and grade the extent of injury.4 ct can accurately assess the severity of splenic injury using the aast grade, estimate the volume of haemoperitoneum, characterise vascular injuries and help direct appropriate therapy.3,8 the primary purpose of this study was to determine the splenic salvage rate in the nom of blunt splenic injury. the secondary purpose was to evaluate the complications of sae. research method and design all patients admitted to our level i trauma centre, between january 2005 to april 2010, who underwent sae for blunt splenic injury, were retrospectively reviewed. patient demographics included age and sex. by study design, all patients included in the analysis required documentation of splenic injury on an admission ct scan. all pre-procedure ct scans were retrospectively reviewed by an interventional radiologist and a program-year 4 radiology resident for evidence of a vascular injury (i.e. arteriovenous fistula [avf], pseudoaneurysm [pa], vessel truncation and active extravasation of intravenous [iv] contrast), estimation of the volume of haemoperitoneum and determination of aast injury grade. significant haemoperitoneum was defined as blood extending beyond the perisplenic recesses. if a post-procedural ct scan was obtained, it was reviewed for evidence of a complication, including splenic infarction, abscess formation, pleural effusion and persistent or new vascular injury. the splenic angiograms and procedural notes were reviewed for the findings that necessitated embolisation, the sae technique and the embolic agent used. the sae technique consisted of main sae (figure 1), selective distal branch vessel embolisation (figure 2) or a combined main and distal sae (figure 3). the technique and embolic agents used for the sae were at the discretion of the performing interventional radiologist. figure 1: fluoroscopic images demonstrating: (a) angiography of the main splenic artery and (b) coil embolisation of the proximal main splenic artery. figure 2: fluoroscopic images demonstrating: (a) angiography of the main splenic artery with a splenic contusion and pseudoaneurysm formation and (b) coil embolisation of both the proximal main and distal (black arrow) splenic branches. figure 3: fluoroscopic images demonstrating: (a) angiography of the main splenic artery showing pseudoaneurysm and arteriovenous fistula formation in the lower pole of the spleen and (b) combined distal and proximal coil embolisation. the primary outcome of the study was splenic salvage, defined as the percentage of patients not requiring splenectomy. splenic salvage rates were analysed, taking into consideration the aast injury grade, quantity of haemoperitoneum and the presence of a vascular injury. failure of nom was defined as the need for abdominal surgery during hospital admission regardless of the indication. post-procedure, patients were assessed clinically for evidence of complications. follow-up ct examination was performed in patients with clinical deterioration at the discretion of the referring physician. complications were stratified into major and minor categories based on the 2010 society of interventional radiology quality improvement guidelines for percutaneous transcatheter embolisation.9 minor complications included post-procedure pain and endovascular coil migration. major complications included death, splenic infarct involving greater than 25% of the splenic parenchyma, post-procedural abscess formation, persistent or new vascular injury and left pleural effusion. descriptive statistics were performed and validated by a statistician at our institution. ethical considerations formal ethics approval was obtained from the institutional ethics review board. results during the study period, there were 67 patients who underwent sae for blunt splenic trauma. seven patients did not have an available pre-procedure ct (these were performed at peripheral rural centres from which the patient was subsequently transferred) and thus were excluded from the data analysis. therefore, a total of 60 patients were included in the study (46 males and 14 females) with a mean age of 36 years (ranging between 15 to 88 years). on pre-procedural ct, there were 8 grade ii, 44 grade iii and 8 grade iv splenic injuries. in the study cohort, there were no patients with either an aast splenic grade i injury or a grade v injury. forty-three patients presented with a significant haemoperitoneum and 31 patients had evidence of a vascular injury (table 1). four patients had a pa involving one branch vessel and active extravasation of iv contrast from a separate branch vessel. table 1: splenic injury grades and vascular injuries. the chosen sae technique was at the discretion of the performing interventional radiologist at the time of the procedure: 54 patients were treated with a proximal sae (53 with coils and 1 with an amplatzer plug) and 6 patients underwent combined selective distal and main sae. selective embolisation was performed either with coils alone or coils in combination with n-butyl cyanoacrylate glue. no exclusive selective distal embolisation was performed (table 2). table 2: embolisation technique. overall, the splenic salvage rate following sae was 97%. in 16 patients with grade ii and grade iv splenic injuries, there was a 100% splenic salvage rate. in 44 patients with a grade iii injury, there was a 95% splenic salvage rate. of the 60 patients, 40 (67%) progressed to further assessment with a ct examination post-embolisation. two patients failed nom, one of whom required subsequent abdominal surgery for haemodynamic instability from multiple concurrent abdominal injuries and the other required splenectomy because of a splenic abscess. both patients had grade iii splenic injuries and were treated with proximal sae. both patients also had evidence of a vascular injury at presenting ct, one with active extravasation of iv contrast and the other with a pa (figure 4). both patients had significant haemoperitoneum at the time of presentation. figure 4: vascular injuries in two patients who failed nom management with splenic artery embolisation: (a) patient 1: contrast-enhanced axial ct shows active extravasation of iv contrast (white arrow) beyond the splenic margin and (b) patient 2: fluoroscopic image from selective splenic artery angiogram shows splenic artery pseudoaneurysm (black arrow). the overall complication rate of sae per patient in our study was 27%, with 16 of the 60 patients having at least one complication. in total, there were 19 complications in 16 patients, with 14 patients having one complication each, one patient having two complications and one patient having three complications. of the complications, 10 were major and nine were minor. the most common major complication was a left pleural effusion, occurring in four patients following sae, one of whom required chest tube placement for symptomatic relief. the most common minor complication was distal migration of a main splenic artery coil, occurring in seven patients. the patient with three complications had a distal coil migration that was further complicated by a post-procedure splenic infarct and subsequent abscess formation (figure 5). there was one death following sae, but this was not directly related to the procedure but because of other injuries (table 3). figure 5: complications included coil migration, splenic infarction and splenic abscess: (a) fluoroscopic image shows distal migration of main splenic artery embolisation coil (arrow), (b) contrast-enhanced coronal ct shows non-enhancement of the superior pole of the spleen consistent with splenic infarct and (c) contrast-enhanced axial ct shows rim enhancing splenic abscess (circle). table 3: outcomes of splenic artery embolisation. discussion the spleen is the most frequently injured solid organ in blunt abdominal trauma.10 for many years, splenectomy was the preferred method of treatment for traumatic splenic injury; however, because of the risk of fatal post-splenectomy sepsis and impaired resistance to infection with encapsulated organisms, many trauma physicians began seeking alternative management strategies.11 over the past several decades, there has been a shift in the approach to blunt splenic injury, with nom now preferred for haemodynamically stable patients.2,4,5,6,7 this generally consists of various observational strategies including bed rest, limiting oral intake, serial haemoglobin and/or haematocrit levels and regular physical examinations.6 in 2000, the multicentre eastern association for the surgery of trauma (east) trail, demonstrated an overall observational nom failure rate of 10.8%.12 significantly, higher failure rates were demonstrated with grades iii–v splenic injuries and with vascular injuries. sae as an adjunct therapy to observational nom continues to gain favour as multiple studies have demonstrated improved non-operative splenic salvage rates, especially in those patients at risk of failing observational management.2,4,5,6,7,12 the use of sae for blunt splenic injury was first described in 1995 by sclafani et al.4 since then, there have been several retrospective studies analysing the efficacy of transcatheter sae with success rates ranging from 75% to 100%.2,4,5,6,7 this study further contributes to the existing literature that sae is an effective management strategy for blunt splenic injury and can achieve excellent salvage rates, even for higher grade splenic injuries and vascular injuries.5,6 the overall splenic salvage rate was 96.7% (including a salvage rate of 96.2% for grades iii and iv injuries), which is comparable with other published studies.2,4,5,6,7 in our study, there were no patients with grade v injuries. multiple studies have indicated that the presence of a splenic vascular injury increases the failure rate of nom.2,6,13 in our study, 31 patients had evidence of a vascular injury on either their pre-procedure ct or on catheter angiography (table 2). both patients who failed nom had evidence of a vascular injury: one had a pa and the other had active extravasation of iv contrast. both patients were treated by main sae. the quantity of haemoperitoneum was also assessed, being significant if blood extended beyond the splenic bed. both patients who failed nom had a significant quantity of haemoperitoneum on their pre-procedure ct. there was, however, no statistically significant correlation between the quantity of haemoperitoneum and the splenic salvage rate. there remains debate in the literature regarding the optimal technique for sae in the setting of trauma.6,10,13,14 described approaches include main sae, superselective embolisation of an injured distal splenic artery or a combined main and distal sae. embolisation of the proximal splenic artery allows for reconstitution of distal arterial flow via short gastric, gastroepiploic and pancreatic arteries.10,14 proximal embolisation reduces the arterial pressure in the splenic parenchyma, allowing the spleen to heal and reducing the risk of re-bleeding.10 in cases of significant focal arterial injury demonstrated by angiography, a distal branch vessel embolisation is often preferred, excluding it from the circulation and reducing the risk of ongoing haemorrhage.14 a 2004 study by haan et al. demonstrated statistically equivalent efficacy rates with either a main approach or a distal approach, but a statistically higher failure rate if a combined embolisation was performed.6 a 2011 systematic review by schnüriger et al. was inconclusive in determining whether proximal or distal sae should be performed to avoid significant re-bleeding.14 in our study, there was a 100% splenic salvage rate for patients undergoing main and distal sae. complications after sae were relatively frequent, occurring in 16 of the 60 patients (27%). the overall major complication rate was 8 of 60 patients (13%). the 2010 society of interventional radiology quality improvement guidelines for percutaneous transcatheter embolisation list overall major complication rates of 8% – 22%, with a suggested threshold of 15%.9 other studies list overall complication rates of up to 38% and major complication rates ranging from 0% to 28.5%.6,7,14,15 the most common major complication in our study was the development of a post-procedural left pleural effusion seen in four patients, followed by partial splenic infarction in three patients. one patient died after sae, but this was secondary to multiple other severe traumatic injuries rather than the sequelae of the embolisation procedure. one patient developed a large splenic infarct (involving an estimated 50% of the parenchyma) and a subsequent splenic abscess that was treated by splenectomy. minor complications occurred in 9 of 60 patients (15%) and included post-procedure pain in two patients and clinically silent distal migration of intended proximal coils in seven patients. of note is that detachable coils were not yet available during the study period. although our complication rates are slightly high, they do still correlate with other studies. of the 60 patients in our study cohort, 16 patients (27%) failed initial observational nom based on clinical deterioration or ct findings of vascular injury, who then went on to delayed (at least 48 h post-admission) but successful sae. of these patients, 12 had a grade iii injury, 2 had a grade ii injury and another 2 had a grade iv injury. this further corroborates the findings from the 2014 study by miller et al. that all patients with grades iii–v injuries should proceed directly to sae to reduce nom failure rates.5 limitations of the study limitations of this study include that it is a single-centre retrospective analysis and no patients with grade v injuries were referred for sae. another limitation with respect to the assessment of post-procedure complications is that not every patient had a follow-up ct examination. conclusion our retrospective study contributes to the existing literature that sae is an effective and safe therapy to improve splenic salvage rates in patients with high aast grade splenic and vascular injuries because of blunt abdominal trauma. acknowledgements we would like to thank yukun zhang, statistical analyst, for validation of the statistical methods and justin chun and sherif idris for assisting with chart review. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.k.w. and s.p. were the project leaders and responsible for project design. s.p., r.c. and m.c.m.f. collected data and were responsible for most of the manuscript creation and preparation. all authors were involved in manuscript editing. references tinkoff g, esposito tj, reed j, et al. american association for the surgery of trauma organ injury scale i: spleen, liver, and kidney, validation based on the national trauma data bank. j am coll surg. 2008;207:646–655. http://dx.doi.org/10.1016/j.jamcollsurg.2008.06.342 sabe a, calridge j, rosenblum d, lie k, malangoni m. the effects of splenic artery embolisation on nonoperative management of blunt splenic injury: a 16-year experience. j trauma. 2009;67:565–572. http://dx.doi.org/10.1097/ta.0b013e3181b17010 marmery h, shanmuganathan k, alexander m, mirvis s. optimization of selection for nonoperative management of blunt splenic injury: comparison of mdct grading systems. ajr am j roentgenol. 2007;189:1421–1427. http://dx.doi.org/10.2214/ajr.07.2152 sclafani s, shaftan g, scalea t, et al. nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolisation for hemostasis. j trauma. 1995;39:818–825. http://dx.doi.org/10.1097/00005373-199511000-00004 miller pr, chang mc, hoth jj, et al. prospective trial of angiography and embolisation for all grade iii to v blunt splenic injuries: nonoperative management success rate in significantly improved. j am coll surg. 2014;218:644–651. http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.040 haan j, biffl w, knudson m, et al. splenic embolisation revisited: a multicenter review. j trauma. 2004;54:542–547. http://dx.doi.org/10.2214/ajr.07.2152 wei b, hemmila m, arbabi s, taheri p, wahl w. angioembolisation reduces operative intervention for blunt splenic injury. j trauma. 2008;64:1472–1477. http://dx.doi.org/10.1097/ta.0b013e318174e8cd thompson b, munera f, cohn s, et al. novel computed tomography scan scoring system predicts the need for intervention after splenic injury. j trauma. 2006;60:1083–1086. http://dx.doi.org/10.1097/01.ta.0000218251.67141.ef angle jf, siddiqi nh, wallace mj, et al. quality improvement guidelines for percutaneous transcatheter embolisation: society of interventional radiology standards of practice committee. j vasc interv radiol. 2010;21:1479–1486. http://dx.doi.org/10.1016/j.jvir.2010.06.014 madoff d, denys a, wallace m, et al. splenic artery interventions: anatomy, indications, technical considerations, and potential complications. radiographics. 2005;25:s191–s211. http://dx.doi.org/10.1148/rg.25si055504 dasgupta n, matsumoto a, arslan b, turba u, sabri s, angle j. embolisation therapy for traumatic splenic lacerations. cardiovasc intervent radiol. 2012;35:795–806. http://dx.doi.org/10.1007/s00270-011-0186-y peitzman ab, heil b, rivera l, et al. blunt splenic injury in adults: multi-institutional study of the eastern association for the surgery of trauma. j trauma. 2000;49:177–189. http://dx.doi.org/10.1097/00005373-200008000-00002 imbrogno bf, ray ce. splenic artery embolisation in blunt trauma. semin intervent radiol. 2012; 29: 147–149. http://dx.doi.org/10.1055/s-0032-1312577 schnüriger b, inaba k, konstantinidis a, lustenberger t, chan ls, demetriades d. outcomes of proximal versus distal splenic artery embolisation after trauma: a systematic review and meta-analysis. j trauma. 2011;70:252–260. http://dx.doi.org/10.1097/ta.0b013e3181f2a92e ekeh ap, khalaf s, ilyas s, kauffman s, walusimbi m, mccarthy mc. complications arising from splenic artery embolisation: a review of an 11-year experience. am j surg. 2013;205:250–254. http://dx.doi.org/10.1016/j.amjsurg.2013.01.003 the use of an ‘itinerant’ expert witness in our civil courts used to be confined mostly to the field of forensic pathology, but has now become established in radiology. doctors are often accused of closing ranks in malpractice claims against colleagues by a patient. in my experience, radiologists invariably have been balanced and responsible when asked to comment on malpractice issues; in 40 years of practise, i have never seen or heard of a deliberate cover-up to protect a colleague’s interests above those of a patient. the itinerant radiology expert, however, represents a totally new and, to us in south african practise, foreign development: an ‘expert’ witness traveling from one provincial high court to the next involving some sort of litigation against a colleague (usually a fellow radiologist) and often concerning advanced ct or mri neuro-imaging issues. i asked my good friend, the world-renowned forensic pathologist, professor deon knobel, to discuss some issues regarding the radiologist and the law. as usual, he goes to the nub of the matter: the need for a non-partisan witness for the truth. the role of the expert witness in court has been a point for discussion in medical and legal circles for many decades. the expert witness is called to give evidence and an opinion on specialised fields of medicine and other scientific and professional disciplines and is also often expected to listen to and interpret the evidence of colleagues, and afterwards to express an opinion to the court. the expert may also be appointed as assessor to assist the presiding officer in the interpretation and evaluation of scientific evidence.1 it is not necessary for me to remind you of some of the incidents of civil litigation by patients whose permanent injury or death was caused by treatment rendered and where the doctor became the defendant. under such circumstances, the role of the expert witness becomes invaluable; i have collected numerous examples in my own career of 40 years in forensic medicine, in some of which the ‘expert evidence’ given was highly questionable. the need for peer review the opinions of historical figures such as sir bernard spilsbury – and even men like the late professor milton helpern from new york, and hillel shapiro of south africa, who practised ‘the art of forensic medicine’ – were accepted as holy fact. professor hugh johnson of london expresses himself on this topic as follows: ‘i hope, though, that we will never go back to the expert having the status that the late sir bernard spilsbury enjoyed; whose evidence, when he was in his prime, was accepted as having the authority of holy writ and there was seldom any effective opposition from the other side’2 in contrast, we in modern forensic medicine have become aware of its multidisciplinary character and, at formal inquests enquiring into the circumstances of death associated with medical care such as surgery or anaesthetics and other therapeutic mishaps, advise the magistrate more and more to make use of specialists in each field to assist him as an assessor or expert witness. we hope thus eventually to reach the stage where peer review and professional assessment of our medical skills will lead to improvement of medicine and better service to the patient.1 too often a phenomenon described by raanon gillon as follows, occurs in court: ‘ … doctors ... have a tendency to close ranks in their own individual and group interests and against the interest of our patients to an extent that is incompatible with our professed adherence to a principle of benefiting our patients. we have had inculcated into us throughout our professional training and socialisation a sort of public school ethos that we do not “split” about a colleague even if we know that the colleague has made a damaging mistake or is frankly incompetent’.3 i also wish to venture the opinion that the adversarial approach of our south african legal system may be to blame here. despite the fact that an inquest is not a trial, the finding at the inquest may yet lead to prosecution of or litigation against a health care worker. therefore, the attitude of witnesses and expert witnesses alike is very often still that of giving evidence ‘for the accused’ or ‘for the defence’. lundberg, an eminent authority, expressed the position eloquently in the following question: ‘expert witness for whom? expert witness for the prosecution? expert witness for the defence? expert witness for the court? how about unbiased expert witness for the truth?’ in theory, all such experts seek the truth and, while under oath in court, must speak the truth; however, it is very difficult for any person who has grown up in a system of ‘sides’ on the football field or in the debating hall not to share an advocacy position when their services have been secured by legal counsel committed to such advocacy. should not the best experts be available to the court simply to assist in arriving at the correct verdict so that justice, society and the individuals concerned are properly served? current american medical association policy on medical expert witnesses states that ‘the physician should not allow himself to become an advocate or a partisan in the trial [inquest proceedings]. he has a responsibility not to withhold, conceal or distort information. he should not slant or twist his medical opinion. the physician should maintain scientific objectivity’.4 professor bernard ackerman, a well-known dermatopathologist of new york, states: ‘there is an urgent need to reassess the role of the physician, and particularly that of the pathologist, in the courtroom. ‘irrespective of the behavior in court of lawyers (who take no oath comparable to that of hippocrates, and who are often fiercely engaged in adversarial relationships), physicians should not be advocates of either a prosecutor or a defence lawyer – but of the unvarnished truth. continued on page 5 the role of the expert witness in court jan lotz editor-in-chief editorial � sa journal of radiology • march 2009 editorial.indd 2 3/12/09 2:05:08 pm about the author(s) shalendra misser lake smit and partners inc, durban, south africa citation misser s. abdominal and neuroimaging quiz case. s afr j rad. 2016;20(1), a1029. http://dx.doi.org/10.4102/sajr.v20i1.1029 quiz case abdominal and neuroimaging quiz case shalendra misser received: 06 may 2016; accepted: 12 may 2016; published: 22 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a 40-year-old lady had a ct and an mri scan of her brain for investigation of severe headache following recent recurrent bowel surgery. the post-operative course was complicated by abdominal wall haematoma, and she required multiple blood transfusions. the background history of multiple previous bowel resections and chronic anti-inflammatory therapy for inflammatory bowel disease was noted. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to shalendra.misser@lakesmit.co.za not later than 31 july 2016. the winning respondent will receive r2000 as a reward from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. figure 1: coronal reformat images (a, b and c) of the abdomen in venous phase after intravenous contrast administration. figure 2: sagittal (a) and (b) axial images of the abdomen in venous phase after intravenous contrast administration. figure 3: axial non-contrasted (a) ct image, (b) t2 and (c) axial t1-weighted mri images. figure 4: coronal flair mri image. figure 5: axial diffusion-weighted b1000 mr images (a, b, c and d). figure 6: corresponding axial adc-mapped mr images (a, b, c and d). figure 7: axial swi mr images (a and b). figure 8: corresponding axial phase mr images (a and b). abstract introduction references about the author(s) paul rischbieter department of radiology, university of pretoria, south africa christine sinclair department of radiology, university of pretoria, south africa andrew lawson department of radiology, university of pretoria, south africa samia ahmad department of radiology, university of pretoria, south africa citation rischbieter p, sinclair c, lawson a. & ahmad s. ‘uterine artery embolisation as an effective choice for symptomatic fibroids: five-year outcome’. s afr j rad. 2016;20(1):a959. http://dx.doi.org/10.4102/sajr.v20i1.959 original research uterine artery embolisation as an effective choice for symptomatic fibroids: five-year outcome paul rischbieter, christine sinclair, andrew lawson, samia ahmad received: 23 nov. 2015; accepted: 05 jan. 2016; published: 31 mar. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: uterine artery embolisation for the treatment of symptomatic uterine fibroids is a relatively new but internationally recognised procedure. the present study seeks to report the results of the largest south african series of uterine artery embolisations for symptomatic fibroids to date. it is the fourth article to be published in south africa on the outcomes of this procedure, and the largest south african series to date. objective: to evaluate the long-term efficacy of uterine artery embolisation in women with symptomatic fibroids in a tertiary hospital in south africa. methods: eighty-two women who presented for uterine artery embolisation at a single site in south africa for symptomatic fibroids were retrospectively studied. outcomes included recurrence and re-intervention rates, patient satisfaction and complication rate. results: two patients required repeat embolisation, and one patient experienced fibroid recurrence without further intervention. no repeat myomectomies were performed. eighty percent of patients reported being satisfied, 12% partially satisfied and 7% not satisfied. no major complications were reported. conclusion: uterine artery embolisation was shown to be a good choice in the treatment of symptomatic fibroids and presents favourable long-term outcomes in the south african population. introduction uterine artery embolisation (uae) is a minimally invasive, uterine-sparing treatment option in the management of uterine leiomyomas (fibroids). since the first uae was described in 1995,1 an increasing body of international research has sought to understand its place in clinical practice. there is now a growing need to further investigate clinical results at five years post procedure, when recurrence and re-intervention rates become more important. african black women are more frequently affected by uterine fibroids and experience more severe symptoms than white or asian women.2,3 this fact, in addition to the cultural stigma of hysterectomy within african communities, makes uterine artery embolisation a potentially important treatment option in the south african context. two previous studies in the south african population have shown good, relatively short-term results.4,5 the present study investigated the long-term outcomes of uterine artery embolisation as a treatment option for symptomatic fibroids within the south african clinical environment. background symptomatic uterine leiomyomas can cause pain, heavy bleeding, pressure effects and reduced fertility. traditionally, definitive treatment has been through hysterectomy or myomectomy. today, uae has become a standard procedure for the treatment of uterine fibroids around the world.6 more than 100 000 procedures have been performed globally and ongoing research continues to contribute to our knowledge of this procedure. a cochrane review by gupta et al.7 showed that uae had overall patient satisfaction rates similar to those of myomectomy and hysterectomy for the same indication, with faster recovery times, shorter hospital stays, and a quicker return to routine activities. kröncke et al.8 recently published the results of the 4th radiology-gynaecology experts meeting in europe, which provides up-to-date consensus guidelines for the incorporation of uae into routine practice, and the society of interventional radiology (sir) standards of practice committee recently released the updated ‘quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata’,6 showing clear data to guide the ongoing support of this procedure. methods the present retrospective observational study was performed at steve biko academic hospital, pretoria, and conducted on all patients treated between 2006 and 2014 for symptomatic fibroids with uterine artery embolisation. embolisation was performed on a total of 82 patients. all patients presented initially to the department of obstetrics and gynaecology with symptomatic fibroids and were selected on the basis of their clinical suitability for the procedure. a multi-disciplinary team comprising gynaecologists, anaesthetists and radiologists provided operative and peri-operative care. as part of the pre-operative workup, all patients underwent pelvic sonography to assess the number and size of uterine fibroids. all patients attended outpatient follow-up at six months and one year post-procedure, at which time follow-up sonography was performed. all patients were contacted telephonically one to eight years after the procedure to determine their well-being. all uterine artery embolisations were performed in the interventional radiology suite at steve biko academic hospital. patients were given either spinal or general anaesthesia at the discretion of the attending anaesthetist as per the protocol of the department of anaesthesia. right common femoral arterial puncture was performed, followed by arteriography of the pelvic vessels. the uterine arteries were sequentially catheterised using a roberts catheter (cook inc., bloomington, indiana, usa). the embolic agents in all cases were a combination of non-absorbable polyvinyl alcohol particles (300µm – 500µm) and gelfoam. in all procedures, both uterine arteries were successfully embolised (figure 1, figure 2). post-embolisation anaesthesia was provided at the discretion of the anaesthetist as a combination of opioids and benzodiazepines. figure 1: pre-embolisation fluoroscopic image of catheterised uterine artery with contrast injection (ap projection). figure 2: post-embolisation fluoroscopic image of catheterised uterine artery (ap projection). in addition to the objective clinical outcomes measured, and particularly any re-intervention procedures, patients were assessed on their overall subjective satisfaction with the procedure. patients were assessed as ‘satisfied’ with uae if they felt that they were relieved of their presenting symptoms; ‘partially satisfied’ if they were still mildly symptomatic; and ‘dissatisfied’ if there were no relief of major symptoms. specific symptoms that were sought in the assessment of the degree of satisfaction were persistent menorrhagia, persistent bloating and constipation, and persistent dysmenorrhoea. at the time of the telephonic interview, patients were also asked if they had experienced any urinary incontinence or loss of defecation function. patients were also asked if they would recommend the procedure to another person suffering from the same condition. post-surgical complications were divided into ‘major’ and ‘minor’ categories. major complications were those that required surgical intervention or were potentially life threatening. minor complications referred to all other reported complications. all results were reported using descriptive statistics. no advanced statistical modelling was performed. results eighty-two women were identified within the study population. fifty-two (63%) women were followed up between five and eight years post procedure with an average follow-up period of 79 months (six-and-a-half years) and were therefore selected for the long-term follow-up group. the median age of this group at the time of procedure was 46 years. a second group of 30 (37%) women was followed up between three and five years with an average follow-up period of 49 months (4 years). the median age of this group at the time of the procedure was also 46 years. the average gravidity for the long-term group was 2.7 and average parity 2 (table 1). there were no patients included with a follow-up period <3 years. thirty (37%) patients were lost to planned clinical follow-up. all patients were, however, successfully contacted telephonically. table 1: summary of results: 5–8-year follow-up. of the long-term follow-up group, three women had undergone previous myomectomy. no patient had undergone a previous uae before the start of the study period. there were no major complications and no incidences of sepsis following the procedure. recurrence and re-intervention two patients required repeat embolisation for insufficient improvement of persistent menorrhagia. both patients had undergone technically successful primary procedures and underwent secondary embolisation between 12 and 18 months after their primary intervention. both patients were followed up more than three years after the secondary intervention and reported complete resolution of symptoms. one patient experienced fibroid recurrence four years post primary procedure with the development of new onset mild dysmenorrhoea. the patient has continued on medical therapy. no interval myomectomies were performed. patient satisfaction sixty-six (80.5%) patients reported being satisfied with the procedure. ten (12.2%) patients reported being partially satisfied, and six (7.3%) patients reported being dissatisfied (table 2). table 2: patient satisfaction with the procedure. in the dissatisfied group, all patients complained of only partial resolution of menorrhagia and dysmenorrhoea. however, only one patient found the persistent symptoms to be severe enough to seek additional medical consultation. in the partially satisfied group, eight patients reported a degree of ongoing dysmenorrhoea, and no further menorrhagia. two patients who returned for successful uae re-intervention procedures for persistent menorrhagia reported being partially satisfied as a result of the re-intervention procedure; their symptoms resolved after the second intervention. excluding the patient who experienced fibroid recurrence at four years, no patients within the study population reported using ongoing medication for bleeding control or pain management. no patients reported loss of urinary continence or defecation function. ninety percent of patients would recommend the procedure to another patient. only one pregnancy was reported in the patient cohort post embolisation (pregnancy carried to term). the patient was 36 years old at the time of pregnancy. indications and imaging the indications for uae varied across the patient population, with most patients having several indications (table 3). menorrhagia was reported in 84% and 59% reported dysmenorrhoea. table 3: presenting symptoms. the pre-operative ultrasound imaging confirmed the presence of fibroids and did not detect any adnexal disease. the retrospective nature of this study and lack of standardised follow-up data capture via sonography did not allow accurate and uniform assessment of uterine volume and fibroid size pre and post embolisation. mri is not part of the diagnostic workup for uterine fibroids at steve biko academic hospital. complications no major complications were reported in our patient population and no patients underwent hysterectomy. all patients reported a degree of post-operative pain, nausea and pyrexia consistent with post-embolisation syndrome.9 discussion minimally invasive treatment has gained substantial popularity, amongst both the medical fraternity and the public. given the correct clinical indications and in skilled hands, uae has been accepted by the international community as part of the standard of care that should be offered to patients with symptomatic fibroids.6,8 prior studies conducted in south africa in 20044 showed that uae could be considered as an effective treatment option in south african centres with adequate training and expertise. a more recent prospective study5 again showed results consistent with previous local experience and in line with international reports.10,11 the present retrospective analysis focused on the long-term outcomes of uae with respect to symptom resolution and whether patients required any form of re-intervention, be it medical or surgical. in this study of 82 women with symptomatic fibroids, bilateral uterine artery embolisation was technically successful in all patients. no major complications were encountered. post-operative pain still remains a big challenge in the peri-operative setting.9 the pathophysiology of fibroids is poorly understood, and it is well recognised that they generally cause no symptoms. fifty-two patients had been followed-up for between five and eight years and, although none of these patients received follow-up imaging, they reported that they had remained symptom free. it is a limitation of the present study that there was no indication whether the fibroids had objectively involuted and no proof that none had re-appeared in asymptomatic patients. better understanding of the imaging and clinical picture might in future predict which fibroids could respond better to certain treatment strategies. the link between bulk and pressure symptoms is certainly easier to understand than fibroids resulting in menorrhagia.10 menorrhagia is more common with submucosal fibroids but occurs with fibroids in other anatomical locations as well. production of cytokines and vasoactive agents differ between women with fibroids and those without, which may explain the increased menstrual blood loss. there is no evidence of a relationship between fibroid vascularity and menstrual blood loss, and it is over-simplistic to assume that complete fibroid infarction would cure menorrhagia. in any fibroid group, there will always be some patients with dysfunctional uterine bleeding where the fibroids are simply a coincidental association.10 no identifiable cause was found in the two patients with recurrence leading to re-intervention. a postulated cause could have been unrecognised uterine artery spasm, resulting in inadvertent under-embolisation. our recurrence rate of 2.4% is well below the observed value of 15%.6 the single patient who experienced demonstrable fibroid recurrence with dysmenorrhoea at four years chose conservative medical therapy and has remained without further, or worsening, symptoms. patients who have undergone myomectomy are also at risk of developing recurrent symptomatic fibroids.12,13 the reported incidence varies between 10% and 62%.13 in the present series, three patients who had already had myomectomy presented for embolisation. all three of these patients were followed up at three years and remain symptom free. the average patient age at the time of embolization was 46 years. the gynaecology unit was not a specialist infertility centre, so no emphasis was placed on objective or biochemical measurements of ovarian function or reserve such as luteinising hormone (lh), follicle stimulating hormone (fsh) or anti-mullerian hormone (amh). the review did therefore not focus on ovarian function post uae. a limitation of the present study is the poor clinical follow-up, with 30 patients lost to planned outpatient follow-up. all patients were successfully contacted telephonically which gives some reassurance as to the unlikelihood of severe symptom recurrence. our findings may nevertheless underestimate the real recurrence rate. previous international studies have reported re-intervention rates as high as 33%.14 a number of factors may explain the lower figures reported in this study. patients were not assessed for transition into menopause; the average age of the patient cohort was high; and low recurrence might, at least in part, have been a result of transition into menopause. patients may also avoid reporting recurrent symptoms for fear of hysterectomy or further surgical intervention, as well as owing to financial limitations in seeking further hospital treatment. our follow-up imaging data were limited mainly by socio-economic factors. once the patients had formally been discharged from the gynaecology clinic, usually at the 6-month follow-up, they were referred back to primary health care facilities in the community. these clinics do not have the staff or resources to offer basic imaging services such as ultrasound. long-term data acquisition was mostly determined via telephonic consultation. the present retrospective review again shows uae to be a good choice in the treatment of symptomatic fibroids and presents favourable long-term outcomes. long-term imaging follow-up was not available to objectively measure the fibroids post embolisation. in our setting, the clinical improvement and reduction in morbidity associated with fibroids was considered adequate to advocate the usage of uae in south africa in centres with the appropriate skill and clinical support. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions p.r. (university of pretoria) was the lead author, c.s. (university of pretoria) assisted with compiling clinical data, a.l. (university of pretoria) assisted with project design, review and analysis, and s.a. (university of pretoria) was the supervisor. references ravina jh, ciraru-vigneron n, bouret jm, et al. arterial embolisation to treat uterine myomata. lancet. 1995;346(8976):671–672. http://dx.doi.org/10.1016/s0140-6736(95)92282-2 catherino wh, eltoukhi hm, al-hendy a. racial and ethnic differences in the pathogenesis and clinical manifestations of uterine leiomyoma. semin reprod med. 2013;31:370–379. http://dx.doi.org/10.1055/s-0033-1348896 stewart ea, nicholson wk, bradley l, borah bj. the burden of uterine fibroids for african-american women: results of a national survey. j women’s health. 2013;22:807–816. http://dx.doi.org/10.1089/jwh.2013.4334 prollius a, de vries c, loggenberg e, et al. uterine artery embolization for symptomatic fibroids. international journal of gynecology & obstetrics. 2004;84: 236–240. http://dx.doi.org/10.1016/j.ijgo.2003.09.006 lawson a, cluver c, olarogun j, et al. uterine artery embolisation for uterine leiomyomas. south african journal of obstetrics and gynaecology. 2014;40: 18–21. http://dx.doi.org/10.7196/sajog.798 dariushnia sr, nikolic b, stokes ls, spies jb. quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. j vasc interv radiol. 2014;25:1737–1747. http://dx.doi.org/10.1016/j.jvir.2014.08.029 gupta jk, sinha a, lumsden ma, hickey m. uterine artery embolization for symptomatic uterine fibroids. cochrane database syst rev. 2014;12:cd005073. http://dx.doi.org/10.1002/14651858.cd005073.pub4 kröncke t, david m. uterine artery embolisation (uae) for treatment of myomas. geburtshilfe und frauenheilkunde. 2014;74:433–435. http://dx.doi.org/10.1055/s-0033-1350827 van overhagen h, reekers ja. uterine artery embolization for symptomatic leiomyomata. cardiovasc intervent radiol. 2015;38:536–542. http://dx.doi.org/10.1007/s00270-014-1031-x moss j, cooper k, khaund a, et al. randomised comparison of uterine artery embolisation (uae) with surgical treatment in patients with symptomatic uterine fibroids (rest trial): 5-year results. bjog. 2011;118:936–944. http://dx.doi.org/10.1111/j.1471-0528.2011.02952.x van der kooij sm, hehenkamp wjk, volkers na, birnie e, ankum wm, reekers ja. uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized emmy trial. am j obstet gynecol. 2010;203:105. e1–e13. walker wj, barton-smith p. long-term follow up of uterine artery embolisation—an effective alternative in the treatment of fibroids. bjog. 2006;113:464–468. http://dx.doi.org/10.1111/j.1471-0528.2006.00885.x hanafi m. predictors of leiomyoma recurrence after myomectomy. obst gynecol. 2005;105:877–881. http://dx.doi.org/10.1097/01.aog.0000156298.74317.62 ananthakrishnan g, murray l, ritchie m, et al. randomized comparison of uterine artery embolization (uae) with surgical treatment in patients with symptomatic uterine fibroids (rest trial): subanalysis of 5-year mri findings. cardiovasc intervent radiol. 2013;36:676–681. http://dx.doi.org/10.1007/s00270-012-0485-y original article 56 sa journal of radiology • september 2010 original article introduction airway compression is a common complication of tb lymphadenopathy in children,1 and the diagnostic workup of patients with suspected tracheal or bronchial stenoses includes bronchoscopy and ct (computed tomography).2 this process affords the opportunity to study aspects of ct relating to airway stenosis. axial ct scans produce excellent resolution in the horizontal plane, but the extent of airway disease may be underestimated if only axial images are obtained. an advantage of using multidetector ct (mdct) is the use of multiplanar reconstruction (mpr) to align the image along the longitudinal axis of the airway. there is also uncertainty if window settings affect the measurement of the airway diameter. aim we wished to determine if there was a significant difference between the measurements of compressed airway diameter in the axial plane compared with measurements of diameter using mpr for determining longitudinal axis of the airway; and to evaluate how measurements on lung window settings compare with soft tissue window settings. patients and methods for the study, 34 ct scans of children with central airway compression due to tuberculous lymphadenopathy were sourced from a digitally stored ct database (on cd) kept by a paediatric pulmonologist. the ct scans were all performed in one academic hospital according to a standard protocol, and were evaluated on a radiology workstation where mpr was performed. the maximum stenosis in the trachea, right main bronchus, bronchus intermedius and left main bronchus was measured, if present. the minimum diameter was taken on the axial scan as well as after mpr, providing the true longitudinal axis (figs 1 a and 1b). all measurements were performed both in soft tissue window (window 350/level 50) and lung window (window 1600/level 500) settings (figs 1c and 1d). intraclass correlation (icc) was used for statistical analysis of the data. results scans of 18 male and 16 female children were evaluated. their ages ranged from 1 month to 13.25 years (mean age 2.75 years). there were a total of 62 stenoses, comprising 14 in the trachea, 6 in the right main bronchus, 22 in the bronchus intermedius, and 20 in the left main bronchus. the average diameter of the narrowed airway size in the is airway diameter measured accurately on routine axial ct scans? comparison with true axial diameter using mpr in children with airway compression owing to pulmonary tb marie grobbelaar, mb chb, mmed (rad diag) (deceased) department of radiodiagnosis, faculty of health sciences, university of stellenbosch medical school savvas andronikou, mb bch, fcrad, frcr (lond), phd department of radiology, university of of the witwatersrand, johannesburg graph 1. comparison of axial measurements v. measurements after mpr in the trachea. graph 1. comparison of axial measurements v. measurements after mpr in the trachea  icc(agreement)=0.950 icc(consistency)=0.946 function = x 0 2 4 6 8 10 trachea axial 0 2 4 6 8 10 t ra ch ea m p r graph 2. comparison of axial measurements v. measurements after mpr in the right main bronchus. graph 2. comparison of axial measurements v. measurements after mpr in the right main bronchus.  icc(agreement)=0.848 icc(consistency)=0.858 function = x 0 1 2 3 4 5 6 7 8 right main bronchus axial 0 1 2 3 4 5 6 7 8 r ig ht m ai n br on ch us m p r original article 57 sa journal of radiology • september 2010 selected children of this study was 4.2 mm (measured in soft tissue windows). graph 1 illustrates little difference (icc agreement 0.950) between the sets of measurements of stenosis in the trachea, with a high consistency value (icc consistency 0.946). of the differences in measurements, 64.3% were <0.5 mm, 35.7% were 0.5 1.0 mm, and none was >1 mm. graph 2 illustrates the values of the 6 stenoses measured in the right main bronchus. the icc values are lower (icc agreement 0.848 and icc consistency 0.858) compared with the figures for the trachea, bronchus intermedius and left main bronchus. of the differences in measurements, 33.3% were <0.5 mm, 33.3% were 0.5 1.0 mm, and 33.3% were >1 mm. graph 3 illustrates little difference (icc agreement 0.909) between the sets of measurements in the bronchus intermedius, with a high consistency value (icc consistency 0.907). of the differences in measurements, 54.5% were <0.5 mm, 36.4% were 0.5 1.0 mm, and 91% were >1 mm. graph 4 illustrates little difference (icc agreement 0.945) between the sets of measurements in the left main bronchus, with a high consistency value (icc consistency 0.943). of the differences in measurements, 60% were <0.5 mm, 35% weres 0.5 1.0 mm, and 5% were >1 mm. graph 3. comparison of axial measurements v. measurements after mpr in the bronchus intermedius. graph 3. comparison of axial measurements v. measurements after mpr in the bronchus intermedius icc(agreement)=0.909 icc(consistency)=0.907 x=y line 0 1 2 3 4 5 6 7 8 bronchus intermedius axial 0 1 2 3 4 5 6 7 8 b ro nc hu s in te rm ed iu s m p r graph 4. comparison of axial measurements v. measurements after mpr in the left main bronchus. graph 4. comparison of axial measurements v. measurements after mpr in the left main bronchus icc(agreement)=0.945 icc(consistency)=0.943 x=y line 0 1 2 3 4 5 6 7 8 left main bronchus axial 0 1 2 3 4 5 6 7 8 le ft m ai n br on ch us m p r graph 5. comparison between measurements in soft tissue and lung windows in the trachea. graph 5. comparison between measurements in soft tissue and lung windows in the trachea  icc(agreement)=0.652 icc(consistency)=0.972 x=y line 0 2 4 6 8 10 soft tissue w indow 0 2 4 6 8 10 lu ng w in do w graph 6. comparison between measurements in soft tissue and lung windows in the right main bronchus. graph 6. comparison between measurements in soft tissue and lung windows in the right main bronchus icc(agreement)=0.558 icc(consistency)=0.923 x=y line 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 soft tis sue w indow 1 2 3 4 5 6 7 8 lu ng w in do w table i. the difference in millimetres between axial measurements and measurements after mpr in the longitudinal axis (total number of stenoses = 62) difference <0.5 mm 0.5 1.0 mm >1 mm trachea 9 5 0 right main bronchus 2 2 2 bronchus intermedius 12 8 2 left main bronchus 12 7 1 total 35 22 5 original article 58 sa journal of radiology • september 2010 original article table i indicates the differences between axial measurements and those after mpr in the longitudinal axis for all the airways: of the differences, 56.4% were <0.5 mm, 35.5% were 0.5 1.0 mm, and 8.1% were >1 mm. graphs 5 and 6 illustrate a high consistency (icc consistency of 0.972 for tracheal measurements and 0.923 for right main bronchus measurements) between values on soft tissue window and lung window for the trachea and right main bronchus. lung window measurements in the trachea were 1.58 mm (root mean square error) less than measurements in soft tissue windows and 1.52 mm (root mean square error) less in the right main bronchus. graphs 7 and 8 also illustrate diameter measurements taken in the bronchus intermedius and left main bronchus on lung window and were consistently less than measurements in soft tissue windows (icc consistency 0.889 for bronchus intermedius and 0.923 for left main bronchus). here there was less difference for smaller diameter airways a c b d fig. 1a d. mdct of the chest in a 25-month-old boy with compression of the left main bronchus owing to tuberculous lymphadenopathy. a: standard axial image in soft tissue windows illustrating the measurement at the maximum stenosis in the left main bronchus (3.5 mm). b: measurement of diameter after mpr along the longitudinal axis of the airway (4.3 mm). note the calcified lymphadenopathy around the airway. c: image a in lung windows, measurement 2.2 mm. d: image b in lung windows, measurement 2.3 mm. original article 59 sa journal of radiology • september 2010 (more severe stenoses) compared with differences for larger diameters. on average, the diameters were smaller by 1.4 mm on lung windows compared with soft tissue window at the same location. discussion ct detects mediastinal, airway and lung abnormalities with high accuracy, sensitivity and specificity.3-5 the introduction of mdct scanners has made it possible to acquire high-resolution images of the upper, central and segmental airways within a short acquisition time.6 in patients with airway compression, the advantage of ct over bronchoscopy is that the cause of airway compression can be diagnosed and the airway distal to the obstruction can be evaluated in areas that are usually inaccessible to bronchoscopy. additional areas of stricture beyond an area of narrowing can also be evaluated.5,7 chest ct is therefore an indispensable tool for identifying airway stenoses caused by tb lymphadenopathy. although axial ct images are sufficient for evaluating most airway abnormalities, there are inherent limitations of axial images for assessing the airways: • limited ability to detect subtle airway stenoses • underestimation of the craniocaudal extent of the disease • difficulty in displaying the complex 3-d relationships of the airway to adjacent mediastinal structures • inadequate representation of airways oriented obliquely to the axial plane (figs 2 4) graph 7. comparison between measurements in soft tissue and lung windows in the bronchus intermedius. graph 7. comparison between measurements in soft tissue and lung windows in the bronchus intermedius icc(agreement)=0.530 icc(consistency)=0.889 x=y line 1 2 3 4 5 6 7 sof t tissue w indow 0 1 2 3 4 5 6 7 8 lu ng w in do w graph 8. comparison between measurements in soft tissue and lung windows in the left main bronchus. graph 8. comparison between measurements in soft tissue and lung windows in the left main bronchus  icc(agreement)=0.583 icc(consistency)=0.923 x=y line 1 2 3 4 5 6 7 sof t tissue w indow 0 1 2 3 4 5 6 7 8 lu ng w in do w fig 2. illustration of axially imaged central airways. the cuts demonstrated are through the trachea, carina and main bronchi. an axial cut through the vertical trachea provides an accurate diameter of this tubular structure. if a more oblique structure is cut axially, the shape is oblong and may give an inaccurate measurement if there is asymmetrical compression. fig. 3. illustration of a horizontal, tubular structure. to get an accurate axial diameter of this structure, alignment should be through the centre of the longitudinal axis of the structure. concentric or asymmetrical compression limits the ability to measure this on routine axial ct. fig. 4. illustration of a partially compressed segment of a tubular structure. there is a higher possibility that cuts through the compressed segment might not be through the centre; therefore, an inaccurate diameter will be measured. there are at least 2 slices that may give a realistic diameter on the non-compressed segment and none in the compressed segment in this theoretical example. original article 60 sa journal of radiology • september 2010 original article • difficulty in assessing the interfaces and surfaces of airways that lie parallel to the axial plane.8 both axial ct and ct with mpr are accurate in detecting airway stenoses.5,9 remy-jardin et al. stated that mpr did not provide information that was not evident on transverse images. they did, however, find that mild airway narrowing was easier to recognize on mpr and the length of airway narrowing was easier to measure on mpr than on transverse ct images.9 quint et al. found that ct with mpr occasionally provided information that was not evident on axial images, and advocated the use of mprs in imaging of the central airways.5 mpr to produce images of each of the major airways into its longitudinal axis, so as to obtain a true ‘axial’ diameter, is timeconsuming as it must be performed manually and individually for each bronchus as these are oriented uniquely in each patient. measurements in the axial scan plane are more convenient and rapid as this is the routine image plane provided; i.e. there is no standard practice. from the results of this study, no significant statistical difference was found between axial measurements and measurements taken after mpr providing the longitudinal axis, even in the relatively horizontal left main bronchus. the majority (56.4%) of differences were <0.4 mm with only 8.1% of the differences being >1 mm. therefore, central airway stenoses are accurately detected and also not significantly overestimated or underestimated on axial images without mpr (figs 5 a and 5b). it was, however, easier to evaluate mild stenoses and measure the length of stenoses with mpr. measurements taken in lung windows consistently measured the diameter of stenoses of the central airways less than soft tissue (1.4 mm on average) (figs 5c and 5d). the wide window and low-level setting of lung window should make it the desired setting for evaluating the airfilled airways. it is therefore more likely that soft tissue underestimates stenoses. in small-calibre airways, it is therefore important to measure stenoses on lung window to prevent underestimation. currently, a coarse parameter of 50% luminal obstruction of a main stem or lobar bronchus is considered a significant clinical indicator for management of children with airway obstruction. in the future, when there is less reliance on bronchoscopy and more reliance on imaging for airway narrowing, more refined measurement may become important to management decisions. a b c d fig. 5a d. mdct of the chest in a 52-month-old boy with compression of the bronchus intermedius owing to tuberculous lymphadenopathy. a: standard axial image in soft tissue windows illustrating the measurement of the maximum stenosis in the bronchus intermedius (4.1 mm). note the subcarinal lymphadenopathy. b: measurement of the true diameter after mpr along the longitudinal axis (5.0 mm). c: image a in lung windows measuring 2.3 mm. d: image b in lung windows measuring 2.3 mm. original article 61 sa journal of radiology • september 2010 conclusion the degree of central airway stenoses is accurately assessed on axial images, obviating the need to perform mpr to obtain a true axial diameter of the airways in children. measurements taken on soft tissue window consistently underestimate stenoses. 1. andronikou s, joseph e, lucas s, et al. ct scanning for the detection of tuberculous mediastinal and hilar lymphadenopathy in children. pediatr radiol 2004;34:232-236. 2. kauczor hu, wolcke b, fischer b, mildenberger p, lorenz j, thelen m. three-dimensional helical ct of the tracheobronchial tree: evaluation of imaging protocols and assessment of suspected stenoses with bronchoscopic correlation. am j roentgenol 1996;167:419-424. 3. hartman te, primack sl, lee ks, swensen sj, muller nl. ct of bronchial and bronchiolar diseases. radiographics 1994;14:991-1003. 4. sorantin e, geiger b, lindbichler f, eber e, schimpl g. ct-based virtual tracheobronchoscopy in children – comparison with axial ct and multiplanar reconstruction: preliminary results. pediatr radiol 2002;32:8-15. 5. quint le, whyte ri, kazerooni ea, martinez fj, cascade pn, lynch jp 3rd. stenosis of the central airways: evaluation by using helical ct with multiplanar reconstructions. radiology 1995;194:871-877. 6. hoppe h, dinkel hp, walder b, von allmen g, gugger m, vock p. grading airway stenosis down to the segmental level using virtual bronchoscopy. chest 2004;125(2):704-711. 7. choe ko, jeong hj, sohn hy. tuberculous bronchial stenosis: ct findings in 28 cases. am j roentgenol 1990;155:971-976. 8. boiselle pm, ernst a. recent advances in central airway imaging. chest 2002;121:1651-1660. 9. remy-jardin m, remy j, deschildre e, artaud d, ramon p, edme jl. obstructive lesions of the central airways: evaluation by using spiral ct with multiplanar and three-dimensional reformations. eur radiol 1996;6:807-816. marie grobbelaar 31 july 1969 – 31 october 2009 almost a year since her passing, it is with great sadness that we think back on the life of our dear colleague and friend marie. she completed her studies at stellenbosch university in june 2008, and stayed on in the department as a senior specialist. she was a popular doctor, a favourite amongst all, and well known for her work ethic, enthusiasm, humility, caring nature and special sense of humour. she was a pillar to lean on, always making herself available and willing to go the extra mile. she had had intermittent headache for a week, was scanned on a wednesday, a phaeochromocytoma was found, she came to work on the friday, and passed away the next morning. with the publication of her master’s thesis in this issue of the sajr, we salute and honour this unique and beautiful soul. we extend our deepest sympathy to her husband johan and their children chris and jenna. consultants and registrars department of diagnostic imaging stellenbosch university in memoriam milestones and new ventures author: razaan davis1 affiliation: 1faculty of medicine and health sciences, stellenbosch university, south africa postal address: division of radiodiagnosis, department of medical imaging and clinical oncology, tygerberg hospital, po box 19063, tygerberg 7505, south africa how to cite this book review: davis r. milestones and new ventures. s afr j rad. 2014;18(1); art. #610, 1 page. http://dx.doi.org.10.4102/sajr.v18i1.610 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. content open access we take cognisance of the 50 years since the south african journal of radiology (sajr) first appeared as a supplement of the south african medical journal (samj) in april 1963. although not in continuous print, it nevertheless documented the development of south african radiology, serving as a repository for the mostly unique and always interesting cases. the sajr, however, must continue to evolve in order to remain contemporary. i therefore happily announce that the sajr will now publish exclusively online, with no print copy, except inter alia a copy for the national archives of south africa. this is a considerable step toward making the journal accessible to a broader international audience. african online scientific information systems (pty) ltd (aosis) openjournals will publish the sajr online in pdf, html, xml and epub format as a rolling publication, its archives accessible to all users. signing up for ‘article alerts/notification’ on the sajr webpage will inform users when a new article is available online. the sajr will remain an open access peer-reviewed scholarly journal. the radiological society of south africa (rssa) has undertaken, at this time, to fully subsidise the publishing cost, which translates to ‘no author fees’. the journal meets the criteria of the department of higher education and training (dohet) and is therefore accredited and approved by the dohet for inclusion in the subsidy system. we will continue to provide a continuous professional development (cpd) programme. the sajr aims to refine its focus and scope, thereby carving its niche. it is my intention to give south african radiology wider exposure by including a special focus musculoskeletal issue during the course of this year. the cases presented by the south african musculoskeletal imaging group (samsig) at the first rssa/samsig advanced musculoskeletal imaging course at the v & a waterfront, cape town, 21–23 february 2014, provides this opportunity. in further contributory efforts to excellence in radiology, and marking the next 50 years of the sajr, i am delighted to introduce an important series of editorials contributed by the centre for evidence-based health care and division of community health located at the faculty of medicine and health sciences, stellenbosch university. the intent is to encourage appropriate imaging in south africa by promoting the practice of evidence-based radiology. i hope that you will find this series both enlightening and encouraging. article information author: joel h. bortz1 affiliation: 1lsg imaging, los angeles, united states of america correspondence to: joel bortz email: joelbortzmd @gmail.com postal address: 13031 villosa place, apartment 141, playa vista, california 90094, united states of america dates: received: 19 june 2014 accepted: 27 july 2014 published: 04 dec. 2014 how to cite this article: bortz, jh. computed tomographic colonography: diagnosis of an incarcerated spigelian hernia. s afr j rad. 2014;18(1); art. #673, 4 pages. http://dx.doi.org/10.4102/sajr.v18i1.673 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. computed tomographic colonography: diagnosis of an incarcerated spigelian hernia in this case report... open access • abstract • introduction    • case report • discussion • acknowledgements    • competing interests • references abstract top ↑ a 68-year-old obese man underwent computed tomographic colonography (ctc) scanning to investigate worsening constipation and lower abdominal discomfort on his left side. optical colonoscopy was contraindicated because of his comorbidities. a preliminary ctc diagnosis of incarcerated spigelian hernia was made, based on lateral deviation of the sigmoid colon to the left as well as extrinsic impressions on it, and the central location of the small bowel. spigelian hernia is a rare form of anterior abdominal wall hernia. ctc can play a role in its diagnosis. introduction top ↑ computed tomography (ct) has been shown to produce the most accurate imaging in the diagnosis of spigelian hernia. in this case report, ct colonography (ctc) demonstrated additional findings, making the diagnosis more readily achievable. case report a 68-year-old obese man was referred for ctc scanning by a gastroenterologist. his primary clinical history was worsening constipation and lower abdominal discomfort on his left side. optical colonoscopy was contraindicated because of his comorbidities of hypertension, ischaemic heart disease, diabetes and chronic obstructive airways disease. a low-dose ctc technique, co2 insufflation and a 16-slice general electric multidetector ct (mdct) scanner were used for the study. as the patient was obese, a standard two-view supine and prone study could not be performed; therefore right and left decubitus views were done instead. filling the colon with three litres of co2 took approximately seven minutes, compared with the average time of three minutes. the ctc study showed an incarcerated spigelian hernia (sh), without evidence of obstruction. the colon map views showed three important findings: (1) the sigmoid colon was markedly displaced to the left; (2) the small bowel was in a central position (figure 1a); and (3) in addition, the air-contrast colon map demonstrated two external impressions on the sigmoid colon at the point where it enters and exits the muscular defect (figure 1b). slight narrowing of both the afferent and efferent loops of the sigmoid was noted on 3d fly-through imaging (figure 2). figure 1: colon map showing small bowel (light green) in central positon. note that the sigmoid colon is markedly displaced to the left; (b) colon map using air-contrast indicates locus of narrowing of the sigmoid loops (arrows). figure 2: a 3d fly-through image shows narrowing of efferent loop of sigmoid colon (arrows). a 2d image below the umbilicus confirmed a defect through both the internal oblique and the transversus muscles. the sigmoid colon was contained in a hernia. an axial view demonstrated a thin rim of the external oblique muscle laterally, indicating an interstitial or interparietal geographic location of the hernia (figure 3). coronal and sagittal 2d images clearly demonstrated the sh (figure 4 and figure 5). figure 3: axial view shows the sigmoid colon passing through the hernial defect (yellow arrow). blue arrow shows the thin rim of the external oblique muscle. figure 4: coronal 2d image of spigelian hernia through the muscular defect. the hernia is contained by the external oblique muscle laterally, and shows marked thinning inferiorly (orange arrows). yellow arrow indicates site of muscular defect. figure 5: sagittal 2d image shows the spigelian hernia sandwiched between (1) the internal oblique muscle and transversus muscle superiorly (red arrows) and (2) thinned-out external oblique muscle inferiorly (green arrow). in view of the patient's comorbidities, surgical intervention was not an option at this stage. he was fully briefed by the gastroenterologist in this regard and made aware of the risk of obstruction or strangulation. he was informed that, should this occur, surgical intervention would be required. discussion top ↑ spigelian hernia is also known as spontaneous anterior abdominal hernia. it is a rare acquired hernia occurring in less than 2% of all abdominal hernias, with just over 1000 reported cases in the literature. 1 congenital cases of sh have been reported in children. 2 sh is often undetected clinically as the symptoms and physical findings are subtle or inconclusive, particularly in obese adult patients. sh is prone to complications, such as incarceration, small or large bowel obstruction and strangulation, because the hernia defect is usually narrow (2 cm – 3 cm). 1–3 diagnosis is, however, primarily made by ct. 1, 4, 5 in the present case report, a ctc was performed for investigation of abdominal discomfort and worsening constipation. a diagnosis of sh was made based on the lateral deviation of the sigmoid colon as well as the two extrinsic defects on its wall (figure 1a and figure 1b). the diagnosis was confirmed by the 2d study which showed an interparietal sh containing sigmoid colon and a clear hernial defect in both the internal oblique and transversus muscles (figure 4 and figure 5). ctc is a minimally invasive, fast, safe and accurate screening examination for colorectal cancer. it is also suitable as a diagnostic study for patients with gastrointestinal symptoms. furthermore, it allows evaluation of extracolonic structures in the abdomen and pelvis. ultrasound is often the first line of imaging used to investigate sh. 1, 2, 5 although operator dependent, it can be used to make a diagnosis of sh in a large proportion of patients. in addition, a valsalva manoeuvre can be used in supine and erect sonography to determine the presence of sh. 3 there is a slightly higher incidence of sh in women than in men; in adults, it usually occurs during the fourth and seventh decades. 1, 2, 6 it may occur on either side of the body, or occasionally bilaterally. 1 there are several known predisposing factors: obesity, chronic obstructive airways disease, previous surgery or laparoscopy, peritoneal dialysis, multiple pregnancies, and rapid weight loss, for example. 2, 6, 7 clinical presentation varies, depending on the content of the hernial sac. in obese individuals, detection of sh may be particularly difficult as the hernia may not be palpable on clinical examination. some patients may complain of pain, but no lump is palpable. 6 omentum and/or segments of the small bowel or colon are usually present in the sac. in the present case, the colon map showed small bowel in a central location; it was not included in the hernia sac (figure 1a). other structures, such as the stomach, meckel's diverticulum, the appendix, and testicular and endometrial tissue, have been found in sh. 2, 8 it is important to know the anatomy of the abdominal musculature when diagnosing sh. there are three flat and two vertical muscles of the anterior abdominal wall (figure 6a and figure 6b). the flat group consists of the external and internal oblique muscles and the transversus abdominis muscles. the vertical group comprises the rectus abdominis and pyramidalis. figure 6: (a) view of the anterior abdominal wall with the external oblique, internal oblique and rectus abdominis muscles peeled away on the right side of the body (adaptation with grateful acknowledgement). 2 identified are (1) the transversus muscle; (2) the posterior rectus sheath; (3) the spigelean aponeurosis; (4) the spigelian hernia belt (5) the linear alba; and (6) the anterior superior iliac spine. yellow arrow = semilunar line; red arrow = umbilicus; green arrow = arcuate line; and double-pointed blue arrow = 6 cm width of the spigelian hernia belt. (b) axial ct image shows the three flat abdominal muscles: yellow arrow = external oblique; red arrow = internal oblique; and green arrow = abdominis transversus. the external oblique muscle arises from the lower eight ribs; it is the largest and most superficial muscle of the antero-lateral abdominal wall. the muscle fibres pass infero-medially. the aponeurosis of the upper part of the muscle splits to cover the anterior and posterior portions of the rectus abdominis. inferiorly, the superior margin of the external oblique aponeurosis thickens and folds back on it to form the inguinal ligament. 9 the internal oblique is the middle of the flat muscle group. it is a thin muscular sheet that fans out antero-medially. its fibres become aponeurotic and split to envelop the anterior and posterior margins of the rectus in its upper two-thirds of the abdomen. in the lower third, the aponeurosis does not split; it passes as a whole in front of the rectus to reach the linear alba (figure 6a). 9 the transversus abdominis muscle is the innermost of the three flat muscles, with a transversomedial orientation. superior to the arcuate line, the aponeurosis of the tranversus abdominis muscle splits to form part of both the anterior and posterior rectus sheath. inferiorly to the arcuate line, the aponeurosis of the transversus abdominis muscle passes anteriorly to form part of the anterior rectus sheath layer. this arrangement allows for a potential area of weakness posteriorly. the rectus abdominis is a vertical muscle that is wrapped anteriorly and posteriorly by the aponeurosis of the three flat muscles. the lower third has no posterior cover. the pyramidalis is absent in approximately 25% of individuals. it is a small, insignificant muscle situated in relation to the inferior margin of the rectus. the spigelian (semilunar) line represents the vertical fibrous band formed by the union of the rectus sheath with the fascia of the three flat muscles of the anterior abdominal wall. in the upper two-thirds of the abdomen, the aponeurosis splits at the lateral margin of the rectus into a posterior layer, which passes behind the rectus muscle, and an anterior layer which passes in front of the rectus. the level at which this occurs is known as the arcuate line (figure 6a), the semicircular line or the line of douglas. the deep layer of the abdominal wall is only weakly reinforced by separated fascial bands. the spigelian aponeurosis is the portion of the transversus abdominis that is bordered by the semilunar (spigelian) line laterally and the lateral borders of the rectus muscle medially (figure 6a). sh protrudes through this aponeurosis; most are found in a transverse band lying between 0 cm and 6 cm cranially to a line running between both the anterior and superior iliac spines. 8 this band is referred to as the ‘spigelian hernia belt’ where the spigelian fascia is widest (figure 6a). 6 a diagnosis of sh, based on plain-film radiographs, upper and lower gastrointestinal studies, and follow-through studies, is not readily made in the absence of an intestinal obstruction. 7 there has been reported use of magnetic resonance imaging (mri) for investigation of sh. 10 ct, however, is the main imaging modality. as is evident in the present case report, ctc can play an important part in the diagnosis of sh. the main advantage of ctc is that the entire large bowel and all extracolonic components can be visualised. the complementary role of 2d and 3d imaging in the diagnosis of sh is well demonstrated in this case report. acknowledgements top ↑ clinton bopp is thanked for drawing the line diagram of the abdominal musculature. competing interests the author declares that he had no financial or personal relationship(s) that might have inappropriately influenced him in writing this report. references top ↑ . moles morenilla l, docobo durántez f, mena robles j, de quinta frutos r. spigelian hernia in spain. an analysis of 162 cases. rev esp enferm dig. 2005;97:338–347. http://dx.doi.org/10.4321/s1130-01082005000500006 salameh jr. primary and unusual abdominal wall hernias. surg clin n am. 2008;88:45–60. http://dx.doi.org/10.1016/j.suc.2007.10.004 mariolis-sapsakos t, kalles v, papapanagiotou i, et al. a rare case of spigelian hernia penetrating the external oblique muscle. oa case reports. 2013;28;2(2):11. emby dj, aoun g. ct technique for suspected anterior abdominal wall hernia. ajr. 2003;181(2):431–433. http://dx.doi.org/10.2214/ajr.181.2.1810431 balthazar ej, subramanyam br, megibow a. spigelian hernia: ct and ultrasonography diagnosis. gastrointest radiol. 1984;9(1):81–84. http://dx.doi.org/10.1007/bf01887808 mittal t, kumar v, khullar r, et al. diagnosis and management of spigelian hernia: a review of literature and our experience. j minim access surg. 2008;4(4):95–98. http://dx.doi.org/10.4103/0972-9941.45204 ribeiro ea, cruz rj, moreira sm. intestinal obstruction induced by a giant incarcerated spigelian hernia. case report and review of the literature. sao paulo med j. 2005;123(3):148–150. http://dx.doi.org/10.1590/s1516-31802005000300012 angelici am, nasti ag, petrucciani n, leonetti g, palumbo p. spigelian hernia: a case report and review of the literature. g chir. 2006;27(11-12):433–435. netter f. the ciba collection of medical illustrations. vol 3. digestive system. part 2. lower digestive tract. new york: colour press, 1962; p. 12–14. kassir r, tarantino e, lacheze r, brek a, bartolmeo ad, tiffet o. management of spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman. int j surg case rep. 2013;4(12):1176–1178. http://dx.doi.org/10.1016/j.ijscr.2013.10.010 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) garba h. yunusa nuclear medicine division, department of radiation medicine, university of cape town, south africa anita brink nuclear medicine division, department of paediatrics, university of cape town, south africa red cross memorial children’s hospital, cape town, south africa citation yunusa g.h., brink a. assessment of the impact of application of single-photon emission computed tomography and spect-ct on lesion categorisation in bone scintigraphy. s afr j rad. 2016;20(1), a990. http://dx.doi.org/10.4102/sajr.v20i1.990 original research assessment of the impact of application of single-photon emission computed tomography and spect-ct on lesion categorisation in bone scintigraphy garba h. yunusa, anita brink received: 16 feb. 2016; accepted: 15 mar. 2016; published: 29 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objectives: to assess initial experience with the use of a new single-photon emission computed tomography-computed tomography (spect-ct) in the evaluation of lesions. methods: the folder number, radiopharmaceutical used and type of scan of patients examined with a new siemens t6 spect-ct between 02 april 2016 and 31 december 2013 were retrieved. the number of 99mtc-mdp bone scans was sufficient for a detailed analysis. the scans were re-processed and reported by the observer before he was given any clinical information. whole body planar, whole body planar plus spect and whole body planar plus spect-ct images were assessed successively in three separate sessions at least 2 weeks apart. at each session, the certainties of detection, localisation and categorisation of each lesion were recorded. results: a total of 539 lesions were seen on the whole body, spect and computed tomography (ct) images in 133 patients. the whole body images showed no lesions in 3 patients and 378 lesions in 130 patients. spect detected 122 additional lesions in 79 patients. thirty-nine (12.2%) lesions were seen only on ct in 32 (24.1%) patients. for the 261 lesions seen on the planar images in the spect field of view, lesion detection was definite in 233 (89.3%), localisation definite in 151 (57.9%) and categorisation definite in 123 (47.1%) lesions. on the spect, definite lesion detection, localisation and categorisation were recorded, respectively, for 259 (99.2%), 228 (87.4%) and 176 (67.4%) of the 261 lesions. lesion detection, localisation and categorisation certainties were definite for 100%, 99.1% and 94.7% of the spect-ct lesions, respectively. conclusion: spect markedly improves lesion detection and localisation, and ct enhances lesion categorisation. introduction the use of hybrid imaging consisting of single-photon emission computed tomography (spect) and x-ray transmission computed tomography (ct) scan is increasing globally. it has the advantage of providing functional and morphologic information for a given lesion. radionuclide imaging has high sensitivity early in the disease before morphological changes become visible on other imaging modalities.1 the addition of ct provides morphological information with high spatial resolution. the combination of spect and ct has improved staging of disease as well as the prognostic and treatment monitoring potentials of the functional and metabolic information provided by conventional nuclear medicine examinations.2,3 over the years, the use of spect-ct has been shown to accurately reclassify lesions previously classified as indeterminate on planar and spect imaging in both skeletal and non-skeletal nuclear medicine examinations with certainties of 88%–100%.4,5,6,7 however, the limitations in previous studies included the low resolution of the ct used which did not reveal the exact anatomical sites of abnormal radiotracer accumulation, and the prolonged ct acquisition time of 10–15 min by the dual slice ct scanners that resulted in increased patient motion and degradation of image quality.8 these factors have implications on the observer’s confidence. prolonged acquisition time and poor spatial resolution have been addressed by the recent introduction of multi-slice ct scanners in newer versions of the spect-ct systems.7,8 therefore, the use of a faster higher resolution ct may improve observer’s confidence. a new spect machine integrated with a helical 6-slice ct was installed in the department of nuclear medicine at groote schuur hospital in march 2012. the objectives of this study were to assess the initial experience with the use of spect-guided ct in the evaluation of lesions, the impact of spect and addition of 6-slice ct in spect-ct on lesion categorisation, and the difference between the use of spect alone and fused spect-ct in lesion localisation and categorisation. methods approval for the study was obtained from the research ethics committee of the faculty of health sciences, university of cape town and groote schuur hospital. all of the scans were done for clinical purposes and the initial reports issued used for patient management. patients’ confidentiality was observed throughout the study by the use of a coding system. the folder number, radiopharmaceutical used and type of scan of all patients examined on the new stand-alone siemens t6 spect-ct (siemens medical solutions sw, erlangen) machine between 02 april 2012 and 31 december 2013 were retrieved from the electronic archives of the nuclear medicine department. a filter was then applied to identify all bone scans for which spect-ct was performed. in patients who had multiple studies, only the first study was included. each patient had planar whole body and selected static images. spect and subsequently ct images of the region of clinical interest were recorded depending on the abnormalities seen on the initial images or the indication for the study as deemed fit by the supervising nuclear medicine registrar or consultant at the time of image acquisition. whole body images were acquired using a low-energy high-resolution collimator with a matrix size of 256 × 256 and a scan speed of 14 cm/s. spect images were obtained using a 128 × 128 matrix with 25 s per step acquiring 64 projections with 180° rotation for each gamma camera head. ct images were acquired using a low-dose protocol without intravenous contrast administration. the low-dose ct parameters used were: 2.5 mas–30 mas, 120 kv, slice thickness of 1.25 mm–5 mm and pitch of 1.2–1.5. spect images were reconstructed using the flash 3d ordered subset expectation maximisation (osem) iterative reconstruction algorithm in four subsets and eight iterations, and smoothed with a spatial gaussian filter 6.0 (fwhm). the ct images were reconstructed using high-resolution reconstruction algorithms (b08s kernel) while the images were viewed using the siemens b80s kernel, for bone and b31s kernel for soft tissues. for the purposes of this study, all examinations were re-processed and reported on the siemens (syngo ve32b, 2008, siemens medical solutions, sw, erlangen) and hermes (version v1.0, 2005, hermes medical systems, sweden) physicians’ workstations by a single observer who is a qualified radiologist and a nuclear medicine senior registrar. during the reconstruction and review of the images for this study, the observer was blinded to the history, clinical examination findings, laboratory and histology results as well as the previous reports issued. a four-point score (unknown, possible, probable or definite) was assigned for each lesion for the certainty of lesion detection, localisation and categorisation. lesion ‘detection’ refers to visualisation of the lesion; ‘localisation’ refers to its anatomical location, while categorisation refers to ascribing the lesion to a specific morphology, pathology or physiological process. the lesions were assessed successively in separate reading sessions on planar, planar plus spect and planar plus spect-ct images with at least two weeks in between the sessions. the information on patient demographics and indications for the study were made available for the observer. data analysis was performed on per lesion and per patient basis. assessments were made on per lesion and per patient bases for lesion detection, localisation, and categorisation. analysis of levels of certainty for lesion detection, localisation and categorisation was made for planar, planar plus spect and planar plus spect-ct. results within the period under review, from 02 april 2012 to 31 december 2013, 241 spect-ct scans were done. after exclusion of 50 follow-up scans, four technically poor-quality studies and two with an incomplete data set, 185 studies were left for analysis. the 133 patients referred for 99mtc-mdp bone scintigraphy comprised 92 (69.2%) females and 41 (30.8%) males with a mean age of 53.3 ± 15.7 years. the majority of the patients were referred for metastatic survey (42.9%), or because of musculoskeletal pain (29.3%) or suspected infection and/or inflammation (16.5%). lesion detection: a total of 539 lesions were seen on the whole body, spect and ct images (table 1). there were three patients in whom no lesions were seen on the whole body images. spect and spect-ct were done because of clinical information: one patient was a 49-year-old female with breast carcinoma who complained of back pain; the second patient was a 28-year-old female with three month history of wrist pain, while the third patient was a 39-year-old female with history of injury to the right knee, four weeks prior to presentation. in the remaining 130 patients, 378 lesions were detected on the whole body images, 261 (69.0%) lesions within the field of view (fov) of the spect images. of the total number of lesions detected on spect, 122 (31.9%) were not seen on the whole body images. these additional lesions were detected in 79 patients. spect-ct detected 318 lesions, 39 (12.2%) of which were seen only on ct in 32 (24.1%) patients. table 1: lesions detected on 99mtc-mdp bone scan. lesion detection, localisation and categorisation certainty: for the 261 lesions seen on the planar images in the spect fov, lesion detection was definite in 233 (89.3%), localisation was definite in 151 (57.9%) and categorisation was definite in 123 (47.1%) lesions (tables 2, 3 and 4). on the spect, definite lesion detection, localisation and categorisation were recorded for 259 (99.2%), 228 (87.4%) and 176 (67.4%) of the 261 lesions, respectively. table 2: lesion detection certainty. table 3: lesion localisation certainty. table 4: lesion categorisation certainty. on spect, out of the 383 lesions detected the certainty of lesion detection, localisation and categorisation were definite for 381 (99.5%), 328 (85.6%) and 267 (69.7%) lesions, respectively. for the 279 spect lesions seen in the ct fov the lesion detection, localisation and categorisation was definite in 279 (100%), 276 (98.9%) and 262 (93.9%) lesions, respectively. lesion detection certainty was definite for all the 318 (100%) spect-ct lesions, while lesion localisation and categorisation certainties were definite in 99.1% and 94.7% of the lesions, respectively. of the 42 lesions categorised as indeterminate on planar, 20/42 (47.6%) and 35/42 (83.3%) were re-categorised following the addition of spect and spect-ct, respectively. discussion this study reports the initial experience with new multi-slice spect-ct scanner as well as the impact of the addition of spect with and without a low-dose ct in the evaluation of lesions in patients referred for 99mtc-mdp bone scintigraphy. spect not only improved the ability of radionuclide imaging to detect lesions by revealing more lesions, it also increased observer’s confidence regarding lesion localisation. this is in agreement with earlier reports that showed spect is more sensitive than planar in detecting and localising lesions, particularly vertebral lesions with a 20%–50% increase in lesion detection.1,9,10,11,12 the addition of spect has been shown to increase the accuracy of lesion categorisation by improving localisation, especially in complex skeletal structures such as spine, skull and pelvis.1,11,12,13 in this study, the addition of spect has markedly improved the observer’s confidence with regard to lesion detection, localisation and categorisation by increasing certainty when compared with planar imaging. the addition of ct detected more lesions in a quarter of the patients while spect-ct markedly increased the interpreter’s confidence with respect to lesion localisation and categorisation in comparison with spect and planar images (figures 1 and 2). this agrees with the reports from other studies.2,4,5,6,7,14,15 in addition, some of these studies reported marked reduction of indeterminate lesions from a rate of between 48% and 72% using whole body planar scintigraphy with or without spect, to a rate between 0% and 15%.4,5,6 the current study showed a reduction in the indeterminate lesion rate among patients referred for 99mtc-mdp bone scintigraphy from 21.3% on planar alone to 11.2% and 3.6% following the addition of spect and spect-ct, respectively. while the proportion of spect-ct indeterminate lesions in this study is similar to that found in the study reported by palmedo et al.,15 the lower rate found on the planar images in the current study may be due to the criteria used when referring patients for scintigraphy. figure 1: sagittal low-dose ct (a) and fused sagittal spect-ct (b) images showing moderate to intense 99mtc-mdp uptake localised to an oblique lucency traversing the right pars interarticularis of l5, in keeping with a fracture in a young athlete. figure 2: a 79-year-old male known with carcinoma of the prostate and a prostate specific antigen (psa) doubling time of less than 6 months: sagittal (a) and coronal (b) fused spect-ct images showing an area of intense 99mtc-mdp uptake adjacent to an expansile lytic lesion localised to the spinous process and lamina of t6. the ct component of the hybrid imaging spect-ct systems can assist in the diagnosis of benign skeletal findings, such as osteophytes or degenerative changes, or haemangiomas causing abnormal tracer uptake in patients referred for metastatic survey. however, it is important to note that foci of increased tracer uptake on bone scintigraphy due to metastatic bone lesions may not show any morphologic abnormality on ct. likewise, lytic bone lesions with increased tracer uptake on bone scintigraphy may only be visualised on ct after they have destroyed 50–75% of the trabecular bone.1,3,4,11 therefore, under these circumstances the lack of anatomical abnormalities despite abnormal tracer uptake suggests medullary disease, and hence spect-ct improves specificity. improved lesion categorisation on spect-ct makes a difference with regard to patient management decisions especially in patients referred for skeletal survey for metastases or musculoskeletal pain in patients with known malignancy.4,5,6,7,11,15 some of the limitations of this study include the retrospective nature of the study as well as the lack of independent standards such as histological correlation, or clinical or imaging follow-up. conclusion in conclusion, this study is consistent with prior research that found spect improved lesion detection and observer’s confidence regarding lesion localisation and that spect-ct has a marked impact on lesion categorisation as well as improved observer’s confidence. our study thus adds to the existing body of literature on the incremental value of spect-ct in skeletal pathology. better lesion categorisation has important implications on patient management decision especially among cancer patients referred for bone scintigraphy for suspected skeletal metastases or musculoskeletal pain. acknowledgements the authors acknowledge the support of prof. m.d. mann for his invaluable contribution during the design and conduct of this study. they also thank dr t. kotze, the head of nuclear medicine at groote schuur hospital, for the support throughout the period of the study. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions g.h.y. was responsible for study conception, design, data analysis and manuscript writing. a.b. made conceptual contributions and reviewed the manuscript. references horger m, bares r. the role of single-photon emission computed tomography/computed tomography in benign and malignant bone disease. semin nucl med. 2006;36(4):286–294. http://dx.doi.org/10.1053/j.semnuclmed.2006.05.001 jacene ha, goetze s, patel h, wahl rl, ziessman ha. advantages of hybrid spect/ct alone. open med imag j. 2008;2:67–9. http://dx.doi.org/10.2174/1874347100802010067 mariani g, bruselli l, kuwert t, et al. a review on the clinical uses of spect-ct. eur j nucl med mol imaging. 2010;37(10):1959–1985. http://dx.doi.org/10.1007/s00259-010-1390-8 romer 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g, lerman h, lievshitz g, metser u. spect/multislice low-dose ct: a clinically relevant constituent in the imaging algorithm of non-oncologic patients referred for bone scintigraphy. j nucl med. 2007;48(2): 319–324. strobel k, burger c, seifert b, husarik db, soyka jd, hany tf. characterisation of focal bone lesions in the axial skeleton: performance of planar bone scintigraphy compared with spect and spect fused with ct. ajr am j roentgenol. 2007;188(5):w467–474. http://dx.doi.org/10.2214/ajr.06.1215 palmedo h, marx c, ebert a, et al. whole-body spect-ct for bone scintigraphy: diagnostic value and effect on patient management in oncological patients. eur j nucl med mol imaging. 2014;41(1):59–67. http://dx.doi.org/10.1007/s00259-013-2532-6 article information author: john m. zietkiewicz1 affiliation: 1lake, smit and partners, durban, south africa correspondence to: john zietkiewicz postal address: lake smit and partners, private bag x08, overport 4067, south africa dates: received: 24 july 2014 accepted: 17 oct. 2014 published: 09. dec 2014 how to cite this article: zietkiewicz, jm. post-traumatic myositis ossificans. s afr j rad. 2014;18(2); art. #701, 3 pages. http://dx.doi/org/10.4102/ sajr.v18i2.701 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. post-traumatic myositis ossificans in this case report... open access • abstract • case report • discussion    • conventional radiographs    • ultrasound    • computed tomography    • isotope bone scans    • magnetic resonance imaging • differential diagnosis • treatment • conclusion • acknowledgements    • competing interests • references abstract top ↑ post-traumatic myositis ossificans (ptmo) is characterised by abnormal heterotopic bone formation involving striated muscle. ptmo is usually associated with trauma and is most common in the second and third decades. an important teaching point is that in the early or subacute phase, clinical and imaging features can mimic a soft-tissue sarcoma. a combination of imaging modalities is required to evaluate the muscle lesion. case report top ↑ a 19-year-old man was referred for a magnetic resonance imaging (mri) scan of his right elbow. he presented with a large, hard mass anteriorly situated in the right elbow with an associated flexion deformity. there was a history of trauma following a motor vehicle accident four months previously. initial radiographs were normal. a second set of radiographs obtained four weeks later demonstrated a subtle soft-tissue mass with subtle mineralisation anterior to the right elbow (figure 1). the mri four months post injury demonstrated a large mass in the anterior cubital fossa that corresponded with the brachialis muscle. the mass had central signal intensity isointense to fat on the t1w (figure 2) and t2w images. these features represent bone marrow surrounded by a low-signal-intensity rim of lamellar bone. figure 1: lateral radiograph demonstrates subtle soft-tissue mineralisation (arrow) anterior to the elbow joint. figure 2: t1w sagittal image demonstrates a mass (arrow), within the right brachialis muscle, isointense to fat with a low–signal-intensity rim of lamellar bone. discussion top ↑ post-traumatic myositis ossificans (ptmo) is the most common form of myositis ossificans.1 ptmo frequently follows a history of trauma, with a predilection for anterior, proximal muscle groups in the thigh and arm.1,2 the histological evolution of ptmo parallels the radiographic or computed tomography (ct) evolution and mri appearances.3,4 imaging choices are usually limited to conventional radiography, ultrasound and ct.1,2 mri is not commonly performed. conventional radiographs a localised periosteal reaction secondary to a subperiosteal haematoma may be seen within 7–10 days. over the next few weeks, subtle soft-tissue mineralisation that becomes coarser, maturing from the periphery, is noted. within two months, a well-defined cortex is seen peripherally.1,5,6 there is eventual mature heterotopic bone formation (figure 3). calcifications typically lie parallel to the shaft of long bones or the long axis of a muscle (as in this case). this is an important distinguishing feature from non-benign bone lesions.1 figure 3: lateral radiograph of the elbow demonstrates mature heterotopic soft-tissue bone formation (arrow). ultrasound in the first few weeks, ptmo has a non-specific appearance. a heterogeneous, hypoechoic area within the muscle is noted, often with associated fluid collections. later, as the lesion matures, a hyperechoic peripheral rim reflecting calcification develops.7 an important imaging characteristic is the demonstration of normal muscle between bone and the mass, distinguishing it from a parosteal sarcoma.7 computed tomography ct is the imaging modality of choice because it optimally demonstrates the cross-sectional zonal pattern. in the first few weeks, ct shows soft-tissue swelling without calcification. after several weeks, a centrifugal zonal maturation pattern develops with the centre remaining isodense to muscle and a developing rim calcification which continues to mature.1,3,6,8 ct is valuable in evaluating a periosteal reaction and lack of continuity with underlying cortex, helping to distinguish ptmo from parosteal sarcoma.1 isotope bone scans radionuclide bone scanning (technetium 99mdiphosphonate) is sensitive but largely non–specific.1 early ptmo lesions show increased uptake in all phases.1 as the lesion matures, there is a progressive decrease in tracer uptake. magnetic resonance imaging an early ptmo lesion can mimic a soft-tissue tumour. intense perilesional muscle oedema is a common feature not usually seen in sarcomas and is an important diagnostic finding.1 acute/subacute lesions less than eight weeks old are isointense to muscle on t1w images and of mixed signal (mainly high) on t2w images with large areas of perilesional oedema and enhancement.1,2,3,4,8 these lesions can be inappropriately biopsied and excised. lesions greater than eight weeks old have two different patterns on mri: (1) central signal intensity that is isointense with fat on both t1w and t2w images, representing bone marrow surrounded by a low–signal-intensity rim of lamellar bone; and (2) diffuse intermediate signal intensity on t1w images and slightly higher on t2w images, representing fibrosis.3 differential diagnosis top ↑ in the acute/subacute setting, a muscle abscess, soft-tissue sarcoma and focal myositis are considerations. in more mature lesions with more bone formation, parosteal osteosarcoma, osteochondroma, chronic avulsion injuries and tumoral calcinosis are considerations.1,9 treatment top ↑ ptmo is usually self-limiting and is treated conservatively. further treatment options include active early mobilisation, physiotherapy and extracorporeal shockwave therapy.10 surgery, as in this case, may be considered when lesions cause disfigurement, mechanical limitation and impingement on neurovascular structures.1 conclusion top ↑ myositis ossificans represents heterotopic formation of non-neoplastic bone and cartilage in soft tissue. it is usually post-traumatic, but the trauma can be minor. pain is a common feature in an evolving lesion. ptmo evolves over time, with different imaging characteristics correlating with the age of the pathology. mri scans should always be interpreted in conjunction with conventional radiographs and ct scans. acknowledgements top ↑ competing interests the author declare that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1. tyler p, saifuddin a. the imaging of myositis ossificans. semin musculoskelet radiol. 2010;14(2):201–216. http://dx.doi.org/10.1055/s-0030-1253161 2. stoller dw. magnetic resonance imaging in orthopaedics and sports medicine. 3rd edn. philadelphia: lippincott williams and wilkins, 2007; p. 2154–2157. 3. helms ca, major nm, anderson mw, kaplan pa, dussault r. musculoskeletal mri. 2nd edn. philadelphia: saunders elsevier, 2009; p. 66–67. 4. kansdorf mj, meis jm, jelinek js. myositis ossificans: mr appearance with radiologic-pathologic correlation. am j roentgenol. 1991;157(6):1243–1248. http://dx.doi.org/10.2214/ajr.157.6.1950874 5. helms ca. fundamentals of skeletal radiology. 3rd edn. philadelphia: elsevier, 2005; p 55. 6. anderson j, read j. atlas of imaging in sports medicine. 2nd edn. new york: mcgraw hill, 2008; p. 338–339. 7. bianchi s, martinoli c. ultrasound of the musculoskeletal system. new york: springer, 2007; p. 628–629. 8. shirkhoda a, armi ar, bis kg, makris j, irwin rb, shetty an. mr imaging of myositis ossificans: variable patterns at different stages. j magn reson imaging. 1995;5(3):287–292. http://dx.doi.org/10.1002/jmri.1880050312 9. manaster bj, may da, disler dg. musculoskeletal imaging: the requisites. 3rd edn. philadelphia: elsevier, 2007; p. 523–525. 10. buselli p, coco v, notarnicola a, et al. shock waves in the treatment of post-traumatic myositis ossificans. ultrasound med biol. 2010;36(3):397–409. http://dx.doi.org/10.1016/j.ultrasmedbio.2009.11.007 case report case report 24 sa journal of radiology • march 2007 although there are a number of reports of successful drainage of deep pelvic collections using transrectal, transvaginal, transgluteal and other routes,1,2 some collections remain difficult to access. an elderly female patient with renal failure presented with features of sepsis following a partial sigmoid colectomy for diverticular disease, with a left iliac fossa colostomy in place. a left pelvic sidewall collection was demonstrated by ct scanning (fig. 1), but was not felt to be accessible by the usual routes. a standard lower abdominal or pelvic approach was not possible because of overlying loops of bowel. the collection was too high and small for transgluteal or anterolateral approaches, added to which, the left iliac fossa colostomy further limited any approaches. following a suggestion by one of the authors (pg), an attempt was made to drain the collection under fluoroscopy, using a transcolonic access route. the patient was sedated and laid left side down in a left decubitus position, and the catheter was introduced per rectum with the aid of lubricating gel and a guiding finger. an initial attempted passage through the rectosigmoid with a headhunter catheter and hydrophilic guidewire was complicated by the somewhat tortuous sigmoid colon and the residual diverticulae. the catheter was very inclined to enter the diverticulae and stretch them, but by retraction and rotation, the main lumen could be re-entered. some diverticulae were noted to contain concretions, presumably faecoliths. gentle rotation, supplemented by intermittent contrast injections, hydrophilic guidewires and cobra catheters eventually allowed entry into the pelvic sidewall collection (fig. 2), presumably through a previously perforated diverticulum that may have led to the abscess in the first place. using an exchange wire, a standard 8f locking pigtail catheter was placed in the collection, with withdrawal of approximately 200 ml of pus. the hub of the catheter was secured in the gluteal cleft, and the patient’s features of sepsis improved over subsequent days. the catheter appeared well tolerated by the patient. after a few weeks, the pigtail was accidentally dislodged. this was replaced with a longer internal-external drainage catheter which was again retained by locking the pigtail. again purulent material was obtained from the collection, with clinical improvement. this technique provides an alternative method for draining deep pelvic sidewall collections, but is probably only applicable where there is a breach in the colonic wall, as when the source of sepsis is the sigmoid colon, or the sepsis erodes into the colon. 1. loren i, lasson a, lundagards j, nilsson a, nilsson pe. transrectal catheter drainage of deep abdominal and pelvic abscesses using combined ultrasonography and fluoroscopy. eur j surg 2001; 167: 535-539. 2. gupta s, madoff dc, ahrar k, et al. ct-guided needle biopsy of deep pelvic lesions by extraperitoneal approach through iliopsoas muscle. cardiovasc intervent radiol 2003; 26: 534-538. transcolonic pelvic abscess drainage s beningfield, mb chb, ffrad (d) department of radiology, university of cape town p goldberg, mb chb, fcs (sa), mmed division of surgery, groote schuur hospital, cape town figs. 1. ct scan showing the pelvic sidewall collection containing gas (arrow). note left colostomy site (open arrow) blocking anterolateral access. fig. 2 a and b. fluoroscopic image (a) during catheter (black arrow) manipulation showing pelvic sidewall collection (open arrow) apparently arising from diverticulum (white arrow) and (b) after placement of the drainage catheter (arrow). pg24.indd 24 2/26/07 1:53:47 pm article information author: graeme thompson1 affiliations: 1morton and partners, cape town, south africa correspondence to: graeme thompson email: gt@morton.co.za postal address: 20a brommaert avenue, constantia 7806, cape town, south africa dates: received: 06 oct. 2014 accepted: 16 feb. 2015 published: 08 may 2015 how to cite this article: thompson, g. two unusual cases of external rotator muscle pathology producing hip pain. s afr j rad. 2015;19(1); art. #740, 3 pages. http://dx.doi.org/10.4102/sajr.v19i1.740 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. two unusual cases of external rotator muscle pathology producing hip pain in this case report... open access • abstract • introduction • case presentations    • case 1    • case 2 • discussion • conclusion • competing interests • references abstract top ↑ two unusual cases of inflammation of the external rotator muscles of the hip are presented. in each case, the patient presented with acute hip pain. the diagnoses of acute calcific periarthritis involving the gluteus medius muscle, and pyomyositis of the obturator internus muscle secondary to a perianal fistula, were made with the aid of diagnostic imaging and histology. the importance of reviewing the pelvic viscera is highlighted. introduction top ↑ requests for imaging of hip pain and extraspinal sciatica are increasingly common, particularly in the setting of femoro-acetabular impingement and the burgeoning field of hip arthroscopy. the two cases discussed represent uncommon causes of hip pain with similar imaging features, stressing the need for vigilance beyond the acetabular labrum. case presentations top ↑ case 1 a 46-year-old woman presented with a 6-month history of left hip stiffness and a 1-week history of severe pain. she was apyrexial with a normal erythrocyte sedimentation rate (esr) and white cell count. the initial pelvic radiograph (figure 1) demonstrated a focus of globular calcification above the left greater trochanter. an axial proton density fat saturation (pdfs) magnetic resonance image (mri) (figure 2) showed enlargement of her left gluteus medius muscle, with diffuse oedema. in addition, there were globular foci of calcium within the muscle and connective tissue (figure 3). a provisional diagnosis was made of acute calcific periarthritis that was presumed to have arisen as a complication of long-standing gluteus medius calcific tendonitis. however, owing to the extent of the abnormal signal and unusual imaging appearance, the possibility of a synovial sarcoma could not be excluded, and an open biopsy was performed that confirmed an acute inflammatory process with calcification and no sign of malignancy. the patient was treated conservatively and her pain resolved completely with resolution of the residual calcification. figure 1: anteroposterior radiograph of the left hip. globular, poorly defined calcific deposits (short black arrows) above the greater trochanter (long white arrow) – a characteristic site for gluteus medius calcific tendonitis. figure 2: axial proton density fat saturation (pdfs) image of the pelvis. mass-like enlargement and hyperintensity of the gluteus medius muscle (long black arrow) with amorphous hypointense calcium deposits (short white arrows). reactive external iliac adenopathy is also evident. figure 3: axial proton density fat saturation (pdfs) image of the pelvis. defined globular calcium deposits are evident. case 2 a 57-year-old man presented with pain in the left leg. clinical examination suggested a lumbar disc lesion, but the mri of the lumbar spine was normal. an mri of the left hip was requested. the initial large field of view coronal images with fat suppression revealed marked oedema of the obturator internus and gemelli muscles on the left (figure 4) with a loculated fluid component (figure 5) corresponding to the site and ‘boomerang’ shape of the obturator internus bursa.1 review of the pelvic viscera revealed an anorectal fistula on the left (figure 6), containing fluid and extending to both the skin of the natal cleft and the left scrotum. the esr was subsequently reported raised (80 mm/hr). antibiotic therapy was initiated, to which the patient responded. a dedicated mri fistula study was performed that did not demonstrate a direct connection to the obturator internus muscle but did show abnormal signal related to the levator ani and the pre-coccygeal soft-tissue. the patient was referred to a general surgeon for further treatment. figure 4: coronal short t1 inversion recovery (stir) of the pelvis. oedema of the extrapelvic obturator internus (long black arrow) and gemelli muscles (short black arrows). the medial intrapelvic portion of the obturator internus bursa (short white arrows) and muscle (medium black arrow) are shown. figure 5: axial t2fs of the pelvis. fluid in the obturator internus bursa with a ‘boomerang’ configuration around the iliac spine (short white arrows). the obturator internus tendon (long white arrow) and pre-coccygeal signal (long black arrow) are also shown. figure 6: coronal t1w image. a perianal fistula (long black arrows) extending vertically from the anus (short white arrow) to the natal cleft. the vertical course of the sciatic nerve (long white arrows) is closely related to inflammatory changes in the adjacent fat (short black arrows) which may account for the presentation mimicking sciatica discussion top ↑ acute calcific periarthritis is a diagnostic subset of hydroxyapatite deposition disease in which the clinical presentation is acute and associated with periarticular calcification that is either in a tendon, bursa or joint capsule.2 most cases are idiopathic, although the calcification may also be secondary to systemic disease such as hypervitaminosis d and renal failure. the most common site of hydroxyapatite deposition is the rotator cuff of the shoulder, accounting for 69%.3 of cases and commonly termed calcific tendonitis. speed et al.4 described four stages of calcific tendonitis. in the third or ‘resorptive’ phase, calcium extrudes into the surrounding tissues with resultant severe pain and limitation of movement; this may be associated with erythema and local warmth, resulting in confusion with infective causes.5 the diagnosis relies on the identification of characteristic calcification. radiographs demonstrate globular, poorly defined calcific deposits, although occasionally they may be small and well defined and therefore overlooked as dystrophic deposits or ossicles, which are common around the hip. extrusion of calcium into an adjacent bursa or soft-tissue is well shown on ultrasound or mri. the resultant severe inflammatory reaction is demonstrated on mri as bursal, muscular or soft-tissue oedema and enhancement. the differential diagnoses besides infection include trauma or synovial sarcoma, the latter commonly peri-articular and containing calcification.6 following the acute phase, many patients will have symptoms that resolve spontaneously, although often there is some residual limitation of movement. pyomyositis of the obturator internus muscle is an unusual condition that has been described in children,7 with the predominant organism being staphylococcus aureus and the mechanism, haematogenous seeding. the lesser sciatic foramen, through which the obturator internus passes, is a known pathway for pelvic infection to spread externally.8 in the present case, the pyomyositis was associated with fluid distention of the obturator internus bursa which lies between the tendon and the cartilage-covered posterior surface of the ischium9 and could be mistaken for a muscle abscess. obturator internus muscle and bursal infection respond well to antibiotics and mri may prevent surgery.7 an important clinical differential diagnosis in the setting of pain and fever is septic arthritis of the hip joint. the imaging differential includes trauma, neoplasia and acute calcific peri-arthritis discussed above. conclusion top ↑ the present two cases highlight the importance of applying a large field of view fat-suppressed sequence to evaluate the whole pelvis, including the viscera, when imaging the hip. the author utilises a coronal intermediate weighted sequence with fat saturation; however, short t1 inversion recovery (stir) may also be utilised. it is also prudent to evaluate the pelvis mri in conjuction with a plain radiograph of the pelvis because the former is relatively insensitive to the detection of calcification. that calcification is common around the greater trochanter should not blind one to its unusual acute presentations. competing interests top ↑ the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ hwang jy, lee sw, kim jo. mr imaging features of obturator internus bursa of the hip. korean j radiol. 2008;9:375–378. http://dx.doi.org/10.3348/kjr.2008.9.4.375 hayes cw, conway wf. calcium hydroxyapatite deposition disease. radiographics. 1990;10:1031–1048. http://dx.doi.org/10.1148/radiographics.10.6.2175444 gondos b. observations on periarthritis calcarea. ajr. 1957;77:93–108 speed ca, hazleman bl. calcific tendinitis of the shoulder. n engl j med. 1999;340:1582–1584. http://dx.doi.org/10.1056/nejm199905203402011 selby cl. acute calcific tendinitis of the hand: an infrequently recognized and frequently misdiagnosed form of periarthritis. arthritis rheum. 1984;27:337–340. http://dx.doi.org/10.1002/art.1780270314 murphey md, gibson ms, jennings bt, crespo-rodriguez am, fanburg-smith j, gajewski da. from the archives of the afip imaging of synovial sarcoma with radiologic-pathologic correlation. radiographics. 2006;26:1543–1565. http://dx.doi.org/10.1148/rg.265065084 viani rm, bromberg k, bradley js. obturator internus muscle abscess in children: report of seven cases and review. clin infect dis. 1999;28:117–122. http://dx.doi.org/10.1086/515080 cher ht, raghunandan v, piyaporn b. pathways of extrapelvic spread of pelvic disease: imaging findings. radiographics. 2011;31:117–133. http://dx.doi.org/10.1148/rg.311105050 williams a, newell rl. pelvic girdle, gluteal region and hip joint. in: standring s, editor. gray's anatomy. 39th ed. philadelphia: elsevier, 2005; p. 1447–1448. 108 sa journal of radiology • december 2010 case report abstract gout is the most common form of microcrystal arthropathy that results in deposition of uric acid crystals in and around the joints and soft tissues. the most common cause is decreased uric acid clearance by the kidneys. the radiological manifestations of gout are generally well known and have remained unchanged. we describe a case of chronic tophaceous gout with diffuse extensive involvement of the synovium around the knees bilaterally. case report a 50-year-old hypertensive indian man, known to have had chronic gout for the past 19 years, presented with clinically large, hard, nodular masses around the knees with limitation in the range of movement. he had features of metabolic syndrome (hypertensive, impaired fasting glucose, increased abdominal girth, increased triglyceride level), with hyperuricaemia. his serum uric acid levels were 7.2 mg/dl with suboptimal therapeutic response to allopurinol and anti-inflammatory drugs. other laboratory investigations showed an erythrocyte sedimentation rate (esr) of 10 mm/hr, rheumatoid factor <11 iu/l, and normal antinuclear antibody titre. a 24-hour urine test showed uric acid to be 2.4 mg/dl. the b2 glycoproteins, anticardiolipin and antidouble stranded dna antibody titres were within normal range. the following radiological examinations were performed: • anteroposterior radiograph of the feet (fig. 1) demonstrates characteristic first metatarsophalangeal (mtp) joint involvement on the right with eccentric, dense soft-tissue swelling and para-articular punched-out erosions with overhanging margins. the sub-articular lucencies most probably represent intra-osseous tophi. there is also a case of extensive synovial involvement by tophaceous gout nausheen khan, mb bs, fcrad (d) irma van de werke, mb chb, frcr farzanah ismail, mb chb, fcrad (d) department of radiology, kalafong hospital, pretoria, and university of pretoria peter f levay, msc, mmed (int) department of internal medicine, kalafong hospital fig. 1. anteroposterior radiograph of the feet demonstrates first mtp joint involvement on the right. note the eccentric, dense soft-tissue swelling and para-articular erosions. the sub-articular lucencies represent intra-osseous tophi. there is also involvement of the second, third and fifth metatarsals on the right, and fifth mtp joint on the left. sa journal of radiology • december 2010 109 case report extensive involvement of the second, third and fifth metatarsals on the right and fifth mtp joints on the left. there is lack of osteopenia. • lateral radiograph of both ankles (fig. 2) shows increased nodular density in the posterior recess of the ankle joint in keeping with tophaceous deposits on the left. there is also pressure erosion of the right talo-navicular joint and posterosuperior aspect of the right calcaneus by overlying soft-tissue tophi. • anteroposterior radiograph of the hands (fig. 3) shows diffuse asymmetrical involvement of metacarpophalyngeal and interphalangeal joints. the wrists are not involved. • anteroposterior and lateral radiographs of both knees (fig. 4) show increased dense soft-tissue swelling around the joint, with extension into the supra and infra patella bursae and posterior aspect of the joint. there are characteristic gouty erosions and chondrocalcinosis with secondary osteoarthritis. the differential diagnosis at this point was possible tophaceous involvement of the synovium in a patient with known gout. a mass of synovial origin was also considered; however, bilateral disease was unlikely. a non-contrast computed tomography (ct) scan was performed (fig. 5) of both knees that showed diffuse lobulated involvement of the entire synovium by tophaceous deposits that had a hounsfield value of 160 175. this extensive involvement has not been previously described. discussion the word gout comes from the latin gutta (drop), in keeping with the early belief that an acute attack of the disease was a result of a poisonous body fluid dropping into the joints.1 gout has traditionally been classified as primary and/or secondary; however, this distinction has become blurred with improved understanding of the pathological bases of the various forms of the disease. clinical progression of the disease is best described in 4 clinical phases:2,3 • asymptomatic hyperuricaemia • acute gouty arthritis • intercritical gout • chronic tophaceous gout. the peak incidence is between 30 and 50 years, with a male:female ratio of 5:1. the prevalence of the disease increases with age.2-4 tophaceous gout, however, occurs in less than 10% of cases.2 asymptomatic hyperuricaemia increased levels of uric acid are found years before the onset of symptoms, and there is no evidence to suggest that treatment is warranted for asymptomatic hyperuricaemia.2,3 acute gouty arthritis this is the most common manifestation of gout, as acute inflammation owing to precipitation of urate crystals within the joint. the arthritis is initially monoarticular; as the disease progresses, more joints may be involved. the first joint to be involved is usually (50% of cases) the mtp joint.2 intercritical gout the disease is asymptomatic; the patient has persistent hyperuricaemia, and synovial fluid analysis shows monosodium urate (msu) crystals. fig. 2. lateral radiograph of both ankles shows nodular density in the posterior recess of the left ankle joint in keeping with tophaceous deposits, and pressure erosion of the right talo-navicular joint and postero-superior aspect of the right calcaneus by soft-tissue tophi. 110 sa journal of radiology • december 2010 case report chronic tophaceous gout in this form, the disease is established with deposition of msu crystals in the tendons, ligaments, cartilage, bone and soft tissues including bursae and other synovial spaces.1,3 although tophi can be deposited within a joint, the imaging characteristics of such intra-articular tophi are rarely reported and not well known.5 tophaceous deposits may mimic space-occupying lesions and occasionally be confused with rheumatoid nodules.6 msu crystals do not calcify. these opaque crystal deposits are composed of calcium pyrophosphate dehydrate, reflecting an association with pseudo-gout.4 fig. 3. photograph of the right hand and anteroposterior radiograph of both hands show large soft-tissue tophi around the mtp joints and typical involvement of the mtp joints by gout. fig. 4. photograph of both knees shows extensive tophi. accompanying anteroposterior and lateral radiographs show dense soft-tissue swelling around the joint, with extension into the supra and infra patella bursae and posterior aspect of the joint. also note typical gouty erosions. sa journal of radiology • december 2010 111 case report imaging radiographs radiographs remain the imaging modality of choice in the diagnosis of gouty arthritis. a characteristic feature of gout is preservation of bone mineral density until late stages of the disease; well-marginated paraarticular erosions with overhanging margins are characteristic – some of them remote from the joint. punctate bone sclerosis may be seen owing to intra-osseous deposition of the tophi;2 with para-articular deposition of tophi, there is asymmetric soft-tissue swelling. tophi may cause fig. 5. coronal non-enhanced ct images of the patient’s knees show diffuse lobulated hyperdense synovial tophaceous deposits measuring 160 175 hounsfield units. 112 sa journal of radiology • december 2010 case report pressure erosion of the underlying bone. diffuse synovial involvement around the knee, as seen in our case, has not been reported. ct ct has not been extensively used until recently, owing to its multiplanar capability that facilitates the recognition of para-articular calcifications when present. when not calcified, ct scans show high hounsfield values most likely owing to high concentration of sodium nuclei in the msu crystals.2,5,7 gerster et al. have suggested that nodular lesions with hounsfield units of 160 or above on ct may be diagnostic of gout.7 mri the mri appearance is variable; an inflamed joint shows effusion and para-articular oedema seen as low signal on t1and high on t2-weighted images. during acute episodes, the para-articular structures are enhanced, following gadolinium administration. the tophaceous deposits may have a low to imtermediate signal on t1-, and a low signal (if calcified) or high signal on t2-weighted images, depending on the degree of hydrated calcium.2,5 conclusion tophaceous gout is a rare clinical manifestation that has been observed in patients with chronic gout; diffuse involvement of the knees, as in our case, is even rarer. ct imaging, because of its speed and multiplanar capabilities, facilitates the diagnosis and assessment of tophaceous arthritis, as soft-tissue nodules of hounsfield units above 160 may be diagnostic of gout. 1. cornelius r, schneider hj. gouty arthritis in the adult, arthritis and other arthropathies. radiol clin north am 1988;26:1267-1277. 2. monu uvm, pope tl. gout: a clinical and radiologic review. radiol clin north am 2004;42:169-184. 3. mandell bf. clinical manifestations of hyperuricaemia and gout. cleve clin j med 2008; 75(suppl 5):5-8. 4. murray ro, jacobson hg, stoker dj. the radiology of skeletal disorders. 3rd ed. london: churchill livingstone, 1990. 5. clement khc, lee ry, huay-ben p, et al. intra-articular gouty tophi of the knee: ct and mr imaging in 12 patients. skeletal radiol 1999;28:75-80. 6. baker dl, stroup js, gilstrap ca. tophaceous gout in a patient with rheumatoid arthritis. j am osteopath assoc 2007; 107:554-556. 7. gerster jc, landry m, duvoisin b, rappoport g. computed tomography of the knee joint as an indicator of intraarticular tophi in gout. arthritis rheum 1996;39:1406-1409. editorial 102 sa journal of radiology • december 2009 some aspects of computed tomography in russia to the editor: computed tomography (ct) is increasingly used in russia. some ct departments are intensely busy, concentrating on outpatient cases. free medical insurance covers only a small percentage of ct examinations, however;1 many patients pay for the procedure themselves, and some also prescribe it for themselves without consulting a physician, i.e. practice self-referral.2 scanning is usually performed after following a standard protocol and takes several minutes; then the patient leaves and the next one is consulted. detailed examination and analysis of images is performed by a radiologist in the late afternoon or evening, after the technicians have finished their work. consequently, a radiologist’s working day can last 14 hours or more, which can impair diagnostic quality because of fatigue. such a workflow does not permit immediate re-examination with enhanced resolution or modified scanning parameters, which can be indicated for an unclear lesion or a group of lesions – for example, a pneumonia-like infiltrate or dissemination in a lung.3 one of the reasons for this workflow pattern is a shortage of upto-date literature and insufficient acquaintance with foreign experience.4 misleading statements can be found in some domestic publications; for example: ‘ct has become three-dimensional, which excludes missing small pathologic lesions and structures’.5 such generalisations tend to maintain a belief in the unlimited capabilities of ‘computer diagnostics’ in order, among other things, to enhance the number of self-referred patients. as a result, an expensive procedure accompanied by x-ray exposure is sometimes performed without justifiable indications. some excerpts from one of the most broadly used russian manuals (translated verbatim): ‘… uninterrupted scanning cycle of the spiral ct allows image reconstruction at any level … in the spiral ct, a level of reconstruction does not depend on the main scanning parameters such as speed of the table or gantry positioning. as the scanning occurs uninterruptedly, the level of each section and the distance between adjacent sections are selected optionally by an operator not before but after the scanning … possibility of optional positioning of sections along the scanning axis and arbitrary choice of the section width allow forming blocks of partially overlapping images, whereas degree of mutual overlapping is practically unlimited … in conventional ct, a similar effect can be achieved only if the table feed per gantry rotation would be less than the thickness of a tomographic layer … in spiral ct, mutual overlapping of the slides is independent of the scanning parameters being a post-processing procedure … location of pathological lesions between the tomographic layers, as it can occur in conventional ct, is therefore excluded’.6 the impression is created by such assertions that a computer can reconstruct an image that is representative of the morphological substrate, on any level from the first to the last scanning plane. this notion does not take into account that a computer disposes only of the data that have been obtained as a result of radiodensity averaging of the tissue layers encompassed by the x-ray beam. if the pitch is >1, ‘the patient would have a candy-striped appearance with unmarked flesh between ribbons of paint’.7 another quotation (verbatim from the russian): ‘a result of the spiral scanning is an uninterrupted data volume, which can be arbitrarily subdivided into a required number of slides of optional thickness’.6 note that information flows uninterruptedly along a spiral line but not along the axis of table movement (z-axis), where information is intermittent and subdivided by intervals if the pitch is >1. a reconstruction algorithm interpolates the data from adjacent sections into the spaces between them. these spatial relationships can be illustrated by a plane cutting a helicoid. overextension of the spiral, and excessive elevating of the pitch and/or collimation, can cause inadequate visualisation of pathological lesions. it is sometimes argued that spatial resolution is defined only by pixel size (tiurin ie, personal communication). one must note that pixel (or voxel) size is a characteristic of the equipment, while spatial resolution is defined also by information density per volume unit of the scanned tissue, which in turn depends on the scanning parameters. with high pitch values, the volume of interest is under-sampled.8 all the above applies also to the multi-slice spiral ct, although spatial relationships here are more complicated: collimation values of a single section and of the whole detector array are distinguished, with 2 corresponding pitch values. therefore, information density (as well as x-ray exposure) depends on the table feed per gantry rotation and on the distance between adjacent sections. the issue of radiation exposure in multi-slice spiral ct is beyond the scope of this letter, but the question should be posed in principle: under which conditions is the enhanced x-ray exposure caused by crossings of beam trajectories with repeated exposure of the same tissue areas compensated by the advantages of multi-slice spiral ct, such as isotropy and high resolution volumetric data?9 ct technology is progressing – scanning time is being reduced and image quality improved. this is no reason, however, to discard the principle of image analysis that is common to radiological and microscopic methods: in the case of an unclear lesion, one should be able to go to a ‘high magnification’ i.e. to repeat an examination with necessary adjustment to scanning parameters. it is therefore advantageous, when all images are examined by a radiologist, if the patient is still in the office, so that secondary scanning can be performed, if indicated. the total time per patient would probably be lower than in delayed image viewing, because a radiologist would not have to delve twice into a case. to maintain the same productivity, reception hours and, correspondingly, the working time of technicians should be prolonged. the great difference between the length of the working day for technicians and radiologists seems to be specific to russia, as well as the relatively low remuneration for radiologists (<10% of the amount paid by the patient or insurer). additionally, it has been reported that ct productivity is enhanced when several technicians work simultaneously.10 the workflow described in the first paragraph (scanning performed after a standard protocol, and images viewed after reception hours) can be justified for screening purposes. however, the usefulness of ct screening and examination to selfreferred patients is questionable.2,11 a concluding point is that clinicians in modern hospitals have access to ct images via a computer network.12 but in many russian hospitals, they can obtain only images on an xray film and a verbal description. overall, however, there are grounds for optimism: the improved economy now makes it possible to acquire modern equipment and literature, while broadening international cooperation will attract foreign expertise into the country. sergei v jargin department of pathology letters letter to the editor.indd 102 11/19/09 2:27:27 pm 103 sa journal of radiology • december 2009 peoples’ friendship university of russia, moscow elena e jargina clinical hospital nr. 83, moscow sjargin@mail.ru 1. jargin s. some aspects of medical insurance in russia. s afr med j 2008; 98(12): 907. 2. fenton jj, deyo ra. patient self-referral for radiologic screening tests: clinical and ethical concerns. j am board fam pract 2003; 16: 494-501. 3. tiurin ie, neishtadt as, sigina oa. disseminated pulmonary tuberculosis: significance of high-resolution computerized tomography (in russian) vestn rentgenol radiol 1998; (6): 10-17. 4. jargin sv. limited access to foreign medical literature in russia. cilip health libraries group newsletter, 25(4). http://www.cilip.org.uk/specialinterestgroups/bysubject/health/newsletter (accessed 15 april 2009). 5. ternovoĭ sk, sinitsyn ve. progress in computed tomography and radiodiagnosis (in russian with english summary) ter arkh 2006; 78(1): 10-12. 6. tiurin ie. computed tomography of thoracic organs [in russian]. st. petersburg: elbi, 2003: 72-73. 7. cody dd, mahesh m. aapm/rsna physics tutorial for residents: technologic advances in multidetector ct with a focus on cardiac imaging. radiographics 2007; 27: 1829-1837. 8. prokop m. principles of ct, spiral ct, and multislice ct. in: prokop m, galanski m, van der molen aj, schaefer-prokop c, eds. spiral and multislice computed tomography of the body. stuttgart: thieme, 2003: 2-43. 9. dalrymple nc, prasad sr, el-merhi fm, chintapalli kn. price of isotropy in multidetector ct. radiographics 2007; 27: 49-62. 10. boland gw, houghton mp, marchione dg, mccormick w. maximizing outpatient computed tomography productivity using multiple technologists. j am coll radiol 2008; 5: 119-125. 11. furtado cd, aguirre da, sirlin cb, et al. whole-body ct screening: spectrum of findings and recommendations in 1192 patients. radiology 2005; 237: 385-394. 12. van ooijen pm, bongaerts ah, witkamp r, wijker a, tukker w, oudkerk m. multi-detector computed tomography and 3-dimensional imaging in a multi-vendor picture archiving and communications systems (pacs) environment. acad radiol 2004; 11: 649-660. role of abdominal ultrasound in the context of the hiv/aids epidemic to the editor: i read the article in the june 2009 edition of the sajr entitled ‘trans-abdominal ultrasonic findings correlated with a cd4+ counts in adult hiv-infected patients in benin, nigeria’,1 with interest. i totally agree that the use of ultrasound (us) is invaluable in the assessment of hiv-positive patients and in the monitoring of treatment in these patients. i must, however, disagree with the statement that it should be used in all hiv-infected patients as a baseline investigation. the authors themselves clearly state that ‘few of the ultrasound findings correlated statistically with the cd4+ counts.’ this is unsurprising, given the unfocused use of us in terms of the patients’ symptomatology in their study. the manpower needs to perform a baseline us study of the abdomen in every patient diagnosed with hiv, regardless of their clinical state, are also probably not realistically achievable, given the workload and staffing ratios of our hospitals. in the appropriate clinical setting, however, us can be a vital tool in the assessment of patients with abdominal symptoms and in patients with an unexplained pyrexia in whom the chest x-ray is normal and sputum examination for acid-fast bacilli is negative. in this setting, us of the abdomen has the potential to detect many conditions, but in particular to demonstrate evidence of disseminated tb (which is a relatively common condition in our immuno-compromised population). in 2002, dr mike hunter and i published our experience with the use of abdominal sonar in hiv-infected patients with a fever of undetermined origin in a letter to the south african medical journal.2 three findings were of particular note. the first was that pericardial effusion (which is easily demonstrated via the infra-sternal approach on abdominal us, and should be a routine component of every abdominal us) was a not uncommon, and often unexpected, finding, even in patients where the cardiac density was not enlarged on chest x-ray. because small pericardial effusions are common in hiv-infected patients, we used a threshold of 5 mm for the diagnosis of a pathological collection. as tuberculous pericarditis is by far the most common cause of an effusion in this setting, patients with a pericardial effusion >5 mm in width were started on treatment for tb and closely monitored. secondly: in our experience, the most common cause by far of abdominal lymphadenopathy in hiv-infected patients with pyrexia is tuberculous lymphadenitis. the distribution typically involves the porta hepatus, peripancreatic region, and occasionally the splenic hilum. the differential diagnosis includes lymphoma and persistent generalised lymphadenopathy (a component of the aids-related complex). both these latter conditions appear to be very uncommon in our population. we therefore regard abdominal lymphadenopathy (in the appropriate clinical setting) as diagnostic of tuberculous lymphadenitis in the first instance, and therefore an indication for tb treatment. should the patient fail to respond to antituberculous treatment (a very rare occurrence in our series), further investigation of the lymphadenopathy is indicated. the third important finding in our series, in the diagnosis of disseminated tb, is that of splenic micro-abscesses. we found the demonstration of micro-abscesses within the spleen to be highly correlated with a diagnosis of disseminated tb. although a number of other causes of splenic micro-abscesses (including salmonella, candida, lymphoma and histoplasmosis) have been described, disseminated tb is by far the most common cause in our population, and is regarded as an indication for commencing tb treatment. as with the other findings (as described above), these patients are closely monitored on both clinical and sonographic follow-up. only patients who fail to respond to tb treatment (again, very rare in our series) are subjected to further investigation. when used in this way, us of the abdomen results in substantial savings in terms of rendering more expensive and invasive investigations and their substantial costs unnecessary. this is of particular relevance in a resource-constrained setting, where access to sophisticated diagnostic modalities is limited. us, with its immediate results, also has the potential to save days (sometimes even weeks) in the time interval between performing the diagnostic examination and commencing treatment (compared with, for example, awaiting the results of tissue biopsy or bone marrow aspiration). although i do not dispute that the article is valuable in furthering our knowledge of hiv/aids via the medium of us imaging, i believe that there are very limited indications for us in asymptomatic patients, even those who are hiv-positive. however, in our hospital (and in several other institutions that i am aware of ), abdominal us is not only being successfully used on a daily basis not only for the evaluation of patients with abdominal symptoms but also, according to the above criteria, in the diagnosis or exclusion of disseminated tb. d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com letter to the editor.indd 103 11/19/09 2:27:28 pm 104 sa journal of radiology • december 2009 1. igbinedion b o-e, marchie t t, ogbeide e. trans-abdominal ultrasonic findings correlated with cd4+ counts in adult hiv-infected patients in benin, nigeria. s afr j radiol 2009; 13(2): 34-40. 2. emby d j, hunter m. the value of ultrasound in the hiv-infected patient with a fever of undetermined origin. s afr med j 2002; 92(8): 566. dr igbinedion and co-authors reply: we thank dr emby for his interest in our article. during the course of the study, the recruiting physicians noted its usefulness, especially in renal scans, where we detected several asymptomatic nephropathies; consequently, these patients benefitted from improved follow-up laboratory reports after medical intervention. we are therefore of the opinion that radiologists should, if at all possible, not shy away from their responsibilities, even in the context of unbalanced staff ratios. this is one of the reasons why unqualified individuals offering ultrasonography in several nigerian communities have led to increased frequencies of quackery and missed diagnosis, which is a major and potentially disastrous non-biological hazard of ultrasound. our study was rather an abridged version of a broader perspective. in the study, fever, cough, skin rash and diarrhoea were the most common presenting complaints (45.3%, 25%, 20% and 14.7% respectively) while uncommon complaints constituted only 8.6%. unfortunately, apart from skin rash, these symptoms did not correlate significantly with abnormal sonographic findings on univariate analysis. but, as would be expected, patients with abdominal symptoms had more abnormal sonographic findings compared with those with other complaint or no presenting complaint at all. however, since we are currently undertaking a followup study, there may be further interesting findings in the offing. b o-e igbinedion department of radiology, college of medical sciences, university of benin and university of benin teaching hospital, benin, edo, nigeria igbins2@yahoo.com letters letter to the editor.indd 104 11/19/09 2:27:28 pm case report case report 28 sa journal of radiology • june 2007 case report introduction chondrosarcoma is a malignant bone tumour containing tumour cells that produce cartilage. this tumour may form de novo as a primary lesion or from malignant transformation of a pre-existing benign condition or cartilage lesion, for example enchondroma or osteochondroma. there are numerous types of primary chondrosarcomas, including conventional intramedullary, clear cell, juxtacortical, myxoid, mesenchymal, extraskeletal, and dedifferentiated chondrosarcomas. the primary conventional chondrosarcoma, also known as central or medullary chondrosarcoma, is more commonly seen in adults 30 years and older, with the most frequently affected sites being the pelvis and long bones, especially the femur and humerus in up to 65% of cases.1,2 secondary chondrosarcomas usually develop at a younger age, 20 40 years, and are usually of low grade malignancy.1 enchondromas are benign cartilaginous neoplasms that are usually solitary lesions in intramedullary bone. these benign lesions are most frequently found in the small bones of the hands and feet. these lesions replace normal bone with hyaline cartilage, and arise from cartilaginous rests displaced from the growth plate. malignant transformation is very rare in solitary enchondromas of the hands and feet.3 we present a rare case of appendicular skeleton chondrosarcoma which left us asking the age-old question: ‘what came first?’ that is, was this a case of a rare primary appendicular chondrosarcoma, or the rarer transformation of an appendicular enchondroma into a secondary chondrosarcoma? the usual ‘chicken or the egg’ conundrum. history and clinical findings a 38-year-old woman presented with a 2-year history of a large progressive swelling of the left index finger, with occasional pain. the patient had recently developed bleeding from ulceration of the mass. radiological investigations on plain radiography, the left hand index finger showed expansile destruction of the proximal phalangeal bone with areas of speckled calcification showing a ring-and-arc pattern, a known classical pattern of enchondroma calcification.2 in addition, a lytic permeative component as seen in chondrosarcomas, especially higher-grade lesions, was noted. extension of the lesion into the soft-tissue mass involving most of the left index finger was demonstrated. there was erosion of the middle and distal phalangeal bones at their bases and erosion of the distal end of the 2nd metacarpal bone (fig. 1). the features were suggestive of a secondary bone malignancy of cartilage origin. thus, to exclude further cartilaginous lesions, radiographs of the right hand and both feet were also done. no enchondromas were demonstrated in the bones of either feet or bones of the right hand. a ct scan with contrast of the left hand was performed which demonstrated a low attenuation mass, reflecting the high water content of hyaline cartilage, containing central speckled calcifications with a ring-and-arc pattern in the central region of the mass. post intravenous contrast-enhanced ct showed inhomogeneous mild peripheral rim a rare appendicular skeleton chondrosarcoma k spiegel, mb bch, fcrad(d) e joseph, mb bch, ffrad(d) helen joseph hospital, johannesburg figs 1a and b. pa and lateral views of the left hand. fig. 1a shows an expansile lesion of the second digit proximal phalangeal bone with areas of speckled calcification and a ring pattern (white arrows). fig. 1b demonstrates the lateral view with arc calcifications (white arrowhead). pg28-31.indd 28 6/13/07 9:22:04 am and septal enhancement of the mass. lytic bone erosion of the proximal phalanx and middle phalanx of the index finger with erosion of the distal lateral end of the 3rd metacarpal bone was also shown. the mass encased the ligaments of the left index finger and involved the 2nd digit interosseos and lumbrical muscles. a prominent vascular supply of the lesion with neovascularisation pattern was seen (figs 2a and b and fig. 3). mri of the left hand in t1-weighted axial and coronal sequences, pre and post gadolinium enhancement confirmed involvement of the left index finger proximal and middle phalageal bones as well as distal ends of the 2nd and 3rd metacarpal bones. non-contrast t1-weighted axial and coronal images showed low to intermediate signal intensity of the mass indicating marrow replacement. matrix mineralisation was seen as low signal intensity. post-gadolinium enhancement t1-weighted images showed intense peripheral and septal enhancement of the lesion, with involvement of the ligaments of the index finger and 2nd digit muscles distally (fig. 4). the patient underwent a ray amputation of both the index and middle fingers of the left hand. the histology result showed a chondrosarcoma grade 3 which had been adequately excised. discussion chondrosarcomas and enchondromas primary chondrosarcoma is the third most common primary malignant tumour of bone, representing 20 27% of primary malignant osseous neofig. 2a. coronal reconstructed image in bone window setting showing the left hand index finger mass with central speckled calcifications with ringand-arc pattern in the central region of the mass (white arrow). fig. 2b. post intravenous contrast-enhanced ct in the coronal view with inhomogeneous mild peripheral rim and septal enhancement of the mass (white arrow). fig. 3. ct volume-rendered representation of the elaborate vascular supply to the lesion. 29 sa journal of radiology • june 2007 case report pg28-31.indd 29 6/18/07 4:24:49 pm 30 sa journal of radiology • june 2007 plasms.2 most frequently affected sites in primary chondrosarcoma include the pelvis and long bones in up to 65% of cases, with the short tubular bones of the hand and feet being rarer sites (1 4% of all cases), with less than 200 cases having been described.2,4-6 chondrosarcomas are categorised as central, peripheral, or juxtacortical (periosteal) lesions depending on their osseous location. central chondrosarcomas are intramedullary in origin, and large tumours may erode the cortex and invade the surrounding soft tissue.2 bovée et al.4 reported 35 cases of chondrosarcoma of the phalanx, with the range of patient age at the time of diagnosis being 21 87 years. there was a slight female predominance. occurrence in the hand was noted more commonly than in the foot, with the proximal phalanx affected most often. histological grading of conventional intramedullary chondrosarcomas correlates with clinical behaviour and prognosis. a three-grade system is commonly used. grade 1 lesions low grade, with a predominantly chondroid stroma, with distinction of grade 1 chondrosarcoma from enchondroma often proving difficult.2 grade 2 chondrosarcomas intermediate grade, have less chondroid matrix and are correspondingly more cellular. necrosis may be seen.2 grade 3 chondrosarcomas high grade, show greater cellularity and nuclear pleomorphism than grade 2 tumors. chondroid matrix is sparse or absent. foci of necrosis are seen and are frequently extensive.2 enchondromas are usually solitary lesions in intramedullary bone and are commonly seen in the hands and feet, while hands and feet are rare sites for intramedullary chondrosarcomas. the primary significance of enchondromas is related to their complications, being pathological fractures, and a small incidence of malignant transformation.3 many texts have noted the rarity of an enchondroma progressing to become a malignant chondrosarcoma. enchondromatosis is a condition where multiple enchondromas are present. three distinct disorders associated with multiple enchondromas are known: ollier disease, maffucci syndrome and metachondromatosis. solitary enchondromas are intramedullary lesions; they may expand enough to cause endosteal scalloping of the cortex. they have a predilection for the small bones of the hands and feet, with half involving the proximal phalanx, followed in frequency by the metacarpal, middle phalanx and distal phalanges and carpus. approximately 50% of solitary enchondromas are found in the hands. other locations include the shoulder, pelvis, and long bones. enchondromas tend to occupy the diaphyseal region in the short tubular bones and the metaphyseal region in the longer bones. multiple clinical and imaging parameters have demonstrated statistically significant differences between enchondroma and chondrosarcoma, particularly pain related to the lesion, deep endosteal scalloping of more than two-thirds of cortical thickness, cortical destruction and soft-tissue mass seen on ct or mri and periosteal reaction seen at radiography. all of these features strongly suggest the diagnosis of chondrosarcoma and thus allow distinction of appendicular enchondroma and chondrosarcoma in at least 90% of cases.7 in a study of 30 cases of chondrosarcoma lesions in the hands and feet dahlin and salvador5 noted that the lesions produced lytic areas of destruction that lacked, at least in part, well-defined margins commonly seen in enchondromas as well as causing apparent expansion of a portion or all of the bone of origin. ct and mri demonstration of soft-tissue extension of the lesion with mass formation essentially excludes the diagnosis of enchondroma. the typical radiological findings on plain film, ct and mri, of both enchondromas and chondrosarcomas are represented in table i. treatment and prognosis for conventional intramedullary chondrosarcoma there are two choices of surgical treatment in the case of ‘low-grade’ type (grade 1). the first is intra-lesional curettage, adjunct chemical or thermal ablation, and cementation or bone grafting of the defect. the second surgical option is wide excision with structural graft or metal reconstruction. with obvious histological grade 2 or 3 features aggressive surgical management is necessary to optimise local disease control and reduce the frequency of fig. 4. mri of the left hand t1-weighted coronal sequences post gadolinium enhancement, showing intense peripheral and septal enhancement of the lesion, with involvement of the ligaments of the index finger. case report case report pg28-31.indd 30 6/18/07 4:24:49 pm 31 sa journal of radiology • june 2007 table i. common radiological features of enchondromas and chondrosarcomas on plain film, ct and mri enchondroma conventional intramedullary chondrosarcoma plain film radiography 1) classic ring-and-arc pattern of calcifications, 1) mixed lytic and sclerotic appearance. being pathognomonic when seen in the hands. 2) characteristic appearance of ring-and-arc pattern. 2) endosteal scalloping greater than two-thirds of 3) sclerotic areas represent chondroid matrix the normal thickness of the long bone cortex is mineralisation and are seen in 60 78% of lesions.2 strong evidence of chondrosarcoma versus 4)aggressive pattern of bone lysis with a moth-eaten enchondroma.7 and permeative pattern may be seen with higher-grade conventional chondrosarcomas grade 3. computed tomography 1) mineralisation in the form of rings and arcs, 1) in chondrosarcoma of long bones calcification which correspond to calcification around throughout the lesion is seen in 94% of cases. lobules of cartilage. 2) the soft-tissue component frequently reveals typical 2) endosteal scalloping may be present, and may punctate or ring-and-arc matrix mineralisation represent degeneration of the enchondroma to a and a lobular growth pattern. chondrosarcoma. 3) higher-grade lesions may show higher ct 3) should not penetrate the cortex or extend into attenuation, caused by increased cellularity the soft tissues and resultant reduced water content. 4) neither the extent nor the presence of matrix mineralisation identified on ct scans helps distinguish between long bone enchondroma and chondrosarcoma. magnetic resonance imaging 1) lobulated borders with a cluster of numerous 1) on t1-weighted mr images, marrow replacement tiny locules of high-signal-intensity foci on appears as low to intermediate signal intensity. t2-weighted images that appear to coalesce 2) on t2-weighted mr images the non-mineralised with one another and reflect the high fluid components of chondrosarcoma have high signal content of hyaline cartilage.3 intensity, a reflection of the high water content 2) on t1-weighted images, enchondromas of hyaline cartilage. demonstrate low-to-intermediate signal 3) the cartilaginous lobules may be surrounded by intensity.3 low-signal-intensity septa. 4) areas of matrix mineralisation are common in intramedullary chondrosarcoma (79% of long bone lesions on mr images) and have low signal intensity with all mr pulse sequences. this feature often creates marked heterogeneity on t2-weighted mr images. metastatic spread of disease. the local recurrence rate of grade 3 chondrosarcoma is 47%, while the reported rate of distant metastases is 10 50% for grade 2 lesions and 50 71% for grade 3 lesions.2 metastases most commonly involve the lung, regional lymph nodes, and liver. the overall 5-year survival rates for chondrosarcoma are 90 94% (grade 1), 61 81% (grade 2), and 43 44% (grade 3), whereas the 10year survival rates are 83 87% (grade 1), 41 64% (grade 2), and 27 29% (grade 3).2 phalangeal chondrosarcoma behaves as a locally aggressive lesion, and in contrast to chondrosarcomas located elsewhere, rarely metastasises.3 conclusion primary chondrosarcoma is the third most common primary malignant tumour of bone, and most commonly affects the pelvic bones and long bones, with the bones of the hands and feet being rare sites for primary involvement. enchondromas are benign cartilaginous neoplasms that are usually solitary lesions in intramedullary bone, with malignant transformation being very rare in solitary enchondromas of the hands and feet. since no previous imaging was available on our case we are still faced with the dilemma as to whether the lesion was a primary or a secondary chondrosarcoma. however, since the literature points to the rarity of primary chondrosarcomas in the hand and feet, we suggest that this case may represent that rare transformation of a solitary enchondroma into a chondrosarcoma. 1. greenspan a. orthopedic radiology a practical approach. 3rd ed. philadelphia: lippincott williams and wilkins, 2000. 2. murphey md, walker ea, wilson aj, et al. from the archives of the afip imaging of primary chondrosarcoma: radiologic-pathologic correlation. radiographics 2003; 23:1245-1278. 3. chew fs. enchondroma and enchondromatosis. www.emedicine.com/radio/topic247.htm (last accessed 20 february 2007). 4. bovee jv, van der heul ro, taminiau ah, hogendoorn pc. chondrosarcoma of the phalanx: a locally aggressive lesion with minimal metastatic potential: a report of 35 cases and a review of literature. cancer 1999; 86:1724–1732. 5. dahlin dc, salvador ah . chondrosarcomas of bones of the hand and feet. a study of 30 cases, cancer 1974; 34:755-760. 6. mittermayer f, dominkus m, krepler p, et al. chondrosarcoma of the hand. clin orthop 2004; 424: 211–215. 7. murphey md, flemming dj, boyea sr, bojescul ja, sweet de, temple ht. enchondroma versus chondrosarcoma in the appendicular skeleton: differentiating features. radiographics 1998; 18:1213-1245. case report pg28-31.indd 31 6/18/07 4:24:49 pm article information author: lynda albertyn-cross1 affiliation: 1child, adolescent and family unit, charlotte maxeke johannesburg academic hospital, johannesburg, south africa postal address: 24 duncombe road, forest town, johannesburg 2193, south africa how to cite this article: albertyn-cross, l. obituary – dr. christian george albertyn. s afr j rad. 2014;18(1); art. #711, 2 pages. http://dx.doi/org/10.4102/ sajr.v18i1.711 note: a previous version of this obituary was published in the south african medical journal. it can be directly accessed online, here: http://dx.doi.org/10.7196/ samj.8344 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. obituary – dr. christian george albertyn in this obituary... open access content top ↑ christian george albertyn was born on 13 december 1920 in bethal, transvaal (south africa). he moved to middelburg and then pietermaritzburg, where his father dr christopher james albertyn was the district surgeon and who later served on the gluckman commission to investigate the setting up of a national health service in the 1930s.george started studying medicine at the university of the witwatersrand (wits) in 1939. his studies were interrupted by world war ii; he enlisted in 1941 and served in egypt and italy. he returned home in 1945 and resumed studying medicine, qualifying in 1949. he did his internship at edenvale hospital. george worked as a general practitioner in vereeniging until 1966, when he started his specialisation in radiology at the university of pretoria, qualifying in 1969. he worked as a radiologist in private practice until he retired at the age of 65 years, and then continued to work as a radiologist at the steve biko academic hospital until the age of 75 years, where he was involved in teaching registrars. during his career as a radiologist, george served a term as president of the radiological society of south africa. george had a wonderful memory; until the month before he died, despite his virtual blindness, he was able to keep up to date with events and to read avidly using his merlin magnifier to enable him to see text. a few weeks before he died, he wrote to the wits graduate magazine to correct the mislabelling of a name on a photo of a 1940s wits water polo team. he could do complex mathematical calculations in his head. he remembered every telephone number he had ever had in his long life of 93 years. he could remember the names of people he had met in his childhood, and continued to be able to remember details of events in his life right up until his death. he adapted to new inventions, taking to the computer and later his ipad with alacrity. he could also learn new languages with ease, and spoke english, afrikaans and dutch fluently and picked up some isizulu, italian and greek. he remembered the names of every winner of the us open golf tournaments and almost all wimbledon winners. if anyone wanted to know something from the past, george could invariably supply the answer. he did cryptic crosswords every day until the day before he died. he was a keen sportsman. he swam for natal and was captain of the wits university water polo team. he played tennis into his 70s and golf until he was 90. he loved rugby and cricket and continued to take an interest in these sports until his death. he was such an enthusiastic man. he loved music, mostly jazz from the 1930s and 1940s; to read; learning about new things; and the stories and activities of other people. he loved visiting game reserves and going on holiday with his family; he loved the sea and surfed until he could no longer manage the beach; to bake and cook, to teach, to entertain, travelling to other countries; and he adored his wife, children, grandchildren and great-grandchildren. he was a very tolerant and stoical man and never liked to show that he was in pain or discomfort. he had a wonderful sense of humour and laughed plentifully. he had enormous energy and zest for life, especially his interest in other people. he had a particular way of talking and meant every word he said. he listened with focused attention, genuinely interested in people and their accounts. his politeness and respectful attention to everyone, no matter their age or station in life, was a wonderful example to everyone he encountered. george was not one-dimensional at all; he was cheerful company when entertaining friends but was also a methodical and careful professional and parent. he was blessed with the talent to use his energy astutely and effectively, thus achieving many things in his long life on a very broad front. as a medical doctor, he sometimes had the sad task of helping families over their own grief at the passing of a loved one. he was a district surgeon at sharpeville after the sharpeville shootings, a bitter and terrible experience for a war veteran. this experience could have made a lesser man become cynical but he knew and acted upon the knowledge that ultimately everyone is responsible for their own happiness. you have to ’turn up’ for your own life – every day. he used his close relationships to express his life and dreams. thus it was that he and his wife helen, also a radiologist, had one of the most remarkable and exemplary marriages one could imagine. helen was his companion, guiding star, great passion and support. he had four children, ten grandchildren and two great-grandchildren, and had a special relationship with them all. george albertyn has left us a rich and brilliantly lit path and example. he took hold of life with both hands and shared his journey with us all. whether you were a tennis player or not, you were welcome on his court; if you could not remember the cards and lost every time at card games, there was still much enjoyment and laughter to be shared. george died peacefully in his sleep on 20 march 2014. christian george albertyn college of radiology refresher course (product of the education committee) this annual event took place on 2 august 2008 in cape town. it involves 2 tracks running simultaneously and is intended to service candidates hoping to sit for the college exams. the part i track involves a physics refresher summary as well as a mock exam entitled anatomy spot test. the part ii section involves at least four examiners posing mock questions and model answers, representing all sections of the part ii exam. these include questions for written and long case reporting and two types of oral questions (discussion cases and ‘aunt minnie’ films). by using actual examiners from the college pool, delegates can discover ‘what examiners really want’ and often gain insight into the personalities of certain examiners. for examiners, this is an excellent venue to discover that not all other examiners think like oneself; which promotes balanced leniency towards candidates. this event has been a great success in the past. for further information on attending or sponsoring, please contact annalie rich, tel. 021 938 9320 or email aj@sun.ac.za. gold medal awards dr s theron and dr s przybojewski (university of stellenbosch) were awarded gold medals for their performances in the college of radiology examination. reciprocity two universities applied for reciprocity with the college for part i examinations; this was granted for the university of stellenbosch. the university of pretoria is making minor modifications to their curriculum to guarantee acceptance of their part i exams. paediatric imaging workshop product of pissa (paediatric imaging society of south africa), rssa and the education committee of the college of radiology three leading paediatric radiologists from outside south africa (dr kieran mchugh, great ormond street, london; dr alan daneman, sick kids hospital, toronto; dr hans blickman, the netherlands) as well as local paediatric radiologists are bringing this workshop to our doorstep. it will be held in two centres (johannesburg, 13 14 september) and (cape town, 20 21 september) to afford more opportunity to attend. please visit the website and register as soon as possible (early registration discounts available). website: http://www. paediatric2008.co.za/. the local contact is lindi pretorius, paediatric radiology workshop, unistel consultus (pty) ltd, po box 19063, tygerberg 7505, south africa, telephone +27 (0)21 938 9082, fax: +27 (0)21 933 2649, email consult@sun.ac.za. rssa congress the radiology tract of the rssa congress in durban, from 25 27 april 2008, included 4 international speakers and 16 local speakers (4 academic and 12 private practitioners). topics fell under two main areas: msk and chest imaging. talks were relevant and the quality excellent, and attendance was very good. forthcoming congresses/ workshops pae diatric imaging workshop: 13 14 september 2008 in johannesburg, and 20 21 september 2008 in cape town. website: w w w.paediatric2008.co.za head and neck imaging course: 25 26 october 2008 in cape town. website: www.unistel.co.za/headneck radiological society of north america (rsna) rsna committee on international relations and education (cire) the rssa was successful in its application to the rsna for the international visiting professor program. three of our universities were selected for educational visits by international lecturers. the venues are the university of stellenbosch (tygerberg hospital), grey’s hospital in pietermaritzburg, and the university of the free state, bloemfontein. the events will take place in the second half of 2009. professor andronikou is the contact person. rssa travel award this award was shared by dr salomine theron and dr murray hayes (university of stellenbosch). they were each awarded r10 000 for congress use for their presentations at the 2008 rssa meeting. dr hayes presented a paper entitled postinfective physeal bars – mri features and choice of management; dr theron presented a paper entitled pulmonary kaposi’s sarcoma in 7 children. the travel award is for use to attend a congress abroad. radioactive news contributor: s andronikou examination report (12 14 may 2008) part i physics part i anatomy part ii 22 candidates 25 candidates 16 candidates 16 (73%) qualified for orals 15 (60%) qualified for orals 11 (69%) qualified for orals 16 (100%) passed 15 (100%) passed 8 (73%) passed 6/22 (27%) overall fail rate 10/25 (40%) overall fail rate 50% overall fail rate rssa pissa 54 sa journal of radiology • july 2008 radioactive news.indd 54 8/1/08 10:03:40 am university news university think tank south african national academic radiology think tank (sanart) the second universities academic think tank takes place in cape town on 2nd august 2008. at the previous think tank, all university radiology training leaders attended, and the event was endorsed by the college of radiologists and also featured representation by the college and rssa. teaching in radiology was reviewed, the video-lecture programme was re-evaluated, and a national curriculum was discussed. even though participation was excellent, with progressive ideas and general enthusiasm, no concrete results (other than the short pilot video-lecture programme) have materialised. we hope to solidify the think tank and come up with solutions to our problems that can be implemented. cubic (cross universities brain imaging centre (3t mri facility) number of projects performed since 19 april 2007: 18 funding of these: • 4 by the nih (national institute of health) • 7 by the nrf (national research foundation) • 2 by the mrc (medical research council) • 2 by pharmaceutical trials • 1 by stellenbosch university • 1 by the netherlands research innovation grant • 1 by a private grant graduate student participation: • biomedical engineering: 5 masters, 2 phds • computer sciences: 2 masters • radiology: 1 masters, 2 phds • psychology: 3 masters, 5 phds • psychiatry: 2 masters, 4 phds • total: 13 masters, 13 phds uct pmz uovs us wits up university publication report 2007 and 2008 to date 2007 local international total uct 5 13 18 pmz 2 1 3 uovs 1 0 1 us 20 17 37 wits 9 4 13 up 0 0 0 ukzn n/a n/a n/a total 37 35 72 2008 till june uct 0 2 2 pmz 0 0 0 uovs 0 0 0 us 0 10 10 wits 0 2 2 up 2 0 2 ukzn n/a n/a n/a total 2 14 16 55 sa journal of radiology • july 2008 radioactive news.indd 55 8/1/08 10:03:44 am untitled part i – introduction, techniques and phase assessment video swallows, or as previously performed cine swallow studies, are valuable in the sense that they render obscure images both detectable and usually identifiable. the analogy is the animal in the game park that is invisible by virtue of its camouflage among the surrounding vegetation. a slight movement by the animal will immediately betray its presence, following which identification is usually possible. since the act of swallowing occupies only 0.40 of a second, continuous image recording allows not only the holistic aspect of the physiological mechanism but also ensures registration of momentary episodes of the process, rendering them satisfactorily comprehensible the request in many x-ray departments vague and non-descriptive requests for a swallow examination often results in the ensuing examination being of an indifferent nature. reasons for video or cine studies other than specific requests to assess post-laryngectomy cases for leaks, or when carcinoma has been identified on oesophagoscopy, are often in the nature of a single world: ‘dysphagia’. this latter request should immediately alert the examining radiologist to obtain an adequate history from the patient. the following points should be ascertained prior to any video study: (i) is there coughing after ingestion of fluid or solids? (ii) is there a sense of obstruction or pain in the chest anteriorly or posteriorly?; (iii) is there heartburn?; (iv) is there inflammatory change in the lungs, seen on a chest control film?; and (v) is there any evidence of possible gastric or duodenal symptomatology? depending on the information listed, the nature of the examination should be crafted to the circumstances. in all dysphagia studies the examination should be initiated using hexabrix (mallinckrodt inc, st louis, missouri, usa), a solution composed of meglumine loxagalate (39.30 g) and sodium loxagalate (19.65 g) as the contrast medium of choice. objectives of the procedure the objectives of the procedure are: (i) to obtain a complete anatomical and dynamic study of the swallowing mechanism; (ii) to be able to replay the episodes so as to fine-tune diagnostic assessment; (iii) for the video record to be available for review by referring clinicians; and (iv) for the video study to enhance any presentation to interested groups, e.g. swallowing and speech therapy units, etc. technical considerations (positioning) variable postural imaging includes: (i) supine lateral with horizontal beam; (ii) supine anteroposterior; (iii) erect lateral; (iv) erect anteroposterior; and (v) lateral in variable angles, e.g. 45°. the importance of postural imaging is to ascertain whether tracheal spill at the laryngeal level is observed. does it disappear or diminish with changes in position as itemised above. it is naturally of importance to the clinician or swallowing therapists to have this information in order to minimise the risk of pulmonary infection, e.g. during the healing phase of inco-ordination arising from a stroke, trauma or surgery. video swallows in children whether a child is either breast or bottle-fed, it is important to assess the sucking reflex, and to this end a bottle using sweetened hexabrix mixed with a small amount of milk formula should be used. where the reflex is absent, a syringe with a tubal extension should be used to introduce the contrast into the mouth. in children with swallowing defects, e.g. in cerebral palsy, the study should be commenced in the supine lateral position, the beam being directed horizontally enabled by a 90° rotation of the tube and intensifier. an anteroposterior position is then assumed with return of the tubeintensifier assembly to the overhead position. the mother or accompanying attendant should ensure that the head is kept in a true anteroposterior position. an extra radiographer or assistant can keep the child’s arms at his or her side. this avoids repetitive radiation to the attendant radiographer. with this phase of the examination completed, the removable footplate is added to the table at a suitable height to allow the mother to sit in a sideways position facing the radiologist. she will then hold the child on her lap, the patient also facing the radiologist. administration of the contrast either by bottle or syringe will then be repeated, commencing the video run immediately before the contrast is administered. apart from identifying any aberration of swallowing, the presence or absence of an adenoid pad in the post-nasal space should be noted. the presence of a large adenoid pad will significantly complicate any existing inco-ordination. the lateral study completed, the child will then rotate through 90° and face the tube. an anteroposterior study will then be repeated in the erect position, a manoeuvre that will identify the symmetrical use of both lateral food channels or alternatively one of the commonest variations, the unilateral food channel filling. if the child is old enough to have reached the ‘puree’ or semi-solid stage, ‘thick-and-easy’ is added to the hexabrix, thickening it to the extent that the mother review article 8 sa journal of radiology • december 2005 video analysis of swallowing and speech defects m b m denny mb chb, dmr (lond) department of radiology johannesburg hospital 11 11/29/05 12:29 pm page 8 identifies it as the same consistency as food normally given to the child. this done, the supine and erect procedures already described will be repeated. sometimes in children it will be necessary to examine the handling of ingested solids, and to this end biscuits and bread soaked in hexabrix should be administered in a teaspoon. by now it should be sufficiently clear to the reader that the examination can be prolonged and fairly complicated. in children the procedure should be completed by placing the child on the right side in a slight trendellenberg position to assess the presence or absence of gastro-oesophageal reflux, which may well complicate pre-existing inco-ordination. reflux may occur spontaneously or be initiated by giving the child water, either by bottle or syringe. video swallows in adults in adults who are able to stand, the sequence is reversed, commencing with erect lateral studies of the cervical region and ending in the supine position. an important exception to this rule is where coughing follows ingestion of food or fluid, raising the suspicion of a tracheooesophageal fistula. this is even more the case when there is the longstanding existence of a tracheostomy tube. in this instance hexabrix should be given with the patient in the erect right oblique position centering the beam on the upper thoracic region. this study should identify a tracheooesophageal fistula (tof) which might be obscured by spill at laryngeal level and which may not be appreciated if the imaging is initially at cervical level. not infrequently a tracheo-oesophageal fistula appears to give rise to laryngeal or pharyngeal inco-ordination, which will result in a concomitant spill at vallecular level. patients in the erect position who exhibit tracheal spill at laryngeal level may not spill in the supine postions due to gravitational posterior displacement of food or contrast. it may in fact be possible to demonstrate a critical angle of the patient on the tilting table at which level spill commences. this may well simplify feeding compared with problems encountered feeding the patient in a supine position. in adults, repetition of the sequences, using thickened or solid mixtures may be necessary. in all cases the inco-ordination may be of such a degree that marked nasopharyngeal or oesophago-pharyngeal reflux will occur. in such cases contrast entering the ethmoid recess will sometimes pass into the ethmoidal sinuses and thence into the sphenoidal sinus. turning the patient into the prone position will empty the sinus, contrast exiting by the same channel, and into the nasal cavity. contrast is shown in both the sphenoidal sinus and maxillary antra (fig. 1) indicating the necessity to exclude gastrooesophageal reflux in all cases of resistant sinusitis (figs 1 and 2a,b). nasogastric tubes in infants the tube should be removed and repositioned after the examination is complete. in adults and older children the swallow study may be preceded by giving a small bolus of hexabrix. if no tracheal spill is present a larger bolus is given, this in the most suitable position for the patient. not infrequently, especially in cerebrovascular accident (cva) patients, this will be the supine position. the larger bolus may produce distress and laryngeal block, which consists of coughing mixed with rapid swallowing, which in turn results in ingestion of the fluid as it passes the vocal cords. alternatively there may be actual spill into the trachea. if no spill is present with a small bolus, even though filling of only one food channel is noted, this being due to unilateral deflection of the epiglottis, the tube should be permanently removed and nutrition established by small frequent feeds. fluids would appear to be the only form of nutrition given at this stage, but as the swallowing improves, as is the case in most cvas, a repeat study using thickened and solid medium may be requested. if after the tube has been removed tracheal spill is still present, the tube should be repositioned. phase assessment assessment of the swallowing mechanism should be divided into three phases, namely oral, pharyngo-laryngeal and oesophageal. oral phase the efficiency of the propulsive mechanism of the tongue should be registered. with severe inco-ordination of neurological origin the propulsive movement may be review article 9 sa journal of radiology • december 2005 fig. 1. contrast in the sphenoidal sinus and maxillary antra. 11 11/29/05 12:29 pm page 9 poor or non-existent. a characteristic feature is tongue rocking. in children oral incompetence may occur, with marked spill from the mouth. ignore this and carry on with the investigation. inadequate velopalatal apposition may result in significant naso-pharyngeal reflux, with contrast being ejected from the nose. pharyngeal phase the primary cause of inco-ordination is failure of posterior deflection of the epiglottis. this may be complete or unilateral. the causes are as follows: 1. unilateral fixation due to carcinoma of the larynx. this may be the earliest sign. in one case this phenomenon was apparent some 6 months prior to the lesion being identified endoscopically. 2. direct trauma with haematoma formation. 3. neurological, where a clinical indication of a central lesion is often present. 4. following laryngeal surgery. 5. infections, viral or otherwise, in which instance the anomaly is transient. 6. gastro-oesophageal reflux extending to the larynx. oesophageal phase idiopathic or post laryngectomyinduced spasm of the commencement of the oesophagus may occur. this results in failure of clearance of the contrast bolus which immediately challenges the larynx, resulting in what is often a massive tracheal aspiration (fig. 3a-c). this may be related to extensive laryngeal surgery and is possibly in the nature of a lower motor neuron lesion due to nerve injury. in other cases the cause is not immediately apparent and repeated dilatations do no appear to relieve the defect significantly. where such oesophageal spasm follows a stroke, healing will on occasion result in the swallowing mechanism returning to a normal or near-normal state. this may occur as early as 3 months after initial demonstration of the inco-ordination. donner and jones1,2 describe the assessment of swallowing defects, and in their video of abnormal swallowing indicate the association between gastro-oesophageal reflux and crico-pharyngeal hypertrophy and diverticulum formation. the mechanism would appear to be chronic mucosal irritation with underlying muscle stimulation eventually resulting in hypertrophy. this in turn leads to obstruction and diverticulum formation. failure of contrast clearance will clearly lead to spill into the trachea as the vocal cords open. these authors also describe the presence of congenital laryngo-oesophageal fistula and demonstrate this lesion in their video study. the presence of extensive gastrooesophageal reflux will also result in tracheal aspiration, particularly at night, and is recognised as a prominent factor in precipitating asthma attacks. review article 10 sa journal of radiology • december 2005 fig. 2a. lateral study in the supine position showing contrast in the sphenoidal sinus. fig. 2b. prone lateral study. the contrast in the sphenoidal sinus has emptied via the same channel, into the nasal cavity leaving a thin mucosal coating in the sinus. fig 3a. lateral erect study revealing failure of the oesophagus to accept contrast bolus, with consequent reflux into the nasopharynx. fig. 3b. tracheal spill as vocal cords open. fig. 3c. anteroposterior study showing tracheal spill. fig. 4a. oesophageal web shown in lateral erect position. fig. 4b. lesion shown in erect anteroposterior postion. 11 11/29/05 12:29 pm page 10 thoracic lesions of the oesophagus, which may be associated with pharyngolaryngeal inco-ordination, include: (i) traumatic lesions; (ii) malignant lesions; (iii) reflux-related lesions; and (iv) surgical lesions, e.g. gastro-oesophageal (fig. 4a and b). part ii – apparatus, indications and speech assessment technique technical considerations — apparatus a screening unit capable of rotatory tube and intensifier movement across the long axis of the x-ray table is essential (fig. 5). the table itself should tilt from vertical to at least 15° 30° trendellenburg. the image registration system should preferably be digital allowing for direct filming from the screen, which has the advantage over conventional radiography of being instantaneous. conventional radiography has an inherent pause due to the relay delay, which allows the anode to reach the required speed. modern machines have a built-in cine capacity (15 25 frames per second) and most have a work station enabling tape or disc recording to take place. the unit should also have the facility for radiography at a frame rate of 8/s, which does tend to be instantaneous, but has the disadvantage of tube overload and wear in addition to increased radiation doses to the patient. a video recorder has the facility of slow-motion replay. it should also be equipped with sound recording, which enables the examiner to vocally preface different swallowing positions, and as described later, it is necessary for speechdefect studies. the intensifier should be 38 cm in size and is adequate for all examinations. specific attention should be paid to coning if the machine is not provided with a filtration system, which cuts down extra light resulting in a premature cessation of the exposure. the processing is electronic and the imaging choice varies from one single exposure to six on a 35 x 43 cm film. it is also possible during video recording to choose one of three image sizes, namely small, medium, or enlarged. in infants chest control is done with the third modality, but the cervical region is usually recorded on the middle magnification. indications acid laryngitis this is caused by chronic gastrooesophageal reflux with or without an associated hiatus hernia. this was well described by ardran and delahunty.3 delahunty subsequently confirmed the initial finding of reflux oesophagitis being an aetiological factor in globus hystericus.4 this is the commonest cause of dysphagia in this department, and as previously indicated may be associated with: (i) unilateral food channel filling; and (ii) tracheal spill at night. local cervical lesions 1. trauma, e.g. laryngeal haematoma with epiglottic fixation and unilateral food channel filling. 2. laryngeal surgery: (i) postoperative leaks; and (ii) tracheal spill, which occurs particularly with the supraglotic type of laryngectomy — the image resembles an inverted y, the contrast being shared equally by trachea and oesophagus. 3. spasm of oesophageal commencement as described previously, with consequent laryngeal overload and spill through intermittently open vocal cords. note that movement of the vocal cords following the expiratory phonation eeee should be commented on. paralysis of one of both will be found from time to time. 4. cricopharyngeal hypertrophy with or without divecticulum formation and obstruction as described previously. 5. possible tracheo-oesophageal fistula, the handling of which has already been described. 6. kirschner5 describes the effects of neurological upper and lower motor neurone pseudobulbar lesions. causes of upper motor neurone lesions are: (i) strokes; (ii) anoxic damage; (iii) traumatic injuries; (iv) tumours; (v) demyelinating plaques; (vi) degenerative diseases; and (vii) huntingtons disease. upper motor neurone lesions related to the above conditions reveal increased jaw and gag reflexes, dysarthria and emotional lability. lower motor neurone lesions are as follows: (i) tumours; (ii) strokes; (iii) syrinx cavities; (iv) multiple sclerosis; (v) motor neurone disease; (vi) post-polio syndrome; (vii) focal cranial neuropathies; and (viii) neuromuscular junction lesions, i.e. bulbar weakness as seen in botulism, myasthenia gravis and the myopathies. mixed upper and lower motor neurone lesions may be seen as strokes, multiple sclerosis, amyotrophic lateral sclerosis (als) and parkinson’s disease. all the above conditions may produce oral, pharyngeal and laryngeal inco-ordination manifested by: (i) oral incompetence; (ii) tongue rocking; (iii) nasopharyngeal reflux; (iv) pharyngo-oral reflux; (v) epiglottic insufficiency; (vi) vallecula spill; and (vii) failure of oesophageal clearance with consequent tracheal spill. in relation to childhood inco-ordination, ascertain the position in which the child is fed, i.e. semi erect or supine. if spill occurs in the semi-erect and supine positions and gastro oesophageal reflux is identified in the supine position, the child should be held erect for 60 minutes after feeding is completed. review article 11 sa journal of radiology • december 2005 fig. 5. apparatus allowing for a horizontal position of the image intensifier and x-ray tube is essential to assess the possible beneficial result of swallowing in the supine position. 11 11/29/05 12:29 pm page 11 speech aberration here the video swallow is associated with the relevant speech studies, which record the patient’s voice and image simultaneously. this is most frequently done in children. the method of the examination is as follows. the examination is usually done in conjunction with speech therapists, but in their absence the radiographer can read from the vocal list (which has been supplied by the therapists). contrast coating of the pharynx high-density barium (1 oz) is given to the patient to gargle. this should be fully explained to the child by the mother or the radiographer before commencing the coating; this also applies to nasophyrangeal coating. nasopharyangeal coating it is advisable to bring the child to the examination room so as to aquaint him or her with the environment, and the apparatus to be used. a 12 or 14 calibre french foley’s catheter is inserted into the one nostril and high-density barium is injected whilst the patient is instructed to sniff. this is repeated in the opposite nostril. it is recommended that the mother or speech therapist accustom the child to this procedure before the day of examination. obviously this is confined to insertion of the foley tube into the nasal cavity. the vocal examination is then commenced after control lateral and vertically angled ap views are done. the latter is done with the head extended and the tube angled vertically so that it tends to form a right angle with the base line. various sounds and sentences to be uttered are included in the speech supplement. in the lateral study uveo-palatal occlusion is assessed whilst the angled submento-vertical study reveals approximation of the lateral walls of the pharynx. these movements, adequate or otherwise, are correlated with synchronous vocal recording on the tape, which is usually supplied by the speech therapist. it is worth repeating that in cva and other neurological lesions, ventilation may be an associated problem necessitating a tracheostomy. be aware that a long indwelling tracheostomy tube may erode through the trachea into the oesophagus. the tracheal spill arising at laryngeal level, induced by inco-ordination associated with the stroke may then be complicated by additional spill through a tof. initial thoracic imaging will identify the two separate lesions. the laryngeal spill can be confirmed by a repeat study at cervical level. note that if anatomical deformity of the larynx or pharynx is demonstrated, laryngeal tomography or other further sectional imaging should be carried out. conclusion a video swallow is a highly varied examination, tailored according to the nature of the underlying clinical defect and also the age of the patient. swallowing therapists are of great assistance and often attend the examinations in our department. the proper fluoroscopic and recording apparatus is essential for completion of a satisfactory examination. the author has no financial, personal or other interest in the product hexabrix. references 1. jones b, donner m. rsna videotape programme. what the radiologists need to know about the pharynx and dysphagia. 2. jones b, donner m. examination of the patient with dysphagia. radiology 1988; 167: 319 326. 3. ardran gm, delahunty je. globus hystericus. a manifestation of reflux oesophagitis. laryngology and otology 1970; 84: 1049-1056. 4. delahunty je. globus hystericus. a manifestation of reflux oesophagitis laryngology and otology 1972; 86: 335-342. 5. kirschner sh. causes of neurogenic dysphagia. dysphagia 1989; 3: 184-188. review article 12 sa journal of radiology • december 2005 xmas special price: r145.00 to order contact: the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. tel: (021) 530-6520/27 fax: (021) 531-4126/3539 carmena@hmpg.co.za or avrilm@hmpg.co.za 11 11/29/05 12:29 pm page 12 19-21 case report 19 sa journal of radiology • july 2005 introduction bronchiolitis obliterans organising pneumonia (boop) is a distinct entity with various clinical, radiographic and prognostic features. pathologically it is characterised by the presence of granulation tissue polyps within the lumina of bronchioles and alveolar ducts with patchy areas of organising pneumonia. chronic inflammation is noted in the walls of the surrounding alveoli with preserved lung architecture. the preferred term is cryptogenic organising pneumonia (cop) when no aetiology is found.1-3 we report on a patient recently seen with this condition. case report a 36-year-old woman presented with a history of persistent non-productive cough for 4 weeks. she complained of pleuritic chest pain, night sweats and progressive shortness of breath with decreased effort tolerance, and she remained symptomatic despite numerous antibiotics. there were no contributing factors in the history to elucidate the aetiology of her symptoms. there was no history of previous allergies, drug use, recent upper respiratory tract infection, significant dust exposure, radiation therapy, transplantation or autoimmune disease. systematic examination revealed a young female in respiratory distress, with decreased breath sounds and fine inspiratory crackles at both bases. the cardiovascular system and the rest of the examination were normal. the blood results revealed mild microcytic hypochromic anaemia. the c-reactive protein and erythrocyte sedimentation rate (esr) were within normal limits. the urea and electrolytes were normal. liver function tests demonstrated a mildly elevated alanine transaminase (66 iu/l), aspartate transaminase (79 iu/l) and lactate dehydrogenase (284 iu/l). the rheumatoid factor and antinuclear factor were negative. serological tests for legionnaire’s disease, mycoplasma and chlamydia were negative. sputum examination revealed no organisms on gram-stain and culture. thoracentesis demonstrated a transudate. the lung function test showed a moderate restrictive pattern. the chest x-ray demonstrated bilateral basal infiltrates with blunting of both costophrenic angles suggesting pleural effusions (fig. 1). despite intravenous antibiotics there was no clinical response. highresolution computerised tomography (hrct) scan of the chest was then performed which demonstrated patchy bilateral air space consolidation involving predominately the lower lobes. this consolidation appeared to be subpleural and peribronchovascular in distribution. small bilateral pleural effusions were also confirmed (fig. 2). there was evidence of patchy ground-glass opacification in the lower lobes. the diagnosis of atypical pneumonia and boop was considered. bronchiolitis obliterans organising pneumonia (boop) or cryptogenic organising pneumonia (cop) v k bhagwandas mb bch, fcrad (d) (sa) x-ray department lenmed clinic lenasia johannesburg r morar mb chb, mmed, fcp (sa), fccp department of pulmonology university of the witwatersrand johannesburg hospital h d bhula bsc (micro), mb bs (bombay), fcp (sa) lenmed clinic lenasia johannesburg fig. 1. bibasal infiltrate with blunting of the costophrenic angles suggesting effusions. 19-21 7/29/05 3:19 pm page 19 case report 20 sa journal of radiology • july 2005 an open lung biopsy of the lingula and left lower lobe segments revealed interstitial thickening with lymphocytes and plasma cells, with granulation tissue-type exudates and fibroblast proliferation filling the alveolar spaces (fig. 3). there was no evidence of tuberculosis, sarcoidosis or malignancy. multiple sections examined revealed features in keeping with boop. following confirmation of the diagnosis of idiopathic boop, treatment with corticosteroids was commenced at a dose of 0.5 mg /kg. a follow-up chest x-ray obtained 3 weeks post treatment (fig. 4) showed significant resolution of the bilateral basal infiltrates. discussion boop or cop is an inflammatory lung disease and thus is related to the inflammatory pathway rather than the fibrosing pathway that occurs with usual interstitial pneumonitis / idiopathic pulmonary fibrosis (uip/ ipf).2 boop may be classified as follows1-3: (i) idiopathic; (ii) rapidly progressive; (iii) focal nodular; (iv) multiple nodular; (v) post infection; (vi) drug related; (vii) autoimmune disease; (viii) bone marrow transplantation; (ix) lung transplantation; (x) renal transplantation (xi) radiotherapy; (xii) environment-related; (xiii) miscellaneous. idiopathic boop the clinical presentation of idiopathic boop, which is the most common type encountered, and the type present in our patient, is one of flulike illness with fever, mild cough and dyspnoea. haemoptysis is uncommon. bilateral basal crackles are noted. pulmonary function tests demonstrate a restrictive pattern and abnormal diffusing capacity. the esr is usually raised.1-3 chest x-ray findings may include unilateral or bilateral patchy alveolar airspace consolidation which is subpleural and peribronchial in location, usually in the lower regions of each lung. the consolidation may be multifocal and non-segmental or unilateral and focal. nodules 3 5 mm in size and other linear opacities may also be seen. pleural thickening and/or effusions may also be noted.1, 3 hrct scans may show bilateral areas of consolidation and groundglass opacities are seen mainly in a peripheral location.4 two types of linear opacities may be noted. the first extends in a radial manner along the line of the bronchi toward the pleura, and the second occurs in the subpleural location with no relation to bronchi. both types usually occur in the lower lobes, frequently associated with multifocal areas of consolidation.5 centrilobular nodules measuring 3 5 mm in diameter may be observed. bronchial wall thickening and cylindrical bronchial dilation may also be noted. small ill-defined nodular opacities of 1 10 mm in diameter may also be seen. pleural effusions may be present.4,5 cavitating lung masses are rare.6 the differential diagnosis includes eosinophilic pneumonia, pulmonary haemorrhage, multifig. 2. patchy bibasal consolidation with subpleural and peribronchovascular distribution. fig. 3. interstitial thickening with lymphocytes and plasma cells with granulation tissue type exudates and fibroblast proliferation filling the alveolar spaces. fig. 4. significant resolution of bibasal infiltrates post treatment. 19-21 7/29/05 3:19 pm page 20 case report 21 sa journal of radiology • july 2005 focal infection and diffuse alveolar damage.4-8 magnetic resonance imaging (mri) currently has no significant diagnostic role in boop, but may have a role to play in the follow-up of patients with boop. it may be used to assess the response to treatment and disease activity. broncho-alveolar carcinoma may mimic boop. the white lung sign is an uncommon finding in pulmonary consolidation evaluated with heavily t2-weighted sequences. this sign is usually negative in patients with boop but positive in patients with broncho-alveolar carcinoma.9 therefore mri has a potential role to play in the exclusion of other conditions. ultrasound may assist in the characterisation of pleural effusions and for the guidance of pleurocentesis. the gold standard for confirming the diagnosis is a lung biopsy either by video-assisted thoracoscopic surgery (vats) or open lung biopsy. histologically there is evidence of intraluminal organising and polypoid granulation tissue within small bronchioles, alveolar ducts and alveoli. there are also foamy macrophages, inflamed alveolar walls and evenly spaced rounded balls of myxomatous connective tissue present.1-3 the diagnosis of boop/cop is definite in a patient with a typical pathologic presentation on a lung biopsy of sufficient size. however, transbronchial lung biopsy (smaller samples) in a patient with typical clinico-radiological presentation may suggest the diagnosis of boop. conditions that mimic boop include pulmonary lymphoma, chronic eosinophilic pneumonia, broncho-alveolar carcinoma and pulmonary embolism. it is important that the classified aetiological factors related to boop be excluded from the history, examination and investigations, especially infection, drug or radiation-induced pulmonary reaction, autoimmune diseases and systemic inflammatory disease. when no aetiology is found, as in our patient, the organising pneumonia may be called cryptogenic. this condition is a form of idiopathic interstitial pneumonitis. finally, treatment for this condition is usually prolonged corticosteroid administration for approximately 6 12 months in tapering doses depending on clinical response. the prognosis is usually good, except in a rapidly progressive form of this condition.1, 3 references 1. cordier jf. cryptogenic organizing pneumonia. clin chest med 2004; 25: 727-738, vi-vii. 2. american thoracic society; european respiratory society. american thoracic society/european respiratory society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias. this joint statement of the american thoracic society (ats), and the european respiratory society (ers) was adopted by the ats board of directors, june 2001 and by the ers executive committee, june 2001. am j respir crit care med 2002; 165: 277-304. 3. epler gr. bronchiolitis obliterans organising pneumonia. arch intern med 2001; 161: 158164. 4. webb wr, muller nl, naidich dp. highresolution ct of the lung. 3rd ed. philadelphia: lippincott-raven, 2001: 373-378, 529-537. 5. murphy jm, schnyder p, verschakelen j, leuenberger p, flower cd. linear opacities on hrct in bronchiolitis obliterans organising pneumonia. eur radiol 1999; 9: 1813-1817. 6. akira m, yamamoto s, sakatari m. bronchiolitis obliterans organising pneumonia manifesting as multiple large nodules or masses. am j roentgenol 1998; 170: 291-295. 7. muller n, staples c, miller r. bronchiolitis obliterans organizing pneumonia: ct features in 14 patients. am j roentgenol 1990; 154: 983987. 8. nishimura k, itoh h: high-resolution computed tomographic features of bronchiolitis obliterans organizing pneumonia. chest 1992; 102: 26s-31s. 9. murphy j, schnyder p, herold c, flower c. bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma. eur radiol 1998; 8: 1165-1169. 19-21 7/29/05 3:19 pm page 21 25-27 introduction mesial temporal sclerosis is the commonest cause of partial complex seizures. the aetiology of this condition is controversial, but it is postulated that both acquired and developmental processes may be involved. familial cases have also been reported. magnetic resonance imaging (mri) is the imaging investigation of choice for the diagnosis and has been shown to be highly sensitive and specific. once diagnosed, medical treatment is successful in 25% of cases, whilst anterior temporal lobectomy is effective in 70 95% of patients.1 case report the case under discussion involved a 42-year-old woman. she had had numerous previous admissions related to her alcoholism, but presented on this occasion with new onset partial complex seizures and secondary generalisation. on clinical examination she had impaired shortterm memory, however, no focal neurology was present. an eeg was performed and was assessed as normal. a mri scan was done which revealed abnormal high signal in the right hippocampus on the t2-weighted and flair sequences. the head, body and tail of the hippocampus were involved, with associated poor greywhite matter differentiation. in addition, there was atrophy of the hippocampus and fornix, with dilatation of the temporal horn (figs 1 4). discussion mesial temporal sclerosis (mts) is the commonest cause of temporal lobe epilepsy. pathologically, there is neuronal loss, atrophy and hippocampal gliosis. these findings are characteristic of this disorder and are thought to serve as an epileptogenic substrate. the histologic substrates can be divided into four other major catergories: (i) tumours; (ii) disorders of neuronal migration and cortical organisation; (iii) vascular malformations; and (iv) neocortical sclerosis attributable to brain injury (trauma, infection, inflammation, or infarction).1,2 in mts, dual pathology occurs in 15% of cases, with cortical dysplasia being the commonest.1 mri has the ability to detect subtle alterations in cortical architecture and changes in signal intensity and is therefore the most sensitive and specific imaging technique for non-invasive identification of these epileptogenic foci.2 in order to achieve accurate mri interpretation, it is essential to know the regional anatomy of the inferomedial temporal lobe and its related structures (fig. 5). the hippocampus comprises the head (pes), body and tail. the hippocampal/dentate comcase report 25 sa journal of radiology • july 2005 mesial temporal sclerosis d h jogi mb bch, fcrad (diag) (sa), frcr (lond) n17 east rand private community hospital springs m patel mb chb, fcrad (diag) (sa) department of radiology chris hani baragwanath hospital johannesburg fig. 1. coronal flair demonstrating atrophy of the right hippocampal head with dilatation of the temporal horn. fig. 2. coronal t1wi displaying loss of greywhite matter differentiation in the region of the right hippocampal head. figs 3 and 4. coronal flair sequences exhibiting atrophy of the right hippocampal body and tail as well as the right fornix. 25-27 7/29/05 3:26 pm page 25 case report 26 sa journal of radiology • july 2005 plex is located in the medial aspect of the temporal lobe, posterior to the amygdala. it is separated from the amygdala by the uncal recess of the temporal horn and the alveus and its long axis is parallel to temporal gyri. two interlocking ‘c’-shaped sheets of cortex form the hippocampal /dentate complex: (i) cornis ammonis (ca1, ca2, ca3 and ca4); and (ii) dentate gyrus (figs 5 and 6). on mri, the hippocampal head is seen in the same coronal plane as the interpeduncular cistern (fig. 6). the body of the hippocampus is seen at the level of the midbrain (fig. 7). it is ovoid in shape and is the most uniform portion. it lies inferior to the choroidal fissure and is separated from the parahippocampal gyrus by the hippocampal fissure. the tail of the hippocampus is located at or behind the midbrain where it is seen adjacent to the crura of the fornices (fig. 8). various mri sequences are recommended for evaluation of the temporal lobe. these include t1wi sagittal images for the localisation of the hippocampus and thin-section highresolution t2wi and flair acquisitions angled perpendicular to the long axis of the hippocampus (table i). contrast is unnecessary unless there is a focal lesion.1 a spoiled gradient recalled (spgr) echo sequence using 1.5 mm cuts in the oblique coronal plane can also be done. this provides a high-resolution t1-weighted volume data set which can be reformatted in any plane, and can also be used to measure hippocampal volumes and co-register functional data.4,5 primary findings in mts are hippocampal atrophy (recognised by asymmetry in the case of unilateral atrophy) and increased signal intensity of the hippocampus on t2wi. this is best appreciated on the coronal flair sequence, which suppresses out the cerebrospinal fluid (csf) signal from the uncal recess and the choroidal fissure thus avoiding false positive high signal changes. recent studies have shown that visual mri interpretation of these features has sensitivities of 87 100%. 1,4 there are numerous secondary mr features that support the diagnosis of mts (table ii). these include temporal horn dilatation, loss of hippocampal internal architecture, decreased hippocampal signal on t1wi and poor parahippocampal grey-white matter definition. other findings include ipsilateral atrophy of the temporal lobe, thalamus, fornix and mamillary body. these secondary features are present in 40 60% of table i. mri imaging protcols • high-resolution mr of the temporal lobes • t1 wi sagittal for localising the hippocampus • coronal high-resolution t2 wi and flair perpendicular to hippocampal axis (3 4 mm) • coronal spgr t1 perpendicular to hippocampal axis (1.5 mm) fig. 5. 1. temporal horn; 2. cornu ammonis (ammon’s horn, hippocampus proper); 3. fornix; 4. subarachnoid space; 5. hippocampal sulcus; 6. dentate gyrus; 7. parahippocampal gyrus (containing entorhinal cortex); 8. subiculum; 9. choroid plexus.3 fig. 6. coronal t2 at the level of the interpeduncular cistern showing the amygdala (large square), uncal fissure (large dot), hippocampal head (small dot) fig. 7. coronal t2 wi at the level of the midbrain, demonstrating the ovoid hippocampal body (small sqaure) under the choroidal fissure (circle). fig. 8. coronal t2 wi just posterior to the midbrain illustrating the fornix (line) and hippocampal tail (square). 25-27 7/29/05 3:27 pm page 26 case report 27 sa journal of radiology • july 2005 patients with mts. on their own, the above signs are unreliable, but in conjunction with the primary findings the diagnostic accuracy is improved.4 decreased apparent diffusion coefficient (adc) levels may be seen on diffusion-weighted imaging. mr spectroscopy would show reduced nacetylaspartate levels in the ipsilateral mesial temporal lobe assisting in the lateralisation of temporal lobe epilepsy (tle), even in cases with negative mr images.1,4,5 there is bilateral involvement in 20% of cases and in these cases mri-based hippocampal volumetry has been shown to quantitatively indicate the presence of hippocampal volume loss.1,6 mri also provides information on the predictive value concerning neurologic outcome in patients undergoing temporal lobe surgery. mri can identify hippocampal volume loss and coexisting extrahippocampal lesions which predict an unfavourable postoperative neurocognitive outcome.1,4 the mri findings of the patient discussed in this case report are compatible with mts. she is currently on medical treatment and is being followed up monthly. conclusion mri is the radiological investigation of choice for diagnosing mts. familiarity with the regional medial temporal lobe anatomy is important for correct mri interpretation. coronal high-resolution flair is the best sequence to diagnose mts, where hyperintensity and atrophy of the hippocampus are the most sensitive signs. references 1. osborn ag, cooper ja, castillo m, et al. diagnostic imaging – brain. st louis: wb saunders, 2004. 2. jack cr jun. magnetic resonance imaging in epilepsy. mayo clin proc 1996; 71: 695-711. 3. hippocampus. www.laxtha.com/bhbae/hippocampus/hippocampus.htm. (last accessed 4 april 2005). 4. connor ej, jarosz jm. magnetic resonance imaging of patients with epilepsy. clin radiol 2001; 56: 787-801. 5. cascino g. clinical correlations with hippocampal atrophy. magn reson imaging 1995; 13:1133-1136. 6. arı´stides a. capizzano, kenneth dl, et al. temporal lobe epilepsy: qualitative reading of 1h mr spectroscopic images for presurgical evaluation. radiology 2001; 218:144-151. table ii. imaging findings primary signs secondary signs hyperintense signal on t2 enlarged temporal horn of lateral ventricle and flair sequences loss of internal architecture decreased signal on t1wi atrophy of hippocampus poor grey-white matter definition fornix, mamillary body, temporal lobe and thalamic atrophy 25-27 7/29/05 3:27 pm page 27 103 sa journal of radiology • july 2008 rssa congress sponsorship the medical imaging society of south africa (misa) and member companies siemens healthcare, ge healthcare, philips medical systems and aec amersham have announced a generous sponsorship of r20 000, to be applied in the form of a refund of r1 000 to each of up to 20 registrars who incur long-distance travel and accommodation expenses in attending rssa congresses and workshops. the terms of the sponsorship are that the first 20 registrars who register and pay their registration fees by the ‘early bird’ deadline will receive a refund of r1 000 after the course ends. awarding the sponsorships depends on the course location and where the participants come from; for the congress in sandton (see below), for example, gauteng registrars will be excluded from sponsorship. this is to ensure that recipients are those who have to pay for airfare and accommodation. first rssa/icis cancer imaging course an historic ‘first’: a joint satellite cancer imaging course, presented by the radiological society of south africa (rssa) and the international cancer imaging society (icis), will take place at the spier estate, near stellenbosch, from 6 8 february 2009. after more than 2 years of careful review and planning by members of both societies, the 2009 cancer imaging course has been created to meet the challenges of advancing imaging in the multidisciplinary management of cancer. the course offers an extremely well-balanced and full programme, presented by an international faculty consisting of 12 highly distinguished fellows of the icis, a canadian neuroradiologist, and a leading south african endoscopic skull base surgeon. they will address a wide variety of topics important to daily practice as well as the basics of cancer imaging. a course of this nature is essential and long overdue for all south african and indeed african radiologists. clinical oncologists, radiotherapists, oncology surgical specialists, and diagnostic radiographers will gain enormously from the course. it will also be of benefit to the wider oncology fraternity, with special emphasis on cost-effective mdct/ mr imaging protocols and the application of advanced modalities such as pet-ct. it is designed for everyone with a special interest in oncology. the social programme at the historic spier estate will also allow ample time to meet colleagues and initiate new friendships. we gratefully acknowledge the support from all our sponsors. without them, events like these cannot be hosted; their commitment to radiology, training and teaching is appreciated and indispensable. thank you! i extend a special word of gratitude to the fellows of the icis, who have made their lectures and images available on cd to all participants; this is unique in the history of the icis and demonstrates the enormous commitment of the satellite committee to teaching and in particular to south africa. on behalf of the rssa, the icis satellite committee, the icis president, professor jay p heiken, the president elect, professor wolfgang schima, and professor rodney reznek, i invite you to join this very unique meeting. for further details and registration, please go to www.spiercancercourse2009. co.za. professor leon janse van rensburg rssa congress chairman rssa head and neck imaging workshop a most sucessful 2-day workshop, attended by 160 delegates, was conducted by 4 internationally renowned european radiologists on 25 26 october at the investec auditorium in cape town. the faculty consisted of dr jan casselman and dr bert de foer (belgium), dr alexandra borges (portugal) and dr bert-jan de bondt (the netherlands). it was a very intensive course with a full syllabus. the basic as well as advanced principles of mdct and mri in head and neck imaging were clearly and concisely explained. rssa neuroradiology and mri advances congress the rssa neuroradiology and mri advances congress will be held at the sandton convention centre, johannesburg, on 28 30 august 2009. it’s a joint venture between the rssa, the radiological society of north america’s (rsna) visiting international professors programme, and the international society of magnetic resonance in medicine’s (ismrm) global outreach programme. both the rsna and ismrm are sponsoring the participation of 3 international experts. the congress’s scientific committee consists of professors leon janse van rensburg, zarina lockhat, mala modi, coert de vries, jan lotz and richard hewlett, and doctors tracy kilborn, sally candy and bruce spottiswoode. free papers and poster presentations are invited. further information will be on the rssa website early in 2009. contributor: l janse van rensburg 103 sa journal of radiology • december 2008 radioactive news cpd instructions: 1. cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission, you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. 2. read the articles in the journal to find the answers to the questions. 3. go to www.cpdjournals.org.za to answer the questions. radioactive news dec 08.indd 103 12/5/08 11:25:44 am case report case report 32 sa journal of radiology • july 2008 case report abstract endovascular stent graft repair for the treatment of post-traumatic aortic rupture is emerging as a safe, minimally invasive and attractive alternative to surgery. this report covers the importance of computer tomographic (ct) angiography as a non-invasive imaging modality in the diagnoses of post-traumatic aortic rupture and the role of ct in preendovascular stent work-up. a detailed discussion on the endovascular procedure including the major limitations to stent insertion follows, and a comparison of endovascular stent graft versus surgery. introduction post-traumatic aortic rupture is the cause of 16% of all deaths from motor vehicle accidents; of all patients sustaining such injury, 85% will die before reaching hospital. fifty per cent of the remaining survivors will die within 24 hours.1 therefore, prompt diagnosis and treatment within this critical stage remains crucial.1 the recent development of aortic stent grafts has brought the management of thoracic aortic aneurysms into the realm of interventional radiology as an alternative to conventional open surgery.2 stent graft placement is proving to be a safe, minimally invasive and effective treatment for thoracic aortic disease in poor surgical candidates, and short-term morbidity and mortality rates from endovascular repair compare favourably with those from surgery.2 endovascular stent grafting of traumatic aortic arch pseudo-aneurysm n mahomed, mb bch t briede, mb bch, fcrad (sa) m modi, mb bch, fcrad (sa), mmed department of radiology, chris hani baragwanath hospital, university of the witwatersrand, johannesburg fig. 1. post-contrast chest ct angiogram (axial view), demonstrating a tear in the distal aortic arch associated with a left haemothorax. fig. 2. post-contrast chest cta (coronal view), demonstrating the pseudo-aneurysm in the distal aortic arch. fig. 3. digital subtraction angiogram with the pigtail catheter in the aortic arch demonstrating the descending thoracic aortic pseudo-aneurysm distal to the origin of the lsa. endovascular stent.indd 32 8/1/08 10:05:05 am case reportcase report case report a 51-year-old taxi driver presented with significant chest pain following a high-impact motor vehicle accident. chest x-ray demonstrated a widened mediastinum, and an urgent ct angiogram (cta) of the chest was performed. the cta revealed a dissection of the descending thoracic aorta distal to the origin of the left (l) subclavian artery (stanford b), complicated by a 4 cm long pseudo-aneurysm3 (figs 1 and 2). an associated l haemothorax suggested leakage from the aneurysm. the patient had a bovine-type aortic arch (i.e. the right (r) brachiocephalic artery and the l common carotid artery shared a common origin). these branches and the l subclavian artery were not involved in the dissection. as the patient also had underlying hypertension and ischaemic heart disease, making him a poor surgical candidate, but was haemodynamically stable with no contraindication to aortic stenting, the decision was made to undertake an endovascular repair of the thoracic pseudo-aneurysm. endovascular procedure the procedure was carried out under conscious sedation and local anaesthesia. the r common femoral artery was selected for deployment of the thoracic endograft (stent). an arterial cut-down was performed to obtain access for the required 20f introducer sheath. the cut-down was performed by the vascular surgical team. the previous cta had revealed that the common femoral arteries were suitable in calibre as well as not being tortuous, so as to accommodate the introducer sheath and provide an arterial access site for the interventional procedure. the l common femoral artery was also punctured percutaneously via a standard single-puncture needle with insertion of a 5f introducer sheath. this access site was used to perform thoracic arterial runs pre and post-vascular stent deployment. pre-stent deployment thoracic aortography confirmed a large contained thoracic aorta pseudo-aneurysm originating just below the origin of the left subclavian artery (lsa) (fig. 3). it was calculated that there was approximately 2 cm of normal aorta between the lsa and the start of the pseudo-aneursym. at the outset, this seemed to indicate sufficient length for a good ‘landing zone’ to avoid any possible occlusion of the lsa. a sharply angulated curve between the aortic arch and thoracic aorta was noted, however; hence, deployment distal to the origin of the lsa would lead to excessive kinking of the stent with likely failure of the device and possible occlusion of the aorta. it was decided that the stent needed to be placed more proximally, with the risk of occluding the lsa (fig. 4). the thoracic aortic stent used was a gore tag thoracic covered endoprosthesis (stent). this required a 20f sheath introducer. the selected endoprosthesis diameter was 28 mm, with the stent length 15 cm. the stent diameter needs to be oversized relative to vessel diameter by approximately 10 15% to prevent migration of the stent and ensure good apposition against the vessel walls.2 the stent contains an external nitinol support structure which enables it to self-expand and provide sealing by radial force. in addition, there are sealing cuffs on both ends to prevent type 1 endovascular leaks.2 intravenous heparin (5 000 iu) was administered prior to deployment of the stent. the delivery catheter containing the constrained stent was deployed via the introducer sheath with the proximal end of the graft occluding the lsa at the ‘landing zone’, as placement more distally was deemed unsuitable owing to the angulation between the aortic arch and the descending aorta. at the time of stent deployment, a 9 ml balloon was inflated to ensure adequate and complete stent expansion. post-deployment angiography demonstrated complete exclusion of the pseudo-aneurysm by the stent, with partial occlusion of the lsa 33 sa journal of radiology • july 2008 fig. 4. digital subtraction angiogram obtained after endovascular stent graft deployment, demonstrating complete exclusion of the pseudoaneurysm and occlusion of the origin of the lsa. fig. 5. digital subtraction angiogram demonstrating lsa opacification due to retrograde flow from the left vertebral artery (as a subclavian artery steal phenomenon). endovascular stent.indd 33 8/1/08 10:05:08 am case report case report 34 sa journal of radiology • july 2008 (fig. 4). no endovascular leaks were demonstrated. the patient did not complain of any posterior fossa or left upper limb ischaemic symptoms post-procedure, due to adequate retrograde l vertebral and other collateral arterial flow (fig. 5). discussion there is controversy concerning the appropriate role of ct in the screening of chest trauma patients for aortic injuries, as plain radiographic findings for post-traumatic aortic rupture are nonspecific.1 traditional chest radiographic findings that suggest aortic injury include mediastinal widening >8 cm, loss of clarity of the aortic knob, displacement of the nasogastric tube to the right of the t4 spinous process, left apical pleural capping, widened paraspinal lines, widened right paratracheal stripe >5 mm, and loss of the descending aortic line.1,3 however, the value of these as positive predictive signs is poor. most patients with mediastinal widening on chest x-ray (cxr) have normal ct findings with no mediastinal haemorrhage.1 on the other hand, the negative predictive value of a normal cxr is high, at approximately 98%.1 ct findings of aortic injuries include blood within the mediastinum, deformities of the aortic contour, intimal flaps, thrombus or debris protruding into the aortic lumen, the presence of a pseudo-aneurysm, or an abrupt tapering of the diameter of the descending aorta compared with the ascending aorta (‘pseudocoarctation’).1,3 most of these aortic injuries occur at or distal to the level of the ligamentum arteriosus1 in the aortic isthmus. in addition to the evaluation of aortic injuries, ct demonstrates associated injuries such as subtle pneumothoraces, pneumomediastinum, lung trauma, thoracic spine fractures and other skeletal injuries. cta of the abdomen allows evaluation of the arteries, including the diameter of the common iliac and femoral arteries and tortuosity as potential access sites for endovascular stent deployment.1 it is well established that there is a high mortality rate for major aortic surgical repair, such as that for chronic stanford type-b dissection which is 15%, reaching almost 40% for acute dissection.2 endovascular repair of thoracic aneurysms is emerging as an attractive alternative to surgical graft replacement in both highand low-risk surgical patients.2,4 the benefit in high-risk surgical patients has already been established and, although the long-term results in low-risk patients are not known, the short-term mortality and morbidity compare favourably with that for surgery.2 the major limitations in selecting patients for endovascular repair are the lack of a suitable proximal landing zone (i.e. the aneurysm should arise at least 5 mm beyond the lsa) with ‘first-generation’ endovascular stents and inadequate vascular access.2,4 generally, 10 15% oversizing of stent grafts is required to prevent migration and provide good apposition to the aortic wall. ideally, the covered portion of stent grafts (excluding the length of the uncovered, bare extremities) should cross the lesion and at least 1.5 cm of the normal aorta at either end. whenever possible, greater proximal and distal coverage should be used to prevent late stent graft migration and endovascular leak due to aortic disease progression. however, a stent used for the treatment of aortic dissection may be relatively short as the goal is then simply to close the entry point.2 when there is <15 mm of normal aorta between the aneurysm and the normal lsa, the covered part of the stent will have to occlude the origin of the lsa to ensure adequate length of the proximal landing zone. as described in our case report, the lsa origin would also have to be occluded when there is sharp angulation between the aortic arch and thoracic aorta such that deployment distal to the origin of the lsa would lead to excessive kinking of the stent with possible aortic occlusion.2 if the lsa origin is to be occluded, a left carotid-subclavian artery bypass may be created electively beforehand if contralateral vertebral artery perfusion is inadequate or if the patient develops symptoms after stenting.2 an alternative to covering the lsa would be the use of newergeneration notched or fenestrated stents.2,4 closure of the tear in post-traumatic arch rupture often occurs spontaneously after stent graft insertion. the most common complication after stent graft implantation is leakage into the aneurysm due to incomplete fixation of the stent graft to the aortic wall or due to graft defects.5 other complications of endovascular repair of thoracic aortic aneurysms include expansion of the aortic tear and weakening of the aortic wall due to excessive balloon dilation of the stent graft, graft thrombosis and graft kinking.5 rare complications, with reported rates of 4 17%, include graft occlusion caused by the inability of the stent graft to bend along the acute angle in the aortic arch, and shower embolism due to mural thrombus dispersion during repeated introduction of guide wires, angiographic catheters and delivery systems; this may cause cerebral infarction during the endovascular procedure.5 conclusion ct will remain at the forefront in the diagnosis of post-traumatic aortic rupture and for preand post-endovascular stent management. good ct imaging obviates the need for invasive angiography in a significant number of patients. stent graft placement is proving to be a safe, minimally invasive and effective treatment for the management of post-traumatic aortic pseudoaneurysms. the limitations of surgical repair include underlying comorbid disease, as described in our patient, whereas the major limitation to endovascular graft repair is anatomical suitability. in selected patients, short-term morbidity and mortality compare favourably with that obtained surgically. 1. kuhlman j, posniak m, collins j. radiographic and ct findings of blunt chest trauma: aortic injuries and looking beyond them. radiographics 1998; 18: 1085-1106. 2. therasse e, soulez g, giroux mf, et al. stent graft placement for the treatment of thoracic aortic diseases. radiographics 2005; 25: 157-173. 3. baron rl, sagel rg, stanley rj. computed tomography in the evaluation of mediastinal widening. radiology 1981; 138: 107-113. 4. kato n, shimono t, hirano t, et al. aortic arch aneurysms, extra-anatomical bypass and endovascular stent grafting. cardiovasc intervent radiol 2002; 25: 419-422. 5. mita t, arita t, matsunaga n. complications of endovascular repair for thoracic and abdominal aortic aneurysm: an imaging spectrum. radiographics 2000; 20: 1263-1278. endovascular stent.indd 34 8/1/08 10:05:08 am article information authors: juruan f. de witt1 stephanie griffith-richards1 richard d. pitcher1 affiliations: 1division of radiodiagnosis, department of medical imaging and clinical oncology, tygerberg hospital and stellenbosch university, south africa correspondence to: juruan de witt postal address: po box 7062, stellenbosch 7599, south africa dates: received: 07 nov. 2013 accepted: 18 jan. 2014 published: 16 may 2014 how to cite this article: de witt jf, griffith-richards s, pitcher rd. the accuracy of after-hour registrar computed tomography (ct) reporting in a south african tertiary teaching hospital. s afr j rad. 2014;18(1); art. #591, 3 pages. http://dx.doi.org/10.4102/ sajr.v18i1.591 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the accuracy of after-hour registrar computed tomography (ct) reporting in a south african tertiary teaching hospital in this original research... open access • abstract • introduction • materials and methods • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: the division of radiodiagnosis at tygerberg academic hospital, a 1384-bed tertiary training institution in cape town, south africa provides a comprehensive 24-hour clinical radiology service, and has a duty registrar on-site at all times. the demand for computed tomography (ct) imaging is increasing and plays a pivotal role in patient management.objectives: the purpose of this study was to determine the accuracy of after-hour registrar ct reporting, to identify possible factors that may affect the error rate, and to assess whether or not errors had any clinical impact. method: a set of senior registrar reports (provisional reports) issued during a 28-day period was compared with the corresponding consultant reports (final reports). discrepancies were identified and quantified, based on their impact on patient management. results: the overall discrepancy rate was 8% (18 out of 225) and the overall accuracy rate was 92% (207 out of 225). the major error rate was 4% (9 out of 225) and the minor error rate was also 4% (9 out of 225). conclusion: we observed that the accuracy of after-hour ct reporting by senior registrars at the division of radiodiagnosis at tygerberg hospital was on par with international standards. we investigated three factors which may have affected discrepancy rates, and only found one factor, namely the time of day, to be significant. steps can be taken to create awareness of this fact amongst registrars, which hopefully would result in improved patient care and management. introduction top ↑ the division of radiodiagnosis at tygerberg academic hospital, a 1384-bed tertiary training institution in cape town, south africa provides a comprehensive 24-hour clinical radiology service, and has a duty registrar on-site at all times. the demand for computed tomography (ct) imaging is increasing amongst all referring specialties and plays a pivotal role in patient management, resulting in an ever-increasing workload on the division of radiodiagnosis.on weekdays, registrars have on-site consultant supervision from 08:00 to 21:00. over weekends and between 21:00 and 08:00 on weekdays, radiological services at the hospital are provided solely by a senior registrar, who has two or more years of clinical radiology experience. it is the prerogative of the senior registrar to seek telephonic advice from the off-site duty radiology consultant and, if necessary, to request that the consultant provide on-site assistance for an opinion on complicated cases or technical assistance with a challenging interventional procedure. ct scan reporting represents the most important after-hour work. all weekday after-hour registrar reports are reviewed by a consultant the following morning, whilst weekend after-hour reports are reviewed on mondays. the relevant registrar and referring clinicians are informed of any reporting errors. the purpose of this study was to determine the accuracy of after-hour registrar ct reporting, to identify possible factors that may affect the error rate, and to assess whether or not errors had any clinical impact. materials and methods top ↑ a report issued by a senior registrar in the after-hour setting is referred to as a ‘provisional report’. only after review (and possible alteration) by a consultant would the ‘final report’ be issued. all reports are stored on pacs, the picture archiving and communication system, and can easily be viewed by clinicians.a set of senior registrar reports (provisional reports) issued during a 28-day period was collected after institutional ethics review board approval. these reports were compared with the corresponding consultant reports (final reports). studies included trauma-related investigations (ct imaging of the brain, cervical spine, chest, abdomen, pelvis and vascular system) and medical investigations (ct imaging of the brain, chest and abdomen). any discrepancy in interpretation was identified and quantified. errors were classified as either major errors or minor errors. examples of major errors include: fractures not identified, vascular injuries not identified, major organ injuries not identified, no mention made of cerebral oedema, et cetera.1,2,3,4,5,6 examples of minor errors include: incidental benign lesions not identified or mentioned (such as cysts in various organs), incorrect classification (e.g. fracture or laceration classification) which did not change the management of the patient, minor fractures not identified (whilst mention of major fractures was made), et cetera.1,2,3,4,5,6 our rationale for quantifying errors (major vs minor) was based on their impact on patient management. it is easy to acknowledge that a major misinterpretation could result in major mismanagement of the patient. when one considers box 1, one can appreciate why such mismanagement could result in devastating consequences. for example, when no mention is made of cerebral oedema, the swelling may progress to herniation and eventually death. similarly, by not recognising significant fractures, the patient may develop infection, haemorrhage or even paralysis. missed arterial and major organ injuries may continue to haemorrhage, leading to anaemia, organ failure and ultimately death. box 1: major errors encountered. a literature search was performed in order to determine whether similar research had been done. five relevant publications of research performed at similar international institutions were reviewed – our results were compared with existing data to determine whether our error rate is acceptable and whether we should consider alternatives to current protocols in order to maximise patient benefit. furthermore, we determined whether any correlation existed between error rate on the one hand, and years of training, time of report and number of reports during a shift on the other. reports compiled by registrars who had completed the fellowship of the college of radiology, south africa (fcrad) part ii examination, reports compiled by junior registrars, and reports not considered due to technical factors met the exclusion criteria. during the 28-day period a total of 372 after-hour ct investigations were performed. of these investigations’ reports, 147 met the exclusion criteria and were not considered, whilst 225 reports were considered for statistical analysis. table 1 reflects the scanned body regions and referring disciplines. table 1: scanned body regions and referring disciplines. results top ↑ the overall discrepancy rate was 8% (18 out of 225) and the overall accuracy rate was 92% (207 out of 225). the major error rate was 4% (9 out of 225) and the minor error rate was also 4% (9 out of 225).table 2 represents the statistical breakdown of the three factors under investigation, namely time of report, number of reports during a shift and years of registrar training. table 2: statistical breakdown of factors under investigation. we utilised a 95% confidence interval. discussion top ↑ the reviewed literature revealed discrepancy rates ranging from 0.9% to 25%.1,2,4,5,7 the discrepancy rate at tygerberg hospital (8%) was considered favourable when compared with a similar training institution (17.1%) with almost identical socio-economical parameters and patient profile (i.e. resource-limited environment within the same developing country).7 when compared with well-resourced environments (i.e. developed countries), where the discrepancy rates ranged from 0.9% – 25%, our results were regarded as acceptable.we found it somewhat surprising that significantly more errors occurred during the day shift (08:00–21:00) than during the night shift (21:00–08:00). possible explanations include the following: • emergency cases (stable patients requiring ct imaging as soon as possible) enjoy priority over urgent cases (stable patients who, in the opinion of the referring clinician, need ct imaging within 24 hours), resulting in urgent cases only being scanned the following morning. the high frequency of trauma-related emergency cases conditions registrars to be vigilant regarding certain crucial findings, thereby minimising discrepancies. on the other hand, urgent cases generally tend to be acute or chronic with loaded co-morbidity. it is this co-morbidity that introduces a time-consuming component to interpretation and reporting and contributes to the overall complexity of the study. • registrars may experience a false sense of security during daytime. our belief is that a registrar would be more confident in issuing a report at a time of day when a consultant is more readily available. should a discrepancy arise (for example when a clinician queries the validity of a report), the process of contacting a consultant who would then review the case and offer his or her opinion would be less cumbersome. as inappropriate as it may seem, registrars perceive the processes of contacting consultants who are ‘awake’ and therefore more readily available, and ‘unlikely to be awake’ and therefore not readily available, differently. fourth-year registrars appeared to be more likely to make errors when compared with 2nd-year and 3rd-year registrars. however, a larger sample size would be necessary to confirm this trend. possible explanations may be that: • a more senior registrar would take responsibility of a more complex case • senior registrars who are preparing for their final examinations are more sensitive to subtle pathology, thereby increasing the likelihood of overcalling certain findings. the number of investigations during a shift played no statistical role in the likelihood of error occurrence. possible explanations include the following: • the rate at which scans can physically be performed on a 6-slice ct scanner, compared with the time required to report on the scans, is manageable for a senior registrar at tygerberg hospital. however, there are other training institutions in south africa with a significantly more demanding workload, where the number of investigations performed (on more than one ct scanner) is likely to affect accuracy rate. • the effect that lack of sleep has on report discrepancy rate appears to be insignificant. senior registrars at tygerberg hospital are offered the privilege of a ‘post-call’ day, which may provide some incentive regarding the timely issuing of reports, as the assurance of total removal from the clinical milieu may be comforting. conclusion top ↑ we observed that the accuracy of after-hour ct reporting by senior registrars in the division of radiodiagnosis at tygerberg hospital was on par with international standards. we investigated three factors which may have affected discrepancy rates, and only found the time of day to be significant.steps can be taken to create awareness of this fact amongst registrars, which hopefully would result in improved patient care and management. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions j.f.d.w. (tygerberg hospital and stellenbosch university) was solely responsible for the manuscript, whilst s.g.-r. (tygerberg hospital and stellenbosch university) and r.d.p. (tygerberg hospital and stellenbosch university) acted as supervisors. references top ↑ 1. briggs rh, rowbotham e, johnstone al, et al. provisional reporting of polytrauma ct by on-call radiology registrars. is it safe? clin radiol. 2010;65:616–622. http://dx.doi.org/10.1016/j.crad.2010.04.0102. miyakoshi a, nguyen qt, cohen wa, et al. accuracy of preliminary interpretation of neurologic ct examinations by on-call radiology residents and assessment of patient outcomes at a level i trauma center. j am coll radiol. 2009;6:864–870. http://dx.doi.org/10.1016/j.jacr.2009.07.021 3. cooper vf, goodhartz la, nemcek aa, et al. radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies. acad radiol. 2008;15:1198–1204. http://dx.doi.org/10.1016/j.acra.2008.02.011 4. lal nr, murray um, eldevik op, et al. clinical consequences of misinterpretations of neuroradiologic ct scans by on-call radiology residents. am j neuroradiol. 2000;21:124–129. 5. roszler mh, mccarroll ka, rashid t, et al. resident interpretation of emergency computed tomographic scans. invest radiol. 1991;26:374–376. http://dx.doi.org/10.1097/00004424-199104000-00016 6. hillier jc, tattersall dj, gleeson fv. trainee reporting of computed tomography examinations: do they make mistakes and does it matter? clin radiol. 2004;59:159–162. http://dx.doi.org/10.1016/s0009-9260(03)00309-x 7. terreblanche od, andronikou s, hlabangana lt, et al. should registrars be reporting after-hours ct scans? a calculation of error rate and the influencing factors in south africa. acta radiol. 2012;53:61–68. http://dx.doi.org/10.1258/ar.2011.110103 untitled 2 sa journal of radiology • december 2005 editorial bounding ahead with our journal savvas andronikou mb bch, fcrad (sa), frcr (lond), phd (uct) department of radiology tygerberg hospital university of stellenbosch this will read more like a memo than an editorial but i guess this is the best avenue for informing our readers. we must extend our gratitude as a society and as a professional body to ian duncan who served this journal as chief editor and brought it alive. i see ian is still active in publishing, with a current paper in paediatric radiology. keep up the good work ian and we hope we can continue your impetus to improve the journal. this will be the first issue with the editorial team changes. i have taken over duties of chief editor and i have brought in mala modi and nicky wieselthaler as assistant editors because of their publication experience. we hope to bring some variety and enthusiasm working as a team. the journal has also undergone a minor face-lift as you can see. we have changed to a smaller more ‘professional’ font and will use the space for larger images, seeing that this is an imaging journal. you will also notice a new but small section called the specialty corner at the back of each issue. this will be managed by the assistant editors and hopefully will highlight subspecialty expertise that exists nationwide. the one in this issue concentrates for obvious reasons on paediatric radiology and is produced by pissa (paediatric imaging society of south africa), a subgroup of the radiological society of south africa. we hope that the other subgroups that exist will take up the reins using our first contribution as a template to deliver news, journal article reviews and conference information regarding their subspecialty. congratulations must go to the contributing universities for their issues to date. in particular you will notice that this issue is formed primarily from ‘spillover’ from the previous wits issue, which shows the enthusiasm and desire to get down and publish. some words of warning must accompany this, however. in their eagerness some contributors ignored regular methodology and referencing requirements that make a journal what it is and that differentiate it from a periodical. i have also noted an increasing amount of long-winded case reports rather than solid research or review material. case reports should be truncated into pictorial interludes where the picture tells the story. review articles are essential for a worthwhile read and for educational purposes but they should be written by someone with insight into the topic of interest. publication of mmed theses is encouraged as this will add significantly to the journal content quality. we have redesigned the instructions to authors indicating the types of articles acceptable for publication and giving a description of each. we have also decided on a restriction in article length to encourage concise work and to create more topics per journal issue. these will be available on the rssa website. our editorial team will be involved in accepting or rejecting submissions which will be delivered via the guest editor from each university. the schedule for 2006 will also be announced on the rssa website. i hope you will enjoy our input as we move towards a peer-reviewed publication that is cited on the major databases. savvas andronikou chief editor ed 11/25/05 12:17 pm page 1 musculoskeletal imaging quiz case authors: shalendra k. misser1; j.m. zietkiewicz1 affiliations: 1lake smit and partners inc, durban, south africa postal address: private bag x08, overport 4067, durban, kwazulu-natal, south africa how to cite this article: misser sk, zietkiewicz jm. musculoskeletal imaging. s afr j rad. 2014;18(1); art. #702, 2 pages. http://dx.doi.org/10.4102/sajr.v18i1.702 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. presentation open access a 33-year-old female runner presented with chronic right hip pain. these are selected plain film, computed tomography (ct) and magnetic resonance (mr) images. figure 1: plain radiograph of right hip. figure 2: axial t2-weighted magnetic resonance (mr) image of right hip. figure 3: sagittal proton-density magnetic resonance (mr) image of right hip. figure 4: coronal computed tomography (ct) reformat of chest and abdomen. figure 5a: coronal t1-weighted magnetic resonance (mr) image of pelvis. figure 5b: coronal proton density magnetic resonance (mr) image of pelvis. figure 6a: coronal computed tomography (ct) reformat image of right hip. figure 6b: volume rendered computed tomography angiography (cta) reformat of right hip. figure 7: axial computed tomography (ct) image acquired in biopsy mode. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 01 december 2014. the winning respondent will receive a r1000 award from the rssa. a detailed diagnosis and discussion will be presented later this year. article information authors: antoinette reinders1 coert s. de vries1 g. joubert2 affiliations: 1department of clinical imaging sciences, university of the free state, south africa 2department of biostatistics, university of the free state, south africa correspondence to: antoinette reinders email: antoinette.reinders@gmail.com postal address: 1 logeman street, universitas 9301, bloemfontein, south africa dates: received: 03 dec. 2014 accepted: 12 feb. 2015 published: 04 june 2015 how to cite this article: reinders a, de vries cs, joubert, g. pre-interventional assessment and calcification score of the aortic valve and annulus, with multi-detector ct, in transcatheter aortic valve implantation (tavi) using the medtronic corevalve. s afr j rad. 2015;19(1); art. #762, 7 pages. http://dx.doi.org/10.4102/sajr.v19i1.762 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. pre-interventional assessment and calcification score of the aortic valve and annulus, with multi-detector ct, in transcatheter aortic valve implantation (tavi) using the medtronic corevalve in this original articles... open access • abstract • introduction • research method and design    • materials and setting    • design    • procedure    • imaging analysis    • facts, rosenhek and hu score • results    • statistical analysis       • ethical considerations          • benefits and hazards          • recruitment procedures          • informed consent          • data protection          • trustworthiness • discussion    • limitations    • recommendation • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: transcatheter aortic valve implantation (tavi) provides an acceptable alternative for aortic valve replacement in the elderly, but needs accurate pre-procedural imaging to optimise intervention. objectives: to evaluate an alternative manual aortic valve calcification scoring system with computed tomography, for patients undergoing tavi. we hypothesise a correlation between the free state aortic valve calcium computed tomography score (facts) scoring system, valve plaque density and procedure-related complications. methods: twenty patients suitable for tavi were selected according to standard international guidelines and received multimodality imaging prior to intervention. images were reviewed by two reviewers who were blinded to each other's scores. where large inter-individual score variations existed, retraining was done and scores repeated, using a double-blinded method. matched scores were included in the final analysis. rosenhek calcification scores were used as a standard of reference. results: the study comprised 9 (45%) men and 11 (55%) women, with a median age of 83.5 years. median euroscore was 15.5. facts scores ≥6 were associated with the presence of a paravalvular leak (p = 0.01). procedure-related complications (left bundle branch block, repositioning of the valve and anaemia) were seen in patients with plaques measuring ≥1000 hu (p = 0.07). conclusion: the facts score and averaged valve plaque hu showed potential for predicting a paravalvular leak and procedure-related complications, and could be valuable in the future for optimising patient selection for tavi. introduction top ↑ aortic stenosis is a global major debilitating health concern that is associated with high mortality and morbidity in the elderly population. until recently, the only treatment for such patients was surgical aortic valve replacement, showing reasonable peri-operative results, but excluding a large number of symptomatic patients owing to unacceptably high peri-operative risk as indicated by a european society of cardiology score >20% (euroscore) or society of thoracic surgeons (sts) score >10.1 in the above pre-interventional scoring systems, patients are allocated specific numerical values according to comorbid conditions such as hypertension, hypercholesterolaemia and chronic obstructive pulmonary disease. since the early 1990s, alternative routes for aortic valve replacement have been sought. 1,2,3 transcatheter aortic valve replacement (tavi) has emerged as a suitable and clinically better-tolerated alternative to surgical aortic valve replacement in selected patients.1 results from the partner trial (cohort b) showed an absolute reduction in one-year mortality of 20% with marked and durable improvement in functional status and reduced hospitalisation in patients who had undergone tavi, compared with those who had been treated medically.1 because tavi is carried out in selected high-risk patients, pre-interventional assessment of the cardiac and aorta iliac anatomy is of the utmost importance.4 trials have shown multi-detector computed tomography (mdct) emerging as a valid alternative, and is in some institutions preferred to catheter angiography in assessing the aorta and ilio-femoral circulation prior to valve deployment. this trend is of particular importance in planning a percutaneous entry site as well as artificial valve sizing. mdct is often also used as an adjunct to trans-oesophageal echocardiography in assessing the aortic annulus and valve cusps.4,5 this fast-growing approach has intertwined the interventional cardiologist's and radiologist's expertise, as well as heralded the start of a dedicated ’heart team’ for adequate assessment of the suitability of a patient prior to tavi. several mdct acquisition protocols, including dual energy virtual non-contrast (devnc),6 have been suggested and reviewed in quantifying the aortic valve and annulus prior to percutaneous intervention with tavi. some authors advocate the agatston7,8 calcium scoring method, whilst others rely on a ’gestalt’ or manual scoring system based on the rosenhek diagrammatic calcium score9 in an attempt to predict post-procedural outcomes in these high-risk patients. heinsig8 alluded to the fact that patients with a high agatston aortic valve calcification burden were more prone to paravalvular leaks (pvl) as well as a subsequent increase in hospital morbidity and one-year mortality post tavi. he demonstrated this within a study population of 120 patients.7, 8 although the agatston aortic valve calcium score (avcs) and its ability to predict the probability of a post-procedural paravalvular leak have been extensively written about in larger study groups,7,8,9 it has fallen out of favour at some institutions owing to its labour-intensive and time-consuming reconstructions. manual scoring systems, on the other hand, have failed to accurately predict complications in patients undergoing tavi as they do not take into consideration the density of the calcified plaque. the aim of the present study was to describe our local experience with mdct in evaluating patients with clinically significant aortic stenosis, in preparation for tavi, specifically proposing an alternative manual system for grading the calcification of the aortic valves annulus as well as the cusps, denoting calcification burden and density with single-source mdct. we aimed to hypothesise a link between the free state aortic valve calcium ct score (facts) and valve plaque averaged hounsfield units (ahu), with patient/procedure-related complications. we regarded complications such as paravalvular leak, stroke, death and myocardial infarction as major complications, and complications such as anaemia, left bundle branch block, and repositioning of the valve post/during the procedure as minor complications. research method and design top ↑ materials and setting a total of 20 patients from july 2011 – january 2013 were included. consent was obtained from the hospital superintendent, prospective patients and the faculty of health sciences ethics committee, university of the free state, prior to the study (ecufs no. 148/2012). patients were evaluated by the department of cardiology, university of the free state, and found eligible for tavi. all fulfilled the criteria for clinically significant aortic stenosis, as determined by standardised inclusion criteria.10 no additional cardiac rhythm stabilising drugs were added to the patients’ usual drug regime. renal function was confirmed to be fit for intravenous contrast administration (omnipaque 350, ge healthcare ireland, cork, ireland) prior to imaging. exclusion criteria for imaging were severely impaired renal function <40 ml/min/1.73 m2 or previous severe adverse reaction to iodinated contrast material, such as anaphalactoid reaction, severe bronchospasm and cardiorespiratory collapse.11 patients were evaluated by cardiac echocardiography (trans-oesophageal echocardiography (tee) and trans-thoracic echo (tte)) prior to and after tavi at the cardiology interventional suite by dedicated echocardiographers using the sellers technique as a guideline; see table 1. table 1: sellers proposed echocardiogram grading for aortic regurgitation. design this was a proand retrospective, double-blinded, cohort analytical study. procedure examinations were done on a single source, dual energy, high definition 64-detector ct scanner (hd750 discovery, general electric, milwaukee). patients were scanned using one of two standardised ct protocols, dependent on body weight (≥70 kg, 120 kv, 160 ml 350 omnipaque; and ≤70 kg 100 kv 160 ml 350 omnipaque), with ecg-prospectively gated, single-source energy scan of the chest, including gated cardiac ct and ungated single-source cta of the abdomen and pelvis. scan parameters were set with acquisition thickness of 0.625 mm, small field of view of 25 cm, a pitch of 0.16:1 and gantry rotation speed of 0.25 sec. – 0.35 sec., with kv and mas dependent on body habitus. scans were done in a craniocaudal direction on 75% of the rr interval. automated bolus injection was implemented with the region of interest placed over the ascending aorta with scanning of the chest commencing at an attenuation value of 120 hu. contrast was administered via an automated pump at 5 ml/sec., with a 40 ml saline bolus ’chaser’ given after contrast injection. imaging analysis images were reviewed weekly by a qualified radiologist and a training fellow at the university of the free state, universitas hospital complex. post processing of images took place on an advantage workstation 4.5 (general electric) and analyses were performed using standard software (reformat, general electric). data were loaded into a standard multiplanar reformat package, with image reconstructions in the coronal, sagittal and axial orientation and analysed using a multiplanar oblique tool. the coronal image was used to visualise the left ventricular outflow tract, with placement of the oblique tool in the middle of the ascending aorta, producing a sagittal oblique view. placement of the oblique tool was in the centre axis of the ascending aorta, producing true axial images in the aortic leaflets and annulus planes, on which the calcification scoring was done. the aortic annulus and valve leaflets calcification burden was scored using a bone window level (ww2000 wl350). two views were used with the facts scoring of the aortic valve. the first view visualised the entire aortic annulus on the modified true axial views as done by using the multiplanar oblique tool. outer ring scoring was done on this initial view. the second view visualised the distal ends of the leaflets as they converged; inner ring scoring was done on this view. the aortic annulus was divided into quarters on the first view and scored. one point was given for every calcification/plaque seen on the individual regions as described. the total score added to 16, where each valve had 4 possible sections as well as the annulus, which was also divided into 4 sections (figure 1). figure 1: schematic representation of the facts score average hounsfield units (hu) score. each number represents 25%/1 point of the valve cusp = total score of 12. the outer numbers represent 25%/1 point of the annulus. total score of both aortic annulus and cusps therefore = 16. the most heavily calcified plaque on each cusp was measured in hu and divided by a factor of 3 to obtain an average score of either ≥1000 hu or <1000 hu). annulus calcifications were not taken into account with the hu scores. facts, rosenhek and hu score facts scores were done individually and each observer blinded to the other's score. these scores were correlated to the rosenhek diagrammatic calcium valve scoring system (figure 2). the diagrammatic rosenhek scoring system is shown in figure 3. figure 2: facts and rosenhek scores v. complications. figure 3: rosenhek score. patients for whom the observers’ facts scores showed a difference >15%/2 points were rescored, after retraining, by the same two observers and included in the final data set for statistical analysis. an agreement score was seen as a difference of up to 10%–15%/2 points between observers. complications were associated with scores where the two observers were in agreement after the final scoring. eighteen patients’ facts scores and 16 patients’ rosenhek scores matched in the final analysis. hus were done separately to the facts scores and calculated on each aortic valve cusp. the largest calcified plaque density was taken on each valve cusp and summed. this figure was divided by a factor of 3 for an average score and grouped to either ≥1000 hu or <1000 hu as agreed upon between the observers, taking an hu ≥1000 as denoting calcified bone on routine ct. correlations between the two observers’ ahu scores were measured and 18 scores matched according to category. all data (original and rescored) were captured and typed into a microsoft excel spreadsheet for statistical analysis. age, race, sex, comorbid factors, grades of dyspnoea, left ventricular outflow fraction (prior and after the procedure) and presence of aortic regurgitation, complications and the presence of a pacemaker prior to and after procedures were included. complications considered as major were stroke, myocardial infarction, death, paravalvular leak and ’other’. ’other’ included minor complications such as repositioning of the valve, anaemia post procedure and left bundle branch block. patients’ were followed up at 30, 90 and 180 days. no patients died during the follow-up period. results top ↑ a total of 20 patients (9 men [45%] and 11 women [55%]), who happened to all be white, were enrolled in the study. only 18 patients’ facts scores were used in the final analysis. patient demographics are shown in table 2. table 2: patient demographics. new york heart association (nyha) criteria were recorded prior to and following the procedure, with 35% of patients being nyha 2, 50% nyha 3, and 15% nyha 4 prior to the procedure and showed marginal improvement post tavi (nyha 1 (10%), nyha 2 (70%), and nyha 3 (20%), but this was not statistically significant (p = 0.41). the median age of the patients was 83.5 years (range 68–95 years), with a euroscore median of 15.5 (range: 5–22). sixteen (80%) of the 20 patients had a grade 1 aortic incompetence prior to tavi, and 17 (85%) had paravalvular leak (pvl) post tavi, of whom 10 patients had grade 1 pvl, 5 patients had grade 2 pvl, and 1 patient had grade 3 pvl. facts scores ≥6 were significantly associated with the presence of a paravalvular leak (p = 0.01) post tavi. grade 1 pvl = mild pvl, grade 2 pvl = moderate pvl, and grade 3 pvl = severe pvl. the facts scores were similar to the rosenhek score in this regard, and both major and ’other’ complications were seen to arise at a rosenhek score >2, but were not statistically significant (p = 1.00; ’other’ complications p = 0.09). no patient suffered from a myocardial infarction or death during or immediately after the procedure (see figure 2). nine patients fell into the ‘other’ complication category. the totals of complications were similar in both rosenhek score groups, with both groups having close to the same number of complications in the ’other’ category. the median left ventricular ejection fraction (lvef) was 56.5% (range 27%–77%) and marginally increased to 61.5% (range 29%–75%) at follow-up. comorbid conditions (see figure 4) prior to tavi were recorded and were as follows: hypertension − 80%, diabetes − 15%, renal impairment − 10%), ischaemic heart disease − 35%), hypercholesterolaemia − 24%, chronic lung disease − 65%, peripheral vascular disease − 65%, and congestive cardiac failure − 5%. figure 4: comorbid factors prior to tavi. four patients received pacemakers; 1 was inserted prior to tavi and 3 post tavi. left bundle branch block is a known complication of the tavi procedure. all of our patients had degenerative aortic stenosis. an ahu ≥1000 was associated with ’other complications’ amongst which left bundle branch block, anaemia post procedure and repositioning of the valve were seen; this was close to being statistically significant (p = 0.07). a graph of ahu v. complications is shown in figure 5. ahus ranged from 795 to 1336. figure 5: averaged hounsfield units versus complications. only one female patient had a transient ischaemic event, which resolved in 24 hours. she had high facts and ahu scores (facts = 9 and ahu ≥1000). male patients also had a higher incidence and grade of pvl than female patients, which we associated with a plaque density ≥1000 hu. one patient had a grade 3 pvl that was the result of initial incorrect positioning of the artificial valve, with a grade 1 pvl after repositioning of the medtronic valve. plaques ≥1000 hu were associated with comorbidities; diabetes was found to be the main comorbid factor in plaque density differences, as seen in figure 6. figure 6: plaque characteristics v. comorbidities. no adverse events were recorded either during or after image acquisition. all tavi procedures were performed after multidisciplinary discussion, using a transfemoral approach by a dedicated cardiac team, using the self-expandable medtronic corevalve. statistical analysis results were summarised by frequencies and percentages (categorical variables) and means or percentiles (numerical variables, depending on the distribution of the data). groups were compared using chi-squared, fisher's exact test or mcnemar's test for categorical variables, the kruskal-wallis test, or mann-whitney test for numerical variables. ethical considerations benefits and hazards if an association between plaque burden and density could be drawn to facts score ≥6 and hu ≥1000, pre-procedural evaluation could be streamlined and post-procedural complications be anticipated and timeously treated. recruitment procedures patients undergoing pre-interventional imaging were asked to take part in the study. prospective and retrospective data capturing was done. no monetary compensation was offered to patients for taking part in the study. there was no discrimination against patients who declined participation. informed consent each patient received an information document, explaining the goal of the study and the imaging procedure involved. patients were asked to sign this document prior to imaging, if they agreed to participate in the study. data protection patients’ data were captured onto a standardised excel sheet and numbers allocated to each patient. only the first observer/researcher had access to patients’ names. confidentiality was maintained in all circumstances. trustworthiness all tavi procedures were performed by a dedicated cardiology team with the same two operators, with the standard use of a transfemoral approach. all patients’ aortic valves were reviewed, and calcified valve plaques scored by the same two radiology reviewers on the same ge workstation, using a standard double-blinded method. discussion top ↑ tavi is an established percutaneous method for the treatment of critical aortic stenosis1,2,3,4,5,6,7,8,9,10,11,12 in high-risk patients and is relatively new in the south african context.12 the agatston calcification scoring system5,7,8,10 for aortic valve calcification has been proposed in the past as well as manual valve plaque calcification scoring systems9 with and without the use of computer software, linking complications such as paravalvular leak and long-term patient survival to these scores13,14,15 and proposing better patient selection prior to intervention. we aimed to introduce an alternative manual scoring system that was easy to implement, took plaque density into account, was not time consuming, and at the same time could predict clinically significant adverse patient outcomes. in our small study sample, we found that a facts score ≥6 was significantly associated with the presence of a paravalvular leak. literature has shown that paravalvular leak post tavi is an independent risk factor for longer hospital stay as well as an increased mortality risk factor at one-year follow-up.7 procedure-related complication was close to statistically significantly associated with average valve plaque densities ≥1000 hu. unfortunately, we were not able to differentiate between grades of paravalvular leak in our study, which could be attributed to our attempt to introduce a new manual scoring system and/or that our study population was small. nevertheless, all the artificial valves were inserted by the same dedicated cardiology team, so the fact that an association between ahu score and complications such as anaemia, left bundle branch block and repositioning of the artificial valve could be shown is, we feel, some achievement. we used the rosenhek score as a reference standard, although in hindsight the two scoring systems are inherently different in that the facts and ahu scores offer quantification as well as qualification of the calcified plaques versus the first-mentioned score that only relies on a ’gestalt’ or quantification of the calcification burden of the aortic valves, excluding the aortic annulus. our score included the aortic annulus which, we postulate, could play a role in the pathology of paravalvular leaks post tavi in our population. a possible reason for this could be the limited pliability of the aortic annulus with bulky calcified plaque. the rosenhek score could also not differentiate between specific complications (e.g. stroke v. pvl) in our small study population but was, however, associated with no complications if the score was <2, when compared with the facts score; and, interestingly, the rosenhek scores were seen to match in 80% of cases between the two observers, in the final statistical analysis. the lvef and nyha only marginally improved after tavi procedure and were found to be statistically unrelated to either the facts or ahu scores. pacemaker insertion could also be linked to high ahu scores, although this was not statistically significant and is a known complication of the medtronic corevalve.13 limitations in our study population, complications were minimal, which could be due to the small study size or because the tavis were done meticulously by a qualified cardiac team. moderate inter-individual variations were seen with the facts scores initially but, after retraining, the differences were markedly less. one explanation for the variation could be the relative inexperience of both observers with a new scoring system or because of the lack of experience in calcification scoring. only two observers scored in this article. maybe a larger number of observers could have improved the results. the facts and ahu scores were looked at individually and could have been incorporated into a single scoring system. recommendation we recommend the incorporation of the ahu with the facts score in future for a uniform score, giving a specific numeral value to a specific hu density as well as a larger sample size. individual scoring of the annulus versus the cusp calcification could also be considered for future studies. conclusion top ↑ the facts and ahu scores are easy to implement, not labour intensive or time consuming, and show promise in providing important added information for patients undergoing pre-interventional assessment for the tavi procedure, especially in determining the risk of paravalvular leak, left bundle branch block, repositioning of the artificial aortic valve and anaemia. a larger study sample is necessary to confirm these preliminary findings. acknowledgements top ↑ the authors thank dr w. harmse, diagnostic radiologist and current fellow in interventional radiology, alberta health services, foothills medical centre; professor s. brown, department of paediatric cardiology, university of the free state; professor h. theron, head of department cardiology, universitas academic hospital, university of the free state; and mrs c. swanepoel, chief radiographer computed tomography, department of clinical imaging sciences, university of the free state, for their invaluable contribution to the completion and publication of the study. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions a.r. (university of the free state) protocol and study design, first blinded observer, writing and planning of the article draft and final version, main corresponding author. c.s.d.v. (university of the free state) second blinded observer, study coordinator, protocol and final article draft reviewer. professor g.j. (university of the free state) is thanked for reviewing the statistics and protocols and for her invaluable input in the final draft of this article. references top ↑ webb j, rodes-cabau j, fremes s, et al. transcatheter aortic valve implantation: a canadian cardiovascular society position statement. can j cardiol. 2012;28: 520–528. http://dx.doi.org/10.1016/j.cjca.2012.04.015 anderson hr, knudsen ll, hasenkam jm. transluminal implantation of artificial heart valves: description of new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs. eur heart j. 1992;13: 704–708. cribier a, eltchaninoff h, bash a, et al. percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. circulation. 2002;106: 3006–3008. http://dx.doi.org/10.1161/01.cir.0000047200.36165.b8 tamborini g, fusini l, gripari p, et al. feasibility and accuracy of 3dtee versus ct for the evaluation of aorticvalve annulus to left main ostium distance before transcatheter aortic valve implantation. jacc cardiovasc imaging. 2012;5: 579–588. http://dx.doi.org/10.1016/j.jcmg.2012.02.012 rixe j, schuhbaeck a, liebetrau c, et al. multi-detector computed tomography is equivalent to trans-oesophagal echocardiography for the assessment of the aortic annulus before transcatheter aortic valve implantation. eur radiol. 2012;22: 2662–2669. http://dx.doi.org/10.1007/s00330-012-2530-2 mahoney r, pavitt cw, gordon d, et al. clinical validation of dual-source dual-energy computed tomography for coronary and valve imaging in patients undergoing trans-catheter aortic valve implantation. clin radiol. 2014;69: 786–794. http://dx.doi.org/10.1016/j.crad.2014.03.010 haensig m, lehmkuhl l, rastan aj, et al. aortic valve calcium scoring is a predictor of significant paravalvular aortic insufficiency in transapical-aortic valve implantation. eur j cardiothorac surg. 2012;41:1234–1241. http://dx.doi.org/10.1093/ejcts/ezr244 haensig m, rastan ja. aortic valve calcium load before tavi: is it important? ann cardiothorac surg. 2012;1:160–164. http://dx.doi.org/10.3978/j.issn.2225-319x.2012.06.02 willman jk, weishaupt d, lachat m, et al. electrocardiographically gated multi-detector row ct for asessment of valvular morphology and calcification in aortic stenosis. radiology. 2002;225:120–128. http://dx.doi.org/10.1148/radiol.2251011703 leipsic j, gurvitch r, labounty tm, et al. multidetector computed tomography in transcatheter aortic valve implanation. jacc. 2011;4:416–419. http://dx.doi.org/10.1016/j.jcmg.2011.01.014 blanke p, euringer w, baumann t, et al. combined assessment of aortic root anatomy and aortoiliac vasculature with dual-source ct as a screening tool in patients evaluated for transcatheter aortic valve replacement. am j roentgenol. 2010;195:872–881. http://dx.doi.org/10.2214/ajr.10.4232 weich h, mabin t, van wyk j, et al. first experience with the edward sapien transcatheter aortic valve implantation (tavi). data from the western cape, south africa. sa heart j. 2012;9:6–13. leber aw, kasel m, ischinger t, et al. aortic valve calcium score as a predictor for outcome after tavi using the corevalve revalving system. int j cardiol. 2011;166:652–657. http://dx.doi.org/10.1016/j.ijcard.2011.11.09 feuchtner gm, muller s, grander w, et al. aortic valve calcification as quantified with multislice computed tomography predicts short-term clinical outcome in patients with asymptomatic aortic stenosis. j heart valve dis. 2006;15:494–498. delgado v, ng act, van de veire n, et al. transcatheter aortic valve implantation: role of multidetector row computed tomography to evaluate prosthesis positioning and deployment in relation to valve function. eur heart j. 2010;31:1114–1123. http://dx.doi.org/10.1093/eurheartj/ehq018 contents tib abstract fibrous mastopathy is a condition seen mainly in premenopausal, insulin-dependent diabetics. the condition simulates breast cancer and is often poorly recognised. one of the main reasons for reporting this well-described entity is to make radiologists and surgeons more aware of this condition, thereby reducing unnecessary morbidity by establishing a correct diagnosis more efficiently, and differentiating it from breast carcinoma. case report case 1 a premenopausal 49-year-old woman with no risks for breast cancer, no history of trauma, and with a history of previous biopsies of both breasts presented with a 6month history of a lump in the left breast. the patient had been diabetic for more than 25 years, on insulin and oral hypoglycaemic agents (ohas). there was a history of poor glycaemic control, with endorgan involvement, and renal impairment. clinically rock-hard solid lesions were palpated in the lateral aspect of the left breast. the mammogram showed an increased ill-defined density in the left upper outer quadrant (figs 1a,b). no focal lesion was identified at ultrasound. fine needle aspiration cytology (fnac), core needle biopsy (cnb), could not be undertaken because the tissue was too fibrotic to biopsy. the incision biopsy revealed diabetic mastopathy. case 2 a 53-year-old nulliparous patient with no history of trauma who had been postmenopausal for 4 years presented with a history of a lump in the right breast for a period of 8 months. 26 sa journal of radiology • october 2005 case report diabetic mastopathy – clinical and mammographic findings i j movson mb chb, dmrd (uk) department of radiology addington hospital, durban i buccimazza mb chb, fcs (sa) department general surgery addington hospital, durban fig.1a,b. mediolateral and craniocaudal mammograms of case 1 demonstrate nonspecific increased density in the upper outer quadrant of the left breast. pg26-28 tib 10/8/05 11:56 am page 26 the patient had been diabetic for more than 10 years on oha and insulin. clinically both breasts had a very dense fibroglandular pattern, making it difficult to identify the palpable lesion on the mammogram, although the right breast was denser than the left (figs 2a,b). the patient had also had a breast abscess drained on the left side 4 years previously. the ultrasound examination revealed 2 poorly defined hypo-echoic masses 4.3 cm x 3.2 cm and 3 x 3 cm on the right side and similar masses at 5 o'clock and 12 o'clock on the left side (fig. 2c). the incision biopsy of both breasts revealed diabetic mastopathy. case 3 a 60-year-old nulliparous, postmenopausal woman with no previous history of breast problems presented with a lump in the right breast. the patient was also being treated with insulin and oha. clinically a 5 x 6 cm diameter lump was palpated at 12 o'clock on the right side, and a 2.7 cm x 2.7 cm diameter lump was palpated in the left upper outer quadrant. the mammogram demonstrated areas of increased density in both breasts requiring biopsy to exclude malignancy. the ultrasound examination revealed ill-defined lesions in both breasts with irregular margins and posterior acoustic shadowing suggesting non-benign lesions (fig. 3). a sestamibi scan was undertaken and there were no focal areas of increased uptake bilaterally. fnac revealed fat necrosis on both sides. cnb revealed fat necrosis on the right side and hyalinised fibro-fatty connective tissue with no evidence of malignancy. incision biopsies of both breasts revealed fat necrosis and extensive hyalinised fibrosis. discussion according to the breast pathology textbook by paul peter rosen1 most of all reported examples, with two exceptions of diabetic mastopathy, have been in females, and most patients were younger that 30 years of age. all the cases were type i insulin-dependent diabetics.1 our 3 patients were aged 49, 53 and 60 years. there is no evidence to suggest that this condition predisposes to the development of breast cancer. most patients with diabetic mastopathy also have complications such as retinopathy, neuropathy and nephropathy.2-4 according to camuto et al. 5 approximately 60% of diabetic mastopathy tends to be bilateral or to recur after surgical excision. according to them recurrence tends to be in the same location and involves more breast tissue than the preceding lesion. they suggest that surgical biopsy should not be considered. cnb under ultrasound guidance avoids unnecessary surgical procedures. case report 27 sa journal of radiology • october 2005 fig. 2a,b. craniocaudal and mediolateral mammograms of case 2 demonstrate diffusely dense breasts. the left marker outlines the scar from the abscess drainage site. pg26-28 tib 10/8/05 11:58 am page 27 summary of main points in relation to this relatively rare entity 1. this condition is seen mainly in premenopausal longstanding insulin-dependent female diabetics. 2. the condition presents as hard masses in one or both breasts simulating carcinoma of the breast. 3. the mammogram demonstrates areas of ill-defined increased density, difficult to differentiate from carcinoma. 4. sonography demonstrates a hypoechoic solid mass with poor margins and well-marked acoustic shadowing. 5. mri was seldom used in most reported cases of diabetic mastopathy. wong and associates6 reported early and strong enhancement of contrast medium at the area of the palpable mass in a few cases when mri was used. yet others reported poor enhancement in the early phase. mr spectroscopy has been used to confirm benignity of lesions in recent cases reports.7 6. fna is usually unsuccessful in diagnosing the condition as resistance of the mass to the needle motion is very high. cnb can be useful in the diagnosis of recurrent lesions on follow-up, but the hard tissue often makes this procedure unsuccessful. a definite diagnosis was achieved in most cases by open surgical biopsy. the authors thank cornelia harmse for typing and setting out this manuscript. references 1. rosen pp. textbook of breast pathology. lippincott, 1999: 347. 2. soler ng, khardori r. fibrous disease of the breast, thyroiditis, and cheiroarthropathy in type i diabetes mellitus. lancet 1984; 1: 193-195. 3. ely ka, tse g, simpson jf, clarefeld r, page dl. diabetic mastopathy, a clinicopathologic review. am j clin pathol 2000; 113: 541-545. 4. morgan mc, weaver mg, crowe jp, abdul-karim fw. diabetic mastopathy; a clinicopathologic study in palpable and nonpalpable breast lesions. mod pathol 1995; 8: 349-354. 5. camuto pm, zetrenne b, ponn t. diabetic mastopathy; a report of 5 cases and a review of the literature. arch surg 2000; 135: 1190-1193. 6. wong kt, tse, g mk, yang wt. ultrasound and mr imaging of diabetic mastopathy. clin radiol, 2002; 57: 730-735. 7. balan p, turnbull lw. dynamic contrast enhanced magnetic resonance imaging and magnetic resonance spectroscopy in diabetic mastopathy. beast 2005; 14: 68-70. case report 28 sa journal of radiology • october 2005 fig. 2c. ultrasound of the left breast demonstrates a 3 cm diameter hyperechoic mass (arrow) that was confirmed to be fibrous matopathy on biopsy. fig. 3. ultrasound of the left breast demonstrates an ill-defined irregular hyperechoic lesion suggesting malignancy (arrow). pg26-28 tib 10/8/05 12:02 pm page 28 article information author: sharon miller1 affiliation: 1department of radiology, university of pretoria, south africa correspondence to: sharon miller email: sharonlmiller4@gmail.com postal address: 1501/92-100 quay street, brisbane city 4000 qld, australia dates: received: 23 june 2014 accepted: 28 aug. 2014 published: 26 mar. 2015 how to cite this article: miller, s. breast hamartoma: is this an uncommon or an under-recognised lesion?. s afr j rad. 2015;19(1); art. #675, 2 pages. http://dx.doi.org/10.4102/sajr.v19i1.675 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. breast hamartoma: is this an uncommon or an under-recognised lesion? in this pictorial interlude... open access • abstract • introduction • case report • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ a hamartoma is a disorganised focus of a mature overgrowth of cells composed of tissue elements of the organ in which it is found, and it can occur anywhere in the body. a breast hamartoma is a rare, benign tumour consisting of fat, glandular and fibrous tissue, and is known by various names such as lipofibroadenoma or fibroadenolipoma, depending on the dominant tissue found within the lesion. the reported incidence is low (0.1% – 0.7%), but is increasingly thought to be because of under-diagnosis of the condition. introduction top ↑ breast hamartomas are uncommon lesions with a low incidence, according to the literature, but this may also be the result of under-diagnosis. the reported incidence in the literature is between 0.1% and 0.7%, as described by arrigoni et al. in 1971.1 the lesion is known by several names: fibroadenolipoma, lipofibrodenoma or adenolipoma.2 clinically, it is a painless, smooth, mobile breast lump that may or may not be palpable and can slowly enlarge in size.3 radiologically, small lesions may appear as normal breast tissue but larger lesions tend to develop a characteristic appearance. we describe a case of hamartoma of the breast with typical radiological features that allow a diagnosis to be made without biopsy. case report top ↑ a 38-year-old woman presented with a palpable, soft, mobile, non-tender breast lump in the supra-areola region of the right breast. on enquiry, she revealed that it had been present at her previous ultrasound performed at another practice and had not changed in size or consistency in the last 12 months. the patient had been informed by the radiologist at the time that it was a rare type of benign fatty tumour that should not cause any concern. the mammogram demonstrated a well-circumscribed lesion in the right breast supra-areolar region, with a heterogeneous density and a thin uniform radiodense pseudocapsule (figure 1). figure 1: craniocaudal (a) and mediolateral oblique (b) mammogram views of the right breast, demonstrating a well-circumscribed heterogeneous mass in the supra-areolar region of the right breast (arrows). note the radiodense pseudocapsule. on ultrasound, a well-circumscribed breast lesion was noted in the 12 o’clock position that demonstrated a mixed echogenic pattern with a predominant echogenic pattern consistent with fat (figure 2). in comparison with the previous ultrasound study, as indicated on the report, the lesion had not changed in size or character significantly. figure 2: ultrasound image at the 12 o’clock position of the right breast demonstrates a well-defined oval lesion with a mixed echogenic pattern. after consultation and discussion with the patient, no further management other than regular self-examinations and follow-up breast screening was recommended. the patient was advised to seek immediate attention, however, if any change in the size or nature of the lesion was detected. discussion top ↑ breast hamartomas are benign breast tumours described as resembling a ‘breast within a breast’ on mammography.4 they have a heterogeneous density with a mottled centre and are usually round or ovoid, with a well-circumscribed pseudo-capsule that results from the displacement and compression of surrounding breast tissue.3 coarse or punctate calcifications are rarely seen within the lesion.2 on ultrasound, the features may appear as normal breast tissue or a well-circumscribed oval, solid mass that is predominantly hypoechoic but may present with a mixed echogenicity owing to the presence of adipose and fibroglandular tissue. the tumour is easily compressible when pressure is applied with a transducer.5 some articles in the literature3,4 describe the presence of coexistent malignancy in a small percentage of hamartomas whilst others indicate that there may be a low risk of malignant transformation. patient education regarding the importance of self-examination and compliance with follow-up must therefore be emphasised, and the radiologist should always be vigilant about any small change within the tumour. regarding definitive diagnosis of a breast hamartoma, views differ. most advocate that fine-needle aspiration (fna) or core biopsy has a limited role, and recommend full excision biopsy for a better diagnosis. if a biopsy is not done, then regular clinical and radiological follow-up is recommended. conclusion top ↑ breast hamartomas are rare benign breast tumours that, whilst having characteristic radiological findings, do not possess definitive histological features and can often be reported as normal breast tissue. it is therefore important to have good clinical, radiological and histological correlation to avoid under-diagnosing such lesions.6 if a biopsy is going to be performed, excision biopsy is recommended rather than fna or core biopsy. with the increasing practice of mammographic breast screening, it is important for the radiologist to be aware of this tumour and to pay attention to the clinical information and good radiological correlation. acknowledgements top ↑ competing interests the author declares that she has no financial or personal relationship(s) that may have inappropriately influenced her in writing this article. references top ↑ 1. arrigoni mg, dockerty mb, judd es. the identification and treatment of mammary hamartoma. surg gynecol obstet. 1971;133:577–582. 2. feder jm, de paredes es, hogge jp, wilken jj. unusual breast lesions: radiologic-pathologic correlation. radiographics. 1999;19:11–26. http://dx.doi.org/10.1148/radiographics.19.suppl_1.g99oc07s11 3. wei-feng l, shyr-ming s, shun-yu c, hsuan-ying h, sheung-fat k. hamartoma of the breast: an underrecognised disease? tumori. 2008;94:114–115. 4. sonmez fc, gucin z, yildiz p, tosuner z. hamartoma of the breast in two patients: a case report. oncol lett. 2013;6:442–444. 5. rohini a, prachi k, vidyabhargavi. multimodality imaging of giant breast hamartoma with pathological correlation. international j of basic and appl. med. sci. 2014;4:278–281. 6. tse gmk, law bkb, ma tkf, et al. hamartoma of the breast: a clinicopatho­logical correlation. j clin pathol. 2002;55:951–954. http://dx.doi.org/10.1136/jcp.55.12.951 it seems that the desire to undertake and publish research is at an alltime high. for once, university departments are asking to guest-editor journal issues without my having to put out an sos. as a matter of fact more and more registrars are signing up to write mmed dissertations and theses and i have many requests from registrars and registrar hopefuls to assist them in producing case reports and research papers. at stellenbosch university radiology department we initiated (a year ago) what we refer to as a research group composed of all the registrars and academically minded consultants in the department, to perform research and write up cases unrelated to the more complex mmed theses underway. we divided ourselves into 4 groups (about 5 members in each), with 4 consultant group leaders, and me at the overall lead. we meet each tuesday morning partly prior to work hours and partly into work hours. at the meeting we review pending publications, completed work for submission, work in progress, new ideas, and keep a current list of work. each registrar is delegated a new duty by the group leader and each group gets to meet me each week for motivation, advice and new ideas. we have so far published 10 international articles and many more local articles, have had a further 10 international articles accepted for publication in the correction or proof stages, and have 80 more in other stages of development. that is 25 papers per group. this is an exceptional research result for a group of people who (apart from myself ) had not published anything before. in 2005 the department had received research subsidy for only 1 publication. we expect between 10 and 15 times the amount of academic financial reward for our current work which we will pump into our new phd candidates, into computers and other hardware for our research department. the groups have become so independent that some have moved on from case reports and small series to planning complex prospective blinded work using ct and mri. other groups have ignored my hesitancy in writing up certain cases and have managed to have cases published that i insisted would not be accepted. group members have learnt to work together by dividing the work, giving the less experienced members lighter papers to lead, and by contributing small components to each project so as to gain inclusion as authors on almost every paper. we have registrars who have 2 first-author publications in their first year of study. editorial pull together to publish for the home team savvas andronikou, mb bch, fcrad, frcr, phd department of radiology, university of stellenbosch and tygerberg hospital editorial patient care optimum minimum risk of air bubble injection1 – optiray® is available in pre-filled syringes. non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 10/8/06 3:28 pm page 1 examination time1 optimise non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request in contrast to many agents optiray®, is available as a pre-filled syringe. tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 3/8/06 10:30 am page 2 pg2-3.indd 2 2/26/07 1:55:28 pm our lessons learnt: • with a proper structured and supervised system, all registrars and consultants are capable of producing publishable work in a fun environment. • after some successes the morale is so high that research becomes not only a normal component of the department work, but also integral to job satisfaction. • successful publication results in financial gain that can be pumped back into producing a professional research outfit, which in turn attracts external and internal phd candidates. (remember that each paper published, each mmed thesis produced and each phd graduate results in large sums of money from the government which filters down to the department as a research fund.) • the least likely academics often become great paper writers who may need no motivation and who may in turn motivate others. • always write down interesting or baffling cases in a book at clinical meetings for later use. • always call on your clinical colleagues’ guidance and co-operation to identify interesting patients, write up imaging findings for their papers, collect patient databases and plan prospective patient collection. • there is always an angle if you have great imaging, e.g. submitting a common disease with great imaging to a gp interest journal such as the samj; or a new type of imaging for an old disease such as dwi for tuberculomas; or using known phenomena for a different population group such as children; and lastly by collecting a loose bunch of cases as a series by identifying a common denominator such as ‘unusual involvement of the spinal cord and spinal column by tb identified on mri’. the possibilities are endless. there is no such thing as ‘no time for publication’. there is no-one who cannot be published. there is always a journal somewhere that is interested in what you have and it’s up to you to find it. it is a fallacy that there is no-one to ask or refer to….we are available and amenable and invite you to either form your own groups or join us! i have assisted in the writing of case reports for registrars in bristol, oxford, edinburgh, pietemaritzburg, durban, melbourne, johannesburg and london all by long-distance communication. we can arrange workshops or visits and we even welcome masters and phd students to our new 3 tesla research mri unit here at stellenbosch. savvas andronikou guest editor editorial patient care optimum minimum risk of air bubble injection1 – optiray® is available in pre-filled syringes. non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 10/8/06 3:28 pm page 1 examination time1 optimise non-ionic, monomeric, low-osmolar iodinated contrast medium additional information is available on request in contrast to many agents optiray®, is available as a pre-filled syringe. tyco healthcare (pty) ltd, corporate park north, midrand. co no. 1997/022355/07 schedule 2 optiray® 300 50 contains 636 mg/ml of ioversol. reg. no. z/28/418 optiray® 300 100 contains 636 mg/ml of ioversol. reg. no. z/28/417 optiray® 300 125 contains 636 mg/ml of ioversol. reg. no. 30/28/281 optiray® 350 50 contains 741 mg/ml of ioversol. reg. no. z/28/420 optiray® 350 125 contains 741 mg/ml of ioversol reg. no. 30/28/0282 1. enterline ds. pre-filled syringes: applications in ct imaging. applied radiology 2001; 30(suppl): 1-14. optiray isr ad horiz aw 3/8/06 10:30 am page 2 pg2-3.indd 3 2/26/07 1:55:29 pm radiology abstract lhermitte-duclos disease (ldd) is a rare cerebellar lesion of uncertain origin. it is linked to an autosomaldominant phakomatosis known as cowden’s disease in 40% of patients. the mri features of ldd are almost unique and can be considered diagnostic. we report on a patient who presented with the typical mri features of the above disease, and discuss the imaging features, pathology and genetics. introduction lhermitte-duclos disease (ldd) or dysplastic gangliocytoma is a rare slow-growing benign lesion of the cerebellum. only 150 cases have been reported.1 its precise aetiology is uncertain. it is postulated that this disease may be a hamartoma, a developmental anomaly, a manifestation of a phakomatosis or a low-grade neoplasm. recent published data suggest that ldd is a hamartomatous lesion related to a phakomatosis, rather than a neoplasm.2 ldd is often asymptomatic in early life, but usually becomes clinically apparent in the third and fourth decades. reported cases have presented from birth to 74 years old.1 there is no gender bias. the clinical manifestations are usually related to posterior fossa mass-effect and resultant secondary obstructive hydrocephalus. the most frequent complaints are headaches and ataxia due to intracranial hypertension. this occurs in 70% of patients. cerebellar signs and symptoms are present in 40 50%. one-third of patients have associated cranial nerve palsies and long tract dysfunction. visual problems, neck stiffness, vertigo and subarachnoid haemorrhage are less commonly noted presenting features.1 case a 62-year-old male patient presented in a delirious state to the casualty department. he had complained of severe headaches for the 4 days prior to his admission. there was no associated nausea and vomiting or obvious gait disturbance. on examination no papilloedema was noted. in view of his symptoms, a computed tomography (ct) scan (siemens somatom sensation 16, erlangen, germany) of the brain was performed. ct revealed a large hypo dense lesion involving the posterior aspect of the right cerebellar hemisphere and the vermis (fig. 1). it had a geographic shape, was well-defined, with no calcification. compression and distortion of the 4th ventricle with consequent supratentorial hydrocephalus was noted. magnetic resonance imaging (mri) (1,5t siemens symphony maestro, erlangen, germany) revealed a well-marginated infratentorial mass in the right cerebellar hemisphere. preservation and enlargement of the gyral pattern was noted (figs 2 and 3). no enhancement was seen after administration of intravenous contrast. discussion the definitive diagnosis of ldd is histopathological, but mr imaging can preoperatively characterise the disease sufficiently well. the abnormality seen in ldd is related to abnormal development of the cerebellar cortex. usually, the normal cerebellar cortex consists of an inner gran30 sa journal of radiology • february 2005 case report ct and mri findings in lhermitteduclos disease m r h bayat mb chb (uct), dip pec (sa) j sarawan mb bch (wits), fcr (sa) department of radiology nelson r mandela school of medicine university of kwazulu-natal durban fig. 1. contrast-enhanced ct scan demonstrates a large non-enhancing intra-axial mass in the right cerebellum with a large temporal horn of left lateral ventricle. radiology 2/24/05 4:50 pm page 30 case report 31 sa journal of radiology • february 2005 ular layer, an outer molecular layer and an intervening purkinje cell layer. in ldd there are abnormal ganglion cells in the granular layer, thickening and hypermyelination of the molecular layer and loss of the middle purkinje cell bodies.3 on ct, ldd is usually seen as a well-defined isodenseto hypodense mass in the posterior cranial fossa with no contrast enhancement. alternating bands of density that are usually seen on mri may be seen on high-resolution fine-slice ct through the posterior fossa. calcifications may be present. depending on the size, mass effect with displacement of the 4th ventricle and obstructive hydrocephalus may be present the histopathology of ldd forms the basis of the mri findings. the demonstration of the typically striated, laminated or ‘tiger-striped’ appearance involving the cerebellar tissue is unique. focal or diffuse cerebellar engorgement with prominent cerebellar folia and mass-effect are noted. this is caused by the close apposition of thickened cerebellar folia that have lost their secondary arborisation, resulting in alternating bands of tissue intensities. the atrophic white matter, the adjacent layers of abnormal ganglionic neurons and the innermost part of the molecular layers have prolonged signal (hypointense on t1 and hyperintense on t2 and flair). the outer part of the molecular layer of adjacent folia and the intervening leptomeningeal space are iso-intense to normal cerebellar tissue both on t1 and t2 sequences. lack of mr contrast enhancement is emphasised as an important mr diagnostic criterion of the disease but according to spaargaren et al.3 contrast enhancement has been reported. this is postulated to be due to venous proliferation that may also explain the large draining veins that are seen on angiography and as flow voids on mri. ldd is the only lesion besides cerebellar infarction that respects the normal cerebellar convolution markings despite causing enlargement. it is the abovementioned features together with the history that are pathognomonic. the only other lesion that may produce similar findings is cerebellar infarction, but the clinical presentation is usually very different. mri is excellent in defining the limits of the lesion to accomplish the most radical excision during surgery. there is an association between lhermitte-duclos and cowden’s disease. this association has been noted in 40% of cases.4 cowden’s disease is an autosomal-dominant condition with a prevalence of 1 in 200 000. it is due to a mutation of the pten gene that is located on chromosome 10q 22-23. this gene is related to tumour suppression. mutation promotes proliferation and invasion of cells and failure of normal apoptosis. cowden’s disease is characterised by multiple hamartomas and neoplasms affecting the skin, thyroid, breast, and genitourinary and gastrointestinal tracts. the skin lesions are present in 90% of patients. the mucocutaneous manifestations form the pathognomonic basis for diagnosing cowden’s disease and consist of the following features: trichilemmomas, acral keratoses, as well as mucinous fibromas and oral papillomas.1,4 despite the benign nature, surgical excision is the treatment of choice, although some centres may prefer conservative management in asymptomatic cases. wide excision is necessary due to the risk of recurrence. however this is difficult because of ill-defined macroscopic margins. radiation therapy is ineffective. references 1. perez-nunez a, lagares a, benitez j, et al. lhermitte-duclos disease and cowden disease: clinical and genetic study in five patients with lhermitte-duclos disease and literature review. acta neurochir 2004; 146: 679-690. 2. buhl r, barth h, hugo h-h, straube t, mehdorn hm. dysplastic gangliocytoma of the cerebellum: rare differential diagnosis in space occupying lesions of the posterior fossa. acta neurochir 2003; 145: 509-512. 3. spaargaren l, cras p, bomhof mam, et al. contrast enhancement in lhermitte-duclos disease of the cerebellum: correlation of imaging with neuropathology in two cases. neuroradiology 2003; 45: 381-385. 4. nagaraja s, powell t, griffiths pd, wilkinson id. mr imaging and spectroscopy in lhermitteduclos disease. neuroradiology 2004; 46: 355358. fig. 2. contrast-enhanced parasagittal coronal t1weighted image reveals a hypo-intense mass with bands isodense to normal cerebellar tissue. a prominent vein is also noted draining into the straight sinus. fig. 3. axial t2-weighted image shows the classic findings of a right hemi-cerebellar lesion with laminated hypertrophic folia and alternating curvilinear bands of high and low signal intensity. similar findings were noted on the fluid attenuated inversion recovery (flair) images. radiology 2/24/05 4:50 pm page 31 case report case report � sa journal of radiology • march 2009 case report case report a 35-year-old man presented with a right chest wall mass. chest radiographs revealed pleural thickening underlying a soft tissue mass which obscured the 5th to 7th ribs, and an expansile osteolytic lesion of the 7th rib. ultrasound examination demonstrated a fluid-filled cystic lesion of the chest wall with intrathoracic extension. a computed tomographic (ct) scan of the chest and upper abdomen revealed a fluid-filled cystic structure protruding from the chest wall into the subcutaneous tissues. an abutting cyst extended within the thoracic cavity but did not involve the lung parenchyma. three-dimensional reconstruction of the bony elements revealed an expanding bony lesion with multiple cysts in the 7th rib, surrounded by the large fluidfilled cyst. no hepatic cysts were demonstrated. an elisa (enzyme linked immuno-sorbent assay) test for echinococcus granulosis was positive to a titre of 1:256. the patient is currently on a course of albendazole chemotherapy and is followed up at the surgical outpatient clinic. discussion a hydatid cyst may be found in almost any part of the body; however, a primary chest wall cyst is rare.1 this patient had an extra-pulmonary but intrathoracic hydatid cyst that presented as a chest wall tumour. a possible mechanism of primary hydatid disesase of the chest wall may be for the embryo to pass through the duodenal wall into either the portal vein or the periduodenal and perigastric lymphatics, which connect to the thoraco-mediastinal lymphatics and the thoracic duct.2 this mechanism may explain the development of primary chest wall hydatid disease in the absence of pulmonary or hepatic cysts. the natural course of costal echinococcosis starts when the larvae lodge in the rib and buds start vegetating out of the mother cyst to produce a multilocular cavity. this process invades the spongiosa of the bone. the primary rib lesion is multiloculated and osteolytic and continues to grow slowly. the lesion may then involve adjacent organs such as vertebrae, pleura and soft tissues.3 if this lesion breaks through the cortical portion of the rib, it produces a soft tissue mass.4 the posterior ends of the ribs are most commonly involved in costal echinococcosis. cysts grow along the long axis of the rib, causing expansion of the cortex the many faces of hydatid disease a lawson, mb bch department of radiology, groote schuur hospital, cape town a parrish, mb chb, da(sa), fcp(sa), mmed(med), mmedsci(clinepi) department of medicine, cecilia makiwane hospital, east london fig. 1. ct coronal reconstruction. fig. 2. ct 3-d reconstruction. the many faces.indd 4 3/12/09 2:05:36 pm case reportcase report � sa journal of radiology • march 2009 where they meet more resistance from the solid cortical portion of the rib. the differential diagnosis of such a radiographic picture includes giant cell tumour, osteolytic metastases, plasmacytoma, aneurysmal bone cyst and cystic neurofibromas. biopsy is generally considered to be contraindicated in echinococcosis owing to fear of dissemination of scolices and other potentially fatal acute anaphylactic reactions. however, aspiration cytology has been suggested as being safe and the procedure of choice in suspected cases of skeletal echinococcosis. conclusion a case of primary hydatid disease arising in a rib is reported. this potentially curable condition should be considered in the differential diagnosis of both abdominal wall masses and mass lesions identified on chest radiographs. 1. findikcioglu a, kilic d, canpolat t, et al. primary hydatid disease of the chest wall. ann thorac cardiovasc surg 2007; 13(3): 203-205. 2. heath dd. the migration of oncospheres of taenia pisiformis, t. serialis and echinococcus granulosus within the intermediate host. int j parasitol 1971; 1: 145-152. 3. beggs i. the radiology of hydatid disease. am j roentgenol 1985; 145: 639-648. 4. bonakdarpour a, ali zadeh yf, maghssoudi h, et al. costal echinococcosis. report of six cases and review of literature. am j roentgenol 1973; 118: 371-377. the role of the expert witness (continued from page 2) ‘in sum, we pathologists [health care workers] have an obligation to ourselves and to our specialty to set standards for behaviour in the courtroom that are consistent with our behavior in the rest of our professional lives. that behavior should be elevated and elevating. the behavior of pathologists in the courtroom should be no different from their behavior in the laboratory – but very different from the behavior of all too many lawyers in the courtroom’.5 hugh johnson puts it even more strongly: ‘the fundamental difference between the doctor and the lawyer is in their approach to the case. a lawyer is not interested in the real truth in its entirety but only such part as pertains to his client’s case. the lawyer obviously must take sides. the expert pathologist must not’.2 these are harsh words, but the expert witness should always be reminded of the prescribed oath that is taken: ‘i swear that the evidence i am about to give is the truth, the whole truth and nothing but the truth. so help me god’. withholding important facts, especially quoting selectively from the literature with deliberate omission and withholding of important facts from the court, is as good as outright lying, and tantamount to perjury. conclusion to conclude with some wise words from bernard ackerman:6 ‘how should a conscientious pathologist [any health care worker] deal intellectually and emotionally with an error he has made? first and foremost, he must acknowledge it promptly and unequivocally. second, he must attempt to determine why the error was made, and strive to learn from it. … how can we as … [health care workers]... put this distasteful, disagreeable and often demeaning but very real aspect of our (professional) lives in perspective? ‘perhaps it can be done if each of us acknowledges to himself and tacitly to others that, although we are capable professionals, we nonetheless have human limitations, inadequacies and failings. we are bound to make mistakes, yet we must try to perform as best as we can within the confines of our human limitations’.6 in her letter to the samj, van der heyde, a young forensic pathologist from cape town, who has experienced difficult interrogation during inquests, highlights the difficulty in persuading medical doctors to assist the prosecutor and give expert evidence at inquests and trials: ‘the medical protection society (mps) legal team …. has access to specialists in different fields of medicine who are paid well to give expert testimony and assist the mps in defending their clients … .court proceedings are generally unpleasant for health care workers. however, does the medical profession not have an ethical responsibility … [to give unbiased evidence for justice and the truth]…, given that the standard by which conduct is tested at an inquest is based on what the reasonable doctor would do?’7 1. knobel gj. varied facets of forensic medicine. inaugural lecture 13 august 1986: new series no. 125. 2. johnson h. the pathologist as expert witness. med leg j 1986; 54, part 1: 26 41. 3. gillon r. doctors and patients. bmj 1986; 292: 466-469. 4. lundberg gd. expert witness for whom? jama 1984: 252: 251. 5. ackerman b. the pathologist in the courtroom: peer review is needed. hum pathol 1985; 16: 761-762. 6. ackerman a bernard. accountability of pathologists. am j derm path 1985; 7; 305-306. 7. van der heyde y. medical responsibility at inquests. s afr med j 2008; 98: 820-822. emeritus professor g j (deon) knobel formerly of the department of forensic medicine university of cape town the many faces.indd 5 3/12/09 2:05:36 pm case report 62 sa journal of radiology • september 2010 background extramedullary haematopoiesis (emh) is a rare cause of spinal cord compression. when a patient with a haematological disorder that causes chronic anaemia (particularly thalassaemia) presents with neurological deficits referable to the spine, emh with paraspinal masses should be considered and imaging planned appropriately. case history we present a case of thalassaemia intermedia with marked paraspinal emh and spinal cord compression. clinical presentation a 38-year-old man with thalassaemia intermedia presented with a 6-week history of progressive muscle weakness, back pain, paraesthesia and spasm in both legs. he did not have any bladder dysfunction. the patient had a cholecystectomy at age 34. one of his brothers had died from an unknown cause at age 7 years. however, he had also had thalassaemia. his other brother died from severe cardiac failure brought on by chronic anaemia at age 40 years. on examination, the patient had normal vital signs and normal cardiac and respiratory examination. hepatosplenomegaly was present. neurological examination revealed muscle power of 3/5 in the lower limbs in all the muscle groups, brisk tendon reflexes and bilateral positive babinski reflexes. the sensory level was at t3. biochemical evaluation showed microcytic hypochromic anaemia. haemoglobin was 9.5 g/decilitre (normal=13.8 18.8 g/decilitre), mean cell volume was 73.2 fl (normal=79 100 fl), and mean cell haemoglobin was 25.5 picograms (normal=27 35 pg). he also had an elevated total bilirubin of 62 µmol/l (normal=2 26 µmol/l) and elevated conjugated bilirubin of 11 µmol/l (normal=1 7 µmol/l). the serum urate was also elevated at 0.45 mmol/l (normal=0.21 0.43 mmol/l). these changes may be secondary to haemolysis. imaging findings a chest radiograph (fig. 1) demonstrates lobulated soft-tissue posterior mediastinal masses, medullary expansion of the ribs and clavicles with thinning of the cortices. a biopsy of one of the masses showed hypercellular marrow with erythroid hyperplasia, moderate dyserythropoiesis, megaloblastic changes and overloaded iron stores which were in keeping with emh. extramedullary haematopoiesis causing spinal cord compression f ismail, mb bch l huang, mb chb z lockhat, fcrad (d) sa department of radiology, pretoria academic hospital, university of pretoria s ellemdin, mb bch, mmed (int med) l van der linde, mb chb, doh&m department of internal medicine, pretoria academic hospital, university of pretoria fig. 1. frontal and lateral radiographs of the chest show lobulated soft-tissue posterior mediastinal masses and medullary expansion of the ribs and clavicles with thinning of the cortices. case report 64 sa journal of radiology • september 2010 case report the patient also underwent magnetic resonance imaging (mri) which showed extradural lobulated soft-tissue masses causing compression of the spinal cord at vertebral body levels t5 to t8 (fig. 2). the mass lesions are iso-intense to the marrow within the adjacent vertebral bodies on t1and t2-weighted sequences. the masses extend from the vertebral bodies laterally and anteriorly into the posterior mediastinum (figs 3 and 4). the patient underwent surgical decompression of his thoracic spine (posterior laminectomies) and multiple blood transfusions. discussion thalassaemia (the greek etymon literally means ‘anaemia of the sea’) occurs in a broad geographical band from the mediterranean (‘mediterranean anaemia’) through asia. the cause is an inherited defect in the synthesis of one of the alpha or beta globin chains. homozygous (major) or heterozygous (minor) forms of the condition exist.1 defective globin chains lead to excessive haemolysis and compensatory haematopoiesis within bone marrow, which in turn leads to enlargement of the medullary cavities and thinning of cortices. extrusion of bone marrow through a defect of a severely thinned cortex may be a mechanism in the development of emh.2 another possible theory for the development of emh is transformation of haematopoietic precursors of mesodermal origin, located in the thoracic epidural space, into marrow. the liver, spleen, kidney, posterior mediastinum and lymph nodes are the most common sites of extramedullary haematopoiesis.3 it may also occur in uncommon locations such as the skin, central nervous system, adrenal glands, middle ear and paratracheal region.3 in the spine, emh is commonly located in the midor lower thoracic regions; the differential diagnosis for these lesions includes metastases, abscesses, haematomas and lymphoma.3 emh is radiosensitive, responding to low doses of radiotherapy, and therefore a favourable prognosis depends on early diagnosis.3 other treatment options include blood transfusions and surgery. our patient underwent both treatment options. on plain chest radiography, thoracic extramedullary haematopoiesis lesions appear as smooth or lobulated posterior mediastinal masses. these paraspinal masses can be unilateral or bilateral, isolated or extensive.2 they have a predilection for the lower thoracic spine region, and rarely appear at anterior rib ends. calcification and vertebral anomalies are rare, therefore other causes of posterior mediastinal masses, such as neurenteric cyst and neuroblastoma, can be excluded. in patients with chronic anaemia not requiring hyper-transfusion, the typical bony thorax appearance demonstrates osteopenia, medullary expansion, coarse trabecular pattern and cortical thinning. rib changes include bulbous widening of the posterior ribs, localised lucencies, cortical erosions and the ‘rib within rib’ picture.4 on non-contrast computed tomography (ct) scanning, extramedullary haematopoiesis lesions appear as soft tissue masses that are denser than fat. if these lesions are adjacent to the posterior fig. 2. sagittal t1and t2-weighted sequences demonstrate extradural lobulated soft-tissue masses which cause compression of the spinal cord at levels t5 t8. these masses are iso-intense to the marrow within the adjacent vertebral bodies. there is enlargement of the central canal distal to the region of compression. there is also a mass anterior to the t9 vertebral body. case report 65 sa journal of radiology • september 2010 ribs, the underlying rib will be widened with a thin cortex.4 on ct scan with contrast, extramedullary haematopoiesis lesions enhance inhomogeneously owing to the iron deposition and fat infiltration. as lymphadenopathy and neurogenic tumours enhance homogeneously and neurogenic tumours may have calcifications, these masses are differentiated from emh masses.2 mri is the most effective imaging modality for demonstrating extramedullary haematopoiesis.3 the lesions are iso-intense with the bone marrow and may show different degrees of hyperintensity on t1and t2-weighted images.3 however, mixture of blood products of different age within the extramedullary haematopoiesis foci results in increased or decreased t1 or t2 signal. for example, ferrous or ferric iron shortens t1 and t2 signal, methaemoglobin causes an increased t1 signal and variable t2 signal whereas haemosiderin decreases t1 and t2 signal.5 some masses show a peripheral hyperintense rim which is attributed to fat. this distinguishes extramedullary haematopoiesis lesions from other lesions such as metastasis. in patients with a known primary malignancy, it may be difficult to differentiate emh from an epidural metastasis.3 with positron emission tomography – computed tomography (pet-ct), extramedullary haematopoiesis lesions demonstrate mild to moderate metabolic activity when compared with malignant lesions which demonstrate high metabolic activity.5 conclusion emh is a rare cause of posterior mediastinal masses6 but in patients with thalassaemia should be considered as part of the differential diagnosis. in patients with thalassaemia who present with spinal cord symptoms, mri is the study of choice for evaluation of the spine. 1. griffith jf, king ad, chan yl. clinics in diagnostic imaging (29). singapore med j 1997; 38: 402-404. 2. berkman ym, zatta az. case 126: extramedullary haematopoiesis. radiology 2007; 245: 905-908. 3. chiam qll, lau kk. extramedullary haematopoiesis in thalassaemia major causing spinal cord compression. australas radiol 2007; 51: 168-171. 4. pfeiffer ea, coppage l, conway wf. cases of the day. radiographics 1995; 15: 235-238. 5. mosley c, jacene ha, holz a, grand dj, wahl rl. extramedullary hematopoiesis on f-18 fdg pet/ct in a patient with metastatic colon carcinoma. clin nucl med 2007; 32: 878-880. 6. kanat f, tulek b. posterior mediastinal masses in a patient with beta-thalassaemia intermedia. neth j med 2007; 65: 271-273. fig. 3. para-sagittal t1-weighted sequence demonstrates multiple lobulated masses extending from the thoracic vertebrae which are iso-intense to the vertebral bodies. the masses extend laterally and anteriorly into the posterior mediastinum. fig. 4. coronal t3-weighted sequence shows lobulated masses extending laterally into the posterior mediastinum, with similar signal to the adjacent vertebral bodies. article information author: shalendra k. misser1 affiliation: 1lake smit and partners inc, durban, south africa correspondence to: shalendra misser email: misser@lakesmit.co.za postal address: private bag x08, overport 4067, durban, south africa how to cite this article: misser, sk. paediatric neuroimaging quiz case. s afr j rad. 2015;19(2); art. #873, 3 pages. http://dx.doi.org/10.4102/sajr.v19i2.873 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. paediatric neuroimaging in this ... open access • presentation presentation top ↑ a three and a half year-old male child was referred for neuroimaging under general anaesthesia for intractable seizures. these are selected mr images. figure 1: axial t2-weighted mr image. figure 2: axial flair mr image. figure 3: coronal flair mr image. figure 4: coronal t1-inversion recovery mr image. figure 5: coronal t1-weighted mr image. figure 6: coronal t1 inversion recovery mr image. figure 7: mr angiography image of the circle of willis. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 30 november 2015. the winning respondent will receive a r1000 award from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. original article the renal transplant score a different way of evaluating renal transplant pathology abstract the renal transplant is a notoriously difficult organ to assessfor pathology. radionuclide imaging can help, but, although sensitive, the evaluation is not very specific. for this reason, a different approach was used to examine renal images and resuits were correlated with histology. the transplant score is determ ined from images of perfusion rpclauss mbchb, mmed(nucmed), nuclear medicine department, a kobryn specialist in generaf surgery, surgery department, both at medunsa. / 16 sa journal of radiologyjune 1997 and function on certain criteria such as time of appearance of the kidney after tracer injection, intensity of background, size and homogeneity of tracer uptake by the kidney. although small, the pilot study could distinguish between hyperacute rejection, acute rejection, chronic rejection and cyclosporin toxicity. introduction attempts have previously been made to detect renal transplant pathology scintigraphic ally, usually with 99mm tc dtpa. the most successful of these is probably the perfusion index.l" others include functional imaging' and fractional mean transit time." with all these aids at hand, diagnosis of renal transplant pathology is still difficult. serial scintigraphy of both perfusion and function often over a period of days or weeks is necessary for decent monitoring of the progress in renal transplants. to aid the detection of pathology in renal transplants, a different approach to reading the scintigram was tested, based on renal and background information on the scintigram. renal perfusion, uptake and excretion using 99m tc glucoheptonate to page 17 the renal transplant scorea different vvav of evalu<'lting renal transplant pathology (rampage 16 was scored on selected criteria. the score was compared to the histological diagnosis of various transplants. glucoheptonate was chosen for interpretation of function (perfusion and early excretion) and parenchymal integrity (delayed views after furosemide injection). method eight renal transplants were imaged using 99m tc glucoheptonate and biopsied within 24 hours of the scintigraphy for histological diagnosis. 150 mbq of 99m tc glucoheptonate were injected into an antecubital vein while a dynamic acquisition of 60 frames of one second was in progress, anterior to the patient. the camera field of view included the renal transplant, large blood vessels, spleen, ureter and bladder. the first acquisition phase was immediately followed by a second phase of 120 frames of 15 seconds, imaging kidney function. a delayed static view of the transplant was acquired 3 hours later after 20 mg furosemide injection. the perfusion frames were combined to 15 frames of 4 seconds and the 120 frames of function were combined to 15 frames of 2 minutes. a renogram was generated and frames were displayed, assessed and scored for perfusion, uptake and excretion. perfusion criteria (phase i) included: background score: o photopenic region in place of kidney 1 maximal kidney intensity equal to background 2 maximal kidney intensity between background and liver 3 maximal kidney intensity same as maximal liver perfusion 4 maximal kidney intensity better than maximal liver perfusion iliac vessels score: o photopenic region in place of the kidney 1 tracer bolus reaches kidney after it reaches iliac vessels 2 tracer bolus reaches kidney before it reaches iliac vessels liver score: o photopenic region in place of the kidney 1 maximal kidney perfusion after maximal venous liver perfusion 2 maximal kidney perfusion before maximal venous liver perfusion maximum perfusion score: 4+2+2=8 function criteria (phase 2) included: background score: o photopenic region in place of kidney 1 maximal kidney uptake equal to background 2 maximal kidney uptake with prominent background 3 maximal kidney uptake with minimal background renogram score: 0no peak on renogram 1 peak after 4 minutes 2 peak before 4 minutes homogeneity score: 0no kidney seen on delayed image 1 lnhomogenous tracer uptake on delayed image 2 homogenous tracer uptake on delayed image size score: 0no kidney seen 1 small kidney 17 sa jou rnal of radiology. ju ne 1997 2 normally sized kidney elimination score: o no kidney seen 1 elimination half life from region of interest over the heart> 100 min 2 elimination half life from region of interest over the heart of 50-100 min 3 elimination half life from region of interest over the heart < 50 min maximum function score: 3 + 2 + 2 + 2 + 3 = 12 results table i shows the perfusion scores for the various patients. table ii shows the function scores for the same group of patients. perfusion and uptake of tracer in acute and hyper-acute transplant rejection are seen in figures 1 figure la: fifteen frames of 4 seconds showing the perfusion of a renal transplant undergoing acute rejection. figure 1b: fifteen frames of 2 minutes showing the function of a renal transplant undergoing acute rejection. to page 18 the renal transplant scorea different vvay of evaluating renal transplant pathology (rom page 17 table i: perfusion scores of patients with various transplant pathologies table ii: function scores of patients with various transplant pathologies name em ak jt pm jm as ms am name em ak jt pm jm as ms am background 2 2 0 2 background 2 iliac 2 0 peak 2 liver 2 0 homogeneity 0 size 0 total 5/8 4/8 6/8 4/8 3/8 7/8 4/8 elimination 1 0 % total 63% 50% 75% 50% 38% 88% 0% 50% total 7/12 8/12 8/12 7/12 6/12 9/12 0/12 10/12 diagnosis cr er cr er ar norm har ct percentage 58% 67% 67% 58% 50% 75% 0% 83% diagnosis er er er er ar norm har ct er chronic rejection nonm nonmal ar acute rejection ct cyclosporin toxicity er chronic rejection norm normal har hyper-acute rejection ar acute rejection ct cyclosporin toxicity har hyper-acute rejection figure 28: fifteen frames of 4 seconds showing the perfusion of 8 renal transplant undergoing hyper-acute rejection. figure 2b: fifteen frames of 2 minutes showing the function of a renal transplant undergoing hyper-acute rejection. and 2. figure 3 shows the renogram and the half life of tracer in the blood from a region of interest over the heart figure 4: bar diagram showing the perfusion and function scores in patients with various transplant pathologies. figure 3b: half life of tracer in the blood from a region of interest over the heart in a transplant undergoing acute rejection reporteds,6,7,8 and can be seen in our study.the perfusion score as estimated in our patient group showed a clear difference between the normal transplant, acute and chronic rejection. attempts have been made previously to use sulphur colloid to predict transplant rejection. these were however unsuccessful." it has been shown previously that cyclosporin toxicity causes parenchymal tracer retention but does not impair perfusion." such patient presented with a moderate perfusion but good function score in our study. in hyper-acute rejection there was no perfusion or uptake of the tracer. in a patient with acute rejection. figure 4 is a bar diagram that compares perfusion and function scores (converted to percent) for various transplant pathologies. perfusion and function score of renal transplants with various pathologies. norm eye ehr rej pathologies _ perlualon ~ function acute rej our pilot study suggests that a renal transplant score may be a way to distinguish renal transplant pathology. further evaluation of score criteria and exploration of the method with different tracers is necessary. conclusion figure 3a: renogram of a transplant undergoing acute rejection. discussion perfusion scintigraphy is a good indicator for acute rejection in renal transplants. this has often been 18 sa journal of radiology. june 1997 references 1, anaise d, oster zh, atkins hl, arnold an, weis s, waltzer wc, rapaport ft. cortex perfusion index: a sensitive detector of acute rejection crisis in transplanted kidneys. j nucl med 1986; 27: 1697-1701,:,,", __ -:_ topage23 radiology abstract objective. to determine the efficiency of latex detachable balloons in the treatment of post-traumatic carotid-cavernous fistulae (ccf). methods. management and outcome were reviewed for 34 consecutive patients with post-traumatic ccf personally treated by one of the authors (ps) using latex detachable balloons during the 4-year period 1996 2000. results. endovascular embolisation of 34 ccfs was attempted in 33 patients. in 1 patient where the fistula was a result of rupture of an intracavernous aneurysm, the fistula thrombosed spontaneously before embolisation was attempted. in the 33 treated patients, the fistula was occluded in 30 cases (91%). patency of the internal carotid artery was preserved in 16 cases (53%). conclusion. a high percentage (91%) of direct ccfs were successfully occluded with latex detachable balloons. there were no permanent neurological complications in any of the patients treated. introduction a carotid-cavernous fistula (ccf) is an abnormal connection between the carotid artery and the surrounding cavernous sinus. ccfs are usually classified in three ways: (i) pathologically (or aetiologically), as spontaneous or traumatic; (ii) haemodynamically, into high-flow or lowflow; or (iii) angiographically, as direct or indirect. the barrow angiographic classification is most commonly used. it is based on the pattern of arterial supply and has therapeutic implications.1-3 this allows ccfs to be placed into one of four angiographic categories as follows: type a fistulae (direct) have abnormal connections (or shunts) between the internal carotid artery (ica) and cavernous sinus. types b, c and d are all indirect (or dural) fistulae. the angioarchitecture of these is analogous to dural arteriovenous fistulae (avfs) occurring in other locations. type b fistulae are shunts between meningeal branches of the ica and the cavernous sinus. type c are shunts between meningeal branches of the external carotid artery (eca) and the cavernous sinus. type d are shunts between meningeal branches of both the eca and the ica and the cavernous sinus. direct connections between the ica and the cavernous sinus may occur as a consequence of blunt or penetrating trauma, ruptured intracavernous carotid aneurysms, collagen deficiency syndromes (such as ehlers-danlos iv syndrome), fibromuscular dysplasia and arterial dissection.2-4 causes of the indirect type are often unknown, but may be related to pregnancy, undisclosed or minor trauma, surgical procedures and cavernous sinus thrombosis.1,5 the symptoms caused by direct ccfs are related to the size, location, duration, route of venous drainage and presence of arterial and venous collaterals. the clinical features of direct, high-flow ccfs include proptosis, conjuctival oedema, orbital bruit, progressive visual deterioration and cranial nerve palsies. some low-pressure ccfs present with progressive symptoms mainly affecting the eye. features of indirect ccfs are similar to those of direct ccfs but as indioriginal article 4 sa journal of radiology • february 2005 endovascular treatment of posttraumatic carotidcavernous fistulae using latex detachable balloons p szkup md, fcrad (diag) sa, mmed (uct) department of medical imaging royal university hospital university of saskatchewan canada s beningfield mb chb (uct), ffrad d (sa) department of radiology groote schuur hospital university of cape town radiology 2/24/05 4:50 pm page 4 rect ccfs are usually chronic they seldom lead to visual deterioration. the goals of treatment are the elimination of the fistula, ideally with preservation of the patency of the ica, at the same time avoiding cranial nerve palsies and other complications (fig. 1). the treatment options for ccfs have undergone significant evolution. surgical and endovascular techniques have been described for the closure of both direct and indirect ccfs. these include surgical carotid artery occlusion, trapping procedures (such as clipping of the supraclinoid and cervical parts of the ica) and direct surgical exposure of the ccf with surgical closure of the fistula. embolisation with coils, cyanoacrylate, blood clot and detachable balloons are some endovascular options. 6-9 in 1971 prolo and hanberry7 first reported successful occlusion of ccfs with non-detachable balloons. although this technique required sacrifice of the ica, ischaemic complications were less common than encountered with routine carotid ligation. in 1973 parkinson6 reported direct surgical repair of a ccf with preservation of the ica flow, but the procedure was technically difficult, required cardiac arrest and was associated with significant neurological morbidity. in 1974 mullan10 introduced surgical packing of the cavernous sinus using thrombogenic materials such as gelatin sponge (‘gelfoam’), oxidised cellulose, cotton or bronze wire placed via surgical transvenous routes. in december 1969, serbinenko successfully performed occlusion of a direct ccf and the affected ica using a self-made silicone detachable balloon placed via a common carotid artery puncture.11,12 this balloon was inflated at the target site with a radio-opaque mixture of polymer and tantalum powder to create a material that gradually became a stable gel within the balloon and distal catheter lumen. this allowed the catheter to be severed using the cutting edge of the arterial needle, leaving the catheter segment still attached to the inflated balloon in the thrombosed arterial lumen. unfortunately the silicone polymer proved to be highly viscous, often preventing balloon deflation where the balloon position was not satisfactory on trial inflations. this technique was improved by performing initial test inflation of the balloon with less viscous iodinated contrast material in order to determine whether the position of the balloon was satisfactory. once correct placement was confirmed, the contrast medium was aspirated and silicone polymer was then injected into the balloon. serbinenko subsequently developed a balloon with an ingenious valve mechanism that allowed the 6 sa journal of radiology • february 2005 original article fig. 1a. lateral internal carotid angiogram showing fistula with preferential venous drainage via dilated superior ophthalmic vein (arrow). fig. 1b. frontal left internal carotid angiogram showing unusually well demonstrated fistula site (arrow). fig. 1c and 1d. frontal and lateral internal carotid angiograms following embolisation with one balloon (arrow) and preservation of the carotid artery. radiology 2/24/05 4:50 pm page 6 balloon to be detached from its delivery catheter by placing traction on the catheter, without the balloon deflating after detachment. from 1969 to 1972, serbinenko performed 304 permanent carotid artery occlusions with this system, with only 2 deaths.11,12 in 1974, debrun et al.9,13 developed a latex tie-on detachable balloon to occlude direct ccfs. they were able to preserve the ica in 59% of cases. subsequently, latex and silicone detachable balloons with internal valves were developed, with various modifications.14 in 1980, transvenous approaches were developed independently by debrun et al.15,16 halbach et al.17 and higashida et al.18 to treat patients in whom transarterial attempts had failed. by 1991 guglielmi introduced retrievable electrolytically detachable platinum coils and these were later used to occlude ccfs.8 despite progress in coil technology, transarterial embolisation with detachable balloons is still considered the best initial treatment for direct ccfs.2,3,16,18 patient details and methods management and outcome were reviewed for 34 consecutive patients with ccfs personally treated by one of the authors (ps) using detachable latex balloons during the 4-year period 1996 2000. these patients were treated at chris hani baragwanath and groote schuur hospitals in the departments of radiology of the universities of the witwatersrand and cape town, south africa. there were 17 men and 17 women ranging in age from 22 to 56 years, with a mean age of 39 years. other than in case 4, all patients had direct posttraumatic ccfs (table i). a prominent orbital bruit was heard by the patient and/or the doctor, using a stethoscope in every case. the most common initial symptoms were proptosis and chemosis in 31 patients and an isolated abducens nerve palsy on the affected side in 13 patients. less often, patients complained of headache (11 patients) and visual deterioration (10 patients). radiographic evaluation the initial radiographic evaluation consisted of axial computed tomography (ct) of the head, with and without intravenous iodinated contrast material to evaluate the extent of head trauma. ideally, evaluation of skull fractures was performed using high-resolution axial and coronal ct through the base of the skull, viewed with bony settings. the presence of a ccf was suspected by detection of any of the following: dilated cavernous sinus, dilated superior ophthalmic vein(s) or the presence of any other prominent draining vein(s). a 4-vessel cerebral angiogram was then obtained to evaluate the location and extent of any vascular injury, the presence of any collateral supply via the circle of willis and the pattern of venous drainage. because most direct ccfs are high-flow fistulae, the cavernous sinus is usually immediately opacified on angiography and the precise communication site is commonly obscured (fig. 2). the heuber maneuvre, with injection of the dominant vertebral artery while manually compressing the affected carotid artery is often used for better visualisation of the fistula site. during this maneuvre, the compression of the ipsilateral carotid artery allows flow of contrast medium via the posterior communicating artery into the cavernous part of the ica and fistula, showing the fistula site more clearly without excessive overlying contrast (fig. 3). in all cases, contralateral carotid angiography during compression of the ipsilateral carotid artery was peroriginal article 7 sa journal of radiology • february 2005 table i. aetiology of 33 cases of carotid-cavernous fistulae (n) blunt trauma motor vehicle accident 17 blunt assault 6 penetrating trauma knife stab to orbit 5 gunshot wound to the head 5 fig. 2a. lateral internal carotid angiogram showingdirect fistula. radiology 2/24/05 4:50 pm page 7 formed to evaluate the presence or absence of cross-flow via the anterior communicating artery, in case the carotid artery with the fistula had to be occluded during the balloon embolisation. the degree of crossflow into the anterior and middle cerebral arteries was specifically noted. method small ccfs may thrombose spontaneously or during diagnostic angiography. this usually only occurs with ccfs with eca contributions. manual compression of the ipsilateral ica or the draining angular vein can also be used to treat slow-flow fistulae. in this series, initial attempts at manual compression of the ica proved to be ineffective, as has been found with other high-flow ccfs. all embolisation procedures were performed in the angiography suite by the same radiologist, with the patient under local anaesthesia and sedated as necessary. in 2 cases, patients required deep intravenous sedation performed by an anaesthetist. a right common femoral artery approach using an appropriately sized vascular introducer sheath was employed in all cases. eight french (envoy-cordis), or 9 or 10french (nycomed-amersham) guiding catheters were used, depending on the size of the balloon used. the 9french catheter (nycomedamersham) has an internal diameter large enough to accommodate the most commonly used goldvalve 9 balloon (nycomed amersham) with 1.3 ml capacity, and this catheter was therefore used most frequently. the guiding catheter was then positioned in the ica, at approximately the second cervical vertebral body level. five thousand units of heparin were then given intravenously to prevent thrombus formation on the catheter and balloon systems. the detachable goldvalve balloon system was used in all the cases. the goldvalve balloon is made of latex with an internal valve to prevent deflation when detached. it also has an internal radio-opaque metal ball in the balloon lumen to permit visualisation on fluoroscopy during positioning. the balloon is available in a variety of sizes and shapes, with a numbering system identifying specific models (table ii). the most commonly used medium-large gvb9 balloon measures 19 x 11 mm when fully expanded, with a capacity of 1.3 ml (table ii). the balloon is manually attached to a coaxial catheter system consisting of paired inner 2-french (red) and outer 3-french (black) catheters (nycomed-amersham). the entire system is then passed through the guiding catheter. the space between the coaxial 2/3 french system and guiding catheter is perfused with pressurised normal saline to prevent thrombus formation. injections of contrast into the guiding catheter around the 2/3 french coaxial system can be made through a 3-way tap. before the balloon is placed intraarterially, it is tested in vitro. using a provided blunt needle, the balloon is 8 sa journal of radiology • february 2005 original article fig. 2b. lateral common carotid angiogram following embolisation with one balloon (arrow) and preservation of the carotid artery. fig. 3. lateral vertebral artery angiogram with carotid compression — heuber maneuvre. note filling of anterior circulation and fistula via posterior communicating artery. bullet in the cavernous sinus is visible (arrow). table ii. sizes of the latex goldvalve balloons (nycomed-amersham) used goldvalve volume inflated diameter no. of balloons balloon no. (ml) (mm) used 9 1.3 19 x 11 23 16 0.8 21 x 8 10 12 2.5 22.5 x 14 3 7 1.0 13 x 13 1 radiology 2/24/05 4:50 pm page 8 filled with contrast medium that is diluted to be iso-osmolar, without exceeding the maximum recommended volume. the inflated balloon is then detached from the needle and checked for integrity of its valve and the absence of wall abnormality. the balloon is then attached to the 2-french delivery catheter that has been previously passed through the 3-french catheter, and the balloon is then allowed to deflate. the balloon attached to the coaxial 2/3french delivery system is advanced through the guiding catheter under fluoroscopic guidance into the fistula site. it may be partially inflated with iso-osmolar iodinated contrast agent while attempting entry into the fistula. usually because of the high flow through the fistula, the balloon will spontaneously traverse the tear of the vessel. this is often detected by observing a fluttering motion of the metal marker or balloon on entering the fistula. once through the fistula, iso-osmolar contrast agent is used to inflate the balloon. when the balloon is inflated in what appears to be the correct position, a diagnostic angiogram is obtained through the guiding catheter to ensure that the fistula is occluded, and ideally that the ica is patent. the patient is examined neurologically and, if stable, the balloon is detached by traction on the 2-french delivery catheter. this can be combined with counter-traction and stabilisation by advancing the 3-french catheter to the balloon neck. if the ica has to be sacrificed, the patient is examined for any neurological deficit for 20 minutes with the balloon inflated. if the patient fails this test, the balloon is deflated immediately. after the procedure, the heparin is not corrected with protamine sulfate. the vascular introducer sheath is removed not earlier than 4 hours following heparin administration. results endovascular embolisation was attempted in 33 of the 34 patients with ccfs. in 1 patient where the ccf was a result of rupture of an intracavernous aneurysm, the fistula thrombosed spontaneously before embolisation was attempted (case 4). in the 33 treated patients, the fistula was occluded in 30 cases (91%) (table iii). in 27 cases, a single detachable balloon was required to close the fistula. in 3 cases, 3 balloons were required to close the fistula (table iv). case 20 needed 3 large 1.3 ml balloons to close a fistula following an orbital knife stab wound. patency of the ica was preserved in 16 cases (53%). endovascular treatment failed to occlude the fistula in 3 patients (9%). in the first case (case 5), a partially inflated balloon was accidentally detached during manipulation in a very tortuous ica. the balloon lodged in the petrous part of the ica. the patient was immediately taken for surgery where a trapping procedure with clipping of the supraclinoid part of the ica was performed, and the fistula subsequently thrombosed. the patient had good cross-flow from the contralateral carotid artery and suffered no permanent neurological deficit. the second patient (case 6) had a very tortuous carotid artery that was not possible to navigate with the balloon. the inferior petrosal sinus was not visualised during diagnostic angiography and as this prevented a venous approach to the fistula, the patient was submitted to surgery where the fistula and ica were occluded by occluding the supraclinoid and cervical parts of the ica. in the final patient (case 29) with a mixed direct and indirect ccf following a facial gunshot, the proximal ica was already occluded by the trauma. the ccf was supplied by the retrograde flow from intracranial arteries. the inferior petrosal sinus was not visualised on angiography of the contralateral carotid artery. an unsuccessful attempt was made to occlude the fistula by means of surgical exposure of the facial and superior ophthalmic veins. in 1 patient (case 32), 2 initial balloons ruptured during inflation in the cavernous sinus, most likely due to the presence of sharp bony spicules in the cavernous sinus, although high-resolution ct of the base of the skull failed to visualise any such abnormality. the third balloon was placed in a slightly different position in the cavernous sinus, and was subsequently inflated and detached without complication. transient hemiparesis lasting less than 24 hours occurred in the first patient treated (case 1), and resolved completely with heparin. there was no permanent neurological deficit in any patients treated. seven patients experienced severe pain during inflation of the balloon in the cavernous sinus, requiring administration of intravenous pethidine. this pain may be related to pressure or displacement of cranial nerves, dura mater or other structures during balloon inflation. there were no permanent cranial nerve palsies related to the presence of balloons in the cavernous sinus. there was also no clinical evidence of original article 9 sa journal of radiology • february 2005 radiology 2/24/05 4:50 pm page 9 nerve compression where more than 1 balloon was placed in the cavernous sinus. two patients became restless during balloon placement and required deep sedation by the anaesthesiologist. all patients were followed up clinically with neurological and ophthal10 sa journal of radiology • february 2005 original article table iii. summary of 34 patients with carotid-cavernous fistulae (in chronological order) case age approach fistula ica treatment/ no no (yrs) sex cause arterial venous occluded patent of balloons 1 22 f gunshot y yes no 1 2 30 m gunshot y yes no 1 3 34 m mva y yes yes 3 4 55 f ruptured yes yes thrombosed aneurysm neither approach 5 26 f mva y yes no surgery 6 55 f mva y yes no surgery 7 35 f mva y yes yes 1 8 48 f mva y yes yes 1 9 36 m mva y yes yes 1 10 29 m mva y yes no 1 11 49 f mva y yes no 1 12 50 f mva y yes yes 1 13 30 m assault y yes yes 1 14 31 m assault y yes yes 1 15 45 m mva y yes no 1 16 54 f mva y yes no 1 17 46 m mva y yes yes 1 18 52 f assault y yes yes 1 19 37 f stab wound y yes no 3 20 25 m stab wound y yes no 3 21 35 m assault y yes yes 1 22 41 f assault y yes no 1 23 40 m gunshot y yes no 1 24 35 m stab wound y yes no 1 25 29 f assault y yes yes 1 26 38 m stab wound y yes yes 1 27 41 f stab wound y yes no 1 28 39 m gunshot y yes no 1 29 40 m gunshot y no no 1 30 30 m mva y yes yes 1 31 50 m mva y yes yes 1 32 49 f mva y yes yes 1 33 42 f mva y yes yes 1 34 39 f mva y yes no 1 mva = motor vehicle accident; ica = internal carotid artery. table iv. patients requiring more than one balloon to occlude the fistula case no. balloon type no. of balloons used 3 gvb 16 3 19 gvb 9 3 20 gvb 9 3 radiology 2/24/05 4:50 pm page 10 mological examinations performed on an outpatient basis. an average follow-up of 5 months was used to ensure that the fistula remained clinically closed, although poor patient compliance limited this duration. the outcomes of all 34 patients are summarised in table iii. technical problems that occurred during embolisation are summarised in table v. discussion ccf has evolved from being an untreatable condition to a readily curable one over the past 35 years. the early treatment by proximal occlusion or trapping of the ica has fallen into disfavour because of the high associated incidence of complications and incomplete closure of the fistula.6,10,20 serbinenko11 and debrun et al. 13,15,16,20 pioneered techniques of closing these fistulae with detachable latex or silicone balloons while preserving the ica in the majority of cases. large series have proved the effectiveness of endovascular balloon embolisation,3,4,12,15,21,22 which is now the treatment of choice for this entity. the overall results of the 33 patients treated by the endovascular approach in this series show that the fistula was successfully occluded in 30 cases (91%), preserving the carotid artery in 16 cases (53%). these results compare reasonably with those of other centres (table vi). the largest series of 482 patients is from china23 where 100% success and 84% ica preservation were achieved. in 14 of the successfully embolised cases where the ica could not be preserved in the present series, 9 fistulae were the result of stab wounds or gunshots. this could suggest that gunshots and stab wounds may cause larger tears in the carotid artery. in 1 case (case 20), an antelope’s horn caused an orbital stab wound. large tears in the carotid artery could also be responsible for herniation of the balloon from the cavernous sinus into the ica, resulting in a parent vessel occlusion (fig. 4). the presence of cross-flow via the anterior communicating artery is vital to determine with a cross-compression angiogram. it is also critical when ica occlusion is considered to examine the patient neurologically for at least 20 minutes while the baloriginal article 11 sa journal of radiology • february 2005 table v. technical problems during embolisation (grouped by type of problem) case no. problems outcome 5 balloon accidentally detached in the ica surgery — trapping procedure 6 attempt at embolisation failed due to the tortuous ica surgery — trapping procedure 29 facial and ophthalmic veins approach failed lost to follow-up 30 spasm of the ica during placement of 9-french guiding catheter second attempt uncomplicated 32 two balloons ruptured during inflation in the cavernous sinus third balloon succeeded 12 9french guiding catheter kinked at the origin of the left cca more rigid 10-french catheter (cook) was used 18 9-french guiding catheter kinked at the origin of the left cca more rigid 10-french catheter (cook) was used 31 9-french guiding catheter kinked at the origin of the left cca more rigid 10-french catheter (cook) was used 32 9-french guiding catheter kinked at the origin of the left cca more rigid 10-french catheter (cook) was used 21 severe pain during inflation of the balloon in the cavernous sinus deep sedation 25 severe pain during inflation of the balloon in the cavernous sinus deep sedation 3 partially inflated balloon accidentally detached in the cavernous two balloons required to occlude the fistula, sinus ica preserved 28 balloon migrated deeper into the cavernous sinus shortly after second balloon used to close the fistula detachment 29 facial and ophthalmic venous approaches failed ica = internal carotid artery; cca = common carotid artery. fig. 4a. lateral internal carotid angiogram showing fistula and dilated inferior petrosal sinus (arrow). the origin of the fistula was most likely from the posterior aspect of the cavernous part of the carotid artery. transarterial placement of the balloon was unsuccessful despite multiple attempts. radiology 2/24/05 4:50 pm page 11 loon is inflated. endovascular embolisation of the ccf should therefore be performed under local anaesthesia, allowing continous neurological monitoring of the patients. however, angiographic and clinical (neurological) assessment prior to permanent ica occlusion is far from ideal and does not prevent delayed ischaemic complications. carotid artery occlusion in patients without ccfs is associated with a 5 22% rate of neurological ischaemic complications, despite a clinically tolerated test occlusion.24,25 in an effort to reduce the morbidity of carotid artery occlusion, several quantitative blood-flow imaging techniques are available, including transcranial doppler sonography, tc-99m hexamethyl-propylene-amine oxime (hmpao) spect perfusion imaging, xenon ct perfusion, perfusion ct, perfusion mri, diffusion-weighted mri and contrast-enhanced fluidattenuated inversion recovery (flair) mri imaging.24,25 the sensitivity of the balloon test occlusion can be further increased by performing hypotensive test occlusion.24 practically, the initial test is often cerebral angiography performed during cross-compression, which aids in determining the presence of collateral circulation via the circle of willis. no neurological deficit was observed in all 14 patients where the ica had to be sacrificed in this series. overall, there was no permanent neurological deficit in any patient treated. the patient with a ccf may be at less risk from carotid occlusion because of the haemodynamics involved. of the 34 cases of ccf, 31 fistulae were less than 4 months old while the remaining 3 were over 6 months old. there were no complications 12 sa journal of radiology • february 2005 original article fig. 4b. lateral internal carotid angiogram following placement of single balloon (arrow) via the inferior petrosal sinus, closing the fistula with preservation of the internal carotid artery. table vi. ccf embolisation — comparative results from different centres autbor no. of cases results balloon type complications (n) debrun et al.13 17 100% -ccf occluded (1978) 70% -ica preserved latex iii n. palsy (1) debrun g et al.16 54 98% ccf occluded iii n. palsy (1) (1981) 59% -ica preserved latex middle cerebral artery infarcts (2) norman d, 10 90% ccf occluded newton t29 40%ica preserved silicone none (1983) larsen d, 206 92% ccf occluded iii n. palsy (1) higashida r, 88% ica preserved silicone ischaemic stroke (5) halbach v (1989) joseph s, 25 80% ccf occluded rao v 64% ica preserved silicone death (1) (1993) lewis a et al.3 100 86% ccf occluded latex death (1) (1995) 75% ica preserved silicone permanent neurological complications (4) wu z et al.23 482 100% ccf occluded latex (2000) 84% ica preserved silicone not stated coils radiology 2/24/05 4:50 pm page 12 observed during the treatment of those of over 6 months duration, despite the potential risks involved in treating longstanding fistulae. established fistulae may impair the brain’s ability to autoregulate its own perfusion. abrupt closure of these longstanding fistulae can therefore sometimes result in overperfusion, termed ‘normal perfusion pressure breakthrough’,26 first described by spetzler et al.27 this may also occur during occlusion of cerebral arteriovenous malformations. the incidence is small for ccfs (1.2%), but higher for chronic vertebral fistulae (15%).26 all 33 fistulae were treated electively. there was no need for any urgent intervention. the usual indications for urgent treatment of ccfs are: (i) haemorrhage or epistaxis; (ii) cerebral ischaemia due to vascular steal by the fistula from the other cerebral arteries; (iii) marked aneurysmal dilatation of the cavernous sinus, which may result in fatal subarachnoid hemorrhage; (iv) prominent, abnormal venous drainage into cortical veins, which could produce venous hypertension and parenchymal hemorrhage; and (v) rapidly progressive visual deterioration, potentially leading to blindness.2,4 technical aspects in all of these cases, latex goldvalve balloons were used. the most frequently used balloon was the gvb 9 balloon of 1.3 ml volume, measuring 19 x 11 mm when fully inflated. both silicone (target-boston scientific, fremont, ca) and latex balloons are commonly used for endovascular embolisation and their safety as biomedical materials has been confirmed.28-30 the relative advantages and disadvantages of latex versus silicone balloons are not clearly defined.29 latex goldvalve balloons are far less expensive than silicone balloons. latex balloons have the advantage of greater distensibility and can therefore be inflated to larger size. often a single balloon is sufficient to close the fistula. latex balloons have proved to be more thrombogenic than silicone balloons, and endothelialisation and thrombus formation occur more rapidly with latex than with silicone balloons.22,26 this is thought to be related to the surface structure of the latex balloons26 and local tissue reaction around the latex balloon.26,29 when the surface of latex and silicone balloons is examined under electron microscopy, the silicone balloon has a smooth, even surface with a homogeneous structure, whereas the latex balloon is rough and porous with numerous large deep craters. this irregular surface may cause turbulent flow and thrombosis, entrapping blood cells and platelets.28 latex balloons also induce a mild to moderate degree of local tissue reaction. this could be advantageous as it may promote further thrombosis.29 there is some concern regarding latex allergy, following several reported fatalities due to allergic reactions to rectal latex balloons inserted during barium enemas.28 however, there is no clinical evidence that latex balloons in the cerebral vasculature can cause these allergic reactions.22 the balloon should remain inflated for approximately 1 week to guarantee its fibrous attachment to the vascular wall and permanent occlusion of the fistula.22 presumably, the vascular obstruction and irritation caused by the balloon initiates the sealing process. the haemostatic plug that forms should develop into an organised thrombus. as this clot organises further over several days, it is transformed into a scar attached to the vessel wall. this ultimately keeps the balloon in place. ideally the debrun latex balloon remains inflated for 3 5 weeks. silicon detachable balloons with integrated valves remain inflated for months. 22,28,29,31 as yet, there are no long-term follow-up studies of latex goldvalve balloons. when the balloon deflates rapidly, venous pouches or false aneurysms frequently form. these can grow silently, reaching sizes as large as 4 5 cm without producing any oculomotor nerve palsy or other problems.16 anatomical factors play a dominant role in balloon delivery. in 1 patient (case 6), the procedure had to be abandoned due to a very tortuous carotid artery, and in another patient (case 5) the partially inflated balloon was accidentally detached during manipulation within a tortuous carotid artery. use of large balloons requires large 9 or 10french guiding catheters to be introduced into the ica. these catheters can cause dissection or spasm of the vessel. they may also kink as they bend to enter the common carotid or brachiocephalic artery. transvenous embolisation via the inferior petrosal sinus or superior ophthalmic vein remain an alternative but potentially difficult route (fig. 4). the venous drainage from the cavernous sinus is normally variable and can be diverted by the presence of a fistula. anatomically, the cavernous sinus is usually drained by the contralateral cavernous sinus, the superior ophthalmic vein, the original article 13 sa journal of radiology • february 2005 radiology 2/24/05 4:50 pm page 13 sphenoparietal sinus, the pterygoid venous plexus, and the superior and inferior petrosal sinuses (fig. 5).32 the lack of inferior petrosal sinus visualisation during angiography does not necessarily indicate its occlusion or absence. direct catheterisation of the inferior petrosal sinus, whether angiographically demonstrated or not, may be technically difficult due to the small calibre of the often tortuous vessel, and carries a risk of perforation with subsequent subarachnoid haemorrhage.3,17 it is extremely difficult to navigate a catheter with a balloon into or through the partitions of the cavernous sinus to the fistula site. another pitfall of either approach is converting the cavernous sinus into an aneurysm by blocking all venous drainage without occluding the fistula. occluding posterior venous drainage can result in the diversion of flow into the superior ophthalmic vein and an abrupt loss of vision. occluding the anterior drainage may increase cortical or petrosal venous drainage and could cause cerebral or brainstem venous hypertension or haemorrhage.3,17 electrolytically detachable coils such as guglielmi detachable coils (gdcs) and pushable, fibre-coated micro-coils can be used in the presence of difficult anatomy to occlude the ccf from the arterial side. they can also be employed from the venous side to navigate into and through the septated cavernous sinus.33,34 gdc coils are especially useful for ccfs caused by ruptured intracavernous aneurysms or where use of balloons can be very dangerous, such as in patients with ehlers danlos syndrome.8,19,34,35 coils can also be helpful when balloons cannot enter the fistula, as sometimes occurs after placement of a number of balloons narrows the entry into the fistulae. other detachable coils and endovascular stents are promising new devices that may increase the rate of fistula occlusion and ica preservation. in the meantime, transarterial detachable balloons remain the treatment of choice for direct ccfs. 2,3,17,19,30,32 conclusion from this analysis of the 34 cases of ccf treated over 4 years, the following conclusions can be drawn: (i) a high percentage (91%) of direct ccfs were successfully occluded with detachable balloons; (ii) in 53% of cases the ica was preserved; (iii) the latex goldvalve balloons used in all cases proved to be very effective; and (iv) there were no permanent neurological complications in any of the patients treated. references 1. halbach v, hieshima g, higashida r, reicher m. carotid cavernous fistula — indications for urgent treatment. am j neuroradiol 1987; 8: 627-633. 2. phatouros c, meyers p, dowd c, higashida r. carotid artery cavernous fistulas. neuroendovascular surgery 2000; 11(1): 67-84. 3. lewis a, tomsik t, tew j. management of 100 consecutive direct carotid cavernous fistulae. results of treatment with detachable balloons. neurosurgery 1995; 36: 239-244. 4. barrow dl, spector h, braun jf. classification and treatment of spontaneous carotid cavernous fistulae. j neurosurg 1985; 65: 248-258. 5. debrun gm, vinuela f, fox a. indications for treatment and classification of 132 carotid cavernous fistulas. neurosurgery 1988; 22: 285-289. 6. parkinson d. carotid cavernous fistula — direct repair with preservation of carotid artery. j neurosurg 1973; 38: 99-105. 7. prolo d, hanberry jw. intraluminal occlusion of a carotid cavernous fistula with a balloon catheter: technical note. j neurosurg 1971; 35: 237-242. 8. siniluto t, seppanen s. transarterial embolization of direct carotid cavernous fistula with gdc coils. am j neuroradiol 1997; 18: 219-256. 9. debrun gm, lecour p, caron j. experimental approach to the treatment of carotid cavernous fistulae with inflatable and isolated balloon. neuroradiology 1975; 9: 9-12. 10. mullan s. treatment of carotid cavernous fistula by cavernous sinus occlusion. j neurosurg 1979; 50: 131-144. 11. serbinenko fa. balloon catheter and occlusion of major cerebral vessels. j neurosurg 1974; 41: 125-143. 12. teitelbaum g, larsen d, zelman v, lysachev a, likhterman l. a tribute to dr fedor a serbinenko, founder of endovascular neurosurgery. neurosurgery 2000; 46: 426-470. 13. debrun gm, lacour p, fox a. detachable balloon and calibrated-leak balloon catheter in treatment of cavernous lesions. j neurosurg 14 sa journal of radiology • february 2005 original article fig. 5a. lateral internal carotid angiogram showing fistula with venous drainage into the superior ophthalmic vein (arrow) and cortical veins (double arrows). fig. 5b. lateral internal carotid angiogram following embolisation, showing fistula occluded and carotid artery preserved. radiology 2/24/05 4:50 pm page 14 original article 15 sa journal of radiology • february 2005 1978; 49: 635-549. 14. hieshima g, verity s. a detachable balloon for therapeutic transcatheter occlusions. radiology 1981; 138: 227-228. 15. debrun gm. teatment of traumatic carotid cavernous fistulae using detachable balloon catheters. am j neuroradiol 1983; 4: 355-366. 16. debrun gm, lacour p, vinuela f, fox a. treatment of 54 carotid cavernous fistulae. j neurosurg 1981; 55: 678-692. 17. halbach v, higashida r, hieshima g, hardin c, yang p. transvenous embolization of direct carotid cavernous fistula. am j neuroradiol 1988; 9: 741-747. 18. higashida r, halbach v, tsai f. interventional neurovascular treatment of traumatic carotid and vertebral lesions. am j roentgenol 1989; 153: 577-582. 19. hanneken a, neil a, miller r, debrun g, haring j, nauta w. treatment of ccf using a detachable balloon catheter through the superior ophthalmic vein. acta ophtalmol 1989; 107: 87-92. 20. debrun gm, lacour p, fox. a. traumatic carotid cavernous fistulae — clinical presentation, diagnosis. j neurosurg 1987; 3: 242-247. 21. berenstein a, kricheff j, rausohoff j. carotid cavernous fistulae — intraarterial treatment. am j neuroradiol 1980; 1: 449-457. 22. lewis a, tomsik t. long term results in direct carotid cavernous fistulae after treatment with detachable balloons. j neurosurg. 1996; 84: 400404. 23. wu z, zhang y, wang c, yang x, li y. treatment of traumatic carotid-cavernous fistula. interventional neuroradiology 2000; 6: 277-289. 24. scott c, arvind a, lee r. balloon test occlusion of the internal carotid artery with hypotensive challenge. am j neuroradiol 1995; 16: 14531458. 25. michel e, liu h, remley k. perfusion mr neuroimaging in patient undergoing balloon test occlusion of the internal carotid artery. am j neuroradiol 2001; 22: 1590-1595. 26. halbach v, higashida r, hieshima g. normal perfusion pressure breakthrough occurring during treatment of carotid and vertebral fistulae. am j neuroradiol 1987; 8: 751-756. 27. spetzler rf, wilson c, wenstein p. normal perfusion pressure breakthrough theory. clin neurosurg 1978; 25: 651-672. 28. miyachi s, negoro m, handa t, terashima k, keino h, sugita k. histopathological study of balloon embolization; silicone versus latex. neurosurgery 1992; 30: 483-489. 29. norman d, newton t. carotid cavernous fistula — closure with detachable silicone balloons. radiology 1983; 149: 149-157. 30. graeb d, robertson d, lapointe j, nugent a. avoiding intraarterial balloon detachment in the treatment of post traumatic carotid cavernous fistulae with detachable balloons. am j neuroradiol 1985; 6: 602-605. 31. thomsick t. osmotic effect upon long term inflation of latex detachable balloons. neurosurgery 1985; 17: 952-954. 32. gebarski s, gebarski ks. inferior petrosal sinus. imaging, anatomic correlations. radiology 1995; 194: 239-247. 33. miller n, monsein l, debrun g, tamargo r, haring j, nauta m. treatment of carotid cavernous fistula using a superior ophthalmic vein approach. j neurosurg 1995; 83: 838-842. 34. kanner a, maimon s, rappaport z. treatment of spontaneous carotid-cavernous fistula with ehlers-danlos syndrome by transvenous occlusion with guglielmi detachable coils. j neurosurg 2000; 93: 689-692. 35. hollister d. heritable disorders of connective tissue: ehlers-danlos syndrome. pediatr clin north am. 1978; 25: 575-590. pacific health limited is seeking to appoint a general radiologist and/ora locum to work up to 40 hours per week. the positions will be based at tauranga hospital (321 beds), which serves a population base of 130,000 in the western bay of plenty, new zealand. the bay of plenty enjoys a sunny climate which is ideal for growing avocados, grapes, kiwifruit, citrus and other subtropical fruits for which the region is famous. the fruit along with timber, paper and dairy products, is exported through the port of tauranga, the largest export port in new zealand and the commercial centre of the northern bay of plenty. the harbour and south pacific ocean that give tauranga so much of its natural beauty also offers some exciting deep sea game fishing and is an important offshore commercial fishing base. the radiology department comprises four general rooms, an angiographic and special procedures room, a ge spiral ct (prospeed) soon to be upgraded to a 64 multi-slice ct scanner, three colour doppler ultrasound machines and a fluoroscopy room. a private mri facility is operational onsite. the appointee would join 9 other radiologists, 2 registrars, 4 sonographers, 5 nurses, 17 radiographers and other support staff who offer a 24-hour acute service. applicants must be eligible for registration as a specialist diagnostic radiologist with the medical council of new zealand. closing date: open we need a hand....in new zealand radiologists radiologist position no 0409-41-sar radiology department , tauranga 1.0 fte (80 hours per fortnight) locum radiologist position no 0407-21-sar radiology department, tauranga 1.0 fte (80 hours per fortnight) for an application pack and job description visit www.bopdhb.govt.nz or contact the recruitment centre bop dhb tel: +64 7 579 8036 or +64 7 579 8361. enquiries can be emailed to jillian.wright@bopdhb.govt.nz or roy.buchanan@bopdhb.govt.nz radiology 2/24/05 4:50 pm page 15 126 sa journal of radiology • december 2010 radioactive news molecular imaging at the rssa/sgr meeting last august at spier, we were treated to a fascinating presentation by an ex-capetonian, professor jonathan kruskal (harvard), that included an in vivo video of liver tumour deposition and angiogenesis in a rat model. as we watched tumours grow from a single cell and observed the angiogenesis, we were reminded that the future of imaging lies not in the anatomical depiction of tumours already containing millions of cells but in molecular imaging techniques. medical imaging has been through revolutions before. the discovery and harnessing of x-rays allowed images of the inside of the living human body for the first time, and there seemed to be no limit to the body spaces into which radiologists could introduce positive or negative contrast agents to better delineate anatomy. cormack (ex uct) and hounsfield shared a nobel prize for the mathematics which facilitated the development of ct. the subsequent refinements, which lead to modern multidetector ct scanners, have revolutionised this technology so that we are able to acquire 3-d submillimetre isometric datasets which can be sliced, diced and modelled, cut away, rotated and viewed. software can now take us on virtual journeys through bronchi, colons and vessels. images can be enhanced by the administration of contrast agents and temporal changes in contrast density be mapped, but the images remain anatomical maps of the body according to the attenuation of radiation. mri has allowed us to map the density and behaviour of perturbed precessing protons in bodies placed in a magnetic field. imaging sequences continue to be modified to produce exquisitely detailed anatomical images.we are able to interrogate chemical composition and metabolism with mr spectroscopy and functional imaging techniques. advances in nanoand microparticle contrast have potential to expand clinical molecular imaging beyond the current techniques of spect and pet. ultrasound allows real-time imaging, but molecularly targeted microbubbles represent a new strategy. targeted contrast agents will pave the way for targeted therapeutic delivery. non-ionising techniques such as mri/mrs, optical imaging, ultrasound and hybrid technologies are suited to early disease detection and screening. the new frontier is molecular imaging (mi), and a revolutionary new chapter in the history of medical imaging is about to be written. at the end of it, we will all wonder how we ever practiced medicine without mi as the new technology ushers in more personalised treatments. will radiologists be at the forefront of developments in mi and, more specifically, are there young south african radiologists who will embrace the challenge of new technology and enter this exciting field? there are those who make things happen, those who watch things happen, and those who wonder what happened! good luck. clive sperryn president, rssa samsig seeks growth dr mark velleman samsig (the south african musculoskeletal imaging group) was established in october 2005, with the aim of promoting musculoskeletal radiology among radiologists and interested disciplines in south africa; it is an official subgroup of the rssa. the majority of members come from the rssa, but membership is open to all clinicians with an interest in imaging. the current committee comprises dr richard de villiers (chairman), dr mark velleman (vice-chairman), dr ralph posner (treasurer), dr graeme thompson (secretary), dr john zietkiewicz (it), and regional contacts dr peter mercouris (kzn/central region), dr andrew van den heever (western cape) and dr mark velleman (northern region). the group holds yearly meetings to run concurrently with the south african sports medicine association congress, where possible. the most recent meeting took place from 4 8 october 2010 at chobe, botswana, in the form of a well-filled 3-day conference devoted to high-level msk imaging with interactive case presentations by delegates from around the country as well as australia and the usa. attendance was fully subscribed. interaction between presenters and delegates was encouraged and proved to be very successful. case studies were also shown by delegates for further discussion, and were equally popular. feedback on the lectures was most positive, and all the delegates were keen to return for the next meeting in two years’ time. the social programme included morning game drives, fishing trips and sunset river cruises, and a visit to the local school which was well received by the locals. most of the delegates came with their children and spouses who took part in the social activities and could enjoy day trips too. during the concluding dinner, some of the children spontaneously joined the traditional dancers on stage, epitomising the success of the event. all look forward to the 2012 samsig meeting, the idea being to again host it in a safari-like setting; the venue has yet to be finalised. further information is on the website www.samsig.co.za. sa journal of radiology • december 2010 127 radioactive news report-back by 2009 rssa travel award winner pieter janse van rensburg i used the 2009 rssa travel award to attend the 8th interventional mri symposium held on 24 25 september 2010 in leipzig, germany. the scope of the symposium was quite wide, with the main topics being intraoperative mri; thermometry; laser, rf and cryoablation therapy; cellular therapies and targeted drug delivery; mr-guided high-intensity focused ultrasound (hifu); biopsy and vascular applications. it was clear to me that many of the percutaneous interventions performed commonly under ultrasound or ct guidance, can quite easily be adapted to mri-guided procedures. an open mri is ideally suited for many of the more complex procedures, but there were many presentations where interventions were guided by short-bore conventional closed magnets. therefore, mr-guided interventions are well within reach of radiologists who perform percutaneous biopsies under ultrasound or ct guidance in south africa, and the transition to performing such a procedure should be relatively straightforward, given the availability of the correct mr-compatible needles and related equipment. another interesting aspect was the application of intraoperative mri, currently mostly used during neurosurgical procedures such as tumour resections and deep brain stimulator implantations. one of the common reasons for incomplete tumour resection is that the brain shifts during surgery. an intra-operative mr system therefore allows the radiologist to identify residual tumour while the patient is still within the operating room under general anaesthetic and guide the surgeon accordingly. these fused or shared mr and neurosurgical suites are going to be mainstream in the first world very soon, and south africa is sure to follow this trend. mr-guided hifu is probably the most revolutionary technology that i witnessed at the symposium. the basic concept involves a special ultrasound transducer that is embedded into an mr table. the ultrasound beam is then focused analogously to a magnifying glass focusing the sun’s rays to a point. the intense heat generated by the focused ultrasound causes protein denaturation, irreversible cell damage and coagulative necrosis at specific target locations. it is used thus to ablate neoplasms within the body. mr is the ideal modality to guide and monitor the hifu ablation of tumours because not only does it provide high-detail anatomical data on the target, but it also provides accurate thermometry to measure the local temperature at the target and so allows safe execution of the procedure. hifu is used to ablate tumours without any physical transgression of the patient’s skin, so it is a non-invasive therapy that radiologists will perform. current and quite established applications are the ablation of uterine fibroids and small breast carcinomas, as an alternative to lumpectomy. other potential applications are the ablation of liver tumours, prostate carcinoma and bone lesions. it is my opinion that mr-guided hifu is a groundbreaking technology that radiologists should embrace. the role that mr will play in molecular imaging was also discussed, and it is very promising. alginate-poly-l-lysine-alginate (apa) microcapsules can be used to encapsulate stem cells that contain a gene that expresses luciferase, which can be used for bioluminescence imaging. however, the gene can also express truncated thymidine kinase for pet imaging. the same apa microcapsules can also be used to encapsulate perfluorobromide (pfob-apa), which is useful because the fluorine is visible on 19f mri and the bromide is visible on x-ray. consequently, x-ray, mr, pet and bioluminescence imaging can all play a role in visualising these apa capsules and therefore will be helpful in confirming whether a certain gene or stem cell therapy has been successful or not. leipzig has a rich heritage and a beautiful old inner city which is a joy to explore by foot or bicycle. famous residents include johan sebastian bach, gottfried leibniz, felix mendelssohn and felix bloch. i thank the rssa for this opportunity and their continued support. article information author: graeme thompson1 affiliation: 1morton and partners, cape town, south africa correspondence to: graeme thompson email: gt@morton.co.za postal address: 20a brommaert avenue, constantia 7806, cape town, south africa dates: received: 06 oct. 2014 accepted: 22 feb. 2015 published: 22 may 2015 how to cite this article: thompson, g. painful snapping hip owing to bifid iliopsoas tendon and concurrent labral tear. s afr j rad. 2015;19(1); art. #741, 2 pages. http://dx.doi.org/10.4102/sajr.v19i1.741 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. painful snapping hip owing to bifid iliopsoas tendon and concurrent labral tear in this case report... open access • abstract • introduction • case presentation • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ a case of internal snapping hip owing to a bifid iliopsoas tendon is described with a concurrent labral tear in a young active female. the labral tear was identified on magnetic resonance imaging, and the snapping bifid tendon on dynamic ultrasound. the patient was administered bupivicaine and steroid around the tendon and symptoms resolved. a snapping bifid tendon must be identified pre-operatively to avoid incomplete release. labral repair may be accompanied by psoas release when psoas impingement is suspected owing to a labral tear at the 3 o’clock position in an otherwise normal hip. introduction top ↑ painful snapping hip or coxa sultans is a condition seen in young active patients. this report presents the features of a snapping bifid iliopsoas tendon and discusses the potential relationship of the psoas tendon to anterior labral tears. case presentation top ↑ a 20-year-old, physically active female presented with a painful, snapping right hip. clinical tests for impingement were negative and the patient had a full range of movement. magnetic resonance imaging (mri) of the right hip showed a bifid psoas tendon (figure 1) but no abnormal tendon signal or bursitis. mri also revealed a full thickness labral detachment confined to the anterior 3 o’clock position, deep to the iliopsoas tendon (figure 2). figure 1: coronal proton density fat saturation (pdfs) image of the pelvis shows a bifid iliopsoas tendon on the right with medial (short black arrows) and lateral (short white arrows) components. the inferior edge of the superior pubic ramus is also shown (long white arrow). figure 2: axial oblique pdfs image of the right hip. detachment (short white arrows) of the anterior labrum (short black arrow) which on consecutive images was full thickness. the overlying psoas tendon (long black arrows) ‘dips’ laterally, raising suspicion of psoas impingement. the femoro-acetabular morphology was normal. a dynamic ultrasound of the iliopsoas tendon was performed at the same appointment with an audible snap occurring whilst the patient returned the leg from flexion, abduction and external rotation or the frog-leg position (figure 3) to neutral (figure 4). the snap occurred as the medial component of the bifid tendon (which had rolled laterally over the lateral component during the frog-leg manoeuvre) returned abruptly over the lateral component to its original position, striking the superior pubic ramus. the referring surgeon elected to treat the patient conservatively with a bupivicaine and steroid injection under the bifid iliopsoas tendon, that produced symptomatic relief. figure 3: axial ultrasound image with the patient beginning to return to neutral from the frog-leg position. the medial psoas tendon component (m) lies anterolateral to the lateral component (l). the iliopsoas muscle (long black arrows) and femoral head (long white arrow) are shown on this image just below the acetabular rim. figure 4: at the same level as in figure 3 but with the leg in the neutral position, the medial tendon (m) has returned with a snap to lie medially against the acetabular rim in its normal position relative to the lateral tendon (l). discussion top ↑ a painful snapping hip is typically seen in young athletic individuals such as ballet dancers.1 intra-articular causes include labral tears or loose bodies. extra-articular causes are classified as internal due to iliopsoas, or external secondary to conflict of the iliotibial band and gluteus maximus with the greater trochanter.2 deslandes et al.3 demonstrated sonographically that most cases of internal snapping hip result from the dynamic relationship of the iliopsoas tendon with the muscle belly and pubic ramus. three of the snapping hips they studied were, as in the present case, because of a bifid tendon with the mechanism described above in the case presentation. the importance of this finding is that the bifid tendon must be identified pre-operatively to avoid persistence of symptoms owing to incomplete arthroscopic release.4 also of interest in the present case is the possible relationship of the psoas tendon to labral tears or ‘psoas impingement’. cascio et al.5 found a subset of patients at arthroscopy with normal femoro-acetabular morphology and labral tears confined to the 3 o’clock position, underlying the psoas tendon. these patients were treated with labral repair and psoas release, with good results. the mechanism of this relationship is unknown but one postulate is traction on the hip capsulo-labral complex by a tight psoas tendon. the patient in this case responded to a psoas injection, and the snapping iliopsoas is the presumed aetiology of symptoms but, in a patient with otherwise normal hip morphology, a labral tear confined to between the 2 and 3 o’clock positions should prompt the suggestion of psoas impingement, with a lateral dip of the tendon as supporting evidence in some cases.6 conclusion top ↑ the present case highlights an unusual cause of internal snapping hip of which the surgeon should be made aware pre-operatively to avoid incomplete psoas release. moreover, the possibility of psoas impingement as a contributor to a labral tear must be raised when the tear is confined to between the 2 and 3 o’clock positions. acknowledgements top ↑ competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. references top ↑ howse ajg. orthopaedists aid ballet. clin orthop relat res. 1972;89:52–63. pelsser v, cardinal e, hobden r, aubin b, lafortune m. extraarticular snapping hip: sonographic findings. ajr. 2001;176:67–73. deslandes m, guillin r, cardinal e, hobden r, bureau nj. the snapping iliopsoas tendon: new mechanisms using dynamic sonography. ajr. 2008;190: 576–581. shu b, safran mr. case report: bifid iliopsoas tendon causing refractory internal snapping hip. clin orthop relat res. 2011;469:289–293. cascio bm, king d, yen ym. psoas impingement causing labrum tear: a series from three tertiary hip arthroscopy centers. j la state med soc. 2013;165: 88–93. blankenbaker dg, tuite mj, keene js, del rio am. labral injuries due to iliopsoas impingement: can they be diagnosed on mr arthrography? ajr. 2012;199: 894–900. a. gradient magnetic fields may stimulate nerves or muscles. b. peripheral nerve stimulation is perceptible as ‘tingling’ or ‘tapping’ sensations. c. at gradient magnetic field exposure levels 50% to 100% above perception threshold, patients may experience pain. d. the majority of radiofrequency (rf) power transmitted for mr imaging is transformed into sound. 2. which of the following statements associated with aortic rupture is true? cpd questionnaire give one correct answer for each question. 56 sa journal of radiology • july 2008 instructions: 1. cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission, you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. 2. read the articles in the journal to find the answers to the questions. 3. go to www.cpdjournals.org.za to answer the questions. 1. regarding magnetic resonance, choose one false answer. a. ct is the gold standard for evaluating aortic rupture. b. the negative predictive value of a normal chest radiograph is high. c. there is a low mortality rate for major aortic surgical repair. d. best selection criterion for endovascular repair is rupture immediately adjacent to the left subclavian artery (lsa) origin. 3. which of the following statements is false? a. the covered portion of stent grafts should cross the lesion and at least 1.5 cm of the normal aorta at either end. b. when there is less than 15 mm of normal aorta between the aneurysm and the normal lsa, the covered part of the stent will not necessarily occlude the origin of the lsa in ensuring adequate length of the proximal landing zone. c. closure of the tear in post-traumatic arch rupture often occurs spontaneously after stent graft insertion. d. the most common complication after stent graft implantation is leakage into the aneurysm. 5. which of the following statements is false? a. the use of a standard breast phantom for entrance dose estimation does not reflect the true skin dose for larger or smaller breasts. b. a well-defined square root relationship that exists between sal and agd is dependent on the kilovoltage used. c. in computed radiography, the displayed image density is automatically adjusted by system image processing and is dependent on the applied dose. d. in conventional radiography, the amount of exposure is directly related to the average optical density whilst in computed radiography it determines the signal-to-noise ratio. 6. identify the correct statement in the following choices. a. protein-losing enteropathy is defined as a condition in which excess protein loss into the gastrointestinal lumen is severe enough to produce hypoproteinaemia. b. there are no benefits in using a tc-99m labelled tracer. c. peutz jeghers syndrome is not associated with protein-losing gastroenteropathy. d. faecal clearance of alpha 1-antitrypsin is an expensive and unreliable test of protein-losing enteropathy. 7. regarding conn’s syndrome, all the following is false except: a. conn’s syndrome is a common entity among hypertensive patients. b. adrenal adenomas are usually 3 cm or less in size. c. for adenomas measuring close to 1 cm or more, mri is the modality of choice. d. the disease is more common in males who present between the third and sixth decades of life. 8. identify the false statement among the following: a. cholesteatomas are non-neoplastic but destructive lesions containing layers of keratin in a cavity lined by squamous epithelium. b. they occur mainly in the middle ear cleft but have also been reported intracranially and in the external auditory canal. c. traumatic cholesteatomas occur as a complication with different types of injury to the temporal bone. d. the time interval between injury 9. regarding pet-ct, identify a single false statement: a. pet has the ability to demonstrate abnormal metabolic activity (at the molecular level) in organs that as yet do not show an abnormal appearance based on morphologic criteria. b. pet-ct scanners are applied in imaging in which precisely co-registered functional and anatomic images are obtained by performing a pet study and a ct study on different scanners without moving the patient. c. fdg is a radiopharmaceutical analog of glucose that is taken up by metabolically active tumour cells using facilitated transport similar to that used by glucose. d. pet is based on the detection of annihilation photons released when radionuclides, such as f-18, c-11 and o-15, emit positrons (ß+) that undergo annihilation with electrons. 10. if you cannot answer question 9: a. phone a friend. b. phone george bush. c. don’t worry, worldcup 2010 is more important. d. read the next issue of sajr. 4. which of the following radiological signs is not associated with meconium peritonitis? a. highly echogenic material creating ‘snowstorm’ appearance on ultrasound. b. dense calcifications in the scrotum. c. meconium peritonitis results from prenatal intestinal perforation nearly always involving the large bowel. d. on plain films, calcifications are amorphous and irregular. and diagnosis of post-traumatic cholesteatomas is approximately 3 months. cpd.indd 56 8/1/08 2:24:22 pm sajr 864 endovascular therapy for acute tumour-related obstruction of the superior vena cava using a self-expanding nitinol stent p kamusella, dr med; c wissgott, pd, dr med; r andresen, dr med institute of diagnostic and interventional radiology/neuroradiology, westkuestenklinikum – academic teaching hospital of the universities of kiel, lübeck and hamburg, heide, germany corresponding author: p kamusella (pkamusella@wkk-hei.de) objective. to evaluate, in a retrospective study, the clinical efficacy and safety of the self-expanding nitinol stent in the superior vena cava to alleviate upper venous congestion. method. in 22 patients (15 men, 7 women), a tumour-related compression of the superior vena cava was diagnosed by spiral ct after intravenous application of contrast medium. clinically, acute superior vena cava syndrome was found in all patients. histologically, a bronchial carcinoma was present in 14/22, a lymphoma in 6/22, and mediastinal lymphnode metastases (1 breast carcinoma, 1 malignant melanoma) in 2/22. after a transfemoral approach, cavography was initially performed. the degree of stenosis was classified according to the stanford classification. in accordance with the degree of stenosis, a self-expanding nitinol stent was placed. results. endovascular stent implantation was conducted without complications in all patients. a marked improvement in acute symptoms was observed clinically within 24 hours in all patients. in the follow-up period of up to 2 years, there were no cases of stent migration. in 7/22 patients, the ct follow-ups revealed tumour progression (3/7 after 3 months, 2/7 after 6 months, and 2/7 after 12 months) with evidence of residual stenosis caused by tumour growth through the stent mesh. during the follow-up period, 15/22 patients died (mean survival 6.4 months). conclusion. self-expanding nitinol stents provide endovascular therapy for superior vena cava syndrome, having a high radial expansive force and the facility to be placed precisely, and alleviating acute, life-threatening symptoms in the palliative situation. s afr j rad 2013;17(4):123-127. doi:10.7196/sajr.864 superior vena cava syndrome (svcs) is characterised by venous congestion and increased pressure resulting from displacement or compression of the superior vena cava (svc). venous congestion leads to swelling of the soft tissues of the face and neck, dyspnoea and dysphagia, extending to glottal and laryngeal oedema and the development of cerebral oedema with headache and clouded consciousness. the evolving life-threatening situation generally takes a slow and progressive course, and is rarely acute.1 the cause of the obstruction can be a thrombosis or an invasion or external compression of the svc by topographically adjacent pathological processes, especially originating in the right lung, lymph nodes and other mediastinal structures. in rare cases, a combination of external compression and cava thrombosis is present.2 in 74 95% of cases, malignant tumours are the primary cause of upper venous congestion, which typically results from an advanced lung carcinoma (about 80%), more rarely from a lymphoma (about 15%) or metastasis of an extrathoracic tumour (about 5%). up to 5% of patients with a lung carcinoma develop upper venous congestion during their illness.3 as a result of the usually rapidly advancing central tumour growth, small cell lung carcinomas (sclcs) lead to compression of the svc more often than do non-small cell lung carcinomas (nsclcs). the increasing use of central venous catheters or the implantation of cardiac pacemakers can lead to thromboses or central nervous obstructions and thus also, in rare cases, result in svcs.4 in the case of life-threatening svcs, rapid assistance is required to alleviate the acute symptoms and improve quality of life. endovascular therapy by stent implantation has proved to be an effective treatment method here. self-expanding metal stents, such as the wallstent (boston scientific, nastrick ma, usa) have been used till now.6 objective this retrospective study (2009 -2013) assessed the clinical efficacy and safety of self-expanding nitinol stents (sinus xl, optimed, ettlingen, germany) in the treatment of acute, tumour-related svcs. these stents have been authorised for the treatment of cava obstructions and for vena cava syndrome. method the indication for intervention was previously established by an interdisciplinary tumour board, consisting of internists/oncologists, surgeons, gynaecologists, neurosurgeons, radio-oncologists and radiologists. pre-interventionally, patients were advised by the treating interventionalist about the course of the procedure, risks and expected outcome. written consent was obtained from all patients before the intervention was performed. patients in 22 patients (15 men, 7 women, average age 65.9 years), a tumour-related compression of the svc was diagnosed by multidetector computed tomography (mdct) of the chest (table 1). after injecting 100 ml imeron 350 via an antecubital vein in the left arm at a rate of 3 ml/s and a delay of 30 s, ct was performed, with a 3 mm slice thickness and 3 mm reconstruction interval. clinically, acute svcs was found in all patients. acute or rapidly progressive dyspnoea and a swelling of the soft tissues of the face and neck led to inpatient admission in all cases (22/22). all patients were also characterised by dilatation of the jugular veins. dilated veins of the chest wall were also found in 7/22 patients. histologically, 14/22 had a lung carcinoma (9 sclc, 5 nsclc), 6/22 a lymphoma (non-hodgkin lymphoma) and 2/22 mediastinal lymph node metastases (1 breast carcinoma, 1 malignant melanoma). at the time of endovascular therapy, a definitive histological diagnosis was known in 18/22 patients. a ct-assisted biopsy was conducted in 4/22 over the further course. if the tumour entity was known, intensive therapy (radiochemotherapy) was started or continued. in planning the procedure, the chest ct was evaluated to determine the extent and cause of the occlusion, and thrombotic substrate was searched for. in addition, cavography was performed immediately before stent implantation for an exact assessment of the venous system. procedure under sterile conditions, after local anaesthesia with mecain 2%, the seldinger technique was used to puncture the right common femoral vein just below the inguinal ligament. a 10-french sheath (terumo, tokyo, japan) was then inserted, followed by wire probing (terumo stiff guide wire 0.035 inch) of the svc and insertion of a 4-french pigtail catheter. to prepare serial angiograms in different planes, an automated contrast medium application system (10 15 ml/s, total of 20 25 ml per series) was used for the cavography. examinations were conducted on a digital flat detector angiography system (alluraxper fd 20, philips healthcare, best, the netherlands) by means of pulsed fluoroscopy (image frequency 15/s). after cavography (fig. 1), the stenosis was classified according to the stanford classification7 system into 4 types: (i) type i describes a partial obstruction of the svc (up to 90%) with remaining patency and antegrade perfusion of the azygos vein; (ii) type ii shows increasing obstruction (90 100%); (iii) type iii is complete obstruction with reverse circulation in the azygos vein; and (iv) type iv is characterised by complete obstruction of the svc and the azygos vein, with the development of collateral circulations via the chest wall and the internal mammary veins. fig. 1. digital subtraction angiography of the superior vena cava (cavography) with evidence of severe lumen reduction (type ii, stanford classification). corresponding to the stenosis, a self-expanding nitinol stent was placed. despite the high radial expansion force of the stent, residual tumour-related constrictions were subsequently dilated with a balloon (zelos, optimed, ettlingen, germany) in all patients for optimisation in the area of the stenosis. a non-compliant balloon was used, which was chosen to be slightly smaller in relation to the stent diameter and with a length of 40 mm. a stent with a diameter of 20 mm was subsequently dilated with the aid of a balloon with a diameter of 18 mm, without exceeding the working pressure of 4 bar. accordingly, a 20 mm balloon was used for a 22 mm stent. the stent length and the diameter were determined on the basis of the ct and cavography. the stent length was chosen according to the stenosis. the stent diameter was determined on the basis of the diameter of the svc in the normal calibre range, taking into account respiratory variability (fig. 2). fig. 2. superior vena cava at the time of stent deployment. before stent implantation, each patient received an intravenous bolus of 5 000 iu heparin. serial angiograms in 2 planes (ap and 45° oblique projections) were then prepared to check for adequate recanalisation of the svc. the treatment was considered to have been completed successfully if the stent was in the correct position and showed a normal contrast medium outflow in the cavogram, and the collaterals had markedly receded (fig. 3). after removal of the sheath from the common femoral vein, the puncture site was manually compressed until haemostasis was achieved, and a light compression bandage was applied for at least 6 h. bed rest was recommended for at least 12 h. on the following day, a renewed chest ct was conducted to check the post-interventional outcome. fig. 3. cavography after stent implantation and balloon angioplasty. presentation of the stented uncaged superior vena cava with correct stent position and a regression of collateral circulation. the follow-up period included presentation in the oncological outpatient department with a clinical examination and radiological diagnostics (chest ct). the follow-ups were after 3 months up to 24 months, and were carried out in those patients who had survived the course. in the event of renewed clinical deterioration, the algorithm was departed from. restenosis was defined as >50% lumen reduction. the indication for re-intervention was discussed by an interdisciplinary team only if clinical symptoms recurred. results the cavography performed before stent placement revealed a partial obstruction of the svc in 4/22 (18.2%, type i) and in 11/22 (50%, type ii) of the patients. a complete obstruction of the svc (type iii) was seen in 7/22 (31.8%) of the patients. no cases of complete obstruction of the svc and the azygos vein (type iv) were detected. additional cava thrombosis was not found. stenosis lengths averaging 3.8 cm (2.5 5 cm) were measured. stents with a length of 60 mm were used in all patients, with sufficient cover of the stenosis. a stent with a diameter of 20 mm was chosen for 2 patients. in 20 patients, stents of 22 mm diameter were used. a self-expanding nitinol stent was implanted in all cases. the technical success rate was 100%, with optimal cover of the stenosis. in all (22/22) cases, the stenosis was successfully bridged with a single stent. there were no stent-related complications such as stent migration. complications relating to the procedure, especially in the area of the stenosis or the puncture site, were not observed. in the follow-up period of up to 2 years, no stent migration was found. an improvement in clinical symptoms was observed within 24 h after stent implantation in all cases. of subjective importance for the patients was the improvement in dyspnoea, which meant that they could assume a lying position without difficulty, and oxygen substitution could be discontinued. objective signs of improvement were the decline in facial and neck oedema and regression of the venous cervical and thoracic dilatation. patients with known tumour disease continued their intensive therapy (radio-chemotherapy). patients with newly discovered tumour disease (3 sclc and 1 non-hodgkin lymphoma) were able to start oncological treatment shortly after histological clarification. in the follow-up ct, tumour progression was found in 7/22 patients (3/7 after 3 months, 2/7 after 6 months, and 2/7 after 12 months), with evidence of restenosis caused by tumour growth through the stent mesh (fig. 4). this resulted in a renewed svcs. ct detected a restenosis <50% in 4/7 and a stenosis >50% in 3/7 of the patients. for the primary patency rate, a value of 86.4% was obtained. during the follow-up period, 15/22 (68.2%) of the patients died, yielding a mean survival of 6.4 months. only one patient has so far survived a period of 2 years after stent implantation, and continues to be followed along with the remaining patients. fig. 4. (a) a central, small cell lung cancer in the upper mediastinum with encasement of mediastinal structures, in particular the superior vena cava. in the area of the chest wall, especially on the left side, an increased venous drawing is visible at skin level. (b) follow-up computed tomography (at 3 months) after stent implantation. the stent in the superior vena cava is in the correct position and the vascular lumen is free perfused. (c) follow-up computed tomography (at 6 months) after stent implantation. restenosis of the superior vena cava by progression of tumour growth, in particular through the stent mesh. a planned re-intervention was not performed because the patient died from the consequences of the disease. discussion rapid diagnostics and effective therapy are necessary to correct tumour-related compression of the svc within the context of acute life-limiting symptoms. imaging in conventional projection radiography of the chest, the majority of patients with svcs show pathologies that present mainly as a mediastinal broadening, and to a lesser extent also with accompanying pleural effusions. mdct is the method of choice; it clarifies the extent of venous obstruction, identifies the venous collateral system and enables an estimation of the cause of the svcs. in practice, obstruction of the svc is often diagnosed on routine contrast-enhanced chest ct via an antecubital vein in the left arm.8 to avoid lack of opacification or streak artefacts, qanadli et al.9 recommend a simultaneous bilateral antecubital vein injection; sheth et al.8 prefer a delay of 60 s, instead of 30 s. in the literature, typically 120 ml (up to 180 ml) of contrast medium was injected.8 , 9 our experience with a unilateral injection of 100 ml contrast medium and a delay of 30 s has been good. in our study, ct also served as a basis for further therapy planning within the context of an interdisciplinary therapeutic decision. mri is another method that can be used to image the central venous system, supplying valuable information for therapy planning,10 but this was not conducted in our patient population. based on the ct findings, conventional imaging of the veins was performed within the context of the procedure for stent implantation in our study. cavography enables assessment of the obstruction and visualisation of the collateral circulations.7 partial obstructions (types i and ii; up to 68%) and complete obstruction (type iii; 32%) of the svc were detected most frequently in our study. complete obstructions including the azygos vein were not found. in their patient population with 27 venographies performed, stanford et al.7 most often described type iv obstructions (37%), followed by type ii and iii (26% each), while type i (11%) occurred less frequently. lanciego et al.11 showed a similar distribution of the obstruction types (type i: 9%; type ii: 40%; type iii: 28%; type iv: 23%). therapy various therapeutic options are available, with the aim of rapidly alleviating the acute symptoms and improving the quality of the remaining time available to the patient in the palliative situation. general and pharmacotherapeutic treatments (e.g. bed rest and raised upper body, diuretics, cortisone anticoagulation) can alleviate symptoms, but only show limited clinical success. standard tumour treatment procedures are radiotherapy and chemotherapy, or a combination of the two, which create relief by reducing the tumour mass. an improvement in symptoms is achieved in 80% of patients with these treatment methods. in the case of nsclc, a decline in symptoms of 46 63% is seen with radiotherapy, and of 59% with chemotherapy. in the case of sclc, success rates of 62 80% with chemotherapy and 83% with combined radiochemotherapy have been achieved.3 however, these therapeutic options take 7 14 days before symptoms improve, and in some studies up to 4 weeks.. aggressive radiotherapy (8gy 3 times a week for 3 weeks) achieved a response of up to 90%, but this treatment also leads to an increase in radiation-related complications, such as tumour necrosis with fever attacks, the risk of bleeding and even perforation of the svc. in addition, side-effects such as nausea and vomiting, skin irritations and oesophagitis have been observed. in the light of morbidity, mortality and limited life expectancy, surgical resection with vascular reconstruction is performed in only the rarest of cases in this patient population with acute symptoms. in contrast, surgical interventions are effective in benign causes of upper venous congestion and show relatively few complications. if, in the case of a malignant cause of upper venous congestion, a mean life expectancy of 6 months is assumed, which is analogous to the 6.4 months observed in our patient population, the remaining time should comprise alleviating the symptoms and maintaining quality of life. endovascular stent implantation in the event of severe symptoms, endovascular stent implantation represents the method of choice for acute treatment and is characterised by its capability of providing rapid relief from the acute symptoms (within 24 h) in up to 90% of cases. the technical success rate is around 95 100%. in our patient population, an improvement in dyspnoea and facial swelling in particular, was observed within 24 h, with a technical success rate of 100%. the transfemoral approach proved effective for placing the stent. the right common femoral vein is preferred, while other venous approaches such as the internal jugular vein or the peripheral veins of the upper arm are used in special cases only.6 based on this experience, we also used a right-sided transfemoral approach, after previous skin disinfection and local anaesthesia, in all cases in our study. in none of the cases was it necessary to puncture a different vein region. when selecting the stent size, the stent length should exceed the measured obstruction cranially and caudally by 1 cm each way, while the stent diameter should be adapted to the svc in its unobstructed state.6 regarding efficacy, no significant difference is found in the literature between the 3 most commonly used stents (gianturco z-stent, cook medical inc., bloomington, usa; palmaz stent, johnson & johnson, warren, usa; wallstent, boston scientific, natrick, usa). in the past, the gianturco z-stent has been described as having an increased rate of stent migration and stent malpositioning. these stents are self-expanding and characterised by largely resistance-free stenosis passage and a wide range of lengths and widths. compared with the standard metal stents, more recent self-expanding stents made of a nickel-titanium alloy (nitinol) have a higher precision in stent placement within the stenosis, an only minimal stent shortening, lower thrombogenicity and a higher radial expansion force, while remaining highly flexible.12 , 13 in our study, a 10-f nitinol stent system authorised for svcs was used and is available in various widths (16 34 mm) and lengths (30 100 mm). at stenosis lengths of 2.5 5 cm, 6 cm stents were applied with a diameter of 2.0 and 2.2 cm. overlapping stent implantations were not necessary in our study, as the available stent sizes enabled complete coverage of the obstruction with one stent in each case. if both brachiocephalic veins are involved in the obstruction, the patients may benefit from a unilateral stent implantation. uni­lateral treatment is sufficient; on the one hand, blood flow is also possible from the contralateral side through the stent mesh; on the other, blood circulation takes place via cervicothoracic collateral channels.6 bilateral recanalisation does not improve the outcome. in the case of parallel positioning of the stents in the svc, the stents may not expand fully, which may be accompanied by increased recurrence of svcs.11 , 14 if a central venous catheter is in place, various options present. if chemotherapy has been concluded, removal of the catheter may be considered prior to stent placement. if it is still required, an attempt can be made to move the catheter tip temporarily into another position before implantation of the stent, e.g. into the cervical or brachial veins, and move it back afterwards. if this is not possible, the central venous catheter can be overstented. 6 balloon dilatation may be necessary before stent implantation. though desirable in cases of benign svc obstruction, it is not always required in malignant stenoses, but may be necessary for total obstructions.6 after stent implantation, balloon dilatation is recommended to optimise an eccentric stent position and remove residual stenoses. if a thrombus is additionally present, it can be pushed back further by angioplasty in the case of incomplete stent expansion.6 so-called noncompliant balloons were exclusively used in our study; they are characterised by the fact that they only change their diameter minimally upon dilatational pressure and therefore minimise the risk of overexpansion. complications of stent placement are seen in 3 7 % of patients.1 the early complications include pulmonary artery embolism, stent migrations, haematomas and bleeding, ranging up to the rare perforation or rupture of the svc.15 no such complications were observed in our study. failures after stent implantation may be linked to tumour invasion into the svc through the stent mesh and thrombus formation. lanciego et al.11 described such re-occlusion as a result of tumour growth in 16/149 patients (~10%) and in only 2 cases as a result of a thrombus in their patient population. in our study, tumour-related restenoses were seen in about 30% of patients over a period up to 12 months, the high tumour burden and deterioration of the overall situation meaning that renewed intervention was no longer indicated. if a relevant stenosis is defined as a lumen constriction >50%, 3 restenoses were present in our patient population, thus yielding a primary patency rate of 86.4%. this value is slightly higher than that achieved by da ines et al.,6 using wallstents, of about 81%. in the case of re-obstruction, re-intervention should fundamentally be discussed.3 , 11 in such cases, the use of covered stents is conceivable, but possible thrombogenicity and potential risk of blocking afferent vessels must be borne in mind.6 at present, only individual case reports are available16 but they demonstrate that tumour growth through the stent mesh, or stent migration with vascular rupture, can be treated with a covered stent. covered stents were not used in our study. within the context of treatment of svcs, clear recommendations are not available for anticoagulation and platelet aggregation inhibition. while most interventionalists routinely use a heparin bolus of 5 000 iu,6 opinion is divided about follow-up treatment and its duration. for example, the interdisciplinary s3 guideline of the german respiratory society and the german cancer society says that anticoagulation is generally not necessary. therefore, after stent implantation, a middle way must be found between the risk of early re-occlusion and haemorrhagic complications. to avoid thrombus formation, platelet aggregation inhibition with acetylsalicylic acid and/or clopidogrel is to be recommended. if a thrombus is present, anticoagulation with heparin is necessary for the duration of tumour treatment.6 the duration of anticoagulation is dependent on therapy-related factors, and side-effects and should be discussed in conjunction with attending oncologists on an individual basis. conclusion self-expanding nitinol stents provide endovascular therapy for svcs with a tool that can be placed precisely and that alleviates the patient’s acute, life-threatening symptoms quickly and effectively in the palliative setting. as a result of post-interventional clinical improvement, it is then possible to pass on the patient for further targeted oncological therapy. 1. wilson ld, detterbeck fc, yahalom j. clinical practice. superior vena cava syndrome with malignant causes. n engl j med 2007;356(18):1862-1869. [http://dx.doi.org/10.1056/nejmcp067190] 1. wilson ld, detterbeck fc, yahalom j. clinical practice. superior vena cava syndrome with malignant causes. n engl j med 2007;356(18):1862-1869. [http://dx.doi.org/10.1056/nejmcp067190] 2. garcía mónaco r, bertoni h, pallota g, et al. use of self-expanding vascular endoprostheses in superior vena cava syndrome. eur j cardiothorac surg 2003;24(2):208-211. [http://dx.doi.org/10.1016/s1010-7940(03)00293-8] 2. garcía mónaco r, bertoni h, pallota g, et al. use of self-expanding vascular endoprostheses in superior vena cava syndrome. eur j cardiothorac surg 2003;24(2):208-211. [http://dx.doi.org/10.1016/s1010-7940(03)00293-8] 3. rowell np, gleeson fv. steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. clin oncol (r coll radiol) 2002;14(5): 338-351. 3. rowell np, gleeson fv. steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. clin oncol (r coll radiol) 2002;14(5): 338-351. 4. qanadli sd, el hajjam m, mignon f, et al. subacute and chronic benign superior vena cava obstructions: endovascular treatment with self-expanding metallic stents. am j roentgenol 1999;173(1):159-164. [http://dx.doi.org/10.2214/ajr.173.1.10397119] 4. qanadli sd, el hajjam m, mignon f, et al. subacute and chronic benign superior vena cava obstructions: endovascular treatment with self-expanding metallic stents. am j roentgenol 1999;173(1):159-164. [http://dx.doi.org/10.2214/ajr.173.1.10397119] 5. schainfeld rm. turning the old school on its head: stenting as the therapy of choice for svc syndrome. catheter cardiovasc interv 2005;65(3):424-426. [http://dx.doi.org/10.1002/ccd.20439] 5. schainfeld rm. turning the old school on its head: stenting as the therapy of choice for svc syndrome. catheter cardiovasc interv 2005;65(3):424-426. [http://dx.doi.org/10.1002/ccd.20439] 6. da ines d, chabrot p, cassagnes l, et al. endovascular treatment of svc syndrome from neoplastic origin: a review of 34 cases. j radiol 2008;89(7-8 pt 1):881-889. [http://dx.doi.org/jr-09-2008-89-9-0221-0363-101019-200808521] 6. da ines d, chabrot p, cassagnes l, et al. endovascular treatment of svc syndrome from neoplastic origin: a review of 34 cases. j radiol 2008;89(7-8 pt 1):881-889. [http://dx.doi.org/jr-09-2008-89-9-0221-0363-101019-200808521] 7. stanford w, jolles h, ell s, et al. superior vena cava obstruction: a venographic classification. am j roentgenol 1987;148(2): 259-262. [http://dx.doi.org/10.2214/ajr.148.2.259] 7. stanford w, jolles h, ell s, et al. superior vena cava obstruction: a venographic classification. am j roentgenol 1987;148(2): 259-262. [http://dx.doi.org/10.2214/ajr.148.2.259] 8. sheth s, ebert md, fishman ek. superior vena cava obstruction evaluation with mdct. am j roentgenol 2010;194(4): 336-346. [http://dx.doi.org/10.2214/ajr.09.2894] 8. sheth s, ebert md, fishman ek. superior vena cava obstruction evaluation with mdct. am j roentgenol 2010;194(4): 336-346. [http://dx.doi.org/10.2214/ajr.09.2894] 9. qanadli sa, el hajjam m, bruckert f, et al. helical ct phlebography of the superior vena cava: diagnosis and evaluation of venous obstruction. am j roentgenol 1999;172(5):1327-1333. [http://dx.doi.org/10.2214/ajr.172.5.10227511] 9. qanadli sa, el hajjam m, bruckert f, et al. helical ct phlebography of the superior vena cava: diagnosis and evaluation of venous obstruction. am j roentgenol 1999;172(5):1327-1333. [http://dx.doi.org/10.2214/ajr.172.5.10227511] 10. thornton mj, ryan r, varghese jc, et al. a three-dimensional gadolinium-enhanced mr venography technique for imaging central veins. am j roentgenol 1999;173(4):999-1003. [http://dx.doi.org/10.2214/ajr.173.4.10511166] 10. thornton mj, ryan r, varghese jc, et al. a three-dimensional gadolinium-enhanced mr venography technique for imaging central veins. am j roentgenol 1999;173(4):999-1003. [http://dx.doi.org/10.2214/ajr.173.4.10511166] 11. lanciego c, chacón jl, julián a, et al. stenting as first option for endovascular treatment of malignant superior vena cava syndrome. am j roentgenol 2001;177(3):585-593. [http://dx.doi.org/10.2214/ajr.177.3.1770585] 11. lanciego c, chacón jl, julián a, et al. stenting as first option for endovascular treatment of malignant superior vena cava syndrome. am j roentgenol 2001;177(3):585-593. [http://dx.doi.org/10.2214/ajr.177.3.1770585] 12. thierry b, merhi y, bilodeau l, et al. nitinol versus stainless steel stents: acute thrombogenicity study in an ex vivo porcine model. biomaterials 2002;23(14):2997-3005. 12. thierry b, merhi y, bilodeau l, et al. nitinol versus stainless steel stents: acute thrombogenicity study in an ex vivo porcine model. biomaterials 2002;23(14):2997-3005. 13. schmidt w, wissgott c, andresen r, et al. performance characteristics of modern self-expanding nitinol stents indicated for sfa. fortschr röntgenstr 2011;183(9):818-825. 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[http://dx.doi.org/10.1055/s-0031-1273445] 14. dinkel hp, mettke b, schmid f, et al. endovascular treatment of malignant superior vena cava syndrome: is bilateral wallstent placement superior to unilateral placement? j endovasc ther 2003;10(4):788-797. 14. dinkel hp, mettke b, schmid f, et al. endovascular treatment of malignant superior vena cava syndrome: is bilateral wallstent placement superior to unilateral placement? j endovasc ther 2003;10(4):788-797. 15. smith sl, manhire ar, clark dm. delayed spontaneous superior vena cava perforation associated with a svc wallstent. cardiovasc intervent radiol 2001;24(4):286-287. 15. smith sl, manhire ar, clark dm. delayed spontaneous superior vena cava perforation associated with a svc wallstent. cardiovasc intervent radiol 2001;24(4):286-287. 16. jean-baptiste r, williams dm, gemmete jj. successful treatment of superior vena cava rupture with placement of a covered stent: a report of two cases. cardiovasc intervent radiol 2011;4(3):667-671. [http://dx.doi.org/10.1007/s00270-011-0128-8] 16. jean-baptiste r, williams dm, gemmete jj. successful treatment of superior vena cava rupture with placement of a covered stent: a report of two cases. cardiovasc intervent radiol 2011;4(3):667-671. [http://dx.doi.org/10.1007/s00270-011-0128-8] a. presence of microcalcifications is an important marker for ductal carcinoma in situ (dcis). b. in screening mammography, a palpable mass may not be present and as many as 30 50% of non-palpable breast cancers present themselves as clusters of microcalcifications alone. c. it is important to develop good radiological and histopathological correlation. d. depending on the radiological appearance on mammography and ultrasound, patients do not require further evaluation. 2. which of the following statements is false? cpd questionnaire give one correct answer for each question. 104 sa journal of radiology • december 2008 1. regarding screening and diagnostic mammography, choose one false answer. a. according to bi-rads, the calcification patterns suggestive of malignancy are heterogeneous or pleomorphic, amorphic or indistinct, fine linear and/or branching types. b. a study by gulsun et al. compared the positive predictive value (ppv) of using legal’s classification and the bi-rads classification in terms of identification of malignancy and concluded that both succeed in reducing the ambiguity in assessment of breast calcifications and they are useful in standardisation of reports. c. atypical ductal hyperplasia (adh), lobular carcinoma in situ (lcis) and atypical lobular hyperplasia (alh) may also present with calcifications which may exhibit high density, clustered punctuate calcification and tend to lack the characteristic features of dcis such as rod shapes, ductal distribution and branching. d. dcis can present as a stellate mass without calcifications. 3. which of the following statements is false? a. diffuse signal changes in the liver on mri often represent a depositional process. b. the signal is decreased when iron is deposited or increased with copper or fatty deposition. c. diffuse signal change is often incidental when imaging is done to identify a cause for other symptoms or to assess for complications of primary pathology. d. in patients who receive multiple blood transfusions, the excess iron is initially deposited in the reticuloendothelial system of the liver, spleen and bone marrow as well as the heart and endocrine system. 5. which of the following statements regarding ct of the appendix is false? a. ct scanning has emerged as a valuable resource in the imaging of appendicitis. b. this modality has the advantage of improved rates of visualisation of the appendix and surrounding structures, as well as more accurate evaluation of the rest of the abdomen. c. the ionising radiation dose delivered is negligible. d. it allows more confident detection of a normal appendix, thus excluding appendicitis as a cause of symptoms. 6. identify the false statement in the following choices. a. peripancreatic pseudo-aneurysms in patients with chronic pancreatitis are an uncommon but serious complication. b. mortality rates can reach 40%, depending on the clinical status, site and characteristics of the bleeding lesion, and the surgical management. c. arterial lesions related to pancreatitis are predominantly localised in the splenic artery, the pancreaticoduodenal arteries and the gastroduodenal artery. d. the pathogenesis of pseudo-aneurysms in pancreatitis is due to the proteolytic action of the pancreatic enzymes in the pseudocyst, mainly lipase, in direct contact with the visceral artery. 7. the following is true about ductal carcinoma in situ (dcis), excepting: a. dcis may present with multifocal or multicentric disease. b. the above implies that all visible lesions should be biopsied. c. comprehensive baseline mammography is indicated in young patients with breast disease so that abnormal calcification patterns are not missed. d. in patients under the age of 40, ultrasound is still the investigation of choice, but a single baseline medio-lateral oblique mammogram view of the affected breast should be performed to exclude any abnormal calcification patterns as this may be missed on ultrasound. 8. identify the false statement among the following. features that are important when evaluating calcifications are: a. form i.e. are they round, oval or linear in shape, or do they have no specific shape (amorphic). b. sizes of the microcalcifications i.e. are they large calcifications or small punctuate calcifications and do they demonstrate homogenous or heterogeneous size. c. distribution i.e. are they clustered together or sporadic or are they distributed in a particular pattern e.g. in a breast segment or along a duct. d. margin – calcifications with regular margins are more likely to be malignant. 9. regarding pseudo-aneurysm of the gastroduodenal artery, identify the one false statement. a. in chronic pancreatitis, several factors may increase the risk of acute bleeding, such as duration of disease, proximity of a vessel to a pseudocyst, communication with the biliary or pancreatic ducts, and splenic vein occlusion due to thrombosis. b. in the diagnostic workup, invasive diagnostic procedures are the priority; ultrasonography with colour doppler is a second choice. c. the pseudo-aneurysm size, presence of thrombus, and pseudo-aneurysm topography could often be well defined by non-invasive procedures. d. catheter angiography remains important in the visualisation of the exact gastroduodenal artery pathology measurement of artery width and presence of arteriovenous fistula. it is an invasive procedure, but can also allow treatment of the pseudoaneurysm at the same time. 10. identify one false statement. a. the medical imaging society of south africa (misa) and member companies siemens healthcare, ge healthcare, philips medical systems and aec amersham have announced a sponsorship of r20 000. b. the sponsorship will be applied in the form of a refund of r1 000 to each of up to 20 registrars who incur long-distance travel and accommodation expenses in attending rssa congresses and workshops. c. the terms of the sponsorship are that the first 20 registrars who register and pay their registration fees by the ‘early bird’ deadline will receive a refund of r1 000 after the course ends. d. awarding the sponsorships depends on the course location and where the participants come from. for the congress in sandton, for example, gauteng registrars will be included. this is to ensure that recipients are those who have to pay for their spouses, children or girlfriends. a. ultrasound evaluation of appendicitis was first described by puylaert in 1968. b. in a meta-analysis conducted between 1986 and 1994, orr et al. reported a sensitivity of 95% and a specificity of 82% among adult and paediatric populations. c. sonography has the advantage of being quick to perform without any need for patient preparation. d. ultrasound of the appendix is not operator dependent and the appendix is readily visualised. 4. which of the following statements regarding ultrasound of appendicitis is true? see previous page for cpd instructions. cpd dec 08.indd 104 12/5/08 11:26:19 am case report case report 36 sa journal of radiology • july 2008 case report introduction protein-losing enteropathy (ple) is defined as a condition in which excess protein loss into the gastrointestinal lumen is severe enough to produce hypoproteinaemia.1 previously reported procedures for the detection of protein loss have many limitations (such as rapid reabsorption of the radiolabel, unstable protein binding both in vivo and in vitro, and limited availability2) and were, moreover, cumbersome as well as unpleasant, as they involved 24-hour urine and stool collection. the study was also prone to error owing to the long urine and stool collection period. although tc-99m-labelled human serum albumin (hsa) has been used to diagnose ple with success, a literature search yielded few results, thus raising the question of the diagnostic value of this radiotracer.2,3 the benefits of using a tc-99m-labelled tracer are manifest and include: • shorter duration for performing the study • good imaging characteristics • no stool or urine collection. case report an 11-year-old girl presented with a 6-month history of weight loss, fatigue, loss of appetite, hyperpigmented macules, general body swelling and chronic diarrhoea. laboratory tests at the time of scintigraphy showed hypoproteinaemia (53 g/l) and hypoalbuminaemia (20 g/l). the findings of renal and liver function tests were normal. on physical examination, vital signs were normal and the patient was saturating at 97%. the chest was clear bilaterally with normal heart sounds. the abdomen was soft with no tenderness. clinically, the lesions were brownish macules visible on the lower lips and buccal mucosa, and dorsa of the hands, forearms and lower limbs. stool cultures were negative for pathogens. colonoscopy revealed hundreds of polyps. peutz-jeghers syndrome and ple were considered as part of the differential diagnosis, and further investigation was needed. for the protein-losing enteropathy demonstrated on tc-99m hsa p mpikashe, mb chb, mmed, fcnp (sa) m m sathekge, mb chb, mmed b j meyer, bsc, msc, med i+sod, dsc, mb chb, md, mmed department of nuclear medicine, university of pretoria and pretoria academic hospital fig. 1. tc-99m hsa, 6-hour anterior and posterior images demonstrating abnormal tracer accumulation (arrows) in keeping with evidence of ple. fig. 2. tc-99m hsa, anterior image showing abdominal tracer accumulation still present at 24 hours. protein-losing.indd 36 8/1/08 10:05:33 am case reportcase report confirmation of ple, tc-99m-labelled human serum albumin (hsa) scintigraphy was performed. tc-99m hsa 444 mbq was injected intravenously, and scintigraphic images were obtained 10 minutes, 30 minutes, 40 minutes, 1 hour, 2 hours and 6 hours after injection; 24-hour imaging was also performed. images of the thyroid were also obtained after 30 minutes to monitor for free pertechnetate. abnormal tracer accumulation was visualised in the bowel from the 6-hour image up to the 24-hour image (figs 1 and 2). no tracer activity was noted in the thyroid, stomach and salivary glands. discussion ple is characterised by excessive loss of serum proteins in the gastrointestinal tract. it may be caused by a diverse group of disorders such as gastric carcinoma, ulcerative colitis, regional enteritis, whipple’s disease, tropical and non-tropical sprue, and giant hypertrophy of the gastric mucosa.4 peutz-jeghers syndrome is also associated with proteinlosing gastroenteropathy.5 in our case, the patient had peutz-jeghers syndrome; this is a dominantly inherited human disorder characterised by gastrointestinal hamartomatous polyposis and mucocutaneous melanin pigmentation.6 localising the site of protein loss and its quantification are important in the management of ple. faecal clearance of alpha1antitrypsin is an inexpensive and quite reliable test of ple, and is measured by determining stool volume and both stool and plasma alpha-antitrypsin concentrations. however, it is unable to ascertain the site of the leak; to do so, iodine 131 polyvinylpyrrolidine, iodine 125 polyvinylpyrrolidone, chromium 51-labelled albumin, chromium 51 chromic chloride, iodine 125 albumin, indium 111 chloride, indiumtransferring tc-99m diethylenetriaminepenta-acetic acid hsa, tc-99m dextran, and tc-99m human immunoglobulin have been used with success.2 technetium-labelled hsa is valuable for the diagnosis of ple. a lower radiation burden, faster background clearance and higher in vitro and in vivo stability support tc-99m hsa as a more effective agent for ple imaging. although tc-99m is the ideal tracer for the imaging of ple, it does not allow quantification of protein loss due to its short physical half-life. on the other hand, tc-99m-labelled agents cannot cross intestinal mucosa because of the impermeable barrier between the vascular endothelium and luminal contents. they therefore remain in the vascular compartment with a long intravascular half-life,2,7 which is helpful in localising the site of enteric protein loss. hence, sites of protein loss may also be demonstrated within the 24-hour imaging period. since technetium is taken up and trapped by the thyroid gland, it is essential to image the thyroid gland at 30 minutes to confirm that the binding of albumin to the technetium is good. other organs that normally demonstrate technetium accumulation include the stomach and salivary glands, which further confirms the need to ensure excellent binding. detecting the location of a leak is very useful for diagnosis and therapy planning, especially if surgery is needed. based on the abovementioned advantages of using technetiumlabelled tracers, we recommend the continuing use of technetiumlabelled hsa in the diagnosis of ple. 1. greenberger nj, isselbacher kj. disorders of absorption. new york: mcgraw-hill, 1998; 1616-1633. 2. nan-tsing c, bifang l, shang-jyh h, jer-ming c, gin-chung l, hsin-su y. protein-losing enteropathy: diagnosis with tc-99m labelled human serum albumin scintigraphy. radiology 2001; 219: 86-90. 3. seok jw, kim sj, lee sh, kim yk. protein-losing enteropathy detected on tc-99m hsa and tc-99m mdp scintigraphy. clin nucl med 2002; 27: 431-433. 4. nikolaos n, konstantinos t, olga g, dimitros g. protein-losing enteropathy as the principal manifestation of constricitive pericarditis. j gen intern med 2005; 20: c5-c7. 5. kazuhiro y, masafumi i, yosuke a, et al. peutz-jeghers polyposis with bleeding from polyps of the sigmoid colon successfully treated by laparoscopic surgery. dig endoscopy 2003; 15: 51-54. 6. gennaro s, concetta fc, filippo c, gianluca t, salavatore c. a case of protein-losing enteropathy caused by intestinal lymphangiectasia in a preterm infant. pediatrics 2001; 107: 416-417. 7. halaby h, bakheet sm, shabib s, et al. tc-99m human serum albumin scans in children with protein losing eneteropathy. j nucl med 2000; 41: 215. 37 sa journal of radiology • july 2008 protein-losing.indd 37 8/1/08 10:05:33 am article information authors: sucari vlok1 vicci du plessis2 affiliations: 1division radio-diagnosis, stellenbosch university, tygerberg hospital, south africa 2department radiology, grey’s hospital, south africa correspondence to: sucari vlok email: sucarivlok@gmail.com postal address: po box 19010, tygerberg hospital, cape town 7505, south africa dates: received: 09 june 2015 accepted: 14 oct. 2015 published: 09 dec. 2015 republished: 15 dec. 2015 how to cite this article: vlok ssc, du plessis v. meconium pseudocyst associated with congenital cmv infection. s afr j rad. 2015;19(2): art. #893, 3 pages. http://dx.doi.org/10.4102/sajr.v19i2.893 note: manuscript republished under correct section from ‘original research’ to ‘case report’. copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. meconium pseudocyst associated with congenital cmv infection in this case report... open access • abstract • introduction • case report • discussion • conclusion • acknowledgements    • authors’ contributions    • competing interests • references abstract top ↑ meconium pseudocyst is a rare complication of fetal bowel perforation in utero, following extravasation and localised containment of meconium within the intra-peritoneal cavity. introduction top ↑ meconium pseudocyst is a rare, perinatal complication of intra-uterine fetal bowel perforation, with very few cases reported in the literature. intestinal obstruction and perforation with subsequent intra-peritoneal extravasation of meconium causes a sterile, chemical inflammatory response and the formation of dystrophic calcifications. sporadically, meconium peritonitis may result in fixation of the inflamed bowel loops, forming a contained collection with a membranous wall, into which meconium may leak continuously from the perforation site.1,2,3,4,5 the presence of a meconium pseudocyst indicates complex peritonitis which necessitates specialist evaluation, delivery at a tertiary care facility and, in most cases, neonatal surgical intervention.2 case report top ↑ a 25-year-old hiv-positive pregnant woman (g3p2) was referred for antenatal ultrasound (us) at 28 weeks, which revealed a large, cystic intra-abdominal mass within the fetus, with an irregularly calcified rim and internal echoes (figure 1). there was associated polyhydramnios and an oedematous placenta. the patient presented at the obstetric unit 4 weeks later with premature rupture of the membranes. the baby was born prematurely via a normal vertex delivery at 32 weeks. figure 1: transverse (a) and coronal (b) antenatal ultrasound at 28 weeks revealed a large, cystic intra-abdominal mass with internal echoes (white arrows) and calcified rim (dashed arrows) within the fetus. note the polyhydramnios (white star) and oedematous placenta (black star). a computed tomography (ct) scan performed on the day of birth revealed a large, cystic intra-abdominal mass with a calcified rim, displacing adjacent abdominal organs (figure 2). subsequent laparotomy was performed with extensive adhesiolysis to free the bowel, and biopsies obtained for histological evaluation, which confirmed meconium pseudocyst. neonatal infection screening revealed the presence of cytomegalovirus (cmv) infection. figure 2: topogram (a), coronal (b) and transverse (c) ct images of the abdomen on the day of birth revealed a large, cystic intra-abdominal mass (white arrows) with calcified rim (dashed arrows) displacing the internal organs, which radiologically confirmed the diagnosis of a meconium pseudocyst. the neonate tested positive for cmv infection at birth. discussion top ↑ meconium peritonitis is a sterile, chemical inflammatory response, occurring as a result of bowel perforation proximal to a partial or complete obstruction in utero. if the perforation site is not sealed off properly, meconium continues to extravasate into the peritoneal cavity.1,2,3,4,5 dystrophic peritoneal calcifications are present in 85% of cases and may form as early as 12 hours postperforation,2,3 but may only become visible radiologically after a few weeks.1 occasionally, a contained, meconium-filled collection outlined by adhered bowel loops may form – a meconium pseudocyst.1,2,3,4,5 meconium peritonitis is a rare entity, with an incidence of 1:35 000 live births, usually presenting during or after the 2nd trimester of pregnancy.3 various causes of meconium peritonitis exist, including intestinal atresia/stenosis, volvulus, intussusception, meckel’s diverticulum or peritoneal bands.1,2,3,4,5 a relatively strong association with cystic fibrosis is seen in between 8% – 40% of patients diagnosed with meconium peritonitis, in which meconium ileus with subsequent perforation is the most likely cause.1,2,4 the association of meconium peritonitis with intra-uterine cmv and parvovirus b19-infections is documented.4,5 characteristic anteand postnatal us findings include ascites, numerous scattered intra-peritoneal calcifications, and bowel distention (a combination which is pathognomonic for meconium peritonitis),2 and polyhydramnios (secondary to bowel obstruction).1,2,3,4,5 fluid and/or calcifications may also be present in the scrotum owing to a patent processus vaginalis (meconium periorchitis). a meconium pseudocyst may be isolated or multiple, and appears as a cystic mass with a thick, irregular wall (with or without calcification) and content of variable echogenicity.2 neonatal abdominal radiography reveals ascites, punctate or curvilinear peritoneal calcifications, and dilated bowel loops, with a soft-tissue mass in the presence of a meconium pseudocyst.1,2,3,4 the pseudocyst may displace intestinal loops, and demonstrate internal or rim calcification.2 the differential diagnosis for the individual imaging features of meconium peritonitis is wide, and final diagnosis is dependent on the pathognomonic combination of findings. associated conditions should be sought, such as trisomy 21, cystic fibrosis or in utero infection in the setting of echogenic bowel on pre/postnatal us. in the presence of intra-abdominal calcifications, infection, gallstones or calcifying tumours should be considered (such as hepatoblastoma, teratoma or neuroblastoma). most other intra-abdominal cysts do not calcify.2 several surgical scoring systems exist, predicting the need for neonatal surgical intervention in patients with meconium peritonitis. the zangheri scoring system (score 0–3) has been found to be very accurate.4 the likelihood of surgical intervention in patients with simple peritonitis (score 0) – those patients found to have calcifications only – is low, and careful postnatal evaluation is advised. patients with complex peritonitis (scores 1–3) need to be transferred to and delivered at a tertiary care facility, evaluated by a neonatologist and/or paediatric surgeon, and carefully followed up after birth, as the majority of these patients will require urgent neonatal surgery.2,4 consequently, the prognosis of meconium peritonitis is better if diagnosis is made antenatally, particularly in cases of complex peritonitis. new advances in intra-uterine treatment, such as fetal paracentesis and/or pseudocyst drainage, and anti-inflammatory injection, are currently under investigation.2 conclusion top ↑ meconium pseudocyst is a rare entity. however, it is an indication of complex peritonitis where early imaging diagnosis is critical for timely specialist evaluation/intervention and improved prognosis. in the hiv-positive population, cmv is an important aetiological consideration of meconium peritonitis, and further research into this association is warranted. acknowledgements top ↑ authors’ contributions s.c. (stellenbosch university) drafted the article. v.d.p. (grey’s hospital) reviewed and edited the article. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. references top ↑ valladares e, rodriguez d, vela a, cabré s, lailla jm. meconium pseudocyst secondary to ileum volvulus perforation without peritoneal calcification: a case report. j med case rep. 2010;4:292. pmid: 20807399, http://dx.doi.org/10.1186/1752-1947-4-292 woodward pj. statdx premier. meconium peritonitis, pseudocyst. salt lake city: amirsys; 2005–2014. c2005 [cited 2015 may 14–22]. available from: http://my.statdx.com dähnert w. radiology review manual. 6th ed. philadelphia: lippincott williams & wilkins; 2007; p. 856. saleh n, geipel a, gembruch u, et al. prenatal diagnosis and postnatal management of meconium peritonitis. j perinat med. 2009;37:535–538. pmid: 19492926, http://dx.doi.org/10.1515/jpm.2009.097 pletcher ba, williams mk, mulivor ra, barth d, linder c, rawlinson k. intrauterine cytomegalovirus infection presenting as fetal meconium peritonitis. obstet gynecol. 1991;78:903–905. pmid: 1656350. abstract introduction objective methodology ethical consideration results discussion conclusion acknowledgements references appendix 1 about the author(s) kevin daffue department of clinical imaging sciences, university of the free state, south africa gina joubert department of clinical imaging sciences, university of the free state, south africa susan otto department of biostatistics, university of the free state, south africa citation daffue k, joubert g, et al. computed tomography stroke findings and population demographics at pelonomi hospital, bloemfontein. s afr j rad. 2016;20(1), a993. http://dx.doi.org/10.4102/sajr.v20i1.993 research project no.: 65/2014 original research computed tomography stroke findings and population demographics at pelonomi hospital, bloemfontein kevin daffue, gina joubert, susan otto received: 23 feb. 2016; accepted: 19 july 2016; published: 22 sept. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: stroke remains the highest cause of death in patients more than 50 years old in south africa, and the fourth highest cause of death overall. there is a paucity of information regarding this disease in the free state province. objectives: to assess the stroke profile of patients referred for computed tomography (ct) imaging to our institution along with evaluating factors that could improve stroke management. method: the demographic information, stroke risk factors, stroke types and time to imaging were evaluated for all patients who presented for ct stroke imaging from july 2014 until july 2015. information was gathered prospectively from the hospital and radiology information systems. results: the study included 174 patients (53.5% female, 46.5% male). their mean age was 59 years (standard deviation (sd) 14.6). the most prevalent risk factors were hypertension (83.7%), smoking (20.5%) and diabetes (15.0%). the population group consisted of 67.8% ischaemic (n = 118) and 32.2% (n = 56) haemorrhagic strokes. the majority of patients with a known time of symptom onset (n = 102) presented after 8 hours (82.4%). the median order to report time (ort) was 61 min (range 18 min–1361 min). the median arrival to report time (art) was 32 min (range 4 min–893 min). conclusion: our stroke population did not differ significantly from others in south africa and africa overall. preand in-hospital delays significantly influenced patient numbers qualifying for thrombolysis. introduction the effect of stroke worldwide and in south africa is well known. it remains, however, the highest cause of death in patients more than 50 years of age in south africa, and the fourth highest cause of death overall.1 the impact on surviving patients, their families and support systems is considerable. to alter the course of this burden, it is first necessary to know the disease profile in the local population, which will aid in identifying reversible factors in those at risk. similar socio-demographic and risk profile studies have been conducted in south africa2,3,4 but research of this nature is lacking in the free state province. in addition, literature evaluating the various time parameters influencing stroke imaging and patient treatment is also deficient in south africa. objective the aim of the present study was to assess the stroke profile of patients referred for computed tomography (ct) imaging to our institution and to evaluate factors that could improve stroke management. methodology this prospective descriptive study was conducted at the department of clinical imaging sciences, pelonomi regional hospital, bloemfontein. the study period was one year, starting 01 july 2014. inclusion criteria all patients referred for ct brain imaging to pelonomi hospital with clinical symptoms of new onset stroke. exclusion criteria patients with a previous history of stroke and no new neurology. collection of data an electronic request form was completed for each patient by the referring physicians, using the hospital information system (his). this contained demographic-, disease profileand stroke-specific clinical information. data on the patients’ age, gender, stroke risk factors and time of symptom onset were collected from the his. time periods considered and definitions time from symptom onset (tso) time from onset of symptoms to the availability of the ct report on the his. order to report time (ort) period from when the referring physician requested imaging until report availability on the his. arrival to report time (art) period from when the patient entered the department and was registered on the radiology information system (ris) until report availability on the his. the above-mentioned information was collected from the ris. imaging and interpretation all patients were scanned by a ge discovery hd 750 64-slice multidetector computed tomography (mdct) machine. the imaging findings were interpreted by the radiology registrar responsible for the ct list on the day of imaging and were reviewed by the main researcher before data collection. findings were interpretated according to a standardised departmental imaging and reporting protocol (appendix 1). the imaging protocol was adapted from the recommended algorithm of wintermark et al., with the exclusion of magnetic resonance imaging (mri) as it was not routinely available during the study period.5 in summary, this entailed rapid assessment for ischaemic versus haemorrhagic stroke and the use of computed tomography angiography (cta) and perfusion studies where indicated. the alberta stroke programme early ct (aspect) score was applied to all acute ischaemic stroke patients considered for thrombolysis.6 interpretation style was also modelled on previous works and recommendations.7 data analysis results were summarised by frequencies and percentages (categorical variables) and means, standard deviations or percentiles (numerical variables). ethical consideration ethics approval was obtained from the ethics committee of the faculty of health sciences of the university of the free state prior to the study initiation date. as imaging and interpretation of results were performed according to existing departmental guidelines, informed consent was not needed prior to imaging. all data were noted confidentially by using the patients’ hospital number as identification. permission was also obtained from the chief medical officer of pelonomi regional hospital. results risk factors and demographics a total of 174 patients were included in the study. their mean age was 59 years (sd 14.6), ranging from 17 years – 96 years. the study population was predominantly female (n = 93, 53.5%). the most prevalent risk factor was hypertension (83.7%), followed by smoking (20.5%) and diabetes (15.0%) (table 1). table 1: demographics and risk profile. stroke type and territories the population group consisted of 67.8% ischaemic (n = 118) and 32.2% (n = 56) haemorrhagic stroke patients. the majority of them (77.3%) had middle cerebral artery (mca) territory infarcts (n = 92). the vascular territories of ischaemic infarcts are demonstrated in figure 1. four patients had no signs of ischaemia or haemorrhage (3.4%). because these patients had focal neurological deficits at the time of imaging, they were included in the ischaemic group. of these four, one had progressive neurological deficit in hospital. clinical notes could not be retrieved for the other three patients. figure 1: vascular territories of ischaemic infarcts (n = 118). time from symptom onset and scan time the tso was unknown for 72 (41.4 %) of the total number of patients. of the remaining 102, the majority (82.4%) presented after 8 hours. in the group with a known tso and ischaemic strokes (n = 67), only five patients (7.5%) presented within the four-and-a-half-hour therapeutic window for thrombolysis (figure 2). of these five, only one received intravenous recombinant tissue plasminogen activator (rtpa). clinical records on the outcome of this patient were not available. one patient had an aspect score of 4. one fell out of the therapeutic window owing to inter-hospital delays, and two did not receive rtpa for reasons not stated in the clinical notes. figure 2: stroke type versus time from symptom onset (tso). graphic illustration of the 102 patients with ischaemic infarcts and known tso. of the 63 patients with acute ischaemic stroke (< 24 hours), 33 (52.4%) had aspect scores > 7 (figure 3). figure 3: alberta stroke programme early ct (aspect) score for patients with acute ischaemic strokes (< 24 hours) and known time from symptom onset (n = 63). the median ort was 61 min (range 18–1361). coincidentally, the median was the same for the group with a known tso < 8 hours. the median art was 32 min (range 4–893). for the group presenting within 8 hours (n = 18), the median was 36.5 min (table 2). nearly two-thirds (63.1%) of the ct requests were received after normal working hours. table 2: order to report time and arrival to report time compared with international recommendations (american heart association). discussion the patient mean age of 59 years was similar to that found by connor et al. in a study conducted in johannesburg published in 2009.3 hypertension (83.7%), smoking (20.3%) and diabetes (15.0%) as the leading risk factors correlate with those observed in other studies conducted in the african continent. the meta-analysis published in 2015 by owolabi et al. established that hypertension was present in 98% of stroke sufferers in africa and was identified as the strongest modifiable risk factor.9 closer to home, connor et al. also identified hypertension as the leading risk factor (70% of patients), followed by current smoking (30%) and alcohol consumption (26%).3 the prevalence of diabetes in their study was similar to that in our population group (14%). assessing the management of such medical conditions and advocating lifestyle modification by reinforcing public awareness is pivotal in addressing stroke management. the prevalence of hiv infection could not be assessed, as this was inconsistently recorded; this was unfortunate as it would have been an interesting contribution to the study. tipping et al. found in their 2007 study that of 1087 stroke patients, 6.1% were hiv infected. the majority of the 67 patients were younger than 46 years, and had ischaemic strokes (96%). infectious meningitis or vasculitides (28%) and hiv vasculopathy (20%) were more common underlying aetiologies. the more traditionally accepted risk factors (hypertension, diabetes, etc.) were not significant risk factors in this young stroke group.10 hiv infection and antiretroviral treatment contribute to accelerated atherosclerosis and aneurysmal changes, thus increasing the risk of stroke. as found by benjamin et al., it would be difficult to identify hiv as a stand-alone risk factor in our population group, considering the high prevalence of hypertension.11 the stroke distribution (ischaemic 67.8%, haemorrhagic 32.2%) is in line with that of other population groups in africa, where the incidence of haemorrhagic stroke ranged between 29% and 57%.3,9,12 owing to unretrievable clinical records, transient ischaemic attacks could not be ascertained in terms of a cause in three of the four patients previously mentioned with normal ct findings. as stated in our imaging protocol, these patients could have benefited from additional ct perfusion studies but, owing to technical difficulties at the time (non-functional injection pump), this was not possible. a routine mri service was also not yet available. given that 52.4% of the patients with acute ischaemic strokes had aspect scores ≥ 7, but only 7.5% presented within four-and-a-half hours from symptom onset, expediting the referral and transport process would significantly increase the number of patients qualifying for rtpa. understandably, there are contributing factors beyond our control, such as the distance from hospital at the time of symptom onset. it should also be noted that our institution has an ever-enlarging catchment area owing to loss of resources in peripheral hospitals. in-hospital delays are not unique to our situation, as other developing countries experience similar problems, which was evident from an article published by gurav et al. in may 2015.13 many factors can, however, be addressed as outlined in the target stroke campaign manual released by the american heart association (aha).8 these include early notification of emergency departments by emergency medical services (ems), education of the ems personnel on appropriate triage of patients eligible for intravenous treatment, expedited in-hospital assessment and improved guidelines and protocols to minimise uncertainty by the treating physicians. such guidelines, specifically designed for the south african setting, have already been established.14 the treating physician could also accompany appropriately selected patients to the scanner; this would shorten the door-to-needle time as drug administration could then commence as soon as a relevant ischaemic stroke pattern is identified. another recommendation is to make use of a ‘single-call activation system’. this was implemented with good effect by nolte et al.15 at their institution in the form of an all-points alarm. the entire stroke team was notified simultaneously by means of an sms-based system. this method reduced their median in-hospital delay time from 54 min to 35 min and increased the number of patients treated with rtpa by 24%. as time intervals were deduced from the ris, the time of arrival in hospital and ‘door to physician time’ were unknown. we therefore used the ort, as previously defined under methodology. this is an obvious underestimation but nonetheless is still longer than recommended by international guidelines.8 our median ort was 61 min, with the recommended ‘door to report time’ being 45 min. the median reporting time of 32 min should also be addressed, as the aha recommendations permit 20 min (door-to-scan report time: 45 min; door-to-scan time: 25 min). comparison of our time parameters with aha guidelines is depicted in table 2. this period could be improved by clear interpretation protocols and increased awareness on utilising tools such as the aspect score. the effect of delayed reporting time on treatment is crucial. when applicable, the referring physician was telephonically informed of the ct findings immediately. a formal report was only released after a protracted period, which could explain the wide interquartile ranges. measuring these variables was not practically possible and could not be assumed. the fact that almost two-thirds of the scan requests occurred after hours is not surprising, as a working day consists of 8 hours. it is also a reflection of functionality of the after-hours services. following the outcome of the present study, it is our intention to reconvene with our internal medicine department about implementing the above-mentioned plans and determining further progress. limiting factors the small study population prohibits further delineation of results. as all the steps for data collection are already in place, a larger follow-up study would address this issue. because we only considered patients who underwent ct, the total number of strokes during the period could be underestimated. however, patients who did not receive imaging probably did not fall within a period in which medical intervention would alter the course of the disease process. unavailability of the exact tso onset for 72 of the 174 patients is an obvious limitation that could not be overcome. this once again reiterates the importance of public awareness in stroke management. the onset and management of hypertension and diabetes was not recorded, as this was not part of the initial study outcomes. conclusion our stroke population did not differ significantly from those documented in the rest of south africa and africa as a whole. preand in-hospital delays contributed significantly to patient numbers qualifying for thrombolytic treatment. acknowledgements competing interests the authors declare that they have no financial or personal relationships, which may have inappropriately influenced them in writing this article. authors’ contributions k.d. undertook the protocol and study design, data collection, planning and writing of the article first draft and final version, and is the main corresponding author. s.f.o was the study co-ordinator and reviewed the protocol, draft and final article. g.j. processed and reviewed data, and reviewed the draft and final article. references statistics south africa. mortality and causes of death in south africa, 2011: findings from death notification. 2011;(july). bradshaw d, groenewald p, laubscher r, nannan n, nojilana b, norman r, et al. initial burden of disease estimates for south africa, 2000. south african med j. 2003;93(9):682–8. connor md, modi g, warlow cp. differences in the nature of stroke in a multiethnic urban south african population the johannesburg hospital stroke register. stroke. 2009. p. 355–362. http://dx.doi.org/10.1161/strokeaha.108.521609 connor md, walker r, modi g, warlow cp. burden of stroke in black populations in sub-saharan africa. lancet neurol. 2007;6(3):269–278. http://dx.doi.org/10.1016/s1474-4422(07)70002-9 wintermark m, sanelli pc, albers gw, bello j a, derdeyn cp, hetts sw, et al. imaging recommendations for acute stroke and transient ischemic attack patients. jacr [internet]. 2013;1–5. http://dx.doi.org/10.1016/j.jacr.2013.06.019 understanding alberta stroke program early ct score (aspects) [internet]. available from: http://www.aspectsinstroke.com/collateral-scoring/ de lucas em, sánchez e, gutiérrez a, mandly ag, ruiz e, flórez af, et al. ct protocol for acute stroke: tips and tricks for general radiologists. radiographics. 2008;28(6):1673–87. http://dx.doi.org/10.1148/rg.286085502 american heart association. target: stroke campaign manual. 2010. available from: http://www.strokeassociation.org/idc/groups/heart-public/@wcm/@hcm/@gwtg/documents/downloadable/ucm_308277.pdf owolabi mo, akarolo-anthony s, akinyemi r, arnett d, gebregziabher m, jenkins c, et al. the burden of stroke in africa: a glance at the present and a glimpse into the future. cardiovasc j afr. 2015;26(2):27–38. http://dx.doi.org/10.5830/cvja-2015-038 tipping b, de villiers l, wainwright h, candy s, bryer a. stroke in patients with human immunodeficiency virus infection. j neurol neurosurg psychiatry. 2007;78(12):1320–1324. http://dx.doi.org/10.1136/jnnp.2007.116103 benjamin l a, bryer a, emsley hc, khoo s, solomon t, connor md. hiv infection and stroke: current perspectives and future directions. lancet neurol [internet]. 2012;11(10):878–890. http://dx.doi.org/10.1016/s1474-4422(12)70205-3 bryer a. “time is brain” and stroke units: stroke care today: editorial. south african j diabetes vasc dis. 2008;5(4):151–153. gurav s, zirpe k, wadia r, pathak m, deshmukh a, sonawane r, et al. problems and limitations in thrombolysis of acute stroke patients at a tertiary care center. indian j crit care med [internet]. 2015;19(5):265. http://dx.doi.org/10.4103/0972-5229.156468 bryer a, connor m, haug p, cheyip b, staub h, tipping b, et al. south african guideline for management of ischaemic stroke and transient ischaemic attack 2010: a guideline from the south african stroke society (sass) and the sass writing committee. s afr med j. 2010;100(11 pt 2):747–778. http://dx.doi.org/10.7196/samj.4422 nolte ch, malzahn u, kühnle y, ploner cj, müller-nordhorn j, möckel m. improvement of door-to-imaging time in acute stroke patients by implementation of an all-points alarm. j stroke cerebrovasc dis. 2013;22(2):149–153. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.07.004 appendix 1 imaging protocol used step 1 assess the aetiology of the intracranial haemorrhage (ncct [non-contrast ct]), (cta [ct angiogram]) for vascular pathologies, such as aneurysms, arteriovenous malformations, vasculopathies. additionally, determine if the patient is not a candidate for iv tpa (contraindication to tpa, outside the time window for tpa or if iv tpa failed or it is thought that it might fail). step 2 for patients who are outside the time window for acute reperfusion therapies (4.5 hours at sites where only iv tpa is being considered; 8 hours at sites where endovascular therapy is considered) and for patients with tias. emphasis is on secondary prevention, and their imaging work-up should focus on vascular imaging (cta or doppler-ultrasound [dus]) to assess carotid arteries as a possible cause of the ischaemic stroke, with secondary prevention in mind (pct = perfusion ct). a. assess for intracranial haemorrhage. b. assess the extent of the ischaemic core. c. assess the location and extent of the intravascular clot. d. assess carotid atherosclerotic disease. e. assess the extent of viable tissue. interpretation questions to be answered following each scan is the lesion(s) in the cns caused by ischaemia or haemorrhage, or is it related to a nonvascular stroke mimicker? where is the lesion, what is its size, shape and extent? what is the nature of the severity of the vascular lesion? how do the vascular lesions and brain perfusion abnormalities relate to the lesion? are abnormalities of blood constituents causing or contributing to ischaemia or haemorrhage? perceived age of infarction (hyperacute, acute, subacute). these findings should be documented in the report. article information author: eleanor a. ochodo1 affiliation: 1centre for evidence-based health care, faculty of medicine and health sciences, stellenbosch university, south africa correspondence to: eleanor ochodo email: eochodo@sun.ac.za postal address: centre for evidence-based health care, faculty of medicine and health sciences, stellenbosch university, po box 19063, tygerberg 7505, south africa how to cite this article: ochodo ea. reporting of diagnostic accuracy studies in radiology. s afr j rad. 2014;18(1); art. #712, 2 pages. http://dx.doi/org.10.4102/sajr.v18i1.712 note: dr eleanor ochodo is a specialist in diagnostic test evaluation, systematic reviews and evidence-based medicine. she has an mb chb degree from the university of nairobi (kenya), a master's degree in international health from the free university of amsterdam (the netherlands), and a doctorate in clinical epidemiology from the university of amsterdam. she is currently a senior scientist at the centre for evidencebased health care at stellenbosch university. dr ochodo serves as an extended member of the stard initiative, in a group that is currently revising the original stard guidelines. copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. reporting of diagnostic accuracy studies in radiology in this editorial... open access • introduction • acknowledgements • references introduction top ↑ the use of technologically based imaging tests to diagnose diseases and lesions is a fundamental function in radiology. such tests must be evaluated before their introduction, and during their routine use, in clinical practice to ensure that their performance remains constant. one way of measuring the performance of a medical test is by evaluating its accuracy. accuracy is defined as the ability of a test to correctly distinguish those subjects who have a target condition from those who do not.1, 2, 3 a target condition can be the presence or stage of a disease or infection. accuracy is commonly measured by parameters such as sensitivity (the probability of a positive test result amongst those with disease) and specificity (the probability of a negative test result amongst those without disease). other parameters include predictive values, likelihood ratios and area under the receiver operating characteristic (roc) curve. in research, the accuracy of a test is estimated by comparing the results of the test of interest (index test) with the results of the best available test (reference test).1, 2, 4 for instance, one may wish to estimate the accuracy of chest radiographs in detecting a chest lesion. this may be done by subjecting a sample of patients to chest radiography and to computed tomography (ct) scanning, which is the best available test. chest radiographs can then be compared with ct scans. once a study has been carried out, it is important to report the results adequately. comprehensive and transparent reporting of the conduct and results of a study enable an objective appraisal by readers of the study.5 a study may report impressive accuracy measures but fail to report flaws in the study design or study conduct that might have compromised the accuracy measures. the accuracy of diagnostic tests is also known to vary according to the spectrum of patients tested, the severity or stage of disease, differences in test types or technology, and how a test is conducted.6 a test may perform well in one setting but dismally in another setting. poor or inadequate reporting may consequently lead to the uptake or use of suboptimal tests in practice, unnecessary testing, high health care costs and compromising the wellbeing of patients. more guidance and information on the importance of adequate reporting can be obtained via a network that is devoted to enhancing the quality and transparency of health research (the equator network; http://www.equator-network.org). to guide authors of diagnostic accuracy studies on how to report their work for publication, a guideline for standards for the reporting of diagnostic accuracy (stard) was introduced in 2003. the stard guideline comprises a checklist of 25 items that are recommended for reporting.5 more information on the stard initiative can be found at http://www.stard-statement.org. in view of the existence of stard, has reporting improved? in general, evidence suggests that reporting is slowly improving.7, 8, 9 a recently published systematic review by korevaar and colleagues that examined 16 studies which assessed adherence to stard showed that there was a small improvement in the reporting quality of diagnostic accuracy studies.8 in the area of diagnostic radiology, one study showed that the reporting quality of many published diagnostic accuracy studies remained low.10 the former study was published 5 years after the introduction of stard. a slow uptake has also been observed in reporting guidelines for other types of studies, including the consolidated standards for reporting of trials (consort).11 this slow uptake may be attributed to lack of knowledge of the existence of stard, or vagueness in journal instructions to authors on the use of stard. in addition, some of the reporting items may not be applicable to some accuracy studies, leading to authors abstaining from using the guideline.12 against this background, how can adherence to stard guideline be improved? increased awareness of the existence and importance of stard by authors, peer reviewers and journals would be a good start; this could be done by alerting journals to the existence of stard by publishing more articles and letters on the importance of the proper reporting of diagnostic accuracy studies; more and clearer author instructions in journals on adherence to the stard guideline; and via other forums such as medical conferences and interactive medical meetings. evidence is that these interventions may not be effective in changing behaviour when used in isolation, but are more effective when in combination.13, 14, 15, 16 in addition, the consort statement has been revised twice (in 2001 and 2010) since its initial introduction in 1996.17, 18 likewise, plans are underway to revise the stard guideline to make it simpler and accommodate other aspects of diagnostic accuracy.12 it is hoped that this revised version will become more known to authors and further improve the reporting of accuracy studies. lastly: change in practice takes time. given sufficient time, growing awareness of stard should lead to more improvements in reporting diagnostic accuracy studies. in south africa, increased awareness may begin within radiology, a field that is characterised by the widespread use of imaging tests for diagnostic purposes. acknowledgements top ↑ the author acknowledges professor charles wiysonge for critical comments on an earlier version of this submission. references top ↑ macaskill p, gatsonis c, deeks jj, harbord rm, takwoingi y. chapter10: analysing and presenting results. in: deeks jj, bossuyt pm, gatsonis c, editors. cochrane handbook for systematic reviews of diagnostic test accuracy, version 1.0. london: the cochrane collaboration, 2010. available from http://srdta.cochrane.org/ van stralen kj, stel vs, reitsma jb, dekker fw, zoccali c, jager kj. diagnostic methods i: sensitivity, specificity, and other measures of accuracy. kidney int. 2009;75(12):1257–1263. http://dx.doi.org/10.1038/ki.2009.92 reitsma jb, glas as, rutjes aws, scholten rjpm, bossuyt pm, zwinderman ah. bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. j clin epidemiol. 2005;58(10):982–990. http://dx.doi.org/10.1016/j.jclinepi.2005.02.022 ochodo ea, leeflang mmg. systematic reviews of diagnostic test accuracy for evidence-based diagnostic practice in africa. afr j lab med. 2011;1(1):1–3. http://dx.doi.org/10.4102/ajlm.v1i1.7 bossuyt pm, reitsma jb, bruns de, et al. towards complete and accurate reporting of studies of diagnostic accuracy: the stard initiative. ann intern med. 2003;138(1):40–44. http://dx.doi.org/10.7326/0003-4819-138-1-200301070-00010 whiting p, rutjes aws, reitsma jb, glas as, bossuyt pmm, kleijnen j. sources of variation and bias in studies of diagnostic accuracy: a systematic review. ann intern med. 2004;140(3):189–202. http://dx.doi.org/10.7326/0003-4819-140-3-200402030-00010 bossuyt pmm. stard statement: still room for improvement in the reporting of diagnostic accuracy studies. radiol. 2008;248(3):713–714. http://dx.doi.org/10.1148/radiol.2483080868 korevaar da, van enst wa, spijker r, bossuyt pmm, hooft l. reporting quality of diagnostic accuracy studies: a systematic review and meta-analysis of investigations on adherence to stard. evid based med. 2014;19(2):47–54. http://dx.doi.org/10.1136/eb-2013-101637 korevaar d, wang j, van enst w, et al. reporting diagnostic accuracy studies: still improving after nine years of stard? radiol. in press 2014. wilczynski nl. quality of reporting of diagnostic accuracy studies: no change since stard statement publication before-and-after study. radiol. 2008;248(3):817–823. http://dx.doi.org/10.1148/radiol.2483072067 hopewell s, altman dg, moher d, schulz kf. endorsement of the consort statement by high impact factor medical journals: a survey of journal editors and journal ‘instructions to authors’. trials. 2008;9:20. http://dx.doi.org/10.1186/1745-6215-9-20 ochodo ea, bossuyt pm. reporting the accuracy of diagnostic tests: the stard initiative 10 years on. clin chem. 2013;59(6):917–919. forsetlund l, bjørndal a, rashidian a, et al. continuing education meetings and workshops: effects on professional practice and health care outcomes. cochrane database syst rev. 2009;15(2):cd003030. giguère a, légaré f, grimshaw j, et al. printed educational materials: effects on professional practice and healthcare outcomes. cochrane database syst rev. 2012;17(10):cd004398. flodgren g, parmelli e, doumit g, et al. local opinion leaders: effects on professional practice and health care outcomes. cochrane database syst rev. 2011;10(8):cd000125. ivers n, jamtvedt g, flottorp s, et al. audit and feedback: effects on professional practice and healthcare outcomes. cochrane database syst rev. 2012;13(6):cd000259. moher d, schulz kf, altman dg. the consort statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. ann intern med. 2001;134(8):657–662. http://dx.doi.org/10.7326/0003-4819-134-8-200104170-00011 moher d, hopewell s, schulz kf, et al. consort 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. j clin epidemiol. 2010;63(8):e1–e37. http://dx.doi.org/10.1016/j.jclinepi.2010.03.004 article information authors: farzanah i. ismail1 rule human2 anith chacko1 parmanand naran2 samia ahmad1 siraj ellemdin2 affiliations: 1department of radiology, steve biko academic hospital and university of pretoria, south africa 2department of internal medicine, steve biko academic hospital and university of pretoria, south africa correspondence to: farzanah ismail postal address: level 5, bridge e, steve biko academic hospital, voortrekker road, gezina, pretoria 0002, south africa dates: received: 09 nov. 2013 accepted: 05 dec. 2013 published: 30 may 2014 how to cite this article: ismail fi, human r, chacko a, naran p, ahmad s, ellemdin s. incidental right bochdalek hernia with interruption of the inferior vena cava and hepatic venous collateral continuation: a case report. s afr j rad. 2014;18(1); art. #592, 3 pages. http://dx.doi.org/10.4102/ sajr.v18i1.592 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. incidental right bochdalek hernia with interruption of the inferior vena cava and hepatic venous collateral continuation: a case report in this case report... open access • abstract • case report • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ a 36-year-old asymptomatic female had a routine chest radiograph to exclude pulmonary tuberculosis, as part of an employee wellness programme. there was opacification of the right lower thorax. computed tomography and venography demonstrated an incidental right bochdalek hernia with interruption of the inferior vena cava (ivc) and hepatic venous collateral continuation. the association of a bochdalek hernia with an anomaly of the ivc is rare, with only one case described in the literature. case report top ↑ a 36-year-old female underwent a routine medical evaluation as part of an employee wellness programme. she was diagnosed positive for human immunodeficiency virus (hiv) and was referred for a chest radiograph as part of a work-up to exclude pulmonary tuberculosis. the chest radiograph demonstrated opacification in the right lower chest (not shown). the differential diagnosis included an elevated right hemidiaphragm, a diaphragmatic hernia or a subpulmonic pleural effusion. she had an absolute cd4 count of 752 x 106/l and a slightly elevated aspartate transaminase (ast) of 42 u/l (normal range 13–35 u/l). other biochemical markers were normal. a chest drain was inserted but as no fluid drained from the tube it was removed, and she was referred for further evaluation.contrast-enhanced computed tomography (ct) of the chest and abdomen demonstrated a posterior defect in the right hemidiaphragm with herniation of the liver into the thorax (see figure 1). the intrahepatic component of the inferior vena cava (ivc) was interrupted and drained directly into a medial hepatic vein in the right lobe of the liver. the hepatic venous anatomy was distorted. it consisted of a collection of dilated, tortuous veins within the liver parenchyma. one of the hepatic veins drained directly into the right atrium (see figure 2). the azygous vein was also enlarged (see figure 3). the portal venous system was not affected. the findings were confirmed on a venography study of the ivc (see figure 4). the final diagnosis was an incidental right-sided bochdalek hernia associated with interruption of the ivc with continuation via the azygous vein and hepatic venous collaterals into the right atrium. figure 1: coronal contrast-enhanced ct of the chest and upper abdomen demonstrating a defect in the posterior right hemidiaphragm (arrow) with herniation of the liver into the thoracic cavity, in keeping with a bochdalek hernia. figure 2: coronal contrast enhanced ct of the chest and abdomen which shows (a) the interrupted ivc (arrow) draining draining into (b) an enlarged hepatic vein in the medial right middle lobe which enters (c) the right atrium (arrow). figure 3: axial contrast-enhanced ct of the chest which demonstrates enlarged tortuous intrahepatic venous collaterals (arrow 1) and an enlarged azygous vein (arrow 2). figure 4: angiographic evaluation of the ivc. the catheter is placed within the infrahepatic ivc (a) with abrupt truncation of the ivc superiorly. later phase of the study (b) shows filling of the distal interrupted ivc with draining of multiple hepatic venous collaterals, one of which drains into the right atrium (arrow). discussion top ↑ the diaphragm develops at weeks 4–12 in embryogenesis and consists of four parts, namely the pleuroperitoneal folds, the transverse septum, the oesophageal mesentery and the muscular body wall. a posterior (bochdalek) hernia represents a developmental defect in the pleuroperitoneal folds or failure of fusion between the pleuroperitoneal folds and the transverse septum.1 it was first described by victor alexander bochdalek in 1867 and is the most common type of congenital diaphragmatic hernia.2 left-sided bochdalek hernias are more common than right-sided bochdalek hernias, although patients may also present with bilateral bochdalek hernias (which are very rare).3bochdalek hernias are usually detected in the neonatal period as the hernia causes compression of the lung parenchyma, which may cause respiratory distress and cyanosis.4 bochdalek hernias were found to be asymptomatic in 14% of patients (usually in females with right-sided hernias) in a review conducted by brown et al.3 they also found that 12% of patients with a bochdalek hernia may have associated cardiac, pulmonary or gastrointestinal abnormalities but associated ivc abnormalities were not described. the incidence of developmental abnormalities of the ivc is approximately 1%. 5 the embryogenesis of the ivc is complex, involving the development, regression, anastomosis and replacement of three pairs of venous channels, namely the posterior cardinal, subcardinal and supracardinal veins.5,6 by the seventh week of development in utero, the subcardinal venous system (also known as the retrohepatic segment of the ivc) is dominant. the right subcardinal vein and the hepatic vein fuse to form the prerenal segment of the ivc. failure of this fusion results in the so-called interruption of the infrahepatic ivc.5 this results in the formation of collateral venous drainage, which commonly involves the azygous, hemi-azygous and portal venous system. development of multiple intrahepatic veins (as in the case of our patient) occurs exceptionally, with only a few cases having being reported in the literature. chevallier et al. found that a prerequisite for the formation of intrahepatic venous continuation is the presence of an inferior right hepatic vein, which is present in 10% of the population. it drains the right dorsolateral aspect of the liver directly to the ivc.6 the combination of a right-sided bochdalek hernia together with interruption of the ivc and the formation of intrahepatic venous collaterals (as is presented in this case study) is extremely rare, with only one similar case having being reported in the literature.7 conclusion top ↑ an adult patient presenting with the combination of a right-sided bochdalek hernia and an interrupted ivc with hepatic venous collaterals, as described in this case report, is an extremely rare occurrence. patients with bochdalek hernias should always be investigated in order to exclude associated anomalies. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions f.i.i. and r.h. (both from steve biko academic hospital and university of pretoria) were initial contributors and main authors. a.c., f.i.i. and s.a. (from steve biko academic hospital and university of pretoria) were involved in the interventional radiology procedures and provided interpretation of the radiological images used in the article. p.n. and s.e. (both from steve biko academic hospital and university of pretoria) provided clinical input and advice in write-up. references top ↑ 1. nason lk, walker cm, mcneeley mf, burivong w, fligner cl, godwin jd. imaging of the diaphragm: anatomy and function. radiographics. 2012;32:e51–e70. http://dx.doi.org/10.1148/rg.3221151272. temizöz o, gençhellaç h, yekeler e, et al. prevalence and mdct characteristics of asymptomatic bochdalek hernia in adult population. diagn interv radiol. 2010;16(1):52–55. http://dx.doi.org/10.4261/1305-3825.dir.2750-09.1 3. brown sr, horton jd, trivette e, hofmann lj, johnson jm. bochdalek hernia in the adult: demographics, presentation, and surgical management. hernia. 2011;15:23–30. http://dx.doi.org/10.1007/s10029-010-0699-3 4. kinoshita f, ishiyama m, honda s, et al. late-presenting posterior transdiaphragmatic (bochdalek) hernia in adults: prevalence and mdct characteristics. j thorac imaging. 2009;24:17–22. http://dx.doi.org/10.1097/rti.0b013e31818c6bc8 5. balkanci f, ozmen mn. case report: interruption of the inferior venal cava with anomalous intrahepatic continuation. brit j radiol. 1993;66:457–459. http://dx.doi.org/10.1259/0007-1285-66-785-457 6. chevallier p, peten ep, marcy p, fabiani p, diaine b, padovani b. inferior vena cava hypoplasia with intrahepatic venous continuation: sonographic, angiographic and mr features including mr angiography. clin imaging. 1999;23:99–102. http://dx.doi.org/10.1016/s0899-7071(99)00111-4 7. mori m, sakamoto t, aoki s, et al. a case of bochdalek hernia accompanied by complicated anomalies of the ivc and hepatic vein. [case reports, english abstract, journal article]. rinsho hoshasen. 1988;33:495–498. untitled introduction lymphoctytic interstitial pneumonitis (lip) is an interstitial pneumonia, recently included in the radiological/histopathological classification of the interstitial pneumonias.1,2 although known to be aidsdefining in children, lip is still thought to be unusual in hiv-positive adults. materials and methods between 1996 and 2003, 93 hiv-positive patients with indeterminate chest pathology at helen joseph hospital, johannesburg were subjected to diagnostic bronchoscopy. wherever possible, biopsies were taken. the only selection criterion, was an inability to arrive at a diagnosis either clinically or radiologically. helen joseph hospital admits a cross-section of the south african population, namely black, white and asian patients. a high percentage of admissions are hiv-positive. the findings were evaluated retrospectively. results thirteen of the 93 patient were found to have lip. where the diagnosis came back as lip histopathologically, the slides were then sent for review to the pathology department. of the 15 cases of lip originally diagnosed, 13 were confirmed to be lip, 1 was tuberculosis (tb) and the other was nonspecific interstitial pneumonitis. discussion lip is an inflammatory, lymphoproliferative non-neoplastic process representing a pulmonary reaction to various external stimuli or systemic diseases.2,3 in 1969, liebow and carrington1 classified lip together with the other interstitial pneumonias. subsequently, however, a number of the lesions were found to be low-grade malignant lymphoproliferative diseases. lip was then excluded from the classification of interstitial pneumonias. recently, lip has been reincluded in the american thoracic society and european respiratory society 2002 cassification of idiopathic interstitial pneumonia. 1 pathologically, lip is a diffuse pulmonary lymphoid proliferation, predominantly in the interstitium, in an alveolar septal distribution.1-5 it appears that a transient lymphocytic alveolitis may develop in some hiv-positive patients, as an immune response to the hiv virus which, in a certain percentage of individuals, evolves into lip. both b and t-cells, plasma cells and macrophages are present within the interstitial infiltrate. lymphoid follicules with germinal centres occur. lung architecture is preserved (fig.1). pertinent negative features are the absence of cell atypia and airspace disease. the lack of tracking along lymphatic routes in the pleura, bronchovascular bundles and interlobular septae, helps to differentiate lip from lymphomas. lymph node involvement in lip is now more often recognised than it was in the past. lip is associated with a number of systemic conditions, typically sjogren’s syndrome and autoimune diseases. it also occurs post bone marrow transplantation, may be drug induced, e.g. after phenytoin exposure, and may rarely be idiopathic.3 it is twice as common in women. recently, it has become an aids-defining condition in children 6,7, but it has been described as being uncommon or infrequently associated with hiv-positive adults. it was first described in hiv-positive adults, in the haitian, afro-caribbean/afro-american population in aids-related literature between 1983 and 1985.8,9 sporadic reports of lip in hiv-positive adults have been published since then.3 clinically, patients present with progressive cough and dyspnoea. they may, however, remain stable without significant deterioration. spontaneous resolution may occur. the disease usually follows an indolent course and is often an incidental finding rather than the patient’s presenting complaint. the mortality of hiv-positive patients afflicted with lip is not adversely affected.2 lip is variable in its course. it usually occurs in patients whose cd4 t-cell counts are within the normal range. hiv-positive patients with nonspecific interstitial pneumonitis usually have lower cd4 t-cell counts, around 200 cells x 106/l,5 but both conditions are reported in patients with normal range cd4 counts. the outcome and prognosis of lip is significantly affected by its natural history and response to antiretroviral treatment of original article 14 sa journal of radiology • december 2005 lymphocytic interstitial pneumonitis (pneumonia) in hivpositive adults e joseph mb bch, ffrad (diag) g rubin mb bch, da (sa), fcrad (diag) (sa) department of radiology university of the, witwatersrand johannesburg j murray ba, mb bch, doh, pgce (lond), ffpath national institute of occupational health johannesburg fig. 1. a lymphoplasmacytic cellular infiltrate is present in the interstitium forming nodules (a) and expanding the alveolar walls (b). alveolar spaces (c) are compressed. 12 11/25/05 12:24 pm page 14 original article 15 sa journal of radiology • december 2005 the underlying hiv infection. in most cases, lip in hiv-infected patients improves in response to corticosteroids. the literature also suggests that improvement of lip occurs in parallel to a decrease of hiv viral load and with an increase in cd4 cell count.3 paradoxically, however, the stronger the immune system the more severe the interstitial infiltration is likely to be.3,8 thus resolution in the absence of antiretroviral or corticosteroid therapy can herald a worsening of immune suppression. it should be noted, however, that spontaneous clinical and radiographic resolution without immune deterioration can also occur.2,3,5 the classical chest radiograph presentation is of bilateral, predominantly lowerzone nodular or reticular-nodular opacities. four radiographic categories have been most recently described (figs 2-5).3 these presenting histories are typical for hiv-positive adults with lip. the respiratory symptomatology is minimal and the disease process is indolent. the chest x-ray opacities are confirmed on high-resolution computed tomography (hrct) to be centrilobular and subpleural nodules of various sizes. patchy bilateral and diffuse ground glass opacities on hrct contribute to the infiltrates seen on chest x-ray, and represent a summation of lymphoid cellular infiltrates within the interstitium, rather than air space disease. ct also helps identify hilar and mediastinal lymphadenopathy, both of which have been found to be more common than previously thought. the high frequency of cysts noted on ct in lip patients is a consequence of post-obstructive bronchiolar ectasia from infiltrate compressing the bronchioles.1,3,4,5 the differential diagnosis of the radiographic findings and patterns of lip includes infection with pneumocystis carinii and special stains are done to exclude the presence of the microorganism.2-4 viral diseases such as infectious mononucleosis, fungal pneumonias and tb may mimic lip, as does post-transplant lymphoproliferative disorder. nonspecific interstitial pneumonia is described more commonly in hiv-positive adults, and other benign lymphoproliferative disorders such as follicular type ii. coarse reticularnodular opacities, nodules, < 3 5 mm. fig. 3. twenty-five-year-old female patient, presented with dysphagia due to oral candidiasis. she was on anti-tb treatment for 2 months. no respiratory symptoms. type 1. fine reticularnodular opacities, nodules, < 3 mm. fig. 2. fifty-year-old female patient, relatively well, with a non-productive cough of some months’ duration. 12 11/25/05 12:24 pm page 15 broncholitis are considered together with lip to be along the same morphological spectrum, with some overlap.3 differentiation from hypersensitivity pneumonitis, organising pneumonia and usual interstitial pneumonia needs to be considered. importantly, the major differential diagnosis is the separation of lip from lowgrade lymphoma, where tracking along lymphoid routes, invasion of parietal pleura and lymph nodes are present, together with destruction of lung architecture and the presence of intranuclear inclusions in b-lymphocytes. in hiv-positive patients lip is not considered pre-lymphomatous.2,6 in most cases where lip was followed by the development of lymphoma in an individual patient, the lesion was subsequently thought to have represented malignant lymphoma from the beginning, rather than lip. conclusion our observation leads us to believe that at least in the south african context, lip in hiv-positive adults is more common than reports in the world literature suggest. we believe that lip should be included in the differential diagnosis in an interstitial pneumonitis presenting in the hiv-positive adult population. references 1. wittram c, mark f, mcloud tc. ct histological correlation of the ats/ers 2002 classification of idiopathic interstitial pneumonias. radiographics 2003; 23: 1057-1071. 2. travis wd, galvin jr. non-neoplastic pulmonary lymphoid lesions. thorax 2001; 56: 964-971. 3. swigris jj, berry gj, raffin ta, et al. lymphoid interstitial pneumonia, a narrative review. chest 2002; 122: 2160-2164. 4. mcguinness g, scholes jv, jagirdar js, et al. unusual lymphoproliferative disorders in nine adults with hiv or aids: ct and pathological findings. radiology 1995; 197: 59-65. 5. das s, miller rf. lymphocytic interstitial pneumonia in hiv infected adults. sex transm infect 2003; 79: 88-93. 6. mcguinness g. changing trends in the pulmonary manifestations of aids. radiol clin north am 1997; 35: 1029-1082. 7. miller cr. paediatric aspects of aids. radiol clin north am 1997; 35: 1191-1221. 8. oldham aa, castillo m, jacobson fl, et al. hivassociated lymphocytic interstitial pneumonia: radiologic manifestations. and pathologic correlation. radiology 1989: 170: 83-87. 9. heitzman er. pulmonary neoplastic and lymphoproliferative diseases in aids: a review. thoracic radiology 1990; 177: 347-351. 16 sa journal of radiology • december 2005 original article type iii. findings of either type i or type ii plus at least one patchy opacity. fig. 4. forty-year-old female patient. no history available. type iv. findings of either type i or type ii with focal alveolar consolidation resembling pneumonia. fig. 5. thirty-five-year-old male patient. treated for bacterial infection for 1 month. a febrile, persistent non-productive cough. chest x-ray was done for follow-up of his pneumonia. 12 11/25/05 12:24 pm page 16 abstract introduction mapping subtypes: technical clinical utility future developments conclusion acknowledgements references about the author(s) rebecca schofield barts heart centre, st bartholomews hospital, london, united kingdom anish bhuva barts heart centre, st bartholomews hospital, london, united kingdom katia manacho barts heart centre, st bartholomews hospital, london, united kingdom james c. moon barts heart centre, st bartholomews hospital, london, united kingdom institute of cardiovascular science, university college london, united kingdom citation schofield r, bhuva a, manacho k. & moon jc. cardiovascular magnetic resonance frontiers: tissue characterisation with mapping. s afr j rad. 2016;20(2), a1019. http://dx.doi.org/10.4102/sajr.v20i2.1019 review article cardiovascular magnetic resonance frontiers: tissue characterisation with mapping rebecca schofield, anish bhuva, katia manacho, james c. moon received: 01 may 2016; accepted: 04 aug. 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the clinical use of cardiovascular magnetic resonance (cmr) imaging has expanded rapidly over the last decade. its role in cardiac morphological and functional assessment is established, with perfusion and late gadolinium enhancement (lge) imaging for scar increasingly used in day-to-day clinical decision making. lge allows a virtual histological assessment of the myocardium, with the pattern of scar suggesting disease aetiology, and the extent of predicting risk. however, even combined, the full range of pathological processes occurring in the myocardium are not interrogated. mapping is a new frontier where the intrinsic magnetic properties of heart muscle are measured to probe further. t1, t2 and t2* mapping measures the three fundamental tissue relaxation rate constants before contrast, and the extracellular volume (ecv) after contrast. these are displayed in colour, often providing an immediate appreciation of pathology. these parameters are differently sensitive to pathologies. iron (cardiac siderosis, intramyocardial haemorrhage) makes t1, t2 and t2* fall. t2 also falls with fat infiltration (fabry disease). t2 increases with oedema (acute infarction, takotsubo cardiomyopathy, myocarditis, rheumatological disease). native t1 increases with fibrosis, oedema and amyloid. some of these changes are large (e.g. iron, oedema, amyloid), others more modest (diffuse fibrosis). they can be used to detect early disease, distinguish aetiology and, in some circumstances, guide therapy. in this review, we discuss these processes, illustrating clinical application and future advances. introduction cardiac imaging has focussed on the assessment of myocardial function, cardiac morphology, valves and coronary artery disease. assessment of cardiac fibrosis and infiltration was the domain of histopathology. late gadolinium enhanced (lge) imaging by cardiovascular magnetic resonance (cmr) changed this. the identification of infarcted myocardium and its transmural extent became possible, which was the first in vivo histological assessment of the myocardium, representing a turning point in our approach to myocardial disease. however, it was rapidly realised that lge was also visible in most other diseases, such as cardiomyopathies and infiltrative diseases. the patterns and location of lge could aid diagnosis, whilst the extent was prognostic. lge made a major difference to clinical care in many areas. however, there are limitations: scar is a final common pathway in many conditions and largely irreversible – it is the remote myocardium where the potential to modify disease lies. the lge technique misses diffuse fibrosis and provides no information about how non-scarred myocardium is adapting or the risk of future scar. the lge technique also fails to adequately distinguish acute oedema from chronic scar, and many dozens of other pathologies are completely missed (all cellular processes, and most exogenous processes such as infiltration by iron or fat). mapping is a new approach. here, the three intrinsic magnetic relaxation properties of the myocardium are measured (t1, t2, t2*) for every image pixel and the absolute values displayed as a colour map with no need for subsequent processing. this represents a major change from the past when imaging used to be ‘weighted’ so that areas of higher t1 or t2 would appear brighter. this was useful for regional heterogeneity (myocarditis, sarcoid, infarction), but values could not be compared between individuals or tracked in the same individual over time. diffuse processes were missed. however, mapping changed this situation. the differences from normal in some diseases are large and clinical utilities are wide and potentially diverse, including early diagnosis, detection of phenotypes, new diseases, prognostication and therapy monitoring. mapping subtypes: technical t1 mapping native t1 mapping (performed prior to contrast administration) has great promise. t1 mapping sequences require three components: (1) a saturation or inversion recovery preparation pulse; (2) the collection of 6 to 10 images at different times post preparation pulse; and (3) curve fitting to derive a t1 value for every image pixel. this is done in a single breath-hold. many of the initial challenges are now solved and the accuracy and precision of the test is good for test indications with large pathological changes, although more is needed for some indications, particularly diffuse fibrosis. standardisation is also needed as t1 measures differently in different scanners and set-ups, so local reference ranges are needed.1 partial voluming of the myocardium from the blood pool remains a valid concern regarding accuracy. progress is being made with an initial consensus statement2 and several planned quality control phantom systems. t2 mapping absolute t2 values are sensitive for oedema and thus helpful in assessment of myocarditis, takotsubo cardiomyopathy, acute myocardial infarction (mi), sarcoidosis, allograft rejection and rheumatological disease. to generate a t2 map, the same principles as t1 apply, but this time with sampling of the t2 recovery curve, usually with three images. t2*mapping the most established use of parametric mapping is t2* imaging. it revolutionised the diagnosis and quantification of cardiac siderosis and routinely guides therapy. it can be used to detect myocardial haemorrhage and it can utilise the difference in the magnetic state of oxyhaemoglobin (diamagnetic) and deoxyhaemoglobin (paramagnetic) in blood oxygen level dependent (bold>) imaging. mapping removes the need for post processing. t2* is much less scanner dependent and is more robust. extracellular volume fraction (ecv) mapping measuring the myocardial interstitium is becoming easier with progressive simplification. initial multi-breath-hold flash techniques were replaced by t1 maps pre and post-contrast (administered as a bolus followed by infusion or with scanning performed at several time points).3 this procedure is now replaced by a single preand single post-contrast t1 map.4 these images can now be combined into an ecv map.5 most recently, a synthetic ecv map can be automatically generated during scanning, in which the haematocrit (hct) of blood is inferred from the t1 of the blood pool (as the relationship between hct and r1 {1/blood t1} is linear), removing the need for a blood test.6 ecv quantification is less field and sequence sensitive than native t1 mapping but ecv standardisation is ongoing. clinical utility as previously mentioned, t1 maps show elevated t1 values in amyloid, oedema and fibrosis and shortened values in lipid accumulation and iron deposition. t2 values are elevated in the presence of oedema and t2* is exquisitely sensitive for myocardial iron and haemorrhage. ecv maps allow quantification of the ecv which increases in fibrosis, oedema and infiltrative processes (figure 1). figure 1: extracellular volume fraction versus native t1 across a variety of conditions including physiological adaptation in athletes. acute myocardial infarction not every mi is the same and mapping helps to decode why this is so. patient profiles, ischaemic time and revascularisation methods, presence of microvascular obstruction (mvo) causing no-reflow, intramyocardial haemorrhage (imh), oedema and myocardial necrosis are some of the variables at play. post mi cmr imaging can identify mvo, intramyocardial haemorrhage (imh), infarct size and oedema, all of which have prognostic implications for left ventricle (lv) remodelling. mapping provides a window into the remodelling process. recent work has shown that acute imh leads to chronic iron deposition which may be a source of ongoing inflammation as t2 values around the iron remained high. in addition, remote myocardial raised t1 and ecv were predictive of adverse remodelling. in addition, procedural percutaneous coronary intervention (pci)-related micro-infarcts are detectable using lge cmr imaging7 (figure 2). figure 2: mid short-axis cross-section through the left ventricle and right ventricle. t1, t2, t2* maps and lge images (from left to right respectively) show a large septal, anteroseptal and anterior wall infarct (lad territory) acute mi. the t2* maps show imh and mvo which can be seen on the lge image as a black penumbra around the ‘bright’ infarcted myocardium. myocarditis the lake louise criteria (llc) for cmr diagnosis of myocarditis are based on the presence of lge and increased regional signal intensity on t1and t2-weighted images. global myocarditis is an important finding and can potentially be missed by traditional llc-based imaging. when used with lge imaging, the parametric mapping was more sensitive and specific than the llc criteria alone. the t1 and t2 maps were the most diagnostic single parameters8 (figure 3). figure 3: lge (a), t1 (b) and t2 (c) maps in myocarditis. increased t1 and t2 values in the inferolateral, lateral and anterolateral walls are clearly seen on colour maps but largely missed on lge imaging (some subtle mid-wall enhancement). multi-system disorders chronic auto-immune conditions such as systemic sclerosis may involve sub-clinical chronic myocardial involvement which, through t1 and t2 mapping, has been detected for the first time.9 the first case of anti-synthase syndrome, causing a global myocarditis, was diagnosed by cmr mapping techniques. acute heart failure cmr is a useful tool in the assessment of acute heart failure, helping to differentiate aetiology using lge imaging by scar patterns (e.g. infarcted myocardium-subendocardial scar, dilated cardiomyopathy (dcm) mid-wall scar etc.). parametric mapping can aid prognostication and t2 mapping may highlight cases of myocarditis presenting as acute heart failure where management may be very different and other treatment options are available. bonhen et al. compared the diagnostic accuracy of t1 maps, ecv maps, t2 maps and llc in biopsy-proven myocarditis presenting as acute heart failure. global t2 values was the only parameter with significant differences between the two groups.10 dilated cardiomyopathy ecv fraction increases in dcm. the use of parametric mapping, however, is not simply limited to diagnosis. in addition, absolute native t1 values, ecv fraction and presence and extent of lge have been shown to be predictive of heart failure events and all-cause mortality in dcm. in multivariate analysis, native t1 was the sole independent predictor of all causes and heart failure composite end points.11 the ecv fraction and derived myocyte volume may be considered in terms of potential myocardial function or power per unit volume. left ventricular hypertrophy once ecv is quantified, interstitial volume (ecv fraction × lv mass) and myocyte volume ({1-ecv} × lv mass can be calculated. this value has particular use in identification of the various aetiologies of left ventricular hypertrophy (lvh) (although this term is used here to encompass other causes of increased wall thickness related to interstitial expansion rather than cellular hypertrophy). physiological athletic lvh: the use of parametric mapping and ecv quantification has lead to the recent confirmation that athletic lvh results from cellular hypertrophy with a relative reduction in ecv.12 cardiomyopathy conditions such as dcm and hypertrophic cardiomyopathy (hcm) consistently show an increase in ecv fraction. cmr therefore is exquisitely sensitive and specific for differentiating subtle changes owing to athletic remodelling versus myopathy. adaptive hypertension: native t1 values and ecv fraction appear to be higher in hypertensive patients with lvh but not in hypertension without lvh. the overall ecv expansion and cellular hypertrophy may be balanced, explaining in part a modest rise in ecv fraction. further work in this group with modest changes is required before parametric mapping becomes a useful clinical tool. aortic stenosis: the degree of lvh in aortic stenosis can be variable and is likely to be dependent on genetic and environmental/conditional factors. diffuse myocardial fibrosis, assessed by ecv quantification, has been demonstrated in aortic stenosis. in post aortic valve replacement patients who demonstrated lv hypertrophy regression, this was secondary to cellular and not interstitial regression.13 hypertrophic cardiomyopathy: in hypertrophic cardiomyopathy, there has been much research on the presence and degree of lge and its use in predicting outcomes. there is evidence that the amount of scar predicts heart failure, and some evidence that it may help to predict ventricular arrhythmia burden. although scar is the common final pathway of cardiomyopathies and is irreversible, there is evidence that early diffuse fibrosis occurs before the development of overt lge. puntmann at al. showed an increase in native t1 values in hcm compared with healthy controls and which tracked lv mass.14 this may help to direct the use of antifibrotic therapies to change the course of disease trajectory. elevated native t1 also shows promise in differentiating lvh (in the absence of lge) owing to hcm, from hypertension (where native t1 values remain in the normal range), and elevated native septal t1 values perhaps demonstrate early fibrosis in genotype positive-phenotype negative hcm cohorts.15 infiltration fabry disease low t1 values have been demonstrated in fabry disease (fd).16,17 although this x-linked enzyme disorder is rare, it is treatable with enzyme replacement therapies. cardiac manifestations include lvh, arrhythmia and heart failure. lge imaging has identified a predilection for basal inferolateral mid-wall fibrosis in patients with fd. t1 mapping in addition to demonstrating low values, felt to result from sphingolipid deposition within the myocardium, has also shown pseudo-normalisation of t1 values in areas of lge-confirmed scar and sphingolipid deposition. assessment of native t2 values may also prove helpful to the diagnosis and our understanding of the disease process (figure 4). figure 4: lge images: (a) showing lge in the basal infero-lateral wall and corresponding t1 map (b). note the general blue colour of the whole myocardium confirming low t1 values (seen in fat and iron deposition) and that the area of lge (seen in the mid wall of the basal inferolateral wall) corresponds to an area of green colour representing normal t1 values (highlighted by the arrow). this is probably pseudo-normalisation in the presence of fibrosis (as fibrosis increases t1 values). cardiac amyloid cardiac amyloidosis has been historically difficult to diagnose until late in the disease process when treatment options are limited and hence with a grave prognosis. native t1 mapping has proved a significantly useful addition to the diagnostic armamentarium in both amyloid light chain (al)18 and transthyretin amyloid (attr).19 native t1 values are significantly elevated compared to normal, with al amyloid native t1 values generally higher than attr values.18,19 in addition, ecv maps have also aided diagnosis and given further insight into the disease. ecv is significantly elevated in cardiac amyloid (slightly higher in attr amyloid than al amyloid) (figure 5). figure 5: lge (a), t1 map (b) and ecv map (c) in ttr amyloid. lge image shows abnormal gadolinium kinetics (blood pool nulls ahead of myocardium) and t1 maps. t1 values are globally elevated, and heart muscle appears thickened. ecv maps show an ecv volume of 60%. cardiac siderosis major changes in the diagnosis of cardiac siderosis were put down to t2* detection of myocardial iron deposition. although t2* is specific, it is prone to errors in measurement if little or no iron is present, and some may argue that perhaps the current cut-off is too high. recent work by abdel-gadir et al. using t1 and t2* maps in 250 patients with possible iron overload, suggests that the cut-off should be higher – perhaps 29 ms instead of 20 ms.20 use of t1 maps alongside t2* may aid the diagnosis of early myocardial iron (figure 6). figure 6: t1 map in severe iron loading (a) and a normal t1 map (b). as in fabry’s, t1 is low and t1 map appears blue but here there is no hypertrophy. future developments fingerprinting using a cmr atlas one criticism of parametric mapping is the additional scan time required and appropriate patient selection. a technique which is short enough to be performed on all comers would negate this issue. one potential solution to this problem is ecg-triggered 2d magnetic resonance fingerprinting. this technique uses pattern recognition and a dictionary of possible signal evolution which is simulated for each scan. the pulse sequence uses variable flip angles, repetition times, inversion recovery times and t2 prep dephasing times. initial phantom and healthy volunteer scans show promising results.21 conclusion cmr is transforming our understanding of the myocardium – the place where most cardiac disease ultimately occurs. function, combined with scar imaging, via the lge technique was a major advance. incorporating parametric mapping to this is incrementally useful across pathologies. using four parameters (t1, t2, t2* and ecv mapping), major insights across diseases are being obtained. imaging fibrosis, oedema, iron and interstitial volume provides a huge histological insight. the ability to detect serial changes in vivo is ground-breaking. for some pathologies, the advantages of tissue characterisation using parametric mapping in terms of clinical utility and early translation are readily apparent. but this is the beginning of a journey with perhaps the major insights still to come. for rare diseases, these techniques are becoming established, and the current challenges are about delivery on a healthcare system level. however, the future will centre on another key theme: splitting the myocardium into its interstitial and cellular compartments and their quantification in common diseases such as lvh and heart failure. already, major insights are being obtained – a key one being the striking findings in athletic adaptation versus other lvh causes, and the demonstration of fibrosis lvh regression using ecv mapping after aortic valve replacement. further work is needed to aid the transition of mapping to the frontline of cmr. large-volume studies to explore the multitude of potential uses and assess reproducibility will then follow. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.m. was responsible for the text, with editing and contributions from r.s. and a.b. and k.m. a.b., k.m., j.m. and r.s. were responsible for collation of the images. references kellman p, hansen ms. t1-mapping in the heart: accuracy and precision. j cardiovasc magn reson. 2014;16:2. http://dx.doi.org/10.1186/1532-429x-16-2 moon jc, messroghli dr, kellman p, et al. myocardiam t1 mapping and extracellular volume quantification: a scmr and cmr working group of the european society of cardiology consensus statement. jcmr. 2013;15:92. arheden h, saeed m, higgins cb, et al. measurement of the distribution volume of gadopentetate dimeglumine at echo-planar mr imaging to quantify 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magnetic resonance non-contrast myocardial t1 mapping. circ cardiovasc imaging. 2013;6:392–398. http://dx.doi.org/10.1161/circimaging.112.000070 thompson rb, chow k, khan a, et al. t(1) mapping with cardiovascular mri is highly sensitive for fabry disease independent of hypertrophy and sex. circ cardiovasc imaging. 2013;6:637–645. http://dx.doi.org/10.1161/circimaging.113.000482 banypersad sm, fontana m, maestrini v, et al. t1 mapping and survival in systemic light-chain amyloidosis. eur heart j. 2015;36:244–251. http://dx.doi.org/10.1093/eurheartj/ehu444 fontana m, banypersad sm, treibel ta, et al. native t1 mapping in transthyretin amyloidosis. jacc cardiovasc imaging. 2014;7:157–165. http://dx.doi.org/10.1016/j.jcmg.2013.10.008 abdel-gadir a, sado d, murch s, et al. myocardial iron quantification using t2* and native t1 mapping – a 250 patient study. jcmr. 2015;17(suppl. 1):312. hamilton ji, jiang y, chen y, et al. mr fingerprinting for rapid quantification of myocardial t1, t2, and proton spin density. magn reson med. march 2016. http://dx.doi.org/10.1002/mrm.26216 32 sa journal of radiology • june 2007 introduction hypophosphatasia is a genetic disorder that is characterised by deficient activity of the enzyme alkaline phosphatase. clinically, it can present as a lethal infantile form, an intermediate childhood form with rachitic changes and premature deciduous tooth loss or a mild adult form with a tendency for fractures and bone pain. both autosomal-dominant and recessive inheritance has been reported for the mild forms, but only autosomal-recessive inheritance has been implicated in the lethal infantile form.1 our case presented as a severe skeletal dysplasia antenatally and was carried to term. the baby succumbed shortly after delivery. initially, the radiographic findings were thought to be consistent with the severe lethal form of osteogenesis imperfecta (oi) type iia. investigations performed at birth including genetic testing, conclusively determined that the correct diagnosis was the perinatal lethal form of hypophosphatasia. differentiating these two entities can be difficult given the variability of findings and the wide spectrum of severity (tables i and ii). cases of perinatal lethal hypophosphatasia commonly have markedly reduced ossification and may have complete absence of ossification of some bones. the type of ossification defect in oi type iia is slightly different in that there is usually severe diffuse demineralisation of the skull2 (fig. 1) instead of the demineralisation with ‘island-like’ centres of ossification in the frontal, parietal and occipital bones which is seen in hypophosphatasia3 (fig. 2). also, in oi type iia there is overall diffuse osteopenia (demineralised bones) and usually not the near complete lack of mineralisation in individual bones with adjacent more densely mineralised bones. the latter is a feature of hypophosphatasia (figs 3 and 4). one specific prenatal sonographic area to help differentiate between the two is the infant’s hands. the bones of the hands are sonolucent in patients with hypophosphatasia but are echogenic in patients with osteogenesis imperfecta.4 case report this was a planned pregnancy for a healthy 33-year-old mother and 38year-old father. there were 2 prior uncomplicated pregnancies that gave rise to a healthy son and daughter. the mother was on paroxetine hydrochloride, fluticasone propionate and doxylamine succinate-pyridoxine hydrochloride during the pregnancy. there were no known exposures to any teratogens. folic acid supplementation was initiated pre-conceptionally. the family history was unremarkable. parents were both caucasians and of european descent. they were not known to be consanguineous. at 17.8 weeks’ gestation, a routine antenatal ultrasound identified multiple skeletal abnormalities. there was complete absence of cranial ossification and severe shortening of all four limbs, especially proximally. all the long bones were found to be less than 2 standard deviations below the mean for gestational age. the long bones were thickened and bent, compatible with callous formation. vertebral ossification appeared normal. the remainder of the fetal anatomy was unremarkable and there was adequate amniotic fluid. the working diagnosis was oi type ii, however hypophosphatasia and achondrogenesis were also considered in the differential diagnosis. maternal serum screening was declined and amniocentesis was not offered. the couple declined to terminate the pregnancy. repeat ultrasounds in the 27th and 36th week of gestation identified similar skeletal findings. other findings included ventricular dilatation (22 mm) at 27 weeks and polyhydramnios, platyspondyly and a small thoracic cavity at 36 weeks’ gestation. radiographic and prenatal ultrasound features of perinatal lethal hypophosphatasia – differentiation from osteogenesis imperfecta type ii s wiebe, md, frcpc department of medical imaging, royal university hospital and university of saskatchewan, saskatoon, canada i suchet, mb bch, frcpc regina qu’appelle health region, regina, saskatchewan, canada e g lemire, md, phd, frcpc, fccmg, facmg division of medical genetics, department of paediatrics, royal university hospital and university of saskatchewan, saskatoon, canada table i. radiographic features of osteogenesis imperfecta type iia and the perinatal form of hypophosphatasia osteogenesis imperfecta type iia hypophosphatasia, perinatal form skull caput membranaceum, wormian bones caput membranaceum, absence of ossification of calvaria and bones of the skull base ribs short, thick ribs with continous beading short, thin ribs vertebrae flat and irregularly deformed poorly ossified, especially neural arches long bones thick, short, crumpled shafts, multiple tubular bones, absent ossification of whole bones, diaphyseal fractures, callous formation spurs, punched out metaphyseal irregularities, kyphomelia other generalised hypomineralisation generalised hypomineralisation case reportcase report pg32-35.indd 32 6/18/07 4:28:53 pm 33 sa journal of radiology • june 2007 a male infant was delivered at term by vaginal delivery weighing 3.4 kg. compassionate care was provided and the infant succumbed within several minutes. other growth parameters included a crown to heel length of 47 cm and a head circumference of 34 cm. all limbs were visibly short, thickened, curved and measured much less than two standard deviations below the mean for gestational age. the chest appeared narrowed and the abdomen was protuberant. there were no other visible anomalies. the following investigations were requested: dna banking for future studies, karyotype analysis, skin biopsy for collagen studies, skeletal x-ray survey, clinical photographs and a full autopsy examination. permission was not given for an internal examination on the postmortem. x-rays revealed abnormalities thought to be consistent with oi type ii.a chromosome studies revealed a normal male karyotype, 46,xy. collagen studies from the fibroblasts did not reveal any abnormality in type i and type iii pro-collagen and collagen molecules, thus excluding most cases of oi type ii. a review of the x-rays suggested that the radiographic findings were more in keeping with hypophosphatasia. mutation analysis was performed and two mutations (g863a and g1001a) in the alkaline phosphatase gene (alpl) were identified. this is consistent with autosomal-recessive inheritance and the perinatal (lethal) form of hypophosphatasia. both mutations resulted in glycine to aspartic acid substitutions in the mature protein. the parents were each subsequently confirmed to be heterozygous mutation carriers for hypophosphatasia. discussion the perinatal lethal form of hypophosphatasia is an autosomal-recessive inborn error of bone metabolism. there is a deficiency of alkaline phosphatase activity in the bone which results in abnormal unossified bones with variable involvement. the prenatal ultrasound findings include short limbs with multiple deformities and a soft non-ossified calvarium, which allows the brain to be seen unobscured by the normally echogenic cranium. polyhydramnios may be present. postnatal radiographs will demonstrate a variable appearance of non-ossified bones, osteopenia and some segments of more normal ossification. the clavicles are usually spared in the infantile form.3 the cranial ossification is deficient table ii. sonographic findings of osteogenesis imperfecta type iia and the perinatal form of hypophosphatasia osteogenesis imperfecta type iia hypophosphatasia, perinatal form short limbs with wrinkled appearance of long bones short, bowed limbs multiple fractures with callus formation polyhydramnios demineralised calvarium small for gestational age abnormal skull shape decreased echogenicity of the bones small chest circumference with broad and irregular ribs prominent falx cerebri increased nuchal translucency underossification of vertebrae, neural arches and hands fig. 2. prenatal ultrasound of the head with lack of shadowing from the unossified skull shows better than normal visualisation of the brain due to unmineralised cranium. fig. 1. ap view of a different child with the lethal form of osteogenesis imperfecta. note the diffuse osteopenia and multiple fractures. case report pg32-35.indd 33 6/18/07 4:28:53 pm 34 sa journal of radiology • june 2007 but there may be ‘island-like’ areas of ossification as seen in our case.5 in some cases there are osteochondral projections at right angles to the mid-diaphysis of the long bones of the arms and legs which are called bowder spurs1,3,5 and may be more specific for hypophosphatasia. our case did not have bowder spurs present however we did find sonolucent and radiolucent bones of the hands in keeping with the diagnosis of hypophosphatasia (figs 5a and b, and fig. 6). differentiating these cases from oi type ii can be difficult based on imaging because of the variability of findings and the overlap of the lack of ossification, multiple fractures, etc. some of the radiographic features seen in our case direct us to favour hypohosphatasia, which was fig. 4. postnatal lateral view of the skull demonstrating diffuse lack of ossification and patchy island-like areas of ossification of the occipital bone, skull base, and to a lesser extent in the frontal and parietal bones. fig. 6. postnatal view of the arm with abnormal ossification of the short bones with multiple fractures present. figs 5a and b. prenatal ultrasound of the arm demonstrating short angulated bones in keeping with multiple fractures. fig. 5b. fig. 3. postnatal ap view of the chest and abdomen revealing lack of mineralisation of many vertebrae and abnormally thin irregular (fractured) ribs. more normal ossification of some of the sacral vertebrae. case report case report pg32-35.indd 34 6/18/07 4:28:55 pm 35 sa journal of radiology • june 2007 subsequently confirmed molecularly. this case clearly demonstrates the importance of performing cytogenetic, radiographic, pathologic and molecular investigations, whenever possible, for confirmation of the diagnosis when a skeletal dysplasia is suspected on antenatal ultrasound. looking at the infant’s hands on the prenatal ultrasound may help make the diagnosis of hypophosphatasia if the bones are sonolucent. this couple had inappropriately received a low recurrence risk based on the diagnosis of oi type iia. the perinatal lethal form of hypophosphatasia is inherited in an autosomal-dominant fashion and is associated with a 25% recurrence risk. identification of the two alkaline phosphatase mutations in the infant and confirmation of carrier status in the parents now allows us to offer prenatal diagnostic testing for future pregnancies. 1. taybi h, lachman rs. radiology of syndromes, metabolic disorders, and skeletal dysplasias. 4th ed. philadelphia: mosby, 1996: 628-630. 2. taybi h, lachman rs. radiology of syndromes, metabolic disorders, and skeletal dysplasias. 4th ed. philadelphia: mosby, 1996: 876-881. 3. kuhn jp, slovis tl, haller jo. caffey’s pediatric diagnostic imaging. 10th ed. st. louis: mosby/elsevier science, 2004: 2165-2167, 2264-2265. 4. tongsons t, pongsatha s. early prenatal sonographic diagnosis of congenital hypophosphotasia. ultrasound obstet gyenecol 2000; 15:252-255. 5. shohat m, rimoin dl, gruber he, lachman rs. perinatal lethal hypophosphatasia: clincal, radiographic and morphological findings. pediar radiol 1991; 21:421-427. case report pg32-35.indd 35 6/18/07 4:28:56 pm abstract introduction objectives method results discussion limitations conclusion acknowledgements references about the author(s) samuel manikkam department of radiology, university of kwazulu-natal, durban, south africa moherndran archary department of paediatrics and child health, university of kwazulu-natal, durban, south africa raziya bobat department of paediatrics and child health, university of kwazulu-natal, durban, south africa citation manikkam s., archary m., bobat r. ‘chest x-ray patterns of pulmonary multidrug-resistant tuberculosis in children in a high hiv-prevalence setting’ s afr j rad. 2016;20(1); art. #829, 6 pages. http://dx.doi.org/10.4102/sajr.v20i1.829 postal address: po box 1305, wandsbeck, 3631 original research chest x-ray patterns of pulmonary multidrug-resistant tuberculosis in children in a high hiv-prevalence setting samuel manikkam, moherndran archary, raziya bobat received: 22 apr. 2015; accepted: 13 oct. 2015; published: 18 mar. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: paediatric multidrug-resistant tuberculosis (mdr-tb) necessitates a prolonged duration of treatment with an intensive treatment regimen. the chest x-ray patterns of pulmonary tb depend on a multiplicity of factors, including immune status, and therefore identifying the influence of hiv on the chest x-ray appearances of mdr-tb may assist with improving the diagnostic criteria. objectives: to describe the demographic characteristics and chest x-ray patterns of children with pulmonary mdr-tb and to compare the chest x-ray patterns of pulmonary mdr-tb between children who are hiv-infected and hiv-uninfected. method: retrospective chart review of hospital notes and chest x-rays of children with pulmonary mdr-tb at king dinuzulu hospital, durban. the chest x-rays were systematically reviewed for the presence of the following variables: hilar/mediastinal lymphadenopathy, bronchopneumonic opacification, segmental/lobar consolidation, cavities, miliary opacification and pleural effusion. results: forty-five children (mean age, 6.29 years; median age, 6.00 years) with pulmonary mdr-tb met the inclusion criteria. the most common chest x-ray finding was consolidation (53.5%), followed by lymphadenopathy (35.6%), bronchopneumonic opacification (33.3%) and cavities (31.1%). cavities were more common (or 6.1; 95% ci 1.52–24.66) in children who had been initiated on standard anti-tb treatment for the current tb episode. there were no statistically significant differences in any of the chest x-ray patterns in hiv-uninfected (n = 22) compared with hiv-infected (n = 20) children. conclusion: the most common chest x-ray finding was consolidation, followed by lymphadenopathy, bronchopneumonic opacification and cavities. the finding of a significantly higher frequency of cavities in children who had received prior standard anti-tb treatment for the current tb episode could reflect poor disease containment and increased parenchymal damage, owing to a delay in the recognition of mdr-tb. the development of cavitation in chest x-rays of children with tb could raise concern for the possibility of mdr-tb, and prompt further testing. introduction globally, paediatric tuberculosis (tb) remains an area of significant concern. in 2012, the total estimated number of childhood notifications from all countries was 349 000.1 in the paediatric population, chest x-rays remain the initial investigation in the work-up of suspected pulmonary tb; however, overlapping clinical and chest x-ray features with other causes of acute pneumonia, and poor sensitivities for the tuberculin skin test (tst), make confirmation of tb difficult.2 the emergence of multidrug-resistant tb (mdr-tb), defined as resistance to both isoniazid and rifampicin, is a particular area of public health concern in south africa, where the estimated mdr-tb burden in 2012 was 1.8% for new cases and 6.7% for retreatment cases, with a total number of laboratory-confirmed mdr-tb cases of 15 419.1 drug-resistant tb necessitates a prolonged duration of treatment with a more intensive treatment regimen. in terms of the clinical outcome of paediatric mdr-tb, in a cohort study of children with culture-confirmed mdr-tb in the western cape, south africa, the majority of children were treated successfully, with 82% having favourable outcomes (cured and treatment completed) in contrast to adult data.3 although the majority of children were treated successfully, a further study in this region, which documented four known deaths (10%), suggested that earlier recognition of drug resistance could probably have prevented a further two deaths and morbidity.4 this observation highlights the importance of early detection and treatment of mdr-tb. in poorly resourced settings, drug-susceptibility testing is frequently reserved for cases that do not respond to standard anti-tb treatment. early identification of mdr-tb with early onset of treatment may prevent morbidity and mortality; therefore identifying chest x-ray features which may alert the clinician to the possibility of mdr-tb on initial presentation may be important. the most commonly described chest x-ray findings in children with mdr-tb are segmental/lobar opacification (70%)3,4 and hilar/mediastinal lymphadenopathy (48% – 51%).3,4 cavities have been described in 35% – 38%.3,4 the chest x-ray manifestations of pulmonary tb depend on several factors, including age and immune status;5 therefore identifying the influence of hiv on the chest x-ray appearances of mdr-tb may be of value. to our knowledge, no studies have compared the chest x-ray appearance of pulmonary mdr-tb between hiv-infected and hiv-uninfected children. objectives the objectives of the study were to: describe the demographic characteristics of children with pulmonary mdr-tb describe the chest x-ray patterns of children with pulmonary mdr-tb compare the chest x-ray patterns of pulmonary mdr-tb between children who are hiv-infected and hiv-uninfected. ethical clearances ethical approval was obtained from the university of kwazulu-natal biomedical research ethics committee and site approval was obtained from the hospital. informed consent was not required for the retrospective study. method a retrospective review of patient records was conducted at the paediatric ward and paediatric outpatients’ department of a referral mdr-tb facility in durban (king dinuzulu hospital) for the period 01 january 2013 to 31 december 2013, to identify children diagnosed with pulmonary mdr-tb. children (<12 years) were included if they had been diagnosed with pulmonary mdr-tb between 01 january 2013 and 31 december 2013, and a baseline chest x-ray performed within one week of initiation of mdr-tb treatment. mdr-tb (defined as resistance to both isoniazid and rifampicin) was diagnosed on samples of sputum, gastric aspirate or bronchoalveolar lavage using the following methods: molecular testing using polymerase chain reaction (pcr) with mtbdrplus, a molecular genetic assay for identification of resistance to rifampicin and/or isoniazid of mycobacterium tuberculosis complex agar-based culture and drug sensitivity testing if the results for the above methods were not available, rifampicin resistance was confirmed with molecular testing using gene xpert. data were collected through chart review. the following information was extracted from the available records: results of drug-susceptibility testing history of contact with an adult with pulmonary tb, obtained through primary caregiver recall (as recorded in chart notes) duration of any previous anti-tb treatment for the current episode. this was defined as a standard treatment regimen (i.e. isoniazid, rifampicin and pyrazinamide, with or without ethambutol) and did not include tb prophylaxis. history of a previous tb episode, which was defined as standard tb treatment for at least 1 month, followed by a symptom-free period of at least 6 months (determined on the basis of reports by the parent/caregiver) before the start of the current mdr-tb episode; this is a commonly used programmatic definition of a separate episode3 hiv status. in hiv-infected children, the following additional information was obtained from the patient records: antiretroviral (arv) treatment regimen, and absolute cd4 t-lymphocyte count and percentage, at the time of the baseline chest x-ray. in this group of children, the degree of immunosuppression was stratified, depending on the cd4 count, using the who immunological classification.6 frontal chest x-rays were acquired using digital radiography (with kodak dual or single receptor units dr 7500 and 9500 respectively) or analogue radiography (with a picker synergen 350 unit). the images were printed to make film hard copies. the chest x-rays were all read by the same senior consultant radiologist, who read chest x-rays systematically with a standardised recording. the reporting radiologist was blinded to the hiv status and immunological data. the chest x-rays were reviewed for the presence of the following variables: hilar/mediastinal lymphadenopathy, described as nodular masses according to site7 bronchopneumonic opacification, described as multiple, ill-defined, confluent, nodular opacities8 segmental/lobar consolidation, described as a homogeneous increase in pulmonary parenchymal attenuation that obscures the margins of vessels and airway walls9 cavities, described as gas-filled spaces, seen as a lucency or low-attenuation area, within pulmonary consolidation9 miliary opacification, described as profuse, tiny, discrete, rounded pulmonary opacities (≤3 mm in diameter) that are generally uniform in size and diffusely distributed throughout the lungs9 pleural effusion, described as pleural opacification.7 statistical analysis was performed using ibm spss statistics software. for continuous variables such as age, the mean, median and range were calculated. results were recorded as frequencies and percentages for categorical variables. the pearson chi-square test or fisher exact test (where cell frequencies were <5) were used to test for significant relationships between the frequency of each chest x-ray pattern, and the age. the level of significance was set at p < 0.05. the odds ratio (or) and 95% confidence limits (ci) were estimated using univariate logistic regression in spss. results during the study period, 55 children <12 years were diagnosed with pulmonary mdr-tb based on clinical and laboratory findings; however, 10 children were excluded from this analysis as they did not have a retrievable chest x-ray taken within 1 week of mdr-tb treatment initiation; therefore the chest x-rays of 45 children were analysed in the present study (figure 1). the median age was 6.00 years, and age range 3 months to 11 years and 9 months. twenty-two children (48.9%) were hiv uninfected, and 20 children (44.4%) were hiv infected. the hiv status was unknown for 3 children (figure 1). in the 20 children who were hiv infected, 16 (80%) were on an arv treatment regimen. mdr-tb was confirmed using specimens of sputum (19 children [42.2%]), gastric aspirate (14 children [31.1%]) and bronchoalveolar lavage (1 child [2.2%]), and was unspecified in 11 children (figure 2 and figure 3). figure 1: demographics. figure 2: pulmonary multidrug-resistant tuberculosis in an 11-year-old girl. frontal chest radiograph. bronchopneumonic opacification and consolidation with cavitation is noted in the left upper lobe. ill-defined focal consolidation with cavitation is evident in the right upper zone. dense nodular opacities are noted in the right lower zone, suggesting calcified granulomas. aortopulmonary window and right hilar lymphadenopathy is noted. evidence of right lower lobe atelectasis. figure 3: multidrug-resistant tuberculosis in a 6-year-old girl. frontal chest radiograph demonstrating diffuse miliary opacification. there is enlargement of the hilar regions bilaterally suggestive of associated hilar lymphadenopathy. eighteen children (40%) had a history of contact with an adult with tb, of whom 8 children reported a history of a contact diagnosed with mdr-tb; and 6 children indicated no prior tb treatment for the current episode. prior to presentation at the mdr-tb facility, 19 children (42.2%) had been initiated on a standard anti-tb treatment regimen for the current tb episode. in this group, there was a mean duration of 4.39 months (range 0.25 – 12 months) of treatment prior to a diagnosis of mdr-tb being made. sixteen children (35.6%) were immediately initiated on mdr-tb treatment following diagnosis. in 10 children (22.2%), no history of an anti-tb treatment regimen for the current tb episode was recorded. a history of a prior episode of tb was found in 13 children (28.9%), of whom only 1 child had a reported history of previous mdr-tb. on evaluation of the chest x-ray patterns, 22 children (48.9%) had ≥2 findings on the chest x-ray, and 10 (22.2%) had no abnormality. the most common chest x-ray finding in all children was segmental/lobar consolidation (53.5%), followed by lymphadenopathy (35.6%), bronchopneumonic opacification (33.3%) and cavities (31.1%). when comparing the chest x-ray patterns in children of ages 0 – 6 years and 6 – 12 years, miliary opacification and pleural effusions were not seen in the 0 – 6-year age group, and cavities were found more frequently in the 6 – 12-year age group (40.7% in older children compared with 16.7% in younger children) (table 1). table 1: chest x-ray patterns in all children and comparison by age. cavities were found more frequently in children who had been initiated on a standard anti-tb treatment regimen for the current tb episode, compared with children with no recorded history of standard anti-tb treatment for the current episode (52.6% compared with 15.4%; or 6.111 (1.515–24.658) (table 2). table 2: comparison of chest x-ray patterns in children with prior standard tb treatment for the current episode and children with no recorded prior standard tb treatment for the current episode. chest x-ray findings of bronchopneumonic opacification, segmental/lobar consolidation, cavities and miliary opacification were common in hiv-infected children compared with hiv-uninfected children; however, this was not statistically significant (table 3). table 3: comparison of chest x-ray patterns in hiv-uninfected and hiv-infected children. discussion mdr-tb represents a significant challenge in the attainment of global tb control. the identification of this clinical entity is equally important in the paediatric population, because a child with tb was shown to be as likely as an adult to have mdr-tb.1 in clinical practice, early identification is important as it will result in a reduction of morbidity and mortality relating to the disease. factors contributing to early identification include chest x-ray changes as well as a history of contact. the most frequent chest x-ray finding in children with pulmonary mdr-tb in our study was consolidation, followed by lymphadenopathy, bronchopneumonic opacification and cavities. when comparing the chest x-ray patterns in the different age groups, pleural effusions were not seen in the 0 – 6-year age group. this is consistent with the literature which described tuberculous pleural effusion developing mainly in children >5 years old following recent primary infection.10 cavities were found more frequently in the older age group (6 – 12 years), consistent with adult-type cavitating disease, which is the dominant disease manifestation following recent primary infection in older children (>10 years of age).10 the finding of a significantly higher frequency of cavities in children who had received prior standard anti-tb treatment for the current tb episode, compared with children with no recorded history of standard anti-tb treatment for the current episode, may reflect poor disease containment and increased parenchymal damage,10 either owing to a delay in the recognition of mdr-tb, or the development of mdr-tb owing to an inappropriate treatment regimen or poor compliance with the standard treatment regimen, although the development of mdr-tb may be a less likely consideration because of the paucibacillary nature of paediatric tb.4 regarding the effect of drug resistance on the chest x-ray appearance of pulmonary tb, we compared our findings with studies by donald et al.11 and lamont et al.7 of children in the western cape with bacteriologically confirmed pulmonary tb. although these study populations were not tested for mdr-tb, the incidence is presumed to be low because mdr-tb was first detected in south africa in the mid-1980s, with subsequent surveillance data for this period showing low prevalence levels.12 our study found a higher frequency of cavitation (31.3% v. 14.0%11 – 16.2%7). the finding of a higher frequency of cavitation in mdr-tb reflects a similar trend in adult patients, where cavities were more frequently observed in computed tomography (ct) scans of mdr-tb adult patients as compared with drug sensitive (ds)-tb;13 and multiple cavities were seen more frequently in mdr-tb adult patients as compared with ds-tb on both chest x-rays13 and ct.14 the development of cavitation in chest x-rays of children with tb could raise concern for the possibility of mdr-tb, and prompt further testing. when compared with the studies of donald et al.11 and lamont et al.,7 our study found a lower frequency of lymphadenopathy (35.6% v. 62.5%11 – 63.0%7) that could be partly explained by the absence of lateral chest x-rays in our study, which are of value in detecting lymphadenopathy in children investigated for tb.15 although our study found a lower frequency of lymphadenopathy when compared with the studies of donald et al.11 and lamont et al.,7 lymphadenopathy was the second most common finding in our study, and is considered the radiological hallmark of primary tb in childhood.16 therefore the combination of consolidation, cavitation and lymphadenopathy may alert the clinician to the possibility of mdr-tb and prompt further investigation. the frequency of the rest of the chest x-ray findings in the study by donald et al. were similar to those of our study: segmental lesion, referring to any radiographic opacity which filled a lobe or a segment of a lobe (56%); bronchopneumonia (30%); pleural effusion (16%) and a miliary pattern (10%).11 when comparing the frequency of chest x-ray patterns in hiv-uninfected and hiv-infected children, bronchopneumonic opacification was found more commonly in the hiv-infected group. although not statistically significant, this may be the result of poor disease containment at the site of the ghon focus or lymphadenopathy, owing to the immunosuppressive effect of hiv and subsequent intra-bronchial spread of disease.10 the absence of statistically significant differences between hiv-uninfected and hiv-infected children is consistent with a study evaluating the clinical features and outcome of children admitted to a tb hospital in the western cape in south africa, where no statistically significant difference in chest x-ray appearances of tb was seen between these subgroups; however, in that study, drug resistance was confirmed in 19% of the 93 children for whom these test results were available.17 the chest x-ray patterns of children with pulmonary mdr-tb described in our study are similar to the results of studies describing the clinical features of children with mdr-tb by seddon et al.3 and schaaf et al.;4 however, bronchopneumonic opacification was found more frequently in our study than in those by seddon et al.3 and schaaf et al.4 (33% v. 19%). the difference may be explained partly by the fact that the studies by seddon et al.3 and schaaf et al.4 included children with extrapulmonary tb as well as pulmonary tb. a further reason may be the limitation of the classification of bronchopneumonic opacification to describe widespread bronchopneumonic changes in the study by seddon et al.3 limitations the limitations of the present study include its retrospective study design. a limitation in obtaining a history of a tb contact was that the history was based on recall of the parent or caregiver present at the first visit; in some cases, there might have been a tb contact that was not diagnosed at this time, and the actual figure might be even higher. the x-rays were read by a single radiologist only; therefore interobserver variability could not be determined, reducing the reliability of results. the presence of a viral or bacterial co-infection might have accounted for the chest x-ray appearances in certain cases. missing cd4 counts and the sample size limited our ability to compare the influence of degree of immunosuppression owing to hiv on the chest x-ray patterns. conclusion the most common chest x-ray finding in children with mdr-tb in our study was consolidation, followed by lymphadenopathy, bronchopneumonic opacification and cavities. cavities were found more frequently in children who had received standard anti-tb treatment for the current tb episode, which may reflect poor disease containment and increased parenchymal damage owing to delay in the recognition of mdr-tb. the chest x-ray findings of consolidation, cavitation and lymphadenopathy on initial presentation, or the development of cavitation in chest x-rays of children receiving standard anti-tb treatment, could raise concern for the possibility of mdr-tb and prompt further testing. we intend to pursue research with the inclusion of children with ds-tb as controls for further assessment. there were no statistically significant differences between patterns in hiv-uninfected and -infected children. acknowledgements the authors thank dr j.m. kallideen and the management and staff of king dinuzulu hospital for their assistance; fikile nkwanyana, biostatistician at the university of kwazulu-natal, for statistical analysis of the data; and leora sewnarain, university of kwazulu-natal, for assistance with the editorial preparation of the manuscript. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions s.a.m. (university of kwazulu-natal) was the principal investigator and prepared the manuscript. r.b. (university of kwazulu-natal) and m.a. (university of kwazulu-natal) made conceptual contributions and were involved with the manuscript editing, and are respectively the supervisor and co-supervisor of s.a.m.’s master’s research. references world health organization. global tuberculosis report 2013. c2013 [cited 22 march 2014]. available from: http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf jeena pm. the interaction of hiv and tuberculosis in childhood. s afr med j. 2007;97:989–991. seddon ja, hesseling ac, willemse m, donald pr, schaaf hs. culture-confirmed multidrug-resistant tuberculosis in children: clinical features, treatment, and outcome. clin infect dis. 2012;54:157–166. http://dx.doi.org/10.1093/cid/cir772 schaaf hs, shean k, donald pr. culture confirmed multidrug resistant tuberculosis: diagnostic delay, clinical features, and outcome. arch dis child. 2003;88:1106–1111. http://dx.doi.org/10.1136/adc.88.12.1106 leung an. pulmonary tuberculosis: the essentials. radiology. 1999;210:307–322. http://dx.doi.org/10.1148/radiology.210.2.r99ja34307 world health organization. who case definitions of hiv for surveillance and revised clinical staging and immunolgical classification of hiv-related disease in adults and children. c2007 [cited 17 august 2013]. available from: http://www.who.int/hiv/pub/guidelines/hivstaging150307.pdf lamont ac, cremin bj, pelteret rm. radiological patterns of pulmonary tuberculosis in the paediatric age group. pediatr radiol. 1986;16:2–7. http://dx.doi.org/10.1007/bf02387495 lange s. radiology of chest diseases. 3rd ed. stuttgart: georg thieme verlag; 2007. http://dx.doi.org/10.1055/b-002-59222 hansell dm, bankier aa, macmahon h, mcloud tc, muller nl, remy j. fleischner society: glossary of terms for thoracic imaging. radiology. 2008;246:697–722. http://dx.doi.org/10.1148/radiol.2462070712 marais bj, gie rp, schaaf hs, et al. a proposed radiological classification of childhood intra-thoracic tuberculosis. pediatr radiol. 2004;34:886–894. http://dx.doi.org/10.1007/s00247-004-1238-0 donald pr, ball jb, burger pj. bacteriologically confirmed pulmonary tuberculosis in childhood. clinical and radiological features. s afr med j. 1985;67:588–590 weyer k, brand j, lancaster j, levin j, van der walt m. determinants of multidrug-resistant tuberculosis in south africa: results from a national survey. s afr med j. 2007;9:1120–http://dx.doi.org/10.1148/radiol.24620707121128 cha j, lee hy, lee ks, et al. radiological findings of extensively drug-resistant pulmonary tuberculosis in non-aids adults: comparisons with findings of multidrug-resistant and drug-sensitive tuberculosis. korean j radiol. 2009;10:207–216. http://dx.doi.org/10.3348/kjr.2009.10.3.207 myung jin c, kyung soo l, won-jung k, et al. drug-sensitive tuberculosis, multidrug-resistant tuberculosis, and nontuberculous mycobacterial pulmonary disease in nonaids adults: comparisons of thin-section ct findings. eur radiol. 2006;16:1934–1941. http://dx.doi.org/10.1007/s00330-006-0174-9 smuts na, beyers n, gie rp, et al. value of the lateral chest radiograph in tuberculosis in children. pediatr radiol. 1994;24:478–480. http://dx.doi.org/10.1007/bf02015003 leung an, müller nl, pineda pr, fitzgerald jm. primary tuberculosis in childhood: radiographic manifestations. radiology. 1992;182:87–91. http://dx.doi.org/10.1148/radiology.182.1.1727316 soeters m, de vries am, kimpen jl, donald pr, schaaf hs. clinical features and outcome in children admitted to a tb hospital in the western cape--the influence of hiv infection and drug resistance. s afr med j. 2005;95:602–606. sajr 914 adrenal lesions encountered in current medical practice − a review of their radiological imaging v naidu,1 mb chb, fcrad diag (sa); b singh,2 mb chb, fcs (sa), md 1 department of radiology, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 2 department of surgery, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: v naidu (vanesha@mweb.co.za) modern radiological technology has transformed the way that adrenal lesions are currently investigated. the contemporary radiologist has been catapulted to the forefront in the management of adrenal disease. with the increasing use of cross-sectional imaging, adrenal lesions are being serendipitously discovered in radiological studies undertaken for non-adrenal-related conditions – the so-called adrenal ‘incidentaloma’. this review discusses the imaging modalities available for characterising these lesions, highlighting current concepts and controversies in differentiating benign from malignant pathology. the article also provides a brief overview of the spectrum of adrenal pathology commonly encountered in the adult population. s afr j rad 2013;17(4):128-138. doi:10.7196/sajr.914 ‘i’m unaware that any modern authority has ventured to assign to them any special function or influence.’ (dr thomas addison) tremendous strides have been made in medicine since these words uttered by dr thomas addison in 1855.1 the adrenal glands, despite their size and obscure structure, are considered among the most vital organs in the human body. they are also an important site for disease processes, harbouring a myriad pathologies. historically, adrenal lesions were discovered mainly at surgery or autopsy. however, with the advent of modern technology and the increasing use of advanced cross-sectional imaging techniques, adrenal lesions are now being detected incidentally in radiological examinations performed for other abdominal, non-adrenal-related conditions.2 this poses a diagnostic and clinical dilemma to the radiologist, clinician and patient alike. the medical fraternity seeks to characterise these lesions using non-invasive measures. perhaps the most challenging question is whether the adrenal ‘incidentaloma’ is benign or malignant. adrenal masses are estimated to occur in approximately 9% of the general population. about 5 8% of computed tomography (ct) and magnetic resonance imaging (mri) studies of the abdomen demonstrate incidentally detected adrenal lesions. the vast majority of adrenal incidentalomas are benign, non-hyperfunctioning and require no treatment.2 adrenocortical adenomas are the most commonly encountered adrenal incidentaloma, with a reported prevalence of 3 8.7% of patients.3 most incidental adrenal lesions in patients who do not have a background history of malignancy are benign. indeed, in this subgroup of patients, the incidence of adrenal malignancy approaches nil.4 however, a clinical problem is encountered in patients with a known extra-adrenal primary malignancy, raising the probability of metastatic disease. the clinical and radiological challenge is greatest in this subgroup of patients, as inaccurate characterisation of the adrenal lesion has severe consequences. in these oncology patients with detected adrenal masses, about 50% have adrenal metastasis on biopsy.5 in the setting of widespread metastatic disease, it is not critical if the adrenal gland is one of many sites of metastasis. however, if the adrenal gland is the solitary focus of spread, accurate characterisation is imperative, as it advances the patient’s stage of disease, affecting treatment and prognosis. conversely, reporting a benign adrenal adenoma as metastasis will imply advanced disease, potentially denying the patient definitive treatment and potential cure.1 imaging modalities imaging of adrenal pathology must be guided by the patient’s clinical and biochemical profile. the intracellular lipid content, perfusion dynamics and metabolic activity of an adrenal mass are key properties that underpin adrenal imaging. a. computed tomography ct is the cornerstone of adrenal imaging. morphology, ct densitometry, washout percentage and distant spread are crucial determinants that help to characterise an adrenal mass and guide diagnosis. morphological features size: size of an adrenal incidentaloma is an important variable in assessing malignant potential. larger lesions are more likely to be malignant. in an adrenal lesion >4 cm, the chance of malignancy approaches 70%; and if >6 cm it approaches 85%. traditionally, tumours >6 cm were surgically resected owing to their high malignant potential. however, most centres of endocrine surgery now recommend 4 cm as the threshold for adrenalectomy. exceptions are myelolipomas which can present as large masses, but their signature ct appearance allows confident diagnosis.2 size as a criterion alone is limited, as it does not distinguish malignant from benign lesions with 100% accuracy; it should therefore always be reconciled with other radiological phenotyping as a predictor of malignancy. stability: prior/serial imaging is of cardinal value in assessing the stability of a lesion. stability/slow growth of a lesion over a 6-month period often signifies benignity. conversely, a rapidly growing lesion is often malignant. a caveat is haemorrhage into a benign lesion which can result in abrupt change in size.6 in ternal characteristics: morphological features are nonspecific and considerable overlap between benign and malignant lesions exists. a large lesion with heterogeneous attenuation and irregular contours is suspicious of malignancy, as compared with a small, well-defined, smoothly marginated, homogenous lesion which favours benignity.4 large areas of intralesional necrosis are often associated with malignancy. calcification and haemorrhage are non-specific features, seen in both benign and malignant lesions. ct densitometry ct densitometry is the workhorse in the adrenal radiological assessment. about 70% of adrenal adenomas are lipid-rich and contain abundant intracytoplasmic fat, as opposed to most malignant lesions that lack intracellular lipid. lee et al.7 were the first to report the importance of unenhanced ct densitometry in differentiating adenomas from non-adenomatous lesions.the high lipid concentration lowers the density of most adenomas. korobkin et al.8 reiterated this finding, demonstrating an inverse linear relationship between the lipid content of an adrenal lesion and the ct attenuation on unenhanced images. conversely, almost all non-adenomatous lesions were deficient in intracellular fat and exhibited higher ct attenuation values. later, boland et al.9 in their meta-analysis concluded that a hounsfield unit (hu) <10 on unenhanced ct had a 71% sensitivity and 98% specificity in diagnosing adenomas. to date, this threshold value of <10 hu has strong support in clinical practice and is the most widely endorsed standard value. it is proposed that any adrenal lesion with an hu <10 is probably benign and no further investigations or serial follow-up is required. furthermore, blake and colleagues[5 ] recognised that a non-contrast density of >43 hu is highly suspicious of malignancy. technique: the densitometry measurement must be made through the centre of the lesion to prevent partial volume averaging of adjacent retroperitoneal fat. a circular region of interest (roi) should cover at least ½ ⅔ of the surface area of the lesion. limitations: • approximately 30% of adenomas are lipid-poor; lipid-sensitive imaging techniques may therefore be less accurate. these lesions will often display unenhanced hu values >10. • a small percentage of malignant lesions (e.g. adrenal carcinomas, metastases and phaeochromocytomas) may contain fat and have an hu <10. • many adrenal lesions are detected incidentally on studies performed with contrast only; hence no images are available for unenhanced densitometry measurement.2 ct washout other ct parameters used to distinguish adenomatous from non-adenomatous lesions exploit the different perfusion dynamics and washout characteristics of adrenal lesions. contrast in a benign lesion tends to wash out rapidly, whilst malignant lesions retain contrast for longer periods. it is proposed that this occurs because of increased microvascularity and capillary permeability, resulting in leakage of contrast into the extravascular space of malignant lesions. there are two percentage washout methods employed in clinical practice (table1): • if an unenhanced scan was obtained, then an absolute percentage washout value (apw) is calculated. • if no unenhanced scan is available, a relative percentage washout value (rpw) is calculated. the washout protocol uses the postcontrast ct attenuation values obtained at 60 seconds after contrast administration and after a delay of 15 minutes. an apw >60% or rpw >40% is compatible with a benign adrenocortical adenoma (figs 1a c). conversely, a lesion with an apw <60% or rpw <40% is almost always malignant.10 contrast washout is independent of the lipid content of an adrenal lesion, making it one of the key standard imaging investigations. this superior technique has found prime position in imaging the category of lipid-poor adenomas.6 fig.1. adrenocortical adenoma in a 45-year-old woman with cushing syndrome. (a) axial precontrast ct image demonstrates a homogenous, well-defined right adrenal mass (blue arrow) with hu of 7. imaging could have stopped here as the unenhanced ct density (hu <10) is consistent with a lipid-rich adenoma. (b) at 60 seconds post contrast, the hu measures 43 (blue arrow). (c) delayed post-contrast image at 15 minutes demonstrates a hu of 18. the corresponding absolute percentage washout (apw) is 69%, confirming the diagnosis of an adenoma (blue arrow). 10-minute ct washout to aid scanning workflow, some investigators have proposed that the delayed contrast scan in the washout protocol be performed at 10 minutes. however, sangawaiya et al.11 recently revisited the accuracy of the 10 min. delay scan and reported suboptimal sensitivities in its detection of adenomas. it is therefore recommended that the 15 min. delay continues to be endorsed in standard clinical practice. loco-regional and distant spread vascular extension, invasion of surrounding structures, loco-regional lymphadenopathy and metastases are findings compatible with malignancy. ct histogram and dual energy ct (dect) most studies have shown these two ct techniques to have low sensitivities, limiting their use in routine clinical practice. these methods are reserved as adjunct tools in evaluation of the ‘indeterminate’ adrenal lesion.5 ct histogram: like unenhanced ct densitometry, ct histogram analysis is based on the intracytoplasmic lipid content in an adenoma. whilst conventional ct densitometry is a measure of the mean attenuation of a lesion, a ct histogram has the added advantage of assessing the distribution of tissue attenuation within a mass. ct histogram analysis entails placing the roi within the adrenal lesion and then post-processing each pixel with a histogram analysis tool that is present on most viewing workstations. the ct histogram generated is a graphic display of the pixel attenuation values within a prescribed roi plotted along the x-axis against the frequency/number of each pixel along the y-axis. the percentage of negative pixels of fat attenuation (values <0) is then calculated. blake et al.5 proposed that a threshold value >10% negative pixels is highly specific for adenomas. dect: this ct technique allows images to be acquired with two different energies, of 80 kv and 140 kv, respectively. lipid-containing lesions will demonstrate a decrease in attenuation as the tube voltage setting decreases. gupta et al.5 , 10 recognised that a decrease in attenuation of an adrenal mass between 140 kv and 80 kv is highly specific for an adrenal adenoma. in comparison, adrenal metastases demonstrated an increase in attenuation on dect. furthermore, new dect scanners are able to reconstruct virtual unenhanced images from contrast-enhanced ct data, by subtracting the iodine content. in daily practice, many abdominal scans are performed after the administration of intravenous contrast. furthermore, a 15-minute delay scan is at times difficult to obtain as patients have often left the ct department prior to the scan being reviewed. characterisation of an adrenal incidentaloma in these cases is not possible. virtual reconstructed unenhanced images thus allow unenhanced ct densitometry to be performed for lesion characterisation without needing the patient to return for a repeat scan, and obviate a repeat radiation dose.10 b. magnetic resonance imaging chemical shift imaging chemical shift imaging (csi) is the principal technique employed in mr evaluation of adrenal lesions. it uses out-of-phase (op) and in-phase (ip) techniques. similar to ct densitometry, csi exploits the presence of abundant intracellular lipid in adenomas that helps to distinguish them from non-adenomatous lesions. the basis of csi is the existence of different resonant frequencies of hydrogen nuclei of water and fat within a given voxel. thus, on out-of-phase imaging, the net effect is a cancellation of signal between lipid and water protons within a voxel. therefore, lesions such as adenomas that contain almost equal voxel concentrations of lipid and water, exhibit complete signal intensity loss/drop-off on op and appear darker than the ip image (fig. 2).6 fig. 2. axial in-phase (ip) and opposed-phase (op) chemical shift mri images of a lipid-rich adenoma. intralesional signal loss is demonstrated on the opposed-phase image (red arrow) compared with the in-phase image (blue arrow). (s = spleen.) to qualitatively evaluate chemical shift change and assess signal drop-off visually, comparison with an internal standard reference is helpful. in clinical practice, the spleen is used as the internal reference organ. the liver should not be used as reference, as many patients have incidental diffuse fatty hepatic infiltration that will also exhibit signal drop on op, resulting in erroneous results. the sensitivity and specificity of csi for distinguishing benign from malignant lesions are reported at 78 100% and 87 100%, respectively.5 the csi signal loss can be calculated quantitatively by measuring the adrenal-to-spleen chemical shift ratio (asr) or the adrenal signal intensity index (asii). measurements <0.71 on asr or >16.5% on asii are consistent with an adenoma (table 2).10 most studies have shown no significant difference between ct densitometry and csi in characterising lipid-rich adenomas. however, csi is superior in evaluating lipid-poor adenomas that measure 10 30 hu on unenhanced ct.5 limitations. adrenal carcinomas, phaeo-chromocytomas and clear cell renal cell carcinoma metastases can contain variable amounts of fat and may demonstrate signal loss on op images. diffusion-weighted imaging (dwi) in theory, malignant lesions should demonstrate lower apparent diffusion coefficient (adc) values and restricted diffusion. despite resounding success in the evaluation of tumours elsewhere in the body, dwi has not shown promising use in differentiating malignant from benign adrenal lesions, as evidenced by the recent study by sandrasegaran et al.12 mr spectroscopy based on specific pattern change in metabolite concentration, spectroscopy has shown some promise in adrenal lesion characterisation. although not in widespread clinical use, values of 1.2 for choline-creatine ratio, 0.38 for choline-lipid ratio and 2.1 for lipid-creatine ratio enabled distinction of adenomas and phaeochromocytomas from adrenal carcinomas and metastases.6 c. positron-emission tomography positron-emission tomography (pet) plays an increasingly pivotal role in functional imaging, governed by the metabolic activity of the adrenal lesion. like most other non-benign lesions, malignant adrenal neoplasms show increased 18f-fluoro-deoxyglucose (18fdg) activity owing to increased glucose utilisation. the strength of pet lies in its accurate ability to assess physiological change, which often precedes gross anatomical changes that are detected much later. excellent results observed by boland et al.13 in a meta-analysis, reported a 97% sensitivity and 91% specificity in distinguishing benign from malignant lesions. the use of hybrid pet-ct has improved the diagnostic yield through including ct densitometry, morphological features and accurate localisation. qualitative pet analysis using visual comparison with liver uptake is used more commonly. quantitative suv analysis is of limited diagnostic use. pet-ct, although a supreme diagnostic tool, is not without limitations: • it is less sensitive in detecting and characterising small lesions, particularly those less than 1 cm. • a small percentage of adenomas and infective lesions are mildly fdg avid. • false negatives may be encountered in adrenal metastases from primary malignancies that are non-fdg avid, e.g. bronchoalveolar carcinoma, carcinoid tumours. other primary agents (f-fluoro-dopamine, 11c-hdroxyephedrine, f-dopa,) are also in use, particularly for the diagnosis of phaeochromocytomas. d. adrenal scintigraphy scintigraphy provides functional character­isation of the adrenal gland based on the uptake and accumulation of radiotracer. adreno­medullary agents (e.g. meta-iodo­benzylguanidine (mibg)) and adrenocortical agents (e.g. np59 (iodomethylnorcholesterol)) are the two major categories of radio­pharmaceuticals in use. mibg is a structural and functional analogue of norephedrine, taken up by adrenergic neoplasms includ­ing phaeochromocytomas, neuroblastomas and para­gangliomas whole-body imaging allows the detection of multifocal disease, extra-adrenal phaeochromocytomas (para-gangliomas), metastatic disease and residual/recurrent tumour. octreotide (a somatostatin analogue) is occasionally used for the evalu­ation of medullary disorders, but carries a lower sensitivity of approximately 30% in the detection of phaeochromocytomas.6 n59 is the main radio-isotope employed in adrenal cortical scintigraphy. it is a cholesterol analogue that binds to lipoprotein receptors of adrenal cortical cells. adenomas, with intact steroidogenesis, show uptake of np59, whereas malignant and non-adenomatous lesions do not. e. ultrasonography owing to the widespread use of abdominal ultrasound, many adrenal masses are discovered incidentally. although ultrasound has a limited role in adrenal lesion characterisation, it is reliable in detecting size, assessing serial growth and determining the solid or cystic nature of an adrenal mass (fig. 3). fig. 3. longitudinal ultrasound image demonstrating a well-defined, solid hypo-echoeic left suprarenal mass (blue arrow), which was a pathologically confirmed adenoma. f. percutaneous adrenal biopsy radiological advances in dedicated adrenal imaging have allowed more accurate noninvasive characterisation of adrenal neo­plasms, thereby reducing the number of adrenal biopsies performed. to establish a definitive diagnosis, biopsies are still performed for adrenal lesions that remain indeterminate on imaging. percutaneous biopsies carry a complication rate of 8 12.7%. complications include bleeding, pancreatitis, pneumothorax, infection and needle tract seeding. biopsy of an unsuspected phaeochromocytoma carries the potential risk of precipitating a catecholamine storm. biochemical testing to exclude a possible phaeochromocytoma is therefore advocated prior to undertaking any adrenal biopsy.2 g. venous sampling selective adrenal vein sampling is infrequently performed. it is invasive and requires specialised expertise. venous sampling is used to localise the source of adrenal hormonal secretion, especially in the evaluation of hyperaldosteronism. adrenal pathology when classifying an adrenal neoplasm, it is imperative to broadly establish if the lesion is hyperfunctioning or non-hyperfunctioning, and whether it is benign or malignant. hyperfunctioning lesions, although rare, can potentially be fatal if unrecognised. whilst these lesions usually present with a characteristic clinical syndrome, the disease may remain occult and subclinical. conditions with excessive hormone production include: • cushing syndrome: increased cortisol secre­tion • conn syndrome: increased aldosterone produc­tion • adrenogenital syndrome: androgen over­production • phaeochromocytoma: excess catechol-amine secretion. adrenocortical adenomas adenomas are the most frequently encountered adrenal cortical lesion, representing 80% of all adrenal neoplasms. the prevalence of adenomas increases with age, occurring in approximately 0.2% of ct scans in patients aged 20 29 years, escalating to 7 10% in the elderly.2 adenomas are benign and usually non-hyperfunctioning. a small fraction of adenomas are active, however, resulting in a hyperfunctioning syndrome. ten to 20 per cent of adenomas are bilateral.14 adenomas measure 1 3 cm in size. most are round/oval in shape, well-defined, smooth-margined, homogenous and stable/slow-growing. calcification, haemorrhage and necrosis are rare but may be present in larger lesions. atypical adenomas can appear heterogeneous, irregular and large. seventy per cent of adenomas are lipid rich with abundant intracellular fat, and display classic imaging characteristics (table 3). the 30% of adenomas that are lipid poor have hu >10 and may not conform to the classic imaging findings. ct washout, chemical shift imaging and pet will further help to differentiate this subgroup of adenomas from non-adenomatous lesions. metastasis metastasis is the most common malignant lesion affecting the adrenal gland. at autopsy, it is found in approximately 27% of cancer patients.3 the adrenal gland is the 4th most common site for overall metastatic disease. primary tumours that commonly metastasise to the adrenal gland include bronchogenic, breast, thyroid and colon carcinomas and melanoma.14 half of adrenal metastases are bilateral. when small, adrenal metastases have no specific features. however, larger lesions are ill-defined with irregular margins and display heterogeneity owing to areas of haemorrhage, necrosis and calcification (figs 4a and b). fig. 4. adrenal metastases in a 56-year-old woman with advanced breast carcinoma. (a) axial unenhanced ct scan image shows bilateral ill-defined adrenal masses (blue arrows) and a large hypodense hepatic lesion (red arrow). (b) axial pet image demonstrates intense fdg uptake in both adrenal (blue arrows) and liver lesions (red arrows) consistent with metastases. adrenocortical carcinoma primary adrenal carcinoma (acc) is a rare, aggressive malignancy arising from the adrenal cortex. it has a bimodal age distribution, affecting children <5 years of age and adults in their 4th 5th decade.10 most accs are hormonally active. acc is associated with various syndromes including carney complex, beckwith-wiedemann syndrome, men-i and li-fraumeni syndrome.10 the tumours are large, often exceeding 6 cm.2 most accs demonstrate aggressive features with vascular invasion, local infiltration, distant metastases and retroperitoneal lymphadenopathy.14 accs have irregular margins and can display necrosis, intratumoral haemorrhage and calcification. the tumours enhance avidly, and characteristically have a rim of peripheral nodular enhancement. accs retain contrast, resulting in apw <60% and rpw <40%. mri demonstrates variable heterogeneous t1 and t2 signal intensities and shows no significant chemical shift change. mri better evaluates tumour extension into the ivc and renal veins. acc is fdg avid (figs 5a and b). pet has the added advantage of detecting metastatic spread. fig. 5. histologically proven adrenocortical carcinoma. (a) axial enhanced ct image demonstrating a large heterogeneous left adrenal mass (blue arrow) with ivc invasion (red arrow). (b) coronal pet image showing marked fdg activity in the left adrenal tumour (blue arrow) and within the ivc tumour thrombus (black arrow). (by courtesy of dr i francis) phaeochromocytoma phaeochromocytomas are neuro-endocrine catecholamine-secreting tumours that arise from chromaffin cells of the adrenal medulla or sympathetic paraganglia. phaeochromocytomas are dubbed the ‘10% tumour’ as 10% are extra-adrenal, 10% bilateral, 10% malignant and 10% familial (fig. 6). most phaeochromocytomas are sporadic but there is a strong association with various syndromes (von hippel-lindau, neurofibromatosis 1, men ii).10 clinically, patients present with paroxysmal hypertension, palpitations, flushing, diaphoresis and elevated levels of cathecholamines, vanillylmandelic acid and metanephrines. fig. 6. familial phaeochromocytomas in a 23-year-old woman. axial t2-weighted image demonstrating bilateral phaeochromocytomas. a large heterogeneous right adrenal mass (blue arrow) with central necrosis (yellow arrow) and a smaller, well-defined, homogenous left adrenal mass (red arrow) are shown. phaeochromocytomas have variable imaging characteristics, with a reported size of 1.2 15 cm (mean size 5.5 cm). smaller lesions are homogenous and display a density of 40 50 hu.14 larger lesions have a heterogeneous appearance with areas of cystic necrosis, myxoid degeneration, haemorrhage and calcification (fig. 7a). phaeochromocytomas enhance avidly. their washout dynamics are variable and inconsistent. most phaeochromocytomas (irrespective of their malignant potential) demonstrate apw <60% and rpw <40%. however, some phaeochromocytomas display ct washout values that mimic adenomas. historically, the use of intravenous ionic contrast in patients with phaeochromocytomas was guarded, as it could potentially precipitate an adrenal crisis. however, recent experience shows no adverse events with non-ionic contrast, eliminating the need for premedication.10 mibg has a high sensitivity and specificity in detecting phaeo­chromocytomas (fig. 7b). the advantage of scintigraphy is that extra-adrenal phaeochromocytomas and metastases can be detected. increased fdg activity is noted in phaeochromocytomas. recent studies also suggest a role for pet in detecting mibg-negative phaeochromocytomas.6 fig. 7. benign phaeochromocytoma in a 57-year-old woman. (a) contrast-enhanced ct scan demonstrates a well-encapsulated heterogeneous left adrenal mass representing a phaeochromocytoma (blue arrow) with peripheral enhancement (red arrow) and a central area of low attenuation owing to necrosis (yellow arrow). k = displaced left kidney. f = incidental uterine fibroid. (b) mibg image shows accumulation of radiotracer in the left phaeochromocytoma (blue arrow). photopenic area (red arrow) is consistent with necrosis. phaeochromocytomas show intermediate to high t2-weighted signal intensity (figs 8a and b). the classic ‘light bulb’ t2 hyperintensity that was thought to be a characteristic feature, is only present in 34% of phaeochromocytomas.14 imaging plays a vital role in demonstrating local invasion and metastatic spread, being the only reliable criteria that help to establish a diagnosis of malignant phaeochromocytoma (figs 9a c). fig. 8. histologically proven phaeochromocytoma in a 56-year-old man. (a) coronal t2-weighted image showing a heterogeneous right suprarenal mass (blue arrow) with central necrosis (red arrow), displacing the kidney inferomedially (yellow arrow). (b) axial gadolinium-enhanced t1-weighted image demonstrates intense enhancement (blue arrow). central non-enhancing area corresponds to the area of central necrosis (red arrow). fig. 9. malignant phaeochromocytoma in a 28-year-old man. (a) axial postcontrast ct scan demonstrates a large phaeochromocytoma (blue arrow) with central necrosis (red arrow) and invasion into the ivc (yellow arrow). enhancing tumour thrombus is noted to expand the intrahepatic ivc (blue arrow in b) and extend into the right atrium of the heart (blue arrow in c). adrenal lymphoma primary adrenal lymphoma is rare, with less than 100 reported cases. secondary lymphomatous involvement of the adrenal gland occurs typically with non-hodgkin’s lymphoma, and is seen in 4% of ct studies with disseminated disease.14 forty-three per cent of adrenal lymphoma is bilateral.10 the ct appearance ranges from a discrete mass to diffuse infiltration, whereby the adrenal gland is characteristically enlarged but maintains its adreniform shape (fig. 10). calcification is rare, occurring only post therapy. mri characteristics are variable but parallels the imaging features of metastases. adrenal lymphoma demonstrates marked increased fdg activity. fig. 10. a 50-year-old woman with non-hodgkin’s lymphoma. coronal reformatted enhanced ct scan demonstrates bilateral soft-tissue masses with preservation of the adreniform shape of the adrenal gland (blue arrows). myelolipoma myelolipoma is a benign, non-functioning adrenal neoplasm composed of an admixture of mature adipose tissue and haemopoietic elements. myelolipomas are usually unilateral and vary in size, some of which grow extremely large. macroscopic fat is the hallmark feature. ct demonstrates a well circumscribed, heterogeneous mass with areas of fat density and scattered amounts of soft-tissue myeloid elements (fig. 11a). a pseudocapsule comprising a thin rim of compressed adrenal cortex is seen in most myelolipomas. calcification is noted in approximately 24% of lesions.10 on ultrasound, myelolipomas display doppler flow and heterogeneous echogenicity with the fatty components being characteristically echogenic (fig. 11b). on mri , the diagnosis can be confirmed, with the fatty elements demonstrating t1 hyperintensity and suppression following fat saturation. an ‘india ink’ artifact may be seen as a sharp black line outlining the fat-adrenal interface on chemical shift imaging (fig. 11c). the presence of macroscopic fat is not exclusive to myelolipomas, as very rarely other adrenal lesions (acc, phaeochromocytomas and metastatic clear cell renal carcinomas) may contain fat. fig. 11. myelolipoma. (a) axial unenhanced ct scan image showing a well-defined right adrenal mass with macroscopic fat (red arrow). the myeloid elements have a higher soft-tissue density (blue arrow). (b) longitudinal ultrasound image demonstrating a heterogeneous predominantly echogenic adrenal mass abutting the superior pole of the right kidney (blue arrow). (c) axial opposed phase mri image demonstrating india-ink artifact (blue arrow). infection granulomatous infections affecting the adrenal gland are often secondary to tuberculosis or histoplasmosis. involvement is usually bilateral but asymmetric. it is frequently associated with adrenal insufficiency. imaging characteristics are nonspecific and include adrenal gland enlargement, soft-tissue masses, cystic change, heterogeneous enhancement and calcification (fig. 12).10 fig. 12. a 48-year-old man with a background history of disseminated tb. axial contrast-enhanced ct scan demonstrates dense calcification of the right adrenal gland (blue arrow). adrenal haemorrhage adrenal haemorrhage may result from trauma, coagulopathies, venous thrombosis, orthotopic liver transplantation, stress related to surgery, sepsis and hypotension, and among neonates. a fifth of haematomas are bilateral.10 acute haematomas appear as oval/round high-attenuation (50 90 hu) masses.2 on serial imaging, these lesions decrease in size and attenuation. mri appearance varies with the age of the haematoma. areas of t1 hyperintensity are present in acute haemorrhage with a characteristic haemosiderin hypo-intense rim noted in the subacute stage. chronic haematomas are t1-weighted and t2-weighted hypo-intense. gradient echo sequence is sensitive to the detection of blood products. the magnetic susceptibility results in a pronounced t2 signal loss that visually accentuates the haemorrhagic focus, the so-called ‘blooming artifact’. adrenal cysts three types of adrenal cysts are identified: • endothelial cysts are the most common and are simple in nature. they have thin walls, an hu <20, no enhancement and are t2 hyperintense. • pseudocysts are usually secondary to a previous insult, e.g. haemorrhage and infarction. the cysts are complex, with thick walls, internal septations, solid components, curvilinear calcification and haemorrhagic products. • parasitic cysts are often secondary to ecchinococcal infection. depending on the stage of disease, the cyst can range from simple to a multilocular complex cystic lesion. complex cysts can be difficult to differentiate from more sinister lesions such as adrenal abscess, cystic metastasis and necrotic adrenal neoplasms.3 diagnostic algorithm the recent white paper of the american college of radiology committee on incidental findings recommended a comprehensive approach to the management of an adrenal incidentaloma (fig. 13).15 does such a guideline have a place in the african healthcare context? in an already overburdened healthcare system, with limited resources, poor patient referral patterns and financial constraints, is it pragmatic to adopt first-world recommendations? the answer is yes, as most adrenal lesions are successfully detected and accurately characterised on a single patient visit, using ct methods only. very few lesions will require further evaluation by specialised techniques or expertise. the greater challenge is to ensure that all imagers have an astute understanding of the modern principles, imaging modalities and specialised techniques available for the evaluation and management of adrenal pathology. fig. 13. american college of radiology white paper-recommended algorithm for the management of an adrenal incidentaloma (by courtesy of dr l l berland). 15 fig. 14. adrenal incidentaloma. a 72-year-old woman had a ct scan performed for non-specific lower abdominal discomfort. the ct findings were unremarkable except for an incidentally detected left adrenal mass. (a) pre-contrast axial ct image shows a left adrenal mass with a ct density measuring 14 hu (blue arrow). (b). post-contrast 60 seconds measures 87 hu (blue arrow). (c). post-contrast 15 minutes’ delay 32 hu (blue arrow). the lesion is indeterminate by unenhanced ct attenuation criteria (hu >10) alone and does not permit accurate characterisation of the lesion. washout analysis : apw = absolute percentage washout; e = enhanced ct attenuation value at 60seconds; d = delay 15-minute ct attenuation value; u = unenhanced ct attenuation value. the washout parameters (apw >60%) indicate benign disease, consistent with a lipid-poor adenoma. acknowledgements. we thank drs a mitha and k amod, and professor d rubens, for their help in compiling the images for this review. 1. boland gw. adrenal imaging: why, when, what, and how? part 1. why and when to image? am j roentgenol 2010;195(6):w377-381. [http://dx.doi.org/10.2214/ajr.10.4204] 1. boland gw. adrenal imaging: why, when, what, and how? part 1. why and when to image? am j roentgenol 2010;195(6):w377-381. [http://dx.doi.org/10.2214/ajr.10.4204] 2. boland gw, blake ma, hahn pf. incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. radiology 2008;249(3):756-775. [http://dx.doi.org/10.1148/radiol.2493070976] 2. boland gw, blake ma, hahn pf. incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. radiology 2008;249(3):756-775. [http://dx.doi.org/10.1148/radiol.2493070976] 3. lockhart me, smith jk, kenney pj. imaging of adrenal masses. eur j radiol 2002;41(2):95-112. [http://dx.doi.org/10.1016/s0720-48x(01)00444-2] 3. lockhart me, smith jk, kenney pj. imaging of adrenal masses. eur j radiol 2002;41(2):95-112. [http://dx.doi.org/10.1016/s0720-48x(01)00444-2] 4. song jh, mayo-smith ww. incidentally discovered adrenal mass. radiol clin north am 2011;49(2):361-368. [http://dx.doi.org/10.1016/j.rcl.2010.10.006] 4. song jh, mayo-smith ww. incidentally discovered adrenal mass. radiol clin north am 2011;49(2):361-368. [http://dx.doi.org/10.1016/j.rcl.2010.10.006] 5. blake ma, holalkere n-s, boland gw. imaging techniques for adrenal lesion characterization. radiol clin north am 2008;46(1):65-78. [http://dx.doi.org/10.1016/j.rcl.2008.01.003] 5. blake ma, holalkere n-s, boland gw. imaging techniques for adrenal lesion characterization. radiol clin north am 2008;46(1):65-78. [http://dx.doi.org/10.1016/j.rcl.2008.01.003] 6. boland gw. adrenal imaging: from addison to algorithms. radiol clin north am 2011;49(3):511-528. [http://dx.doi.org/10.1016/j.rcl.2011.02.010] 6. boland gw. adrenal imaging: from addison to algorithms. radiol clin north am 2011;49(3):511-528. [http://dx.doi.org/10.1016/j.rcl.2011.02.010] 7. lee mj, hahn pf, papanicolou n, et al. benign and malignant adrenal masses: ct distinction with attenuation coefficients, size and observer analysis. radiology 1991;179(2):415-418. 7. lee mj, hahn pf, papanicolou n, et al. benign and malignant adrenal masses: ct distinction with attenuation coefficients, size and observer analysis. radiology 1991;179(2):415-418. 8. korobkin m, giordano tj, brodeur fj, et al. adrenal adenomas: relationship between histologic lipid and ct and mr findings. radiology 1996;200(3):743-747. 8. korobkin m, giordano tj, brodeur fj, et al. adrenal adenomas: relationship between histologic lipid and ct and mr findings. radiology 1996;200(3):743-747. 9. boland gw, lee mj, gazelle gs, et al. characterization of adrenal masses using unenhanced ct: an analysis of the ct literature. am j roentgenol 1998;171(1):201-204. [http://dx.doi.org/10.2214/ajr.171.1.9648789] 9. boland gw, lee mj, gazelle gs, et al. characterization of adrenal masses using unenhanced ct: an analysis of the ct literature. am j roentgenol 1998;171(1):201-204. [http://dx.doi.org/10.2214/ajr.171.1.9648789] 10. taffel m, haiji-momenian s, nikolaidis p. adrenal imaging: a comprehensive review. radiol clin north am 2012;50(2):219-243. [http://dx.doi.org/10.1016/j.rcl.2012.02.009] 10. taffel m, haiji-momenian s, nikolaidis p. adrenal imaging: a comprehensive review. radiol clin north am 2012;50(2):219-243. [http://dx.doi.org/10.1016/j.rcl.2012.02.009] 11. sangawaiya mj, boland gw, cronin cg, et al. incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector ct-10 minute delayed imaging protocol revisited in a large patient cohort. radiology 2010;256(2):504-510. [http://dx.doi.org/10.1148/radiol.10091386] 11. sangawaiya mj, boland gw, cronin cg, et al. incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector ct-10 minute delayed imaging protocol revisited in a large patient cohort. radiology 2010;256(2):504-510. [http://dx.doi.org/10.1148/radiol.10091386] 12. sandrasegaran k, patel aa, ramasawamy r, et al. characterization of adrenal masses with diffusion-weighted imaging. am j roentgenol 2011;197(1):132-138. [http://dx.doi.org/10.2214/ajr.10.4583] 12. sandrasegaran k, patel aa, ramasawamy r, et al. characterization of adrenal masses with diffusion-weighted imaging. am j roentgenol 2011;197(1):132-138. [http://dx.doi.org/10.2214/ajr.10.4583] 13. boland gw, dwamena ba, sangawaiya mj, et al. characterization of adrenal masses by using fdg pet: a systematic review and meta-analysis of diagnostic test performance. radiology 2011;259(1):117-126. [http://dx.doi.org/10.1148/radiol. 11100569] 13. boland gw, dwamena ba, sangawaiya mj, et al. characterization of adrenal masses by using fdg pet: a systematic review and meta-analysis of diagnostic test performance. radiology 2011;259(1):117-126. [http://dx.doi.org/10.1148/radiol. 11100569] 14. low g, dhliwayo h, lomas dj. adrenal neoplasms. clin radiol 2012;67(10):988-1000. [http://dx.doi.org/10.1016/j.crad.2012.02.005] 14. low g, dhliwayo h, lomas dj. adrenal neoplasms. clin radiol 2012;67(10):988-1000. [http://dx.doi.org/10.1016/j.crad.2012.02.005] 15. berland ll, silverman sg, gore rm, et al. managing incidental findings on abdominal ct: white paper of the acr incidental findings committee. j am coll radiol 2010;7(10):754-773. [http://dx.doi.org/10.1016/j.jacr.2010.06.013] 15. berland ll, silverman sg, gore rm, et al. managing incidental findings on abdominal ct: white paper of the acr incidental findings committee. j am coll radiol 2010;7(10):754-773. [http://dx.doi.org/10.1016/j.jacr.2010.06.013] article information authors: nasreen mahomed1,2 evance chisama1 sanjay prabhu3 affiliations: 1department of radiology, university of the witwatersrand, south africa 2consultant radiologist, chris hani baragwanath hospital, south africa 3department of radiology, boston children's hospital, harvard medical school, united states of america correspondence to: nasreen mahomed email: nasreen.mahomed@wits.ac.za postal address: private bag x3, university of the witwatersrand, johannesburg 2050, south africa dates: received: 14 apr. 2014 accepted: 17 oct. 2014 published: 05 dec. 2014 how to cite this article: mahomed n, chisama e, prabhu s. the ivy sign. s afr j rad. 2014;18(1); art. #622, 3 pages. http://dx.doi/org.10.4102/sajr.v18i1.622 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the ivy sign in this signs... open access • abstract • signs of diffuse bilateral leptomeningeal enhancement • experiences at boston children's hospital • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ the ivy sign refers to diffuse bilateral leptomeningeal enhancement on postcontrast t1-weighted magnetic resonance imaging (mri) and increased signal intensity in bilateral subarachnoid spaces and perivascular spaces on t2-weighted fluid attenuation inversion recovery (flair) mri sequences in patients with moyamoya disease. signs of diffuse bilateral leptomeningeal enhancement top ↑ moyamoya disease is an idiopathic cerebrovascular occlusive disorder characterised by progressive stenosis of the distal aspect of the internal carotid arteries, the proximal aspects of the middle cerebral arteries and the anterior cerebral arteries, with subsequent collateral vessel formation. the ivy sign represents neovascularisation over the cerebral cortex via leptomeningeal anastomosis through collateral circulation, and represents diffuse engorgement of the pia vasculature. the ivy sign was first described in 1995, so called because of its resemblance to ‘ivy creeping on stone’. the sign refers to diffuse bilateral leptomeningeal enhancement on post-contrast t1-weighted magnetic resonance imaging (mri) (figure 1) and increased signal intensity in bilateral subarachnoid spaces and perivascular spaces on t2-weighted fluid attenuation inversion recovery (flair) mri (figure 2) sequences in patients with moyamoya disease.1, 2 figure 1: post-contrast t1-weighted mri demonstrating the ivy sign, namely diffuse leptomeningeal enhancement (arrows) resembling ivy creeping on stone. figure 2: t2-weighted flair mri sequences demonstrating the ivy sign, namely increased signal intensity in the bilateral subarachnoid spaces and perivascular spaces. this represents neovascularisation over the cerebral cortex via leptomeningeal anastomosis through collateral circulation that develops from the diffuse pial arterial network. moyamoya disease is an idiopathic cerebrovascular occlusive disorder characterised by progressive stenosis of the distal aspect of the internal carotid arteries (icas), the proximal aspects of the middle cerebral arteries (mcas) and the anterior cerebral arteries (acas), with subsequent collateral vessel formation. moyamoya is a japanese term, meaning a puff or spiral of smoke, and describes the cloudlike lenticulostriate and thalamostriate collaterals on angiography. the three basic collateral pathways involved include the basal moyamoya vessels from perforators, leptomeningeal collateral vessels from the posterior cerebral artery, and the transdural collateral vessels from the external carotid artery (figure 3).3, 4 figure 3: mr angiography demonstrating moyamoya disease, with stenosis of the distal aspect of the internal carotid arteries, the proximal aspects of the middle cerebral arteries and the anterior cerebral arteries, with subsequent collateral vessel formation resembling a puff or spiral of smoke, which describes the cloud-like lenticulostriate and thalamostriate collaterals. the leptomeningeal enhancement on post-contrast t1-weighted mri (figure 1), seen in the ivy sign in patients with moyamoya disease, represents neovascularisation over the cerebral cortex via leptomeningeal anastomosis through collateral circulation. this develops from the anastomosis of external carotid collateral arteries and icas, and represents diffuse engorgement of the pia vasculature.2 this collateral flow is very slow owing to its retrograde direction via leptomeningeal anastomosis. from this phenomenon, the engorged pial network shows post-contrast enhancement.2 recent literature suggests that 3.0-tesla mr imaging is superior to 1.5-tesla mr imaging in visualising the ivy sign and associated changes in moyamoya disease because of the higher resolution and increased signal-to-noise ratio and contrast-to-noise ratio, thus enabling better depiction of pathological small vessel segments, with greater angiographic detail.5 it has become evident in moyamoya disease that, when successful bypass surgery is performed, the leptomeningeal enhancement (the ivy sign) on contrast-enhanced t1-weighted sequences decreases or disappears. this classical finding implies that the ivy sign in moyamoya disease represents cortical insufficiency rather than reactive hyperaemia.6 in the postoperative period following pial synangiosis, the resolution of the ivy sign in conjunction with development of more robust collaterals underlying the site of pial synangiosis indicates successful revascularisation and improved, faster flow in the involved areas.7, 8 the ivy sign can be seen in new areas following surgery, and this can be an indication that slow flow in new collaterals has developed underlying the synangiosis. these areas need to be carefully assessed on serial studies to ensure that the flow improves over time and is matched by flow enhancement in collaterals on time-of-flight or post-contrast mr angiography (mra).7, 8, 9 pitfalls of the ivy sign include the leptomeningeal enhancement on post-contrast t1-weighted mri in cases of meningitis and meningeal carcinomatosis characterised by inflammation or carcinomatous infiltration of the leptomeninges, with or without involvement of the small leptomeningeal vessels.1 experiences at boston children's hospital top ↑ owing to inherent difficulties with post-contrast mra in young children, including intravenous access, need for sedation and limitations to pump injection, we rely on a combination of 3d time-of-flight mra and arterial spin labelling studies with several time delays to assess the cerebral bloodflow in patients with moyamoya disease. with our experience of over 400 paediatric patients at boston children's hospital who have undergone pial synangiosis and correlation of a large proportion of cases with conventional angiography, we found that post-contrast mra is not necessary in most cases to help assess post-surgical collateral flow. arterial spin labelling studies are challenging as bloodflow through the synangiosis comes in via a longer pathway (external carotid arteries and its branches), and this necessitates longer delay times to assess the label in this portion of the brain. absence of the ivy sign in previously involved areas and new vessels on time-of-flight suffices in most cases to assess whether the surgery has worked or not. conventional angiography is used in equivocal cases at our institution. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions n.m. (university of the witwatersrand & chris hani baragwanath hospital) conceptualised and wrote the article and is the corresponding author. e.c. (university of the witwatersrand) performed the literature review on pubmed and assisted in preparing the article. s.p. (boston children's hospital, harvard medical school) provided important information of the ivy sign from his experience at boston children hospital, contributed to the images, and edited the article. references top ↑ ohta t, tanaka h, kuroiwa t. diffuse leptomeningeal enhancement, ‘ivy sign’, in magnetic resonance images of moyamoya disease in childhood: case report. neurosurgery. 1995;37(5):1009–1112. http://dx.doi.org/10.1227/00006123-199511000-00024 maeda m, tsuchida c. ‘ivy sign’ on fluid-attenuated inversion-recovery images in childhood moyamoya disease. am j neuroradiol. 1999;20(10):1836–1838. yoon hk, shin hj, chang yw. ‘ivy sign’ in childhood moyamoya disease: depiction on flair and contrast-enhanced t1-weighted mr images. radiology. 2002;223(2):384–389. http://dx.doi.org/10.1148/radiol.2232011094 mori n, mugikura s, higano s, et al. the leptomeningeal ‘ivy sign’ on fluid-attenuated inversion recovery mr imaging in moyamoya disease: a sign of decreased cerebral vascular reserve? am j neuroradiol. 2009;30(5):930–935. http://dx.doi.org/10.3174/ajnr.a1504 jin q, noguchi t, irie h, et al. assessment of moyamoya disease with 3.0-t magnetic resonance angiography and magnetic resonance imaging versus conventional angiography. neurol med chir (tokyo). 2011;51(3):195–200. http://dx.doi.org/10.2176/nmc.51.195 kawashima m, noguchi t, takase y, et al. decrease in leptomeningeal ivy sign on fluid-attenuated inversion recovery images after cerebral revascularization in patients with moyamoya disease. am j neuroradiol. 2010;31(9):1713–1718. http://dx.doi.org/10.3174/ajnr.a2124 scott rm, smith jl, robertson rl, et al. long-term outcome in children with moyamoya syndrome after cranial revascularization by pial synangiosis. j neurosurg. 2004;100(2 suppl pediatrics):142–149. jackson em, lin n, manjila s, et al. pial synangiosis in patients with moyamoya younger than 2 years of age. j neurosurg pediatr. 2014;13(4):420–425. http://dx.doi.org/10.3171/2014.1.peds13251 lin n, baird l, koss m, et al. discovery of asymptomatic moyamoya arteriopathy in pediatric syndromic populations: radiographic and clinical progression. neurosurg focus. 2011;31(6):e6. http://dx.doi.org/10.3171/2011.10.focus11228 sa journal of radiology • december 2010 105 case report introduction macrodystrophia lipomatosa (mdl) results from progressive overgrowth of all the mesenchymal elements, with a disproportionate increase in fibro-adipose tissue. this rare congenital abnormality occurs most frequently in the distribution of the median nerve in the upper, and medial plantar nerve in the lower, extremity.1 excess of unencapsulated fibro-adipose tissue on magnetic resonance imaging (mri) is virtually diagnostic and can differentiate this entity from other diseases with similar presentations. involvement of the ulnar aspect of the hand and the lateral aspect of the foot as seen in our cases is exceedingly rare. case report case 1 a 13-year-old boy presented to us from the department of plastic surgery for x-ray of his right foot for a painless soft-tissue mass present since birth (fig. 1a). local examination revealed soft, non-oedematous, non-tender, non-pulsatile swelling on the plantar aspect of the right foot. there was no history of fever or trauma or familial gigantism. no bruit or skin changes were present over the mass. the rest of the examination was normal. on plain skiagram, hyperextension of the 3rd, 4th and 5th metatarsophalangeal joints was found, with overgrowth of distal phalanges. there was no evidence of osteolytic/osteosclerotic changes, periosteal reaction or abnormal calcifications. the rest of the bones macrodystrophia lipomatosa – mr imaging of a rare congenital anomaly: review of 3 cases pallavi aga, md umesh c parashari, md anit parihar, md ragini singh, md neera kohli, md rajesh yadav, md chattrapati shahuji maharaj medical university, lucknow, uttar pradesh, india fig. 1a. photograph showing swelling on the plantar aspect of the right foot (white arrow). first and 2nd digits are spared (white arrow heads). fig. 1b. plain skiagram of right foot revealing hyperextension of the 3rd, 4th and 5th metatarsophalangeal joints ( open white arrow), with overgrowth of distal phalanges. first and 2nd digits are seen normally (white arrow heads). fig. 1c. t1w sagittal image of right foot revealing diffused thickening of soft tissue (thick white arrow) appearing heterogeneously hyperintense with multiple thin linear low-signal intensity areas consistent with fibrous strands ( thin white arrow). hyperextension is seen at metatarsophalangeal joints ( open white arrow). fig. 1d. t1w fat-suppressed sagittal image of right foot shows suppression of the signal from the unencapsulated fat (white arrow). fig. 2. t1w coronal image of the left hand showing focal hypertrophy of the thumb and index finger (distribution of median nerve) owing to enlarged soft tissue showing a striated pattern with fatty infiltration ( thick white arrow). bony excrescences are seen in involved phalanges (thin white arrow). 106 sa journal of radiology • december 2010 case report appeared normal (fig. 1b). a grey-scale ultrasound with colour doppler study was done to exclude vascular pathology. ultrasound revealed a soft-tissue mass with abnormal subcutaneous fat, without dilated vascular channels or calcification. mr imaging on 1.5 t units revealed diffused thickening of soft tissue of the right foot, involving the 3rd, 4th and 5th digits, appearing heterogeneously hyperintense on t1and t2-weighted sequences with multiple thin linear low-signal intensity areas consistent with fibrous strands (fig. 1c). fat-suppressed images showed suppression of the soft-tissue areas consistent with unencapsulated fat (fig. 1d). areas of hyperintensity were seen in the tarsal bones on t2-weighted fatsuppression images. the rest of the underlying bones revealed normal signal intensity with intact periosteum. underlying metatarsals appeared to be widened. there was no associated nerve hypertrophy or soft-tissue calcification. no evidence of haemangioma or lymphangioma was seen. from the above findings, a radiological diagnosis of mdl was made, which was consistent with the histopathology. case 2 a 24-year-old woman presented to our department for mr imaging of painless non-tender and non-pitting swelling in the thumb and index finger of her left hand. the swelling was atraumatic, had been present for a long time, and was slowly increasing in size. there was no history of swelling in any other part of body, and no family history. overlying skin was normal, and there was no bruit. mri of the hand showed focal hypertrophy of the thumb and index finger (distribution of median nerve) owing to enlarged soft tissue showing a striated pattern with fatty infiltration. the soft tissue displayed hyperintense signals on t2and t1-weighted imaging (wi) with a few linear hypointense areas alternating with hyperintense areas on both t1and t2weighted images (fig. 2). on fat-suppressed shorttau inversion recovery (stir) images, hypointensity was seen within the lesion suggestive of fatty componentsforming the bulk of the soft-tissue swelling. numerous bony excrescences resembling small osteophytes and osteochondromas were seen in involved phalanges. no definite flow voids were seen within the lesion. case 3 a 3-year-old boy was referred to us from the department of plastic surgery, with a history of a huge painless swelling involving his right foot since birth. physical findings were consistent with the above two cases. mri showed evidence of local gigantism in the foot, involving the 1st, 2nd and 3rd digits owing to gross hypertrophy of fat and soft tissue in a striated pattern. hyperextension of the great toe was noted, with hypertrophy of metatarsals and phalanges of the great toe and widening of the first web space. the underlying metatarsals appeared broadened, suggestive of macrodactyly. varying signal patterns consistent with bony sclerosis, oedema and erosions were seen along with subluxation of bones at the ankle joint (figs 3a and 3b). fig. 3a. t1w sagittal images of the right foot showing local gigantism owing to gross hypertrophy of fat (thick white arrows) and soft tissue in a striated pattern ( thin white arrow). fig. 3b. t1w axial image of the right foot showing gross hypertrophy of fat and soft tissue in a striated pattern ( thick white arrow). hyperextension of the great toe is noted, with hypertrophy of metatarsals and phalanges of the great toe and widening of the first web space (open white arrow). sa journal of radiology • december 2010 107 case report discussion macrodystrophia lipomatosa was first described by feriz in 1925 and is a rare cause of focal gigantism by deposition of fat in the soft tissue of one or more digits of the hand or foot in association with hypertrophy of the phalanges and affected limbs.2 described as a rare congenital condition, it is classified with other phakomatoses, such as tuberous sclerosis and neurofibromatosis.3-5 the precise aetiology is unknown; however, there are many hypotheses suggesting that it is due to fibrofatty tumours impinging on nerves supplying the enlarged digit, or due to alteration of somatic cells during limb bud development. it is now believed to be a part of generalised hamartomatous disorder featuring fat in the soft tissues and even in the bowel, known as proteus syndrome.6,7 the characteristic feature of the condition is that the anatomical location of the abnormality corresponds closely with the zone of innervation by the sclerotome.1 involvement of the 2nd and 3rd digits of the hands and feet is common, corresponding to the median and the medial plantar nerve supply in the upper and lower limbs respectively; but 5th digit involvement is rare.1,8,9 major clinical features are gigantism of a digit, hands, feet or the entire extremity since birth. associated features are lipomas over other parts of the body or numerous bony excrescences resembling small osteochondroma or osteophytes (seen in case 2) as well as associated secondary osteoarthritic changes and carpal tunnel syndrome in long-standing cases.1 the patient usually seeks surgical correction for cosmetic reasons; however, mechanical problems caused by secondary osteoarthritis in early adulthood could also be the presenting problem. blackskin et al. were the first to describe the mr findings of this entity.10 mri, owing to its inherently excellent soft-tissue contrast, is of great value in demonstrating excess fibrofatty tissue, which has signal characteristics similar to subcutaneous fat, showing high signal intensity on t1-weighted, intermediate signal on t2-weighted, and low signal on fat-suppressed. this fat is not encapsulated, as opposed to a lipoma. mri can also well demonstrate fatty infiltration of muscles, bony overgrowth and cortical thickening. linear hypointense bands within the excess fatty tissue, representing fibrous strands, are well visualised. similar mr findings were demonstrated in all our 3 patients, with the fat appearing to be unencapsulated. mri may also demonstrate fibrolipomatous hamartoma of the nerve of the affected region in some cases.7,9 we did not find this in our patient. radiologists, using different imaging modalities, play a very important role in diagnosing this condition. the diagnosis could be suspected on plain radiograph but mri is the better diagnostic imaging modality as it can rule out other differential diagnoses such as neurofibromatosis, haemangiomatosis, lymphangiomatosis, proteus syndrome and fibrolipomatous hamartoma. neurofibromas are seen in close relation to nerves and show marked hyperintensity on t2-wi. the absence of cutaneous lesions, a negative family history and sclerotomal involvement with characteristic mri findings establish a diagnosis of mdl.11 lymphangiomas have a signal intensity similar to or slightly less than muscle on t1-wi, and greater than fat on t2-wi, owing to the ectatic channels containing clear fluid. visible septations are also seen on mri.12 mri imaging in haemangiomatosis demonstrates vascular channels and fibrous strands, with a palpable bruit clinically. osseous overgrowth is not a feature of both these entities. proteus syndrome may mimic mdl owing to its asymmetric overgrowth of bones and adipose tissue; however, associated features of macrocrania, intracranial abnormalities, cutaneous thickening, pigmented naevi, lung cysts and intra-abdominal lipomas distinguish it from mdl. some consider mdl to be a localised form of proteus syndrome.11 fibrolipomatous hamartomas (flh) of nerves is a rare tumour-like condition in which there is fatty deposition within nerve sheaths. the median nerve of the hand is the most commonly involved. when this disorder is associated with macrodactyly, it presents as a diagnostic dilemma with mdl. in as much as 30.7% of cases of mdl, flh is an associated finding.13 mri of mdl characteristically demonstrates fatty deposition not only in nerve sheaths but also in soft tissues, bone marrow and periosteum. hence, mri plays an important diagnostic role because of the practical importance of differentiation of these conditions as they differ in their course, prognosis, complications and treatment. 1. sone m, ehara s, tamakawa y, nishida j, honjoh s. macrodystrophia lipomatosa: ct and mr findings. radiat med 2000; 18: 129-132. 2. feriz h. makrodystrophia lipomatosa progressiva. virchows arch 1925; 260: 308-368. 3. murray ro, jackobson hg, stoker dj. the radiology of skeletal disorders: exercises in diagnosis, 3rd ed. new york: churchill livingstone, 1990: 1384. 4. broadwater bk, major nm, goldner rd, layfield lj. macrodystrophia lipomatosa with associated fibrolipomatous hamartoma of the median nerve. pediatric surg 2000; 16: 216-285. 5. boren wl, henry re jr, wintch k. mr diagnosis of fibrolipomatous hamartoma of nerve: association with nerve territory oriented macrodactyly [macrodystrophia lipomatosa]. skeletal radiol 1995; 24: 296297. 6. gupta sk, sharma op, sharma sv, sood b, gupta s. macrodystrophia lipomatosa: radiographic observations. br j radiol 1992; 65: 769-773. 7. balakrishna bv, prasad s. macrodystrophia lipomatosa – a rare congenital disorder. indian j radiol imaging 2005; 15: 349-352. 8. hafeez s, syed m, syed a. macrodystrophia lipomatosa –letter to the editor. jk-practitioner 2006; 13: 41-42. 9. dayal j, tyagi ar, jain p, ranjan r, sharma a. images: macrodystrophia lipomatosa. indian j radiol imaging 2001; 11: 139-141. 10. blackskin m, barnes fj, lyons mm: mr diagnosis of macrodystrophia lipomatosa. am j roentgenol 1992; 158: 1295-1297. 11. singla v, virma v, tuli p, khandelwal n. case report : macrodystrophia lipomatosa – illustration of two cases. indian j radiol imaging 2008; 18: 298-301. 12. seigel mj, glazer hs, st. amour te, rosenthal dd. lymphangiomas in children: mr imaging. pediatric radiol 1989; 170: 467-470. 13. cavallaro mc, taylor ja, gorman jd, haghighi p, resnick d. imaging findings in a patient with fibrolipomatous hamartoma of the median nerve. am j roentgenol 1993; 161: 837-838. sajr 876 torus palatinus p naidoo, mb bch, fcrad diag (sa); n maharaj , mb chb, fcrad diag (sa); j maharajh, mb chb, ffrad (d) sa, mmed rad (d); a y moosa, mb chb, fcrad diag(sa) department of diagnostic radiology, nelson r mandela school of medicine, university of kwazulu-natal and king edward viii hospital, durban, south africa corresponding author: p naidoo (pumersh@hotmail.com) kupffer and bessel-hagen coined the term torus palatinus in 1879 for a benign osseous protuberance arising from the midline of the hard palate. tori are present in approximately 20% of the population and are occult until adulthood. recent advances in modern radiology have led to improved evaluation and diagnosis of tori. s afr j rad 2013;17(4):141-142. doi:10.7196/sajr.876 a 54-year-old woman presented with a firm, painful swelling of the hard palate of 4 years’ duration. a clinical diagnosis of maxillary torus without ulceration was made. computed tomography (ct) was performed for confirmation of torus palatinus and to aid surgical planning. the ct scan demonstrated lobulated bony outgrowths arising from the inferior margin of the hard palate, consistent with torus palatinus. (fig. 1). fig. 1. reconstructed coronal ct scan demonstrates a highly calcified, lobulated bony protuberance from the hard palate. discussion torus palatinus is a benign, reactive hyperplasia of osseous tissue extending outward from the surface of the bone.1 it is an intra-oral osseous protruberance of varying size arising along the midline suture of the hard palate.2 jainkittivong and langlais3 characterised these developmental anomalies as sessile nodular bony masses comprising hyperplastic mature and trabecular bone. the torus can arise from the inner or outer surface of the maxillary bone, and is generally named according to location.1 , 4 torus palatinus presents in approximately 20% of the population and is occult until adulthood.1 , 5 the term was coined by kupffer and bessel-hagen in 1879, many years after its first observation.2 the aetiology of torus palatinus has been researched extensively and is thought to arise from an interplay between genetic and environmental factors and masticatory function. the quasi-continuous genetic or threshold model states that the environmental factors responsible must first reach a threshold level before genetic factors can express themselves in the individual. there is a prevalence in middle-aged females, with racial and ethnic group differences.2 , 3 the other most common intra-oral exostosis − torus mandibularis − is a bony outgrowth on the lingual surface of the mandible, most frequently in the premolar or canine area. the concurrence of the different forms of tori shows a low prevalence.2 , 3 tori are usually asymptomatic except when complicated by trauma or ulceration. they may also interfere with speech, mastication or fabrication of maxillary dentures.1 , 5 on panoramic radiographs, small tori palatini are not well demonstrated owing to overlying bony structures; larger tori can be easily detected with a bosselated or multi-lobulated appearance.1 , 5] with advances in imaging techniques, multidetector ct including multiplanar imaging, 3d reconstructions and volume rendering techniques, these osseous protuberances of varying size and locations can be diagnosed to facilitate surgical planning.1 when treatment is elected, the lesions may be chiselled off the cortex or removed via a burr, cutting through the base of the lesion. recurrent lesions may occur, but there is no malignant potential. gardner syndrome should be excluded if patients present with multiple exostoses that are not in the classic torus locations. intestinal polyposis, desmoids and cutaneous fibromas are other common features of this autosomal dominant syndrome.5 fig. 2. reconstructed sagittal ct image shows lobulated outgrowths from the hard palate. fig. 3. three-dimensional ct image shows torus palatinus. conclusion this report highlights a case of torus palatinus − a benign bony exostosis arising from the midline of the hard palate. tori have been well documented and researched for some centuries, they occur currently, and are clinically and radiologically diagnosed and managed. 1. delbalso am. lesions of the jaw. semin ultrasound ct, mr 1995;16(6):487-512. [http://dx.doi.org/10.1016/s0887-2171(06)80022-3] 1. delbalso am. lesions of the jaw. semin ultrasound ct, mr 1995;16(6):487-512. [http://dx.doi.org/10.1016/s0887-2171(06)80022-3] 2. antoniades dz, belazi m, papanayiotou p. concurrence of torus palatinus with palatal and buccal exostoses. oral surg oral med oral path oral radiol endod 1998;85:552-557. [http://dx.doi.org/10.1016/s1079-2104(98)90290-6] 2. antoniades dz, belazi m, papanayiotou p. concurrence of torus palatinus with palatal and buccal exostoses. oral surg oral med oral path oral radiol endod 1998;85:552-557. [http://dx.doi.org/10.1016/s1079-2104(98)90290-6] 3. jainkittivong a, langlais rp. buccal and palatal exostoses: prevalence and concurrence with tori. oral surg oral med oral path oral radiol endod 2000;90:48-53. [http://dx.doi.org/10.1067/moe.2000.105905] 3. jainkittivong a, langlais rp. buccal and palatal exostoses: prevalence and concurrence with tori. oral surg oral med oral path oral radiol endod 2000;90:48-53. [http://dx.doi.org/10.1067/moe.2000.105905] 4. yonetsu k, nakamura t. ct of calcifying jaw bone diseases. ajr 2001;177(4):937-943. [http://dx.doi.org/10.2214/ajr.177.4.1770937] 4. yonetsu k, nakamura t. ct of calcifying jaw bone diseases. ajr 2001;177(4):937-943. [http://dx.doi.org/10.2214/ajr.177.4.1770937] 5. bouquot je, muller s, hiromasa n. lesions of the oral cavity. in: gnepp d. diagnostic surgical pathology of the head and neck. 2nd ed. amsterdam: saunders, 2009:191-308. 5. bouquot je, muller s, hiromasa n. lesions of the oral cavity. in: gnepp d. diagnostic surgical pathology of the head and neck. 2nd ed. amsterdam: saunders, 2009:191-308. untitled introduction the advent of multislice computerised tomography (ct) has resulted in a huge step in diagnostic accuracy due to better image quality, multiplanar capabilities and faster speed of the scans. pseudolesions are not unknown in radiology or in ct imaging. however the observation of some artefacts, especially the flow-related ones, has increased with the faster scanning. lack of familiarity with these new pseudolesions can lead to misdiagnoses. pseudolesions the lesions described below are noted frequently during imaging. this pictorial essay aimed at highlighting them as some of these lesions still confound junior staff, especially in their early learning curve. the commonly viewed pseudolesions are as follows: azygos vein in the newer multislice scanners contrast is now routinely seen in the major thoracic arteries and veins without opacification of the azygos vein (fig. 1). this is because of delayed filling of the azygous vein. this leads to the impression of a mass or a node in this location especially if the vein is dilated.1 however the location, shape and the relationship to the superior vena cava are clues that the ‘lesion’ is the unopacified azygous vein. if there is doubt a delayed scan usually clarifies things. pulmonary veins the unopacified portions of the right and left superior pulmonary veins can be mistaken for nodes in the hila (figs 2 and 3).2 the chest scan must be prolonged enough to allow these to fill (30 35 seconds on 4-slice ct). if the scan is performed for diagnosis of pulmonary embolus, then both arterial and venous phases must be done to confirm venous emboli. aorta motion artefacts can complicate the diagnosis of thoracic aortic dissection.3 their position in the ascending aorta is predictable and is related to systolic aortic motion from the left anterior to the right posterior position (fig. 4). oesophagus air or contrast in the oesophagus seen on multiple (4 or more) contiguous slices is a sign of motility disorder on single-slice ct.4 on newer scanners, due to fast speed, the oesophagus can be imaged during a single swallow, thus air in the oesophagus is not abnormal (fig. 5). however large amount of intra-oesophageal air with or without fluid level can still be considered abnormal. scalloped or nodular appearance of muscular attachments of the diaphragm these were occasionally noted on single-slice ct in older patients, but are now routinely observed (fig. 6). these should not be confused with the nodularity of peritoneal deposits. metastatic nodules change size abruptly on multiple contiguous scans, while diaphragm-related nodular invaginations remain smooth on sequential slices.5 inferior vena cava laminar flow within the inferior vena cava (ivc) can cause artefacts that may simulate thrombus.6 a ‘pseudothrombus’ artefact within the suprarenal inferior vena cava produced by rapid infusion of contrast material is believed to be from laminar flow of renal venous effluent of increased opacipictorial essay 30 sa journal of radiology • december 2005 pseudolesions as seen on multislice ct a k bajwa mb bs, fcrad (sa) department of diagnostic radiology chris hani baragwanath hospital university of the witwatersrand johannesburg fig. 1. partly opacified azygous vein due to reflux from superior vena cava can be mistaken for nodes if unopacified. fig. 4. aortic pulsation imitating dissection in the ascending aorta. fig. 3. coronal image showing the normal vertical course of the partially opacified vein. fig. 2. portion of the right superior pulmonary vein appearing as a lymph node on axial image. 8 copy 12/1/05 12:30 pm page 30 ty around less opacified infrarenal caval contents (figs 7 and 8).this artefact, seen in 21% of older ct scans, is now noted routinely. similar appearances may be encountered in the iliac and femoral veins. liver and spleen heterogeneous enhancement in the early arterial phase is normal. the pattern becomes more pronounced with the faster rate of injection.7 portal venous phase studies should be used to confirm any suspected parenchymal perfusion abnormality (e.g. buddchiari syndrome). similarly, the hepatic veins are hypodense on the arterial phase and can be mistaken for low-density lesions (figs 9 and 10). the liver study should routinely include triphasic examination for complete evaluation. uterus there may be transitory subendometrial and /or myometrial enhancement (in the arterial and parenchymal phase of the scan). this is followed by diffuse enhancement on delayed scan (3 minutes or more). these patterns depend on variables such as the menopausal status and age of the patient.8 knowledge of these normal findings might help when confronted with unusual uterine enhancement during routine studies obtained with ct (fig. 11). conclusion we have noted some of these common artefacts since the introduction of multislice ct in our hospital. familiarity with these pitfalls and optimal procedural protocols will result in fewer misdiagnoses and prevent radiological embarrassment. references 1. smathers rl, buschi aj, pope tl jun., benbridge an, williamson br. the azygous arch: normal and pathologic ct appearance. am j roentgenol 1992; 139: 477-483. 2. naidich dp, khouri nf, scott ww, wang kp, siegelman ss. computed tomography of the pulmonary hila: normal anatomy. j comput assist tomogr 1981; 5: 459-467. 3. duvernoy o, coulden r, ytterberg c. aortic motion: a potential pitfall in ct imaging of dissection in the ascending aorta. j comput assist tomogr 1995; 19: 569-572. 4. bhalla m, silver rm, shepard ja, mcloud tc. chest ct in patients with scleroderma: prevalence of asymptomatic esophageal dilatation and mediastinal lymphadenopathy. am j roentgenol 1993; 161: 269-272. 5. brink j, heiken jp, semenkovich j, teefey sa, mcclennan bl, sagel ss. abnormalities of the diaphragm and adjacent structures: finding on multiplaner spiral ct. am j roentgenol 1994; 163: 307-310. 6. mcwilliams rg, chalmers ag. pseudothrombosis of the infra-renal inferior vena cava during helical ct. clin radiol 1995; 50: 751-755. 7. urban ba, fishman ek. helical ct of the spleen. am j roentgenol 1998; 170: 997-1003. 8. kaur h, loyer em, minami m, charnsangavej c. patterns of uterine enhancement with helical ct. eur j radiol. 1998; 28: 250-255. pictorial essay 31 sa journal of radiology • december 2005 fig. 5. air in the oesophagus is routine on multi-detector ct. fig. 6. the anterior diaphragm can look quite thick as it becomes continuous with the anteriolateral diaphragm. fig. 8. a later scan at the same table position. the ivc flow artefact has disappeared. fig. 7. pseudothrombus in the ivc. fig. 10. delayed scan at the same level showing the filling of hepatic veins. spleen now has uniform enhancement. fig. 9. unopacified hepatic veins appearing as hypodense lesions. note the heterogeneous enhancement of the spleen. fig. 11. unusual early uterine enhancement. 8 copy 12/1/05 12:30 pm page 31 article information authors: sanjay prabhu1 nasreen mahomed2 affiliations: 1department of radiology, boston children’s hospital, harvard medical school, united states of america 2department of diagnostic radiology, university of the witwatersrand, south africa correspondence to: sanjay prabhu email: sanjay.prabhu@childrens.harvard.edu postal address: private bag x3, university of the witwatersrand, johannesburg 2050, south africa dates: received: 01 sept. 2015 accepted: 15 oct. 2015 published: 09 dec. 2015 how to cite this article: prabhu s. & mahomed n. ‘imaging of intractable paediatric epilepsy’. s afr j rad. 2015;19(2): art. #936, 10 pages. http://dx.doi.org/10.4102/sajr.v19i2.936 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. imaging of intractable paediatric epilepsy in this review article... open access • abstract • introduction    • phases in the evaluation of children with epilepsy       • phase 1       • phase 2       • phase 3       • phase 4 • imaging techniques • optimisation of epilepsy protocols using 1.5t mri scanners • new techniques used on 3t mri scanners • reviewing an mri for childhood epilepsy: a systematic approach • features of common epileptogenic substrates    • focal cortical dysplasia    • mesial temporal sclerosis    • sturge-weber syndrome    • tuberous sclerosis complex    • rasmussen encephalitis    • neoplastic lesions    • perinatal stroke    • post-traumatic epilepsy • pitfalls and traps • putting it all together • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ approximately 20% of paediatric patients with epilepsy are refractory to medical therapies. in this subgroup of patients, neuroimaging plays an important role in identifying an epileptogenic focus. successful identification of a structural lesion results in a better outcome following epilepsy surgery. advances in imaging technologies, methods of epileptogenic region localisation and refinement of clinical evaluation of this group of patients in epilepsy centres have helped to widen the spectrum of children who could potentially benefit from surgical treatment. in this review, we discuss ways to optimise imaging techniques, list typical imaging features of common pathologies that can cause epilepsy, and potential pitfalls to be aware of whilst reviewing imaging studies in this challenging group of patients. the importance of multidisciplinary meetings to analyse and synthesise all the non-invasive data is emphasised. our objectives are: to describe the four phases of evaluation of children with drug-resistant localisation-related epilepsy; to describe optimal imaging techniques that can help maximise detection of epileptogenic foci; to describe a systematic approach to reviewing magnetic resonance imaging of children with intractable epilepsy; to describe the features of common epileptogenic substrates; to list potential pitfalls whilst reviewing imaging studies in these patients; and to highlight the value of multimodality and interdisciplinary approaches to the management of this group of children. introduction top ↑ approximately 20% of children with epilepsy are refractory to medical therapy, which has a significant adverse effect on patients and their families.1 the term ‘drug-resistant epilepsy’ has been proposed by the international league against epilepsy (ilae) to replace terms such as refractory and intractable epilepsy. neuroimaging plays an important role in identifying epileptogenic foci that can be surgically resected. advances in neuroimaging, including advances in scanner hardware and software, have allowed improved signal-to-noise ratio and achieve faster scan times and fewer motion artifacts. in addition, use of advanced imaging techniques, including multimodality fusion, has enabled improved lesion detection and localisation. it is important to choose tests based on their potential to further define the epileptogenic region, acknowledge their known strengths and limitations, and weigh the expected clinical benefit and incremental cost-effectiveness. any additional test should be chosen on the basis of the likelihood that it can change the resection plan or surgical method. it should be pointed out that a review in 2011 by an ilae panel found no studies that qualified as class 1 evidence, and little class 2 evidence on the utility of diagnostic tests in pre-surgical evaluation of patients with pediatric epilepsy.2 recommendations provided in the present review are based on the first author’s personal experience of working in paediatric epilepsy groups over the last decade and is similar to consensus recommendations from various ilae panels.3 phases in the evaluation of children with epilepsy phase 1 one must first define the seizure syndrome and ensure that medical therapy is optimised; this includes a detailed history, including preand postnatal events, seizure history including the semiology (type of seizure), characteristics of onset and manifestations of the seizures, a full neurological examination, detailed electrophysiology via several electroencephalography (eeg) exams that record interictal and ictal events, and neuroimaging. functional imaging with single-photon emission computed tomography (spect) and/or positron emission tomography (pet), functional magnetic resonance imaging (fmri) and magneto encephalography (meg) are also used in some cases. results are discussed at multidisciplinary team meetings involving specialists in neurology, neurosurgery, neurophysiology, neuroradiology and neuropsychology. if the anatomical and functional images are concordant with the seizure semiology and information gathered is considered adequate, surgical resection may be planned. if there is no concordance of data, further testing may be required, such as hospital admission for continuous scalp eeg or video-telemetry to better define the seizure frequency and semiology, particularly if the seizures are predominantly nocturnal or ill-defined on routine eeg. neuropsychological testing helps to assess baseline performance, the level of neurodevelopment, deficits in various domains including verbal and non-verbal communication, and psychosocial factors. this evaluation helps in documenting the extent of premorbid damage and predicting possible outcomes following epilepsy surgery. phase 2 invasive monitoring is used to further lateralise and localise the seizure focus that remains incompletely defined by noninvasive studies in phase 1 or to determine the location of the seizure focus relative to eloquent cortex. phase 3 comprehensive review of the data is done by the epilepsy team, to confirm concordance of findings; and to decide if surgery is the best option (either curative or palliative). phase 4 the postoperative assessment is routinely performed 6–24 months after the surgical procedure to document the final outcome. imaging techniques top ↑ neuroimaging is recommended when localisation-related epilepsy is known or suspected, when the epilepsy classification is in doubt, or when an epilepsy syndrome with remote symptomatic cause is suspected. mri is the modality of first choice. aims of structural imaging include locating the epileptogenic region, providing a surgical planning map, defining the relation of a focal lesion to eloquent areas, and as a base for functional studies including pet, spect, fmri and meg. in the last decade, advances in scanner hardware and software have improved the rate of detection of epileptogenic lesions. wherever possible, a high-resolution protocol on a 3t scanner is preferred as it improves the pre-surgical evaluation in focal epilepsies. as 3t mri scanners are rarely available in developing countries, epilepsy protocols should be optimised when using 1.5t. although outcomes are improved after complete resection of cortical dysplasia, microscopic cortical dysplasia can be found in adjacent areas of the brain, which may be epileptogenic and not visualised on mri. specifically epilepsy-tailored protocols on both 1.5t and 3t scanners can improve detection of focal cortical dysplasia (fcd) and other epileptic substrates. the literature has demonstrated that the ‘catch rate’ of epilepsy protocols is appreciably higher than conventional ‘brain screen’ protocols (72% v. 49% and 91% v. 50%).4,5 based on the recommendations by consensus panels of the ilae3 and the author’s personal experience, the following mri protocol sequences are recommended in children with epilepsy, irrespective of the strength of the mri scanner (box 1). box 1: recommended mri protocol for epilepsy at 1.5t and 3t. optimisation of epilepsy protocols using 1.5t mri scanners top ↑ with 3t mri scanners, a 3d sagittal fluid-attenuated inversion recovery (flair) with multiplanar reformats is recommended to look for focal cortical dysplasia. in lieu of this, a coronal flair can be used at 1.5t scanning the whole brain. thin section, no-gap axial t2 (3 mm – 4 mm thick slices) is recommended. increasing the number of averages or number of excitations to increase the signal-to-noise ratio at 1.5t may be employed; this generally means a longer scan time and may call for sedation of younger patients. a susceptibility-weighted imaging (swi) or gradient echo sequence can be added to the protocol in populations with higher incidence of calcified lesions such as tuberculomas and in patients with neuro-cutaneous syndromes. new techniques used on 3t mri scanners top ↑ isotropic motion-compensated multi-echo t1w magnetisation-sprepared rapid gradient echo allows optimal characterisation of the cortical outline in three planes. the author includes a diffusion tensor imaging sequence (35 diffusion directions, 3 mm slice thickness, b value of 0 and 1000 seconds/mm2) in all patients to produce tractography maps for surgical planning in patients with lesions in eloquent areas and arterial spin labelled images to assess perfusion without the need for a contrast medium. mr spectroscopy and contrast-enhanced imaging is reserved for selected cases. reviewing an mri for childhood epilepsy: a systematic approach top ↑ axial and coronal t2-weighted images are usually the starting point to look for cerebral hemispheric asymmetry (both size and signal intensity), gyral folding pattern, blurring of the gray and white matter junction, and symmetry of the white matter signal. following this, volumetric t1w images are reviewed and assessed for midline structures including the hypothalamic region, gyral folding pattern, cortical thickness, sulcal asymmetry, uniformity of cortical signal, and subcortical and periventricular gray matter lesions. finally, the hippocampi and temporal lobes are reviewed in detail. at this point, available eeg reports and the seizure semiology are reviewed and, based on this information, the areas of concern are reassessed on mri. features of common epileptogenic substrates top ↑ focal cortical dysplasia the ilae describes three types of focal cortical dysplasia (fcd) and the corresponding subtypes as follows:6 fcd type i – type 1a: abnormalities of cortical lamination (figure 1). type 1b: abnormal tangential cortical lamination. type 1c: abnormal radial lamination. figure 1: three-year-old girl with pharmaco-resistant left frontal lobe epilepsy. axial t2w (a) shows focal thickening of the cortex in the posterior orbital gyrus in the left inferior frontal lobe (arrow) extending into the anterior aspect of the insula and inferiorly to the junction of the insula and anterior aspect of the superior temporal lobe gyrus. coronal mprage (b); note the mildly increased t1 signal of the affected cortex and blurred gray and white matter interface (arrowhead). resected specimen showed focal regions of dyslamination of the cortex and moderate to severe reactive gliosis in keeping with fcd type 1a. fcd type ii – type iia: abnormal cortical dyslamination and dysmorphic neurons without balloon cells. type iib: with balloon cells (figure 2). figure 2: twenty-month-old child with drug-resistant seizures from birth. coronal (a) and axial (b) t2w show left frontal cortical dysplasia characterised by cortical thickening and adjacent white matter abnormality extending to the ventricular margin (arrows). note the mineralisation indicated byt2 hypointensity in the left subcortical white matter (arrowhead). resection specimen revealed palmini type iib focal cortical dysplasia and coexisting low-grade astrocytoma. proximity of the posterior margin of the lesion to the central sulcus made surgical resection challenging in this patient. fcd type iii – type iiia: includes fcds with an associated lesion such as hippocampal sclerosis (figure 3). type iiib: an epilepsy-associated tumour. type iiic: vascular malformation. type iiid: other lesions. figure 3: nine-year-old child with a year-long history of refractory generalised tonic-clonic seizures after cigarette olfaction aura. axial flair shows enlargement of the left temporal lobe compared with the right; abnormal signal intensity within the thickened cortex; and loss of gray and white matter differentiation (arrow). pathology of the resected specimen revealed focal cortical dysplasia type 1 with hippocampal sclerosis, consistent with type iiia fcd as per the latest fcd classification. features of fcd on mri include cortical thickening (which should be confirmed in at least two planes and on two different imaging sequences), blurring of the gray and white matter junction, t2 and flair hyperintensity in the cortex and adjacent subcortical white matter, t1 shortening in the cortex and abnormal sulcal/ gyral pattern. mri is able to show abnormalities in the majority of type ii dysplasias but only in some of the type i cortical dysplasias although, in practice, it may be possible to distinguish between type i and type ii.7 the typical appearance of fcd type iib (with balloon cells) is a band of hyperintensity on t2-weighted and flair images extending from the gray and white matter interface to the surface of the ventricles (figure 2). to visualise this often subtle finding, multiplanar thin-section images should be performed. at 3t, volumetric flair with multiplanar reformats is an excellent sequence to look for the white matter hyperintensity characteristic of type ii fcds. mesial temporal sclerosis mesial temporal sclerosis (mts) is an uncommon finding in children. although some studies have shown a high correlation with epilepsy, hippocampal atrophy and t2 prolongation can also be seen in asymptomatic subjects.8,9 an important factor that contributes to earlier detection of mesial temporal sclerosis in children is the use of dedicated epilepsy protocols which include thin-section coronal t2 and flair perpendicular to the hippocampus. an initial event such as prolonged febrile seizures, prior infection, trauma, factors that increase vulnerability to neuronal injury such as hippocampal dysgenesis together with genetic predisposition are thought to work in tandem for mts to develop. the author has reported on young children presenting with seizures that are accompanied by diffusion restriction in the hippocampus acutely followed by development of mts within the next 2 years.10 findings that suggest mts include: hippocampal t2 hyperintensity, reduced hippocampal size, loss of hippocampal interdigitations, atrophy of the collateral white matter, reduced gray and white matter differentiation in the anterior temporal lobe, decreased temporal lobe size, and ipsilateral temporal horn enlargement (figure 4). figure 4: three-year-old girl with mesial temporal sclerosis. coronal t2w images demonstrate t2 prolongation and loss of volume within the left hippocampus (a) (arrow). note also the blurring of the gray and white matter in the left temporal lobe (b) (arrowhead). mts is widely acknowledged to be a progressive disease; however, the secondary signs of mts including ipsilateral fornix and mammillary body atrophy are very uncommon in children. it is important to look for dual pathology including cortical dysplasia and neoplasms, as the prevalence of dual pathology after temporal lobe resection has been reported to range between 12% and 79%.11,12,13 it is also necessary to evaluate for bilateral mts as this can change the management plan, particularly in patients with bilateral seizures and bilateral eeg abnormalities. other techniques with varying degrees of success have been described, including voxel-based morphometry, voxel-based diffusion tensor imaging and t2 relaxometry analysis to detect mts, but are not routinely used.14,15,16 sub-millimetre-high resolution scans using 64and 128-channel coils are being investigated by various groups including the author’s, as earlier detection and treatment of mts can help to reduce the cognitive and developmental morbidity in these children. sturge-weber syndrome sturge-weber syndrome (sws) is a neurocutaneous disorder clinically characterised by epilepsy, progressive mental retardation, and facial telangiectatic nevi, often in the trigeminal nerve distribution. mri is the most useful imaging study in the first year of life, as an abnormal scan is the best predictor of adverse clinical outcomes in these patients. most authors agree that a gadolinium-enhanced brain mri should be performed within the first 3 months of life, with the caveat that a negative result should not be considered conclusive if neurological symptoms develop.17 on mri, the main findings of sws are cerebral atrophy, white matter abnormalities in the region of the leptomeningealangiomatosis, hypertrophy of the overlying calvarium, and congested deep cerebral veins. contrast should always be used when evaluating a child with suspected sws to demonstrate the enhancement of the superficial gyri and define the extent of leptomeningeal vascular abnormality, even before the rest of the abnormalities become visible (figure 5).18 mri perfusion studies are useful in detecting perfusion defects. assessment of the contralateral hemisphere is especially important as bilateral involvement is well recognised. figure 5: an 8-month-old girl with bilateral facial port-wine stains, seizures and congenital glaucoma. axial t2w (a) demonstrates cerebral atrophy. contrast-enhanced axial t1w (b) shows leptomeningeal enhancement involving both cerebral hemispheres, left side (arrowheads) greater than right (arrows), consistent with bilateral sturge-weber syndrome. tuberous sclerosis complex tuberous sclerosis complex (tsc) is a multisystem genetic disorder of variable phenotypic expression, with an incidence of about 1 in 5800 live births worldwide.19 the disorder results from a mutation in the tsc1 gene in chromosomal region 9q34 or the tsc2 gene in chromosomal region 16p13, and is inherited in an autosomal dominant fashion. up to two-thirds of cases result from spontaneous genetic mutation. clinical manifestations of tuberous sclerosis include seizures, autism, developmental delay, and behavioural and psychiatric disorders. epilepsy is common in patients with tsc, occurring in up to 90% of affected individuals during their lifetime.19 up to one-third of children will develop infantile spasms. although not completely understood, the incidence of epilepsy is thought to relate to the neuropathologic features of the disorder, including cortical tubers and other dysgenetic features. individuals with tsc frequently have epileptiform features on their electroencephalograms. in addition to medical therapies, surgery plays an important role in the management of children with drug-resistant epilepsy in tsc. the focus of pre-surgical evaluation in these patients is to identify the most epileptogenic tubers by multimodality non-invasive tests, including using a combination of mri (figure 6), pet (including [(11) c] methyl-l-tryptophan-positron emission tomography [amt-pet]), ictal and interictal spect, and meg. based on this evaluation, a subset of patients with tsc can become suitable candidates for surgical resection. in some cases, subdural electrode placement may be required to identify a single or conglomerate of epileptogenic tubers. figure 6: axial t2w demonstrates multiple tubers and white matter lesions. note how the subcortical tuber is associated with linear white matter high signal that tracks towards the ventricle (arrow). also note the hypointense subependymal nodule (arrowhead). rasmussen encephalitis rasmussen encephalitis is a rare chronic progressive encephalitis characterised by drug-resistant epilepsy (including partial seizures and epilepsy partialis continua) with unilateral brain atrophy on imaging studies. in the acute stage, imaging studies can be normal or demonstrate gyral swelling without enhancement. as the disease progresses, there is progressive volume loss and abnormal t2w and flair hyperintensity within the white matter and cortex (figure 7). a study by our group found the 2005 bien diagnostic criteria for rasmussen encephalitis to have reasonably high sensitivity and specificity and good clinical-pathologic correlation in most cases.20 figure 7: twelve-year-old girl with drug-resistant complex partial seizures. serial axial t2w images obtained at presentation (a) followed by serial studies at 1 year (b) and 2 years (c) after presentation show unilateral progressive frontal and temporal atrophy as indicated by prominence of the sulci and ventricles. note that there is no appreciable signal abnormality in the caudate head, but the ipsilateral (left-sided) basal ganglia are slightly smaller than those on the right on all three images. neoplastic lesions neoplastic lesions associated with drug-resistant epilepsy are usually cortically based and may remain indolent for many years prior to presentation. the vast majority of tumours are located in the temporal lobe and the most frequent tumour type is aganglioglioma, followed by pilocyticastrocytomas and dysembryoplastic neuroepithelial tumors (dnet) (figure 8).21 in addition to imaging and characterising the tumour, it is important to evaluate for coexisting pathology, such as mesial temporal sclerosis in cases of temporal lobe neoplasms. the epileptogenic area should carefully be determined by non-invasive and/or invasive eeg recordings of the zone of seizure onset and persistent interictal activity. also, imaging in many cases includes functional studies including functional mri and/or the wada test. based on this pre-surgical evaluation, complete resection of the tumour and any surrounding abnormalities helps to reduce seizure frequency in a large number of cases. follow-up studies should be tailored to evaluate for tumour recurrence (and therefore necessitating use of contrast medium in most cases) and residual abnormalities in cases where seizure reduction does not occur as expected. figure 8: three-year-old boy presenting with new onset seizures. axial t2w (a), mprage (b) and contrast-enhanced mprage (c) demonstrate focally thickened cortex in the left parietal lobe with slightly t2 hyperand t1 isointense signal of the thickened cortex in the left postcentral gyrus (arrows). although this could be a focal cortical dysplasia, the presence of blush of enhancement (arrow) on the contrast-enhanced sequence (c) raises concerns of a neoplastic process. pathology of the resected specimen (after initial biopsy) showed an angiocentric glioma. perinatal stroke there is a significant risk of developing epilepsy after perinatal stroke, hypoxic-ischaemic injury, and intracerebral haemorrhage (figure 9). seizures can become refractory to medications in approximately 25% of these patients.22 challenges in managing seizures in these patients include multifocal or bilateral cortical injury, non-focal or poorly lateralising video electroencephalography (eeg) findings, and limited functional reserve. seizure onset zone may not be limited to the abnormality identified on imaging studies, and subdural electrode placement for invasive monitoring may be required. in addition to acquiring a functional mri, we track the corticospinal, visual and language pathways using diffusion tensor imaging and tractography to aid the neurosurgeon in developing a resection plan. when surgical resection is planned using this approach, functional outcomes are generally good in this group of patients, with improvements in independence, quality of life, cognitive development and motor skills, despite transient postoperative monoparesis or hemiparesis and occasional mood disorders. figure 9: an 8-year-old girl with drug-resistant epilepsy since age 2. axial t2w demonstrates cystic encephalomalacia in the left middle cerebral artery territory related to remote infarction involving the left temporal lobe, insula, left frontal and parietal regions. note ex vacuo dilatation of the left lateral ventricle (arrow), wallerian degeneration of the cerebral peduncle and encephalomalacia of the left thalamus. post-traumatic epilepsy seizures and epilepsy are relatively common in children with post-traumatic brain injury (tbi) and portend worse functional outcome.23 the exact pathogenesis of post-traumatic seizures and epilepsy is not well understood, but the window of development of epilepsy after tbi can last up to 10 years or longer after the event.24 it is important to consider post-traumatic epilepsy even in cases where a recent history of trauma is not forthcoming or if the imaging findings seen during a workup for seizures include evidence of trauma such as hemosiderin staining or focal encephalomalacia. areas of damage that may not be apparent on studies obtained at the time of prior trauma (usually ct scans in the acute period) include the inferior frontal and temporal lobes, which are affected as a result of the contracoup mechanism following trauma over the lateral convexities (figure 10). susceptibility-weighted images should be included to increase sensitivity of the study for hemosiderin at sites of prior injury. post-traumatic seizures may be associated with other pathological changes seen following brain trauma such as reactive gliosis, wallerian degeneration, microglial scar formation, and cystic white matter lesions. some of these pathologies have imaging correlates. studies suggest that post-traumatic seizures may be a result of alterations of intrinsic membrane properties of pyramidal neurons together with enhanced n-methyl-d-aspartate (nmda) synaptic conductance.23,24 figure 10: sixteen-year-old girl with history of traumatic head injury 5 years prior to the current study presented with refractory temporal lobe epilepsy. coronal t2w demonstrates gliosis in the anterior inferior frontal lobes and anterior right temporal pole (arrow). resection of the anterior right temporal lobe resulted in cessation of her epileptic seizures. pitfalls and traps top ↑ a few pitfalls and pointers are worth mentioning when reviewing scans of children with drug-resistant epilepsy. these include the following: normal variants can be problematic, particularly in the temporal lobes; for example, incomplete inversion of the hippocampus can be seen in asymptomatic individuals. dual pathology has been reported in approximately 15% of patients. in view of this finding, a careful review should be carried out even if a lesion is identified in the initial phase of the scan review. in cases with a convincing unihemispheric abnormality, it is extremely important to review the contralateral hemisphere for subtle anomalies as this may alter management. neoplastic lesions can masquerade as cortical dysplasia. clinically, this should be suspected in cases where seizures are of relatively recent onset, and on imaging when cortical thickening is accompanied by large overlying vessels with avid lesion enhancement post contrast. there are documented cases, albeit rare, where the detected lesion was unrelated to the er. the presence of multiple lesions (e.g., tuberous sclerosis or nodular heterotopias) does not necessarily mean that seizures are multifocal in onset. focal lesions, particularly fcds, can be masked between the ages of 6 months and 2 years owing to incomplete myelination. in these cases, repeat imaging is recommended every 3–6 months and, if tolerated, after 2 years of age. also, one should evaluate any scans available from the neonatal period, as these may reveal the extent of cortical malformations of cortical development (such as polymicrogyria) before myelination commenced. one of the dangers of focusing attention on a particular suspect location is that it can lead to elevated sensitivity at the cost of diminished specificity. therefore, it is advisable to make a concerted attempt to exclude other lesions elsewhere at similar sensitivity thresholds. in mri-negative patients with drug-resistant epilepsy, serial assessment is advised to document temporal consistency of localisation and attempt to exclude other aetiologies such as genetic/idiopathic (e.g. scn1a epilepsies), auto-immune (e.g. nmda), voltage gated potassium channel (vgkc), and neurodegenerative syndromes. repeat mri should be considered after completion of myelination around 2 years, preferably on a 3t scanner. in non-lesional cases, one or more ancillary tests are required to allow a hypothesis for er location that can then be confirmed by either ecog or iem. imaging studies performed on patients with persistent seizures after resection of a lesion determined as epileptogenic, or surgical procedures such as callosotomy or functional hemispherectomy, should be compared carefully with preoperative studies. this comparison should examine for completeness of resection and for a second lesion that was not detected during the workup for the first procedure, particularly if the seizure semiology changes after the first surgical procedure. putting it all together top ↑ the summary of the information gathered from various non-invasive tests including neuroimaging studies should be analysed and discussed at multidisciplinary team meetings. this may entail amending prior interpretation of tests in the light of collective information. subtle fcd lesions become apparent on mri that has been reported as normal; this may be because of 3d reconstruction of multimodality data to assess convergence or plan intracranial electrode placement or surgical navigation. the case discussion is aimed at defining surgical candidacy, goals of the procedure chosen and guiding future patient management strategies. one of the key decisions at this conference is to decide between hemispherectomy versus tailored focal resection. in patients with extensive unihemispheric pathology such as hemimegalencephaly, sturge-weber syndrome and hemispheric stroke documented on mri, no additional tests are generally required. in cases where the scalp eeg abnormalities appear more prominent over the contralateral normal hemisphere, the mri should be carefully re-evaluated for subtle occult pathology. in some of these cases, the eeg findings may be falsely lateralising, particularly if the clinical semiology is clearly lateralised to the abnormal hemisphere and consistent with the mri lesion. in these cases, the radiologist can help to reduce aggressive pursuit of additional unnecessary testing by clearing the contralateral hemisphere. new mri techniques include isotropic motion-compensated multi-echo t1w magnetisation-prepared rapid gradient echo sequence, diffusion tensor imaging and tractography maps, mr spectroscopy and arterial spin labelled images to assess perfusion without the need for contrast medium. additional functional imaging with spect and/or pet and, in some cases, fmri and meg is also utilised in some cases (figure 11). figure 11: six-year-old boy presented with intractable seizures and left fronto-central eeg abnormality. axial t2w (a) shows cortical thickening in the left frontal lobe (arrows). this is matched by hypoperfusion on the regional cerebral blood flow (recbf) map (b) from the pulsed asl acquisition and by decreased uptake of fdg on the pet scan (c). conclusion top ↑ advances in neuro-imaging continue to improve the rates of detection of lesional substrates in paediatric patients with epilepsy. it is important to utilise tailored mri protocols as described above on the best scanner hardware available. further, a systematic and meticulous approach is key to evaluating these scans, which should be combined with information from other modalities at a multidisciplinary conference to define possible candidate lesions for surgical resection. acknowledgements top ↑ we are indebted to the department of epilepsy, royal children’s hospital, melbourne, australia, and boston children’s hospital, boston, usa, and the rsna derek harwood nash international fellowship 2013 which n.m. completed at boston children’s hospital. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions s.p. (boston children’s hospital) wrote the article and contributed all the cases. n.m. (university of the witwatersrand) conceptualised the article, proposed the concept to the editor of the sajr, adapted the article to a south african audience, edited the article and was responsible for addressing all the reviewers’ comments. references top ↑ weaver df, pohlmann-eden b. pharmacoresistant epilepsy: unmet needs in solving the puzzle(s). epilepsia. 2013;54(suppl 2):80–85. pmid: 23646978, http://dx.doi.org/10.1111/epi.12191 gaillard wd, cross jh, duncan js, stefan h, theodore wh, task force on practice parameter imaging guidelines for international league against epilepsy cfd. epilepsy imaging study guideline criteria: commentary on diagnostic testing study guidelines and practice parameters. epilepsia. 2011;52:1750–1756. pmid: 21740417, http://dx.doi.org/10.1111/j.1528-1167.2011.03155.x jayakar p, gaillard wd, tripathi m, et al. diagnostic test utilization in evaluation for resective epilepsy surgery in children. epilepsia. 2014;55:507–518. pmid: 24512473, http://dx.doi.org/10.1111/epi.12544 wieshmann uc. clinical application of neuroimaging in epilepsy. j neurol neurosurg psychiatry. 2003;74:466–470. pmid: 12640065, http://dx.doi.org/10.1136/jnnp.74.4.466 von oertzen j, urbach h, jungbluth s, et al. standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy. j neurol neurosurg psychiatry. 2002;73:643–647. pmid: 12438463, http://dx.doi.org/10.1136/jnnp.73.6.643 blumcke i, thom m, aronica e, et al. the clinicopathologic spectrum of focal cortical dysplasias: a consensus classification proposed by an ad hoc task force of the ilae diagnostic methods commission. epilepsia. 2011;52:158–174. pmid: 21219302, http://dx.doi.org/10.1111/j.1528-1167.2010.02777.x leach jl, miles l, henkel dm, et al. magnetic resonance imaging abnormalities in the resection region correlate with histopathological type, gliosis extent, and postoperative outcome in pediatric cortical dysplasia. j neurosurg pediatr. 2014;14:68–80. 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temporal lobe epilepsy improves detection of hippocampal sclerosis. am j neuroradiol. 2014;35:77–83. pmid: 23868151, http://dx.doi.org/10.3174/ajnr.a3640 waelchli r, aylett se, robinson k, chong wk, martinez ae, kinsler va. new vascular classification of port-wine stains: improving prediction of sturge–weber risk. br j dermatol. 2014;171:861–867. pmid: 24976116, http://dx.doi.org/10.1111/bjd.13203 prabhu sp. imaging parameters are important to completely rule out sturge-weber syndrome. pediatr neurol. 2013;49:e1. pmid: 23827433, http://dx.doi.org/10.1016/j.pediatrneurol.2013.02.005 thiele ea. managing and understanding epilepsy in tuberous sclerosis complex. epilepsia. 2010;51 suppl 1:90–91. pmid: 20331728, http://dx.doi.org/10.1111/j.1528-1167.2009.02458.x olson he, lechpammer m, prabhu sp, et al. clinical application and evaluation of the bien diagnostic criteria for rasmussen encephalitis. epilepsia. 2013;54:1753–1760. pmid: 23980696, http://dx.doi.org/10.1111/epi.12334 zentner j, hufnagel a, wolf hk, et al. surgical treatment of neoplasms associated with medically intractable epilepsy. neurosurgery. 1997;41:378–386; discussion 86–87. pmid: 925730. ghatan s, mcgoldrick p, palmese c, et al. surgical management of medically refractory epilepsy due to early childhood stroke. j neurosurg pediatr. 2014;14:58–67. pmid: 24866497, http://dx.doi.org/10.3171/2014.3.peds13440 statler kd. pediatric posttraumatic seizures: epidemiology, putative mechanisms of epileptogenesis and promising investigational progress. dev neurosci. 2006;28:354–363. pmid: 16943659, http://dx.doi.org/10.1159/000094162 christensen j, pedersen mg, pedersen cb, sidenius p, olsen j, vestergaard m. long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. lancet. 2009;373:1105–1110. pmid: 19233461, http://dx.doi.org/10.1016/s0140-6736(09)60214-2 article information authors: susanna c.s. vlok1 georg w.w. wagener1 dan zaharie2 affiliations: 1division of radiodiagnosis, stellenbosch university and tygerberg hospital, south africa 2department of anatomical pathology, stellenbosch university and tygerberg hospital, south africa correspondence to: susanna vlok. email: sucarivlok@gmail.com postal address: 11 bergzicht, wylant street, welgemoed, bellville 7530, south africa dates: received: 28 jul. 2014 accepted: 20 nov. 2014 published: 15 dec. 2014 how to cite this article: vlok, s.c.s., wagener, g.w.w., zaharie, d. secondary chondrosarcoma: malignant transformation of pre-existing hereditary and non-hereditary cartilaginous lesions. s afr j rad. 2014;18(2); art. #703, 5 pages. http://dx.doi/org/10.4102/sajr.v18i2.703 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. secondary chondrosarcoma: malignant transformation of pre-existing hereditary and non-hereditary cartilaginous lesions in this case report... open access • abstract • introduction • case reports    • case 1    • case 2 • discussion    • multiple hereditary osteochondromas/exostoses (diaphyseal aclasis)    • multiple enchondromatosis (ollier disease) • teaching point • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ secondary chondrosarcoma is a malignant hyaline cartilage tumour originating from a cartilaginous precursor, either osteochondroma or enchondroma. we contrast two different cases of biopsy-proven secondary chondrosarcomas resulting from benign, pre-existing cartilaginous lesions – our aim is to contrast and compare these two benign conditions consisting of multiple cartilaginous lesions – one hereditary and the other non-hereditary – and emphasise their potential for malignant transformation. introduction top ↑ chondrosarcoma is a malignant cartilaginous tumour of either primary or secondary origin.1 primary chondrosarcoma originates in previously normal bone in the absence of a precursive cartilaginous lesion1,2,3 and is more common than secondary chondrosarcoma2 which results as a complication of a pre-existing cartilaginous lesion.3 case reports top ↑ case 1 an 18-year-old girl presented with bilateral bony knee deformities and associated pain. a full-length radiograph of the lower extremities demonstrated multiple sessile and pedunculated exostoses bilaterally. peripheral permeation and heterogenous appearance of the medial distal femoral exostosis was noted (figure 1). figure 1: full-length radiograph (a) of the lower extremities reveals multiple hereditary exostoses (diaphysial aclasia) with multiple exostoses of the femorae, tibiae and fibulae bilaterally, with irregular enlargement and calcification of the medial distal femoral exostosis (red arrows; image b is of a smaller field of view). magnetic resonance imaging (mri) showed a large osteochondroma of the medial distal femur covered by an irregular lobular cartilage cap with a maximum diameter of 10 mm as well as underlying t2 hyperintense bone changes (figure 2), suggestive of malignant transformation. histological analysis confirmed a low-grade chondrosarcoma (figure 3 and figure 4). figure 2: coronal t1 (a) and protein density fat-saturation (b) mr images of the distal right femur demonstrate a large osteochondroma of the medial distal femur (blue arrow) accompanied by a thick overlying t1 iso-intense and pd fat-saturated hyperintense cartilaginous cap (10 mm in diameter) (red arrows) with bony (yellow arrow, image b), but not soft-tissue, infiltration visualised. figure 3: haematoxylin and eosin staining, x 20 magnification. well-formed hyaline cartilage cap (black arrow) overlying newly formed cancellous bone (white arrow), which contains fatty marrow. figure 4: haematoxylin and eosin staining, x 100 magnification. hypocellular cartilaginous lesion comprising chondrocytes (black arrow) with minimal cytological atypia. the chondrocytes are arranged in vague columns. in deeper layers, the chondrocytes enlarge with more abundant cytoplasm. case 2 a 60-year-old woman with known ollier disease presented with increased swelling and pain of the right middle finger. conventional radiography of the hands showed multiple enchondromas unilaterally in the right hand (figure 5). figure 5: anteroposterior radiograph of both hands demonstrates multiple enchondromas of the metacarpals and phalynges with expansile growth in the third middle phalynx (red arrow) of the right hand, and exophytic growth of the third metacarpal enchondroma (green arrow). note the unilateral nature of the pathology as well as madelung's deformity of the right wrist (blue arrow). cortical destruction of the intermediate phalanx of the right middle finger, with an associated soft-tissue mass containing chondroid calcifications (figure 6), suggested malignant transformation. figure 6: lateral radiography displays soft-tissue extension and dorsal cortical destruction of the right intermediate phalynx of the right middle finger (red arrow). histology obtained after surgical amputation of the third finger revealed a grade ii chondrosarcoma (figure 7 and figure 8). figure 7: haematoxylin and eosin staining, x 20 magnification. lobulated hypercellular, cartilaginous neoplasm with a homogeneous basophilic hyaline matrix. figure 8: haematoxylin and eosin staining, x 100 magnification. neoplastic chondrocytes (black arrow) that are pleomorphic, occasionally vacuolated, bipolar and stellate. some of the cells are binucleated. discussion top ↑ multiple hereditary osteochondromas/exostoses (diaphyseal aclasis) osteochondroma, the most common benign cartilaginous tumour, is a cartilage-capped bony exostosis arising from the cortical surface of bone. the cortex is uninterrupted from the underlying bone, and the marrow cavity is continuous with the native bone.3,4 a diagnosis of multiple hereditary osteochondroma can be made when at least two osteochondromas are detected radiologically in the juxta-epiphyseal region of long bones. a positive family history is obtained in only 60% of cases.4 multiple hereditary osteochondromas is an uncommon, autosomal dominant condition with a prevalence of 1:50 000 – 1:100 000 people4 and a slight male predominance.3 osteochondromas develop shortly after birth in the metaphyses of long bones, in close proximity to the epiphyseal plates, and are usually discovered around the median age of three years – almost all by the age of 12 years – when patients present with bony deformities, nerve compression and pain.4,5 malignant transformation of these exostoses is much higher than in sporadic cases (where it is less than 1%), and has been found to be as high as 25% (lower rates of 3% – 5% have also been published).6 lesions typically form and enlarge during growth until the skeleton is fully matured. osteochondromas are more commonly broad-based and sessile and less often pedunculated.2 lesions are typically multiple and bilateral, and most commonly affect the knee, humerus, hip and, to a lesser extent, the wrist, ankle and ribs.3 radiographs of the sessile form show a well-defined bulging cortex associated with normal underlying bone. lesions tend to be symmetric and associated with several bone deformities including bilateral coxa valga. in the pedunculated form, a stalk arises from normal underlying bony cortex and medulla, projecting away from the joint line, growing along the direction of the tendons. mri of exostoses demonstrates a cortex which is continuous with that of the underlying bone, covered by a t2 bright cartilage cap, with no soft-tissue mass or underlying native bony abnormalities. ultrasound can be used to evaluate and measure the cartilaginous cap diameter if the lesion is superficial. radiographic features suggesting malignant transformation to chondrosarcoma include osseous destruction, scattered calcifications, irregularity and lobulation of the cartilage cap (as demonstrated by the patient described in case 1) and a cartilaginous cap diameter exceeding 10 mm.1,2,4 careful follow-up and monitoring of the size of osteochondromas (in particular, those involving the pelvis or scapula which are known to have an increased tendency to malignant transformation) may aid in early identification of secondary chondrosarcoma.5 multiple enchondromatosis (ollier disease) an enchondroma is a benign cartilaginous lesion originating from the medullary cavity. enchondromas are the result of the continued growth of residual benign cartilaginous rests owing to failure of cartilage ossification.7 multiple enchondromatosis (ollier disease) is a rare developmental abnormality with an incidence of 1:100 000 people.8 the disease usually appears in early childhood, is neither hereditary nor familial, and is considered to be a dysplasia. it is characterised by the presence of enchondromas in the metaphyses and diaphyses of multiple bones, with a tendency to be unilateral and localised to one extremity (as with our patient in case 2).7 patients usually present with unilateral, multiple, painless, palpable bony masses on the fingers or toes, associated with shortening of extremities on the affected side and mildly delayed bone age. enchondromas that enlarge after puberty are suggestive of malignant transformation, especially if associated with pain and pathological fractures.8 radiographic and computed tomographic (ct) examinations reveal multiple lucent lesions with narrow zones of transition, in the absence of periosteal reactions, cortical breakthrough or soft-tissue involvement. chondroid calcifications in the form of rings and arcs may be present.7,8 lesions may sometimes be large and even grotesque, especially in the fingers.2 on mri, enchondromas appear as intra-medullary, well-circumscribed lesions with intermediate to low t1 signal, high t2 signal and no surrounding oedema.2,7,8,9 the most severe complication of ollier disease is malignant transformation to chondrosarcoma,2 which is seen in approximately 25% – 30% of cases by the age of 40 years.10 this happens in less than 1% of sporadic cases.9 radiological features suggestive of malignant transformation include cortical breach, scalloping involving more than two-thirds of the surrounding cortex, an associated soft-tissue mass, and lesions localised to the spine, pelvis, sacrum, ribs and sternum. distinguishing enchondromas from low-grade chondorsarcomas may prove a diagnostic dilemma as both these entities may have similar radiological and histological appearances.7,8 treatment of ollier disease consists of intervention to treat deformities and surveillance for malignant transformation. malignancy typically requires surgical intervention.7 teaching point top ↑ exostoses of multiple hereditary osteochondromas and enchondromas owing to ollier disease undergo malignant transformation to chondrosarcomas in about 25% of cases whereas sporadic exostoses and enchondromas undergo malignant transformation in less than 1% of cases. conclusion top ↑ rare, pre-existing cartilaginous lesions such as multiple hereditary osteochondromas and ollier disease may undergo malignant transformation to chondrosarcoma. malignant transformation occurs in up to 25% of cases, especially if the lesions are located in the pelvis or scapula. ollier disease is a non-hereditary condition consisting of multiple enchondromas. enlargement of enchondromas post puberty, especially when associated with pain, raises the suspicion of malignant transformation, which happens in 25% – 30% of cases. lesions localised to the spine, pelvis, sacrum, ribs and sternum carry a high probability for malignant transformation. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions s.c.s.v. (stellenbosch university), g.w.w. (stellenbosch university) and z.d. (stellenbosch university) contributed equally to the writing of this manuscript. references top ↑ manaster bj. chondrosarcoma. statdx premier.amirsys; 2005–2014. [cited 2014 may 20–25]. available from: http://my.statdx.com manaster bj, may da, disler dg. the requisites, musculoskeletal imaging. 3rd edn. philadelphia: mosby; 2007; p. 445, 477–488. dähnert w. radiology review manual. 6th edn. philadelphia: lippincott williams & wilkins; 2007; p. 58–60, 133–135. bovée jvmg. multiple osteochondromas. orphanet j rare dis. 2008;3:3. http://dx.doi.org/10.1186/1750-1172-3-3 wuyts w, schmale ga, chansky ha, raskind wh. hereditary multiple osteochondromas. genereviews [homepage on the internet]. [updated 2000 aug 3; cited 2013 nov 21]. available from: http://www.ncbi.nlm.nih.gov/books/nbk1235 lee jk, yao l, wirth cr. mr imaging of solitary osteochondromas: report of eight cases. ajr. 1987;149(3):557–560. http://dx.doi.org/10.2214/ajr.149.3.557 murphey md, flemming dj, boyea sr, bojescul ja, sweet de, temple ht. enchondroma vs chondrosarcoma in the appendicular skeleton: differentiating features. radiographics. 1998;18(5):1213–1237. http://dx.doi.org/10.1148/radiographics.18.5.9747616 thomas aj. multiple enchondromatoses. statdx premier. amirsys; 2005–2014. [cited 2014 may 20–25]. available from: http://my.statdx.com bullough pg. orthopedic pathology. 4th ed. philadelphia: mosby; 2004; p. 405–408, 416. gabos pg, bowen jr. epiphyseal-metaphyseal enchondromatosis. a new clinical entity. j bone joint surg am. 1998;80(6):782–792. article information author: richard de villiers1 affiliation: 1drs van wageningen and partners, somerset west, south africa correspondence to: richard de villiers email: rmldev@mweb.co.za postal address: drs van wageningen and partners, somerset west 7129, south africa how to cite this article: de villiers r. musculoskeletal radiology in south africa. s afr j rad. 2014;18(2); art. #702, 1 page. http://dx.doi.org/10.4102/sajr.v18i2.742 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. musculoskeletal radiology in south africa in this editorial... open access musculoskeletal radiology in south africa has shown significant growth in the last decade. this was achieved through advanced educational programmes, international input and significantly improved imaging techniques and equipment — which in turn has enabled musculoskeletal (msk) radiologists to offer an improved service to referring physicians. the progress in technology has served radiology well. digital imaging enables radiologists to readily share and discuss problematic cases with colleagues elsewhere. high-resolution imaging is comparable to sectioned anatomy and histology, which makes imaging challenging but also rewarding, as extremely accurate reporting is possible. herein lies the challenge to the radiologist. samsig, the south african musculoskeletal imaging group, was formed in 2005 by a dedicated group of radiologists who aimed to elevate the level of msk radiology to international standards. at the time, there was no dedicated subgroup within the rssa, nor were there any dedicated local fellowships or msk–specific meetings. by many and various means, samsig has achieved its goal — with the support of the rssa, significant input from international speakers and continued improvement by south african radiologists with a special interest in msk radiology. without the contributions of international msk radiologists jock anderson, phil lucas, rusty fritz, john feller and george koulouris, to name a few, this task would not have been accomplished. the local samsig committee members showed dedication, determination and leadership to establish a subgroup that south african radiology can be proud of. samsig has elevated the standard of msk radiology to an international level. the radiological society of south africa (rssa), under the academic leadership of leon janse van rensburg and jan labuscagne, have been extremely supportive of the samsig dream. international msk congresses were hosted locally. this level of radiology enabled local radiologists to experience world-class speakers right here, face to face. the following congresses were pivotal in the advancement of msk radiology: 1st sa sports imaging congress in 1999 sa sports medicine bi-annual congress, since 2001 mri update in sports medicine by david stoller in 2010 samsig bi-annual international conference, since 2010 1st rssa/samsig advanced msk course in 2014. as radiologists, we need to offer a superior service to our referring market. orthopaedic surgeons, rheumatologists, sports physicians and others who are involved with the msk system deserve the best imaging service available to answer their questions, the ultimate goal being improved patient care. with the aid of high-level imaging techniques, continued technical skill improvement, interaction with our clinical colleagues and dedicated msk reporting, we can face possible turf wars with confidence. perhaps the time has arrived where we should now offer dedicated msk radiology fellowships to further improve the levels of expertise. a strong and active msk imaging group is essential to achieve these goals. 29 sa journal of radiology • june 2009 abstract spinal segmental dysgenesis is a rare congenital spinal abnormality seen in neonates and infants, in which a segment of the spine and spinal cord fails to develop normally. the condition is segmental in nature, with vertebrae above and below the malformation. it is commonly associated with various abnormalities that affect the heart and genitourinary and gastrointestinal tracts and skeletal systems. we report two cases of spinal segmental dysgenesis with associated abnormalities. introduction spinal segmental dysgenesis (ssd) is a spinal anomaly characterised by localised agenesis or dysgenesis of the lumbar or thoraco-lumbar spine, severe congenital kyphosis or kypho-scoliosis, and focal abnormalities of the underlying spinal cord and nerve roots.1,2 there have been only a few reported cases of ssd as an autonomous entity. the neuro-radiological presentation is variable depending on the extent and level of the abnormality, the degree of resulting kyphosis and the presence of associated abnormalities. although computed tomography (ct) has a role in imaging, magnetic resonance imaging (mri) is the gold standard in the imaging of the spinal cord abnormalities and plays an important role in the planning of surgery. case report 1 a 2-week-old boy was referred from the paediatric neurology department with a history of flaccid paralysis of both lower limbs since birth. the mother described a normal pregnancy with no complications during the pregnancy or the puerperium. clinically, the child had club feet and was dysmorphic with a scaphoid-shaped back, with clinical suspicion of spina bifida occulta. spinal x-rays and mri were requested. the spinal x-rays (figs 1a and 1b) demonstrated complete absence of all the lumbar vertebrae and no twelfth thoracic vertebra. in association, only 11 paired ribs were present, and the lower thoracic ribs were flared. the sacrum and pelvis were normally developed. mri confirmed complete disconnection of the spinal segments above and below the dysgenesis i.e. between t12 to l5 (fig. 2a). normal sacrum and sacral nerve roots were demonstrated. an associated abnormality was a horseshoe kidney (fig. 2b). case report 2 an 8-week-old boy was referred from the paediatric neurosurgery department with club feet, a sacral dimple and bilateral lower limb paralysis since birth. spinal x-rays demonstrated complete absence of the lower thoracic, lumbar and sacral spine (figs 3a and 3b). mri showed that the thoracic vertebrae and spinal cord terminated at t9. there was an associated syrinx from t6 to t9 (figs 4a and 4b). below t9 was a linear bony septum which ended abruptly, and an associated dorsal dermal sinus posterior to this. bilateral malrotated and hydronephrotic kidneys were also present. discussion spinal segmental dysgenesis (ssd) is a rare sporadic disorder first described by scott et al. in 1988 (cited in tortori-donati et al.1). this abnormality has also been called medial spinal aplasia, congenital spinal stenosis, or congenital kyphosis and subluxation of the thoraco-lumbar spine owing to vertebral aplasia. the diagnostic criteria include lumbar or thoraco-lumbar spinal dysgenesis or agenesis causing kyphosis of one or more vertebrae, focal spinal cord narrowing with absent exiting nerve roots, congenital paraplegia and congenital lower limb deformity.3 bony defects include dysmorphic, hypoplastic or absent vertebrae, focal spinal canal stenosis and subluxation of the spinal cord.1 it is often difficult to precisely assess the extent of the anomalous segment because of the presspinal segmental dysgenesis nasreen mahomed, mb bch, fcrad (diag) jaishree naidoo, mb bch, fcrad (diag) chris hani baragwanath hospital and university of the witwatersrand, johannesburg case series fig. 1a. ap x-ray demonstrates complete absence of all the lumbar vertebrae and twelfth thoracic vertebrae. eleven paired ribs are present, and the lower thoracic ribs are flared. the sacrum and pelvis are normally developed. case report 30 sa journal of radiology • june 2009 ence of indeterminate, aplastic, hypoplastic or incompletely segmented vertebrae. the condition is segmental with vertebrae above and below the malformation. the spinal cord at the level of the abnormality is typically thinned or indiscernible, with an absence of nerve roots and a bulky, low-lying cord segment present caudal to the focal abnormality in most cases; this is a unique feature of ssd. however, in the presence of a low lesion with lumbosacral spine involvement, the segmental abnormality is too caudal for normal cord to develop below it.1 in these instances, as demonstrated in our case reports, there is no spinal cord visible distal to the lesion. embryology initially, it was believed that the lesion arose during the embryological stage of primary neuralation. data now suggest that these complex malformations occur sooner, during gastrulation. gastrulation is the process whereby the bilaminar embryonic disk is converted into a trilaminar disk, which occurs in the third gestational week.1 there is transient embryonic communication between the amniotic and yolk sacs, disappearing at the beginning of the third week of gestation, just before primary neurulation.3 therefore, chordo-mesodermal derangement during gastrulation related to positional programmed cell death of cells with incorrect axial specification can result in ssd.1 the severity of the disorder correlates with the degree of notochordal cell depletion. from this developmental theory, associated visceral abnormalities can be explained, including neurenteric fistula, as reported by tortoridonati et al.1 ssd and caudal regression syndrome (crs) probably represent two faces of a single spectrum of segmental malformations of the spine and spinal cord. they differ from an embryological point of view in the segmental location of the derangement along the longitudinal axis of the embryo. in ssd, the intermediate segment is involved as opposed to the caudal segment in crs.1 clinical presentation neurological features depend on the severity of the malformation and on the segmental level along the longitudinal embryonic axis, the degree of resulting kyphosis and the presence of associated abnormalities. bilateral case series fig. 1b. lateral spinal x-ray demonstrates absent t12 and lumbar vertebrae. fig. 2a. saggital t2 mri demonstrates spinal cord hypoplasia with disconnection of the spinal segments above and below the dysgenetic t12 segment at thoracic level 6, with the bony vertebrae terminating at t10, and complete aplasia of t12. the sacrum and pelvis are normally developed. fig. 2b. axial t2 mri demonstrates horseshoe kidney (arrowed). case series →→ 31 sa journal of radiology • june 2009 talipes equinovarus deformity of the feet is present in all cases. patients have hypertrophied, deformed lower limbs. hip and knee abnormalities have been described. a neurogenic bladder is almost always present and can present as recurrent urinary tract infections complicated by vesicoureteric reflux and hydronephrosis.1,4 other associated abnormalities closed spinal dysraphisms such as diastomatomyelia, dermal sinus, terminal myelocystocoele, lipomas, thickened filum terminale, tethered cord and sacral spina bifida have been described in the literature. open spinal dysraphisms have not been reported in ssd. multiple renal abnormalities including crossed ectopia, single kidney and horseshoe kidney are reported, as demonstrated in both our cases. dextrocardia, situs inversus, tetralogy of fallot and hypoplasia of the lungs have been described. bowel abnormalities include imperforate anus, rectovaginal fistulae and malrotation of the bowel.1,4 x-ray features moderate to severe kyphosis can be present, with the gibbus apex marking the level of vertebral malformation. aplastic or hypoplastic vertebrae, hemivertebrae and butterfly vertebrae may be demonstrated at the thoracic, lumbar or sacral regions. there may be marked stenosis or even interruption of the spinal canal at the level of the malformation, and the osseous canal can resemble an hour-glass shape. associated costal abnormalities, such as bifid, fused, or absent ribs, can also be present. fig. 3a. lateral spinal x-ray demonstrating kyphotic deformity at t9 (arrow) where the spinal vertebrae end abruptly. fig. 3b. ap spinal x-ray demonstrating the agenesis of the lower thoracic, lumbar and sacral spines. fig. 4a. sagittal t2 mri: the thoracic vertebrae and spinal cord terminate at t9. note the linear bony septum below t9, and the syrinx above. case series 32 sa journal of radiology • june 2009 treatment even though patients with ssd are not necessarily paraplegic at presentation, they have an increased risk for the development of neurological deficits owing to the associated instability and congenital stenosis of the spine.1 mri therefore plays an important role and can influence the surgical strategy. hughes et al. and flynn et al. (cited in faciszewski et al.3) recommend early reconstructive surgery in infancy, so allowing for motor development.3 spinal cord decompression and anterior and posterior arthrodesis is pivotal at an early stage to limit the progression of the kyphosis and worsening of neurological impairment.3,4 conclusion the ssd malformation is typically segmental with normal vertebrae above or below the anomaly, as if an intermediate segment of the spinal vertebrae and spinal cord were omitted during embryonic development. as there are many associated abnormalities such as neurogenic bladder, renal and other problems, it is important that they are identified early because this aids surgical planning. imaging therefore plays an important role in the diagnosis, surgical planning and follow-up of such cases. 1. tortori-donati p, fondelli mp, rossi a, raybaud ca, cama a, capra v. segmental spinal dysgenesis: neuroradiologic findings with clinical and embryologic correlation. am j neuroradiol 1999; 20: 445-456. 2. moriya j, kakeda s, korogi y, soejima y, urasaki e, yokota a. an unusual case of split cord malformation. am j neuroradiol 2006; 27: 1562-1564. 3. zana e, chalard f, sebag g. an atypical case of segmental spinal dysgenesis. pediatr radiol 2005; 35: 914-917. 4. faciszewski t, winter rb, lonstein je, sane s, erickson d. segmental spinal dysgenesis. a disorder different from spinal agenesis. j bone joint surg am 1995; 77: 530-537. fig. 4b. sagittal t2 mri demonstrating the hydronephrotic kidney. case series new blood invariably brings change. having very recently taken over from savvas andronikou, who set a very high standard for this journal (and who insisted on manuscripts being forwarded in printed format), i was immediately and completely taken with the electronic process of submission that appears on the south african journal of radiology webpage: www.sajr.org.za. from the home page, one can register as a reader and/or author, and a personal profile is created in the process. authors can electronically upload a manuscript that will proceed through the steps of unassigned, in review, editing, layout, publishing – and be able to track its progress if they wish. the process is straightforward and simple. e-mail responses are automatically generated by the ojs (open journal system), as it’s called, and the potentials for error are minimised. this is undoubtedly the way forward, and i kindly request that all future submissions and correspondence take this route. we have in the past utilised a rotating guest editorship assigned to individual faculties. this might have assisted in sharing the load, but we have witnessed fluctuating quality and a lack of consistent editorial policy. under the editorship of professor andronikou, this has largely disappeared and we intend to abolish the process completely. sharing the load, however, remains critical. to ensure future progress of the journal towards an internationally recognised peer-reviewed publication, we need only 3 manuscripts from our 8 academic institutions annually. the wealth of excellent material in the private sector remains essentially untapped, and contributions from this sector are continually sought – and greatly appreciated. cpd registration will take place in due course. a questionnaire at the end of each issue can be electronically filled in and submitted and cpd points will be automatically assigned. a cpd certificate in the name of the participant can be generated on the website. we hope also to publish regular contributions on ethics in order to assist our members in accumulating points in this area. you have in your hands the first issue of volume 12. i very much hope and trust that we will look back, in 2 3 years from now, and agree that the goals were worthwhile and that the first issue of volume 14 will be that of a peer-reviewed, internationally recognised radiological journal. vires acquirit eundo – it gathers strength as it goes (virgil; 70 19 bc). vires acquirit eundo. jan lotz editor-in-chief editorial � sa journal of radiology • april 2008 new rssa committee dr clive sperryn has recently been voted in as president of the radiological society of southern africa (rssa). a former head of school at michaelhouse (1979), he won a tongaat hulett group scholarship to study medicine at uct, and the zwarenstein prize for the most outstanding student in his first year. he was a member (business manager) of the rag executive, the medical students council executive and the mountain and ski club committee, and was awarded the sir abe bailey travel bursary in 1984. after internship at edendale, he spent time in casualty, paediatrics, general practice (including diving medicine), neurosurgery and world travel, before commencing radiology at groote schuur in 1991. studying initially under professor ronnie kottler, he was subsequently appointed by professor steve beningfield to head the vascular and interventional unit. an unexpected phone call from joel bortz led to a partnership with lake, smit and partners in durban before a final return to cape town in 2000 to join morton and partners. the rssa has been well served by richard tuft, who led the society to the enviable position we find ourselves in today, and continues to be involved as past president. bates alheit remains executive director, and trevor alnutt and jako calitz continue to run the secretariat. we bid farewell to jan labuscagne and wish him well in his new role as secretary-general of the isr and with the founding of the african society of radiology in marrakech this year. jan has been replaced as congress chairman by leon janse van rensburg, who has tackled this role with phenomenal enthusiasm. the new vice-president is sheldon godinho, with ralph posner as treasurer, mark velleman as secretary, and nigel flint and ashesh ranchod completing the executive. radiologists are a highly mobile, scarce resource and one of our challenges is to retain those who have been trained in south africa. the rssa supports academic radiology through journal sponsorship, publication of the sajr (which is provided free to all members), moving to electronic format for greater access, organisation of congresses and workshops and, recently, the establishment of a prize for an outstanding lecture given by any junior member at an rssa congress. we thank dr savvas andronikou for his enormous contribution to the sajr and welcome jan lotz as the new editor-in-chief. we have recently been made an extremely generous offer of free corresponding membership of the european society of radiology for all our members. benefits include: • free electronic access to european radiology, one of the most prestigious publications in the field of imaging • reduced registration rates for the european congress of radiology (ecr) from 2009 onwards • free electronic access to eurorad, the largest peer-reviewed teaching database of radiology on the internet • free electronic access to epos™, the electronic presentation online system which comprises more than 6 300 electronic presentations shown during ecr, escr, esgar, esmrmb, sir and cirse that can be viewed and downloaded • free electronic access to eecr, which contains over 350 recorded lectures that can be viewed from ecr, esgar or esmrmb • free electronic access to edips download, ecr's digital preview system which enables one to download 1 099 microsoft® office powerpoint presentations of ecr lectures throughout the year • all activities of the european school of radiology (esor) are offered exclusively to members of the esr • free access to the esr online job forum. we invite all our members to take advantage of this opportunity by following the links in the news and views section of the rssa website. we also invite all radiologists to contribute to our journal, to consider lecturing at our congresses, and to join the rssa and enjoy the benefits of membership, including the opportunity for free corresponding membership of the ecr. rssa fees are nominal for those who are not in private practice. patricia trietsch is the rssa secretary and is contactable at radsoc@iafrica.com. dr clive sperryn pg 2.indd 2 4/16/08 9:28:06 am original article original article 14 sa journal of radiology • april 2008 original article abstract aim. to determine the accuracy of magnetic resonance cholangiopancreatography (mrcp) compared with the gold standard endoscopic retrograde cholangiopancreatography (ercp) in the diagnosis of bile duct disorders at universitas hospital, university of the free state (ufs), bloemfontein. patients and methods. fifty-two patients with suspected pancreatobiliary pathology were included in this prospective observational study. mrcp was performed in the 24-hour period prior to ercp. results. mrcp had sensitivity, specificity, positive and negative predictive values of 87%, 80%, 83.3% and 84.2% respectively for choledocholithiasis, which correlates well with results obtained in other parts of the world. conclusion. at ufs, mrcp has high diagnostic accuracy for bile duct calculi. owing to a small study population, results for other biliary pathology were inconclusive. introduction accurate methods for detecting bile duct and pancreatic duct abnormalities in patients with obstructive jaundice are important to both surgeons and endoscopists. biliary obstruction may be the result of choledocholithiasis, tumours or trauma, among other causes. the most common cause is choledocholithiasis. ercp is still the gold standard for exploration of the biliopancreatic region. however, it requires direct cannulation of the common bile or pancreatic duct, sedation, the use of ionising radiation and a team of trained and experienced personnel. in addition, ercp is associated with significant complication rates of 1 7%, such as haemorrhage, sepsis, pancreatitis and bile leak, as well as a recognised mortality of up to 1%.1 mrcp is a non-invasive and safe alternative to diagnostic ercp for imaging the biliary tree and investigating biliary obstruction. mrcp refers to selective fluid-sensitive magnetic resonance imaging (mri) of the pancreatic and biliary ducts. it was developed in 1991 and techniques have progressively improved since then. a major detriment or disadvantage of mrcp is that it is not a therapeutic procedure, whereas ercp is used for diagnosis and treatment. however, if no therapeutic intervention is found to be necessary, mrcp avoids the potential morbidity and mortality associated with ercp. mrcp is particularly useful where ercp is difficult, hazardous or impossible. it is also an important option for patients with failed ercps. ercp and mrcp have different contraindications, allowing them to be used as complementary techniques.2 aim the aim of our study was to compare the accuracy of mrcp as a diagnostic tool at our institution with invasive ercp in the diagnosis of bile duct abnormalities, using specificity, sensitivity, and positive and negative predictive values. materials and methods during the period may 2003 to november 2004, 52 patients with suspected pancreaticobiliary pathology and a clear indication for ercp were included in this prospective study. patients had to be at least 18 years old, and informed written consent was obtained prior to both procedures. our study was run at the mri and the ercp units of universitas hospital, ufs, bloemfontein. all the patients had both examinations performed within 24 hours of each other. patients with absolute contraindications to the mrcp technique (e.g. cardiac pacemaker, claustrophobia, large patient size, degenerative or ankylotic conditions or senile dementia) were excluded from the study because of the impossibility of their co-operation, as were patients with severe clinical conditions requiring urgent therapeutic intervention. mrcp and mri technique mrcp was performed on a 1.5 t general electric unit (signa) using a torso phased-array coil. 1. three plane gradient-echo localising images were obtained and used to plan mrcp sequence. 2. axial slices were performed using single-shot fast spin-echo (ssfse) sequences; parameters: 90 te. • field of view 28 38 cm • slice thickness: 10 mm • spacing: 2 mm • frequency: 256 khz • phase encoding: field of view (fov): 8cm • frequency encoding direction: right to left 3. radial slice acquisitions with high resolution, thick slab using long te were performed in the region of the biliary and pancreatic ducts. eleven reconstructed slices with 10-degree spacing were used. 4. coronal 3 mm fov – spacing 3 mm. all the sequences were acquired during a single breath-hold after a 4 6-hour period of fasting to promote gallbladder filling. the entire examination was usually completed within 20 minutes. accuracy of mrcp compared with ercp in the diagnosis of bile duct disorders d hurter, mb chb c de vries, mb chb, mmed (rad) p h potgieter, mb chb r barry, mb chb, mmed (chir) f j h botha, mb chb g joubert, msc departments of radiology, surgery and biostatistics, faculty of health sciences, university of the free state, bloemfontein pg 14-22.indd 14 4/14/08 12:22:50 pm original articleoriginal article 15 sa journal of radiology • april 2008 ercp technique fluoroscopy: a philips diagnost 93 was used for screening and taking hard copy plain films. duodenoscopy: an evis olympus jf type 230 duodenovideoscope was used. the procedure was performed with patients under conscious sedation or general anaesthesia, depending on the individual evaluation of the patients by the anaesthetist. patients were positioned in the prone position and ercp performed by an experienced surgical endoscopist. the endoscopist had no access to information from the prior mrcp. image analysis the diagnostic quality, coverage of the relevant anatomy and results of the mrcp were reviewed by one general radiologist blinded to the ercp results. he received only clinical information related to the symptoms of patients. the ercp was interpreted by an experienced consultant surgeon also blinded to the mrcp results. results for cholangiography and pancreatography obtained from both techniques were compared. results were analysed according to the pathology found, e.g. choledocholithiasis, pancreaticobiliary strictures and dilatation. statistical analysis the sensitivity, specificity, and positive and negative predictive values were used to compare the two imaging techniques. analysis focused on the comparison of cholangiography and pancreatography as obtained by both techniques. fisher’s 2x2 exact test was used to compare groups. statistical significance was set at p<0.05, with 95% confidence intervals. results patients’ ages ranged from 21 to 86 years, with a mean of 60.5 years. thirty-two patients (61.5%) were female and 20 patients (38.5%) were male. patients were evaluated for clinical and biochemical jaundice: 32 patients (65.3%) and 41 patients (83.7%) were clinically and biochemically jaundiced, respectively. in 3 patients, these results were not obtainable (table i). ercp choledocholithiasis was found in 26 patients; in these, the bile ducts were involved in 23 patients and the ampulla of vater in 3 patients. strictures were diagnosed in 15 patients; 12 were seen in the bile ducts, 2 were found in the pancreatic duct and 1 was thought to be due to a tumour in the main papilla. dilated bile ducts were found in 34 patients in conjunction with either stones or strictures. the ercp was normal in 3 patients. ercp failed in 5 patients due to papillary oedema, impacted stone just above the ampulla, duodenal tumour, pharyngeal tumour and patient non-compliance. mrcp choledocholithiasis was seen in 31 patients, affecting the ampulla of vater in 7 patients and the bile ducts in 24 patients. strictures were diagnosed in 9 patients; 3 owing to suspected tumours in the main papilla, 5 were seen in the bile ducts and 1 was found in the pancreatic duct. dilated bile ducts were found in 20 patients in conjunction with either stones or strictures. the mrcp was normal in 3 patients. mrcp failed in 1 patient due to artifacts caused by surgical clips. two subjects had ascites, leading to failed mrcp due to lack of visibility of the ducts. mrcp v. ercp (table ii) mrcp correctly diagnosed 20 of the 23 patients with ercp-proven bile duct calculi, and 16 of the 20 patients without calculi. there were 3 false-negative and 4 false-positive results for mrcp. stones in the ampulla of vater were correctly diagnosed in 1 of the 3 affected patients, and excluded in 35 of the 41 patients. there were 6 false-positive and 2 false-negative results when mrcp was used to diagnose stones in the ampulla. the sensitivity, specificity, and positive and negative predictive values for bile duct calculi were 87%, 80%, 83.3% and 84.2%, respectively. strictures were correctly diagnosed by mrcp in 4 of the 12 affected patients, and excluded in 28 of the 29 unaffected patients. there were 1 false-positive and 8 false-negative results for mrcp. the sensitivity, specificity, positive and negative predictive values were 33.3%, 96.6%, 80% and 77.8%, respectively. mrcp correctly diagnosed 1 of the 2 patients with bile duct occlusion, and 30 of the 38 patients without occlusion. there were 1 false-negative and 8 false-positive results for mrcp in the diagnosis of occlusion of the bile ducts. in this instance, the sensitivity, specificity, and positive and negative predictive values were 50%, 78.9%, 11.1% and 96.8%, respectively. bile duct dilatation was found by mrcp in 18 of the 34 affected patients and excluded by mrcp in 7 of the 9 unaffected patients. there were 2 false-positive and 16 false-negative results for mrcp. the sensitivity, specificity, and positive and negative predictive values were 52.9%, 77.8%, 90% and 30.4%, respectively. ampullary tumours were correctly diagnosed in the only affected patient, but 2 false-positive results were found. mrcp failed to diagnose all patients with bile duct leaks. the overall sensitivity, specificity, and positive and negative predictive values for bile duct pathology were 60.5%, 84.3%, 74.1% and 74.3%, respectively. the sensitivity and positive predictive values for pancreatic duct filling defects were 100%. regarding the diagnosis of pancreatic duct strictures, a sensitivity of 100%, specificity of 50%, positive predictive value of 94.1%, and negative predictive value of 100% were found. table i. patient demographics total number of patients (n) 52 female 32 (61.5%) male 20 (38.5%) age 21 86 years (mean 60.5) jaundice clinically 32 (65.3%) biochemically 41 (83.7%) unknown 3 pg 14-22.indd 15 4/14/08 12:22:51 pm original article 16 sa journal of radiology • april 2008 in all of the patients with failed mrcp, ercp was 100% successful. ercp failed in 1 patient due to papillary oedema; in this case, mrcp successfully diagnosed choledocholithiasis and secondary bile duct dilatation. in the patient with the stone impacted just above the ampulla and the other patient with the pharyngeal tumour, mrcp was able to show the anatomy of the remaining duct system. mrcp also failed in the patient with the duodenal tumour, due to severe ascites. in addition, ercp allowed therapeutic intervention with sphincterotomy, stone extraction and/or stent placement. where relevant, histology could also be obtained. discussion the aim of our study was to compare the accuracy of mrcp as a diagnostic tool at our institution with invasive ercp in the diagnosis of bile duct abnormalities, using specificity, sensitivity, and positive and negative predictive values. if these values were favourable for mrcp, then the latter could be proposed as the examination of choice for diagnostic imaging of bile duct abnormalities, and ercp could then be reserved for therapeutic intervention alone. mrcp is a non-invasive and safe alternative to ercp for imaging the biliary tree and investigating biliary obstruction. even though fig. 2. high-resolution thick slab long te 1 100 ms (rotated to rao position) mrcp demonstrating a stone impacted in the common bile duct (white arrow). fig. 1. coronal single-shot fast spin-echo t2 mri demonstrating a lowintensity stone (white arrow) impacted in the common bile duct. table ii. main specificity and sensitivity results negative predictive system diagnostic feature sensitivity (%) specificity (%) positive predictive value (%) value (%) main papilla tumour present 100 95.3 33.3 100 stones 33.3 85.4 14.3 94.6 bile ducts stones 87 80 83.3 84.2 dilated 52.9 77.8 90 30.4 strictures 33.3 96.6 80 77.8 occlusion 50 78.9 11.1 96.8 gallbladder stones 80 50 80 50 pancreatic duct occlusion 90 94.7 filling defects 100 100 strictures 50 100 100 94.1 the following mrcp and ercp images demonstrate stones and strictures. pg 14-22.indd 16 4/14/08 12:22:51 pm original article original article 18 sa journal of radiology • april 2008 evaluation of indications for diagnostic and therapeutic ercp is not yet finalised, the usefulness of ercp stands beyond debate. as diagnostic ercp is used less and less, the widespread use of the technique could be restricted to expert centres where skill in therapeutic ercp and management of complications are available. for diagnosis, mrcp offers sufficient advantages over ercp to be considered as the initial modality. there is no risk of complications associated with the procedure of cannulation of the pancreatic duct, and diagnostic yield is similar in most pathology. mrcp exceeds the possibilities of ercp in providing additional information by crosssectional mri and mr angiography. there is no exposure to ionising radiation or to potentially risky iodinated contrast medium, and sedation is seldom indicated. patients should be fasting and the procedure takes a few minutes, usually without sedation. the main potential problems with mrcp are image artifacts and difficulty in patient compliance because of claustrophobia. image artifacts can be seen as bright signals arising from stationary fluid within the adjacent duodenum, duodenal diverticulae and ascitic fluid. in addition, local areas of signal dropout can be caused fig. 3. ercp image (lao view) demonstrating a stone impacted in the common bile duct (white arrow) in the same patient. 4a 4c figs 4a, b and c. mris demonstrating stenosis of the common bile duct (grey arrows) due to a tumour in the head of the pancreas (white arrow). fig. 4a: axial ssfse t2; fig. 4b: coronal ssfse t2; fig. 4c: high-resolution thick slab long te 1 100 ms. 4b pg 14-22.indd 18 4/14/08 12:22:53 pm original article 20 sa journal of radiology • april 2008 by metallic clips following cholecystectomy, defects induced by the right hepatic artery crossing the bile duct, or from severely narrowed ducts, such as occurs in primary sclerosing cholangitis (psc). currently, mrcp has poorer resolution than direct cholangiography and can miss small stones (<4 mm), small ampullary lesions, primary sclerosing cholangitis, and strictures of the ducts. mrcp also has difficulty visualising small stones in the pancreatic duct. obstructing stones are generally easier to identify than non-obstructing stones (especially if smaller than the thickness of the acquired image slices). small stones may not be distinguishable from sludge, mucin or even blood. stones >4 mm are readily seen but cannot be differentiated from filling defects such as blood clots, tumour, sludge or parasites. other mimickers of choledocholithiasis include flow artifacts, biliary air and a pseudocalculus at the ampulla.3 in the light of the current data, mrcp has the potential to replace diagnostic ercp and thereby avoid possible complications related to ercp. the accuracy of mrcp has been evaluated by several authors, with overall sensitivity of 85 97%, specificity of 75 98%, positive predictive values of 83 89%, and negative predictive values of 82 98%.4-6 a recent systemic review analysed the results according to underlying pathology. the median sensitivity for the 13 studies of choledocholithiasis was 0.93 (range 0.81 1.00) and the median specificity 0.94 (0.83 0.99). for malignancy, sensitivity was 81 94.4% and specificity 92 100%. the sensitivity to biliary dilatation was 87 100% and specificity 91 100%. for obstruction, both sensitivity and specificity were 91 100%. sensitivity for strictures was 100% and specificity 98 99%. the review concluded that there is some evidence that mrcp is an accurate investigation compared with diagnostic ercp, although the values for malignancy compared with choledocholithiasis were somewhat lower.3 another systematic review that included a total of 67 studies found that the overall sensitivity and specificity of mrcp for the diagnosis of biliary obstruction were 95% and 97% respectively. sensitivity was lower for stones (92%) and for malignant conditions (88%).7 in a recent prospective study, 33 patients with jaundice due to bile duct strictures were examined by ercp plus intraductal ultrasound (idus) v. mrcp. diagnostic image quality for ercp was 88% against 76% for mrcp (p>0.05). comparing ercp and mrcp, complete depiction of the biliary tract was achieved in 94% and 82%, respectively (p>0.05). ercp and mrcp allowed correct differentiation of malignant from benign lesions in 76% and 58% (p= 0.057) of cases, respectively. by supplementing ercp with idus, the accuracy of correct differentiation of malignant from benign lesions increased significantly to 88% (p= 0.0047).8 a study was undertaken by park et al. to evaluate criteria retrospectively for differentiating extrahepatic bile duct cholangiocarcinoma from benign causes of stricture at mrcp, and to compare diagnostic accuracy of this modality with ercp. the study concluded that accuracy of mrcp is comparable with that of ercp. regardless of modality, a lengthy segment of extrahepatic bile duct stricture with irregular margin and asymmetric narrowing suggests cholangiocarcinoma, while a short segment with regular margin and symmetric narrowing supports a benign cause.9 in another study (moon et al.), 32 patients with suspected biliary pancreatitis were studied prospectively. mrcp was performed immediately before ercp by separate blinded examiners within 24 hours of admission. the sensitivities of mrcp and ercp for identifying choledocholithiasis were 80.0% and 90.0%, respectively. the overall agreement between mrcp and ercp was 90.6% for choledocholithiasis (p<0.01). the sensitivity of mrcp in detecting choledocholithiasis decreased with dilated bile ducts (with a bile duct diameter >10 mm it was 72.7%, versus 88.9% in ducts ≤10 mm).10 in our unit, mri only supports single-shot fast spin-echo sequences. newer variants of mrcp, including rapid acquisition with relaxation enhancement (rare) and half-fourier acquisition single-shot turbo figs 5a and b. ercp (lao view) demonstrating stenosis (white arrow) of the common bile duct due to a tumour in the head of the pancreas. a: before stenting, b: after inserting a stent. 5a 5b stent pg 14-22.indd 20 4/14/08 12:22:54 pm original article 22 sa journal of radiology • april 2008 original article spin-echo (haste), provide superior images. single-shot rare and haste techniques can be performed in a breath-hold period with a scan time of <20 seconds. the optimal protocol to perform mrcp has not been defined and there continues to be variation across centres. as a general rule, the protocol depends upon the specific mr magnet being used, including its field strength (e.g. 1.5 v. 3t) and the manufacturer, as well as institutional experience and preferences. however, all acquisition protocols obtain heavily t2-weighted images as thick slabs and the images are reformatted in planes to optimise depiction of the hepatic and pancreatic ducts. volume-rendered images may be used to depict the intraand extrahepatic bile ducts. in our study, mrcp had sensitivity, specificity, and positive and negative predictive values of 87%, 80%, 83.3% and 84.2%, respectively, for bile duct calculi, which correlates well with results obtained in other parts of the world. it is known that the sensitivity of mrcp for detecting choledocholithiasis decreases with bile duct dilatation (72.7% for bile duct diameters >10 mm v. 88.9% for diameters <10 mm).10 of our 3 patients with false-negative results on mrcp, 2 had dilated bile ducts of 8 mm and 9 mm, respectively. for strictures, mrcp yielded sensitivity, specificity, and positive and negative predictive values of 33.3%, 96.6%, 80% and 77.8%, respectively. our sensitivity is substantially lower than international results. a systemic review reported a sensitivity of 100% for strictures.2 the review does not specifically mention the mrcp-protocol applied in each study. the reason for the low sensitivity in our study may be a result of the lower resolution of mrcp than direct cholangiography; it may also be the small number of our patients who definitely had strictures (12 out of 52 patients). if more advanced mri sequences were used in the review, this could explain their high levels of sensitivity. for bile duct occlusion, the sensitivity, specificity, and positive and negative predictive values were 50%, 78.9%, 11.1% and 96.8%, respectively. only 2 of our 52 patients had definite bile duct occlusion, explaining the low statistical power. internationally, sensitivity and specificity ranges from 91% to 100%.2 the sensitivity, specificity, and positive and negative predictive values for bile duct dilatation were 52.9%, 77.8%, 90% and 30.4%, respectively. elsewhere, values for sensitivity and specificity are between 87% and 100%, and 91% and 100%, respectively. of the 34 affected patients, 16 false-negative results were obtained for mrcp. the possible reason for the false-negative results may be that the reporting was performed by a general radiologist. overall, only 2 patients had proven pancreatic duct pathology on ercp, again making the results difficult to interpret. conclusion the aim of our study was to analyse the performance of mrcp as a diagnostic tool at our institution, using specificity, sensitivity, and positive and negative predictive values. we concluded that mrcp has high diagnostic accuracy solely for bile duct calculi. owing to a small study population, results for other biliary pathology were inconclusive. consequently, we propose mrcp as the method of choice for the diagnostic imaging of bile duct calculi. ercp is reserved for therapeutic intervention in this setting. it is well proven in current literature that mrcp has the potential to replace diagnostic ercp in a wide range of bile duct abnormalities (tumour, stricture, occlusion), thereby avoiding possible complications related to ercp. at our institution, further study with more patients is needed in future to reach the same conclusion. ercp is still employed in the diagnosis of these abnormalities. 1. bilbao mk, dotter ct, lee tg, et al. complications of ercp; a study of 10 000 cases. gastroenterology 1986; 70: 314-320. 2. kaltenthaler e, bravo vergel y, chilcott j, et al. a systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography. executive summary. health technology assessment 2004; 8(10): 1-6. 3. david v, reinhold c, hochman m, et al. pitfalls in the interpretation of mr cholangiopancreatography. ajr am j roentgenol 1998; 170: 1055-1059. 4. taylor acf, little af. prospective assessment of mrcp for non-invasive imaging of the biliary tree. gastrointest endosc 2002; 55(1): 17-22. 5. soto ja, yucel ek. mrcp: comparison with ercp. gastroenterology 1996; 110: 589-597. 6. varghese jc, farrell ma, courtney g, et al. a prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patients with suspected biliary tract disease. clin radiol 1999; 54: 513-520. 7. romagnuolo j, bardou m, rahme e, et al. magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. ann intern med 2003; 139: 547-557. 8. domagk d, wessling j, reimer p, et al. endoscopic retrograde cholangiopancreatography, intraductal ultrasonography, and magnetic resonance cholangiopancreatography in bile duct strictures: a prospective comparison of imaging diagnostics with histopathological correlation. am j gastroenterol 2004; 99(9): 1684-1689. 9. mi-suk park, tae kyoung kim, kyoung won kim, et al. differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at mrcp versus ercp. radiology 2004; 233: 234240. 10. jong ho moon, young deok cho, sang woo cha, et al. the detection of bile duct stones in suspected biliary pancreatitis: comparison of mrcp, ercp, and intraductal us. am j gastroenterol 2005; 100: 1051-1057. pg 14-22.indd 22 4/14/08 12:22:55 pm in the previous issue of the sa journal of radiology,1 the editor-in-chief of the journal expressed serious concerns about the future of positron emission tomography (pet) in south africa – and not without reason. business day on 4 september 2008 reported that ‘high-tech scan centres look set to sink’.2 according to this article, south africa’s private petct scanning centres are struggling to recoup their multi-million-rand investments. this is happening in spite of international sentiments expressed regarding the ‘unparalleled contribution of f-18 fdg pet to medicine over 3 decades’.3 pet-ct is battling to establish itself in south africa, notwithstanding numerous reports confirming the costeffectiveness of this modality by virtue of inter alia obviating unnecessary surgical procedures and ineffective chemotherapy regimens. the question of why this situation has developed in south africa should be investigated. pet using the glucose analogue f-18 fdg was first introduced in the late 1970s. if we look back at the history of pet in south africa, interest in obtaining pet systems first arose in the mid-1980s. these efforts were discontinued with the political changes taking place in south africa and the new government’s initial emphasis on primary medicine. although there had been marked growth in the use of pet worldwide since its inception, south africa lagged behind in acquiring pet cameras. it was only after the development of pet-ct machines that there was renewed interest in this technology, not only from nuclear physicians but also from radiologists; this eventually led to the installation of the first pet-ct system in johannesburg in late 2005. because of strong interest in this modality, the south african pet users association (sapua4) was established in december 2004, under the auspices of the south african society of nuclear medicine. members of sapua include nuclear physicians, medical physicists, radiographers, other scientists and colleagues from the industry. there has, however, been limited utilisation of sapua by the many groupings involved with pet, including the radiology community. in 2005, sapua performed a needs analysis for pet in south africa because serious concerns had been expressed about the possibility of oversupply and/or maldistribution of facilities, if the technology were introduced in a piecemeal fashion. using data from the national cancer registry, it was predicted that between 5 and 7 facilities should initially be established to service both the private and public sectors, with a subsequent review to determine whether additional facilities were required.5 sapua suggested that in some regions, facilities should be shared between public and private practices. despite this needs analysis, the installation of pet-ct facilities suddenly boomed in south africa. six pet-ct facilities are currently operational in the private sector, of which 3 are in gauteng, and there are currently 3 in public hospitals. the first private pet-ct facility was established in johannesburg in 2005, with most of the others following in 2006. despite warnings about the number of pet facilities, it seems that there was minimal consultation between the various groupings, and no consultation between the public and private sectors regarding the location or use of these facilities. another grave concern is the current geographical and socio-economic maldistribution of pet-ct facilities, with the unavailability of this service to a large number of south africans, especially those who cannot afford high-tech medical care. the gross under-utilisation of the existing facilities is unacceptable in a resource-poor country like south africa. according to the report in business day, medical aid schemes are to blame for this situation, as they either refuse to pay for pet-ct scans, or put too many bureaucratic hurdles in the way. the question can be asked whether they should be entirely blamed for taking such an approach. there is no doubt that pet is an expensive modality. the two components that make up the cost of pet-ct studies are the cost of the equipment and the cost of the radiopharmaceutical (f-18 fdg). a recent report by the usa department of health and human services analysed, among other factors, the increase in ‘advanced imaging’ procedures;6 these included pet. according to this report, pet imaging accounted for about only 5% of the growth in services, but for more than 18% of the growth in allowed charges. without controls, the same trend in expenditure for pet-ct services as in the usa would probably occur in south africa. it is therefore understandable that medical aid schemes acted cautiously. however, medical aid schemes need to accept the reality of the important contribution that pet-ct currently makes to the management of many cancer patients. they also need to look beyond the cost of a pet-ct scan on its own. in many cases, the expense of a pet-ct scan will be outweighed by the savings that follow correct diagnosis, staging, and evaluation of treatment, as provided by the scan. suppliers of fdg should also look critically at the cost of this radiopharmaceutical. while there is a risk in lowering the price, this needs to be weighed against the possibility of increasing the number of patients scanned, and even preventing the possibility of pet-ct practices having to close their doors. is there a way forward? should struggling practices close their doors and sell their pet-ct cameras? at present, only a minority of south africans have access to pet-ct. now is the time for the nuclear medicine and radiology communities utilising pet in south africa to stand together and save this modality for the people of the country. with optimal collaboration between practices and public health facilities, so that both public and private patients can share the benefits of this modality, the cameras will be used more cost-effectively, and oncology patients especially will benefit. medical aid schemes will also benefit, as unnecessary surgery in patients who are upstaged will be obviated, and the administration of futile chemotherapy regimens stopped timeously in patients who do not respond to the therapy. 1. lotz j. pet-ct meltdown is looming (editorial). s afr j radiol 2008; 12: 26. 2. kahn t. high-tech scan centres look set to sink. business day 4 sept 2008. http://www.businessday.co.za articles/tarkarticle.aspx?id=3314642 (accessed 4 october 2008). 3. basu s, alavi a. unparalleled contribution of f-18 fdg pet to medicine over 3 decades. j nucl med 2008; 49(10): newsline 17n. 4. sapua website. www.sasnm.com/sapua.htm (accessed 4 october 2008). 5. sasnm website. www.sasnm.com/national_strategy_discussion_document_final.pdf (accessed 5 october 2008). 6. growth in advanced imaging paid under the medicare physician fee schedule. boston, usa: department of health and human services. http://oig.hhs.gov/oei/reports/oei-01-06-00260.pdf (accessed 6 october 2008). pet/ct in south africa: a lost cause? annare ellmann president: world federation of nuclear medicine and biology editorial 58 sa journal of radiology • october 2008 editorial.indd 58 10/15/08 11:35:37 am contents tib kidney dysfunction is a serious complication that can occur following the administration of contrast media (cm). although the incidence of contrast nephropathy (cn) is low in the general population (1 2%) it poses a serious risk to those with impaired kidney function. other risks include diabetes, old age and dehydration. the first step in prevention is to identify patients at risk. in such patients a small dose of non-ionic iso-osmolar cm together with adequate hydration (preferably an intravenous infusion of 0.45% or 0.9% normal saline) and oral n-acetylcysteine (nac) dramatically reduces cn. although the disease occurs infrequently with normal kidney function, its frequency increases with decreasing kidney function, ranging from 5% in patients with mild kidney insufficiency to 50% in those with severe dysfunction and diabetes. given that cn is associated with increased morbidity, mortality and prolonged hospitalisation, and possibly with long-term kidney impairment, there is great interest in its prevention.1 epidemiology although definitions may vary, a commonly accepted and applied definition is a > 25% increase in serum creatinine level that occurs within 48 hours of contrast exposure.2 once cn occurs, kidney function remains depressed for 1 3 weeks but returns to normal or near normal in most cases.3 the presence of predisposing risk factors (table i) increases the risk of cn and in the elderly patient multiple risk factors may be present. the most important risk factors seem to be the presence of preexisting kidney insufficiency, diabetes mellitus and the volume of contrast used. the use of non-ionic agents4 appears to lower the incidence of cn and this has been confirmed in animal models.5 pathophysiology the mechanism by which contrast administration induces kidney injury is uncertain. a combination of the following factors appears to be most feasible: • reduced renal blood flow and medullary ischaemia related to an inhibition of prostacyclin production and stimulation of the renin-angiotensin system.6 • direct nephrotoxicity and uric acid precipitation.7 • red blood cell sludging.8 • the generation of reactive oxygen species.9 preventive strategies first and foremost is the ever-important fact that the decision to perform the procedure must be debated continuously. without contrast there would be no nephrotoxicity and the decision to perform the intervention must take into cognisance the risks for and outcomes of cn. prevention or mitigation of renal failure after the administration of a radiographic contrast agent has been notably difficult. previous studies have attempted to identify methods to reduce the incidence of cn, particularly in high-risk groups. pretreatment with diuretics such as furosemide,10,11 or with drugs thought to prevent vasoconstriction, such as calcium channel blockers, adenosine receptor blockers, dopamine, aminophylline,12 endothelin antagonists,13 and atrial natriurtic peptide, have not provided clear benefit and may even be harmful. volume expansion with intravenous 0.45% or 0.9% saline (2 3 litres prior to the procedure and continued after) has been found to be safe and effective but has not eliminated the condition. the use of low osmolar, non-ionic contrast agents in patients with mild renal insufficiency has been shown to moderately reduce the risk of cn. in a randomised trial involving more than 1 100 patients, rudnick et al.14 demonstrated acute nephrotoxicity in 7% of patients receiving the ionic agent diatrizoic acid and in 3% using the non-ionic agent iohexol (p < 0.002). such data have been confirmed in other studies and the effect is especially noticeable in those with kidney insufficiency and those with diabetes. review article 14 sa journal of radiology • october 2005 practical issues in the prevention and treatment of contrast nephrotoxicity g bihl mb bch, mmed, fcp(sa) winelands kidney and dialysis centre somerset west table i. risk factors for contrast-associated nephropathy ccoonnffiirrmmeedd ssuussppeecctteedd serum creatinine > 150 µmol/l hypertension diabetic nephropathy abnormal liver function metformin older age class iii/iv congestive heart failure concomitant use of loop diuretics multiple myeloma . volume and osmolality of contrast media used repeat contrast within 48 hours intracardiac injection nephrotoxic drugs (nsaids, chemotherapy, cyclosporin a) pg14-16 9/28/05 1:22 pm page 14 n-acetylcysteine (acc 200, salmucol, parvolex) a thiol-containing antioxidant, has been used to treat a variety of pulmonary diseases and to treat acute paracetamol poisoning. recently this agent has been used successfully to amend the toxic effects of experimentally and clinically induced ischaemia-reperfusion injuries in the heart, kidney, lung and liver.15-17 oxidants activate a signal-transduction cascade and molecular response that may engage the cell-death pathway and provoke apoptosis. such pathways seem to be sensitive to the prevailing redox state of the cell and are inhibited by nac. studies have shown that nac inhibits cell death induced by ischaemia-reperfusion injury in the kidney, liver and lung, and promotes pathways that lead to repair and survival whenever cells are under oxidant stress. in a randomised study, tepel et al. 18 administered nac at a dose of 1 200 mg/day (in divided doses per os) on the day before and on the day of the procedure in all high-risk patients, especially those with kidney insufficiency. in this study all patients received saline intravenously and low-osmolality, non-ionic agents were administered. the expected decline in renal function in these patients was significantly reduced. these data are supported by data from kay et al.19 who used a similar dosing schedule and showed a lower serum creatinine and higher creatinine clearance in those pre-treated with nac. haemodialysis does not remove the contrast agent given and may increase the risk of cn. a recent study20 concluded that in patients with moderate to severe kidney insufficiency undergoing coronary interventions, periprocedural haemofiltration given in an icu setting appeared to prevent deterioration in kidney function related to the administration of a contrast agent.20 this is a plausible modality to use in highrisk patients requiring intervention although it does increase the costs of the overall procedure significantly. it is important to realise that not every increase in serum creatinine following contrast administration is due to the contrast agent. atheroembolic disease with a rapid decline in renal function or a more slow and indolent decline needs to be considered in the differential diagnosis. in those patients requiring dialysis following coronary angiography, atheroembolic emboli may be a fairly common cause of kidney insufficiency. clinical recommendations the algorithm proposed in fig. 1 suggests a practical approach to cn prevention, realising that patients with pre-existing renal impairment alone or three or more of the risk factors detailed in table i pose a significant risk for cn. normal kidney function. in patients with normal serum creatinine adequate hydration is all that is necessary. although serum creatinine levels may be normal, diabetics, elderly patients and those with reduced muscle mass may have a normal u&e although their creatinine clearance may be reduced thereby imparting a risk for cn.21 a calculated creatinine clearance using the cockroft-gault formula [(140-age) x ideal body weight (kg)] [0.8 x serum creatinine (µmol/l)] would easily identify such patients. preventive measures as for moderate insufficiency could then be instituted. moderate/ severe kidney insufficiency (creatinine 150 µmol/l 250 µmol/l, creatinine clearance < 50 ml/min). • intravenous volume administration with saline 0.45% or 0.9% for 12 hours before and 6 hours after the procedure. review article 15 sa journal of radiology • october 2005 eennssuurree aa pprree--pprroocceedduurraall cchheecckklliisstt iiss ccoommpplleetteedd if high risk for cn, reconsider the procedure or consider other non-nephrotoxic investigations ddiissccuussss ddiissccoonnttiinnuuaattiioonn ooff nnoonn--eesssseennttiiaall mmeeddiiccaattiioonnss wwiitthh rreeffeerrrriinngg cclliinniicciiaann:: nsaids diuretics metformin eennssuurree aaddeeqquuaattee hhyyddrraattiioonn ((uunnlleessss ccoonnttrraaiinnddiiccaatteedd)) 0.45% or 0.9% saline at 1ml/kg/hr 6-12 hours before and 12-24 hours after nn--aacceettyyllccyysstteeiinnee consider this medication in all patients. 600mg bd po the day before and on the day ccoonnttrraasstt aaggeenntt low osmolar or non-ionic iso-osmolar as low a dose as possible. avoid re-administration uurreeaa aanndd eelleeccttrroollyytteess prior to procedure if high risk repeat at 48-72 hours if an inpatient repeat at 3-6 days if an outpatient encourage oral hydration fig. 1. recommended peri-procedural methods to prevent contrast nephropathy. pg14-16 9/28/05 1:22 pm page 15 • low-osmolality, non-ionic contrast agents with judicious dose limitation. • acetylcysteine 600 mg twice daily on the day before and on the day of the procedure. severe kidney insufficiency (creatinine > 250 μmol/l, creatinine < 30 ml/min) consider that there is a risk of irreversible kidney failure in such patients despite the abovementioned preventive measures. such a risk should be discussed with the patient prior to the intervention and the need for the intervention should be debated. in such patients it is imperative to discuss risks with the patient while ensuring adequate hydration; preferably perform the procedure pre-dialysis in those patients receiving chronic dialysis (as dialysis dehydrates patients and may modestly remove contrast), use low-volume iso-osmolar contrast, and monitor renal function closely for 3 5 days following transplant. practical implications • provide generous intravenous hydration, except in the presence of heart failure. • avoid postprocedural volume depletion. • avoid mannitol and furosemide in patients with kidney insufficiency. • minimise contrast volume. • allow a 5-day interval between 2 procedures requiring contrast. • minimise the development of hypotension and hypoxia. • eliminate the administration of other nephrotoxic drugs, e.g. non-steroidal anti -inflammatory drugs (nsaids). conclusion successful prediction and prevention of cn would diminish the morbidity and mortality associated with acute kidney failure related to the administration of contrast agents. patient convenience and medical care costs would also be optimised by negating the need for prolonged admission, long-term monitoring of kidney function, and the possibility of end-stage kidney failure. references 1. murphy sw, barrett bj, parfrey ps. contrast nephropathy. j am soc nephrol 2000;11:177-182. 2. porter g. contrast medium-associated nephropathy. invest radiol 1993; 28: suppl. 4, s11-18. 3. berns as. nephrotoxicity of contrast media. kidney int 1989; 36: 730-740. 4. esplugas e, cequier a. comparative tolerability of contrast media used for coronary interventions. drug sa,f 2002; 25: 1079-1098. 5. soejima k, uozumi j, kanou t. non-ionic contrast media are less nephrotoxic than ionic contrast media to rat renal cortical slices. toxicol lett 2003; 143(1): 17-25. 6. katzberg rw, morris tw, burgener fa. renal renin and hemodynamic responses to selective renal artery catheterisation and angiography. invest radiol 1977; 12: 381-388. 7. davidson cj, hlatky m. cardiovascular and renal toxicity of a non-ionic radiographic contrast agent after cardiac catherterisation: a prospective trial. ann intern med 1989; 110: 119-124. 8. gabern gl, read rc. red cell factors in renal damage from hypertonic solutions. proc soc exp biol med 1961; 107: 165-169. 9. sandhu c, newman dj, morgan r. the role of oxygen free radicals in contrast induced nephrotoxicity. acad radiol 2002; 9: suppl 2, s436-437. 10. solomon r, werner c, mann d, d’elia j, silva p. effects of saline, mannitol, and furosemide on acute decreases in renal function induced by radiocontrast agents. n engl j med 1994; 331: 14161420. 11. stevens ma, mccullough pa, tobin kj. a prospective randomised trial of prevention measures in patients at high risk for contrast nephropathy:results of the prince study. prevention of radiocontrast induced nephropathy clincal evaluation. j am coll cardiol 1999; 33: 403-411. 12. abizaid as, clark ce, mintz gs. effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with pre-existing renal insufficiency. am j cardiol.1999; 83: 260-263. 13. wang a, holcslaw t, bashore tm, et al. exacerbation of radiocontrast nephrotoxicity by endothelin receptor antagonism. kidney int 2000; 57: 1675-1680. 14. rudnick mr, goldfarb s, wexler l. nephrotoxicity of ionic and non-ionic contrast media in 1196 patients: a randomised trial. kidney int 1995; 47: 254-261. 15. arstall ma, yang j, stafford i, betts wh, horowitz jd. n-acetylcysteine in combination with nitroglycerin and streptokinase for treatment of evolving acute myocardial infarction: safety and biochemical effects. circulation 1995; 92: 2855-2862. 16. dimari j, megyesi j, udvarhelyi n, price p, davis r, safirstein rl. n-acetyl cysteine ameliorates ischemic renal failure. am j physiol 1997; 272: f292-f298. 17. weinbroum aa, rudick v, ben-abraham r, karchevski e. n-acetyl-l-cysteine for preventing lung reperfusion injury after liver ischemia-reperfusion: a possible dual protective mechanism in a dose-response study. transplantation 2000; 69: 853-859. 18. tepel m, van der giet m, laufer u. prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. n engl j med 2000; 343: 180-184. 19. kay j, chow wh, chan tk. acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention. a randomised control trial. jama 2003; 289: 553-559. 20. marenzi g, marana i, lauri g. the prevention of radio-contrast-agent-induced nephropathy by hemofiltration. n engl j med 2003; 349: 13331340. 21. curhan gc. prevention of contrast nephropathy. jama 2003; 289: 606-608. review article 16 sa journal of radiology • october 2005 sonographers sonographers wwanted for secure, fanted for secure, familamilyy-friendl-friendlyy, , relaxed lifestyle in perrelaxed lifestyle in perth, th, western western aaustraliaustralia perth’s largest employer of radiographers and sonographers is looking for at least 3 qualified sonographers and is offering : • excellent hourly rates of pay and working conditions • family-friendly hours and locations of practices • attractive leave, travel allowance and training conditions • payment of relocation costs • payment of first 2 weeks accommodation costs whilst you are settling in for further details please email niels andersen at : info@premiermigration.com.au. pg14-16 10/2/05 9:08 am page 16 head and neck imaging quiz case author: shalendra k. misser1 affiliation: 1lake smit and partners inc, durban, south africa postal address: private bag x08, overport 4067, durban, kwazulu-natal, south africa how to cite this article: misser sk. head and neck imaging. s afr j rad. 2014;18(1); art. #624, 1 page. http://dx.doi.org/10.4102/sajr.v18i1.624 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. presentation open access a 26-year old lady presented with a painful paramedian anterior neck mass. these are her ultrasound and ct scan images. figure 1: sagittal b-mode sonar image. figure 2: axial ct scan image at level of hyoid bone. figure 3: sagittal paramidline ct scan image figure 4: coronal ct scan image of anterior neck triangles. describe the relevant findings and provide the most appropriate clinical diagnosis. please submit your response to dr misser at misser@lakesmit.co.za not later than 11 july 2014. the winning respondent will receive a r1000 award from the rssa. a detailed diagnosis and discussion will be presented later this year. abstract introduction objective methods results discussion limitations of the study conclusion acknowledgements references about the author(s) chris van zyl department of clinical imaging sciences, university of the free state, south africa delmé hurter department of radiology, kimberley hospital complex, university of the free state, south africa vishesh sood department of radiology, kimberley hospital complex, university of the free state, south africa lizanne koning emergency centre, kimberley hospital complex, university of the free state, south africa citation van zyl c, hurter d, sood v, koning l. role of cranial computed tomography in human immunodeficiency virus-positive patients with generalised seizures s afr j rad. 2016;20(1), a965. http://dx.doi.org/10.4102/sajr.v20i1.965 original research role of cranial computed tomography in human immunodeficiency virus-positive patients with generalised seizures chris van zyl, delmé hurter, vishesh sood, lizanne koning received: 06 dec. 2015; accepted: 01 apr. 2016; published: 14 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: emergency neuroimaging of human immunodeficiency virus (hiv)-positive patients with generalised new onset seizures (nos) and a normal post-ictal neurological examination remains controversial, with the general impression being that emergency imaging is necessary because immunosuppression may blur clinical indicators of acute intracranial pathology. the objectives of our study were to establish whether cranial computed tomography (ct) affects the emergency management of hiv-positive patients with generalised nos and a normal post-ictal neurological examination. method: we conducted a prospective descriptive observational study. consecutive hiv-positive patients of 18 years and older, who presented to the kimberley hospital complex’s emergency department within 24 hours of their first generalised seizures and who had undergone normal post-ictal neurological examinations, were included. emergency ct results as well as cd4-count levels were evaluated. results: a total of 25 hiv-positive patients were included in the study. the results of cranial ct brought about a change in emergency care management in 12% of patients, all of them with cd4 counts below 200 cells/mm3. conclusion: we suggest that emergency cranial ct be performed on all hiv-positive patients presenting with generalised nos and a normal post-ictal neurological examination, particularly if the cd4 count is below 200 cells/mm3. introduction emergency neuroimaging of new onset seizures (nos) in patients infected with the human immunodeficiency virus (hiv) remains controversial, with the general impression being that emergency imaging is necessary because immunosuppression may blur clinical indicators of acute intracranial pathology.1,2 in our institution, which is a centre with a significant radiological burden (serving a population of 1.2 million people), we currently use the kimberley hospital rule for urgent computed tomography (ct) of the brain in a resource-limited environment,3 which includes emergency scanning of all patients with focal seizures. however, no clear guideline exists for hiv-infected patients presenting with generalised seizures and a normal post-ictal neurological examination, and therefore it is an area requiring further investigation. objective the aim of our study was to establish whether cranial ct has an influence on the emergency management, and ultimately expedites the treatment, of hiv-positive patients with generalised nos and a normal post-ictal neurological examination. literature review review of the literature produces conflicting findings, with some authors advocating emergency neuroimaging on all hiv-positive patients, and some reliance on clinical signs as indications for emergency neuroimaging. furthermore, few authors differentiate between generalised seizures and focal seizures. barber et al. noticed that the majority of urgent cranial ct requests for hiv-infected patients at their hospital was motivated by clinicians believing that immune-compromised patients might have focal intracranial sepsis without the usual clinical signs. barber et al. gained the impression that many of these scans were normal, and they investigated whether clinical signs were helpful in pointing to patients who harboured intracranial pathology. the authors divided their study sample into two groups: hiv-positive patients, and patients with acquired immune deficiency syndrome (aids). in the hiv-positive group, no patient had treatable intracranial pathology without focal neurological signs. in the aids group, the majority of patients with treatable intracranial disease presented with either seizures (no differentiation was made between generalised or focal seizures) or focal neurology. however, two patients in the aids group had treatable intracranial disease, and only presented with headache or diffuse cerebral dysfunction, without focal neurology. the authors thus suggested that clinical signs remain useful for deciding whether urgent ct was appropriate.1 rothman et al. attempted to correlate neurological signs and symptoms with new focal intracranial lesions in hiv-positive patients. the authors found that nos was strongly associated with intracranial lesions; however, no differentiation was made between generalised and focal seizures.2 holtzman et al. retrospectively reviewed 100 cases of nos in hiv-positive patients. in this case series, mass lesions were found to be the most common cause of nos in the hiv-positive population. of note, however, is the fact that all the patients who presented with generalised seizures and a normal neurological examination either had meningitis, or no identifiable cause of their seizures could be identified. the authors further suggested that, despite the seizure type, a normal neurological examination implied a low probability of identifying an underlying cause for nos.4 modi et al. at the university of the witwatersrand evaluated 37 hiv-infected patients with nos with regards to seizure type, cd4 count and viral load. all patients for whom no identifiable cause for seizures could be determined presented with generalised seizures; however, 48% of the patients with focal brain lesions also presented with generalised seizures. the authors did not report whether the patients with focal brain lesions had co-existing focal neurology.5 the most specific research regarding generalised seizures in hiv-positive patients was done on a sample of 26 patients by pesola et al. in 1998. they studied the aetiology of generalised nos in patients with aids who presented at their emergency department. six (43%) of their patients necessitated emergency clinical management (requiring immediate hospitalisation and treatment); five were suffering from central nervous system (cns) toxoplasmosis and one with cns lymphoma. notably, only two of these patients presented with focal neurology, and the authors therefore recommended emergency neuroimaging on all hiv-positive patients with generalised seizures, regardless of neurological examination findings.6 it is worth noting that the authors only investigated patients with a cd4 count < 200 cells/mm3 (aids defining, according to the centers for disease control and prevention (cdc) staging system). the incidence of nos in the hiv-positive population has been reported to be as high as 17%7,8 (or even 20%, as reported by satishchandra et al., although selection bias might have been present because their hospital is an independent neurological referral centre).9 furthermore, most of these patients present with generalised seizures, at a percentage as high as 71%.4,5,8,9,10,11 obtaining emergency neuroimaging in so many of the patients could potentially overload emergency and radiology departments. methods study design and setting we conducted a prospective descriptive observational study. approval was obtained from the ethics committee of the faculty of health sciences of the university of the free state, as well as the clinical director of kimberley hospital complex. informed consent was obtained from either the patient or a family member. data were collected from october 2014 to september 2015. inclusion and exclusion criteria consecutive hiv-positive patients ≥ 18 years old who presented to kimberley hospital complex emergency department within 24 hours of their first generalised seizures and who had a normal post-ictal neurological examination, were included. patients known to suffer from epilepsy, who had suffered any previous seizure (with or without secondary generalisation), who had any contra-indication to ct, or for whom there was clinical uncertainty, were excluded from the study. measurement patients who met the inclusion criteria for the study received a ct within 8 hours of clinical presentation, according to the kimberley hospital rule.3 patients with clinically suspected hiv infection received confirmatory laboratory testing with preand post-test counselling. if a patient’s recent cd4 count was not known, it was obtained during admission. the cd4 count results were divided into three groups, namely, cd4 counts < 200 cells/mm3, > 200 cells/mm3 ≤ 499 cells/mm3, and > 500 cells/mm3, in accordance with the cdc classification system. cranial ct was reported by a radiology registrar, with findings confirmed by a qualified radiologist; the differential diagnosis was completed on the datasheet. decision to administer iodinated contrast was based on non-contrast ct findings. it was also noted whether the ct findings changed the emergency management (i.e. immediate hospitalisation and treatment). statistical analysis descriptive statistics, namely median and ranges, were calculated for continuous data. frequencies and percentages were calculated for categorical data. results a total of 25 hiv-positive patients with generalised nos and a normal post-ictal neurological examination were included in the study, of whom 15 (60%) patients were male and 10 (40%) were female; the median age was 40 years (minimum age 22 years and maximum age 56 years). of the 25 patients, 19 (76%) had had seizures that had been witnessed by medical personnel. the cd4 counts for 2 patients were unknown, whilst 15 (65%) patients had cd4 counts < 200 cells/mm3, 3 (13%) patients had cd4 counts ≥ 200 ≤ 499 cells/mm3, and 5 (22%) patients had cd4 counts > 500 cells/mm3 (figure 1). figure 1: percentage of patients in each cd4 count category according to the cdc cd4 count classification. ct was normal in 15 (60%) patients and abnormal in 10 (40%) patients; three (12%) of the patients with an abnormal ct had intracranial lesions requiring urgent medical or surgical management. two of these patients were diagnosed with ring-enhancing lesions and one with intracranial haemorrhage. all had cd4 counts < 200 cells/mm3. the emergency management did not have to be changed for the rest of the patients with abnormal ct findings. the predominant finding in these patients was generalised cerebral atrophy (which was defined as enlargement of intraand extra-cerebral cerebrospinal fluid-containing spaces), which was diagnosed in four (16%) patients (figure 2). the results are summarised in table 1. table 1: summary of the findings in our study population. figure 2: computed tomography (ct) findings in our study population. discussion the results of cranial ct brought about a change in emergency care management in 12% of patients, which suggests that cranial ct has a role to play in the emergency management of the hiv-positive patient who presents with generalised nos and a normal post-ictal neurological examination. most patients (90%) with positive ct findings, and all patients for whom emergency clinical management was changed, had cd4 counts < 200 cells/mm3. similar findings were noted in the study by barber et al., where patients without focal neurology but with treatable intracranial pathology were in the aids-defined group.1 this suggests that a cd4 count < 200 cells/mm3 can be used as an indication for ct in patients presenting with generalised nos and a normal post-ictal neurological examination, and that clinical neurological signs are indeed blurred in patients with severe immunosuppression. however, keeping in mind our small study population, larger prospective studies are needed to confirm this finding. our study demonstrated that seizures manifest late in the course of hiv infection, with 65.2% of our entire sample size in the aids-defining category (cd4 < 200 cells/mm3) (figure 1). the most common positive ct finding in our study population was generalised cerebral atrophy, which is a known feature of hiv encephalopathy; this is also a common finding in other studies.1,2,4,6,9,10,11 limitations of the study the study was limited by the relatively small sample size. the frequent rotation of doctors through the emergency department made it difficult logistically to inform all clinical staff of our study and, consequently, not all eligible patients were included. however, considering that we only evaluated patients with generalised seizures, our study size compares well with that of pesola et al. (who also only evaluated patients with generalised seizures), who had a sample size of 26 patients.6 inaccuracies in seizure history were unavoidable, but we countered this by documenting on our datasheet whether the seizure had been witnessed by a me dical staff member. conclusion our study demonstrated that cranial ct changed emergency care management in a clinically relevant number of patients. results also suggest that a cd4 count < 200 cells/mm3, in the presence of generalised nos, could be used as an indication for emergency cranial ct. we suggest that emergency cranial ct be performed on all hiv-positive patients presenting with generalised nos and a normal post-ictal neurological examination, especially if the cd4 count is < 200 cells/mm3. acknowledgements we thank mr c. van rooyen, researcher, department of biostatistics, university of the free state, for help with statistical analysis. competing interests the authors declare that they have no financial or personal relationship that may have inappropriately influenced them in writing this article. authors’ contributions c.v.z. was the project leader. c.v.z., d.h. and l.k. were responsible for protocol planning. l.k. and v.s. helped with data collection. c.v.z. was the primary author of the manuscript and d.h. and v.s. helped with manuscript editing. references barber c, rowlands p, mccarty m, choudhri a, stevens j. clinical utility of cranial ct in hiv positive and aids patients with neurological disease. clin radiol. 1990;164–165. rothman r, keyl p, mcarthur j, beauchamp jr n, danyluk t, kelen g. a decision guideline for emergency department utilization of noncontrast head computed tomography in hiv-infected patients. acad emerg med. 1999;6:1010–1019. bezuidenhout a, hurter d, maydell a, et al. the kimberley hospital rule (khr) for urgent computed tomography of the brain in a resource-limited environment. s afr med j. 2013;103:646–651. http://dx.doi.org/10.7196/samj.6876 holtzman d, kaku d, so y. new-onset seizures associated with human immunodeficiency virus infection: causation and clinical features in 100 cases. am j med. 1989;87:173–177. modi m, mochan a, modi g. new onset seizures in hiv — seizure semiology, cd4 counts, and viral loads. epilepsia. 2009;50:1266–1269. http://dx.doi.org/10.1111/j.1528-1167.2008.01942.x pesola g, westfal r. new-onset generalized seizures in patients with aids presenting to an emergency department. acad emerg med. 1998;5: 905–911. modi g, modi m, martinus i, vangu m. new onset seizures in hiv-infected patients without intracranial mass lesions or meningitis — a clinical, radiological and spect scan study. j neurol sci. 2002;202:29–34. pascual-sedano b, iranzo a, martí-fàbregas j, et al. prospective study of new onset seizures in patients with human immunodeficiency virus infection. arch neurol. 1999;56:609–612. satishchandra p, sinha s. seizures in hiv-seropositive individuals: nimhans experience and review. epilepsia. 2008;49:33–41. http://dx.doi.org/10.1111/j.1528-1167.2008.01754.x kellinghaus c, engbring c, kovac s, et al. frequency of seizures and epilepsy in neurological hiv-infected patients. seizure. 2008;17:27–33. http://dx.doi.org/10.1016/j.seizure.2007.05.017 garg r. hiv infection and seizures. postgrad med j. 1999;75:387–390. case report case report 38 sa journal of radiology • july 2008 case report abstract conn’s syndrome is a rare condition among hypertensive patients; imaging of the aldosterone-producing adenoma (apa) can prove challenging but is nonetheless very important for surgical planning and cure. we present two patients with mri (magnetic resonance imaging) confirmation of apa with negative and equivocal ct (computed tomography) scans. case 1 a 40-year-old woman presented with uncontrolled hypertension and weakness since may 2001. on examination, her blood pressure was 144/107 mmhg. a 12-lead electrocardiogram (ecg) reading showed left ventricular hypertrophy. haematological investigation demonstrated that the patient had a metabolic alkalosis with bicarbonate of 26.4 mmol/l. her initial potassium level was low, i.e. 1.3 mmol/l (normal is 3.3 5.3 mmol/l) and initial sodium was high, i.e. 149 mmol/l (normal is 135 147 mmol/l). her renin level was <4.5 miu/l (low), aldosterone was 2 234 pmol/l (high) and her transtubular potassium gradient was 17 (high). a diagnosis of conn’s syndrome was confirmed biochemically. she was referred for radiological evaluation to establish the site of the pathology. imaging computed tomography (ct) (fig. 1) was indicative of a low-density, non-contrast-enhancing lesion in the right adrenal gland. this apparent lesion measured 5.9×6.2 mm and had a density of 20 hu post-contrast. the lesion was not well demonstrated as it was not possible to separate conned by conn’s syndrome f ismail, mb bch z lockhat, fcrad (d) sa department of radiology, pretoria academic hospital, university of pretoria s ellemdin, mb bch, mmed int med l van der linde, mb chb, doh&m department of internal medicine, pretoria academic hospital, university of pretoria fig. 1. axial venous phase ct demonstrates a low-density area in the region of the right adrenal gland suggestive of a possible mass. fig. 2. axial t2 (tr 2.01/te 100) weighted mri sequence demonstrates a right adrenal mass which has higher signal compared with the liver but lower signal compared with surrounding fat. fig. 3. the post-gadolinium t1 weighted (tr 525/te 13) axial mri demonstrates contrast enhancement of the mass easily visualised in the right adrenal gland. there is an incidental simple cyst in the left kidney. the left adrenal gland is well demonstrated and is normal. conned .indd 38 8/1/08 10:06:03 am case reportcase report the lesion from the surrounding vasculature and organs, and there was insufficient abdominal fat around the gland. also, it was not possible to determine which part of the gland was affected. the left adrenal gland demonstrated homogeneous density, with the medial limb measuring 3.3 mm and the lateral limb 3.5 mm. the ct scan thus suggested apa in the right gland but further imaging was required for confirmation. magnetic resonance imaging (mri) confirmed the lesion in the medial limb of the right adrenal gland, measuring 1.2×1.2 cm, and demonstrated a high signal on the t2 sequence (fig. 2) and contrast enhancement on the post-gadolinium t1-weighted sequence (fig. 3). the lateral limb measured 3.8 mm with a homogeneous signal on all sequences. the mri also confirmed that the left adrenal gland was normal. thus, right adrenal apa was confirmed on mri. the patient underwent a right laparoscopic adrenalectomy and subsequently recovered from her hypertension and metabolic disturbances. macroscopic histology of the specimen confirmed a well-circumscribed nodule in the right adrenal gland, measuring 1.8×1.2 cm, which was yellow in colour when sectioned. on microscopy, a cortical adenoma was found, consisting of cells with clear cytoplasm. case 2 a 30-year-old woman presented with uncontrolled hypertension. there were no other clinical symptoms of note. examination revealed elevated blood pressure of 150/100 mmhg. cardiac and ecg examination was normal. biochemical evaluation was unremarkable. imaging as part of her investigation, the patient had a renal ultrasound scan which demonstrated a small left kidney measuring 7.7×3.5 cm. the right kidney was 9.2×4.6 cm. both kidneys demonstrated good cortico-medullary differentiation. the left renal artery demonstrated normal flow and calibre. resistance indices were normal bilaterally. the patient went on to have a diuretic renogram to assess renal function. tc-99m dtpa was administered intravenously, and the left kidney was found to be smaller than the right (fig. 4). both kidneys demonstrated normal tracer uptake and excretion. 39 sa journal of radiology • july 2008 fig. 4. tc-99m dtpa scintigraphy in coronal posterior-anterior view demonstrates that the left kidney is smaller than the right, but both kidneys demonstrate normal tracer uptake. figs 5a and 5b demonstrate the mass in the body of the left adrenal gland, which is low signal on the t2 weighted sequence (fig. 5a), and demonstrates contrast enhancement post-gadolinium (fig. 5b). 5a 5b conned .indd 39 8/1/08 10:06:04 am case report case report 40 sa journal of radiology • july 2008 the patient then had a formal angiogram (to exclude renal artery stenosis as a possible cause of her hypertension) which demonstrated normal flow and calibre in the renal arteries bilaterally. venous sampling for aldosterone levels was performed. an elevated aldosterone level was found in the left renal vein, i.e. 244.0 pmol/l. this was still within normal limits for a patient in the supine position, with the upper limit of normal being <440 pmol/l; however, this was much higher than the level in the right renal vein (77.3 pmol/l) as well as higher than the aldosterone level in the inferior vena cava (80.5 pmol/l). contrast-enhanced ct was normal, with no enlargement of the adrenal glands present. both adrenal glands were visualised displaying homogeneous contrast enhancement. the right adrenal gland measured 3.3 mm in the medial limb and 3.7 mm in the lateral limb; the left adrenal gland measured 4.1 mm in the medial limb and 3.5 mm in the lateral limb. thus, ct was not helpful in the diagnosis of apa. mri demonstrated a mass in the left adrenal gland involving the body of the gland. it measured 1.1×0.93 cm. it was low signal as compared with the left kidney on the t2 weighted sequence (fig. 5a) with contrast enhancement post gadolinium (fig. 5b). the right adrenal gland was normal, and a diagnosis of left apa was confirmed. in two patients with adrenal adenoma, therefore, the ct scan was inconclusive, while the diagnosis was made on mri. discussion conn’s syndrome was first described in 1955 by j w conn in a patient who had an apa. the disease is more common in females, who present between the third and sixth decades of life. it is part of the differential for primary hyperaldosteronism, where bilateral adrenal hyperplasia (bah) is the other differential. the prevalence is 0.3 1.2% of the hypertensive population.1 radiological studies that aid the diagnosis of adrenal adenomas include contrast-enhanced ct, mri and adrenal vein sampling of aldosterone levels. nuclear medicine studies include adrenal scintigraphy. for adenomas measuring close to 1 cm or more, ct is the investigation method of choice. ct is reported to have a sensitivity of 60 85%.1 protocols include pre-contrast densitometry measurement and contrast enhancement densitometry measurement in the venous and delayed phase with calculation of contrast washout. more recently, adrenal venous sampling is reported to be the standard of reference for determining the cause of primary aldosteronism. however, this method is technically demanding, operator-dependent, costly and time-consuming, with a low but significant complication rate.2 mri is valuable in the diagnosis of apa. in a study by sohaib et al., mri detection of apa had an overall specificity of 100%, sensitivity of 70%, and accuracy of 85%. the mean size of lesions detected was 0.2×1.6 cm.3 ct and mri are therefore both sensitive and specific in the diagnosis of apa. a comparative study by lingam et al. demonstrated similar sensitivities and specificities for the detection of an apa for both ct (86% and 87.5%, respectively) and mri (87.5% and 87.5%, respectively) with good inter-observer agreement.2 sohaib et al. have shown that mr imaging is a specific test for the detection of apa. in the correct clinical setting, if apa is suspected and a unilateral nodule is detected with a contralateral normal gland, then the diagnosis of apa can be made and the patient may be treated surgically. both apa and bah show evidence of a substantial amount of intracellular lipid and signal intensity (si) characteristics similar to those of other adenomas (as was demonstrated with our patient). therefore, si did not help in distinguishing between the two.3 it is important to distinguish bah from apa as the former is treated medically and the latter, surgically. the best way is to measure each limb of the gland as well as the body. a study by lingam et al. showed that ct has a sensitivity of 100% when a mean limb width >3 mm was used to diagnose bilateral adrenal hyperplasia, and a specificity of 100% was achieved when the mean limb width was ≥5 mm.4 radiopharmaceuticals allow non-invasive assessment of adrenal function and can be used to differentiate between an apa and bah.2 recommendations both ct and mri are valuable diagnostic tools in the diagnosis of apa and in differentiating apa from bah. mri has a similar sensitivity and specificity in the literature as compared with ct, but at our institution we are finding that mri has a higher sensitivity, as demonstrated by these two cases. however, two cases alone are not statistically significant, therefore further research in this field is required. adrenal vein sampling is the gold standard but has disadvantages. we intend to undertake further research in this regard to establish the best diagnostic protocol for our patients at our institution. 1. jabbour sa, goldstein bj, talavera f, chausmer ab, cooper m, griffing gt. conn syndrome. www. emedicine.com (accessed 13 may 2007). 2. patel sm, lingam rk, beaconsfield ti, tran tl, brown b. role of radiology in the management of primary aldosteronism. radiographics 2007; 27: 1145-1157. 3. sohaib sa, peppercorn pd, allan c, et al. primary hyperaldosteronism (conn syndrome): mr imaging findings. radiology 2000; 214: 527-531. 4. lingam rk, sohaib sa, vlahos i, et al. ct of primary hyperaldosteronism (conn's syndrome): the value of measuring the adrenal gland. am j roentgenol 2003; 181: 843-849. conned .indd 40 8/1/08 10:06:04 am article information authors: nausheen khan1 irma vandewerke1 affiliations: 1department of radiology, kalafong hospital and university of pretoria, south africa correspondence to: nausheen khan postal address: private bag x396, pretoria 0001, south africa dates: received: 15 nov. 2013 accepted: 05 jan. 2014 published: 04 july 2014 how to cite this article: khan n, vandewerke i. unusual cause of paraplegia in a child of 5 years. s afr j rad. 2014;18(1); art. #594, 3 pages. http://dx.doi.org/10.4102/ sajr.v18i1.594 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. unusual cause of paraplegia in a child of 5 years in this case report... open access • abstract • case report • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ ‘hydatid’ originates from the greek word meaning ‘watery vesicle’. it refers to a cyst formed as a result of infestation by larvae of the tapeworm echinococcus granulosus, endemic to sheep-raising areas of the world. humans are an accidental intermediary host, with lungs and liver most commonly affected. hydatid involvement of the spine accounts for less than 1% of the total cases of hydatid disease and isolated extradural involvement is even rarer. we report a case of extradural hydatid cyst involving a boy of 5 years. case report top ↑ a 5-year-old boy accompanied by his grandmother presented with the inability to walk for five months. on examination he was paraplegic with bedsores, increased tone, brisk reflex and clonus of the lower limbs. there were contractures of both ankles and he had no bladder or bowel control. blood count and chemistry were normal. a serology for amoeba and cysticercosis was done that suggested past exposure to entamoeba histolytica. echinococcus serology was not done.radiography of the chest did not reveal any abnormality. radiography of the thoracolumbar spine demonstrated a levoscoliosis with the apex at t7 and flattening of the pedicles from t5 to t7 suggestive of an intraspinal mass (figure 1). computed tomography (ct) of the same area showed a widened canal with a well circumscribed oval (dome-shaped) extradural cystic mass measuring 4.8 cm x 2 cm x 1.6 cm. the cyst extended through the left t6/7 intervertebral foramen (figure 2). there was pressure erosion of the left t6 transverse process and severe pressure effect and compression on the spinal cord with anterior displacement. a differential diagnosis of cystic neurofibroma and hydatid cyst was considered. the patient was referred for magnetic resonance imaging (mri), which confirmed an extradural lobulated cystic mass extending from t4 to t7 and extending through the left t6/7 widened neural foramen (figure 3). there was no peripheral rim enhancement on intravenous injection of gadolinium (figure 4). the lesion occupied the entire spinal canal with compression of the spinal cord from t4 to t8. a cystic mass was also demonstrated in segment 4 of the liver with similar signal intensity as the spinal lesion (figure 5). these features were highly suggestive of an echinococcus cyst, with differential diagnosis of cysticercosis, cystic neoplasm such as schwannoma, and arachnoid cyst. figure 1: anterior posterior view of the thoracolumbar spine shows levoscoliosis with apex at t7 and flattened pedicles from t5 to t7 in keeping with an intraspinal mass. figure 2: (a) ct scan of the thoracic spine sagittal view on bone window demonstrates a widened canal with oval-shaped extradural cystic mass; (b) axial ct scan soft tissue window demonstrates cystic mass extending through left t7/6 intervertebral foramen; (c) same level as (b), bone window demonstrates enlarged exit foramen at that level. figure 3: (a) axial mri showing t2 weighted image cyst (arrow) extending through exit foramen of t6–7; (b) sagittal t1 weighted mri image demonstrates the cyst to have dome-shaped ends (arrow) filling up the entire spinal canal with compression of cord from t4 to t7; (c) sagital t2 weighted mri image demonstrating cyst to be of high signal intensity with no solid components (arrow). figure 4: axial gadolinium-enhanced mri image does not demonstrate significant enhancement. figure 5: (a) and (b) sagittal t1 and t2 weighted mri images showing cystic lesion in segment 4 of the liver (arrows). the patient underwent surgery with laminectomy and removal of the cyst which contained clear contents. the surgical appearance was in keeping with that of a hydatid cyst. the cyst was removed and the specimen sent for histology, which revealed an open cyst with a relatively thin wall and a laminated appearance with dense eosinophilic granular debris on the surface, features highly suggestive of a hydatid cyst. discussion top ↑ hydatid disease is a rare infection caused by the larvae of taenia, echinococcus granulosus, and less commonly echinococcus multilocularis. according to islekel et al., cited by arif et al.,1 bone disease was first described by bidloo in 1708. the first description of spinal hydatid disease was made by churrier in 1807, and the first surgical intervention was reported by reydellet in 1819.1 , 2 hydatid disease of the spine affects the vertebral column in 0.2% – 1% of all patients.3 due to the rarity of its presentation, clinicians should include spinal hydatid disease in the differential list for cystic masses of the spine causing paralysis; otherwise this potentially curable disease may be missed, or a delay in diagnosis may occur, as did in our case. the disease presents with radiculopathy, myelopathy and local pain if the bone is destroyed, and signs of cord compression. in some patients the spinal hydatid cyst has the potential to grow to enormous size. it can clinically remain asymptomatic for years until it becomes large enough to produce symptoms. cyst rupture can lead to severe anaphylaxis and death.3,7 arif et al.,1 suslu et al.4 and benzagmout et al.5 cite braithwaite and lees’s classification of five types of spinal involvement in hydatid disease, of which the first three are rare: 1. primary intramedullary hydatid cyst 2. intradural extramedullary hydatid cyst 3. extradural intraspinal hydatid cyst 4. hydatid disease of the vertebrae 5. paravertebral hydatid disease. our case falls into the third category. spinal involvement is believed to occur through vertebral portovenous anastomosis.1,3,4,8 the hydatid cyst wall has three layers. the daughter cysts arise from the inner germinal layer; they eventually detach and float freely in the hydatid cyst fluid. the number of scolices increases within the daughter cysts, causing the cyst to enlarge. symptoms are usually caused by the mass effect of the cyst.1 radiological examinations may be helpful in diagnosis. plain x-rays may show peripherally calcified lesions in the liver, spleen and other organs.1 ct and mri are the investigations of choice. the radiographic findings may be similar to those indicating tumours and infection, which makes differential diagnosis difficult. mri is the best modality, as it shows the relationship to bony structures, the spinal cord and extension into soft tissues.2 , 6 , 8 the appearance of a hydatid cyst on mri is quite characteristic: dome-shaped ends, with no debris in the lumen.6 the contents of the cyst have signal intensity similar to cerebrospinal fluid: low on t1w and high on t2w. the wall is sharply defined and hypointense on t1w images, which may show mild enhancement with intravenous gadolinium.5,6 extradural cysts may spread through widened neural foramina into the muscle planes, as in our case. the invasive nature of the disease in the spine makes total removal and therefore permanent eradication difficult. a recurrence risk of 30% – 40% has been described.2 conclusion top ↑ hydatid disease should be included in the differential diagnosis in cases of cystic spinal cord masses causing paraplegia in endemic areas. our case demonstrates a liver and extradural lesion without involvement of the vertebral column, confirming that the disease most likely spread via the portovenous route. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions n.k. (kalafong hospital and university of pretoria) was the project leader, whilst i.v. (kalafong hospital and university of pretoria) did the literature search and editing. references top ↑ 1.arif sh, zaheer s. intradural extramedullary primary hydatid cyst of the spine in a child: a very rare presentation. eur spine j. 2009;18(suppl 2):179–182. http://dx.doi.org/10.1007/s00586-008-0777-8 2.sapkas gs, machinis tg, chloros gd, et al. spinal hydatid disease – a rare but existent pathological entity: case report and review of the literature. south med j. 2006;99(2):178–182. http://dx.doi.org/10.1097/01.smj.0000199747.81684.54 3.scarlata f, giordano s, saporito l, et al. cystic hydatidosis: a rare case of spine localization. infez med. 2011;1:39–41. 4.suslu ht, cecen a, karaaslan a, et al. primary spinal hydatid disease. turk neurosurg. 2009;19(2):186–188. 5.benzagmout m, kamaoui i, chakour k, et al. primary spinal epidural hydatid cyst with intrathoracic extension. neurosciences. 2009;14(1):81–83. 6.kahilogullari g, tuna h, aydin z, et al. primary intradural extramedullary hydatid cyst. am j med sci. 2005;329(4):202–204. http://dx.doi.org/10.1097/00000441-200504000-00006 7.bhake a, agrawal a. hydatid disease of the spine. j neurosci rural pract. 2010;1(2):61–62. 8.gunecs m, akdemir h, tugcu b, et al. multiple intradural spinal hydatid disease: a case report and review of literature. spine. 2009;34(9):346–350. http://dx.doi.org/10.1097/brs.0b013e3181a01b0f 03-04 3 sa journal of radiology • july 2005 editorial a new era at wits mala modi mb bch, fcrad (sa), mmed department of radiology chris hani baragwanath hospital university of the witwatersrand johannesburg when i was requested to do the editorial for this issue of sajr from the radiology department of the university of the witwatersrand, i was quite excited as it gave me the opportunity to be in ‘speakers corner, hyde park’ on a sunday morning (cold and wet of course) and to express my views freely on the many issues that plague, as well as the occasional issues that please. my congratulations to the gauteng department of health for finding the antidote to the y2k bug! johannesburg general, helen joseph and coronation hospitals all have new 16-slice ct scanners (chris hani baragwanath hospital has had two 4-slice ct scanners for the last few years), and 20 years after its inception the richest province in south africa is bringing mr imaging to the public sector. the johannesburg general has just had a state-of-the-art siemens mri installed, and at chris hani baragwanth we are getting a ge mri soon. this will undoubtedly have a profound impact on the affected radiology departments. the university of the witwatersrand’s academic hospitals can now get on board and join the 21st century. this has brought much-needed enthusiasm to our department. i fully understand the need to improve the services in outlying referral hospitals, however i do not think that the powers-that-be are looking at the bigger picture. it is well and good to have state-of-the-art equipment in outlying hospitals, but remember these hospitals are recruiting qualified staff from the academic circuits, and it makes little sense not to educate our staff on such equipment and then to send them out to work, often alone, on very sophisticated equipment that they are not at all familiar with! there is also a need to have some equity among all the academic hospitals, at least within a single circuit, in terms of staffing and financial remuneration. at present the bulk of the staffing, contract research, and private hospital facilities are still channelled to the previously advantaged hospitals. on a different note, the university of the witwatersrand, which is actively encouraging research and publications in an attempt to improve its academic profile, will no doubt benefit from the better equipment and recent increased demand for consultant posts in radiology. this should be a catalyst for research. i am already seeing an improvement in our department in terms of papers and mmed dissertations. it is a pity that all the articles submitted could not be printed in this issue of the journal due to insufficient sponsorship from our trade partners (which is rather disappointing). i believe they also have a responsibility to foster academia. the original article in this issue highlights the probems experienced approaching focal brain lesions (fbls) in hiv-positive patients. i am sure that the algorithm we propose will help clinicians and radiologists diagnose and manage fbls in hiv-positive patients collectively. the case reports describe common and not so common pathologies. my personal experience at chbh is that we do not see haemorrhage in intracranial tb 03-04 7/29/05 2:50 pm page 3 4 sa journal of radiology • july 2005 often, and as such the case of intracerebellar haemorrhage in association with tbm and tuberculomas was particularly interesting, made more so by the extensive histopathological findings. as radiologists we do need clinical backup and pathological confirmation, and this case as well as the case report on boop highlights that. although lemierre’s syndrome is relatively rare, following my receiving the article for review a similar case was seen at chbh. now that we will be getting our own mri scanner the case report on mesial temporal sclerosis is welcome. finally, a big thank you to all my colleagues who submitted articles to the sajr, good luck to those working on their mmeds, and best wishes to all as we tackle the ‘new’ language of mri. editorial mala modi guest editor 03-04 7/29/05 2:50 pm page 4 abstract curse of the chromosome: convulsions, cutaneous and cognitive clinical syndrome answer discussion conclusion acknowledgements references about the author(s) shalendra misser lake smit and partners inc., durban, south africa citation misser, s. answer and discussion paediatric neuroimaging quiz case. s afr j rad. 2016;20(1); a999. http://dx.doi.org/10.4102/sajr.v20i1.999 quiz case answer and discussion paediatric neuroimaging quiz case shalendra misser received: 10 mar. 2016; accepted: 14 apr. 2016; published: 30 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract a three-and-a-half-year-old male child was referred for neuroimaging under general anaesthesia for intractable seizures. a final diagnosis of probable tuberous sclerosis with associated left hippocampal sclerosis was made. differential diagnosis of malformation of cortical development with hippocampal sclerosis (type 3a) was considered with respect to the left temporal lobe abnormality. it is heartening to note that several good submissions were received for the paediatric quiz case. noteworthy responses were received from dr samuel mannikam, dr thandi buthelezi, dr philip janse van rensburg and dr ian haynes, however, the prize of r2000 was awarded to dr richard busayo ulatunji for the most inclusive answer. curse of the chromosome: convulsions, cutaneous and cognitive clinical syndrome a three-and-a-half-year-old male child was referred for neuroimaging under general anaesthesia for intractable seizures. figures 1, 2, 3, 4, 5 and 6 are the selected mr images. figure 1: axial t2-weighted mr image. figure 2: axial flair mr image. figure 3: coronal flair mr image. figure 4: coronal t1-inversion recovery mr image. figure 5: coronal t1-weighted mr image. figure 6: coronal t1 inversion recovery mr image. answer the child referred for imaging in this case was significantly debilitated by the intractable seizures he suffered. the convulsions were predominantly tonic-clonic in nature, while some were focal with secondary generalisation. we were fortunate to obtain a good quality mri study under general anaesthesia in a seizure-free interval. the axial t2-weighted image (figure 1) shows left frontal cortical swelling with hyperintensity due to hamartomatous cortical-subcortical tubers. one tuber is also noted at the postero-superior right parietal lobe in the angular gyrus. figure 2 is an axial flair sequence image demonstrating numerous transmantle radial migration lines as hyperintense bands. these lines traverse the white matter from the ventricular ependymal surface to the subcortical white matter. one such band in the right frontal lobe is associated with a cortical–subcortical tuber as are two further bands in the postero–inferior parietal lobes on both sides. there are several abnormalities depicted in figure 3 which is a coronal flair sequence image. firstly, there are several subtle hyperintense cortical hamartomas. one of these at the left temporal lobe is contiguous with a transmantle radial band which extends up to a hyperintense left hippocampal formation. the margins of the hippocampus are indistinct and the appearance may be due to recurrent seizure activity or concomitant mesial temporal sclerosis. also noted are several subependymal nodular foci probably representing subependymal tubers. these are of higher signal when compared to the cerebral cortex and are therefore unlikely to represent nodular heterotopia. figures 4 and 6 are coronal t1inversion recovery sequence images and figure 5 is a coronal t1-weighted image – all three confirming that the subependymal nodules are probably tubers. also further delineating the cortical-subcortical hamartomas, left hippocampal signal abnormality and adjacent transmantle left temporal lobe band. magnetic resonance angiogram (mra) was performed to ensure that the circle of willis (figure 7) was intact with no evidence of vasculopathy, particularly childhood vasculitis or transient cerebral arteriopathy. the mra was normal, and importantly no aneurysms were noted. figure 7: mr angiography image of the circle of willis. a final diagnosis of probable tuberous sclerosis (ts) with associated left hippocampal sclerosis was made. differential diagnosis of malformation of cortical development (mcd) with hippocampal sclerosis (type 3a) was considered with respect to the left temporal lobe abnormality. discussion ts is a neurocutaneous syndrome with protean manifestations involving several organ systems. ts is the second most common neurocutaneous syndrome after neurofibromatosis type 1 and has been documented since the late 1800s. also known as bourneville disease or ts complex, this disease has a variable prevalence according to sampled population groups from 1:6000 to 1:12 000.1 there is no gender predilection. sporadic cases are reported to occur in up to 70% of patients while autosomal dominant inheritance is noted in 30%. the underlying pathophysiology is thought to be due to a genetic predisposition with two major genes that interplay in a series of complex relationships. tsc1 gene located on chromosome band 9q34, which codes for the protein hamartin, and tsc2 gene located on chromosome band 16p13.3, which codes for the protein tuberin, are tumour suppressor genes. failure of the tsc1–tsc2 protein complex, due to inactivation of the genes, results in upregulation of the mammalian target of rapamycin (mtor) pathway. this leads to the phenotypic abnormalities predominantly of benign tumours of embryonic ectodermal origin. the classically described vogt triad, comprising adenoma sebaceum/skin lesions, seizures and mental retardation is only encountered in a third of patients. radiological investigations demonstrate valuable supplementary features, particularly intracranial manifestations, that aid in making a diagnosis. table 1 outlines the major and minor features encountered in ts.2 table 1: typical major and minor features of tuberous sclerosis. the neurocognitive morbidity associated with ts accounts for the clinical presentation in a large number of patients. approximately 90% of patients present with seizures. autism spectrum disorder and intellectual disability are the other frequent neurological sequelae of ts. table 2 describes the clinical syndromes associated with neurological manifestations of ts including three of which are major criteria for the diagnosis. these lesions have been extrapolated to the schematic drawing in figure 8. table 2: common neurologic features of tuberous sclerosis. figure 8: schematic drawing depicting the location of the most common neuroimaging features of tuberous sclerosis. cortical tubers are hamartomas comprising glial, neuronal elements as well as giant cells with abnormal lamination of the cortex. loss of grey–white matter differentiation and bulging of the cortex may be noted. gallagher et al.3 described three subtypes of tubers with variable mri appearance associated with different phenotypic and/or clinical presentations as annotated in table 3. in neonates, the hamartomatous tubers may be undetectable on t2-weighted sequences due to similar relaxation time to premyelinated cerebrum and may only be seen on t1-weighted imaging.4 contrast enhancement, calcification and central cystic degeneration are infrequent features. greater tuber load is associated with greater neurological fallout and poorer seizure control. diffusion tensor imaging (dti) of tubers shows lesions with reduced fractional anisotropy (fa) and increased mean diffusivity (md).5 table 3: tuber subtypes based on mri features in tuberous sclerosis and associated phenotypic presentation. subependymal nodules (sens) are also hamartomatous in nature with a large proportion showing early calcification. these lesions are easily demonstrated on non-contrast ct scans or susceptibility-weighted imaging (swi) or gradient echo sequences. see figure 9, subtly showing the calcified sens on a gradient echo sequence and figure 10 demonstrating many more well-delineated calcified sens in the patient reported here. subependymal giant cell tumours or astrocytomas (segas) are typically larger than sens and occur particularly at the foramen of monro or the caudothalamic groove region. these are who grade 1 tumours with slow progression, lack of local invasion, absence of surrounding oedema or cerebrospinal fluid (csf) tumour seeding. mtor pathway inhibitor everolimus is an approved therapeutic agent for non-surgical management segas. figure 9: gradient echo sequence image showing multiple subtle calcified subependymal nodules. figure 10: susceptibility-weighted imaging sequence images showing multiple and more obvious calcified subependymal nodules (a, b and c). griffiths et al.6 described a spectrum of four types of white matter lesions found at mri in ts complex. the commonest was spongiosis and hypomyelination related to cortical tubers. transmantle bands or radial lines were less frequently identified in relation to cortical tubers, and these are probably heterotopic glia and neurons along the expected path of cortical migration. this glial scaffolding forms the basis of neuronal migration from the periventricular germinal matrix zone to the subcortical region and the eventual establishment of the six-layered cerebral cortex. in a child, these radial bands appear hyperintense on t1-weighted and isoor hypointense on t2-weighted sequences relative to premyelinated white matter. in a minority of cases, these lesions are reported to show mild post-gadolinium enhancement.7 dti values are noted to be abnormal in radial migration lines correlating with the histological findings of clusters of giant cells of varying degrees of differentiation.8 ts is therefore the upshot of a dysgenetic event that occurs early in development with resultant variable cellular differentiation and hamartoma formation. dti of white matter lesions has been listed as a biomarker for ts and for prognostication. other white matter lesions described include white matter cysts and infarcts. cyst-like white matter lesions described by van tassel et al. are typically located close to the lateral ventricles.9 these lesions are probably dilated perivascular spaces or they reflect areas of cystic degeneration related to focal gliosis or spongiosis. on all sequences, these white matter cystic foci remain iso-intense to csf. infarcts may be attributed to embolic aetiology or may be related to underlying vascular dysplasias that predispose to vascular occlusion. rarely, moyamoya phenomenon or aneurysm rupture may be implicated in causing cerebral infarcts.6 beltramello et al.10 recommended in 1999 that vascular dysplasias including intracranial aneurysms encountered in patients with ts be added to the other non-primary diagnostic features for the clinical diagnosis of ts. conclusion the coexistence of ts lesions and hippocampal sclerosis is an enigmatic phenomenon. it is not a frequently reported correlate. there are several theories to explain this occurrence. in the presence of an adjacent cortical lesion and white matter abnormality, hippocampal sclerosis may be a consequence of seizure activity induced by the tuber or mcd. this subtype of mcd has been classified according to blümcke et al.11 as type 3a (figure 11). a further explanation for the coexistence of hippocampal sclerosis with adjacent cerebral cortical or subcortical lesions is the probability of a common pathogenetic mechanism that can be traced back along the path of neuronal migration.12 figure 11: classification of focal cortical dysplasia (fcd). acknowledgements competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references leung ak, robson wl. tuberous sclerosis complex: a review. j pediatr health care. 2007;21:108–114. http://dx.doi.org/10.1016/j.pedhc.2006.05.004 roach es, gomez mr, northrup h. tuberous sclerosis complex consensus conference: revised clinical diagnostic criteria. j child neurol. 1998;13:624–628. http://dx.doi.org/10.1177/088307389801301206 gallagher a, grant ep, madan n, jarrett dy, lyczkowski da, thiele ea. mri findings reveal three different types of tubers in patients with tuberous sclerosis complex. j neurol. 2010;257(8):1373–1381. http://dx.doi.org/10.1007/s00415-010-5535-2 baron y, barkovich aj. mr imaging of tuberous sclerosis in neonates and young infants. ajnr am j neuroradiol. 1999;20:907–916. peters jm, taquet m, prohl ak, et al. diffusion tensor imaging and related techniques in tuberous sclerosis complex: review and future directions. future neurol. 2013;8(5):583–597. http://dx.doi.org/10.2217/fnl.13.37 griffiths pd, bolton p, verity c. white matter abnormalities in tuberous sclerosis complex. acta radiol. 1998;39:482–486. http://dx.doi.org/10.1080/02841859809172211 bernauer ta. the radial bands sign. radiology. 1999;212(3):761–762. http://dx.doi.org/10.1148/radiology.212.3.r99se17761 caruso p. the neuroanatomical phenotype of tuberous sclerosis complex: focus on radial migration lines. neuroradiology. 2013;55(8):1007–1014. http://dx/doi.org/10.1007/s00234-013-1184-3 van tassel p, cure jk, holden kr. cystlike white matter lesions in tuberous sclerosis. ajnr am j neuroradiol. 1997;18:1367–1373. beltramello a, puppini g, bricolo a, et al. does tuberous sclerosis complex include intracranial aneurysms? a case report and review of the literature. pediatr radiol. 1999;29:206–211. http://dx.doi.org/10.1007/s002470050573 blümcke i, thom m, aronica e, et al. the clinicopathologic spectrum of focal cortical dysplasias: a consensus classification proposed by an ad hoc task force of the ilae diagnostic methods commission. epilepsia. 2011;52(1):158–174. http://dx.doi.org/10.1111/j.1528-1167.2010.02777.x kier el, kim jh, fulbright rk, bronen ra. embryology of the human fetal hippocampus: mr imaging, anatomy, and histology. ajnr am j neuroradiol 1997;18:525–532. article information authors: tracy kilborn1 halvani moodley1 anita brink1 peter nourse1 affiliations: 1red cross war memorial children’s hospital, cape town, south africa correspondence to: tracy kilborn email: tracykilborn@gmail.com postal address: red cross war memorial children’s hospital, klipfontein road, rondebosch, cape town 7700, south africa dates: received: 01 june 2015 accepted: 07 oct. 2015 published: 18 dec. 2015 how to cite this article: kilborn t. a case-based approach to uti imaging – making sense of the guidelines. s afr j rad. 2015;19(2): art. #877, 7 pages. http://dx.doi.org/10.4102/sajr.v19i2.877 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a case-based approach to uti imaging – making sense of the guidelines in this clinical perspective... open access • abstract • introduction • case-based approach to uti    • case 1    • ultrasound    • case 2       • one-week-old boy with a uti    • case 3       • eighteen-month-old with uti    • micturating cystourethrogram (mcug)    • case 4       • one-year-old with uti    • case 5       • six-month-old boy with uti    • case 6       • ten-year-old with bilateral hydronephrosis and recurrent utis    • case 7       • three-year-old with recurrent utis and normal ultrasound study (not shown)    • nuclear medicine in the investigation of uti       • 99mtc-mag3 versus 99mtc-dmsa    • radionuclide cystography (rnc) • emerging techniques    • contrast-enhanced voiding ultrasonography (cevus)    • three-dimensional ultrasound (3d us)    • mri • conclusion • competing interests • authors’ contributions • references abstract top ↑ urinary tract infections (utis) are common amongst children and invariably result in imaging tests to look for correctable causes that may predispose the child to infection. the objective of imaging is to identify those children at risk of long-term renal damage. the ideal imaging algorithm is extensively debated in the literature owing to the lack of evidence-based data, evolving theories on the pathophysiology of uti and vesicoureteric reflux (vur). the present article provides a case-based approach to the imaging of utis and proposes guidelines relevant to the south african setting. introduction top ↑ approximately 7%–8% of girls and 2% of boys have a urinary tract infection (uti) within the first 8 years of life, with the highest incidence within the first year in both sexes.1 historic management of uti has been based on the premise that recurrent utis, particularly with vesicoureteric reflux (vur), increase the risk of chronic kidney disease, hypertension and ultimately end-stage renal disease. guidelines therefore focus on aggressive treatment and extensive imaging studies to detect obstructive malformations, vur and renal scarring.2,3 the national institute for health and clinical excellence (nice) altered guidelines in the uk in 2007 and the aap (american academy of pediatrics) in 2011, both of which recommended radically reducing the use of imaging, particularly fluoroscopy and nuclear medicine, in the setting of a first typical uti.4,5 nice in addition no longer recommends any imaging in a first uti unless atypical (non-escherichia coli organism, poor urine flow, abdominal mass, septicaemia, raised serum creatinine or failure to respond to antibiotics).6 the less aggressive approaches are finding favour as it is recognised that medical radiation exposure is not without risks and because of the uncertainty of benefits to the patient of identifying low-grade reflux and minor parenchymal scars.2 the actual relationship between vur and renal scarring is poorly understood. some relationship does exist; however, one does not require reflux to develop a scar nor does one always develop scarring with a reflux-related uti.7,8 in some cases, renal damage previously attributed to acquired scarring post pyelonephritis or vur is now recognised as being more likely the sequela of renal dysplasia.3,9 also, a child with structurally normal kidneys is not at significant risk of developing chronic kidney disease because of utis.9 another risk factor for scarring that receives less attention in the radiology literature is the presence of bladder and bowel dysfunction known as dysfunctional elimination (de). the propensity for scarring is diminished when de is effectively treated; therefore, regardless of the type of radiographic evaluation, the most important intervention may be to identify those children with de and treat it.7 figure 1: suggested algorithm for management of paediatric uti. case-based approach to uti top ↑ case 1 we recommend in our setting that all children presenting with a uti undergo ultrasound. document renal length supine (figure 2a) and/or prone (figure 2b), and a look at vascularity (figure 2c). kidney sizes must be compared with age-related normal values at the time of scanning and these same norms should be used at follow-up. the anteroposterior diameter of the renal pelvis should always be measured at the hilum on the transverse view (figure 2d; arrow). if normal (as in this case) and a first-time uti, the patient would require no further imaging. ultrasound ultrasound should remain part of the evaluation of first-time uti as it provides a gross anatomic evaluation that is non-invasive and does not use ionising radiation. it can assist in depicting structural and positional anomalies, differential renal size, hydronephrosis, dilated ureters and bladder abnormalities.10 despite the aap stating that the diagnostic yield from ultrasound is low, as only 1%–2% of children will have actionable findings, it remains relevant in the south african setting.4 with poor access to antenatal scanning, abnormalities that would normally be identified (posterior urethral valve, pelviureteric junction obstruction and severe vur) may present postnatally with a uti. ultrasound is limited by its inability to provide a quantitative assessment of renal function, has a sensitivity and specificity of 40% and 76% respectively for vur, and is poor at demonstrating renal scars.9 box 1: what needs to be documented on a sonogram11 although widely available, the quality of the study is dependent on the skill of the technician, and therefore strict guidelines should be followed with regards to technique, particularly in paediatric patients.11 despite the limitations, it is often comforting to the family and referring clinician to have a safe, non-invasive examination that grossly reveals the condition of the kidneys. case 2 one-week-old boy with a uti figure 2: ultrasound images referred to in the text. case 3 eighteen-month-old with uti figure 3: one-week-old male infant with uti. longitudinal ultrasound (a) shows dilated renal pelvis (white arrow) and a dilated ureter (black arrow). longitudinal (b) and transverse(c) views of the bladder show wall thickening and a distended posterior urethra (white arrows). (d) the marked bladder thickening (white line) is better demonstrated on this transverse image post micturition. these findings suggest a posterior urethral valve and the patient requires an mcug. (e) frame grab image from mcug confirms dilated posterior urethra (white arrow) and bilateral grade 5 vur (black arrows). mcug, micturating cystourethrogram; vur, vesicoureteric reflux. micturating cystourethrogram (mcug) as a result of the controversy surrounding reflux and the attempt to limit exposure to ionising radiation, most of the discussion around uti imaging has centred on the rationalised use of this test. using modern grid-controlled variable rate pulsed fluoroscopy with last-frame grab reduces the dose to an eighth when compared with continuous screening. nevertheless, the effective dose still remains higher than radionuclide cystography.10,12 mcug should only be performed in the setting of an abnormal ultrasound (calyceal, pelvic and ureteric dilatation or scarring) to look for vur in children under the age of 2 years. mcug requires catheterisation that may be distressing for the patient and the parent. the advantages are the standardised international grading system for vur and anatomical detail, particularly visualisation of the urethra in boys.10 box 2: how to perform a mcug13,14 case 4 one-year-old with uti figure 4: longitudinal ultrasound of the kidney (a) and ureter (b) shows dilated pelvicalyceal system and ureter containing debris in a child under 2 years with dilatation of the pelvicalyceal system and ureter, mcug is indicated. frame grab image (4c) from mcug confirming bilateral vur (white arrows). case 5 six-month-old boy with uti figure 5: longitudinal ultrasound (a) of the bladder shows dilated distal ureter and ureterocoele. frame grab image (b) of early filling view on mcug shows bilateral ureterocoeles (white arrows). note how these are obscured in the full bladder view of the same patient (c). case 6 ten-year-old with bilateral hydronephrosis and recurrent utis figure 6: longitudinal view (a) of the kidney shows hydronephrosis and dilated calyces. transverse view (b) demonstrates where to measure the renal pelvis. no dilatation of the mid or distal ureter was seen (the proximal ureter may be seen in a puj obstruction but not the mid or distal ureter) and the bladder was normal. the patient has features of a pelviureteric junction obstruction and requires a 99mtc mag3 study. summated images (c) from the 99mtc mag3 study show a normal left kidney – the corresponding renogram/activity curve (red) rises until 20 minutes with a normal decrease in amplitude after furosemide administration. the right kidney (outlined in green) appears larger than the left, with a photopaenic area in the region of the pelvis. the corresponding activity curve (green) rises for the duration of the study with no response to furosemide. these findings confirm pelviureteric junction obstruction of the right kidney. case 7 three-year-old with recurrent utis and normal ultrasound study (not shown) figure 7: longitudinal ultrasound image (a) demonstrates hydronephrosis. 99mtc mag3 indirect cystogram (b) demonstrates vur into the left kidney from frames 7–9. the increase in activity in the left kidney is best appreciated when comparing frames 4–6 with frames 19–21. nuclear medicine in the investigation of uti 99mtc-mag3 versus 99mtc-dmsa technetium-99m dimercaptosuccinic acid (99mtc dmsa) is actively taken up by the proximal renal tubules and is regarded as the gold standard for the assessment of cortical defects. the long residence time of 99mdmsa within the cortex leading to high radiation doses to paediatric patients has been a cause of concern.16 figure 8: the 99mtc mag3 indirect cystogram demonstrates left vur from frames 55–56 onwards. technetium-99m mercaptoacetyltriglycine (99mtc mag3) is a renal tubular agent. it provides information about cortical uptake, transit and drainage of tracer from each kidney.17 the tracer is rapidly excreted, and therefore there is a significant reduction in radiation dose (0.3 msv for mag3 as opposed to 1 msv for dmsa).17 99mtc-mag3 is mainly used to evaluate hydronephrosis and renal drainage. evaluation of the 1–2 minute image also allows the detection of cortical defects. studies have shown that clear cortical defects seen on 99mtc dmsa were also detected on 99mtc mag3 with sensitivity and specificity recorded as 88%–89% and 88%–100% respectively.16,17,18 we therefore recommend 99mtc-mag3 in children as it provides adequate estimation of the renal function, can evaluate for scars, provide information on drainage and be used to evaluate vur in older children. radionuclide cystography (rnc) in children who are toilet trained and have normal renal function, the indirect radionuclide cystography is an elegant investigation. at the end of a normal 99mtc mag3 renogram, most of the injected activity is in the bladder, and the activity from the kidneys has cleared. the child then voids in front of an upright camera, and vur and bladder emptying can be evaluated. the advantage is that bladder catheterisation is not required and the radiation dose is less than that of an mcug. in addition, the preceding renogram provides additional information about renal function and cortical defects.10 the disadvantage is reduced anatomic resolution and no imaging of the urethra.19 a rnc study should be considered in girls as urethral pathology is less common, in boys older than 2 years in whom posterior urethral valves are not suspected, and in follow-up studies assessing for resolution of vur. direct rnc requires urethral catheterisation and direct installation of tracer. it is more sensitive than mcug in detecting reflux at a reduced dose; however, it is not widely used as it lacks high spatial resolution and does not have the advantage of the functional assessment provided by the indirect study.20 emerging techniques top ↑ contrast-enhanced voiding ultrasonography (cevus) sonographic assessment for vur using installation of an intravesical contrast agent via catheter has gained popularity over the last decade, given the possibility of avoiding radiation. sensitivity and specificity for the detection of reflux are reported as 90% and 92% respectively.21 there are still a number of limitations that restrict its widespread use: the availability of the contrast agent and contrast modality scan mode on the machine; the cost is significantly higher than that of an mcug or rnc; the procedure is long, lacks standardisation and depends on the experience of the operator19,20; and it also still requires catheterisation of the bladder. the inadequate assessment of bladder morphology and lack of a panoramic view of the urinary tract are also reported to be disadvantageous.18 urethrosonography during vus has been reported but it is not widely practiced and urethral imaging is still largely done via mcug.19,22 three-dimensional ultrasound (3d us) 3d us improves the calculation of renal parenchymal volume and is particularly useful in irregularly shaped or hydronephrotic kidneys as the collecting system can be subtracted from the trace of the renal parenchymal volume. the rendered view gives images comparable to those of ivu and mru.23 3d ultrasound-based cystoscopy allows visualisation of the internal surface of the bladder.24 mri functional mr urography (mru) is widely used in evaluation of the anatomy of the paediatric urinary tract. dynamic contrast-enhanced mru can provide functional evaluation of renal uptake, excretion and drainage.10 the spatial and contrast resolution have shown promise in differentiating between acquired renal damage and renal dysplasia.7 interactive mri for vur (imrvc) shows promise, providing results comparable to mcug.25 the benefits of mri and the lack of radiation remain offset by the sedation needed for the lengthy examinations, the cost of the procedure and lack of access to the study by the vast majority of patients undergoing investigation for uti. conclusion top ↑ imaging of paediatric uti is complex and controversial with no universally accepted protocol. we have attempted to provide an approach relevant to our setting whilst taking into account the evolution in guidelines that seek to limit unnecessary intervention and minimise radiation exposure. competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article. authors’ contributions t.k. (red cross war memorial children’s hospital) was responsible for the literature search. document construction. figure editing. h.m. (red cross war memorial children’s hospital) – image collection. schematics. document editing. a.b. (red cross war memorial children’s hospital) – image collection. text editing. fact checking. p.n. (red cross war memorial children’s hospital) literature review. text editing. fact checking. references top ↑ montini g, tullus k, hewitt i. febrile urinary tract infections in children. n engl j med. 2011;365:239–250. pmid: 21774712, http://dx.doi.org/10.1056/nejmra1007755 paintsil e. update on recent guidelines for the management of urinary tract infections in children: the shifting paradigm. curr opin pediatr. 2013;25:88–94. pmid: 23241875, http://dx.doi.org/10.1097/mop.0b013e32835c14cc la scola c, de mutiis c, hewitt ik, et al. different guidelines for imaging after first uti in febrile infants: yield, cost and radiation. pediatrics. 2013;131:665–671. pmid: 23439905, http://dx.doi.org/10.1542/peds.2012-0164 tullus k. what do the latest guidelines tell us about utis in children under 2 years of age. pediatr nephrol. 2012;27:509–511. pmid: 22203365, http://dx.doi.org/10.1007/s00467-011-2077-5 roberts kb. revised aap guideline on uti in febrile infants and young children. am fam physician. 2012;86:940–947. pmid: 23157147. urinary tract infection in children: diagnosis, treatment and long-term management. nice clinical guideline 54. london: national institute for health and clinical excellence; 2007. c2007 [cited 2015 apr 20]. available from: http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf prasad mm, cheng ey. radiographic evaluation of children with febrile urinary tract infection: bottom-up, top-down, or none of the above? adv urol. 2012; article id 716739, 8 pages. http://dx.doi.org/10.1155/2012/716739 moorthy i, easty m, mchugh k, ridout d, biassoni l, gordon i. the presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. arch dis child. 2005;90:733–736. http://dx.doi.org/10.1136/adc.2004.057604 salo j, ikaheimo r, tapiainen t, uhari m. childhood urinary tract infections as a cause of chronic kidney disease. pediatrics. 2011;128:840–847. http://dx.doi.org/10.1542/peds.2010-3520 lim r. vesicoureteral reflux and urinary tract infection: evolving practices and current controversies in pediatric imaging ajr am j roentgenol. 2009;192:1197–1208. pmid: 19380542, http://dx.doi.org/10.2214/ajr.08.2187 govender n, andronikou s, goodier md. adequacy of pediatric renal tract ultrasound requests and reports in a general radiology department. pediatr radiol. 2012;42:188–195. pmid: 21997513, http://dx.doi.org/10.1007/s00247-011-2259-0 ward vl, strauss kj, barnewoldt ce, et al. pediatric radiation exposure and effective dose reduction during voiding cystourethrography. radiology. 2008;249:1002–1009. pmid: 18941159, http://dx.doi.org/10.1148/radiol.2492062066 agrawalla s, pearce r, goodman tr. how to perform the perfect voiding cystourethrogram. pediatr radiol. 2004;34:114–119. pmid: 14564427, http://dx.doi.org/10.1007/s00247-003-1073-8 goodman tr, kilborn t, pearce r. warm or cold contrast medium in the micturating cystourethrogram (mcug): which is best? clin radiol. 2003;58:551–554. pmid: 12834639, http://dx.doi.org/10.1016/s0009-9260(03)00161-2 zerin jm, chen e, ritchey ml, bloom da. bladder capacity as measured at voiding cystourethrography in children: relationship to toilet training and frequency of micturition. radiology. 1993;186:803–806. pmid: 8497634, http://dx.doi.org/10.1148/radiology.187.3.8497634 othman s, al-hawas a, al-maqtari r. renal cortical imaging in children: 99mtc mag3 versus 99m tc dmsa. clin nucl med. 2012;37:351–355. pmid: 22391703, http://dx.doi.org/10.1097/rlu.0b013e3182443f68 ritchie g, wilkinson ag, prescott rj. comparison of differential renal function using technetium-99m mercaptoacetyltriglycine (mag3) and technetium-99m dimercaptosuccinic acid (dmsa) renography in a pediatric population. pediatr radiol. 2008;38:857–862. pmid: 18551288, http://dx.doi.org/10.1007/s00247-008-0908-8 smokvina a, grbac-ivanković s, girotto n, dežulović ms, saina g, barković mm. the renal parenchyma evaluation: mag3 vs. dmsa. coll antropol. 2005;29:649–654. pmid: 16417177. darge k. voiding urosonography with ultrasound contrast agents for the diagnosis of vesicoureteric reflux in children. comparison with radiological examinations. pediatr radiol. 2008;38:54–63. kis e, nyitrai a, varkonyi i, et al. voiding urosonography with second-generation contrast agent versus voiding cystourethrography. pediatr nephrol. 2010;25:2289–2293. pmid: 20686902, http://dx.doi.org/10.1007/s00467-010-1618-7 darge k, ceus task force of the society for pediatric radiology. contrast-enhanced us (ceus) in children: ready for prime time in the united states. pediatr radiol. 2011;41:1486–1488. pmid: 21938505, http://dx.doi.org/10.1007/s00247-011-2240-y duran c, valera a, alguersuari a, et al. voiding urosonography: the study of the urethra is no longer a limitation of the technique. pediatr radiol. 2009:39:124–131. pmid: 19002449, http://dx.doi.org/10.1007/s00247-008-1050-3 darge k, grattan-smith dj, riccabona m. pediatric uroradiology: state of the art. pediatr radiol. 2011;41:82–91. pmid: 20407766, http://dx.doi.org/10.1007/s00247-010-1644-4 riccabonna m, pilhatsch a, haberlik a, ring e. three-dimensional ultrasound-based virtual cystoscopy of the pediatric urinary bladder: a preliminary report on feasibility and potential value. j ultrasound med. 2008;27:1453–1459. pmid: 18809955. arthurs oj, edwards ad, joubert i, graves mj, set pa, lomas dj. interactive magnetic resonance imaging for paediatric vesicoureteric reflux (vur). eur j radiol. 2013;82:e112–e119. pmid: 23238363, http://dx.doi.org/10.1016/j.ejrad.2012.10.024 article information authors: tracy sharbaugh1 karen van zijl2 emily beauchemin3 catherine boland4 affiliations: 1boston children's hospital – massachusetts general hospital, united states of america 2organsation for paediatric support in south africa (opssa), south africa 3carolinas healthcare system – levine children's hospital, charlotte, united states of america 4global health sciences, university of california, united states of america correspondence to: tracy sharbaugh email: tracylsharbaugh@gmail.com postal address: 1333 via isidro oceanside, ca 92056, united states of america dates: received: 13 july 2015 accepted: 20 aug. 2015 published: 20 nov. 2015 how to cite this article: sharbaugh t, van zijl k, beauchemin e, boland c. paediatric radiology from a psychosocial lens. s afr j rad. 2015;19(2); art. #913, 3 pages. http://dx.doi.org/10.4102/sajr.v19i2.913 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. paediatric radiology from a psychosocial lens in this review article... open access • abstract • history and overview of the child life profession • significance of child life services and specific research in paediatric imaging • current status of child life in south africa • the future of child life in south africa • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ globally, hospitals and medical centres have a reputation of causing individual patients an increased level of anxiety, stress and pain owing to their foreign environments, intimidating examinations and rigorous treatments. because of children's cognitive and developmental levels of understanding and communication, they are more susceptible to increased levels of stress and trauma associated with medical examinations and hospitalisation. certified child life specialists (cclss) are professionals trained in child development and family systems expertise who work directly with children and families to meet their psychosocial and emotional needs in order to help them overcome some of life's most challenging events, including hospitalisation, illness and trauma. this article aims to address the history of the child life profession and the significance of child life in a paediatric imaging unit, and to discuss the current and future status of psychosocial services in south africa. history and overview of the child life profession top ↑ historically, in the first half of the twentieth century, infants and children who required medical interventions were placed in institutionalised medical settings and isolated from their caregivers and families. research on medical care during this time showed alarming rates of infant and toddler sensory deprivation, an absence of sufficient human contact resulting in increased levels of stress, and a disturbingly high rate of premature infant death.1 hospitalised children and adolescents face emotional disturbances including, but not limited to, post-traumatic stress, anxiety and depression.2,3,4 to address these issues and provide higher quality care for children facing chronic illnesses, hospitals employed teachers, play and recreational therapists, and other professionals to provide psychosocial and emotional support services. in 1965, a group of these teachers and therapists came together in massachusetts, united states of america (usa), to share stories of both triumph and hardship, forming a group that is known today as the child life council (clc).1,5 in 2006, the american academy of pediatrics (aap) stated that certified child life specialists (cclss) ’have become a standard in most large paediatric centers, and even on some smaller paediatric inpatient units’.1 even more notable is that the aap officially recognised child life professionals as members of the multidisciplinary team, integral to family-centred care and best-practice models.1,6 the mission of the clc in 1965 was to change the culture of medical environments to be more child and family-centred. today the mission stands to continue to enhance optimal patientand family-centred care through advocacy, education, play, assessment, intervention and policy building.1,7 the clc intends that all cclss should ‘strive to reduce the negative impact of stressful or traumatic life events and situations that affect the development, health and well-being of infants, children, youth and families by embracing the value of play as a healing modality’.1,7 significance of child life services and specific research in paediatric imaging top ↑ traditionally, child life services focused on providing support for inpatients; however, in recent years, ccls have adapted services to accommodate acute outpatient medical settings such as diagnostic imaging. patients, families and staff alike report that radiological procedures are especially challenging for paediatric patients because they often are invasive and require the child to be still for extended periods of time7 this results in heightened levels of anxiety and stress in both children and parents. often, medical professionals have to revert to sedation or forced restraint to complete basic radiological procedures. dean et al. reported that forcible interventions, such as restraint, implemented by medical personnel impair admission outcomes and the therapeutic relationship between the child and medical personnel.2 ccls, alongside the medical team, work to decrease this stress in children by assessing their developmental and cognitive understanding of procedures and then providing procedural preparation and medical play: techniques used to explain medical information to children using developmentally appropriate language.5,6,7 simultaneously, ccls work to increase coping by providing emotional support, distraction and relaxation techniques such as imaginary play, guided imagery, and progressive muscle relaxation. through these individually designed supportive services, children are more able to comply with examination requirements, complete clear diagnostic imaging and take an active role in their healthcare, whilst minimising potential trauma and stress.5,6,7 with healthcare costs rising globally, psychosocial services such as child life programmes have been targeted during budget cuts because they are traditionally viewed as non-revenue producing programmes. however, recent exploratory research has been conducted with initial results indicating that child life services reduce costs associated with imaging for patients and families. at children's national health system in washington, dc, usa, cclss employed in radiology departments designed and implemented ’mr-i can do it’, a programme aimed to reduce the rates of paediatric anaesthesia sedation for children 3–18 years old through child life preparation and emotional support. the programme reported that, whilst most adults perceive claustrophobia as the main stressor related to magnetic resonance imaging (mri) scanning, children like to hide in small spaces for fun (e.g. hide and seek). instead, children described the unfamiliarity of a new environment, large equipment and intensity of sounds as the most stress-inducing factors related to their mri. to minimise these fears, ccls created educational preparation material that is distributed online and by email to parents and children using real-life pictures and child-friendly language describing what the child would experience. the educational material also provides age-specific tips on ways for parents to best support their child before and during the scan. ccls used desensitisation techniques by instructing parents and children to pre-emptively play a game while listening to mp3 files of mri recordings, thus minimising the related anxiety and fears. statistical analysis of the mr-i can do it programme reported that, for 94% of children who participated in the programme, diagnostic quality mri images were successfully obtained at the first time without the use of sedation.8 no demographic variances including age, gender, type of study etc. were found to be statistically significant during the analysis. ensuing results also indicated that the programme reduced time for patients and families at hospital and increased overall patient satisfaction. current status of child life in south africa top ↑ medical care for children is a human right. south africa's population consists of more than 18.6 million children under the age of 18.9 despite research findings on the negative impact of illness, hospitalisation and stress in children, the level of psychosocial services available to patients in south africa is minimal. currently in south africa, it is rare for a hospital to render services such as play and expressive activities in support of normal development. barriers to providing psychosocial care include a lack of funding, resources, professional experience and training, and overall awareness regarding the need and value for psychosocial care.10 despite barriers and challenges, influential organisations and individuals are collaborating to make positive changes to enhance and optimise children's and families’ experiences with healthcare. psychosocial services are currently formally rendered in two hospitals in south africa: red cross war memorial children's hospital and the netcare unitas hospital. outside the hospital, psychosocial professionals provide support to children with health issues within private practice and community settings on a limited basis. non-profit organisations, such as childhood cancer foundation south africa (choc) and umduduzi – hospice care for children, employ social workers and auxiliary social workers who implement psychosocial services to paediatric haematology-oncology patients and palliative patients.10 these programmes both serve a minute percentage of the paediatric population in south africa; accordingly, the present paper aims to increase awareness of the importance of standardising psychosocial support in all medical institutions in south africa. the future of child life in south africa top ↑ with the aim of furthering paediatric psychosocial services in south africa, the organisation for paediatric support in south africa (opssa) hosted two one-day seminars in 2011 and 2014. additionally, opssa hosted the first international interdisciplinary academic conference in johannesburg in conjunction with netcare in 2013. in 2014, karen van zijl, president of opssa, became the first south african citizen to obtain her certification as a certified child life specialist. opssa is currently in discussion with tertiary institutions about the development of academic courses in paediatric psychosocial support with the support of clc in the usa. the future vision of child life and psychosocial services in south africa is to register child life workers with the health professions council of south africa (hpcsa). conclusion top ↑ programmes that foster psychosocial and emotional growth of paediatric patients build resiliency and increase patient coping skills, whilst decreasing the stress and trauma of the hospital setting. appropriate preparation and support for diagnostic testing decreases the need for sedation, reduces the recovery time of patients and families and increases overall patient satisfaction. globally, children deserve to be provided with psychosocial support during hospitalisation. south africa is an ideal country for continuing to implement these invaluable services. with the current initiatives taking place, south africa aims to continue to expand these psychosocial support services. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions t.s. (boston children's hospital – massachusetts general hospital) wrote ‘history and overview of the child life profession’ and ‘significance of child life services and specific research in paediatric imaging’. e.b. (carolinas healthcare system – levine children's hospital) contributed the ‘current status of child life in south africa and internationally; k.v.z. (organsation for paediatric support in south africa) contributed the ‘future of child life in south africa’; and c.b. (global health sciences) contributed to the document with inserted additions and edits throughout the article. all authors contributed to the comprehensive review and editing process of the document. references top ↑ child life council. overview of child life. 1998–2015. c2015 [cited 2015 june 1]. available from http://www.childlife.org dean aj, duke sg, scott j, bor w, george m, mcdermott bm. physical aggression during admission to a child and adolescent inpatient unit: predictors and impact on clinical outcomes. aust n z j psychiatry. 2008;42:536–543. pmid: 18465381, http://dx.doi.org/10.1080/00048670802050587 jansen gj, dassen twn, burgerhof jgm, middel b. psychiatric nurses’ attitudes toward inpatient aggression: preliminary report of the development of attitude towards aggression scale (atas). aggress behav. 2006;32:44–53. http://dx.doi.org/10.1002/ab.20106 mackenzie a. everybody stay calm. victoria: global publishing group; 2014. thompson rh, stanford g. child life in hospitals: theory and practice. springfield, il: charles c. thomas; 1981. brown c, chitkara mb. policy statement: child life services. paediatrics. 2014;1. thompson rh. the handbook of child life: a guide for pediatric psychosocial care. springfield, il: charles c. thomas; 2009. sze rw. the economic value of a child life program for non-sedated mr imaging. technical research report to the child life council. c2014 [cited 2015 june 26]. available from http://www.childlife.org/files/mr%20nonsedate%20tech%20report%20may%202014.pdf hall k, meintjes h. demography – children in south africa. children count: statistics on children in south africa. c2014 [cited 2015 june 28]. available from: http://www.childrencount.ci.org.za/indicator.php?id=1&indicator=1 child life council. international summit on pediatric psychosocial services: a global perspective on play and psychosocial care for children in hospitals; 2014 may 25–27; new orleans. article information authors: sourav talukder1 anindya bandyopadhay1 shamick biswas1 sumit chakraborty1 suchismita chakrabarti2 affiliations: 1institute of post-graduate medical education and research and seth sukhlal karnani memorial hospital (ipgme&r and sskm), india 2r.g. kar medical college and hospital, india correspondence to: sourav talukder email: talukdersourav@gmail.com postal address: bagbazar, nilkantha sarkar road bye lane (west), chandannagar, hooghly, west bengal, india dates: received: 02 june 2014 accepted: 09 oct. 2014 published: 11 dec. 2014 how to cite this article: talukder s, bandyopadhay a, biswas s, chakraborty s, chakrabarti s. imaging of compound palmar ganglion with pathologic correlation. s afr j rad. 2014;18(1); art. #654, 4 pages. http://dx.doi/org.10.4102/sajr.v18i1.654 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. imaging of compound palmar ganglion with pathologic correlation in this case report... open access • abstract • introduction • ethical considerations • case presentation • management and outcome • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ compound palmar ganglion, or chronic flexor tenosynovitis, most commonly of tuberculous origin, is a rare extrapulmonary manifestation of tuberculosis (tb). the flexor synovial sheath is not a common site for tb but, once involved, causes rapid involvement of all flexor tendons. we discuss the case of a 70-year-old farmer who presented to us with pain and progressive swelling of the palmar aspect of the wrist. on clinical examination, swelling both above and below the proximal wrist crease was found, with positive cross-fluctuation. on ultrasonography and magnetic resonance imaging, features suggestive of compound palmar ganglion were present. the patient underwent surgical resection (extensive tenosynovectomy) and chemotherapy. post-operative histopatholgical findings correlated with the radiological features. introduction top ↑ tuberculous chronic flexor tenosynovitis of the wrist is also termed compound palmar ganglion. although it is a rare extrapulmonary manifestation of tuberculosis (tb), it is not uncommon in a developing country such as india. the route of infection is either direct inoculation or haematogenous spread from a primary focus such as lungs, lymph nodes, kidney or spine. clinical diagnosis is often delayed owing to a wide range of differential diagnoses and poor clinical awareness. sensitive radiological investigations such as ultrasonography (us) and magnetic resonance imaging (mri) aid in the early diagnosis of, and treatment for, this locally destructive condition. ethical considerations top ↑ appropriate consent was taken from the patient for relevant investigations before surgery as per institutional protocol. case presentation top ↑ a 70-year-old man, a farmer by profession, presented with swelling in the volar aspect of his right wrist with associated dull aching pain for 6 months. tingling and numbness was present in the volar aspect of the wrist and the ring and little fingers. there was associated history of evening pyrexia and weight loss. on examination, an hour-glass swelling above and below the proximal palmar crease (figure 1), with a positive cross-fluctuation test, was noted. blood parameters were within normal limits except for a high erythrocyte sedimentation rate (esr) of 70 mm/hr in the first hour. figure 1: photograph of the patient's wrist demonstrates bilobed swelling both proximal (larger arrow) and distal (smaller arrow) to the proximal wrist crease. on chest radiography, no obvious abnormality was noted. the mantoux test was positive (induration of 15 mm). nerve conduction studies (ncs) revealed features suggestive of median nerve compression; there was increased distal motor latency (5.1 milliseconds) and distal sensory latency (4.2 milliseconds) of the median nerve with decreased median nerve conduction velocity (41 m/s). radiography of the hand and wrist revealed diffuse soft-tissue swelling without any osseous abnormality. us of the wrist revealed a heterogeneously hypoechoic bilobed mass (figure 2) containing both solid and cystic components in and around the flexor tendon sheaths, with involvement both above and below the flexor retinaculum. figure 2: ultrasonography demonstrates heterogenous solid-cystic lesion (larger arrow) in close proximity to the tendon sheath (smaller arrow). on power doppler study, there was no obvious increased vascularity. a 3-tesla mri scan confirmed the bilobed mixed solid-cystic nature of the lesion (figure 3). figure 3: coronal t2-weighted fat-suppressed image demonstrates a mixed signal intensity lesion containing solid-cystic components (larger arrow) encasing the flexor tendon sheaths (smaller arrow) both above and below the flexor retinaculum. the solid component of the lesion was hypointense on t1-weighted images (figure 4) and isoto hypointense on t2-weighted and 3d fast gradient refocussed echo (3dfgre) imaging. figure 4: coronal t1-weighted image demonstrates an isoto hypointense lesion (arrow). the synovial fluid was hypointense on t1-weighted, and hyperintense on t2-weighted and 3dfgre sequences. on postcontrast study, there was irregular rim enhancement of the lesion (figure 5). a provisional diagnosis of compound palmar ganglion was made, based on the radiological findings. figure 5: postcontrast axial t1-weighted image reveals peripheral rim-like contrast enhancement (arrow). management and outcome top ↑ the patient subsequently underwent surgery; the lesion was completely excised along with the involved tendon sheaths. intra-operative findings revealed characteristic melon seed bodies. a sample was sent for histopathological and polymerase chain reaction (pcr) examination. the histopathology of the resected specimen revealed granulomatous inflammation with central caseous necrosis, surrounded by epithelioid cells and multiple giant cells (figure 6). pcr was positive for mycobacterium tuberculosis. the patient received a full course of antituberculous chemotherapy. to date, he remains asymptomatic without any further recurrence. figure 6: histological specimen reveals a large granuloma of epithelioid cells (arrow) (haematoxylin-eosin, 600x). discussion top ↑ compound palmar ganglion affects the radial and ulnar bursae. the radial bursa is the synovial sheath that surrounds the tendon of the flexor pollicis longus in its course through the carpal tunnel. it arises 2.5 cm proximal to the flexor retinaculum and continues to form the digital sheath of the thumb. the ulnar bursa includes the little finger tendon sheath which begins at the terminal phalanx and extends proximally halfway up the palm, where it envelops the superficial and deep tendons of the third, fourth and fifth fingers. in 80% of cases, the ulnar bursa communicates with the radial bursa, which accounts for horseshoe-shaped tenosynovitis that simultaneously affects both the bursae.1 tb is widespread in india, affecting various organ systems in people. the most commonly affected extrapulmonary sites are the lymph nodes, genito-urinary tract, bone marrow, central nervous system and musculoskeletal system, which include bones, joints, bursae, tendons and tenosynovium. infection of the wrist and hand, however, is quite rare, and diagnosis and treatment of this clinical entity is usually delayed; but early diagnosis and treatment is most important, as the lesion is destructive. pathogenesis of the condition is either direct inoculation or haematogenous spread from a distant focus in the lung, lymph nodes, genito-urinary tract or bones. the lesion has a gradual onset and progresses slowly, so patients usually present at a fairly advanced stage. severe swelling may compress the median nerve, resulting in neurological symptoms. laboratory investigations are mostly normal except for a raised esr and strongly positive mantoux test. the chest radiograph is mostly unremarkable. ncs and electromyography (emg) may reveal features of median nerve compression, if present. ncs reveal delayed distal latencies and slowed conduction velocities as a result of damage to the myelin sheath owing to nerve compression. with sustained or more severe compression, axonal loss may also occur, resulting in a reduction of the median nerve compound motor or sensory action potential amplitude. emg may reveal evidence of pathological changes in muscles innervated by the median nerve, by demonstrating either active denervation (e.g. spontaneous activity such as fibrillation potentials, positive sharp waves and fasciculation potentials) or chronic changes that indicate denervation with subsequent reinnervation (e.g. changes in the motor unit action potential amplitudes, durations and recruitment). radiological modalities play a pivotal role in the diagnosis of compound palmar ganglion. plain radiography may demonstrate soft-tissue opacity and evidence of bone destruction. computed tomography (ct) can show bone destruction and simultaneously demonstrate the solid-cystic nature of the lesion. b-mode us is a very useful tool to visualise, in real time, the proximal and distal extent of the lesion, and its contents and relation to the flexor tendon sheath. usually, heterogenous solid-cystic components are noted in and around the flexor pollicis longus, flexor digitorum superficialis and flexor digitorum profundus tendons, both proximal and distal to the flexor retinaculum. mri, by virtue of its excellent soft-tissue delineation, is the best imaging modality in this context. preand postcontrast t1, t2 and 3dfgre sequences in both the axial and coronal planes are commonly used. as the lesion is predominantly fluid-containing with thickened synovium and tenosynovium, it is hypointense on t1w1; on t2wi, the fluid component is hyperintense and the thickened synovium and tenosynovium appear hypointense. t2*-weighted images also reveal the fluid component to be hyperintense and the solid component to be hypointense. 3, 4 on postcontrast studies, there is usually rim enhancement of the lesion. histopathological testing of the specimen reveals the granulomatous nature of the lesion. there are three histological forms of tuberculous tenosynovitis as a result of the long duration of the disease, depending upon the resistance of the individual and varying virulence of the micro-organism. in the earliest stage, the tendon is replaced by vascular granulation tissue. later on, the sheath is obliterated by fibrous tissue. fluid is contained within the sheath, and rice bodies may appear as a result of caseation. if healing by fibrosis fails to curtail the pathologic process, extensive caseation and granulation occur.5 the treatment of compound palmar ganglion consists of antituberculous drugs along with excision of the lesion.6 complete excision and evacuation of the lesion along with excision of the inflamed tendon sheaths is done via the volar aspect.6 conclusion top ↑ radiological imaging is important in assisting with the early diagnosis of tuberculous compound palmar ganglion; it is otherwise delayed owing to the rarity of the condition and its nonspecific clinical presentation. the diagnosis is, however, confirmed by histopathological testing. early diagnosis and proper treatment can cure this otherwise destructive condition. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions s.t. (ipgme&r and sskm hospital) was responsible for the conception and design, drafting the article, revising it critically for intellectual content, us and mr image acquisition, analysis and interpretation and final approval of the version to be published. s.b. (ipgme&r and sskm hospital) was responsible for the conception and design, revising the article critically for intellectual content, us and mr image acquisition, analysis and interpretation and final approval of the version to be published. a.b. (ipgme&r and sskm hospital) was responsible for the conception and design, revising the article critically for intellectual content, us and mr image acquisition, analysis and interpretation and final approval of the version to be published. s.c. (ipgme&r and sskm hospital) was responsible for the conception and design, revising the article critically for intellectual content, us and mr image acquisition, analysis and interpretation and final approval of the version to be published. s.c. (r.g. kar medical college and hospital) was responsible for the conception and design, revising the article critically for intellectual content, pathological specimen collection, slide preparation and interpretation and final approval of the version to be published. references top ↑ pimm lh, waugh w. tuberculous tenosynovitis. j bone joint surg br. 1957;39-b(1):91–101. kumar ka, kanthimathi b, krishnamurthy cs, sujai s. compound palmar ganglion: a tubercular manifestation of flexor tenosynovitis of the wrist. international journal of case reports and images. 2012;3(2):28–31. http://dx.doi.org/10.5348/ijcri-2012-02-93-cr-7 hsu cy, lu hc, shih tt. tuberculous infection of the wrist: mri features. am j roentgenol. 2004;183(3): 623–628. http://dx.doi.org/10.2214/ajr.183.3.1830623 parmar r, mehta k, gandhi r, mohite n. compound palmar ganglion. international journal of health sciences and research. 2013;3(12):172–176. lall h, nag sk, jain vk, khare r, mittal d. tuberculous extensor tenosynovitis of the wrist with extensor pollicis longus rupture: a case report. journal of medical case reports. 2009;3:142. http://dx.doi.org/10.1186/1752-1947-3-142 krishna d, bisht rs, sikarwar v, chand. compound palmar ganglion: a case report. iosr journal of pharmacy. 2012;2(6):20–22. http://dx.doi.org/10.9790/3013-26502022 case report case report 66 sa journal of radiology • august 2009 case report abstract sandhoff ’s disease is a rare autosomal recessive disorder of sphingolipid metabolism that results from deficiency of the lysosomal enzymes, β-hexosaminidase a and b. the resultant accumulation of gm2 ganglioside within both grey matter nuclei and myelin sheaths of the white matter results in eventual severe neuronal dysfunction and neurodegeneration. disease progression is rapid, resulting in early death. currently, there is no curative treatment, with therapy remaining primarily supportive. this case report is of a 13-month-old aboriginal canadian boy who was referred for further investigations related to global developmental delay and loss of developmental milestones, at which time the diagnosis was discovered. clinical presentation a 13-month-old canadian aboriginal boy presented with global developmental delay and loss of developmental milestones. he was born at 38 weeks to nonconsanguinous parents after an uncomplicated pregnancy. he experienced normal development until the age of 3 months, at which time-delayed motor skills, followed by episodes of myoclonic jerks, were observed. verbal and social development was normal until approximately 6 months of age. physical examination was remarkable for increased head circumference relative to weight, with frontal bossing and hypotonic, nondysmorphic facies. no organomegaly was present. neurological examination revealed central hypotonia with head lag and symmetric spasticity involving all four limbs. deep tendon reflexes were normal, with the exception of ankle clonus and upgoing plantar reflexes. bilateral macular cherry red spots were visualised, and visual evoked responses were absent. further investigations including routine bloodwork and metabolic studies were normal. an eeg showed excessive slowing of delta frequencies associated with drowsiness. plasma hexosaminidase levels were significantly decreased. infantile sandhoff’s disease kimberly sass, md sheldon wiebe, md, frcpc, faap department of medical imaging, royal university hospital, saskatoon, saskatchewan, canada e lemire, md, phd, frcpc, fccmg, facmg department of pediatrics, division of medical genetics, royal university hospital, saskatoon fig. 1. axial t2wi at the thalamic level demonstrating bilateral diffusely hypointense thalami, hyperintense speckled putamina, and delayed myelination. fig. 2. axial t1wi at the thalamic level demonstrating diffuse thalamic hyperintensity. infantile.indd 66 8/17/09 3:02:36 pm case reportcase report diagnosis the diagnosis was infantile onset sandhoff ’s disease. radiographic findings bilateral, diffuse, t1 hyper-, t2 (figs 1 and 2) and flair hypointense (not shown) thalami were seen. hyperintense, speckledappearing putamina on t2w images containing punctate t2 and flair hypointense foci are demonstrated in fig. 1. additional mri findings include a delayed myelination pattern for age, with no visible areas of diffusion restriction. single voxel stimulated echo acquisition mode (steam) acquisition of the right lentiform nucleus for magnetic resonance spectroscopy revealed diminished n-acetylaspartate (naa), suggestive of neuronal loss/dysfunction (fig. 4). multivoxel acquisition through deep grey matter structures revealed diffusely diminished naa, most notable within the thalami (not shown). choline levels were found to be elevated which, while a nonspecific finding, may relate to dysmyelination. a few, small, nonspecific lactate peaks were also seen. discussion sandhoff ’s disease is a rare autosomal recessive disorder of sphingolipid metabolism, with an incidence of 1 in 384 000 live births,1 related to a genetic deficiency of the enzyme βhexosaminidase. two catalytically active forms of this enzyme exist: β-hexosaminidase a, composed of one α and one β subunit, and βhexosaminidase b, which contains two β subunits.2 the gene hexa encodes the α subunit, and mutations affecting this gene result in a deficiency of β-hexosaminidase a, clinically known as tay-sachs disease.1 in sandhoff ’s disease, both β-hexosaminidase a and b have been found to be deficient secondary to mutations within the hexb gene which encodes the common β subunit.1-3 clinically, these two genetic disorders are indistinguishable from each other.1,4 β-hexosaminidase is a lysosomal enzyme responsible for degrading the ganglioside gm2 to gm3 by removing the β-n-acetyl galactosamine residue from the nonreducing terminal of the gm2 ganglioside.1,5 in sandhoff ’s disease, total hexosaminidase activity is reduced to less than 2 3% of normal, unlike tay sachs, where total hexosaminidase activity is preserved due to functional βhexosaminidase b activity.5 however, the b isoenzyme is unable to hydrolyse the gm2 ganglioside, which accumulates in the brain 5 and also within the liver, spleen, and kidneys, which may become enlarged.4,5,14 gangliosides have been found to be present primarily within grey matter nuclei and, to a lesser degree, within myelin sheaths of the white matter.6 gm2 ganglioside accumulation within lysosomes of cortical neurons results in distension of neuronal cell bodies and nucleus displacement.5,7,8 over time, this cellular enlargement results in neuronal dysfunction and severe neurodegeneration from eventual neuronal loss.5,8-10 neuronal deterioration and death results in cortical atrophy with widened sulci, narrowed gyri, dilated ventricles and atrophy of the optic nerves and cerebellum.9 ganglioside storage has been found to induce degeneration of white matter.5,10 pathologically, there is evidence for demyelination11,12 as well as delayed myelination,11 which is believed to be secondary to the grey matter disease.13 at autopsy, lipid storage and oedema have been found within the white matter.14 while the biochemical basis of sandhoff ’s disease is well understood, the exact aetiology resulting in neuronal death and cerebral atrophy is yet to be elucidated.15 animal models have sug67 sa journal of radiology • august 2009 fig. 3. coronal mprage demonstrating diffuse thalamic hyperintensity. fig. 4. magnetic resonance spectroscopy data: single voxel steam acquisition (tr/te = 3 000/20 ms) of the right lentiform nucleus, demonstrating unusual peak configuration near 2.07 ppm. infantile.indd 67 8/17/09 3:02:39 pm case report case report 68 sa journal of radiology • august 2009 gested that neurons distorted by accumulated sphingolipids directly activate inflammatory pathways and cause eventual apoptosis.14,15 sphingolipid accumulation is also thought to incite reactive gliosis, resulting in a progressive increase of head circumference by 1½ to 2 years of age.12,15-17 the clinical expression of sandhoff ’s disease is variable. the classic infantile form is characterised by an onset between 3 and 9 months of age,1,16,18 following initial normal development. clinical manifestations are variable and may include initiation of a pronounced startle response after 3 or 4 months of age.17,19 previously acquired developmental milestones decline, and severe muscular hypotonia, followed by spastic quadraparesis and seizures, are additional features.16,18 macular cherry red spots are occasionally observed,17,19 though this finding is nonspecific and also seen in several other lysosomal storage disorders. disease progression is rapid, resulting in death by 3 to 5 years of age. currently, there is no curative treatment and therapy remains supportive.18 the juvenile/subacute variant often presents with ataxia between 2 and 5 years of age,19 and has a slowly progressive course and more favourable prognosis.1,2 the adult/chronic subtype generally presents in the second or third decade of life, with a variable clinical picture of either spinocerebellar degeneration or motor neurone disease19 and typically has a fair survival rate.1,2,19 imaging although sandhoff ’s disease has been traditionally considered to be a grey matter disease, neuroimaging studies have characterised abnormalities within both the white and grey matter of sandhoff patients. despite extensive variability in findings among studied patients, bilateral symmetric thalamic changes have been found to be an early, predictable finding that is probably specific to the gm2 gangliosidoses, such as sandhoff ’s disease, and may be useful in determining whether to perform more specific investigations in infants suspected of having a neurodegenerative disease.5,17 the thalami are usually homogeneously hyperdense on computed tomography (ct)5,16,17,20 and t2 hypointense11,12,20 and t1 hyperintense12,20 on magnetic resonance imaging (mri). mr findings have been found to be particularly variable within the caudate nucleus, globus pallidus, and putamen, though these structures have been shown to be t2-hyperintense.17 currently, there are several theories as to how the stored sphingolipids affect neuroimaging. abnormal accumulation of macromolecules or lipids increases tissue viscosity and shortens t2 relaxation time, manifesting as a decreased t2 signal, explaining the mr findings among sandhoff patients.8 dystrophic calcification involving the thalami is thought to be responsible for the hyperdense ct appearance.7,8,17 however, it is generally thought that the neuroimaging features are the end result of intralysosomal storage and gliosis owing to axonal and myelin loss in the central cortical neurons.8,16,17 the white matter changes in sandhoff ’s disease are best appreciated with mri. during the early, asymptomatic disease stage, normal neurological development20,21 and mri neuroimaging6 presume normal myelination.20 later imaging of cerebral white matter has demonstrated homogeneous or patchy t2 hyperintensity within frontal,18 temporal and occipital regions,6,18 and periventricular white matter,18 and also within the internal and external capsules.11 involvement of brainstem white matter has been found to extend from the internal capsules to the level of the pons,17 medulla,20 and cerebellar white matter,20 though infratentorial involvement is regarded as secondary to the primary abnormalities of the supratentorial white matter.17 these late-occurring white matter abnormalities are presumed to be the result of secondary demyelination following cortical neuronal death and axonal deterioration, rather than from primary dysmyelination.13,20,22 however, a combination of delayed myelination and demyelination11,17 has also been proposed. diffuse thinning of the corpus callosum as well as both cerebellar and cerebral cortical atrophy have been demonstrated as abnormal signal intensities on t1and t2-weighted images that have invariably been attributed to disturbed myelination or calcification.5,10,11,17,20,23 a correlation between the degree of thalamic hyperdensity and the presence or severity of white matter disease or atrophy has not yet been demonstrated.5,11,17 proton magnetic resonance spectroscopy (mrs) has revealed progressive elevation in myoinositol (mi):cr ratios12,18 within white matter, grey matter, and the thalamus.18 as the mi peak signifies glial cell activity, it has been hypothesised that accumulation of gm2 gangliosides results in glial cell proliferation, or reactive gliosis.12 demyelination in sandhoff ’s disease is expected as a consequence of neuronal loss although, despite clinical and radiographic deterioration, cho/cr ratios have been found to remain normal.12,18 it is thought that the accumulation of gangliosides within cell membranes results in a relative reduction of cho precursors, thus minimising mrs evidence of demyelination.12 naa and n-acetylaspartylglutamate (tnaa) are markers of neuroaxonal integrity and have been found to decline with neuronal damage and loss.12,25,26 progressive declines in naa and tnaa, consistent with neuronal loss, have been observed in sandhoff patients.12,18 sandhoff ’s disease is characterised by the accumulation of nacetylhexosamine-containing oligosaccharides, both within glycosphingolipids and as free oligosaccharides, both of which contain n-acetyl moieties.10,26 further analysis has revealed that it is the level of stored glycosphingolipids, and not the level of cerebral oligosaccharides, that correlates with disease severity.10 both animal and human data have confirmed a new spectrum adjacent to the tnaa resonance with a resonance frequency of approximately 2.07 ppm which has been assigned to the n-acetyl moiety of n-acetylhexosamine (nahex).10,18,26 human data have shown this resonance to be most prominent in white matter and the thalamus and, to a lesser degree, within paramedian parietal grey matter, though this was not seen within the basal ganglia.18 this resonance is believed to relate directly to the pathophysiology of sandhoff ’s disease by suggesting that oligosaccharides containing nahex accumulate in cortical and subcortical grey matter as well as in white matter.18 animal proton mrs studies have demonstrated consistently higher intensities of nacetyl resonances than controls, and have also shown a progression of increasing intensity of these resonances from presymptomatic infantile.indd 68 8/17/09 3:02:40 pm case report case report 70 sa journal of radiology • august 2009 to terminal disease stages.10,26 this presymptomatic nahex resonance has yet to be demonstrated within presymptomatic sandhoff patients.18 knowledge of the existence of the nahex resonance may be of direct clinical relevance in the future as the use of mrs broadens to include both non-invasive diagnostic and treatment strategies.10,12 this approach may also be helpful in evaluating potential experimental strategies in the treatment of this and other disorders of lysosomal storage10,26 as well as in helping to monitor disease progression.12 1. maegawa ghb, stockley t, tropak m, et al. the natural history of juvenile or subacute gm2 gangliosidosis: 21 new cases and literature review of 134 previously reported. pediatrics 2006; 118(5): 1550-1562. 2. zhang z, wakamatsu n, mules eh, et al. impact of premature stop codons on mrna levels in infantile sandhoff disease. hum mol genet 1994; 3(1): 139-145. 3. o’dowd bf, klavins mh, willard hf, et al. molecular heterogeneity in the infantile and juvenile forms of sandhoff disease (o-variant gm2 gangliosidosis). j biol chem 1986; 261(27): 12680-12685. 4. faerber en, young poussaint t. magnetic resonance of metabolic and degenerative diseases in children. top magn reson imaging 2002; 13(1): 3-22. 5. brismar j, brismar g, coates r, et al. increased density of the thalamus on ct scans in patients with gm2 gangliosidoses. am j neuroradiol 1990; 11: 125-130. 6. koelfen w, freund m, jaschke w, et al. gm-2 gangliosidosis (sandhoff ’s disease): two year follow-up by mri. neuroradiology 1994; 36: 152-154. 7. chen c-y, zimmerman ra, lee c-c, et al. neuroimaging findings in late infantile gm1 gangliosidosis. am j neuroradiol 1998; 19: 1628-1630. 8. autti t, joensuu r, aberg l. decreased t2 signal in the thalami may be a sign of lysosomal storage disease. neuroradiology 2007; 49: 571-578. 9. becker le. lysosomes, peroxisomes and mitochondria: function and disorder. am j neuroradiol 1992; 13: 609-620. 10. lowe jp, stuckey dj, awan fr, et al. mrs reveals additional hexose n-acetyl resonances in the brain of a mouse model for sandhoff disease. nmr biomed 2005; 18: 517-526. 11. alkan a, kutlu r, yakinci c, et al. infantile sandhoff ’s disease: multivoxel magnetic resonance spectroscopy findings. j child neurol 2003; 18: 425-428. 12. assadi m, baseman s, janson c, et al. serial 1h-mrs in gm2 gangliosidoses. eur j pediatr 2007; doi 10.1007/s00431-007-0469-0. 13. kroll ra, pagel ma, roman-goldstein s, et al. white matter changes associated with feline gm2 gangliosidosis (sandhoff disease): correlation of mr findings with pathologic and ultrastructural abnormalities. am j neuroradiol 1995; 16: 1219-1226. 14. huang j, trasler jm, igdoura s, et al. apoptotic cell death in mouse models of gm2 gangliosidosis and observations on human tay-sachs and sandhoff disease. hum mol genet 1997; 6(11): 1879-1885. 15. myeorwitz r, lawson d, mizukami h, et al. molecular pathophysiology in tay-sachs and sandhoff diseases as revealed by gene expression profiling. hum mol genet 2002; 11(11): 1343-1350. 16. caliskan m, ozmen m, beck m, et al. thalamic hyperdensity – is it a diagnostic marker for sandhoff disease? brain dev 1993; 15(5): 387-388. 17. yuksel a, yalcinkaya c, islak c, et al. neuroimaging of four patients with sandhoff disease. pediatr neurol 1999; 21: 562-565. 18. wilken b, dechent p, hanefeld f, et al. proton mrs of a child with sandhoff disease reveals elevated brain hexosamine. eur j paediat neurol 2008; 2(1): 56-60. 19. praamstra p, wevers ra, gabreels fjm, et al. gm2-gangliosidosis. clin neurol neurosurg 1990; 92-2: 143-148. 20. hittmair k, wimberger d, bernert g, et al. mri in a case of sandhoff ’s disease. neuroradiology 1996; 38: s178-s180. 21. schulte fg. clinical course of gm2 gangliosidoses. a correlative attempt. neuropediatrics 1984; 15: 66-70. 22. kendall be. disorders of lysosomes, peroxisomes, and mitochondria. am j neuroradiol 1992; 13: 621653. 23. mugikura s, takahashi s, higano s, et al. mr findings in tay-sachs disease. j comput assist tomogr 1996; 20(4): 551-555. 24. valk j, van der knapp ms. mr of myelin, myelination, and myelin disorders, 2nd ed. new york: springer, 1995: 80-89. 25. filippi cg, ulug am, deck mdf, et al. developmental delay in children: assessment with proton mr spectroscopy. am j neuroradiol 2002; 23: 882-888. 26. lowe jp, stuckey dj, awan fr, et al. mrs reveals new resonances in extracts of sandhoff mouse brain. proc intl soc mag reson med 2003; 11: 1957. infantile.indd 70 8/17/09 3:02:40 pm untitled by savvas andronikou figs 1 and 2 demonstrate the contrast meal in a child with alleged ‘bile-stained’ vomiting. the second part of the duodenum shows a loop to the right of the spine prior to crossing to the left of the spine, suggesting malrotation. a falsepositive diagnosis was made by the reporting registrar because a normal duodeno-jejunal flexure is expected to be located to the left of the spine, behind the stomach at the level of the duodenal bulb. the above images are consistent with a duodenum inversum or a duodenum reflexum.1 this subtle variation of normal demonstrates the distal duodenum to ascend to the right of the spinal column up to the level of the duodenal bulb and crossing the spine horizontally where it is fixed in a normal location by the ligament of treitz. it may result in delayed gastric emptying which gives rise to the presenting symptoms but is not associated with midgut volvulus. an accurate diagnosis is imperative to avoid unnecessary surgery.1 1. long fr, kramer ss, markowitz ri, taylor ge, liacouras ca. intestinal malrotation in children: tutorial on radiographic diagnosis in difficult cases. radiology 1996; 119988:: 775-780. pediatric radiology october 2005; 35: 947-979. the minisymposium consists of 2 articles on the evaluation of vascular rings and slings and the imaging thereof. a vascular ring refers to any vascular or ligamentous anomaly that encircles the trachea or oesophagus. there are 2 groups: complete and incomplete. complete vascular rings include double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum. incomplete vascular rings include pulmonary artery sling and innominate artery compressive syndrome. the first article written by m oddone et al. is: ‘multi-modality evaluation of the abnormalities of the aortic arches in children: techniques and imaging spectrum with emphasis on mri’. a fantastic article discussing embryology and classification as well as the imaging with chest radiography, barium oesophagography and mri. each subtype is then comprehensively described under separate sections with great images and additional line diagrams. the second article, written by m hernanzschulman, is ‘vascular rings: a practical approach to imaging diagnosis’. this article also discusses imaging techniques in detail and includes modalities such as ultrasound and multislice ct. specific subtypes are also described in detail with superb images. the articles combined are 30 pages but well worth the read. by nicky wieselthaler ggiirrsstt ttmm,, tthhoorrnnttoonn ffjj.. mmrraa iinn cchhiillddrreenn:: tteecchh-nniiqquuee,, iinnddiiccaattiioonnss aanndd iimmaaggiinngg ffiinnddiinnggss.. ppeeddiiaattrriicc rraaddiioollooggyy 22000055;; 25: 2266--3399.. this article explains the conventional mra techniques that can be used in children as well as contrast-enhanced 3d mra with rapid t1 spoiled gradient-recalled echo (fspgr). injection parameters and indications are discussed in detail. rating: ***. comment: very educational and practical. ttaayylloorr cchhuunngg.. mmrraa ooff tthhee bbooddyy iinn ppeeddiiaattrriicc ppaattiieennttss:: eexxppeerriieennccee wwiitthh aa ccoonnttrraasstt--eennhhaanncceedd ttiimmee rreessoollvveedd tteecchhnniiqquuee.. ppeeddiiaattrriicc rraaddiioollooggyy 22000055;; 35:33--1100.. this article compares ct angiography with other available modalities and techniques. it also provides valuable and practical scan parameters that can be used in practice. dose-specific parameters are discussed with useful suggestions for radiation reduction. applications in paediatric practice are listed. by savvas andronikou • espr – 2005 the european society for pediatric radiologists held its annual conference in dublin. the members of pissa who attended (s andronikou and n wieselthaler) presented 2 papers and 1 paper which were well received. the long papers were delivered by s andronikou on behalf of carey makenzie and stefan przybojewski and dealt with physeal bar and objective features of basal enhancement in tbm respectively. the main focus and keynote speakers dealt with increasing scientific evidence of the decreasing importance of vescicoureteric reflux. abstracts were published in a supplement issue of pediatric radiology. • espr/ ipr 2006 in 2006 there is a combined meeting of north american, european and oceanic societies of pediatric radiologists at ipr in montreal. abstracts have already closed. pissa has entered 4 abstracts including long papers on radiographer reporting in ct brain and correlation of infants with outcome in tbm. • isr 2006 jan labuschagne has secured this massive international conference to be held at the cape town icc in september 2006. good news for pissa is that there is a dedicated pediatric tract for thursday 14 september, friday 15 september and saturday 16 september with over 8 hours of talks and over 30 invited international speakers just for the pediatric tract. these will be from europe, the usa, canada, australia, asia and africa and include the likes of j barkovich, susan blaser, steven chapman, francis brunelle, alan daneman, marilyn siegel, isky gordon, kieran mchugh and douglas jamieson. one session is dedicated to neuroimaging, one to abdominal imaging and one to tb/hiv in children. the last day will be jam-packed with internationally renowned tb/hib experts. abstracts for posters and long papers are welcome: docsav@mweb.co.za. check out the programme: www.isr2006.co.za. baby steps into pediatric neuro imaging. s andronikou, n wieselthaler, e kader (2004) sama health and medical publishing group (cape town). a product of pissa, this national collaboration is finally in print, but has already run out of print! the massive demand has prompted another print of 200 books for 2006. feedback has shown this to be an excellent quick reference, particularly for the myelin maturation and standardised us imaging of the head. pissa intends to produce its next book ‘a guide to pediatric imaging procedures’ sometime in 2006. the rssa and college of radiologists are collaborating to produce a free imaging atlas for radiologists and clinicians. the publishing team of pissa is heading the project even though most of the atlas will deal with adult anatomy. an excellent chapter in paediatric imaging anatomy is in progress and will form an integral part of the book. the rssa has donated over r120 000 for the publication which is sanctioned by the college of radiologists of south africa. a pre-exam course is held annually by the college of radiology. this year paediatric imaging was given as much emphasis as imaging of all the other body systems and the conference was a huge success. vivas, spot tests and long cases were added to the programme of physics and written question preparation lectures. the next course will be held in cape town in 2006. enquiries contact the organiser: dr savvas andronikou at docsav@mweb.co.za. the october 2005 college of radiology exams have just taken place. paediatric imaging was a focus of 2 written questions and 2 of the 10 long cases. it also formed a large proportion of the oral exam as one examiner asked only paediatric radiology-related questions. written by s andronikou & n wieselthaler 36 sa journal of radiology • december 2005 specialty corner produced by: pissa figs 1 and 2. images demonstrating the course of the duodenum, consistent with duodenum inversum. case of the day an unusual duodenal cloop journal review – hermes conference news books pre-exam course college of radiology newspaper2 11/25/05 1:50 pm page 36 a. it is the third most common extracranial solid malignancy in children. b. it is a tumour of primitive mesenchymal cells committed to skeletal muscle.differentiation can occur in a variety of organs. c. there are three main histological types i.e. embryonal, alveolar and botryoid. d. tumours originating in the middle ear and mastoid have a particularly good prognosis. 2. regarding metastatic calcification, choose one false answer: cpd questionnaire give one correct answer for each question 24 sa journal of radiology • april 2008 instructions: 1. read the articles in the journal to find the answers to the questions. 2. place your answers on the cpd answer form which is on the back of the address sheet mailed with this journal. 3. answer questions by marking correct answers with an ‘x’ in the appropriate box. use a black pen. see instruction above each question. 4. keep a copy for your records. 5. post the completed form to cpd points, sajr, private bag x1, pinelands, 7430. 6. all completed forms must be posted — not faxed. 7. answers are recorded by the rssa and are submitted directly to the hpcsa. 1. regarding rhabdomyosarcoma, choose one false answer: a. occurs in patients with chronic renal failure. b. occurs in primary hyperparathyroidism. c. occurs in hypervitaminosis d, diffuse myelomatosis, and milkalkali syndrome 4. d. metastatic calcification only occurs in the presence of hypercalcaemia. 3. choose one correct answer: a. ct is an excellent modality to demonstrate soft-tissue injury and instability. b. bilateral fractures which result in disruption of the bony ring of c2 constitute a hangman’s fracture. c. the hangman’s fracture represents fractures of the neural arch of c2 that are produced by a hyperflexion force. d. neurological consequences of the hangman’s fracture are often more severe than might be anticipated. 4. choose one correct answer: a. the dependent viscera sign is seen with diaphragmatic rupture when there is loss of the anterior support of the diaphragm. b. the dependent viscera sign obliterates the lateral costophrenic recess. c. the dependent viscera sign is said to be present on the left side if the upper one-third of the liver abuts the posterior ribs, and on the right side if the stomach or bowel abuts the posterior ribs or lies posterior to the spleen. d. the collar sign is a waist-like constriction of the viscera. 5. identify one incorrect answer: a. pulmonary valve atresia with a vsd is an extreme form of tetralogy of fallot. b. it usually presents in the neonatal period as a ductal-dependent lesion. c. surgery is usually optimal at 1-2 years. d. anomalous origin of either pulmonary artery branch from the aorta has been reported. 6. all below is true concerning the causes of diffuse sclerosis of the skull, except: a. chronic phenytoin therapy. b. van buchem’s diseases (sclerosteosis). c. osteopetrosis. d. cleido-cranial dysostosis. 7. which is correct concerning ercp: a. safe procedure with negligible morbidity and mortality. b. remains the gold standard for exploration of the biliopancreatic region. c. does not require sedation or ionising radiation. d. widely available and not restricted to specialised centres. 8. concerning mrcp, identify one false response: a. it is a non-invasive and safe alternative to diagnostic endoscopic retrograde cholangiopancreatography (ercp). b. it refers to selective fluid-sensitive magnetic resonance imaging (mri) of the pancreatic and biliary ducts. c. it was developed in 1991, and techniques have progressively improved since then. d. no advantages over ercp and should not be considered as initial investigative modality of choice. 9. all below are drawbacks of mrcp except: a. currently has poorer resolution than direct cholangiography. b. can miss small stones (<4 mm), small ampullary lesions, primary sclerosing cholangitis, and strictures of the ducts. c. has difficulty visualising small stones in the pancreatic duct. d. stones >4 mm are not readily seen and cannot be differentiated from filling defects such as blood clots, tumour, sludge or parasites. 10. regarding sajr, all is true except: a. the editor prefers electronic manuscript submission on the web site. b. illustrations and tables should be submitted as supplementary files. c. electronic submission of cpd questionnaires will happen in the near future. d. electricity policy in south africa may sway the editorial board to scrap the web page and return to using the south african postal service. pg 24.indd 24 4/14/08 12:23:32 pm m_sajr_v9_n3_a9.pdf 29 sa journal of radiology • october 2005 abstract neutropenic enterocolitis is a lethal, necrotising inflammation of the caecum and contiguous bowel, found in immunocompromised, neutropenic patients. a high index of clinical suspicion coupled with appropriate imaging modalities allows earlier diagnosis and can expedite the management of these severely ill patients. we describe the clinico-radiological features of this condition in the following case report, as well as a brief management approach to this rare, but increasingly recognised condition. case report a 23-year-old female patient was referred from a peripheral hospital with a 1-week history of fever and frank rectal bleeding. on examination, the patient was pyrexial and pale. numerous petechial haemorrhages were present on both forearms and shoulders. shotty cervical and axillary lymph nodes, 4 cm hepatomegaly and 2 cm splenomegaly were palpated. the abdomen was mildly tender but there was no peritonism. fundoscopy revealed bilateral retinal haemorrhages. her neurological assessment was unremarkable. an initial chest radiograph was normal. full blood count, on admission, revealed a haemoglobin level of 3.3 g/dl, a white cell count of 29.3 × 109/l with severe neutropenia (1%), predominance of blast cells (94%) and thrombocytopenia with a platelet count of 9 × 109/l. blood cultures, on admission, were negative. bone marrow aspirate and trephine biopsy confirmed the diagnosis of acute lymphoblastic leukaemia. on immunophenotyping, the leukaemia cells were cd19+ (68.7%), cd10+ (83.8%) and cd34+ (86.5%) confirming calla+ acute lymphoblastic leukaemia. the absolute cd4 count was 93 cells/µl. the patient was transfused with packed red cells and platelets, and intravenous antibiotics (amikacin and tazocin) were commenced. the following day combined induction chemotherapy with vincristine, doxorubicin, cyclophosphamide, cytosinearabinoside and prednisone was instituted. following chemotherapy, there was persistent, severe pancytopenia. two weeks later, despite continuous high-care treatment, the patient’s condition deteriorated. she developed acute, severe abdominal tenderness, pyrexia and hypotension, which necessitated immediate transfer to the intensive care unit (icu). abdominal radiograph (fig. 1) revealed an abnormal bowel gas pattern with marked gastric and small bowel dilatation, and paucity of air in the right iliac fossa (rif). chest radiograph (fig. 2) demonstrated air-space opacification bilaterally with areas of confluence in the mid to lower zones, especially on the right in keeping with bronchopneumonia. blood cultures confirmed septicaemia with a resistant strain of escherichia coli, sensitive to meropenem only. the pancytopenia deteriorated and the patient developed acute renal failure with anuria. her abdomen was moderately distended with generalised abdominal tenderness and rebound tenderness in the rif. bowel sounds were absent. abdominal ultrasound demonstrated free intra-peritoneal fluid, acalculus cholecystitis and bowel wall thickening in the rif. contrast-enhanced computed tomography (ct) scan confirmed presence of ascites and acalculus cholecystitis. there was also marked dilatation of the caecum with extensive bowel wall thickening involving the entire right colon, proximal transverse colon and terminal ileum. stranding of the surrounding fat was present, indicative of the pericolic inflammatory process. (figs 3 -7). case report neutropenic enterocolitis complicating acute lymphoblastic leukaemia s k misser mb chb p corr mb chb, md, ffrad (d) sa, frcr department of radiology inkosi albert luthuli central hospital nelson r. mandela school of medicine durban v b jogessar mb chb, mrcp (uk), frcpath(lond), fcpath(sa) department of haematology inkosi albert luthuli central hospital nelson r mandela school of medicine durban fig. 1. supine abdominal radiograph performed while in icu. fig. 2. bed side unit supine chest radiograph. 30 sa journal of radiology • october 2005 case report the radiological features were consistent with a diagnosis of neutropenic enterocolitis (ne). the patient’s condition progressively worsened despite supportive therapy, which included inotropic agents, assisted ventilation and broad-spectrum antimicrobials. the patient died in icu. discussion ne, also referred to as typhlitis, is a lifethreatening infectious disease with the epicentre located at the caecum and ascending colon. the term ne partly describes the aetiology and pathology of this condition, which is being reported with increasing frequency. patients who are profoundly neutropenic due to underlying medical conditions such as leukaemia or aids,1 or who are rendered neutropenic following chemotherapy for an underlying malignancy, are at special risk of developing ne. the chemotherapeutic agents commonly incriminated are taxol, doxorubicin, cytosine-arabinoside and vinca alkaloids, which are administered in various combinations. many mechanisms leading to the development of ne have been proposed. some authors have provided evidence to suggest that ne is a toxin-mediated disease and prior chemotherapy is unnecessary for its pathogenesis. others have reported the condition only following combined regimens of chemotherapy. it is postulated that a combination of factors in most patients (as in the patient reported here) precipitates ne. autopsy studies identified multiple clostridial species in necrotic bowel wall of patients with ne.2,3 clostridia, which are a normal component of the alimentary flora are thought to secrete a necrotising β-toxin. ordinarily this toxin is inactivated by neutrophil proteases. in severely neutropenic patients, the absence of neutrophil proteases permits clostridial toxin-mediated bowel wall injury.4 the appendix has the highest carriage rate of clostridia. this is the reason that the inflammatory process and ensuing necrosis are concentrated in the terminal ileum, caecum and right colon.5 following clostridial toxin-mediated mucosal necrosis, secondary bacterial translocation leads to acute septicaemia (fig. 8). the commonest organisms cultured include e. coli, klebsiella, pseudomonas, enterococcus, candida and clostridia.6 pathologically, ne is characterised by inflammation and oedema that progresses to ulceration, necrosis and bowel wall perforation.7 the differential diagnosis for ne includes acute appendicitis, appendix mass, intussusception, ischaemic colitis or other inflammatory processes, e.g. bacterial gastro-enteritis, viral colitis, inflammatory bowel disease or pseudomembranous colitis. blood cultures are an important laboratory investigation that should be performed as early as possible, such that organism isolation and sensitivity can be known early on. this allows rapid, directed antimicrobial therapy. the findings of plain abdominal radiographs are usually nonspecific and they rarely help in the diagnosis of ne. occasionally, right colonic and small bowel dilatation, thumb printing, paucity of air in the right colon and soft tissue mass displacfig. 3. contrast-enhanced ct scan at the level of the mid-upper poles of the kidneys demonstrates pericolic inflammatory stranding (black arrows) surrounding the colon, proximal to hepatic flexure, in the anterior pararenal space. note the distended stomach anteriorly (white arrow). fig. 4. contrast-enhanced ct scan at the level of the inferior poles of the kidneys demonstrates marked mural thickening (black arrow) of the ascending colon with pericolic inflammation. fig. 5. contrast-enhanced ct scan demonstrating the thick-walled right colon (black arrows) and mesenteric stranding. note free fluid in the left paracolic gutter (white arrow). fig. 6. contrast enhanced ct scan at the pelvic inlet demonstrating marked caecal wall thickening (black arrows) and inflammatory reaction at the ileocaecal valve (white arrow). fig. 7. contrast-enhanced ct scan at mid to lower pelvis revealed ascites. ing small bowel loops may be noted.8 free intra-abdominal air is an ominous sign. contrast enema, uncommonly performed in ne, may demonstrate rigidity and thickening of the caecum. barium enema is usually contraindicated as there is a potential risk of perforation. ultrasound (us) is a useful additional tool. bowel wall thickening that produces a target or halo, with echogenic walls is suggestive of colitis, but is nonspecific.9 it may be used as a follow-up tool to assess gradual decline in bowel wall thickening during treatment. the diagnostic procedure of choice is contrast-enhanced abdominal ct scan10 with the lowest false-negative rate of 15%. severe transmural inflammation, symmetrical circumferential bowel wall thickening of the caecum and pericaecal inflammation can all be accurately depicted.11,12 high attenuation within the thickened colonic wall may represent haemorrhage. inflammatory pericolonic stranding of mesenteric fat is common. in addition, ct readily demonstrates complications of ne, viz. pneumatosis coli, pneumoperitoneum, pericolonic collections and abscess formation. these complications may require urgent surgical management.13 endoscopic procedures including colonoscopy and flexible sigmoidoscopy are rarely performed, as they are relatively contraindicated in the setting of neutropenia and thrombocytopenia. management is necessarily empiric because there is no diagnostic test that is entirely sensitive and specific for ne. medical care includes: • admission to icu with close monitoring, especially abdominal us examinations, full blood counts and biochemistry. • intravenous fluids, blood and platelet transfusions as required. • nil by mouth with nasogastric tube suction. • parenteral broad-spectrum antibiotics that cover enteric gram-negative and anaerobic organisms (including clostridia). some centres add metronidazole, if pseudomembranous colitis cannot be immediately excluded.14 • postpone all chemotherapy (for leukaemia) until symptoms have completely resolved.15 • discontinuation of medications, which may worsen the condition or confuse the clinical picture, e.g. drugs with anticholinergic side-effects, anti-diarrhoeal agents and narcotics. • if the patient remains febrile after 72 hours of antibiotic therapy, fungal cultures should be taken and an antifungal agent16 should be added. • in addition, viral studies especially for cytomegalovirus (cmv) are advised as cmv colitis may closely mimic ne. ganciclovir may then be instituted. • additional medical support with recombinant granulocyte colony stimulating factor has been advocated.17 surgical intervention is clearly limited to specific indications, in light of the inherent risks of surgery in the pancytopenic, immunocompromised individual. shamberger et al 13 proposed these indications for surgery: • persistent gastro-intestinal bleeding after resolution of neutropenia, thrombocy31 sa journal of radiology • october 2005 case report fig. 8. algorithm of the pathophysiological processes in ne. 32 sa journal of radiology • october 2005 case report topenia or other clotting abnormality. • free intra-abdominal perforation. • unrelenting intra-abdominal sepsis ± septicaemia (suggested by clinical deterioration requiring vasopressors or large volumes of fluid). • clinical signs or radiological evidence for intra-abdominal abscess. surgical procedures performed include: • caecostomy and drainage • two-stage right hemi-colectomy or total colectomy • defunctioning of the colon with a loop ileostomy. extensive resection is deemed necessary as necrotic mucosa in the bowel may be concealed by relatively normal appearing serosal surface at operation. ne carries a poor prognosis with an average mortality rate of 40 50%. earlier detection with better imaging modalities and high index of suspicion has resulted in much lower mortality rates. joint medical/surgical consultation is vital in the management of the ne patient. an increase in the neutrophil count is an important indicator of recovery and prognosis. it is essential that the physician consider the possibility of this potentially fatal condition in any neutropenic patient with the appropriate clinical presentation. modern imaging modalities have changed ne from being diagnosed as a late-stage disease, best managed with immediate surgery and poor outcome, to a condition recognisable in its early stage and amenable to conservative, active medical management. references 1. cutrona af, blinkhorn rj, crass j, spagnuolo pj. probable neutropenic enterocolitis in patients with aids. rev infect dis 1991; 113: 828-831. 2. moir dh, bale pm. necropsy findings in childhood leukaemia, emphasising neutropenic enterocolitis and cerebral calcification. pathology 1976; 88: 247-258. 3. king a, rampling a, wight dg, warren re. neutropenic enterocolitis due to clostridium septicum infection. j clin pathol 1984; 337: 335-343. 4. newbold km, lord mg, baglin tp. role of clostridial organisms in neutropenic enterocolitis. j clin pathol 1987; 440: 471. 5. blenkinsopp wk, dupont pa. bacteria in necrotising enterocolitis. lancet 1977; 22: 617. 6. gomez l, martino r, rolston kv. neutropenic enterocolitis: spectrum of the disease and comparison of definite and possible cases. clin infect dis 1998; 227: 695-699. 7. katz ja, wagner ml, gresik mv, mahoney dh, fernbach dj. typhlitis: an 18-year experience and post-mortem review. cancer 1990; 665: 10411047. 8. mcnamara mj, chalmers ag, morgan m, smith sew. typhlitis in acute childhood leukaemia: radiological features. clin radiol 1986; 337: 83-86. 9. gootenberg je, abbondanzo sl. rapid diagnosis of neutropenic enterocolitis (typhlitis) by ultrasonography. american journal of paediatric haematology/oncology 1987; 99: 222. 10. frick mp, maile cw, crass jr. computed tomography of neutropenic colitis. am j roentgenol 1984; 1143: 763. 11. vas wg, seelig r, mahanta b. neutropenic colitis: evaluation with computed tomography. journal of computed tomography 1988; 112: 211-215. 12. gayer g, zissin r. typhlitis: a computed tomography diagnosis. israel medical association journal 2002; 44: 146-147. 13. shamberger rc, weinstein hj, delorey mj, levey rh. the medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukaemia. cancer 1986; 557: 603. 14. wade ds, nava hr, douglass ho. neutropenic enterocolitis. clinical diagnosis and treatment. cancer 1992; 669(1): 17-23. 15. keidan rd, fanning j, gattenby ra, weese jl. recurrent typhlitis: a disease resulting from aggressive chemotherapy. dis colon rectum 1989; 332: 206-209. 16. marr ka. empirical antifungal therapy new options, new tradeoffs. n engl j med 2002; 3346: 278-280. 17. hanada t, ono i, hirano c. successful treatment of neutropenic enterocolitis with recombinant granulocyte colony stimulating factor in a child with acute lymphocytic leukaemia. eur j paediatr 1990; 1149: 811-812. www.aucklandhealthcareers.co.nz look here first...look here first... staff nuclear medicine technologist / mrt do you like variety? here is a chance for you to work 20 hours per week as an mrt and 20 hours per week as a staff nuclear medicine technologist. the nuclear medicine department provides the sole public radionuclide imaging service and most of the specialised paediatric nuclear medicine examinations to the upper north island of new zealand. the department is well equipped with modern imaging equipment. your responsibilities will include working in all aspects of diagnostic nuclear medicine, performing examinations on both outpatients and inpatients. applicants must hold a qualifi cation recognised for registration by the new zealand medical radiation technologists board. ref no: 006144 to apply online please go to www.aucklandhealthcareers.co.nz if you’re looking to work in an up to if you’re looking to work in an up to the minute healthcare environmentthe minute healthcare environment new blood invariably brings change. having very recently taken over from savvas andronikou, who set a very high standard for this journal (and who insisted on manuscripts being forwarded in printed format), i was immediately and completely taken with the electronic process of submission that appears on the south african journal of radiology webpage: www.sajr.org.za. from the home page, one can register as a reader and/or author, and a personal profile is created in the process. authors can electronically upload a manuscript that will proceed through the steps of unassigned, in review, editing, layout, publishing – and be able to track its progress if they wish. the process is straightforward and simple. e-mail responses are automatically generated by the ojs (open journal system), as it’s called, and the potentials for error are minimised. this is undoubtedly the way forward, and i kindly request that all future submissions and correspondence take this route. we have in the past utilised a rotating guest editorship assigned to individual faculties. this might have assisted in sharing the load, but we have witnessed fluctuating quality and a lack of consistent editorial policy. under the editorship of professor andronikou, this has largely disappeared and we intend to abolish the process completely. sharing the load, however, remains critical. to ensure future progress of the journal towards an internationally recognised peer-reviewed publication, we need only 3 manuscripts from our 8 academic institutions annually. the wealth of excellent material in the private sector remains essentially untapped, and contributions from this sector are continually sought – and greatly appreciated. cpd registration will take place in due course. a questionnaire at the end of each issue can be electronically filled in and submitted and cpd points will be automatically assigned. a cpd certificate in the name of the participant can be generated on the website. we hope also to publish regular contributions on ethics in order to assist our members in accumulating points in this area. you have in your hands the first issue of volume 12. i very much hope and trust that we will look back, in 2 3 years from now, and agree that the goals were worthwhile and that the first issue of volume 14 will be that of a peer-reviewed, internationally recognised radiological journal. vires acquirit eundo – it gathers strength as it goes (virgil; 70 19 bc). vires acquirit eundo. jan lotz editor-in-chief editorial � sa journal of radiology • april 2008 new rssa committee dr clive sperryn has recently been voted in as president of the radiological society of southern africa (rssa). a former head of school at michaelhouse (1979), he won a tongaat hulett group scholarship to study medicine at uct, and the zwarenstein prize for the most outstanding student in his first year. he was a member (business manager) of the rag executive, the medical students council executive and the mountain and ski club committee, and was awarded the sir abe bailey travel bursary in 1984. after internship at edendale, he spent time in casualty, paediatrics, general practice (including diving medicine), neurosurgery and world travel, before commencing radiology at groote schuur in 1991. studying initially under professor ronnie kottler, he was subsequently appointed by professor steve beningfield to head the vascular and interventional unit. an unexpected phone call from joel bortz led to a partnership with lake, smit and partners in durban before a final return to cape town in 2000 to join morton and partners. the rssa has been well served by richard tuft, who led the society to the enviable position we find ourselves in today, and continues to be involved as past president. bates alheit remains executive director, and trevor alnutt and jako calitz continue to run the secretariat. we bid farewell to jan labuscagne and wish him well in his new role as secretary-general of the isr and with the founding of the african society of radiology in marrakech this year. jan has been replaced as congress chairman by leon janse van rensburg, who has tackled this role with phenomenal enthusiasm. the new vice-president is sheldon godinho, with ralph posner as treasurer, mark velleman as secretary, and nigel flint and ashesh ranchod completing the executive. radiologists are a highly mobile, scarce resource and one of our challenges is to retain those who have been trained in south africa. the rssa supports academic radiology through journal sponsorship, publication of the sajr (which is provided free to all members), moving to electronic format for greater access, organisation of congresses and workshops and, recently, the establishment of a prize for an outstanding lecture given by any junior member at an rssa congress. we thank dr savvas andronikou for his enormous contribution to the sajr and welcome jan lotz as the new editor-in-chief. we have recently been made an extremely generous offer of free corresponding membership of the european society of radiology for all our members. benefits include: • free electronic access to european radiology, one of the most prestigious publications in the field of imaging • reduced registration rates for the european congress of radiology (ecr) from 2009 onwards • free electronic access to eurorad, the largest peer-reviewed teaching database of radiology on the internet • free electronic access to epos™, the electronic presentation online system which comprises more than 6 300 electronic presentations shown during ecr, escr, esgar, esmrmb, sir and cirse that can be viewed and downloaded • free electronic access to eecr, which contains over 350 recorded lectures that can be viewed from ecr, esgar or esmrmb • free electronic access to edips download, ecr's digital preview system which enables one to download 1 099 microsoft® office powerpoint presentations of ecr lectures throughout the year • all activities of the european school of radiology (esor) are offered exclusively to members of the esr • free access to the esr online job forum. we invite all our members to take advantage of this opportunity by following the links in the news and views section of the rssa website. we also invite all radiologists to contribute to our journal, to consider lecturing at our congresses, and to join the rssa and enjoy the benefits of membership, including the opportunity for free corresponding membership of the ecr. rssa fees are nominal for those who are not in private practice. patricia trietsch is the rssa secretary and is contactable at radsoc@iafrica.com. dr clive sperryn pg 2.indd 2 4/16/08 9:28:06 am editorial 102 sa journal of radiology • december 2009 some aspects of computed tomography in russia to the editor: computed tomography (ct) is increasingly used in russia. some ct departments are intensely busy, concentrating on outpatient cases. free medical insurance covers only a small percentage of ct examinations, however;1 many patients pay for the procedure themselves, and some also prescribe it for themselves without consulting a physician, i.e. practice self-referral.2 scanning is usually performed after following a standard protocol and takes several minutes; then the patient leaves and the next one is consulted. detailed examination and analysis of images is performed by a radiologist in the late afternoon or evening, after the technicians have finished their work. consequently, a radiologist’s working day can last 14 hours or more, which can impair diagnostic quality because of fatigue. such a workflow does not permit immediate re-examination with enhanced resolution or modified scanning parameters, which can be indicated for an unclear lesion or a group of lesions – for example, a pneumonia-like infiltrate or dissemination in a lung.3 one of the reasons for this workflow pattern is a shortage of upto-date literature and insufficient acquaintance with foreign experience.4 misleading statements can be found in some domestic publications; for example: ‘ct has become three-dimensional, which excludes missing small pathologic lesions and structures’.5 such generalisations tend to maintain a belief in the unlimited capabilities of ‘computer diagnostics’ in order, among other things, to enhance the number of self-referred patients. as a result, an expensive procedure accompanied by x-ray exposure is sometimes performed without justifiable indications. some excerpts from one of the most broadly used russian manuals (translated verbatim): ‘… uninterrupted scanning cycle of the spiral ct allows image reconstruction at any level … in the spiral ct, a level of reconstruction does not depend on the main scanning parameters such as speed of the table or gantry positioning. as the scanning occurs uninterruptedly, the level of each section and the distance between adjacent sections are selected optionally by an operator not before but after the scanning … possibility of optional positioning of sections along the scanning axis and arbitrary choice of the section width allow forming blocks of partially overlapping images, whereas degree of mutual overlapping is practically unlimited … in conventional ct, a similar effect can be achieved only if the table feed per gantry rotation would be less than the thickness of a tomographic layer … in spiral ct, mutual overlapping of the slides is independent of the scanning parameters being a post-processing procedure … location of pathological lesions between the tomographic layers, as it can occur in conventional ct, is therefore excluded’.6 the impression is created by such assertions that a computer can reconstruct an image that is representative of the morphological substrate, on any level from the first to the last scanning plane. this notion does not take into account that a computer disposes only of the data that have been obtained as a result of radiodensity averaging of the tissue layers encompassed by the x-ray beam. if the pitch is >1, ‘the patient would have a candy-striped appearance with unmarked flesh between ribbons of paint’.7 another quotation (verbatim from the russian): ‘a result of the spiral scanning is an uninterrupted data volume, which can be arbitrarily subdivided into a required number of slides of optional thickness’.6 note that information flows uninterruptedly along a spiral line but not along the axis of table movement (z-axis), where information is intermittent and subdivided by intervals if the pitch is >1. a reconstruction algorithm interpolates the data from adjacent sections into the spaces between them. these spatial relationships can be illustrated by a plane cutting a helicoid. overextension of the spiral, and excessive elevating of the pitch and/or collimation, can cause inadequate visualisation of pathological lesions. it is sometimes argued that spatial resolution is defined only by pixel size (tiurin ie, personal communication). one must note that pixel (or voxel) size is a characteristic of the equipment, while spatial resolution is defined also by information density per volume unit of the scanned tissue, which in turn depends on the scanning parameters. with high pitch values, the volume of interest is under-sampled.8 all the above applies also to the multi-slice spiral ct, although spatial relationships here are more complicated: collimation values of a single section and of the whole detector array are distinguished, with 2 corresponding pitch values. therefore, information density (as well as x-ray exposure) depends on the table feed per gantry rotation and on the distance between adjacent sections. the issue of radiation exposure in multi-slice spiral ct is beyond the scope of this letter, but the question should be posed in principle: under which conditions is the enhanced x-ray exposure caused by crossings of beam trajectories with repeated exposure of the same tissue areas compensated by the advantages of multi-slice spiral ct, such as isotropy and high resolution volumetric data?9 ct technology is progressing – scanning time is being reduced and image quality improved. this is no reason, however, to discard the principle of image analysis that is common to radiological and microscopic methods: in the case of an unclear lesion, one should be able to go to a ‘high magnification’ i.e. to repeat an examination with necessary adjustment to scanning parameters. it is therefore advantageous, when all images are examined by a radiologist, if the patient is still in the office, so that secondary scanning can be performed, if indicated. the total time per patient would probably be lower than in delayed image viewing, because a radiologist would not have to delve twice into a case. to maintain the same productivity, reception hours and, correspondingly, the working time of technicians should be prolonged. the great difference between the length of the working day for technicians and radiologists seems to be specific to russia, as well as the relatively low remuneration for radiologists (<10% of the amount paid by the patient or insurer). additionally, it has been reported that ct productivity is enhanced when several technicians work simultaneously.10 the workflow described in the first paragraph (scanning performed after a standard protocol, and images viewed after reception hours) can be justified for screening purposes. however, the usefulness of ct screening and examination to selfreferred patients is questionable.2,11 a concluding point is that clinicians in modern hospitals have access to ct images via a computer network.12 but in many russian hospitals, they can obtain only images on an xray film and a verbal description. overall, however, there are grounds for optimism: the improved economy now makes it possible to acquire modern equipment and literature, while broadening international cooperation will attract foreign expertise into the country. sergei v jargin department of pathology letters letter to the editor.indd 102 11/19/09 2:27:27 pm 103 sa journal of radiology • december 2009 peoples’ friendship university of russia, moscow elena e jargina clinical hospital nr. 83, moscow sjargin@mail.ru 1. jargin s. some aspects of medical insurance in russia. s afr med j 2008; 98(12): 907. 2. fenton jj, deyo ra. patient self-referral for radiologic screening tests: clinical and ethical concerns. j am board fam pract 2003; 16: 494-501. 3. tiurin ie, neishtadt as, sigina oa. disseminated pulmonary tuberculosis: significance of high-resolution computerized tomography (in russian) vestn rentgenol radiol 1998; (6): 10-17. 4. jargin sv. limited access to foreign medical literature in russia. cilip health libraries group newsletter, 25(4). http://www.cilip.org.uk/specialinterestgroups/bysubject/health/newsletter (accessed 15 april 2009). 5. ternovoĭ sk, sinitsyn ve. progress in computed tomography and radiodiagnosis (in russian with english summary) ter arkh 2006; 78(1): 10-12. 6. tiurin ie. computed tomography of thoracic organs [in russian]. st. petersburg: elbi, 2003: 72-73. 7. cody dd, mahesh m. aapm/rsna physics tutorial for residents: technologic advances in multidetector ct with a focus on cardiac imaging. radiographics 2007; 27: 1829-1837. 8. prokop m. principles of ct, spiral ct, and multislice ct. in: prokop m, galanski m, van der molen aj, schaefer-prokop c, eds. spiral and multislice computed tomography of the body. stuttgart: thieme, 2003: 2-43. 9. dalrymple nc, prasad sr, el-merhi fm, chintapalli kn. price of isotropy in multidetector ct. radiographics 2007; 27: 49-62. 10. boland gw, houghton mp, marchione dg, mccormick w. maximizing outpatient computed tomography productivity using multiple technologists. j am coll radiol 2008; 5: 119-125. 11. furtado cd, aguirre da, sirlin cb, et al. whole-body ct screening: spectrum of findings and recommendations in 1192 patients. radiology 2005; 237: 385-394. 12. van ooijen pm, bongaerts ah, witkamp r, wijker a, tukker w, oudkerk m. multi-detector computed tomography and 3-dimensional imaging in a multi-vendor picture archiving and communications systems (pacs) environment. acad radiol 2004; 11: 649-660. role of abdominal ultrasound in the context of the hiv/aids epidemic to the editor: i read the article in the june 2009 edition of the sajr entitled ‘trans-abdominal ultrasonic findings correlated with a cd4+ counts in adult hiv-infected patients in benin, nigeria’,1 with interest. i totally agree that the use of ultrasound (us) is invaluable in the assessment of hiv-positive patients and in the monitoring of treatment in these patients. i must, however, disagree with the statement that it should be used in all hiv-infected patients as a baseline investigation. the authors themselves clearly state that ‘few of the ultrasound findings correlated statistically with the cd4+ counts.’ this is unsurprising, given the unfocused use of us in terms of the patients’ symptomatology in their study. the manpower needs to perform a baseline us study of the abdomen in every patient diagnosed with hiv, regardless of their clinical state, are also probably not realistically achievable, given the workload and staffing ratios of our hospitals. in the appropriate clinical setting, however, us can be a vital tool in the assessment of patients with abdominal symptoms and in patients with an unexplained pyrexia in whom the chest x-ray is normal and sputum examination for acid-fast bacilli is negative. in this setting, us of the abdomen has the potential to detect many conditions, but in particular to demonstrate evidence of disseminated tb (which is a relatively common condition in our immuno-compromised population). in 2002, dr mike hunter and i published our experience with the use of abdominal sonar in hiv-infected patients with a fever of undetermined origin in a letter to the south african medical journal.2 three findings were of particular note. the first was that pericardial effusion (which is easily demonstrated via the infra-sternal approach on abdominal us, and should be a routine component of every abdominal us) was a not uncommon, and often unexpected, finding, even in patients where the cardiac density was not enlarged on chest x-ray. because small pericardial effusions are common in hiv-infected patients, we used a threshold of 5 mm for the diagnosis of a pathological collection. as tuberculous pericarditis is by far the most common cause of an effusion in this setting, patients with a pericardial effusion >5 mm in width were started on treatment for tb and closely monitored. secondly: in our experience, the most common cause by far of abdominal lymphadenopathy in hiv-infected patients with pyrexia is tuberculous lymphadenitis. the distribution typically involves the porta hepatus, peripancreatic region, and occasionally the splenic hilum. the differential diagnosis includes lymphoma and persistent generalised lymphadenopathy (a component of the aids-related complex). both these latter conditions appear to be very uncommon in our population. we therefore regard abdominal lymphadenopathy (in the appropriate clinical setting) as diagnostic of tuberculous lymphadenitis in the first instance, and therefore an indication for tb treatment. should the patient fail to respond to antituberculous treatment (a very rare occurrence in our series), further investigation of the lymphadenopathy is indicated. the third important finding in our series, in the diagnosis of disseminated tb, is that of splenic micro-abscesses. we found the demonstration of micro-abscesses within the spleen to be highly correlated with a diagnosis of disseminated tb. although a number of other causes of splenic micro-abscesses (including salmonella, candida, lymphoma and histoplasmosis) have been described, disseminated tb is by far the most common cause in our population, and is regarded as an indication for commencing tb treatment. as with the other findings (as described above), these patients are closely monitored on both clinical and sonographic follow-up. only patients who fail to respond to tb treatment (again, very rare in our series) are subjected to further investigation. when used in this way, us of the abdomen results in substantial savings in terms of rendering more expensive and invasive investigations and their substantial costs unnecessary. this is of particular relevance in a resource-constrained setting, where access to sophisticated diagnostic modalities is limited. us, with its immediate results, also has the potential to save days (sometimes even weeks) in the time interval between performing the diagnostic examination and commencing treatment (compared with, for example, awaiting the results of tissue biopsy or bone marrow aspiration). although i do not dispute that the article is valuable in furthering our knowledge of hiv/aids via the medium of us imaging, i believe that there are very limited indications for us in asymptomatic patients, even those who are hiv-positive. however, in our hospital (and in several other institutions that i am aware of ), abdominal us is not only being successfully used on a daily basis not only for the evaluation of patients with abdominal symptoms but also, according to the above criteria, in the diagnosis or exclusion of disseminated tb. d j emby anglogold ashanti health, western deep levels hospital, carletonville demby@anglogoldashanti.com letter to the editor.indd 103 11/19/09 2:27:28 pm 104 sa journal of radiology • december 2009 1. igbinedion b o-e, marchie t t, ogbeide e. trans-abdominal ultrasonic findings correlated with cd4+ counts in adult hiv-infected patients in benin, nigeria. s afr j radiol 2009; 13(2): 34-40. 2. emby d j, hunter m. the value of ultrasound in the hiv-infected patient with a fever of undetermined origin. s afr med j 2002; 92(8): 566. dr igbinedion and co-authors reply: we thank dr emby for his interest in our article. during the course of the study, the recruiting physicians noted its usefulness, especially in renal scans, where we detected several asymptomatic nephropathies; consequently, these patients benefitted from improved follow-up laboratory reports after medical intervention. we are therefore of the opinion that radiologists should, if at all possible, not shy away from their responsibilities, even in the context of unbalanced staff ratios. this is one of the reasons why unqualified individuals offering ultrasonography in several nigerian communities have led to increased frequencies of quackery and missed diagnosis, which is a major and potentially disastrous non-biological hazard of ultrasound. our study was rather an abridged version of a broader perspective. in the study, fever, cough, skin rash and diarrhoea were the most common presenting complaints (45.3%, 25%, 20% and 14.7% respectively) while uncommon complaints constituted only 8.6%. unfortunately, apart from skin rash, these symptoms did not correlate significantly with abnormal sonographic findings on univariate analysis. but, as would be expected, patients with abdominal symptoms had more abnormal sonographic findings compared with those with other complaint or no presenting complaint at all. however, since we are currently undertaking a followup study, there may be further interesting findings in the offing. b o-e igbinedion department of radiology, college of medical sciences, university of benin and university of benin teaching hospital, benin, edo, nigeria igbins2@yahoo.com letters letter to the editor.indd 104 11/19/09 2:27:28 pm article information authors: e.b. arkink1,2 j.h.m. frijns3 b.m. verbist1,4 affiliations: 1department of radiology, leiden university medical center, the netherlands 2department of radiology, medical center haaglanden, the netherlands 3department of otorhinolaryngology, leiden university medical center, the netherlands 4department of radiology, radboud university nijmegen medical center, the netherlands correspondence to: e.b. arkink email: e.b.arkink@lumc.nl postal address: albinusdreef 2, 2333 za leiden, netherlands how to cite this article: arkink, e.b., frijns, j.h.m., verbist, b.m. temporal bone imaging. s afr j rad. 2015;19(1); art. #834, 2 pages. http://dx.doi.org/10.4102/sajr.v19i1.834 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. temporal bone imaging in this quiz case... open access a 46-year-old man presented to the department of otolaryngology with congenital deafness of unknown cause. with the help of hearing aids (which did not provide any speech understanding in the sound-only condition) and by mastering speech reading, he had learned to speak quite fluently at a school for deaf and hearing-impaired children. despite these capabilities, he came to seek advice about cochlear implants, as he would like to communicate more conveniently with his family, of whom none had significant hearing loss. on physical examination, he was completely deaf and had adapted to major vestibular deficits (i.e. bilateral vestibular areflexia). the following ct scan of the petrous bone (figure 1) and mri images of the cerebellopontine angle (figure 2) were obtained. figure 1: axial images through the right (panel a, c, e and g) and left (panel b, d, f and h) petrous bone. axial images through the right (panel a, c, e and g) and left (panel b, d, f and h) petrous bone. figure 2: axial t2-weighted mri of the inner ear, internal auditory canal and cerebellopontine angle. describe the relevant imaging findings and formulate the most appropriate clinical diagnosis. please submit your response to misser@lakesmit.co.za not later than 31 july 2015. the winning respondent will receive r1000 from the rssa. a detailed diagnosis and discussion will be presented in the next issue of the sajr. radiology introduction indirect carotid-cavernous fistulae (ccfs) or dural arteriovenous fistulae of the cavernous sinus are relatively uncommon lesions treated primarily by endovascular means. indirect ccfs acquire blood supply from dural branches of the internal carotid artery (ica), external carotid artery (eca) or dual supply from both arteries. the cause is often unknown, but they may be associated with pregnancy, trauma, sinusitis, surgical procedures, or cavernous sinus thrombosis.1 symptoms are related to the degree of arteriovenous shunting and the route of venous drainage. venous drainage via the superior ophthalmic vein produces ocular symptoms; most frequently, conjunctival injection (red eye), glaucoma, diplopia, proptosis and decreased visual acuity. indirect ccf can be treated by manual extracranial compression or transarterial and/or transvenous endovascular techniques. the venous route is usually through the inferior petrosal sinus.1 the superior ophthalmic vein (sov) approach is another valuable alternative endovascular route. we report on a case of indirect ccf treated successfully using the sov approach. case report a 53-year-old woman presented with a 4-month history of pulsatile headaches, tinnitus and hyperaemia of both eyes. she had a 2-month history of blurred vision and diplopia in all gaze positions. there was no history of head trauma. the patient was otherwise healthy and was a nonsmoker. physical examination revealed conjuctival chemosis without proptosis. she had arterialisation of the conjuctival blood vessels. prominent exophthalmos was noted. there was no anisicoria. visual acuity was 20/40 in the right eye and 20/25 in the left eye. fundal examination revealed retinal blot haemorrhages and bilateral optic nerve cupping. the patient had bilateral raised intraocular pressures. the remainder of the neurological and physical examination was unremarkable. she was investigated with magnetic resonance imaging (mri) and magnetic resonance angiography of the brain performed at an outside institution. this was reported as normal. cerebral angiography demonstrated a barrow type d indirect ccf supplied by meningeal branches of the left ica and both ecas via accessory and middle meningeal, superficial temporal and ascending pharyngeal branches (fig. 1). drainage from the cavernous sinus was via both superior ophthalmic veins. there was no cortical venous drainage or drainage to the inferior petrosal sinus from the cavernous sinus. attempted manual carotid artery case report 23 sa journal of radiology • february 2005 indirect carotidcavernous fistula — embolisation using the superior ophthalmic vein approach p szkup md, fcr (d) sa, mmed (uct) department of medical imaging royal university hospital university of saskatchewan, saskatoon canada m kelly md k meguro md, frcs (c) division of neurosurgery royal university hospital university of saskatchewan saskatoon canada fig .1a. left common carotid angiogram, ap view, showing the carotid-cavernous fistula. note opacification of the left cavernous sinus (arrow) and filling of the right cavernous sinus (double arrows). radiology 2/24/05 4:50 pm page 23 compression treatment performed by the patient was ineffective. transarterial embolisation via the external and internal carotid arterial feeders was not used as it was feared that this might promote multiple new feeders if the fistula occlusion was incomplete (as is often the case), together with the risk of potential complications associated with transarterial procedures. transvenous embolisation via the inferior petrosal sinuses was therefore attempted. transfemoral venous catheterisation of the origin of the left inferior petrosal sinus using a 5 french h1 (cook) catheter was performed initially. however a fastracker-18 microcatheter (targetboston scientific) could not be advanced further into the inferior petrosal sinus. similarly cannulation of the right inferior petrosal sinus also failed. therefore, a microsurgical approach under general anaesthesia was performed in the operating room, with direct exposure of the left sov via a 2 cm skin incision in the upper left eyelid and opening of the orbital septum. the sov was exposed and secured with a vascular loop. the sov was punctured using a 4 french micropuncture set (target-boston scientific), which was also used as a sheath for introducing a microcatheter. the sheath was temporarily fixed with a suture and attached to a side-arm adaptor allowing continuous flushing of the sheath with saline. the patient was then transferred to the vascular suite for embolisation. a fastracker-18 microcatheter with a 0.014 microguidewire were navigated through the left sov, left cavernous sinus and into the right cavernous sinus under fluoroscopic guidance (fig. 2). seven platinum tornado microcoils (cook, bloomington il, usa) were deployed in the right cavernous sinus. the catheter was then withdrawn back into the left cavernous sinus and proximal segment of the left sov where further microcoils were deposited. a total of 27 microcoils of 4/2 mm and 3/2 mm diameter were placed in both cavernous sinuses and the origin of the left sov (fig. 3). systemic heparinisation was omitted in order to promote thrombosis of the cavernous sinus and reduce the likelihood of bleeding. control angiography of both common carotid arteries following embolisation showed occlusion of the fistula (fig. 4). after embolisation, the cannula was removed from the sov and the sov was ligated with 3-0 silk thread. the 24 sa journal of radiology • february 2005 case report fig. 1b. left common carotid angiogram, delayed phase lateral view, showing prominent venous drainage from the cavernous sinus (double arrows) through both sovs (arrow). fig. 2. ap view of cavernous sinus venogram via microcatheter (arrow) passed through the sov. fig. 3. ap view of cavernous sinus venograms performed via microcatheter passed through the sov (arrow). note coils in both cavernous sinuses. fig. 4a. anteroposterior and (b) lateral left common carotid angiograms after embolisation. the fistula is obliterated completely. multiple coils can be seen in both cavernous sinuses (arrow). radiology 2/24/05 4:50 pm page 24 skin incision was closed with subcutaneous 5-0 vicryl suture. the postprocedural course was uneventful. the congestion of the eye and the intracranial noise disappeared. the patient was discharged from the hospital in satisfactory condition. on follow-up, the diplopia and 6th nerve palsy were found to have resolved and the visual symptoms had improved. the glaucoma had also resolved, with normal intraocular pressures measured at 4 months’ follow-up. discussion indirect ccfs are rarely life threatening. spontaneous regression of indirect ccfs is not uncommon, with reported incidence ranging from 9.4% to 46%.2 because of the usually benign nature of this disease, attempted conservative treatment by means of carotid/jugular compression is recommended initially. in cases with rapidly deteriorating ocular symptoms and/or cortical venous drainage more urgent interventional therapy is necessary. there are three methods of embolising ccfs: (i) transarterial; (ii) transvenous; and (iii) direct with surgical exposure of the cavernous sinus. transarterial embolisation of the supplying ecas is often attempted initially using polyvinyl alcohol particles or liquid adhesives. arterial embolisation alone is seldom successful as it is often incomplete with development of multiple additional feeders despite apparent initial success.3 the use of small particles or liquid adhesives carries the risk of cranial nerve palsies and tissue necrosis. small arterial feeders originating from the ica can be endovascularly inaccessible or dangerous to catheterise. arterial embolisation may play a role as an adjunct to venous embolisation, by decreasing the magnitude of the shunt. transvenous embolisation is probably the preferred option in the majority of patients with dural arterio-venous malformations (avms) including indirect ccf.1,3 this allows preservation of the ica. the specific approach depends on the venous drainage route from the cavernous sinus and the location of the distended part of the cavernous sinus. the cavernous sinus is most easily accessed through the inferior petrosal sinus (ips) via a femoral or internal jugular vein access.1,4 if the ips approach is not possible or has failed, an anterior transvenous approach to the cavernous sinus through the sov is a good alternative. other transvenous approaches described to date include those via the superior petrosal sinus, pterygoid plexus and through the cortical veins.1,5,6 teng et al.7 described the transorbital approach with percutaneous puncture and catheterisation of the sov. direct percutaneous puncture of the cavernous sinus through the superior orbital fissure has also been reported.8,9 many interventional radiologists consider the latter two techniques to have an unacceptably high risk of intraorbital haematoma. derang10 strongly discourages direct puncture of the sov or angular vein without surgical exposure of the vein. the risk of damaging the vein or creating an intraorbital hematoma is felt to be greatly reduced by microsurgical exposure of the vein. transfemoral cannulation of the sov through the facial vein may be a safe and elegant alternative approach, but can be difficult due to unfavourable venous anatomy, lack of venous distention or the presence of venous stenoses. small and tortuous facial and angular veins often do not allow use of detachable balloons. this technique can be modified by using internal or external jugular vein approaches.11,12 the anterior approach to the cavernous sinus through the sov is usually performed after surgical exposure of the sov or the angular vein. the sov surgical route was first described in 1969 and later refined.11 surgical loops are applied proximal and distal to the site of the intended venous puncture. the vein can be then catheterised with a microcatheter or small sheath. the surgical exposure and catheterisation of the sov can be difficult, and a vein that appears very large at angiography can be surprisingly elusive in the surgical field. potential complications of the sov approach include haemorrhage from the surgical cut-down, rupture of the sov, damage to the trochlea or other orbital structures and infection. although anatomically venous, the draining veins are arterialised in fistulae and so behave and bleed as arteries do. current opinion supports use of the surgical sov approach only when transfemoral venous access has failed.1,3,13,14 in patients without alternatives this approach can be very effective. surgical exposure permits direct visualisation and immobilisation of the sov with less risk of rupture of the vein than with percutaneous puncture. the more direct approach should also need fewer catheter manipulations. a variety of microcoils, detachable microcoils and detachable balloons can be used via this approach. orbital haemorrhage can also be addressed more directly. perforation of one of the ophthalmic case report 25 sa journal of radiology • february 2005 radiology 2/24/05 4:50 pm page 25 26 sa journal of radiology • february 2005 veins with a micro-guidewire may occur during catheterisation. as long as the leak is sealed quickly with coils the haematoma should resolve within a few days. other risks include overdistention of the cavernous sinus by coils causing cranial nerve palsies (mainly the vith nerve). dural dissection or penetration rarely occur. in conclusion, we find that retrograde catheterisation of the sov following surgical exposure appears to be a safe, direct, controlled and efficient way of accessing the cavernous sinus, allowing endovascular coil occlusion of dural cavernous fistulae with excellent angiographic and clinical results. this technique is recommended for use in patients with indirect ccfs in the following circumstances: (i) progression of ocular symptoms with decreasing visual acuity; (ii) arterial supply via multiple feeders from the eca and meningeal branches of the ica; and (iii) when the inferior petrosal sinus route fails. acknowledgements the authors wish to thank m conlon (department of ophthalmology) for his help in management of the patient, a dangor (department of anaesthesiology) for anaesthesia administered during the angiographic procedure, and s j beningfield and i duncan for assistance with the manuscript. references 1. halbach v, higashida r, hieshima g, harding c, yang p. transvenous embolization of direct carotid cavernous fistulas. am j neuroradiol 1988; 9: 741-747. 2. komiyama m, morikawa k, fu y, yagura h, yasui t, baba m. indirect carotid-cavernous sinus fistula: transvenous embolization from the external jugular vein using a superior ophthalmic vein approach. a case report. surg neurol 1990; 33: 57-63. 3. quinones d, duckwiler g, gobin y, goldberg a, vinuela f. embolization of dural cavernous fistulas via superior ophthalmic vein approach. am j neuroradiol 1997; 18: 921-928. 4. miller n, monstein l, debrun g, tamargo r, nauta h. treatment of carotid-cavernous sinus fistulas using a superior ophthalmic vein approach. j neurosurg 1995; 83: 838-842. 5. chun g, tomsick t. transvenous embolization of a direct carotid cavernous fistula through the pterygoid plexus. am j neuroradiol 2002; 23: 1156-1159. 6. bellon r, liu a, adler a, norbash a. percutaneous transfemoral embolization of an indirect carotid-cavernous fistula with cortical access to the cavernous sinus. j neurosurg 1999; 90: 959-963. 7. teng m, guo w, huang c, wu c, chang t. occlusion of arteriovenous malformation of the cavernous sinus via the superior ophthalmic vein. am j neuroradiol 1988; 9: 539-546. 8. teng mm, lirng jf, chang t, et al. embolization of carotid cavernous fistula by means of direct puncture through the superior orbital fissure. radiology 1995; 194: 705-711. 9. benndorf g, bender a, campi a, menneking h, lankish w. treatment of a cavernous sinus dural arteriovenous fistula by deep orbital pucture of the superior ophthalmic vein. neuroradiology 2001; 43: 499-502. 10. derang j, ying h, long y, reifa s, qiming w, yimu f. treatment of carotid-cavernous fistulas retrograde via the superior ophthalmic vein. surg neurol 1999; 52: 286-293. 11. biondi a, milea d, cognar c, ricciardi k, bonneville f, van effenterre r. cavernous sinus dural fistulae treated by transvenous approach through the facial vein: report of seven cases and review of the literature. am j neuroradiol 2003; 24: 1240-1246. 12. naito i, magarisawa s, wada h. facial vein approach by direct puncture at the base of the mandible for dural carotid-cavenous fistula. interventional neuroradiology 2002; 8: 67-70. 13. monsein l, debrun g, miller n, nauta h, chazaly j. treatment of dural carotid-cavernous fistulas via the superior ophthalmic vein. am j neuroradiol 1991; 12: 434-439. 14. cheng k, chan c, cheung y. transvenous embolization of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases. acta neurochir 2003; 145: 17-29. case report radiology 2/24/05 4:50 pm page 26 article information authors: shalendra k. misser1 dion b. steer2 stephen purcell3 affiliations: 1lake smit and partners inc, durban, south africa2alberlito hospital, ballito, south africa 3hainsworth, purcell and associates inc, durban, south africa correspondence to: shalen misser postal address: private bag x08, overport 4067, durban, kwazulu-natal, south africa how to cite this article: misser sk, steer db, purcell s. body imaging: diagnosis. s afr j rad. 2014;18(1); art. #625, 3 pages. http://dx.doi.org/10.4102/ sajr.v18i1.625 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. body imaging: diagnosis in this quize case... open access • abstract • answer • discussion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ we congratulate dr ian haynes from pietermaritzburg for his spot-on diagnosis for which he will receive the prize of r1000 sponsored by rssa. drs misser et al. elaborate on the findings and provide a brief discussion.a 38-year-old woman presented with a painful left paramedian infra-umbilical abdominal wall mass. she is a keen athlete and is otherwise well. these are her ultrasound images and magnetic resonance imaging (mri) sequences (after gadolinium administration). answer top ↑ the ultrasound images (figures 1 and 2) demonstrate a spindle-shaped soft tissue mass of low central echogenicity, located at the medial margin of the left rectus abdominus muscle. the colour duplex sonar image reveals differential vascularity at the various aspects of the lesion. at the time of the sonar, we performed an ultrasound-guided biopsy of the lesion. in order to avoid peritoneal breach, a tangential caudocranial trajectory of the biopsy needle was employed. three passes were made through the less vascular aspect of the lesion. figure 1: sagittal b-mode sonar image. figure 2: sagittal colour duplex sonar image. figures 3 and 4 are axial and coronal post-gadolinium magnetic resonance (mr) images showing the intense enhancement pattern of the mass limited to the abdominal wall with no associated peritoneal or visceral abnormality. the transverse signal abnormality related to previous pfannenstiel incision for caesarean section was noted. no synchronous lesions were identified. figure 3: axial post-gd t1 weighted image through lesion. figure 4: coronal post-gd t1 weighted image. based on the location of the lesion, sonar features and mri enhancement pattern, the principal radiological diagnosis was that of a desmoid tumour of the left rectus muscle. in fact, the initial sonar-guided core biopsy specimen was reported as a benign desmoid tumour. in light of the persistent cyclical pain and impact on the patient’s activities, including sport, an excision of the mass was performed. the margins were complete and the lesion, measuring 2 x 1.8 x 1.5 cm, had a peculiar increased vascularity in the central part of the specimen relative to the rest of the tumour. microscopic pathologic assessment (figure 5) confirmed, in addition to a background fibromatous stroma, the presence of endometrial tissue within the lesion. this included the presence of cysts and/or endometrial glands lined by tall columnar endometrial cells associated with a small amount of surrounding endometrial stroma. some of the cysts were haemorrhagic. surrounding mixed inflammatory cell infiltrate was present, including oedematous fibrous connective tissue stroma with lipid-laden macrophages. figure 5: microscopy of the mass – haematoxylin and eosin stain (x 50 magnification). in retrospect it was noted that the patient had had a previous caesarean section, which predisposed her to endometrial seeding. the final diagnosis was abdominal wall endometriosis with surrounding fibrosis. discussion top ↑ endometriosis is a fairly common entity in women of child-bearing age, occurring in 10% of the population, and is defined as the presence of normal endometrial tissue outside of the uterine cavity.1 these extra-uterine deposits of endometrium usually settle in the pelvis around the ovary or broad ligament. extrapelvic sites are uncommon but increasingly being recognised. abdominal wall endometriosis (awe) is one example of extrapelvic endometriosis, accounting for 0.5% – 4.0% of all cases of endometriosis. awe is identified by the triad described by esquivel-estrada et al.,2 consisting of periodic pain, associated with menses, history of caesarean section, and tumour inside a surgical scar confirmed as endometrium after histopathologic examination. awe usually develops in relation to a previous surgical scar and should be considered in the differential diagnosis of any young adult female patient with an abdominal wall mass. with increasing numbers of surgical obstetric deliveries by caesarean section, the incidence of awe is increasing and likely to be more frequently identified. awe may develop months or years following the surgery. pelvic endometriosis may not necessarily be present in the setting of awe and is therefore not a prerequisite for the diagnosis.3 symptoms associated with endometriosis may mimic other abdominal wall lesions (table 1), therefore a definitive preoperative diagnosis is not always easy in every case. in horton’s series,3 the majority presented with mass, pain or less likely, cyclical symptoms. the major differential diagnoses include desmoid tumour, haematoma, abscess, neoplasm or injection-related granuloma. desmoid tumour, also known as aggressive fibromatosis, is the primary differential diagnosis. there are several subtypes of desmoid tumours, including those associated with familial adenomatous polyposis (gardner’s) syndrome. the pain in awe is typically cyclical but may be constant or lesions may be painless. this makes differentiation from desmoid tumours difficult clinically. table 1: differential diagnosis of anterior abdominal wall masses. on ultrasound, awe demonstrates heterogeneous reduced echogenicity with internal vascularity on colour duplex and power doppler imaging.4 desmoid tumours are more homogeneous in echo texture and seldom show increased vascularity. computed tomography (ct) scans show well-circumscribed masses of isodensity to muscle in both cases. abscesses may demonstrate lower central attenuation of < 20 hu. the mri signal of endometriomas varies depending on the cystic component. awe usually shows iso-intense to hyperintense signal on both t1 and t2 weighted sequences relative to muscle. table 2 describes the mri appearances of awe and the major differential diagnoses. atypical awe, which resembles cystic ovarian endometriomas, may have t1 weighted uniform hyperintensity and t2 weighted low signal. desmoid tumours are generally hyperintense to muscle on t2 weighted images, but as they mature with increasing collagenous component, the t2 signal decreases and approximates skeletal muscle. table 2: mri features of the major differential diagnoses. fluorodeoxyglucose (fdg) positron emission tomography (pet) scanning has only been described in a few reports for assessment of endometriomas. most of the described lesions appear photopenic with reduced tracer uptake. the management of awe includes conservative pharmacotherapy using hormonal agents or surgical excision.5 progestogen drug therapy is usually only beneficial in controlling symptoms temporarily, with recurrence on cessation of therapy. surgical extirpation after confirmation of diagnosis on fine needle or core biopsy is the recommended treatment of choice. recurrence after surgery is generally not expected. awe is becoming more frequently diagnosed because of the increasing awareness of this condition and the increasing number of caesarean section deliveries. it is the radiologist who should raise the alarm when sonar imaging of a mass in the anterior abdominal wall close to a surgical scar reveals heterogeneous echo and increased vascularity. although there remains a wide list of differential diagnoses, the possibility of awe should always be raised. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions s.k.m. (lake smit and partners inc) was responsible for concept design, literature search, manuscript preparation and review. d.b.s. (alberlito hospital) was involved in manuscript review and definition of intellectual content. s.p. (haisworth, purcell and associates inc) was involved in histopathological slide preparation and manuscript editing. references top ↑ 1. stein l, elsayes km, wagner-bartak m. subcutaneous abdominal wall masses: radiological reasoning. ajr. 2012;198:w146–151. http://dx.doi.org/10.2214/ajr.10.7238 2.esquivel-estrada v, briones-garduño jc, mondragón-ballesteros r. endometriosis implant in caesarean section surgical scar. cir cir. 2004;72(2):113–115. http://dx.doi.org/10.1016/j.amjsurg.2007.07.035 3.horton jd, dezee kj, ahnfeldt ep, wagner m. abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. am j surg. 2008;196:207–212. 4.hensen jj, van breda vriesman ac, puylaert jbcm. abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. ajr. 2006;186:616–620. http://dx.doi.org/10.2214/ajr.04.1619 5.blanco rg, parithivel vs, shah ak, gumbs ma, schein m, gerst ph. abdominal wall endometriomas. am j surg. 2003;185(6):596–598. http://dx.doi.org/10.1016/s0002-9610(03)00072-2 abstract introduction utility of cardiovascular magnetic resonance structure and function planning intervention tissue characterisation risk stratification hypertrophic cardiomyopathy phenocopies and infiltrative cardiomyopathies limitations of cardiovascular magnetic resonance conclusion competing interests references about the author(s) rebecca schofield barts heart centre, london, united kingdom katia manacho barts heart centre, london, united kingdom silvia castelletti istituto auxologico italiano irccs ‘san carlo’, milan, italy james c. moon barts heart centre, london, united kingdom institute of cardiovascular science, university college london, united kingdom citation schofield r, manacho k, castelletti s. & moon jc. cardiovascular magnetic resonance in hypertrophic cardiomyopathy and infiltrative cardiomyopathy. s afr j rad. 2016;20(2), a1020. http://dx.doi.org/10.4102/sajr.v20i2.1020 review article cardiovascular magnetic resonance in hypertrophic cardiomyopathy and infiltrative cardiomyopathy rebecca schofield, katia manacho, silvia castelletti, james c. moon received: 02 may 2016; accepted: 09 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract hypertrophic cardiomyopathy (hcm) is the most common inherited cardiac disease. cardiac imaging plays a key role in the diagnosis and management, with cardiovascular magnetic resonance (cmr) an important modality. cmr provides a number of different techniques in one examination: structure and function, flow imaging and tissue characterisation particularly with the late gadolinium enhancement (lge) technique. other techniques include vasodilator perfusion, mapping (especially t1 mapping and extracellular volume quantification [ecv]) and diffusion-weighted imaging with its potential to detect disarray. clinically, the uses of cmr are diverse. the imaging must be considered within the context of work-up, particularly the personal and family history, electrocardiogram (ecg) and echocardiogram findings. subtle markers of possible hcm can be identified in genotype positive left ventricular hypertrophy (lvh)-negative subjects. cmr has particular advantages for assessment of the left ventricle (lv) apex and is able to detect both missed lvh (apical and basal antero-septum), when the echocardiography is normal but the ecg abnormal. cmr is important in distinguishing hcm from both common phenocopies (hypertensive heart disease, athletic adaptation, ageing related changes) and rarer pheno and/or genocopies such as fabry disease and amyloidosis. for these, in particular the lge technique and t1 mapping are very useful with a low t1 in fabry’s, and high t1 and very high ecv in amyloidosis. moreover, the tissue characterisation that is possible using cmr offers a potential role in patient risk stratification, as scar is a very strong predictor of future heart failure. scar may also play a role in the prediction of sudden death. cmr is helpful in follow-up assessment, especially after septal alcohol ablation and myomectomy. introduction hypertrophic cardiomyopathy (hcm) is mainly an autosomal-dominant condition caused by mutations in sarcomeric proteins, with a prevalence of around 1 in 500 in the general population. first-degree relatives of known sarcomeric hcm patients have a one-in-two chance of developing hcm. major advances in cardiac imaging and genetics over the last 50 years have improved our diagnostic ability in cases of hcm. the condition is linked to over 1500 genetic mutations, most commonly missense mutations in beta myosin heavy chain (40%), myosin binding protein c sarcomere (40%), and troponin (11%) genes.1 point mutations between affected individual families may be diverse.2 genetic testing is helpful for family screening and also enables the exclusion of hcm mimics including storage disorders such as pragk2, fabry’s, danon and lamp2 which have very different prognosis and treatment options. the clinical presentation and natural history of hcm may be equally as diverse, even between family members sharing the same mutation. affected individuals may develop symptoms owing to left ventricular outflow tract obstruction (lvoto) such as reduced exercise tolerance, dyspnoea, chest pain, pre-syncope and syncope on exertion. they may develop a heart failure syndrome owing to diastolic or systolic ‘burnt out’ dysfunction. most concerning, they may have atrial arrhythmias (leading to stroke) or ventricular arrhythmias leading to syncope or sudden cardiac death. the ages of presentation vary widely. some gene-positive family members may not express left ventricular hypertrophy (lvh) owing to incomplete penetrance, in part because of environmental factors and the presence or absence of other, as yet poorly defined, modifier genes. the diagnosis of hcm may be acquired genetically (sarcomeric protein mutations), histologically (fibrosis, small vessel disease, disarray, no infiltration) or by cardiac morphology (unexplained hypertrophy). the clinical diagnosis is largely based on family history, ecg and cardiac imaging. imaging has other roles beyond diagnosis, including risk stratification, defining features (i.e. obstruction) and subtype, detecting early disease and also in planning intervention. echocardiography remains the first-line modality but cmr is becoming an essential next-line cardiac imaging test. in the present review, we focus on the role of cmr in the diagnosis and management of hypertrophic cardiomyopathy, heart muscle diseases with hypertrophy – hcm, and its gene and/or phenocopies. utility of cardiovascular magnetic resonance cmr offers good spatial resolution and contrast between the myocardium and blood pool to accurately assess left ventricle (lv) wall thickness and mass. short-axis slices from base to apex enable this assessment and also help to identify the subtype of hcm. flow mapping can demonstrate lvoto. vasodilator (typically adenosine) stress can assess microvascular disease and coronary perfusion defects. tissue characterisation by late gadolinium enhancement (lge) imaging and parametric mapping can help to quantify the degree of replacement and interstitial fibrosis and differentiate hcm from other diseases causing lvh (i.e. infiltrative cardiomyopathies) and aid in risk stratification. a standard cmr protocol for hcm involves a 10-minute assessment of anatomy and cardiac structure and function, followed by gadolinium-based contrast administration and scar imaging. additional scanning may be added, such as thin (5 mm) slices through the apex or left ventricular outflow tract (lvot), and additional sequences including parametric mapping (t1, t2 and ecv) can aid differentiation from cardiac amyloid, fabry disease with cardiac involvement, diffuse myocardial inflammation and diffuse fibrosis. flow mapping of the lvot and cardiac valves can be used to assess obstruction and concomitant valve disease. the future may bring diffusion imaging (for disarray), spectroscopy and other metabolic imaging. structure and function volumes and ejection fraction the improved spatial resolution and the contrast between dark myocardium and bright blood pool on the steady-state free precession (ssfp) ciné enables accurate tracing of the epiand endocardial borders. there are several areas of the heart that are better defined by cmr including the apex (figure 1),3 early basal antero-septal hypertrophy (figure 2)4 and right ventricular hypertrophy (rvh). wall thickness is well measured, but caution is needed as this is not well standardised by either echo or cmr, and typical risk algorithms use echocardiographic measurement. similarly, normal values of volume and ejection fraction in cmr differ slightly from those calculated by echocardiography. figure 1: relative apical hypertrophy, seen in two-chamber view in diastole (a) and systole (b). note also the basal inferior crypts. figure 2: asymmetrical septal hypertrophy seen on a four-chamber ciné. shown are the end diastolic (just after mitral valve [mv] closure) frame (a), and the end systolic frame (b). left ventricle crypts and subtle abnormalities the use of cmr extends the spectrum of detected cardiac changes in hcm. in patients with extensive t-wave inversion but non-diagnostic echo, relative apical hypertrophy may be found that does not meet current diagnostic criteria for hcm and can be demonstrated by cmr. flett et al.3 described the lack of tapering of the lv wall thickness towards the apex in 22 patients with ecg abnormalities. an apical to basal wall thickness ratio (abr) >1 is used as a criterion for diagnosis of relative apical hypertrophy (figure 3). presence of apical scar, left atrial dilatation and atrial fibrillation was also more common in this group than the general population, and apical micro-aneurysms (figure 4) also occurred. this appears to be a variant of hcm, although there may be an environmental contribution as the pattern is found sometimes in athletes – raising the suspicion that there are hcm genetic backgrounds where a ‘second hit’ is required for phenotypic expression. figure 3: relative apical hypertrophy. here, the normal tapering of wall thickness to the apex is absent and the maximum thickness is greater than that at the base. also note the biatrial dilatation. shown are the end diastolic frame (a), and the end systolic frame (b). figure 4: an apical micro-aneurysm. these are hard to see by echocardiography in many cases. before hypertrophy occurs, the heart has a number of characteristic abnormalities if a disease-forming mutation is being carried. these include the presence of myocardial crypts (figure 5).4 these appear to occur in the majority of genotype positive-phenotype negative hcm patients5 and may be multiple. they also occur in healthy volunteers (prevalence 3.6% – 6%) and hypertensive patients (prevalence 11% – 27%).6,7 the prognostic importance of crypts is currently unclear. the number of crypts seems to reflect the degree of abnormality, with a maximum of one crypt seen in healthy volunteers and more than one (2–3) often seen in genetic carriage.8 a recent study of developing hcm hearts in mice and humans suggests that crypts are a normal part of embryological development but disappear before birth, except in hcm, where they persist and are more abundant.9 figure 5: basal inferior crypts; these are best seen in diastole. more than two is associated with cardiomyopathy. increased length of the mitral valve leaflets has been identified in hcm and genotype positive-phenotype negative hcm independently of other variables, and this additional morphological abnormality is felt to contribute to lvoto. a ratio of anterior mitral leaflet (aml) length to lvot diameter of >2 was strongly associated with the presence of sub-aortic obstruction.10 other imaging biomarkers of hcm include increased septal curvature, increased cardiac function and more non-compacted trabeculae, abnormal papillary muscles, increased ecv and increased biomarkers of fibrosis. several of these can be combined into a score that can have 80% accuracy for the presence of a disease (if the pre-test probability is 50%).8,11 flow and perfusion echocardiography is better for peak velocities and short time interval events. cmr, however, adds value in complex obstruction (e.g. multi-level) and membranes, which may be missed on echo. similarly, right ventricular outflow tract (rvot) obstruction is easier to detect using cmr than echo. for recurrent obstruction following gradient reduction therapy (by alcohol ablation or myomectomy), cmr is essential as the precise mechanism of recurrence may be hard to define by echocardiography. perfusion cmr is interesting in hcm, as perfusion defects are often extensive and most often mid-myocardial and circumferential, suggesting they are the result of small vessel disease. these perfusion defects do occur outside areas of lge, but their significance is not yet well understood.12 planning intervention when gradient reduction therapy is planned (alcohol ablation or myomectomy), cmr is helpful. it can define the systolic anterior motion (sam), septal contact point and the wall thickness at the site and in adjacent areas – ensuring particularly that there are no thin areas that are at risk of post-procedure ventricular septal defects (vsds). cmr acts as a second scrutiny to ensure there is no membrane or aortic stenosis; it further helps with mitral valve assessment to determine whether mitral valve replacement or intervention (repair, alfieri) might be needed. post alcohol septal ablation (asa), cmr can assess procedural success by identifying and quantifying the area of septal infarction and the resultant effect on mitral valve function and lvot obstruction (figure 6). post-procedural inter-ventricular thinning or procedural vsds can be identified. possibly owing to the relatively lower pressure in the right ventricle (rv) branches of the septal perforators, it is not uncommon to find that the rv portion of the inter-myocardial septum has in fact infarcted preferentially to the lv portion (and asymmetric septal hypertrophy [ash] gives right bundle branch block [rbbb], myomectomy typically left bundle branch block [lbbb]). figure 6: (a) an alcohol ablation that is acute (microvascular obstruction at the core with a limited scar in the moderator band which may also have been an ‘off-target’ consequence. (b) a myectomy (ciné still in diastole) with alfieri stitch. tissue characterisation late gadolinium enhancement patterns gadolinium occupies the interstitium and cannot enter an intact myocyte. fibrosis is a hallmark of hcm.13 hypothesised aetiologies include repeated ischaemic insults owing to microvascular disease and oxygen supply and demand mismatch; alternatively, the genetic mutation may predispose to the abnormal accumulation of collagen within the myocardium and plexiform diffuse fibrosis owing to an increased number of collagen crosslinking fibres at the lv/rv hinge points. typical patterns of lge include ‘non-ischaemic’ (mid-myocardial) fibrosis of the maximally hypertrophied segments which may include the lv/rv insertion points or commonly the septum and anteroseptal walls (figure 7). there may be a combination of diffuse interstitial fibrosis and focal replacement fibrosis. the replacement fibrosis may, in progressive disease cases, involve most of the myocardial walls. figure 7: patterns of lge. (a) two-chamber view in apical hcm-note heterogeneous lge in mid to apical lv. (b) mid short-axis (sax) slice in septal hcm-focal inferior lv/rv insertion point lge. (c) basal sax in septal hcm-patchy septal lge. parametric mapping parametric mapping is another technique that helps to characterise tissue. the myocardial native t1 value increases in the presence of water and protein, and is reduced by the presence of fat and iron. ecv maps can be created from t1 values pre and post gadolinium contrast (figure 8). the strength of lge imaging is in demonstrating the difference between normal and abnormal myocardium, the best example being non-infarcted from infarcted myocardium where there is stark contrast between healthy (black myocardium) and dead tissue (white myocardium). in conditions of diffuse myocardial abnormality, choosing a correct inversion time (ti) to null the healthy myocardium can result in both fibrotic and normal myocardium looking similar and, consequently, abnormality being missed. techniques for quantifying the amount of lge can show wide variations in the figures generated when used to assess more subtle replacement and interstitial fibrosis. figure 8: native t1 map (a), ecv map (b) and lge in mid sax slice (c) in hcm. note the inferior lv/rv insertion point fibrosis seen as high t1 and high ecv volume and lge respectively. the lge image sees the inferior rv insertion point lge (long arrow) but misses the wider patchy fibrosis (short arrows) in the maximally hypertrophied septal segments which is easily appreciated in the native t1 and ecv maps. risk stratification hcm sudden death is relatively uncommon but feared – the lack of warning signs and the finality of the event make it of extreme concern. typically, it occurs in the younger hcm population, being less likely over the age of 65 years. with the advent of implantable cardiac defibrillators (icds), sudden cardiac death (scd) may be prevented; however, the devices themselves carry a risk (approximately 5% per year) related to infection, lead defects and inappropriate shocks. appropriate patient selection is important. secondary prevention is essential but, for others, risk stratification is needed. these models are created using large retrospective cohort studies and are evolving over time. the european society of cardiology (esc) risk calculator aims to give an approximate 5 year risk of scd. in patients with a 5 year risk of scd < 4%, an icd is generally not indicated, in patients with a risk of 4 to less than 6%, an icd may be considered and in patients with a 5 year risk ≥ 6%, an icd should be considered. the algorithm includes several continuous variables (age, maximal wall thickness by echo, left atrial size, maximum lvot gradient), and three dichotomous ones (family history of scd, previous non-sustained vt (ventricular tachycardia) and unexplained syncope). the aha (american heart association) guidelines acknowledge the potential use of lge by cmr as a risk modifier, with class iib evidence in risk stratification. cmr to assess myocardial scar and fibrosis is an attractive additional variable as fibrosis appears to be linked to outcome.14,15,16 fibrosis and disruption of the myocardial architecture has been suggested as the substrate for scd, leading to research quantifying the degree of fibrosis and the relationship to scd and vt. the lge analysis technique assesses macroscopic fibrosis, and all are subject to the difficulties in ti (inversion time) selection, windowing and detection of diffuse fibrosis discussed earlier. what is clear, however, is that scar is common in hcm – occurring in 60% – 70% of cases – so scar alone is not sufficient for adverse outcomes. there have been several studies with numbers into the low 1000s. the link of scar to sudden death appears present although, in some studies, this was present as a univariate but not multivariate risk factor; in one study by o’hanlon et al.,15 the presence of non-sustained vt was the stronger factor, whilst in another by chan et al.,16 scar over 15% predicted events, although events were driven by appropriate icd discharges (not the same as sudden death).16 what does appear clear, however, is that extensive scar predicts heart failure; the problem is that the evidence for interventions (drug therapy – conventional or otherwise) is not strong and more research is needed. another issue is lge analysis. although reasonable agreement can be reached,17 the choice of method can alter the apparent scar burden by a factor of two in hcm.18 this reflects that scar in hcm is in a continuum between normal interstitium and complete replacement fibrosis, yet the lge technique dichotomises with a threshold method that therefore becomes crucial. analysis on commercially available software (rather than corelabs) would be more clinically relevant, and newer lge sequences (phase-sensitive inversion recovery [psir], moco and implantable device corrected) are more robust than previous lge sequences. all studies thus far have quantified lge on a single-entry cmr only. rate of progression of lge may be of importance, as may myocardial ischaemia. more data are needed. currently, cmr is typically used as a red flag or arbitrator for borderline cases rather than a core part of stratification. hypertrophic cardiomyopathy phenocopies and infiltrative cardiomyopathies sarcomeric hcm has a wide differential. approaches to heart muscle disease with hypertrophy are familiar from european and us guidelines (taking phenotype or genetic approaches respectively). both approaches are useful, but ‘grey areas’ remain. cmr tissue characterisation permits a new way of considering lvh by dividing it into two compartments: the interstitium and cell volume. usually, the volume of interstitium and cells increase together (afterload – hypertension and aortic stenosis), but in some diseases (amyloid), the interstitial volume predominates and in others (storage diseases – at least early, such as fabry’s), cell volume appears to predominate. differentiating causes of lvh by imaging is familiar from echocardiography, and these features are visible by cmr. imaging, of course, is just part of investigation, and the history (including family history), ecg, exercise testing and other investigations are important. cmr adds some value with the added features for hcm (clefts) and may see early disease better than echo (focal hypertrophy). when differentiating hypertension or athlete’s heart from hcm, mapping may help; early data suggest that athletic hypertrophy has a slightly lower than normal fibrosis percentage (low ecv, low t1) with cellular hypertrophy dominating.19 these tissue characterisation techniques, however, have a major advantage in infiltration. infiltration: cardiac amyloid and fabry disease in cardiac amyloid, gadolinium kinetics are abnormal and the blood pool nulls before the myocardium (figure 9). choosing the appropriate ti value can be challenging and, if incorrect, can result in misleading lge images. the psir technique solves this problem.20 lge starts subendocardially, becoming transmural initially at the base of the lv before extending down to the apex. transmural lge confers a poor prognosis in both amyloid light-chain (al) and transthyretin-related amyloidosis (attr). when there is subendocardial lge, outcomes are intermediate and research is currently under way to determine the best treatments for this group. cardiac amyloid can be detected without using gadolinium contrast if native t1 values are significantly elevated throughout the myocardium (typically six to eight standard deviations above normal). the native t1 can be used as an early marker disease, to differentiate subtypes (al and attr) and as a prognostic tool.21 figure 9: four-chamber lge sequence in cardiac amyloid. the gadolinium kinetics are abnormal. blood pool nulls before myocardium (which appears bright). most storage diseases (glycogen, lysomal) appear to cause lv scar, but the natural history of these diseases is not well known. in fabry disease, an x-linked disorder of sphingolipid metabolism, there are more specific features: the basal inferolateral wall typically shows mid-wall lge (figure 10) and the native t1 values are lower than the normal range. moreover, it has been shown that the t1 value can be an early marker of disease in fabry’s patients, even in the absence of hypertrophy.22 recent work measuring t2 values in areas of lge has demonstrated high t2 values that correlate with high-sensitivity troponin t (hs-tnt), suggesting a possible chronic inflammatory component. figure 10: basal lateral mid-wall lge in fabry disease. the differential for this scar pattern includes previous myocarditis, which t1 mapping would confirm. other forms of infiltration: sarcoidosis and iron perhaps implied by the history, cardiac sarcoid can be detected by cmr. acutely, there may be myocardial thickening and evidence of oedema on t2-weighted short ti inversion recovery (stir) imaging or t2 mapping. there may be patchy focal epicardial, transmural or mid-wall lge and rv involvement. t2* imaging is exquisitely specific for myocardial iron deposition but the diagnostic cut-off may be set too high. refinement of new diagnostic thresholds may be possible using concomitant native t1 values. characteristically, there is no wall thickening and low t2* and t1 values. fabry disease and iron are largely the main causes of low t1. limitations of cardiovascular magnetic resonance although newer scanners have a larger bore, there are still patients who cannot tolerate the confined space of the scanner. in addition, there are patients where image degradation is intolerable and results in non-diagnostic image quality owing to arrhythmias and difficulty with breath-holding. patients with cardiac devices, including pacemakers and icds, may have non-mr compatible devices or leads. in those who have compatible devices, the artefact from the device can obscure the images, rendering the images uninterpretable. newer sequences to address some of these issues are in progress. future developments although cmr now offers significant utility, there are problems. cmr is expensive and access is limited. choosing the right patients to scan for maximal cost-effectiveness is not easy. protocols may need to become shorter, less involved for patients and more focused. standardisation is needed for the latest techniques (such as t1 mapping), which may conflict with efforts to continue development. for example, t1 mapping sequences which do not require breath hold are being developed, and motion-corrected (moco) free-breathing lge sequences are in clinical use in some centres that may enable the visualisation of more detail. nevertheless, cmr roll-out is continuing and should continue to inform our understanding of disease, particularly in hypertrophy. newer techniques are pending, such as diffusion tensor imaging (dti) to visualise fibre architecture that may help our understanding of myocardial remodelling; and 4d flow is beginning to inform on cardiac haemodynamic and energetic efficiency during rest and exercise. conclusion cmr is pushing the envelope in hcm both in terms of early and more accurate diagnosis and a better understanding of the conditions and their true pathogenesis. use of tissue characterisation techniques, such as lge and parametric mapping, provides detailed information about the myocytes and cellular matrix in vivo that is beginning to translate into better care and treatment choices, to the patient’s benefit. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions s.c. and k.m. contributed images. the text was written by r.s. and j.m., with contributions from s.c., and was reviewed by s.c. references maron bj, maron ms, semsarian c. genetics of hypertrophic cardiomyopathy after 20 years: clinical perspectives. j am coll cardiol. 2012;60:705–715. http://dx.doi.org/10.1016/j.jacc.2012.02.068 seidman ce, seidman jg. identifying sarcomere gene mutations in hypertrophic cardiomyopathy: a personal history. circ res. 2011;108:743–750. http://dx.doi.org/10.1161/circresaha.110.223834 flett a, maestrini v, miliken d, et al. diagnosis of apical hypertrophic cardiomyopathy: t-wave inversion and relative but not absolute apical left ventricular hypertrophy. int j cardiol. 2015;183:143–148. http://dx.doi.org/10.1016/j.ijcard.2015.01.054 maron ms, rowin ej, lin d, et al. prevalence and clinical profile of myocardial crypts in hypertrophic cardiomyopathy. circ cardiovasc imaging. 2012;5:441–447. http://dx.doi.org/10.1161/circimaging.112.972760 germans t, wilde aa, dijkmans pa, et al. structural abnormalities of the inferoseptal left ventricular wall detected by cardiac magnetic resonance imaging in carriers of hypertrophic cardiomyopathy mutations. j am coll cardiol. 2006;48:2518–2523. http://dx.doi.org/10.1016/j.jacc.2006.08.036 johansson b, maceira am, babu-narayan sv, moon jc, pennell dj, kilner pj. clefts can be seen in the basal inferior wall of the left ventricle and the interventricular septum in healthy volunteers as well as patients by cardiovascular magnetic resonance. j am coll cardiol. 2007;50:1294–1295. http://dx.doi.org/10.1016/j.jacc.2007.06.026 child n, muhr t, sammut e, et al. prevalence of myocardial crypts in a large retrospective cohort study by cardiovascular magnetic resonance. j cardiovasc magn reson. 2014;16:66. http://dx.doi.org/10.1186/s12968-014-0066-0 captur g, lopes l, patel v, et al. abnormal cardiac formation in hypertrophic cardiomyopathy: fractal analysis of trabeculae and preclinical gene expression. circ cardiovasc genet. 2014;7(3):241–248. http://dx.doi.org/10.1161/circgenetics.113.000362 captur g, ho cy, schlossarek s, et al. the embryological basis of subclinical hypertrophic cardiomyopathy. sci rep. 2016;6:27714. http://dx.doi.org/10.1038/srep27714 maron m, olivotto i, harrigan c, et al. mitral valve abnormalities identified by cardiovascular magnetic resonance represent a primary phenotype expression of hypertrophic cardiomyopathy. circualtion. 2011;124:40–47. http://dx.doi.org/10.1161/circulationaha.110.985812 captur g, lopes lr, mohun tj, et al. prediction of sarcomere mutations in subclinical hypertrophic cardiomyopathy. circ cardiovasc imaging. 2014;7(6):863–871. http://dx.doi.org/10.1161/circimaging.114.002411 ismail tf, hsu ly, greve am, et al. coronary microvascular ischemia in hypertrophic cardiomyopathy – a pixel-wise quantitative cardiovascular magnetic resonance perfusion study. j cardiovasc magn reson. 2014;16:49. http://dx.doi.org/10.1186/s12968-014-0049-1 davies mj, mckenna wj. hypertrophic cardiomyopathy – pathology and pathogenesis. histopathol. 1995;26:493–500. http://dx.doi.org/10.1111/j.1365-2559.1995.tb00267.x maron ms, appelbaum e, harrigan cj, et al. clinical profile and significance of delayed enhancement in hypertrophic cardiomyopathy. circ heart fail. 2008;1:184–191. 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http://dx.doi.org/10.1016/j.jcmg.2010.11.015 mcdiarmid ak, swoboda pp, erhayiem b, et al. athletic cardiac adaptation in males is a consequence of elevated myocyte mass. circ cardiovasc imaging. 2016;9(4):pii:e003579. http://dx.doi.org/10.1161/circimaging.115.003579 fontana m, pica s, reant p, et al. prognostic value of late gadolinium enhancement cardiovascular magnetic resonance in cardiac amyloidosis. circulation. 2015;132(16):1570–1579. http://dx.doi.org/10.1161/circulationaha.115.016567 banypersad sm, fontana m, maestrini v. t1-mapping and survival in systemic light-chain amyloidosis. eur heart j. 2015;36:244–251. http://dx.doi.org/10.1093/eurheartj/ehu444 sado dm, white sk, piechnik sk. identification and assessment of anderson-fabry disease by cardiovascular magnetic resonance non-contrast myocardial t1 mapping. circ cardiovasc imaging. 2013;6(3):392–398. http://dx.doi.org/10.1161/circimaging.112.000070 article information authors: sucari s.c. vlok1 georg w.w. wagener1 dan zaharie2 affiliations: 1division of radiodiagnosis, stellenbosch university, south africa 2department of anatomical pathology, stellenbosch university, south africa correspondence to: sucari vlok email: sucarivlok@gmail.com postal address: 11 bergzicht, wylant street, welgemoed, bellville 7530, south africa dates: received: 28 jul. 2014 accepted: 13 nov. 2014 published: 12 dec. 2014 how to cite this article: vlok, ssc, wagenaar, gww, zaharie, d. synovial sarcoma. s afr j rad. 2014;18(2); art. #704, 3 pages. http://dx.doi.org/10.4102/sajr.v18i2.704 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. synovial sarcoma in this case report... open access • abstract • introduction • case report • discussion • teaching point • conclusion • acknowledgements    • competing interests    • author contributions • references abstract top ↑ synovial sarcoma is a malignant, predominantly juxta-articular, soft-tissue tumour representing approximately 10% of all soft-tissue sarcomas. frequently initially incorrectly diagnosed as a benign lesion, it should be considered as a diagnosis when a young adult patient presents with a calcified juxta-articular soft-tissue mass of insidious onset. introduction top ↑ synovial sarcoma was first reported in 18931 and named after its microscopic resemblance to normal synovium.2 it is thought to originate from primitive mesenchymal cells that undergo differentiation to resemble synovial cells.2,3,4,5 synovial sarcomas usually occur in adolescents and young adults, with no gender or racial predilection.2,3,4 they typically affect the extremities (80%–95% of cases),4 arising from tendons, tendon sheets and bursal structures. it is important to note that they usually arise beyond the confines of the joint capsule. the single most commonly affected site is the knee.2,3,4,5,6 synovial sarcomas are frequently initially incorrectly diagnosed as benign processes such as myositis, synovitis, haematoma, tendinitis or bursitis,2 resulting in the time to final diagnosis ranging from two to four years.4 it is therefore important to consider synovial sarcoma when a young adult patient presents with a calcified juxta-articular soft-tissue mass of insidious onset.5 case report top ↑ a 14-year-old boy presented at initial consultation with a one-year history of a tender, slow-growing, juxta-articular left knee mass. conventional radiographs revealed a soft-tissue mass with coarse calcifications (figure 1). magnetic resonance imaging (mri) displayed a soft-tissue mass with heterogeneous t1 and t2 signal characteristics (figure 2). an excision biopsy, followed by haematoxylin and eosin staining (figure 3) and subsequent examinations, was performed in order to establish the diagnosis. the cells were positive for mnf (a pan-epithelial marker), ema (epithelial membrane antigen), cd99 and bcl2. fish (fluorescence in situ hybridisation) was positive, confirming the diagnosis of synovial sarcoma. figure 1: anteroposterior (a) and lateral (b) radiographs of the left knee display a soft-tissue mass anteromedial to the proximal tibia (red arrows) of an adolescent patient. note the coarse calcifications (blue arrow, ap view). figure 2: sagittal (a) and axial (b) t1w images reveal mixed isoand hyperintense changes within the soft-tissue mass (green arrows) owing to haemorrhage, without bony or subcutaneous fat involvement. figure 3: haematoxylin and eosin staining, x 100 magnification. overlapping spindle cells with scanty cytoplasm and hyperchromatic nuclei. some of the cells formed small nests (white arrows) reminiscent of epithelial differentiation. also present are stag horn blood vessels with a haemangiopericytic pattern (black arrow). discussion top ↑ synovial sarcoma is a slow-growing, high-grade malignant neoplasm with extensive metastatic potential.4,5 it accounts for approximately 10% of all soft-tissue sarcomas3 and occurs predominantly in adolescents and young adults between the ages of 15 and 40 years.2,3,4,5 the extremities are affected in 95% of cases, and the lower limb in 70% of the former.6 the neoplasms usually occur in close proximity to large joints of the extremities, predominantly around the knee,2,3,4,5,6,7 followed by the ankle, elbow and shoulder.2 they rarely occur in the head, neck, thorax and abdomen.3 synovial sarcomas are usually found in close association with tendon sheets, bursae and joint capsules, but joint involvement is rare.2 when intra-articular involvement does occur, it usually extends from an extra-articular site into the joint space.4,5 patients most commonly present with insidious onset of a peri-articular, palpable, deep-seated swelling or mass that is commonly associated with pain or tenderness.2,3,4,5,6,7 the duration of symptoms varies from weeks to decades, with an average duration of 2–4 years.2,3,4 metastases are present in a quarter of patients at initial diagnosis,5 and mainly affect the lungs2,3,4,5 and, to a lesser extent, lymph nodes, bone and rarely the liver or brain.3 conventional radiographs may appear normal in approximately 50% of cases.4 typical radiographic features include a juxta-articular soft-tissue mass within 5 cm of the joint and amorphous calcifications in 20%–30% of cases, which are often eccentric or peripheral.4 an associated periosteal reaction is present in 15%–20% of cases.2,3,4,5,6,7 computed tomography (ct) scanning shows a soft-tissue mass with or without calcifications and bony involvement.2,3,4,5,6,7 mri is reserved for local staging of the extent of the disease. characteristic changes include a heterogeneous, multi-lobulated soft-tissue mass with a signal intensity similar to or slightly higher than that of muscle on t1w, and a mixed high, intermediate, low signal on t2w that has been described as the triple sign. fluid-fluid levels are seen in 25% of cases.2,3,4,5,6 fluorodeoxyglucose positron emission tomography (fdg-pet) is helpful in differentiating recurrent tumour from post-therapeutic changes, and is valuable in determining prognosis.3,7 it is important to note that imaging appearances are largely non-specific; biopsy is always necessary for the final diagnosis. at our institution, this is the domain of the clinician and not the radiologist. the current treatment of choice is surgery with or without radiotherapy. the use of chemotherapy is controversial.3,5 teaching point top ↑ synovial sarcoma features prominently in the differential diagnosis of a soft-tissue tumour around the knee in a young patient. conclusion top ↑ synovial sarcoma represents approximately 10% of all soft-tissue sarcomas and must be considered in addition to other sarcomas when adolescents or young adults present with insidious onset of a calcified juxta-articular mass, especially around the knee. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. author contributions dr wagener presented the case at the musculoskeletal imaging congress held in cape town in february 2014. the report was written by dr vlok and reviewed by dr wagener. histological images and legends were supplied by dr zaharie. references top ↑ craig rm, pugh dg, soule eh. the roentgenologic manifestations of synovial sarcoma. radiology. 1955;65(6):837. http://dx.doi.org/10.1148/65.6.837 siegel hj, sessions w, casillas ma, said-al-naief n, lander ph, lopez-ben r. synovial sarcoma: clinicopathologic features, treatment and prognosis. orthopedics. 2007;30(12):1020–1025. bakri a, shinagare ab, krajewski km, et al. synovial sarcoma: imaging features of common and uncommon primary sites, metastatic patterns and treatment response. ajr. 2012;199(2):w208–w215. http://dx.doi.org/10.2214/ajr.11.8039 murphey md, gibson ms, jennings bt, crespo-rodriguez am, fanburg-smith j, gajewski da. imaging of synovial sarcoma with radiologic-pathologic correlation. radiographics. 2006;26(5):1543–1565. roberts cc. statdx premier. synovial sarcoma. salt lake city: amirsys; 2005–2014. [cited 10–30 may 2014]. available from: http://my.statdx.com o'sullivan pj, harris ac, munk pl. radiological features of synovial cell sarcoma. br j radiol. 2008;81(964):346–356. http://dx.doi.org/10.1259/bjr/28335824 dähnert w. radiology review manual. 6th ed. philadelphia: lippincott williams & wilkins; 2007; p. 166–167. article information authors: paul scholtz1 steve beningfield1 sally candy1 affiliations: 1division of radiology, groote schuur hospital, cape town, south africa correspondence to: paul scholtz postal address: division of radiology, room 16, c16, new groote schuur hospital, private bag 7935, observatory 7935, cape town dates: received: 07 jan. 2014 accepted: 22 may 2014 published: 20 oct. 2014 how to cite this article: scholtz p, beningfield s, candy s. a retrospective study of computed tomography angiography versus digital subtraction angiography in penetrating neck trauma at groote schuur hospital, south africa. s afr j rad. 2014;18(1); art. #601, 7 pages. http://dx.doi.org/10.4102/ sajr.v18i1.601 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a retrospective study of computed tomography angiography versus digital subtraction angiography in penetrating neck trauma at groote schuur hospital, south africa in this original research... open access • abstract • introduction • method • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: penetrating neck trauma is commonly encountered in south african trauma units, and is associated with high mortality and morbidity rates. the imaging protocol for stable patients with penetrating neck trauma remains controversial. there is only sparse data validating the use of computed tomography angiography (cta) in the evaluation of penetrating neck trauma in south africa. objectives: to assess the sensitivity and specificity of cta versus digital subtraction angiography (dsa) in detecting arterial injury and secondarily evaluate the ability of ct to assess non-arterial injury. method: using hospital and radiology databases, 23 patients were identified who had undergone both cta and dsa for penetrating neck trauma. the data was retrospectively anonymised and randomised. a radiologist experienced in the interpretation of both trauma cta and dsa re-reported all the imaging and the findings were compared and analysed. results: twenty-four arterial injuries were detected. the sensitivity of cta for detecting arterial injury was 78% and the specificity 83%. the ability of cta to delineate wound track and detect non-arterial visceral injury was also confirmed. conclusion: cta is an attractive initial diagnostic investigation that, along with clinical evaluation, effectively guides further investigation and intervention. it is important for the radiologist to understand the limitations of cta and have a low threshold for dsa in equivocal cases. introduction top ↑ south african violent crime and trauma rates are high,1 and penetrating neck trauma is common in south african trauma centres. these injuries have high mortality and morbidity rates of between 3% and 6%, with most fatalities due to major neck vessel injuries.2the role and type of imaging of stable patients with penetrating neck trauma is controversial. given the probability of vascular, aerodigestive tract and/or neurological injury, important clinical decisions have to be made regarding further investigation or intervention. although digital subtraction angiography (dsa) is the gold standard for detecting arterial vascular injury, it is an invasive procedure with potential complications, such as puncture-site haematoma, iatrogenic vascular damage and embolic complications, including stroke.3 dsa is also resource intensive, although it does permit therapeutic endovascular options during the same procedure in some cases. because computed tomography (ct) has become an integral part of emergency units worldwide, ct angiography (cta) provides an attractive alternative to dsa. ct also has the ability to determine the direction and course of any wound tracks that can suggest particular damage, along with direct evidence of visceral, bony or aerodigestive tract injury. although frequently used, the role of cta remains unclear. sparse data exist in south africa regarding the use of cta in evaluating penetrating neck trauma. this study aims to retrospectively compare and analyse the findings of cta and dsa in patients with penetrating neck trauma at groote schuur hospital, a tertiary referral university hospital in cape town, south africa, serving a drainage population of approximately 2 million. the hospital has a busy trauma unit, with a high incidence of penetrating trauma due to gunshot and stab wounds. from july 2004 to june 2005 (12 months), 203 patients with penetrating neck injuries were admitted into the trauma unit, of whom 21% sustained gunshot wounds and 78% stab wounds.4 method top ↑ formal ethics approval was obtained from the research ethics committee, health sciences faculty, university of cape town.using the hospital and radiological databases, all patients with penetrating neck trauma who underwent both dsa and cta (in either order) during the period from march 2009 to march 2012 were identified for the study. in these patients, cta and dsa were performed for various reasons, including clinical suspicion, imaging features of injury on the other modality, surgical planning and/or endovascular treatment. cta was performed using a 16-slice siemens emotion multidetector ct scanner in the radiology department. intravenous access was obtained using a cubital or forearm cannula of at least 18 gauge placed in an upper limb vein, if possible contralateral to the side of injury. a volume of 100 ml of non-ionic contrast medium (iohexol 350) was administered using an injector pump at a rate of 6 ml/s. caudocranial helical acquisition was planned using the lateral scout view of the neck from at least the aortic arch to the circle of willis. the scan was initiated using a bolus tracker system placed over the aortic arch triggering at 100 hounsfield units. a saline chaser was not utilised. typical reconstruction parameters were 1 mm slice thickness, a pitch of 1.5, 110 kvp and 100 ma. digital subtraction angiography was performed using a single c-arm ceiling-suspended dsa system (toshiba infinix vc-i). for initial diagnostic purposes, aortic arch and relevant selective brachiocephalic and branch vessel arteriograms where performed. approximately 100 ml of non-ionic contrast (iopromide 300) was used on average. the cta and dsa images were retrospectively anonymised and randomised. a radiologist experienced in the interpretation of both trauma cta and dsa and who was blinded to the clinical data and prior opinions, reported on all the imaging. various window settings, multiplanar reconstructions (mpr) and maximum intensity projections (mip) were permitted. bone subtraction was used when considered warranted in cta. both cta and dsa were evaluated for both vascular and non-vascular pathology. unsubtracted dsa images were not always available due to image archiving technicalities. all vessels within the field of view were assessed. any identified vascular injuries on cta and dsa were localised and described. injury types were categorised as occlusion, contrast extravasation, pseudo-aneurysm, arteriovenous fistula (avf), intimal flap or a combination of these. non-vascular evaluation in both modalities included the soft tissues, aerodigestive tract, bones, lungs and mediastinum. contrast swallows were also included. where possible, the wound tract was identified on cta. clinical data that was retrospectively analysed included patient demographics, penetrating agent, zone of injury, indications for investigation, associated injuries and management. cta and dsa findings were compared and analysed. dsa findings were considered the standard of reference for arterial pathology, whilst cta was considered the reference for soft-tissue damage. true positives required the correct definition and appropriate clinical correlation of injury type and location. sensitivity, specificity and positive and negative predictive values were specifically calculated for arterial vascular injuries. results top ↑ over the 3-year period, 23 patients (18 male and 5 female) were included in the study. all imaging was considered to be of diagnostic quality, and complete clinical data was available on folder and radiological review. the delays between cta and dsa ranged from an immediate follow-on procedure to up to 72 hours. all but one patient underwent cta prior to dsa; the single follow-on cta was performed due to concern of an injury at the origin of the left common carotid artery on dsa. the mean age was 30 years, with a range of 19–51 years. stab wounds accounted for 20 (87%) and gunshots for 3 (13%) of the injuries. the location of the entry sites of penetrating neck injury was allocated into the three standard anterior triangle anatomical zones (figure 1). there were no injuries involving the posterior triangle. figure 1: anatomical zones and percentage injuries. injury locations amounted to 8 (35%) in zone 1, 14 (61%) in zone 2 and 1 (4%) in zone 3. sixteen (70%) of the patients suffered injuries to the left neck and six (26%) to the right, whilst one (4%) had bilateral injuries. various clinical signs for vascular injury were recorded in the clinical notes (figure 2). three patients had no detectable significant clinical signs of injury at the time of scanning. figure 2: clinical signs and corresponding injuries detected on digital subtraction angiography. foley-catheter tamponade using the inflated balloon to temporarily arrest bleeding within the wound tract was employed in six (26%) patients. contrast swallows were performed on 14 (61%) of the patients on the basis of clinical symptoms and signs, with a single oesophageal injury detected. a further oesophageal injury was detected intra-operatively (this patient had not undergone a contrast swallow as the patient was intubated and had other existing indications for surgical exploration). digital subtraction angiography demonstrated 18 arterial injuries in 17 patients, with one patient having both a vertebral and an inferior thyroid artery injury (table 1). table 1: table showing cta and dsa findings and subsequent treatment. in comparison to dsa, the sensitivity of cta for detecting arterial injury was 78%, the specificity 83%, the positive predictive value (ppv) 93% and the negative predictive value (npv) 56%. conservative management was undertaken in three (17%) patients. endovascular management was used to manage eight (44%) injuries, of whom five were treated with covered stents, two were embolised with cyanoacrylate glue and one was embolised using a detachable balloon. surgical vascular repair was performed in seven (39%) cases. during the in-hospital course, one patient suffered a middle cerebral artery infarction seven days after primary surgical repair of a common carotid injury, and another died of hypoxic brain injury two days after surgical repair of a common carotid injury. discussion top ↑ classically, stable patients with injuries penetrating the platysma muscle mandated exploratory surgery.5 since the 1990s, however, selective non-operative management (snom) has gained favour and has become the rule.4,5 yet the optimal management and imaging strategy for stable patients with penetrating neck trauma remains controversial. vascular injury is suspected clinically when certain ‘hard’ signs are present. the most reliable pointers to vascular injury include a bruit or thrill, expanding or pulsating haematoma, pulsating haemorrhage (including a history thereof), pulse deficit and/or major neurologic deficit. ‘soft’ signs are less reliable and include systemic hypotension, identifiable injury in proximity to vessels and a moderate to large stable haematoma. injuries crossing the midline or those that require use of foley-catheter balloon tamponade also may influence the decision to perform angiography. other clinical signs included in our study included rapid drainage of blood from an intercostal drain and a widened or abnormal mediastinal contour on chest radiography. the most reliable clinical sign to predict arterial injury was pulsatile haemorrhage. three patients had no vascular signs on presentation. one of these patients had a significant injury (subclavian artery pseudo-aneurysm with an avf) requiring endovascular stenting, but the other two were normal on imaging. all patients with foley-catheter balloon tamponade suffered arterial injuries. several groups have compared cta with dsa for detection of arterial injury in penetrating neck trauma; reported sensitivities ranged between 80% and 100%, with specificities above 90%.6,7,8,9 our study demonstrated a cta sensitivity of 78% and specificity of 83%. four false-negative findings and one false-positive finding occurred with cta. of the false-negative findings, a small (3 mm) pseudo-aneurysm in case 2 seen on dsa of the vertebral artery was not detected on cta (figure 3). the lesion could also not be detected on retrospective review of the cta using mpr and mip imaging. subtle lesions may not be well demonstrated on ct as compared to dsa due to the inferior spatial resolution of ct, lack of bone subtraction and pulsation artefact. although the clinical significance of these ‘minor’ lesions may be controversial, studies show that many of these lesions either resolve or remain asymptomatic.10the small vertebral artery aneurysm was managed conservatively and therefore no significant management difference occurred. figure 3: (a) the coronal reformatted mip cta image demonstrates no extraforaminal (part one) vertebral artery injury. on the selected dsa of the left subclavian artery (b), the arrow shows a subtle vertebral artery pseudo-aneurysm. the arrowheads on both images depict a pseudo-aneurysm arising from the ascending cervical artery. another false-negative cta result in case 4 was due to an avf arising from the inferior thyroid branch of the left thyrocervical trunk (figure 4). this injury had been misdiagnosed as an internal jugular vein injury on presentation. clinical concern of an injury persisted due to the presence of a bruit. the patient was therefore referred for dsa, confirming the avf, for which endovascular embolisation was performed. as cta is not a dynamic study, the single acquisition during the contrast bolus may include physiological venous ‘contamination’ masking early venous filling due to an avf. dsa is arguably required when an avf is clinically suspected but not detected on cta. figure 4: (a) the coronal reformatted mip cta shows an apparent injury to the left internal jugular vein (arrow). on the dsa (b), an avf from the inferior thyroid artery to the internal jugular vein is demonstrated (arrowhead). in case 12, a transection of the external carotid artery was misinterpreted as a pseudo-aneurysm on cta as the ascending pharyngeal artery was interpreted as spasm of the continuation of the external carotid artery (figure 5). when this was referred for dsa and endovascular embolisation, it was revealed as an eca transection. after debate, the vessel was occluded with a detachable balloon. figure 5: (a) the sagittal reformatted mip cta was interpreted as an eca pseudo-aneurysm (arrow). dsa revealed an eca transection (arrowhead, b). incorrect localisation of a pseudo-aneurysm accounted for the last false-negative result in case 11. cta reported the lesion to involve a cervical branch of the subclavian artery, whereas on dsa the lesion arose from the subclavian artery itself, near the cervical vessel origin. the pseudo-aneurysm was managed with a covered endovascular stent of the subclavian artery. it is questionable whether this led to a significant management difference, as either lesion was amenable to endovascular management. the only false-positive result was the over-interpretation of what was thought to be a small avf from the ascending cervical artery to the internal jugular vein on cta, with dsa revealing no injury. although an avf may have occluded spontaneously, this was felt to be unlikely. cta was performed after dsa in one patient in whom suspicion of an injury at the origin of the left common carotid artery was suspected on dsa. cta confirmed the injury as a pseudo-aneurysm at the common carotid artery origin. the ability of ct to evaluate structures other than the arterial vasculature adds further benefits. assessment of the aerodigestive tract, viscera (lungs, thyroid), veins and bony structures (especially the spine) assist in clinical management. determining the trajectory of the wound track further aids in the evaluation of patients with penetrating neck trauma, because the organs lying along the path can be considered to have a higher likelihood of injury (figure 6). figure 6: axial ct image (a) demonstrates a bullet tract (arrow) passing through the left thyroid lobe, crossing the midline and fracturing the right-sided elements of the first thoracic vertebra, with a high index of suspicion for oesophageal injury. the contrast swallow confirms an oesophageal injury with a left sided contrast leak (arrowhead, b). the assessment of bullet and bone fragments not only aid in identifying the wound track but may also be helpful in assessing the direction of travel of a projectile such as a bullet. careful evaluation of the bone should show bevelling toward the direction of travel, which is important in forensic analysis.11 in penetrating neck trauma, it is also important to deliberately assess the airway on ct. close attention has to be paid to airway narrowing due to surrounding haematoma or direct injury. patient 5, with an avf detected on cta, acutely deteriorated on the dsa table, requiring intubation and emergency surgery due to airway compromise as a result of a large mediastinal haematoma (figure 7). signs of direct tracheal injury include tracheal wall defects or deformity, excessive surgical emphysema, pneumomediastinum and pneumothorax (figure 8). a low threshold for endoscopy is required to accurately assess suspected airway injury. figure 7: axial ct shows severe tracheal narrowing (arrow) due to mediastinal haematoma (arrowhead). figure 8: (a) demonstrates extensive cervical surgical emphysema with a tracheal defect at the 7 o’clock position (arrow). a right-sided tension pneumothorax is also present with mediastinal shift to the left (b). multiple types of artefacts have to be taken into account during cta and dsa, including those induced by patient size, motion, incoming dense venous contrast and post-traumatic fragments (bullet shrapnel, knife or bone fragments). contrast inflow artefact is usually due to use of upper limb venous injections resulting in streak artefact at the thoracic inlet. this may interfere with the visualisation of the proximal arteries exiting the thorax, especially the ipsilateral subclavian artery. injection of contrast into the contralateral side of injury or using femoral venous access is helpful in reducing this artefact. the use of a saline chaser also reduces the amount of streak artefact. multiple limitations were present in the study. most other studies used two experienced radiologists during the retrospective review, with the consensus reached as the definitive impression. little short-term to long-term patient follow-up was present. unsubtracted images on dsa were not always available due to archiving technicalities; this reduced the ability to evaluate for foreign bodies, bony detail and soft tissues, which are important for thorough assessment. although sensitivity and specificity in this study is lower than reported, cta remains attractive as the initial diagnostic investigation. it is readily available, non-invasive and less resource-intensive, although it may take longer to analyse than dsa. to our knowledge, this is the first study documenting the use of 16-slice multidetector ct in penetrating neck trauma. larger, prospective trials are required for further evaluation. conclusion top ↑ selective non-operative management is the rule in management of stable patients with penetrating neck trauma. cta is an attractive initial diagnostic investigation that, along with clinical evaluation, effectively guides further investigation and intervention. high sensitivities and specificities for detecting arterial vascular injury have been documented. the added advantages of cta include the ability to detect wound trajectory and determine visceral, bony and aerodigestive tract injury. however, it is important for the radiologist to understand the limitations of cta and have a low threshold for conventional angiography in equivocal cases, or where there is a strong suspicion of an avf. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions p.s. (groote schuur hospital) was the lead researcher and was responsible for the concepts, design, literature review and preparation of the manuscript. p.s. and s.b. (groote schuur hospital) conducted the study. s.b. and s.c. made conceptual contributions and were involved with the manuscript editing. references top ↑ 1.centre for the study of violence and reconciliation. why does south africa have such high rates of violent crime? supplement to the final report of the study on the violent nature of crime in south africa. johannesburg: csvr; 2009 [cited 2012 april 04]. available from: http://www.csvr.org.za/docs/study/7.unique_about_sa.pdf2.brywczynski jj, barrett tw, lyon ja, cotton ba. management of penetrating neck injury in the emergency department: a structured literature review. emerg med j. 2008;25:711–715. http://dx.doi.org/10.1136/emj.2008.058792 3.schroeder jw, baskaran v, aygun n. imaging of traumatic arterial injuries to the neck with an emphasis on cta. emerg radiol. 2005;13(3):158–163. 4.thoma m, navsaria ph, edu s, nicol aj. analysis of 203 patients with penetrating neck injuries. world j surg. 2008;32:2716–2723. http://dx.doi.org/10.1007/s00268-008-9766-7 5.macfarlane c, benn ca. penetrating neck trauma: a review. trauma. 2002;4:79–90. http://dx.doi.org/10.1191/1460408602ta226oa 6.leblang sd, núñez db, rivas la, falcone s, pogson se. helical computed tomographic angiography in penetrating neck trauma. emerg radiol. 1997;4:200–206. http://dx.doi.org/10.1007/bf01508171 7.múnera f, soto ja, palacio dm, velez sm, medina e. diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical ct angiography and conventional angiography. radiology. 2000;216(2):356–362. http://dx.doi.org/10.1148/radiology.216.2.r00jl25356 8.múnera f, soto ja, palacio dm, et al. penetrating neck injuries: helical ct angiography for initial evaluation. radiology. 2002;224:366–372. http://dx.doi.org/10.1148/radiol.2242010973 9.inaba k, múnera f, mckenney m, et al. prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. j trauma. 2006;61:144–149. http://dx.doi.org/10.1097/01.ta.0000222711.01410.bc 10.frykberg er, vines fs, alexander r. the natural history of clinically occult arterial injuries: a prospective evaluation. j trauma. 1989;29:577–583. http://dx.doi.org/10.1097/00005373-198905000-00006 11.wilson aj. gunshot injuries: what does a radiologist need to know? radiographics. 1999;19:1358–1368. http://dx.doi.org/10.1148/radiographics.19.5.g99se171358 article information authors: ebrahim banderker1 elias pretorius2 rik de decker3 affiliations: 1department of diagnostic radiology, red cross war memorial children’s hospital, university of cape town, south africa 2department of diagnostic radiology, tygerberg hospital, stellenbosch university, south africa 3division of cardiology, department of paediatrics and child health, red cross war memorial children’s hospital, university of cape town, south africa correspondence to: ebrahim banderker email: ebanderker@iafrica.com postal address: department of diagnostic radiology, red cross war memorial children’s hospital, kliptown road, rondebosch 7700, south africa dates: received: 12 june 2015 accepted: 14 oct. 2015 published: 17 dec. 2015 how to cite this article: banderker e, pretorius e, de decker r. the role of cardiac ct angiography in the preand postoperative evaluation of tetralogy of fallot. s afr j rad. 2015;19(2); art. #899, 9 pages. http://dx.doi.org/10.4102/sajr.v19i2.899 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the role of cardiac ct angiography in the preand postoperative evaluation of tetralogy of fallot in this original research... open access • abstract • introduction • imaging modalities used in tof • the role of cardiac ct angiography in tof    • overview    • cardiac cta protocols       • patient preparation       • contrast agents    • non-ecg-synchronised and ecg-synchronised cardiac ct    • non-ecg synchronised ct    • ecg-synchronised ct       • prospective gating       • retrospective gating    • strategies for radiation dose reduction • preand postoperative evaluation of tof    • branch pulmonary arteries and mapcas    • complex coronary arteries    • evaluation of previous palliation       • blalock-taussig and central shunts       • brock procedure, rvot and pulmonary artery stents       • restenosis of the pulmonary outflow tract       • pulmonary outflow tract aneurysm       • rv-pulmonary artery conduit stenosis       • restenosis of the pulmonary arteries • conclusion • competing interests • authors’ contributions • references abstract top ↑ tetralogy of fallot (tof) is the first described and most common cyanotic congenital heart anomaly that generated the first successful surgical palliation procedure and definitive intracardiac repair. classical tof comprises the four typical features of right ventricular outflow tract obstruction (rvoto), right ventricular hypertrophy (rvh), ventricular septal defect (vsd) and aortic dextroposition. complex forms of the condition include tof associated with absent pulmonary valve and tof with pulmonary atresia (tof-pa) with or without major aortopulmonary collateral arteries (mapcas). the pathophysiological understanding that the tetrad is basically the sequel of a singular abnormality of infundibular malformation, with anterior deviation of the infundibular septum, had major surgical consequences that improved survival. diagnostic and functional imaging play a key role in the clinical and surgical management of patients with tof. we revisit the role of traditionally employed imaging modalities (echocardiography and cardiac catheterisation) only briefly as these remain within the domain of cardiology practice. the emphasis of the present review is to outline the role of cardiac computed tomographic angiography (cta) in the evaluation of tof, with special reference to the technical considerations and best practice recommendations. cardiovascular magnetic resonance imaging (cmr) is addressed only in passing, as this service is not currently available at our institution. introduction top ↑ maude abbott, variously known as the ‘queen of canadian cardiology’ and ’the beneficent tornado’, first coined the now familiar term of tetralogy of fallot (tof) in 1924. the earliest reports of the anomaly are, however, attributed to niels stensen (1671), edouard sandifort (1777) and william hunter (1784), amongst many others. etienne-louis arthur fallot published five serialised reports in the marseille medical in 1888 in which he described his now famous ‘blue malady’. whilst fallot described the classical tetrad of pulmonary outflow tract obstruction, ventricular septal defect (vsd), aortic override and right ventricular hypertrophy (rvh) (figure 1), stella van praagh in 1970 attributed the anomaly to a single defect of pulmonary valve and subpulmonary infundibular malformation, the so-called ‘monology of stensen’.1 the diagnostic and surgical consequences of this realisation have resulted in improved long-term patient survival. figure 1: schematic depicting the characteristic defects associated with tof: rvot obstruction and pulmonary atresia, right ventricular hypertrophy (rv), overriding aorta (ao) and a large vsd (double-pointed arrow). the era of clinicophysiological understanding in cardiology, between 1940 and 1970, drew special attention to the need for accurate imaging of the complex and variable pulmonary blood flow that exists in the more severe form of tof such as tetralogy of fallot with pulmonary atresia (tof-pa) (figure 2). figure 2: tof-pulmonary atresia (tof-pa) – more severe variant of tof in an 8-week-old girl. axial cta mip (a) shows non-confluence of the pulmonary arteries. thin-section sagittal oblique cta (b) with main pulmonary trunk and rvot atresia. volume-rendered cta (c) demonstrating absence of the obliterated rvot. also note the bovine aortic arch (arrow). imaging modalities used in tof top ↑ the objectives of imaging are addressed in box 1. box 1: objectives of imaging in congenital heart disease. whilst diagnostic paradigms for the evaluation of congenital heart disease (chd) may be institution specific, echocardiography remains the primary diagnostic modality of choice worldwide.2 echocardiography has wide appeal on account of its accessibility, portability, favourable cost, lack of harmful radiation and extensive experience of use. serious limitations relate mainly to the small acoustic window that sometimes precludes the evaluation of certain anatomical structures such as the ascending aorta, right ventricle (rv) size and function, aberrant coronary anatomy, pulmonary arteries and major aortopulmonary collateral arteries (mapcas). ancillary diagnostic tests are requested in the small number of cases where echocardiography fails to answer specific questions. the role of cardiac catheterisation as the gold-standard modality for the assessment of intra-cardiac pressures, coronary artery anatomy, branch pulmonary arteries and mapcas is well established. its invasive nature, prolonged sedation-anaesthesia, high cost and ionising radiation burden, however, limit its utility to a carefully selected number of cases, including instances where catheter-based intervention such as balloon dilatation and stenting of the pulmonary arteries or right ventricular outflow tract (rvot) is anticipated. cardiovascular magnetic resonance imaging (cmr) offers significant advantages over the traditional imaging modalities of echocardiography and x-ray angiography, providing detailed assessment of cardiac and extra-cardiac morphology, functional analysis (rv size and function, pulmonary valve competence, pulmonary arterial flow) without radiation or iodinated contrast agents, and is suitable for numerous longitudinal follow-ups. in resource-limited environments such as ours it is expensive, however, the imaging times are long (requiring lengthy sedation and anaesthesia), and the post-processing is time-consuming. other disadvantages include artefacts from non-mr-compatible implants, poor evaluation of lungs and airways, and the risk of nephrogenic systemic sclerosis with gadolinium-based products. the role of cardiac ct angiography in tof top ↑ overview modern-generation multi-detector computed tomography (mdct) allows fast imaging with very short acquisition times (often within a single breath hold) that translates into superior spatial and temporal resolution from diminished motion artefact. its widespread availability in institutions that perform cardiac surgery offers greater accessibility at relatively reduced cost compared with cmr. flexibility in ct protocols based on patient age, suspected cardiac defect, anticipated type of surgical repair, level of patient co-operation and the need for functional assessment further adds to its appeal. strategies for radiation dose sparing, via carefully selected paediatric adaptive ct protocols, have gone a long way to alleviating radiation-related anxieties. whilst its utility in the structural and functional assessment of the heart is without doubt, cardiac ct angiography (cta) has its principle strength in the evaluation of the extra-cardiac anatomy. its complementary use with echocardiography frequently obviates the need for invasive cardiac catheterisation of the haemodynamically unstable infant. the objectives of imaging in tof are most often more than adequately satisfied with echocardiography alone,2 and cardiac cta should only be employed as an ancillary tool for specific indications. cardiac cta protocols patient preparation the procedure is precluded and contra-indicated by iodine allergy. the laterality of the aortic arch needs to be established from the echocardiography report so as to determine the opposite cubital fossa for intravenous access. a large-bore peripheral iv cannula, at least a 22g, should be used to accommodate the large-volume, high-pressure contrast injection. a 20g cannula is preferred when the patient is >3 years of age or if ecg-synchronised ct is planned. pharmacological heart rate manipulation using beta blockade is sometimes necessary in ecg-gated studies (see later). preparations for sedation or anaesthesia should be made as per local protocol. medical personnel skilled in the management of cardiac emergencies must accompany the patient. contrast agents a volume of 2 ml/kg bodyweight of non-ionic iodinated contrast agent is administered through a large bore iv cannula at a rate of 2 ml/second via a power injector. a right arm injection is preferred in a known left-sided aortic arch. we employ a bolus tracking technique with the region of interest (roi) placed within the descending thoracic aorta, at the level of the carina, and scan threshold set at 150 hounsfield units (hu). scan trigger after a fixed delay of 12 seconds for a peripheral line or 8 seconds for a central line, can also be used but is less favored.3 a volume of 10 ml – 15 ml of contrast saline solution (50% dilution) is utilised in a bolus chasing technique to dilute contrast within the right heart and improve contrast within the cardiac chambers. non-ecg-synchronised and ecg-synchronised cardiac ct non-ecg synchronised ct non-gated ct combined with echocardiography is sufficient in the structural and functional evaluation of most congenital heart conditions. thicker detector collimation and a pitch of greater than 1 (typically 1–1.5) allows fast acquisition at the expense of superior spatial resolution. the evaluation of small cardiac defects and the coronary structures is further compromised by motion artefact. it has, however, been reported that 82% of the origins and proximal segments of the coronary arteries are in fact evaluable with non-ecg-synchronised ct.4 furthermore, the radiation dose, defined by the dose length product, is typically less than 1 msv.3 ecg-synchronised ct prospective gating this technique utilises unique cone beam reconstruction5 following ’step-and-shoot’ non-spiral data acquisition with an effective pitch of 1. imaging occurs during a user-selected brief period of the r-r interval, that is radiation exposure only during specifically determined periods of diastole. hence the imaging is forward looking (prospective) and based on r-wave timing. heartbeat irregularities are compensated for using ’padding’ – the addition of an imaging window around the anticipated beam-on time. image quality is enhanced during this technique by the fact that there is no table motion during imaging. the disadvantages of prospective gating include longer acquisition time – for a 64-slice mdct, the 4 cm table motion during the beam-off time takes about 1 second every alternate beat – resulting in greater propensity for motion artefact. single sector gating is also limited to heart rates less than 75 bpm. imaging during a small portion of the r-r interval does not allow functional assessment related to wall motion, valve motion or the calculation of ejection fractions. retrospective gating retrospective gating, on the other hand, employs spiral scanning with table motion and uses a low pitch (typically 0.2–0.26), resulting in over scanning. the imaging is hence gapless. the technique uses backward measurement of the r-wave and the beam is turned on throughout the r-r interval. this allows functional assessment. despite employing radiation dose-sparing techniques such as beam intensity modulation (see later), radiation dose to the patient is in the order of 8–19 msv.6 superior image quality with artefact-free visualisation of the coronary arteries, even at elevated heart rates, comes at the expense of increased radiation. retrospective gating increases radiation exposure by 77% over prospectively gated studies.6 two further studies have shown the radiation burden to increase by 50% and 83% respectively.7,8 strategies for radiation dose reduction radiation-sparing techniques must always be fastidiously implemented, in accordance with the broader principles of alara (as low as reasonably achievable) and the ‘image gently’ campaign, as advocated by the south african society of paediatric imaging (saspi). the lifetime cumulative radiation dose is of particular importance in vulnerable children with genetic-, sexand age-related increased radiation susceptibility. in the domain of congenital heart disease imaging, where longitudinal follow-up may be lifelong, radiation consciousness assumes even greater significance. the process ensues with the appropriate selection of ct protocols where the lowest possible radiation is employed without losing detail. functional cardiac ct is not a priority as function is most often adequately determined at echocardiography. ecg-synchronised cardiac ct should only be performed in very specific indications such as when detailed coronary artery anatomy beyond its origins is needed. even then, prospective gating should be preferred. the need for repeat studies must also be carefully considered, as echocardiography is most often sufficient. radiation dosage is directly proportional to the volume of patient scanned. meticulous attention to z-axis (cranio-caudal length) limits, to incorporate only the anatomy of interest and relevant adjacent structures, can result in a radiation dose saving of 0.7 msv per centimeter.3 fine-tuning of kvp and tube current according to paediatric adaptive protocols based on body weight will also result in dose reduction. ecg-based tube current modulation3 is a technique used to diminish radiation dose when retrospective ecg-synchronisation is required for functional imaging. reduced current of between 4% and 20% is used outside of the pulsing window for morphological assessment that occurs at about 70% of the r-r interval. left ventricle (lv) functional assessment is still possible. slower heart rates are better for gated ecg as the optimal pulsing window for morphological imaging is heart-rate dependent.3 tube current modulation during retrospective ecg-synchronisation ct can result in up to 64% reduction in radiation dosage.9 preand postoperative evaluation of tof top ↑ tof is one of the earliest described cyanotic congenital heart conditions and, despite a long history of both palliative and definitive surgical repair, uniform successful outcomes remain elusive. surgical techniques underpinned by a better understanding of post-tof repair physiology have demonstrated improved outcomes. a departure from the traditional quest for elimination of the ’undesirable’ right ventricular outflow tract obstruction, at the expense of free pulmonary regurgitation, has resulted in an avoidance of long-term complications such as rv dilatation and consequent rv and lv dysfunction.10 preoperative imaging is directed at confirmation of the diagnosis and differentiation of tof from other common mixing disorders such as a common arterial trunk, transposition of the great vessels with a ventricular septal defect or a double-outlet right ventricle (dorv). further goals of preoperative imaging are to establish the severity of the primary anatomical lesion, the associated anomalies and the degree of functional disturbance, that in turn dictate appropriate timing of surgical intervention – either definitive early repair or a staged approach following initial palliation. the surgical approach itself may be altered by anatomical relationships of cardiac, coronary and extra-cardiac structures, such as a right-sided aortic arch (figure 3), mapcas and variant coronary anatomy.11 the debate around timing of surgery and the multitude of institutional preferences of surgical approach is beyond the scope of the present paper. figure 3: right-sided aortic arch in a young boy with tof. thin-section axial contrasted ct (a) demonstrates a right-sided aortic arch (arrows) and stenosis of the main pulmonary artery (asterisk). volume rendered ct (b) chest demonstrates the right-sided aortic arch (arrows). in his presentation entitled ‘the essential echocardiographic features of tetralogy of fallot’,2 norman h. silverman very eloquently illustrates the comprehensive role of echocardiography in the pre-operative evaluation of tof. the four features of tof as well as the pulmonary valve morphology, main and branch pulmonary arteries, proximal coronary anatomy, aortic arch anatomy and even aortopulmonary collateral arteries can all be adequately identified at echocardiography in skilled and experienced hands. cardiac cta provides the ideal alternative to invasive and potentially hazardous cardiac catheterisation when the limitations of echocardiography fail to meet the goals of imaging.12 box 2 illustrates the indications for preoperative cardiac cta in tof. box 2: indications for preoperative cardiac cta in tof. branch pulmonary arteries and mapcas the variability in surgical management of tof is frequently because of the diverse arrangement of the pulmonary arterial anatomy and the source of pulmonary artery blood supply. tof with pulmonary atresia (tof-pa) is a more severe variant that accounts for 20.3% of tof13 where the arrangement of the pulmonary arteries may vary from well-formed, confluent pulmonary arteries (pulmonary arteries in free communication) supplied by the patent ductus arteriosus (figure 4), to absence of the pulmonary valve and the native pulmonary arteries, with mapcas providing all the pulmonary supply. the anatomy of the native pulmonary arteries and vessels of supply must be clearly established in order to plan corrective surgery.11 figure 4: sagittal oblique mip in a 2-year-old boy with a pda (arrow) reconstituting a small-calibre left pulmonary artery (asterisk). the most frequent arrangement is where the pulmonary arteries are confluent but hypoplastic, with flow into them supplied by mapcas. mapcas most frequently arise from the descending thoracic aorta (figure 5) but can also take origin from the ascending aorta and the head and neck vessels (subclavian artery most commonly) (figure 6) and even from the coronary arteries or from the infra-diaphragmatic supply. figure 5: numerous mapcas (arrows) arise from the descending thoracic aorta and join the left upper lobe pulmonary artery prior to its first order bifurcation. sagittal thick-section mip (a). volume rendered cta (b) in the same patient. figure 6: two young tof patients with large mapcas that take origin from the subclavian arteries. coronal thin-section mpr (a) demonstrating right subclavian artery mapca to rpa. coronal thick-section mip (b) demonstrating tortuous left subclavian artery mapcas to lpa. complete absence of the native pulmonary arteries (non-confluent) with absent antegrade flow of blood from the rv to the pulmonary arteries is much less common. large calibre, hypertensive mapcas are then the only source of supply, necessitating early surgical intervention. cardiac cta, with its multi-planar and three-dimensional reconstruction capabilities, allows accurate depiction of pulmonary artery anatomy, mapcas and the aorta at the level of the diaphragm. these features allow calculation of the mcgoon index and the nakata index (figure 7) to quantitate the degree of pulmonary artery hypoplasia. the mcgoon index is the preferred index in our institution and is used post-palliation (central shunt, classic or modified blalock-taussig shunt, brock procedure or stent) to guide definitive repair and vsd closure when it exceeds 1.6–1.8. figure 7: mcgoon and nakata indices. complex coronary arteries coronary artery anomalies in tof have an incidence of 5% 12%13 and, whilst they in themselves do not present any risk of ischaemia or sudden death, surgical morbidity and mortality are significantly increased when they cross the rvot. when undiagnosed, these vessels are at significant risk of surgical injury during right ventriculotomy or rvot repair. the most frequently encountered coronary artery anomaly is left anterior descending (lad) or accessory lad arising from the right coronary artery (rca) or right sinus of valsalva14 (figure 9) that crosses the rvot to reach the anterior interventricular groove. the second-most common anomaly seen in most studies is that of a single coronary ostium from one of the sinuses of valsalva (left, right or non-coronary sinus); these may or may not traverse the rvot. figure 8: landmarks to determine an accurate mcgoon index: the sum of the rpa and lpa (a) prior to their first order bifurcation divided by the calibre of the aorta at the diaphragmatic hiatus (b). figure 9: conjoined anomalous origin of the coronary arteries in a 33-month-old girl. thin-section axial ct shows the common origin of the lad (white arrowhead) arising in conjunction with the rca from the right coronary sinus (asterisk). the left circumflex coronary artery takes normal origin from the left coronary sinus (black arrow). single or double enlarged conus arteries that take origin from the rca (figure 10) and a rca that arises from the lca, are further common anomalies that can present a serious hazard at the time of surgery. figure 10: large conus branch (arrowhead) of the rca in a 6-year-old boy post tof palliation. also note central shunt (asterisk) between the anteromedial aspect of the aorta and pulmonary artery stump (arrow). surgical repair can be successfully contemplated even in the presence of a major coronary artery anomaly, provided that the surgeon is made aware thereof. in most instances, proximal coronary anatomy is effectively and reliably demonstrated at echocardiography15 except in instances of previous palliation, late tof repair or reoperation resulting in a suboptimal acoustic window, or where the coronary arteries pursue an intramyocardial course. cardiac cta, when ecg synchronised (see section above entitled ‘cardiac cta protocols’), is an alternative non-invasive modality of high diagnostic performance and accuracy, to demonstrate coronary artery origins, their course and spatial relationships to adjoining structures. evaluation of previous palliation tof repair involves closure of the vsd and augmentation of the rvot. the technique for vsd closure is relatively standard whilst rvot relief is variously achieved, depending on the severity of the lesion. the two procedures may occur simultaneously, or vsd closure may only take place post palliation. blalock-taussig and central shunts systemic to pulmonary artery shunting procedures are well recognised interim surgical interventions, performed to augment pulmonary bloodflow prior to definitive corrective repair, to improve cyanosis, symptoms and general quality of life. despite the trend towards single reparative operations, physiological and anatomical conditions (hypoplastic pulmonary arteries, coronary anomalies crossing the rvot, avoidance of a conduit in a small rvot) may preclude early definitive repair. several types of palliative shunts have been described since the classic blalock-taussig (cbt) procedure of 1945, many of which have fallen out of favour (such as potts and waterston shunts) owing to subsequent pulmonary hypertension. the modified blalock-taussig (mbt) shunt (figure 11) directs blood from the subclavian artery opposite the aortic arch to the pulmonary artery via a ptfe or goretex conduit graft rather than an end-to-side anastomosis of the ligated and divided native subclavian artery of the cbt shunt. improved patency rates and ease of subsequent closure, favour the use of these shunts in our institution. figure 11: modified blalock-taussig (mbt) shunt in a 3-year-old girl. sagittal mip (a) depicts the mbt shunt (white asterisks) extending from the undersurface of the right sca to the ipsilateral pulmonary artery. axial thick-section mip (b) shows mbt shunt (black asterisk) origin from the right sca. central shunts using ptfe interposed between the ascending aorta and the main pulmonary artery are also in use. where echocardiography may be challenging, cta is once again perfectly suited to establish shunt anatomy and patency (figure 12). figure 12: palliative central shunt in a 6-year-old boy with tof. thick-section coronal mip image demonstrates ptfe graft (arrow) between the ascending aorta and the pulmonary artery. pulmonary artery distortion owing to previous palliative shunting in older children lost to follow-up is elegantly displayed at cta as an alternative to invasive angiography. brock procedure, rvot and pulmonary artery stents the effectiveness of the brock procedure (rvot relief without vsd closure) can also be effectively demonstrated via cta. the brock procedure is performed when the mcgoon index is unfavourable and does not allow closure of the vsd at the time of rvot relief. pulmonary artery and rvot stent patency and its related complications (figure 13) are well documented at cta and obviate the need for repeat angiography. figure 13: contrasted cta in a 15-year-old patient with a large aneurysm of the refashioned rvot (asterisk). axial mip (a) and sagittal mip (b): note metallic stents within both right and left main pulmonary arteries (arrows). restenosis of the pulmonary outflow tract infundibulectomy is reserved for cases of mild to moderate obstruction of the rvot with an adequate pulmonary valve annulus. the hypertrophic muscle is resected via a transatrial-transpulmonary (ta-tp) approach without significant disruption of the pulmonary valve. persistent or recurrent rvot obstruction is a known consequence of this procedure, and serial imaging studies may be needed to assess the need for further surgical or catheter-based intervention. pulmonary outflow tract aneurysm when the rvot stenosis is more severe or involves the pulmonary valve annulus, a trans-annular patch repair, using treated pericardium or synthetic material to approximate the margins of the incision, is performed. the trans-annular anterior approach is associated with a variable amount of pulmonary valve insufficiency, resulting in eventual long-term rv dysfunction when excessive. residual rvot stenosis is implicated in the pathogenesis of the well-documented post repair complication of rvot aneurysm (figures 13–14). the ventriculotomy aneurysm may be complicated by the rare formation of intraluminal thrombus.16 figure 14: thirty-three-month-old girl with a rvot aneurysm post repair. axial ct demonstrates a large post-surgical aneurysm of the transannular patch (asterisk) and worsening stenosis of both pulmonary arteries at their origins (arrows). rv-pulmonary artery conduit stenosis the rare, severe variant of tof-pa associated with atresia of the pulmonary valve or pulmonary artery is repaired by way of a rastelli operation whereby a synthetic or biological conduit (homograft) is interposed between the rvot and pulmonary arteries, which might have required prior augmentation. conduit complications arise from stenosis at the anastomosis site, degenerative conduit stenosis itself and/or regurgitation of the conduit valve. in many instances, cta is superior to echocardiography in assessing these stenosed conduits, owing to the aliasing that can occur with doppler flow. restenosis of the pulmonary arteries recurrent or residual stenosis of the main or branch pulmonary arteries can occur regardless of the type of surgery employed to relieve the rvot obstruction (figure 14). serial imaging of the arteries may be needed to ascertain when intervention is required. conclusion top ↑ echocardiography remains the principal imaging modality of choice in the investigation of chd, including tetralogy of fallot. comprehensive single-modality investigation to address all the structural and functional queries preoperatively is often not achievable. cta, in a resource-limited environment, can be used judiciously to complement the echocardiographic findings. the growing role of cmr and cta as the preferred adjunctive tests to echocardiography is related to a simultaneous proportional decline in the use of invasive angiography.12 competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions e.b. (university of cape town) is the principal author of this article. e.p. (stellenbosch university) is responsible for the editing of the images and literature review. r.d.d. (university of cape town) acted in a clinical advisory role. references top ↑ van praagh r. the first stella van praagh memorial lecture. pediatric cardiac surgery annual. beverly: american association for thoracic surgery; 2009; p. 19–38. silverman nh. the essential echocardiographic features of tetralogy of fallot. cardiol young. 2013;23:871–882. pmid: 24401261, http://dx.doi.org/10.1017/s1047951113001704 stinn b, stoltzmann p, fornaro j, et al. technical principles of computed tomography in children with chd. insights imaging. 2011;2:349–356. http://dx.doi.org/10.1007/s13244-011-0088-1 goo hw, yang dh. coronary artery visibility in free breathing young children with chd on cardiac 64-slice ct: dual-source ecg-triggered sequential scan vs. single-source non-ecg-synchronized spiral scan. paediatr radiol. 2010;40:1670–1680. http://dx.doi.org/10.1007/s00247-010-1693-8 desjardins b, kazerooni ea. ecg-gated cardiac ct. am j roentgenol. 2004;182:993–1010. http://dx.doi.org/10.2214/ajr.182.4.1820993 shuman wp, branch kr, may jm, et al. prospective versus retrospective ecg gating for 64-detector ct of the coronary arteries: comparison of image quality and patient radiation dose. radiology. 2008; 248:431–437. pmid: 18552312, http://dx.doi.org/10.1148/radiol.2482072192 hsieh j, londt j, vass m, li j, tang x, okerlund d. step-and-shoot data acquisition and reconstruction for cardiac x-ray computed tomography. med phys. 2006;33:4236–4248. pmid: 17153402, http://dx.doi.org/10.1118/1.2361078 earls jp, berman el, urban ba, et al. prospectively gated coronary ct angiography versus retrospectively gated helical technique. radiology. 2008;246:742–753. pmid: 18195386, http://dx.doi.org/10.1148/radiol.2463070989 weustink ac, mollet nr, pugliese f, et al. optimal electrocardiographic pulsing windows and heart rate: effect on image quality and radiation exposure. radiology. 2008;248:792–798. pmid: 18710975, http://dx.doi.org/10.1148/radiol.2483072098 karl tr. tetralogy of fallot: current surgical perspective. ann pediatr cardiol. 2008;1:93–100. http://dx.doi.org/10.4103/0974-2069.43873 prieto lr. management of tetralogy of fallot with pulmonary atresia. images paediatr cardiol. 2005;7:24–42. han bk, lesser am, vezmar m, et al. cardiovascular imaging trends in congenital heart disease. j cardiovasc comput tomogr. 2013;7:361–366. pmid: 24331931, http://dx.doi.org/10.1016/j.jcct.2013.11 van ferenz c, rubin jd, mccarter rj, et al. congenital heart disease: prevalence at livebirth. am j epidemiol. 1985;121:31–36. pmid: 3964990. kervancioglu m, tokel k, varan b, yildirim sv. frequency, origins and courses of anomalous coronary arteries in 607 turkish children with tetralogy of fallot. cardiol j. 2011;18:546–551. pmid: 21947991. jureidini sb, appleton rs, nouri s. detection of coronary artery abnormalities in tetralogy of fallot by two-dimensional echocardiography. j am coll cardiol. 1989;14:960–967. pmid: 2794284, http://dx.doi.org/10.1016/0735-1097(89)90473-7 peer sm, bhat pss, furtado ad, chikkatur r. right ventricular outflow tract aneurysm with thrombus. interact cardiovasc thorac surg. 2012;14:488–490. http://dx.doi.org/10.1093/icvts/ivr151 article information authors: francois van schouwenburg1 christelle ackermann1 richard pitcher1 affiliations: 1division of radiodiagnosis, department of medical imaging and clinical oncology, faculty of medicine and health sciences, tygerberg hospital and stellenbosch university, south africa correspondence to: francois van schouwenburg email: vanschou@gmail.com postal address: 20 boschendal terrace, van riebeeckshof, bellville 7530, south africa dates: received: 14 july 2014 accepted: 27 oct. 2014 published: 09 dec. 2014 how to cite this article: van schouwenburg, f., ackermann, pitcher, r. an audit of elective outpatient magnetic resonance imaging in a tertiary south african public-sector hospital. s afr j rad. 2014;18(1); art. #689, 5 pages. http://dx.doi/org/10.4102/sajr.v18i1.689 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. an audit of elective outpatient magnetic resonance imaging in a tertiary south african public-sector hospital in this original research... open access • abstract • introduction • aim • methods    • ethical considerations • results    • patient load    • referring departments    • scheduled examinations    • clinical indications for referrals       • magnetic resonance imaging spine       • magnetic resonance imaging brain       • musculoskeletal magnetic resonance imaging    • appropriateness of scheduled examinations • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: increasing demand for magnetic resonance imaging (mri) has resulted in longer waiting times for elective mri, particularly in resource-limited healthcare environments. however, inappropriate imaging requests may also contribute to prolonged mri waiting times. at the time of the present study, the waiting time for elective mri studies at tygerberg hospital (tbh), a tertiary-level public-sector healthcare facility in cape town (south africa), was 24 weeks. objectives: to document the nature and clinical appropriateness of scheduled tbh outpatient mri examinations. method: a retrospective analysis of the referral forms of all elective outpatient mri examinations scheduled at tbh from 01 june to 30 november 2011 was conducted. patient age, gender, clinical details, provisional diagnosis, examination requested and referring clinician were recorded on a customised data sheet. two radiologists independently evaluated the appropriateness of each request by comparing the clinical details and the provisional diagnosis provided with the 2012 american college of radiology (acr) guidelines for the appropriate use of mri. results: four hundred and sixty-six patients (median age 42 years; interquartile range 19–55) who had 561 examinations were scheduled in the review period; 70 (15%) were children less than 6 years old. neurosurgery (n = 164; 35%), orthopaedic (n = 144; 31%), neurology (n = 53; 11%) and paediatric (n = 27; 6%) outpatients accounted for the majority (81%) of referrals; 464 (99.6%) were from specialist clinics. mris of the spine (n = 314; 56%), brain (n = 152; 27%) and musculoskeletal system (n = 70, 13%) accounted for more than 95% of the investigations. in 455 cases (98%), the referral was congruent with published acr guidelines for appropriate mri utilisation. conclusion: scheduled outpatient mri examinations at tbh reflect optimal clinical use of a limited resource. mri utilisation is largely confined to traditional neuro-imaging. any initiative to decrease the elective mri waiting time should focus on service expansion. introduction top ↑ as a diagnostic modality, magnetic resonance imaging (mri) affords unsurpassed tissue contrast without exposing patients to the harmful effects of ionising radiation.1 in the 35 years since its first clinical use, mri has established a pivotal role in central nervous system (cns) imaging.2,3,4 furthermore, as a result of ongoing technical advances that have consistently increased spatial resolution, decreased scan times and contributed to the development of new imaging sequences, mri currently plays a burgeoning role in musculoskeletal, cardiac, hepatobiliary, gastro-intestinal, urogenital, gynaecological, fetal, vascular and paediatric imaging.5,6,7,8,9,10 the ever-increasing clinical applications of mri have resulted in a proliferation of scanners in well-resourced countries. japan and north american and western european countries now have between 6 and 41 mri scanners per million population. given the high capital and operating costs of mri systems, this relative plethora of scanners has raised concerns of overuse and fears of unsustainable increases in healthcare expenditure.11,12,13,14,15 whilst the south african private healthcare sector has adequate mri resources, those in the public sector are limited. in the public healthcare sector of western cape province, where this study was conducted, only three 1.5-tesla mri scanners serve approximately 4.4 million people, equating to 0.7 scanners per million population.16 one of the western cape’s public-sector mri scanners is installed at tygerberg hospital (tbh), a tertiary-level teaching facility offering a broad range of medical, surgical, paediatric, obstetric, oncological and psychiatric specialist and subspecialist services. at the time of this study, tbh possessed a 1.5-t siemens magnetom symphony mri scanner, commissioned in 2002. elective outpatient mri scans were scheduled during normal working hours (weekdays 08h00–16h00). the waiting time for elective mri scans was 24 weeks. the present study was prompted by an initiative of the department of health of the provincial government of western cape province to increase access to specialised radiological services, and particularly mri, in the knowledge that early access to appropriate mri improves patient outcomes. furthermore, mri waiting time represents a key performance indicator for modern radiology departments and healthcare systems.17,18,19 long mri waiting times are not the exclusive domain of resource-limited healthcare environments, and have been documented in well-resourced countries,18,19,20,21 being attributed to ever-increasing clinical indications for mr examinations, a growing clinician dependence on diagnostic imaging, and inappropriate imaging requests.18 the nature of scans performed has also been shown to affect patient throughput and thus indirectly influence access. prolonged scanning time is associated with the body region scanned, conducting several examinations on a single patient, use of oral and intravenous contrast agents, and the scanning of young children.20 waiting times may be shortened by matching supply with demand. reduced demand could be achieved by eliminating inappropriate investigations, whilst an increase in supply requires service expansion.20 the present study was undertaken from the standpoint that inappropriate examinations should be eliminated prior to considering service changes. at the time of the study, all tbh mri requests were screened and approved by a consultant radiologist. although departmental protocols were available for the validation of emergency mr scans, no formal guidelines governed the approval of elective scans; this was seen as the prerogative of the duty consultant, based on the clinical merit of each case. no formal quality assurance procedures were in place to assess the appropriateness of elective scan validation. coinciding with the commencement of the study, guidelines for the appropriate clinical use of mri were published by the american college of radiologists (acr).22 studies of mri utilisation in well-resourced countries have shown that referral patterns are determined by ease of access to the modality.23 to the best of our knowledge, there is no comparable data from resource-limited healthcare environments, where a different disease burden and more stringent resource constraints may affect mri utilisation. knowledge of the utilisation of capital-intensive healthcare resources is important at provincial and national government level to facilitate planning for optimal public-sector resource allocation, particularly in resource-restricted environments. it was hypothesised that inadequate vetting of clinical referrals contributed substantially to the long waiting times for elective tbh mri examinations. aim top ↑ to document the nature and clinical appropriateness of scheduled tbh outpatient mri examinations. methods top ↑ a retrospective analysis of the referral forms of all elective outpatient mri examinations scheduled at tbh from 01 june – 30 november 2011 was conducted. patient age, gender, clinical details, provisional diagnosis, the examination requested and referring clinician were recorded on a customised data sheet. two radiologists independently evaluated the appropriateness of each mr request by comparing the clinical details and the provisional diagnosis provided on the request form, with the 2012 acr guidelines for the appropriate use of mri.22 where radiologists differed in their individual assessment of the appropriateness of an imaging request, consensus was reached after discussion. ethical considerations the study was approved by the health research ethics committee of the faculty of medicine and health sciences at stellenbosch university and by tbh management. results top ↑ patient load four hundred and sixty-six outpatients (female = 267; 57%) with a median age of 42 years (interquartile range 19–55), had 561 elective examinations scheduled in the review period. multiple examinations were requested for 72 (16%) patients; 70 (15%) patients were below the age of six years and required sedation or general anaesthesia for a technically optimal study. referring departments the neurosurgery (n = 164; 35%), orthopaedic (n = 144; 31%), neurology (n = 53; 11%) and paediatric (n = 57; 6%) outpatient clinics accounted for the majority (81%) of referrals. with the exception of two cases from general outpatients, referrals (n = 464; 99.6%) were from specialist or subspecialist clinics (table 1). table 1: referrals by outpatient department. scheduled examinations examinations of the spine (n = 314; 56%), brain (n = 152; 27%) and musculoskeletal system (n = 70, 13%) accounted for more than 95% of investigations (table 2). table 2: examinations and clinical indications by body part. clinical indications for referrals magnetic resonance imaging spine more than 90% (n = 284) of examinations were referred from the neurosurgery, (153/314; 49%), orthopaedic (108/314; 34%) and neurology (23/314; 7%) outpatient clinics. more than half were for degenerative disease of the spine (161/314; 51%) (table 2). magnetic resonance imaging brain referrals from neurosurgery (48/152; 32%), neurology (41/152; 27%), paediatrics (28/152; 18%) and endocrinology (18/152; 12%) predominated. definitive evaluation of an intracranial mass was the most common indication (61/152; 40%), whilst familial syndromes (22/152; 15%) and perinatal insults (20/152; 13%) together accounted for more than a quarter of referrals. musculoskeletal magnetic resonance imaging the majority of referrals were from orthopaedic outpatients (n = 54/65; 83%) and indications included follow-up for joint trauma, congenital abnormalities and soft-tissue tumours (table 2). appropriateness of scheduled examinations in 11 cases (n = 11/466; 2.4%), the clinical details provided were considered insufficient to justify approval of the mri request. in all other cases (n = 455; 97.6%), the clinical indication was congruent with published acr guidelines for appropriate use of the modality.22 discussion top ↑ to our knowledge, the present study is the first of its kind in a tertiary hospital in a resource-restricted environment, and provides important insights into the utilisation of mri in such a setting. we have shown only limited use of mri by clinicians other than neurosurgeons, orthopaedic surgeons and neurologists, suggesting that, in a resource-limited environment, utilisation is confined to the more established clinical indications, and the role of mri in areas such as oncology, cardiology, urology, hepatobiliary, gastro-enterology, female imaging and fetal medicine is constrained. the study has also shown that the vast majority (97.6%) of scheduled tbh elective outpatient mri examinations had sound clinical indications, representing optimal use of a limited resource. a number of recent studies have outlined management options when attempting to align imaging capacity with demand.19,21 given the appropriateness of tbh clinical referrals and the knowledge that mri utilisation at tbh was confined to a relatively narrow spectrum of ’classical’ brain, spine and musculoskeletal studies, it was felt that the only way to address the waiting list was to extend the hours of operation. of note is that no attempt was made to modify institutional imaging protocols for marginal savings in scan time, since we had shown that tbh used a limited number of standard examinations that had been consistently refined and optimised by both the vendor and international users over more than 30 years of clinical application. from september 2012, mri scanning hours were extended by nine hours per week (tuesday – thursday, 16h00 – 19h00). this intervention stabilised the waiting time but did not reduce it (figure 1). unforeseen barriers to successful utilisation of the additional scanning hours were transport problems amongst patients in getting to and from tbh in the early evening, and patient concerns for personal safety when travelling home. figure 1: elective mri waiting time in working days. the grey arrow indicates when longer weekday hours were introduced. the solid black arrow indicates when weekend scanning was introduced. from february 2013, tbh hospital management sanctioned a further 13 scanning hours per week, from 08h00 – 16h00 on saturdays and 08h00 – 13h00 on sundays. this resulted in an immediate and striking decrease in waiting time, from 125 working days in january 2013 to 59 days in may 2013 and 31 days in august 2013 (figure 1). the additional scanning hours were implemented at an estimated annual operating cost of r371 000 (about r7500/weekend) for additional radiographic and nursing services. this represents approximately 2.5% of the current capital outlay for an mri machine and approximates the ’cost-to-company’ of one fulltime entry-level public-sector radiographer. conclusion top ↑ some important considerations relating to the provision of capital-intensive imaging services in a resource-limited healthcare environment have been highlighted. these include the imperative to constantly evaluate the appropriateness of clinical utilisation of a scarce resource, the ongoing challenge of matching clinical need with system capacity, the importance of collaboration between hospital management and the radiology department in addressing service pressures, and the potential for minor, affordable service changes to yield major clinical benefits. our experience suggests that the artificial barrier separating ’normal hours’ and ’after hours’ imaging services should be annulled in a resource-constrained environment, and that capital-intensive equipment should be fully utilised, seven days a week.1 we have demonstrated the substantial service benefits resulting from a small additional investment in key personnel. we recommend that all capital-intensive equipment be commissioned with budgetary provision for the personnel required to run an optimal service seven days a week. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships that might have inappropriately influenced them in writing this article. authors’ contributions f.j.v.s (tygerberg hospital and stellenbosch university) was solely responsible for data collection and collation. f.j.v.s (tygerberg hospital and stellenbosch university) and c.a. 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[cited 30 june 2013]. reston: american college of radiology. available from: http://www.acr.org/quality-safety/appropriateness-criteria rosen mp, oake n, forster aj, goelman a, levy f. the effect of imaging capacity on the imaging workup of patients with stroke: a preliminary case for a cross-country comparison. j am coll radiol. 2011;8(6):428–435. http://dx.doi.org/10.1016/j.jacr.2011.02.012 contents tib 2 sa journal of radiology • october 2005 editorial mr breast imaging does it have a place in your practice? peter corr ffrad (d) sa department of radiology university of kwazulu-natal and inkosi albert luthuli hospital durban the incidence of breast cancer appears to be increasing worldwide, especially in westerncountries, and also in south africa. the demand among patients for breast cancer screening is increasing as they become better informed about the benefits of early detection. radiologists have an important role to play in educating patients on the benefits of breast screening for cancer. mr breast imaging shows great promise for the early detection of cancer in mammographically dense breasts found in some younger women. the sensitivity of mr approaches 100% for invasive malignancy, but it is lower for intraductal cancer, varying between 40% and 100%.1 however the specificity for cancer is much lower, ranging from 37% to 70% in most series.1 this is due to comparing different study populations, different imaging protocols, and different interpretation criteria. however, to confound the issue further it is important to remember that the normal breast parenchyma can enhance focally following gadolinium injection in pre-menopausal women.2 contrast enhancement is minimal in days 7 20 of the menstrual cycle and this is the best time to image the breast using mr. 3 the role of breast mr imaging is not yet clearly defined in relation to mammography and ultrasound but it is important in solving difficult cases with equivocal mammogram and ultrasound findings. it has been demonstrated to be superior to other modalities in accurately determining the tumour stage for preoperative staging and detecting multifocal tumour involvement.1 it is useful in detecting residual or recurrent tumour following lumpectomy if the study is performed 28 days or more following the surgery.4 mr is especially useful in detecting invasive lobular cancer, which is often multifocal or bilateral. lobular cancer does not usually demonstrate a desmoplastic response and this makes detection more difficult on mammography.1 breast mr imaging has been demonstrated to be more sensitive than screening mammography in the detection of familial cancer which may be multifocal in patients who are brca1 or 2 positive or who have a strong family history of breast cancer.5 as in all investigations, good technique is essential for diagnostic studies. fat suppression techniques and gadolinium enhancement are critical in detecting small cancers. new techniques are appearing on the diagnostic horizon, namely mr elastography and mr multivoxel spectroscopy. mr elastography is an interesting technique being investigated in germany to stage breast cancer accurately. this technique images the elastic properties of the breast to detect any desmoplastic response from occult cancers.6 there is a steep learning curve for radiologists interpreting mr breast studies. the best results are achieved working in a multidisciplinary team together with breast surgeons, oncologists and pathologists. 1. lee c. problem solving mr imaging of the breast. radiol clin north am 2004; 42:919-934. 2. kuhl c, bieling hb, gieseke j, kreft bp, sommer t, lutterbey g. healthy premenopausal breast parenchyma in dynamic contrast enhanced mr imaging of the breast: normal contrast medium enhancement and cyclical phase dependency. radiology 1997; 203:137-144. 3. muller-schimpfle m, ohmenhauser k, stoll p, dietz k, clauseen cd. menstrual cycle and age: influence on parenchymal contrast enhancement in mr imaging of the breast. radiology 1997; 203:145-149. 4. frei ka, kinkel k, bonel hm, lu y, esserman lj, hylton nm. mr imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and mr imaging. am j roentgenol 2000; 175:1577-1584. 5. kuhl ck, schmutzler rk, leutner cc, kempe a, wardelman e, hocke a. breast mr imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene; preliminary results. radiology 2000; 215:267-269. 6. sinkus r, tanter m, catheline s, et al. imaging anisotropic and viscous properties of breast tissue by mr elastography. magn reson med 2005; 53:372-387. peter corr guest editor pg2 9/28/05 1:23 pm page 1 article information authors: g.j. du toit1 d. hurter2 m. nel3 affiliations: 1department of clinical imaging sciences, university of the free state, bloemfontein, south africa 2department of radiology, kimberley hospital complex, kimberley, south africa 3department of biostatistics, university of the free state, bloemfontein, south africa correspondence to: g. j. du toit email: reghard.dt@gmail.com postal address: po box 42662, heuwelsig 9332, south africa dates: received: 14 oct. 2014 accepted: 26 apr. 2015 published: 07 aug. 2015 how to cite this article: du toit, gj, hurter, d, nel, m. how accurate is ultrasound of the optic nerve sheath diameter performed by inexperienced operators to exclude raised intracranial pressure?. s afr j rad. 2015;19(1); art. #745, 5 pages. http://dx.doi.org/10.4102/sajr.v19i1.745 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. how accurate is ultrasound of the optic nerve sheath diameter performed by inexperienced operators to exclude raised intracranial pressure? in this original research... open access • abstract • introduction • methods    • study design and setting    • inclusion and exclusion criteria    • procedure protocols    • onsd technique protocol    • lumbar puncture technique protocol    • statistical analysis • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: it has been well documented that ultrasound measurement of the optic nerve sheath diameter performed by an experienced operator shows good correlation with raised intracranial pressure, irrespective of the cause. objective: to establish the accuracy of this technique performed by inexperienced operators. method: a prospective analytical cross-sectional study was conducted. all patients ≥18 years of age who presented at our medical casualty and emergency departments with suspected meningitis were enrolled in the study. all patients were evaluated with the use of optic nerve sheath diameter ultrasound with or without computed tomography brain scan prior to lumbar puncture. lumbar puncture opening pressure measurements were compared with the ultrasound measurements. results: a total of 73 patients were enrolled in the study, of whom 14 had raised intracranial pressure. the study had a sensitivity of 50% (95% confidence interval (ci) 26.8%–73.2%) and specificity of 89.8% (95% ci 79.5%–95.3%) with a positive predictive value of 54.8% (95% ci 29.1%–76.8%) and negative predictive value of 88.3% (95% ci 77.8%–94.2%). the likelihood ratio of a positive test was 4.92 (95% ci 1.95–11.89) and that of a negative test 0.56 (95% ci 0.29–0.83). cohen’s kappa value was 0.41 which indicates a moderate agreement. the receiver operating characteristic (roc) curve had an area under the curve (auc) of 0.73 (95% ci 0.51–0.95). conclusion: ultrasound measurement of the optic nerve sheath diameter can be used to exclude raised intracranial pressure, even in the hands of inexperienced operators. introduction top ↑ it is well documented that ultrasound measurement of the optic nerve sheath diameter (onsd) shows good correlation with a raise in intracranial pressure (icp), irrespective of the cause.1,2,3,4,5,6 the optic nerve sheath is a continuation of the dura mater, and a raise in icp is transmitted via the subarachnoid space to the optic nerve sheath and the optic nerve head.1 the increase in onsd has been established to emerge earlier than other findings evaluated by ophthalmoscopy.7 in vitro studies suggest that the retrobulbar onsd may undergo ultrasound-detectable distension only seconds after the development of intracranial hypertension.8 several studies have compared the accuracy of ultrasound onsd measurements with invasive icp measurements with good results.3,4,6,9,10,11 focal and systemic pathology such as tumours, metastasis, haemorrhage, grave’s disease and pseudotumour, however, may render false positive results.4 bäuerle et al.12 found no correlation between onsd and gender, age (only patients ≥18 years included) and body mass index to provide a single cut-off value for all patients. rajajee et al.1 found ultrasound measurement of the onsd to be an accurate, easy, non-invasive and cost-effective screening method to predict raised icp in experienced hands. there are, however, a few unanswered questions. hansen et al.13 reported that onsd reversibility might be impaired after episodes of prolonged intracranial hypertension, specifically with pressures exceeding 45 mmhg.this finding was confirmed by rajajee et al.8 who found that the specificity and positive predictive value of onsd for icp >20 mmhg are substantially decreased in patients with acute fluctuating icp between high and normal, which could lead to false positive real-time values. the effectiveness of ultrasound measurement of the onsd has also been evaluated mainly when performed by experienced operators, with only one study that specifically looked at inexperienced operators. this latter study by potgieter et al.14 found the technique to be highly accurate, even in the hands of inexperienced operators. a limitation to their study was that only healthy volunteers were used as test subjects and that the measurements of the novice operators were compared with measurements made by an expert operator, and were not compared with icp measurements.14 additionally relevant is that conflicting literature has recently been published regarding the exact onsd cut-off value to accurately predict an increase in icp. geeraerts et al.10 found that values <5.8 mm are not likely to be associated with icp >20 mmhg. kimberly et al.11 reported an onsd >5.0 mm to correlate with icp >20 mmhg. the most recent study found that a cut-off of 6.3 mm predicted icp >20 mmhg, with a 100% sensitivity and 73% specificity.15 a review study by raboel et al.9 found a cut-off value of 5.0–5.9 mm for predicting a raise in icp. sensitivity and specificity were 74%–95% and 79%–100%, respectively. rajajee et al.1 published the best results, with a sensitivity of 96% and specificity of 94% for icp >20 mmhg and an onsd cut-off value ≥4.8 mm. these variations can be attributed mainly to inter-observer variability and the retrobulbar hypoechoic artifact.1,8 in summary, previous studies found that a value < 4.8 mm was normal and in one study a value >5.9 mm was abnormal in predicting icp >20 mmhg.1,9 values between 4.8 mm and 5.8 mm are seen as equivocal. rajajee et al.1 identified the most accurate values; for the purpose of our study, 4.8 mm was used as the cut-off value. the kimberley hospital complex in northern cape province, south africa, treats a high number of suspected meningitis patients with either focal neurological signs or decreased consciousness and subsequent requests for computed tomography (ct) brain scans to assess the safety of lumbar puncture (lp) prior to the procedure. being the only tertiary facility in northern cape province, we are burdened with large patient numbers and the specific problem of patients having to travel long distances to reach our facility. the aim of our study was to establish the accuracy of ultrasound onsd performed by inexperienced operators to exclude raised icp. in the event of a positive outcome, this technique can be used to exclude raised icp in all patients presenting at emergency and casualty departments with decreased consciousness or signs suggestive of raised icp. this approach would especially benefit doctors in peripheral hospitals with limited resources to establish the urgency of treatment and referral of patients. methods top ↑ study design and setting we conducted a prospective analytical cross-sectional study. approval was obtained from the ethics committees of the faculty of health sciences of the university of the free state and the department of health of the northern cape. informed consent was obtained either from the patient or a family member. data were collected during march–april and november–december 2013. inclusion and exclusion criteria patients ≥18 years old who presented at the kimberley hospital complex emergency and medical casualty departments with clinically suspected meningitis, and who received a lp with opening pressures, were included in the study. patients with contra-indications for lp including thrombocytopaenia or other bleeding diathesis and suspected spinal epidural abscess, any orbital and/or globe injury or pathology, and patients with failed and/or incorrect technique of lp, were excluded from the study. procedure protocols onsd measurements were performed by a total of 11 radiology medical officers and registrars, all familiar with routine ultrasound procedures, but with no previous exposure to this specific technique. a 30-minute didactic session explaining the basic anatomy and technique was followed by a small pilot study which took approximately one hour, giving each operator the opportunity to practise on at least five healthy volunteers. all patients enrolled in the study were evaluated by ultrasound of the onsd with or without ct of the brain (based on departmental protocol) prior to lp. following the ultrasound examination, patients had a lp if there were no contra-indication(s) detected clinically or on ct findings. when performed, ct scans were evaluated for predetermined signs of raised icp, including midline shift, size and shape of the ventricles, status of the basal cisterns and effacement of the sulci. all ct scans were performed and evaluated after completion of the onsd ultrasound to prevent bias, as the ultrasound study and the ct report were performed by the same investigator. all ct scans were reviewed by a single radiologist; amendments were made if necessary. ultrasound and ct findings (when available) were compared with lp opening pressures. results were also compared with previously published results to assess the accuracy of this technique when performed by inexperienced operators. onsd technique protocol all onsd measurements were made using a ge healthcare logiq s8 ultrasound machine with a 9 mhz linear array probe with settings on small parts, field reduced to 4 cm and the optic nerve not zoomed. doppler measurements were not performed owing to the theoretical risk of retinal detachment. the ultrasound technique used in this study was the technique described by rajajee et al.1 the examination was performed with the patient in the supine position and the head elevated 20°–30° to the horizontal. the probe was placed on the lateral aspect of the closed upper eyelid; care was taken not to apply pressure on the globe. the probe was angled medially and caudally until the hypoechoic optic nerve could be clearly demonstrated posterior to the globe. care was taken in distinguishing the margins of the optic nerve sheath from the retrobulbar linear hypoechoic artifact. the onsd was measured 3 mm behind the retina (figure 1). two axial measurements for each eye were recorded, and a mean value for the four measurements was recorded for each patient. figure 1: ultrasound image of normal optic nerve sheath diameter to minimise bias, none of the ultrasound operators was informed about the assumed normal cut-off value and no conclusions were made based on ultrasound measurements, as this would not have altered patient management during the study. lumbar puncture technique protocol lumbar punctures were performed by medical casualty and emergency department registrars and medical officers. opening pressures were recorded with the patient lying in either the left or right decubitus positions and the legs straightened at the time of the pressure measurement. the zero level of the manometer was adjusted to approximate the level of the left atrium, which corresponds to the position of the spinal canal in the left decubitus position. patients were also urged to relax to avoid false elevation of the opening pressure owing to the valsalva effect. as the study from rajajee et al.1 used invasive intracranial pressure monitoring and mmhg as the unit of measurement, we had to convert mmhg to cmh2o. using standard international conversion tables (1 mmhg:1.36 cmh2o), an opening pressure >27 cmh2o was therefore considered as raised icp. table 1: ultrasound optic nerve sheath diameter (onsd) measurements compared with lumbar puncture (lp) opening pressure. the cerebrospinal fluid (csf) laboratory results and whether the patient received empiric antibiotics were also recorded. the medical officers performing the lp and the ultrasound operators were blinded to each other’s results. statistical analysis descriptive statistics, namely frequencies and percentages for categorical data and medians and percentiles for continuous data, were calculated. the sensitivity, specificity, positive and negative predictive values, likelihood ratios, area under the curve (auc) and cohen’s kappa value with their respective 95% confidence interval (ci) were calculated for the ultrasound measurements. results top ↑ a total of 102 patients were evaluated with ultrasound of the onsd with or without ct scan. of these, 29 patients were excluded owing to missing data forms (23 patients), failed lp (2 patients) and incorrect lp technique (4 patients). no patients were excluded owing to orbital/globe trauma or pathology or a contra-indication to lp. of the 73 enrolled patients, 59 (80.8%) patients had lp opening pressures ≤27 cmh2o and 14 (19.1%) patients had lp opening pressures >27 cmh2o. ultrasound measurements <4.8 mm were recorded in 60 (82.2%) patients and ≥4.8 mm in 13 (17.8%) patients. these measurements resulted in true negative findings in 53 (72.6%) patients, true positive findings in 7 (9.6%), false negative findings in 7 (9.6%) and false positive findings in 6 (8.2%) patients (table 1). sensitivity of 50% (95% ci 26.8%–73.2%) and specificity of 89.8% (95% ci 79.5%–95.3%) were achieved. a resulting positive predictive value of 54.8% (95% ci 29.1%–76.8%) and negative predictive value of 88.3% (95% ci 77.8%–94.2%) were demonstrated. the likelihood ratio of a positive test was 4.92 (95% ci 1.95–11.89) and the likelihood ratio of a negative test was 0.56 (95% ci 0.29–0.83). cohen’s kappa value for symmetric agreement between onsd and lp opening pressure was 0.41 (95% ci 0.14–0.67), which indicates moderate agreement (figure 2). figure 2: the receiver operating characteristic (roc) curve. source: figure provided by authors. the roc curve had an auc of 0.73 (95% ci 0.51–0.95). the ci for auc overlaps with the results of rajajee et al.1, therefore suggesting similar results. of the 14 patients with raised icp, 13 (92.9%) had csf laboratory results consistent with either viral, bacterial, tuberculous or cryptococcal meningitis or combinations of these. a total of 28 (38.4%) patients also had a ct brain scan after the ultrasound onsd measurements were recorded. of the 14 patients with raised icp, 5 (35.7%) had ct scans, of which 3 (60.0%) scans revealed signs suggestive of raised icp. one patient had an ultrasound measurement ≥4.8 mm with features of raised icp on ct and had a csf laboratory result consistent with viral meningitis. the lp opening pressure, however, measured only 9 cmh2o. another patient had an ultrasound measurement <4.8 mm and a normal csf laboratory result with a lp opening pressure >27 cmh2o. discussion top ↑ to our knowledge, the present study is the first to assess the accuracy of onsd ultrasound performed by inexperienced operators in the specific setting of suspected meningitis. previous studies have shown that this technique is accurate in predicting raised icp irrespective of the cause.1,2,3,4,5,6 in theory, this approach then provides the emergency care physician (especially in peripheral hospitals with limited recourses) with a cost-effective, accessible and simple way to exclude raised icp owing to primary causes ranging from head trauma to a primary brain tumour, and to establish the urgency of management and/or referral of the patient. the sensitivity and specificity were lower than those reported by rajajee et al.1 but not significantly, as the auc tested similar and confidence intervals overlapped. to further clarify our findings, we draw attention to the following: firstly, even though the technique appears to be fairly simple, the reality is that it is not that easy to perform, and accuracy will only be achieved with experience. most of the previous studies used operators with experience ranging between at least 2 months and 3 years.1 the unit of measurement is small: for example, 4.7 mm being normal and 4.9 mm suggesting raised icp, which then proves that the 5 healthy volunteers used to gain experience in the pilot study were not sufficient. a limitation of our study is that we had no experienced operator to teach and guide our training. the technique and training were solely done as described by rajajee et al.1 secondly, previous studies were mostly done on ventilated and sedated patients in an intensive care unit setting and icp measured by intracranial monitors. these patients, for obvious reasons, were substantially more ’co-operative’ than our patient population. some of our patients were confused and restless, leading to them moving their heads and, even when their heads were still, moved their eyes. accurate measurement of the onsd was consequently very difficult and in some cases nearly impossible. we have to assume that poor co-operation of this small group of patients might have contributed to less accurate measurements which ultimately might have led to an underestimation of the operator’s true ability to accurately measure the ultrasound onsd. it was, however, not possible to quantify this assumption. a further limitation of our study was the small number of patients with raised icp. potgieter et al.14, however, used only normal volunteers as test subjects and concluded that the technique was accurately performed by novice operators. we were unable to establish inter-observer variability owing to the large number of operators and the small number of patients with raised icp. another limitation was the lp opening pressure measurements. we are aware that invasive icp monitors are considered the gold standard for measuring icp.9,14 our study would not have been possible without using lp opening pressure measurements which, although fairly accurate, still have shortcomings. this was demonstrated with the two patients referred to in the last paragraph of the results. we have to assume possible lp opening pressure measurement errors in these two scenarios. it is unlikely to have a normal lp opening pressure with signs of raised icp on ct, abnormal ultrasound onsd measurements and csf laboratory results consistent with viral meningitis. it is also unlikely to have normal csf laboratory results and ultrasound onsd measurements with raised lp opening pressures. this resulted in an inaccurate false positive finding with the first patient and an inaccurate false negative result with the second patient (not adjusted as such in the final results). we could correlate all findings in the remainder of the patients and can assume that the other opening pressure measurements were accurate. when available, we also compared ct findings with ultrasound measurements and lp opening pressures. there is currently no accurate method to estimate icp based on ct findings alone; however, a linear but non-predictive relationship has been described between baseline icp and initial ct brain findings.9 this factor, however, was not our main aim and did not alter our results. conclusion top ↑ whilst the study did not demonstrate an acceptable positive predictive value, onsd ultrasound had a high negative predictive value, even in inexperienced hands. a moderate agreement between ultrasound operators was also demonstrated and similar results to rajajee et al.1 were found. acknowledgements top ↑ we thank dr daleen struwig, medical writer, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions g.d.t. (university of the free state) was involved in planning and writing the study protocol and obtaining ethics approval, presented the didactic session, and performed some of the ultrasound procedures, data collection, compilation of results and writing of the manuscript; d.h. (kimberley hospital complex) was involved in planning the study protocol and contributed to the final manuscript; m.n. (university of the free state) performed the statistical analysis of data and contributed to the final manuscript. references top ↑ rajajee v, vanaman m, fletcher jj, jacobs tl. optic nerve ultrasound for the detection of raised intracranial pressure. neurocrit care. 2011;15:506–515. http://dx.doi.org/10.1007/s12028-011-9606-8 girisgin as, kalkan e, kocak s, candar b. the role of optic nerve ultrasound in the diagnosis of elevated intracranial pressure. emerg med. 2007;25:251–254. http://dx.doi.org/10.1136/emj.2006.040931 geeraerts t, launey y, martin l, et al. ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. intensive care med. 2007;33:1704–1711. http://dx.doi.org/10.1007/s00134-007-0797-6 soldatos t, karakitsos d, chatzimichail k, papathanasiou m, gouliamos a, karabinis a. optic nerve sonography in the diagnostic evaluation of adult brain injury. crit care. 2008;12:r67. http://dx.doi.org/10.1186/cc6897 blaivas m, theodoro d, sierzenki pr. elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. acad emerg med. 2003;10:376–381. http://dx.doi.org/10.1111/j.1553-2712.2003.tb01352.x moretti r, pizzi b, cassini f, vivaldi n. reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. neurocrit care. 2009;11:406–410. http://dx.doi.org/10.1007/s12028-009-9250-8 hansen hc, helmke k. validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. j neurosurg. 1997;87:34–40. http://dx.doi.org/10.3171/jns.1997.87.1.0034 rajajee v, fletcher jj, rochlen lr, jacobs tl. comparison of accuracy of optic nerve ultrasound for the detection of intracranial hypertension in the setting of acutely fluctuating vs stable intracranial pressure: post-hoc analysis of data from a prospective, blinded single center study. crit care. 2012;16:r79. http://dx.doi.org/10.1186/cc11336 raboel ph, bartek j, andresen m, bellander bm, romner b. intracranial pressure monitoring: invasive versus non-invasive methods – a review. crit care res pract. 2012; article id 950393. 14 pages. geeraerts t, merceron s, benhamou d, vigue b, duranteau j. non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. intensive care med. 2008;34:2062–2067. http://dx.doi.org/10.1007/s00134-008-1149-x kimberly hh, shah s, marill k, noble v. correlation of the optic nerve sheath diameter with direct measurement of intracranial pressure. acad emerg med. 2008;15:201–204. http://dx.doi.org/10.1111/j.1553-2712.2007.00031.x bäuerle j, lochner p, kaps m, nedelmann m. intraand interobserver reliability of sonographic assessment of the optic nerve sheath diameter in healthy adults. j neuroimaging. 2012;22:42–45. http://dx.doi.org/10.1111/j.1552-6569.2010.00546.x hansen hc, lagrèze w, krueger o, helmke k. dependence of the optic nerve sheath diameter on acutely applied subarachnoidal pressure-an experimental ultrasound study. acta ophthalmol. 2011;89:e528–e532. http://dx.doi.org/10.1111/j.1755-3768.2011.02159.x potgieter dw, kippin a, ngu f, mckean c. can accurate ultrasonographic measurement of the optic nerve sheath diameter (a non-invasive measure of intracranial pressure) be taught to novice operators in a single training session? anaesth intensive care. 2011;39:95–100. sahoo ss, agrawal d. correlation of optic nerve sheath diameter with intracranial pressure monitoring in patients with severe traumatic brain injury. indian j neurotrauma. 2013;10:9–12. http://dx.doi.org/10.1016/j.ijnt.2013.05.010 article information authors: jacqueline du toit1 tracy kilborn1 llewellyn padayachy2 komala pillay3 marc hendricks4 affiliations: 1department of radiology, red cross children’s hospital, cape town, south africa 2department of neurosurgery, red cross children’s hospital, cape town, south africa 3department of pathology, red cross children’s hospital, cape town, south africa 4department of oncology, red cross children’s hospital, cape town, south africa correspondence to: jacqueline du toit email: jacqueline.dut@gmail.com postal address: private bag x5, rondebosch, 7700, south africa dates: received: 26 july 2015 accepted: 12 oct. 2015 published: 09 dec. 2015 how to cite this article: du toit j, kilborn t, padayachy l, pillay k, hendricks m. cystic hemispheric medulloepithelioma. s afr j rad. 2015;19(2); art.  #915, 5 pages. http://dx.doi.org/10.4102/sajr.v19i2.915 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. cystic hemispheric medulloepithelioma in this case report... open access • abstract • introduction • case report • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ medulloepithelioma is a rare primitive embryonal tumour of the central nervous system which typically occurs in early childhood. the histopathological appearance has been confused with primitive neuroectodermal tumours (pnets), but medulloepitheliomas have a more aggressive clinical course. imaging typically demonstrates a well-circumscribed, poorly or non-enhancing solid mass, with cyst formation being infrequent. we report the imaging findings in a case of a cystic hemispheric medulloepithelioma. the importance of considering this diagnosis is discussed in view of the propensity to aggressive recurrence in subtotal resection. introduction top ↑ medulloepithelioma is a rare central nervous system (cns) tumour of childhood with a very poor prognosis. although the tumour has a variable appearance on neuroimaging, cyst formation is said to be infrequent. we report the imaging and histological findings of a predominantly cystic medulloepithelioma with an innocuous radiological appearance belying its aggressive behaviour. case report top ↑ a five-year-old girl presented to the casualty department of our institution with a two-week history of progressive headache and vomiting. on examination she was generally well, with no demonstrable neurological deficit. computerised tomography (ct) of the brain (figure 1) revealed a predominantly cystic mass in the right posterior parietal lobe, with the impression of a small nodular enhancing solid component medially. there was mass effect with midline shift to the left and contralateral ventricular dilatation. figure 1: ct brain at presentation. pre (a) and post (b) contrast axial ct images demonstrate a cyst in the right parietal lobe with a nodular enhancing component at its medial margin. there is associated right hemispheric swelling with midline shift to the left. magnetic resonance imaging (mri) of the brain (figure 2) confirmed the predominantly cystic nature of the well-circumscribed mass within the right parietal lobe, with minimal surrounding peritumoral oedema. the cystic component was t1 hypoand t2 hyperintense. images post gadolinium showed both peripheral rim enhancement and a small nodular enhancing solid component medially, abutting the lateral ventricle. neither the cystic nor the solid components of the mass showed diffusion restriction. neovascularity, haemorrhage, calcification, drop metastases and leptomeningeal spread were absent. figure 2: mri brain at presentation. t1 (a) and t2 (b) axial mri reveals a predominantly cystic mass in the right posterior parietal lobe with associated mass effect and contralateral ventricular dilatation. there is only minimal peri-tumoral oedema. the t1 post contrast image (c) shows peripheral rim-enhancement and a small nodular solid component medially. there is no significant neovascularity and no evidence of haemorrhage. a right parieto-occipital craniotomy with subtotal resection was performed. histological sections (figure 3) showed a primitive neuro-ectodermal tumour with a heterogeneous appearance and cystic change. figure 3: tumour biopsy histology haematoxylin and eosin sections showing an embryonal tumour with neuronal and ependymal differentiation (a), trabecular areas displaying basement membrane deposition (b), and a primitive embryonal component with homer-wright rosettes (c). immunohistochemistry shows positivity with the epithelial marker ae1/ae3 (d) and confirms collagen iv positive basement membrane material (e). areas of primitive embryonal cells alternated with areas showing trabecular, papillary and tubular architecture, with variable amounts of eosinophilic matrix material resembling basement membrane-like material. mitotic figures were brisk in the more primitive areas. a small focus of necrosis was also seen. the pan-keratin marker mnf-116 was strongly positive in the tubulopapillary areas and there was focal positivity with ae1/ae3 (pan-keratin marker and epithelial membrane antigen). collagen iv highlighted the basement membrane-type material bordering the trabecular areas. these areas also showed focal weak glial fibrillary acidic protein (gfap) positivity. neuronal markers (neurofilament and synaptophysin) were negative. according to the world health organization (who) 2007 classification, the overall features were compatible with an embryonal tumour displaying evidence of ependymal and glial differentiation consistent with a diagnosis of medulloepithelioma (figure 3). the patient was subsequently commenced on chemotherapy comprising high-risk medulloblastoma/supratentorial primitive neuroectodermal tumour (pnet) protocol, which is joe-e (vincristine iv, carboplatin iv, etoposide iv and etoposide po) alternating with opec (vincristine iv, cisplatin iv, etoposide iv and cyclophosphamide iv). follow-up imaging six weeks post-surgery, on chemotherapy, showed an increase in the size of the solid enhancing tumour component (figure 4). a repeat craniotomy with gross total resection was performed, followed by radiotherapy and an intensive six-week cycle of chemotherapy. repeat imaging is awaited. figure 4: follow-up mri brain six weeks post-surgery, on chemotherapy. an axial t1 post-contrast image shows interval increase in the size of the solid tumour component. discussion top ↑ first described by bailey and cushing in 1926, cns medulloepitheliomas are rare, highly malignant embryonal tumours which tend to occur in early childhood, usually between the ages of 6 months and 5 years.1,2,3 the prognosis is dismal, with a mean survival of 8.5 months from diagnosis.2,4 interestingly, a histologically similar tumour, the intraorbital medulloepithelioma, which usually arises within the ciliary body, exhibits a much less malignant course, with excellent long-term survival. the difference in biological behaviour is unexplained.2 a review of the literature reveals relatively few descriptions of the neuroimaging characteristics of these tumours, with mri findings only having been reported in a handful of cases.2,5 despite a variable radiological appearance, most cases are isodense or hypodense on ct and seldom display contrast enhancement as described in our case.2 the tumours tend to be large at the time of presentation, with extensive haemorrhagic and necrotic components.4,6 hyperdense and partially cystic lesions have also been described.5,6 our patient demonstrated a predominantly cystic mass with a small peripheral nodule, a similar appearance to that in the first reported case on ct.3 in the few reported cases, mri has shown a solid mass predominantly hypointense on t1-wi, hyperintense on t2-wi and rarely displaying contrast enhancement. this lack of enhancement is said to distinguish medulloepitheliomas from pnets, which enhance avidly and are one of the main differential diagnoses in this clinical setting.2 our case of a predominantly cystic lesion with a peripheral and enhancing nodular component has not been reported previously. gadolinium enhancement is more commonly demonstrated in the case of tumour recurrence, likely indicating the more aggressive nature of recurrent disease as was also seen in the follow-up imaging of our patient.2 at the time of tumour progression, cns medulloepithelioma is also prone to subarachnoid dissemination. the diverse imaging appearance can be explained by the variable differentiation seen histologically.1,2 these tumours contain structures that resemble the primitive neural tube and approximately half of the cases exhibit the capacity for divergent differentiation into astroglial, ependymal or neuronal cell lines. medulloepitheliomas are classified as who grade iv embryonal tumours, but unlike other pnets they have a dismal prognosis. the tumour responds poorly to treatment – gross total resection and radiotherapy may provide some benefit.2 post-operative scanning is needed to alert the neurosurgeon to the need for early intervention as all cases of subtotal resection reported within the literature went on to early progression, as in our case. conclusion top ↑ cns medulloepithelioma is a rare tumour, but it should be considered in the differential diagnosis of a cystic hemispheric mass since the innocuous appearance belies its locally aggressive behaviour and a high incidence of recurrence post subtotal resection. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.d.t. (red cross children’s hospital) and t.k. (red cross children’s hospital) analysed the imaging, conducted a literature review and wrote the original manuscript. l.p. (red cross children’s hospital) provided the clinical and operative details. k.p. (red cross children’s hospital) performed the histopathological analysis and provided the relevant histology slides. m.h. (red cross children’s hospital) provided clinical and management information. all authors were involved in final editing and checking. references top ↑ bailey p, cushing h. a classification of tumours of the glioma group on a histogenetic basis with a correlated study of progress. philadelphia: jb lippincott, 1926; p. 54–56. molloy pt, yachnis at, rorke lb, et al. central nervous system medulloepithelioma: a series of eight cases including two arising in the pons. j neurosurg. 1996;84:430–436. pmid: 8609554, http://dx.doi.org/10.3171/jns.1996.84.3.0430 grainger rd, allison dj, editors. diagnostic radiology. 5th edn. churchill livingston elsevier, 2008; p. 1684. poot rd. medulloepithelioma: first ct images. neuroradiology. 1986;28:286. pmid: 3725021, http://dx.doi.org/10.1007/bf00548211 pang lm, roebuck dj, ng hk, chan yl. sellar and suprasellar medulloepithelioma. pediatr radiol. 2001;31:594–596. pmid: 11550774, http://dx.doi.org/10.1007/s002470100495 sundaram c, vydehi b, reddy j, reddy ak. medulloepithelioma: a case report. neurol india. 2003;51:546–547. pmid: 14742946. 22-24 abstract lemierre’s syndrome (postanginal sepsis/necrobacillosis) is a rare clinical entity characterised by the triad of acute oropharyngeal infection, with secondary thrombophlebitis of the internal jugular vein and metastatic septic emboli. a high degree of clinical suspicion is needed to diagnose the syndrome and the radiologist’s awareness of it may expedite the diagnosis and therefore the appropriate treatment for these potentially fatal sequelae of a ‘sore throat’. we present a case of a 20-year-old man admitted to helen joseph hospital in july 2004 with multiple lung abscesses, in whom internal jugular vein thrombophlebitis was subsequently diagnosed. chest radiographic and computed tomography (ct) images accompany a brief review of this largely forgotten syndrome . introduction lemierre’s syndrome is a rare form of postanginal septicaemia, usually caused by gram-negative oral anaerobes, the most common pathogen being fusobacterium necrophorum (necrobacillosis).1 bacterial oropharyngeal infection, such as pharyngitis or tonsillitis, is followed by local invasion of the lateral pharyngeal space and septic thrombosis of the internal jugular vein, and finally the occurrence of metastatic complications.2 the entity was first described in detail by lemierre in 1936.3 before the advent of antibiotics, lemierre’s syndrome was common, often following a fatal course, with a 90% mortality rate.3,4 more recently, however, the widespread use of antibiotics in the treatment of oropharyngeal infections has led to a marked decline in prevalence and lemierre’s has become a largely forgotten disease.3,5 the syndrome typically occurs in previously healthy adolescents and young adults, with a short interval between the oropharyngeal infection and the onset of septicaemia.6,7 the most common sites of secondary septic emboli are the lungs (79.8%)2 and large joints,7 whilst less commonly documented sites include the liver, spleen and brain.1,3,8 today the prognosis is relatively favourable with early, directed antimicrobial therapy.4,9 the radiologic findings in lemierre’s syndrome are integral to its diagnosis. case report a 20-year-old man was admitted to helen joseph hospital with a 2-week history of increasing left-sided facial swelling and mild neck stiffness, followed by a productive cough of 1 week’s duration. on examination he was pyrexial, with mild neck stiffness, left-sided facial swelling and scattered crepitations throughout both lungs on auscultation. ent and cardiac examinations were documented as normal. the admission chest x-ray (fig.1) revealed multiple, bilateral, poorly defined nodules with central breakdown or cavitation in the majority, a small right-sided pleural effusion and cervical soft-tissue prominence. the differential diagnosis at this stage included infectious causes, e.g. tuberculosis, staphylococcus, klebsiella and septic emboli, with wegener’s granulomatosis, rheumatoid nodules and metastases less likely.10 the patient had no history of rheumatic heart disease or intravenous drug abuse. investigations yielded the following results. full blood count revealed a neutrophil leucocytosis (white cell count case report 22 sa journal of radiology • july 2005 lemierre’s syndrome – the uncommon cold r such mb mch, fcrad (diag) e joseph mb bch, ffrad (diag) department of radiology university of the witwatersrand helen joseph and chris hani, baragwanath hospitals johannesburg fig.1 chest x-ray demonstrates cavitating nodules, a small right-sided pleural effusion and soft-tissue fullness in the neck bilaterally. 22-24 7/30/05 6:26 am page 22 23.8 x 109/l) and thrombocytopaenia (platelets 39 x 109/l). the hiv elisa was negative and the cerebrospinal fluid specimen was normal. echocardiography and abdominal ultrasound examinations were also unremarkable. serial sputum specimens were collected for mc & s and acid-fast bacillus which eventually yielded escherichia coli, whilst blood cultures were contaminated by a coagulase-negative staphylococcus (staphyloccus epidermidis). initial treatment was commenced with intravenous cefuroxime and gentamicin, a second-generation cephalosporin and an aminoglycoside respectively, for synergistic broad spectrum ß-lactam and gram-negative cover.11 however, the patient remained intermittently pyrexial and described increasing neck pain and dysphagia, prompting further investigation with a pre-and post-contrast axial ct scan of the neck, utilising 100ml jopamiron 300 at a rate of 2 ml/s (figs 2 and 3) this revealed a small leftsided parapharyngeal abscess, ipsilateral internal jugular vein (ijv) thrombosis with enhancement of the vessel wall and numerous pulmonary nodules in the visible lung apices, with varying degrees of cavitation. these were situated predominantly in the lung periphery and were associated with a right-sided pleural effusion. the diagnosis of oropharyngeal abscess with secondary ijv thrombophlebitis and septic emboli was made and metronidazole was added to the existing treatment regimen in order to cover anaerobic pathogens. in addition warfarin anticoagulation was commenced. favourable clinical response was obtained, and follow-up chest x-ray and ct scan of the neck after a 3-week interval revealed supporting radiologic improvement. the abscess had resolved, the left ijv remained thrombosed but without mural enhancement, and the pulmonary nodules and pleural effusion were decreasing in number and size (figs 4 and 5). discussion whilst gram-negative anaerobes including fusobacterium necrophorum (a commensal organism) are documented as the most common pathogens associated with lemierre’s syndrome,1-3,5-9 postanginal sepsis has been linked to other organisms including eikenella corrodens12 and salmonella, which may act as an oxygen consumer and facilitate the growth of anaerobes.13 we postulate that the escherichia coli (like salmonella, an aerobic, gram-negative, enteric rod) cultured from the sputum of this patient, may have played a similar role in the pathogencase report 23 sa journal of radiology • july 2005 fig.2. ct scan demonstrates a left ijv hypoattenuating filling defect and a thickened enhancing wall, as well as a small abscess lateral to the hyoid on the ipsilateral side. fig.3. ct scan of the lung apices confirms peripheral cavitating nodules and a right pleural effusion. fig.4. repeat ct scan of the neck demonstrates ongoing left ijv thrombosis, without the presence of parietal contrast fixation. fig.5. repeat ct scan of the lung apices confirms resolution of pulmonary nodules and pleural effusion 22-24 7/30/05 6:26 am page 23 esis of lemierre’s syndrome.14 as the offending anaerobe was not definitively cultured, appropriate anaerobic antibiotic therapy was not instituted until the ct investigation documented evidence of oropharyngeal infection and secondary internal jugular vein thrombophlebitis, thus suggesting the diagnosis of lemierre’s. it is interesting to note that infection of the parapharyngeal space may affect not only the ijv in the carotid space, but also cranial nerves ix xii and the cervical sympathetic chain, with consequent neurologic signs and symptoms including hoarseness and dysphagia, collectively known as villaret’s syndrome.3,15 many patients with lemierre’s present with nonspecific signs and symptoms ranging from acute pharyngitis to fever and malaise with the onset of systemic sepsis.3 ijv thrombosis typically causes tenderness and swelling in the neck, along the line of the sternocleidomastoid muscle,5 however these findings may be minor and readily overlooked.3 chest x-ray findings may be normal, or may exhibit nonspecific infiltrates early in the evolution of the syndrome, with the classic features of septic emboli developing only later.2,3 the triad of pharyngitis, a tender or swollen neck and a pulmonary infiltrate, should alert the clinician to the possibility of lemierre’s.2 typical associated radiographic findings may prove integral in the diagnosis. ijv thrombus may be demonstrated at colour doppler ultrasound as non-compressible clot, frequently associated venous distention, and the absence of phasic flow.3 contrast ct diagnostic signs include widening of the vein calibre, inhomogeneous or absent luminal opacification, and parietal contrast fixation.16 chest x-ray or ct findings characteristic for septic emboli are multiple, peripheral, round and wedgeshaped opacities that progress rapidly to cavitation, often with associated pleural effusions. these features may be readily appreciated at ct, when the additional finding of a ‘feeding vessel’ sign (pulmonary artery leading to a nodule) may be seen.3,10 radiologic investigations may therfore be instrumental in reaching a specific diagnosis of lemierre’s. treatment the management of lemierre’s requires a prolonged course of highdose, intravenously administered antibiotics, including adequate anaerobic activity.1,3 the role of anticoagulation remains controversial, but may enhance resolution of the source of septic embolisation.3 if signs of sepsis persist, with propagation of the infected thrombus, ligation or excision of the ijv may be required.1,7 more recently, hyperbaric oxygen has been investigated as a potential adjunctive therapy in postanginal sepsis.17 conclusion today morbidity and mortality in lemierre’s syndrome is caused mainly by a lack of knowledge of the syndrome.18 it follows that awareness of this syndrome on the part of the radiologist should lead to the suggestion of lemierre’s, whether by demonstration of ijv thrombosis by ultrasound or ct, or through findings indicative of septic emboli in the correct clinical setting, as this may expedite the correct treatment. early directed antibiotic therapy with anaerobic cover is mandatory to ensure recovery without sequel. references 1. venkataraman mt, policar m. fever, sore throat and pulmonary infiltrates in a 20-year-old man. chest 1997; 112: 268-270. 2. chironos ja, lichtstein dm, garcia j, tamariz lj. the evolution of lemierre syndrome: report of 2 cases and review of the literature. medicine (baltimore) 2002; 81: 458-465. 3. screaton nj, ravenel jg, lehner pj, heitzman er, flower cdr. lemierre syndrome: forgotten but not extinct – report of four cases. radiology 1999; 213: 369-374. 4. ma m, jauch ec, johnson mc. a case of lemierre’s syndrome (abstract). eur j emerg med 2003; 10: 139-142. 5. ritter m, tebbe j, battmann a, gorg c. lemierre’s syndrome: the forgotten disease. an unusual presentation of sepsis (abstract). ultraschall med 2004; 25(1):70-73. 6. shaham d, sklair-levy m, weinberger g, gomori jm. lemierre’s syndrome presenting as multiple lung abscesses (abstract). clin imaging 2000; 24: 197-199. 7. golpe r, marin b, alonso m. lemierre syndrome (necrobacillosis) (abstract). postgrad med j 1999; 75: 141-144. 8. clarke mg, kennedy mj, kennedy k. serious consequences of a sore throat (abstract). ann r coll surg engl 2003; 85: 242-244. 9. auber ae, mancuso pa. lemierre syndrome: mri and ct appearance (abstract). mil med 2000; 165: 638-640. 10. dahnert w. radiology review manual. 4th ed. baltimore: lippincott williams and wilkins, 2000. 11. gibbon cj, swanepoel cr. south african medicines formulary. 4th ed. cape town: south african medical association, 1997. 12. celikel th, muthuswamy pp. septic pulmonary emboli secondary to internal jugular phlebitis (postanginal sepsis) caused by eikenella corrodens (abstract). am rev respir dis 1984; 130: 510-513. 13. leiberman a, tovi f, barki y, alkan m. salmonella neck abscess with jugular vein thrombosis (abstract). j laryngol otol 1991; 105: 966-967. 14. murray pr, baron ej. manual of clinical microbiology. 6th ed. washington, dc : asm press, 1995. 15. boon p, de reuck j, van de velde e. villaret’s syndrome due to thrombosis of the jugular vein (abstract). clin neurol neurosurg 1990; 92: 337341. 16. pereira m, van beers b, pringot j. diagnosis of internal jugular vein thrombosis by x-ray computed tomography (abstract). j radiol 1985; 66: 797-800 (abstract). 17. hodgson r, emig m, pisarello j. hyperbaric oxygen (hbo2) in the treatment of lemierre’s syndrome (abstract). undersea hyperb med 2003; 30: 87-91. 18. gong j, garcia j. lemierre’s syndrome (abstract). eur radiol 1999; 9: 672-674. case report 24 sa journal of radiology • july 2005 22-24 7/30/05 6:26 am page 24 sajr 959 dual (type iv) left anterior descending artery o baskan, md; e cengiz, md; p yahya, md department of radiology, istanbul medipol university, istanbul, turkey corresponding author : o baskan (obaskan@medipol.edu.tr) congenital coronary artery anomalies are uncommon. dual left anterior descending coronary artery (lad) is defined as the presence of two lads within the anterior interventricular sulcus (aivs), and is classified into four types. type iv is a rarely reported subtype and differs from the others, with a long lad originating from the right coronary artery (rca). dual lad is a benign coronary artery anomaly, but should be recognised especially before interventional procedures. with the increasing use of multidedector computed tomography (mdct), it is essential for radiologists to be aware of this entity and the cross-sectional findings. s afr j rad 2013;17(4):145-146. doi:10.7196/sajr.959 dual left anterior descending coronary artery (lad) is defined as the presence of two lads within the anterior interventricular sulcus (aivs): a short lad that courses and terminates high in the aivs, and a long lad that originates from either the lad proper or from the right coronary artery (rca), then enters the distal aivs and courses to the apex.1 type iv can be differentiated from the other types by the long lad originating from the rca. case report a 52-year-old man was referred to our hospital for chest pain during exercise. the physical examination and laboratory findings were unremarkable. the patient underwent coronary ct angiography (cta) for evaluation of coronary artery disease. the cta showed a short lad ending high in the aivs, arising from the left main coronary artery. the major septal perforators and the diagonal branches originated from the short lad. the long lad arose from the rca, after travelling anterior to the pulmonary artery and right ventricle, re-entering the aivs at the distal part (fig. 1). fıg. 1. (a) three-dimensional volume-rendered (3d-vr) image. (b) two-dimensional map of the coronary tree. (c) maximum intensity projection 3d-globe view. long lad (long white arrow) has anomalous origin from the right coronary artery (long black arrow) and after travelling anterior to the pulmonary artery and right ventricle, enters the aivs at the distal part. short lad (short white arrow), which terminates high in the aivs arising from the left main coronary artery. the major septal perforator (short thick black arrow) as well as the diagonal branches (short thin black arrows) originate from this short lad. ramus intermedius identified by curved arrow. discussion coronary artery anomalies associated with their origin, course and distribution are frequently asymptomatic and have been diagnosed during conventional coronary angiography.2 with advances in mdct technology, it is possible to examine the coronary arteries and heart structures with high spatial and temporal resolution.3 the precise course of the coronary arteries may be easier to appreciate with cta than with conventional angiography because of the omniplanar capability of ct. the dual lad is classified as a congenital course anomaly of the coronary artery. dual lad has been classified into four types by spindola-franko et al. (fig 2).1 the incidence of dual lad in otherwise normal hearts has been reported to range from 0.13%2 to about 1.38%. 1 , 3 this anomaly is seen relatively often with congenital malformations such as complete transposition of the great arteries and tetralogy of fallot.2 fıg. 2. (a) type i. the l lad descends on the left ventricular side of the s lad then enters the distal aivs. (b) ype ii. the l lad descends on the right ventricular side of the s lad and enters the distal aivs. (c) type iii. the l lad courses deep within the interventricular septum proximally and appears on the epicardial surface in the distal part of the aivs. (d) type iv is characterised by a l lad originating from the rca that traverses the right ventricular infundibulum and enters the aivs. (a = aorta; lad = left anterior descending coronary artery; l lad = long lad; rca = right coronary artery; s lad = short lad; lm = left main coronary artery; s = septal perforator; d = diagonal branches; lcx = left circumflex artery). when a short or hypoplastic lad is detected, a differential diagnosis should be sought. there may be a long dominant posterior descending branch of the rca, terminating in the aivs beyond the apex; a long parallel diagonal branch; or a dual lad.4 short lad should not be misdiagnosed as total occlusion and a long lad should not be misdiagnosed as a conus branch. in conclusion, coronary cta is a non-invasive imaging technique using multiplanar reformat and volume rendering images to show complex anatomy and variations of the coronary arteries. the radiologist should be familiar with, and looking for, these conditions during interpretation of coronary cta imaging. 1. spindola-franco h, grose r, solomon n. dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. am heart j 1983;105:445-455. [http://dx.doi.org/10.1016/0002-8703(83)90363-0] 1. spindola-franco h, grose r, solomon n. dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. am heart j 1983;105:445-455. [http://dx.doi.org/10.1016/0002-8703(83)90363-0] 2. sajja lr, farooqi a, shaik ms, yarlagadda rb, baruah dk, pothineni rb. dual left anterior descending coronary artery: surgical revascularization in 4 patients. tex heart inst j 2000;27(3):292-296. 2. sajja lr, farooqi a, shaik ms, yarlagadda rb, baruah dk, pothineni rb. dual left anterior descending coronary artery: surgical revascularization in 4 patients. tex heart inst j 2000;27(3):292-296. 3. erol c, seker m. the prevalence of coronary artery variations on coronary computed tomography angiography. acta radiologica 2012;53:278-284. [http://dx.doi.org/10.1097/rct.0b013e31822aef59] 3. erol c, seker m. the prevalence of coronary artery variations on coronary computed tomography angiography. acta radiologica 2012;53:278-284. [http://dx.doi.org/10.1097/rct.0b013e31822aef59] 4. yoshikai m, kamohara k, fumoto h, kawasaki h. dual left anterior descending coronary artery: report of a case. surg today 2004;34(5):453-455. [http://dx.doi.org/10.1007/s00595-003-2733-x] 4. yoshikai m, kamohara k, fumoto h, kawasaki h. dual left anterior descending coronary artery: report of a case. surg today 2004;34(5):453-455. [http://dx.doi.org/10.1007/s00595-003-2733-x] article information authors: ewoudt van der linde1 vanesha naidu1 ayesha mitha2 antoine rocher3 affiliations: 1department of radiology, university of kwazulu-natal, south africa 2department of radiology, inkosi albert luthuli central hospital, south africa 3department of orthopedics, inkosi albert luthuli central hospital, south africa correspondence to: ewoudt van der linde email: ewoudt@eventdoctors.co.za postal address: po box 171, hyper by the sea, durban 4053, south africa dates: received: 23 jan. 2015 accepted: 20 june 2015 published: 15 oct. 2015 how to cite this article: van der linde, e, naidu, v, mitha, a, rocher, a. diagnosis of nerve root avulsion injuries in adults with traumatic brachial plexopathies: mri compared with ct myelography. s afr j rad. 2015;19(1); art. #779, 9 pages. http://dx.doi.org/10.4102/sajr.v19i1.779 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. diagnosis of nerve root avulsion injuries in adults with traumatic brachial plexopathies: mri compared with ct myelography in this original research... open access • abstract • introduction • method • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: computed tomography myelography (ctm) has been broadly adopted as the ‘gold standard’ imaging technique in the diagnosis of nerve root avulsion injuries in traumatic brachial plexopathies. ctm has the distinct advantage of better spatial resolution than magnetic resonance imaging (mri); however, this technique is invasive and can result in significant patient discomfort. mri, therefore, seems relatively more advantageous as it is less invasive (requires no lumbar puncture), lacks radiation exposure, has no adverse reactions related to intrathecal contrast agents and confers excellent soft-tissue contrast. objectives: to compare the sensitivity and specificity of mri with ctm in the diagnosis of preganglionic nerve root avulsion injuries in adults with traumatic brachial plexopathies at the inkosi albert luthuli central hospital. method: a retrospective comparative analysis was performed on 16 adult patients with traumatic preganglionic brachial plexopathies who underwent both mri and ctm at inkosi albert luthuli central hospital. radiologists experienced in both ctm and mri interpreted the data and a comparison was made using ctm as the gold standard. results: the sensitivity and specificity for mri detecting preganglionic nerve root avulsion injuries and pseudomeningoceles was 82% and 100% respectively. the interobserver agreement between ctm and mri for the detection of preganglionic nerve root avulsion injuries was 81.25% (kappa = 0.77) and 87.5% (kappa = 0.84) for the detection of pseudomeningoceles. conclusion: mri was as sensitive as ctm at detecting preganglionic nerve root avulsion injuries and pseudomeningoceles of spinal nerve roots c7–t1 of the brachial plexus. some mild discrepancies existed at the c5 and c6 nerve root levels. owing to the invasiveness of the procedure and resultant patient discomfort, ctm should be reserved for complicated cases or for patients with contraindications to mri. introduction top ↑ the brachial plexus is a complex network of nerves that originate in the neck and is formed from the ventral rami of c5 to t1. it gives rise to numerous nerves that control motor and sensory function of the upper limbs. motorcycle accidents are the most common cause of all brachial plexus injuries in adults resulting from forced traction applied to the nerves (c5–t1) of the brachial plexus. the head and shoulders are forced apart and cause either nerve root avulsion injuries or stretch/rupture injuries. preganglionic injuries are located proximal to the dorsal root ganglion whilst postganglionic injuries are located distal to the dorsal root ganglion.1 differentiating between preganglionic and postganglionic brachial plexopathies is a crucial distinction as it determines patient management. nerve transfers are used in the management of preganglionic injuries whilst postganglionic injuries are repaired with nerve grafting or managed conservatively.2 most surgeons (94%) operating on brachial plexopathies would prefer either computed tomography myelography (ctm) or magnetic resonance imaging (mri) as their investigations of choice whilst 41% would prefer using both ctm and mri.3 ctm is the imaging modality of choice in the diagnosis of preganglionic brachial plexopathies, with mri as an additional investigation, whilst mri alone is preferred in postganglionic injuries for visualising damaged peripheral nerves.2,4,5 nerve root avulsion injuries are further classified as either partial or complete. partial avulsion refers to avulsion of either the dorsal or ventral nerve root, whereas complete avulsion is the avulsion of both ventral and dorsal nerve roots.4 as a result of the direct visualisation of ventral and dorsal nerve roots, traumatic pseudomeningoceles are no longer regarded as the only incontrovertible evidence for nerve root avulsion injuries.6 nerve roots can be identified on multi-axial ctm or mri slices and should be compared with the contralateral intact nerve roots to avoid false-positive findings. although ctm is the gold standard for detecting nerve root avulsion injuries in traumatic brachial plexopathies, debate still exists whether it should not be replaced by mri (because of all the advantages of mri over ctm) and/or whether ctm should be reserved for patients with contraindications to mri. method top ↑ formal ethics approval was obtained from the biomedical research ethics committee (brec), college of health sciences, university of kwazulu-natal. the study was conducted at inkosi albert luthuli central hospital (ialch), durban. data was collected retrospectively on all adult patients 18 years or older with traumatic preganglionic brachial plexopathies who underwent both cervical mri and ctm from may 2012 to june 2014. jopamiron 300 (iopamidol) was the contrast media used in all patients undergoing ctm. under fluoroscopic guidance and aseptic conditions, contrast was introduced into the intrathecal space via a lumbar puncture. ctm of the cervical spine was performed approximately 45 minutes to 90 minutes after intrathecal injection using a siemens somatom definition as 128-slice computed tomography (ct) scanner with the following settings: reconstructions 1 mm × 1 mm, window – inner ear, kernel b70 (very sharp). multiplanar reconstructed ct images of the cervical spine from c2–t3 were obtained. mri of the cervical spine was performed using a siemens magnetom symphony 1.5t eco scanner. all images were obtained using a spinal cord coil, 256 × 256 matrix, and a 260 mm field of view (fov). t2-weighted images (tr = 1500, te = 126) with 1 mm slice thickness were obtained in three orthogonal planes. radiologists experienced in both ctm and mri interpretation evaluated the images and retrospectively analysed the data. image criteria for the diagnosis of nerve root avulsions were based on the absence of either one (partial avulsion) or both (complete avulsion) nerve roots. when both ventral and dorsal nerve roots were visualised, the nerve roots were documented as being intact. the evidence of pseudomeningoceles was also documented at the various levels it occurred. the analysis of each avulsed nerve root was compared to the contralateral normal/intact side in both ctm and mri. patient demographics, injury lateralisation, cause of injury, nerve conduction study results, clinical examination, associated injuries and management were retrospectively analysed. ctm and mri findings were compared using ctm findings as the ‘gold standard’ (standard of reference). sensitivity, specificity, as well as positive and negative predictive values were calculated and documented accordingly. the kappa statistic (k-value) was used to evaluate interobserver agreement.7 results top ↑ within a 2-year period, 16 patients were included in the study. of these, 15 were male and only one female. the mean age was 30 years (youngest 19 years, oldest 43 years). all imaging was considered to be of diagnostic quality except for one ctm study that was interpreted as being of ‘poor quality’. this was owing to the fact that contrast did not reach the cervical spine post fluoroscopic infiltration and was therefore not visualised on the ctm images. on average, ctm and mri were done 98 days following sustained injury (lower limit = 40 days; upper limit = 208 days). ctm was the modality of first choice in 12 occasions. mri was done before ctm in the remaining four occasions. there was a total of seven (44%) brachial plexus injuries on the left and nine (56%) injuries on the right. the major causes of traumatic brachial plexopathies were motor vehicle accidents (69%), pedestrian vehicle accidents (19%), motorcycle accidents (6%) and blunt trauma (6%). the majority of patients had poly-trauma presenting with multiple upper and/or lower limb injuries. clinical presentation included pain, loss of sensation, motor function deficits, wasting of the muscles around the shoulder joint and scapular winging. horner’s syndrome was documented in two patients (13%). nerve conduction studies were performed on all patients; however, the majority of the results showed mixed sensory and motor deficits involving the c5–t1 nerve roots which were inconclusive. in comparison to ctm, the sensitivity for mri in the detection of preganglionic nerve root avulsion injuries and pseudomeningoceles was 82%, the specificity 100%, the positive predictive value (ppv) 100% and the negative predictive value (npv) 71% (figure 1). mri had the same results as ctm for the detection of preganglionic nerve root avulsion injuries and pseudomeningoceles involving nerve roots c7–t1; however, ctm detected some pseudomeningoceles and preganglionic nerve root avulsion injuries at nerve roots c5/c6 of one patient, which was not detected on mri. an epidural meningocele (em) was detected in both ctm and mri in one patient (figures 2 and 3). figure 1: receiver operating characteristic (roc) curve showing relationships between the sensitivity and specificity for magnetic resonance imaging compared with computed tomography myelography. figure 2: pseudomeningoceles and nerve root avulsion injuries detected by computed tomography myelography at the various nerve roots of the brachial plexus. figure 3: pseudomeningoceles and nerve root avulsion injuries detected by magnetic resonance imaging at the various nerve roots of the brachial plexus. the interobserver agreement was measured using the kappa statistic (k-value). the agreement between ctm and mri for the detection of nerve root avulsion injuries was 81.25% (k = 0.77) and 87.5% (k = 0.84) for the detection of pseudomeningoceles. all patients with confirmed preganglionic nerve root avulsion injuries were managed surgically with intercostal nerve transfers. discussion top ↑ accurate assessment of the preganglionic nerve roots is imperative in the diagnosis of traumatic brachial plexopathies as it impacts on surgical approach and patient prognosis. clinical examination and neurophysiological testing are useful adjuncts that add great value to the diagnosis of these injuries. the clinical assessment of the patient can guide radiological evaluation. limthongthang et al.8 reported signs and symptoms that suggest preganglionic injuries, namely horner syndrome (t1), winged scapula (c5–c7), atrophy of parascapular muscles (c5), cervical paraspinal muscle weakness and loss of posterior neck sensation, hemidiaphragm paralysis (c3–c5), pseudomeningocele on myelogram, and intact sensory nerve action potentials in the area of sensory deficit. neurophysiological testing plays an important role in the diagnosis of traumatic brachial plexopathies.9 nerve conduction studies test for sensory and motor nerve functions. motor nerve testing for detecting more distal nerve injuries is less helpful with traumatic brachial plexopathies when the muscles become completely denervated; however, conduction blocks may still be present in incomplete injuries. sensory testing is one of the most important components of nerve conduction studies for traumatic brachial plexopathies. sensory testing can assist in localising the site and severity of the plexus injury and is essential in differentiating preganglionic or postganglionic root injury. the cell body of the sensory nerve (dorsal root ganglion) resides outside the spinal cord but within the neural foramen. nerve root avulsions that occur proximal to the foramen typically spare the dorsal nerve root ganglion, with sensory amplitudes remaining normal in preganglionic avulsion injuries. a reduction or unobtainable sensory response will be noted in high intraforaminal or extraforaminal injuries that involve the dorsal nerve root ganglia or peripheral nerve. nerve traction injuries can cause segmental injuries resulting in mixed preganglionic and postganglionic components.9 however, clinical assessment and neurophysiological testing in isolation are not reliable enough and should always be reconciled with radiological imaging for a more accurate and holistic diagnosis.4 ctm and mri scans are undertaken to help the surgeon determine whether the brachial plexus injury is preganglionic, postganglionic or a combination of these. ctm begins with an invasive procedure (lumbar puncture) whereby patients have contrast injected (under sterile technique) into the lumber spinal canal under fluoroscopic guidance (figure 4). the patients are then transferred to the ct unit lying in a prone position with the head reclined to prevent contrast entering the intracranial cerebrospinal fluid (csf) spaces. if the procedure is not performed adequately and timeously, contrast will not fill the correct csf spaces, resulting in the ct being done with the contrast in the incorrect position (figure 5). this reduces ctm sensitivity significantly and potentially exposes the patient to a higher radiation dose should the ct examination need to be repeated. further postprocedural complications such as headache, nausea and vomiting are also common. the advantages and disadvantages of ctm are presented in table 1. figure 4: lateral lumbar radiograph demonstrating the technique used for injecting contrast into the spinal canal under the guidance of fluoroscopy (l2/l3 level) using a spinal needle (arrow) for all patients undergoing computed tomography myelography. figure 5: (a) lateral radiograph of the cervical spine demonstrating contrast in the correct location (arrow) of the cervical spinal canal (post lumbar puncture) before undergoing the computed tomography (ct) scan. (b) lateral radiograph of the cervical spine demonstrating no contrast visualised within the cervical spinal canal (post lumbar puncture), thus making it difficult for the radiologist to visualise the preganglionic nerve roots on axial ct scan images (arrow in d). (c) lateral radiograph of the cervical-thoracic junction demonstrating the incorrect location of contrast that was noted within the upper thoracic spinal canal (arrow). this was as a result of technical inadequacy. table 1: advantages and disadvantages of ctm. mri is non-invasive and does not expose the patient to radiation. it offers good contrast resolution and clearly demonstrates the preganglionic nerve roots (figure 6). the distal brachial plexus can also be visualised, which provides the surgeon with more information regarding the brachial plexopathy. mri allows for better characterisation of the injury, differentiating preganglionic, postganglionic or combined lesions. mri, therefore, confers a superior diagnosis that is more comprehensive than ctm.6 the advantages and disadvantages of mri are presented in table 2. figure 6: (a) computed tomography myelography and (b) t2-weighted mri axial images demonstrating normal ventral and dorsal preganglionic nerve roots (arrows) of the brachial plexus. table 2: advantages and disadvantages of mri. images comparing mri with ctm are shown in figure 7. pseudomeningoceles and preganglionic nerve root avulsion injuries are clearly visualised on both imaging modalities. some discrepancies were noted, however, in a patient where ctm demonstrated c5/c6 nerve root avulsion injuries and pseudomeningoceles, which could not be visualised on the mri study (figure 8). this was thought to be as a result of technical factors. figure 7: pseudomeningoceles (arrows) detected within the same patient on computed tomography myelography (ctm) axial (a), coronal (c), sagittal (e) and t2-weighted magnetic resonance imaging (mri) axial (b), coronal (d), sagittal (f) images. axial images also demonstrate complete preganglionic nerve root avulsions (asterisk) of the left c7 nerve roots (dorsal and ventral) detected on ctm (a) and t2-weighted mri (b). figure 8: discrepancies noted between ctm and mri. pseudomeningoceles (arrows) visualised on axial ctm images at the c5 (a) and c6 (c) nerve roots on the right, which was not visualised on axial t2-weighted magnetic resonance imaging (mri) images (b, d) of the same nerve roots. axial computed tomography myelography (ctm) images also demonstrated complete (dorsal and ventral) preganglionic nerve root avulsion (asterisk) at c5 on the right (a) with a partial preganglionic nerve root avulsion of the dorsal nerve root (asterisk) at c6 on the right (c). no preganglionic nerve root avulsion injuries could be visualised on axial t2-weighted mri of c5 (b) or c6 (d). following a brachial plexus injury, any of the following or combinations may occur: avulsion, rupture or stretch injuries. certain patterns are more prevalent: supraclavicular regions are more affected than retroclavicular or infraclavicular regions.1 roots and trunks of the brachial plexus are much more affected than divisions, cords or terminal branches.1 approximately 70%–75% of injuries are found to be supraclavicular whilst 75% of these injuries involve an injury to the entire brachial plexus (c5–t1).1 in addition: 20%–25% of injuries involve injury to the nerve roots of c5–c7 and 2%–35% of injuries have isolated supraclavicular patterns to c8 and t1.1 panplexal injuries usually involve a c7–t1 nerve root avulsion together with a c5–c6 rupture.1 the remaining 25% of brachial plexus injuries are infraclavicular.1 although still controversial, gasparotti et al.6 state that mri and mri myelography may offer many advantages over ctm and should be used as the primary investigation of choice when it comes to brachial plexopathies, whilst ctm should be reserved for patients with contraindications to mri. limthongthang et al.8 also reported a sensitivity of 92.9% and specificity of 81.3% for the detection of nerve root avulsion injuries using overlapping coronal-oblique mri slices. moreover, mri was capable of producing useful images of the entire brachial plexus. yamazaki et al.10 demonstrated that mri was superior to conventional and ct myelography for the visualisation of small meningoceles which did not fill with contrast medium in the presence of dural scars. yamazaki et al. also showed that with ctm it was difficult to determine the exact level of the nerve root with axial imaging as nerve roots run obliquely. coronal and coronal-oblique views of ctm were therefore more advantageous for detecting nerve root avulsion injuries than axial views (figure 9). figure 9: coronal images demonstrating intact preganglionic nerve roots (arrows) on computed tomography myelography (ctm) (a) and t2-weighted magnetic resonance imaging (mri) (b, c) together with left c7/c8 pseudomeningoceles and avulsed nerve roots (asterisk). new mri sequences are available, such as 3d ciss (three-dimensional constructive interference in steady state). these enable the acquisition of thin slices to perform reconstruction in three different planes to increase diagnostic accuracy. another new mri technique is diffusion-weighted mr neurography (mrn); however, the main limitation of this technique is the lack of depiction of nerve roots above the level of c5. mrn can be done on 1.5t or 3t, with the primary benefit of increased signal-to-noise ratio (snr) of imaging at high field strength. diffusion-weighted imaging (dwi), diffusion tensor imaging (dti) and dti with tractography have also become valuable techniques in evaluating peripheral nerve pathologies. further newer imaging sequences include t2 drive, fiesta and other heavily t2-weighted sequences.11,12 conclusion top ↑ mri was reported to be just as sensitive as ctm in detecting preganglionic nerve root avulsion injuries and pseudomeningoceles of spinal nerve roots c7–t1 of the brachial plexus. some mild discrepancies existed at the c5 and c6 nerve root levels, with mri detecting half of the injuries that were noted on ctm. owing to the invasiveness of the procedure and associated patient discomfort, it is recommended that ctm be reserved for patients with contraindications to mri or for complicated cases. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions e.v.d.l (university of kwazulu-natal) was the principal investigator and wrote the manuscript. v.n. (university of kwazulu-natal) was the supervisor of the study and together with a.m. (inkosi albert luthuli central hospital) and a.r. (inkosi albert luthuli central hospital) made conceptual contributions towards the study and participated in manuscript editing. references top ↑ moran sl, steinmann sp, shin ay. adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. hand clin. 2005;21(1):13–24. http://dx.doi.org/10.1016/j.hcl.2004.09.004 yoshikawa t, hayashi n, yamamoto s, et al. brachial plexus injury: clinical manifestations, conventional imaging findings, and the latest imaging techniques. radiographics. 2006;26:s133–s143. http://dx.doi.org/10.1148/rg.26si065511 belzberg aj, storm pb, moriarity jh. surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons. j neurosurg. 2004;101:365–376. http://dx.doi.org/10.3171/jns.2004.101.3.0365 carvalho ga, nikkhah g, matthies c, penkert g, samii m. diagnosis of root avulsions in traumatic brachial plexus injuries: value of computerized tomography and magnetic resonance imaging. j neurosurg. 1997;86:69–76. http://dx.doi.org/10.3171/jns.1997.86.1.0069 ozdoba c, rieke a, binggeli r, schroth g. myelography in the age of mri: why we do it, and how we do it. radiol res pract. 2011; art #329017. http://dx.doi.org/10.1155/2011/329017 gasparotti r, garozzo d, ferraresi s. chapter 18 – radiographic assessment of adult brachial plexus injuries. in: chung kc, yang ljs, mcgillicuddy je, editors. practical management of pediatric and adult brachial plexus palsies. philadelphia: w.b. saunders, 2012; p. 234–248. http://dx.doi.org/10.1016/b978-1-4377-0575-1.00018-6 altman dg. practical statistics for medical research. london: chapman and hall; 1991. limthongthang r, bachoura a, songcharoen p, osterman al. adult brachial plexus injury: evaluation and management. orthop clin north am. 2013;44(4):591–603. http://dx.doi.org/10.1016/j.ocl.2013.06.011 o’shea k, feinberg jh, wolfe sw. imaging and electrodiagnostic work-up of acute adult brachial plexus injuries. j hand surg eur vol. 2011;36(9):747–759. http://dx.doi.org/10.1177/1753193411422313 yamazaki h, doi k, hattori y, sakamoto s. computerized tomography myelography with coronal and oblique coronal view for diagnosis of nerve root avulsion in brachial plexus injury. j brachial plex peripher nerve inj. 2007;2:16. abul-kasim k, backman c, björkman a, dahlin lb. advanced radiological work-up as an adjunct to decision in early reconstructive surgery in brachial plexus injuries. j brachial plex peripher nerve inj. 2010;5:14–20. mallouhi a, prayer d, kainberger f, bodner g, kasprian g. 3t mr tomography of the brachial plexus: structural and microstructural evaluation. eur j radiol. 2012;81:2231–2245. http://dx.doi.org/10.1016/j.ejrad.2011.05.021 untitled orginal article 17 sa journal of radiology • december 2005 abstract oobbjjeeccttiivvee. to test: (i) the sensitivity and positive predictive value of tagged material in delineating ulcerations of the oesophagus in the preand post-treatment periods and at follow-up; and (ii) whether tagging could reduce the need for invasive endoscopic procedures in patients with carcinoma of the oesophagus. mmaatteerriiaallss aanndd mmeetthhooddss.. twenty-nine patients with carcinoma of the oesophagus selected for radiation therapy underwent the 99mtc sucralfate scintimaging prior to radiation therapy. patients were asked to drink 10 ml suspension of 10 mci 99mtc sucralfate. the sequential images of the oesophagus were acquired at 2 minutes, 2 hours, 4 hours and 6 hours following ingestion. in some patients images were also acquired at 24 hours and at follow-up. the comparison was done with endoscopy as the gold standard. rreessuullttss aanndd oobbsseerrvvaattiioonnss.. the overall positivity of the test was 83% at 4 hours (24 of 29 patients), 34% at 6 hours (10 of 29 patients) and 24% at 24 hours (7 of 29 patients). the sensitivity of the test was 85%, and the positive predictive value 50%. ccoonncclluussiioonn.. due to low positive predictive value, this investigation cannot can ulceration in carcinoma of the oesophagus be detected by 99mtcsucralfate scan? v sharma md, phd johannesburg hospital and tata-memorial hospital and radiation medicine centre mumbai, inda s awasare msc v rangrajan drm, dnb h h shimpi msc u mahantshetty md, dnb tata memorial hospital and radiation medicine centre mumbai, india p s choudhary drm, dnb rajeer gandhi hospital and research institute new delhi, india fig. 1a. pre-radiation scan. static sucralfate study scans at varying intensities at 2 minutes, 2 hours and 4 hours post ingestion. sharma 11/30/05 10:50 am page 17 18 sa journal of radiology • december 2005 orginal article replace endoscopy to diagnose ulcerative disease in patients with carcinoma of the oesophagus. introduction the diagnosis of presence of deep ulceration in the oesophagus due to disease has value for both diagnosis and management. patients with ulcerative tumours are treated with surgery as the first choice unless found inoperable because of advanced disease at presentation or poor general conditioin. radiation therapy can aggravate the condition of the patient as ulceration may become worse with higher doses of radiation leading to severe pain and sometimes fistula formation. sucralfate (the aluminium salt of sulphated sucrose) labelled with selenium75 and 99m technetium (99m tc) has been shown to give variable results for detection of ulceration throughout the gastrointestinal tract (git).1-5 the results have, however, been mainly negative for oesophageal ulceration from static imaging scans. a non-invasive scan would be much better tolerated by patients than oesophagoscopy and might be more accurate than a barium swallow which is frequently non-diagnostic in patients with oesophagitis.6 objectives the purpose of the study was to test: (i) the sensitivity and positive predictive value of tagged material in delineating ulcerations in the oesophagus pre-treatment, post-treatment and at follow-up; and (ii) whether it could reduce the need for invasive endoscopic procedures in patients with carcinoma of the oesophagus. we evaluated the use of 99mtc labelled sucralfate in the investigation of oesophageal mucosal ulcerations in the preand post-radiotherapy periods in patients with carcinoma of the oesophagus with endoscopy as the gold standard. the results form the basis of this report. material and methods twenty-nine patients with carcinoma of the oesophagus selected for radiation therapy underwent the 99mtc sucralfate scintiimaging prior to starting radiation therapy. the lesions involved the upperthird in 2 patients, mid-third in 20 patients and lower-third in 7 patients. all patients had endoscopy to confirm the diagnosis of malignancy. the morphological appearances of the lesions were grouped into ulcerative in 14 patients (ulcerative 6, ulceroproliferative in 8) and non-ulcerative in 15 patients (infiltrative in 8, polypoidal in 7). labelling and sucralfate tagging with 99mtc sucralfate and other chemicals were obtained from commercial sources. 99mtc04 was obtained from alkaline 99m004 using 2 butanole by the solvent extraction process and further processed into an injectable form.7 instant labelling kits of sucralfate prepared at the radiation medicine centre in mumbai, india were used.8 the lyophilised sucralfate was suspended in 2.0 3.0 ml of distilled water. a desired amount fig. 1b. post radiation scan. static sucralfate study scans at varying intensities at 2 minutes, 2 hours and 4 hours post ingestion. sharma 11/30/05 10:50 am page 18 of 99mtc 04in 0.5 1.5 ml was added to it and incubated for 10 minutes at room temperature. unlabelled 99mtc04 was removed following centrifugation for 1 2 minutes at 3 000 revolutions per minute (rpm). distilled water was used for additional rinses. the percentage of labelling was calculated from the observed radioactivity in the final suspension and that present in the combined supernatant layer.9 imaging protocol patients were asked to drink a 10 ml suspension of 10 mci 99mtc sucralfate. an initial dynamic acquisition was carried out for 30 seconds with a frame rate of 0.5 seconds/frame. one minute post ingestion an oesophageal view was acquired and the patient was then asked to drink 20 ml water to wash out the labelled sucralfate that had not adhered to the affected mucosa. following this sequential images of the oesophagus were acquired for 2 minutes, 2 hours, 4 hours and 6 hours (fig 1a and b). in some patients images were also acquired at 24 hours and at follow-up. pre-radiotherapy scans were performed on 29 patients, pre-radiotherapy scans as well as post-radiotherapy scans on 13 patients, and post-radiotherapy scans on 18 patients. all patents underwent endoscopy at follow-up evaluation to confirm whether ulceration was present. results and observations the criteria used for positivity of the scans were an increased concentration of the tagged material, for at least 4 hours. the criteria used for positivity were taken from the report by bailer et al.10 true-positive was defined as ulceration on endoscopy and increased concentration on scan. true-negative was defined as no ulceration on endoscopy and no uptake on scan. false-positive was defined as no ulceration on endoscopy but increased uptake on scan. false-negative was defined as ulceration on endoscopy but no uptake on scan. the overall positivity of the test was 83% at 4 hours (24 of 29 patients), 34% at 6 hours (10 of 29 patients), and 24% at 24 hours (7 of 29 patients). the sensitivity of the test was 85% at 4 hours but the positive predictive value was 50%. the specificity of the test was 20% and negative predictive value was 60%. the false-positive rate was 50% and it was due to stasis of the radioisotope in the cases with no evidence of ulceration on endoscopy (table i). in 18 patients, for whom only postradiotherapy scans were done, an increased uptake was noted in 9 patients (50%) at 4 hours, 4 patients (22%) at 6 hours and 3 patients (17%) at 24 hours. in the 13 patients who had preand post-radiation scans, 6/13 patients (46%) at 4 hours, 3/13 patients (23%) at 6 hours and 2/13 patients (15%) at 24 hours had positive scans. six patients were followed up between 3 months and 6 months post-radiation; 5/6 patients (83%) showed positivity at 4 hours, with evidence of ulceration in 2 patients on endoscopy and a positive predictive value of 40% (table ii). discussion dynamic radionuclide scintigraphy is becoming an established test in the assessment of functional abnormalities of the oesophagus such as strictures, spasm and achalasia.11 it is non-invasive, simple to perform, is well tolerated by patients, and can produce quantitative indices of function. however, this technique will only identify sites of mucosal damage in the oesophagus if they are gross enough to precipitate transit abnormalities, and as such it is of no value in the early detection and follow-up of oesophageal ulceration. reports have described the labelling of sucralfate with selenium-75 and technetium-99m with variable results for the detection of ulceration throughout the git.1-5 orginal article 19 sa journal of radiology • december 2005 table i. correlation between sucralfate tagging and endoscopy pre-radiotherapy ssuuccrraallffaattee eennddoossccooppyy tteecchhnneettiiuumm--9999mm ssccaann ppoossiittiivvee nneeggaattiivvee positive (n) 24 12 12 negative (n) 5 2 3 total (n) 29 14 15 sensitivity 12/14 = 85% specificity 03/15 = 20% positive predictive value 12/24 = 50% negative predictive value 03/05 = 60% table ii. correlation between sucralfate tagging and endoscopy at follow-up ssuuccrraallffaattee eennddoossccooppyy tteecchhnneettiiuumm--9999mm ssccaann ppoossiittiivvee nneeggaattiivvee positive (n) 5 2 3 negative (n) 1 0 1 total (n) 6 2 4 sensitivity 2/2 = 100% specificity 1/4 = 25% positive predictive value 2/5 = 40% sharma 11/30/05 10:50 am page 19 orginal article 20 sa journal of radiology • december 2005 the results in our study showed almost similar uptake in 13 patients who had scans both before and on completion of radiation at 4 hours, 6 hours and 24 hours when compared with 18 patients who had scans only on completion of radiation at the same intervals. mearns et al11 have shown a 92% positive predictive value for dynamic sucralfate imaging of oesophageal ulceration. the present study, however, showed the sensitivity of the test to be 85%, but the positive predictive value was only 50%. the most probable explanation for the low positive predictive value is the stasis of the radioisotope in cases with non-ulcerative disease at endoscopy. previous work has focused on the applications of labelled sucralfate in the imaging of the stomach and small and large bowel, but its use has been documented in the oesophagus11 with mainly negative results from static imaging techniques. due to positive results from their study, mearns et al.11 suggest limiting endoscopy to initial evaluation using histological examination to exclude the possibility of a malignant process. this is not supported by the present study due to the low positive predictive value. although mearns et al. suggested that the 99mtc sucralfate dynamic study has a real value, firstly as a screening test in deciding who should be endoscoped, and secondly as a test suitable for following the progress of patients undergoing therapy for oesophageal ulceration, we are unable to recommend the use of sucralfate tagging in the follow-up period. in conclusion, this study does not support the use of sucralfate tagging to replace endoscopy in cancer of the oesophagus due to a low positive predictive value. we would like to sincerely acknowledge professor bernard donde, head of department of radiation oncology, johannesburg hospital, for corrections to the manuscript. references 1. vasquez te, bridges rl, braunstein p, jansholt al, meshkinpour h. gastrointestinal ulceration: detection using a technetium-99m. labelled ulcer avid agent. radiology 1983; 114488:: 227-231. 2. dawson dj, khan an, nuttall p, shreeve dr. technetium-99m labelled sucralfate isotope scanning in the detection of peptic ulceration. nucl med commun 1985; 66:: 319-325. 3. dawson dj, khan an, miller v, ratcliffc jf, shreeve dr. detection of inflammatory bowel disease in adults and children: evaluation of a new isotope technique. bmj 1985; 229911:: 1227-1230. 4. maurer ah, knight lc, kollman m et al. validation of binding of 75se-labelled scralfate to sites of gastrointestinal ulceration (abstract). european nuclear medicine society congress, london, 1985. 5. crump bj, field s, rake mo, kettle ag, buxton thomas ms, coakley aj. 99mtc sucralfate imaging in inflammatory bowel disease – poor correlation with radiology (abstract). london: british nuclear medicine society annual meeting, 1987. 6. goff js, adcock ka, schmelter r. detection of esophageal ulcerations with technetium-99m albumin sucralfate. j nucl med 1986; 2277:: 11431146. 7. naronha opd. solvent extraction technology of 99mo-99mtc-generator system performance, characteristics. proceedings of the 1984 radiopharmaceuticals and labelled compound conference, tokyo: 223-232. 8. shimpi hh, naronha opd, samuel am. development of 99mtc. sucralfate as a diagnostic agent for ulcers of gastrointestinal (gi) tract: physicochemical factors affecting the oral dosage form. indian journal of nuclear medicine 1996; 1111:: 42 46. 9. shimpi hh, naronha opd, samuel am. transport patterns and orally fed 99mtc sucralfate in ulcer induced animal model. indian journal of nuclear medicine 1996; 1111:: 93 97. 10. bailer jc, mosteller f. medical technology assessment. in: bailer jc iii, mosteller f, eds. medical uses of statistics. 2nd ed boston: n engl j med books, 11999922:: 393 411. 11. mearns aj, hart gc, cox ja. dynamic radionuclide imaging with 99mtc-sucralfate in the detection of oesophageal ulceration. gut 1989; 3300::12561259. to order contact: the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za hmpg price r145.00 price r110.00 price r110.00 sharma 11/30/05 10:51 am page 20 abstract introduction research method and design results discussion conclusion acknowledgements references about the author(s) jaco pieterse department of diagnostic radiology, university of the free state, south africa coert s. de vries department of clinical imaging sciences, university of the free state, south africa susanna f. otto department of clinical imaging sciences, university of the free state, south africa citation pieterse j, de vries cs. investigation of the growth patterns of non-functioning pituitary macroadenomas using volumetric assessments on serial mri investigations. s afr j rad. 2016;20(1), a962. http://dx.doi.org/10.4102/sajr.v20i1.962 original research investigation of the growth patterns of non-functioning pituitary macroadenomas using volumetric assessments on serial mri investigations jaco pieterse, coert s. de vries, susanna f. otto received: 01 dec. 2015; accepted: 18 may 2016; published: 28 july 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: benign non-functioning pituitary macroadenomas (nfma) often cause mass effect on the optic chiasm necessitating transsphenoidal surgery to prevent blindness. however, surgery is complicated and there is a high tumour recurrence rate. currently, very little is known about the natural (and residual post-surgical) growth patterns of these nfma. conflicting data describe decreased growth to exponential growth over various time periods. due to lack of information on growth dynamics of these nfma, suitable follow-up imaging protocols have not been described to date. objective: to determine if nfma grow or stay quiescent over a time period using serial mri investigations and a stereological method to determine tumour volume. in addition, to evaluate if nfma adhere to a certain growth pattern or grow at random. method: thirteen patients with nfma had serial mri investigations over a 73-month period at the universitas academic hospital. six of the selected patients had undergone previous surgery, while seven patients had received no medical or surgical intervention. by using a stereological method, tumour volumes were calculated and plotted over time to demonstrate growth curves. the data were then fitted to tumour growth models already described in literature in order to obtain the best fit by calculating the r2 value. results: positive tumour growth was demonstrated in all cases. tumour growth patterns of nine patients best fitted the exponential growth curve while the growth patterns of three patients best fitted the logistic growth curve. the remaining patient demonstrated a linear growth pattern. conclusion: a specific growth model best described tumour growth observed in non-surgical and surgical cases. if follow-up imaging confirms positive growth, future growth can be predicted by extrapolation. this information can then be used to determine the relevant follow-up-imaging interval in each individual patient. introduction pituitary adenomas are almost always benign (>99.9%), arise from the anterior pituitary and account for approximately 15% of all intra-cranial tumours.1,2 the majority of these adenomas show no local invasion of bone, cavernous sinus or vascular encasement and malignant transformation and metastases are extremely rare (0.2% of all adenoma cases).2,3 pituitary adenomas can be divided into microadenomas (< 1 cm) or macroadenomas (> 1 cm) according to their widest diameter.1,4 the prevalence of pituitary adenomas in the general population has been reported to be 10%–27%, with macroadenomas considerably lower at 0.2%.5 macroadenomas are predominantly non-functioning (> 80%),5,6 that is, there is no clinical and biochemical evidence of pituitary hormonal overproduction and serum prolactin levels of ≤ 100 ng/ml are required for classification as such.1,5 non-functioning pituitary macroadenomas (nfma) are the most prevalent pituitary neoplasm and their growth is haphazard with lobulation.7 growth normally occurs through the diaphragma sellae into the suprasellar cistern with a characteristic ‘snowman’ appearance.1 clinically, patients present with visual field defects, headache or hypopituitarism due to nfma mass effect on surrounding structures.2,4,5 it is well accepted that once visual disturbances are present, transsphenoidal surgery is required to prevent blindness.6,8 although up to 80% of patients experience significant visual improvement post-surgery,6,8 it is a technically difficult procedure with a high tumour recurrence rate of 12%–46%.4,5 multi-lobulated macroadenomas with vertical suprasellar expansion are less likely to be totally removed than round tumours.9 apoplexy is another possible complication seen in approximately 5% of cases.10 it is defined as infarct or haemorrhage in the pituitary gland, most likely due to alterations in perfusion pressure.2,10 incidentally detected pituitary adenomas represent 20%– 40% of all nfma.3,7 asymptomatic non-functioning macroadenomas incidentally found on imaging pose a treatment dilemma. in the absence of visual symptoms, the neurosurgeon may opt for an expectant approach although complications like apoplexy, blindness and hypopituitarism may occur.5 in addition, the time interval between imaging and performing surgery on these patients remains unclear.8 a meta-analysis by ezzat et al. found that the prevalence of pituitary adenomas is 14.4% in autopsy studies and 22.5% in radiological studies.11 due to uncertainty regarding growth of pituitary adenomas, various authors have attempted to study their growth over a selected time period. in a series of pituitary adenomas detected incidentally, donovan and corenblum,7 found positive growth in 4 of 16 large tumours (> 1 cm in height) but no growth in 15 tumours smaller than 1 cm in height over 6.1 and 6.7 years, respectively. this suggests that a small percentage show considerable growth but the majority remain stable. tumour enlargement thus seems more predominant in macroadenomas compared with microadenomas.11 reincke et al.12 also noted an increase in tumour height in three of 14 incidentalomas monitored over 22 months. average tumour height was 13 mm with a range of 5 to 25 mm in diameter. dekkers et al.8 investigated the natural growth course of nfma. growth was defined as a 0.01 cm increase in size in any direction and positive growth was shown in 14 of the 28 cases. they used an ellipsoid formula to approximate tumour volume but unfortunately this method does not allow for the measurement of irregular edges. in addition, a spontaneous decrease in tumour volume was reported in 29% of patients. growth of postoperative residual adenomas has also been studied. turner et al.13 observed tumour regrowth in 21 of 65 patients over a 76-month follow-up period. however, in all of the mentioned studies; however, heterogeneous criteria were used for defining tumour growth. tumour height was seen as the most important predictor of optic chiasm compression resulting in calculations based on tumour height only.3 other authors calculated initial and end tumour volumes with no description of the actual growth pattern. thus, these studies failed to provide suitable quantitative information on the actual growth velocity of pituitary macroadenomas. tanaka et al.14 used the first volumetric assessment technique to calculate tumour volume by scanning the tumour outline on a computer. regrowth was seen in 38 of 40 residual post-surgical tumours mostly in an exponential fashion. honneger et al.11 performed the first quantitative assessment of growth on incidentalomas in post-surgical cases. they used the stereological method to calculate tumour volume based on calculating tumour area on each contiguous slice. they found statistically significant exponential tumour growth in the majority of cases which enabled them to suggest a follow-up imaging protocol for patients. based on the results from studies done to date, the stereological method is the most accurate way to assess tumour volumes on imaging because it accommodates the haphazard growth often observed. in this study, the nfma growth pattern and rate was determined in a south african population using the stereological method used by honneger et al.11 measurements were, however, taken in two planes from thin mri slices to increase measurement accuracy. the growth patterns observed were then fitted to mathematical growth models described in literature. research method and design approval was obtained from the university of the free state ethics committee as well as the national health research database in the free state prior to study commencement. retrospective data were collected from patients who received follow-up mris between 29 october 2008 and 10 november 2014 at the universitas academic hospital in bloemfontein. suitable cases were chosen from the information available from 46 patients on the database. informed consent was therefore not required for this study. subjects were assigned random numbers and are referred to as such. patient selection was based on benign macroadenoma appearance on imaging regardless of age, race or sex. histological confirmation of pituitary macroadenoma was required in post-surgical cases. nfma also had to be classified as non-functional in order to ensure that dopamine antagonists were not concomitantly used, which might have caused a decrease in tumour size. potential patients were therefore required to have a baseline serum prolactin level of below 100 ng/ml and these results were obtained from the university national health laboratory service (nhls). serial mri investigations of 13 patients (3 women and 10 men) from the age of 25 years to 69 years who had all the necessary evaluations done according to the above criteria, were studied over a 73-month period. vertical tumour measurement had to be more than 1 cm and all patients had received between three and six serial mri investigations. six of these patients had undergone initial adenoma surgery, and only follow-up imaging was used for calculations. post-surgery imaging was typically done within 3 months after the initial procedure. the remaining seven patients had received no medical or surgical intervention. the decision to withhold surgery was made by the managing clinicians and reasons included patients declining surgery, carotid artery encasement and poor anaesthetic risk. patients with apoplexy were excluded as this could have influenced tumour volume. the average tumour volume was calculated from the measurements in two planes (sagittal and coronal). the primary researcher did the measurements on two separate occasions under the direct supervision of a neuroradiologist. the average of these two values was then used to calculate the in-depth volumetric assessment according to the stereological model. materials all mri investigations were obtained with a 1.5 tesla mri machine (general electric, signa dual gradient, milwaukee, usa). procedure thin mri slices in the coronal and sagittal planes were studied in all cases. all patients received intravenous gadolinium at a dose of 0.2 ml/kg. a standard imaging protocol was used for all patients: field of view = 20 mm2 matrix = frequency 320 × phase 224 slice thickness between 2 and 5.0 mm spacing between 0.2 and 0.5 mm number of excitations = 5. a stereological method was used to obtain tumour volumes in both sagittal and coronal planes. tumour edges were outlined by free-hand on each slice and then the respective two-dimensional area was calculated using an imaging processing software program (isite) available on the patient archive and communication system (pacs). tumour volume was calculated on standard radiology reporting monitors. tumour area (measured in cm2) on each slice was then multiplied by the sum of the slice thickness and the intervening gap to calculate the volume of one slice. all values were then added to estimate the total tumour volume for each serial mri investigation. all tumour volumes were measured in cm3 and all time periods were recorded in days. the data were captured into microsoft excel before submission to the department of biostatistics for further statistical analysis. analyses average tumour volume of the sagittal and coronal planes was plotted using at least four consecutive data points and fitted to the following three established mathematical models: logistic: initially exponential growth followed by a linear growth phase and finally approaching a constant plateau. exponential: during a period of time there is a constant percentage increase in tumour volume. linear: constant increase in tumour volume. the ‘goodness of fit’ was obtained by calculating the square of the correlation coefficient (r2 value). for patients with insufficient data points, the r2 value could not be calculated. growth was nonetheless described based on the shape of the observed curve when plotted using the available points. results figure 1 demonstrates six serial t1 weighted post-contrasted mri slices through the tumour in the coronal plane. as demonstrated in figure 2a and figure 2b, these tumours often have lobulated outer margins. figure 1: non-functioning pituitary macroadenoma in a 46-year-old male. figure 2: large non-functioning pituitary macroadenoma in a 54-year-old male: sagittal (a) and coronal (b) t1-weighted images (post-contrast) of the brain. all subjects demonstrated positive tumour growth over the observation period (table 1). the initial measured median tumour volume was 11.96 cm3 compared to an end median volume of 19.00 cm3 after the 73-month period. table 1: clinical data, imaging studies as well as growth patterns observed during the observation period. in nine cases, nfma growth was best demonstrated by an exponential curve. of these, three had sufficient data points to calculate the r2 value. higher r2 values for the exponential model (mean r2 = 0.99) were found compared with the logistic model (mean r2 = 0.95). no statistical significance was found when comparing the exponential to the logistic growth patterns (p = 0.06). observed growth that best fitted the exponential model had an r2 value of 0.97 (figure 3). of the nine cases, three had received surgery and six had been treated conservatively. the initial mean volume was 16.24 cm3 (±10.15) and end volume was 25.69 cm3 (±16.03). the minimum initial tumour volume was 2.68 cm3 and maximum tumour end volume was 52.08 cm3. figure 3: macroadenoma growth observed in a 46-year-old male. the logistic model best described three cases, with only two patients having sufficient data points to calculate the r2 value. of these, a mean r2 value of 0.94 was seen compared with a mean r2 value of 0.85 in the exponential model. no statistical significance was found on comparing the logistic and exponential growth patterns (p = 0.37). observed growth that best fitted the logistic growth model had an r2 value of 0.94 (figure 4). in two of the cases, the patients had received surgery and, in one case, the patient had received conservative treatment only. the initial mean volume was 2.33 cm3 (±2.77) and end volume was 2.92 cm3 (±3.64). the minimum initial volume was 0.70 cm3 and maximum end volume was 7.13 cm3. figure 4: macroadenoma growth observed in a 25-year-old female. only one case exhibited a linear trend; however, there were insufficient data points to calculate the r2 value. this patient had received surgical intervention. initial tumour volume was 2.35 cm3, and end volume was 7.01 cm3. in adherence to exponential growth, the five largest tumours, with an initial calculated volumes of more than 15 cm3 demonstrated a higher average growth rate of 5.15 cm3/year compared with 1.10 cm3/year seen in tumours smaller than 15 cm3. furthermore, tumours adhering to the exponential growth pattern had an average initial size of 16.24 cm3 compared with 2.33 cm3 seen in the logistic pattern. discussion mathematical modelling has been applied to describe growth of other tumours in literature. experimental tumour paradigms of malignant and rapidly growing tumours typically adhere to a sigmoidal curve (figure 5). this is described as the logistic mathematical model: an exponential phase followed by a linear phase and lastly, a plateau phase. final deceleration is likely due to impaired blood supply with central necrosis and restricted growth in the peripheral regions.11 figure 5: logistic growth curve representing growth observed in malignant tumours. however, in contrast to malignant tumours, nfma are benign, homogenous and solid, and it is hypothesised that they should show stable growth behaviour. if the entire volume of a solid tumour grows at a constant rate, exponential tumour growth would be expected resulting in a constant tumour volume doubling time.11 all the patients in this study showed an increase in tumour volume over time. it seems that when volumetric assessment is applied on high quality imaging, the incidence of growth is much higher compared with previous studies. on follow-up imaging, the tumours often appeared unchanged in size only to find a significant volume increase after the necessary calculations. this contrasts the spontaneous decrease in tumour volume reported in 29% of patients in the study by dekker et al.11 a decrease in volume is, however, highly improbable due to the solid nature of these tumours. no clear trend in the tumour growth patterns could be deducted for conservatively treated adenomas versus post-surgical cases or in different age groups. observations of this study were similar to those of honegger et al.,11 with the majority of cases (69%) adhering to the exponential growth model. in the five cases with enough data points, high r2 values for the exponential and logistic models were obtained, but the p-value was not statistically significant to classify growth into a specific model. in cases with insufficient data points, the graph trend was used to classify growth to a specific growth model. larger initial mean nfma (16.24 cm3) tend to show exponential growth when compared with smaller tumours (2.33 cm3), which exhibited logistic growth. on an individual case level, however, initial tumour size cannot be used to accurately determine the growth velocity or pattern (e.g. patient 1 who demonstrated exponential nfma growth had an initial tumour volume of 2.68 cm3, and patient 2 who showed logistic nfma growth had an initial volume of 5.54 cm3). the hypothesis that adenomas with an exponential pattern would eventually follow a logistic growth pattern could not be determined due to the fixed observation period. one patient demonstrated adherence to the linear model; however, it can be postulated that the nfma might have been in the linear growth phase of the logistic model. these results demonstrate that if there is a significant increase in growth at first follow-up, exponential or logistic growth can be expected in future. if no increase in growth is found, it is unlikely that the tumour will grow rapidly in the near future. once the individual patient trends are established, appropriate and effective treatment can be prescribed for these patients, which includes a follow-up mri-protocol tailored for each individual. limitations of the study the lack of long-term follow-up due to the fixed observation period was seen as a study limitation. as a result, the possibility that these benign tumours would eventually demonstrate logistic growth could not be determined. conclusion based on these results, it can be recommended that radiologists calculate tumour volume using this stereological method on serial mri imaging to determine the growth rate. in conjunction with imaging, regular follow-up regarding ophthalmology evaluation and hormonal assessment is advised. this insight into the growth dynamics of nfma may facilitate the development of a tailored follow-up imaging protocol for patients with either incidentalomas or post-surgical nfma. this may reduce healthcare expenses by allowing an individualised rational treatment plan. acknowledgements the first author would like to thank dr otto for reviewing the measurement process, prof. de vries for his guidance as study leader, the department of neurosurgery for providing the subject information, the national health laboratory services for assisting me with the relevant blood results and the department of biostatistics at the uofs. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions c.s.d.v. was the project leader. j.p. performed the measurements and performed all the calculations and s.f.o. made conceptual contributions and supervised the measurement process. references dekkers om. nonfunctioning pituitary macroadenomas: treatment and long-term follow-up. phd thesis. universiteit leiden; 2006. mamelak an, carmichael jd, park p, bannykh s, fan x, bonert hv. atypical pituitary adenoma with malignant features. pituitary 2011;14(1):92–97. http://dx.doi.org/10.1007/s11102-008-0151-1 berkmann s, schlaffer s, buchfelder m. tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma. j neurosurg 2013;119(6):1447–1452. http://dx.doi.org/10.3171/2013.8.jns13790 arita k, tominaga a, sugiyama k, et al. natural course of incidentally found nonfunctioning pituitary adenoma, with special reference to pituitary apoplexy during follow-up examination. j neurosurg. 2006;104(6):884–891. http://dx.doi.org/10.3171/jns.2006.104.6.884 dekkers om, pereira am, romijn ja. treatment and follow-up of clinically nonfunctioning pituitary macroadenomas. j clin endocrinol metab. 2008;93(10):3717–3726. http://dx.doi.org/10.1210/jc.2008-0643 turner he, stratton im, byrne jv, adams cb, wass ja. audit of selected patients with nonfunctioning pituitary adenomas treated without irradiation – a follow-up study. clin endocrinol (oxf) 1999;51(3):281–284. http://dx.doi.org/10.1046/j.1365-2265.1999.00865.x honegger j, ernemann u, psaras t, will b. objective criteria for successful transsphenoidal removal of suprasellar nonfunctioning pituitary adenomas. a prospective study. acta neurochir (wien). 2007;149(1):21–29. http://dx.doi.org/10.1007/s00701-006-1044-6 dekkers om, hammer s, de keizer rjw, et al. the natural course of non-functioning pituitary macroadenomas. eur j endocrinol. 2007;156(2):217–224. http://dx.doi.org/10.1530/eje.1.02334 donovan le, corenblum b. the natural history of the pituitary incidentaloma. arch intern med. 1995;155(2):181–183. http://dx.doi.org/10.1001/archinte.1995.00430020067008 lee j-s, park y-s, kwon j-t, nam t-k, lee t-j, kim j-k. radiological apoplexy and its correlation with acute clinical presentation, angiogenesis and tumor microvascular density in pituitary adenomas. j korean neurosurg soc. 2011;50(4):281–287. http://dx.doi.org/10.3340/jkns.2011.50.4.281 honegger j, zimmermann s, psaras t, et al. growth modelling of non-functioning pituitary adenomas in patients referred for surgery. eur j endocrinol. 2008;158(3):287–294. http://dx.doi.org/10.1530/eje-07-0502 glass rm, drummond w, cole hμ, et al. the ‘incidentaloma’ of the pituitary gland. is neurosurgery required? j am med assoc. 1990;263(20):2772–2776. http://dx.doi.org/10.1001/jama.1990.03440200076026 anagnostis p, adamidou f, polyzos sa, efstathiadou z, panagiotou a, kita m. non-functioning pituitary adenomas: a single center experience. exp clin endocrinol diabetes. 2011;119(5):314–319. http://dx.doi.org/10.1055/s-0030-1267991 tanaka y, hongo k, tada t, sakai k, kakizawa y, kobayashi s. growth pattern and rate in residual nonfunctioning pituitary adenomas: correlations among tumor volume doubling time, patient age, and mib-1 index. j neurosurg. 2003;98(2):359–365. http://dx.doi.org/10.3171/jns.2003.98.2.0359 article information authors: binit sureka1 mahesh k. mittal1 aliza mittal2 mukul sinha1 brij b. thukral1 affiliations: 1department of radiodiagnosis and imaging, vardhman mahavir medical college and safdarjung hospital, india2department of paediatrics, vardhman mahavir medical college and safdarjung hospital, india correspondence to: binit sureka postal address: vmmc & safdarjung hospital, resident doctors hostel, room 57, second floor, new delhi 110029, india dates: received: 12 july 2013 accepted: 01 jan. 2014 published: 23 apr. 2014 how to cite this article: sureka b, mittal mk, mittal a, sinha m, thukral bb. pseudomyxoma peritonei. s afr j rad. 2014;18(1); art. #585, 3 pages. http://dx.doi.org/10.4102/ sajr.v18i1.585 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. pseudomyxoma peritonei in this pictorial interlude... open access • abstract • discussion • acknowledgements    • authors’ contributions    • competing interests • references abstract top ↑ pseudomyxoma peritonei is a rare complication of mucinous tumours of appendiceal or ovarian origin. other associations are malignancies of the colon, urachus and biliary tree. large amounts of extracellular and peritoneal mucin result in distortion and loss of function of visceral organs. currently, radiology plays a critical role in diagnosing this rare entity, in follow-up and in predicting the outcome of cytoreductive surgeries. discussion top ↑ pseudomyxoma peritonei (pmp), also known as ‘jelly belly’, ‘gelatinous ascites’ or ‘false mucinous tumour of the peritoneum’, is a rare complication with an estimated incidence of one to two cases per million per year.1 it occurs due to spillage of mucin from a ruptured mucinous tumour, leading to foreign body peritonitis. the most common cause is spread from a mucinous tumour of the appendix (see figure 1).2 there is controversy over whether in these cases the ovary is the primary site or the appendix is the primary site and the ovarian lesion is metastatic (see figure 2).3 recently, mucin-2 protein (muc 2) over-expression has been suggested as a molecular marker for pmp of intestinal origin.4 other rare sources of pmp include malignancy of the colon (see figures 3 and 4), stomach, uterus, pancreas, gallbladder, common bile duct and urachus (see figure 5). pseudomyxoma retroperitonei, also known as pseudomyxoma extraperitonei, is mucinous collection in the retroperitoneum, usually due to retroperitoneal rupture of a primary mucinous appendiceal tumour in a retrocaecal appendix.the term pseudomyxoma peritonei was coined by werth5 in 1884. ronnet et al.6 classified three pathological types of pseudomyxoma peritonei, namely (1) low-grade disseminated peritoneal adenomucinosis (dpam), (2) high-grade peritoneal mucinous carcinomatosis (pmca) and (3) peritoneal mucinous carcinomatosis with intermediate-grade or discordant features (pmca-i/d). patients with low-grade dpam had significantly higher 5-year and 10-year survival rates compared to patients with pmca and pmca-i/d. the basic pathophysiology in pmp is leakage of mucus containing epithelial cells into the peritoneal cavity from a ruptured mucinous tumor.7the epithelial cells within the peritoneal cavity continue to proliferate, producing large quantities of mucus. the distinctive feature of pmp is its characteristic ‘reorganisation’ within the peritoneal cavity due to lack of adhesion molecules by the tumour cells. the open lymphatic lacunae on the under surface of the right hemidiaphragm and the lymphoid aggregate in the omentum absorb fluid, leading to bulky accumulations of concentrated mucus. from a radiological perspective, the concentrated tumour masses result in ‘scalloping’ of the liver surface and ‘omental caking’.7 on imaging, plain films of the abdomen may reveal annular or semicircular calcific plaques, ascites and poorly defined soft-tissue masses. calcification may also occur following chemotherapy. ultrasound shows ascites with echogenic particles, displacement of small bowel loops medially and scalloping of surfaces of the liver and spleen. characteristically, the echogenic particles in pmp do not move, unlike ascites associated with haemorrhage or pus in the peritoneum. ct shows low attenuation voluminous ascites, scalloping of visceral surfaces – particularly of the liver and spleen – and sometimes scattered (curvilinear or punctate) calcifications. medial displacement of the tip of the right lobe of the liver due to focal collection of mucin in the right subhepatic space, known as hellmer’s sign, may be seen.8 treatment involves surgical debulking, followed by infusion of intraperitoneal chemotherapy. imaging also plays an important role in predicting the response to treatment. according to jacquet, jelinek, chang et al.,9predictors of incomplete cytoreduction are segmental obstruction of the small bowel and tumour masses greater than 5 cm in width on the small bowel and its mesentery (exclusive of the distal ileum). delayed enhancement of fluid on gadolinium-enhanced mri suggests a favourable response to cytoreductive surgery.10 differential diagnoses of pmp include peritoneal carcinomatosis, lymphomatosis, sarcomatosis, infectious peritonitis, inflammatory pseudotumour, gliomatosis peritonei, peritoneal hydatidosis and peritoneal melanosis. figure 1: pseudomyxoma peritonei in a 34-year-old male with abdominal distension and pain due to mucinous cystadenoma of the appendix. intravenous and oral contrast-enhanced ct scans showing (a) low-density ascites causing scalloping of the liver surface (arrow) and (b) distended appendix (arrowhead) in right iliac fossa. figure 2: pseudomyxoma peritonei in a 37-year-old female due to mucinous adenocarcinoma of the ovaries. intravenous and oral contrast-enhanced ct scans showing (a) low-density ascites causing scalloping of bowel surface and omental caking (arrow) and (b) bilateral complex cystic ovarian masses (black arrows). figure 3: histologically confirmed pseudomyxoma peritonei in a 12-year-old child due to mucinous adenocarcinoma of the colon. contrast-enhanced ct scans showing asymmetric thickening of the ascending colon (black arrow) with coarse calcifications in the mesentry (arrowhead) and omental thickening (white arrow). figure 4: pseudomyxoma peritonei in a 55-year-old male due to intestinal polyposis and mucinous carcinomatous transformation. coronal reconstructed ct scan image showing multiple intestinal polyps (black arrows), leading to ileocolic intussusception (white arrow) and low-density ascites causing scalloping of the liver surface (arrowhead). figure 5: histologically confirmed pseudomyxoma peritonei in a 65-year-old male with mucinous urachal adenocarcinoma. axial contrast-enhanced ct scan showing urachal malignancy (white arrow) involving and extending up to the umbilicus with focal localised adjacent mucinous collection (arrowhead). acknowledgements top ↑ authors’ contributions b.s. (vardhman mahavir medical college and safdarjung hospital) was responsible for concept design, literature search and manuscript preparation, m.k.m. (vardhman mahavir medical college and safdarjung hospital) for manuscript review and definition of intellectual content, and a.m. (vardhman mahavir medical college and safdarjung hospital) for literature search, manuscript editing and the clinical study. m.s. (vardhman mahavir medical college and safdarjung hospital) was involved in manuscript editing and in the clinical study, whilst b.b.t. (vardhman mahavir medical college and safdarjung hospital) was the guarantor and was involved in manuscript editing. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. references top ↑ 1. smeenk rm, van velthuysen ml, verwaal vj, zoetmulder fa. appendiceal neoplasms and pseudomyxoma peritonei: a population based study. eur j surg oncol. 2008;34:196–201. http://dx.doi.org/10.1016/j.ejso.2007.04.002 2. takeuchi m, matsuzaki k, yoshida s, et al. imaging findings of urachal mucinous cystadenocarcinoma associated with pseudomyxoma peritonei. actaradiol. 2004;45:348–350. http://dx.doi.org/10.1080/02841850410004959 3. misdraji j. appendiceal mucinous neoplasms: controversial issues. arch pathol lab med. 2010;134:864–870. 4. ferreira cr, carvalho jp, soares fa, et al. mucinous ovarian tumors associated with pseudomyxoma peritonei of adenomucinosis type: immunohistochemical evidence that they are secondary tumors. int j gynecol cancer. 2008;18:59–65. http://dx.doi.org/10.1111/j.1525-1438.2007.00988.x 5. werth r. klinische and anastomische untersuchungen zur lehre von der bauchgeswullsten und der laparotomy. arch gynecol obstet. 1884;4:100–118. 6. ronnett bm, yan h, kurman rj, et al. patients with pseudomyxoma peritonei associated with disseminated peritoneal adenomucosis have a significantly more favourable prognosis than patients with peritoneal mucinous carcinomatosis. cancer. 2001 jul; 92(1):85–91. http://dx.doi.org/10.1002/1097-0142(20010701)92:1<85::aid-cncr1295>3.0.co;2-r 7. bevan ke, mohamed f, moran bj. pseudomyxoma peritonei. world j gastrointest oncol. 2010;2:44–50. http://dx.doi.org/10.4251/wjgo.v2.i1.44 8. dähnert w. gastrointestinal disorders. in: dähnert w, editor. radiology review manual. 7th ed. philadelphia, pa: lippincott williams & wilkins, 2011; p. 836. 9. jacquet p, jelinek js, chang d, et al. abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery. j am coll surg. 1995;181:530–538. 10. low rn, barone rm, gurney jm, et al. mucinous appendiceal neoplasms: preoperative mr staging and classification compared with surgical and histopathologic findings. am j roentgenol. 2008;190:656–665. http://dx.doi.org/10.2214/ajr.07.2018 article information authors: nausheen khan1 dimakatso c. thebe1 farhanah suleman2 irma van de werke3 affiliations: 1kalafong hospital, university of pretoria, south africa 2consultant radiologist, university of pretoria, south africa 3frcr, university of pretoria, south africa correspondence to: nausheen khan email: nausheenkhan5@yahoo.com postal address: 209 milner street, waterkloof 0181, south africa dates: received: 17 mar. 2015 accepted: 03 aug. 2015 published: 21 oct. 2015 how to cite this article: khan n, thebe dc, suleman f, van de werke i. pitfalls and mimics: the many facets of normal paediatric thymus. s afr j rad. 2015;19(1); art. #803, 5 pages. http://dx.doi.org/10.4102/sajr.v19i1.803 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. pitfalls and mimics: the many facets of normal paediatric thymus in this pictorial essay... open access • abstract • introduction • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ the thymus is a lymphatic organ that was often thought of as an organ of mystery by the ancient greeks. a soft, pliable lymphatic organ positioned in the anterior superior mediastinum, it does not compress or displace the adjacent structures. it is disproportionately larger in the paediatric population and then gradually regresses to ‘hide’ in the mediastinum as the child advances into puberty. it regresses in size under conditions of stress and may be absent in various congenital abnormalities such as digeorge syndrome and conditions of stress. the thymus appears in a variety of shapes and sizes on a paediatric chest radiograph and at times may be misinterpreted as pathology. this article describes the normal thymus as it appears on paediatric radiography, and addresses mimickers. introduction top ↑ the thymus has long been thought of as a mystical organ. the word ‘thymus’ is a latin derivation from the greek word ’thymos’ that means ‘warty excrescence’. for very long, the thymus was apportioned blame for a variety of childhood illnesses, based on the assumption that it compressed the airway, and was even regarded as the ‘seat of satan’.1 the thymus arises during the 6th gestational week from the 3rd and the 4th pharyngeal pouches bilaterally, as a bud-like primordium that elongates at the 7th week, becomes cylindrical and migrates inferiorly and medially into its final position in the anterior mediastinum where the two lobes fuse.2,3,4 it may extend superiorly to the lower pole of the thyroid, to which it is connected by the thyrothymic ligament, and an inferior extension up to the diaphragm.1,5 the thymus is a lymphatic organ that has an important role in the development of the immune system of the body, especially the t and b lymphocytes, which in turn play a major role in cellular and humoral immunity respectively. discussion top ↑ despite the advances in imaging technology, the fear of radiation in children means that the chest radiograph remains the imaging modality of choice in paediatric patients. the thymus on the radiograph lies in the anterior mediastinum, overlying the pericardium, aortic arch, left innominate vein and trachea.4,5,6,7 there are numerous variations in the size and shape of the thymus on chest radiographs that are often misconstrued as pathology. a basic understanding of the anatomy and physiology of the thymus is helpful in the radiographic interpretation of its variations in chest radiography. the thymus is extremely variable in its radiographic appearance; it widens on expiration and narrows and elongates on inspiration.8 it is a homogenous quadrilateral structure with the lateral margin being convex outward with gentle undulating margins. there is usually an increase in size in the first few months of life (figure 1), the prominence of the thymus reflecting the health of the child.9 it is more prominent in boys than girls and decreases in size by the end of the first decade of life.4 figure 1: frontal chest radiograph in an infant. a prominent thymus (arrows) gives an impression of a widened mediastinum. on a frontal chest radiograph, the thymus is a prominent soft-tissue density in the superior mediastinum which appears to be inseparable from the superior cardiac margins (figure 2a).8 the lateral view, however, confirms the opacity's location in the anterior mediastinum (figure 2b). on the frontal view, the left lobe of the thymus produces widening of the mediastinum that usually overlaps the left pulmonary artery (figure 3), which is occasionally visible through it.8 the anterior lateral margin often has smooth undulations from the overlying ribs and the costal cartilages (figure 4), the so-called ‘wave’ or ’ripple’ sign.4,8,9,10 this may be especially prominent in infants with bronchiolitis.9 a small notch (figure 5) sometimes marks the inferior border between the thymus and the heart.8,10 the angular corner, usually of the right lobe flattened at the right minor fissure, gives the classical ‘sail sign’ (figure 6).4,8,9,11 a normal gland may potentially obscure anywhere from one-third to the entire left upper lobe (figure 7); the right lobe may exhibit similar features.3 figure 2: frontal chest radiograph (a) showing apparent cardiomegaly as a result of thymus (arrow) density overlying the left heart border. a lateral view (b) identifies the opacity as a thymus (arrow) in the anterior mediastinum separate from the cardiac silhouette. figure 3: frontal chest radiograph. the left lobe of the thymus (arrow) projects over the left hilum. the left pulmonary artery is clearly visible through the thymic shadow. figure 4: frontal chest radiograph. smooth undulations of the right lateral margins of the thymus from the overlying ribs and cartilages, the so-called ‘wave’ or ‘ripple’ sign (arrows). figure 5: frontal chest radiograph. there is a notch between the inferior border of the right lobe of the thymus and the heart (arrow). figure 6: frontal chest radiograph. a classic sail sign (arrow) formed by the right lobe of the thymus flattened at the minor fissure. figure 7: the normal thymus may obscure an entire upper lobe, as seen in this radiograph simulating pneumonia (black arrow). note the notch sign (white arrow) on the right. prominence of one or more lobes can simulate cardiomegaly on frontal radiography (figure 8) that can, however, be seen to be thymus on the lateral radiograph. normal thymus may obscure or simulate upper lobe pneumonia (figure 7).4,7,8 sometimes the presence of other pathologies may cause the thymus to appear abnormal, as seen in pneumomediastinum or pneumothorax where the thymus has been likened to ’angel's wings’ or 'spinnaker sail’ (figure 8). pneumothorax, when under tension, may cause displacement of the thymus, disguising it as an abnormality (figure 9). figure 8: ʻangel's wing’ sign (arrows) of the thymus in a patient with pneumomediastinum. the patient also has a bilateral pneumothorax. figure 9: patients with a left-sided tension pneumothorax. the thymus is displaced to the right (arrow) simulating a mediastinal mass (a). in another patient (b) with a pneumothorax, the thymus is displaced superiorly (arrows), appearing as an apical pleural abnormality. if radiographic findings are not conclusive, ultrasound can be used as a non-invasive modality to confirm. the normal thymus on ultrasound has an echogenicity similar to that of the liver and spleen and appears as a homogenous pliable structure that does not compress or displace adjacent structures.1 conclusion top ↑ it is important for the radiologist and paediatrician to empirically recognise and differentiate normal thymus, its variants and mimics from pathology on a chest radiograph. a thorough knowledge of its anatomy and dynamic changes through life is essential to prevent errors in diagnosis. in cases of diagnostic confusion, imaging modalities such as ultrasound, computed tomography (ct) and positron emission tomography (pet)–ct are available and useful in differentiating thymus from other anterior mediastinal masses. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.k. (university of pretoria), d.c.t. (university of pretoria), f.s. (university of pretoria) and i.v. (university of pretoria), contributed equally to the writing of this manuscript. references top ↑ nasseri f, eftekhari f. clinical and radiologic review of normal and abnormal thymus: pearls and pitfalls. radiographics. 2010;30:413–428. pmid: 20228326, http://dx.doi.org/10.1148/rg.302095131 nishino m, ashiku sk, kocher on, thurer rl, boiselle pm, hatabu h. the thymus: a comprehensive review. radiographics. 2006;26:335–348. pmid: 16549602, http://dx.doi.org/10.1148/rg.262045213 francis ir, glazer gm, bookstein fl, gross bh. the thymus: re-examination of age-related changes in size and shape. ajr. 1985;145:249–254. pmid: 3875220, http://dx.doi.org/10.2214/ajr.145.2.249 donelly lf, jones bv, o’hara sm, et al., editors. diagnostic imaging: pediatrics. salt lake city: amirsys; 2005, p. 2 (78–79). mittal mk, sureka b, sinha m, mittal a, thukral bb. thymic masses: a radiological review. s afr j radiol. 2013;17:108–111. http://dx.doi.org/10.1594/ecr2015/c-0895 gwande rs, khurana a, messing s, et al. differentiation of normal thymus from anterior mediastinal lymphoma and lymphoma recurrence at pediatric pet/ct. radiology. 2012;262:613–622. pmid: 22157202, http://dx.doi.org/10.1148/radiol.11110715 federle mp, rosado-de-christenson ml, woodward pj, et al. diagnostic and surgical imaging anatomy: chest, abdomen, pelvis. salt lake city: amirsys; 2006, p. 1 (297–298). kuhn jp, slovis tl, o haller j. caffey's pediatric diagnostic imaging, vol. 1. 10th edn. st louis: mosby; 2004, p. 1175–1184. singleton eb, wagner ml, dutton rv. radiologic atlas of pulmonary abnormalities in children. philadelphia: wb saunders; 1971, p. 13–23. gupta ak. normal thymus mimicking ‘mediastinal mass’. indian j pediatr. 2009;76:1067–1068. pmid: 19907946, http://dx.doi.org/10.1007/s12098-009-0207-x arthur r. interpretation of the paediatric chest x-ray. curr paediatr. 2003;13:438–447. http://dx.doi.org/10.1016/s0957-5839(03)00089-7 radiology editorial 2 sa journal of radiology • february 2005 new route to specialisation — unity at last? steve beningfield mb chb, ffrad d (sa) department of radiology groote schuur hospital and university of cape town up to the end of 2003, the department of education paid substantial subsidiesto the universities for every successful graduate, including those obtaining colleges of medicine qualifications. from 2004, only university academic degrees but not college qualifications have been subsidised, meaning a significant potential loss of income to the universities unless an mmed or equivalent is also obtained by college graduates. this policy change may serve as a catalyst in resolving the longstanding issues around the dual processes of professional certification for all specialties, namely the mmed and college routes. there is now a concerted move to create a unified examination system at all south african universities. the proposed exam sequence will most likely be similar for all specialties. 1. the part one college examination, as before. there would not necessarily be a separate part one mmed examination. 2. an obligatory mmed programme, involving: • a coursework element comprising courses on, inter alia, evidence-based medicine, critical reading, statistics, research methodology and the art (and sweat!) of writing articles. a generic group of programmes for all specialists is proposed, but allowance will be made for specialty-specific courses. • a thesis to be examined and approved by external examiners, of a level that is potentially publishable. 3. depending on individual colleges, entry into the part two college examination may be subject to completion of the mmed coursework and thesis. 4. only after passing the college part two examination and the mmed will registration with the health professions council of south africa as a specialist be possible. in the end, both college and mmed (possibly alternatively designated, e.g. mphil) degrees will be awarded. the advantages of this system would be a single national process of specialisation, and promotion of broader skill development, including critical enquiry and academic writing. this system should also benefit our local journals, including the sajr, by supplying them with articles. however, specific radiology-related skills may warrant inclusion in the courses offered, including general computer literacy, preparation and delivery of imaging presentations, consultancy skills and business and financial concepts. although the more theoretical computer aspects are covered in medical physics, word, excel and powerpoint familiarity is surely very relevant to us. the fear of ‘contaminating’ the pure academic environment with practical life skills is surely unfounded. don’t we all wish we had been taught more business and accounting proficiency at school? radiology 2/24/05 4:50 pm page 2 consistency in the coursework elements between radiology departments at all universities would be highly desirable, creating a golden opportunity for those interested to come together and review the existing processes. similarly, the debate concerning a 4-year versus 5-year training schedule, the correct timing and nature of anatomy and physics training, and the possibility of postgraduate fellowships could be explored. recently the south african college of radiology has permitted physics and anatomy credits to be carried to the next examination. the royal college has recently changed its medical physics examination, which now takes place before entry into hospital training, principally to ensure that radiation protection and safety concepts are known to the new registrars. the topics covered are therefore directed at more conventional radiological imaging, avoiding high-tech subjects such as mri. conversely, anatomy has been relocated to their final examination, on the basis that much anatomy is learned while undergoing clinical radiology training. the counter argument is that learning the anatomy earlier allows one to benefit more from clinical training. the opportunity for restructuring the training received by our registrars by including both more academic and practical exposure in a more formalised setting is very promising and will hopefully be addressed at a workshop attended by all interested parties in 2005. editorial 3 sa journal of radiology • february 2005 steve beningfield guest editor radiology 2/24/05 4:50 pm page 3 untitled stenosis or atresia of the posterior nasal cavity, i.e. the choanae, is the most common congenital abnormality of the nasal cavity. stenosis is considered to be more common than atresia. bilateral atresia is life-threatening in neonates, who are obligate nasal breathers. these patients present early with severe respiratory distress, aggravated by feeding. other pointers to the diagnosis include the inability to pass a nasogastric tube and relief of respiratory compromise on crying. the patients with unilateral disease typically present later in life with unilateral, chronic suppurative rhinorrhoea. this form of the condition is more common but due to its chronic, relapsing symptomatology the diagnosis is often delayed. definitive diagnosis can be made by computed tomography (ct) scanning. using images from our practice, we would like to propose an approach to scanning and interpretation of this entity. ct is the imaging modality of choice. patients are examined supine, with nasal passages well suctioned before imaging commences. topical nasal vasoconstrictors may be helpful to reduce mucosal swelling. the gantry is angled 5° cephalad to a plane parallel to the hard palate. one to 1.5 mm thick uncontrasted scans are obtained contiguously. the skull base is only partially ossified at birth and therefore conventional bone-window settings may not show the bony margins. high-resolution bone filters help overcome this problem. interpretation of the images rests on measurements of the posterior vomer, the choanal openings and the shape of the posteromedial maxilla. the anatomical landmark at which to evaluate the scan is at the level of the pterygoid plates (fig. 1). below this level the hard palate is visualised and above this level structures within the nasal cavity make measurement difficult. at this level the width of both posterior choanae at maximum stenosis and the maximum width of the inferoposterior vomer are measured. the vomer is widened in most cases. in patients less than 8 years of age the mean vomer width is 2.8 mm and should not exceed 5.5 mm. the mean width of the posterior choanal airspace in the neonate is 6.7 mm, increasing to 8.6 mm at 6 years and 11.3 mm by age 16.1,2 32 sa journal of radiology • december 2005 pictorial interlude choanal stenosis and atresia s moosa mb chb, bsc hons (pharm), mphil, fcrad (diag) department of radiology groote schuur hospital and university of cape town. y vadachia mb chb s andronikou mb bch, fcrad (d) (sa), frcr (lond) department of radiology tygerberg hospital and university of stellenbosch figs 1 a and b. normal scan at the level of the pterygoid plates. note the parallel medial walls of the nasal cavity, the thin vomer and the wide posterior chaoana. pictorial interlude 11/29/05 12:33 pm page 32 the normal posteromedial maxilla is straight and parallel. in choanal stenosis/atresia, it is typically medially bowed and may touch the lateral extent of the vomer (fig. 2). membranous atresias will show soft-tissue densities in the posterior choanae and narrowing of the posterior choanae just anterior to the pterygoid plates. in the case of bony atresia, the thickness of the atretic plate should be reported for surgical planning. patients require surgical treatment, which is urgent in the case of bilateral atresia. ct evaluation of suspected choanal atresia/stenosis confirms the diagnosis and helps plan surgery. measurements of the structures outlined allows for an objective and reproducible set of criteria for the diagnosis of choanal atresia and stenosis. references 1. slovis tlr. choanal atresia: precise ct evaluation. radiology 1985; 115555:: 345-348. 2. hudgins pa, jacobs in, castillo m. pediatric airway disease. in: som pm, curtin hd, ed. head and neck imaging. philadelphia: mosby, 1996. pictorial interlude 33 sa journal of radiology • december 2005 fig. 2. ct scan showing unilateral left-sided stenosis with unilateral thickening of the vomer and medially bowed left medial maxillary wall. to order contact: the south african medical association, health & medical publishing group 1-2 lonsdale building, gardener way, pinelands, 7405. tel: (021) 530-6520/27 fax: (021) 531-4126/3539 email: carmena@hmpg.co.za or avrilm@hmpg.co.za price r420.00 price r420.00 pictorial interlude 11/29/05 12:33 pm page 33 reviewer acknowledgement open accesshttp://www.sajr.org.za page 1 of 1 the editorial team of sa journal of radiology recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of sa journal of radiology: 164 we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for sa journal of radiology, we ask that you take a moment to update your electronic portfolio on www.jamba. org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajr.org.za 2. in your ‘user home’ [http://www.sajr.org.za/ index.php/sajr/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to sa journal of radiology. please do not hesitate to contact me if you require assistance in performing this task. rochelle flint submissions@sajr.org.za tel: +27 21 975 2602 fax: +27 21 975 4635 sa journal of radiology aadil ahmed abraham h. dachman anil bhaya anju sahdev anthony levy arthur maydell asif bagadia blessing o-e. igbinedion bruce spottiswoode chirag k. ahuja dilesh chhiba dirk van der merwe franck girard francois roux girish tyagi hein els himal gajjar jaishree naidoo kamini gupta kumaresan (kumar) sandrasegaran mariam q. said-hartley nausheen khan prashant k. gupta r. minne ramy mansour sandeep jakhere shaun scheepers sulaiman moosa suresh k. chamarthi tharbit hartley victor mngomezulu zarina lockhat article information authors: nathanael sabbah1 sinclair wynchank2,3 affiliations: 1department of nuclear medicine, school of medicine, stanford university, united states of america 2innovation centre, medical research council, south africa 3faculty of health sciences, university of cape town, south africa correspondence to: sinclair wynchank postal address: po box 19070, tygerberg 7505, south africa dates: received: 26 nov. 2013 accepted: 18 jan. 2014 published: 04 july 2014 how to cite this article: sabbah n, wynchank s. tele-nuclear medicine. s afr j rad. 2014;18(1); art. #595, 5 pages. http://dx.doi.org/10.4102/ sajr.v18i1.595 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tele-nuclear medicine in this review article... open access • abstract • introduction • relevant history and current trends • technology • clinical tele-nuclear medicine • tele-education • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ this article presents a description of tele-nuclear medicine and, after outlining its history, a wide, representative range of its applications. tele-nuclear medicine has benefited greatly from technological progress, which for several decades has provided greater data transfer rates and storage capacity at steadily decreasing cost. differences in the practice of nuclear medicine between developed and developing countries arise mainly from disparities in their available infrastructure, funding and education levels of personnel involved. consequently there are different emphases in their tele-nuclear medicine, which are elaborated. it is concluded that tele-nuclear medicine is important for all countries, but the emphasis on its application may differ between developed and developing nations, with an emphasis on distance learning in the latter. introduction top ↑ applications of tele-nuclear medicine are steadily increasing in all parts of the world, though often for different reasons in developed and developing countries. these differences are described below. tele-nuclear medicine uses information and communication technology (ict) to transmit information about nuclear medicine between two or more locations. this information most often includes scintigraphic images, but also their reports, patient and research data and associated educational material. nuclear medicine can investigate many different pathologies. therefore a wide range of medical specialists use nuclear medicine studies, but particularly cardiologists, oncologists, neuropsychiatrists, nephro-urologists, orthopaedic surgeons and rheumatologists. satisfactory but limited tele-nuclear medicine is possible using transmissions along copper telephone wires, as is often the situation in non-urban regions of developing countries. but modern sophisticated nuclear medicine, such as positron emission tomography/computer tomography (pet/ct) and single-photon emission tomography/ct (spect/ct), can produce large data sets, requiring rapid transmission and wide bandwidths for effective tele-nuclear medicine. such ict links are commonly found in developed countries and also within and between large cities of some developing countries. but these nations’ tele-nuclear medicine most often transmits simple nuclear medicine images and data sets, which do not require sophisticated transmission facilities. tele-nuclear medicine has often been slow to be applied, in contrast to tele-radiology and tele-pathology, whose advantages were appreciated early in the history of tele-medicine. for example, in norway, a wealthy developed country and pioneer in the field of tele-medicine, tele-nuclear medicine was only introduced and available about two decades after the first use of tele-medicine. norway has a large area and many sparsely populated rural regions. it has this in common with developed nations such as the united states of america (usa), australia and canada, and also with very many developing countries, which now appreciate the benefits of all types of tele-medicine. tele-medicine was mainly pioneered in developed countries and later its equipment and experience were used in developing nations. however, late and slow introduction of extensive tele-nuclear medicine has generally been the situation in all countries. fortunately applications of tele-medicine and tele-nuclear medicine are now steadily increasing everywhere. emergency nuclear medicine can clearly benefit from tele-nuclear medicine, as can nuclear medicine associated distance learning and those clinical disciplines mentioned above. because of the growing importance and application of all types of tele-nuclear medicine, and because little has been written about it, it merits an appraisal. relevant history and current trends top ↑ modern tele-medicine probably began in about 1935, when the italian international radio medical centre used radio communications to provide free medical assistance to ships at sea without any doctor on board. an early form of italian tele-nuclear medicine existed in 1986.1 tele-nuclear medicine allows consultations with specialists located away from the nuclear medicine facilities and patients. this can result in better management, savings in health care costs and fewer inappropriate studies. these benefits can arise from both fixed-link tele-nuclear medicine and internet connections. also, tele-nuclear medicine may reduce travel costs for patients and practitioners and can aid provision of a nuclear medicine service where or when a nuclear medicine specialist is unavailable. there are considerable advantages in using distance-learning techniques for appropriate nuclear medicine (and other) education. high-speed fibre-optic and radio ict links, available in many locations, can also facilitate rapid data transfer for studies in some parts of certain developing countries for cardiology and various dynamic nuclear medicine investigations, or spect/ct with large data sets, for example. a recent comprehensive review of nuclear medicine trends in developing countries by the international atomic energy agency (iaea)2 emphasised increasing mortality and morbidity in developing nations from chronic and non-communicable diseases. thus nuclear medicine’s role in disease management there has increased, especially for neoplastic and cardiological conditions, although its application has been slower than desired. the two main reasons for this are the costs of modern, sophisticated equipment in countries with severely limited healthcare budgets and, equally importantly, insufficient education and training in nuclear medicine. the latter can be improved greatly by using tele-nuclear medicine, as examples given below indicate. initiatives, mainly from the iaea, assist in supplying appropriate nuclear medicine equipment to developing nations. such aid has included over 50 dual-head spect cameras since 2004 and about 130 ongoing technical cooperation programmes, especially for developing countries. nuclear medicine practice differs between developed and developing countries, mainly because of insufficient funds and training in developing countries. in addition, there are different levels of infrastructure and prevalence for causes of morbidity. regrettably some nuclear medicine departments in developing countries are inactive several days each month, typically because of unavailability of 99mo/99mtc generators, especially in africa and latin america, which have the lowest departmental efficiencies overall.2 these drawbacks, especially inadequate training, ‘hamper the growth of nuclear medicine practice in the developing world’ and reduce ‘the ability of nuclear medicine facilities to respond to the needs of referring clinicians’.2 technology top ↑ web-based information can aid most tele-nuclear medicine applications – for example, virtual picture archiving and communication systems, which can include nuclear medicine and other image data – and are particularly useful in remote rural areas. mobile telephone use in africa is now widespread. many current african mobile telephone users have never had, nor are likely ever to have, fixed land lines, because of this explosive increase in inexpensive mobile telephone availability. health care using mobile ict devices (mhealth) is well established and steadily growing in developed countries, especially for home care surveillance. mhealth is also now increasingly used in developing nations. in 2011, the first published report on mobile phone tele-dermatology, from egypt, used a 5 megapixel camera.3 many more mhealth trials are underway. although mhealth has limits for transmitting high-resolution images comprising large data sets, it is highly suitable for other tele-nuclear medicine, such as reports delivered from a distant site and transmission of many types of static image. image compression with acceptable degradation increases tele-nuclear medicine’s effectiveness when using links with limited bandwidth. many successful mhealth applications in developing countries use the short message service, ensuring compliance for those medicated for hiv or multidrug-resistant tuberculosis infections, for example. cochrane reviews have also shown that such reminders4 are equally effective to ensure attendance of (nuclear medicine and other) medical appointments. over the last few decades there has been a steady increase in electronic computing capacity, accompanied by decreasing costs, often expressed in terms of moore’s law. one of the consequences is that more powerful tele-nuclear medicine equipment is becoming less expensive and thus more readily available, even in developing countries. this applies to pet/ct and especially spect/ct, which has been described by the iaea5 as ‘a brilliant diagnostic tool in medical imaging, where anatomical details may delineate functional and metabolic information’. images from the two different types of scans (spect and ct) are fused. spect can recognise specific tissues or tumours, which may be difficult to locate accurately with relation to other anatomical structures such as bones, usually readily identifiable by ct. this is especially useful where tissue location is very variable. one well-known application is to locate parathyroids, which may be distant from their usual site in the thyroid gland. tele-nuclear medicine is most appropriate in supplying expert opinion, thus aiding interpretation of such sophisticated images. clinical tele-nuclear medicine top ↑ medical emergencies require speedy reporting and tele-nuclear medicine can provide this for emergency nuclear medicine studies, as necessary. it is appreciated, however, that ct and ultrasound comprise most emergency imaging. emergency nuclear medicine studies include ventilation-perfusion pulmonary scans for suspected pulmonary embolism, especially in young women of reproductive age or pregnant. this minimises radiation exposure of breast and foetus and requires no iodinated contrast media in pregnancy. patients who are diabetic, in renal failure, or sensitive to contrast media also benefit from this nuclear medicine study, which can also diagnose comorbidity, such as chronic obstructive pulmonary disease, left heart failure, or pneumonia.6 similarly, with equivocal ultrasound investigations, a radionuclide testicular study can obviate unnecessary exploratory surgery. to avoid needless hospitalisation, and a premature discharge of misdiagnosed patients wrongly suspected of having the acute coronary syndrome, a resting myocardial perfusion study can provide more effective triage and it is an appropriate procedure for developing countries.7 other nuclear medicine studies can offer efficient solutions to emergency situations, thus reducing the need for more expensive and complex procedures. they investigate chest pain in low-risk patients, acute cholecystitis, gastrointestinal bleeding and radiographically occult fractures.8 a less frequent emergency is a blocked cerebrospinal fluid shunt in a paediatric patient, for which nuclear medicine provides increased sensitivity.9 if local reporting is impossible or impractical for emergency nuclear medicine, tele-nuclear medicine can usually provide an acceptable substitute. tele-nuclear medicine also provides valuable support in many non-urgent situations. cardiology database access may allow improved management. an iaea study10 established that approximately 80% of cardiovascular deaths occur in developing nations and suggested that regional training centres could reduce such morbidity by disseminating instruction, allowing increased utilisation of nuclear cardiology. as shown below, tele-nuclear medicine can greatly increase such training centres’ effectiveness. incidence of diabetes mellitus, and hence silent myocardial ischemia, is increasing in developing countries. for its management nuclear medicine studies have been shown to be more accurate than stress echocardiography.11 these studies’ interpretation may also benefit by accessing distant specialists using tele-nuclear medicine. tele-nuclear medicine links have many other applications useful for developing countries, such as database access. relevant medical databases include one for the francophone indian ocean island nations (dr joseph mourouvin 2011, personal communication, september) and another in china.12 both have been associated with emergencies related to infectious disease outbreaks (in the case of the former, with a bubonic plague outbreak in madagascar) and the rapid resulting action averted an epidemic. when magnetic resonance imaging (mri) and ct availability are limited, as is often the case in developing countries, there are situations where tele-nuclear medicine can be very useful in the absence of hybrid imaging, such as in skeletal studies with suspicion of multifocal lesions or poor symptomatic localisation where there is a need for a second opinion.13 thyroid problems, frequently investigated with nuclear medicine, commonly occur in developing countries where they unfortunately often present very late. an indian project aimed at managing thyroid cancer established a most successful tele-medicine network between a specialist hospital and secondary hospitals, which was able to ‘disseminate knowledge, educate doctors and paramedical staff, improve and develop their consultation and surgical skills’. this network also provided similar benefits for rheumatology patients.14 tele-education top ↑ nuclear medicine tele-education uses tele-nuclear medicine links. for many years one longstanding bidirectional tele-nuclear medicine link connected a south african medical faculty (university of stellenbosch) with the windhoek national hospital, namibia and later the university of namibia’s school of medicine, allowing distance reporting, remote processing and expert second opinions, all partially overcoming problems of relative isolation for nuclear medicine practice in namibia. however, this link is no longer operational (prof. annare ellmann 2013, personal communication, november 17). a similar tele-nuclear medicine link has been used between the university of cape town and the university hospital in lusaka, zambia. the iaea has provided appropriate ict equipment for both these nominally clinical links. however, both links also had an important tele-nuclear medicine education function (both formal and informal), clearly demonstrating the power of clinical tele-nuclear medicine links to permit tele-education, when not occupied with clinical nuclear medicine. many people, located at different receiving sites, can benefit simultaneously from one tele-education teaching session, whether it comprises lectures, demonstrations, case presentations or self-administered computer-controlled instruction. the iaea has recently invested much effort and funding in providing distance-learning web-based training for nuclear medicine15 in basic topics and also for some advanced studies, especially for nuclear medicine technologists. the basic training programme (particularly relevant to developing countries) uses 14 modules and the advanced studies 6 modules, covering complex equipment such as pet/ct and pet/mri. english and spanish versions are currently available and used in 24 mostly developing nations. turkish translations are underway, for turkey currently has over 200 nuclear medicine departments, with little formal training in nuclear medicine technology. in australia, completion of appropriate modules allows licensing of some nuclear medicine scientists. the development of all these programmes has received many contributions, but the universities of sydney and cape town were major providers of teaching material. both obtained much support and coordination aid from the iaea. its human health division recently indicated that its nuclear medicine training programme aims (1) to improve basic knowledge, necessary for effective practice of the discipline, with emphasis on practical skills and (2) to establish assessed common basic standards of training.16 currently, about 450 students participate and over 370 students have completed sections of the various courses. an extensive system of cost-free web-based educational nuclear medicine seminars (webinars) has also recently been described by the iaea.15 the united states society of nuclear medicine and molecular imaging also provides such webinars, live workshops and lectures.17 other informal tele-nuclear medicine activities are underway in africa, serving both clinical and educational needs. adequate medical physics expertise and facilities are essential components of the effective and safe practice of nuclear medicine. inadequacies in medical physics often serve as an obstacle to achieving the full potential of nuclear medicine in developing countries. tele-nuclear medicine can often aid medical physicists in ensuring effective limits on radiation exposure. a report from a developing country stated that, after 131i treatment in one location, the general public and patients’ families (children in particular) received an excessive radiation dose equivalent to or greater than the annual dose limit; in addition, some of the patients were overdosed.18 this arose directly from inadequate medical physics monitoring. it was remedied by further training, which tele-nuclear medicine using distance-learning techniques can effectively provide. similarly, the iaea has found that inadequate quality control and faulty radioactivity measurements in nuclear medicine laboratories of some developing countries resulted in inconsistent and unsafe conditions. regional training centres and dissemination of appropriate tele-education from the iaea can resolve this situation.19 another application of nuclear medicine’s tele-education is teaching effective management of radiation release accidents (and also ‘dirty’ bomb detonations), such management often being the responsibility of nuclear medicine departments and their medical physicists. relevant advice for treating patients and protecting personnel and the environment can be provided rapidly. these links can also be used effectively in such circumstances to assist with control of resources and patient transport decisions.20 tele-education, although very useful, is not always a simple, direct and universal substitute for other learning methods, as one report from a brazilian project on early sentinel lymph node diagnosis shows.21 although participants completed the tele-nuclear medicine course, insufficient preparation and consequent lack of motivation of the physician trainees resulted in unsatisfactory results. it was deduced that appropriate preparation was lacking in this application of non-traditional learning methods and that the pro-active participation of a tele-nuclear medicine course coordinator is essential. this sentinel lymph node project was a notable exception in tele-nuclear medicine education. other such education programmes usually prove most successful and effective, with clear cost benefits. it is not always understood that the ‘optimization of current resources is more important than obtaining additional equipment and resources’.22 as illustrated, tele-nuclear medicine education is seen to be very effective overall and in high demand in developing nations. this successful aspect of tele-nuclear medicine complements all its other applications outlined above. hence the discipline’s achievements and potential deserve to be expounded more widely. conclusion top ↑ in all parts of the world, tele-nuclear medicine is playing an increasing role in the improved practice of nuclear medicine, by allowing access to expertise that is unavailable otherwise. an important part of this is the educational power of tele-nuclear medicine, which is particularly cost-effective, especially for developing countries where adequate numbers of experts and levels of training often lack for financial reasons. tele-nuclear medicine has two principal, proven advantages. the first is the rapid and efficient transmission of data sets of all degrees of complexity, without significant loss of resolution, thus aiding provision of a nuclear medicine service with any degree of distance between the participating nuclear medicine physician and the location of camera and patient. the second is that tele-nuclear medicine can allow cost-effective distance learning at all levels. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions n.s. (stanford university) and s.w. (medical research council and university of cape town) jointly decided upon the type of material to be researched for this review and agreed what each would study. then each researched his assigned field, contributed a comparable amount of text and took part in the final editing. references top ↑ 1.rotondo g. evolution and current uses of telematics in medicine. future perspectives of telemedicine. minerva med. 1986;28:67–77. 2. dondi m, kashyap r, paez d, et al. trends in nuclear medicine in developing countries. j nucl med. 2011;52(suppl 2):16s–23s. http://dx.doi.org/10.2967/jnumed.111.089193 3.tran k, ayad m, weinberg j, et al. mobile teledermatology in the developing world: implications of a feasibility study on 30 egyptian patients with common skin diseases. j am acad dermatol. 2011;64:302–309. http://dx.doi.org/10.1016/j.jaad.2010.01.010 4.atherton h, sawmynaden p, meyer b, car j. email for the coordination of healthcare appointments and attendance reminders. cochrane database syst rev. 2012;8:cd007981. http://dx.doi.org/10.1002/14651858.cd007981.pub2 5.iaea. clinical applications of spect/ct: new hybrid nuclear medicine imaging system iaea-tecdoc-1597 [homepage on the internet]. 2008 [cited 2014 april 23]. available from: http://www-pub.iaea.org/mtcd/publications/pdf/te_1597_web.pdf 6. bajc m,  neilly b,  miniati m,  mortensen j,  jonson b. methodology for ventilation/perfusion spect. semin nucl med. 2010;40:415–425. http://dx.doi.org/10.1053/j.semnuclmed.2010.07.002 7.better n, karthikeyan g, vitola j, et al. performance of rest myocardial perfusion imaging in the management of acute chest pain in the emergency room in developing nations (premier trial). j nucl cardiol. 2012;19:1146–1153. http://dx.doi.org/10.1007/s12350-012-9622-x 8.amini b, patel cb, lewin mr, kim t, fisher re. diagnostic nuclear medicine in the ed. am j emerg med. 2011;29:91–101. http://dx.doi.org/10.1016/j.ajem.2009.03.008 9.ouellette d, lynch t, bruder e, et al. additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department. pediatr emerg care. 2009;25:827–830. http://dx.doi.org/10.1097/pec.0b013e3181c07461 10.vitola jv, shaw lj, allam ah, et al. assessing the need for nuclear cardiology and other advanced cardiac imaging modalities in the developing world. j nucl cardiol. 2009;16(6):956–961. http://dx.doi.org/10.1007/s12350-009-9104-y 11.barthelemy o, le feuvre c, timsit j. silent myocardial ischemia screening in patients with diabetes mellitus. arq bras endocrinol metabol. 2007;51:285–293. http://dx.doi.org/10.1590/s0004-27302007000200018 12.li yp,  fang lq,  gao sq, et al. decision support system for the response to infectious disease emergencies based on webgis and mobile services in china. plos one. 2013;8:e54842. http://dx.doi.org/10.1371/journal.pone.0054842 13.warwick j, lotz j. integrated imaging – the complementary roles of radiology and nuclear medicine. s afr j radiol. 2013;17:149–153. http://dx.doi.org/10.7196/sajr.1033 14.mishra sk. tele-healthcare and distance medical education – sanjay gandhi postgraduate institute of medical sciences experience [homepage on the internet]. no date [cited april 2013]. available from: http://unpan1.un.org/intradoc/groups/public/documents/un-dpadm/unpan037168.pdf 15.patterson he, nunez m, philotheou gm, hutton bf. meeting the challenges of global nuclear medicine technologist training in the 21st century: the iaea distance assisted training (dat) program. semin nucl med. 2013;43:195–201. http://dx.doi.org/10.1053/j.semnuclmed.2012.11.010 16.casas-zamora ja, kashyap r. the iaea technical cooperation programme and nuclear medicine in the developing world: objectives, trends, and contributions. semin nucl med. 2013;43:172–180. http://dx.doi.org/10.1053/j.semnuclmed.2012.11.007 17.society of nuclear medicine and molecular imaging (snmmi). virtual meeting. [homepage on the internet]. no date [cited 2014 april 23]. available from: http://conference-cast.com/snm/common/sessions.aspx/6/3 18.muhammad w, faaruq s, matiullah, hussain a, khan aa. release criteria from hospitals of 131-i thyrotoxicosis therapy patients in developing countries – case study. radiat prot dosimetry. 2006;121:136–139. http://dx.doi.org/10.1093/rpd/ncl003 19.zimmerman be, herbst c, norenberg jp, woods mj. international guidance on the establishment of quality assurance programmes for radioactivity measurement in nuclear medicine. appl radiat isot. 2006;64:1142–1146. http://dx.doi.org/10.1016/j.apradiso.2006.02.012 20.fuse a, okumura t, hagiwara j, et al. new information technology tools for a medical command system for mass decontamination. prehosp disaster med. 2013;28:1–3. http://dx.doi.org/10.1017/s1049023x13000095 21.kelmer s de c, coelho-oliveira a, barbosa da fonseca lm. internet-conducted distance education: ‘sentinel lymph node, prevention, early diagnosis and biopsy – a new technique for approaching breast cancer’. radiol bras. 2007;40:251–254. http://dx.doi.org/10.1590/s0100-39842007000400010 22.zaidi h. medical physics in developing countries: looking for a better world. biomed imaging interv j. 2008;4:e29. http://dx.doi.org/10.2349/biij.4.1.e29 article information author: shalen misser1 affiliation: 1lake smit and partners inc., durban, south africa correspondence to: shalen misser postal address: private bag x08, overport 4067, durban, south africa how to cite this article: misser. s. answer to head and neck imaging. s afr j rad. 2014;18(1); art. #705 3 pages. http://dx.doi/org/10.4102/ sajr.v18i1.705 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. answer to head and neck imaging in this quiz case... open access • abstract • presentation • findings and diagnosis • discussion • acknowledgements    • competing interests • references abstract top ↑ several answers to the quiz question were received from all quarters of the country. noteworthy responses came from drs ian haynes, nikelo mabandla, francois roux, mlindeli masango, andrew lawson, zakariya vawda and zain ally. spot-on diagnoses with the best radiological descriptions obtained were from dr naye sihlali and dr fourie bezuidenhout, who share the prize. congratulations to all respondents. presentation top ↑ a 26-year-old woman presented with a painful paramedian anterior neck mass. her ultrasound and computerised tomography (ct) images appear below. figure 1: sagittal b-mode sonar images of the right para-median anterior neck mass, demonstrating the thyroglossal duct cyst (tdc) with intracystic postero-inferior echogenic nodule. posterior acoustic shadowing indicates calcification of the nodule. figure 2: axial computerised tomography (ct) scan image of the neck at the level of the hyoid bone, demonstrating the thyroglossal duct cyst (tdc) with a partly calcified, papillary, intracystic nodule. figure 3: sagittal paramidline computerised tomography (ct) image of the neck showing the relation of the thyroglossal duct cyst (tdc) to the hyoid bone. figure 4: coronal computerised tomography (ct) image of the anterior neck triangles demonstrating the multinodular thyromegaly. findings and diagnosis top ↑ the ultrasound image (figure 1) shows a right para-median anterior neck mass of mixed echogenicity measuring 2.3 cm x 1.9 cm, including a predominant cystic component and an internal microlobulated papillary projection containing calcification. the computerised tomography (ct) image (figure 2) at the level of the hyoid bone demonstrates the anterior neck cystic mass with an internal solid and calcific component. figure 3 is a sagittal ct reformat demonstrating the cyst just inferior to the submental space, lying anterior to the hyoid bone, as well as the enlarged thyroid gland. in figure 4, the thyroid enlargement with a nodular texture, internal calcification and mass effect on the trachea and adjacent carotid sheath structures is evident. the patient underwent extirpation of the cyst and the entire thyroid gland. histological analysis confirmed that the cystic lesion was in fact a thyroglossal duct cyst (tdc) with intracystic papillary carcinoma. the thyroid gland, despite several reviews of the histological slides, failed to show any features of malignant change. there was, however, diffuse enlargement of the follicles with intervening areas of haemorrhage, calcification and fibrosis. there were no regional nodes showing evidence of malignant infiltrate. the final diagnosis was benign multinodular thyromegaly with tdc and a nodule containing papillary thyroid carcinoma. discussion top ↑ the embryology of the thyroid gland is complex. it is the first endocrine gland to develop in a fetus. under the influence of fibroblast growth factor (fgf) signalling pathways, the thyroid diverticulum begins around day 24 as a proliferation of endodermal cells, at the midline pharyngeal floor between two structures (the tuberculum impar and copula), an area that is traditionally known as the foramen caecum.1 this duct-like invagination from the ventral pharyngeal endoderm is located between the first and second pharyngeal pouches. a tubular thyroglossal duct subsequently develops in a caudal direction along the midline, descending anterior to the hyoid bone and the airway. by the 7th week, two lateral anlages of the 4th and 5th branchial pouches develop into the ultimobranchial body which contains parafollicular c-cells. these are of neural crest origin and are later responsible for the secretion of calcitonin. these lateral bodies fuse with the midline descending thyroid primordium to form the thyroid gland. the thyroglossal duct atrophies by the 7th week to the 10th week, leaving a gland consisting of a median isthmus and two lateral lobes. in 50% of individuals, a pyramidal lobe, which is a residuum of the thyroglossal duct, is seen extending cranially from the isthmus. remnants of the thyroglossal duct anywhere along its track can result in ectopic thyroid tissue or a thyroglossal cyst. the sites of ectopic thyroid tissue and/or thyroglossal cyst formation are shown in figure 5. figure 5: (a) sagittal line diagram showing the common sites of ectopic thyroid rests or thyroglossal cyst formation; (b) explanation of figure 5a sites and locations. tdc is the most common congenital cystic mass of the neck, occurring in up to 90% of cases.1 approximately 80% of these cysts are located at or below the level of the hyoid bone.2 clinically, tdc presents as a painless paramedian swelling or anterior neck mass that moves on protruding the tongue or swallowing, owing to attachment to the hyoid bone. ultrasound of a tdc usually shows a midline anechoic mass in the typical locations described above, with a thin outer wall. there may be a variable internal echo within the cyst, depending on content, predominantly owing to proteinaceous material rather than infection or inflammation.3 on ct scans, tdc appears as a well circumscribed, smooth-walled hypoattenuated mass along the course of embryologic thyroid migration (shown in figure 5). mean internal density measurements are typically less than 20 hounsfield units. increased density within a cyst may be the result of thicker, more viscous content, suggestive of prior infection.4 tdcs are usually unilocular with enhancing walls on post-contrast ct scans. septation of a tdc may sometimes be observed.3 thyroid scintigraphy using technetium 99 m uptake scans is highly sensitive and specific in determining the presence of thyroid ectopia including tdc. several cases of multifocal thyroid rests have been reported in the literature. often, these rests of thyroid ectopia are the sole functional thyroid tissue, with no normal thyroid gland present. generally, tdcs have mri features of a cyst with t1-weighted reduced signal and corresponding t2-weighted shortening. an exception to the rule occurs in cases of high protein content, where t1-weighted hyperintensity is noted. typically, there is no restricted diffusion within a tdc. solid component with an intracystic nodule is well demonstrated on preand post-contrast mri studies. calcification shown on susceptibility weighted imaging (swi) or gradient echo images should prompt suspicion of a malignant nodule within the tdc. associated malignancy within a tdc has been reported in 1% of cases.1 tdc carcinoma must be considered in the presence of a mural nodule and/or calcification on cross-sectional imaging studies.2 although more than 80% are of the papillary carcinoma type, there have been reports of all the malignant thyroid subtypes associated with tdc (except for medullary carcinoma which is related to parafollicular calcitonin-secreting cells). nodal metastases are much less common in tdc-associated carcinoma than with primary neoplasms arising in the thyroid gland.3 the differential diagnoses of tdc are listed in box 1. abscesses can occur anywhere in the neck and may track between neck spaces. mri typically shows retricted diffusion of abscess content. branchial cleft cysts, particularly second branchial cleft cysts, are located off-midline along the sternocleidomastoid muscle, posterior to the submandibular glands, and are often noted to insinuate between the carotid branches after the common carotid artery bifurcation. dermoid and epidermoid cysts are easily differentiated from tdc by the presence of t1-weighted hyperintensity owing to fatty content and restricted diffusion on mri studies respectively.2 plunging or diving ranulas show a thin cystic tract to the sublingual space; t2-weighted sequences are useful in demonstrating these tracts which usually pass around the mylohyoid muscle. lymphatic malformations are detected earlier in life (usually before age 3 years), as these are congenital masses that may extend across cervical neck spaces and cause mass effect. laryngocoeles arise from the laryngeal ventricle and extend superolaterally through the thyrohyoid membrane. these may be internal or external to the larynx and can become fluid-filled, in which case they are called saccular cysts. tdcs can also perforate the thyrohyoid membrane but are not intimately related to the laryngeal ventricle. an important differential diagnosis is necrotic nodal metastasis from squamous carcinoma of the head and neck region in an adult patient presenting with a painless cystic cervical mass. thymic cysts in the neck, akin to thyroglossal cysts, are remnants of the thymopharyngeal duct during a similar descent through the neck resulting in thymic rests. these foci are occult on thyroid uptake isotope imaging.2 box 1: differential diagnoses for thyroglossal duct cysts.2 upon confirmation of a diagnosis of tdc-associated carcinoma, a surgical approach with a view to complete extirpation is mandatory. simple cyst excision is inadequate and results in recurrence in 30%–60% of patients.5 the recommended standard surgical treatment in these patients is by the sistrunk procedure which includes excision of the cyst, surrounding core of tissue around the tdc up to the foramen caecum and the central hyoid bone. a recurrence rate of less than 10% is noted following a sistrunk procedure. treatment of tdc-associated carcinoma, in the absence of a native thyroid tumour, raises the question of thyroidectomy being indicated. it has been recommended that the thyroid gland should be removed along with the tdc carcinoma in cases where (1) the thyroid gland is nodular, with cold nodule on isotope uptake scan, (2) enlarged lymph nodes are present, or (3) a history of previous neck irradiation exists.6 others recommend a more aggressive, albeit cautious, approach, to remove the thyroid gland along with the tdc carcinoma routinely at the time of sistrunk operation.5 acknowledgements top ↑ competing interests the author declares that he has no financial or personal relationship(s) that may have inappropriately influenced him in writing this article. references top ↑ 1.som pm, smoker wr, reidenberg js, bergemann ad, hudgins pa, laitman j. embryology and anatomy of the neck. in: som pm, curtin hd, editors. head and neck imaging. 5th edn. st louis: mosby, 2011; p. 2117–2163. http://dx.doi.org/10.1016/b978-0-323-05355-6.00034-3 2.zander da, smoker wrk. imaging of ectopic thyroid tissue and thyroglossal duct cysts. radiographics. 2014;34:37–50. http://dx.doi.org/10.1148/rg.341135055 3.koeller kk, alamo l, adair cf, smirniotopoulos jg. from the archives of the afip. congenital cystic masses of the neck: radiologic-pathologic correlation. radiographics. 1999;19:121–146. http://dx.doi.org/10.1148/radiographics.19.1.g99ja06121 4.branstetter bf, weissman jl, kennedy tl, whitaker m. the ct appearance of thyroglossal duct carcinoma. ajnr. 2000;21:1547–1550. 5.chrisolidou a, iliadou pk, doumala e, et al. thyroglossal duct cyst carcinomas: is there a need for thyroidectomy? hormones. 2013;12(4):522–528. http://dx.doi.org/10.14310/horm.2002.1440 6.kazemi m, assadi m, kazemi aa, ghazvini la. primary papillary carcinoma in a thyroglossal duct cyst. hell j nucl med. 2006;9:39–40. opinion new interventional techniques in the treatment of carotid stenosis abstract recent advances in catheter, guide wire and stent design have provided the interventional cardiologist and radiologist with the opportu n ity to treat cerebrovascu lar disease. the role of these new therapies is explored in relation to conventional medical and surgical options. petercorr mbchb, ffrad(d)sa, frcr, mmed(uct) department of radiology, university of natal stroke is the third most common cause of death in south africa, accounting for 9.6 % of all deaths in 1990.1 stroke is also a major cause of morbidity and contributor to health costs in this country. most strokes are due to atherosclerotic disease of the proximal internal carotid artery and bifurcation.! prevention of stroke by treatment of carotid disease is the 4 sajournal of radiology. june 1997 most important goal of current therapy. carotid endarterectomy is the treatment of choice if the lesion has a 70% or greater stenosis or by treatment with aspirin if there is a less significant stenosis' carotid endarterectomy is a safe effective procedure if performed by an experienced surgeon. the stroke council of the american heart association recommends that for carotid endarterectomy to be effective the combined morbidity and mortality must be less than 6%.4 in the nascet trial the complication rate was 5.8% for perioperative stroke and death and 7.5% in the ecs trial.' both trials were performed in centres of excellence by highly experienced surgeons. however a review of published data of 16000 procedures in 50 studies showed a 1.6% mortality but stroke rates from 1 to 35%16 the critical factor is the experience of the surgeon and the icu and anaesthetic support in the hospital. both carotid angioplasty and self expandable stenting have become popular alternative therapies to the treatment of significant carotid stenosis. angioplasty of the carotid artery was first performed in 1980 and a number of cardiologists and radiologists have large personal series.theron recently published his experience with 259 angioplasties over a 12 year period.' he reported a 5% dissection rate and 8% embolic complication rate with the first 38 angioplasties but after changing to a triple lumen catheter with a distal balloon to prevent embolism his complication rate decreased to 2%. indications for angioplasty would probably be patients unsuitable for endarterectomy. this includes patients with very distal internal carotid artery stenosis above topage5 nevv interventional techniques in the treatment of carotid stenosis frompage4 the angle of the mandible where surgical access is limited. also included are patients with cardiovascular disease who are an anaesthetic risk. theron had a restenosis rate of 16% (13 of 81 patients) within the first two years. 8 contraindications to this procedure are: calcified tortuous arteries that would be difficult to access and to balloon, and free floating thrombus on the angiogram-this is an absolute contraindication. a major concern is the risk of distal embolisation. it is important that the patient is fully conscious during the procedure and is monitored by a neurologist so that subtle neurological signs can be detected and treated early. if procedural thrombosis occurs, urgent thrombolysis is indicated. if a dissection occurs, immediate placement of a stent is required. the cavatas trial which is a multieentre randomised study of angioplasty vs endarterectomy is currently being conducted and will provide some of the answers about the role of angioplasty. new developments in stent technology and design have resulted in the arrival of carotid self expandable stents. the most commonly used is the wallstent (schneider, switzerland). the balloon expandable stents have not proved popular because of the risk of distal embolization. initially indicated for iatrogenic carotid dissection and as an adjunct to angioplasty this procedure has become popular as a primary treatment.v" restenosis following stent insertion was seen in 4% of theron's patients (4 out of 93 cases). the same indications and contraindications that apply to angioplasty also apply to primary carotid stenting. technically this is a demanding procedure with a steep learning curve. familiarity with coronary guide wires and low profile coronary balloons is a distinct advantage.there have been no prospective trials of stent vs endartectomy yet. the major concern is the risk of distal embolisation and thrombosis and the long term risk of restenosis. immediate complications of primary stenting appear to be minimal if meticulous technique is used. perhaps the most important factor for a good outcome is careful patient selection and working in a team environment with a stroke neurologist and vascular surgeon. references 1. bradshaw 0, bourne de, schneider m, sayed r. mortality pattern of chronic disease of lifestyle in south africa. in chronic disease of lifestyle eds fourie j and steyn k. mrc technical report 1995. 2. mohr j, caplan l, melski 1. the harvard cooperative stroke registry: a prospective registry. neurology 1978;28:754-762 3. north american symptomatic carotid endarterectomy trial collaborators. beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis. ne1m 1991 ;325:445-453. 4. american heartassociation.1992. heart stroke and facts. bethesed md 1992;2. 5. hurst r. carotid angioplasty. radiology 1996;201 :613-616. 6. rothwell p, slattery j, warlow c. a systematic review of the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis. stroke 1996;27;260-265. 7. mullan s, duda e, petronas n. some examples of balloon technology in neurosciences. ] neurosurgery 1980;52:321-329. 8. theron j, payelle g, coskun o. carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. radi%gy 1996;201 :627-636. 9. marks m, dake m, steinberg g, norbash a, lake b. stent placement for arterial and venous eer brovascular disease: preliminary experience. radiology 1994;191:441-446. 10. eskridge 1. neurovascular stents. radiology 1994;191 :313-314 university of the witwatersrand, johannesburg ga uteng provincial administration chief specialist/professor (radiology) applications are invited from suitably qualified candidates for the above post on the joint staff of the university of the witwatersrand and the gauteng provincial administration. the post normally carries the academic status of professor. applicants should be registrable as specialists with the interim national medical and dental council. • salary: r 191 712 per annum but the total remuneration package is in excess of r 350 000 per annum. • enquiries: for a detailed information sheet relating to this post, please contact the university's personnel office at: (0 ll) 716-2954 / 716-3568. alternatively, e-mail: 080amd@atlas.wits.ac.za. • to apply, submit a detailed cv with the names and addresses of 3 referees and certi fied copies of degrees/diplomas to: the personnel office (academic), university of the witwatersrand, private bag 3, wits 2050. \,j oil ~~ closing date: 29 august 1997. quote ref: sa .t/radiology 15565. 'the university is an affirmative action and equal opportunity employer' 5 sajournal of radiology· june 1997 mailto:080amd@atlas.wits.ac.za. article information author: joel bortz1 affiliation: 1lsg imaging, los angeles, united states of america correspondence to: joel bortz email: joelbortzmd@gmail.com postal address: 13031 villosa place, apartment 141, playa vista, california 90094, united states of america dates: received: 03 nov. 2014 accepted: 04 june 2015 published: 14 aug. 2015 how to cite this article: bortz j. inverted appendix: computed tomographic colonography diagnosis in a patient and lesson learned. s afr j rad. 2015;19(1); art. #748, 4 pages. http://dx.doi.org/10.4102/sajr.v19i1.748 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. inverted appendix: computed tomographic colonography diagnosis in a patient and lesson learned in this case report... open access • abstract • introduction • case report • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ the role of computed tomographic colonography in the diagnosis of an inverted appendix is described in an adult woman, with mayer-rokitansky-küster-hauser syndrome, who underwent a laparotomy during her childhood for severe abdominal pain. according to the patient, both a hysterectomy and an incidental appendectomy were performed. introduction top ↑ this report underscores the importance for radiologists to consider appendiceal inversion after appendectomy by any method when interpreting computed tomography colonography (ctc) images. such awareness could reduce unnecessary interventions, such as colonoscopy. case report top ↑ a screening ctc was performed in 2012 on a 53-year-old asymptomatic woman who reported a hysterectomy and an appendectomy as part of her surgical history. the significant finding at ctc was a 5 cm linear structure arising from the appendiceal orifice in the caecal pole (figure 1a). the structure projected into the colonic lumen on the prone study (figures 1b–1c) but changed shape in the supine position (figures 1d–1e). the translucent display showed high-attenuation tissue interspersed with areas of fat (figure 1f). the appearance was that of an intact inverted appendix but, with the patient’s recall of an appendectomy, a pedunculated polyp was considered. the remainder of the colon was normal. figure 1: prone air contrast colon map (a) shows an elongated structure (arrow). the prone 3d image (1b) shows the intact vertical appendix (arrow). the 2d prone axial view (1c) shows the vertical appendix (arrow). the 3d supine view (1d) shows the appendix (circled) surrounded by barium. the 2d supine view (1e) shows the appendix at the base of the caecal pole (circled). the prone translucent display (1f) shows the appendix (yellow arrows) with a small pool of barium at the tip (black arrow). upon further questioning following the ctc, the patient, whose childhood medical and surgical records were not available, provided an articulate verbal report of her surgical history. she recalled that at the age of 15 years she developed acute lower abdominal pain without vaginal bleeding which necessitated an emergency laparotomy. according to the patient, the intra-operative findings included haematometra within a hypoplastic uterus and she was diagnosed with mayer-rokitansky-küster-hauser (mrkh) syndrome. the patient was certain that the surgeon had informed her that both a hysterectomy and an appendectomy were performed during the surgery. a same-day optical colonoscopy was performed which confirmed the presence of a 5 cm elongated structure compatible with an inverted appendix (figure 2). histological analysis confirmed normal mucosa with numerous small benign lymphoid aggregates of colonic mucosa. she was advised to undergo ctc screening every 5 years. figure 2: digital photograph via optical colonoscopy, performed on the same day as the computed tomographic colonography, confirms an intact 5 cm appendix (arrow). discussion top ↑ the vermiform appendix is part of the caecum. its length varies from 2.5 cm to 33 cm.1,2 its average length is between 5 cm and 10 cm and its base is usually situated 2 cm below the ileo-caecal valve. its intra-abdominal position may vary widely, depending on the peritoneal fold which represents the mesentery of the appendix.1 the appendix in this case report was of average length, namely 5 cm. appendectomy for acute appendicitis remains one of the most frequently performed surgical procedures.3,4 from the patient’s recall, she underwent a simple appendectomy at the time of abdominal surgery to prevent the risk of future acute appendicitis.4,5 according to her, the procedure was performed when she had a hysterectomy at the age of 15 years, at which stage mayer-rokitansky-küster-hauser syndrome, belonging to class 1 müllerian duct anomalies,6 was diagnosed. historically, incidental appendectomy was performed mainly during open cholecystectomy and gynaecological operations.4,5 a full length appendix was noted during the ctc study which indicated that surgical resection of the appendix had not taken place (see figures 1a–1c). the ctc images favoured a simple inversion appendectomy as the most likely procedure. variations of this type of surgery would include inversion-ligation appendectomy, as well as appendectomy with stump inversion.3,7,8,9 simple inversion appendectomy comprises ligation and division of the mesoappendix, full length inversion into the caecum and a seromuscular purse-string suture placed around the base of the appendix.9,10 with simple inversion or inversion ligation, 31% of the appendices disappear and 69% remain visible, floating in the caecal lumen.8 the shape of the appendix may alter with postural change,1 as shown in figures 1b–1e in the present report. figures 1a–1c depict an inverted appendix in the caecal lumen. simple inversion3 involves devascularisation of the appendix through ligation and cutting of the mesoappendix.9,10 an alternative technique, known as inversion-ligation, has also been employed which eliminates most of the appendix. the last 2 mm–4 mm of the appendix near the base is kept from protruding from the caecal wall. using absorbable suture material, the stump is tied and the appendix base is buried by a purse-string suture. this technique devascularises the appendix which causes it to necrose; it then becomes detached and may appear in the stool within a few days post-surgery.9,10 incidental appendectomy comprises removal of the appendix at the time of surgery for other unrelated conditions.11 chalya and mchembe12 showed that simple ligation was as good as and probably better than inversion of the appendiceal stump. pathological inversion should not be confused with therapeutic inversion. pathological inversion may be secondary to appendiceal pathology, such as benign adenomas, malignant tumours,13 mucocele or appendiceal endometriosis,14 and may result in appendiceal intussusception.2 despite the appendix in the present patient having apparently been inverted 38 years previously, it appeared intact and was of average length. a pedunculated polyp was considered in the differential diagnosis, but excluded as no definitive head was noted during the ctc examination. a 3d diagnostic translucent display (figure 1f) was used at it provides a semi-transparent view in different colours beneath the surface.15 the software’s different colour attenuation values are: red indicates soft tissue; white indicates high attenuation values, such as barium; green indicates negative values in the fat attenuation range; and blue indicates negative values, such as air. radiologists should be aware of appendiceal inversion after appendectomy by any method; this awareness might possibly reduce unnecessary interventions, such as optical colonoscopy.11 in addition, radiologists need to consider the different forms of appendectomy performed prior to the laparoscopic approach4,12 because the procedure might have been of the inversion variety as opposed to surgical removal. asymptomatic appendiceal intussusception should be included in the differential diagnosis of a suspected inverted appendix.2 conclusion top ↑ in the present report, the patient’s recall of an appendectomy caused confusion during a screening ctc examination. the diagnosis of an inverted appendix using ctc should not present a diagnostic dilemma if the radiologist remembers that a history of an appendectomy might not necessarily equate with complete removal of the appendix. when radiologists encounter ctc findings similar to those discussed in the present report, they should ascertain whether the surgery was performed at a time when appendiceal inversion was common practice.7 acknowledgements top ↑ dr marc harwitt is thanked for providing the optical colonoscopy digital photograph. competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references top ↑ ahmed i, asgeirson k, beckingham i, lobo d. the position of the vermiform appendix at laparoscopy. surg radiol anat. 2007;29:165–168. http://dx.doi.org/10.1007/s00276-007-0182-8 varsamis n, pouggouras k, salveridis n, et al. appendiceal intussusception. in: lule g, editor. current concepts in colonic disorders. c2012 [cited 2015 may 19]. available from: http://www.intechopen.com/books/current-concepts-in-colonic-disorders/appendicealintussusception lilly jr, randolph jg. total inversion of the appendix: experience with appendectomy in children. j pediatr surg. 1968;3:357–363. http://dx.doi.org/10.1016/0022-3468(68)90341-2 neulander ez, hawke ck, solowa ms. incidental appendectomy during radical cystectomy: an interdepartmental survey and review of the literature. urology. 2000;56:241–244. http://dx.doi.org/10.1016/s0090-4295(00)00628-2 pearce c, torres c, stallings s, et al. elective appendectomy at the time of cesarean delivery: a randomized controlled trial. am j obstet gynecol. 2008;199:491.e1–e5. http://dx.doi.org/10.1016/j.ajog.2008.03.063 strübbe eh, willemsen wn, lemmens ja, thijn cj, rolland r. mayer-rokitansky-küster-hauser syndrome: distinction between two forms based on excretory urographic, sonographic, and laparoscopic findings. ajr. 1993;160:331–334. http://dx.doi.org/10.2214/ajr.160.2.8424345 prout jm, taylor aj, pickhardt pj. inverted appendiceal stumps simulating pedunculated polyps on screening ct colonography. ajr. 2006;186:535–538. http://dx.doi.org/10.2214/ajr.04.1791 almasad jk, daoud fs. long-term outcome of simple inversion of the appendix as an alternative to incidental appendectomy. ann saudi med. 2008 [cited 2014 oct 20 ];28:179–182. available from: http://applications.emro.who.int/imemrf/ann_saudi_med/2008_28_3_179.pdf?origin=publication_detail bishop hc, filston h. an inversion-ligation technique for incidental appendectomy. j pediatr surg. 1973;8:889–892. http://dx.doi.org/10.1016/0022-3468(73)90006-7 johnson ek, arcila m, steele sr. appendiceal inversion: a diagnostic and therapeutic dilemma. jsls. 2009 [cited 2014 oct 20 ];13:92–95. available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3015910/ snyder te, selanders jr. incidental appendectomy – yes or no? a retrospective case study and review of the literature. infect dis obstet gynecol. 1998;6:30–37. http://dx.doi.org/10.1155/s1064744998000076 chalya pl, mchembe m. is invagination of appendicular stump in appendectomy necessary? a prospective randomised clinical study. east cent afri j surg. 2012 [cited 2014 oct 20];17:85–89. available from: http://www.ajol.info/index.php/ecajs/article/view/76500 siddiqui g, lipka s, freedman l, et al. mucinous adenocarcinoma of the appendix presenting as intussusception in 27 year old female. j gastrointest oncol. 2012 [cited 20 october 2014 ];3:369-372. available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3492470/ soylu l, aydin o, aydin s, özcay n. invagination of the appendix due to endometrioses presenting as acute appendicitis. ulusal cer derg. 2014 [cited 2014 oct 2014 ];30:106–108. available from: http://www.ulusalcerrahidergisi.org pickhardt pj, kim, dh. ct colonography: principles and practice of virtual colonoscopy. philadelphia: saunders, 2009; p. 224–225. abstract introduction paediatric interventional radiology procedures vascular access biopsy drainage enteric access and intervention image-guided tumour therapy angiography and intervention catheter-directed thrombolysis vascular anomalies biliary interventions genitourinary interventions conclusions and the future of paediatric interventional radiology acknowledgements references about the author(s) gulraiz chaudry division of interventional radiology, boston children’s hospital, united states citation chaudry, g. paediatric interventional radiology. s afr j rad. 2016;20(1), a940. http://dx.doi.org/10.4102/sajr.v20i1.940 review article paediatric interventional radiology gulraiz chaudry received: 16 sept. 2015; accepted: 07 apr. 2016; published: 29 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract paediatric interventional radiology (ir) is a rapidly developing subspecialty, seeking to meet the increasing demand for image-guided minimally invasive procedures. the wide range of procedures performed and the conditions treated reflect the varying ages and complexity of the patient population. this article reviews the various interventional procedures performed and the unique challenges faced in paediatric ir. conditions, such as vascular anomalies, that are primarily treated by paediatric interventional radiologists are highlighted. the requirements for establishing a paediatric ir practice are reviewed, as are the challenges facing the future development of the specialty. introduction paediatric interventional radiology (ir) is a young but rapidly expanding subspecialty. the use of image guidance for performing some minimally invasive procedures was first suggested in the 1970s, but the range and complexity of procedures performed by paediatric interventionalists principally expanded in the 1980s and 1990s.1 the field was initially slow to develop due to limited training in performing image-guided procedures in children and the challenge of adapting equipment and techniques for use in small children.2 recently, however, the need for paediatric ir has been recognised at local and national levels, with increased funding and provision of training programs. the field has now developed beyond offering an alternative to more invasive surgical techniques by introducing new and innovative therapy that has transformed the treatment of many patients. paediatric interventional radiology procedures the range of procedures performed in paediatric institutions often reflect local or institutional practice and availability of interventionalists. box 1 summarises the types of procedures commonly performed by paediatric ir physicians, although the numbers of these procedures performed can vary significantly between institutions, particularly if traditionally performed by non-radiologists. box 1: paediatric interventional radiology procedures. vascular access sonographic guidance and interventional procedures have long been shown to offer the most reliable and safe method of central venous access.2 improvements in sonographic technology and types of machines available have resulted in increasing use of sonography for vascular access by non-radiologists, including vascular access teams and intensive care units. interventional radiologists, however, generally possess a greater level of expertise in catheter placement and management of complications, including management of venous stenosis (figure 1). active involvement of ir departments in interdisciplinary vascular access teams ensures that children receive the access (peripherally inserted central catheter [picc], central venous catheter, port-a-cath, etc.) that most appropriately addresses their clinical needs.2 figure 1: a 17-year-old male status post-bone marrow transplant requiring central intravenous access: (a) right-upper extremity venogram demonstrates occlusion of the right subclavian vein (arrow); (b) using a guidewire, the picc has been placed through a collateral vein into the superior vena cava. biopsy percutaneous image-guided needle biopsy is now the standard for solid organ biopsies in most institutions. the most commonly biopsied organs are the kidneys and liver, with the biopsies performed percutaneously under sonographic guidance. this technique has been demonstrated to be safe and effective with high diagnostic yield and very low complication rate.3 transjugular liver biopsies are not commonly performed as these can be particularly challenging in smaller children and often yield small and fragmented samples. image-guided needle biopsies of suspected tumours has also increased in recent years (figure 2). the vast majority of solid organ tumours can be biopsied with sonography alone, with ct and fluoroscopic guidance reserved for bone and lung tumours.2 the use of a coaxial technique allows multiple cores to be obtained through a single puncture and allows the tract to be embolised, reducing the risk of tumour seeding and haemorrhage.2,3, figure 2: a 16-year-old girl with new chest masses: (a) axial ct scan image demonstrates two masses in the right thoracic cavity; (b) sonographic-guided percutaneous needle biopsy of the posterior chest mass. (pathology confirmed eosinophilic pulmonary granulomatous disease). drainage percutaneous drainage of abdominal abscesses is the standard in children. early surgery in cases of perforated appendicitis with abscess formation is associated with increased morbidity due to haemorrhage, infection and adhesion formation. interventional techniques, including percutaneous and transrectal drainage of pelvic abscesses, significantly decrease the complication rates in these children (figure 3).4 aspiration and drainage of ascites and pleural effusions can be safely performed with sonographic guidance, even in the smallest infants. placement of pigtail drains into empyemas and lung abscesses is safe and effective and offers a minimally invasive alternative to video-assisted thoracoscopic surgery (vats), with similar success rates.5 figure 3: a 15-year-old male with perforated appendicitis: (a) axial ct scan demonstrates a collection posterior to the bladder (arrow); (b) transrectal ultrasound image shows needle puncture of the abscess. enteric access and intervention percutaneous image-guided retrograde or anterograde placement of gastrostomy and gastrojejunostomy tubes is now the standard in some large paediatric institutions, although there remains considerable local variability in practice. radiologic percutaneous gastrostomy tube placement is a safe and minimally invasive way of providing enteral nutrition in children of all sizes, including infants with significant coexisting morbidities such as cardiac disease.6 maintenance and exchange of gastrojejunostomy tubes are also commonly performed by interventional radiologists, as skills with guidewires and catheters greatly facilitate accurate positioning of post-pyloric feeding tubes. image-guided tumour therapy paediatric interventional oncology remains a small part of the paediatric ir practice when compared to adults. this is primarily due to the relative rarity of paediatric cancers, and the fact that standardised treatment protocols are determined by cooperative oncology groups. in addition, the extra protection afforded to children as a vulnerable population limits the introduction of new treatments and devices.7 standardised treatment regimens have increased the 5-year survival rate to over 80% in many solid tumours, but occasionally regional interventional tumour therapy is utilised to increase the effectiveness of existing treatment or for palliation.8 bland embolisation with coils, liquid agents or particles is occasionally required, such as in cases of rapidly involuting congenital haemangiomas of the liver, with cardiac decompensation resulting from arteriovenous shunting. intra-arterial chemotherapy and radioembolisation have also been used in a small percentage of cases of hepatoblastoma or hepatocellular carcinoma.8 the most common ablative procedure performed in children is radiofrequency ablation of osteoid osteoma. using fluoroscopy and/or ct, the nidus of the osteoid osteoma is accessed and a radiofrequency probe inserted to ablate the nidus (figure 4). this can often result in immediate improvement of the chronic pain experienced by these children. other ablative modalities, such as cryoablation, have also been more recently introduced to treat conditions such as desmoids and fibroadipose vascular anomalies. figure 4: a 14-year-old male with calf pain for 6 months: (a) axial ct scan shows a lesion in the posterior tibia consistent with osteoid osteoma; (b) ct-guided percutaneous radiofrequency ablation of the lesion. angiography and intervention improvements in non-invasive vascular imaging in recent years have resulted in decreased need for catheter angiography as a diagnostic tool. in our institution, like many others, arteriography is predominantly performed as a precursor to further interventions such as angioplasty and embolisation. the safety and efficacy of renal angioplasty has been established in children with refractory hypertension secondary to renal artery stenosis.9 non-operative management is the standard of care in children with blunt solid organ trauma. however, as with adults, transcatheter arterial embolisation can play a key role in the treatment of traumatic injuries when conservative observation has failed, providing effective control of haemorrhage with a low complication rate.10 catheter-directed thrombolysis catheter-directed thrombolysis (cdt) is considered to be the treatment of choice in children with extensive deep venous thrombosis.11 indications include paget–schroetter disease (thoracic outlet syndrome) (figure 5), may-thurner syndrome, iliofemoral and inferior vena cava (ivc) thrombosis. an ivc filter can also be placed in selective cases, followed by a combination of local thrombolysis through an infusion catheter and mechanical thrombectomy. a variety of devices can be used for the latter technique, including angiojet rheolytic system (possis medical, minneapolis, mn) or the trellis-8 (bacchus vascular, santa clara, ca) and arrow-trerotola devices (arrow international, reading, pa). figure 5: a 15-year-old boy with new onset left arm swelling: (a) left-upper extremity venogram shows occlusive thrombus in axillary and subclavian veins; (b) post-catheter-directed thrombolysis venogram demonstrates resolution of thrombus with focal area of stenosis at the level of the first rib (arrow), consistent with thoracic outlet syndrome. catheter-directed arterial thrombolysis is also indicated in a select group of patients, helping restore flow towards end organs and threatened limbs. vascular anomalies vascular anomalies can be broadly classified into tumours and malformations. tumours can spontaneously involute or respond to medical therapy. in contrast, malformations usually require invasive treatment. over the past 20 years, the treatment of vascular anomalies has been revolutionised by the use of interventional techniques, which now form the primary method of treatment in the majority of malformations.12 however, the care of these patients should be directed by an interdisciplinary team to ensure optimal treatment for individual patients. in our institution, all cases are directed through the vascular anomalies centre with physicians from 14 different specialties providing input if required. slow-flow (venous and lymphatic) malformations are predominantly treated with percutaneous sclerotherapy, with the choice of sclerosant determined by the type of malformation (figure 6). arteriovenous malformations are fast-flow anomalies consisting of a network of vessels forming a nidus, which connects arteries and veins without an intervening capillary network. these malformations can be technically challenging to treat, requiring a combination of arterial and venous intervention. transvenous embolisation of large dominant draining veins offers the best hope of a successful outcome.12 figure 6: a 4-year-old boy with chronic left cheek swelling: (a) axial t2 mri image shows a venous malformation in the left masseter muscle, with intralesional thrombi; (b) intralesional venogram via percutaneous access shows spongiform venous malformation, with late drainage via the facial vein (arrow); (c) post-procedure fluoroscopic image confirms intralesional injection of opacified sclerosant. combined vascular anomalies syndromes, such as klippel-trenaunay syndrome and cloves syndrome (congenital lipomatous overgrowth, vascular malformations, and epidermal nevi [and spinal and/or skeletal anomalies]), are sometimes associated with persistence of embryonic superficial veins, such as the lateral marginal vein (of servelle). these veins are typically incompetent and can become significantly enlarged over the course of childhood; in addition to pain, these are also associated with a significantly increased risk of thromboembolism. endovenous laser ablation of these veins in childhood can obliterate these, promoting the development of the deep venous system.13 bleeding or leaking lymphatic vesicles are also common in these children, which can be photoevaporated with co2 laser. biliary interventions biliary interventions in children are most commonly performed to manage complications of hepatic transplantation. less common indications include cholangitis, cholecystitis or traumatic biliary leaks. percutaneous transhepatic cholangiography is often the first step, with a peripheral duct accessed under sonographic guidance. this can be followed by angioplasty of ductal stenosis or internal–external biliary drainage (figure 7). gangrenous cholecystitis may necessitate transhepatic cholecystostomy drain placement. percutaneous biliary drainage can also be used to divert biliary flow and allow healing of a biliary leak.14 figure 7: an 18-year-old girl with hyper igm syndrome and periampullary pancreatic neuroendocrine tumour: (a) percutaneous transhepatic cholangiogram demonstrates stenosis of common hepatic and common bile ducts (arrow); (b) cholangioram following placement of internal-external biliary drain. genitourinary interventions in addition to renal biopsies, the most common genitourinary (gu) intervention is placement of percutaneous nephrostomy tubes. indications include posterior urethral valves, pyelo-ureteric junction obstruction, pyonephrosis and renal calculi. the procedures are predominantly performed under a combination of sonographic and fluoroscopic guidance. occasionally, the anterograde placement of ureteric stents is also required following nephrostomy tube placement.1 conclusions and the future of paediatric interventional radiology the future of paediatric ir appears to be bright. children’s hospitals are increasingly recognising the necessity of having appropriately trained paediatric interventional radiologists. the main challenges to the growth of the specialty are the availability of dedicated paediatric ir fellowships and standardisation of training. given the significant variability in local practice, trainees completing a fellowship can currently emerge with a strikingly different set of skills depending on the training hospital.15 in the future, it is likely that a specific set of skills will be mandated for all trainees completing fellowships, which may require elective time spent at other children’s hospitals or adult institutions. the key to creating a successful ir division lies in having the right number and mix of essential personnel. an ir team should include a radiation technologist (radiographer) with an understanding of optimal ways to reduce radiation in children, a paediatric nurse comfortable with administering sedation, a nurse practitioner and/or physician assistant and an anaesthesiologist comfortable with the particular demands of paediatric ir procedures. inadequate facilities, including sharing of rooms with other specialties, can often hinder the development of ir in a hospital; dedicated commitment by department and hospital administrators is therefore required. the experience at our institution and other children’s hospitals has been that once a safe and reliable service can be provided and relationships developed with other specialties, ir can become an integral part of any children’s hospital. acknowledgements competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references roebuck d. paediatric interventional radiology. pediatr radiol. 2009;39 suppl 3: 491–495. http://dx.doi.org/10.1007/s00247-009-1245-2 barnacle am. interventional radiology in infancy. early hum dev. 2014;90(11): 787–790. http://dx.doi.org/10.1016/j.earlhumdev.2014.08.017 govender p, jonas mm, alomari ai, et al. sonography-guided percutaneous liver biopsies in children. ajr am j roentgenol. 2013;201(3):645–650. http://dx.doi.org/10.2214/ajr.12.9802 brown c, kang l, kim st. percutaneous drainage of abdominal and pelvic abscesses in children. semin intervent radiol. 2012;29(4):286–294. http://dx.doi.org/10.1055/s-0032-1330062 hogan mj, coley bd. interventional radiology treatment of empyema and lung abscesses. paediatr respir rev. 2008;9(2):77–84; quiz 84. http://dx.doi.org/10.1016/j.prrv.2007.12.001 sy k, dipchand a, atenafu e, et al. safety and effectiveness of radiologic percutaneous gastrostomy and gastro jejunostomy in children with cardiac disease. ajr am j roentgenol. 2008;191(4):1169–1174. http://dx.doi.org/10.2214/ajr.07.3655 hoffer fa. interventional oncology: the future. pediatr radiol. 2011;41 suppl 1: s201–6. http://dx.doi.org/10.1007/s00247-011-1990-x roebuck dj. paediatric interventional oncology. canc imag. 2010;10(1a):s27–34. http://dx.doi.org/10.1102/1470-7330.2010.9089 kari ja, roebuck dj, mclaren ca, et al. angioplasty for renovascular hypertension in 78 children. arch dis child. 2015;100(5):474–478. http://dx.doi.org/10.1136/archdischild-2013-305886 vo nj, althoen m, hippe ds, prabhu sj, valji k, padia sa. pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. j vasc interv radiol. 2014;25(2):215–220. http://dx.doi.org/10.1016/j.jvir.2013.09.014 kukreja k, vaidya s. venous interventions in children. tech vasc interv radiol. 2011;14(1):16–21. http://dx.doi.org/10.1053/j.tvir.2010.07.005 alomari a, dubois j. interventional management of vascular malformations. tech vasc interv radiol. 2011;14(1):22–31. http://dx.doi.org/10.1053/j.tvir.2010.07.006 king k, landrigan-ossar m, clemens r, chaudry g, alomari ai. the use of endovenous laser treatment in toddlers. j vasc interv radiol. 2013;24(6): 855–858. http://dx.doi.org/10.1016/j.jvir.2012.12.023 racadio jm, kukreja k. pediatric biliary interventions. tech vasc interv radiol. 2010;13(4):244–249. http://dx.doi.org/10.1053/j.tvir.2010.04.007 lord dj. the practice of pediatric interventional radiology. tech vasc interv radiol. 2011;14(1):2–7. http://dx.doi.org/10.1053/j.tvir.2010.07.002 radiology 32 sa journal of radiology • february 2005 introduction a small percentage of patients who suffer a global cerebral hypoxic/ ischaemic injury develop reversal of the normal density relationship of grey and white matter on ct scans.1,2 the neuroradiology texts are confusing in their description of the ct appearance of the ‘reversal sign’3,4 which is a feature related to severe hypoxia (birth asphyxia, cardiopulmonary arrest), trauma (child abuse) and infection.1,2,5 we present two paediatric cases with this type of injury, one of which demonstrates the ‘white cerebellum sign’ and the other the true ‘reversal sign’, in order to demonstrate the imaging differences. case reports case 1 a ct scan was performed on a 4year-old child who presented with acute convulsions and herpetic ulcers with an associated metabolic acidosis. the scan showed global hypodensity of the supratentorial parenchyma with effacement of the grey-white interface and of the central and peripheral cerebrospinal fluid (csf) spaces (fig. 1). the density of the cerebellum and other infratentorial structures is preserved and shows a relatively hyperdense appearance that contrasts with the supratentorial structures. this is an example of the ‘white cerebellum sign’. case 2 in contrast, the ct scan in the second case, a young patient with streptococcal meningitis, shows hypodensity of the peripheral cortex with sparing of the central white matter, grey matter nuclei and posterior fossa structures, and reversal of the greywhite difference (gwd) (figs 2a, b). this is consistent with cortical laminar necrosis, which later resulted in the linear calcification of the cortex seen on a long-term follow-up ct scan (fig. 3). discussion the pathogenesis of the reversal sign is not well understood.2 several factors may play a role. mechanical factors 1. preservation of central areas of the brain has been demonstrated in animal experiments. transtentorial herniation during the acute stage of oedema relieves the pressure on the expanding cerebral mass as brain is herniated through the incisura. perfusion improves centrally and prevents necrosis.2,5 metabolic factors 1. anoxia and ischaemia elevate brain glucose. this hyperglycaemic state preferentially damages the cortex and basal ganglia.2,5 2. hypoxia limits atp production and disrupts the sodium pump. the influx of water and sodium into cells causes cytotoxic oedema. later, the water content rises in the extracellular and intracellular spaces (vasogenic oedema). low density changes appear in the areas most vulnerable to hypoperfusion.5 case report hypoxic-ischaemic injury — the ‘white cerebellum sign’ versus the true ‘reversal sign’ s moosa mb chb mphil, bsc (hons) pharm department of radiology groote schuur hospital and university of cape town s andronikou mb bch, fcrad (diag), frcr (lond) department of paediatric radiology red cross children’s hospital and university of cape town fig. 1. white cerebellum sign. there is global hypodensity of the supratentorial brain with relative hyperdensity of the infratentorial compartment. there is also obliteration of the surface and central csf spaces in keeping with the severe oedema. radiology 2/24/05 4:50 pm page 32 case report 33 sa journal of radiology • february 2005 metabolic demand 1. the basal ganglia and cortex have high metabolic activity, and are vulnerable to tissue hypoxia and hypoperfusion. cortex and basal ganglia density decrease with loss of normal gwd. sometime the grey density loss is so great that normal contrast is reversed, i.e. the reversal sign.5 haemodynamic changes 1. increased density of white-matter is caused by distended medullary veins and central venous congestion, contrasting with the peripheral cortical oedema.1,2,5 during hypoxia, hypoperfusion and oedema, thrombi are formed in these veins. when perfusion is established again, the outflow is obstructed and these veins become distended.5 the reversal sign is associated with a poor prognosis.1,2,5 one-third of patients demonstrating this sign on ct scans will die. the remainder suffer severe permanent brain damage, later developing diffuse atrophy and cystic encephalomalacia.2,5 it is therefore very important to recognise the features described above for diagnostic, therapeutic and prognostic purposes. references 1. bird cr, drayer bp, gilles fh. pathophysiology of ‘reverse’ edema in global cerebral ischemia. am j neuroradiol 1989; 10: 95-98. 2. han bk, towbin rb, de courten-meyers g, mclaurin rl, ball ws jun. the reversal sign: effect of anoxic/ischemic cerebral injury in children. am j neuroradiol 1989; 10: 1191-1198. 3. barkovich aj. brain and spine injuries. in: barkovich aj, ed. pediatric neuroradiology. 3rd ed. pennsylvania: lippincott williams and wilkins, 2000. 4. osborne go. craniocerebral trauma. in: osborne go, ed. diagnostic neuroradiology. st louis, missouri: mosby, 1994. 5. vergote g, vandeperre h, de man r. the reversal sign. neuroradiology 1992; 34: 215-216. fig. 2a and b. reversal sign. there is central hyperdensity compared with the peripheral cortex, involving the thalami and central white matter, as well as in the infratentorial structures. fig. 3. the long-term follow-up ct in patient 2 demonstrates severe cortical and white matter losses, as well as peripheral cortical linear calcification in keeping with cortical laminar necrosis. radiology 2/24/05 4:50 pm page 33 article information authors: abraham fourie bezuidenhout1 jared m. lipsitz1 anne-marie du plessis1 affiliations: 1department of diagnostic radiology, stellenbosch university, south africa correspondence to: fourie bezuidenhout postal address: po box 19179, tygerberg 7505, south africa dates: received: 05 mar. 2014 accepted: 02 sept. 2014 published: 17 nov. 2014 how to cite this article: bezuidenhout, af, lipsitz, jm, du plessis, a. intramedullary spinal masses: a pictorial essay. s afr j rad. 2014;18(1); art. #602, 7 pages. http://dx.doi.org/10.4102/ sajr.v18i1.602 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. intramedullary spinal masses: a pictorial essay in this pictorial essay... open access • abstract • introduction • glial neoplasms    • ependymoma    • astrocytoma • mixed neuronal/ glial neoplasm    • ganglioglioma • non-glial neoplasm: vascular neoplasms    • haemangioblastoma    • paraganglioma • rare non-glial neoplasm    • lymphoma    • metastasis    • solitary fibrous tumour    • primitive neuroectodermal tumour    • atypical teratoid/rhabdoid tumour • benign neoplasms    • epidermoid    • lipoma • infective masses    • abscess    • tuberculous granuloma    • hydatid disease • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ this pictorial essay provides a classification system for the most common intramedullary spinal masses and describes distinguishing imaging features that will aid the radiologist in providing a relevant differential diagnosis to guide further management. introduction top ↑ the clinical symptoms of intramedullary spinal masses, such as back pain, radiculopathy and myelopathy, are nonspecific; therefore responsibility falls on the radiologist to provide a relevant differential diagnosis. the imaging gold standard for the evaluation of intramedullary masses is magnetic resonance imaging (mri). on mri, almost all intramedullary neoplasms expand the spinal cord, with variable post-contrast enhancement; absence of a combination of these features should suggest a non-neoplastic aetiology.1 further associated imaging findings include spinal canal remodeling, syrinx formation, and tumoural and non-tumoural cysts.2 the most common differential diagnoses to be considered for intramedullary masses are malignant neoplasms (glial and non-glial tumours), benign neoplasms and, considering the large hiv-positive population, infective aetiologies. spinal cord ependymomas are the most common intramedullary neoplasms in adults, and astrocytomas in children; combined, they constitute 70% of intramedullary neoplasms.1the aforementioned neoplasms, together with gangliogliomas, comprise the most common intramedullary spinal glial tumours. non-glial neoplasms include vascular tumours such as haemangioblastomas and paragangliomas, and less common neoplasms such as lymphoma, primitive neuroectodermal tumours (pnets), solitary fibrous tumours and metastases. benign neoplasms include epidermoids and lipomas (table 1).3,4 table 1: intramedullary masses. glial neoplasms top ↑ ependymoma ependymomas are the most common intramedullary spinal neoplasms in adults.5 most of these are low-grade neoplasms (i.e. world health organization [who] classification grade i or grade ii). histologically, the cellular subtype is classic and the most common (figure 1).1 as these neoplasms arise from the ependymal cells lining the central canal, they are located centrally in the spinal cord, grow concentrically outward, are well circumscribed and demonstrate intense homogenous post-contrast enhancement. cystic degeneration is seen in 50% of cases and haemorrhage is common at the superior and inferior margins; this causes the so-called haemosiderin ‘cap sign’ identified as hypointensity on t2-weighted images (t2wi) seen in about 20%–33% of cases.1,5 figure 1: intramedullary ependymoma in a 41-year-old man. (a) sagittal t2-weighted image demonstrates a heterogeneous, well-circumscribed mass (white arrow) with extensive syrinx formation (yellow arrows); (b) contrast-enhanced t1-weighted image demonstrates intense contrast enhancement of the tumour (blue arrow). six histological subtypes are recognised; of note is the myxopapillary subtype which has a predilection for the conus medullaris and filum terminale, and represents the most common conus neoplasm. these neoplasms occur predominantly in young men and may occasionally demonstrate high signal intensity on both t1wi and t2wi, a finding that reflects mucin content or haemorrhage.1 however, the imaging findings are generally non-specific and the conus medullaris location should be suggestive of the diagnosis (figure 2). figure 2: intramedullary myxopapillary ependymoma in a 15-year-old boy. sagittal t2-weighted (a) and axial contrast-enhanced t1-weighted; (b) images demonstrate a well-circumscribed mass (white arrow in 2a) in the conus with cystic degeneration (blue arrow in 2a), with an exophytic growth pattern and avid enhancement of the solid components of the mass (yellow arrows in 2b). astrocytoma astrocytomas arise from astrocytic glial cells and are the most common intramedullary tumours in children.2 these are usually low-grade neoplasms, with less than 2% being glioblastomas (figure 3).5 figure 3: a rare case of intramedullary conus medullaris glioblastoma multiforme in a 37-year-old woman. sagittal t1-weighted image (a) demonstrates isointense, irregular expansion of the conus medullaris (white arrows). sagittal t2-weighted image (b) reveals abnormal hyperintensity throughout the expanded region (yellow arrows) and an associated tumoural cyst (red arrow). contrast-enhanced sagittal t1-weighted image (c) displays irregular, intense enhancement of the glioblastoma multiforme (blue arrows). unlike their intracranial counterparts, spinal astrocytomas often demonstrate patchy post-contrast enhancement. they are usually eccentrically located within the cord and ill-defined owing to their infiltrative growth pattern. as cerebrospinal fluid (csf) dissemination may occur, imaging of the entire neuraxis is recommended.2 diffusor tensor imaging (fiber tractography) has been used to differentiate ependymomas, which displace rather than infiltrate white-matter tracts, from astrocytomas that disrupt the descending fibres (figure 4).5,6 it is very difficult to distinguish ependymomas from astrocytomas on imaging, but table 2 provides some detail that might help to simplify the process. figure 4: intramedullary ependymoma of the spinal cord. sagittal t2-weighted image (a) demonstrates a bulky mass (white arrow) expanding the spinal cord at the level of t1–t3 with oedema (yellow arrows) and patchy enhancement (blue arrow in [b]) on the contrast-enhanced sagittal t1-weighted image; (b) fibre tractography clearly shows displacement of the fibre tracts concentrically outward at the level of the tumour; (c) suggesting an ependymoma arising from the ependymal cells of the central canal. table 2: spinal cord ependymoma vs astrocytoma. mixed neuronal/ glial neoplasm top ↑ ganglioglioma gangliogliomas are low-grade neoplasms that occur in people at an average age of 19 years, and represent a mixture of neuronal elements (ganglion cells) and glial elements (primarily neoplastic astrocytes).1 a study by patel et al. found that 84% of gangliogliomas had mixed signal intensity on t1wi (which is a unique finding for spinal neoplasms) and speculated that this was because of the dual cellular population.7 these neoplasms may involve long segments of the cord (commonly extending more than eight vertebral body segments), contain calcifications and often have very little surrounding oedema.8 non-glial neoplasm: vascular neoplasms top ↑ haemangioblastoma most cord haemangioblastomas (80%) are solitary with multiple lesions indicative of von hippel–lindau syndrome (figure 5a).1 these neoplasms are capillary-rich nodular masses abutting the leptomeninges, with prominent dilated and tortuous vessels on the cord surface (figure 6). their appearance may reflect the classic cystic lesion with an enhancing mural nodule, commonly seen in their intracranial counterparts (figure 5b). syrinx and spinal cord oedema are characteristic findings even in small tumours.8 imaging of the entire neuraxis is recommended for patients with a positive family history of von hippel–lindau syndrome. paraganglioma paragangliomas are neuroendocrine neoplasms arising from paraganglia. paraganglia are accessory organs of the peripheral nervous system.1 they are encapsulated, highly vascular neoplasms with a predilection for the conus medullaris, cauda equina and filum terminale.8 haemorrhage produces the ’cap sign’, and intratumoural vessels with flow voids are common features of this tumour. occasionally the characteristic ‘salt-and-pepper’ appearance, similar to neck and skull base paragangliomas, may be seen. figure 5: multiple cord haemangioblastoma in a 27-year-old man with von hippel lindau syndrome. the contrast-enhanced sagittal t1-weighted image (a) demonstrates multiple enhancing nodules along the cord (white arrows) with associated cystic components (yellow arrows). the contrast-enhanced axial t1-weighted image (b) demonstrates the classic cystic lesion (yellow arrow) with an enhancing mural nodule (white arrow), commonly seen with cns haemangioblastomas. figure 6: intramedullary haemangioblastoma in a 24-year-old woman. the sagittal t2-weighted image (a) demonstrates heterogeneous cord expansion (white arrows), syrinx formation (yellow arrows) and prominent flow voids (blue arrows). the contrast-enhanced sagittal t1-weighted image (b) demonstrates a well-circumscribed, intensely enhancing mass (red arrow), syrinx formation and prominent flow voids (blue arrow). rare non-glial neoplasm top ↑ lymphoma primary intramedullary lymphomas are rare, comprising 3.3% of central nervous system (cns) lymphomas.9 there are only a handful of reports on the mri findings of intramedullary lymphomas that describe high signal intensity on t2wi in contrast to the low signal intensity found in intracranial lesions and non-specific post-contrast enhancement (figure 7).1 figure 7: lymphoma of the conus medullaris in a 52-year-old man. sagittal t2-weighted image (a) reveals a hyperintense mass (white arrow) in the conus medullaris with an exophytic growth pattern. syrinx formation (blue arrow) is also seen. contrast-enhanced sagittal t1-weighted image (b) demonstrates a well-circumscribed homogenously enhancing mass (yellow arrow) in the conus medullaris. metastasis intramedullary metastases are rare and most commonly secondary to bronchus and breast carcinoma (figure 8).1 cerebellar medulloblastoma has also been known to cause intramedullary metastasis.1 spread may either be haematogenous or from the leptomeninges. intramedullary metastases show avid post-contrast enhancement and profuse oedema which is often disproportionately extensive compared with the size of the lesion.8 associated cysts are rare, compared with primary neoplasms. as cord expansion may be mild, differentiating intramedullary metastasis from demyelinating conditions can be difficult. figure 8: intramedullary conus medullaris metastasis from a primary bronchus carcinoma in a 56-year-old man. sagittal t1-weighted image (a) demonstrates irregular expansion of the conus medullaris (white arrow) with a focus of hyperintensity posteriorly (yellow arrow). sagittal t2-weighted image (b) reveals abnormal hyperintensity throughout the expanded region (red arrows) with associated heterogenous hypointense areas (blue arrows). cord oedema is also seen extending superiorly (white arrowhead). contrast-enhanced sagittal t1-weighted image (c) displays patchy but intense enhancement (black arrow). solitary fibrous tumour solitary fibrous tumours (sfts) are uncommon spindle-cell neoplasms that typically arise in the pleural cavity. the first cns sft was described in 1996 and has received great attention since then.10 these tumours typically occur in adults and are usually well-circumscribed and show homogenous enhancement post contrast. until this point, we have not dwelled on signal characteristics of the described conditions, as most spinal cord neoplasms are hypoto isointense on t1wi and hyperintense on t2wi, offering no assistance in differentiating individual intramedullary neoplasms. sfts, however, demonstrate hypointense signal on t2wi, clearly defining this from other intramedullary neoplasms (figure 9). this unique imaging appearance is caused by the hypocellularity of, and abundant collagen stroma within this tumour.11 figure 9: intramedullary solitary fibrous tumour in a 38-year-old woman. sagittal t2-weighted image (a) reveals the characteristic t2 hypointense mass (white arrow) in the thoracic cord. contrast-enhanced axial t1-weighted image (b) demonstrates homogenous contrast enhancement (yellow arrow). primitive neuroectodermal tumour intramedullary primitive neuroectodermal tumour (pnet) is a rare, aggressive embryonal tumour and is more commonly seen secondary to metastatic spread through the csf from an intracranial primary tumour. intramedullary pnet is slightly more common in young adults than in children.2 mri findings are non-specific including t1 hypointensity, t2 hyperintensity and avid post-contrast enhancement. atypical teratoid/rhabdoid tumour atypical teratoid/rhabdoid tumour (atrt) is a rare intramedullary tumour that mainly occurs in children less than 2 years old, and shares mri characteristics with pnets.2 benign neoplasms top ↑ epidermoid intramedullary epidermoids are ectodermal inclusion neoplasms that result from anomalous implantation during neural tube closure.12 progressive desquamation of keratin from the epithelial lining into the interior of the neoplasm produces a cystic lesion that follows csf intensity on t1and t2-weighted sequences but demonstrates characteristic ‘dirty’ or heterogenous hyperintense fluid-attenuated inversion recovery (flair) signal and restricted diffusion on diffusion-weighted imaging, which aids in differentiating this neoplasm from others.13 lipoma intramedullary lipomas consist of normal fat. the pathophysiology of these lesions is poorly understood. they usually occur along the dorsal midline of the spinal cord but rarely infiltrate the cord.14 they follow fat signal on all sequences and suppress on fat-supression sequences. infective masses top ↑ abscess intramedullary suppuration of the spinal cord is rare. diagnosis of an intramedullary abscess should be considered in cases of acute neurological deterioration referable to spinal cord fall-out. csf analysis plays an important role in differentiating between neoplastic and infective masses on initial imaging.8 chronological mri changes in intramedullary abscesses are similar to those in the brain. in the early stages of infectious myelitis, mri demonstrates hyperintensity on t2wi with poorly defined enhancement on post-contrast t1wi; ultimately the mass becomes less diffusely hyperintense on t2wi, with more clearly defined marginal post-contrast enhancement.15 tuberculous granuloma tuberculous granuloma (tuberculoma) needs special mention owing to its characteristic caseating solid centre demonstrating hypoto isointense signal on both t1and t2wi with post-contrast rim enhancement (figure 10).16 figure 10: intramedullary tuberculoma in an 18-year-old woman. sagittal t2-weighted (a), sagittal t1-weighted (b) and sagittal contrast-enhanced t1-weighted (c) images demonstrate a t2 hypointense (white arrow) and t1 isointense (yellow arrow) intramedullary mass with rim enhancement post contrast administration (red arrow). there is extensive surrounding cord oedema on the t2-weighted image (blue arrows) (a). table 3: specific magnetic resonance imaging (mri) characteristics of intramedullary masses. hydatid disease although intramedullary hydatid disease is extremely rare, owing to its endemicity, it should be considered in the differential of a cystic intramedullary mass. spinal cord hydatid disease follows csf signal intensity on all sequences but differs from its intracranial counterparts in that it does not demonstrate rim enhancement post contrast and rarely calcifies (figure 11).17 figure 11: rare case of an intramedullary conus medullaris echinococcus cyst in a 3-year-old girl. sagittal t1-weighted (a) and coronal t2-weighted (b) images demonstrate an intamedullary cystic lesion (white arrows) that follows csf signal intensity on all sequences and did not show post-contrast enhancement. associated finding of a hepatic hydatid cyst (red arrow). acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions a.f.b. (stellenbosch university), j.m.l. (stellenbosch university) and a-m.d.p. (stellenbosch university) contributed equally to the writing of this article. references top ↑ 1.koeller kk, rosenblum rs, morrison al. neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation. radiographics. 2000;20(6):1721–1749. http://dx.doi.org/10.1148/radiographics.20.6.g00nv151721 2.smith ab, soderlund ka, rushing ej, smirniotopolous jg. radiologic-pathologic correlation of pediatric and adolescent spinal neoplasms: part 1, intramedullary spinal neoplasms. am j roentgenol. 2012;198(1):34-43. http://dx.doi.org/10.2214/ajr.10.7311 3.louis dn, ohgaki h, wiestler od, et al. the 2007 who classification of tumors of the central nervous system. acta neuropathol. 2007;114(2):97–109. http://dx.doi.org/10.1007/s00401-007-0243-4 4.dähnert wf. radiology review manual. alphen aan den rijn: wolters kluwer; 2007. 5.yousem dm, grossman ri. neuroradiology, the requisites. maryland heights: mosby; 2010. 6.thurnher mm, law m. diffusion-weighted imaging, diffusion-tensor imaging, and fiber tractography of the spinal cord. magn reson imaging clin n am. 2009;17(2):225–244. http://dx.doi.org/10.1016/j.mric.2009.02.004 7.patel u, pinto rs, miller dc, et al. mr of spinal cord ganglioglioma. am j neuroradiol. 1998;19:879–887. 8.abul-kasim k, thurnher mm, mckeever p, sundgren pc. intradural spinal tumors: current classification and mri features. neuroradiology. 2008;50(4):301–314. http://dx.doi.org/10.1007/s00234-007-0345-7 9.koeller kk, smirniotopoulos jg, jones rv. primary central nervous system lymphoma: radiologic-pathologic correlation. radiographics. 1997;17:1497–1526 http://dx.doi.org/10.1148/radiographics.17.6.9397461 10.metellus p, bouvier c, guyotat j, et al. solitary fibrous tumors of the central nervous system: clinicopathological and therapeutic considerations of 18 cases. neurosurgery. 2007;60(4):715–722. http://dx.doi.org/10.1227/01.neu.0000255418.93678.ad 11.kawamura m, izawa k, hosono n, hirano h. solitary fibrous tumor of the spinal cord: case report and review of the literature. neurosurgery. 2004;55(2):433. http://dx.doi.org/10.1227/01.neu.0000130037.45768.84 12.gonzalvo a, hall n, mcmahon jh, fabinyi gc. intramedullary spinal epidermoid cyst of the upper thoracic region. j clin neurosci. 2009;16(1):142–144. http://dx.doi.org/10.1016/j.jocn.2008.04.017 13.chen s, ikawa f, kurisu k, et al. quantitative mr evaluation of intracranial epidermoid tumors by fast fluid-attenuated inversion recovery imaging and echo-planar diffusion-weighted imaging. am j neuroradiol. 2001;22(6):1089–1096. 14.wood bp, harwood-nash dc, berger p, goske n. intradural spinal lipoma of the cervical cord. am j roentgenol. 1985;145(1):174–176. http://dx.doi.org/10.2214/ajr.145.1.174 15.iwasaki m, yano s, aoyama t, hida k, iwasaki y. acute onset intramedullary spinal cord abscess with spinal artery occlusion: a case report and review. eur spine j. 2011;20(suppl 2):294–301. 16.burrill j, williams cj, bain g, conder g, hine al, misra rr. tuberculosis: a radiologic review. radiographics. 2007;27(5):1255–1273. http://dx.doi.org/10.1148/rg.275065176 17.polat p, kantarci m, alper f, suma s, koruyucu mb, okur a. hydatid disease from head to toe. radiographics. 2003;23(2):475–494. http://dx.doi.org/10.1148/rg.232025704 article information authors: andrew j. van den heever1 affiliations: 1tuft and partners incorporated radiologists, cape town, south africa correspondence to: andrew van den heever email: andrew.vdh@tuft.co.za postal address: po box 461, plumstead 7801, south africa dates: received: 09 jun. 2014 accepted: 10 nov. 2014 published: [to be released] how to cite this article: van den heever, aj. macrodystrophia lipomatosa. s afr j rad. 2014;18(2); art. #667, 4 pages. http://dx.doi.org/10.4102/sajr.v18i2.667 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. macrodystrophia lipomatosa in this case report... open access • abstract • introduction • case presentation • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ macrodystrophia lipomatosa (mdl) is a rare congenital, but non-hereditary, form of localised gigantism of the fingers or toes. the hallmark of the condition is hypertrophy of all mesenchymal elements in the involved region, with a predominance of fibro-adipose tissue. a clinically subtle case of mdl is presented. introduction top ↑ a clinically subtle case of macrodystrophia lipomatosa (mdl) of the left hand is presented, with emphasis on the characteristic magnetic resonance imaging (mri) features of the condition that assisted in the radiological diagnosis. case presentation top ↑ a 16-year-old girl presented with a swollen, erythematous and warm left hand of long-standing duration (figure 1). the initial clinical suspicion included cellulitis or a retained foreign body. there was no trophic skin change, and the neuromuscular examination of the limb was normal. figure 1: photograph of the left hand. subtle hypertrophy of the third digit. following a plain radiograph of the left hand (figure 2), an ultrasound scan was requested; a diagnosis of mdl was suggested, based on the findings of excessive fatty and vascular elements within a region of relative hypertrophy matching that of the median nerve sclerotome (figure 3). figure 2: plain radiograph of the left hand. note hypertrophied soft tissues around the second and third digits and elongation of the third digit. figure 3: ultrasound of the left hand shows (a) increased diameter of the radial artery, but no vascular malformation, and (b) linear increased reflectivity of the thenar, interossei and lumbrical muscles consistent with fatty infiltration. note: this differs from denervation change where the muscle bulk is decreased. magnetic resonance imaging (mri) confirmed the diagnosis and excluded vascular or lymphatic malformation. the patient was scanned with both hands and wrists together (palms facing) to demonstrate the asymmetrical fatty and vascular hypertrophy (figures 4–7.) figure 4: axial t1-weighted fast spin echo (fse) images demonstrate increased subcutaneous and intramuscular fat (white arrows) with numerous prominent vascular structures throughout the subcutaneous tissues (red arrows). figure 5: t1 fse coronal image of the left hand (a) and pd fat-saturated coronal image (b) prominent subcutaneous and intramuscular fat (arrows). figure 6: comparative coronal t1 fse images of the right and left hands (acquired in a single volume). the increased subcutaneous fat (white arrows) and intramuscular fat (red arrows) as well as the hemihypertrophy of all of the mesenchymal elements in the left hand are easily appreciated when compared with the unaffected right hand. figure 7: comparative axial t1 fse images of the right and left hands (acquired in a single volume). the increased subcutaneous fat (white arrows) and intramuscular fat (red arrows) as well as the hemihypertrophy of all of the mesenchymal elements in the left hand are easily appreciated when compared with the unaffected right hand. discussion top ↑ mdl is a rare congenital, but non-hereditary, form of localised gigantism of the fingers or toes with progressive proliferation of all mesenchymal elements in the distribution of a sclerotome and a disproportionate increase in fibro-adipose tissue.1,2,3 it can involve both the upper extremities (usually in the distribution of the median nerve with the index and middle fingers most commonly involved) and the lower extremities (usually in the distribution of the medial plantar nerve).4 mdl is mostly unilateral, with lower limb involvement more common. accelerated soft-tissue and osseous growth in the involved region is self-limiting and usually terminates at puberty.5 mdl may be associated with syndactyly, polydactyly, brachydactyly or clinodactyly.4 the hallmark of mdl is hypertrophy of all mesenchymal elements in the involved region, with a predominance of fatty tissue. fibro-adipose tissue is produced in association with localised hyperplastic vascular and lymphatic elements.6 the pathologic findings are infiltration and hypertrophy of adipose tissue in subcutaneous tissue, nerve sheaths and periosteum.5 proposed aetiologies include disturbed foetal circulation, trophic influence of a tumified nerve, in utero disturbance of growth-limiting factor, or an error in segmentation.7 the differential diagnoses include neurofibromatosis type 1, vascular malformation, fibrolipomatous hamartoma of the median nerve, klippel-trenaunay-weber syndrome and hemihypertrophy (proteus and beckwith-wiedemann syndromes).8 treatment goals are to (1) maintain nerve and joint function by minimising local tissue trauma; and (2) improve cosmesis. surgical management includes inter alia debulking, epiphyseodesis and osteotomy. plain radiographs usually demonstrate the osseous overgrowth in the involved digits. however, in cases such as the present, where the hypertrophy is not marked, it may be overlooked. this case also demonstrates how the fatty overgrowth typical in mdl may be confusing on ultrasound examination. the diffuse fatty hypertrophy in the subcutaneous tissues and within the intrinsic musculature all appears diffusely echogenic, which results in a loss of soft-tissue detail and a decrease in the extent of grey-scale difference (reflectivity) between soft-tissue structures. the key to making the diagnosis on ultrasound is recognising the abnormal tissue echogenicity consistent with increased fat. mri is the investigation of choice owing to its superior soft-tissue contrast and its ability to characterise soft tissue, particularly fat. the contrast between fat and muscle allows effective visualisation of fatty infiltration of muscle; this can be confirmed with fat suppression techniques. increased vascularity is also clearly visualised as vascular flow-voids or by performing mr angiography. conclusion top ↑ mdl is a rare congenital form of localised gigantism. in cases such as the present, where the hypertrophy of involved tissues is not marked, the condition may be missed or incorrectly diagnosed. in such cases, mri is the investigation of choice owing to its ability to differentiate and characterise soft-tissue structures. ultrasound is useful in excluding conditions included in the clinical differential diagnosis, but may be misleading owing to the uniform echogenicity of structures infiltrated by fat. acknowledgements top ↑ competing interests the author declares that they he has no financial or personal relationships that he might have inappropriately influenced him in writing this article. references top ↑ singla v, virmani v, tuli p, singh p, khandelwal n. case report: macrodystrophia lipomatosa – illustration of two cases. indian j radiol imaging. 2008; 18(4): 298–301. http://dx.doi.org/10.4103/0971-3026.43844 suleman fe, kisansa m. imaging of a rare disorder: macrodystrophia lipomatosa. s afr j rad. 2010; 14(2): 39–42. aga p, parashari uc, parihar a, et al. macrodystrophia lipomatosa – mr imaging of a rare congenital anomaly: review of 3 cases. s afr j rad. 2010; 14(4): 105–107. khan ra, wahab s, ahmad i, chana rs. macrodystrophia lipomatosa: four case reports. ital j pediatr. 2010; 36:69. http://dx.doi.org/10.1186/1824-7288-36-69 mannan r, et al. cyto-radiological diagnosis of macrodystrophia lipomatosa: a report of rare entity with review of literature. int j med health sci. 2013; 2(4): 469–471. murphey md, carroll jf, flemming dj et al. from the archives of the afip: benign musculoskeletal lipomatous lesions. radiographics 2004; 24(5): 1433–1466. blacksin m, barnes fj, lyons mm. mr diagnosis of macrodystrophia lipomatosa. ajr am j roentgenol 1992; 158(6): 1295–1297. rohilla s, jain n, sharma r, dhaulakhandi db. macrodystrophia lipomatosa involving multiple nerves. j orthop traumatol. 2012; 13(1): 41–45. http://dx.doi.org/10.1007/s10195-011-0159-6 abstract introduction case 1 case 2 case 3 case 4 pericardial cmr imaging pulse sequences acknowledgements references about the author(s) miranda durand clinical unit, grey’s hospital, university of kwazulu-natal, south africa citation durand m. cardiovascular mri of the pericardium: a case review of the anatomy, scan protocols and pathology of the pericardium. s afr j rad. 2016;20(2), a1022. http://dx.doi.org/10.4102/sajr.v20i2.1022 case series cardiovascular mri of the pericardium: a case review of the anatomy, scan protocols and pathology of the pericardium miranda durand received: 02 may 2016; accepted: 08 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the aim of this article was to present a case based review of the anatomy, scan protocols and pathology of the pericardium. cardiovascular magnetic resonance imaging provides excellent anatomic depiction of the pericardium, vital information on myocardial infiltration and characterisation of mass lesions and pericardial effusions. it adds valuable information in the assessment of complicated pericardial disease. introduction cardiovascular magnetic resonance imaging (cmr) is emerging as an important modality for the assessment of pericardial disease. it has the advantage of providing excellent anatomic depiction of the pericardium; cine images provide vital information on local myocardium infiltration; and the different mri sequence options help to characterise mass lesions and pericardial effusions. the aim of this article is to use clinical cases as a basis from which to review and discuss the anatomy, scan protocols and pathology of the pericardium. case 1 a 19-year-old man with a repaired left bochdalek congenital diaphragmatic hernia, subsequently presented with right atrial and ventricular enlargement on echocardiography secondary to left pulmonary artery hypoplasia. the patient was sent for cmr to assess right ventricular function and size; the scan also demonstrated an incidental absent pericardium. the axial cine steady-state free precession (ssfp) images demonstrated the left upper lobe of the lung herniating into the potential space between the aorta and the main pulmonary artery (figure 1a). in this region, the pericardium is normally seen as a bridge between the aorta and the main pulmonary artery (figure 1b). in cases of absent pericardium, the heart is also often more horizontally orientated and displaced to the left (figure 2a). at the level of the atrioventricular groove, the pericardium that is normally seen as a thin line lateral to the right coronary artery (figure 2b), is absent in this patient (figure 2a). figure 1: a 19-year-old man with absent pericardium. the axial ssfp image (a) demonstrates left lung (*) herniating into the space between the aorta (ao) and main pulmonary artery (pa). normally (b) the pericardium is seen as a thin grey line (white arrow) bridging the space between the aorta (ao) and pulmonary artery (pa). diagnosis: absent pericardium the pericardium can be partially or completely absent. partially absent pericardium is more common than a complete absence. it is more common for the left pericardium to be absent in the setting of partial absent pericardium than the right. approximately a third of all absent pericardium is associated with other disorders such as tetralogy of fallot, patent ductus arteriosus and atrial septal defects.1 pericardium anatomy the pericardium is a flask-like structure covering the heart and origin of the great arteries. it consists of the visceral and parietal layers, with a potential space between these two layers that can contain up to 15 ml – 50 ml of fluid. the pericardium acts as a barrier against infection and inflammation, reduces friction between the heart and the mediastinal structures, and prevents excessive dilatation of the heart chambers.2 the normal pericardium measures less than 2 mm (figure 2b) whilst a pericardial thickness of more than 4 mm indicates pericardial disease.3 a pericardial thickness of 3 mm – 4 mm is equivocal and should be assessed in the setting of the clinical presentation of the patient. figure 2: a 19-year-old man with absent pericardium. axial ssfp image (a) demonstrates a horizontally orientated heart with absence of the pericardium across the atrioventricular (av) groove (white arrow). normally (b) the pericardium is seen as a thin grey line crossing the av groove (white arrow) lateral to the right coronary artery (black arrow). case 2 a 54-year-old woman presented to the dermatology clinic with cutaneous papules. biopsy of these lesions demonstrated non-caseating granulomas in keeping with cutaneous sarcoidosis. during the work-up of the patient, the echocardiography demonstrated a small pericardial effusion. a cmr was requested to assess for myocardial involvement and functional assessment. cmr demonstrated a small pericardial effusion and pericardial thickening (figure 3), with the pericardium measuring 4 mm; this is often best demonstrated on the black blood sequence. the late gadolinium enhancement also demonstrated avid pericardial enhancement (figure 4) in keeping with pericarditis. the patient did not have a pericardial tap or biopsy to confirm the diagnosis, but in light of the other clinical findings and absence of acute symptoms, the diagnosis of sarcoidosis pericarditis was made. figure 3: a 54-year-old woman with biopsy-proven cutaneous sarcoidosis. the black blood image in a short-axis orientation demonstrates a small pericardial effusion (*) as well as thickening (white arrow) of the pericardium, with the pericardium measuring 4 mm. figure 4: a 54-year-old woman with biopsy-proven cutaneous sarcoidosis. the late gadolinium enhancement image in the short-axis orientation demonstrates the pericardial effusion (*) as well as avid pericardial enhancement (white arrow). this patient did not demonstrate any myocardial thickening or abnormal myocardium enhancement to suggest myocardial involvement. diagnosis: sarcoidosis pericarditis pericardial involvement in sarcoidosis may occur with or without associated myocardial involvement. up to 20% of patients with sarcoidosis will also have asymptomatic pericardial effusions.4 however, pericardial sarcoidosis can rarely present as a symptomatic pericardial effusion with or without associated tamponade or as a chronic constrictive pericarditis. in the absence of myocardial involvement, most of these patients have a good prognosis.5 the role of cmr imaging in pericarditis not all patients with acute pericarditis need to undergo a cmr investigation most cases with classical clinical findings can accurately be assessed and treated with basic investigations. the role of cmr is to further assess those patients with atypical presentations, therapy failure, and those with a complicated course, with chronic or recurrent pericarditis, with or without constriction. in patients with associated diseases, such as sarcoidosis, or penetrating injury, cmr can also supplement computed tomography imaging to confirm the diagnosis, identify associated pathology and assess the influence on cardiac output and function.6 case 3 a 62-year-old man with end-stage renal failure, on renal dialysis for the past 2 years, was sent for a cmr assessment for constrictive pericarditis after an echocardiogram demonstrated mildly dilated left and right atria. the cmr demonstrated pericardial thickening with loculated pericardial effusions as well as hyperintensity of the pericardium on the short tau inversion recovery (stir) images (figure 5). the free-breathing cine ssfp images demonstrated ‘septal bounce’, confirming constrictive pericarditis (figures 6 and 7). figure 5: a 62-year-old man with constrictive pericarditis. the short-axis stir image demonstrates a loculated pericardial effusion (*) and thickened hyper-intense pericardium (white arrow). diagnosis: constrictive pericarditis constrictive pericarditis is often idiopathic or viral but, in south africa, a common cause is scarring from tuberculous pericarditis. other causes also include previous surgery, radiation and malignancy. rarely, end-stage renal disease (esrd) can also result in constrictive pericarditis,6,7 although the more common manifestations of pericardial involvement of esrd are acute uraemic or dialysis pericarditis.7 cases of rapidly progressive pericardial calcification and calcified pericardial effusion as part of extra-skeletal calcification in esrd owing to hyperparathyroidism have also been described.8 physiology of the ‘septal bounce’ on free-breathing steady-state free precession images ‘septal bounce’ is the characteristic septal movement seen in constrictive pericarditis and is used to differentiate constrictive pericarditis from restrictive cardiomyopathy. the ‘septal bounce’ occurs as a result of fixed pericardial volume secondary to pericardial fibrosis or calcification. this causes interventricular volume dependence, meaning that increased volume in the one ventricle causes a decrease in the volume in the adjacent ventricle. the filling of the right ventricle starts slightly earlier than that of the left ventricle and, with inspiration, there is an increase in the venous return to the right atrium and right ventricle, increasing the pressure in the right ventricle. the change in pressure results in a leftwards motion of the septum towards the left ventricle, flattening the normal curvature of the interventricular septum (figure 6). figure 6: a 62-year-old man with constrictive pericarditis. free-breathing cine ssfp image at the mid-ventricular level on the short-axis view demonstrates flattening (solid line) of the interventricular septum during inspiration when the diaphragm is flat (dotted line). during expiration, there is decreased venous return to the right ventricle, and the pressure in the left ventricle increases relative to that of the right ventricle. this differential causes the septum to move towards the right ventricle reassuming its normal curvature (figure 7). on the free-breathing ssfp images, these physiological changes can be visualised and accentuated by asking the patient to take in a deep breath during the acquisition of the short-axis cine images.9 figure 7: a 62-year-old man with constrictive pericarditis. free-breathing cine ssfp image at the mid-ventricular level on the short-axis view demonstrates bulging (solid line) of the interventricular septum during expiration when the diaphragm is rounded (dotted line). the ‘septal bounce’ is very sensitive for constrictive pericarditis but not very specific. the ‘septal bounce’ has also been seen in other conditions such as cardiac tamponade, pulmonary arterial hypertension, left bundle branch block and right ventricular pacing.9 case 4 a 33-year-old man with a 4-week history of chest pain had an echocardiogram as part of his work-up, which demonstrated a large mass adjacent to the right ventricle. the patient was sent for cmr assessment of the mass for further surgical planning. the cmr demonstrated a large hyper-intense mass adjacent to the right ventricle on the axial black blood images (figure 8). the lesion was composed of fat signal intensity on all the sequences and demonstrated no enhancement on the late enhancement images. the axial cine ssfp images demonstrated in most regions a clear plane of separation between the mass and the myocardium of the right ventricle (figure 9a), best seen during systole. however, there was a point on the cine ssfp images where the right ventricular myocardium did not pull away from the lesion during systole (figure 9b) and a small area of myocardial infiltration with extension of the lesion into the right ventricle was demonstrated. figure 8: a 33-year-old man with liposarcoma of the pericardium. the axial black blood image demonstrates a large hyper-intense mass arising from the pericardium adjacent to the right ventricle (black star). figure 9: a 33-year-old man with liposarcoma of the pericardium. the cine ssfp axial image (a) demonstrates a large hyper-intense mass adjacent to the right ventricle (*) with clear separation (white arrow) between the mass and the right ventricular myocardium (white arrow heads) during systole when the ventricle moves away from the lesion. the cine ssfp axial image (b) demonstrates a small area of local invasion of the right ventricular myocardium (white dashed arrow) at the mid-ventricular level with extension of the tumour into the right ventricle. the patient underwent surgical resection of the lesion and part of the right ventricular wall. the histology demonstrated a low-grade liposarcoma. diagnosis: liposarcoma of the pericardium primary pericardial tumours are extremely rare, with a prevalence of 0.001% – 0.007%.10 metastases and direct infiltration of the pericardium by direct extension or haematogeneous spread from lung and breast cancer are most common. the most common benign pericardial masses are pericardial cysts and pericardial lipomas.10 mesotheliomas, sarcomas and lymphoma are the most common primary pericardial tumours.11 primary sarcoma of the pericardium is uncommon. there is a wide range of histopathological subtypes but the prognosis of these groups is uniformly poor. the mean survival for these patients ranges between 3 months and 12 months.10 liposarcomas are normally slow growing and are usually large at the time of presentation. the late presentation often prevents complete excision of these tumours and, because of the lack of response to chemotherapy and radiation, contributes to the poor prognostic outcome.12 pericardial cmr imaging pulse sequences the variety of sequences provided by cardiac mri allows the pericardium and its lesions to be visualised and characterised. however, this is also often the downfall of the modality as it is easy to become lost in the large choice of potential sequences, resulting in prolonged investigations and non-diagnostic studies. the basic sequences outlined below will provide adequate clinical information in a reasonable time for the majority of pathologies. suggested pulse sequences anatomy and outline of the pericardium is best seen on black blood images, and it helps to run these sequences in at least two planes: axial images at a slice thickness of 8 mm as well as short-axis images (figure 3) with a slice thickness of 8 mm. pericardial oedema is best demonstrated on the stir images in a short-axis plane with a slice thickness of 10 mm (figure 5). pericardial enhancement is normally best seen on the late enhancement images at approximately 12-minute post contrast injection (figure 4). these sequences will also demonstrate enhancement of pericardial masses. cine ssfp images in a short-axis plane are useful to assess ventricular function as well as myocardial invasion (figure 10). for constrictive pericarditis, real-time free-breathing images are useful to assess for septal bounce (figures 6 and 7). this is usually done as a single slice at a mid-ventricle level.1 figure 10: a 33-year-old man with liposarcoma of the pericardium. the axial black blood image demonstrates a large hyper-intense mass arising from the pericardium adjacent to the right ventricle (black star). acknowledgements competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article. references bogaert j, francone m. cardiovascular magnetic resonance in pericardial diseases. j cardiovasc magn reson. 2009;11:14. http://dx.doi.org/10.1186/1532-429x-11-14 rajiah p. cardiac mri: part 2, pericardial diseases. ajr am j roentgenol. 2011;197(4):w621–w634. http://dx.doi.org/10.2214/ajr.10.7265 wang zj, reddy gp, gotway mb, yeh bm, hetts sw, higgins cb. ct and mr imaging of pericardial disease. radiographics. 2003;23 spec no:s167-80. navaneethan sd, venkatesh s, shrivastava r, mehta j, israel r. recurrent pleural and pericardial effusions due to sarcoidosis. plos med. 2005;2(3):e63. http://dx.doi.org/10.1371/journal.pmed.0020063 sekiguchi m, yazaki y, isobe m, hiroe m. cardiac sarcoidosis: diagnostic, prognostic, and therapeutic considerations. cardiovasc drugs ther. 1996;10(5):495–510. http://dx.doi.org/10.1007/bf00050989 verhaert d, gabriel rs, johnston d, lytle bw, desai my, klein al. the role of multimodality imaging in the management of pericardial disease. circ cardiovasc imaging. 2010;3(3):333–343. http://dx.doi.org/10.1161/circimaging.109.921791 kleynberg rl, kleynberg vm, kleynberg lm, farahmandian d. chronic constrictive pericarditis in association with end-stage renal disease. int j nephrol. 2011;2011:469602. http://dx.doi.org/10.4061/2011/469602 park ea, lee w, kim kh, chung jw, park jh. rapid progression of pericardial calcification containing a ‘calcium paste’ in a patient with end-stage renal disease. circulation. 2011;123(9):e262–e264. walker cm, chung jh, reddy gp. septal bounce. j thorac imaging. 2012;27(1):w1. restrepo cs, vargas d, ocazionez d, martinez-jimenez s, betancourt cuellar sl, gutierrez fr. primary pericardial tumors. radiographics. 2013;33(6):1613–16s30. burazor i, aviel-ronen s, imazio m, et al. primary malignancies of the heart and pericardium. clin cardiol. 2014;37(9):582–588. http://dx.doi.org/10.1002/clc.22295 lococo f, cesario a, meacci e, et al. huge primary pericardial liposarcoma. thoracic cardiovasc surg. 2011;59(3):172–173. http://dx.doi.org/10.1055/s-0030-1250187 article information authors: eric gous1 janet smal2 farhana e. suleman3 affiliations: 1department of diagnostic radiology, university of pretoria, south africa 2department of radiology, university of pretoria, south africa 3department of radiology, university of pretoria and steve biko academic hospital, south africa correspondence to: eric gous email: ericgous@hotmail.com postal address: private bag x323, pretoria 0001, south africa dates: received: 13 apr. 2015 accepted: 20 june 2015 published: 15 oct. 2015 how to cite this article: gous e, smal j, suleman, fe. ‘congenital infiltrating lipomatosis of the face with enlargement of the ipsilateral cerebellar hemisphere’, s afr j rad. 2015;19(1); art. #817, 3 pages. http://dx.doi.org/10.4102/sajr.v19i1.817 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. congenital infiltrating lipomatosis of the face with enlargement of the ipsilateral cerebellar hemisphere in this case report... open access • abstract • introduction • case report • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ congenital infiltrating lipomatosis of the face (cilf) is a rare disorder in which overgrowth of fatty tissue with infiltration of underlying structures leads to craniofacial deformities and asymmetry. imaging plays an important role in the diagnosis, surgical planning and evaluation of underlying structures. to our knowledge, our case is the first to describe cilf associated with isolated enlargement of a cerebellar hemisphere in the absence of an enlarged ipsilateral cerebral hemisphere (hemimegalencephaly). introduction top ↑ congenital infiltrating lipomatosis of the face (cilf) is a rare congenital disorder characterised by overgrowth of fatty tissues of the face. infiltration into adjacent soft tissues and bony elements leads to craniofacial deformities and asymmetry.1 it may be associated with neurocutaneous syndromes and intracranial abnormalities.2 imaging plays an important role in the diagnosis, evaluation of underlying structures, detection of associated intracranial abnormalities and surgical planning.2,3,4 case report top ↑ a male 1 year and 9 months old was referred for a magnetic resonance imaging (mri) study of a left facial mass present since birth. the mother gave a history of two previous liposuctions performed at 3 months and 15 months of age. the mass recurred after each procedure. previous ultrasound examination demonstrated a mass consisting of adipose tissue that was confirmed histologically. mri demonstrated an extensive, non-encapsulated left facial mass with signal corresponding to that of adipose tissue. the lesion extended into the left masticator, submandibular, parotid and parapharyngeal spaces with associated hypertrophy of the masseter muscle and the parotid and submandibular glands. mild hypertrophy of the left sphenoid and maxillary bones as well as the ramus of the mandible was noted (figures 1a–1b). the left cerebellar hemisphere was enlarged with slight displacement of the midline to the right (figure 2a). there was no evidence of hypoplasias, dysplasias, infarction or previous infections of the cerebellum. the remaining soft tissues, bony elements and intracranial structures were unremarkable (figure 2b). figure 1: (a) axial t2w mri demonstrates an extensive, non-encapsulated left facial mass with fat signal (arrowheads) extending into the soft tissue spaces of the neck (short arrow) with associated hypertrophy of the left masseter muscle (asterisk) and parotid gland (open arrow). mild hypertrophy of the left ramus of the mandible (long arrow) compared to the right can also be seen. (b) axial fat suppressed image demonstrates complete suppression of signal within the lesion consistent with adipose tissue. figure 2: (a) axial t2w mri image of the posterior fossa demonstrates enlargement of the left cerebellar hemisphere (arrows) with midline shift to the right. (b) note the normal size of the cerebral hemispheres on axial t2w mri image more cranially. a diagnosis of cilf was made based on imaging findings, histology and clinical presentation. discussion top ↑ cilf is a rare disorder of infancy and early childhood and is classified as a subgroup of lipoma.1,5 the aetiology is poorly understood. slavin et al.6 introduced the term ‘congenital infiltrating lipomatosis of the face’ in 1983 and described the lesions as having the following characteristics: non-encapsulated proliferation of mature adipose tissue infiltration of muscle and adjacent soft tissues presence of fibrous tissue with various nerve bundles and thick walled vessels absence of lipoblasts and signs of malignancy hypertrophy of subadjacent bone congenital in origin with a tendency to recur after surgical excision. cilf may occur as an isolated condition; or associated with intracranial abnormalities and neurocutaneous syndromes; or as part of ‘total unilateral hypertrophy’2. intracranial abnormalities described include hemimegalencephaly, arachnoid cysts, mucosal neuromas and lipomas.1,3 to our knowledge, our case is the first in the literature to describe cilf associated with isolated enlargement of a cerebellar hemisphere in the absence of hemimegalencephaly (figure 2a–2b). the common clinical presentation of cilf is facial asymmetry at birth. associated features described include: vascular blush, ptosis, enlargement of the lower lip, ipsilateral hemimacroglossia, increased facial hair on the affected side, early eruption of deciduous and permanent teeth, missing teeth associated with dentigerous cysts and ipsilateral hypertrophy of the underlying facial skeleton.1,7 the main role of imaging is to define the extent of lipomatous infiltration in underlying structures and facilitate the planning of surgery. the association of cilf with various intracranial anomalies is well established and emphasises the need for neuroimaging in these patients, even in the absence of neurological features.2,3,4 radiologically, cilf is a non-encapsulated, diffusely infiltrating lipomatous mass with hypertrophy of underlying soft tissue structures and bony elements. both computed tomography (ct) and mri are useful in demonstrating the fatty nature of the mass (ct density of –65 to –125 hounsfield units and mri signal high on t1-weighted and t2-weighted images and low on fat suppressed images), as well as identifying underlying abnormalities. although ultrasound can be helpful in confirming adipose tissue in the mass, it remains inferior to ct and mri in demonstrating the extent of infiltration as well as the exact size of the lesion.7 there are no reports of malignant transformation of cilf and aesthetic appearance remains the main concern.7 treatment modalities include surgical excision or liposuction, and the type of treatment depends on the extent of the lesion. as a result of the diffuse infiltration and involvement of underlying structures, complete surgical excision is often not possible, resulting in a high recurrence rate after surgical intervention.1 conclusion top ↑ cilf is a rare congenital disorder characterised by overgrowth of fatty tissue of the face which leads to craniofacial deformity and asymmetry. imaging plays an important role in the diagnosis and management. our case is the first to describe cilf associated with isolated enlargement of a cerebellar hemisphere in the absence of hemimegalencephaly. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions e.g. (university of pretoria) wrote the original manuscript and worked on the literature review. j.s. (university of pretoria) worked up the patient, contributed to diagnosis and was involved in the final editing of the document. f.e.s. (university of pretoria and steve biko academic hospital) edited the document and contributed to writing the legends and preparing images. references top ↑ mahadevappa a, raghavan vh, ravishankar s, manjunath gv. congenital infiltrating lipomatosis of the face: a case report. case rep pediatr. 2012;2012: 134646. http://dx.doi.org/10.1155/2012/134646 flores-sarnat l. congenital infiltrating lipomatosis of the face: recognition and pathogenesis. neuropediatrics. 2012;43(6):346–348. http://dx.doi.org/10.1055/s-0032-1330853 unal o, cirak b, bekerecioglu m, kutluhan a, ugraş s, tali t. congenital infiltrating lipomatosis of the face with cerebral abnormalities. eur radiol. 2000;10(10): 1610–1613. http://dx.doi.org/10.1007/s003300000427 aydíngӧz ü, emir s, karlí-oğuz k, kӧse g, büyükpamukçu m. congenital infiltrating lipomatosis of the face with ipsilateral hemimegalencephaly. pediatr radiol. 2002;32(2):106–109. http://dx.doi.org/10.1007/s00247-001-0614-2 sahai s, rajan s, singh n, arora h. congenital infiltrating lipomatosis of the face with exophytic temporomandibular joint ankylosis: a case report and review of the literature. dentomaxillofac radiol. 2013;42(3):16128745. http://dx.doi.org/10.1259/dmfr/16128745 slavin sa, baker dc, mccarthy jg, mufarrij a. congenital infiltrating lipomatosis of the face: clinicopathologic evaluation and treatment. plast reconstr surg. 1983;72(2):158–164. http://dx.doi.org/10.1097/00006534-198308000-00006 heymans o, ronsmans c. congenital infiltrating lipomatosis of the face. eur j plast surg. 2005;28(3):186–189. http://dx.doi.org/10.1007/s00238-005-0739-x sajr 878 cerebral schistosomiasis n ravi,1 md; w x yi,1 phd; l yu, 1 md; h j ping,2 mb bs; d z hao,3 phd 1 department of radiology, xiangya first affiliated hospital, changsha, hunan, china 2 department of radiology, changsha 8th hospital, changsha, hunan, china 3 department of pathology, xiangya first affiliated hospital, changsha, hunan, china corresponding author: n ravi (drnawei@gmail.com) although schistosomiasis (bilharzia) is one of the most common parasitic infections in humans, schistosomal infection of the nervous system is rare. this report is of an unusual case of primary cerebral schistosomiasis and describes its magnetic resonance imaging appearance. s afr j rad 2013;17(4):143-144. doi:10.7196/sajr.878 a 21-year-old previously healthy man presented with symptoms of continuous headache of 3 days’ duration. his physical examination was unremarkable. laboratory investigations were significant for an elevated white blood cell count of 17 700 cells/ml of blood. mri examination of the brain revealed a tumour-like lesion in the left temporoparietal lobe that was hypo-intense on t1-weighted imaging (fig. 1) and hyperintense on t2wi (fig. 2). there was intense perilesional oedema, with considerable mass effect. additionally, there was a diffuse region of hyperintense t1 signal within the lesion that was attributed to haemorrhage. on post-contrast t1wi (fig. 3), a cluster of intensely enhancing nodular lesions were detected. some of these nodules coalesced, forming a confluent lesion, and some were arranged around regions of linear or slit-like enhancement, creating an arborising appearance. the patient then underwent surgical resection of the lesion which was pathologically proven to be a schistosomal granulomatous lesion (fig. 4). postoperatively, the patient received praziquantel and corticosteroids, and made an uneventful recovery. fig. 1. axial mr t1wi demonstrating a hypo-intense mass-like lesion of the left temporoparietal region with mass effect. the diffuse hyperintense signal within the lesion can be attributed to haemorrhage. fig. 2. axial mr t2wi demonstrating a hyperintense mass-like lesion with intense perilesional oedema, compression of the ipsilateral lateral ventricle, effacement of surrounding sulci, and a noticeable shift of the midline to the right. fig. 3. axial mr t1wi post contrast revealing a cluster of intensely enhancing nodules within the mass, each measuring approximately 1 3 mm in size. some of the nodules appear to have coalesced together, creating a confluent enhancing lesion. also noticeable are subtle regions of linear or slit-like enhancement surrounded by closely packed nodules, creating an arborising appearance. fig. 4. haematoxylinand eosin-stained histopathological specimen following surgical excision, demonstrating numerous granulomas surrounding eggs of s. japonicum. the image also depicts an intense inflammatory infiltrate. discussion an estimated 200 million people globally have schistosomiasis.1 it is endemic in over 70 tropical and sub-tropical countries worldwide.1 however, cerebral schistosomiasis (cs) is an uncommon form of schistosomal infection; most cases result from s. japonicum.2 individuals affected by cs commonly present with headache, confusion, speech disturbances, motor deficits, visual abnormalities, seizures, altered mental state, vertigo, sensory impairment, vomiting and ataxia.2 on mri, cs usually has a pseudotumour-like appearance that is hypo-intense on t1wi and hyperintense on t2wi. it is often associated with an intense perilesional oedema and mass effect.3 , 5 on contrast administration, the characteristic feature described is that of a central linear (slit-like) enhancement surrounded by numerous enhancing nodules, creating an arborised appearance.3 , 5 some of the nodules may be clustered together, creating a confluent enhancing mass.3 at present, the most accurate way of diagnosing cs is the demonstration of schistosoma eggs surrounded by a granulomatous reaction on nervous tissue biopsies.2 , 4 recently, it has been suggested that the treatment approach for cs should be based on the presence or absence of signs of raised intracranial pressure and/or hydrocephalus.4 when present, the treatment should include prompt surgical resection followed by antiparasitic medications (praziquantel), corticosteroids and anticonvulsants. in their absence, a non-invasive approach using a combination of praziquantel, cortico­steroids and anticonvulsants should be tried.4 1. centers for disease control and prevention. http://www.cdc.gov/parasites/schistosomiasis (accessed 18 march 2012). 1. centers for disease control and prevention. http://www.cdc.gov/parasites/schistosomiasis (accessed 18 march 2012). 2. ferrari tca, moreria prr. neuroschistosomiasis: clinical symptoms and pathogenesis. lancet neurol 2011;10(9):853-864. [http://dx.doi.org/10.1016/s1474-4422(11)70170-3] 2. ferrari tca, moreria prr. neuroschistosomiasis: clinical symptoms and pathogenesis. lancet neurol 2011;10(9):853-864. [http://dx.doi.org/10.1016/s1474-4422(11)70170-3] 3. liu h, lim cct, feng x, et al. mri in cerebral schistosomiasis: characteristic nodular enhancement in 33 patients. ajr 2008;191(2):582-588. [http://dx.doi.org/10.2214/ajr.07.3139] 3. liu h, lim cct, feng x, et al. mri in cerebral schistosomiasis: characteristic nodular enhancement in 33 patients. ajr 2008;191(2):582-588. [http://dx.doi.org/10.2214/ajr.07.3139] 4. vale tc, de sousa-pereira sr,ribas, lambertucci jr. neuroschistosomiasis mansoni literature review and guidelines. neurologist 2012;18:333-342. [http://dx.doi.org/10.1097/nrl.0b013e3182704d1e] 4. vale tc, de sousa-pereira sr,ribas, lambertucci jr. neuroschistosomiasis mansoni literature review and guidelines. neurologist 2012;18:333-342. [http://dx.doi.org/10.1097/nrl.0b013e3182704d1e] 5. sanelli pc, lev mh, gonzalez rg, schaefer pw. unique linear and nodular mr enhancement pattern in schistosomiasis of the central nervous system: report of three patients. ajr 2001;177(6):1471-1474. 5. sanelli pc, lev mh, gonzalez rg, schaefer pw. unique linear and nodular mr enhancement pattern in schistosomiasis of the central nervous system: report of three patients. ajr 2001;177(6):1471-1474. article information authors: tracy kilborn1 halvani moodley1 stewart mears1 affiliations: 1red cross war memorial children’s hospital, cape town, south africa correspondence to: tracy kilborn email: tracykilborn@gmail.com postal address: red cross war memorial children’s hospital, klipfontein road, cape town 7700, south africa dates: received: 02 june 2015 accepted: 11 aug. 2015 published: 18 dec. 2015 how to cite this article: kilborn t, moodley, h, mears, s. elbow your way into reporting paediatric elbow fractures – a simple approach. s afr j rad. 2015;19(2): art. #881, 10 pages. http://dx.doi.org/10.4102/sajr.v19i2.881 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. elbow your way into reporting paediatric elbow fractures – a simple approach in this pictorial essay... open access • abstract • introduction    • a systematic approach to reporting       • reporting checklist1    • step 1 – evaluate radiographic technique    • step 2 – look for soft tissue swelling and joint effusion    • step 3 – evaluate alignment    • step 4 – identify ossification centres    • step 5 – look for distal humeral fractures       • a) supracondylar fracture (50%–70%) (diagram 1)       • not to be missed look–alike – non-accidental injury (nai)       • b) lateral condyle 10%–15% (diagram 2)       • c) medial epicondyle 10% (diagram 3)       • d) medial condyle (<1%) (diagram 4)       • e) lateral epicondyle (<1%) (diagram 5)       • f) intercondylar <1% (diagram 6)       • g) transcondylar (transphyseal) <1% (diagram 7)    • step 6 – look for radial and/or ulnar fractures       • a) olecranon fracture 4%–7%       • b) proximal radial fracture 4%–5% • conclusion • acknowledgements    • competing interests    • author’s contribution • references abstract top ↑ the evaluation of x-rays of the paediatric elbow in the setting of trauma is challenging. the difficulty arises from the complex developmental anatomy of the elbow, with its multiple ossification centres and the differences in the pattern of injuries between adults and children. it is essential to evaluate the radiographs systematically. this review will provide an overview of the developmental anatomy, the range of soft tissue and skeletal findings, and demonstrate tips and pitfalls in radiographic interpretation in paediatric elbow trauma. introduction top ↑ paediatric elbow trauma is common. radiographic diagnosis of the various fracture types is critical due to the overlapping clinical presentations and to avoid misdiagnosis that can result in growth disturbances. a systematic approach to reporting, supported by an understanding of the age-dependent variation in developmental anatomy of the elbow, is indispensable to the radiologist in tackling these challenging injuries. we now discuss a practical and simple guide to post-traumatic paediatric elbow radiographic reporting. a systematic approach to reporting reporting checklist1 technically adequate film (ap and lateral). soft tissue swelling and joint effusion (fat pads). alignment – anterior humeral and radiocapitellar lines. ossification centres (critol). visible fracture of distal humerus. visible fracture of radius or ulna. no visible fracture but positive fat pad – follow up in 7–10 days. step 1 – evaluate radiographic technique initial radiographic interpretation consists of the anteroposterior (ap) and lateral projections. the ap should be performed with the elbow in full extension and the forearm supinated (figure 1). for the true lateral projection, the elbow should be flexed 90 degrees with the forearm supinated (figure 2). the cassette should be centred on the elbow joint with its long axis parallel to the forearm. in an optimal lateral projection, the posterior supracondylar ridges of the humerus are superimposed and the olecranon process is viewed in profile (figure 3). radiographic landmarks are unreliable and significant pathology can be obscured in a suboptimal lateral projection. the internal oblique view is useful in the demonstration of lateral condyle fractures and in assessing the degree of displacement.2 figure 1: positioning for the anteroposterior (ap) projection. the elbow should be in contact with and in the middle of the cassette in full extension with the forearm supinated. figure 2: positioning for the lateral projection. the elbow should be flexed at 90 degrees with the forearm supinated and thumb superior. figure 3: (a) good quality lateral projection with the posterior supracondylar ridges superimposed and olecranon in profile. note the normal anterior fat pad lying parallel to the anterior humeral shaft (arrow). (b) lateral projection in patient with radial neck fracture showing a posterior fat pad (long arrow) and displaced anterior fat pad (short arrow). the routine use of comparative views is not recommended as it comes at a considerable cost of radiation exposure to the child.3 in addition, several studies have shown that the routine use of comparative views was a predominant choice of inexperienced clinicians, did not alter patient management in the majority of cases and therefore could not be justified.4,5,6,7 step 2 – look for soft tissue swelling and joint effusion localised soft tissue swelling either over the medial or the lateral aspects of the elbow should raise suspicion of a medial epicondylar or lateral condylar fracture. the elbow fat pads are situated external to the synovium. on a true lateral radiograph with 90 degrees of flexion the normal anterior fat pad is within the coronoid fossa and is seen as a radiolucent line parallel to the anterior humeral cortex; the posterior fat pad is pressed deep into the olecranon fossa by the triceps tendon and the anconeus muscle and is invisible.8 distention of a structurally intact joint causes displacement of the fat pads – the posterior fat pad moves posterior and superior and becomes visible; the anterior fat pad becomes more sail-like (figure 3). a false negative fat pad sign may occur in poor positioning, in capsular rupture or in the setting of significant extracapsular abnormality.8 approximately 70%–90% of children with an elbow effusion will have a visible fracture; however, there is wide debate in the literature about the presence of radiographically occult fractures in the setting of a joint effusion at presentation – radiographic follow-up by donnelly et al reported 54% of patients showing healing fractures.9 more recent studies looking at mri and mdct show occult fractures in the majority of patients, although they do stress that these investigations did not significantly alter management.10,11. the standard protocol for suspected occult fractures in most institutions remains posterior elbow splinting with follow-up radiographs at 7–10 days. step 3 – evaluate alignment the anterior humeral and radio-capitellar lines should be used to gauge elbow alignment. the anterior humeral line is drawn along the anterior cortex of the humerus and should bisect the middle third of the capitellum. since the line evaluates the relative positions of two parts of the same bone, malalignment indicates a fracture – in most cases, posterior displacement of the capitellum in a supracondylar fracture. this sign relies on adequate ossification of the capitellum and therefore is reliable in children over the age of 4 years only.12 in younger children when the capitellar ossification centre is still small, the anterior humeral line may not pass through the ossified portion (figure 4). figure 4: (a) normal anterior humeral line in a 4 year old passes through the middle third of the capitellum (black line). (b) anterior humeral line in a 6 month old child with will not pass through the middle third of the partially ossified capitellum (black line). the radiocapitellar line evaluates the relationship of the proximal radius to the capitellum on all views. if the integrity of this line is compromised, then dislocation should be suspected (figure 5). figure 5: (a) normal radiocapitellar line (black line). (b) displaced radiocapitellar line that does not intersect the capitellum in radial dislocation (black line). step 4 – identify ossification centres although ossification of the elbow is complex, this knowledge is essential to all practitioners involved in the evaluation of paediatric trauma. the ossification appears earlier in girls than in boys and there is wide variation between individuals of the same sex. in boys, with the exception of the capitellum, an average delay of two years is seen when compared to girls and there are also differences between population groups.13,14,15 the sequence of appearance of the six centres of secondary ossification is mostly predictable (table 1) and is best remembered by using the acronym critol (figure 6). it should be noted that there are no specific reference data about the timing and sequence of ossification in south african children, and a previous study showed differences in the sequence of ossification in chinese children when compared to the reported standards.14 figure 6: timeline of the appearance of ossification centres. table 1: ossification centres.13,14,15 table 2: summary of paediatric elbow fracture/dislocations.1,15 step 5 – look for distal humeral fractures a) supracondylar fracture (50%–70%) (diagram 1) diagram 1: t!ps lateral view most helpful – look for posterior fat pad. anterior humeral line abnormal in 94% cases (figure 7). baumann’s angle predicts varus deformity. malunion causes a varus abnormality, the severity of which is measured on the true ap projection by the baumann angle, which uses radiographically identifiable landmarks to compare the healed with the normal elbow (figure 8). although primarily a cosmetic deformity, it may cause pain and late development of posterolateral elbow instability, which can be corrected with a valgus osteotomy. figure 7: type 1 supracondylar fracture on (a) ap and (b) lateral (arrow) with positive posterior fat pad and intact posterior cortex. note with the incompletely ossified capitellum that one cannot use the anterior humeral line to assess alignment. (c) type 2 supracondylar fracture showing posteriorly displaced fragment as evidenced by abnormal anterior humeral line (black line), although fracture is visible, posterior cortex is intact(white arrow) and positive posterior fat pad. (d) type 3 supracondylar fracture with displaced fragment (arrow), discontinuous anterior humeral line (black line) and posterior fat pad. figure 8: baumann’s angle (shown) is formed by the intersection of a line drawn perpendicular to the humeral shaft and a line along the physis of the lateral condyle. a normal baumann’s angle within the paediatric population ranges from 85 – 89 degrees. it is important to compare angles between the normal and abnormal side, a difference of more than 5 degrees predicts a possible varus deformity. figure 9: (a) ap and (b) lateral views in a one-month-old with a swollen elbow who died soon after admission. note the marked soft tissue swelling, the presence of a posterior fat pad and the bucket handle metaphyseal fracture. multiple additional fractures were identified at post mortem. not to be missed look–alike – non-accidental injury (nai) t!ps non-mobile infant. history will be suspicious. bucket handle or corner fracture of distal humerus. requires full skeletal survey. b) lateral condyle 10%–15% (diagram 2) diagram 2: t!ps second most common fracture, so look carefully. lateral soft tissue swelling is the clue on ap view. cortical breach is posterior on lateral view. need to document amount of displacement. internal oblique view helpful (figure 10). figure 10: (a) undisplaced right lateral condyle fracture (long arrow). note lateral soft tissue swelling (short arrow). (b) displaced right lateral condyle fracture (arrow). (c) internal oblique showing left lateral condyle fracture that was suspected but not visible on the ap projection. c) medial epicondyle 10% (diagram 3) diagram 3: t!ps displacement best seen on ap view. look for medial soft tissue swelling. always confirm normal position in a child >6 years. if no epicondyle seen, look for entrapment in the joint (figure 11). figure 11: (a) right medial epicondyle fracture (long arrow) with minimal displacement treated conservatively. note the striking medial soft tissue swelling (short arrow). (b) ap and (c) lateral projections of a six-year-old. the radiocapitellar line is broken (black line), in keeping with dislocation. medial soft tissue swelling and absence of the normal medial epicondyle (white arrow) in a child of this age should prompt careful evaluation for an entrapped epicondyle within the joint (white and black arrow). (d) post reduction image of the same child as (a and b), showing radiocapitellar alignment (black line) and relocated medial epicondyle (black arrow). (e) ap of right elbow in a nine-year-old – the ossification centre of the trochlea is normally positioned (t); the medial epicondyle is not seen (short arrow) as it lies trapped within the joint (white and black arrow). d) medial condyle (<1%) (diagram 4) diagram 4: t!ps look for medial soft tissue swelling. uncommon. often difficult to differentiate from medial epicondyle fracture. may be difficult to see extent; external oblique projection helpful (figure 12). figure 12: left medial condyle fracture in a 4 year old. note the medial soft tissue swelling (short arrow) and the subtle fracture line involving the medial condyle (long arrow). e) lateral epicondyle (<1%) (diagram 5) diagram 5: t!ps very rare! make sure you are not looking at a lateral condyle fracture instead. only ossifies after 11 years. lateral soft tissue swelling may be only finding. internal oblique projection may be helpful (figure 13).16 figure 13: a 12-year-old with direct blow to elbow. note the lateral soft tissue swelling and linear fracture through the lateral epicondyle (arrow). f) intercondylar <1% (diagram 6) diagram 6: t!ps often misdiagnosed as supracondylar fracture. look for sagittal component that splits medial and lateral condyles and extends to articular surface (figure 14). figure 14: intercondylar fracture that extends sagittally to the articular surface (black and white arrow) splitting the medial and lateral condyles (white arrows). g) transcondylar (transphyseal) <1% (diagram 7) diagram 7: t!ps mimics posterior dislocation. radius and ulna not aligned with humerus on lateral. nb: radiocapitellar line is maintained; cf. dislocation (figure 15). figure 15: (a) lateral projection in neonate with a swollen elbow shows marked soft tissue swelling. ulna and radius appear posteromedially displaced (arrow). (b) ap projection with line drawn along radial shaft that intersects with expected position of the capitellum excluding dislocation and implying a transcondylar fracture. step 6 – look for radial and/or ulnar fractures a) olecranon fracture 4%–7% t!ps normal ossification centre may be fragmented. look for soft tissue swelling. look for associated fractures of medial and lateral condyles and radial neck. look for elbow dislocation (figure 16). figure 16: (a) soft tissue swelling overlying the olecranon, which has a subtle undisplaced fracture (arrow). (b) olecranon fracture (arrow) in the setting of dislocation. note the interrupted radiocapitellar line (black line). b) proximal radial fracture 4%–5% t!ps neck more common than head. posterior fat pad is a clue. oblique views are helpful. in radial dislocation, look for associated ulna fracture (figure 17). figure 17: (a) lateral and (b) oblique images of a four-year-old with a radial neck fracture (arrows). (c) a five-year-old with radial dislocation (note interrupted radiocapitellar line) and proximal ulnar fracture. conclusion top ↑ a systematic approach to paediatric elbow reporting in the post-traumatic setting is an asset for everyday radiological practice. knowledge of the developmental anatomy of the elbow underscored by an understanding of common mimics and pitfalls is fundamental. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. author’s contribution t.k. (red cross war memorial children’s hospital) – written text and legends. graphics. h.m. (red cross war memorial children’s hospital) diagrams, figures, data collection. s.m. (red cross war memorial children’s hospital) – fact checking, editing, figures and legends. references top ↑ iyer rs, thapa mm, khanna pc, chew fs. pediatric bone imaging: imaging elbow trauma in children – a review of acute and chronic injuries. ajr. 2012;198:1053–1068. pmid: 22528894, http://dx.doi.org/10.2214/ajr.10.7314 song ks, kang ch, min bw, bae kc, cho ch. internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. j bone joint surg am. 2007;89(1):58–63. pmid: 17200311, http://dx.doi.org/10.2106/jbjs.e.01387 johnson kl, bache e. in pediatric skeletal trauma – techniques and applications. berlin heidelberg new york: springer; 2008. chacon d, kissoon n, brown t, galpin r. use of comparison radiographs in the diagnosis of traumatic injuries of the elbow. ann emerg med. 1992;21 (8):895–899. pmid: 1497152, http://dx.doi.org/10.1016/s0196-0644(05)82923-3 kissoon n, galpin r, gayle m, chacon d, brown t. evaluation of the role of comparison radiographs in the diagnosis of traumatic elbow injuries. j pediatr orthop. 1995;15(4):449–453. pmid: 7560032. rickett ab, finlay db. an audit of comparative views in elbow trauma in children. br j radiol. 1993;66(782):123–125. pmid: 8457824, http://dx.doi.org/10.1259/0007-1285-66-782-123 dowling s, farion k, clifford t. comparison views to diagnose elbow injuries in children: a survey of canadian non-pediatric emergency physicians. can j emerg med. 2005;7(4):237–240. pmid: 17355679. goswami gk. the fat pad sign. radiology. 2002;222:419–420. http://dx.doi.org/10.1148/radiol.2222000365 donnelly lf, klostermeier tt, klosterman la. traumatic elbow effusions in pediatric patients: are occult fractures the rule? ajr. 1998;171:243–245. pmid: 9648797, http://dx.doi.org/10.2214/ajr.171.1.9648797 major nm, crawford st. elbow effusions in trauma in adults and children: is there an occult fracture? ajr. 2002;178:413–418. pmid: 11804906. chapman v, grottkau b, albright m, elaini a, halpern e, jaramillo d. mdct of the elbow in pediatric patients with posttraumatic elbow effusion. ajr. 2006;187:812–817. pmid: 16928950, http://dx.doi.org/10.2214/ajr.05.0606 herman mj, boardman mj, hoover jr, chafetz rs. relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. j bone joint surg am. 2009;91(9):2188–2193. pmid: 19723996, http://dx.doi.org/10.2106/jbjs.h.01316 patel b, reed m, patel s. gender-specific pattern differences of the ossification centres in the pediatric elbow. pediatr radiol. 2009;39:226–231. pmid: 19125245, http://dx.doi.org/10.1007/s00247-008-1078-4 cheng jc, wing-man k, shen wy, et al. a new look at the sequential development of elbow-ossification centres in children. j pediatr orthop. 1998;18(2):161–167. pmid: 9531396. beaty jh, kasser jr. rockwood and wilkins’ fractures in children. 6th ed. lippincott williams & wilkins; 2006. untitled abstract background. hiv-associated focal brain lesions (fbls) are caused by opportunistic infections, neoplasms, or cerebrovascular diseases. in developed countries toxoplasma encephalitis (te) is the most frequent cause followed by primary cns lymphoma (pcnsl). guidelines based on these causes have been proposed and successfully implemented. these guidelines do not consider the causes of hiv-associated fbl in developing countries where treatable infections predominate. the guidelines as proposed would adversely influence outcome if applied to patients in developing countries. objective. to determine a practical approach to the management of hivassociated fbls in developing countries. design. prospective case series. methods. management based on presumed aetiologies of the fbls determined by collating information obtained from computed tomography (ct) scans, cerebrospinal fluid and blood studies, concurrent nonneurological illness and response to treatment. results. the principal presumed cause of fbl was tuberculosis (tb) (69%), and the therapeutic response was good in 69% of patients. conclusions. in developing countries infections are the predominant cause of hiv-associated fbl. the principal cause is determined by the infection that is endemic to the population being studied. empiric treatment based on limited investigations should be directed according to the nature of this infection. a modified algorithm is proposed. introduction focal brain lesions (fbls) caused by opportunistic infections, neoplasms, or cerebrovascular diseases are common neurological consequences of hiv infection.1 in developed countries toxoplasma encephalitis (te) is the most frequently identified cause of hiv-associated fbl, followed by primary cns lymphoma (pcnsl).1,2 on this basis the quality standards subcommittee of the american academy of neurology (aan) proposed that hiv-positive patients presenting with fbl should be empirically treated for toxoplasmosis initially.1 failure to improve clinically or radiologically over the succeeding 10to 14-day period warrants stereotactic brain biopsy in order to institute specific and appropriate therapy.1 an alternative non-invasive approach that is otherwise similar is based on the fact that brain biopsies do not influence survival in these patients.2 with this approach diagnosis is determined by the response to anti-toxoplasma treatment.2 failed responders are reviewed and presumed to have pcnsl or toxoplasmosis resistant to standard therapy and treated appropriately.2 these guidelines and approaches to the management of hiv-associated fbl have been effective in developed countries. in developing countries infections are the main cause of fbl associated original article 5 sa journal of radiology • july 2005 management of hiv-associated focal brain lesions in developing countries – experience at chris hani baragwanath hospital m modi fcrad (sa), mmed department of radiation sciences university of the witwatersrand johannesburg a mochan fcp (sa) g modi phd (lond), fcp (sa), frcp (lond) department of neurosciences university of the witwatersrand johannesburg 5-13pgs 9/28/05 9:20 am page 5 with hiv.3-10 studies from african and central american countries describe either tuberculosis (tb) or toxoplasmosis as the two most frequently occurring causes.3-8 these observations have been corroborated in similar studies from india.9,10 the relative frequencies with which these infections cause fbl are not well documented. the nature of the hiv-associated fbl is probably determined by the infection/s that are endemic to the population being studied.7 tb is endemic in developing countries.11 this therefore implies that if the aan or british guidelines are strictly applied to developing regions where tb is endemic large numbers of patients will be inappropriately managed. we therefore prospectively studied and managed 32 patients with hivassociated fbl. our approach was to presume the most likely cause in our setting determined by collating information obtained from computed tomography (ct) scans, cerebrospinal fluid (csf) and blood studies, concurrent non-neurological illness and response to treatment. we did not emphasise the need for accurate histological diagnosis of the fbl. study design this was a prospective case series. patients and methods we studied 32 hiv-infected patients (older than 18 years) with fbl as diagnosed on ct scans. the study was carried out at the chris hani baragwanath hospital (chbh) in soweto, south africa. patients were recruited over a 12-month period. chbh is a 3 300-bed public university hospital that serves a predominantly black urban population of approximately 3 million people. the patients were all inpatients, admitted to the medical wards of the chbh. all patients in the study were black, heterosexual, non-intravenous drug abusers and were anti-retroviral therapy-naive. none of the patients was on prophylactic treatment for pneumocystis carinii or toxoplasma. the following data were recorded. demographics: age, sex, ethnic group, medication/drug use, and associated non-neurological illnesses. blood: full blood count, erythrocyte sedimentation rate (esr), glucose, urea and electrolytes, serum calcium, phosphate and magnesium, liver function tests, t-cell subsets, hiv viral loads (hiv-1 rna), serological tests for syphilis (wr, tpha, ftaabs), cysticercosis (elisa), toxoplasma gondii (cft), typhoid (tmx), viral studies for hepatitis a, b and c, cytomegalovirus (cmv), htlv-i and blood cultures. cerebrospinal fluid (csf): chemistry, cell counts, cytology, and adenosine deaminase (ada) level. tb elisa and polymerase chain reaction (pcr), syphilis, cysticercosis and toxoplasma serology, hiv viral load (hiv-1 rna), pcr for herpes simplex, varicella zoster, cytomegalovirus (cmv), epstein-barr virus (ebv) and herpes simplex type 6, india ink staining, cryptococcal antigen, bacterial (including mycobacterium tuberculosis) and fungal cultures. sputum: cytology, microscopy, culture and sensitivity, and acid-fast bacilli (afb). radiology: chest x-rays (cxrs). ct scans without and with contrast enhancement were done prior to treatment and repeated days or weeks later depending on the patients’ clinical condition. presumed diagnosis of fbl: the accurate and definitive diagnosis of fbl is dependent on histopathology. in this study as we were unable to obtain histopathological diagnosis we presumed the diagnosis of the fbl by collating information obtained from the ct scans (at the time of presentation and on empiric treatment), csf and blood studies, cxr findings, associated non-neurological illness/es and response to treatment. presumed diagnosis of tb was based on some or all of the following: (i) ct brain scan appearance, i.e. hypodense or isodense rounded lesions with irregular walls of varying thickness, oedema and mass effect, cortical location, ring or nodular enhancement, and increased basal meningeal enhancement; (ii) positive tb culture in the csf; (iii) pulmonary tb (ptb) on cxr and/or afb on sputum microscopy; (iv) increased protein, decreased glucose, pleocytosis (lymphocytes and/or polymorphonuclear cells), positive tb elisa, pcr in the csf; (v) negative toxoplasma cft; and (vi) response to tb treatment, clinically and radiologically. neurosyphilis was diagnosed on the basis of csf serology (wr, tpha, fta). presumed diagnosis of toxoplasmosis was based on some or all of the following: (i) positive toxoplasma cft; (ii) cd4+ count less than 100 cells/mm3; (iii) hypodense, multiple (> 5) rim-enhancing lesions with oedema, with basal ganglia and original article 6 sa journal of radiology • july 2005 5-13pgs 9/28/05 9:20 am page 6 grey/white matter zones as common sites; and (iv) response to toxoplasma treatment. diagnosis of neurocysticercosis was based on some or all of the following: (i) regular thin-walled, cystic, ring-enhancing lesions (often with a scolex); (ii) intracranial calcifications; and (iii) positive blood and/or csf serology (elisa). cryptococcosis was diagnosed on csf studies (india ink, latex agglutination, fungal cultures). presumed diagnosis of pcnsl was based on some or all of the following: (i) hyperdense lesion/s, often confluent, with no oedema, homogeneous contrast enhancement, periventricular/subependymal in location, corpus callosum involvement; (ii) cd4+ count less than 100 cells/mm3; (iii) atypical lymphocytes in the csf; (iv) ebv pcr-positive in csf; and (v) no response to anti-tb or anti-toxoplasma treatment. presumed diagnosis of progressive multifocal leucoencephalopathy (pml) was based on some or all of the following: (i) lesions confined to white matter, hypodense, nonenhancing appearance on ct scan, t2 hyperintense and t1 hypointense signal on mri scans if performed, no mass effect; and (ii) jc (john cunningham) virus pcr-positive in csf. treatment: patients were treated with specific medication based on the presumed diagnosis: tb (isoniazid, rifampicin, pyrazinamide, ethambutol), neuroyphilis (ivi penicillin g), toxoplasmosis (sulfadiazine, pyrimethamine), and cysticercosis (albendazole). if response was good, the initial treatment regimen was continued. if response was poor, a new or second presumed diagnosis was entertained, and additional treatment for this diagnosis was instituted. the additional or new treatment was as described above. a good response was one in which the patient showed ongoing improvement measured radiologically by a reduction in size and/or number of lesions on scan. a poor response was one in which the patient showed no improvement with no change or worsening of the fbl on scan. results (tables i iii) age and sex the age range was 18 49 years (mean 33.5 years), with 19 male patients and 13 female patients (male/female 1.5:1). clinical presentation on cns examination there were focal signs in 21 patients (66%), normal in 9 patients (28%), dementia in 6 patients (19%), and encephalopathy in 2 patients (6%). patients were examined clinically on admission by the authors gm or am who were blinded to the ct scan result. once patients were recruited into the study the follow-up examinations done by either gm or am were not blinded. non-neurological illnesses non-neurological illnessess were present in 27 patients (84%): active ptb (19 patients (60%)), active ptb and tuberculous breast abscess (1 patient), tuberculous lymphadenitis (1 patient (diagnosed on fine needle aspirate)), pneumocystis carinii pneumonia (pcp) (1 patient (diagnosed on sputum cytology)), and positive syphilis blood serology (wr, tpha) (11 patients). cd4 counts and staging staging was determined using the centers for disease control (cdc) 1993 revised classification system for hiv infection and aids-defining illnesses.12 the patients had cd4+ t-lymphocyte counts ranging from 1 to 768 cells/mm3. four patients (12%) had cd4+ counts of greater than 500 cells/mm3. four patients (12%) had cd4+ counts between 200 and 500 cells/mm3. twenty-four patients (76%) had cd4+ counts of less than 200 cells/mm3. hiv viral loads hiv blood viral loads were obtained in 29 of the 32 patients. these ranged from 10 750 copies/ml to > 750 000 copies/ml. csf results there was elevated csf protein, with or without pleocytosis in 23 patients. cysticercosis elisa was positive in 8 patients, tb elisa was positive in 1 patient, tb pcr was positive in 1 patient, tb culture was positive in 1 patient, cryptococcal antigen was positive in 1 patient, syphilis serology was positive in 1 patient, atypical bcells were present in 1 patient, and toxoplasma immunoglobulin g (igg) was positive in 1 patient, normal in 7 patients (22%), and not performed in 2 patients for practical reasons. radiology chest x-rays features of ptb were present in 20 patients (63%), there were bilateral peri-hilar reticulo-nodular infiltrates in 1 patient, and cxr was normal in 11 patients (34%). original article 7 sa journal of radiology • july 2005 5-13pgs 9/28/05 9:20 am page 7 ct scans these were performed on admission and repeated days or weeks later depending on the patient’s clinical condition. the following observations were made: 12 patients had solitary lesions (38%) and 20 patients had multiple lesions (62%). in the 12 patients with solitary lesions the ct scans were suggestive of tb in 8 patients, neurocysticercosis in 3 patients and pcnsl in 1 patient. in the 20 patients with multiple lesions the ct scans were suggestive of tb/toxoplasmosis (12 patients), neurocysticercosis (3 patients), pml (1 patient), and tb/toxoplasmosis and neurocysticercosis (2 patients). two patients had cerebral infarcts. meningeal enhancement (fig. 1) was present in 5 of the 12 patients with solitary lesions and in 12 of the 20 patients with multiple lesions. none of the patients diagnosed radiologically as neurocysticercosis, pcnsl or pml had meningeal enhancement. the radiological diagnoses were therefore tb (17 patients), neurocysticercosis (6 patients), pml (1 patient), pcnsl (1 patient), tb/toxoplasmosis and neurocysticercosis (2 patients), tb/toxoplasmosis (3 patients), and in 2 patients cerebral infarcts (both had basal meningeal enhancement). presumed causes presumed diagnoses were determined after correlating the radiological diagnosis with blood, csf and non-neurological manifestations. the 2 patients with cerebral infarctions had meningitis. in 1 patient tb meningitis (tbm) was confirmed by culture positivity, and in the other cryptococcosis was identified on india ink stains and confirmed by fungal cultures and latex antigen tests. of the 17 patients with radiological diagnosis of presumed tb, 14 patients had active ptb (sputum afb-positive), 1 patient had histologically confirmed tb adenitis, 1 patient had pcp and 1 patient had no nonneurological disease. the csf and blood studies in these patients showed no specific diagnostic abnormalities other than neurosyphilis in 1 patient. tb cultures were negative in all 17 patients. one patient had a positive tb pcr in the csf. this patient had ptb and a solitary enhancing fbl. as indicated above, all 17 patients had increased basal meningeal enhancement. in this group correlating the radiological diagnosis with blood, csf and non-neurological manifestations did not alter the diagnosis. these patients were therefore treated with the 4-drug anti-tb regimen as firstline treatment. five patients had radiological diagnoses of tb/toxoplasmosis (2 of whom had associated neurocysticercosis). in these 5 patients, 1 had positive toxoplasma serology in the blood and csf. this patient had multiple enhancing fbl (including lesions suggestive of neurocysticercosis) on ct scan with basal meningeal enhancement. the patient also had ptb. one patient had a positive blood toxoplasma serology, no ptb, and multiple enhancing fbl with no basal meningeal enhancement on ct scan. the 3 other patients had ptb, negative toxoplasma serology, multiple enhancing fbl with no basal meningeal enhancement (including lesions suggestive of neurocysticercosis in 1 patient) on ct scan. in this group correlating the radiological diagnosis with blood, csf and nonneurological manifestations influenced the presumed diagnosis. one of these 5 patients was therefore diagnosed with isolated toxoplasmosis and treated with anti-toxoplasmosis treatment as first-line therapy. of the remaining patients in this group, 2 were classed as tb, 1 as tb and neurocysticercosis, and 1 as tb, toxoplasmosis and neurocysticercosis, and treated accordingly. the following presumed diagnoses were therefore made: 17 patients (53%) tb, 6 patients (19%) neurocysticercosis, 2 patients (6%) tb and neurocysticercosis, 2 patients (6%) multiple infarcts (1 tbm, 1 cryptococcal meningitis), 1 patient tb and neurosyphilis, 1 patient toxoplasmosis, 1 patient toxoplasmosis, tb and neurocysticercosis, 1 patient pml, and 1 patient pcnsl. in the patients with multiple infections as diagnoses, these were based on positive serology in the case of neurosyphilis, positive serology and ct scan features in the case of neurocysticercosis, basal enhancement on ct scan with non-neurological tb in the case of tb, and positive serology in the case of toxoplasmosis. original article 8 sa journal of radiology • july 2005 fig.1. ct scan showing basal meningeal enhancement in a patient with presumed tb. 5-13pgs 9/28/05 9:20 am page 8 treatment was instituted for each infection at the outset. response to empirical treatment initiated the following overall response to treatment was obtained (table iii): (i) good response 22 patients (69%); (ii) poor response 3 patients (9%); and (iii) demised 7 patients (22%). in the patients with a presumed diagnosis of tb and treated only with anti-tb treatment (17 patients): 12 patients had a good response (fig. 2) (cd4+ counts 21 to 610 cells/mm3), 3 patients had a poor response (cd4+ counts 1, 55, and 180 cells/mm3), and 2 patients demised (cd4+ counts 6, 14 cells/mm3). the 6 patients with neurocysticercosis (cd4+ counts 106 768 cells/mm3) responded well to treatment. the 2 patients with infarctions as fbl (cd4+ counts of 96 and 240 cells/mm3) demised. the patient treated as isolated toxoplasmosis (cd4+ count 8 cells/mm3) demised. in the mixed infection group (2 tb and neurocysticercosis, 1 tb and neurosyphilis, 1 tb, toxoplasmosis and neurocysticercosis) response to treatment was good in all 4 cases (cd4+ counts of 30 104 cells/mm3). the patients diagnosed with pcnsl (cd4+ count 22 cells/mm3) and pml (cd4+ count 7 cells/mm3) demised. the patient with presumed pml had autopsy confirmation of this diagnosis. the 3 poor responders to first-line tb treatment (all presumed tb) received additional anti-toxoplasmosis treatment and broad-spectrum antibiotics. there was no clinical or radiological change in spite of these added treatments during the followup period. discussion the fbls seen in our patients were determined to be almost exclusively infectious in nature. of the 32 patients only 1 patient was presumed to have a non-infectious aetiology (pcnsl). four patients (12%) were diagnosed with dual/multiple infections. dual/multiple cns infections are not common in hiv but have been described.13 we determined the principal presumed cause of fbl in our patients to be tb. the key features differentiating suspected tb from other infectious aetiologies were: concurrent presence of ptb or other non-neurological tb, and basal meningeal enhancement. the fbls in the patients with presumed tb were predominantly cortical, with thick irregular walls, hypodense centres, and rim enhancement. despite detailed analysis, of all the parameters used the only possible differentiating radiological feature was the presence of basal meningeal enhancement in tb (table ii). of the 22 patients presumed to have tb (alone or in combination with other infections), basal meningeal enhancement was present in 16 patients (72%). the patients with presumed toxoplasmosis and neurocysticercosis had no basal meningeal enhancement. patients with multiple infections who had basal meningeal enhancement all had tb as one of the presumed infections. the only patient with basal meningeal enhancement whose presumed diagnosis was not tb, had cryptococcal meningitis with cortical infarctions as the fbl. tb cultures were not helpful in the acute management of our patients. only 1 of our patients had a positive csf tb culture. this was the patient with tbm and cortical infarctions as the fbl. csf tb pcr and elisa were also of no value in our study, being positive in only 1 patient respectively. in terms of non-neurological tb, this was diagnosed in 21 (66%) of our patients, of whom 19 had active ptb. tb is endemic in our population.8,11 in the gauteng province of south africa in 1999, the incidence of tb was 270/100 000 population. in 2001 the incidence was 315/100 000. ptb accounts for 75% and extra-pulmonary tb accounts for 25% of cases (gauteng department of health — original article 9 sa journal of radiology • july 2005 fig. 2a and b. ct scans of a patient with presumed tb at presentation (top) and on antitb treatment after 6 weeks (bottom). 5-13pgs 9/28/05 9:20 am page 9 unpublished data obtained from dr riana louw, with permission). sixtythree per cent of our patients had ptb. it is therefore not surprising that our presumed diagnoses showed a bias towards tb. with regard to toxoplasmosis we found that only 2 of our patients had positive serology (1 in serum, 1 in csf and serum). prevalence figures for toxoplasmosis in our region and south africa as a whole have been published. in gauteng the prevalence amongst blacks is 29%,14 and in kwazulu-natal the prevalence is 46% in black pregnant women, the highest in the country.15 it may be, as is widely recognised, that serological tests are falsely negative in patients with advanced immunosuppression. however, active non-neurological toxoplasmosis has not been described in our population. we were unable to find data for toxoplasma retinitis, toxoplasma septicaemia, and toxoplasma pneumonitis in our adult population (with or without hiv). none of our patients had evidence of toxoplasmosis outside the nervous system. the kwazulu-natal study found toxoplasmosis as the main cause of hiv associated fbl.3 in another south african series of 38 hiv-infected patients with meningitis, toxoplasma igg was positive in 14 patients (37%).16 two of these 14 patients also had fbl, both of which were tb (one confirmed histologically) and responded to tb treatment.16 the only other study from this country on hiv-associated fbl concurred with our findings that tb is the commonest cause of hiv-associated original article 10 sa journal of radiology • july 2005 table i. focal brain lesions (fbls) – clinical and laboratory findings with presumed cause/s neurological non-neurological cd4+ count patient data examination illnesses csf results (cells/mm3) presumed cause n = 32 focal signs 66% ptb 60% elevated protein 59% 72%: < 200 53% tb m/f ratio 1.5: 1 normal 28% ptb+tb breast pleocytosis 9% 13%: 200 500 19% ncc (1 patient) mean age 33.5 yrs dementia 19% tb lymphadenitis tb pcr/elisa + 6% 15%: > 500 3% toxoplasmosis (1 patient) encephalopathy 6% pcp (1patient) cryptococcal ag + 3% 3% pml syphilis (11 patients) cysticercosis elisa + 21% 3% pcnsl syphilis + 3% 6% infarcts toxoplasma + 3% 13% mixed normal 22% csf = cerebrospinal fluid, tb = tuberculosis, ptb = pulmonary tuberculosis, pcp = pneumocystis carinii pneumonia, ncc = neurocysticercosis, pcnsl = primary central nervous system lymphoma, pml = progressive multifocal leucoencephalopathy, pcr = polymerase chain reaction, elisa = enzyme linked immunosorbent assay. table ii. imaging characteristics of focal brain lesions (fbls) fbl enhancement basal meningeal n type of lesions site of lesions wall definition density relative to brain characteristics enhancement 90 solitary 38% cortical 79% regular hyperdense 6% ring 63% present 53% multiple 62% subcortical 11% thick 0% isodense 9% nodular 6% absent 47% basal ganglia 7% thin 100% hypodense 85% lobular 3% bs/cerebellar 3% irregular gyriform 5% thick 61% mixed 21% thin 39% nil 2% n = number of fbls. 5-13pgs 9/28/05 9:20 am page 10 fbl.4 further studies are required to clarify this issue. in our patients the presence of positive toxoplasma serology was used as an indication for toxoplasmosis treatment. neurocysticercosis, alone or in combination with other infections occurred in 9 patients (28%). this may be a chance association of endemic infections.17 in a case report of 4 patients from zimbabwe, the occurrence of neurocysticercosis in hiv-positive patients was likewise suggested to be due to chance association in endemic regions or due to the effect of hiv on the host immune response to cysticercosis.17 non-specific host factors (innate resistance) together with acquired immunity are known to have an effect on the outcome of the primary infection in experimental models of cysticercosis.17 host immunity is also an important factor in limiting the occurrence of cysticercosis in humans.17 the immunodeficient state accompanying hiv infection might therefore increase the frequency and severity of neurocysticercosis.17 in our series the mean cd4+ count in patients with neurocysticercosis alone was 509 cells/mm3. these patients were therefore not immunocompromised. this implies a chance association. further studies in respect of this association will be needed. in contradistinction to the histopathologically based american guidelines,1 the initial treatment in the majority of our patients, where diagnosis (presumed) was based on collating clinical information (as described above), was directed against tb. only 1 patient had initial toxoplasmosis treatment alone. patients with multiple infections were treated for these different infections. sixty-nine per cent of patients improved clinically and radiologically. these patients had a mean cd4+ count of 188 cells/mm3. fifty-five per cent of these good responders were diagnosed with tb. twenty-seven per cent of the good responders had neurocysticercosis. the remainder had dual/multiple infections associated with tb. there were 3 poor responders (9%). the mean cd4+ count in these patients was 80 cells/mm3. all 3 were diagnosed with tb. seven of the 32 patients demised. these patients had a mean cd4+ count of 28 cells/mm3. in these patients the diagnoses were tb, toxoplasmosis, pml, pcnsl, and cryptococcosis. the good responders had higher cd4+ counts than those who responded poorly or demised. there was no similar correlation with blood hiv viral loads. this may imply that our diagnoses were more accurate in patients with cd4+ counts in excess of 100 cells/mm3 but that they were less accurate when the cd4+ counts were less than 100 cells/mm3. the patients who demised or responded poorly did not improve clinically or radiologically once additional treatments were instituted as described above. the patients who demised deteriorated rapidly, with death occurring within a few days of presentation to hospital. this may therefore also imply that the poor responders original article 11 sa journal of radiology • july 2005 table iii. treatment outcomes of focal brain lesions (fbls) cd4+ count cd4+ count hiv viral loads patients (n (%)) response (mean cells/mm3) presumed cause (range cells/mm3) (range copies/ml) 22 (69%) good 188 tb 55% 21 610 76 000 > 750 000 ncc 27% 107 768 10 751 305 123 tb + other 18% 63 238 288 281 > 750 000 3 (9%) poor 80 tb (100%) 1 180 647 696 > 750 000 7 (22%) demised 28 tb 44% 6 40 242 000 > 750 000 toxoplasmosis 14% 8 nd pcnsl 14% 22 > 750 000 pml 14% 7 > 750 000 cryptococcosis 14% 96 228 668 tb = tuberculosis, ncc = neurocysticercosis, pcnsl = primary central nervous system lymphoma, pml = progressive multifocal leucoencephalopathy, nd = not done. 5-13pgs 9/28/05 9:20 am page 11 original article 12 sa journal of radiology • july 2005 and those who demised did so from advanced immune deficiency rather than incorrect diagnosis and treatment of the fbl. a limitation of our study is the small number of patients and the lack of long-term follow-up. the patients who improved were discharged and continued treatment as outpatients. after a few consultations most were lost to further follow-up. conclusions our data demonstrate that applying the ‘developed nations guidelines for hiv associated fbl’ to a developing region could have a deleterious effect on outcome. this is largely because non-infectious aetiologies, namely pcnsl are uncommon and te is not necessarily the most frequent infectious aetiology. we agree with the british proposal that brain biopsies are not necessary for treatment. the aan guidelines are not possible to implement in developing regions, because of financial constraints and the limited availability of neurosurgical and neuropathological resources and services. in developing countries hiv-positive patients who present with fbl should be treated initially with medication specific to the infection that is endemic to that population. in areas where tb is endemic our results indicate that anti-tb treatment should be fig.3. algorithm for the initial assessment of hiv-associated focal brain lesions (fbls) in developing regions.( tb =tuberculosis, ncc = neurocysticercosis, toxo = toxoplasmosis, pcnsl = primary central nervous system lymphoma, pml = progressive multifocal leucoencephalopathy, + = positive, = negative.) 5-13pgs 9/28/05 9:20 am page 12 the initial treatment of known or suspected hiv-associated fbl. further studies of this nature from other developing regions are needed to validate our approach especially with respect to the role of the endemic infection, which is treatable and would influence outcome and survival. perhaps the most important contribution of our study is that we show that detailed laboratory investigations (such as hiv viral loads, viral cultures, tb cultures, tb elisa, tb pcr, and even cd4 counts) are not necessary to arrive at a reasonable presumed diagnosis of a fbl in hivpositive patients in order to institute effective treatment. ct scans of the fbl, with the exception of neurocysticercosis and possibly pml, were found to be nonspecific. the most useful parameters that assisted us were non-neurological illness, toxoplasma serology, and meningeal enhancement on ct scans. algorithm (fig. 3) on the basis of our results we propose the following approach to the presumed diagnosis and thereby initial treatment of hiv-associated fbl in developing regions. the important parameters as discussed above are meningeal enhancement on ct scan, presence of non-neurological tb, and toxoplasma serology. the fbls are first categorised into solid or cystic. the cystic fbls are indicative of neurocysticercosis (except in rare cases, e.g. hydatid). the solid fbls are subdivided into enhancing or non-enhancing lesions. lack of enhancement suggests pml. enhancing fbls are divided into those with and those without increased basal meningeal enhancement. the presence of increased basal meningeal enhancement is suggestive of tb. fbls without increased meningeal enhancement are separated on the basis of accompanying nonneurological tb and toxoplasma serology (see algorithm). initial treatment is instituted accordingly. patients are monitored clinically. good responders are maintained on this treatment. poor responders are reassessed with ct scans. presumed diagnosis and treatment is appropriately adjusted, e.g. addition of antitoxoplasma treatment, antibacterial treatment (pyogenic abscess). a limitation of this approach is the requirement of a ct scan for evaluation. in developing regions where this is not available, it might be best advised to treat suspected fbl in hiv patients for tb (in endemic areas) and toxoplasmosis. references 1. quality standards subcommittee of the american academy of neurology. evaluation and management of intracranial mass lesions in aids. neurol 1998; 50: 21 26. 2. sadler m, brink ns, gazzard bg. management of intracerebral lesions in patients with hiv: a retrospective study with discussion of diagnostic problems. qjm 1998; 91: 205 217. 3. bhigjee aj, naidoo k, patel vb, govender d. intracranial mass lesions in hiv-positive patients – the kwazulu/natal experience. s afr med j 1999; 89: 1284-1288. 4. smego ra, orlovic d, wadula j, modi g. a diagnostic and therapeutic algorithm for cns mass lesions in hiv/aids. s afr j epidemiol infect 2000; 15: 7-13. 5. trujillo jr, garcia-ramos g, novak is, rivera vm, huerta e, essex m. neurologic manifestations of aids: a comparative study of two populations from mexico and the united states. j acquir immune defic syndr hum retrovirol 1995; 8: 23-29. 6. lucas sb, hounnou a, peacock c, et al. the mortality and pathology of hiv in a west african city. aids 1993; 7: 1569-1579. 7. modi m, modi g. new onset seizures in hiv infected patients – a review and guide to management. s afr med j 2001; 91: 1025-1026. 8. karstaedt as, valtchanova s, barriere r, crewebrown hh. tuberculous meningitis in south african urban adults. qjm 1998; 91: 743-747. 9. santosh v, shankar sk, das s, et al. pathological lesions in hiv positive patients. indian j med res 1995; 101: 134-141. 10. mathew mj, chandy mj. central nervous system toxoplasmosis in acquired immunodeficiency syndrome: an emerging disease in india. neurol india 1999; 47: 182-187. 11. raviglione mc. the tb epidemic from 1992 to 2002. tuberculosis 2003; 83: 4-14. 12. centers for disease control. 1993 revised classifications system for hiv infection and expanded surveillance case definition for aids among adolescents and adults. mmwr cdc surveill summ. 1993: 1-19. 13. silber e, sonnenberg p, koornhof hj, morris l, saffer d. dual infective pathology in patients with cryptococcal meningitis. neurology 1998; 51: 1213-1215. 14. mason pr, jacobs mr, fripp pj. serological survey of toxoplasmosis in the transvaal. s afr med j 1974; 48: 1707-1709. 15. schneider e, schutte chj, bommerw. the prevalence of toxoplasma gondii infection in women of different ethnic groups in natal, south africa. s afr j epidemiol inf 1992; 7: 4145. 16. sonnenberg p, silber e, jentsch u. toxoplasmosis and hiv infection in southern africa. s afr j epidemiol inf 1998; 13: 104-106. 17. thornton ca, houston s, latif as. neurocysticercosis and human immunodeficiency virus infection – a possible association. arch neurol 1992; 49: 963-965. original article 13 sa journal of radiology • july 2005 reprinted from qjm 2004; 97: 413-421, with permission. 5-13pgs 9/28/05 9:20 am page 13 article information author: kimberly applegate1 affiliation: 1department of radiology and imaging sciences, emory university school of medicine, united states of america correspondence to: kimberly applegate email: keapple@emory.edu postal address: department of radiology and imaging sciences, emory university school of medicine, the emory clinic, inc., building c, 1365 clifton road, ne, room ct-076, atlanta, ga 30322, united states of america dates: received: 02 aug. 2015 accepted: 13 oct. 2015 published: 14 dec. 2015 how to cite this article: applegate k. image gently: a campaign to promote radiation protection for children worldwide. s afr j rad. 2015;19(2): art. #919, 5 pages. http://dx.doi.org/10.4102/sajr.v19i2.919 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. image gently: a campaign to promote radiation protection for children worldwide in this original research... open access • abstract • introduction • why reducing children’s and adolescents’ exposure to radiation from medical imaging matters    • increased use of medical imaging • the image gently campaign    • key principles of radiation protection    • campaign key goals    • campaign messaging for each modality • conclusion • acknowledgements    • competing interests • references abstract top ↑ with the goal of raising awareness and developing stakeholder educational tools for the appropriate imaging of children, the image gently campaign was launched in 2007. this campaign is a product of a multidisciplinary alliance with international representation which now numbers nearly 100 medical and dental professional societies and organisations, and includes regulatory organisations. the alliance focuses on increasing awareness and developing education materials that support the protection of children worldwide from unnecessary radiation in medicine. the alliance members work with agencies and regulatory bodies to improve standards and measures that are specific to children. the campaign has produced open source modules for all stakeholders regarding ct, fluoroscopy, nuclear medicine, interventional radiology, digital radiography and dental imaging. the philosophy of the image gently steering committee is to collaborate, to share information freely, to keep messaging simple and to commit to lifelong learning. many healthcare practitioners may not understand how to decrease children’s radiation exposure; the goal of image gently is to increase all stakeholders’ understanding of both the benefits and the risks and to encourage radiation reduction strategies. this article summarises the rationale and goals of the global campaign to date. introduction top ↑ unquestionably, diagnostic imaging has revolutionised modern medicine. many studies show that the appropriate use of radiology imaging tests saves lives and improves patient care. examples include computed tomography (ct) scans to diagnose or exclude appendicitis, trauma and acute vascular disorders.1 however, patients, especially young children, may face a potential cancer risk from repeated low-dose exposure to routine diagnostic medical imaging.2 the remarkable advance of imaging technology and its exponential increase in use over the past 25 years has led to an unanticipated increase in human exposure to radiation worldwide, including the population of the united states.3 determining the correct examination and dose is most important for children and adolescents, who are often more sensitive than adults to radiation, are potentially exposed to more lifetime risk from either early or ongoing exposures, and have a longer lifetime during which cancer from radiation exposure can develop. this article reviews the rationale behind the creation of the image gently campaign and the strategies used (awareness, advocacy and education) to reduce children’s exposure to radiation from diagnostic imaging. why reducing children’s and adolescents’ exposure to radiation from medical imaging matters top ↑ medical radiation is used for both diagnostic and therapeutic purposes. diagnostic imaging tests that use ionising radiation include the x-ray (or radiograph), fluoroscopy (and interventional cardiology and radiology) and ct scans. most importantly, radiation exposure may increase a child’s risk of cancer later in adult life, although definitive data are lacking, and exposure from medical imaging is a modifiable risk factor.2,4,5,6 other epidemiological data regarding the longterm effects of low-level radiation (100–150 milliseverts (msv)) exposure comes from the wellknown life span study of atomic bomb survivors in japan.the internaional council on radiation protection continues to uphold its stance that the linear non-threshold dose response assumption for extrapolating from high-dose exposures to the low doses used in medical imaging is the best interpretation of radiation-induced cancer risk for protection purposes.7,8 though controversial, this conservative model states that the risk from exposure to ionising radiation is estimated to be linear, from the known exposures during higher-dose events (e.g. atomic bombs dropped in japan and the nuclear power plant explosions in chernobyl) to exposures during low-dose events such as those that occur during medical imaging. a single abdominal ct scan exposes a teenaged patient to a low dose – typically no more than 10 msv of ionising radiation – although the dose depends on the reason for the ct scan and how it is performed.1,3 bear in mind that the overall lifetime risk of death due to cancer in developed nations is 20%–25%.3 the estimated increased risk of cancer over a lifetime from a single ct scan is estimated as being a tiny fraction of this risk (0.03%–0.05%).8,9 to put this percentage in perspective, researchers have estimated that the risk from one abdominal ct scan is about equal to the risk of a crash occurring if a car were driven 7500 miles (12 070 km) or a motorcycle 1000 miles (1609 km).10 given this small estimated risk, the critical principle is to determine which radiological examinations are necessary, when they are necessary, and how to ensure they are done with the lowest radiation dose to answer the clinical question. increased use of medical imaging the reason for focusing on ct scanning is that it is becoming an increasingly large source of radiation exposure – and it is a modifiable potential risk of cancer induction. diagnostic radiation accounts for approximately half of the united states population’s total annual radiation exposure.3 ct scans contribute the highest dose and they account for approximately half of adult medical radiation exposure and two-thirds of paediatric medical exposure.3 worldwide, an estimated 320 million ct scans are performed annually. the united states accounts for approximately one-quarter of all ct scans worldwide, representing more than 80 million each year.1,2,3,4,5,6 if we apply a recent estimate that 11% of ct scans being performed are on children, then the number of annual paediatric ct scans would be estimated to be up to 7.1 million in the united states.11 when the average effective dose per person in the united states increased from 3.6 msv in the 1980s to 6.2 msv in 2006, the percentage of the received dose from medical imaging increased from 15% to 48%.3 after establishing that radiation exposure from imaging is increasing, we must consider children’s unique situation. depending on their age, organ, and tumor type, children are reported to be on average 2–3 times more sensitive to radiation than adults, and the younger the infant or child, the more radiosensitive at high doses they are. however, a recent unscear report found that only 35% of cancers are associated with increased sensitivity in children compared to adults.8 in addition, children have a longer lifetime during which cancer may develop from exposure to radiation.6,12,7,8 for these reasons, we tend to have a more cautious approach to the use of ionising radiation imaging in children than in adults. the rate of ct use increases throughout the paediatric years and is the highest in the adolescent population – for example, imaging from trauma and to evaluate for suspicion of appendicitis.11 adolescent girls undergoing breast development have higher breast radiosensitivity at high doses compared to younger children or to adult women. adolescents also have higher thyroid radiosensitivity at high doses.8 although the individual risk estimates are small, the population risks from the rapid increase in ct use is of growing concern. small individual risks applied to an increasingly large population may create a public health issue some years in the future. in 2010, the american college of radiology developed a policy statement to respond to public media concern: the expanding use of imaging modalities using ionizing radiation may eventually result in an increased incidence of cancer in the exposed population; this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing imaging tests that are performed to obtain the best image quality with the lowest radiation dose.13 it is with this goal in mind that the image gently campaign seeks to educate concerned patients, families and healthcare professionals and to share information that will help to reduce radiation exposure to children and adolescents resulting from imaging. the image gently campaign top ↑ initiated by a group of paediatric radiologists in 2007, image gently is an educational, awareness and advocacy campaign of the alliance for radiation safety in pediatric imaging. the alliance is a coalition of healthcare, regulatory and guidance organisations dedicated to providing safe, high-quality paediatric imaging worldwide. the primary objective of the alliance is to raise awareness in the imaging community of the need to adjust the radiation dose when imaging children. the ultimate goal of the alliance is to change clinical practice so as to reduce radiation exposure. image gently is directed and run by a steering committee of volunteers with small financial contributions from the four founding organisations (the american association of physicists in medicine, american college of radiology, american society of radiologic technologists and society for pediatric radiology). comprising nearly 100 healthcare organisations and regulatory agencies,10 image gently attempts to include all stakeholders involved in paediatric imaging, including parents and families. stakeholders include more than 1 000 000 professionals throughout the world, including radiologists, technologists, medical physicists, dentists and paediatricians. all educational and promotional materials for the image gently campaign are provided free of charge (cf. http://www.imagegently.org). the timeline of major activities of the campaign is provided in figure 1. figure 1: the timeline of major activities by the alliance for radiation safety in pediatric imaging from inception to present. key principles of radiation protection one of the most important goals of image gently is to raise all stakeholders’ awareness about the three key principles of radiation protection: justification, optimisation and dose limits. these principles are based on the international council for radiation protection guidelines.7 justification focuses on appropriateness. we need to ask ourselves whether the benefits outweigh the risks of performing the imaging test on the individual patient. risks include potential harm such as later cancer induction from ionising radiation. in addition, in some instances, alternative diagnostic tests that do not use ionising radiation – such as ultrasound (us) or magnetic resonance imaging (mri) – can provide the same information as ct scans. image gently initiatives include producing and disseminating parent education brochures and informing the medical community about which imaging tests are best suited to common clinical indications and when alternative modalities such as mri and us may be substituted for ionising radiation tests. the second key principle of radiation protection is optimisation. image gently focuses on providing guidance so that imaging tests using ionising radiation are done to provide sufficient diagnostic information while at the same time limiting radiation exposure. for example, the alliance worked with its members to create ct imaging protocols that can be adjusted for the size of the infant and child rather than a one-size-fits-all protocol. there are free training modules for ct technologists to learn how to apply a number of important physics and technical parameters when imaging children in order to use the lowest possible radiation dose to achieve the necessary image quality. along these same lines, image gently provides members with periodic email updates on the latest educational modules, information from collaborative organisations, convenes summits and works with regulatory bodies (e.g. the food and drug administration [fda], joint commission, nuclear regulatory commission) to develop and promote appropriate dose standardisation and dose limits. these outcomes are aligned with the third key principle of radiation protection. dose limits in medicine are relative; surveys are used to develop dose reference levels for common imaging examinations, and audits should be performed to ensure compliance with good-quality practice. image gently efforts include partnering with equipment vendors and regulators to convene summits and discuss standard dose metrics across vendors, to explain the importance of accurate metrics for infants and children, and to have all stakeholders understand the consequences of radiation exposures in this unique population. finally, when we educate patients and caregivers and encourage a shared decision-making environment in healthcare, the health outcomes improve.14 campaign key goals the steering committee identified six key goals during its first five years of volunteer work.15 the first was to provide educational materials to parents to help them understand the benefits and potential risks of medical imaging before their child underwent a test or procedure. these materials include questions for them to ask the referring physician and achieve the outcome of shared decision-making. the second goal was to tailor the imaging equipment for use in children. this effort involved vendor summits that brought together radiologists, physicists, radiographers, educators, the fda and members from mita (the medical imaging and technology alliance). the third goal was to provide educational materials to users of imaging equipment. these materials included web modules and slide presentations that were developed for meetings and local presentations to medical practitioners, including radiographers. the fourth goal was to develop a radiation dose estimate for individual ct scans based on the specific size of the patient. with the collaboration of the image gently alliance, in 2011, the aapm (american association of physicists in medicine) published a method to adjust for the patient’s trunk size (chest, abdomen and/or pelvis) by converting the volume ct dose index (ctdivol) into a size-specific dose estimate (ssde).16 the ssde uses the scout image from the ct imaging to calculate the adjusted dose estimate automatically. the fifth goal was to provide a way for patients and their families to track examinations, and eventually doses. image gently provides a written guide for patients and families to track examinations and dates without needing to understand the dose indices. currently, healthcare facilities are required or encouraged to track doses. new software will make this more widely possible. the sixth and final goal was the development of dose reference levels (drls) for common paediatric imaging examinations. ct and nuclear medicine examination drls have been developed but more need to be generated using the expansion of the american college of radiology dose index registry programme and/or the european union drls. campaign messaging for each modality an educational and awareness campaign should capture the attention of its intended audience. the messaging uses the science of social marketing techniques to provide educational materials that are open source to eliminate barriers to best practices at the local level.15 the simple message of the initial ct scan educational rollout to the medical community states that ‘one size does not fit all’ (figure 2). the campaign has a few important, eye-catching messages. first, imaging is a positive force in medicine. second, we all must be aware of the radiation protection principles when we use ionising radiation, especially in children. and third, the following are a few simple things we all can do when we perform ionising radiation imaging tests (e.g. ct scans) that will reduce childhood radiation exposure: figure 2: the image gently campaign’s simple message about ct scanning in children. the photograph of the girl shows her wearing an adult-sized life jacket, which is paired with the message that ‘one size does not fit all’. for safety reasons, we would not put an adult life jacket on a child; equally, we should not perform an imaging test on a child using an adult level of ionising radiation. (reprint permission granted by the image gently campaign). clearly, imaging saves children’s lives, but when we image, radiation matters. children are more sensitive to radiation [than adults]. what we do now lasts a lifetime. so when we image, let’s image gently. more often is not better. when using ionizing radiation for pediatric imaging, remember the following: (1) take into account the patient’s age and size and then dose accordingly, (2) most information can be gained from a single study, please do not repeat studies unnecessarily, and (3) image only the indicated area.10 the image gently campaign has created educational information for each ionising radiation modality (ct scan, fluoroscopy, radiography, nuclear medicine, interventional radiology and dental imaging), beginning with ct scans. each educational module provides information for all stakeholders involved in paediatric diagnostic imaging: (1) the radiologists, medical physicists and technologists who plan, carry out and interpret imaging tests, (2) the referring providers who order imaging tests, and (3) the patients, parents and caregivers. in addition, image gently advocates best practices specifically for children because educational efforts and national guidelines alone cannot achieve the goals of radiation protection. examples of educational strategies include a brochure for parents and patients: ‘what parents should know about ct scans for children: medical radiation safety’ (figure 3). this brochure is available in many languages, and it describes in lay language what an x-ray and a ct scan are, and presents imaging alternatives to ct. it also suggests questions that patients or caregivers can ask healthcare workers about the quality of an imaging facility (e.g. questions about licensing, credentialing and accreditation) and provides data on relative radiation doses and potential cancer risk. there are also addresses of websites for those who want further information. image gently encourages radiology departments, emergency departments and paediatric offices to hand out these brochures to patients and patients’ caregivers. alternatively, if resources are limited, the brochures may be displayed in the facility waiting area. figure 3: parent brochure describing medical radiation and radiation safety from image gently for patients and families. notice that the colours are bright and the photograph has a smiling child with a health worker. the full brochure is available at http://www.imagegently.org (reprint permission granted by the image gently campaign). to educate practitioners, image gently describes the alara (‘as low as reasonably achievable’) principle on its website. this principle is one of minimising radiation exposure to both patients and radiation workers. for workers, alara is typically linked to a dose limit. for patients, we use diagnostic reference levels for common imaging tests that patient doses should generally not exceed. conclusion top ↑ diagnostic imaging using ionising radiation, and in particular ct, is commonly used for children’s and adolescents’ medical care. radiological tests have many medical benefits, yet these imaging tests must be justified, optimised and audited for children’s care. it is with this knowledge in mind that image gently seeks to promote education and awareness of best practices and shared decision-making with concerned patients, families and healthcare professionals. such work has led to decreased radiation doses in paediatric ct protocols and to partnerships with regulators with the aim of promoting best practices. image gently embodies the hippocratic oath ideal, in that while agreeing that diagnostic imaging is an exceptional medical tool, healthcare practitioners must also agree to use it judiciously in order to minimise the risks to patients, and to remember: ‘first, do no harm.’ acknowledgements top ↑ competing interests the author is a member of the steering committee of image gently. references top ↑ rubin gd. computed tomography: revolutionizing the practice of medicine for 40 years. radiology. 2014;273:s45–s74. pmid: 25340438, http://dx.doi.org/10.1148/radiol.14141356 mathews jd, forsythe av, brady z, et al. cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million australians. bmj. 2013;346:f2360. pmid: 23694687, http://dx.doi.org/10.1136/bmj.f2360 schauer da, linton ow. ncrp report no. 160, ionizing radiation exposure of the population of the united states, medical exposure—are we doing less with more, and is there a role for health physicists? health phys. 2009;97(1):1–5. pmid: 19509507, http://dx.doi.org/10.1097/01.hp.0000356672.44380.b7 pearce ms, salotti ja, little mp, et al. radiation exposure from ct scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. lancet. 2012;380:499–505. pmid: 22681860, http://dx.doi.org/10.1016/s0140-6736(12)60815-0 huang wy, muo ch, lin cy, et al. paediatric head ct scan and subsequent risk of malignancy and benign brain tumour: a nation-wide population-based cohort study. br j cancer. 2014;110(9):2354–2360. pmid: 24569470, http://dx.doi.org/10.1038/bjc.2014.103 boice jd. radiation epidemiology and recent paediatric computed tomography studies. ann icrp. 2015;44(1 suppl):236–248. http://dx.doi.org/10.1177/0146645315575877 international commission on radiological protection. 2007 recommendations. icrp publication 103. ann. icrp 37 (2–4). oxford: elsevier; 2007. unscear. sources, effects and risks of ionizing radiation. annex b: uncertainties in risk estimates for radiation-induced cancer. united nations scientific committee on the effects of atomic radiation. new york: united nations; 2012. berrington de gonzalez a, darby s. risk of cancer from diagnostic x-rays: estimates for the uk and 14 other countries. lancet. 2004;363(9406):345–351. pmid: 15070562. home. image gently campaign. available from: http://www.imagegently.org/procedures/computedtomography.aspx dorfman al, fazel r, einstein aj, et al. use of medical imaging procedures with ionizing radiation in children: a population-based study. arch pediatr adolesc med. 2011;165(5):458–464. pmid: 21199972, http://dx.doi.org/10.1001/archpediatrics.2010.270 pierce da, preston dl. radiation-related cancer risks at low doses among atomic bomb survivors. radiat res. 2000;154(2):178–186. http://dx.doi.org/10.1667/0033-7587(2000)154[0178:rrcral]2.0.co;2 amis es, jr., butler pf. acr white paper on radiation dose in medicine: three years later. j am coll radiol. 2010;7(11):865–870. pmid: 21040868, http://dx.doi.org/10.1016/j.jacr.2010.04.006 bulas d, goske m, applegate k, wood b. image gently: improving health literacy for parents about ct scans for children. pediatr radiol. 2009;39(2):112–116. pmid: 19083213, http://dx.doi.org/10.1007/s00247-008-1101-9 goske mj, applegate ke, bulas df, et al. image gently 5 years later: what goals remain to be accomplished in radiation protection for children? ajr. 2012;199(3):477–479. pmid: 22915386, http://dx.doi.org/10.2214/ajr.12.9655 boone jm, strauss kj, cody dd, et al. size-specific dose estimate (ssde) in paediatric and adult body ct examinations. aapm report no. 204. 2011. available from: www.aapm.org/pubs/reports/rpt_204.pdf contents tib 17 sa journal of radiology • october 2005 abstract how contrast medium-induced nephropathy (cin) comes about is poorly understood, although cin is a common cause of acute renal failure. hitherto, the various studies performed have led to different interpretations and partially contradictory conclusions. this article aimed to review the mechanisms underlying cin and to outline existing data obtained with the newer iodinated agents in patients with pre-existing renal failure. osmolality, which has received considerable attention, is but one of several physico-chemical properties of contrast media (cm). the more recently developed iso-osmolar cm are dimers, not monomers as the widely used non-ionic low osmolar cm. thus, in spite of them being iso-osmolar, they have physicochemical features different from other cm, e.g. in terms of viscosity (> 5 fold greater than plasma viscosity), which may be of considerable pathophysiologic and clinical importance. many experimental studies provide evidence for greater perturbation in renal function with iso-osmolar cm compared with non-ionic lowosmolar cm. conversely, some clinical trials indicate an advantage of the iso-osmolar cm, although others do not. in this review, the possible causes of cin are highlighted, including altered rheological properties, perturbation of renal haemodynamics, regional hypoxia, autoand paracrine factors (adenosine, endothelin, reactive oxygen species) and direct cytotoxic effects. it is concluded that caution must be taken to avoid a false sense of security with the use of iso-osmolar cm. introduction this review critically surveys recent clinical studies with regard to contrast medium-induced nephropathy (cin) and focuses on mechanisms believed to mediate cin, which implies impairment of renal function occurring within 3 days of the intravascular administration of contrast medium (cm) and the absence of an alternative aetiology.1,2 an increase in serum creatinine by more than 25% or 44 µmol/l (0.5 mg/100 ml, within 48 72 hours of contrast administration) is often taken as a marker for the occurrence of cin. 3-6 the serum creatinine concentration typically peaks on the second or third day after exposure to cm and usually returns to the baseline value within 2 weeks.7,8 generally, cin is reversible. nevertheless, the use of cm increases inhospital morbidity, mortality and costs, in particular in those rare cases where dialysis is required. thus, despite the small relative risk of developing adverse effects, cin is the third leading cause of acute renal failure in patients who have been admitted, accounting for 10% of all cases.9,10 the incidence of nephropathy induced by lowosmolar cm is low in the general population and has been calculated to be less than 2%.11,12 in selected subgroups of patients, however, like those with pre-existing renal insufficiency or diabetes mellitus or a combination of both, the incidence is significantly higher, in the range of 12 50%10,13-17 requiring transient dialysis or progress to end-stage renal disease.18 risk factors by far the greatest risk of developing cin is pre-existing renal impairment combined with diabetes, dehydration, or a combination of both.19 remarkably, however, original article potential mechanisms behind contrast medium-induced nephropathy p b persson d med, d med habil a patzak d med, d med habil institute of physiology humboldt university berlin, germany table i. osmolality and viscosity for various cms. note differences in iodine concentrations physicochemical properties of cm iodine concentration viscosity osmolality generic name (mg/ml) (mpa’s at 37°c) (at 37°c mosm/kg h2o) iopamidol 300 5.25 636 iopromid 300 4.6 610 iohexol 300 5.7 690 ioxaglate 320 7.5 600 iomeprol 300 4.5 521 iodixanol 320 11.4 290 diatrizoat 292 4.0 1500 iopentol 300 6.5 640 iotrolan 300 8.1 320 pg17-21 9/28/05 2:32 pm page 17 18 sa journal of radiology • october 2005 diabetes mellitus per se without renal insufficiency is not a risk factor.15 additional risk factors are: dosage of cm and type of cm, congestive heart failure, old age, hypertension, route of administration of cm, and the use of other nephrotoxic drugs.13,20 any condition associated with decreased effective circulating volume enhances vulnerability with regard to cin.19 of course, other causes of acute renal failure, such as atheromatous embolic disease, ischaemia, prerenal azotemia, sepsis, or other nephrotoxins should always be considered, particularly if cin is suspected in a patient without known risk factors. for example, cin might be mistaken for cholesterol crystal embolisation after intravascular catheterisation. when comparing the renal effects of different vascular contrast agents in patients with normal renal function, there are inconclusive results in the literature. patients with no pre-existing renal impairments have been shown to be highly resistant to cin, even when using ionic highosmolar cm.3,21 unfortunately, though, patients with pre-existing renal impairments are to a large extent also the patients requiring angiography22 and in this subpopulation high doses of cm increases the risk for cin.23 substance groups for over 50 years the various available cm have been based on triiodobenzene. their characteristics vary due to the osmolality and ionicity of the product. earlier, during the time of high-osmolar cm (which have osmolalities approximately 6 times higher than plasma found in broad clinical use), it made sense to differentiate cm with regard to osmolality. however, already then it was obvious that many of the side-effects were actually caused by the electric charge. the current use of lowosmolar cm (which still have considerably higher osmolality than plasma) and isoosmolar cm is widespread and it may be that the subdivision of cm according to their osmolality should be reconsidered. this is so since iso-osmolar cm are dimers, thus revealing greater viscosities than the monomeric low-osmolar cm (table i). as outlined below, this difference can be of importance for renal and systemic haemodynamics. clinical studies use of the more modern cm that are lowor iso-osmolar has reduced the likelihood of cin compared with high-osmolar cm. in a prospective, randomised study involving 1 196 patients undergoing angiocardiography, rudnick et al.5 found no differences in incidence of nephropathy between patients receiving iohexol (lowosmolar, 780 mosm/kg h2o) and patients receiving diatrizoate (high-osmolar, 1 870 mosm/kg h2o) among low-risk patients (patients without diabetes who had a baseline serum creatinine concentration of less than 1.5 mg/dl (133 µmol/l)). however, in patients without diabetes whose serum creatinine concentrations were higher than 1.5 mg/dl, the incidence of nephropathy was reduced from 27.0 to 12.2% with the use of iohexol.5 for patients with diabetes, the incidence was reduced from 47.7 to 33.3%. overall, patients receiving high-osmolar cm were 3.3 times as likely to develop cin as those receiving low-osmolar cm. for all practical purposes, all the newer lowosmolar or iso-osmolar agents are considered to be the agents of choice in patients at higher than usual risk for the development of cin.19 some comparative studies in patients with pre-existing renal impairment have shown similar susceptibility for cin with both nonionic monomeric and nonionic dimeric cm,24-26 whereas other trials have concluded that iso-osmolar cm have advantages with regard to the occurrence of cin in renally impaired patients.1,27 in particular aspelin et al.1 in the nephric study concluded that iohexol (n = 65) was significantly more nephrotoxic than the nonionic dimer iodixanol (n = 64) in patients with pre-existing chronic renal failure undergoing coronary or aortofemoral angiography. these results have received considerable attention due to the conclusions of the authors, but also due to some serious shortcomings of the study design. previous studies have shown that critical factors for the susceptibility of cin are duration of diabetes, metabolic status and renal function before cm injection.8 the investigated groups in the study of aspelin and co-workers1 were significantly different in all of these parameters and thus the outcome of the study is more likely to reflect the differences of the studied populations rather than differences of the administered cm with regard to cin. in addition, the hydration regimen was not pursued with vigour, as indicated by considerable variance in fluid intake. the conclusion of the nephric study that the use of iso-osmolar cm, as opposed to low-osmolar cm, results in reduced incidence of cin is not in line with our current understanding of cin, as mentioned below, and contradicts studies in which the use of iso-osmolar cm conferred no advantage.28,29 in light of the controversy whether patients at risk actually benefit from iso-osmolar cm1,27 or not24-26 and the experimental data on physiologic/pathophysiologic renal mechanisms that do not support any beneficial effects of iso-osmolar cm, the cm of choice still remains an open question.30 mechanisms of cin there is a particularly vulnerable kidney region in the deeper portion of the outer medulla. this is an area remote from the vasa recta that supply the renal medulla with blood. the reason for the vulnerability of the outer medullary portion of the nephron is the relative high oxygen requirements due to salt reabsorption. in this area of the kidney, the limbs of the loop of henle exhibit hypoxic damage, for instance by perfusion with erythrocyte free solution.31 oxygen delivery to the peripheral tissues can be impaired by cm due to an increase oxygen affinity of haemoglobin.32 it is not fully clear what the underlying mechanism is with regard to cin. several suggestions have been put forward and it is widely held that a combination of various mechanisms need to act in concert to cause cin.19 among these mechanisms, a reduction in renal perfusion caused by a direct effect of cm on the kidney and toxic effects on the tubular cells are generally recognised as important. however, the pathophysiological relevance of direct effects of cm on original article pg17-21 9/28/05 2:32 pm page 18 19 sa journal of radiology • october 2005 tubular cells remains disputed,19 as are the other proposed aetiologies. by adding cm to the perfusate of the kidney, hypoxic injury to the region at risk is enhanced, probably by increasing renal vascular resistance.33 it has been shown that an iso-osmolar dimer with high viscosity (iodixanol) compromises blood flow to all regions of the kidney to a greater extent than low-osmolar, and even high-osmolar cm.29 however, it must be kept in mind that this decrease in perfusion was accompanied by profound systemic effects of iodixanol. blood pressure in this study dropped considerably.29 in fact, it is well known that local renal hypoxia can be aggravated by the systemic effects of some cm, such as transiently reduced cardiac output,34 and suboptimal pulmonary perfusion-ventilation relationship.35 another study36 supports the particular potency of dimeric cm in causing renal hypoxia – the iso-osmolar cm iotrolan was also found to impair local po2 to a greater extent than the low-osmolar cm iopromide. the tubuloglomerular feedback (tgf) is a powerful mechanism in the control of renal vascular resistance and glomerular filtration and has often been taken as an explanation for the development of cin. specifically, it is believed that increased osmotic pressure brought about by cm elicits renal ischaemia. the macula densa cells of the thick ascending limb mediate the tgf by sensing na+, k+, and clconcentrations in the tubular fluid via the na+-k+-2clcotransporter. this transporter is effectively blocked by furosemide. the affinity for clis very low, so in a physiological setting there will always be enough na+ and k+ to keep the system running; clis the limiting factor.37,38 a widespread explanation for the development of cin is that hyperosmotic cm causes an increased osmotic gradient at the macula densa, which activates the tgf and subsequently compromises renal blood flow and glomerular filtration. obviously, this chain of events is not a likely explanation for cin, and this has been shown already by pioneer experiments with retrograde perfusions of the tubule. in this setting, osmolality has no effect on the tgf.37,38 the ruling out of the osmotic diuresis theory is further supported by experiments using mannitol, an osmotic diuretic. increases in osmolality, such as after mannitol infusion or after cm application, decrease nacl concentration at the macula densa, however, simultaneously increasing tubular flow. therefore, the resulting net change in the amount of nacl passing the macula densa is negligible.39 moreover, furosemide, a known blocker of the tgf, does not decrease serum creatinine after application of cm, which is usually the parameter taken to indicate cin.2 blocking the transport using furosemide should dramatically lower local oxygen consumption and alleviate the reduced oxygen supply. in fact, this has been demonstrated to occur in experiments in rats showing that outer medullary po2 is elevated after furosemide.40 however, furosemide given just before angiography fails to limit increases in serum creatinine after cm application, indicating that yet other mechanisms are involved in cin.2 among the often-discussed mechanisms, endothelin and adenosine have received much attention. the effects of endothelin on vascular beds is very dependent upon the receptor subtype activation, but both subtypes of receptors (et-a and et-b) are thought to mediate the vascular actions of endothelins in human blood vessels.41 endothelin has been suggested as a key element in the scenario leading to cin because of the elevated endothelin levels in plasma and urine that are found after cm application.42-44 further support for the role of endothelin in cin is derived from the observed enhancement of endothelin transcription and release from endothelial cells in response to cm.45 finally, in patients with impaired renal function, the increase in endothelin after giving cm is exaggerated.46 a potential beneficial effect of endothelin in preventing cin may be mediated by the et-b mediated effects, such as vasorelaxation. thus, a selective eta receptor blockade could prove to be effective in the prevention of cin. indeed, a positive effect of et-a selective blockade on the renal outer medullary hypoxic response to cm has been reported in the normal rat.47 however, when both et-a and et-b receptors are blocked in humans receiving cm, serum creatinine concentration rises to a greater extent than in patients receiving placebo and the cin incidence is significantly increased in the patients who received combined et-a and et-b blockade.48 diabetes mellitus is among the most important risk factors for cin and diabetics often have endothelial dysfunction of renal vessels. in this setting, no is suppressed in the renal microvasculature which contributes to the endothelial dysfunction.49 superoxide is a scavenger of no and may cause the attenuated no activity found in the diabetic renal microvasculature. indeed, superoxide production has been found to be increased in renal cortical tissue from diabetic rats50 and the afferent and efferent arteriolar vasoconstrictor response to nos inhibition is impaired.51 taken together, superoxide, and perhaps other reactive oxygen species (ros) may be crucial in the development of cin. since ros are extracellular signalling molecules, they may be significant in mediating the part of the endothelin effects.57 due to the possible role of ros in cin, clinical trials have been undertaken to prevent cin by scavenging ros.52-55 in these trials, n-acetylcysteine was given and showed a positive outcome in four studies.53-56 however, this recommendation is by no means unequivocal.57 in analogy to endothelin, a prominent role in causing cin has also been suggested for adenosine. the renal vasculature of diabetics reveals an enhanced sensitivity to adenosine, thus it has been suggested that adenosine is a particularly important contributor to cin in patients with this metabolic disorder.58 however, the role for adenosine in cin may be considerably overestimated. for instance, in normal rats,59 a1-receptor blockade fails to alleviate medullary hypoperfusion and hypoxia in response to cm. moreover, the general reduction in renal plasma flow and gfr caused by cm is not attributable to enhanced adenosine action.60 cm can also have direct cytotoxic effects on renal tubular cells. a perturbation of mitochondrial enzyme activity and mitochondrial membrane potential is found under ex vivo conditions in a proximal tubule cell line.61 noteably, low-osmooriginal article pg17-21 9/28/05 2:32 pm page 19 lar monomeric cm cause less damage than iso-osmolar dimeric cm and ionic compounds reveal the most profound effect.61 in the more distal segments of the kidney, cm can cause apoptosis, as indicated in another cell line model.62 apoptosis may be brought about by hypoxic damage63 and by a direct influence on these cells.62 a quite simple mechanism that seems to be of paramount importance for the development of cin has hitherto attracted rather little attention: the rhelogical properties of cm. the viscosity of the fluid is of particular importance with regard to the renal vascular bed, since the length of the capillaries that supply the renal medulla with blood are extremely long. although the vasa recta have the same diameter as usual capillaries, they are several cm long. this increases vascular resistance, as indicated by poiseuille’s law: (equation 1) r=η *8*1/π*r4 (η is viscosity, l refers to the length of the vessel and r is the radius). the viscosity of the blood flowing through the vasa recta is maintained very low in order to minimise the large resistance caused by capillary length. this is brought about by the fåhraeus-lindqvist effect and plasma skimming. the fåhraeus-lindqvist effect guarantees that blood viscosity in the capillary is very low. in fact, it is not much higher than plasma viscosity. this is so due to the high-flow velocity of the erythrocytes flowing through capillaries (single line flow). in effect haematocrit is very low in these vessels. the low haematocrit is further brought about by plasma skimming: the afferent arterioles separate from the interlobular arteries at a right angle. since the erythrocytes are concentrated in the centre of the interlobular arteries (laminar flow), the plasma-rich blood near the endothelium is skimmed off into the juxtamedullary afferent arterioles. taking these general considerations in to account, it is clear that iso-osmolar cm are not a priori superior to low-osmolar agents, since the dimeric iso-osmolar cm have very high viscosities. therefore, isoosmolar cm should impair renal medullary blood flow to a greater extent than low-osmolar agents, which indeed seems to be the case, as indicated by the particularly reduced po2 levels caused by iso-osmolar cm (fig. 1). augmented fluid viscosity caused by dimeric iso-osmolar cm may be of even more importance in the renal tubule. under normal conditions, tubular fluid is of lower viscosity than plasma, as the ultrafiltrate contains very few plasma proteins. use of dimeric iso-osmolar cm will increase tubular fluid viscosity dramatically and thereby increase the resistance to flow in renal tubules.64 in consequence, renal interstitial pressure may take on values as high as 50 mmhg (fig. 2). such pressure will dramatically decrease renal medullary flow and decrease gfr. volume expanding the patient before application of cm will markedly alleviate this effect since the cm will not become as concentrated in the renal collecting ducts. this may be the mechanism responsible for the generally accepted best way to prevent cin: periprocedural hydration.2,65,66 conclusions the current understanding of cin development now includes the rheological properties of a fluid. resistance depends on fluid viscosity, not osmolality (poiseuille’s law). thus, perhaps too much attention has been directed to the osmolality of different cm, while neglecting the impact of other physicochemical properties. well-controlled animal studies cannot confirm that iso-osmolar cm are superior with regard to the occurrence of cin. the contrary seems to be the case. references 1. aspelin p, aubry p, fransson sg, et al. nephrotoxic effects in high-risk patients 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146: 1094-1097. 36. liss p, nygren a, erikson u, et al. injection of low and iso-osmolar contrast medium decreases oxygen tension in the renal medulla. kidney int 1998; 53: 698-702 37. briggs jp, schnermann j, wright fs. failure of tubule fluid osmolarity to affect feedback regulation of glomerular filtration. am j physiol 1980; 239: f427-f432. 38. schnermann j, ploth dw, hermle m. activation of tubulo-glomerular feedback by chloride transport. pflugers arch 1976; 362: 229-240. 39. leyssac pp, holstein-rathlou nh, skott o. renal blood flow, early distal sodium, and plasma renin concentrations during osmotic diuresis. am j physiol regul integr comp physiol 2000; 279: r1268-r1276. 40. liss p, nygren a, ulfendahl hr, et al. effect of furosemide or mannitol before injection of a nonionic contrast medium on intrarenal oxygen tension. adv exp med biol 1999; 471: 353-359. 41. seo b, oemar bs, siebenmann r, et al. both eta and etb receptors mediate contraction to endothelin-1 in human blood vessels. circulation 1994; 89: 1203-1208. 42. bagnis c, idee jm, dubois m, et al. role of endothelium-derived nitric oxide-endothelin balance in contrast medium-induced acute renal vasoconstriction in dogs. acad radiol 1997; 4: 343348. 43. clark ba, kim d, epstein fh. endothelin and atrial natriuretic peptide levels following radiocontrast exposure in humans. am j kidney dis 1997; 30: 82-86 44. heyman sn, clark ba, kaiser n, et al. radiocontrast agents induce endothelin release in vivo and in vitro. j am soc nephrol 1992 3:58-65. 45. oldroyd sd, morcos sk. endothelin: what does the radiologist need to know? br j radiol 2000; 73: 1246-1251. 46. fujisaki k, kubo m, masuda k, et al. infusion of radiocontrast agents induces exaggerated release of urinary endothelin in patients with impaired renal function. clin exp nephrol 2003; 7: 279-283. 47. liss p, carlsson po, nygren a, et al. et-a receptor antagonist bq123 prevents radiocontrast mediainduced renal medullary hypoxia. acta radiol 2003; 44: 111-117. 48. wang a, holcslaw t, bashore tm, et al. exacerbation of radiocontrast nephrotoxicity by endothelin receptor antagonism. kidney int 2000; 57: 1675-1680. 49. schnackenberg cg. physiological and pathophysiological roles of oxygen radicals in the renal microvasculature. am j physiol regul integr comp physiol 2002; 282: r335-r342. 50. ishii n, patel kp, lane ph, et al. nitric oxide synthesis and oxidative stress in the renal cortex of rats with diabetes mellitus. j am soc nephrol 2001; 12: 1630-1639. 51. palm f, cederberg j, hansell p, et al. reactive oxygen species cause diabetes-induced decrease in renal oxygen tension. diabetologia 2003; 46: 11531160. 52. briguori c, manganelli f, scarpato p, et al. acetylcysteine and contrast agent-associated nephrotoxicity. j am coll cardiol 2002; 40: 298303. 53. diaz-sandoval lj, kosowsky bd, losordo dw. acetylcysteine to prevent angiography-related renal tissue injury (the apart trial). am j cardiol 2002; 89: 356-358. 54. shyu kg, cheng jj, kuan p. acetylcysteine protects against acute renal damage in patients with abnormal renal function undergoing a coronary procedure. j am coll cardiol 2002; 40: 1383-1388. 55. tepel m, van der giet m, schwarzfeld c, et al. prevention of radiographic-contrast-agentinduced reductions in renal function by acetylcysteine. n engl j med 2000; 2200:: 180-184. 56. kay j, chow wh, chan tm, et al. acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention: a randomized controlled trial. jama 2003; 289: 553-558. 57. durham jd, caputo c, dokko j, et al. a randomized controlled trial of n-acetylcysteine to prevent contrast nephropathy in cardiac angiography. kidney int 2002; 62: 2202-2207. 58. pflueger a, larson ts, nath ka, et al. role of adenosine in contrast media-induced acute renal failure in diabetes mellitus. mayo clin proc 2000; 75: 1275-1283. 59. liss p, carlsson po, palm f, et al. adenosine a (1) receptors in contrast media-induced renal dysfunction in the normal rat. eur radiol 2004; 14: 1297-1302. 60. oldroyd sd, fang l, haylor jl, et al. effects of adenosine receptor antagonists on the responses to contrast media in the isolated rat kidney. clin sci (lond) 2000; 98: 303-311. 61. hardiek k, katholi re, ramkumar v, et al. proximal tubule cell response to radiographic contrast media. am j physiol renal physiol 2001; 280: f61-f70. 62. hizoh i, strater j, schick cs, et al. radiocontrastinduced dna fragmentation of renal tubular cells in vitro: role of hypertonicity. nephrol dial transplant 1998; 13: 911-918. 63. beeri r, symon z, brezis m, et al. rapid dna fragmentation from hypoxia along the thick ascending limb of rat kidneys. kidney int 1995; 47: 1806-1810. 64. ueda j, nygren a, hansell p, et al. influence of contrast media on single nephron glomerular filtration rate in rat kidney. a comparison between diatrizoate, iohexol, ioxaglate, and iotrolan. acta radiol 1992; 33: 596-599. 65. murphy sw, barrett bj, parfrey ps. contrast nephropathy. j am soc nephrol 2000; 11: 177-182. 66. trivedi hs, moore h, nasr s, et al. a randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity. nephron clin pract 2003; 93: c29-c34. original article pg17-21 9/28/05 2:32 pm page 21 radiology abstract löffler’s syndrome was initially described as a disorder characterised by transient pulmonary infiltrates accompanied by peripheral blood eosinophilia in asymptomatic or mildly ill patients. abnormal chest radiographic findings are said to occur in 95% of patients but there are no descriptions of ct findings. there are many causes of this syndrome, but in developing countries the most common presentation remains secondary to the migratory larvae of common intestinal helminths. we present the clinical and radiological features of a boy with clearly defined löffler's syndrome due to larval migration. introduction löffler’s syndrome was initially described by the swiss internist wilhelm löffler (1887 1972) as a clinical disorder characterised by transient pulmonary infiltrates accompanied by peripheral blood eosinophilia in asymptomatic or mildly ill patients. migratory pulmonary infiltrates are recognised in many lung diseases1 and the term löffler’s syndrome is used interchangeably with a myriad of other different names; these include, ‘simple pulmonary eosinophilia’, ‘cryptogenic eosinophilic pneumonia’, ‘larval pneumonitis’, ‘pulmonary infiltrates with eosinophilia (pie)’, and ‘löffler’s pneumonia’. dr wilhelm löffler also described a condition of fibroplastic parietal endocarditis with eosinophilia which further complicates the correct use of terminology. eosinophilic pulmonary reactions are typical of the immediate type i allergic response,1 which may be induced by differing factors including allergic bronchopulmonary mycoses, parasitic infestations, drug reactions, eosinophilia-myalgia syndrome, löffler’s syndrome, chronic eosinophilic pneumonia, allergic granulomatosis of churg and strauss, hypereosinophilic syndrome, and acute eosinophilic pneumonia.2 noninfectious causes include drug reactions (to penicillin, the sulphonamides, aminosalicylic acid, nitrofurantoin),3 smoke and dust inhalation (mouldy hay, zinc chloride, beryllium, nickel), collagen vascular diseases (polyarteritis nodosa, rheumatoid arthritis, systemic lupus erythematosis) and neoplastic disorders (hodgkin’s disease). infectious causes of löffler’s syndrome include protozoa, fungi, bacteria and helminths.1 in developing countries with high parasitic loads, helminthic causes predominate. the majority of worms implicated are nematodes, including strongyloides stercoralis, ascaris lumbricoides, toxocara canis, schistosoma mansoni, paragonimus westermani, wuchereria bancrofti, dirofilaria immitis, trichuris trichiura and fasciola hepatica.1 this case study and brief review will concern itself only with löffler’s syndrome occurring as a consequence of larval migration through the lung. a spectrum of disease severity may result as a consequence of this phase in the nematode life cycle involving one or more of the following: cough with or without sputum, haemoptysis, prolonged expiration and wheezing, dyspnoea, chest pain, occasional rales, and pleural and pericardial effusion. abnormal chest radiographic findings are said to occur in 95% of case report 27 sa journal of radiology • february 2005 imaging findings in a patient with eosinophilic pneumonia (löffler’s syndrome) s andronikou mb bch, fcrad (diag) (sa), frcr (lond) department of paediatric radiology red cross children’s hospital and university of cape town g du toit mb bch, dch, mmed, fcp, frcpch d allergy department of paediatric allergy and immunology imperial college at st mary’s hospital london m carrighal mb chb, dch, fc paeds a argent mb bch, fc paeds, mmed (paed), dch department of paediatrics red cross children’s hospital and university of cape town radiology 2/24/05 4:50 pm page 27 patients. we present the clinical and radiological findings of a young child who experienced severe respiratory compromise due to larval-induced pulmonary eosinophilia. to the best of our knowledge high-resolution computed tomography (hrct) findings have not been described previously for löffler’s syndrome as a consequence of larval migration. case report a previously well 26-month-old boy presented with fever and acute severe respiratory distress, for which he required intubation and ventilatory support. initial investigations revealed a microcytic hypochromic anaemia (hb 10.1 g/dl, mcv 73 fl), with an elevated wcc of 23.1 × 109/l and peripheral blood eosinophilia of 26%. erythrocyte sedimentation rate was 39 mm/hour. bronchoalveolar lavage revealed 57% eosinophilia. further investigations revealed positive toxocara canis serology (immunoglobin g enzyme-linked immunosorbent assay > 100 units; normal < 0 units) and ascaris lumbricoides adults and ova were present in his stool. serial chest radiography demonstrated flitting bilateral patchy opacification. a hrct was performed in the subacute phase of the disease. this demonstrated bilateral, asymmetrical, patchy, peripheral, upper and lower zone areas of interlobular septal thickening with associated areas of airspace disease in the central rather than peripheral dependent areas of the lungs (figs 1a and b). there was relative sparing of the anterior or nondependent areas of the lungs. the septal thickening outlining the secondary pulmonary lobules was smooth, as was the thickening around the bronchovascular bundles. no ground glass attenuation was noted, but the hrct was performed during the subacute phase of the illness at which time clinical and radiological resolution was occurring. the patient responded rapidly to corticosteroid and antihelminthic therapy, and at follow-up was asymptomatic with a clear chest radiograph. discussion we report the case of a young boy who presented with life-threatening löffler’s syndrome secondary to parasitic infestation. although our patient met many of the diagnostic criteria for acute eosinophilic pneumonia4 (table i), a parasitic cause was unequivocally established. in making a diagnosis of löffler’s syndrome, heavy reliance is frequently placed on radiological features. chest radiographs obtained during the migratory phase classically demonstrate fine miliary nodules or diffuse, reticulonodular interstitial areas of increased opacity. with the development of heavier infestation, bilateral, patchy air-space / alveolar areas of increased opacity and segmental or even lobar areas of opacification may develop. serial radiographs may show migration of areas of increased opacity. such findings are associated with several pulmonary processes, but the presence of filariform larvae in the sputum, bronchial washings, or lung biopsy specimens is diagnostic. striking sputum and peripheral blood eosinophilia is often associated. the presence of eggs of the causative nematode, except in early infestation or with a population of purely male worms, further strengthens the diagnosis of löffler’s syndrome secondary to migratory larvae. the hrct findings of helminthassociated pulmonary eosinophilic pneumonitis (löffler’s syndrome) have not been reported. hrct is generally more useful than plain radiographs in defining severity and extent of diffuse lung disease.5 hrct findings have, however, been reported for drug-induced pulmonary eosinophilia and include bilateral, non-segmental, peripheral areas of groundglass attenuation or consolidation, indistinguishable from those seen in organising pneumonia, typically involving the upper lobes.3,6,7 the findings may be difficult to distinguish from adult respiratory distress syndrome, overhydration pulmonary 28 sa journal of radiology • february 2005 case report fig. 1a. figs .1a and b. high resolution ct scan findings of the chest. (a) upper zone patchy areas of interlobular septal thickening, right worse than left, with associated areas of air-space disease. fig. 1b. (b) mid/ lower zone scan demonstrating patchy, predominantly peripheral and basal interlobular septal thickening outlining the secondary pulmonary lobules. there are associated central and dependent areas of dense air-space disease. the anterior portions of the lung are relatively spared. radiology 2/24/05 4:50 pm page 28 case report 29 sa journal of radiology • february 2005 oedema or atypical bacterial or viral pneumonia.8,9 our hrct findings correspond with the histological reports of pulmonary eosinophilia and löffler’s disease, which demonstrate thick alveolar walls and interstitial infiltration by eosinophils, lymphocytes and plasma cells.1,3 alveolar spaces contain aggregates of histiocytes and numerous eosinophils.1 in contradistinction to wegner’s disease, which also has pulmonary eosinophilic infiltrates, eosinophilic pneumonia preserves the lung architecture.1 true hypersensitivity pneumonitis (usually caused in children by exposure to numerous bird antigens) shows ground-glass attenuation, but has centrilobular nodules.6,10 hrct findings have been reported for numerous diffuse lung diseases in children including bronchiolitis obliterans, hypersensitivity pneumonitis, recurrent aspiration, langerhans cell histiocytosis, idiopathic pulmonary haemosiderosis, pulmonary alveolar proteinosis, lymphangioleiomyomatosis, congenital lymphangiectasia, alveolar microlithiasis, pulmonary vein atresia, capillary hemangiomatosis, gaucher’s disease, niemanpick disease, as well as for the idiopathic pneumonitides (desquamative interstitial pneumonitis (dip), normal interstitial pneumonitis (nip), lymphocytic interstitial pneumonitis (lip), and chronic organising pneumonitis (cop)/ bronchiolitis obstructive organising pneumonitis (boop).5-7,10 the hrct findings in our patient correspond with those reported for drug-induced pulmonary eosinophilic pneumonia, except for the absence of ground-glass attenuation. ground-glass attenuation is a nonspecific finding in many diffuse lung diseases of childhood, usually indicating reversible or potentially reversible disease.6 the absence of this finding in our patient is probably due to the scan being performed during the subacute period of the disease when acute alveolitis may have resolved spontaneously or on treatment. follow-up hrct may be useful in identifying chronic interstitial changes and possible fibrosis and as suggested by the hrct findings in the sub-acute period, may also demonstrate improvement by demonstrating resolution of ground-glass attenuation. references 1. bedrossian cw, greenberg sd, williams lj jun. ultrastructure of the lung in loeffler’s pneumonia. am j med 1975; 58: 438-443. 2. tazelaar hd, linz lj, colby tv, myers jl, limper ah. acute eosinophilic pneumonia: histopathologic findings in nine patients. am j respir crit care med 1997; 155: 296-302. 3. cleverley jr, screaton nj, hiorns mp, flint jd, muller nl. drug induced lung disease: highresolution ct and histological findings. clin radiol 2002; 57: 292-299. 4. badesch db, king te jun, schwarz mi. acute eosinophilic pneumonia: a hypersensitivity phenomenon? am rev respir dis 1989; 145: 716-718. 5. copley sj, coren m, nicholson ag, rubens mb, bush a, hansell dn. diagnostic accuracy of thin-section ct and chest radiography of pediatric interstitial lung disease. am j roentgenol 2000; 174: 549-554. 6. lynch da, hay t, newell jd jun, divgi vd, fan ll. pediatric diffuse lung disease: diagnosis and classification using high resolution ct. am j roentgenol 1999; 173: 713-718. 7. erasmus jj, mcadams hp, rossi se. high-resolution ct of drug-induced lung disease. radiol clin north am 2002; 40(1):61-72. 8. king ma, pope-harman al, allen jn, christoforidis ga, christoforidis aj. acute eosinophilic pneumonia: radiologic and clinical features. radiology 1997; 203(3):715-719. 9. cheon je, lee ks, jung gs, chung mh, cho yd. acute eosinophilic pneumonia: radiographic and ct findings in six patients. am j roentgenol 1996; 167: 1195-1199. 10. kuhn jp, brody as. high resolution ct of pediatric lung disease. radiol clin north am 2002; 40(1): 89-110. table i. proposed diagnosxtic criteria for acute eosinophilic pneumonia2 acute febrile illness (days, rarely weeks in duration) hypoxaemic respiratory failure diffuse alveolar/mixed alveolar interstitial radiographic changes bronchoalveolar lavage — eosinophils > 25%, or biopsy confirmation of eosinophilic lung infiltrates* no identifiable infection prompt and complete response to steroids failure to relapse after discontinuation of steroids *biopsy evidence of acute and/or organising diffuse alveolar damage with eosinophils is the most characteristic feature, but marked tissue eosinophilic infiltrate with clinical confirmation of the history is also sufficient. radiology 2/24/05 4:50 pm page 29 abstract introduction methods results discussion conclusion references about the author(s) senzwesihle c. magagula department of diagnostic radiology, university of kwazulu-natal, south africa timothy hardcastle trauma service and trauma icu, inkosi albert luthuli central hospital, durban, south africa department of surgical sciences, university of kwazulu-natal, south africa citation magagula sc, hardcastle t. defining current facial fracture patterns in a quaternary institution following high-velocity blunt trauma. s afr j rad. 2016;20(1), a1005. http://dx.doi.org/10.4102/sajr.v20i1.1005 original research defining current facial fracture patterns in a quaternary institution following high-velocity blunt trauma senzwesihle c. magagula, timothy hardcastle received: 22 mar. 2016; accepted: 22 july 2016; published: 22 sept. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: in the early 20th century, rené le fort studied facial fractures resulting from blunt trauma and devised a classification system still in common use today. this classification, however, was based on low-velocity trauma. in modern practice, in a quaternary-level referral hospital, patients are often admitted following high-velocity injuries that mostly result from motor vehicle collisions. objectives: a retrospective study to define facial bone fractures occurring subsequent to high-velocity trauma. method: a retrospective study comprising the review of ct scans of 52 patients with high-velocity facial fractures was performed between april 2007 and march 2013. injuries were classified using the le fort classification system. deviations from the true le fort types, which are often depicted in the literature as occurring bilaterally and symmetrically, were documented; these included unilaterality, occurrence of several le fort fractures on one side of the face, occurrence of several le fort fractures on different levels and on different sides of the face, and occurrence of other fractures in addition to le fort fractures. results: of the 52 cases, 12 (23%) had le fort injuries, with true le fort fractures occurring in only 1, and 11 deviating from the classic description. nine patients had le fort fractures and additional fractures. mandibular and zygomatic bone fractures were found to be common associations with le fort injuries, occurring in 58% and 33% of the cases respectively. conclusion: fractures occurring in modern practice often deviate from the traditional le fort classification. precise recognition of these deviations and recognition of additional associated fractures is pivotal in their management, assisting the surgeon in determining the treatment plan, such as the surgical approach and the order in which to fix the various fractured components. introduction around the turn of the 19th into the 20th centuries, rené le fort, a renowned french surgeon, conducted a series of experiments using human cadavers to study facial bone fractures resulting from blunt trauma. various forces were applied to inflict these injuries, some of which are controversial. the impacts included hitting the midface of a whole or decapitated cadaver with a baseball bat, and hitting the midface region onto a granite tabletop. he then cut the body segments open and studied the fractures they had sustained. additionally, he boiled the skulls to strip off the flesh and expose the underlying fractures. he concluded that midface fractures occurred through ‘lines’ of inherent weakness in the facial skeletal structure, producing defined injury patterns.1 the fracture patterns were predictable and reproducible, depending on the site of impact on the midface. he then formulated a classification system still extensively used today: the le fort classification. common to these fractures is involvement of the pterygoid plates, resulting in cranio-maxillary dissociation. the le fort i fracture extends horizontally across the maxilla above the level of the roots of the teeth, traversing the lower lateral walls of the pyriform aperture and the lower nasal septum. it extends posteriorly across the lateral, medial and posterior walls of the maxillary sinus and involves the pterygoid plates. unique to le fort i fracture is the involvement of the lateral walls of the pyriform aperture. the le fort ii fracture is pyramidal, with the apex at the naso-frontal suture. from the apex, the fracture line extends inferolaterally through the medial wall of the orbit, orbital floor, inferior orbital rim and through the zygomatico-maxillary suture. it also extends posteriorly to the pterygoid plates. unique to le fort ii fractures is involvement of the inferior orbital rim. the le fort iii, also known as cranio-facial disjunction, is like the le fort ii, and comprises dissociation of the naso-frontal suture. however, this is horizontally oriented, traversing the medial and lateral walls of the orbits, the zygomatico-frontal suture and the zygomatic arch. involvement of the latter is unique to type iii fractures2,3 (figure 1). figure 1: le fort fracture patterns: (a) ap view of a 3d reformat of a facial bone ct; and (b) left oblique view. le fort i (black line), le fort ii (red line) and le fort iii (blue line). note how all le fort patterns extend posteriorly to involve the pterygoid plates in (b). some authors have suggested the addition of the le fort type iv, which is the propagation of any le fort-type fracture to the orbital apex (with a frontal sinus fracture). identification of involvement of the latter preoperatively is of paramount importance because considerable force is often required to reduce le fort fractures with a disimpaction forceps. if the surgeon is unaware, this can pose significant risk of inadvertent injuries to vital structures around the orbital apex, including the internal carotid artery.4 le fort’s classification is today one of the most widely used and understood classifications. in modern clinical practice, however, patients treated at a quaternary-level referral institution, such as inkosi albert luthuli central hospital (ialch), present following mainly high-velocity trauma, which commonly follows motor vehicle collisions. this circumstance is in contrast to le fort’s work, which was based on low-velocity trauma. the purpose of the present descriptive observational study was to define facial bone fracture patterns occurring in patients involved in high-velocity blunt trauma, admitted to a quaternary-level referral centre. the traditional le fort classification was applied. more importantly, however, the prevalence of variations from the classic le fort classification was evaluated, including: unilaterality, occurrence of multiple le fort fractures on one side of the face, occurrence of multiple le fort fractures at different levels, and on different sides of the face, and occurrence of other fractures in addition to le fort fractures. radiologists’ awareness of these different variations is essential for patient care. accurate diagnosis and classification of facial fractures is crucial in their management, as it assists the surgeon in planning surgical access and the order in which to fix various fractured components. for instance, if a le fort i fracture has an associated sagittal or parasagittal fracture of the hard palate extending to the alveolar ridge, this would require fixation to re-establish normal dental occlusion prior to fixation of the maxilla. the primary goals are for the surgeon to restore normal function (such as dental occlusion, sinus clearance, vision and airway patency) and cosmesis (i.e. facial projections and facial height).4 methods the study design was of the retrospective observational descriptive type. a pre-existing list of trauma patients with facial bone fractures following high-velocity blunt facial trauma was obtained from the inkosi albert luthuli trauma service. it contained the following information: patient age, gender, mechanism of injury and injuries sustained. these data were already present in an approved biomedical research ethics committee (brec) class approval for these types of studies (be207-09). ialch uses a picture archiving and communication system (pacs), enabling patient files and all imaging studies to be readily retrievable from the hospital and radiology information systems respectively. all cases admitted to ialch trauma service between april 2007 and march 2013 with facial fractures were reviewed. both male and female patients were evaluated, and of all ages. children were included because they have similar fracture patterns to those seen in adults, despite their different anatomical and physiological craniofacial skeletal characteristics.5 high-velocity trauma included mechanisms such as motor vehicle and motorcycle collisions and severe assault. although it is practically impossible to quantify the amount of force responsible for the facial injuries in each patient, it is generally accepted that in motor vehicle collisions, randomly distributed high-velocity forces are usually involved.5,6,7 in addition, motor vehicle collisions are the most common cause of complex maxillo-facial fractures in developing countries.8 the patients had ct scans done with a siemens somatom 64-slice multidetector scanner (siemens, germany). the following ct scanning protocol was applied: unenhanced scan with a field of view from just above the frontal sinuses to the hyoid bone to include the entire mandible. axial sections were acquired in a plane parallel to the hard palate. submillimetre slices (0.625 mm), with overlap (0.4 mm) obtained for best three-dimensional (3d) volume rendering and multiplanar reconstruction (mpr), using bone and soft tissue algorithms. the scans were reviewed at a radiology reporting station: 2 mm slice thickness images; axial, coronal and sagittal multiplanar reconstruction (mpr), with the coronal and sagittal planes perpendicular to the hard palate; and 3d images were reviewed. chen et al.9 and saigal et al.10 reported that whilst 2d-ct is useful for tiny and deep-structure fractures, 3d-ct is the best imaging method for the diagnosis of le fort-type fractures and can provide valuable information on spacial relationships of fragments, especially for surgical planning. the scans were read by a junior radiology consultant to define the fractures and classify them using the le fort classification. each case was then classified into categories (box 1). box 1: cases with and without le fort fractures. patients whose scans were irretrievable on the pacs, or incomplete on the radiology information system (ris) were excluded. additionally excluded were patients admitted with imaging from external referring hospitals, as the required reconstructed images were not available. patients with facial injuries that were detected on radiographs and not evaluated by ct scan were also excluded; these would include isolated nasal bone fractures, which are usually adequately evaluated by radiographs and treated on an outpatient basis. high-velocity facial fractures are usually complex, requiring evaluation with cross-sectional imaging. ct scan is currently the modality of choice for this purpose. facial fractures resulting from penetrating injuries were also excluded from the study. results a total of 82 cases were retrieved from the ialch trauma service data (be 209-07). following the described inclusion and exclusion criteria, the final sample size was reduced to 52 cases. twenty cases were excluded as there were no records of facial bone ct scans having been performed on the ris. four cases could not be retrieved from the archive. one case had no facial bone fractures, the patients in 2 cases died before the scans could be performed (owing to haemodynamic instability) and 3 patients presented with imaging from referring hospitals. of the 52 cases, 34 (65%) of the subjects were male and 18 (35%) were female. their ages ranged from 2 to 72 years, with a mean age of 30 years. in 50 cases, the mechanism of injury was motor vehicle accident injury. twenty-four (46%) subjects were pedestrians, 19 (37%) were passengers and 7 (13%) were drivers. assaults comprised only 2 cases (4%) of the sample. in the present study, 12 (23%) patients had le fort fractures, but only 1 had a true le fort injury, which was bilateral, symmetrical and on one level. nine (75%) had le fort plus other additional fractures. a unilateral le fort fracture only occurred in 1 patient, whilst 4 patients had le fort injuries bilaterally with more than one level involvement on at least one side. the details are presented in table 1 and table 2. table 1: cases of facial bone fractures at ialch between april 2007 and march 2013. table 2: cases with le fort plus additional fractures. discussion the present study illustrates that at a quaternary level referral hospital, such as ialch, where most patients present following high-velocity trauma, variations of the traditional le fort classification occur more commonly than the classic le fort fractures. the latter are commonly depicted in the literature as occurring at one level and symmetrically on both sides of the face. in the present study, this classic fracture pattern was found in only one case. this might have been because, in le fort’s experiments, these injuries were inflicted by blows directed centrally at different levels of the midface, as there was significant difficulty in directing these forces to the lateral aspect of the maxilla, without hitting the zygoma or the mandible.1 this consideration may also account for the high association between le fort and mandibular fractures, as well as le fort and zygomatico-maxillary complex fractures, which were seen in 7 (58%) and 4 (33%) of the cases respectively (figure 2, figure 3). in a trauma setting, different forces are applied from endless direction and angle variations. combined le fort and mandibular injuries are thought to be secondary to impact from a broad object to the mandible and the midface simultaneously. the zygoma is the most anteriorly projected bone in the facial skeletal structure, making it prone to injury from any blow to the antero-lateral midface.11 this finding matches that of the study by chen et al. comparing 2d and 3d ct, where 88.7% (55/62) of patients with le fort fractures were found to have co-existent fractures in the maxillofacial region.9 figure 2: 3d reconstructed ct scan of the facial bones of a 38-year-old man involved in a mvc as a driver. bilateral le fort i (black arrowheads) and left le fort ii fractures (dotted lines). note the presence of the left zmc (red arrowheads) and right parasymphysial mandibular fracture (black arrow), which are the two most common associations with le fort injuries. in addition, there is a sagittal fracture of the maxilla extending to the alveolar ridge (blue arrow). figure 3: 3d reconstructed ct scan of the facial bones of a 40-year-old woman involved in a mvc as a passenger, showing bilateral markedly displaced le fort i (black arrowheads), le fort ii (dotted line) and right le fort iii (red arrowheads) fractures. additionally, there is a fracture of the body of the right mandible (black arrow) and dislocation of the left temporomandibular joint (not shown). the total number of le fort injuries in the series under discussion was 12 (23%). this figure is comparable to that of 25.5% found on a much larger study of 663 cases by turner et al. on patients investigated for possible facial fractures.12 similar to the current study, theirs was also a retrospective study performed at a level 1 referral trauma centre. this relatively low incidence of le fort injuries in both studies is thought to be owing to inclusion of cases with isolated mandibular fractures, which contributed to 14 cases (27%) in the current study. these fractures result from a direct impact to the mandible without involvement of the midface. in addition, facial bone injuries resulting from the propagation of skull vault and base of skull fractures were also included. these patterns of fracture extensions were seen in 2 cases in the current study, where one was an extension of a frontal bone fracture to the frontal sinuses. the second case was involvement of the greater wing of the sphenoid, which forms the lateral wall of the orbit, and was therefore classified under facial bones. the skull and facial bones are flat bones that, when fractured, are split by long fissures which are not limited in extension by suture lines.1 in le fort’s experiments, after the infliction of injuries to the facial skeleton, the skull was sawed open and the dura mater stripped off the bone to examine the facial bones for fractures. the specimens were then boiled and macerated to easily remove the flesh. with this process of specimen preparation, by le fort’s own admission, it was impossible to avoid creating additional fractures. in current practice, however, high-resolution ct scan, which is the standard point of reference,13 is readily available in most institutions. with ct scan, fractures can be studied non-invasively. in addition, deep-seated fractures in the very complex facial bone structure can be evaluated with ease; these may otherwise be missed at surface views. furthermore, ct scan allows rapid acquisition of images in often critically injured patients and adds additional value in assessing the soft tissues (especially intra-orbital structures) and associated brain injuries. patients with severe facial trauma often have co-existing cervical spinal injuries, and ct scan eliminates the need to manipulate the head into different positions, which is always required in plain radiography. the mechanism of injury in the current study was overwhelmingly motor vehicle collisions (mvcs), which accounted for 96% of the cases. interestingly, this was in contrast to the findings of a large multicentre european study on the epidemiology of facial bone fractures, where mvcs contributed only 11% (375/3396) of the study population and assaults were the leading cause, contributing 39%. a decreasing trend of mvcs (which used to be the most common cause of facial bone fractures) in developed countries has been documented in recent years, and has been attributed to changes in road traffic legislation.14 stringent traffic policy-making and enforcement are necessary in developing countries to prevent these sometimes devastating injuries. it is generally accepted to regard motor vehicle and motorcycle collisions as high-velocity trauma, which was clearly established by luce et al.6 as far back as 1979. it remains, however, practically impossible in live patients to quantify the magnitude of the forces involved, which is one of the limitations of the present study. this shortcoming is in contrast to studies performed in cadaveric skulls where some quantification of the forces involved may be estimated. notably, on le fort’s experiments, there is use of words such as ‘minimal’, ‘moderate’ or ‘violent’ with respect to the amount of force exerted to inflict injuries. furthermore, exact directions and locations of the forces applied could be documented. another limitation to the present study was the small sample size, which was owing to unavailable or incomplete data, and is common in retrospective studies. a further prospective study with a larger sample size would be recommended. precise recognition of fracture complexes such as le fort types, the pattern variants and additional associated fractures is pivotal in their management. radiologists, if unaware of these different variations, may miss le fort fractures and instead create a long list of seemingly isolated fractures, without clinical context or categorisation of fracture severity and criticality. all these variables are important to the surgeon in determining the treatment plan, surgical access, incisions, order in which to fix the different fractured components, expected treatment outcomes and prognostication. to exclude or include le fort fractures in a patient with several facial bone fractures, it is suggested that sequential examination of the facial bones be performed one side at a time, starting at the pterygoid plates and body of the pterygoid bone. the presence of fractures in this area should raise the suspicion of a le fort injury as, by definition, all le fort fractures involve the pterygoid. thereafter, fractures unique to a particular le fort level should be specifically sought. the easiest place to start is at the zygomatic arches (for le fort iii), then the inferior orbital rims (for le fort ii) and then the pyriform aperture (for le fort i). finally, follow a sequential search for the rest of the components of a particular fracture level. the mandible and zygomatic bone fractures (tripod or malar complex injury) should then be sought, as they were found to be common associations with le fort injuries. conclusion le fort’s classification, based on low-velocity trauma, is one of the most widely used facial bone fracture classification systems. the present study demonstrates that high-velocity facial fractures seen at a quaternary level hospital in modern practice, often deviate from the traditional le fort classification. precise recognition of these variables and additional associated fractures is pivotal in their management. it assists the surgeon in determining the treatment plan, appropriate surgical access and the order in which to fix different fractures. in addition, it allows accurate prognostication of treatment outcomes. read online: scan this qr code with your smart phone or mobile device to read online. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions s.c.m. was the principal investigator and wrote the manuscript. t.h. was the supervisor of the study and made conceptual contributions towards the study as well as manuscript editing. references le fort. experimental study of fractures of the upper jaw. rev chir de paris 1901; 23:208–227. http://dx.doi.org/10.1148/rg.331125080 winegar b, murillo h, tantiwongkosi b. spectrum of critical imaging findings in complex facial skeletal trauma. radiographics 2013;33:3–19. http://dx.doi.org/10.2214/ajr.184.5.01841700 rhea j, novelline r. how to simplify the ct diagnosis of le fort fractures. am j of roentgenol 2005;184:1700–1705. fraioli r, branstetter b, deleyiannis f. facial fractures: beyond le fort. otolarygol clin n am 2008;41:51–76. http://dx.doi.org/10.1016/j.otc.2007.10.003 alcala-galliano a, arribas-garcia i, martin-perez m, et al. paediatric facial fractures: children are not just small adults. radiographics 2008;28:441–461. http://dx.doi.org/10.1148/rg.282075060 luce ea, tubb td, moore am. review of 1000 major facial fractures and associated injury. plast reconstr surg 1979;63(1):26 http://dx.doi.org/10.1097/00006534-197901000-00005 pappachan b, alexander m. biomechanics of craniofacial trauma. j maxillofac oral surg 2012 jun;11(2):224–230. http://dx.doi.org/10.1007/s12663-011-0289-7 rasmané b, dakouré p, et al. epidermiology of facial fractures: an analysis of 349 patients. med buccale chir buccale 2014;20:13–16. http://dx.doi.org/10.1051/mbcb/2013099 chen wj, yang yj, fang ym, xu fh, zhang l, cao gq. identification and classification in le fort type fractures by using 2d and 3d computed tomography. chin j traumatol. 2006;9:59–64. saigal k, winokur r, finden s et al. use of three-dimensional computerized tomography reconstruction in complex facial trauma. facial plastic surgery 2005; 21(3): 214–219. http://dx.doi.org/10.1055/s-2005-922862 mehta n, butala p, bernstein m. the imaging of maxillofacial trauma and its pertinence to surgical intervention. radiol clin n am 2012;50:43–57. http://dx.doi.org/10.1016/j.rcl.2011.08.005 turner gb, rhea jt, thrall jh et al. trends in the use of ct and radiography in the evaluation of facial trauma, 1992–2002: implications for current costs. am j roentgenol 2004;183(3):751–754. http://dx.doi.org/10.2214/ajr.183.3.1830751 hopper r, salemy s, sze r. diagnosis of midface fractures with ct: what the surgeon needs to know. radiographics 2006;26:783–793. http://dx.doi.org/10.1148/rg.263045710 boffano p, roccia f, zavattero e et al. european maxillofacial trauma project: a multicenter and prospective study. journal of cranio-maxillo-facial surgery 2015;43:62–70. http://dx.doi.org/10.1148/rg.263045710 article information authors: leon malan1 abraham f. bezuidenhout1 ebrahim banderker1 affiliations: 1department of radiology, stellenbosch university, south africa correspondence to: leon malan email: lnmalan86@gmail.com postal address: ravensteyn road, camps bay, cape town 8005, south africa dates: received: 04 june 2015 accepted: 11 aug. 2015 published: 11 dec. 2015 how to cite this article: malan l, bezuidenhout af, banderker, e. fibrolipomatous hamartoma of the median nerve. s afr j rad. 2015;19(2); art. #886, 3 pages. http://dx.doi.org/10.4102/sajr.v19i2.886 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. fibrolipomatous hamartoma of the median nerve in this case report... open access • abstract • introduction • case presentation • discussion • conclusion • acknowledgements    • competing interests • references abstract top ↑ fibrolipomatous hamartoma is a rare benign tumour most commonly affecting the median nerve and is characterised by fibro-fatty nerve infiltration. it results in fusiform nerve enlargement with a pathognomonic ‘spaghetti-like’ imaging appearance. patients present with numbness and paraesthesia and later with motor deficits in the affected nerve distribution. the condition frequently coexists with macrodystrophia lipomatosa in up to two-thirds of cases. introduction top ↑ fibrolipomatous hamartoma, neural fibrolipoma or lipomatosis of the median nerve as described by the who is a rare benign tumour.1 fibrolipomatous hamartoma is characterised by mature adipocyte proliferation within the nerve separating axonal bundles within the perineurium. perineural and endoneural fibrosis thicken the axonal bundles, which are interspersed throughout the proliferative fat.2 the most commonly affected nerve is the median nerve (66%–80%), followed by the radial nerve, the ulnar nerve, the dorsal nerves of the foot, the brachial plexus and the cranial nerves.2,3,4 the diagnosis is made primarily with radiological imaging.5 case presentation top ↑ a five-year-old healthy boy presented with a one-year history of a slowly growing mass over the volar aspect of the left wrist with increasing paraesthesia and a decreasing range of movement. conventional radiography demonstrated mild soft tissue swelling over the volar aspect of the wrist with no underlying bony abnormality (figure 1). figure 1: conventional radiography demonstrates mild soft-tissue swelling over the volar aspect of the wrist with no underlying bony abnormality. ultrasound evaluation of the soft tissue mass demonstrated fusiform enlargement of the median nerve with alternating hypoechoic and hyperechoic linear bands, resulting in a ‘spaghetti-like’ appearance (figure 2) on longitudinal images and a ‘coaxial cable-like’ appearance (figure 3) on transverse images. figure 2: longitudinal ultrasound image demonstrates fusiform enlargement of the median nerve with alternating hypoechoic and hyperechoic linear bands, resulting in a ‘spaghetti-like’ appearance (white arrows). figure 3: transverse ultrasound image demonstrates enlargement of the median nerve with alternating hypoechoic and hyperechoic dots resulting in a ‘coaxial cable-like’ appearance (white arrows). mri investigation followed which also showed fusiform enlargement of the median nerve fascicles with fibro-fatty proliferation in a characteristic ‘spaghetti-like’ (figure 4) and ‘coaxial cable-like’ (figure 5) appearance of the median nerve. the enlarged median nerve resulted in crowding of the carpal tunnel and compression of the adjacent flexor tendons. there was no associated macrodactyly. figure 4: t1wi sagittal mr image demonstrates fusiform enlargement of the slightly hyperintense median nerve fascicles with a characteristic ‘spaghetti-like’ appearance (white arrows). figure 5: t1wi axial mr image demonstrates enlargement of the slightly hyperintense median nerve fascicles with a characteristic ‘coaxial cable-like’ appearance (white arrows). mr findings were pathognomonic of a fibrolipomatous hamartoma of the left median nerve. discussion top ↑ clinically, patients present with a gradually enlarging, non-tender palpable mass.2 neurological symptoms are often present in the distribution of the specific nerve. if the median nerve is involved, these symptoms may overlap with the symptoms of carpal tunnel syndrome.6 neurological symptoms include numbness and paraesthesia with motor deficits occurring late.3 nerve conduction studies demonstrate no stimulation response of the affected nerve. the underlying aetiology is unknown; however, some authors believe the proliferation is secondary to nerve irritation, inflammation or trauma.5 fibrolipomatosis hamartoma was first described in 1953. johnson and bonfiglio coined the term ‘fibrolipomatous hamartoma’ as they differentiated it from macrodystrophia fibromatosa and neurofibroma in neurofibromatosis.7 mri is now considered the gold standard in imaging fibrolipomatous hamartoma and is considered to be definitive if the typical imaging findings are present, obviating the need for further investigation.5 mri demonstrates a high signal intensity fusiform mass on t1 and t2 weighted imaging representing the adipose proliferation. signal void is appreciated on fat suppression techniques. the mass has a characteristic ‘coaxial cable-like’ appearance on axial images and a ‘spaghetti-like’ appearance on sagittal images which represent the circumferentially fibrosed neural bundles within the proliferative fat. no contrast enhancement is present after gadolinium administration.3,8,4 ultrasonographic imaging of fibrolipomatous hamartoma also demonstrates the characteristic hypoechoic ‘coaxial cable-like’ mass encased by an echogenic substrate, and some authors believe such imaging to be as effective as mri in establishing the diagnosis; however, no comparative study is available.9 macrodystrophia lipomatosis is associated with fibrolipomatous hamartoma in 22%–67% of cases.3,7 it is a non-hereditary congenital macrodactyly and is characterised by diffuse proliferation of all the tissues involved: skin, bone and fatty proliferation between the nerve fascicles. this association has a 2:1 female predominance but the relationship between the two entities is unknown.5 in 1994, guthikonda et al. further divided lipid-containing masses according to their relationship with the parent nerve. this characterisation included: soft tissue lipoma, intraneural lipoma, macrodystrophia lipomatosis and fibrolipomatous hamartoma. soft tissue lipomas are differentiated by their position outside the nerve and a lack of any neural proliferation. similarly, intraneural lipomas demonstrate focal lipid masses separated from individual nerve bundles and in the absence of neural proliferation.10 currently there is no effective treatment for fibrolipomatous hamartomas and conservative management is preferred if symptoms are minimal. surgical resection risks permanent nerve damage and minor surgical decompression procedures, that is, carpal tunnel release, for symptomatic relief are more commonly performed.6,11 conclusion top ↑ fibrolipomatous hamartoma is a benign fibrofatty infiltration of the median nerve with associated fibrosis of the neural bundles. it can be diagnosed on mri findings alone due its typical ‘co-axial cable-like’ and ‘spaghetti-like’ appearances on longitudinal and axial imaging respectively. these features were well demonstrated in our case and thus made the diagnosis straightforward. it is important always to consider macrodystrophia lipomatosis due to its strong association with fibrolipomatous hamartoma and to differentiate these from other lipid-containing soft tissue masses. acknowledgements top ↑ competing interests the author declares that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. references top ↑ nielsen gp. lipomatosis of nerve. in: fletcher cdm, unni kk, mertens f, editors. pathology and genetics of tumours of soft tissue and bone. lyon: iarc press, 2002; p. 24–25. nouira k, belhiba h, baccar s, et al. fibrolipoma of the median nerve. joint bone spine. 2007;74:98–99. pmid: 17178460, http://dx.doi.org/10.1016/j.jbspin.2006.02.012 van breuseghem i, sciot r, pans s, geusens e, brys p, de wever i. fibrolipomatous hamartoma in the foot: atypical mr imaging findings. skeletal radiol. 2003;32:651–655. pmid: 12955352, http://dx.doi.org/10.1007/s00256-003-0684-3 marom em, helms ca. fibrolipomatous hamartoma: pathognomonic on mr imaging. skeletal radiol. 1999;28:260–264. pmid: 10424331, http://dx.doi.org/10.1007/s002560050512 tahiri y, xu l, kanevsky j, luc m. lipofibromatous hamartoma of the median nerve: a comprehensive review and systematic approach to evaluation, diagnosis, and treatment. j hand surg am. 2013;38(10):2055–2067. pmid: 23684521, http://dx.doi.org/10.1016/j.jhsa.2013.03.022 johnson rj, bonfigilio m. lipofibromatous hamartoma of the median nerve. j bone and joint surg. 1969;51:984–990. silverman ta, enzinger fm. fibrolipomatous hamartoma of nerve. a clinicopathologic analysis of 26 cases. am j surg pathol. 1985;9:7–14. pmid: 3970300. campbell cs, wulf rf. lipoma producing a lesion of the deep branch of the radial nerve; case report. j neurosurg. 1954;11:310–311. pmid: 13163731. toms ap, anastakis d, bleakney rr, marshall tj. lipofibromatous hamartoma of the upper extremity: a review of the radiologic findings for 15 patients. am j roentgenol. 2006;186:805–811. pmid: 16498111, http://dx.doi.org/10.2214/ajr.04.1717 guthikonda m, rengachary ss, balko mg, van loveren h. lipofibromatous hamartoma of the median nerve: case report with magnetic resonance imaging correlation. neurosurgery. 1994;35(1):127–132. pmid: 7936133, http://dx.doi.org/10.1227/00006123-199407000-00019 paletta fx, senay lc jr. lipofibromatous hamartoma of median nerve and ulnar nerve: surgical treatment. plast reconstr surg. 1981;68(6):915–921. pmid: 7301986. abstract introduction aim method results discussion proposed guidelines for workup of a psychiatric patient conclusion acknowledgements references about the author(s) praniel bennimahadeo department of radiology, king edward viii hospital, nelson r mandela school of medicine, university of kwazulu-natal, south africa jaynund maharajh department of radiology, king edward viii hospital, nelson r mandela school of medicine, university of kwazulu-natal, south africa citation bennimahadeo p, maharajh j. the prevalence of abnormal findings in screening ct brains performed on patients admitted with psychiatric symptoms. s afr j rad. 2016;20(1), a976. http://dx.doi.org/10.4102/sajr.v20i1.976 original research the prevalence of abnormal findings in screening ct brains performed on patients admitted with psychiatric symptoms praniel bennimahadeo, jaynund maharajh received: 10 jan. 2016; accepted: 20 sept. 2016; published: 22 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: no clear guidelines exist regarding the role of computerised tomography (ct) as a screening neuroimaging tool in psychiatric practice. the aim of this study was to evaluate the usefulness of historical and clinical parameters on the ct request form, identify the spectrum of ct findings and correlate these to develop guidelines for the use of screening ct brains in patients who present with psychiatric symptoms. methods: requests and reports for the brain ct’s of 507 consecutive patients over a 2-year period, between 2013 and 2014, referred from a psychiatric institute for screening ct brain scans, were reviewed. analysis was performed for the history of trauma and seizures, glasgow coma scale (gcs) score, focal neurological signs, papilloedema, electroencephalograph, relevant blood results and abnormal ct findings. all reports were approved by a consultant radiologist. results: no abnormality was noted in 69% of ct scans. cerebral atrophy, infarcts, cysts and calcific foci were present in 30% of patients. one patient presenting with focal neurology had a ct demonstrating an extradural haematoma which required neurosurgical intervention. no focal brain lesions, potentially responsible for the psychosis, were identified in any other patient. conclusion: routine ct screening of patients who present with psychotic symptoms, in the absence of focal neurological deficit, does not add value to patient outcome, but rather contributes to the escalating health care expenses and unnecessary radiation dose. ct screening of psychiatric patients should be reserved for patients with reliable predictors of intracranial abnormalities such as lateralising signs, seizures, persistent or worsening headaches; decrease in gcs, papilloedema and in patients where the onset of symptoms occurred at an age above 50. introduction according to the south african federation of mental health, approximately one in five south africans suffer from a mental illness, and approximately 25% of all general practitioner consultations are because of psychiatric conditions.1 many of these patients will be referred to a psychiatrist or undergo a battery of investigations to exclude an organic aetiology for their presenting symptoms. computerised tomography (ct) is used extensively in psychiatric practice as a neuroimaging screening tool to identify possible intracranial pathology. the average cost of a ct brain scan is between r3000 and r5000 in south africa. the approximate effective radiation dose of a contrasted ct brain scan is 4 millisieverts (msv), which is comparable to 200 chest x-rays (0.02 msv). these estimates highlight the potential burden of disease associated with psychiatric conditions. there is also the increased radiation exposure and its risk to patients must be weighed against the possible benefit of investigative ct brain scans in the psychiatric patient population. there are no official south african guidelines regarding the use of ct as an investigative tool in psychiatric patients. much debate has occurred with regard to appropriate screening tests in patients who present with psychiatric symptoms. the royal australian and new zealand college of psychiatrists (ranzcp) recommend routine neuroimaging for patients presenting with first-episode psychosis. they do, however, acknowledge that evidence regarding the possibility of routine ct imaging altering patient outcomes or clinical management is currently not available and needs to be explored.2 aim the study aimed to determine the spectrum of abnormalities seen on brain ct scans of psychiatric patients for whom ct screening was performed. the study was undertaken in order to provide preliminary data for the development of guidelines for the use of ct in this cohort. the objectives of the study were to: identify the demographic, historical and clinical information, assess the indications on the ct request form, and describe the spectrum of findings of the ct brain screenings. method townhill hospital is a provincial facility specialising in mental health care located in pietermaritzburg, kwazulu-natal province. the ct brain scans that are requested by townhill’s psychiatrists are performed at the neighbouring grey’s hospital, which is a tertiary level referral and teaching institution. the electronic request forms and reports for inpatients referred for psychiatric screening ct brain scans from townhill hospital were retrospectively analysed for 507 consecutive ct brain scans performed over a 2-year period, between 2013 and 2014. this information was retrieved from the computerised appointment records and the radiology information system that links scanned hand-written request forms to the radiology report and ct images. the forms were reviewed for the presence or absence of the following information: demographic (age and gender), historical (history of trauma, seizures), clinical examination (glasgow coma scale [gcs] score, focal neurological signs, papilloedema), clinical investigations (electroencephalograph results and relevant blood tests as shown below) and indication for the study. the abnormal ct scan report findings were also captured, especially those that could cause psychosis and alter the patient’s management. all reports were performed by trained staff and approved by a consultant radiologist. approval was obtained from the university of kwazulu-natal biomedical research ethics committee (ref: beo19/14) and the hospital. patient informed consent was not required. numeric data were summarized using medians and interquartile range (iqr) or means and standard deviations as appropriate, categorical data by frequencies and percentages. two group comparisons of categorical data were made using chi-squared test or fisher’s exact test as appropriate. a significance level of p < 0.05 was used for statistical testing of significance. the analyses were performed utilising the stata v 13.1, statacorp college station. results of the 507 records reviewed, 279 male (median age 29 years) and 228 female patients (median age 35.5 years) were evaluated. the highest number of men were in the 25–34 age group (33%) and the highest number of women were in the above 45 age group (34%). the age distribution of women was significantly different to the men (p = 0.001), and the median age of women (35.5) was significantly greater than that of men (29). a contributing factor may have been due to the increased substance use in the younger male cohort (table 1). table 1: age and gender distribution. the clinical history and motivation for the investigation were absent in the vast majority of patients referred. relevant information such as a history of trauma was not provided in 448 patients (88%). no information about previous seizures was provided in 500 patients (98%). clinical information relating to the gcs score, focal neurological signs and papilloedema and results of an electroencephalograph and blood tests were not provided in more than 93% of patients (table 2). table 2: relevant history and clinical data provided on the ct request form. there were various indications for requesting the ct scans; 75% were requested to exclude a general medical condition (gmc) with no supporting laboratory or clinical information. other patients had multiple indications, for example, to exclude a gmc and to exclude a substance-induced psychosis. twelve patients did not have any indication provided (table 3). table 3: the number of indicators per patient. taking into account that patients had multiple indications, the most common reasons for requesting the ct scan were to exclude gmcs or organic causes in 336 patients, first onset of psychosis in 190 patients, known psychosis in 161 patients and mood disorders in 138 patients as shown in figure 1. figure 1: indications for requesting computerised tomography brain scans. of the 507 cases, 348 (69%) had no intracranial abnormality noted on the ct scan. of these 348 patients, four had extracranial abnormalities including a scalp foreign body, sinusitis, a previous burr hole defect and an old depressed skull fracture. in the studies demonstrating pathology, 111 cases (21%) demonstrated cerebral atrophy, 18 cases (4%) had calcific foci, 24 patients (5%) had infarcts and 6 patients (1%) were found to have cysts. many patients with cerebral atrophy do not have psychosis, and even though there is an association between schizophrenia and global atrophy,3 this was not stated as an indication for referral on the request form. the one patient with a positive focal sign had a proven parietal extradural haematoma (figure 2). figure 2: spectrum of computerised tomography results. discussion in this study, ct has been implemented as a routine investigation for a significant majority of psychiatric patients to exclude possible organic pathology. in this situation, radiologists rely on the clinical information provided by clinicians to advise on the use and timing of appropriate investigations. the patients involved in this study were appointed ct scan dates via an elective booking system. the lack of relevant trauma and seizure history, as well as of significant clinical and laboratory investigations provided, prevented the appropriate selection of patients who may have benefitted from early utilisation of ct scans of the brain to identify a treatable aetiology for their symptoms. it further increased the duration of the waiting time for patients to be scanned and added to the workload of the scanner, all escalating the burden on our strained health system. the majority of ct scans performed in this study were normal, indicating a discordance between psychosis and abnormal findings on ct scans. however, there are prior studies that refute this. in the 2007 south african study by jeenah and moosa,3 conducting ct screening was encouraged as a central nervous system disorder may initially manifest as a psychiatric symptom with a treatable cause such as an intracranial tumour, which can be diagnosed by ct and may otherwise be missed. they studied 55 eligible ct scans of 600 psychiatric patients and concluded that abnormalities were found in 20 (36.4%). of these abnormalities, six had old infarcts, seven had global atrophy, one had sustained a trauma and six were grouped with the following conditions: pituitary adenoma, tuberculous granuloma and neurocysticercosis. this study differed from jeenah’s study, evaluating 507 ct scans compared to 55 ct scans. the incidence of cerebral atrophy was 21% in this study compared to 12% in their study. similarly, an article by andreasen from the department of psychiatry at the university of iowa, college of medicine, stated that ventricular enlargement and cortical atrophy are abnormalities noted on ct that assist in diagnosing schizophrenia and implicate a structural cause of the disease, thus supporting the need to conduct ct screening of psychiatric patients. however, managing schizophrenic patients with or without ventricular enlargement or cortical atrophy remains the same.4 mcclellan et al.5 conducted a comprehensive retrospective audit of the ct brain scans of 261 patients admitted with psychiatric symptoms over a 3-year period, of whom 88% were normal and 12% were found to be abnormal because of cortical atrophy, basal ganglia calcifications and old lacunar infarction, all of which were unrelated to the patient’s psychiatric condition. their results showed that there was no justification for routinely conducting ct scans for psychiatric inpatients in the absence of focal neurological signs. in concordance with the above findings was khandapour et al.,6 who reviewed 112 consecutive mri brain scans and 204 consecutive ct brain scans performed on patients with first onset psychosis, the aim being to determine whether imaging was associated with early detection of organic causes of psychosis. their conclusion revealed that routine magnetic resonance imaging (mri) and ct brain scans performed on patients without focal neurology were unlikely to identify a disease process and did not impact on their management. the performance of the published criteria used by psychiatrists,7 whereby ct brain scans were used in all patients presenting with schizophrenia or first onset psychosis, was critiqued by rock and owen.8 their study consisted of a 3-year retrospective case note audit of 143 patients (one abnormality was noted that did not alter the diagnosis or management of the patient), which revealed that the efficacy of the published criteria was not supported. they recommended that new clinically relevant guidelines for the use of ct scans be developed. supporting the above findings was a study by agzarian et al.,9 who retrospectively assessed 397 consecutive ct brain scans of patients who presented with psychiatric symptoms without focal neurology over a 2-year period. no abnormalities were found in 95% of the scans, with 5% showing non-specific minor abnormalities that were followed up by mri, which showed no relevant abnormality, whereas those noted on the ct scan were considered to be unrelated to the patient’s psychiatric condition. in their conclusion, agzarian et al. made mention of two important factors, the cost of performing the 397 scans (approximately 6000 australian dollars), with little apparent benefit related to the patient’s management, and the risk of radiation exposure outweighing any real assistance to their management. similarly, strahl et al.10 identified inconsistencies in the worldwide recommendation of brain ct algorithms of 237 patients presenting with first onset psychotic symptoms without focal neurological signs who had ct scans. all reports were approved by a consultant radiologist, and the results did not identify any focal brain lesion potentially responsible for the psychosis or focal lesion requiring surgical intervention in any patient. hrabrić et al.,11 goulet et al.12 and bain13 reached related conclusions. psychiatric geriatric populations ranging between 55 and 90 years were evaluated by rozenbilds and gilchris14 who had similar findings to hollister and harris15 in demonstrating that factors which correlated strongly with an abnormal ct were a recent alteration in behaviour or personality or a first psychotic event after the age of 50. the current study also found ct scans to be of little benefit, with clinical examination, history of seizures, focal neurological deficit and age at onset of symptoms being more specific in predicting positive causative outcomes, thus supporting the role of ct in refuting or confirming abnormal findings of other clinical investigations. the low rate of organic abnormalities, high cost low yield and exposure to radiation warrant consideration of the value of ct as an investigative tool (table 4). table 4: ct findings in previous psychiatric population studies. proposed guidelines for workup of a psychiatric patient this study has revealed similar findings to the authors mcclellan et al.,5 khandapour et al.,6 rock and owen,8 agzarian et al.,9 strahl et al.,10 hrabrić et al.,11 goulet et al.12 and bain,13 who are against using ct as a screening neuroimaging tool. relevant laboratory investigations are more cost effective than advanced radiological tests and could be used instead of conducting a ct scan. ct scans are not only expensive but also expose the patient to radiation. this study therefore recommends using patient demographics, that is, age at presentation, gcs score, focal neurological signs, seizures and papilloedema, as clinical criteria to warrant the use of ct. guidelines have been proposed in the workup of a psychiatric patient noting that ct brain is not routinely indicated with an emphasis on history, physical examination and relevant laboratory investigations to inform such a decision.16 in this study, one patient with a focal neurological sign required intervention and an organic cause was identified. it has been recommended that a patient presenting with the following history, symptoms and signs warrants a ct brain: age at onset of symptoms greater than 50 years14,15 history of head trauma or seizures5 persistent or increasing headache14 decrease in the gcs presence of focal neurological signs5 presence of papilloedema5 conclusion the limitations identified in this study are that patients were limited to referrals from a single hospital, this is a retrospective study of referred patients and case ascertainment was not controlled. the evidence from this study indicates that routine requests for ct brain scanning of patients who present with psychotic symptoms in the absence of focal neurological deficit do not add value to patient outcome, but rather contribute to the escalating health care expenses and increase their radiation dose. ct of the brain should be carefully considered within the context of a clinical presentation of psychosis. acknowledgements the authors thank dr d. naidoo, department of anaesthetics, university of kwazulu-natal for help with data collection and analysis and the staff of greys hospital for their assistance. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions p.b. was responsible for conceptualising the project, drafting the research protocol and journal article and completing the data collection. j.m. supervised the study, made conceptual contributions, facilitated interpretation of the results and edited the research protocol and final manuscript. references xoliswa zulu, mental health on the rise in south africa. health systems trust website http://www.hst.org.za/news/mental-illnesses-rise-sa royal australian and new zealand college of psychiatrists clinical practice guidelines team for the treatment of schizophrenia and related disorders. royal australian and new zealand college of psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. aust n z j psychiatry. 2005;39:1–30. http://dx.doi.org/10.1111/j.1440-1614.2005.01516.x jeenah fy, moosa myh. ct scans in psychiatric patientsan exploratory study at chris hani baragwanath hospital. sajp. 2007;13(1):22–25, 88. andreasen n. brain imaging: applications in psychiatry. science. 1988;239:1381–1388. mcclellan rl, eisenberg rl, giyanani vl. routine ct screening of psychiatric inpatients. radiology. 1988;169:99–100. http://dx.doi.org/10.1148/radiology.169.1.3420286 khandapour n, hoggard n, connoly dia. the role of mri and ct of the brain in first episode of psychosis. clin radiol. 2013;68:245–250. weinberger dr. brain disease and psychiatric illness: when should a psychiatrist order a cat scan? am j psychiatry. 1984;141(12):1521–1527. http://dx.doi.org/10.1176/ajp.141.12.1521 rock jd, owen pw. an investigation of criteria used to indicate cranial ct in males with schizophrenia. acta neuropsychiatr. 2003;15:284–289. http://dx.doi.org/10.1034/j.1601-5215.2003.00041.x agzarian mj, chryssidis s, davies rp, pozza ch. use of routine computed tomography brain scanning of psychiatry patients. australas radiol. 2006;50:27–28. http://dx.doi.org/10.1111/j.1440-1673.2005.01542.x strahl b, cheung y, stuckey s. diagnostic yield of computed tomography of the brain in first episode psychosis. j med imaging radiat oncol. 2010;54:431–434. hrabrić k, jukić v, bilić p, celić i, herceg m. neuroradiologic diagnostics in patients hospitalized in vrapce psychiatric hospital. gen hosp psychiatry. 1998;20(5):282–291. goulet k, deschamps b, evoy f, trudel jf. use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. can j psychiatry. 2009;54(7):493–501. bain bk. ct scans of first-break psychotic patients in good general health. psychiatr serv. 1998;49:234–235. http://dx.doi.org/10.1176/ps.49.2.234 rozenbilds uy, gilchris pn. the value of ct head scan in elderly psychiatric patients. int j geriatr psychiatry. 1989;4:155–157. hollister le, harris nb. clinical use of ct and mr scans in psychiatric patients. j psychiatry neurosci. 1991;16(4):194–198. assessment of psychosis. step by step diagnostic approach [homepage on the internet]. bmj [cited 2015 sept 17]. available from http://bestpractice.bmj.com/best-practice/monograph/1066.html article information authors: john-henry corbett1 werner s. harmse1 affiliations: 1department of clinical imaging sciences, university of the free state, south africa correspondence to: john-henry corbett postal address: department of clinical imaging sciences (g61), faculty of health sciences, university of the free state, 205 nelson mandela drive, bloemfontein 9300, south africa dates: received: 29 jan. 2014 accepted: 04 mar. 2014 published: 11 sept. 2014 how to cite this article: corbett j-h, harmse ws. in vivo determination of renal stone composition with dual-energy computed tomography. s afr j rad. 2014;18(1); art. #605, 5 pages. http://dx.doi.org/10.4102/ sajr.v18i1.605 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in vivo determination of renal stone composition with dual-energy computed tomography in this original research... open access • abstract • introduction • method    • study design    • computed tomography technique    • image processing    • crystallography    • statistical analysis • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: composition of renal stones influences management of patients with renal stone disease. currently stone composition can only be analysed ex vivo after stone extraction or passage, but recent introduction of dual-energy computed tomography (ct) to clinical practice has raised interest in the ability of this technology to determine composition of renal stones in vivo.objectives: to determine renal stone composition in patients using single-source dual-energy rapid-peak kilovolt (kvp) switching ct. method: nineteen patients with renal stones for percutaneous nephrolithotomy were evaluated with single-source dual-energy computed tomography on a discovery ct 750hd. the gemstone spectral imaging (gsi) effective atomic number (zeff) and attenuation at 70 kev monochromatic energy were used to predict the stone composition. infrared spectroscopy and x-ray diffraction of stones after extraction served as the reference standard. results: two (10.5%) of the 19 stones had uric acid as major component. the other 17 (89.5%) were calcium-based stones. no statistically significant difference between the gsi zeff and calculated effective atomic number (z) for stone compounds was found. the gsi zeff and attenuation could differentiate between uric acid and non-uric acid stones. no differentiation between different calcium stones could be made. conclusion: uric acid and non-uric acid renal stones can be differentiated with single-source dual-energy in vivo. the gsi zeff reflects the dominant material in polycrystalline stones. introduction top ↑ the incidence of renal stone disease is high, with a lifetime risk in the united states of america (usa) of 6% for women and 12% for men.1 renal stone disease has not been researched extensively in africa due to a lack of resources and facilities, and therefore no recent data on the incidence of renal stones in south africa are available.2sixteen different chemical compounds can form renal stones, although most of these are rare.3 calcium oxalate (70%), calcium phosphate (20%), uric acid (8%) and cystine (2%) are the most common stone components.4 developed countries have seen an increase in the incidence of calcium oxalate stones over the last 50 years, compared to developing countries, where the percentage of uric acid and phosphate stones remains relatively high.1 untreated renal stone disease can lead to obstruction of an infected urinary tract, which may lead to urosepsis and death. persistent urinary obstruction may also result in renal insufficiency and end-stage renal disease. long-term complications can include recurrent pyelonephritis and ureteric strictures.5 the chemical composition of renal stones will influence the management of patients. firm stones (such as calcium oxalate monohydrate and cystine) may not break up at extracorporeal shock wave lithotripsy. if the chemical composition of their stones is known, these patients can be offered percutaneous nephrolithotomy (pcnl) from the start. systemic or familial metabolic disease may lead to urolithiasis and knowledge about the stone composition can assist in the diagnosis and treatment of such a disorder. the recurrence of certain stones can be prevented by medical and dietary measures; however, such measures can only be implemented if the stone composition is known. improved treatment decisions could be made if accurate, non-invasive methods are available to distinguish between different stone types.1,5 the three most common methods used to determine stone composition are in vitro x-ray diffraction, infrared spectroscopy and polarisation microscopy. these methods are costly, time consuming and can only be performed after the surgical extraction of the stones, or when the passed stones are large enough for analysis. consequently, they generally offer no benefit to pre-operative treatment planning.1,6 non-enhanced multidetector computed tomography (ct) of the abdomen and pelvis is the imaging examination of choice for evaluating suspected renal stone disease, offering high sensitivity and specificity.6 it can also provide information about the presence and degree of the obstruction and other possible causes of the patient’s symptoms. only 45% – 59% of renal stones demonstrated with ct are visible on abdominal overview x-rays.1 the utility of abdominal overview x-rays therefore remains limited in renal stone disease.5,7 a combination of abdominal overview x-rays to detect radio-opaque stones and renal ultrasound to detect hydronephrosis can be used where ct resources are limited and when radiation should be kept to a minimum, such as in pregnant or paediatric patients.5,7 it has been shown that renal stone characterisation with single-energy ct using the ct number (hounsfield units [hu]) is inaccurate due to the overlap in densities, and it is thus not advisable for use in clinical practice.3,8 dual-energy ct combines high-energy and low-energy scanning during a single acquisition. this dual-energy data provide information related to the varying responses of different x-ray energies to tissues, which allows material differentiation and elemental decomposition.6,9,10 three main technologies are available for dual-energy scanning, namely dual-source dual-detector, single-source rapid-peak kilovolt (kvp) switching single-detector, and single-source layered-detector systems.1 a number of studies have reported the ability of dual-energy ct to accurately differentiate between the major pure-stone groups in vitro.9,11,12 limited in vivo studies have proven accuracy in differentiation between uric acid and non-uric acid groups. the subclassification of non–uric acid stones is limited to cystine-containing, struvite-containing and calcium-containing stones.6,10,13 to date only one publication could be located on in vivo renal stone characterisation using single-source rapid kvp switching dual-energy ct.10 method top ↑ study design a prospective, descriptive clinical study involving the pre-operative in vivo assessment of stone composition with dual-energy ct was conducted. all stones were renal in origin. the findings were compared to ex vivo laboratory stone analysis after stone extraction via pcnl.the study was conducted in the universitas academic hospital bloemfontein at the faculty of health sciences of the university of the free state (ufs).the research protocol was approved by the ethics committee of the faculty of health sciences, ufs, and written informed consent was obtained from all participants. the study population consisted of patients booked for pcnl from january 2011 to november 2013. these patients were all diagnosed with renal stones prior to admission, but due to a long waiting list for pcnl, a repeat non-contrast renal stone ct was performed for pre-operative planning and evaluation of disease progression. the standard non-contrast renal stone ct protocol consists of scanning from the top of the kidneys to the bottom of the bladder with 0.625 mm slice thickness and 3 mm image reconstructions in axial, sagittal and coronal planes. once the renal stone was identified, a targeted dual-energy ct with limited field of view was performed covering the stone area. computed tomography technique the ct examinations were performed using a 64 multidetector ct single-source with fast kvp switching (discovery ct 750hd, ge healthcare, milwaukee, wisconsin). the dual-energy protocol used was gemstone spectral imaging (gsi) with rotation time 0.6 s; pitch 1.375:1; detector width 20 mm; and slice thickness 1.25 mm. milliampere was set automatically at 640 ma distributed between 80 and 140 kvp acquisitions. gsi is a feature unique to this specific scanner. image processing dual-energy data were processed by the gsi general protocol on the ct workstation (advantage windows, version 4.5; ge healthcare). a region of interest (roi) was applied over the renal stone viewed on the bone window settings (figure 1) occupying approximately 50% of the stone area on axial images. the gsi effective z (gsi zeff) represents the calculated effective atomic number of the roi area and forms part of the standard dual-energy roi data calculated by the gsi software (figure 2). attenuation of the roi area at monochromatic energy 70 kev also forms part of the vendor-specific gsi roi data (figure 3). both these values were obtained from the gsi data exported to a standard spreadsheet. figure 1: region of interest on a right renal stone viewed in the gsi viewer on bone window settings. figure 2: histogram of the zeff ranges of pixels in the roi. this is displayed in the gsi viewer on the workstation. the average effective z for the roi is calculated by the gsi software and represented on a spreadsheet of all gsi data for the specific roi (not shown here). figure 3: figure 3: stone attenuation (hu) plotted against monochromatic kev, displayed in the gsi viewer on the workstation. specific attenuation values (hu) for every monochromatic energy from 40 to 140 kev are also provided in the roi-specific spreadsheet data (not shown). we plotted the stone zeff against the attenuation at monochromatic 70 kev to attempt separating different groups (figure 4). crystallography the stones extracted via pcnl were sent for analysis to the local national health laboratory service (nhls) laboratory. stone composition was determined using infrared spectroscopy and x-ray diffraction. the zeff value according to stone composition analysis (calc zeff) was calculated using mayneord’s equation14 and then used as the standard against which to compare the gsi zeff. statistical analysis statistical analysis was performed using sas/stat statistical analysis software and microsoft excel. two different strategies were used to evaluate the accuracy of determination of renal stone composition. firstly, we wanted to determine whether the gsi zeff for each stone was similar to the calc zeff. the gsi zeff was subtracted from the calc zeff for each stone to determine the difference (diff_z), and the median diff_z for all stones was calculated to determine whether the difference between the gsi zeff and calc zeff was statistically significant. secondly, we plotted the gsi zeff against the attenuation (hu) at 70 kev for each stone group to determine whether there was good separation between the groups based on the gsi zeff. results top ↑ twenty-five patients were included in the study. six patients had to be excluded due to pcnl cancellations or insufficient extracted stone fragments for laboratory analysis. thus only 19 patients with confirmed ex vivo renal-stone analysis results were included in the study. the patients’ ages ranged from 19 years to 66 years, with a mean age of 45 years. eleven (57.9%) patients were male.the laboratory stone compositions, gsi zeff, calculated zeff and attenuation (hu) at 70 kev are listed in table 1. table 1: composition, effective atomic number and hounsfield units of urinary tract stones (n = 19). the median diff_z was 0.82, although the difference between the gsi zeff value and calculated zeff value was not statistically significant, with a 95% confidence interval (ci) of [-0.28; 1.54]. the scatter plot of the gsi zeff of the individual renal stones versus their attenuation at 70 kev demonstrates that uric acid separation from the calcium-containing stones was graphically possible (figure 4). both stones with a predominant uric acid component fell below a gsi zeff of 10 and an attenuation of 400 hu at 70 kev. figure 4: gsi zeff of individual renal stones versus their attenuation at 70 kev. discussion top ↑ knowledge of the chemical composition of urinary tract stones is essential for planning the management of patients.8 dual-energy ct is an emerging application for possible in vivo characterisation of renal stones, although data on the subject are limited at this stage. this was the first study on in vivo renal stone characterisation done in south africa using the single-source, dual-energy system by ge healthcare.our results indicate that the gsi zeff measurement can differentiate between uric acid and non-uric acid stones, which was in keeping with the findings of a recent study by kulkarni et al. on a machine with the same specifications.10 as found in previous in vivo studies,10,13 we could not accurately differentiate between the different subtypes of calcium stones. in our small study of 19 patients, only two patients had stones with uric acid as major component; the other 17 had calcium-based stones. as we did not encounter any stones of the cystine or struvite group, we could not provide data on the differentiation of these stones from other stone groups. the polycrystalline composition of our calcium-based stone group complicated the differentiation of stone compositions, which was demonstrated by the inability to separate clearly different stone compositions from one another on the scatter plot (figure 4). only three (15.8%) of the 19 stones were pure. the single pure calcium oxalate monohydrate (com) stone had a mean gsi zeff of 13.16, which was very similar to the in vitro (13.21) and in vivo (13.86) results obtained by kulkarni et al.10 in the only published study using similar technology in vivo. their study did not contain carbonite apatite stones10 and therefore no comparison could be made to this stone type. our findings also confirmed that the gsi zeff value in a polycrystalline stone reflects the dominant composition, similar to the findings of kulkarni et al.10 our stone composed of 10% com and 90% uric acid (ua) had a gsi zeff of 7.78, compared to their value of 7.77 (20% com and 80% ua stone). this value is close to the gsi zeff value of pure ua in vivo (7.3).10 similarly, our calcium oxalate 80% and uric acid 20% stone had a gsi zeff of 11.77, compared to their 11.45 (80% com and 20% ua).10 the lack of a statistically significant difference between the gsi zeff and calculated zeff for stone groups in our study, and the similarity in gsi zeff results to other studies using similar technology,10,12 support gsi zeff accuracy for possible renal stone composition determination in future. it should be noted, however, that no clinically acceptable margins of error have been proposed for zeff values due to the small number of in vivo studies on limited stones. in our study, the measured gsi zeff values ranged between 7.78 and 13.98 (11.13 and 13.98 when excluding uric acid–containing stones). this small difference (2.85) in gsi zeff values is likely to make stone differentiation of non-uric acid polycrystalline stones very difficult in the clinical setting, where pure stones appear to be minimal. the polycrystalline stones differ slightly regarding their effective atomic number and any combination of stone constituents can result in a given zeff value. large stones are surgically managed by stone fragmentation using shock wave lithotripsy or alternatively by ureteroscopy or pcnl.5,11 el-assmy et al.8 demonstrated that high ct attenuation (> 1000 hu) of a stone is a significant predictor of failure to fragment renal stones by shock wave lithotripsy. future studies on dual-energy monochromatic attenuation values or gsi zeff values as predictors of failure to fragment renal stones may be of value to refine treatment algorithms. there were a number of limiting factors in the study. only a small number of stones were included due to the limited patient cohort. we did not evaluate the effect of stone and patient size on attenuation values, as this was not our primary research question. no stones of cystine or struvite composition were encountered in our study population. due to insufficient stone fragments for laboratory analysis and pcnl cancellations, six patients had to be excluded from the study. continued in vivo studies on dual-energy ct renal stone characterisation with larger stone numbers are needed to attempt better differentiation of calcium-based stones and refinement of dual-energy ct protocols. conclusion top ↑ single-source dual-energy ct with gsi in the study accurately distinguished between uric acid and non-uric acid renal stones, but failed to subclassify calcium-based non-uric acid stones. mixed uric acid and non-uric acid stones demonstrate characteristics of the dominant component.the effective atomic number of renal stones determined by means of dual-energy ct shows no significant difference to the calculated effective number using the laboratory stone composition. despite limited stone numbers, effective atomic number calculation with dual-energy ct shows promise in determination of renal stone composition. acknowledgements top ↑ the authors acknowledge the personnel of the department of urology and the radiographers at universitas academic hospital for assistance; the personnel of the unit for interventional radiology for extraction of the renal stones; mr cornel van rooyen, department of biostatistics, faculty of health sciences, university of the free state, for statistical analysis of data; and dr daleen struwig, medical writer, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. the authors are not employees of ge healthcare and no funding was received from ge healthcare for the study. authors’ contributions j.h.c. (university of the free state) was the principal investigator and wrote the manuscript. w.s.h. (university of the free state) made conceptual contributions and was involved with manuscript editing. references top ↑ 1.eliahou r, hidas g, duvdevani m, sosna j. determination of renal stone composition with dual-energy computed tomography: an emerging application. semin ultrasound ct mr. 2010;31(4):315–320. http://dx.doi.org/10.1053/j.sult.2010.05.002,pmid: 206919322.rodgers a. the riddle of kidney stone disease: lessons from africa. urol res. 2006;34(2):92–95. http://dx.doi.org/10.1007/s00240-005-0017-1,pmid: 16555110 3.schubert g. stone analysis. urol res. 2006;34(2):146–150. http://dx.doi.org/10.1007/s00240-005-0028-y,pmid: 16477427 4.saita a, bonaccorsi a, motta m. stone composition: where do we stand? urol int. 2007;79(suppl. 1):16–19. http://dx.doi.org/10.1159/000104436,pmid: 17726347 5.tseng ty, stoller ml. medical and medical/urologic approaches in acute and chronic urologic stone disease. med clin north am. 2011;95(1):169–177. http://dx.doi.org/10.1016/j.mcna.2010.08.034,pmid: 21095420 6.hidas g, eliahou r, duvdevani m, et al. determination of renal stone composition with dual-energy ct: in vivo analysis and comparison with x-ray diffraction. radiology. 2010;257(2):394–401. http://dx.doi.org/10.1148/radiol.10100249,pmid: 20807846 7.catalano o, nunziata a, altei f, siani a. suspected ureteral colic: primary helical ct versus selective helical ct after unenhanced radiography and sonography. am j roentgenol. 2002;178(2):379–387. http://dx.doi.org/10.2214/ajr.178.2.1780379,pmid: 11804898. 8.el-assmy a, abou-el-ghar me, el-nahas ar, refaie hf, sheir kz. multidetector computed tomography: role in determination of urinary stones composition and disintegration with extracorporeal shock wave lithotripsy – an in vitro study. urology. 2011;77(2):286–290. http://dx.doi.org/10.1016/j.urology.2010.05.021,pmid: 20719366 9.li x, zhao r, liu b, yu y. gemstone spectral imaging dual-energy computed tomography: a novel technique to determine urinary stone composition. urology. 2013;81(4):727–730. http://dx.doi.org/10.1016/j.urology.2013.01.010,pmid: 23453078 10.kulkarni nm, eisner bh, pinho df, joshi mc, kambadakone ar, sahani dv. determination of renal stone composition in phantom and patients using single-source dual-energy computed tomography. j comput assist tomogr. 2013;37(1):37–45. http://dx.doi.org/10.1097/rct.0b013e3182720f66,pmid: 23321831 11.joshi mc, langan da, sahani ds, et al. effective atomic number accuracy for kidney stone characterization using spectral ct. bellingham, washington: international society for optical engineering, 2010. 12.li xh, zhao r, liu b, yu yq. determination of urinary stone composition using dual-energy spectral ct: initial in vitro analysis. clin radiol. 2013;68(7):e370–e377. http://dx.doi.org/10.1016/j.crad.2012.11.022,pmid: 23535316 13.manglaviti g, tresoldi s, guerrer cs, et al. in vivo evaluation of the chemical composition of urinary stones using dual-energy ct. am j roentgenol. 2011;197(1):w76–w83. http://dx.doi.org/10.2214/ajr.10.5217,pmid: 21700999 14.goodsitt mm, christodoulou eg, larson sc. accuracies of the synthesized monochromatic ct numbers and effective atomic numbers obtained with a rapid kvp switching dual energy ct scanner. med phys. 2011;38(4):2222–2232. http://dx.doi.org/10.1118/1.3567509,pmid: 21626956 article information authors: lili huang1 belinda j. mitchell2 savvas andronikou1 zarina i. lockhat1 farhana suleman1 affiliations: 1department of radiology, university of pretoria, south africa 2department of paediatrics university of pretoria, south africa correspondence to: lili huang email: llhuang0415@yahoo.com postal address: 29 mooiplaas, boardwalk meander, faerie glen, pretoria 0081, south africa dates: received: 26 june 2015 accepted: 30 sept. 2015 published: 09 dec. 2015 how to cite this article: huang l, mitchell bj, andronikou s, lockhat zi, suleman f. heterotaxy syndrome: this is the left, right? s afr j rad. 2015;19(2); art. #902, 5 pages. http://dx.doi.org/10.4102/sajr.v19i2.902 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. heterotaxy syndrome: this is the left, right? in this clinical perspective... open access • abstract • introduction • imaging findings    • chest       • cardiovascular    • lungs    • abdomen • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ heterotaxy syndrome is a rare and complex disorder of the chest and abdominal organ arrangements, and presents a diagnostic challenge to the radiologist. this article describes the morphological characteristics of heterotaxy and situs abnormalities, in particular left and right atrial isomerism, and suggests an approach in evaluating the spectrum of abnormalities associated with heterotaxy syndromes, using appropriate imaging modalities. introduction top ↑ heterotaxy includes a spectrum of malformations involving abnormal right-left axis determination. thoraco-abdominal visceral laterality is deranged, often accompanied by midline defects of the face and brain. the incidence of heterotaxy is 1 in 5000–7000 live births with congenital heart disease.1,2 patients may present incidentally when a chest radiograph shows dextrocardia or a right-sided stomach bubble, or with symptoms associated with cardiac defects, intestinal obstruction or immune deficiencies. despite current advances in medical and surgical management, the long-term prognosis remains guarded.1,3 right isomerism has an overall 5-year survival of 30% – 74% whereas left isomerism, owing to the less complex associated cardiac defects, fares better, with survival of between 65% and 84%.1,2 various human genes associated with heterotaxy syndrome have been identified with varying phenotypical expression.1,2,4 there are four embryonic phases where left-right development may be affected: (1) breaking of left-right symmetry at early embryogenesis; (2) transmission of asymmetric signals from the node to the lateral plate mesoderm; (3) asymmetric gene expression in the left lateral plate mesoderm; and (4) left-right asymmetric morphogenesis of the internal organs. if alteration occurs at the initial stages of embryogenesis, there is usually complete inversion of the left-right axis (situs inversus), whilst interference at a later stage might result in only some organs being affected, with randomised positioning of organs along the left-right axis (heterotaxy) and mirror image duplication of organs (isomerism).4 the term ‘situs’ refers to the position of the atria and viscera in relation to the midline. situs solitus is the usual arrangement of organs and vessels within the body, inferred when the systemic atrium, trilobed lung, liver, gallbladder and inferior vena cava (ivc) are positioned on the right; and the pulmonary atrium, bilobed lung, aortic arch, cardiac apex and stomach bubble are positioned on the left. in situs inversus, the anatomical arrangement of these structures is reversed and is the mirror image of situs solitus. any other presentation with visceral malposition/dysmorphism associated with indeterminate atrial arrangement and vascular anomalies is termed situs ambiguous or heterotaxy.3,5,6 heterotaxy is subdivided into right or left isomerism, according to the atrial appendage anatomy. the atrium with a broad-based appendage receiving blood from the ivc, is called the systemic or right atrium. the atrium with a smaller, narrower appendage receiving blood from the pulmonary veins, is the pulmonary or left atrium.3,5 common morphological characteristics of right and left isomerism are summarised in table 1.1,2 table 1: common morphological characteristics of right and left isomerism. thorough radiological examination of every organ system is needed to delineate all rotational abnormalities and their associated complications in order to plan optimal management.1,2 the appropriate imaging approach to heterotaxy is summarised in figure 1.3,6,7 figure 1: flow diagram illustrating the imaging approach to heterotaxy syndrome. imaging findings top ↑ chest cardiovascular the presence or absence of normal situs solitus can be determined on chest radiography, as well as certain features that are commonly seen in heterotaxy, such as dextrocardia (figure 2) or mesocardia (figure 3), right-sided stomach bubble, right-sided aortic arch and midline liver (figure 4).1,3 figure 2: frontal chest radiograph demonstrating dextrocardia with right-sided aortic arch and right-sided stomach bubble in right isomerism. figure 3: frontal chest radiograph demonstrating mesocardia with right-sided stomach bubble with prominent pulmonary vasculature in right isomerism. figure 4: frontal chest radiograph demonstrating cardiomegaly with left-sided stomach bubble in left isomerism. echocardiography defines the intracardiac and cardiovascular anatomy.1,2 right or left isomerism is defined by the arrangement of the atrial appendages. there are four possible atrial appendage arrangements (figure 5).1,8 right isomerism (figure 6) is characterised by bilateral broad-based pyramidal-shaped right atrial appendages, whereas left isomerism (figure 7) is identified by bilateral finger-like left atrial appendages.1,8 right isomerism commonly presents with atrioventricular canal defects (avcd) (figure 8), pulmonary stenosis or atresia, and transposition of the great arteries (tga), with or without double outflow from the right ventricle (dorv) (figure 9).1 heart defects associated with left isomerism tend to be less complex. total anomalous pulmonary venous return (tapvr) is common in both forms of isomerism. figure 5: illustration of four possible atrial appendages. figure 6: 2d echocardiogram 4-chamber view demonstrating pyramidal-shaped bilateral right atrial appendages. figure 7: 2d echocardiogram 4-chamber view demonstrating bilateral finger-like atrial appendages in left isomerism. figure 8: 2d echocardiogram 4-chamber view demonstrating a large atrioventricular septal defect. figure 9: 2d echocardiograph colour doppler 4-chamber view demonstrating classic double-outlet right ventricle. while echocardiography remains the first-line investigation, cardiovascular magnetic resonance (cmr) is now the gold standard imaging modality in this context and is useful for assessment of cardiac and vascular structures and function. furthermore, cmr and computed tomography (ct) are both useful for the study of other organs within the chest and abdominal cavities.3 echocardiography and cmr are preferred for the absence of ionising radiation.5 however, the newer multidetector ct (mdct) scanners have the advantage of evaluating cardiac morphology, coronary vasculature, great vessels angiography and abdominal viscera at acceptable radiation doses.5 if cardiac ct or cmr are not available or not conclusive, cardiac catheterisation can be done to further delineate the cardiac anatomy as well as the location of the aorta and ivc for surgical planning, as was done in our hospital. right isomerism is characterised by bilateral morphological right pulmonary arteries, as well as bilateral superior vena cavas (svcs) (see the following video: https://youtu.be/bqggztxtkdq)1 and persistent left-sided ivc (see the following video: https://youtu.be/q2zqorhck9g).1 the abdominal aorta and ivc are positioned on the ipsilateral side of the midline (figure 10). typical left isomerism is characterised by bilateral morphological left pulmonary arteries (see the following video: https://youtu.be/bvjajwjmy9c)1 and ivc interruption at the supra-renal level with continuation as azygous or hemi-azygous to the svc (see the following videos: https://youtu.be/b6_n5tkjldo https://youtu.be/cuzhjuhvecc).1 the abdominal aorta and ivc are located on contra-lateral sides of the midline (figure 11).1,2 a persistent left svc draining to the right atrium (ra) (see the following video https://youtu.be/r3fgdja-sdm)1 may also be seen in left isomerism.1,3 figure 10: illustration showing the position of the aorta and ivc in right isomerism. figure 11: illustration showing interrupted ivc continuing with azygous or hemizygous vein. the aorta is located on the opposite side of the midline. lungs bronchopulmonary anatomy is consistent with atrial appendage structures and reinforces the diagnosis of heterotaxy. right isomerism is associated with trilobed lungs with eparterial bronchi (figure 12) whereas left isomerism is associated with bilobed lungs with hyparterial bronchi (figure 13).1,8 major lung fissures can be identified on conventional ct as hypovascular lucent bands, or on high-resolution ct as sharp lines.1,9 figure 12: illustration of trilobed lungs with eparterial bronchus in right isomerism. figure 13: illustration of bilobed lungs with hyparterhal bronchus in left isomerism. abdomen abdominal ultrasound is performed to determine the presence or absence of the spleen, the position of the liver, the presence and position of the gallbladder, and the position of the mesenteric arteries.1,3 asplenia in right isomerism has the complication of increased risk of infection. polysplenia in left isomerism is more common in female subjects.3 there may be hyperclefting of the spleen or numerous separate splenules (from 5 to 16) located in the region of the greater curvature of the stomach.10 whilst the anatomy described is most typical, there is enormous variability and the splenules are not necessarily nonfunctional.7,10 intestinal malrotation occurs in both right and left isomerism, with a slightly higher incidence in right isomerism. fluoroscopic upper gastrointestinal examination (such as barium meal with follow-through) can show the duodenal and jejunal locations; there is often malor non-rotation with malposition of the duodenal-jejunal junction (djj) but the position of the small bowel beyond the djj is variable.7,10 ct and mri may be necessary if further anatomical detail is required.1,3 there is a direct association of bowel malrotation with abnormal morphology, malposition and inversion of the pancreas as both develop embryologically in the dorsal mesogastrium.10 it is also important to be aware of the position of the pre-duodenal portal vein and mesenteric arteries and veins if surgical procedures are to be performed. the latter vessels are useful as a marker for malrotation.7,10 conclusion top ↑ heterotaxy syndrome is associated with serious congenital heart defects as well as abnormalities in many other organ systems. accurate and timeous investigation with appropriate imaging can greatly improve patient outcomes. as cardiac surgical techniques advance with increasing patient survival, so too will the need to investigate and address the many extra-cardiac systems involved. acknowledgements top ↑ this article was adapted from an electronic poster entitled ‘this is the left, right?’ presented at the european congress of radiology in vienna, austria, in 2013. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions l-l.h. (university of pretoria) wrote literature review, prepared images. b.j.m. (university of pretoria) clinical details and images. f.e.s. (university of pretoria) edited the document, selected images, coordinated between authors and university regarding videos. s.a. (university of pretoria) assisted with layout, gave idea of the manuscript. z.l. (university of pretoria) coordinated between various authors and contributed to final editing references top ↑ huang l, mitchell l, andronikou s, suleman f, lockhat z. this is the left, right? poster session presented at: european congress of radiology; 2013 mar 7–11; vienna, austria. http://dx.doi.org/10.1594/ecr2013/c-1214 shiraishi i, ichikawa h. human heterotaxy syndrome – from molecular genetics to clinical features, management, and prognosis. circ j. 2012;76:2066–2075. pmid: 22864291, http://dx.doi.org/10.1253/circj.cj-12-0957 applegate ke, goske mj, pierce g, murphy d. situs revisited: imaging of the heterotaxy syndrome. radiographics. 1999;19:837–852. pmid: 10464794, http://dx.doi.org/10.1148/radiographics.19.4.g99jl31837 deng h, xia h, deng s. genetic basis of human left–right asymmetry disorders. expert rev mol med. 2014;16:1–24. http://dx.doi.org/10.1017/erm.2014.22 balan a, lazoura o, padley sp, rubens m, nicol ed. atrial isomerism: a pictorial review. j cardiovasc comput tomogr. 2012;6:127–136. pmid: 22398009, http://dx.doi.org/10.1016/j.jcct.2011.10.019 lapierre c, dery j, guerin r, viremouneix l, dubois j, garel l. segmental approach to imaging of congenital heart disease. radiographics. 2010;30:397–411. pmid: 20228325, http://dx.doi.org/10.1148/rg.302095112 newman b, koppolu r, murphy d, sylvester k. heterotaxy syndromes and abnormal bowel rotation. pediatr radiol. 2014;44:542–551. pmid: 24419494, http://dx.doi.org/10.1007/s00247-013-2861-4 jacobs jp, anderson rh, weinberg pm, et al. the nomenclature, definition and classification of cardiac structures in the setting of heterotaxy. cardiol young. 2007;17(suppl. 2):1–28. pmid: 18039396, http://dx.doi.org/10.1017/s1047951107001138 hayashi k, aziz a, ashizawa k, hayashi h, nagaoki k, otsuji h. radiographic and ct appearances of major fissures. radiographics. 2001;21:861–874. pmid: 11452059, http://dx.doi.org/10.1148/radiographics.21.4.g01jl24861 abreu a, nieto-morales ml, margarita f. heterotaxy syndrome in a young adult. am j clin med. 2012;9:36–44. http://www.aapsus.org/userfiles/files/ajcm8.pdf abstract introduction conclusion references about the author(s) miranda durand clinical unit, grey’s hospital, university of kwazulu-natal, pietermaritzburg, south africa citation durand m. cardiovascular magnetic resonance imaging in valvular heart disease. s afr j rad. 2016;20(2), a1023. http://dx.doi.org/10.4102/sajr.v20i2.1023 review article cardiovascular magnetic resonance imaging in valvular heart disease miranda durand received: 02 may 2016; accepted: 12 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract the superb spatial and temporal resolution of cardiovascular magnetic resonance (cmr), as well as its reproducibility and independence from patient body habitus and acoustic window, make it an excellent tool for not only diagnostic assessment but also follow-up of valvular heart disease (vhd) patients to determine the optimal time for intervention. this article reviews the anatomy and pulse sequences used to assess these patients and provides an approach for cmr valvular assessment. in addition, it reviews the role of cmr in the assessment of patients with vhd. introduction echocardiography remains the first line of imaging assessment for valvular heart disease (vhd) because of its wide availability, portability and low cost. recent developments in real-time 3d echocardiography have improved the imaging of native valve anatomy and the quantification of valve geometry and function.1 echocardiography, however, is often limited by the patient’s acoustic window. also, inter-observer variation limits the assessment of changes in disease severity and progression. in 2006, the american college of cardiology acknowledged the increasing role that cardiovascular magnetic resonance (cmr) has to play in the assessment of patients with vhd, and gave cmr an ‘a’ appropriateness rating for ‘characterization of native and prosthetic cardiac valves – including planimetry of stenotic disease and quantification of regurgitation diseases’ and ‘patient(s) with technically limited images from echocardiograms or tee’.2 the superb spatial and temporal resolution of cmr, as well as its reproducibility and independence from patient body habitus and acoustic window, make it an excellent tool for not only diagnostic assessment but also follow-up of these patients to determine the optimal time for intervention.3 the present article reviews the anatomy and pulse sequences used to assess patients with vhd and provides an approach for cmr valvular assessment. pulse sequences for patients with vhd, start with a basic cmr protocol: axial black blood images of the thorax two-chamber cine steady state free precession (ssfp) images four-chamber cine ssfp images left ventricular outflow tract (lvot) cine ssfp images short-axis cine ssfp images of the ventricles axial cine ssfp images through the valve. after this, the protocol is tailored to the valve involved. for left-sided heart valves, phase contrast images should be added through the aorta. for right-sided heart valves, right ventricular outflow tract (rvot) cine ssfp images and phase contrast images are added through the pulmonary artery. when determining if the stenosis or pathology is at the level of the valve or subvalvular, as in cases involving the aorta and pulmonary valves, coronal images through the valve may also be helpful (figure 1). figure 1: coronal ssfp image of the aortic valve demonstrates an aneurysm (arrowhead) of the sinus of valsalva (*). the coronal image demonstrates the aneurysm above the level of the leaflet (white arrow). cine image available at https://www.youtube.com/watch?v=mhb_6cmlhmq&feature=youtu.be the two-chamber, four-chamber and lvot cine images are useful to assess for mitral regurgitation. the axial cine images though the mitral valve give a good view of all the leaflets, allowing assessment of leaflet morphology. similarly, the four-chamber and axial cine images are useful to assess for tricuspid regurgitation. the four-chamber cine image also best depicts the attachment of the septal leaflet of the tricuspid valve for the assessment of ebstein’s abnormality. for assessing leaflet morphology, the axial cine images through the tricuspid valve are most useful. cardiovascular magnetic resonance in valvular heart disease the assessment of valves using cmr can be structured in the following way: normal anatomy valve morphology valve function ventricular function. anatomy aortic valve the aortic valve is a tricuspid valve with three valve cusps: the right coronary cusp, the left coronary cusp and the non-coronary cusp (figure 2a). small spaces are seen between the attachments of the cusps to the aortic wall, called commissures (figure 2b). on the coronal images of the aortic root the aortic cusps, the sinus of valsalva and sinotubular junction can be assessed in plane (figure 2c). the coronary arteries normally arise from the sinus of valsalva below the level of the sinotubular junction. figure 2: (a) axial cine ssfp image through the aortic valve in diastole demonstrates a closed valve with three valve cusps: the right coronary cusp (rcc), the left coronary cusp (lcc) and non-coronary cusp (ncc). the left atrium (la) and right atrium (ra) are also identified; (b) axial cine ssfp image through the aortic valve in systole demonstrates an open valve with the cusp leaflets (white arrows) and the commissures between the cusp attachments (arrowheads). the aorta (ao), left atrium (la) and right atrium (ra) are identified. (c) coronal ssfp cine image of the aortic valve demonstrates the aortic cusp (white arrow), the coronary sinus (*) and the sinotubular junction (dashed arrow) and the coronary artery coming off the coronary sinus (arrowhead). the left ventricle (lv) and pulmonary artery (pa) are identified. mitral valve the mitral valve consists of leaflets (the anterior and posterior leaflets; figure 3a), each of which can be divided into three components. each of the leaflets are attached to a papillary muscle via a tendinous cord (figure 3b), and two sets of papillary muscles are seen on the short-axis images – the anterior lateral and the inferior medial papillary muscles. figure 3: (a) short-axis cine ssfp image demonstrates a closed mitral valve during systole, the anterior leaflet with a1, a2 and a3 portions, as well as the posterior leaflet with p1, p2 and p3 segments. (b) short-axis cine ssfp image demonstrates the anterior lateral (arrowhead) and inferior medial (white arrow) papillary muscles of the mitral valve. pulmonary valve the pulmonary artery is the most anterior great vessel on the axial images. the pulmonary valve appears anatomically very similar to the aortic valve and also has three cusps: the anterior, left and right cusps (figure 4). figure 4: axial cine ssfp image through the pulmonary valve demonstrates the three cusps of the pulmonary valve: the anterior (ac), right (rc) and left (lc) cusps. tricuspid valve the tricuspid valve is a three-leaflet valve with an anterior, septal and posterior leaflet (figure 5a). each of these leaflets is attached to similarly named papillary muscles via tendinous cords (figure 5b). figure 5: (a) short-axis cine ssfp image of the tricuspid valve demonstrates the anterior (a), septal (s) and posterior (p) leaflets. the left ventricle (lv) and right ventricular outflow tract (rvot) are identified; (b) short-axis cine ssfp image demonstrates the anterior (a), septal (s) and posterior (p) papillary muscles of the tricuspid valve. valve morphology number of leaflets part of the morphological assessment of the cardiac valves is to assess the number of valve leaflets. congenital leaflet number abnormalities are fairly uncommon and are most often in the aortic valve. the most common leaflet abnormality of the aortic valve is a bicuspid aortic valve. the most common form of the bicuspid aortic valve is that of a valve with one raphe (figure 6a) which is the result of fusion of two adjacent cusps.4 on rare occasions, the bicuspid valve is secondary to a bisinus valve, with only two sinuses of valsalva and two cusps. no raphes are seen in these cases but the abnormality still results in the same characteristic ‘fish mouth’ opening of the valve (figure 6b). figure 6: (a) short-axis cine image of the aortic valve demonstrates the very characteristic ‘fish mouth’ opening of the bicuspid aortic valve secondary to a raphe (solid white arrow). two normal commissures can also be seen (dashed white arrows). cine image available at https://www.youtube.com/watch?v=swx3jiax4dq&feature=youtu.be; (b) axial cine ssfp image of the aortic valve demonstrates only two coronary sinuses of valsalva with two normal commissures (dashed white arrows) resulting in the characteristic ‘fish mouth’ opening of the bicuspid aortic valve. cine image available at https://www.youtube.com/watch?v=1nhgzob-y_w&feature=youtu.be leaflet number abnormalities in the other valves are extremely rare, but leaflets ranging from 2 to 5 have been described for the pulmonary and tricuspid valves.5 attachment abnormalities the most common attachment abnormality of the valves is ebstein’s abnormality, where there is apical displacement of the implantation of the septal leaflet of the tricuspid valve (figure 7). the degree of apical displacement varies with ebstein’s abnormality and is classified as abnormal if apical displacement of the septal leaflet of more than 8 mm/m2 is present.6 this results in part of the right ventricle being incorporated into the right atrium and subsequently increases the right atrial size and decreases the functional right ventricle volume. figure 7: four-chamber ssfp cine image demonstrates the apical displacement of the septal leaflet of the tricuspid valve (white arrow) from the level of the mitral valve annulus (white line). this results in a true right atrium (*) and an atrialised portion of the right ventricle (white square), and a reduced functional right ventricle volume. leaflet integrity the leaflets need to be assessed for tears, clefts or prolapses. normally the flow jet from regurgitation secondary to ventricular dilatation is directed directly posteriorly. tears and clefts can be acquired or congenital and are normally seen as an extra or eccentric flow jet arising from the leaflet (figure 8). figure 8: four-chamber ssfp cine image demonstrates an eccentric flow jet (white arrow) close to the interatrial septum arising from the aortic septum of the mitral valve (arrowhead) owing to a leaflet cleft. cine image available at https://www.youtube.com/watch?v=evadurgblgu&feature=youtu.be prolapse is seen as atrial displacement of the leaflets. the easiest way to assess this is to draw a line through the annulus and measure the distance from the line to the leaflet. if the displacement is more than 2 mm, it is in keeping with prolapse.7 an associated regurgitation jet is also normally seen. with leaflet prolapse, as with tears and clefts, the flow jet is eccentric. in mitral valve prolapse, the jet is directed antero-medially towards the septum with prolapse of the posterior leaflet, and is postero-central or postero-lateral with anterior leaflet prolapse. in the instance of bi-leaflet prolapse, the flow jet is in a postero-medial direction (figure 9).8 figure 9: ssfp four-chamber view demonstrates prolapse of the anterior leaflet (white arrow) in relation to the posterior leaflet (black arrow) and a posterolateral directed regurgitation jet (arrowhead). papillary muscle and tendinous cords there is considerable variation in the number of tendinous cords normally seen attaching to each of the five papillary muscles, with an average of 12 tendinous cords per papillary muscle. the individual papillary muscles are normally the same thickness as the normal left ventricular myocardium. the most common congenital abnormality of the papillary muscles is a single papillary muscle to which all the tendinous cords of the mitral valve attach (figure 10), resulting in a ‘parachute’ mitral valve.9 figure 10: four-chamber cine ssfp image demonstrates a thickened single papillary muscle (*) in the left ventricle (lv) with all the tendinous cords (white arrow) attaching to this single papillary muscle. acquired abnormalities of the papillary muscles are, however, much more common. the most common primary tumour of the papillary muscles is fibroelastoma which may be situated on the papillary muscle or on the tendinous cords. however, more common than primary tumours of the papillary muscles is the local invasion or involvement of the papillary muscles owing to direct extension of left ventricular myocardial disease, tumours (figure 11) or ischaemic scarring. figure 11: axial spair image demonstrates extension of a myocardial tumour (*) into the papillary muscle (white arrow). valvular function ssfp and gradient echo sequences can visualise flow disturbances caused by valvular stenosis or regurgitation on the basis of signal loss owing to dephasing of moving protons. this helps to locate the jet for the dephasing origin and direction. although ssfp imaging provides better visualisation of valve anatomy, it is less sensitive to phase disturbances than gradient echo sequences, making it easier to miss or underestimate severe regurgitation.10 phase contrast sequences are also used for valvular assessment, particularly of the aortic and pulmonary valves. these sequences are based on the accumulated phase of moving protons and are used to measure the peak velocity, stroke volume, and regurgitation fraction in a vessel. these images needs to be acquired directly perpendicular to the vessel for accurate measurements (figure 12). valvular stenosis is seen as increased signal in the region of the flow jet (figure 13). figure 12: lvot ssfp image demonstrates the orientation of the phase contrast image for the aorta (white line). figure 13: phase contrast images through the pulmonary valve demonstrate pulmonary valve stenosis with flow acceleration (*) demonstrated as increased intensity in the pulmonary artery on the magnitude (left) and phase (right) contrasted images. stenosis in patients with valvular stenosis, dephasing or a flow jet can be seen distal to the valve (figure 14). smaller openings, characteristic of severe disease, cause more dephasing and a darker jet is seen. the phase contrast images in severe stenosis will also demonstrate higher velocities, which will be seen as an area of complete signal loss owing to aliasing if it is above the programmed maximum velocity. this will result in an underestimation of the peak velocity as velocities higher than the programmed maximum velocities cannot be detected. in these instances, the programmed maximum velocity needs to be adjusted until the aliasing artefact disappears. the area of maximum opening of the valve can also be measured on the axial ssfp cine images through the valve (figure 15). figure 14: coronal cine ssfp image of the aortic valve demonstrates a jet (white arrow) distal to the valve as a result of aortic valve stenosis. figure 15: axial cine ssfp image of the aortic valve demonstrates maximum opening of the valve traced (white line) to allow for surface area measurement. regurgitation valvular regurgitation is seen as dephasing or as a flow jet proximal to the valve (figure 16). with regurgitation, more severe disease results in a large opening which causes less dephasing and thus results in a less obvious jet. figure 16: lvot cine ssfp image demonstrates a flow jet (white arrow) proximal to the aortic valve, in keeping with aortic regurgitation. aortic and pulmonary valve regurgitation is normally measured directly with phase contrast images. by drawing a region of interest in the vessels, the forward volume and regurgitation volume can be measured and used to calculate the regurgitation fraction (regurgitation volume/forward volume × 100).11 normally, phase contrast images are not used to directly assess the regurgitation fraction for the mitral and tricuspid valves. for these two valves, the regurgitation fraction, as measured on the phase contrast images of the aorta and pulmonary arteries, is calculated using the ventricular stroke volume and the aortic and pulmonary forward volumes respectively: mitral regurgitation = left ventricular stroke volume – aortic forward stroke volume10 tricuspid regurgitation = right ventricular stoke volume – pulmonary forward stroke volume.10 ventricular function cmr is not only an excellent modality for assessing the cause of valvular disease and quantifying the severity of the disease, but it has also been shown to be the most reliable modality to assess the consequences of the vhd.12 the consequences of vhd are assessed by looking at the ventricular size and function. because of the reproducibility of cmr, it now forms an integral part in the assessment of these patients for valve replacement surgery.12 conclusion cmr plays in increasingly important role in the pre-surgical assessment of patients with vhd. cmr is particularly useful to assess valvular anatomy and function, quantify the severity of the disease, as well as assess the sequelae of vhd, with accurate assessment of ventricular size and function. competing interests the author declares that she has no financial or personal relationships which may have inappropriately 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2012;126(12):1452–1460. http://dx.doi.org/10.1161/circulationaha.111.083600 lopez-mattei jc, shah dj. the role of cardiac magnetic resonance in valvular heart disease. methodist debakey cardiovasc j. 2013;9(3):142–148. http://dx.doi.org/10.14797/mdcj-9-3-142 14-15 abstract papillary thyroid carcinoma may be multifocal in up to 50% of affected children. surgeons must weigh the higher risks of recurrence when surgical resection is less than subtotal thyroidectomy against the higher risks of complications with subtotal/total thyroidectomy. an 11-year-old girl presented to our surgical department with a thyroid mass. computed tomography (ct) revealed a lesion, missed by ultrasonography, which reversed the decision to perform conservative thyroid surgery. the lesion proved to be non-neoplastic. ct may be a useful adjunct when ultrasound demonstrates a solitary lesion and conservative surgery is considered, and may prove to be able to distinguish neoplastic from non-neoplastic lesions based on contrast enhancement characteristics, but caution is advised in assuming that all nodules are neoplastic. introduction the literature presents two views regarding the treatment of paediatric papillary thyroid carcinoma. there are those supporting conservative surgical procedures and those supporting subtotal or total thyroidectomy.1-7 surgeons must weigh the higher risks of recurrence when surgery is less than subtotal thyroidectomy against the higher risks of complications with subtotal/total thyroidectomy. ct may be a useful adjunct when ultrasound demonstrates a solitary lesion and conservative surgery is considered, and may prove to be able to distinguish neoplastic from non-neoplastic lesions based on contrast enhancement characteristics. case report an 11-year-old girl presented to our surgical department with a thyroid mass. computed tomography (ct) revealed a finding, missed by ultrasonography, which reversed the decision to perform conservative thyroid surgery. ultrasound demonstrated a single lesion in the left thyroid lobe (fig. 1). ct confirmed the primary lesion in the left thyroid lobe measuring 2.2 x 2.2 x 3 cm, but also revealed a small right lobe lesion measuring 0.1 x 0.2 x 1.5 cm (fig. 2a), which was not observed on ultrasound. contrast ct showed enhancement of the left lobe nodule, but no enhancement of the right lobe nodule (fig. 2b). more extensive surgery than originally planned was undertaken based on this finding, presuming that the right nodule was also a possible focus of malignancy. pathological examination diagnosed the larger nodule to be a papillary thyroid carcinoma with vascular invasion but concluded that the smaller nodule was not neoplastic. discussion in the consideration of surgical treatment of paediatric papillary thyroid carcinoma, the higher risks of case report 14 sa journal of radiology • july 2005 ct scanning may adversely influence choice of surgery in paediatric papillary thyroid carcinoma a note of caution s andronikou mb bch, fcrad (diag) (sa), frcr (lond) formerly: department of paediatric radiology red cross children’s hospital and university of cape town fig. 1. ultrasound demonstrates the inhomogeneous left thyroid lobe mass (white arrows) and the adjacent carotid and jugular vessels (black arrows). fig. 2a. non-contrast ct scan of the neck shows the low-density nodule in the left thyroid lobe (whte arrow) with a thin rim of normal dense thyroid parenchyma anteriorly (white arrowhead). a small second low-density lesion is demonstrated in the right lobe laterally (black arrow). 14-15 8/1/05 12:31 pm page 14 recurrence when surgery is less than subtotal thyroidectomy must be weighed against the higher risks of complications with subtotal/total thyroidectomy. complications of subtotal/total thyroidectomy include hypoparathyroidism in up to 30% of patients and recurrent laryngeal nerve injury in up to 11% of patients.1-7 papillary thyroid carcinoma may be multifocal in up to 50% of affected children1-3,5,7 and, as a result, recurrence rates are higher when less than subtotal thyroidectomy is performed.2 residual thyroid tissue also diminishes the specificity of thyroglobulin as a tumour marker and interferes with radioiodine as a diagnostic tool postoperatively.3 some authors maintain, however, that there is no evidence that patients who undergo total thyroidectomy fare better than those with conservative surgery at long-term followup,2,3,5 even though recurrence in thyroid remnants is higher in children than in adults.6 ultrasonography is used to rule out thyroid anomalies, to determine if nodules are solitary or multiple, and to determine if nodules are cystic or solid.6,8 a cystic nodule does not exclude malignancy8 and therefore imaging is largely directed toward excluding multifocality. the sensitivity for ultrasound detection of microscopic nodules (less than what size?) is quoted to be 50%.4 when there is a solitary nodule, fine needle aspiration (fna) may be sufficient to confirm or exclude malignancy4,8 and conservative surgery can be considered. scintigraphy in patients who have undergone ultrasonography and fna is not expected to contribute useful information in such cases and has been omitted in some protocols.8 ct scanning has only been recommended for the evaluation of paediatric thyroid lesions by two authors.1,6 in our patient, ct proved to be more sensitive than ultrasound in detecting the small right thyroid lesion. although the small lesion was not neoplastic, it led to more aggressive surgery. with non-contrast ct, these lesions are seen as low-density lesions against the dense background of iodine-rich normal parenchyma (fig. 2a). conversely, enhancement of a small lesion may make it less conspicuous on ct compared with the adjacent dense thyroid tissue. contrast ct in our patient showed enhancement of the primary neoplastic left lobe nodule, but no enhancement of the non-neoplastic right lobe nodule. this may be a means of differentiating neoplastic from non-neoplastic lesions, but this remains to be proved. conclusion identification of more than one lesion in childhood thyroid carcinoma will affect surgical management in centres where conservative surgery is preferred, and imaging must be directed towards identification of these. ct may be a useful adjunct when ultrasound demonstrates a solitary lesion and conservative surgery is considered, and may prove to be able to identify small lesions and possibly distinguish neoplastic from non-neoplastic lesions based on contrast enhancement characteristics. however, prospective studies to compare ct and ultrasound detection of thyroid lesions are difficult to perform because of the rarity of thyroid malignancy in childhood (1 1.5% of all malignancies in this age group).5,7 references 1. la quaglia mp, black t, holcomb gw 3rd, et al differentiated thyroid carcinoma: clinical characteristics, treatment and outcome in patients under 21 years of age who present with distant metastases. a report from the surgical discipline committee of the children’s cancer group. j pediatr surg 2000; 35: 955-960. 2. welch dinauer ca, tuttle rm, robie dk, mc clellan dr, francis gl. extensive surgery improves recurrence-free survival for children and young patients with class i papillary thyroid carcinoma. j pediatr surg 1999; 34: 1799-1804. 3. kuefer mu, moinuddin m, heideman rl, et al. papillary thyroid carcinoma: demographics, treatment and outcome in eleven pediatric patients treated at a single institution. med pediatr oncol 1997; 28: 433-440. 4. karguzel g, tanyel fc, buyukpamukcu n, hicsonmez a. is there any predictive characteristic for malignancy in thyroid enlargements during childhood? eur j pediatr surg 1996; 6: 70-74. 5. massimino m, gasparini m, ballerini e, del bo r. primary thyroid carcinoma in children: a retrospective study of 20 patients. med pediatr oncol 1995; 24: 13-17. 6. gorlin jb, salan se. thyroid cancer in childhood. endocrinol metab clin north am 1990; 19: 649-662. 7. desjardins jg, bass j, leboeuf g, et al. a twenty-year experience with thyroid carcinoma in children. j pediatr surg 1988; 23: 709-713. 8. hung w. solitary thyroid nodules in 93 children and adolescents: a 35 years experience. horm res 1999; 52: 15-18. case report 15 sa journal of radiology • july 2005 fig. 2b. post contrast ct scan of the same region demonstrates inhomogeneous enhancement of the larger nodule (white arrow) making it more difficult to differentiate from normal parenchyma. the small right lobe lesion does not enhance and is now more evident (black arrow). 14-15 8/1/05 12:31 pm page 15 radiology abstract pathology affecting the suprasellar cistern is varied in paediatric neuroradiology practice. although mri is the imaging modality of choice for lesions of the suprasellar cistern, abnormalities can be detected on ct with knowledge of the normal anatomy and a sound approach to the possible pathological entities. we present our approach to pathology affecting the suprasellar cistern and highlight this using various cases seen at our institution in the recent past. introduction in modern radiology practice it is accepted that the suprasellar and sellar regions are best imaged using mri.1 however, in both the first and thirdworld, obtaining an mri scan is often difficult due to the constraints of cost and availability. ct is fairly ubiquitous in modern times and is often the first imaging modality used in paediatric patients requiring neuroradiological evaluation. pathology is often subtle on ct compared with mri and careful review of images by the radiologist is necessary to make accurate diagnoses. the suprasellar cistern is an area that warrants review as it can be involved in a number of pathological processes. our approach to pathology affecting the suprasellar cistern is based on the normal anatomical structures adjacent to and within it (table i). fig. 1 normal suprasellar cistern on contrast-enhanced ct showing the characteristic pentagonal shape.2 the vessels comprising the circle of willis are clearly seen. note the optic chiasm (long black arrow) and the contrastenhancing normal infundibular stalk posterior to the chiasm (white arrow). 16 sa journal of radiology • february 2005 pictorial review the paediatric suprasellar cistern as an important ct review area v dahya mb bch, fcrad (diag) sa s andronikou mb bch, fcrad (diag) sa, frcr department of radiology university of cape town and red cross children’s hospital table i. relations and contents of suprasellar cistern and the more common paediatric pathological entities structure pathology relations inferior: pituitary gland/sella • craniopharyngioma/ rathke cleft cyst (embryological rests along vestigeal craniopharygeal duct) • pituitary adenoma (rare) superior: hypothalamus • hamartoma • glioma anterior: gyrus rectus • granuloma • glioma posterior: pons • glioma lateral: medial temporal lobes • uncal herniation contents circle of willis • aneurysms meninges • inflammatory, infective or neoplastic thickening / nodularity optic chiasm • glioma infundibulum/stalk • langerhans cell histiocytosis • germ cell tumour • metastases radiology 2/24/05 4:50 pm page 16 fig. 2 normal suprasellar cistern seen on contrast-enhanced ct showing the normal hypothalamus within it (black arrow). fig. 3 craniopharyngiomas in two separate patients on contrast-enhanced ct with dense calcification within the suprasellar cistern. solid (thin black arrow) and cystic (open black arrow) components are present in (b), with hydrocephalus. fig. 4 a more subtle craniopharyngioma with peripheral rim calicification (white arrow) seen pre-contrast administration (a). rim enhancement is seen post-contrast (white arrow) (b). note that the bulk of the tumour is isodense to grey-matter. fig. 5 post-contrast ct showing a tubercinerium hamartoma. note the nonenhancing subtle abnormality (white arrow). the child presented with gelastic seizures. fig. 6 a pontine glioma encroaching on the posterior suprasellar cistern on contrast-enhanced ct. note the nonenhancement of the tumour. partial pictorial review 17 sa journal of radiology • february 2005 fig. 1. fig. 2. fig. 3a. fig. 3b. fig. 4a. fig. 4b. radiology 2/24/05 4:50 pm page 17 18 sa journal of radiology • february 2005 encasement of the basilar artery (open black arrow) is an important clue to detection.3 fig. 7 haemorrhage from a suprasellar aneurysm on: (i) non-contrast ct and the aneurysm viewed from above on: (ii) ssd (shaded-surface display) ct angiogram of the circle of willis (open white arrow). fig. 8 a meningeal granuloma within the suprasellar cistern (white arrows) pre (a) and post (b) contrast. intense post-contrast ring-enhancement is present. microbiological studies confirmed the diagnosis of tuberculosis. fig. 9 a patient with confirmed tuberculous meningitis with intense meningeal enhancement within the suprasellar cistern (white arrow) and bilateral extension into the sylvian fissures and the ambient-wing cisterns bilaterally. note the complicating hydrocephalus. fig. 10 post-contrast ct showing a typical homogeneously enhancing optic chiasm glioma (white arrow). the patient has neurofibromatosis type one. fig. 11 a germ-cell tumour with hyperdensity of the tumour and calcification (open black arrow) pre-contrast pictorial review fig. 5. fig. 6. fig. 7a. fig. 7b. fig. 8a. fig. 8b. radiology 2/24/05 4:50 pm page 18 (a) and strong enhancement postcontrast administration (b). hydrocephalus is also present. fig. 12 a patient with proven tuberculous meningitis with thickening and enhancement of the infundibular stalk4 (open black arrows). similar findings can be noted with langerhans-cell histiocytosis.5 of note is that this patient did not have diabetes insipidus, which commonly occurs with infundibular stalk lesions.6 references 1. connor sej, penney cc. mri in the differential diagnosis of a sellar mass. clin radiol 2003; 58: 20-31. 2. kuuliala j. the normal suprasellar subarachnoid space in computed tomography. clin radiol 1980; 31: 155-159. 3. naidich p, zimmerman ra. primary brain tumours in children. semin roentgenol 1984; 19: 100-114. 4. manelfe c, louvet jp. computed tomography in diabetes insipidus. j comput assist tomogr 1979; 3: 306-309. 5. schmitt s, wichmann w, martin e, zachmann m, schoenle ej. pituitary stalk thickening with diabetes insipidus preceding typical manifestations of langerhans cell histiocytosis in children. eur j paediatr 1993; 152: 399-401. 6. andronikou s, furlan g, fieggen ag, wilmhurst j. two unusual causes of pituitary stalk thickening in children without clinical features of diabetes insipidus. pediatr radiol 2003; 33: 499-502. pictorial review 19 sa journal of radiology • february 2005 fig. 9. fig. 10. fig. 11a. fig. 11b. fig. 12a. fig. 12b. radiology 2/24/05 4:50 pm page 19 article information authors: vicci du plessis1 farhana suleman2 affiliations: 1south african society of paediatric imaging (saspi), cresta, south africa 2department of radiology, grey's hospital, south africa correspondence to: vicci du plessis email: paediatric.imaging.sa@gmail.com postal address: private bag x9001, pietermaritzburg 3200, south africa how to cite this article: du plessis v, suleman f. paediatric imaging in south africa – from baby steps to giant strides. s afr j rad. 2015;19(2); art. #951, 2 page. http://dx.doi.org/10.4102/sajr.v19i2.951 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. paediatric imaging in south africa – from baby steps to giant strides in this editorial... open access    • to optimise national paediatric imaging protocols    • to promote the reduction of radiation exposure to children during imaging    • to advance education in paediatric radiology    • to support outreach projects locally, regionally and internationally    • to encourage paediatric radiology research    • a giant leap forward for the sajr the south african society of paediatric imaging (saspi) is honoured to guest edit this special issue of the sa journal of radiology (sajr) in celebration of the international day of radiology (idor) on 08 november, which is dedicated to paediatrics this year. formally inaugurated in march 2011, saspi is a sub-group of the radiological society of south africa (rssa), consisting of over 100 members including registrars, radiologists, paediatric radiology fellows, and paediatric radiologists. saspi is expanding globally, having spearheaded the foundation of the african society of paediatric imaging (afspi), a sub-group of the african society of radiology (asr). saspi is also strongly affiliated to the world federation of pediatric imaging (wfpi). founding and past saspi chair and afspi president savvas andronikou established the wfpi outreach programme, and the present saspi chair and afspi president jaishree naidoo currently represents south africa at international conferences as wfpi vice-secretary. over the past five years, saspi has striven for excellence in paediatric imaging in south africa and beyond. supported by our few, but world-renowned, south african paediatric radiologists (all of whom have published articles in the current special issue), saspi has pursued the following aims: to optimise national paediatric imaging protocols the saspi/rssa paediatric imaging guidelines (based on the red cross war memorial children's hospital guidelines) were compiled during 2012 and have since been available to all south african radiologists on the rssa website. saspi thanks savvas andronikou, jaishree naidoo, tracy kilborn, richard pitcher, nicky wieselthaler and aadil ahmed for contributing to this initiative. to promote the reduction of radiation exposure to children during imaging this has been a major goal for saspi, as reflected in the national guidelines, as well as the personal pledge by each of our members to support this cause in accordance with the ‘image gently’ campaign. this priority for south african paediatric imaging has also filtered its way into written questions for the fcraddiag(sa) exit examination. it is therefore appropriate and our privilege to have an article in this special issue by kimberly applegate, one of the steering committee members of the alliance for radiation safety in pediatric imaging. to advance education in paediatric radiology the red cross war memorial children's hospital paediatric radiology fellowship has produced five fellows since 2009, thanks to its fine teachers: tracy kilborn, nicky wieselthaler, richard pitcher and ebrahim banderker. initially it was funded by the harry crossley foundation, and is currently possible thanks to the generous financial support of drs schnetler, corbett and partners inc., diagnostic radiologists. the charlotte maxeke johannesburg academic hospital observership has been kindly facilitated by jaishree naidoo, who will also be co-ordinating the upcoming nelson mandela children's hospital fellowship. few will forget the first saspi/rssa paediatric imaging congress in sandton in november 2012, a phenomenal success and a milestone for south african paediatric radiology. 2016 marks the year of the 2nd saspi/rssa paediatric imaging congress to be held at spier estate, stellenbosch, from 04–06 november. the esteemed panel of local and international speakers will focus on abdominal (gastro-intestinal and genito-urinary) and chest (pulmonary and cardiac) imaging, with a strong emphasis on radiation protection of paediatric patients. as an additional idor 2015 initiative, saspi initiated a series of educational paediatric imaging webinars in collaboration with the rssa and the children's hospital of philadelphia (chop). these were very well-supported and received outstanding feedback from attending delegates. thank you to tanyia pillay, kassa darge and the rssa and chop administrative staff. to support outreach projects locally, regionally and internationally apart from site visits to durban, pietermaritzburg, bloemfontein and ga-rankuwa, saspi has also organised outreach projects in swaziland and malawi. saspi members have volunteered for local and international tele-reporting projects and also contribute to the wfpi's ‘tb corner’ via the wfpi outreach programme. to encourage paediatric radiology research by granting saspi the unique opportunity to guest edit this issue, the sajr has assisted in achieving this final goal. saspi would like to take this opportunity to thank the rssa, the sajr editorial board (razaan davis and farhana suleman), the aosis publishing team, and of course all local and international contributors (authors and reviewers) for their tremendous support in pioneering this remarkable special paediatric issue. yours in paediatric imaging vicci du plessis secretary: south african society of paediatric imaging (2011 – 2015) guest editor: sajr paediatric special issue a giant leap forward for the sajr a huge advantage of online publication of journals, especially imaging journals, is the improved content that can be afforded to the readership in terms of quality and diversity of the images provided. if a picture says a thousand words, then a video can tell an entire story, and this special paediatric issue of the sajr introduces for the first time an article with video content. when authors from the university of pretoria approached the editorial team to discuss the feasibility of including videos in the article ‘heterotaxy syndrome: this is the left, right?’, it generated huge excitement but, as always with publications, cost became a huge factor. refusing to be discouraged, the authors then approached the department for education innovation at the faculty of health sciences, university of pretoria, who willingly provided assistance in preparing the videos, uploading them onto the website, and providing the url links for the article at no cost to the authors or publishers. the result is a major step forward for the journal in keeping with international publication trends, and confirms the commitment of the editorial team, and in particular the editor-in-chief razaan davis, to establishing the sajr as a proudly south african journal. we take this opportunity to thank marizanne booyens, anton van dyk and hannelie untiedt of the department for education innovation at the university of pretoria for their assistance with the images and videos that enables us to take the sajr into a new era. farhana suleman south african journal of radiology radiology 34 sa journal of radiology • february 2005 letters the hyperdense middle cerebral artery sign in a polycythaemic child to the editor: the hyperdense middle cerebral artery (hmca) sign is known to be an early sign of intracranial arterial occlusion or infarction during unenhanced ct imaging of the brain.1 this sign has also been seen after treatment with bromide,2 in cocaine abusers3 and in adults with elevated haematocrit,4 but has not previously been reported to be a result of polycythaemia in children. we recently encountered this sign as an incidental finding throughout the vessels of the circle of willis in a child with a cyanotic heart condition and speculate that the dense appearance of these intracranial vessels was the result of polycythaemia. a 4-year-old girl was admitted with headaches, vomiting and fever. the child had an atrial septal defect, ventricular septal defect, pulmonary atresia and multiple aorto-pulmonary collateral arteries. clinically, she was cyanotic and clubbed. the neurological examination was normal. laboratory tests showed a haematocrit of 67.6% and haemoglobin level of 21.9 g/dl in keeping with polycythaemia. a ct scan of the head was performed in order to exclude a brain abscess or meningitis. the uncontrasted ct scan did not show any findings of a brain abscess but the hmca sign was seen involving both middle cerebral arteries as well as the basilar artery (figs 1 a and b). there was no clinical or radiological evidence of cerebral infarction or vessel occlusion. the high haematocrit may therefore have increased the density of the blood leading to an hmca sign. although the hmca sign has been shown to be a false indicator of vascular occlusion in adults,4 an association between an elevated haematocrit and a hmca in children has not yet been reported. references 1. petitti n. the hyperdense middle cerebral artery sign. radiology 1998; 208: 687-688. 2. osborne d, bohan t, hodson a. ct demonstration of hyperdense cerebral vasculature due to bromide therapy. j comput assist tomogr 1984; 8: 982-984. 3. hall a, wagle v. ct enhancement after use of cocaine. am j neuroradiol 1990; 11:1083. 4. rauch ra, bazan c 3rd, larsson em, jinkins jr. hyperdense middle cerebral arteries identified on ct as a false sign of vascular occlusion. am j neuroradiol 1993; 14: 669-673. figs 1 a and b. sequential non-contrast ct slices in a 4-year-old girl show increased density of the arteries of the circle of willis due to polycythaemia. h douis s andronikou s jadwat department of paediatric radiology red cross children’s hospital university of cape town radiology 2/24/05 4:50 pm page 34 article information authors: jacobus h. otto1 jacques janse van rensburg1 david k. stones2 affiliations: 1department of clinical imaging sciences, university of the free state, south africa 2paediatric haematology and oncology, department of paediatrics and child health, university of the free state, south africa correspondence to: jacobus otto email: flipotto@gmail.com postal address: 4 kipling street, dan pienaar, bloemfontein 9301, south africa dates: received: 02 feb. 2015 accepted: 15 may 2015 published: 05 aug. 2015 how to cite this article: otto jh, janse van rensburg, j, stones dk. post-treatment surveillance abdominopelvic computed tomography in children with wilms tumour: is it worth the risk?. s afr j rad. 2015;19(1); art. #784, 6 pages. http://dx.doi.org/10.4102/sajr.v19i1.784 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. post-treatment surveillance abdominopelvic computed tomography in children with wilms tumour: is it worth the risk? in this original research... open access • abstract • introduction • methods • results • discussion • limitations of the study • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: wilms tumour is a comparatively common paediatric malignancy with a relatively good prognosis. routine post-treatment surveillance at our institution currently includes regular abdominopelvic computed tomography (ct) over a two-year period for the early detection of disease recurrence. the rationale is that early salvage therapy may improve overall patient survival, and thus justifies the exposure to potentially harmful ionising radiation. objective: to critically evaluate the routine use of post-treatment abdominopelvic ct by determining the detection rate of disease recurrence and associated clinical outcomes. methods: sixty-four patients in remission following initial treatment for wilms tumour were included in this retrospective study. variables obtained from patient records included gender, age, histological grading and tumour stage at presentation, number of abdominopelvic ct scans, site(s) of relapse, method of recurrence detection and confirmation, time to recurrence and clinical outcome. results: the patients received a total of 334 surveillance abdominopelvic ct scans. nine (14%) patients developed disease recurrence during the follow-up period. in three cases, the initial detection method was abdominopelvic ct. all three of these patients subsequently died despite salvage therapy (22 months median survival). five false-positive diagnoses of recurrence occurred, with two being made on abdominopelvic ct. conclusion: routine post-treatment abdominopelvic ct showed a low detection rate of disease recurrence in children treated for wilms tumour, while subjecting patients to a large radiation burden. the recommendation is that current practice be changed in line with the ultrasound-based société internationale d’oncologie pédiatrique (siop) imaging guidelines. introduction top ↑ wilms tumour (nephroblastoma) is the second most common intra-abdominal tumour presenting during childhood, with approximately 80% of cases diagnosed before the age of 5 years.1 advances in treatment have greatly improved the prognosis for children with this condition. where survival rates were once less than 30%, they are currently quoted at 90%, making it one of the success stories of modern medicine.2 nephroblastomas metastasise predominantly to the lungs (58%) and liver (29%), and only rarely to other sites such as the skeleton, mediastinum and brain. most relapses (90%) occur within 4 years of diagnosis.3 the practice of post-treatment surveillance imaging is aimed at the early detection of tumour recurrence, thereby enabling early salvage therapy. long-term survival following salvage therapy has reportedly increased from below 30% in the mid-1980s, to the current range of 50% – 60%.4 recommendations for post-treatment surveillance imaging of patients with wilms tumour that are currently in use include the guidelines proposed by the american cog (childhood oncology group) (table 1) and european société internationale d’oncologie pédiatrique (international society of paediatric oncology) (siop) (table 2). these imaging recommendations were originally created for research purposes, but are often used to guide the clinical use of imaging studies. as far as could be determined, no other standardised guidelines have been published.1 table 1: cog recommendations for ct as part of off-therapy surveillance imaging in wilms tumour.5 table 2: siop imaging recommendations for long-term follow-up of children with renal neoplasms.6 the universitas academic hospital paediatric oncology unit in bloemfontein, south africa, follows the siop guidelines to stage and manage patients who have been diagnosed with wilms tumour. the imaging protocol for off-treatment surveillance is, however, largely based on the cog guidelines. routine surveillance abdominopelvic computed tomography (ct) scans are performed at three-month intervals during the first year and six-monthly in the second year of post-treatment follow-up. concurrent radiographs or ct of the chest are performed to screen for pulmonary metastases. according to the cog guidelines, patients with high-risk wilms tumours may receive up to 8 abdominopelvic ct scans during the post-treatment follow-up period.1 the estimated cumulative effective dose to an individual patient from all the ionising diagnostic radiological investigations performed at diagnosis, while on treatment, and during the follow-up period – according to the cog trials – amounts to 152.8 msv,5 which is the equivalent of approximately 7500 chest radiographs.7 the possible long-term adverse effects of low-dose radiation associated with radiological investigations are increasingly being put under the spotlight, with the most worrisome risk being that of radiation-induced cancer.8 the paediatric population is particularly susceptible to the harmful effects of ionising radiation owing to the increased radiosensitivity of their rapidly dividing cells, in particular thyroid, breast and gonadal tissue. children also have a longer lifetime during which radiation-related cancers have time to develop.7 compared with an adult, a dose of radiation results in a ten-fold increase in neoplastic potential in a growing child.9 the estimated lifetime risk of radiation-induced fatal cancer in children who have had a ct scan is 1 in 1000.10 there is also an incremental increase in cancer risk for each additional ct scan.11 paediatric oncology patients are often exposed to a large number of serial and frequently high-dose examinations, resulting in a considerable cumulative radiation exposure. to justify the risk, albeit small, of radiation-induced malignancy owing to exposure from a radiological surveillance programme, two conditions have to be met. firstly, disease recurrence has to be accurately detected before it becomes clinically apparent; and secondly, earlier detection of relapse should lead to improved overall survival.5 the aim of the present study was to critically evaluate the use of abdominopelvic ct scans in the post-treatment surveillance programme of children with wilms tumour, with the purpose of effective minimisation of exposure to ionising radiation and optimal utilisation of limited resources. our objectives were, firstly, to determine the radiological, and specifically abdominopelvic ct, detection rate of tumour recurrence during the routine surveillance programme in children who have successfully completed their treatment for nephroblastoma; and secondly, to determine the value of a positive radiological finding of recurrent disease by describing the clinical outcomes in these children. methods top ↑ a retrospective descriptive study was undertaken after obtaining approval from the ethics committee of the faculty of health sciences, university of the free state. patients who had been treated for wilms tumour and followed up at the paediatric oncology unit at universitas academic hospital between january 2000 and december 2012 were included. further inclusion criteria included a clinical and radiological diagnosis of complete disease remission at the completion of treatment, as well as completion of the two-year period of routine off-treatment imaging surveillance. patients who had residual or progressive disease at the end of treatment, absconded from treatment or follow-up, or had died owing to comorbidities or other causes during the follow-up period, were excluded from the study population. the variables collected from paper and electronic patient records included age at diagnosis, gender, initial tumour staging and histological grading, and the total number of abdominopelvic ct scans, including the number of surveillance scans. in the event of disease relapse during follow-up, the time between treatment completion and relapse, the anatomical site(s) of relapse, initial method of relapse detection and the method of confirming or refuting the diagnosis of relapse, were recorded. the last known clinical outcome for each patient was also established. a total of 126 patients were treated for wilms tumour during the period under investigation. of these, 22 patients were lost to follow-up and 9 absconded. a further 31 patients were excluded owing to progressive or residual disease after completing the standard treatment protocol. results top ↑ of the 64 patients included in the study population, there were slightly more girls (n = 35) than boys (n = 29). the median age at diagnosis was 3 years (range 0.6 to 11 years). the majority of patients (61%, n 64) had siop stage i disease. data on histological tumour grading was lacking in 42% (27/64) of patients, especially in those diagnosed before 2005. of those with known histological grading, 81% (30/37) had grade 2 or intermediate-grade tumour histology. the patients included in the study population received a total of 479 abdominopelvic ct scans (mean of 7.5 per patient) during the process of disease staging, treatment monitoring and surveillance. a total of 334 surveillance abdominopelvic ct scans were done, with a mean of 5.2 scans per patient. nine patients (14% of the study population) had confirmed disease relapse during the follow-up period. the characteristics of these patients are set out in table 3. the median time interval between completion of treatment and the diagnosis of relapse was 6 months (range 3–12 months). the most common anatomical site of relapse was the lungs (56%, n = 9), followed by local recurrence and liver metastases, both occurring in one-third of cases of relapse. no disease recurrence was found in the pelvis. one patient presented clinically with skeletal metastasis during the follow-up period. table 3: characteristics and outcomes of cases (n = 9) with recurrence of wilms tumour. of the 9 confirmed cases of relapse, 3 were initially detected by surveillance abdominopelvic ct (figure 1). a further 3 were detected by plain chest radiography, 1 by chest ct, and 2 presented with clinical symptoms of relapse. figure 1: abdominopelvic ct in two patients with local recurrence of nephroblastoma, in the right kidney bed (a), and in the left kidney bed (b). both patients subsequently developed disease progression and died. the clinical outcomes in the patients who presented with relapse following disease remission were very discouraging. eight of the 9 patients responded poorly to salvage therapy and died. the median duration of survival following the diagnosis of disease recurrence was 18 months (range 7–27 months). the only patient who could be successfully salvaged presented with lung metastases detected initially by chest radiograph. in 5 patients diagnosed with disease relapse during the period of imaging surveillance, it was found not to be the case on subsequent biopsy or clinical and radiological follow-up. of these false-positive cases, 2 were diagnosed on abdominopelvic ct, 2 on chest ct and 1 on a chest radiograph (figures 2–3). figure 2: surveillance abdominopelvic ct showing a soft-tissue density in the left kidney bed, not present on a previous follow-up scan, incorrectly interpreted as local recurrence of nephroblastoma. a follow-up ct, done one month later, confirmed this as unopacified small bowel. the patient was still in remission two years later. figure 3: follow-up abdominopelvic ct in a patient, previously in remission following treatment for stage ii nephroblastoma, shows a well-defined hypodense lesion in the right lobe of the liver. this lesion was not present on baseline imaging and had increased in size compared with a previous follow-up ct, making the lesion highly suggestive of a liver metastasis. the patient subsequently underwent liver resection. histology revealed hydatid disease. discussion top ↑ our rate of detecting disease recurrence with routine surveillance abdominopelvic ct was one recurrence for every 111 scans performed, which is similar to that found in a study by howell et al.,12 where routine ct detected one recurrence for every 129 scans performed in the follow-up of children with solid tumours. in their study, only 30% of the total recurrences were detected by routine investigations, with the majority presenting symptomatically between routine clinic appointments. this finding led the investigators to question the usefulness of frequent routine follow-up investigation in paediatric oncology.12 in contrast, the majority of relapses in our study were detected by imaging investigations, which may be attributed to differences between the natural history of wilms tumour and the other solid tumours included in the study by howell et al.,12 the different frequency of routine follow-up investigations, and the relatively small patient populations of both studies. a few studies have evaluated the outcomes of the detection of disease relapse by routine surveillance imaging following completion of therapy for paediatric cancers. most indicate little or no improvement in salvage rates between relapses detected by imaging or clinically.13 the salvage rates were equally dismal in relapses detected clinically or by imaging in our study. all 3 of our patients with disease recurrence detected by abdominopelvic ct, developed progressive disease and died regardless of salvage therapy, with a median survival of 22 months (range 21–26 months). the alara (as low as reasonably achievable) principle advocates the reduction of radiation exposure through the optimisation of scanning parameters, the elimination of unnecessary examinations and the use of alternative non-ionising imaging modalities. ways of decreasing the radiation exposure of a ct scan include optimising scan settings according to patient size and limiting the area of the body being scanned. studies by kaste et al.14 and kan et al. 2 found no benefit from including the pelvis in routine surveillance ct of patients with wilms tumour. omitting pelvic ct saves an average of 30% to 45% of the effective dose of abdominopelvic ct.14 no pelvic recurrences were observed in our study population, further supporting these findings. the elimination of unnecessary investigations and the use of alternative non-ionising imaging modalities constitute the most effective ways of reducing radiation exposure. the use of ultrasound in the initial diagnosis of wilms tumour is well established. renal ultrasonography is also considered the optimal screening modality for the detection of wilms tumour in at-risk individuals.15 there are to our knowledge, however, no studies that compare the diagnostic performance of abdominal ultrasound with abdominopelvic ct in routine off-treatment surveillance. daw et al.16 investigated abdominal relapse in wilms tumour and found that all cases of recurrence were detected by ultrasound obtained at the time of relapse. their results suggest that regular sonographic surveillance for three years after completion of treatment is likely to detect most abdominal recurrences,16 making it an attractive alternative to abdominopelvic ct. the cost-effectiveness of routine follow-up investigations should also be taken into consideration, especially within the context of resource constraints. guadagnolo et al.17 analysed the cost-effectiveness of ct in the routine follow-up of patients with hodgkin’s disease, comparing it with non-ct modalities. their study also took into account the decrement in quality-adjusted life expectancy owing to false-positive ct results. it was found that annual follow-up ct is associated with minimal survival benefit. for advanced stage patients, annual ct for 5 years was associated with a small quality-adjusted survival gain over non-ct follow-up, but at an incremental cost-effectiveness ratio of $us9 million per quality-adjusted life year gained.17 the poor outcomes of patients with recurrence detected by abdominopelvic ct in our study, as well as the morbidity and anxiety associated with false-positive results, suggest an unfavourable cost-benefit ratio for the use of this modality in the routine post-treatment surveillance of wilms tumour. to promote a more rational approach to follow-up imaging in children with cancer, it is important to understand the motivation of the different role players. the good treatment response of certain childhood cancers, including wilms tumour, leads to optimistic attempts to achieve permanent control at any price. the difference in attitude of paediatric oncologists, compared with adult oncologists, also leads to a more aggressive approach to post-treatment surveillance.18 ultimately, it remains the responsibility of the radiologist to ensure that any request for an imaging investigation is justified and that exposure to ionising radiation be kept as low as reasonably achievable. although it may be argued that the parents or the patients themselves derive reassurance from negative routine follow-up investigations, these may also lead to unnecessary anxiety, practical inconvenience and physical discomfort related to preparation for ct scans and intravenous contrast administration. limitations of the study top ↑ the study was limited by the relatively small study population. a large number of patients were excluded owing to poor treatment response associated with advanced disease at presentation, or were lost to follow-up. these circumstances compare poorly with the 90% remission rates reported in developed countries, and can most likely be attributed locally to poor socioeconomic conditions, low levels of education and a sub-optimally functioning primary healthcare system. conclusion top ↑ our study set out to critically evaluate the routine use of abdominopelvic ct in the post-treatment surveillance of patients with wilms tumour. we found that in the past 12 years, routine abdominopelvic ct detected only 3 cases of disease recurrence. unfortunately, none of these patients survived much longer than 2 years following the diagnosis of disease recurrence, despite salvage therapy. at the same time, patients who did not go on to develop disease recurrence were subjected to a significant radiation burden, with the associated risk of radiation-induced cancer later in life. in view of the findings, we propose the use of the siop surveillance imaging recommendations, using ultrasound in preference to ct for abdominal surveillance. this will lead to a significant reduction in radiation exposure and cost, without jeopardising patient outcomes. our findings highlight the need for improved and ongoing collaboration between paediatric oncologists and radiologists to re-assess current practices and devise optimised imaging strategies that take the risks associated with potentially avoidable exposure to ionising radiation, as well as the impact on limited resources, into account. acknowledgements top ↑ the authors thank mr cornel van rooyen, department of biostatistics, faculty of health sciences, university of the free state, for his contribution to the study design and statistical analysis of the data; and dr daleen struwig, medical writer, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.j.v.r. (university of the free state) was the study leader; j.h.o. (university of the free state) was responsible for originating the research question, the study design, data collection and writing of the research article; and d.k.s. (university of the free state) made conceptual contributions, assisted with the process of data collection and critically evaluated the intellectual content of the final written manuscript. references top ↑ davidoff am. wilms’ tumour. curr opin pediatr. 2009;21:357–364. http://dx.doi.org/10.1097/mop.0b013e32832b323a kan jh, hwang m, lowas sr, hernanz-schulman m. impact of pelvic ct on staging, surveillance, and survival of pediatric patients with wilms tumour and hepatoblastoma. am j roentgenol. 2011;196:w515–w518. http://dx.doi.org/10.2214/ajr.10.5179 brisse hj, smets am, kaste sc, owens cm. imaging in unilateral wilms tumour. pediatr radiol. 2008;38:18–29. http://dx.doi.org/10.1007/s00247-007-0677-9 metzger ml, dome js. current therapy for wilms tumour. oncologist. 2005;10:815–826. http://dx.doi.org/10.1634/theoncologist.10-10-815 mchugh k, roebuck dj. pediatric oncology surveillance imaging: two recommendations. abandon ct scanning, and randomize to imaging or solely clinical follow-up. pediatr blood cancer. 2014;61:3–6. http://dx.doi.org/10.1002/pbc.24757 international society of paediatric oncology (siop). nephroblastoma clinical trial and study siop 2001. c2007 [cited 30 january 2015]. available from: http://web.visu.uni-saarland.de/rtsg/fileadmin/templates/logistix/files/siop_interim_statistical_report.pdf brody as, frush dp, huda w, brent rl, american academy of pediatrics section on radiology. radiation risk to children from computed tomography. pediatrics. 2007;120:677–682. http://dx.doi.org/10.1542/peds.2007-1910 voss sd, reaman gh, kaste sc, slovis tl. the alara concept in pediatric oncology. pediatr radiol. 2009;39:1142–1146. http://dx.doi.org/10.1007/s00247-009-1404-5 shah nb, platt sl. alara: is there cause for alarm? reducing radiation risks from computed tomography scanning in children. curr opin pediatr. 2008;20:243–247. http://dx.doi.org/10.1097/mop.0b013e3282ffafd2 brenner d, elliston c, hall e, berdon w. estimated risks of radiation-induced fatal cancer from pediatric ct. am j roentgenol. 2001;176:289–296. http://dx.doi.org/10.2214/ajr.176.2.1760289 mathews jd, forsythe av, brady zb, et al. cancer risk in 680000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million australians. bmj. 2013;346:f2360. http://dx.doi.org/10.1136/bmj.f2360 howell l, mensah a, brennan b, makin g. detection of recurrence in childhood solid tumours. cancer. 2005;103:1274–1279. http://dx.doi.org/10.1002/cncr.20896 kaste sc. oncological imaging: tumour surveillance in children. pediatr radiol. 2011;41(suppl 2):505–508. http://dx.doi.org/10.1007/s00247-011-2108-1 kaste sc, brady sl, yee b, et al. is routine pelvic surveillance imaging necessary in patients with wilms tumour? cancer. 2013;119:182–188. http://dx.doi.org/10.1002/cncr.27687 scott rh, walker l, olsen øe, et al. surveillance for wilms tumour in at-risk individuals: pragmatic recommendations for best practice. arch dis child. 2006;91:995–999. http://dx.doi.org/10.1136/adc.2006.101295 daw nc, kauffman wm, bodner sm, pratt cb, hoffer fa. patterns of abdominal relapse and role of sonography in wilms tumour. pediatr hematol oncol. 2002;19:107–115. http://dx.doi.org/10.1080/08880010252825696 guadagnolo ba, punglia rs, kuntz km, mauch pm, ng ak. cost-effectiveness analysis of computerized tomography in the routine follow-up of patients after primary treatment for hodgkin’s disease. j clin oncol. 2006;24:4116–4122. http://dx.doi.org/10.1200/jco.2006.07.0409 kagan ar, steckel rj. diagnostic imaging in the surveillance of treated children with cancer. med pediatr oncol. 1993;21:323–326. http://dx.doi.org/10.1002/mpo.2950210503 article information author: razaan davis1 affiliation: 1faculty of medicine and health sciences, stellenbosch university, south africa correspondence to: razaan davis email: razdavis87@gmail.com postal address: po box 19063, tygerberg 7505, south africa how to cite this article: davis r., the south african journal of radiology growing in leaps and bounds. s afr j rad. 2015;19(1); art. #956, 1 page. http://dx.doi.org/10.4102/sajr.v19i1.956 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the south african journal of radiology growing in leaps and bounds in this editorial... open access it has been an eventful year for the south african journal of radiology (sajr) which has grown in leaps and bounds. the online publication of the sajr and its inclusion in the scielo sa (scientific electronic library online) index provides improved exposure. the increasing number of first time unique visitors to the online journal, including local south african (23.25%) and international visitors from the united states of america (23.25%), india (10.27%) and the united kingdom (4.18%), is testament. the journal has applied for inclusion in the scopus, norwegian and thomson reuters web of science indices. i acknowledged the rssa/ heads of department (hod) committee for its unwavering and continued support of the sajr. as a result of that support, the number and quality of submitted and published original research manuscripts is steadily on the rise. this will hopefully contribute to the success of the application. the first special edition (musculoskeletal radiology in south africa) published by the sajr in december 2014 was immensely successful and has received continued online exposure throughout 2015 on the aosis open access platform. the editorial team, encouraged by this success, decided to publish a second special edition which is currently rolling out online. collaborating with the dynamic south african society of paediatric imaging (saspi), the team worked toward publishing the sajr/saspi paediatric edition consisting of 18 articles. the publication coincided with the international day of radiology on 08 november 2015, which this year (2015) was dedicated to paediatric imaging. with contributions from both local and international academic radiologists i foresee that the sajr will expand its readership and assist in bringing south african radiology to the attention of the international radiology community. with this goal we announce the intended publication in 2016 of the third sajr special edition, a collaborative effort between the sajr and the newly established south african society of cardiac imaging (sasoci). a technical innovation for the sajr is the inclusion of video content in one of the articles (refer to the editorial: paediatric imaging – from baby steps to giant strides) published in the sajr/saspi special issue. the ever popular quiz case, organised and edited by dr shalendra misser, has enjoyed enormous success with contributions from internationally renowned radiologists visiting south africa to participate as invited speakers in the successful rssa congresses. the prize, currently r1000 for the best answer, will be increased to r2000 as of 2016. thank you to our readership, authors and reviewers for your overwhelming of the support of the sajr during 2015. razaan davis editor in chief, sajr abstract introduction play the cine movie of the short-axis images first delete repeated slices pick the end-systolic and end-diastolic phases deciding on the basal slice for each phase contouring the epicardial and endocardial borders conclusion acknowledgements references about the author(s) miranda durand clinical unit, grey’s hospital, university of kwazulu-natal, south africa citation durand m. basic processing in cardiovascular mri: tips and tricks. s afr j rad. 2016;20(2), a1024. http://dx.doi.org/10.4102/sajr.v20i2.1024 review article basic processing in cardiovascular mri: tips and tricks miranda durand received: 03 may 2016; accepted: 19 july 2016; published: 11 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract cardiovascular magnetic resonance (cmr) imaging has gained popularity in the past few years as a reliable, comprehensive assessment tool for the evaluation of patients with congenital and acquired heart disease. however, the overwhelming amount of data generated by cmr makes it difficult to know where to start and what to report. to ensure consistency and reproducibility of cmr reporting, the society of cardiovascular magnetic resonance (scmr) board of trustees task force on standardised post processing has published guidelines to standardise cmr imaging and post processing. the present article aims to provide a pictorial review of these guidelines as well as a framework to basic processing that encompasses: left ventricular function and mass assessment; right ventricular function assessment; atrial size measurements; flow analysis; and t2* analysis and aortic measurements. cardiac mri is a robust and rapidly developing field that has significantly advanced the management of cardiac patients. it is important that accuracy and consistency be maintained to ensure that we gain and maintain clinicians’ confidence in the use of this modality. introduction cardiovascular magnetic resonance (cmr) imaging has gained popularity in the past few years as a reliable, comprehensive assessment tool for the evaluation of patients with congenital and acquired heart disease. a recent review has shown that, compared with modalities such as echocardiography and radionuclide studies, cmr is able to most accurately quantify a patient’s clinical condition as well as best predict clinical outcomes across a range of cardiac diseases.1 cmr generates many quantitative parameters, and it can be difficult for the beginner to know where to start and what to report. to ensure consistency and reproducibility of cmr reporting, the society of cardiovascular magnetic resonance (scmr) board of trustees task force on standardised post processing has published guidelines to standardise cmr imaging and post processing.2 the present article aims to provide a pictorial review of these guidelines as well as a framework on how to approach and interpret the multitude of images acquired by cmr. the basic cmr processing measurements includes: left ventricular (lv) function and mass assessment right ventricular (rv) function assessment atrial size measurements flow analysis t2* analysis aortic measurements. more advanced processing such as myocardial tagging, t1 and t2 mapping, as well as diffusion imaging is not covered in the article.3 left ventricular function and mass studies have demonstrated that there is less variance in lv volume and ejection fraction assessment with cmr in comparison with echocardiography and radionuclide ventriculography, which has led to cmr becoming the gold standard for lv function assessment.4 however, processing cmr images of lv function can be daunting to the uninitiated and it is useful to have an approach that will guide the beginner through the process. the basic approach is as follows. play the cine movie of the short-axis images first this provides an overview of the lv function and wall motion and allows visual assessment of the lv function. thereafter, correlate this qualitative assessment with the calculated values to ensure that major errors do not occur, such as when the incorrect phase is selected. regional wall motion is assessed by using the degree of wall thickening during systole in each lv segment. however, small differences are sometimes difficult to appreciate visually at first glance. tip: it helps to put the mouse cursor in the middle of the ventricle as a point to fix the eye upon, and then to assess the degree of lv wall movement towards the cursor (figure 1). figure 1: single short-axis cine steady-state free precession (ssfp) image of the lv. the black arrow in the centre of the lv blood pool provides a fixed point to focus the eye upon, which assists in the assessment of the lv wall motion. the degree by which one segment of the lv wall moves towards the arrow (when compared with the rest of the lv segments) simplifies wall motion dysfunction assessment. for video footage, visit https://www.youtube.com/watch?v=8ijrhhyqows&feature=youtu.be. delete repeated slices scroll through all the slices, from the basal slices at the atrioventricular (av) valve to the apex, to ensure that the whole ventricle has been included in the data set. examine the data set for duplicate slices; this may occur when the patient takes one excessively deep breath hold which then causes the next scanned slice (acquired with a regular breath hold) to overlap with the previous slice. any repeated slice must be deleted. tip: the easiest way to detect a slice that has been repeated is to look for papillary muscles that are in exactly the same position as those in the previous slice (figure 2). figure 2: a series (a–l) of short-axis cine ssfp images of the lv during a single phase at different slice positions. slices that repeat the same slice position should be deleted to prevent over-sampling. this is easily determined by observing the configuration of the papillary muscles; the papillary muscle of the second slice (solid black arrow) is in the exact same position and configuration as the papillary muscles of the third slice (stippled black arrow), hence one of these slices must be deleted and not included in the lv volume and mass assessment. pick the end-systolic and end-diastolic phases most processing software will automatically suggest the end-systolic and end-diastolic phases but the operator still has to check to ensure that it is the correct phase. arrhythmias may cause the automatic software to select the wrong phase. the end-systolic phase is the phase during the cardiac cycle when the ventricular volume is at its minimum. tip: the easiest way to identify end-systole is to examine all the phases at a particular slice level; the mid-ventricular level is normally the easiest to use. end-systole is normally the phase where the myocardium is closest to the papillary muscles (figure 3). figure 3: three short-axis cine ssfp images of the lv at the phases (a, b and c) close to end-systole. when selecting the end-systolic and end-diastolic phases, it is advisable to observe the relationship of the lv wall to the papillary muscles. when the myocardium is closest to the papillary muscle (white arrow), just before it starts moving away from the lv wall again, is the end-systolic phase. when the lateral wall is furthest away from the papillary muscles, just before it starts moving towards the lv wall again, that is the end-diastolic phase. for video footage, visit: https://www.youtube.com/watch?v=ltbqvpuyguo&feature=youtu.be. however, this technique is ineffective in patients with lv dyssynchrony or with severe mitral valve regurgitation. in such cases, the closure of the aortic valve will indicate end-systole. end-diastole is the phase where the ventricular volume is at its maximum and it is normally the phase just before the myocardium starts moving in towards the papillary muscle again. deciding on the basal slice for each phase the operator selects the most basal slice to use for contouring the end-systolic and end-diastolic phases. this is normally not the same slice for both phases as the mitral annulus moves apically during systole. there are normally one or two slice differences between the basal slice for the end-systolic and end-diastole phases. with severe lv dysfunction, there may be very little apical movement and the basal slice may be the same for end-systole and end-diastole. the recommendation for deciding the most basal slice to be utilised is the one in which at least 180 degrees of myocardium surrounds the lv blood pool (figure 4). figure 4: single short-axis cine ssfp image of the basal lv myocardium. the basal slice is the first slice where the blood pool (*) is encircled by more than 180 degrees of myocardium (white contour). contouring the epicardial and endocardial borders tip: it often helps to play the cine movie of the short-axis on a different window while one contours, as this will assist to determine where to draw the endocardial border. when contouring the endocardial border, the lv outflow tract should be included in the blood pool to the level of the aortic valve (figure 5). if only myocardium is present in the most basal or most apical slice with no discernible lv blood pool, only an epicardial border is contoured for lv mass assessment (figure 6). the papillary muscles are not part of the blood pool but, because most entry-level software does not automatically exclude the papillary muscles, and manual contouring of the papillary muscles is extremely labour intensive, the task force recommends that the papillary muscles be included or excluded at the operator’s preference. whether including or excluding the papillary muscles, that decision should be reflected in the report and should be consistently applied at any one institution. figure 5: single short-axis cine ssfp image of the basal lv myocardium. the left ventricular outflow tract should be included in the blood pool when contouring the lv endocardium contour up to the level of the aortic valve leaflets. figure 6: single short-axis cine ssfp image of the basal lv myocardium. if only a small portion of the lv myocardium is evident in the most basal slice with no discernible lv blood pool, then only the epicardial border is contoured for the lv mass assessment. right ventricular function rv function plays a particularly large role in the assessment of patients with congenital heart disease, and serial assessments of rv function are used to determine the timing of surgical interventions. cmr has now emerged as the reference standard for this assessment owing to its accuracy and reproducibility.5 the same contouring principles used for lv post-processing apply for the contouring of rv functional assessments: play the cine movie initially; delete any repeat slices; select the end-systolic and end-diastolic phases; and contour the endocardial border. only the rv endocardial border is contoured as the rv myocardium is very thin, and rv myocardial mass is usually only important in research settings. the rv can be contoured on the short-axis cine images (figure 7), which is the same stack of images used for lv contouring, or on the transaxial cine images (figure 8). because both these sequences have their own advantages and disadvantages, the task force guideline does not specify which one to utilise. the biggest advantage to using the short-axis view is that it is the same sequence used for the lv function, which saves time. the disadvantages are that it is often difficult to choose the basal slice on the short-axis stack, and that the pulmonary valve is normally not well visualised. the pulmonary and tricuspid valves are easily observed on the transaxial images which defines the ventricular borders clearly, but this means that an extra data stack must be acquired. the rv endocardial border is drawn as a smooth line at the inner margin of the rv myocardium. the moderator band should be included in the blood pool unless it is exceptionally large, in which case it can be excluded. figure 7: single short-axis cine ssfp image at the mid-ventricular level. the rv is contoured on the stack of short-axis cine images (white line). figure 8: transaxial cine ssfp image of the heart. the levels of the tricuspid and pulmonary valves are easily visualised on the transaxial images for the contouring of the rv volumes and function (white line). tip: if there is no cardiac shunt, the stroke volume of the lv should roughly match that of the rv. atrial size measurement the atria are measured during ventricular systole when the mitral valve is closed (figure 9). there are a number of ways to measure the atria, and the importance of obtaining the exact size of the atria will determine which of these are used. routine measurements are normally done as a transverse measurement of the maximum diameter of the atrium, taking care to exclude the ostia of the pulmonary veins and the appendages (figure 9). normal atrium size is less than 4 cm on this measurement. the atria can also be measured using the biplane area-length method, using a longitudinal measurement from the posterior wall to the mid av valve as well as a transverse measurement perpendicular to this in the mid atrial level (figure 10). lastly, the atria can be contoured like the ventricles for exact volumes. figure 9: four-chamber cine ssfp images (a–d) of the heart. the atria are measured at the end of the ventricular end-systole when the ventricle blood pool is the smallest (*) and the mitral valve is closed (white arrow). the atria can be measured with a transverse measurement at the level of the mid atrium (right atrium – black line; left atrium – white line), avoiding the atrial appendages and pulmonary vein orifices. figure 10: four-chamber cine ssfp image of the heart. the atria can also be measured with the biplanar method with a longitudinal measurement from the mid atrioventricular valve to the posterior atrial wall and a perpendicular measurement transversely through the mid atrium. flow analysis phase contrast analysis currently plays an important part in the functional assessment of patients with valvular and congenital heart disease.6 for these values to be reliable, it is important to acquire these sequences correctly. the images need to planned and acquired perpendicular to the vessel in question (figure 11). normally, this will be performed for the aorta and the pulmonary artery; this allows calculation of the pulmonary-to-systemic flow ratio (qp:qs) during shunt assessment. flow analysis is also used in valvular heart disease for peak velocity and regurgitation fraction assessment. the flow sequence generates two image sets: a magnitude and a phase contrast set (figure 12). figure 11: right ventricle outflow tract cine ssfp image. the phase contrast sequence is planned perpendicular to the vessel (white line), in this case the pulmonary artery. figure 12: phase contrast images perpendicular to the pulmonary valve. the phase contrast series generates two sets of images: the magnitude image: (a) that clearly defines the anatomical structure, and (b) the phase contrast image that depicts the blood flow with less anatomical detail. when performing contours, it is advisable to draw the roi on the magnitude image (white contour) and then to propagate them to the phase contrast image. tip: the magnitude image set has more anatomical detail and should be used to draw the region of interest (roi) (figure 12); this can then be propagated to the phase contrast images. it helps to be generous with the margins when drawing the roi to ensure that peripheral flow in the vessel is included. however, care should be taken not to include adjacent vessels as this will influence the flow values. t2* analysis and aortic measurement t2* analysis is used to quantify the amount of iron deposition in the myocardium and is an important diagnostic and prognostic factor for siderotic cardiomyopathy in transfusion-dependent patients.7 the sequence is performed in the short-axis orientation and will provide an image set with different time-to-echo (te) times for the same slice position (figure 13). the septum is used for the analysis and a roi is drawn to include as much of the septum as possible, but taking care to avoid the blood pool in both ventricles as well as the anterior and inferior hinge points (figure 13); this will avoid the blood pool trapped in the myocardial trabeculations in the hinge point regions and also avoid septal perforator arteries. the software will then generate a curve (figure 14). figure 13: serial short-axis t2* images at the mid ventricular level at different echo times. the roi for t2* assessment is drawn to include as much of the myocardium as possible, excluding the blood pool in both ventricles. the signal loss in the liver (*) owing to iron infiltration can also be seen. figure 14: signal intensity to echo time graft of the t2* analysis with the sample points for the roi at each te time having a smooth continuous contour. tip: if there is a point on the graft that is an outlier, review the contours for the correlating te time; usually that results from the inclusion of some of the blood pool in the roi. normal myocardial te times are more than 20 ms; 15 ms – 19 ms is considered mild iron infiltration, 10 ms – 14 ms is moderate iron infiltration, and <10 ms is considered severe iron infiltration.8 aortic measurements aortic measurement levels for vascular assessment have been standardised by the task force and are measured at the: sinus of valsalva, sinotubular junction, mid ascending aorta, distal ascending aorta (proximal to the brachiocephalic artery), arch (between the left common carotid artery and the left subclavian artery), proximal descending aorta (just distal to the left subclavian artery), mid descending aorta, distal descending aorta (at the level of the diaphragm), and abdominal aorta (above the coeliac trunk) (figure 15). figure 15: line drawing of the standard aortic measurement positions: sinus of valsalva; (2) sinotubular junction; (3) mid ascending aorta; (4) distal ascending aorta (just proximal to the brachiocephalic artery); (5) mid aortic arch (between the left common carotid artery and left subclavian artery); (6) proximal descending artery (just distal to the left subclavian artery); (7) mid descending aorta; (8) distal ascending aorta (at the level of the diaphragm); (9) abdominal aorta (just above the coeliac trunk). the aortic valve can be measured either as a sinus-to-sinus measurement (figure 16) or as a sinus-to-commissure measurement (figure 17). figure 16: axial cine ssfp image through the aortic valve. one of the methods of measuring the aortic valve is to measure the maximum diameters between the adjacent sinus of valsalva (white lines) sinus-to-sinus measurement. figure 17: axial cine ssfp image through the aortic valve. the second method of measuring the aortic valve is to measure the distances from the sinus of valsalva to the opposite commissure (white lines). this is called the sinus-to-commissure measurement. conclusion cardiac mri is a robust and rapidly developing field that has significantly advanced the management of cardiac patients. it is important that accuracy and consistency be maintained to ensure that we gain and maintain the clinicians’ confidence in the use of this modality. acknowledgements competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article. references flett as, westwood ma, davies lc, mathur a, moon jc. the prognostic implications of cardiovascular magnetic resonance. circ cardiovasc imaging. 2009;2(3):243–250. http://dx.doi.org/10.1161/circimaging.108.840975 schulz-menger j, bluemke da, bremerich j, et al. standardized image interpretation and post processing in cardiovascular magnetic resonance: society for cardiovascular magnetic resonance (scmr) board of trustees task force on standardized post processing. j cardiovasc magn reson. 2013;15:35. http://dx.doi.org/10.1186/1532-429x-15-35 mekkaoui c, reese tg, jackowski mp, bhat h, sosnovik de. diffusion mri in the heart. nmr biomed. 2015. http://dx.doi.org/10.1002/nbm.3426 bellenger ng, burgess mi, ray sg, et al. comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance; are they interchangeable? eur heart j. 2000;21(16):1387–1396. http://dx.doi.org/10.1053/euhj.2000.2011 geva t. is mri the preferred method for evaluating right ventricular size and function in patients with congenital heart disease?: mri is the preferred method for evaluating right ventricular size and function in patients with congenital heart disease. circ cardiovasc imaging. 2014;7(1):190–197. http://dx.doi.org/10.1161/circimaging.113.000553 nayak ks, nielsen jf, bernstein ma, et al. cardiovascular magnetic resonance phase contrast imaging. j cardiovasc magn reson. 2015;17(1):71. http://dx.doi.org/10.1186/s12968-015-0172-7 carpenter jp, he t, kirk p, et al. on t2* magnetic resonance and cardiac iron. circulation. 2011;123(14):1519–1528. http://dx.doi.org/10.1161/circulationaha.110.007641 kremastinos dt, farmakis d. iron overload cardiomyopathy in clinical practice. circulation. 2011;124(20):2253–2263. http://dx.doi.org/10.1161/circulationaha.111.050773 article information authors: tracy kilborn1 winnie c.w. chu2 k.m. das3 bernard laya4 edward y. lee5 affiliations: 1department of paediatric radiology, red cross war memorial children’s hospital, university of cape town, cape town, south africa 2department of imaging and interventional radiology, faculty of medicine, the chinese university of hong kong, hong kong 3department of radiology, college of medicine and health sciences, united arab emirates (uae) university, al ain, united arab emirates 4institute of radiology, st. luke’s medical center – quezon city and global city, philippines 5department of radiology, boston children’s hospital and harvard medical school, united states of america correspondence to: edward y. lee email: edward.lee@childrens.harvard.edu postal address: 300 longwood avenue, boston, ma 02115, united states of america dates: received: 14 aug. 2015 accepted: 09 oct. 2015 published: 11 dec. 2015 how to cite this article: kilborn t, chu, w.c.w, das km, laya bf, lee ey. current updates on hiv-related pulmonary disease in children: what do radiologists and clinicians need to know? s afr j rad. 2015;19(2); art. #928, 5 pages. http://dx.doi.org/10.4102/sajr.v19i2.928 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. current updates on hiv-related pulmonary disease in children: what do radiologists and clinicians need to know? in this review article... open access • abstract • introduction • human immunodeficiency virus (hiv) pulmonary infection    • etiology    • clinical presentation    • imaging findings    • management • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ despite substantial advances in diagnosis and treatment, pulmonary human immunodeficiency virus (hiv) infection continues to be a major cause of morbidity and mortality in infants and children particularly those who live in developing countries. this article provides an up-to-date review on underlying etiology, often characteristic imaging findings and current management of pulmonary hiv infection in infants and children. increased understanding of clinical and unique imaging findings of pulmonary hiv infection has a great potential for early and accurate diagnosis which, in turn, can eventually improve pediatric patient care. introduction top ↑ despite substantial advances in diagnosis and treatment, pulmonary human immunodeficiency virus (hiv) infection continues to be a major cause of morbidity and mortality in infants and children particularly those who live in developing countries. this article provides an up-to-date review on etiology, imaging findings and management of pulmonary hiv infection in infants and children. increased understanding of clinical and imaging findings of pulmonary hiv infection has a great potential for early and accurate diagnosis which, in turn, can eventually improve pediatric patient care. human immunodeficiency virus (hiv) pulmonary infection top ↑ etiology the joint united nations programme on hiv/aids (unaids) 2013 global report identifies 2.9 million children infected with hiv living in sub-saharan africa, which is the highest incidence in the world.1 the hallmark of hiv infection is the progressive depletion of cd4+t lymphocytes as a result of reduced production and increased destruction.2 within the lung, direct infection of pulmonary macrophages and lymphocytes plays an important role in the pathogenesis of pulmonary disease as does an increase in immune activation.2 in addition to t cell destruction and impaired cell-mediated immune response, hiv infection is also associated with defects in humoral (b cell) immunity leading to an impaired ability to generate antigen specific response.3 hiv leads to progressive immunodeficiency, opportunistic infection, aids related malignancy and ultimately death. the prognosis of children infected with hiv has improved since the advent of highly active antiretroviral therapy (haart) with the emerging problem of chronic lung disease. clinical presentation the hiv epidemic has resulted in an increase in childhood respiratory disease related morbidity and mortality.3,4 this is particularly evident in africa where it is compounded by poorly implemented preventative strategies and limited access to highly active antiretroviral therapy (haart).1 six major respiratory disorders related to hiv infection in the pediatric patient population include: (1) pneumonia; (2) tuberculosis (tb); (3) lymphocytic interstitial pneumonia (lip); (4) immune reconstitution inflammatory syndrome (iris); (5) malignancy; and (6) chronic lung disease, which are discussed in the following section. pneumonia remains the most common cause of hospital admission in african children infected with hiv. pneumonia related mortality in children infected with hiv is currently 3–6 times that of non-hiv infected patients.5 pneumocystis jirovecii (pcp) pneumonia remains a frequent underlying infectious cause in infants infected with hiv. these affected infants typically present with mild to severe acute respiratory distress and hypoxia.5 superimposed infection with cytomegalovirus (cmv) in hiv infected infants with pcp pneumonia is common and results in more rapid progression of underlying hiv disease.5,6 the common respiratory viruses of childhood (respiratory syncytial virus, influenza, parainfluenza and adenovirus) are more common in older children with hiv and are more likely to be complicated by bacterial pneumonia.4 outside of infancy, streptococcus pneumoniae is the most common cause of bacterial infection and may be recurrent in pediatric patients with hiv infection. other frequent pathogens include hemophilus influenzae, staphlococcus aureus (including methicillin resistant strains), klebsiella pneumoniae, salmonella spp. and eschericia coli.5,6 factors complicating treatment of bacterial infection include reduced efficacy of vaccines and reduced antibiotic susceptibility in children infected with hiv.7,8 in areas with a high incidence of tuberculosis such as africa, mycobacterium tuberculosis (tb) is an important cause of acute and chronic respiratory infection in hivinfected children. they have an increased risk of developing complicated or disseminated disease.5 standard tb therapy is less efficacious with lower cure rates and higher mortality.9 co-infection with tb and hiv results in more rapid deterioration in immune function, viral replication and eventually hiv progression.9 other fungal infection such as chronic oropharyngeal, laryngeal or oesophageal candida albicans infection is also common and may result in dysmotility, gastro-oesophageal reflux disease and/ or aspiration and present with respiratory symptoms.10 lymphocytic interstitial pneumonia (lip) can still occur in hiv-infected children who have limited access to haart (30%–40%).11,12 co-infection with epstein barr virus and hiv is thought to cause a lymphoproliferative response in multiple organs including the lungs.5 affected children typically present with cough, tachypnea, and mild hypoxia. eventually, chronic lung disease may eventually develop in this pediatric patient population. with the improved access to haart, the recovery of the immune system may manifest as immune reconstitution inflammatory syndrome (iris). this presents as either deterioration of a known infection as a result of a florid immune response or as an unmasking of a previously undiagnosed subclinical infection. in africa, pulmonary iris is seen most commonly with mycobacterial infection such as tb.13 however, clinical diagnosis of pulmonary iris must be accompanied by (1) evidence of immune restoration such as a rise in the cd4+ count; (2) documented fall in viral load and (3) exclusion of alternative explanations of patient’s symptoms such as drug resistance, non-compliance or new infection. iris is more common in pediatric patients with severe immunosuppression at the time of commencing haart.13 children with hiv also have an increased risk of malignancy most commonly non-hodgkin’s lymphoma. it can occur primarily in the lungs or as a result of dissemination from a distant primary focus. kaposi’s sarcoma is a common aids-defining malignancy. affected pediatric patients often present with progressively worsening dyspnea, cough, and fever.14 with improved survival of hiv infected children, hiv-associated chronic lung disease has become increasingly more prevalent especially older children with lower cd4 counts and high viral loads. these children often present with chronic cough and clinical features of bronchiectasis.5 the cause may be multifactorial and includes chronic infections such as tb, recurrent bacterial or severe viral or fungal infection. lip, iris and chronic aspiration are also associated with long term sequelae.10 imaging findings in infants with pcp and/or cmv, the radiograph usually demonstrates varying degrees of ground glass opacification that may be symmetrical or asymmetrical (figure 1). short term complication such as air-leaks or long term complication such as cystic lung change (e.g., pneumatocele formation) (figure 2) may also subsequently develop. figure 1: infant boy with hiv infection who presented with respiratory distress and hypoxemia. frontal chest radiograph shows diffuse bilateral ground glass opacification from pcp and cmv co-infection. figure 2: infant girl with hiv infection and chronic pcp pneumonia. frontal chest radiograph shows cystic changes in both lungs as a long term complication. imaging findings of bacterial lung infections from s. pneumonia and s. aureus are similar in both children infected with hiv and immunocompetent children. they are characterised by diffuse patchy airspace disease in bronchopneumonia and confluent airspace disease with air-bronochograms in lobar pneumonia. however, these bacterial lung infections are often more severe in children infected with hiv and result in complications such as lung abscess and empyema (figure 3).5,15 figure 3: young boy with hiv infection and s. pneumonia bacterial infection. (a) frontal chest radiograph shows extensive consolidation and effusion in the right hemithorax. (b) ultrasound image of the right hemithorax demonstrates underlying consolidation and complex effusion with pleural thickening suggesting empyema. tb is commonly encountered in children infected with hiv. on chest radiographs, tb infection typically presents with lung parenchymal disease characterised by either ‘tree-in-bud’ pattern small nodular opacities or consolidation (figure 4). mediastinal and hilar lymphadenopathy is also typically present. in comparison to immunocompetent children with tb infection, extensive lung disease with cavitation occurs more frequently in hiv-infected children (figure 5).5 although ct is associated with potentially harmful radiation exposure, ct can better detect and characterise thoracic infections from tb. enlarged mediastinal and hilar lymph nodes demonstrating central low attenuation and peripheral contrast enhancement should suggest tb infection in children with hiv infection especially when lung parenchymal disease is concomitantly present.16,17 with concerns about radiation exposure from ct imaging, alternative imaging modalities which are not associated with radiation exposure such as ultrasound and mri are currently gaining favor particularly in the pediatric population. figure 4: young girl with hiv infection and tb infection. frontal chest radiograph shows right upper lobe consolidation. figure 5: 1-year-old boy with hiv infection, severe immunosuppression and recent diagnosis of tb. (a) frontal chest radiograph obtained while receiving haart, shows right paratracheal and hilar adenopathy as well as diffuse small nodular opacities in both lungs. (b) frontal chest radiograph obtained 3 weeks later demonstrates worsening mediastinal adenopathy and nodular lung opacities as well as interval development of bilateral pleural effusions despite viral suppression and improved cd4 count. typical imaging feature of tb iris in children with hiv infection. lip most commonly causes diffuse often symmetrical reticulo-nodular pattern opacities on chest radiographs and ct (figure 6).5,10,18 the nodules may coalesce to produce areas of confluent airspace opacification (figure 7).11 peribronchial thickening alone or cysts and bronchiectasis in long-standing disease may also occur.10,19 although lymphadenopathy may present in pediatric patients with lip, it rarely causes tracheobronchial compression which can be often seen in the setting of tb infection.19 it is often difficult to distinguish between lip and miliary tb on imaging alone. parotid enlargement as a result of lymphoepithelial cysts, hepatosplenomegaly and digital clubbing are more common in lip. on hrct, which may improve the diagnostic accuracy, characteristic perilymphatic and subpleural nodules are often present in pediatric patients with lip.15 figure 6: 4 year-old boy with newly diagnosed hiv. frontal chest radiograph shows symmetric reticulo-nodular pattern opacities as well as hilar lymphadenopathy from lip. figure 7: 3-year-old boy with known lip who presented with worsening respiratory distress. frontal chest radiograph shows bilateral reticulo-nodular pattern opacities with areas of confluent opacifications particularly in the lingual and left lower lobe. pediatric patients with hiv may also present with rare pulmonary kaposi sarcoma, which is characterised by the perihilar airspace and reticular opacification predominately involving the lower lung zone in addition to hilar lymphadenopathy and often large pleural effusion (figure 8).10 figure 8: 6-year-old boy infected with hiv and severe immunosuppression who presented with a violaceous mass in the upper airway. frontal chest radiograph shows reticulo-nodular perihilar opacities predominately located in the lower lung zones, right hilar lymphadenopathy, and bilateral effusions. the final diagnosis was pulmonary kaposi sarcoma. with improved survival of pediatric patients with hiv, chronic lung changes are now commonly seen in this pediatric patient population. on chest radiographs, increased bronchovascular markings, reticular and/or nodular pattern opacifications, cavities, cysts and bronchiectasis may present.20,21 ct is beneficial for characterising these chronic changes as well as guiding surgical planning such as lobectomy for focal, severe, and non-reversible bronchiectasis (figure 9). figure 9: 10-year-old boy with hiv infection who presented with chronically worsening cough not responding to bronchodilator. (a) frontal chest radiograph shows increased bronchovascular markings and reticulo-nodular opacifications. (b) axial lung window ct image demonstrates areas of bronchiectasis and underlying small airway disease characterized by areas of mosaic attenuation due to underlying air-trapping. management currently, universal access to haart using world health organisation guidelines has dramatically improved outcomes of children infected with hiv. medical management currently focuses on preventing mother-to-child transmission, screening pregnant women for hiv status, and using anti-retroviral therapy during pregnancy and breast feeding period in affected mothers. it has been proven that the early diagnosis of hiv-infected infants and timely treatment with trimethoprim-sulphamethoxazole pcp prophylaxis are effective interventions.5 unfortunately, the emerging problem of chronic lung disease can lead to severe disability in this vulnerable population.5,21 acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions t.k. (university of cape town), w.c.w.c. (university of hong kong), k.m.d. (college of medicine and health sciences), b.l. (st. luke’s medical center – quezon city and global city), e.y.l. (boston children’s hospital and harvard medical school) contributed equally to the writing of this article. references top ↑ unaids: report on the global hiv/aids epidemic. 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